ORIGINAL ARTICLE

FREQUENCY OF INTERAPPOINTMENT PAIN OBSERVED WITH SODIUM HYPOCHLORITE AND HYDROGEN PEROXIDE BASED ROOT CANAL IRRIGANTS. Laila Sangi 1 FerozeAli Kalhoro2 Naresh Kumar 3 Muhammad Arif Shaikh4 BDS, M.Sc BDS, FCPS BDS, Ph.D , BDS

OBJECTIVE: To compare the frequency of interappointment pain between 2.5% Sodium Hypochlorite and 3% Hydrogen Peroxide as a root canal irrigation material. Design: Clinical trial. Setting: Study was conducted at Dental OPD, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan from February 2009 to July 2009. METHODOLOGY: Sixty single-rooted, single-canal permanent teeth of sixty patients were selected randomly and equally divided in two groups. In group A (n=30), 2.5% Sodium hypochlorite (NaOCl) was used as an irrigation material while in group B (n=30), 3% Hydrogen peroxide (H2O2) was used. Canals were left empty for 72 hrs between visits. On second visit, interappointment pain was scored on Visual Analogue Scale (VAS) (0= No pain,13= mild, 4-6= moderate, 7-10= severe) by each patient on the proforma provided. RESULTS: Interappointment pain was observed in 32/60 patients and the rest did not experience any pain. Pain was significantly high in group B than A (70% vs. 36.7%; p=0.01). Severity of pain was also compared which was significantly high in group B than group A (p<0.012). Female experience more pain as compared to male. While correlation of age with pain was not found (p>0.05). CONCLUSION: NaOCl performed better clinically in terms of interappointment pain when compared with H2O2. KEY WORDS: Hydrogen Peroxide (H2O2), Interappointment pain, Root canal Irrigants, Sodium Hypochlorite (NaOCl), VisualAnalogue Scale (VAS). J Pak DentAssoc. 2011 (4) : 211-215 INTRODUCTION infectious agent due to an imbalance in host-bacteria 2 relationship induced by intracanal procedures. These factors include (a) certain species of bacteria responsible 3-7 8-9 for flareup, (b) prominence of virulent clones, (c) environmental condition responsible for turning on or off 9-11 the expression of certain virulent clones, (d) host 2 resistance. This leads us to the importance of the antimicrobial irrigation material during mechanical 12-13 instrumentation of root canal. The root canal irrigation serves to neutralize bacteria, inactivates bacterial toxins, dissolves necrotic pulpal tissue, lubricates canal during instrumentation, and reaches those areas which are otherwise inaccessible for 13-15 mechanical instrumentation. The interappointment pain between 2.5% NaOCl and 3% H2O2 as an irrigation material has been investigated in the current study. The previous studies were mostly done to investigate different effects of irrigant like antimicrobial properties, tissue dissolving capabilities and effect on dentine. But the association of
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nterappointment pain is a disappointing experience for the patient as well as for the dentist as it costs sometimes an unscheduled visit or unsatisfactory prediction of prognosis of root canal treatment by the patient. It is important for us to understand the causes of interappointment pain which may aid to reduce its frequency during root canal treatment. The causative factors include chemical, mechanical and most important 1 of all microbial factor. Several factors are individually or collectively responsible for pain development by
Lecturer, Operative Dentistry Department, Institute of Dentistry LUMHS Associate Professor, Operative Dentistry Department, Institute of Dentistry LUMHS. Assistant Professor Science of Dental Materials Department, Institute of Dentistry LUMHS Lecturer, Operative Dentistry Department, Institute of Dentistry LUMHS

Correspondence: Laila Sangi, <Laila_sangi@yahoo.com >

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Frequency of interappointment pain observed with sodium hypochlorite and hydrogen peroxide. based root canal irrigants.

interappointment pain with root canal irrigants needs to be investigated. So we tried in current study to find out a root canal irrigant with less interappointment pain. Therefore the current study is to test the null hypothesis that there would be no difference in the frequency of interappointment pain using 2.5% NaOCl and 3% H2O2 as root canal irrigants.

intensity of pain considered was the highest score recorded (1 to 3=mild, 4 to 6=moderate and 7 to 10 severe). Frequency of the variables namely gender and age groups of the patients were also computed. Mean with standard deviation, 95% confidence interval, median with IQR were computed for age and interappointment pain. Chi-square test was applied to compare interappointment pain and severity of pain between groups. Independent sample t test was used to compare mean difference between groups for age. Stratification of age and gender were also done to observe an effect of interappointment pain. P<0.05 was considered level of significance.

METHODOLOGY
Sixty patients with single-rooted, non-vital teeth of either gender attending for dental treatment were selected at Dental OPD, Liaquat University of Medical and Health Sciences teaching Hospital, Jamshoro, Pakistan. Complete history, clinical examination, vitality test with compressed refrigerant spray, dichloro-difluoro-methane (Endo-Frost, Roeko, Langenau, Germany), and preoperative radiograph was taken to discriminate the non vital teeth. Teeth with resorbed roots, mobile teeth and teeth with open apices, and periapical radiolucencies were excluded. The purpose of study, risks, and benefits of the materials used were explained to the patients and a signed consent was obtained from each patient. Patients were then divided randomly by lottery method into two groups. Group A (n=30) were treated with 2.5% NaOCl (Endo Wash, Star International, Washington DC, USA) and Group B (n=30) were treated with 3% H2O2 made by diluting 6% H2O2 (6% H2O2 w/n, Shahbaz Laboratories SITE B/8 Hyderabad, Pakistan) with distilled water. After obtaining the anesthesia, the access to the tooth was made with round and then straight fissure burs (Mani, Japan) respectively. Working length was estimated and then confirmed with radiographs. Coronal flaring was done with G.G burs (Mani, Japan) and remaining canal was prepared with step back technique on all teeth. During canal preparation, canals were treated with respective irrigation material of that group. After preparation, canals were subsequently dried with paper points and left empty. The pulp chamber was then closed with sterile cotton and cavit (Provis, Favodent, Germany). All the cases were performed and assessed by a single operator. Second appointment was scheduled after 72 hrs. Patients were then asked about their pain and any emergency treatment if needed. Each patient was then asked to mark on the Visual Analogue scale according to the severity of pain (0= No pain, 1-3= mild, 4-6= moderate, 7-10= severe) on the proforma provided. The treatment of each patient was then completed accordingly. Data Analysis Procedure The statistical package for social science (version 13.0, SPSS Inc., Chicago, IL, USA) was used to analyze data. Evaluation of the frequency of interappointment pain was determined by Visual Analogue Scale as: yes (VAS ranging from 1 to 10) and no (VAS = 0), and the
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RESULTS
Frequency of interappointment pain was observed in 53.3% (32/60) patients. Interappointment pain was significantly higher in group B compared with group A (70% vs. 36.7%; p=0.01). Comparison of interappointment pain between groups is presented in table 2.
INTERAPPOINTME NT PAIN NO PAIN GROUP-A N=30 19(63.3%) GROUP-B N=30 09(30%) TOTAL N=60 28(46.7%)

YES

11(36.7%)

21(70%)

32(53.3%)

Table 2: Comparison of Interappointment Pain Between Groups.

Chi-square test =6.69 DF=1 P-value=0.01.

Comparison of severity of interappointment pain in multi-visit root canal treatment, mild pain was observed in 3(5%) patients, moderate pain was in 21(35%) and severe pain was observed in 8(13.3%) patients. Severity of pain was significantly higher in group B than group A (chisquare = 10.93, DF=1; p<0.012). Patients distribution according to age groups and gender is shown in table 1.
AGE GROUPS GROUP A(n=30) MALE (n=16) < 20 YEARS OLD 01 GROUP B(n=30) FEMALE (n=14) 05 04 02 03 16 16 18 10 TOTAL (n=60) FEMALE MALE (n=14) 05 04 03 02 (n=16) 05 03 05 03

21-30 YEARS OLD 05 31-40 YEARS OLD 08 > 40 YEARS OLD 02

Table1: Distribution between groups according to age group and gender.

Group A: Sodium Hypochlorite, Group B: Hydrogen Peroxide.

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Minimum age of the patients was 14 years and maximum age was 55 years. The average age of the patients was 29.15 10.33 years (95%CI: 26.48 to 31.82). The average interappointment pain score was 2.87 2.91 (95%CI: 2.12 to 3.62). Proportion of gender was similar in both groups. Similarly mean age was also not significant between the groups (p=0.87).

Naenni et al. also concluded in his study that NaOCl showed effective necrotic tissue dissolution among 10 % chlorhexidene, 3 % H2O2, 10 % peracetic acid, 5 % dichloroisocyanurate (NaDCC), and 10 % citric acid.18 So effectiveness of NaOCl is dependent on its ability to 25 dissolute organic matter within pulp cavity. Moreover, its strong antibacterial effect exerted by formation of 25 hypochlorous acid, responsible for inactivating Comparison of interappointment pain between important metabolic enzymes thus killing bacterial cells.25 groups with respect to gender and age group is presented Sensitivity of DNA synthesis to hypochlorous acid 26 in table 3. (HOCl) has also been reported. Finally, it acts as a 27 SUBJECTS GROUP A (n=30) GROUP B (n=30) TOTAL (n=60) lubricant, thus flushing loose debris out of root canal. On contrary, few clinical studies have evidenced the use of INTERAPPOINTME INTERAPPOINTMENT 17 NT PAIN PAIN NaOCl to be less effective.
YES GENDER MALE FEMALE AGE GROUPS < 20 YEARS OLD 21-30 YEARS OLD 31-40 YEARS OLD > 40 YEARS OLD 02 04 07 03 16 10 05 06 09 06 11 10 03 32 28 NO YES NO

02

07

05

02

16

06

05

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03

18

Clinically H2O2 exhibited less interappointment pain when compared with NaOCl as an irrigation material. In vitro study by Vijaykumar et al. demonstrated 60% negative culture with 3% NaOCl, 33.3% with H2O2 and 70% when combination of H2O2 + NaOCl is used as an 28 irrigation material. Similarly Ercan et al. concluded limited success of 3% H2O2 in eliminating bacteria from 29 root canal in a vivo study, which is in agreement with the findings of Patterson C.J.W et al.30 Other investigators, shared low effectiveness of H2O2, but when used with Clorhexidene their efficiency increased. But they added 31-32 that the efficiency of combination decreases with time. Besides the choice of irrigation material used, age and gender can have significant influence over development of interappointment pain. Interappointment pain is significantly high between groups in female while significant difference was not observed in male. Severe and moderate pain was noticed high in females. Similar results can be seen in several other studies in which large numbers of patients were evaluated and investigators have 33 found more flare-ups in females. But when considering the overall incidence of comparatively high frequency of pain in females, it is uncertain whether the differences are statistically significant and a meta-analysis from these 34 studies has not yet been performed. It is reasonable that females would be more likely to seek treatment when 34 experiencing significant symptoms. This has been consistently demonstrated in investigations that compare 28,35 male and female behavior when pain is a factor. Age is not observed to be a significant factor (p>0.05) in current study. Similarly some other investigations have also failed 33 to find any evidence .

01

03

05

01

10

Table 3: Comparison of Interappointment Pain Between Groups with Respected To Gender And Age Group.

Pain was significantly high between group in female while significant difference was not observed in male. Severe and moderate pain was high in female. Pain was not significant between groups in all ages (p>0.05).

DISCUSSION
Antimicrobial irrigation supplementing the preparation of root canal has always been a subject of interest when success of endodontic treatment is questioned. NaOCl has already found a good place among 12, 16-18 different irrigation materials.

In current study, a well-known irrigation material namely NaOCl was compared with H2O2. Standard concentration established by some previous studies that is It was also observed that the overall incidence of pain 3% for H2O2,19 and 2.5% for NaOCl,20-21 were used . is 32/60 which is higher than expected from literature The cleaning of root canals were evaluated clinically review of different researchers. One possible explanation by checking interappointment pain through Visual could be that the canals were left empty (without intra22 canal medicaments) between the visits in both groups. So, Analogue Scale (VAS) as proposed by Seymour et al. the high incidence of pain noticed in the study can be Current study confirmed that NaOCl performed justified by saying that there may be some residual significantly better than H2O2 in terms of interappointment bacteria in the canal which can re-multiply between pain. Ringel et al compared 2.5% NaOCl with 2% appointments to nearly original level to produce pain. We chlorhexidene in an in vivo study and the authors observed will refer to the conclusion of different in vitro studies and 23 the effectiveness of NaOCl as an irrigation material. studies reporting the microbiological status of canal after
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antimicrobial irrigation who noticed the presence of bacteria at the end of appointment.36 The number of persisting bacterial cells are usually low, but these remaining bacteria can recover and rapidly increasing in number between treatment visits if no antibacterial 36 dressing is present in the root canal. So it may be possible that irrigation significantly reduces the number of bacteria but does not make canal completely free of bacteria. That can also be supported through the results of the present study in which pain was found less when NaOCl used to clean the canal as it's proved powerful antimicrobial agent as compared to H2O2. Bystrom and Sundqvist have demonstrated that chemo-mechanical preparation combined with a non-antiseptic irrigating solution was capable of reducing approximately 50% of bacteria in root canals, while NaOCl material eliminated 37 approximately 80% of bacteria. A limitation of this study was lack of microbial culture to support the clinical outcome. The combined strategy should be designed to correlate the clinical outcome of canal irrigants with support of microbiological study. Clinical symptoms should be compared with the bacteriologic status of canals for further confirmation of results.

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CONCLUSION
Within the limitations of the current study, it appears that NaOCl may perform better than H2O2 in terms of interappointment pain.

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REFERENCES
1. 2. Iqueira JF, Barnett F. Interappointment pain: mechanisms, diagnosis, and treatment. Endod T 2004; 7: 931-939. Siqueira JF Jr. Endodontic infections: concepts, paradigms and perspectives. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94: 281293. Siqueira JF Jr, Rocas IN, SoutoR, UzedaM, ColomboAP. Microbiological evaluation of acute p eri r adi cul ar ab scess es by D N A DN A hybridization. Oral Surg Oral Med Oral Pathol. Oral Radiol Endod 2001; 92: 451-457. Siqueira JF Jr, Rocas IN. Bacteroides forsythus in primary endodontic infections as detected by nested PCR. J Endod 2003; 29: 390-393. Rocas IN, Siqueira JF Jr,AndradeAFB, Uzeda M. Identification of selected putative oral pathogens in primary root canal infections associated with symptoms.Anaerobe 2002; 8: 200-208. Gomes BPFA, Lilley JD, Drucker DB. Associations of endodontic symptoms and signs with particular combinations of specific bacteria. 15.

16.

3.

17. 18.

4. 5.

19. 20. 21.

6.

Int Endod J 1996; 29: 69-75. Jacinto RC, Gomes BPFA, Ferraz CCR, Zaia AA, Souza Filho FJ. Microbiological analysis of infected root canals from symptomatic and asymptomatic teeth with periapical periodontitis and the antimicrobial susceptibility of some isolated anaerobic bacteria. Oral Microbiol Immunol 2003; 18: 285-292. Zmeric NO, Preus HR, Olsen I. Genetic diversity of Porphyromonas gingivalis and its possible importance to pathogenicity. Acta Odontol Scand 2000; 58: 183-187. Baker PJ, Dixon M, Evans RT, Roopenian DC. Heterogeneity of Porphyromonas gingivalis strains in the induction of alveolar bone loss in mice. Oral Microbiol Immunol 2000; 15: 27-32. Kjelleberg S, Molin S. Is there a role for quorum sensing signals in bacterial biofilms? Curr Opin Microbiol 2002; 5: 254-258. Kievit TR, Iglewski BH. Bacterial quorum sensing in pathogenic relationships. Infect Immun 2000; 68: 4839-4849. Haapasalo M, Endal U, Zandi H, Coil JM. Eradication of endodontic infection by instrumentation and irrigation solutions. Endod T 2005; 10: 77-102. Gulabivala K, Patel B, Evans G, Yuan-ling NG. Effects of mechanical and chemical procedures on root canal surfaces. Endod T 2005; 10: 103-122. Leonardo MR, Filho MT, Silva LAB, Filho PN, Bonifacio KC.In vivo antibacterial activity of 2% Chlorhexidine used as root canal irrigating solution. J Endod 1999; 25: 167-171. Spngberg LSW, Haapasal M. Rationale and efficacy of root canal medicaments and root filling materials with emphasis on treatment outcome. Endod T 2002; 2: 35-58. Karim I El, Kennedy J, Hussey D. The antimicrobial effects of root canal irrigation and medication. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103: 560-569. Bergenholtz G, Spngberg L. Controversies in endodontics. Crit Rev Oral Biol Med 2004; 15: 99-114. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod 2004; 30: 785-787. Hlsmann M, Hahn W. Complications during root canal irrigation literature review and case reports. Int Endod J 2000; 33: 186-193. Kudiyirickal MG, Ivanakov R. Antimicrobial agents used in endodontic treatment. Acta Medica (Hradec Kralove) 2008; 51: 312. Oncag O, Hosgar M, Hilmioglu S, Zekioglu O,

JPDA Vol. 20 No. 04 Oct-Dec 2011

214

Sangi. L / F. A Kalhoro / N. Kumar Shaikh. M. A

Frequency of interappointment pain observed with sodium hypochlorite and hydrogen peroxide. based root canal irrigants.

22.

23.

24.

25.

26. 27.

28.

29.

Eronat C, Burhanoglu D. Comparison of antibacterial and toxic effects of various root canal irrigants. Int Endod J 2003; 36: 423-432. Seymour A, Simpson J, Charlton J, Phillip M. An evaluation of length and end-point of visual analogue sales in dental pain. Pain 1985; 21: 177-185. Ringel AM, Patterson SS, Newton CW et al. In vivo evaluation of chlorhexidine gluconate and sodium hypochlorite solutions as root canal irrigants. J Endod 1982; 8: 2004. 200-204 Clarkson RM, Moule AJ, Podlich H, et al. Dissolution of porcine incisor pulps in sodium hypochlorite solutions of varying compositions and concentrations.Aust Dent J 2006; 5: 245-251. Dychdala GR. Chlorine and chlorine compounds. In: Block SS, ed. Disinfection, sterilization, and preservation. 4th ed. Philadelphia; Lippincott, Williams, 1991. p. 133-135. McKenna SM, Davies KJA. The inhibition of bacterial growth by hypochlorous acid. Biochem J 1988; 254: 685-692. Oliveira DP, Barbizam JVB, Trope M, Teixeira FB, Hill C. In vitro antibacterial efficacy of endodontic irrigants against Enterococcus faecalis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103: 702-706. Vijaykumar S, GunaShekhar M, Himagiri S. In vitro effectiveness of different endodontic irrigants on the reduction of Enterococcus faecalis in root canals. J Clin Exp Dent. 2010; 2: 169-172. Ercan E, Dulgergil T,Yavuz I. The effects of

30. 31.

32.

33. 34. 35. 36. 37.

Antibacterial solutions on Microorganisms isolated from infected Root canals in vivo. Biotechnol. & Biotechnol. Eq. 2006; 20: 149156. Patterson CJW, McLundie AC. Apical penetration by a root canal irrigant: a case report. Int Endod J 1989; 22: 197-199. Shahriari S, Mohammadi Z, Mokhtari MM, Yousefi R. Effect of Hydrogen Peroxide on the Antibacterial Substantivity of Chlorhexidine. Int J Dent 2010; 1-4. Steinberg D, Heling I, Daniel I, Ginsburg I. Antibacterial synergistic effect of chlorhexidine and hydrogen peroxide against Streptococcus s o b r i n u s, S t r ep t o co c cu s f ae cal i s a n d Staphylococcus aureus. J Oral Rehab 1999; 26: 151-156. Walton R, Fouad A. Endodontic interappointment flareups. a prospective study of incidence and related factors. J Endod 1992; 18: 172-177. Richard E, Walton. Interappointment flare-ups: incidence, related factors, prevention, and management. Endod T 2002; 3: 67-76. Dao T, LeResche L. Gender differences in pain. J Orofac Pain 2000; 14: 169-84. Figdor D, Sundqvist G. A big role for the very small understanding the endodontic microbial flora.Aust Dent J 2007; 52: 38-51. Bystrom A, Sundqvist G. Bacteriologic evaluation of the effect of 0.5 percent sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol 1983; 55: 307-312.

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