| Abstract|| |
Aim: The aim of the present study was to compare the incidence of postoperative pain in single sitting root canal treatment after using two reciprocating and two continuous rotating file systems.
Methodology: One hundred and four permanent mandibular canine and first premolar teeth were selected for the study and were divided into two groups 1 and 2 comprising 52 teeth each. Group 1 was treated using reciprocating file systems and was subdivided into two subgroups A and B using WaveOne Gold (WOG) and Reciproc Blue (RB), respectively. Group 2 was treated using continuous rotating file systems and was divided into two subgroups A and B using One Curve (OC) and Vortex Blue (VB), respectively. Treatments were performed in a single sitting. After the visit, the patients were given a prescription for ibuprofen 400 mg to be taken every 6 h if they experience pain. Participants were asked to rate the intensity of the postoperative pain on a visual analog scale according to four classes (no pain, mild pain, moderate pain, and severe pain) after 24 h, 48 h, 72 h, and 7 days. Patients were also asked to record the number of prescribed analgesic medication tablets taken at these time points.
Results: There was a statistically significant difference (P = 0.00) among the reciprocating file systems and continuous file systems regarding the incidence of postoperative pain after 24, 48, and 72 h which signifies that pain incidence and duration is less with respect to reciprocation instrumentation as compared to continuous instrumentation.
Conclusion: The use of Reciproc instrumentation system (WOG and RB) showed significantly less intensity and duration of posttreatment pain compared to the single-file rotary system (OC and VB) in patients with symptomatic irreversible pulpitis with apical periodontitis.
Keywords: Continuous rotating file; reciprocating rotating file; single sitting root canal treatment
|How to cite this article:|
Vijayran VK, Khetarpal A, Vats A, Ahlawat M, Singhal N, Harshita. Comparison of the incidence of postoperative pain in single sitting root canal treatment after using two reciprocating systems and two continuous rotary systems: An in vivo study. J Conserv Dent 2023;26:12-9
|How to cite this URL:|
Vijayran VK, Khetarpal A, Vats A, Ahlawat M, Singhal N, Harshita. Comparison of the incidence of postoperative pain in single sitting root canal treatment after using two reciprocating systems and two continuous rotary systems: An in vivo study. J Conserv Dent [serial online] 2023 [cited 2023 Dec 8];26:12-9. Available from: https://www.jcd.org.in/text.asp?2023/26/1/12/362911
| Introduction|| |
Postendodontic pain (PEP) is described as the sensation of discomfort experienced following endodontic intervention and is reported by 25%–40% of patients, regardless of pulp and periradicular status.,, PEP is most commonly caused by an acute inflammatory response in the periradicular tissues. It usually starts within a few hours or days of the treatment. However, it is a poor predictor of long-term success and a poor sign of pathosis.
According to Pak and White's systematic study from 2011, the prevalence of discomfort in the first 24 h is 40%, dropping to 11% after 7 days. During root canal preparation, dental debris, pulp tissue, bacteria, and irrigants can be transported to the periradicular tissues, causing postoperative problems including flare-ups. As a result, while proper control of the working length (WL) can limit material extrusion via the apical foramen, it cannot totally eliminate it.
Single-visit endodontic treatment has several advantages, including a lower flare-up rate, fewer operative procedures, and no chance of inter-appointment leakage through interim restorations. It is also less time-consuming and less expensive, making it more ideal for itinerant and busy patients. However, even after successful root canal therapy, there is the possibility of postoperative discomfort.
With the introduction of the Reciproc (VDW, Munich, Germany) and WaveOne (Dentsply Tulsa Dental Specialties, Johnson City, TN) instrumentation systems, the notion of single-file canal preparation was introduced to endodontics. The reciprocating motion consists of an initial counterclockwise rotation of the instrument, during which the instrument enters and cuts the dentin, followed by an opposite clockwise spin, during which the instrument is released.
Reciproc Blue (RB) (VDW, Munich, Germany) has a lower surface microhardness and is more flexible and resistant to cyclic fatigue-related fractures.
In severe canal curvatures, the RC Blue system can prebend and work without creating a glide path. Small (#20, 0.07), primary (#25, 0.07), medium (#35, 0.06), and large (#45, 0.05) WaveOne Gold [WOG] (Dentsply Maillefer, Switzerland) G-wire technology is available in four sizes. G-wire NiTi has greater flexibility and improved cyclic fatigue resistance. The engagement zone is limited by the reverse helix, semi-active and modified guiding tip, and offset parallelogram-shaped cross section.
One Curve (OC) (Micro-Mega Company [Coltene], Besancon, France) is a single-use, heat-treated NiTi rotary file that allows shaping of the canal's whole length with a single instrument, all the way to the apex. OC's personality features are defined by C-wire as if it was its own DNA. The benefits of the C-wire heat treatment include greater blade flexibility and separation resistance. It has the correct taper and diameter for a final shape that satisfies the standards for optimal cleaning and shaping while preserving the root canal's original anatomy.,
In 2011, the Vortex Blue (VB) file system (Dentsply Tulsa Dental Specialties, Tulsa, OK, USA) was introduced. M-wire is also used to make VB files, which have a distinctive blue tint due to the titanium oxide layer. The cyclic fatigue resistance and flexibility of VB files have been observed to be enhanced. During rotation, the VB instrument has a triangular cross section and demonstrates uniform contact while having three points of contact with the canal wall. At the apical level, VB has a distinct inward transportation propensity (at 1 and 3 mm levels from the apex).
The purpose of this experimental study was to clinically compare the incidence of postoperative pain after single sitting root canal treatment (RCT) using two reciprocating and two continuous rotating file systems and to assess the role of analgesic medication in postoperative pain in single visit RCT.
| Materials and Methods|| |
This in vivo study included 104 permanent teeth in patients ≥18 years of age reporting to the department of conservative dentistry and endodontics. They were divided into two groups 1 and 2 comprising 52 teeth each. Group 1 was treated using reciprocating file systems and was subdivided into two subgroups A and B using WOG and RB, respectively. Group 2 was treated using continuous rotating file systems and was divided into two subgroups A and B using OC and VB, respectively [Figure 1]. The patients were selected after complete clinical and radiographic examination and after evaluating the presence of inclusion criteria. Patients above 18 years, requiring endodontic treatment, teeth indicated for single sitting RCT, teeth with accidental/mechanical pulp exposure and vital pulp exposure due to caries or trauma were the inclusion criteria. Exclusion criteria included teeth with mature roots, showing root resorption, limited access, with calcified canals and weeping canals. Furthermore, patients with uncontrolled systemic disease, using any medication preoperatively such as steroids, analgesics or NSAIDS, presence of swelling, furcal pathosis were not included.
All the patients were informed for the possible complications, and informed consent was obtained from all participants.
An EPT (Coxo, Foshan, Guangdong, China) and Endo-Frost (Coltene/Whaledent, Langenau, Germany) were used to perform a baseline pulp vitality test before providing nerve block injection to permanent teeth that met the inclusion criteria. The function and validity of the pulp tester were first tested using an unanesthetized control tooth on the other side of the jaw.
The tooth was anesthetized with 2% lidocaine with 1:80,000 epinephrine (Xicaine, ICPA Health Products Ltd., India) and then isolated with a rubber dam (Hygienic, Coltene/Whaledent, Langenau, Germany) after clinical and radiographic assessment. After gaining access, the canals were examined with #06, #08, #10, and #15 K-type hand files (Dentsply Maillefer, Ballaigues, Switzerland) in a watch-winding motion, based on the foramen's initial diameter, degree of flattening, and canal curvature. The WL was estimated by inserting a #10 K-file up to the apical foramen, as determined by an apex finder (E-PEX Pro, Changzhou Sifary Medical Technology Co. Ltd., China), then removing the file, and deducting 0.5 mm from the length, which was measured using an endodontic ruler.
The WL was radiographically confirmed. All of the instruments were powered by a low-torque electric micromotor (ORIKAM, E-Connect Pro, Changzhou Sifary Medical Technology Co. Ltd., China). Each file system's torque limitations and rotation speed were established separately. In reciprocating motion, WOG and RB instruments were employed. According to the manufacturer's recommendations, debris was cleaned from the instrument with alcohol-soaked gauze either immediately after each instrument change (OC and VB systems) or after three in-and-out (pecking) motions (WOG and RB systems).
Throughout all of the procedures, the apical foramen was kept open by inserting a #10 or #15 K-type file (Dentsply) to a point 1 mm beyond the WL at each instrument change. The coronal chamber was flushed with 1 mL 2.5% NaOCl once the instrumentation was completed, followed by irrigation with 5 mL 17% ethylenediaminetetraacetic acid solution. Irrigation with 5 mL 2.5% NaOCl was then repeated, followed by irrigation with 5 mL 0.9% physiological saline solution to complete the process. During preparation, a total of 40 mL of irrigant was used on all of the teeth. The teeth were then dried using Meta Biomed paper points for the VB group, WOG absorbent paper points for the WOG group, RB paper points (VDW, Munich, Germany) for the RB group, and OC paper points for the OC group. Using the continuous wave of condensation approach, the canals were then filled with gutta-percha cones from the respective systems and Sealapex sealer (SybronEndo, India). The coronal access cavity was sealed with a dentinal adhesive and composite resin Tetric N-Ceram at the end of the treatment phase. After the endodontic treatment, all patients were given postoperative instructions to take analgesics (400 mg ibuprofen) at a dose of 1 tablet every 6 h if they experienced pain.
All participants were given a questionnaire based on a visual analog scale (VAS) following treatment to record their pain rating and analgesic intake (frequency and quantity) after 24 h, 48 h, 72 h, and 7 days. Patients were asked to rate their pain on a VAS after 24 h, 48 h, 72 h, and 7 days, as well as provide the following information: their perceived pain rating, whether they had taken the analgesic medication prescribed, and, if so, the number of tablets and days required to control the pain.
| Results|| |
In the present study, the mean pain postoperative after 24 h in subgroups 1A (WOG), 1B (RB), 2A (OC), and 2B (VB) was 36.77, 37.35, 53.31, and 54.58, respectively, whereas the mean pain after 48 postoperatively was 9.77, 11.08, 20.54, and 19.92, respectively, on VAS scoring. The mean pain score after 72 h of endodontic treatment was 0.00, 0.00, 0.77, and 1.35, respectively, in all the groups. There was a statistically significant difference (P = 0.00) among the reciprocating file systems and continuous file systems in regard to the incidence of postoperative pain after 24, 48, and 72 h, which signifies that pain incidence and duration is less with respect to reciprocation instrumentation as compared to continuous instrumentation. In the present study, 24 h postoperatively, 11 (42.3%) subjects in group 1A, 12 (48.0%) in group 1B, 15 (57.7%) in group 2A, and 18 (69.2) in group 2B took one analgesic tablet, whereas 5 (19.2%) subjects in group 2A and 3 (11.3%) in group 2B took two analgesic tablets for pain control. Moreover, after 48 h of endodontic treatment, 2 (7.7%) subjects in group 1A and 3 (11.3%) in group 1B took analgesic tablets, whereas in groups 2A and 2B, 10 (38.5%) and 7 (26.9%) subjects took an analgesic tablet for pain control. Therefore, the greatest mean pain in all groups in this study occurred in the first 24 h, with a significant reduction in pain ratings at the subsequent observation time points of 48 h, 72 h, and 7 days.
[Table 1] and [Graph 1] and [Graph 2] show the baseline demographic and clinical features of patients in the study groups. Fifty percent study comprised males and 50% comprised female population. Among the teeth involved for endodontic treatment, 35% were mandibular permanent canine and 65% were mandibular first premolar. The mean age of the 104 patients enrolled in the study was 41.50 (standard deviation ± 8.99) years.
|Table 1: Baseline demographic and clinical features of patients in the study groups|
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[Table 2] and [Graph 3] show descriptive statistics and Kruskal–Wallis test applied to the postoperative pain results for different file systems used. All the patients who underwent endodontic treatment answered the questionnaire satisfactorily at all the time points assessed (24 h, 48 h, 72 h, and 7 days). The mean pain postoperative after 24 h in subgroups 1A (WOG), 1B (RB), 2A (OC), and 2B (VB) was 36.77, 37.35, 53.31, and 54.58, respectively, on VAS scoring, whereas the mean pain after 48 postoperatively was 9.77, 11.08, 20.54, and 19.92, respectively, on VAS scoring. The mean pain score after 72 h of endodontic treatment was 0.00, 0.00, 0.77, and 1.35, respectively, in all the groups. There was a statistically significant difference (P = 0.00) among the reciprocating file systems and continuous file systems in regard to the incidence of postoperative pain after 24 h [Table 1]. Similarly, a significant difference between both the groups was noticed in regard to incidence of pain after 48 h and 72 h with P = 0.00 and P = 0.13, respectively, as depicted in [Table 1]. However, there was no statistically significant difference (P >.05) among the ProTaper Next, WaveOne, and Reciproc systems in regard to the incidence of postoperative pain after 7 days postoperatively with respect to all file systems. The highest mean postoperative pain scores were observed 24 h after treatment in all the instrumentation groups with a significant decline thereafter as shown in [Graph 4].
|Table 2: Descriptive statistics and Kruskal–Wallis test applied to the postoperative pain results for different file systems used|
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[Table 3], [Table 4] and [Graph 5], [Graph 6] show the quantity of analgesic tablets taken and the number of days required to control postoperative pain after endodontic instrumentation using different file systems. 24 h postoperatively, 11 (42.3%) subjects in group 1A, 12 (48.0%) in group 1B, 15 (57.7%) in group 2A, and 18 (69.2%) in group 2B took one analgesic tablet, whereas 5 (19.2%) subjects in group 2A and 3 (11.3%) in group 2B took two analgesic tablets for pain control. Moreover, after 48 h of endodontic treatment, 2 (7.7%) subjects in group 1A and 3 (11.3%) in group 1B took analgesic tablets, whereas in groups 2A and 2B, 10 (38.5%) and 7 (26.9%) subjects took an analgesic tablet for pain control. Thereafter, no analgesic was taken by any subject in each group. A statistically significant difference was found among the four groups assessed in the study in terms of frequency and quantity of analgesic medication intake after 24 h and 48 h postoperatively (P = 0.00 and P = 0.02, respectively). In general, analgesic intake was confined to the first 48 h after treatment in all the groups assessed. None of the participants reported severe pain or flare-ups during the period of the study.
|Table 3: Quantity of analgesic tablets and number of days required to control postoperative pain after instrumentation using different file systems|
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|Table 4: Number of analgesics taken to control postoperative pain after different instrumentation used|
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| Discussion|| |
While effective management of postendodontic pain is a major issue for both patients and doctors, the exact reasons of pain after RCT have yet to be thoroughly reported. In most of the cases, root canal therapy reduces the frequency and severity of pain, but only a few patients experience acute posttreatment discomfort that subsides within the first 2 days. Postendodontic pain is certainly complex, with the instrumentation process being one of the most common causes. If there is preexisting peri-radicular inflammation, this could be the result of debris and bacterial extrusion during chemomechanical preparation, which enhances the inflammatory response.,,, The subjective nature of this evaluation and the inherent difficulty in measuring pain are two of the key hurdles to assessing postoperative pain found in clinical trials undertaken for this purpose. As a result, one of the most important steps in this research is to construct the most appropriate questionnaire to use. Patients must be able to fully comprehend the questions, and they must be easy to interpret. The pain scales used in this research were adapted from prior studies and modified. Patients find it easier to score numbers rather than a broad category such as light, moderate, or severe, which can be confusing for patients to evaluate pain. As a result, number-based VAS was used in the current investigation based on its verified reliability for pain assessment, and the operators used the range of values to categorize the pain intensity ratings.,,,
The sensation of postoperative pain is influenced by a number of factors. This makes clinical investigations that link pain occurrence to potential causes even more difficult. Although minor discomfort is to be expected after endodontic treatment, the incidence of postoperative pain and flare-up has been documented to range from 3% to 58% in the literature.,,,
Acute periapical inflammation is caused by mechanical, chemical, or microbiological injuries to the periapical tissues. One of the most powerful predictors of postoperative pain is preoperative discomfort. As a result, only teeth with important pulp that needed endodontic treatment for prosthodontic reasons were chosen for this investigation. In order to separate potential postoperative pain variables from those solely linked to the instrumentation approach, teeth having a nonvital pulp response, symptomatic/asymptomatic apical periodontitis, endodontic retreatment, or symptomatic/asymptomatic irreversible pulpitis were all excluded. Furthermore, all of the teeth were treated in one session to rule out the possibility of intracanal medication or other pain-causing factors.,,,
One of the goals of providing RCT in an ideal clinical situation is to reduce discomfort. As a result, only individuals with a severe pain score were included in this study. Patients were encouraged to take analgesics only if they were in significant pain, as the goal was to assess postoperative pain following root canal instrumentation. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been recommended as the first-line treatment for postendodontic treatment pain, and ibuprofen has been used in numerous studies examining the effects of various procedures and medications on pain reduction following RCT. As a result, ibuprofen was chosen as the nonsteroidal anti-inflammatory medicine of choice for managing postoperative pain in our study.,,,
On VAS scoring, the mean postoperative pain after 24 h in subgroups 1A (WOG), 1B (RB), 2A (OC), and 2B (VB) was 36.77, 37.35, 53.31, and 54.58, respectively, while the mean pain after 48 h was 9.77, 11.08, 20.54, and 19.92. In all four groups, the mean pain score after 72 h of endodontic therapy was 0.00, 0.00, 0.77, and 1.35, respectively. In terms of the incidence of postoperative pain after 24, 48, and 72 h, there was a statistically significant difference (P = 0.00) between reciprocating file systems and continuous file systems, indicating that pain incidence and duration are lower with reciprocating instrumentation than with continuous instrumentation. Our findings are consistent with those of prospective randomized multicenter clinical research conducted by Neelakantan and Sharma, who found that reciprocation movement provides a more predictable and safer approach to root canal preparation, as well as less postoperative pain. Patients' demand for analgesics may be reduced as a result of this strategy. The explanation for this could be that reciprocating motion has been shown to result in less bacterial extrusion than multifile rotational systems. Clin Oral Invest had a better reduction of the neurotransmitter substance P and calcitonin gene-related peptide. Although the efficacy of single-file rotary instruments is unknown, Reciproc has been documented.,
On the other hand, Kherlakian et al. in their prospective randomized clinical trial found that reciprocating systems and the continuous rotary system were found to be equivalent in regard to the incidence of postoperative pain and intake of analgesic medication at the time points assessed. Even our finding contrasts with the results from a randomized clinical trial conducted by Nekoofar et al., who found postoperative pain to be significantly lower in patients treated with the ProTaper Universal rotary system than in those treated with the WaveOne reciprocating system. This disparity between the studies may be explained by the differences in the inclusion criteria (diagnosis of irreversible pulpitis versus vital teeth), irrigating solution (chlorhexidine vs. NaOCl), and the kinematics adopted during reciprocating instrumentation.
In the present study, 24 h postoperatively, 11 (42.3%) subjects in group 1A, 12 (48.0%) in group 1B, 15 (57.7%) in group 2A, and 18 (69.2) in group 2B took one analgesic tablet, whereas 5 (19.2%) subjects in group 2A and 3 (11.3%) in group 2B took two analgesic tablets for pain control. Moreover, after 48 h of endodontic treatment, two (7.7%) subjects in group 1A and 3 (11.3%) in group 1B took analgesic tablets, whereas in groups 2A and 2B, 10 (38.5%) and 7 (26.9%) subjects took an analgesic tablet for pain control. Therefore, the mean pain in all groups in this study occurred in the first 24 h, with a significant reduction in pain ratings at the subsequent observation time points of 48 h, 72 h, and 7 days. Similar findings were found in a systematic review research conducted by Pak and White in 2011, in which pain incidence was 40% in the first 24 h, dropping dramatically subsequently, notably over the first 2 days, and peaking at 11% at 7 days. Ng et al. employed a VAS in their 2004 study and reported that 40.2% of patients had pain 48 h after obturation, but only about 12% had severe discomfort. Preparation procedures are more frequently associated with postoperative discomfort and edema, which might result from an immunological response to the irrigant, bacteria in extruded debris, overinstrumentation, or foreign body reactions to filling materials.
All instrumentation techniques result in some debris extrusion; however, the amount of material extruded varies depending on the system's preparation process and instrument design. In the literature, there has been a lot of variation in debris extrusion between different mechanical systems. Burklein and Schafer investigated trash extrusion in vitro produced by two rotating systems (Mtwo [VDW, Munich, Germany] and ProTaper Universal) and two reciprocating systems (Mtwo [VDW, Munich, Germany] and ProTaper Universal). Full-sequence rotational instrumentation was linked to less extruded debris, according to the scientists. Conversely, in an ex vivo assessment of the apical extrusion of bacteria produced using reciprocating files of the Reciproc and WaveOne systems and rotary files of the BioRace system (BioRace, FKG Dentaire, La Chaux-de-Fonds, Switzerland), Tinoco et al. observed less extrusion of bacteria when single-file systems were used. According to the same authors, differences in the cross section, cutting-edge design, taper, tip type, configuration, use concept, flexibility, alloy type, number of files utilized, kinematics, or cutting efficacy could explain the observed variation.
The uniform and regulated kinematics utilized in this investigation may have also contributed to decreasing debris remains or extrusion, potentially reducing the occurrence of postoperative pain. In conclusion, when comparing reciprocating instrumentation systems to continuous instrumentation systems, the incidence of postoperative pain and the intake (frequency and quantity) of analgesic medication prescribed for all postoperative time points were significantly lower in reciprocating instrumentation systems. Although the exact cause of this was not investigated in this work, it could be linked to the kinematics of the instruments. Further research is needed to determine the exact reasons for this.
| Conclusion|| |
The use of Reciproc instrumentation system (WaveOne Gold and RB) showed significantly less intensity and duration of posttreatment pain compared to the single-file rotary system (OC and VB) in patients with symptomatic irreversible pulpitis with apical periodontitis. Although the exact reason for this was not assessed in this study, it may be attributed to the instrumentation kinematics. Thus, reciprocation movement offers a more predictable and safer approach of root canal preparation, in addition to producing less postoperative pain. The need for patients to take analgesics may reduce following this approach. Further research is warranted on elucidating the exact reasons for the same.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Ambica Khetarpal
Department of Conservative Dentistry and Endodontics, PDM University, Bahadurgarh, Haryana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]