Contemporary Clinical Dentistry
   
  Home | About us | Editorial board | Search
Ahead of print | Current Issue | Archives | Advertise
Instructions | Online submission| Contact us | Subscribe |

 

Login  | Users Online: 752  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size 



 
 Table of Contents  
SYSTEMATIC REVIEW
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 3-8  

Evaluation of postoperative pain after pulpectomy using different file systems in primary teeth: A systematic review


Department of Pediatric and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Science, Chennai, Tamil Nadu, India

Date of Submission23-Jun-2020
Date of Decision22-Jul-2020
Date of Acceptance24-Aug-2020
Date of Web Publication20-Mar-2021

Correspondence Address:
Dr. Lakshimi Lakshmanan
Department of Pediatric and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Science, 162, Poonamallee High Road, Chennai - 600 077, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccd.ccd_561_20

Rights and Permissions
   Abstract 


Objective: The purpose of this systematic review was to compare the incidence and intensity of postoperative pain after pulpectomy using different instrumentations in primary teeth. Materials and Methods: An extensive literature search in PubMed, Cochrane Library, Science Direct, LILAC, SIGLE, and Google Scholar was performed to identify English language articles with human subjects that evaluated the effects of different instruments on postoperative pain after pulpectomy. Results: The search retrieved 187 references. After screening of the abstracts and articles, based on the inclusion and exclusion criteria, a total of three articles were included in the systematic review. Of the three included studies, two of them had a moderate risk of bias and one showed a high risk of bias. Conclusion: The use of rotary instruments contributed to a lower incidence and intensity of postoperative pain than did the hand instruments in all the three studies. More high-quality randomized clinical trials are needed in this field in future studies to support the evidence.

Keywords: Instrumentation, postoperative pain, pulpectomy, randomized clinical trials, systematic review


How to cite this article:
Lakshmanan L, Somasundaram S, Jeevanandan G, Subramanian E M. Evaluation of postoperative pain after pulpectomy using different file systems in primary teeth: A systematic review. Contemp Clin Dent 2021;12:3-8

How to cite this URL:
Lakshmanan L, Somasundaram S, Jeevanandan G, Subramanian E M. Evaluation of postoperative pain after pulpectomy using different file systems in primary teeth: A systematic review. Contemp Clin Dent [serial online] 2021 [cited 2021 Jun 18];12:3-8. Available from: https://www.contempclindent.org/text.asp?2021/12/1/3/311576




   Introduction Top


Pulpectomy is the treatment of choice for the primary tooth where there is evidence of chronic inflammation involving radicular pulp or pulp necrosis with or without periapical involvement.[1] Endodontic treatment in the primary teeth is more challenging due to the complex anatomy and tortuous course of root canals.[2] The success of pulpectomy is determined by the aseptic root canal preparation and hermetic seal of the root canals.[3] The biomechanical preparation (BMP) is the paramount step that determines the success of the pulpectomy.[4]

In the field of pediatric endodontics, there has been improvement not only with the materials used but also with the techniques used for instrumentation. Hand files were used for canal preparation of the primary teeth traditionally but have also been reported to be more time-consuming and resulted in iatrogenic errors. The BMP in the primary teeth using nickel-titanium rotary files reduced the instrumentation time and resulted in more conical-shaped canals by considerable dentin removal ensuring adequate root canal cleaning and shaping.[4],[5]

The reciprocating files work in a reverse “balanced force” cutting motion instead of a rotary motion and are driven by a preprogrammed motor that directs the files in a back and forth “reciprocating motion.” The reciprocating motion improved the flexibility of files that adapts better to the tortuous root canals, thereby providing better cleaning efficacy and improved safety of the shaping procedure.[6],[7]

A brief complication is the postoperative pain that embarks within few hours or days after endodontic therapy. Several factors have been associated with the incidence of postendodontic pain including age, sex, pulpal and periradicular status, type of tooth, sinus tract, preoperative pain, and technical factors. The significant factor is the instrumentation procedure that can provoke an acute periapical inflammatory response, secondary to chemical, mechanical, and/or microbial damage to the periradicular tissues.[8],[9] During chemomechanical preparation, the extrusion of dentinal debris, microorganisms, pulp tissue, and irrigants into the periapical tissues results in inflammation.[8] Postendodontic pain is considered as a poor indicator in terms of success of a case.[10],[11]

Investigators have evaluated various root canal systems and compared the postoperative pain in the primary teeth following manual, rotary, or reciprocating instrumentation. Each study has used different methods for evaluating the effectiveness of the root canal system, thus giving a literature of various methods available. The aim of this study is to systematically and qualitatively review the existing literature, which evaluates the postoperative pain after pulpectomy using different instrumentation systems in primary teeth, and to find out the instrumentation system that can result in lower incidence and intensity of pain following pulpectomy in the primary teeth.


   Materials and Methods Top


This systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.[12] The scientific approval for the study was obtained from the institutional scientific review board (SDC/Pedo-1803/19/040).

Focused Participants, Interventions, Control, and Outcomes question

The research question formulated was based on the Participants, Interventions, Control, and Outcomes (PICO) principle: “Which file system result in lower incidence and intensity of postoperative pain following pulpectomy in the primary teeth?” [Table 1].
Table 1: Research question in Participants, Interventions, Control, and Outcome format

Click here to view


Eligibility criteria

Studies were considered eligible if they met the following criteria:

  • Studies published in English language
  • Studies reporting the incidence of pain after pulpectomy in primary teeth using hand, rotary, or reciprocating instrumentation
  • Studies reporting the intensity of postoperative pain after pulpectomy in the primary teeth using hand, rotary, or reciprocating instrumentation
  • Randomized clinical trials (RCTs) comparing two or more root canal instruments.


Studies such as in vitro studies, animal studies, case reports, non-RCTs, or RCTs focusing on permanent teeth and those lacking any of the “PICO” components were excluded.

Search strategy

A comprehensive literature search with “English” language restriction was conducted to identify the available literature up to October 2019 using MEDLINE/PubMed, the Cochrane library (CENTRAL), Science Direct, LILAC, SIGLE, and Google Scholar database. In addition, the reference list of reviews and selected studies was also hand searched to reclaim the papers that might be undetected during the database search.

The following search strategy was adapted for each database search: (Primary teeth OR deciduous tooth) AND (pulpectomy OR pulp therapy OR root canal therapy OR root canal preparation OR endodontic treatment) AND (rotary instrumentation OR reciprocating instrumentation OR manual instrumentation) AND (post-operative pain OR post-endodontic pain OR post-treatment pain).

Data collection

Two reviewers independently screened all titles and abstracts. If the abstracts did not provide adequate information to make decision, full articles were further reviewed. Any discrepancy was resolved by discussion between the reviewers. For each study, the following data were systematically reported: publication details, study design, sample size according to instrumentation technique used, methodology used for comparison, and comparative analysis.

Risk of bias within the studies

Risk of bias in the included studies was independently assessed by the two reviewers referring to the guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions.[13] The methodological quality of the included studies was assessed by evaluating the following parameters: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. The final risk of bias of each individual study was determined accordingly:

  • Low risk of bias: If all the parameters were evaluated to be of “low risk”
  • Moderate risk of bias: If one or more parameters were evaluated to be “unclear”
  • High risk of bias: If any of the parameters were evaluated as “high risk.”



   Results Top


Study selection

A total of 187 articles were retrieved from the databases during the search process. After screening titles, abstracts of six articles were assessed by two independent investigators (inter-reviewer agreement, κ = 0.91). Finally, three studies were included in the review, based on the inclusion and exclusion criteria. The study selection process is presented as a flow diagram in [Figure 1]. The excluded studies and reason for their exclusion are mentioned in [Table 2].
Figure 1: Flow diagram of study selection

Click here to view
Table 2: Studies excluded after screening and reason for exclusion

Click here to view


Study characteristics

The detailed characteristics of the included studies are listed in [Table 3]. All the three clinical trials compared the postoperative pain after pulpectomy using hand files and different systems of rotary files.[14],[15],[16] The various rotary instrumentation included are Kedo-S, Revo-S, and MTwo files. None of the studies compared the pain after preparation using reciprocating system in primary teeth.
Table 3: Characteristics of included studies

Click here to view


Risk of bias of the studies

[Figure 2] and [Figure 3] show the results of the risk of bias assessment in the included studies, which we performed according to the Cochrane Handbook for Systematic Reviews of Interventions.[13] All the three studies reported the means of randomization generation clearly, and two trials adopted suitable methods of allocation concealment. Although outcome assessments were masked in the trials, the masking of operators was not clearly indicated. Based on these criteria, two studies showed moderate risk of bias and one showed a high risk of bias.
Figure 2: Risk of bias summary: Review authors' judgments about each risk of bias item for each included study. Green, yellow, and red refer, respectively, to low risk of bias, unclear risk of bias, and high risk of bias

Click here to view
Figure 3: Risk of bias graph: Review authors' judgments about each risk of bias item presented as percentages across all included studies. Green, yellow, and red refer, respectively, to low risk of bias, unclear risk of bias, and high risk of bias

Click here to view


Synthesis of results

A meta-analysis was infeasible. The included studies were heterogeneous in terms of their methodology, and the comparisons between interventions could not be performed.


   Discussion Top


Postoperative pain is a prime criterion that determines the clinical success of endodontic therapy in both primary and permanent dentition.[17] In case of young children, postoperative pain is often escalated with increased anxiety.[18] Postendodontic pain has multifactorial etiology and depends on the association of host immunological response, infection, and physical damage.[19] During BMP, dentinal residue, pulp tissue, necrotic debris, irrigation solution, and microorganisms are incontrovertibly pushed into periapical tissues. The apical extrusion of debris could occur more readily in the primary teeth due to physiological root resorption. Purging of these rudiments into periapical tissues may cause undesired consequences, such as induction of inflammation, delay in healing, and postoperative pain.[20] A positive correlation between preoperative and postendodontic pain has been explained by the presence of pretreatment infection, leading to secondary infection during treatment.[21] The foremost goal is to render optimal treatment with merest postoperative pain by proper cleaning and shaping of the canals in such a way that all the debris and bacteria containing tissues are eliminated.

Crown-down technique and use of engine-driven instruments control the preparation in the apical third of the canal preventing apical extrusion of debris.[22] Rotary instrumentation is well known to reduce the preparation time and has also reduced postoperative pain. Increased extrusion of debris associated with hand instrumentation can be ascribed to the piston-like motion of the usage of instrument.[23] Studies have reported that the reciprocating system resulted in less apical extrusion than hand instrumentation and comparable to that of rotary instrumentation.[24],[25]

Postendodontic pain is highly subjective, and the measurement of subjective variables is a huge challenge. The intensity of pain can be measured accurately when more than one scale is used.[24] Moreover, determination of exact cause of pain may provide affirmation regarding the hypothesis.

There are various instrumentation techniques available in the literature. However, only few studies evaluated the postoperative pain after pulpectomy in the primary teeth based on instrumentation technique. The goal of this study was to systematically review the available information on postoperative pain after pulpectomy using different instrumentation techniques in primary teeth, which would help pediatric dentists to make choices based on the scientific evidence available.

The present systematic review includes three studies based on the predetermined inclusion and exclusion criteria, evaluating the incidence and intensity of postoperative pain after pulpectomy in the primary teeth using manual and rotary instrumentation. No studies have evaluated the pain intensity in the primary teeth using reciprocating file system.

According to Topçuoğlu et al.,[14] canal preparation with hand files causes more intense postoperative pain compared to Revo-S rotary system. The author also stated that the increased extrusion of debris by hand files than rotary Revo-S file as the reason associated with higher pain intensity in hand files group. Nair et al.[15] compared Kedo-S and Mtwo rotary files with manual K-files and reported less pain frequency in rotary file system without much difference between the two rotary files. This was in accordance to the study conducted by Panchal et al.,[16] who compared Kedo-S rotary file with manual H- and K-files. The highest postoperative pain scores were noted at 6–12 h interval and decreased over time in all the studies. The studies used a subjective method of evaluation of pain, which is the major limitation creating bias. In addition, the studies did not evaluate the exact cause of the postoperative pain and failed to consider preoperative pain as a variable. Among the three included studies, two showed moderate risk of bias and one showed high risk of bias.

The major limitation of this review is the small number of included studies and that the small sample size of all the included studies. More studies with high sample size and standardized operation procedures are required to evaluate the efficacy of these interventions.


   Conclusion Top


The results of the present review showed that:

  1. The use of rotary instrumentation contributed to lower incidence and intensity of postoperative pain than that of hand instrumentation
  2. There is a paucity of high-quality randomized trials assessing the effectiveness of different instrumentation for pulpectomy. A strong conclusion cannot be drawn from the available literature due to low evidence. Further studies with high-quality and standardized experimental designs are required to strengthen the evidence.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Moskovitz M, Sammara E, Holan G. Success rate of root canal treatment in primary molars. J Dent 2005;33:41-7.  Back to cited text no. 1
    
2.
Salama FS, Anderson RW, McKnight-Hanes C, Barenie JT, Myers DR. Anatomy of primary incisor and molar root canals. Pediatr Dent 1992;14:117-8.  Back to cited text no. 2
    
3.
Rodd HD. UK National Clinical Guidelines in Paediatric Dentistry. Int J Paediatr Dent 2006;Suppl 1:15-23.  Back to cited text no. 3
    
4.
Barr ES, Kleier DJ, Barr NV. Use of nickel-titanium rotary files for root canal preparation in primary teeth. Pediatr Dent 2000;22:77-8.  Back to cited text no. 4
    
5.
Musale PK, Mujawar SA. Evaluation of the efficacy of rotary vs. hand files in root canal preparation of primary teeth in vitro using CBCT. Eur Arch Paediatr Dent 2014;15:113-20.  Back to cited text no. 5
    
6.
Sotokawa T. An analysis of clinical breakage of root canal instruments. J Endod 1988;14:75-82.  Back to cited text no. 6
    
7.
Varela-Patino P, Martin Biedma B, Rodriguez N, Cantatore G, Malentaca A, Ruiz-Pinon M. Fracture rate of nickel-titanium instruments using continuous verses alternating rotation. Endo 2008;2:193-7.  Back to cited text no. 7
    
8.
Ng YL, Glennon JP, Setchell DJ, Gulabivala K. Prevalence of and factors affecting post-obturation pain in patients undergoing root canal treatment. Int Endod J 2004;37:381-91.  Back to cited text no. 8
    
9.
Sun C, Sun J, Tan M, Hu B, Gao X, Song J. Pain after root canal treatment with different instruments: A systematic review and meta-analysis. Oral Dis 2018;24:908-19.  Back to cited text no. 9
    
10.
Ali SG, Mulay S, Palekar A, Sejpal D, Joshi A, Gufran H. Prevalence of and factors affecting post-obturation pain following single visit root canal treatment in Indian population: A prospective, randomized clinical trial. Contemp Clin Dent 2012;3:459-63.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Alves Vde O. Endodontic flare-ups: A prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e68-72.  Back to cited text no. 11
    
12.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred reporting items for systematic reviews and metaanalyses: The PRISMA statement. Open Medicine 2009;3:e123.  Back to cited text no. 12
    
13.
Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Ver. 5.1.0. Oxford, UK: The Cochrane Collaboration; 2011.  Back to cited text no. 13
    
14.
Topçuoğlu G, Topçuoğlu HS, Delikan E, Aydınbelge M, Dogan S. Postoperative pain after root canal preparation with hand and rotary files in primary molar teeth. Pediatr Dent 2017;39:192-6.  Back to cited text no. 14
    
15.
Nair M, Jeevanandhan G, Vignesh R, Subramanian EM. Comparative evaluation of post-operative pain after pulpectomy with K-files, Kedo-S files and Mtwo files in deciduous molars-A randomized clinical trial. Braz Dent Sci 2018;21:411-7.  Back to cited text no. 15
    
16.
Panchal V, Jeevanandan G, Subramanian EM. Comparison of post-operative pain after root canal instrumentation with hand K-files, H-files and rotary Kedo-S files in primary teeth: A randomised clinical trial. Eur Arch Paediatr Dent 2019;20:467-72.  Back to cited text no. 16
    
17.
Genet JM, Hart AA, Wesselink PR, Thoden van Velzen SK. Preoperative and operative factors associated with pain after the first endodontic visit. Int Endod J 1987;20:53-64.  Back to cited text no. 17
    
18.
Perković I, Romić MK, Perić M, Krmek SJ. The level of anxiety and pain perception of endodontic patients. Acta Stomatol Croat 2014;48:258-67.  Back to cited text no. 18
    
19.
Shokraneh A, Ajami M, Farhadi N, Hosseini M, Rohani B. Postoperative endodontic pain of three different instrumentation techniques in asymptomatic necrotic mandibular molars with periapical lesion: A prospective, randomized, double-blind clinical trial. Clin Oral Investig 2017;21:413-8.  Back to cited text no. 19
    
20.
Topçuoğlu G, Topçuoğlu HS, Akpek F. Evaluation of apically extruded debris during root canal preparation in primary molar teeth using three different rotary systems and hand files. Int J Paediatr Dent 2016;26:357-63.  Back to cited text no. 20
    
21.
Risso PA, Cunha AJ, Araujo MC, Luiz RR. Postobturation pain and associated factors in adolescent patients undergoing one- and two-visit root canal treatment. J Dent 2008;36:928-34.  Back to cited text no. 21
    
22.
Al-Omari MA, Dummer PM. Canal blockage and debris extrusion with eight preparation techniques. J Endod 1995;21:154-8.  Back to cited text no. 22
    
23.
Madhusudhana K, Mathew VB, Reddy NM. Apical extrusion of debris and irrigants using hand and three rotary instrumentation systems - An in vitro study. Contemp Clin Dent 2010;1:234-6.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
García-Font M, Duran-Sindreu F, Calvo C, Basilio J, Abella F, Ali A, et al. Comparison of postoperative pain after root canal treatment using reciprocating instruments based on operator's experience: A prospective clinical study. J Clin Exp Dent 2017;9:e869-74.  Back to cited text no. 24
    
25.
Adıgüzel M, Yılmaz K, Tüfenkçi P. Comparison of postoperative pain intensity after using reciprocating and continuous rotary glide path systems: A randomized clinical trial. Restor Dent Endod 2019;44:e9.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed1457    
    Printed4    
    Emailed0    
    PDF Downloaded125    
    Comments [Add]    

Recommend this journal