COMPARISON OF POST PULPECTOMY PAIN USING DEXAMETHASONE INFILTRATION INJECTION VS COLD SALINE IRRIGATION POST OPERATIVELY IN PATEINTS PRESENTING WITH SYMPTOMATIC IRREVERSIBLE PULPITIS: AN RCT STUDY

ABSTRACT:

Objective: The main purpose  of this study is the comparison of  post pulpectomy pain using dexamethasone infiltration injection vs. cold saline irrigation post operatively in patients presenting with symptomatic irreversible pulpitis.

Materials and methods:  A total of 100 patients who presented to a private dental clinic in Khyber Pakhtunkhwa were placed in two separate groups, dexamethasone infiltration group and cold saline group.  The root canal treatment was performed in two sittings. The first appointment consisted of cleansing and shaping of the canals and in one group dexamethasone infiltration was done and in another group canals were irrigated with cold saline. After 48 hours patients were called and their pain was assessed through visual analogue scale (VAS)

Results: For Dexamethasone injection as infiltration, N=15 (30%) of the participants felt no post-operative pain, 17 (34%) of the participants faced Mild pain, 13 (26%) complained of moderate pain and 5 (10%) faced severe pain. Whereas, with cold saline as an irrigant, 12 (24%) out of 50 participants felt no pain, 21 (42%) had mild pain, 13(26%) had moderate pain and 4(8%) complained of severe pain (Fig2). However, no statically significant difference was found in the level of pain between the irrigants used (p=0.416).

Conclusion: It was found that there is slight difference in pain controlling effect of these two. Dexamethasone 0.2ml has better results than cold saline although cold saline also controls post-operative pain. Therefore, there use is recommended.

Key words: Cold saline, Dexamethasone, post operatively, pulpitis

INTRODUCTION:

One of the most significant parts of endodontic practice is pain control during and after root canal treatment. ⁽¹⁾ Attempts to educate patients about post-operative pain (PEP) and prescribe drugs to alleviate it can boost patient trust in their practitioners, raise patients' pain thresholds, and improve their mindset toward future dental procedures. When compared to other dental operational procedures, root canal treatment (RCT) and pulp therapy produce more acute and repeated postoperative discomfort, according to past research studies. ⁽²⁾ The root canals are cleaned from microorganisms by proper cleaning and shaping , followed by three-dimensional obturation to achieve a protective seal, hence providing a suitable atmosphere for peri-radicular healing. Despite executing root canal treatments with extreme caution, some patients have pain or flare-ups as a result of the procedure. ⁽²⁾ Microorganism remnants are the most common cause of post-endodontic discomfort. ⁽³⁾ The prevalence of post-endodontic pain (PEP) has been estimated to be between 3 - 58% ⁽⁴⁾ Many writers have proposed hypothetical theories for why edema and/or pain occur after endodontic therapy. Injuries to the peri-radicular tissue might be chemical, mechanical, or microbiological. ⁽⁵⁾

Some of the treatments explored for post-endodontic pain management include premedication with preventive analgesics and corticosteroids prior to endodontic treatment, occlusal reduction, and the provision of long-lasting anesthesia. ⁽⁶⁾ For number of years Dexamethasone has been used in endodontics. Dexamethasone inhibits the production of prostaglandins and leukotrienes, lowering polymorphonuclear leukocyte chemotaxis. It also inhibits endothelial cell synthesis of oxygen and nitric oxide free radicals. It can also reduce proinflammatory cytokines (interleukin-1, -2, -6, and -7, as well as tumor necrosis factor) that are implicated in the inflammatory and immunological responses. ⁽⁷⁾ For pain control, several treatments have been approved, including the use of dexamethasone before, during, and after an operation; this pharmaceutical substance can be taken orally or injected intrafilamentary, periapical, intracanal, or intramuscularly. ⁽⁸⁾

Another method to control post endodontic pain is the use of cold saline. Physiologic and clinical data shows that administering cold via various means reduces nerve signal conduction velocity, bleeding, edema, and local inflammation, making it beneficial in the treatment of musculoskeletal pain, muscular spasm, and connective tissue distension. ⁽⁹⁾ In a recent  vitro study, continuous intracanal supply of cold saline solution at 2.5°C with negative pressure irrigation reduced the external root surface temperature by more than 10°C for 5 minutes, ⁽¹⁰⁾ which, according to the studies mentioned, would be sufficient to produce a local anti-inflammatory effect in peri-radicular tissues. The aim of the study is to compare the post pulpectomy pain using dexamethasone infiltration injection vs. cold saline irrigation post operatively in patients presenting with symptomatic irreversible pulpitis.

 

METHODOLOGY:

This study was conducted in a private clinic in Khyber Pakhtunkhwa. The study was conducted over a 6-month period by two consultant endodontists who were competent in their work, techniques and materials. They adhered to a pre-established protocol employing the same preparation, irrigation, and obturation techniques. Inclusion criteria for the study was, (1) participants between the age group of 18 to 35 (2) patients who were willing to participate in the study, (3) patients with maxillary or mandibular molar tooth that had been identified as having symptomatic irreversible pulpitis, (4) patients who have taken painkillers or anti-inflammatory drugs for less than past eight hours.

These criteria were used to exclude people: (1) Patients with medical conditions like Hypertension and Diabetes Mellitus; (2) Pregnant patients; (3) Patients taking systemic steroids; (4) Patients with undeveloped apices or root resorption. (5) Patients who have dexamethasone allergy.

Using a practical sample technique, 100 patients of both genders in good general health were chosen for the study after receiving informed consent. They were then randomly split into two equal groups using a scientific random number table. All volunteers who met the criteria completed informed permission forms after hearing verbal and written explanations of the study's design.

Every bit of information (including age, sex, pulpal state, pain level, and duration of pain) was entered on the patient's chart, along with demographic data, medical and dental history, pertinent clinical examination, and periapical radiographs. Each volunteer was given a brief explanation of the study's methodology before being randomly split into two groups (n = 50). Two groups received infiltration injections of 1.8 mL (equivalent to one cartridge) of 2% lidocaine with 1/100000 epinephrine for maxillary molars and 2 percent lidocaine with 1/100000 epinephrine for mandibular molars using the alveolar nerve block technique.

The endodontic access cavities were prepared with sterile burs after a rubber barrier was put in place. None of the patients needed additional anesthesia. A glide path was created using a #10 K file after the pulp tissue was removed with a broach. Using a Root ZX small apex finder, the working lengths (WL) were calculated and radiographically verified. After pulpectomy participants in group 1 were carried out Dexamethasone 0.2 mL injections using comparable infiltration an aesthetic procedures and equipment. In group 2 the root canals were irrigated with at a temperature of 2.5°C, the fluid was kept in the refrigerator until needed.

After 48 hours participants were called again for the second appointment. Dr. Torabinejad's modified visual analogue scale was used to measure the intensity of the pain. ⁽¹¹⁾ The operator graded the level of pain from 0 to 9.

There was no discomfort at zero. 1-3 denoted minor pain, which was noticeable but not uncomfortable. 4-6 stood for moderate pain, which was uncomfortable but manageable. Having a pain score of 7 or higher denoted extreme pain that was both uncomfortable and challenging to bear.

RESULTS:
A total of 100 participants were included in this study, out of which 42% were females and 58% were males (Fig1). The participants were divided into two groups equally to compare the post-operative pain faced by the patients, Dexamethasone was used on group 1 containing 50 participants and “Cold Saline” was used on group 2 containing 50 participants. For Dexamethasone injection as infiltration, N=15 (30%) of the participants felt no post-operative pain, 17 (34%) of the participants faced Mild pain, 13 (26%) complained of moderate pain and 5 (10%) faced severe pain. Whereas, with cold saline as an irrigant, 12 (24%) out of 50 participants felt no pain, 21 (42%) had mild pain, 13(26%) had moderate pain and 4(8%) complained of severe pain (Fig2). However, no statically significant difference was found in the level of pain between the irrigants used(p=0.416). When compared between the two genders, 15 (35.7%) of the females faced moderate pain whereas 11 (18.9%) of males complained the same, and 3 (7.1%) females had severe pain while 6(10.3%) males complained the same (Table1). According to the independent- Samples Mann-Whitney U test, the distribution of pain is the same across the categories of gender (Sig. 0.218) and irrigant (Sig. 0.862) (fig3 &4).

 

Gender N		Pain
		No Pain (%)	Mild Pain (%)	Moderate Pain (%)	Severe Pain (%)
42 58	Female	9(21%)	15(35.7%)	15(35.7%)	3(7.1%)
	Male	18(31)	23(39.6%)	11(18.9%)	6(10.3%)

 

Fig 3 showing the results of independent samples Mann-Whitney U test.

DISCUSSION;

One of the most crucial objectives for physicians is to manage pain during endodontic procedures and in the postoperative period. ⁽¹²⁾ Even with painkillers, the pain connected to symptomatic irreversible pulpitis is frequently excruciating and challenging to manage. ⁽¹³⁾ Depending on the severity of the inflammation and the body's reaction, the pressure that builds up in the pulp cavity during pulp inflammation affects the nerve fiber, resulting in mild to severe pain. ⁽⁸⁾ The release of inflammatory mediators such prostaglandins, leukotrienes, serotonin, and bradykinin are a common cause of prolonged pulpal pain. ⁽¹⁴⁾ As a result, these mediators, particularly prostaglandins, activate and sensitize nociceptors, resulting in peripheral and central hyperalgesia. ⁽¹⁵⁾

The patients in this study generally experienced and reported low VAS scores. None of the patients reported any symptoms or side effects, including paresthesia, or edema. These results are similar to the study results of Keskin C et al. ⁽¹⁾ At 48-hour checkups after receiving a root canal treatment 55.2% of the patients said they had no pain. These results are contrary with the results of Keskin C at al’s study who reported that 77.05% of the patients said they had no pain. ⁽¹⁾ These findings may be due to the study's inclusion criteria, which excluded teeth with apical abscesses, necrotic pulp, or retreatment cases and preserved aseptic protocol to reduce the likelihood of flare-ups brought on by lingering bacteria and microorganism contamination.

30% patients in which dexamethasone injection was used showed no post-operative pain where as 24% of the patients in which cold saline was used had no pain. Therefore dexamethasone, a corticoid, is a powerful painkiller and anti-inflammatory against a variety of inflammatory mediators released or generated throughout pulpal inflammation. ⁽¹⁶⁾ In our study dexamethasone was administered via supra periosteal injections. However, dexamethasone was injected supraperiosteally and intraligamentarily by Mehrvarzfar et al. ^{(17, 18)}. In one of the investigations, compared to a placebo group, pain was dramatically reduced within the first 24 hours following therapy. ⁽¹⁸⁾ The pain was also reduced in the other trial, primarily within the first 12 hours following therapy. The patients in the dexamethasone group, who did not experience any moderate or severe pain, were contrasted with those in the placebo group and those who had an intraligamentary injection of 2% lidocaine. Thus, even when compared to the use of intracanal lidocaine 2%, dexamethasone injected in the oral region is helpful in reducing pain in individuals with irreversible pulpitis. ⁽¹⁷⁾ Some data on the discomfort of patients reported within 24 hours of endodontic therapy is provided by the meta-analysis. Dexamethasone statistically only effectively reduced pain during the first 24 hours following therapy; following this time, all groups reported experiencing the same levels of pain, and more than 90% of the patients under study had alleviation. Greater statistical significance was shown by Mehrvarzfar et al. ⁽¹⁸⁾ for all medication duration times examined. They provided evidence to support the use of the supraperiosteal injection, claiming that it is superior to the other methods of delivery. They claimed that infiltration of the buccal vestibule is the most efficient method for delivering corticoids, which must be present at the site of inflammation to exert their anti-inflammatory effects. ⁽¹⁸⁾

According to our study 42% of the patients had mild pain with cold saline as an irrigating material. Vasoconstriction results from cryotherapy's restriction of tissue metabolism and blood flow to tissues. ⁽¹⁹⁾ The external root surface's lowered temperature may limit the occurrence of edema, inflammatory responses, and the production of pain-producing chemicals in the periapical region. It has been demonstrated that cryotherapy slows down peripheral nerve conduction. ⁽²⁰⁾  The conduction velocity of nerve fibers diminishes as the temperature drops and eventually ceases. ⁽²⁰⁾However, Ernst and Fialka discovered that the application of mild cold could not reduce the neuronal conduction of C fibers. ⁽²¹⁾ Thermal receptors are also activated by cryotherapy, which lessens the transmission of unpleasant impulses.

In a previous in vitro investigation, cryotherapy was recently studied for application in endodontics. ⁽¹⁰⁾ The background for this investigation was established by Vera et al., who demonstrated that irrigating root canals for 5 min with cold saline 2.5°C  results in reducing the temperature of external root surface. ⁽¹⁰⁾ We used the same procedure, applying the cooling agent for 5 minutes while utilizing a 2 cold saline solution as the cooling agent. In order to prevent the vapor lock effect and guarantee the ongoing supply of the cold irrigant to the apical third, Vera et al. additionally used the EndoVac system (Kerr Endo, Orange Country, CA, USA). ⁽¹⁰⁾ EndoVac usage has been shown to lessen the likelihood of periapical inflammatory responses by reducing apical extrusion. ^{(22, 23)} In the current investigation, all patients received traditional needle irrigation using a side-vented 31 G Navi Tip needle that was implanted 2 mm short of working length. Negative apical pressure devices have been proven to considerably reduce postoperative pain and irrigant extrusion compared to conventional needle irrigation. ^{(22, 23)} As a result, in order to create a safe irrigation procedure, the needle was not inserted more than 2 mm from the working length. ⁽²⁴⁾

 

LIMITATIONS:

The limitations of this study are sample size. If we have large sample size, we can have more predictable data and secondly there should be a placebo group in this study for better comparison.

CONCLUSION:

This clinical study compared the efficacy of intra-ligamentary injection of a very low-dose dexamethasone and cold saline to control pain in patients suffering from symptomatic irreversible pulpitis. It was found that there is slight difference in pain controlling effect of these two. Dexamethasone 0.2ml has better results than cold saline although cold saline also controls post-operative pain. Therefore, there use is recommended.