Effect of 2% Chlorhexidine as an Irrigant on Postoperative Symptoms Following Foraminal Instrumentation: A Randomized Clinical Trial

Fernanda Garcias Hespanhol; Ludmila Silva Guimarães; Erlange Andrade Borges da Silva; Lívia Azeredo Alves Antunes; Leonardo Santos Antunes

Authors

Fernanda Garcias Hespanhol
Ludmila Silva Guimarães
Erlange Andrade Borges da Silva
Lívia Azeredo Alves Antunes
Leonardo Santos Antunes

Keywords:

Chlorhexidine, Edema, Root Canal Irrigants, Pain, Sodium Hypochlorite

Abstract

Objective: To compare postoperative pain, tenderness, edema, and medication use after foraminal enlargement in a single visit, using 2.5% sodium hypochlorite (NaOCl) and 2% chlorhexidine gel (CHX). Material and Methods: Seventy patients with single-rooted teeth with apical periodontitis were randomized into two groups according to the irrigation protocol: control (NaOCl - 35 patients) and case (CHX - 35 patients). Pain intensity was assessed using the visual analog scale (recorded every day for seven days, on the 14^th and 30^th days after treatment). Edema was assessed by two independent evaluators on the 2^nd, 3^rd, and 7^th days after treatment using photographs. Data were analyzed using Chi-square, Fisher's Exact, and Mann-Whitney U tests in SPSS. Results: There was a statistically significant difference in postoperative pain and tenderness between the groups on the 2^nd day (p<0.05). There was no difference between the groups for edema (p=1.00) and use of medication (p=0.77). Conclusion: Chlorhexidine resulted in more significant postoperative pain and tenderness after foraminal enlargement.

References

Card SJ, Sigurdsson A, Orstavik D, Trope M. The effectiveness of increased apical enlargement in reducing intracanal bacteria. J Endod 2002; 28(11):779-783. https://doi.org/10.1097/00004770-200211000-00008

Borges Silva EA, Guimarães LS, Küchler EC, Antunes LAA, Antunes LS. Evaluation of effect of foraminal enlargement of necrotic teeth on postoperative symptoms: A systematic review and meta-analysis. J Endod 2017; 43(12):1969-1977. https://doi.org/10.1016/j.joen.2017.07.014

Zehnder M. Root canal irrigants. J Endod 2006; 32(5):389-398. https://doi.org/10.1016/j.joen.2005.09.014

Barrios R, Ferrer-Luque CM, Arias-Moliz MT, Ruiz-Linares M, Bravo M, Baca P. Antimicrobial substantivity of alexidine and chlorhexidine in dentin. J Endod 2013; 9(11):1413-1415. https://doi.org/10.1016/j.joen.2013.07.038

Rahimi S, Janani M, Lotfi M, Shahi S, Aghbali A, Vahid Pakdel M, et al. A review of antibacterial agents in endodontic treatment. Iran Endod J 2014; 9(3):161-168.

Ruiz-Linares M, Aguado-Pérez B, Baca P, Arias-Moliz MT, Ferrer-Luque CM. Efficacy of antimicrobial solutions against polymicrobial root canal biofilm. Int Endod J 2017; 50(1):77-83. https://doi.org/10.1111/iej.12598

Zhu WC, Gyamfi J, Niu LN, Schoeffel GJ, Liu SY, Santarcangelo F, et al. Anatomy of sodium hypochlorite accidents involving facial ecchymosis - A review. J Dent 2013; 41(11):935-948. https://doi.org/10.1016/j.jdent.2013.08.012

Bashetty K, Hegde J. Comparison of 2% chlorhexidine and 5.25% sodium hypochlorite irrigating solutions on postoperative pain: a randomized clinical trial. Indian J Dent Res 2010; 21(4):523-527. https://doi.org/10.4103/0970-9290.74225

Almeida G, Marques E, De Martin AS, da Silveira Bueno CE, Nowakowski A, Cunha RS. Influence of irrigating solution on postoperative pain following single-visit endodontic treatment: randomized clinical trial. J Can Dent Assoc 2012; 78:c84.

da Silva EJ, Monteiro MR, Belladonna FG, Almeida JF, De-Deus G, Neves Ade A. Postoperative pain after foraminal instrumentation with a reciprocating system and different irrigating solutions. Braz Dent J 2015; 26(3):216-221. https://doi.org/10.1590/0103-6440201300311

Orstavik D, Kerekes K, Eriksen HM. The periapical index: A scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986; 2(1):20-34. https://doi.org/10.1111/j.1600-9657.1986.tb00119.x

Cruz Junior JA, Coelho MS, Kato AS, Vivacqua-Gomes N, Fontana CE, Rocha DG, et al. The effect of foraminal enlargement of necrotic teeth with the reciproc system on postoperative pain: A prospective and randomized clinical trial. J Endod 2016; 42(1):8-11. https://doi.org/10.1016/j.joen.2015.09.018

Rôças IN, Provenzano JC, Neves MA, Siqueira JF Jr. Disinfecting effects of rotary instrumentation with either 2.5% sodium hypochlorite or 2% chlorhexidine as the main irrigant: A randomized clinical study. J Endod 2016; 42(6):943-947. https://doi.org/10.1016/j.joen.2016.03.019

Saini HR, Sangwan P, Sangwan A. Pain following foraminal enlargement in mandibular molars with necrosis and apical periodontitis: A randomized controlled trial. Int Endod J 2016; 49(12):1116-1123. https://doi.org/10.1111/iej.12583

Fergusson D, Glass KC, Waring D, Shapiro S. Turning a blind eye: The success of blinding reported in a random sample of randomised, placebo controlled trials. BMJ 2004; 328(7437):432. https://doi.org/10.1136/bmj.37952.631667.EE

Morse DR, Furst ML, Belott RM, Lefkowitz RD, Spritzer IB, Sideman BH. A prospective randomized trial comparing periapical instrumentation to intracanal instrumentation in cases of asymptomatic pulpal periapical lesions. Oral Surg Oral Med Oral Pathol 1987; 64(6):734-741. https://doi.org/10.1016/0030-4220(87)90178-2

Kells CE. Immediate root-filling. Dental Cosmos 1887; 29:366-367.

Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth: A Cochrane systematic review. J Endod 2008; 34(9):1041-1047. https://doi.org/10.1016/j.joen.2008.06.009

Bürklein S, Schäfer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod 2012; 38(6):850-852. https://doi.org/10.1016/j.joen.2012.02.017

Siqueira JJ, Barnett F. Interappointment pain: Mechanisms, diagnosis, and treatment. Endod Topics 2004; 7(1):93-109. https://doi.org/10.1111/j.1601-1546.2004.00062.x

Glennon JP, Ng YL, Setchell DJ, Gulabivala K. Prevalence of and factors affecting post preparation pain in patients undergoing two-visit root canal treatment. Int Endod J 2004; 37(1):29-37. https://doi.org/10.1111/j.1365-2591.2004.00748.x

Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms. Int Endod J 2002; 35(8):660-667. https://doi.org/10.1046/j.1365-2591.2002.00541.x

Gesi A, Hakeberg M, Warfvinge J, Bergenholtz G. Incidence of periapical lesions and clinical symptoms after pulpectomy- -A clinical and radiographic evaluation of 1- versus 2-session treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101(3):379-388. https://doi.org/10.1016/j.tripleo.2005.05.073

Penesis VA, Fitzgerald PI, Fayad MI, Wenckus CS, BeGole EA, Johnson BR. Outcome of one-visit and two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod 2008; 34(3):251-257. https://doi.org/10.1016/j.joen.2007.12.015

El Mubarak AH, Abu-bakr NH, Ibrahim YE. Postoperative pain in multiple-visit and single-visit root canal treatment. J Endod 2010; 36(1):36-39. https://doi.org/10.1016/j.joen.2009.09.003

Imura N, Zuolo ML. Factors associated with endodontic flare-ups: A prospective study. Int Endod J 1995; 28(5):261-265. https://doi.org/10.1111/j.1365-2591.1995.tb00311.x

Tanomaru Filho M, Leonardo MR, Silva LA, Aníbal FF, Faccioli LH. Inflammatory response to different endodontic irrigating solutions. Int Endod J 2002; 35(9):735-739. https://doi.org/10.1046/j.1365-2591.2002.00544.x

Kvist T, Molander A, Dahlén G, Reit C. Microbiological evaluation of one- and two-visit endodontic treatment of teeth with apical periodontitis: A randomized, clinical trial. J Endod 2004; 30(8):572-576. https://doi.org/10.1097/01.don.0000121607.87969.6e

Gomes BP, Ferraz CC, Vianna ME, Berber VB, Teixeira FB, Souza-Filho FJ. In vitro antimicrobial activity of several concentrations of sodium hypochlorite and chlorhexidine gluconate in the elimination of Enterococcus faecalis. Int Endod J 2001; 34(6):424-428. https://doi.org/10.1046/j.1365-2591.2001.00410.x

Okino LA, Siqueira EL, Santos M, Bombana AC, Figueiredo JA. Dissolution of pulp tissue by aqueous solution of chlorhexidine digluconate and chlorhexidine digluconate gel. Int Endod J 2004; 37(1):38-41. https://doi.org/10.1111/j.1365-2591.2004.00749.x

Mohammadi Z, Abbott PV. The properties and applications of chlorhexidine in endodontics. Int Endod J 2009; 42(4):288-302. https://doi.org/10.1111/j.1365-2591.2008.01540.x

Siqueira JF Jr, Rôças IN, Favieri A, Lima KC. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1%, 2.5%, and 5.25% sodium hypochlorite. J Endod 2000; 26(6):331-334. https://doi.org/10.1097/00004770-200006000-00006

Rutala WA, Weber DJ. The healthcare infection control practices advisory committee. Guideline for disinfection and sterilization in healthcare facilities. Atlanta: Centers for Disease Control and Prevention; 2008. 158p.

Dychdala GR. Chlorine and chlorine compounds. In: Block SS, ed. Disinfection, Sterilization, and Preservation. 4th ed. Philadelphia: Lea & Febiger; 1991.

Gomes BP, Vianna ME, Zaia AA, Almeida JF, Souza-Filho FJ, Ferraz CC. Chlorhexidine in endodontics. Braz Dent J 2013; 24(2):89-102. https://doi.org/10.1590/0103-6440201302188

Leonardo MR, Tanomaru Filho M, Silva LA, Nelson Filho P, Bonifácio KC, Ito IY. In vivo antimicrobial activity of 2% chlorhexidine used as a root canal irrigating solution. J Endod 1999; 25(3):167-171. https://doi.org/10.1016/s0099-2399(99)80135-6

Dametto FR, Ferraz CC, Gomes BP, Zaia AA, Teixeira FB, de Souza-Filho FJ. In vitro assessment of the immediate and prolonged antimicrobial action of chlorhexidine gel as an endodontic irrigant against Enterococcus faecalis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99(6):768-772. https://doi.org/10.1016/j.tripleo.2004.08.026

Khademi AA, Mohammadi Z, Havaee A. Evaluation of the antibacterial substantivity of several intra-canal agents. Aust Endod J 2006; 32(3):112-115. https://doi.org/10.1111/j.1747-4477.2006.00033.x

Rosenthal S, Spangberg L, Safavi K. Chlorhexidine substantivity in root canal dentin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98(4):488-492. https://doi.org/10.1016/j.tripleo.2003.07.005

Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006; 15 Suppl 1(Suppl 1):S17-24. https://doi.org/10.1007/s00586-005-1044-x