ABSTRACT

Objective:

To evaluate resin- and bioceramic root canal sealers affect postoperative intensity and pain occurrence.

Material and Methods:

From the electronic databases, PubMed, Cochrane Library, Embase, ISI have been used to perform systematic literature until September 2020. Electronic titles were managed using the Endnote X8 software. They performed searches with mesh terms. Two reviewers blindly and independently extracted data from studies that included data for data extraction.

Results:

A total of 186 potentially relevant titles and abstracts were found. Finally, four studies were included. Pain score was (RR = -0.20; 95% CI -1.09-0.68; p= 0.65). This result showed no statistically significant difference for the resin-based and bioceramic root canal sealers after 24 hours between the VAS scores.

Conclusion:

Postoperative pain was low in Patients requiring root canal retreatment and obturated with resin-based or bioceramic-based sealers without extrusion beyond the apex. No differences were observed between postoperative pain in resin-based and bioceramic root canal sealers 24 and 48 hours postoperatively.

Keywords:
Endodontics; Root Canal Filling Materials; Pain, Postoperative

Introduction

Studies have shown that endodontic postoperative pain between 3 to 58 % [¹[1] Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single-and multiple-visit endodontic treatment: a systematic review. Int Endod J 2008; 41(2):91-9. https://doi.org/10.1111/j.1365-2591.2007.01316.x
https://doi.org/10.1111/j.1365-2591.2007...

[2] Cunha TC, de Souza Matos F, Paranhos LR, de Macedo Bernardino Í, Moura CC. Influence of glide path kinematics during endodontic treatment on the occurrence and intensity of intraoperative and postoperative pain: a systematic review of randomized clinical trials. BMC Oral Health 2020; 20(1):1-13. https://doi.org/10.1186/s12903-020-01164-w
https://doi.org/10.1186/s12903-020-01164... -³[3] Sudhakar K, Kumar CS, Lavanya A, Swapna S. Influence of instrument design on post-operative pain in single-visit root canal treatment with Protaper Next and V taper 2H rotary systems in symptomatic irreversible pulpitis of multirooted teeth-A randomized clinical trial. J Clin Transl Res 2020; 5(5):230-5. https://doi.org/10.18053/jctres.05.202005.002
https://doi.org/10.18053/jctres.05.20200... ]. Pain may occur in periodontal tissues after mechanical, chemical, and microbiological injuries [⁴[4] Nagendrababu V, Gutmann JL. Factors associated with postobturation pain following single-visit nonsurgical root canal treatment: A systematic review. Quintessence Int 2017; 48(3):193-208. https://doi.org/10.3290/j.qi.a36894
https://doi.org/10.3290/j.qi.a36894... ]. There are various parameters in treatment that can cause postoperative pain. One of these parameters is including working length (WL). Also, the number of visits, selection of instruments, and the selection of root canal sealers are other related parameters [⁵[5] Thakur S, Emil J, Paulaian B. Evaluation of mineral trioxide aggregate as root canal sealer: A clinical study. J Conserv Dent 2013; 16(6):494-8. https://doi.org/10.4103/0972-0707.120944
https://doi.org/10.4103/0972-0707.120944...

[6] Lee DS, Lim MJ, Choi Y, Rosa V, Hong CU, Min KS. Tooth discoloration induced by a novel mineral trioxide aggregate-based root canal sealer. Eur J Dent 2016; 10(3):403-7. https://doi.org/10.4103/1305-7456.184165
https://doi.org/10.4103/1305-7456.184165... -⁷[7] Graunaite I, Skucaite N, Lodiene G, Agentiene I, Machiulskiene V. Effect of resin-based and bioceramic root canal sealers on postoperative pain: a split-mouth randomized controlled trial. J Endod 2018; 44(5):689-93. https://doi.org/10.1016/j.joen.2018.02.010
https://doi.org/10.1016/j.joen.2018.02.0... ].

Sealers placed in the root canals and interact with the periodontal tissues through the apical perforation, lateral canals, or leaching can affect the periodontium's healing process. As a result, postoperative pain is caused by local inflammation of the root canal [⁸[8] Zhang W, Peng B. Tissue reactions after subcutaneous and intraosseous implantation of iRoot SP, MTA and AH Plus. Dent Mater J 2015; 34(6):774-80. https://doi.org/10.4012/dmj.2014-271
https://doi.org/10.4012/dmj.2014-271... ].

Bioceramic materials can help endodontic treatment by releasing biologically active substances and promoting odontoblasts' differentiation [⁹[9] de Miranda Candeiro GT, Correia FC, Duarte MA, Ribeiro-Siqueira DC, Gavini G. Evaluation of radiopacity, pH, release of calcium ions, and flow of a bioceramic root canal sealer. J Endod 2012; 38(6):842-5. https://doi.org/10.1016/j.joen.2012.02.029
https://doi.org/10.1016/j.joen.2012.02.0...

[10] Zordan-Bronzel CL, Torres FF, Tanomaru-Filho M, Chávez-Andrade GM, Bosso-Martelo R, Guerreiro-Tanomaru JM. Evaluation of physicochemical properties of a new calcium silicate-based sealer, Bio-C Sealer. J Endod 2019; 45(10):1248-52. https://doi.org/10.1016/j.joen.2019.07.006
https://doi.org/10.1016/j.joen.2019.07.0...

[11] Lee JK, Kwak SW, Ha JH, Lee W, Kim HC. Physicochemical properties of epoxy resin-based and bioceramic-based root canal sealers. Bioinorg Chem Appl 2017; 2017:2582849. https://doi.org/10.1155/2017/2582849
https://doi.org/10.1155/2017/2582849... -¹²[12] Poggio C, Dagna A, Ceci M, Meravini MV, Colombo M, Pietrocola G. Solubility and pH of bioceramic root canal sealers: a comparative study. J Clin Exp Dent 2017; 9(10):e1189-94. https://doi.org/10.4317/jced.54040
https://doi.org/10.4317/jced.54040... ]. In vitro studies have shown that bioceramic materials were less cytotoxic than resin-based materials [¹³[13] Zhang W, Li Z, Peng B. Ex vivo cytotoxicity of a new calcium silicate-based canal filling material. Int Endod J 2010; 43(9):769-74. https://doi.org/10.1111/j.1365-2591.2010.01733.x
https://doi.org/10.1111/j.1365-2591.2010...

[14] Jung S, Libricht V, Sielker S, Hanisch MR, Schäfer E, Dammaschke T. Evaluation of the biocompatibility of root canal sealers on human periodontal ligament cells ex vivo. Odontology 2019; 107(1):54-63. https://doi.org/10.1007/s10266-018-0380-3
https://doi.org/10.1007/s10266-018-0380-...

[15] Almeida LH, Moraes RR, Morgental RD, Pappen FG. Are premixed calcium silicate-based endodontic sealers comparable to conventional materials? A systematic review of in vitro studies. J Endod 2017; 43(4):527-35. https://doi.org/10.1016/j.joen.2016.11.019
https://doi.org/10.1016/j.joen.2016.11.0... -¹⁶[16] Lee JK, Kim S, Lee S, Kim HC, Kim E. In vitro comparison of biocompatibility of calcium silicate-based root canal sealers. Materials 2019; 12(15):2411. https://doi.org/10.3390/ma12152411
https://doi.org/10.3390/ma12152411... ]. Other studies have also shown that resin-based have stronger bonding capacity and higher radiopacity than bioceramic materials [¹⁷[17] Ozkocak I, Sonat B. Evaluation of effects on the adhesion of various root canal sealers after Er: YAG laser and irrigants are used on the dentin surface. J Endod 2015; 41(8):1331-6. https://doi.org/10.1016/j.joen.2015.03.004
https://doi.org/10.1016/j.joen.2015.03.0... ,¹⁸[18] Crozeta BM, Lopes FC, Silva RM, Silva-Sousa YT, Moretti LF, Sousa-Neto MD. Retreatability of BC Sealer and AH Plus root canal sealers using new supplementary instrumentation protocol during non-surgical endodontic retreatment. Clin Oral Investig 2021; 25(3):891-9. https://doi.org/10.1007/s00784-020-03376-4
https://doi.org/10.1007/s00784-020-03376... ]. Graunaite et al. [¹⁹[19] Graunaite I, Lodiene G, Arandarcikaite O, Pukalskas A, Machiulskiene V. Leachables and cytotoxicity of root canal sealers. J Oral Sci 2018; 60(3):381-7. https://doi.org/10.2334/josnusd.17-0173
https://doi.org/10.2334/josnusd.17-0173... ], in a split-mouth randomized controlled trial, showed resin-based sealer (AH Plus) and Total Fill had a similar occurrence and intensity of postoperative pain.

Given that the exact results are not noticeable, and a systematic review and meta-analysis studies have not been performed in this field, the researcher decided to review the results of RCT studies; the aim of this study is to evaluate the effect of resin-based and bioceramic root canal sealers on postoperative pain intensity and occurrence.

Material and Methods

Search Strategy

From the electronic databases, PubMed, Cochrane Library, Embase, ISI have been used to perform systematic literature over the last five years between 2015 to September 2020. Endnote X8 software was used to manage electronic titles. Searches were performed using mesh terms: ("Dental Pulp Cavity"[Mesh] OR "Root Canal Therapy"[Mesh] OR “Root Canal Filling Materials"[Mesh]) OR "Endodontics"[Mesh]) AND "iRoot BP Plus" [Supplementary Concept]) AND "epoxy resin-based root canal sealer" [Supplementary Concept]) AND "Pain, Postoperative"[Mesh].

This study is based on the Systematic Review and Meta-Analysis (PRISMA) Statement-Preferred Reporting Items [²⁰[20] Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement (Chinese edition). Chin J Integr Med 2009; 7(9):889-96. https://doi.org/10.3736/jcim20090918
https://doi.org/10.3736/jcim20090918... ] and the PICO or PECO Strategy (Table1).

Selection Criteria

The following inclusion criteria were adopted: 1) Randomized controlled trial studies, controlled clinical trials, and prospective and retrospective cohort studies; 2) Used AH Plus; 3) Used bioceramic root canal sealers; 4) Patients requiring root canal retreatment; 5) VAS scale; and 6) In English.

Regarding the exclusion criteria, the following were established: 1) Periapical lesions; 2) Studies carried out in vitro, case reports, case studies, and reviews; and 3) Animal studies.

Data Extraction and Method of Analysis

The data were extracted from the research that included information about the study, years, study design, sample size, mean/ range of age, number of teeth, scale, root canal sealers, and follow-up period. The quality of the included studies has been evaluated using the tool of Cochrane Collaboration [²¹[21] Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343:d5928. https://doi.org/10.1136/bmj.d5928
https://doi.org/10.1136/bmj.d5928... ]. The scale scores for low risk were 1 and for High and unclear risk was 0. Scale scores range from 0 to 6. A higher score means higher quality. Two reviewers blinded and extracted data independently for data extraction of studies that included.

Moreover, the risk ratio between two groups (resin-based and bioceramic root canal sealers), the model for random effect and the method for restricted maximum likelihood (REML) were calculated with a 95% confidence interval (CI). Random effects were used to resolve the potential heterogeneity, and I² showed heterogeneity. Stata Statistical Software, V.16 (StataCorp LLC., TX, USA) was used in meta-analysis.

Results

According to the research design, 186 potentially important research abstracts and titles have been discovered in our electronic searches. In the first phase of the study selection, 156 research has been about the topics and abstracts. Therefore, we thoroughly assessed the complete full-text papers of the rest 28 studies in the second stage to exclude 24 publications due to the lack of the defined inclusion criteria. Then, four papers remained in agreement with our inclusion criteria required (Figure 1).

Sample Size

Therefore, four studies (randomized controlled trials) have been included. The number of patients a total was 121. The mean age was 42.6 years. The number of teeth a total was 276. Per patient received a visual analog scale (VAS) in all studies to record pain intensity 24 hours, 48 hours, 72 hours, and seven days after treatment (Table 2).

Bias Assessment

According to Cochrane Collaboration's tool, two studies had a total score of 4/6, one study had a total score of 5/6, and one study had a total score of 6/6. This result showed a low bias risk in all studies and high quality (Table 3).

Pain Scores after 24 Hours

Pain score was (RR = -0.20; 95% CI -1.09-0.68; p= 0.65) among four studies and heterogeneity found (I² = 30.61%; p=0.19). This result showed that, after 24 hours, no statistically significant difference existed between the VAS scores for resin and bioceramic root canal sealers (p=0.65), and no statistically significant difference was observed between the studies (p=0.19) (Figure 2).

Pain Scores after 48 Hours

Pain score was (RR = -0.10; 95% CI -1.44-1.23; p=0.88) among 4 studies and heterogeneity found (I² = 46.61%; p=0.12). This result showed that after 48 hours, no statistically significant difference was observed between the VAS scores for the resin and bioceramic root canal sealers (p=0.88) and no statistically significant difference was observed between the studies (p=0.19) (Figure 3).

Pain Scores after Seven Days

No pain or mild pain was reported in the studies after seven days.

Compared to Pain Scores after 24 and 48 Hours

Postoperative pain was felt more in the first 24 hours than after 48 hours, and the VAS score was higher after 24 hours vs. 48 hours.

Discussion

The local inflammatory response in periapical tissues causes postoperative pain in endodontics treatment [²⁵[25] West AP, Shadel GS, Ghosh S. Mitochondria in innate immune responses. Nat Rev Immunol 2011; 11(6):389-402. https://doi.org/10.1038/nri2975
https://doi.org/10.1038/nri2975... ,²⁶[26] West AP, Shadel GS. Mitochondrial DNA in innate immune responses and inflammatory pathology. Nat Rev Immunol 2017; 17(6):363-75. https://doi.org/10.1038/nri.2017.21
https://doi.org/10.1038/nri.2017.21... ]. In vivo studies have reported that reactive oxygen species can be directly associated with inflammatory pain [²⁷[27] Vengerfeldt V, Mändar R, Saag M, Piir A, Kullisaar T. Oxidative stress in patients with endodontic pathologies. J Pain Res 2017; 10:2031-40. https://doi.org/10.2147/JPR.S141366
https://doi.org/10.2147/JPR.S141366... ]. If human pulp cells were treated in vitro with the root canal sealers, reactive oxygen species would increase from 4 to 7 times [²⁸[28] Silva GO, Cavalcanti BN, Oliveira TR, Bin CV, Camargo SE, Camargo CH. Cytotoxicity and genotoxicity of natural resin-based experimental endodontic sealers. Clin Oral Investig 2016; 20(4):815-9. https://doi.org/10.1007/s00784-015-1567-4
https://doi.org/10.1007/s00784-015-1567-... ,²⁹[29] Fonseca DA, Paula AB, Marto CM, Coelho A, Paulo S, Martinho JP, et al. Biocompatibility of root canal sealers: A systematic review of in vitro and in vivo studies. Materials 2019; 12(24):4113. https://doi.org/10.3390/ma12244113
https://doi.org/10.3390/ma12244113... ].

Resin-based AH Plus can also release toxic monomers such as diglicidyl ether bisphenol A, and the bioceramic sealer can have cytotoxic effects. But it should be noted that iRoot SP is less toxic than AH Plus [³⁰[30] Lodienė G, Kopperud HM, Ørstavik D, Bruzell EM. Detection of leachables and cytotoxicity after exposure to methacrylate-and epoxy-based root canal sealers in vitro. Eur J Oral Sci 2013; 121(5):488-96. https://doi.org/10.1111/eos.12065
https://doi.org/10.1111/eos.12065... ,³¹[31] Rosen E, Goldberger T, Taschieri S, Del Fabbro M, Corbella S, Tsesis I. The prognosis of altered sensation after extrusion of root canal filling materials: a systematic review of the literature. J Endod 2016; 42(6):873-9. https://doi.org/10.1016/j.joen.2016.03.018
https://doi.org/10.1016/j.joen.2016.03.0... ]. Postoperative pain is triggered when the sealers' cytotoxicity implied contact with the periapical tissue. In gross overfilling cases, it can also be caused by the sealer [³²[32] Okiji T. Non-Surgical Root Canal Treatment Case V: Mandibular Premolar. In: Komabayashi T. Clinical Cases in Endodontics. London: Wiley Blackwell; 2017; pp. 79-90.,³³[33] Victoria-Escandell A, Ibañez-Cabellos JS, de Cutanda SB, Berenguer-Pascual E, Beltrán-García J, García-López E, et al. Cellular responses in human dental pulp stem cells treated with three endodontic materials. Stem Cells Int 2017; 2017:8920356. https://doi.org/10.1155/2017/8920356
https://doi.org/10.1155/2017/8920356... ].

No statistically significant difference in the present systematic review results and meta-analysis is shown in the postoperative pain observed at any of the points in time between the root canals obturated with resin-based and bioceramic sealers. It took 24 hours, 48 hours, 72 hours, and seven days to measure pain by 4 points. These time points have been used in studies to assess postoperative pain, as well as in vitro cytotoxicity tests [³³[33] Victoria-Escandell A, Ibañez-Cabellos JS, de Cutanda SB, Berenguer-Pascual E, Beltrán-García J, García-López E, et al. Cellular responses in human dental pulp stem cells treated with three endodontic materials. Stem Cells Int 2017; 2017:8920356. https://doi.org/10.1155/2017/8920356
https://doi.org/10.1155/2017/8920356... ]. Although differences between AH Plus and Total Fill have already been reported in vitro studies, no clinical differences have been observed. According to the present study results, the highest VAS score was reported 24 hours after surgery, which decreased after 48 hours. No pain was reported after seven days or was very mild. These results can be explained by the fact that to induce ROS formation, cytotoxic unpolymerized root canal sealers can play a role in the first 24 hours. The amount of pain varies from 24 hours to 48 hours in studies, but almost all results are the same. The quality of the selected studies was high in the present study, so this study's results can be cited. However, low postoperative pain scores can also be explained by not being overfilled. In this case, more studies are needed to achieve better results. Resin-based and bioceramic root canal sealers on the intensity and occurrence of postoperative pain could help the results of the present study.

Conclusion

Postoperative pain was low in patients requiring root canal retreatment and obturated with resin-based or bioceramic-based sealers without extrusion beyond the apex. No differences were observed 24 and 48 hours postoperatively between postoperative pain in resin-based and bioceramic root canal sealers. This means that resin-based and bioceramic root canal sealers act the same in incidence and postoperative pain severity. It will also require randomized controlled trial studies comparing resin-based and bioceramic root canal sealers with high sample sizes and seven days.

References

Edited by

Publication Dates

History