10.59987/ads/2013.1.152-155
Aims. Apical extrusion of infected debris to the periradicular tissues is one of the principal causes of post-operative pain and discomfort. Recent researches have shown that reciprocating instrumentation techniques seem to significantly increase the amount of debris extruded beyond the apex and, consequently, the risk of postoperative pain. The goal of the present study was to evaluate and compare postoperative pain using three different nickel-titanium instrumentation techniques: a rotary crown-down technique using TF instruments (Sybro-nEndo, Orange, Ca), a reciprocating single-file technique using WaveOne instruments (Maillefer DEntsply, Bail-lagues, CH), and a novel instrumentation technique (TFAdaptive, SybronEndo, Orange, Ca), using a unique,proprietary movement, combining reciprocation andcontinuous rotation.
Methods. Ninety patients requiring endodontic treatment on permanent premolar and molar teeth with non vitalpulps preoperatively were included in the study. The patients were assigned into three groups of 30 patients each, trying to make the groups very similar, concerning the number of root canals, presence of initial pain and periapical lesions. The teeth in group 1 (n = 30) were instrumented with a crown-down technique using TF instruments, whilst those in group 2 (n = 30) were instrumented with a single-file technique using Waveone 08 25. The thirdgroup (n = 30) used the 3-file Tf Adaprtive sequence. All techniques were performed following manufacturers’ instructions and all canals were shaped, cleaned and obturated in a single-visit by the same operator. The assessment of postoperative pain was carried out at 3 days by using a visual analogue scale. VAS pain scores were compared using one-way ANOVA post hoc Tukey test. A valueof p &lt; 0.05 was required for statistical significance.
Results. Results for VAS pain scores showed a statistically significant difference was found between the WaveOne (p=0,021) technique and the other two techniques. No statistical significant differences were found between TF and TF Adaptive (p= 0,087). When evaluating patient experiencing sever pain the incidence of symptoms was significantly higher with the WaveOne technique.
Conclusions.Since the incidence of preoperative pain,the type of tooth and the pulp and periodontal pathology were quite similar between the three tested groups, and all the other variables (operator, irrigation, obturation) were identical, we may conclude that the difference in postoperative pain can be mainly related to the different instrumentation techniques
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Annali di stomatologia
endodontic instru-ments
The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment
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Original Article
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The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment
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                                                                                                        Original article


The influence of three different instrumentation
techniques on the incidence of postoperative pain
after endodontic treatment




                                                                                              li
                                                                                           na
Gianluca Gambarini, MD, PhD1                                   structions and all canals were shaped, cleaned and obtu-
Luca Testarelli, MD, PhD1                                      rated in a single-visit by the same operator. The assess-
                                                               ment of postoperative pain was carried out at 3 days by




                                                                                        io
Massimo De Luca, MD, PhD1
                                                               using a visual analogue scale. VAS pain scores were com-
Valerio Milana, MD, PhD1
                                                               pared using one-way ANOVA post hoc Tukey test. A value
Gianluca Plotino, MD1
                                                               of p < 0.05 was required for statistical significance.




                                                                                     az
Nicola Maria Grande, MD1
                                                               Results. Results for VAS pain scores showed a statisti-
Alessio Giansiracusa Rubini, DDS1                              cally significant difference was found between the
Dina Al Sudani, DDS2                                           WaveOne (p=0,021) technique and the other two tech-
Gianpaolo Sannino, MD1                                         niques. No statistical significant differences were found




                                                                       n
                                                               between TF and TF Adaptive (p= 0,087).
1
    Department of Oral and MaxilloFacial Sciences,             When evaluating patient experiencing sever pain the in-
    “Sapienza” University of Rome, Italy




                                                                    er
                                                               cidence of symptoms was significantly higher with the
2
    King Saud University, Riyadh City, Saudi Arabia            WaveOne technique.
                                                               Conclusions. Since the incidence of preoperative pain,
                                                               the type of tooth and the pulp and periodontal pathology
Corresponding author:
Valerio Milana, MD, PhD
                                           nt
Department of Oral and MaxilloFacial Sciences
                                                               were quite similar between the three tested groups, and
                                                               all the other variables (operator, irrigation, obturation)
                                                               were identical, we may conclude that the difference in
                                                               postoperative pain can be mainly related to the different
                                         iI
“Sapienza” University of Rome
Via Caserta, 6                                                 instrumentation techniques.
00161 Rome, Italy
                                                               Key words: root canal treatment, pain, endodontic instru-
                                       on

Phone: +39 3283129607
                                                               ments.
E-mail: valeriomilana@gmail.com


Summary                                                        Introduction
                               i


Aims. Apical extrusion of infected debris to the peri-
                            iz


radicular tissues is one of the principal causes of post-      The completion of endodontic therapy can be done in a
operative pain and discomfort. Recent researches have          single appointment or with multiple visits. Clinical reports
shown that reciprocating instrumentation techniques            have shown that patients generally tolerate and prefer sin-
              Ed




seem to significantly increase the amount of debris ex-        gle-visit endodontic therapy (1-2). Therefore, single-visit
truded beyond the apex and, consequently, the risk of          root canal treatment has become a common practice
postoperative pain. The goal of the present study was to       also in non-vital cases, and offers several advantages, in-
evaluate and compare postoperative pain using three dif-       cluding a decreased number of operative procedures (3),
ferent nickel-titanium instrumentation techniques: a ro-       and no risk of inter-appointment leakage through tempo-
tary crown-down technique using TF instruments (Sybro-         rary restorations (1). In addition, single-visit root canal
 IC




nEndo, Orange, Ca), a reciprocating single-file technique      therapy is less time consuming and more economical; as
using WaveOne instruments (Maillefer DEntsply, Bail-           a consequence, innovative manufacturing processes to
lagues, CH), and a novel instrumentation technique (TF         produce better istruments (4-7), and new instrumentation
Adaptive, SybronEndo, Orange, Ca), using a unique,             techniques have been recently commercialized to im-
C




proprietary movement, combining reciprocation and              prove simplicity and safety of treatment by using recipro-
continuous rotation.                                           cation motion instead of continuous rotation and by reduc-
Methods. Ninety patients requiring endodontic treatment
                                                               ing the number of nickel titanium (NiTi) instruments and
on permanent premolar and molar teeth with non vital
                                                               consequently instrumentation time (8-10).
©




pulps preoperatively were included in the study. The pa-
                                                               More precisely, a few years ago Dentsply Maillefer (Bail-
tients were assigned into three groups of 30 patients
each, trying to make the groups very similar, concerning
                                                               lagues, Switzerland) and Dentsply VDW (Munchen, Ger-
the number of root canals, presence of initial pain and pe-    many) have developed two different nickel titanium instru-
riapical lesions. The teeth in group 1 (n = 30) were instru-   ments of greater tapers (Waveone® and Reciproc®),
mented with a crown-down technique using TF instru-            which are designed to be used with an innovative, propri-
ments, whilst those in group 2 (n = 30) were instrumented      etary reciprocating movement, and allow root canals to be
with a single-file technique using Waveone 08 25. The third    prepared with one single instrument: in the majority of
group (n = 30) used the 3-file Tf Adaprtive sequence. All      cases a taper.08 size 25 instrumentis selected. The two
techniques were performed following manufacturers’ in-         above-mentioned instruments are slightly different in de-

152                                                                              Annali di Stomatologia 2013; IV (1): 152-155
The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment


sign and motion, but performance is quite similar (9-10).          ously taken antibiotics or analgesics were excluded. Age,
More recently, a new instrumentation technique (TF Adap-           gender, tooth location, pulp vitality and radiographically
tive®) has been developed by SybronEndo (Orange, Ca),              visible lesions were recorded. An electric pulp-testing de-
aiming at combining the advantages of both continuous              vice (Elements pulp vitality tester, Sybron endo, Orange,
rotation and reciprocation. More precisely it is a patented,       Ca) was used to assess pulp vitality.




                                                                                                    li
undisclosed, unique motion which automatically adapts to           Before initiating treatment, each tooth was examined ac-
instrumentation stress. When the TF Adaptive instrument            cording to clinical complaints, including the presence or




                                                                                                 na
is not (or very lightly) stressed the movement can be de-          absence of pain. Overall, 41 patients had symptomatic
scribed as a continuous rotation, allowing better cutting ef-      (preoperative pain) and 49 had asymptomatic teeth, re-
ficiency and removal of debris, since cross-sectional and          spectively. Of the 90 teeth previously diagnosed as non-
flute design are meant to perform at their best in a clock-        vital, 76 showed periapical lesions.




                                                                                              io
wise motion (11-12). On the contrary while negotiating the         A single clinician evaluated all patients, using radiographic
canal, due to increased instrumentation stress and metal           and clinical findings, and the the same clinician was as-
fatigue, the motion of the TF Adaptive instrument changes          signed for treatment of all cases. This procedure was per-
into a reciprocation mode, with specifically designed CW           formed to eliminate or minimize interpersonal variability in




                                                                                           az
and CCW angles. Moreover these angles are not con-                 the treatment between clinicians.
stant, but vary depending on the anatomical complexities           The patients were assigned into three groups of 30 pa-
and the intracanal stress.This “adaptive” motion is there-         tients each, trying to make the groups very similar, con-
fore meant to reduce the risk intracanal failure, without af-      cerning the number of root canals, presence of initial




                                                                            n
fecting performance, due to the fact that the best move-           pain and periapical lesions. After isolation and access, the
ment for each different clinical situation is automatically        canals of all teeth were prepared using two different in-




                                                                         er
selected by the Adaptive motor.                                    strumentation techniques, irrigated with 5% NaOCl and
The TF Adaptive technique is basically a 3-file technique,         17% EDTA, and obturated with gutta percha and a zinc-
designed for all canals, with differences between small,           oxide eugenol sealer using warm vertical compaction. The


                                             nt
difficult canals andlarge, easy ones, allowing in both
cases an adaquate taper and increased apical prepara-
tion. The number of instruments within the sequence can
also vary and adapt to canal anatomy, being the last in-
                                                                   teeth in group 1 (n = 30) were instrumented with a crown-
                                                                   down technique using TF instruments, whilst those in
                                                                   group 2 (n = 30) were instrumented with a single-file
                                                                   technique, using WaveOne 08 25. The teeth in group 3
                                           iI
strument of the sequence used only when a greater api-             were instrumented using a TF Adaptive technique (n =
cal enlargement is needed due to larger original canal di-         30), using both sequences for small or large canals de-
mensions and/or enhanced final irrigation techniques.              pending on the initial tooth anatomy. All the three instru-
                                         on

It is well known that a small, inadvertent extrusion of de-        mentation technique strictly followed manufacturers’ in-
bris and irrigants into periapical tissues is a frequent           structions. All canals were shaped, cleaned and obturated
complication during the cleaning and shaping proce-                in a single-visit.
dures, both with manual stainless steel and nickel-titanium        Although no systemic medication was prescribed, the pa-
                                i


rotary instrumentation techniques (13-14). However, re-            tients were instructed to take mild analgesics (400 mg of
                             iz


cent studies have shown that reciprocating instrumenta-            ibuprofen), if they experienced pain. The assessment of post
tion techniques seem to significantly increase the amount          operative pain was carried out at 3 days after initial appoint-
of debris extruded beyond the apex and, consequently,              ment by one independent evaluator without knowledge of
              Ed




the risk of postoperative pain (15). A previous clinical           visit group under examination. The presence or absence of
study comparing Reciproc and NiTi rotary instruments has           pain, or the appropriate degree of pain was recorded as
also confirmed these findings (16). Based on these prem-           none, slight, moderate, or severe, by using a visual ana-
ises, the goal of the present study was to evaluate and            logue scale (VAS), validated in previous studies (3):
compare the incidence and intensivity of postoperative             - No pain: the treated tooth felt normal. Patients don’t
pain using three different nickel-titanium instrumentation              have any pain.
 IC




techniques: a rotary crown-down technique using Twisted            - Mild pain: recognizable, but not discomforting, pain,
Files (TF) instruments (SybronEndo, Orange, Ca), a re-                  which required no analgesics.
ciprocating single-file technique using WaveOne instru-            - Moderate pain: discomforting, but bearable, pain
ments (Maillefer Dentsply, Baillagues, CH) and a novel in-              (analgesics, if used, were effective in relieving the
C




strumentation technique (TF Adaptive, SybronEndo,                       pain).
Orange, Ca.), using a unique, proprietary movement,                - Severe pain: difficult to bear (analgesics had little or
combining reciprocation and continuos rotation.                         no effect in relieving the pain).
                                                                   VAS pain scores were compared using one-way ANOVA
©




                                                                   post hoc Tukey test. A value of p < 0.05 was required for
Materials and methods                                              statistical significance.

Ninety patients requiring endodontic treatment on perma-
nent premolar and molar teeth with non vital pulps preop-          Results
eratively were included in the study. These patients
rangedin age from 19 to 73 years (average 46,5 years),             Results are shown in (Table 1). For VAS pain scores a sta-
and all were in good health, as determined from a written          tistically significant difference was found between the
health history and oral interview. Patients who had previ-         Wave One (p=0,021) technique and the other two tech-

Annali di Stomatologia 2013; IV (1): 152-155                                                                                    153
V. Milana et al.


    Table 1. Overall incidence of post operative pain with TF, Reciproc and TF Adaptive instrumentation techniques.

Technique                          No pain                    Mild                      Moderate                      Severe

TF15 ( 50%)                        7 (23,3%)                  6 (20%)                   2 (6,6%)                      –
WaveOne                            9 (30%)                    5 ( 16,6%)                8 ( 26,6%)                    8 (26,6%)




                                                                                                         li
TF Adaptive                        14 (46,6%)                 8 ( 26,6%)                6 (20%)                       2 (6,6%)




                                                                                                      na
niques. No statistical significant differences were found               bris but push them apically. Reciproc and WaveOne mo-
between TF and TF Adaptive (p= 0,087).                                  tion is very similar (even if not precisely disclosed by
When comparing patients who developed no pain, TF and                   manufacturers), and this fact could also explain the higher




                                                                                                   io
TF Adaptive instrumentation technique showed signifi-                   incidence and intensitivity of postoperative pain that was
cantly better results. When evaluating patient experienc-               found in the present study in the WaveOne group.
ing sever pain the incidence of symptoms was signifi-                   Moreover, both WaveOne and Reciproc techniques use




                                                                                                az
cantly higher with the Wave Onesingle-file technique.                   a quite rigid, big single-file of increased taper (usually 08
Overall, severe pain occurred in 13,3% patients. More                   taper, size 25), which directly reach the apex. In many
precisely, it occuredin 30% of patients treated with                    cases, in order to reach the apical working length, recip-
WaveOne and in 6,6% of patients treated with TF and TF                  rocating instruments are used with force directed api-




                                                                                 n
Adaptive.                                                               cally, which makes an effective piston to propel debris
                                                                        from a patent apical foramen. Since instruments are used




                                                                              er
                                                                        without any preliminar coronal enlargement. This results
Discussion                                                              in agreater engagement of flutes and, consequently, more
                                                                        torque or applied pressure are needed. More over cutting



                                                 nt
Root canal preparation procedures are not easy to per-
form, due to anatomical complexities and limitations of the
endodontic instruments, which often result in a high risk
of intracanal failure and other iatrogenic errors (17-18). In
                                                                        ability of a reciprocating file is smaller when compared to
                                                                        a continuous rotation, and also debris removal is smaller,
                                                                        thus increasing the frictional stress and torque demand,
                                                                        due to entrapment of debris within the flutes (19).
                                               iI
most cases dentine chips, pulp tissue fragments, necrotic               The TF Adaptive technique has been proposed in order
tissue, microorganisms and intracanal irrigants may be                  to maximize the advantages of reciprocation, while min-
extruded from the apical foramen during the canal instru-               imizing disadvantages, by using a unique, patented mo-
                                             on

mentation. This is of concern since material extruded                   tion and a 3-file technique. The aim of a sequence is to
from the apical foramen may be related to inflamation of                reduce frictional stress and torque demand, while the
periapical tissue, postoperative pain and or to a flare-up              patented adaptive motor selects automatically the best
(13-14). While there are statistical predictors of postoper-            angles for best performance and safety. In the present
                                   i


ative pain (nonvital teeth, patients already in pain, asymp-            study TF Adaptive technique showed very similar results
                                iz


tomatic teeth with lesions, etc.), its occurrence is not in-            to the TF instrumentation technique which utilize contin-
evitable, and to a large extent, can be avoided, by using               uous rotation. No statistical significant differences were
proper instrumentation and irrigation techniques. Severe                found between the two techniques for both incidence
                 Ed




postoperative pain should be relatively uncommon. In                    and intensitivity of postoperative pain. On the contrary
large measure, its prevention is a function of providing ex-            both techniques were found to produce less post-opera-
cellent treatment, more precisely by creating a well-                   tive pain when compared to the Reciproc technique.
cleaned and shaped canal andby minimizing extrusion of                  Since the incidence of preoperative pain, the type of
canal contents during the process.                                      tooth and the pulp and periodontal pathology were quite
It is quite a common experience during endodontic instru-               similar between thetested groups, and all the other vari-
 IC




mentation courses on extracted teeth, that partecipants vi-             ables (operator, irrigation, obturation) were identical, this
sualize the creation of the “endodontic worm”, a tubular                difference was mainly related to the different instrumen-
mass of canal debris produced primarily by debris pro-                  tation technique. These findings maybe related to two dif-
pelled through the apical foramen by forceful instrumen-                ferent factors: the movement and the sequence.
C




tation, improper irrigation, and a lack of recapitulation.              Despite the fact that the angles are not closed by manu-
This worm is more likely to occur when reciprocation mo-                facturers, visual inspection and/or video recordings shows
tion is used. In clinical practice this worm of debris in-              that the TF Adaptive motion is a reciprocating motion
cludes bacteria, dentin chips, irrigants, and inflamed or               with cutting angles (CW angles) much greater than
©




dead pulp, that when pushed into the periapical tissues                 WaveOne movements. As a consequence the TF Adap-
may elicitate postoperative pain.                                       tive instrument is working more time with a CW angle,
In a previous study (16) a reciprocating single-file tech-              which allows better cutting efficiency and removal of de-
nique (Reciproc) was found to produce a more significant                bris (and less tendency to push debris apically), because
inflamatory response and pain when compared to a rotary                 the flutes are designed to remove debris in a CW rotation.
nickel-titanium crown down instrumentation technique                    In such case TF Adaptive is taking advantage of the use
(TF). Since reciprocation movement is formed by a wider                 of a motion that is more similar to continuous rotationfor
cutting angle and a smaller releasing angle, while rotat-               optimal debris removal. There are obviously some
ing in the releasing angle, the flutes will not remove de-              changes in the angles depending on canal anatomy (the

154                                                                                        Annali di Stomatologia 2013; IV (1): 152-155
The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment


more complex, the smaller the CW angle), but they do not                6.    Plotino G, Grande NM, Mazza C, Petrovic R, Testarelli L,
seem to significantly influence the overall result. On the                    Gambarini G. Influence of size and taper of artificial canals
contrary, these changes influence resistance to metal fa-                     on the trajectory of NiTi rotary instruments in cyclic fatigue
tigue, since TF instruments used with the Adaptive motion                     studies. Oral Surg 2010; 109:60-66.
                                                                        7.    Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa
were found to have superior resistance to cyclic fatigue
                                                                              A, Grande NM, Gambarini G. Bending properties of a new




                                                                                                           li
when compared to the same TF instruments used in con-                         nickel-titanium alloy with a lower percent by weight of nickel.
tinuous rotation.                                                             J Endod 2011; 375




                                                                                                        na
Moreover the use of a sequence and the use of more flex-                8.    Kim HC, Kwak SW, Cheung GS, Ko DH, Chung SM, Lee W.
ible NiTi instruments can be also a important factors in de-                  Cyclic fatigue and torsional resistance of two new nickel-ti-
termining a lower incidence and intensivity of postopera-                     tanium instruments used in reciprocation motion: Reciproc
tive pain, by reducing the amount of apical transportation                    versus WaveOne. J Endod 2012; 38:541-4.
                                                                        9.    Pedullà E, Grande NM, Plotino G, Palermo F, Gambarini G,




                                                                                                     io
and by avoiding to push debris by forcing instruments api-
cally. TF instruments were found to be the most flexible                      Rapisarda E. Cyclic fatigue resistance of two reciprocating
                                                                              nickel-titanium instruments after immersion in sodium
Niti instruments, being significantly more flexible that Pro-
                                                                              hypochlorite. Int Endod J 2012; 3 [Epub ahead of print]
taper and M2, which are instruments with design and




                                                                                                  az
                                                                        10.   Plotino G, Grande NM, Testarelli L, Gambarini G. Cyclic fa-
mass very similar to WaveOne and Reciproc (20-21).                            tigue of Reciproc and WaveOne reciprocating instruments.
In the most complex cases, the initial use of a small NiTi                    Int Endod J 2012; 45:614-618.
instrument (the Tf Adative sequence uses a.04 20 instru-                11.   Gambarini G, Gergi R, Naaman A, Osta N, Al Sudani D.
ment, which can be considered as a reciprocating                              Cyclic fatigue analysis of twisted file rotary NiTi instruments




                                                                                  n
pathfinder) could be very useful. It has been shown with                      used in reciprocating motion. Int Endod J 2012; 45:802-806.
Reciproc and WaveOne instrumentation techniques that                    12.   Gambarini G, Rubini AG, Al Sudani D, Gergi R, Culla A, De




                                                                               er
the use of a small Niti rotary pathfinder is very helpful in                  Angelis F, Di Carlo S, Pompa G, Osta N, Testarelli L. Influ-
reducing iatrogenic errors, such as extrusion of debris and                   ence of Different Angles of Reciprocation on the Cyclic Fa-
                                                                              tigue of Nickel-Titanium Endodontic Instruments. J Endod
apical transportation (22).
                                                                              2102; 38:1408-11.


                                                nt
Hence we may conclude that the new TF Adaptive tech-
nique is a unique reciprocating technique that is able to
minimize the risk of pushing debris apically and conse-
quently higher postoperative pain, a risk which is always
                                                                        13.   Oginni A, Udoye C. Endodontic flare-ups: comparison of in-
                                                                              cidence between single and multiple visit procedures in pa-
                                                                              tients attending a Nigerian teaching hospital. BMC Oral
                                                                              Health 2004; 4:4-6.
                                              iI
present in a reciprocating morion (to a less or higher ex-              14.   Siqueira JF, Jr Rocas IN, Favieri A, Machado AG, Gahyva
tent), due to the fact that in one sense of rotation the flutes               SM, Oliveira JC, Abad EC. Incidence of postoperative pain
remove debris, while in the opposite sense the debris are                     after intracanal procedures based on an antimicrobial strat-
                                            on

pushed apically.                                                              egy. J Endod 2002; 28:457-460.
                                                                        15.   Bürklein S, Schäfer E. Apically extruded debris with recip-
                                                                              rocating single-file and full-sequence rotary instrumentation
                                                                              systems. J Endod 2012; 38:850-2.
Acknowledgments                                                         16.   Gambarini G, Sudani DAL, Di Carlo S, Pompa G, Pacifici A,
                                  i


                                                                              Pacifici L, Testarelli L. Incidence and intensivity of postop-
                               iz


Authors thank SybronEndo for supporting the study by                          erative pain and periapical inflammation after endodontic
providing the Adaptive TF instruments and motor.                              treatment with two different instrumentation techniques. Eu-
                                                                              rop J Inflam 2102; 10:99-103.
               Ed




                                                                        17.   Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini
                                                                              G. Measurement of the trajectory of different NiTi rotary in-
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Annali di Stomatologia 2013; IV (1): 152-155                                                                                             155
