Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper Next rotary file systems: A randomized clinical trial

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124 © 2017 Indian Journal of Health Sciences and Biomedical Research KLEU | Published by Wolters Kluwer - Medknow
Comparative evaluation of
postoperative pain after single visit
endodontic treatment using ProTaper
Universal and ProTaper Next rotary le
systems: A randomized clinical trial
Neha Arora, Sonal Bakul Joshi
Abstract:
INTRODUCTION: Root canal preparation may cause inadvertent apical extrusion of debris causing
postoperative pain. This debris varies with the instrumentation technique and design characteristics.
One of the major revolutions in the design of the instruments is the introduction of les with an offset
center of mass or/and rotation, which causes asymmetric rotary motion in the canal. An example is the
ProTaper Next (PTN) rotary le system. In vitro studies have shown that this system extrudes lesser
debris than more commonly used ProTaper Universal (PTU). However, in clinical circumstances,
periapical tissues may act as a natural barrier and host immune response may affect the response.
Hence, the aim of the present study was to evaluate and compare the postoperative pain after single
visit endodontic treatment using PTU and PTN rotary le systems.
STUDY DESIGN: A total of 80 patients were assigned to two groups according to the root canal
instrumentation technique used, PTU or PTN. Root canal treatment was carried out in a single
appointment, and the severity of postoperative pain was assessed using visual analog scale score
after 6, 24, 48, and 72 h. The association of variables (age and sex) and root canal preparation time
were also evaluated and compared between the groups.
RESULTS: Postoperative pain was signicantly higher in PTU group than PTN group. The highest
pain was observed at 6 h interval which reduced with each time with no pain at 72 h interval in
both the groups. Signicantly, more amount of time was involved with PTU as compared to PTN.
A signicantly higher pain was observed with advancing age and in females.
CONCLUSION: The postoperative pain was signicantly higher in patients undergoing canal
instrumentation with PTU rotary instruments as compared to the PTN rotary instruments.
Keywords:
Postoperative pain, ProTaper Next, ProTaper Universal, single visit endodontics
Introduction
The increase in the lifespan of the
individuals and higher success rates
in endodontics have widened the scope
of endodontics. Today, extraction of the
teeth has become a rarity and endodontic
intervention a norm.[1] Even with a better
understanding of the internal tooth anatomy,
evolution of instruments and materials and
a greater know‑how regarding techniques
for treatment modalities, complications
do surface. Postoperative pain, which is
an undesirable complication, is frequently
encountered and found to range between
3% and 58% in root canal treatment.
Address for
correspondence:
Dr. Neha Arora,
Department of
Conservative Dentistry
and Endodontics, KLE
V. K. Institute of Dental
Sciences, Belagavi,
Karnataka, India.
E-mail: neha.arora.dr@
gmail.com
Department of
Conservative Dentistry
and Endodontics, KLE
V. K. Institute of Dental
Sciences, Belagavi,
Karnataka, India
Original Article
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DOI:
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How to cite this article: Arora N, Joshi SB.
Comparative evaluation of postoperative pain after
single visit endodontic treatment using ProTaper
Universal and ProTaper Next rotary le systems: A
randomized clinical trial. Indian J Health Sci Biomed
Res 2017;10:124-30.
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Arora and Joshi: Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper
Next rotary le systems: A randomized clinical trial
Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 10, Issue 2, May-August 2017 125
This postoperative pain is dependent on many
factors that include host‑dependent factors such as
host immunity, history of preoperative pain, and
occlusal trauma or operator‑dependent factors such as
chemical, mechanical, or bacterial injury during root
canal preparation.[2] Of these, inadvertent extrusion of
dentin chips, microorganisms, pulpal tissue remnants,
or necrotic debris into the periapical region during
preparation forms a major factor of postoperative pain.
This debris varies with the instrumentation technique
and the instrument per se Therefore, an instrument that
extrudes minimal debris into the periapical area, thus
causing lesser pain, is desirable.[3]
Over the decades, research has led to a full
sequence, variable taper rotary instrument, that is,
ProTaper Universal (PTU) by Dentsply‑Maillefer
(Ballaigues, Switzerland). This system has shown
encouraging results in terms of shaping ability. However,
its disadvantages include the increased number of
instruments, learning curve, and instrument fatigue.[4]
The newer fth generation of les has been designed
such that the center of mass and/or the center of rotation
are offset. This produces a mechanical wave of motion
that travels along the active length of the le, minimizing
the engagement of le to the root dentin ProTaper Next
(PTN) (Dentsply‑Maillefer, Ballaigues, Switzerland) is
an example of this generation.[5]
In vitro studies have shown that the PTN extruded
lesser debris as compared to the conventional and
more commonly used PTU.[6] However, in clinical
circumstances, periapical tissues may act as a natural
barrier, positive and negative pressure at the apex,
normal or pathological periapical tissues, immature root
development, and open apices affect debris extrusion.
Furthermore, the host immune response could affect
the presentation of postoperative pain.[2] A randomized
clinical trial evaluating the two abovementioned systems
with respect to the postoperative pain was aimed for as it
provides the highest level of support for evidence‑based
clinical practice.[7]
Endodontic treatment could be offered in single or
multiple visits. Single visit endodontic treatment with its
advantages such as reduction in the number of operative
procedures, no risk of inter‑appointment leakage,
lesser time, relatively inexpensive, and decreased
overall postoperative pain has taken over multiple visit
treatment in recent times as the preferred modality.[8]
Hence, a study aimed at evaluating and comparing
the postoperative pain after single visit endodontic
treatment using PTU and PTN rotary le systems has
been conducted.
Aim
To evaluate and compare the postoperative pain after
single visit endodontic treatment using PTU and PTN
rotary le systems in a randomized clinical trial.
Materials and Methods
This randomized clinical trial was conducted in the
Department of Conservative Dentistry and Endodontics,
KLE V. K. Institute of Dental Sciences, Belagavi,
Karnataka. This study was approved by the Research
and Ethical Committee, KLE University’s V K Institute of
Dental Sciences (Reg. No 906; Dated: 30th October 2014).
Eighty patients in the age group 18–50 years, taking into
account 10% dropouts if present, requiring endodontic
treatment on asymptomatic permanent maxillary premolar
teeth diagnosed as vital using pulp sensitivity tests were
selected for the study from the regular pool of patients.
The procedure was explained to the patient in his/her own
language, and a written informed consent was obtained.
Important prognostic determinants of postoperative pain
such as age and gender were recorded. A single clinician
evaluated and treated all patients. Patients were divided
into two groups using table of random numbers.
Local anesthesia (2% lignocaine 1:80,000 adrenaline)
(Xicaine, ICPA Health Products Ltd., Ankleshwar,
Gujarat, India) was administered and rubber dam
applied (Hygienic, Coltene/Whaledent). The tooth was
then disinfected with Möller’s procedure.[9]
Access cavity was prepared and canal patency checked
by #10 K‑le. (Mani Inc., Japan). The working length was
determined using DentaPort ZX (J. Morita Mfg. Corp.,
Kyoto, Japan) and conrmed with radiograph. Glide
path was created by #15 K‑le (Mani Inc., Tochigi, Japan).
Subsequently, root canal preparation was accomplished
by one of the following two instrumentation systems, in
Group A (n = 40) with full‑sequence rotary PTU les up to
size F2 (25/08) and in Group B (n = 40) PTN les up to size
X2 (25/06) according to the manufacturer’s instructions.
Irrigation was performed with 3% NaOCl, 17%
ethylenediaminetetraacetic acid, and 0.9% normal saline
according to protocol suggested by Schafer et al.[10]
Master cone radiograph was taken and both groups
were obturated with single cone obturation technique
with an epoxy resin based sealer (AH Plus® Sealer
(Dentsply DeTrey, Konstanz, Germany)). Temporary
restoration (Cavit G, 3M ESPE Dental‑Medizin GmbH
Co, Seafeld, Germany) was given and postobturation
IOPAR was taken.
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Arora and Joshi: Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper
Next rotary le systems: A randomized clinical trial
126 Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 10, Issue 2, May-August 2017
In group B, a statistically signicant difference (P < 0.05)
was observed between the VAS scores at time periods 6 h
versus 24 h, 6 h versus 48 h, 6 h versus 72 h, 24 h versus
48 h, 24 h versus 72 h [Table 3].
Time for canal preparation was measured from the rst
le that was used to check canal patency till the last le
that was used to instrument the canal.[11]
The patients were instructed to take mild analgesic
(400 mg ibuprofen), if they experienced pain. The
presence or absence of postoperative pain, or the
appropriate degree of pain was recorded as none, slight,
moderate, or severe, using a modied visual analog
scale (VAS), validated in previous studies:[12]
• No pain (0): The treated tooth felt normal. Patients
did not have any pain
• Mild pain (1): Recognizable, but not discomforting,
pain, which required no analgesics
• Moderate pain (2): Discomforting, but bearable,
pain (analgesics, if used, were effective in relieving
the pain)
• Severe pain (3): Difcult to bear (analgesics had little
or no effect in relieving the pain).
The amount of analgesic, if taken, was recorded at that
particular time interval. The patients were instructed to
call the clinic if adequate pain relief was not obtained
with the prescription.
Statistical analysis
Statistical analysis was performed using SPSS software
(IBM SPSS Statistics for Windows, Version 20.0. Armonk,
NY: IBM Corp ).
• Intergroup pairwise comparison with VAS scores
at different time points was carried out using
Man–Whitney U‑test
• Intragroup pairwise comparison with VAS scores at
different time points was carried out using Wilcoxon
matched pairs test
• To assess the association of variables (age and sex)
with VAS scores, Chi‑square test was used
• The time required for instrumentation of the canals in
both groups was compared using independent t‑test.
Results
At the end of 6 h, although not statistically signicant
(P = 0.1021), higher VAS scores were observed in Group
A than Group B, which were clinically signicant. A
statistically signicant difference was observed with
VAS scores between Groups A and B at the end of 24 h
(P = 0.0133) and 48 h (P = 0.0493) with higher VAS scores
observed in Group A [Table 1 and Figure 1].
In group A, a statistically signicant difference (P < 0.05)
was observed between the VAS scores at all time periods
6 h versus 24 h, 6 h versus 48 h, 6 h versus 72 h, 24 h
versus 48 h, 24 h versus 72 h, 48 h versus 72 h [Table 2].
Table 1: Comparison of Group A and Group B with
visual analog scale scores at different time points
using Mann‑Whitney U‑test
Time Scores Group A (%) Group B (%) Total (%)
6 h Score 0 23 (57.50) 29 (72.50) 52 (65.00)
Score 1 5 (12.50) 6 (15.00) 11 (13.75)
Score 2 12 (30.00) 5 (12.50) 17 (21.25)
Score 3 0 0 0
Mann‑Whitney U‑test, Z=−1.6350, P=0.1021
24 h Score 0 25 (62.50) 34 (85.00 59 (73.75)
Score 1 9 (22.50) 6 (15.00) 15 (18.75)
Score 2 6 (15.00) 0 6 (7.50)
Score 3 0 0 0
Mann‑Whitney U‑test, Z=−2.4763, P=0.0133*
48 h Score 0 34 (85.00) 39 (97.50) 73 (91.25)
Score 1 6 (15.00) 1 (2.50) 7 (8.75)
Score 2 0 0 0
Score 3 0 0 0
Mann‑Whitney U‑test, Z=−1.9660, P=0.0493*
72 h Score 0 40 (100.00) 40 (100.00) 80 (100.00)
Score 1 0 0 0
Score 2 0 0 0
Score 3 0 0 0
Mann‑Whitney U‑test, Z=0.0000, P=1.0000
Total 40 (100.00) 40 (100.00) 80 (100.00)
*P<0.05
Table 2: Intra‑group (Group A) pairwise comparison
of visual analog scale scores at 6, 24, 48, and 72 h
by Wilcoxon matched pairs test
Time points Percentage of change t Z P
6 h versus 24 h 27.59 0.00 2.5205 0.0117*
6 h versus 48 h 79.31 0.00 3.6214 0.0003*
6 h versus 72 h 100.00 0.00 3.6214 0.0003*
24 h versus 48 h 71.43 0.00 3.4078 0.0007*
24 h versus 72 h 100.00 0.00 3.4078 0.0007*
48 h versus 72 h 100.00 0.00 2.2014 0.0277*
*P<0.05
Table 3: Intra‑group (Group B) pairwise comparison
of visual analog scale scores at 6, 24, 48, and 72 h
by Wilcoxon matched pairs test
Time points Percentage of change t Z P
6 h versus 24 h 62.50 0.00 2.8031 0.0051*
6 h versus 48 h 93.75 0.00 2.9341 0.0033*
6 h versus 72 h 100.00 0.00 2.9341 0.0033*
24 h versus 48 h 83.33 0.00 2.0226 0.0431*
24 h versus 72 h 100.00 0.00 2.2014 0.0277*
48 h versus 72 h 100.00 0.00 ‑ ‑
*P<0.05
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Arora and Joshi: Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper
Next rotary le systems: A randomized clinical trial
Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 10, Issue 2, May-August 2017 127
Figure 1: Comparison of Group A and Group B with visual analog scale scores at
different time points Figure 2: Comparison of Group A and Group B with mean time taken
The canal preparation time was signicantly shorter in
the Group B in comparison with the Group A (5.49 ± 1.06
min vs. 11.28 ± 1.72 min) [Table 4 and Figure 2].
Discussion
Evolution is the way of life and endodontics is not
untouched by it. Manufacturers and researchers have
readily come up with newer file systems utilizing
the most proven design features from the past and
adding to it the most recent technological advancement
available, to produce safer, more efcient, and simpler
le systems.[5]
However, it has been observed that all instrumentation
techniques, either manual or mechanical cause
inadvertent extrusion of debris into the periapex.[13]
This debris may include dentinal chips, microorganisms,
pulpal tissue remnants, irrigating solutions, or necrotic
tissue.[14] Extrusion of this debris causes injury resulting
in inammation.[15]
However, it has also been observed that some instruments
and instrumentation techniques extrude lesser debris
than others.[16] Thus, causing lesser postoperative pain.
This postoperative pain affects the patient’s quality of
and in turn serves as a benchmark to judge the clinician’s
skill. Hence, postendodontic pain is an undesirable
occurrence for even the clinicians.[17]
The design of the root canal instrument has been
determined to be the most influential factor for
neuropeptide expression after root canal preparation,
regardless of the number of files or the type of
movement.[18] There is a plethora of research in the design
of the instrument to decrease this postoperative pain.
There has been a revolution in the alloy used for
manufacturing these instruments too. The progression
from manual to the mechanical usage of NiTi instruments
in a rotary motion revolutionized the way root canals
were treated.[19]
The clinical effectiveness of the les increased manifold
through the introduction of thermomechanically treated
NiTi le systems such as M‑Wire, R‑phase, controlled
memory, and gold wire.[20]
Another major advancement was the introduction
of reciprocating motion. However, it was shown to
extruded more debris apically than les in continuous
motion.[21]
Thus, continuous research is going on in terms of their
designs, alloy types, and the motions employed to
accomplish an ideal preparation with predictability and
minimal postoperative pain.[22]
One of the results of the continuous research was a
progressively tapered design in a single le. This design
has been shown to signicantly improve exibility,
cutting efciency, and safety.[23] The full sequence PTU
system is an example of such a design. It is one of the
most commonly used rotary NiTi systems.[24] This system
has shown encouraging results in terms of its shaping
ability. Its disadvantages include the use of increased
number of instruments, increased learning curve,
increased fatigue, and increased treatment time.[4]
The newer fifth generation of rotary files has been
designed such that the center of mass and/or the
Table 4: Comparison of two study groups (Group A
and Group B) with mean time by independent t‑test
Group nMean±SD t P
Group A 40 11.28±1.72 18.1443 0.0001*
Group B 40 5.49±1.06
*P<0.05. SD=Standard deviation
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Arora and Joshi: Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper
Next rotary le systems: A randomized clinical trial
128 Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 10, Issue 2, May-August 2017
center of rotation are offset. Such a design produces a
mechanical wave of motion that travels along the active
length of the le further minimizing the engagement
of le to the root dentin[25] PTN is an example of this
generation.
In vitro studies have concluded that PTN les were
associated with significantly lesser apical debris
extrusion as compared to PTU system. However, the
results of in vitro (simulated) studies cannot be directly
extrapolated to the clinical situations. In clinical
circumstances, dental pulp, and periapical tissues may
act as a natural barrier for extrusion of this debris.[6]
A common difculty encountered in studying pain is
the patient’s subjective evaluation of pain.[26] Therefore,
the design of the questionnaire is critical, and it must be
fully understood by the patients and easily interpreted
by statisticians and researchers.[27] For rating the
intensity of pain, a modied VAS was selected as it has
been recommended in a report of Cochrane database
of systematic reviews for postendodontic pain. They
suggest that the level of discomfort/pain must be rated
in categories arranged in advanced order and exactly
described with the use of analgesics. Thus, making it
accurate criteria for quantifying pain.[12]
Nonsteroidal anti‑inflammatory drugs, especially
Ibuprofen has been recommended as first choice
medication for postoperative pain management after
endodontic treatment.[28]
The results obtained in this study indicate that the
postoperative pain obtained after root canal
instrumentation with PTU rotary le system (Group A)
was consistently higher than in instrumentation with PTN
system (Group B). Hence, the null hypothesis was rejected.
Koçak et al.,[6] Ozsu et al.[29] and Capar et al.[30] in their
in vitro studies have found that PTU extruded more
debris apically as compared to PTN. As the postoperative
pain after endodontic treatment is strongly implicated
to the apical extrusion of debris, we can conclude that
these results are similar to the abovementioned studies.
The design of PTN le system boasts of an off‑centered
rectangular cross section resulting in only two point
contact to the root canal wall at a time. The axis of
rotation in the PTN system differs from the center of
mass. The offset design of the PTN system along with
its swaggering motion in the canal could have enhanced
the augering of debris out of the canal coronally rather in
the apical direction.[5,6] Thus, causing lesser postoperative
pain.
As there were more number of files (five) in PTU
group (Group A) as compared to three les only in
PTN (Group B), the le insertion time increased leading
to more debris produced and compacted tightly along
dentine walls which made it difcult to be ushed out
of the canal.[31]
In addition, the larger taper in PTU F2 le (8%) (Group A)
as compared to PTN X2 (Group B) which has only 6%
taper, could result in more aggressive cutting, thus more
debris production.[29]
The thermomechanical treatment results in an increase
in exibility of the PTN les (M‑wire) due to which
it maintains the canal curvature well, causing lesser
canal transportation than PTU (conventional NiTi).
Maintaining the canal curvature well has been shown
to result in lesser iatrogenic defects and thus lesser
potential to create and extrude debris and thus, lesser
postoperative pain.[32]
The difference between postoperative pain between
Group A (PTU) and B (PTN) at 6 h was, however, not
signicant. This could be rst attributed to the in vivo,
controlled and randomized study design.[33] Another
major factor could be the “Hawthorne effect.” This
effect refers to the change in behavior of a subject
because of the special attention and status received from
participation in an investigation which could provoke
them to overestimate their pain levels initially causing
an apparent discordance until a day has passed.[34]
In the results of this study, a pattern was also seen
regarding the intensity of pain experienced by patients
within the group wherein the greatest intensity of pain,
if any, was recorded 6 h after the therapy, and afterward
it decreased continuously (statistically significant,
P < 0.05) resulting in no pain at all in both the groups
at 72 h.
These results are similar to the results obtained by
Kherlakian et al.[15] and Relvas et al.[34] Apart from the
Hawthorne effect another possible reason attributable to
this result, is the wearing off of the local anesthetic effect in
the immediate 6 h following the endodontic procedure.[35]
In addition to this, the glide path establishment before
rotary instrumentation, as followed in this study, has
been shown to result in less postoperative pain and faster
symptom resolution.[36]
There was no pain seen at the 72 h follow‑up in either
of the groups. This is in accordance with previous
studies that state that postendodontic pain, if present,
lasts <72 h.[37]
Furthermore, because the active time of canal preparation
required when using an instrumentation system is an
important factor considered by most clinicians because
of its impact on patient’s overall comfort and time
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Arora and Joshi: Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper
Next rotary le systems: A randomized clinical trial
Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 10, Issue 2, May-August 2017 129
available for irrigation, the preparation time of each
of the evaluated instrumentation systems was also
calculated.[21]
In this study, it was observed that the difference in
the canal preparation time was highly signicant. The
time required was much more in Group A (PTU) in
comparison with the Group B (PTN) (11.28 ± 1.72 min vs.
5.493 ± 1.06 min, P < 0.001). The results are similar
to a study by Bürklein et al.[38] This could be due to
the difference in a number of les used, that is, ve
for PTU group on comparison with only three for
PTN group.[30] Another possible explanation could be
off‑centered rectangular cross section of PTN les. Such a
modication in the cross‑section involves a reduction of
the contact area with the canal and therefore, results in
higher cutting efciency resulting in less time required
for preparation.[39]
In the present study, it was observed that as the age
advanced among the samples, the severity of pain also
increased. These results are similar to Ali et al. This may
be because of less pain tolerance, less blood ow, and
delayed healing.
In this study, it was observed that the female patients
experienced more pain as compared to their male
counterparts. These results are similar to Ali et al. This
could be attributed to uctuating female hormone levels.[7]
The ultimate success in endodontics cannot be correlated
directly to postoperative pain. The success and failure
of endodontic treatment are determined by long‑term
results and not the presence or absence of short‑term
postoperative pain.[40]
It should be noted that the results of this one clinical
study cannot be generalized to all clinical cases, and more
such studies with a larger sample size and association
of more number of variables are required. Future
research comparing the postoperative pain after root
canal preparation experienced by symptomatic patients
is suggested.
Conclusion
Within the limitations of this study, the following
conclusions were drawn:
• Highest intensity of pain was observed at 6 h after the
treatment, after which the intensity of pain decreased
in both the groups, with no pain observed at 72 h
follow‑up
• Postoperative pain was significantly higher in
patients undergoing root canal instrumentation with
the PTU rotary instruments than PTN le system at
the end of 24 and 48 h
• The canal preparation time was signicantly lesser
in the PTN group than the PTU group.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
References
1. Castellucci A. Magnication in endodontics: The use of the
operating microscope. Pract Proced Aesthet Dent 2003;15:377‑84.
2. Siqueira JF Jr., Rôças IN, Favieri A, Machado AG, Gahyva SM,
Oliveira JC, et al. Incidence of postoperative pain after intracanal
procedures based on an antimicrobial strategy. J Endod
2002;28:457‑60.
3. Ruiz‑Hubard EE, Gutmann JL, Wagner MJ. A quantitative
assessment of canal debris forced periapically during root
canal instrumentation using two different techniques. J Endod
1987;13:554‑8.
4. Gambarini G, Laszkiewicz J. A scanning electron microscopic
study of debris and smear layer remaining following use of GT
rotary instruments. Int Endod J 2002;35:422‑7.
5. Ruddle CJ, Machtou P, West JD. The shaping movement:
Fifth‑generation technology. Dent Today 2013;32:94, 96‑9.
6. Koçak MM, Çiçek E, Koçak S, Saglam BC, Yilmaz N. Apical
extrusion of debris using ProTaper Universal and ProTaper Next
rotary systems. Int Endod J 2015;48:283‑6.
7. 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.
8. Sathorn C, Parashos P, Messer HH. Effectiveness of single‑ versus
multiple‑visit endodontic treatment of teeth with apical
periodontitis: A systematic review and meta‑analysis. Int Endod
J 2005;38:347‑55.
9. Möller AJ. Microbiological examination of root canals and
periapical tissues of human teeth. Methodological studies.
Odontol Tidskr 1966;74 Suppl:1‑380.
10. Schafer E. Irrigation of the root canal. ENDO 2007;1:11‑27.
11. Bürklein S, Benten S, Schäfer E. Quantitative evaluation of apically
extruded debris with different single‑le systems: Reciproc, F360
and OneShape versus Mtwo. Int Endod J 2014;47:405‑9.
12. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits
for endodontic treatment of permanent teeth. Cochrane Database
Syst Rev 2007;(4).
13. Silva EJ, Carapiá MF, Lopes RM, Belladonna FG, Senna PM,
Souza EM, et al. Comparison of apically extruded debris after
large apical preparations by full‑sequence rotary and single‑le
reciprocating systems. Int Endod J 2016;49:700‑5.
14. Fava LR. A comparison of one versus two appointment
endodontic therapy in teeth with non‑vital pulps. Int Endod J
1989;22:179‑83.
15. Kherlakian D, Cunha RS, Ehrhardt IC, Zuolo ML, Kishen A,
da Silveira Bueno CE. Comparison of the incidence of
postoperative pain after using 2 reciprocating systems and a
continuous rotary system: A prospective randomized clinical
trial. J Endod 2016;42:171‑6.
16. Reddy SA, Hicks ML. Apical extrusion of debris using two hand
and two rotary instrumentation techniques. J Endod 1998;24:180‑3.
17. El Mubarak AH, Abu‑bakr NH, Ibrahim YE. Postoperative pain
in multiple‑visit and single‑visit root canal treatment. J Endod
2010;36:36‑9.
[Downloaded free from http://www.ijournalhs.org on Wednesday, January 23, 2019, IP: 93.176.134.160]

Arora and Joshi: Comparative evaluation of postoperative pain after single visit endodontic treatment using ProTaper Universal and ProTaper
Next rotary le systems: A randomized clinical trial
130 Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 10, Issue 2, May-August 2017
18. Topçuoglu HS, Zan R, Akpek F, Topçuoglu G, Ulusan Ö, Akti A,
et al. Apically extruded debris during root canal preparation using
Vortex Blue, K3XF, ProTaper Next and Reciproc instruments. Int
Endod J 2016;49:1183‑7.
19. Hargreaves K, Cohen S. Cohen’s Pathways of the Pulp Expert
Consult. 10th ed. St. Louis: Mosby; 2010.
20. Brantley W, Alapati SB. Heat treatment of dental alloys: A review.
Rijeka, Croatia: InTech Open Access Publisher; 2012.
21. Bürklein S, Schäfer E. Apically extruded debris with reciprocating
single‑le and full‑sequence rotary instrumentation systems.
J Endod 2012;38:850‑2.
22. Kim S. Modern endodontic practice: Instruments and techniques.
Dent Clin North Am 2004;48:1‑9.
23. Ruddle CJ. TheProTaper technique. Endodontic Topics
2005;10:187‑90.
24. Brito‑Júnior M, Faria‑E‑Silva AL, Camilo CC, Pereira RD,
Braga NM, Sousa‑Neto MD. Apical transportation associated
with ProTaper Universal F1, F2 and F3 instruments in curved
canals prepared by undergraduate students. J Appl Oral Sci
2014;22:98‑102.
25. Hashem AA, Ghoneim AG, Lutfy RA, Foda MY, Omar GA.
Geometric analysis of root canals prepared by four rotary NiTi
shaping systems. J Endod 2012;38:996‑1000.
26. DiRenzo A, Gresla T, Johnson BR, Rogers M, Tucker D, BeGole EA.
Postoperative pain after 1‑ and 2‑visit root canal therapy. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:605‑10.
27. Arias A, Azabal M, Hidalgo JJ, de la Macorra JC. Relationship
between postendodontic pain, tooth diagnostic factors, and apical
patency. J Endod 2009;35:189‑92.
28. Keiser K, Byrne BE. Endodontic pharmacology. In: Hargreaves KM,
Cohen S, editors. Pathways of the Pulp. 10th ed. St. Louis: Mosby
Elsevier; 2011. p. 671‑90.
29. Ozsu D, Karatas E, Arslan H, Topcu MC. Quantitative evaluation
of apically extruded debris during root canal instrumentation with
ProTaper Universal, ProTaper Next, WaveOne, and self‑adjusting
le systems. Eur J Dent 2014;8:504‑8.
30. Capar ID, Arslan H, Akcay M, Ertas H. An in vitro comparison of
apically extruded debris and instrumentation times with ProTaper
Universal, ProTaper Next, Twisted File Adaptive, and HyFlex
instruments. J Endod 2014;40:1638‑41.
31. Li H, Zhang C, Li Q, Wang C, Song Y. Comparison of cleaning
efciency and deformation characteristics of Twisted File and
ProTaper rotary instruments. Eur J Dent 2014;8:191‑6.
32. Ansari I, Maria R. Managing curved canals. Contemp Clin Dent
2012;3:237‑41.
33. Nekoofar MH, Sheykhrezae MS, Meraji N, Jamee A, Shirvani A,
Jamee J, et al. Comparison of the effect of root canal preparation
by using WaveOne and ProTaper on postoperative pain: A
randomized clinical trial. J Endod 2015;41:575‑8.
34. Relvas JB, Bastos MM, Marques AA, Garrido AD, Herkrath FJ,
Sponchiado EC Jr. Erratum to: Assessment of postoperative
pain after reciprocating or rotary NiTi instrumentation of root
canals: A randomized, controlled clinical trial. Clin Oral Investig
2016;20:1995.
35. Peñarrocha‑Diago M, Maestre‑Ferrín L, Peñarrocha‑Oltra D,
Gay‑Escoda C, von‑Arx T, Peñarrocha‑Diago M. Pain and swelling
after periapical surgery related to the hemostatic agent used:
Anesthetic solution with vasoconstrictor or aluminum chloride.
Med Oral Patol Oral Cir Bucal 2012;17:e594‑600.
36. Pasqualini D, Mollo L, Scotti N, Cantatore G, Castellucci A,
Migliaretti G, et al. Postoperative pain after manual and
mechanical glide path: A randomized clinical trial. J Endod
2012;38:32‑6.
37. Marshall JG. Consideration of steroids for endodontic pain. Endod
Topics 2002;3:41‑51.
38. Bürklein S, Mathey D, Schäfer E. Shaping ability of ProTaper
NEXT and BT‑RaCe nickel‑titanium instruments in severely
curved root canals. Int Endod J 2015;48:774‑81.
39. Blum JY, Machtou P, Micallef JP. Location of contact areas on
rotary Prole instruments in relationship to the forces developed
during mechanical preparation on extracted teeth. Int Endod J
1999;32:108‑14.
40. Paredes‑Vieyra J, Acosta Guardado J. Incidence and severity
of post‑operative pain following root canal treatment of teeth
with non‑vital pulps using hand and rotary instrumentation
techniques. Endod Pract 2009;2:27‑30.
[Downloaded free from http://www.ijournalhs.org on Wednesday, January 23, 2019, IP: 93.176.134.160]