CONSORT Randomized Clinical Trial

Postoperative Pain Intensity after Single- versus

2-visit Nonsurgical Endodontic Retreatment:
A Randomized Clinical Trial
€
Yelda Erdem Hepsenoglu, PhD,* Tan F. Eyuboglu, PhD,* and Mutlu Ozcan, PhD†

Abstract
Introduction: The aim of this study was to evaluate
postoperative pain after single-visit and 2-visit
non-surgical endodontic retreatments with 2 different
R oot canal treatment
(RCT) is a dental pro-
cedure that consists of the
Significance
The present study helps to better understand the
effects of single-visit and multiple-visit retreatment
intracanal medicaments. Methods: A total of 150 removal of infectious tissue
methods on postoperative pain.
patients with asymptomatic root canal–treated teeth followed by cleaning and
in need of nonsurgical endodontic retreatment were shaping of the remaining
randomly divided into 3 groups (n = 50). Patients tooth structure based on the original root canal. With novel techniques and materials,
were selected randomly from among those without pre- RCT can be completed safely in a single visit instead of multiple visits. Retreatment is a
operative pain. Patients in group 1 (single visit) were type of procedure that is applied when previous RCTs have failed. Postoperative pain
treated in a single visit. Patients in group 2 and group after endodontic retreatment is an undesirable occurrence for patients and clinicians
3 were treated in different visits with calcium hydroxide (1).
and chlorhexidine (CHX) as intracanal medicaments. The Postoperative pain is the result of acute inflammation in the periradicular tissue
presence of postoperative pain was assessed 1, 2, 3, and caused by the penetration of microorganisms from the root canal during endodontic
7 days and 1 month after treatment. All 2-visit treat- retreatment (2). Postoperative pain is associated with the number of visits as well as
ments were completed 1 week after the initial visit. preoperative factors, preoperative complications, the periapical index (PAI) score,
Data were analyzed using the Mann-Whitney U, the size of the radiolucency, the quality of the coronary restoration, intraoperative fac-
Kruskal-Wallis, and Pearson chi-square tests tors, the intracanal medications, tooth localization, inadequate instrumentation, extru-
(a = 0.01, 0.05). Results: Postoperative pain was signif- sion of intracanal medicament, age, sex, periapical pathosis, and apical debris
icantly higher in the CHX group in comparison with the extrusion and irrigant extrusion (3, 4).
single-visit group (P # .05) on the first day of assess- Calcium hydroxide (Ca[OH]2) has been recommended as a very effective intraca-
ment. On the second day, postoperative pain was signif- nal medicament to control infection. It reduced the incidence of interappointment
icantly less in the single-visit group (P < .05) than in the symptoms more effectively than traditional medications, such as camphorated paramo-
other 2 groups. There were no significant differences nochlorophenol iodine, potassium iodide, and formocresol. The exact mechanism of
among the groups on the third and seventh days of action of Ca(OH)2 is not clearly understood. Most of its favorable properties have
assessment. At the 1-month assessment, postoperative been correlated with its high alkalinity (5, 6). However, Ca(OH)2 is not effective
pain was significantly higher in both the calcium hydrox- against all microorganisms found in the root canal system (7). It has been reported
ide group (P < .05) and the CHX group (P < .05) in com- that Enterococcus faecalis shows a resistance to elevated pH; it has the ability to pene-
parison with the single-visit group. Conclusions: trate dentinal tubules and to adapt to different environmental conditions (8). Therefore,
Single-visit nonsurgical endodontic retreatment pre- different intracanal medicaments have been used inside the root canal to overcome the
sented fewer incidences of postoperative pain in com- disadvantages of Ca(OH)2.
parison with 2-visit nonsurgical endodontic Chlorhexidine (CHX) is another commonly used intracanal material in endodontic
retreatment based on assessments ranging from 1 day therapy that has significant antibacterial effects on intracanal microorganisms (9). The
to 1 month. (J Endod 2018;-:1–8) gel form of CHX was introduced as a root canal medicament because of its wide ranging
antimicrobial activity and low toxicity, which makes it an ideal medicament for end-
Key Words odontic purposes (2).
Intracanal medicament, multiple-visit root canal treat- Over the past several years, there has been a growing concern about the urgency of
ment, postoperative pain, retreatment, single-visit root multiple appointments in endodontic treatments because no significant differences in
canal treatment antimicrobial efficacies have been reported between single-visit and multiple-visit

From the *Department of Endodontics, School of Dentistry, Istanbul Medipol University, Istanbul, Turkey; and †Dental Materials Unit, Center for Dental and Oral
Medicine, Clinic for Fixed and Removable Prosthodontics and Dental Materials Science, University of Z€urich, Z€urich, Switzerland.
€
Address requests for reprints to Dr Yelda Erdem Hepsenoglu, Istanbul Medipol University, Unkapanı, Atat€urk Bulvarı, No: 27 Fatih, 34083 _Istanbul, Turkey. E-mail
address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.05.017

JOE — Volume -, Number -, - 2018 Single-visit Root Canal Retreatments 1

CONSORT Randomized Clinical Trial
treatments (9). The recent novelty of rotary nickel-titanium systems and Inc) with a paralleling technique, an exposure time of 0.16 seconds,
developments in the understanding of irrigation dynamics have simpli- and an exposure dose of 1.22 mGy. A periapical radiograph of the rele-
fied the mechanical instrumentation and disinfection of the root canal, vant tooth was taken immediately after the retreatment using a paralle-
which makes a single-appointment treatment a more practical and ling technique with the same digital radiograph. The postoperative and
acceptable treatment regimen than multiple appointments. control film data were recorded in the database.
Single-visit RCT has been recommended for use in cases with pu-
rulent inflammation, traumatic pulpal exposure, or necrotic pulp with a PAI
present sinus tract (10). Single-visit RCT is more advantageous than
The PAI is a basic radiographic method of interpretation consist-
multiple-visit RCT in terms of time and cost. Thus, it is a treatment
ing of a scale from 1 to 5. It was first described by Ørstavik et al in 1986
plan that is more amenable to the needs of busy patients (11, 12).
(14). For each subject, the periapical tissue was assessed radiograph-
In addition, RCT performed over the course of multiple visits has
ically using the PAI as follows:
negative clinical consequences, such as the inability of the intracanal
medicament to come into contact with the residual microorganisms 1. PAI 1: normal periapical structure
within the dentinal tubules, isthmus, or lateral canals because of the 2. PAI 2: small changes in the bone structure not pathognomonic of
complicated anatomic structure of the root canal or the ineffectiveness apical periodontitis
of the medicament to fight these microorganisms even if the medica- 3. PAI 3: changes in the bone structure with mineral loss characteristic
ment comes into contact with them (6). Moreover, dentin resistance of apical periodontitis
is reduced in multiple-visit RCT because of the fragile state of the crown 4. PAI 4: well-defined apical radiolucency characteristic of apical peri-
with a temporary filling and the caustic effect of some intracanal medi- odontitis
caments, such as Ca(OH)2. This can result in a high risk of fractures 5. PAI 5: severe periodontitis with exacerbating features and bone
during or after the treatment procedure (13). expansion
Therefore, the present study aimed to compare the incidence of
postoperative pain for single-visit and multiple-visit primary nonsur- The quality of the existing root canal fillings and the status of the
periapical tissues were determined according to the PAI by 1 author us-
gical endodontic retreatments with 2 different intracanal medicaments,
ing the periapical radiographs. The measurements were taken using the
Ca(OH)2 and CHX, in asymptomatic teeth. The hypothesis is that the in-
tensity of postoperative pain is lower in single-visit retreatments than in paralleling technique. The PAI scores were dichotomized to reflect the
absence (PAI #2) or presence (PAI >2) of apical periodontitis (15).
multiple-visit retreatments.
Those teeth with multiple root canals were scored based on the root ca-
A number of confounding factors were evaluated, including sex,
age, number of visits, dental arch (upper or lower), tooth position nal with the highest PAI score.
(anterior or posterior), PAI score, preoperative periapical radiolu-
cency, preoperative coroner restoration quality, preoperative root canal Retreatment
filling density and length, and sealer and gutta-percha extrusion, with Endodontic retreatment was conducted according to the contem-
different intracanal medicaments in asymptomatic teeth. porary standards of endodontic therapy. Each patient was anesthetized
with 40 mg articaine hydrochloride + 0.006 mg/mL epinephrine hydro-
Materials and Methods chloride (Ultracaine DS Forte; Aventis Pharma, Istanbul, Turkey). All
the patients were anesthetized to provide maximum comfort. The stan-
This clinical study was approved (10840098-604.01.01-E.14947)
dard procedure for each group at the first appointment included rubber
by the Research Ethics Committee at the Medipol University of Science
dam isolation and the removal of the previous coronal restorations and
and Technology, Istanbul, Turkey. The study population was selected
root canal filling materials. We achieved patency in all the canals. After
from those patients requiring conventional endodontic retreatment
gaining access to the previously obturated root canals, #1, #2, and #3
who presented at the Medipol University Endodontics Clinic from
Gates Glidden burs (Mani Inc, Tochigi, Japan) were used on the coronal
January 21, 2015, through November 11, 2015. All the patients read
two thirds of the canal, whereas a #15 Kerr file (Dentsply Maillefer, Bal-
and signed forms giving their consent to participate before they were
laigues, Switzerland) was used to gain access to the apical third of the
included in the study.
root canal. During the removal of the root canal filling material, a
A patient was excluded from the study if 1 or more of the following
copious amount of a 2.5% sodium hypochlorite (NaOCl) solution
conditions were observed: complicating systemic disease, severe pain
was used as irrigation. No chemical solvents were used to remove the
and/or acute apical abscess, under 18 years of age, antibiotic or corti-
gutta-percha or the sealer. Apical patency was achieved in all root canals
costeroid use, and multiple teeth that required pretreatment to elimi-
before cleaning and shaping, which were performed by using a crown-
nate the possibility of pain referral. In total, this study included 150
down technique using hand files and nickel-titanium rotary instruments
teeth from 150 patients between the ages of 18 and 75 years. The pa-
(Revo-S; Micro-Mega, Besançon, France). After measuring the root
tients were consecutively distributed into 3 different groups as follows:
lengths with an apex locater (Apex Pointer, Micro-Mega), each tooth
1. Group 1: single-visit retreatment (n = 50) was prepared up to an AS 40 file 0.5 mm short of the apex. Irrigation
2. Group 2: multiple-visit retreatment with the interappointment appli- was performed with 2.5% NaOCl (Wizard; Rehber Chemistry, Istanbul,
cation of Ca(OH)2 (n = 50) Turkey) after the use of each instrument in all cases. At the end of instru-
3. Group 3: multiple-visit retreatment with the interappointment appli- mentation, the final irrigation was performed using 2.5 mL 5% EDTA
cation of CHX gel (n = 50) (Wizard, Rehber Chemistry), 2.5 mL 2.5% NaOCl, and 5 mL distilled wa-
ter, respectively, and the root canals were dried with paper points.
In the Ca(OH)2 group, after removing the excess irrigant with
Radiographic Evaluation paper points, Ca(OH)2 (Vision Calcium Hydroxide; USP, Darmstadt,
The diagnoses of the relevant teeth were made using panoramic Germany) medication was introduced into the root canal using a Len-
radiographs (Kodak 9000; Carestream Health, Inc, Rochester, NY) tulo spiral as the 7-day interappointment medication. In the third group,
and periapical radiographs (Kodak RVG 5100, Carestream Health, the root canals were medicated with a 2% CHX gel (GLUCO-CHeX 2%

2 Erdem Hepsenoglu et al. JOE — Volume -, Number -, - 2018

 CONSORT Randomized Clinical Trial
gel; PPH Cerkamed, Stalowa Wola, Poland) for 7 days. The teeth in this uation of the study data, regarding the quantitative data comparisons
group were closed with a sterile dry cotton pellet and a minimum of and descriptive statistical methods (mean, standard deviation, median,
3 mm temporary restorative material (Cavit; ESPE Dental, Seefeld, Ger- frequency, and ratio), the Kruskal-Wallis test was used for the inter-
many). When the patient came in for the second visit after 7 days, the group comparisons of the parameters without normal distributions.
medicaments in the root canal walls were removed mechanochemically. The Mann-Whitney U test was used in determining the group causing
At the end of instrumentation, the final irrigation was performed using the difference and in the evaluation of 2 groups. The Yates correction
2.5 mL 5% EDTA, 2.5 mL 2.5% NaOCl, and 5 mL distilled water, respec- for continuity test, chi-square test, Fisher exact test, Fisher-Freeman-
tively. All the root canals were dried with paper points (SU 40, Revo-S, Halton test, and Pearson chi-square test were used to compare the qual-
Micro-Mega) before the root canal filling procedure. The root canal itative data. The results were evaluated using 95% confidence intervals,
filling paste (AH Plus; Dentsply DeTrey, Konstanz, Germany) was intro- and the level of significance was P < .05.
duced into the root canal with master cones using a brushing motion.
Accessory gutta-percha cones (SU 40, Revo-S, Micro-Mega) were used,
when needed, via a noncompaction technique. Results
A total-etch technique (Single Bond 2; 3M ESPE, St Paul, MN) was The results obtained from the study are summarized in Tables 1–3.
used according to the manufacturer’s instructions for the coronal res- A total of 150 teeth of 150 patients who were diagnosed and scheduled
torations. A flowable resin composite (Filtek Ultimate, 3M ESPE) was for nonsurgical retreatment were divided into 3 different treatment
introduced into the pulp chamber as a base material in order to seal groups (n = 50). Several different factors were taken into
the root canal orifices before incrementally building up the permanent consideration while evaluating postoperative pain throughout the
restoration with composite filling material (Filtek, 3M ESPE). If needed, groups (Table 1).
the tooth was treated using a fiber post (Cytec Blanco HT-Glasfiber; E With regard to age, the pain incidence was higher in women
Hahnenkratt GmbH, K€onigsbach-Stein, Germany), luting agent, and #45 years old than in those >45 years old at 30 days (P < .05)
composite core (RelyX U200 self-adhesive resin cement; 3M Deutsch- (Table 2). On the first day of observation, postoperative pain was signif-
land GmbH, Neuss, Germany) before the prosthetic restoration. Periap- icantly higher in females than males (P < .05) (Table 2). Moreover, the
ical x-rays were taken before and immediately after the retreatment. postoperative pain results were significantly higher on the first day of
measurement in teeth with preoperative pain than in teeth with no pre-
Postoperative Pain Analysis operative pain (P < .05). With regard to the tooth type and pain inci-
dence, there were no significant differences among the 5 groups
At the beginning of the second appointment, each patient was
(P > .05). Additionally, there was no correlation between the PAI score
asked about the presence or absence of pain between visits as well as
its intensity. The postoperative pain was recorded using a verbal rating (PAI #2 indicated no signs or symptoms or presence of apical peri-
odontitis and PAI >2 indicated signs or symptoms) and postoperative
scale (VRS) with well-defined categories at the 5 time intervals after
pain in the study (P > .05).
obturation: 1, 2, 3, 7, and 30 days. The postoperative pain assessment
Periapical lesions with diameters larger than 2 mm showed
was defined as no pain, mild pain, moderate pain, and severe pain or
significantly higher postoperative pain than lesions smaller than
flare-up, suggesting the acute exacerbation of an asymptomatic pulpal
2 mm (P < .05). On the first day, with regard to the root filling length,
and/or periradicular pathological condition occurring after root canal
the incidence of pain was higher in the short root filling teeth than in
treatment (16). With regard to the level of discomfort, each patient was
asked to categorize their pain according to the following criteria: the adequate root filling and over teeth (P < .05) (Table 2). The root
filling material density and gutta-percha extrusion exhibited no signif-
1. No pain: the treated tooth felt normal. icant effects on postoperative pain (P > .05). On the third day, with
2. Mild pain: the tooth involved was slightly painful for a time, regard- regard to the quality of the coronal restoration, postoperative pain
less of the duration, but there was no need to take analgesics. incidence was higher in the teeth with marginal defects in the coronal
3. Moderate pain: the tooth involved caused discomfort and/or pain, restorations (P = .007) (Table 2). When considering sealer extru-
which was either tolerable or was rendered tolerable by analgesics. sion, postoperative pain incidence was high on the second day
4. Severe pain: the pain caused by the treated tooth disturbed normal (P < .05) (Table 2).
activity or sleep, and analgesics had little or no effect. In the single-visit group, 28 (56%) patients reported no pain af-
ter 24 hours, 9 (18%) experienced mild pain, and 13 (26%) reported
For the purposes of this study, a specific questionnaire was de-
moderate pain, but none of the patients reported severe pain. After
signed, including the patient’s name, sex, age, preoperative complica-
48 hours, 35 (70%) patients reported no pain, 8 (16%) reported
tions (file separations and perforations), tooth type, preoperative PAI
mild pain, and 7 (14%) reported moderate pain, but none of them
score, size of the periapical radiolucency, and quality of the coronary
reported severe pain. After 72 hours, 40 (80%) patients reported
restoration. It also included intraoperative factors, such as the apical
no pain, 6 (12%) reported mild pain, and 4 (8%) reported moderate
extrusion of the sealing material and gutta-percha. The patients were
pain, but none reported severe pain. Seven days after the retreatment,
informed about the possible occurrence of pain after the procedure,
45 (90%) individuals reported no pain, 3 (6%) reported mild pain,
and analgesics were suggested for mild to moderate pain. In cases of
and 2 (4%) reported moderate pain. Thirty days after the retreatment,
severe pain that did not respond to analgesics or swelling, the patients
49 (98%) patients reported no pain, and only 1 (2%) reported mild
were advised to immediately report back to the clinic. The postoperative
pain (Table 3).
pain scores were recording using a VRS. Each patient was recalled and
In the 2-visit CHX group after 24 hours, 15 (30%) patients re-
asked about the occurrence of postoperative pain 1, 2, 3, 7, and 30 days
ported no pain, 16 (32%) reported mild pain, 13 (26%) reported mod-
after the initial appointment.
erate pain, and 6 (12%) reported severe pain. After 48 hours, 22 (44%)
patients reported no pain, 17 (34%) reported mild pain, 6 (12%) re-
Statistical Analysis ported moderate pain, and 5 (10%) reported severe pain. After
The 2007 Number Cruncher Statistical System (NCSS Statistical 72 hours, 29 (58%) patients reported no pain, 11 (22%) reported
Software, Kaysville, UT) was used for statistical analysis. During the eval- mild pain, 7 (14%) reported moderate pain, and 3 (6%) reported

JOE — Volume -, Number -, - 2018 Single-visit Root Canal Retreatments 3

CONSORT Randomized Clinical Trial
TABLE 1. The Distribution of Prognostic Factors, Inception Cohort, Study Sample, and P Values (Univariate Analysis)
Groups
P value P value
Single Multiple-visit Multiple-visit P value (single-visit (single-visit P value
Preoperative factors visit, n (%) CHX, n (%) Ca(OH)2, n (%) (3 group) CHX) Ca[OH]2) (CHX Ca[OH]2)
Age
#45 y 20 (40.0) 25 (50.0) 32 (64.0) .055* .421† .028†,‡ .226†
>45 y 30 (60.0) 25 (50.0) 18 (36.0)
Sex
Female 25 (50.0) 26 (52.0) 24 (48.0) .923* 1.000† 1.000† .841†
Male 25 (50.0) 24 (48.0) 26 (52.0)
Preoperative complications
Present 6 (12.0) 7 (14.0) 9 (18.0) .689* 1.000† .575† .785†
Absent 44 (88.0) 43 (86.0) 41 (82.0)
Tooth
Maxillary anterior 9 (18.0) 9 (18.0) 4 (8.0)
Mandibular anterior 8 (16.0) 5 (10.0) 3 (6.0)
Maxillary premolar 13 (26.0) 10 (20.0) 13 (26.0)
Mandibular premolar 7 (14.0) 5 (10.0) 7 (14.0) .329* .278* .177* .499§
Maxillary molar 7 (14.0) 5 (10.0) 9 (18.0)
Mandibular molar 6 (12.0) 16 (32.0) 14 (28.0)
Preoperative PAI score
1 5 (10.0) 7 (14.0) 6 (12.0) .156* .253* .188* .151*
2 19 (38.0) 12 (24.0) 14 (28.0)
3 13 (26.0) 11 (22.0) 20 (40.0)
4 9 (18.0) 9 (18.0) 3 (6.0)
5 4 (8.0) 11 (22.0) 7 (14.0)
Radioluceny
<2 mm 25 (50.0) 24 (48.0) 19 (38.0) .434* .841* .227* .313*
$2 mm 25 (50.0) 26 (52.0) 31 (62.0)
Root filling density
Good 3 (6.0) 4 (8.0) 6 (12.0)
Poor 39 (78.0) 41 (82.0) 36 (72.0) .722‡ .738‡ .693§ .492*
Unfilled canal 8 (16.0) 5 (10.0) 8 (16.0)
Length of root filling
Adequate (0–2 mm) 3 (6.0) 5 (10.0) 9 (18.0)
Short (>2) 46 (92.0) 45 (90.0) 40 (80.0) .230‡ .726‡ .121§ .264‡
Extensive overfill 1 (2.0) 0 (0) 1 (2.0)
Quality of coronal restoration
Adequate 8 (16.0) 10 (20.0) 11 (22.0) .741* .795† .610† 1.000†
Marginal deficiency 42 (84.0) 40 (80.0) 39 (78.0)
Sealer extrusion
Yes 14 (28.0) 9 (18.0) 11 (22.0)
No 36 (72.0) 41 (82.0) 39 (78.0)
Gutta-percha extrusion
Yes 10 (20.0) 8 (16.0) 9 (18.0) .873* .795† 1.000† 1.000†
No 40 (80.0) 42 (84.0) 41 (82.0)
Ca(OH)2, calcium hydroxide; CHX, chlorhexidine; PAI, periapical index.
*Pearson chi-square test.
†
Yates Continuity Correction test.
‡
P < .05.
§
Fisher-Freeman-Halton test.

severe pain. Seven days after the retreatment, 41 (82%) individuals re- reported mild pain, and 2 (4%) reported moderate pain, but none re-
ported no pain, 6 (12%) reported mild pain, and 3 (6%) reported ported severe pain (Table 3).
moderate pain, but none reported severe pain. Thirty days after the re- On the third and seventh days, no specific differences between the
treatment, 41 (82%) patients reported no pain, 6 (12%) reported mild pain categories (none, mild, moderate, or severe) were identified
pain, and 2 (4%) reported severe pain (Table 3). (P > .05). When the incidence of pain was compared between the sin-
In the 2-visit Ca(OH)2 group after 24 hours, 20 (40%) patients gle- and multiple-visit groups (Table 4), it was found that the single-
reported no pain, 18 (36%) reported mild pain, 8 (16%) reported visit group experienced significantly less pain than the multiple-visit
moderate pain, and 5 (10%) reported severe pain. After 48 hours, group on days 1, 2, and 30 (P < .05). Overall, there were no statis-
21 (42%) patients reported no pain, 15 (30%) reported mild pain, tically significant differences between the 2 medications with regard
6 (12%) reported moderate pain, and 5 (10%) reported severe to the incidence of postoperative pain in any of the comparisons
pain. After 72 hours, 33 (66%) patients reported no pain, 11 (22%) (Table 3).
reported mild pain, 5 (10%) reported moderate pain, and 1 (2%) re- When considered together, on the first day, the results of the 150
ported severe pain. Seven days after the retreatment, 45 (90%) individ- cases revealed that 63 (42%) teeth exhibited no postoperative pain. On
uals reported no pain, 1 (2%) reported mild pain, 3 (6%) reported the second day, 78 (52%) teeth exhibited no postoperative pain. On the
moderate pain, and 1 (2%) reported severe pain. Thirty days after third day, 102 (68%) teeth exhibited no postoperative pain. On the sev-
the retreatment, 37 (74%) patients reported no pain, 11 (22%) enth day, 131 (87%) teeth exhibited no postoperative pain, and on the

4 Erdem Hepsenoglu et al. JOE — Volume -, Number -, - 2018

 CONSORT Randomized Clinical Trial
TABLE 2. The Effect of Preoperative and Intraoperative Factors on Postoperative Pain
1-day pain 2-day pain 3-day pain 7-day pain 30-day pain
P value P value P value P value P value
Age
#45 y .439 .241 .188 .888 .038*
>45 y
Sex
Female .013* .251 .863 .198 .818
Male
Preoperative complications
Present .039* 1.000 .220 .279 1.000
Absent
Tooth
Maxillary anterior .906 .343 .947 .399 .382
Mandibular anterior
Maxillary premolar
Mandibular premolar
Maxillary molar
Mandibular molar
Preoperative PAI score
#2 .395 .098 .620 .654 .911
>2
Radiolucency
<2 mm .507 .039* .280 .503 .634
$ 2 mm
Root filling density
Good .316 .514 .286 .657 .846
Poor
Unfilled canal
Length of root filling
Adequate (0–2) .026* .133 .057 1.000 .614
Short (>2)
Extensive overfill
Intraoperative quality of coronal restoration
Adequate 1.000 .129 .007† .325 .141
Marginal deficiency
Intraoperative quality of root canal filling
Dense and tapered .692 .917 .903 .583 .544
Voids present
Poorly condensed
Intraoperative sealer extrusion
Present .091 .036* .157 .764 .784
Absent
Intraoperative gutta-percha extrusion
Present .884 .271 .936 .539 .263
Absent
PAI, periapical index.
Pearson chi-square, Fisher exact, and Fisher-Freeman-Halton tests.
Bold values indicate statistically significant differences.
*P < .05.
†
P < .01.

30th day, 127 (84%) teeth exhibited no postoperative pain (Table 3). In mediators, and various physiological factors. Many different scales
this study, no flare-ups were observed in any of the groups. and methods have been used to detect the pain that occurs after
root canal treatment (1, 19–23).
The postoperative pain severity was evaluated numerically, grading
Discussion the pain into none, slight, moderate, severe, and agonizing categories
It has been reported previously that the sensitivity of panoramic using a VRS (24, 25). A VRS can be used for both the identification
radiographs is lower than that of periapical radiographs, especially in and measurement of pain. In addition, a visual analog scale (VAS) is
the anterior region of the jaws; therefore, periapical radiographs considered to be a valid and reliable scale for measuring pain. A VAS
should be used to evaluate periapical tissues (17, 18). In this can accurately predict the pain intensity and effect along a ratio, not
study, periapical film was used when the postoperative and control an interval. Some studies have used VASs, and some studies have
films were taken. used VRSs (21, 26). However, pain is affected by many different
A person’s pain perception is influenced by many factors, so it factors; therefore, in this study, the level of discomfort was measured
varies widely according to the amount of preoperative pain, num- using a VRS that was classified into only 4 categories in order to
ber of appointments, use of intracanal medication, tooth localiza- simplify the pain rating (1). With regard to the postoperative pain collec-
tion, pulpal vitality, microbial factors, change in the periapical tion methods, the VRS was used because it is considered to be the most
tissue pressure, chemical mediators, change in the cyclic adequate method for reporting the pain experienced by a patient (27).

JOE — Volume -, Number -, - 2018 Single-visit Root Canal Retreatments 5

CONSORT Randomized Clinical Trial
TABLE 3. The Frequency and Percentage of Postoperative Pain in Retreatment Groups
Groups
P value P value
Single Multiple-visit Multiple-visit P value (single visit / multiple (single visit / multiple P value
Pain levels visit, n (%) CHX, n (%) Ca(OH)2, n (%) (3 group) visit CHX) visit Ca[OH]2) (CHX / Ca[OH]2)
Day 1
None 28 (56.0) 15 (30.0) 20 (40.0) .016*,† .006*,‡ .023*,† .489§
Mild 9 (18.0) 16 (32.0) 18 (36.0)
Moderate 13 (26.0) 13 (26.0) 8 (16.0)
Severe 0 (0.0) 6 (12.0) 4 (8.0)
Day 2
None 35 (70.0) 22 (44.0) 21 (42.0) .018*,† .008*,‡ .010*,† .862§
Mild 8 (16.0) 17 (34.0) 15 (30.0)
Moderate 7 (14.0) 6 (12.0) 9 (18.0)
Severe 0 (0.0) 5 (10.0) 5 (10.0)
Day 3
None 40 (80.0) 29 (58.0) 33 (66.0) .255* .063* .331* .686*
Mild 6 (12.0) 11 (22.0) 11 (22.0)
Moderate 4 (8.0) 7 (14.0) 5 (10.0)
Severe 0 (0.0) 3 (6.0) 1 (2.0)
Day 7
None 45 (90.0) 41 (82.0) 45 (90.0) .386* .568* .757* .188*
Mild 3 (6.0) 6 (12.0) 1 (2.0)
Moderate 2 (4.0) 3 (6.0) 3 (6.0)
Severe 0 (0.0) 0 (0.0) 1 (2.0)
Day 30
None 49 (98.0) 41 (82.0) 37 (74.0) .003*,‡ .021*,† .001*,‡ .398*
Mild 1 (2.0) 6 (12.0) 11 (22.0)
Moderate 0 (0.0) 2 (4.0) 2 (4.0)
Severe 0 (0.0) 1 (2.0) 0 (0.0)
Ca(OH)2, calcium hydroxide; CHX, chlorhexidine.
Bold values indicate statistically significant differences.
*Fisher-Freeman-Halton test.
†
P < .05.
‡
P < .01.
§
Pearson chi-square test.

Di Renzo et al (21) evaluated postoperative pain at 6, 12, 24, and for the radiographic assessment of periapical status, and this was used
48 hours after single- and multiple-visit root canal treatments. In addi- in our study. This system allows for easier tracking of periodic changes
tion, El Mubarak et al (28) observed postoperative pain during the first and a significant comparison of the outcomes of retreatment in clinical
12 and 24 hours after patients had completed their treatments. In this studies.
study, the level of discomfort was rated in only 4 categories 1, 2, 3, 7, An aseptic technique and intracanal medication with Ca(OH)2
and 30 days after root canal treatment. must be complemented with a 2% CHX solution in order to decrease
In a recent study, Ertan et al (29) reported that the postoperative the number of microorganisms (34). Yoldas et al (1) conducted a clin-
pain in molar teeth was greater than that in premolar and anterior teeth. ical study to compare the efficacy of 1-visit versus 2-visit retreatments
Salma (30) found that the postoperative pain in premolar teeth was using a medication that combined Ca(OH)2 and a 2% CHX solution.
greater than the pain in anterior teeth. In our study, no differences They showed that the 2-visit retreatment was more effective for reducing
were noted between the localizations and postoperative pain levels. postoperative pain and any potential flare-ups. In this study, there were
Moreover, the incidence of pain in relation to sex was significantly no flare-ups observed in any of the groups. Previous studies have sug-
higher in women than in men. In agreement with our results, Gotler gested that CHX gel is an effective intracanal medication, which is in
(31) and Sadaf et al (32) also reported that women exhibited more agreement with our results. However, CHX is not an effective intracanal
postoperative pain than men. Furthermore, there was no significant as- barrier, and it is also radiolucent, making it hard to visualize while it is
sociation between postoperative pain and any of the tooth types inside the canal (35). Neelakantan et al (36) investigated the antimicro-
included in our study. These findings are incompatible with some bial activity of several canal medicaments against Porphyromonas gin-
studies (21) but in agreement with others (22). givalis and Prevotella intermedia, indicating that the effect of Ca(OH)2
The age factor showed no significant relationships with postoper- was significantly reduced after 48 hours, whereas the CHX gel lasted for
ative pain as reported by the patients at 1, 2, 3, and 7 days. These find- 72 hours.
ings are consistent with the results of another study (33). On day 30 day, Previous studies have shown that the use of an intracanal medica-
although the number of patients #45 years old who reported postop- ment in symptomatic teeth can significantly reduce the incidence of
erative pain was higher among the groups, statistically significant differ- flare-ups and postoperative pain (1). Moreover, Sj€ogren et al (37)
ences could not be shown. Overall, there was less postoperative pain showed that there may be high error rates in root canal disinfection
because of greater sensitivity in the younger patients and reduced blood in single-visit root canal treatments. Siqueira et al (38) and Maatscheck
flow in the elderly patients. et al (39) found that there were no significant differences in postoper-
Repeated endodontic treatment is a very interesting endodontic ative pain between the retreatment and the primary root canal treatment
problem that requires a complex analysis of the indications and excel- in their studies. In these studies, different medicaments were used for
lent procedural practice. Ørstavik et al (14) introduced the PAI system the root canal treatments, and the teeth were treated in 2 or more visits.

6 Erdem Hepsenoglu et al. JOE — Volume -, Number -, - 2018

 CONSORT Randomized Clinical Trial
TABLE 4. A Comparison of Pain Levels according to the Number of Treatment periapical area. This may have coupled with the healing process and,
Visits therefore, resulted in the increased incidence of pain at the 1-month
Groups follow-up (20). Although the caregiver paid extreme attention and tried
not to extrude any intracanal medicament into the periapical area, this
Single Multiple may not have been the case in every patient. The disrupted periapical
Pain levels visit, n (%) visits, n (%) P value anatomy because of a previous root canal treatment and the status of
Day 1 the periapical tissue before retreatment may result in the extrusion of
None 28 (56.0) 35 (35.0) .005*,† intracanal medicament into the periapical area (28).
Mild 9 (180) 34 (34.0)
Moderate 13 (26.0) 21 (21.0) The presence of a periapical lesion is a risk factor for the develop-
Severe 0 (0.0) 10 (10.0) ment of postoperative pain. In the study by de Oliveira Alves et al (16),
Day 2 there was more postoperative pain in the teeth with periapical radiolu-
None 35 (70.0) 43 (43.0) .003*,† cency. When the full-scale PAI scores were evaluated individually, no
Mild 8 (16.0) 32 (32.0)
Moderate 7 (14.0) 15 (15.0)
significant correlation was recorded between the preoperative PAI
Severe 0 (0.0) 10 (10.0) scores and the incidence of postoperative pain. Even after the PAI scores
Day 3 were dichotomized to reflect the absence (PAI #2) or presence (PAI
None 40 (80.0) 62 (62.0) .141* >2) of apical periodontitis according to previous studies (14, 15),
Mild 6 (12.0) 22 (22.0) there was still no correlation between the preoperative PAI scores
Moderate 4 (8.0) 12 (12.0)
Severe 0 (0.0) 4 (4.0) and the incidence of postoperative pain. Although the baseline PAI
Day 7 score was reported to impair the outcome results because of the
None 45 (90.0) 86 (86.0) .950* strong predictive value, this study was not an outcomes study, and the
Mild 3 (6.0) 7 (7.0) preoperative PAI scores were recorded for the purpose of
Moderate 2 (4.0) 6 (6.0)
Severe 0 (0.0) 1 (1.0)
determining a correlation between the preoperative PAI scores and
Day 30 postoperative pain. Moreover although the mentioned study criticized
None 49 (98.0) 78 (78.0) .005*,† the PAI scores, no better method has been suggested. With cone-
Mild 1 (2.0) 17 (17.0) beam computed tomographic imaging being out of question because
Moderate 0 (0.0) 4 (4.0) of ethical issues in Turkey (higher exposure values), we were left
Severe 0 (0.0) 1 (1.0)
with PAI scoring for further evaluation (44).
Bold values indicate statistically significant differences. On the second day, there was a correlation between the periapical
*Fisher-Freeman-Halton test. radiolucency and postoperative pain; the teeth with periapical lesions
†
P < .01. exhibited greater postoperative pain. Our findings are compatible
with the study conducted by Eyuboglu et al (15).
Sari and Durut€urk (45) reported that the complete resorption of
Some researchers have reported that the application of intracanal the amount of extruded AH Plus sealer in 56.09% of the successfully
medicament reduces postoperative pain. However, they found no signif- treated canals at the end of a 4-year follow-up showed that any excess
icant differences in postoperative pain after 1 week of medicament AH Plus filling material at the periapex disappears over time. In this
administration between Ca(OH)2 and 0.2% CHX (40). Because of post- study, we used AH Plus as the root canal filling material. On the second
operative pain, several intracanal medicaments are used to temporarily day, there was a relationship between the sealing extrusion and postop-
fill the root canal, such as CHX or Ca(OH)2, and they can play important erative pain, but there was no significant difference between the
roles in suppressing the recontamination of the root canal between visits extruded gutta-percha and postoperative pain.
(38). However, the apical extrusion of contaminated debris and medi-
caments may also cause postoperative pain (1). Walton et al (20) re- Conclusions
ported that there was no statistical difference in postoperative pain Based on the results of this study, it was found that postoperative
with regard to the frequency and quantity of Ca(OH)2 used as an intra- pain incidence in single-visit endodontic retreatments without intraca-
canal medicament. Fox et al (41) and Roane et al (22) argued that the nal medicaments was less than that in multiple-visit endodontic retreat-
postoperative pain percentages in single-visit root canal treatments were ments. When the medicaments were compared among themselves, the
lower than those in multiple-visit root canal treatments. pain intensity was higher in the CHX group.
Peckruhn (42) reported that 1140 teeth of 918 patients were
treated in single visits. When the patients were recalled 1 year later,
there was less failure reported in the single-visit root canal treatments.
Acknowledgments
In a 2008 study of dissatisfaction scores, it was reported that single-visit The authors deny any conflicts of interest related to this study.
root canal treatment was preferred by patients to multiple-visit root ca-
nal treatment, but Australian endodontists were reluctant to accept References
single-visit root canal treatments (43). In this study, on the second 1. Yoldas O, Topuz A, Isci AS, Oztunc H. Postoperative pain after endodontic retreat-
day, the postoperative pain rate in the single-visit root canal retreatment ment: single-versus two-visit treatment. Oral Surg Oral Med Oral Pathol Oral Radiol
group (30%) was significantly lower than that in the multiple-visit re- Endod 2004;98:483–7.
2. Petrovic V, Opacic-Galic V, Zivkovic S. Postoperative pain after primary endodontic
treatment group (54%). treatment and retreatment of asymptomatic teeth. Stomatoloski glasnik Srbije 2011;
An increase in pain incidence at the 1-month follow-up was 58:75–81.
observed in patients with multiple-visit retreatments, which was not 3. Shahi S, Asghari V, Rahimi S, et al. Postoperative pain after endodontic treatment of
the case in the single-visit retreatments. Although the patients are still asymptomatic teeth using rotary instruments: a randomized clinical trial. Iran En-
dod J 2016;11:38.
being followed up for further evaluation, it was strongly suspected 4. Nekoofar MH, Sheykhrezae MS, Meraji N, et al. Comparison of the effect of root ca-
that the introduction of the root canal medicaments into the root canal nal preparation by using Wave One and ProTaper on postoperative pain: a random-
space may have resulted in the extrusion of some of the material into the ized clinical trial. J Endod 2015;41:575–8.

JOE — Volume -, Number -, - 2018 Single-visit Root Canal Retreatments 7

CONSORT Randomized Clinical Trial
5. Siqueira JF, de Uzeda M. Intracanal medicaments: evaluation of the antibacterial ef- 26. Price DD, McGrath PA, Rafii A, Buckingham BÇ. The validation of visual analogue
fects of chlorhexidine, metronidazole, and calcium hydroxide associated with three scales as ratio scale measures for chronic and experimental pain. Pain 1983;17:
vehicles. J Endod 1997;23:167–9. 45–56.
6. Barbosa CA, Goncalves RB, Siqueira JF, De Uzeda M. Evaluation of the antibacterial 27. Stinson JN, Kavanagh T, Yamada J, et al. Systematic review of the psychometric prop-
activities of calcium hydroxide, chlorhexidine, and camphorated paramonochloro- erties, interpretability and feasibility of self-report pain intensity measures for use in
phenol as intracanal medicament. A clinical and laboratory study. J Endod 1997;23: clinical trials in children and adolescents. Pain 2006;125:143–57.
297–300. 28. El Mubarak AHH, Abu-bakr NH, Ibrahim YE. Postoperative pain in multiple-visit and
7. R^oças IN, Siqueira JF, Santos KR. Association of Enterococcus faecalis with single-visit root canal treatment. J Endod 2010;36:36–9.
different forms of periradicular diseases. J Endod 2004;30:315–20. 29. Ertan T, Şahinkesen G, Tunca YM. Evaluation of postoperative pain in root canal
8. Love RM. Enterococcus faecalis–a mechanism for its role in endodontic failure. Int treatment. Agri 2010;22:159–64.
Endod J 2001;34:399–405. 30. Salma J. A study of post obturation pain following single visit root canal treatment.
9. Kvist T, Molander A, Dahlen G, Reit C. Microbiological evaluation of one- and two- Chatt Maa Shi Hosp Med Coll J 2013;12:16–9.
visit endodontic treatment of teeth with apical periodontitis: a randomized, clinical 31. Gotler M, Bar-Gil B, Ashkenazi M. Postoperative pain after root canal treatment: a
trial. J Endod 2004;30:572–6. prospective cohort study. Int Endod 2012;2012:310467.
10. Calhoun RL, Landers RR. One-appointment endodontic therapy: a nationwide survey 32. Sadaf D, Ahmad MZ. Factors associated with postoperative pain in endodontic ther-
of endodontists. J Endod 1982;8:35–40. apy. Int J Biomed Sci 2014;10:243–7.
11. Soltanoff W. A comparative study of the single-visit and the multiple-visit endodontic 33. Abbott PV. Factors associated with continuing pain in endodontics. Aust Dent J 1994;
procedure. J Endod 1978;4:278–81. 39:157–61.
12. Jurcak JJ, Bellizzi R, Loushine RJ. Successful single-visit endodontics during Oper- 34. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: its role in root
ation Desert Shield. J Endod 1993;19:412–3. canal treatment failure and current concepts in retreatment. J Endod 2006;32:93–8.
13. de Almeida Gomes BP, Vianna ME, Sena NT, et al. In vitro evaluation of the antimi- 35. Souza-Filho FJ, Soares ADJ, Vianna ME, et al. Antimicrobial effect and pH of chlor-
crobial activity of calcium hydroxide combined with chlorhexidine gel used as intra- hexidine gel and calcium hydroxide alone and associated with other materials. Braz
canal medicament. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102: Dent J 2008;19:28–33.
544–50. 36. Neelakantan P, Sanjeev K, Subbarao CV. Duration-dependent susceptibility of end-
14. Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radio- odontic pathogens to calcium hydroxide and chlorhexidine gel used as intracanal
graphic assessment of apical periodontitis. Dent Traumatol 1986;2:20–34. medicament: an in vitro evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol
15. Eyuboglu TF, Olcay K, O €zcan M. A clinical study on single-visit root canal retreat- Endod 2007;104:138–41.
ments on consecutive 173 patients: frequency of periapical complications and clin- 37. Sj€ogren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root
ical success rate. Clin Oral Investig 2017;21:1761–8. filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int
16. de Oliveira Alves V. Endodontic flare-ups: a prospective study. Oral Surg Oral Med Endod J 1997;30:297–306.
Oral Pathol Oral Radiol Endod 2010;110:68–72. 38. Siqueira JF, Lopes HP, de Uzeda M. Recontamination of coronally unsealed root ca-
17. Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prev- nals medicated with camphorated paramonochlorophenol or calcium hydroxide
alence and technical quality of root canal treatment in a French subpopulation. Int pastes after saliva challenge. J Endod 1998;24:11.
Endod J 2002;53:229–38. 39. Mattscheck DJ, Law AS, Noblett WC. Retreatment versus initial root canal treatment:
18. Allard U, Palmqvist S. A radiographic survey of periapical conditions in elderly peo- factors affecting posttreatment pain. Oral Surg Oral Med Oral Pathol Oral Radiol En-
ple in a Swedish county population. Dent Traumatol 1986;2:103–8. dod 2001;92:321–4.
19. Siqueira JF Jr, Rjcas IN, Favieri A, et al. Incidence of postoperative pain after intra- 40. Menakaya IN, Oderinu OH, Adegbulugbe IC, Shaba OP. Incidence of postoperative
canal procedures based on an antimicrobial strategy. J Endod 2002;28:457–60. pain after use of calcium hydroxide mixed with normal saline or 0.2% chlorhexidine
20. Walton RE, Holton IF, Michelich R. Calcium hydroxide as an intracanal medication: digluconate as intracanal medicament in the treatment of apical periodontitis. Saudi
effect on posttreatment pain. J Endod 2003;29:627–9. Dent J 2015;27:187–93.
21. DiRenzo A, Gresla T, Johnson BR, et al. Postoperative pain after 1- and 2-visit 41. Fox J, Atkinson JS, Dinin AP, et al. Incidence of pain following one-visit endodontic
root canal therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1970;30:123–30.
93:605–10. 42. Pekruhn RB. The incidence of failure following single-visit endodontic therapy.
22. Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single- and J Endod 1986;12:68–72.
multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol Oral Radiol 43. Sathorn C. Effectiveness and Efficiency: Systematic Reflections on Single and
Endod 1983;55:68–72. Multiple Visit Root Canal Treatment [Thesis]. Melbourne, Australia: University
23. Anjaneyulu K, Nivedhitha MS. Influence of calcium hydroxide on the post-treatment of Melbourne, School of Dental Science; 2008.
pain in endodontics: a systematic review. J Conserv Dent 2014;17:200–7. 44. Kirkevang LL, Ørstavik D, Bahrami G, et al. Prediction of periapical status and tooth
24. Houde RW, Wallenstein SL. A method for evaluating analgesics in patients with extraction. Int Endod J 2017;50:5–14.
chronic pain. Bull Drug Addict Narcot 1953;660–82. 45. Sari Ş, Durut}urk L. Radiographic evaluation of periapical healing of permanent teeth
25. Revill SI, Robinson JO, Rosen M, Hogg MI. The reliability of a linear analogue for with periapical lesions after extrusion of AH Plus sealer. Oral Surg Oral Med Oral
evaluating pain. Anaesthesia 1976;31:1191–8. Pathol Oral Radiol Endod 2007;104:54–9.

8 Erdem Hepsenoglu et al. JOE — Volume -, Number -, - 2018