The fundamental goal of soft tissue remedy is to uphold the reliability and well-being of the teeth and the tissues that sustain them. A pulpectomy procedure is used to treat pulp tissue that has become infected or necrotic as a result of caries or trauma. Postendodontic pain can be stressful for both patients and clinicians, 35% of patients have been reported for unpleasant sensation after the treatment. As a result, in endodontic practice, pain prevention and supervision are critical throughout and after root canal therapy. During pulpectomy treatment, debris, organic tissue, bacteria, and irrigating solutions extruded outside the apical foramen cause inflammation and postoperative complications that include mild-to-severe discomfort and flare-ups.
Sodium hypochlorite has a number of negative effects, including an unlikeable flavor, aroma, tissue toxicity, inability to remove smear layer and microorganisms from root canals along with staining of clothing. Cryotherapy is relatively a new therapeutic option in which the body is open to the elements to exceptionally cold temperature for a tiny episode of time in a quest to promote healing and other therapeutic effects. The fundamental cryotherapy approach emphasizes rapid cooling, gradual thawing, and repeated freezing to enhance tissue damage. It will limit local blood flow by vasoconstriction, resulting in a local inflammatory reaction, swelling, furthermore heat sensation, as well as slowing nerve signal transmission, potentially lowering pain transmission. Cryotherapy has been reported to be useful in lowering swelling and pain following intraoral surgical operations such as periodontal surgery, extractions, in addition to implant supplement.
Curcumin is the foremost curcuminoid in turmeric, a renowned Indian spice and belong to the ginger family (Zingiberaceae). Curcumin's analgesic and anti-inflammatory properties have been shown to be useful in the treatment of pain and inflammation. Curcumin has been shown to be effective in the treatment of dry socket, has antibacterial properties, and has an inhibitory impact on osteoclastogenesis. Curcumin, the most important yellow bioactive component of turmeric, has a wide range of biological effects, which makes it the perfect option for use in endodontics. Curcumin's anti-inflammatory properties are used as a pulpectomy irrigant to relieve postendodontic discomfort. Normal saline is a basic pulpectomy irrigant used for debridement in dentistry. There is a lack of information on the consequence of using room temperature saline as the absolute irrigating agent on postendodontic discomfort. To the best of our knowledge, there is no study available in the literature addressing and comparing the possessions of cryotherapy, curcumin irrigant on the alleviation of postendodontic pain in primary teeth. Hence, the present study was carried out to compare the effect of cryotherapy utilizing 2.5°C cold saline and curcumin solution as a final irrigant in alleviating the postendodontic pain in primary teeth.
Materials and Methods
The institutional ethics committee received the study protocol and gave its approval vide Ref. No: TMDCRC/IEC/19-20/PPD1 dated November 6, 2019. Before the beginning of the study, a legally accountable person or parents of the sorted out participants were educated about the risk, benefits, and alternatives of the given procedure or intervention and signed a consent form, allowing their children to participate in the study. A minimum sample size of 120 subjects (since there are three groups, 40 in each group) would yield 80% power to detect significant differences, with an effective size of 0.32 and a significance level of 0.05. A minimum of 40 samples were required in each group to estimate the difference at 5% significance level. A total of 120 (maxillary and mandibular) primary teeth were included in the study after screening children aged 4–7 years who reported to the department of pedodontics and preventive dentistry. Inclusion criteria included children within the age group of 4–7 years with symptoms of irreversible pulpitis, radiographic confirmation of carious lesion nearing or affecting the pulp, and at least 2/3rd of the root length present. Children under antibiotic or analgesic coverage, presence of sinus tract, radiolucency in the furcation area, uncooperative and medically compromised, or suffering from any systemic disease were excluded from the study. Before starting the pulpectomy procedure, children were explained regarding the Visual Analog Pain Rating Scale and preoperative pain scores were recorded. After that local anesthesia was administered, rubber dam isolation was done. A small round diamond bur was used to excavate the carious tooth structure. Access was gained into the pulp chamber and an Endo-Z bur was used for deroofing. The coronal pulp was removed with a small spoon excavator. While eliminating the radicular pulp tissue with a barbed broach, a path was prepared with a #15K file. Copious irrigation was done with 2.5% sodium hypochlorite in addition to saline, K-files (35 no.) were also used to complete chemomechanical preparation on the same day, and the irrigants were used according to the group assigned to the patient. The allocation ratio utilized was 1:1:1 using a nonrandomized approach.
Group I: Cryotherapy (n = 40)
Before the beginning of pulpectomy procedure, 5 ml normal saline was filled into a two-way needle syringe and stored in the refrigerator and allowed it to reach a temperature of 1°C by constant monitoring using a digital thermometer. After access into the pulp chamber, working length determination and chemomechanical preparation was done, the canals were then irrigated with 2.5°C cold saline as a final irrigant as indicated by the digital thermometer. The difference in the temperature of 1°C and 2.5°C was utilized for its removal from refrigerator until its use.
Group II: Curcumin irrigation (n = 40)
Preparation of curcumin irrigant
Pure curcumin powder in capsule form (West Coast Pharmaceutical Works Ltd., Gota, Ahmedabad, India) was utilized in the study. The curcumin powder from these capsules was weighed using an electronic balance and mixed with distilled water in a glass beaker in the ratio of 1 g: 5 mL. The solution was heated up using a hot plate (100°C) to its boiling point until a homogenous mixture was formed. The solution thus formed was allowed to cool down and filtered through Whatman filter paper. Individually, the irrigant was stored in screw cap test tubes at 4°C in refrigerator until its use. Before its use, the irrigant was allowed to return to room temperature. After gaining access into the pulp chamber, working length determination and chemomechanical preparation of the canal was done. Then, root canals were irrigated with curcumin solution as a final irrigant.
Group III: Normal saline (n = 40)
After getting access to the pulp chamber, working length determination and chemomechanical preparation canals carried out. The children in this group received normal saline at room temperature as a final irrigant.
A sterile paper point was inserted in each canal of all the groups and held it for 1 min. A temporary restorative material was placed in the access cavity. Immediate postoperative Visual Analog Scale (VAS) score was recorded when the effect of local anesthesia was diminished. All the children were recalled for further evaluation of pain score using VAS after 24 h. The data obtained from this study were imported into Microsoft Excel 2007 and Using Statistical Package for Social Sciences software version 23 for windows (IBM SPSS Statistics, IBM Corp, 2018, Chicago, USA). Mean and standard deviation were part of descriptive statistics. Friedman test and Kruskal–Wallis test followed by post hoc analysis were employed for statistical analysis. The level of significance was predetermined at P ≤ 0.05.
The current study included teeth that had vital pulps that were treated with pulpectomy therapy to rule out the effects of the presence of diseased necrotic pulps and the use of intracanal medicament.
[Table 1] shows the mean age and distribution of the study subjects according to gender. There were no differences observed in the distribution according to maxillary or mandibular teeth in respective groups. Tables 2 and 3 shows the comparison of mean VAS scores at different time intervals between the groups. A statistically significant difference in VAS scores was observed between various time intervals (P < 0.05) indicating the effectiveness of all irrigating regimens in alleviating the postendodontic pain. Table 4 shows the intergroup comparison of change in mean VAS scores between the three groups. A statistical nonsignificant difference in change in mean VAS scores was observed indicating that either of the irrigating regimens can be utilized.
Clinical investigations show that bacteria stay in the canals despite more than a century of technological advancements in pulpectomy procedure. In many teeth where pulpectomy is the preferred treatment, chemomechanical preparation and irrigation alone are insufficient to remove all bacteria from the infected root canals. In addition, irrigating solutions also determines the prognosis of these endodontically treated primary teeth. Hence, in the search for an ideal irrigant for pediatric pulpectomy procedure, this study evaluated intra canal cryotherapy, curcumin irrigant, and normal saline for their antimicrobial and antiinflammatory efficacy on the basis of their ability to reduce post endodontic pain. It is important to achieve a reduction in postoperative pain after endodontic treatment as it is considered as one of the major problems.
Researchers verified pulp vitality when hemorrhage from pulp through the access cavity preparation was visually identified and considered as goldstandard to validate pulp vitality. Patients with compromised health were also excluded from the study as systemic health-related issues could change results.
Gender, age, and tooth type were all patient-related characteristics with no significant differences in distribution between groups. Cryotherapy, curcumin, and normal saline groups had mean VAS scores of 7.07 ± 1.047, 7.00 ± 0.905, and 6.90 ± 1.07 at the preoperative level, respectively. The effect of cold saline in lowering inflammation can be explained by the fact that it operated as a local antiinflammatory agent in the apical area. The intergroup comparison for change in scores (from preoperative levels) at immediate and postoperative time periods was statistically nonsignificant. The post hoc Tukey analysis revealed nonsignificant difference between all the groups.
In comparison, Al-Nahlawi et al. and Keskin et al. observed in their studies that using cold saline solution as a final irrigant reduced outer root exterior temperature by more than 10°C and maintained it for 4 min. The decline was found to be sufficient to induce a local anti-inflammatory impact in periradicular tissues. Intracanal irrigant was used in these research to assess its impact on postoperative pain in individuals with together asymptomatic and symptomatic irreversible pulpitis, as well as symptomatic apical periodontitis/normal apical tissues. When cryotherapy was used in both the studies, it resulted in significantly decreased postoperative pain levels when compared to organize groups. Similarly, leukocytes play a significant part in the inflammatory response of soft tissue lesions because cold promotes vasoconstriction, which has an anti-edema impact and, as a result, a reduction in pain. The curcumin group's mean VAS score after 24 h was 0.275 ± 0.784. The difference in scores (from preoperative levels) at postoperative and in the interim was statistically nonsignificant. Furthermore, ChainaniWu reviewed on the safety and antiinflammatory activity of curcumin and concluded that it was regarded as safe in six human trials with substantial antiinflammatory activity. Curcumin's anti-inflammatory properties may be due to the suppression of many compounds involved in inflammation. Balasubramaniam performed an agar well-diffusion test to determine the antibacterial efficacy of numerous intracanal irrigants. Curcuma longa possesses antibacterial activity against Enterococcus faecalis, a common endodontic pathogen, according to the findings. Based on the observations of the current study, it can be proposed that cryotherapy and curcumin can be used as a final irrigant in alleviating postendodontic pain in primary teeth.
Hence, cryotherapy uses low temperatures to treat harms and inflammation. Cryotherapy aims at removing heat and thus gaining an advantage by reducing inflammation. Cryotherapy is a long-standing method that has been regularly applied in sports injuries and medical procedures for pain management and postoperative care. Cryotherapy, by itself, suggests that applying cold through several methods may reduce the transmission speed of nerve motions, hemorrhage, edema, and local inflammation. It is, therefore, effective in the reduction of musculoskeletal pain, muscular spasm, and connective tissue distension.
In addition, Curcumin has been well established in other fields of medicine as it has good antioxidant, anti-inflammatory, hepatoprotective, anti-platelet aggregation, antimutagenic, antimicrobial, and cardiovascular effects. In dentistry, Curcumin has proved its therapeutic actions in periodontal problems, local drug delivery system, subgingival irrigant, pit and fissure sealant, anticancer properties, precancerous lesions, and the treatment of dental pain. Hence, Curcumin could be used as an irrigant as it is a cost-effective, readily available potent antioxidant.
The present study has some limitations, including limited sample size and an uneven gender distribution. Excessive cryotherapy use in children might lead to mouth sores and irritate soft tissues.
Future research could include pulpectomy of nonvital primary teeth and permanent mature teeth, which would necessitate a large number of subjects and a long period of summary.
The conclusions drawn from this study are as follows:
- All the three irrigant regimens, i.e., 2.5°C cold saline cryotherapy, curcumin-irrigating solution, and normal saline, were effective in alleviating postendodontic pain associated with infected primary teeth
- The differences in reduction of postendodontic pain between the three irrigating regimens were statistically not significant.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Menni AC, Ambati NR, Prasad MG. Clinical and radiographic evaluation of curcumin
gel mixed endoflas (CGE) powder as obturating material in primary molars Braz Dent Sci. 2020;23:1–4
2. Vieyra JP, Guardado JA. Reduction of post-endodontic pain after one-visit root canal treatment using three cryotherapy
protocols with different temperature Ann Mater Sci Eng. 2018;3:1–5
3. Saxena D, Saha SG, Saha MK, Dubey S, Khatri M. An in vitro evaluation of antimicrobial activity of five herbal extracts and comparison of their activity with 2.5% sodium hypochlorite against Enterococcus faecalis Indian J Dent Res. 2015;26:524–7
4. Vieyra JP, J Enriquez FJ, Acosta FO, Guardado JA. Reduction of postendodontic pain
after one-visit root canal treatment using three irrigating regimens with different temperature Niger J Clin Pract. 2019;22:34–40
5. Chamele J, Bhat C. Efficacy of turmeric extract as an intracanal medicament in deciduous teeth against enterococcus faecalis: An in vitro study Int J Curr Microbiol App Sci. 2014;3:17–25
6. Spratt DA, Pratten J, Wilson M, Gulabivala K. An in vitro evaluation of the antimicrobial efficacy of irrigants on biofilms of root canal isolates Int Endod J. 2001;34:300–7
7. Vera J, Ochoa-Rivera J, Vazquez-Carcaño M, Romero M, Arias A, Sleiman P. Effect of intracanal cryotherapy
on reducing root surface temperature J Endod. 2015;41:1884–7
8. Dedhia J, Mukharjee E, Luke AM, Mathew S, Pawar AM. Efficacy of Andrographis paniculata compared to Azadirachta indica, Curcuma longa, and sodium hypochlorite when used as root canal irrigants against Candida albicans and Staphylococcus aureus: An in vitro antimicrobial study J Conserv Dent. 2018;21:642–5
9. Agarwal S, Tyagi P, Deshpande A, Yadav S, Jain V, Rana KS. Comparison of antimicrobial efficacy of aqueous ozone, green tea, and normal saline as irrigants in pulpectomy
procedures of primary teeth
J Indian Soc Pedod Prev Dent. 2020;38:164–70
10. Al-Nahlawi T, Hatab TA, Alrazak MA, Al-Abdullah A. Effect of intracanal cryotherapy
and negative irrigation technique on postendodontic pain
J Contemp Dent Pract. 2016;17:990–6
11. Keskin C, Özdemir Ö, Uzun İ, Güler B. Effect of intracanal cryotherapy
on pain after single-visit root canal treatment Aust Endod J. 2017;43:83–8
12. Vera J, Ochoa J, Romero M, Vazquez-Carcaño M, Ramos-Gregorio CO, Aguilar RR, et al Intracanal cryotherapy
reduces postoperative pain in teeth with symptomatic apical periodontitis: A randomized multicenter clinical trial J Endod. 2018;44:4–8
13. Chainani-Wu N. Safety and anti-inflammatory activity of curcumin
: A component of tumeric (Curcuma longa) J Altern Complement Med. 2003;9:161–8
14. Balasubramaniam R. Comparative evaluation of antimicrobial activity of 3% naocl, 0.5% metronidazole, 12.5% Curcuma longa and 25% mimusops elengi against Enterococcus faecalis – An in vitro study IP Ind J Cons Endod. 2020;5:17–21