Postoperative Pain Associated With Resin And Bioceramic Based Sealers: A Systematic Review

Keywords

Bioceramic Sealer; Resin Based Sealers; Postoperative Pain.

Introduction

Postoperative pain after endodontic treatment is uninvited but it may manifest in a few hours to a few days after treatment.[9] Different studies show that the postoperative pain ranges from 3% to 60%.[10] Pain can occur due to mechanical, chemical or microbial causes.[11] There are umpteen treatment related factors which are responsible for postoperative pain, few of them being loss of working length, instrumentation technique, overzealous use of intracanal irrigants, forceful instrumentation and choice of sealers.[12] Sealers tend to interact with the periapical tissues and surrounding periodontal tissues and thus might interfere with the healing process. [13] They tend to extrude through the periapex, which can cause local inflammatory reactions.[12] The composition of sealers also markedly influence the inflammatory reaction. [14]

Different types of sealers are commonly used in endodontics. The most commonly used ones are zinc oxide eugenol based sealers and resin based sealers. Of late calcium phospho silicate based sealers have emerged to be successful in endodontics. [15] The two major advantages of bioceramic sealers are its biocompatibility and good sealer-to-dentin bonding.[16] But the major disadvantage of bioceramic sealers is the difficulty in removing the sealer after it has set as indicated in post space preparation or retreatment.[17] Resin based sealers have good sealing ability and are biocompatible with moderate antimicrobial properties.[18] Previously our team has a rich experience in working on various research projects across multiple disciplines [19-33] Now the growing trend in this area motivated us to pursue this project.

Aim

The aim of this review is to compare the incidence of postoperative pain using bioceramic and resin based sealers in endodontically treated teeth.

Research question

Is there any difference in the incidence of postoperative pain after using resin based or bioceramic sealers in endodontically treated teeth?

Null Hypothesis

There is no significant difference in the incidence of postoperative pain using bioceramic sealers and resin based sealers in endodontically treated teeth.

Alternate hypothesis

There is a significant difference in the incidence of postoperative pain using bioceramic and resin based sealers in endodontically treated teeth.

PICO

P - Endodontically treated teeth
I - Bioceramic sealer
C - Resin based Sealer
O - Postoperative pain

Materials and Methods

Sources used

Detailed search strategies were carried out on the following databases.

- PubMed

- Pubmed advanced search

- Scopus database

- Cochrane database

Language restrictions

No limits and language restrictions were applied during the electronic search to include the search phase of the systematic review. No time restriction was applied.

Hand search

Additionally, hand searching was done in the following journals

? Clinical oral investigations

? E Cronicon open access journal

Inclusion criteria

Criteria for considering studies for this review:

- Studies which compared the bioceramic sealers and resin based sealers in postoperative pain.

- Clinical trials, prospective studies.

Exclusion criteria

The following studies were excluded:

- Case reports

- Case series

- In vitro studies

- Studies comparing other sealers

Results And Discussion

Description of studies

The search identified 6 publications which were relevant to the title. A total of 6 publications that fulfilled the criteria were included in this review.[Table 1]

Risk of bias of Included studies

The assessment for the four main methodological quality items are shown in the table. The study was assessed to have a ‘High risk of bias’ if it did not record a ‘yes’ in three or more of the four main categories, ‘Moderate risk of bias’ if it did not record yes in two out of the four categories and ‘Low risk of bias’ if randomization, allocation concealment, assessor blinding and completeness to follow up were considered adequate.[Table 2-6]

Quality Assessment

(Higgins and Green. Cochrane reviewer’s Handbook 2009) The quality assessment of included trials was undertaken independently as a part of the data extraction process. Four main criteria were examined.

1. Method of randomization

a. Yes- Adequate as described in the text

b. No- Inadequate as described in the text

c. Unclear in the text

2. Allocation Concealment

a. Yes- Adequate as described in the text

b. No- Inadequate as described in the text

c. Unclear in the text

3. Outcome assessors blinded to intervention

a. Yes- Adequate as described in the text

b. No- Inadequate as described in the text

c. Unclear in the text

4. Completeness of follow up

a. Yes- Adequate as described in the text

b. No- Inadequate as described in the text

c. Unclear in the text

The purpose of this review is to assess the intensity of postoperative pain after using bioceramic sealers and resin based sealers. Six clinical studies fulfilled the criteria for being included in this review. (Indre Graunite et al, 2018; Ana Paz et al, 2018; Ayfer Atav Ates et al, 2018; Braulio Fonseca et al, 2019; T. Aslan et al, 2020; Gabriel et al, 2021).

Interpretation of the results

From the six included studies, a total of 815 teeth (from 573 patients) were included. The gender distribution was 150 males and 213 females with different age groups.

In the study conducted by Indre Graunite et al, out of 61 patients only premolars and anterior teeth were included. Based on the results, it was observed that lower premolars had a significantly higher pain compared with the anterior teeth. Postoperative pain was measured at 4 time points: 24 hours, 48 hours, 72 hours, and 7 days. In this trial, there was no statistically significant difference in the pain occurrence between root canals obturated with different sealers observed at any of the assessed time points. In this study, it was concluded that the sealers performed similarly in terms of occurrence and intensity of postoperative pain.

In the study conducted by Braulio Fonseca et al, 64 patients requiring endodontic treatment of single-rooted maxillary teeth with necrotic pulps were included. The treatments of necrotic teeth were performed in a single visit with the same single-file reciprocating protocol. The canals were irrigated, dried and were randomly divided into two different groups depending on the type of sealer used: resin-based group (RG) in which the canals were filled with the AH Plus, and the bioceramic group (BG) in which the canals were filled with the Sealer Plus BC. The pain score was recorded on VAS at 24-hour, 48-hour, 72-hour, and 1-week intervals. The results showed that sealer extrusion occurred in nine patients of the RG and in 19 patients of the BG which highlights that sealer extrusion was significantly more in BG group compared to RG group. But the sealer extrusion was not associated with pain. This study concluded that the average pain levels were similar in both groups.

In a study conducted by Aslan et al, a total of 90 patients having one first or second molar tooth diagnosed with asymptomatic irreversible pulpitis were randomly divided into three groups according to the sealer used. The patients included in the study underwent single visit root canal treatment. The pain score was recorded on VAS 6, 12, 24 and 48 h, and 3, 4, 5, 6 and 7 days. The results showed that there were no significant differences amongst the groups in terms of postoperative pain at any time points assessed. The study concluded that the sealers tested were associated with similar levels of postoperative pain.

Ana Paz et al conducted a study wherein he evaluated the postoperative pain after using a bioceramic material as an endodontic sealer with single cone technique, and compared the 1results with a resin based endodontic sealer with the cold lateral condensation technique and the continuous wave of condensation. A total of 30 patients were divided randomly for each group of obturation systems. The pain score was recorded on VAS for 7 days post treatment. The results showed that Single cone + Bioceramic referred post-operative pain more frequently than Continuous wave + resin sealer or Lateral condensation + resin sealer. The results also showed that the bioceramic group presented the highest intensity of moderate pain intensity during the 7 day evaluation period. The study concluded that more number of studies are required with larger sample sizes.

Ayfer Atav et al conducted a study wherein 160 patients with vital and non vital teeth. They were randomized into four groups using a randomized block design with block sizes of 10 patients each with two types of sealers AH plus and Bioceramic sealers. Postoperative pain was recorded by visual analogue scale at 6, 12, 24, and 72 h after obturation. The results showed that there was no significant difference between groups in the incidence of postoperative pain.

Gabriel et al conducted a study wherein 168 patients with non vital teeth. At the time of obturation, teeth were randomly assigned to use AH plus or TotalFill BC sealer using random permuted block design. Postoperative pain was recorded using a 5 point Likert scale over a period of seven days. The results showed that there was no significant difference between the two sealers in terms of pain experienced.

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Figure 1:

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Figure 1. Demonstrating the search flowchart.

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Figure 2:

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Figure 2. Demonstrating Risk of bias summary.

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Figure 3:

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Figure 3. DemonstratingRisk of bias graph.

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Table 1:

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Table 1. Representing theGeneral information of selected studies (Data Extraction).

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Table 2:

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Table 2. Representing the Study design and Outcome.

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Table 3:

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Table 3. Evidence level of significant studies.

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Table 4:

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Table 4. Risk of bias- Major criteria.

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Table 5:

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Table 5. Risk of bias: Minor criteria.

Summary

Of the six included studies, it is seen that there is no significant difference in the incidence of postoperative pain after using bioceramic and resin based sealers except in a study conducted by Ana Paz et al wherein it was shown that usage of bioceramic sealer was associated with increased postoperative pain compared to Resin sealer. However the quality of the clinical trial was low having a high risk of bias. In one of the studies, it was found that there was no correlation between sealer extrusion and the occurrence of postoperative pain. [12] On the other hand, one of the studies highlighted that there were no significant differences among the groups in terms of postoperative pain at any time points assessed nor for analgesic intake of patients among the groups.[34] The other study inferred that bioceramic sealer caused more extrusion compared to resin sealer. But it was seen that sealer extrusion was not associated with postoperative pain. [35]

Whereas in one of the studies conducted by Ana Paz et al, he studied the combined effect of obturation technique and the type of sealer that influences the postoperative pain. In this study, it was found that the highest intensity of postoperative pain was presented by single cone and bioceramic sealer compared to continuous wave and resin sealer. However the sample size was limited to make a conclusive study and the mechanism by which the technique of obturation influenced the postoperative pain was not explained clearly. [36]

In another study conducted by Ayfer Atal et al, results showed that there was no significant difference between groups in the incidence of postoperative pain; however, iRoot SP sealer (bioceramic sealer) was associated with less analgesic intake compared to AH Plus sealer (resin sealer).[37] In another study conducted by Gabriel et al, results showed that there was no significant difference in the pain experienced between the two groups( AH plus sealer and Total Fill BC sealer). [38]

Our institution is passionate about high quality evidence based research and has excelled in various fields [23, 39-48].

Implications for Practice

Bioceramic or resin based sealers should be chosen to aim at reducing the postoperative pain.

Implications for Research

In future, research should be aimed at utilizing a sealer to reduce the postoperative pain.

Conclusion

With the available evidence from the included studies, the quality of the clinical trials was moderate. Most of the included studies did follow a common methodology to assess the incidence of postoperative pain. The results of five included studies concluded that there was no significant difference in the pain level when the different sealers were used. More number of clinical trials adhering to the correct method of randomisation, allocation concealment and blinding have to be carried out to arrive at a definitive conclusion regarding the occurrence of postoperative pain following the usage of resin based and bioceramic sealers in endodontically treated teeth.

Acknowledgements

We would like to acknowledge the department of Conservative dentistry and Endodontics for helping us to access the required data.