Evaluation of the Effect of Propolis versus Calcium Hydroxide, Intracanal Medicaments, on Post-Operative Pain in Patients with Necrotic Pulp (A Randomized Clinical Trial)

doi:10.21203/rs.3.rs-1559517/v1

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Research Article

Evaluation of the Effect of Propolis versus Calcium Hydroxide, Intracanal Medicaments, on Post-Operative Pain in Patients with Necrotic Pulp (A Randomized Clinical Trial)

https://doi.org/10.21203/rs.3.rs-1559517/v1

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Aim

Propolis is an immunomodulatory, antioxidant, flavonoid-rich resinous product of honeybees. Propolis was reported as less cytotoxic and more effective against resistant microorganisms than calcium hydroxide (Ca(OH)₂) as well as biocompatible to the periradicular tissues than existing intracanal medicaments. The aim of this single-blinded randomized clinical trial was to evaluate the effect of propolis versus Ca(OH)₂, intracanal medicaments, on post-operative pain in patients with necrotic single canal teeth.

Methods

Forty-six participants, aged 20–40 years, with necrotic pulp in their single-rooted, single canal teeth were randomized into this parallel study, with 23 participants in Ca(OH)₂ (control) group and 23 participants in propolis (intervention) group. Root canal treatment was done in two visits and the medicament was applied for one week in between. The participants were blinded to the medicament used. The participants rated their pain score by a numerical rating scale after 24, 48, 72 hours and at 7 days before medicament removal and canals obturated. The data was statistically analyzed by multivariate analysis and t-test. The significance level was set at P ≤ 0.05 for all tests.

Results

The incidence of post-operative pain between both groups showed no statistically significant difference at different time intervals (p > 0.05). There was a non-significant, gradual decrease in post-operative pain of all 46 participants in both propolis (P = 0.17) and Ca(OH)₂ group (P = 0.274), at different time intervals.

Conclusions

The intracanal use of both Ca(OH)₂ and propolis were equally effective in controlling post-operative pain. Propolis can be used, as an alternative intracanal medicament, to Ca(OH)₂ paste.

This trial is registered at ClinicalTrials.gov, number NCT04983524

Calcium hydroxide is the most widely used intracanal medicament; its high alkalinity provides it with antimicrobial action, organic tissue dissolution capability and anti-inflammatory effects [1], [2]. Some studies established that Ca(OH)₂ decreased the amount of bacteria present in root canals [3]–[6]; however, the buffering action of dentine neutralizes the action of Ca(OH)₂ resulting in the survival of microorganisms [7], [8]. Ca(OH)₂ has a detrimental effect on periodontal tissues [9] and is not effective against the elimination of Entercoccus faecalis, which is the bacterium associated with persisting endodontic infections [2], [10], [11], since it could survive and buffer the high alkalinity of Ca(OH)₂ [7]. Due to the controversy concerning its efficacy as an intracanal medicament, natural products, such as propolis, are now being introduced as alternatives with great antibacterial activity [12].

Propolis is an immunomodulatory, antioxidant, flavonoid-rich resinous product of honeybees [12]. It has been used in dentistry as an anticaries agent [13], pulp capping agent [14], a storage medium for avulsed teeth[15], [16] and a sealant for dentinal hypersensitivity [17]. It was reported that propolis is less cytotoxic [18] and more effective against resistant microorganisms than Ca(OH)₂ as well as biocompatible to the periradicular tissues than existing intracanal medicaments [19], [20]. Until now, there are very few clinical trials that have examined the efficacy of propolis as an intracanal medicament on post-operative pain; therefore, the aim of this trial was to compare the effect of propolis and Ca(OH)₂ as intracanal medicaments on post-operative pain.

The null hypothesis of this trial was that there was no difference between propolis and Ca(OH)₂ as intracanal medicaments on post-operative pain in patients with necrotic, single canal teeth.

A power analysis based on previous studies Ehrmann et al and Singh et al showed that minimum sample size oof 23 for each group will give 80% statistical power of the experimental group

This is a self-funded, parallel randomized clinical trial was approved by the Human Subjects Review and Ethics Committee of Cairo University of Dentistry. The sample size calculation to detect an effect size of 0.2, a power of 80%, a significance level of 5% and for non-parametric distribution of the outcome variable indicated that a sample size of 23 in each group would be required, based on papers by Ehrmann et al [21] and Singh et al [22].

Patients were recruited from the Outpatient Endodontic Clinic at the Faculty of Dentistry, Cairo University to meet the target sample size. All 46 adult participants were medically-free of systemic diseases determined by a written questionnaire and oral questioning. Participants with necrotic, single canal maxillary and mandibular teeth with periapical infection shown as widening in the periodontal membrane space and complete root formation were included in the trial and any contraindication (pregnant or lactating females, resorption or anatomic abnormalities, teeth with cracks, curvatures, root caries, calcified canals, multi-rooted teeth, facial swelling, sinus tracts, acute pulpal or periapical lesion, teeth that are not indicated for endodontic treatment: Bad oral hygiene, mobile or recessed and previously endodontically-treated teeth) were excluded from participation. Patients younger than 18 and older than 50 years were also excluded. A written consent was obtained from each participant. All participants had negative palpation, percussion, hot and cold tests.

The participants recorded their pain level on a NRS [23] scale. It is an 11-point line divided into no pain (grade 0), mild pain (grades 1–3), moderate pain (grades 4–6) and severe pain (grades 7–10). All participants had no pre-operative pain.

Preparation of Propolis

[24]

250g of crude propolis powder was macerated in 70% ethyl alcohol and kept for 2 weeks in the dark at room temperature.

The aqueous ethanolic extract was filtered through Whatman filter paper no. 1.

Step 1 and 2 were repeated. The resulted filtrates were combined and evaporated using a rotary evaporator at 50°C under thermal, mechanical and reduced pressure.

The resulted viscous extract was manipulated by distilled water and alcohol then dried in an oven under vacuum at 50°C until a creamy consistency was reached.

The resulted mixture was rendered radio-opaque by 15% barium sulfate.

A random sequence generator by Microsoft Excel denoted intervention and control as A and B and randomly distributed and kept with the co-supervisor. This trial was single-blinded, where the participant was blind to the assigned intervention.

A pilot study was done on a symptomatic patient to test the efficacy of propolis in pain reduction and it showed a gradual decrease in post-operative pain.

At the first appointment

The tooth was accessed and put out of occlusion then isolated with a rubber dam. Working length was determined by an electronic apex locator (Root ZX mini, J MORITA, Tokyo, Japan) and confirmed by a periapical radiograph. Cleaning and shaping were done using a hybrid technique with preflaring using Sx at coronal two thirds for establishing a straight-line access. Protaper Universal rotary NiTi system (Dentsply Maillefer, Ballaigues, Switzerland) were used for apical preparation (operated according to manufacturer’s instructions). The sequence of the canal preparation started with S1, S2, F1 till F5 prepared to the full working length and then the master apical file was selected accordingly.

Irrigation sequence

1ml of 2.5% NaOCl was irrigated and manually agitated between each file delivered by a 28-gauge disposable plastic needle with a side-vented tip (Steri-pro Tips, DiaDent Group International, Chungcheongbuk-do, Korea) inserted 1mm shorter than the working length. Final irrigation sequence was done by 5ml 2.5% NaOCl then 5ml normal saline and finally 5ml 17% EDTA solution (Prevest Denpro Limited, Digiana, India). The canal was then dried using paper points before medicament application.

Intervention

The co-supervisor was phone-called to assign the participant to either group according to the generated random sequence.

Intervention group (23 participants)

Propolis paste was injected inside the canal using a long disposable tip 3mm less than working length and then checked with periapical radiograph.

Control group (23 participants)

Ca(OH)₂ Metapaste is a ready-made paste in a plastic syringe. It was injected in an apico-coronal direction inside the canal 3mm less than the full working length withdrawing slowly using its long disposable tip and checked with periapical radiograph.

Both medicaments were kept in the canal for one week.

Resin-modified glass ionomer capsule was used as a temporary filling material to ensure proper sealing and no leakage. The participant was given the NRS and phone-called to assess his pain at 24, 48 and 72 hours post-operatively.

If a participant experienced interappointment flare-up pain, he was allowed to take a non-steroidal anti-inflammatory drug every 8 hours. However, if the pain was too severe with presence of swelling, then an emergency visit was done and antibiotics were prescribed. Emergency visit: The medicament was removed and the apical constriction was violated by K-file #25 (if no drainage occurred). Irrigation with warm saline was done when there was pus/exudate then by 5ml 2.5% NaOCl followed by 5ml saline then by 5ml 17% EDTA solution. The canals were dried with paper points and medicament was re-applied. In all flare-up cases, pain was recorded normally. They were included in the trial, recorded as flare-up cases and was stated that the medicament was reapplied.

At the second appointment (After 1 week)

Pain was assessed by the participant on the NRS before obturation. The glass ionomer was removed then rubber dam was applied. Removal of the medicament using NaOCl irrigation and lateral strokes on the canal walls with the master apical file along the full working length.

Final irrigant rinse: 5ml 2.5% NaOCl followed by 5ml saline followed by 5ml of 17% EDTA solution for 3 minutes. The canal was then dried using paper points.

Master cone gutta percha was confirmed with a periapical radiograph. Obturation was done using a resin sealer. Access cavity was then sealed.

Statistical analysis

Categorical data was presented as frequencies (n) and percentages (%). Chi square test was used for statistical analysis followed by pairwise comparisons utilizing z-test with Bonferroni correction when the main test was significant. Quantitative data was explored for normality using Kolmogorov-Smirnov and Shapiro-Wilk tests. Age of the participants showed normal distribution, so it was presented as mean and standard deviation (SD) values and was analyzed using Independent t-test. Non-parametric numerical rating system (NRS) was presented as median and range values and was analysed using Mann Whitney U test for intergroup comparisons and Friedman test of repeated measures followed by multiple pairwise comparisons utilizing Wilcoxon signed-ranks test with Bonferroni correction for intragroup comparisons when the main test was significant. The significance level was set at P ≤ 0.05 for all tests. Statistical analysis was performed with IBM® SPSS® (SPSS Inc., IBM Corporation, NY, USA) Statistics Version 25 for Windows. The data was statistically analyzed by multivariate analysis and t-test.

The 46 participants included in this trial is presented in the PRIRATE 2020 flowchart below (Figure 1).

Baseline demographic data and clinical characteristics, presented in Table 1, of age, gender and tooth type had no statistically significant difference in their distribution of both groups.

Table (1): Baseline demographic data and clinical characteristics

Baseline demographic and clinical characteristics	Propolis (n)	Ca(OH)₂ (n)	P-Value
Male	7 (30.4%)	7 (30.4%)	0.625
Female	16 (69.6%)	16 (69.6%)	0.625
Mean Age (y)	31.82 ± 9.95	35.43 ± 9.31	0.211
Anterior	21 (91.3%)	20 (87%)	0.5
Premolar	2 (8.7%)	3 (13%)	0.5

In the propolis group, there was a gradual non-significant decrease in the distribution of pain scores between different time intervals at each category (P = 0.17). The highest incidence of ‘no pain’ was found at 7 days; ‘mild pain’ was found at 48 hours and ‘moderate’ and ‘severe’ pain were found at 24 hours.

In the calcium hydroxide group, there was a gradual non-significant decrease in the distribution of pain scores between different time intervals (P = 0.274). The highest incidence of ‘no pain’ was found at 7 days; ‘mild pain’ was found at 48 hours, ‘moderate pain’ was found at 24 hours and ‘severe pain’ was found equally at 24 and 48 hours.

The intensity of post-operative pain showed no significant difference in median and range values of NRS scores between both groups. Ca(OH)₂ group (P = 0.518), propolis group (P = 0.73).

The incidence of post-operative pain between both groups, presented in Table 2, showed no statistically significant difference at different time intervals (p > 0.05).

Table (2)

Frequencies (n) and percentages (%) comparing incidence of post-operative pain categories between both groups at different time intervals

Time interval	Pain category	Propolis		Calcium hydroxide		P-value
Time interval	Pain category	%	(n)	%	(n)	P-value
24 hours	None	60.9%	(14)	60.9%	(14)	0.774ns
	Mild	21.7%	(5)	17.4%	(4)
	Moderate	8.7%	(2)	17.4%	(4)
	Severe	8.7%	(2)	4.3%	(1)
48 hours	None	69.6%	(16)	65.2%	(15)	0.793ns
	Mild	26.1%	(6)	26.1%	(6)
	Moderate	0%	(0)	4.3%	(1)
	Severe	4.3%	(1)	4.3%	(1)
72 hours	None	78.3%	(18)	78.3%	(18)	1.000ns
	Mild	17.4%	(4)	17.4%	(4)
	Moderate	4.3%	(1)	4.3%	(1)
	Severe	0%	(0)	0%	(0)
7 days	None	95.7%	(22)	91.3%	(21)	0.600ns
	Mild	4.3%	(1)	4.3%	(1)
	Moderate	0%	(0)	4.3%	(1)
	Severe	0%	(0)	0%	(0)

Propolis, known for its therapeutical properties [25], was found to be effective against resistant microorganisms and biocompatible to the periradicular tissues than existing intracanal medicaments [19], [20]. Propolis has been proven to have antimicrobial activity against polymicrobial cultures collected from necrotic root canals [18]

Necrotic pulp with asymptomatic periapical infection contain microorganisms that produce enzymes and endotoxins causing persistent painful periapical lesions [26]. Therefore, intracanal medicaments were used for eradicating these microorganisms.

This study was conducted as a randomized clinical trial following the CONSORT 2010 statement. Treatment outcomes vary from one person to the other. “Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences. [27]”

Hot and cold tests assessed pulp vitality because they are convenient and reliable. Absence of response to both tests were indicative of a necrotic pulp. Patients aged 21–50 years had more accurate response to cold when compared with other age categories [28]. Others stated that necrotic teeth might respond to cold test due to remnants of fluid or gases in the pulp canal space extending into the periapical tissues [29].

The NRS quantitatively evaluated pain intensity at four stages giving enough time for symptoms to subside after chemomechanical preparation [30]. Pain perception and intensity are multifactorial, therefore, quantifying and standardizing pain objectively across a group of individuals can be challenging. NRS is traditionally used for quantitative analysis of pain [31]. It is easy to use, reliable and generates data that can be statistically analyzed; additionally, NRS is more sensitive to small changes than simple descriptive ordinal scales [32].

Studies show minimal extrusion of debris using the crown-down technique with engine-driven Ni-Ti systems and less probability for flare-ups [33], [34]. Preflaring with Sx reduces the amount of apically extruded debris [35] as well as reducing the failure rate of Ni-Ti files [36].

Irrigating solutions, 2.5% NaOCl and 17% EDTA were used for antimicrobial activity[37] and smear layer removal, respectively [38]. They also prevent the reduction of tissue dissolution capability and antimicrobial activities [39]. Their combination was associated with root canal cleanliness when done with manual agitation [40].

Results of the baseline data (age, gender and tooth type) showed no statistically significant difference which assured similar distribution and avoided the influence of confounding factors as well as all participants recorded no pre-operative pain.

The results showed no significant difference in incidence of post-operative pain between both groups at all time intervals. Thus, the null hypothesis was accepted.

Both groups recorded a non-significant gradual decrease in post-operative pain scores through all time intervals. For Ca(OH)₂, this could be attributed to its chemical and antimicrobial effects as the release of its hydroxyl ions leads to an alkaline environment, which is not favorable for the survival of microorganisms in the root canal [41]–[43]. On the other hand, the effect of Ca(OH)₂ might not have been effective due to the buffering capacity of dentine. Furthermore, E. faecalis and C. albicans, are highly resistant to Ca(OH)₂, limiting its efficacy [43], [44] and antimicrobial activity when compared with other intracanal medicaments [45], [46]

As for propolis, this non-significant gradual decrease in post-operative pain might be due to the antimicrobial activity as stated by several studies [20], [47], [48], in which propolis was proven to be more effective against resistant microorganisms than Ca(OH)₂. Furthermore, Ca(OH)₂ was reported to be potentially more toxic than propolis to both pulpal and periapical tissues [18], [49].

Within the conditions of this clinical trial, it could be concluded that both groups recorded a drop in post-operative pain score. The intracanal use of propolis was effective in decreasing post-operative pain and could be a good alternative to calcium hydroxide, without its drawbacks. Future trials should be conducted on a bigger scale for testing propolis as an intracanal medicament.

Acknowledgements:

The author denies any conflict of interest. The trial was self-funded.

Conflict of Interests

There are no third party, financial, patents planned, pending or issued, broadly relevant to the work nor other relationships/conditions/circumstances that present a potential conflict of interest.

Ethics Approval and Consent to Participate

A written consent was obtained from each participant and was approved by the Research Ethics Committee, Faculty of Dentistry, Cairo University. Number: 8.9.15 and dated 30/9/2015.

Funding:

No funding was obtained for this study as it was self-funded.

Author Contributions:

Serene Sirry: Conceptualization, Methodology, Funding, Writing-Original Draft, Resources, Visualization, Investigation

Abeer Marzouk: Writing-Editing & Review, Supervision

Shaimaa Gawdat: Writing-Editing & Review, Supervision, Project Administration

ElSayed Omer: Resources

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Evaluation of the Effect of Propolis versus Calcium Hydroxide, Intracanal Medicaments, on Post-Operative Pain in Patients with Necrotic Pulp (A Randomized Clinical Trial)

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