|Year : 2018 | Volume
| Issue : 1 | Page : 7-13
Comparative evaluation of single-visit endodontic treatment with and without the use of iodine potassium iodide as an endodontic irrigant: In vivo study
Gaurav Aggarwal1, Poonam Bogra1, Ayushi Jindal2, Nitesh Jain1
1 Department of Conservative Dentistry and Endodontics, D.A.V (c) Dental College, Yamuna Nagar, Haryana, India
2 Pedodontics and Preventive Dentistry (PGIDS, Rohtak), Haryana, India
|Date of Web Publication||10-Jan-2018|
Dr. Gaurav Aggarwal
H. No. 536, Sector 17, Huda, Jagadhri, Yamuna Nagar - 135 003, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: The root canal treatment in asymptomatic necrotic teeth in single visit has been an area of discussion for long. The purpose of this study was to compare the single-visit root canal treatment of asymptomatic nonvital mature mandibular molars with and without the use of 5% iodine potassium iodide (IKI) as an endodontic irrigant with the minimal use of postoperative medications.
Materials and Methods: Sixty patients requiring root canal treatment on asymptomatic nonvital mandibular molars were included in the study and were randomly allocated into two groups of thirty each. In Group I, no IKI was used and in Group II, 5% IKI was used as an irrigant. The complete treatment was done in single visit. The occurrence of postoperative pain and swelling was noted at various time intervals.
Results: Mann–Whitney U-test showed no statistically significant difference between the two groups regarding both the parameters. In Group I, 20% of patients experienced moderate-to-severe pain during the first 24 h (P = 0.25463) while only 10% of patients experienced moderate pain in Group II. In Group I, 20% of patients developed swelling after 24 h while none of the patients in Group II had any postoperative swelling (P = 0.09342).
Conclusion: Irrigants with better disinfection properties, penetration, and quick action such as 5% IKI are important adjunct to complete the disinfection of root canal system in single-visit endodontics.
Keywords: Endodontic irrigant, iodine potassium iodide, nonvital teeth, single visit
|How to cite this article:|
Aggarwal G, Bogra P, Jindal A, Jain N. Comparative evaluation of single-visit endodontic treatment with and without the use of iodine potassium iodide as an endodontic irrigant: In vivo study. Saudi Endod J 2018;8:7-13
|How to cite this URL:|
Aggarwal G, Bogra P, Jindal A, Jain N. Comparative evaluation of single-visit endodontic treatment with and without the use of iodine potassium iodide as an endodontic irrigant: In vivo study. Saudi Endod J [serial online] 2018 [cited 2018 Jan 22];8:7-13. Available from: http://www.saudiendodj.com/text.asp?2018/8/1/7/222762
| Introduction|| |
The appropriateness of single-visit endodontic treatment for treating nonvital teeth is controversial.,,, It is generally recommended that the infected root canals be treated in multiple visits along with the placement of an intracanal medicament to eradicate pathogens present in root canal and ensure a successful therapeutic result. A variety of antimicrobial agents such as camphorated monochlorophenol, camphorated phenol, antibiotic pastes, and calcium hydroxide [Ca(OH)2] either alone or in combination with various other agents have been tested for their ability to eradicate these microorganisms from root canals and dentinal tubules. However, Ca(OH)2, which has been the most commonly used and due to its long contact time of at least 2 weeks, limited ability to penetrate and disinfect the dentinal tubules, and its ineffectiveness against the commonly found microorganisms in root canal, i.e., Enterococcus faecalis,, does not make this an intracanal medicament of choice in single-visit endodontics.
Unfortunately, multiple visits also entail considerable additional time along with extra expense for both the patient and the dentist. Even intervisit microleakage due to partial or complete loss of temporary restoration may lead to reinfection in the root canal system from saliva. Ideally, if an antimicrobial agent that could avoid the necessity of placing an intracanal medicament between visits by disinfecting the root canal with a short contact time of minutes rather than days and allowing dentist to obturate and restore the tooth on same day, single-visit root canal treatment can be done., One such medicament, iodine potassium iodide (IKI) has a rapid antiseptic action against a wide range of microorganisms, low toxicity, hypoallergencity, and a very high probability of eliminating microorganisms including E. faecalis even when the contact time is as short as 10–15 min. Its low cytotoxicity and high antimicrobial properties give merit to its use as an endodontic irrigant. Moreover, it kills E. faecalis in the dentinal tubules more efficaciously than Ca(OH)2.,,,,
Hence, the present study was undertaken to compare the single-visit endodontic treatment of nonvital mature mandibular molars with and without the use of 5% IKI.
| Materials and Methods|| |
The present study was conducted in the Department of Conservative Dentistry and Endodontics, D.A.V Centenary Dental College, Yamuna Nagar. The patients requiring root canal therapy on asymptomatic nonvital permanent mandibular molars with periapical lesions <5 mm × 5 mm were randomly selected from the regular pool of patients reporting to the department. A study was approved by the Institutional Ethical Committee, Yamuna Nagar. A written informed consent was obtained from all the patients. Patients were included and excluded on the basis of criteria as given in [Table 1]. Diagnosis of pulpal necrosis was confirmed by negative response to heat, cold, and electric pulp tests.
Seventy-four patients were assessed for eligibility and sixty patients were finally enrolled in the study as depicted in the flow diagram [Table 2]. Patients were divided into two groups of thirty each. In Group I, single-visit root canal treatment was done without the use of 5% IKI while in Group II teeth, 5% IKI was used as an intracanal irrigant.
|Table 2: Flow diagram demonstrating patient assignment to different groups|
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For preparation of 5% IKI, ten parts potassium iodide and five parts iodine were added to 85 ml of distilled water. The solution obtained was filter sterilized and stored in tightly closed amber-colored bottle with storage time of <1 month.
Local anesthesia, if needed, was administered for patient comfort. Initial caries excavation was performed. Under rubber dam isolation, access preparation and initial negotiation of canals were done with size #10 or #15 K-files. Occlusion was relieved and working length was determined using electronic apex locator (Root ZX mini, J. Morita, USA). Root canals were prepared with rotary files (Protaper Universal, Dentsply Maillefer, Switzerland) by the technique described by Ruddle. All instrumentation was done in wet canals with pulp chamber brimful with 3% sodium hypochlorite (NaOCl) (Prevest DenPro, India) and was liberally coated with ethylenediaminetetraacetic acid (EDTA) and carbamide peroxide preparation (Glyde, Dentsply Maillefer). Intracanal irrigation was done with 2 ml of 3% NaOCl after each instrument using 28-gauge side vent irrigation needle.
After completion of canal instrumentation, all canals were irrigated with 5.0 ml of 3% NaOCl followed by 2 ml of normal saline. After that, in Group I, no IKI was used. In Group II, teeth were irrigated with 5 ml of 5% IKI and kept for 10 min in the canal. A final rinse of the root canals was then done with 2 ml of normal saline. Canals were dried with sterile paper points. Obturation was done with Protaper gutta-percha points (Dentsply Maillefer, Switzerland) and accessory cones with lateral condensation technique using zinc oxide eugenol (Prime Dental Products Private Ltd., India) as a sealer [Figure 1] and [Figure 2]. Permanent silver amalgam restoration was done after obturation.
|Figure 1: Few cases of Group I. Preoperative intraoral periapical radiographs (1a, 2a, 3a, 4a, 5a, and 6a). Postoperative intraoral periapical radiographs (1b, 2b, 3b, 4b, 5b, and 6b)|
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|Figure 2: Few cases of Group II. Preoperative intraoral periapical radiographs (7a, 8a, 9a, 10a, 11a, and 12a). Postoperative intraoral periapical radiographs (7b, 8b, 9b, 10b, 11b, and 12b)|
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Postoperative instructions were given. Each patient was given a prescription for paracetamol tablets (650 mg) to be taken 8 hourly with an instruction to take the medication only if pain occurs. In case pain still did not subside or swelling developed, the patient was given a prescription of amoxicillin 500 mg t.d.s in addition to the analgesics. Metronidazole 400 mg t.d.s was added if the swelling did not subside after the administration of amoxicillin in the first 24 h. If pain still did not subside, the patient was recalled and retreatment was initiated after removing the obturation.
Pain felt by the patient was categorized as follows. If the patient felt no postoperative discomfort, it was categorized as no pain; if there was a slight discomfort but did not require any medication, it was categorized as mild pain; and if analgesic (paracetamol 650 mg) was needed to relieve pain, it was categorized as moderate pain. If antibiotics had to be added along with analgesics to relieve pain, it was categorized as severe, and if retreatment needed to be done, it was categorized as a flare-up. All patients were asked to report any other reactions, if felt. Data were compiled and statistically analyzed using Mann–Whitney U-test.
| Results|| |
In Group I, 20% of patients experienced moderate-to-severe pain during the first 24 h while only 10% of patients experienced moderate pain in Group II (P = 0.25463) [Table 3]. In addition, 20% of the patients in Group I developed swelling after 24 h while none in Group II (P = 0.09342) [Table 4]. No statistical significant difference was found between the groups for all the above parameters.
|Table 3: Incidence of postendodontic pain in Groups I and II at various time intervals|
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|Table 4: Incidence of swelling in Groups I and II at various time intervals|
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After 1 and 3 weeks, there was no pain, swelling, or flare-up in any patient in both groups.
| Discussion|| |
The present study was undertaken to compare the single-visit endodontic treatment of asymptomatic nonvital mandibular molars with and without the use of 5% IKI as an intracanal medicament. Molar teeth were selected as they are difficult to manage due to limited access and anatomical variations, including multiple apexes and lateral canals. Necrotic teeth have been shown to be more prone to flare-up. Furthermore, it is difficult for exudate in mandibular molars to drain out of tooth as drainage is against gravity. It has been found that the preoperative size of the lesion has no influence on healing of the periapical lesion  if the canals are adequately disinfected. Hence, irrigation was done with 3% NaOCl followed by 5% IKI irrigation in Group II of the present study to further decrease the bacterial load. All teeth were prepared with standardized protocol of biomechanical preparation with Protaper rotary instruments using same amount/type of irrigants and chelating agents.
In Group I, 24 cases (80%) were symptom-free and did not develop any pain or swelling. This may be due to the use of NaOCl as an irrigant which is a well-known nonspecific proteolytic agent which is antibacterial in nature and also capable of dissolving the necrotic tissue and organic components of smear layer. A decrease in bacterial load up to 95% has been revealed by usage of 1.3% NaOCl in a previous clinical trial; however, approximately 30%–40% of teeth still had remnant bacteria in postchemomechanical samples., Law also reported that the combined application of NaOCl and EDTA as irrigants improved bacterial elimination significantly, but approximately 50% of teeth still harbored detectable bacteria postinstrumentation. Moreover, it is incapable of completely removing the smear layer. NaOCl irrigation adds to a number of advantages in endodontics, but complete bacterial elimination is not possible by this adjunctive measure. These remnant bacteria could be the possible cause of pain and swelling which occurred in rest of the cases (n = 6) of Group I.
In a study conducted by Fava  on asymptomatic necrotic central incisors treated in single visit, 5% teeth had pain at 2 days, while in the present study, incidence was 20%. Al Al-Negrish and Habahbeh  reported moderate-to-severe pain in 9.2% of the necrotic central incisors treated in single visit. A slightly higher incidence of postoperative pain in the present study could be due to the inclusion of different teeth (molars) as study sample which have more complex anatomical variation. The present study reported no incidence of flare-up which is supported by a previous study by Eleazer and Eleazer  who also reported only a 3% incidence of flare-up on treating necrotic molars in single visit. Eleazer and Eleazer related this low incidence of flare up to the fact that bacteria or other irritants are not allowed to remain in the empty canal isolated from the healing system, deletion of the intracanal medicament which may elicit an immune reaction as well as to early sealing of the canal which eliminates the possibility of bacterial ingress from a leaky restoration, lateral canal, or caries.
In Group II, only three cases experienced pain for the first 24 h as both the irrigants, i.e., 3% NaOCl and 5% IKI were used which might have resulted in a synergistic effect of these compounds. Peciuliene et al. reported that NaOCl irrigation and a final rinse of IKI after instrumentation resulted in 95% culture negative in retreatment cases. The combined use of NaOCl and EDTA increases the dentinal permeability resulting in enhanced penetration of IKI into the dentinal tubules, giving better antimicrobial effects and better results in the study. It can penetrate deep up to a depth of 1000 μm into dentin when irrigated for 5 min. A short period of exposure to IKI has a more efficient antibacterial effect in the dentinal tubules.
IKI is a very potent antimicrobial irrigating solution. The average number of bacteria remaining after a 24 h treatment with IKI was found to be 99.99% lower than the average number remaining after a 24 h application of Ca(OH)2. IKI has a favorable clinical contact time as endodontic irrigant. IKI applied for 10 min significantly reduced the bacterial count. Iodine is a strong oxidizing agent which reacts with free sulfhydryl groups of bacterial enzymes, resulting in disulfide linkages and disruption of bacterial cell wall. IKI also acts by way of its vapors and has been shown to have long distance bactericidal effects in vitro. Its decreased tendency to stain dentin compared to other iodine-containing antiseptics makes it a desirable irrigant in endodontics.
However, when the results were statistically analyzed, there was no significant difference in the mean postoperative pain and swelling scores of the two groups at any time interval (P > 0.05). None of the patients in any group developed flare-up or required retreatment. This may be because proper technique for chemomechanical preparation of root canal and proper irrigation regimen was followed in both the groups, and isolation was adequately maintained. Furthermore, severity of the disease process depends on the number and virulence of microorganisms and resistance of the host. Bacteria remaining in the root canals may not be in sufficient numbers to cause reinfection.
It has been documented that it is impossible to achieve a sterile canal. Even if some bacteria are left after proper obturation of the root canal, nutrient supply to the bacteria will be cut off and bacteria will either be dying or lie in a stage of dormancy. Furthermore, the presence of microorganisms does not ensure endodontic failure anymore than the absence of microorganisms guarantees success., It has also been reported that microorganisms are not effective unless inflammation has been caused by other factors such as overinstrumentation, overmedication, and unfilled root canal. All these causes were not present in teeth treated in either of the groups. However, the presence of microorganisms does provide an additional source of irritation for the body to overcome gaining optimal healing. Hence, every effort should be made to minimize the number of residual bacteria in the root canal system.
The sample size of the study was very small, and if power statistics are applied, a much larger sample size would be required for better statistical analysis between the two groups. Furthermore, pain is not a criterion for evaluating long-term success. Periapical lesions may act as a buffer against buildup of pressure by exudate decreasing the incidence of pain. Bacteriological studies and studies that compare periapical healing are needed to be done to substantiate the results. In multiple visits, Ca(OH)2 was reported to increase the healing rate by 10%. Studies are needed to whether IKI could achieve this or not.
| Conclusion|| |
Continuously evolving technology and materials have increased the predictability of success of single-visit endodontics. Irrigation is one of the important steps in determining this success. Five percent IKI is a promising endodontic irrigant with better disinfection properties, penetration depth, and quick action. These properties are important adjunct to complete the disinfection of root canal system in single-visit endodontics.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Malhotra N, Kundabala M, Acharya S. Contemporary endodontic approach: Single-visit root canal treatment revisited. ENDO Endod Pract Today 2009;3:215-25.
Jacob S. Single Visit Endodontics. Fam Prac Dent Handbook 2006;6:1-6.
Kenrick S. Endodontics: A multiple-visit or single-visit approach. Aust Endod J 2000;26:82-5.
Field JW, Gutmann JL, Solomon ES, Rakusin H. A clinical radiographic retrospective assessment of the success rate of single-visit root canal treatment. Int Endod J 2004;37:70-82.
Baker NE, Liewehr FR, Buxton TB, Joyce AP. Antibacterial efficacy of calcium hydroxide, iodine potassium iodide, betadine, and betadine scrub with and without surfactant against E faecalis in vitro
. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:359-64.
Sirén EK, Haapasalo MP, Waltimo TM, Ørstavik D.In vitro
antibacterial effect of calcium hydroxide combined with chlorhexidine or iodine potassium iodide on Enterococcus faecalis
. Eur J Oral Sci 2004;112:326-31.
Hosoya N, Takahashi G, Arai T, Nakamura J. Calcium concentration and pH of the periapical environment after applying calcium hydroxide into root canals in vitro
. J Endod 2001;27:343-6.
Fuss Z, Mizrahi A, Lin S, Cherniak O, Weiss EI. A laboratory study of the effect of calcium hydroxide mixed with iodine or electrophoretically activated copper on bacterial viability in dentinal tubules. Int Endod J 2002;35:522-6.
Siqueira JF Jr., Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361-9.
Weiger R, Rosendahl R, Löst C. Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 2000;33:219-26.
Barnhart BD, Chuang A, Lucca JJ, Roberts S, Liewehr F, Joyce AP. An in vitro
evaluation of the cytotoxicity of various endodontic irrigants on human gingival fibroblasts. J Endod 2005;31:613-5.
Orstavik D, Haapasalo M. Disinfection by endodontic irrigants and dressings of experimentally infected dentinal tubules. Endod Dent Traumatol 1990;6:142-9.
Lamers AC, van Mullem PJ, Simon M. Tissue reactions to sodium hypochlorite and iodine potassium iodide under clinical conditions in monkey teeth. J Endod 1980;6:788-92.
Safavi KE, Dowden WE, Introcaso JH, Langeland K. A comparison of antimicrobial effects of calcium hydroxide and iodine-potassium iodide. J Endod 1985;11:454-6.
Sakamoto M, Rôças IN, Siqueira JF Jr., Benno Y. Molecular analysis of bacteria in asymptomatic and symptomatic endodontic infections. Oral Microbiol Immunol 2006;21:112-22.
Figdor D, Sundqvist G. A big role for the very small – Understanding the endodontic microbial flora. Aust Dent J 2007;52 1 Suppl:S38-51.
Ruddle CJ. The protaper technique. Endod Topics 2005;10:187-90.
Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic treatment. J Endod 1998;24:614-6.
Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30:297-306.
Joshi N, Kundabala M, Shenoy S, Kamath S, D'Souza V, Rukmini. Evaluation of antimicrobial efficacy of 0.5% IKI, 3% NaOCI and 0.2% CHX when used alone and in combination as intracanal irrigants against Enterococcus faecalis
– An in vitro
study. Endodontology 2009;21:8-18.
Law A, Messer H. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. J Endod 2004;30:689-94.
Sayin TC, Cehreli ZC, Deniz D, Akcay A, Tuncel B, Dagli F, et al.
Time-dependent decalcifying effects of endodontic irrigants with antibacterial properties. J Endod 2009;35:280-3.
Rahabi ML, Abdulkhayum AM. Single visit root canal treatment: Review. Saudi Endod J 2012;2:80-4.
Fava LR. One-appointment root canal treatment: Incidence of postoperative pain using a modified double-flared technique. Int Endod J 1991;24:258-62.
Al-Negrish AR, Habahbeh R. Flare up rate related to root canal treatment of asymptomatic pulpally necrotic central incisor teeth in patients attending a military hospital. J Dent 2006;34:635-40.
Peciuliene V, Reynaud AH, Balciuniene I, Haapasalo M. Isolation of yeasts and enteric bacteria in root-filled teeth with chronic apical periodontitis. Int Endod J 2001;34:429-34.
Lin S, Kfir A, Laviv A, Sela G, Fuss Z. The in vitro
antibacterial effect of iodine-potassium iodide and calcium hydroxide in infected dentinal tubules at different time intervals. J Contemp Dent Pract 2009;10:59-66.
Safavi KE, Spangberg LS, Langeland K. Root canal dentinal tubule disinfection. J Endod 1990;16:207-10.
Weine FS. Endodontic Therapy. 6th
ed. St. Louis: CV Mosby; 2004. p. 139.
Ng YL, Glennon JP, Setchell DJ, Gulabivala K. Prevalence of and factors affecting post-obturation pain in patients undergoing root canal treatment. Int Endod J 2004;37:381-91.
Silveira AM, Lopes HP, Siqueira JF Jr., Macedo SB, Consolaro A. Periradicular repair after two-visit endodontic treatment using two different intracanal medications compared to single-visit endodontic treatment. Braz Dent J 2007;18:299-304.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]