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Background This study used micro-computed tomography (µCT) to assess the post space preparation systems [Rebilda (VOCO), RelyX (3M)] and preparations of varying lengths to create root dentin cracks. Methods Forty extracted maxillary first premolars with two roots were randomly divided into four groups. Teeth were decoronated to a length of 18 mm. Following root canal treatment, first µCT scans were performed. Post spaces were prepared with Rebilda post drills at 1/2 of the working length (WL) in Group 1 and at 2/3 of the WL in Group 2, while post spaces were prepared with RelyX post drills at 1/2 of the WL in Group 3 and at 2/3 of the WL in Group 4. After post space preparation, second µCT scans were performed. Dentinal cracks were detected by comparing the first and second µCT scan images, which were classified as “newly formed cracks”, “advanced cracks” and “completed cracks”. The chi-square test was used to compare among the groups, with a p-value of < 0.05 considered statistically significant. Results No statistically significant differences were observed between the groups for completed and advanced cracks ( P  > 0.05). In terms of newly formed cracks, the Rebilda-2/3 group showed more cracks than the RelyX-1/2 group, and the RelyX-2/3 group had more cracks than the RelyX-1/2 group ( P  < 0.05). Conclusion Completed and advanced cracks were observed in all groups, while no newly formed cracks were detected in the RelyX-1/2 group. The type of post drill and the preparation length are crucial factors in preventing the development of root dentinal cracks. Preparing 1/2 of the canal length may be a safer preparation length, and the RelyX drill may pose less risk of inducing root dentinal cracks.

Background Postoperative pain is a common complication following endodontic treatment, often caused by acute inflammatory responses in the periapical tissues. Several factors contribute to this, including inadequate instrumentation, apical extrusion of debris during canal preparation, and other aspects of the procedure. Advances in technology have led to the development of nickel-titanium (NiTi) instruments that have shown potential to reduce postoperative discomfort. The purpose of this study was to evaluate postoperative pain in patients undergoing endodontic treatment with different NiTi systems. Methods This randomized clinical trial will include 128 patients between the ages of 18 and 50 years with a diagnosis of pulp changes in molars without pain or radiographic lesions requiring endodontic treatment. Patients will be randomized to receive root canal preparation with the rotary ProTaper Ultimate rotary system or the Reciproc Blue reciprocating single-file system. The primary outcome will be the intensity of postoperative pain measured by a numerical rating scale (NRS-10 cm) in 24 h postoperatively. Secondary outcomes will include the intensity of postoperative pain measured by a visual analog scale (VAS-0–10 cm) at 6 and 12 h and spontaneous pain, occlusion sensitivity, and quality of life, assessed by the OHIP-14 questionnaire. Discussion Our null hypothesis is that there will be no significant difference in postoperative pain between the two systems. The results of this study will provide information on the incidence and intensity of postoperative pain after instrumentation of root canal instrumentation with different NiTi systems and may help improve patient outcomes and quality of life. Trial registration Brazilian Clinical Trials Registry (REBEC): RBR-10kbw6nx. Registered on April 6, 2024.

Objective This study investigated the associations among endodontic instruments, ultrasonic tips and various final irrigation protocols for removing intracanal and intratubular biofilms in long oval canals. Methodology One hundred mandibular premolars inoculated with Enterococcus faecalis were divided into two groups: the control group (CG: n  = 10), which received no treatment; and the test groups ( n  = 30), which included saline (SS), sodium hypochlorite (2.5% NaOCl) and chlorhexidine (2% CHX). The samples were prepared with Reciproc ® Blue 25/0.08, Flatsonic, Clearsonic and Reciproc Blue 40/0.06. Each test group was divided into three subgroups ( n  = 10): conventional irrigation (CI) with syringes and needles, passive ultrasonic irrigation (PUI) and continuous ultrasonic irrigation (CUI) with an Irrisonic tip. The root canals were examined using confocal laser scanning microscopy. Mann‒Whitney and Kruskal‒Wallis tests followed by Dunn post hoc tests ( p  < 0.05) were used for statistical analysis. Results NaOCl and CHX were effective for intracanal and intratubular decontamination. Saline showed significant decontamination in the intratubular areas when CUI was used. The CI method was the least effective for intracanal decontamination. Conclusion The use of Flatsonic and Clearsonic ultrasonic tips is promising for root canal disinfection. Clinical relevance The disinfection techniques in endodontic treatment focus on the removal of biofilms from long oval canals, which is crucial for effective cleaning during root canal procedures.

Background This randomized clinical trial aimed to evaluate the effect of intracanal cryotherapy with 2–4 °C normal saline irrigation on post-operative pain after single-visit non-surgical root canal retreatment. Methods Forty-six single-rooted, single-canal teeth requiring non-surgical root canal retreatment were randomly assigned to two groups ( n  = 23): a cryotherapy group and a control group. All the treatments were completed during a single visit. A combination of nickel-titanium and stainless-steel files was used for the removal of gutta-percha and root canal preparation, and irrigation was performed using 5.25% NaOCl and 17% EDTA. The cryotherapy group had a final irrigation temperature of 2–4 °C for 5 min before root canal obturation, whereas the control group received irrigation at room temperature. Post-operative pain levels were assessed via the Numerical Rating Scale at 6, 18, 24, 48, 72, and 168 h (up to 7 days). The number of analgesics consumed at the same intervals was also recorded. Statistical analysis was performed using the Chi-Square test, Mann-Whitney test, and Independent Samples test, with the significance level set at 0.05. Results There was a statistically significant difference in post-operative pain between the cryotherapy group and the control group at 6 h after treatment ( P  < 0.05). However, post-operative pain levels were not significantly different at 18, 24, 48, 72, or 168 h after treatment ( P  > 0.05). Additionally, there was no statistically significant difference between the groups in terms of analgesic intake ( P  > 0.05). Conclusion Intracanal cryotherapy can effectively reduce short-term post-operative pain, but it has no effect on long-term pain or the need for analgesics.

This trial assessed post-operative pain and healing of apical periodontitis following endodontic therapy with a reciprocating system compared to a crown-down technique with hand files and lateral compaction filling. One-hundred and twenty nonvital anterior teeth with apical periodontitis were randomly treated using either a reciprocating single file followed by matching-taper single-cone filling or a hand file and lateral compaction filling. Postoperative pain was assessed during the 7 days after the treatment, using a visual analogue scale and a verbal rating scale. Apical healing was assessed using the periapical index score after a 12-month follow-up. The hypothesis tested was that both protocols were equivalent and present similar effectiveness in healing periapical lesions. Data were analyzed through two one-sided tests, t-tests, as well as Mann-Whitney and Chi-squared tests (α = 0.05). Logistic regression was used to investigate the association of clinical and demographic factors with the success of treatment. Regardless of the assessment time, no difference in incidence (38%-43% at first 24h), intensity of postoperative pain, and incidence of flare-up (≈ 3%) was observed between the two endodontic protocols. Both protocols resulted in a similar healing rate of apical periodontitis. After 12 months, the success rate ranged from 73% to 78% and the difference between the treatments fell within the pre-established equivalence margin (-0.1; -0.41 to 0.2). Endodontic treatment combining a reciprocating single file with matching-taper single cone showed similar clinical effectiveness to the treatment using hand-file instrumentation and the lateral compaction filling.

Background Nickel titanium (NiTi) rotary files have drastically altered the treatment protocol in endodontics, allowing for faster and easier preparation and more thorough irrigation of the root canal system. Despite the advantages of the NiTi files, instrument separation still remains a major concern. The aim of this study was to compare the cyclic fatigue resistance of three different single-file NiTi systems after clinical use: WaveOne Gold (WOG, Dentsply Maillefer, Ballaigues, Switzerland), One Curve (OC, Micro Mega, Besancon, France), and Reciproc Blue (RPC Blue, VDW, Munich, Germany). Methods A total of 120 patients requiring endodontic treatment to first or second mandibular molars, were randomly divided into three groups (patient n  = 40) and root canals were prepared with WOG, OC or RPC Blue. Each group consists of 2 subgroups: first use (file n  = 10, patient n  = 10) and third use of file (file n  = 10, patient n  = 30). In control group, files were subjected to cyclic fatigue test without use (file n  = 10). Cyclic fatigue resistance of files was assessed by groove method. The data was evaluated by two-way ANOVA, Games & Howell post hoc and Weibull reliability analyses ( p  < .05). Results RPC Blue files showed the highest failure time value in all groups. In third use group, OC and RPC Blue files showed significantly higher failure time values compared to WOG files ( p  < .05). In general, RPC Blue files show the highest values in terms of number of cycles to fracture (NCF) in all groups, while OC and WOG files follow RPC Blue files respectively. There was statistically significant difference among groups considering the fragment length ( p  < .05). Conclusions Within the limitations of this study, RPC Blue files exhibited highest cyclic fatigue resistance after clinical use.

Background Ni-Ti instruments with varying design features may lead to different levels of postoperative pain, which is a significant clinical concern, particularly in previously asymptomatic teeth. Therefore, the purpose of this randomized clinical trial is to compare postoperative pain following instrumentation with TruNatomy versus ProTaper Next Ni-Ti systems in mandibular molars with asymptomatic apical periodontitis. Methods 90 healthy participants were randomly assigned to two groups: TruNatomy (TN) or ProTaper Next (PTN) instruments. After single-visit root canal treatments, participants were asked to rate their postoperative pain levels at 6, 12, 24, 48, and 72 h and seven days later, using the Numerical Rating Scale (NRS) through an online questionnaire. In cases of pain, 400 mg of ibuprofen was prescribed. Data from 80 participants were finally included in the analysis. Data were analyzed using the Mann-Whitney U, Friedman, and Fisher’s Chi-Square tests ( p  < 0.05). Results There was no statistically significant difference in postoperative pain intensity at 6, 12, 24, and 48 h and seven days between the groups ( p  > 0.05). At the 72-hour time point, TN group showed statistically higher postoperative pain intensity ( p  < 0.05). No statistically significant differences in the incidence of postoperative pain were observed at any of the time points ( p  > 0.05). Analgesic intake and flare-up incidence were not significantly different between the groups ( p  > 0.05). Conclusion Postoperative pain levels were not significantly influenced by the type of rotary Ni-Ti instrument. Both TN and PTN instruments led to low-level and similar postoperative pain intensity, minimal analgesic use, and a low incidence of flare-ups in teeth with asymptomatic apical periodontitis. Trial registration ClinicalTrials.gov ID NCT06545773, Registration Date 8 August 2024 (retrospectively registered).

Background Precise knowledge of the apical construction, which determines the end of the area for canal preparation and filling, is essential for the success of root canal treatment and the management of postoperative pain. For this purpose, devices based on various methods that determine the working length (WL) are used. However, it is still controversial which method provides the most accurate measurements. Aim To investigate the compatibility of the electronic apex locator (EWL) and simultaneous working length determination (SWL) methods in single-root teeth in comparison with the radiographic working length determination (RWL) method and to determine which one produced more effective results in terms of postoperative pain. Materials & methods One hundred patients scheduled for root canal treatment (RCT) were randomly assigned to one of the three groups according to the working length measurement method (EWL, SWL or RWL). After WL determination with assigned method, root canals were prepared and then obturated. Age, gender, simplified oral hygiene index (OHI-S), oral and dental examinations and Visual Analogue Scale (VAS) results of all participants were recorded. The incidence and intensity of postoperative pain were rated on a Visual Analogue Scale (VAS) by patients 6, 12, 24, 48 h and 7 days after RCT. The number of analgesic tablets (400 mg Ibuprofen) taken by patients was also recorded. Data were analyzed using the chi-square, One- way ANOVA and Kruskal-Wallis tests. Bland-Altman and Passing-Bablock regression analysis were used as method comparison techniques. Results It was determined that the number of patients receiving analgesia and the total number of analgesia doses were higher in EWL and RWL groups compared to SWL group ( p  < 0.0001). When the WL values at which the treatment was applied were compared in the patient groups; WL values of EWL group were statistically lower than SWL group ( p  < 0.01). While there was no difference between the preoperative VAS scores of the groups ( p  = 0.7590), the postoperative 6th and 12th hour VAS scores of SWL group were lower than those of EWL and RWL groups ( p  = 0.005 and p  = 0.0002, respectively). Again, the VAS scores of SWL group at the 24th and 48th postoperative hours were lower than those of RWL group ( p  < 0.05). According to the Bland-Altman and Passing-Bablock regression analysis results, although there was no statistically significant difference between the EWL and SWL methods ( p  = 0.471), the bias value of -0.1190 was well below the acceptable total error (0.1648). Additionally, a strong relationship was found between EWL and SWL methods ( r  = 0.9698, r 2  = 0.9406, p  < 0.001). Therefore, statistically these two methods were considered compatible with each other. It was determined that there was a statistically significant bias (0.340, p  < 0.0001) between the RWL and SWL methods, exceeding the total error. Conclusions As a result, it was determined that the SWL method, which is used to determine working length for the success of endodontic treatment, can be used as an alternative to the EWL method thus producing more effective results in the management of postoperative pain. However, in addition to the method used, the technology of the device developed for this method should not be ignored. Clinical relevance Precise knowledge of the apical construction, which determines the end of the area for canal preparation and filling, is essential for the success of root canal treatment and the management of postoperative pain. For this purpose, devices based on various methods that determine the working length are used. However, it is still controversial which method provides the most accurate measurements. This study found that the simultaneous working length determination method can be used as an alternative to the electronic working length determination method and produces more effective results in the management of postoperative pain. Another important outcome of this study is that the Total Allowable Error (TEa) for the electronic apex locator method, which is accepted as the reference, has been calculated for the first time. Other methods have been evaluated according to this reference method. This is a first in literature.

Advanced irrigation techniques, such as the XP-endo Finisher file and sonic EDDY system, have been introduced to overcome the limitations of conventional needle irrigation by enhancing irrigant penetration and disinfection. However, their influence on post-operative pain remains under investigation. This study aimed to evaluate the effect of these techniques on post-operative pain following single-visit root canal treatment. Thirty patients requiring endodontic treatment for asymptomatic vital maxillary central incisors or canines were enrolled. All procedures were performed in a single visit using the ProTaper Universal rotary system. Irrigation was carried out with 2.5% sodium hypochlorite (NaOCl). Participants were randomly assigned into three equal groups based on the final irrigation protocol: Group I – conventional needle irrigation (control), Group II – XP-endo Finisher file, and Group III – sonic EDDY activation. Post-operative pain was assessed using a Visual Analogue Scale (VAS) at 8, 24, and 48 h, and at 1 and 2 weeks. Data were statistically analyzed with significance set at P  ≤ 0.05. Pain scores significantly decreased overtime in all groups. While between-group differences were not statistically significant, within-group reductions were significant. Group II exhibited the lowest pain levels, followed by Group III, while Group I reported the highest. Additionally, female participants had significantly higher odds of reporting pain. The XP-endo Finisher and sonic EDDY systems resulted in better pain reduction over time than conventional needle irrigation, with XP-endo Finisher being most effective. Clinical relevance: Advanced irrigation systems may enhance patient comfort and compliance by reducing post-operative pain after endodontic therapy. Clinical trial registration: The study protocol was registered on https://beta.clinicaltrials.gov identifier: NCT05450003 on (08/07/2022).

Background TruNatomy instruments promises a more conservative alternative to conventionally used instruments. They are claimed by the manufacture to decrease the amount of debris extrusion as well as the torque generated during instrumentation, potentially resulting in lower post-operative discomfort and a safer more convenient experience for the patient and clinician. Aim To compare the effect of canal shaping using TruNatomy (TN) rotary system to RaCe (RC) rotary system on post-operative pain in necrotic maxillary bi-rooted premolars, while simultaneously inspecting the real-time dynamic forces produced during instrumentation. Methods In this parallel group superiority trial, following power calculation, 40 patients diagnosed with pulp necrosis in asymptomatic bi-rooted maxillary premolars were recruited and randomly allocated into two equal groups ( n  = 20) according to the instrumentation system used. Treatment was completed in a one visit for all cases. Pain levels were recorded immediately before RCT and at 6,12,24,48, 72 h, and 1-week post RCT using mVAS. The number of analgesics taken if any was also recorded. Operative torque generated during root canal preparation as well as the time taken for the instrument to reach the working length were simultaneously recorded during instrumentation. Outcome data was statistically analyzed using Shapiro Wilk test, independent t test, Mann–Whitney U, Chi square, Fisher exact tests, spearman’s correlation coefficient. Significance level (α) was set at 0.05. Results There was no statistically significant difference between pain scores in the test groups at all time points measured (P > .05). No significant different was also recorded in terms of number of analgesics taken (P > .05). Mean torque, average peak torque and maximum torque values showed no statistically significant difference as well, however the instrumentation time was significantly shorter for the TN Group (P < .05). A moderate significant positive correlation was found between the instrumentation time and generated operative torque. Conclusion TN and RC rotary instruments resulted in similar and acceptable levels of post-operative pain in cases of asymptomatic necrotic teeth. However, TN rotary system combined torque and instrumentation time values suggest an overall higher cutting efficiency and potentially a better safety profile as compared to RC rotary system. Trial registration ClinicalTrials.gov identifier: NCT04616469; registration date (10/08/2020).