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Year : 2017  |  Volume : 9  |  Issue : 3  |  Page : 160-164

Comparative evaluation of interappointment flare-ups in diabetic and nondiabetic patients

Department of Conservative Dentistry and Endodontics, H. P. Government Dental College, Shimla, Himachal Pradesh, India

Date of Web Publication7-Aug-2017

Correspondence Address:
Nayantara Sen
Department of Conservative Dentistry and Endodontics, H. P. Government Dental College, Shimla, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_54_17

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Aims: This study aims to compare the incidence of interappointment flare-up during endodontic treatment in diabetics and nondiabetics patients using calcium hydroxide and chlorhexidine gel as intracanal medicament. Materials and Methods: A total of 60 patients requiring root canal treatment were chosen. 30 known diabetic patients with fasting blood sugar (FBS) = 100–120 mg/dl were in Group 1 while others non-diabetic patients with FBS ≤ 100 mg/dl were placed in Group 2. After initiation of endodontic procedures and biomechanical preparation, 15 patients were chosen randomly to place calcium hydroxide paste or chlorhexidine gel, as intracanal medicament in both groups. The pain was recorded on day 1, 2, 3, 7, and 14 posttreatment using verbal rating scale. Result: A total of 10 of 60 patients developed interappointment flare-up, of which 5 (16.6%) were diabetics, and 2 (6%) were nondiabetic patients. The results comparing the interappointment flare-ups between the groups were statistically nonsignificant (P - 0.2179). Conclusions: Although the incidence of interappointment flare-up in diabetic patients is approximately twice than that seen in nondiabetic patients, these results are nonsignificant. This indicates that interappointment flare-ups in diabetic patients with good glycemic control are essentially similar to healthy individual with no metabolic diseases.

Keywords: Controlled glycemic status, diabetes, flare-up, interappointment flare-up

How to cite this article:
Sen N, Gupta AK, Singh BP, Dhingra A. Comparative evaluation of interappointment flare-ups in diabetic and nondiabetic patients. Indian J Dent Sci 2017;9:160-4

How to cite this URL:
Sen N, Gupta AK, Singh BP, Dhingra A. Comparative evaluation of interappointment flare-ups in diabetic and nondiabetic patients. Indian J Dent Sci [serial online] 2017 [cited 2018 Jun 21];9:160-4. Available from: http://www.ijds.in/text.asp?2017/9/3/160/212398

  Introduction Top

Flare-up phenomenon is a true complication of an endodontic procedure, characterized by the development of pain, swelling or both, which commences within a few hours or days after root canal procedures and is of sufficient severity to require an unscheduled visit for emergency treatment.[1] Flare-up phenomenon is complex and is not well understood.[2]

Injury to the pulp or periradicular tissues can be mechanical, chemical and/or microbial factor, of which microorganisms are major causative agents. These includes inadequate debridement and disinfection of the root canals, which gives an environment for microbes to propagate within the canal.[3]

Patients with diabetes mellitus have a higher propensity for severe endodontic infections and increased incidence of flare-up, which can be attributed to alterations in immune functions,[4] and the presence of more virulent microorganisms in root canals of diabetic patients compared to nondiabetics.[5]

Intracanal medicament works as a mechanical barrier to eliminate microorganisms or neutralize residual toxic products and helps chemomechanical preparation of teeth with pulp-periapical infections.[6]

Calcium hydroxide, considered to be most effective medicament, is most commonly due to its antibacterial properties owing to its high pH (11-12.5)[7] while chlorhexidine gluconate is a synthetic cationic biguanide with a broad spectrum antimicrobial activity targeting both gram-positive and gram-negative microbes. Its efficacy is based on the interaction between the positive charge of the molecule and negatively charged phosphate groups on the bacterial cell wall, which allows the chlorhexidine molecule to penetrate the bacteria with intracellular toxic effects.[8] Its use in endodontics has been demonstrated to have inhibitory effects on bacteria commonly found in endodontic infections.[9]

This study was aimed to compare the rate of interappointment flare-ups in diabetic patients with controlled glucose level to nondiabetic patients during endodontic treatment while using two different kinds of intracanal medicaments, with known antibacterial activity.

  Materials and Methods Top

An ethical clearance was obtained from the College Committee before beginning the study, and all procedure have been performed in accordance with the ethical standards laid down by the Declaration of Helsinki. A total of 60 patients were randomly chosen, 30 were known diabetics, with fasting blood sugar (FBS level) =100–120 mg/dl, were included in Group 1. Moreover, 30 healthy nondiabetic patients (control), with FBS ≤ 100 mg/dl, were placed in Group 2. These 30 patients of each group were further divided into two subgroups according to the intracanal medicament placed, i.e., calcium hydroxide (Ammdent, India) and chlorhexidine gel (gluco-chex 2% gel).

Maxillary and mandibular multiple rooted teeth with deep caries and pulp exposure, teeth with necrotic pulps (negative response to hot, cold and electric stimulation), absence of preoperative pain or tenderness on percussion, were included in this study. Teeth with symptomatic irreversible pulpitis, preoperative pain, or necrotic pulp associated with clinical symptoms such as swelling or purulence, discharging sinus, root fractures (in which conventional root canal treatment is contraindicated), immature root apices, root resorption (as conventional root canal treatment that cannot be performed) and retreatment cases were excluded from the study.

Multiple three visit protocol was used for endodontic treatment of patients was followed. After attaining an informed consent from all patients, an initial clinical examination, local anesthesia was administered, and root canal treatment was initiated, after isolation using rubber dam. On the first appointment (day 1), access cavity was prepared, and the walls of access cavity were flared to provide a straight line access for instrumentation. Working length was determined using electronic apex locator Propex-pixi, Dentsply Maillefer, Switzerland) and confirmed radiographically to be 1 mm short of the radiographic apex. The coronal one-third of the canal was enlarged using Gates Glidden drills (1–3 no.). The apical portion of the canal was enlarged using K-files to size 3–4 files larger than the initial apical file, and the rest of the canal was prepared using step-back technique. EDTA paste (Ammdent, India) was employed intermittently during cleaning and shaping. Final irrigation was done using 3% sodium hypochlorite (Prevest Dentpro Ltd., India), 17% EDTA (Ammdent, India), normal saline, and 0.2% chlorhexidine (Ammdent, India) with intermittent use of normal saline. Following instrumentation and irrigation, canals were dried and treated in the following manner: In 15 randomly chosen patients of each group, calcium hydroxide paste was placed while in other 15 patients, chlorhexidine gel was placed, as an intracanal medicament into the canal and access cavity was restored temporarily with zinc oxide eugenol cement (Cavit-G, 3M-ESPE, Germany). Patients were asked to note the intensity of pain intensity, experienced on 1st, 2nd, and 3rd postoperative day on the questionnaire provided [Figure 1].
Figure 1: The clinical procedure followed in the study

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On the second visit (day 7), patients were recalled after 7 days of the first visit. The root canals were evaluated for any kind of discharge. And subsequently, cleaned and irrigated with 3% sodium hypochlorite (Prevest Dentpro Ltd., India), 17% EDTA (Ammdent, India), normal saline, and 0.2% chlorhexidine (Ammdent, India) with intermittent use of normal saline. Subsequently, the intracanal medicament was placed. Here, also patients were asked to note pain intensity on the 1st postoperative day on the questionnaire.

On the third visit (day 14), the patient was examined for pain, swelling related to the same region of the oral cavity, and the root canals were examined for any kind of discharge or tenderness. When the patient was asymptomatic, and root canals were clean obturation was done, using gutta-percha points and AH-Plus sealer using lateral compaction technique. Here, also patients were asked to note pain intensity on the 1st postoperative day on the questionnaire.[5]

All patients during treatment were prescribed paracetamol tablets to be taken S.O.S., and the same would be noted down in the questionnaire provided.

Interappointment flare-up was assessed using verbal rating scale (VRS)[5] using the following criteria [Table 1].
Table 1: The verbal rating scale[5]

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Cases with VRS 4 and 5 were regarded as interappointment flare-ups.[5]

  Results Top

Among the total 60 patients, 30 diabetic patients (Group 1) and 30 nondiabetic patients (Group 2), the incidence of interappointment flare-up was evaluated at the end of day 1, day 2, day 3, day 4, day 7 and day 14. A total of 10 of 60 patients developed interappointment flare-up, of which 5 (16.6%) were diabetics, and 2 (6%) were nondiabetic patients [Table 2].
Table 2: The number of cases and percentages of flare-up in both groups

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Chi-square test was applied to the incidences of flare-ups in Group I and Group II (P - 0.2179) using Statistical Package for the Social Sciences (SPSS) 16 [Table 3].
Table 3: Comparing the results and P value

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  Discussion Top

A flare-up is an acute exacerbation of an asymptomatic pulpal and/or periradicular pathosis after the initiation or continuation of root canal treatment.[10] It is characterized by the development of pain, swelling, or both following endodontic intervention.

Diabetes mellitus acts as a modulating factor in endodontic infections.[11] According to Paz Villanueva et al., root canal system of diabetic patients is colonized with different microbial profiles including, Fusobacterium nucleatum, Prevotella micros, and Streptococcus species, from nondiabetic, with significant associations to preoperative pain, susceptibility to severe periradicular diseases,[12] delayed healing, and interappointment flare-ups.[13] Well-controlled diabetic is at no greater risk of postoperative infection than the nondiabetic patients and do not require prophylactic antibiotics before routine endodontic treatment.[14] In addition, studies by Fouad and Pickenpaug et al., have established no difference in the amount of interappointment pain when patients were given antibiotics (mostly penicillin, amoxicillin in Pickenpaug et al. 2001) or with placebos.[15],[16]

According to Ernest et al., preoperative pain is also a predictor of interappointment flare-ups. Moreover, the frequency of flare-ups in cases with necrotic pulp was significantly higher than in vital pulp cases.[17]

Hence, this study was planned to compare the frequency of interappointment flare-ups in patients with controlled diabetic status with nondiabetic patients, using two different types of intracanal medicaments. And for above reasons, patients without preoperative pain and swelling were chosen for study.

Intracanal medicaments are an integral part of endodontics while some researchers believe its important for the success of endodontic therapy,[18] others have reported no influence on the incidence of postoperative pain.[19],[20]

The intracanal medicament used calcium hydroxide paste and 2% chlorhexidine gel. Calcium hydroxide has high pH and is lethal to bacterial cells on direct contact.[6] Since it takes about 10–14 days for the inflammation to subside in healthy human body, so minimum interappointment time interval should also not be less than this.[21] Hence, the intracanal dressing was given to disinfect root canals for at least 7 days,[21] where it should occupy the apical regions in a sufficient quantity to permit its biological effect on appropriate tissues in its proximity.[22]

Calcium hydroxide has shown to decrease the numbers of Enterococcus faecalis at all depths of dentinal tubules within 24 h. Although complete elimination of E. faecalis is not possible with calcium hydroxide.[21] Instead, 2% chlorhexidine gel and liquid both, have shown complete elimination even 7 days after biomechanical instrumentation.[21]

For these reasons, three-sitting protocol was adopted, where two intervals of 7 days were given for placing the intracanal dressing, which minimizes bacterial load from accessible and inaccessible areas of the root canal systems, reducing the chances of interappointment flare-up.

A similar study done by Pai et al.,[5] in which interappointment flare-ups in diabetic patients using calcium hydroxide and triple antibiotic paste was compared and showed triple antibiotic paste being more effective than calcium hydroxide in preventing the occurrence of flare-up in diabetic patients. In our present study, patients with a controlled diabetic status were only included while Pai et al. did not consider the level of blood glucose level as an inclusion criteria.

In a retrospective study by Fouad et al.,[10] the incidence of flare-up during endodontic treatment was 8.6% for diabetics and 2.3.% for nondiabetics. Further, the authors have stated that though statistically not significant, the diabetics had twice as many flare-ups than nondiabetics. This could be due to high glucose levels which can inhibit macrophage function (chemotaxis, phagocytosis and bacterial death) resulting in an inflammatory state that impairs host cellular proliferation and wound healing. Therefore, these patients are more susceptible to infection processes, especially anaerobic ones, due to reduced oxygen diffusion through the capillary wall, and increase in the formation of irreversibly glycated proteins forming advanced glycation end products.[23],[24]

Diabetic state is accompanied by delayed or decreased repair capacity at almost all stages of wound healing including cellular migration, cellular proliferation, capillary growth, and metabolic activity within the granulation tissue.[25],[26] According to a study by O'Sullivan et al., tight glycemic control has shown to significantly improve wound healing among diabetic patients.[27] In addition, improved glucose control has a stimulatory effect on wound healing.[25] A study by Goodson and Hunts have shown that depressed synthesis of protocollagen and collagen in insulin resistance and hyperglycemia, impair wound healing.[26]

In the present study, 5 out of 30 diabetic patients developed interappointment flare-up while only 2 in nondiabetic group developed interappointment flare-up. Among the diabetics, 20% patients of calcium hydroxide group while 13% in the chlorhexidine group developed flare-up. However, among the nondiabetics, only 13% in calcium hydroxide group and none in chlorhexidine group developed flare-up. The results of this study were statistically insignificant indicating that the inflammation and wound healing in the periradicular region accounting to the interappointment flare-ups is essentially similar in patients with controlled diabetes and healthy individual with no metabolic diseases owing to the controlled blood glucose levels.

  Conclusion Top

Within the limitations of the present study, it can be concluded that though the incidence of interappointment flare-up in diabetic patients (16.6%) was more than twice than that seen in nondiabetic patients (6.6%). These results were statistically nonsignificant indicating that interappointment flare-ups in patients with controlled diabetes are essentially similar to healthy individual with no metabolic diseases. In addition, calcium hydroxide and 2% chlorhexidine gel were effective for managing interappointment flare-up in diabetic patients and nondiabetic patients. However, 2% chlorhexidine gel showed lesser incidences of interappointment flare-up compared to calcium hydroxide paste. However, more studies are required for further clinical validation of the findings pertaining to the present study.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Priyanka SR. Flare-ups in endodontics-a review. IOSR J Dent Med Sci 2013;9:26-31.  Back to cited text no. 3
Delamaire M, Maugendre D, Moreno M, Le Goff MC, Allannic H, Genetet B. Impaired leucocyte functions in diabetic patients. Diabet Med 1997;14:29-34.  Back to cited text no. 4
Pai S, Vivekananda Pai AR, Thomas MS, Bhat V. Effect of calcium hydroxide and triple antibiotic paste as intracanal medicaments on the incidence of inter-appointment flare-up in diabetic patients: An in vivo study. J Conserv Dent 2014;17:208-11.  Back to cited text no. 5
[PUBMED]  [Full text]  
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Gomes BP, Souza SF, Ferraz CC, Teixeira FB, Zaia AA, Valdrighi L, et al. Effectiveness of 2% chlorhexidine gel and calcium hydroxide against Enterococcus faecalis in bovine root dentine in vitro. Int Endod J 2003;36:267-75.  Back to cited text no. 8
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Fouad AF, Burleson J. The effect of diabetes mellitus on endodontic treatment outcome: Data from an electronic patient record. J Am Dent Assoc 2003;134:43-51.  Back to cited text no. 11
Chávez de Paz Villanueva LE. Fusobacterium nucleatum in endodontic flare-ups. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:179-83.  Back to cited text no. 12
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McKenna SJ. Dental management of patients with diabetes. Dent Clin North Am 2006;50:591-606, vii.  Back to cited text no. 15
Walton RE, Chiappinelli J. Prophylactic penicillin: Effect on post-treatment symptoms following root canal treatment of asymptomatic periapical pathosis. J Endod 1993;19:466-70.  Back to cited text no. 16
Ehrmann EH, Messer HH, Clark RM. Flare-ups in endodontics and their relationship to various medicaments. Aust Endod J 2007;33:119-30.  Back to cited text no. 17
Kawashima N, Wadachi R, Suda H, Yeng T, Parashos P. Root canal medicaments. Int Dent J 2009;59:5-11.  Back to cited text no. 18
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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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