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Title Intracanal Cryotherapy May Reduce Postoperative Endodontic Pain
Clinical Question For patients with pulpitis and/or apical periodontitis, is intracanal cryotherapy with cold (2.5 degrees C) saline irrigation more effective than room temperature saline in reducing postoperative pain following root canal therapy?
Clinical Bottom Line Based on moderate quality evidence, using 20 mL of cold (2.5 degrees C) saline irrigation as a final irrigant during root canal therapy significantly reduces the intensity of postoperative pain at 6 and 24 hours. However, no significant difference in pain was noted at 48 hours, 72 hours, or 7 days following root canal therapy.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 32916207Sadaf/20208 RCTs/810 adult patientsMeta-Analysis
Key resultsIncluded 8 RCTs evaluating the effect of cold saline as a final irrigant (intracanal cryotherapy) on postoperative pain intensity following root canal therapy in patients presenting with pulpal or periradicular pathoses at 6, 24, 48, 72 hours and 7 days following treatment. Six studies were included in the meta-analysis, which showed significantly less postoperative pain reported at 6 hours (mean difference = -1.37; 95% CI, -0.61 to -2.14; P< .05) and 24 hours (mean difference = -1.43; 95% CI, -0.70 to -2.15; P < .05) in patients who received intracanal cryotherapy compared to the control group. The results at both 6- and 24-hour time periods were based on moderate-quality evidence. The meta-analysis revealed no significant difference in pain between groups at any other time period.
Evidence Search ((((apical periodontitis) OR (irreversible pulpitis)) AND (((cryotherapy) OR (cold therapy)) OR (cold saline))) AND ((endodontic therapy) OR (root canal therapy))) AND ((postoperative pain) OR (dental pain))
Comments on
The Evidence
Validity: Sadaf et al. systematically reviewed the literature published on 4 electronic databases through December 2019. The authors also searched the top 3 endodontic journals and unpublished gray literature. Two reviewers independently evaluated studies for inclusion and assessed them for risk of bias (RoB) using the Cochrane criteria. The review included 8 randomized controlled trials, which evaluated a total of 810 adult patients diagnosed with pulpal (irreversible pulpitis/necrosis) or periapical (apical periodontitis) pathoses on their level of postoperative pain following instrumentation or obturation. Two of the studies were dissimilar in how their outcomes were reported, so only 6 studies were included in the meta-analysis. The overall RoB in the included studies was judged to be moderate, with the majority of studies having a high risk of performance and detection bias. The quality of evidence for each outcome was evaluated using the GRADE system, and the author’s confidence in the evidence of impact at 6 and 24 hours was moderate due to the RoB and heterogeneity of the included studies. Due to the level of RoB throughout the studies, in addition to the substantial heterogeneity, the internal validity of the results of the meta-analysis is questionable. Furthermore, the sample sizes of most of the studies included was small, which may have resulted in an overestimation of the effects of the cryotherapy intervention. Therefore, the external validity in this review is uncertain. Perspective: The results of this review should be interpreted cautiously, given the low quality of available evidence. The subgroup analysis showing a more significant effect of cryotherapy when preoperative pain was reported as severe should be considered. Additionally, the secondary outcome of this study demonstrated a trend in reduced usage of rescue analgesics in patients who received cryotherapy, which indicates that intracanal cryotherapy may serve as an adjunct for treating persistent pain in endodontic patients.
Applicability This review demonstrates the potential effectiveness of intracanal cryotherapy for controlling pain following root canal therapy, in patients presenting with either pulpal or periapical preoperative pathoses. Although no distinction was made between diagnoses, the broad range of pulpal and periapical diagnoses as well as the wide range of tooth types responding to intracanal cryotherapy make this a pragmatic meta-analysis and therefore highly applicable to clinical practice. The reported prevalence of post-endodontic pain at 24 hours is 40% (J Endod. 2011;37(4):429-38) and pain reduction is a primary treatment outcome for endodontic therapy. The reduction in pain with use of cryotherapy was shown to be higher as the patient’s preoperative pain intensity increased. While the certainty of evidence available at this time is moderate to low, and the effects of intracanal cryotherapy on the long-term success of endodontic treatment are unknown, no adverse effects were reported in patients treated with intracanal cryotherapy. For patients presenting with moderate to severe preoperative pain associated with pulpal and/or periapical pathoses, the clinician may want to consider the use of cold saline as a final irrigant in their root canal treatment, especially considering the ease with which cryotherapy can be added to a practitioner’s typical treatment protocol. However, well-designed multi-center randomized clinical trials are warranted to establish the extent to which intracanal cryotherapy effects post endodontic pain.
Specialty/Discipline (Endodontics) (General Dentistry)
Keywords apical periodontitis; cold saline; cryotherapy; dental pain; irreversible pulpitis; postoperative pain.
ID# 3446
Date of submission: 11/24/2020spacer
E-mail reimnitz@livemail.uthscsa.edu
Author Leah Reimnitz, DDS
Co-author(s) Nima Moaven, DDS, MS
Co-author(s) e-mail moaven@livemail.uthscsa.edu
Faculty mentor/Co-author Nikita Ruparel, DDS, MS, PhD
Faculty mentor/Co-author e-mail Ruparel@uthscsa.edu
Basic Science Rationale
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Comments and Evidence-Based Updates on the CAT
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by Bradley Phares, DDS (San Antonio, TX) on 10/01/2022
As of October 2022, there have been four additional meta-analyses published on this topic. Gupta et al., 2022 (PMID 33585681) found intracanal cryotherapy had no significant effect on post-operative pain, whereas Monteiro et al., 2021 (PMID 33222053); Almohaimede & Al-Madi, 2021 (PMID 34831517); and Hespanhol et al., 2022 (PMID 36090511) all found a significant reduction in post-operative pain for varying duration's up to 72 hours.

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