| Abstract|| |
Background: Extrusion of infected debris into the periapical tissue has been cited as the major cause of postoperative pain, regardless of instrumentation technique.
Aim: Comprehensively review two different kinematics of instrumentation (reciprocating and rotary) and association to the postoperative pain after endodontic treatment.
Methods: Two investigators performed a systematic review with meta-analysis. MEDLINE/PubMed, Cochrane Library, and Scopus supplied relevant data from studies published until February 2018 to answer the PICO question. Primary outcome was overall postoperative pain, and the secondary outcomes were nature of the pain (mild, moderate, and severe) at 12, 24, and 48 h.
Results: Ten randomized clinical trials fulfilled eligibility criteria, and five of them were submitted in the meta-analysis. Primary outcome indicated that reciprocating system results in less postoperative pain compared to rotary system (P < 0.05). As a secondary outcome, there was no statistical difference for mild, moderate, and severe pain after 12 and 24 h using reciprocating or rotary systems (P > 0.05). However, the reciprocation system showed less severe pain after 48 h (P < 0.05).
Conclusion: Rotary motion had a negative impact on postoperative pain after endodontic treatment. Furthermore, after 48 h, more patients presented severe pain under rotary motion. More randomized clinical studies would be helpful.
Keywords: Endodontics; postoperative pain; reciprocating system; root canal therapy; rotary system
|How to cite this article:|
Martins CM, De Souza Batista VE, Andolfatto Souza AC, Andrada AC, Mori GG, Gomes Filho JE. Reciprocating kinematics leads to lower incidences of postoperative pain than rotary kinematics after endodontic treatment: A systematic review and meta-analysis of randomized controlled trial. J Conserv Dent 2019;22:320-31
|How to cite this URL:|
Martins CM, De Souza Batista VE, Andolfatto Souza AC, Andrada AC, Mori GG, Gomes Filho JE. Reciprocating kinematics leads to lower incidences of postoperative pain than rotary kinematics after endodontic treatment: A systematic review and meta-analysis of randomized controlled trial. J Conserv Dent [serial online] 2019 [cited 2019 Dec 15];22:320-31. Available from: http://www.jcd.org.in/text.asp?2019/22/4/320/270496
| Introduction|| |
Endodontic treatment is a conservative way of treating teeth with pulpal disease. Due to recent advances in dental treatment modalities, patients are constantly being challenged to choose between root canal treatments and implant placement.
Although root canal therapy should be the treatment of choice over implant placement in teeth with favorable prognosis, the presence of postoperative pain could pose as an unfavorable outcome. In a systematic review, Sathorn et al. reported a prevalence rate ranging from 3% to 58% for pain after root canal treatment, corroborating with recent studies.,
Furthermore, studies have reported intensity standards of postoperative pain as mild, moderate, and severe.,,,, The highest postoperative pain level is recorded in the early stages post root canal treatment – up to 12 h – and this might be attributed to the ongoing inflammatory process. The prevalence and severity of pain substantially decrease within the first 48 h.,,,
Several etiologic factors are attributed to this postoperative pain such as history of preoperative pain, insufficient root canal debridement, hyperocclusion, periapical disease, and extrusion of infected debris into the periapical tissue. The last has been cited as the major cause of pain after endodontic treatment., Every endodontic instrumentation technique available can produce apical extrusion of debris during chemomechanical preparation of the root canals, even when short of the apical foramen. It can be stated that extrusion of debris is an inevitable occurrence that could be reduced using accurate irrigation and aspiration techniques, instrumentation limited to the confines of the canal, and use of different endodontic files and their kinematics.,,,,,
The first rotary Nickel–Titanium (NiTi) instrument was placed on the market in 1992, and since then, its refinement can be noted through the use of new technologies such as reduced number of files and heat treatments which therefore resulted in improvements on the file quality and resistance. Those changes led to the emerging of the reciprocating files, which have a different motion that relieves the stress on the instrument by special counterclockwise and clockwise movements. Research findings comparing rotary and reciprocating systems have reported a decrease in preparation time and increase in cyclic fatigue in reciprocating files, while keeping similar shaping ability to rotary systems.
Some studies have shown that the prevalence of pain after endodontic treatment is greater when using rotary instrumentation with multiple instruments., On the other hand, there are several studies reporting the decrease of postoperative pain using reciprocating systems.,, These findings could be attributed to differences in systems, regarding to the cross-section, cutting-edge design, taper, tip type, configuration, flexibility, alloy type, number of files used, kinematics, or cutting efficacy.,,,,, In addition, the singularity, personality, and operator training can also influence the extrusion of debris in periapical area contributing to the pain outcome.,,,,, Some recent studies have reported no significant difference in postoperative pain between rotary and reciprocating systems, and therefore, instrumentation kinematics had no impact on intensity of postoperative pain.,,,
A systematic review and meta-analysis was performed by Caviedes-Bucheli at al. in 2015 regarding the influence of reciprocating and rotary files on the apical extrusion of debris and its biological relationship with symptomatic apical periodontitis. They concluded that both rotary and reciprocating systems generate apical extrusion of debris and expression of neuropeptides. The authors included and evaluated in vitro and clinical studies and supported the fact that the inflammatory reaction is not influenced by the number of files but by the type of movement (reciprocating movement) and the instrument design (triangular cross-sectional design).
Recently, Hou et al. published a systematic review and meta-analysis considering postendodontic pain following root canal preparation with rotary versus reciprocating instruments. Three studies were included, and the conclusion was that rotary instruments were associated with a lower incidence of postoperative pain after endodontic treatment when compared to reciprocating instruments, while reciprocating instruments were associated with less mild postoperative pain incidence. However, since then, several randomized clinical trials have been published driving the need of a new systematic review.
In summary, clinicians who read the published literature hoping to have their questions answered regarding to the appropriate technique to adopt in treating teeth with potential for postoperative pain will find conflicting results. Certainly, current literature does not contain a clear guide toward choosing a correct kinematic system on automated endodontic treatment to prevent postoperative pain.
Thus, the purpose of this systematic review was to comprehensively review two different kinematics of instrumentation (reciprocating and rotary) regarding to the postoperative pain after endodontic treatment. Null hypothesis was that there would be no difference in postoperative pain between the tested kinematics.
| Methods|| |
Protocol and registration
This article was designed according to the Cochrane criteria (Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0) for elaborating a systematic review and meta-analysis and adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO-CRD42017077490).
The inclusion criteria were: (1) randomized controlled trials, (2) studies that evaluated reciprocating versus rotary system for root canal treatment, (3) studies that evaluated postoperative pain, and (4) studies published in English language. Exclusion criteria included any articles that failed to meet the inclusion criteria and studies that evaluated root canal retreatment.
A specific clinical question was structured according to the PICO approach: the addressed focus question was: does the endodontic treatment using reciprocating system cause more pain than using the rotary system? In this process, (P) represents teeth endodontically treated with (I) reciprocating system, (C) compared to rotary system and (O) the primary outcome to be extracted and analyzed in the meta-analysis was the overall postoperative pain. The postoperative pain after 12, 24, and 48 h was the secondary outcome.
An electronic search in the PubMed/MEDLINE, Cochrane Library, and Scopus databases was conducted until August 2018. Furthermore, a manual search was conducted to identify gray literature and registered trials not yet published until 2018 from the following journals: Journal of Dental Research, Journal of Endodontics, International Endodontic Journal, PLOS ONE, Journal of Dentistry, Clinical Oral Investigations, International Journal of Oral Science, Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology.
Two independent researchers (C.M.M and A.C.A.S) performed the electronic search at the selected databases. The search terms used were: (1) clinical trial and reciprocating and rotary and endodontic, (2) reciprocating and rotary and endodontic, (3) reciprocating and endodontic, and (4) rotary and endodontic.
Two researchers (C.M.M. and A.C.A.S.) independently selected the studies according to their titles and abstracts and categorized them as included or excluded. Any disagreements were settled through discussion and consensus with a third researcher (V.E.S.B.). After that, both investigators read the articles selected for inclusion, and a manual search was performed on the reference list.
Data collection process and data items
Subsequently, the full-text of the obtained articles was analyzed. The analysis of these selected articles was used to answer the PICO questions. The researcher (C.M.M.) collected relevant information from the articles, including author, year, study type, number of patient and teeth sample size, gender, age average, teeth with necrosis, teeth with vital pulp, number of visit, number of teeth treated with reciprocation system, number of teeth treated with rotatory system, irrigating solution type, use of ultrasonic, brand of endodontic fill cement, obturation method and temporary restoration, methods of analysis of pain, pain control, follow-up, and pain outcome. Then, a second researcher (V.E.S.B.) checked all of the collected information. A fourth researcher (A.C.A.) settled any disagreement between the investigators through discussion until a consensus was obtained. Duplicate subject publications within separate unique studies were not reported twice.
Risk of bias
The risk of bias assessment in the included studies was evaluated using the Cochrane Collaboration's Tool for Assessing Risk of Bias in Randomized Trials. The assessment criteria is a domain-based evaluation in which critical assessments are made separately for different domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. For each domain, the risk of bias was graded as high, low, or unclear based on criteria described in the Cochrane Handbook for Systematic reviews of Interventions 5.1.0.
The meta-analysis was based on the Mantel-Haenszel method. Overall postoperative pain was the dichotomous outcome measure that was evaluated. To assess the postoperative pain, the statistical unit for the outcome was the number of patients who attribute a value to their perceived pain based on the visual analog scale (VAS) by the presence or absence of pain. Accordingly, risk ratio (RR) and corresponding 95% confidence intervals (CI) using a random-effects model were applied to the recent studies., The RR values were considered significant when P < 0.05. To perform the meta-analysis and the funnel plot it was used the software Reviewer Manager 5 (Cochrane Group).
Bias risk among the studies
An asymmetric funnel plot may indicate publication bias or other biases related to sample size, although the asymmetry may also show a true relationship between trial size and effect size. The heterogeneity was assessed using the Q method (χ2) and the value of I2. The outcomes were dichotomized into good and poor results. The I2 values above 75 (range 0–100) were considered to indicate significant heterogeneity.
To analyze the sensitivity of the tests employed, a subgroup analysis was performed to identify any potential causes of heterogeneity. Specifically, the subgroups considered were (1) the nature of pain (mild, moderate, and severe pain) after 12 h, (2) 24 h, and (3) 48 h. The nature of postoperative pain was categorized since each protocol can cause more pain than the other. Postoperative pain is more common in the early hours, up to 12 hours, having the tendency to decrease over days (24 and 48 hours).
The kappa statistic was calculated to define the inter-reader agreement in the study selection process. According to Landis and Koch, the level of inter-reader agreement is almost perfect if the value of Kappa (κ) is 0.81–1.00, substantial if κ is 0.61–0.80, moderate if κ is 0.41–0.60, fair if κ is 0.21–0.40, and poor if κ is <0.20.
| Results|| |
A total of 983 articles were retrieved, of which only 10 fulfilled eligibility criteria (inter-reader agreement, κ =0.8 for PubMed/Medline, κ =1 for Cochrane Library, and κ=1 for Scopus) [Figure 1]. All the studies selected were randomized clinical trials and compared the postoperative pain after using reciprocating and rotary endodontic systems.,,,,,,,,, The risk of bias assessment of the included studies is described in [Table 1]. Extracted data are summarized in [Table 2].
For the first selection, three articles were selected and subsequently excluded. Gomes et al., 2017, evaluated intraoperative pain, and the goal of this present work was to evaluate the postoperative pain. Arslan et al., 2016, evaluated various kinematic movements on postoperative pain using only the Reciproc (VDW, Germany) system. Gambarini et al., 2013, performed a research to evaluate and compare postoperative pain using three different NiTi instrumentation techniques; however, this was not a randomized clinical trial.
A total of 1442 patients, regardless of gender, with an average age of 36.3 years had 2047 teeth treated endodontically. From this, 1035 teeth were treated with reciprocation system and 1012 teeth were treated with rotary system. The reciprocation systems used were WaveOne (Dentsply Maillefer, Switzerland),,,,, and Reciproc (VDW, Germany),,,,, and the rotary systems used were OneShape (MicroMega, France),, ProTaper (Dentsply Maillefer, Switzerland),,,, ProTaper Next (Dentsply Maillefer, Switzerland),, Mtwo (VDW, Germany), and RaCe. Protocols were used according to manufacturer recommendations for the determination of file size and instrumentation techniques.
Vital pulp was diagnosed in 1758 teeth, and 374 teeth were diagnosed with pulp necrosis with the presence or absence of periapical lesion. Only four studies performed endodontic treatment in teeth diagnosed with vital pulp.,,, Likewise, only four studies performed endodontic treatment in teeth with pulp necrosis.,,, Only 2 studies evaluated the postoperative pain in both pulp conditions.,
The endodontic treatment was completed in a single visit in all studies except 2 clinical trials that performed two-visit endodontic treatment. Nekoofar et al., 2015, study consisted of a two-visit endodontic treatment, although they did not use any dressing between appointments. Likewise, Krithikadatta et al., 2016, also performed a root canal treatment in two visits but with the use of intracanal medication with calcium hydroxide. They analyzed pain by VAS after cleaning and shaping of the root canal system and the use of intracanal medication before and after the obturation.
During chemical mechanical preparation, different irrigating solutions were used. Sodium hypochlorite (NaOCl) was the irrigant of choice in 6 articles, with concentrations ranging from 2.5% to 5.25%.,,,,, Neelakantan et al., 2015, used 3% NaOCl associated with ethylenediaminetetraacetic acid (EDTA) gel-form as lubricant for glidepath. Pasqualini et al., 2015, used an association of 5% NaOCl and 10% EDTA. Nekoofar et al., 2015 used 2% Chlorhexidine as an irrigating solution and Zand et al., 2016 used 17% EDTA gel-form associated with saline solution.
As a final rinse, 8 researches used EDTA followed by its irrigating solution, distilled water, saline solution or even chlorhexidine.,,,,,,, Zand et al., 2016 used EDTA as an irrigating solution, so they used NaOCl associated with saline solution as a final irrigant. Three studies reported the use of ultrasonic during the irrigation steps.,,
For obturation, the most used cement was AH 26 Sealer and AH Plus Sealer.,,,,,, Additionally, Mineral Trioxide Aggregate Plus Sealer  and Pulp Canal Sealer  were used. The most common method for obturation was lateral condensation.,,,,, Two clinical trials used continuous wave technique , and one used single cone with thermomechanical compaction through McSpadden.
After completion of the endodontic treatment, Nekoofar et al. 2015 and Shokraneh et al. 2017 prescribed a single dose of 400 mg ibuprofen tablet to their patients and six clinical trials indicated the use of analgesics as needed.,,,,,
The follow-up was completed mostly using VAS for 1st h until 7 days after endodontic treatment. The main objective was to analyze postoperative pain. As conclusion, four studies have reported more pain using reciprocating system,,,, and four studies have reported no difference between the kinematics.,,,
The main goal and its respective primary outcome is synthetized in [Table 3].
|Table 3: Summary of each study according to aim of the study and outcome|
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To answer the PICO question, the primary outcome was performed on the five studies ,,,, that reported the presence or absence of pain after endodontic treatment using reciprocating or rotary systems. A weighted average across the studies was provided according to a random-effects model, which indicated that reciprocating system causes absence of pain more often when compared with rotary system (RR: 0.75; 95% CI: 0.62–0.90; P = 0.003). The intrastudy heterogeneity measures were χ2 = 2.13. The interstudy heterogeneity measures were I2 = 0%. The funnel plot showed an evident symmetry among the differences of means for the studies evaluated, showing absence of bias [Figure 2]a.
|Figure 2: Forest plot and funnel plot; comparison of rotary and reciprocating system on postoperative pain: (a) Overall; (b-d) according to the nature of postoperative pain - mild, moderate, and severe - after 12 h; (e-g) according to the nature of postoperative pain - mild, moderate, and severe - after 24 h; (h-j) according to the nature of postoperative pain - mild, moderate, and severe - after 48 h|
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A specific analysis for the nature of pain (mild, moderate, and severe pain) after 12 h, 24 h, and 48 h was performed. There was no statistical difference for mild (RR: 0.69; 95% CI: 0.36–1.33; P = 0.27, χ2 = 0.02, I2 = 0%), moderate (RR: 1.08; 95% CI: 0.51–2.26; P = 0.84, χ2 = 3.03, I2 = 34%), and severe (RR: 0.69; 95% CI: 0.27–1.76; P = 0.44, χ2 = 0.19, I2 = 0%) pain after 12 h of endodontic treatment using reciprocating or rotary systems. Furthermore, there was no statistical difference for mild (RR: 1.21; 95% CI: 0.63–2.33; P = 0.57, χ2 = 6.90, I2 = 57%), moderate (RR: 0.82; 95% CI: 0.65–1.04; P = 0.10, χ2 = 2.96, I2 = 0%), and severe (RR: 1.03; 95% CI: 0.99–1.07; P = 0.14, χ2 = 9.23, I2 = 57%) pain after 24 h of endodontic treatment using reciprocating or rotary systems. Finally, there was no statistical difference for mild (RR: 1.64; 95% CI: 0.31–8.84; P = 0.56, χ2 = 4.64, I2 = 78%) and moderate (RR: 0.46; 95% CI: 0.07–3.14; P = 0.42, χ2 = 9.15, I2 = 78%) pain after 48 h of endodontic treatment using reciprocation or rotary systems; however, the reciprocating system showed less severe pain (RR: 1.02; 95% CI: 1.01–1.03; P = 0.003, χ2 = 0.38, I2 = 0%) after 48 h of endodontic treatment compared with rotary systems [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f, [Figure 2]g, [Figure 2]h, [Figure 2]i, [Figure 2]j.
| Discussion|| |
Postoperative pain is one of the major unfavorable outcomes after endodontic treatment. This systematic review addressed the influence of two different kinematics, rotary and reciprocating systems, on postoperative pain. It is important to understand that systematic review and meta-analysis concerning randomized clinical trials has a strong relationship with clinical reality. The null hypothesis was that there would be no difference in postoperative pain between the tested kinematics studied. However, after performing the research, the null hypothesis was denied, as rotary motion seems to negatively impact the postoperative pain after root canal treatment.
Overall, rotary motion causes more cases of postoperative pain, regardless of pain intensity and time. Reciprocating motion has been demonstrated to bring about lesser bacterial extrusion compared to multifile rotary systems, and consequently, there is a minor frequency of pain.
Furthermore, most of cases analyzed on meta-analysis were on vital pulp teeth, which were considered to have less extrusion of microorganisms into the periapex since root canal was not massively infected. It is reported in the literature that an asymptomatic necrotic pulp with a periapical lesion is the most likely predisposing clinical condition for the occurrence of postoperative pain. It is also observed that nonvital pulp teeth presented with more pain at 6 h and continued till 48 h irrespective of file system and motion used.
Studies have reported that instrumentation using rotary instruments extruded significantly more debris than instrumentation with reciprocating files., Furthermore, the association of debris extrusion and increase of bacterial colonies in the conventional multi-file rotary system is greater when compared to the reciprocating single-file instrumentation. On the other hand, studies demonstrated that full-sequence rotary instrumentation was associated with less debris extrusion when compared with the use of reciprocating single-file systems. Their explanation was that preenlargement of coronal third allows for the removal of debris.,, This inconsistency between studies might be attributed to the differences in the experimental setup and design.
This systematic review included studies that have used different rotary and reciprocating files. Reciprocating files used were WaveOne and Reciproc. Both systems are NiTi files treated with M-Wire technology and use a single instrument for cleaning and shaping of root canal system. The instruments are designed to work with a reverse cutting action. WaveOne system has three instruments that can be used according to the initial diameter of the main root canal. All instruments have a modified convex triangular cross-section at the tip end and a convex triangular cross-section at the coronal end. Reciproc file system is also composed of three instruments that have a noncutting tip and a S-shaped cross-section.
The rotary systems used were OneShape, ProTaper, Protaper Next, MTwo, and RaCe. OneShape is a one single NiTi instrument in continuous rotation with asymmetrical cross-section along the entire blade, variable cross-section and longer pitch. ProTaper is a NiTi system containing six regular files with triangular section, variable helical angle, noncutting guide tip, and multiple conicities. Differently, ProTaper Next is a unique asymmetric rotary motion for added efficiency, with an off-centered rectangular cross section for increase file strength. Mtwo system has several instruments that have an S-shaped cross-section and two efficient cutting edges It is designed with minimum radial contact as well as large deep flutes for continuous upward evacuation of dentinal chips. RaCe has a NiTi alloy with triangular section, alternate cutting edges, rounded safety tip and final treatment with electronic polishing.
Among the researches, different types of files were used and due to their peculiar characteristic distinct results were achieved. This can be the explanation for the heterogeneity of results. Although all the files are different, the main objective of this systematic review was to compare the two different motions (rotary and reciprocating) regarding the postoperative pain. Afterwards, reciprocating motion seems to have better results than rotary.
Both genders were analyzed in all the studies with exception of Relvas et al., 2016, that only analyzed the male gender because it is reported that women are more susceptible to postoperative pain. Despite that, all studies using both genders did not report any difference between them regarding to the postoperative pain.
NaOCl was the first choice of irrigating solution. Some studies have reported the toxicity and aggressiveness of the substance. Nevertheless, considering the use of the irrigant only into the root canal space without extravasation to the periapical region, and its capacity of eliminating organic substances, killing microorganisms, lubricating root canal, and helping on the elimination of dentinal chips it is proved to be safe for use. Nekoofar et al., 2015, only used chlorhexidine and their explanation was to avoid any confounding effect of irrigating solution and/or intracanal medication.
Currently, it is known that the instruments do not reach each part of the complex root canal system during cleaning and shaping. With this knowledge in mind, the modern scientific community have encouraged the use of chelating substances such as EDTA and the final rinse with the aid of ultrasonic tips., Nevertheless, only three studies selected in our systematic review cited the use of ultrasound in their papers.,,
Krithikadatta et al., 2016 performed two visits endodontic treatment, using calcium hydroxide as an intracanal medication. Nekoofar et al., 2015 also prefer moded two visits treatment, although not using any dressing between appointments. All other studies reported single visit treatment. Single visit root canal treatment has been shown to produce lower levels of postoperative pain than multi visit treatments, but the cited researches performed two visits to try to avoid confounding response related to the obturation process. All the sealers used and cited in the articles have excellent biocompatibility and great properties for tissue repair.,,, Moreover, the obturation techniques are consolidated into the literature as being efficient.,,,
Regarding to medication intake, some studies gave a single dose of analgesic after endodontic treatment in order to prevent acute and severe pain in the 1st h, as well as to avoid facial pain caused by lengthy appointments., Also, most clinicians prescribed analgesic as needed.,,,, They observed no statistically significant differences between instrument motions on analgesic intake.
In addition to postoperative pain Pasqualini et al., 2015 evaluated some indicators of postoperative quality of life such as difficulty eating, performing daily activities, sleeping, and social relations. Their results showed that the activities cited were more significantly affected by reciprocating instrumentation than rotary instrumentation. They concluded that reciprocating motion had an impact on immediate postoperative discomfort when preexisting periradicular inflammation was present and treatment was performed in a single visit, thereby negatively influencing patients' quality of life.
In addition to overall postoperative pain, the nature of pain (mild, moderate and severe) after 12, 24 and 48 h was analyzed as a secondary outcome. It is known that in the 1st h after endodontic treatment, there is a pain peak, which is uniquely related to the presence of inflammation. After day 1, pain begins to decrease significantly. In spite of this occurrence statistically difference in severe pain after 48 h was observed in this meta-analysis. Rotary instrumentation generated more events of pain confirming the hypothesis that rotary motion causes more postoperative pain after endodontic treatment.
To be qualified to participate on our meta-analysis, the research must have been evaluated by VAS, informed the number of patients with the presence or absence of pain and ranked the pain into mild, moderate and severe. For the sub analysis, it must have been presented the number of patients with pain after 12, 24, and 48 h and the same ranking.
Only five out of ten studies fulfilled the requirements to participate in this meta-analysis, showing the importance of continuous research in this matter from our scientific community in order to confirm the presented result.
| Conclusion|| |
This systematic review and meta-analysis indicates that rotary motion had a negative impact on postoperative pain after endodontic treatment. In addition, more patients presented with severe pain after 48 h under rotary motion compared to reciprocating motion. Additional randomized clinical studies are required on this subject.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Prof. Christine Men Martins
Dentistry, Endodontic Area, Dental School of Presidente Prudente, University of Western São Paulo. José Bongiovani Street, 19050-920, Presidente Prudente, Sao Paulo
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]