Systematic Review

Post‑operative Pain after using Sodium Hypochlorite and Chlorhexidine

as Irrigation Solutions in Endodontics: Systematic Review and
Meta‑Analysis of Randomised Clinical Trials
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Abstract Christine
Context: Is it possible that the irrigating solutions can have the potential to cause post‑operative M.Martins1,2,
pain? Unfortunately, the current literature does not provide clear guidance. Aim: The purpose of Nathália E. da Silva
this systematic review and meta‑analysis was to comprehensively review two different irrigation
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/11/2024

solutions (sodium hypochlorite and chlorhexidine) regarding the post‑operative pain after endodontic Machado2,
treatment. Settings and Design: This study was prepared according to the Cochrane criteria for Bianca V. Giopatto2,
creating a systematic review and meta‑analysis and confirms the Preferred Reporting Items for Victor E. de Souza
Systematic Reviews and Meta‑Analyses (PRISMA) statement. Material and Methods: This Batista1,
search was conducted in the PubMed/MEDLINE, SCOPUS and Cochrane Library databases until Juliane A.
February 2018 to answer the In [(Population) what is the effect of (Intervention) on (Outcome),
compared with (Comparison) Intervention] (PICO) question: could sodium hypochlorite cause Marsicano1,2,
more post‑operative pain than chlorhexidine in teeth subjected to endodontic treatment? The Graziela G. Mori1,2
primary outcome was overall post‑operative pain after 24 h. Results: After applying the inclusion 1
Dental School of Presidente
and exclusion criteria, three randomized clinical trials fulfilled the eligibility criteria, and two were Prudente, University of Western
subjected to the meta‑analysis. There was no difference in post‑operative pain between the tested Sao Paulo, Presidente Prudente,
irrigating solutions. Conclusions: There are few studies published in the current literature; therefore, SP, 2Graduate Program in
Dentistry, University of Western
additional randomized clinical studies are required to on this topic to help clinicians make the best Sao Paulo, Presidente Prudente,
decision concerning treatment. SP, Brazil

Keywords: Endodontics, irrigating solution, post‑operative pain, randomized clinical trial,

systematic review

Introduction techniques are not completely effective

Currently, it is understood that the greatest
difficulty in achieving successful endodontic
treatment is to overcome the anatomy,[1]
in order to clean and shape the root
canal well.[2] Otherwise, an unfavourable
outcome, such as post‑operative pain, can
occur.[3] Sathorn et al., in a 2008 systematic
review, observed a prevalence rate ranging
from 3% to 58% for pain after root canal
treatment.[3] Most of the etiologic factors
of postoperative pain were related to
insufficient disinfection, poor removal
of remaining tissue and the extrusion of
infected debris into periapical tissue.[4‑6]
Chemomechanical preparation is considered
the most essential procedure to minimize
microorganisms and pathologic debris
and to remove the remaining tissue.[7] The
literature indicates that instrumentation
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for deep cleaning of the root canal system
because of their peculiar anatomy.[8] Thus,
it is necessary to use irrigation solutions
because flushing can remove tissue
remnants and bacteria in the root canal
walls that are not touched by mechanical
instrumentations.[9‑11]
Address for correspondence:
For decades, sodium hypochlorite (NaOCl) Dr. Graziela G. Mori,
Rua José Bongiovani,
has been the most widely used irrigation 700 ‑ Cidade
solution for cleansing and disinfection of the Universitária ‑ Presidente
root canal.[12,13] The main characteristics of Prudente, SP, Brazil.
this substance are its antimicrobial activity, E‑mail: graziela@unoeste.br
properties as an excellent organic solvent,
lubricating activity and rapid action.[8,12,14,15] Received : 01-04-2019
However, NaOCl may be cytotoxic to the Revised : 13-12-2019
Accepted : 06-05-2020
peri‑radicular tissues, particularly at high
Published : 08-01-2021
concentrations.[16,17]Additionally, NaOCl
accidents commonly occur,[18] in which
Access this article online
the substance extrudes beyond the apex,
Website: www.ijdr.in
especially when using a conventional
DOI: 10.4103/ijdr.IJDR_294_19
Quick Response Code:
How to cite this article: Martins CM,
da Silva Machado NE, Giopatto BV,
de Souza Batista VE, Marsicano JA, Mori GG.
Post‑operative pain after using sodium hypochlorite
and chlorhexidine as irrigation solutions in endodontics:
Systematic review and meta‑analysis of randomized
clinical trials. Indian J Dent Res 2020;5:774-81.

774 © 2021 Indian Journal of Dental Research | Published by Wolters Kluwer - Medknow
 Martins, et al.: NaOCl and CLX on post‑operative pain: systematic review
open‑ended 30‑G needle.[19] Kleier et al., in their
retrospective study, showed that 42% of diplomates of the
American Board of Endodontics reported having at least
one NaOCl accident during their career.[20]
Chlorhexidine 2% (CHX) is available in liquid or gel
form and can be used instead of NaOCl. CHX has
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antimicrobial action like NaOCl,[10] high substantivity,
low toxicity and good lubricating activity.[21,22] Some
investigators have suggested CHX as a good choice
of irrigation solution, especially in cases of persistent
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/11/2024
Enterococcus faecalis[23] and as a final irrigation solution.[24]
Despite its advantages, CHX activity is reduced in the
presence of organic substances because it is not an organic
solvent.[23,24] In addition, its activity is pH‑dependent.[23,24] In
the current literature, allergic reactions to CHX have been
described.[25,26] Furthermore, CHX can triggers the release
of by‑products such as parachloroaniline and reactive oxide
species, which are carcinogenic substances in humans.[27]
Considering that NaOCl and CHX are the irrigating
solutions with the greatest clinical applicability, neither is
considered ideal, and the question that clinicians who read
the published articles has is as follows: what is the most
appropriate irrigating solution for the treatment of teeth
with the potential for post‑operative pain? Unfortunately,
the currently literature does not provide clear guidance.
Thus, the purpose of this systematic review and
meta‑analysis was to comprehensively review two
different irrigation solutions (NaOCl and CHX) regarding
post‑operative pain after endodontic treatment. The
null hypothesis was that there would be no difference
in post‑operative pain between the tested irrigation
solutions.
Materials and Methods
Registry protocol
This article was designed according to the Cochrane
criteria[28] for elaborating a systematic review and
meta‑analysis. We followed the PRISMA (Preferred
Reporting Items for Systematic Reviews and
Meta‑Analyses) statement. [29]
The study was registered
at the International Prospective Register of Systematic
Reviews (PROSPERO ‑ Register nº 83771).
Eligibility criteria
The inclusion criteria were: (A) randomized controlled
trials (RCT), (B) studies that evaluated post‑operative
pain in teeth with endodontic treatment, (C) studies that
used sodium hypochlorite compared to chlorhexidine
as an irrigation solution and (D) studies published in
English language with available abstracts. Exclusion
criteria included any articles that did not compare sodium
hypochlorite with chlorhexidine and studies that evaluated
irrigation methods but did not evaluate irrigation solutions.
Indian Journal of Dental Research | Volume 31 | Issue 5 | September-October 2020 
A specific clinical question was structured according to the
PICO approach: could sodium hypochlorite cause more
post‑operative pain than chlorhexidine in teeth subjected
to endodontic treatment? In this process, (P) represents
teeth submitted to endodontic treatment, and (I) represents
chlorhexidine in comparison with (C) sodium hypochlorite
regarding to (O) post‑operative pain.
The overall post‑operative pain after 24 h was the
primary outcome to be extracted and analysed through
meta‑analysis.
Information sources
An electronic search of the PubMed/MEDLINE, SCOPUS
and Cochrane Library databases was conducted up to
February 2018. A manual search was conducted to identify
gray literature and registered trials not yet published until
February 2018 from the following journals: Journal of Dental
Research, Journal of Endodontics, International Endodontic
Journal, PLOS One, Journal of Oral Science, Oral Surgery,
Oral Medicine, Oral Pathology and Oral Radiology.
Search
Two independent researchers (NESM and BGV) performed
the electronic search of the selected databases. The keywords
used were: (A) irrigating solution, (B) endodontics, (C)
randomized clinical trial, and (D) post‑operative pain. We
performed keyword crossing as follows: #1 (irrigation
solution and endodontics); #2 (irrigation solution and
randomized clinical trial); #3 (irrigation solution and
post‑operative pain); #4 (irrigation solution and endodontics
and randomized clinical trial); #5 (irrigation solution
and endodontics and post‑operative pain); #6 (irrigating
solution and endodontics and randomized clinical trial
and post‑operative pain). Others keyword crossing were
eliminated due to unspecific results with the purpose of our
work. No filter was used in the databases.
Study selection
Two researchers (NESM and BGV) 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 another researcher (GGM). Then, the articles
selected for inclusion were read by both investigators, and a
manual search was performed of the reference lists.
Data collection process and data items
Subsequently, the full text of the obtained articles was
analysed. The analysis of these selected articles was used
to answer the PICO questions. One researcher (NESM)
collected relevant information from the articles, including
authors, year, study type, gender, average age, number
of patients, tooth sample size, details of treatment (pulp
condition, number of sessions, instrumentation technique,
irrigating solution, irrigation protocol, irrigation final, and
775
 Martins, et al.: NaOCl and CLX on post‑operative pain: systematic review

pain control), methods of pain analysis, follow‑up and

pain outcome. Then, a second researcher (BGV) checked
all collected information. Another researcher (CMM)
settled any disagreement between the investigators through
discussion until a consensus was reached.
Risk of bias
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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.[28] The assessment
criteria are a domain‑based evaluations in which critical
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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.[28] For each domain, the risk of bias was
graded as high, low, or unclear based on the criteria
described in the Cochrane handbook for systematic reviews
of interventions 5.1.0.[28] Two researchers (CMM and GGM)
independently performed the risk of bias analysis.
Summary measures
The meta‑analysis was based on the inverse variance (IV)
method. Overall post‑operative pain was the continuous
outcome measure that was evaluated for mean difference (MD)
and the corresponding 95% confidence intervals (CI). When
statistically significant (P < 0.10) heterogeneity was detected,
a random‑effects model was used to assess the significance
of treatment effects. When no statistically significant
heterogeneity was found, the analysis was performed using
a fixed‑effects model.[30,31] The MD values were considered
significant when P < 0.05. The software program Reviewer
Manager 5 (Cochrane Group) was used for the meta‑analysis
and to generate the funnel plot.
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.[32] Heterogeneity was assessed using the Q method (x2)
and the value of I2.[33] The outcomes were dichotomized into
good and poor results. I2 values above 75 (range 0–100) were
considered to indicate significant heterogeneity.[33]
Additional analysis
The kappa statistic was calculated to define the inter‑reader
agreement in the study selection process. According to
Landis and Koch (1977), the level of inter‑reader agreement
is almost perfect if the value of Kappa (K) is 0.81–1.00,
substantial if K is 0.61–0.80, moderate if K is 0.41–0.60,
fair if K is 0.21–0.40 and poor if K is < 0.20.[34]
Results
Study selection
A total of 785 articles were retrieved [Figure 1], of which
only seven fulfilled the eligibility criteria (inter–reader
776 Indian Journal of Dental Research | Volume 31 | Issue 5 | September-October 2020
Figure 1: Flow diagram of the articles selected
agreement, Kappa = 0.71 for PubMed/Medline, Kappa = 1
for Cochrane Library and Kappa = 1 for Scopus). All
the studies selected were randomised clinical trials that
compared the post‑operative pain after using sodium
hypochlorite and chlorhexidine as irrigation solutions.[35‑37]
Initially, four articles were selected and were subsequently
excluded. Tachieri et al., in 2009,[38] and Gondim et al.,
in 2010,[39] performed a study, but they did not compare
sodium hypochlorite with chlorhexidine. In its turn,
Tannure et al., in 2011,[40] compared the efficiency of
removing the smear layer using distinct irrigation solution.
Ramamoorthi et al., in 2015,[41] evaluated post‑operative
pain using various irrigating techniques; however, they did
not compare irrigating solutions.
Study characteristics
The selected articles were published in three journals: one[35]
was published in the Indian Journal of Dental Research,
another[36] in the Journal Canadian Dental Association
and the other the Brazilian Dental Journal.[37] The number
of cases ranged from 62 to 126.[35,37] All articles aimed
to analyse whether there is a difference in post‑operative
pain when using 5.25% sodium hypochlorite vs 2%
chlorhexidine as irrigation solution in endodontics.[35‑37]
Risk of bias within studies
The aspects evaluated for risk of bias can be found in
Table 1. The articles of Bashetty and Hegde (2010) and da
Silva et al. (2015) presented low risk of bias for most of
key domains;[35,37] and the article of Almeida et al. (2012)
presented a similar number of low and high key domains.[36]
Individual studies
A total of 254 patients, regardless of gender, with an average
age of 37.1 years had 254 teeth treated endodontically.
From these teeth, 126 teeth were irrigated using sodium
hypochlorite and the remaining teeth were irrigated using
chlorhexidine. All studies used 5.25% sodium hypochlorite
and 2% chlorhexidine.[35‑37] Bashetty and Hegde, in 2010,
did not clarify the irrigation protocol used.[35] Almeida et al.,
in 2012, and da Silva et al., in 2015, used 2 mL and 3 mL,
respectively, of the appropriate solution for each group each
time instruments were switched, and both used passive
 Martins, et al.: NaOCl and CLX on post‑operative pain: systematic review
Table 1: Risk of bias among the studies
Bashetty and Hegde,[35] 2010
1) Random sequence generation
2) Allocation concealment
3) Blinding of participants and personnel
4) Blinding of outcome assessment
5) Incomplete outcome date
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6) Selective reporting
7) Other bias
Abbreviations: + : Low risk of Bias; - : High risk of Bias; ? : Unclear risk of Bias
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ultrasonic irrigation (PUI) as a final irrigation.[36,37] Almeida
et al. removed smear layer with 10 mL of 17% ethylene
diamine tetraacetic acid (EDTA) applied with an ultrasonic
cavitation unit for 3 min, followed by a final washout with
5 mL of 5.25% NaOCl for the sodium hypochlorite group
or 10 mL of normal saline for the chlorhexidine group.[36]
Silva et al. also removed smear layer but only applying
3 mL of 17% EDTA for 3 min followed by irrigation with
3 mL of 5.25% NaOCl for the sodium hypochlorite group
or 3 mL of normal saline for the chlorhexidine group.[36]
Vital pulp was diagnosed in 26 teeth and 228 teeth were
diagnosed with pulp necrosis with the presence or absence
of peri‑apical lesion. Two studies performed endodontic
treatment only on teeth with pulp necrosis.[36,37]
The endodontic treatment was completed in a single visit
in two studies,[36,37] but Bashetty and Hegde, in 2010, that
performed two‑visit endodontic treatment, although they
did not use any dressing between appointments.[35]
Each clinical trial used one instrumentation technique.
Bashetty and Hegde, in 2010, used manual file in a
crown‑down technique: The canal orifices were enlarged
using orifice shapers; initial glide path was obtained by using
#10 K‑file of 0.02 taper; working lengths were determined
with an apex locator and confirmed radiographically;
memory instrument were determined using an apical ISO
size of 30 using the two cited different root canal irrigants
with 30‑gauge Max‑i‑Probe syringe that had been placed
down the canal and 3 mm short from apex.[35]
Almeida et al., in 2012, modified the ProTaper universal
technique: initial exploration was performed with a size
10 or size 15 K‑file, followed by S1 and SX rotary files;
coronal flaring was completed with size 4, 3 and 2 gates–
glidden drills keeping a constant 5‑mm distance from the
radiographically determined apical limit, and in curved
canals, going as far as the beginning of the curve; the
preparation length was kept 1 mm short of the apical
foramen, as defined by an apex locator; cavity refinement
with a minimum size 25, 30 or 35 flexofile, depending on
the anatomy of the canal; apical patency was maintained
with a size 10 file.[36]
Da Silva et al., in 2015, used the Reciproc system
according to the manufacturer’s instructions: an initial
Indian Journal of Dental Research | Volume 31 | Issue 5 | September-October 2020 
Almeida et al.,[36] 2012 da Silva et al.,[37] 2015
+ + +
- - -
+ - -
+ - -
? + +
+ + +
+ ? +
exploration of the root canal was performed with size 10,
15 and 20 K‑files and only cases where a 30 K‑file did
not go passively to the working length were selected; a
R40 Reciproc instrument was advanced in the root canal;
the working length was confirmed by an electronic apex
locator; the irrigation solutions were kept in and dispensed
using a 30‑G Max‑i‑Probe needle up to 3 mm short of the
working length.[37]
After completion of the endodontic treatment, only da
Silva et al., in 2015, prescribed a single dose of 400 mg of
ibuprofen to their patients.[37] Bashetty and Hegde, in 2010,
asked the patients to take notes if they needed medication
intake in order to exclude these patients.[35] Almeida et al.,
in 2012, did not prescribe analgesics and did not describe
what they made if analgesics were used.[36]
The follow‑up was completed mostly using 4‑point scale
from 6 h to 7 days after endodontic treatment. The main
objective was to analyse the post‑operative pain. As a
conclusion, one study reported more pain using sodium
hypochlorite,[35] only 6 h after the treatment, and the
remaining studies reported no difference between the
experimental groups.[36,37]
The details regarding each study are present in Table 2, and
the main goal and their respective primary outcomes are
synthesized in Table 3.
Meta‑analysis
To answer the PICO question, the outcome was performed
by two studies[35,37] that reported the main of pain after
24 h of endodontic treatment using NaOCl and CLX
irrigation solutions. There was no significant difference for
pain (P = 0.28; MD: ‑0.10: 0.69; 95% CI: ‑0.29 to 0.08;
x2 = 0.01, I2 = 0%) after using the different irrigating
solution in the endodontic treatment [Figure 2]. The funnel
plot [Figure 3] showed an evident symmetry among the
differences in means for the studies evaluated, suggesting
the absence of bias.
Discussion
Although the current literature suggests a high level
of success in endodontic treatment,[42‑45] the presence
of post‑operative pain could pose an unfavourable
outcome.[3] This systematic review addressed the influence of
777
 Martins, et al.: NaOCl and CLX on post‑operative pain: systematic review

Table 2: Summary of each study according to aim of the study and outcome
Author Aim
Compare post-operative pain after two-visit endodontic treatment,
Bashetty and Hegde,[35] with either 5,25% NaOCl or 2% CHX solution as the irrigant of
2010 teeth diagnosed with irreversible pulpitis, pulp necrosis and non-
vital teeth exhibiting acute apical periodontitis using hand files.
Compare post-operative pain after single-visit endodontic
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Outcome
Significant difference in post-operative
pain was observed. Pain was more present
in 5.25% NaOCl group at 6th hour post-
operatively.
No difference between the groups were

treatment, with either 5.25% NaOCl or 2% CHX plus normal

Almeida et al., [36]
2012
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observed; Both of the irrigants were
saline (0.9% NaCl) as the irrigant of teeth with radiographically
associated with low rates of post-operative
visible chronic apical periodontitis and necrotic pulp usingrotary
pain.
instrumentation.

Evaluate and compare postoperative pain after foraminal
instrumentation using 5.25% sodium hypochlorite (NaOCl) or 2%
da Silva et al.,[37] 2015
chlorhexidine (CHX) gel irrigation protocol in non-vital single-
rooted teeth after reciprocating instrumentation.
No difference between the groups were
observed; both of the irrigants were
associated with low rates of post-operative
pain.

Figure 2: Forest plot of meta‑analysis that evaluated the pain after 24 h from endodontic treatment using NaOCl and CHX irrigation solutions of two
selected articles[35,37]

reported the first evaluation period time at 24 h after

Figure 3: Funnel plot of meta-analysis with the studies evaluated
two irrigating solutions, NaOCl and CHX, on post‑operative
pain. It is important to emphasise that systematic review
and meta‑analysis of randomised clinical trials has a strong
relationship with clinical reality. Based on these results,
the null hypothesis of ‘no difference in post‑operative pain
between the tested irrigation solutions’ was confirmed.
After meta‑analysis, there was not statistically significant
difference regarding post‑operative pain between 5.25%
NaOCl and 2% CHX after 24 h. However, Bashetty and
Hegde, in 2010,[35] observed that the 5.25% NaOCl group
presented more pain than did 2% CHX only at the 6th hour
post‑operatively (P < 0.05). It is known that in the first hours
after endodontic treatment there is a pain peak, which is
uniquely related to the presence of inflammation.[46] After one
day, pain begins to decrease significantly.[46] Nevertheless,
Almeida et al., in 2012,[36] and da Silva et al., in 2015,[37]
endodontic treatment and did not find differences between
the groups in any experimental period.
In addition, the study of Bashetty and Hegde, in 2010,[35]
was the only one to evaluate post‑operative pain in teeth
diagnosed with irreversible pulpitis. Endodontic treatment
on vital pulp teeth seems to be associated with less
post‑operative pain. Asymptomatic necrotic pulp with a
peri‑apical lesion is the most likely pre‑disposing clinical
condition for the occurrence of post‑operative pain.[47] On the
other hand, NaOCl can be a toxic substance to the peri‑apical
tissues, especially because of its dissolution ability, and it can
be related to pain and acute inflammation.[15,18‑20,48] However,
the relationship between pulp condition and post‑operative
pain using distinct irrigation solutions cannot be made
through this systematic review.
Single‑visit treatment was often performed,[36,37] however,
Bashetty and Hegde[35] performed endodontic treatment in
two visits using no intracanal medications between visits.
Single‑visit root canal treatment is associated with less
post‑operative pain,[49] but the cited studies performed
two visits to try to avoid confounding responses related
to the obturation process, and they did not use intracanal
medication for this reason.
Each study used one instrumentation technique and
one type of instrument with a particular transverse
section.[35‑37] Martins et al. (2019) performed a systematic
review to comprehensively review two different kinematics
of instrumentation (reciprocating and rotary) and association
to the post‑operative pain after endodontic treatment. After
meta‑analysis, it was observed that rotary motion had a

778 Indian Journal of Dental Research | Volume 31 | Issue 5 | September-October 2020

 Martins, et al.: NaOCl and CLX on post‑operative pain: systematic review

Table 3: Articles included in the systematic review

Author/Year Study N of N of Gender Age Pulp Condition N of Visit Instrumentation
Type Patients Patients range / average technique
NaOCl CHX
Irreversible pulpitis, Two visits,
Bashetty and Crown-down
21 - 40 years necrosed pulp and without
Hegde,[35] RCT 32 34 Unclear technique with
/30.5 years nonvital teeth exhibiting intracanal
2010 profile series
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acute apical periodontitis medication

Chronic apical ProTaper
Almeida et 80 women 18–59 years / 38 periodontitis with Universal
RCT 63 63 Single visit
al.,[36] 2012 / 46 men years perira-dicular bone modified
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loss and apical patency technique

39
da Silva et >18 years / 42.85 Assymptomatic
RCT 31 31 women/23 Single visit Reciproc
al.,[37] 2015 years necrosis
men

Author/Year Irrigating Irrigating Final Irrigation Pain Method of Analysis Pain control Follow- Pain Outcome
Solution protocol up
No analgesics
5.25% NaOCl
were
group presented
VAS was classified on prescribed,
G1 - 5.25% 6 and 24 statistically
Bashetty and 4-point scale, where 0 = in case of use
NaOCl; G2 hours, significant
Hegde,[35] Unclear Unclear absent, 1 to 3 = mild, 4 to of analgesic,
- 2% CHX 4 and 7 difference from
2010 6 =moderate and 7 to 9 = patient
solution days 2% CHX only
severe. wasremoved
at 6th hour
from the
postoperatively.
study.
PUI using No significant
2 mL of the EDTAfollowed by Pain was classified on differences
G1 - 5.25% appropriate final washout with a 4-point scale, where between 5.25%
24, 48
NaOCl; G2 solution for 5 mL of 5.25% 0 =absent, 1 =mild (not No analgesics NaOCl and 2%
Almeida and 72
- 2% CHX each group NaOCl for the requiring analgesia), 2 were CHX gel with
et al.,[36] 2012 hours and
gel + 0.9% each time NaOCl group or = moderate (relieved by prescribed 0.9% NaCl
7 days
NaCl instruments 10mL of normal analgesia) and 3 = severe in terms of
were switched. saline for the CHX (not relieved by analgesia). postoperative
group. pain.
Pain was classified on a
4-point scale, where 1
Appliance of = no pain (not requiring
No significant
3 mL of the EDTAfollowed by analgesia), 2 =slight pain
differences
G1 - 5.25% appropriate final washout with (not requiring analgesia), 3
Prescription between 5.25%
NaOCl; G2 solution for 3 mL of 5.25% = moderate pain (analgesic 24, 48
da Silva et of 400 mg NaOCl and 2%
- 2% CHX each group NaOCl for the was required) and 4 = and 72
al.,[37] 2015 ibuprofen in CHX gel with
gel + 0.9% each time NaOCl group or severe pain (analgesics hours
case of pain 0.9% NaCl in
NaCl instrument was 3 mL of normal had little or no effect in
terms of post-
inserted saline for the CHX relieving the pain). The
operative pain.
group. number of analgesic
tablets used was also
recorded.

negative impact on post‑operative pain after endodontic
treatment. Furthermore, after 48 h, more patients presented
severe pain under rotary motion.[50] Sun et al. (2018) also
studied the incidence and intensity of post‑operative pain
after single‑visit root canal treatment using manual, rotary
and reciprocating instruments through systematic review,
and they have observed that manual instrumentation leads
to high levels of post‑operative pain.[51] Both systematic
reviews related post‑operative pain to debris extrusion,
which can lead to an inflammatory response, presenting
pain as one of the five cardinal signs.[50,51]
Nevertheless, the pattern of response was the same. The
similarity among the techniques was the instrumentation
in the crown‑down direction, which was associated with
the highest success rate and less post‑operative pain due to
minor debris extrusion.[52]
Regarding substances availability, NaOCl is commercially
available in various concentrations.[53] There is a directly

Indian Journal of Dental Research | Volume 31 | Issue 5 | September-October 2020  779

 Martins, et al.: NaOCl and CLX on post‑operative pain: systematic review
proportional relationship between concentration and
toxicity, but overall, it has great cleaning and disinfection
properties, antimicrobial activity and organic solvent
properties.[8,12,14,15,18] All studies used 5.25% NaOCl,[35‑37] but
the concentration can range from 0.5% to 6%.[53]
CHX is available in solution or gel forms. Bashetty
and Hegde (2010) used the solution,[35] and Almeida
Downloaded from http://journals.lww.com/ijdr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
et al. (2012) and da Silva et al. (2015) used the gel
form.[36,37] As a consequence to gel form, the flushing
ability is limited. To overcome this difficulty, a saline
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/11/2024
solution is used during the irrigating procedure.[36,37]
Studies have reported that both forms present similar
properties: antimicrobial activity, especially against
gram‑positive bacteria, low toxicity and the absence of
organic solvent.[10,21‑23]
Currently, there is a new endodontic concept: ‘shaping
for cleaning.’[53,54] In other words, the chemo‑mechanical
preparation is an important step that is associated not only
with the endodontic instruments but also with irrigating
solutions. The instruments and instrumentation technique
will provide the space for the irrigation solution to
complete its function.[53,54] The associations of techniques
with forms of irrigation will allow greater success in this
phase of endodontic treatment. Almeida et al., in 2012,
and da Silva et al., in 2015, reported the use of passive
ultrasonic irrigation as a final step in order to improve
the quality, penetration and solution action.[36,37] Therefore,
the irrigation solution plays an important role. To the best
of our knowledge, there is no ideal irrigation solution in
the market. NaOCl and CHX are good solutions, but both
have disadvantages. Therefore, the decision to use one or
another solution should be made based on clinical case
characteristics.[53,54]
One important characteristic to be considered is
the possibility of post‑operative pain. Regardless of
meta‑analysis result, the main question of this study was
not clearly answered due to the small number of studies;
unpublished studies; the absence of studies that evaluated
initial times of post‑operative pain; and the absence of
studies that correlate post‑operative pain, pulp diagnosis
and irrigating solutions. It is necessary to elucidate the
importance of carrying out new randomised clinical studies
in relation to this topic and to encourage new investigators
to perform these studies.
Finally, this systematic review and meta‑analysis indicate
that there was no difference in terms of post‑operative pain
using NaOCl and CLX as irrigation solutions. There are
few studies published in the current literature; therefore,
additional randomised clinical studies are required on this
topic to help clinicians make the best decision for the
treatment of their patients.
Financial support and sponsorship
Nil.
780 Indian Journal of Dental Research | Volume 31 | Issue 5 | September-October 2020
Conflicts of interest
There are no conflicts of interest.
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