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Monica Romero, DDS, Ana Arias, DDS, PhD, and Philippe Sleiman, DDS, DSO#**
Abstract
Introduction: The positive effect of cryotherapy has
been widely described in medicine. The aim of the
present study was to validate a new methodology to
reduce and maintain external root surface temperature
for at least 4 minutes. Methods: Twenty extracted
single-rooted teeth were instrumented to size 35/.06
and subjected to 2 different irrigation interventions
with a repeated-measures design using 5% sodium hypochlorite first (control) and 2.5 C cold saline solution
later (experimental). In both, 20 mL of the irrigant solution was delivered for a total time of 5 minutes with a
microcannula attached to the EndoVac system (Kerr
Endo, Orange County, CA) inserted to the working
length. The initial and lowest temperatures were
recorded in the apical 4 mm with a digital thermometer
for both irrigants. Data were analyzed with the repeated
measure analysis of variance (Greenhouse-Geisser
correction) and Bonferroni post hoc tests. Differences
in maintaining a 10 C temperature reduction over
4 minutes were assessed with the Fisher exact test. Results: Although significant differences were found
between the initial and lowest temperatures in both
the control and experimental irrigation procedures
(P < .001), the experimental intervention reduced it
almost 10 times that of the control. When maintaining
a 10 C temperature reduction over 4 minutes, the
teeth in the experimental group also sustained significantly better results (P = 3.047 1010). Conclusions:
Using cold saline solution as the final irrigant reduced
the external root surface temperature more than 10 C
and maintained it for 4 minutes, which may be enough
to produce a local anti-inflammatory effect in the periradicular tissues. (J Endod 2015;-:14)
Key Words
Cryotherapy, EndoVac, negative pressure irrigation,
temperature reduction
he term cryotherapy is derived from the Greek word cryos, meaning cold. In
physiotherapy, it means lowering or decreasing the temperature of tissues for therapeutic purposes. In reality, cryotherapy does not imply implementing cold but rather
extracting heat (1, 2). The magnitude of the temperature change and the biophysical
alterations in the tissues depend on the difference between the temperature of the
object and the application of cold or heat, exposure time, thermal conductivity of the
tissues, and type of agent used to apply the heat or cold. The use of this type of
therapy in human tissues causes changes in the hosts local temperature (3, 4).
The 3 basic physiological tissue responses after the application of either heat or
cold are an increase or decrease in local blood flow, stimulation or inhibition of neural
receptors in the skin and subcutaneous tissues, and an increase or decrease in metabolic activity (2). Physiological and clinical evidence suggest that cold therapy, in
different forms, may reduce musculoskeletal pain, muscular spasm, connective tissue
distension, nerve conductivity time, hemorrhage, and inflammation (1, 2).
Bleakley reported that cold therapy seemed to be efficient in limiting inflammation
and reducing pain in the short-term (5). According to Vant Hoffs law, cryotherapy
causes vasoconstriction and slows down cellular metabolism by limiting biochemical
reactions. Vasoconstriction produces antiedema, and a reduction in pain is achieved
after temperature reduction because of blocking of the nerve endings that cold produces (6). The intensity of the vasoconstriction effect reaches the highest value at a temperature of 15 C (6). In fact, some studies have shown that the highest temperature in
the skin that produces therapeutic effects (anesthesia, analgesia, or muscle relaxation
that allows post-treatment movement of painful areas) is 16 C (5). A temperature
decrease from 30 C to 17 C was achieved after only 15 minutes of cold therapy (1,
2). Lowering the body temperature also decreases peripheral nerve conduction, and
when it reaches less than 15 C, nerve conductivity is deactivated completely.
Ice application reduces tissue temperature, blood flow, pain, and cell metabolism,
which minimizes the degree of tissue damage and the lesion caused by secondary hypoxia (5). An important reduction in local enzyme activity and profound local vasoconstriction occur after cold application. The analgesic effect is produced by a combination
of a decreased release of chemical mediators of pain and a slower propagation of neural
pain signals. Also, metabolism is lowered more than 50%, which allows better oxygen
diffusion into the injured tissues (5).
Despite the generalized use of cryotherapy in medicine, there is little scientific
basis for the methods used in efficient application. A systematic understanding of factors
such as the time necessary to cool down an area, the time during which this area
remains cold enough after removal of the cooling agent, and the amount of cooling
From the *Department of Postgraduate Endodontics, University of Tlaxcala, Tlaxcala; Private Practice, Puebla; Private Practice, Jalapa; Private Practice, Tlaxcala;
and Department of Endodontics, Benemerita Universidad Autonoma de Puebla, Puebla, Mexico; jjDepartment of Endodontics, Arthur A. Dugoni School of Dentistry,
University of the Pacific, San Francisco, California; #Department of Endodontics, University of North Carolina School of Dentistry, Chapel Hill, North Carolina; and **Lebanese University Dental School, Beirut, Lebanon.
Address requests for reprints to Dr Jorge Vera, Madrid 4920-101 y 102 2a Seccion Gabriel Pastor, CP 72420, Puebla, Mexico. E-mail address: jveraro@yahoo.com.mx
0099-2399/$ - see front matter
Copyright 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.08.009
Intracanal Cryotherapy
Basic ResearchTechnology
that extends beyond the area in contact with the cooling agent have so far
received scant attention in the scientific literature (1, 2).
In dentistry, cryotherapy has been used after intraoral surgical
procedures such as periodontal surgery, extractions, and implant
placement (7), but there are no studies on the effect of intracanal cryotherapy to lower the external root temperature in order to reduce
inflammation of the periapical tissues, resulting in a certain degree of
pain relief. One way to apply cryotherapy to the inflamed periradicular
tissues is by intracanal irrigation with a cold substance after flaring the
root canal system. This has been proven to be an easier task when using
a negative pressure irrigation system such as the EndoVac system (Kerr
Endo, Orange County, CA) (8). The microcannula (MICRO) of the
system can be placed to the full working length (WL) and be used to
aspirate the irrigant with a continuous flow (8, 9).
This article suggests a new methodology for intracanal cryotherapy
that should be histologically and clinically validated in future studies.
The specific objective of the present study was to determine whether
the external temperature of the apical 4 mm of root canals could be
reduced after continuous irrigation with cold (2.5 C) saline solution
and maintained for at least 4 minutes.
Vera et al.
Results
The average temperature of positive controls was 30.8 C,
whereas negative controls showed an average temperature of 23.2 C.
In the experimental teeth, the temperature started to descend within
seconds and decreased 10 C after an average of 30 seconds.
The lowest temperatures recorded were 5.2 C and 20.4 C in the
experimental and control irrigation interventions, respectively.
As shown in Table 1, the mean temperature differed significantly
among the 4 different time points (P = 9.14 1025). Post hoc tests
using Bonferroni correction revealed significant differences between
pre-post control intervention temperatures (time points 1 and 2,
P = 3.03 106) and pre-post experimental intervention temperatures (time points 3 and 4, P = 9.27 1017). However, although
the control intervention slightly reduced the initial temperature in the
specimen (mean difference = 1.56; 95% confidence interval, 0.941
2.179), the experimental intervention (mean difference = 14.33;
95% confidence interval, 12.9415.72) reduced it almost 10 times
as much as the control.
Moreover, when the maintenance of a 10 C temperature reduction for 4 minutes was assessed, the teeth in the experimental group also
exhibited significantly better results (P = 3.047 1010). No temperature reduction was found in any of the teeth in the control group,
whereas only 1 of 20 in the experimental group did not show a 10 C
reduction over the 5 minutes.
Discussion
This in vitro, within-subject design or repeated measures study
was intended to readily detect differences across levels of the independent variable (temperature) and to compare changes in the root surface
temperature of extracted teeth after a novel method of irrigation with
JOE Volume -, Number -, - 2015
Basic ResearchTechnology
Figure 1. The experimental model used to measure temperature reduction in the control and experimental roots.
cold saline solution and negative pressure irrigation was applied. The
results showed that a significant temperature reduction was achieved
(14.33 C 2.12 C) after the experimental irrigation intervention
compared with control (1.56 C 0.94 C) in which no root showed
temperature reduction on its external surface of more than 2 C.
There are no previous reports in the literature about cryotherapy
as an irrigation protocol and its effect in reducing the root surface temperature. This study shows that it is possible to reduce the external temperature of the apical 4 mm of the root below 15 C and maintain that
reduction for at least 4 minutes, which, according to the limited
research in the field, may be enough to initiate an anti-inflammatory
effect. In only 1 root of the experimental group was this reduction
neither achieved nor maintained. This inconsistency could have been
caused by a blockage of the MICRO during irrigation.
Mean SD
( C)
1. Initial temperature
23.45 1.09
2. Temperature after
21.9 0.83
control intervention
3. Temperature before
22.7 1.20
experimental
intervention
4. Temperature after
8.37 2.39
experimental
intervention
4-min maintenance of
10 C temperature
reduction (n/%)
0/0
19/95
Intracanal Cryotherapy
Basic ResearchTechnology
Tooth temperature can vary daily from 5 C to 76.3 C (15).
Thermophysical temperatures also vary between the enamel and dentin
(16). In dentin, thermal conductivity is reduced when the surface volume of the dentinal tubules increases (17).
Thermal conductivity of human dentin varies from 0.11 (18) to
0.96 to 0.98 W m1 K1 (19, 20). Other studies have shown
differences from 0.36 to 0.88 W m1 K1 (21, 22). At the same
time, human dentin has shown limited thermal conductive properties
(22). However, the temperature on the external surface of the root
was reduced more than 10 C and maintained for at least 4 minutes
in the present study when the experimental irrigation was performed
using negative pressure irrigation with 2.5 C saline solution and a
cold (2.5 C) MICRO.
To our knowledge, there is no published research about the time
needed for a cryotherapy therapeutic effect; however, there are several
studies in the field of physiotherapy (2327). After treating 7000
ambulatory patients, Grant (24) reported that between 5 and 7 minutes
of ice therapy was enough to produce muscle numbness. Waylonis (25)
proved superficial anesthesia after massaging legs with ice for 4.5 minutes. McGown (26) showed that a 5-minute ice massage was enough
to induce changes in the inflamed tissue of the quadriceps muscles.
Hochberg (27) showed that continuous cold application resulted
in a significant reduction of pain when compared with intermittent
application. To our knowledge, this is the only study that compared
both treatment methods.
Another source of uncertainty is the temperature needed for cell
death. It seems that cell death does not occur at temperatures higher
than 20 C although most tissues freeze at 2.2 C (28). Tissue damage by cryotherapy can occur through different mechanisms. Cold
application with ice and similar methods use temperatures around
0 C; this low temperature may lower lymphatic drainage (6).
Within the limitations of this in vitro study, the results suggest that
intracanal delivery of cold (2.5 C) saline solution with negative pressure irrigation reduced the external root surface temperature more
than 10 C and maintained it long enough to possibly produce a local
anti-inflammatory effect in the periradicular tissues. The effect of a temperature decrease on the root surface in reducing pain and inflammation of the periradicular tissues is yet not known, but this research
provides a framework for the exploration of that effect and might serve
as a basis for future trials. Further studies are underway to assess pain
reduction in human subjects, a reduction of inflammation in connective
and periradicular tissue, and a reduction of some chemical mediators
of pain after intracanal cryotherapy compared with normal irrigation.
Using cold saline solution as the final irrigant reduced the external
root surface temperature more than 10 C and maintained it for 4 minutes, which may be enough to produce a local anti-inflammatory effect
in the periradicular tissues.
References
1. Belitsky RB, Odam SJ, Hubley-Kozey C. Evaluation of the effectiveness of wet ice, dry
ice, and cryogen packs in reducing skin temperature. Phys Ther 1987;67:10804.
2. Knight KL. Cryotherapy in Sports Injury Management. Champaign, IL: Human Kinetics; 1995:60.
Vera et al.
3. Rennie S. Electrophysical agentscontraindications and precautions: an evidencebased approach to clinical decision making in physical therapy. Physiother Can
2010;62:18.
4. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue
injury? J Athl Train 2004;39:2789.
5. Bleakley C, McDonough S, Domhnall MD. The use of ice in the treatment of acute
soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports
Med 2004;32:25161.
6. Modabber A, Rana M, Ghassemi A, et al. Three-dimensional evaluation of postoperative swelling in treatment of zygomatic bone fractures using two different cooling
therapy methods: a randomized, observer-blind, prospective study. Trials 2013;14:
238.
7. Laureano Filho JR, de Oliveira e Silva ED, Batista CI, Gouveia FM. The influence of
cryotherapy on reduction of swelling, pain and trismus after third-molar extraction:
a preliminary study. J Am Dent Assoc 2005;136:7748.
8. Schoeffel JG. The EndoVac method of endodontic irrigation, part 2efficacy. Dent
Today 2008;27:4851.
9. Hockett JL, Dommisch JK, Johnson JD, et al. Antimicrobial efficacy of two irrigation
techniques in tapered and nontapered canal preparations: an in vitro study.
J Endod 2008;34:13747.
10. Tay FR, Gu LS, Schoeffel GJ, et al. Effect of vapor lock on root canal debridement by
using a side-vented needle for positive-pressure irrigant delivery. J Endod 2010;36:
74550.
11. Vera J, Arias A, Romero M. Dynamic movement of intracanal gas bubbles during
cleaning and shaping procedures: the effect of maintaining apical patency on their
presence in the middle and cervical thirds of human root canals: an in vivo study.
J Endod 2012;38:2003.
12. de Gregorio C, Estevez R, Cisneros R, et al. Efficacy of different irrigation and activation systems on the penetration of sodium hypochlorite into simulated lateral canals and up to working length: an in vitro study. J Endod 2010;36:121621.
13. de Gregorio C, Paranjpe A, Garcia A, et al. Efficacy of irrigation systems on penetration of sodium hypochlorite to working length and to simulated uninstrumented
areas in oval shaped root canals. Int Endod J 2012;45:47581.
14. Parente JM, Loushine RJ, Susin L. Root canal debridement using manual dynamic
agitation or the EndoVac for final irrigation in a closed system and an open system.
Int Endod J 2010;4:100112.
15. Jacobs HR, Thompson RE, Brown WS. Heat transfer in teeth. J Dent Res 1973;52:
24852.
16. Kishen A, Ramamurty U, Asundi A. Experimental studies on the nature of property
gradients in the human dentine. J Biomed Mater Res 2000;51:6509.
17. Magalh~aes MF, Ferreira RA, Grossi PA. Measurement of thermophysical properties
of human dentin: effect of open porosity. J Dent 2008;36:58894.
18. Johnson RJ, Phillips LJ, Phillips RW. An improved method for measuring the
coefficient of thermal conductivity of dental cement. J Am Dent Assoc 1956;53:
57783.
19. Carda C, Peydro A. Ultrastructural patterns of human dentinal tubules, odontoblasts
processes and nerve fibres. Tissue Cell 2006;38:14150.
20. Lisanti VF, Zander HA. Thermal conductivity of dentin. J Dent Res 1950;29:4937.
21. Brown WS, Dewey WA, Jacobs HR. Thermal properties of teeth. J Dent Res 1970;49:
7525.
22. Soyenkoff BC, Okun JH. Thermal conductivity measurements of dental tissues with
the aid of thermistors. J Am Dent Assoc 1958;57:2330.
23. Kowal MA. Review of physiological effects of cryotherapy. J Orthop Sports Phys Ther
1983;5:6672.
24. Grant AE. Massage with ice (cryokinetics) in the treatment of painful conditions of
the musculoskeletal system. Arch Phys Med Rehabil 1964;45:2338.
25. Waylonis GW. The physiological effect of ice massage. Arch Phys Med Rehabil 1967;
48:3742.
26. McGown HL. Effects of cold application on maximal isometric contraction. Phys
Ther 1967;47:18592.
27. Hochberg J. A randomized prospective study to assess the efficacy of two cold
therapy treatments following carpal tunnel release. J Hand Ther 2001;14:
20815.
28. Farah CS, Savage NW. Cryotherapy for treatment of oral lesions. Aust Dent J 2006;51:
25.