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Basic ResearchTechnology

Effect of Intracanal Cryotherapy on Reducing Root


Surface Temperature
Jorge Vera, DDS,* Jorge Ochoa-Rivera, DDS,* Marino Vazquez-Carca~
no, DDS,*

jj
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

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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.

Materials and Methods


Uniradicular roots of 20 freshly extracted human teeth were
selected for this study. Those roots with incomplete apexes, decay, fractures, fissures, abnormal anatomy, or previous endodontic treatment
were discarded. All roots were standardized to 15 mm, immersed in
5% sodium hypochlorite (NaOCl) for 30 minutes, and immersed in
distilled water to prevent dehydration until needed for the experiment.
Access was gained with a size 4 round bur (Brasseler USA,
Savannah, GA) using an air turbine handpiece (Brasseler USA) under
copious water cooling. To establish the WL, a #10 K-file (Kerr Endo)
was inserted into the root canal until it was visible through the foramen,
and 0.5 mm was subtracted from that distance. All canals were instrumented to a #20 K-file to the WL, and the TF Adaptive system (Kerr
Endo) was used to further flare the root canal to the WL up to an ML
2 (35/.06) instrument. Two milliliters of 5% NaOCl was used to irrigate
the root canal after each instrument. A final rinse with 17% EDTA
(REDTA Roth International, Chicago, IL) was used to irrigate all root
canals for 1 minute and then dried with sterile paper points.
After cleaning and shaping, the teeth were mounted on an acrylic
device designed to hold them in place and were further fixed with clay.
The teeth were isolated with a rubber dam and Block-Out Resin (Ultradent Products, South Jordan, UT). Type K thermocouples (model TP-01
(Thomas Edison Co, Wengzhou, China), RoHs compliant [temperature
range, 50 C to 1350 C], connected to a digital thermometer [A-Plus
Type K RoHs; Thomas Edison Company, Wengzhou, China]), were
attached to the apical 4 mm of the root surface. A flexible Youngs rubber dam frame was used to allow visibility of the root and thermocouples while irrigating (Fig. 1)
The 20 teeth were subjected to 2 different irrigation interventions:
a control irrigation using NaOCl 5% at room temperature (first) and the
experimental cold irrigation using 2.5 C saline 5 minutes later. Both
initial and lowest temperatures for each intervention were recorded
for the apical 4 mm using the thermocouples connected to the digital
thermometer described previously.
The control irrigation, performed first, consisted of 20 mL NaOCl
5% delivered at the WL with the EndoVac system for 5 minutes. The master delivery tip and a 31-mm MICRO were used during this procedure.
Both the syringe and the NaOCl solution were used at room temperature.
Irrigation time was controlled with a chronometer. The initial temperature (time point 1) and the lowest temperature reached during the
2

Vera et al.

procedure (time point 2) were recorded; if a reduction of 10 C


was maintained for at least 4 minutes, this was also recorded.
The experimental irrigation was performed 5 minutes later on the
same specimens. The same irrigation procedure was performed, except
for the use of a cold irrigant solution (2.5 C cold saline) and cold MICROs. The experimental irrigation consisted of 20 mL 2.5 C cold saline
solution delivered at the WL with the EndoVac system for 5 minutes. The
master delivery tip and a 31-mm MICRO were used during this procedure. Both the saline solution and the MICRO were kept in a calibrated
refrigerator at 2.5 C until used. Irrigation time was controlled with a
chronometer. The initial temperature (time point 3) and the lowest temperature reached during the procedure (time point 4) were recorded; if
a reduction of 10 C was maintained for at least 4 minutes, this was
also recorded.
Five roots were used as positive controls and another 5 as negative
controls. Positive controls were kept in the freezer for 24 hours. Then,
the external temperature was measured. In negative controls, the
temperature of the root surface was measured at room temperature.
After confirming the assumption of normal distribution of the recorded temperatures, a repeated measures analysis of variance (ANOVA) was used to detect any overall difference among the 4
intrasubject measurements. A Greenhouse-Geisser correction was
applied to the repeated-measure ANOVA because the data violated the
assumption of sphericity. A Bonferroni post hoc test was used for pairwise comparisons and to interpret further main effects of interaction of
the intrasubject. Pre-post measurements were made of the irrigation
procedures when repeated measures ANOVA showed significant differences. The Fisher exact test was also used to compare the number of
samples that were maintained at a 10 C temperature reduction for
4 minutes.

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
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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.

TABLE 1. Mean ( standard deviation) Time Point Temperatures and


Distribution of Samples Maintaining 10 C Temperature Reduction for
4 Minutes
Time
point

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

In the current study NaOCl was used as a control instead of saline


solution. In pilot studies, room temperature saline solution did not
lower the external root surface temperature more than NaOCl. At the
same time, room temperature NaOCl is the irrigant of choice for
many clinicians for cleaning purposes. For both reasons, NaOCl was
selected as a more clinically acceptable control in the final protocol.
Irrigants seldom reach the root apices because of the vapor lock
effect (10, 11). In our study, the EndoVac system was used to
predictably deliver the irrigant to the apical third of the prepared
root canals. De Gregorio et al (12, 13) proved in a series of studies
that the use of negative pressure irrigation was the only method for
consistently delivering irrigants to the apical third of prepared root
canals. Parente et al (14) proved that the EndoVac system efficiently
delivered irrigant to the apical third of root canals when compared
with manual, dynamic irrigation with a gutta-percha cone in a closed
system model.
The MICRO of the EndoVac system was used to the full WL for constant cold application to the apical 4 mm of the root canal. Twenty milliliters of a cold saline solution was delivered into the access cavity and
the entrance to the root canal with the master delivery tip, allowing the
constant flow of the cold irrigant to the apical third. It was then noted
that the external temperature started to descend within seconds and that
the reduction was maintained for at least 4 minutes during irrigation,
proving that the irrigant was delivered efficiently to that third with the
negative pressure irrigation device.
Care was taken to avoid leakage of the irrigant through the rubber
dam and the tooth by proper rubber dam isolation. Leakage could have
resulted in contact of the irrigant with the thermocouples and biased
results. To further avoid contact, any excess of irrigant was aspirated
at the access cavity with the master delivery tip of the EndoVac system,
and a second operator visually inspected the contact between the thermocouples and the root surface during the entire irrigation procedure.

SD, standard deviation.

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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.

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