Fecal Is

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E N D O D O N TO LO G Y E N D O D O N TO LO G Y E N D O D O N TO LO G Y E N D O D O N TO LO G Y E N D O D O N TO LO G Y
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Editorial
Original Research
5
Volume: 21 Issue 2 December 2009 1-100
C O N T E N T S Page
Presidents Message 4
Evaluation of antimicrobial efficacy of 0.5% IKI, 3% NaOCI and 0.2% CHX
when used alone and in combination as intracanal irrigants against
Enterococcus Faecalis. An in vitro study
An in vitro study to evaluate apical seal in roots filled with a thermoplastic
synthetic polymer based root canal filling material
Evaluation of the effect of chlorhexidine gluconate as an endodontic irrigant
on the apical seal - An in vitro study
Evaluation of the effect of EDTA, EDTAC, RC-Prep and BioPure MTAD on
the microhardness of root canal dentine- An in vitro study
To treat and to retreat Protaper universal rotary system, the double delight
Enterococcus faecalis; clinical significance & treatment considerations
As sem evalution of the type of smear layer produced by newer rotary
instruments and effectiveness of different combinations of irrigants
Analysis of percentage of gutta-percha filled area using single cone,
continuous wave compaction, Thermafil & Obtura II in 0.06 taper prepared
root canals.
Case Report
External apical root resorption: Two case reports
Endodontic treatment of mandibular second premolar with three root canals
using dental operating microscope
Management of a large periapical cyst (apical matrix & surgical
complications) - A case report
Dens evaginatus (talon cusp) of anterior teeth
- A case report
Immediate reattachment of fractured crown fragment
A case report
Current Endodontics Literature
Neera Joshi 6-16
Kundabala M
Shalini Shenoy
Sarita Kamath
Vivian DSouza
Rukmini
Rhythm Bains 17-23
Anil Chandra
Aseem P. Tikku
Kapil Loomba
Promila Verma
Roopashree M. S. 24-32
Kala M.
Sandeep Singh 33-39
Shashi Rashmi Acharya
Vasudev Ballal
Rijesh M
Sandhya U. M. 40-45
Mohan Thomas Nainan
Mangala T. M.
Sharad Kamat
Vibha Hegde 46-52
Shishir Shetty 53-66
Sureshchandra B.
Vasundhara Shivanna 67-72
Prashanth B. R.
Archana J. Gilda 73-77
Mohan Thomas Nainan
Sharad Kamat
Mangala T. M.
Neelam Mittal 78-81
Suraj Arora
Verghese George M. 82-87
George Thomas
M. A. Kuttappa
Girish Kumar Govind
Moksha Nayak 88-91
Jitendra Kumar
Krishna Prasad L.
Anil Dhingra 92-94
Dhirendra KR. Srivastava
Sowmya Shetty 95-99
Roma
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INDIAN ENDODONTIC SOCIETY
(Estd. 1988)
FORM IV
RULE 8
1. Place of Publication : Mangalore
2. Periodicity of publication : Biannual
3. Printers name, nationality and address : Srinivas Prabhu at Indian
M/s. Sunline Enterprises
Lower Car Street
Mangalore - 575 001
4. Publishers name, nationality, and address : Dr. Anil Kohli Indian
Indian Endodontic Society
E-601, Greater Kailas - II
Delhi - 110 048
5. Editors name, nationality and Address : Dr. B. Sureshchandra Indian
Department of Conservative Dentistry / Endodontics
A. J. Institute of Dental Sciences
N. H.-17, Kuntikana, Mangalore - 575 004, Karnataka.
6. Name and address of the owner of the newspaper : Indian Endodontic Society
Delhi - 110 048
Mangalore Signature of publisher.
Sd/-
Dr. K. S. Banga
Secretary General
Date: 15/6/2005 Indian Endodontic Society
Delhi - 110 048
President:
Dr. Ravi Kapur
Secretary General:
Dr. K. S. Banga
Joint Secretary:
Dr. R. Miglani
Treasurer:
Dr. J. Dhillon
President Elect:
Dr. R. C. Kakkar
Imm Past President:
Dr. A. P. Tikku
Vice Presidents:
Dr. Kapil Loomba
Dr. Manisha Chaudhary
Dr. Rajiv Chugh
Executive committee
Permanent members:
Dr.Anil Kohli Dr.R.C.Kakkar
Dr. Anil Chandra Dr. Gopi Krishna
Dr. J. S. Baath Dr. Kundabala Shenoy
Dr. Moksha Nayak Dr. Roopa Nadig
Members:
Dr. S. Ramachandran Dr. Sharad Kamath
Dr. Sameer Makkar Dr. Sanjay Miglani
Dr. Sukesh Kumar Dr. Vivek Hegde
Editor:
Dr. B. Sureshchandra
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Editor:
Scientific Advisory Committee
Dr. Govila C. P. (India)
Dr. Gulabivala (U. K.)
Dr. Gutmann James L. (U.S.A.)
Editorial Office
Department of Conservative Dentistry / Endodontics
A. J. Institute of Dental Sciences
N.H.-17, Kuntikana, Mangalore - 575 004, Karnataka.
Ph: 0824-2224938.Telefax: 0824-2224968.
Clinic: 0824-2444041.
E-mail: bsureshc@satyam.net.in
A publication of Indian Endodontic society
Editorial Board
Dr. Banga K. S.
Dr. Choudhary M.
Dr. Gopikrishna
Dr. Indira R.
Dr. Kandaswamy D.
Dr. Kohli Anil
Dr. Laxminarayanan L.
Dr. Mithra N. Hegde
Dr. Moksha Nayak
Dr. Naseem Shah
Dr. Ravi Kapur
Dr. Shenoy Kundabala
Dr. Shivanna V.
Dr. Tikku A. P.
Dr. Usha H. L.
Dr. Vineeta Nikhil
Dr. Wadhvani K. K.
Abstracts
Dr. Sowmya Shetty
Endodontology is indexed in IndMED, the database of Indian Biomedical Journals, maintained by National
Informatics Centre, Ministry of Information Technology, Govt. of India.
Bibliographic details of the journal available in ICMR-NIC Centres IndMED database
(http:// indmed.nic.in). Full text of articles, from 2000 onwards, being made available in MedlND database
(http://medind.nic.in ).
The journal is aIso listed with Indian National Scientific Documentation Centre (INSDOC), Qutab
Institutional Area, New Delhi-110016 and English Serial Division, National Library, Kolkata.
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Greetings to all of you from IES.
You have another issue of our journal in your hand and I am sure you will enjoy and update while
scrolling through the pages.It feels pleasurable to me to be actively associated with such a branch
of dentistry that is continuously remodelling and restructuring.It goes beyond assumption that
more than 80% of practice in dentistry is devoted to this speciality. However practicing endodontics
in an ethical way is the need of the hour. This can be acheived only by updating yourself and
attending the continuing education programmes.One needs to spare some time from routine to
upgradeand open ones mind to change or modify because minds are like parachutes and they
function only when they are open.
With this thought in mind I surely hope to see you all in Kochi at the forthcoming annual conference.
I assure you that you will depart enriched in many aspects.
May god be with you.
Ravi Kapur
President
Indian Endodontic Society
Presidents Message
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I have here for you some thoughts written by WILLIAM J. GIES as a forward in the
1956 edition of Operative Dentistry by WILLIAM H.O. McGEHEE.
I realized the full significance of dentistry, and idealized it as a philosophy and as a
procedure in public service. Idealization of the dental profession has literally wound me
up and keeps me going.
An ideal is something that exists only in idea. It is a standard of desire, a model of
perfection. Ideals are the basis of justice, the foundation of generosity, the mainspring of
altruism, the justification of a profession. Prevention of all dental disorders is the ideal of
ultimate dental health care.
May your successors, in each of endless generations, merit the commendation that
you deserve. To all dentists, I make this direct appeal: Be grateful and happy that you are
among the accredited servants and benefactors of mankind. In your daily progress, follow
impulses and leadership that express, in integrity, fidelity, service and lofty purposes, the
finest that is in you, individually and professionally. The soul of dentistry is marching
on. Keep on proudly marching with it.
And the words by Dr. H.J. Cody, President emeritus and chancellor of the University
of Toronto, in an address to the American College of Dentists.
Behind all the knowledge and skill that professional training can give, lies the
personality of the practitioner. In essence, the success of a professional man in the long
run depends on his personality and his character. Personal integrity is the only dynamic
that endures. A mans character and his capacity, what he is and what he can do, are the
only possessions he can carry out of this life. They have been termed the only coins that
ring true on the counters of this life and the next. Let every professional man cultivate and
hold fast and practice those virtues which constitute good and winsome character. Can
you trust him? Is he loyal to family, to friends, to country, to God? Can he engage with
others in seeking to realize desirable ends? Is he sympathetic, kindly, helpful, hopeful?
Does he think more of his duties than of his rights? Has he any magnanimity in his make-
up? Is work to him a blessing or a curse? Has he the fear of God before his eyes?
Are these words from legends and great men relevant today? you decide as reader!!!
Editorial
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Evaluation of antimicrobial efficacy of 0.5% IKI, 3%
NaOCI and 0.2% CHX when used alone and in
combination as intracanal irrigants against Enterococcus
Faecalis. An in vitro study
* Speci al i st Resi dent, * * Professor and Head, * * * Asst. Professor, * * * * Professor, * * * * * Assoc. Professor, # Department of Conservati ve Denti stry & Endodonti cs, # #
Department of Mi crobi ol ogy, # # # Department of Bi ochemi stry, $ MCODS Mangal ore, $$ K.M.C. Mangal ore
NEERA JOSHI * #$
KUNDABALA M ** #$
SHALINI SHENOY ** ##$$
SARITA KAMATH *** ##$$
VIVIAN DSOUZA **** ###$$
RUKMINI ***** ###$$
ABSTRACT
The success of endodontic treatment depends on the complete elimination of microorganisms from the complex
root canal system. This is accomplished by chemo-mechanical preparation of the root canal system. Persistence
of micro-organism and reinfection are the main causes of failed root canal therapy. Highly virulent Enterococcus
faecalis has been implicated in endodontic treatment failure because of its resistance to intracanal irrigants and
medication. The purpose of the study was to evaluate the antimicrobial efficacy of 0.5% iodine potassium iodide,
3% NaOCl, 0.2%CHX, as intracanal irrigants against Enterococcus faecalis, when used individually and their
combination.
A total number of 64 single rooted extracted teeth were sterilized by autoclaving and Enterococcus faecalis was
inoculated into the root canals and left for 24 hours. Teeth were then divided into 8 groups and each group had
8 teeth, irrigated with 0.5% Iodine potassium iodide, 3% Sodium hypochlorite, 0.2% Chlorhexidine and their
combination were performed in the root canals. Dentinal shavings were collected from specimens and cultured
on brain heart infusion agar plates. Bacterial colonies of treated teeth and control specimens were counted and
results were statistically analyzed.
IKI when used alone showed the best antimicrobial effect at the middle third of the root canal. Combination of
CHX and NaOCl showed the best antimicrobial effect at the apical third of the root canal. However there was no
statistically significant difference between the irrigants IKI and CHX & NaOCl combination.
From the results of the present study it can be concluded that IKI can be very useful intra canal irrigant in
retreatment of root canal cases failed due to E faecalis.
INTRODUCTION
Complete elimination of microorganisms from
the complex root canal system is the main objective
of root canal therapy. Persistence of micro-organism
and reinfection are the main cause of failed root
canal therapy. Currently, more than 300 species
are recognized as normal inhabitants of the oral
cavity. But only limited numbers of species have
been isolated from infected root canals.
(1)
Original Research
Corresponding author: KUNDABALA M.
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Enterococcus faecalis is one of the most
predominant microorganisms found in the failed
cases of root canal treatment. Enterococcus faecalis
is a non spore forming, gram positive cocci that
occur singly, in pairs or as short chains.
Enterococcus faecalis cells are ovoid and 0.5 to
1m in diameter. It is a facultative anaerobic, normal
commensal, adapted to the ecologically complex
environment of the oral cavity and gastrointestinal
and vaginal tracts.

Enterococcus is the most
commonly isolated or detected species from oral
infection, including marginal periodontitis, infected
root canal and periradicular abscesses.
(2)
Sundqvist et al (1998) reported that 38% of
failed endodontically treated teeth were infected
with Enterococcus faecalis. He concluded that it is
also the most commonly recovered species from
obturated root canal.
(3)
Molander et al (1998)
showed that Enterococcus faecalis was present in
50% of the culture positive retreatment cases and
Peciuliene et al found E faecalis in 71% of culture
positive teeth undergoing retreatment.
(4)
The successful elimination of this
microorganism and its substrate can be achieved
only through meticulous removal of contaminants
from the canal system as well as from anatomic
irregularities such as root canal fins, webs, cul de
sacs etc. Canal system is chemo-mechanically
prepared to eliminate the micro flora from it.
Shaping the canals both manually and
mechanically opens this complex space for the
action of irrigant.
(5)
Biomechanical preparation and chemical
preparation of the canal system are used
concomitantly in order to debride the canal system.
Chemical preparation refers to the use of an irrigant
or combination of irrigants during and after
biomechanical preparation. The irrigating and
disinfecting solutions are very important because
it aids in cleaning of the root canal, lubricate the
files, flush out the debris, have an antimicrobial
effect, tissue dissolving capability and nontoxic to
the periapical tissues .The important requirement
of an endodontic irrigant include properties such
as antimicrobial activity, tissue dissolving capability
and nontoxicity to the periapical tissue.
(5)
Various chemicals have been investigated to
disinfect the root canal system. Sodium
hypochlorite is one chemical agent which is
capable of dissolving necrotic tissue and vital pulp
tissue.
(9)
Sodium hypochlorite in 5.25%
concentration is an extremely effective
antimicrobial agent. It is inexpensive, has a long
shelf life, provides lubricating effect for
instrumentation of the canal walls, exerts bleaching
action on discolored teeth and increases the
permeability of dentinal tubules for easier
penetration by an intracanal medicament.
(6)
Inspite
of these properties, sodium hypochlorite produces
allergic reaction and can cause problems if
accidentally extruded periapically.
(7)
Chlorhexidine gluconate is a wide spectrum
antimicrobial agent. It is unique in its ability to bind
oral tissues for extended period from which it is
released slowly (substantively) and it is relatively
non toxic.
(8)
These advantages however fail to make
up for its lack of tissue dissolving property and
ability to remove the smear layer. Therefore to
obtain their optimal properties, the combined
action of sodium hypochlorite and Chlorhexidine
gluconate was evaluated. An In vitro study by
Kuruvilla and Kamath concluded that when these
NEERA JOSHI, KUNDABALA M, SHALINI SHENOY, SARITA KAMATH, VIVIAN DSOUZA, RUKMINI
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solutions were combined within the root canal, the
antimicrobial action was suggestive of being
augmented.
(9)
Bettina et al studied the interaction
between Sodium hypochlorite and Chlorhexidine
gluconate. They determined the minimum
concentration of NaOCl required to form
precipitate with 2% CHX and concluded that
combination of Sodium hypochlorite (NaOCl) and
Chlorhexidine (CHX) results in the formation of a
precipitate, PCA (para-chloroaniline) which was
reported to be carcinogenic in rats.
(10)
Iodine potassium iodide has been successfully
used in tooth surface disinfection. IKI is a very
potent antimicrobial agent of low toxicity.
Potassium iodide is used to dissolve iodine in water,
but the antibacterial activity is carried out by the
iodine, while potassium iodide has no activity
against the microbes. IKI is a biocompatible,
antibacterial agent which exhibits a long distance
bactericidal effect due to its evaporation and
sublimation. IKI effectively penetrates the dentinal
tubules and kills bacteria.
(11)
The main
disadvantages of iodine are that it causes staining
and may be allergic to the patient.
Hancock et al suggested IKI, as an irrigant with
demonstrated low tissue toxicity than sodium
hypochlorite (NaOCl) or Chlorhexidine (CHX)and
found to be more potent in eliminating
Enterococcus faecalis.
(12)
Hence this study was
undertaken to determine the antimicrobial efficacy
of iodine potassium iodide solution as an intracanal
irrigant against Enterococcus faecalis, and to
compare it with 0.2%CHX and 2.5% NaOCl and
their combinations.
AIM AND OBJECTIVES
1. To evaluate the antimicrobial efficacy of 0.5%
IKI, 3% NaOCl, 0.2%CHX, as an irrigant against
Enterococcus faecalis, when used individually.
2. To evaluate antimicrobial efficacy of
combination of
a. 0.5%IKI and 3% NaOCl
b. 3% NaOCl and 0.2% CHX
c. 0.5% IKI and 0.2% CHX against E .Faecalis
3. To compare the antimicrobial efficacy of 0.5%
IKI, 3% NaOCl, 0. 2% CHX, as an intracanal
irrigant when used individually as well as in
various combinations against E. Faecalis.
4. To evaluate antimicrobial action of 0.9% saline,
using it as positive control
MATERIALS AND METHODS
The present study was conducted in the
department of Conservative Dentistry and
Endodontics, Manipal College of Dental Sciences,
Mangalore and department of Microbiology,
Kasturba Medical College, Mangalore. 64 single
rooted extracted human teeth with type I canal
anatomy were collected and stored in tap water
till the period of study. Access cavity was prepared
on the lingual surfaces of anterior teeth and occlusal
surface of the premolar teeth using diamond points
with high speed airotor hand piece. Root canals
were prepared with crown down technique using
protaper hand instruments (Dentsply/Tulsa Dental)
and K files up to 25 size apically. Canals were
treated with 17% EDTA for 1 min to facilitate
removal of smear layer. Root apices were sealed
with nail varnish and teeth were sterilized by
autoclaving.
EVALUATION OF ANTIMICROBIAL EFFICACY OF 0.5% IKI, 3% NAOCI AND 0.2% CHX WHEN USED ALONE AND IN
COMBINATION ASINTRACANAL IRRIGANTSAGAINST ENTEROCOCCUSFAECALIS. AN IN VITRO STUDY
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A turbid suspension of Enterococcus faecalis
was obtained by growing the cells in brain heart
infusion broth(Hi Media Laboratories Pvt. Ltd) for
6 hrs at 36.5
0
C.The bacteria laden suspension was
placed into the canal using a sterile 27 gauge needle
with syringe and incubated at 36.5
0
C for 24 hours.
The teeth were then divided into 8 groups of
8 teeth each .All the samples were irrigated with
the test solution for 30 sec and divided into the
following groups.
GROUP I - Negative control group,
no irrigation
GROUP II - Positive control group, canals are
flushed with 0.9% saline for
1 min.
GROUP III - 0.5% IKI (freshly obtained from
Biochemistry Dept)
GROUP IV - 3% sodium hypochlorite (Vishal
Dent Care Pvt Ltd.India)
GROUP V - 0.2% Chlorhexidine(Vishal Dent
Care Pvt Ltd.India)
GROUP VI - a combination of 0.5% IKI and
0.2% chlorhexidine
GROUP VII - a combination of 0.5% IKI and
3% sodium hypochlorite
GROUP VIII - 0.2% chlorhexidine and 3%
sodium hypochlorite
In all the groups the canls were passively
irrigated with respective test solution using sterile
27 gauge needle for 30 secs. With the sterile round
bur of diameter 1 mm, a hole was drilled from the
proximal surface of the tooth into the root canal in
the middle third region as far as the head of the bur
penetrated dentin to collect dentinal shaving.
Shavings were allowed to fall on the entire agar
plate with brain heart infusion agar culture medium
(Fig.1) .128 agar plates with dentinal shaving were
incubated for 48 hours at 36.5
0
C. After 48 hours,
the viable organisms were expressed as colony
forming units (CFU/ml) from fallen dentinal
shaving. Statistical analysis was done with Kruskal
Wallis test and results obtained are presented.
RESULTS AND STATISTICAL ANALYSIS
The present study included 64 teeth divided
into 8 groups of 8 each. Results of the study are
analyzed by Mann Whitney U test and Kruskal
Wallis test.
In Group I - (Fig.2) (negative control), no
irrigation, only microorganism was inoculated in
the root canal middle third of the root canal had a
median colony count was 44 ,minimum colony
count was 7 and maximum was 1000.Similarly in
the apical third median colony count was 23.5,
minimum colony count was 2 and maximum
colony count was 1000.
In Group II (Fig.3) - (positive control), canal
was irrigated with saline only middle third of the
root canal had a median colony count of 6
,minimum colony count was 1 and maximum was
15.Similarly in the apical third median colony
count was 3.5, minimum colony count was 0 and
maximum colony count was 31.
In Group III (Fig.4) - canal was irrigated with
0.5% Iodine potassium iodide only middle third
of the root canal had a median colony count of
1,minimum colony count was 0 and maximum was
5.Similarly in the apical third median colony count
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was 2, minimum colony count was 0 and maximum
colony count was 3.
In Group IV (Fig.5) - canal was irrigated with
3% Sodium hypochlorite only middle third of the
root canal had a median colony count of 4.5
,minimum colony count was 0 and maximum was
9.Similarly in the apical third Median colony count
was 3, minimum colony count was 0 and
maximum colony count was 7.
In Group V (Fig.6) - canal was irrigated with
0.2% Chlorhexidine only middle third of the root
canal had a median colony count of 3, minimum
colony count was 0 and maximum was 4.Similarly
in the apical third median colony count was 2,
minimum colony count was 0 and maximum
colony count was 6.
In Group VI (Fig.7) - canal was irrigated with
0.5% iodine potassium iodide and 0.2%
Chlorhexidine middle third of the root canal had
a median colony count of 2,minimum colony count
was 0 and maximum was 4.Similarly in the apical
third median colony count was 3, minimum colony
count was 0 and maximum colony count was 4.
In Group VII (Fig.8) - canal was irrigated with
0.5% iodine potassium iodide and 3% Sodium
hypochlorite middle third of the root canal had a
median colony count of 4,minimum colony count
was 0 and maximum was 7.Similarly in the apical
third median colony count was 4, minimum colony
In Group VIII(Fig.9) - canal was irrigated with
0.2% Chlorhexidine and 3% Sodium hypochlorite
middle third of the root canal had a median colony
count of 2,minimum colony count was 0 and
maximum was 5.Similarly in the apical third
median colony count was 1, minimum colony
The total median colony count on the middle
third was 3 and in the apical third was also 3.
Kruskal Wallis was used to test between apical third
and the middle third. Middle third was highly
significant than apical third i.e, P<0.001
RESULTS AND STATISTICAL ANALYSIS
Analysis done using Mann- Whitney U test
P< 0.001 - VHS (very highly significant)
P< 0.01 - HS (highly significant)
P > 0.05 - NS (not significant)
Z - Mann whitney U test
Inter group comparisions were done both at
middle third and apical third (Bar
diagram1&2).When group I was compared to group
II, Group III, Group IV, Group V, group VII and
group VIII the results were statistically significant
in both apical third and middle third. (Table 1 and
table 2).
When Group II was compared with group III,
group V, group VI, and Group VIII in the middle
third and Group II compared with group VIII in
the apical third the results were statistically
significant. But when Group II compared with
group IV , Group VII in the middle third and when
group II compared with group III , group IV , Group
V , Group VI , group VII the result were not
statistically significant ( table 1and table 2).
When Group III was compared with group IV,
group V, group VI, group VIII in the middle third
and apical third the results were not statistically
significant. But it was significant when compared
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to Group VII in the middle third. (Table 1 and table 2).
When Group IV was compared with GroupV,
Group VI, group VII and Group VIII in the middle
third and apical third the results were not
significant.
When Group V compared with Group VI,
Group VII and Group VIII in the middle and apical
third the results were not significant.
When Group VI compared with Group VII and
Group VIII in the middle and apical third the results
were not significant
When Group VII compared with Group VIII
in the apical third the results were highly significant
whereas it was not significant in the middle third
DISCUSSION
The prime objective of endodontic treatment
is sterilization of root canal system. It depends on
the complete elimination of micro-organisms from
the complex root canal system. F ailed root canal
therapy occurs when microrganisium persists in the
root canal and cause reinfection
(1)
The effectiveness of irrigant largely depends
upon the type of bacteria present within the tubules.
The present study compares bactericidal effect of
endodontic irrigants at middle third and apical third
of the root canal. The dentinal chips from both
middle third and the apical third were infected by
Enterococcus faecalis and was spread over the agar
plates. This method of culturing the bacteria on
the agar plates is simple and is routinely used. It
has been used in the past by researchers (RA Buck,
PD Eleazer) to test the effectiveness of endodontic
irrigants at various tubular depths in human dentin.
(3)
According to the result of the present study,
Group III, i.e, irrigating with IKI showed the best
antimicrobial effect at the middle third of the root
canal when compared with all the experimental
groups. It is very highly significant in comparison
with Group I (No irrigation) and highly significant
in comparison with group II (saline).This could be
because of better antimicrobial property of IKI, its
ability to penetrate the dentinal tubules to a greater
depth; moreover it is more potent than NaOCl. This
result is in agreement with the study by Hancock
et al, where IKI as an irrigant has low tissue toxicity
and when used as an irrigant appears to be more
potent than sodium hypochlorite or CHX in
eliminating Enterococcus faecalis
(12)
.Similarly,
Safavi et al reported that IKI eliminated
Streptococcus faecium (a closely related but
distinct species) from infected tubules, in 10
minutes when compared to Ca(OH)
2
which took
24 hours.Orstavik and Haapasolo also reported that
IKI was able to penetrate the dentinal tubules to
eliminate S Sanguis to a depth greater than 1000
m within 5 min. Even the study shown by
Peculiene et al reported the ability of single
appointment chemo-mechanical preparation
followed by 5 min irrigation with IKI to eliminate
yeast and enterococcus species.
(13)
Group V (CHX) and Group VI (CHX + IKI)
showed better antimicrobial property when
compared to group I (without irrigation) which was
highly significant. CHX has a bactericidal effect for
both gram negative and gram positive bacteria.
Similarly, IKI has been used as an intracanal agent
in endodontics. It is effective against various
organisms found in root canals and moreover 2%
IKI has been proved to be less toxic. In favour of
these results in the present study only 0.5% of IKI
is used in combination with 0.2% CHX. Hence,
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TABLE 1
STATISTICAL ANALYSIS
Analysis done using Mann- Whitney U test
MIDDLE THIRD
GROUP 1 GROUP 2 GROUP 3 GROUP 4 GROUP 5 GROUP 6 GROUP 7
GROUP 2 Z -2.949 - - - - - -
P 0.003 hs - - - - - -
GROUP 3 Z -3.376 -2.712 - - - - -
P 0.001 vhs 0.007 hs - - - - -
GROUP 4 Z -3.103 -.953 -1.281 - - - -
P .002 hs 0.341 .200 - - - -
GROUP 5 Z -3.576 -2.559 -.996 -1.312 - - -
P 0.001vhs 0.011sig .316 0.190 - - -
GROUP 6 Z -3.368 -2.541 -.970 -1.112 -.546 - -
P 0.001vhs 0.011sig .332 .266 .585 - -
GROUP 7 Z -3.431 -1.306 -2.245 -.146 -1.706 -1.901 -
P 0.001vhs 0.191 0.025sig .886 .088 .057 -
GROUP 8 Z -3.477 -2.524 -.738 -1.270 -.337 -.098 -1.793
P 0.001vhs 0.011sig .460 .204 .736 .922 .073
GROUP 1 GROUP 2 GROUP 3 GROUP 4 GROUP 5 GROUP 6 GROUP 7
GROUP 2 Z -1.949 - - - - -
P 0.05 sig - - - - -
GROUP 3 Z -2.923 -1.390 - - - -
P 0.003 hs .165 - - - -
GROUP 4 Z -2.372 -.476 -1.239 - - -
P 0.018 sig .634 .215 - - -
GROUP 5 Z -2.819 -1.162 -.275 -.904 - -
P 0.005 hs .207 .783 .366 - -
GROUP 6 Z -2.653 -.852 -1.140 -.428 -.182 -
P .008 hs .394 .254 .669 .855 -
GROUP 7 Z -2.224 -.048 -1.757 -.679 -1.525 -1.125
P .008 hs .961 .079 .497 .127 .260
GROUP 8 Z -3.298 -2.101 -1.344 -2.056 -.801 -1.772 -2.601
P 0.001vhs 0.036 sig .179 0.04 sig .423 .076 0.009 Hs
TABLE 2
Analysis done using Mann - Whitney U test
APICAL THIRD
15
15
TABLE 3
Middle Vs Apical
GROUP CLASS N Mean Std. Deviation Z
1.00 Middle 8 269.0000 452.18296 .52700
Apical 8 161.8750 339.78541 p=.598 ns
2.00 Middle 8 8.0000 10.71714 .73700
Apical 8 6.5000 4.20883 p=.461 ns
3.00 Middle 8 1.8750 1.24642 .97300
Apical 8 1.5000 1.60357 p=.331 ns
4.00 Middle 8 3.2500 2.37547 .58100
Apical 8 4.2500 3.61544 p=.561 ns
5.00 Middle 10 2.3000 2.40601 .00000
Apical 10 2.3000 1.70294 p=1 ns
6.00 Middle 8 2.5000 1.69031 .80500
Apical 8 2.0000 1.30931 p=.421 ns
7.00 Middle 9 4.2222 2.90593 .08900
Apical 9 4.1111 2.36878 p=.929 ns
8.00 Middle 9 1.1111 1.05409 1.18100
Apical 9 2.1111 1.83333 p=.239 ns
Group I - No Irrigation (negative control)
Similarly Intra group comparision was done between apical third and the middle third and the
result was obtained by Mann- Whitney U test and the results were not significant
Fig: 1 Agar Plates with dentinal shavings labeled
Fig: 2 Colonies observed after only microorganism inoculation
Fig: 3 colonies observed after
irrigation with saline Group II
(positive control)
irrigation with iodine potassium
iodide (Group III)
Fig: 5 Colonies observed after
irrigation with 3% sodium
hypochlorite (Group IV)
Fig.6 colonies observed after
irrigation with 0.2%
Chlorhexidine( Group V) with
CHX ( Group V)
16
16
Fig: 7 Colonies observed after
irrigation with 0.5% IKI and
0.2% CHX (Group VI)
irrigation with 5% IKI and 3%
Naocl (Group VII)
Fig: 8 colonies observed after irrigation with 5% IKI
and 3% Naocl (Group VII)
combining two irrigants would be better to obtain
additional or synergistic antimicrobial effects
without increasing its toxicity. Siren et al reported
that CHX and IKI are more effective against
Enterococcus faecalis than pure Ca (OH)
2
in vitro
and also showed that the properties were not
negatively affected by adding CHX or IKI,on the
contrary the addition clearly increased the
antimicrobial effect of the medication.
(14)
However, when group V (CHX), Group VII
(IKI + NaOCl) and group VIII (CHX +NaOCl)
when compared with each other at the middle
third, the results were not statistically significant
.When group IV (NaOCl) and group VI (IKI+
NaOCl) were compared to group I the results are
highly significant. This shows that they are equally
effective but their results were not significant when
compared to group II (saline). The reduction of
colonies with saline can be attributed to its flushing
action more than its antibacterial action. When
group IV (NaOCl) and GroupV (CHX) were
compared the results were not significant. This can
be compared with the study done by Kuruvilla and
Kamath, where the percentage reduction in the
number of microorganism after irrigation with CHX
teeth was lower than NaOCl.
In the apical third group VIII (CHX + NaOCl)
showed the best antimicrobial effect. It is highly
significant in comparison with group I and groupII.
The possible reason for this could be the following
reaction - Chlorhexidine is a base, capable of
forming salts with a number of organic acids.
Sodium hypochlorite is capable of oxidizing the
gluconate part of Chlorhexidine gluconate to
gluconic acid. The chloro group might be added
onto the guanidine component of Chlorhexidine
17
17
molecule, thereby forming Chlorhexidine
chloride This would increase the ionizing capacity
of the Chlorhexidine molecule and it is known that
ionized species exert better antibacterial action
than unionized species.
(9)
Intra group comparison showed there is no
statistically significant difference in disinfection
action at the middle third and apical third levels.
In conclusion the best antimicrobial activity
was achieved by IKI in the middle third and
Combination of irrigants i.e. CHX and NaOCl in
the apical third.
Further studies have to be conducted
1. With more sample size to confirm the result.
2. To check its efficacy of against Enterococcus
faecalis, in vivo
3. To check its antimicrobial action against other
organisms found in the root canal system
4. To check the staining caused by iodine potassium
iodide in vivo
5. To check for the allergic reaction caused by
Iodine potassium iodide
According to the results of the present study,
it can be concluded that IKI is a very good
antimicrobial agent in the retreatment of failed root
canal cases which are infected by E. Faecalis.
Eventhough combination of CHX and NaOCL has
given excellent result at the apical third ,this
combination forms a precipitate containing PCA
which is proved to be carcinogenic in rats.
CONCLUSION
The present study concluded that:
1. IKI is very good antimicrobial irrigating
solution against E .Faecalis amongst the
experimental irrigants.
2. The antimicrobial action of IKI is
comparable with antimicrobial action of
combination of CHX and NaOCl which is proved
best till date against E. faecalis.
3. Saline as an irrigant is not effective against
E. faecalis.
REFERENCES:
1. Siren EK Haapasalo MPP, Waltimo TMT, Orstavik D.; In
vitro antimicrobial effect calcium hydroxide combined with
chlorhexidine or iodine potassium iodide on Entercoccus
faecalis; Eur J Oral Sci 2004 ;11(2) : 326-331.
2. Isabela N,Rocas, Jose F , Siquerira Jr and Katia R R.N Santos.
Association of Enterococcus faecalis with Different Forms of
Periradicular Diseases, J Endod May 2004; 30( 5)
3. R. A. Buck, P.D. Eleazer R.H. Staat, J.P.Scheetz.
Effectiveness of three endodontics irrigants at various tubular
depths in human dentin. J Endod , March 2001; 27(3)
4. Portenier, H.Haapasalo, A.Rye, T.Waltimo, D.Orstavik and
M. Haapasalo. Inactivation of root canal medicaments by
dentine, hydroxylapatite and bovine serum albumin. Int
Endod J 2001, 34; 184-188.
5. Eewehr,Thomas B. Buxton, Anthony P. Joyes Elio Berutti,
Riccardo Marini and Alessandra Angeretti. Penetration Ability
of Different Irrigants into dentinal Tubule. J Endod, Dec
1997;23(12).
6. John W. Harrison Irrigation of the Root Canal System. Dent
Clin North Am, October 1984;28( 4) .
7. Michael J. Jeansonne, and Robert R.White. A Comparison
of 2.0% Chlorhexidine Gluconate and 5.25% Sodium
Hypochlorite as Antimicrobial Endodontic Irrigants. J Endod
.June 1994;20(6)
8. Ringel A.M, Patterson S.S, Newton CW, Muller, CH
Mulhern J.M. In vivo evaluation of chlorhexidine gluconate
solution and sodium hypochlorite solution as root canal
irrigants. J Endod May 1982,8(5) :200-204
9. Jane Rachel Kuruvilla and M Premanand Kamath
Antimicrobial activity of 2.5% Sodium Hypochlorite and 0.2%
chlorhexidine gluconate separately and combined, as
endodontics irrigants. J Endod July 1998 ;24(7)
10. Bettina R. Basrani, Sheela Manek, Rana N.S. Sodhi, Edward
Fillery, Aldo Manzur. Interaction between Sodium
18
18
Hypochlorite and Chlorhexidine Gluconate. J Endod August
2007;33( 8):966-969
11. Shaul Lin, Gagriel Tillinger, Offer Zuckerman,Endodontic
-Periodontic Bifurcation Lesions,A Novel Treatment Option.
Contempt Endod dent prac. 9(4), May 1 2008.
12. Nathan E. Baker, Frederick R.L. Fort Gordon, GA
Antibacterial efficacy of calcium hydroxide , iodine potassium
iodide, betadine, and betadine scrub with and without
surfactant against E. faecalis in vitro, Oral Surg Oral Med Oral
Pathol Oral Radiol Endod, 2004;98;359-64.
13. Anders Bystrom, Goran Sundqvist ,Umea. Bacteriology
evaluation of the effect of 0.5% sodium hypochlorite in
endodontic therapy .Oral surg March 1983; 55(3)
14. Spano JC, Barbin EL ,Santos TC, Guimaraes LF , Pecora
JD. Solvent action of sodium hypochlorite on bovine pulp
and physico-chemical properties of resulting liquid. Braz Dent
J 2001;12(3):154-7.
19
19
An in vitro study to evaluate apical seal in roots filled with
a thermoplastic synthetic polymer based root canal filling
material
RHYTHM BAINS * #
ANIL CHANDRA ** ##
ASEEM P. TIKKU ** ##
KAPIL LOOMBA *** #
PROMILA VERMA **** ##
* Seni or Lecturer, * * Professor, * * * Di rector PG Educati on, Professor & Head, * * * * Assi stant Professor, Department of Conservati ve Denti stry & Endodonti cs, # Career
Post Graduate Insti tute of Dental Sci ences & Hospi tal , Lucknow (UP), INDIA., # # Chhatrapati Shahuj i Maharaj Medi cal Uni versi ty, Lucknow (UP), INDIA.
ABSTRACT
The aim of present study is to evaluate the apical seal and marginal adaptation to intraradicular dentin of a resin
based obturating material, Resilon / Epiphany system as compared to the gutta-percha/ zinc oxide-eugenol sealer
or gutta percha/ epoxy-resin based sealer using the dye penetration methodology and SEM. The study used 49
extracted human teeth with single root canal, having similar root segments of about 13 mm length. Samples were
randomly divided into three experimental groups of 13 teeth each with each group obturated by different
combination of materials and 10 teeth were prepared as controls. Canals were obturated in Group 1- with Gutta-
Percha/Zinc oxide-eugenol sealer; in Group 2- with Gutta-Percha/AH-Plus sealer; and in Group 3- with Resilon/
Epiphany system. Stereomicroscopic evaluation showed mean value dye penetration for group 1, 4.049 mm
+1.4102, for group 2, 2.6920 mm +1.2298 and for group 3, 1.850 mm +1.1692. The SEM evaluation revealed
Group 3 showed better adaptation to both the intraradicular dentin and the core filling material, as compared to
Group 2 followed by Group 1. Resilon/ Epiphany group had the least penetration followed by Gutta-percha / AH
plus and maximum in Gutta-percha / Zinc oxide-eugenol sealer.
Keywords: Dye Penetration, Monoblock, Epoxy Resin, Polycaprolactone, Resilon
INTRODUCTION
Gutta-percha has universally been accepted
as the gold standard for root canal filling materials.
1
It faces the problem of apical leakage because it
adapts but does not adhere to the dentin walls.
2
Sealer fills the irregularities and minor
discrepancies between the core filling materials and
the canal walls
3,4
. It also acts as a lubricant during
the obturation procedure; and it may fill any patent
accessory canals and multiple foramina
3
; however
due to non-adherence to tooth structure, a
microspace exist between Zinc oxide based sealer
and tooth preventing the establishment of a
hermetic seal
5
. Materials with adhesive properties
as epoxy resins (AH 26 and AH Plus)
5
, polyketone
compounds (Diaket)
6
and glass ionomer cements
7
and more recently, dentin bonding agents
8,9
have
been used as root canal sealers, and shown to have
better sealing abilities than zinc oxide-eugenol
based sealers. Resilon (Resilon Research LLC,
Madison, CT, USA), a filled polycaprolactone
polymer containing a blend of dimethacrylates,
Original Research
20
20
bonds well to methacrylate based resin sealers,
Epiphany sealer (Pentron Clinical Technologies,
Wallingford, CT) is an alternative root canal sealer
that offers the promise of adhesion to the root
dentin
10
. The present study evaluates the apical seal
and marginal adaptation to intraradicular dentin
of the resin based root filling material, Resilon a
thermoplastic filled polymer in combination with
the dual cured Epiphany sealer as compared to the
conventional gutta-percha used along with zinc
oxide-eugenol sealer or epoxy-resin based sealer
using the dye penetration methodology and
Scanning Electron Microscope.
The study used 49 single rooted freshly
extracted human teeth collected from the Oral and
Maxillofacial Surgery department. All the teeth
were sectioned at the cemento-enamel junction
using a diamond disc on a slow speed micromotor
hand piece under water cooling. Each tooth was
endodontically prepared for obturation. Canal
length was determined by passing size 15 K File
into the canal until the tip was visible from the
apical foramen. Working length was established
1mm short of the apex. Instrumentation was
performed with a Crown Down technique using
hand instruments. All canals were prepared till ISO
size 40. Canal patency was maintained with an
ISO size 15 K file. The canal was irrigated between
each instrument with 3ml of 5.25% NaOCl using
a 27 gauge needle. Irrigant was seen passing
through the patent foramen. After final rinse of
NaOCl, 15% EDTA was used for 1 minute after
the completion of instrumentation. Finally the
canals were rinsed with distilled water. The root
canals were dried with multiple paper points and
obturated using lateral condensation technique.
Radiographs of the teeth were taken, to evaluate
the obturation. To minimize variables and to
maintain the uniformity of the study equal number
of samples were kept in each group. Of 49 samples,
39 were randomly divided into three experimental
groups of 13 teeth each. In Group 1- Canals were
obturated with Gutta-Percha/Zinc oxide-eugenol
sealer; An ISO size gutta-percha master cone
corresponding to the prepared canal apex was tried
to within 1 mm of the working length. Sealer was
placed into the canal using hand lentulospirals.
Master cone was coated generously with the sealer
and placed into the canal. Accessory cones were
placed into the canals. Lateral compaction of the
cones was done with the help of finger spreaders
of the ISO standardization. When the canals were
fully compacted they were condensed into the
canals using finger pluggers; In Group 2- Canals
were obturated with Gutta-Percha/AH-Plus sealer
similarly as described earlier; and in Group 3-
Canals were obturated with Resilon/Epiphany
sealer. The self etch Epiphany primer was placed
into the root canal to working length with paper
points. Dry paper points were then used to wick
out the excess primer from the canal. The dual
syringe (containing the sealer) with automixing tip
attached was used to express the sealer into a
mixing pad. The sealer was then placed into the
canal using a hand lentulospiral. A Resilon master
cone of 0.02 taper, corresponding to the size of
the apex prepared was tried within 1 mm of the
canal. It was then coated with the Epiphany sealer
and placed into the canal. The canal was then filled
with the accessory Resilon points using the lateral
condensation technique. When the canals were
fully compacted they were condensed into the
canals using finger pluggers. The root canal was
RHYTHM BAINS, ANIL CHANDRA, ASEEM P. TIKKU, KAPIL LOOMBA, PROMILA VERMA
21
21
the immediately cured coronally with a halogen
based light curing unit (3M, ESPE) for 40 seconds
to produce an immediate coronal seal. When the
dual cure sealer sets (in about 45 minutes), a seal
is created from orifice to apex. Randomly, nine
teeth, 3 from each group were selected for Scanning
Electron Microscopic study at magnification of
150x and 500x.
Remaining 10 teeth of 49, were used as
control group. 5 teeth each were prepared for
negative and positive control respectively. For
negative control, the canals were filled with gutta-
percha cones only, using the same method of lateral
condensation as for the experimental groups. The
teeth were coated with sticky wax at the coronal
end and completely coated with two coats of nail
paint to prevent any leakage inside the canal space
after which they were immersed in 2% methylene
blue dye for 48 hours. For positive control, the
canals were filled using gutta-percha cones only,
without any sealer. The coronal end was coated
with sticky wax, and except for apical 3 mm, the
tooth was coated with two layers of nail paint
before immersing in 2% methylene blue dye for
48 hours.
After obturation, the teeth of the 3
experimental groups were stored for 48 hours at
room temperature to allow for the complete setting
of the sealers. The coronal ends of the teeth were
covered with a layer of sticky wax. A coat of nail
paint was applied on the teeth leaving only 2-3
mm of the apical region. After 1 hour, another coat
of nail paint was applied on the teeth, again leaving
apical 2-3 mm. After 1 hour when the nail paint
had completely dried, the teeth were immersed in
a solution of 2% methylene blue for 48 hours. The
teeth used for control were also immersed in the
dye for 48 hours. The teeth were then removed
from the dye and were washed under running tap
water and nail paint and sticky wax was scraped
from the tooth surface using a scalpel. Grooves
were made along the mesial and distal walls of the
roots using a diamond disc on a slow speed
handpeice. Then the teeth were split into two
halves using a chisel and mallet. Both halves of
the split samples were then evaluated under a
stereomicroscope at magnification of 10x for visible
coronal extent of dye penetration. With the help
of the photomicrographs obtained, the linear
measurement of the dye penetration was noted
from apical to coronal direction. To remove any
interobserver bias, the extent of dye penetration
was evaluated by 3 independent observers, who
were unaware of the materials and method used
in the study but were instructed about the method
of measuring and recording the extent of dye
penetration. Each gradation on the
photomicrograph corresponded to 1 mm on a
linear scale. The recorded measurements were then
statistically analyzed using ANOVA and Student-
t test.
RESULTS
Stereomicroscopic evaluation showed dye
penetration in all samples except for the negative
control group in which no penetration was seen
while the samples of positive control showed
complete dye penetration. The measurements of
linear dye penetration were made in order to
quantify the relative leakage of each group and the
mean dye penetration values are summarized in
Table-1. Highest mean value were seen for group
1 (4.049 mm +1.4102) ( figure 1) and lowest mean
value were seen for group 3 (1.850 mm +1.1692)
AN IN VITRO STUDY TO EVALUATE APICAL SEAL IN ROOTS FILLED WITH A
THERMOPLASTIC SYNTHETIC POLYMER BASED ROOT CANAL FILLING MATERIAL
22
22
(figure 3) while group 2 had mean value of 2.6920
mm +1.2298 (figure 2). Table 2 shows analysis of
variance of dye penetration in different groups.
Since p value is statistically significant, hence
mean values in different groups differ significantly
and was maximum for group-1 than for group-2
and minimum for group-3. Table 3 shows a
comparative analysis of level of significance
between Group 1 and Group 2; Group 2 and Group
3, Group 1 and Group 3. The Scanning Electron
Microscope evaluation revealed Group 3 (figure
6) showed better adaptation to both the
intraradicular dentin and the core filling material,
as compared to Group 2 (figure 2) followed by
Group 1 (figure 1).
Table 1: Mean dye penetration values (in mm)
Group No. of Sample (n) Mean Dye Penetration (in mm) Range
1 10 4.0490+1.4102 2.0 to 6.42
2 10 2.6920+1.2298 1.08 to 5.33
3 10 1.8500+1.1692 0.33 to 4.5
Table 2: ANOVA Table of Dye Penetration in different groups
Source of Variation Degree of Freedom Mean Sum of Square F-Ratio p
Between the group 2 12.310 F= 7.586 p= 0.002
Within the group 27 1.623
Total 29
Table 3: Comparative Statistical Analysis of Different Groups
Comparison Mean Difference t value p value Level of Significance
Group 1 & 2 1.357+0.1804 2.29 p<0.05 Significant
Group 2 & 3 0.842+0.606 1.57 p=0.14 Non-significant
Group 1 & 3 2.199+0.241 3.80 p<0.001 Significant
Figure 1: Photomicrograph showing linear
dye penetration in group 1
23
23
Figure 4: SEM Photomicrograph showing
obturation material- and dentine interface
in group 1
obturation material- and dentine interface in
group 2
obturation material- and dentine interface in
group 3
DISCUSSION
In the present study, dye penetration was
observed in all samples except the negative control
teeth. Due to poor adhesive property of zinc oxide-
eugenol, maximum dye penetration was observed
in group I. Also the chelate formed between two
molecules of eugenol and one molecule of zinc
oxide slowly hydrolyze in presence of water to
release eugenol
9
. Another reason for low sealing
ability of zinc oxide-eugenol is the sudden setting
of this material (transition from paste to solid mass)
which may be responsible for debonding from
dentinal walls or cohesive fracture caused by
shrinkage setting stresses, which may explain the
higher leakage.
11
AH Plus, which is improved form
of AH 26, is an epoxy resin based sealer with better
sealing abilities compared to zinc oxide based
sealers.
12,13
The epoxy resin based sealers are
thought to be able to react with any exposed amino
groups in collagen when the epoxide ring opens,
thus having the higher bonding to dentin.
14
Limkangwalmongkol
3
and Milltic et al.
12
demonstrated that AH-26 (epoxy resin) sealer had
significantly less leakage than other sealers. Venturi
et al.
15
using tooth clearing technique demonstrated
better diffusion of AH Plus into lateral accessory
canals compared with Pulp Canal Sealer (a zinc
oxide-eugenol based sealer). But, Bodrumulu and
Tunga
16
advocated that AH Plus bonds to the dentin
but not to the gutta percha, and hence, the
attachment between the gutta percha and AH Plus
may allow an avenue for leakage. Thus, though it
leaked less than zinc oxide-eugenol, the leakage
is more than Epiphany, which bonds both to the
dentin and the core obturation material.
Resilon/Epiphany system bonds to the dentin
wall
2,4
, resulting in least dye penetration. Bacterial
(Streptococcus mutans and E faecalis) Penetration
1
,
Dye Penetration
16
, and Fluid Filtration
17
studies
evaluating Resilon/Epiphany with gutta percha/AH
Plus sealer, show similar results. The
photomicrographs using SEM were evaluated for
the dentin-sealer-core material interface. Tay et al.
18
found excellent coupling of Resilon to Epiphany
sealer, unlike gutta percha, where there was no
chemical adhesion to AH Plus sealer. Also, the
photomicrographs of the gutta percha zinc oxide
eugenol sealer show a uniform gap between the
sealer and dentin, while it bonded satisfactorily
with the gutta percha
7
. The Resilon/Epiphany sealer
group showed best adaptation both between sealer-
core and sealer-dentin, as the resin based core and
sealer, bonded to each other and sealer bonded to
the primer-conditioned dentin, thus forming a
monoblock which is more resistant to leakage
as well as fracture
2
. Based on the number of
24
24
interface present between the bonding substrate and
bulk material core, monoblocks formed in canal
spaces are classified as primary monoblock with
only one interface; secondary having two
circumferential interfaces; and tertiary monblocks
in which a third circumferential interface is present
between the bonding substrate and the abutment
material.
19
Thus, Resilon /Epiphany system may be
classified as a secondary type of monoblock, it
contains two interfaces, one between sealer and
primed dentine and other between sealer and
Resilon. Gutta percha/ Zinic oxide eugenol or Gutta
percha/ AH Plus rely on the sealer, filling the gap
between the gutta percha and the root wall,
whereas, Resilon /Epiphany system is based on the
same principles as adhesive restoration, and uses
a primer to enhance the bonding of dual curable
resin to the dentinal walls and then sealer bonds
to the fully polymerized core material forming a
block unlike the layers of gutta percha and sealer.
20
Adhesion of the root canal filling to the dentinal
walls seems to be advantageous for two main
reasons. In a static situation, it eliminates any space
that allows the percolation of fluids between the
filling and the wall and in a dynamic situation; it is
needed to resist dislodgement of the filling during
subsequent manipulation.
21
Apart from having
better apical sealing ability, Resilon/Epiphany has
also shown to produce better coronal seal. Coronal
seal has been shown to be critical for periapical
health after root canal treatment. Ray and Trope
22
recognized that the integrity of the coronal part of
the root canal system is of paramount success. The
Resilon system is associated with less apical
periodontitis, which may be because of its superior
resistance to coronal microleakage, by a factor of
6 times better than gutta percha/ AH 26.
1
Also,
endodontically treated teeth are widely considered
to be more susceptible to fracture than vital teeth
and Resin based dental materials have been shown
to reinforce an endodontically treated tooth through
the use of adhesive sealers in the root canal system,
thus having higher fracture resistance (22% more
than gutta percha).
23
CONCLUSION
The linear dye penetration measurements
showed that Resilon/ Epiphany group had the least
penetration followed by Gutta-percha / AH plus
and maximum in Gutta-percha / Zinc oxide-
eugenol sealer. Statistically significant difference
in dye penetration was seen between Gutta-percha
/ Zinc oxide-eugenol and Resilon / epiphany group;
and between Gutta-percha / Zinc oxide-eugenol
and Gutta-percha / AH Plus group, but not between
Gutta-percha / AH Plus and Resilon / Epiphany
group. The SEM evaluation revealed Epiphany
sealer showed best adaptation to both the
intraradicular dentin and the core filling material,
as compared to AH Plus and Zinc oxide-eugenol
sealer.
References
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inflammation after coronal microbial inoculation of dog roots
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2. Chivian Noah. Resilon - The missing link in sealing the
root canal. Compendium 2004; 25: 823-825.
3. Limkangwalmongkol S, Abbott PV, Sandler AB, Dent HD.
Apical dye penetration with four root canal sealers and gutta
percha using longitudinal sectioning. J Endod 1993; 18: 535-
539.
4. William TJ, James LG. Obturation of the cleaned and shaped
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Hargreaves K M. 9
th
Ed, Mosby, 2006, p.361.
5. Zmener O, Pameijer CH. Evaluation of apical seal in root
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Endod 2006; 31: 392-395.
25
25
6. Fraunhofer JA, Branstter J. The physical properties of four
endodontic sealer cements. J Endod 1982; 8: 126-130.
7. Lee KW, Williams MC, Camps JJ, Pashley DH. Adhesion
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8. Zidan O, ElDeeb M. The use of a dentinal bonding agent
as a root canal sealer. J Endod 1985; 11: 176-178.
9. Belli S, Zhang Yi, Periera N.R., Pashley DH. Adhesive
sealing of the pulp chamber. J Endod 2004; 27: 521-526.
10. Stuart CH, Schwartz SA. Reinforcement of immature roots
with a new resin filling material. J Endod 2006; 32: 350-353.
11. Wu MK, Gee AJ. Leakage of root canal sealers at different
thicknesses. Int Endod J 1994; 27: 304-308.
12. Miletic I, Ribaric SP, Jukic S. Leakage of five root canal
sealers. Int Endod J 1999; 32: 415-418.
13. Miletic I, Ribaric SP, Karlovic Z, Jukic S, Bosnajik A, Anic
I. Apical leakage of five root canal sealers after one year of
storage. J Endod 2002; 28: 431-432.
14. Ingle JI, Newton CW, West JD et al. Obturation of the
radicular space. In. Endodontics; Ingle JI, Bakland LK; 5
th
ed;
Mosby 2002, p-571-668.
15. Venturi M, Prati C, Capelli G. A prelimnary analysis of
morphology of lateral canals after root canal filling using a
tooth clearing technique. Int Endod J 2003; 36: 54-63.
16. Bodrumulu E, Tunga U. Apical leakage of Resilon
TM
Obturation Material. J Cont Dent Pract 2006; 7: 1-5.
17. Dummer PMH, Lyle L, Rawle J, Kennedy JK. A laboratory
study of root fillings in teeth obturated by lateral condensation
of gutta-percha or thermafil obturator. Int Endod J 1994; 27:
32-38.
18. Tay FR, Loushine R, Weller RN. Ultrastructural evaluation
of the apical seal in roots filled with a polycaprolactone based
root canal filling material. J Endod, 2005; 31: 514-519.
19. Tay FR, Pashley DH. Monoblocks in root canals: a
hypothetical or a tangible goal. J Endod 2007; 33; 391-398.
20. Shipper G, Dent M, Orstavik D, Teixiera F, Trope M. An
evaluation of microbial leakage in roots filled with a
thermoplastic synthetic polymer-based root canal filling
material (Resilon). J Endod 2004; 30: 342-347.
21. Eldeniz Au, Erdemir A, Belli S. Shear bond strength of
three resin based sealers to dentin with and without the smear
layer. J Endod 2005; 31: 293-296.
22. Ray HA, Trope M. Periapical status of endodontically
treated teeth in relation to the technical quality of root filling
and the coronal restoration. Int Endod J 1995; 28: 12-18.
23. Teixiera F, Teixiera E, Thompson J, Toope M. Fracture
resistance of roots endodontically treated with a new resin
filling material. J Am Dent Assoc 2004; 135: 646-652.
26
26
Evaluation of the effect of chlorhexidine gluconate as an
endodontic irrigant on the apical seal - An in vitro study
ROOPASHREE M. S.
KALA M. *
* Professor and Head, Dept. of Conservati ve Denti stry & Endodonti cs, Govt. dental col l ege & research i nsti tute, Bangal ore.
INTRODUCTION
One of the most important objectives in
nonsurgical Endodontic therapy is to disinfect the
entire root canal system before obturation of the
canal--
1
.
Endodontic therapy is primarily based on the
removal of potentially noxious stimuli from the
complex root canal system. This therapy is more
difficult if the root canal is infected. Although a
variety of instrumentation and irrigation techniques
exist, it has been shown that debris is regularly left
behind. These techniques aid in reducing the
microbial flora of the infected canals and help to
dissolve the necrotic tissue. Irrigants also serve to
lubricate the file during instrumentation. Therefore
several irrigating solutions have been
recommended for use in the pulp space
preparation
2
.
Sodium hypochlorite is used as an endodontic
irrigant due to its necrotic tissue dissolving capacity
and antimicrobial properties. The adverse effects
of Sodium hypochlorite include tissue toxicity,
pungent odor to the patient, and discoloration of
teeth and corrosion of dental equipments. For these
reasons another irrigant, which has the potential
to counteract these adverse effects, are desirable
and Chlorhexidine gluconate serves these
purposes
4
.
Chlorhexidine has broad spectrum of
antibacterial properties, Chlorhexidine has
demonstrated substantivity. Irrigation with 2%
Chlorhexidine has been shown to prevent
microbial activity with residual effects for 48 hours.
Chlorhexidine is an excellent root canal irrigant
for patients who are allergic to Sodium
hypochlorite
5
.
Along with a proper root canal preparation
and disinfection, an effective apical sealing
guarantees a long-term successful endodontic
treatment. A sealer associated with gutta-percha is
generally used to achieve an impervious apical
sealing. The sealer serves as a lubricant when
inserting the gutta-percha point, as a filling material
to fill the irregularities of the preparation, and is
necessary because gutta-percha does not bond
spontaneously to the dentinal walls of the prepared
canal. Adhesion of the sealers to both gutta-percha
and to dentin may also improve the sealing
properties of the endodontic sealers.
The assessment of linear dye penetration
apically or coronally has been the most common
in vitro method of examining the adaptation of a
root filling to the canal walls. This is based on the
supposition that the depth of dye penetration will
represent the gap between the root filling and the
canal wall
12
.
The purpose of this study was to evaluate
whether Chlorhexidine Gluconate (0.2%), when
Original Research
27
27
used as an endodontic irrigant, would affect the
seal obtained when using three different
endodontic sealers.
One hundred human maxillary anterior single
rooted teeth extracted for periodontal reasons were
used in this study, which were collected from the
Department of Oral and Maxillofacial Surgery,
Government Dental College and Research Institute,
Bangalore.
The procedure for preparation and obturation
was standardized for all groups and performed by
a single operator.
The crowns of all hundred maxillary anterior
teeth were severed at proximal Cemento-Enamel
junction using a carborundum disc. The teeth were
randomly divided into nine experimental groups
of ten teeth each, a positive and negative control
group of five teeth each. The working lengths were
established by placing #10 file into the root canal
until it was visible at the apical foramen, then 1mm
was subtracted from that length. The root canals
were instrumented in a step back manner using
flexofiles and Gates Glidden drills up to the
working length to a master apical file size of #40.
The coronal and the middle portion were flared to
a gradual taper using #3 and #4 Gates Glidden
drills.
Three milliliters of irrigant was used after every
use of Gates Glidden drill or the endodontic file.
Three different irrigating solutions were used during
this experiment. Teeth in groups 1, 2, 3 were
irrigated using sterile saline (0.9% sodium
chloride), teeth in groups 4, 5, 6 were irrigated
using 3% Sodium hypochlorite and teeth in group7,
8, and 9 were irrigated using 0.2% Chlorhexidine
Gluconate solution. Both control groups were
irrigated using sterile saline. The apical patency
was checked again by passing a #10 file through
the apical foramen. After every instrumentation,
the canals were thoroughly irrigated using
respected irrigating solutions, later the root canals
were dried with paper points and standardized
Gutta-percha points that fit with tug back at the
working length, were selected as master points.
In groups 1, 4 and 7 Zinc oxide eugenol sealer
was used, AH plus sealer was used in groups 2, 5,
and 8, Metapex sealer was used in-group 3, 6 and
9. The positive control group was obturated with
gutta-percha without sealer, and the negative
control group was obturated using lateral
condensation technique of gutta-percha and Zinc
oxide eugenol sealer. The coronal access cavity
was sealed with glass ionomer cement and final
radiographs were taken in the bucco-lingual
direction to check the density of the filling. After 2
days all the study specimens were thoroughly dried,
the root surface except for the apical 2mm that was
coated with two applications of nail varnish. The
teeth were immersed in Methylene blue 2% for 2
days at 37
0
C. The teeth were rinsed under tap water
for half an hour to remove dye on external root
surface. The teeth were then sectioned vertically
along the long axis.
The samples were then observed under
Stereomicroscope. The depth of dye leakage was
measured with a millimeter scale. Statistical
Analysis was done using One-way Analysis of
Variance (ANOVA).
RESULTS AND OBSERVATIONS
ROOPASHREE M. S., KALA M.
28
28
LEAKAGE VALUES FOR ALL THE GROUPS
TEETH Group-I Group-II Group-III Group-IV Group-V Group-VI Group-VII Group-VIII Group-IX +VE -VE
(mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm) control control
Group Group
(mm) (mm)
1 1.52 0.34 2.85 2.31 0.00 1.56 2.03 0.52 1.65 2.97 0.34
2 2.68 0.87 2.58 1.22 0.00 3.00 1.31 0.00 1.54 1.34 1.45
3 1.39 2.92 0.94 1.11 0.00 2.00 0.29 0.00 0.24 3.43 0.98
4 0.00 0.00 1.56 0.01 0.87 1.48 0.00 0.00 0.00 5.67 2.12
5 0.76 2.74 0.00 0.00 3.76 0.76 0.00 0.00 0.56 3.66 1.04
6 0.00 0.00 0.00 0.23 1.78 1.11 0.00 1.46 1.44
7 0.00 0.98 2.16 0.00 0.00 0.00 0.00 0.29 0.00
8 0.00 0.00 3.60 2.10 2.48 0.00 1.03 1.13 1.56
9 3.76 1.75 0.00 0.00 0.00 0.00 0.08 0.00 2.54
10 2.44 0.00 0.90 0.00 0.31 0.00 0.98 0.00 0.00
This table shows the apical leakage in
millimeters group I to group IX and positive and
negative control groups in which the dye
penetration scores obtained from calibrated value
under stereomicroscope and the mean and standard
deviation of the same.
Comparison between Normal saline 0.9%,
Sodium hypochlorite 3%, Chlorhexidine gluconate
0.2% groups in which Chlorhexidine gluconate
groups showed minimal leakage compared to other
groups with highest leakage in Normal saline group
(Table 1).
When compared each irrigant with the three
types of sealers, showed Metapex whichever
irrigant has been used with it, shows maximum
leakage with minimal leakage in AH Plus sealer
and moderate leakage with Zinc oxide eugenol
sealer (Table 2 and Graph1). When 0.9% normal
saline was compared with the all three types of
sealers; ZnoE sealer, AH Plus and Metapex root
canal sealer even though leakage occurred in all
the groups 0.9% normal saline irrigant- Metapex
root canal sealer showed maximum leakage where
as 0.9% normal saline irrigant-AH Plus sealer
showed minimal leakage with moderate leakage
in 0.9% normal saline irrigant- Zinc oxide eugenol
root canal sealer (Table 2 and Graph2).
When 3% Sodium hypochlorite root canal
irrigant was compared with all three types of root
canal sealers; ZnoE root canal sealer, AH Plus root
canal sealer and Metapex root canal sealer, even
though leakage occurred in all the groups 3%
Sodium hypochlorite - Metapex sealer showed
maximum leakage where as 3% Sodium
hypochlorite irrigant-AH Plus sealer showed
minimal leakage with moderate leakage in 3%
Sodium hypochlorite irrigant- Zinc oxide eugenol
root canal sealer (Table 2 and Graph 3).
0.2% Chlorhexidine gluconate root canal
irrigant was compared with the all three types of
root canal sealers. Even though leakage occurred
in all the groups, 0.2% Chlorhexidine gluconate -
EVALUATION OF THE EFFECT OF CHLORHEXIDINE GLUCONATE ASAN ENDODONTIC IRRIGANT ON THE APICAL SEAL - AN IN VITRO STUDY
29
29
Metapex sealer groups showed maximum leakage,
0.2% Chlorhexidine gluconate -AH Plus sealer
showed minimal leakage with moderate leakage in
0.2% Chlorhexidine gluconate - Zinc oxide eugenol
sealer (Table 2 and Graph 4).
The positive control group showed maximum
leakage values where no sealer had been used than
negative control group, which showed minimal
leakage values (Table 2 and Graph 5).
Samples Showing Microleakage
30
30
DISCUSSION
Cleaning and shaping is undoubtedly of paramount importance
in successful Endodontic treatment. However, this does not negate
the importance of the quality of obturation. This is validated by the
fact that nearly 60% of failures in Endodontics can be attributed to
incomplete obturation of the root canal. Hence, a three dimensional
obturation is critical for Endodontic success.
31
31
Chlorhexidine in the chemical form is a
cationic bis-guanide that is usually marketed as
gluconate salt. The substantive antimicrobial activity
has been identified as a potentially protective
element in the tissues for many hours after
instrumentation. The potential for chlorhexidine
gluconate use in Endodontics has been clearly
demonstrated by numerous investigators. A possible
clinical advantage of chlorhexidine gluconate over
sodium hypochlorite is that, even though both are
effective as antimicrobial agents, chlorhexidine
gluconate is relatively nontoxic
1
.However the
efficacy of Chlorhexidine as an Endodontic irrigant
and intra canal medicament requires further research
in vivo.
Nicholls stated that poor seal may lead to voids
in the apical region of the canal where stagnation
of tissue fluids can occur. The subsequent
proteolysis and irritation can result persistence of
existing periapical lesions.
Traditionally, clinical emphasis has been on
the apical sealing of the root canal obturation.
Though a variety of new methods have come to
evaluate apical seal like electrochemical methods,
radioisotope tracers, fluid filtration technique still
linear dye penetration is followed most commonly
because of its simplicity, ease to perform and are
relatively inexpensive.
Longitudinal sectioning of roots and linear
measurement of dye penetration were used in this
study to measure apical leakage. Alternative
methods are vertical sectioning or clearing the roots.
Clearing technique although visually impressive has
never been satisfactorily verified to completely
demonstrate the pattern of tracer penetration. It is
difficult to measure precisely and the tracer may be
lost during the tissue processing.
An effort was made in this study to balance
the composition of experimental group in terms of
canal anatomy. Absolute standardization is clearly
impossible because of variability in canal anatomy,
however relative standardization is possible,
particularly of the prepared canals, in that of a
standard apical size and taper can be produced.
For years gutta percha has proved to be the
material of choice for successful sealing of the canal
from the canal orifice and the apical constriction.
Though not the ideal filling material, it satisfies the
majority of Grossmans tenets expected out of an
ideal Endodontic obturating material.
Cold lateral condensation of gutta percha is
currently the most accepted obturation technique.
Clearly use of such technique will not result the
movement of the core filling material out of the main
canal. Lateral condensation of gutta percha has
remained the most widely used method of
obturating root canals. This is also reflected in
various dye penetration studies. Advantages of this
technique include its predictability, relative ease of
use, conservative preparation and controlled
placement of materials.
Many studies have shown that the use of sealers
greatly enhances the apical seal produced by
Endodontic therapy. Current Endodontic texts state
that most advantageous and more predictable results
are obtained if the root canal system is as dry as
possible before obturation.
In the present study step back preparation was
followed and all the samples at the apex were
enlarged to ISO size fifty. Although every effort was
made to standardize the root canal preparation and
32
32
filling techniques, it was difficult to control
anatomical variations between the teeth, and this
could influence the quality of the root filling. The
presence of accessory canals should increase
leakage while the difference in thickness of different
tooth structure may affect the electrical resistance
of the tooth
6
.
Dye penetration has been measured
spectrophotometrically or linearly.
Though Chlorhexidine gluconate adsorbs to
surfaces covered with acidic proteins such as
hydroxyapatite and is gradually released in the form
of an active cat ion it did not affect the sealing ability
of sealers used for obturation in this study and also
it did not much contribute in the microleakage. In
this study AH-Plus demonstrated better sealing
ability than a calcium hydroxide based root canal
sealer and Zinc oxide eugenol sealer. The sealer
binds to the dentin chemically and provides a
consistent apical seal and also may be due to
adaptability and solubility of calcium hydroxide
based root canal sealer being poorer than the other
two types of root canal sealer.
Chlorhexidine gluconate 0.2% root canal
irrigant and AH-Plus root canal sealer combination
though showed microleakage, did not affect much
of the apical seal this may be attributed to adhesion
of sealer with root canals. Sodium hypochlorite root
canal irrigant in the concentration of 3% when used
in combination of AH-Plus, Zinc oxide eugenol
sealer and Metapex was not able to achieve hermetic
apical seal. Normal saline 0.9% root canal irrigant
when used in combination of AH-Plus, Zinc oxide
eugenol sealer and Metapex root canal sealer was
not able to achieve hermetic apical seal. But Normal
saline 0.9% when used in combination with AH-
Plus showed comparatively less microleakage.
In this study there was no significant difference
in the sealing abilities of the three types of sealers.
An important consideration, which must not be
overlooked, is that every tooth has its own
configuration of the root canal system. Though this
study was undertaken in single rooted teeth, the
strategic position, the anatomic complexity, larger
tooth pulp chamber, numerous pulp horn and wider
or ribbon shaped canal orifice in multi rooted teeth
makes the posterior teeth more prone to apical
leakage.
Also this study demonstrated no significant
differences in apical leakage using three irrigants
(0.9% sterile saline, 3% sodium hypochlorite, and
Chlorhexidine gluconate 0.2%) and three different
sealers (Zinc oxide eugenol sealer, Metapex, and
Ah Plus) at 2 days observation periods.
However further long term studies are required
for evaluation sealing ability of sealers as well as
the effect of chlorhexidine gluconate, sodium
hypochlorite and saline as an Endodontic irrigants
on the apical seal.
SUMMARY
One hundred extracted human single rooted
maxillary anterior teeth were used in this study and
were randomly divided into nine experimental
groups of ten teeth each and a positive and negative
control group of five teeth each.
After decoronation of all the samples working
length was determined and all the teeth were
instrumented to apical file size of 50 and teeth in
groups 1, 2, 3 were irrigated using sterile Saline
(0.9% sodium chloride), teeth in groups 4, 5, 6 were
irrigated using 3% Sodium hypochlorite and teeth
33
33
in group7, 8, and 9 were irrigated using 0.2%
Chlorhexidine gluconate solution. Both control
groups were irrigated using sterile Saline (0.9%).
Root canals were obturated with gutta-percha points
using the lateral condensation technique. In groups
1, 4 and 7 Zinc oxide eugenol sealer was used, AH
plus sealer was used in groups 2, 5, and 8 and
Metapex sealer was used in-group 3, 6 and 9. The
positive control group was obturated with gutta-
percha without sealer, and the negative control
group was obturated using lateral condensation of
gutta-percha and Zinc oxide eugenol sealer.
The teeth were stored for 2 days at 37
o
C and
humidity to accomplish complete setting of the
sealers. After 2 days all the specimens were
thoroughly dried. The root surface except apical
2mm of apex was coated with two applications of
nail varnish. Each coat was thoroughly dried before
the subsequent one was applied. The teeth were
immersed in Methylene blue 2% dye for 2 days at
37
0
C. Later the teeth were rinsed under tap water
for half an hour to remove dye on external root
surface. The specimens were split longitudinally.
The extent of the dye penetration was evaluated
visually and the depth of the dye penetration was
measured in millimeters using a Stereomicroscope
with an attached calibrated micrometer eyepiece
and the extent of leakage was calculated and
statistically analyzed using one-way ANOVA.
CONCLUSION
The following conclusions have been drawn
from the present study.
Mean microleakage value were comparatively
more for groups 1 and 3 in which Normal saline
0.9% was used as root canal irrigant with Zinc oxide
eugenol root canal sealer and group 6 in which
Sodium hypochlorite 3% was used as root canal
irrigant with AH-Plus root canal sealer, positive
control group irrigated with saline and obturated
without sealer.
Chlorhexidine gluconate 0.2%root canal
irrigant and AH-Plus root canal sealer combination
did not affect much of the apical seal this may be
attributed to adhesion of sealer with root canals.
The positive control group irrigated with saline
and obturated without sealer exhibited maximum
degree of apical leakage thereby indicating a sealer
to be indispensable when obturating. The negative
control group irrigated with normal saline and
obturated with Zinc oxide eugenol sealer also
showed microleakage.
Exposure of filled teeth to Methylene Blue dye
followed by longitudinal sectioning proved to be
an excellent means for studying apical
microleakage.
Though there was a difference in the mean
leakage values, it was not statistically significant.
The ANOVA results showed no significant
difference between any groups.
The result in the present study showed that
Chlorhexidine gluconate did not affect much of the
apical seal as compared to Sodium hypochlorite,
saline and no difference in the sealing ability of
sealers seen.
Further long term in vivo studies are required
for the evaluation of sealing ability of sealers as
well as the effect of root canal irrigants on the apical
seal. So to conclude, none of the groups showed
hermetic apical seal.
34
34
References
1. John T. Marley, David B. Fergusson, and Gary R. Hartwell:
Effects of Chlorhexidine gluconate as an endodontic irrigant
on the apical seal: short-term results. Journal of Endodontics.
2001: 27: 775-777.
2. K.C. Lim, Brian G. Tidmarsh: The sealing ability of sealapex
compared with AH plus. Journal of Endodontics: 1986: 12:
564-566
3. Ludovic Pommel, Imad About, David Pashley, and Jean
Camps: Apical leakage of four endodontic sealers. Journal of
Endodontics: 2003: 29: 208-210
4. M.K.Wu, A.R. Ozok and P.R. Wesselink: Sealer distribution
in root canals obturated by three techniques. International
Endodontic Journal: 2001: 33: 340-345
5. M.K. Wu, P.R. Wesselink and Boersma: A 1 year follow-up
study on leakage of four root canal sealers at different
thicknesses. International Endodontic Journal: 1995: 28: 185-
189
6. M.K.Wu and P.R. Wesselink: Endodontic leakage studies
reconsidered. PartI. Methodology, application and relevance.
International Endodontic Journal: 1993: 26: 37-43
7. Ahlberg KM, Assavanop P, Tay WM. : A comparison of the
apical dye penetration patterns shown by methylene blue and
india ink in root-filled teeth. International Endodontic Journal.
1995 Jan; 28 (1):30-4
8. De Almeida WA, Leonardo MR, Tanomaru Filho M, Silva
LA: Evaluation of apical sealing of three endodontic sealers.
International Endodontic Journal.: 2000 Jan; 33(1):25-7
9. Camps J, Pashley D: Reliability of the dye penetration
studies. Journal of Endodontics. 2003 Sep; 29 (9):592-4.
10. Limkangwalmongkol S, Abbott PV, Sandler AB : Apical
dye penetration with four root canal sealers and gutta-percha
using longitudinal sectioning. Journal of Endodontics. 1992
Nov; 18(11):535-9.
11. Ugur Inan, Hikmet Aydemir, and Tamer Tasdemir: Leakage
evaluation of three different root canal obturation techniques
using electrochemical evaluation and dye penetration
evaluation methods. Aust ralian Endodontic Journal 2007; 33:
1822
12. H. ARI: Effect of moisture on the apical seal of root canal
filling using Ketac-Endo and Grossman Sealer. IADR/AADR/
CADR (March 6-9, 2002)
13. John I Ingle, L K Bakland. Endodontics. 5th edition.
Elsevier, 2002.
14. Stephen Cohen, Richards C Burns. Pathways of Pulp. 8th
edition, Mosby; 2002.
15. Rajeswari P, Gopikrishna, Parameswaran A, and Tina
Gupta, kandaswamy: In-vitro evaluation of apical micro
leakage of thermafil and obtura ii heated guttapercha in
comparison with cold lateral condensation using fluid filtration
system. Endodontology. Vol. 17, I-2, Dec. 2005, 24 -31.
35
35
Evaluation of the effect of EDTA, EDTAC, RC-Prep and
BioPure MTAD on the microhardness of root canal dentine-
An in vitro study
SANDEEP SINGH * #
SHASHI RASHMI ACHARYA ** #
VASUDEV BALLAL *** #
RIJESH M **** ##
* Post Graduate Student, * * Professor and Head, * * * Reader, * * * * Research Schol ar, # Department of Conservati ve Denti stry and Endodonti cs, Mani pal Col l ege of Dental
Sci ences, Mani pal . # # Department of Metal l urgi cal and Materi al s Engi neeri ng,NITKS, Surathkal .
ABSTRACT
Aim: To determine the effect of Ethylenediaminetetraacetic acid (EDTA), Ethylenediaminetetraacetic acid plus
Cetavlon (EDTAC) solutions, RC-Prep and a Mixture of tetracycline isomer/ an acid / a detergent (Biopure
MTAD) on the Coronal, Middle and Apical root canal dentine.
Materials and Methods: Twenty intact freshly extracted single rooted maxillary and mandibular anterior human
teeth were taken and stored in physiological saline solution until used.. The teeth were sectioned longitudinally
by diamond abrasive disc, embedded in acrylic resin and polished with different grades of sand paper and finally
with alumina suspension on felt cloth. 40 samples were divided in to four groups(n=10). Group I samples were
treated with 17% EDTA for 1 minute , Group II samples were treated with EDTAC for 1 minute (n=10),Group III
samples were treated with RC-Prep for 1 minute, Group IV samples were treated with BioPure MTAD for 2
minutes and 5 minutes respectively.
Result: There was no statistically significant difference in the microhardness reduction in the coronal, middle
and apical third of the root canal dentin when treated with 17% EDTA, EDTAC, RC-Prep and BioPure MTAD.
Conclusion: In all the four groups, microhardness of the root canal dentin was reduced. BioPure MTAD was least
effective in reducing the microhardness of root canal dentine and 17% EDTA had the maximum effect.
Keywords: EDTA, EDTAC, RC-Prep BioPure MTAD, Vickers Microhardness Testing Machine
INTRODUCTION
Endodontic instrumentation using either
manual or mechanized techniques, produces a
smear layer and smear plugs which contains
organic and inorganic particles of calcified tissue
and organic elements such as pulp tissue debris,
odontoblastic processes, microorganisms, and
blood cells in dentinal tubules.
1
The use of chelating agents and acids have
been suggested to remove the smear layer from
the root canal, because the components of this
loosely bound structure are very small particles
with a large surface-mass ratio that makes them
highly soluble in acids.
2,3,4
Chelation is a physico-chemical process which
involves the uptake of multivalent positive ions by
specific chemical substances. In the specific case
of root dentine, the agent reacts with the calcium
Original Research
36
36
ions in the hydroxyapatite crystals. This process can
cause changes in the microstructure of the dentine
and changes in the Ca : P ratio.
Various irrigating solutions have been tried,
among which 17% EDTA has been popular as the
most effective chelating agent for the removal of
smear layer.
Initially, the use of EDTA solution in
Endodontics was proposed by stby (1957) who
recommended the use of 15% EDTA to assist with
the instrumentation of calcified, narrow or blocked
canals, because of its ability to foster the chelation
of the calcium ions at a pH close to neutral (Hill
1959).
Hill and Goldberg and Abramovich reported
that addition of a quaternary ammonium bromide
(Cetavlon) to 15% EDTA increased the action by
reducing its surface tension, because EDTA
solutions act only through direct contact with the
substrate. Guerisoli et al
5
stated that the association
of EDTA with a wetting agent enhances its
bactericidal effectiveness.
RC-Prep introduced by Stewart et al. in 1969,
contains 15% EDTA, 10% urea peroxide (UP), and
glycol. Oxygen is set free by the reaction of RC-
Prep with NaOCl irrigant so that pulpal remnants
and blood coagulates can be easily removed from
the root canal wall.
BioPure MTAD a new irrigant, based on a
mixture of antibiotic [ Doxycylcline Hyclate:-
150mg/5ml (3%), citric acid (4.25%), and a
detergent ( 0.5 % Polysorbate 80 detergent or
Tween 80) ]. It has a pH of 2.15 that is capable of
removing inorganic substances.

The recommended
final irrigation to be done by BioPure MTAD is 5
minutes. It has also been confirmed that the smear
layer removing capability of BioPure MTAD is not
compromised when used for 2 minutes as final
irrigant.
6
It has been reported that some chemicals used
for endodontic irrigation are capable of causing
alterations in the chemical composition of dentin.
7,8,9
Any change in the Ca/P ratio may alter the
original proportion of organic and inorganic
components, which in turn change the
microhardness, permeability, and solubility
characteristics of dentin.
8,9,18,19
Panighi and GSell
10
reported a positive
correlation between hardness and the mineral
content of the tooth. It has been indicated that
microhardness determination can provide indirect
evidence of mineral loss or gain in dental hard
tissues.
11
So as microhardness of root canal dentin
is sensitive to its composition and surface changes,
the present study aims to demonstrate that
microhardness tests, being a simple and effective
method to evaluate and compare the
demineralization power of different chelating
agents , given that the tests are carefully calibrated.
Thus the purpose of this study is to determine
the effect of EDTA, EDTAC, RC-Prep and BioPure
MTAD solutions on the microhardness of human
root canal dentine.
Twenty intact freshly extracted single rooted
maxillary and mandibular anterior human teeth
were taken and stored in physiological saline
solution containing 0.1% Sodium azide until use.
They were sectioned transversely at CEJ by
SANDEEP SINGH, SHASHI RASHMI ACHARYA, VASUDEV BALLAL, RIJESH M
37
37
diamond disc and crowns were discarded.
The teeth were sectioned longitudinally and
embedded in acrylic resin followed by polishing
with different grades of sand paper and finally with
alumina suspension on felt cloth. The samples were
randomly divided in to 4 groups (n=10) based on
the test solution used.
Group I: 17% EDTA solution was freshly
prepared by using EDTA solution (pH=7.3) with
the following composition:
Disodium salt of EDTA (17.00g)
Aqua dest. (100.00ml)
5M Sodium hydroxide (9.25mL)
Group II: EDTAC was freshly prepared by
using 15% EDTA at (pH=7.3).
0.75g of the detergent Cetyl-tri-methyl
ammonium bromide is added to 100 ml of the
solution .
12
Group III: RC-Prep ( Premier Dental
Philadelphia, PA, USA), paste type chelator.
Group IV: BioPure MTAD Tulsa Dental, USA
Samples in Group I,II, III were treated with
the chelating agent for 1 minute and in Group IV
samples were treated for 2 and 5 minutes
respectively.
The subjected samples were treated with 1ml
of specific solutions and were irrigated with 0.9%
saline after their prescribed time limit. Since RC-
Prep is a paste type chelator, it was coated on to
the dentin surface by a F1 Protaper File.
A MicroVickers Hardness Tester (Fuel
Instruments and Engineers Pvt. Ltd.) was used. The
diamond-shaped indentations were carefully
observed in an optical microscope with a digital
camera and image analysis software, allowing the
accurate digital measurement of their diagonals.
The average length of the two diagonals was used
to calculate the microhardness value (MHV). All
experiments were completed under the same
conditions: 50 g load and 15 s dwell time
13
,
following the suggestions by Cruz-Filho et al.
(2001)
14
. In each sample, three indentations were
made each in the coronal, middle and apical third
of the root canal dentin sample.
At the beginning of the experiment, reference
microhardness values (MHVs) were obtained for
samples prior to application of the solutions (Before
Application), so that the same samples can act as
their own controls. In Group IV, after obtaining
reference MHVs(Before Application), samples were
subjected to the test solution for 2 minutes [After
Application (2 min)] followed by additional 3
minutes i.e. a total time exposure of 5 minutes [After
Application (5 min)] a second and a third set of
measurements, adjacent to the previous ones, were
obtained respectively.
Statistical analysis for comparing
microhardness values in the coronal, middle and
apical area of the root canal dentin for the four
different test groups were carried out using 2-way
ANOVA with repeated measures (P<0.05).
RESULTS
The mean and SD values of the
coronal,middle and apical third root dentin
microhardness data for various groups are listed in
Table 1. In all the four groups, microhardness was
EVALUATION OF THE EFFECT OF EDTA, EDTAC, RC-PREP AND BIOPURE MTAD ON
THE MICROHARDNESSOF ROOT CANAL DENTINE- AN IN VITRO STUDY
38
38
reduced in the coronal, middle and apical third of
the root canal dentin. BioPure MTAD was least
effective in reducing the microhardness of root
canal dentine and 17% EDTA had the maximum
effect.
Intergroup Comparison
Repeated Measures Anova Test (Table 1)
There was no statistically significant difference
in the microhardness reduction in the coronal,
middle and apical third of the root canal dentin
when treated with 17% EDTA, EDTAC, RC-Prep
and BioPure MTAD.
EDTA Microhardness Mean Std. Deviation N
Before Application mean of Coronal 1/3
rd
50.9600 8.03375 10
Before Application mean of Middle 1/3
rd
52.6067 8.09037 10
Before Application mean of Apical 1/3
rd
56.4200 13.07606 10
After Application (1 min )mean of Coronal 1/3
rd
46.1933 7.79013 10
After Application (1 min ) mean of Middle 1/3
rd
48.0333 7.86653 10
After Application (1 min ) mean of Apical 1/3
rd
51.6533 13.17985 10
EDTAC MicrohardnessMean Std. Deviation N
Before Application mean of Coronal 1/3rd 51.5867 3.50211 10
Before Application mean of Middle 1/3rd 54.7633 2.12327 10
Before Application mean of Apical 1/3rd 58.8900 1.63655 10
After Application (1 min )mean of Coronal 1/3rd 47.7233 3.73264 10
After Application (1 min ) mean of Middle 1/3rd 51.0800 2.19760 10
After Application (1 min ) mean of Apical 1/3rd 54.6833 1.79631 10
RC-Prep Microhardness Mean Std. Deviation N
Bio-Pure - MTAD Microhardness Mean Std. Deviation N
39
39
Befor Application Microhardness
Comparison
In the 40 samples tested, comparison of the microhardness of the
root canal dentin in coronal1/3
rd
, middle1/3
rd
and apical 1/3
rd
respectively was statistically insignificant.
Afteer Application Microhardness
Comparison
In the 40 samples tested, comparison of the microhardness reduction
of the root canal dentin by different chemicals in coronal1/3
rd
,
middle1/3
rd
and apical 1/3
rd
respectively was statistically
insignificant.
DISCUSSION
Smear layer is a negative factor when sealing
the root canal because of its weak adherence to
the root canal walls hindering sealer adhesion.
Thus, the removal before obturation to allow
intimate contact of the sealer with the dentin surface
is mandatory.
15
Serper et al
16
, concluded in their study that
17% EDTA has the potential for causing excessive
peritubular and intertubular dentinal erosion if the
application time exceeds 1 min.

Thus in the present
study, all EDTA based chelating agents had
application time which was limited to 1 minute.
The irrigation regimen for BioPure MTAD is
initial rinse with 1.3% Sodium hypochlorite during
instrumentation and 5 minute final rinse with
BioPure MTAD for effective removal of smear layer
and desired antibacterial effect. A recent study
showed that the use of a 2 minute final irrigation
time did not compromise the smear layer removal
capability of BioPure MTAD.
6
Thus, in the present
study, we used both the time periods i.e. 2 and 5
minutes for the application of BioPure MTAD and
consequently checked the microhardness.
It is clear that the comparison between the
MHV values would be biased by the underlying
differences in dentine morphology. Thus, in the
present work, the actual measurements were
obtained from three indentations each in the
coronal, middle and apical third of root canal
dentin. This methodological approach differs from
the clinical situation in which the chelator
substances affect the dentine walls more strongly.
However, this approach allows a much better
control of experimental variables, leading to readily
comparable results that are fundamental for the
present study.
4
It was also noted in all the samples that their
was a variable increase in the microhardness from
coronal to apical third of root canal dentin
irrespective of treatment with any test agent. This
may be attributed to the histology of the root canal
dentin. Carrigan et al.
20
showed that tubule density
decreased from cervical to apical dentine and
Pashley et al.
21
reported an inverse correlation
between dentine microhardness and tubular
density.
In the present study, maximum decrease in
microhardness was achieved by EDTA followed
by RC-Prep, EDTAC and MTAD. But, the difference
40
40
in microhardness was statistically insignificant.
Zehnder et al.
22
(2005) reported that the
association of an endodontic chelator solution with
a wetting agent that reduces surface tension did
not improve the effectiveness of Calcium ion
removal. This conclusion is confirmed by the
present work, as EDTAC was not more effective
than 17% EDTA in reducing the microhardness.
In our study, BioPure MTAD treatment of root
canal dentin resulted in least microhardness
reduction of root canal dentin. This finding is in
agreement with past study which reported that
BioPure MTAD is effective in removing smear layer
and at the same time is milder on the dentin
structure.
17
However, Gustavo et al
23
reported that there
is full saturation of the demineralizing ability of
BioPure MTAD after 30 seconds. In the present
study, there was reduction in microhardness of root
canal dentin after 2 minutes of treatment with
BioPure MTAD and there was further decrease in
microhardness after a total of 5 minutes of
application. This implies that BioPure MTAD has
demineralizing ability beyond 2 minutes and up
to 5 minutes.
On the basis of the results obtained and
experimental conditions of the present study we
can conclude that..
1. There was no statistically significant
difference in the microhardness reduction of the
root canal dentin by 17% EDTA, EDTAC, RC-Prep
and BioPure MTAD.
2. Overall, BioPure MTAD was least effective
in reducing the microhardness of the root canal
dentine and 17% EDTA had the maximum effect.
REFERENCES
1. Sen BH, Wesselink PR, Turkun M. The smear layer: a
phenomenon in root canal therapy. International Endodontic
Journal 1995;28:141 8.
2. Pashley DH. Smear layer: overview of structure and
function. Proc Finn Dent Soc 1992;88(Suppl l):215-24.
3. Torabinejad M, Handysides R, Khademi AA, Bakland LK.
Clinical implications of the smear layer in endodontics: a
review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2002;94:658-66.
4. De-Deus G, Paciornik S, Mauricio MH. Evaluation of the
effect of EDTA, EDTAC and citric acid on the microhardness
of root dentine. International Endodontics Journal
2006;39:401-7.
5. Guerisoli DM, Marchesan MA, Walmsley AD, Lumley PJ,
Pecora JD. Evaluation of smear layer removal by EDTAC and
sodium hypochlorite with ultrasonic agitation. International
Endodontic Journal. 2002 May;35(5):418-21.
6. Torabinejad M, Cho Y, Khademi AA, Bakland LK,
Shabahang S. The effect of various concentrations of sodium
hypochlorite on the ability of BioPure MTAD to remove the
smear layer. Journal of Endodontics 2003;29:2339.
7. Dogan H, Calt S. Effects of chelating agents and sodium
hypochlorite on mineral content of root dentin. Journal of
Endodontics 2001;27:578-80.
8. Rotstein I, Dankner E, Goldman A, Heling I, Stabholz A,
Zalkind M. Histochemical analysis of dental hard tissues
following bleaching. Journal of Endodontics 1996;22:23-5.
9. Ari H, Erdemir A. Effects of endodontic irrigation solutions
on mineral content of root canal dentin using ICP-AES
technique. Journal of Endodontics 2005;31:187-9.
10. Panighi M, G Sell C. Effect of the tooth microstructure on
the shear bond strength of a dental composite. J Biomed Mater
Res 1993;27:975-81.
11. Rotstein I (1994) Effect of hydrogen peroxide and sodium
perborate on the microhardness of human enamel and
dentine. Journal of Endodontics 20, 613.
12. Pawlicka H (1982) Verwendung der Chelatverbindungen
zur Erweiterung der Wurzelkanale: Mikroharteuntersuchung.
Stomatologie der DDR 3,355-61.
13. Antonio M, Manoel D. Evaluation effect of EDTA, CDTA
and EGTA on Radicular Dentin Microhardness. Journal of
Endodontics 2001; 27;3; 183-184.
14. Cruz-Filho AM, Sousa-Neto MD, Saquy PC, Pecora JD
(2001) Evaluation of the effect of EDTAC, CDTA and EGTA
41
41
on radicular dentine microhardness. Journal of Endodontics
27,1834.
15. Sousa Neto MD, Marchesan MA, Pcora JD, Brugnera
Junior A, Sousa YTCS, Saquy PC. Effect of Er:YAG laser on
adhesion of root canal sealer. Journal of Endodontics
2002;28:185-187.
16. Calt S, Serper A. Time-dependent effects of EDTA on
dentin structures. Journal of Endodontics 2002;28:179.
17. Torabinejad M, Khademi AA, Babagoli J, et al. A new
solution for the removal of the smear layer. Journal of
Endodontics 2003;29:170-5.
18. Hennequin M, Douillard Y. Effects of different pH values
of citric acid solutions on the calcium and phosphorus
contents of human dentin. Journal of Endodontics
1994;20:551 4.
19. Dogan H, Calt S. Effects of chelating agents and sodium
hypochlorite on mineral content of root dentin. Journal of
Endodontics 2001;27:57880.
20. Carrigan PL, Morse DR, Furst ML, Sinai IH. A scanning
electron microscopic evaluation of human dentinal tubules
according to age and location. Journal of Endodontics
1984;10:35963.
21. Pashley D, Okabe A, Parham P. The relationship between
dentin microhardness and tubule density. Endod Dent
Traumatol 1985;1:176 9.
22. Zehnder M, Schicht O, Sener B, Schmidlin P (2005)
Reducing surface tension in endodontic chelator solutions
has no effect on their ability to remove calcium from
instrumented root canals. Journal of Endodontics 31, 5902.
23. Gustavo De-Deus, MD*, Claudia Reis, MS, Sandra Fidel,
PhD, Rivail Fidel, PhD,and Sidnei Paciornik, PhD Dentin
Demineralization When Subjected to BioPure MTAD: A
Longitudinal and Quantitative Assessment. Journal of
Endodontics: 2007 ;33;11
42
42
To treat and to retreat Protaper universal rotary system,
the double delight
* Postgraduate student, * * Professor and Head of the Department, * * * Professor, Department of Conservati ve Denti stry and Endodoti cs, PMNM Dental Col l ege, Bagal kot,
Karnataka- 587101
SANDHYA U. M. *
MOHAN THOMAS NAINAN **
MANGALA T. M. ***
SHARAD KAMAT ***
ABSTRACT
Aim: The aim of this study was to evaluate the efficacy of ProTaper Universal rotary system for guttapercha
removal during endodontic retreatment.
Methodology:30 extracted human maxillary anterior teeth were prepared & filled with laterally condensed gutta-
percha & AH plus sealer. Teeth were divided into three groups: Group A: GP removal with Hedstrom files and
xylene,and further canal preparation with stainless steel K-flex files (Kerr). Group B: GP removal was completed
using Gates Glidden drills & Hedstrom files with xylene as a solvent, followed by further canal preparation with
ProTaper Universal rotary instruments: Group C: GP removal completed with the ProTaper Universal rotary
retreatment system & repreparation of the canal accomplished with ProTaper Universal rotary instruments: The
operating time was recorded. Teeth were rendered transparent for the evaluation of the area of the remaining GP/
sealer in bucco-lingual & mesio-distal directions. Statistical analysis was performed by using repeated measures
analysis of variance & ANOVA.
Results: The ProTaper Universal technique (Group c) resulted in a smaller percentage of canal area covered by
residual GP/sealer than in groups A& B.Conclusions:In this laboratory study all the techniques left GP/sealer
remnants within the root canal. The ProTaper Universal rotary retreatment system proved to be an efficient
method of removing GP & sealer from root canals.
INTRODUCTION
The primary reason for a negative outcome
following root canal treatment is the persistance
of bacteria within the intricacies of root canal
system. Root canal retreatment aims to eliminate
or to subtantially reduce the microbial load from
the root canal.Complete removal of the root filling
enables effective cleaning,shaping and filling of the
root canal system.Various hand and rotary
instruments have been used for gutta-percha(GP )
removal,including endodontic hand files,engine
driven rotary files,ultrasonic tips and files,solvents
and heat carrying instruments. More recently,
ProTaper Universal System including shaping,
finishing and retreatment files has been introduced
for this purpose.
1
ProTaper retreatment files are designated as
D1,D2 &D3, They are available in
16mm(D1),18mm(D2) and 22mm(D3) for
guttapercha removal from coronal third,middle
third and apical third of the canals respectively.The
tip diameter for D1,D2,D3 are 0.30mm,0.25mm
Original Research
43
43
and 0.20mm and their tapers are 9%,8%,&7%
respectively.While others have non cutting tips,D1
has working tip for initial penetration into the root
canals.All three are convex in cross section.
1
AIMS AND OBJECTIVES
The aim of this study was to evaluate the
efficacy of Pro-Taper Universal rotary system for
guttapercha removal from root canals.
Thirty extracted human maxillary anterior
teeth of similar tooth length were collected from
the department of Oral surgery ,P.M.N.M Dental
College ,Bagalkot.The teeth with single straight
canal and size of apical foramen not greater than
no 15 K file were selected for standardisation of
the study.
Initial root canal treatment: (Fig 1 & 2)
Modified step back flare technique is used.i.e.
Flaring the cervical third with GG 1-3(Dentsply
Maillefer).Cleaning and shaping was carried out
by sequential use of K-files upto size 30,followed
by step back procedure in 1mm increment to a
file size of 50.Frequent irrigation with 3% sodium
hypochlorite and RC Prep was used for removal
of smear layer.A working length 15mm was
established in all teeth
Obturation: (Fig 3 & 4)
Teeth were obturated with GP and AH-Plus
sealer and cold lateral compaction method and
stored at room temperature for 30 days
Endodontic retreatment
Teeth were randomly divided into three
groups
Group A: Hedstrom files and xylene,with
further canal preparation using K-flex files.Removal
of the root filling materials is accomplished in the
following way.Coronal flaring with 3-1 GG
drills,followed by H-files #30,#25,#20 in a crown
down manner.Root canal refining was
accomplished with K-flex files with apical
enlargement to size till 35 and step back till #50.
(Fig-5 &6)
Group B: H-files with xylene, further canal
preparation with ProTaper shaping & finishing
files.SX,S1,S2 are used in a brushing motion till
working length is reached. (Fig 7 & 8)
Group C:
GP removal with ProTaper retreatment files
followed by repreparation with ProTaper shaping
and finishing files. Rotary files D1,D2 and D3 are
used in a circumferential manner to reach the
working length. (Fig 9 & 10)
Brushing motion,350-500 rpm are used.
Repreparation accomplished with ProTaper
shaping and finishing instruments at 300 rpm
EVALUATION
CLEARING TECHNIQUE: (Fig 11a,11b,11c)
Teeth were rendered transparent by the
following technique:Decalcification in 5% nitric
acid for 7 days, dehydration in ethanol 85%, 90%,
99%, successively for 12 hrs, 1hr, & 3hrs
respectively.Then the teeth were cleared using
methyl salicyclate solution.The specimens are
observed under Stereomicroscope (at 10x
magnification) and photographs are taken.
Sealer and/or GP and the area of canal in each
1/3
rd
of canal is measured using Image J 1.42a/Java
1.6.0-10 Image analyser software.The ratio of
sealer/GP to the area of canal is then calculated.
SANDHYA U. M., MOHAN THOMASNAINAN, MANGALA T. M., SHARAD KAMAT
44
44
STEREOMICROSCOPIC PHOTOGRAPHS
(Fig12a,12b,13a,13b,14a,14b)
RESULTS: Table 1 & 2
ANOVA: Table3
F ratio=0.34/0.05 =6.8
F tab =5.49
By observing the actual data it is clear that
Group C is better than other two methods at
P<0.001.
MEAN RATIO OF SEALER OR GP TO AREA
OF CANAL: Graph 1
MEAN OPERATING TIME: Graph 2
ILLUSTRATIONS
Fig 3 & 4- Obturation;
Fig 5 & 6- Materials used for retreament in Group A
Fig 1 & 2 -Initial root canal treatment:
Fig 12a - Coronal one third of the specimen,12b - Middle and
apical thirds in Group A
Fig - 11a,11b,11c Materials used for clearing technique.
Fig - 9 & 10 Materials used for retreatment in Group C
Fig 7 & 8- Materials used for retreatment in Group B
TO TREAT AND TO RETREAT-PROTAPER UNIVERSAL ROTARY SYSTEM, THE DOUBLE DELIGHT
45
45
apical third in Group C
apical third in GroupB
TABLE- 1 MEAN RATIO OF SEALER OR GP
TO AREA OF CANAL
GROUP A GROUP B GROUP C
SAMPLE 1 0.56 O.64 0.34
SAMPLE 2 0.42 0.59 0.47
SAMPLE 3 0.47 1.23 0.46
SAMPLE 4 0.52 1.02 0.23
SAMPLE 5 0.60 1.02 0.37
SAMPLE 6 0.53 0.70 0.20
SAMPLE 7 0.70 0.57 0.29
SAMPLE 8 0.60 0.65 0.43
SAMPLE 9 0.65 0.53 0.33
SAMPLE 10 0.60 0.67 0.29
TOTAL 5.65 7.27 3.57
Mean operating time
GROUP A 10.23 min
GROUP B 10.25 min
GROUP C 10.20 min
MEAN OPERATING TIME
ANOVA: Table3
DEGREE OF SUM OF MEAN OF
FREEDOM EQUATION SQUARES
BETWEEN THE 3-2=1 0.68 0.34
METHODS
METHODS OF 29-2=27 1.36 0.05
ERROR
MEAN RATIO OF SEALER OR GP TO
AREA OF CANAL: Graph 1
MEAN OPERATING TIME :Graph 2
DISCUSSION
A prerequisite for successful non surgical root
canal retreatment is the adequate balance between
complete elimination of the existing obturating
material,thorough chemomechanical preparation
followed by three dimensional obturation with an
impervious seal.This demands for such a
46
46
retreatment technique,which not only uncovers
residual necrotic tissues and bacteria but also
allows further cleaning and refilling of the root
canal system.
Previous studies have shown the persistance
of bacteria in root filled teeth with or without apical
periodontitis.45% of teeth without apical
periodontitis,78% of teeth with AP have been
shown to contain bacteria.
2
Different solvents have been used for GP
removal, like xylene, chloroform, eucalyptol,
rectified turpentine oil, white pine oil. Although
xylene and Chloroform are excellent solvents of
GP, they are proved to be toxic and
carcinogenic.When chloroform dissolution of GP
was compared with rectified white turpentine oil,
rectified white turpentine oil was found to be
equally effective in dissolving GP.But it is more
toxic than chloroform.Chloroform and xylene also
leave a thin film of GP on the canal walls which
reduces the action of intracanal antibacterial
medicaments and impair the adaptation of
subsequent filling material on canal walls.(Wilcox
and Juhlin 1994)
3
Different rotary instruments have also been
used for GP removal like GPX drill,GG drill,
Endotec device. GPX gutta percha remover is used
in slow speed,has H-file like flute design.It removes
GP by plasticizing it with frictional heat.Endotec
is hand spreader which is heated at its tip to 55
degree C.Canal wall cleanliness was greater with
GG followed by H- files, GPX guttapercha remover
& then Endotec where as GPX was the first to reach
WL.
6
Quantec SC rotary instruments have also been
tried but compared with hand files, they have been
proved to be less efficient.
5
Profile 0.04 taper rotary files a were used
previously for removing gutta-percha from root
canals-They were found to be inadequate in
complete removal of GP but could reach WL in
less time.
4
ProTaper finishing files had been used
previously for GP removal .They showed high
incidence of fracture of 22.7%.
ProTaper Universal system
In the present study better performance of
ProTaper retreatment files may be due to,their flute
design which pulls GP out and directs it to the
orifice.Also the frictional heat plasticizes GP and
allows its easy removal. It has also been shown in
studies that apical extrusion of debris is significantly
less compared to hand files. The files not only cut
GP but also superficial layer of dentin during root
filling removal. During this study only D3 was
deformed after use in 5 instruments.
For evaluation of the remaining filling
debris,radiography and longitudinal sectioning of
the teeth have also been used.But in the present
study clearing technique which renders the teeth
transparent is used as it is cost effective and
sensitive enough to identify small area of residual
GP/sealer from the canal walls.
1
CONCLUSION
ProTaper Universal system proves to be
efficient method for removing guttapercha during
endodontic retreatment when compared to other
methods in which hand files and chemical solvents
were used.
REFERENCES
1. L.S.Gu, J.Q Ling, X.Wei andX.Y.Huang, Efficacy of ProTaper
Universal Rotary retreatment system for guttapercha removal
from root canals. International Endodontic Journal, 2008, 41,
288-295
2. A.Molander, C.Reit, G.Dahlen &T.Kvist, Microbiological
TO TREAT AND TO RETREAT-PROTAPER UNIVERSAL ROTARY SYSTEM, THE DOUBLE DELIGHT
47
47
status of root filled with apical radiolucencies.International
Endodontic Journal,1998, 31, 1-7
3. Gary J.Kalpovitz, Evaluation of guttapercha solvents, Journal
of Endodontics,1990,16,539-40
4. F.Baratto Filho, E.L.Ferreira & L.F. Fariniuk, Efficiency of
the 0.04 taper Profile during the retreament of guttapercha
filled root canals, International Endodontic Journal, 2002, 35,
651-654
5. L.V.Betti & C.M.Bramante, Quantec SC rotary instruments
versus hand files for guttapercha removal in root canal
retreatment, International Endodontic Journal, 2001, 34, 514-9.
6. M.Hulsmann & S.Stotz, Efficacy cleaning ability and safety
of different devices for gutta-percha removal in root canal
retreatment,International Endodontic Journal, 1997, 30, 227-
233
7. Xiangya Huang, MS, JunqiLing, PhD, and Lisha Gu, MS,
Quantitative evaluation of of debris extruded apically by using
ProTaper universal rotary system in endodontic retreatment,
JOE-Volume 33, Number 9 September 2007
48
48
Enterococcus faecalis; clinical significance & treatment
considerations
Professor, Department of Conservati ve Denti stry & Endodonti cs, YMT Dental Col l ege & Hospi tal , Kharghar, Navi Mumbai - 410210.
VIBHA HEGDE
ABSTRACT
In the past two decades, research data has shown that, apical periodontitis occurring after root canal treatment
presents a more complex etiologic & therapeutic situation than primary apical periodontitis. The long cherished
goal of endodontic treatment has been to eliminate infectious agents or to substantially reduce the microbial load
from the root canal and to prevent re-infection by root filling. E. faecalis is the most commonly implicated micro-
organism in asymptomatic persistent endodontic infection. The highly complex nature of the organism poses a
great challenge to an endodontist. In this article, the clinical significance of this microbe and various considerations
during treatment are emphasized. Use of good aseptic technique, increased apical preparation sizes and inclusion
of 2% chlorhexidine in combination with sodium hypochlorite are currently the most effective methods to combat
E. faecalis within the root canal systems.
INTRODUCTION
In the past few decades research data has
shown that Apical periodontitis occurring after Root
Canal Treatment presents a more complex etiologic
& therapeutic situation than Primary Apical
Periodontitis. There is a universal consensus that
intra-radicular infection is an essential cause of
primary as well as a major contributor of post
treatment apical periodontitis. Enterococcus
faecalis is the most commonly implicated micro-
organism in asymptomatic persistent infections. The
highly complex nature of the organism poses a great
challenge for endodontists [1, 2].
It was the purpose of this article to understand
the clinical significance of E. faecalis in primary &
secondary endodontic infections and to reinstate
current approaches & treatment modalities towards
combating E. faecalis from root canal system.
NATURE & CHARACHTERISTICS
Enterococcus faecalis is Gram positive cocci
that occur singly in pairs or in short chains [Table
1]. It is a facultative anaerobe present in small
proportion of the flora of untreated canal as a part
of polymicrobial flora. It is a predominant bacteria
implicated in root canal failures & persistent
infections [3, 4, 5]. In post treatment apical
periodontitis the prevalence ranges from 24% to
77% [6, 7].
E. faecalis has an ability to survive harsh
environments including extreme alkaline pH, salt
concentrations. It resists bile salts, detergents, heavy
metals, ethanol, azide & desiccation. It can survive
a temperature of 60C. The prevalence of E.
faecalis in primary endodontic infection is 40% and
in Persistent endodontic infection 24 to 77% [7, 8].
Original Research
49
49
SURVIVAL & VIRULENCE FACTORS
E. faecalis endures prolonged period of
nutritional deprivation. It binds to dentin and
proficiently invades dentinal tubules [9]. It alters
the host response and suppresses the action of
lymphocytes. It possesses lytic enzymes, cytolysin,
aggregation substance, pheromones and
lipoteichoic acid [10]. It utilizes serum as the
nutritional source. It resists intracanal medicaments
i.e. calcium hydroxide by maintaining pH
haemostasis.
Properties of dentin lessen the effect of sodium
hypochlorite, chlorhexidine & iodine potassium
iodide. It can colonize root canal and survive
without the support of other bacteria and competes
with other cells. It forms a biofilm that renders it
more resistant to phagocytosis, antibodies &
antimicrobial agents [11].
ANATOMIC CONSIDERATIONS
Enterococcus faecalis is known to colonize
dentinal tubules, isthmus, rami, lateral & accessory
canals. As shown by the LCSM (Laser Confocal
Scanning Microscopy) & SEM (Scanning Electron
Microscopy) analysis, Enterococcus faecalis
penetrates the dentinal tubules to the depth of
1483.33 m (nutrient rich aerobic condition)
1166.66 m (nutrient rich anaerobic condition) 620
m (nutrient deprived anaerobic condition). It is
present as mushroom shaped micro colonies [10].
TREATMENT CONSIDERATIONS FOR
ERADICATION OF E. FAECALIS
The long cherished goal of endodontic
treatment has been to eliminate infectious agents
or substantially reduce the microbial load from the
root canal. [Fig. 1-3]
PRE-TREATMENT STEPS
The patient should rinse with chlorhexidine
before we enter the root canal space.
Application of rubber dam is mandatory. The
tooth & the rubber dam should be disinfected with
chlorhexidine & sodium hypochlorite.
CLEANING & SHAPING
Current concepts focus to prepare the apical
portion of the root canal to a larger instrument size
which will facilitate removal of microorganisms,
which otherwise will not be accessible by small
MAFs (master apical file) [12]. Larger preparations
facilitate removal of the innermost pulpal dentin
which in turn removes intratubular dentin to allow
antimicrobials to penetrate more effectively [13].
Apical patency of the foramen must be checked to
allow irrigants to circulate & vent outwards of the
canal [14]. In re-treatment cases, use of chloroform
solvent & apical enlargement two sizes larger than
original MAF showed significant reduction in
cultivable microorganism [15].
ROOT CANAL IRRIGANTS
1. Sodium hypochlorite.
Sodium hypochlorite is an effective irrigant for
all presentations of E. faecalis including its existence
as biofilm [16]. 0.5 % to full strength of sodium
hypochlorite if used in adequate amounts &
exchanged regularly has the capability to destroy
E. faecalis [17]. Presence of increased amount of
organic material increased resistance to
medicaments at different physiological growth
stages of E. faecalis. Organisms in stationary phase
were found to be more resistant to medicaments
than those in the growing phase. Cells in starvation
phase exhibited maximum resistance to
medicaments and root canal irrigants. Starved cells
VIBHA HEGDE
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survived maximum after challenge with
chlorhexidine, sodium hypochlorite and calcium
hydroxide [18].
2. Chlorhexidine
Chlorhexidine has been shown to be a potent
broad spectrum antimicrobial that is effective
against Gram +ve & Gram ve organisms. 2% gel
or liquid concentration is effective at reducing or
completely eliminating E. faecalis from canal space
& dentinal tubules (upto 100 m) depth & contact
of 15 secs [19].
3. MTAD [Tulsa Dentsply]
MTAD (a mixture of tetracycline isomer, acid
and detergent) is a formulation of doxycycline,
Tween- 80, and citric acid. Its effectiveness is
attributed to its anticollagenase activity, low pH &
ability to be gradually released over time. It is highly
effective against E. faecalis, superior to NaOCl and
beneficial for re-treatment. Doxycycline & Citric
acid exhibits antimicrobial & acid etching
properties [20, 21].
4. COMBINATIONS
Calcium hydroxide & camphorated
paramonochlorophenol can completely eliminate
E. faecalis. Metapex [Calcium hydroxide & 38%
iodoform] provides effective disinfection than when
calcium hydroxide used alone. 2% chlorhexidine
& calcium hydroxide achieve pH of 12.8 and can
completely eliminate E. faecalis. However,
chlorhexidine alone is more superior to this
combination. Tween-80 itself has limited
antibacterial properties and is known to enhance
antibacterial properties of other substances.
However, it may neutralize antibacterial properties
of chlorhexidine & Povidone Iodine.
5. MTAD & CHLORHEXIDINE
DIGLUCONATE with / without CETRIMIDE
Disinfecting agents tested in vitro fail to do so
in vivo due to different components of dentin as
well as other substances in infected root canal can
inhibit antimicrobial activity. MTAD contains
Tween 80 which facilitates penetration of MTAD
into bacterial cell membrane. Synergistic action of
chlorhexidine & cetrixidine killed E. faecalis
effectively & more immediately after contact than
MTAD and chlorhexidine. Dentin delayed
antibacterial property of chlorhexidine in presence
of BSA (Bovine Serum Albumin) [22]. Chlorhexidine
& Cetrimide killed E. faecalis rapidly than
chlorhexidine alone and therefore synergistic action
was observed. Tetracycline shows bacteriostatic
effect by inhibition of cell wall synthesis. Chelating
properties and low pH of citric acid in chasing E.
faecalis is not known.
6. INTRACANAL MEDICAMENT: CALCIUM
HYDROXIDE
E. faecalis is very resistant to calcium
hydroxide because of two reasons. First is the
proton pump which lowers internal pH of the
cell & maintains it, thus pH haemostasis is
maintained. Secondly at pH of 11.5, E. faecalis is
unable to survive, but dentin exhibits inhibitory
effect thereby buffering the pH. Currently calcium
hydroxide utilization technique of delivery &
maintenance needs to be looked upon [23].
SMEAR LAYER REMOVAL
EDTA [ethylene diamine tetraacetic acid]
removes inorganic portion of smear layer allowing
access of irrigants within dentinal tubules, but has
no action against E. faecalis. 10% Citric acid
removes smear layer but less effectively. 0.1%
sodium benzoate & Citric acid can kill E. faecalis.
ENTEROCOCCUS FAECALIS; CLINICAL SIGNIFICANCE & TREATMENT CONSIDERATIONS
51
51
Chlorhexidine & sodium hypochlorite should not
be used together. Chlorhexidine must be used as
inter-appointment irrigant. Biopure MTAD has been
suggested as final rinse [24]. Irrigants do not
penetrate to more than 100 150 microns.
Therefore the mesh of dentinal tubules harbouring
E. faecalis is impossible to reach.
OTHER IRRIGANTS
Ozonated water & stannous fluoride has been
shown to be effective at eliminating E. faecalis.
Superoxidized water inactivates many organisms
responsible for endodontic infections.
Dermacyn [super oxidized water] differs from
others in that it has a neutral pH & shelf life of over
1 year. It is used in medicine as wound cleanser
that has broad spectrum antibacterial properties and
extremely compatible. Studies showed that it has
no ability to prevent growth of E. faecalis. It could
be used as cold sterile solution or surface
disinfectant [24].
CHAIR-SIDE MONITORS
The possibility of monitoring the chair side
bacterial activity is advantageous for the clinician
n beneficial for the total treatment outcome.
Monitoring chair-side bacterial activity provides
advantage for the clinician & beneficial for the
treatment outcome.
1. Polymerase Chain Reaction is faster, more
sensitive & accurate than culturing methods [25].
PCR-based detection methods enable rapid
identification of both uncultivable and cultivable
microbial species with high specificity and
sensitivity. Real-time quantitative PCR (qPCR) and
reverse transcription PCR (RT-PCR) are sensitive
than traditional cultivation in detecting and
quantifying E. faecalis in endodontic infections.
2. Optical spectroscopy detects chair side
presence or absence of E. faecalis [26]. Optical
spectroscopy in conjunction with specific enzyme-
synthetic chromogenic substrate-based medium
allows the early detection of E. faecalis activity
quantitatively and qualitatively, without the need
for additional laboratory based culturing and plating
for cell counting.
OBTURATION OF ROOT CANAL
Long term survival of E. faecalis in obturated
root canals depends mainly on the type of an
endodontic sealer and the microbial gelatinase
activity i.e. the virulence trait of the organism [27].
Chlorhexidine impregnated & Iodoform containing
GP points have shown little inhibitory action against
E. faecalis. AH plus, Grossman sealer, Roths 811
(ZnO based sealers) have shown greatest
antimicrobial activity against E. faecalis.
Roeko seal [silicon based sealer] polymerizes
without shrinkage and renders fluid impermeability
either with cold lateral compaction or warm gutta
percha. Initial antibacterial activity is short term,
exhibits no antibacterial activity.
Real Seal [Resilon] is a synthetic polymer based
root canal filling commercially available as
Epiphany [Pentron, Sybron Endo] was developed
to overcome the GP shortcoming of better
sealability. Preliminary studies have shown
optimistic and encouraging results when comparing
bacterial leakage. However, there is no evidence
to date of sealing abilities of Resilon in apical 1/3
rd
of canal when post space is prepared. There is no
significant difference in bacterial leakage of E.
faecalis after post space preparation in teeth filled
VIBHA HEGDE
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TABLE 1.
Categorization of Enterococcus species and two physiologically related gram
positive cocci based on phenotypic characteristics*
GROUP SPECIES
I. (+) acid formation in mannitol broth E. avium, E. raffinosus
(+) acid formation in sorbose broth E. gilvus, E. saccharolyticus
(-) arginine hydrolysis E. malodoratus, E. pallens
II. (+) acid formation in mannitol broth E. faecalis,
(-) acid formation in sorbose broth E. faecium, E. casseliflavus, E.gallinarum, E. mundtii
(+)arginine hydrolysis
III. (-) acid formation in mannitol broth E. dispar, E. durans, E. hirae,
(-) acid formation in sorbose broth E. ratti
(+) arginine hydrolysis
IV. (-) acid formation in mannitol broth E. asini, E. cecorum, E. sulfureus
(-) acid formation in sorbose broth
(-) arginine hydrolysis
*Adapted From Teixeira & Facklam [29].
Fig 3: Treatment regimens should be aimed at prevention and
elimination of E. faecalis
Fig 1: A. Pre-operative radiograph showing persisting periapical
infection and improper obturation. B. Post operative 6 month
recall showing resolution of periapical radiolucency.
Fig 2: A. Pre-operative radiograph showing post core restoration
with persistent periapical infection. B. Post-operative radiograph
where canal is prepared to full apical extent and obturated. Plan
for post and crown restoration.
CONCLUSION
Current knowledge on the composition of root
canal flora is based on microbial culture
techniques. It is apparent that E. faecalis in
persistent root canal infections remains unclear.
Coaggregation interactions are involved in
establishment and maintenance of biofilms which
play a role in endodontic infections. Adequate
asepsis, instrumentation & use of disinfectants and
irrigants will optimize the chances of targeting E.
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53
faecalis. Continued research awaits newer
challenging measures to combat E. faecalis.
Molecular methods in endodontic
microbiology has widened the taxonomic spectra
of the endodontic flora & is about to herald a new
era of great understanding of complex interaction
among the microbial and host factors. Role of root
canal microbes in apical periodontitis is well
established. Emphasis of treatment procedures
should be with management of problems associated
with control and elimination of infection. Survey
of publications in leading journals of
Endodontology reveals a trend to focus on purely
mechanical aspects of treating the disease. Although
important are impressive technological advances,
sound understanding of etiology & pathogenesis
of the disease is necessary for effective, affordable
clinical management of disease for ultimate benefit
of endodontic patients.
REFERENCES
1. Ras IN, Siqueira JF, Santos KRN. Association Of
Enterococcus Faecalis With Different Forms Of Periradicular
Diseases. J Endod 2004; 30(5): 31520.
2. Kaufman B, Spangberg L, Barry J, Fouad A. Enterococcus
Spp. In Endodontically Treated Teeth With And Without
Periradicular Lesions. J Endod 2005; 31(12): 851-56.
3. Molander A, Reit C, Dahlen G, Kvist T. Microbiological
Status Of Root Filled Teeth With Apical Periodontitis. Int
Endod J 1998;31:1-7.
4. Sundqvist G, Figdor D, Persson S, Sjogren U. Microbiologic
Analysis Of Teeth With Failed Endodontic Treatment And The
Outcome Of Conservative Re-Treatment. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1998; 85:86 93.
5. Baltoh JL Endo 2002; / Distel JW, Hatton JF, Gillespie MJ.
Biofilm Formation In Medicated Root Canals. J Endod
2002;28(10): 689 93.
6. Hancock HH, Sigurdsson A, Trope M, Moiseiwitsch J.
Bacteria Isolated After Unsuccessful Endodontic Treatment
In A North Am Population. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2001;91(11): 57986.
7. Charles H, Stuart, Scott A Schwartz, Thomas B, Cristopher
B. Enterococcus Faecalis: Its Role In Root Canal Treatment
Failure And Current Concepts In Retreatment J Endod
2006;32(2): 93-98.
8. Sedgley C, Buck G, Applebe O. Prevalence Of Enterococcus
Faecalis At Multiple Oral Sites In Endodontic Patients Using
Culture And PCR. J Endod 2006; 32(2): 104-09.
9. Kayaoglu G, Orstavik D. Virulence factors of Enterococcus
faecalis: relationship to endodontic disease. Crit. Rev. Oral.
Biol. Med. 2004; 15 (5): 308 320.
10. Kowalski W, Kasper E, Hatton J, Murray B, Nallapareddy
S, Gillespie M. Enterococcus Faecalis Adhesion, Ace, Mediates
Attachment To Particulate Dentin. J Endod 2006; 32(7): 634-
37.
11. George S, Kishen A, Song K. The Role Of Environmental
Changes On Monospecies Biofilm Formation On Root Canal
Walls By Enterococcus Faecalis. J Endod 2005; 31(12): 867-
76.
12. Card SJ, Sigurdsson A, Orstavik D, Trope M. The
Effectiveness Of Increased Apical Enlargement In Reducing
Intracanal Bacteria. J Endod 2002;28(11): 77983.
13. Yared M, Bou Dagher F. Influence Of Apical Enlargement
On Bacterial Infections During Treatment Of Apical
Periodontitis. J Endod 1994; 20: 535-37.
14. SOUZA, Ronaldo Arajo. The importance of apical
patency and cleaning of the apical foramen on root canal
preparation. Braz. Dent. J. [online]. 2006; 17 (1): 6-9.
15. Scott Edgar, Marshall J, Baumgartner J. The Antimicrobial
Effect Of Chloroform On Enterococcus Faecalis After Gutta
Percha Removal.JEndod 2006;32(12) : 1185-87.
16. Abdullah M, Ng YL, Gulabivala K, Moles DR, Spratt DA.
Susceptibilties Of Two Enterococcus Faecalis Phenotypes To
Root Canal Medications. J Endod 2005;31(1): 306.
17. Siqueira J, Machado A, Silveira R, Lopes H, De Uzeda M.
Evaluation of the effective-ness of sodium hypochlorite used
with three irrigation methods in the elimination of
Enterococcus faecalis from the root canal in vitro. Int Endod J
1997; 30:279 82.
18. Mchugh CP, Zhang P, Michalek S, Eleazer PD. Ph
Required To Kill Enterococcus Faecalis In Vitro. J Endod
2004;30(4): 218 9
19. Vahdaty A, Pitt Ford TR, Wilson RF. Efficacy Of
Chlorhexidine In Disinfecting Dentinal Tubules In Vitro.
Endod Dent Traumatol 1993;9:243 8.
20. Torabinejad M, Shabahang S, Aprecio RM, Kettering JD.
The Antimicrobial Effect Of MTAD: An In Vitro Investigation.
J Endod 2003; 29(6): 400 3.
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21. Krause T, Liewehr F, Hahn C. The Antimicrobial Effect Of
MTAD, Sodium Hypochlorite, Doxycycline & Citric Acid On
Enterococcus Faecalis. J Endod 2007; 33(1):28-30.
22. Portenier I, Waltimo T, Orstavik D. Killing Of Enterococcus
Faecalis By MTAD & Chlorhexidine Digluconate With Or
Without Cetrimide In The Presence Or Absence Of Dentin
Powder Or BSA. J Endod 2006; 32(2): 138-141.
23. Portenier I, Waltimo T, Orstavik D. Susceptibility Of
Starved, Stationary Phase & Growing Cells Of Enterococcus
Faecalis To Endodontic Medicaments. J Endod, 2005;31(5):
380-86.
24. Joshua, Maki J, Babcall J. An In-Vitro Comparison Of The
Antimicrobial Effects Of Various Endodontic Medicaments On
Enterococcus Faecalis. J Endod 2007; 33(5): 567-69
25. Williams J, Trope M, Caplan D, Shugars D. Detection
and Quantification of E. Faecalis by Real-Time PCR (qPCR),
Reverse Transcription-PCR (RT-PCR), and Cultivation During
Endodontic Treatment. J Endod 2006; 32(8): 715-721.
26. Kishen A, Chen NN, Tan L, Asundi A. Chairside Sensor
For Rapid Monitoring Of Enterococcus Faecalis Activity. J
Endod 2004;30(12): 8725.
27. Sedgley C. The Influence Of Root Canal Sealer On
Extended Intracanal Survival Of Enterococcus Faecalis With
& Without Gelatinase Production Ability In Obturated Root
Canals. J Endod 2007; 33(5): 561-66.
28. Munoz H, Lemus G, Florian W, Lainfiesta J. Microbial
Leakage Of Enterococcus Faecalis After Post Space Preparation
In Teeth Filled In Vivo With Real Seal Vs Gutta Percha. J Endod
2007; 33(6): 673-75.
29. Teixeira LM, Facklam RR. Enterococcus. In: Murray PR,
ed. Manual of clinical microbiology, 8th ed. Washington: ASM
Press, 2003:42233.
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An SEM evalution of the type of smear layer produced by
newer rotary instruments and effectiveness of different
combinations of irrigants
SHISHIR SHETTY *
SURESHCHANDRA B. **
* Reader, A.B. Shetty Memori al Insti tute of Dental Sci ences, Mangal ore. * * Formarl y Prof. & HOD & Vi ce Pri nci pal of A.B. Shetty Memori al Insti tute of Dental Sci ences,
Mangal ore, Presentl y Pri nci pal , Prof. & HOD, A. J. Insti tute of Dental Sci ences, Mangal ore
INTRODUCTION
The quality guidelines of the European society
of endodontology identify the elimination of the
residual pulp tissue and the removal of debris as
the main objectives of pulp space instrumentation.
Several researchers have indicated that Scanning
electron microscopes are useful in examining
instrumented pulp space walls within the context
of evaluating the efficacy of different
instrumentation systems. Hand instrumentation has
remained a standard for more than five decades
and continues to be a standard method of pulp
space instrumentation. However more recently
several investigators have demonstrated that rotary
systems using nickel-titanium instruments led to
good results in the instrumentation of pulp spaces.
However little is known about the cleaning efficacy
of these systems. The available endodontic
literature indicates that these rotary systems will in
most cases create a thicker smear layer than manual
instrumentation.
Several investigators have also confirmed to
the extend that the rotary profile system caused a
markedly thicker smear layer than hand
instruments. However there are no studies available
on the newer Protaper instruments marketed by the
Dentsply.
The purpose of this study was that, in the first
phase to evaluate under scanning electron
microscope the type of smear layers produced by
the newer Protaper instruments in comparison to
Original Research
ABSTRACT
The present in vitro study evaluated the smear layer formed with newer Protaper series of rotary instruments in
comparison with the conventional hand instruments and the Profile series of rotary instruments.
The results of the study showed that the Protaper series of rotary instruments caused the maximum amount of
smear layer, followed by the Profile series of rotary instruments. The hand instruments caused the least amount of
smear layer.
The second phase of the study evaluated the efficacy of smear layer removal using different combinations of
irrigants.
The results of the study showed that 3% sodium hypochlorite in combination with 15% EDTA liquid removed the
maximum amount of smear layer, followed by the combination of 3% sodium hypochlorite and GLYDE (EDTA
gel). The smear layer removal was the least, when 3% sodium hypochlorite was used alone.
56
56
the time tested hand instruments. In the second
phase the purpose was to evaluate the efficacy of
different combinations of pulp space irrigants under
scanning electron microscope.
REVIEW OF LITERATURE
Edgar Schafer et al
44
conducted a study to
evaluate the efficacy of manual and automated
instrumentation of root canals with the aid of a
scanning electron microscope. Hand
instrumentation was performed by K- files and H-
files, automated instrumentation was performed
with Kavo Endo Flash device and Profile rotary
systems. Manual instrumentation using Hedstrom
files achieved the best cleaning, followed by K-
Flexo files. While automated Profile systems
brought about the least effective cleaning. The
manual instrumentation and Automated Kavo Endo
Flash resulted in a mostly homogeneous smear
layer, where as rotary Profile system often featured
a thick non-homogenous smear layer.
Ove A. Peters et al
48
evaluated the debris and
smear layer in canals prepared with either Light
speed or Profile rotary instruments. Irrigants used
were Tap water (groupA) and alternating 5.25% of
sodium hypochlorite and 17% EDTA (groupB).
Results showed that neither technique was superior
in removing debris but larger canal preparation with
light speed instrument enabled a more effective
removal of the smear layer in EDTA-Sodium
hypochlorite group.
De Luca M et al
52
conducted a scanning
electron microscopic study to evaluate the smear
layer removal using profile .04 and .06 tapers crown
down instrumentation technique. Results showed
good canal cleanliness only for group A.
Nevertheless a significant difference between the
coronal two thirds and the apical third was found.
Significant statistical differences were found at the
three levels due to the complete lack of chemical
action of the irrigating solution.
MATERIALS AND METHOD
This study was conducted in the department
of conservative dentistry and endodontics.
A.B.Shetty Memorial Institute of Dental Sciences,
Deralakatte, Mangalore, in association with the
department of metallurgy, Indian Institute of
Science, Bangalore.
Thirty freshly extracted caries free human
molars were selected for this study. Teeth had been
extracted for periodontal purposes. None of these
teeth had received endodontic therapy before
extraction. All teeth were stored in containers
containing normal saline at room temperature for
a maximum of 3 days. Teeth were then equally
and randomly distributed among groups. Protocols
in cross infection control as per OSHA regulations
in storing, surfacing and reutilization were
observed.
Infection control protocols for extracted teeth
collected for research purpose: Collection, storage,
sterilization and handling of extracted teeth to be
used for educational purposes were as per the
occupational safety and health administration
(OSHA) and the centre for disease control and
prevention (CDC) recommendation and guidelines.
SPECIMEN PREPARATION
The extracted teeth stored in normal saline
were retrieved; the crowns of all teeth were cut off
at the cement enamel junction with a separating
disc. Only palatal roots of maxillary molars and
distal roots of mandibular molars were selected.
The working length of all teeth was established by
the insertion of an endodontic instrument into the
canal until its tip was visible at the apical foramen
and then 0.5 mm wa substracted.
SHISHIR SHETTY, SURESHCHANDRA B.
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57
INVESTIGATION
AN SEM EVALUTION OF THE TYPE OF SMEAR LAYER PRODUCED BY NEWER ROTARY INSTRUMENTS
AND EFFECTIVENESS OF DIFFERENT COMBINATIONS OF IRRIGANTS
58
58
RESULTS
Results of the study showed that hand
instruments causes the least amount of smear layer,
followed by profile series of rotary instruments.
Protaper rotary instruments caused the maximum
amount of smear layer.
The second phase of the study showed that
3% sodium hypochlorite in combination with 15%
EDTA liquid removed the maximum amount of
smear layer, followed by the combination of 3%
sodium hypchlorite and GLYDE. The smear layer
removal was the least in the sub group in which
3% sodium hypochlorite was used alone.
Table II
MEANS SCORES FOR SMEAR LAYER AT DIFFERENT LEVELS FOR EXPERIMENTAL GROUPS
Method of instrumentation Irrigating solutions Coronal 3
rd
Middle 3
rd
Apical 3
rd
1. Hand instruments a. 3% sodium hypochlorite 1 1 1
b. 3% sodium hypochlorite
+ 15% EDTA liquid 0 0 0
c. 3% sodium hypochlorite
+ GLYDE 0 0 0
2. Profile series a. 3% sodium hypochlorite 1 1 1
+ GLYDE 1 1 1
3. Protaper a. 3% sodium hypochlorite 1 1 1
+ GLYDE 1 1 1
Table I
MEAN SCORES FOR CONTROL GROUP
Method of instrumentation Irrigating solution 1 set II set III set
1. Hand instruments Normal saline 1 2 1
2. Profile series Normal saline 1 2 2
3. Protaper Normal saline 2 2 2
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Table V
OVERALL COMPARISON AMONG SUB
GROUPS IN THE CONTROL GROUP
USING KRUSKAL WALLIS TEST
H P SIGNIFICANCE
5.667 0.0588 N.S.
N.S. = NOT SIGNIFICANT
Table V A
INTER COMPARISON BETWEEN SUB
GROUP A AND SUB GROUP B USING
MANN WHITNEY U TEST
Z P SIGNIFICANCE
-1.106 .269 N.S.
Table V B
GROUP A AND SUB GROUP C USING
MANN WHITNEY U TEST
Z P SIGNIFICANCE
-2.345 .019 SIG
Table V C
GROUP B AND SUB GROUP C USING
MANN WHITNEY U TEST
Z P SIGNIFICANCE
-1.438 .138 N.S.
Table IV
CONTROL GROUP
MEAN AND STANDARD DEVIATION
VALUES FOR SMEAR LAYER PRODUCED
IN THE CONTROL GROUP
Sub Groups Mean Standard Deviation
Sub Group A 1.33. .52
Sub Group B 1.67 .52
Sub Group C 2.00 .00
EXPERIMENTAL GROUP
Table V I
MEAN AND STANDARD DEVIATION
VALUES FOR EXPERIMENTAL GROUP
Sub group A Sub Group B Sub Group C
Groups Mean Std. Dev. Mean Std. Dev Mean Std Dev.
Group II 1.00 .00 .00 .00 .00 .00
Group III 1.00 .00 .33 .52 1.00 .00
Group IV 1.00 .00 .33 .52 1.00 .00
TABLE VIII
OVERALL COMPARISON AMONG SUB
GROUPS IN INDIVIDUAL GROUPS USING
KRUSKAL WALLIS TEST
GROUPS H P SIGNIFICANCE
Group II 17.00 0.0002 VHS
Group III 9.714 0.0077 HSIG
Group IV 9.714 0.0077 HISIG
VHS : VERY HIGHLY SIGNIFICANT
HISIG = HIGHLY SIGNIFICANT
CONTROL GROUP
Group1. Instrumented with Protaper, Irrigated with Saline
Group1. Instrumented with Profile Series, Irrigated with Saline
Group 1. Instrumented with hand instruments, Irrigated with saline
60
60
Group 2. Instrumented with Hand Instruments, Irrigated with
3% Sodium Hypochlorite + 15% EDTA Liquid
Group 3. Instrumented Profile Series, Irrigated with
3% Sodium Hypochlorite + 15% EDTA Liquid
Group 3. Instrumented with Profile Series, Irrigated with
3% Sodium Hypochlorite
3% Sodium Hypochlorite + EDTA Gel (Glyde)
Group 3. Instrumented Profile Series, Irrigated with
3% Sodium Hypochlorite + EDTA Gel (Glyde)
3% Sodium Hypochlorite
Group 4. Instrumented with Protaper Irrigated
with 3% Sodium Hypochlorite
Group 4 Instrumented with Protaper, Irrigated
with 3% Sodium Hypochlorite + EDTA Gel (Glyde)
Gold Sputtering Machine
Scanning Electron Microscope
Specimen after Gold Sputtering
Group 4. Instrumented with Protaper
irrigated with 3% Sodium Hypochlorite + 15% EDTA Liquid
61
61
DISCUSSION
Pulp space preparation has clear and well-
defined goals; to eliminate all pulp tissue, necrotic
debris, or microorganisms and to smoothen, shape
and enlarge the pulp space to converge in a three
dimensional obturation. Pulp space preparation
today is said to be carried out more efficiently, more
predictable with the rotary versions than with the
conventional hand instruments. Clinical
documentation and in vitro studies have to some
extent significantly put forward the advantages of
using rotary versions that do not come under the
conventional ISO standardized endodontic
instruments. Clinical experience has indicated that
the preparations resulting from rotary versions are
faster and more predictable. However long standing
clinical trails are yet to be made available to
endodontists as far as the efficacy of these rotary
versions are concerned.
The endodontic smear layer was recognized
some years ago and the clinical endodontists and
researchers have been trying to understand the
relationship between the presence of this layer and
the success of pulp space therapy.
De Luca M et al
52
studied the efficacy of smear
layer removal using profile .04 and profile .06 taper
rotary instrumentation; a scanning electron
microscopic study. It was observed the profile
nickel titanium rotary instrumentation produced
moderate to heavy smear layer which needed to
be removed with conservative use of EDTA and
sodium hypochlorite solutions.
Edgar Schaffer et al
44
studied the efficacy of
manual and automated instrumentation of root
canals under scanning electron microscope. They
observed that the smear layer is a surface film of
thickness 1-2 micrometers that remains on the pulp
space wall after instrumentation. No smear layers
were found on areas, which were not instrumented.
The smear layer is said to contain dentin particles,
residual vital, or necrotic pulp tissue, bacterial
components and it clogs up the opening of dentinal
tubules. In this way a thick and non homogenous
smear layer on one hand prevents the desired
efficient elimination of the intra canal micro
organisms and on the other hand might present an
obstacle to the complete sealing of the root canal.
Therefore it is recommended by several clinicians
that irrigants with antibacterial effects / or chelating
agents to remove debris as well as the smear layer
be used. To date sodium hypochlorite is the most
accepted canal irrigant due to its antibacterial
efficacy and its tissue dissolving capabilities.
Studies have indicated that sodium hypochlorite is
not an efficient smear layer remover. The regimen
of sodium hypochlorite and EDTA solutions have
been advocated to effectively remove soft tissue
remnants as well as organic and inorganic smear
layer.
Michael S. et al
46
studied the smear layer
removal using different salts of EDTA. All solutions
used were adjusted to ph7 sodium hypochlorite
was used in combination. Bekir Oguz et al
26
evaluated the efficacy of smear layer removal with
different concentrations of EDTA solutions and
inferred that the best results can be obtained after
irrigation with 10 ml of EDTA followed by 10 ml
of sodium hypochlorite solutions. The ability to
effectively clean the Endodontic space is dependent
on both instruments and irrigation. Endodontic
instruments in themselves vary in their debris
removal efficacy due to their specific flute design.
It has been demonstrated that rotary crown down
62
62
technique is very effective, creates predictable
shaping with significantly less time than
conventional technique. The rotary versions create
a smooth funnel formed shape with the orifice
shaper used as the first instrument that permits
deeper penetration of needless and irrigating
solutions during early instrumentation phases.
Mader
14
in a scanning electron microscopic
investigation of canal walls was able to measure
the thickness of smear layer and the depth of
penetration into the dentinal tubules.
David Pashley
20
suggested that the smear
layer is a very thin layer and is soluble in acids and
hence the smear layer will not be apparent on
routinely processed specimens examined with a
light microscope.
The scanning electron microscope has been
extensively applied in studying the structure and
development of normal hard tissues, prepared
dentin substrate, enamel substrate, the hybrid layer
and the cavity margins. The scanning electron
microscope has proved a valuable method for
assessment of the ability of endodontic procedures
to remove debris from pulp space. In particular
scanning electron microscope studes have revealed
that a smear layer of primarily calcified debris is
compacted against dentinal walls and into the
dentinal tubules as a result of rasping action of
Endodontic instruments. Presence or absence of
smear layer during pre and post Endodontic
procedures in vitro can be evaluated for research
using scanning electron microscopic studies.
Scanning electron microscopy while very useful
usually induces shrinkage artifacts in the specimens
during processing, unless the specimens are
perfectly infiltrated with resins.
A scanning electron microscopic picture
would indicate to the clinician the applied clinical
knowledge of what is the actual condition of the
smear layer, dentinal tubules, and the root canal
walls after instrumentation with or without
chelating agents and whether it is a desirable
surface for sealing. The clinical significance of
smear layer however remains unknown and
controversial primarily due to incomplete
knowledge of its morphology, composition,
physical and biological properties. Another
important aspect of smear layer is whether or not it
contains bacteria. While there is a prevailing
opinion that it does, there is little or no evidence
to support this contention.
If the smear layer does indeed contain bacteria,
the clinical goals of sterilization of root canal system
dictate its removal D.Rake
29
. Whether the smear
layer should be removed has been the subject of
several investigations; one suggestion is that the
removal of smear layer may contribute to successful
intra canal disinfecting procedures. Removal of
the occluding layer may allow intra canal
antimicrobial agents to penetrate the dentinal
tubules. Another argument in favor of removal is
that the smear layer while composed primarily of
inorganic material may have a significant organic
component including viable bacteria and its by
products.
David Pashley
20
proposed that smear layer
containing bacteria or bacterial products might
provide a reservoir of irritants. Thus complete
removal of smear layer will be consistent with
elimination of irritants in the pulp space system.
It is interesting to observe here that all of the
rotary versions with Nickel titanium advocate
63
63
utilization of these rotary versions of instruments
without manually extirpating the pulp tissue with
hand instruments. During hand instrumentation
extirpation of vital / nonvital / Infected pulp is a
mandatory initial step before attempting to establish
the working length and pulp space preparation and
debridement.
In the profile series of instruments the first
instrument used after the access has been gained
and orifices have been located, is the orifice
shapers, that involves the preparation of coronal
1/3 rd of the pulp space. Hence any infected, vital
or non vital pulp tissue within the pulp space can
manually be pushed into the dentinal tubules and
probably result in a much thicker smear layer in
combination with bacteria and other
microorganisms commonly included in the
endodontic microflora. Similar instrumentation
steps are also used with Protaper series of
instruments also. Michael. S. Connel 2001
46
studying the efficiency of EDTA solutions in smear
layer removal stated, that a crown down preparation
technique may tend to allow removal of the
majority of radicular pulp tissue early in the root
canal preparation and increases the volume of the
irrigant in the canal.
However rotary instruments may pack debris
further into the dentinal tubules thus making it more
difficult to remove with irrigation. With nickel
titanium rotary systems it may be necessary to
irrigate with higher final volumes or to allow
irrigants to remain in the canal for longer time to
ensure optimal canal cleanliness. They also
concluded that none of the EDTA solutions used
alone were effective in completely removing the
smear layer. However all solutions of EDTA tested
in combination with sodium hypochlorite were
equally effective at completely removing the smear
layer in coronal and middle thirds. In the present
investigation comparatively thicker smear layers
were produced with Protaper series of instruments
and the Profile series in comparison to the smear
layers produced by the hand instruments. This
group was included as the control group to evaluate
and assess the type of smear layers that would be
produced with different methods of pulp space
preparations. In the control group only saline was
used as irrigant. In the experimental group different
regimens of irrigation were attempted. In all the
three groups three subgroups were created. In the
first subgroup sodium hypochlorite was utilized
while in the second and third sub groups a
combination of sodium hypochlorite + 15% EDTA
liquid and sodium hypochlorite+ 15% EDTA gel
was utilized. All the specimens were subjected to
scanning electron microscopic studies. Evaluation
in all the subgroups of experimental groups was
conducted at coronal, middle and apical third
levels. Scoring for the presence or absence of smear
layer was done based on RONE et al system
16a
Scores for smear layer were given according to
RONE et al system O=No smear layer 1=Moderate
layer outlines of dentinal tubules visible or partially
filled with debris. 2=Heavy smear layer outlines
of dentinal tubules obliterated.
In this investigation when 3% sodium
hypochlorite was utilized alone, we could record
a score of ONE in RONES scale indicating
inefficient removal of smear layer with all three
types of instrumentation which included
conventional hand instruments, profile series rotary
instruments and Protaper rotary instruments.
64
64
However when 3% sodium hypochlorite was
followed with 15% EDTA liquid in the second
subgroup B a score of ZERO was recorded with
hand instruments at all three levels of evaluation.
While with the Profile series and the Protaper
systems, smear layer were observed only at the
apical third with the score of ONE, While efficient
smear layer removal was observed at both coronal
and middle thirds. In the third sub group C with
individual instrumentation methods when 3%
sodium hypochlorite was followed by EDTA gel a
score of ZERO was recorded with hand instruments
indicating efficient removal of smear layer at all
three levels of evaluation. With the profile series
and Protaper series of rotary instruments, when 3%
sodium hypochlorite was followed by EDTA gel a
score of ONE was recorded at all three levels of
evaluation indicating inefficient removal of smear
layer at all three levels. One possible reason for
inefficient removal of smear layer with both Profile
series and the Protaper instrument even with
combination irrigants is the presence of thicker
smear layers produced by rotary versions than with
hand instruments. Possibly the solution to this
problem could be using larger volumes of sodium
hypochlorite and EDTA and retention of these
solutions in contact with the dentinal walls for a
longer period of time. Michael. S. Connel et al
2000
46
theorised as mentioned before a crown
down instrumentation technique with all its
advantages may still pack debris further into the
dentinal tubules thus making it more difficult to
remove by irrigation. Hence they suggested that
with nickel titanium it might be necessary to irrigate
with higher final volumes or to allow irrigants to
remain in the canals for longer time to ensure
optimal canal cleanliness. De Luca M et al 2001
50
studied the efficacy of smear layer removal using
profile .04 and .06 tapers with the help of scanning
electron microscopic study. They observed a heavy
smear layer in specimens irrigated with saline
group. Their findings are consistent with the results
of the present study and other available studies.
However in the present investigation we had three
specimens in the control group prepared with hand
instruments, Profile series rotary instruments and
Protaper rotary instruments irrigated with normal
saline.
Heavy smear layers were observed in
specimens prepared with Protaper and Profile series
while a comparatively lower score was recorded
with the hand instruments. According to several
studies including SEN.B.H et al 1995
32
, the
elimination of smear layer seems to be of great
importance since it could allow sodium
hypochlorite to penetrate more easily into the
dentinal tubules thus enhancing its bactericidal
action. Moreover clinical endodontists believe that
the endodontic smear laver may affect the sealing
efficacy of root canal obturation acting as a physical
barrier interfering with adhesion and penetration
of sealer into the dentinal tubules. Based on the
result of this and other investigations the average
good cleanliness of the canal was produced by
EDTA and sodium hypochlorite irrigation technique
especially when prepared with hand instruments.
However when 3 % sodium hypochlorite and 15%
EDTA liquid was used as an irrigant with profile
series and Protaper rotary instruments, coronal and
middle thirds had a ZERO score while at the apical
third smear layer was still present. Thicker smear
layers with a score of ONE in the entire area of
pulp space was observed when 3% sodium
hypochlorite was followed by EDTA gel with Profile
65
65
series and Protaper rotary instruments. De Luca M
et al 2001
50
utilized 5% sodium hypochlorite and
17% EDTA and produced smooth canal surfaces
free of pulpal remnants and hard tissue debris.
Possible reasons for better results in their study may
be due to the higher concentrations of sodium
hypochlorite utilized and may be due to the fact
that in all groups they utilized liquid EDTA. Yet
another variation in their study was against the
manufacturers instructions they extirpated the pulp
using a small barbed broach before using orifice
shapers or the subsequent instruments.
However as far as canal cleanliness of the
apical third is concerned De Luca M
50
also
demonstrated a greater amount of superficial debris
confirming the results of previous studies. The
results of the present study are in agreement with
the observations of De Luca M
50
. The previous
studies have also cited challenges to the chemical
cleaning of the apical portion of the root canals.
FRASER 1976
5
suggested that the softening action
of EDTA is confined to the coronal and middle parts
of the canal with the apical dentin remaining
unaffected. This fact is in agreement of the results
of the present study especially when profile series
and protaper rotary instruments were used.
Anatomic complexities and minimal tissue contact
such as within narrow apical space, limit
debridement capabilities of irrigants. It has been
speculated by number of authors that prolonged
contact might overcome this limited action.
However nickel-titanium rotary Instrument, since
is significantly faster than hand filing consequently
tissue chemical contact is shorter and solvent effect
could be reduced.
AHLQUIST. N et al
42
studied the effectiveness
of manual and rotary techniques in the cleaning of
pulp spaces under scanning electron microscope
and concluded that under the parameters of his
study with 5% sodium hypochlorite being used for
irrigation, they could demonstrate significantly less
debris in the apical region using manual filing
techniques. They also observed that the manual
technique employed in their study produced
cleaner pulp space walls than the rotary profile
technique. However the result of their study is not
to be taken too seriously since the authors have
not used a standardized regimen of irrigation. An
additional reason could be inefficient use of
instruments with hand instrumentation results in
no smear layer at all. It is well known and
understood that sodium hypochlorite is not an
efficient smear layer remover. With some
modification in irrigation techniques probably the
rotary instruments like profile series and Protaper
will still be the market leaders in efficient
management of pulp space cleanliness
management.
It is to be observed here that the nickel titanium
rotary instrumentation give practitioners a
redetermined pulp space funnel shaped eliminating
all the tedious step back previously required to
create a tapered pulp space and saving much time
over conventional methods as well.
A continuously tapering, conical funnel
shaped canal with a smallest diameter at the end
point and the largest at the orifice is perceived to
be the most appropriate to filling with gutta percha.
There has been a technological revolution in the
last few years with the wide spread introduction of
mechanical preparation using nickle titanium files,
obturation with sophisticated eated gutta percha
66
66
devices, digital radiographic techniques and
consistently accurate apex locaters. This has been
paralleled by advances in the biology of
endodontology. The nickel titanium files have two
to three times the elastic flexibility of standardized
files. Due to its very low values of modulus of
elasticity they show superior resistance to torsional
fracture due to the ductility of nickel titanium.
The new generation of nickel titanium
endodontic instruments especially the profile series
and the protapers have the potential to shape
narrow curved root canals more effectively.
Deviation from the original curvature of pulp space
can lead to procedural errors like zipping, stripping
and perforations. Unfortunately stainless steel files
tend to create a number of abrasions during
preparations particularly in curved canals including
zips and danger zones. These undoubtedly occur
as a result of the inherent stiffness of the metal,
which is confined by instrument design, and canal
shape. As a consequence new endodontic
instruments and techniques have been introduced
which serve to minimize these risks. More flexible
nickel titanium instruments for use in slow speed,
high torque hand pieces have been developed and
found to be efficient.
Nickel titanium instruments have been in the
market for almost a decade now. However long
standing clinical trials are not forth coming. The
results reflected in this investigation as with most
in vitro studies remain to be confirmed clinically.
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69
Analysis of percentage of gutta-percha filled area using
single cone, continuous wave compaction, Thermafil &
Obtura II in 0.06 taper prepared root canals.
VASUNDHARA SHIVANNA *
PRASHANTH B. R. **
* Professor & H.O.D, * * Post Graduate Student, Dept. of Conservati ve Denti stry & Endodonti cs, Col l ege of Dental Sci ences, Davangere - 577 004.
ABSTRACT
Aim: The objective of the study was to determine efficacy of 4 different techniques to obturate the root canal
prepared to a constant taper of 0.06.
Materials & methods: 40 extracted human maxillary central incisors were prepared using K3 Ni-Ti rotary system
to a constant taper of 0.06 upto size 40 & were obturated with 4 different techniques. Teeth were horizontally
sectioned at 2 & 4mm from apical foramen, analyzed & cross sectional area of canal & PGFA was calculated.
Results: Obtura II group showed significantly higher (p<0.05) PGFA followed by Thermafil compared to other
groups. CWC demonstrated significantly higher PGFA compared to Single cone at 4mm only. Cold lateral
condensation showed least PGFA.
Conclusion: Quality of fillings is compromised in irregularly shaped canals. Thermoplasticized gutta-percha
techniques could be the material of choice to achieve a 3-dimensionsal obturation.
Keywords: Percentage of Gutta percha Filled Area (PGFA); Cold lateral condensation (Single cone); Continuous
Wave of Compaction (CWC); Thermafil; Obtura II.
INTRODUCTION:
The integrity of the root filling in the apical
few millimeters is important because after post-
space only the apical root filling of 3 to 4 mm
remains (Gencoglu 2002). Studies have shown
sealer dissolution may trigger an increase in leakage
along the root fillings overtime (Gencoglu 2003).
So for optimal results, the sealer component should
be kept to a minimum (De Deus 2006).
Ni-Ti rotary instrumentation has gained rapid
acceptance. Lateral condensation is one of the most
frequently used obturation techniques (Christopher
2005). Gutta-percha cones are now produced to
match the taper of canals prepared with .04 or .06
rotary instruments (Ingle 2007).
The warm gutta-percha technique was
promoted by Schilder (1967) (De Deus 2006). E &
Q plus (Meta Biomed Co. Ltd.) is a newly
developed obturation system variant of System B,
works on principle of Continuous wave of
compaction by Buchanan (1996).
Johnson (1978) introduced concept of carrier
based thermoplasticized gutta-percha obturation.
The ThermaFil technique involves the obturation
of the root canal with heated alpha phase gutta-
percha on a carrier.
Original Research
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70
Yee et al. introduced the concept of obturating
root canals using injection-molded thermo-
plasticized gutta-percha which may be used as
primary obturation or as a back-filling.
In light of new instrumentation & obturation
techniques the present study was conducted.
MATERIAL AND METHODS
Instrumentation: Forty extracted human
maxillary central incisors with complete root
formation were collected. Access opening was
done & patency of canal was confirmed by inserting
size 10 file. Straight line access was gained with
LA Axxess SS bur (Sybron Endo). Size 10 K file
was inserted through the apical foramen until tip
was seen under Dental Operating Microscope (Carl
Zeiss) and working length was determined by
subtracting 1mm from this length.
The root canals were instrumented with K3
rotary Ni-Ti file system (Sybron Endo.). Canal was
enlarged up to working length with 0.06 K3

up to
tip size 40 in the presence of an EDTA gel (Glyde,
DENTSPLY) & debris was flushed away with
Sodium Hypochlorite (5.25%). Any tooth in which
canal failed to enlarge or Size 40 file was loosely
bound was discarded from study. Canal was
prepared to a constant taper of 0.06mm/mm, tip
size 40 to standardize the preparation.
Teeth were randomly divided into 4 groups
of 10 teeth each depending on obturation
techniques. Methodological model used in this
study was introduced by Eguchi et. al (1985). No
sealer was used in this study to prevent the
methodological problems such as standardizing the
volume of sealer
Canal filling
Group 1: Cold lateral condensation technique
(Single cone)
An ISO 0.06 (Sybron Endo) matched taper
master gutta-percha cone with an apical diameter
equal to that of last K3 tip size 40 was used to
obturate. Accessory cones were placed laterally.
Group 2: Continuous Wave of Compaction
(CWC)/ Buchanan Technique.
Matched taper (0.06) gutta-percha cone tip
size 40 trimmed 0.5mm short of working length
was put into position. Activated E and Q plus (Meta
Biomed) pen set at temperature of 200
0
was
introduced to a distance 4 mm short of working
length (for 3 sec) & constant pressure was
maintained for 8 10 seconds. Backfilling was
done with E and Q gun.
Group 3: Thermafil (Dentsply Maillefer)
Size of the canal was checked with Thermafil
verifier. Accordingly the correct Thermafil plus
obturators (size 40) was chosen, heated in
Thermaprep oven for 41 sec as per manufacturer
instruction & were introduced into the canal. Plastic
shaft was cut with Thermacut bur.
Group 4: Obtura II (Obtura Spartan, USA)
Once the Obtura II unit had reached the
operating temperature of 200
0
C, gutta-percha was
injected with needle placed 4mm short of working
length. Condensation was done immediately with
Buchanan Plugger 0.04, 0.06 taper (Elements
Obturation System, Sybron Endo.). Process of
backfilling was continued & subsequently
compacted.
VASUNDHARA SHIVANNA, PRASHANTH B. R.
71
71
Obturated teeth were stored for 7 days at room
temperature to ensure setting of all materials.
Sectioning and Analysis
Resin embedded teeth were horizontally cross
sectioned at 2 &4mm from AF using hard tissue
microtome (Leica SP 1600) with continuous water
irrigation to reduce overheating of gutta-percha.
The sections were viewed under Stereomicroscope
(SZX12 Japan) at 50 X & photographed. Using
Image ProPlus Software (USA.) cross sectional area
of the canal and gutta-percha was recorded and
PGFA was calculated. The results were evaluated
statistically by using nonparametric Kruskal-Wallis
ANOVA and Mann-Whitney (p< 0.05).
TABLE NO. 3
Comparison of PGFA between 2 mm and 4 mm within the same group
Study Groups 2 mm 4 mm Mean difference Wilcoxons Signed p-value Significance
Ranks Test
Single Cone 81.38 81.96 0.579 1.886 0.059 NS
Continuous wave 81.55 87.44 5.892 0.153 0.878 NS
of compaction
(CWC)
Thermafil 93.27 95.44 0.522 1.58 0.114 NS
Obtura 97.49 98.01 2.167 1.362 0.173 NS
NS- Non Significant Wilcoxons signed rank test p>0.05
TABLE No. 1
Mean PGFA At 2mm & 4mm from Apical Foramen
STUDY GROUPS At 2 mm At 4 mm
Mean PGFA S.D Mean PGFA S.D
Single cone
(Group 1) 81.38 12.1 81.95 5.32
CWC
(Group 2) 81.55 6.4 87.44 3.63
Thermafil
(Group 3) 93.27 3.15 95.44 2.47
Obtura II
(Group 4) 97.4 0.71 98.01 0.88
S.D- Standard Deviation
Study groups Mean PGFA Kruskal Wallis p-value SIGNIFICANCE SIGNIFICANCE
DIFFERENCE BETWEEN GROUPS
At 2mm 88.42 26.136 0.00 HS I&III, I&IV, II&III, II&IV
At 4mm 90.71 31.242 0.00 HS I&II, I&III, I&IV, II&III, II&IV
TABLE NO. 2
PGFA at 2 & 4mm from AF- Statistical Significance
HS-Highly Significant, p<0.01
ANALYSISOF PERCENTAGE OF GUTTA-PERCHA FILLED AREA USING SINGLE CONE
CONTINUOUSWAVE OF COMPACTION, THERMAFIL & OBTURA II IN 0.06 TAPER PREPARED ROOT CANALS.
72
72
GRAPH No. 1:
COMPARISON OF PERCENTAGE OF GUTTA FILLED AREA (PGFA)
at 2mm & 4mm from AF.
RESULTS
Results of present study (Table 1 & 2) showed
that thermoplasticized injectable gutta-percha
technique Obtura II (Group 4) demonstrated
statistically significant (p<0.01) higher PGFA
compared to all other groups irrespective of 2mm
& 4mm from AF followed closely by Thermafil
(Group 3). Values for Thermafil (Group 3) was
lower than Obtura II (Group) but not statistically
significant. Group 2 (CWC technique) showed
statistically significant (p<0.01) higher PGFA
compared to Group 1(Cold lateral-Single cone) only
at 4mm but not at 2mm. Lateral condensation-
Single cone (Group 1) ranked the lower PGFA
compared to all other groups.
Within the same group for 2mm & 4mm no
significant difference (p>0.05) was seen.
DISCUSSION
This study was designed to quantify the gutta-
percha component on percentage basis in order to
provide a measure of quality. Under the
experimental design of this study there was a
significant difference found in PGFA between 4
groups irrespective of 2mm & 4mm from AF.
Group 4 (Obtura II): exhibited significantly
higher PGFA than the other groups. The results are
in accordance with previous studies (Andrew 1986;
Cheryl 1991; Goldberg 2000). The probable
explanation for results include ability of material
to flow laterally & vertically allowing for
compaction because of its plasticity, providing
excellent surface adaptation ensuring a dense root
73
73
fill. With Obtura II, material was able to replicate
the canal irregularities & give an impression like
reproduction.
Group 3 (Thermafil): showed significantly
higher PGFA compared to Group1 (Lateral
condensation) & Group 2 (CWC) at both 2 & 4mm
from AF. The results are in accordance with
previous studies (Norman 1997; De-Deus 2007;
De-Deus 2006). The Thermafil system uses gutta-
percha in the heated -phase during the obturation
which has excellent viscosity, fluidity & enhanced
adherence replicating the surface of root better &
have fewer voids. Lesser PGFA compared to
Obtura II may be related to anatomic variability of
teeth, striping of gutta-percha from carrier surface
during insertion.
Group 2 (CWC): showed significantly higher
PGFA only with Group 1 (Single Cone) at 4mm.
The results are in accordance with previous studies
(Richard 2000; Wu M-K 2001; Jarret 2004). The
probable explanation includes CWC technique
plasticizes gutta-percha apical to the heat carrier
& compaction pressure moves the gutta-percha
laterally & apically. Insufficient heat transfer to very
apical portion & better filling of cold gutta-percha
(Single Cone) in round canals may be the probable
reasons why similar PGFA was recorded for both
techniques at 2mm. Insufficient apical heat transfer
& inadequate compaction forces may explain why
CWC scored significantly lesser PGFAs compared
to Group 3 & Group 4.
Group 1 (Single cone): demonstrated least
PGFA when compared to all other groups. The
results are in accordance with previous studies
(Kenan 2001; Wu M-K 2001; Christopher 2005).
The probable explanation includes uninstrumented
recesses may not be completely obturated by cold
lateral condensation, inability to replicate the inner
surface of the root canal & folding of gutta-percha
cone at apices.
Despite higher PGFAs with thermoplasticized
obturation techniques, inherent problems exist is
that there may be extrusion of material into apices,
insertion of injection needle may be prohibited in
curved canals.
Present research protocol has several
limitations which includes; void detected may be
of cul-de-sac type & not run from coronal to apical,
gives no information on fluid leakage.
CONCLUSION
1) Thermoplasticized gutta-percha techniques
will be an effective method to fill the canals better
& can reduce sealer component.
2) With CWC sufficient apical heating &
pressure is essential for a good adaptation.
3) Uninstrumented recesses cannot be
completely obturated by cold lateral condensation
of gutta-percha.
Importance of these findings should still be
evaluated in further in-vitro & clinical studies.
References
1. Andrew E, Michanowicz, Mario, Nicholas. Low-
temperature (70
0
C) Injection Gutta-Percha: A SEM
investigation. J Endod, 1986; 12(2):64-7.
2. Cheryl S Budd, Norman Weller, James C Kulild. A
Comparison of Thermoplasticized Injectable Gutta-percha
Obturation Techniques. J Endod 1991 June; 17(6):260-4.
3. Christopher S Lea, Michael J Apicella, Pete Mines, Peter P
Yancich, Harry Parker M. Comparison of the Obturation
Density of Cold Lateral Compaction Versus Warm Vertical
Compaction Using the Continuous Wave of Condensation
Technique. J Endod 2005 Jan; 31(1):37-9.
ANALYSISOF PERCENTAGE OF GUTTA-PERCHA FILLED AREA USING SINGLE CONE
CONTINUOUSWAVE OF COMPACTION, THERMAFIL & OBTURA II IN 0.06 TAPER PREPARED ROOT CANALS.
74
74
4. De-Deus G, E.D. Gurgel-Filho, Magalhaes K. M. &
Coutinho-Filho T. A laboratory analysis of gutta-percha-filed
area obtained using Thermafil, System B and lateral
Condensation. Int Endod J 2006; 39:378-83.
5. De-Deus G, Maniglia-Ferreira, C M, Gurgel-Filho, Paciornik
S, Machado A.C.R, Coutino-Filho T. Comparison of the
percentage of gutta-percha filled area obtained by Thermafil
and System B. Aust Endod J. 2007 Aug; 33(2):55-61
6. Eguchi DE, Peters DD, Hollinger JO. Lorton LA.
Comparison of the area of the canal s-pace occupied by gutta-
percha following four gutta-percha obturation techniques
using Procosol sealer. J Endod 1985; 11:166-75.
7. Goldberg F, Massone E.J, Esmoris M, Alfe D. Comparison
of different techniques for obturating experimental internal
resorptive cavities. Endod Dent Traumatol 2000; 16: 116-21.
8. Gencoglu N, Garip Y, Samani S. Comparison of different
gutta-percha root filling techniques: Thermafil, Quick-Fill,
System B, and lateral condensation Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2002; 93:333-6.
9. Gencoglu N. Comparison of 6 different gutta-percha
techniques (part II): Thermafil, JS Quick-Fill, Soft Core,
Microseal, System B, and Lateral condensation. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2003; 96:91-5.
10. Ingle, Bakland, Baumgartner. Ingles Endodontics 6
th
Edition BC Decker , pp 1022,2008.
11. Jarret IS, Marx D, Covey D, Karmazin M, Lavin M, Gound
T. Percentage of canals filled in apical cross sections- an in
vitro study of seven obturation techniques. Int Endod J 2004;
37:392-398.
12. Kenan Clinton, Van T. Himel. Comparison of a Warm
Gutta-Percha Obturation Technique and lateral condensation.
J Endod Nov 2001; 27(11):692-95.
13. Norman R Weller, Frank Kimbrough, Ronald W Anderson.
A Comparison of Thermoplastic Obturation Techniques:
Adaptation to the Canal Walls. J Endod Nov 1997; 23
(11):703-6.
14. Richard S Smith, Norman Weller, Robert J Loushine, W.
Frank Kimbrough. Effect of varying the Depth of Heat
Application on the Adaptability of Gutta-percha during Warm
Vertical Compaction. J Endod 2000 Nov; 26(11):668-72.
15. Wu M. K., Ozok A R, Wessselink. Sealer distribution in
root canals obturated by three techniques. Int Endod J 2000;
33:340-45.
16. Wu M-K, Kastakova A, Weselink P. R. Quality of cold
and warm gutta-percha fillings in oval canals in mandibular
premolars. Int Endod J 2001; 34:485-91.
75
75
External apical root resorption: Two case reports
ARCHANA J. GILDA *
MOHAN THOMAS NAINAN **
SHARAD KAMAT **
MANGALA T. M. ***
* Postgraduate Student, * * Professor and Head of the Department, * * * Professor and Gui de, * * * * Professor, Department of Conservati ve Denti stry and Endodonti cs,
P. M. N. M Dental Col l ege, Bagal kot.
ABSTRACT
External apical root resorption in permanent dentition is usually pathological. Local factors are the most frequent
causes of resorption, especially excessive pressure and inflammation. Depending upon the type of resorption
and etiology, different treatment regimens have been proposed. Two cases of different etiology but having a
common sequelae are presented. Both cases exhibited pulpal necrosis leading to periradicular lesion and external
root resorption. Non-surgical root canal therapy was performed with the use of calcium hydroxide as an intracanal
medicament. 2% chlorhexidine solution was used as a vehicle. Three month follow up radiograph revealed
adequate repair of resorption site and teeth were obturated. Subsequent follow up after three months showed
complete repair of periradicular and furcation area.
Key words: External apical root resorption, calcium hydroxide, chlorhexidine.
INTRODUCTION
It is a surprising fact that a permanent tooth
throughout life is placed in an environment of
alveolar bone surrounded by very active osteoblasts
and osteoclasts without being approached by any
of these two cell lines under normal conditions.
1
Physiological root resorption is a process
involving resorptive activity followed by periods
of attempted repair. This results in variable tooth
mobility in deciduous teeth before exfoliation. In
contrast, the process of root resorption in the
permanent dentition is usually pathological
resulting in loss of dentin, cementum or bone.
2
Invariably, tooth resorption results from
injuries to or irritation of the periodontal ligament
and/ or tooth pulp. It may arise as sequelae of
traumatic luxation injuries, orthodontic tooth
movement, or chronic infections of pulp or
periodontal structures, neoplastic process,
associatied with systemic diseases and lesions of
idiopathic origin.
The process of tooth resorption involves an
elaborate interaction among inflammatory cells,
resorbing cells, and hard tissue structures.
Frequently, this pathologic condition is difficult to
predict, diagnose and treat.
3
The treatment goal in the external apical root
resorption is to remove or destroy bacteria to allow
healing to take place in the periradicular space.
Calcium hydroxide as an intacanal medicament
best destroys the bacteria. A side effect, however
of using calcium hydroxide for long term is
weakning of the root structure in immature teeth.
In mature teeth, the problem apparently does not
Case Report
76
76
exist.
1
This article presents successful management
of two cases of external root resorption.
CASE REPORTS
CASE I
A 28-year-old male reported to P.M.N.M
dental college and hospital, Bagalkot, with a chief
complaint of fractured maxillary anterior teeth.
The patient gave history of trauma 3 years
back.
Clinical examination revealed a fully dentate
patient with poor oral hygiene. Ellis class III fracture
was noticed in relation to 11, 12, and 21. Thermal
and electric pulp test revealed that teeth were non
vital. Radiographic examination revealed external
root resorption with tooth 21. No periapical
changes seen with 11, 12. (Fig 1-1).
Definitive diagnosis of chronic periradicular
abscess and external root resoption of 21 and Ellis
class III fracture with 11 and 12 was made. Non-
surgical root canal therapy was planned.
The teeth were isolated, an access cavity was
made, working length was established (Fig1- 2) and
biomechanical preparation was completed with
copious irrigation with 2% chlorhexidine. Aqueous
mixture of calcium hydroxide was used as an
intracanal medicament (2% chlorhexidine was
used as vehicle for calcium hydroxide powder).
One month later patient returned
asymptomatic, teeth were flushed with 10ml of 2%
chlorhexidine solution. Teeth were clinically and
radiographicallty evaluated for repair, clinically
there was formation of hard barrier at the root apex,
which was confirmed by radiograph. Radiograph
also revealed good periapical healing and teeth
were then obturated. (Fig1-3), (Fig 1-4).
Patient was recalled after six months for follow
up. Patient returned for follow up after ten months.
Patient was completely asymptomatic and
radiograph revealed complete periapical healing
and repair.(Fig 1-5)
CASE II
A 27-year-old male reported to P.M.N.M
Dental College and hospital, Bagalkot with a chief
complaint of pain in the mandibular left posterior
region.
Patient gave history of pain since 6 months in
46. Clinical examination revealed fully dentate
patient and multiple carious teeth. Deep carious
lesions were evident in relation to 46, 47 and 37.
There was grade II mobility with 46.
Radiographic examination revealed pulpal
involvement with 46 and 47 (Fig 2-1). It also
revealed diffuse area of bone rarefaction around
46 and in the furcation area. Distal root of 46
exhibited external root resorption. Definitive
diagnosis of chronic periradicular abscess and
external root resoption was made.
An access cavity was made under rubber dam
isolation; copious irrigation with 2% chlorhexidine
was done. Closed dressing was given. In the next
appointment working length was established
biomechanical preparation was completed (Fig 2-
2). Aqueous mixture of calcium hydroxide was
used as an intracanal medicament (chlorhexidine
solution was used as vehicle for calcium hydroxide
powder). One month later, patient was
asymptomatic and mobility was also reduced. The
root canal was slowly flushed with 2%
ARCHANA J. GILDA, MOHAN THOMASNAINAN, SHARAD KAMAT, MANGALA T. M.
77
77
chlorhedxidine and again the aqueous mixture of
calcium hydroxide was used as an intracanal
medicament. Patient was recalled after 3 months.
After 3 months patient returned with
completely asymptomatic tooth, which was not
mobile, and radiograph revealed periradicular
Fig 1-1 Preoperative
radiograph showing peri-
apical lesion and external
root resorption with 21.
Fig 1-2 Working length
determination.
Fig 1-3 Master cone
selection.
Fig 1-4 Post obturation. Fig 1-5 Follow up after 10
months.
Fig 2-2 Working length. Fig 2-3 Master cone. Fig 2-4 Post obturation. Fig 2-5 3- Months follow up
radiograph revealing complete
healing
Fig 2-1 Preoperative
radiographa revealing
external root resorption
with distal root and bone
rarefaction in the
furcation area.
healing. The tooth was then obturated (Fig 2-3),
(Fig 2-4)
Patient was recalled after 3 months for follow
up examination; radiograph revealed complete
healing of periradicular and furcation area. (Fig2-5)
DISCUSSION
External root resorption seems to be a relatively
common incidental radiographic finding in isolated
teeth, but less common in a generalized form. Local
causes are thought to be the most frequent causative
factor, notably excessive pressure from orthodontic
treatment or chronic inflammatory process.
2
External resorption can be classified into 4
categories by the clinical and histologic
manifestations: external surface resorption, external
inflammatory root resorption, ankylosis and
replacement resorption. In addition to these four
categories external resorption are often described
according to their location on the tooth: cervix, body
or apex of tooth.
4
Both the cases presented in this article had
external inflammatory root resorption. This
represents the most common type of external root
resorption. Injury to or irritation of the periodontium
from trauma, periodontal infection, caries or
EXTERNAL APICAL ROOT RESORPTION: TWO CASE REPORTS
78
78
orthodontic treatment initiates an inflammatory
response within the periodontal ligament and leads
to resorption. The most common cause of external
root resorption is trauma particularly in cases where
the injury results in pulpal necrosis and damage to
the root surface, leaving dentinal tubules exposed.
This creates a communication between the internal
and external surfaces of the root. Bacteria, bacterial
byproducts and tissue breakdown products from
within the root canal system stimulate inflammation
in the adjacent periodontal tissues and lead to
aggressive and progressive inflammatory resorption
of the root.
5
Treatment of external root resorption is
dependent on the etiology. In case where the
resorption is due to pulpal necrosis and periodontal
injury, non-surgical root canal therapy is performed
with the use of calcium hydroxide as an interim
medicament. Complete chemo mechanical
preparation is considered as an essential step in root
canal disinfection. However, total elimination of
bacteria is difficult to accomplish. By remaining in
the canal between appointments, intracanal
medicament may help to eliminate surviving
bacteria.
5
2% chlorhexidine was used as an irrigant, since
it is proved to be more effective against
Enterococcus fecalis than sodium hypochlorite.
Chlorhexidine is relatively non-toxic and does not
dissolve tissue. Since the cases presented in this
article had root resorption, sodium hypochlorite was
not used as it can easily flow beyond the apex and
may cause irritation of the periradicular tissues.
The antibacterial mechanism of chlorhexidine
is related to its cationic bisbigunide molecular
structure. The cationic molecule is absorbed on the
negatively charged cell membrane and cause
leakage of intracellular components. Chlorhexidine
also increases the ph of dentine, and therefore
inhibits the activity of osteoclastic acid hydrolases
in the periodontal tissues and activates alkaline
phophatses.Moreover chlorhexidine if applied to
dentin, binds effectively to hydroxapatite, providing
a lasting reservoir of chlorhexidine after the
completion of treatment.
6
Since its introduction calcium hydroxide has
been widely used in endodontics. It is a strong
alkaline substance, which has pH of approximately
11-13. It also has antimicrobial activity, tissue-
dissolving ability, inhibits resorption and induces
repair by hard tissue formation.
7
A plethora of substances have been used as
vehicle for calcium hydroxide. Vehicles have
different water solubility and ideally must not
change the ph of calcium hydroxide significantally.
Most of the substances used as a vehicle for calcium
hydroxide do not have significant antibacterial
activities. They include distilled water, saline
solution and glycerine.
8
Recently, interest has been focused on the
effectiveness of mixture of calcium hydroxide and
chlorhexidine as intracanal medicament.
Chlorhexidine increases the antibacterial
effectiveness of calcium hydroxide paste.
9
Chlorhexidine combined with calcium hydroxide
had greater antimicrobial activity than calcium
hydroxide mixed with water. It achieves a ph of
12.8 and can completely disinfect the root canal
system.
10
In both the cases successful outcome has been
seen following non surgical root canal therapy with
ARCHANA J. GILDA, MOHAN THOMASNAINAN, SHARAD KAMAT, MANGALA T. M.
79
79
interappointment intracanal medicament of
calcium hydroxide and 2% chlorhexidine as an
vehicle for calcium hydroxide. Complete
disinfection of the root canal system is key to
success in treatment of external inflammatory
resorption.
REFERENCES:
1. Ingle, Bakland, Baumgartner: Pathologic tooth resorption.
Ingles Endodontics 6
th
edition, BC Decker inc 2008,pg
no1358.
2. J.M.Armas, L.Savarrio and L.M. Brocklebank: External apical
root resorption: two case reports. Int Endod J 2008; vol
41,997-1004,.
3. David E Witherspoon, James L Gutmann: Tooth resorption.
Quint Int 1999; vol 30, no1, 9-25.
4. Maurice. N Gunraj: Dental root resorption. Oral surg Oral
med Oral pathol vol 1999;88,no6, 647-654.
5. Zvi Fuss, Igor Tsesis, Shaul Lin: Root resorption- diagnosis,
classification and treatment choices based on stimulation
factors. Dental Traumatol 2003; vol 19,175-182.
6. Z.Mohammadi and P V Abott: The properties and
application of chlorhexidine in endodontics. Int Endod J
2009;vol 42, 288-302.
7. J.F.Siqueira Jr and H.P. Lopes: Mechanism of antimocrobial
activity of calcium hydroxide: a critical review. Int Endod J
1999; vol 32,361-369.
8. L.R.G.Fava and W.P.Saunders: Calcium hydroxide pastes:
classification and clinical indications. Int Endod J 1999; vol
32, 257-282.
9. Siqueira J F Jr, Paivass, Rocas IN: Reduction in the cultivable
bacterial populations in infected root canals by a
chlorhexidine based antimicrobial protocol. J Endod 2007;vol
33,541-547.
10. Charles. H.Stuart, Schwartz, Thomas. J. Beeson:
Enterococcus fecalis : its rple in root canal treatment failure
and current concepts in retreatment. J Endod 2006; vol 32,no-
2, 93-98.
EXTERNAL APICAL ROOT RESORPTION: TWO CASE REPORTS
80
80
Endodontic treatment of mandibular second premolar with
three root canals using dental operating microscope
* Dean and Head, * * P. G. Student, Dept. of Operati ve Denti stry, Facul ty of Dental Sci ences, IMS, BHU. # H No. A- 119, Bri j Encl ave, Sunderpur, Varanasi , U.P. # # 19- Ol d
doctors PG hostel , IMS, BHU. Varanasi , U.P.
NEELAM MITTAL *#
SURAJ ARORA **##
ABSTRACT
Mandibular premolars are one of the most difficult teeth to treat endodontically because of the variations in root
canal anatomy(1). There are only a few endodontic publication citing an incidence of mandibular 2
nd
premolar
with 3 root canals. Thorough knowledge of the basic root canal morphology as well as the possible anatomic
variations is important for the successful treatment of such cases. This article describes the successful endodontic
treatment of mandibular 2
nd
premolar with 3 root canals treated with the help of operating microscope in a patient
with more than two canals also in the contralateral side second premolar.
Keywords: Mandibular 2
nd
premolar, three root canals, dental operating microscope.
The success of endodontic treatment depends upon thorough debridement and complete obturation of the entire
root canal system. For this the knowledge of roots and root canal morphology as well as the possible anatomic
variations becomes very important (2,3).
The canal morphology of mandibular 2
nd
premolar can be very complex and variable. Different studies have
looked at the root canal morphology of mandibular premolars over years and reported a fairly high percentage of
these teeth to have more than one canal.(4-6) Zillich and Dowson (7) have reported that an incidence of 0.4% of
mandibular second premolars with three canals. Vertucci(8) does not report any case of mandibular second
premolar with three or more canals at the apex. The incidence of three roots is extremely rare (0.1%). Such
anatomic variations are quite possible and shouldnt be thought of as exceptional. Dental operating microscope,
with its magnification and illumination helps in the easy detection of hidden canals and allows a more detailed
vision of the internal root canal system. With the use of microscope the success rate has definitely increased in
the recent past. This article describes the successful endodontic treatment of mandibular 2
nd
premolar with three
root canals with the help of dental operating microscope.
CASE REPORT
A 20 years old female patient with a non
contributory medical history reported to our
hospital with a chief complaint of pain in right
lower posterior region, she had the history of
endodontic treatment on tooth #29 by a general
practioner 1 year previously.
Clinical examination revealed a gutta percha
cone in the pulp chamber of tooth #29 with a small
access cavity prepared. The tooth was tender on
percussion and painful on palpation. A
preoperative radiograph of the involved tooth was
done and showed incomplete root canal treatment
of tooth #29 with a periapical radiolucency (fig.1).
Case Report
81
81
Fig. 1 : Periapical radiograph of #29 showing incomplete
obturation and periapcal radiolucency.
Radiograph examination revealed a complex
root canal system, evidenced by sudden change in
the radiographic density of the root canal space at
the middle of the root. More than two root canals
were suspected. A diagnosis of acute exacerbation
of chronic periradicular periodontitis was made. A
perapical radiograph of the contralateral side also
showed more than two root canals in tooth #20
(fig.2).
Fig. 2 : Periapical radiograph of #20, suspecting more than
two root canals
Non surgical endodontic treatment was
planned in tooth #29 over two visits with calcium
hydroxide as interappoinment, intracanal
medicament. A surgical operating microscope was
used for the treatment.
After the administration on local anaesthetic
(2% lignocaine with 1:100000 epinephrine) under
rubber dam isolation, previous root canal filling
was removed in #29 using endosolv-E (Septodont,
Paris, France) and C+ files (Maillefer Boillagues,
Switerzerland). Access cavity was widened and it
was found that main canal split into three different
canal orifices at the midroot level. Mesiobuccal,
distobuccal and lingual canals were identified
(fig.3).
Fig. 3 : Three root canal orifices as viewed under
operating microscope
Gates glidden drills were used in a crown
down method to enlarge the main orifice to the
level of trifurcation for a straight line access to all
the three canals.
Irrigation as done using 5.25% sodium
hypochlorite. Working length was estimated using
an apex locator (Tri Auto ZX, J.Morita Inc).
Fig 4 : Working length confirmed using periapical radiograph
A radiograph was taken using K files after the
canals had been instrumented to an apical 20 size
(fig.4). All the canals were cleaned and shaped
NEELAM MITTAL, SURAJ ARORA
82
82
using K files and rotary protaper files (Dentsply).
(fig.5)
Fig 5 : Magnified view under operating microscope
Calcium hydroxide was used as intracanal
medicament for 2 weeks and the access cavity was
sealed with IRM.
After 2 weeks the symptoms had subsided.
The calcium hydroxide dressing was removed,
irrigation was done using 5.25% sodium
hypochlorite and 17% EDTA. After drying the
canals with paper points the canals were obturated
using protaper gutta percha points and AH plus
sealer ( Dentsply ) with warm vertical condensation
technique upto the trifurcation level. Backfilling
as done using thermoplasticised gutta percha by
Obtura II. Access was sealed with IRM and a
radiograph was taken after obturation ( fig 6 ).
Fig 6 : Periapical radiograph after obturation.
The patient was recalled after 1 year for clinical
and radiographic examination (fig 7.). The patient
was totally asymptomatic and the tooth had been
permanently restored.
Fig 7 : Periapical radiograph after 1 year
DISCUSSION
The complex nature of root canal morphology
of mandibular second premolar should not be
underestimated. Good quality radiographs taken
at two different horizontal angulations (9, 10) are
very helpful in providing clues about the number
of root canals a tooth can have. Interpretation of
the radiographs is equally important. The root
canals may not be evident radiographically. There
may be a sudden narrowing of the canal space as
it divides further (11). Careful interpretation of the
PDL space helps in finding extra roots or canals. In
such cases where abberant root anatomy is evident
radiographically and there are chances of finding
additional canals the use of magnification and fiber
optic illumination becomes very important in
locating and treating these additional canals.
An optimum access cavity is absolutely
necessary. Smaller K files (6, 8, 10) are initially used
as they get deviated buccally or lingually as the
main canal divides at the midroot level. So a good
tactile sense is important and the files can be
precurved appropriately before negotiating the
canals. Despite the existence of complex dental
anatomy, shaping outcomes with nickel titanium
instruments are mostly predictable.
ENDODONTIC TREATMENT OF MANDIBULAR SECOND PREMOLAR WITH THREE ROOT CANALSUSING DENTAL OPERATING MICROSCOPE
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83
Efforts should be made to locate the point
where the root or the canals divide. The more
apically a root canal divides, the more difficult is
the case. During obturation of this type of root canal
system it is highly important the canals remain
patent through the apically compacted gutta purcha
with a file or with a spreader of suitable taper while
each canal is being obturated.
CONCLUSION
Successful and predictable endodontic
treatment requires knowledge of biology,
physiology and root canal anatomy. It also requires
proper instruments and the knowledge to use these
instruments effectively. Radiographs and
magnification devices are an important tool in
diagnosing and treating such complicated cases.
REFERENCES :
1. Slowey RR. Root canal anatomy: road map to successful
endodontics. Dent Clin North Am 1979; 23:555-73.
2. Krasner P, Rankow HJ. Anatomy of the pulp chamber floor.
J Endod 2004; 30:5-16.
3. Rodig, Hulsmann M. Diagnosis and root canal treatment
of a mandibular second premolar with three root canals. Int
Endod j 2003; 36:912-9.
4. Barret MT. The internal anatomy of teeth with special
reference to the pulp and its branches. Dental Cosmos 1925;
67:581-92.
5. Amos ER. Incidence of bifurcated root canals in mandibular
bicuspids. J Am Dent Assoc 1955; 50:70-1.
6. England MC Jr, Hartwell GR,Lance JR. Detection and
treatment of multiple canals in mandibular premolars. J Endod
1991; 17:174-8.
7. Zillich R, Dowson J. Root canal morphology of mandibular
first and second premolars. Oral Surg Oral Med Oral Pathol
1973; 36:738-44.
8. Vertucci FJ. Root canal morphology of mandibular
premolars. J Am Den Assoc 1978; 97:47-50.
9. Walton RE. Endodontic radiographic techniques. Dent
Radiogr Phtogr 1973:46:51-9.
10. Fava LR, Dummer PM. Periapical radiographic techniques
during endodontic diagnosis and treatment. Int Endod J 1997;
30:250-61.
11. Yoshioka T, Villegas JC, Kobayashi C, Suda H.
Radiographic evaluation of root canal multiplicity in
mandibular first premolars. J Endod 2004; 30:73-4.
NEELAM MITTAL, SURAJ ARORA
84
84
Management of a large periapical cyst (apical matrix &
surgical complications) - A case report
VERGHESE GEORGE M. * #
GEORGE THOMAS ** #
M. A. KUTTAPPA *** #
GIRISH KUMAR GOVIND **** ##
* Post Graduate Student, * * Professor, * * * Professor & Head of Department, # Department of Conservati ve Denti stry and Endodonti cs, # # Department of Oral & Maxi l l ofaci al
Surgery, Coorg Insti tute of Dental Sci ences, Vi raj pet, Karnataka.
ABSTRACT
The periapical cyst arises from epithelial remnants stimulated to proliferate by an inflammatory process originating
from pulpal necrosis of a non-vital tooth. This condition is usually asymptomatic but can result in a slow-growth
tumefaction in the affected region. Radiographically, the classic description of the lesion is a round or oval, well
circumscribed radiolucent image involving the apex of the infected tooth.
The current concept in management of a periapical cyst is non surgical; However periapical surgeries can be the
treatment of choice in extensive periapical lesions.
INTRODUCTION
A residual dental (or radicular) cyst arises from
epithelial remnants stimulated to proliferate by an
inflammatory process originating from pulpal
necrosis of a non-vital tooth that is no longer
present. The natural history begins with a non-vital
tooth which remains in situ long enough to develop
chronic periapical pathosis such as a dental
(radicular) cyst. Over the years, the cyst may
regress, remain static or grow in size.
8
A case report is presented of an individual with
a large radicular cyst that happened to involve
nearly half of his maxilla.
CASE REPORT
A 12 year old male was referred to the
department of conservative dentistry and
endodontics by a general dental practitioners and
management of a painless swelling in the right
anterior maxillary region. The patient had originally
presented to his dentist with the complaint of a
palatal swelling and broken upper right front tooth.
He gave a history of trauma 2 years back for which
no treatment was sought. Post trauma he had pain
in relation to the upper anteriors which subsided
without medication. He gave a history of swelling
from approximately 1 years along with pus
discharge from gums.
Clinically, there was diffuse palatal swelling (
Fig 1) extending from the right central incisor to
the distal aspect of 2
nd
premolar, the swelling was
fluctuant on palpation which indicated a loss of
integrity of palatal bone, buccally there was a
localized swelling and sinus tract in relation to 13
(Fig 2).
Case Report
85
85
(Fig 2) Localized swelling in
relation to 13
(Fig 1) Diffuse palatal swelling
Hard tissue examination revealed an Ellis Class
II fracture in relation to 11 and the tooth was
Discolored .Vitality Tests were carried out (Heat/
Cold & EPT) which elicited a negative response in
relation to 11,12,13
An occlusal view radiograph (Fig 3) of the
maxilla revealed a well defined periapical
radiolucency (approx 4 cm in diameter) involving
right maxillary anteriors and an open apex in
relation to 11.
(Fig 3) Occlusal view radiograph of the maxilla
From these above clinical findings we reached
a provisional diagnosis of infected radicular cyst
in relation to 11.
The differential diagnosis included
Nasopalatine Cyst
Globulomaxillary Cyst
Dentigerous Cyst
Odonyogenic keratocyst
TREATMENT PLAN
The treatment plan included root canal
therapy with respect to 11, 12 & 13. Surgical
management of the cyst was planned which
included cyst enucleation and apicectomy in
relation to 11.
Treatment options for discoloration in relation
to 11 included walking bleach and a composite
build up or a full coverage restoration.
ENDODONTIC THERAPY
A multivisit endodontic therapy was planned
with respect to 11, 12 & 13. Root canal preparation
and Obturation was carried out uneventfully in
relation to 12 and 13. With respect to 11, a root
end surgical procedure like apicectomy would have
resulted in a compromised crown root ratio. To
overcome this problem we opted not to do
apicectomy and instead, decided to create an apical
matrix using MTA (mineral Trioxide aggregate) to
preserve the existing crown root ratio.
Repeated calcium hydroxide dressings were
given in relation to 11 to obtain a relatively dry
canal and subsequently a custom cone was
prepared. The custom cone was prepared
approximately 3-4 millimeters short of the working
length (Fig 4).
(Fig 4) Radiographic view of custom cone short of
the working length.
VERGHESE GEORGE M., GEORGE THOMAS, M. A. KUTTAPPA, GIRISH KUMAR GOVIND
86
86
(Fig 5) Apical matrix
This custom cone was then used as a plugger
to pack MTA (Pro root MTA, Dentsply Tulsa) into
the apical third and thus produce an Apical Matrix
(Fig 5) against which a thermoplasticized back fill
could be done. The MTA plug was left undisturbed
for a day to allow complete set. Eventually a back
fill was done using thermoplasticized guttapercha
(Elements obturating unit -Sybronendo) (Fig 6).
(Fig 6) Obturation completed in relation to 11
SURGICAL PHASE
For surgical enucleation of the cyst, a buccal
approach was adopted and a full thickness flap was
raised (Fig 7 & 8).
(Fig 7 & 8) Buccal flap raised)
(Fig 9) Cyst enucleation & (Fig 10) Enucleated cyst)
(Fig 11, Immediate post surgical & 1 year follow up radiographs)
Cyst enucleation (Fig 9 & 10) was carried out
in toto. The histopathology report confirmed the
diagnosis of an infected radicular cyst. Immediate
post surgical & 1 yr follow up radiographs are given
below (Fig 11)
Uneventful post surgical healing took place
for a month. However after two months the patient
reported back to us complaining of escape of fluids
through his left nostril whenever he attempts to
drink anything. Clinical examination revealed an
oro nasal communication of approximately 1 cm
diameter (Fig )
(Fig 12) Oro nasal communication
MANAGEMENT OF A LARGE PERIAPICAL CYST (APICAL MATRIX & SURGICAL COMPLICATIONS) - A CASE REPORT
87
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The oro nasal communication was closed
using a modified palatal flap (full thickness flap)
from the contra lateral side of the palate (Fig 13).
The flap was then passed underneath a tunneling
incision for support, approximated and then sutured
into place over the fistula (Fig 14). A gauze dressing
was placed on the raw donor site and secured with
sutures (Fig 15).
(Fig 13) Outline of flap to be raised (Fig 14) Flap secured in
position with sutures
(Fig 15) Gauze dressing in place & (Fig 16) 3 weeks post surgical
(Fig 17) 6 Weeks post surgical & (Fig 18) 3 months post surgical
(Fig 19) Provisional composite restoration done
Figures 16, 17& 18 shows uneventful healing
at intervals of 3 weeks, 6 weeks and 3 months post
surgery.
DISCUSSION
Cysts constitute about 17 percent of the tissue
specimens submitted to oral pathology biopsy
services. The periapical cyst is the most common
odontogenic cyst (52.3-70.7 percent of all
odontogenic cysts) followed by the dentigerous cyst
(16.6-21.3 percent of all odontogenic cysts) and
odontogenic keratocyst, or OKC (5.4- 17.4 percent
of all odontogenic cysts).
9
The choice of treatment
may be determined by some factor such as the
extension of the lesion, relation with noble
structures, evolution, origin, clinical characteristic
of the lesion, cooperation and systemic condition
of the patient .
4
The treatment of these cysts are
still under discussion and many professionals opt
for a conservative treatment by means of
endodontic technique (Hoen, 1990; Rees, 1997).
However, in large lesions the endodontic treatment
alone is not efficient and it should be associated to
a decompression or a marsupialization or even to
enucleation (Neaverth; Burg, 1982; Hoen Et Al.,
1990; Rees, 1997; Danin 1999). In this regard, it is
suggested that the treatment of the apical
periodontal cysts should be defined according to
the clinical and x- ray evaluations according to each
case.
4, 6
Taking into account the patients apprehension
regarding the presence of a swelling and also the
lesions size & extent a surgical procedure was
opted. However in this case a root end resective
procedure would have resulted in a compromised
crown root ratio. Hence a treatment plan was
formulated to create an apical matrix using MTA
88
88
and thus preserve the existing crown root ratio. As
to the fabrication of apical plugs, Torabinejad and
Chivian (1999) recommended carrying the MTA
with a large amalgam carrier to the root canal and
then condensing the material to the apical end of
the root with pluggers or paper points.
1
MTA, when
used as a root-end filling material, showed evidence
of healing of the surrounding tissues. Studies have
shown that osteoblasts have favorable response to
MTA as compared to IRM and amalgam. With
longer duration, new cementum was found on the
surface of the material.MTA is a widely accepted
retrograde filling material which is biocompatible,
has antibacterial action and reduces
microleakage.
5,10
MTA plugs of four-millimeter-
thickness have been shown to be the most efficient
with respect to root canal sealing ability and
resistance to displacement.
1,3
The endodontic treatment was carried out in
multiple visits with interim calcium hydroxide
dressings.
The use of root canal dressings between
sessions in root canal treatment of teeth with
chronic periapical lesions is important for reducing
bacteria beyond levels obtained with mechanical
preparation, particularly by penetration of areas that
are unreachable by instruments or irrigation
solutions, such as dentinal tubules and
ramifications. Calcium hydroxide has also shown
clinical efficiency in reducing exudate due to its
hygroscopic properties. Takahashi et al,

analyzing
the pH and the concentration of calcium ions in
the periapical area, concluded that at least 2 weeks
are necessary for calcium hydroxide bactericidal
activity.
11
Following the build up of the apical matrix a
backfill was done using Thermoplasticized
Guttapercha (Elements Obturation System,
Sybronendo). The lateral condensation method
using cold gutta-percha may result in voids between
the cones and lack of a homogeneous sealing
mass.
7
Root canal obturation with injec-ted
thermoplasticized gutta-percha as a backfill
introduced by Yee et al. has advantages like;
obtaining a homogenous obturating mass and
successfully filling irregularities in the root canals,
while promoting a better apical seal.
2,7
A surgical procedure like enucleation of a
large cyst can result in complications like:
Hemorrhage
Pain And Swelling
Ecchymosis
Infection
In this case it was the formation of an oro
nasal communication or fistula. A modified palatal
flap was used in this case for closure of the fistula.
Successful closure of the fistula is dependant on
the following principles like removal of as much
as epithelial lining of the fistula as possible,
providing a raw surface throughout the periphery
of the wound, maintenance of adequate blood
supply to the flap and causation of minimal trauma
to the pediclled flap.
CONCLUSION
The clinical case reported in this article was
managed successfully by endodontic therapy with
emphasis on thorough debridement, disinfection
and three dimensional obturation of the root canal
system which was followed by surgery. The authors
recommend non surgical management of large
MANAGEMENT OF A LARGE PERIAPICAL CYST (APICAL MATRIX & SURGICAL COMPLICATIONS) - A CASE REPORT
89
89
periapical lesions in view of clinical evidence
present. However in specific situations where the
size and extent of the lesion is of critical importance
surgery is a viable option with good prognosis. An
endodontist should have thorough knowledge
about materials and various treatment options or
techniques involved in management of such a case.
References:
1. In vitro sealing ability of white and gray mineral trioxide
aggregate (MTA) and white portland cement used as apical
plugs. Coneglian P Z A, Orosco F A, Bramante C M, Moraes
I G De, Garcia R B, Bernardineli N J Appl Oral Sci.
2007;15(3):181-5
2. Apical Leakage of Different Gutta-Percha Techniques:
Thermafil, JS Quick-Fill, Soft Core, Microseal, System B and
Lateral Condensation with a Computerized Fluid Filtration
Meter. Nimet Genolu, Hasan Oruolu ,Dilek
Helvacolu, European Journal of Dentistry, April 2007 ,vol1
pages 97-103
3. The use of MTA in teeth with necrotic pulps and open
apices, Giuliani et al. Dental Traumatology 2002; 18: 217
221
4. Surgical approaches of extensive Periapical cyst.
Considerations about Surgical technique Ribeiro, Paulo
Domingos Jr. et al. Salusvita, Bauru, v. 23, n. 2, p. 317-328,
2004.
5. Advantages of ProRoot MTA in treating periapical lesions.
Clinical cases Girdea et al OHDMBSC - Vol. V - No. 4 -
December, 2006
6. Periapical Cyst Repair After Nonsurgical Endodontic
Therapy - Case Report , Caroline R.A. Valois Edson Dias Costa-
Jnior Braz Dent J (2005) 16(3): 254-258
7. Evaluation of the thermoplasticity of Different gutta-percha
cones and the TC System ,Tanomaru-Filho M, Bier C A S,
Tanomaru J M G, Barros D B J Appl Oral Sci. 2007;15(2):131-4
8. Massive residual dental cyst: Case report George
Dimitroulis, John Curtin, Australian Dental Journal
1998;43:(4)
9. Maxillary odontogenic keratocyst A common and serious
clinical misdiagnosis Mohammad Ali, Ronald A. Baughman,
JADA, Vol. 134, July 2003
10. Review of constituents and biological properties of mineral
trioxide aggregate Camilleri & Pitt Ford, International
Endodontic Journal, 39, 747754, 2006
11. Calcium Hydroxide Root Canal Dressing
Histopathological Evaluation of Periapical Repair at Different
Time Periods Leonardo et al, Braz Dent J (2002) 13(1): 17-22
90
90
Dens evaginatus (talon cusp) of anterior teeth
- A case report
MOKSHA NAYAK *
JITENDRA KUMAR **
KRISHNA PRASAD L. ***
* Pri nci pal , Professor & HOD, * * P. G. Student, * * * Professor, Department of Conservati ve Denti stry & Endodonti cs, KVG Dental Col l ege, Sul l i a (Karnataka).
ABSTRACT
The talon cusp, or dens evaginatus of anterior teeth, is a relatively rare dental developmental anomaly characterized
by the presence of an accessory cusp like structure projecting from the cingulum area or ce-mentoenamel junction.
Commonly dens evaginatus occurs in either maxillary or mandibular anterior teeth in both the primary and
permanent dentition. This article reports a case of talon cusp and its management.
INTRODUCTION
The talon cusp, so named because its shape
resembles an eagles talon, (Mellor & Ripa 1970),
is an uncommon dental anomaly that occurs as an
accessory cusp like structure projecting from
cingulum area or cementoenamel junction of
maxillary or mandibular anterior teeth in either the
primary of permanent dentition
1
. Synonyms of
talon cusp are dens evginatus, interstitial cusp,
tuberculated premolar, odontoma of axial core
type, evaginated odontoma, occlusal anomalous
tubercle, and supernumerary cusp. Maxillary teeth
(94%) are the most commonly involved, among
them maxillary lateral incisors (55%) followed by
maxillary central incisor (33%). Predominantly 65%
of the talon cusps occurs in males
2
. Prevalence of
talon cusp varies considerably among ethnic groups
ranging from 0.06% to 7.7%
1
.
Although this anomalous cusp has not been
reported as an integral part of any specific
syndrome, it appears to be more prevalent in
patients with Rubinstein-Taybi syndrome, Mohr
syndrome (oral-facial-digital syndrome type II ) ,
Sturge-Weber syndrome(encephalotrigeminal
angiomatosis), or incontinentia pigmenti
achromians
3
.
The objective of this article is to report a case
of talon cusp in a permanent maxillary central
incisor that required endodontic treatment and
bleaching along with occlusal correction.
CASE REPORT
A healthy 26-year old male patient reported
to the department of oral and maxillofacial surgery
for extraction but considering restorability of tooth,
patient was referred to the department of
conservative and endodontics. His medical and
dental history was uneventful. No other family
member had similar anomaly. Patient had an
accident 7 years back and had discolored left
central incisor since 3 years (fig.1). Intraoral
examination revealed no soft tissue abnormalities
and absence of any tenderness to percussion or
palpation. Discolored tooth exhibited V shaped
Case Report
91
91
conical prominent cusps on the palatal surface. The
cusp was around 3mm wide (mesiodistally),7mm
(incisocervically) and 3mm thick (labiolingually)
extending from cingulum area to the 0.5mm short
of incisal edge (fig.2, 3). The affected tooth was
labially placed in the arch with occlusal
interferences on talon cusp during occlusion.
Electrical and thermal pulp vitality tests revealed
tooth as a non vital entity. Radiographic
examination showed the presence of enamel,
dentin and pulp horn into talon cusp along with
periradicular changes and rarefaction at periapical
area (fig.4). The diagnosis was talon cusp with pulp
necrosis. Single visit endodontic treatment was
performed (fig.5) followed by intra and extra
coronal bleaching using 35% hydrogen peroxide
(Pola office) (fig.6). Coronoplasty of talon cusp was
performed to remove occlusal discrepancy.
Fig.1 Preoperative facial view with occlusal interference
Fig.2 Preoperative palatal view
Fig.3 Preoperative diagnostic cast depicting talons cusp
Fig.4 Pre operative radiograph
Fig.5 Radiograph showing completed endodontic treatment
Fig.6 Post operative view
MOKSHA NAYAK, JITENDRA KUMAR, KRISHNA PRASAD L.
92
92
DISCUSSION
Talon cusp or dens evaginatus is a rare
anomaly with multifactorial etiology including both
genetic and environmental factors. Various theories
were proposed, however most accepted one
suggests that talon cusp might occur as a result of
an outward folding of inner enamel epithelial cells
and a transient focal hyperplasia of mesenchymal
dental papilla
3, 4
.
Hattab et al classified this anomaly into 3 types
on the basis of the degree of cusp formation and
extension. Type I (talon) has an additional cusp that
projects from the palatal surface of an anterior tooth
and extend at least one half the distance from the
cement enamel junction to the incisal edge. Type
II (semitalon) has an additional cusp 1 mm or more
in length but extending less than one half the
distance from the cement enamel junction to the
incisal edge. Type III (trace talon) manifest enlarged
and prominent cingula and their variation
4
. The
talon cusps described in the current case classified
as type1 (talon). Furthermore it is important to
remember that talon cusp is occasionally combined
with other systemic and dental anomalies
5
.
However, none of these alterations was found in
this case.
Clinically talon cusp differs from dens
evaginatus of posterior teeth. The anterior teeth
undergo shearing forces that may result in
displacement of the occluding teeth and
significantly less fracture of the anomalous cusps
as reported in this case
1
. Lin et al reported pulp
exposure and pulp necrosis in 14.1% to 40.2% of
examined cases due to attrition or trauma
6
.
Developmental grooves and fissures at the junction
of the talon cusp and the tooth sur-faces are more
susceptible to caries, depending on the shape, size
and location of these structural defects, associated
periodontal involvement might occur
5
.
Gungor et al histologically detected presence
of pulp horn in accessory cusp which increases the
chances of pulpal insult and death. Teeth with talon
cusp may undergo pulpal necrosis if early diagnosis
is not done and management is neglected or
inappropriate to the case
5
. The present case was
diagnosed as discolored non vital teeth with talon
cusp.
The treatment of talon cusp may be
conservative or radical, depending on the accessory
cusp like shape, location, size, and tooth affected.
Periodic and gradual reduction of the cusp, with
application of a desensitizing agent, reduction of
cusp with or without endodontic therapy, sealant
application on the grooves, and esthetic restorations
are options of treatment
5
. Single visit root canal
offers several advantages likewise reduced flare rate
(Walton and Fouad 1992), good patient acceptance
and practice management. 70% of dentists treat
necrotic teeth in single visit since it has shown 6.3%
higher healing rate than multiple visits
7
. Bleaching
can improve the appearance of discolored teeth
while preserving tooth structure, and it avoids more
costly invasive dental treatment
8
. Cadenaro M et
al showed in vivo application of 38% hydrogen
peroxide or 35% carbamide peroxide to be
clinically safe and reliable, showing no structural
changes to enamel surface even after four
applications
9
.
Ferraz JAB (2001) advocated that occlusal
interferences of talons cusp can be adjusted by
grinding palatal projections
10
. Similar grinding of
DENSEVAGINATUS(TALON CUSP) OF ANTERIOR TEETH - A CASE REPORT
93
93
talon cusp was carried out in this case.
The treatment objectives for taloned teeth may
differ depending on each case. However large,
prominent talon cusp, as in this case report calls
for definitive treatment to overcome esthetic,
occlusal, periodontal and carious problems.
CONCLUSION
Talon cusp is a not an innocuous defect, as it
may provide a substantial challenge during
diagnosis and treatment planning to clinician. Early
diagnosis may minimize local problems such as
caries, periodontal disease and malocclusion.
References:
1) AI-Omari M.A.O, Hattab F. N, Darwazeh A. M. G. &
Dummer P. M. H. Clinical problems associated with unusual
cases of talon cusp. Int Endod J 1999, 32, 183-190,
2) Abbott P. V. Labial and palatal talon cusps on the same
tooth-A case report. Oral Surg Oral Med Oral Pathol Oral
Radial Endod 1998;85:726-30.
3) H. Cern Gungor, Nil Altay, and F. Figen Kaymaz, Ankara.
Pulpal tissue in bilateral talon cusps of primary central incisors.
Report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2000;89:231-5.
4) Hattab FN. Yassin OM. Al-Nimri KS. Talon cusp in
permanent dentition associated with other dental anomalies:
review of literature and report of seven cases. J Dent Child
1996; 63:368-76.
5) Andresa Borges Soares, JuJiana JuJianelli de Araujoe Maria
Galvao de Sousa, Maria Cecilia Veronezi. Bilateral talon cusp:
Case report. Quintessence Int 2001 ;32:283-286.
6) Lin LM, Chance K, Skribner J,Langeland K. Dens evaginatus:
a case report. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1987;63:86-89.
7) Sathorn C, Parashos P, Messer HH. Effectiveness of single
versus multiple-visit endodontic treatment of teeth with
apical periodontitis: a systematic review and meta analysis.
Int Endod J 2005;38:347-355.
8) Faiez N. Hattab, Muawia A. Qudeimat, Hala S. Al-rimawi.
Dental discoloration: an overview. J Esthet Dent1999; 11:291-
310,)
9. Cadenaro M et al. Effect of two in-office whitening agents
on the enamel surface in vivo: a morphological and non-
contact profilometric study. Operative Dentistry 2008;33-
2:127-134.
10) Ferraz JAB, Carvalho Junior JR, Saquy PC, Pecora JD,
Sousa- Neto MD.dental anamoly: Dens evaginatus (talon
cusp). Braz Dent J 2001;12:132-134.
MOKSHA NAYAK, JITENDRA KUMAR, KRISHNA PRASAD L.
94
94
Immediate reattachment of fractured crown fragment:
A case report
ANIL DHINGRA *
DHIRENDRA KR. SRIVASTAVA **
* Professor, * * Post Graduate Student, Department of Conservati ve Denti stry & Endodonti cs, Subharti puram, Del hi - Hari dwar By Pass Road, Meerut. 250002. Uttarpradesh.
ABSTRACT
The immediate fragment reattachment is a very conservative treatment. It allows the restoration of the original
dental anatomy thus rehabilitating function and aesthetics in a short time by preserving dental tissues.
An immediate restorative technique resolving the acute problem of traumatic tooth fracture with pulpal realign
able. Fracture reattachment posses challenging conservative and economically viable procedure within the compass
of a single visit.
KEY WORDS: Fragment Reattachment, Tooth Fracture.
INTRODUCTION
The uncomplicated crown fracture is the most
frequent dental traumatic injury. The maxillary
incisors are most commonly affected.
As esthetics is of utmost importance to the
patient and dentists the importance of adequately
restoring the esthetic elements of the tooth can not
be neglected.
The immediate reattachment of a dental
fragment is a technique that should be considered
while treating patients with crown fractures of
anterior teeth. The use of this technique requires
the entire fractured segment that, if at all possible,
is correctly preserved or stored
1
.
CLINICAL CASE
A 25 Year old male patient reported to the
Department of Conservative Dentistry and
Endodontics, Subharti Dental College, Meerut,
U.P., India. With the chief complaint of broken
upper front tooth following trauma during sports
activity, 2 hours back.
Initial examination revealed; a fracture line
with pulp exposure on the labial surface of left
maxillary central incisor, fracture was not evident
palatally. (Fig. I) Right maxillary central incisor
showed incisal chipping with laceration on the
lower lip.
Radiographic examination reveled a oblique
fracture labio- palatally. (Fig. 2) After routine history
taking and examination, a treatment plan was
formulated to immediately reattach the dental
fragment of the teeth.
Lignocaine 2%, buccal and palatal infiltration
were administered. The fracture segment was
completely removed & preserved in normal saline
in order to prevent dehydration of the tooth
fragment.
A clean fracture, horizontal mesial to distal
Case Report
95
95
angulated incisally from labial to palatal was
evident. No caries or resorption defects were
detected. (Fig.3 a,3 b)
A single visit root canal treatment with
sectional obturation was carried out. (Fig.5a& 5b).
The root canal was then prepared with
parapost drill (3M). A corresponding pre- fabricated
fiber post was cut to size 3-4 mm. for coronal
fixation (Fig.6). Access on coronal part was made
(Fig.4). The both surfaces were etched with 37%
phosphoric acid and a dentin bonding agent
(Hellibond; 3M) applied. Dual cure resin (Rely-X)
placed in the canal and a fiber post was placed up
to proper length. Simultaneously the coronal tooth
fragment was placed in to the post, its bonding
surface and pulp cavity loaded with dual cure resin
composite, this was placed in to position and finger
pressure was applied until the composite was light
cured set. A check radiograph was then recorded
to confirm apposition of the two tooth portions.
The occlusion corrections were made. Final result
showed more than satisfying esthetic results with
restored functionality.(Fig.7)
As with all traumatic injuries follow-up is of
critical importance patient was requested to report
after 24 hrs. At the end of 24 hours the post
operative situation was uneventful. (Fig. 8)
The follow- up was carried out for 1month and
3months with no post operative problems. (Fig.9
& 10).The healing during the follow up period was
uneventful.
Fig 1- Pre-Operative Photograph. Fig 2- Pre-Operative radiograph. Fig 3a- Fracture segment
(palatel view).
Fig 3b- Fracture segment
(labial view).
Fig 4- Access preparation. Fig 5a- Working length. Fig 5b- Sectional obturation. Fig 6- Post placement.
Fig 7- Post operative. Fig 8- Post operative
radiograph after 24 hrs.
Fig 9- Post operative
radiograph after 1 month.
Fig 9- Post operative
radiograph after 3 month.
ANIL DHINGRA, DHIRENDRA K.R., SRIVASTAVA
96
96
DISCUSSION
Traumatic injuries involving tooth fracture can
be treated by reattachment of the tooth fragment
using an adhesive system (acting as a dental super
glue) to provide what is considered to the most
conservative to restoration. Newer dentine bonding
systems work with such efficiency that they easily
allow for normal masticatory forces. Survival rates
for such restoration have been shown to the good
with failure often only resulting from subsequent
trauma.
2
Factor influencing the extent and feasibility
of such repair include the site of fracture, size of
fractured remnants, periodontal status ,pulpal
involvement, maturity of root formation, biological
width invasion, occlusion, time and resources of
the patient.
3
If the fracture involves two- third or more of
the crown a post reattachment is more commonly
used.
Post-placement in addition to bonding, serves
to retain the coronal portion via a friction bond,
and assist in preventing dislodgement non- axial
forces. The composite reinforcement technique
together with these light-transmitting post had been
widely used to functionally and esthetically restore
compromised root filled teeth
4
. The teeth which
previously would have been condemned to
extraction, could now strengthened by a sufficiently
thick lining of intra-radicular re-enforcing
composite , thereby salvaging them for continued
function in the mouth.
Apposition can be affected by cement
thickness as well as problem with relocation even
when using a stent. These would include incorrect
tooth segment placement, distortion of the plastic
during seating, incorrect alignment of the stent
itself. Such problem similarly occur when the
apposition is freehand but with the added difficulty
of maintaining position in three dimension without
movement while the cement sets
2
Options available for the treatment of a
fractured tooth include
2
Root extraction and prosthetic replacement
eg fixed, implant, removable.
Root burial - prosthetic replacement.
Retention of the apical tooth portion and
conventional conservation eg periodontal
correction if required, cast restoration.
Orthodontic extrusion, followed by post
endodontic restoration.
However, many of the above techniques have
associated limitations. These may include multi-
visit appointment, cost,. Stabilization (splinting) and
be less conservative in nature when compared with
the option in the present case.
Reference
1. Rappelli G,Massaccesi C. Clinical procedures for the
immediate reattachment of a tooth fragment. Dental
traumatology 2002; 18:281-284.
2. Wadhwani C.P.K. A single visite, multidisciplinary
approach to the management of traumatic tooth crown
fracture. British dental journal2000; 11:188,593-98.
3. Lui L. J. A case report of reattachment of fractured root
fragment and resin composite reinforcement in a
compromised endodontically treated root. . Dental
traumatology 2001; 17:227-230.
4. Pasini S, Keller E. et al, Surgical removal and immediate
reattachment of coronal fragment embedded in lip. Dental
traumatology 2006 22: 165-168.
IMMEDIATE REATTACHMENT OF FRACTURED CROWN FRAGMENT: A CASE REPORT
97
97
Current Endodontics Literature
Sowmya Shetty, Associate Professor & Roma, Post Graduate Student, Department of Conservative Dentistry and Endodontics, A. J. Institute
of Dental Sciences, Mangalore
Acid Resistance and Structural Changes of Human Dental Enamel Treated with Er:YAG Laser
Laura Emma Rodrguez-Vilchis, D.D.S., M.S.D., Rosala Contreras-Bulnes, D.D.S., Ph.D., Ignacio Snchez-Flores,
D.D.S., M.S.D., Ph.D.,and Enrique Cuauhtmoc Samano, Ph.D.
Objective: The purpose of this study was to evaluate the acid resistance and structural changes in the enamel
surface of permanent teeth after subablative Er:YAG laser irradiation in vitro.
Background Data: Er:YAG irradiation laser is expected to enhance acid resistance and to produce morphological
changes on the enamel surface.
Methods: One hundred twenty samples of human enamel were divided into four groups (n=30): Group I was
the control (no laser irradiation), and Groups II, III, and IV were irradiated with Er:YAG laser at 100mJ (12.7J/cm
2
),
100mJ (7.5J/cm
2
), and 150mJ (11J/cm
2
), respectively, at 10Hz and with water spray. The samples were placed in an
acid solution, and the released calcium was quantified by atomic absorption spectrometry. The weight percentages of
calcium, phosphorus, oxygen, and chlorine on the enamel surface were determined by energy dispersive X-ray
spectroscopy. The morphological changes were observed by scanning electron microscopy. One-way ANOVA and
KruskalWallis tests were performed (pd0.05) to distinguish significant differences among groups.
Results: The weight percentage of calcium in the samples obtained from EDS and the amount of calcium in the
solution did not show any significant difference. All irradiated samples showed morphological changes on the enamel
surface compared to the control group.
Conclusions: The results of this study suggest that acid resistance of enamel due to subablative Er:YAG laser
irradiation on the samples did not increase as expected. Morphological microscopic changes included craters and
cracks on the irradiated zones.
Photomedicine and Laser Surgery, October 5, 2009
Endoscopic root canal treatment
Joshua Moshonov, DMD/Eli Michaeli, DMD/Oded Nahlieli, DMD
Objective: To describe an innovative endoscopic technique for root canal treatment.
Materials and Methods: Root canal treatment was performed on 12 patients (15 teeth), using a newly developed
endoscope (Sialotechnology), which combines an endoscope, irrigation, and a surgical microinstrument channel.
Results: Endoscopic root canal treatment of all 15 teeth was successful with complete resolution of all symptoms
(6-month follow-up). Conclusion: The novel endoscope used in this study accurately identified all microstructures
and simplified root canal treatment. The endoscope may be considered for use not only for preoperative observation
and diagnosis but also for active endodontic treatment.
Quintessence Int 2009;40:7397441.
98
98
Oxygen-Ozone Therapy in Medicine: An Update
Velio Boccia, Nicola Di Paolo
Oxygen-ozone therapy, initially started as an empirical approach, has now reached a stage where most of the
biological mechanisms of action of ozone have been clarified, showing that they are in the realm of orthodox
biochemistry, physiology and pharmacology. Here we have reviewed a few relevant clinical applications and have
shown that ozone therapy is particularly useful in cardiovascular disorders and tissue ischemia. In chronic viral
infections, it is unable to eliminate the viremia but it may display supportive help by stimulating the immune system.
Recently, its use has been successfully extended to the herniated disk pathology and therapy of primary caries in
children.
Blood Purif 2009;28:373-376 (DOI: 10.1159/000236365)
Fracture resistance of thin-walled roots restored with different post systems
B. H. Kvan, T. Alaam, . . A. Ulusoy, . Gen & G. Grgl Department of Operative Dentistry and Endodontics,
Faculty of Dentistry, University of Gazi, Ankara, TurkeyCorrespondence to Dr Badagl Helvacolu Kvan,
Department of Operative Dentistry and Endodontics, Faculty of Dentistry, Gazi University, 8. cd. 82. sk. 06510
Emek, Ankara, Turkey (Tel.: +90 312 203 41 23; e-mail: bagdagulkivanc@gmail.com;
bagdagul@gazi.edu.tr)Copyright 2009 International Endodontic Journal
KEYWORDS fibre-reinforced composite post Fracture resistance thin-walled roots
Aim To compare the fracture resistance of thin-walled roots after restoration with different types of post systems.
Methodology One hundred and sixty-five decoronated maxillary central incisors were root filled and randomly
assigned to three groups with respect to the remaining dentine thickness of root (1.0 mm, 1.5 mm, 2.0 mm). Each
group was randomly divided into five equal subgroups. The subgroups were restored with one of the following post
systems: polyethylene woven fibre (R), composite resin cured by light-transmitting post + glass fibre post (L), electrical
glass fibre post (E), composite corono-radicular restoration (C) and cast metal post (M). Standard cores were constructed
using composite resin in the first four groups. The samples were subjected to a gradually increasing force (1 mm min
1
).
The force required to fracture was recorded. The data was analysed with ANOVA and Tukey test (P = 0.05).
Results The cast metal post group had the highest fracture strength (P < 0.001). There was no significant difference
in fracture resistance between the other four groups. Fracture resistance was affected largely by the remaining dentine
thickness in fibre post groups; however, the difference was not significant. On the contrary in the cast metal post
group load failure was inversely influenced by axio-proximal dimension of dentine walls.
Conclusion The cast post group had a higher fracture strength than resin groups. The force required to fracture
the roots was similar for all fibre post systems and for all dentine thicknesses.
International Endodontic Journal, Volume 42 Issue 11, Pages 997 - 1003 Published Online: 1 Sep 2009
SOWMYA SHETTY
99
99
Wisdom teeth: Mankinds future third vice-teeth?
DuoHong Zouae, Jun Zhaob, WangHui Dingc, LunGuo Xiab, XinQuan Jangd, YuanLiang Huange
Summary: The third molar teeth (wisdom teeth) represent the last eruption of the teeth in the human dentition.
Throughout evolution, the mandible has had a tendency to decrease in size; the third molar teeth are often impacted,
resulting in incomplete tooth eruption that often causes clinical pericoronitis, dental caries, and pericemental abscess.
Therefore, the wisdom teeth are often extracted. Moreover, wisdom teeth are often removed for clinical orthodontic
treatment. On the other hand, tooth loss due to periodontal disease, dental caries, trauma, or a variety of genetic
disorders continues to affect peoples lives. Autologous tissues for dental tissue regeneration that could replace lost
teeth could provide a vital alternative to currently available clinical treatments. To pursue this goal, we hypothesize
that human third molar tooth buds can be obtained during development. Human wisdom tooth germination tissue
could then be placed into an embryonic stem cell bank for storage. When the donors other teeth are missing,
embryonic stem cell and tissue engineering technologies, will permit the restoration of the missing teeth. Therefore
wisdom teeth will be mankinds future third vice-teeth.
Received 31 July 2009; accepted 6 August 2009. published online 18 September 2009.
Effect of dentinal tubules and resin-based endodontic sealers on fracture properties of root dentin
Angsana Jainaena, Joseph E.A. Palamara and Harold H. Messer
Objective: To investigate the role of dentinal tubules in the fracture properties of human root dentin and whether
resin-filled dentinal tubules can enhance fracture resistance.
Materials and methods: Crack propagation in human root dentin was investigated in 200 m thick longitudinal
samples and examined by light and scanning electron microscopy. 30 maxillary premolar teeth were prepared for
work of fracture (Wf) test at different tubule orientations, one perpendicular and two parallel to dentinal tubules.
Another 40 single canal premolars were randomly divided into four groups of 10 each: intact dentin, prepared but
unobturated canal, canal obturated with epoxy rein (AH Plus/gutta percha), or with UDMA resin sealer (Resilon
/
RealSeal
). The samples were prepared for Wf test parallel to dentinal tubules. Wf was compared under ANOVA with
statistical significance set at p < 0.05.
Results Dentinal tubules influenced the path of cracks through dentin, with micro-cracks initiated in peritubular
dentin of individual tubules ahead of the main crack tip. A significant difference (p < 0.001) was found between Wf
perpendicular to tubule direction (254.9 J/m
2
) vs. parallel to tubule direction from inner to outer dentin (479.4 J/m
2
).
Neither canal preparation nor obturation using epoxy- or UDMA-based resins as sealer cements substantially influenced
fracture properties of root dentin, despite extensive infiltration of dentinal tubules by both sealer cements.
Keywords: Crack propagation; Dentin; Dentinal tubules; Work of fracture; Resin-based sealer; AH Plus; Resilon
Dental Materials, Volume 25, Issue 10, October 2009, Pages e73-e81
CURRENT ENDODONTICS LITERATURE
100
100
Micro-XRD and temperature-modulated DSC investigation of nickeltitanium rotary endodontic
instruments
Satish B. Alapatia, William A. Brantleyb
,
Masahiro Iijimac, Scott R. Schrickerb, John M. Nussteind, Uei-Ming Lie and
Timothy A. Svecf
Objectives: Employ Micro-X-ray diffraction and temperature-modulated differential scanning calorimetry to
investigate microstructural phases, phase transformations, and effects of heat treatment for rotary nickeltitanium
instruments.
Methods: Representative as-received and clinically used ProFile GT and ProTaper instruments were principally
studied. Micro-XRD analyses (Cu K X-rays) were performed at 25 C on areas of approximately 50 m diameter near
the tip and up to 9 mm from the tip. TMDSC analyses were performed from 80 to 100 C and back to 80 C on
segments cut from instruments, using a linear heating and cooling rate of 2 C/min, sinusoidal oscillation of 0.318 C,
and period of 60 s. Instruments were also heat treated 15 min in a nitrogen atmosphere at 400, 500, 600 and 850 C,
and analyzed.
Results: At all Micro-XRD analysis regions the strongest peak occurred near 42, indicating that instruments
were mostly austenite, with perhaps some R-phase and martensite. Tip and adjacent regions had smallest peak intensities,
indicative of greater work hardening, and the intensity at other sites depended on the instrument. TMDSC heating and
cooling curves had single peaks for transformations between martensite and austenite. Austenite-finish (A
f
) temperatures
and enthalpy changes were similar for as-received and used instruments. Heat treatments at 400, 500 and 600 C
raised the A
f
temperature to 4550 C, and heat treatment at 850 C caused drastic changes in transformation behavior.
Significance: Micro-XRD provides novel information about NiTi phases at different positions on instruments.
TMDSC indicates that heat treatment might yield instruments with substantial martensite and improved clinical
performance.
Keywords: Nickeltitanium; Endodontics; Rotary instrument; X-ray diffraction; Differential scanning calorimetry;
Heat treatment; Phase transformation; Wrought alloys; Metallurgy; Superelasticity
Dental Materials Volume 25, Issue 10, October 2009, Pages 1221-1229
Nd: YAG Laser Improves Biocompatibility of Human Dental Root Surfaces
Len Hamaoka, Cacio Moura-Netto, Mrcia Martins Marques, Abilio Albuquerque Maranho de Moura.
Photomedicine and Laser Surgery. -Not available-, ahead of print.
Objective: Our goal was to compare the in vivo biocompatibility of dental root surfaces submitted to four
different treatments after tooth avulsion followed by implantation into rat subcutaneous tissue.
Background Data: Dental root surface preparation prior to replanting teeth remains a challenge for endodontists.
Root surface changes made by Nd:YAG irradiation could be an alternative preparation.
Methods: Forty-eight freshly extracted human dental roots were randomly divided into four treatment groups
prior to implantation into rat subcutaneous tissue: G1, dry root, left in the environment up to 3h; G2, the same
SOWMYA SHETTY
101
101
treatment as G1, followed by a soaking treatment in a 2.4% sodium fluoride solution (pH 5.5); G3, root soaked in
physiologic saline after avulsion for 72h; G4, the same treatment as G1, followed by Nd:YAG laser irradiation (2.0W,
20Hz, 100mJ, and 124.34J/cm
2
). The animals were sacrificed 1, 7, and 45d later. Histological and scanning electron
microscopy analyses were done.
Results: All dental roots were involved and in intimate contact with connective tissue capsules of variable
thicknesses. Differences were observed in the degree of inflammation and in connective tissue maturation. In G3 the
inflammatory infiltrate was maintained for 45d, whereas the Nd:YAG laser irradiation (G4) led to milder responses.
The overall aspects of the root surfaces were similar, except by the irradiated roots, where fusion and resolidification
of the root surface covering the dentinal tubules were observed.
Conclusion: Nd:YAG laser irradiation improves the biocompatibility of dental root and thus could be an alternative
treatment of dental root prior to replantation.
Photomedicine and Laser Surgery, doi:10.1089/pho.2008.2288.
CURRENT ENDODONTICS LITERATURE
102
102
NOTES
103
103
104
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