Iranian Endodontic Journal
Volume:10 Issue: 1, Winter 2015

Root canal irrigants play a significant role in elimination of the microorganisms, tissue remnants, and removal of the debris and smear layer. No single solution is able to fulfill all these actions completely; therefore, a combination of irrigants may be required. The aim of this investigation was to review the agonistic and antagonistic interactions between chlorhexidine (CHX) and other irrigants and medicaments. An English-limited Medline search was performed for articles published from 2002 to 2014. The searched keywords included “chlorhexidine AND sodium hypochlorite/ethylenediaminetetraacetic acid/calcium hydroxide/mineral trioxide aggregate«. Subsequently, a hand search was carried out on the references of result articles to find more matching papers. Findings showed that the combination of CHX and sodium hypochlorite (NaOCl) causes color changes and the formation of a neutral and insoluble precipitate; CHX forms a salt with ethylenediaminetetraacetic acid. In addition, it has been demonstrated that the alkalinity of calcium hydroxide (CH) remained unchanged after mixing with CHX. Furthermore, mixing CHX with CH may enhance its antimicrobial activity; mixing mineral trioxide aggregate (MTA) powder with CHX increases its antimicrobial activity but may have a negative effect on its mechanical properties.

Maintaining deciduous teeth in function until their natural exfoliation is absolutely necessary. Vital pulp therapy (VPT) is a way of saving deciduous teeth. The most important factors in success of VPT are the early diagnosis of pulp and periradicular status, preservation of the pulp vitality and proper vascularization of the pulp. Development of new biomaterials with suitable biocompatibility and seal has changed the attitudes towards preserving the reversible pulp in cariously exposed teeth. Before exposure and irreversible involvement of the pulp, indirect pulp capping (IPC) is the treatment of choice, but after the spread of inflammation within the pulp chamber and establishment of irreversible pulpitis, removal of inflamed pulp tissue is recommended. In this review, new concepts in preservation of the healthy pulp tissue in deciduous teeth and induction of the reparative dentin formation with new biomaterials instead of devitalization and the consequent destruction of vital tissues are discussed.

By producing undistorted three-dimensional images of the area under examination, cone-beam computed tomography (CBCT) systems have met many of the limitations of conventional radiography. These systems produce images with small field of view at low radiation doses with adequate spatial resolution that are suitable for many applications in endodontics from diagnosis to treatment and follow-up. This review article comprehensively assembles all the data from literature regarding the potential applications of CBCT in endodontics.

The aim of this study was to evaluate the compressive strength of calcium-enriched mixture (CEM) cement in contact with acidic, neutral and alkaline pH values. Methods and Materials: The cement was mixed according to the manufacturer’s instructions, it was then condensed into fourteen split molds with five 4×6 mm holes. The specimens were randomly divided into 7 groups (n=10) and were then exposed to environments with pH values of 4.4, 5.4, 6.4, 7.4, 8.4, 9.4 and 10.4 in an incubator at 37° C for 4 days. After removing the samples from the molds, cement pellets were compressed in a universal testing machine. The exact forces required for breaking of the samples were recorded. The data were analyzed with the Kruskal-Wallis and Dunn tests for individual and pairwise comparisons, respectively. The level of significance was set at 0.05. The greatest (48.59±10.36) and the lowest (9.67±3.16) mean compressive strength values were observed after exposure to pH value of 9.4 and 7.4, respectively. Alkaline environment significantly increased the compressive strength of CEM cement compared to the control group. There was no significant difference between the pH values of 9.4 and 10.4 but significant differences were found between pH values of 9.4, 8.4 and 7.4. The acidic environment showed better results than the neutral environment, although the difference was not significant for the pH value of 6.4. Alkaline pH also showed significantly better results than acidic and neutral pH. The compressive strength of CEM cement improved in the presence of acidic and alkaline environments but alkaline environment showed the best results.

Solubility of mineral trioxide aggregate (MTA) is an important characteristic that affects other properties such as microleakage and biocompatibility. Distilled water (DW) has previously been used for solubility tests. This experimental study compared the solubility of MTA in DW, synthetic tissue fluid (STF) and new simulated plasma (SP). Methods and Materials: In this study, 36 samples of tooth-colored ProRoot MTA were prepared and divided into three groups (n=12) to be immersed in three different solutions (DW, STF, and SP). Solubility tests were conducted at 2, 5, 9, 14, 21, 30, 50, and 78-day intervals. The unequal variance F-test (Welch test) was utilized to determine the effect of solubility media and Games-Howell analysis was used for pairwise comparisons. The repeated-measures ANOVA was used to assess the importance of immersion duration. Welch test showed significant differences in solubility rates of samples between all the different solubility media at all the study intervals (P<0.05) except for the 14-day interval (P=0.094). The mixed repeated-measures ANOVA revealed a significant difference in solubility rate of MTA in three different solutions at all time-intervals (P=0.000). Games-Howell post-hoc test revealed that all pairwise comparisons were statistically significant at all time-intervals (P=0.000). Based on the findings of this study, the long-term solubility of MTA in simulated plasma was less than that in synthetic tissue fluid and distilled water.

The aim of this cross-sectional study was to determine the prevalence and etiology of traumatic dental injuries (TDI) in school children of the Northeast of Iran. The type of involved teeth, the place of injury and treatment quality as well as the relationship between TDI and anatomic predisposing factors such as overjet and lip coverage were evaluated. Methods and Materials: A total of 778 school children were clinically examined for signs of trauma to their permanent teeth and the amount of overjet and lip coverage were also recorded. A questionnaire containing demographic data of participants and history of the dental trauma was given to the children’s parents. The data were analyzed using the chi-square and Mann-Whitney tests. One hundred and seventy eight (22.9%) children had a history of previous trauma to their permanent teeth. There was a significant difference between boys and girls (P=0.017). A total of 46.1% of children had experienced luxation injuries of permanent teeth, 37% had crown fractures, and 16.9% experienced avulsion of anterior teeth. Maxillary central incisors were the most commonly affected teeth (84%). There was a significant relationship between TDI and overjet (P=0.02) in permanent teeth. On the other hand, there was no statistically significant relationship between TDI and lip coverage. The most common cause of TDI was falling over (42.9%) followed by fighting (34%). The majority of traumas happened at home (46.8%) and school (29.9%). Sixty two (39.7%) children with TDI did not receive any dental or medical care after injury. The prevalence of dental trauma in school children in Iran was rather high (22.9%); the most common type of trauma to the permanent teeth was luxation injuries.

Enterococcus faecalis (E. faecalis) has the ability to invade the dentinal tubules and resist high pH levels. As a result, calcium hydroxide (CH) is not much effective on this bacterium. In theory, nanoparticle calcium hydroxide (NCH) has smaller size and high surface area that enables it to penetrate into the deeper layers of dentin and be more effective on E. faecalis. This in vitro study was designed to compare the antimicrobial activity of NCH and CH against E. faecalis. Methods and Materials: The antimicrobial activity of NCH against E. faecalis was evaluated by two independent tests: the minimum inhibitory concentration (MIC) of intracanal medicament and agar diffusion test (ADT). The efficiency of the medicament in dentinal tubules was evaluated on 23 human tooth blocks that were inoculated with E. faecalis. The tooth blocks were assigned to one control group (saline irrigation) and two experimental groups receiving CH and NCH as intracanal medication. The optical density in each group was assessed with spectrophotometer after collecting samples from dentin depths of 0, 200 and 400 µm. Data were analyzed by SPSS software ANOVA, Kruskal-Wallis and Dunnett’s test. The MIC for NCH was 1/4 of the MIC for CH. NCH with distilled water (DW) produced the greatest inhibition zone in agar diffusion test. NCH had greater antimicrobial activity in dentin samples from depths of 200 and 400 µm compared to CH. The antimicrobial activity of NCH was superior to CH in culture medium. In dentinal tubules the efficacy of NCH was again better than CH on the 200- and 400-µm samples.

Apical transportation changes the physical shape and physiologic environment of the root canal terminus. The aim of the present experimental study was to determine the extent of apical transportation after instrumentation with hand K-Flexofile and K3 rotary instruments by means of cone-beam computed tomography (CBCT). Methods and Materials: Forty mesiobuccal root canals of maxillary first molars, with 19-22 mm length and 20-40° canal curvature, were selected and assigned into two preparation groups. The first group was prepared with K-Flexofile with passive step-back technique and the second group was prepared with K3 rotary instruments. Pre and post instrumentation CBCT images were taken under similar conditions. The amount of root canal transportation was evaluated by Mann-Whitney U test and the chi-square test was used for the qualitative evaluation. The amounts of apical canal transportation with the K3 and K-Flexofile instruments were 0.105±0.088 and 0.150±0.127 mm, respectively with no statistically significant differences. In the manual technique, 25% of the canals had no apical transportation; while 30% of the canals in the K3 group were transportation free. Both systems were able to preserve the initial curvature of the canals and both had sufficient accuracy. Preparation with K3 rotary instruments resulted in apical transportation similar to that of K-Flexofile.

One of the major contributing factors, which may cause failure of endodontic treatment, is the presence of residual microorganisms in the root canal system. For years, most dentists have been using calcium hydroxide (CH) as the intracanal medicament between treatment sessions to eliminate remnant microorganisms. Reducing the size of CH particles into nanoparticles enhances the penetration of this medicament into dentinal tubules and increases their antimicrobial efficacy. This in vitro study aimed to compare the cytotoxicity of CH nanoparticles and conventional CH on fibroblast cell line using the Mosmann’s Tetrazolium Toxicity (MTT) assay. Methods and Materials: This study was conducted on L929 murine fibroblast cell line by cell culture and evaluation of the direct effect of materials on the cultured cells. Materials were evaluated in two groups of 10 samples each at 24, 48 and 72 h. At each time point, 10 samples along with 5 positive and 5 negative controls were evaluated. The samples were transferred into tubes and exposed to fibroblast cells. The viability of cells was then evaluated. The Two-way ANOVA was used for statistical analysis and the level of significance was set at 0.05. Cytotoxicity of both materials decreased over time and for conventional CH was lower than that of nanoparticles. However, this difference was not statistically significant (P>0.05). The cytotoxicity of CH nanoparticles was similar to that of conventional CH.

Flow rate (FR) and compressive strength (CS) are important properties of endodontic biomaterials that may be affected by various mixing methods. The aim of this experimental study was to evaluate the effect of different mixing methods on these properties of mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement. Hand, amalgamator and ultrasonic techniques were used to mix both biomaterials. Then 0.5 mL of each mixture was placed on a glass slab to measure FR. The second glass slab (100 g) was placed on the samples and 180 sec after the initiation of mixing a 100-g force was applied on it for 10 min. After 10 min, the load was removed, and the minimum and maximum diameters of the sample disks were measured. To measure the CS, 6 sample of each group were placed in steel molds and were then stored in distilled water for 21 h and 21 days. Afterwards, the CS test was performed. Data were analyzed with multi-variant ANOVA and post hoc Tukey tests. The level of significance was set at 0.05. There were significant differences in FR of MTA and CEM cement with different mixing techniques (P<0.05). In the MTA group, none of the mixing techniques exhibited a significant effect on CS (P>0.05); however, in CEM group the CS at 21-h and 21-day intervals was higher with the hand technique (P<0.05). Mixing methods affected the flowability of both biomaterials and compressive strength of CEM cement.

The aim of this in vitro study was to evaluate the effect of 2% chlorhexidine (CHX) on the push-out bond strength (BS) of calcium-enriched mixture (CEM) cement. Methods and Materials: Root-dentin slices from 60 single-rooted human teeth with the lumen diameter of 1.3 mm were used. The samples were randomly divided into 4 groups (n=15), and their lumens were filled with CEM cement mixed with either its specific provided liquid (groups 1 and 3) or 2% CHX (groups 2 and 4). The specimens were incubated at 37°C for 3 days (groups 1 and 2) and 21 days (groups 3 and 4). The push-out BS were measured using a universal testing machine. The slices were examined under a light microscope at 40× magnification to determine the nature of bond failure. The data were analyzed using the two-way ANOVA. For subgroup analysis the student t-test was applied. The level of significance was set at 0.05. After three days, there was no significant difference between groups 1 and 2 (P=0.892). In the 21-day specimens the BS in group 3 (CEM) was significantly greater than group 4 (CEM+CHX) (P=0.009). There was no significant difference in BS between 3 and 21-day samples in groups 2 and 4 (CEM+CHX) (P=0.44). However, the mean BS after 21 days was significantly greater compared to 3-day samples in groups 1 and 3 (P=0.015). The bond failure in all groups was predominantly of cohesive type. Mixing of CEM with 2% CHX had an adversely affected the bond strength of this cement.

This study was carried out to evaluate the bacterial leakage of root canal fillings when cavity varnish containing 5% fluoride (Duraflur) was used as root canal sealer. Methods and Materials: Root canals of 88 straight single-rooted teeth were prepared. Eighty teeth were randomly divided into 3 experimental groups (n=20) and two positive and negative control groups of ten each. The roots in group I and II were obturated with gutta-percha and AH-26 sealer using lateral condensation technique. The root canal walls in group II were coated with a layer of varnish before obturation. In group III the canals were obturated with gutta-percha and fluoride varnish as the sealer. Enterococcus faecalis (E. faecalis) was used to determine the bacterial leakage during 90 days. The Kaplan Meier survival analysis was used for assessing the leakage and log rank test was used for pairwise comparison. The rest of eight single rooted teeth were selected for scanning electron microscopy (SEM) evaluation with 5000× magnification. Leakage occurred between 20 to 89 days. Group III showed significantly less bacterial penetration than groups I and II (P=0.001 and P=0.011, respectively). However, there was no significant difference between group I and II (P>0.05). SEM evaluation showed that the varnish had covered all dentinal tubules. The present study showed promising results for the use of fluoride varnish as root canal sealer but further in vitro and in vivo studies are needed.

The aim of the present in vitro study was to evaluate the efficacy of D-RaCe, ProTaper retreatment kit and hand H-files in removal of obturating materials (OM) from the curved root canals using cone-beam computed tomography (CBCT). Sixty extracted molars were prepared and obturated. The samples were divided into three groups (n=20). In each group the OM was removed using hand H-files, D-RaCe and ProTaper retreatment kit. All the samples underwent CBCT imaging. The amount of OM was evaluated in CBCT sagittal cross-sections and scored. The maximum concentration of residual OM was recorded. The duration of the procedure (including the required time for reaching working length=T1 and total working time=TT) and procedural errors were also recorded. Data were analyzed using one-way ANOVA, Tukey’s post hoc test, Fisher’s exact test and Kruskal-Wallis test. The level f significance was set at 0.05. No significant differences were observed in the residual OM among the three groups. T1 and TT were not significantly different in all the groups. There were no significant differences in concentration of OM between the groups (P<0.05). In relation to procedural errors, 4 and 5 cases of file fracture were recorded in the ProTaper and D-RaCe groups, respectively, with no significant differences. Rotary and hand files had similar efficacy in removing root canal filling materials but instrument fracture occurred more frequently in rotary files.

Internal inflammatory root resorption (IIRR) is a rare condition of the root canal and if it is left untreated it may lead to destruction of the surrounding dental hard tissues. Odontoclasts are responsible for this situation which can potentially perforate the root. Many initiating factors have been mentioned for IIRR, almost all causing chronic inflammation in the vital pulp. IIRR is usually symptom free, but in cases of root perforation, a sinus tract usually forms. The prognosis of treatment depends on the size of lesion with small lesions being managed with good prognosis. However, in case of notable destruction of the tooth, the prognosis is poor and tooth extraction may become inevitable. This report represents the management of an extensive perforative IIRR that was successfully sealed with calcium-enriched mixture (CEM) cement. After 12 months the tooth was still symptomless and in function.

Apexification is a method of inducing apical closure for non-vital immature permanent teeth. During this treatment a mineralized barrier is induced [with long term calcium hydroxide (CH) treatment]; or artificially created [with mineral trioxide aggregate (MTA) plug]. This article describes two cases of apexification in immature necrotic teeth treated with these two different techniques. After 6 years of follow-up, clinical and radiographic control showed that both treatments were successful.