Iranian Endodontic Journal
Volume:14 Issue: 1, Winter 2019

After treating the tooth root canal, pain is one of the problems that many patients are facing. In order to reduce pain, and regarding the advice of treating necrotic teeth during several sessions, intra-canal medicaments can be used between sessions. The purpose of this study is to compare pain relieving effect of calcium hydroxide combined with three solutions of normal saline, chlorhexidine 2% and dexamethasone. This triple blind randomized clinical trial was performed on 90 necrotic molars and premolars. The patients were classified in three medicaments' groups including mixture of calcium hydroxide and normal saline (G1), chlorhexidine 2% (G2) or dexamethasone (G3) that were placed in the canal during the first treatment session. The patients were provided with a Heft-Parker Visual Analog Scale form to record their pain in different intervals of 4, 24, 48, 72 and 96 h after cleaning and shaping the root canal. Data analysis was carried out using the Chi-Square, one-way ANOVA and Repeated Measure tests. No significant difference was observed in the mean pain of the groups after 4 h (P>0.05). However, a significant difference was found between G1 and G3 in the mean pain from day 1 to 72 h after treatment. The mean pain was less in dexamethasone (G3) group (P<0.05), but the difference was not statistically significant at 96 h after treatment (P>0.05). No significant difference was found between "G2-G1" and "G2-G3" groups at different time intervals (P>0.05). The mixture of calcium hydroxide and dexamethasone compared to calcium hydroxide and normal saline in short and medium time had a significant effect on reducing pain after cleaning and shaping the root canal. It seems that the mixture of calcium hydroxide and dexamethasone can be considered as an effective medicament on reducing pain during root canal treatment sessions.

The aim of this study was adding the nanostructured silver vanadate decorated with silver nanoparticles (AgVO3) (0, 2.5, 5, and 10%) to the endodontic sealers AH-Plus, Sealer 26 and Endomethasone N, and evaluate the antimicrobial activity, solubility and pH. Methods and Materials: The antimicrobial activity of freshly mixed sealers (n=10) and set sealers (n=9) against Enterococcus faecalis (E. faecalis) was evaluated by colony forming units per milliliter and epifluorescence microscopy. Solubility (n=9) and pH (n=10), 6 and 24 h and 7, 14, and 30 days were also evaluated. The Kruskal-Wallis and Dunn’s post-test were applied for the antimicrobial activity of fresh sealers. ANOVA and Tukey’s post-test was used for set sealers and solubility, and Friedman's two-way analysis of variance for pH (α=0.05). The fresh sealers inhibited E. faecalis. Set Sealer 26 (5 and 10% AgVO3) and Endomethasone N (2.5, 5, and 10% AgVO3) presented higher activity then the corresponding controls. Modification with AgVO3 did not influence the solubility of AH Plus and Sealer 26, but Endomethasone N (5%) presented reduced solubility. The AH-Plus groups showed acidic pH, and Sealer 26, basic pH after 30 days. Endomethasone N (5 and 10% AgVO3) presented statistical difference compared to 0% (P<0.05). In this in vitro study all fresh sealers and set Sealer 26 (5 and 10%) and Endomethasone N (2.5, 5, and 10%) presented higher antimicrobial activity than controls. The modification with 5% and 10% AgVO3 decreased solubility and pH of Endomethasone N, but did not affect the other groups.

File Fracture is one of the most common problems during root canal treatment which can affect treatment procedure and prognosis, so it is important to diagnose and prevent it. The aim of this study was to evaluate and compare the diagnostic value of cone-beam computed tomography (CBCT) and digital periapical radiography for detection of separated instrument retained inside the canal. Methods and Materials: Ninety single-rooted extracted human teeth were selected and randomly divided into 3 groups (n=30). Group 1, separated file #10 at the 2-mm apical third of the root canal; group 2, separated file #35 at the 2-mm apical third of the root canal; and group 3, without a broken file (control group). The teeth were instrumented to size #30 and were shaped to size #55 and then the canals were obturated up to separated instrument, or the working length for the teeth without a separated instrument, with lateral condensation technique. After that all teeth were placed in dry skull, digital radiography and CBCT was taken. After data collection, data was analyzed using SPSS software by means of sensitivity, specificity, positive and negative predictive values, and frequency tables. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of digital periapical radiography in detection of a fractured file #10 in the canal was 96.7% and 63.3%, 76.7%, 73.1%, 67.6%, 70%, for CBCT, respectively. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of digital periapical radiography in detection of a fracture file #35 in the canal was 93.3%, 96.7%, 96.6%, 93.5% and 95%, and 36.7%, 76.7%, 61.1%, 54.8%, 56.66%, for CBCT, respectively. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of digital periapical radiography was better than the CBCT technique in both sizes of broken files.

The main cause of endodontic failure is residual bacteria in the root canal system. Enterococcus faecalis (E. faecalis) is the predominant species isolated from infected root canals. This study aims to compare the antibacterial activity of calcium-enriched mixture (CEM) cement and Biodentine as root canal filling materials on E. faecalis. Methods and Materials: Seventy extracted human single-rooted teeth were prepared and infected with E. faecalis for 24 h. Specimens were randomly divided into control or experimental groups; the later were filled with either CEM cement or Biodentine. Dentinal samples were collected after 7 and 30 days and transferred to test tubes. After incubation, the number of colony forming units (CFUs) were counted and analyzed using the Kruskal-Wallis test, followed by the Mann Whitney U test. The level of significance was set at 0.05. The reduction in mean CFU level of E. faecalis was significantly more in the presence of CEM cement at both time intervals (P<0.001). Compared to the positive control, Biodentine significantly reduced the mean CFU level only after 30 days (P<0.01). Although both biomaterials exerted antibacterial activity against E. faecalis, the CEM cement had more antibacterial activity than Biodentine.

The aim of this study was to evaluate dynamic viscosity, surface tension and dentin wettability of a newly introduced imidazolium-based silver nanoparticle solution (Im AgNP) in comparison with three common root canal irrigants. Methods and Materials: The irrigants were Im AgNPs at 5.7×10-8 mol/L-1, 5.25% Sodium hypochlorite (NaOCl), 2% Chlorhexidine (CHX) and 17% Ethylenediaminetetraacetic acid (EDTA) and distilled water (control group). Dynamic viscosity was measured using rotational digital viscometer at 25, 37, 45 and 60°C. Surface tension was evaluated using dynamic contact angle analyzer at room temperature (25°C). Wettability was assessed by contact angle measurement for five groups of 10 dentin samples after each group was treated in each irrigant for 10 min. One-way ANOVA, and post hoc Tukey’s test were used for statistical analysis. Significance was set at P<0.05. Dynamic viscosity of all irrigants decreased as the temperature increased. 17% EDTA was the most viscous solution in all examined temperatures (P<0.05). Viscosity of Im AgNP solution at 25, 37 and 45°C was significantly lower than that of 17% EDTA and 5.25% NaOCl (P<0.05). Im AgNPs exhibited a higher surface tension than other irrigants except distilled water. The wettability of dentin increased when it was in contact with 2% CHX and 5.25% NaOCl while Im AgNPs decreased the wettability of dentin surfaces (P<0.05). Im AgNP irrigant has the potential to reach apical portions of root canals due to its lower viscosity compared to the other tested irrigants. However, it may not bring better penetration inside dentinal tubules because of its higher surface tension. Furthermore, Im AgNPs can influence physiochemical properties of dentin by decreasing its surface wettability.

Root discoloration is reported after using Ledermix paste for prevention of external inflammatory root resorption in traumatically injured teeth. Therefore, it seems necessary to remove Ledermix completely from the root canal prior to root canal filling. The aim of this study was to evaluate the efficacy of sodium hypochlorite or alcohol with or without passive ultrasonic irrigation in removing Ledermix from standardized grooves in coronal and apical root canal thirds. Methods and Materials: Root canals of ten extracted single-rooted teeth were prepared to size 35 and split longitudinally. Standardized grooves were cut in the coronal and apical part of the root canal and filled with Ledermix paste. The reassembled specimens were irrigated with 1% NaOCl or 80% alcohol delivered with a size 30 syringe or with an ultrasonic device. The amount of remaining Ledermix paste was evaluated by three calibrated observers under 30× magnification using a four-grade scoring system. The data was analysed with a nonparametric ANOVA-type method for longitudinal data in factorial experiments. Pairwise comparisons were adjusted by using the Bonferroni corrections (P=0.05). For the coronal groove, no statistical difference between passive ultrasonic irrigation with NaOCl or alcohol was found (P=0.089). Irrigation with ultrasonically activated alcohol was significantly more effective than manual irrigation irrespective of the irrigant (P=0.0118). Ultrasonic activation of alcohol removed Ledermix paste significantly better from the apical groove than the other irrigation procedures (P<0.05). This in vitro study showed that ultrasonic activation of alcohol was the most effective irrigation technique for removal of Ledermix paste, especially in the apical third of the root canal.

This study aimed to compare the changes in root canal anatomy following the use of PathFile and R-Pilot using cone-beam computed tomography (CBCT). Methods and Materials: In this in vitro, experimental study, 60 extracted maxillary first and second molars with 20 to 40° mesiobuccal root curvature, minimum of 19 mm of root length, no calcified root canals and no history of previous treatment were divided into two groups (n=30). CBCT scans were taken before and after the treatment, and sections at 1, 2 and 3 mm from the apex were compared. Pairwise comparisons were carried out using the Mann Whitney-U test. The centering ratio data were analyzed using the Chi-square test and Fisher’s exact test. All statistical analyses were carried out using Sigma Stat 4 software. The difference between PathFile and R-Pilot in canal transportation in mesiodistal direction was significant at 1 and 2 mm from the apex (P<0.01). The R-Pilot file was significantly superior to PathFile in centering ability in mesiodistal direction at 1 mm from the apex (P<0.05). Canal transportation direction was towards the mesiolingual and distobuccal in R-Pilot and PathFile groups, respectively. Within the limitations of this study, the results showed that R-Pilot with reciprocal movement is a safe and easy to use instrument for creating a glide path.

Endodontic treatment of necrotic immature teeth poses several clinical challenges. A major problem is the elimination of microorganisms from the root canal system. This study evaluates the in vitro antibacterial efficacy of ciprofloxacin (CIP), levofloxacin (LEV), and their combination with N-acetylcysteine (NAC) in root canals infected with Enterococcus faecalis (E. faecalis). Methods and Materials: A total of 120 human extracted teeth with single canals were prepared and randomly divided into six groups: Calcium hydroxide (CH), ciprofloxacin (CIP), levofloxacin (LEV), ciprofloxacin and N-acetylcysteine (CIP+NAC), levofloxacin and N-acetylcysteine (LEV+NAC), and normal saline as a positive control. According to the name of the groups, intracanal medicaments were placed into the canals and the teeth were restored with a temporary filling. After one week, intracanal medicament was removed and the final count of bacteria was measured. Antibacterial effect of medicament was assessed by measuring the percentage reduction in the colony counts (RCC) and scanning electron microscopy (SEM). The Mann-Whitney U test and the Kruskal-Wallis test were used to compare the overall antibacterial efficacy of the intracanal medicaments at significance level of 0.05. All intracanal medicaments were significantly more effective than calcium hydroxide (P<0.05). The combination of LEV and NAC caused significantly higher reduction in colony count in comparison with other tested medicaments (P=0.001). The combination of LEV and NAC showed greater antibacterial activity compared with other tested medicaments against biofilm of E. faecalis. Thus, it has the potential to be used in regenerative endodontic treatments.

The aim of this study was to compare negotiation, centering ability and transportation of three path finder rotary instruments (ProGlider, ScoutRace and M3 Pro-Gold Path File) to create glide path in second mesiobuccal (MB2) canals of maxillary molars with cone-beam computed tomography (CBCT). Methods and Materials: In this in vitro study, 66 maxillary molars with separate second MB2 canals were selected with the following criteria: having 18-21 mm root length, without any resorption or calcification in radiography, without previous treatment and 20-40ºcurve according to Schneider’s method. Then MB2 canals were randomly divided into three groups (n=22). CBCT scan before and after root canal negotiation was taken. A #10 K-file for determination of working length was inserted into all canals. In group1; ProGlider file, group2; ScoutRace file and in group 3; M3 Pro-Gold Path file was implemented. The calculated data from CBCT based on reaching full working length (RFWL) or not (NRFWL) were analyzed using the Pearson Chi-square test. Centering ability was calculated by Fisher’s exact test and amount of transportation was determined with the Pearson Chi-square test in SPSS software. ProGlider file had the least RFWL and ScoutRace was the best, but the results were not statistically significant (P>0.05). Regarding the centering ability and transportation, all 3 groups showed no significant differences (P>0.05), except at level of 2 mm from the apex in buccopalatal direction for ProGlider and ScoutRace files (P<0.05). In spite of insignificantly different results, ScoutRace file was better than other groups in negotiating and centering ability in mesiodistal direction of the MB2 canal in maxillary molars. Also, ProGlider file was significantly better than ScoutRace regarding transportation at level of 2 mm from apex in buccopalatal direction.

This study evaluated the effect of propylene glycol (PG) on the push-out bond strength of calcium-enriched mixture (CEM) cement compared to mineral trioxide aggregate (MTA). Methods and Materials: The lumens of two hundred 2±0.2 mm-thick root sections from human extracted teeth were prepared to achieve a diameter of 1.3 mm. The samples were then allocated into eight groups of 25 on the basis of the materials used (MTA or CEM cement) and different proportions of PG (0%, 20%, 505, and 100%). In each group, 0.4 mL of the liquid was mixed with 1 g MTA or CEM cement. After incubation, the push-out strength of the samples was measured using a universal testing machine. Data were analyzed using the two-way ANOVA followed by one-way ANOVA and student’s t-test. The MTA group showed significantly higher bond strength in comparison with CEM group (P≤0.001). Also 100% and 20% PG increased the bond strength of MTA (P≤0.001). For CEM cement, 100% and 50% PG decreased the bond strength (P≤0.001). This in vitro study demonstrated that while PG increased the push-out bond strength of MTA, it is not recommended for mixing with CEM cement.

The aim of this study was to evaluate the effectiveness of 2.5% sodium hypochlorite associated with 17% Ethylenediaminetetraacetic acid (NaOCl-EDTA), versus that of 1% peracetic acid (PA), in removing the smear layer, as assessed by scanning electron microscopy (SEM), and in exerting bactericidal action against Enterococcus faecalis (E. faecalis), as assessed by the real-time polymerase chain reaction (real-time PCR). Methods and Materials: Fifty-five extracted mandibular single-rooted premolars were selected, and divided into two experimental groups (NaOCl-EDTA and PA; n=25) and one control group (0.9% saline; n=5). Pre- and post-instrumentation samples were collected and assessed for the presence of E. faecalis using real-time PCR. The teeth were instrumented using hand files and the ProTaper Universal system (hybrid technique) for a standardized time of 7 min. A total of 20 mL of NaOCl followed by 5 mL of EDTA were applied during instrumentation in the NaOCl-EDTA group, whereas 20 mL of PA and 20 mL of saline were applied in the PA and control groups, respectively. An additional 5 mL of saline was applied in all the groups to neutralize the environment. A scoring system was used to conduct the SEM assessment. The results were submitted to the Kruskal-Wallis test, complemented by Dunn's test (SEM analysis) (P<0.05). A significant microbial reduction was observed in both the PA and the NaOCl-EDTA groups (P<0.05). In the PA group, the presence of a smear layer in the apical third was significantly greater than in the cervical third (P<0.05); no significant differences were observed between the middle and cervical thirds, or between the middle and apical thirds (P>0.05). In the NaOCl-EDTA group, the smear layer scores were significantly higher in the apical third than in the cervical and middle thirds (P<0.05). This in vitro study showed that there was no significant difference between PA and NaOCl-EDTA irrigation regimens regarding either antimicrobial action against E. faecalis or removal of the smear layer, except for greater removal in the middle third by the NaOCl-EDTA group.

The purpose of this in vitro study was to compare the effectiveness of sonic activation and syringe irrigation of 5.25% sodium hypochlorite in removing the Enterococcus faecalis (E. faecalis) biofilm. Methods and Materials: Root canals of 54 extracted human single-rooted central incisors were prepared with ProTaper S1-S2-F1-F2 and Gates Gliden burs size 1, and 2 at the working length. After sterilization, the root canals were contaminated with E. faecalis suspension and randomly assigned to three groups: G1, conventional syringe irrigation; G2, sonic agitation of NaOCl with Endo Activator system; and G3, no subjected to the mentioned irrigation techniques (negative control). Canals were sampled after the disinfection procedure. The colony forming units (CFU) count was evaluated. Samples were also visualized under fluorescent microscope to count viable bacteria. Data were statistically analyzed using the Kruskal-Wallis and one-way ANOVA followed by Tukey’s test (P<0.05). There was a significant reduction in the CFU count after both irrigation techniques. There was no significant difference between two techniques (P=0.874). Using bacterial viability kit, Endo Activator displayed the least viable bacteria than the other groups (P<0.001) and control group showed the greatest one (P<0.001). In this in vitro study, the Endo Activator system was more successful in reducing intratubular viable bacteria compared with NaOCl syringe irrigation alone.

The purpose of this in vitro study was to assess the effects of anatomic root levels, different adhesive strategies and cementation system on bond strength (BS), nano leakage (NL) and degree of conversion (DC) after fiber posts cementation. Methods and Materials: Sixty-six roots of human premolars were endodontically prepared and divided according to the combination of adhesive application technique (manual passive, manual active and active vibratory) and the cementation system (Adper Single Bond 2/RelyX ARC [SBAR] and Single Bond Universal/RelyX Ultimate [SBUL]). Specimens were transversally sectioned into six 1-mm-thick serial slices, which were subjected to BS testing (n=7), to NL analysis using scanning electron microscopy (SEM) after slice immersion in silver nitrate (n=2), and micro-Raman spectroscopy for DC (n=2). Data were analyzed using two-way ANOVA and Bonferroni post-hoc test (α=5%). Bond strength values significantly increased with active vibratory application technique (P<0.001), no significant difference was noted between adhesive systems. The cementation system Single Bond Universal/RelyX Ultimate demonstrated the lowest nano leakage values (P<0.05). The manual active and vibratory application techniques showed statistically higher degree of conversion values than the manual passive technique at the coronal and medium thirds (P<0.05); and the lowest results were observed with manual passive application to Single Bond Universal/RelyX Ultimate (P=0.016). The study concluded that techniques with active application (vibratory and manual) resulted in higher bond strength values. The mode of adhesive application influence the results.

For a successful root canal treatment, it is critical for the clinician to have a complete knowledge of the root canal morphology, interprets radiographs critically and properly assesses the pulp chamber floor. Anatomical variations are critical in diagnosis and a successful treatment outcome in endodontics. Knowledge of root canal morphology and anomalies is essential to succeed in root canal therapy. Mandibular premolars are famous for their atypical morphology. But the occurrence of type XVII Sert and Bayirli’s root canal type is very rare in them. The purpose of this case report is to present treatment of a seldom root canal system in a mandibular second premolar. Reports of unusual cases cause clinicians to do an accurate clinical examination and radiographic interpretation and consider atypical root canal configurations.

In endodontics, metal artifacts are the major weak points of employing cone-beam computed tomography (CBCT) in teeth with metallic posts and restorations. The aim of this article is to introduce a novel technique for preparation of beneficial CBCT images of anterior teeth with metal posts and/or crowns. In this novel technique, the patient who was instructed to take CBCT images for reason of implant surgery, was asked to puff out his cheeks/lips during the rotation of x-ray tube. By comparing the image taken with this technique to normal image it was obvious that after applying the cheek puffing technique, the metal artifacts around restored anterior teeth significantly reduced. Then it seems that this novel technique removes the metal artifacts from the crowned teeth to distances far from the tooth structure and enables more accurate diagnosis.

Root fracture occurs in 0.5 to 7% of all dental injuries. Subsequent to this injury, the coronal segment is displaced, while the apical segment is rarely displaced. Emergency treatment involves repositioning of the coronal segment close to the radicular segment as much as possible to enhance the chance of pulp revascularization. If pulp necrosis occurs, the infective products cause an inflammatory response and radiolucency is seen at the fracture line. In the present case, the patient had two maxillary central incisors with horizontal middle third root fractures due to a traumatic accident four years earlier. The right central incisor showed an endodontic abscess due to pulp infection in the coronal segment. The coronal fragment was treated. In this case study all signs and symptoms resolved after treatment and three year follow-up showed a successful treatment outcome. The left central incisor had a vital pulp according to vitality tests, so “observation only” strategy was considered for this tooth.

Traumatic dental intrusion is a serious injury and results in significant damage to the periodontal ligament, dentin-pulp complex, and alveolar bone. This article presents a case of severe intrusion of the two upper permanent central incisors where the treatment option was the combination of the surgical and orthodontic technique. The difficulty of accessing the crowns of these teeth to bond the brackets was solved by lifting a full thickness flap. To disengage the teeth from the alveolus, a careful dislocation motion was performed. After suturing the flap, a removable orthodontic appliance was installed and an extrusive force was applied for 8 weeks. After 10 weeks, the endodontic treatment was performed and the crowns were restored. The 10-year clinical control showed normal mobility. Radiographically, minor losses of the cervical alveolar cortical bone and integrity of the periodontal ligament were observed.

This case report documents the clinical approach adopted for two maxillary incisors with intrusion and lateral luxation trauma. The proposed procedures involved reposition of both teeth, one of them with surgical extrusion and endodontic procedure for both, with 10 years of follow-up.