Original Article

In Vitro Spectrophotometry of Tooth Discoloration Induced by Tooth-Colored Mineral Trioxide Aggregate and Calcium-Enriched Mixture Cement

Marjan Arman, Zohreh Khalilak, Moones Rajabi, Ehsan Esnaashari, Keyvan Saati

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 226-230

Introduction: There are numerous factors that can lead to tooth discoloration after endodontic treatment, such as penetration of endodontic materials into the dentinal tubules during root canal treatment. The aim of this in vitro study was to compare discoloration induced by tooth colored mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement in extracted human teeth. Methods and Materials: Thirty two dentin-enamel cuboid blocks (7×7×2 mm) were prepared from extracted maxillary central incisors. Standardized cavities were prepared in the middle of each cube, leaving 1 mm of enamel and dentin on the labial surface. The specimens were randomly divided into two study groups (n=12) and two positive and negative control groups (n=4). In either study groups the cavities were filled with MTA or CEM cement. The positive and negative control groups were filled with blood or left empty, respectively. The cavities were sealed with composite resin and stored in normal saline. Color measurement was carried out by spectrophotometry at different time intervals including before (T0), and 1 week (T1), 1 month (T2) and 6 months (T3) after placement of materials. Repeated-measures ANOVA was used to compare the discoloration between the groups; the material type was considered as the inter-subject factor. The level of significance was set at 0.05. Results: No significant differences were detected between the groups in all time intervals (P>0.05). Conclusion: Tooth discoloration was similarly detectable with both of the two experimental materials.

Keywords: Calcium-Enriched Mixture; CEM Cement; Crown Discoloration; Mineral Trioxide Aggregate; MTA; Spectrophotometer


Cytotoxicity of a New Nano Zinc-Oxide Eugenol Sealer on Murine Fibroblasts

Maryam Javidi, Mina Zarei, Salma Omidi, Ahmad Ghorbani, Maryam Gharechahi, Maryam Shayani Rad

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 231-235

Introduction: The aim of this study was to evaluate the cytotoxicity of a new nano zinc-oxide eugenol (NZOE) sealer in comparison with AH-26 and Pulpdent root canal sealers. Methods and Materials: The L929 mouse fibroblast cells were cultivated and incubated for 24, 48 or 72 h with different dilutions (1/1, 1/2, 1/4, 1/8, 1/16 and 1/32) of culture media previously exposed to either of the test sealers naming NZOE, AH-26 or Pulpdent. At the end of incubation period, the effect of sealers on cell viability was evaluated using Mosmann’s Tetrazolium Toxicity (MTT) colorimetric assay. The data was compared using the one-way analysis of variance (ANOVA) followed by the Tukey’s post hoc test for multiple comparisons. Results: After 24, 48 or 72 h, both NZOE and Pulpdent sealers inhibited cell viability at 1/1, 1/2 and 1/8 dilutions. Within the 24 and 48 h, the AH-26 sealer reduced the cell viability at all dilutions except the 1/32 solution; however after 72 h even the 1/32 dilution was cytotoxic. Conclusion: The biocompatibility of the nano zinc-oxide eugenol sealer was comparable to Pulpdent sealer and lower than AH-26.

Keywords: Cytotoxicity; MTT Assay; Nanoparticles; Root Canal Sealer; Zinc-Oxide Eugenol

Scanning Electron Microscopic Evaluation of Residual Smear Layer Following Preparation of Curved Root Canals Using Hand Instrumentation or Two Engine-Driven Systems

Abbasali Khademi, Masoud Saatchi, Mohammad Mehdi Shokouhi, Badri Baghaei

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 236-239

Introduction: In this experimental study, the amount of smear layer (SL) remnants in curved root canals after chemomechanical instrumentation with two engine-driven systems or hand instrumentation was evaluated. Methods and Materials: Forty-eight mesiobuccal roots of mandibular first molars with curvatures ranging between 25 and 35 degrees (according to Schneider’s method) were divided into three groups (n=16) which were prepared by either the ProTaper Universal file series, Reciproc single file system or hand instrumentation. The canals were intermittently irrigated with 5.25% NaOCl and 17% (ethylenediaminetetraacetic acid) EDTA, followed by distilled water as the final rinse. The roots were split longitudinally and the apical third of the specimens were evaluated under 2500× magnification with a scanning electron microscope (SEM). The mean scores of the SL were calculated and analyzed using the non-parametric Kruskal-Wallis and Mann-Whitney U tests. Results: The mean scores of the SL were 2.00±0.73, 1.94±0.68 and 1.44±0.63 µm for the ProTaper Universal, Reciproc and hand instrumentation, respectively. Mean score of SL was significantly less in the hand instrumentation group than the ProTaper (P=0.027) and Reciproc (P=0.035) groups. The difference between the two engine-driven systems, however, was not significant (P=0.803). Conclusion: The amount of smear layer in the apical third of curved root canals prepared with both engine-driven systems was similar and greater than the hand instrumentation technique. Complete cleanliness was not attained.

Keywords: Canal Preparation; Endodontics; Irrigants; Scanning Electron Microscopy; Smear layer

Comparison of Cleaning Efficacy and Instrumentation Time in Primary Molars: Mtwo Rotary Instruments vs. Hand K-Files

Fatemeh Ramezanali, Farzaneh Afkhami, Ali Soleimani, Mohammad Javad Kharrazifard, Farshid Rafiee

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 240-243

Introduction: Pulpectomy is the preferred treatment for restorable primary teeth with symptomatic irreversible pulpitis or periradicular lesion. Considering the rather new application of rotary files for pulpectomy of primary teeth, the aim of this study was to compare the cleaning efficacy and instrumentation time of hand K-files and Mtwo rotary system for preparation of human primary molars. Methods and Materials: This experimental study was conducted on 100 extracted primary maxillary and mandibular intact molars with no resorption. Access cavities were prepared and India ink was injected into the root canal on a vibrator using an insulin syringe. Canals were then divided into 5 groups (n=20): in group I, canals were instrumented using K-files up to #25 for mesial and buccal canals and #30 for palatal and distal canals. In group II, canals were prepared using Mtwo rotary files (15/0.05, 20/0.06 and 25/0.06 for mesial and buccal canals and 15/0.05, 20/0.06, 25/0.06 and finally 30/0.05 for distal and palatal canals). In group III, root canals were only irrigated with saline. Groups IV and V were the positive and negative control groups, respectively. The time required for cleaning and preparation of the canals for each of the specimens in groups I, II and III was recorded. Results: The mean score of cleanliness of Mtwo was not significantly different from K-file group (P>0.05). However the mean instrumentation time in Mtwo group was significantly shorter (P<0.001). Conclusion: Although there were no differences regarding the cleaning efficacy of either system, Mtwo rotary files were far more time efficient.

Keywords: Deciduous Tooth; Hand K-files; Mtwo; Primary Molars; Pulpectomy; Root Canal Preparation; Root Canal Therapy

The Effect of Orthodontic Forces on Tooth Response to Electric Pulp Test

Jalil Modaresi, Hosein Aghili, Omid Dianat, Farnaz Younessian, Faranak Mahjour

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 244-247

Introduction: The current study investigated the pulp response to electric pulp testing (EPT), before, upon initiation and one month after the start of orthodontic tooth movement. Methods and Materials: A total of 402 anterior teeth from 39 patients (mean age of 16.8±2.7 years) were examined in this non-controlled prospective study. The aligning forces were administered using initial NiTi archwires ligated on fixed appliances by using the MBT straight wire technique. The electrical stimulation was provided by the EPT. The EPT readings were recorded at three time points: before bonding (EPT0), immediately upon initiation (EPT1) and 1 month post-treatment (EPT2). The data were statistically analyzed by the ANOVA and Bonferroni tests (P<0.05). Results: Prior to bonding of the orthodontic brackets, the mean EPT value for all the experimental teeth was 3.42 EPT units. Upon initiation, the mean value of EPT1 for each tooth increased to 7.62 units. One month later, the mean EPT2 values dropped to 6.27 units. At this time point, 64 teeth (16%) of the experimental teeth failed to respond. The differences among EPT values at different time points were significant. There was no association between the EPT values and the location or the type of teeth. Conclusion: The physiological changes in the pulp affect the nerve fibers in the early stages of the orthodontic force application. As a result, thresholds to electrical stimulation would increase and the EPT may not initiate a response. Therefore results obtained by electrical pulp testing should be interpreted accordingly.

Keywords:Electric Pulp Test; Orthodontic Treatment; Pulp Vitality


The Effect of Different Mixing Methods on Working Time, Setting Time, Dimensional Changes and Film Thickness of Mineral Trioxide Aggregate and Calcium-Enriched Mixture

Shahriar Shahi, Negin Ghasemi, Saeed Rahimi, Hamidreza Yavari, Maryam Janani, Hadi Mokhtari, Mahmood Bahari, Parastu Rabbani

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 248-251

Introduction: The aim of the present study was to evaluate the effect of different mixing techniques (conventional, amalgamator and ultrasonic mixing) on the physical properties the working time (WT), setting time (ST), dimensional changes (DC) and film thickness (FT)] of calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA). Methods and Materials: The mentioned physical properties were determined using the ISO 6786:2001 specification. Six samples of each material were prepared for three mixing techniques (totally 36 samples). Data were analyzed using descriptive statistics, two-way ANOVA and Post Hoc Tukey’s tests. The level of significance was defined at 0.05. Results: Irrespective of mixing technique, there was no significant difference between the WT and FT of the tested materials. Except for the DC of MTA and the FT of the all materials, other properties were significantly affected with mixing techniques (P<0.05). The ultrasonic technique decreased the ST of MTA and CEM cement and increased the WT of CEM cement (P<0.05). Conclusion: The mixing technique of the materials had no significant effect on the dimensional changes of MTA and the film thickness of both materials.

Keywords: Calcium-Enriched Mixture; Dimensional Changes; Film Thickness; Mineral Trioxide Aggregate; Setting Time; Working Time

Effects of Reciproc, Mtwo and ProTaper Instruments on Formation of Root Fracture

Sahar Jalali, Behrooz Eftekhar, Payam Paymanpour, Mohammad Yazdizadeh, Mansour Jafarzadeh

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 252-255

Introduction: The aim of this study was to compare the formation of dentinal crack and craze lines in the root dentin during root canal preparation with three different NiTi endodontic systems, naming Reciproc (RCP), ProTaper Universal (PTU) and Mtwo. Methods and Materials: One hundred extracted mandibular premolars with single canals were selected and decoronated. The teeth were randomly divided into four groups of 25 each (n=25). In groups 1, 2 and 3 the teeth were prepared using Mtwo, PTU and RCP, respectively. While in group 4 (control group) the samples were left unprepared. After preparation, all specimens were sectioned perpendicular to the long axis of root at 3, 5 and 9-mm distances from the apex. The sections were then individually observed under 12× magnification using stereomicroscope. The data was analyzed using the chi-square and Fisher’s exact tests. The level of significance was set at 0.05. Results: No cracks were observed in the control group. All engine-driven systems caused dentinal cracks. Mtwo and PTU caused cracks significantly more than RCP (P<0.05). There was no significant difference between RCP and control group (P>0.05). Conclusion: All three engine-driven systems created dentinal defects. Reciproc caused less cracks than Mtwo and ProTaper Universal.

Keywords: Cracks; Craze Lines; Dentin; Nickel-Titanium Instruments; Root Canal Preparation; Tooth Root; Vertical Root Fracture

A Survey over the Dentists’ and Endodntists’ Approaches towards the Management of Endodontic Emergencies in Mashhad, Iran

Maryam Bidar, Maryam Gharechahi, Tayebeh Soleimani, Neda Eslami

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 256-262

Introduction: Pain or swelling caused by various stages of inflammation/infection of the pulp/periradicular area is called endodontic emergencies. Determining the most effective method of emergency treatment is a challenging issue in endodontics. The goal of this study was to determine and compare the level of knowledge in general dentists and Endodontists about endodontic emergency treatment plan in Mashhad, Iran in 2012-2013. Methods and Materials: In this cross-sectional descriptive study, 152 questionnaires were distributed among 120 general dentists and 32 Endodontists of Mashhad. The questionnaire contained two separate parts. The first part included demographic information and in the second part different treatment protocols were suggested for 12 various conditions of pulp/periapical emergencies, and the participants were asked to choose the correct option(s). To determine the relationship between qualitative variables, the chi-square analysis was used. The level of significance was set at 0.05. Results: There were significant differences between treatment plans presented by general dentists and Endodontists about endodontic emergencies, especially in cases of necrotic pulp and subsequent swelling. Conclusion: Level of knowledge of dentists about the indications of incision and drainage, intra-canal medicament, root filing beyond the apical foramen and antibiotic prescription was not enough. These findings highlight the importance of refreshing courses for general dentists to improve their competency in the management of endodontic emergencies.

Keywords: Emergency; Endodontics; Endodontists; Flare Up; General Dentists; Level of Knowledge

Comparing the Coronal Flaring Efficacy of Five Different Instruments Using Cone-Beam Computed Tomography

Amin Homayoon, Mahmood Reza Hamidi, Azam haddadi, Zahra Sadat Madani, Ehsan Moudi, Ali Bijani

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 263-267

Introduction: Fearless removal of tooth structure during canal preparation and shaping has negative effects on the prognosis of treatment. On the other hand, sufficient pre-enlargement facilitates exact measurement of the apical size. The present in vitro study aimed to compare the efficacy of Gates-Glidden drills, K3, ProTaper, FlexMaster and RaCe instruments in dentin removal during coronal flaring using cone-beam computed tomography (CBCT). Methods and Materials: A total of 40 mandibular molars were selected and the coronal areas of their mesiobuccal and mesiolingual root canals were randomly prepared with either mentioned instruments. Pre- and post-instrumentation CBCT images were taken and the thickness of canal walls was measured in 1.5- and 3-mm distances from the furcation area. Data were analyzed using the one-way ANOVA. Tukey’s post hoc tests were used for two-by-two comparisons. Results: At 1.5-mm distance, there was no significant difference between different instruments. However, at 3-mm distances, Gates-Glidden drills removed significantly more dentin compared to FlexMaster files (mean=0.18 mm) (P<0.02); however, two-by-two comparisons did not reveal any significant differences between the other groups. Conclusion: All tested instruments can be effectively used in clinical settings for coronal pre-enlargement.

Keywords: Cone-Beam Computed Tomography; Coronal Flaring; Coronal Pre-Enlargement; Root Canal Treatment; Root Canal Preparation

Effects of Clinical Training and Case Difficulty on the Radiographic Quality of Root Canal Fillings Performed by Dental Students in Saudi Arabia

Reem Siraj Alsulaimani, Kholod Khalil Al-Manei, Sara A. Alsubait, Razan Shafik AlAqeely, Sharifa A. M. Al-Shehri, Ebtissam M. Al-Madi

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 268-273

Introduction: The aim of this study was to evaluate the effects of training duration and case difficulty on the radiographic quality of root canal fillings performed by dental students in Saudi Arabia. Methods and Materials: A longitudinal cohort study was conducted at King Saud University. Root canal treatments performed by 55 dental students from 2012-2014 were included in the study. Each student treated at least five teeth during the first year of clinical endodontic training and another five teeth during the second year. Case difficulty was assessed based on tooth position in the dental arch and preoperative conditions. The radiographic quality of the root canal filling was evaluated by two endodontists blinded to treatment completion date. The evaluation criteria were adequate obturation, presence of mishaps and preparation taper. The data were statistically analysed using univariate and multivariate logistic regression analyses; and the level of significance was set at 0.05. Results: Inadequate obturation and mishaps were significantly less prevalent in teeth treated after 2 years of clinical training. The odds ratios for inadequate obturation and mishaps increased significantly as tooth position moved posteriorly. Inadequate obturation and more mishaps were significantly more prevalent in teeth with preoperative conditions. Preparation taper was not significantly affected by training duration or case difficulty. Conclusion: The quality of root canal fillings performed by Saudi students was adversely affected by case difficulty. The radiographic quality of root canal fillings improved significantly after 2 years of clinical training. Preparation taper outcome is likely dependent on the preparation technique and instrument taper.

Keywords: Obturation Density; Obturation Length; Preparation Taper; Procedural Accident; Root Canal Treatment

Case Report

Craniofacial Pain as the Sole Sign of Prodromal Angina and Acute Coronary Syndrome: A Review and Report of a Rare Case

Mahta Fazlyab, Ehsan Esnaashari, Mojgan Saleh, Farshad Shakerian, Davood Akhlagh Moayed, Saeed Asgary

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 274-280

Orofacial pain can arise from different regions and etiologies. Some of the most debilitating pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). The problem with referred pain is the misdiagnosis and unnecessary therapy directed to the pain location instead of its origin. When craniofacial pain is the sole sign of myocardial ischemia, failure to recognize its cardiac source can endanger the patient. In particular, apart from unnecessary dental treatments, patients with acute myocardial infarction who do not experience chest pain run a very high risk of misdiagnosis and death. As endodontists, each of us may face many patients complaining of pain sensation in the teeth with the main source being other craniofacial/visceral organs. This review plots a diagnostically challenging case paving the way for further literature presentation in this regard. The aim of this compendious review was to gain knowledge about the prevalence, clinical characteristics and possible mechanisms of craniofacial pain of cardiac origin, in order to improve the clinician’s ability to make a correct diagnosis.

Keywords: Craniofacial Pain; Myocardial Infarction; Orofacial Pain; Pre-Infarction Angina; Prodromal Angina; Referred Pain

Conservative Treatment of an Invaginated Maxillary Lateral Incisor with a C-shaped Canal Using Cone-Beam Computed Tomography

Maryam Forghani, Elahe Moghim Farooji, Javad Abuchenari, Maryam Bidar, Neda Eslami

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 281-283

This report describes the non-surgical treatment of an invaginated maxillary lateral incisor with two fused roots. The mesial root had a C-shaped canal, while the distal one had a type III dens invagination. Cone-beam computed tomography (CBCT) was used to help with the diagnosis and treatment decision making. Clinical and radiographic follow-up revealed satisfactory periapical repair and absence of symptoms after 15 months.

Keywords: C-Shaped Canal; Cone-Beam Computed Tomography; Dens Invagination; Dens Invaginatus; Dens in Dente; Invaginated Teeth; Maxillary Lateral Incisor

Vital pulp therapy (VPT) of permanent mature teeth is continuously ascertaining to be a more reliable endodontic treatment. The purpose of this case report was to describe successful VPT of a mature mandibular left first molar with concurrent hyperplastic pulpitis, internal root resorption and periradicular periodontitis in a 35-year-old male patient. After complete caries removal and access cavity preparation, the dental pulp was removed from the coronal third of the roots. To protect the remaining pulp, calcium-enriched mixture (CEM) cement was placed and adapted into the cavities; the tooth was then restored with amalgam. Six months after VPT, radiographic examination showed evidence of periradicular healing. Clinically, the tooth was functional without signs and symptoms of infection/inflammation. The successful outcome of this case suggests that diseased dental pulp (i.e. irreversible pulpitis) has the potential to heal after pulp protection with CEM biocement.

Keywords: Apical Periodontitis; Calcium-Enriched Mixture; Endodontic; Hyperplastic Pulpitis; Irreversible Pulpitis; Permanent Teeth; Pulp Polyp; Pulpotomy; Root Resorption; Vital Pulp Therapy

Treatment of a Maxillary First Molar with Two Palatal Roots

Vahideh Asghari, Saeed Rahimi, Negin Ghasemi, Bita Talebzadeh, Ahmad Nouroloyuni

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 287-289

Thorough knowledge of the morphology and internal anatomy of the root canal system is essential, because it determines the successful outcome of endodontic treatment. The main goal of endodontic treatment is to prevent apical periodontitis and/or to promote the healing of periapical lesion. Presence of two canals or roots on the palatal side of the first maxillary molar has rarely been reported. This case report presents a maxillary first molar with two separate palatal roots.

Keywords: Anatomic Variation; Maxillary First Molar; Palatal Root; Root Canal Anatomy

Review Article

Impact of Ultrasonic Activation on the Effectiveness of Sodium Hypochlorite: A Review

Zahed Mohammadi, Sousan Shalavi, Luciano Giardino, Flavio Palazzi, Saeed Asgary

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 216-220

Using ultrasonic devices in endodontics can enhance the antibacterial and tissue dissolving ability of different root canal irrigants such as sodium hypochlorite (NaOCl) which is the most common irrigant with excellent antibacterial and tissue dissolving abilities. However, due to its high surface tension, its penetration into the irregularities of the root canal system is a challenge. The purpose of this paper was to review the different ultrasonic devices, different types of ultrasonic irrigation, the effect(s) of ultrasonic activation on the antibacterial and biofilm-removal abilities of NaOCl as well as the effect of ultrasonic activation on the smear layer removal ability of NaOCl.

Keywords: Antibacterial Activity; Biofilm; Root Canal Irrigants; Smear Layer; Sodium Hypochlorite; Ultrasonic Activation

Comparison of Endodontic Retreatment in Teeth Obturated With Resilon or Gutta-Percha: A Review of Literature

Ciro Soares, Conceição Maia, Fábio Vale, Cícero Gadê-Neto, Lílian Carvalho, Hanieri Oliveira, Rejane Carvalho

Iranian Endodontic Journal, Vol. 10 No. 4 (2015), 9 September 2015 , Page 221-225

Introduction: Retreatment of endodontically treated teeth is a challenge that requires complete removal of the previous filling material. Several techniques are indicated for this procedure. The present review tries to identify the most efficient method for extirpation of Resilon (RS) root fillings and to compare the speed and efficacy of RS and gutta-percha (GP) root filling removal. Methods and Materials: Three trained evaluators conducted a search through three major databases (PubMed, Cochrane Library and Lilacs) over the articles published in the period from 2001 to 2014. The search keywords were Epiphany Sealer, Resilon, Retreatment and Removal Procedure. Results: Twelve articles were included in the final sample (three in vitro studies and nine randomized trials). Conclusion: The ProTaper (manual or rotatory) system in combination with chemical solvents is the most efficient method for removing Resilon root filling. Retreatment of Resilon is more rapid and associated with less remnants of debris.

Keywords: Endodontic Retreatment; Gutta-Percha; Resilon