Original Article

Introduction: Self-medication with antibiotics may increase the risk of inappropriate use and development of antibiotic-resistant bacteria. The aim of this study was to determine the prevalence of self-medication with antibiotics amongst dental outpatients in Iranian population.  Methods and Materials: One thousand and two hundred of dentistry patients, who were referred to dental school clinics in ten major provinces of Iran, participated in this study. A valid self-administered questionnaire regarding self-medication with antibiotics in case of dental pain was used to collect data. Data were analysed using descriptive statistics and Logistic regression analysis. Results: In our study population, the prevalence of self-medication was 42.6%. Amongst the Iranian cities, the highest prevalence of self-medication with antibiotics belonged to the city of Bandar Abbas (64%) and the lowest was seen in the city of Kerman (27.3%). Men were more likely to take antibiotics. Amoxicillin was the mostly used antibiotic. Severe pain, previous self-medications and high costs of dental visits were the most common reasons for self-medication with antibiotics in the investigated population. In addition, the present study showed that marriage, acceptable financial status and high level of education could decrease self-medication with antibiotics. Conclusions: In the current investigation, an alarming fact was that self-medication for dental problems seemed very common amongst the studied population. One of its most important consequences was bacterial resistance. Therefore, there should be plans to promote and prioritize public health awareness and encourage general public’s motivation to reduce the practice of self-medication.

Keywords: Antibiotics; Dental Clinics; Prevalence; Self-medication

Incidence of Dentinal Micro Cracks during Root Canal Preparation with Self Adjusting File, Reciproc Blue, and ProTaper Next

Tomislav Katanec, Ivana Miletić, Gorana Baršić, Lumnije Kqiku-Bliblikaj, Mirza Žižak, Silvana Jukić Krmek

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 6-11

Introduction: Forces formed during root canal instrumentation could cause the crack formation in dentinal walls. Their propagation may result in vertical root fracture and eventually tooth loss. The aim of the study was to explore microcrack formation after root canal preparation with Self-adjusting File (SAF), Reciproc Blue (RB), and ProTaper Next (PTN) instruments on young premolars by means of micro-computed tomography. Methods and Materials: Forty-five upper premolars with two canals, were extracted due to orthodontic reasons from patients aged 16 to 20 years and stored for up to two months. The teeth were scanned with a micro-CT (Nikon XT H 225, Tring, UK) at structural resolution of 20.2 µm and randomly divided into three groups: SAF, RB, and PTN. Specimens were instrumented and irrigation was performed with 12 mL of 2.5% sodium hypochlorite (NaOCl) and 4 mL of 17% ethylenediaminetetraacetic acid (EDTA) per root canal. Subsequently, the specimens were scanned under the same conditions as before, in wet condition and 24 h after drying. The presence of microcracks in dentinal walls was evaluated using the image-processing software Volume Graphics VGStudio Max 3. Results: No dentinal defect was found in any evaluated specimen, neither in pre-nor post-operative scans in wet and dry condition. Conclusion: Under the circumstances of this in vitro study instruments with improved design and metallurgy do not cause dentinal microcracks in young premolar teeth.

Keywords: Dentin; Micro-computed Tomography; Nickel-titanium; Root Canal Preparation

Introduction: The aim of this in vitro study was to evaluate the accuracy of cone-beam computed tomography (CBCT) and two electronic apex locators (EALs) when measuring the actual length of root canals. Methods and Materials: One hundred and eighty four root canals in 135 extracted anterior and posterior permanent teeth were studied. Root canal curvatures were analyzed on CBCT images, and root canals with curvatures less than 70º were chosen. Root canal length measurements were performed using CBCT, ProPex Pixi, E-Pex Pro, and the actual length (AL). The percentages of the measurements in the range of ±0.5 mm to the AL were compared using Fisher’s Exact test. The ICC indices and Bland-Altman plots were used to display the agreement of three devices with the AL measurements. The statistical significance was set at P<0.05. Results: The accuracies of E-Pex Pro and ProPex Pixi (87.5% and 82.6%, respectively) were better than that of CBCT (71.7%) (P<0.05). Conclusion: This in vitro study showed that although the accuracies of the two EALs were at high level, there was no device that had an agreement with the actual root canal length measurement

Keywords:Cone-beam Computed Tomography; Electronic Apex Locator; Endodontics; Root Canal Length; Root Canal Therapy 


The Effects of Sodium Hypochlorite on Organic Matters: Influences of Concentration, Renewal Frequency and Contact Area

Krah-Sinan Akissi Aline, Marie Adou-Assoumou, Stéphane Xavier Djolé, Franck Diemer, Marie Gurgel

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 18-22

Introduction: Sodium hypochlorite (NaOCl) reacts mainly with proteins and its effectiveness depends on the substances chemical reactivity. It has been reported that volume, concentration, renewal, time, temperature and contact area affect the diffusion of NaOCl in the root canal. However, the relationship between some of these factors is not clear. The purpose of this study was to test the effect of volume, contact area, concentration and renewal frequency of 2.5% and 9.8% NaOCl solutions   on their organic matter dissolving-capacity. Methods and Materials: Pieces of gelatine (18% w/v) with standardized weight, form and structure were either fully or partially exposed to a 2.5% or 9.8% NaOCl solution. In three successive studies, biological dissolution-capacity of NaOCl was tested under different conditions. In experiment 1 the effect of volume/time, in experiment 2 the time/concentration/renewal frequency and in experiment 3 the contact area/renewal frequency/concentration/time of 2.5% or 9.8% NaOCl solutions on dissolving-capacity of organic matter were studied. The weight loss of gelatine pieces over time was registered. The non-parametric tests of Mann-Whitney and Kruskal-Wallis at the 5% threshold were used for statistical analysis. Results: The differences between the two concentrations of NaOCl solution (2.5% and 9.8%) are statistically significant in the effects of different volumes on total dissolution time (P<0.05). Differences in weight loss according to the concentration of the NaOCl solution used (2.5% or 9.8%) were significant after 2 min of contact time (P<0.05). Differences in weight loss between the model and the tube are significant (P<0.05) when the solution is repeated every 30 sec and every 1 min after 2 min of contact. Conclusion: This in vitro study showed that   using a more concentrated NaOCl solution would certainly improve the endodontic disinfection, but the biological risk in case of apical extrusion should be considered.

Keywords: Concentration; Dosage; Gelatine; Root Canal Irrigant; Sodium Hypochlorite

Introduction: The aim of this study was to evaluate the effects of exposure to sodium perborate and H2O2 on the surface characteristics of MTA Angelus, Biodentine and MTA Repair HP after 1 and 6 month time intervals. Methods and Materials: Three calcium silicate-based cements were evaluated: MTA Angelus, Biodentine, MTA Repair HP. A total of 234 specimens were stored in Hank’s balanced salt solution (HBSS) for 1 month or 6 months in which afterwards were divided into 3 groups according to bleaching agent applied: control, sodium perborate, 35% hydrogen peroxide. The microstructural changes were evaluated by scanning electron microscopy and energy-dispersive X-ray spectroscopy. The surface microhardness was also evaluated. Data were analyzed by one-way analysis of variance and Games-Howell post-hoc tests for the effect bleaching agents and hydraulic calcium silicate-based cements and t-test was for the effect of time. Results: Distinctive alterations with uneven depression areas, woodpecker defects and cracks were seen due to exposure to perborate and H2O2 on all evaluated cements. Exposure to H2O2 caused a decrease in Ca/Si ratio in all experimental cements. Both H2O2 and perborate significantly decreased the microhardness of all cement (P<0.05) with H2O2 having a more profound effect (P<0.01). A 6-month delay in exposure to bleaching agents significantly increased the microhardness of Biodentine compared to 1 month (P<0.001 for both bleaching agents). Conclusion: Based on this in vitro study, H2O2 had more detrimental effects on MTA Angelus, Biodentine and MTA Repair HP. Sodium perborate may be a more conservative selection when considering effects on barrier materials.

Keywords: Bleaching Agent; Calcium Silicate Cement; Microhardness; Mineral Trioxide Aggregate; Scanning Electron Microscopy

Root and Canal Morphology of Maxillary Teeth in an Iranian Subpopulation Residing in Western Iran Using Cone-beam Computed Tomography

Nafiseh Nikkerdar, Mohammad Asnaashari, Atena Karimi, Solmaz Araghi, Shahin Seifitabar, Amin Golshah

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 31-37

Introduction: Accurate information regarding the morphology of roots and canals is a prerequisite for successful endodontic treatment. This study aimed to assess the number of roots and canals and canal type of maxillary teeth according to the Vertucci’s classification in an Iranian subpopulation residing in Western Iran using cone-beam computed tomography (CBCT). Methods and Materials: In this cross-sectional study, a total of 1750 teeth were evaluated on CBCT scans taken for purposes other than this study. For each tooth, 250 axial, sagittal and coronal sections with 1 mm slice thickness were evaluated using NNT Viewer software. The number of roots and canals and canal type according to the Vertucci’s classification were determined and reported. Data were analyzed using descriptive and analytical statistics via Fisher’s exact test and Chi square test. All data analyses were performed using SPSS version 18. Results: All of the maxillary anterior teeth were single-rooted, and Vertucci’s type I was the most common canal type. Maxillary premolars were mostly single-rooted and Vertucci’s type I was the most common type except for the first maxillary premolars, in which type V had the highest frequency. Maxillary molars mostly had three roots and two canals in the mesiobuccal root and one canal in the distobuccal and palatal roots. Conclusion: Although the number of roots in this cross-sectional study was similar to the findings of previous studies, canal type was significantly different from the results of previous studies. The result of this study can help clinicians in efficient root canal treatment of teeth.

Keywords: Cone-beam Computed Tomography; Maxilla; Root Canal Morphology

Apical Debris Extrusion with Conventional Rotary and Reciprocating Instruments

Eshagh Ali Saberi, Sediqe Ebrahimipour, Mersad Saberi

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 38-43

Introduction: The aim of the present study was to compare the amount of apical debris extrusion after preparation using hand files, reciprocating files, and full rotary nickel-titanium systems. Methods and Materials: One hundred extracted human mandibular molars with two separated canals in mesial root were divided into five groups and prepared using reciprocating systems (Reciproc and Safesider endodontic reamer files), full rotary systems (Mtwo and Neoniti A1 files) and hand instrumentation systems. Endodontic access was prepared and a #15 K-file was passed beyond the apex of the mesiobuccal canal by 1 mm to ensure the canal patency. All mesiobuccal canals were prepared 1 mm shorter than the anatomic apex. In each case, extruded debris was collected in an Eppendorf tube and weighed after desiccation. The mean weight of extruded material was calculated in each group. The analysis was carried out using the Kruskal–Wallis test followed by two tailed and Mann-Whitney U test at a significance level of 0.05. The Bonferroni correction was also applied to correct multiple comparisons. Results: There was a statistically significant difference between the reciprocal and other techniques in debris extrusion (P<0.05). The order of groups ranked in terms of debris extrusion from the lowest to highest was as follows: 1) Hand instrumentation group (with crown down technique), 2) Mtwo group, 3) Neoniti A1 group, 4) Safesider endodontic reamer group, and 5) Reciproc group. Conclusion: Based on this in vitro study, all systems have some apical debris extrusion; however, using the hand instrumentation system resulted in extrusion of significantly less debris compared to the Reciproc group. It seems that hand and rotary instrumentation systems are better than reciprocating instrumentation systems in terms of the amount of debris extrusion.

Keywords: Endodontics; Root Canal Preparation; Rotary Instrumentation

Different Application Methods for Endoseal MTA Sealer: A Comparative Study

Fariborz Moazami, Mohammadhasan Naseri, Parastoo Malekzade

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 44-49

Introduction: The aim of present ex vivo study was to investigate the filling quality and voids, using Endoseal mineral trioxide aggregate (Endoseal MTA) with a single-cone technique with and without ultrasonic application and to compare these methods with lateral compaction technique. Methods and Materials: Thirty-six extracted human anterior single-root teeth were prepared and assigned to 3 groups: Group 1: EMS group was Endoseal MTA+ single-cone; Group 2: EMSU group was Endoseal MTA+ single-cone with ultrasonic activation; and Group 3: LC group was Endoseal MTA+ lateral condensation technique. Teeth were sectioned transversely in coronal, middle and apical of the teeth and the existence of voidsand their areas in the slices were measured and scored under a dental microscope. One-way analysis of variance and Post Hoc test were used for statistical analysis and also to detect any significance (α=0.05). Results: EMS group showed significantly more void area than lateral compaction group (P<0.05), but the difference between the EMSU group and the other two groups were not significant (P>0.05). Also, EMS group had significantly higher void score than the other two groups (P<0.017). Conclusion:  Endoseal MTA as a premixed calcium silicate sealer has a better performance when used with gutta-percha cone-mediated ultrasonic activation, so we suggest gentle ultrasonic activation for applying Endoseal MTA in the clinical use.

Keywords: Mineral Trioxide Aggregate; Root Canal Obturation; Root Canal Sealer; Ultrasonic

Case Report

Guided Endodontics in Complex Scenarios of Calcified Molars

Warley Luciano Fonseca Tavares, Vinícius de Carvalho Machado, Francielen Oliveira Fonseca, Betânia Canal Vasconcellos, Luiza Cruz Magalhães, Ana Cecília Diniz Viana, Luiz Carlos Feitosa Henriques

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 50-56

This study aimed to report a case series and describe the use of guided endodontics in complex symptomatic cases of mandibular and maxillary molars; presenting calcification of all three root canals. The arches of the referred patients were scanned, and high-resolution cone-beam computed tomography (CBCT) imaging was performed. Then, the taken CBCT and tooth scans were aligned and processed using software. A virtual copy of a drill was superimposed onto the scans and evaluated in 3 dimensions. Subsequently, a 3-dimensional (3D) template was designed and printed. Drilling was performed and a radiograph was taken to confirm its position. The canals were reached and endodontic treatment was performed. At the 12-month follow-up, the teeth were completely asymptomatic. The use of guided endodontics _in cases of calcification in molars_ was demonstrated to be a viable and reliable alternative treatment. The technique was based on 3D planning.

Keywords: Access Opening; Apical Periodontitis; Dental Trauma; Guided Endodontics; Pulp Canal Calcification  

Optimization of Results for Cracked Teeth Using CAD-CAM System: A Case Series

Kenia Maria Soares de Toubes, Lucas Moreira Maia, Livian Cota Goulart, Tassis Freitas Teixeira, Nelson Renato França Alves, Paulo Isaías Seraidarian, Frank Ferreira Silveira

Iranian Endodontic Journal, Vol. 15 No. 1 (2020), 12 January 2020 , Page 57-63

Different restorative techniques have been proposed for the treatment of posterior teeth affected by cracked tooth syndrome (CTS). However, the literature is scarce in protocols of how to solve CTS using ceramic restorations made by computer aided design–computer aided manufacturing (CAD-CAM) system. CAD-CAM provides a fast and efficient restorative treatment usually in a single visit, reducing the risk of contamination and micro-infiltration of the cracked line. The objective of this work was to describe 3 clinical cases of cracked teeth, which presented vertical fracture lines in different directions and extension through the pulp, restored by CAD-CAM system, with 5-year follow-up. Patients with short-term spontaneous masticatory pain, cold sensibility and restored teeth without cuspal coverage were selected. Digital radiographs (DR) were taken to confirm the pulp and periapical status. Periodontal probing depth, sensitivity, percussion, and occlusion tests were performed. The fracture lines with their direction and extension were identified under dental optical microscope (DOM). The treatment plan was performed in two stages: immediate treatment to stabilize the tooth and minimize pain, and final restorative treatment by CAD-CAM system to stabilize the crack. Patients were between the ages of 37 and 45 years. Most of the studied teeth presented extensive restorations without cuspal coverage. The presence of occlusal interference, in lateral movement, was a constant finding. Endodontic treatment was performed in cases of irreversible pulpitis or pulpal necrosis. In all three cases, cavity preparation was performed for full coverage restorations, as the fracture lines extended in several directions, requiring a re-enforcement of the cervical region of the teeth in question. The survival rate of the reported cases was 100% with 5-year clinical and radiographic follow-up, suggesting that CAD-CAM system may be a promising alternative treatment in the management of CTS, improving tooth longevity.

Keywords: CAD-CAM; Cracked Teeth; Cracked Tooth Syndrome; Incomplete Fracture; Prognosis