Systematic Review

Structural analysis of NiTi endodontic instruments: A systematic review

Igor Bastos Barbosa, Fabiano Guerra Ferreira, Pantaleo Scelza, Caroline Adeodato, Isleine Portal Caldas, Fabiano Palmeira Gonçalves, Daniele Masterson, Miriam Fatima Zaccaro Scelza

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 124-139

Introduction: Irregularities and defects on NiTi endodontic instruments originating from the manufacturing process can lead to the structural collapse and fracture of these instruments during treatment. To assess the cause of instrument wear and fracture, as well as increasing fracture incidence, destructive and non-destructive methods have been used for the analysis of surfaces and internal structures of new and used NiTi instruments. The aim of this systematic review was to undertake a detailed analysis of the methods used to evaluate the surface and internal microstructure of endodontic instruments. Methods and Materials: The scientific literature was comprehensively and systematically searched in the MEDLINE (PubMed), Web of Science, Cochrane Library, Scopus, and LILACS/BBO databases for studies published up to June 9, 2019. The eligibility criteria was based on the PICO (Patient, Intervention, Comparison, and Outcome) strategy with the question “What is the best method for structural analysis of endodontic files?” Two aspects were considered for inclusion in this study: (i) endodontic instruments and (ii) methods for structural analysis of NiTi instruments.  Results: Based on the inclusion criteria, 94 articles were selected. The results showed that although specific methods have been used for qualitative and/or quantitative structural analysis of NiTi instruments, no study addressed both the surface and internal structure of the instruments at the same time. According to this review, the need to compare the methodologies used in the selected articles has been identified; however, each type of method used has its own limitation on the analysis of both the surface and the internal structure of the instruments. Conclusions: The comparison between the different types of methodologies used in the studies revealed the reliability and the limitations of the methods employed for structural analysis of endodontic instruments; thus assisting us in determining their validity.

Original Article

Delayed Tooth Replantation after Root Surface Treatment with Papain and Sodium Fluoride in Rats: A Histological and Histomorphometrical Evaluation

Cláudia Letícia Vendrame dos Santos, Eduardo Dias-Ribeiro, Julliana Cariry Palhano Freire, Leonardo Raniel Figueiredo, Luy de Abreu Costa, Paulo Koji Hara Sonoda, Alline Batistussi França, Celso Koogi Sonoda

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 140-146

Introduction: The aim of this study was to examine the histological effect of papain and sodium fluoride in delayed replantation of rat incisor teeth on the repair process. Methods and Materials: Forty upper incisors of Wistar rats were randomly assigned to four groups (n=10). In group I, the dental papilla and the pulp tissue of extracted teeth were removed before immediate replantation in their sockets. In the other groups, the extracted teeth were maintained in dry storage for 60 min and subjected to different root surface treatments. In group II, the teeth were immersed in 10% papain for 20 min, scrubbed with gauze soaked in saline for 1 min, and immersed in a 2% acidulated-phosphate sodium fluoride solution for 20 min. In group III, the teeth were immersed in saline for 20 min, scrubbed with gauze soaked in saline for 1 min, and immersed in a 2% acidulated-phosphate sodium fluoride solution for 20 min. In group IV, root surface treatment was not applied. The root canals were treated and filled with a calcium hydroxide paste and the teeth were replanted. The animals were euthanized after 60 days and anatomic specimens containing the teeth were subjected to routine histochemical processing and staining with hematoxylin and eosin. The Kruskal-Wallis test was used, followed by the Dunn’s test for multiple comparisons. Results: Groups I and II had less inflammatory root resorption and total area of root resorption (P<0.05) than groups III and IV respectively. Conclusions: Based on this animal study, root surface treatment with papain and sodium fluoride in delayed tooth replantation showed greater efficacy in controlling inflammatory root resorption and may be a viable option for clinical application.

Removal of Obturation Material from Root Canals Using a Combination of Reciprocal Instrumentation and Different Final Irrigation Techniques

Patrícia Bastos Oliveira Conceição Limongi , Andressa Pinho Amaral , Rina Andreia Pelegrine , Eduardo da Silveira Bueno, Augusto Soji Kato , Alexandre Sigrist de Martin , Sérgio Pinheiro

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 147-154

Introduction: The predictability of successful non-surgical endodontic retreatment is directly related to it’s ability to completely cleanse and remove obturation material from the canal system. The purpose of this study was to evaluate the removal of gutta-percha from curved canals using three final irrigation methods: passive ultrasonic irrigation (PUI) with a 20/01 E1 insert (Irrisonic); XP-endo Finisher (XPF); and Easy Clean (EC). Methods and Materials: Forty mesial roots of mandibular molars with an angle of curvature between 10° and 20°, two canals, and independent foramina were cut into 16-mm sections. The canals were instrumented using the Reciproc system (R25) and filled with a #25 gutta-percha cone and AH-Plus sealer by the continuous-wave condensation technique. The roots were double-sealed with Coltosol and photopolymerizable resin and stored at 37°C and 100% humidity for 30 days. They were then randomized into 4 groups (n=10): control (C), PUI, XPF, and EC. All specimens were scanned using cone-beam computed tomography (CBCT), and fill volume data (in square pixels) were calculated before retreatment, after retreatment, and after final irrigation. The images were analyzed using Tps Dig software 2.32 by two blinded, calibrated examiners (intra-class correlation coefficient=0.9967). The results were analyzed in BioEstat 4.0. The nonparametric Kruskal-Wallis test with Dunn's post-hoc and Friedman comparison were applied. Significance was accepted at 5% (P<0.05). Results: None of the final irrigation protocols completely removed remnants of obturation material from the root canal systems (P>0.05). On comparative analysis with specimens divided into thirds, all methods were found to remove material equally, with no significant differences (P>0.05). Conclusion: Based on this in vitro study, the additional cleaning methods tested were equivalent to each other and did not lead to an improvement in the removal of residual obturation material.

Quantitative Assessment of Dentinal Tubule Disinfection in Absence of Biofilm on Root Canal Walls: An in vitro Study

Svetlana Fedorovna Byakova, Viktoriya Andreevna Dezhurko-Korol, Nina Evgenievna Novozhilova, Irina Mikhailovna Makeeva, Alexander Nikolaevich Lukashev, Ludmila Vasilievna Akhmadishina, Alexandr Mikhailovich Semenov, Mihail Mikhailovich Moisenovich, Anastasia Yurievna Arkhipova, Evgeny Nikolaevich Ponirovsky

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 155-165

Introduction: This study aimed at assessing the quantitative effect of calcium hydroxide, 2% chlorhexidine gel, and 1.5% chlorhexidine linked to xanthan gel specifically against intratubular bacteria. Methods and Materials: Fifty-two semi-cylindrical bovine dentin specimens were infected with Enterococcus (E.) faecalis by centrifugation with subsequent 7-days incubation. The surface of specimens was disinfected with 3% H2O2. Scanning electron microscopy (SEM), confocal laser scanning microscopy (CLSM) and the count of bacterial colony-forming units (CFU/mg) were used to assess dentin infection. A total of 40 specimens were incubated for 2 weeks with one of the intracanal medication applied (10 samples for each group): 1) calcium hydroxide, 2) 2% chlorhexidine gel, 3) 1.5% chlorhexidine linked to xanthan gel and 4) sterile saline. Final passive ultrasonic irrigation with 3% sodium hypochlorite was performed in half of the total specimens. The effect of intracanal medications and irrigation against intratubular bacteria was assessed by bacterial culturing of dentin shavings. Two-Way ANOVA model was applied followed by post-hoc Tukey's test for multiple pair-wise comparisons of mean CFU/mg values. Results: SEM, CLSM, and bacterial culturing confirmed the absence of the surface biofilm on the root canal wall and showed vital intratubular bacteria at the depth up to 700 mm. Two-week application of 1.5% chlorhexidine with xanthan gel and 2% chlorhexidine gel significantly decreased intratubular bacterial counts compared with saline (P=0.0003 and P=0.0005, respectively). Subsequent passive ultrasonic irrigation with 3% sodium hypochlorite significantly reduced the number of intratubular bacteria in all groups except for the group with 1.5% chlorhexidine-xanthan gel (P=0.0054). Conclusion: This modified ex vivo model study showed ultrasonically activated irrigation with sodium hypochlorite had greater effect on intratubular bacteria counts compared with 2-week application of intracanal medications.

Root Fracture Resistance of Maxillary Premolars Obturated with Three Root Canal Sealers after Passive Ultrasonic Irrigation: An in Vitro study

Ivy Rodrigues Merçon, Carlos Eduardo da Silveira Bueno, Daniel Guimarães Pedro Rocha, Carlos Eduardo Fontana, Andressa Salles Gonçalves Pais, Alexandre Sigrist De Martin

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 166-172

Introduction: Maxillary premolars, may be more susceptible to fracture due to their anatomy; especially when there is loss of tooth structure. Therefore, it is necessary to evaluate materials and techniques that may increase fracture resistance during and post root canal treatment. This in vitro study aimed to evaluate root fracture resistance of maxillary premolars when filled with three root canal sealers as well as whether this resistance would be increased by passive ultrasonic irrigation (PUI). Methods and Materials: Sixty-four maxillary premolars with two roots were randomly divided into one negative control group (intact canals; n=8), one positive control group (instrumented, unsealed canals; n=8), and six experimental groups (n=8), which were instrumented with ProTaper Next rotary system up to X2 file and subdivided according to final irrigation (with or without PUI) and type of sealer used (AH-Plus [AH], MTA Fillapex [MTA], or EndoSequence BC Sealer [ES]). The specimens were subjected to fracture strength test in a universal testing machine at a speed of 1 mm/min until fracture. The maximum force required to induce fracture was recorded (N).  Results: The lowest force required to cause root fracture was observed in the positive control group (310.48±54.08 N); this was significantly different from the other groups (P<0.05). There was no significant difference between experimental groups obturated with the same sealer, whether with or without PUI (AH with PUI: 558.80±87.12 N; AH without PUI: 508.75±97.55 N; MTA with PUI: 507.27±174.55 N; MTA without PUI: 516.69±96.56 N; ES with PUI: 526.76±143.97 N; ES without PUI: 628.40 ± 94.74 N) (P>0.05). There was also no significant difference between the experimental groups and the negative control group (P>0.05). Conclusions: In this in vitro study PUI did not increase the fracture resistance of maxillary premolars, while AH Plus, MTA Fillapex, EndoSequence sealers increased fracture resistance of instrumented root canals.

Effect of Biotitania and Titania Addition on Bioactivity and Antibacterial Properties of Calcium Silicate Cement

Salma M Fathy, Abeer M Abd El-Aziz , Tayseer M Maaly , Habiba Elhendawi , Tarek A Elkhooly

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 173-182

Introduction: Nanoparticles are gaining more interest in dentistry for their antimicrobial, physical as well as other properties. This study aimed to evaluate the effect of adding two types of nanoparticles (NPs) on calcium silicate hydraulic cement’s (CSHC) unique bioactivity and antibacterial properties. Methods and Materials: Biotitania/AgCl NPs were synthetized and characterized for its morphology, types of formed functional groups and crystalline AgCl using field emission scanning electron microscope (FE-SEM) equipped with energy-dispersive X-ray spectroscopy (EDS), X-ray diffractometer (XRD), Fourier transformation infrared spectroscopy (FT-IR) and thermo-gravimetric analysis (TGA). The former NPs and commercial titania (TiO2) NPs were added (0.5, 1.5 and 3-weight %) to commercial CSHS powder. A total of 140 disk-shaped specimens (10 mm×1 mm) were prepared (seven material groups per each test in addition to the eighth cell control group) to evaluate cell viability and alkaline phosphatase activity (ALP) after 3 and 12 days, respectively. All were incubated with mesenchymal stem cells. Antibacterial efficacy against Streptococcus mutans (S. mutans) was evaluated through the bacterial growth curve slopes while being in direct contact with the tested material groups for 18 h. Results: Addition of all NPs percentages had no significant effect (P>0.05) on cell viability in comparison to positive control CSHC. Commercial TiO2 NPs (0.5 weight %) had statistically significant lower values (P≤0.05) for bacterial growth curve slope. However, addition of all NPs percentages had significantly improved (P≤0.05) the ALP activity of CSHC with the most prominent effect to 3-weight% biotitania/AgCl NPs. Conclusion: Based on this in vitro study, addition of biotitania/AgCl NPs up to 3-weight% significantly improved the bioactivity of CSHC without having a significant negative impact on its antibacterial efficacy. Interestingly, the addition of commercial TiO2 even in small amounts can significantly improve CSHC antibacterial efficacy.

Evaluation of Chemical and Physical Properties of an Experimental Endodontic Sealer in Comparison with AH-26 and AH-Plus

Hengame Ashraf, Niloofar Mortezapour, Sanaa Jabari, Saeede Zadsirjan, Fahimeh Saadaat Tabatabaei

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 183-187

Introduction: This study aimed to assess the physical and chemical properties of an experimental endodontic resin sealer (Resil) compared with AH-26 and AH-Plus.  Methods and Materials: In this in vitro experimental study, dimensional stability (by measurement of length; n=5), pH (using a pH meter; n=5), and antibacterial activity (by agar diffusion test; n=8) of Resil, AH-26 and AH-Plus were evaluated and compared using one-way ANOVA and Tukey’s test. Results: All three groups showed significant expansion from day 1 to day 30 (P<0.05). The difference in the mean dimensional changes between the AH-Plus and experimental sealer was significant (P=0.020). Two hours after mixing, the pH of experimental sealer (Resil) was significantly lower than that of AH-Plus (P<0.001) and higher than that of AH-26 (P<0.001). Antibacterial activity of the experimental sealer before and after setting was significantly higher than that of the other two sealers (P<0.001). Conclusion: The results of this in vitro study showed that the experimental sealer had dimensional changes greater than the other two sealers. It had an alkaline pH, and showed superior antibacterial activity compared with AH-26 and AH-Plus. It may be possible to use this sealer in the clinic after animal studies because an epoxy resin based sealer with lower price and more appropriate properties is favorable.

Case Report

Spontaneous Bisphosphonate-related Osteonecrosis Associated with a Tooth that Had a Necrotic Pulp: A Case Report

George Táccio de Miranda Candeiro, Vivian Bradaschia-Correa, Silvana Cristina Gama Vaz Rodrigues, Fabrício Bitu Sousa, Rafael Linard Avelar, Giulio Gavini, Cyrene Piazera Silva Costa, Ceci Nunes Carvalho

Iranian Endodontic Journal, Vol. 15 No. 3 (2020), 1 July 2020 , Page 188-194

This study reports the endodontic treatment performed in a patient who presented with spontaneous bone exposure in the mandible while using intravenous bisphosphonate medication (ZometaÒ, Novartis Pharmaceuticals Co., Basel, Switzerland). A 63-year-old female patient was referred to a private dental clinic at Fortaleza, Brazil. The patient reported that one year before, she had undergone chemotherapy for the treatment of lung cancer and associated bone metastasis. Among the medications administered was the zolendronic acid, with dosage of 4 mg every 21 days. In the oral exam, the presence of extensive bone exposure was observed in the lingual region near tooth 37. The patient reported severe pain on palpation in the region; in the pulpal sensitivity test with cold stimulus, there was an absence of pain, characteristic of pulp necrosis. Radiographically, no periapical lesion was observed. Thus, endodontic treatment was performed, and instrumentation with Reciproc R25 files in the mesial root canals and R40 in the distal canal was done, alongside with abundant 2.5% sodium hypochlorite irrigation. Interappointment medication with calcium hydroxide was maintained for 15 days. In the second session, there was the spontaneous detachment of the exposed cortical bone fragment. The root canals were filled with gutta-percha and Endosequence BC Sealer cement. After two years, complete tissue repair was observed, and the patient presented with normal periapical tissues and the tooth in masticatory function.   It may be concluded that a possible relationship between pulp and periapical infections and osteonecrosis exists in patients who use bisphosphonates.

Letter to the Editor