Clinical Trial

Introduction: This study aimed to determine the success rate of the combination of buccal infiltration (BI) and inferior alveolar nerve block (IANB) injections in irreversible pulpitis in mandibular molars after premedication with ibuprofen. Materials and Methods: From 132 patients participated in the study, 120 patients were included. One hour before root canal treatment, patients with mandibular molars with symptomatic irreversible pulpitis received either a 600 mg ibuprofen capsule or a placebo. All patients received 2% lidocaine with 1:80000 epinephrine and 4% articaine with 1:100000 epinephrine for IANB and BI, respectively. Patients’ pain was evaluated using the Heft-Parker visual analog scale during the preparation of access cavity, exposure of pulp, and instrumentation of root canal. The success of anesthesia was defined as the absence of pain or mild pain. The Chi-square and t-test were employed for data analysis. Results: The difference between patient age and gender in the two groups was not significant (P>0.05). The anesthesia success rate was 85% in the premedicated and 70% in the placebo group, with statistically significant results (P=0.049). Conclusion: Based on this triple-blinded randomized clincal study, mandibular molars with irreversible pulpitis were not thoroughly anesthetized by a combination of IANB+BI after premedication with ibuprofen (600 mg), even though anesthesia success was improved significantly by ibuprofen premedication.

Original Article

Effects of Intracanal Curcumin and Aloe vera on pH Changes in Simulated Root Surface Resorption Defects: An In vitro Study

Aysan Shahmorad Moghanlou, Mohammad Samiei, Sahar Shakoui Bonab

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 172-178

Introduction: Commonly used medicaments in the treatment of external inflammatory root resorption (EIRR) have shown adverse effects; resulting in an increasing tendency to employ natural and/or herbal medication. The present in vitro study aimed to evaluate the effects of curcumin and aloe vera, as two natural medicaments, on the changes of pH in external root surface defects; and compare their outcomes with the results obtained from the application of calcium hydroxide, as a conventional medicament used in endodontic treatments. Materials and Methods: In the current investigation, 92 permanent teeth, with a single root canal, were randomly divided into four groups. Similar cavities were created on the buccal surfaces of roots, 5 mm from their apices. The root canals in each of the study groups were filled with curcumin, aloe vera, calcium hydroxide or normal saline. The pH was measured after 20 min (i.e. the baseline), 1, 7, 14, 21, and 28 days using a digital pH meter. The data were analysed using repeated-measures ANOVA and the statistical significance was set at P<0.05. Results: At the baseline, day 1 and day 7, the mean pH of both curcumin and aloe vera groups was higher than the mean pH of calcium hydroxide and normal saline groups (P<0.05). On day 14, the mean pH of aloe vera group was higher than that of calcium hydroxide and normal saline groups (P<0.05). On days 21 and 28, the mean pH of aloe vera group was higher than the mean pH of all the other groups (P<0.05). All other intergroup differences were not statistically significant at each time point (P>0.05). Conclusion: The current in vitro study demonstrated that aloe vera was more alkaline than curcumin; nevertheless, both groups exhibited more alkalinity than calcium hydroxide.

Impact of Nonsurgical Treatment of Asymptomatic Apical Periodontitis on the Oral Health-related Quality of Life: A Prospective Study

Angela Longo do Nascimento, Theodoro Weissheimer, Maximiliano Schunke Gomes, Jefferson Ricardo Pereira, Ricardo Abreu da Rosa, Marcus Vinicius Reis Só

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 179-184

Introduction: The aim of this study was to evaluate the impact of nonsurgical root canal treatment (nRCT) and the healing of asymptomatic apical periodontitis (AAP) on the oral health-related quality of life (OHRQoL) in a Brazilian population. Materials and Methods: This prospective longitudinal observational study included 56 adults, in which 84 teeth with asymptomatic apical periodontitis underwent nonsurgical root canal treatment. Socio-demographic and medical data were collected; the primary outcome oral health-related quality of life was measured by the short form of the Oral Health Impact Profile (OHIP-14). Statistical analysis was carried out by Mann-Whitney U-test, and changes in the oral health-related quality of life scores post-treatment were estimated by Student t-test. Results: The mean age was 51.0±15.2 years, with 53.5% of females. Overall, nRCT significantly improved the OHRQoL (P<0.001, effect size=0.76). Gender (female) was associated with a higher OHRQoL after nRCT (P<0.05). OHIP-14 showed a significant reduction six months after root canal treatment compared to baseline scores. Conclusion: Present findings revealed that nonsurgical root canal treatment improved the oral health-related quality of life in patients with asymptomatic apical periodontitis.

Human Treated Dentin Matrix Hydrogel as a Drug Delivery Scaffold for Regenerative Endodontics

Eman Mohamed Sedek, Hebatallah S. Barakat , Walid A. Lotfy , Sybel Mohktar Moussa, Mustafa AbouShelib , Rania M. El Backly

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 158-194

Introduction: The objective of the current study was to develop a human treated dentin matrix (hTDM) hydrogel for use as a scaffold to allow the controlled release of an antimicrobial agent for regenerative endodontics. Materials and Methods: Human extracted teeth were treated via chemical demineralization using ethylene diamine tetra-acetic acid solution to produce hTDM powder. Fourier transform infrared spectroscopy (FTIR) was conducted to determine the functional groups of hTDM, scanning electron microscopy (SEM) was used to define the morphology/particle size of hTDM, and energy dispersive X-ray analysis was performed to identify the superficial apatite groups. Prepared hTDM powder was added to the amoxicillin-clavulanate mixture with a mass ratio of 1:1. Then, the combination was dripped into a 5% (w/v) calcium chloride solution. Antibiotic release profiles were evaluated for 14 days via high performance liquid chromatography (HPLC). Hydrogel degradation properties were studied for 14 days using 10 mL of phosphate buffered saline (PBS). Encapsulation efficiency was determined by HPLC, while minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of amoxicillin-clavulanate were determined against Enterococcus faecalis (E. faecalis). The antibacterial activity of amoxicillin-clavulanate against E. faecalis was investigated for 14 days via agar diffusion test. Statistical analysis was performed with the Shapiro-Wilk test (P=0.05). Results: hTDM showed statistically a significant difference for percentage weight change (P=0.1). The encapsulation efficiencies for hTDM hydrogel with antibiotic and hydrogel with antibiotic was 96.08%±0.02 and 94.62%±0.11, respectively. MIC and MBC values of amoxicillin-clavulanate against E. faecalis were 2.4 µg/mL and 9.6 µg/mL, respectively. The antibacterial activity of antibiotic loaded hTDM hydrogels was significantly greater than loaded hydrogels alone by 31% after 4 and 100% at 14 days, respectively (P≤0.001). Conclusions: This in vitro study showed antibiotic-loaded injectable hTDM hydrogel could be an alternative system to transfer antibiotic-based intracanal medicaments for use in regenerative endodontics.

The Effect of Long Service Life on the Accuracy of Dentaport ZX Electronic Apex Locator

Masoud Parirokh, Hamed Manochehrifar, Arash Shahravan, Hamid Reza Hosseini, Siamak Samanipoor

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 195-199

Introduction: Electronic apex locators are among the most acceptable instruments for determining root canal length. The present study aimed to evaluate the effect of long service life on the accuracy of the Dentaport Root ZX (DP ZX) electronic apex locator (EAL). Materials and Methods: In this study, fifty single-rooted freshly extracted human teeth were used. After determining the root canal length with a K-file and a dental operative microscope, the canals were measured with four separate DP ZX apex locators (two with more than 6 years of life service while two others had less than 6 years of life service). Data were analyzed by repeated ANOVA measurement. Results: No significant difference was found between the EALs with different years of life services (P=0.62). All EALs could determine root canal length with high accuracy of more than 94%. Conclusion: Based on the results of this in vitro study, the long service life had no significant impact on the accuracy of DP ZX EALs in terms of root canal length determination.

Ex Vivo Evaluation of Bacterial Leakage and Coronal Sealing Capacity of Six Materials in Endodontically Treated Teeth

Salma Mota da Silva Paiva, Carlos Eduardo Fontana, Daniel Guimaraes Pedro Rocha, Alexandre Sigrist De Martin , Maraisa Greggio Delboni, Carlos Eduardo Da Silveira Bueno

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 200-204

Introduction: Successful endodontic treatment requires an effective coronal sealing to prevent the penetration of saliva and microorganisms into the root canal system. We aimed to investigate the sealing capacity of Maxxion R, Intermediate Restorative Material (IRM), Mineral Trioxide Aggregate-like material (Biodentine), White Cimpat, Flow Resin and Z250 Resin against Enterococcus (E.) faecalis infiltrates, when used as coronal sealants after endodontic treatment. Materials and Methods: Sixty-six roots of adult lower premolars were randomly divided into 6 experimental groups with 10 roots each (n=10), and two control groups (positive and negative) with three roots each. The root canals were instrumented to ProTaper F3 file, irrigated with 2.5% NaOCl and 17% EDTA, and filled using Tagger’s Hybrid technique with AH-Plus cement. After removing 2 mm of the coronal third filling with a Gates Glidden #6 drill, the cervical portion of each of the sixty roots was sealed with a 2 mm-thick plug, plus the respective material being tested in this study. All roots were fitted to silicone devices (Eppendorf) with cut extremities and sterilized with ethylene oxide; experimental procedures were performed in a laminar flow chamber for aseptic chain maintenance. All specimens were inoculated with E. faecalis, and the culture medium was renewed every 3 days for 60 days. Medium turbidity was evaluated daily. The obtained data were subsequently submitted to analysis of variance (ANOVA-R) complemented by Student's t-test at a significance level of 5%. Analyzes of variance were calculated using the SAS system GLIMMIX procedure. Results: Biodentine (56.90), Z250 Resin (54.90) and White Cimpat (53.30) resisted contamination for a longer time compared to Maxxion R (51.30), Flow Resin (50.70), and IRM (48.70) over a period of 60 days. Conclusion: Biodentine, Resin Z 250 and White Cimpat presented the lowest infiltration averages when compared to the other tested materials.

Case Report

Intentional Replantation as Treatment of Extrusive Luxation: A Case Report

Aline Satie Takamiya, Leonardo Raniel Figueiredo, Caio Vinícius Lourenço Debortoli, Paulo Koji Hara Sonoda, Luy de Abreu Costa, Cássio Messias Beija Flor Figueiredo, Celso Koogi Sonoda

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 205-208

Accurate diagnosis, immediate care and proper treatment planning are important factors for the successful treatment of dental traumatic injuries. In extrusive luxation, postponement in treatment may lead to the need for new strategies for the resolution of unwanted consequences. The present case report describes an unusual condition of delayed treatment regarding extrusive luxation of two anterior teeth treated by intentional replantation. An 18-year-old female patient attended the Dental School for the treatment of a traumatic injury to the anterior teeth 5 days after a fall from a bicycle. Clinically, teeth #21 and #22 were extruded in incisal edges for 5 mm from their neighboring teeth, had edematous gingiva, showed grade II mobility and were painful to percussion. Radiographically, the roots were intact and the periodontal ligament space was thickened along its entire length. As immediate repositioning could not be performed, intentional replantation was recommended. After detaching the periodontal ligament, the teeth were extracted and the alveolus was curetted and irrigated with saline solution to remove the already-formed clot. After replantation, the teeth were restrained and the patient was medicated with antibiotics as well as analgesics. After 10 days, the splint was removed, the root canals were instrumented and then, filled with calcium hydroxide. After 30 days, they were completely obturated using gutta-percha. The 5-year follow-up showed root integrity, absence of mobility and normal periodontium. The outcomes of the current case report revealed that when intentional replantation was properly conducted, it could be considered an option for the treatment of extrusive luxation where the teeth were not to be immediately repositioned.

Mandibular Second Premolar with Four Canals: A Case Report

Soheil Niavarzi, Sholeh Ghabraei , Fatemeh Malekpour

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 209-211

The mandibular second premolar can be considered one of the most challenging teeth to treat endodontically; due to the complexity of its root canal morphology and increased incidence of multiple canals. The knowledge of internal anatomy of root canals and their possible variations as well as use of magnification, e.g. operating microscope, radiographic examination and illumination, can increase the chances of finding additional canals and contribute to the success of endodontic treatment. The purpose of the current investigation is to report the successful endodontic treatment of a mandibular second premolar with 4 canals; all of them in one single root.

Endodontic-periodontal lesions have always been a challenge for treatment due to the reduced success rate in comparison to endodontic or periodontal lesions alone. This case report describes surgical/endodontic management of supra-erupted non-vital maxillary incisor with primary periodontal and secondary endodontic lesions with mobility grade III and severe horizontal and vertical loss of attachment apparatus in a 55 years old woman with aggressive periodontitis. The successful results at one-year follow-up revealed that with an appropriate case selection strategy, proper regeneration method and soft tissue enhancement, severe combined endo-perio lesions may treat.

Management of Pulp Canal Obliteration in Mandibular Incisors with Guided Endodontic Treatment: A Case Report

Saideh Nabavi , Sara Navabi, Seyed Mahdi Mohammadi

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 216-219

Successful management of mandibular incisors with pulp canal obliteration using guided endodontics is described, for the first time in Iran. A 58-year-old man was referred for root canal treatment of teeth #24, #25 and #26. Upon radiographic examination, partial obliteration of the root canal system was detected. Cone-beam computed tomography (CBCT) was requested to enhance the diagnosis and detection of root canals. Next, a 3-dimensional (3D) guide was designed and printed to aid in localization and access to the root canal system with minimal destruction of the tooth structure. With the use of a targeted 3D guide, a conservative access cavity was prepared to avoid unnecessary removal of tooth structure. The teeth were successfully treated endodontically. Obtained results revealed that the technique can be effective and predictable for the management of calcified canals.

Endodontic Management of a Two-Rooted Maxillary Central Incisor Using Cone-Beam Computed Tomography: A Case Report

Zahra Jafari , Ali Kazemi , Amin Shiri Ashitiani

Iranian Endodontic Journal, Vol. 17 No. 4 (2022), 26 Aban 2022, Page 220-222

Practitioners need to know the normal and complex anatomy of the root canal system of individual teeth. Maxillary central incisors almost in all cases have one root and one root canal system. This case report describes a non-surgical endodontic treatment of a double-rooted maxillary central incisor using cone-beam computed tomography (CBCT). A fourteen-year-old male with spontaneous pain of the maxillary left incisor showed the presence of an extra root on the periapical radiograph. CBCT was used to assess the root canal details that lead to finding a narrow root in the mesial of the main root. Also, a periapical bone defect was detected. Nonsurgical treatment of tooth performed. At the 3-month follow-up, the tooth was functional and the lesion was healed. Therefore, practitioners should consider the presence of extra roots and canals during root canal treatment. CBCT imaging helps in detecting the exact location of the extra root.

The current case study evaluated the effect of vital pulp therapy on a human dental pulp after a long-term period using micro-computed tomography (MCT) for the first time. In the presented report, the successful outcomes of full pulpotomy using calcium-enriched mixture (CEM) cement on an irreversible pulpitis case were documented clinically/radiographically over 5 years. Due to an unrestorable crown fracture at the 5-year recall, the tooth was extracted and evaluated by MCT; the images showed that CEM pulpotomy allowed the dental pulp to create complete dentinal bridges without pulp canal obliteration (PCO). These MCT results showed that CEM pulpotomy, as a bio-regenerative treatment, caused no negative consequence of PCO or calcific metamorphosis on dental pulp over the long term.