Meta Analysis

The Effect of Number of Visits, Use of Solvent and Gutta-percha Removal Technique on Postoperative Pain following Nonsurgical Endodontic Retreatment; A Systematic Review and Meta-analysis

Iandara Lima Scardini, Giovanna Sarra, Mariana Minatel Braga, Marcelo dos Santos, Laila Gonzales Freire

Iranian Endodontic Journal, Vol. 18 No. 2 (2023), 16 Farvardin 2023, Page 71-84

Introduction: The nonsurgical endodontic retreatment (NERT) is the first choice of dental ministration when primary/initial endodontic treatment fails. The present study aimed to investigate the presence of postoperative pain (POP) after NERT in permanent asymptomatic teeth as well as possible factors associated with POP. Materials and Methods: A comprehensive search of literature was performed in Pubmed/MEDLINE, Embase, Scopus and Web of Science databases, up to January 2023; including randomized clinical trials and prospective studies. The risk of bias was assessed with RoB 2.0 and ROBINS-I tools. Subgroups analyses were conducted to evaluate the differences in the incidence or level of POP between the number of visits, the use/not use of solvent, the removal technique of gutta-percha, and the period of POP analysis. Mean differences and confidence intervals (CI) of 95% were used as measures of effect, and meta‐regression was used along with subgroup analysis. The certainty of evidence was assessed using GRADE, and the probability value of <0.05 was considered significant. Results: Twenty-four studies were selected, with thirteen included in the meta-analysis. There was a statistical difference between the incidence of POP after 24 h (95% CI, 0.28 to 0.52) and one week (95% CI, 0.02 to 0.13) from the endodontic retreatment (P<0.01). However, there was no statistical difference between different techniques, number of visits and use of solvent (P>0.05) in the same period. In addition, the certainty of evidence was very low. Conclusions: Post-operative pain is a common response to NERT, independent of the retreatment technique(s) applied, number of visits and use of solvent(s); with very low certainty of evidence as well as low risk of bias. Moreover, the current analysis showed a (very) serious risk of inconsistency and imprecision. However, POP was significantly reduced within 1 week of the NERT.

Original Article

Antibacterial Efficacy of Polymer Coated Ceramic Microparticles loaded with a novel combination of antibiotics on the Enterococcus Faecalis Biofilm

Nazanin Zargar, Ardavan Parhizkar, Mohammad Javad Nasiri, Sara Saedi

Iranian Endodontic Journal, Vol. 18 No. 2 (2023), 16 Farvardin 2023, Page 85-90

Introduction: Nano-technology applied for the local delivery of different agents and/or drugs has made its path to endodontics. In the current study, the antibacterial efficacy of biopolymer-coated ceramic microparticles loaded with a modified combination of triple antibiotics, i.e. Penicillin G, Metronidazole and Ciprofloxacin (PMC), was evaluated against two strains of Enterococcus faecalis (E.faecalis); a standard clinical strain obtained from previously root-filled teeth with persistent periapical lesions, and compared to the most common antimicrobials used in endodontics. Methods and Materials: After synthesis of the polymer-coated microparticles loaded with antibiotics, the 21-day release of antibiotics were evaluated and a stock solution was produced using the maximum released amount of drugs and distilled water. The antibacterial activity of PMC, triple antibiotic paste (TAP), calcium hydroxide (CH), chlorhexidine (CHX) and sodium hypochlorite (NaOCl) against two bacterial strains was determined using “Minimum Inhibitory Concentration” and “Agar Diffusion Test”. Additionally, “Microtiter Plate Assay” was performed to assess anti-biofilm properties. Results: Minimum inhibitory concentration values reported for TAP and PMC were 1/256. PMC showed the maximum diameter of growth inhibition in both strains (33 mm and 35 mm), while CH had the minimum diameters (13 mm and13 mm). Based on microtiter plate assay, TAP showed higher biofilm formation than PMC. Biofilm formation was higher in the standard strain for PMC; however, NaOCl, CHX and CH completely inhibited biofilm formation. Conclusions: Based on the findings of the present study, it could be concluded that PMC and TAP were the most effective medicaments against E.faecalis in its planktonic form; however, none could inhibit its biofilm formation. Further studies using larger sample size and “Confocal Scanning Laser Microscopy” are recommended.

Association between Clinical Symptoms and Histological Features of Molars with Acute Pulpitis

Mahsa Dastpak, Jamileh Ghoddusi, Amir Hossein Jafarian, Majid Sarmad

Iranian Endodontic Journal, Vol. 18 No. 2 (2023), 16 Farvardin 2023, Page 91-95

Introduction: Diagnosis of dental pulp status on the basis of clinical signs in many cases helps clinicians to better resolve patient problems. Various studies have shown no correlation between clinical and histologic findings. The aim of the present study was to evaluate the associations between clinical findings and histological features in extracted decayed teeth with acute pulpitis. Materials and Methods: One hundred permanent cavitated human teeth with mature apices and pulpitis, which were extracted for reasons not related to the present study, were evaluated. Demographic, clinical, and radiographic data were collected using pre-designed questionnaires. After tooth extraction, 5 micron-thick slices were prepared for microscopic assessment. General pathologist evaluated reactions to stimuli in all areas of the pulp tissue under a light microscope. When present, inflammation was classified according to the type and spread of cell detected and other histological findings, such as abscess formation, pulp stones, and pulpal fibrosis, were also recorded. Results: We found significant associations between pain characteristics, such as pain type and duration, and histological status.  Acute inflammation, severe chronic inflammation, and liquefactive necrosis increased with pain severity. Various histological sections showed the absence of pulpal inflammation. Conclusions: We found a good agreement of patients’ pain histories and pain characteristics with histological pulp status. Thus, the use of specified CHARTs and SCALEs that help patients provide the most accurate responses to questions about pain would aid the diagnosis of pulp status. In cases with an accurate pulpal diagnosis, the clinicians can manage pulpal protection when it is possible.

The Evaluation of Debris and Smear Layer Generated by Three Rotary Instruments Neo NiTi, 2Shape and Revo_S: An Ex-vivo Scanning Electron Microscopic Study

Hengameh Ashraf, Nazanin Zargar, Babak Zandi, Aytan Azizi, Maryam Amiri

Iranian Endodontic Journal, Vol. 18 No. 2 (2023), 16 Farvardin 2023, Page 96-103

Introduction: This study compared the cleaning effectiveness of NeoNiTi, 2Shape and Revo_S rotary instruments. Materials and Methods: Fifty mandibular molar mesial roots were selected with an angle of curvature less than 20 degrees divided into three groups (n=15). Five samples were selected as negative control group. In all three systems, the final file was 25, 6%. The score of debris and smear layer in three thirds (coronal, middle and apical) of the root canal walls were evaluated using scanning electron microscopic (SEM) magnification. The data were analyzed using the Kruskal Wallis and Mann Whitney U tests for intergroup comparison (P≤0.05) and Freidman and Wilcoxon signed-rank test was employed for intragroup comparison (P≤0.05). Results: Residual debris of the 2Shape system in the apical region was significantly higher than the other two systems (P=0.039). Revo_S and 2Shape groups had significantly higher quantities of debris in the apical than the coronal region (P=0.029 and P=0.02, respectively). In the 2Shape group, the amount of mid-region debris was significantly higher (P=0.005) than the coronal. In inter-group comparison there was no significant difference in residual smear layer between the systems. In intra-group comparison in all three systems, the amount of smear layer in the coronal third was significantly higher than in the other two areas. (P=0.017, P<0.001 and P=0.032, respectively). Conclusion: 2Shape left the highest amount of debris in the apical region. The amount of debris in Revo_S and 2Shape groups in the apical region was significantly higher than in the coronal. The amount of smear layer in all three groups in the coronal area was higher than the middle and apical areas.

Case Report

Endodontic Management of Maxillary Central Incisor with Two Roots, and Lateral Incisor with a C-shaped Canal; A Case Report

Mageshwari Mahadevan, Benin Paulaian , Ravisankar Madhavankutty Santhakumari , Arvind Kumar Alexander, Nagaraj Neelamani Jaya

Iranian Endodontic Journal, Vol. 18 No. 2 (2023), 16 Farvardin 2023, Page 104-109

The knowledge of anatomical variations in the morphology of root canal systems can affect the successful diagnosis to deliver proper endodontic treatment. The current case report enlightens the endodontic management of an anomalous maxillary left central incisor with two roots/root canals, a C-shaped root canal configuration in a maxillary left lateral incisor identified by three-dimensional cone-beam computed tomography imaging as well as the successful aesthetic rehabilitation of maxillary fractured incisors. The chief complaint of patient was a history of trauma during his outdoor play and consequent broken upper front teeth. Tooth #9 was diagnosed with pulpal necrosis accompanied by asymptomatic apical periodontitis with two relatively dilacerated roots while the maxillary left lateral incisor (tooth #10) was diagnosed with necrotic pulp and asymptomatic apical periodontitis having a C-shaped canal. Endodontic treatment for teeth #9 and #10 were performed, followed by post and core fabrication. Tooth reinforcement was achieved with prefabricated un-polymerized glass fiber post for lateral incisor and Interlig Fiber for central incisor. Intentional root canal treatment of tooth #8 was considered to reduce labial inclination. The anomalous maxillary central incisor with two roots is an unexpected variant during endodontic treatment, and the presence of C-shaped canal in lateral incisors is extremely rare requiring careful diagnosis with radiographs, clinical examination along with additional aids; e.g. Three-dimensional (3-D) cone-beam computed tomography. 3-D imaging has added the advantages of appropriate identification of anomalous anterior teeth and careful location of additional root canal(s) during endodontic treatment.

A 30-year-old male patient with the chief complaint of pink spot discoloration of the tooth crown in his upper left central incisor was referred for endodontic and esthetic management. After thorough clinical and radiographic examinations, the final diagnosis was class IV invasive cervical resorption (ICR) which was conservatively treated with an orthograde approach; i.e. vital pulp therapy with calcium-enriched mixture cement (VPT/CEM). The use of VPT/CEM was successful to restore esthetics and stop the ICR; confirmed clinically, radiographically, and tomographically at one-year recall. The above-mentioned minimally invasive approach reported in the current case study may be considered a practical treatment modality for ICR, specifically in anterior teeth.

Introduction: The purpose of this review is to investigate the contribution of non-surgical endodontic treatment in the healing process of large periapical lesions as well as looking over other potential non-surgical endodontic treatment options. Materials and Methods: two females and one male patient were referred to the private office, complaining of having pain in the anterior maxillary region which was pertinent to the presence of a large periapical lesion, and subsequently were managed by a non-surgical endodontic approach using cold ceramic. The archive of PubMed and Google Scholar databases was also searched for finding relevant articles in which a nonsurgical endodontic approach was performed to improve the healing process of large periapical lesions. Results: Clinical examination of the case series subjects revealed no signs and symptoms following treatment while relative improvement of the lesion and apical closure was apparent in radiographs 7 months, 9 months, and 4 years subsequently. In twenty-two reviewed clinical trials, a total number of 107 teeth with large periapical lesions were treated by nonsurgical endodontic approaches using MTA, biodentine, gutta-percha, and bioceramic iRoot Bp plus. Complete healing occurred in 38 cases (35.5%) after 12-17 months. Conclusions: Although surgical interventions have been used previously in the management of large periapical lesions, a nonsurgical endodontic approach with cold ceramic seems to be effective, leading to complete healing of the periapical lesion in treated subjects. Further clinical research is recommended to identify the effectiveness of cold ceramic for the treatment of extensive periapical lesions.

Endodontic Management of Three-rooted Mandibular First Premolar Using Cone-beam Computed Tomography: A Case Report

Elham Mahdavisefat, Ali Kazemi, Ehsan Moghtaderi Esfahani

Iranian Endodontic Journal, Vol. 18 No. 2 (2023), 16 Farvardin 2023, Page 122-125

The anatomy of the root canal system always affects endodontic treatment outcomes. Mandibular premolar teeth demonstrate extreme variations in root canal morphology. Mandibular first premolars typically exhibit basic single-root and single-canal anatomy. The occurrence of three roots in the mandibular first premolar has not been commonly reported in the literature. This article reported a case of a 26-year-old male with spontaneous pain of the mandibular first premolar representing the presence of an extra canal on the periapical radiograph. Cone-beam computed tomography (CBCT) was used to assess the root canal details which led to the finding of three canals. Further, a periapical bone defect was detected, and finally, the nonsurgical endodontic management of the mandibular first premolar with three canals and three different apical foramina was performed in one session.