Original Article

Treatment Outcomes of Primary Molars Direct Pulp Capping after 20 Months: A Randomized Controlled Trial

Masoud Fallahinejad Ghajari, Tahereh Asgharian Jeddi, Sonay Iri, Saeed Asgary

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 149-152

Introduction: The aim of this randomized controlled trial was to compare the radiographic and clinical success rates of direct pulp capping (DPC) using ProRoot mineral trioxide aggregate (MTA) or calcium enriched mixture (CEM). Methods and Materials: A total of 42 symptom-free carious vital primary molars (21 pairs) were selected in this split mouth trial and randomly pulpotomized in two experimental groups. Pinpoint pulp exposures were covered by the same blinded operator with MTA or CEM, and then restored by amalgam. Radiographic and clinical successes were evaluated at 20 month follow-up. Data were statistically analyzed using McNemar test. Results: Nineteen patients were available for 20-month follow-up; only one failed tooth was extracted in the CEM group. All available teeth were symptom-free, however, the final evaluated success rate was 89% in CEM (CI 95%: 0.82-0.96) and 95% in MTA (CI 95%: 0.85-1) groups without statistical difference (P=0.360). Worst case scenario was applied for missing value analysis; assuming that the 2 lost cases in CEM group had failed and the only lost case in MTA group was due to treatment success, as a result the success of CEM and MTA were 81% (CI 95%: 0.72-0.90) and 95% (CI 95%:0.85-1), respectively, with no statistical difference (P=0.078). In the reverse scenario, the success of MTA and CEM were 86% (CI 95%: 0.78-0.94) and 90% (CI 95%: 0.82-0.98), respectively; again with no statistical difference (P=0.479). Conclusion: Effectiveness of MTA and CEM biomaterials for primary molars’ DPC was similar; CEM can be a suitable alternative for MTA.

Evaluation of the Effect of Tooth Type and Canal Configuration on Crown Size in Mandibular Premolars by Cone-Beam Computed Tomography

Mohammad SalarPour, Narges Farhad Mollashahi, Elnaz Mousavi, Elahe SalarPour

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 153-156

Introduction: To achieve success in treatment, one cannot ignore the knowledge of pulp anatomy. Mandibular premolars are considered to be the most difficult teeth for endodontic therapy due to high variability in their canal morphology. It is possible that a relation exists between the crown size and the number of extra canals in these teeth, so this in vitro study aims to investigate the relationship between the crown size and the uncommon morphology of mandibular premolars using Cone-Beam Computed Tomography (CBCT). Materials and Methods: Eighty three extracted mandibular human premolars were exposed to radiation using the CBCT device. Root canal configuration was categorized according to the Vertucci’s classification. The crown size was measured in three axial, coronal and sagittal sections. Finally, the relation between these two factors was evaluated with variance analysis (two-way ANOVA) and chi-square. Results: The most common canal type in the mandibular first and second premolars are type I (71% and 76%, respectively), followed by type V (29% and 22%, respectively). No significant relationship was found between the crown size and extra canals in mandibular premolars (P>0.05). Conclusion: In this in vitro study, the average crown size in two-canalled second premolars was less than that in first premolars with a single canal; although the difference was not statistically significant. The research hypothesis was therefore rejected in both first and second mandibular premolars.

Effect of Smear Layer on the Push-Out Bond Strength of Two Different Compositions of White Mineral Trioxide Aggregate

Mehrdad Lotfi, Saeed Rahimi, Negin Ghasemi, Sepideh Vosoughhosseini, Mahmood Bahari, Mohammad Ali Saghiri, Atabak Shahidi

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 157-159

Introduction: The aim of this in vitro study was to evaluate the effect of smear layer on the push-out bond strength of white mineral trioxide aggregate (WMTA) with and without disodium hydrogen phosphate (Na2HPO4). Materials and Methods: Dentin discs with standard cavities were obtained from extracted human single-rooted teeth and divided to 4 groups (n=15) according to the irrigation regimen and the canal filling material. In groups 1 and 3, canals were irrigated with normal saline; in groups 2 and 4, irrigation method included sodium hypochlorite (NaOCl) and then ethylenediaminetetra-acetic acid (EDTA). The canals were filled with WMTA in first and second groups and with WMTA+Na2HPO4; in groups 3 and 4. The samples were wrapped in wet gauze and incubated in 37°C for 3 days. The push-out bond strength was then measured by means of the Universal Testing Machine and the failure modes were examined under stereomicroscope at 40× magnification. Tow-way ANOVA was used to evaluate the effect of material type and smear layer removal. Post hoc Tukey test was used for the two-by-two comparison of the groups. Results: The greatest and lowest mean±standard deviation for push-out bond strength were observed in groups 4 (4.54±1.14 MPa) and 1 (1.44±0.96 MPa), respectively. The effect of removing the smear layer on the push-out bond strength of WMTA+Na2HPO4 was significant (P=0.01), but not for WMTA (P=0.52). Interestingly, there was significant difference between groups 1, 3 and 2, 4 (P<0.05). The failure mode for all experimental groups was of mixed type. Conclusion: Under circumstances of this in vitro study, removal of smear layer increases push-out bond strength when Na2HPO4 is added to WMTA.

Detection of Procedural Errors with Stainless Steel and NiTi Instruments by Undergraduate Students Using Conventional Radiograph and Cone Beam Computed Tomography

Régis Augusto Aleixo Alves, João Batista Souza, Ana Helena Gonçalves Alencar, Jesus Djlama Pécora, Carlos Estrela

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 160-165

Introduction: This study investigated procedural errors made during root canal preparation using stainless steel and nickel-titanium (NiTi) instruments by undergraduate students, using two diagnostic imaging methods. Materials and Methods: Sixty human molars were divided into three groups (n=20; group 1: K-Flexofile, group 2: K3, and group 3: BioRace). The root canals were filled with gutta-percha and AH Plus. Periapical radiographs and cone beam computed tomography (CBCT) images were obtained to detect procedural errors made by undergraduate students during root canal preparation. Two examiners evaluated the presence or absence of fractured instruments, perforations and canal transportations. The agreement between observers was assessed using the kappa coefficient. The Kolmogorov-Smirnov, Fisher exact, ANOVA and Tukey tests were used for statistical analysis. The level of significance was set at 5%. Results: There were no significant differences in detecting procedural errors between two- and three-dimensional diagnostic imaging methods. There were no significant differences in procedural errors between stainless steel and NiTi instruments. Mean preparation time was recorded in minutes, and results were significantly different between the three groups. NiTi instruments had the lowest mean preparation time. Conclusion: Both periapical radiographs and CBCT identified procedural errors, however, three-dimensional images offered more diagnostic resources. The frequency of procedural errors was low for any of the endodontic instruments despite being used by inexperienced operators.

Antimicrobial Efficacy of Mineral Trioxide Aggregate with and without Silver Nanoparticles

Mohammad Samiei, Mohammad Aghazadeh, Mehrdad Lotfi, Sahar Shakoei, Zahra Aghazadeh, Seyyed Mahdi Vahid Pakdel

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 166-170

Introduction: Most current root-end filling materials do not provide a perfect seal. Thus, a microscopic space is likely to exist in the interface between walls of the root-end cavity and filling material, which allows microorganisms and their products to penetrate. In addition to good sealing ability and biocompatibility, root-end filling materials should ideally have some antimicrobial activity. Therefore, this in vitro study aimed to evaluate the antimicrobial properties of Angelus white mineral trioxide aggregate (MTA) and the mixture of MTA with silver nanoparticles (1% weight; MTA/SN). Materials and Methods: Antimicrobial properties of MTA and MTA/SN were tested by agar diffusion technique against Enterococcus faecalis, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans. The microbial inhibition zones around the materials were measured by a caliper with 0.1-mm accuracy. Student’s t-test was used for comparison between the two groups in normal data distribution and Man-Whitney U test for non-normal distribution. Results: Student’s t-test revealed that for E. faecalis, C. albicans, and P. aeruginosa, microbial inhibition zone of MTA/SN was significantly greater than that of MTA (P=0.000). Mann-Whitney U test indicated no significant difference between the effect of MTA and MTA/SN on S. aureus (P>0.05). Conclusion: Based on the results of this study, adding silver nanoparticles to MTA improved its antimicrobial efficacy.

Comparison of Endodontic Treatment Results Yielded from Using Normal Saline with IKI Final Rinse or NaOCl Irrigation: A 30-Month Follow-up Study

Abbas Abbaszadegan, Mohammadreza Nabavizadeh, Ameneh Hoseini Yekani, Akbar Khayat

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 171-176

Introduction: The aim of this clinical trial was to evaluate and compare the endodontic treatment results of teeth with apical periodontitis after thirty-month recall with two different irrigation regimen: normal saline followed by Iodine Potassium Iodide (IKI) or sodium hypochlorite (NaOCl) irrigation alone. Materials and Methods: Twenty seven patients (30 teeth) who had been included in the first part of our antimicrobial survey were recalled. In previous stage, root canal treatments were performed using either normal saline with IKI final rinse (n=15) or NaOCl (n=15) as irrigating solutions. Bacterial samples were taken before and after instrumentation. In this stage, three patients (6 teeth) were excluded from the follow-up schedule since they did not respond to the recall requests. The remaining 24 subjects (12 teeth in each NaOCl and IKI group) were examined clinically and radiologically. Post-operative and follow-up images were coded, blindly evaluated and given a periapical score according to PAI scoring system. The outcome was assessed in two ways; first, the changes in PAI score from base line to the follow-up evaluation in each group were assessed by wilcoxon signed rank test. In addition, Mann-Whitney U test was used to compare the differences between the post-operative and follow-up images of treatment groups. Second, the dichotomous variables as “healed” or “not healed” were compared. Results: The Median (Min, Max) PAI scores for NaOCl group and IKI group were both 5 (3, 5) for immediate post-operative radiographs and declined to 1 (1, 2) and 2 (1, 2), respectively. A statistically significant decrease in PAI score from the base line to the follow-up evaluation was seen in both groups (P=0.002). The decrease in NaOCl group was higher significantly in comparison to IKI group (P=0.036). One hundred percent of the teeth were healed in both groups (PAI≤2) and no teeth showed any abnormal clinical findings. Conclusion: Root canal irrigation with NaOCl resulted in a significant higher decrease in PAI scores in comparison to irrigation with normal saline followed by IKI final rinse. Although, according to results of 30-months recall, complete bone formation was observed in all samples in both groups and no teeth showed any abnormal clinical findings. These findings depict the weight of all important clinical and biological factors which together impact the results of a successful endodontic treatment.

Sealing Ability of Resilon and MTA as Root-end Filling Materials: A Bacterial and Dye Leakage Study

Hengameh Ashraf, Farhad Faramarzi, Payam Paymanpour

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 177-181

Introduction: Endodontic surgery is a valuable option for maintaining patient's natural dentition when previous orthograde endodontic treatments fail to succeed. Proper root-end preparation and placement of a retro-filling material are recommended for successful endodontic surgery. The objective of this experimental study was to compare sealing ability of Resilon/Epiphany system, as a potential root-end filling material, with ProRoot MTA using both dye and bacterial leakage models. Materials and Methods: Ninety two single-rooted extracted human teeth were decoronated and prepared endodontically. Specimens were randomly divided into four experimental groups (n=20) and four control groups (n=3). After removal of apical 3 mm and root-end cavity preparation, MTA, or Resilon were used to fill root end cavities. For bacterial leakage, specimens (20 for each experimental group, 3 negative, and 3 positive controls) were subjected to E. faecalis over a 70-day period. Methylene blue was used for dye leakage (the same in number as before). Using stereomicroscope (40× mag.) complete dye leakage was assessed after 72 h. Kaplan-Meier survival analysis was performed for bacterial leakage. The data was analyzed using t-test and Chi-square analysis (α=0.05). Results: All of the positive controls and none of negative controls revealed leakage.  Result of log rank test showed no significant difference between MTA and Resilon in time of bacterial leakage at the end of the 70 days (P>0.05) There was also no statistical difference in complete dye leakage for both groups (P>0.05). Conclusion: Leakage occurred in both MTA and Resilon as root-end filling material but the difference was not statistically significant. Resilon might be noticed as a potential root-end filling material if good isolation is attainable.

Evaluation of Marginal Adaptation of Root-End Filling Materials Using Scanning Electron Microscopy

Helder Fernandes Oliveira, Ana Helena Gonçalves Alencar, José Antônio Poli Figueiredo, Orlando Aguirre Guedes, Daniel de Almeida Decurcio, Carlos Estrela

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 182-186

Introduction: The importance of perfect apical seal in endodontics, more specifically in periradicular surgery, is the motivation/reason for development of root-end filling materials with favorable physical, chemical and biological characteristics. The aim of this in vitro study was to evaluate the marginal adaptation of root-end filling materials using scanning electron microscopy. Materials and Methods: Twenty five human maxillary anterior teeth were prepared using a K-File #50 to 1 mm short of the apical foramen and filled with gutta-percha and Sealapex using the lateral compaction technique. The apical 3 mm of the roots were sectioned perpendicularly to the long axis of the teeth. A 3-mm-deep root-end cavity was prepared using ultrasonic tips powered by an Enac ultrasonic unit. The teeth were randomly assigned to five groups according to the materials tested including IRM, amalgam, ProRoot MTA, Super-EBA and Epiphany/Resilon. Root-end cavities were filled with the materials prepared according to the manufacturers’ instructions. The root apices were carefully prepared for sputter coating and later evaluation using Scanning Electron Microscope (SEM). The images of root-end fillings were divided into four quadrants and distributed into five categories according to the level of marginal adaptation between the root-end material and the root canal walls. The Fisher exact test with Bonferroni correction was used for statistical analysis. The level of significance was set at P=0.005. Results: SEM images showed the presence of gaps in the root-end filling materials. No significant difference was observed between the tested materials (P>0.005). Conclusion: ProRoot MTA, IRM, amalgam, Super-EBA and Epiphany/Resilon showed similar marginal adaptation as root-end filling materials.

Microleakage of CEM Cement and ProRoot MTA as Furcal Perforation Repair Materials in Primary Teeth

Roza Haghgoo, Sara Arfa, Saeed Asgary

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 187-190

Introduction: Iatrogenic furcal perforation is a procedural accident in endodontic treatments of primary/permanent teeth; prognosis may be favorable if a complete seal with biomaterial is immediately established. The purpose of this in vitro study was to evaluate microleakage of calcium enriched mixture (CEM) cement and ProRoot mineral trioxide aggregate (MTA) for sealing primary molar furcal perforations. Materials and Methods: This study was conducted on 38 extracted human primary molars. Furcation perforations were created in the pulp chamber floor. The teeth were divided randomly in two experimental groups (n=17) and two positive and negative controls (n=2). Perforations were then repaired with biomaterials. After 72 h, the teeth were submerged in 2% fuchsin dye solution for 24h. The samples were sectioned longitudinally and evaluated for dye leakage. Data analyzed statistically using ANOVA test. Results: The negative and positive controls behaved as expected. Dye microleakage was observed in all experimental samples; however, there was no statistically significant difference between the microleakage of MTA (4.411±2.042 mm) and CEM (3.647±1.040 mm) groups (P>0.05). Conclusion: Based on the findings of this in vitro study, CEM and tooth-colored ProRoot MTA have similar sealing ability for furcal perforation repair of primary molar teeth.

Calcium Enriched Mixture and Mineral Trioxide Aggregate Activities against Enterococcus Faecalis in Presence of Dentin

Hasan Razmi, Mohsen Aminsobhani, Behnam Bolhari, Farin Shamshirgar, Shadi Shahsavan, Ahmad Reza Shamshiri

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 191-196

Introduction: The purpose of this in vitro study was to compare the antibacterial activity of Calcium Enriched Mixture (CEM) with ProRoot Mineral Trioxide Aggregate (MTA) against Enterococcus faecalis (E. faecalis) in the presence/absence of dentin powder. Materials and Methods: Two series of freshly mixed (10, 50, and 100 mg), set crushed powder (10, 50, and 100 mg), and pieces of uncrushed set (50, 100 mg) of CEM and MTA were prepared (n=32 groups). All samples were suspended in normal saline for direct exposure test against E. faecalis; in the second series, 50 mg of the dentin powder was also added to the solution. Dentin powder suspension and bacterial suspension served as negative and positive control groups, respectively (n=2). The suspensions were incubated at room temperature for 1, 60, and 240 min; each group was tested five times and survival of the bacteria in test solutions was assessed by 10-fold serial dilutions and cultured on Brain Heart Infusion (BHI) plates. The plates were incubated at 37ºC. The mean values of log10 CFU were calculated and compared in all tested groups. The total number of tests added up to 510 times. Results: In presence of dentin powder, freshly mixed powder from set materials, and pieces of uncrushed set materials of both tested cements killed >95% of the bacterial cell in 1 min. Adding dentin powder caused an increase in antibacterial activity of freshly mixed powder from crushed set CEM and MTA but no acceleration in bacterial killing was observed, when dentin was mixed with set or uncrushed cements. Dentin powder alone reduced the number of viable bacteria in the 4-hour duration. There were no significant differences between different weights of freshly mixed, crushed set powder and uncrushed set of CEM cement and MTA at different times. Conclusion: Under the conditions of this in vitro study, CEM cement as well as MTA have antibacterial effects against E. faecalis. The addition of equal amounts of dentin powder to the suspension of CEM or MTA resulted in swifter elimination of bacteria.

Review Article

Patient-Centered Endodontic Outcomes: A Narrative Review

Reza Hamedy, Bita Shakiba, Sara Fayazi, Jacklyn G Pak, Shane Newport White

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 197-204

Introduction: Root canal treatment (RCT) success criteria inform us of the path to bony healing and of prognostic factors, but tell little about how the patient perceives, feels, or values RCT. Patients choose, undergo, and pay for RCT, they live with the result, and inform their community. The purpose of this narrative review was to appraise patient-centered outcomes of initial non-surgical RCT and nonsurgical retreatment, in adults. Materials and Methods: Patient-centered RCT outcome themes were identified in the extant literature: quality of life, satisfaction, anxiety, fear, pain, tooth survival and cost. Narrative review was applied because the disparate themes and data were unsuited to systematic review or meta-analysis. Results: Application of the Oral Health Impact Profile (OHIP) demonstrated that disease of pulpal origin affects quality of life with moderate severity, primarily through physical pain and psychological discomfort, and that RCT results in broad improvement of quality of life. Satisfaction with RCT is extremely high, but cost is the primary reason for dissatisfaction. Anxiety and fear affect RCT patients, profoundly influencing their behaviors, including treatment avoidance, and their pain experience. Fear of pain is “fair” to “very much” prior to RCT. Pain is widely feared, disliked, and remembered; however, disease of pulpal origin generally produces moderate, but not severe pain. RCT causes a dramatic decrease in pain prevalence and severity over the week following treatment. Survival rates of teeth after RCT are very high; complication rates are low. Cost is a barrier to RCT, but initial costs, lifetime costs, cost effectiveness, cost utility, and cost benefit all compare extremely well to the alternatives involving replacement using implants or fixed prostheses. Conclusion: Dentists must strive to reduce anxiety, fear, experienced and remembered pain, and to accurately inform and educate their patients with respect to technical, practical and psychosocial aspects of RCT.

Case Report

Management of an Intracanal Separated Instrument: A Case Report

Dipti Maulik Choksi, Barkha Idnani, Devendra Kalaria, Ronak N. Patel

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 205-207

Instrument fracture within the root canal during root canal treatment is an unwanted and frustrating complication. The fractured segment may hinder cleaning and shaping procedures with potential impact on prognosis of treatment. Fracture of endodontic instrument often results from incorrect use or overuse. If breakage occurs clinically, the patient should be informed of the incident and consideration should be given whether to remove the fragment or not. When managed properly, the presence of a broken fragment per se may not adversely affect the outcome of root canal treatment. This article reports management of an intracanal separated instrument. Masserann kit along with gates glidden drills were used to remove the intracanal broken instrument.

Tissue Necrosis due to Chloroform: A Case Report

Nahid Mohammadzadeh Akhlaghi, Ladan Baradaran Mohajeri, Mahta Fazlyab

Iranian Endodontic Journal, Vol. 8 No. 4 (2013), 7 October 2013 , Page 208-209

For many years, gutta-percha has been the root canal filling material of choice. Chloroform is one of the most efficient solvents widely used for gutta-percha removal in retreatment cases, despite being toxic and carcinogenic. The present case report discusses a chloroform extrusion through an existing perforation to the surrounding periodontal ligament space and subsequent necrosis in supporting bone and tissues, during an endodontic retreatment visit for an addicted patient. Subsequently, the management and preventive options are reviewed.