Systematic Review

Mineral Trioxide Aggregate vs. Calcium Hydroxide in Primary Molar Pulpotomy: A Systematic Review

Armin Shirvani, Raheleh Hassanizadeh, Saeed Asgary

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 83-88

Introduction: The aim of this quantitative systematic review/meta-analysis was to compare the treatment outcomes of mineral trioxide aggregate (MTA) and calcium hydroxide (CH) in pulpotomy of human primary molars. The focused PICO question was “in case of pulp exposure in vital primary molars, how does MTA pulpotomy compare to CH in terms of clinical/radiographic success?” Methods and Materials: We retrieved published randomized clinical trials (RCTs) of at least 6-month duration; our search included articles published up to March 2013 in five following databases: PubMed (Medline), Cochrane database of systematic reviews, Science Citation Index, EMBASE, and Google Scholar. Mantel Haenszel and Inverse Variance-weighted methods were applied by STATA; the relative risk (RR) was calculated with 95% confidence intervals (CI). Results: A total of 282 English articles were collected. Two authors independently screened the articles and five RCTs were selected; data extraction and quality assessment were then carried out. Four RCTs were appropriate for meta-analysis according to their follow-up times by Mantel Haenszel method. Statistically significant difference was found between success rate of MTA compared to CH, with RR=0.08 (95% CI, 0.02-0.39), RR=0.19 (95% CI, 0.08-0.46), and RR=0.38 (95% CI, 0.21-0.68) for 6-, 12-, and 24-month follow-ups, respectively. A significant difference was also observed for all included RCTs after analyses using the Inverse Variance-weighted method (RR=0.44; 95% CI, 0.27-0.72). Conclusions: Systematic review/meta-analysis of included RCTs revealed that for pulpotomy of vital primary molars, MTA has better treatment outcomes compared to CH.

Review Article

An Update on the Management of Endodontic Biofilms Using Root Canal Irrigants and Medicaments

Zahed Mohammadi, Mohammad Karim Soltani, Sousan Shalavi

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 89-97

Microbial biofilm is defined as a sessile multicellular microbial community characterized by cells that are firmly attached to a surface and enmeshed in a self-produced matrix of extracellular polymeric substances. Biofilms play a very important role in pulp and periradicular pathosis. The aim of this article was to review the role of endodontic biofilms and the effects of root canal irrigants, medicaments as well as lasers on biofilms. A Medline search was performed on the English articles published from 1982 to 2013 and was limited to papers published in English. The searched keywords were “Biofilms AND endodontics”, “Biofilms AND sodium hypochlorite”, "Biofilms AND chlorhexidine", "Biofilms AND MTAD", "Biofilms AND calcium hydroxide", “Biofilms AND ozone”, “Biofilms AND lasers” and "Biofilms AND nanoparticles". The reference list of each article was manually searched to find other suitable sources of information.

Endodontic Epidemiology

Arash Shahravan, Ali Akbar Haghdoost

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 98-108

Epidemiology is the study of disease distribution and factors determining or affecting it. Likewise, endodontic epidemiology can be defined as the science of studying the distribution pattern and determinants of pulp and periapical diseases; specially apical periodontitis. Although different study designs have been used in endodontics, researchers must pay more attention to study designs with higher level of evidence (LoE) such as randomized clinical trials.

Original Article

Cone-Beam Computed Tomography for Evaluation of Apical Transportation in Root Canals Prepared by Two Rotary Systems

Zahra Sadat Madani, Azam Haddadi, Sina Haghanifar, Ali Bijani

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 109-112

Introduction: Due to the importance of apical transportation during root canal preparation, the aim of the current study was to use cone-beam computed tomography (CBCT) to assess the extent of apical transportation caused by ProTaper and Mtwo files. Methods and Materials: Forty extracted maxillary first molars with 19-22 mm length and 20-40 degrees of curvature were selected. The mesiobuccal canals were prepared using either Mtwo or ProTaper rotary files (n=20). CBCT images were obtained before and after canal preparation to compare the apical transportation in different cross-sections of mesial and distal surfaces. The apical transportation values were analyzed using the SPSS software. The results were compared with student’s t-test and Mann-Whitney U test. Results: There was no significant difference in the extent of apical transportation between Mtwo and ProTaper systems in different canal cross-sections. The apical transportation value was less than 0.1 mm in most of the specimens, which was clinically acceptable. Conclusion: Considering the insignificant difference between the two systems, it can be concluded that both system have low rates of apical transportation and can be assuredly used in clinical settings.

Comparing the Fracture Rate of Hero 642, FlexMaster and Mtwo in the Simulated Canals

Hossein Labaf, Roza Haghgoo, Kumars Nazarimoghaddam, Mahshid Mahammadi Basir

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 113-116

Introduction: File fracture is one of the main procedural mishaps in endodontic treatment. The aim of this in vitro study was to compare the fracture rate of three NiTi rotary systems; Hero 642, Mtwo and FlexMaster in artificial canals. Methods and Materials: In this study, bovine long bone was used. After primary preparation of bones, longitudinal sections with 4-cm diameter were cut and encoded. Subsequently, semicircular sections were prepared. A total number of 500 canals were created in the same way; the upper 3 mm of the canals were initially prepared with orifice shapers and then canals were filed with FlexMaster files sizes 25/0.02 and 25/0.04 to 13 mm of canal length. The prepared canals were assigned into 3 groups of the following systems: Hero 642, Mtwo and FlexMaster. Six selected instruments were used from each system; the files were applied 13 mm along the canals for 10 sec with manufacturer’s suggested speed and torque. The number of the canals prepared by each file before its separation was recorded; finally the data was analyzed with ANOVA test. Results: Mean number of prepared canals in Mtwo, FlexMaster and Hero groups before file separation was 15, 25 and 32, respectively. Conclusion: Results of this study showed that the number of prepared canals by Hero 642 was more than FlexMaster and Mtwo systems.

A Comparison of Apical Transportation in Severely Curved Canals Induced by Reciproc and BioRaCe Systems

Mohammadreza Nabavizadeh, Abbas Abbaszadegan, Leila Khojastehpour, Mohsen Amirhosseini, Ebrahim Kiani

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 117-122

Introduction: Preserving the apical root structure during cleaning and shaping of the canal has always been a challenge in endodontics particularly when the root canals are curved. The purpose of this in vitro study was to compare the apical transportation induced by the Reciproc and BioRaCe rotary systems in preparing the mesiobuccal root canal of the human maxillary molars. Materials and Methods: The mesiobuccal canals of sixty extracted maxillary molars with curvature angle of 25-35˚ were selected and randomly assigned into two groups. Each canal was prepared by either Reciproc or BioRaCe rotary systems. A double-digital radiographic technique and AutoCAD software were used to compare the apical transportation at 0.5, 1, 2, 3, 4 and 5 mm distances from the working length (WL). The distance between the master apical rotary file and the initial K-file in the superimposed radiographs determined the amount of apical transportation. An independent t-test was used to compare the groups. The statistical significant level was set at 0.05. Results: Apical transportation of the Reciproc group was significantly greater than the BioRaCe group in all distances (P<0.001). The maximum apical transportation occurred in the Reciproc group at 0.5 mm from the WL (0.048±0.0028 mm) and the minimum occurred for BioRaCe at 5 mm from the WL (0.010±0.0005 mm). Conclusions: The Reciproc system produced significantly more apical transportation than the BioRaCe, but this fact does not seem to negatively alter the clinical success or quality of root canal treatment.

The Ability of Triple Antibiotic Paste and Calcium Hydroxide in Disinfection of Dentinal Tubules

Alireza Adl, Sabie Hamedi, Mohamad Motamedifar, Fereshte Sobhnamayan

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 123-126

Introduction: The purpose of this in vitro study was to compare the ability of triple antibiotic paste (TAP) to calcium hydroxide (CH) in disinfecting dentinal tubules. Material and Methods: Sixty root blocks were obtained from extracted single-rooted human teeth. The root canals were enlarged with Gates-Glidden drills up to size 3 and were contaminated with Enterococcus. faecalis (E. faecalis), and then left for 21 days. The contaminated blocks were treated with saline (as negative control), CH or TAP. Dentin debris was obtained at the end of first and 7th days, using Gates-Glidden drills sizes 4 and 5 from two different depths of 100 and 200 µm. The vital bacterial load was assessed by counting the number of colony forming units (CFUs). The data was analyzed with the Kruskal-Wallis H and Dunn Post-Hoc tests. The Wilcoxon Signed Ranks test was used to check for differences in bacterial growth at both depths (P<0.05). Results: In comparison with CH, the TAP significantly decreased the number of CFUs in both depths and time intervals (P<0.001), while the CH group showed a moderate antibacterial effect. Conclusion: TAP is more effective in disinfecting the canal against E. faecalis compared to CH.

The Impact of Three Different Canal Lubricants on Fracture, Deformity and Metal Slivering of ProTaper Rotary Instruments

Yazdan Shantiaee, Omid Dianat, Farnoud Sharifi, Golnaz Nahvi, Golbarg Kolahi Ahari

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 127-130

Introduction: The aim of this in vitro study was to evaluate the effect(s) of three canal lubricants i.e. sodium hypochlorite, RC-Prep as the paste form of ethylenediaminetetraacetic acid (EDTA) and aqueous EDTA, on the occurrence/incidence of fracture, deformity and metal slivering of ProTaper rotary instruments. Methods: A total of 120 mesial canals (i.e. mesiobuccal and mesiolingual) of first mandibular molars or buccal canals (i.e. mesiobuccal and distobuccal) of first maxillary molars, with curvatures of 10-20 degrees were selected and randomly divided into three groups of forty samples each. These selected canals all had approximate 19-21 mm working length and apical diameter equal to a #15 K-file. In each group, the root canals were prepared using ProTaper rotary instruments with an electric motor using one of the three aforementioned irrigants. Subsequently, samples were compared to each other at different magnifications (16×, 20×, 40× and 57×) for any fracture, deformity or metal slivering, by the Cox regression analysis. Results: The fractures rate of samples in RC-Prep group was significantly higher compared to other groups (P=0.01). No evidence of instrument deformity was detected in any groups. A statistically significant reverse relation between metal slivering and instrument fracture was observed. Conclusions: Application of aqueous EDTA and/or sodium hypochlorite as intracanal lubricants caused less fracture of ProTaper instruments compared to canal lubrication with RC-Prep.

A Scanning Electron Microscope Study on the Effect of an Experimental Irrigation Solution on Smear Layer Removal

Vahid Zand, Hadi Mokhtari, Mehrdad Lotfi, Saeed Rahimi, Aydin Sohrabi, Sina Badamchi Zadeh, Hanieh Mojaver Kahnamooie, Pardis Tehranchi

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 131-136

Introduction: The aim of this in vitro study was to evaluate the effect of an experimental irrigation solution, containing two different concentrations of papain, Tween 80, 2% chlorhexidine and EDTA, on removal of the smear layer. Methods and Materials: Thirty-six single-rooted teeth were divided into two experimental groups (n=12) and two positive and negative control groups of six. The canals were prepared with BioRaCe instruments up to BR7 (60/0.02). In group 1, canals were irrigated with a combination of 1% papain, 17% EDTA, Tween 80 and 2% CHX; in group 2, canals were irrigated with a combination of 0.1% papain, 17% EDTA, Tween 80 and 2% CHX. In group 3 (the negative control), the canal was irrigated with 2.5% NaOCl during instrumentation and at the end of preparation with 1 mL of 17% EDTA was used; in group 4 (positive control), normal saline was used for irrigation. The amount of the remaining smear layer was quantified according to Hulsmann method using scanning electron microscopy (SEM). Data was analyzed by the Kruskal-Wallis and Mann-Whitney tests. Results: Two-by-two comparisons of the groups revealed no significant differences in terms of smear layer removal at different canal sections between the negative control group (standard regiment for smear layer removal) and 1% papain groups (P<0.05). Conclusion: Under the limitations of the present study, combination of 1% papain, EDTA, 2% chlorhexidine and Tween 80 can effectively remove smear layer from canal walls.

A Study on Biocompatibility of Three Endodontic Sealers: Intensity and Duration of Tissue Irritation

Camilla Christian Gomes Moura, Thais Cristina Cunha, Virgínia Oliveira Crema, Paula Dechichi, João Carlos Gabrielli Biffi

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 137-143

Introduction: Several studies have evaluated the inflammatory reaction triggered by Epiphany (EPH), a contemporary endodontic sealer. However, they used conventional parameters, which need additional analysis to better understand the reactions induced by this sealer compared to other traditional sealers. Methods and Materials: The intensity and time span of tissue irritations for three endodontic sealers were assessed by inflammatory reactions, fibrous capsule measurement and mast cell counts. Tubes containing freshly mixed EPH, AH plus (AHP) and Endofill (ENF) were subcutaneously implanted into the backs of 28 Wistar rats. The side wall of the tube was used as the control. At 14, 21, 42 and 60 days, the connective tissue surrounding the implants (n=7) was stainedfor histopathological analysis. The Friedman test was applied to compare the results. The level of significance was set at 0.05. Results: At days 14 and 21, a significant difference among the groups was observed, with the ENF showing the worst tissue response (P<0.001). ENF remained the most aggressive sealer at 42 and 60 days, compared with EPH (P<0.05). No differences were found for the fibrous capsule thicknesses among the groups in each period. The number of mast cells per field did not show difference among the sealers at 21 and 60 days. Conclusions: EPH and AHP elicited similar patterns of irritation, as demonstrated by the inflammatory scores and fibrous capsule thicknesses. ENF caused the highest degree of tissue damage. The increase in mast cell counts observed during the early and late periods shows the possibility of late hypersensitivity to the test materials.

Marginal Adaptation of New Bioceramic Materials and Mineral Trioxide Aggregate: A Scanning Electron Microscopy Study

Noushin Shokouhinejad, Mohmmad Hossein Nekoofar, Kazem Ashoftehyazdi, Shohreh Zahraee, Mehrfam Khoshkhounejad

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 144-148

Introduction: This study aimed to compare the marginal adaptation of new bioceramic materials, EndoSequence Root Repair Material (ERRM putty and ERRM paste), to that of mineral trioxide aggregate (MTA) as root-end filling materials. Materials and Methods: Thirty-six extracted human single-rooted teeth were prepared and obturated with gutta-percha and AH-26 sealer. The roots were resected 3 mm from the apex. Root-end cavities were then prepared with an ultrasonic retrotip. The specimens were divided into three groups (n=12) and filled with MTA, ERRM putty or ERRM paste. Epoxy resin replicas from the resected root-end surfaces and longitudinally sectioned roots were fabricated. The gaps at the material/dentin interface were measured using scanning electron microscope (SEM). Transversal, longitudinal, and overall gap sizes were measured for each specimen. The data were analyzed using the Kruskal-Wallis test. Results: In transversal sections, no significant difference was found between MTA, ERRM putty and ERRM paste (P=0.31). However, in longitudinal sections, larger gaps were evident between ERRM paste and dentinal walls compared to MTA and ERRM putty (P=0.002 and P=0.033, respectively). Considering the overall gap size values, the difference between three tested materials was not statistically significant (P=0.17). Conclusion: Within the limits of this study, the marginal adaptation of ERRM paste and putty was comparable to that of MTA. However, ERRM putty might be more suitable for filling the root-end cavities because of its superior adaptation compared to ERRM paste in longitudinal sections.

Case Report

Extraoral Retrograde Root Canal Filling of an Orthodontic Induced External Root Resorption Using CEM Cement

Sanam Kheirieh, Mahta Fazlyab, Hassan Torabzadeh, Mohamad Jafar Eghbal

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 149-152

Inflammatory external root resorption (IERR) after orthodontic treatments is an unusual complication. This case report describes a non-vital maxillary premolar with symptomatic extensive IERR (with a crown/root ratio of 1:1) after receiving orthodontic treatment. The first appointment included drainage, chemo-mechanical preparation of the canal and intra-canal medication with calcium hydroxide (CH) along with prescription of analgesic/antibiotic. The subsequent one-week follow-up revealed the persistence of symptoms and formation of a sinus tract. Finally, extraoral endodontic treatment was planned; the tooth was atraumatically extracted and retrograde root canal filling with calcium enriched mixture (CEM) cement was placed followed by tooth replantation. Clinical signs/symptoms subsided during 7 days postoperatively. The sinus tract also resolved after one week. Six-month and one-year follow-ups revealed complete healing and a fully functional asymptomatic tooth. This case study showed favorable outcomes in a refractory periapical lesion associated with orthodontically induced extensive IERR. The chemical as well as biological properties of CEM cement may be a suitable endodontic biomaterial for these cases.

Introduction: Coronal anatomic variations in permanent maxillary molars are unusual; conversely variations involving the number of root canals or number of roots are more common. Methods and Materials: This case report presents a successful nonsurgical endodontic therapy of left maxillary first molar with three roots and seven root canals. This unusual morphology was diagnosed using a dental operating microscope (DOM) and confirmed with the help of cone-beam computed tomography (CBCT) images. Results: CBCT axial images showed that both of the palatal and distobuccal roots had Vertucci type II canal pattern, whereas the mesiobuccal root canal showed a Sert and Bayirli’s type XV configuration. Conclusion: The use of a DOM and CBCT imaging in endodontically challenging cases can facilitate a better understanding of the complex root canal anatomy, which ultimately enables the clinician to explore the root canal system, and therefore treat it far more efficiently.

Retreatment of a Mandibular Second Premolar with Three Roots: A Case Report

Eshagh Ali Saberi, Hossein Rasooli, Zeinab Movassagh

Iranian Endodontic Journal, Vol. 9 No. 2 (2014), 9 March 2014 , Page 158-160

Mandibular premolars have earned a reputation for having aberrant anatomy. The occurrence of three canals with three separate foramina in mandibular premolars is very rare. If predictable treatment of a three rooted mandibular premolar is planned, precise knowledge of clinical and radiographic anatomy is absolutely necessary. These teeth may also require special shaping and obturating techniques. This article reports and discusses the treatment recommendations for an unusual occurrence of three canals with three separate foramina in a second mandibular premolar.