Iranian Endodontic Journal

Case selection and treatment plan are important aspects of endodontic treatment. Dentists should organize the treatment plan based on their knowledge, abilities, skills and more importantly the patients’ preference and dentition. Indubitably, the treatment plan for each patient is exclusive and “tailor-made” and cannot be used for all patients. Dentists’ self-estimation of their abilities opens up treatment options; however, in difficult or complicated cases it is advisable to refer to a specialist. Currently, one of the most challenging aspects in dentistry is the choice between extraction and placement of implant (EPI) instead of a complicated root canal treatment (RCT). Overemphasis on one treatment plan while neglecting other options, not only mislead the dentist but also impose unnecessary charges to the patients. This mini-review compares RCT to EPI from various aspects to help practitioners in routine decision making.

Keywords: Case Selection; Dental Implant; Extraction; Implant; Root Canal Treatment; Tooth Replacement; Treatment Plan

Introduction: The aim of this study was to compare the changes that occur in the danger zone (DZ) after preparation of curved mesiobuccal (MB) canals of mandibular first molars with WaveOne instruments in two different movements [reciprocation (RCP) and counter-clockwise rotation (CCWR)] by means of cone-beam computed tomography (CBCT). Methods and Materials: MB canals of 30 mandibular molars were randomly divided into 2 groups (n=15); WaveOne/RCP and WaveOne/CCWR. Pre- and post-instrumentation CBCT images were assessed for changes in the dentin thickness in DZ (2 and 4 mm below the highest point of the root furcation) in both groups. Data was analyzed using the repeated measures ANOVA test. Results: There was no statistically significant difference between two experimental groups in terms of remaining dentin thickness at 2 and 4 mm levels below the highest point of the furcation (P>0.05). Conclusion: The efficacy of WaveOne instrument on changes of the dentin thickness in the DZ was not affected by different file movements.

Keywords: Danger Zone; Reciprocating Handpiece; Reciprocation; Rotation; WaveOne 

Introduction: The aim of the present study was to evaluate whether adding 2% chlorhexidine (CHX) and 2.6% sodium hypochlorite (NaOCl) to calcium-enriched mixture (CEM) cement would affect its setting time (ST), or not. Methods and Materials: In this study, the setting time of CEM cement was evaluated in three groups (n=9) as follows: group 1; CEM cement, group 2; CEM cement+2% CHX and group 3; CEM cement+2.6% NaOCl. Then the mean values of ST were calculated and the Kolmogorov-Smirnov test was used to evaluate the normal distribution of data. The Kruskal-Wallis and Mann-Whitney U tests were used for statistical analysis. Statistical significance was set at 0.05. Results: The mean ST for groups 1, 2 and 3 were 105, 120 and 220 min, respectively. There was a significant increase in the duration of ST in group 3 (NaOCl) in comparison with the two other groups (P<0.05). Conclusion: NaOCl significantly increased the ST of CEM cement, whereas chlorhexidine did not alter the ST.

Keywords: Calcium-Enriched Mixture; CEM Cement; Chlorhexidine; Setting Time; Sodium Hypochlorite

Introduction: Apical debris extrusion (DE) subsequent to root canal instrumentation, is one of the most important causes of endodontic flare-ups. The aim of this study was to compare the amount of DE after root canal instrumentation using nickel-titanium (NiTi) hand files with step-back manual technique or installed on reciprocating handpiece. Methods and Materials: This study was conducted on mesiobuccal (MB) roots of extracted maxillary first molars (n=20) and roots of mandibular premolars (n=20) that were randomly divided into two groups (n=20) according to the armamentarium used for canal preparation (air-driven reciprocating handpiece or hand instrumentation). In each group, the MB and premolar roots were prepared with the main apical sizes of 35 and 40, respectively. The extruded debris were collected and weighed. Finally, the mean dry weights were compared using ANOVA and t-test, and Tukey’s Multiple Comparisons Procedures were used to determine the significant differences in amounts of DE. The level of significance was set at 0.05. Results: Regardless of the type of teeth, the mean values of DE, were significantly lower in the handpiece group (P<0.0001). In addition, significantly lower amounts of DE was observed in premolars in similar group (P<0.001). However, this difference was not significant in MB roots of molars (P=0.20). Conclusion: Root canal preparation with reciprocating handpiece can lead to significantly lower debris extrusion than the manual step-back technique. In handpiece-prepared canals, the amount of extruded debris was significantly lower in premolar teeth.

Keywords: Apical; Apical Extrusion; Debris Extrusion; NiTi Files; Reciprocation; Step-Back Technique

Introduction: Enlargement of the root canal may potentially affect efficient smear layer (SL) removal. The aim of the present in vitro study was to compare SL removal following canal preparation with two different sizes/tapers by means of scanning electron microscopy (SEM). Methods and Materials: A total of 50 extracted human mandibular premolars were decoronated. The teeth were randomly divided into two experimental groups (n=20) and two negative control groups. In groups 1 and 2 the sizes of master apical file (MAF) were #25 and 40, respectively. Coronal part of the canals were flared with #2 Piezo drills in group 1 and sizes #2 to 6 in group 2. Finally FlexMaster NiTi rotary instruments were used to complete canal preparation (25/0.04 and 35/0.06 in groups 1 and 2, respectively). The irrigation protocol consisted of 10 mL of 17% ethylenediaminetetraacetic acid (EDTA) for 1 min followed by 10 mL of 5.25% NaOCl for 3 min. The patency of dentinal tubules was evaluated under SEM with Hülsmann scores. Data were analyzed with the Kruskal-Wallis and Mann-Whitney U tests. Results: The number of patent dentinal tubules in coronal third of the group 1 was significantly more than group 2 (P<0.001). However, this difference was not significant for the middle and apical segments. There was a significant difference in the number of patent dentinal tubules between coronal, middle and apical thirds (P<0.05). Conclusion: Increasing the canal preparation size did not lead to better cleanliness of the canal walls and more efficient smear layer removal.

Keywords: Dentinal Tubules; Ethylenediaminetetraacetic Acid; EDTA; Root Canal Preparation; Scanning Electron Microscopy; Smear Layer

Introduction: Due to the complex anatomy of the root canal system and high surface tension of common root canal irrigants (RCI), conducting an investigation on RCIs containing surfactants is a priority. The aim of this in vitro study was to verify the antibacterial potential of RCI with low surface tension in root canals infected with Enterococcus faecalis (E. faecalis). Methods and Materials: Thirty-five extracted human maxillary anterior teeth were prepared and inoculated with E. faecalis for 60 days. After root canal preparation, the teeth were randomly divided to one positive and one negative control groups and 5 experimental groups: Hypoclean/Tetraclean NA, Hypoclean, Tetraclean, NaOCl/Tetraclean and NaOCl. Bacterial growth was observed by turbidity of culture medium and then measured using a UV spectrophotometer. Data were analyzed in three time intervals (pre-instrumentation and, 20 min and 72 h after canal preparation) using the ANOVA and post hoc Tukey’s tests. The level of significance was set at 0.05. Results: The results indicated the presence of E. faecalis in all post-irrigation samples irrespective of the RCI. However, the optical densities in both post-irrigation periods showed bacterial reduction and significant differences between groups. Conclusion: RCI with low surface tension showed antibacterial potential in E. faecalis infected roots.

Introduction: One of the main goals of endodontic treatment is to decrease the harboring bacteria within the root canal system and dentinal tubules. This experimental study attempted to investigate the antibacterial efficacy of three root canal irrigants in the presence and absence of smear layer (SL). Methods and Materials: A total of 210 sound extracted human single-rooted teeth were prepared. After creating the SL and its removal in half of the samples, they were infected with Candida albicans (C. albicans) and Actinomyces israelii (A. israelii). A total of 180 specimen were used to assess the antimicrobial efficacy of the three irrigants in presence and absence of SL, 24 specimen were placed in the positive and negative controls, 2 samples were utilized for scanning electron microscopy (SEM) analysis and 2 were used for Gram staining. Then, they were exposed to irrigants including 2.61% sodium hypochlorite (NaOCl), 0.2% chlorhexidine gluconate (CHX) and 1% povidone-iodine (PI) for 5, 30 and 60 min. Presence/absence of test microorganisms was determined by incubation of specimens in test tubes containing brain-heart infusion (BHI) broth and then measuring the colony forming units (CFU) on BHI agar. A cumulative logistic model was used to analyze the ordinal response. Results: The 2.61% solution of NaOCl was significantly more effective than 0.2% CHX and the latter was more efficient than 1% PI for decreasing fungal and microbial infection of dentinal tubules in the presence and absence of SL. Conclusion: The presence of smear layer decreased the efficacy of antimicrobial irrigants. The minimum time required for elimination of fungal/microbial infection was 30 min.

Keywords: Actinomyces israelii; Candida albicans; Chlorhexidine; Povidone-Iodine; Smear Layer; Sodium Hypochlorite

Introduction: Calcium hydroxide (CH) is one of the most common intracanal medications. Corticosteroids (CS) are used in endodontics because of their anti-inflammatory activity. This study aimed to evaluate the antimicrobial effect of CH+betamethasone and CH+saline against Enterococcus faecalis (E. faecalis) using agar diffusion test and measuring the microbial zone of inhibition (ZOI). Methods and Materials: Four plates containing Mueller-Hinton broth and E. faecalis culture media, were prepared. In each plate, 5 holes (5×3 mm) were created and a creamy mixture of CH+betamethasone was inserted into the holes (10 holes for each material). Two holes with ampicillin disks and two empty holes were used as negative and positive controls, respectively. Plates were incubated for 24 h and then the diameter of microbial ZOI was measured. The pH of each mixture was measured by pH meter. Data were analyzed using the Mann-Whitney U test. Results: The mean diameter of ZOI for CH+betamethasone and CH+saline was 3.4 and 3 mm, respectively. The difference was not significant (P=0.143). The pH was 12.5 for CH+saline and 12.3 CH+betamethasone, respectively. Conclusion: The mixture of CH+betamethasone had good antimicrobial effects against E. faecalis. Further studies are needed to confirm the value of this mixture in clinical settings.

Keywords: Antimicrobial Activity; Betamethasone; Calcium Hydroxide; Enterococcus faecalis; Intracanal Medication

Introduction: The aim of the present study was to evaluate the expression of fibronectin (FN) and tenascin (TN) after direct pulp capping (DPC) in dogs’ teeth with either mineral trioxide aggregate (MTA), Propolis or Platelet-rich plasma (PRP), by means of immunohistochemistry. Methods and Materials: A total of 48 sound molars and premolars with mature apices from four dogs, were included. The teeth were randomly divided into 4 groups according to the material used for DPC: PRP, Propolis, MTA, and glass-ionomer (as the negative control group). Each group was divided into two 7-day and 30-day subgroups. The teeth were restored at the same session. The animals were sacrificed at the mentioned time intervals and the expression of FN and TN in each test group and between each time intervals was assessed with Wilcoxon and Mann-Whitney U tests, respectively. The Kruskal-Wallis test was used to compare FN and TN staining among the test groups. The significance level was set at 0.05. Results: The amount of FN in the MTA group in the 30-day interval was significantly higher than the 7-day interval; however, there were no significant differences among the other groups. The amount of TN in the MTA and Propolis groups in the 30-day interval was significantly higher than that in the 7-day interval; no recognizable difference was observed in the other groups. Moreover, the difference in expression of FN and TN in the 7-day interval was not significant in the experimental groups. Nevertheless, the difference was significant in the 30-day interval, with the highest and lowest expressions belonging to the MTA and glass-ionomer groups, respectively. Conclusion: Based on the results of the present animal study, MTA is still a better choice for direct pulp capping.

Introduction: Vertical root fracture (VRF) is common in endodontically treated teeth. Conventional and digital radiographies have limitations for detection of VRFs. Cone-beam computed tomography (CBCT) offers greater detection accuracy of VRFs in comparison with conventional radiography. This study compared the effects of metal artifacts on detection of VRFs by using two CBCT systems. Methods and Materials: Eighty extracted premolars were selected and sectioned at the level of the cemento-enamel junction (CEJ). After preparation, root canals were filled with gutta-percha. Subsequently, two thirds of the root fillings were removed for post space preparation and a custom-made post was cemented into each canal. The teeth were randomly divided into two groups (n=40). In the test group, root fracture was created with Instron universal testing machine. The control teeth remained intact. CBCT scans of all teeth were obtained with either New Tom VGI or Soredex Scanora 3D. Three observers analyzed the images for detection of VRF. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for VRF detection and percentage of probable cases were calculated for each imaging system and compared using non-parametric tests considering the non-normal distribution of data. The inter-observer reproducibility was calculated using the weighted kappa coefficient. Results: There were no statistically significant differences in sensitivity, specificity, PPV and NPV between the two CBCT systems. Conclusion: The effect of metal artifacts on VRF detection was not significantly different between the two CBCT systems.

Keywords: Cast Post; CBCT; Cone-Beam Computed Tomography; Vertical Root Fracture

Introduction: Various materials and methods have been recommended for successful root canal obturation. The aim of this experimental in vitro study was to compare the sealing ability of three root canal sealers AH-26, glass ionomer cement (GIC) and zinc oxide eugenol (ZOE) in single gutta-percha obturating system. Methods and Materials: Seventy extracted single-rooted human teeth were decoronated. The teeth were randomly divided into 3 experimental groups (n=20) and 2 positive and negative control groups. After root canal preparation, canals were obturated with single-cone method using either AH-26, GIC and ZOE. The leakage was evaluated using the dye penetration method. The samples were sectioned to evaluate the linear leakage using a stereomicroscope. The data were analyzed using the One-way ANOVA test. Results: All the specimens in the positive control group showed evidence of leakage. In the experimental groups, the lowest leakage scores were observed in the AH-26 group (P<0.05). However, there were no statistically significant differences between GIC and ZOE samples (P=0.676). Conclusion: AH-26 showed a superior seal and less microleakage compared to the two other materials in single gutta-percha obturating system.

Introduction: Successful endodontic treatment depends on elimination of the microorganisms through chemomechanical debridement. The aim of this in vitro study was to evaluate the effectiveness of Fragaria vesca (wild strawberry) extract (FVE) on the removal of smear layer (SL). Methods and Materials: In this analytical-observational study, 40 extracted mandibular and maxillary human teeth were selected. After canal preparation with standard step-back technique, the teeth were randomly divided into 4 groups according to the irrigation solution: saline (negative control), 5.25% NaOCl+EDTA (positive control), FVE and FVE+EDTA. The teeth were split longitudinally so that scanning electron microscopy (SEM) photomicrographs could be taken to evaluate the amount of remnant SL in coronal, middle and apical thirds. The data were analyzed statistically by the Kruskal-Wallis and Mann Whitney U tests and the level of significance was set at 0.05. Results: Significant differences were found among the groups (P<0.001). The use of NaOCl+EDTA was the most effective regimen for removing the SL followed by FVE+EDTA. FVE alone was significantly more effective than saline (P<0.001). Conclusion: FVE with and without EDTA could effectively remove the smear layer; however, compared to NaOCl group it was less effective.

Keywords: Fragaria vesca; Irrigation; Scanning Electron Microscopy; Smear Layer

This case report represents the outcome of endodontic treatment in an infected mandibular molar with periradicular periodontitis and inherent poor prognosis of root canal treatment due to severe root curvature. The tooth was successfully treated by leaving the mesial root non-obturated, the canal orifices were coronally sealed with calcium enriched mixture cement and a definitive coronal amalgam restoration, was placed at the subsequent visit.

Dens invagination is a developmental anomaly requiring specific treatment approaches. Oehler's Type III dens in dente, extends into the root and perforates at the apical area or lateral surface of the root. In this case endodontic treatment of the invaginated tooth was carried out through the central lumen of the invagination with calcium hydroxide without manipulation of the main pulp canal, thereby leaving the tooth vital. The 18-month follow-up examinations were indicative of treatment success; the periapical lesion resolved completely and the tooth remained vital. Conclusion: Information about the three dimensional anatomy of the teeth especially those with an abnormality is necessary for a successful treatment.

Keywords: Apical Periodontitis; Dens Invagination; Dens Invaginatus; Dens in Dente; Invaginated Teeth; Lateral Incisor; Periapical Lesion