Original Article

Efficacy of Articaine and Lidocaine for Buccal Infiltration of First Maxillary Molars with Symptomatic Irreversible Pulpitis: A Randomized Double-blinded Clinical Trial

Hamid Reza Hosseini, Masoud Parirokh, Nouzar Nakhaee, Paul V. Abbott, Syamak Samani

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 79-84

Introduction: The aim of the present study was to compare the efficacy of 2% lidocaine to 4% articaine in buccal infiltration of maxillary first molars with irreversible pulpitis. Moreover, the effect of root length on success of anesthesia irrespective of the type of anesthetic agent was assessed. Methods and Materials: Fifty patients suffering from painful maxillary first molars with irreversible pulpitis received an infiltration injection of either 4% articaine with 1:100000 epinephrine or 2% lidocaine with 1:80000 epinephrine. Each patient recorded their pain score in response to a cold test on a Heft-Parker visual analogue scale (VAS) before commencing the treatment, 5 min following injection, during access preparation, after pulp exposure and during root canal instrumentation. No or mild pain at any stage was considered a success. Data were analyzed using the multivariate logistic regression analysis, chi-square and t tests. Results: Finally, 47 out of 50 patients were eligible to be included in this study. The anesthetic success rates in the lidocaine and articaine groups were 56.52% and 66.67%, respectively and the difference was not significant (P=0.474). Irrespective of the anesthetic agent, the length of the palatal root (Odds Ratio=0.24, P=0.007) had an adverse effect on anesthetic success. There was an association between longer palatal root length and anesthetic failure. Conclusion: No significant difference was found between 2% lidocaine and 4% articaine in terms of anesthetic success in maxillary first molars with irreversible pulpitis. The length of the palatal root had a significant negative influence on anesthetic success.

Keywords: Articaine; Buccal Injection; Infiltration; Irreversible Pulpitis; Lidocaine; Maxillary Molar; Palatal Root; Root Length

Human Pulp Response to Direct Pulp Capping and Miniature Pulpotomy with MTA after Application of Topical Dexamethasone: A Randomized Clinical Trial

Seyed Amir Mousavi, Jamileh Ghoddusi, Nooshin Mohtasham, Shirin Shahnaseri, Payam Paymanpour, Jun-Ichiro Kinoshita

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 85-90

Introduction: The aim of this randomized clinical trial was to compare the histologic pulp tissue response to one-step direct pulp capping (DPC) and miniature pulpotomy (MP) with mineral trioxide aggregate (MTA) after application of dexamethasone in healthy human premolars. Methods and Materials: Forty intact premolars from 10 orthodontic patients, were randomly chosen for DPC (n=20) or MP (n=20). In 10 teeth from each group, after exposure of the buccal pulp horn, topical dexamethasone was applied over the pulp. In all teeth the exposed/miniaturely resected pulp tissue was covered with MTA and cavities were restored with glass ionomer. Teeth vitality was evaluated during the next 7, 21, 42, and 60 days. Signs and/or symptoms of irreversible pulpitis or pulp necrosis were considered as failure. According to the orthodontic schedule, after 60 days the teeth were extracted and submitted for histological examination. The Kruskal-Wallis and Fisher’s exact tests were used for statistical analysis of the data (P=0.05). Results: Although dexamethasone specimens showed less inflammation, calcified bridge, pulpal blood vasculature, collagen fibers and granulation tissue formation were not significantly different between the groups (P>0.05). Conclusion: Topical dexamethasone did not hindered pulp healing but reduced the amount of underlying pulpal tissue inflammation after DPC and MP in healthy human premolars.

Keywords: Dexamethasone; Direct Pulp Capping; Mineral Trioxide Aggregate; Miniature Pulpotomy; Vital Pulp Therapy

Effect of Calcium Hydroxide on the Push-out Bond Strength of Endodontic Biomaterials in Simulated Furcation Perforations

Negin Ghasemi, Mohammad Frough Reyhani, Amin Salem Milani, Hadi Mokhtari, Faezeh Khoshmanzar

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 91-95

Introduction: The aim of this in vitro study was to evaluate the effect of calcium hydroxide (CH) on push-out bond strength of white mineral trioxide aggregate (WMTA) and calcium-enriched mixture (CEM) cement in simulated furcation perforations. Methods and Materials: Furcation perforations, measuring 1.3 mm in diameter and 2 mm in height, were created in 80 human mandibular first molars. The teeth were then divided into 4 groups (n=20). In groups 1 and 3 CH was placed in the perforation for one week, before placement of WMTA and CEM. In groups 2 and 4 perforations were repaired without placement of CH. In groups 1 and 2 the perforation sites were repaired with WMTA and CEM cement was used in groups 3 and 4. After 7 days, the push-out test was carried out using a universal testing machine. Data were analyzed with two-way ANOVA. The level of significance was set at 0.05. Results: The maximum and minimum bond strength values were recorded in the WMTA/CH (13.08±1.8 MPa) and CEM cement groups (8.03±0.98 MPa), respectively. There were significant differences in resistance to dislodgement between the WMTA/CH and other groups (P<0.05). Conclusion: Placement of CH before placement of WMTA in furcation perforation improves the push-out bond strength of this material.

Keywords: Calcium-Enriched Mixture; Calcium Hydroxide; Furcation Perforation; Mineral Trioxide Aggregate; Push-Out

Cone-Beam Computed Tomography Assessment of Root Canal Transportation by Neoniti and Reciproc Single-File Systems

Fariborz Moazzami, Leila Khojastepour, Mohammadreza Nabavizadeh, Mina Seied Habashi

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 96-100

Introduction: The aim of this in vitro study was to compare the canal transportation of two single-file engine-driven systems, Neoniti and Reciproc, using cone-beam computed tomography (CBCT). Methods and Materials: Forty-five non-calcified roots with mature apices and apical curvature of 15-30 degrees were selected from extracted human maxillary molars for this study. Samples were randomly divided into two groups (n=20) and a control group (n=5) and canal preparation with either system was performed according to manufacturers' instructions. Pre- and post-instrumentation CBCT images were captured and the amount of canal transportation within the files was calculated at levels of 3, 4, and 5 mm from the apex. The independent sample t-test was used to analyze the statistical significance between the two groups. The level of significance was defined at 0.05. Results: Reciproc created more canal transportation compared to Neoniti in both mesiodistal and buccolingual directions. The difference between the two systems was statistically significant in all evaluated distances from the apex (P<0.001). During this study fracture of one file (25/0.08) in the Neoniti group occurred. Conclusion: Neoniti and Reciproc systems have significant difference in terms of creating canal transportation. Reciproc created more canal transportation in buccolingual and mesiodistal dimensions.

Keywords: Canal Transportation; Cone-Beam Computed Tomography; Neoniti; Reciproc; Root Canal Preparation

Accuracy of Cone-Beam Computed Tomography in Determining the Root Canal Morphology of Mandibular First Molars

Hadi Mokhtari, Mahdi Niknami, Hamidreza Mokhtari Zonouzi, Aydin Sohrabi, Negin Ghasemi, Amir Akbari Golzar

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 101-105

Introduction: The aim of the present in vitro study was to compare the accuracy of cone-beam computed tomography (CBCT) in determining root canal morphology of mandibular first molars in comparison with staining and clearing technique. Methods and Materials: CBCT images were taken from 96 extracted human mandibular first molars and the teeth were then evaluated based on Vertucci’s classification to determine the root canal morphology. Afterwards, access cavities were prepared and India ink was injected into the canals with an insulin syringe. The teeth were demineralized with 5% nitric acid. Finally, the cleared teeth were evaluated under a magnifying glass at 5× magnification to determine the root canal morphology. Data were analyzed using the SPSS software. The Fisher’s exact test assessed the differences between the mesial and distal canals and the Cohen’s kappa test was used to assess the level of agreement between the methods. Statistical significance was defined at 0.05. Results: The Kappa coefficient for agreement between the two methods evaluating canal types was 0.346 (95% CI: 0.247-0.445), which is considered a fair level of agreement based on classification of Koch and Landis. The agreement between CBCT and Vertucci’s classification was 52.6% (95% CI: 45.54-59.66%), with a significantly higher agreement rate in the mesial canals (28.1%) compared to the distal canals (77.1%) (P<0.001). Conclusion: Under the limitations of this study, clearing technique was more accurate than CBCT in providing accurate picture of the root canal anatomy of mandibular first molars.

Keywords: Cone-Beam Computed Tomography; Root Canal Morphology; Root Clearing

Accuracy of CBCT, Digital Radiography and Cross-Sectioning for the Evaluation of Mandibular Incisor Root Canals

Hadi Assadian, Arash Dabbaghi, Morteza Gooran, Behrouz Eftekhar, Sanaz Sharifi, Nassim Shams, Ali Dehghani Najvani, Hamed Tabesh

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 106-110

ntroduction: The aim of this study was to compare the accuracy of cone-beam computed tomography (CBCT), digital radiography and tooth sectioning in evaluating root canal morphology of mandibular incisors in an in vitro setting. Methods and Materials: A total of 76 samples were imaged using CBCT, and digital radiography in straight and angled views. The samples were then sectioned at different distances from the apex for further visualization under stereomicroscope. The agreement between the observers was statistically analyzed by kappa correlation coefficient and the chi-square test. Results: The results showed that the majority of the samples had a single canal (Vertucci’s Type I). CBCT analysis reported more frequent multi-canal roots in comparison with the other techniques. In pairwise comparisons, the highest agreement was found between digital radiographic imaging and microscopic cross-sectioning both in terms of canal configuration and the number of root canals. Conclusion: None of the used imaging techniques per se could adequately show the exact internal anatomical configuration in accordance with the gold standard.

Keywords: Anatomy; Cone-Beam Computed Tomography; Digital Radiography; Incisor Teeth

X-ray Diffraction Analysis of ProRoot Mineral Trioxide Aggregate Hydrated at Different pH Values

Hengameh Akhavan, Pooneh Mohebbi, Amir Firouzi, Mehdi Noroozi

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 111-113

Introduction: The aim of this study was to compare the chemical compounds of white ProRoot mineral trioxide aggregate (WMTA) hydrated at different pH environments. Methods and Materials: Mixed samples of WMTA were kept in acidic (pH=5.4), neutral (pH=7.4) and alkaline (pH=9.4) environments for 48 h. Then, X-ray diffraction (XRD) analysis was performed for both hydrated and powder forms of WMTA. Portlandite crystalline structures of environments were compared from three aspects: intensity (height of the peak, corresponding to the concentration), crystallinity (peak area/total area) and crystal size (full-width at half-maximum of the peak). Results: After matching the peaks of each sample with those of the International Center for Diffraction Data (ICDD) database, the main constituent of all set cements and powder form was found to be bismuth oxide. Acidic environment exhibited lower intensity and crystallinity of portlandite in comparison with neutral environment. Conclusion: The highest concentration and crystallinity of portlandite were observed in WMTA samples hydrated at neutral pH and the highest crystal size was detected after hydration in alkaline pH.

Keywords: Mineral Trioxide Aggregate; pH; X-ray Diffraction

Physical Properties of Five Brands of K-Files

Arash Izadi, Arash Shahravan, Hoda Shabani Nejad

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 114-118

Introduction: Endodontic K-files are major tools for cleaning and shaping of the root canal systems. As there are various K-files available in Iranian market, the physical properties of the five available brands were investigated to assist the clinician when selecting suitable endodontic K-files according to the intended application. Materials and Methods: Physical properties (including debris creation, machinery defect and corrosion) of the selected K-files were investigated by a scanning electron microscope (SEM) under 250× magnification. For evaluating the flutes number, a stereomicroscope was used with 40× magnification. Results: Maximum and minimum debris and corrosion were observed in the Larmrose and Perfect K-files, respectively. Dentsply showed the least machinery defects. Other brands had intermediary properties. In addition, Larmrose K-files showed the maximum flutes number compared to the other brands. Conclusion: According to the results, none of the K-files had the ideal properties. More studies regarding the physical properties of the K-files and their clinical efficacy, are suggested.

Keywords: Corrosion; Debris; Physical Properties; Scanning Electron Microscopy

Effect of Different Endodontic Sealers on the Push-out Bond Strength of Fiber Posts

Mohammad Frough Reyhani, Negin Ghasemi, Saeed Rahimi, Amin Salem Milani, Elnaz Omrani

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 119-123

Introduction: The aim of this in vitro study was to evaluate the effect of MTA-based sealer (MTA Fillapex), eugenol-based sealer (Dorifill) and an epoxy resin sealer (AH Plus) on the bond strength of fiber posts cemented with a self-etch adhesive. Materials and Methods: The root canals of 72 maxillary incisors were prepared using the step-back technique after removing/cutting off the crowns. The samples were randomly divided to 4 groups (n=18). In group 1 (the controls) gutta-percha was used without sealer. In groups 2, 3 and 4, the canals were filled with gutta-percha using AH Plus, Dorifill and MTA Fillapex sealers, respectively, by cold lateral compaction technique. After post space preparation, the fiber posts were cemented in the root canals using self-etch adhesive. Then 1-mm-thick disks were prepared from the coronal thirds of all the root canals and subjected to a push-out test. Data were analyzed using the one-way ANOVA and post hoc Tukey’s tests. Results: The maximum (4.45±0.09 MPa) and minimum (1.02±0.03 MPa) bond strength values were recorded in the control and Dorifill groups, respectively. The mean push-out bond strength values were similar for MTA Fillapex and AH Plus sealers (P>0.05). However these values were significantly higher than that of the Dorifill sealer (P<0.05). Conclusion: Sealer type affected the bond strength of the fiber posts and MTA Fillapex decreased the dislodgment resistant of the fiber post.

Keywords: Bond strength; Resin Cement; Root Canal Sealer

Biocompatibility of Portland Cement Modified with Titanium Oxide and Calcium Chloride in a Rat Model

Narjes Hoshyari, Hossein Labbaf, Nooshin Jalayer Naderi, Ali Kazemi, Farshid Bastami, Maryam Koopaei

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 124-128

Introduction: The aim of the present study was to evaluate the biocompatibility of two modified formulations of Portland cement (PC) mixed with either titanium oxide or both titanium oxide and calcium chloride. Methods and Materials: Polyethylene tubes were filled with modified PCs or Angelus MTA as the control; the tubes were then implanted in 28 Wistar rats subcutaneously. One tube was left empty as a negative control in each rat. Histologic samples were taken after 7, 15, 30 and 60 days. Sections were assessed histologically for inflammatory responses and presence of fibrous capsule and granulation tissue formation. Data were analyzed using the Fisher’s exact and Kruskal-Wallis tests. Result: PC mixed with titanium oxide showed the highest mean scores of inflammation compared with others. There was no statistically significant difference in the mean inflammatory grades between all groups in each of the understudy time intervals. Conclusion: The results showed favorable biocompatibility of these modified PC mixed with calcium chloride and titanium oxide.

Keywords: Biocompatibility; Mineral Trioxide Aggregate; Portland Cement

The Effect of Canal Dryness on Bond Strength of Bioceramic and Epoxy-resin Sealers after Irrigation with Sodium Hypochlorite or Chlorhexidine

Hasan Razmi, Behnam Bolhari, Negar Karamzadeh Dashti, Mahta Fazlyab

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 129-133

Introduction: The aim of this in vitro study was to evaluate the effect of canal dryness on the push-out bond strength of two resin sealers (AH-Plus and Adseal) and a bioceramic sealer (Endosequence BC sealer) after canal irrigation with sodium hypochlorite (NaOCl) and chlorhexidine (CHX). Methods and Materials: A total of 18 extracted human premolars were used. Canals were prepared and were divided to two groups based on irrigation solution (either NaOCl or CHX). The samples were again divided based on pre-obturation canal condition (wet, half-wet and dry). The samples were sub-divided into 3 groups based on the sealer type; the teeth were obturated with gutta-percha and test sealers (Adseal, AH-Plus or BC sealer). A total number of 18 groups were available to be cut into dentine disks (12 disks in each group). The type of bond failure was also assessed in each group. Data were analyzed using the 3-way ANOVA, post hoc Tukey’s tests, t-test and the Fisher’s exact test. The level of significance was set at 0.05. Results: The bond strength of Adseal was not affected by the canal condition or irrigation with either NaOCl or CHX. Although the bond strength of AH-Plus was not affected by the irrigant type, the highest bond strength was seen in dry canals. For Endosequence BC sealer, the canal conditions did not affect the bond strength; however, CHX reduced the bond strength. Conclusion: Bond strength of resin sealers was not affected by irrigation solution; however, canal moisture negatively affected the bond strength of AH-Plus. CHX reduced the bond strength of BC sealer.

Keywords: Bioceramic; Chlorhexidine; Epoxy Resin-Based Root Canal Sealer; Root Canal Sealer; Sodium Hypochlorite


Endodontic Considerations in Three-canalled Premolars: A Practical Update

Zahed Mohammadi, Sousan Shalavi, Luciano Giardino, Saeed Asgary

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 134-137

The most difficult clinical considertions in orthograde root canal treatment are generally related to the anatomy of the teeth. Three-canalled maxillary and mandibular premolars (mini-molars) have been reported in several studies. The purpose of this paper was to review various aspects of three-canalled premolars including incidence, clinical and radiographic diagnosis, racial predisposition, access cavity preparation, instrumentation and obturation.

Keywords: Mandibular Premolars; Maxillary Premolars; Mini-Molars; Root Canal Anatomy; Three-Canalled Premolars

Case Report

Amputation of an Extra-root with an Endodontic Lesion in an Invaginated Vital Maxillary Lateral Incisor: A Rare Case with Seven-year Follow-up

Mehmet Kemal Çalışkan, Saeed Asgary, Uğur Tekin, Pelin Güneri

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 138-141

The developmental abnormality of tooth resulting from the infolding of enamel/dentin into the root is called dens invaginatus. Management of such cases is usually challenging due to the morphological complexity of root canal system. This report presents a rare treatment protocol of a clinical case of Oehler’s type III dens invaginatus combined with an endodontic lesion in a vital maxillary lateral incisor. Access to the endodontic lesion located between the central and lateral incisors was achieved by reflection of a full mucoperiosteal flap. Granulomatous tissue as well as aberrant root was removed and the surface of the root and adjacent coronal region were reshaped. Three years later, the patient was orthodontically treated. Seven years after completion of surgical/orthodontic management, the tooth remained asymptomatic and functional with normal periodontium/vital pulp. Radiographically, the healing of the lesion was observed. Actually, vitality of the invaginated tooth and communication between the invagination and the root canal were the most important factors in determining such minimally invasive treatment protocol. Depending on the anatomy of the root canal system, surgical amputation of an invaginated root can be performed to achieve a successful outcome in Oehler’s type III dens invaginatus cases, even though it is associated with apical periodontitis.

Keywords: Apical Periodontitis; Dens Invaginatus; Endodontic Therapy; Lateral Incisor; Periradicular Surgery

Management of an Endodontic-Periodontal Lesion in a Maxillary Lateral Incisor with Palatal Radicular Groove: A Case Report

Aidin Sooratgar, Mehdi Tabrizizade, Maryam Nourelahi, Yasin Asadi, Hosein Souratgar

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 142-145

The radicular groove is a developmental anomaly that predisposes the tooth to periodontal break-down. Sometimes the situation becomes more complicated by pulp necrosis and development of a combined endodontic-periodontal lesion which is a diagnostic and treatment challenge for the clinician. This report presents the successful management of an endodontic-periodontal lesion in a maxillary lateral incisor that has a developmental palatal radicular groove using a combination of nonsurgical endodontic therapy and periodontal regenerative techniques. Conclusion: The combination of nonsurgical endodontic and periodontal regenerative treatment is a predictable method in treating combined endodontic-periodontal lesions caused by palato-gingival groove.

Keywords: Endodontic-Periodontal Lesion; Maxillary Lateral Incisor; Palatoradicular Groove; Periodontal Regeneration

How Can Hypnodontics Manage Severe Gag Reflex for Root Canal Therapy? A Case Report

Mohsen Ramazani, Nafiseh Zarenejad, Masoud Parirokh, Samir Zahedpasha

Iranian Endodontic Journal, Vol. 11 No. 2 (2016), 24 March 2016, Page 146-149

In endodontics, severe involuntary gagging can have a severe impact on treatment procedure. There are many ways to ease the gag reflex, one of which is hypnosis. A 34-year-old male was referred for root canal treatment of a molar tooth. He had not received any dental treatments for the past nine years due to fear of severe gag reflex. Three hypnotic sessions based upon eye fixation, progressive muscle relaxation and guided imagery techniques were spent for psychosomatic management. The gag reflex was controlled and reduced to a normal level, and the required dental treatments including root canal therapy and restoration were performed successfully. This report shows that hypnosis can control gag reflex for dental treatments.

Keywords: Dental Treatment; Endodontics; Gag Reflex; Hypnosis; Root Canal Therapy