E-ISSN 2548-0839
European Endodontic Journal - : 5 (2)
Volume: 5  Issue: 2 - 2020
REVIEW ARTICLES
1.Endodontic Periapical Lesion: An Overview on the Etiology, Diagnosis and Current Treatment Modalities
Kasra Karamifar, Afsoon Tondari, Mohammad Ali Saghiri
doi: 10.14744/eej.2020.42714  Pages 54 - 67
Nonsurgical and surgical endodontic treatments have a high success rate in the treatment and prevention of apical periodontitis when carried out according to standard and accepted clinical principles. Nevertheless, endodontic periapical lesions remain in some cases, and further treatment should be considered when apical periodontitis persists. Although several treatment modalities have been proposed for endodontically treated teeth with persistent apical periodontitis, there is a need for less invasive methods with more predictable outcomes. The advantages and shortcomings of existing approaches for the diagnosis and treatment of endodontic periradicular lesions are discussed in this review. (EEJ-2019-08-078)

ORIGINAL ARTICLES
2.Determination of Anesthetic Efficacy of Lidocaine Versus Bupivacaine in Single Visit Root Canal Treatment
Rizwan Jouhar, Muhammad Adeel Ahmed, Bushra Ghani
doi: 10.14744/eej.2020.88597  Pages 68 - 72
Objective: To compare the anesthetic efficacy of 2% Lidocaine with 1: 80,000 epinephrine and 0.5% Bupivacaine with 1: 200,000 epinephrine in one-visit root canal treatment in patients with symptomatic irreversible pulpitis.
Methods: A total of 60 patients presenting with symptomatic irreversible pulpitis with normal periapical tissues on periapical radiography of mandibular 1st and 2nd molars, reporting moderate to severe pain as assessed by visual analogue scale (VAS) for at least 24 hours were included in this study. All patients received local anesthesia via the inferior alveolar nerve block technique by the investigator. These patients were randomly allocated into two groups in which first group received 2% lidocaine with 1: 80,000 epinephrine and the second group received 0.5% bupivacaine with 1: 200,000 epinephrine. Patients were instructed to rate the intensity of pain during root canal treatment which was then noted on visual analogue scale (VAS).
Results: The average age of the patients was 34.15±9.49 years, in which 32 (53.3%) were male and 28 (46.7%) were female. The anesthetic efficacy was significantly high in bupivacaine as compared to lidocaine local anesthesia group (76.7% versus 40%; P=0.004).
Conclusion: The administration of bupivacaine anesthetic agent for inferior alveolar nerve block (IANB) injections can be a better and appropriate pain management aid as compared to lidocaine during root canal treatment of patient with symptomatic irreversible pulpitis. (EEJ-2019-12-125)

3.Current Trends in the Use of Irrigant Activation Techniques Among Endodontists & Post-Graduate Dental Students in India - A Knowledge, Attitude and Practice Based Survey
Velmurugan Natanasabapathy, Archana Durvasulu, Jogikalmat Krithikadatta, Ambalavanan Namasivayam, Kandaswamy Deivanayagam, Srinivasan Manali, Nivedhitha Malli Sureshbabu
doi: 10.14744/eej.2020.98698  Pages 73 - 80
Objective: The aim of this survey was to examine the practice/use of Irrigant Activation Techniques (IAT) among Endodontists and post-graduate dental students in India.
Methods: An invitation to participate in this survey was sent by electronic mail to 902 members of Indian Endodontic society. A total of 32 questions were finalized for the survey after validation by five endodontic experts. Survey contained 2 demographic questions, 7 knowledge based questions, 11 questions on attitude and 12 questions on practice of IAT. The reliability was checked by randomly asking 10 participants to fill the survey forms again after 15 days. The data was analyzed using chi-square test (P<0.05).
Results: The overall response rate for the survey was 30.5%. The content validity ratio for the questionnaire was 0.972 & the reliability calculated using Kappa scores was 0.978. Most of the respondents (87.3%) use IAT, while 4.7% do not use IAT. Most commonly used IAT was Manual dynamic agitation (MDA) used by 28.7%, followed by Ultrasonics in 17.2%. Sonic & negative pressure (EndoVac) was used by less than 10% of respondents. Combination of IAT was used by 39%. In 23 (5 on knowledge, 9 on attitude & 9 on practice) out of the 32 questions in this survey, there was a statistically significant difference (P<0.05) in the answers between the groups, with post-graduate dental students opting the correct choices. Sodium hypochlorite (NaOCl) is the preferred choice of irrigant for IAT according to 48.6%, Chlorhexidine (CHX) is used by 4.2% & Ethylene diamine tetra acetic acid (EDTA) by 2.4%. Combination of two irrigants is used by 28.7% and 6% use all the three irrigants.
Conclusion: Vast majority of the Endodontist in India use some form of IAT to improve the efficacy of irrigation. MDA is the most commonly used IAT.

4.Comparison of Dentinal Wall Thickness in the Furcation Area (Danger Zone) in the First and Second Mesiobuccal Canals in the Maxillary First and Second Molars Using Cone-Beam Computed Tomography
Vesal Feiz Azimi, Iman Samadi, Anahita Saffarzadeh, Reza Motaghi, Nima Hatami, Arash Shahravan
doi: 10.14744/eej.2020.18189  Pages 81 - 85
Objective: Differences in the morphology of the root canal system might result in favorable or adverse treatment outcomes. The present study compared the thickness of the dentinal wall in the danger zone (furcation area) of the first and second mesiobuccal canals in the maxillary first and second molars using cone beam computed tomography.
Methods: In this cross-sectional study, 50 CBCT images of maxillary first and second molars were evaluated from one of the specialized radiology centers in Kerman, Iran. The images were prepared by a Planmeca Promax 3D Max machine (Planmeca, Helsinki, Finland), with a field of view (FOV) of 8×8 cm and a resolution of 0.1 mm and analyzed with Romexis Viewer software version 3.1.1 (Planmeca, Helsinki, Finland). In the 0.1-mm-thick axial cross-sections with a distance of 1 mm, the distances from the center of the MB1 and MB2 root canals to the furcation area were measured in three areas: A) furcation area, B) 2 mm below the furcation area, and C) 4 mm below the furcation area (at a magnification of ×10). The data were then analyzed with paired t-test.
Results: The thickness of the dentinal wall in the MB2 root canal was significantly less than that in the MB1 root canal in all the specimens (P<0.05). In both maxillary first and second molars, the thicknesses of the MB1 and MB2 root canals were significantly different in the furcation area and 4 mm below the furcation area (P=0.001). There was no significant difference between the maxillary first and second molars 2 mm below the furcation area; however, the difference was marginal (P=0.07).
Conclusion: Considering the low thickness of the dentinal wall in the MB2 root canal compared with the MB1 root canal in the maxillary first and second molars, the anti-curvature techniques away from the furcation should be used to prepare this root canal to reduce the risk of strip perforation. On the other hand, it might indicate that highly tapered instruments and other aggressive instruments, such as Gates-Glidden drills, should be used with caution in these root canals. (EEJ-2019-10-106)

5.Implementation of Digital Radiography during Root Canal Treatments in Saudi Endodontic and General Dental Practice
Ahmad A Madarati
doi: 10.14744/eej.2019.41713  Pages 86 - 93
Objective: To report usage of full-digital-radiography (FDR) during root-canal-treatments (RCTs) in Saudi dental-practice and to explore factors and measures that obstacle/contribute to better implementation.
Methods: Following a pilot study, questions on demography, types of radiographic systems used during RCTs, advantages and disadvantages of FDR, reasons of not using it and measures that increase its implementation were included. The sample size was calculated considering the total number of general dentists (GDs) in Saudi Arabia and a 50-60% expected response rate. The questionnaire was emailed to 550 GDs and all endodontists in Saudi Arabia (185). A solo a reminder was emailed two months later. Data were analyzed by the Chi-square test at P=0.05.
Results: Most participants (64.9%) used FDR for RCTs (P<0.001); with all endodontists (100%) and 52% of GDs (P<0.001). While all who were working in governmental-academia (100%) used FDR, 69.2% in private-academia did so (P<0.001); with no difference between private and governmental-clinics (60.6 and 69.2%). As the weekly-performed RCTs increased and participants’ experience decreased, FDR usage increased (P<0.05). While high-cost was the main FDR disadvantage, faster-workflow, better image-quality and less-radiation were the main advantages (P<0.001). The majority (76.1%) of FDR none-users were doing so because of unavailability. Participants reported lower-cost and better undergraduate-education as most effective measures that increase FDR implementation in dental-practice.
Conclusion: FDR was adopted to good extent in Saudi dental-practice. Financial aspects were the main concern that should be addressed to increase FDR implementation in private practice. Endodontists showed better perception towards FDR and suggested more attention to educational aspects. (EEJ-2019-08-073)

6.Usage of Image-Enhancement Tools When Reading Radiographs Taken During Root-Canals Treatments’ Procedures
Ahmad A Madarati
doi: 10.14744/eej.2019.62634  Pages 94 - 104
Objective: This study aimed at exploring the usage of radiographic image-enhancement tools in Saudi dental practice when interpreting radiographs taken for root-canal-treatments’ (RCTs) procedures and the influencing factors.
Methods: An online survey including questions related mainly to the usage of images enhancement tools and the reasons for no or low frequently usage was constructed. The survey was sent to 550 general dentists (GDs), randomly selected from the Saudi Dental Register, and all endodontists (185) in Saudi Arabia using the Google-Drive tool. A reminder email was sent two months later to encourage none-respondents to complete the survey. Data were analyzed using the Chi-square and Linear-by-Linear Association tests at p=0.05.
Results: While the highest percentage of GDs (48.3%) never used the colour-coded tool, the highest percentage of endodontists (46.1%) used it sometimes (P<0.001). The majority (84.2%) used the contrast tool either generally (67.8%) or sometimes (16.4%) (P<0.001); with more endodontists (77.55%) than GDs (63.1%) (P=0.011). As participants experience decreased and the weekly performed cases increased, the trend of using this tool increased (P<0.05). While most GDs (67.6%) either never (46%) or few-times (21.6%) used the highlight tool, most endodontists (56.9%) either used it generally (34.4%) or sometimes (22.5%) (P<0.001). The majority (82.3%) were using the magnification tool either generally (55.1%) or sometimes (27.2%). The highest percentage (36.1%) was generally using the negative-view tool (P=0.045); with more endodontists (63.7%) than GDs (20.8%) (P<0.001). While ''I don’t know how to use it'' was the dominant reason reported by GDs for not using most of the tools, lack of time was the dominant reason reported by endodontists (P≤0.001).
Conclusion: The contrast and magnification were the most common used image-enhancement tools in Saudi dental practice. Endodontists reported greater preferences on using all images-enhancement tools than GDs. Unawareness and lack of time were the dominant reasons for not using the tools reported by GDs and endodontists, respectively. Further studies are required to determine the exact application for each tool and to investigate the impact of all image-enhancement tools on their diagnostic accuracy.

7.Mesiobuccal Root Canal Morphology of Maxillary First Molars in a Brazilian Sub-Population - A Micro-CT Study
Bernardo Camargo Dos Santos, Mariano Simon Pedano, Cassia Katsuki Giraldi, Julio Cezar Machado De Oliveira, Inaya Lima, Paul Lambrechts
doi: 10.14744/eej.2020.29291  Pages 105 - 111
Objective: This study aimed to investigate the root canal system morphology of maxillary first molar mesiobuccal (MB) roots in a Brazilian sub-population using micro-computed tomography.
Methods: Ninety-six MB roots were scanned with a micro-CT (Skyscan 1173, Bruker). Three-dimensional images were analyzed regarding the number of pulp chamber orifices, the number and classification of the canals, the presence of accessory canals in different thirds of the root as well as the number and type of apical foramina.
Results: A single entrance orifice was found in 53.0% of the samples, two in 43.9% and only 3.1% had three orifices. The second mesiobuccal root canal (MB2) was present at some portion of the root in 87.5% of the specimens. A single apical foramen was present in 16.7%, two in 22.9%, and three or more foramina in 60.4% of the roots. Only 55.3% and 76.1% of the root canals could be arranged by Weine’s and Vertucci’s classifications, respectively.
Conclusion: The number of orifices at the pulp chamber level could not work as a predictor of the MB2 presence. The most prevalent canal configuration was Weine type IV / Vertucci type V. The anatomical complexity of the MB root could not be entirely classified by the current most accepted classifications.

8.Comparison of the Self-Adjusting File and Hedström File Used as Supplementary Instruments for the Remaining Filling Material Removal During Retreatment of C-Shaped Canals: A Micro-CT Study
Pablo Andrés Amoroso Silva, Murilo Alcalde, Rodrigo Vivan, Marco Antonio Hungaro Duarte
doi: 10.14744/eej.2020.50570  Pages 112 - 117
Objective: The aim of this study was to evaluate the use of Self-adjusting file (SAF) system and Hedström (H) file for removing remaining filling material (RFM) from C-shaped canals.
Methods: 20 C-shaped mandibular second molars with C1 configurations were instrumented, filled with tagger´s hybrid technique. Samples were divided into 2 groups (n=10). Reciproc R25 and a Mtwo 35/04 file were used for retreatment in both groups. Then, a 2.0 SAF file (group I) and a #35 H file (group II) were used as supplementary steps for RFM removal. Micro-CT scanning was performed after every procedure. Total volumes were calculated and converted into percentages. Also, the minimum wall thickness at 3, 5, 7 mm from apex was calculated. The Prism 7.0 software was used as the analytical tool with a significance of 5%.
Results: Initial obturation removal was approximately 64% in group I and 67% in Group II. The apical third had the highest values of RFM. The use of a H file significantly reduced the RFM compared to SAF in the total canal length respectively (30% vs 18%) and at 1-3 mm and 3-6 mm when compared to the use of SAF. A statistically significant decrease of RFM and minimum wall thickness were observed in both groups (P<0.05).
Conclusion: None of the retreatment techniques completely removed RFM. The apical region was the more unaffected area. Also, the SAF file was less effective than the H file in removing the RFM. Although C-shaped canals possesses thinner dentinal wall thickness, no excessive dentine removal was observed after each instrument use. (EEJ-2019-07-067)

9.Canal Transportation and Centring Ability of Reciproc and Reciproc Blue With or Without Use of Glide Path Instruments: A CBCT Study
Wajih El Hage, Carla Zogheib, Frédéric Bukiet, Germain Sfeir, Issam Khalil, Richard Gergi, Alfred Naaman
doi: 10.14744/eej.2019.86570  Pages 118 - 122
Objective: The objective of this ex vivo study was to evaluate canal transportation and centring ability of Reciproc and Reciproc blue systems in curved root canals with or without prior use of PathFile rotary system (PF) using Cone Beam Computed Tomography (CBCT).
Methods: One hundred and twenty curved root canals from maxillary and mandibular premolars were selected. Canals were divided randomly into 4 groups (n=30): Reciproc 25 (R25), (PF+R25), Reciproc Blue 25 (RB25), (PF+RB 25). Specimens were scanned before and after root canal preparation. Using CBCT, root canal transportation and centring ability was assessed by measuring the shortest distance from the edge of uninstrumented canal to the periphery of the root (mesial and distal) before and after preparation. Data were analysed using a one-way analysis of variance and Tukey test. The p value was set at 0.05.
Results: Less transportation and better centring ability occurred when PF was used before R25 or RB25 (P<0.0001). There was no significant difference between R25 and RB25 groups.
Conclusion: Using PF before R25 and RB25 resulted in less root canal transportation and better centring ability. The specific thermo-mechanical treatment of RB25 did not provide better results when compared to R25. (EEJ-2019-07-070)

10.Analysis of Force and Torque with XP Shaper and OneCurve Systems During Shaping of Narrow Canals
Ahmed Jamleh, Abdulmohsen Alfadley, Nasser Alghofaili, Hani Jamleh, Khalid Al-Fouzan
doi: 10.14744/eej.2020.96967  Pages 123 - 127
Objective: The purpose of this laboratory-based study was to compare the shaping forces and torques developed by the XP Shaper (FKG Dentaire SA, La Chaux-de-fonds, Switzerland) and OneCurve (Micro-Mega, Besancon, France) systems during shaping of narrow canals.
Methods: Mandibular premolars with a single canal were divided equally into two groups; XP Shaper and OneCurve (n=16 each). In both groups, the canals were shaped with XP Shaper file (30/01) or OneCurve file (25/O6) that was inserted three times until it reached the canal length. The tooth was surrounded by water under controlled simulated intracanal temperature throughout the experiment. The inward and outward peak forces and the peak torques were recorded and analyzed statistically using the Mann-Whitney test. The shaping times were analyzed using Student’s t-test. The significance level was set at 5%.
Results: In both groups, the developed forces in both directions and the torques increased with the successive insertions of the file. In the two groups, the inward peak forces ranged from 0.33 to 3.12 N, while the outward peak forces ranged from 0.09 to 1.96 N. In the three insertions, the XP Shaper showed significantly lower peak forces in both directions. The peak torque developed in both groups ranged from 0.12 to 1.52 N.cm. XP Shaper had significantly lower torque values in all the insertions than OneCurve. The XP Shaper system was able to completely shape the canals in 33.4 seconds while the OneCurve system was able to completely shape the canals in 32.8 seconds.
Conclusion: The XP Shaper system showed favorably lower force and torque values during canal shaping compared with the OneCurve system.

11.Evaluation of Mechanical Activation and Chemical Synthesis for Particle Size Modification of White Mineral Trioxide Aggregate
Mohammad Ali Saghiri, Hamed Kazerani, Steven Morgano, James Gutmann
doi: 10.14744/eej.2020.84803  Pages 128 - 133
Objective: Initial setting time is one of the most important properties of calcium silicate cements (CSCs) such as white mineral trioxide aggregate (WMTA). This study aimed to evaluate the effect of two methods used to reduce the particle size of WMTA, mechanical activation and chemical synthesis.
Methods: WMTA without bismuth oxide (WMTA-B) was provided and divided into four groups (n=5) including: WMTA-B, WMTA-B+10 min milling, WMTA-B+30 min milling, and sol-gel. In groups 2 and 3, the milling was performed by using tungsten carbide balls in a ratio 1: 15 (w/w) and a vibration frequency of 30 Hz together with absolute ethanol. For the fourth group, polyethylene glycol (PEG), calcium acetate (Ca(C2H3O2)2), SiO2, and aluminum oxide (Al2O3) were used for the sol-gel process. After preparation, sample powders were mixed with distilled water and placed in cylindrical molds, covered with water-moistened gauze, and incubated at 37°C for 24 hours. The Vicat needle test analyzed the initial setting time. Data were analyzed by ANOVA and Tukey tests at a significance level of P<0.05. The correlation between particle size and setting time was determined.
Results: Initial setting time of the sol-gel and WMTA-B+30 min milling was significantly lower than in the other two groups (P<0.05). A significant correlation was noticed between particle size and initial setting time (P<0.05).
Conclusion: Sol-gel process introduces a promising alternative strategy for the reduction of initial setting time of CSC materials. While both methods increased surface area, mechanical activation was not as successful in reducing surface area and initial setting time as effectively as the sol-gel process.

12.Fracture Resistance of Roots Filled With Bio-Ceramic and Epoxy Resin-Based Sealers: In Vitro Study
Amal Almohaimede, Daniah Almanie, Sara Alaathy, Ebtissam Almadi
doi: 10.14744/eej.2019.33042  Pages 134 - 137
Objective: This study aimed to assess the resistance of roots to fracture after being root canal filled with two types of endodontic sealers; bio-ceramic based sealer (TotalFill) and epoxy-resin based sealer (AH Plus).
Methods: Fifty-nine single canal mandibular premolars were instrumented. Group I (n=14, negative control): root canals were left without instrumentation and unfilled, group II (n=15, positive control): root canals were instrumented only and left unfilled, group III and IV (n=15 each): root canals were instrumented and filled with either gutta-percha/TotalFill or gutta-percha/AH Plus, respectively. The resistance of the roots to fracture was measured with a universal testing machine “Instron Corp” through recording the maximum force in Newton (N) needed to fracture each root. To analyze the data Kruskal–Wallis test was utilized, followed by Dunn’s Bonferroni post hoc test for multiple comparisons. The level of significance was set at 0.05 (P≤0.05).
Results: TotalFill group showed slightly better fracture resistance (734.62 N) than AH Plus group (728.29 N). However, no statistical significant difference was found between the two groups (P>0.05). The greatest mean fracture force was shown in the negative control group (913.915 N) with statistical significant difference between the other three groups (P<0.05).
Conclusion: Gutta-percha/TotalFill and gutta-percha/AH Plus did not reinforce the root canal treated teeth.

13.Histologic Evaluation of Artificial Floors Under MTA and Nano-Filled Resin-Modified Glass Ionomer Used to Repair Furcation Perforations in Dogs
Adel Aladimi, Hatem Alhadainy, Ali Farag, Nahed Abo-Azma, Faisal Torad, Saleem Abdulrab
doi: 10.14744/eej.2020.44127  Pages 138 - 144
Objective: This study aimed to compare the tissue reaction of two repair materials for furcation perforations, nano-filled resin modified glass ionomer (Nano-FRMGI) and mineral trioxide aggregate (MTA), used with or without an artificial floor.
Methods: A total of 96 teeth in 6 dogs were used for this study. After access cavities, root canals were prepared and obturated with gutta percha using cold lateral condensation technique. Perforations were then created on the floors of the pulp chambers. The perforations divided into four groups n=24/group that were sealed with MTA alone, MTA with calcium sulphate artificial floor (CSAF), FRMGI alone and Nano-FRMGI with CSAF. All access cavities were filled with composite resin. Two dogs were sacrificed at 1, 3, and 6 month. The experimental tooth along with the surrounding alveolar bone were cut in block sections and histologically evaluated for tissue response. Data were analyzed by Chi-square (P≤0.05).
Results: MTA and MTA with CSAF showed more bone and cementum apposition when compared to Nano-FRMGI at 6-month interval. MTA and MTA with CSAF showed less bone resorption, epithelium proliferation and inflammation compared to Nano-FRMGI at 6-month interval.
Conclusion: MTA with CSAF or MTA-alone show better outcomes in the repair of pulp chamber floor perforation.

14.Awareness of Parents About the Emergency Management of Avulsed Tooth in Eastern Province and Riyadh
Muhammad Adeel Ahmed, Zohaib Khurshid, Omar Sami Almajed, Abdullah Faisal Albash, Abdul Latif A Alnaim, Dalal N Almuhaidib, Syed Akhtar Bokhari
doi: 10.14744/eej.2020.65265  Pages 145 - 149
Objective: To assess the level of parents knowledge about the emergency management of tooth avulsion in Eastern Province and Riyadh.
Methods: A cross-sectional study was carried out by means of a questionnaire-based internet survey in which 1201 parents from Eastern Province and Riyadh participated. The questionnaire contained 10 closed-ended questions and was used to assess the knowledge of parents about the emergency management of avulsed teeth in Eastern Province and Riyadh. Chi-square test was used for data analysis.
Results: In response to closed-ended questions, the statistically significant result was obtained for the history of child dental trauma in which 35% (P=0.04) of parents reported history of dental trauma in their children. These parents were belong to Eastern province (51%) and Riyadh (49%). Furthermore, only 31.3% of the parents were aware of possible storage media for transportation of avulsed tooth while 68.7% (49.5% in Eastern Province and 50.5% in Riyadh) were unaware (P=0.02) of it.
Conclusion: That the majority of the parents were unaware of emergency management for tooth avulsion in two densely populated regions of Saudi Arabia. Education of parents should be initiated at a national level. (EEJ-2019-11-113)

15.Effect of Gravity on Periapical Extrusion of Irrigating Solution With Different Irrigation Protocols in Immature Anterior Teeth
Radha Sharma, Vijay Kumar, Ajay Logani, Amrita Chawla, Sidhartha Sharma, Bhawna Koli
doi: 10.14744/eej.2020.20592  Pages 150 - 154
Objective: Periapical extrusion is frequently observed during endodontic therapy. It can lead to acute injury of periapical tissues, resulting in interappointment pain or swelling. The effect is pronounced in teeth with immature teeth which are more susceptible to the extrusion of irrigant. The aim of this study was to evaluate the effect of gravity on apical extrusion of irrigating solution with different irrigation protocols in immature anterior teeth.
Methods: An extracted maxillary central incisor was modified to simulate an open apex with an apical diameter of 1.3 mm and parallel canal walls. The tooth was subjected to a cone-beam computed tomographic scan, and the image data set was utilized to prepare 30 resin tooth models with a 3D printer. These resin teeth were used to form an open-ended Myers and Montgomery extrusion models. These were then randomly divided into two groups to simulate their orientation in the jaw during endodontic therapy, i.e., group I (maxillary arch, n=15) models fixed at 45° inclined plane and group II (mandibular arch, n=15) models placed at a plane parallel to the floor. Five models from each group (n=5) were tested by three different irrigation protocols: positive pressure (PP) Irrigation, passive ultrasonic irrigation (PUI), and negative pressure (NP) irrigation. The extruded irrigating solution was collected in glass vials, and the volume was measured.
Results: The volume of extruded irrigating solution in groups I and II was compared using Mann–Whitney U-test. The median values for PP, PUI, and NP irrigation protocols were 0.6, 1, and 0 ml and 10, 10, and 0.5 ml for groups I and II, respectively. PP and PUI protocols were associated with significantly less extrusion in group I when compared to group II (P=0.004). There was no statistically significant difference in the volume of irrigating solution extruded in groups I and II (P=0.007) for NP irrigation protocol.
Conclusion: Gravitation force has an influence on periapical extrusion of irrigant in immature permanent teeth irrespective of the irrigant system used. NP performed better when compared to PP or PUI irrigation protocol irrespective of the tooth orientation.

16.Association between Rheumatoid Arthritis and Apical Periodontitis: A Cross-sectional Study
Ertuðrul Karataþ, Ayhan Kul, Ebru Tepecik
doi: 10.14744/eej.2019.52824  Pages 155 - 158
Objective: The present cross-sectional study aimed to investigate possible association between Rheumatoid Arthritis (RA) and Apical Periodontitis (AP).
Methods: In table one it is mentioned 48 patients diagnosed with RA were included in the experimental group. Another 48 healthy age- and gender-matched participants who reported no history of any systemic disease were selected to form the control group. All the patients were examined radiographically and clinically to diagnose the presence of AP. The following data was recorded for all patients; the number of teeth present, the number of teeth with AP, the number of patients with AP, the number of patients with root canal treated teeth (RCT) and the number of patients with RCT+AP. The chi-square test and logistic regression analysis were used to determine the possible association between RA and AP.
Results: A total of 1026 teeth were examined in the RA group and 45 of them was diagnosed as AP. In the control group, 1025 teeth were examined and 21 teeth were diagnosed as AP. It was found that the prevalence of teeth with AP (4.3%) was significantly higher in the RA group than the control (2%) (odds ratio [OR]=2.193, P=0.003). Logistic regression analysis showed that RA is significantly associated with AP.
Conclusion: It can be concluded that patients with RA can be more prone to develop AP. (EEJ-2019-09-096)

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