E-ISSN 2548-0839
European Endodontic Journal - : 5 (3)
Volume: 5  Issue: 3 - 2020
REVIEW ARTICLES
1.Preferred Reporting Items for Root and Canal Anatomy in the Human Dentition (PROUD 2020) – A Systematic Review and a Proposal for a Standardized Protocol
Hany Mohamed Aly Ahmed, Giampiero Rossi-Fedele
PMID: 33353923  doi: 10.14744/eej.2020.88942  Pages 159 - 176
Objective: Consistent reporting of publications in a given topic is essential. This systematic review aimed to identify and evaluate the reporting items in previous publications related to root canal anatomy in major Endodontic journals.
Methods: A systematic review was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed by 2 independent reviewers using a customized search strategy in major Endodontic journals through Scopus until November 2019. Studies investigating root and canal anatomy were included. The selected publications were divided into 7 categories according to the study design: micro-computed tomography (microCT) and cone-beam computed tomography (CBCT) experimental studies (extracted teeth), CBCT and 2D clinical studies, CBCT and 2D case reports in addition to others (i.e. staining and clearing method and root sectioning). The selected studies were evaluated according to three domains: 1) Criteria for study sample selection; 2) Criteria for methodological procedures and 3) Criteria for detection and evaluation.
Results: After the removal of duplicated and irrelevant papers, 137 articles were included. Results showed that microCT studies reported accurately the tooth type, number of teeth, classifications used, qualitative and/or quantitative analysis (if required) and the evaluation process. However, sample size calculation, calibration, and reproducibility were not reported in the majority of microCT studies. CBCT clinical studies presented information for the type of study, inclusion/exclusion criteria, number of patients, tooth type, and number of teeth. However, the majority did not report sample size calculation and calibration of examiners. Radiographic exposure descriptions and classifications used were not reported adequately in CBCT and 2D case reports. Sample size calculation, calibration and reproducibility were not reported in staining and clearing method.
Conclusion: Despite accurate presentation of certain items, there is considerable inconsistent reporting of root and canal morphology regardless of the type of study and experimental procedure used. The PROUD checklist protocol presented in this systematic review aims to provide an accurate description of root canal anatomy in experimental, clinical, and case report publications.

2.The Influence of Sodium Hypochlorite and Chlorhexidine on Postoperative Pain in Necrotic Teeth: A Systematic Review
Estéfano Borgo Sarmento, Ludmila Guimarães, Sandro Tavares, Katherine Azevedo Batistela Rodrigues Thuller, Livia Antunes, Leonardo Antunes, Cinthya Gomes
PMID: 33353925  doi: 10.14744/eej.2020.94830  Pages 177 - 185
Objective: The purpose of this systematic review was to provide the answer to the question: Can sodium hypochlorite and chlorhexidine influence postoperative pain after the endodontic treatment in necrotic teeth?
Methods: The PROSPERO registration number is CRD42018096433 and was conducted following the PRISMA statements. The MeSH and free terms were used to search for articles published in the electronic databases (PubMed, Web of Science, Scopus, Cochrane Library, and Virtual Health Library), in the gray literature, and by a manual search. The reviewers selected the studies considering predetermined eligibility criteria, performed data extraction, and evaluated the risk of bias. Only clinical trials comparing the effect of sodium hypochlorite and chlorhexidine on postoperative pain in teeth of adult patients with necrotic pulps were included.
Results: Five studies were qualified for the systematic review. Two studies were considered a low risk of bias. The results showed no statistically significant difference regarding postoperative pain in the groups. Only 1 study reported a statistically significant difference in the sixth postoperative hour, and the pain was associated with the sodium hypochlorite group.
Conclusion: There was no influence of auxiliary chemical substance (NaOCl and CHX) on postoperative pain used in endodontic treatment in the teeth with pulp necrosis. However, one study observed a significant difference in the sixth postoperative hour, associated with the sodium hypochlorite group. (EEJ-2020-01-014)

ORIGINAL ARTICLES
3.Anesthetic Efficacy of Lidocaine/Ketorolac in Inferior Alveolar Nerve Block in Patients with Irreversible Pulpitis: A Randomized Clinical Trial
Hessamoddin Faghihian, Reyhaneh Faghihian, Abbasali Khademi, Vivek Aggarwal
PMID: 33353921  doi: 10.14744/eej.2020.74946  Pages 186 - 190
Objective: The purpose of this randomized, double-blind study was to evaluate the anesthetic efficacy of lidocaine-ketorolac administration by Inferior Alveolar Nerve Block (IANB) in patients with irreversible pulpitis.
Methods: Eighty-eight adult patients received a combination of either one cartridge of “2% lidocaine with 1: 80.000 epinephrine” (Li) plus one cartridge of a mixture of 0.8 mL of the same solution and 1mL ketorolac tromethamine (KT)(30 mg/mL), or one cartridge of Li solution plus one cartridge of a mixture of the same solution and saline. Endodontic access was prepared after fifteen minutes. Anesthetic success was defined as no or mild pain [less than 54 mm on the Heft-Parker visual analog scale (HP-VAS)] during access cavity preparation and initial file insertion. Chi-square test was used for data analysis, and the level of significance was set at 0.05 (P=0.05).
Results: Results showed that the success rates were 34.1% and 27.3% for Li-KT and Li-Saline groups, respectively, with no significant difference between the two groups (P=0.48). However, significant decrease of baseline mean VAS pain score of the participants in both groups was found during access cavity preparation or initial file insertion (P<0.05).
Conclusion: Mixed Li-KT solution did not increase the success rate of IANB injection significantly. (EEJ-2019-09-097)

4.Needle Gauge Influences Pain Perception During Intrapulpal Anaesthesia - A Randomized Clinical Trial
Nandini Suresh, Vishnupriya Koteeswaran, Velmurugan Natanasabapathy, Kinnari Kasabwala, Dinesh Kowsky
PMID: 33353913  doi: 10.14744/eej.2020.38358  Pages 191 - 198
Objective: The purpose of this randomized trial was to assess the pain perception during intrapulpal anesthesia (IP) using thinner gauge needles and syringes with or without topical anaesthesia as an adjunct.
Methods: One hundred patients, on whom the inferior alveolar nerve block and intraligamentary injections failed, were recruited for the trial. Block randomization was performed and the patients were allocated into 4 groups based on the needle gauge and topical application of anaesthesia prior to IP injection. In two groups (27GN, 31GN) the patients received IP injection with 27 gauge or 31 gauge needles. The patients of other two groups received topical lignocaine-prilocaine mixture prior to the IP injection with 27 or 31 gauge needles, respectively (27GT, 31GT). The visual analogue scale (VAS) was used to assess the pain immediately after IP injection and after cleaning and shaping by a blinded outcome assessor. The Kruskal-Wallis test for overall comparisons followed by the post-hoc analysis using the Conover’s test (P<0.05) was done. Chi-square and Fischer exact test was used to assess the proportion of patients who were comfortable during IP anaesthesia.
Results: The intensity of pain during IP administration with 31GN and 31GT (3.7 and 2.3 respectively) was significantly less in comparison to 27GN and 27GT (5.6 and 5.7 respectively). The proportion of patients who were significantly comfortable with IP injections in the groups 31GN and 31GT (52% and 80% respectively) were more (VAS<4) when compared to 27GN and 27GT (12% and 8% respectively). Topical application of lignocaine-prilocaine reduced the pain on IP injection significantly when used as an adjunct with 31 gauge needles. The anaesthetic success of IP anaesthesia was comparable and 100% (VAS scoring <4) in all the groups.
Conclusion: Thinner gauge needles (31 gauge) significantly reduce pain perceived during IP anaesthesia. Topical anaesthesia with lignocaine-prilocaine acts as an effective adjunct only with 31gauge needle. (EEJ-2019-11-117)

5.Factors Influencing Pain and Anxiety Before Endodontic Treatment: A Cross-Sectional Study Amongst American Individuals
Riyadh Alroomy, Dana Kim, Robert Hochberg, Joshua Chubak, Paul Rosenberg, Matthew Malek
PMID: 33353908  doi: 10.14744/eej.2020.17363  Pages 199 - 204
Objective: The present study aimed to assess preoperative levels of patient anxiety and pain before root canal treatment, and to explore variables that may affect these levels.
Methods: Ninety-five patients presenting for an endodontic visit were recruited for the study. A questionnaire was administered. Visual analog scales were used to record levels of pain and anxiety. Data was tabulated, and analysis was performed using the Pearson Chi-Squire test with continuity correction, and the level of significance was set at 0.05 (P=0.05).
Results: Anxiety was detected more frequently in females (60%) than in males (33%) (P=0.016). Sixty-two percent of patients who were waiting for a new treatment were anxious, compared to 39% of those who were returning to continue treatment (P=0.049). Sixty-nine percent of patients in pain reported being anxious (P=0.015). Patients aged 18–30 years reported more pain than those older than 30 years (P=0.023). Forty-three percent of new patients reported being in pain, whereas only 20% of patients returning for a treatment reported pain (P=0.027).
Conclusion: Anxiety associated with root canal treatment is prevalent, and it was reported primarily by young females who were presenting for a new treatment. Pain and anxiety are highly inter-related, and they are usually reduced after the first endodontic session. ( EEJ-2020-04-073)

6.Mechanical Properties of ProTaper Gold, EdgeTaper Platinum, Flex Gold and Pro-T Rotary Systems
Murilo Alcalde, Marco Antonio Hungaro Duarte, Pablo Andrés Amoroso Silva, Pedro Henrique Souza Calefi, Emmanuel Silva, Jussaro Duque, Rodrigo Vivan
PMID: 33353917  doi: 10.14744/eej.2020.48658  Pages 205 - 211
Objective: The aim of this study was to evaluate the cyclic fatigue, torsional behavior and bending resistance of EdgeTaper Platinum [ETP (tip 25, taper 0.06)], Flex Gold [FG (tip 25, taper 0.08)], Pro-T [PT (tip 25, taper 0.08)] and ProTaper Gold [PTG (tip 25, taper 0.08)] systems.
Methods: Rotary instruments of ETP, PT, FG, and PTG were used (n=30). Cyclic fatigue tests were performed using an artificial stainless-steel canal with a 60o angle and a 5-mm radius of curvature at body temperature (35°±1°C). The time and number of cycles to fracture (NCF) was recorded. The torsional test evaluated the torque and angle of rotation to failure at 3 mm from the tip according to ISO 3630-1. The fractured surface of each fragment was observed by using scanning electron microscopy (SEM). The bending test evaluated the torque required to bend the instruments at an angular deflection of 60°. Data were analyzed using one-way ANOVA and Tukey tests, and the level of significance was set at 5%.
Results: The ETP had highest time until fracture and NCF than all the groups (P<0.05). The PTG had the highest torsional strength, followed by FG (P<0.05). The ETP had the highest angular rotation, followed by PT and PTG (P<0.05). The FG showed the highest bending resistance, followed by the PTG (P<0.05).
Conclusion: In conclusion, the ETP and PT exhibited higher cyclic fatigue resistance, higher angular deflection values and lower bending force than FG and PTG. The PTG instruments showed the highest torsional strength and the lowest cyclic fatigue resistance.

7.Receptivity and Feedback to the Online Endodontics Congress Concept as a Learning Option - An International Survey
João Meirinhos, Mariana Pires, Rui Pereira da Costa, Jorge Martins
PMID: 33353915  doi: 10.14744/eej.2019.43534  Pages 212 - 218
Objective: The traditional face-to-face or on-site lecturing methods are still among the most common forms of delivering knowledge to students in dental education. However, other innovative learning methodologies have the potential to complement, or even improve, the effectiveness and quality of teaching. The aim of this online survey was to analyze the receptivity of endodontics practitioners to a specific online teaching format of a multi-day congress, mimicking an on-site conference, and perceive whether the participants regarded it as an effective way of acquiring knowledge with application in their clinical practice activity.
Methods: An online questionnaire, composed of 17 items, was sent during the last day of a multi-day online congress. Four strands of information were taken into account: demographics; previous online formation experience; personal involvement in the underway online congress; and overview of the online congress concept. Participation was voluntary and anonymous. Total counts, frequencies and descriptive statistics were generated by using SurveyMonkey software.
Results: A total of 1.827 answers were delivered, which represented a return rate of 15.8%. The results indicated that most of the participants agree that online learning could be a good alternative to the traditional on-site learning methodology in improving their practical abilities. In addition, the present survey found that the majority of the attendees support the use of computers as an assisting tool and only 18.0% reported difficulties when using technologies. A high number of practitioners recognized a favourable cost-benefit ratio of using online lessons and stated they would recommend others to participate in online meetings as well.
Conclusion: Overall, the present results suggest that online learning may be used successfully to improve student’s knowledge and enhance their abilities to apply acquired content in clinical situations. Moreover, the participants felt online learning to be effective, engaging and with a favourable cost-benefit ratio. (EEJ-2019-10-108)

8.Microbiological Investigation in Teeth with Persistent/Secondary Endodontic Infection in Different Stages of Root Canal Retreatment
Marlos Barbosa-Ribeiro, Rodrigo Arruda-Vasconcelos, Lidiane Mendes Louzada, Augusto Rodrigues Lima, Marina Marciano, Jose Flavio Affonso de Almeida, Adriana De- Jesus- Soares, Alexandre Augusto Zaia, Caio Ferraz, Brenda Paula Gomes
PMID: 33353920  doi: 10.14744/eej.2020.73626  Pages 219 - 225
Objective: The present clinical study investigated the microbiota of teeth with persistent secondary endodontic infection in the different phases of root canal retreatment.
Methods: Twenty filled single-rooted teeth with apical periodontitis were included. Samples were collected with sterile paper points before chemo-mechanical preparation (CMP) (S1), after CMP (S2) and after 30 days of calcium hydroxide-based intracanal medication (ICM) (S3). Cultivable bacteria were assessed by colony forming units count (CFU/mL). DNA was extracted and assessed by using nested PCR. Paired t-test and repeated measures ANOVA were applied for intragroup analysis in the stages of endodontic therapy at a significance level of 5%.
Results: Cultivable bacteria were detected in all initial samples. CMP reduced bacteria by 99.4% and ICM by 99.5%. The most prevalent species found in the initial samples were E. faecalis (20/20), P. gingivalis (20/20), F. nucleatum (17/20) and A. actinomycetemcomitans (10/20), whereas D. pneumosintes, F. alocis, P. nigrescens and T. socranskii were not detected. After CMP, A. israelii, A. naeslundii, G. morbillorum, T. forsythia and T. denticola were not detected (P<0.05) either. E. faecalis and P. gingivalis had a low reduction (P>0.05) and F. nucleatum had its DNA significantly reduced after CMP (P<0.05). ICM had no additional effect on microbial reduction.
Conclusion: The microbiota of teeth with persistent/secondary endodontic infection consists of a polymicrobial community with Gram-positive and Gram-negative species, bacillus and cocci, facultative and strict anaerobes. E. faecalis and P. gingivalis were frequently detected in all stages of root canal retreatment, evidencing their great resistance to endodontic procedures. The endodontic procedures were effective in reducing the levels of bacteria from teeth presenting with persistent/secondary endodontic infection. (EEJ-2020-04-063)

9.Ex Vivo Evaluation of the Accuracy of 3 Electronic Apex Locators in Different Environments: A Micro-Computed Tomography Study
Firdevs Çınar, Yakup Üstün
PMID: 33353910  doi: 10.14744/eej.2020.30633  Pages 226 - 230
Objective: The aim of this study was to compare the accuracy of three electronic apex locators (EALs) (Propex Pixi, Mini Root ZX, Raypex 5) in determining working length (WL) under different environments (existence of blood-pulp/sodium hypochlorite in root canal space) using micro-computed tomography (micro-CT) measurements.
Methods: Twenty-five single-rooted human teeth that were scheduled for extraction were selected for the study. Measurements were performed with the Propex Pixi, Mini Root ZX, Raypex 5 in vivo conditions in the presence of NaOCl irrigant solution or blood-pulp tissue. After that the teeth were extracted and scanned using micro-CT. The measurements of WL obtained with the different EALs in different environments were statistically compared. Significance was set at P<0.05.
Results: There were no significant differences among the WL measurements performed with EALs or micro CT groups under different clinical enviroments. All EALs tested gave reliable results in respect to apical constriction.
Conclusion: The accuracy of the tested EALs is not affected by pulp tissues and blood or NaOCl. (EEJ-2020-03-043)

10.Cyclic Fatigue and Torsional Resistance of Four Martensite-Based Nickel Titanium Reciprocating Instruments
Emmanuel Silva, Carolina Oliveira de Lima, Victor Vieira, Henrique Antunes, Edson Jorge Lima Moreira, Marco Versiani
PMID: 33353907  doi: 10.14744/eej.2020.16878  Pages 231 - 235
Objective: To evaluate cyclic fatigue and torsional resistance of Reciproc Blue R25 (VDW, Munich, Germany), WaveOne Gold Primary (Dentsply Maillefer, Ballaigues, Switzerland), ProDesign R (Easy Equipamentos Odontológicos, Belo Horizonte, Brazil), and X1 Blue File (MK Life, Porto Alegre, Brazil) nickel titanium (NiTi) martensite reciprocating instruments.
Methods: In each group, ten instruments were tested for cyclic fatigue resistance using a stainless-steel artificial canal (curvature angle of 80° and radius of 3 mm) and ten instruments for torsional failure according to ISO 3630-1 standard. The surface of the fractured instruments was examined under scanning electron microscopy (SEM) at ×250 magnification. The results were compared statistically with one-way ANOVA and post hoc Tukey tests and the alpha-type error was set at 5%.
Results: X1 blue file and ProDesign Rinstruments showed highest time to fracture than Reciproc Blue and Wave One Gold (P<0.05). However, no differences were found between X1 Blue File and ProDesign R (P>0.05). In addition, Reciproc Blue demonstrated highest time to fracture than WaveOne Gold (P<0.05). The lowest torsional resistance (1.0±0.2 N.cm) and angle of rotation (412º±46) was observed in the ProDesign R group (P<0.05). SEM analyses of fractured surfaces showed a crack initiation area and overload fast fracture zone after cyclic fatigue test, and concentric abrasion marks with microvoids at the centre of rotation after torsional failure experiment.
Conclusion: Overall, X1 Blue File and ProDesign R showed higher cyclic fatigue resistance than Reciproc Blue and WaveOne Gold instruments, while ProDesign R had the lowest torsional resistance and angular rotation values to fracture. SEM analysis of all instruments demonstrated typical failures features in both cyclic fatigue and torsional failure tests. (EEJ-2019-12-130)

11.Assessment of Quality of Root Canal Filling with C Point, Guttacore and Lateral Compaction Technique: A Confocal Laser Scanning Microscopy Study
Sudha Yadav, Ruchika Roongta Nawal, Sarika Chaudhry, Sangeeta Talwar
PMID: 33353918  doi: 10.14744/eej.2020.62534  Pages 236 - 241
Objective: The purpose of this in vitro study was to compare the quality of root canal filling of C Point, GuttaCore and lateral compaction using confocal laser scanning microscopy.
Methods: Ninety recently extracted human mandibular incisors with single canal were selected. Canals were prepared with ProTaper instruments to size F3 and obturated using C Point, GuttaCore or lateral compaction technique. Endosequence BC sealer was labeled with Rhodamine B dye to allow analysis under a confocal microscope. The percentages of gutta-percha filled area (PGFA), sealer filled area (PSFA), voids (POV) and interfacial adaptation (IA) was assessed at 2, 5 and 8 mm from the apex, using image analysis software. Kruskal–Wallis followed by Mann Whitney U tests were used for data analysis, and the P value was set at 0.05 (P=0.05).
Results: No significant difference was seen among the three groups at 2 mm level for PGFA, PSFA and voids (P>0.05). At 5 and 8 mm levels, canals filled with GuttaCore had significantly higher PGFA and lower PSFA than lateral compaction and C Point. Highest POV was seen for lateral compaction group followed by C Point and GuttaCore.
Conclusion: Out of the three techniques examined, best results in terms of quality of root canal filling were observed for GuttaCore. C Point system was found to be associated with internal defects such as tears and delamination which may adversely affect the long term performance of this system. (EEJ-2020-01-012)

12.Effects of Osmotic Stress and Sodium Hypochlorite on Endodontic Microbiota: An In-Vitro Study
Deon Naicker, Peter Zilm, Venkateshbabu Nagendrababu, Giampiero Rossi-Fedele
PMID: 33353919  doi: 10.14744/eej.2020.70883  Pages 242 - 247
Objective: To assess the effect of osmotic stress on various bacteria in a planktonic milieu and the effect of exposure to sodium hypochlorite (NaOCl) on the microbial cells previously subjected to osmotic stress.
Methods: Enterococcus faecalis, Streptococcus sanguinis, Fusobacterium nucleatum, Porphyromonas gingivalis and Prevotella intermedia were suspended as follows: Iso-osmotic group 0.9% NaCl; Hypo-osmotic group "ultrapure water"; Hyper-osmotic group 9% NaCl solution for 120 hours before exposure to 0.0001% NaOCl for 10 minutes. Quantitative analyses of viable cells were performed at 0 and 120 hours and after exposure to NaOCl to obtain colony forming units (CFU/mL). A linear mixed-effects model was used to find the association between mean CFU/mL (logarithmic transformation) and the interaction of solution Group and Time (P<0.001).
Results: F. nucleatum, P. gingivalis and P. intermedia did not survive after 24 hours in any of the solutions and were excluded from further testing. For S. sanguinis there were significant differences at each time interval, when holding solution group constant. After 120 hours, the Hyper-osmotic group presented with the highest CFU/mL and was significantly different to the Iso-osmotic group (P<0.001). For E. Faecalis, there was a significant difference for each pairwise comparison of time (P<0.001) in mean CFU/mL between 0 hours and 120 hours for the Iso-osmotic and Hyper-osmotic groups. At 120 hours, no significant differences were found between the three groups. Significant differences were also found between 0 hours and Post-NaOCl administration, and between 120 hours and Post-NaOCl administration for all three groups (P<0.001). Exposure to NaOCl after hypo-osmotic stress was associated with significantly less CFU/mL for S. sanguinis compared to hyperosmosis and iso-osmosis (P<0.001) and for E. Faecalis only compared to hyperosmosis (P<0.001).
Conclusion: S. sanguinis and E. faecalis were able to withstand osmotic stress for 120 hours. Hypo-osmotic stress before contact with NaOCl was associated with lower viable bacterial numbers, when compared to the other media for the above species. Hyper-osmotic stress was associated with higher viable bacterial numbers after NaOCl exposure for E. faecalis. (EEJ-2020-03-036)

13.Root and Canal Morphology of Mandibular Premolar Teeth in a Kuwaiti Subpopulation: A CBCT Clinical Study
Deena Jassem Alenezi, Saad A Al-Nazhan, Nassr Al-Maflehi, Cristalle Soman
PMID: 33353914  doi: 10.14744/eej.2020.40085  Pages 248 - 256
Objective: To study the root and root canal morphology of mandibular premolars in a Kuwaiti subpopulation using cone-beam computed tomography (CBCT).
Methods: 152 CBCT images were obtained from the radiology department archives of four dental centers in Kuwait. A total of 476 mandibular premolar teeth were analyzed by two observers. The number of roots, root canal configuration types and canal curvature measurements were examined. The relationship between sex, tooth position, and incidence of an additional canal were compared using the chi-square test, and the level of significance was set at 0.05 (P=0.05).
Results: The number of roots in mandibular first premolars was one in 73.9%, two in 24.9%, three and four in 1.2%. On the other hand, the number of roots in mandibular second premolars was one in 79.2% and two in 20.8%. Based on Vertucci’s classification system, 18.7% of the teeth were type II followed by type VI (14.3%). The majority of the examined teeth were straight (74.8%) and the incidence of distal root angulation was about 21%. Canal configurations not included in the Vertucci classification were reported in 102 teeth (21.4%). Variability was significantly higher in the second premolars compared to first premolar (P<0.05).
Conclusion: The Kuwaiti population has complex root canal morphology in mandibular premolar teeth. (EEJ-2019-10-104)

14.Smear Layer Removal from Root Canal Dentin and Antimicrobial Effect of Citric Acid-modified Chlorhexidine
Anat Dewi, Chawin Upara, Danupong Chaiariyakul, Phumisak Louwakul
PMID: 33353912  doi: 10.14744/eej.2020.38258  Pages 257 - 263
Objective: To study the effectiveness of various concentrations of citric acid (CA) added to 2% chlorhexidine (CHX) on smear layer removal from the root canal wall and antimicrobial efficacy against Enterococcus faecalis (E. faecalis) and Candida albicans (C. albicans).
Methods: Fifty-three single-rooted mandibular premolars were decoronate and the root canals underwent mechanical instrumentation using MTwo rotary files to size 40/0.06. The samples were then randomly divided into 5 groups according to the root canal irrigants to be used: 17% ethylenediaminetetraacetic acid (EDTA), 2% CHX, 1%, 6%, and 10% citric acid-modified 2% chlorhexidine (CAmCHX). Three teeth irrigated with phosphate-buffered saline (PBS) were used as a negative control. The smear layer removal effectiveness was evaluated under scanning electron microscopy (SEM). Images were randomly taken at the apical, middle, and coronal third level. Statistical analysis was performed using Kruskal-Wallis and Mann-Whitney U tests. Disc diffusion and direct exposure tests were performed along with three additional control groups consisting of 1%, 6%, and 10% CA groups to assess and compare the antimicrobial efficacy of irrigants against E. faecalis and C. albicans. Statistical analysis was conducted using one-way ANOVA and Dunnett’s T3 tests.
Results: Smear layer removal effectiveness in 17% EDTA group and 6% and 10% CAmCHX groups were not significantly different in the coronal and apical third of the root canal (P>0.05), however at the middle third of the root canal, the 10% CAmCHX group had significantly less remaining smear layer than all of the other experimental groups (P<0.05). There was significantly more smear layer remnant in the CHX group (P<0.01). For antimicrobial efficacy, the largest growth inhibition zone against E. faecalis was recorded in the 10% CAmCHX group (P<0.05). For planktonic E. faecalis, 1%, 6%, and 10% CAmCHX demonstrated an insignificant difference in antimicrobial efficacy compared to CHX (P>0.05). CA demonstrated no antifungal effect against C. albicans. Whereas, 6% and 10% CAmCHX resulted in the largest growth inhibition zone. Also, adding CA to CHX resulted in an insignificant difference in antifungal effect against planktonic C. albicans compared to CHX (P>0.05).
Conclusion: When CA was added into CHX, the mixed irrigant demonstrated smear layer removal ability. Additionally, its antimicrobial effect remained the same. (EEJ-2020-04-082)

15.Dentinal Tubule Penetration and Dislocation Resistance of a New Bioactive Root Canal Sealer Following Root Canal Medicament Removal Using Sonic Agitation or Laser-Activated Irrigation
Esin Özlek, Prasanna Neelakantan, Elif Akkol, Hüseyin Gündüz, Arzu Yağmur Uçar, Sema Belli
PMID: 33353924  doi: 10.14744/eej.2020.92905  Pages 264 - 270
Objective: To investigate the influence of sonic agitation or laser-activated irrigation techniques on the removal chlorhexidine (CHX) and modified triple antibiotic paste (mTAP) on the sealer penetration depth and dislocation resistance of Guttaflow Bioseal.
Methods: Single-rooted mandibular premolars (n=96) were prepared with rotary nickel titanium instruments and randomly divided into two groups (n=48) based on the intracanal medicaments used: Group 1, mTAP; Group 2, CHX gel. After 7 days, the specimens in each group were divided into three subgroups (n=16) based on the supplementary irrigation technique used to remove the medicaments: laser activated irrigation (Er, Cr: YSGG laser, Waterlase MD, Biolase Technology Inc., San Clemente, CA, USA), sonic agitation (EndoActivator, Dentslpy Sirona Endodontics, PA, USA) and syringe-and-needle irrigation (control) techniques. Canals were filled with single matched-taper gutta-percha cone and a calcium silicate-based sealer (GuttaFlow® Bioseal, Coltène/Whaledent, Langenau, Germany). At the end of three weeks, sealer penetration was investigated using confocal microscopy (n=6), and dislocation resistance was calculated by measuring the push-out bond strength (n=10). Statistical analysis was performed using three-way analysis of variance (ANOVA) and Tukey post-hoc test (P=0.05).
Results: Laser activated irrigation resulted in significantly higher depth of sealer penetration compared to sonic agitation and syringe irrigation (P<0.01). The average sealer penetration depths were recorded as 846.6 µm, 786.5 µm and 505 µm in the Er,Cr: YSGG laser, EndoActivator and control groups, respectively. The mean bond strength obtained in group 3 (syringe-and-needle irrigation) was significantly less than the other groups (P<0.05). The mean values were 9.08 in the Er,Cr: YSGG laser group, 8.44 in the EndoActivator group and 5.08 in the needle group.
Conclusion: Er,Cr;YSGG laser irrigation to remove the medicaments was advantageous to other irrigation techniques in sealer penetration and dislocation resistance of the sealer. (EEJ-2020-04-081)

16.Forensic Identification of Endodontically Treated Teeth after Heat-Induced Alterations: An In Vitro Study
Aashray Patel, Vaishali Parekh, Niraj Kinariwala, Abraham Johnson, Mona Somani
PMID: 33353911  doi: 10.14744/eej.2020.37450  Pages 271 - 276
Objective: The study aimed to highlight the relationship between forensic science and endodontics by illustrating CBCT records can be used as legal evidence for forensic analysis and evaluate the effect of elevated temperature on the endodontically treated teeth.
Methods: The present study was conducted on 40 extracted permanent mandibular premolars, which were divided into two groups based on predetermined incineration temperature: Group I - 400°C & Group II - 800°C subjected for 15 minutes holding time in a digital burnout furnace. The root canal treatment was performed for both the groups and a Pre-incineration CBCT scan was taken for both the groups as an ante-mortem data. Following heating analysis, root canal treated teeth were examined using a stereomicroscope at 20x resolution to evaluate the morphological changes. The post-incineration CBCT scan was taken as the post-mortem record for each group. Both ante-mortem records and post-mortem records were compared for the forensic analysis.
Results: The endodontically treated teeth display a series of macroscopic and stereo-microscopic changes for each temperature scale. The CBCT records identify the thermal stress-induced 3D alterations in the gutta-percha filled teeth.
Conclusion: Knowledge of changes in human dentition and traces of the endodontically treated teeth can help forensic experts for the identification of the fire victims. (EEJ-2020-06-167)

17.In Vitro Mitigation of Arsenic-Induced Toxicity by Reduced Glutathione in Rat Pulp Cells
Mohannad Nassar, Ahmad Dargham, Noriko Hiraishi, Yukihiko Tamura, Junji Tagami
PMID: 33353909  doi: 10.14744/eej.2020.26878  Pages 277 - 281
Objective: Despite the controversial results regarding the amount of arsenic (As) in mineral trioxide aggregate (MTA) and MTA-like cements, it is prudent to assess the effect of this heavy metal on pulpal cells and search for methods to attenuate its toxicity. This study investigated the toxic effect of As on pulpal-like cells and evaluated the influence of reduced glutathione (GSH) on As-induced toxicity.
Methods: The cytotoxicity of 50 µm As, 50 µm As+50 µM GSH, 50µm As+500 µM GSH or 50 µm As+5000 µM GSH on rat pulpal cells (RPC-C2A) was evaluated at 24 hours and 72 hours. Cell culture in fresh medium without experimental solution served as the control. Cell viability was measured by means of 3-(4.5-dimethylthiazol-2-yl)-2.5-diphenyltetrazolium bromide (MTT) assay and the optical density was measured with microplate reader. The morphology of the cultured cells was observed under phase contrast microscope. Cytotoxicity data were analyzed by two-way ANOVA and Tukey post hoc tests (P<0.05).
Results: There were statistically significant differences in cell viability amongst the tested groups (P<0.05). As elicited remarkable toxic effect on pulpal cells, while 5000 µM GSH protected the cells from As-induced damage at 24-hour exposure time. The cultured control cells were polygonal-shaped; however, As-treated cells exhibited contracted and spherical morphology with increased intercellular spaces indicative of cellular death and decreased proliferation.
Conclusion: As negatively affected the viability of pulpal cells; however, controlled concentration of GSH had a short-term protective effect against As-induced toxicity. Future research is warranted on the clinical use of GSH with MTA and MTA-like cements to minimize initial inflammation resulting from As release during the setting of the aforementioned cements thus enhancing the success of procedures where these cements are placed in direct contact with vital pulp tissues. (EEJ-2020-01-03)

18.Bacterial Contamination of Gutta-Percha Points From Different Brands and the Efficacy of a Chairside Disinfection Protocol
Francesca Bracciale, Nicole Marino, Anariely Noronha, Maria Da Conceição Manso, Sandra Gavinha, Inês Lopes Cardoso, Cristina Pina, Ana Moura Teles
PMID: 33353916  doi: 10.14744/eej.2020.44265  Pages 282 - 287
Objective: To evaluate the bacterial contamination of different brands of Gutta-Percha (GP) points routinely used in clinical practice and the efficacy of a chairside disinfection protocol with sodium hypochlorite.
Methods: GP points (n=240), in sizes A, B, C, D, K15, K20, K25, K30, K35, K40, F1, F2, F3 (Dentsply®, Proclinic®, ProTaper® and R&S®), were randomly sampled from commercial packages already in use. These were added directly to Fluid Thioglycolate Medium (one GP point per tube) and incubated at 37ºC for 21 days. During this period, the presence/absence of turbidity was evaluated. To evaluate the efficacy of a chairside disinfection protocol, all detected contaminated GP points were immersed for 1 minute in 10 mL of 5.25% sodium hypochlorite, followed by 5 minutes in 10 mL of detergent solution (3% Tween 80 and 5% sodium thiosulfate) and a final rinse with 10 mL of sterile distilled water and incubated. The data was analysed using the chi-square test and differences between characteristics of dichotomic variables were performed using the binomial test. The significance level was set at P<0.05.
Results: Bacterial growth was observed in 22.9% of the total study samples. Dentsply® and R&S® showed the highest level of contamination, 47.3% each, although without significant differences to the other commercial brands. The most contaminated GP point size was K30 (16.4%). The chairside disinfection protocol was effective in disinfection of 76.4% of GP points (P<0.001).
Conclusion: A real small number of GP points in clinical use harboured bacteria, including after the Chairside Disinfection Protocol that, anyway, proved to be effective. No significant difference was observed between tested commercial brands. (EEJ-2020-01-06)

19.Shear Bond Strength of E. Max Ceramic Restoration to Hydraulic Calcium Silicate Based Cement (Biodentine): An In Vitro Study
Kholod Khalil Al-Manei, Asma Ban Owaiwid, Reem AlDhafiri, Khaled Al-Manei, Shahad AlHarran, Reem Alsulaimani
PMID: 33353922  doi: 10.14744/eej.2020.75046  Pages 288 - 294
Objective: The purpose of this study was to evaluate the shear bond strength (SBS) of hydraulic calcium silicate (Biodentine) as a core material to the e.max ceramic restoration.
Methods: Forty discs (6 mm diameter; 2 mm thickness) were fabricated from each core material, Hydraulic calcium silicate [Biodentine™, Septodont], resin composite [Filtek™Z250 XT, 3M ESPE], and resin-modified glass ionomer cement (RMGIC) [GC Fuji II LC, GC Corporation]. Dentine surfaces of 40 extracted human permanent molars were exposed and used as a control group. All specimens were mounted in self-curing acrylic resin. One hundred sixty IPS e.max discs were fabricated (4 mm diameter; 2 mm thickness) and cemented to the core specimens with Variolink N (IvoclarVivadent). After storage in distilled water (37oC; 24h), the specimens were thermocycled 1.500 times. SBS was tested using a universal testing machine at 0.05 mm/min crosshead speed. The fracture modes were determined by a stereomicroscope at ×20 magnification. Data were analyzed using one-way analysis of variance followed by Tukey's test (P=0.05).
Results: The mean SBS values of four tested groups showed statistically significant differences (P<0.05). The resin composite group exhibited the highest SBS value (36.17±6.08 MPa), while the Biodentine had the lowest SBS value (21.86±3.18 MPa). Mixed failure mode was the most common failure type in all tested groups except in the Biodentine group, which had a predominantly cohesive failure.
Conclusion: The SBS of e.max ceramic restorations cemented with resin is affected by the type of core material. Biodentine core material had the lowest SBS to e.max restoration. However, when Biodentine is indicated to be used as core material for pulp preservation, it is recommended to be covered with a layer of resin composite material to enhance its bonding strength to the e.max restoration. (EEJ-2020-03-034)

CASE REPORT
20.Surgical Extrusion of Anterior Teeth with Intrusion Traumatic Injury: A Report of two Cases
Melek Belevcikli, Halenur Altan, Ahmet Altan
PMID: 33353906  doi: 10.14744/eej.2020.07379  Pages 295 - 299
Intrusion is the most severe luxation injury type, which results in both soft and hard tissue damage. In severe intrusions, the crown must be re-positioned in the arch to avoid periapical pathology and marginal bone loss. There is minimal information about the effect of treatment delay on pulpal and periodontal healing in intrusion trauma. The present paper reports on two cases of severe intrusive luxation applied late at different times treated with surgical extrusion. The first patient, an 11-year-old female, referred to Tokat GOP pediatric dentistry clinic three days after the intrusion tooth 21. The second patient, a 13-year-old male, referred to our clinic fifteen days after a traffic accident. The intruded teeth were positioned surgically and splinted. Surgical extrusion should be preferred as soon as possible to initiate root canal treatment in teeth, the crown of which is fully embedded in the alveolar bone. (EEJ-2020-02-025)

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