Inernational Tic Journal IEJ 2010 Issue January

doi:10.1111/j.1365-2591.2009.01656.
EDITORIAL
I would like to acknowledge and thank the Associate Editors for their outstanding contribution during 2009: Kishor Gulabivala, Matt German, Jeremy Hayes, Michael Hulsmann, Yuan-Ling Ng, Ove Peters, Min-Kai Wu, Matthias Zehnder. I would also like to acknowledge and thank the following referees for their critical appraisal of papers received: Paul Abbott, Guido Aesaert, Michael Ahlquist, Anas Al-jadaa, Antonio Apicella, Saeed Asgary, Paul Ashley, Phil Atkin, Graham Bailey, Rafael Yague Ballester, Michael Baumann, Michael Behr, Sema Belli, Lars Bergmans, Matthias Bickel, Lars Bjrndal, Gilles Bluteau, Emre Bodrumlu, Patrick Bogaerts, George Bogen, Fiona Boissonade, Peter Bolhuis, Tatiana Botero, Serge Bouillaguet, Martha Brackett, Peter Briggs, Paul Brunton, Josette Camilleri, Jean Camps, Dermot Canavan, Peter Carrotte, Bruno Cavalcanti, Nick Chandler, Gary Cheung, Bun San Chong, David Cohen, Ben Cole, Georg Conrads, Ian Corbett, Margaret Corson, Bill Costerton, Elisabetta Cotti, Francesco DAiuto, Till Dammaschke, Camillo DArcangelo, Peter Day, Mieke De Bruyne, Roeland De Moor, Carlos de Souza Costa, Gustavo De-Deus, Chris Deery, Anibal Diogenes, Nick Donos, Nicholas Drage, Peter Duckmanton, Johannes Ebert, Martin Ehrbar, Ashraf ElAyouti, Paul Eleazer, George Eliades, Chris Emery, Unni Endal, Carlos Estrela, Marco Ferrari, Jose Figueiredo, Ashraf Fouad, Richard Foxton, Roland Frankenberger, Inge Fristad, Massimo Gagliani, Gianluca Gambarini, Jennifer Gibbs, Alan Gluskin, Michel Goldberg, Brenda Gomes, Harold Goodis, Simone Grandini, Rene Gruythuysen, James Gutmann, Markus Haapasalo, Gunnar Hasselgren, Sivakami Haug, Jianing He, Brian Henderson, Michael Hofmann, Christopher Hope, Keith Horner, Preben Horsted Bindslev, Tony Hoskinson, George Huang, Bart Huybrechts, Richard Kahan, Asma Khan, Andrej Kielbassa, Eun-Cheol Kim, Lise-Lotte Kirkevang, Anil Kishen, Elisabeth Koulaouzidou, Thomas Kvist, Paul Lambrechts, Rachel Leeson, Jim Lewsey, Ludwig Limbach, Shaul Lin, Christina Lindh, Howard Lloyd, Matthew Locke, Claus Lost, Robert Love, Hans Ulrich
Luder, Phil Lumley, Pierre Machtou, Iain Mackie, Francesco Mannocci, Monika Marending, Phil Marsh, Paul McCabe, John McCabe, Robert McConnell, Harold Messer, Thimios Mitsiadis, Dirk Mohn, Anders Molander, Francesca Monticelli, Nicky Mordan, Peter Murray, Akhila Muthukrishnan, P.N.R. Nair, Mohammad Nekoofar, Jacques Nor, Takashi Okiji, Dag rstavik, Ahmet Ozok, Cornelis Pameijer, Frank Paque, Peter Parashos, Shanon Patel, Jorge Perdigao, Hiran Perin panayagam, Christine Peters, Linda Peters, Kerstin Petersson, David Pitt, Heather Pitt Ford, Gianluca Plotino, Carlo Prati, Jonathan Pratten, Alison Qualtrough, Ivana Radovic, Derren Ready, John Regan, Kathrin Reichenmiller, Claes Reit, John Rhodes, Adam Roberts, Sarah Rolland, Martin Rosentritt, Vivian Rushton, Kamran Safavi, Chankhrit Sathorn, Julian Satterthwaite, Bill Saunders, Edgar Schafer, Jorg Schirrmeister, Patrick Schmidlin, Helmut Schweikl, Geoffrey Seccombe, Christine Sedgley, Bilge Sen, Ann Shearer, Hagay Shemesh, Sharan Sidhu, Asgeir Sigurdsson, Nick Silikas, Ulf Sjogren, Alastair Sloan, Carlos Soares, David Sonntag, Manoel Sousa-Neto, Erick Souza, Valerie Sparkes, Dave Spratt, Vidya Srinivasan, Hideaki Suda, Pia Titterud Sunde, Mario TanomaruFilho, Franklin R Tay, Peter Taylor, Fabricio Teixeira, Leo Tjaderhane, Mirek Tolar, Muhittin Toman, Phillip Tomson, Mahmoud Torabinejad, Dimitrios Tziafas, lucas van der Sluis, Peter Velvart, Frank Vertucci, Morgana Vianna, Thomas von Arx, William Walker, Angus Walls, Damien Walmsley, Tuomas Waltimo, Rick Walton, John Wataha, Paula Waterhouse, Roland Weiger, Richard Welbury, Paul Wesselink, John Whitworth, David Witherspoon, Karl Thomas Wrbas, Peter Yaman. Without their commitment, dedication and expertise, the International Endodontic Journal could not maintain its position as the leading publication in the eld of Endodontology. Paul M. H. Dummer Editor-in-Chief
2010 International Endodontic Journal
International Endodontic Journal, 43, 1, 2010
doi:10.1111/j.1365-2591.2009.01627.x
REVIEW
The smear layer in endodontics a review
D. R. Violich1 & N. P. Chandler2

1 Private Endodontic Practice, Tauranga, New Zealand; and 2Sir John Walsh Research Institute, School of Dentistry, University of Otago, Dunedin, New Zealand
Abstract
Violich DR, Chandler NP. The smear layer in endodontics
a review. International Endodontic Journal, 43, 215, 2010.
Root canal instrumentation produces a layer of organic and inorganic material called the smear layer that may also contain bacteria and their by-products. It can prevent the penetration of intracanal medicaments into dentinal tubules and inuence the adaptation of lling materials to canal walls. This article provides an overview of the smear layer, focusing on its relevance to endodontics. The PubMed database was used initially; the reference list for smear layer featured 1277 articles, and for both smear layer dentine and smear layer root canal revealed 1455 publications. Smear layer endodontics disclosed 408 papers. A forward search was undertaken on selected articles and using some author names. Potentially relevant material was also sought in contemporary endodontic
texts, whilst older books revealed historic information and primary research not found electronically, such that this paper does not represent a classical review. Data obtained suggests that smear layer removal should enhance canal disinfection. Current methods of smear removal include chemical, ultrasonic and laser techniques none of which are totally effective throughout the length of all canals or are universally accepted. If smear is to be removed, the method of choice seems to be the alternate use of ethylenediaminetetraacetic acid and sodium hypochlorite solutions. Conict remains regarding the removal of the smear layer before lling root canals, with investigations required to determine the role of the smear layer in the outcomes of root canal treatment. Keywords: dentine, ethylenediaminetetraacetic acid, endodontic treatment, smear layer.
Received 20 June 2007; accepted 21 July 2009
Introduction
Whenever dentine is cut using hand or rotary instruments, the mineralized tissues are not shredded or cleaved but shattered to produce considerable quantities of debris. Much of this, made up of very small particles of mineralized collagen matrix, is spread over the surface to form what is called the smear layer. Identication of the smear layer was made possible using the electron microprobe with scanning electron microscope (SEM) attachment, and
Correspondence: Nicholas Chandler, Associate Professor, School of Dentistry, University of Otago, P.O. Box 647, Dunedin 9054, New Zealand (Tel.: 0064 3 479 7124; fax: 0064 3 479 5079; e-mail nick.chandler@dent.otago.ac.nz).
rst reported by Eick et al. (1970). These workers showed that the smear layer was made of particles ranging in size from less than 0.515 lm. Scanning electron microscope studies of cavity preparations by Brannstrom & Johnson (1974) demonstrated a thin layer of grinding debris. They estimated it to be 25 lm thick, extending a few micrometres into the dentinal tubules. The smear layer in a cavity and in the root canal may not be directly comparable. Not only are the tools for dentine preparation different in coronal cavities, but in the root canal the dentinal tubule numbers show greater variation and there are likely to be more soft tissue remnants present. The rst researchers to describe the smear layer on the surface of instrumented root canals were McComb & Smith (1975). They
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Violich & Chandler Smear layer in endodontics
suggested that the smear layer consisted not only of dentine as in the coronal smear layer, but also the remnants of odontoblastic processes, pulp tissue and bacteria. Lester & Boyde (1977) described the smear layer as organic matter trapped within translocated inorganic dentine. As it was not removed by sodium hypochlorite irrigation, they concluded that it was primarily composed of inorganic dentine. Goldman et al. (1981) estimated the smear thickness at 1 lm and agreed with previous investigators that it was largely inorganic in composition. They noted its presence along instrumented canal surfaces. Mader et al. (1984) reported that the smear layer thickness was generally 12 lm. Cameron (1983) and Mader et al. (1984) discussed the smear material in two parts: rst, supercial smear layer (Fig. 1) and second, the material packed into the dentinal tubules. Packing of smear debris was present in the tubules to a depth of 40 lm. Brannstrom & Johnson (1974) and Mader et al. (1984) concluded that the tubular packing phenomenon was due to the action of burs and instruments. Components of the smear layer can be forced into the dentinal tubules to varying distances (Moodnik et al. 1976, Brannstrom et al. 1980, Cengiz et al. 1990) to form smear plugs (Fig. 2). However, Cengiz et al. (1990) proposed that the penetration of smear material into dentinal tubules could also be caused by capillary action as a result of adhesive forces between the dentinal tubules and the material. This hypothesis of capillary action may explain the packing phenomenon observed by Aktener et al. (1989), who showed that the penetration could increase up to 110 lm when using
Figure 2 Scanning electron micrograph of dentine surface
showing smear plugs occluding tubules. The surface has been treated for 60 s with Tubulicid Blue Label (Dental Therapeutics AB, Nacka, Sweden).
Figure 1 Scanning electron micrograph of smeared surface of
dentine. The crack shapes are processing artefacts overlying dentinal tubules.
surface-active reagents in the canal during endodontic instrumentation. The thickness may also depend on the type and sharpness of the cutting instruments and whether the dentine is dry or wet when cut (Barnes 1974, Gilboe et al. 1980, Cameron 1988). In the early stages of instrumentation, the smear layer on the walls of canals can have a relatively high organic content because of necrotic and/or viable pulp tissue in the root canal (Cameron 1988). Increased centrifugal forces resulting from the movement and the proximity of the instrument to the dentine wall formed a thicker layer which was more resistant to removal with chelating agents (Jodaikin & Austin 1981). The amount produced during motorized preparation, as with GatesGlidden or post drills, has been reported as greater in volume than that produced by hand ling (Czonstkowsky et al. 1990). However, McComb & Smith (1975) observed under SEM that instrumentation with K-reamers, K-les and Giromatic reciprocating les created similar surfaces. Additional work has shown that the smear layer contains organic and inorganic substances that include fragments of odontoblastic processes, microorganisms and necrotic materials (Pashley 1992). The generation of a smear layer is almost inevitable during root canal instrumentation. Whilst a noninstrumentation technique has been described for canal preparation without smear formation, efforts rather focus on methods for its removal, such as chemical means and methods such as ultrasound and hydrodynamic disinfection for its disruption. Root canal preparation without the creation of a smear
Smear layer in endodontics Violich & Chandler
Figure 3 Scanning electron micrograph of dentine surface
with typical amorphous smear layer with granular appearance and moderate debris present (courtesy of Dr Artika Soma).
layer may be possible. A noninstrumental hydrodynamic technique may have future potential (Lussi et al. 1993), and sonically driven polymer instruments with tips of variable diameter are reported to disrupt the smear layer in a technique called hydrodynamic disinfection (Ruddle 2007). When viewed under the SEM, the smear layer often has an amorphous irregular and granular appearance (Brannstrom et al. 1980, Yamada et al. 1983, Pashley et al. 1988) (Fig. 3). The appearance is thought to be formed by translocating and burnishing the supercial components of the dentine walls during treatment (Baumgartner & Mader 1987).
Vassiliadis et al. 1996, Taylor et al. 1997, Timpawat & Sripanaratanakul 1998, Economides et al. 1999, 2004, von Fraunhofer et al. 2000, Froes et al. 2000, Goya et al. 2000, Timpawat et al. 2001, Clark-Holke et al. 2003, Cobankara et al. 2004, Park et al. 2004). Workers have reached different conclusions, with current knowledge of interactions between the smear layer and factors such as lling technique and sealer type being limited. In addition, the methodology of studies, the type and site of leakage tests, and the sample size should be taken into account and consideration given to these variables before conclusions are reached (Shahravan et al. 2007). Some authors suggest that maintaining the smear layer may block the dentinal tubules and limit bacterial or toxin penetration by altering dentinal permeability (Michelich et al. 1980, Pashley et al. 1981, Safavi et al. 1990). Others believe that the smear layer, being a loosely adherent structure, should be completely removed from the surface of the root canal wall because it can harbour bacteria and provide an avenue for leakage (Mader et al. 1984, Cameron 1987a, Meryon & Brook 1990). It may also limit the effective disinfection of dentinal tubules by preventing sodium hypochlorite, calcium hydroxide and other intracanal medicaments from penetrating the dentinal tubules.
Should the smear layer be removed?

The question of keeping or removing the smear layer remains controversial (Drake et al. 1994, Shahravan et al. 2007). Some investigations have focussed on its removal (Garberoglio & Brannstrom 1976, Outhwaite et al. 1976, Pashley 1985), whilst others have considered its effects on apical and coronal microleakage (Madison & Krell 1984, Goldberg et al. 1995, Chailertvanitkul et al. 1996), bacterial penetration of the tubules (Pashley 1984, Williams & Goldman 1985, Meryon & Brook 1990) and the adaptation of root canal materials (White et al. 1987, Gencoglu et al. 1993a, Gutmann 1993). In support of its removal are: 1. It has an unpredictable thickness and volume, because a great portion of it consists of water (Cergneux et al. 1987). 2. It contains bacteria, their by-products and necrotic tissue (McComb & Smith 1975, Goldberg & Abramovich 1977, Wayman et al. 1979, Cunningham & Martin 1982, Yamada et al. 1983). Bacteria may survive and multiply (Brannstro & Nyborg 1973) m and can proliferate into the dentinal tubules (Olgart et al. 1974, Akpata & Blechman 1982, Williams &
The signicance of the smear layer

Root canal treatment usually involves the chemomechanical removal of bacteria and infected dentine from within the root canals. The process is often followed by an intracanal dressing and a root lling. Amongst important factors affecting the prognosis of root canal treatment is the seal created by the lling against the walls of the canal. Considerable effort has been made to understand the effect of the smear layer on the apical and coronal seal (Madison & Krell 1984, Goldberg et al. 1985, 1995, Evans & Simon 1986, Kennedy et al. 1986, Cergneux et al. 1987, Saunders & Saunders 1992, 1994, Gencoglu et al. 1993a, Karagoz-Kucukay & Bayirli 1994, Tidswell et al. 1994, Lloyd et al. 1995, Behrend et al. 1996, Chailertvanitkul et al. 1996,
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Goldman 1985, Meryon et al. 1986, Meryon & Brook 1990), which may serve as a reservoir of microbial irritants (Pashley 1984). 3. It may act as a substrate for bacteria, allowing their deeper penetration in the dentinal tubules (George et al. 2005). 4. It may limit the optimum penetration of disinfecting agents (McComb & Smith 1975, Outhwaite et al. 1976, Goldberg & Abramovich 1977, Wayman et al. 1979, Yamada et al. 1983). Bacteria may be found deep within dentinal tubules (Bystrom & Sundqvist 1981, 1983, 1985) and smear layer may block the effects of disinfectants in them (Goldberg & Abramovich 1977, Wayman et al. 1979, Yamada et al. 1983, Baumgartner & Mader 1987). Haapasalo & rstavik (1987) found that in the absence of smear layer, liquid camphorated monochlorophenol disinfected the dentinal tubules rapidly and completely, but calcium hydroxide failed to eliminate Enterococcus faecalis even after 7 days of incubation. A subsequent study concluded that the smear layer delayed but did not abolish the action of the disinfectant (rstavik & Haapasalo 1990). Bra nnstro (1984) had previously stated that m following the removal of the smear layer, bacteria in the dentinal tubules can easily be destroyed. 5. It can act as a barrier between lling materials and the canal wall and therefore compromise the formation of a satisfactory seal (Lester & Boyde 1977, White et al. 1984, Cergneux et al. 1987, Czonstkowsky et al. 1990, Foster et al. 1993, Yang & Bae 2002). Lester & Boyde (1977) found that zinc oxide eugenol based root canal sealers failed to enter dentinal tubules in the presence of smear. In two consecutive studies, White et al. observed that plastic lling materials and sealers penetrated dentinal tubules after removal of smear layer (White et al. 1984, 1987). Oksan et al. (1993) also found that smear prevented the penetration of sealers into dentinal tubules, whilst no penetration of sealer was observed in control groups. Penetration in their smear-free groups ranged from 40 to 60 lm. It may be concluded that such tubular penetration increases the interface between the lling and the dentinal structures, which may improve the ability of a lling material to prevent leakage (White et al. 1984). If the aim is maximum penetration into the dentinal tubules to prevent microleakage, root canal lling materials should be applied to a surface free of smear and either a low surface activity or, alternatively, an adequate surface-active reagent must be added to them (Aktener et al. 1989). However, there are no reports of a correlation between microleakage and penetration of
lling materials into dentinal tubules, whilst the basis of leakage studies remains questionable. Pashley et al. (1989) observed an extensive network of microchannels around restorations that had been placed in cavities with smear layer. The thickness of these channels was 110 lm. Smear layer may thus present a passage for substances to leak around or through its particles at the interface between the lling material and the tooth structure. Pashley & Depew (1986) reported that, when experimenting with class 1 cavities, microleakage decreased after the removal of smear layer, but dentinal permeability increased. Saunders & Saunders (1992) concluded that coronal leakage of root canal llings was less in smear-free groups than those with a smear layer. 6. It is a loosely adherent structure and a potential avenue for leakage and bacterial contaminant passage between the root canal lling and the dentinal walls (Mader et al. 1984, Cameron 1987b, Meryon & Brook 1990). Its removal would facilitate canal lling (McComb & Smith 1975, Goldman et al. 1981, Cameron 1983). Conversely, some investigators believe in retaining the smear layer during canal preparation, because it can block the dentinal tubules, preventing the exchange of bacteria and other irritants by altering permeability (Michelich et al. 1980, Pashley et al. 1981, Safavi et al. 1990, Drake et al. 1994, Galvan et al. 1994). The smear layer serves as a barrier to prevent bacterial migration into the dentinal tubules (Drake et al. 1994, Galvan et al. 1994, Love et al. 1996, Perez et al. 1996). Pashley (1985) suggested that if the canals were inadequately disinfected, or if bacterial contamination occurred after canal preparation, the presence of a smear layer might stop bacterial invasion of the dentinal tubules. Bacteria remaining after canal preparation are sealed into the tubules by the smear layer and subsequent lling materials. Some studies provide evidence to support the hypothesis that the smear layer inhibits bacterial penetration (Pashley et al. 1981, Safavi et al. 1989). A major limitation is that the experiments were undertaken with dentine discs or root cross-sections, models with little relevance in terms of simulating the clinical conditions of root canal treatment. Drake et al. (1994) developed a more clinically relevant model to determine the effect of the presence or absence of the smear layer on bacterial colonization of root canals. Williams & Goldman (1985) reported that the smear layer was not a complete barrier and could only delay bacterial penetration. In their experiment, using the
motile, swarming bacterium Proteus vulgaris, the smear layer delayed the passage of the organisms through the tubules. Madison & Krell (1984) using ethylenediaminetetraacetic acid (EDTA) solution in a dye penetration study found that the smear layer made no difference to leakage. Goldberg et al. (1995) studied the sealing ability of Ketac Endo and Tubliseal in an India ink study with and without smear layer and found no difference. Chailertvanitkul et al. (1996) found no difference in leakage with or without smear layer, however the time period was short. When the smear layer is not removed, the durability of the apical seal should be evaluated over a long period. Since the smear layer is nonhomogenous and may potentially be dislodged from the underlying tubules (Mader et al. 1984), it may slowly disintegrate, dissolving around a leaking lling material to leave a void between the canal wall and sealer. Meryon & Brook (1990) found the presence of smear layer had no effect on the ability of three oral bacteria to penetrate dentine discs. All were able to digest the layer, possibly stimulated by the nutrient-rich medium below the discs. The adaptation of root canal materials to canal walls has been studied. White et al. (1987) found that pHEMA, silicone and Roth 801 and AH26 sealers extended into tubules consistently when smear layer was removed. Gencoglu et al. (1993b) found removing the smear layer enhanced the adaptation of guttapercha in both cold laterally compacted and thermoplastic root llings without sealer. Gutmann (1993) also showed that after removing the smear layer, themoplastic gutta-percha adapted with or without sealer. A systematic review and meta-analysis by Shahravan et al. (2007) set out to determine whether smear layer removal reduced leakage of root lled teeth ex vivo. Using 26 eligible papers with 65 comparisons, 54% of the comparisons reported no signicant difference, 41% reported in favour of removing the smear layer and 5% reported a difference in favour of keeping it. They concluded that smear layer removal improved the uid-tight seal of the root canal system, whereas other factors such as lling technique or the type of sealer did not produce signicant effects. Urethane dimethacrylate (UDMA) based root canal sealers have been introduced. Their aim is to provide a better bond to allow less microleakage and increase the fracture resistance of root lled teeth through the creation of monoblocks, when a core material such as Resilon replaces gutta-percha. Whilst some studies indicate that smear layer removal leads to higher
tubule penetration, increased sealer to dentine bond strength and enhanced uid-tight seal, a recent report concluded that smear layer removal did not necessarily equate to improved resistance to bacterial penetration along these and older types of sealers (Saleh et al. 2008).
Methods to remove the smear layer Chemical removal

The quantity of smear layer removed by a material is related to its pH and the time of exposure (Morgan & Baumgartner 1997). A number of chemicals have been investigated as irrigants to remove the smear layer. According to Kaufman & Greenberg (1986), a working solution is the one which is used to clean the canal, and an irrigation solution the one which is essential to remove the debris and smear layer created by the instrumentation process. Chlorhexidine, whilst popular as an irrigant and having a long lasting antibacterial effect through adherence to dentine, does not dissolve organic material or remove the smear layer.
Sodium hypochlorite
The ability of NaOCl to dissolve organic tissues is wellknown (Rubin et al. 1979, Wayman et al. 1979, Goldman et al. 1982) and increases with rising temperature (Moorer & Wesselink 1982). However, its capacity to remove smear layer from the instrumented root canal walls has been found to be lacking. The conclusion reached by many authors is that the use of NaOCl during or after instrumentation produces supercially clean canal walls with the smear layer present (Baker et al. 1975, Goldman et al. 1981, Berg et al. 1986, Baumgartner & Mader 1987).
Chelating agents
Smear layer components include very small particles with a large surface : mass ratio, which makes them soluble in acids (Pashley 1992). The most common chelating solutions are based on EDTA which reacts with the calcium ions in dentine and forms soluble calcium chelates (Fig. 4). It has been reported that EDTA decalcied dentine to a depth of 2030 lm in 5 min (von der Fehr & Nygaard-Ostby 1963); however, Fraser (1974) stated that the chelating effect was almost negligible in the apical third of root canals.
Figure 4 Scanning electron micrograph of dentine following
60 s exposure to 18% ethylenediaminetetraacetic acid solution (Ultradent Products Inc., South Jordan, UT, USA).
Different formulations of EDTA have been used as root canal irrigants. In a combination, urea peroxide is added to encourage debris to oat out of the root canal (Stewart et al. 1969). This product (RC-Prep, Premier Dental Products, Plymouth Meeting, PA, USA) also includes a wax that left a residue on the root canal walls despite further instrumentation and irrigation and which may compromise the ability to obtain a hermetic seal (Biesterfeld & Taintor 1980). Many studies have shown that paste-type chelating agents, whilst having a lubricating effect, do not remove the smear layer effectively when compared to liquid EDTA. A recent experiment examining the addition of two surfactants to liquid EDTA did not result in better smear layer removal (Lui et al. 2007). A quaternary ammonium bromide (cetrimide) has been added to EDTA solutions to reduce surface tension and increase penetrability of the solution (von der Fehr & Nygaard-Ostby 1963). McComb & Smith (1975) reported that when this combination (REDTA) was used during instrumentation, there was no smear layer remaining except in the apical part of the canal. After using REDTA in vivo, it was shown that the root canal surfaces were uniformly occupied by patent dentinal tubules with very little supercial debris (McComb et al. 1976). When used during and after instrumentation, it was possible to still see remnants of odontoblastic processes within the tubules even though there was no smear layer present (Goldman et al. 1981). Goldberg & Abramovich (1977) observed that the circumpulpal surface had a smooth structure and that the dentinal tubules had a regular circular appearance with the use
of EDTAC (EDTA and cetavlon). The optimal working time of EDTAC was suggested to be 15 min in the root canal and no further chelating action could be expected after this (Goldberg & Spielberg 1982). This study also showed that REDTA was the most efcient irrigating solution for removing smear layer. In a study using a combination of 0.2% EDTA and a surface-active antibacterial solution, Brannstrom et al. (1980) ob served that this mixture removed most of the smear layer without opening many dentinal tubules or removing peritubular dentine. Bis-dequalinium-acetate (BDA), a dequalinium compound and an oxine derivative has been shown to remove the smear layer throughout the canal, even in the apical third (Kaufman et al. 1978, Kaufman 1981). BDA is well tolerated by periodontal tissues and has a low surface tension allowing good penetration. It is considered less toxic that NaOCl and can be used as a root canal dressing. A commercial form of BDA called Solvidont (De Trey, A.G., Zurich, Switzerland) was available in the 1980s and its use as an alternative to NaOCl was supported experimentally (Kaufman 1983a,b, Chandler & Lilley 1987, Lilley et al. 1988, Mohd Sulong 1989). Salvizol (Ravens Gmbh, Konstanz, Germany) is a commercial brand of 0.5% BDA and possesses the combined actions of chelation and organic debridement. Kaufman et al. (1978) reported that Salvizol had better cleaning properties than EDTAC. When comparing Salvizol with 5.25% NaOCl, both were found comparable in their ability to remove organic debris, but only Salvizol opened dentinal tubules (Kaufman & Greenberg 1986). Berg et al. (1986) found that Salvizol was less effective at opening dentinal tubules than REDTA. Calt & Serper (2000) compared the effects of ethylene glycol-bis (-aminoethyl ether)-N,N,N, N-tetraacetic acid (EGTA) with EDTA. The smear layer was completely removed by EDTA, but it caused erosion of the peritubular and intertubular dentine, whilst EGTA was not as effective in the apical third of root canals. EGTA is reported to bind calcium more specically (Schmid & Reilley 1957). Tetracylines (including tetracycline hydrochloride, minocycline and doxycycline) are antibiotics effective against a wide range of microorganisms. Tetracyclines have unique properties in addition to their antimicrobial aspect. They have low pH in concentrated solution, and because of this can act as a calcium chelator and cause enamel and root surface demineralization (Bjorvatn 1982). The surface demineralization of dentine is comparable with that of citric acid (Wikesjo et al. 1986). Barkhordar et al. (1997) reported that doxycy-
cline hydrochloride (100 mg mL-1) was effective in removing the smear layer from the surface of instrumented canals and root-end cavity preparations. They speculated that a reservoir of active antibacterial agents might remain, because doxycycline readily attaches to dentine and can be subsequently released (Baker et al. 1983, Wikesjo et al. 1986). Haznedaroglu & Ersev (2001) showed that 1% tetracycline hydrochloride or 50% citric acid can be used to remove the smear layer from surfaces of root canals. Although they reported no difference between the two groups, it appeared that the tetracycline demineralized less peritubular dentine than the citric acid. In an effort to produce an irrigant capable of both removing the smear layer and disinfecting the root canal system, Torabinejad et al. (2003) developed a new irrigating solution containing a mixture of a tetracycline isomer, an acid, and a detergent (MTAD). Their work concluded MTAD to be an effective solution for the removal of the smear layer. It does not signicantly change the structure of the dentinal tubules when the canals are irrigated with sodium hypochlorite and followed with a nal rinse of MTAD. This irrigant demineralizes dentine faster than 17% EDTA (De-Deus et al. 2007) and bacterial penetration into lled canals is similar with both solutions (Ghoddusi et al. 2007).
(1989) introduced 25% tannic acid solution as a root canal irrigant and cleanser. Canal walls irrigated with this solution appeared signicantly cleaner and smoother than walls treated with a combination of hydrogen peroxide and NaOCl, and the smear layer was removed. Sabbak & Hassanin (1998) refuted these ndings and explained that tannic acid increased the cross-linking of exposed collagen with the smear layer and within the matrix of the underlying dentine, therefore increasing organic cohesion to the tubules. McComb & Smith (1975) compared the efcacy of 20% polyacrylic acid with REDTA and found that it was no better than REDTA in removing or preventing the build up of smear layer, thought to be as a result of its higher viscosity. McComb et al. (1976) also used 5% and 10% polyacrylic acid as an irrigant and observed that it could remove smear layer in accessible regions. Polyacrylic acid (Durelon liquid and Fuji II liquid) at 40% has been reported to be very effective, and because of its potency users should not exceed a 30 s application (Berry et al. 1987).
Sodium hypochlorite and EDTA

When irrigating a root canal the purpose is twofold: to remove the organic component, the debris originating from pulp tissue and microorganisms, and the mostly inorganic component, the smear layer. As there is no single solution which has the ability to dissolve organic tissues and to demineralize the smear layer, the sequential use of organic and inorganic solvents has been recommended (Koskinen et al. 1980, Yamada et al. 1983, Baumgartner et al. 1984). Numerous authors have agreed that the removal of smear layer as well as soft tissue and debris can be achieved by the alternate use of EDTA and NaOCl (Yamada et al. 1983, White et al. 1984, Baumgartner & Mader 1987, Cengiz et al. 1990). Goldman et al. (1982) examined the effect of various combinations of EDTA and NaOCl, and the most effective nal rinse was 10 mL of 17% EDTA followed by 10 mL of 5.25% NaOCl, a nding conrmed by Yamada et al. (1983). Used in combination with EDTA, NaOCl is inactivated with the EDTA remaining functional for several minutes.
Organic acids
The effectiveness of citric acid as a root canal irrigant has been demonstrated (Loel 1975, Tidmarsh 1978) and conrmed to be more effective than NaOCl alone in removing the smear layer (Baumgartner et al. 1984). Citric acid removed smear layer better than polyacrylic acid, lactic acid and phosphoric acid but not EDTA (Meryon et al. 1987). Wayman et al. (1979) showed that canal walls treated with 10%, 25% and 50% citric acid solution were generally free of the smeared appearance, but they had the best results in removing smear layer with sequential use of 10% citric acid solution and 2.5% NaOCl solution, then again followed by a 10% solution of citric acid. However, Yamada et al. (1983) observed that the 25% citric acidNaOCl group was not as effective as a 17% EDTANaOCl combination. To its detriment, citric acid left precipitated crystals in the root canal which might be disadvantageous to the root canal lling. With 50% lactic acid, the canal walls were generally clean, but with openings of dentinal tubules that did not appear to be completely patent (Wayman et al. 1979). Bitter
Ultrasonic smear removal

Following the introduction of dental ultrasonic devices in the 1950s, ultrasound was investigated in endodontics (Martin et al. 1980, Cunningham & Martin 1982, Cunningham et al. 1982). A continuous ow of
NaOCl activated by an ultrasonic delivery system was used for the preparation and irrigation of canals. Smear-free canal surfaces were observed using this method (Cameron 1983, 1987a,b, Grifths & Stock 1986, Alacam 1987). Whilst concentrations of 24% sodium hypochlorite in combination with ultrasonic energy were able to remove smear layer, lower concentrations of the solutions were unsatisfactory (Cameron 1988). However, Ahmad et al. (1987a) claimed that their technique of modied ultrasonic instrumentation using 1% NaOCl removed the debris and smear layer more effectively than the technique recommended by Martin & Cunningham (1983). The apical region of the canals showed less debris and smear layer than the coronal aspects, depending on acoustic streaming, which was more intense in magnitude and velocity at the apical regions of the le. Cameron (1983) also compared the effect of different ultrasonic irrigation periods on removing smear layer and found that a 3- and 5-min irrigation produced smear-free canal walls, whilst an 1-min irrigation was ineffective. In contrast to these results, other investigators found ultrasonic preparation unable to remove smear layer (Cymerman et al. 1983, Baker et al. 1988, Goldberg et al. 1988). Researchers who found the cleaning effects of ultrasonics benecial used the technique only for the nal irrigation of root canal after completion of hand instrumentation (Ahmad et al. 1987a, Alacam 1987, Cameron 1988). This is given the term passive ultrasonic irrigation and has been the subject of a recent review (van der Sluis et al. 2007). Ahmad et al. (1987a,b) claimed that direct physical contact of the le with the canal walls throughout instrumentation reduced acoustic streaming. Acoustic streaming is maximized when the tips of the smaller instruments vibrate freely in a solution. Lumley et al. (1992) recommended that only size 15 les be used to maximize microstreaming for the removal of debris. Prati et al. (1994) also achieved smear layer removal with ultrasonics. Walker & del Rio (1989, 1991) showed no signicant difference between tap water and sodium hypochlorite when used with ultrasonics, but they reported that neither solution was effective at any level in the canal to remove the smear layer ultrasonically. Baumgartner & Cuenin (1992) also observed that ultrasonically energized NaOCl, even at full strength, did not remove the smear layer from root canal walls. Guerisoli et al. (2002) evaluated the use of ultrasonics to remove the smear layer and found it necessary to use 15% EDTAC with either distilled water
or 1% sodium hypochlorite to achieve the desired result.
Laser removal
Lasers can be used to vaporize tissues in the main canal, remove the smear layer and eliminate residual tissue in the apical portion of root canals (Takeda et al. 1998a,b, 1999). The effectiveness of lasers depends on many factors, including the power level, the duration of exposure, the absorption of light in the tissues, the geometry of the root canal and the tip-to-target distance (Dederich et al. 1984, Onal et al. 1993, Tewk et al. 1993, Moshonov et al. 1995). Dederich et al. (1984) and Tewk et al. (1993) used variants of the neodymiumyttrium-aluminium-garnet (Ne:YAG) laser and reported a range of ndings from no change or disruption of the smear layer to actual melting and recrystallization of the dentine. This pattern of dentine disruption was observed in other studies with various lasers, including the carbon dioxide laser (Onal et al. 1993), the argon uoride excimer laser (Stabholz et al. 1993), and the argon laser (Moshonov et al. 1995, Harashima et al. 1998). Takeda et al. (1998a,b, 1999) using the erbiumyttrium-aluminium-garnet (Er:YAG) laser, demonstrated optimal removal of the smear layer without melting, charring or recrystallization associated with other laser types. Kimura et al. (2002) also demonstrated the removal of the smear layer with an Er:YAG laser. Although they showed removal of the smear layer, photomicrographs showed destruction of peritubular dentine. The main difculty with laser removal of the smear layer is access to the small canal spaces with the relatively large probes that are available.
Conclusion
Contemporary methods of root canal instrumentation produce a layer of organic and inorganic material called the smear layer that may also contain bacteria and their by-products. This layer covers the instrumented walls and may prevent the penetration of intracanal medicaments into the dentinal tubules and interfere with the close adaptation of root lling materials to canal walls. The data presented indicate removal of the smear layer for more thorough disinfection of the root canal system and better adaptation of materials to the canal walls. There are, however, no clinical trials to demonstrate this. Current methods of smear layer removal include
chemical, ultrasonic and laser techniques none of which are totally effective throughout the length of all canals or are used universally. However, if the smear layer is to be removed the method of choice seems to be the alternate use of EDTA and sodium hypochlorite solutions. Whilst much is known about individual irrigants, their use in combination and their interactions (and in some cases precipitates) is less well understood. Conicting reports exist regarding the removal of the smear layer before lling root canals. As several new sealer and core materials have recently been introduced, further investigations are required to determine the role of the smear layer in the outcome of treatment.
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smear layer on root canal walls. Journal of Endodontics 24, 54851. Takeda FH, Harashima T, Kimura Y, Matsumoto K (1999) A comparative study of the removal of smear layer by three endodontic irrigants and two types of laser. International Endodontic Journal 32, 329. Taylor JK, Jeansonne BG, Lemon RR (1997) Coronal leakage: effects of smear layer, obturation technique, and sealer. Journal of Endodontics 23, 50812. Tewk HM, Pashley DH, Horner JA, Sharawy MM (1993) Structural and functional changes in root dentin following exposure to KTP/532 laser. Journal of Endodontics 19, 492 7. Tidmarsh BG (1978) Acid-cleansed and resin-sealed root canals. Journal of Endodontics 4, 11721. Tidswell HE, Saunders EM, Saunders WP (1994) Assessment of coronal leakage in teeth root lled with gutta-percha and a glass of ionomer root canal sealer. International Endodontic Journal 27, 20812. Timpawat S, Sripanaratanakul S (1998) Apical sealing ability of glass ionomer sealer with and without smear layer. Journal of Endodontics 24, 3435. Timpawat S, Vongsavan N, Messer HH (2001) Effect of removal of the smear layer on apical microleakage. Journal of Endodontics 27, 3513. Torabinejad M, Khademi AA, Babagoli J et al. (2003) A new solution for the removal of the smear layer. Journal of Endodontics 29, 1705. Vassiliadis L, Liolios E, Kouvas V, Economides N (1996) Effect of smear layer on coronal microleakage. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 82, 31520. Walker TL, del Rio CE (1989) Histological evaluation of ultrasonic and sonic instrumentation of curved root canals. Journal of Endodontics 15, 4959. Walker TL, del Rio CE (1991) Histological evaluation of ultrasonic debridement comparing sodium hypochlorite and water. Journal of Endodontics 17, 6671. Wayman BE, Kopp WM, Pinero GJ, Lazzari EP (1979) Citric and lactic acids as root canal irrigants in vitro. Journal of Endodontics 5, 25865. White RR, Goldman M, Lin PS (1984) The inuence of the smeared layer upon dentinal tubule penetration by plastic lling materials. Journal of Endodontics 10, 55862. White RR, Goldman M, Lin PS (1987) The inuence of the smeared layer upon dentinal tubule penetration by endodontic lling materials. Part II. Journal of Endodontics 13, 36974. Wikesjo UM, Baker PJ, Christersson LA et al. (1986) A biochemical approach to periodontal regeneration: tetracycline treatment conditions dentin surfaces. Journal of Periodontal Research 21, 3229. Williams S, Goldman M (1985) Penetrability of the smeared layer by a strain of Proteus vulgaris. Journal of Endodontics 11, 3858.
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Yamada RS, Armas A, Goldman M, Lin PS (1983) A scanning electron microscopic comparison of a high volume nal ush with several irrigating solutions: Part 3. Journal of Endodontics 9, 13742.
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doi:10.1111/j.1365-2591.2009.01620.x
Comparison of working length determination with radiographs and two electronic apex locators
J. P. Vieyra1, J. Acosta2 & J. M. Mondaca2

School of Dentistry, Universidad Autonoma de Baja California, Tijuana, Baja California, Mexico; and 2Private Practice in Endodontics, 71OE San Ysidro Blvd., 1513 San Ysidro, California 92173, USA
1
Abstract
Vieyra JP, Acosta J, Mondaca JM. Comparison of working
length determination with radiographs and two electronic apex locators. International Endodontic Journal, 43, 1620, 2010.
Aim To evaluate the accuracy of the Root ZX and Elements-Diagnostic electronic apex locators when compared with radiographs for locating the canal terminus or minor foramen. Methodology The canal terminus of 482 canals in 160 maxillary and mandibular teeth was located in vivo with both locators and radiographically. After extraction, the actual location of the minor foramen was determined visually and with magnication. A paired samples t-test, chi-square test and a repeated measure anova at the 0.05 level of signicance were used to determine differences between the groups. Results The Root ZX located the minor foramen correctly 68% of the time in anterior and premolar teeth, and 58% of the time in molar teeth. The Elements-Diagnostic located the minor foramen
correctly 58% of the time in anterior and premolar teeth and 49% of the time in molar teeth. Radiographs located the minor foramen correctly 20% of the time in anterior and premolar teeth and 11% of the time in molar teeth. There was no statistically signicant difference between the two locators, but there was a signicant difference between them and radiographs. For all teeth, the measurements made by the apex locators were within 0.5 mm of the minor foramen 100% of the time, whereas for the radiographs, the measurements were within this range only 15% of the time. This difference was signicant (P = 0.05). Conclusion Measuring the location of the minor foramen using the two apex locators was more accurate than radiographs and would reduce the risk of instrumenting and lling beyond the apical foramen. Keywords: apical constriction, electronic apex locator, elements-diagnostic, Root ZX, working length determination.
Received 20 November 2008; accepted 8 July 2009
Introduction
Root canal preparation and lling should not extend beyond the tooth root nor leave uninstrumented areas inside the root canal. Anatomically, the apical constriction (AC), also called the minor apical diameter or minor diameter (Kuttler 1955), is a logical location for working length (WL), as it often coincides with the narrowest diameter of the root canal (AAE 2003).
Correspondence: Dr Jorge Paredes Vieyra, PMB#1513, 710E, San Ysidro Blvd., Suite A, San Ysidro, CA 92173, USA (Tel.: +1 619 946 0459; fax: +1 664 687 2207; e-mail: jorgitoparedesvieyra@hotmail.com).
However, locating the AC clinically is problematic. Dummer et al. (1984) concluded that it is impossible to locate the minor foramen clinically with certainty because of its position and topography. The cementodentinal junction (CDJ) has also been suggested as the location for WL, because it represents the transition between pulpal and periodontal tissue (Grove 1931). The location of the CDJ is widely accepted as being 0.500.75 mm coronal to the apical foramen (Ricucci & Langeland 1998) but, as with the AC, the exact location of the CDJ is impossible to identify clinically. In general, the CDJ is considered to be co-located with the minor foramen (Stein et al. 1990); however, this is not always the case (Dummer et al. 1984).
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Vieyra et al. Working length determination
Working length is dened as the distance from a coronal reference point to the point at which canal preparation and lling should terminate (American Association of Endodontists (AAE) 2003). Radiographic determination of WL has limitations such as distortion, shortening and elongation, interpretation variability and lack of three-dimensional representation. Even when a paralleling technique is used, elongation of images has been found to be approximately 5% (Van de Voorde & Bjondahl 1969). A WL 1 mm short of the radiographic apex may result in over or under instrumentation because of the variability in distance between the terminus of the root canal (minor foramen) and the radiographic apex (Gutierrez & Aguayo 1995). Thus, this often used rule is not predictable or reliable. Custer (1918) was the rst to determine WL electronically. Suzuki (1942) investigated the electrical resistance properties of oral tissues and developed the rst electronic apex locator (EAL). The device was resistance-based and measured the resistance between two electrodes to determine the location of an instrument in the canal. Later devices were impedance-based (Nekoofar et al. 2006) and used multiple frequencies. More recently, resistance- and capacitance-based devices emerged that measure resistance and capacitance, directly and independently. The Root ZX (J. Morita Corp., Tokyo, Japan) uses the ratio method to locate the minor foramen (Kobayashi & Suda 1994) by the simultaneous measurement of impedance using two frequencies. The Root ZX claims to work in the presence of electrolytes and nonelectrolytes and requires no calibration (Kobayashi 1995). The Elements-Diagnostic (Sybron Endo, Sybron Dental, Orange, CA, USA) uses multiple frequencies, in an attempt to eliminate the inuence of canal conditions. In addition to improving WL accuracy (Nekoofar et al. 2006), EALs address concerns about radiation, as they have the potential to reduce the number of radiographs taken during root canal treatment (Pagavino et al. 1998). The purpose of this study was to evaluate in vivo the accuracy and predictability of two EALs for determining WL as compared with radiographs.
prosthodontic reasons. Ethical approval for the study and an informed consent to participate was signed by the patients. After local anaesthesia, rubber dam isolation and access cavity preparation were performed, the canals were ared coronally with size 1 and 2 Orice Shapers (Dentsply Tulsa Dental, Tulsa, OK, USA) using 3% sodium hypochlorite (NaOCl) for irrigation. The nal rinse was aspirated, but no attempt was made to dry the canals. The AC of each tooth was located with two EALs and radiographically. The minor foramen was located with the Root ZX by advancing a size15 stainless steel K-le in the canal, until the locator indicated that the minor foramen had been reached, according to the manufacturers instructions (J. Morita Corp. 2004). The LCD showed a ashing bar between APEX and 1 and a ashing tooth. The silicone stop on the le was positioned at the reference point. The le was removed from the canal and the length was measured to the nearest 0.01 mm with a digital caliper. This was the insertion length. The AC was located with the Elements-Diagnostic EAL by advancing the same size 15 K-le in the canal, until the locator indicated that the minor foramen had been reached, as per the manufacturers instructions (Sybron Endo 2003). The stop was positioned at the reference point and the insertion length measured. The sequence of testing alternated between the two locators. The minor foramen was located radiographically by advancing the size15 K-le, until its tip was 1.0 mm from the radiographic apex (determined from a pretreatment parallel technique radiograph). A radiograph was exposed and if the le tip was seen not to be 1.0 mm from the radiographic apex, the le was repositioned and another radiograph taken to ensure that it was. The distance from the stop to the tip was the insertion length. The le was then re-inserted to the insertion length (1 mm from the radiographic
Table 1 Distribution of 160 teeth (482 canals)

Number of canals Tooth (n) Maxillary 7 6 3 11 225 252 Mandibular 3 2 2 6 217 230
Materials and methods

One hundred and sixty teeth (482 canals) with fully formed apices and without apical resorption were used (Table 1). All teeth gave positive responses to hot and cold tests and were extracted for periodontal or
Central incisor (10) Lateral incisor (8) Canine (5) Premolar (17) Molar (120) Total (160)
17
Working length determination Vieyra et al.
apex) and cemented in place with Fuji II LC dual-cure glass ionomer cement (GC Corp, Tokyo, Japan). The le handle was sectioned with a high-speed bur and the tooth was extracted without disturbing the le, placed in 6% NaOCl for 15 min to clean the root surface and stored in a 0.2% thymol solution. All of the clinical procedures were conducted by the principal investigator. After the tooth was removed from the solution and with the le still in place, the apical 5 mm of the root was ground parallel to the long axis of the canal with a ne diamond bur and abrasive discs. When the le
Table 2 Distance of le tip from minor foramen determined by Root ZX, Elements and radiograph (anteriors)
Distance from minor foramen (mm) )1.0 )0.5 MF +0.5 +1.0 Root ZX n = 23 (%) 17 (73.9) 6 (26.08) Elements n = 23 (%) 15 (65.2) 8 (34.7) Radiograph n = 23 (%) 5 (21.7) 10 (43.47) 8 (34.78)
MF, minor foramen. (+) and ()) values indicate le tip beyond (+) or short ()) of the AC.
became visible, additional dentine was removed under 20 magnication (OPMI Pico microscope; Carl Zeiss, Munich, Germany) until the le tip, the canal terminus, and the foramen were in focus. A digital photograph was taken and stored in Adobe Photoshop 5.5 (Adobe Systems Inc., San Jose, CA, USA) and the distance of the le tip to the minor foramen was measured. This distance was recorded as being: )1.0 mm from the minor foramen; )0.5 mm from the minor foramen; at the minor foramen; +0.5 mm from the minor foramen or +1.0 mm from the minor foramen. A minus symbol ()) indicated a le short of the minor foramen; a plus symbol (+) indicated it was long. Once the actual length to the minor foramen was measured visually, the distance from the minor foramen determined by the two EALs was also completed ()1.0 mm from the minor foramen; )0.5 mm from the minor foramen, etc.), by comparing their insertion lengths to the actual length (distance to the AC) (Tables 24). The measurements obtained by the two EALs and radiographs relative to the actual location of the minor foramen were compared using a paired samples t-test, chi-square test and a repeated measure. anova evaluation was conducted at the 0.05 level of signicance.
Results
Table 3 Distance of le tip from minor foramen determined by
Root ZX, Elements and radiograph (premolars)

Distance from minor foramen (mm) )1.0 )0.5 MF +0.5 +1.0 Root ZX n = 17 (%) 9 (52.94) 8 (47.05) Elements n = 17 (%) 7 (41.17) 10 (58.82) Radiograph n = 17 (%) 6 (35.29) 5 (29.41) 6 (35.29)
For anterior teeth, the Root ZX, Elements and radiographs located the minor foramen 74%, 65% and 22% of the time, respectively. For premolar teeth, the Root ZX, Elements and radiographs located the minor foramen 53%, 41% and 35% of the time, respectively. For molar teeth, the Root ZX, Elements and radiographs located the minor foramen 58%, 49% and 11% of the time, respectively. There was no statistically signicant difference between the two EALs, but there was a difference when the EALs and radiographs were compared (Tables 24).
Table 4 Distance of le tip from minor foramen determined by Root ZX, Elements and radiograph (molars)
Root ZX (n = 444) Canal Distance from minor foramen (mm) )1.0 )0.5 MF +0.5 +1.0 MB 2 65 53 ML 3 61 45 D 58 27 DB 19 16 DL 19 16 Pa 38 22 Elements (n = 423) Canal MB 6 66 48 ML 5 59 41 D 18 54 15 DB 18 22 DL 19 21 Pa 8 2 21 Radiograph (n = 414) Canal MB 1 11 61 43 ML 8 41 34 D 2 12 47 26 DB 6 17 11 DL 5 17 12 Pa 1 5 28 26
18
Vieyra et al. Working length determination
For anterior, premolar and molar teeth, none of the measurements were 1.0 mm short of the minor foramen. For anterior and premolar teeth, none of the measurements were 0.5 mm short of the minor foramen, but for molar teeth 1%, 8% and 1% of the measurements using the Root ZX, Elements and radiographs, respectively, were short. For anterior teeth, the Root ZX, Elements and radiographs were 0.5 mm long of the minor foramen a 26%, 35% and 39% roots, respectively. For premolar teeth, the Root ZX, Elements and radiographs were 0.5 mm long of the minor foramen 47%, 59% and 29% roots, respectively, and for molar teeth it was 41%, 42% and 48%, respectively. No EAL measurements were 1.0 mm long of the minor foramen for anterior, premolar and molar teeth, but for radiographs it was 35% for anterior teeth, 35% for premolar teeth and 37% for molar teeth. There was no statistically signicant difference between the two EALs, but there was a signicant difference (P = 0.05) when the EALs and radiographs were compared.
similar to the present ndings. In general, this study also agrees with others (Usun et al. 2007, 2008) that EALs are more accurate than radiographs and greatly reduce the risk of instrumenting and lling short or beyond the canal terminus. As the minor foramen varies in location and anatomy (sharply dened, parallel, or missing) (Nekoofar et al. 2006), caution should be used to avoid over estimating WL. According to Gutierrez & Aguayo (1995), over-instrumentation of the root canal must be a common and unnoticed occurrence. An instrument passing through a necrotic pulp and through the foramen most likely carries bacteria and toxins into the apical tissues (Siqueira et al. 2002, Siqueira & Barnett 2004). An indication by an EAL of reaching the minor foramen or foramen is very helpful in avoiding mishaps. Indeed this study showed that WL obtained with radiographs was 1.0 mm long of the AC 37% of the time, but 0% for the two EALs. This high incidence of error is clinically important, because a WL 1.0 mm long would result in canals being instrumented beyond the foramen.
Discussion
The use of electronic devices to determine WL has gained in popularity. When using them, an important consideration is being aware of the possible sources of error such as metallic restorations, salivary contamination, dehydration, etc. However, as shown in this and other studies, the accuracy of EALs is superior to radiographs (Van de Voorde & Bjondahl 1969, Pratten & McDonald 1996, Venturi & Breschi 2007). One of the reasons why a radiographically determined WL lacks accuracy is that it is based on the radiographic apex rather than the canal terminus the minor foramen. WL is obtained with a radiograph by positioning the tip of a le a certain distance (usually 1.0 mm) from the radiographic apex. However, WL should be based on the location of the minor foramen rather than the apex, because the foramen frequently is not at the apex (Wrbas et al. 2007). In this study, radiographs correctly located the minor foramen 15% of the time, whereas for the Root ZX and Elements it was 63% and 53% of the time, respectively. Both EALs were within 0.5 mm from the minor foramen 100% of the time, whereas radiographs were within 0.5 mm of 63% of cases. An in vivo study by Shabahang et al. (1996) reported that the Root ZX was within 0.5 mm from the minor foramen 96% of the time, a value
Conclusion
Under clinical conditions, the EALs identied the minor foramen with high degree of accuracy. EALs were more accurate compared with radiographs with the potential to greatly reduce the risk of instrumenting and lling beyond the apical foramen.
Acknowledgements
We thank Dr E. Steve Senia and Dr Michael Hulsmann for their valuable assistance in reviewing this manuscript.
References
American Association of Endodontists (AAE) (2003) Glossary of Endodontic Terms, 7th edn. Chicago, IL: American Association of Endodontists. Custer LE (1918) Exact method of locating the apical foramen. Journal of the National Dental Association 5, 8159. Dummer PMH, McGinn JH, Rees DG (1984) The position and topography of the apical canal constriction and apical foramen. International Endodontic Journal 17, 1928. Grove CJ (1931) The value of the dentinocemental junction in pulp canal surgery. Journal of Dental Research 11, 4668. Gutierrez JH, Aguayo P (1995) Apical foraminal openings in Human teeth. Number and location. Oral Surgery, Oral
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Working length determination Vieyra et al.
Medicine, Oral Pathology, Oral Radiology, and Endodontics 79, 76977. J. Morita Corp. (2004) Fully Automatic Root Canal Measuring Device. Root ZX Operation. Tokyo: J. Morita Corp. Kobayashi C (1995) Electronic canal length measurement. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 79, 1779. Kobayashi C, Suda H (1994) New electronic canal measuring device based on the ratio method. Journal of Endodontics 20, 1114. Kuttler Y (1955) Microscopic investigation of root apexes. Journal of the American Dental Association 50, 54452. Nekoofar MN, Ghandi MM, Hayes SJ, Dummer PMH (2006) The fundamental operating principles of electronic root canal length measurement devices. International Endodontic Journal 39, 595609. Pagavino G, Pace R, Baccetti T (1998) An SEM study of in vivo accuracy of the Root ZX electronic apex locator. Journal of Endodontics 24, 43841. Pratten DH, McDonald NJ (1996) Comparison of radiographic and electronic working lengths. Journal of Endodontics 22, 1736. Ricucci D, Langeland K (1998) Apical limit of root canal instrumentation and obturation, part 2: a histological study. International Endodontic Journal 31, 394409. Shabahang S, Goon WWY, Gluskin AH (1996) An in vivo evaluation of Root ZX electronic apex locator. Journal of Endodontics 22, 6168. Siqueira JF, Barnett F (2004) Interappointment pain: mechanisms, diagnosis, and treatment. Endodontic Topics 7, 93109.
Siqueira JF Jr, Rocas IN, Favieri A, et al. (2002) Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. Journal of Endodontics 6, 45760. Stein TJ, Corcoran JF, Zillich RM (1990) The inuence of the major and minor foramen diameters on apical electronic probe measurements. Journal of Endodontics 16, 5202. Suzuki K (1942) Experimental study on iontophoresis. Journal of the Japanese Stomatology 16, 411. Sybron Endo (2003) Elements Diagnostic: Instruction Guidelines. Glendora, CA: Sybron Endo, pp. 13. Usun O, Topuz O, Tinaz AC, Sadik B (2007) Accuracy of the apex locating function of TCM Endo V in simulated conditions: a comparison study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 103, e736. Usun O, Topuz O, Tinaz C, Nekoofar MH, Dummer PMH (2008) Accuracy of two root canal length measurement devices integrated into rotary endodontic motors when removing gutta-percha from root-lled teeth. International Endodontic Journal 41, 72532. Van de Voorde HE, Bjondahl AM (1969) Estimating endodontic working length with paralleling radiographs. Oral Surgery, Oral Medicine, and Oral Pathology 27, 10610. Venturi M, Breschi L (2007) A comparison between two electronic apex locators: an ex vivo investigation. International Endodontic Journal 40, 36273. Wrbas KT, Ziegler AA, Altenburger MJ, Schirrmeister JF (2007) In vivo comparison of working length determination with two electronic apex locators. International Endodontic Journal 40, 1338.
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doi:10.1111/j.1365-2591.2009.01621.x
Evaluation of the radiopacity of calcium silicate cements containing different radiopaciers
J. Camilleri1,2 & M. G. Gandol3,4

Department of Building and Civil Engineering, Faculty for the Built Environment, University of Malta, Msida; 2Department of Dental Surgery, Faculty of Dental Surgery, University of Malta, Msida, Malta; 3Department of Earth Sciences, University of Bologna, Bologna; and 4Department of Odontostomatological Sciences-Endodontic Section, University of Bologna, Bologna, Italy
1
Abstract
Camilleri J, Gandol MG. Evaluation of the radiopacity of
calcium silicate cements containing different radiopaciers. International Endodontic Journal, 43, 2130, 2010.
Aim To identify the suitable ratio of alternative radiopaciers to impart the necessary radiopacity to calcium silicate cements (CSC) and assess the purity of the radiopacifying agents. Methodology Alternative radiopacifying materials for incorporation into CSC included barium sulphate, titanium oxide, zinc oxide, gold powder and silver/tin alloy. The chemical composition of the alternative radipacifying materials and bismuth oxide, which is used in mineral trioxide aggregate (MTA), was determined using energy dispersive X-ray analysis. In addition, using an aluminium step-wedge and densitometer, the radiopacity of each material was evaluated as recommended by international standards. The optical density was compared with the relevant thickness of aluminium (Al). A commercial MTA and CSC were used as controls. Statistical analysis comparing the radiodensity of the different cements to MTA was performed using anova with P = 0.05 and post hoc Tukey test.
Results All percentage replacements of bismuth oxide, gold and silvertin alloy powder, and the 25% and 30% replacements with barium sulphate and zinc oxide had radiopacities greater than 3 mm thickness of aluminium (Al) recommended by ISO 6876 (2002). The 25% replacement of cement with gold powder and 20% replacement of cement with silver/tin alloy powder exhibited radiopacity values of 8.04 mm Al and 7.52 mm Al, respectively, similar to MTA (P > 0.05). The cement replaced with 20% bismuth oxide showed a radiopacity of 6.83 mm Al, lower than MTA (P = 0.003). Conclusions Silver/tin alloy and gold powder imparted the necessary radiopacity to a calcium silicatebased cement. Barium sulphate was also a suitable radiopacier together with a lower concentration of silver/tin alloy and gold powder that achieved the radiodensity recommended by ISO 6876. Further research is required to investigate the broader properties of the calcium silicate-based cement with the different radiopaciers. Keywords: bismuth oxide, calcium silicate-based cement, chemical composition, mineral trioxide aggregate, radiopacity.
Received 20 April 2009; accepted 30 June 2009
Introduction
Calcium silicate-based cements [white Portland cement and mineral trioxide aggregate (MTA)] are hydraulic
Correspondence: Dr Josette Camilleri PhD, Department of Building and Civil Engineering, Faculty for the Built Environment, University of Malta, Msida MSD 2080, Malta (Tel.: 356 2340 2870; fax: 356 21330190; e-mail: josette.camilleri@um.edu.mt).
cements composed primarily of tricalcium silicate, dicalcium silicate and tricalcium aluminate (Taylor 1997, Camilleri et al. 2005, Camilleri 2008b). In dentistry, MTA is used amongst other things to seal lateral root perforations (Lee et al. 1993, Pitt Ford et al. 1995) and as a root-end lling material (Torabinejad et al. 1995a, 1997, Chong et al. 2003, Saunders 2008). Calcium silicate cements (CSC) without radiopacifying additives have intrinsic radiopacity values ranging from 0.86 to 2.02 mm aluminium (Al) (Islam
21
Radiopacity of calcium silicate cements Camilleri & Gandol
et al. 2006, Kim et al. 2008, Saliba et al. 2009), values lower than the 3 mm aluminium recommended by the International Standards for dental root canal sealing materials (ISO 6876 Section 7.8 2002). Thus, a radiopacifying material has to be added to calcium silicate-based cements to allow the cement to be detected radiographically and thus distinguished from surrounding anatomical structures (Beyer-Olsen & rstavik 1981). Mineral trioxide aggregate is said to be composed of a mixture of CSC and bismuth oxide in 4 : 1 ratio (Torabinejad & White 1995). Bismuth oxide is added to the MTA to increase the radiopacity of the material. MTA is commercially available as white and grey ProRoot MTA (Dentsply, Tulsa Dental Products, Tulsa, OK, USA) and white and grey MTA-Angelus (Angelus gicas, Londrina, Brazil). The addition Solucoes Odontolo of bismuth oxide increased the radiopacity of the material to higher levels than the equivalence of 3 mm Al suggested by ISO 6876 (2002). ProRoot was reported to have a radiopacity ranging from 5.34 mm Al to 6.92 mm Al (Laghios et al. 2000, Chng et al. 2005, Danesh et al. 2006, Islam et al. 2006, Kim et al. 2008). White ProRoot MTA showed higher radiopacity than the grey version (Chng et al. 2005, Islam et al. 2006, Tanomaru-Filho et al. 2008). MTAAngelus demonstrated a radiopacity of 33.3 mm Al (Tanomaru-Filho et al. 2008). Most of the materials used in endodontics have radiopacifying agents added to them such as barium or bismuth compounds. There have been few investigations on the effect that radiopaciers have on the properties of materials. The bismuth oxide added to white ProRoot MTA has been shown to affect its hydration mechanism. The bismuth formed part of the structure of calcium silicate hydrate, replacing the silica in its structure. Approximately 5% by weight of bismuth was attached to the calcium silicate hydrate structure. Bismuth oxide reduced the precipitation of calcium hydroxide in the hydrated paste (Camilleri 2007) and was also leached out from the material together with calcium hydroxide (Camilleri 2008b). It has been reported that bismuth is toxic (Bloodworth & Render 1992) and induces cell death (Camilleri et al. 2004). Other researchers demonstrated that CSC containing bismuth oxide induced cytotoxicity in dental pulp cells (Min et al. 2007). Conversely, most research performed on the biocompatibility of MTA has proved that this material is biocompatible and induces cell growth and activity. This may demonstrate that addition of bismuth oxide to CSC does not seem to
affect the biocompatibility of the material (Kim et al. 2008, Koulaouzidou et al. 2008). The use of bismuth oxide with CSC has been shown to be deleterious to the physical properties of the material, particularly the compressive strength in a concentration-related manner (Coomaraswamy et al. 2007). This is in accordance with other reports where Portland cement clinker was used (Camilleri 2008a) but in opposition to studies reporting no signicant difference in the strength of Portland cement with varying additions of bismuth oxide (Saliba et al. 2009). The difference in the results of the studies performed could be due to nonstandardization of testing when performing compressive strength tests (Camilleri et al. 2006). The bismuth oxide in MTA can be replaced by other radiopacifying materials. Ideally, an alternative radiopacier should only impart the necessary radiopacity to the cement and should be inert, free from any contaminants, colourless and nontoxic and be added in minimal amounts. Addition of minimal amounts of any material necessitates the use of elements that have a high relative atomic mass. A number of materials with high relative atomic masses are already used in dental practice. Such materials include zinc oxide, which is used in restorative dentistry, endodontics and periodontology as a base material, root canal sealer and as a dressing, respectively. Silvertin alloy is the alloy used in dental amalgam, gold is used in alloyed form in cast restorations, and titanium is used for the construction of endosseous implants. Barium sulphate is used extensively in the medicine as a radiopacier for colonoscopies. The extensive use of these materials in both medicine and dentistry indicates that the materials have been well researched and thus their interaction with the host tissues should be favourable. However, not all have been evaluated for implantation into deep sites. The addition of a radiopacier even in minimal amounts can affect the physical properties of the resultant material. The replacement of the cement with a noncementitious material affects the water to cement ratio (Neville 1981). In turn, variations to the water to cement ratio affects the workability and the strength of the resultant material. Other factors that affect the water required to achieve a workable mixture include particle size distribution and particle shape. This study aimed at identifying the suitable ratio of alternative radiopaciers for CSC and assessing the purity and physical properties of the radiopaciying agents.
22
Camilleri & Gandol Radiopacity of calcium silicate cements

The materials used in this study were white calcium silicate-based cement (Aalborg White, Aalborg, Denmark manufactured to BS EN 197-1: British Standard Institution 2000, type CEM I), and six radiopacifying materials, which included titanium dioxide (rutile; Sigma-Aldrich, Gillingham, UK), zinc oxide (Fischer Scientic, Leicester, UK), barium sulphate (SigmaAldrich), gold powder (Sigma-Aldrich), bismuth oxide (Fischer Scientic), and silver/tin alloy powder (Degussa Dental GmbH, Hanau, Germany). The radiopaciers and the cement were placed in plastic containers and were blended by placing the container on a rotary shaker for 15 min (Luckham 4RT, Burgess Hill, UK). White ProRoot MTA (Dentsply, Tulsa Dental Products) and white MTA-Angelus (Angelus Solucoes Odontolog icas) were used as controls and received no additional radiopacier.
Scanning electron microscopy and elemental analysis

Scanning electron microscopy of the radiopaciers was performed in order to determine the particle shape of the materials. A thin layer of powder was dispersed onto an aluminium stub (Agar Scientic, Stansted, UK) over double-sided carbon tape and then carbon coated (Agar Scientic) for electrical conductivity. The specimens were then observed by scanning electron microscope (SEM; Leo 1430, Philips, Cambridge, UK) and photomicrographs were recorded. Energy dispersive X-ray analysis (EDX) was performed to determine the constituent elements. Semi-quantitative analysis of cements and radiopaciers was performed using a cobalt standard. Two samples for each material were prepared and the analysis was performed twice for each sample.
Particle size distribution of powders

The particle size distribution of the radiopacifying materials was determined using a laser particle size analyser (CILAS 1180, Orleans, France) having a range of 0.042500 lm.
Evaluation of radiopacity
The radiopacifying materials were added to the calcium silicate-based cement by replacing 10%, 15%, 20%, 25% and 30% of the cement by weight. Calcium silicate-based cement without additive, ProRoot MTA
and MTA-Angelus were used as controls. The experimental protocol was based on ISO 6876 Section 7.8 (2002) for dental root canal sealing materials. The cement and the cement containing the radiopaciers were mixed with water, at a water to cement ratio of 0.30 measured by weight of materials. The MTAs were mixed according to the manufacturers instructions. The materials were compacted incrementally using hand pluggers into stainless steel ring moulds 10 mm in diameter and 1 mm high, and pressed against two glass cover slips to make the specimens 1 mm thick. Three specimens of each material were prepared. The cements were allowed to cure for 24 h at 37 C and 100% relative humidity covered by a plastic sheet to avoid cement desiccation. After removal from the moulds, they were stored in distilled water at 37 C for 7 days. The cements were placed directly on a cassette loaded with a cephalostat type lm with an intensifying screen (Kodak, Rochester, NY, USA) adjacent to a 10step aluminium step-wedge made of aluminium, where each step measured 1 mm in height (Agfa Mamoray, Agfa Gevaert, Mortsel, Belgium) and X-ray irradiated using a standard X-ray machine (GEC Medical Equipment Ltd., Middlesex, UK) at tube voltage of 50 kV, and current 50 mA and exposure time of 0.05 s. The target to lm distance was set at 100 cm. Three specimens per material under test were arranged on the cassette and two radiographs were taken of the specimens. Eight layers of lead foil covered a small area of each lm to obtain a small area of nonexposure. The radiographs were processed in an automatic processing machine (Clarimat 300, Gendex Dental Systems, Medivance Instruments Ltd., London, UK). A photographic densitometer (PTWdensix, Freiburg, Germany) was used to measure the density of the radiographic images of the specimens, of each aluminium step and the un-exposed part of the lm. Three density values of each material were obtained for each radiograph of each specimen and the mean density was calculated. The net radiographic density was calculated by subtracting the base and fog value from the gross radiographic density. The base and fog value is the inherent optical transmission density (lowest density) of a lm base plus the nonimage density contributed by the developed emulsion. Graphs were plotted for net radiographic density of the aluminium steps (NRDAL) versus the logarithm of the thickness of aluminium (log d) for each radiograph. From the resultant plots, the gradient and the intercept were calculated for each lm. Linear regression of the data was obtained using the following formula:
23
NRDAL m: log d I where NRDAL was the net radiographic density of the aluminium step wedge, m was the gradient, log d was the logarithm of the step height, I was the intercept. By rearranging the above equation into: log d I NRD m
performed. The KolmogorovZmirnov test revealed normal distribution and parametric statistics using anova with post hoc Tukey test was performed.
Results Scanning electron microscopy and elemental analysis

Scanning electron micrographs of the radiopacifying materials are shown in Fig. 1(af). Both zinc oxide and barium sulphate (Fig. 1b,c respectively) were composed of very ne particles that were difcult to discern by SEM even at a magnication of 2000. Thus, the magnication was increased until the individual particles could easily be identied on the micrographs. The bismuth oxide was composed of elongated needleshaped particles (Fig. 1e). The particle shape of gold (Fig. 1d) and titanium (Fig. 1a) were spherical and the silver/tin alloy was composed of lathe cut particles (Fig. 1f). The results of semi-quantitative analysis
The logarithm of the relevant thickness of aluminium for each material could be calculated from its net radiographic density for each lm taking into consideration that specimen thickness was 1 mm. Logarithms of step height were then converted to thicknesses of aluminium (Watts & McCabe 1999).
Statistical analysis
The data was evaluated using Statistical Package for the Social Sciences (SPSS) software (SPSS Inc., Chicago, IL, USA). The distribution was rst evaluated to determine what kind of statistical test would be
(a)
(b)
(c)
(d)
(e)
(f)
Figure 1 Scanning electron micrographs of (a) titanium oxide (b) zinc oxide (c) barium sulphate (d) gold powder (e) bismuth oxide (f) silver/tin alloy powder (2000 magnication). The micrographs for barium sulphate and zinc oxide were at higher magnications because of the small size of the powders.
24
(elemental analysis percentage) of the cements and radiopacifying materials are shown in Table 1, and the EDX spectra are shown in Fig. 2. The radiopacifying materials were mostly pure. The silver/tin alloy powder had an inclusion of approximately 4% copper. The calcium silicate-based cement and MTAs were composed of calcium, silicon and aluminium with MTAs including bismuth. The bismuth loading of MTAAngelus was lower than that of ProRoot MTA.
and zinc oxide had very ne particles. Most of the gold particles ranged between 2 and 4 lm. The silver/tin alloy powder and bismuth oxide had a wider range of particle sizes ranging from 0.1 to 53 lm for the silver/tin alloy and 5100 lm for the bismuth oxide with the bismuth oxide exhibiting the largest particle sizes compared with the other radiopacifying agents.
Evaluation of radiopacity Particle size distribution

The particle size distribution of the radiopacifying materials is shown in Fig. 3. The barium sulphate The radiopacity values of the materials tested are shown in Fig. 4. The calcium silicate-based cement exhibited a low intrinsic radiopacity value of
Table 1 Semi-quantitative analysis of powders using cobalt standard

Elemental analysis (%) Material Calcium silicate-based cement Titanium dioxide Zinc oxide Silver/tin alloy powder Barium sulphate Gold powder Bismuth oxide White MTA (Dentsply) White MTA (Angelus) Ag 0 0 0 66 0 0 0 0 0 Al 0.7 0 0 0 0 0 0 0.6 1.7 Au 0 0 0 0 0 100 0 0 0 Ba 0 0 0 0 7 0 0 0 0 Bi 0 0 0 0 0 0 62 8 5 Ca 19 0 0 0 0 0 0 29 32 Cu 0 0 0 4 0 0 0 0 0 O 40 77 22 0 90 0 12 45 42 S 0 0 0 0 3 0 0 0 0 Si 9 0 0 0 0 0 0 6 6 Sn 0 0 0 26 0 0 0 0 0 Ti 0 22 0 0 0 0 0 0 0 Zn 0 0 90 0 0 0 0 0 0
(a)
(b)
(c)
(d)
(e)
(f)
Figure 2 Elemental analysis of (a) titanium oxide (b) zinc oxide (c) barium sulphate (d) gold powder (e) bismuth oxide (f) silver/tin alloy powder.
25
100 90 80 70 Cumulative value % 60 50 40 30 20 10 0 Titanium oxide Zinc Oxide Barium sulphate Gold Bismuth oxide Silver/Tin
Diameter m
Figure 3 Particle size analysis of radiopacifying materials using laser particle size distribution.
Mean thickness of aluminium mm
0. 04 0. 1 0. 3 0. 5 0. 7 0. 9 1. 1 1. 3 1. 6 2 2. 4 3 5 6. 5 7. 5 8. 5 10 12 14 16 18 20 25 32 38 45 53 63 75 85 95 10 6 12 5 14 0 15 0
12.00 11.00 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 No addition Titanium Zinc oxide Barium Gold Bismuth Silver/tin MTA MTA-Angelus oxide sulphate powder oxide alloy Dentsply Addition of radiopacifier to calcium silicate-based cement % 10% 15% 20% 25% 30%
Figure 4 Radiopacity of cement with varying additions of radiopacifying materials expressed as mean thicknesses of aluminium SD (n = 2). The dotted line shows the minimum value for radiopaque restorative material.
1.62 0.29 mm Al. The bismuth oxide, gold and silver/tin alloy replaced cements at all the percentage replacements and 2530% cement replaced with barium sulphate and zinc oxide showed radiopacity values greater than 3 mm thickness of Al. Thus, these replaced cements complied with the recommendations by ISO 6876 Section 7.8 (2002). The radiopacity of calcium silicate-based cement, all additions of titanium oxide, the 10% and 15% replacement with barium sulphate and 10%, 15% and 20% replacement with zinc oxide demonstrated a radiopacity lower than 3 mm thickness of aluminium. MTA-Angelus had a lower radiopacity value than ProRoot MTA (P < 0.001). The MTA-Angelus displayed a similar radiopacity to CSC with 10% gold and silver/tin alloy, to 10% and 15% bismuth oxide
and 25% and similar to 30% barium sulphate and zinc oxide (P > 0.05). The 25% replacement of cement with gold powder and 20% replacement of cement with silver/tin alloy powder displayed radiopacity values of 8.04 0.67 mm Al and 7.52 0.20 mm Al, respectively, similar to ProRoot MTA (P > 0.05). The cement replaced with 20% bismuth oxide revealed a radiopacity of 6.83 0.48 mm Al. The radiopacity of this cement was lower than that of ProRoot MTA (P = 0.003).
Discussion
In the present study, the radiopacity of calcium silicatebased cement with varying additions of different radiopacifying materials was investigated. The different
26
radiopacifying materials were added by replacing the amount by weight in percentages varying from 10 30%. The materials used to render the cement radiopaque were powdered metals, metal oxides or salts. The materials used in this study had no major contaminants; thus, the radiopacity increase was due to the radiopacier itself and not caused by contamination. The lack of contaminants was checked on the material data sheets provided with the chemicals and veried by semi-quantitative analysis (EDX). The alternative radiopacifying materials replaced the cement portion by weight. This was carried out to standardize the amount of radiopacier added to the cement. The radiopacier materials used had different relative atomic masses which affected the amount of material added to make up the necessary weight of material used. The water to cement ratio was standardized and other properties affecting the physical properties of the resultant material were investigated. These included the particle shape and the particle size distribution. Addition of small-sized particles increases the specic surface area and would potentially make the mixture less workable if the water to cement ratio is kept constant. The effect that particle shape and particle size distribution of a cement-replacing material have on the physical properties of the resultant material are still to be investigated. The radiopaciers were chosen because of their easy availability and the long-term use in dental clinical practice. In dentistry, titanium is used in dental composites and porcelain to add whiteness and opacity; zinc oxide as a base materials under plastic restorative materials, as temporary restorative materials, as root canal sealers, as a dressing in periodontal surgery and is the main constituent compound in gutta-percha points; silver/tin alloy powder is the c phase of dental amalgam (Van Noort 2002). The alloy used in the present study was composed of lathe-cut particles. The amount of copper was lower than that anticipated for high copper silver/tin alloys; however, the tests carried out were semi-quantitative, and thus the precise amount of copper present could not be determined. Barium sulphate is a compound characterized by an extremely low solubility and is clinically used as a radio-contrast agent for X-ray imaging and other diagnostic procedures (Ott & Gelfand 1983) such as imaging of the gastrointestinal tract. It is also used in root canal lling materials. It has been reported that the addition of barium sulphate to glass ionomer cement at low concentrations reduced working and
initial setting times, but further addition delayed the setting reaction of glass ionomer cements. However, both compressive strength and surface hardness decreased with increasing concentrations of the radiopacier (Prentice et al. 2006). The effects of barium sulphate on the physicalchemical properties of Portland cement are yet to be investigated. In dentistry, bismuth oxide is used as a radiopacifying agent for dental material such as dental acrylic resin and MTAs. ProRoot MTA has a 20% loading of bismuth oxide as reported by the manufacturer. The amount present in MTA-Angelus is not specied by the manufacturer. The 20% loading for the ProRoot was veried by Rietveld X-ray diffraction analysis (Camilleri 2008b). Other researchers reported both higher (Song et al. 2006) and lower bismuth oxide loading for ProRoot MTA (Oliveira et al. 2007). The bismuth oxide loading of MTA-Angelus varied from 38.8% to 9% reported in different studies (Song et al. 2006, Oliveira et al. 2007, respectively). In the current study, EDX analysis was used to determine both the purity of the radopaciers and also the bismuth oxide loading of both ProRoot and MTA-Angelus. EDX provides only semi-quantitative analysis which would explain the lower level of bismuth oxide detected in ProRoot MTA when compared with other studies (Camilleri 2008b) and the data provided by the manufacturer. Bismuth oxide used in this study was composed of elongated needle-shaped crystals similar to that previously observed in ProRoot MTA (Camilleri et al. 2005, Camilleri 2007). In the present study, calcium silicate-based cement revealed an intrinsic radiopacity of 1.62 mm Al, in accordance with previous studies that reported radiopacity values equivalent to 0.95 mm Al (Islam et al. 2006), 2.02 mm Al (Saliba et al. 2009) and 0.86 mm Al (Kim et al. 2008). This intrinsic value does not satisfy the recommendation of the International Standards for dental root canal sealing materials (ISO 6876 Section 7.8 2002). Others have reported radiopacities equivalent to 3.32 mm Al (Danesh et al. 2006), which is higher than the recommended 3 mm Al. Thus, unmodied calcium silicate-based cement is not suitable as a root-end lling material or as a sealer as its presence will not be detected easily on a radiograph. In the present study, the cement with 20% replaced bismuth oxide revealed a radiographic density equivalent to 6.83 mm thickness of Al in accordance with previous studies that reported that the cement with 20% bismuth oxide showed a radiopacity of 6.81 mm Al (Kim et al. 2008) and 6.62 mm Al (Saliba et al.
27
2009). In the present study, the values reported for CSC replaced with 20% bismuth oxide were not similar to those obtained for ProRoot MTA (8.26 mm Al). The radiopacity of MTA-Angelus in the present study was similar to that reported by others (Tanomaru-Filho et al. 2008) who reported the radiopacity of MTAAngelus to be equivalent to 3 mm Al, which is lower than that reported for ProRoot MTA by other groups (Torabinejad et al. 1995b, Laghios et al. 2000, Chng et al. 2005, Danesh et al. 2006, Islam et al. 2006, Kim et al. 2008) and also in the present study. The variation in the results obtained in different studies is likely because of differences in the cements tested. Calcium silicate-based cement can be obtained from a wide range of manufacturers, and thus results cannot be compared. The full details of the types of materials used are not always reported nor are the water/cement ratios specied and other details that affect the material properties. Particle size and shape affect the water absorption of the material. Addition of radiopaciers composed of very ne particles causes an increase in water uptake of the material as the specic surface area is increased, and thus using the same water/powder ratio the consistency of the resultant mix can vary. Radiopaciers that do not absorb water cause a decrease in the water/cement ratio (Neville 1981). High water/cement ratios have been reported to cause a reduction in the radiopacity of the material (Coomaraswamy et al. 2008). Specimen size can also affect the resultant radiopacity of the material. ISO 6876 (2002) suggests the use of specimens 10 mm in diameter and 1 mm thick. Other researchers (Laghios et al. 2000) have used thicker specimens thus making comparisons between different studies difcult. Variations may also arise from differences in the techniques used to evaluate radiopacity. In the present study, a technique adopted by Watts & McCabe (1999) was used to convert the optical density to thickness of aluminium. The ISO 6876 (2002) does not give any details in this regard. Other researchers used linear regression (Laghios et al. 2000) or converted the radiographs to digital images (Kim et al. 2008) and measured the grey pixel value. In most publications, no details are given whether the base and fog values were reduced in optical density calculations, in fact, no technical detail is given on parameters used (Chng et al. 2005, Islam et al. 2006). The radiopacity values of a material are related to the relative atomic mass of constituent elements. The presence of elements with low relative atomic mass like titanium and zinc caused low radiopacity values
and increase in the percentage of the material added to the cement did not increase proportionally the radiopacity values of the cement. Materials containing elements with a high relative atomic mass like bismuth and gold exhibited high radiopacity values, which were proportional to the increase in the quantity of material added to the cement. Barium sulphate, although having a high atomic number, conferred low radiopacity values to the cement. This is due to low levels of barium element present in the material BaSO4, as conrmed by EDX analysis. Gold and silver/tin alloy could potentially be alternative radiopacifying materials for use with CSC. Cement replaced with 25% gold and 20% silver/tin alloy displayed radiopacity values comparable to ProRoot MTA but higher than MTA-Angelus. Thus, gold and silver/tin alloy powders can both be used to replace bismuth oxide in MTAs as these alternative materials impart the necessary radiopacity to the resultant cement. The use of gold powder could be prohibitive because of the high cost of the material. In addition, gold and silver/tin alloy impart a dark colour to the material and can thus cause tattooing of the adjacent tissues produced by corrosion products of silver from the silver/tin alloy. Barium sulphate and zinc oxide used in 2530% replacement and lower loadings of gold, silver/tin alloy and bismuth oxide exhibited similar radiopacity values to MTA-Angelus. Different radiopacier materials and lower loadings can be used in conjunction with CSC to achieve radiopacity values greater than 3 mm Al, which is the value recommended by ISO 6876 Section 7.8 (2002). Further research is required to establish the optimal loading and the effects that the radiopaciers have on the other properties and compatibilities of the calcium silicatebased cement.
Conclusions
Silver/tin alloy and gold powder impart the necessary radiopacity to calcium silicate-based cement. In addition, barium sulphate and zinc oxide represent suitable radiopaciers able to confer the radiodensity recommended by ISO 6876. Further research is required to investigate the properties of the calcium silicate-based cement with the different radiopaciers.
Acknowledgements
The University of Malta Research Fund Committee for funding; Mr J. Sand Damtoft of Aalborg Cement Denmark
28
for providing the cement. Mr L. Spiteri of Heritage Malta for his assistance with the electron microscopy; Mr R. Mallett of the Biomaterials Department at Kings College London Dental Institute at Guys, Kings and St Thomas Hospitals, London for his assistance with the particle size distribution; Mr E. Grupetta for access to equipment and Mr R. Spiteri and Ms G. Bonnici, radiographers at Mater Dei and St Lukes Hospitals Malta for their help with the radiography of the samples.
References
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doi:10.1111/j.1365-2591.2009.01625.x
The effect of sodium hypochlorite and ethylenediaminetetraacetic acid irrigation, individually and in alternation, on tooth surface strain
R. Rajasingham1, Y.-L. Ng1, J. C. Knowles2 & K. Gulabivala1

Unit of Endodontology, and 2Unit of Biomaterials Science, Divisions of Restorative Dental Sciences and Biomaterials Science and Tissue-Engineering, UCL Eastman Dental Institute, University College London, London, UK
1
Abstract
Rajasingham R, Ng Y.-L, Knowles JC, Gulabivala K. The
effect of sodium hypochlorite and ethylenediaminetetraacetic acid irrigation, individually and in alternation, on tooth surface strain. International Endodontic Journal, 43, 3140, 2010.
Aim To evaluate the effect of irrigation regimens on tooth surface strain using saline, sodium hypochlorite (3% and 5% NaOCl) and ethylenediaminetetraacetic acid (17% EDTA), individually and in alternating combinations. Methodology Single-rooted premolar teeth with single canals prepared to standardized dimensions were grouped by anatomical features and randomly distributed amongst six experimental groups (n = 12 each). The six groups were: (1) saline; (2) 5% NaOCl; (3) 3% NaOCl; (4) 17% EDTA; (5) 3% NaOCl and 17% EDTA; (6) 5% NaOCl and 17% EDTA. All groups underwent four (group 1) or ve (groups 2, 3, 4, 5, 6) sequential 30-min irrigation periods following each of which the tooth was subjected to a standard regime of cyclic, nondestructive, occlusal loading. Tooth surface strain was measured during each loading cycle using electrical strain gauges
mounted cervico-proximally. The data were analysed by Hierarchical anova and post hoc multiple comparisons. Results Irrigation with 5% NaOCl alone or alternating with 17% EDTA signicantly (P < 0.001) increased the peak strain values for each of the irrigation periods compared with that of saline (group 1). The data for the other groups revealed no signicant differences compared with those of saline. The strain increase after the fourth irrigation cycle was signicantly higher for group 6 than for group 2. The measured canal morphology and dentine thickness parameters did not prove to have a signicant effect on tooth surface strain. Conclusions Irrigation with 5% NaOCl acting alone or alternated with 17% EDTA (used in 30 min cycles), signicantly increased tooth surface strain. The alternated regimen showed signicantly greater changes in tooth surface strain than NaOCl alone. Irrigation with 3% NaOCl and 17% EDTA individually or in combination did not signicantly alter the tooth surface strain. Keywords: ethylenediaminetetraacetic acid, irrigation, sodium hypochlorite, tooth surface strain.
Received 28 January 2009; accepted 15 July 2009
Introduction
It is widely believed that root lled teeth are more susceptible to fracture than teeth with vital pulps (Rosen 1961, Johnson et al. 1976, Gher et al. 1987)
Correspondence: K. Gulabivala, Professor and Head of Endodontology, UCL Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, UK (Tel.: 020-7915-1033; fax: 0207915-2371; e-mail: k.gulabivala@eastman.ucl.ac.uk).
but conclusive evidence is lacking. Nevertheless, there is circumstantial evidence for putative causes of nonvital and root lled tooth fracture (Burke 1992). The main causes could be: loss of tooth tissue, altered physical properties of dentine, and altered proprioceptive/nociceptive properties (Gutmann 1992, Gulabivala 1995, Kinney et al. 2003). These factors probably interact cumulatively to inuence tooth loading, stress distribution and, ultimately result in catastrophic failure.
31
Effect of irrigants on tooth strain Rajasingham et al.
Tooth tissue loss reduces the force required to strain and ultimately fracture teeth in vitro. The pattern of tooth tissue loss inuences the magnitude of the induced strain (Mondelli et al. 1980, Larson et al. 1981, Panitvisai & Messer 1995, Lang et al. 2006); clinical studies conrm these observations (Cavel et al. 1985, Hansen et al. 1990). The relative importance of intact marginal ridge and the width/depth characteristics of cavities are under debate, but original tooth anatomy may also play a part (Khera et al. 1990). Endodontic access cavities potentially weaken teeth further (Reeh et al. 1989, Howe & McKendry 1990, Panitvisai & Messer 1995) as does wide preparation of canals (Hansen & Asmussen 1993, Lang et al. 2006). The properties of dentine have been investigated intensively and may be inuenced by many factors (Kinney et al. 2003, Kishen 2006). Factors investigated include: changes in moisture content (Helfer et al. 1972, Huang et al. 1992, Jameson et al. 1994, Papa et al. 1994, Kishen 2006), nature of collagen (Rivera et al. 1988) and standard laboratory physical properties (Lewinstein & Grajower 1981, Carter et al. 1983, Huang et al. 1992, Sedgley & Messer 1992). Unfortunately, the ndings have been contradictory or equivocal and no denitive proof of mechanical weakening of dentine exists, except for the inuence of water content. The fundamental problem is that all ex vivo tests are by denition on teeth without vital pulps and it is debatable whether teeth can become signicantly dehydrated in the mouth. Two studies (Loewenstein & Rathkamp 1955, Ran dow & Glantz 1986) suggest that pulp necrosis or loss compromises the tooths proprioceptive/nociceptive properties, predisposing to greater loading in function with consequent increased likelihood of fracture (Ran dow & Glantz 1986). In addition to these factors, there is increasing evidence that intracanal irrigants, medicaments and materials also inuence the physical and mechanical properties of dentine. The implicated materials include sodium hypochlorite (NaOCl) (Grigoratos et al. 2001, Sim et al. 2001, ODriscoll et al. 2002, Oyarzun et al. 2002, Slutzky-Goldberg et al. 2004), hydrogen peroxide (Chng et al. 2002), MTAD (Machnick et al. 2003), chloroform, xylene and halothane (Rotstein et al. 1999), calcium hydroxide (Grigoratos et al. 2001, Andreasen et al. 2002, Rosenberg et al. 2007) and eugenol (Biven et al. 1972). Sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA) are widely used during root canal treatment for established and sound biological reasons
(Bystrom & Sundqvist 1985). However, their potential inuence on the biomechanical properties of teeth and dentine has only recently gained signicant attention (Yamada et al. 1983, Dogan & Calt 2001, Grigoratos et al. 2001, Sim et al. 2001, Calt & Serper 2002). A laboratory study by Sim et al. (2001) found that irrigation with a 5.25% solution of NaOCl signicantly increased the tooth surface strain of dentine using cyclical nondestructive loading in a whole tooth model. The possible mechanisms involved in dentine weakening were shown to be due to the disintegration of the organic element, leaving the mineral component intact (ODriscoll et al. 2002). Sim et al. (2001) found that sequential, repeated 30-min irrigation steps with 5.25% NaOCl did not result in a linear increase in tooth surface strain but one that plateaued after the rst two steps. This may be because the mineral component of dentine is not depleted and consequently poses a barrier to further NaOCl penetration. It may be further hypothesized that the use of EDTA, an agent that chelates the calcium may deplete the inorganic component of dentine and expose more of the organic structure for further depletion. Therefore, alternate irrigation with NaOCl and EDTA (Yamada et al.1983, Marending et al. 2007) may eliminate the plateauing tendency evident when irrigating solely with NaOCl (Dogan & Calt 2001, Calt & Serper 2002, Yoshioka et al. 2002). The aims of this study were to evaluate the effect of irrigation on tooth surface strain when using saline, NaOCl (3%, 5%) and EDTA (17%) individually, and in alternate combination as follows; irrigation with NaOCl (either 3% or 5%) followed by EDTA (17%).
Materials and methods Preparation of teeth and allocation to experimental groups and anatomical sub-groups
Human extracted teeth were obtained with consent from patients undergoing routine extractions for orthodontic or restorative reasons. Seventy-two single-rooted premolars with single root canals, all of which were noncarious and crack-free (conrmed by transillumination under a microscope), were used after temporary storage in 4% formal-saline (Lam & Gulabivala 1996) immediately following extraction. Gross debris on the external surfaces of the teeth was removed with a sharp scalpel. The crowns of the teeth were removed 4 mm coronal to the cemento-enamel junction with a diamond bur in a high-speed hand-piece leaving a
32
Rajasingham et al. Effect of irrigants on tooth strain
attened surface that was perpendicular to the long axis of the tooth. The remaining enamel was removed with a high-speed hand-piece (Sim et al. 2001). The access cavity size and shape were dictated by the form of the pulp chamber and was not standardized. Access to the canals was standardized with Prole orice shapers (Maillefer Instruments, Ballaigues, Switzerland), the pulps were extirpated with a Hedstrom le (Kerr UK, Peterborough, UK) and the canals were prepared to a standard maximum apical size (30) and taper (0.06), where preoperative canal size allowed engagement of dentine; no attempt was made to gauge canal diameter and enlarge further by a standard number of instruments. Each canal was prepared to the apical foramen, the position of which was determined by the emergence of a size 10 le through it. A crowndown sequence of Prole nickeltitanium endodontic instruments (Maillefer Instruments) was used with saline as the irrigant. The teeth were maintained in a hydrated state within saline-soaked tissue paper during all procedures. Following canal preparation, the apices were sealed with two coats of nail varnish (Boots No.17 Clear Nail Varnish, Nottingham, England). Periapical radiographs in two planes (bucco-lingual and mesio-distal) were taken for all teeth. The width of the dentine at the cemento-enamel junction on the two radiographic views was measured with digital callipers and the average obtained. The teeth were grouped into like types by anatomical features; the main criterion was the apico-coronal position at which the root canal started to narrow as follows: (i) immature apex or no canal narrowing; (ii) coronal 1/3; (iii) middle 1/3; and (iv) apical 1/3. The middle and coronal groups were further partitioned by root length. This resulted in six anatomically distinct groups with 12 teeth in each
group; teeth from each anatomical group were randomly assigned amongst six experimental irrigation groups to give a sample size of 12 per group.
Mounting of teeth and bonding of strain gauges

Clear acrylic resin (Specix-20, Struers Epoxy resins; Struers A/S, Copenhagen, Denmark), mixed according to the manufacturers instructions was used to secure each tooth centrally within circular plastic moulds (2.5 cm high). The long axes of the teeth were strictly aligned parallel to the walls of the plastic moulds and 23 mm of the root was left exposed below the cemento-enamel junction, simulating the level of the alveolar bone. Constantan strain gauges (gauge factor = 2.05; Measurements Group UK Ltd, Basingstoke, UK) with short attached copper leads (resistance = 120 X; type EA-06-062AP-120, option LE) were used. The gauge polyimide backing was trimmed to an 1-mm border to enable easier positioning on the tooth (Fig. 1). The proximal bonding site on each tooth was prepared by rinsing with water, drying with air (3-in-1 syringe) and application of a thin layer of cyanoacrylate adhesive (M-Bond 200 Adhesive, Measurements Group UK Ltd). The gauge was positioned with the top edge of the backing 1 mm below the occlusal surface and vertically aligned along the long axis of the tooth, using an engineering T-square. Gentle but rm pressure was applied until the adhesive had set. The strain gauge and exposed wire leads were protected with M-Coat D airdrying acrylic varnish (Measurements Group UK Ltd). The teeth were wrapped in damp gauze and placed in a sealed polythene bag for storage until use. Every effort was made to prevent dehydration of the teeth during testing using damp gauze. Shortly before use, a length
Point at which load is applied Strain gauge Premolar with flattened coronal face
Instron grip
Figure 1 Experimental set-up of tooth,
acrylic holder and strain gauge.
33
of shielded twin cable (RS Components Ltd, Corby, UK) was soldered to the copper leads and the resistance of the gauge checked with an Ohm-meter to ensure absence of component burnt out.
Preparation of strain gauge circuit

The active strain gauge on the tooth was incorporated as one arm of a quarter bridge Wheatstone bridge circuit; two arms consisted of a precision wirewound 1 kX resistor (RS Components Ltd) and the fourth arm incorporated a dummy strain gauge bonded to a tooth for temperature compensation. A 100 kX precision wirewound resistor (RS Components Ltd) with a switch in parallel with the active gauge, served to calibrate the strain gauge circuit. Shielded cable was used to minimize electro-magnetic interference from proximal equipment. The excitation voltage to the Wheatstone bridge circuit was supplied by an RDP Transducer Indicator E308 (RDP Electronics Ltd, Wolverhampton, UK) and was set at 1.45V continuously for the duration of the experimental period. This also amplied and displayed the output voltage from the circuit and allowed zeroing prior to loading. The strain-induced voltage could then be measured relative to this baseline. The output from the Wheatstone bridge circuit was also logged via the transducer by a computer. The software used (Waveview for Dos 1.24; Eagle Appliances Pty Ltd, Brighton, UK) was set to sample the output at intervals of 0.1 s.
size 25 Flexo-le (Maillefer Instruments) for 10 s and leaving undisturbed for 50 s; (ii) irrigation with 0.5 mL over 20 s, followed by agitation for 10 s, and then leaving undisturbed for 90 s; (iii) cycle 2 was repeated 13 more times. At the end of this period, the canals were ushed with 9 mL saline over 3 min. In total therefore, each irrigation cycle consisted of 33 min (30 min test solution and 3 min saline).
Cyclic loading
Following each 30-min irrigation period, each tooth was subjected to a standard regime of cyclic nondestructive occlusal loading (Goldsmith et al. 2002). Tooth surface strain was measured during each loading cycle. To perform the loading, the acrylic block containing the test tooth was secured in a brass receptacle with four restraining screws. The receptacle was clamped via an attachment to the crosshead of a Universal loading machine (Instron Ltd, High Wycombe, UK). A ball bearing of 5.0 mm diameter xed to the end of the loading arm (with 1kN load cell) delivered the load accurately to the centre of the tooth access preparation along its long axis, by adjustment of the receptacle position. Once positioned, the tooth was not moved during the entire testing procedure; access for irrigation procedures being achieved by lowering the crosshead to leave 5 cm between the end of the loading arm and the tooth. Each loading cycle consisted of 3 stages: (1) Loading from 0 N to 20 N (the pre-load); (2) Five cycles of loading from 20 N up to 110 N and unloading down to 20 N at a crosshead speed of 0.7 mm/s (usually completed over 23 mins); and (3) Unloading from 20 N to 0 N. The pre-load was set at the start of each cycle through the Instron console, whilst the loading regime was controlled by the Instron Series XII software (Instron Ltd).
Preparation of experimental solutions

The physiologic saline was commercially obtained (Baxter Healthcare Ltd, Thetford, UK), whilst the 3% and 5% solutions of NaOCl were diluted from 12% NaOCl stock (BDH Laboratory Supplies, Poole, UK) and the concentrations veried by iodometric titration. A 17% solution of EDTA (BDH Laboratory Supplies) was obtained by adjusting the appropriate mass in water at pH 7.8. Freshly made solutions were stored in opaque bottles under controlled room temperature until use but never longer than 2 weeks.
Strain measurement
At completion of the rst irrigation cycle, the bridge was balanced to zero and output logging was commenced. After 1520 s, the calibration resistor was activated for 20 s and the zero dial adjusted to record a second baseline value before the loading procedure was commenced; the baselines facilitated later calculations. The data sampled from the output voltage were saved electronically at the end of the loading period. The irrigation and loading procedures were repeated four (Group 1) or ve (Groups 2, 3, 4, 5, 6) times for each
Irrigation regimen per experimental group

The teeth in groups 16 were exposed to four or ve sequential 30-min standardized irrigation cycles (Table 1). Each 30-min irrigation cycle consisted of delivering 10 mL of test solution as follows: (i) irrigation with 3 mL over 1 min followed by agitation with
34
tooth, generating four or ve data les per tooth. The entire experimental period was completed in a single sitting for each tooth. Five peak outputs were obtained from the recorded data for each loading period and a mean value calculated (peak strain value). The data were analysed using the STATA software programme (stata version 9 2005; STATA Corporation, College Station, USA). The change in the mean strain values of teeth following each irrigation period from the baseline were calculated for each experimental group and analysed using the hierarchical anova analysis followed by the Bonferroni analysis.
Results
The mean peak strain values of the teeth after each consecutive irrigation period are summarized by each experimental group in Table 1. In group 1 (negativecontrol saline), there was little change in these values following each consecutive irrigation period. In groups 2 (positive control 5% NaOCl) and 6 (5% NaOCl/17% EDTA), there was marked increase in strain values following the second and third irrigation periods, this increase plateaued at the fourth irrigation period for teeth without the alternate irrigation with 17% EDTA
Table 1 Mean peak strain values [microstrains (le)] and standard deviations (n = 12) for each group and irrigation cycle depicted by time and cycle number. The irrigant used at each 30 min cycle is also shown
(Group 2). In groups 3 (3% NaOCl) and 5 (3% NaOCl/ 17% EDTA), there was a proportionately smaller increase in the strain values following the second and the third irrigation periods, but again this increase plateaued for the teeth without the alternate irrigation with 17% EDTA (Group 3). In group 4 (17% EDTA), there was a continuous but small increase in the strain values following each irrigation period. For test groups 24, there was no signicant difference between the mean peak strain values obtained after the fourth (test solution) and fth (saline) irrigation cycles. In contrast, the difference was signicant (P = 0.002) for the teeth in group 6, although the magnitude was small (4.8 le; 95% CI 2.8 le, 6.7 le) (Table 1). Therefore the values obtained following the fth irrigation cycle were not considered when comparing the changes in mean peak strain. The difference in the mean peak strain values for teeth after each irrigation period and the baseline are plotted by each experimental group in Fig. 2. The differences in the changes in the mean peak strain values were found to be normally distributed. Hierarchical anova analysis showed that there was a signicant interaction between test groups and irrigation period (P < 0.001) with signicant differences between the test groups (P < 0.001). This indicated that the rates of change of
1 Baseline Time (min) Group 1 Irrigant Mean SD Group 2 Irrigant Mean SD Group 3 Irrigant Mean SD Group 4 Irrigant Mean SD Group 5 Irrigant Mean SD Group 6 Irrigant Mean SD 30
2 60
3 90
4 120
5 150
Saline 507.6 343.4 Saline 319.0 93.1 Saline 259.0 136. 8 Saline 229.3 140.3 Saline 370.0 233. 9 Saline 231.9 129.2
Saline 520 359.9 5%NaOCl 404.8 125.6 3%NaOCl 273.8 141.4 17%EDTA 234.7 138.6 3%NaOCl 386.3 234.9 5%NaOCl 317.3 176.5
Saline 510.5 337.8 5%NaOCl 450.6 144.9 3%NaOCl 294.2 142.2 17%EDTA 241.2 137.0 17%EDTA 396.3 235.5 17%EDTA 355.7 190.3
Saline 515.4 344.8 5%NaOCl 431.1 162.4 3%NaOCl 284.7 132.3 17%EDTA 245.6 135.8 3%NaOCl 409.3 235.9 5%NaOCl 434.5 246.9 Saline 427.6 162.5 Saline 273.1 137.5 Saline 247.2 136.4 Saline 409.0 238.8 Saline 439.3 247.7
35
Change in strain from first irrigation

300 250 200 Group 1 Group 2 Group 3 Group 4 Group 5 Group 6
Strain (units)
150 100 50 0 2 50 3 4 5
Figure 2 Graph depicting change in
Irrigation period
mean peak strain values (microstrains [le]) from baseline, with condence interval lines (colour coded); the obviously different groups are 2 and 6.
tooth surface strain between groups were signicantly different. In contrast, the irrigation cycle (P = 0.3), average dentine thickness (P = 0.8) and canal morphology (P = 0.5) had no signicant inuence on the changes in the strain values. Multiple comparisons between test groups for each period were subsequently carried out using the Bonferroni test. Following the second, third and fourth irrigation periods, the changes in mean peak strain values of teeth in groups 2 (5% NaOCl) and 6 (5% NaOCl/17% EDTA) were signicantly (P < 0.001) higher than those in group 1 (negative-control saline) and other experimental groups. There were no signicant differences (P = 1.0) in the changes between teeth in group 1 (saline) and those in groups 3 (3% NaOCl), 4 (17% EDTA) and 5 (3% NaOCl/17% EDTA). Following the second and third irrigation periods, the differences in the change of mean peak strain values between groups 2 and 6 (P = 1.0) and between groups 3 and 5 (P = 1.0) were not signicant. However, the change was signicantly (P = 0.02) higher in group 6 compared with group 2 following the fourth irrigation period.
Discussion
Previous work (Goldsmith et al. 2002, Sim et al. 2001) had suggested that root canal irrigation with sufciently concentrated NaOCl could alter tooth surface strain, potentially predisposing teeth to fracture. This effect was attributed to depletion of the organic content of the root canal surface dentine (ODriscoll et al. 2002). It has been suggested that alternation of irrigation with 17% EDTA could facilitate greater
bacterial load reduction (Bystrom & Sundqvist 1985), removal of the smear layer and bacterial biolm from noninstrumented surfaces (Gulabivala et al. 2005). The potential disadvantage of this combination may be that alternate depletion of organic and inorganic substrate may allow the tooth to be weakened further as demonstrated by an increase in tooth surface strain. To test this hypothesis, the previous work was repeated with a relevant study design and stringent attention to detail in order to overcome the data variation seen in the experiments of Goldsmith et al. (2002). The 72 teeth used in this study were single-rooted premolars with single root canals. The teeth were grouped anatomically according to the location of root canal narrowing and root length. Sim et al. (2001) had standardized their sample by using mandibular second premolars with single mature roots, whilst Goldsmith et al. (2002) used a mixture of single and two-rooted premolars with mature or immature apices. As would be expected, the latter study showed greater variability of the data. It is difcult to quantify tooth anatomy but the adopted method indirectly described the dentine distribution within the tooth. The potential confounding effect of tooth anatomy was reduced by stratied randomized allocation of teeth and accounted for in the hierarchical anova analysis by incorporating the average thickness of dentine at the cemento-enamel junction as well as canal morphology as co-variates. The remaining enamel from the coronal 4 mm of the prepared teeth was removed to show the effect of the irrigant on dentine, since it has been shown that the band of enamel around the cervical dentine has a signicant effect on tooth stiffness (Meredith 1992, Sim et al. 2001). Equally, this measure should be taken into
36
account when considering the clinical implications of the results. The root canals were prepared to a standardized taper to allow the irrigating needle to penetrate to a realistic depth towards the apices; the precise method of preparation was not considered important (Sim et al. balanced force with hand les; Goldsmith et al. Quantec 2000 instruments), as long as stresses were not induced in the residual dentine. A clear acrylic resin (epoxy) was used for mounting in this study because it showed minimal dimensional change after setting compared to self-curing acrylic resin used by Goldsmith et al. (2002). The single-element strain gauge used by Goldsmith et al. (2002) was again chosen for this study in contrast to the rosette gauge used by Sim et al. (2001) because the latter found that the main axial loading stress was compressive and was mainly recorded by the gauge element orientated in the longitudinal axis. The location of the single-element strain gauge was determined by the outcome of full eld stress pattern analysis (SPATE), which showed the chosen site to be a zone of stress concentration during loading of posterior teeth (Meredith 1992). Other studies also concur regarding the distribution of strains within loaded teeth (Asundi & Kishen 2000, Palamara et al. 2002). The choice of solutions and their concentrations were informed by clinical usage and prior work (Grigoratos et al. 2001, Sim et al. 2001, Goldsmith et al. 2002). A 9 mL saline nal ush immediately prior to occlusal loading, as per Sim et al. (2001) was repeated here because Goldsmiths work was suggestive of possible tooth dehydration during NaOCl irrigation. Figure 2 did not indicate signicant alteration due to the nal saline irrigation phase but minor uctuations during recording conrmed the probability of some minor individual tooth-related effect due to dehydration. The maximum load applied (110 N) and the rate of loading and unloading was the same as that used by Goldsmith et al. (2002). The actual time taken to complete a loading cycle differed between sample teeth (range: 2030 s) but remained constant for individual teeth at each of the ve loading periods. The range of 20 N to 110 N is within physiological limits for the human dentition (De Boever et al. 1978). Values of peak strain reported in this study were slightly higher than those found by Sim et al. (2001), but were of the same order of magnitude as those reported by Meredith (1992) and Goldsmith et al. (2002). The wide range of baseline strain values seen
in all experimental groups can be accounted for at least partly by the position of the loading arm on the attened surface of the resected crown. Once the tooth position was xed in the Universal loading machine, it remained constant throughout the test, allowing comparison between irrigation cycles and for each tooth to act as its own control. The magnitude of strain recorded at the cervical target site was dependent on loading position. Other factors expected to inuence strain might be tooth anatomy and dentine thickness. Although the precise thickness of coronal dentine was not measured after tooth preparation, one would expect higher strain values to be found in teeth with the thinnest walls (Goldsmith et al. 2002). In the present study, neither of the tooth anatomy parameters (average dentine thickness at the cemento-enamel junction and canal morphology) were found to have a signicant inuence on the change in tooth surface strain. This negative nding may be true or could possibly be attributed to the crude and possibly inaccurate estimate of dentine thickness obtained from radiographic images. It may also be hypothesized that whilst there may be straining of the dentine at the point of loading, the transmission of this strain through the entire thickness of dentine may be limited at certain surfaces (given the complex nature of resolution of tensile and compressive stresses and strains), resulting in absence of detection at the point of measurement (Lertichirakarn et al. 2003). The potential issue of recovery time between cycles was addressed by Sim et al. (2001) and data from this study conrmed that on the whole, the possibility of accumulative strain was not a problem. Occasional unexpected changes in strain in individual samples were attributed to micro-fractures propagating with each loading cycle or errors in strain gauge positioning. It was evident that the method was sufciently sensitive and transparent to detect such aberrant readings. The effect of 5% NaOCl irrigation had yielded contrasting results in the two previous reports (Sim et al. 2001, Goldsmith et al. 2002), the latter of which had considerable variation in their data. The present study clearly conrmed that the ndings of Sim et al. (2001) were reliable and that consistent patterns may only be revealed with precise attention to detail in the experimental set-up. The key steps of inuence were: (i) alignment of the strain gauges to the long axis of the tooth; (ii) attening of the occlusal surface of the tooth to allow true perpendicular loading; and (iii) mounting of the tooth in a resin with minimal dimensional changes. All 12 teeth showed an increase in peak strain
37
values after irrigation with 5% NaOCl followed in the majority by a plateauing of strain increase. Alternate irrigation with 5% NaOCl and 17% EDTA resulted in increases in tooth surface strain that were highly signicantly different from the saline control; the plateauing of strain increase (evident with irrigation with 5% NaOCl alone) was eliminated as predicted by the test hypothesis. The results therefore support the hypothesis that alternate irrigation with NaOCl (5%) and EDTA (17%) probably allows the alternate depletion of organic and inorganic material, with a greater accumulative depth of effect on dentine and therefore tooth surface strain. Teeth undergoing root canal treatment, already compromised by loss of tooth structure, particularly with breaks in the continuity of the band of circumferential enamel, could be further weakened by 5% NaOCl irrigation acting alone but particularly when alternated with 17% EDTA. The increase in strain, although signicant, does not yet indicate whether it is sufcient to result in increased risk of tooth fracture due to fatigue. It could be hypothesized that since such irrigation patterns produce surface aws in dentine (Calt & Serper 2002), cyclic loading at the normal stresses of mastication may allow fatigue crack growth to catastrophic proportions (Kinney et al. 2003, Kishen 2006). Irrigation with 3% NaOCl and 17% EDTA individually or in combination showed similar trends as for the higher concentration sodium hypochlorite solution (Fig. 2) but the difference was not signicant and the groups were comparable to the saline control. The negligible changes in strain from baseline values for all teeth irrigated with 17% EDTA alone implies the effect on inorganic component of dentine is conned enough to not affect tooth surface strain signicantly. Alternate irrigation with 3% NaOCl and 17% EDTA produced small but noticeable increases in strain values between the third (17% EDTA) and fourth (3% NaOCl) irrigation cycles in some teeth. The duration, concentration and irrigant combination appear to be critical as shown in other in vitro work (Marending et al. 2007). The slight reduction in peak strain values for some teeth, following the nal saline irrigation could be explained by rehydration of the dentine, as anticipated from Goldsmith et al. (2002). The irrigation regime as used during the cyclic nondestructive loading phase may not be directly comparable to the clinical practice of all practitioners; nevertheless it was well dened and provided key insight into the potential clinical effects. In the clinical scenario, the irrigant would have to contend with more
organic tissue in the root canal system and would therefore become spent more rapidly. In this study, pulpal tissue was removed during the canal preparation stage, prior to irrigation with NaOCl and EDTA. The intention was to test the worst case scenario to nd any differences, if they existed. Irrigation with 3% NaOCl on its own, despite showing some increase in strain values, was not signicantly different from irrigation with saline and may be a safer concentration to use. Its antimicrobial and tissue-dissolving properties should be adequate (Bystrom & Sundqvist 1985, Baumgartner & Cuenin 1992). It would be prudent to select a suitable lower concentration of NaOCl that would have minimal undesirable effects on the physical properties of dentine. Likewise, the use of EDTA on its own did not result in any signicant difference from irrigation with saline. The experiment provided no evidence for depletion of structural components that could induce alteration in the mechanical properties of the teeth.
Conclusions
This study showed that within the connes of its design, irrigation with 5% NaOCl alone but especially when alternated with 17% EDTA for sufcient duration may signicantly increase tooth surface strain.
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Carter JM, Sorensen SE, Johnson RR, Teitelbaum RL, Levine MS (1983) Punch shear testing of extracted vital and endodontically treated teeth. Journal of Biomechanics 16, 8418. Cavel WT, Kelsey WP, Blankenhall RJ (1985) An in vivo study of cuspal fracture. Journal of Prosthetic Dentistry 53, 3841. Chng HK, Palamara EA, Messer HH (2002) Effect of hydrogen peroxide on biomechanical properties of human dentine. Journal of Endodontics 28, 627. De Boever JA, McCall WD, Holdens S, Ash MM (1978) Functional occlusal forces : an investigation by telemetry. Journal of Prosthetic Dentistry 40, 32633. Dogan H, Calt S (2001) Effects of chelating agents and sodium hypochlorite on mineral content of root dentin. Journal of Endodontics 27, 57880. Gher ME, Dunlap RM, Anderson MH, Kuhl LV (1987) Clinical survey of fractured teeth. Journal of American Dental Association 114, 1747. Goldsmith M, Gulabivala K, Knowles J (2002) The effect of sodium hypochlorite irrigant concentration on tooth surface strain. Journal of Endodontics 28, 5759. Grigoratos D, Knowles J, Ng Y-L, Gulabivala K (2001) Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its exural strength and elastic modulus. International Endodontic Journal 34, 1139. Gulabivala K (1995) Chapter 15 Restoration of the root-lled tooth. In: Stock CJR, Gulabivala K, Walker RT, Goodman JR, eds. Color Atlas and Text of Endodontics, 2nd edn. London: Mosby-Wolfe, 24172. Gulabivala K, Patel B, Evans G, Ng Y-L (2005) Effects of mechanical and chemical procedures on root canal surfaces. Endodontic Topics 10, 10322. Gutmann JL (1992) The dentine-root complex: anatomic and biologic considerations in restoring endodontically treated teeth. Journal of Prosthetic Dentistry 67, 45867. Hansen EK, Asmussen E (1993) Cusp fracture of endodontically treated posterior teeth restored with amalgam Teeth restored in Denmark before 1975 versus after 1979. Acta Odontologica Scandinavica. 51, 737. Hansen EK, Asmussen E, Christiansen NC (1990) In vivo fractures of endodontically treated teeth restored with amalgam. Endondontics and Dental Traumatology 6, 4955. Helfer AR, Melnick S, Schilder H (1972) Determination of the moisture content of vital and pulpless teeth. Oral Surgery, Oral Medicine, Oral Pathology 34, 66170. Howe CA, McKendry DJ (1990) Effect of endodontic access preparation on resistance to crown-root fracture. Journal of the American Dental Association 121, 7125. Huang TG, Schilder H, Nathanson D (1992) Effects of moisture content and endodontic treatment on some mechanical properties of human dentine. Journal of Endodontics 18, 20915. Jameson MW, Tidmarsh BG, Hood JAA (1994) Effect of storage media on subsequent water loss and regain by human and bovine dentine and on mechanical properties of human dentine in vitro. Archives of Oral Biology 39, 75967.
Johnson JK, Schwartz NL, Blackwell RT (1976) Evaluation & restoration of endodontic treated posterior teeth. Journal of the American Dental Association 93, 597605. Khera SC, Carpenter CW, Vetter JD, Staley RN (1990) Anatomy of cusps of posterior teeth and their fracture potential. Journal of Prosthetic Dentistry 64, 13947. Kinney JH, Marshall SJ, Marshall GW (2003) The mechanical properties of human dentin: a critical review and reevaluation of the dental literature. Critical Reviews in Oral Biology & Medicine 14, 1329. Kishen A (2006) Mechanisms and risk factors for fracture predilection in endodontically treated teeth. Endodontic Topics 13, 5783. Lam MCJA, Gulabivala K (1996) Inuence of storage conditions of extracted teeth on dentine removal by a standardised method of ling. Endodontics and Dental Traumatology 12, 2532. Lang H, Korkmaz Y, Schneider K, Raab WHM (2006) Impact of endodontic treatments on the rigidity of the root. Journal of Dental Research 85, 3648. Larson TD, Douglas WH, Geistfeld RE (1981) Effect of prepared cavities on the strength of teeth. Operative Dentistry 6, 25. Lertichirakarn V, Palamara JEA, Messer HH (2003) Finite element analysis and strain-gauge studies of vertical root fracture. Journal of Endodontics 29, 52934. Lewinstein I, Grajower R (1981) Root dentine hardness of endodontically treated teeth. Journal of Endodontics 7, 4212. Loewenstein NR, Rathkamp R (1955) A study on the presso receptive sensibility of the tooth. Journal of Dental Research 34, 28794. Machnick TK, Torabinejad M, Munoz CA, Shabahang S (2003) Effect of MTAD on exural strength and modulus of elasticity of dentin. Journal of Endodontics 29, 74750. Marending M, Paque F, Fischer J, Zehnder M (2007) Impact of irrigant sequence on mechanical properties of human root dentin. Journal of Endodontics 33, 13258. Meredith N (1992) An in-vitro analysis of the stresses in natural and restored human teeth. PhD Thesis, University of London. Mondelli J, Steagall I, Ishikiriama A, Navarro MF, Soares FB (1980) Fracture strength of human teeth with cavity preparations. Journal of Prosthetic Dentistry 43, 41922. ODriscoll CO, Dowker S, Anderson P, Wilson R, Gulabivala K (2002) Effects of sodium hypochlorite solution on root dentine composition. Journal of Materials Science: Materials in Medicine 13, 21923. Oyarzun A, Cordero AM, Whittle M (2002) Immunohisto chemical evaluation of the effects of sodium hypochlorite on dentin collagen and glycosaminoglycans. Journal of Endodontics 28, 1526. Palamara JEA, Palamara D, Messer HH (2002) Strains in the mariginal ridge during occlusal loading. Australian Dental Journal 47, 21822. Panitvisai P, Messer HH (1995) Cuspal deection in molars in relation to endodontic and restorative procedures. Journal of Endodontics 21, 5761.
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Papa J, Cain C, Messer HH (1994) Moisture content of vital vs endodontically treated teeth. Endodontics and Dental Traumatology 10, 913. Randow K, Glantz PO (1986) On cantilever loading of vital and non-vital teeth An experimental clinical study. Acta Odontologica Scandinavica 44, 2717. Reeh ES, Messer HH, Douglas WH (1989) Reduction in tooth stiffness as a result of endodontic & restorative procedures. Journal of Endodontics 15, 5126. Rivera E, Yamaguchi G, Chandler G, Bergenholtz G (1988) Dentine collagen cross-links of root lled and normal teeth. Journal of Endodontics 14, 195. (Abstract 13). Rosen H (1961) Operative procedures on mutilated endodontically treated teeth. Journal of Prosthetic Dentistry 11, 97386. Rosenberg B, Murray PE, Namerow K (2007) The effect of calcium hydroxide root lling on dentin fracture strength. Dental Traumatology 23, 269. Rotstein I, Cohenca N, Teperovich E et al. (1999) Effect of chloroform, xylene, halothane on enamel and dentine
microhardness of human teeth. Oral Surgery, Oral Medicine, Oral Pathology 87, 3668. Sedgley CM, Messer HH (1992) Are endodontically treated teeth more brittle? Journal of Endodontics 18, 3325. Sim TP, Knowles J, Ng YL, Shelton J, Gulabivala K (2001) Effect of sodium hypochlorite irrigant concentration on strain in teeth. International Endodontic Journal 34, 120 32. Slutzky-Goldberg I, Maree M, Liberman R, Heling I (2004) Effect of sodium hypochlorite on dentin microhardness. Journal of Endodontics 30, 8802. Yamada RS, Armas A, Goldman M, Sun LinP (1983) A scanning electron microscopic comparison of high volume nal ush with several irrigating solutions: part 3. Journal of Endodontics 9, 13742. Yoshioka WN, Kobayashi C, Suda H (2002) A scanning electron microscopic study of dentinal erosion by nal irrigation with EDTA and NaOCl solutions. International Journal of Endodontics. 35, 9349.
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doi:10.1111/j.1365-2591.2009.01630.x
Effect of restorations on pulpal blood ow in molars measured by laser Doppler owmetry
N. P. Chandler1, T. R. Pitt Ford2 & B. D. Monteith1

Department of Oral Rehabilitation, School of Dentistry, University of Otago, Dunedin, New Zealand; and 2Department of Conservative Dentistry, Dental Institute, Kings College London, London, UK
1
Abstract
Chandler NP, Pitt Ford TR, Monteith BD. Effect of restorations on pulpal blood ow in molars measured by laser Doppler owmetry. International Endodontic Journal, 43, 4146, 2010.
Aim To: (i) compare laser Doppler pulpal blood ow (PBF) signals from restored and unrestored rst molar teeth, (ii) investigate PBF in teeth with large and small restorations, and (iii) to relate PBF to pulp chamber dimensions on radiographs. Methodology Bitewing radiographs of young adults with restored rst molars were obtained and pulp chamber dimensions measured. Subjects were divided into 2 groups: group A with a restored tooth and an unrestored contralateral (43 subjects) and group B, those with a molar with a small (usually occlusal) restoration whilst the contralateral tooth had an extensive occlusal restoration (or restorations) or restored proximal surface(s) and/or cuspal overlay (31 subjects). The 148 teeth responded to electric pulp
testing, and their PBF was recorded using a laser Doppler owmeter. Data were analysed using Students t-test. Results In group A the PBF in the restored teeth was signicantly lower than in unrestored contralaterals (P = 0.028) and the total pulp chamber area and that in the clinical crown were smaller (P = 0.039 and 0.021 respectively). The group B molars with large restorations had signicantly lower PBF than contralaterals with small restorations (P = 0.001), and their total pulp chamber area and pulp chamber width at cervix were reduced signicantly (P = 0.003 and 0.032 respectively). Conclusions In molars the size of the pulp chamber was inuenced by the presence of restorations and the PBF was reduced when restorations were present. Size and extent of restorations had a signicant effect on PBF. Keywords: bitewing radiographs, endodontics, laser Doppler owmetry, pulp vitality.
Received 20 August 2008; accepted 5 August 2009
Introduction
Conventional pulp sensitivity tests rely on an intact nerve supply and a patient response to a noxious stimulus. Problems of electric pulp testing restored posterior teeth include limited access to enamel and/or dentine and the leakage of current via metallic restorations or adjacent teeth (Pantera et al. 1992, Myers 1998). A test involving blood perfusion such as laser
Correspondence: Associate Professor Nicholas Chandler, Department of Oral Rehabilitation, School of Dentistry, University of Otago, P.O. Box 647, Dunedin 9054, New Zealand (Tel.: 0064 3 479 7124; fax: 0064 3 479 5079; e-mail: nick.chandler@dent.otago.ac.nz).
Doppler owmetry (LDF) eliminates the need for a patient response. LDF has been used to assess the pulp condition of anterior teeth, but few investigators have focused on posterior teeth or teeth with restorations. Whilst endodontic diagnosis involves integration of clinical and radiographic ndings, in a study of treatment need only one-third of molars with disease could be diagnosed from radiographs alone, compared with half of the incisors (Petersson et al. 1986). Improvements to pulp testing of posterior teeth are therefore important, especially when there is a risk of misdiagnosis and the economics of molar root canal treatment are considered. The aims of this study were to investigate pulpal blood ow (PBF) in rst molar teeth of subjects of
41
Blood ow in restored molars Chandler et al.
similar age, and to relate this to the restorations present and to pulp chamber dimensions on radiographs.
(a)

Ethical approval was granted by the Otago Ethics Committee. An examination of the bitewing radiographs of 275 dental students was carried out to screen for appropriate combinations of healthy and restored maxillary and mandibular rst molar teeth. The bitewings were available and none were taken for the study. The images were all taken with the same X-ray machine (Source 1, Belmont Co., Osaka, Japan: 70 kVp, 10 mA) using E speed lm (Kodak Co., Rochester, NY, USA) held in a Rinn bitewing holder/ beam alignment device (Dentsply Rinn, Weybridge, UK) and lm processing was automatic (All-Pro 2000M, Hicksville, NY, USA). Seventy-four individuals had radiographs which indicated suitable dentitions and they gave their written informed consent for investigation of PBF. The subjects were examined clinically. Their rst molars were caries and symptom-free and there was no history of operative dental work, orthodontics or trauma in the previous 6 months. Restorations were recorded and their radiographic appearances veried; none of the teeth had carious lesions. There were two groups: Group A. Unrestored teeth were compared with contralateral restored teeth (Fig. 1). The 43 subjects were 26 females and 17 males with a mean age of 22 years 0 months (range 19 years 0 month to 24 years 7 months). The teeth were 19 maxillary and 24 mandibular rst molars. Twenty-eight of the restored teeth had single or multiple occlusal restorations. Four teeth had both occlusal and buccal restorations. Eleven teeth had mesio-occlusal (MO) or disto-occlusal (DO) restorations, with two having a buccal extension or separate buccal restoration. Group B. Teeth with small and large restorations were compared (Fig. 2). Restoration size was related to the numbers of restored tooth surfaces, otherwise this judgement was more subjective. Many small restorations seen on radiographs during the screening process proved to be extensive when the subjects were examined clinically. Similarly, several very extensive composite resin overlays were found that were nearly invisible on the bitewings. The 31 subjects were 23 females and 8 males with a mean age of 21 years 4 months (range 19 years 10 months to 25 years 2 months). There were 16 maxillary and 15 mandibular rst molars. Two teeth had buccal
(b)
Figure 1 Group A; example of unrestored (a) and restored (b)
contralateral mandibular rst molar teeth.
restorations and two had occlusopalatal restorations. One tooth had an occlusobuccal restoration, and there were four teeth with small DO restorations. In the group of heavily restored contralateral teeth were six large or multiple occlusal restorations and 25 teeth with either an MO, a DO or a mesio-occlusal-distal restoration. One of these proximally restored teeth was overlaid and three of these teeth also had restored buccal surfaces. The teeth were tested with an electric pulp tester (Vitality Scanner Model 2001; Analytic Technology, Redmond, WA, USA) with the probe tip on the mesiobuccal cusp tip whenever possible (Lin et al. 2007). All the subjects gave unambiguous positive responses for both teeth under investigation; as dental students, they had a good understanding of electric testing and responses to the stimuli so further pulp tests were considered unnecessary. From the dental history, clinical examination and radiological evidence available all the pulps were considered healthy. A laser Doppler blood ow monitor (MBF3-D, Moor Instruments, Axminster, UK) was used to display and store
42
Chandler et al. Blood ow in restored molars
(a)
(b)
Figure 3 Pulpal blood ow trace as seen on owmeter screen.
Figure 2 Group B; example of contralateral mandibular rst
molar teeth with small (a) and large (b) restorations, in this patient gold inlays.
PBF signals from the teeth. The laser probe (Moor P5a, Axminster, UK) was positioned 2 mm from the gingival margin of the teeth (Roebuck et al. 2000) on the midbuccal surface using a splint made of a dark brown ` silicone putty (President, Coltene AG, Altsta tten, Switzerland). This stabilized the probe and excluded light. The same probe was used throughout the experiment and regularly recalibrated. For the small number of teeth featuring restorative material on the buccal surface a site to the mesial was adopted for both teeth in that individual. Two subjects had discrete opaque hypoplastic regions of buccal enamel which were also avoided. An accurate, clean hole was cut in the putty to support the probe using a 1.5 mm dermal biopsy punch (Miltex, Bethpage, NY, USA). The subjects lay supine for 10 min in a quiet, draft-free room and then a resting PBF trace was recorded at 20 Hz for 3 min for each tooth. All the teeth provided clearly pulsatile traces at heart beat frequency (Fig. 3). The mean ux (PBF, machine units) was calculated for each trace by the owmeters processor.
The radiographs were code numbered and scanned (DSR-1000 scanner; Electromedical Systems, Nyon, Switzerland) and pulp measurements were made on a desktop computer by a single operator using the Scion Image Program (Scion Corp., Frederick, MD, USA). A calibration radiograph of a measuring grid with 1 mm squares (PHIL-X Grid; Medidenta International, Woodside, NY, USA) was also made and scanned. Prior to measurement three pilot studies involving linear and area assessments of bitewings were performed. These revealed a high correlation of repeat measurements by the operator (r = 0.90, 0.92 and 0.92 respectively) with a regression slope not signicantly different to 1.0. For each tooth a line was drawn across the image between the mesial and distal enamel-cementum margins, the area above this being termed the clinical crown. Two areas were measured, the total pulp chamber area (above a line across the most superior part of the pulpal oor) and the pulp chamber area in the clinical crown. The pulp chamber width at the cervix and the heights of the mesial and distal pulp horns (from the enamel-cementum line) were also measured (Fig. 4). Following the PBF recordings the radiograph codes were broken and the data matched for each tooth. Statistical signicance was determined using Students t-test (2-tailed in related samples).
Results
Means and standard deviations of the pulp chamber measurements and PBF values are shown for group A in Table 1 and for group B in Table 2. In group A the presence of restorations was associated with a signicant reduction of total pulp chamber area, pulp chamber area in the clinical crown, mesial pulp horn height and PBF (P-values all <0.05,
43
tions in PBF, with this change more pronounced in the maxillary teeth (P-values 0.003 and 0.047).
Discussion
Previous blood ow studies have made use of radiographs when available (Odor et al. 1994a,b, Premdas & Pitt Ford 1995). Other workers have taken radiographs to determine that the pulp chamber of the tooth was visible and that the periapical condition was normal (Hartmann et al. 1996). The present study is unique in including radiographic measurements alongside PBF data. Radiographs had already been taken; ethical approval would not have been granted to take radiographs purely for the experiment. Digitization allowed accurate measuring of magnied images of the pulp spaces. The images and their measurements were not available to the clinical researcher when the PBF recordings were made. This was a deliberate aspect of the experimental design in order to avoid bias. Had radiographs been observed it might have been possible to direct the LDF probe towards a maximal region of pulp in an attempt to achieve stronger PBF signals. Undergraduate students provided a group with a narrow age range to reduce major variation due to dentine deposition (Woods et al. 1990) and the decrease in pulp chamber size (Ketterl 1983) and PBF (Ikawa et al. 2003), which accompany increasing age. A maximum of 6 months elapsed between taking radiographs and recording PBF, with most readings made within a few weeks. There are few LDF studies of molars, and no consensus on optimum probe positions. In studies of local anaesthesia on mandibular rst molars the probes were positioned on the mid-buccal surfaces of the teeth (Odor et al. 1994a,b). Laser owmetry studies of maxillary incisors reveals an increase in PBF signal as probes are moved from incisal to gingival (Ramsay et al. 1991, Ingolfsson et al. 1994, Hartmann et al. 1996). This could be due to a larger volume of tissue being sampled as the probe is
Table 1 Group A. Mean pulp dimensions and PBF for unrestored and restored rst molars (standard deviations in parentheses)
Figure 4 Diagram of measurements made from radiographs.
(1) Total pulp area (area above a line drawn across the most superior part of the pulpal oor). (2) Pulp area in the clinical crown (area above a line drawn between mesial and distal enamel-cementum junctions). (3) Pulp width at cervix (between mesial and distal enamel-cementum junctions). (4) Mesial horn height (above a line drawn between mesial and distal enamel-cementum junctions). (5) Distal horn height (above a line drawn between mesial and distal enamelcementum junctions).
Table 1). In group B the presence of large restorations was associated with a signicant reduction in total pulp chamber area, pulp chamber width at the cervix and PBF compared with teeth with smaller restorations (P-values all <0.05, Table 2). In group A the maxillary teeth revealed a signicant reduction in PBF (P = 0.008). In group B both the maxillary and mandibular teeth demonstrated reduc-
Unrestored (n = 43) Restored (n = 43) t-test P-value Total pulp area (mm2) Pulp area clinical crown (mm2) Pulp width at cervix (mm) Mesial horn height (mm) Distal horn height (mm) PBF (machine units) PBF, pulpal blood ow. *Signicant at the 0.05 level. 8.92 3.41 3.67 1.57 0.99 98 (2.59) (1.58) (0.71) (0.57) (0.47) (47) 8.32 2.89 3.40 1.34 0.90 83 (2.55) (1.66) (1.15) (0.58) (0.46) (46) 0.039* 0.021* 0.075 0.012* 0.200 0.028*
44
Chandler et al. Blood ow in restored molars
Table 2 Group B. Mean pulp dimensions and PBF for rst molars with small restorations and large restorations (standard deviations in parentheses)
Small restoration (n = 31) Total pulp area (mm2) Pulp area clinical crown (mm2) Pulp width at cervix (mm) Mesial horn height (mm) Distal horn height (mm) PBF (machine units) PBF, pulpal blood ow. *Signicant at the 0.05 level. 8.20 2.43 3.54 1.19 0.74 102 (2.47) (1.34) (1.02) (0.50) (0.40) (55)
Large restoration (n = 31) 7.20 2.09 3.19 1.08 0.63 73 (2.73) (1.43) (1.25) (0.60) (0.44) (44)
t-test P-value 0.003* 0.134 0.032* 0.218 0.162 0.001*
moved apically. No data on this effect in molar teeth have been published. It has been shown that light from an LDF probe placed 2 mm above the buccal enamel-cementum junction in molars is transmitted apically towards the radicular pulp (Odor et al. 1996). It should therefore be possible to use LDF to investigate the health of molar pulps which have diminished size or are situated unusually deeply. The pulp chamber width at the cervix of mandibular rst molar teeth is signicantly larger than for maxillary teeth (Chandler et al. 2003). A signicant decrease in pulp chamber width was found in group B, and this may have a role in the success of LDF if an optimal probe position cannot be achieved. A study of maxillary central incisors found PBF measurements made at various mesiodistal locations at the same level on the tooth did not differ (Ramsay et al. 1991). Forty teeth (38%) in the present study had proximal restorations. In a previous study, 26% of the teeth had proximal restorations (Chandler et al. 2003). In keeping with the present ndings, those restorations were also related to a signicant reduction in total pulp chamber area. The pulp chamber area in the clinical crown was also smaller amongst the restored teeth. Most investigations of the dimensions of opposite pairs of teeth have been done in man (Black 1980). The differences are small and probably because of complex genetic and environmental factors and known as uctuating asymmetry. Despite radiographic standardization, minor changes in lm position and beam geometry across the jaws are likely in the present study, together with anatomical variations such as tooth rotation. Fluctuating asymmetry of the pulp space has not been reported; the variations in PBF signals were in any event much larger. Data may have been recorded from the gingival crest (Vongsavan & Matthews 1996) and it is assumed this was comparable on both sides of the mouth. There appears to be no published data on differences in blood perfusion on
different sides of the jaws, or LDF studies which compare signal strengths between healthy maxillary and mandibular rst molars. In radiographic studies pulp horn location is more reliable in mandibular molars with bitewings, with the mesiolingual horn responsible for clarity of the image and longer than that of the mesiobuccal horn of maxillary teeth (Kandemir 1998, Chandler et al. 2003). The maxillary rst molar has the largest pulp chamber volume of human teeth, followed by the mandibular rst molar; in one study the difference was 23% (Fanibunda 1986). This difference in volume may account for the more noticeable reductions in PBF in maxillary molars in both groups in the present experiment.
Conclusion
In rst molars, the pulp chamber size was inuenced by the presence of restorations. PBF was reduced when restorations were present. The size and extent of the restorations had a signicant effect on the blood ow recordings.
References
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Ingolfsson AER, Tronstad L, Riva CE (1994) Reliability of laser Doppler owmetry in testing vitality of human teeth. Endodontics and Dental Traumatology 10, 1857. Kandemir S (1998) The radiographic determinability of the distance between the pulp horns in the permanent rst and second molar teeth. Journal of Oral Science 40, 1436. Ketterl W (1983) Age-induced changes in the teeth and their attachment apparatus. International Dental Journal 33, 262 71. Lin J, Chandler NP, Purton DG, Monteith B (2007) Appropriate electrode placement site for electric pulp testing rst molar teeth. Journal of Endodontics 33, 12968. Myers JW (1998) Demonstration of a possible source of error with an electric pulp tester. Journal of Endodontics 24, 199 200. Odor TM, Pitt Ford TR, McDonald F (1994a) Effect of inferior alveolar nerve block anaesthesia on the lower teeth. Endodontics and Dental Traumatology 10, 1448. Odor TM, Pitt Ford TR, McDonald F (1994b) Adrenaline in local anaesthesia: the effect of concentration on dental pulpal circulation and anaesthesia. Endodontics and Dental Traumatology 10, 16773. Odor TM, Watson TF, Pitt Ford TR, McDonald F (1996) Pattern of transmission of laser light in teeth. International Endodontic Journal 29, 22834.
Pantera EA, Anderson RW, Pantera CT (1992) Use of dental instruments for bridging during electric pulp testing. Journal of Endodontics 18, 378. Petersson K, Wennberg A, Olsson B (1986) Radiographic and clinical estimation of endodontic treatment need. Endodontics and Dental Traumatology 2, 624. Premdas CE, Pitt Ford TR (1995) Effect of palatal injections on pulpal blood ow in premolars. Endodontics and Dental Traumatology 11, 2748. Ramsay DS, Artun J, Martinen SS (1991) Reliability of pulpal blood-ow measurements utilizing laser Doppler owmetry. Journal of Dental Research 70, 142730. Roebuck EM, Evans DJP, Stirrups D, Strang R (2000) The effect of wavelength, bandwidth, and probe design and position on assessing the vitality of anterior teeth with laser Doppler owmetry. International Journal of Paediatric Dentistry 10, 213200. Vongsavan N, Matthews B (1996) Experiments in pigs on the sources of laser Doppler blood-ow signals recorded from teeth. Archives of Oral Biology 41, 97103. Woods MA, Robinson QC, Harris EF (1990) Age-progressive changes in pulp widths and root lengths during adulthood: a study of American blacks and whites. Gerodontology 9, 41 50.
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doi:10.1111/j.1365-2591.2009.01631.x
Analysis of resin tags formation in root canal dentine: a cross sectional study
Y. Malyk, C. Kaaden, R. Hickel & N. Ilie

Department of Restorative Dentistry and Periodontology, Ludwig-Maximilians University, Munich, Germany
Abstract
Malyk Y, Kaaden C, Hickel R, Ilie N. Analysis of resin tags
formation in root canal dentine: a cross sectional study. International Endodontic Journal, 43, 4756, 2010.
Aim To evaluate the length, density and quality of resin tags formed by penetration of various types of adhesive systems into dentinal tubules at various cross section levels of the root canal in correlation to the density of dentinal tubules. Methodology Thirty mandibular premolars were instrumented and bre posts were inserted with three different adhesive systems with and without activator: etch & rinse XP Bond and XP Bond/Self Cure Activator; self-etch (two-step) AdheSE and AdheSE/AdheSE DC Activator and self-etch (one-step) Hybrid Bond and Hybrid Bond/Hybrid Brushes. The resin tags were evaluated from slices obtained from sections perpendicular to the long axis of the teeth at 3, 6, and 9mm from the root apex under a Confocal Laser Scanning microscope.
Results In all groups, lack of continuity of resin tag length, density and quality was observed not only from the cervical to the apical region of each root canal, but also in a mesio-distal direction to the long axis of the root. Application of etch & rinse adhesive in contrast to the self-etch adhesives provided the formation of the shorter, but considerably denser, more homogeneous and not interrupted resin tags with similar length. Use of the activator for all types of adhesives signicantly increased the completeness (P=0.014) and continuity (P=0.024) of resin tags. Conclusions None of the investigated adhesives were able to completely inltrate the dentinal tubules in the entire root canal. Use of the etch & rinse adhesive system and the activators signicantly increased the density and the quality of resin tags. Keywords: adhesive systems, confocal laser scanning microscopy, resin tags, root canal dentine.
Received 3 February 2009; accepted 5 August 2009
Introduction
The bonding principle of dental adhesives is based on the formation of a hybrid layer (Nakabayashi et al. 1991) as well as the penetration of adhesive into dentine tubules and the formation of resin tags (Titley et al. 1995, Ferrari & Davidson 1996). Adaptation of adhesive systems for bre post bonding in root canal is an attractive clinical concept, but its implementation is
Correspondence: Yuriy Malyk, Department of Restorative Dentistry and Periodontology, Ludwig-Maximilians University, Goethe st. 70, 80336, Munich, Germany (Tel.: +498951609337; fax: +498951509302; e-mail: ymalyk@ dent.med-uni.muenchen.de).
controversial for several reasons: inuence of the endodontic procedure, polymerization shrinkage (Feilzer et al. 1993, Carvalho et al. 1996), unfavourable cavity conguration factor (C-Factor) (Carvalho et al. 1996, Tay et al. 2005), poor control of moisture (Bouillaguet et al. 2003) or polymerization difculties in the apical regions (Roberts et al. 2004). So far there are no conclusive and specic reports on the importance of the resin tags in the quality of the bond. While some authors measured a higher bond strength in the coronal section of the root canal because of the higher density of dentinal tubules and the longer resin tags formed in this area (Patierno et al. 1996, Kurtz et al. 2003, Mallmann et al. 2005), other authors found no correlation between bond strength
47
Analysis of resin tags Malyk et al.
and resin penetration into dentinal tubules (Tay & Pashley 2001, Kremeier et al. 2008). Duret et al. (1990) and Pegoretti et al. (2002) noted that the resultant homogeneous biomechanical unit allows a more uniform stress distribution, which better preserves the weakened tooth structure and reduces microleakage at the dentine-cement interface as well as reinfection of the peri-apical area (Bachicha et al. 1998, Reid et al. 2003). Currently, various types of adhesives systems that either follow an etch & rinse or self-etch approach, can be used to bond bre posts into root canals. Previous studies showed that self-etching primers are more advantageous for bonding of bre posts, since they contain a high concentration of acidic monomers that demineralize the substrate, that acid does not need to be removed with water, and the bond forms simultaneously to dentine (Yoshiyama et al. 1998, Tay et al. 2003). A recently published investigation showed that bond strength was not inuenced by the demineralization of root canal dentine neither with phosphoric acid nor with self-etching systems, but was affected by the luting agent and the region of the root canal (Bitter et al. 2006). As the number of tubules decreases from the crown to the apex (Carrigan et al. 1984), the response to acid etching and, consequently, dentine bonding can vary among different areas of the same root canal (Ferrari et al. 2000a). The application of adhesive systems in the root canal usually shows a non-uniform resin tag formation with consequent decrease of retention towards the apex (Ferrari & Mannocci 2000, Mannocci et al. 2004). Although bonding to the root dentine wall has made undeniable progress in recent years, the loss of adhesion at the adhesive/root dentine interface is still the main reason for leakage (Ferrari et al. 1994, Ferrari & Davidson 1996), decrease in bond strength (Bouillaguet et al. 2003, Bolhuis et al. 2005) and hence, failure of restorations (Ferrari et al. 2000b, Bouillaguet et al. 2003, Mannocci et al. 2003). To decrease these negative inuences, some manufactures recommend the use of an activator, which triggers the self-curing reaction of the adhesives, to produce an additional set that should improve the bonding to root canal walls. On the basis of this consideration the aim of this study was to analyze the resin tags formed by various types of adhesive systems in relation to the density of dentinal tubules in the cervical, middle and apical third of the root canal using Confocal Laser Scanning Microscopy (CLSM). Three types of adhesive systems were compared in this study: an etch & rinse, a self-etch two-step
and a self-etch one-step system each with and without addition of self-cure activators. Moreover, the density of dentinal tubules and the quality of resin tag formation were recorded. The null hypothesis tested was that both the type of adhesive system and the morphology of the dentinal tubules do not affect the formation of the resin tags.
Material and methods

Thirty extracted human mandibular premolars were used. The criteria for tooth selection were the presence of a single root canal, veried radiographically, along with a fully formed apex and no visible root caries or fractures, veried by examination with a 3.2 magnifying glass. Each root was separated from the crown with a lowspeed diamond saw (Isomet, Buehler, Lake Bluff, IL, USA) to obtain a 12mm long specimen. The root canals were shaped with K- and H-les (Dentsply Maillefer, Ballaigues, Switzerland) to size 50, 1mm short of the apex. After each instrument size, the canals were irrigated with 1mL of 1% sodium hypochlorite (NaOCl). The teeth were then randomly divided into six groups (n=5). The roots were enlarged with low-speed DT Drills sizes 03 designated for the respective post system (VDW, Munich, Germany). The depth of the post space preparation was 11mm. Irrigation was performed after change of each drill size with 1mL of 1% NaOCl. Afterwards, the root specimens were irrigated with 9% EDTA for 1min to remove the smear layer, and then rinsed for 1min with 0.9% NaCl. The bre posts DT Light size 3 (VDW) were shortened to a length of 15mm with water-cooled diamond rotary cutting instrument and inserted into the root specimens using six different adhesive systems. Inserted adhesive systems: XP Bond (Dentsply DeTrey, Konstanz, Germany), XP Bond/Self Cure Activator (SCA) (Dentsply DeTrey), AdheSE (Ivoclar Vivadent, Schaan, Lichtenstein), AdheSE/AdheSE DC Activator (Ivoclar Vivadent), Hybrid Bond (Sun Medical, Shiga, Japan) and Hybrid Bond/Hybrid Brushes (Sun Medical). The uorescent dye 0.1% Rhodamine B isothiacyanate (RITC) (Merck, Darmstadt, Germany) was mixed into the components of the adhesive systems, to highlight the resin tags under CLSM. The labelled adhesives were applied into the canal space using microbrush tips for the cervical and middle third of the canal and paper points for the apical third. The adhesive systems and application method in this study are summarized in Table 1. The dual-cured cement Calibra Esthetic Resin
48
Table 1 The adhesive systems and application method used in this investigation
Manufacture Dentsply DeTrey; Konstanz, Germany 0609001329 Total-etch Carboxylic acid modied dimethacrylate (TCB resin), PENTA, UDMA, TEGDMA, HEMA Lot No Adhesive type Bond Primer Activator Application
Group
Adhesive
XP Bond
XP Bond/ Self Cure Activator
Dentsply DeTrey; Konstanz, Germany
060516
Total-etch
Carboxylic acid modied dimethacrylate (TCB resin), PENTA, UDMA, TEGDMA, HEMA
UDMA, HEMA, catalyst, photoinitiator, acetone, water
AdheSE Primer/ AdheSE Bond K00997 Self-etch HEMA, dimethacrylate, silicon dioxide, initiators 4-methacryloxyethyltrimellitate anhydride 4-methacryloxyethyltrimellitate anhydride
Ivoclar Vivadent; Schaan, Lichtenstein
Primer: JO 6075 Bond: AK 03345
Self-etch
HEMA, dimethacrylate, silicon dioxide, initiators
Dimethacrylate, phosphonic acid acrylate, water
AdheSE/ AdheSE DC Activator LF-2 Self-etch one-bottle Self-etch one-bottle
Dimethacrylate, phosphonic acid acrylate, water
Initiators, solvents, ethanol
Hybrid Bond Sun Medical; Shiga, Japan LF-2
Ivoclar Vivadent; Schaan, Lichtenstein Sun Medical; Shiga, Japan
Hybrid Bond/Hybrid Brushes
Hybrid Brushes contain a bonding promoter
Total etch with 34% phosphoric acid for 15s Water spray, dry with air and paper points Bond apply Excess remove using paper points Light cure for 10s Total etch with 34% phosphoric acid for 15s Water spray, dry with air and paper points Bond mix with activator (1:1) and apply PRIMER apply for 30s Dry with air and paper points Bond apply Excess remove using paper points Light cure for 10s Primer apply for 30s Dry with air and paper points Bond mix with activator (1:1) and apply Bond apply for 20s Excess remove using paper points Light cure for 10s Bond mix with brush and apply for 20s Excess remove using paper points Light cure for 10s
Malyk et al. Analysis of resin tags
PENTA, Di-Pentaerytrithol-Penta-Acrylate-Monophosphate; UDMA, urethane dimethacrylate; TEGDMA, triethylene glycol dimethacrylate; HEMA, hydroxyethyl-methacrylat.
49
Cement (Dentsply DeTrey) was mixed for 20s and spread onto the surface of the bre post and into the root canal with a Lentulo Spiral, as recommended by manufacture. The posts were inserted into the root canal and manually held in place throughout the selfcure set time of 5min. After initial set, the light source (Freelight 2; 1241mWcm)2; 3M-ESPE, Seefeld, Germany) was placed on the post surface and the resin luting cement was polymerized for 20s. All procedures were performed by the same operator. After storing for 24h at 37C and 100% humidity the samples were sectioned in 1mm thin slices at 9mm (cervical), 6mm (middle) and 3mm (apical) from the root apex with a microtome saw (Leica SP 1600; Leica, Nussloch, Germany). The slices were then polished with a series of silicon carbide abrasive papers (1200, 2400 and 4000 grit) on an automatic polishing device (Exact 40 CS; Exact Apparatebau, Norderstedt, Germany). The samples were kept moist during the study.
CLSM examination
The density, length and quality of resin tags, as well as the density of dentinal tubules and the amount of noninltrated dentinal tubules were recorded in the cervical, middle and apical regions of the root canal using LSM-510 Meta microscope (Carl Zeiss, Jena, Germany) equipped with a water-immersion objective (Achroplan63/0.95W). Microscopy was performed at four standardized areas (buccal, lingual, mesial, and distal to the long axis of the root) of each root slice (Fig. 1). The visualized layer was selected 10lm below the slice
surface and was 15lm thick (15 images, distance between images was 1lm). The image size was 150150lm with resolution of 26562924 pixels. The image analysis and 3D reconstruction were carried out using LSM Image Browser 4.6 (Carl Zeiss). The slices were scanned with multitracking, allowing the simultaneous evaluation of labelled adhesive and the density of the dentinal tubules. To observe the RITC labelled adhesive, the 488nm laser line for excitation (beamsplitter: HFT 405/488) was used, thus allowing emitted uorescent light to pass through and hit the detector (lter: BP 530560nm). To identify the dentinal tubules, which were not inltrated by adhesive labelled with uorescent dye a second channel was added. The reection mode (excitation 488nm) was used with a special beam splitter (NT 80/20) and a long-pass lter with a detection window for the reected light (long pass 420nm). In reection, all dentinal tubules give a strong and clear signal because of a change in the optical medium between the dentine and the medium (distilled water). Counting of dentinal tubules was performed on images taken on an area 15100lm. The results were indicated as tubules/ mm2. Additionally, to determine the quality of resin penetration into the dentinal tubules, the three factors of completeness, continuity and evenness of resin tags were evaluated using the classication system with scores from 0 to 3 indicating best to worst quality. Completeness (homogeneity of adhesive penetration into dentinal tubules): 0=90100% of the dentinal tubules were homogenously lled with adhesive; 1=5090%; 2=1050%; 3=010%. Continuity (uninterruptedly of the resin tags): 0=90 100% of resin tags were not interrupted; 1=5090%; 2=1050%; 3=010%. Evenness (equability of the resin tags length): 0=90 100% of resin tags were of equal length; 1=5090%; 2=1050%; 3=010%. The general linear model procedure of sas/stat 9.2 Software (SAS Institute, Cary, NC, USA) was used to quantify the inuence of the adhesive and root canal region on the quality of the adhesive/root dentine interface (a=0.05). One- and multiple-way anova and Tukey post hoc tests for the morphology of dentinal tubules were used (a=0.05).
1 mm
Results
Figure 1 Preparation of cross sectional slice. Microscopy was
performed at four standardized areas (buccal, lingual, mesial, and distal to the long axis of the root) of each root slice.
The results obtained regarding density of resin tags, dentinal tubules and resin tags length are summarized
50
Table 2 Dentinal tubules density, resin tags length and amount of dentinal tubules not penetrated with adhesive components (mean+SD)
Adhesive Position systems 37985 (2608)
Number of dentinal Length of tubules resin tags (mm2) (lm) Length of resin tags (buccal, lm) Length of resin tags (lingual, lm) Length of resin tags (mesial, lm) Length of resin tags (distal, lm) Not inltrated dentinal tubules with adhesive (%) Not inltrated dentinal tubules with adhesive (buccal, %) Not inltrated dentinal tubules with adhesive (lingual, %)
Not inltrated dentinal tubules with adhesive (mesial, %) (3.5) (4.3) (1.6) (0.4) 7.4 0 9.2 2.1 0 1.8
Not inltrated dentinal tubules with adhesive (distal, %) 7.2 1.8 11.3 2.0 6.8 0 (2.5) (0.4) (10.8) (0.6) (0.4)
26.4 27.5 93.7 65.5 79.1 152.3 19.5 23.6 76.6 70.8 64.6 101.1 20.0 24.0 77.6 79.6 65.7 96.5 15.9 19.5 22.4 13.4 47.1 59.6 (3.1) (2.8) (14.2) (2.8) (7.0) (16.7) 17.0 19.6 18.1 14.4 45.4 59.1 (3.5) (12.0) (10.5) (3.1) (6.1) (13.9) 14.4 11.8 16.3 11.3 44.7 54.4 (4.7) (3.2) (12.9) (5.1) (9.1) (15.0) 13.8 12.2 16.1 12.2 42.7 55.7 (5.3) (3.0) (12.8) (2.6) (7.4) (16.9) 4.43 4.17 7.89 6.55 5.47 4.88 (2.1)b (3.2)a (3.2)c (3.1)a,b (3.1)a (2.6)a 3.4 0 5.8 2.2 1.7 0 (4.4) (3.8) (19.0) (14.2) (11.7) (35.4) 19.4 24.0 82.8 64.5 69.1 95.4 (4.2) (6.1) (22.9) (12.3) (14.6) (38.0) 18.4 18.2 69.1 61.8 61.4 84.0 (3.9) (4.0) (17.9) (13.2) (13.7) (29.2) 18.8 20.7 74.6 60.8 62.2 95.3 (3.8) (5.8) (26.8) (13.1) (10.9) (35.5) 5.66 2.88 5.74 5.36 3.66 1.02 5.0 0.8 3.8 3.2 1.7 0 16.1 18.9 19.19 13.8 46.2 58.2 (3.3)a (6.4)a (12.7)a (4.7)a (10.2)b (15.6)c (4.5)a (5.7)a (21.4)b (15.2)b (12.8)b (34.8)c (2.1)b (1.2)a (2.7)c (2.8)a,b (1.9)a (0.4)a (1.6) (0.4) (3.1) (1.6) (0.8) 4.3 1.7 4.2 3.4 0 0 (0.8) (0) (1.6) (1.7) (1.1) 3.2 0 5.4 2.2 1.9 2.1 (3.0) (0.8) (2.5) (2.4)
27.0 (5.3)a 28.1 (6.8)a 95.1 (26.2)c (11.2)b 66.1 78.2 (19.6)b,c 156.6 (29.2)d (7.5) 27.3 (6.4) 27.4 (20.0) 92.2 (11.0) 67.3 (20.8) 81.5 (24.8) 152.7 (5.9) 22.3 (6.5) 22.9 (30.0) 80.6 (11.0) 65.3 (18.0) 77.8 (21.5) 150.2 (5.9) 21.5 (4.2) 23.8 (38.8) 84.1 (10.2) 64.6 (16.6) 78.7 (27.1) 149.8 6.6 (2.7) 0 5.2 (3.9) 2.2 (1.1) 0 0 6.4 (2.2) 0 8.4 (4.6) 1.8 (0.7) 0 0
(3.9) 6.63 (2.8)b (7.3) 0.4 (0.2)a (36.0) 9.91 (4.8)c (12.2) 1.6 (0.7)a (18.2) 2.4 (0.7)a (26.1) 0.52 (0.2)a
31028 (3671)
7.7 4.8 6.2 10.2 5.3 3.3 (2.0) (0) (2.1) (1.8) (0.8) (1.1) 5.0 10.2 9.6 12.5 12.2 9.5
(2.0) (2.7) (1.7) (6.8) (2.4) (0.6) (1.2) (9.2) (6.7) (11.4) (8.8) (3.8)
8.8 4.0 15.0 3.8 4.9 0.9 6.2 5.4 14.4 12.4 9.8 9.0
(6.2) (2.9) (11.2) (1.6) (2.2) (0.4) (5.2) (3.2) (9.0) (10.2) (2.7) (6.6)
Cervival XP Bond XP Bond/SCA AdheSE AdheSE HB HB/Hybrid Brushes Middle XP Bond XP Bond/SCA AdheSE AdheSE HB HB/Hybrid Brushes Apical XP Bond XP Bond/SCA AdheSE AdheSE HB HB/Hybrid Brushes 26042 (2792)
Superscript letters indicate statistically homogeneous subgroups (a=0.05).
51
in Table 2. The typical bonding morphology between adhesive systems and root dentine is shown in Fig. 2. The dentinal tubule density varied depending on the region examined. In the cervical region the tubule density was signicantly higher (37985 per mm2) than those observed in the middle (31028 per mm2) and apical (about 26042 per mm2) thirds. Differences in dentinal tubule densities between the four standardized areas (buccal, lingual, mesial and distal) within one part of a root slice were not signicant. Signicant differences of the resin tag length were found between groups (P<0.001). In all groups also a discontinuity of resin tag length from cervical to apical region was observed. The resin tags formed by Hybrid Bond/Hybrid Brushes (Group 6) were found to be longer than in the other ve groups and consisted of 152.3lm for the cervical, 101.1lm for the middle and 58.2lm for the apical thirds. In contrast, the lengths of resin tags for XP Bond (Group 1) samples were the shortest and reached lengths of up to 26.4lm, 19.5lm and 16.1lm, accordingly. Bonferroni adjustment indicated signicant differences in the depth of adhesive penetration within the apical and middle regions of the root canal at four standardized areas (buccal, lingual, mesial and distal) (P<0.001). The adhesive penetration was deeper at buccal and lingual areas to the long axis of the root than at mesial and distal. None of the adhesive systems tested was able to inltrate and ow inside all the dentinal tubules along the entire root canal. An increase in non-inltrated dentinal tubules from cervical to apical region was observed for all groups (P<0.001). The lowest numbers of non-inltrated dentinal tubules were observed for XP Bond/SCA (Group 2), Hybrid Bond (Group 5) and Hybrid Bond/Hybrid Brushes (Group 6). Non-inltrated dentinal tubules were signicantly more frequently
(a) (b)
observed at the mesial and distal areas than at the buccal and lingual (P=0.04). The quality of resin penetration into the dentinal tubules was signicantly different between the study groups (Table 3). A signicant reduction in completeness, continuity and evenness of resin tags from the cervical to the apical region of the root canal for all adhesive systems tested was observed. The resin tags formed by XP Bond/SCA (Group 2) were more complete and even than those of other adhesives. In the cervical region the dentinal tubules were 100% homogenously lled with adhesive components, declining to 90% in the middle and 80% in the apical. The least homogenous adhesive penetration was observed for AdheSE (Group 3) and consisted 55%, 25% and 0%, accordingly. For all types of adhesive systems the use of an activator inuenced signicantly the completeness (P=0.014) and continuity (P=0.024) of resin tags, but not the evenness of resin tags.
Discussion
Good quality dentine bonding is obtained when a continuous hybrid layer forms with regular, dense resin tags (Mjor & Nordahl 1996, Mannocci et al. 1998). The current investigation compared resin tags length, quality and density created by various types of adhesive systems in relation to the density of dentinal tubules in root canals under CLSM. Because of the lack of information regarding the adhesive inltration in the apical part of the root canal (Tay et al. 2005) the bre post was inserted intentionally 1mm from the working length to examine the resin tags formation along the whole root canal wall. The null hypotheses tested in this study that the type of adhesive material and the morphology of the dentinal tubules will not affect the formation of the resin tags were both rejected.
(c)
Figure 2 CLSM images of the adhesive/root dentine interface under 63 magnications in reection and uorescence mode: RT resin tags, DT dentinal tubules, RD root dentine, RC resin composite. (a) Penetration of the adhesive system AdheSE/AdheSE DC Activator into the dentinal tubules in the cervical region of the root canal. The adhesive system labelled with RITC appears red in uorescent mode. (b) Dentinal tubules appear white in reection mode. (c) Adhesive/root dentine interface in uorescent and reection mode.
52
Table 3 Quality of adhesive penetration into the dentinal tubule (%). Completeness (I), continuity (II) and evenness (III) of resin tags were evaluated using the classication system with scores from 0 to 3 indicating best to worst quality
AdheSE/Activator III 0 40 60 0 0 50 55 5 0 0 90 10 I 80 20 0 0 80 15 5 0 65 15 20 0 II 70 30 0 0 30 65 5 0 50 30 20 0 III 5 90 5 0 80 15 5 0 65 25 10 0 Hybrid Bond/ hybrid brushes I 10 80 10 0 5 45 50 0 0 65 35 0 II 80 20 0 0 40 55 5 0 30 60 10 0 III 0 80 20 0 0 45 55 0 0 15 85 0
XP Bond Position Cervical Scale 0 1 2 3 0 1 2 3 0 1 2 3 I 40 50 10 0 25 65 10 0 5 45 40 10 II 80 10 10 0 70 20 10 0 20 55 20 5 III 75 25 0 0 60 30 10 0 70 15 10 5
XP Bond/SCA I 100 0 0 0 90 10 0 0 90 10 0 0 II 100 0 0 0 90 10 0 0 80 20 0 0 III 85 10 5 0 65 20 15 0 75 15 10 0
AdheSE I 55 40 5 0 25 30 30 15 0 50 40 10 II 35 60 5 0 5 30 50 15 0 15 70 15
Hybrid Bond I 5 65 30 0 0 30 70 0 0 20 75 5 II 5 80 15 0 0 70 30 0 0 55 40 5 III 0 45 55 0 0 30 70 0 0 5 90 5
Middle
Apical
The CLS microscopy offers multidimensional access to different structures of the same sample by staining them with different markers. In this study, a combination of the reection mode with uorescence markers allowed 3D-analysis of the adhesive resin penetration revealing the morphological structure (Fig. 2). For the visualization of detailed information of the penetration and distribution of resin tags several advantages of the confocal technique, compared with SEM imaging were reported (Bitter et al. 2009). There is no additional sample preparation necessary, which could cause shrinking, swelling or similar artefacts by drying or freezing the sample, as is essential for high resolution electron microscopy. The RITC used as a uorochrome marker in this study is effective in very low concentrations, soluble in water as well as in organic solutions such as dentine primers (Pioch et al. 1997), moves freely across the bonded interface, and is stable under various pH-levels (Sidhu & Watson 1998). In accordance with the ndings of Ferrari & Mannocci (2000) and Mjor et al. (2001) who observed signicantly higher density of dentinal tubules in the cervical third of the root canal than in the middle and apical thirds, the results of this study revealed decreases in the density of the dentinal tubules from 37985 per mm2 in the cervical region to 31028 per mm2 in the middle and 26042 per mm2 at the apex. Disparity of dentinal tubule density in four standardized areas (buccal, lingual, mesial and distal) within one slice of the root canal was not signicant. The length of resin tags in this study decreased from cervical to apical within the root canal. The type of adhesive system signicantly affected the resin tags
length (P<0.001). The self-etch adhesive Hybrid Bond/ Hybrid Brushes (one-step) created the deepest penetration into the dentinal tubules compared with the selfetch (two-step) and to etch & rinse adhesives. The deeper penetration of the self-cure adhesive might be explained not only by dentine conditioning, but also with material permeability and the conduct of the adhesive component. The morphological reasons that can impact on resin penetration in an apical direction are the diameter of the dentinal tubules, which are larger cervically than apically (Marion et al. 1991) as well as sclerotic processes, that hamper the access to the dentinal tubules (Mjor 1985, Wang & Weiner 1998). It should be highlighted that resin tag length was signicantly dependent not only on the root region observed, but also on the area of observation within one slice. Longer resin tag formation was observed at buccal and lingual areas to the long axis than at mesial and distal in the apical and middle regions of the root canal. It is because of more prominent intratubular calcications of the dentinal tubules in the mesial and distal root directions compared with buccal and lingual (Paque et al. 2006). The signicant difference in the density of the resin tags was highly dependent on the type of adhesive system used (P<0.001) and on the root region (P<0.001). Numerous resin tags might provide a more durable bond of the post to the root canal dentine (Bitter et al. 2004) and prevent leakage (Mannocci et al. 2001). Conditioning of the root canal dentine with phosphoric acid revealed considerably more resin tags than observed after the application of self-etching adhesives. Lowest numbers of inltrated dentinal
53
tubules for the self-etch (two-step) adhesive AdheSE, when compared with etch & rinse XP Bond adhesive were observed. The reason for this might be that the multiple-stage adhesive system was able to produce a more uniform and thick resin-dentine interdiffusion zone than the self-etching primer (Bitter et al. 2004). In the apical region, the amount of dentinal tubules that were not inltrated with adhesive was more frequent than in the cervical region. Just like resin tag length, non-inltrated dentinal tubules were more frequently observed at mesial and distal areas than at buccal and lingual. The completeness of resin inltration into dentinal tubules is responsible for the long-term monomer/ dentine strength and stability (Zicari et al. 2008). In this study, signicant differences were found in the qualitative evaluation of the resin tags by scores with reference to the root region, area of observation and adhesive type (Fig. 3). Despite the deepest penetrations of Hybrid Bond, the interaction of this adhesive system with the wall of dentinal tubule was irregular: the dentinal tubules were incompletely inltrated and often interrupted. Only 5% of the dentinal tubules were inltrated completely when using Hybrid Bond in the cervical region, declining to none in the apical region. The worst completeness and continuity of the resin tags with various lengths was recorded in the specimens in which self-etch adhesive AdheSE was applied. The self-etch (two-step) adhesive AdheSE Primer is characterized by less acidity (pH=1.7), compared with the self-etch (one-step) Hybrid Bond (pH=1.0). Therefore, the acidic monomers of the self-etch AdheSE Primer may not solubilize enough mineral to achieve homogenous resin penetration. In addition, the mineral components from the smear layer may neutralize the
acidity of these self-etch systems (Tay & Pashley 2001). Non and/or insufciently resin inltrated dentinal tubules may cause the passage of uids whereas homogenous resin tags might be responsible for a tight seal. Application of the conventional adhesive XP Bond/SCA after dentine etching provided mainly formation of homogeneous and complete tags of similar length. This was probably caused by the etching effect that dissolved the smear layer, thus allowing better access and complete lling of dentinal tubule by the monomers of the etch & rinse adhesive. Use of the activator for all types of adhesives signicantly increased the completeness and continuity of resin tags (P=0.014). A better quality of resin penetration was observed at buccal and lingual areas to the long root axis than at mesial and distal. It has to be considered that bonding to root canal dentine might be hampered by a lack of direct vision and luting agent application techniques (DArcangelo et al. 2008). In this study, poorer tag formation in the apical third might be due to the fact that conditioning with a microbrush would be better in the cervical region whereas in the apical third the contact and uid exchange with paper cones might be reduced, resulting in resin penetration less deeply into the tubules. These ndings agree with the results of Ferrari et al. (2002), who reported that the microbrush promoted a higher number of resin tags.
Conclusion
The application of the etch & rinse adhesive system resulted in shorter, but more dense and more complete resin tags compared with the two- or one-step self-etch adhesives. There was a signicant difference in resin
(a)
(b)
(c)
Figure 3 CLSM images of the resin tags formed by various types of adhesive systems in root canal under 63magnication in
uorescence mode: RT resin tags, RD root dentine, HL hybrid layer, RC resin composite. (a) Penetration of the adhesive system Hybrid Bond into the dentinal tubules in the cervical region of the root canal. The resin tags are not homogenously, often interrupted and not of equal length. (b) Penetration of the adhesive system AdheSE into the dentinal tubules in the middle region of the root canal. The resin tags have an equal length, are continuous but not homogenous. (c) Penetration of the adhesive system XP Bond into the dentinal tubules in the apical region of the root canal. The resin tags are not completeness but equal length.
54
tags formation not only among different regions of the root canal (cervical, middle and apical), but also in the direction of dentinal tubules (buccal, lingual, mesial and distal to the long axis of the root). Use of the activator for all types of adhesive systems signicantly increased density and quality of resin tags. The clinical importance of the length of resin tags and/or their quality in relation to bonding should be further investigated.
Acknowledgements
The authors would like to thank Prof. Matthias Folwazcny for permitting the use of the CLS microscope, Dr. Jan-Erik Heil for CLSM technical support and Dr. Alexander Crispin from IBE for statistical analysis.
References
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doi:10.1111/j.1365-2591.2009.01637.x
Haemostatic effect and tissue reactions of methods and agents used for haemorrhage control in apical surgery
S. S. Jensen1,2, P. M. Yazdi3, E. Hjrting-Hansen1,4, D. D. Bosshardt1 & T. von Arx1

Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland; 2Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Glostrup, Denmark; 3Department of Oral & Maxillofacial Surgery, School of Dental Medicine, University of Arhus, Arhus, Denmark; and 4Department of Oral & Maxillofacial Surgery, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
1
Summary
Jensen SS, Yazdi PM, Hjrting-Hansen E, Bosshardt DD, von Arx T. Haemostatic effect and tissue reactions of methods
and agents used for haemorrhage control in apical surgery. International Endodontic Journal, 43, 5763, 2010.
Aim To compare the haemostatic effect and tissue reactions of different agents and methods used for haemorrhage control in apical surgery. Methodology Six standardized bone defects were prepared in the calvaria of six Burgundy rabbits. Five haemostatic modalities were tested for their haemostatic effect and tissue reactions, and were compared with untreated control defects: ExpasylTM + Stasis, ExpasylTM + Stasis + freshening of the bone defect with a bur, Spongostan, Spongostan + epinephrine, and electro cauterization. The haemostatic effect was analysed visually and compared using Wilcoxons signed rank test. Two groups of three animals were evaluated histologically for hard and soft tissue reactions related to the different haemostatic measures, after 3 and 12 weeks of healing respectively.
Results ExpasylTM + Stasis and electro cauterization proved most effective in reducing bleeding (P < 0.05), but were accompanied by unfavourable tissue reactions, as indicated by the presence of necrotic bone, inammatory cells and the absence of bone repair. These adverse tissue reactions did not recover substantially over time. However, adverse reactions were not observed when the supercial layer of bone had been removed with a rotary instrument. In contrast, Spongostan + epinephrine showed only a moderate haemostatic effect, but elicited also only mild adverse tissue reactions. Conclusions Haemostasis in experimental bone defects is most effectively accomplished by using ExpasylTM + Stasis or electro cauterization. However, the bone defects should be freshened with a rotary instrument before suturing so as not to compromise healing. Keywords: animal study, apical surgery, haemorrhage control, haemostatic agent.
Received 15 July 2009; accepted 25 August 2009
Introduction
Haemorrhage control is important in apical surgery to facilitate inspection of the root-end surface and to allow placement and setting of the root-end lling. Usually, one or more local agents are needed to achieve
Correspondence: Dr Simon Storgard Jensen, Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital Glostrup, Ndr. Ringvej, DK-2600 Glostrup, Denmark (Tel.: +45 43 23 32 08; fax: +45 43 23 39 63; e-mail: simon.storgaard@jensen.mail.dk).
sufcient haemostasis. These agents should be either removed completely or should be fully biocompatible and degrade without interfering with periapical healing. The haemostatic effect and tissue reactions of bone wax, ferric sulphate (Stasis, Belport Co, Camarillo, CA, USA), and an aluminium chloride-containing paste (ExpasylTM, Pierre Rolland, Merignac, France) intended for application into the sulcus prior to impression-taking has been reported (von Arx et al. 2006). The combination of Stasis and ExpasylTM or ExpasylTM alone proved most efcient in controlling haemorrhage. However, their use was accompanied by an inammatory and a
57
Haemostasis in apical surgery Jensen et al.
foreign body tissue reaction at the histological level. Based on these ndings, the clinical use of ExpasylTM has been modied to include freshening the bony surface of the periapical crypt with a bur after placement and initial setting of the root-end lling material. Resorbable gelatin-based sponges, such as Spongostan, Spongostan, Dental, Johnson & Johnson medical Ltd., Ascot, UK, are frequently used for haemostasis in several surgical specialties (Petersen et al. 1984, Finn et al. 1992, Schonauer et al. 2004). Spongostan can be used alone, but is often combined with a vasoconstrictor to enhance the haemostatic effect (Rud et al. 2001). Tissue reactions to Spongostan are generally considered to be mild (Alpaslan et al. 1997). However, when Spongostan is left inside osseous defects, delayed healing has been reported (Liening et al. 1997, Schonauer et al. 2004). It is not known how the tissue reacts if the gelatin sponge is removed after haemorrhage control has been achieved. Electro cauterization is an effective method for producing haemostasis by coagulation and vesicular clumping. Most often, electro cauterization is used to stop localized bleeding in the soft tissues, but it has also been reported to be efcient when used on oozing bone surfaces (Jensen et al. 2002). With this approach, no foreign substance is introduced into the bony crypt. However, concern has been raised about the inuence on healing due to the thermal damage to the bone tissue (Eriksson et al. 1982). The purpose of the present study was twofold: To compare the haemostatic effects of ExpasylTM + Stasis, Spongostan, Spongostan + epinephrine and electro cauterization in standardized bone defects.
(a) (b)
To evaluate the tissue reactions after using ExpasylTM + Stasis with and without freshening of the bone defect with a bur, after electro cauterization, and after using Spongostan alone or in combination with epinephrine.
Material and methods Study design

Approval to perform the study was granted by the authorities of the Canton of Bern, Department of Agriculture, Section Veterinary Service, Experimental Animal Studies (study number 100/06). The experimental study was conducted in six adult Burgundy rabbits, each at least 5 months old and weighing between 3 and 4.5 kg. The surgical procedures were performed under intravenous general anaesthesia using the medication and surgical protocol presented by von Arx et al. (2006). In each rabbit, six standardized monocortical bone defects were created in the calvarium. The defects were prepared using a trephine with an outer diameter of 4 mm. The depth of the defects depended on the thickness of the outer cortical bone layer. Each defect then received one of the following treatments in a randomized sequence (Fig. 1), with a randomization scheme generated using http://www.randomization.com (seed: 2604): Control: no haemostatic agent was placed. ExpasylTM and Stasis: ExpasylTM (Pierre Rolland, Merignac, France) was placed into the bone defect with a spatula, ush with the adjacent outer cortex; after 2 min the paste was removed with a dental curette.
(c)
Figure 1 a) Standardized monocortical bone defects in the rabbit calvarium before application of haemostatic agents. Example of
photograph used for visual assessment of initial bleeding score. b) Schematic illustrations used for visual assessment of bleeding. c) Presentation after application of haemostatic agents. Example of photograph used for visual assessment of nal bleeding score.
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Jensen et al. Haemostasis in apical surgery
Subsequently, a small sponge soaked with Stasis (Belport Co, Camarillo, CA, USA) was placed for 5 s into the bone defect. ExpasylTM and Stasis with freshening of the bone defect: ExpasylTM and Stasis were applied as described above. Before primary closure, the bone defect was freshened using a small round bur (: 1.2 mm) under copious saline irrigation to remove all macroscopically visible remnants of ExpasylTM. Spongostan: A Spongostan sponge, 1 cm3 (Spongostan Dental; Johnson & Johnson Medical Ltd., Ascot, UK) was compressed into the defect for 2 min using a gauze tampon, and then removed. Spongostan and epinephrine: A Spongostan sponge 1 cm3 was soaked in three drops of epinephrine 1%, compressed into the defect for 2 min using a gauze tampon, and then removed. Electro cauterization: Any visible bleeding within the defect was cauterized using a spatula-shaped cauterization head (straight, 2.35 19 mm) (ERBOTOM ICC, ERBE Swiss AG, Winterthur, Switzerland. Setting: Soft coagulation 60 Watt). Before primary closure, the defect was curetted using a surgical spoon.
per site was assessed on a scale from 0 (completely dry defect) to 7 (profuse bleeding from the defect) (von Arx et al. 2006). Three evaluators independently examined the photos and determined the bleeding score per site. A mean bleeding score was calculated per treatment for the different sites before application (=initial score) and after removal (=nal score) of the haemostatic agents. The difference between the two means determined the mean haemostatic effect per agent (reduction of bleeding).
Statistics
The results of the visual analysis of haemostatic effect were compared using Wilcoxons signed rank test for paired samples. Exact two-sided P-values were computed to detect differences between the various treatment options. As pair wise comparisons were completed on the same data, the P-values would have needed to be adjusted to compensate for the multiple testing situation. However, because of the explorative nature of the study and the small sample size, no adjustment was carried out. Cohens weighted kappa values were calculated to evaluate inter-observer variations (Fleiss & Cohen 1973).
Sacrice
One group of three animals was allowed to heal for 3 weeks, and a second group of three animals for 12 weeks. Following each designated healing period, sacrice was performed as previously described (von Arx et al. 2006). The retrieved calvarial specimens were immediately immersed in a solution of 4% formaldehyde and 1% calcium chloride.
Results
One animal in the 12-week group died immediately postoperatively because of an anaesthetic complication. An additional animal was therefore included, resulting in seven animals being included in the visual evaluation of the haemostatic effect. Another animal in the 12-week group died 7 weeks postoperatively. The calvarium of this animal was evaluated histologically and was found to demonstrate tissue reactions comparable to the two remaining animals in the 12-week group. This animal was therefore included in the qualitative histologic evaluation.
Histological analysis
The non-decalcied specimens were embedded in methyl-methacrylate and stained with combined basic fuchsin and toluidine blue. Transversal sections with a thickness of approximately 80 lm were obtained for descriptive histology (Schenk et al. 1984). The histologic examination for the description of qualitative tissue reactions included absence or presence of (i) remnants of anticoagulation agents; (ii) new bone; (iii) necrotic bone; (iv) an inammatory cell inltrate; and (v) multinucleated giant cells.
Haemostatic effect
In the visual quantication of the bleeding, there was strong agreement between the three observers (weighted kappa values: 0.71 to 0.98) (Fleiss & Cohen 1973). The initial bleeding scores, nal bleeding scores, and reduction of bleeding for the individual test groups are presented in Table 1. Pair wise comparisons of the different test groups regarding nal bleeding score and bleeding reduction are given in Tables 2 and 3. No signicant differences were found between the initial mean bleeding scores for the different treatment
Visual analysis of haemostatic effect

Photos were taken before application and after removal of the haemostatic agents (Fig. 1). The amount of blood
59
modalities (P between 0.14 and 1.00). The mean nal bleeding score was signicantly smaller nal than the control for all groups except Spongostan (P = 0.798). ExpasylTM + Stasis and ExpasylTM + Stasis + freshening both had signicantly smaller mean bleeding scores than Spongostan and Spongostan + epinephrine (P < 0.05). Electro cauterization exhibited borderline signicantly smaller nal mean bleeding scores than Spongostan and Spongostan + epinephrine (P = 0.059 and P = 0.051, respectively). With regard to the mean bleeding reduction scores, all but the two Spongostan groups (P = 0.866 and P = 0.295, respectively) demonstrated signicantly higher bleeding reduction than the control defects (P < 0.05). ExpasylTM + Stasis showed borderline signicantly higher bleeding reduction than Spongostan (P = 0.050). ExpasylTM + Stasis + freshening reduced the bleeding signicantly more than Spongostan (P = 0.031) and borderline signicantly more than Spongostan + epinephrine (P = 0.051). Electro
cauterization resulted in signicantly higher bleeding reduction than Spongostan (P = 0.034).
Histology
No attempt was made to preserve the volume of the original bone defects by covering them with a barrier membrane. Therefore, herniation of soft tissues into the defects was a frequent nding, irrespective of the haemostatic agent applied (Fig. 2). Control sites 3 Weeks: Vivid bone formation was observed extending from the defect walls. Ongoing osteogenic activity was observed throughout the defects with woven bone trabeculae with osteoblastic seams. 12 Weeks: Maturation of the newly formed bone was generally observed (Fig. 2). However, pressure from the covering soft tissue caused surface resorption of some of the newly formed bone.
Table 1 Mean bleeding scores ( SD) before application and after removal of haemostatic agents, and mean reduction in bleeding scores (n = 7)
Mean initial score ( SD) Control ExpasylTM + Stasis ExpasylTM + Stasis + freshening of defect Electro cauterization Spongostan Spongostan + epinephrine 3.81 ( 1.68) 3.24 ( 0.83) 4.24 ( 1.74) 4.57 ( 2.12) 3.62 ( 1.33) 3.86 ( 1.59)
Mean nal score ( SD) 3.33 ( 1.60) 0.43 ( 0.29) 0.29 ( 0.21) 1.05 ( 0.90) 3.10 ( 0.90) 2.24 ( 0.92)
Mean reduction ( SD) 0.48 ( 1.87) 2.81 ( 0.71) 3.95 ( 1.84) 3.52 ( 1.74) 0.52 ( 1.32) 1.62 ( 0.93)
Table 2 P-values of pairwise comparisons of the nal bleeding scores using Wilcoxons signed rank test
Control Expasyl + Stasis Expasyl + Stasis + freshening of defect Electro cauterization Spongostan Spongostan + epinephrine
ExpasylTM + Stasis 0.586 0.100 0.022 0.031
ExpasylTM + Stasis + freshening of defect 0.181 0.016 0.016
Electro cauterization 0.059 0.051
Spongostan 0.104
0.036 0.022 0.034 0.798 0.034
Table 3 P-values of pairwise comparisons of the scores of calculated bleeding reduction using Wilcoxons signed rank test
Control ExpasylTM + Stasis ExpasylTM + Stasis + freshening of defect Electro cauterization Spongostan Spongostan + epinephrine 0.036 0.031 0.031 0.866 0.295 ExpasylTM + Stasis 0.106 0.444 0.050 0.141 ExpasylTM + Stasis + freshening of defect 0.400 0.031 0.051 Electro cauterization 0.034 0.150 Spongostan 0.204
60
Figure 2 Control defect after 12 weeks of healing. Most of the
original defect volume (marked with lines) is occupied by soft tissue with the character of loose connective tissue dominated by epidermal fat cells. Bone formed form the defects walls has the character of mature lamellar bone.
Figure 3 Defect 12 weeks after application of ExpasylTM +
Stasis without freshening the defect with a round bur. Remnants of ExpasylTM (E) are surrounded by lots of multinucelated giant cells (large arrows). Empty osteocyte lacunae can be see in a bone trabecula undermined by resorption cavities (Small arrows).
ExpasylTM and Stasis 3 Weeks: The entire bone surface was necrotic, without signs of repair activity. The osteocyte lacunae were empty along the surfaces of the cavities, and numerous macrophages and multinucleated giant cells were observed close to the defect walls and to remnants of ExpasylTM, which were particularly evident in concavities of the defect wall. 12 Weeks: Necrotic areas could still be identied within the defect walls with areas of undermining resorption, nearly forming a sequester (Fig. 3). Remnants of ExpasylTM were often observed, and were always surrounded by an extensive foreign body reaction (Fig. 3). ExpasylTM and Stasis with freshening of the bone defect 3 Weeks: Moderate amounts of woven bone formation were observed close to the defect walls, particularly at sites where the bone marrow spaces were opened widely. Remnants of ExpasylTM were seen rarely. However, if present, they were always accompanied by multinucleated giant cells. 12 Weeks: The amount of osseous repair was limited, but no signs of necrotic bone or foreign body reaction were present. Spongostan 3 Weeks: Woven bone formation was observed along the entire surface of the bone cavities. However, the osteoblastic activity along the defect surfaces was reduced compared with the control defects.
12 Weeks: The defects were dominated by maturation of the newly formed bone, with layers of parallelbered bone reinforcing the woven bone trabeculae. Spongostan and epinephrine 3 Weeks: Vivid new bone formation could be seen, with woven bone throughout the former bone defect (Fig. 4). Ongoing osteogenic activity, as indicated by the presence of osteoid seams and osteoblasts, was a dominating feature. 12 Weeks: Maturation of woven bone formed earlier was seen, with only sparse signs of ongoing bone formation. In general, the surfaces demonstrated lamellar bone coverage.
Figure 4 Defect three weeks after application of Spongostan.
The former defect (marked with lines) is completely occupied by newly formed woven bone. The ePTFE suture used to close the periosteal layer can be recognized (asterisks).
61
Figure 5 Defect three weeks after using electro cauterization
for haemorrhage control. Multiple empty osteocyte lacunae (small arrows) can be seen close to the defect walls (large arrows). The soft tissue occupying the defect has the character of immature granulation tissue. A coagulum containing many erythrocytes is observed along the defect walls.
Electro cauterization 3 Weeks: The surfaces of the entire cavities appeared necrotic, without any signs of bone repair. The osteocyte lacunae near to the surface were empty (Fig. 5). The cell populations adjoining the surfaces consisted almost exclusively of inammatory cells, mainly macrophages and some multinucleated giant cells. In addition, many erythrocytes were often seen on the cauterized bone surface. The opened bone marrow often revealed signs of degeneration. 12 Weeks: The bone surface appeared vital, but jagged after extensive osteoclastic activity. The size and shape of the cavities were nearly identical to the situation immediately postoperatively with very limited signs of new bone formation.
Discussion
This study evaluated the haemostatic efcacy and tissue reactions of different methods for local haemorrhage control used in apical surgery. Overall, ExpasylTM + Stasis and electro cauterization proved most efcient in reducing bleeding, while the use of Spongostan alone did not demonstrate any signicant haemostatic effect as compared with the control defects. The addition of epinephrine to the Spongostan had some effect on the nal bleeding score, without reaching the efcacy of ExpasylTM + Stasis. The efcacy of ExpasylTM + Stasis in reducing bleeding was in accordance with a previous study
using the same model (von Arx et al. 2006). However, a concern was the localized foreign body reaction elicited by remnants of ExpasylTM in the bone defects. Only limited documentation exists on tissue reactions to aluminium chloride in paste form, but studies which have evaluated topical application of aluminium chloride in liquid form have also reported inammatory reactions (Barr et al. 1993, Kopac et al. 2002). The results of the present study suggest that these tissue reactions can be signicantly reduced by freshening the defect with a bur. In the clinical case of using a rootend lling material that does not set during the surgical procedure [e.g. mineral trioxide aggregate (MTA)], there is a risk of ushing out the material during the freshening of the bony cavity. To avoid this, it has proved important to use a relatively small round bur to reduce the risk of touching the cut root surface and MTA lling, and to prevent direct water spray on the cut root surface. Spongostan is widely used in several surgical specialties to control bleeding, but most often in surgical sites where it can be left in situ, such as in dental extraction sockets or in donor sites after bone graft harvesting (Petersen et al. 1984, Finn et al. 1992, Blinder et al. 1999). In the present study, the sponge was removed after 2 min to conform with the typical protocol in apical surgery (Rud et al. 2001). This eliminated the compressive element, and the resulting intrinsic haemostatic effect proved to be limited. Histologic analysis revealed slightly delayed bone healing that was qualitatively comparable to the control defects. Similar ndings have been reported in previous experimental and clinical studies, where the gelatin sponges were left in situ (Petersen et al. 1984, Finn et al. 1992). Addition of epinephrine 1% to a gelatin sponge or cotton pellet has been reported to provide sufcient haemostasis to allow undisturbed placement and setting of dentine-bonded composite resin root-end llings (Rud et al. 2001, Jensen et al. 2002). In the present experimental setting, the addition of epinephrine to Spongostan only marginally increased the haemostatic effect, without reaching statistical signicance. No histologic difference in healing pattern was observed with the addition of epinephrine. As epinephrine is a naturally occurring circulating hormone in the organism, disturbance of healing was not to be expected. Electro cauterization provided a haemostatic effect similar to that of ExpasylTM + Stasis. However, bone healing was delayed when compared to control defects and to ExpasylTM + Stasis-treated defects that were
62
freshened with a bur. Limited bone formation was observed after 12 weeks of healing, following initial signs of supercial necrosis. This can presumably be ascribed to thermal injury, as has previously been documented (Eriksson et al. 1982). In the early healing phase, an adverse tissue reaction was seen in relation to the necrotic zones. This inammatory and foreign body reaction was not observed after 12 weeks of healing. Coagulated tissue remnants were removed with a curette before suturing. It can be speculated that the osseous healing conditions could have been improved by removing the supercial bone layer with a rotary instrument, as was observed with the freshened ExpasylTM + Stasis-treated defects.
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Alpaslan C, Alpaslan GH, Oygur T (1997) Tissue reaction to three subcutaneously implanted local hemostatic agents. British Journal of Oral and Maxillofacial Surgery 35, 12932. von Arx T, Jensen SS, Hanni S, Schenk RK (2006) Haemo static agents in periradicular surgery: an experimental study of their efcacy and tissue reactions. International Endodontic Journal 39, 8008. Barr RJ, Alpern KS, Jay S (1993) Histiocytic reaction associated with topical aluminium chloride (Drysol reaction). The Journal of Dermatologic Surgery and Oncology 19, 101721. Blinder D, Manor Y, Martinowitz U, Taicher S (1999) Dental extractions in patients maintained on continued oral anticoagulant comparison of local hemostatic modalities. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 88, 13740. Eriksson A, Albrektsson T, Grane B, McQueen D (1982) Thermal injury to bone A vital-microscopic description of heat effects. International Journal of Oral Surgery 11, 11522. Finn MD, Schow SR, Schneiderman ED (1992) Osseous regeneration in the presence of four common hemostatic agents. Journal of Oral and Maxillofacial Surgery 50, 60812. Fleiss JL, Cohen J (1973) The equivalence of weighted kappa and the intraclass correlation coefcient as measures of reliability. Educational and Psychological Measurement 33, 6139. Jensen SS, Nattestad A, Egd P, Sewerin I, Munksgaard EC, Schou S (2002) A prospective, randomized, comparative clinical study of resin composite and glass ionomer cement for retrograde root lling. Clinical Oral Investigations 6, 23643. Kopac I, Cvetko E, Marion L (2002) Gingival inammatory response induced by chemical retraction agents in beagle dogs. International Journal of Prosthodontics 15, 149. Liening DA, Lundy L, Silberberg B, Finstuen K (1997) A comparison of the biocompatibility of three absorbable hemostatic agents in the rat middle ear. Otolaryngology Head and Neck Surgery 16, 4547. Petersen JK, Krogsgaard J, Nielsen KM, Nrgaard EB (1984) A comparison between two absorbable hemostatic agents: gelatin sponge (Spongostan) and oxidized regenerated cellulose (Surgicel). International Journal of Oral Surgery 13, 40610. Rud J, Rud V, Munksgaard EC (2001) Periapical healing of mandibular molars after root-end sealing with dentinebonded composite. International Endodontic Journal 34, 285 92. Schenk RK, Olah AJ, Herrmann W (1984) Preparation of calcied tissues for light microscopy. In: Dickson GR, ed. Methods of Calcied Tissue Preparation. Amsterdam, Netherlands: Elsevier, pp. 156. Schonauer C, Tessitore E, Barbagallo G, Albanese V, Moraci A (2004) The use of local agents: bone wax, gelatin, collagen, oxidized cellulose. European Spine Journal 13(Suppl. 1), S89 96.
Conclusion
ExpasylTM + Stasis and electro cauterization proved most efcient in the reduction of bleeding from standardized bone defects. However, the same measures were accompanied by the most pronounced adverse tissue reactions. It is recommended to thoroughly remove the supercial layer in the bone defect with a rotary instrument after application of ExpasylTM + Stasis or electro cauterization in apical surgery to reduce these unfavourable tissue reactions. Defects treated with Spongostan demonstrated no adverse tissue reactions but delayed bone healing. Despite the reduced haemostatic effect of Spongostan and epinephrine compared with ExpasylTM + Stasis and electro cauterization, this combination will often clinically ensure sufcient haemostasis for the undisturbed placement and setting of a root-end lling.
Acknowledgements
The authors gratefully acknowledge the assistance of Dr. med. vet. Daniel Mettler and the veterinarian team of the Department of Experimental Surgery, Bern University Hospital, Inselspital, Bern, Switzerland. We also thank Mrs. Britt Hoffmann and Mr. David Reist, Department of Oral Surgery and Stomatology, University of Bern, for the histologic preparation of the specimens. The statistical assistance of Mr. D. Klingbiel, Institute of Mathematical Statistics and Actuarial Science, University of Bern, was highly appreciated. Funding: The study was generously funded by a grant from the Foundation for Dental Research and Education (FDR), Basel, Switzerland (Grant 104/17). The authors declare no conicts of interest.
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doi:10.1111/j.1365-2591.2009.01638.x
Volumetric analysis of root llings using spiral computed tomography: an in vitro study
R. Anbu, S. Nandini & N. Velmurugan

Department of Conservative Dentistry & Endodontics, Meenakshi Ammal Dental College, Maduravoyal, Chennai, Tamilnadu, India
Abstract
Anbu R, Nandini S, Velmurugan N. Volumetric analysis of
root llings using spiral computed tomography: an in vitro study. International Endodontic Journal, 43, 6468, 2010.
Aim To analyse volumetrically using spiral computed tomography (SCT) the efcacy of various techniques to ll root canals. Methodology Root canals in 40 maxillary central incisors were instrumented with K-les to size 60 and the volume of the canal measured using SCT. The teeth were divided into four groups of 10 each and root lled by lateral compaction, Thermal, Obtura II and System B techniques, respectively. AH plus was used as sealer with all techniques. The lled volume in each canal was measured using SCT and the percentage of
obturated volume (POV) was calculated. The data were statistically analysed using KruskalWallis test and MannWhitney U-test. Results The four groups were comparable in canal volume. The overall POV was 80.4%, 93.3%, 84.8% and 93.7% for lateral compaction, Thermal, Obtura II and System B, respectively (P < 0.05). Conclusion The greatest POV was obtained with System B and Thermal. Voids were seen in all root llings. Keywords: Obtura II, obturation, percentage of obturated volume, spiral CT, three dimensional, volumetric analysis.
Received 9 May 2009; accepted 25 August 2009
Introduction
A good root lling is essential to prevent bacteria and/ or their by-products from reaching the periapical region. There are various methods available for lling canals ranging from cold lateral compaction to thermoplasticized techniques. Various experimental methods have been used to assess the quality of root llings, such as radioisotope (Hakel et al. 2000), dye penetration (McRobert & Lumley 1997, Venturi 2006), uid ltration (Kontakiotis et al. 2007), bacterial leakage (Jacobson et al. 2002), microscopic analysis (De-Deus et al. 2006, 2008), clearing techniques (Oliver & Abbott 2001) and Micro CT (Hammad et al.
2009). It has been reported that spiral computerized tomography (SCT) has been a useful tool in various in vivo and laboratory studies. It was concluded that with SCT three-dimensional volume measurements are possible without sectioning specimens thus avoiding loss of material (Nandini et al. 2006, Hammad et al. 2009). The aim of this study was to assess the efcacy of different root lling techniques by calculating the percentage of obturated volume (POV).
Materials and methods Tooth specimens

Forty single rooted maxillary central incisors were selected. Soft tissue remnants and calculus were removed. Collection, storage, sterilization and handling of extracted teeth followed the Occupational Safety and Health Administration (OSHA) guidelines and regulations (Reuben et al. 2008).
Correspondence: Dr Natanasabapathy Velmurugan, (Prof and Head), Department of Conservative Dentistry & Endodontics, Meenakshi Ammal Dental college, Allapakkam main road, Maduravoyal, Chennai 95, Tamil nadu, India (Tel.: 09840164167; fax: 91 44 23781631; e-mail: Vel9911@ yahoo.com).
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Anbu et al. Volumetric analysis of root llings
All specimens were checked for number and curvature of root canals radiographically. Teeth with single straight canals were chosen whilst teeth with incompletely formed apices, calcied canals, fractures or resorption were excluded.
Tooth preparation
An access cavity was prepared in each tooth and a size 10 K-le introduced until the tip was just visible at the foramen of the root. The working length was derived by subtracting 0.5 mm from the measured length. Orice enlargement was achieved with sizes 2, 3 and 4 Gates Glidden drills (Dentsply Maillefer, Ballaigues, Switzerland). Apical enlargement was completed to size 60 with K-les and a step-back procedure was used until the preparation blended with the coronal aring. Two millilitres of 1% sodium hypochlorite and 2 mL of saline were used as irrigants between each le size. Ethylene-Diamine Tetraacetic acid (EDTA) paste (RC Help; Prime Dental Products, Thane, India) was used as a lubricant during instrumentation. Before lling, root canals were dried using a size 60 paper point. The teeth were numbered from 1 to 40. Specimens were scanned using a Light Speed VCT Scanner (GE Electricals, Milwaukee, WI, USA). They were then viewed under high resolution, both cross-sectionally and longitudinally with a constant thickness of 0.625 mm/slice and a constant spiral or table speed of 0.5 and 140 kVp. The scanned data was then transferred to Advantage windows work station (GE system, Milwaukee, WI, USA) image analysis and evaluated. The area of prepared root canal in each slice was measured from cemento-enamel junction (CEJ) to the apex of the root. The volume of root canal in each slice was calculated by multiplying the root canal area by the slice thickness (0.625 mm). Finally, the volume of each canal was calculated. The root length was divided into three equal parts; coronal, middle and apical thirds and the volume of each segment was calculated separately. Forty teeth were randomly divided into four groups of 10 each. In all the teeth AH Plus sealer (Dentsply Maillefer) was placed into the canal using a lentulo-spiral ller.
achieved using additional accessory GP cones and standardized nger spreaders (Dentsply Maillefer) starting 1 mm short of working length. When the points prevented the spreader penetration beyond the coronal third of the canal, the canal was considered to be adequately lled and excess GP was removed at the CEJ using a heated condenser. The GP at the CEJ was compacted using a cold plugger.
Group-II: Thermal
A 60 size Thermal (Dentsply Maillefer) verier was used to check the size of the canal. A 60 size Thermal cone was heated (ThermaPrep Plus Oven, Tulsa Dental Products, OK, USA) according to the manufacturers instruction and introduced into each canal using rm apical pressure within 0.5 mm short of working length. An inverted cone bur was used to cut the plastic shaft 12 mm within the access cavity. Excess GP was removed using pluggers (Gencoglu et al. 2008).
Group-III: Obtura II
A 20 gauge Obtura (Obtura Spartan, Fenton, MI, USA) needle tip was selected. The tip was inserted into the canal 35 mm short of the working length. The temperature was set at 200 C, the trigger was pressed so that the molten GP owed and the tip was withdrawn slowly out of the canal. The apical segment was compacted using appropriate Obtura pluggers. Backlling was achieved by the application of thermoplasticized GP in 45-increments, followed by uniform compaction with pluggers.
Group-IV: System B
A medium-large nonstandardized GP cone was placed to within 0.5 mm of the working length. A mediumlarge System B (EIE/Analytic Technology, Redmond, WA, USA) insert tip, which bound in the canal 3 mm from the working length, was used for the down-pack. The heat was preset to 200 C during the rst downpack. An accessory GP cone was then placed into the canal and the heat was preset to 100 or 250 C during the second down-pack. This procedure was repeated until the entire root canal was lled (Gencoglu et al. 2008). A second SCT scan was performed to determine the volume of GP and sealer. POV in each tooth was calculated. POV in the coronal, middle and apical thirds for each tooth was calculated separately (Fig. 1).
Group-I: lateral compaction (LC)

A size 60 gutta-percha (GP) (Dentsply Maillefer) was coated with the sealer and placed in the canal to working length with tug-back. Lateral compaction was
65
Volumetric analysis of root llings Anbu et al.
(a)
(b)
Figure 1 (a) SCT slice showing canal
obturated with Obtura II. (b) SCT slice showing canal obturated by System B. 203 123 mm (300 300 DPI).
Statistical analysis
Statistical analysis was performed with nonparametric tests (KruskalWallis and MannWhitney U-test). The software used was SPSS (Statistical Package for Social Sciences, Chicago, IL, USA) version 11.5. The level of signicance was set at P < 0.05.
Results
The volume (mean & standard deviation) of root canals after cleaning and shaping for each group is given in Table 1. The four groups were statistically comparable in respect of canal volume (P > 0.05). All POV values are summarized in Table 2. The System B and Thermal gave the highest POV values and were signicantly different in comparison with Obtura II and lateral compaction (P < 0.05).
Discussion
Traditional methods of evaluating root llings have disadvantages. On sectioning the root, there could be loss of material which might mimic voids. Radiographs
Table 1 The volume (in cm3) of root canals for each group
Groups LC Thermal Obtura II System B LC, lateral compaction. Mean 0.033 0.035 0.034 0.035 Standard deviation 0.0055 0.0043 0.0051 0.0047
give only two-dimensional interpretations (Robinson et al. 2002). The time taken for uid ltration (Pommel & Camps 2001) and clearing techniques (Oliver & Abbott 2001) may be a concern. Dye penetration studies do not correlate clinically (Oliver & Abbott 2001) whereas dye extraction studies evaluate only the apical third of the tooth (Camps & Pashley 2003). Bacterial leakage studies do not simulate exact clinical conditions, need long periods of observation and do not allow quantication of the number of penetrating bacteria (Siqueira et al. 1999, 2000). A literature search revealed that only sectioning studies have been undertaken to assess thermoplasticized root llings at various levels (Jung et al. 2003, ElAyouti et al. 2005, De-Deus et al. 2006). SCT, a noninvasive technique gives a 3D interpretation (Nair & Nair 2007) at various levels, avoids loss of material (Hammad et al. 2009), yields reproducible results and the specimens can be used for further research. The specic location of voids can be determined accurately. Recent studies have proved that SCT provides volumetric analysis of root llings and remaining remnants of root llings (Bartletta et al. 2008, Hammad et al. 2008). Hence, SCT was chosen as the tool for investigating the efcacy of llings in this study. The only limitation of SCT is that it is difcult to differentiate GP and sealer. In this study, Thermal and System B gave the highest overall POV. The reason could be that the use of heat softened GP had created a better homogenous mass with less voids and better adaptation of the GP to the canal wall. This is in accordance to the studies reported by De-Deus et al. (2006) and Gencoglu et al.
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Anbu et al. Volumetric analysis of root llings
Table 2 POV values for each group
Groups LC Thermal Obtura II System B
Overall 80.4 1.6 (X) 93.3 2.4 (Y) 84.8 6 (X) 93.7 3.6 (Y)
Coronal third 80.7 92.5 92.9 92.1 3.6 3.4 8.5 5.7 (a) (b) (b) (b)
Middle third 81.5 3.1 (a) 95.5 4.7 (b) 95.6 6.1 (b) 94.7 6 (b)
Apical third 83 3.6 (a) 97.4 5.4 (b) 54.3 19.3 (c) 96.2 6.2 (b)
Cells with the same letter denote no statistical signicance between them (P > 0.05). Capital letters were used for the overall data. POV, percentage of obturated volume; LC, lateral compaction.
(2002), who showed that Thermal produced a signicantly higher POV. In this study two specimens in the System B group had voids between the coronalmiddle and middle-apical segments. These voids were not through and through but were found only in a few sections, which could have been missed in a conventional radiograph. Obtura II, a thermoplastic injectable technique had only 85% of overall POV. Presence of voids in the apical region had reduced the overall POV, which may be due to failure of the needle tip to reach the apical third, poor compaction and entrapment of air. The use of a 20-guage Obtura needle which has an outer diameter of 0.81 mm could have prevented the tip from reaching the appropriate depth. Lateral compaction had 83% of overall lling, the lowest value of all the llings. This was mainly because this technique does not produce a homogenous mass and may leave spaces between the GP and the dentinal walls or accessory cones. According to Schilder (2006), in lateral compaction the nal lling had the appearance of numerous GP cones that had been tightly pressed together and joined by frictional grip and the cementing substance. Spreader tracts can be devoid of sealer or the sealer can resorb later leading to voids. In this study, voids were seen between the accessory cones throughout the length of the canal. When comparing the POV of coronal, middle and apical thirds of Thermal, System B and lateral compaction techniques, there was no difference in the efcacy of llings. It was seen that the POV of coronal third of lateral compaction, Thermal and System B was slightly less than apical third. This could be due to the use of coronal orice enlargement with Gates Glidden drills and lack of additional vertical condensation with pluggers in the Thermal group. Even though pluggers were used in case of System B for coronal compaction there was a decrease in efcacy. This could be due to the mismatch in taper of the instrument to that of the enlarged canal orice.
Conclusion
Within the limitations of this study, voids were seen in all the root llings. The greatest POV was obtained with System B and Thermal techniques; lateral compaction, produced the least POV. SCT appears to be a valuable tool to locate voids and to assess the efcacy of obturation at various levels.
References
Bartletta F, Reis M, Wagner M, Borges J, DallAgnol C (2008) Computed tomography assessment of three techniques for removal of lling material. Australian Endodontic Journal 34, 1025. Camps J, Pashley D (2003) Reliability of the dye penetration studies. Journal of Endodontics 29, 5924. De-Deus G, Gurgel-Filho ED, Magalhaes KM, Coutinho-Filho T (2006) A laboratory analysis of gutta-percha-lled area obtained using Thermal, System B and lateral condensation. International Endodontic Journal 39, 378 83. De-Deus G, Reis C, Beznos D, de Abranches AMG, CoutinhoFilho T, Paciornik S (2008) Limited ability of three commonly used thermoplasticized gutta-percha techniques in lling oval-shaped canals. Journal of Endodontics 34, 14015. ElAyouti A, Achleithner C, Lost C, Weiger R (2005) Homogeneity and adaptation of a new gutta-percha paste to root canal walls. Journal of Endodontics 31, 68790. Gencoglu N, Garip Y, Bas M, Samani S (2002) Comparison of different gutta-percha root lling techniques: thermal, Quick-Fill, System B and lateral condensation. Oral Surgery Oral Medicine Oral Pathology, Oral Radiology and Endodontics 9, 3336. Gencoglu N, Yildirim T, Garip Y, Karagenc B, Yilmaz H (2008) Effectiveness of different gutta-percha techniques when lling experimental internal resorptive cavities. International Endodontic Journal 41, 83642. Hakel Y, Freymann M, Fanti V, Claisse A, Poumier F, Watson M (2000) Apical microleakage of radiolabeled lysozyme over time in three techniques of root canal obturation. Journal of Endodontics 26, 14852.
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Hammad M, Qualtrough A, Silikas N (2008) Three-dimensional evaluation of effectiveness of hand and rotary instrumentation for retreatment of canals lled with different materials. Journal of Endodontics 34, 13703. Hammad M, Qualtrough A, Silikas N (2009) Evaluation of root canal obturation: a three dimensional in vitro study. Journal of Endodontics 35, 5414. Jacobson HLJ, Xia T, Baumgartner JC, Marshall JG, Beeler WJ (2002) Microbial leakage evaluation of the continuous wave of condensation. Journal of Endodontics 28, 26971. Jung IY, Lee S, Kim E, Lee C, Lee S (2003) Effect of different temperatures and penetration depths of a system B plugger in the lling of articially created oval canals. Oral Surgery Oral Medicine Oral Pathology, Oral Radiology and Endodontics 96, 4537. Kontakiotis EG, Tzanetakis GN, Loizides AL (2007) A 12month longitudinal in vitro leakage study on a new siliconbased root canal lling material (gutta-ow). Oral Surgery Oral Medicine Oral Pathology, Oral Radiology and Endodontics 103, 8549. McRobert AS, Lumley PJ (1997) An in vitro investigation of coronal leakage with three gutta-percha backlling techniques. International Endodontic Journal 30, 4137. Nair MK, Nair UP (2007) Digital and advanced imaging in endodontics: a review. Journal of Endodontics 33, 16. Nandini S, Velmurugan N, Kandaswamy D (2006) Removal efciency of calcium hydroxide intracanal medicament with two calcium chelators: volumetric analysis using spiral CT, an in vitro study. Journal of Endodontics 32, 1097101.
Oliver CM, Abbott PV (2001) Correlation between clinical success and apical dye penetration. International Endodontic Journal 34, 63744. Pommel L, Camps J (2001) Effect of pressure and measurement time on the uid ltration method in endodontics. Journal of Endodontics 27, 2568. Reuben J, Velmurugan N, Kandaswamy D (2008) The evaluation of root canal morphology of the mandibular rst molar in an Indian population using spiral computed tomography scan: an in vitro study. Journal of Endodontics 34, 2125. Robinson S, Czerny C, Gahleitner A, Bernhart T, Kainberger FM (2002) Dental CT evaluation of mandibular rst premolar root congurations and canal variations. Oral Surgery Oral Medicine Oral Pathology, Oral Radiology and Endodontics 93, 328 32. Schilder H (2006) Filling root canals in three dimensions. Journal of Endodontics 32, 28190. Siqueira JF Jr, Rocas IN, Lopes HP, De Uzeda M (1999) Coronal leakage of two root canal sealers containing calcium hydroxide after exposure to human saliva. Journal of Endodontics 25, 146. Siqueira JF Jr, Rocas IN, Favieri A, Abad EC, Castro AJR, Gahyva SM (2000) Bacterial leakage in coronally unsealed root canals obturated with 3 different techniques. Oral Surgery Oral Medicine Oral Pathology 90, 64750. Venturi M (2006) Evaluation of canal lling after using two warm vertical gutta-percha compaction techniques in vivo: a preliminary study. International Endodontic Journal 39, 53846.
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doi:10.1111/j.1365-2591.2009.01641.x
Inuence of the shape of articial canals on the fatigue resistance of NiTi rotary instruments
G. Plotino1, N. M. Grande1, M. Cordaro2, L. Testarelli1 & G Gambarini1

1
University of Roma La Sapienza, Rome, Italy; and 2Catholic University of Sacred Heart, Rome, Italy
Abstract
Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. Inuence of the shape of articial canals on the
fatigue resistance of NiTi rotary instruments. International Endodontic Journal, 43, 6975, 2010.
Aim To investigate the inuence of the trajectory of NiTi rotary instruments on the outcome of cyclic fatigue tests. Methodology Ten ProFile and Mtwo instruments tip size 20, taper 0.06 and tip size 25, taper 0.06 were tested in two simulated root canals with an angle of curvature of 60 and radius of curvature of 5 mm but with different shape. Geometrical analysis of the angle and radius of the curvature that each instrument followed inside the two different articial canals was performed on digital images. The instruments were then rotated until fracture at a constant speed of 300 rpm to calculate the number of cycles to failure
(NCF) and the length of the fractured fragment. Mean values were calculated and analysed using two different multivariate linear regression models and an independent sample t-test. Results The shape of the articial root canal used in cyclic fatigue studies inuenced the trajectory of the instrument. This difference is reected by the NCF measured for the same instrument in the different articial root canals and by the impact of the type of canal on both the NCF (St.b = 0.514) and fragment length (St.b = )0.920). Conclusions Small variations in the geometrical parameters of the curvature of an instrument subjected to exural fatigue could have a signicant inuence on the results of fatigue tests. Keywords: angle of curvature, articial canal, cyclic fatigue test, radius of curvature.
Received 27 June 2009; accepted 2 September 2009
Introduction
Fracture of instruments used in rotary motion occurs in two different ways: fracture due to torsion and fracture due to exural fatigue (Serene et al. 1995, Sattapan et al. 2000, Ullmann & Peters 2005). Torsional fracture occurs when an instrument tip or another part of the instrument is locked in a canal whilst the shank continues to rotate. When the torque exerted by the hand-piece exceeds the elastic limit of the metal, fracture of the tip becomes inevitable (Peters 2004, Parashos & Messer 2006). Instruments fractured
Correspondance: Dr Gianluca Plotino, Via Eleonora Duse 22, 00197 Rome, Italy (Tel.: +393396910098; fax: +3968072289; e-mail: gplotino@fastwebnet.it).
because of torsional loads often carry specic signs such as plastic deformation (Sattapan et al. 2000). Fracture due to fatigue through exure occurs because of metal fatigue. The instrument does not bind in the canal but it rotates freely in a curvature, generating tension/compression cycles at the point of maximum exure until the fracture occurs (Pruett et al. 1997, Haikel et al. 1999). As an instrument is held in a static position and continues to rotate, one half of the instrument shaft on the outside of the curve is in tension, whilst the half of the shaft on the inside of the curve is in compression. This repeated tension compression cycle, caused by rotation within curved canals, increases cyclic fatigue of the instrument over time and may be an important factor in instrument fracture (Pruett et al. 1997).
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Inuence of trajectory on fatigue resistance Plotino et al.
Resistance of rotary instruments to cyclic fatigue is affected by the angle and radius of canal curvature and the size and taper of the instrument. Increased severity in the angle and radius of the curves around which the instrument rotates decreases instrument lifespan (Pruett et al. 1997, Haikel et al. 1999, Grande et al. 2006). Instruments have been tested in canals having radii of 2 mm, 5 mm and 10 mm, with the conclusion that the smaller the radius, the shorter the life of the instrument when rotating (Pruett et al. 1997, Haikel et al. 1999, Grande et al. 2006). Similarly, several studies have shown that increased diameter at the point of maximum curvature of the instrument, which is determined by tip size and taper, reduces the time to fracture (Pruett et al. 1997, Haikel et al. 1999, Plotino et al. 2006, 2007). Only the study by Yared et al. (2000) did not support these ndings. Ruddle (2002) has asserted that the position of the curvature of a canal is a factor in instrument safety, a point that was demonstrated in an earlier study (Malagnino et al. 1999). When the curvature is localized in a coronal portion of the root canal, the instrument is subjected to the maximum stress in the area in which its diameter is largest. In nearly all studies reported in the endodontic literature, the rotating instrument was either conned in a glass or metal tube, in a grooved block-and-rod assembly or in a sloped metal block (Plotino et al. 2009); there has been no mention of the t of the instrument in the tube or groove. As the instrument is likely to be tting loosely, the description of the radius of curvature in those studies is likely to be overstated; that is, the le was actually bent less severely than reported. Previous studies using cylindrical metallic tubes to test the cyclic fatigue life of NiTi rotary instruments reported that the tubes do not sufciently constrain the shafts of the smaller instruments (Pruett et al. 1997, Mize et al. 1998, Yared et al. 1999, 2000). The aim of the present study was to investigate the inuence of the trajectory of NiTi rotary instruments on the outcome of cyclic fatigue tests. The null hypothesis tested was that there was no difference in the cyclic fatigue resistance of the same instrument tested in two articial canals with the same radius and angle of curvature but with different shapes.

Ten ProFile NiTi rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland) tip size 20, 0.06 taper, ten ProFile instruments tip size 25, 0.06 taper, ten Mtwo
NiTi rotary instruments (Sweden & Martina, Padova, Italy) tip size 20, 0.06 taper and ten Mtwo instruments tip size 25, 0.06 taper were selected. Two simulated root canals with an angle of curvature of 60 and radius of curvature of 5 mm were constructed for each instrument size. The centre of the curvature was approximately 5 mm from the tip of the instrument, the curved segment of the canal was approximately 5 mm in length and the linear segment between the tip of the instrument and the end-point of the curvature was approximately 2.5 mm. The articial canals with two different shapes were milled in stainless-steel blocks with a precision milling machine. An articial canal (A) was constructed with a tapered shape corresponding to the dimensions of the instruments tested (tip size and taper) (Fig. 1a), thus providing the instrument with a suitable trajectory. To ensure the accuracy of the size of each canal a copper duplicate of each instrument was milled increasing the original size of the instrument by 0.1 mm using a computer numerical control machining bench (Bridgeport VMC 760XP3; Hardinge Machine Tools Ltd., Leicester, UK). The copper duplicates were constructed according to the curvature parameters that were chosen for the study. With these negative moulds the articial canals were made using a die-sinking electrical-discharge machining process (Agietron Hyperspark 3, AGIE Sa, Losone, Switzerland) in a stainless-steel block. The depth of each articial canal was machined to the maximum diameter of the instrument +0.2 mm, allowing the instrument to rotate freely inside the articial canal. The blocks were hardened through annealing. A second articial canal (B) was constructed with a tapered shape but with larger dimensions that did not match the instrument size and taper; the articial canal was machined increasing the original size of the instrument by 0.3 mm (Fig. 1b). Each articial canal was mounted on a stainless-steel block that was connected to a frame to which a mobile plastic support for the hand-piece was also connected. The dental hand-piece was mounted upon a mobile device that allowed for precise and simple placement of each instrument inside the articial canal, ensuring three-dimensional alignment and positioning of the instruments to the same depth. The articial canal was covered with tempered glass to prevent the instruments from slipping out and to allow for observation of the instrument. Geometrical analysis of the trajectory that each instrument followed inside the two different articial
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Plotino et al. Inuence of trajectory on fatigue resistance
(a)
(b)
Figure 1 The articial canals used in the
present study. (a) canal A; (b) canal B.
canals was performed on digital images, determining two parameters: angle and radius of the curvature described by the instruments as measured by Pruett et al. (1997). A straight line (PQ) was drawn along the long axis of the coronal straight portion of the instrument. A second line (TS) was drawn along the long axis of the apical straight portion of the instrument. There was a point on each of these lines at which the instrument deviated to begin (Q) or end (S) the curvature. The curved portion of the instrument was represented by a segment of a circle (C) with tangents at these points. The most precise circumference that lied on the trajectory of the instrument was geometrically determined using the osculating circumference method (Gray 1997). The osculating circle of a curve at a given point is the circle that best approximate the curve at that point and it is unique. This method was chosen because the curvature followed by an instrument not constrained in a precise trajectory is not a circumference, but a plain curve with a different equation. In these cases, the above described is the most precise method to dene a curvature by the parameters of radius and angle of a circumference. It is possible to determine the osculating circle passing through three points of a curve. The points that were chosen on the trajectory of the instruments were the beginning (Q) and the end (S) of the curve and a point B that was chosen as the centre of mass of the triangle resulting from the points Q, S and R that was the point in which the straight coronal and apical portions of the instrument met. The angle of curvature was dened as the number of degrees on the arc of the circle between the beginning and end-points of the curvature; the
radius of the circle was dened as the radius of the canal curvature in millimetres (Fig. 2). The calculation of the radius and angle of curvature determined by the osculating circumference method was repeated for each instrument analysed in the two
Figure 2 The osculating circumference method to determine
the geometrical parameters of the trajectory of the instrument.
71
different articial canals. Mean values were then calculated for each instrument size. ProFile and Mtwo instruments were then tested within the two different articial canals. The instruments were rotated at a constant speed of 300 rpm using a 6:1 reduction hand-piece (Sirona Dental Systems GmbH, Bensheim, Germany) powered by a torque-controlled motor (Silver, VDW GmbH, Munich, Germany). To reduce the friction of the le as it contacted the articial canal walls, high-ow synthetic oil designed for lubrication of mechanical parts (Super Oil, Singer, Elizabethport, NJ, USA) was applied. All instruments were rotated until fracture occurred. Fracture was easily detectable because the instruments were visible through the glass window. The time to fracture for each le was recorded visually with a 1/ 100 s chronometer, and the number of rotations was calculated to the nearest whole number. The time to fracture was multiplied by the number of rotations per minute to obtain the number of cycles to failure (NCF) for each instrument. Mean values were then calculated. The length of the fractured tip was also recorded for each instrument and the mean values were then calculated for each instrument type in each group. Analysed data consisted of NCF and the length of the fractured tip for each instrument tested under the specied articial canal, and the radius and angle of curvature curvature followed by the instruments in both the articial root canals tested. The data were
processed using spss software (SPSS, Oakbrook, IL, USA). Means and standard deviations (SD) were calculated. Two different multivariate linear regression models were performed to investigate the effects of the independent variables considered in the model (size of the instrument, type of the instrument, type of the articial root canal) on the dependent variables analysed (NCF and fragment length). An independent sample t-test was used to analyse signicant differences for the angle and radius of curvature measured between the two articial root canals for each instrument tested. Signicance was determined at the 95% condence level.
Results
Mean values and SD of the radius and angle of curvature described by the instruments in the different articial canals are displayed in Table 1. Mean values SD expressed as NCF and the mean length of the fractured segment are displayed in Table 2. In the rst model, considering the NCF as dependent variable, the overall regression model was statistically signicant (F = 13.4; P = 0.000; R = 0.586). Furthermore, amongst the independent variables canal type (A, B) and instrument size (20, 0.06; 25, 0.06) were statistically signicant (P < 0.05), whilst the instrument type (Mtwo, ProFile) was not (P = 0.371). The
Table 1 Mean values SD of the radius and angle of curvature described by the instruments in the different articial canals and P-values (t-test between canal A and B)
ProFile size 20/0.06 taper Canal A Canal B ProFile size 25/0.06 taper Canal A Canal B Angle () 60 0.1 51 0.1 Angle () 60 0.1 50 0.1 Radius (mm) 4.9 0.3 5.7 0.3 Radius (mm) 5 0.2 6.6 0.4 Mtwo size 20/0.06 taper Canal A Canal B Mtwo size 25/0.06 taper Canal A Canal B Angle () 60 0.01 55 0.1 Angle () 60 0.1 54 0.3 Radius (mm) 5 0.1 5.9 0.2 Radius (mm) 4.9 0,3 6 0,4
Table 2 Mean SD expressed in number of cycles to failure (NCF) registered during the cyclic fatigue testing, mean length of the fragments SD registered for each group (in mm) and increase of the lifespan between the two groups
ProFile size 20/0.06 taper Canal A Canal B Difference* ProFile size 25/0.06 taper Canal A Canal B Difference* NCF 605 52 677 55 10% NCF 564 63 645 75 12.5% mm 4.9 0.4 3.3 0.4 mm 4,9 0.3 3.1 0.3 Mtwo size 20/0.06 taper Canal A Canal B Difference* Mtwo size 25/0.06 taper Canal A Canal B Difference* NCF 617 73 703 61 12% NCF 566 84 659 82 14% mm 5 0.2 3.5 0.3 mm 5.1 0.3 3,6 0.3
*Indicates an increase of the lifespan for canal B compared to canal A.
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multivariate linear regression showed that canal type was the independent variable with the greatest impact in the model; canal B positively affected the NCF value (St.b = 0.514, P < 0.000) when compared with canal A, whilst an increasing in size negatively affected the outcome variable (St.b = )0.260, P < 0.000). In the second model, considering the fragment length as dependent variable, the overall regression model was statistically signicant (F = 178.9; P = 0.000; R = 0.935). Even considering the fragment length the variable with the greater impact in the model was the canal type, canal B negatively affected the length of the fragment (St.b = )0.920, P < 0.000) whilst size of the instrument was not statistically signicant (P = 0.844) and type of instrument has a lower impact on the output variable (St.b = )0.179, P < 0.000). For all the instruments tested a statistically signicant difference was found between canal A and canal B for both angle and radius of curvature (P < 0.000).
Discussion
Clinically, NiTi rotary instruments are subjected to both torsional load and cyclic fatigue (Gambarini 2001, Ullmann & Peters 2005), and ongoing research aims to clarify the relative contributions of both factors to instrument separation (Peters 2004). Both cyclic fatigue tests (Pruett et al. 1997, Haikel et al. 1999) and torsion tests (Camps & Pertot 1995, Yared 2004, Ullmann & Peters 2005) have been performed to investigate how these factors may inuence the behaviour of NiTi rotary instruments in vitro. In addition, torsional properties of used instruments have been investigated (Yared et al. 2003, Yared 2004, Ullmann & Peters 2005) to analyse how the combination of these two factors may inuence instrument failure. The results of the present study showed that the shape of the articial root canal used in cyclic fatigue studies inuenced the trajectory of the instrument; for all the instrument tested both angle and radius of the curve statistically varied between canal A and B (P < 0.000). This difference is reected by the number of cycles to failure measured for the same instrument in the different articial root canals and in the high impact of the type of canal on both the NCF (St.b = 0.514) and fragment length (St.b = )0.920). The results of the present study showed a statistically signicant increase in the number of cycles to failure when instruments were tested in an articial canal that
does not sufciently restrict the instrument shaft (canal B). In this canal, the instrument would tend to regain its original straight shape, aligning into a trajectory of greater radius and reduced angle; that is, the le was actually bent less severely than reported. The results of the present study conrmed that the size of the instrument at the point of maximum curvature inuenced resistance to fracture for cyclic fatigue: bigger instruments are less resistant than smaller instruments. That is, NCF decreased as the diameter of the instrument increased (Pruett et al. 1997, Haikel et al. 1999, Grande et al. 2006, Plotino et al. 2006, 2007). This is due to the fact that when a curved root canal instrument rotates, any points within it in the segment subjected to the maximum stress, except those in the centre (neutral axis), are subjected to repeated tensile or compressive strains. The farther away from the central axis, the greater the imposed strain at that point (Craig 1997). This explains why instruments of a larger diameter are affected by fatigue more than smaller ones. Analysis of the data regarding the length of the fractured segment revealed a statistically signicant difference in the mean size between canal A and canal B for all of the instrument sizes. The centre of the curvature was constructed approximately 5 mm from the tip of the instrument for both canal A and canal B. Instruments subjected to cyclic fatigue fractured at the centre of the curvature or just below this point (Pruett et al. 1997, Fife et al. 2004). The results of the present study demonstrated that when the instruments were tested in a precise articial root canal they followed precisely the trajectory established in the construction of the canal. In fact, in the present study instruments tested in canal A fractured at the established point of maximum stress, as expected. This conrms previous ndings (Fife et al. 2004, Grande et al. 2006, Plotino et al. 2006, 2007). On the contrary, data demonstrated a signicant decrease in the mean length of the fragments for instruments tested in canal B. This was due to the fact that instruments tested in canal B did not followed the trajectory established by parameters with which the articial canal was constructed and consequently the point of maximum stress were the instrument fracture may vary. Furthermore, considering the fragment length, there was a minor but statistically signicant impact of the type of instrument on this variable (St.b = )0.179). This was because different instruments followed an unpredictable trajectory if the canal in which they were tested did not guide them in a precise trajectory.
73
As above mentioned, bending properties of different les may determine a different trajectory if the le is not constrained in a precise trajectory. If testing is completed for all different les at a given angle to ensure consistency, the bending properties of the different les determining different angles of curvature, thus bias the results and the comparisons. To limit these problems, Cheung & Darvell (2007a,b,c) constrained the instrument into a curvature using three stainless-steel pins. They used three smooth cylindrical pins of 2 mm diameter from a high hardness stainless steel mounted in acrylic shims, which were adjustable in the horizontal direction; the position of the pins determines the curvature of the instrument. A small V-shaped groove prepared on the lowest pin maintained the position of the tip of the instrument during rotation. The authors reported in detail on the effect of surface strain amplitude on fatigue failure using it as a different indicator of the stress on instruments instead of radius and angle of curvature. It has been reported in a three-point bending test of NiTi wires that such constraints will produce a curvature that is circular (Wick et al. 1995). The authors afrmed that although this cannot actually be true, the approximation should be reasonable. Unfortunately, NiTi endodontic les are tapered and with different cross-sectional design. The different bending properties of the different les and the different bending properties between the coronal and apical portion of the same le may determine a different trajectory between the pins, if the le is not constrained precisely. The present study sought to overcome the limitations of some laboratory studies in terms of the model used for testing. The articial canal was specically designed for each instrument in terms of size and taper, giving it a precise trajectory. Cylindrical metallic tubes used in previous studies (Pruett et al. 1997, Mize et al. 1998, Yared et al. 1999, 2000, Melo et al. 2002) did not sufciently restrict the instrument shaft, which would tend to regain its original straight shape, aligning into a trajectory of greater radius and reduced angle (Yared et al. 1999, 2000, Melo et al. 2002, Bahia & Buono 2005). The results of a previous study (Plotino et al. 2009b) reported that an articial canal manufactured as described in the present to riproduce instrument size and taper seems to guarantee that different NiTi rotary instruments may follow a precise and repeatable trajectory in terms of radius and angle of curvature. On the contrary, if the articial canal is not identical (in shape and size) to the instrument, its trajectory will not respond to the established parameters, thus having a reduced curvature during the test. The results of the
present study demonstrated that the variation in the trajectory followed by the instruments in the articial canals used to test fatigue resistance could inuence the results of cyclic fatigue tests.
Conclusions
The null hypothesis tested in the present study has been rejected. Results of the present study reported that even small variations of the geometrical parameters of the curvature of an instrument subjected to exural fatigue could determine a signicant inuence on the results of fatigue tests. The standardization of the parameters and devices used for cyclic fatigue testing of NiTi rotary instruments is lacking. A more precise regulation is required to obtain more consistent and comparable results in different studies.
References
Bahia M, Buono V (2005) Decrease in the fatigue resistance of nickel-titanium rotary instruments after clinical use in curved root canals. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology 100, 24955. Camps JJ, Pertot WJ (1995) Torsional and stiffness properties of nickel-titanium K les. International Endodontic Journal 28, 23943. Cheung GS, Darvell BW (2007a) Fatigue testing of a NiTi rotary instrument. Part 1: strain-life relationship. International Endodontic Journal 40, 6128. Cheung GS, Darvell BW (2007b) Fatigue testing of a NiTi rotary instrument. Part 2: fractographic analysis. International Endodontic Journal 40, 61925. Cheung GS, Darvell BW (2007c) Low-cycle fatigue of NiTi rotary instruments of various cross-sectional shapes. International Endodontic Journal 40, 62632. Craig RG (1997) Restorative Dental Materials, 10th edn. St. Louis, MO, USA: Mosby. Fife D, Gambarini G, Britto LR (2004) Cyclic fatigue testing of ProTaper NiTi rotary instruments after clinical use. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology 97, 2516. Gambarini G (2001) Cyclic fatigue of ProFile rotary instruments after prolonged clinical use. Internatiomal Endodontic Journal 34, 3869. Grande NM, Plotino G, Pecci R, Bedini R, Somma F (2006) Cyclic fatigue resistance and three-dimensional analysis of instruments from two nickel-titanium rotary systems. International Endodontic Journal 39, 75563. Gray A (1997) Osculating circles to plane curves. In: Gray A, Abbena E, Salamon S, eds. Modern Differential Geometry of Curves and Surfaces with Mathematic, 2nd edn. Boca Raton, FL: CRC Press, pp. 1115.
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Haikel Y, Serfaty R, Bateman G, Senger B, Allemann C (1999) Dynamic and cyclic fatigue of engine-driven rotary nickel titanium endodontic instruments. Journal of Endodontics 25, 43440. Malagnino VA, Passariello P, Corsaro S (1999) The inuence of root canal trajectory on the risk of cyclic fatigue failure on Ni-Ti engine driven endodontic instruments. Italian Journal of Endodontics 13, 190200. Melo MC, Bahia MGA, Buono VTL (2002) Fatigue resistance of engine-driven rotary nickel-titanium endodontic instruments. Journal of Endodontics 28, 7659. Mize SB, Clement DJ, Pruett JP, Carnes DL Jr (1998) Effect of sterilization on cyclic fatigue of rotary nickel-titanium endodontic instruments. Journal of Endodontics 24, 8437. Parashos P, Messer HH (2006) Rotary NiTi instrument fracture and its consequences. Journal of Endodontics 32, 103143. Peters OA (2004) Current challenges and concepts in the preparation of root canal systems: a review. Journal of Endodontics 30, 55965. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. (2009) A review on cyclic fatigue test of nickel-titanium rotary instruments. Journal of Endodontics. In press. Plotino G, Grande NM, Sorci E, Malagnino VA, Somma F (2006) A comparison of cyclic fatigue between used and new Mtwo NiTi rotary instruments. International Endodontic Journal 39, 71623. Plotino G, Grande NM, Sorci E, Malagnino VA, Somma F (2007) Inuence of a brushing working motion on the fatigue life of NiTi rotary instruments. International Endodontic Journal 40, 4551. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G (2009b) Measurement of the trajectory of different NiTi rotary instruments in an articial canal specically designed
for cyclic fatigue tests. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 108, e1526. DOI: 10.1016/j.tripleo.2009.05.046. Pruett JP, Clement DJ, Carnes DL (1997) Cyclic fatigue of nickel-titanium endodontic systems. Journal of Endodontics 23, 7785. Ruddle C (2002) Cleaning and shaping the root canal system. In: Cohen S, Burns RC, eds. Pathways of the Pulp, 8th edn. St. Louis: Mosby, pp. 23192. Sattapan B, Nervo G, Palamara J, Messer H (2000) Defects in nickel titanium endodontic rotary les after clinical usage. Journal of Endodontics 26, 1615. Serene TP, Adams JD, Saxena A (1995) Nickel-Titanium Instruments: Applications in Endodontics. St Louis, MO, USA: Ishiyaku EuroAmerica. Ullmann CJ, Peters OA (2005) Effect of cyclic fatigue on static fracture loads in ProTaper nickel-titanium rotary instruments. Journal of Endodontics 31, 1836. Wick A, Vohringer O, Pelton AR (1995) The bending behavior of NiTi. Journal de Physique IV, Colloque C8 (ICOMAT-95) 5, 78994. Yared GM (2004) In vitro study of the torsional properties of new and used prole nickel titanium rotary les. Journal of Endodontics 30, 4102. Yared GM, Bou Dagher FE, Machtou P (1999) Cyclic fatigue of prole rotary instruments after simulated clinical use. International Endodontic Journal 32, 1159. Yared GM, Bou Dagher FE, Machtou P (2000) Cyclic fatigue of prole rotary instruments after clinical use. International Endodontic Journal 33, 2047. Yared G, Kulkarni GK, Ghossayn F (2003) Torsional properties of new and used rotary K3 NiTi les. Australian Endodontic Journal 29, 758.
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doi:10.1111/j.1365-2591.2009.01645.x
CASE REPORT
Apexogenesis after initial root canal treatment of an immature maxillary incisor a case report
S. R. Kvinnsland1, A. Bardsen2 & I. Fristad2
Clinic of Dentistry Endodontics; and 2Department of Clinical Dentistry Endodontics, University of Bergen, Bergen, Norway
1
Abstract
Kvinnsland SR, Bardsen A, Fristad I. Apexogenesis after initial root canal treatment of an
immature maxillary incisor a case report. International Endodontic Journal, 43, 7683, 2010.
Aim To present a case where a traumatized, immature tooth still showed capacity for continued root development and apexogenesis after root canal treatment was initiated based on an inaccurate pulpal diagnosis. Summary Traumatic dental injuries may result in endodontic complications. Treatment strategies for traumatized, immature teeth should aim at preserving pulp vitality to ensure further root development and tooth maturation. A 9-year-old boy, who had suffered a concussion injury to the maxillary anterior teeth, was referred after endodontic treatment was initiated in tooth 21 one week earlier. The tooth had incomplete root length, thin dentinal walls and a wide open apex. The pulp chamber had been accessed, and the pulp canal instrumented to size 100. According to the referral, bleeding from the root made it difcult to ll the root canal with calcium hydroxide. No radiographic signs of apical breakdown were recorded. Based on radiographic and clinical ndings, a conservative treatment approach was followed to allow continued root development. Follow-up with radiographic examination every 3rd month was performed for 15 months. Continued root formation with apical closure was recorded. In the cervical area, a hard tissue barrier developed, which was sealed with white mineral trioxide aggregate (MTA). Bonded composite was used to seal the access cavity. At the nal 2 years follow-up, the tooth showed further root development and was free from symptoms. Key learning points Endodontic treatment of immature teeth may result in a poor long-term prognosis. The pulp of immature teeth has a signicant repair potential as long as infection is prevented.
Correspondence: Inge Fristad, Department of Clinical Dentistry Endodontics, University of Bergen, Arstadveien 17, N-5009 Bergen, Norway (Tel.: + 47 55 58 66 04; e-mail: inge.fristad@ iko.uib.no).
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Treatment strategies of traumatized, immature permanent teeth should aim at preserving pulp vitality to secure further root development and tooth maturation. Radiographic interpretation of the periapical area of immature teeth may be confused by the un-mineralized radiolucent zone surrounding the dental papilla.
CASE REPORT
Keywords: apexogenesis, diagnosis, endodontic treatment, immature tooth, pulp necrosis, root development.
Received 5 June 2009; accepted 20 September 2009
Introduction Traumatic dental injuries may jeopardize pulp survival in affected teeth. Luxation injuries and avulsions are the most frequent traumatic causes for pulp necrosis resulting in the need for endodontic treatment. In immature teeth, preservation of pulp vitality is crucial for continued dentine formation and root development. Thus, treatment strategies for the immature young dentition are important for the long-term prognosis of teeth and should aim at preserving pulp vitality to secure tooth maturation and root development. In immature teeth with pulp necrosis and bacterial infection, the long-term prognosis is related to the stage of root development and the amount of root dentine present at time of injury (Cvek 1992). In teeth with an open apex, luxation may occur without disruption of the pulpal blood and nerve supply. Moreover, pulp revascularization and repair will more readily occur in teeth with a wide apical foramen (Andreasen et al. 1986). Consequently, a more conservative treatment approach is recommended during follow-up of traumatized immature teeth. Bacterial control is important and decisive to avoid infection resulting in arrested root development. The repair potential of immature teeth following luxation injuries is reected in a more favourable outcome after injury compared to mature teeth (Andreasen & Pedersen 1985). Two factors have been found to be signicantly related to the development of pulp necrosis; the type of luxation injury and stage of root development (Andreasen 1970). The frequency of pulp necrosis after luxation injuries in the permanent dentition has been found to range from 5% to 59% (Andreasen & Andreasen 2007). Concussion and subluxation injuries seldom results in pulp necrosis in immature teeth, whereas pulp necrosis occurs in approximately 5% of teeth with complete root development (Andreasen & Pedersen 1985). Following more serious luxation injuries, such as extrusive and lateral luxation, approximately 10% of teeth with an open apex will develop pulp necrosis (Andreasen et al. 1987, Andreasen 1989). From previous studies, there appears to be a general agreement that lack of pulp sensitivity or coronal discolouration alone is not sufcient diagnostic criteria to justify pulp necrosis (Magnusson & Holm 1969, Bhaskar & Rappaport 1973, Zadik et al. 1979, Jacobsen 1980). Periapical radiolucency has so far been considered to be the safe sign of pulp necrosis. However, investigations have questioned the validity of this assumption (Andreasen 1989). In teeth with incomplete root formation, the radiographic interpretation of the periapical area may be confused by the un-mineralized radiolucent zone surrounding the dental papilla (Andreasen 1989). Even the concomitant presence of all three classical signs of pulp necrosis; coronal discolouration, loss of pulp sensitivity and periapical radiolucency, can in rare cases be followed by pulp repair (Andreasen 1989). Pulp necrosis should be conrmed by sensitivity tests, keeping in mind that false positive or negative result may be recorded. Pulp diagnosis is decisive for appropriate
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treatment and long-term prognosis. Infected teeth left untreated (false positive) might be lost because of infectious related resorptions (Fuss et al. 2003). On the other hand, the initiation of endodontic treatment of vital immature teeth (false negative) will impair dentine formation and root development, thus substantially reducing the chances of longterm survival (Cvek 1992). The aim of this report is to present a case where a traumatized, immature tooth still showed capacity for further root development and apexogenesis even after endodontic instrumentation of the root canal. The treatment was based on an inaccurate pulp diagnosis.
CASE REPORT
Case report A 9-year-old boy was referred from the public dental health service to the clinic for postgraduate endodontic training, University of Bergen, Bergen, Norway. The referral was based on the following information: the maxillary central incisors were subjected to a traumatic dental injury during ice-skating. Immediately after the accident, the patient was examined at a public dental emergency clinic where concussion of the maxillary central incisors was diagnosed. No emergency treatment was performed, and the patient was referred to the public dental health service for follow-up. One month later, the patient claimed weak and diffuse symptoms in the maxillary anterior region. An appointment at the public dental health service was organized. Based on radiographic and clinical ndings, apical periodontitis was diagnosed (Fig. 1a). Vital pulp tissue with normal bleeding was recorded when the pulp chamber was accessed. The root canal was then instrumented to size 100 and irrigated with sodium hypochlorite 0.5% (Fig. 1b). According to the patient record, there was profound bleeding with difculties applying calcium hydroxide paste in the instrumented root canal. Following the referral, a clinical and radiographic examination was performed 1 week after initial endodontic treatment. Tooth 21 was free from symptoms. Radiographs revealed an immature tooth with incomplete root length, thin dentinal walls and a wide open apex (Fig. 2a). No radiographic signs of apical breakdown were recorded. A radio-
(a)
(b)
Figure 1 Radiographs taken 1 month after subluxation of the anterior teeth. The diagnosis apical periodontitis form an infected root canal was set based on radiograph (a). The instrumentation length was set according to radiograph (b), followed by instrumentation of the root canal to reamer ISO 100.
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CASE REPORT
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Figure 2 Radiographs showing continued root development during a 2 year follow-up period. (a) Radiograph taken at the rst appointment shows an immature tooth with incomplete root length, thin dentinal walls and an open apex. Calcium hydroxide is visible in the coronal part of the root canal. (b) One month later, slight growth of the root and mineralization in the cervical area is noted. (cf) Continued root formation and apical closure is observed during 15 months follow-up. (g) Radiograph taken after application of mineral trioxide aggregate (MTA). (h) Final follow-up 2 years after the rst appointment. Bonded composite is used to seal the access cavity.
opaque material (calcium hydroxide) was visible only in the coronal part of the root canal (Fig. 2a). Based on the radiographic and clinical ndings, the diagnosis previous initiated root canal treatment (vital tooth) was recorded. Because of the insufcient introduction of calcium hydroxide into the root canal, a conservative approach was decided upon, thereby allowing observation of any further continued root development. Completion of the endodontic treatment at this stage would result in a weak tooth with poor prognosis. The patient and his parents were informed and agreed to the proposed treatment strategy. At follow-up, 1 month later, (Fig. 2b) the tooth was still free of symptoms. The colour of the tooth was normal, and signs of slight growth of the root could be noticed from the radiographs. Four months later, (Fig. 2c) the radiographs showed continued root formation and thickening of the dentinal walls. The calcium hydroxide dressing was removed with sodium hypochlorite 0.5%. A calcied bridge of hard tissue was veried in the cervical 1/3 of the root by visual inspection through a dental surgical microscope. The coronal part of the tooth was dried and packed with calcium hydroxide paste, and IRM was placed as a temporary lling (Fig. 3a). The tooth was then followed with radiographic examination every 3rd month for the following 15 months (Figs 2df). Continued root formation and apical closure were registered. No clinical symptoms were recorded. Finally, a 23 mm thick plug of white mineral trioxide aggregate (MTA, Angulus) was placed in contact with the hard tissue bridge (Fig. 2g, and the access cavity lled with bonded composite (Tetric ow/Tetric Ceram, Ivoclar Vivadent AG, Liechtenstein). Follow-up was performed 7 months later
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CASE REPORT
(a)
(b)
Figure 3 Clinical situation before placement of mineral trioxide aggregate (MTA) (a). Follow-up 7 months after application of white MTA showing light grey discolouration in the cervical area of tooth number 21 (b).
(Fig. 2h). The tooth was free from symptoms, and radiographs showed further root development. Slight discolouration was noted in the cervical area (Fig. 3b).
Discussion This case report illustrates the repair potential of a tooth with incomplete root formation. The capacity for continued root development was preserved after traumatic injury and treatment complications. Furthermore, it underlines the importance of an accurate pulp diagnosis and a proper plan for treatment and follow-up of these teeth. Development of pulp necrosis after dental trauma can be associated with symptoms such as spontaneous pain or tenderness to percussion (Andreasen 1989). From previous studies, it appears to be a general agreement that lack of pulp sensitivity (Magnusson & Holm 1969, Bhaskar & Rappaport 1973, Zadik et al. 1979, Jacobsen 1980) or coronal discolouration alone is not sufcient to justify pulp necrosis (Magnusson & Holm 1969, Jacobsen 1980). Diagnosing traumatized, immature teeth may be a challenge to the dentist, as demonstrated in the present case. The radiolucent zone surrounding the apical dental papilla was interpreted as a periapical lesion from an infected necrotic pulp. The initial endodontic treatment was based on misinterpretation of clinical and radiographic ndings. Although the root canal was instrumented to size 100, some odontoblasts and pulp cells may have been left intact. The incomplete administration of calcium hydroxide paste into the pulp canal was in this sense favourable. In addition, the copious solid bleeding from the pulp tissue may have favoured reorganization of surviving pulpal tissue. Different traumatic injuries may interfere with the pulpal neurovascular supply and give rise to various defence and repair responses, ranging from localized or generalized pulpal inammation, tissue regeneration, reparative dentine formation or bone metaplasia and internal resorption, as well as pulp necrosis with or without bacterial
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CASE REPORT
contamination (Andreasen et al. 1988). A common pattern of the repair process is reorganization of the damaged pulp tissue, formation of new vessels and recruitment of pulp progenitor cells to the injured area, whereby a tissue loss is gradually replaced by new tissue (Andreasen et al. 1988). The character of the pulpal responses varies, not only according to the type and severity of the traumatic injury, but also on the origin of the progenitor cells involved in the process. Tissue repair may be initiated from progenitor cells of pulpal origin, from periodontal tissues or from a combination of the two. If damaged pulp tissue is renewed by progenitor cells of pulpal origin, differentiation of new odontoblasts, forming reparative dentine, may occur. The new dentine formed may even be re-innervated by sensory nerves (Kvinnsland et al. 1991). In contrast, when the damaged tissue is restored by cells from periodontal tissues, periodontal stem cell progenitors may invade the root canal resulting in collagen and hard tissue formation. In the present case, continued normal root formation was seen, indicating repair based on cells of pulpal origin. If a pulp exposure site is covered with a suitable capping material, limiting or preventing bacterial contamination, a hard tissue barrier is normally established (Watts & Paterson 1981, Cvek 2007). In the present case, radiographic examination indicated the presence of calcium hydroxide paste only in the coronal part of the tooth. The initial application of calcium hydroxide paste may have initiated the formation of a hard tissue bridge in the canal entrance. The type and quality of this hard tissue bridge cannot be evaluated by radiographic or clinical inspection. The cells responsible for the formation of this hard tissue barrier include mesenchymal, paravascular cells that differentiate into odontoblasts like cells (Ruch 1945, Sveen & Hawes 1968, Zach et al. 1969, Feit et al. 1970, Luostarinen 1971, Yamamura 1985). Hard tissue bridges formed after calcium hydroxide application are often incomplete with multiple tunnel defects that may lead to micro leakage (Cox et al. 1996). As a consequence, a bacteria tight seal should be established over the bridge. In this case, white MTA followed by bonded composite was used for this purpose. Discolouration of the tooth because of the use of Grey MTA in the cervical region has been reported (Glickman & Koch 2000). As an attempt to overcome this problem, white MTA has recently been introduced. The major difference between grey and white MTA is the concentration of Al2O3, MgO and, especially, FeO, with the observed values for each of these oxides being considerably lower in the white MTA (Asgary et al. 2005). Differences in the observed FeO concentration are thought to be primarily responsible for the variation in colour of the white MTA when compared to gray MTA. The present case showed slight grey discolouration even after lling with white MTA in the cervical part of the root canal, indicating that the aesthetic properties of MTA are not completely solved. Although the cervical discolouration of the crown was noted, it was accepted by the patient and his parents.
Conclusion Special care should be taken during the evaluation and follow-up of traumatized immature teeth, and more then one sign indicating pulp necrosis should be recorded before endodontic treatment is started. In this case, the apical un-mineralized apical area surrounding the developing dental papilla was unintentionally interpreted as apical pathosis from an infected necrotic pulp. An observation strategy is recommended and no intervention should be carried out before pulp necrosis is properly veried. Initially, a frequent follow-up regime should be used for periodontal injuries at high risk of inammatory resorption to allow early identication of this pathology. The long-term prognosis of immature teeth is dependent on continued root formation.
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CASE REPORT
Disclaimer Whilst this article has been subjected to Editorial review, the opinions expressed, unless specically indicated, are those of the author. The views expressed do not necessarily represent best practice, or the views of the IEJ Editorial Board, or of its afliated Specialist Societies.
References
Andreasen JO (1970) Luxation of permanent teeth due to trauma. A clinical and radiographic follow-up study of 189 injured teeth. Scandinavian Journal of Dental Research 78, 27386. Andreasen FM (1989) Pulpal healing after luxation injuries and root fracture in the permanent dentition. Endodontics and Dental Traumatology 5, 11131. Andreasen FM, Andreasen JO (2007) Luxation injuries of permanent teeth: general ndings. In: Andreasen JO, Andreasen FM, Andreasen L, eds. Traumatic Injuries to the Teeth, 4th edn. Copenhagen: Blackwell Munksgaard, pp. 37297. Andreasen FM, Pedersen BV (1985) Prognosis of luxated permanent teeth the development of pulp necrosis. Endodontics and Dental Traumatology 1, 20720. Andreasen FM, Zhijie Y, Thomsen BL (1986) Relationship between pulp dimensions and development of pulp necrosis after luxation injuries in the permanent dentition. Endodontics and Dental Traumatology 2, 908. Andreasen FM, Zhijie Y, Thomsen BL, Andersen PK (1987) Occurrence of pulp canal obliteration after luxation injuries in the permanent dentition. Endodontics and Dental Traumatology 3, 10315. Andreasen JO, Kristerson L, Andreasen FM (1988) Damage of the Hertwigs epithelial root sheath: effect upon root growth after autotransplantation of teeth in monkeys. Endodontics and Dental Traumatology 4, 14551. Asgary S, Parirokh M, Eghbal MJ, Brink F (2005) Chemical differences between white and gray mineral trioxide aggregate. Journal of Endodontics 31, 1013. Bhaskar SN, Rappaport HM (1973) Dental vitality tests and pulp status. Journal of American Dental Association 86, 40911. Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH (1996) Tunnel defects in dentin bridges: their formation following direct pulp capping. Operative Denistryt 21, 411. Cvek M (1992) Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and lled with gutta-percha. A retrospective clinical study. Endodontics and Dental Traumatology 8, 4555. Cvek M (2007) Endodontic Management and the use of Calcium Hydroxide in Traumatized Permanent Teeth. In: Andreasen JO, Andreasen FM, Andersson L, eds. Traumatic Injuries to the Teeth, 4th edn. Copenhagen: Blackwell Munksgaard, pp. 598647. Feit J, Metelova M, Sindelka Z (1970) Incorporation of 3H thymidine into damaged pulp of rat incisors. Journal of Dental Research 49, 7836. Fuss Z, Tsesis I, Lin S (2003) Root resorption diagnosis, classication and treatment choices based on stimulation factors. Dental Traumatology 19, 17582. Glickman GN, Koch KA (2000) 21st-century endodontics. Journal of American Dental Association 131(Suppl), 39S46S. Jacobsen I (1980) Criteria for diagnosis of pulp necrosis in traumatized permanent incisors. Scandinavian Journal of Dental Research 88, 30612. Kvinnsland I, Heyeraas KJ, Byers MR (1991) Regeneration of calcitonin gene-related peptide immunoreactive nerves in replanted rat molars and their supporting tissues. Archives of Oral Biology 36, 81526. Luostarinen V (1971) Dental pulp response to trauma. An experimental study in the rat. Suomi Hammaslaak Toim 67(Suppl 2), 374. Magnusson B, Holm AK (1969) Traumatised permanent teeth in children a follow-up. I. Pulpal complications and root resorption. Svenske Tandlakare Tidskrift 62, 6170.
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Ruch J (1945) Odontoblast differentiation and the formation of the odontoblast layer. Journal of Dental Research 64, 48998. Sveen OB, Hawes RR (1968) Differentiation of new odontoblasts and dentine bridge formation in rat molar teeth after tooth grinding. Archives of Oral Biology 13, 1399409. Watts A, Paterson RC (1981) Cellular responses in the dental pulp: a review. International Endodontic Journal 14, 109. Yamamura T (1985) Differentiation of pulpal cells and inductive inuences of various matrices with reference to pulpal wound healing. Journal of Dental Research 64, 53040. Zach L, Topal R, Cohen G (1969) Pulpal repair following operative procedures. Radioautographic demonstration with tritiated thymidine. Oral Surgery Oral Medicine Oral Pathology 28, 58797. Zadik D, Chosack A, Eidelman E (1979) The prognosis of traumatized permanent anterior teeth with fracture of the enamel and dentin. Oral Surgery Oral Medicine Oral Pathology 47, 1735.
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doi:10.1111/j.1365-2591.2009.01644.x
CASE REPORT
Non-resolving periapical inammation: a malignant deception

D. Saund, S. Kotecha, J. Rout & T. Dietrich
Birmingham Dental Hospital, University of Birmingham, Birmingham, UK
Abstract
Saund D, Kotecha S, Rout J, Dietrich T. Non-resolving periapical inammation: a malignant deception. International Endodontic Journal, 43, 8490, 2010.
Aim To report a case of oral non-Hodgkins lymphoma with a delayed diagnosis. Summary Non-Hodgkins lymphoma of the oral cavity is an uncommon but important condition. Early diagnosis is complicated when the presenting signs and symptoms are similar to those of odontogenic infections. This report describes the case of a 38-year-old female patient who presented to her dentist complaining of pain in her upper jaw. Subsequent dental treatment, including extraction, root canal treatment and apicectomy including biopsy were carried out by the patients dentist and local dental hospital. Nine months elapsed before a more extensive surgical exploration established a diagnosis of lymphoma. Key learning points To appreciate the importance of recognizing discrepancies between the clinical scenario and histopathological ndings. To appreciate subtle radiographic changes that may accompany malignant disease of the jaw bones. To appreciate the need for early referral when a patients symptoms do not satisfactorily respond to conventional dental therapies. To appreciate lymphoma should be considered in the differential diagnosis of nonhealing periapical inammation and non-healing socket. Keywords: lymphoma, non-healing socket, periapical infection. Received 16 December 2008; accepted 7 September 2009
Introduction The incidence of non-Hodgkins lymphoma (NHL) has increased by over 50% in the 20-year period between 1986 and 2005 (Cancer Research UK 2008a). NHL now accounts for 4% of all malignant neoplasms in the UK (Cancer Research UK 2008b). It is the third most common malignancy to affect the head and neck region, after squamous cell
Correspondence: Daniel Saund, Birmingham Dental Hospital, St Chads Queensway, Birmingham, B4 6NN, UK (e-mail: d.s.saund@bham.ac.uk).
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carcinoma and salivary gland tumours (Barker 1984). NHL can be classied according to the cell of origin into T-cell or B-cell lymphoma; the latter being more common in the oral cavity (Neville et al. 2009). The incidence of NHL is rare in patients under the age of 40, with approximately 70% of all cases being diagnosed in people over 60 years. It predominately occurs in lymph nodes but 2040% arise in extra-nodal sites (Neville et al. 2009). The gut is the commonest site for extra-nodal lymphoma, but bone and the mouth are other frequently affected sites. Non-Hodgkins lymphoma can present in a number of different forms within the oral cavity, the more frequent being palatal (Tomich and Shafer 1975) and gingival swellings (Spatafore et al. 1989, Payne and al-Damouk 1993). It is reported that 3645% of oral NHL can affect the jaw bones (Keyes et al. 1988). The initial diagnosis of oral lymphomas can be challenging as they may resemble pyogenic granulomas, ulcers, sinusitis (Spatafore et al. 1989), a non-healing socket (Thomas et al. 1991) or mimic an acute dental abscess (Spatafore et al. 1989, Rog 1991, Payne & al-Damouk 1993). Patients may complain of non-specic pain, which may be misdiagnosed as periapical inammatory disease. This report presents a case of malignant NHL which was originally diagnosed and treated as an odontogenic infection.
Case report A 38 year-old Afro-Caribbean female referred herself to the Birmingham Dental Hospital, UK primary care unit in November 1998. She described a 6-month history of a spontaneous intermittent dull ache in the upper left canine region. There was no disturbance to her sleep pattern. She had visited her GDP on several occasions over the preceding 6 months without resolution of her discomfort, despite extraction of tooth 22 and root canal treatment to teeth 23 and 24. Her medical history was unremarkable. She was a non-smoker and drank 2 units of alcohol per week. On clinical examination, there was no lymphadenopathy of the head and neck region. An intra oral inspection revealed a non-healing socket where the 22 had been removed 4 months previously. The buccal sulcus was tender to palpation over the apex of the 23, but no swelling or ulceration was apparent. The 23 and 24 were not mobile and were nontender to percussion. She had a good standard of oral hygiene and there was no evidence of periodontal disease. A periapical radiograph revealed a radiolucency and a dense radiopaque foreign body, probably amalgam, at the base of the 22 socket (Fig. 1). The 23 and 24 (Fig. 2) had satisfactory root canal llings with no associated apical radiolucencies and good periodontal support. She was prescribed a course of amoxicillin and reviewed a week later. As her symptoms had not improved the 22 socket was surgically investigated. During this procedure, granulation tissue was removed but not submitted for histopathology. Curettage of the 22 socket and a further two courses of amoxicillin failed to resolve her symptoms so the 23 and 24 region was investigated and an apicectomy performed on both teeth. Soft tissue was curetted from around the apices of 23 and 24 resulting in an oro-antral communication due to loss of bone. The histology revealed chronically inamed granulation tissue. Three months after her presentation to the dental hospital and 9 months following onset of her symptoms, radiographic follow-up revealed destructive bony changes (Fig. 3). The 23 and 24 apical radiolucency had increased in size, showed perforation of the cortical bone and loss of the bony antral oor (Fig. 3). As a consequence, a further biopsy was performed, which revealed extensive soft tissue replacement of the left maxillary alveolar process extending from close to the
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Figure 1 Periapical radiograph taken at presentation of UL2 socket demonstrating foreign body.
palatal midline, posteriorly to the left maxillary buttress and superiorly towards the oor of the nose. Extraction of the 23 led to the simultaneous removal of the 24 encased in a loose segment of surrounding maxillary alveolus. The histology of the soft tissue component again showed a granulomatous foreign body reaction consistent with a periapical granuloma, whereas examination of the tissue block containing bone and teeth revealed a dense inltrate of cells that had the appearance of malignant lymphoid cells. A preliminary diagnosis of lymphoma was made and the patient referred for further assessment and management. A computerized tomography (CT) scan showed destruction of the left maxillary alveolus (Fig. 4). Further biopsy conrmed a diagnosis of non-Hodgkins lymphoma of the left maxilla. Additional investigations showed that there were no other lesions elsewhere in the body and thus the disease was classied stage 1AE (single extranodal site without systemic signs of disease). She was treated with radiotherapy to the left maxilla and chemotherapy. Seven years later the patient has no signs of recurrence and remains under annual review.
Discussion Inammatory processes of the jaws may present in an indolent manner or show a more aggressive behaviour. Typically odontogenic inammation results in pain, widening of the periodontal ligament space, and the development of a periapical radiolucency that is usually well dened. Occasionally developmental anomalies, metabolic diseases and malignancies can resemble dental inammatory disease but do not respond to root canal treatment or tooth extraction. In this situation the clinician should review the accuracy of the diagnosis so that the appropriate treatment is not delayed.
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Figure 2 Periapical radiograph taken at presentation showing root llings UL34 and periradicular bone.
Figure 3 Periapical radiograph taken 3 months after presentation showing destructive features with cortical bony destruction above UL3.
The presented case and several others in the literature have demonstrated that extranodal lymphoma of the jaws may initially present, particularly in the early stages, with unspecic signs and symptoms mimicking periapical disease (Slootweg et al. 1985, Macintyre 1986). Lymphomas can become secondarily infected and present with swelling mimicking a dental abscess (Rog 1991, Bavitz et al. 1992, Ardekian et al. 1996). The initial clinical impression of inammatory disease was supported when antibiotic therapy appeared to reduce symptoms (Keyes et al. 1988). Whilst many malignant lesions are easily recognized there are situations when they resemble other conditions. Although
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Figure 4 Axial CT image showing erosion of left maxillary alveolus following diagnosis of lymphoma.
certain clinical features such as increased tooth mobility in the absence of advanced periodontal disease and neurosensory disturbances may point towards non-odontogenic disease, they may not be present initially (Gusenbauer et al. 1990). Similarly, radiographs used to investigate dental disease may demonstrate ndings such as poorly dened or moth-eaten osteolytic lesions (Macintyre 1986), root resorption and erosion of crestal bone, which are not typical for odontogenic lesions. However, destructive radiographic changes may not be evident in slow growing lymphomatous lesions of the jaws (Keyes et al. 1988, Rog 1991). Malignant disease involving bone can resemble periapical inammatory disease particularly when the latter is infected changing its margin so it is less well dened. Periapical inammation is common whilst lymphoma in the jaws is not thus one tends not to consider it in the diagnosis. It is important to review the clinical features and radiological ndings, and when these are unusual the diagnosis needs to be reconsidered rather than persisting with inappropriate treatment. In addition, early referral to a secondary setting for specialist opinion must always be considered. However, cases such as the one presented here have to be cautiously interpreted with respect to missed clinical and radiographic signs, as post-hoc interpretation may be misleading because primary manifestation of lymphoma or other malignancies as periapical pathology is uncommon. Therefore, a signicant proportion of cases presenting with one or more of the atypical signs and symptoms discussed above may still represent odontogenic pathologies. Whilst the authors cannot comment on the indications for, and the sequence of treatment undertaken by the general practitioner during the 6-month period prior to the patients attendance in the hospital, it is quite clear that several therapeutic attempts aimed at what was thought to be an odontogenic problem had failed. When initially seen at our clinic, the non-healing extraction socket was attributed to the foreign body visible on the radiograph and surgically revised without obtaining any material for histopathological examination. Although an unlikely cause for the patients symptoms, it is not unreasonable to remove a foreign body from a non-healing socket. However, the long history and failure to respond to previous treatment should have raised the suspicion that the condition was not infective and a tissue sample for histopathological examination should have been retrieved (Rog 1991). In the present case it is however unclear if this would have resulted in an earlier diagnosis, particularly when the
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subsequent histology suggested an inammatory process and the age of the patient was younger than one expects for lymphoma. Histologically, the distinction between lymphoma and periapical inammation is often challenging, and as in this and other cases, lymphoma has been interpreted as being inammatory in nature (Keyes et al. 1988, Richards et al. 2000). These difculties have been attributed to inadequate biopsy specimens and poor handling of the tissue by the clinician leading to crush artefact which obscures the ne cytological detail needed to distinguish between benign and malignant lymphocytes. It is often difcult to obtain an adequate tissue sample because of the close location to roots (Wannfors and Hammarstrom 1990). To increase the chances of accurate diagnosis large specimens representative of the tumour are required (Rog 1991). One biopsy may be insufcient to make a diagnosis and re-biopsy of non-healing lesions including bone within the sample may be required. The diagnostic difculty increases when lymphomas become inamed, obscuring the neoplastic nature of the inltrate (Wright and Radman 1995). Indeed, the soft tissue samples retrieved during the course of treatment were found to be consistent with a chronic inammatory lesion. The histopathological diagnosis of lymphoma was made from the hard tissue block accidentally retrieved during the extraction of the associated teeth. This illustrates that, in order to obtain a correct diagnosis earlier, a block biopsy of the affected bone may have been required to yield the true nature of the disease process.. However, this constitutes a rather invasive, if not destructive procedure, and given that lymphoma is extremely rare, adoption of a practice of early block biopsy would result in unnecessary morbidity in many cases. However, in light of diagnostic difculties with histopathological examination and plain lm radiography earlier referral for more advanced imaging techniques such as computed tomography or magnetic resonance imaging should have been considered. Over the course of her treatment, the patient received three courses of antibiotics without resolution of her symptoms. Antibiotics have no role in the treatment of persistent non-healing sockets. Lymphomas and other non-odontogenic diseases may become secondarily infected. In this situation a reduction of symptoms with antibiotic treatment may delay proper diagnosis (Keyes et al. 1988). Although extranodal lymphoma of the jaws is uncommon, perhaps with the increasing incidence of HIV infection (UNAIDS 2008), a continued increase in the incidence of lymphoma will be observed. As demonstrated, lymphoma may masquerade as common dental inammatory disease and clinicians should be alert to the possibility of sinister pathology. In the study by Maxymiw et al. 2001 a high percentage of patients with NHL had dental symptoms. These cases often demonstrate recurrent or protracted disease patterns, as seen in this case with a delay of 9 months before making the correct diagnosis. This is longer than the average 2.5 months between presentation and treatment reported in other cases (Gusenbauer et al. 1990). NHL of the head and neck has a good prognosis with a median survival rate of 1015 years but the prognosis is improved with early diagnosis (Payne & al-Damouk 1993).
Conclusion Despite its rare occurance, dentists must consider lymphoma in the differential diagnosis of pain, swelling, ulceration and non-healing periapical inammation. In general, dentists should have a high index of suspicion for lesions (including periapical lesions) that do not respond to conventional therapy or appear unusual in other ways and as such have a role in early diagnosis and prompt referral of patients for specialist secondary care. Finally, the possibility of false negative biopsy results must be considered and referral to specialist care may be warranted even in a case of a negative initial biopsy result.
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Disclaimer Whilst this article has been subjected to Editorial review, the opinions expressed, unless specically indicated, are those of the author. The views expressed do not necessarily represent best practice, or the views of the IEJ Editorial Board, or of its afliated Specialist Societies.
References
Ardekian L, Peleg M, Samet N, Givol N, Taicher S (1996) Burkitts lymphoma mimicking an acute dentoalveolar abscess. Journal of Endodontics 22, 6978. Barker GR (1984) Unifocal lymphomas of the oral cavity. British Journal of Oral & Maxillofacial Surgery 22, 42630. Bavitz JB, Patterson DW, Sorensen S (1992) Non-Hodgkins lymphoma disguised as odontogenic pain. Journal of the American Dental Association 123, 99100. Cancer Research UK (2008a) UK Non-Hodgkin lymphoma incidence statistics. http://info.cancerresearchuk.org/cancerstats/types/nhl/incidence/?a=5441 [Accessed on December 6, 2008]. Cancer Research UK (2008b) UK Non-Hodgkin Lymphoma (NHL) statistics. http://info.cancerresearchuk.org/cancerstats/types/nhl/?a=5441 [Accessed on December 6, 2008]. Gusenbauer AW, Katsikeris NF, Brown A (1990) Primary lymphoma of the mandible: report of a case. Journal of Oral and Maxillofacial Surgery 48, 40915. Keyes GG, Balaban FS, Lattanzi DA (1988) Periradicular lymphoma: differentiation from inammation. Oral Surgery Oral Medicine Oral Pathology 66, 2305. Macintyre DR (1986) Lymphomas of the mandible presenting as acute alveolar swellings. British Dental Journal 161, 2534. Maxymiw WG, Goldstein M, Wood RE (2001) Extranodal non-Hodgkins lymphoma of the maxillofacial region: analysis of 88 consecutive cases. South African Dental Journal 56, 5247. Neville BW, Damm DD, Allen CM, Bouquot JE (2009) Hemotologic Disorders. In: BW Neville, DD Damm, CM Allen, JE Bouquot eds. Oral and Maxillofacial Pathology, 3rd edn. St Louis: Saunders Elsevier, pp. 5928. Payne M, al-Damouk JD (1993) Gingival swelling as a manifestation of non-Hodgkins lymphoma. British Dental Journal 175, 2934. Richards A, Costelloe MA, Eveson JW, Scully C, Irvine GH, Rooney N (2000) Oral mucosal nonHodgkins lymphoma a dangerous mimic. Oral Oncology 36, 5568. Rog RP (1991) Beware of malignant lymphoma masquerading as facial inammatory processes. Oral Surgery Oral Medicine Oral Pathology 71, 4159. Slootweg PJ, Wittkampf AR, Kluin PM, de Wilde PC, van Unnik JA (1985) Extranodal non-Hodgkins lymphoma of the oral tissues. An analysis of 20 cases. Journal of Maxillofacial Surgery 13, 8592. Spatafore CM, Keyes G, Skidmore AE (1989) Lymphoma: an unusual oral presentation. Journal of Endodontics 15, 43841. Thomas DW, Gray W, Tate RJ (1991) Non-Hodgkins lymphoma presenting at the site of a recent dental extraction: a report of two cases. British Journal of Oral and Maxillofacial Surgery 29, 347. Tomich CE, Shafer WG (1975) Lymphoproliferative disease of the hard palate: a clinicopathologic entity. A study of twenty-one cases. Oral Surgery Oral Medicine Oral Pathology 39, 75468. UNAIDS (2008) North America, Western and Central Europe: AIDS epidemic updates regional summary. http://data.unaids.org/pub/Report/2008/jc1532_epibriefs_namerica_europe_en.pdf [Accessed on December 6, 2008]. Wannfors K, Hammarstrom L (1990) Periapical lesions of mandibular bone: difculties in early diagnostics. Oral Surgery Oral Medicine Oral Pathology 70, 4839. Wright JM, Radman WP (1995) Intrabony lymphoma simulating periradicular inammatory disease. Journal of American Dental Association 126, 1015.
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doi:10.1111/j.1365-2591.2009.01656.

2010 International Endodontic Journal

International Endodontic Journal, 43, 1, 2010

The smear layer in endodontics a review

D. R. Violich1 & N. P. Chandler2

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

Figure 2 Scanning electron micrograph of dentine surface

Figure 1 Scanning electron micrograph of smeared surface of

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

Smear layer in endodontics Violich & Chandler

Figure 3 Scanning electron micrograph of dentine surface

Should the smear layer be removed?

The signicance of the smear layer

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

Smear layer in endodontics Violich & Chandler

Methods to remove the smear layer Chemical removal

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

Figure 4 Scanning electron micrograph of dentine following

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

Smear layer in endodontics Violich & Chandler

Sodium hypochlorite and EDTA

Ultrasonic smear removal

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

or 1% sodium hypochlorite to achieve the desired result.

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

Smear layer in endodontics Violich & Chandler

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

Smear layer in endodontics Violich & Chandler

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

Smear layer in endodontics Violich & Chandler

International Endodontic Journal, 43, 215, 2010

2010 International Endodontic Journal

Violich & Chandler Smear layer in endodontics

2010 International Endodontic Journal

International Endodontic Journal, 43, 215, 2010

J. P. Vieyra1, J. Acosta2 & J. M. Mondaca2

International Endodontic Journal, 43, 1620, 2010

2010 International Endodontic Journal

Vieyra et al. Working length determination

Table 1 Distribution of 160 teeth (482 canals)

Materials and methods

2010 International Endodontic Journal