Effect of a calcium hydroxide-based root canal dressing on periapical repair in dogs: a histological study

Biological response to endodontic treatment in one versus two-visit: a systematic review and meta-analysis of animal studies

OBJECTIVES

To perform a systematic review of animal studies that compared the histopathological characteristics between teeth with apical periodontitis after endodontic treatment in one or two visits.

MATERIALS AND METHODS

This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) - CRD42022340849. Studies were collected from PubMed/MEDLINE, LILACS, EMBASE, Livivo, SciELO, Web of Science, Scopus, and Cochrane Library and manual and gray literature searches. Animal studies that evaluated histological characteristics after endodontic treatment of teeth with apical periodontitis in one or two visits were included. Risk of bias analysis of the included studies was performed using the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE) tool. Data synthesis of the included studies with quantitative data was performed, and meta-analysis was conducted with the Comprehensive Meta-Analysis software, using the random effects model and odds ratio (OR).

RESULTS

Eighteen studies met the inclusion criteria (Kappa = 0.891). Meta-analyses indicated values in inflammatory infiltrate intensity with effect size of 5.5% (95% CI: 0.020-0.148; p < 0.001), periodontal ligament thickness: 25.6% (95% CI: 0.134-0.487; p < 0.001), dentin resorption: 13% (95% CI: 0.015-1.141; p = 0.066), cementum resorption: 7.1% (95% CI: 0.015-0.325; p = 0.001), bone resorption: 1.4% (95% CI: 0.002-0.130; p < 0.001), mineralized tissue resorption: 42.8% (95% CI: 0.110-1.671; p = 0.222), biological apical sealing: 13.1% (95% CI: 0.055-0.314; p < 0.001), and presence of microorganisms: 10.3% (95% CI: 0.014-0.747; p = 0.025).

CONCLUSIONS

When considering animal studies, the two-visit endodontic treatment, using calcium hydroxide-based intracanal medication, resulted in better biological repair characteristics.

CLINICAL RELEVANCE

A two-visit endodontic treatment with calcium hydroxide-based intracanal medication yields superior histopathological outcomes.

Therapeutic Potential of Chlorhexidine-Loaded Calcium Hydroxide-Based Intracanal Medications in Endo-Periodontal Lesions: An Ex Vivo and In Vitro Study

Endo-periodontal lesions are challenging clinical situations where both the supporting tissues and the root canal of the same tooth are infected. In the present study, chlorhexidine (CHX)-loaded calcium hydroxide (CH) pastes were used as intracanal medications (ICMs). They were prepared and tested on pathogens found in both the root canal and the periodontal pocket. Exposure to 0.5% and 1% CHX-loaded ICMs decreased the growth of Porphyromonas gingivalis and was effective in eradicating or inhibiting an Enterococcus faecalis biofilm. CH was injected into the root canal of extracted human teeth immersed in deionized water. CHX-loaded ICMs resulted in the transradicular diffusion of active components outside the tooth through the apex and the lateral dentinal tubules, as shown by the release of CHX (from 3.99 µg/mL to 51.28 µg/mL) and changes in pH (from 6.63 to 8.18) and calcium concentrations (from 2.42 ppm to 14.67 ppm) after 7 days. The 0.5% CHX-loaded ICM was non-toxic and reduced the release of IL-6 by periodontal cells stimulated by P. gingivalis lipopolysaccharides. Results indicate that the root canal may serve as a reservoir for periodontal drug delivery and that CHX-based ICMs can be an adjuvant for the control of infections and inflammation in endo-periodontal lesions.

The Vehicles of Calcium Hydroxide Pastes Interfere with Antimicrobial Effect, Biofilm Polysaccharidic Matrix, and Pastes' Physicochemical Properties

The objective of the present study was to investigate the pH, volumetric alteration, antimicrobial action, and effect on biofilm matrix polysaccharides of calcium hydroxide (CH) pastes with different vehicles available in endodontics: CH + propylene glycol (CHP), UltraCal XS^®, Metapaste^®, and Metapex^®. The pH was analyzed at different time intervals using a pH meter. For volumetric alteration, a microtomographic assay was performed before and after immersion in water. Enterococcus faecalis was chosen for microbiological tests. The bacterial viability and extracellular matrix were quantified with direct contact evaluation (dentin blocks) and at the intratubular level (dentin cylinders) using LIVE/DEAD BacLight and Calcofluor White dyes via confocal laser scanning microscopy (CLSM). Kruskal-Wallis and Dunn's tests were used to analyze pH and direct contact assays, while one-way ANOVA and Tukey tests were used to analyze volumetric alteration and intratubular decontamination (α = 0.05). Higher pH values were obtained during the initial days. Volumetric alterations were similar in all groups. Lower bacterial viability was obtained for dentin blocks and cylinders when CH pastes were used. UltraCal XS and Metapex had lower values for the extracellular matrix. The pH of all CH pastes decreased with time and did not promote medium alkalization for up to 30 days. CH paste can reduce bacterial viability through direct contact and at an intratubular level; however, UltraCal XS and Metapex are involved with lower volumes of extracellular matrices.

PHYSIOLOGICAL AND HISTOLOGICAL STUDY OF THE CALCIUM OXIDE NANOPARTICLES EFFECT ON THE TESTIS OF MALE WISTER RATS

OBJECTIVE

The aim: The study carried out to determine the effect of the Calcium Oxide Nano Particles on the male rats. In this study were used calcium oxide nano powder to enhancing apoptosis in germ cells and disrupting hormonal regulation of reproductive processes in the adult male rats.

PATIENTS AND METHODS

Materials and methods: The experiment using nine male rats, were distributed into three groups. Group one A was doses orally of Calcium Oxide Nano Particles 50 mg/kg of body weight, while group two B was doses orally of Calcium Oxide Nano Particles 100 mg/kg of body weight; also, group three C were a control C group treated with 0.9% saline only, these orally doses continuous 10 days. After 10 days blood samples collected and all rats were euthanatized and the weights, histological changes and hormonal analysis were conducted.

RESULTS

Results: Results show a significantly increased at p<0.05 for both groups A & B compare with control C in weight of testis tissue and the level of testosterone hormone, also histology changes in testis of treatment rats include: necrosis of spermatogonia, primary spermoocyte and spermatids in both groups compared to control group.

CONCLUSION

Conclusions: Through the study, it is recommended to use medium or low doses of CaO NPs that can be used as a testicular tonic and urge it to increase production of the Testosterone hormone.

Update on Endodontic, Restorative, and Prosthodontic Therapy

Endodontic therapy is intended to preserve the function of mature teeth with irreversible pulpitis or pulp necrosis or to maintain the vitality of endodontically compromised immature teeth. Standard root canal therapy and vital pulp therapy are 2 mainstays of endodontic treatment. Recent knowledge has improved the outcomes of endodontic treatment with newer materials, such as mineral trioxide aggregate. Composite or prosthodontic crown restoration is also a critical key to success.

The use of host defense peptides in root canal therapy in rats

OBJECTIVES

In order to evaluate host defense peptides (HDPs) HHC-10 and synoeca-MP activity in in vitro osteoclastogenesis process and in vivo induced apical periodontitis, testing the effect of molecules in the inflammatory response and in apical periodontitis size/volume after root canal treatment.

MATERIALS AND METHODS

In vitro osteoclastogenesis was assessed on bone marrow cell cultures extracted from mice, while in vivo endodontic treatment involved rats treated with Ca(OH)₂ or HDPs. In vitro osteoclasts were subjected to TRAP staining, and in vivo samples were evaluated by radiographic and tomographic exams, as well as histologic analysis.

RESULTS

None of the substances downregulated the in vitro osteoclastogenesis. Nevertheless, all treatments affected the average of apical periodontitis size in rats, although only teeth treated with HDPs demonstrated lower levels of the inflammatory process. These results demonstrated the in vivo potential of HDPs. Radiographic analysis suggested that HHC-10 and synoeca-MP-treated animals presented a similar lesion size than Ca(OH)₂-treated animals after 7-day of endodontic treatment. However, tomography analysis demonstrated smaller lesion volume in synoeca-MP-treated animals than HHC-10 and Ca(OH)₂-treated animals, after 7 days.

CONCLUSIONS

These molecules demonstrated an auxiliary effect in endodontic treatment that might be related to its immunomodulatory ability, broad-spectrum antimicrobial activity, and possible induction of tissue repair at low concentrations. These results can encourage further investigations on the specific mechanisms of action in animal models to clarify the commercial applicability of these biomolecules for endodontic treatment.

CLINICAL SIGNIFICANCE

HDPs have the potential to be adjuvant substances in endodontic therapy due to its potential to reduce inflammation in apical periodontitis.

Assessment of Nitrofurantoin as an Experimental Intracanal Medicament in Endodontics

Background and Objectives. Multiple antibacterial agents have been mixed and used as an intracanal medicament-like modified triple antibiotic paste (MTAP) to eliminate Enterococcus faecalis (EF), which has been most frequently identified in the cases of failed root canal treatment and periapical lesions. This study is aimed at using a single antibacterial agent, nitrofurantoin (Nit), as an experimental intracanal medicament paste against different clinical isolates of EF), which has been most frequently identified in the cases of failed root canal treatment and periapical lesions. This study is aimed at using a single antibacterial agent, nitrofurantoin (Nit), as an experimental intracanal medicament paste against different clinical isolates of Materials and Methods. Three strains of EF), which has been most frequently identified in the cases of failed root canal treatment and periapical lesions. This study is aimed at using a single antibacterial agent, nitrofurantoin (Nit), as an experimental intracanal medicament paste against different clinical isolates of n = 90), group M (MTAP) (n = 90), group M (MTAP) (n = 90), group M (MTAP) (EF), which has been most frequently identified in the cases of failed root canal treatment and periapical lesions. This study is aimed at using a single antibacterial agent, nitrofurantoin (Nit), as an experimental intracanal medicament paste against different clinical isolates of n = 90), group M (MTAP) (n = 90), group M (MTAP) (n = 90), group M (MTAP) (EF), which has been most frequently identified in the cases of failed root canal treatment and periapical lesions. This study is aimed at using a single antibacterial agent, nitrofurantoin (Nit), as an experimental intracanal medicament paste against different clinical isolates of

Physicochemical and Biological Evaluation of Endodontic Filling Materials for Primary Teeth

This study assessed the pH, radiopacity, antimicrobial effect, cytotoxicity and biocompatibility of endodontic filling materials for primary teeth. Zinc oxide eugenol (ZOE), Vitapex and Calen paste thickened with zinc oxide (ZO) were evaluated in comparison to an experimental MTA-based material. Radiopacity was tested using a graduated aluminum stepwedge with a digital sensor (n=5). The materials pH was recorded at 1, 4, 12 h; 1, 3, 7, 15 and 30 days (n=5). Direct contact test was used to assess the antimicrobial efficacy against Enterococcus faecalis after 1, 4, 12, 24 h (n=5). Cytotoxicity assay used MTT test for cell viability after incubation for 1, 3 and 7 days (n=5). For biocompatibility test, Wistar rats had received implants containing each material (n=5). The biopsied tissues were histologically analyzed after 15, 30 and 60 days. The results of radiopacity, pH, antimicrobial capacity and cytotoxicity were analyzed using ANOVA and Tukey tests. The histological data were submitted to Kruskal-Wallis test. The experimental material presented the lowest radiopacity (3.28 mm Al) and had a pH>12.0 throughout the test period. The experimental material showed the highest antibacterial effect, killing over 99.97% bacteria in 4 h. Vitapex presented the highest cell viability. Initially, biocompatibility test showed moderate to severe inflammation in all groups. After 60 days, Calen+ZO group showed moderate inflammation, while the others showed predominantly mild inflammatory reaction. The present results demonstrated that the experimental MTA-based material exhibited satisfactory behavior regarding the studied properties. Additional in vivo studies are necessary for a better evaluation of the material.

Nonsurgical Clinical Management of Periapical Lesions Using Calcium Hydroxide-Iodoform-Silicon-Oil Paste

Background

The study aim is to avoid tooth extraction by nonsurgical treatment of periapical lesion. It assesses healing progress in response to calcium hydroxide-iodoform-silicon oil paste (CHISP). Numeric Pain Rating Scale was used to validate the approach. Furthermore, CHISP was used to treat cystic lesions secondary to posttraumatic avulsion of permanent teeth.

Materials and Methods

Over 200 patients with radicular cysts were treated with CHISP through the root canal. Radiographs were used to verify lesion size and position, ensure correct delivery to the site, and monitor the progress of bone healing in the lesion area. Ten males and 10 females were randomly selected for statistical assessment.

Results

No severe pain, complications, or failure in cyst healing was reported. Complete healing was achieved in an average of 75 days. Furthermore, healing of radicular cyst secondary to posttraumatic tooth avulsion was successful.

Conclusion

CHISP indicated an antiseptic effect, which enhanced and shortened healing time of periapical lesions. The less invasive procedure avoids tooth extraction and reduces bone resorption. Cyst management with CHISP can remedy failed root canal treatments. The results show a bone regenerative capacity of CHISP suggested in first rapid phase and a second slow phase.

Factors affecting the periapical healing process of endodontically treated teeth

Tissue repair is an essential process that reestablishes tissue integrity and regular function. Nevertheless, different therapeutic factors and clinical conditions may interfere in this process of periapical healing. This review aims to discuss the important therapeutic factors associated with the clinical protocol used during root canal treatment and to highlight the systemic conditions associated with the periapical healing process of endodontically treated teeth. The antibacterial strategies indicated in the conventional treatment of an inflamed and infected pulp and the modulation of the host's immune response may assist in tissue repair, if wound healing has been hindered by infection. Systemic conditions, such as diabetes mellitus and hypertension, can also inhibit wound healing. The success of root canal treatment is affected by the correct choice of clinical protocol. These factors are dependent on the sanitization process (instrumentation, irrigant solution, irrigating strategies, and intracanal dressing), the apical limit of the root canal preparation and obturation, and the quality of the sealer. The challenges affecting the healing process of endodontically treated teeth include control of the inflammation of pulp or infectious processes and simultaneous neutralization of unpredictable provocations to the periapical tissue. Along with these factors, one must understand the local and general clinical conditions (systemic health of the patient) that affect the outcome of root canal treatment prediction.

Nonsurgical endodontic treatment of teeth associated with large periapical lesion using triple antibiotic paste and mineral trioxide aggregate apical plug: A case series

Periapical diseases are induced as a result of the direct or indirect involvement of oral bacteria. The etiologic factor being the degenerating pulp tissue. A periapical lesion is formed within an area of apical periodontitis which cannot form by itself and is inflammatory in origin. If the microbial etiology of periapical lesions and in the root canal is removed by nonsurgical root canal therapy the lesions regress. Mere surgical removal of the periapical lesions without proper root canal disinfection and obturation will not result in the healing of periapical tissues. Nonsurgical treatment with triple antibiotic paste offers a high success rate in the healing of large periapical lesions. The present clinical cases show the nonsurgical endodontic management of large periapical pathosis using triple antibiotic paste and mineral trioxide aggregate.

Strength of recommendation for single-visit root canal treatment: grading the body of the evidence using a patient-centred approach

AIM

To identify, search for and critically interpret the results from clinical studies on single- versus multiple-visit root canal treatment in the light of an evidence-based paradigm. For that purpose, the quality of the available body of evidence was assessed using the SORT 'grade' - Strength of Recommendation Taxonomy.

METHODOLOGY

A protocol was followed including all aspects of the review methods: (i) search strategy, (ii) inclusion criteria for studies, (iii) screening methods, (iv) quality assessment, (v) data synthesis of the selected studies, and (vi) the assessment of quality of the body of evidence available by the means of the SORT 'grade'. An extensive search of recent biomedical literature was performed in PubMed (up to May, 2014), EMBASE (dating from 1980 to May 2014) and Cochrane databases with appropriate headings and keywords related to single- and multiple-visit root canal treatment. Selected studies were stratified according to their level of evidence using the SORT criteria: (i) quality - Level A high-quality evidence, Level B medium/low-quality evidence and Level C no evidence; (ii) degree of consistency - consistent, when most studies found a similar conclusion, or inconsistent, when there was considerable variation amongst study findings.

RESULTS

After the digital and manual searches, 246 studies were indentified. Two hundred and seven studies were eliminated by exclusion criteria, resulting in a yield of 39 articles that were selected for retrieval. Of the 39 articles, only 11 could be classified as Level 2 (B); the other 28 articles did not obey the criteria to be considered as real patient-oriented evidence; thus, they were classified as Level 3 (C). No studies were ranked as Level 1 because they did not obey the minimum standard to be considered as both good-quality research and patient-oriented evidence. Despite this, all of the selected Level B studies reported no significant differences between single- and multiple-visit treatments.

CONCLUSION

There is B-level (mid-level) evidence to confirm there is no difference between the two different treatments, based on research addressing clinical outcomes and using some consistent but limited-quality methods of scientific investigation. More studies focused on evaluating patient-centred outcomes are urgently required.

Effect of addition of lycopene to calcium hydroxide and chlorhexidine as intracanal medicament on fracture resistance of radicular dentin at two different time intervals: An in vitro study

BACKGROUND

Long-term use of intracanal medicaments such as calcium hydroxide (CH) reduces the fracture resistance of dentin. The present study was undertaken to evaluate the fracture resistance of radicular dentin on long-term use of CH, chlorhexidine (CHX) with lycopene (LP).

AIM

To compare the fracture resistance of radicular dentin when intracanal medicaments such as CH, CHX with LP were used for 1-week and 1-month time interval.

SETTINGS AND DESIGN

Sixty single-rooted extracted human permanent premolars were collected, and complete instrumentation was done. Samples were divided into three groups based on intracanal medicament used.

MATERIALS AND METHODS

Group 1 - no medicament was placed (CON), group 2 - mixture of 1.5 g of CH and 1 ml of 2% CHX (CHCHX), group 3 - mixture of 1.5 g of CH, 1 ml of CHX and 1 ml of 5% LP solution (CHCHXLP). After storage period of each group for 1-week and 1-month, middle 8 mm root cylinder was sectioned and tested for fracture resistance.

STATISTICAL ANALYSIS

Results were analyzed using paired t-test.

RESULTS

At 1-month time interval, there was a statistically significant difference in fracture resistance between CHCHX and CHCHXLP groups.

CONCLUSION

Addition of LP has not decreased the fracture resistance of radicular dentin after 1-month.

Healing of a large periapical lesion using triple antibiotic paste and intracanal aspiration in nonsurgical endodontic retreatment

A patient with a large periapical lesion in relation to the maxillary right central and lateral incisors is presented here. During the conservative root canal treatment, aspiration of the fluid was done through the root canal, followed by placement of triple antibiotic paste for two weeks. Complete periapical healing was observed at the 24-month recall. This report confirms that for treatment of a large periapical lesion it is not always necessary to do surgical treatment and even cyst-like periapical lesions heal following conservative endodontic therapy.

Efficacy of ethylene-diamine-tetra-acetic acid associated with chlorhexidine on intracanal medication removal: a scanning electron microscopy study

The aim of this study was to evaluate the effectiveness of 17% ethylene-diamine-tetra-acetic acid (EDTA) used alone or associated with 2% chlorhexidine gel (CHX) on intracanal medications (ICM) removal. Sixty single-rooted human teeth with fully formed apex were selected. The cervical and middle thirds of each canal were prepared with Gates Glidden drills and rotary files. The apical third was shaped with hand files. The specimens were randomly divided into two groups depending on the ICM used after instrumentation: calcium hydroxide Ca(OH)(2) +CHX or Ca(OH)(2) +sterile saline (SS). After seven days, each group was divided into subgroups according to the protocol used for ICM removal: instrumentation and irrigation either with EDTA, CHX+EDTA, or SS (control groups). All specimens were sectioned and processed for observation of the apical thirds by using scanning electron microscopy. Two calibrated evaluators attributed scores to each specimen. The differences between the protocols for ICM removal were analyzed with Kruskal-Wallis and Mann-Whitney U tests. Friedman and Wilcoxon signed rank tests were used for comparison between the score of debris obtained in each root canal third. Remains of Ca(OH)(2) were found in all specimens independently of the protocol and ICM used (P > 0.05). Seventeen percent EDTA showed the best results in removing ICM when used alone (P < 0.05), particularly in those associated with CHX. It was concluded that the chelating agent 17% EDTA significantly improved the removal of ICM when used alone. Furthermore, the type of the vehicle associated with Ca(OH)(2) also plays a role in the ICM removal.

Comparison of calcium hydroxide removal by self-adjusting file, EndoVac, and CanalBrush agitation techniques: An in vitro study

Objectives:

This study comparatively evaluated the efficacy of self-adjusting file (SAF), Endovac, and CanalBrush irrigant agitation protocols in removing calcium hydroxide (Ca(OH)₂) from the root canals.

Materials and Methods:

Sixty extracted human mandibular canine teeth were instrumented with ProTaper rotary instruments to size #40 and dressed with Ca(OH)₂. The roots were randomly assigned to four groups according to irrigant agitation protocol used (n = 15). In Group 1: Conventional syringe irrigation (no activation, control); Group 2: Rotary brush agitation (CanalBrush); Group 3: Apical negative pressure irrigation (EndoVac system); and Group 4: Sonic agitation (SAF) were used. Scanning electron microscopic (SEM) evaluation was done for assessment of Ca(OH)₂ removal in the coronal and apical thirds. Statistical analysis was performed by Wilcoxon and Kruskal-Wallis tests.

Results:

There were statistically significant differences among the groups (P = 0.218). A statistically significant difference was seen between the test groups in Ca(OH)₂ removal from the apical third of the canal (P < 0.05). In the coronal third, there was no difference between the groups (P > 0.05). The most efficient Ca(OH)₂ removal in apical third was recorded in Group 3 (EndoVac) and Group 4 (SAF) (P < 0.05). In Group 4 (sonic agitation), there was no significantly difference between Ca(OH)₂ removal in coronal and apical thirds.

Conclusions:

SAF and EndoVac showed significantly better performance than CanalBrush and conventional syringe irrigation in removing Ca(OH)₂ from apical third of the root canals.

Healing of a tooth with an overinstrumented apex, extensive transportation and periapical lesion using a 5 mm calcium hydroxide apical plug: an 8-year follow-up report

Besides the risk of filling material extrusion throughout the apex, a satisfactory apical seal can be difficult to achieve in canals with open apices or iatrogenic enlargements of the apical constriction. These situations pose a challenge to root canal filling. This paper describes the root canal filling of a maxillary right canine with an overinstrumented apex, complete loss of the apical stop, extensive canal transportation and apical periodontitis. A 5 mm calcium hydroxide apical plug was placed before root canal filling. The plug was made by soaking paper points with saline, dipping the points in calcium hydroxide powder and then applying it to the apex several times, until a consistent apical plug was obtained. The canal was then irrigated with saline in order to remove any residual calcium hydroxide from the root canal walls, dried with paper points and obturated with an inverted #80 gutta-percha cone and zinc oxide-eugenol based sealer by the lateral condensation technique. An 8-year radiographic follow-up showed formation of mineralized tissue sealing the apical foramen, apical remodeling and no signs of apical periodontitis.

Biocompatibility of intracanal medications based on calcium hydroxide

Objective. The aim of this study was to evaluate the rat subcutaneous tissue reaction to calcium hydroxide-based intracanal medicaments, UltraCal XS (calcium hydroxide, barium sulphate, aqueous matrix), Hydropast (calcium hydroxide, barium sulphate, and propyleneglycol), and Calen (Calcium hydroxide, zinc oxide, colophony, and polyethyleneglycol), used as a control. Methods. Forty-eight rats (Rattus Norvegicus Holtzman) were distributed in three groups: Calen, UltraCal XS, and Hydropast. Polyethylene tubes filled with one of the medicaments were implanted in the dorsal subcutaneous. After 7 and 30 days, the implants were removed and the specimens were fixed and embedded in paraffin. Morphological and quantitative analyses were carried out in the HE-stained sections. The numerical density of inflammatory cells in the capsule was evaluated and statistical analyses were performed (P ≤ 0.05). Results. At 7 days, all materials induced an inflammatory reaction in the subcutaneous tissue adjacent to the implants. In all groups, a significant reduction in the number of inflammatory cells and giant cells was verified in the period of 30 days. Conclusion. These results indicate that the calcium hydroxide-based medicaments evaluated present biocompatibility similar to Calen.

Estudo longitudinal do sucesso clínico-radiográfico de dentes tratados com medicação intracanal de hidróxido de cálcio

INTRODUÇÃO: O tratamento endodôntico é de fundamental importância para abolir a infecção presente em dentes que apresentam necrose pulpar. OBJETIVO: O objetivo do presente estudo foi avaliar clínica e radiograficamente a eficácia dos tratamentos de canais radiculares de dentes com lesão periapical crônica, efetuados pelos graduandos em Odontologia, da Faculdade de Odontologia de Araçatuba - UNESP. MATERIAL E MÉTODO: Foram selecionados 100 pacientes que possuíam dentes com lesão periapical crônica para serem tratados. Após o preparo biomecânico, os canais radiculares receberam uma medicação intracanal de hidróxido de cálcio durante o período de 14 dias. Os canais radiculares foram obturados com cimento endodôntico à base de hidróxido de cálcio. Foi realizada a proservação por um período entre oito e 11 meses. RESULTADO: A análise dos resultados permitiu constatar a porcentagem de 78,46% dos casos com reparo total da lesão periapical e de 21,54% dos casos em que não houve evidências de reparo. CONCLUSÃO: Ocorreu reparo das lesões periapicais nos dentes tratados pelos graduandos da Faculdade de Odontologia de Araçatuba - UNESP.

Efficacy of the NaviTip FX irrigation needle in removing calcium hydroxide from root canal

OBJECTIVE

To evaluate the effectiveness of the NaviTip FX, brush-covered irrigation needle, in removing calcium hydroxide from the root canal.

STUDY DESIGN

Thirty single-rooted teeth were randomly divided into three groups: A - irrigation with a hypodermic needle inserted as far as possible without binding and activation with #30 K-type file; B - Irrigation with a hypodermic needle without activation; C - irrigation with NaviTip FX needle. Sodium hypoclorite 1% was used in irrigation. The root canals were examined trough scanning electron microscopy. Calcium hydroxide removal was recorded at 1, 5, and 10mm from the working length (WL) and the data were analysed using one-way ANOVA test (p<0.05).

RESULTS

NaviTip FX and hypodermic needle activated with #30K-type file showed lower score at 10 and 5mm with no significant difference between them. Comparison within groups did not show significant differences. All groups showed significantly better smear layer removal at 5 and 10 mm from the WL.

CONCLUSION

The apical third (1mm) of the root canal was found to be the most critical site for Ca(OH)2 removal. Key words:Calcium hydroxide, irrigation, scanning electron microscope, NaviTip FX.

Response of mice connective tissue to intracanal dressings containing chlorhexidine

Substances containing chlorhexidine (CHX) have been studied as intracanal medicaments. The aim of the present study was to characterize the response of mouse subcutaneous connective tissue to CHX-containing medications by conventional optical microscopy. The tissue response was evaluated by implanting polyethylene tubes containing one of the substances evaluated: Calen paste + 0.5% CHX, Calen + 2% CHX, 2% CHX gel, and Calen paste (control). After experimental periods of 7, 21, and 63 days, the implants (n = 10) were removed along with the subcutaneous connective tissue. Tissue samples were subjected to histological processing, and sections were stained with hematoxylin and eosin. Qualitative and quantitative analyses of the number of inflammatory cells, blood vessels, and vascularized areas were performed. Results were analyzed by ANOVA and Tukey tests with the significance level set at 5%. We concluded that Calen + 0.5% CHX led to reparative tissue response in contrast with Calen + 2% CHX and 2% CHX gel, which induced persistent inflammatory response, pointing to the aggressive nature of this mixture. When Calen + 2% CHX and 2% CHX gel were compared, the latter induced more intense inflammatory response.

Subcutaneous connective tissue response to primary root canal filling materials

This study evaluated the response of the subcutaneous connective tissue of BALB/c mice to root filling materials indicated for primary teeth: zinc oxide/eugenol cement (ZOE), Calen paste thickened with zinc oxide (Calen/ZO) and Sealapex sealer. The mice (n=102) received polyethylene tube implants with the materials, thereby forming 11 groups, as follows: I, II, III: Calen/ZO for 7, 21 and 63 days, respectively; IV, V, VI: Sealapex for 7, 21 and 63 days, respectively; VII, VIII, IX: ZOE for 7, 21 and 63 days, respectively; X and XI: empty tube for 7 and 21 days, respectively. The biopsied tissues were submitted to histological analysis (descriptive analysis and semi-quantitative analysis using a scoring system for collagen fiber formation, tissue thickness and inflammatory infiltrate). A quantitative analysis was performed by measuring the area and thickness of the granulomatous reactionary tissue (GRT). Data were analyzed by Kruskal-Wallis, ANOVA and Tukey's post-hoc tests (?=0.05). There was no significant difference (p>0.05) among the materials with respect to collagen fiber formation or GRT thickness. However, Calen/ZO produced the least severe inflammatory infiltrate (p<0.05). The area of the GRT was significantly smaller (p<0.05) for Calen/ZO and Sealapex. In conclusion, Calen/ZO presented the best tissue reaction, followed by Sealapex and ZOE.

Sealing ability, marginal adaptation and their correlation using three root-end filling materials as apical plugs

Objective

This study used dye leakage assay and scanning electron microscopy to evaluate, respectively, the sealing ability and marginal adaptation of three root-end filling materials used as apical plugs, as well as the possible correlation between these properties.

Material and Methods

Ninety-eight single-rooted human teeth were prepared to simulate an open apex. The teeth were allocated to three experimental groups (n = 30), which received a 5-mm thick apical plug of (1) gray MTA Angelus^TM, (2) CPM^TM and (3) MBPc, and two controls groups (n = 4). After immersion in 0.2% Rhodamine B solution for 48 h, the teeth were sectioned longitudinally and analyzed by Image Tool 3.0 software. The marginal adaptation between apical plugs and the root canal walls were analyzed by SEM.

Results

MBPc had significantly less (p<0.05) apical leakage than the other materials. Regarding marginal adaptation, CPM^TM showed the best numerical results, though without statistical significance from the other materials (p<0.05). There was no correlation between the two properties.

Conclusions

When used as apical plugs, the tested root-end filling materials had similar marginal adaptation to the dentin walls, but MBPc had the best sealing ability, as demonstrated by the least apical leakage from all tested materials.

Calcium hydroxide promotes cementogenesis and induces cementoblastic differentiation of mesenchymal periodontal ligament cells in a CEMP1- and ERK-dependent manner

Periodontal tissue engineering is a complex process requiring the regeneration of bone, cementum, and periodontal ligament (PDL). Since cementum regeneration is poorly understood, we used a dog model of dental pulpal necrosis and in vitro cellular wounding and mineralization assays to determine the mechanism of action of calcium hydroxide, Ca(OH)(2), in cementogenesis. Laser capture microdissection (LCM) followed by qRT-PCR were used to assay responses of periapical tissues to Ca(OH)(2) treatment. Additionally, viability, proliferation, migration, and mineralization responses of human mesenchymal PDL cells to Ca(OH)(2) were assayed. Finally, biochemical inhibitors and siRNA were used to investigate Ca(OH)(2)-mediated signaling in PDL cell differentiation. In vivo, Ca(OH)(2)-treated teeth formed a neocementum in a STRO-1- and cementum protein-1 (CEMP1)-positive cellular environment. LCM-harvested tissues adjacent to the neocementum exhibited higher mRNA levels for CEMP1, integrin-binding sialoprotein, and Runx2 than central PDL cells. In vitro, Ca(OH)(2) and CEMP1 promoted STRO-1-positive cell proliferation, migration, and wound closure. Ca(OH)(2) stimulated expression of the cementum-specific proteins CEMP1 and PTPLA/CAP in an ERK-dependent manner. Lastly, Ca(OH)(2) stimulated mineralization by CEMP1-positive cells. Blocking CEMP1 and ERK function abolished Ca(OH)(2)-induced mineralization, confirming a role for CEMP1 and ERK in the process. Ca(OH)(2) promotes cementogenesis and recruits STRO-1-positive mesenchymal PDL cells to undergo cementoblastic differentiation and mineralization via a CEMP1- and ERK-dependent pathway.

Matrix metalloproteinase expression in teeth with apical periodontitis is differentially modulated by the modality of root canal treatment

INTRODUCTION

The objective of this study was to investigate the expression of matrix metalloproteinases (MMPs) in apical periodontitis and during the periapical healing phase after root canal treatment.

METHODS

Apical periodontitis was induced in dog teeth, and root canal treatment was performed in a single visit or by using an additional calcium hydroxide root canal dressing. One hundred eighty days after treatment the presence of inflammation was examined, and tissues were stained to detect bacteria. Bacterial status was correlated to the degree of tissue organization, and to further investigate molecules involved in this process, tissues were stained for MMP-1, MMP-2, MMP-8, and MMP-9. Data were analyzed by using one-way analysis of variance followed by Tukey test or Kruskal-Wallis followed by Dunn test.

RESULTS

Teeth with apical periodontitis that had root canal therapy performed in a single visit presented an intense inflammatory cell infiltrate. Periapical tissue was extremely disorganized, and this was correlated with the presence of bacteria. Higher MMP expression was evident, similar to teeth with untreated apical periodontitis. In contrast, teeth with apical periodontitis submitted to root canal treatment with calcium hydroxide presented a lower inflammatory cell infiltrate. This group had moderately organized connective tissue, lower prevalence of bacteria, and lower number of MMP-positive cells, similar to healthy teeth submitted to treatment.

CONCLUSIONS

Teeth treated with calcium hydroxide root canal dressing exhibited a lower percentage of bacterial contamination, a lower MMP expression, and a more organized extracellular matrix, unlike those treated in a single visit. This suggests that calcium hydroxide might be beneficial in tissue repair processes.

Calcium hydroxide intracanal dressing removal with different rotary instruments and irrigating solutions: a scanning electron microscopy study

This study evaluated the efficacy of 2 types of rotary instruments employed in association with sodium hypochlorite (NaOCl) or EDTA in removing calcium hydroxide (CH) residues from root canals dentin walls. Forty-two mandibular human incisors were instrumented with the ProTaper System up to F2 instrument, irrigated with 2.5% NaOCl followed by 17% EDTA and filled with a CH intracanal dressing. After 7 days, the CH dressing was removed using 4 techniques: NiTi rotary instrument size 25, 0.06 taper (K3 Endo) and irrigation with 17% EDTA (Group 1), NiTi rotary F1 instrument (ProTaper) and irrigation with 17% EDTA (Group 2), NiTi rotary instrument size 25, 0.06 taper and irrigation with 2.5% NaOCl (Group 3) and NiTi rotary F1 instrument and irrigation with 2.5% NaOCl (Group 4). Two roots without intracanal dressing were used as negative controls. Teeth were evaluated by scanning electron microscopy, in the cervical and apical canal thirds. None of the techniques removed the CH dressing completely. In the apical and cervical thirds, F1 instrument was better than instrument size 25, 0.06 taper in removing CH residues (p<0.05), regardless of the final irrigating solution. No difference was found between the irrigating solutions in the groups of F1 instrument and of instrument size 25, 0.06 taper (p>0.05). The negative controls had no CH residues on the dentin walls. In conclusion, the ProTaper F1 instrument was better than K3 Endo instrument size 25, 0.06 taper in the removal of CH intracanal medication, regardless of irrigating solution used.

Histopathological evaluation of root canal filling materials for primary teeth

This study aimed to assess the response of apical and periapical tissues of dogs' teeth after root canal filling with different materials. Forty roots from dogs' premolars were prepared biomechanically and assigned to 4 groups filled with: Group I: commercial calcium hydroxide and polyethylene glycol-based paste (Calen®) thickened with zinc oxide; Group II: paste composed of iodoform, Rifocort® and camphorated paramonochlorophenol; Group III: zinc oxide-eugenol cement; Group IV: sterile saline. After 30 days, the samples were subjected to histological processing. The histopathological findings revealed that in Groups I and IV the apical and periapical regions exhibited normal appearance, with large number of fibers and cells and no resorption of mineralized tissues. In Group II, mild inflammatory infiltrate and mild edema were observed, with discrete fibrogenesis and bone resorption. Group III showed altered periapical region and thickened periodontal ligament with presence of inflammatory cells and edema. It may be concluded that the Calen paste thickened with zinc oxide yielded the best tissue response, being the most indicated material for root canal filling of primary teeth with pulp vitality.

Evaluation of the biocompatibility of root canal sealers using subcutaneous implants

The purpose of this study was to evaluate in vivo the biocompatibility of Endométhasone, Pulp Canal Sealer EWT and AH-Plus root canal sealers after implantation in rat connective tissue. Twenty-four Wistar-Furth rats were used. Polyethylene tubes were filled with the sealers and implanted into specific dorsal subdermal tissue sites of the rats. Implants were removed after 3, 7 and 30 days, fixed and processed for glycol methacrylate-embedding technique to be examined microscopically. On the 3rd day, there was a mild inflammatory reaction to Pulp Canal Sealer EWT implants, but a severe response to the other sealers with presence of acute inflammatory cells. On the 7th day, tissue organization was more evident with attenuation of the inflammatory reaction, especially for the AH-Plus implants. On the 30th day, connective tissue with few inflammatory cells was observed in contact with all sealer implants. In this time interval, the tissue in contact with Pulp Canal Sealer EWT implants was more organized, while the tissue close to Endométhasone and AH-Plus implants showed a mild persistent inflammatory reaction and had similar results to each other. In conclusion, the sealers had a similar pattern of irritation, which was more severe in the beginning and milder with time, in such a way that all sealers showed a persistent mild reaction. Pulp Canal Sealer EWT yielded better tissue organization than Endométhasone and AH-Plus, which, in turn, showed similar results to each other.

Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts

It is a general belief that large cyst-like periapical lesions and apical true cysts caused by root canal infection are less likely to heal after nonsurgical root canal therapy. Nevertheless, there is no direct evidence to support this assumption. A large cyst-like periapical lesion or an apical true cyst is formed within an area of apical periodontitis and cannot form by itself. Therefore, both large cyst-like periapical lesions and apical true cysts are of inflammatory and not of neoplastic origin. Apical periodontitis lesions, regardless of whether they are granulomas, abscesses, or cysts, fail to heal after nonsurgical root canal therapy for the same reason, intraradicular and/or extraradicular infection. If the microbial etiology of large cyst-like periapical lesions and inflammatory apical true cysts in the root canal is removed by nonsurgical root canal therapy, the lesions might regress by the mechanism of apoptosis in a manner similar to the resolution of inflammatory apical pocket cysts. To achieve satisfactory periapical wound healing, surgical removal of an apical true cyst must include elimination of root canal infection.

Comparison of different irrigants on calcium hydroxide medication removal: microscopic cleanliness evaluation

Calcium hydroxide dressing residuals can compromise endodontic sealing. This study evaluated the cleaning efficacy of different endodontic irrigants in removing calcium hydroxide by SEM image analysis. Fifty-four single-rooted mandibular premolars were instrumented to a master apical file #60 and dressed with calcium hydroxide. After 36 hours, the teeth were reopened and Ca(OH)(2) medication was removed by 5 different experimental groups: 0.5% NaOCl (G1), EDTA-C (G2), citric acid (G3), EDTA-T (G4), and re-instrumentation with MAF using NaOCl and lubrificant, followed by EDTA-T (G5). The roots were split in the buccal-lingual direction and prepared for SEM analysis in cervical, middle, and apical thirds (9, 6, and 3mm from the apex). Five blinded examiners evaluated the wall cleanliness using a scale from 1 to 5. Statistical analysis was performed using Kruskal-Wallis at 5% level of significance. Group G5 had the best results in all thirds, with significant statistical differences compared to all other groups in the middle and coronal third, and to G1 in the apical third. On the other hand, G1, only flushed with NaOCl, had the worst results, with statistical differences in all thirds compared to the other groups. The best cleanliness was achieved by G4 and G5 groups. The recapitulation of MAF in combination with irrigants improved the removal of calcium hydroxide medication better than an irrigant flush alone.

Effects of the association between a calcium hydroxide paste and 0.4% chlorhexidine on the development of the osteogenic phenotype in vitro

The present study aimed to evaluate whether the association between a calcium hydroxide paste (Calen paste) and 0.4% chlorhexidine (CHX) affects the development of the osteogenic phenotype in vitro. With rat calvarial osteogenic cell cultures, the following parameters were assayed: cell morphology and viability, alkaline phosphatase activity, total protein content, bone sialoprotein immunolocalization, and mineralized nodule formation. Comparisons were carried out by using the nonparametric Kruskal-Wallis test (level of significance, 5%). The results showed that the association between Calen paste and 0.4% CHX did not affect the development of the osteogenic phenotype. No significant changes were observed in terms of cell shape, cell viability, alkaline phosphatase activity, and the total amount of bone-like nodule formation among control, Calen, or Calen + CHX groups. The strategy to combine Ca(OH)(2) and CHX to promote a desirable synergistic antibacterial effect during endodontic treatment in vivo might not significantly affect osteoblastic cell biology.

Histopathological evaluation of different methods of experimental induction of periapical periodontitis

This study evaluated histopathologically different methods of experimental induction of periapical periodontitis. The radiographic and microbiological evaluations have been performed in a previous investigation. Fifty-seven root canals from dogs' teeth were assigned to 4 groups. In GI (n=14) and GII (n=14), the root canals were exposed to oral environment for 180 days; in GIII (n=14) and GIV (n=15) the root canals were exposed for 7 days and then the access cavities were restored and remained sealed for 53 days. The root apices of GI and GIII were perforated, whilst those of GII and GIV remained intact. After induction of periapical periodontitis, the dogs were euthanized. Serial sections were obtained and stained with hematoxylin and eosin. Data of the histopathological evaluation were submitted to Kruskal-Wallis and Dunn's tests at 5% significance level. The inflammatory periapical reaction and resorption of mineralized tissues were less intense in GII than in the other groups (p<0.05). There was no histopathological difference among the experimentally induced periapical lesions in the teeth with coronal sealing. On the other hand, when coronal sealing was not performed, greater intensity of induced periapical periodontitis was observed in the teeth with apical perforation.