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Fiorillo L, D'Amico C, Meto A, Mehta V, Lo Giudice G, Cervino G. Sodium Hypochlorite Accidents in Endodontic Practice: Clinical Evidence and State of the Art. J Craniofac Surg 2024; 35:e636-e645. [PMID: 39418527 DOI: 10.1097/scs.0000000000010407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 05/19/2024] [Indexed: 10/19/2024] Open
Abstract
Sodium hypochlorite (NaOCl) is widely utilized in endodontics for its effective antimicrobial properties and ability to dissolve necrotic tissues. However, its use is not devoid of risks, including potential severe tissue damage and chemical burns. This systematic review evaluates the documented risks of using NaOCl in endodontic treatments. It compares its safety and efficacy with other endodontic irrigants, such as EDTA and chlorhexidine. This review followed the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines and registered with PROSPERO. Comprehensive searches were performed in PubMed, Scopus, Web of Science, and CENTRAL databases, with additional hand searches in grey literature. Studies were selected reporting adverse effects related to NaOCl used in endodontic procedures, ranging from randomized controlled trials to case reports. Data extraction and risk of bias assessment were systematically performed using standardized tools. Seventeen studies were included, detailing instances from chemical burns to severe allergic reactions and tissue necrosis associated with NaOCl use. The risk of bias was predominantly low across the studies. Sodium hypochlorite demonstrated a higher efficacy in microbial eradication and tissue dissolution than other irrigants, though it also showed a higher incidence of severe complications when mishandled. Sodium hypochlorite remains a cornerstone in endodontic disinfection due to its potent antimicrobial and tissue dissolution properties. However, its application must be meticulously managed to prevent complications. Future research should focus on optimizing concentrations and application techniques to enhance safety and effectiveness, potentially integrating safer alternatives or complementary solutions like EDTA to mitigate risks while preserving irrigant benefits.
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Affiliation(s)
- Luca Fiorillo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, School of Dentistry, University of Messina, via Consolare Valeria, Messina
- Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties, University of Campania "Luigi Vanvitelli", Naples, Italy
- Department of Dental Cell Research, Dr D.Y. Patil Dental College and Hospital, Dr D.Y. Patil Vidyapeeth, Pimpri, Pune, MH, India
- Department of Dentistry, Faculty of Dental Sciences, University of Aldent, Tirana, Albania
| | - Cesare D'Amico
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, School of Dentistry, University of Messina, via Consolare Valeria, Messina
- Department of Dentistry, Faculty of Dental Sciences, University of Aldent, Tirana, Albania
| | - Aida Meto
- Department of Dental Cell Research, Dr D.Y. Patil Dental College and Hospital, Dr D.Y. Patil Vidyapeeth, Pimpri, Pune, MH, India
- Department of Dentistry, Faculty of Dental Sciences, University of Aldent, Tirana, Albania
| | - Vini Mehta
- Department of Dental Cell Research, Dr D.Y. Patil Dental College and Hospital, Dr D.Y. Patil Vidyapeeth, Pimpri, Pune, MH, India
| | - Giuseppe Lo Giudice
- Department of Clinical and Experimental Medicine, Messina University, Messina, Italy
| | - Gabriele Cervino
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, School of Dentistry, University of Messina, via Consolare Valeria, Messina
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de Oliveira LD, de Carvalho LS, Xavier ACC, de Oliveira FE, Leão MVP, Diamantino MGG, Khoury RD, Valera MC, Carvalho CAT, Abu Hasna A. In Vitro Evaluation of Sodium Hypochlorite, Chlorhexidine, Propolis, and Calcium Hydroxide Effect on Lipoteichoic-Acid-Induced Proinflammatory Cytokines Production. Dent J (Basel) 2024; 12:286. [PMID: 39329852 PMCID: PMC11431833 DOI: 10.3390/dj12090286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 08/27/2024] [Accepted: 08/30/2024] [Indexed: 09/28/2024] Open
Abstract
This study aimed to evaluate the effects of sodium hypochlorite (NaOCl), chlorhexidine (CHX), and the glycolic extract of propolis (GEP) as endodontic irrigants and of calcium hydroxide [Ca(OH)2], CHX, or Ca(OH)2 + CHX as intracanal medications on the capacity of the lipoteichoic acid (LTA) of Enterococcus faecalis in macrophages' proinflammatory cytokines production. Freshly extracted 108 human single-rooted teeth were used in this study. The LTA of E. faecalis was standardized in double-distilled pyrogen-free water (250 µg/mL) and inoculated into the specimens subdivided into nine subgroups (n = 12). Cultures of murine macrophages (RAW 264.7) were treated with 30 µL of each sample collected from root canals and incubated (37 °C, 5% CO2) for 24 h. Lastly, anti-TNF-α, anti-IL-6, anti-IP-10, anti-MIP-1α, anti-G-CSF, and anti-IL-1β DuoSet kits were used to perform an ELISA assay. Data were analyzed using one-way ANOVA and Tukey test (p ≥ 0.05). It was found that 1% NaOCl was the most effective irrigant in reducing the capacity of LTA in cytokines production, followed by 12% GEP and 2% CHX, respectively. Ca(OH)2 + CHX presented the best results when associated with NaOCl or GEP. Thus, NaOCl or GEP associated with Ca(OH)2 + CHX were effective in reducing the capacity of LTA in different macrophages pro-inflammatory cytokines production.
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Affiliation(s)
- Luciane Dias de Oliveira
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (L.D.d.O.); (L.S.d.C.); (M.V.P.L.)
| | - Lara Steffany de Carvalho
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (L.D.d.O.); (L.S.d.C.); (M.V.P.L.)
| | - Ana Claudia Carvalho Xavier
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (L.D.d.O.); (L.S.d.C.); (M.V.P.L.)
| | - Felipe Eduardo de Oliveira
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (L.D.d.O.); (L.S.d.C.); (M.V.P.L.)
| | - Mariella Vieira Pereira Leão
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (L.D.d.O.); (L.S.d.C.); (M.V.P.L.)
| | - Mariana Gadelho Gimenez Diamantino
- Department of Restorative Dentistry, Endodontics Division, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (M.G.G.D.); (R.D.K.); (M.C.V.); (C.A.T.C.)
| | - Rayana Duarte Khoury
- Department of Restorative Dentistry, Endodontics Division, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (M.G.G.D.); (R.D.K.); (M.C.V.); (C.A.T.C.)
| | - Marcia Carneiro Valera
- Department of Restorative Dentistry, Endodontics Division, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (M.G.G.D.); (R.D.K.); (M.C.V.); (C.A.T.C.)
| | - Cláudio Antonio Talge Carvalho
- Department of Restorative Dentistry, Endodontics Division, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (M.G.G.D.); (R.D.K.); (M.C.V.); (C.A.T.C.)
| | - Amjad Abu Hasna
- Department of Restorative Dentistry, Endodontics Division, Institute of Science and Technology, Campus of São José dos Campos, São Paulo State University, São Paulo 12245-000, Brazil; (M.G.G.D.); (R.D.K.); (M.C.V.); (C.A.T.C.)
- School of Dentistry, Universidad Espíritu Santo, Samborondón 092301, Ecuador
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Dumitrel SI, Matichescu A, Dinu S, Buzatu R, Popovici R, Dinu DC, Bratu DC. New Insights Regarding the Use of Relevant Synthetic Compounds in Dentistry. Molecules 2024; 29:3802. [PMID: 39202881 PMCID: PMC11357206 DOI: 10.3390/molecules29163802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 08/05/2024] [Accepted: 08/08/2024] [Indexed: 09/03/2024] Open
Abstract
Worldwide, synthetic compounds are used for both in-office and at-home dental care. They are a valuable resource for both prophylactic and curative treatments for various dental problems, such as tooth decay, periodontal diseases, and many more. They are typically preferred due to their broad range of actions and ability to produce targeted, rapid, and long-lasting effects. Using a 0.12% chlorhexidine mouthwash is capable of reducing the plaque index from 47.69% to 2.37% and the bleeding index from 32.93% to 6.28% after just 2 weeks. Mouthwash with 0.1% OCT is also highly effective, as it significantly lowered the median plaque index and salivary bacterial counts in 152 patients in 5 days compared to a control group (p < 0.0001), while also reducing the gingival index (p < 0.001). When povidone-iodine was used as an irrigant during the surgical removal of mandibular third molars in 105 patients, it resulted in notably lower pain scores after 2 days compared to a control group (4.57 ± 0.60 vs. 5.71 ± 0.45). Sodium hypochlorite is excellent for root canal disinfection, as irrigating with 1% NaOCl completely eliminated the bacteria from canals in 65% patients. A 0.05% CPC mouthwash proved effective for perioperative patient care, significantly decreasing gingival bleeding (p < 0.001) and suppressing Streptococcus levels even one week post-surgery. Lastly, a 6% H2O2 paint-on varnish and 6% H2O2 tray formulations successfully bleached the teeth of 40 patients, maintaining a noticeably whiter appearance up to the 6-month follow-up, with significant color differences from the baseline (p < 0.005). Synthetic compounds have a large research base, which also provides a greater awareness of their mechanism of action and potential adverse effects. For a better understanding of how they work, several methods and assays are performed. These are protocolary techniques through which a compound's efficacy and toxicity are established.
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Affiliation(s)
- Stefania-Irina Dumitrel
- Department of Toxicology, Drug Industry, Management and Legislation, Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Sq., 300041 Timisoara, Romania;
| | - Anamaria Matichescu
- Department of Preventive, Community Dentistry and Oral Health, Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, 14A Tudor Vladimirescu Ave., 300173 Timisoara, Romania
- Translational and Experimental Clinical Research Centre in Oral Health, Victor Babes University of Medicine and Pharmacy, 14A Tudor Vladimirescu Ave., 300173 Timisoara, Romania
| | - Stefania Dinu
- Department of Pedodontics, Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, 9 No., Revolutiei 1989 Bv., 300041 Timisoara, Romania;
- Pediatric Dentistry Research Center, Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, 9 No., Revolutiei 1989 Bv., 300041 Timisoara, Romania
| | - Roxana Buzatu
- Department of Dental Aesthetics, Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, 9 No., Revolutiei 1989 Bv., 300041 Timisoara, Romania;
| | - Ramona Popovici
- Department of Management, Legislation and Communication in Dentistry, Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, 9 No., Revolutiei 1989 Bv., 300041 Timisoara, Romania;
| | - Dorin Cristian Dinu
- Family Dental Clinic, Private Practice, 24 Budapesta Street, 307160 Dumbravita, Romania;
| | - Dana Cristina Bratu
- Department of Orthodontics II, Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy Timisoara, 9 No., Revolutiei 1989 Bv., 300041 Timisoara, Romania;
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Chen J, Zhang H, Zhao T, Yu Y, Song J, Zhao Y, Alshawwa H, Zou X, Zhang Z. Oxygen Self-Supplied Nanoplatform for Enhanced Photodynamic Therapy against Enterococcus Faecalis within Root Canals. Adv Healthc Mater 2024; 13:e2302926. [PMID: 38273674 DOI: 10.1002/adhm.202302926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Indexed: 01/27/2024]
Abstract
The successful treatment of persistent and recurrent endodontic infections hinges upon the eradication of residual microorganisms within the root canal system, which urgently needs novel drugs to deliver potent yet gentle antimicrobial effects. Antibacterial photodynamic therapy (aPDT) is a promising tool for root canal infection management. Nevertheless, the hypoxic microenvironment within the root canal system significantly limits the efficacy of this treatment. Herein, a nanohybrid drug, Ce6/CaO2/ZIF-8@polyethylenimine (PEI), is developed using a bottom-up strategy to self-supply oxygen for enhanced aPDT. PEI provides a positively charged surface, which enables precise targeting of bacteria. CaO2 reacts with H2O to generate O2, which alleviates the hypoxia in the root canal and serves as a substrate for Ce6 under 660 nm laser irradiation, leading to the successful eradication of planktonic Enterococcus faecalis (E. faecalis) and biofilm in vitro and, moreover, the effective elimination of mature E. faecalis biofilm in situ within the root canal system. This smart design offers a viable alternative for mitigating hypoxia within the root canal system to overcome the restricted efficacy of photosensitizers, providing an exciting prospect for the clinical management of persistent endodontic infection.
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Affiliation(s)
- Jiawen Chen
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Hong Zhang
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Tiancong Zhao
- College of Chemistry and Materials, Department of Chemistry and Laboratory of Advanced Materials, Shanghai Key Laboratory of Molecular Catalysis and Innovative Materials, State Key Laboratory of Molecular Engineering of Polymers, Collaborative Innovation Center of Chemistry for Energy Materials (2011-iChEM), Fudan University, Shanghai, 200433, P. R. China
| | - Yiyan Yu
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Jiazhuo Song
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Yuanhang Zhao
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Hamed Alshawwa
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Xinying Zou
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
| | - Zhimin Zhang
- Department of Endodontics, Jilin Provincial Key Laboratory of Oral Biomedical Engineering, School and Hospital of Stomatology, Jilin University, Changchun, 130021, P. R. China
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Boppré LM, Menezes Savaris J, Catherine Maiola E, Peressoni Vieira-Schuldt D, da Fonseca Roberti Garcia L, da Silveira Teixeira C, Antunes Bortoluzzi E. Can Heated Distilled Water Effectively Prevent Precipitate Formation between NaOCl and CHX? Int J Dent 2024; 2024:6612675. [PMID: 38222303 PMCID: PMC10787650 DOI: 10.1155/2024/6612675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/25/2023] [Accepted: 12/19/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction The present study aimed to investigate the capacity of different irrigation protocols using heated distilled water at 65°C (HDW), in preventing the formation of the brown-orange precipitate observed after the interaction between sodium hypochlorite (NaOCl) and chlorhexidine (CHX). Methods Forty human canines were selected, prepared, and cleaved in two halves. Images of delimited areas in each root canal thirds were obtained through a stereomicroscope (16x and 40x). After reassembly, the teeth were distributed into four groups (n = 10) according to the final irrigation protocol: G1 (no HDW): EDTA + NaOCl + CHX with conventional irrigation (CI); G2 (HDW + CI): EDTA with passive ultrasonic irrigation (PUI) + NaOCl (PUI) + HDW (CI) + CHX (PUI); G3 (HDW + PUI): EDTA + NaOCl + HDW + CHX with PUI; G4 (HDW + CUI): EDTA (PUI) + NaOCl (PUI) + HDW with continuous ultrasonic irrigation (CUI) + CHX (PUI). After irrigation, the teeth were re-separated and images of the same delimited areas were obtained again. Scores were assigned according to the amount of precipitate observed, comparing the initial and final images. The data were submitted to Kruskal-Wallis, Dunn and Friedman statistical tests (α = 5%). Results G1(no HDW) showed the highest scores in the analysis between groups (p < 0.001), with a greater amount of precipitate in the cervical and medium thirds (p < 0.001). The thirds of the other experimental groups did not differ from each other (p > 0.05). Conclusion The intermediate irrigation with heated distilled water at 65°C prevented the formation of brown-orange precipitate, regardless of the use of ultrasonic activation (PUI or CUI).
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Affiliation(s)
- Letícia Mendes Boppré
- Department of Dentistry-Endodontics Division, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Julia Menezes Savaris
- Department of Dentistry-Endodontics Division, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Emanuelle Catherine Maiola
- Department of Dentistry-Endodontics Division, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | | | - Lucas da Fonseca Roberti Garcia
- Department of Dentistry-Endodontics Division, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Cleonice da Silveira Teixeira
- Department of Dentistry-Endodontics Division, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Eduardo Antunes Bortoluzzi
- Department of Diagnosis and Oral Health, Division of Endodontics, University of Louisville, Louisville, KY, USA
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Wenzler JS, Falk W, Frankenberger R, Braun A. Temporary Root Canal Obturation with a Calcium Hydroxide-Based Dressing: A Randomized Controlled Clinical Trial. Antibiotics (Basel) 2023; 12:1663. [PMID: 38136697 PMCID: PMC10740497 DOI: 10.3390/antibiotics12121663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Successful bacterial inactivation or elimination is essential for successful outcomes in endodontics. This study investigated the efficacy of a calcium hydroxide paste (Ca(OH)2) as a temporary medical dressing for 1 week after chemomechanical root canal treatment (CMRCT). Microbiological samples from 26 patients were collected after endodontic emergency treatment as follows: (1) removal of the provisional filling material; (2) CMRCT; (3) irrigation with sodium hypochlorite I (3%); (4) medicinal insertion of Ca(OH)2; and (5) irrigation with sodium hypochlorite II (3%). A microbiological examination was carried out after the specimens had been taken from the root canals via saline and sterile paper points. CMRCT resulted in a significant reduction in total bacterial load (TBL) in the root canal (p < 0.05). Additional irrigation (3) resulted in a further significant reduction in TBL (p < 0.05). In contrast, Ca(OH)2 medication did not prevent the bacterial load from returning to the previous level immediately after CMRCT, but did not increase above that level either (p < 0.05). However, the increase in TBL was significant (p < 0.05) in comparison with the disinfection groups (I/II). Administration of Ca(OH)2 for 1 week shows that in combination with an additional disinfection procedure, an increase in TBL must be expected, but not above the level of conditions after CMRCT.
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Affiliation(s)
- Johannes-Simon Wenzler
- Department of Operative Dentistry, Periodontology and Preventive Dentistry, Rheinisch-Westfälische Technische Hochschule University Hospital, Pauwelsstrasse 30, 52074 Aachen, Germany;
- Department of Operative Dentistry, Endodontics and Pediatric Dentistry, Campus Marburg, University Medical Center Giessen and Marburg, Georg-Voigt-Strasse 3, 35039 Marburg, Germany
| | - Wolfgang Falk
- Center for Oro-Dental Microbiology, Hamburger Chausse 25, 24220 Flintbek, Germany
| | - Roland Frankenberger
- Department of Operative Dentistry, Endodontics and Pediatric Dentistry, Campus Marburg, University Medical Center Giessen and Marburg, Georg-Voigt-Strasse 3, 35039 Marburg, Germany
| | - Andreas Braun
- Department of Operative Dentistry, Periodontology and Preventive Dentistry, Rheinisch-Westfälische Technische Hochschule University Hospital, Pauwelsstrasse 30, 52074 Aachen, Germany;
- Department of Operative Dentistry, Endodontics and Pediatric Dentistry, Campus Marburg, University Medical Center Giessen and Marburg, Georg-Voigt-Strasse 3, 35039 Marburg, Germany
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Weissheimer T, Pinto KP, da Silva EJNL, Hashizume LN, da Rosa RA, Só MVR. Disinfectant effectiveness of chlorhexidine gel compared to sodium hypochlorite: a systematic review with meta-analysis. Restor Dent Endod 2023; 48:e37. [PMID: 38053784 PMCID: PMC10695732 DOI: 10.5395/rde.2023.48.e37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/25/2023] [Accepted: 09/07/2023] [Indexed: 12/07/2023] Open
Abstract
This study aimed to compare the disinfectant ability of chlorhexidine (CHX) gel and sodium hypochlorite (NaOCl). Systematic searches were conducted from inception until December 8th, 2022 (MEDLINE/PubMed, Cochrane Library, Web of Science, Scopus, Embase, and Grey Literature databases). Only randomized clinical trials were included. The revised Cochrane risk of bias tools for randomized trials were used to assess the quality of studies. Meta-analyses were performed. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation tool. Six studies were included. Five had a low risk of bias and 1 had some concerns. Three studies assessed bacterial reduction. Two were included in the meta-analysis for bacterial reduction (mean difference, 75.03 [confidence interval, CI, -271.15, 421.22], p = 0.67; I2 = 74%); and 3 in the meta-analysis for cultivable bacteria after chemomechanical preparation (odds ratio, 1.03 [CI, 0.20, 5.31], P = 0.98; I2 = 49%). Five studies assessed endotoxin reduction. Three were included in a meta-analysis (mean difference, 20.59 [CI, -36.41, 77.59], p = 0.48; I2 = 74%). There seems to be no difference in the disinfectant ability of CHX gel and NaOCl, but further research is necessary.
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Affiliation(s)
- Theodoro Weissheimer
- Department of Endodontics, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Karem Paula Pinto
- Department of Endodontics, School of Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil
| | - Emmanuel João Nogueira Leal da Silva
- Department of Endodontics, School of Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil
- Department of Endodontics, School of Dentistry, Grande Rio University (UNIGRANRIO), Rio de Janeiro, RJ, Brazil
| | - Lina Naomi Hashizume
- Department of Preventive and Social Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Ricardo Abreu da Rosa
- Department of Endodontics, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Marcus Vinicius Reis Só
- Department of Endodontics, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Gomes BPFA, Aveiro E, Kishen A. Irrigants and irrigation activation systems in Endodontics. Braz Dent J 2023; 34:1-33. [PMID: 37909632 PMCID: PMC10642269 DOI: 10.1590/0103-6440202305577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 11/03/2023] Open
Abstract
Root canal infections are typically polymicrobial and involve strong bacterial interactions. The goal of endodontic treatment is to remove infected content from the root canal system to allow the healing of a pre-existing periapical lesion or to prevent infection of the periradicular tissues. Instrumentation alone is not capable of touching all of the root canal walls. Therefore, the irrigation process is an essential step in the endodontic treatment. However, due to the complex anatomy of the root canal system, this cleaning is very challenging. Although syringe and needle irrigation associated with the use of chemical substances is still the most used method, it does not guarantee optimal cleaning of the root canals. As a result, not only alternative irrigating substances but also numerous activation systems - which are technologies that aim to optimize the action of irrigating substances, both chemically and physically - have been developed. This work aimed to review the characteristics of both classic and current alternatives of irrigating substances and irrigation activation systems.
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Affiliation(s)
- Brenda P. F. A. Gomes
- Department of Restorative Dentistry, Division of Endodontics,
Piracicaba Dental School - State University of Campinas, UNICAMP, Brazil
| | - Emelly Aveiro
- Department of Restorative Dentistry, Division of Endodontics,
Piracicaba Dental School - State University of Campinas, UNICAMP, Brazil
| | - Anil Kishen
- Department of Dentistry, University of Toronto, Canada
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Chalub LO, Nunes GP, Strazzi-Sahyon HB, Ferrisse TM, Dos Santos PH, Gomes-Filho JE, Cintra LTA, Sivieri-Araujo G. Antimicrobial effectiveness of ultrasonic irrigation in root canal treatment: a systematic review of randomized clinical trials and meta-analysis. Clin Oral Investig 2023; 27:1343-1361. [PMID: 36757461 DOI: 10.1007/s00784-023-04897-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/01/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE The objective of this systematic review and meta-analysis (SRM) was to answer the question as to whether the use of ultrasonic irrigation (UI) results in better antimicrobial activity in root canal disinfection compared to conventional irrigation (CI). METHODS A literature search was performed in the main scientific databases, carried out until October 2021. The eligibility criteria were randomized clinical trials (RCTs). Two meta-analyses were conducted using R software with the "META" package. The mean difference (MD) and odds ratio (OR) measure of effect were calculated. The fixed effect model was applied with a 95% confidence interval. The Cochrane collaboration scale was used to assess risk of bias and the GRADE tool to assess the quality of evidence. RESULTS A total of 1782 records were screened, and 12 studies meeting the criteria were included in this review. A low risk of bias was observed for most domains, except allocation concealment that was considered unclear. The certainty of evidence was classified as moderate in the OR meta-analyses and low in the MD meta-analyses. Ultrasonic irrigation resulted in a better antimicrobial effect in both meta-analyses, MD 1.42 [1.60; 1.23] p < 0.0001, I2 = 80%; and OR 3.86 [1.98; 7.53] p< 0.0001, I2 = 28.7%. CONCLUSION Within the limitations of this SRM, UI presented better antimicrobial efficacy than CI. CLINICAL RELEVANCE UI should be used by clinicians as it promotes better antimicrobial efficacy in patients undergoing endodontic treatment.
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Affiliation(s)
- Lucas Orbolato Chalub
- Department of Preventive and Restorative Dentistry, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil
| | - Gabriel Pereira Nunes
- Department of Preventive and Restorative Dentistry, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil
| | - Henrico Badaoui Strazzi-Sahyon
- Department of Dental Materials and Prosthodontics, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil
| | - Túlio Morandin Ferrisse
- Oral Medicine, Department of Diagnosis and Surgery, Araraquara School of Dentistry, São Paulo State University - UNESP, 1680 Humaitá Street, Araraquara, SP, 14801-385, Brazil
| | - Paulo Henrique Dos Santos
- Department of Dental Materials and Prosthodontics, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil
| | - João Eduardo Gomes-Filho
- Department of Preventive and Restorative Dentistry, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil
| | - Luciano Tavares Angelo Cintra
- Department of Preventive and Restorative Dentistry, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil
| | - Gustavo Sivieri-Araujo
- Department of Preventive and Restorative Dentistry, Araçatuba School of Dentistry, São Paulo State University - UNESP, 1193 José Bonifácio Street, Araçatuba, SP, 16015-050, Brazil.
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10
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Ahmad MZ, Merdad KA, Sadaf D. An overview of systematic reviews on endotoxins in endodontic infections and the effectiveness of root canal therapy in its removal. Evid Based Dent 2022:10.1038/s41432-022-0826-x. [PMID: 36482195 DOI: 10.1038/s41432-022-0826-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 02/16/2022] [Indexed: 06/17/2023]
Abstract
Background The objective of this overview was to synthesise the current evidence on the role of endotoxins in endodontics infections and to evaluate the effectiveness of endodontic procedures in its removal using information from published systematic reviews.Methods Electronic databases Medline, Scopus, Embase, Cochrane Library and Google Scholar were searched for reviews published up to July 2021. Systematic reviews on endotoxins based on clinical and/or observational studies were included. The quality of systematic reviews was assessed with the AMSTAR2 tool.Results A total of five systematic reviews were selected, of which two reviews were of high quality. A significantly higher level of endotoxins were found in teeth with exudation, teeth with a previous episode of pain and pain on percussion. Chemomechanical preparation of root canals significantly reduce endotoxin levels. Calcium hydroxide intracanal medication in symptomatic teeth was significantly effective in endotoxin reduction (standardised mean difference -1.051 [95% confidence interval -2.039 to -0.063]; p <0.05; I2 = 83.3%; certainty of evidence = very low). Multiple session root canal treatment in teeth with symptomatic apical periodontitis was significantly more effective in endotoxins/lipopolysaccharides removal than single-session treatment.Conclusion Limited quality of evidence showed a significant association of endotoxins in infected teeth with clinical symptoms. Conventional chemomechanical preparation of root canals and intracanal medication were unable to eliminate endotoxins from the root canal system. Future evolution of effective disinfection therapies is warranted.
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Affiliation(s)
- Muhammad Z Ahmad
- Restorative Dentistry Department, College of Dentistry in Ar Rass, Qassim University, Alrass, Saudi Arabia
| | - Khalid A Merdad
- Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Durre Sadaf
- Department of Microbial Diseases, University College London, Eastman Dental Institute, London, United Kingdom.
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11
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Kirkevang LL, El Karim IA, Duncan HF, Nagendrababu V, Kruse C. Outcomes reporting in systematic reviews on non-surgical root canal treatment: A scoping review for the development of a core outcome set. Int Endod J 2022; 55:1128-1164. [PMID: 35969087 DOI: 10.1111/iej.13812] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Studies related to non-surgical root canal treatment are amongst the most frequently performed clinical studies in endodontics. However, heterogeneity in reporting outcomes and lack of standardization is a significant challenge to evidence synthesis and guideline development. OBJECTIVES The aims of the present scoping review were to (a) identify outcomes reported in systematic reviews evaluating non-surgical root canal treatment; (b) identify how and when the reported outcomes were measured; (c) assess possible selective reporting bias in the included studies. The information obtained in this study should inform the development of a core outcome set (COS) for non-surgical root canal treatment. METHODOLOGY Structured literature searches were performed to identify systematic reviews on non-surgical root canal treatments published in English between January 1990 and December 2020. Two reviewers undertook study selection and data extraction. Outcomes were categorized according to a healthcare taxonomy into five core areas (survival, clinical/physiological changes, life impact, resource use, and adverse events). The outcome measurement tools and length of follow-up were recorded. RESULTS Seventy-five systematic reviews were included, of which 40 included meta-analyses. Most reviews reported on physiological and clinical outcomes, primarily pain and/or radiographic assessment of periapical status, and a variety of measurement tools and scales were used. Few reviews focused on tooth survival, life impact, resources, and adverse events. The heterogeneity amongst the reviews was large on all parameters. Less than 40% of the reviews assessed the risk of selective reporting. DISCUSSION Overall aims of the included reviews were highly heterogenic; thus, outcomes and how they were measured also varied considerably. Patient-centred outcomes and the use of resources were rarely reported on. CONCLUSIONS Most studies reported on physiological and clinical outcomes, in particular pain and/or radiographic healing. Measurement tools, scales, thresholds, and follow-up periods varied greatly within each outcome, making comparison across studies complicated. Less than 40% of the reviews assessed risk of selective reporting; thus, selective bias could not be ruled out. The presented information on reported outcomes, measurement tools and scales, and length of follow-up may guide the planning of future research and inform the development of a COS for non-surgical root canal treatment.
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Affiliation(s)
| | - Ikhlas A El Karim
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Henry Fergus Duncan
- Division of Restorative Dentistry & Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Venkateshbabu Nagendrababu
- Department of Preventive and Restorative Dentistry, College of Dental Medicine, University of Sharjah, Sharjah, UAE
| | - Casper Kruse
- Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
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12
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Nunes IAM, Novais TMG, Garcia PP, Silva WS, Tavarez RRDJ, Rizzi CDC, Carvalho CN, Filho EMM. Antimicrobial action of ozonated water and photodynamic therapy with sonic activation in root canals infected with Enterococcus faecalis. J Clin Exp Dent 2022; 14:e486-e491. [PMID: 35765359 PMCID: PMC9233916 DOI: 10.4317/jced.57909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 04/20/2022] [Indexed: 11/05/2022] Open
Abstract
Background New protocols are constantly being tested in the search for complete disinfection of root canals without the undesirable effects of sodium hypochlorite. This study evaluated the antimicrobial effect of ozonated water and photodynamic therapy (PDT) with sonic activation in root canals infected with Enterococcus faecalis. Material and Methods Seventy single-rooted canals of human teeth were prepared and contaminated with E. faecalis for 21 days. The teeth were divided into six experimental groups (n=10): ozonized water without (O + S-) and with sonic activation (O + S +); PDT without (PDT + S-) and with sonic activation (PDT + S +); PDT + ozonized water without (PDT + O + S-) and with sonic activation (PDT + O + S +); and two control groups, one positive (n = 5) and one negative (n = 5). Microbial collections were performed before and shortly after treatment, counted in the log of colony-forming units and tested for significant difference between these counts, if any (Student's t-test). The ANOVA two-way test was applied to evaluate whether the Treatment factor (Ozone, PDT and Ozone + PDT) and the Sonic factor (With and without sonic activation) had any effect on microbial reduction. Results In all protocols, there was a significant microbial reduction (p=0.025), whereas in the groups in which sonic activation was used, the microbial reduction was significantly greater (p=0.001). Conclusions The treatments significantly reduced the number of microorganisms in the root canals. Sonic activation helped to increase the microbial reduction in infected root canals. Key words:Endodontics, ozone, photodynamic therapy, enterococcus faecalis.
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Barbosa AFA, de Lima CO, Moreira T, Sassone LM, Fidalgo TKDS, Silva EJNL. Photodynamic therapy for root canal disinfection in endodontics: an umbrella review. Lasers Med Sci 2022; 37:2571-2580. [PMID: 35507120 DOI: 10.1007/s10103-022-03569-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
To evaluate and synthesize the evidence from the individual reviews that evaluated the efficacy of PDT therapy in root canal disinfection by undertaking an umbrella review. The protocol of the review was registered in the PROSPERO database under number CRD42021214056. The literature search was conducted using the following electronic databases: PubMed, Scopus, Web of Science, BVS, Cochrane Database of Systematic Reviews, Embase, and Epistemonikos, from inception to July 2021. Systematic reviews that evaluated the efficacy of PDT for root canal disinfection were included. Two authors independently performed a literature search, data extraction, and quality assessment of the included studies. Any disagreements were resolved by a third reviewer. The quality of the reviews was assessed using the AMSTAR 2 tool and the final categorization of each systematic reviews was classified as of "high," "moderate," "low," or "critically low" quality. Six systematic reviews were included in the current umbrella review and all of them were graded as critically low quality. From the critically low-quality evidence available, this umbrella review showed that the efficacy of PDT in root canal disinfection remains yet undetermined.
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Affiliation(s)
| | - Carolina Oliveira de Lima
- Department of Dentistry, Federal University of Juiz de Fora (UFJF-GV), Governador Valadares, MG, Brazil.
| | - Thiago Moreira
- Department of Preventive and Community Dentistry, School of Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil
| | - Luciana Moura Sassone
- Department of Endodontics, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil
| | - Tatiana Kelly da Silva Fidalgo
- Department of Preventive and Community Dentistry, School of Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil
| | - Emmanuel João Nogueira Leal Silva
- Department of Endodontics, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil.,Department of Endodontics, Grande Rio University (UNIGRANRIO), Rio de Janeiro, RJ, Brazil
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14
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Comparison of Herbal Agents with Sodium Hypochlorite as Root Canal Irrigant: A Systematic Review of In Vitro Studies. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:8967219. [PMID: 34868334 PMCID: PMC8639255 DOI: 10.1155/2021/8967219] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/10/2021] [Indexed: 11/18/2022]
Abstract
During endodontic treatment, eliminating microorganisms from the root canals should be considered with utmost importance. Before filling the canal, every effort should be made to ensure optimal shaping and adequate disinfection of the root canal system. This systematic review aimed to compare the efficacy of herbal agents with sodium hypochlorite (NaOCl) in reducing the microbial load while used as a root canal irrigant. The research question in the present study was to assess “Is there a significant difference in reducing microbial load comparing sodium hypochlorite (NaOCl) and herbal agents.” Electronic databases (PubMed, Scopus, and Web of Science) were searched from their start dates to November 2020 using strict inclusion and exclusion criteria and reviewed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Only in vitro studies comparing herbal agents with NaOCl regarding antimicrobial efficiency were included. Two reviewers independently assessed the included article. 825 articles were obtained from an electronic database. Twenty papers were included for review of the full text. Eleven papers were excluded because they did not meet the inclusion criteria. Finally, nine articles were included in the systematic review. The present systematic review was at the in vitro level; therefore, the result cannot translate the exact clinical conditions. This systematic review concludes that herbal agents cannot be used as a main irrigant for canal disinfection.
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15
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Lee AHC, Neelakantan P, Dummer PMH, Zhang C. Cemental tear: Literature review, proposed classification and recommendations for treatment. Int Endod J 2021; 54:2044-2073. [PMID: 34403513 DOI: 10.1111/iej.13611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022]
Abstract
Cemental tears are an important condition of relevance to Endodontics but are often overlooked. A cemental tear is the partial or complete detachment of the cementum from the cemento-dentinal junction or along the incremental line within the body of cementum. The limited attention received is most likely due to the limited awareness amongst dental professionals and challenges in accurately diagnosing them, resulting in misdiagnosis and erroneous treatment. The aim of this review is to describe the: (i) epidemiology and predisposing factors; (ii) clinical, radiographic and histological features and (iii) the clinical management and treatment outcomes of cemental tear. The review included 37 articles published in English that comprised eight observational studies and 29 case reports. The prevalence of cemental tears was reported to be lower than 2%; whilst the incidence remains unknown. Internal factors due to the inherent structural weakness of cementum and its interface with the dentine, and external factors that are associated with stress have been proposed as the two mechanisms responsible for the development and propagation of cemental tears. Predisposing factors that have been implicated were tooth type, gender, age, previous root canal treatment, history of dental trauma, occlusal trauma and excessive occlusal force; however, evidence is limited. Common clinical and radiographic manifestations of cemental tears resemble the presentations of primary endodontic diseases, primary periodontal diseases and combined endodontic-periodontal lesions. Clinical management tended to focus on complete removal of the torn fragments and periodontal treatment, often combined with regenerative treatment. In this article, a new classification for cemental tears is developed that consists of classes 0 to 6 and stages A, B, C and D based on the: (i) location and accessibility of the torn cemental fragment; (ii) the pattern and extension of the associated bony defect in relation to the root length and (iii) the number of root surface/s affected by the cemental tear/s and the associated bony defect. Recommendations for treatment strategies are also provided and linked to the classification to aid in streamlining the process of treatment decision making.
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Affiliation(s)
- Angeline H C Lee
- Division of Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Prasanna Neelakantan
- Division of Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Paul M H Dummer
- School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Chengfei Zhang
- Division of Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
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16
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Jeong JW, Sarmast ND, Terlier T, van der Hoeven R, Holland JN, Parikh N. Assessment of the cytotoxic effects and chemical composition of the insoluble precipitate formed from sodium hypochlorite and chlorhexidine gluconate. Int Endod J 2021; 54:1892-1901. [PMID: 34081782 DOI: 10.1111/iej.13583] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022]
Abstract
AIM To investigate (1) the cytotoxic potential of the brown precipitate (BP) formed with sodium hypochlorite (NaOCl) and chlorhexidine gluconate (CHX), using both a small animal model of Caenorhabditis elegans (C. elegans) and cultured human gingival fibroblasts; and (2) the chemical composition of BP using Time-of-Flight Secondary Ion Mass Spectrometry (ToF-SIMS). METHODOLOGY Brown precipitate was obtained by mixing equal volumes of 6% NaOCl and 2% CHX and separating the BP from clear supernatant by centrifugation. The brown precipitate was weighed and solubilized in dimethyl sulfoxide for cytotoxicity experiments. The cytotoxic effect of BP was assessed using C. elegans larvae and primary immortalized human gingival fibroblasts-hTERT (hTERT-hNOF) cells. Various dilutions of BP (25 ng/µL-150 ng/µL), supernatant (0.15% v/v), NaOCl (1:100-1:1000 dilutions of 6% NaOCl) or CHX (1:500-1:1000 dilutions of 2% CHX) along with vehicle control (0.5% v/v ethanol and 0.15% v/v DMSO) or untreated control (growth medium) were tested on C. elegans larvae and hTERT-hNOF cells. Viability was assessed in C. elegans larvae using stereomicroscopy and in hTERT-hNOF cells using dehydrogenase-based colorimetric assay. ToF-SIMS was used to assess the chemical composition of BP in comparison with CHX and para-chloroaniline (PCA). The C. elegans and cell line data were analysed using Log-Rank test and Student's t-test, respectively (p < .05). RESULTS BP-75 ng/µL and BP-150 ng/µL were significantly more toxic to C. elegans larvae than the untreated, vehicle, supernatant or CHX treatment groups (p < .0001). Similarly, in hTERT-hNOF cells, BP-50 ng/µL, BP-75 ng/µL and BP-150 ng/µL induced significant cytotoxicity within 2 h compared with untreated, vehicle, supernatant and CHX treatments (p < .05). ToF-SIMS analysis of BP revealed ion composition characteristic of both CHX and the carcinogen PCA. CONCLUSIONS Brown precipitate was toxic in both C. elegans larvae and hTERT-hNOF cells. The ToF-SIMS analysis of BP revealed ions characteristic of CHX and PCA that could account for the toxicities observed in C. elegans larvae and human gingival fibroblasts. Because of the insoluble and toxic nature of BP, consecutive use of CHX and NaOCl irrigants should be avoided in root canal treatment.
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Affiliation(s)
- Ji Wook Jeong
- Department of Endodontics, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nima D Sarmast
- Department of Periodontics, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tanguy Terlier
- SIMS Laboratory, Shared Equipment Authority, Rice University, Houston, TX, USA
| | - Ransome van der Hoeven
- Department of Diagnostic and Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julian N Holland
- Office of Research, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Neha Parikh
- Department of Diagnostic and Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Identification of Fusobacterium nucleatum in primary and secondary endodontic infections and its association with clinical features by using two different methods. Clin Oral Investig 2021; 25:6249-6258. [PMID: 33844080 DOI: 10.1007/s00784-021-03923-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/29/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Fusobacterium nucleatum is an important oral pathogen involved in endodontic infections. This study aimed to assess the frequency of Fusobacterium nucleatum in primary and secondary endodontic infections and its associations with the clinical features in a Brazilian population by using both culture and nested PCR methods. METHODS A total of 100 microbial samples from patients with primary (n=50) and secondary endodontic infections (n=50) were analyzed by using culture and nested PCR methods. Strict anaerobic techniques were used for culture and identification of F. nucleatum. The DNA extracted from the samples was analyzed for the presence of target species by using species-specific primers. RESULTS Culture and nested PCR methods detected F. nucleatum, respectively, in 11/100 and 82/100 root canals. F. nucleatum was isolated by culture from 10/50 (20%) root canals with primary infections and from 1/50 (2%) root canal with secondary/persistent infections. Nested PCR detected F. nucleatum in 42/50 (84%) root canals with primary infections and in 40/50 (80%) root canals with secondary/persistent endodontic infections. F. nucleatum was associated with spontaneous pain, tenderness to percussion, pain on palpation, swelling, tooth mobility, wet root canals, hemorrhagic exudate, tooth decay, inadequate restoration, and poor endodontic filling. CONCLUSION F. nucleatum was found in more cases of primary endodontic infections than in cases of secondary/persistent ones. A higher prevalence of F. nucleatum was detected by using the nested PCR method than by using culture. The presence of F. nucleatum in the root canals was associated with several clinical features. CLINICAL RELEVANCE The high prevalence of F. nucleatum in the root canals detected by molecular methods, and its association with several clinical features reveals the importance of these species in the development of apical pathologies and reinforces the need of an endodontic treatment directed to bacterial elimination.
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Brandão-Neto DDO, Mello JVZ, Marceliano-Alves MFV, Carvalho Coutinho TMD, Marceliano EFV, Galhardi MPW, Tavares VS, Muzy Dias AP, Lins RX. Final Endodontic Irrigation with 2% Peracetic Acid: Antimicrobial Activity and Cytotoxicity. Eur J Dent 2021; 15:533-538. [PMID: 33535247 PMCID: PMC8382456 DOI: 10.1055/s-0041-1723068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The aim of present study was to assess the cytotoxicity and antimicrobial efficacy of 2% peracetic acid (PAA) compared with 5.25% sodium hypochlorite (NaOCl) and 2% chlorhexidine (CHX). MATERIAL AND METHODS For the cytotoxicity test, 100 µl of the tested solutions were added in 12 wells with ECV 304 endothelial cells in each group: NaOCl, CHX, and PAA, in addition to the control group. Each solution was evaluated after 24 hours of contact in four dilutions: 0.2, 0.1, 0.05 and 0.025 through mitochondrial function using MTT colorimetric assay. In the antimicrobial evaluation, 40 dentin blocks 5 mm in length and 0.2 g in weight were incubated with 400 µl of Enterococcus faecalis suspension for 21 days at 37°C. The contaminated samples were divided into three experimental groups within 5 minutes of contact: NaOCl group, CHX group, PAA group, as well as the positive control group. The specimens received treatment and were transferred to a tube with saline for serial dilution of the solution and seeding for isolation and colony forming unit (CFU) count. STATISTICAL ANALYSIS The results obtained were expressed as mean (A570 nm) ± standard deviation (SD) and in a multiple linear regression model and multiple comparisons conducted. RESULTS The antimicrobial evaluation revealed that the NaOCl and CHX groups showed a statistically significant difference compared with the control group (p < 0.001), while the PAA reduced only the CFU growth. It can be concluded that, among the agents tested, PAA expressed greater cell viability, followed by CHX and NaOCl. However, it did not show greater antimicrobial activity in vitro in the mature biofilm of Enterococcus faecalis.
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Affiliation(s)
- Daniel de Oliveira Brandão-Neto
- Postgraduate Program in Dentistry, Health Institute of Nova Friburgo, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
| | - João Victor Zebende Mello
- School of Dentistry, Health Institute of Nova Friburgo, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
| | | | | | | | | | - Vívian Souza Tavares
- School of Dentistry, Health Institute of Nova Friburgo, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
| | - Aline Peçanha Muzy Dias
- School of Dentistry, Health Institute of Nova Friburgo, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
| | - Renata Ximenes Lins
- Postgraduate Program in Dentistry, Health Institute of Nova Friburgo, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
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Bandeira AVL, Lima MDDMD, Lima CCB, Moura MSD, Cury AADB, Moura LDFADD. Topography of Primary Molar Pulp Chamber Floor: A Scanning Electron Microscopy and Micro-Computed Tomography Analysis. PESQUISA BRASILEIRA EM ODONTOPEDIATRIA E CLÍNICA INTEGRADA 2021. [DOI: 10.1590/pboci.2021.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Arruda-Vasconcelos R, Louzada LM, Feres M, Tomson PL, Cooper PR, Gomes BPFA. Investigation of microbial profile, levels of endotoxin and lipoteichoic acid in teeth with symptomatic irreversible pulpitis: a clinical study. Int Endod J 2020; 54:46-60. [PMID: 32892394 DOI: 10.1111/iej.13402] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/31/2020] [Indexed: 12/28/2022]
Abstract
AIM To investigate the microbial profile, and levels of endotoxin (LPS) and lipoteichoic acid (LTA), in infected dentine (ID) and root canals (RC) at different phases of root canal treatment in teeth with symptomatic irreversible pulpitis. METHODOLOGY Ten volunteers were included, and samples were collected from infected dentine (ID) and the root canal lumen (RC) using sterile excavators and paper points, respectively. RC samples were taken before (S1) and after (S2) chemo-mechanical canal preparation (CMP), and after intracanal medication (ICM; S3). Checkerboard DNA-DNA hybridization was used for microbial analysis. The levels of LPS and LTA were evaluated using the limulus amebocyte lysate assay and ELISA, respectively. Shapiro-Wilk's test was used to verify data normality. Friedman's test was used to evaluate statistical differences using checkerboard DNA-DNA hybridization in the ID and RC at the different phases of the RC treatment. Post hoc Dunn's multiple comparison test was used to verify significant differences recorded at the different time-points. The levels of LPS and LTA were analysed statistically by using repeated measures anova and Tukey's post hoc test to evaluate differences in both sites. The significance level was set at 5% (P < 0.05). RESULTS A total of 40 DNA probes were used for microbial investigation of ID and RC samples using checkerboard DNA-DNA hybridization. The levels and complexity of bacteria were similar in the ID and initial RC samples. The levels of LPS and LTA in ID were significantly higher than the initial RC samples (S1; P < 0.05). Canal preparation was effective in significantly decreasing the levels of bacteria, LPS and LTA (P < 0.05). ICM did not provide additional reduction in the levels of bacteria and LPS (P > 0.05). However, a significant reduction in the levels of LTA was observed after ICM (P < 0.05). CONCLUSION The microbial profile of infected dentine and root canals of teeth with irreversible pulpitis was complex, harbouring different species including Gram-positive and Gram-negative, cocci and bacilli, and facultative and strict anaerobes. Root canal preparation was effective in reducing the levels of bacteria, LPS and LTA from the root canals of teeth with pulpitis.
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Affiliation(s)
- R Arruda-Vasconcelos
- Division of Endodontics, Department of Restorative Dentistry, Piracicaba Dental School, State University of Campinas - UNICAMP, Piracicaba, Brazil.,Department of Oral Biology, Institute of Clinical Sciences, The University of Birmingham School of Dentistry, Birmingham, UK
| | - L M Louzada
- Division of Endodontics, Department of Restorative Dentistry, Piracicaba Dental School, State University of Campinas - UNICAMP, Piracicaba, Brazil
| | - M Feres
- Dental Research Division, Department of Periodontology, Guarulhos University, Guarulhos, Brazil
| | - P L Tomson
- Department of Oral Biology, Institute of Clinical Sciences, The University of Birmingham School of Dentistry, Birmingham, UK
| | - P R Cooper
- Department of Oral Sciences, Faculty of Dentistry, Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand
| | - B P F A Gomes
- Division of Endodontics, Department of Restorative Dentistry, Piracicaba Dental School, State University of Campinas - UNICAMP, Piracicaba, Brazil
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21
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Bedran NR, Nadelman P, Magno MB, de Almeida Neves A, Ferreira DM, Braga Pintor AV, Maia LC, Primo LG. Does Calcium Hydroxide Reduce Endotoxins in Infected Root Canals? Systematic Review and Meta-analysis. J Endod 2020; 46:1545-1558. [PMID: 32795549 DOI: 10.1016/j.joen.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/01/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate the potential of endotoxin reduction by comparing the number of lipopolysaccharides (LPSs) before and after the use of calcium hydroxide (Ca[OH]2) as intracanal medication (ICM). METHODS Searches were performed up to June 2020. Clinical and experimental studies comparing the amount of LPSs before and after the use of Ca(OH)2 as ICM in infected root canals were included. Risks of bias assessment and data extraction were performed. Meta-analysis was conducted by subgrouping according to Ca(OH)2, the presence of an antimicrobial substance (AS), irrigant solution during chemomechanical preparation (CMP), and the incidence of LPS reduction. The certainty of evidence was determined by the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Nine studies were included in the qualitative synthesis and 7 in the meta-analysis. Three articles had low risk of bias (RB), 1 had moderate RB, 2 had high RB, and 3 "some concerns." Overall, Ca(OH)2, with or without AS, reduced mean LPSs before CMP (standardized mean difference [SMD] = -1.087 [confidence interval {CI}, -1.453 to -0.721], P < .001, I2 = 58.7%) and after CMP (SMD = -0.919 [CI, -1.156 to -0.682], P < .001, I2 = 24.7%). Considering the irrigant solutions, the overall results showed a reduction before (SMD = -1.053 [CI, -1.311 to -0.795], P < .001, I2 = 58.7%) and after CMP (SMD = -0.938 [CI, -1.147 to -0.729], P < .001, I2 = 24,6%). Analyses presented very low certainty of evidence. The incidence of LPS reduction was 98.9% and 61.7% for Ca(OH)2 with and without AS, respectively. CONCLUSIONS Ca(OH)2 reduces endotoxin levels when used as ICM but is unable to eliminate LPSs completely independent of the irrigating solution used with very low certainty of evidence.
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Affiliation(s)
- Natália Rocha Bedran
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia Nadelman
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcela Baraúna Magno
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aline de Almeida Neves
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil; Center for Oral Clinical and Translational Sciences, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, London, United Kingdom
| | - Daniele Masterson Ferreira
- Central Library of the Health Science Center, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andréa Vaz Braga Pintor
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lucianne Cople Maia
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Laura Guimarães Primo
- Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil.
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Ruksakiet K, Hanák L, Farkas N, Hegyi P, Sadaeng W, Czumbel LM, Sang-ngoen T, Garami A, Mikó A, Varga G, Lohinai Z. Antimicrobial Efficacy of Chlorhexidine and Sodium Hypochlorite in Root Canal Disinfection: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Endod 2020; 46:1032-1041.e7. [PMID: 32413440 DOI: 10.1016/j.joen.2020.05.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/20/2020] [Accepted: 05/05/2020] [Indexed: 02/02/2023]
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Abu Hasna A, Pereira Da Silva L, Pelegrini FC, Ferreira CLR, de Oliveira LD, Carvalho CAT. Effect of sodium hypochlorite solution and gel with/without passive ultrasonic irrigation on Enterococcus faecalis, Escherichia coli and their endotoxins. F1000Res 2020; 9:642. [PMID: 33149896 PMCID: PMC7573735 DOI: 10.12688/f1000research.24721.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 01/15/2023] Open
Abstract
Background: Sodium hypochlorite (NaOCl) is the most commonly used irrigant in endodontics
. The purpose of this study was to evaluate the effect of NaOCl solution (2.5%) and gel (3%) with/without passive ultrasonic irrigation (PUI) on
Enterococcus faecalis, Escherichia coli, and their endotoxins, lipopolysaccharide (LPS) and lipoteichoic acid (LTA). Methods: 40 human lower premolars were contaminated with
E. coli (ATCC 25922) for 28 days and
E. faecalis (ATCC 29212) for 21 days. Specimens were randomly divided into four groups: (1) 2.5% NaOCl irrigating the canals without PUI activation; (2) 2.5% NaOCl with PUI; (3) 3% NaOCl gel irrigating the canals without PUI; and (4) 3% NaOCl gel with PUI. 40 mL of irrigant was used for each group. PUI activation was carried out using E1-Irrisonic stainless-steel tip at 10% frequency. After treatment, all specimens were filled with 3mL of 17% ethylenediaminetetraacetic acid (EDTA) for 3min and then washed with nonpyrogenic saline solution. Three samples were collected from the canals: S1, at baseline to confirm biofilm formation; S2 after treatment; and S3 after EDTA. Samples were assessed for
E. coli and
E. faecalis colony forming units, and LPS and LTA were assessed using chromogenic kinetic LAL assay and ELISA, respectively. Data were analyzed by Kruskal-Wallis, Friedmann and Dunn tests with α≤0.05. Results: All groups were effective in reducing the microbial load of
E. coli and
E. faecalis after treatment without a significant difference among the groups. NaOCl and NaOCl gel groups had no significant difference in reducing LPS and LTA. Statistically increased reduction was seen for NaOCL + PUI and NaOCl gel + PUI compared for groups without PUI. Conclusions: NaOCl gel has the same antimicrobial action of NaOCl solution and can partially detoxify endotoxins. PUI improves NaOCl (gel or solution) action over
E. faecalis and
E. coli and their endotoxins.
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Affiliation(s)
- Amjad Abu Hasna
- Department of Restorative Dentistry, Endodontic Division., São Paulo State University (UNESP), Institute of Science and Technology, São José dos Campos, São Paulo, 12245000, Brazil
| | - Laiana Pereira Da Silva
- Department of Restorative Dentistry, Endodontic Division., São Paulo State University (UNESP), Institute of Science and Technology, São José dos Campos, São Paulo, 12245000, Brazil
| | - Fernanda Carvalho Pelegrini
- Department of Restorative Dentistry, Endodontic Division., São Paulo State University (UNESP), Institute of Science and Technology, São José dos Campos, São Paulo, 12245000, Brazil
| | - Cláudia Luísa Ribeiro Ferreira
- Department of Restorative Dentistry, Endodontic Division., São Paulo State University (UNESP), Institute of Science and Technology, São José dos Campos, São Paulo, 12245000, Brazil
| | - Luciane Dias de Oliveira
- Department of Biosciences and Oral Diagnosis, São Paulo State University (UNESP), Institute of Science and Technology, São José dos Campos, São Paulo, 12245000, Brazil
| | - Cláudio Antonio Talge Carvalho
- Department of Restorative Dentistry, Endodontic Division., São Paulo State University (UNESP), Institute of Science and Technology, São José dos Campos, São Paulo, 12245000, Brazil
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Silva EJNL, Prado MC, Soares DN, Hecksher F, Martins JNR, Fidalgo TKS. The effect of ozone therapy in root canal disinfection: a systematic review. Int Endod J 2019; 53:317-332. [PMID: 31587303 DOI: 10.1111/iej.13229] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/01/2019] [Indexed: 12/15/2022]
Abstract
AIM To answer the following focused question: 'As regards microorganism load reduction for patients undergoing root canal treatment, is the use of ozone therapy comparable to conventional chemomechanical techniques using sodium hypochlorite (NaOCl)?' DATA SOURCES A systematic review was conducted using controlled vocabulary and free-text key words in the following databases: PubMed, Science Direct, Scopus, Web of Science and Open Grey until 2 November 2018. Additional studies were sought through hand searching of endodontic journals. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS The inclusion criteria comprised studies that compared microbial reduction in root canals after treatments with ozone and NaOCl in extracted mature human teeth or randomized clinical trials. STUDY APPRAISAL AND SYNTHESIS METHODS The quality assessment of included laboratory studies was performed with the following parameters: (i) sample size calculation, (ii) samples with similar dimensions, (iii) control group, (iv) standardization of procedures, (v) statistical analysis and (vi) other risk of bias. For randomized clinical trials, the qualitative analysis of the studies was performed from the bias risk assessment using the tool 'Bias Risk Assessment of Randomized Controlled Studies' Cochrane Handbook 5.0.2. RESULTS The search resulted in 180 published studies. After removal of duplicate studies and full-text analysis, eight studies were selected and seven were considered low risk of bias (seven ex vivo studies and one random clinical trial). Overall, the results demonstrated that ozone therapy provides significantly less microbial load reduction than NaOCl. As an adjunct in chemomechanical preparation, ozone was ineffective in increasing the antimicrobial effect of NaOCl. Ozone performance was strongly associated with the application protocol used: it is dose, time and bacterial strain dependent, besides the correlation with the use of complementary disinfection sources. LIMITATIONS A restricted number of randomized clinical trial was found, and the difference amongst the methodology of the studies did not allow a meta-analysis to be performed. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Although the selected studies had limitations, this review reached a satisfactory methodological and moderate evidence quality contributing to important preliminary information regarding ozone therapy. As regards load reduction of microorganisms for patients undergoing root canal treatment, ozone is not indicated neither to replace nor to complement the antimicrobial action of NaOCl.
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Affiliation(s)
- E J N L Silva
- Department of Endodontics, School of Dentistry, Grande Rio University (UNIGRANRIO), Rio de Janeiro, Brazil.,Department of Endodontics, School of Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - M C Prado
- Department of Endodontics, School of Dentistry, Grande Rio University (UNIGRANRIO), Rio de Janeiro, Brazil
| | - D N Soares
- Preventive and Community Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - F Hecksher
- Department of Endodontics, School of Dentistry, Grande Rio University (UNIGRANRIO), Rio de Janeiro, Brazil
| | - J N R Martins
- Instituto de Implantologia, Lisboa, Portugal.,Centro de Estudo de Medicina Dentária Baseada na Evidência, Faculdade de Medicina Dentária, Universidade de Lisboa, Lisboa, Portugal
| | - T K S Fidalgo
- Preventive and Community Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
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