Antimicrobial efficacy of QMix on Enterococcus faecalis infected root canals: a systematic review of in vitro studies

Objectives@#This study aimed to summarize the outcome of in vitro studies comparing the antibacterial effectiveness of QMix with other irrigants against Enterococcus faecalis. @*Materials and Methods@#The research question was developed by using population, intervention, comparison, outcome, and study design framework. The literature search was performed using 3 electronic databases: PubMed, Scopus, and EBSCOhost until October 2019. The additional hand search was performed from the reference list of the eligible studies. The risk of bias of the studies was independently appraised using the revised Cochrane Risk of Bias tool (RoB 2.0). @*Results@#Fourteen studies were included in this systematic review. The overall risk of bias for the selected studies was moderate. QMix was found to have a higher antimicrobial activity compared to 2% sodium hypochlorite (NaOCl), 17% ethylenediaminetetraacetic acid (EDTA), 2% chlorhexidine (CHX), mixture of tetracycline isonomer, an acid and a detergent (MTAD), 0.2% Cetrimide, SilverSol/H2O2, HYBENX, and grape seed extract (GSE). QMix had higher antibacterial efficacy compared to NaOCl, only when used for a longer time (10 minutes) and with higher volume (above 3 mL). @*Conclusions@#QMix has higher antibacterial activity than 17% EDTA, 2% CHX, MTAD, 0.2% Cetrimide, SilverSol/H2O2, HYBENX, GSE and NaOCl with lower concentration. To improve the effectiveness, QMix is to use for a longer time and at a higher volume.

Limited Evidence Suggests Benefits of Single Visit Revascularization Endodontic Procedures - A Systematic Review.

Revascularization endodontic procedures commonly require multiple treatment sessions. However, single visit procedures may be advantageous from the clinical and patient management standpoints. The purpose of this review was to evaluate the outcomes of single-visit revascularization endodontic procedures for the management of immature permanent teeth with non-vital pulp. Two electronic databases (Scopus and PubMed) were searched, from their inception to July 2018, for studies that assessed clinical and/or radiographic and/or histologic outcomes of single-visit revascularization endodontic procedures performed in immature permanent teeth with non-vital pulp. Case reports, animal studies and clinical trials were included. The quality of case reports was appraised by Joanna Briggs Institute Critical Appraisal Checklist for Case Reports. The quality of randomized clinical trials was assessed by the revised Cochrane risk of bias tool for randomized trials. The risk of bias for animal studies was assessed using SYRCLE's risk of bias tool. Tabulation followed by narrative synthesis was used to draw conclusions. Seven studies satisfied the selection criteria. Five were classified as case reports, one as a randomized clinical trial and one as animal study. The latter presented with a high risk of bias, whilst the remaining showed a low risk. The evidence supporting the potential use of single-visit revascularization endodontic procedures is scarce. Successful single-visit revascularization endodontic procedures commonly include the use of high concentrations of sodium hypochlorite and EDTA combined with the use of agitation systems. Further clinical trials with long term follow up are needed to confirm the results of the current review.

Limited evidence suggests benefits of single visit revascularization endodontic procedures - a systematic review

Abstract Revascularization endodontic procedures commonly require multiple treatment sessions. However, single visit procedures may be advantageous from the clinical and patient management standpoints. The purpose of this review was to evaluate the outcomes of single-visit revascularization endodontic procedures for the management of immature permanent teeth with non-vital pulp. Two electronic databases (Scopus and PubMed) were searched, from their inception to July 2018, for studies that assessed clinical and/or radiographic and/or histologic outcomes of single-visit revascularization endodontic procedures performed in immature permanent teeth with non-vital pulp. Case reports, animal studies and clinical trials were included. The quality of case reports was appraised by Joanna Briggs Institute Critical Appraisal Checklist for Case Reports. The quality of randomized clinical trials was assessed by the revised Cochrane risk of bias tool for randomized trials. The risk of bias for animal studies was assessed using SYRCLE's risk of bias tool. Tabulation followed by narrative synthesis was used to draw conclusions. Seven studies satisfied the selection criteria. Five were classified as case reports, one as a randomized clinical trial and one as animal study. The latter presented with a high risk of bias, whilst the remaining showed a low risk. The evidence supporting the potential use of single-visit revascularization endodontic procedures is scarce. Successful single-visit revascularization endodontic procedures commonly include the use of high concentrations of sodium hypochlorite and EDTA combined with the use of agitation systems. Further clinical trials with long term follow up are needed to confirm the results of the current review.

Resumo Os protocolos clínicos de procedimentos endodônticos de revascularização comumente requerem múltiplas sessões. Entretanto, procedimentos em única sessão podem apresentar vantagens clínicas relacionadas ao paciente. O objetivo desta revisão sistemática foi avaliar os resultados clínicos dos procedimentos endodônticos de revascularização para o manejo de dentes permanentes imaturos realizados em única visita. Duas bases de dados eletrônicas (Scopus e PubMed) foram utilizadas, do seu início à julho de 2018, buscando estudos que avaliaram resultados de procedimentos endodônticos clínicos e/ou radiográficos, e/ou histológicos da revascularização em sessão única realizados em dentes permanentes imaturos com necrose pulpar. Relatos de casos, estudos em animais e estudos clínicos foram incluídos e avaliados quanto à qualidade e risco de viés. A qualidade dos relatos de casos foi avaliada utilizando-se a ferramenta própria de análise crítica do Instituto Joanna Briggs. A qualidade dos estudos clínicos randomizados controlados foi analisada pela ferramenta de risco de viés da Cochrane. O risco de viés para os estudos em animais foi mensurado utilizando-se a ferramenta SYRCLE. Os dados foram tabulados e a síntese narrativa foi utilizada para análise dos mesmos. Sete estudos satisfizeram os critérios de inclusão. Cinco foram classificados como relatos de casos, um como ensaio clínico randomizado e um outro como estudo em modelo animal. Este último apresentou alto risco de viés, enquanto o restante dos estudos mostrou baixo risco. A evidência que apoia a utilização potencial de procedimentos endodônticos de revascularização em sessão única é escassa. Os procedimentos endodônticos de revascularização em sessão única geralmente incluem o uso de altas concentrações de hipoclorito de sódio e EDTA, combinadas com o uso de sistemas de agitação. Assim, estudos clínicos com longos períodos de acompanhamento são necessários para confirmação dos resultados do presente estudo.

Root canal irrigants influence the hydrophobicity and adherence of Staphylococcus epidermidis to root canal dentin: an in vitro study

OBJECTIVES: To determine the effect of root canal irrigants on the hydrophobicity and adherence of Staphylococcus epidermidis (S. epidermidis) to root canal dentin in vitro. MATERIALS AND METHODS: Root dentin blocks (n = 60) were randomly divided into 4 groups based on the irrigation regimen: group 1, saline; group 2, 5.25% sodium hypochlorite (NaOCl); group 3, 5.25% NaOCl followed by 17% ethylenediaminetetraacetic acid (EDTA); group 4, same as group 3 followed by 2% chlorhexidine (CHX). The hydrophobicity of S. epidermidis to root dentin was calculated by cell surface hydrophobicity while the adherence was observed by fluorescence microscopy, and bacteria were quantified using ImageJ software (National Institutes of Health). Statistical analysis of the data was done using Kruskal-Wallis test and Mann-Whitney U test (p = 0.05). RESULTS: The hydrophobicity and adherence of S. epidermidis to dentin were significantly increased after irrigating with group 3 (NaOCl-EDTA) (p < 0.05), whereas in group 4 (NaOCl-EDTA-CHX) both hydrophobicity and adherence were significantly reduced (p < 0.05). CONCLUSIONS: The adherence of S. epidermidis to dentin was influenced differently by root canal irrigants. Final irrigation with CHX reduces the bacterial adherence and may impact biofilm formation.

Evaluation of the Antibacterial Efficacy of Azadirachta Indica, Commiphora Myrrha, Glycyrrhiza Glabra Against Enterococcus Faecalis using Real Time PCR.

AIM: To compare the antibacterial efficacy of Azadirachta indica (Neem), Commiphora myrrha (Myrrh), Glycyrrhiza glabra (Liquorice) with 2% Chlorhexidine (CHX) against E. faecalis by using Real Time PCR. MATERIALS AND METHODS: A total of fifty teeth specimens (n=50) were inoculated with E. faecalis for 21 days. Specimens were divided into five groups (Group 1: Myrrh, Group 2: Neem, Group 3: Liquorice, Group 4: 2% CHX and Group 5: Saline (negative control)). The intracanal medicaments were packed inside the tooth. After 5 days, the remaining microbial load was determined by using real time PCR. RESULTS: Threshold cycle (Ct) values of Myrrh extract, Neem extract, Liquorice Extract, 2% CHX and saline were found to be 30.94, 23.85, 21.38, 30.93 and 17.8 respectively. CONCLUSION: Myrrh extract showed inhibition of E.faecalis equal to that of 2% CHX followed by Neem, Liquorice and Saline.

Natural Therapeutic Options in Endodontics - A Review.

Complete eradication of microbial biofilms and elimination of the smear layer are the key factors during endodontic treatment. Various chemical irrigants have been proposed in the literature for the same. The major setback with these chemical irrigants is that they are not bio-friendly to the dental and peri-radicular tissues. In the recent years, research to use natural products for root canal disinfection has gained importance. The aim of this article is to compile various herbal products that have been used as an irrigants and intracanal medicaments in the field of Endodontics to eradicate the biofilm and remove smear layer.

A comparative assessment of fracture resistance of endodontically treated and re-treated teeth: An in vitro study.

AIM: To compare and assess the fracture resistance of endodontically treated teeth with those that have been subjected to endodontic retreatment. MATERIALS AND METHODS: 30 extracted mandibular premolars were decoronated at cementoenamel junction and randomly divided into 2 groups. In Group I endodontic treatment was performed with ProTaper rotary system till size F2 and obturated. In Group II, cleaning and shaping was done and teeth were subjected to Spiral CT to assess the remaining dentin thickness and obturated. Later retreatment was done using Protaper Universal Retreatment system and final shaping was performed till size F3. Remaining dentin thickness was again assessed using Spiral CT and then obturated. All the specimens were subjected to fracture resistance using universal testing machine. The results were statistically analyzed using Independent Samples t-test for analysis of remaining dentin thickness using SCT within Group II and Paired Samples t-test was used for assessment of fracture resistance between Group I and II (P < 0.05). RESULTS: In Group II, the intra group comparison of the remaining dentin thickness in the coronal third reveals statistical significance, with a significant difference noted in the apical third. Results of the fracture resistance reveal a statistically significant difference (P < 0.05) between Groups I and II with the mean fracture resistance of Group I being higher than Group II. CONCLUSION: Endodontically retreated teeth have shown significantly decreased resistance to fracture and this has a positive correlation to the increased loss of root dentin during the retreatment procedures.

Dentinal tubule disinfection with 2% chlorhexidine, garlic extract, and calcium hydroxide against Enterococcus faecalis by using real-time polymerase chain reaction: In vitro study.

AIM: To compare the efficacy of garlic extract with 2% chlorhexidine (CHX) and calcium hydroxide Ca(OH)2 in disinfection of dentinal tubules contaminated with Enterococcus faecalis by using real-time polymerase chain reaction (PCR). MATERIALS AND METHODS: Agar diffusion test was done to evaluate the minimum inhibitory concentration of garlic extract against E. faecalis. Forty human extracted mandibular premolar teeth were selected for this study, access cavity was prepared and cleaning and shaping was done. Middle third of the root was cut using a rotary diamond disc. The teeth specimens were inoculated with E. faecalis for 21 days. Specimens were divided into four groups---Group 1: 2% CHX, Group 2: Garlic extract, Group 3: Ca(OH)2, and Group 4: Saline (negative control). The intracanal medicaments were packed inside the tooth specimens and incubated for 5 days. The dentinal chips were collected at 400 µm depth using a Gates-Glidden drill, following which DNA isolation was done. The specimens were analyzed using real-time PCR. The results were then statistically analyzed using one-way analysis of variance, followed by post hoc Tukey's honestly significant difference (HSD) multiple comparison of means. RESULTS: Threshold cycle (Ct) values of 2% CHX was found to be 32.4, garlic extract to be 27.5, and Ca(OH)2 to be 25.6. CONCLUSION: A total of 2% CHX showed the maximum efficacy against E. faecalis, followed by garlic extract and Ca(OH)2.

Efficacy of F file compared to ultrasonic techniques using scanning electron microscopy.

A study was undertaken to compare the debridement efficacy of the F file with ultrasonics. Thirty mandibular premolars were instrumented with the Protaper file series using a crown-down technique. All the canals were irrigated using 2 ml of 5.25% sodium hypochlorite and 2 ml of 17% EDTA for one minute, alternating each instrument. The teeth were then divided into three groups of 10 each. In Group I, a final flush with only 5.25% NaOCl concluded the preparation (control group). Group II underwent 5.25% NaOCl and ultrasonic irrigation for one minute. Group III, 5.25% NaOCl and F-file for 30 seconds. Smear layer and debris scores were examined under a scanning electron microscope. In a blind manner, two investigators scored the presence or absence of smear layer and debris. Significantly higher smear layer and debris scores were found at the apical level compared to the middle and coronal levels in all the three groups. In the end, the F file proved more beneficial in removing smear layer and debris than ultrasonics.

Comparison of the canal centring ability of K3, Liberator and EZ Fill Safesiders by using spiral computed tomography.

The purpose of the study was to compare the canal centring ability of K3, Liberator and EZ Fill Safesiders by using spiral computed tomography (SCT). Forty curved mandibular premolars were selected. Before and after instrumentation teeth were scanned by spiral computed tomography and nine cross-sectional views of each tooth were obtained at 1.5 mm intervals from the apex. Canal centring ratio was calculated. Mean values were compared between different study groups by using one-way ANOVA followed by Tukey - HSD procedure. At 1st, 2nd and 3rd levels, there was no statistical difference between groups. From 4th to 9th levels Safesider showed higher centring ratio, followed by Liberator and K3. Safesider showed better canal centring ability followed by Liberator and K3.

Shear bond strength evaluation of resin composite bonded to glass-ionomer cement using self-etching bonding agents with different pH: In vitro study.

AIM: To evaluate the bonding ability of composite to unset glass-ionomer cement (GIC) using different self-etching bonding systems. MATERIALS AND METHODS: One hundred samples of composite bonded to unset GIC were prepared and were divided into four groups. In Group A, composite was bonded to unset GIC employing a strong (pH 1) self-etch primer was used. In Group B, intermediary strong (pH 1.4) self-etch primer was employed. In Group C and D, mild (pH 2) and (pH 2.2) self-etch primer was employed. Shear bond strength analysis was performed at a cross-head speed of 0.5 mm/min. RESULTS: Statistical analysis performed with one way analysis of variance and Tukey's test showed that the bond strength of composite to unset GIC was significantly higher for the mild self-etch primer group. In addition, energy dispersive x-ray (EDX) analysis was used to determine the composition of various structural phases identified by FE-SEM along the GIC-bonding agent interfaces. CONCLUSION: Hence this present study concludes that clinically the use of mild self-etching bonding agent over unset GIC has improved bond strength compared to the use of strong and intermediate self-etching bonding agent.

Disinfection of dentinal tubules with two different formulations of calcium hydroxide as compared to 2% chlorhexidine: As intracanal medicaments against Enterococcus faecalis and Candida albicans: An in vitro study.

AIM: To evaluate the disinfection of dentinal tubules using calcium hydroxide with propylene glycol and calcium hydroxide with iodoform in silicone oil, as compared to 2% chlorhexidine gel. MATERIALS AND METHODS: The antimicrobial efficacy of the medicaments against E.faecalis and C.albicans were assessed in vitro, using a dentinal tubule model at depths of 200 µm and 400 µm in extracted single rooted teeth. Saline was taken as the negative control (Group I) RESULTS: All three medicaments used in this study exerted antibacterial and antifungal activity. Group II (calcium hydroxide with propylene glycol) and Group IV (2% chlorhexidine gel) had the highest antimicrobial activity and the differences between their antibacterial activities were not statistically significant. Group III (calcium hydroxide with iodoform in silicone oil) and Group IV had the highest antifungal activity and the differences between their antifungal activities were not statistically significant. The inhibition of growth at 200 µm and 400 µm was uniform, with no statistical difference. CONCLUSIONS: Two percent chlorhexidine gel was effective against both E.faecalis and C.albicans. Calcium hydroxide with propylene glycol was the most effective intracanal medicament along with 2% chlorhexidine against E.faecalis, whereas, calcium hydroxide with iodoform in silicone oil was the most effective intracanal medicament along with 2% chlorhexidine against C.albicans.

Effects of various final irrigants on the shear bond strength of resin-based sealer to dentin.

AIM: This study has been designed to evaluate the effect of strong (MTAD) or soft (1- hydroxyethylidene - 1, 1-bisphosphonate (HEBP) final irrigating solution on the shear bond strength of AH plus sealer to coronal dentin. 17% EDTA was used as the reference. MATERIALS AND METHODS: Forty freshly extracted human maxillary first premolars were prepared using different irrigation protocols (n=10). All the test groups had 1.3% NaOCl as initial rinse and followed by specific final rinse for each group: G1 - distilled water(control), G2 - 17% EDTA, G3- 18% HEBP and G4 - MTAD. Sections of polyethylene tubes that are 3mm long were filled with freshly mixed sealer and placed on the dentin surfaces. The bonding between the sealer and dentine surface was evaluated using shear bond testing. The values were statistically evaluated using one-way ANOVA followed by Tukey's test. RESULT: Significant difference was found among the irrigating regimes. EDTA showed highest bond strength followed by HEBP and MTAD.

Evaluation of the effect of MTAD in comparison with EDTA when employed as the final rinse on the shear bond strength of three endodontic sealers to dentine.

The purpose of the study was to evaluate the effect of MTAD in comparison with EDTA as a final rinse on the shear bond strength of Kerr, Apexit and AH plus. Dentine surfaces of 135 extracted human non-carious maxillary premolars were divided into three groups (n = 45). Groups I and II were conditioned with 1.3% NaOCl for 20 min, followed by a final rinse of 17% EDTA for 1 min and MTAD for 5 min respectively. Group III was treated with distilled water. Each group was further divided into three subgroups (n = 15). Subgroup 1: Kerr, Subgroup 2: Apexit and Subgroup 3: AH plus. Three-millimetre-long sections of polyethylene tubes were filled with freshly mixed sealer and placed on the dentine surfaces. The bonding between the sealer and dentine surface was evaluated using shear bond testing. The values were statistically evaluated using one way anova followed by Tukey's test. Significant difference was found among the bond strength of the sealers and irrigating regimes. AH plus showed superior bond strength among the tested sealers, when EDTA was employed as the final rinse (P < 0.05). MTAD as a final rinse affected the bond strength of AH plus and Apexit, which were significantly lower than the control group.

Root canal irrigants.

Successful root canal therapy relies on the combination of proper instrumentation, irrigation, and obturation of the root canal. Of these three essential steps of root canal therapy, irrigation of the root canal is the most important determinant in the healing of the periapical tissues. The primary endodontic treatment goal must thus be to optimize root canal disinfection and to prevent reinfection. In this review of the literature, various irrigants and the interactions between irrigants are discussed. We performed a Medline search for English-language papers published untill July 2010. The keywords used were 'root canal irrigants' and 'endodontic irrigants.' The reference lists of each article were manually checked for additional articles of relevance.

Assessment of pulp vitality: a review.

BACKGROUND: One of the greatest diagnostic challenges in clinical practice is the accurate assessment of pulp status. This may be further complicated in paediatric dentistry where the practitioner is faced with a developing dentition, traumatized teeth, or young children who have a limited ability to recall a pain history for the tooth in question. A variety of pulp testing approaches exist, and there may be confusion as to their validity or appropriateness in different clinical situations. AIM: The aim of this paper is to provide the clinician with a comprehensive review of current pulp testing methods. A key objective is to highlight the difference between sensitivity testing and vitality testing. A biological basis for pulp testing is also provided to allow greater insight into the interpretation of pulp testing results. The rationale for, and methods of, assessing pulpal blood flow are described.

Canal-centering ability: An endodontic challenge.

During instrumentation of the root canal, it is important to develop a continuously tapered form and to maintain the original shape and position of the apical foramen. However, the presence of curvatures may cause difficulty in root canal instrumentation. The ability to keep the instruments centered is essential to provide a correct enlargement, without excessive weakening of the root structure. Several studies have shown that Ni-Ti instruments remain significantly more centered and demonstrated less canal transportation than stainless steel files. Considerable research has been undertaken to understand the several factors related to an instrument's canal-centering ability. In this article, we have discussed the influence of various parameters such as alloys used in the manufacture of instruments, instrument cross-section, taper, and have given tips on canal-centering ability.

Comparison of laterally condensed, vertically compacted thermoplasticized, cold free-flow GP obturations - A volumetric analysis using spiral CT.

AIM/OBJECTIVE: To compare the laterally condensed gutta-percha, vertically compacted thermoplastized gutta-percha (E and Q Plus system) and cold free-flow gutta-percha (GuttaFlow). This is a volumetric analysis using spiral CT, an in vitro study. MATERIALS AND METHODS: Access cavities were prepared in 60 single rooted anterior teeth; cleaning and shaping was done and obturated with three of the different techniques: group A: cold lateral; group B: vertically compacted thermoplasticized and group C: cold free-flow obturation techniques. Volume analysis was done using spiral computed tomography (CT). The percentage difference was calculated and statistically analyzed using one-way ANOVA and post hoc multiple comparison Tukey HSD tests. RESULTS: There were statistical significant differences between group A (0.183cm(3)) and group B (0.136cm(3)); group A (0.183cm(3)) and group C (0.128cm(3)). But there was no statistical significance between group B (0.136cm(3)) and group C (0.128cm(3)). CONCLUSION: Within the limitations of this in vitro study it can be concluded that cold free-flow obturation technique showed the highest volume of obturation, followed by the vertically condensed thermoplasticized technique. The least volume of obturation was observed in cold lateral condensation technique.

Evaluation of the pulp chamber size of human maxillary first molars: an institution based in vitro study.

The aim of this in vitro study was to determine the morphological measurements of the pulp chamber and also to establish the relationship of the cemento-enamel junction (CEJ) to the roof of the pulp chamber of the maxillary first molars in an Indian population. One hundred extracted human maxillary first molars were used. Each molar tooth was radiographed by radio visiography (RVG). Measurements were made by using the grid option in RVG. The results (mean +/- SD; in mm) were as follows: distance from floor of the pulp chamber to the furcation = 2.7 +/- 0.63; distance from roof of the pulp chamber to the furcation = 5.34 +/- 0.9; distance from tip of the palatal cusp to the furcation = 11.58 +/- 1.01; distance from the tip of the palatal cusp to the floor of the pulp chamber = 8.86 +/- 0.68; distance from the tip of the palatal cusp to the roof of the pulp chamber = 6.2 +/- 0.66; height of the pulp chamber = 2.62 +/- 0.61. The results of these measurements revealed that the morphological measurements of the maxillary first molars in the Indian population were similar to that reported by previous studies; the roof of the pulp chamber was found at the CEJ in 96% of the specimens.

Comparison of coconut water, propolis, HBSS, and milk on PDL cell survival.

Coconut water is biologically pure and sterile, with a rich presence of amino acids, proteins, vitamins, and minerals. The purpose of this study was to use a collagenase-dispase assay to investigate the potential of a new storage medium, coconut water, in comparison with propolis, Hank's balanced salt solution (HBSS), and milk in maintaining viable periodontal ligament (PDL) cells on simulated avulsed teeth. Seventy freshly extracted human teeth were divided into 4 experimental groups and 2 control groups. The positive and negative controls corresponded to 0-minute and 8-hour dry times, respectively. The experimental teeth were stored dry for 30 minutes and then immersed in 1 of the 4 media (coconut water, propolis, HBSS, and milk). The teeth were then treated with dispase grade II and collagenase for 30 minutes. The number of viable PDL cells was counted with a hemocytometer and analyzed. Statistical analysis showed that coconut water kept significantly more PDL cells viable compared with propolis, HBSS, or milk. Coconut water can be used as a superior transport medium for avulsed teeth.