Bending, buckling and torsional resistance of rotary and reciprocating glide path instruments.

AIM: To evaluate the bending, buckling and torsional resistance of ProGlider (PG) (Dentsply Sirona, Ballaigues, Switzerland), R-Pilot (RP) (VDW, Munich, Germany) and WaveOne Gold Glider (WOGG) (Dentsply Sirona). METHODOLOGY: Ninety instruments were used: 30 PG (size 0.16, .02v taper), 30 RP (size 0.125, .04 taper) and 30 WOGG (size 0.15, .02v taper). The bending resistance test was performed on 10 randomly selected instruments of each system according to ISO 3630-1 specifications. For the buckling resistance test, a loading was applied in the axial direction of each instrument using a universal test machine, with a 20 N cell and 15 mm min-1 speed, in the axial direction. When a lateral elastic displacement of 1 mm occurred, the force was registered. The torsional resistance test was performed according to ISO 3630-1 specifications. Statistical analysis was performed using one-way anova and post hoc Student-Newman-Keuls test (P < 0.05). RESULTS: WOGG had the lowest bending resistance, whilst RP had the highest bending resistance (P < 0.05). RP also had the highest buckling resistance, and WOGG had the lowest (P < 0.05). PG had intermediate results regarding bending and buckling resistance, with significant differences to RP and WOGG (P < 0.05). RP had the highest torsional strength and the lowest angular deflection when compared to PG and WOGG (P < 0.05). No differences in the torsional strength and angular deflection were observed between WOGG and PG (P> 0.05). CONCLUSION: The glide path instruments had different behaviours in term of bending, buckling and torsional resistance.

Influence of solvent and a supplementary step with a finishing instrument on filling material removal from canals connected by an isthmus.

AIM: To evaluate the effectiveness of a solvent (eucalyptol) in improving filling material removal from canals connected by isthmuses, and the additional cleaning effect of a finishing instrument. METHODOLOGY: The mesial canals from 32 mandibular molars (Vertucci's type II morphology) were instrumented and filled with the single-cone technique using Reciproc R25 gutta-percha points (VDW, Munich, Germany) combined with Sealer 26 (Dentsply, Petrópolis, RJ, Brazil). Each root was then subjected to retreatment using the Mtwo instrument system (VDW), with or without a solvent (n = 16 per group). The volume of filling material in the canals was assessed by micro-computed tomographic (micro-CT) scans taken before and after retreatment. Canals with remnants of filling material received a supplementary procedure with the XP-endo Finisher R instrument (FKG Dentaire, La Chaux-de-Fonds, Switzerland), with or without eucalyptol, and another micro-CT scan was taken. All retreatment procedures were performed inside a cabinet under a controlled temperature (37 °C). Filling material removal was evaluated in the 5-mm apical canal system for the canal+isthmus space or the isthmus alone. Statistical analyses were performed to compare the removal of filling material with and without eucalyptol, and after a supplementary approach with XP-endo Finisher R. The level of significance was set at 5% for all statistical tests (P < 0.05). RESULTS: The amount of filling material removed from the canal+isthmus with Mtwo instruments was 83.2% when no solvent was used and 83.8% using the solvent (P > 0.05). When the isthmus area was evaluated separately, most specimens were associated with a reduction in the filling material, with no significant difference between the groups with or without using a solvent (P > 0.05). The supplementary step with XP-endo Finisher R significantly improved removal of filling material from both canal and isthmus area (P < 0.05), regardless of the use of a solvent (P > 0.05). CONCLUSION: The use of eucalyptol did not improve filling material removal from Vertucci's type II molar mesial canals and isthmuses. XP-endo Finisher R significantly enhanced removal of filling material from the canals and isthmuses.

Association between missed canals and apical periodontitis.

AIM: To evaluate the frequency of post-treatment apical periodontitis associated with root filled teeth with at least one untreated root canal. METHODOLOGY: Eight hundred and seven cone beam computed tomography images containing at least one root filled tooth were selected from a collection of 1543 images from Brazilian individuals. Scans were taken using ICAT Classic devices (Imaging Sciences, Hatfield, PA, USA) in a private oral radiology clinic from January to April 2015. All root filled teeth were analysed for the presence of missed canals and apical periodontitis. The chi-square and odds ratio tests were used to verify if there were an association and risk relationship between the occurrence of untreated canals and apical periodontitis. RESULTS: A total of 2294 teeth with evidence of root fillings were identified. Two hundred and eighty-one teeth had at least one untreated missed canal (12%). The frequency of apical periodontitis in teeth with at least one untreated canal was significantly greater in comparison to teeth with all canals treated (274/281, 98% versus 1736/2013, 86%) (P < 0.01). The odds for apical periodontitis to be present was 6.25 times greater for teeth with an untreated canal. The mesiobuccal roots of maxillary first molars had the greatest frequency of untreated canals (114/154, 74%), with the second mesiobuccal canal being the most frequently missed (n = 106/114, 93%). CONCLUSION: Root filled teeth with at least one missed canal had a high prevalence of post-treatment apical periodontitis.

Association between bacteria occurring in the apical canal system and expression of bone-resorbing mediators and matrix metalloproteinases in apical periodontitis.

AIM: To evaluate the association between the presence of selected bacterial species/groups in the apical root canal and expression of mediators of soft and bone tissue destruction in apical periodontitis lesions. Relationships between bacteria and some other features of apical periodontitis were also investigated. METHODOLOGY: Seventeen freshly extracted teeth with pulp necrosis and apical periodontitis were included. The apical root segment was sectioned and cryopulverized; DNA was extracted and evaluated for the presence of 9 bacterial species/groups using real-time polymerase chain reaction. Lesions were processed for histopathological and immunohistochemical analyses, which targeted matrix metalloproteinase-2 (MMP-2) and -9 (MMP-9), receptor activator of NFκB (RANK), RANK ligand (RANKL) and osteoprotegerin (OPG). Associations of the target bacteria with expression of these mediators, presence of symptoms, lesion size and histopathological diagnosis were evaluated. Data were analysed using the chi-square, Fisher's exact, Mann-Whitney and Pearson tests. P values lower than 0.05 were considered significant. RESULTS: All pulverized apical root samples were positive for bacteria. The most prevalent taxa were Actinobacteria (53%), Streptococcus species (35%), Fusobacterium species and Parvimonas micra (18%). The target mediators exhibited a high mean expression in the lesions (MMP-2: 82%; MMP-9: 73%; RANK: 78%; RANKL; 81%; OPG; 83%). Mean RANKL:OPG ratio was significantly higher in granulomas than cysts (P < 0.05, Mann-Whitney test). Actinobacteria were associated with granulomas, higher MMP-2 expression, lower OPG expression, and higher RANKL:OPG ratio (P < 0.05 for all, Fisher's exact test or Mann-Whitney test). No other significant associations were found. CONCLUSION: Actinobacteria may play an important role in the active phase of soft and bone tissue destruction in apical periodontitis.

What happens to unprepared root canal walls: a correlative analysis using micro-computed tomography and histology/scanning electron microscopy.

AIM: To microscopically examine the cleanliness of root canal walls that remained unprepared as revealed by micro-CT. METHODOLOGY: The root canals of 10 freshly extracted mandibular premolars with necrotic pulps and apical periodontitis along with the mesiobuccal canals of 11 mandibular molars with vital pulps were prepared using Reciproc instruments R40 and R25, respectively, and 2.5% sodium hypochlorite irrigation. Specimens were scanned in micro-CT before and after preparation, and the unprepared areas were identified. The outer root surface corresponding to the untouched areas was marked on each root third to guide further analysis using histological (for teeth with vital pulps) and scanning electron microscopic (SEM; for necrotic teeth) examination. In the teeth with vital pulps, the root canal area occupied by tissue remnants was calculated. In SEM analysis of teeth with necrotic pulps, scores were attributed for the amount of debris on the untouched areas. RESULTS: The proportion of unprepared areas in the mesiobuccal molar canals was 18.1% and 9.6% over the full canal length and apical canal, respectively. In premolars, corresponding figures were 34.6% and 17.6%, respectively. Histological analysis of canals with vital pulps revealed tissue remnants over the untouched walls almost exclusively in the apical canal. SEM analysis of the canals with necrotic pulps revealed debris along the untouched walls in all root canal thirds. CONCLUSION: The areas that remain untouched by Reciproc instruments used with 2.5% NaOCl irrigation as revealed by micro-CT analysis were usually covered with debris, in the form of pulp tissue remnants, bacteria and dentine chips, especially in the apical root canal.

Effects of increased apical enlargement on the amount of unprepared areas and coronal dentine removal: a micro-computed tomography study.

AIM: To evaluate the effects of progressive apical enlargement on the amount of unprepared root canal surface area and remaining dentine thickness. METHODOLOGY: The root canals of 30 extracted mandibular incisors with Vertucci's type I configuration were instrumented with rotary HyFlex CM instruments (Coltene-Whaledent, Altstätten, Switzerland) up to 4 instruments larger than the first one that bound at the working length (WL). Teeth were scanned in a micro-computed tomography (micro-CT) device before canal preparation and after instrumentation with the 2nd, 3rd and 4th larger instruments. The amount of unprepared surface area in the full canal or in the apical 4 mm as well as the remaining dentine thickness at 10 mm from the WL were calculated and compared. The general linear model for repeated measures adjusted by Bonferroni's post hoc test was used for statistic analysis. RESULTS: There was a significant reduction in the amount of unprepared areas after each increase in preparation size (P < 0.01). This was observed for both the full canal length and the 4-mm apical segment. The amount of remaining dentine was also significantly reduced after each file size (P < 0.01). However, dentine thickness always remained greater than 1 mm, even after using the largest instrument. CONCLUSION: Apical preparations up to 4 instruments larger than the first one to bind at the WL caused a significant progressive reduction in the unprepared canal area.

Influence of oestrogen deficiency on the development of apical periodontitis.

AIM: To evaluate the effects of a long period of oestrogen deficiency on the development of apical periodontitis in rats. METHODOLOGY: Wistar rats (n = 24), 3 months old, evaluated by vaginal cytology, were included in the study. Twelve animals were ovariectomized (OVX group) and the other 12 were sham operated (control group). One hundred and twenty days after castration, the pulps of the left mandibular first molars were exposed to induce the development of apical periodontitis. Body mass was verified on a weekly basis. Following 21 and 40 days of lesion induction, the animals were sacrificed. Blood was collected for biochemical analysis, and mandibles were removed for radiographic analysis. Comparative analysis of the data was performed by the nonparametric Kruskal-Wallis and Dunn's multiple-comparisons tests. The t-test was applied to compare the oestrogen levels between control and OVX groups. RESULTS: Radiographs revealed that apical periodontitis lesions were significantly larger in the 40-day OVX group when compared with both 40-day (P < 0.05) and 21-day (P < 0.001) control groups. Serum oestrogen levels were significantly lower in the OVX group (P < 0.01), confirming the efficacy of castration. Oestrogen deficiency resulted in significantly greater body mass gain (P < 0.01) in 40-day OVX group when compared with 40-day control group. Serum concentrations of calcium were similar between groups (P > 0.05). Alkaline phosphatase levels, although higher in the OVX groups (21 and 40 days), were not significantly different. CONCLUSIONS: Ovariectomized rats had significantly larger apical periodontitis lesions after 40 days of pulp exposure when compared with controls. These findings suggest that bone alterations as a result of long periods of oestrogen deficiency can influence the progression of apical periodontitis.

Micro-CT evaluation of the efficacy of hard-tissue removal from the root canal and isthmus area by positive and negative pressure irrigation systems.

AIM: To evaluate the removal of accumulated hard-tissue debris (AHTD) from the root canal system of mandibular molars by positive and negative pressure irrigation systems, using micro-CT imaging analysis. METHODOLOGY: Mandibular molars with a single canal in the distal root and 2 canals connected by an isthmus in the mesial root were matched based on similar morphological dimensions using micro-CT evaluation and assigned to 2 experimental groups (n = 20 mesial and 10 distal canals), according to the irrigation protocol: apical positive (conventional irrigation) or negative (EndoVac system) pressure. Changes in root canal volume and surface area as well as percentage of uninstrumented canal wall surface and accumulated hard-tissue debris (AHTD) after canal preparation were compared statistically using the independent sample t-test and Mann-Whitney U-test, with the significance level set at 5%. RESULTS: Volume, surface area and percentage of static voxels in either mesial or distal root canal systems were not significantly different between groups before or after root canal preparation (P > 0.05). After preparation, AHTD was not observed in the distal canal of both groups. However, in the mesial root canal system, the conventional irrigation group was associated with a significantly higher median percentage of AHTD (11.48%; IQR: 5.9-22.6; range: 1.86-41.98) than the EndoVac group (3.40%; IQR: 1.5-7.3; range: 0.82-12.84) (P < 0.05). CONCLUSIONS: Neither irrigation protocol succeeded in rendering the mesial canal system free of AHTD; however, apical negative pressure irrigation resulted in lower levels of AHTD than conventional irrigation.

Sealing ability of two root-end filling materials in a bacterial nutrient leakage model.

AIM: To compare in vitro the sealing ability of root-end fillings with mineral trioxide aggregate (MTA) and EndoSequence BioCeramic Root Repair Material-Fast Set (BC-RRM) Putty using a novel bacterial nutrient leakage model, which provides information on whether or not intracanal bacteria are receiving nutrients from serum via leakage channels. METHODOLOGY: Sixty single-rooted decoronated mandibular incisors with instrumented root canals were subjected to root-end resection and ultrasonic preparation. The root specimens were mounted in the experimental apparatus, and the root-end cavities filled with the test materials. The positive control group used warm Gutta-percha and no sealer. In the negative controls, the entire resected surface was covered with varnish. After sterilization in ethylene oxide, the root canal was inoculated with 1.5 × 10(5) washed cells of Enterococcus faecalis. The apparatus was filled with foetal bovine serum, leaving only the apical root immersed. After 30-day incubation, samples were taken from the canal, cultured and the colony-forming units (CFUs) counted. Statistical analysis was performed using the Mann-Whitney test for quantitative and the Fisher exact test for qualitative data. RESULTS: In the MTA group, 10 of 20 (50%) specimens still had detectable viable bacteria in the canals (mean, 8.97 × 10(3)  CFUs). In the BC-RRM Putty group, 5 of 18 (28%) specimens were positive for bacterial growth (mean, 2.88 × 10(4)  CFUs). There was no significant difference when comparing the quantitative or presence/absence data from the MTA and BC-RRM Putty groups. Positive and negative controls yielded the expected results. CONCLUSIONS: MTA and BC-RRM Putty had similar sealing ability. The experimental model was effective in determining whether or not residual intracanal bacteria could survive by receiving nutrients from outside.

Antibacterial, physicochemical and mechanical properties of endodontic sealers containing quaternary ammonium polyethylenimine nanoparticles.

AIM: To evaluate the antibacterial, physicochemical and mechanical properties of two endodontic sealers incorporating quaternary ammonium polyethylenimine (QPEI) nanoparticles at concentrations of 1% and 2% (w/w). METHODOLOGY: The sealers tested were AH Plus and Pulp Canal Sealer EWT in the commercial unmodified form or containing 1% or 2% QPEI. Antibacterial activity was evaluated using a direct contact test (DCT) against Enterococcus faecalis ATCC 29212 and two endodontic isolates (RW35 and RN44). Sealers freshly mixed or set for 7 days were exposed to bacterial suspensions for 10, 30 and 60 min. Setting time, flow test, solubility, apparent porosity, dimensional change following setting, wettability, zeta potential and compressive strength were assessed according to the International Standard Organization 6876:2001 (ISO 6876). RESULTS: DCT results revealed that both freshly prepared sealers had antibacterial effects unaffected by QPEI incorporation. Both unmodified sealers had lost much of their antibacterial effects after 7 days. However, for Pulp Canal Sealer EWT incorporated with 1% and 2% QPEI nanoparticles, the antibacterial effects against all test E. faecalis strains within 30 and 60 min of contact were significantly greater than the unmodified formula. Addition of QPEI resulted in no significant increase in the antibacterial effects of AH Plus after ageing. As for physicochemical and mechanical tests, setting time, wettability and zeta potential were influenced by the presence of QPEI nanoparticles. CONCLUSION: Incorporation of QPEI nanoparticles can improve the long-term antibacterial activity of Pulp Canal Sealer EWT without relevant changes in physicochemical and mechanical properties.

Quantitative molecular and culture analyses of bacterial elimination in oval-shaped root canals by a single-file instrumentation technique.

AIM: Bacterial reduction in oval-shaped root canals by a single-instrument technique was compared ex vivo with a conventional nickel-titanium rotary technique. Data obtained from two quantification methods, quantitative real-time polymerase chain reaction (qPCR) and culture, were also compared. METHODOLOGY: Oval-shaped canals of extracted teeth contaminated with Enterococcus faecalis were instrumented using either a single Reciproc instrument or the BioRaCe instrument series. Bacteriological samples were taken before (S1) and after instrumentation (S2). Bacterial quantification was performed using qPCR and culture. RESULTS: Intragroup analysis showed that both protocols promoted a highly significant bacterial reduction (P < 0.001). Intergroup analysis (S2 samples) showed no significant differences between the two instrumentation systems (P > 0.05). As for the quantification methods, qPCR revealed significantly higher counts of E. faecalis in S1 than culture (P < 0.05), but no significant differences occurred for S2 (P > 0.05). CONCLUSION: The single-file technique was comparable with the conventional technique in oval-shaped canals provided the width of apical preparation, volume of irrigants and duration of irrigation are kept similar. No significant difference was observed for qPCR and culture in post-instrumentation samples, indicating that both methods can be reliably used for studies of antibacterial effectiveness.

Drug interactions during periodontal therapy in HIV-infected subjects.

Despite the beneficial effect of the HAART, adverse reactions and drug interaction have been observed. Abnormalities in lipid and glucose metabolism make HIV-positive patients to high risk for the development of coronary heart disease and diabetes, respectively. Besides adverse reactions, drug interaction with other medication can also be observed. In fact, drug interaction may interfere in the periodontal therapy in HIV-infected individuals. For instance, fluconazole, ketoconazole, itraconazole, metronidazole, ciprofloxacin, midazolam and triazolam can interact with some antiretroviral medications, such as zidovudine, nevirapine and ritonavir. The aim of the current study was to show to periodontists and general dental practitioners the importance of understanding the drug interaction in HIV-infection in order to establish a better control during periodontal treatment.