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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 9  |  Page : 1289-1293

Efficacy of Passive Ultrasonic Activation in Removing Calcium Hydroxide from Simulated Internal Resorption Cavities at Different Root Regions


Department of Endodontics, Faculty of Dentistry, Eskişehir Osmangazi University, Turkey

Date of Submission19-Nov-2020
Date of Acceptance12-Jan-2021
Date of Web Publication16-Sep-2021

Correspondence Address:
Dr. K Y Yeter
Department of Endodontics, Faculty of Dentistry, Eskişehir Osmangazi University, Odunpazarı, Eskişehir - 26480
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_650_20

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   Abstract 


Aims: The aim of this study was to evaluate the effect of passive ultrasonic activation on calcium hydroxide removal from simulated internal root resorption (IRR) cavities at different root levels. Methods and Material: Sixty mandibular canines were prepared and divided into 3 groups to create IRR cavities at apical, middle, coronal root levels. The cavities filled with calcium hydroxide (CH). Specimens were divided into two subgroups according to the technique used for CH removal: Passive ultrasonic activation (PUA), Classic syringe irrigation (CSI). The cavities were photographed with a stereomicroscope, and percentage of remaining CH was measured using digital image analysis software (Image J). Statistical analysis was performed with two-way ANOVA and post-hoc Duncan tests. Results: PUA removed significantly more CH at apical and middle levels. (p < 0.05) There was no significant difference between PUA and CSI at coronal level. (p > 0.05) In PUA group, the amount of residual CH was the highest at coronal level. (p < 0.05) In CSI group, the amount of residual CH was the highest at apical level. (p < 0.05) Conclusions: None of the tested technique was able to completely remove CH from the simulated IRR cavities. CH was removed better with PUA than CSI at middle and apical root levels. For both techniques, the best results were obtained at middle root level.

Keywords: Calcium hydroxide removal, endodontics, image analysis, internal root resorption, passive ultrasonic activation


How to cite this article:
Yeter K Y, Gunes B, Danaci Z. Efficacy of Passive Ultrasonic Activation in Removing Calcium Hydroxide from Simulated Internal Resorption Cavities at Different Root Regions. Niger J Clin Pract 2021;24:1289-93

How to cite this URL:
Yeter K Y, Gunes B, Danaci Z. Efficacy of Passive Ultrasonic Activation in Removing Calcium Hydroxide from Simulated Internal Resorption Cavities at Different Root Regions. Niger J Clin Pract [serial online] 2021 [cited 2022 May 22];24:1289-93. Available from: https://www.njcponline.com/text.asp?2021/24/9/1289/325921




   Introduction Top


Resorption is related to either a physiological or a pathological process resulting in the loss of enamel, dentin and/or cementum.[1] Root resorption can be classified as internal or external resorption, depending on its location with reference to the root surface.[2],[3] The etiology and pathogenesis of internal root resorption (IRR) remains uncertain.[4],[5],[6] The early stage of IRR is asymptomatic and might be diagnosed by a routine radiograph or clinical examination.[1],[7] IRR is a pathological process that involves the loss of dentine and cementum as consequence of the osteoclastic activity of inflammatory cells.[1],[8]

During nonsurgical endodontic treatment, IRR presents challenges for the practitioner in cleaning, disinfection and obturation procedures due to the irregular root canal anatomy.[9] During chemomechanical preparation, an IRR cavity poses a challenge when attempting adequate disinfection and debridement in the root canal system.[10],[11] The use of medicaments is recommended between appointments to ensure adequate disinfection in irregular areas. Calcium hydroxide (CH) is recommended for this purpose due to its therapeutic properties, including interruption of tooth resorption, tissue dissolving and antimicrobial activity in teeth with IRR.[12],[13] CH should be removed from the IRR cavity and radicular space prior to the obturation procedure. Failure in removing CH from the radicular space completely, may negatively affect the adhesion and penetration of sealers into dentinal tubules.[14],[15]

Different root canal irrigation protocols have been developed to allow irrigation solutions to penetrate the IRR cavity more effectively, and to allow better cleaning and disinfection of the mechanically untouched areas.[16],[17] Contemporary irrigation activation devices are the Gentle Wave system, XP Endo Finisher, RinsEndo, photon-initiated photoacoustic streaming, canal brush, laser systems, and PUA.[18] PUA was introduced to help the irrigation solutions to penetrate the root canal space by transmission of acoustic streaming.[16] In previous studies, PUA showed better removal efficacy of CH than other irrigation activation protocols (CSI, sonic irrigation, RinsEndo, Canal Brush), but none of the irrigation protocols resulted in completely clean root canal walls.[19],[20],[21],[22],[23] To our knowledge no study has examined the efficacy of PUA for CH removal from IRR cavities at different root levels.

Different methods have been used to evaluate the residual medicament in the root canal previously. The area of the remaining CH in the root canal wall could be calculated by either using digital imaging software[19],[22],[24] or using a scoring method.[20],[21] Using image analysis program can overcome potential evaluator bias and provide to obtain quantitative data.[25]

The aim of this study was to evaluate the effect of supplementary use of passive ultrasonic activation (PUA) on the removal of calcium hydroxide (CH) paste from simulated internal resorption cavities at different root levels. The null hypothesis was that there would be no differences between different irrigation methods and among different root levels in removing CH from the simulated IRR cavities.


   Materials and Methods Top


This study was approved by Eskisehir Osmangazi University Ethics Committee (25403353-050.99-E.110426). Single oval-rooted canine human teeth that had been extracted for periodontal reasons were selected for this study. Teeth were cleaned from tissue remnants. Radiographs of all teeth were obtained from the mesio-distal and bucco-lingual directions. The inclusion criteria for the selection of teeth were a single oval-shaped canal with a canal diameter ratio in the mesio-distal and bucco-lingual direction greater than 2 at 5 mm from the apex. Teeth with root resorption, caries, immature apices, previous treatment and/or fractures were excluded. A total of 60 teeth selected for this study. The specimens were stored in distilled water at 37°C. After access cavity preparation, a size 15 K-file was inserted into the canal until the tip of the file was visible at the apical foramen. The root canals were prepared using Reciproc (VDW, Munich, Germany) size R50 (50.05) and irrigated with 5% sodium hypochlorite (NaOCl) using a 30-gauge side-vented needle (NaviTip; Ultradent, South Jordan, UT) during preparation. After chemo-mechanical preparation, the root canals were irrigated with 2.5 mL 17% EDTA solution, followed by 2 mL distilled water. Then the root canals were dried with paper points.

The test apparatus was prepared as described by Topçuoğlu et al.[26] The specimens were fixed in silicone impression material placed in Eppendorf tubes. [Figure 1] After removal of the specimen from this mold, longitudinal grooves were prepared along the roots on the buccal and lingual surfaces using a diamond-coated disk with water-cooling, without penetrating into the root canal. Each specimen was split into two halves. The length of the root canals was measured to determine the location of the resorption cavity. Simulated resorption cavities were prepared with 1.6-mm diameter and 0.8-mm depth at 3 different root levels: Apical (5 mm over the anatomic apex), middle (10 mm over the anatomic apex), and coronal (15 mm over the anatomic apex) in each half of each specimen. CH powder was mixed with saline until a creamy consistency was achieved, and the cavities were filled. [Figure 2] The root halves were reassembled with wax and remounted in the same impression material. The access cavities were sealed with temporary filling material; the specimens were stored at 37°C/100% humidity for 1 week. After removing temporary filling material, a size #15 K-file was inserted into the root canal to create a space for the irrigation needle.
Figure 1: The specimens were embedded in silicone impression material placed in Eppendorf tubes

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Figure 2: Stereomicroscopic images of (a) Simulated IRR cavity, (b) Simulated IRR cavities filled with CH

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In Group CSI, the root canals were irrigated with 9 mL 5% NaOCl for 1 min, followed by 1 min irrigation with 9 mL 17% EDTA, followed by 1 min irrigation with 3 ml distilled water using a Navi-Tip needle placed 1 mm short of the WL using an in-and-out motion. In Group PUA, 3 mL 5% NaOCl was flushed into the root canals and activated ultrasonically for 20 s. This procedure was repeated 3 times. Then the root canals were flushed with 3 mL 17% EDTA and activated for 20 s. This procedure was repeated 3 times and was followed by 1 minute of irrigation with 3 ml distilled water using a Navi-Tip needle placed 1 mm short of the WL. The total activation time was 1 min for the NaOCl and EDTA solutions. For all experimental groups, the irrigation solution volume was similar as 9 ml NaOCl, 9 ml EDTA and 3 ml distilled water. All experimental procedures were performed by one operator, who was a specialist in endodontics.

After removal of the medicaments, the roots were split into two halves and the resorption cavities were photographed using a camera attached to a stereomicroscope (ZEISS Stemi 508, Germany). The area of remaining CH in the resorption cavity and total resorption cavity area was measured using digital image analysis software (Image J), [Figure 3]. The percentage of the remaining CH was calculated by dividing remaining CH area to total IRR area and multiplying this result by 100.
Figure 3: Analysis of stereomicroscopic images with Image J software. (a) Simulated IRR cavity limit was determined. (b) Outside of the simulated IRR cavity was cleared. (c) Remaining calcium hydroxide area was selected and measured

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Statistical analysis

Data were statistically analyzed using two-way ANOVA and Duncan's multiple comparison test at 5% significance. Statistical analyses were performed using SPSS 18.0 software (SPPS Inc, Chicago, IL, USA).


   Results Top


[Table 1] presents the means and standard errors of the tested protocols. None of the tested methods could completely remove the CH from the simulated internal resorption cavities at the root canal level. There was no statistically significant difference between PUA and CSI at the coronal level. PUA removed more CH than CSI at the apical and middle levels. CSI group was worse in removing CH than PUA at the apical level of the root canal. In the PUA group, the amount of residual CH was the highest at the coronal level. In both groups, the best results were obtained at the middle level.
Table 1: Mean and standard errors (SE) of the residual CH percentages of the groups in the different root levels. (Different lowercase letters indicate statistically significant difference in rows. Different uppercase letters indicate statistically significant difference in columns)

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   Discussion Top


CH is frequently used as an intracanal medicament in cases of internal resorption due to its ability to inhibit the resorption process and antibacterial activity.[12],[13] Although the correlation with clinical results is not well established, residual CH negatively affects the adaptation of root canal filling material to root canal walls.[27] Therefore, CH should be removed from the root canal completely prior to root canal filling. As it is difficult to remove CH completely from the root canal by using conventional irrigation techniques, new irrigation activation techniques can be used for this procedure.[28] PUA was developed to improve the penetration of irrigation solutions into irregular areas within the root canal using acoustic streaming.[26],[29] This study evaluated the amount of remaining CH in internal resorption cavities prepared in three different regions of the root canal after using two different irrigation protocols. According to the findings of this study, no irrigation protocol removed all the CH from the IRR cavity. PUA was significantly more effective than CSI at the apical and middle levels but there was no significant difference at the coronal level. Therefore, the null hypothesis was rejected.

A systematic review reported that PUA activation was more effective than CSI at removing CH from the root canal.[30] Similar to our results, Keskin et al. reported that PUA and XP Endo Finisher were superior to other methods used to remove CH from the simulated IRR cavity prepared at the apical level.[16] Also, Topcuoğlu et al. stated that PUA and Safety Adjusted File (SAF) were more effective than CSI and EndoActivator (EA) in debris removal from the simulated IRR cavity.[26] Pabel et al. investigated the effect of EA, RinsEndo, Canal Brush, PUA, and CSI methods on the removal of CH from artificial coronal and apical grooves and the best results were reported for PUA-activated method; the results of this study also showed that the coronal groove had significantly more residual CH than the apical groove.[18] Vivan et al. examined the removal of dentinal debris from artificial grooves in the cervical, middle and apical thirds of the root, it was reported that in the control and PUA groups more CH was removed in the apical third than in the coronal third.[31] Similarly, in the present study, PUA activity was less effective in the coronal third than in the middle and apical thirds in removing CH. Acoustic streaming is defined as continuous unidirectional fluid motion around small vibrating objects independent of time.[32] According to the formula used to calculate the streaming velocity, the diameter of the file, frequency and amplitude displacement are important factors affecting the efficiency of irrigation.[29] The best effect is achieved when the tip of the file is small, the frequency is high, and the amplitude displacement is wide. The displacement amplitude is greatest at the tip of the file, so it probably directs the fluid flow towards the coronal third.[29],[31] This may be why PUA was more effective in the apical and middle thirds than the coronal third. In previous CH and debris removal studies, the resorption cavities were prepared only in apical third of the root canal, for this reason we could not compare the results of the middle and coronal thirds of our study with the literature.

In the present study, IRR cavities were prepared in the apical, middle, and coronal thirds in both halves of the same tooth using a diamond round bur. The advantage of simulated IRR cavities is that they offer a standardized size, location, and standard assessment. However, simulated IRR cavities do not reflect actual clinical conditions as they cannot mimic the irregular structure of a real IRR case. It should be considered that removing CH from simulated IRR cavities might be easier than naturally developed IRR cavities.

In this study, a digital imaging program (İmage J) was used to evaluate the percentage of remaining CH in the IRR cavities. Using this program, the total area of the cavity and the amount of remaining CH were calculated in square millimeters and were compared to each other. Since this method is more quantitative than a scoring method, it can provide standardization in the assessment of images. The limitation of this study is that a volumetric evaluation of the amount of remaining CH could not be performed since the program used measures in square millimeters.


   Conclusions Top


Within the limitations of this study, none of the tested techniques completely removed the Ca(OH)2 medicament from root canals of simulated IRR cavities of root canals. Using PUA might be more effective in removing CH from middle and apical internal resorption cavities than CSI.

Acknowledgements

We would like to thank to Dr. Yasin Altay from Eskişehir Osmangazi University, Faculty of Agriculture for statistical analysis.

This study was presented as a poster in the 20th Scientific Congress of the Asian Pacific Endodontic Confederation, Istanbul, 2019.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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