Effectiveness of root canal irrigation and dressing for the treatment of apical periodontitis: A systematic review and meta-analysis of clinical trials.

BACKGROUND: Sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic acid (EDTA) and/or calcium hydroxide (Ca(OH)2 ) are commonly used during root canal treatment. Evaluation of their effectiveness regarding clinical and patient-related outcomes requires further understanding. OBJECTIVES: To assess the effectiveness of root canal irrigation and dressing for the treatment of teeth with apical periodontitis (AP). METHODS: A search was conducted in the PubMed-MEDLINE, Scopus, EMBASE, Google scholar databases and available repositories, followed by hand searches, until July 2021. Eligibility criteria followed the a priori formulated Population, Intervention, Comparator, Outcomes, Timing, and Study design (PICOTS) framework. Clinical studies restricted to English language were included. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to assess the quality of included studies. Meta-analyses were performed using the fixed-effect model to obtain Risk Ratio (RR) and 95% Confidence Interval (CI), with sensitivity analysis. Overall quality of evidence of meta-analyses was assessed through the Grading of Recommendations Assessment, Development, and Evaluation tool. RESULTS: The search identified 1357 records of which six fulfilled the inclusion criteria, providing data for 'irrigation' from 212 teeth and for 'dressings' from 438 teeth. Two studies reported no significant difference regarding the outcome 'pain at 7 days' using 2% chlorhexidine vs. 5.25% NaOCl and EDTA or after using different concentrations of NaOCl (1% vs. 5%). No significant difference was detected between different NaOCl concentrations regarding the reduction of AP. A meta-analysis was possible for the comparison of single-visit (SV) versus multiple-visits including the use of Ca(OH)2 demonstrating a significant effect in favour of SV (RR: 1.10; 95% CI: 1.03-1.19; p = .007; I2  = 0). RoB of included studies was moderate to low. DISCUSSION: The use of Ca(OH)2 for the treatment of AP may not be beneficial. There is scarce or no evidence fulfilling the proposed PICOTS regarding irrigants and dressings. CONCLUSIONS: There is moderate certainty that SV treatment is associated with better radiographic evidence of normal periodontal ligament space (strict criteria) compared with the use of Ca(OH)2. Reduction of AP is comparable after irrigation with 1% and 5% NaOCl, whereas postoperative pain at 7 days for the irrigants assessed is similar. REGISTRATION: PROSPERO database CRD42021260271.

Effect of Passive Ultrasonic Activation on Organic Tissue Dissolution from Simulated Grooves in Root Canals Using Sodium Hypochlorite with or without Surfactants and EDTA.

INTRODUCTION: The aim of this study was to evaluate the porcine palatal mucosa dissolution from artificial grooves using a final rinse with sodium hypochlorite (NaOCl) with or without a surfactant or ultrasonic activation (PUI). METHODS: The root canals of 130 human maxillary central incisors were chemomechanically prepared and the teeth split. A standardized longitudinal intracanal groove was created in 1 of the root halves. One hundred thirty porcine palatal mucosa samples were collected, adapted in order to fit into the grooves, and weighed. The reassembled specimens were randomly divided in 3 experimental groups (n = 40) based on their irrigation protocol (ie, positive pressure [PP] and PUI during 15 [PUI-15] or 30 seconds [PUI-30]) and divided in subgroups according to the NaOCl preparation used: Vista 6% plain (Vista Dental Products, Racine, WI) or Chlor-XTRA (Vista Dental Products) (containing surfactant). An EDTA intermediate rinse was included. Palatal mucosa weights were measured after the assays. The intergroup weight changes were statistically analyzed. RESULTS: Complete dissolution did not occur in any sample. Chlor-XTRA subgroups were associated with increased weight reduction compared with Vista 6% plain subgroups; however, the differences were significant (P < .05) only for PP and PUI-15. PUI-30 increased weight reduction compared with PP for both hypochlorites and PUI-15 using Vista 6% plain (P < .05). PUI-30 with Vista 6% plain performed significantly better than PP with Chlor-XTRA (P < .05). CONCLUSIONS: The addition of a surfactant to NaOCl and/or PUI activation increased palatal mucosa dissolution within artificial grooves in the root canal of incisor teeth. PUI agitation was often able to compensate for the absence of surfactants.

D-amino acids reduce Enterococcus faecalis biofilms in vitro and in the presence of antimicrobials used for root canal treatment.

Enterococcus faecalis is the most frequent species present in post-treatment disease and plays a significant role in persistent periapical infections following root canal treatment. Its ability to persist in stressful environments is inter alia, due to its ability to form biofilms. The presence of certain D-amino acids (DAAs) has previously been shown to reduce formation of Bacillus subtilis biofilms. The aims of this investigation were to determine if DAAs disrupt biofilms in early and late growth stages for clinical E. faecalis strains and to test their efficacy in disrupting E. faecalis biofilms grown in sub-minimum inhibitory concentrations of commonly used endodontic biocides. From thirty-seven E. faecalis strains, the ten "best" biofilm producers were used to test the ability of a mixture containing D-leucine, D-methionine, D-tyrosine and D-tryptophan to reduce biofilm growth over a period of 24, 72 and 144 hours and when compared to their cognate L-Amino Acids (LAAs). We have previously shown that sub-MIC levels of tetracycline and sodium hypochlorite promotes biofilm growth in clinical strains of E. faecalis. DAAs were therefore tested for their effectiveness to reduce biofilm growth in the presence of sub-minimal concentrations of sodium hypochlorite (NaOCl-0.031%) and Odontocide™ (0.25% w/v), and in the presence of Odontopaste™ (0.25% w/v). DAAs significantly reduced biofilm formation for all strains tested in vitro, while DAAs significantly reduced biofilm formation compared to LAAs. The inhibitory effect of DAAs on biofilm formation was concentration dependent. DAAs were also shown to be effective in reducing E. faecalis biofilms in the presence of Odontopaste™ and sub-MIC levels of NaOCl and Odontocide™. The results suggest that the inclusion of DAAs into current endodontic procedures may reduce E. faecalis biofilms.