Update on chelating agents in endodontic treatment: A systematic review.

Background: The aim of this review was to assess the evidence regarding the most commonly used chelating agents in terms of efficacy, erosive potential, cytotoxicity, interaction, antimicrobial effect, impact on sealers adhesion, and release of growth factors. Material and Methods: MEDLINE (PubMed) database, Cochrane Library and Scopus were searched up to January 14, 2023, including studies with one or more of the following chelating agents: 17% EDTA, 9% and 18% HEDP, 10% and 20% citric acid, 2%-2.25% peracetic acid and 7% maleic acid. In addition, the reference lists of all selected articles were also checked to identify additional relevant studies. Articles published in English and available in full-text were selected. The quality of studies was assessed using the modified CONSORT checklist guide and the Cochrane Collaboration tool. Results: The electronic search yielded 538 citations, 56 of which were included. The articles included had moderate and low evidence values. Among 56 articles included, 55 were in vitro studies and one was a randomized clinical trial. Among the in vitro studies, 15 evaluated efficacy and dentin erosion, 12 evaluated interaction with other endodontic irrigants, 9 tested antimicrobial effect, 4 evaluated cytotoxicity in hamster and rat lung cells, 9 evaluated intervention in adhesion of filling materials and 8 focused on release of growth factors and on behavior of stem cells in regenerative endodontic. The RCT tested antimicrobial effect. Conclusions: 17% EDTA is the most effective in smear layer removal and in releasing growth factors on regenerative endodontics. However, the current incorporation of 9% and 18% etidronic acid has shown optimal results due to its compatibility with sodium hypochlorite and its capability on avoiding smear layer formation through a continuous chelation action. Despite these preliminary findings, methodological standardization between studies is required and in vivo studies are necessary to confirm in vitro studies. Key words:Chelating Agents, Smear Layer, Systematic Review, Endodontics, Root Canal Irrigants.

Evaluation of dental trauma associated with cycling accidents in a city in the south of Brazil: an observational study / Avaliação de traumatismos dentários associados a acidentes com bicicletas em uma cidade do sul do Brasil: um estudo observacional

Aim: to evaluate the cyclists' profile and the frequency of dental trauma associated with cycling in a southern city in Brazil. Materials and Methods: a questionnaire was applied to 234 cyclists with at least 18 years old. The variables of interests were: sociodemographic data, data related to the profile of users, and data on the occurrence of all traumas and dental traumas. Descriptive and inferential statistical analyses were carried out (α=5%). Results: The mean age of participants was 31.38 ± 11.6 years, ranging from 14 to 67 years. The majority of the participants were male (62.8%), had attended higher education (45.7%), and had incomes equivalent to 1 to 3 times the minimum wage (39.3%). The main reason given for riding a bicycle was leisure (35.9%). Users of their own bicycles had fewer items of mandatory safety equipment fitted to their bicycles than users of rented bicycles (Student's t test, P<0.0001). However, study participants riding their own bicycles wore personal protective equipment more frequently than renters (Student's t test, P<0.0001). Moreover, 33.7% of the respondents reported having suffered an accident, and 25% had traumatized some part of the body. Among those who reported traumas, 20% (4/20) had suffered traumas to hard dental tissues and supporting structures. Discussion: Dental trauma was not frequent in a population predominantly from an urban area that uses bicycles, especially for leisure, despite the prevalence of accidents involving bicycle use. Conclusion: Health education campaigns should emphasize the importance of personal protective equipment for cyclists and of safety items fitted to bicycles, whether cyclists' own or rented.

Objetivo: avaliar o perfil dos ciclistas e a frequência de traumatismo dentário associado ao ciclismo em uma cidade do sul do Brasil. Materiais e Métodos: aplicou-se um questionário a 234 ciclistas com idade mínima de 18 anos. As variáveis ​​de interesse foram: dados sociodemográficos, dados relacionados ao perfil dos usuários e dados sobre a ocorrência de todos os traumatismos e traumas dentários. Foram realizadas análises estatísticas descritivas e inferenciais (α=5%). Resultados: A idade média dos participantes era de 31,38 ±11,6 anos, variando de 14 a 67 anos. A maioria dos participantes era do sexo masculino (62,8%), tinha curso superior (45,7%) e renda equivalente a 1 a 3 salários mínimos (39,3%). O principal motivo para andar de bicicleta foi lazer (35,9%). Usuários de suas próprias bicicletas tinham menos itens de equipamentos de segurança obrigatórios instalados do que os usuários de bicicletas alugadas (teste t de Student, P<0,0001). Porém, participantes do estudo que andavam em sua própria bicicleta usavam equipamentos de proteção individual mais frequentemente do que os locatários (teste t de Student, P<0,0001). Ainda, 33,7% dos entrevistados relataram ter sofrido algum acidente e 25% traumatizado alguma parte do corpo. Entre os que relataram traumatismos, 20% (4/20) sofreram traumas em tecidos duros dentais e estruturas de suporte. Discussão: O traumatismo dentário não foi frequente em uma população predominantemente de área urbana que utiliza bicicletas, principalmente para lazer, apesar da prevalência de acidentes envolvendo o uso de bicicletas. Conclusão: As campanhas de educação em saúde devem enfatizar a importância dos equipamentos de proteção individual dos ciclistas e dos itens de segurança instalados nas bicicletas, sejam elas próprias ou alugadas.

The Impact of Cone-beam Computed Tomography on Diagnostic Thinking, Treatment Option, and Confidence in Dental Trauma Cases: A Before and After Study.

INTRODUCTION: The aim of this study was to identify whether cone-beam computed tomographic (CBCT) imaging affects endodontists' diagnostic thinking, treatment option, and confidence in dental trauma cases. METHODS: Twelve endodontists reviewed 15 dental trauma cases with clinical histories and periapical radiography (PR) and answered questions regarding their diagnostic thinking and treatment decisions and their confidence in both. One month later, the same participants reviewed the same cases and answered similar questionnaires with the aid of CBCT imaging. A statistical analysis of their responses was conducted. RESULTS: Differences were observed in diagnostic thinking when using PR or CBCT imaging (P < .05), and the use of PR was associated with a higher number of "unsure" answers to questions about diagnoses. After reviewing periapical radiographic images, the approach most frequently endorsed was "don't start conventional endodontic treatment and order CBCT," whereas the most common decision made after analyzing the CBCT images was "start conventional endodontic treatment." Clinical interventions were proposed more often when participants evaluated the clinical case using CBCT imaging than when using PR (P < .05). The participants' degree of confidence in their diagnostic thinking was not different after analysis using PR or CBCT imaging (P > .05). However, there was a difference between PR and CBCT imaging in participants' confidence in their treatment decisions (P < .05). Participants who initially indicated a lack of confidence in their diagnosis or treatment option gained confidence when CBCT images were available. However, the inverse behavior was also observed for participants who were initially confident on the basis of PR (P < .05). Participants who decided to start treatment after CBCT analysis were less confident than when using PR (P < .05). CONCLUSIONS: In dental trauma cases, CBCT imaging influenced participants' diagnostic thinking and choice of treatment modality and affected their confidence in the decision-making process.

Self-reported confidence and anxiety over endodontic procedures in undergraduate students-Quantitative and qualitative study.

PURPOSE: The current literature shows a growing interest to assess the feelings and perceptions of students associated with the performance of elective endodontic procedures. This study aimed to evaluate the students' anxiety and self-perceptions related to performing such treatments. METHODS: Forty-five students participated in the research (G1 = 22 beginners students; G2 = 23 senior students). Demographic data, STAI-State and Numerical Rating Scale (NRS) for pre-operative anxiety were completed before the appointment with patient. The STAI-Trait; NRS for post-operative anxiety; previous experiences in endodontics; and level of confidence in each stage of endodontic treatments were collected after appointment. Focal groups for qualitative data collection were performed on separate occasion. RESULTS: Both groups showed higher scores in STAI-State than for STAI-Trait scale. G1 showed higher levels of anxiety in the pre-operative, compared with post-operative moment in the NRS scale. G2 reported feeling more confidence to insert intracanal medication and to restore teeth between appointments than G1. In both focus groups, participants reported insecurity in performing endodontic procedures due to difficulty in visualisation and to anatomic complexities. G1 reported that all the confidence they had was based in pre-clinical experience, and G2 mentioned concern about the end of graduation. CONCLUSION: The participants' anxiety diminishes as they gain more experience in performing endodontic procedures. However, as they approach the end of the course anxiety levels increase. Greater availability of elective courses in endodontics could be a valuable alternative to provide students with more exposure to and experience with these procedures.

Antimicrobial action, pH, and tissue dissolution capacity of 2,5% sodium hypochlorite gel and solution / Ação antimicrobiana, pH, e capacidade de dissolução tecidual de gel e solução de hipoclorito de sódio 2,5%

Objective: to evaluate antimicrobial action, pH, and tissue dissolution capacity of 2.5% sodium hypochlorite (NaOCl) gel and solution. Methods: The 2.5% NaOCl gel was produced from a colloidal base. The test groups included 2.5% NaOCl gel and solution and the control groups included gel base and distilled water. The antimicrobial activity was evaluated by the broth dilution technique against Enterococcus faecalis (ATCC 29212) at 15 and 30 seconds and at 1, 5, and 10 minutes. To evaluate tissue dissolution capacity, 30 pulp fragments of bovine incisors were weighed, 10 for each test group and 5 for each control group before and after exposure to the chemical auxiliaries. The final mass percentage of each fragment was calculated. The pH of the substances was measured in triplicate through a digital pH meter. Results: pH levels of 13.08 and 9.75 were observed for 2.5% NaOCl solution and gel, respectively. The antimicrobial action of 2.5% NaOCl was the same for both solution and gel, for all tested times. The 2.5% NaOCl solution group showed higher tissue dissolution capacity (Kruskal-Wallis and Student-Newman-Keuls tests P<0.0001). Conclusions: The type of medium, either solution or gel, containing 2.5% NaOCl did not influence the antimicrobial action at any of the tested times. However, 2.5% NaOCl gel did not present tissue dissolution capacity

Objetivo: avaliar a ação antimicrobiana, pH e capacidade de dissolução tecidual promovida por hipoclorito de sódio (NaOCl) 2,5%, nas formas líquida e gel. Métodos: O gel de NaOCl 2,5% foi produzido a partir de base coloidal. Os grupos testes foram NaOCl 2,5% gel e solução e os grupos controle incluíram a base gel e água destilada. A ação antimicrobiana foi avaliada por meio de método de diluição em caldo, frente a Enterococcus faecalis (ATCC 29212) após 15 e 30 segundos, e também a 1, 5 e 10 minutos. Para o teste de diluição tecidual, 35 fragmentos de polpa bovina (sendo 10 para cada grupo teste e 5 para o grupo controle) foram pesadas antes e após a exposição aos auxiliares químicos. O percentual de massa final de cada fragmento foi calculada. O pH dos auxiliares químicos foi medido em pHmetro digital, em triplicata. Resultados: Valores de pH iguais a 13,08 e 9,75 foram observados para solução e para o gel de NaOCl, respectivamente. A ação antimicrobiana do NaOCl foi a mesma para o gel e a solução, em todos os períodos testados. Maior capacidade de dissolução tecidual foi obtida no grupo onde se utilizou a solução de NaOCl 2,5% (Testes de Kruskal-Wallis e Student-Newman-Keuls, P<0,0001). Conclusões: A apresentação na forma de gel ou de líquido do NaOCl 2,5% não modificou a ação antimicrobiana em qualquer um dos períodos testados. Porém, o gel de NaOCl 2,5% não demonstrou capacidade de dissolução tecidual.

Avaliação da formação de smear layer no preparo químico mecânico realizado com solução ou gel de hipoclorito de sódio a 2, 5% / Evaluation of smear layer formation in mechanical chemical preparation performed with 2. 5% sodium hypochloride solution or gel

Introdução: a formação de smear layer durante o preparo dos canais radiculares com o uso de hipoclorito de sódio solução já foi amplamente estudada; entretanto, na apresentação em gel não existem relatos na literatura. Objetivo: avaliar, em MEV, a formação de smear layer durante o preparo endodôntico, utilizando o NaOCl nas formas líquida e gel, associado ou não ao EDTA. Métodos: sessenta raízes palatinas de molares superiores ou distais de inferiores, com comprimento radicular padronizado em 15 mm, foram utilizadas. As amostras foram divididas em quatro grupos controle com n = 5 cada (soro fisiológico ou base gel, associados ou não ao EDTA) e quatro grupos testes com n = 10 cada, de acordo com a substância irrigadora empregada durante o preparo (solução ou gel de NaOCl a 2,5%, associados ou não ao EDTA). Os canais foram modelados e posteriormente clivados para análise em MEV (ampliação de 2000x). Imagens de eletromicrografias foram obtidas nos terços cervical, médio e apical. A presença e as características da smear layer formadas foram categorizadas. As imagens foram analisadas por dois avaliadores, previamente, calibrados. Após a análise de concordância (Kappa = 0,806) dos escores, os dados foram tratados com o uso do teste Kruskall-Wallis, complementado pelo teste de Comparações Múltiplas SNK. O nível de significância foi de 5%. Resultados: a utilização do soro fisiológico e do NaOCl líquido, associados à irrigação final com EDTA, apresentou os melhores resultados de limpeza. Com o uso do NaOCl gel e da base gel, sem associação ao EDTA, houve uma maior quantidade de resíduos sobre as paredes dentinárias. Além disso, independentemente da substância irrigadora testada, pode-se observar que houve uma melhor capacidade de remoção da smear layer no terço cervical em relação ao apical. Conclusões: observou-se formação de smear layer após o preparo do canal radicular associado ao NaOCl líquido ou gel. A aplicação de EDTA promoveu a remoção da smear layer produzida durante o preparo do canal.

Introduction: the formation of smear layer during the preparation of root canals with the use of sodium hypochlorite solution has been widely studied; however, in the gel presentation there aren't reports in the literature. Objective: to evaluate, in SEM, the formation of smear layer during endodontic preparation, using NaOCl in liquid and gel forms, associated or not with EDTA. Methods: sixty palatal roots of maxillary molars or distal roots of lower molars, with a root length of 15 mm, were used. The samples were divided into four control groups with n = 5 each (saline or gel base, associated or not with EDTA) and four test groups (n = 10 each) according to the irrigation substance used during the preparation (2.5% NaOCl solution or gel, associated or not with EDTA). The root canals were instrumented and later split for SEM analysis (2000x magnification). Electromicrographic images were obtained from the cervical, middle and apical thirds. The presence and characteristics of the smear layer formed were categorized. The images were analyzed by two previously calibrated evaluators. After the Kappa analysis (0.806), the data were treated using the Kruskall-Wallis test, complemented by the SNK Multiple Comparison Test. The level of significance was 5%. Results: the use of saline and liquid NaOCl, associated with final rinsing with EDTA, showed the best cleaning results. With the use of NaOCl gel and gel base, with no EDTA association, there was a greater amount of residues on the dentin surfaces. In addition, despite the irrigation substance tested, it can be observed that there was a better capacity of removal of the smear layer in the cervical third in relation to the apical. Conclusion: root canal instrumentation associated with NaOCl solution or gel EDTA produced smear layer. Smear layer was removed with the use of EDTA as a final flushing.

Experiences during the execution of emergency endodontic treatment and levels of anxiety in dental students.

PURPOSE: This study aims to evaluate the experience of dental students and assess their anxiety levels when performing emergency endodontic treatments. METHODS: Undergraduate students completed the STAI-Trait/State and a questionnaire to assess their confidence level to perform each step of an emergency endodontic procedure. They also answered a numerical scale (NRS) for anxiety before and after emergency care. Ten randomly selected students from the same sample further participated in a focus group aimed at obtaining qualitative data on their perception of endodontic treatments' conduction and the learning process necessary to perform them. RESULTS: A total of 23 students joined the study. The majority of the participants reported feeling "confident" when performing local anaesthesia (57.6%), rubber dam placement (57.6%) and coronal sealing (72.7%). However, a small number reported feeling "little confident" to perform access cavity (15.2%) or pulpotomy/pulpectomy (24.2%). Students who scored above the 3rd quartile of STAI-Trait/State were classified as "highly anxious," and comprised 26.1% of the sample. The values of NRS scale were higher in the preoperative when compared with the post-operative assessment. All students classified as "highly anxious" reported low confidence in performing "access cavity" and "pulpotomy/pulpectomy." CONCLUSION: Both quantitative and qualitative analysis showed different anxiety levels in dental students. It can possibly contribute to a reduction in confidence prior to emergency endodontic procedures. The current findings suggest it might be important to rearrange activities in order to allow for more practical classes in Endodontics.