Bismuth release from endodontic materials: in vivo analysis using Wistar rats.

Calcium silicate-based materials are used to block the communication between the root canal and the periodontal ligament space. This brings the materials into contact with tissues and the potential for local and systemic elemental release and movement. The aim of the study was to evaluate the elemental release of bismuth from ProRoot MTA in contact with connective tissues after 30 and 180 days as well as any accumulation in peripheral organs using an animal model. Tricalcium silicate and hydroxyapatite containing 20% bismuth oxide (HAp-Bi) were used as controls. The null hypothesis was that bismuth migrates from tricalcium silicate-based materials when associated with silicon. The materials were examined using scanning electron microscopy, energy dispersive spectroscopy (SEM/EDS) and X-ray diffraction prior to implantation as well as using SEM/EDS, micro X-ray fluorescence and Raman spectroscopy after implantation to assess elemental presence in surrounding tissues. Histological analysis was used to evaluate the changes in tissue architecture and inductively coupled plasma mass spectrometry (ICP-MS) was used to investigate the elemental deposition. For the systemic investigation, routine blood analysis was performed and organs were obtained to evaluate the presence of bismuth and silicon using ICP-MS after acid digestion. In the histological analysis of the implantation sites, macrophages and multinucleated giant cells could be observed after 30 days which after 180 days became a chronic infiltrate; although, no major differences were identified in red and white blood cell analyses and biochemical tests. Implantation altered the materials as observed in the Raman analysis and bismuth was detected both locally and within kidney samples after both periods of analysis, indicating the potential for accumulation of bismuth in this organ. Smaller amounts of bismuth than observed in the kidney were also detected in blood, liver and brain for the ProRoot MTA and HAp-Bi after 180 days. Bismuth was released from the ProRoot MTA locally and was detected systemically and in samples without silicon; thus, the null hypothesis was rejected. The bismuth release demonstrated that this element accumulated both locally and systemically, mainly in the kidneys in comparison with brain and liver regardless of the material base.

Quantitative analysis of culturable bacteria, levels of endotoxins, inflammatory mediators and substance P in teeth with symptomatic irreversible pulpitis and in teeth with vital normal pulp tissues.

AIM: To comparatively analyse the levels of culturable bacteria, endotoxins (LPS), tumour necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1ß) and substance P in teeth with symptomatic irreversible pulpitis (SIP) and vital normal pulp (VNP) tissues. METHODOLOGY: Thirty-two patients were included (20 teeth with SIP and 12 teeth with VNP tissues) in this cross-sectional study. Samples were collected from the full length of the root canals (microbial analysis) and periapical tissues (2 mm beyond the apex for immunological analysis), using sterile absorbent paper points. The levels of culturable bacteria (culture method), endotoxins (LAL Pyrogent 5000), TNF-α, IL-1ß and substance P (ELISA) were assessed. The Mann-Whitney test was used for comparisons between the levels of CFU/mL, LPS, TNF-α, IL-1ß and substance P in the SIP and VNP groups. The statistical analysis was performed with the significance level set at 5%. RESULTS: Culturable bacteria were recovered from all teeth with SIP. On the other hand, no positive cultures were observed in the VNP tissues group (p > .05). The levels of LPS were approximately four times higher in teeth with SIP than in teeth with VNP tissues (p < .05). Higher levels of TNF-α and substance P were detected in teeth with SIP (p < .05). On the other hand, no difference in the levels of IL-1ß was detected between the two groups (p > .05). CONCLUSION: Teeth with symptomatic irreversible pulpitis present higher levels of culturable bacteria, endotoxins, TNF-α and substance P than those with vital normal pulp tissues. On the other hand, the levels of IL-1ß were similar in teeth from both groups suggesting reduced implications of this inflammatory mediator in the early stages of infection.

Heating stability, physical and chemical analysis of calcium silicate-based endodontic sealers.

AIM: To evaluate possible modifications in root canal sealers subjected to a variety of heating conditions using vibrational spectroscopy and analysis of physical and chemical properties. METHODOLOGY: EndoSequence BC Sealer HiFlow, Bio-C Sealer, BioRoot RCS and AH Plus were analysed chemically using Raman spectroscopy (25-220 °C) and Fourier-transform infrared spectroscopy (FT-IR) (37-100 °C ). For FT-IR, the materials were tested individually and mixed with root dentine powder. Scanning electron microscopy (SEM) and coupled energy dispersive spectroscopy (EDS) were used to evaluate surface and chemical elements. ISO 6876-2012 and ASTM-C266-07 specifications were followed to evaluate flow, setting time (moist and dry), solubility and radiopacity. Also, pH analysis at 37 and 100 °C was performed. Shapiro-Wilk and Mixed ANOVA (within and between the effects of the subjects), Levene, and a post hoc analyses with Bonferroni correction were performed (P < 0.05). RESULTS: Vibrational spectroscopy revealed peaks of tricalcium silicate, dicalcium silicate and zirconium dioxide. Chemical changes in the Raman spectra during heating were discrete, as the inorganic content predominated the signalling for all root canal sealers. FT-IR analysis exhibited spectral changes in water absorption for EndoSequence BC Sealer HiFlow and Bio-C Sealer, probably related to dehydration. For BioRoot RCS and AH Plus, no significant chemical changes were observed. Bio-C Sealer exhibited a band of polyethylene glycol only after heating to 100 °C, probably related to its thermal decomposition. SEM/EDS analysis corroborated the composition results observed in vibrational spectroscopy for all materials. Heating to 100 °C significantly changed the flowability of all calcium silicate-based sealers with a wide variation in setting times at both temperatures, along with solubility levels above ISO standards. For all tested sealers, radiopacity fulfilled the requirements, and pH exhibited alkaline values. CONCLUSIONS: The tested calcium silicate-based sealers were affected by heating. Calcium silicate-based root canal sealers had high solubility which is a concern for their clinical use. AH Plus was the only root canal sealer that was stable after heating.

Bacteria and virulence factors in periapical lesions associated with teeth following primary and secondary root canal treatment.

AIM: This cross-sectional study aimed to investigate the microbial profile and to quantify the levels of endotoxins (LPS) and lipoteichoic acid (LTA) present in periapical lesions associated with root filled teeth and those that had received root canal retreatment. It also aimed to investigate the association between microorganisms and their virulence factors with clinical and radiographic features. METHODOLOGY: Patients with periapical lesions in teeth with post-treatment endodontic disease following primary root canal treatment (n = 19) and unsuccessful root canal retreatment (n = 13) were treatment planned for endodontic microsurgery, where the periapical lesions were collected. Clinical and radiographic data were also collected. For microbiological analysis, nested polymerase chain reaction was used to detect 17 bacterial species. Levels of LPS and LTA were determined using limulus amebocyte lysate and enzyme-linked immunosorbent assays, respectively. The Student t-test or Wilcoxon-Mann-Whitney tests were applied to compare the data on LPS and LTA with clinical and radiographic features. The associations between the clinical and radiographic features and the bacterial species were analysed using the Fisher's exact test. A significance level of 5% was adopted. RESULTS: Bacterial DNA, LPS and LTA were detected in all samples. Parvimonas micra was the most commonly detected species in all groups, followed by Enterococcus faecalis, Fusobacterium nucleatum and Porphyromonas endodontalis. The type of endodontic treatment, whether a primary root canal treatment or retreatment, was not associated with the presence of any bacterial species in periapical lesions. The levels of LPS and LTA in periapical lesions of root filled teeth were not significantly different from those that had been retreated. Associations between the levels of LPS and LTA with clinical signs and symptoms were found. No association was found between specific bacteria and clinical features. CONCLUSION: Periapical lesions associated with teeth after primary root canal treatment and retreatment had similar polymicrobial composition. The levels of LPS and LTA in periapical lesions associated with teeth after primary root canal treatment and retreatment were similar, and both were associated with the same symptomatology.

Efficacy of reciprocating and ultrasonic activation of 6% sodium hypochlorite in the reduction of microbial content and virulence factors in teeth with primary endodontic infection.

AIM: To evaluate in a clinical trial the efficacy of reciprocating and ultrasonic activation of 6% sodium hypochlorite (NaOCl) in the microbial composition and reduction in microbial load as well as in levels of lipopolysaccharide (LPS) and lipoteichoic acid (LTA) in teeth with primary endodontic infections. METHODOLOGY: Samples were collected from 24 root canals with pulp necrosis and periapical lesions, before and after chemo-mechanical canal preparation. The teeth were randomly divided according to the activation protocol as follows: control group without activation (WA, n = 8), reciprocating activation group using Easy Clean tip (EC, n = 8) and ultrasonic activation group using Irrisonic insert (US, n = 8). Microbiological specimens were processed using a culture technique and microbiota composition was analysed using the checkerboard technique. The levels of LPS and LTA were quantified using limulus amebocyte lysate (LAL) and enzyme-linked immunosorbent assay (ELISA), respectively. The Fisher's exact test, Kruskal-Wallis, Dunn's and Wilcoxon's test with a significance level of P < 0.05 were used for statistical analysis. RESULTS: All initial specimens had growth of viable bacteria in fastidious anaerobe agar (FAA), with an average of 105  CFU mL-1 , whereas only one case had such growth after chemo-mechanical canal preparation. LPS and LTA were recovered in 100% of the cases. Chemo-mechanical canal preparation significantly decreased the levels of LPS and LTA (P < 0.05), but no significant differences were found between the groups (P > 0.05). Through the checkerboard technique, bacteria were found in 100% of the initial specimens with concentrations between <105 and 106 . The most frequently identified microorganisms were Prevotella nigrescens and Enterococcus hirae. After chemo-mechanical canal preparation, many species were not detected in any of the three groups tested. A significant reduction occurred in Group US, followed by Groups EC and WA. CONCLUSIONS: Activation of 6% NaOCl reduced the levels of LPS and LTA with no differences between the groups. However, ultrasonic activation was associated with a greater reduction in microbial load within root canals.

Relación entre el piso del seno maxilar y las raíces de las piezas posteriores superiores, mediante tomografía computada / Relationship between maxillary sinus floor and the posterior upper teeth roots, by means of computed tomography

Objetivo: El objetivo de este estudio fue evaluar la frecuencia con que las raíces de premolares y molares superiores se encuentran dentro del seno maxilar. Conocer la relación entre dichas estructuras es importante para planificar los procedimientos endodónticos y quirúrgicos a ser realizados en esa región. Materiales y métodos: Se realizó el análisis cualitativo dinámico de 82 tomografías computadas de haz cónico (CBCT) unilaterales, analizándose 738 raíces correspondientes a premolares y molares de una sola hemiarcada superior. Se utilizó sala con iluminación controlada y la observación fue realizada por un solo examinador. El criterio de inclusión requería que la cortical inferior del seno maxilar debía ser visible para poder establecer la relación. Se utilizaron los tres planos tomográficos de visualización, permitiendo ajustes de brillo y contraste. La escala de clasificación de cada raíz consideró su relación como: dentro o fuera del seno maxilar. Los datos obtenidos fueron sometidos a las pruebas de Chi-cuadrado y Test Exacto de Fisher. Resultados: el primer premolar superior mostró una proyección hacia el interior del seno maxilar significativamente menor que las otras piezas dentarias posteriores (p>0.05), observándose su raíz vestibular sin proyección. La raíz palatina del primer premolar superior mostró la mayor incidencia dentro del seno maxilar, con un 39,02% del total de las raíces analizadas (p<0,05). El segundo molar superior mostró considerable proximidad con el seno maxilar, pero con menor incidencia con relación a la raíz palatina del primer molar. Conclusión: los procedimientos endodónticos o quirúrgicos a realizarse en cercanía al seno maxilar deben considerar siempre la relación raíz/seno, para evitar maniobras que lo invadan. La raíz palatina del primer molar superior mostró la mayor incidencia dentro del seno maxilar, con un 39,02% (AU)

The effect of mixing method on tricalcium silicate-based cement.

AIM: To evaluate the effect of three methods of mixing on the physical and chemical properties of tricalcium silicate-based cements. METHODOLOGY: The materials evaluated were MTA Angelus and Portland cement with 20% zirconium oxide (PC-20-Zr). The cements were mixed using a 3 : 1 powder-to-liquid ratio. The mixing methods were manual (m), trituration (tr) and ultrasonic (us) activation. The materials were characterized by means of scanning electron microscope (SEM) and energy dispersive X-ray spectroscopy. Flowability was analysed according to ANSI/ADA 57/2012. Initial and final setting times were assessed following ASTM C266/08. Volume change was evaluated using a micro-CT volumetric method. Solubility was analysed according to ADA 57/2012. pH and calcium ion release were measured after 3, 24, 72 and 168 h. Statistical analysis was performed using two-way analysis of variance. The level of significance was set at P = 0.05. RESULTS: The SEM analysis revealed that ultrasonic activation was associated with a homogeneous distribution of particles. Flowability, volume change and initial setting time were not influenced by the mixing method (P > 0.05). Solubility was influenced by the mixing method (P < 0.05). For pH, at 168 h, significant differences were found between MTA-m and PC-20-Zr-m (P < 0.05). For calcium ion release, PC-20-Zr-tr had higher values than MTA-m at 3 h, and MTA-tr had higher values than PC-20-Zr-m at 168 h (P < 0.05). CONCLUSIONS: The ultrasonic and trituration methods led to higher calcium ion release and pH compared with manual mixing for all cements, whilst the ultrasonic method produced smaller particles for the PC-20-Zr cement. Flow, setting times and volume change were not influenced by the mixing method used; however, it did have an impact on solubility.

Efficacy of xylene and passive ultrasonic irrigation on remaining root filling material during retreatment of anatomically complex teeth.

AIM: To evaluate the volume of remaining filling material in the mesial root canals of mandibular molars after root canal retreatment with different procedures performed sequentially. METHODOLOGY: The mesial root canals of 12 human first mandibular molars were instrumented using the BioRace system until a size 25, .06 taper instrument. The mesial roots were filled with gutta-percha and AH-Plus using a vertical compaction technique. The specimens were scanned using microcomputed tomography with a voxel size of 16.8 µm before and after the retreatment procedures. To remove the filling material, the root canals were enlarged until the size 40, .04 taper instrument. The second step was to irrigate the root canals with xylene in the attempt to clean the root canals with paper points. In the third step, the passive ultrasonic irrigation technique (PUI) was performed using 2.5% sodium hypochlorite. The initial and residual filling material volume (mm(3) ) after each step was evaluated from the 0.5 to 6.5 mm level. The obtained data were expressed in terms of percentage of residual filling material. Statistical analysis was performed using the Friedman test (P < 0.05). RESULTS: All specimens had residual filling materials after all retreatment procedures. Passive ultrasonic irrigation enhanced the elimination of residual filling material in comparison with the mechanical stage at the 0.5-2.5 mm and 4.5-6.5 mm levels (P < 0.05). No significant difference was found between xylene and PUI methods. CONCLUSIONS: Filling materials were not completely removed by any of the retreatment procedures. The use of xylene and PUI after mechanical instrumentation enhanced removal of materials during endodontic retreatment of anatomically complex teeth.

Influence of powder-to-water ratio on radiopacity, setting time, pH, calcium ion release and a micro-CT volumetric solubility of white mineral trioxide aggregate.

AIM: To evaluate the radiopacity, setting time, pH level, calcium ion release and solubility of white mineral trioxide aggregate (MTA; Angelus, Londrina, Pr, Brazil) with different powder-to-water ratios. METHODOLOGY: Three MTA groups were prepared using 4 : 1, 3 : 1 and 2 : 1 powder-to-water ratios. For the radiopacity analysis, the 10 × 1 mm specimens were arranged on occlusal films with a cylinder of dentine and an aluminium stepwedge. The digitized radiographs were evaluated with Digora 1.51 software to determine the radiographic density. The setting time test was performed according to the American Society for Testing and Materials 266/08 standard specifications, but the specimens were made according to International Organization for Standardization 6876:2001. Thirty acrylic teeth with root-end filling material were immersed in ultrapure water for measurement of pH level and calcium ion release (atomic absorption spectrophotometer) at 3, 24, 72 and 168 h. In the solubility test, the root-end fillings of 30 acrylic teeth were scanned twice by a Micro-CT, before and after immersion in ultrapure water for 168 h. Digital data were reconstructed, and the volume (mm(3) ) of the samples was obtained using CTan software (CTan v1.11.10.0, SkyScan). The data were statistically analysed by the anova, Tukey, Kruskal-Wallis and Dunn's tests. RESULTS: The radiopacity was higher (P < 0.05) when the 4 : 1 proportion was utilized. The setting time was longer, and the pH level and calcium ion release were higher (P < 0.05) with a greater volume of water. The group with more water (2 : 1) had significantly (P < 0.05) more material volume loss (6.46%) compared with the other groups. CONCLUSIONS: The ratio of powder/water significantly interfered with the physical and chemical properties of white MTA Angelus.

Analysis of four gutta-percha techniques used to fill mesial root canals of mandibular molars.

AIM: To compare the percentage of gutta-percha, sealer and voids and the influence of isthmuses in mesial root canals of mandibular molars filled with different techniques. METHODOLOGY: Canals in 60 mesial roots of mandibular first molars were prepared with ProTaper instruments to size F2 (size 25, 0.08 taper) and filled using a single-cone, lateral compaction, System B or Thermafil techniques. An epoxy resin sealer was labelled with Rhodamine-B dye to allow analysis under a confocal microscope. The percentage of gutta-percha, sealer and area of voids was calculated at 2, 4 and 6 mm from the apex, using Image Tool 3.0 software. Statistical analysis was performed using nonparametric Kruskal-Wallis and Dunn tests (P < 0.05). The influence of isthmuses on the presence or absence of voids was evaluated using the Fisher test. RESULTS: At the 2 mm level, the percentage of gutta-percha, sealer and voids was similar amongst the System B, lateral compaction and single-cone techniques. The single-cone technique revealed significantly less gutta-percha, more sealer and voids in comparison with the Thermafil technique at the 2 and 4 mm level (P < 0.05). The analysis of all sections (2, 4 and 6 mm) revealed that more gutta-percha and less sealer and voids were found in root canals filled with Thermafil and System B techniques (P < 0.05). The Fisher test revealed that the presence of isthmuses increased the occurrence of voids in the lateral compaction group only (P < 0.05). CONCLUSION: Gutta-percha, sealer filled area and voids were dependent on the canal-filling technique. The presence of isthmuses may influence the quality of root filling.