How To Remove Calcium Hydroxide From Root Canal
J Dent Sci. 2022 Jan; 17(1): 128–134.
Efficacy of five irrigation techniques in removing calcium hydroxide from simulated S-shaped root canals
Received 2022 May iv; Revised 2022 May 26
Abstract
Background/purpose
Calcium hydroxide [Ca(OH)2], a wildly used intracanal medicament, should be completely removed from the root canal before obturation to avoid negative effects on the handling. This study evaluated the effectiveness of conventional needle irrigation (CNI), passive ultrasonic activation (PUI), photon-induced photoacoustic streaming (PIPS), XP-endo Finisher (XP) and EDDY for the removal of Ca(OH)2 from S-shaped root canal.
Materials and methods
Eighty-four South-shaped root canals in resin blocks were prepared using Protaper Gold upward to size #25/0.08 and filled with Ca(OH)2. Five groups were established according to the removal techniques (n = xvi): CNI, PUI, PIPS, XP and Eddy group. The positive and negative control grouping (n = 2) were also established. Sodium hypochlorite 3% was used as the irrigant. Digital radiographs were used to measure the remaining Ca(OH)ii. Statistical assay of the information was performed past using the Kruskal–Wallis test, followed by Dunn'southward mail hoc test with Bonferroni correction (α = 0.05).
Results
All the tested techniques completely removed Ca(OH)ii from the straight portion and coronal curve of the S-shaped root canal in 100% of cases. Regarding the apical curve, PUI, Eddy, PIPS and XP removed significantly more Ca(OH)ii than CNI (P < 0.05), with no meaning differences among these iv groups (P > 0.05). The consummate clearance of Ca(OH)2 from the apical curve was observed in 75%, 62.5%, 56.3%, 43.8% and 0% of cases of PUI, EDDY, PIPS, XP and CNI group, respectively.
Conclusion
Irrigant activation enhanced Ca(OH)2 removal from the apical region of the Due south-shaped root culvert. CNI was significantly less effective than all activation techniques.
Keywords: Intracanal medicament, South-curvature, Sonic activation, Ultrasonic activation, Laser-activated irrigation
Introduction
Intracanal medication comprises application of a chemical substance into the root culvert in order to improve disinfection after chemomechanical preparation. Calcium hydroxide [Ca(OH)2] is the almost commonly recommended antimicrobial agent to be used as an interappointment dressing. Withal, this medication has to be removed before root canal obturation, to avoid any possible negative influence on treatment. The residual Ca(OH)2 on the root canal walls might collaborate with zinc oxide eugenol and increase apical leakage afterwards obturation when the zinc oxide-eugenol sealer is used.1 Moreover, Ca(OH)2 resides might prevent the penetration of sealers into dentinal tubules and provide a reduction in bond strength values of epoxy resin AH Plus (Dentsply Sirona, Konstanz, Federal republic of germany).2,3
Nevertheless, complete removal of Ca(OH)2 using diverse techniques remains a claiming in root canal therapy, particularly in complex root canal system. The most ofttimes described method for Ca(OH)2 removal is the recapitulation of the master upmost file in combination with copious irrigation using conventional needle irrigation (CNI).iv Even so, previous studies have shown the difficulty to remove Ca(OH)2 from root canals using this conventional method.5 Passive ultrasonic activation (PUI) is another extensively researched technique and is regarded every bit the gold standard for irrigant activation inquiry.6 Although PUI removed residual Ca(OH)ii from the coronal and middle thirds of the root culvert, it is remains a business that the big amount of Ca(OH)2 in the critical apical area and irregular areas of the complex root culvert system.5, half dozen, 7, 8
Promising results for the removal of Ca(OH)two have been shown using an erbiu:yttrium-aluminum-garnet (Er:YAG) laser coupled with a brusque radial-stripped tip in a technique known as photon-induced photoacoustic streaming (PIPS) (Fotona, Ljubljana, Slovenia). In this technique, Er:YAG light amplification by stimulated emission of radiation is used with small free energy (20 mJ) and very short pulses (l μs), intracanal cavitations and stupor waves generated as a result of photo-acoustic and photograph-mechanical effect. PIPS provided complete removal of Ca(OH)2 from bogus grooves in direct root canals.8 Compared with PUI, PIPS showed pregnant higher removal of Ca(OH)two in the apical third of Weine Type II mandibular molars and isthmus in maxillary premolars.vii,9
The XP-endo Finisher (FKG Dentaire, La Chauxde-Fonds, Switzerland) was introduced to be used as a final step to improve root canal cleaning while conserving dentin. It is a size #25 non-tapered instrument made of MaxWire (Martensite-Austenite Electropolish Flex, FKG Dentaire). Considering of this new alloy, the shape of the XP-endo Finisher changes according to the temperature. In room temperature, the file is in its martensitic stage (M-phase) and stands direct. When exposed to the temperature within the root canal, it changes to its austenitic phase (A-phase) assuming a spoon shape of 1.5 mm depth in the final x mm of its length. The C shaped tip enables the file to admission and clean areas that other instruments might not have reached. The effectiveness of XP-endo Finisher in the removal of Ca(OH)2 intracanal medicament accept been investigated in premolar teeth, imitation internal resorption cavities, and artificial standardized groove.3,x,11
Boil (VDW, Munich, Germany) is a polyamide tip with a size 25 and 0.04 taper, which is powered at a loftier frequency of upwards to 6000 Hz by airscaler. The vibration produced is transferred to the polyamide tip, which is moved in an oscillating movement at high amplitude. According to the manufacturer, this iii-dimensional motion triggers cavitation and acoustic streaming attributed with higher cleaning efficiency.
Considering of the considerable heterogeneity in the methodologies, including types of root canal organization, types of Ca(OH)2, irrigation times, irrigation solutions, and their concentration and upshot measurements, the outcomes of in vitro studies comparing the effectiveness of these activated irrigation for removing calcium hydroxide from root canals were disharmonize. Regarding the apical region of artificial grooves in straight root canals, EDDY and PUI were significantly more constructive in the removal of calcium hydroxide than the XP-endo Finisher.6 Nevertheless, in fake internal root resorption cavities created by bur plus additional 20% nitric acid protocol, EDDY and XP-endo Finisher produced similar results and removed more than Ca(OH)2 than ultrasonic irrigation.12
Moreover, none of the described technique could completely clean Ca(OH)2 from the root culvert. The complexity of root canal system is a crucial factor that might influence the efficacy of Ca(OH)2 removal technique. Swimberghe and the colleagues assessed the influence of the canal curvature on the efficacy of sonically, ultrasonically, and laser activated irrigation in removing a biofilm-mimicking hydrogel (BMH) from false canal irregularities.13 In the forty° canal curvature model, the highest BMH removal was observed for ultrasonic group (99.9%), followed by Eddy (99.4%) and PIPS (96.eight%). In the lx° canal curvature model, ultrasonically activated irrigation removed 99.5%, followed by PIPS (82.5%) and EDDY (78.1%). The results indicated that canal curvature negatively affects the cleaning efficacy of different irrigation methods. Canals with double curvatures, also named as S-shaped canals, represent one of the nigh challenging canal configurations regarding preservation of the integrity of the root culvert beefcake and maintenance of the location of the upmost foramen.xiv The frequencies of S-shaped canals are reported to exist 30%–forty% and 35%–59% in the distobuccal root of maxillary molars and in the mesial root of mandibular molars, respectively.xv Currently, calcium hydroxide removal studies conducted in models with S-shaped root canals are scarce. Therefore, the purpose of this study was to compare v unlike irrigation techniques regarding the removal of calcium hydroxide from Due south-shaped root canals: conventional needle irrigation (CNI), passive ultrasonic activation (PUI), laser-activated irrigation using photon-induced photoacoustic streaming (PIPS), mechanical activation using the XP-endo Finisher (XP) and sonic activation using Eddy.
Materials and methods
Simulated canals
Eighty-4 Due south-shaped endo grooming blocks (Dentsply Maillefer, Ballaigues, Switzerland) with a taper of 0.02, an upmost diameter of 0.15 mm, and a length of sixteen mm were involved. The respective angles and radii of the curvatures were xxx° and five mm for the coronal curvature and twenty° and 4.5 mm for the upmost curvature.
Root culvert preparation
The patency of the canals was confirmed past passing a size ten G-file (Dentsply Maillefer) just beyond the apex. A glide path was created with ProGlider instrument (tip size/taper: #16/0.02) (Dentsply Maillefer) at 300 rpm and a torque of 4.0 Ncm to full working length (WL). Then, the root canals were prepared using ProTaper Gold NiTi instruments to size F2 (tip sizes/taper: #25/0.08). The files were powered by an electric motor (Ten-Smart plus, Dentsply Maillefer) with the manufacturer's recommendations as follows: SX at 250 rpm and 3 Ncm torque, S1 at 250 rpm and three Ncm torque, S2 at 250 rpm and one Ncm torque, F1 at 250 rpm and 1.five Ncm torque, and F2 at 250 rpm and ii Ncm torque. Throughout the period, 5 mL 3% NaOCl was used as an intracanal irrigant solution past using a 30-Chiliad side-cutting open up-ended needle (Navitip, Ultradent, Due south Jordan, UT, United states) after each instrument. After completion of the mechanical grooming, a final rinse was applied using 5 mL 17% EDTA followed by 5 mL three% NaOCl. The canals were stale with paper points.
Ca(OH)two placement
The apical foramen of each shaped canal was sealed with sticky wax to create a closed-terminate system. Then, all the root canals were filled with a water-based calcium hydroxide paste with barium sulfate (Well-Paste®, Lot.WS0N6100, Vericom, Gangwon-Practise, Korea) by using a size #25 Lentulo spiral (Dentsply Maillefer). The Ca(OH)two paste was not applied to the negative command (n = 2). Information technology was applied to the positive control (n = 2), but no removal procedure was carried out. Complete placement of Ca(OH)ii inside the canals was confirmed by radiographs. The root culvert orifice was sealed with a temporary filling material (3M™ Cavit™, Saint Paul, Minn, Usa). All specimens were finally stored in 37 °C at 100% relative humidity for 1 calendar week.
Ca(OH)2 paste removal
Later on the storage procedure, the surface of each block except the orifice was covered with opaque stickers to reduce the manual interference in the following process. Then, the coronal access was opened, and a size xv Chiliad file (Dentsply Maillefer) was introduced to the working length for Ca(OH)2 loosening and creating space for the irrigation tips. Afterwards, the samples were randomly divided into 5 groups (northward = sixteen) co-ordinate to the removal techniques: conventional needle irrigation (CNI) grouping, passive ultrasonic activation (PUI) group, photon-induced photoacoustic streaming (PIPS) grouping, XP-endo Finisher (XP) group, and EDDY group. 3% NaOCl acted equally irrigant. For each group, the volume and fourth dimension were standardized at 12 mL and 2 min, respectively.
For CNI group, a five-mL syringe with a 30-G side-cut open-ended needle (Navitip) was placed 2 mm brusque of the working length into the culvert, and in-and-out movements with an amplitude of 5 mm were performed; 3 mL NaOCl three%was applied over thirty southward. This was repeated 4 times, resulting in a total of two min of irrigation with a total of 12 mL irrigant.6
For PUI group, an endodontic irrigation tip IrriSafe® #20/0.00 (Satelec®, Acteon, Mérignac, France) was used with ultrasonic unit P5 Newtron® XS (Satelec®, Acteon) at power setting 5. The ultrasonic file was prebent in order to avoid wall contact.xiii The tip was inserted to 1 mm short of the working length into the canal, and in-and-out movements with an aamplitude of v mm were performed. Before each cycle of activation, three mL NaOCl iii% was applied to the root canal with a syringe. The irrigant was activated for 30s. Four applications were performed.
For PIPS group, an Er:YAG laser with a wavelength of 2940 nm (Fidelis AT, Fotona) was used with a fourteen-mm long, 300 μm diameter quartz laser tip. The laser parameters were pulse energy, 20 mJ; frequency, fifteen Hz; pulse duration, 50 μs; and energy density, 2.06 J/cmii with the light amplification by stimulated emission of radiation system water and air turned off.16 The tip was positioned at the culvert entrance, and remained stationary during activation. Before each cycle of activation, 3 mL NaOCl three% was practical to the root canal with a syringe. The irrigant was activated for 30s.17 Four applications were performed.
For XP group, the XP-endo Finisher NiTi file was powered by Ten-Smart plus motor at a speed of 800 rpm and a torque of one Ncm. The XP-endo Finisher file was placed one mm brusque of the working length, and in-and-out movements with an amplitude of 5 mm were performed. Earlier each cycle of activation, 3 mL NaOCl 3% was applied to the root canal with a syringe. The irrigant was activated for 30s. 4 applications were performed.
For EDDY group, a non-cutting polyamide size 25, 0.04 tip operated by an airscaler (Sonic Southward SS-M4, Shenghua Co.,Ltd., Guangzhou, Cathay) was used in the canals at 1 mm from the working length and used in an upward and down motility over five mm at maximum intensity (frequency 6000 Hz). Before each cycle of activation, iii mL NaOCl 3% was practical to the root culvert with a syringe. The irrigant was activated for 30s. 4 applications were performed.
Ten-ray test and evaluation
Any remaining Ca(OH)2 in the fake root canal was determined using periapical radiographs. Digital radiographs (CS2100 Intraoral X-ray Organisation, Carestream Health, Rochester, NY, USA) from the aforementioned angles (vertical and horizontal angles were parallel with the axial and sagittal planes respectively) were taken of each specimen and coded to prevent identification of the specimens.18 All exposures were standardized at 60 Kv, 7 mA, a movie-focus altitude of 10 cm.
Images were analyzed using Photoshop CC software program (Photoshop CC, Adobe, San Jose, CA, Us). The ane-mm incremental reference lines were positioned perpendicularly to the long centrality of the resin blocks. Thus, the Southward-shaped root canal was divided into three portions: points 0 to iii corresponded to the apical curve, points iii to 7 corresponded to the coronal curve, and points 7 to ten belonged to the straight portion of the canal (Fig. 1).19 Tow calibrated operators blinded to the groups independently evaluated the amount of the remaining Ca(OH)ii in each portion of the root canal using the following criteria: 0, empty culvert; 1, <50% of the culvert is filled with Ca(OH)ii; two, >50% of the canal is filled with Ca(OH)2; and iii, the canal is completely filled with Ca(OH)2 (Fig. 1).half dozen
Representative images of scores were showed. (A) Positive control (score 3). (B) Negative control (score 0). (C) The upmost curvature was empty (score 0). (D) Less than half of the apical curvature was filled with Ca(OH)2 remnants (score i). (E) More one-half of the apical curvature was filled with Ca(OH)2 remnants (score 2). (F) The complete apical curvature was filled with Ca(OH)2 remnants (score 3).
Statistical analysis
Statistical analysis of the data was done by using IBM SPSS xx Software (IBM SPSS Inc., Armonk, NY, United states of america). Inter-examiner agreement was analyzed by using the kappa test. The Shapiro–Wilk normality test was used to test the data distribution of Ca(OH)2 for the dissimilar groups and revealed a nonnormal data distribution. Subsequently, differences in Ca(OH)2 scores among the experimental groups were explored with Kruskal–Wallis examination followed by Dunn's mail hoc test with Bonferroni correction. The testing was performed at the 95% level of confidence (P < 0.05).
Results
The Cohen kappa value was 0.826 for inter-examiner agreement indicating expert reproducibility of the results.
All the experimental techniques achieved consummate clearance of Ca(OH)2 from the straight portion and coronal curve of the S-shaped root canal in 100% of cases (score = 0). The positive controls showed a score of 3, and the negative controls showed a score of 0 (Fig. 1).
However, none of the tested methods could completely make clean the Ca(OH)2 from the upmost curve. The results of Ca(OH)two removal scores of different removal techniques in the upmost curve were shown in Table 1. Fig. ii presented the distribution of the scores for the removal of Ca(OH)2 from the upmost bend. PUI, PIPS, XP and Boil removed significantly more Ca(OH)2 than CNI (P < 0.05), with no meaning differences among these four groups (P > 0.05) (Table 1). The complete clearance of Ca(OH)two from the apical curve (score 0) was observed in 75%, 62.5%, 56.three%, and 43.8% of cases of PUI, Boil, PIPS, and XP group, respectively. CNI was the least efficient method of Ca(OH)ii removal, leaving 12.v% of the apical curve completely covered with Ca(OH)2 (score 3), while none of the cases in the other iv groups received this score (Fig. 2).
Tabular array 1
The scoring results of Ca(OH)2 removal from the apical curve of the Due south-shaped root culvert.
| Group | Median | Interquartile range | Minimum | Maximum |
|---|---|---|---|---|
| CNI | 2.0a | one.0 | i.0 | three.0 |
| PUI | 0.0b | 0.75 | 0.0 | 1.0 |
| PIPS | 0.0b | ane.0 | 0.0 | two.0 |
| XP | 1.0b | 1.0 | 0.0 | 2.0 |
| EDDY | 0.0b | 1.0 | 0.0 | ii.0 |
The distribution of scores for the removal of Ca(OH)ii paste from the apical curvature of the S-shaped root culvert according to the experimental groups. CNI: conventional needle irrigation, PUI: passive ultrasonic activation, PIPS: photon-induced photoacoustic streaming, XP: XP-endo Finisher.
Discussion
The models previously developed to investigate Ca(OH)ii remnants in root canals include imitation internal root resorption cavity, standardized groove, faux curved root canals resin blocks and extracted human teeth with dissimilar blazon of root canal arrangement, for example C-shaped root canals, Weine Type Two systems, and and then on.5, half-dozen, seven,ten,20 According to the fluid dynamics theory, the pattern and effect of the fluid flow are largely dependent on the geometry of the container in which the fluid is located.21 Irrigation efficiency may be affected by apical preparation size, root canal taper and root culvert morphology.22, 23, 24 In the present report, the effectiveness of 5 irrigation techniques on Ca(OH)2 removal in S-shaped root canals were compared. A limitation of the present written report could be the in vitro blueprint with the utilize of simulated S-shaped root canals in resin blocks. Only on the other hand, the utilise of standardized root culvert is conducive to reduce the sampling error.20
In vitro studies accept used several methods to measure balance Ca(OH)two in root canals, such every bit directly visualization, digital microscopy, scanning electron microscopy, micro-computed tomography and periapical radiographs.v,12,18 The amount of remaining Ca (OH)2 in a culvert was calculated past measuring the area of the residues on the canal walls, or assessing the percentage of volume of residual Ca(OH)2 in the culvert. In the nowadays report, periapical radiographs were taken and a scoring method was used. The images were contrasted with the negative and positive control. The radiopacity image was recognized as residual Ca(OH)2 regardless of the intensity. Comparison radiographic projections is a adept way of reproducing clinical atmospheric condition. Positive correlation between stereomicroscope and radiographic analyses confirmed the validity of radiography to depict medicament removal.18 However, considering of the limitation of the sensitivity and the two-dimensional nature of radiographs, minuscule amounts of medicament were sometimes non detected in radiographs, while, sometimes the amounts of medicament were overestimated.18 This method tin only determine whether there is residual calcium hydroxide, but can non precisely quantify the amount of the remnants. The corporeality of remaining Ca(OH)2 was represented by the surface area occupied by the residues on the root canal epitome. In the present study, Ten-ray photography parameters were standardized to allow the remnant Ca(OH)two to exist imaged under the consistent conditions and to minimize the impact of 10-ray paradigm superimposition.
In this written report, all of the tested techniques resulted in highly effective removal of Ca(OH)2 from the straight portion and coronal curvature of the S-shaped root canal. This finding is in understanding with previous studies, which could be attributed to the larger diameter in these areas, exposing dentin to a higher volume of irrigants and making Ca(OH)2 removal easier.5,20 However, none of the protocols could completely remove Ca(OH)2 from the apical curvature. It remains hard for the current irrigation techniques to remove the intracanal medicaments from the apical part of the root culvert.5,seven,10 Consistent with previous studies, conventional needle irrigation was significantly less effective than all activation techniques. The flushing action of irrigants helps to remove organic and dentinal debris and microorganisms from the canal. Irrigants must be brought into direct contact with the entire canal area and specially with the apical portions of narrow root canals for optimal effectiveness.25 The flushing action created past syringe irrigation is relatively weak and dependent non only on the anatomy of the root canal system just likewise on the depth of placement and the diameter of the needle.26 xxx-M needle is the finest needle currently used in endodontic treatment with an external bore of 0.3 mm. Theoretically, in a directly root culvert with a grooming width of 0.25 mm, regardless of the taper of 0.06 or 0.08, the 30-G needle could easily be placed 1 mm from the noon. However, in the S-shaped root canal, because of the restriction of the double curves and the limitation of the elasticity of the needle, the xxx-G needle could merely exist placed 2 mm from the apex in the present study. Based on the result of a computational fluid dynamics report, it was suggested that irrigation needles should exist placed to within 1 mm from working length to ensure fluid commutation.23
In a systematic review of in vitro studies, ultrasonically activated irrigation was found to exist superior to syringe irrigation and upmost negative pressure irrigation regarding Ca(OH)2 removal, merely insufficient show was found to indicate its superiority over the other irrigation techniques such every bit sonically activated irrigation, the Self-Adjusting File, (ReDent-Nova, Ra'anana, Israel) and the RinsEndo, (D€urr Dental, Bietigheim, Germany).27 In the present study, PUI showed a college Ca(OH)two removal from the upmost bend of the S-shaped root culvert, followed past EDDY, PIPS and XP-Endo finisher. 75% samples in PUI group were completely clean. The sonic or ultrasonic agitation causes the generation of streaming motion with a thin boundary layer, which later generates a large shear stress on the surface of the instrument and root canal wall. The ultrasonic agitation of the instrument also generates a large-scale streaming design. The streaming flow at the end of the instrument can penetrate into the region of spent resident irrigant located at the apical portion of the root culvert organization and it is this that is likely to play an of import function in debriding the apical anatomy.28 Moreover, in a curved root canal, EDDY undergoes elastic deformation and is under tension. This will dampen its 3-dimensional motion, and reduce the oscillation in the irrigant. The more astringent the curve, the greater the dampening effect.13 In Due south-shaped root canal, EDDY underwent a more severe deformation due to the double curvatures with different management, which may further impede the oscillation. The contact between the ultrasonic tip and the root culvert wall has been shown to significantly decrease PUI efficacy. Therefore, pre-bending the ultrasonic tip facilitated the placement of the tip in S-shaped root culvert past avoiding the wall contact. Thus, the dampening upshot on EDDY's oscillation and pre-bending the ultrasonic tip may explicate the better result of PUI than Boil.
Among the 4 agitation techniques, Xp-endo Finisher showed a relatively less efficiency. The way of activity of Xp-endo Finisher is based on its rotation at 800 rpm and the concrete contact between the rotating instrument and the culvert walls. As a outcome, the irrigant is agitated and the Ca(OH)two is removed from root canal. Information technology was reported that prolonged activation of XP-endo Finisher showed a superiority over the PUI in removing the Ca(OH)ii from the apical third in single-rooted teeth.29
Previously published studies on Ca(OH)2 removal involving PIPS remarked that the use of PIPS improved the results. The cleaning efficiency of PIPS was equal to or better than that of PUI. They also performed better than EndoActivator, XP-endo Finisher file, and CanalBrush and CNI.vii, 8, 9,30 In the present written report, PIPS removed relatively lower Ca(OH)2 than PUI and EDDY, yet the differences were not statistically pregnant. To appointment, no studies accept been reported on the cleaning efficacy of PIPS in Due south-shaped canals. Swimberghe'due south results demonstrated that the canal curvature does influence the efficacy of PIPS, although the deviation in debridement between the ii curvature models (xl° and threescore°) was small.13 In moderately curved canals, PIPS caused college average fluid speeds when compared to PUI, both close and distant from the instrument.31 However, there is a lack of more detailed studies of the PIPS mechanism of action in more challenging root canal configurations like S-shaped root culvert or severely curved root canal. The touch of canal curvature on the irrigant catamenia and the cleaning efficacy of the current irrigation activation techniques deserves farther investigation to define the all-time strategy for the consummate cleanliness of the root canal walls.
In conclusion, complete removal of calcium hydroxide from the apical curvature of S-shaped root canals remained as a challenge for any of the tested techniques. CNI was significantly less constructive compared with all other activation techniques. PUI seemed to exist more than effective than other activation techniques, although no statistically pregnant departure was plant among the 4 activation techniques. No divergence was found in the coronal section.
Declaration of competing interest
The authors accept no conflict of interest relevant to this article.
Acknowledgments
This piece of work was supported past the joint construction project of the medical science and technology research plan of Henan Province (grant no. LHGJ20190197).
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Manufactures from Journal of Dental Sciences are provided here courtesy of Association for Dental Sciences of the Democracy of China
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8739234/
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