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Article

Evaluation of Fracture Strength of Roots to Determine the Duration Limit of Activated Ethylene Diamine Tetraacetic Acid Irrigation for Intracanal Calcium Hydroxide Dressing Removal In Vitro

by
Sena Kolunsağ Özbek
1,
Sena Kaşıkçı
1,* and
Olcay Özdemir
2
1
Department of Endodontics, Faculty of Dentistry, Kocaeli University, 41190 Kocaeli, Türkiye
2
Department of Endodontics, Faculty of Dentistry, Karabük University, 78050 Karabük, Türkiye
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(13), 5931; https://doi.org/10.3390/app14135931
Submission received: 28 May 2024 / Revised: 27 June 2024 / Accepted: 28 June 2024 / Published: 7 July 2024
(This article belongs to the Section Applied Dentistry and Oral Sciences)
Browse Figures
Versions Notes

Abstract

:
This study evaluated the effect of the use of EDTA solution at various intervals to remove intracanal calcium hydroxide medication on fracture resistance. One hundred and one extracted lower premolar teeth were randomly allocated into one control group (n = 5), two main experimental groups (CH(+), with calcium hydroxide dressing, and CH(−), without calcium hydroxide dressing), with four subgroups (EDTA intervals: 1 min, 3 min, 5 min, 10 min, n = 12). Ready-to-use injectable calcium hydroxide was used for the samples in the four CH(+) subgroups, and the samples were kept in an incubator at 37 °C and 100% humidity for seven days. All samples (CH(+), CH(−)) were irrigated with 17% EDTA, which was accompanied by activation with EndoActivator for 1, 3, 5, and 10 min, and then rinsed with 2.5% NaOCl in a standardized manner. The obturation was conducted using the warm obturation technique; experiments were conducted with a universal testing device, and their fracture strength was recorded. Compliance with the normal distribution was examined with ±2 skewness coefficients. Two-way ANOVA, Tukey’s, one-way ANOVA, and Dunnett’s tests were used for statistics (p < 0.050). A statistically significant difference was found between the mean values of the force between the groups (p = 0.009). The mean strength of the tooth at fracture that CH(−) was 401.7, CH(+) was 335.35. There was no statistically significant difference between the mean values of the forces according to time intervals (p = 0.387). While there was no significant difference among the experimental groups (p = 0.229), the mean fracture strength of the negative control group was found to be significantly higher (p < 0.001). The highest fracture resistance was observed in the nonprepared group. Irrigation with EDTA for up to 5 min showed more acceptable fracture resistance results than the other groups. Using calcium hydroxide significantly and negatively affected the root strength.

1. Introduction

Tooth fracture is one of the most common reasons for tooth loss, after caries and periodontal disease. Additionally, fractures of teeth with root canal treatment are common occurrences in clinical practice [1]. Although the risk factors have not been fully defined [2], it was reported that the microstructure of dentin affects how the fracture line extends [3]. Vertical root fractures, described as longitudinal fractures extending parallel to the axis of the root of the tooth, have received attention due to their irremediable prognosis and significantly increased incidence rate after root canal treatment [4]. Several studies have highlighted root canal treatment as an important etiological factor in the vertical fracture of teeth [1,4,5,6]. The main factor is loss of vitality, which highly relevant due to its biochemical effects on dentin–pulp bonding, which provides a natural monoblock structure of the tooth, the prevalence of which is significantly higher in endodontically treated than in vital teeth, resulting in a loss of structural integrity [5]. Although the loss of vitality is considered as the main predisposing factor, root canal treatment procedures like the removal of excess hard tissue during access cavity preparation, especially from pericervical dentin, as well as extensive preparation for root canal instrumentation, long-term exposure to medication, and chelator irrigation solutions, are the other predisposing factors for the formation of microcracks/distortions of structure corresponding to vertical root fractures [2,5,7,8].
Calcium hydroxide (Ca(OH)2, CH) is widely used in endodontics as an intracanal medication, a pulp capping, or as a component of some root-canal-filling materials [9,10,11]. It is frequently used to eliminate bacteria and reduce inflammation in cases where the root canal treatment cannot be completed in a single visit [9,12]. It also supports hard tissue formation by activating root canal mineralization [13]. Despite the benefits of CH, its use between appointments for root canal treatment has some disadvantages. Failure to properly remove the medication from the dentin surface or irregularities before obturation may affect the sealing of the root canal filling [14,15,16]. Residual CH not only negatively affects the physical properties of root canal filling materials, but also blocks the bonding of the sealers to the dentinal walls [16,17]. These occurrences may reduce the success of the root canal filling and reduce the resistance of the tooth to forces. Therefore, CH should be effectively removed from the root canal system before obturation.
Different irrigation solutions, such as saline, sodium hypochlorite (NaOCl), ethylene diamine tetraacetic acid (EDTA), and citric acid and their combinations, have been used to remove CH from the root canal system [16]. However, using the fundamental solution of root canal treatment (NaOCl) alone is insufficient to remove CH [18]. The combined use of EDTA and NaOCl for CH removal is more effective than using the solutions separately. In addition, by increasing the effectiveness of the solution by applying it with an activation method, the solution can reach intracanal irregularities and remove the medication more effectively [19,20]. The removal of the medicated dressing and both components of the smear layer and irrigation of the root canal system using 17% EDTA followed by NaOCl are recommended [21,22]. The effectiveness of EDTA is directly proportional to the duration of its use. However, as the contact time with the root dentinal walls increases, the selator solution becomes more likely to cause erosion of the organic–inorganic component of the dentin [22]. The deterioration of dentin may weaken the structure of the tooth and affect its fracture resistance and strength.
Due to being a calcium-binding chelating agent, EDTA dissolves the inorganic component of the smear layer [23,24,25]. In this context, in addition to mechanical removal, EDTA is effective in chemical removal by neutralizing calcium ions by binding them to form soluble calcium chelates in the CH structure [18,23,24]. On the other hand, since CH creates a mechanical barrier on the dentin surface and calcium ions in the CH structure when bound to EDTA, the null hypothesis in this study is based on the possibility that the presence of CH may passivate the solution and, as such, may require a longer time to affect the dentin surface and the removal of excess smear layer. Therefore, the null hypothesis in this study is that the duration of EDTA exposure does not affect the fracture resistance of teeth. Thus, this study aimed to assess the limit of the duration of activated EDTA irrigation by evaluating the fracture strength with/without an intracanal CH dressing in vitro.

2. Materials and Methods

The main methods in this experimental laboratory study were developed according to the Preferred Reporting Items for Laboratory Studies in Endodontology (PRILE) 2021 guidelines (Figure 1) [26]. The ethics committee approval required for this study was obtained from the Kocaeli University Non-Interventional Ethics Committee (KÜ GOKAEK-2023/11.21 project No.: 2023/189).

2.1. Sample Size Calculation

The sample size was calculated using the software G*Power version V3.1.9.6 (Kiel University, Kiel, Germany) based on data obtained from a previous study [27]. It revealed a minimum size of at least 12 in each group with an α error of 0.05.

2.2. Sample Selection and Eligibility

With the patients’ consent to utilize the extracted teeth, one hundred and one carie-free samples, extracted from patients aged 17–30 years for periodontal or orthodontic reasons, with a single straight root canal, closed root apices, similar shape, and mandibular premolar teeth, were selected. The remnants of tissue and calculus were removed mechanically with an ultrasonic device (Woodpecker DTE-D600 LED, Guilin Woodpecker Medical Instrument Co., Ltd., Guilin, Guangxi, China). The presence of a single apical foramen and a single root canal were determined using periapical radiography with different angles and under a dental operating microscope visually (S100/OPMI pico, Carl Zeiss Meditec AG, Oberkochen, Germany). Teeth with curved root formation, anatomical variations, internal or external resorption, crack or fracture lines, or immature apical formation were excluded from the study. The same length of root samples (13 mm) was obtained after removing the crowns with a diamond disc over a 2-mm cementoenamel junction (Figure 2a). Samples that had lingual and buccal thickness at the coronal section of the root dentin of 1.5–2 mm were included in the study. All samples were examined using fiberoptic lighting and a dental operating microscope to check for cracks or craze lines within the root portions.

2.3. Negative Control Group

The allocation of five teeth for a negative control was conducted in a randomized manner. These five samples were not subjected to any procedure other than decoronation, including apical patency, root canal preparation, irrigation procedure, and obturation.

2.4. Preparation of the Samples

The patency of the root canal was checked with a #10 K type hand file (Dentsply Maillefer, Ballaigues, Switzerland). The working length of teeth was determined as 12 mm by subtracting 1 mm from the actual length. Except for the negative control group (n = 5), the root canals were instrumented with a CM-Blue NiTi rotary file system up to 30/0.04 (EndoArt, Inci Dental, Istanbul, Türkiye), following the manufacturer’s instructions. During the shaping procedure, the root canals were irrigated with 1 mL of 2.5% NaOCl via a lateral perforated irrigation tip (Kerr Endodontics, Orange, CA, USA) after each instrument. After the preparation, the last irrigation before the harvest of the samples was performed with 2 mL of distilled water. All samples were kept in physiological saline throughout the experimental period.

2.5. Allocation of Groups and Experimental Setup

The selected and prepared lower premolar teeth were allocated randomly into two main groups according to whether medication (CH (+), CH (−)) was applied or not, and eight subgroups (n = 12), according to the duration of EDTA application (1 min, 3 min, 5 min, 10 min) by a computer-assisted randomization program (Research Randomizer Program, version 4.0; Geoffrey C. Urbaniak & Scott Plous, Lancaster, PA available at http://www.randomizer.org) by a blind operator.

2.5.1. Groups with Calcium Hydroxide Dressing

Injectable, ready-to-use CH (Diapaste, DiaDent Europe B.V., Almere, The Netherlands) was placed in the root canals of the teeth in the subgroups (CH (+), 1 min, 3 min, 5 min, and 10 min). The medication dressing in the root canal was confirmed radiographically (Figure 2b). The dressing of samples that appeared inadequate radiographically was repeated. The coronal access of the samples was closed with cotton pellets and 1–2 mm thick temporary filling material (Cavit, Nucavfil PSP Dental Co. Ltd., Belvedere, Kent, UK). The samples were kept in an adjustable incubator (100% humidity at 37 °C) for seven days.

2.5.2. Final Irrigation Procedure

In all groups (CH (+), CH (−)), 17% EDTA irrigation was applied with a 30 G lateral perforated needle tip and activated with EndoActivator (Dentsply-Sirona, Ballaigues, Switzerland). The periods in the groups (1 min, 3 min, 5 min, and 10 min) were conducted as follows: 30 s of needle irrigation and 30 s of activation; 1 mL of EDTA solution was used per minute. Finally, the root canals were rinsed with 2 mL 2.5% NaOCl. Before proceeding with the obturation phase, all root canals were dried with sterile paper points (EndoArt, Inci Dental, Istanbul, Türkiye).

2.5.3. Obturation of Root Canals

The tug-back feeling was checked by placing the resin-based root canal sealer (ADSeal, Meta Biomed, Cheongju-si, Republic of Korea) coated master cone 30/0.04 (Endoart, Inci Dental, Istanbul, Türkiye) following the working length. A Fast Pack (Eighteeth Medical, Changzhou, China) device was heated, and the gutta-percha was down-packed to 3–4 mm from the working length. After the heated material in the apical region was condensed using a plugger, the root canals were cartridge-dispensed warm gutta-percha obturated with a Back Fill device (Eighteeth Medical, Changzhou, China) to the cementoenamel junction and compacted with a vertical force using a handpiece. The quality of the root canal fillings was confirmed with periapical radiographs (Figure 2c). The cavity chamber of the samples was cleaned to remove the excess sealer and obturation material. A dentin-bonding agent (Solare Universal Bond, GC, Tokyo, Japan) was applied to all samples, and the cavity was sealed with light-cured nanohybrid flowable composite resin (Fusion Flo, Prevest DenPro, Jammu, India). The samples were stored at 37 °C in 100% humidity in an incubator for 14 days to allow the obturation material to harden completely.

2.6. Preparation of Models and Fracture Strength Testing

All samples were immersed 8 mm from the apex in molten wax to obtain a 0.2–0.3 mm thickness layer. They were then embedded in autopolymerizing acrylic resin. After polymerization, samples were removed, and the wax was cleaned. The roots were covered with the second silicon-type impression material (Zetaplus, Zhermack, Italy) and mounted in the pre-spaced acrylic resin to imitate the periodontal ligament.
A load was applied to the samples at a right angle at a 1 mm/min speed with the steel tip of the Instron Universal Testing Device (Figure 2d,e) [28]. The load application process continued until fracture occurred in the samples. The force values at the time of fracture were meticulously recorded in Newton (N) (Figure 3).

2.7. Statistical Analysis

Data were analyzed in IBM SPSS V23. Compliance with normal distribution was examined with ±2 skewness and kurtosis coefficients. Two-way ANOVA was used to compare data with normal distribution by group and time, and multiple comparisons were examined with the Tukey test. A one-way ANOVA test was used to compare normally distributed data according to three or more groups, and multiple comparisons were examined with the Dunnet test. Analysis results were presented as mean ± standard deviation and median (minimum–maximum). The significance level was taken as p < 0.050.

3. Results

Regardless of time, a statistically significant difference was obtained between the average values of the forces at the moment of tooth fracture according to the groups (p = 0.009). While the average force in the group without CH dressing was 401.7, in the group with CH dressing, it was found to be 335.35. No statistically significant difference was observed between the average values of the forces according to time, regardless of group (p = 0.387). According to the interaction between group and time, no statistically significant difference was found between the average fracture resistance values (p = 0.229). The average force in groups that CH(−)-1 min was 392.35, CH(−)-3 min was 421.43, CH(−)-5 min was 449.19, CH(−)-10 min was 343.83, CH(+)-1 min was 299.14, CH(+)-3 min is 369.15, CH(+)-5 min was 319.38, CH(+)-10 min was 353.73, and the group of negative control was 623.96. The negative control group differed from other experimental groups (p < 0.001) (Table 1 and Table 2). The average strength values of the groups are presented in Figure 4.

4. Discussion

This study protocol aimed to determine the time-dependent effects of EDTA on the fracture strength of the tooth. In addition, the chemical interactions formed during the procedures were also considered for the design of the study hypothesis, and all possible clinical variations were included in the cause–effect relationship to be obtained, such as with or without CH dressing. The null hypothesis of this study focused on the possibility that the solution may passivate by the presence of CH and may require a longer time to affect the dentin surface; the null hypothesis was partially accepted based on the CH group’s statistical analysis.
For this study, mandibular premolar teeth were preferred due to their high exposure to functional chewing forces in the oral cavity [29,30]. Premolar teeth are exposed to more vertical than lateral forces during function so a load was applied vertically to the model to simulate occlusal forces [31]. Lin et al. reported that lower tapered preparation strengthens the fracture resistance of the mandibular premolar tooth and emphasizes the loss of pericervical dentine structure [32]. Coronal preflaring is necessary to enable clear access into the middle and apical thirds of root regions, facilitate irrigation solution circulation, and allow subsequent engine-driven endodontic files to prepare the apical section with less frictional force; however, it causes lead dentinal defects [33]. Although the teeth were decoronated without coronal preflaring and the preparation of root canals was as minimally invasive as possible (by using a 0.04 tapered file system) in this study, it should be mentioned that root canal preparation decreased the root resistance of fracture, based on the study results. Compared to previous reports [1,5,6,34], when the results of this study were evaluated in general, it was observed that the highest fracture resistance belonged to the group which had not undergone any treatment procedure. Therefore, it is imperative to emphasize maintaining tooth vitality if possible and avoiding unnecessary root canal treatment in teeth that is not indicated.
Chelation agents support the irrigation process but may cause physicochemical changes on dentin tissue, such as roughness, microhardness, and surface structure [35,36,37]. Although the increase in surface roughness achieved in endodontic procedures may provide clinical benefits in terms of micromechanical bonding of obturation materials to root dentin, the microhardness of dentin and the mineral composition changes may affect the resistance of the root structure against such forces [5,38]. The effects of agents on dentin have been evaluated by various types of experimental studies in vitro [21,22,27,28,35,36,38]; however, it may be stated that the primarily interpretive contribution of our research to clinical practice is its evaluation of the effects on tooth resistance and strength. Therefore, this study aimed to examine the impact of chelator agents with activation on the dentin surface in the best way possible to mimic clinical impact, i.e., via fracture resistance tests. However, although the CH group had the lowest fracture resistance compared to the other groups, no significant difference was found in EDTA application times when the groups with and without CH application were evaluated individually.
Poudyal et al. evaluated the effectiveness of applying 17% EDTA solution for different periods (1, 3, 5, and 7 min) in terms of removing the smear layer. They observed that a 1-min EDTA application was insufficient to remove it completely. However, 7 min of EDTA exposure successfully removed the smear layer with a minimal change on the dentin surface [39]. According to the present results, although no statistically significant difference was found among the 1, 3, and 5-min EDTA application groups on the non-subjected CH group, the raw values indicated a tendency for fracture resistance to increase up to 5 min. This situation may be explained by the fact that the smear layer is removed more effectively as the EDTA application time increases by up to 5 min. Consequently, the filling materials bond better to the dentin walls.
The duration of intracanal medication application varies depending on the reason for its use. While this period is shorter for canal disinfection between appointments, it can take up to 11 weeks for apexification or regenerative treatments [40]. In routine endodontic treatment, it is known that CH shows its effect in 1–4 weeks [41]. In this study, the CH-placed samples were kept in an incubator (37 °C and 100% humidity) for one week, representing the time between two appointments in the oral environment for the most effective minimum duration. Yassen et al. stated that CH causes significant collagen degradation in superficial root dentin, even after only one week of application [42]. Collagen is responsible for hard tissue durability, and prolonging the residence time of CH in the root canal reduces the fracture resistance of the tooth [43,44]. In this study, the fracture resistance of the CH-applied group was found to be statistically significantly lower compared to the fracture resistance of the non-subjected CH group. Therefore, it can be stated that CH affects the structure of dentin, even in a short time.
Resistance decreased the root structure after root canal preparation, but it can be strengthened after obturation [45]. Gutta-percha and root canal sealers are the most commonly used filling materials for root canal obturation. However, the elastic modulus of gutta percha is very low compared to dentin. On the other hand, root canal sealers increase resistance to fracture by bonding to the dentin surface and strengthening the remaining tooth structure [46,47]. This situation can be explained by the effective penetration of the sealer into the dentinal tubules and its ability to bind to the root dentin [45]. Various types of root canal sealers are used for root canal treatment. Epoxy resin-based root canal filling pastes are widely used for obturation due to the lack of polymerization shrinkage, good adhesion abilities, and antimicrobial properties [48]. In this context, in this study, warm obturation was applied with a resin-based root canal sealer to prevent the material from being negatively affected by temperature and to increase its fluidity.
Additionally, the root canal obturation material was allowed two weeks to harden entirely before the fracture test. The authors think that possible CH residues that could not completely be removed from the root canal may have continued to affect the dentin structure, as well as the durability of the tooth. Unfortunately, this is also a fact of an unpredictable and inevitable clinical condition.
Beyond its erosive effect on dentin, EDTA also affects the removal of the smear layer and CH. Such multifactorial conditions within the root canal system may have contributed to the lack of statistically significant differences observed in this study. Additionally, as the duration of EDTA usage increases up to a certain point, it effectively removes the smear layer. This situation can enhance the penetration of the obturation material into the dentin tubules, increasing the tooth’s fracture resistance. Due to the multifactorial nature of fracture resistance, its evaluation can be challenging. Therefore, it is recommended that future studies correlate fracture resistance with factors such as dentin penetration, the presence of the smear layer, and the remaining CH.
In the results of Poudyal et al., no statistically significant difference was found in the smear removal efficacy between the 3 and 5-min EDTA application groups. Additionally, they found no statistical difference in the degree of erosion on the dentin surface with 1, 3, 5, and 7 min of application [39]. The lack of a significant difference in our results when associating fracture resistance with dentin erosion and residual smear layer appears consistent with this study.
When conducting a comparative study, it is crucial to standardize all the parameters except the variable that will focus to be tested. Excluding limitations for standardization in experimental setups also creates some limitations in itself in terms of reflecting the clinical conditions sufficiently. One of the limitations of this study was the removal of the crowns of the samples. Although this process was performed to standardize the samples, it should be remembered that the residual structure of the tooth, its coronal restoration, and occlusal and parafunctional habits affect the fracture resistance of root canal-treated teeth [2,4]. Additionally, since the study was conducted under in vitro conditions, it cannot fully reflect intraoral conditions. Since vertical root fractures are of multifactorial origin, it is recommended that study designs be conducted to evaluate the correlation between other factors, CH, and irrigation protocols. Further studies are required to better understand the limitations and achievements of CH dressing side effects and the clinical impact of the results.

5. Conclusions

All root canal treatment procedures affect root strength, even if narrow files are used. The highest fracture resistance was observed in the nonprepared group. According to the present results, although no statistically significant difference was found among the groups, there was an observed tendency whereby fracture resistance appeared to increase with EDTA application up to 5 min. However, this tendency was not statistically significant. Using CH significantly negatively affected the root strength.

Author Contributions

Conceptualization, O.Ö.; Data curation, S.K.; Formal analysis, S.K.Ö. and S.K.; Methodology, S.K.Ö., S.K. and O.Ö.; Software, S.K.; Supervision, O.Ö.; Validation, S.K.Ö. and S.K.; Writing—original draft, S.K.Ö., S.K. and O.Ö.; Writing—review & editing, S.K. and O.Ö. All authors have read and agreed to the published version of the manuscript.

Funding

The authors declare that no funding source is related to this study.

Institutional Review Board Statement

Ethics committee approval required for the study was obtained from the Kocaeli University Non-Interventional Ethics Committee (KÜ GOKAEK-2023/11.21 project No.: 2023/189).

Informed Consent Statement

Informed consent was obtained from all subjects and/or their legal guardian(s).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Kishen, A. Mechanisms and risk factors for fracture predilection in endodontically treated teeth. Endod. Top. 2006, 13, 57–83. [Google Scholar] [CrossRef]
  2. Haupt, F.; Wiegand, A.; Kanzow, P. Risk Factors for and Clinical Presentations Indicative of Vertical Root Fracture in Endodontically Treated Teeth: A Systematic Review and Meta-Analysis. J. Endod. 2023, 49, 940–952. [Google Scholar] [CrossRef] [PubMed]
  3. Jaganathan, V.; Kumar, R.; Nawal, R.R.; Talwar, S. Comparison of Dentin Microstructure and Its Correlation to the Direction of Fracture Line in Mandibular Molars of Young and Older Individuals: In Vitro Study. J. Endod. 2023, 49, 1508–1513. [Google Scholar] [CrossRef] [PubMed]
  4. Zhou, Y.; Hu, Z.; Hu, Y.; Gao, A.; Pan, X.; Tang, R.; Lin, Z. Patterns of stress distribution of endodontically treated molar under different types of loading using finite element models—The exploring of mechanism of vertical root fracture. J. Mech. Behav. Biomed. Mater. 2023, 144, 105947. [Google Scholar] [CrossRef] [PubMed]
  5. Patel, S.; Bhuva, B.; Bose, R. Present status and future directions: Vertical root fractures in root filled teeth. Int. Endod. J. 2022, 55, 804–826. [Google Scholar] [CrossRef]
  6. Liao, W.C.; Tsai, Y.L.; Wang, C.Y.; Chang, M.C.; Huang, W.L.; Lin, H.J.; Liu, H.C.; Chan, C.P.; Chang, S.H.; Jeng, J.H. Clinical and Radiographic Characteristics of Vertical Root Fractures in Endodontically and Nonendodontically Treated Teeth. J. Endod. 2017, 43, 687–693. [Google Scholar] [CrossRef]
  7. Plotino, G.; Grande, N.M.; Isufi, A.; Ioppolo, P.; Pedullà, E.; Bedini, R.; Gambarini, G.; Testarelli, L. Fracture Strength of Endodontically Treated Teeth with Different Access Cavity Designs. J. Endod. 2017, 43, 995–1000. [Google Scholar] [CrossRef]
  8. Batur, Y.B.; Erdemir, U.; Sancakli, H.S. The long-term effect of calcium hydroxide application on dentin fracture strength of endodontically treated teeth. Dent. Traumatol. 2013, 29, 461–464. [Google Scholar] [CrossRef] [PubMed]
  9. Ordinola-Zapata, R.; Noblett, W.C.; Perez-Ron, A.; Ye, Z.; Vera, J. Present status and future directions of intracanal medicaments. Int. Endod. J. 2022, 55, 613–636. [Google Scholar] [CrossRef]
  10. Özdemir, O.; Kopac, T. Cytotoxicity and biocompatibility of root canal sealers: A review on recent studies. J. Appl. Biomater. Funct. Mater. 2022, 20, 22808000221076324. [Google Scholar] [CrossRef]
  11. Pedano, M.S.; Li, X.; Yoshihara, K.; Landuyt, K.V.; Van Meerbeek, B. Cytotoxicity and bioactivity of dental pulp-capping agents towards human tooth-pulp cells: A systematic review of in-vitro studies and meta-analysis of randomized and controlled clinical trials. Materials 2020, 13, 2670. [Google Scholar] [CrossRef] [PubMed]
  12. Mergoni, G.; Ganim, M.; Lodi, G.; Figini, L.; Gagliani, M.; Manfredi, M. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst. Rev. 2022, 12, CD005296. [Google Scholar] [CrossRef] [PubMed]
  13. Mizuno, M.; Banzai, Y. Calcium ion release from calcium hydroxide stimulated fibronectin gene expression in dental pulp cells and the differentiation of dental pulp cells to mineralized tissue forming cells by fibronectin. Int. Endod. J. 2008, 41, 933–938. [Google Scholar] [CrossRef] [PubMed]
  14. Usta, S.N.; Erdem, B.A.; Gündoğar, M. Comparison of the removal of intracanal medicaments used in regenerative endodontics from root canal system using needle, ultrasonic, sonic, and laser-activated irrigation systems. Lasers Med. Sci. 2024, 39, 27. [Google Scholar] [CrossRef]
  15. Usta, S.N.; Eymirli, A.; Arias-Moliz, M.T. Evaluation of the removal of 2-Hydroxyisocaproic acid from the root canal and its effect on the bond strength of MTA. Aust. Endod. J. 2023, 49, 311–317. [Google Scholar] [CrossRef]
  16. Tavella E Silva, N.C.; Gibin, J.T.; Rivera, I.C.M.M.; Rached Junior, F.J.A.; Leoni, G.B.; Raucci-Neto, W. Calcium hydroxide paste removal strategies and bond strengths of epoxy- and silicate-based sealers. Aust. Endod. J. 2021, 47, 236–244. [Google Scholar] [CrossRef] [PubMed]
  17. Guiotti, F.A.; Kuga, M.C.; Duarte, M.A.; Sant’Anna, A.J.; Faria, G. Effect of calcium hydroxide dressing on push-out bond strength of endodontic sealers to root canal dentin. Braz. Oral Res. 2014, 28, 1–6. [Google Scholar] [CrossRef]
  18. Nandini, S.; Velmurugan, N.; Kandaswamy, D. Removal Efficiency of Calcium Hydroxide Intracanal Medicament With Two Calcium Chelators: Volumetric Analysis Using Spiral CT, An In Vitro Study. J. Endod. 2006, 32, 1097–1101. [Google Scholar] [CrossRef]
  19. Moon, W.; Chung, S.H.; Chang, J. Sonic irrigation for removal of calcium hydroxide in the apical root canal: A micro-CT and light-coupled tracking analysis. PLoS ONE 2022, 17, e0268791. [Google Scholar] [CrossRef]
  20. Shi, L.; Wu, S.; Yang, Y.; Wan, J. Efficacy of five irrigation techniques in removing calcium hydroxide from simulated S-shaped root canals. J. Dent. Sci. 2022, 17, 128–134. [Google Scholar] [CrossRef]
  21. Yamada, R.S.; Armas, A.; Goldman, M.; Lin, P.S. A scanning electron microscopic comparison of a high volume final flush with several irrigating solutions: Part 3. J. Endod. 1983, 9, 137–142. [Google Scholar] [CrossRef] [PubMed]
  22. Calt, S.; Serper, A. Time-Dependent Effects of EDTA on Dentin Structures. J. Endod. 2002, 28, 17–19. [Google Scholar] [CrossRef] [PubMed]
  23. van der Sluis, L.W.; Wu, M.K.; Wesselink, P.R. The evaluation of removal of calcium hydroxide paste from an artificial standardized groove in the apical root canal using different irrigation methodologies. Int. Endod. J. 2007, 40, 52–57. [Google Scholar] [CrossRef] [PubMed]
  24. Violich, D.R.; Chandler, N.P. The smear layer in endodontics—A review. Int. Endod. J. 2010, 43, 2–15. [Google Scholar] [CrossRef]
  25. da Silva, J.M.; Silveira, A.; Santos, E.; Prado, L.; Pessoa, O.F. Efficacy of sodium hypochlorite, ethylenediaminetetraacetic acid, citric acid and phosphoric acid in calcium hydroxide removal from the root canal: A microscopic cleanliness evaluation. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2011, 112, 820–824. [Google Scholar] [CrossRef] [PubMed]
  26. Nagendrababu, V.; Murray, P.E.; Ordinola-Zapata, R.; Peters, O.A.; Rôças, I.N.; Siqueira, J.F.; Priya, E.; Jayaraman, J.; Pulikkotil, S.J.; Camilleri, J.; et al. PRILE 2021 guidelines for reporting laboratory studies in Endodontology: A consensus-based development. Int. Endod. J. 2021, 54, 1482–1490. [Google Scholar] [CrossRef] [PubMed]
  27. Ulusoy, Ö.İ.; Genç Şen, Ö.; Zeyrek, S.; Kaya, M.; Paltun, Y.N. Effect of final irrigation protocols on the fracture resistance of roots with varying dentine thickness. Eur. J. Oral Sci. 2021, 129, e12769. [Google Scholar] [CrossRef]
  28. Uzunoglu, E.; Aktemur, S.; Uyanik, M.O.; Durmaz, V.; Nagas, E. Effect of ethylenediaminetetraacetic acid on root fracture with respect to concentration at different time exposures. J. Endod. 2012, 38, 1110–1113. [Google Scholar] [CrossRef]
  29. Wu, M.K.; van der Sluis, L.W.; Wesselink, P.R. Comparison of mandibular premolars and canines with respect to their resistance to vertical root fracture. J. Dent. 2004, 32, 265–268. [Google Scholar] [CrossRef]
  30. Kakani, A.K.; Veeramachaneni, C.; Tummala, M.; Majeti, C.; Ravi, R.; Chaudhari, W.A. Relationship between the Depth of Penetration and Fracture Resistance of Various Sealers: A Comparative Study. J. Contemp. Dent. Pract. 2021, 22, 34–38. [Google Scholar]
  31. Ayrancı, F.; Ayrancı, L.B.; Özdoğan, A.; Özkan, S.; Peker, M.Ö.; Aras, M.H. Resistance to vertical root fracture of apicoected teeth using different devices during two root canal irrigation procedures. Lasers Med. Sci. 2018, 33, 1685–1691. [Google Scholar] [CrossRef] [PubMed]
  32. Lin, G.S.S.; Singbal, K.P.; Noorani, T.Y.; Penukonda, R. Vertical root fracture resistance and dentinal crack formation of root canal-treated teeth instrumented with different nickel–titanium rotary systems: An in-vitro study. Odontology 2022, 110, 106–112. [Google Scholar] [CrossRef] [PubMed]
  33. Arslan, H.; Karataş, E.; Capar, I.D.; Özsu, D.; Doğanay, E. Effect of ProTaper Universal, Endoflare, Revo-S, HyFlex Coronal Flaring Instruments, and Gates Glidden Drills on Crack Formation. J. Endod. 2014, 40, 1681–1683. [Google Scholar] [CrossRef] [PubMed]
  34. Karataş, E.; Arslan, H.; Topçuoğlu, H.S.; Yılmaz, C.B.; Yeter, K.Y.; Ayrancı, L.B. The Effect of Diode Laser With Different Parameters on Root Fracture During Irrigation Procedure. Artif. Organs 2016, 40, 604–609. [Google Scholar] [CrossRef]
  35. Eldeniz, A.U.; Erdemir, A.; Belli, S. Effect of EDTA and Citric Acid Solutions on the Microhardness and the Roughness of Human Root Canal Dentin. J. Endod. 2005, 31, 107–110. [Google Scholar] [CrossRef] [PubMed]
  36. Ballal, N.V.; Mala, K.; Bhat, K.S. Evaluation of the Effect of Maleic Acid and Ethylenediaminetetraacetic Acid on the Microhardness and Surface Roughness of Human Root Canal Dentin. J. Endod. 2010, 36, 1385–1388. [Google Scholar] [CrossRef] [PubMed]
  37. Fernandes Zancan, R.; Hadis, M.; Burgess, D.; Zhang, Z.J.; Di Maio, A.; Tomson, P.; Duarte, M.A.H.; Camilleri, J. A matched irrigation and obturation strategy for root canal therapy. Sci. Rep. 2021, 11, 4666. [Google Scholar] [CrossRef] [PubMed]
  38. Atalay, I.; Erişen, F.R. Evaluation of the effects of different chelation agents on root dentin roughness. Aust. Endod. J. 2023, 49, 71–78. [Google Scholar] [CrossRef] [PubMed]
  39. Poudyal, S.; Pan, W.H.; Zhan, L. Efficacy of solution form of ethylenediaminetetraacetic acid on removing smear layer of root canal at different exposure time in Vitro. J. Huazhong Univ. Sci. Technol. Med. Sci. 2014, 34, 420–424. [Google Scholar] [CrossRef]
  40. Amonkar, A.D.; Dhaded, N.S.; Doddwad, P.K.; Patil, A.C.; Hugar, S.M.; Bhandi, S.; Raj, A.T.; Patil, S.; Zanza, A.; Testarelli, L. Evaluation of the effect of long-term use of three intracanal medicaments on the radicular dentin microhardness and fracture resistance: An in vitro study. Acta Stomatol. Croat. 2021, 55, 291–301. [Google Scholar] [CrossRef]
  41. Siqueira, J.F., Jr.; Lopes, H.P. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int. Endod. J. 1999, 32, 361–369. [Google Scholar] [CrossRef] [PubMed]
  42. Yassen, G.H.; Chu, T.M.; Eckert, G.; Platt, J.A. Effect of Medicaments Used in Endodontic Regeneration Technique on the Chemical Structure of Human Immature Radicular Dentin: An In Vitro Study. J. Endod. 2013, 39, 269–273. [Google Scholar] [CrossRef] [PubMed]
  43. Wang, X.; Bank, R.A.; TeKoppele, J.M.; Mauli Agrawal, C. The role of collagen in determining bone mechanical properties. J. Orthop. Res. 2001, 19, 1021–1026. [Google Scholar] [CrossRef] [PubMed]
  44. Yassen, G.H.; Vail, M.M.; Chu, T.G.; Platt, J.A. The effect of medicaments used in endodontic regeneration on root fracture and microhardness of radicular dentine. Int. Endod. J. 2013, 46, 688–695. [Google Scholar] [CrossRef] [PubMed]
  45. Osiri, S.; Banomyong, D.; Sattabanasuk, V.; Yanpiset, K. Root Reinforcement after Obturation with Calcium Silicate–based Sealer and Modified Gutta-percha Cone. J. Endod. 2018, 44, 1843–1848. [Google Scholar] [CrossRef] [PubMed]
  46. Phukan, A.H.; Mathur, S.; Sandhu, M.; Sachdev, V. The effect of different root canal sealers on the fracture resistance of endodontically treated teeth-in vitro study. Dent. Res. J. 2017, 14, 382–388. [Google Scholar] [CrossRef] [PubMed]
  47. Mohammed, Y.T.; Al-Zaka, I.M. Fracture resistance of endodontically treated teeth obturated with different root canal sealers (A comparative study). J. Contemp. Dent. Pract. 2020, 21, 490–493. [Google Scholar] [CrossRef]
  48. Rekha, R.; Kavitha, R.; Venkitachalam, R.; Prabath, S.V.; Deepthy, S.; Krishnan, V. Comparison of the sealing ability of bioceramic sealer against epoxy resin based sealer: A systematic review & meta-analysis. J. Oral Biol. Craniofacial Res. 2023, 13, 28–35. [Google Scholar] [CrossRef]
Applsci 14 05931 g001
Figure 1. PRILE Flowchart of the study.
Figure 1. PRILE Flowchart of the study.
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Figure 2. Experimental setup: (a) Verification of standardization of samples; (b) Radiographic image of the medicament; (c) Radiographic image of the root canal filling; (d) Instron Universal Testing Device; (e) A sample mounted and fractured on the universal testing machine.
Figure 2. Experimental setup: (a) Verification of standardization of samples; (b) Radiographic image of the medicament; (c) Radiographic image of the root canal filling; (d) Instron Universal Testing Device; (e) A sample mounted and fractured on the universal testing machine.
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Figure 3. Representative value measured on the universal test device.
Figure 3. Representative value measured on the universal test device.
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Figure 4. Average strength values of the experimental groups.
Figure 4. Average strength values of the experimental groups.
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Table 1. Descriptive statistics and multiple comparison results of forces at fracture (Newton) by group and time.
Table 1. Descriptive statistics and multiple comparison results of forces at fracture (Newton) by group and time.
GroupTotal
CH(+)CH(−)
1 min299.14 ± 103.8392.35 ± 128.85345.75 ± 123.93
3 min369.15 ± 128.08421.43 ± 92.85395.29 ± 112.61
5 min319.38 ± 127.29449.19 ± 79.81384.28 ± 123.26
10 min353.73 ± 178.18343.83 ± 103.44348.78 ± 142.57
Total335.35 ± 135.5401.7 ± 107.01368.52 ± 125.94
Fp *ηp2
Group (CH(+), CH(−))7.1990.0090.076
Time1.0210.3870.034
Group × Time1.4660.2290.048
Mean ± Standard Deviation, CH(+) = with calcium hydroxide, CH(−) = without calcium hydroxide. * Two-Way ANOVA, F: Analysis of variance test statistic, ηp2: Partial eta-squared.
Table 2. Comparison of forces at fracture (Newton) according to experimental and control groups.
Table 2. Comparison of forces at fracture (Newton) according to experimental and control groups.
SamplesTest Statisticsp *
Mean ± Standard DeviationMedian (min–max)
CH(+) 1 min299.14 ± 103.8 a323.5 (162.4–442.2)4.602<0.001
CH(+) 3 min369.15 ± 128.08 a308.65 (239.3–587.9)
CH(+) 5 min319.38 ± 127.29 a288.65 (115.2–524.6)
CH(+) 10 min353.73 ± 178.18 a275.75 (183.2–750.6)
CH(−) 1 min392.35 ± 128.85 a386.55 (167–588)
CH(−) 3 min421.43 ± 92.85 a395.6 (272.4–579.9)
CH(−) 5 min449.19 ± 79.81 a446.1 (331–609)
CH(−) 10 min343.83 ± 103.44 a325.5 (186.7–521.9)
Control623.96 ± 72.4 b631.4 (505.8–702.8)
* One-way analysis of variance; a,b: there is no difference between groups with the same letter.
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Kolunsağ Özbek, S.; Kaşıkçı, S.; Özdemir, O. Evaluation of Fracture Strength of Roots to Determine the Duration Limit of Activated Ethylene Diamine Tetraacetic Acid Irrigation for Intracanal Calcium Hydroxide Dressing Removal In Vitro. Appl. Sci. 2024, 14, 5931. https://doi.org/10.3390/app14135931

AMA Style

Kolunsağ Özbek S, Kaşıkçı S, Özdemir O. Evaluation of Fracture Strength of Roots to Determine the Duration Limit of Activated Ethylene Diamine Tetraacetic Acid Irrigation for Intracanal Calcium Hydroxide Dressing Removal In Vitro. Applied Sciences. 2024; 14(13):5931. https://doi.org/10.3390/app14135931

Chicago/Turabian Style

Kolunsağ Özbek, Sena, Sena Kaşıkçı, and Olcay Özdemir. 2024. "Evaluation of Fracture Strength of Roots to Determine the Duration Limit of Activated Ethylene Diamine Tetraacetic Acid Irrigation for Intracanal Calcium Hydroxide Dressing Removal In Vitro" Applied Sciences 14, no. 13: 5931. https://doi.org/10.3390/app14135931

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