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Article

Quantitative Evaluation of Apically Extruded Debris of Root Canal Dentin Layer with WaveOne, ProTaper Next, ProTaper Gold Rotary File Systems

by
Muhammad Ali
1,
Muhammad Adeel Ahmed
2,
Azeem Ul Yaqin Syed
3,
Asmat Jamil
4,
Seher Pervaiz Khan
5,
Ahmed A. AlMokhatieb
6,
Abdulaziz Abdulwahed
6,
Khulud A. Al-Aali
7,
Fahim Vohra
8,* and
Tariq Abduljabbar
8
1
Department of Endodontics, Fatima Jinnah Dental College, Karachi 75500, Pakistan
2
Department of Restorative Dental Sciences, College of Dentistry, King Faisal University, Hofuf 31982, Saudi Arabia
3
Department of Prosthodontics, University of Science and Technology of Fujairah, Fujairah 2202, United Arab Emirates
4
Department of Operative Dentistry, Ziauddin Dental College, Ziauddin University, Karachi 75600, Pakistan
5
Department of Prosthodontics, Fatima Jinnah Dental College, Karachi 75500, Pakistan
6
Department of Conservative Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Riyadh 11942, Saudi Arabia
7
Department of Clinical Dental Sciences, College of Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh 11671, Saudi Arabia
8
Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh 11545, Saudi Arabia
*
Author to whom correspondence should be addressed.
Coatings 2022, 12(4), 451; https://doi.org/10.3390/coatings12040451
Submission received: 17 February 2022 / Revised: 16 March 2022 / Accepted: 18 March 2022 / Published: 26 March 2022
(This article belongs to the Special Issue Surface Coating for Biomedical Applications)
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Versions Notes

Abstract

:
Endodontic flare-up or post-operative pain occurs when debris such as necrotic pulp tissue, dentin chips, irrigants, and microorganisms are extruded from the apical foramen intraoperatively into the periradicular tissue during root canal instrumentation. This study compared the amount of apical debris extrusion of the root canal dentin layer after using reciprocating and rotary file systems (WaveOne, ProTaper Next and ProTaper Gold). Sixty extracted human maxillary central incisors with one canal and closed apex were included in the study. Samples were randomly and equally divided into three groups (n = 20) according to the file systems used for preparation of the root canal. Teeth in the WO group were instrumented by WaveOne, while the PTN group were instrumented by ProTaper Next, and teeth samples in the PTG group were cleaned and shaped by ProTaper Gold. The mean apically extruded debris weight in grams was estimated using the modified Myers and Montgomery experimental model. Analysis of variance (ANOVA) test was used for the comparison of debris weight in three groups. Post hoc LSD test was applied for pairwise comparison of debris weight. The α value of significance was 0.05. The WO group had significantly lower mean debris weight than the PTN and PTG groups (p = 0.001). Post hoc pairwise comparison revealed that there was a statistically significant difference in mean debris weight between the WO group and PTN group (0.0215 vs. 0.0341, p = 0.001); and the WO group and PTG group (0.0215 vs. 0.0324, p = 0.003). Root canal preparations with different file systems were associated with apical extrusion of the debris from the root canal dentin layer. However, the WaveOne system resulted in a comparatively lower amount of apical debris layer extrusion than the ProTaper Next and ProTaper Gold rotary file systems.

1. Introduction

Successful root canal treatments are based on cleaning and shaping, through mechanical instrumentation, of the root dentin layer, and adequate cleaning, shaping and filling of the root canal system to obtain a hermetic seal [1]. This treatment eventually provides a sterile environment for periapical healing and preserves natural teeth. Adequate cleaning and shaping of the root canal dentin layer is critical for endodontic care, and it is desirable to remove pulp tissues, bacteria and dentin waste from the canal system in order to achieve a better treatment outcome [2]. During preparation of the canal, there are chances of debris extrusion into the periapical tissues through the apical foramen [3]. Though this can be minimized by monitoring of the working length (WL), debris extrusion may result in post-operative complications such as flare-ups, marked by pain and swelling emergencies [4].
Apical extrusion of the debris layer, also referred to as a “worm of necrotic debris”, is a detrimental event that occurs during the instrumentation of the root canal system [5]. In asymptomatic chronic lesions of the periapical area, a subtle equilibrium is present between the infecting root canal microorganisms and the host defenses of the periapical tissues. Apical extrusion of bacteria from dentin layer can disrupt this balance and cause an acute inflammatory response [6]. Tanalp and Güngör [5] reported that extrusion of bacterial products, pulp tissue, and irrigants outside the root apex is one of the causes of root canal failure. Natural factors associated with tooth anatomy along with the type of endodontic instrument and preparation technique including rotary instruments, can influence debris extrusion [3].
Rotary file systems were developed to efficiently clean and shape the root canal system with the benefit of requiring fewer steps for root canal treatment and decreasing the number of patient visits [7]. The flutes of the rotary file system are designed in such a way that they lock canal debris in and push them coronally towards the cervical part of the tooth [8]. This leads to decreased accumulation of debris in the root canal and also prevents apical extrusion. Numerous studies have reported that apical debris extrusion is inevitable, even with different rotary file systems. Surakanti et al. [9] compared the rotary and reciprocating file systems WaveOne, ProTaper, and Hyflex with respect to the amount of apical debris extrusion. They suggested that all systems extruded debris apically, whereas less debris was associated with the use of the full-sequence rotary instrument. Similarly, Vyavahare et al. [10] conducted a comparative study among Self-Adjusting, ProTaper Next, V-Taper file systems, and determined that all file systems extruded debris apically. However, the self-adjusting file system resulted in the least amount of debris extrusion among them. Likewise, Hussein et al. [11] evaluated the quantity of apical extrusion of debris using Rotary ProTaper, Rotary M two, Reciproc and WaveOne. The results showed that these instruments resulted in apical extrusion however, WaveOne produced the highest amount of debris extrusion. Siqueira et al. [12] reported that despite proper cleaning and shaping, apical extrusion of debris cannot be completely avoided. Nevertheless, Reddy et al. [13] further added that the amount of apical extrusion of debris is subject to the instrument system that is used during root canal treatment.
Although the total amount of extruded debris varies based on the preparation method and the filing system used, none of the existing instruments and preparation techniques are able to prepare root canals without debris extrusion [6,13]. Studies in Sudan and India have reported that the most commonly used NiTi rotary file system is ProTaper Universal, followed by ProTaper Next [14,15], and both systems are based on rotary motion. However, WaveOne is a single-file system, with reciprocating motion composed of M-Wire technology, with increased resistance to cyclic fatigue and better strength compared to other rotary files [16]. WaveOne files work with reverse cutting action and possess a convex triangular cross-section (particularly files D9-D16). Its safety features include different pitch flutes along its length. On the other hand, ProTaper Next files have rectangular cross-section, which causes the file to produce “a snake-like-swaggering” movement. Similarly, the ProTaper Gold files, with a triangular cross-section and a gradual taper, demonstrate improved cutting and reduced friction between the tooth and the instrument. We assumed that there may be variations in apically extruded debris between these root canal preparation file systems. Therefore, it is critical to compare the amount of apical debris extrusion using the different canal cleaning and shaping systems. The null hypothesis was that no difference exists in the amount of root canal preparation debris between the WaveOne, ProTaper Next and ProTaper Gold systems. The aim of the present study was to compare the file systems and identify that with the least amount of debris extrusion from the root canal dentin layer among WaveOne, ProTaper Next and ProTaper Gold in order to provide effective root canal operations with reduced risk of endodontic flare-up.

2. Materials and Methods

2.1. Inclusion and Exclusion Criteria

This in vitro study was conducted at the Department of Endodontics, Fatima Jinnah Dental College Hospital, Karachi, Pakistan for a period of six months. The ethics and review committee of the institute provided the approval for the experiments. Sixty extracted human maxillary central incisors with one canal and closed apex were included. These teeth were extracted due to periodontal disease. The mean age of the patients from whom teeth were extracted was 44.60 ± 5.47. The length of maxillary central incisor was 21 ± 1 mm. Teeth with fractures, cracks, calcified canal; curved root and open apex were excluded. The included teeth were autoclaved at 121 °C (15 psi) for 30 min and were stored in water with 0.1% thymol. Digital radiographs were used to examine and verify the root morphology of the included teeth and ensure that they met the inclusion criterion. With an ultrasonic scaler, soft tissue and calculi were mechanically removed from the root surfaces.

2.2. Sample Preparation

Access cavity was prepared using small round bur (Mani, Tokyo, Japan) on a high-speed motor and working length was established with a #25K-file (Mani, Tokyo, Japan). The file was kept 1 mm shortere than the canal length by retracting the tip of the file visibly at the apical foramen. The patency of the canal was maintained by using size 10 K-file in between filing. The experimental model of Myers and Montgomery was modified [17], i.e., the Eppendorf tube for specimen collection with rubber stopper was placed in a transparent glass vial (Figure 1). Analytical balance (Sartorius, CP225D, Goettingen, Germany) with an accuracy of 10−5 g was used to measure the initial weight of the tube (Figure 2). Three consecutive weights of each tube were obtained, and means were taken.
Each tooth was placed into a rubber stopper before the cemento-enamel junction was reached, and a 27-gauge needle inserted alongside the stopper to adjust the air pressure (internal and external). To prevent any flaws in the process and remove bias, a single operator (MA) used the reciprocating and rotary files to clean and shape the canals according to the manufacturer instructions.

2.3. Canal Cleaning and Shaping

Samples were randomly and equally divided into three groups by lottery method.
WO group: Twenty teeth were instrumented by WaveOne (Dentsply Maillefer, Ballaigues, Switzerland) primary file (25/08) with pecking motion in reciprocation, as guided by the manufacturer using endo-motor X-Smart Plus (Dentsply Maillefer, Ballaigues, Switzerland).
PTN group: Twenty teeth were instrumented by ProTaper Next (Dentsply Maillefer, Ballaigues, Switzerland) X1 (0.17/0.04) and X2 (0.25/0.06) files in a gentle in and out motion as per manufacturer guidelines using endo-motor X-Smart Plus (Dentsply Maillefer, Ballaigues, Switzerland).
PTG group: Twenty teeth were instrumented by ProTaper Gold (Dentsply Maillefer, Ballaigues, Switzerland) S1 (0.18/0.02 v), S2 (0.20/0.04 v), F1(0.20/0.07 v) and F2 (0.25/0.08 v) files in a gentle pecking motion as per manufacturer guidelines using endo-motor X-Smart Plus (Dentsply Maillefer, Ballaigues, Switzerland).
All canals were irrigated with 5 mL of 3.0% sodium hypochlorite (CanalPro NaOCl, Coltène/Whaledent, Altstätten, Switzerland) in between filing.

2.4. Quantitative Evaluation of Apically Extruded Debris

Torque and speed for each rotary file system were adjusted according to manufacturer guidelines (Table 1). The teeth attached to the rubber stoppers were withdrawn after instrumentation. One ml of distilled water was used to remove adhered debris at the apices and debris was collected in the tubes. The Eppendorf tubes were placed in an incubator (Sanfa, DNP-9022, Yangzhou, China) at 37 °C for 10 days (Figure 3) to allow water to evaporate. Dry debris was measured using an analytical balance (Sartorius, CP225D, Goettingen, Germany). The average of three consecutive weights was estimated. The dry weight of the debris in grams (g), was calculated by subtracting the weight of tube from the tube with debris. The overall methodology of the study is presented in Figure 4.

2.5. Statistical Analysis

The data obtained were assessed using statistical program for social sciences (SPSS-Version 25.0. Armonk, NY, USA). Mean and SD were calculated for debris weight in grams. Debris weight among the study groups was compared by analysis of variance (ANOVA); and post hoc Tukey test. A p-value ≤ 0.05 was considered as statistically significant.

3. Results

The means and standard deviation values of apically extruded debris in all three groups are presented in Table 2. WaveOne file-treated (WO group) specimens showed significantly lower mean debris weight compared to Protaper Next (PTN group)- and ProTaper Gold (PTG group)-prepared specimens (p = 0.001) (Figure 5).
An inter-group comparison revealed that there was a statistically significant difference in mean debris weight between WaveOne- and ProTaper Next file-treated samples (0.0215 vs. 0.0341, p = 0.001). Similarly, WaveOne samples produced significantly less debris than ProTaper Gold (0.0215 vs. 0.0324, p = 0.003)-treated specimens. In addition, the mean debris weight between ProTaper Next and ProTaper Gold system files (0.0341 vs. 0.0324 p = 0.627) was statistically comparable (Table 3).

4. Discussion

The current study was conducted to compare the amount of apically extruded debris after root canal instrumentation using WaveOne, ProTaper Next and ProTaper Gold rotary file systems. We hypothesized that there might be a variation in apically extruded debris between the different file systems. The results of the study showed a statistically significant difference (p = 0.001) in the amount of debris apically extruded with WaveOne in comparison to ProTaper Next and ProTaper Gold rotary file systems. It also showed that ProTaper Next extruded slightly more debris compared to ProTaper Gold. Therefore, the null hypothesis was rejected.
In the study by Dincer et al. [18] less debris extrusion was observed with WaveOne gold compared to ProTaper Next rotary systems. However, the quantity of extruded debris due to the use of ProTaper Next was significantly higher in the present study compared to the findings of Dincer et al. In the authors’ opinion, this difference in the overall quantity of apical debris extrusion could be due to the difference in the type of the teeth used, the volume and type of irrigant, and the lack of maintaining the patency of the canal. Similarly, a study by Karataş et al. [19] revealed that ProTaper Universal extruded more debris than the ProTaper Gold and WaveOne rotary file systems. Ozsu et al. [20] also reported that the ProTaper Next and WaveOne file systems resulted in low debris extrusion compared to ProTaper Universal. This difference in result may be due to the differences in instrument configuration, cutting blade design, cutting efficacy, cross-section, tip type, taper, alloy, kinematics, or flexibility [17,21,22].
Root canal treatment is dedicated to removing dentin debris, necrotic pulpal tissue, and microorganisms, leaving cleaned and shaped canals [23]. During cleaning and shaping, the main goal is to prevent the apical extrusion of dentin debris, necrotic pulpal tissue, and irrigants. To prevent apical extrusion, a series of steps are taken to accurately shape and clean canals, by measuring the working length accurately. Numerous studies have reported that despite taking preventive measures and following the proper root canal treatment steps, there is still extrusion of canal debris into the periradicular area that causes post-operative inflammation, increases intervals of flare-ups, and delays healing [5,13,17,18,24]. The slow healing leads to delayed obturation of root canals and an increase in patient visits [23]. It is the authors’ opinion that apical extrusion of debris carrying microorganisms is associated with postoperative pain and discomfort to patients during treatment visits, as well as possibly delayed healing and relief of symptoms after root filling. Kocak et al. [25] confirmed that biomechanical preparation plays a substantial role during root canal treatment. However, for root canal treatment to be successful, it is of the utmost importance that dentists clean the canal and eliminate all vital and necrotic tissues, dentin debris and microbes from the canal system. Burklein S. et al. [6] further confirmed that these materials can be extruded from apical foramen and spread into the periradicular area during canal preparation.
ProTaper Next is a multi-rotary file with variable taper performance, but with the inclusion of an off-centered, rectangular cross-section for improved file strength [26]. On the other hand, ProTaper Gold has a progressive taper and a convex triangular cross-section. Additionally, ProTaper Gold has a non-cutting tip that allows the instrument to preserve the root canal’s original form [27]. In addition, these systems also exhibit torsional resistance due to their polar moment of inertia and cross-section shape [28]. Although both instruments have different kinematics and cross-sections, they do not exhibit significantly different amounts of apical debris extrusion [24]. Similarly, no statistically significant difference in debris weight between ProTaper Next and ProTaper Gold (p = 0.627) was observed in the present study. However, Cakici et al. [29], found dissimilar results and showed that the ProTaper Gold file system was linked with significantly higher debris weight than ProTaper Next.
It is suggested that all file systems are associated with apical extrusion of debris [5]. The findings of previous studies have also shown that no method can fully prevent debris extrusion, and the results of the present study are in line with the findings of previous studies [29,30,31]. It is also worth mentioning that during root canal treatment, extrusion occurs through a combination of events, including instrumentation, irrigant extrusion with bacterial microleakage, and root filling. Therefore, prevention of debris extrusion must be ensured by using the crown down preparation technique [32], selecting an apical patency file that is not adjusted to the apical portion, rather than one that binds to the foramen [33], and using an apical negative pressure device for irrigation [34]. This cumulative practice will minimize post-operative complications such as pain and swelling caused by apical extrusion of debris.
In the present study, the Myers and Montgomery approach was used for collecting extruded debris, but the experimental model was modified with the use of Eppendorf tubes with stoppers for specimen collection [16,35,36]. Myers also stated that a working length 1 mm shorter than the canal length is associated with less extruded debris [16]. Therefore, in the current study, instrumentation was limited to 1 mm from the canal apex to minimize procedural errors. However, this method is limited in its ability to simulate vital periapical tissues, which ensures that the negative pressure produced by periapical tissues cannot be mimicked [20,21,29]. Therefore, the findings of the present study should be interpreted cautiously.
In the present study, extracted teeth were sterilized by autoclaving. Sterilization of teeth by autoclaving can influence micro-hardness, but without interfering with dentinal permeability [37]. In the present study, only three file systems were used for quantitative evaluation of apically extruded debris. However, use of minimally invasive file systems (TruNatomy, Dentsply, Tulsa Dental Specialties, Johnson City, TN, USA) designed to respect the true natural anatomy of the root canal system can minimize root dentin micro-cracks, which could have resulted in different study findings [38]. Therefore, further studies comparing different contemporary rotary canal preparation systems for residue formation are recommended. In addition, only single-rooted anterior teeth were used for the evaluation of the amount of apical extrusion of the debris. Moreover, periapical tissues were not mimicked, and the outcomes in a clinical in vivo setting may vary. Therefore, future in vivo studies are desirable using multi-rooted teeth with different instrument sizes and simulated oral conditions to assess debris extrusion. In addition, randomized controlled trials assessing the clinical outcomes of contemporary root canal instrumentation systems and their debris extrusion are recommended.

5. Conclusions

The present study concluded that rotary file systems for root canal treatment are associated with apical extrusion of root canal dentin layer debris. In addition, the WaveOne system resulted in a comparatively lower amount of apical debris layer extrusion than the ProTaper Next and ProTaper Gold rotary file systems.

Author Contributions

Conceptualization: M.A., M.A.A., A.U.Y.S., A.J., A.A., K.A.A.-A.; methodology: M.A., M.A.A., F.V., T.A.; software: A.U.Y.S., A.J., F.V., T.A.; validation, S.P.K.; formal analysis: M.A., A.A.A., M.A.A., A.J., F.V., T.A.; resources: M.A., K.A.A.-A., A.A.A., M.A.A., F.V., T.A.; data curation: M.A., A.U.Y.S., K.A.A.-A., A.J., T.A., writing—original draft preparation: M.A., A.A., A.J., F.V., T.A.; writing—review and editing: M.A., M.A.A., A.A.A., F.V., T.A.; Funding: T.A. All authors have read and agreed to the published version of the manuscript.

Funding

Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2022R6), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Institutional Review Board Statement

This in vitro study was reviewed and approved by the ethics and review committee FR-0632. All the recommendations of the Helsinki Declaration and its later amendments were strictly followed.

Informed Consent Statement

Informed consent was obtained for removal of teeth and use of extracted teeth.

Data Availability Statement

The data is available on contact from the corresponding author.

Acknowledgments

Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2022R6), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Conflicts of Interest

The authors declare no conflict of interest.

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Coatings 12 00451 g001 550
Figure 1. The experimental model used to collect extruded debris.
Figure 1. The experimental model used to collect extruded debris.
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Figure 2. Analytical balance with an accuracy of 10−5 g (Sartorius CP225D).
Figure 2. Analytical balance with an accuracy of 10−5 g (Sartorius CP225D).
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Figure 3. Incubator for drying of Eppendorf tubes (Sanfa DNP-9022).
Figure 3. Incubator for drying of Eppendorf tubes (Sanfa DNP-9022).
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Figure 4. Study methodology.
Figure 4. Study methodology.
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Figure 5. Box plot showing comparison of median and interquartile ranges of debris weight in grams using 20 samples in each group. WO: WaveOne file, PTN: Protaper Next, PTG: ProTaper Gold.
Figure 5. Box plot showing comparison of median and interquartile ranges of debris weight in grams using 20 samples in each group. WO: WaveOne file, PTN: Protaper Next, PTG: ProTaper Gold.
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Table
Table 1. Torque and speed of different file systems used.
Table 1. Torque and speed of different file systems used.
File SystemTorque (Ncm)Speed (RPM)
WaveOne2.5350
ProTaper Next files4–5.2300
ProTaper Gold (S1)5.10300
ProTaper Gold (S2 and F1)1.50300
ProTaper Gold (F2)3.10300
Table
Table 2. Minimum, maximum and mean values of apically extruded debris weight (g) among the study groups.
Table 2. Minimum, maximum and mean values of apically extruded debris weight (g) among the study groups.
Study GroupsMinimumMaximumMean (g)Std. Deviation
WO group0.00120.04320.02150.0116
PTN group0.01120.05930.03410.0114
PTG group0.01120.05430.03240.0096
WO: WaveOne file, PTN: Protaper Next, PTG: ProTaper Gold.
Table
Table 3. Post hoc pairwise comparison of debris weight (LSD).
Table 3. Post hoc pairwise comparison of debris weight (LSD).
Comparison of File SystemsMean Differencep-Value
WO group vs. PTN group −0.0125 *0.001
WO group vs. PTG group −0.0108 *0.003
PTN group vs. PTG group 0.00160.627
* Statistically significance at p < 0.05. WO: WaveOne file, PTN: Protaper Next, PTG: ProTaper Gold.
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Ali, M.; Ahmed, M.A.; Syed, A.U.Y.; Jamil, A.; Khan, S.P.; AlMokhatieb, A.A.; Abdulwahed, A.; Al-Aali, K.A.; Vohra, F.; Abduljabbar, T. Quantitative Evaluation of Apically Extruded Debris of Root Canal Dentin Layer with WaveOne, ProTaper Next, ProTaper Gold Rotary File Systems. Coatings 2022, 12, 451. https://doi.org/10.3390/coatings12040451

AMA Style

Ali M, Ahmed MA, Syed AUY, Jamil A, Khan SP, AlMokhatieb AA, Abdulwahed A, Al-Aali KA, Vohra F, Abduljabbar T. Quantitative Evaluation of Apically Extruded Debris of Root Canal Dentin Layer with WaveOne, ProTaper Next, ProTaper Gold Rotary File Systems. Coatings. 2022; 12(4):451. https://doi.org/10.3390/coatings12040451

Chicago/Turabian Style

Ali, Muhammad, Muhammad Adeel Ahmed, Azeem Ul Yaqin Syed, Asmat Jamil, Seher Pervaiz Khan, Ahmed A. AlMokhatieb, Abdulaziz Abdulwahed, Khulud A. Al-Aali, Fahim Vohra, and Tariq Abduljabbar. 2022. "Quantitative Evaluation of Apically Extruded Debris of Root Canal Dentin Layer with WaveOne, ProTaper Next, ProTaper Gold Rotary File Systems" Coatings 12, no. 4: 451. https://doi.org/10.3390/coatings12040451

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