0099-2399/93/1909-0458/$03.

00/0 JOURNALOF ENDODONTICS Copyright 1993 by The American Association of Endodontists

Printed in U.S.A.

VOL. 19, NO. 9, SEPTEMBER 1993

Human Saliva Penetration of Coronally Unsealed Obturated Root Canals

Akbar Khayat, DMD, Seung-Jong Lee, DDS, MS, and Mahmoud Torabinejad, DMD, MSD

Studies have shown significant coronal dye and bacterial leakage following exposure of sealed root canals to artificial and natural saliva. The purpose of this study was to determine the time needed for bacteria in natural saliva to contaminate the entire length of root canals obturated by lateral and vertical condensation techniques. Forty root canals were cleaned and shaped using a step-back technique. Thirty root canals were obturated with gutta-percha and root canal sealer using either lateral or vertical condensation techniques. Five root canals were obturated without a root canal sealer and served as positive controls. After obturation, the coronal 3 mm of five root canals were sealed with sticky wax and served as negatie controls. The coronal portions of the filling materials were placed in contact with human saliva and the number of days required for bacteria in saliva to penetrate the entire root canals were determined. No bacterial leakage occurred in the negative control group. Complete bacterial leakage occurred within 2 days in the positive control group. All root canals were recontaminated in less than 30 days. No statistical significant difference was found between the two methods of obturation.

question remains as to how quickly the entire root canal system becomes contaminated to the point that retreatment of the canal is necessary. In vitro studies using artificial saliva and Pelikan ink as a tracer have shown high levels of dye penetration in the majority of their specimens (2, 3). In an in vivo microleakage study, Madison and Wilcox (4) showed inconclusive results when they determined the coronal dye leakage in monkeys' teeth after exposure to the oral cavity for 1 wk. Because of inherent inadequacies associated with dye studies (5-7), bacterial leakage studies might be more meaningful and clinically more relevant. Torabinejad et al (8) used two species of bacteria, Staphylococcus epidermidis and Proteus vulgaris, to evaluate the coronal leakage of root canal-filled teeth. Eighty-eight percent of the root canals were completely recontaminated in 30 days following exposures to Staphylococcus epidermidis and 85% in 66 days following exposure to

Proteus vulgaris.
Magura etal. (9) evaluated the coronal leakage in obturated root canals using fresh human saliva. They found that salivary leakage was slower than dye penetration. They also reported that salivary penetration at 90 days was significantly greater than that seen after 2, 7, 14, and 28 days. The purpose of this study was to determine the length of time for bacteria present in natural human saliva to penetrate through the entire root canal system obturated by lateral and vertical condensation techniques in an in vitro model. MATERIALS AND METHODS

Incomplete obturation of the root canal plays a significant role in the endodontic prognosis (1). Among factors related to failure following endodontic therapy, the role of the coronal seal has not been extensively discussed. However, the importance of the coronal seal after completion of root canal therapy has increasingly been recognized in dental literature (2-4). Sealed root canals can be coronally recontaminated under several circumstances: (a) recurrent decay exposing the endodontic filling material; (b) the filling materials and/or tooth structures have fractured or been lost; or (c) the patient has delayed placement of permanent restorations. When these situations occur, the coronal portion of the root canal system is exposed to the oral flora, which can allow ingress of bacteria to the periapical tissues. although it is known that coronally exposed root canal filling materials can be recontaminated by oral flora, the

Forty mandibular and maxillary molar teeth were used for this study. The teeth had been stored in 10% formalin and were kept moist prior to and during the experiment. No other information regarding these teeth was available to the investigators. The teeth were radiographed and those with calcified or multiple canals in distal or palatal roots were eliminated. the buccal or mesial roots of the maxillary and mandibular molars, respectively, were removed at their furcations. The orifice of each canal was enlarged with a # 1 round bur and was double sealed with a layer of Cavit and amalgam. After enlarging the apical foramen of each root to a #40 file, the rest of the canal was cleansed and shaped using a step-back technique. Approximately 2 ml of 5.25% NaOC1 were used between each file size to irrigate each canal. The root canals of 15 randomly chosen teeth were then obturated

458

Vol. 19, No. 9, September 1993

Coronal Leakage

459

FIG 1. Apparatus setup with an uncontaminated fresh broth media.

FIG 2. Turbidity of the broth media after coronal leakage.

with gutta-percha and Roth's sealer (Roth Drug Co., Chicago, IL) using a lateral condensation technique, and another 15 teeth obturated with gutta-percha and Roth's sealer using a vertical condensation technique. To obtain a standardized length of tilling, the coronal portion of the gutta-percha was removed with hot pluggers until only 10 m m of the tilling material remained in each canal. No vertical condensation was used during removal of root canal tilling materials. Five roots were obturated with single gutta-percha cones without any root canal sealer and served as positive controls. The remaining five roots were obturated with gutta-percha and Roth sealer using lateral condensation technique. The entire external surface (including the apical foramen) of each root in this latter group was coated with a double layer of nail varnish. These roots served as negative controls. After wrapping each tooth in a wet piece of gauze and placing it in a capped plastic vial, each was left for 48 h to allow the root canal sealer to set. Excluding those teeth in the negative control group, the teeth were coated with two coats of nail varnish, except for their apical 2 mm and their coronal access cavities. By using #2 and #4 round burs in a high-speed handpiece, two circular openings were made through the cap of a 4-oz scintillation flask. A piece of paper clip wire was threaded through the small opening and extended into the cap about 2 inches. The outside end of the wire was bent and attached to the cap with acrylic material. The inside end of the wire was

attached with cyanoacrylate to a small hole prepared on the occlusal surface of the tooth. A plastic Teflon tube with an inside diameter of 2 mm was inserted through the bigger opening of the cap and extended into the access cavity of the tooth. This served as a route for saliva deposition. A collar of rubber dam was placed and glued over the cervical portion of each tooth to prevent any saliva overflow during the experiment. The whole apparatus was sterilized overnight with ethylene dioxide. Trypticase soy broth was placed into the flask to a level of 2 to 3 m m above the apical foramen of each filled root (Fig. 1). Saliva collected every other day from a number of students was carefully placed into the access cavity of each tooth with a tuberculin syringe through the plastic tubing. The saliva was then replenished every 2 days. The number of days it took for the broth to become turbid was recorded as an indicator of entire root canal recontamination (Fig. 2). Saliva leakage was confirmed by placing 0.1 ml of India ink into the access cavity of each tooth and allowing it to penetrate for 24 h and map the pathway of saliva penetration. The teeth were then cleared according to the method described by Swanson and Madison (2). The means and standard deviations of salivary leakage for various groups were determined. Student's t test was used to determine the statistical difference between the experimental groups.

460

Khayat et al.

Joumal of Endodontics

NUMBER OF SPECIMENS CONTROL VERTICAL CONDENSATION 0 LATERAL CONDENSATION

0 0
@
0 2 4 6

@0
10 12

0 0

20 22 24

0 0 O0

26

0
@ O
44 46 48

@ O0
14 16

18

28

0
30 32

0
34

@
36 38

40

0@
42

NUMBER OF DAYS
FIG 3. Pattern of leakage in positive control group as well as roots filled with lateral and vertical condensation techniques.

RESULTS All roots in the positive control group caused broth turbidity within 48 h. In contrast, broth in the negative control group remained clear throughout the experimental period. The pattern of leakage is shown in Fig. 3. Canals obturated with lateral condensation technique were entirely contaminated within an average of 28.8 _+ 4.7 days, ranging from 8 to 48 days. Canals obturated with vertical condensation technique were contaminated entirely within an average of 25.4 + 13.6 days, ranging from 4 to 46 days. Student's t test showed no significant statistical difference between the lengths of time for contamination in lateral versus vertical condensation groups (p = 0.508). After placing India ink into the access cavities of recontaminated root canals, penetration occurred in a linear pattern between the filling materials and the dentinal walls. The same pattern was observed regardless of the obturation techniques or the period of recontamination. Removal of filling materials with hot pluggers might be the reason for a lack of leakage difference between the two experimental groups. Examination of cleared teeth showed penetration of ink through the entire junction of filling materials and the denfinal walls in all of the specimens. In addition to studying the pattern of recontamination, we also examined the species present in the soy broth. Most of the oral flora was isolated from the contaminated broth. DISCUSSION All samples in the positive control group showed complete leakage within 2 days. The results of the positive control group are a confirmation of studies by Marshall and Massler (10), Evans and Simon (11), and Skinner and Himel (12) who showed that sealers are needed to improve the canal seal. As none of the negative controls cause broth turbidity, it appears that the set-up provided a contamination-free chamber. In previous studies the coronal portion of the root filling materials were placed in contact with artificial saliva (2, 3) or trypticase soy broth contaminated with two species of bacteria (8) to determine the length of time for the dye or bacteria to

penetrate the exposed root canal filling materials. The media used in these studies lacked the proteins, enzymes, bacterial populations, and their products normally found in natural saliva. The use of human saliva provides these elements. However, it is still a static model and does not simulate clinical conditions. Recontamination time of this experiment was between 4 and 48 days. Similar variations have been reported by other investigators (2, 4). Swanson and Madison (2) demonstrated that the dye penetrated 79 to 85% of the root length in experimental time periods of 3, 7, 14, 28, and 56 days. Torabinejad et al. (8) used two different species of bacteria, Proteus vulgaris which is highly motile and Streptococcus epidermidis which is non-motile, for an apical recontamination study. Their results showed that S. epidermidis contaminated the exposed root canal system faster (average 24.1 days) than P. vulgaris (48.6 days), indicating that the motility of the bacteria may not be an important factor for recontamination of an exposed obturated root canal system. Evaluation methods are important factors in leakage studies. Dyes and isotopes are good substances for comparing relative leakage, but because of their small molecules, they may not give a true picture of the leakage of bacteria or their by-products. After exposure of root canal filling materials to human saliva, Magura et al. (9) reported that saliva penetration was significantly slower than dye leakage. Because of the limitations of in vitro studies (dye, radioisotope, and bacterial), in vivo animal models simulating clinical conditions are needed to investigate the rate of coronal leakage in unsealed and exposed, obturated root canals.
Dr. Khayat is associate professor and chairman, Department of Endodontics and Shiraz University, Shiraz, Iran. Dr. lee is an associate professor of Yonsei University, Seoul, Korea. Dr. Torabinejed is professor and Graduate Program Director of Endodontics, Loma Unda University, Loma Unda, CA.

References
1. Ingle JI, Talntor JF. Endodontics. 3rd ed., Vol 36. Philadelphia: Lea & Febiger, 1985. 2. Swanson K, Madison S. An evaluation of coronal microleakage in endodontically treated teeth. Part I. Time periods. J Endodon 1987;13:56. 3. Madison S, Swanson K, Chiles SA. An evaluation of coronal microlaakage in endodontically treated teeth. Part I1. Sealer type. J Endodon 1987;13:109.

Voh 19, No. 9, September 1993 4. Madison S, Wilcox L. An evaluation of coronal microleakage in endodonticaliy treated teeth. Part III. In vivo study. J Endodon 1988;14:455. 5. Mortansen DW, Boucher NE Jr, Ryge G. A method of testing for marginaJ leakage of dental restorations with bacteria. J Dent Res 1965;44:58. 6. Krakow AA, deStoppelaarJD, Groan P. In vivo study of temporary filling materials used in endodontics in anterior teeth. Oral Surg 1977;43:615. 7. Goldman LB, Goldman M, Kronman JH, Letoumeau JM. Adaptation and porosity of poly-HEMA in a modal system using two microorganisms. J Endodon 1980;6:683. 8. Torabinejad M, LJng B, Kettering JD. in vitro bacterial penetration of coronally unsealedendodonticaliy treated teeth. J Endodon 1990;16:566.

Coronal Leakage

461

9, Magura ME, Kafrawy AH, Brown CE Jr, Newton CW. Human saliva coronal microleakage in obturated root canals: An in vitro study. J Endodon 1991 ;17:324. 10. Marshall FJ, Massler M. The sealing of pulpless teeth evaluated with radioisotopes. J Dent Med 1961;16:172. 11. Evans JT, SimonJHS. Evaluationof the apical seal produced by injected thermoplasticized gutta-percha in the absence of smear layer and root canal sealer. J Endodon 1986;12:101. 12. Skinner RL, Himel VT. The sealing ability of injectk)n-molded thermoplasticized gutta-percha with and without the use of sealers. J Endodon 1987;13:315.

You Might Be Interested Differential diagnosis of pain by endodontists occasionally requires consideration of such entities as cluster headaches and migraine. A useful review of these afflictions (J Neurol Neurosurg Psychiatry 55:1103) notes a relief rate of about 80% from treatment with sumatripton, a 5-hydroxy tryptamine agonist.
Wallace Sturr