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doi:10.1111/j.1365-2591.2009.01577.x

doi:10.1111/j.1365-2591.2009.01577.x

REVIEW

Apexification: the beginning of its end

G. T.-J. Huang

Department of Endodontics, Prosthodontics and Operative Dentistry, College of Dental Surgery, University of Maryland, Baltimore, MD, USA

Abstract

Huang G.T.-J. Apexification: the beginning of its end. Inter- national Endodontic Journal, 42, 855–866, 2009.

Apexification is a procedure for treating and preserving immature permanent teeth that have lost pulp vitality. It contrasts apexogenesis in terms of its outcome in that apical maturation and normal root thickness cannot be obtained. Apexification has been a routine practice for such teeth for many decades, and despite a literature replete with discussion, including recent artificial barrier methods with mineral trioxide aggregate, ulti- mately there has been no major breakthrough to improve this treatment. Recently, two new clinical concepts have emerged. One involves a revitalization approach to achieve tissue generation and regenera- tion. In this method, new living tissue is expected to

form in the cleaned canal space, allowing continued root development in terms of both length and thickness. The other is the active pursuit of pulp/dentine regen- eration via tissue engineering technology to implant or re-grow pulps. Although the technology is still at its infancy, it has the potential to benefit immature pulpless teeth by allowing continued growth and maturation. With this understanding, it may be predicted that apexification will become less needed in years to come. This study will overview the recent concept of pulp revitalization in the treatment of immature teeth with nonvital pulps and the emerging research on pulp tissue engineering and regeneration.

Keywords: apexification, calcification, pulp/dentine tissue regeneration, stem cells.

Received 15 July 2008; accepted 26 February 2009

Introduction

Apexification is a procedure to promote the formation of an apical barrier to close the open apex of an immature tooth with a nonvital pulp such that the filling materials can be contained within the root canal space (Rafter 2005). The capacity of materials such as calcium hydroxide [Ca(OH) 2 ] to induce the formation of this calcific barrier at the apex made apexifica- tion possible and allowed the preservation of many

Correspondence: George T.-J. Huang, DDS, MSD, DSc, Depart- ment of Endodontics, Prosthodontics and Operative Dentistry, College of Dental Surgery, Dental School, University of Maryland, 650 West Baltimore St, Baltimore, 21201 MD, USA (Tel.: +410 706 7680; fax: +410 706 3028; e-mail:

ghuang@umaryland.edu).

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compromised, immature teeth with nonvital pulps by endodontic and restorative means. Clinically, when the pulpal diagnosis of an immature tooth is nonvital, apexification is undertaken to close the root-end, but with an understanding that there will be no more development of the root in terms of apical maturation and thickening of its dentine walls. The clinical decision as to whether to perform apexogenesis or apexification for immature teeth appears to be clear cut with the teeth deemed to contain vital pulp tissue being subject to apexogenesis and teeth deemed to have nonvital pulp tissue receiving apexification. However, certain clinical observations reported recently have broken this clear-cut guideline by showing that apexogenesis may occur in teeth which have nonvital pulps (Iwaya et al. 2001, Banchs & Trope 2004, Chueh & Huang 2006). Moreover, it is

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likely that many clinicians had been treating some cases by an apexogenesis approach despite apparent pulp necrosis, but never reporting the outcome. A new protocol has been suggested in which a haemorrhage is induced to fill the canal with blood clot as a scaffold to allow generation of live tissues in the canal space and continued root formation (length and wall thickness) (Banchs & Trope 2004, Thibodeau & Trope 2007, Thibodeau et al. 2007). Instead of using Ca(OH) 2 as the intracanal medicament between visits to disinfect and to induce apical barrier formation, an antibiotic paste is used for the purpose of disinfection only (Iwaya et al. 2001, Banchs & Trope 2004). This new protocol of treatment coincides with the recent concept of regen- erative medicine which promotes the research and practice of tissue regeneration (National Institutes of Health 2006). On another front, pulp/dentine tissue may be regenerated using tissue engineering technologies. Attempts to regenerate pulp tissue have been consid- ered impossible until recently and major developments in two basic research, namely tissue engineering and stem cell biology. Investigations on dental pulp tissue engineering began in the late 1990s (Mooney et al. 1996, Bohl et al. 1998, Buurma et al. 1999). The isolation and characterization of dental pulp stem cells (DPSCs) (Gronthos et al. 2000), stem cells from exfoliated deciduous teeth (SHED; Miura et al. 2003) and stem cells from apical papilla (SCAP) (Sonoyama et al. 2006) has capitalized the possibility for pulp/ dentine regeneration (Huang et al. 2006, 2008, Murray et al. 2007a, Cordeiro et al. 2008, Prescott et al. 2008). Because of the wide-open apex of the immature tooth, vascularization via apical ingrowth of blood vessels into an engineered construct containing stem cells may facilitate a successful regeneration of pulp/dentine within the canal space (Huang et al.

2008).

This study will overview the shifting concept of treating immature teeth using revitalization rather than apexification and the current status of pulp tissue engineering and regeneration. The review will analyse the fate of apexification as a first-line treatment for immature teeth with nonvital pulps and how this is affected by the shifting paradigm of the management and the coming era of pulp/dentine tissue regenera- tion. Again, apexification does not allow generation or regeneration of vital tissues in the canal space whereas the revitalization or tissue regeneration approaches provide a new chance for those affected teeth to regain biological tissue recovery and growth.

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From this point of view, it seems inevitable that in the interest of patients, apexification may become a less- desirable and less needed clinical treatment in the foreseeable future.

Apexification

Immature teeth undergoing apexification are usually disinfected with irrigants including NaOCl, chlorhexi- dine, EDTA and iodine–potassium iodide (Rafter 2005). The canal is then filled with Ca(OH) 2 paste for the purpose of further disinfection and induction of an apical calcific barrier. Ca(OH) 2 is antimicrobial because of its release of hydroxyl ions which can cause damage to the bacterial cellular components. The best example is the demonstration of its effect on lipopolysaccharide (LPS). Ca(OH) 2 chemically alters LPS which affects its various biological properties (Safavi & Nichols 1993, 1994, Barthel et al. 1997, Nelson-Filho et al. 2002, Jiang et al. 2003). Filling the root canal is undertaken normally when the apical calcific barrier is formed. Without the barrier, there is nothing against which the traditional gutta- percha filling material can be condensed. Besides the fact that Ca(OH) 2 functions as a potent disinfectant, early evidence has suggested osteo-inductive properties (Mitchell & Shankwalker 1958), although it has been difficult to demonstrate this effect in vitro (Raquel Assed Bezerra da et al. 2008). It was considered that the high pH may be a contributing factor for the induction of hard tissue formation (Javelet et al. 1985). The time required for apical barrier formation in apexification using Ca(OH) 2 may be considerable, often as long as 20 months and other conditions such as age and presence of symptoms or periradicular radiolucencies may affect the time needed to form an apical barrier. Refreshing the Ca(OH) 2 paste usually takes place every 3 months (Rafter 2005). A number of shortcomings can be summarized for Ca(OH) 2 apexification: (i) long time-span of the entire treatment; (ii) multiple visits with heavy demands on patients and carers and inevitable clinical costs; (iii) increased risk of tooth fracture using Ca(OH) 2 as a long-term root canal dressing (Cvek 1992, Andreasen et al. 2002). These drawbacks led to the use of mineral trioxide aggregate (MTA) to fill the apical end without the need for calcific barrier formation. In comparison to Ca(OH) 2 , some data suggest that MTA appears to be more predictable with consistent hard-tissue formation based on in vivo studies in dogs (Shabahang et al. 1999). Using MTA for apexification may shorten the treatment period with

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more favourable results and improved patient compli- ance (Maroto et al. 2003, El-Meligy & Avery 2006, Pace et al. 2007). Many authors and clinicians propose a one-visit apexification protocol with MTA, which presents a major advantages over traditional Ca(OH) 2 methods (Witherspoon & Ham 2001, Steinig et al. 2003). This expedient cleaning and shaping of the root canal system followed by its apical seal with MTA makes the rapid placement of a bonded restoration within the root canal possible, which may prevent potential fractures of immature teeth. While advances with MTA and bonded restorations go some way towards a better outcome, ultimately no apexification method can produce the outcome that apexogenesis can achieve, i.e. apical maturation with increased thickness of the root. As noted above, clinical experience on the outcome of apexified teeth with thin and weak roots after successful treatment is that they are highly susceptible to fracture (Cvek 1992, Katebzadeh et al. 1998). Therefore, alternative ap- proaches that allow the increase of root thickness and/or length should be pursued.

A paradigm shift in the management of immature teeth

Although the standardized clinical approach for apexo- genesis or apexification has been widely practiced, some clinicians inevitably modify their treatment procedures based on their clinical judgement. Some reported their cases using alternative approaches, with three appearing to capture great interest from the endodontic community. The first, reported by Iwaya et al. (2001) presented an immature mandibular premolar with a sinus tract and periradicular radiolu- cency. During canal preparation, they did not instru- ment to full working length because the patient felt discomfort on the insertion of instruments. The canal was mainly irrigated with NaOCl and hydrogen perox- ide and further disinfected with antibiotic agents (metronidazole and ciprofloxacin). Thirty-five months after the completion of these procedures, they observed complete maturation of the root apex with thickened root structure. The tooth also responded positively to electronic pulp testing. After observing the success of this alternative approach, the same idea was applied to treatment of a mandibular premolar having a similar condition but with more extensive periradicular bone loss. During careful follow-up to 2 years after the treatment, complete maturation of the root was observed with a positive response to cold testing

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(Banchs & Trope 2004). Chueh & Huang (2006) later reported four mandibular premolars in a similar clinical condition that were treated between 1988 and 2000, all again demonstrating healing and apical maturation. These reports raised a great response and encouraged further reports (Thibodeau & Trope 2007, Hargreaves et al. 2008, Jung et al. 2008). A more conservative approach and a shifting paradigm for the treatment of nonvital immature teeth has thus been proposed (Huang 2008). Furthermore, the Regenerative End- odontics Committee of the American Association of Endodontists has initiated a pilot study by encouraging endodontists to submit their cases to a data base (http://www.aae.org/members/revascularizationsurvey. htm). The study is designed to determine the incidence and predictors of healing of apical periodontitis in cases considered to have nonvital pulps when treated by nonconventional, biologically based revitalization methods. Currently, the success rate of this type of approach is only available from an animal study model (Thibodeau et al. 2007) and a pilot clinical study in humans (Shah et al. 2008). In the animal model, it was found that after disinfection of the root canals, 43.9% of the cases had thickened canal walls, 54.9% had apical closure and 64.6% had no radiographic evidence of periapical radiolucency or showed improvement/ healing of previous periapical radiolucencies (Thibo- deau et al. 2007). The clinical pilot study involving teeth in 14 patients demonstrated 93% resolution of periradicular radiolucencies, thickening of lateral den- tinal walls in 57%, and increased root length in 71%. None of the cases presented with pain, reinfection or radiographic enlargement of pre-existing periapical lesions (Shah et al. 2008). However, due the prelimin- ary nature of the study, the clinical success rates should be interpreted with caution (Messer 2008). Regarding the use of Ca(OH) 2 versus antimicrobial paste, it was suggested that the former may not be suitable if there is remaining vital pulp tissue in the canal. The direct contact of Ca(OH) 2 paste with the tissue will induce the formation of a layer of calcific tissue which may occlude the pulp space, therefore preventing pulp tissue from regeneration (Huang 2008). Another concern is that Ca(OH) 2 may damage the Hertwig’s epithelial root sheath (HERS) and thereby destroy its ability to induce the nearby undifferentiated cells to become ododontoblasts (Banchs & Trope 2004). The effectiveness of a triple-antibiotic regimen to disinfect root canal space was first tested and verified by Sato et al. (1996) and the clinical use of the mixture has shown success in terms of clinical outcome (Sato

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et al. 1996, Banchs & Trope 2004, Jung et al. 2008). Whether the three antibiotics originally described (i.e. metronidazole, minocycline and ciprofloxacin) must be used for this purpose or if other choices may serve this purpose requires further investigation. These clinical case reports demonstrate that despite the formation of periapical abscesses with extensive periradicular bone resorption as the result of root canal infection in immature teeth, conservative treatment may allow roots to increase in length and thickness or even reach mature form. One explanation is that the clinical diagnosis of pulp status is inaccurate and that some of those teeth must have contained vital tissues in the apical pulp space despite negative pulp testing and periapical lucencies. It is also acknowledged that there is a lack of scientific studies on the diagnosis of pulpal pathology in permanent teeth with open apices (Camp 2008). It has been considered that, to have continued root development, HERS and the recently identified tissue, apical papilla, must be functional (Huang et al. 2008). On the other hand, if the pulp, HERS and apical papilla are completely lost, the root may still gain some level of thickness by the ingrowth of cementum from the periapical areas onto the internal root canal dentine walls. Additionally, this cementum ingrowth is accom- panied by periodontal ligament (PDL) and bone tissue (Kling et al. 1986, Andreasen et al. 1995a,b).

The outcome of guided generation and regeneration approach

The use of the term ‘revascularization’ was adapted by Iwaya et al. (2001) to describe the clinical healing of periapical abscesses and continued root formation in immature teeth with nonvital pulps. Other authors adapted the term without questioning until Huang & Lin (2008) considered that ‘revascularization’ did not encompass the actual healing and repair process that takes place in these clinical cases (Huang & Lin 2008). The term ‘revitalization’ used by earlier studies attempting to revive tissues in the pulp space would perhaps describe the phenomenon more accurately (Nevins et al. 1976).

Pulp space filled with regenerated pulp

The ideal situation is that there is surviving pulp and apical papilla tissue after root canal disinfection. Continued root formation to its maturity and an increased thickness of root dentine may then be anticipated. The dental papilla at the apex contains

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stem cells, ‘SCAP’ that have been recently described to be more robust stem cells than DPSCs (Sonoyama et al. 2006). The SCAP may survive the infection and retain the capacity to give rise to new odontoblasts influenced by HERS, allowing new root dentine to form and root maturation to proceed to completion. It was speculated that the surviving DPSCs in the remaining vital pulp may rebuild the lost pulp tissue in the canal and differentiate into replacement odontoblasts to substitute for the damaged primary odontoblasts (Sonoyama et al. 2008). Under this circumstance, one may anticipate the newly formed odontoblasts from SCAP to produce root dentine that leads to the apical extension of the root. Additionally, the existing primary odontoblasts that survived in the residual pulp tissue and perhaps some new replacement odontoblasts may continue to lay down dentine on the dentinal walls, causing the root to increase its thickness (Fig. 1). Whilst this explanation is conjecture and requires further basic and clinical investigation, some data on the recovery of pulp tissue after tooth replantation appear to support this speculation (Kling et al. 1986, Ritter et al. 2004).

Pulp space filled with periodontal tissues

In cases where the entire pulp, apical papilla tissues and the HERS are lost, current understanding is that self-regeneration of pulp and new dentine formation is unlikely to occur. There is abundant evidence in the literature demonstrating that when the pulp tissue of

Apical papilla Epithelial diaphragm Bone CementumCementum PDL Pulp Dentin Odontoblasts ? Figure 1 Hypothetical
Apical papilla
Epithelial diaphragm
Bone
CementumCementum
PDL
Pulp
Dentin
Odontoblasts
?
Figure 1 Hypothetical pulp regeneration from the remaining
recovered pulp. The question mark indicates that the regen-
eration of pulp into the empty pulp space is uncertain at
present.

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Figure 2 Ingrowth of periodontal tissue into pulp space. (a) Radiographs show- ing an immature tooth 11 (FDI notation) with an open apex which was re-implanted and healed. At recalls, the ingrowth of bone tissue with the PDL space and lamina dura is evident [adapted from Kling et al. (1986) with permission). (b) Illustration depicting the ingrown tissues of bone, PDL and cementum into the canal space.

immature teeth with wide-open apices undergoes complete necrosis but in a sterile environment, other tissues are capable of filling the canal space. As shown in the radiographic images (Fig. 2), the replanted avulsed immature tooth lost pulp vitality but the pulp

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a
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(b)

Bone Bone PDL PDL Bone
Bone
Bone
PDL
PDL
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Cementum

Cementum

PDL

Cementum

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space became occupied by the ingrowth of alveolar bone from the periapex (Kling et al. 1986). There is a space separating the ingrown bone and the canal dentinal walls. If one traces this space, it is apparent that it is continuous with the PDL space on the external

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root surfaces. Lamina dura also appears to have been established in the ingrown bone occupying the pulp space. The contents of the pulp space were described by Holan (1998) as ‘tube-like mineralization’ and follow- ing histological examination it was interpreted that secondary dentine and the pulp tissue existed in the canal space. In fact, this ‘secondary dentine’ was actually cementum and the ‘pulp tissue’ was PDL. Careful examination of the characteristics of the ectopic cementum and PDL in the canal space should be the basis of further research. There also seems to have been some degree of vertical and horizontal extension of the root over time (Fig. 2). Since the pulp tissue has been entirely lost, it has not been possible to deposit new dentine, and the newly acquired calcified tissue has to come from a tissue source where the cellular components are capable of proliferating and producing new tissues. Cementum has the capacity to fulfill this purpose. Histologically, the hard tissues, bone, cementum and dentine can usually be distinguished unambiguously merely for their anatomical location. However, when ectopic formation of these tissues occurs, discerning them without specific markers may be difficult. None- theless, the ingrown hard tissues within the pulp space have been verified by histological examination, reveal- ing the deposition of cementum onto the dentine surface in the canal, extending from the outside surface of the apex (Nevins et al. 1977, Lieberman & Trow- bridge 1983). The apical extension of roots resulting from the apposition of cementum is a normal physio- logical process. The apposition of calcified cemental tissue on the internal canal wall also increases the thickness of the root. A distinct feature of cementum is its connection with the PDL by Sharpey’s fibres, which can also be observed in the ingrown tissues in the pulp space. The ingrowth of periodontal tissue may reach all the way to the coronal pulp chamber (Nevins et al. 1977, 1978, Ellis et al. 1985, Hitchcock et al. 1985). Similar results were observed in a dog as a study model (Thibodeau et al. 2007). When the pulp space is filled with periodontal tissues, the situation is totally different from normal because the pulp space is no longer part of the root canal system, but part of periapical tissues. If the tooth becomes reinfected causing destruction of the peri- odontal tissue in the canal space, the understanding of a root canal infection to this type of infection cannot be applied, but perhaps more appropriately that of a periapical tissue pathosis. It is known that periapical tissue loss will recover if the source of infection from the

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root canal space is eliminated though the establishment of a biofilm by the invading microbes may complicate management (de Paz 2007). From this perspective, disinfection does not have to involve with the aggres- sive entrance into the canal space, but rather dealing mainly with the source of infection in the crown. Currently, there is no case report showing the man- agement and the outcome of infected canal space that has been filled with periodontal tissues.

Severe disorganized calcification of the pulp space

Whether the pulp space is filled with regenerated pulp or periodontal tissues, long-term radiographic observa- tions demonstrate that the pulp space becomes severely narrowed or filled with radio-opaque mineralized tissue over time. Histologically, the mineralizing tissues are either bone-like or dentine-like (Robertson et al. 1997). The hard tissues may begin as calcific particles that have been observed to originate or are closely associ- ated with blood vessels and perineurium sheaths (Pashley et al. 2002). Interestingly, these are also the locations where pulp stem cells are believed to exist (Shi & Gronthos 2003). Whether these stem cells are activated by the low-grade inflammation to undergo osteogenic differentiation is unclear at present. Over time, these particles merge into larger calcific masses and obliterate the pulp space (Fig. 3). Although this calcifying phenomenon within the pulp has been well- documented, the mechanisms underlying this process are still elusive. Prolonged inflammation causes calcification in many parts of the body, e.g. calcifying tendonitis (Uhthoff 1996). Arthritic joints tend to build osteophytes as a result of the expanding bone tissue over the damaged cartilaginous tissues (van der Kraan & van den Berg 2007). Another phenomenon named heterotropic ossification is characterized by the formation of miner- alized inclusions within the soft tissues (McCarthy & Sundaram 2005), e.g. muscles of patients who suffered from severe trauma to their extremities including soldiers injured by bomb explosions (Owens et al. 2006). It has been speculated that the causes of such phenomena include systemic factors and/or local inflammatory conditions. Stem cells in the muscle have been investigated for their potential contributory role in this disease. Deficiencies in osteopontin may lead to vascular calcification (Giachelli 2005). There has been an ongoing debate on the relative benefits of calcified material or gutta-percha filled canals. From a physiological point of view, calcific

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Figure 3 Common feature of pulp undergoing calcific metamorphosis. (a) Pulp tissue from a tooth which had been previously restored with old fillings and a clinical diagnosis of normal pulp (arrows indicate mineral deposits that appear to have been associated with vascular structures) (b, c) Pulp tissues from teeth diagnosed with irreversible pulpitis. Arrows indicate heavy mineral deposits.

(a) (b) (c)
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metamorphosis is a degenerative disease. Moreover, from a technical perspective, calcified canals pose a challenge if they need treatment. Most of the literature does not support endodontic intervention in the case of mineralized obliteration unless periradicular pathoses is detected or the involved tooth becomes symptomatic (Robertson et al. 1997, Gopikrishna et al. 2004). Sur- gical intervention may be the only option to contain the infection from the periradicular tissues if calcified canals are not accessible for nonsurgical root canal treatment.

Progress on pulp/dentine tissue engineering and regeneration

The potential of pulp tissue to regenerate lost dentine is well-known. Direct pulp capping therapy to induce dentinal bridge formation is practiced on the basis of this understanding. The use of various cement-based mate- rials such as Ca(OH) 2 and MTA is believed to promote such activity. Long-term success using MTA for direct pulp capping has been reported recently (Bogen et al. 2008). The application of recombinant growth factors to the injured site to enhance the regeneration of dentine has also been investigated (Rutherford & Gu 2000). Cell-based therapy using isolated pulp cells or DPSCs, with genetic manipulation to express bone morphogenic proteins, to augment the generation of new dentine bridge formation is an additional area of exploration (Rutherford 2001, Iohara et al. 2004). When dealing with the initial phases of dentine destruction where there is minimal damage, applying a

complicated biotechnological approach appears imprac- tical. When the tooth is further damaged, regeneration of dentine becomes difficult as it needs a healthy pulp which may be compromised by the disease. Ideally, the regenerated dentine should not replace the pulp space. Two types of pulp regeneration can be considered based on the clinical situations: (i) partial pulp regeneration and (ii) de novo synthesis of pulp. It has been observed that pulpal infection and inflammation is compartmentalized until the entire pulp tissue undergoes necrosis (Seltzer et al. 1963, Trowbridge 2002). Before the end stage, the remaining pulp tissue may be recoverable and help regenerate the lost portion. To enhance the regeneration, engineered pulp tissues may be inserted into the pulp space to facilitate the entire recovery of pulp tissue and the generation of new dentine. When the entire pulp tissue is lost, de novo synthesis of pulp must take place to regenerate the tissue.

Early efforts on pulp regeneration

Regenerating pulp tissue has been a long quest. Ostby (1961) studied the tissue re-organization in the canal space filled with blood clot. It was observed that the tissue formed in the canal was not pulp but granulation or fibrous tissues and in some cases the ingrowth of cementum and bone occurred. Similar findings were observed by Myers & Fountain (1974) in a primate study using blood clot as a scaffold. The average generation of soft connective tissue into the canal was only 0.1–1.0 mm, although the authors mentioned

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that teeth with open apices had a few more millimetres of ingrowth than those with mature apicies (Myers & Fountain 1974). It appears that in a natural situation, regeneration of pulp cannot occur following total loss of pulp tissue. Pulp cells have been isolated for various studies for many decades and they have been shown to have the capacities to differentiate into mineral forming odonto- blast-like cells in vitro (Tsukamoto et al. 1992, About et al. 2000, Couble et al. 2000). However, it was not until it was demonstrated the formation of ectopic dentine/pulp-like complex in vivo by isolated pulp cells that the isolation of odontoblast progenitor cells or pulp stem cells was truly confirmed (Gronthos et al. 2000). These cells were termed postnatal DPSCs.

Pulp tissue engineering

Before the isolation of DPSCs, pulp regeneration was tested using modern tissue engineering concepts by growing pulp cells onto synthetic polymer scaffolds of polyglycolic acid (PGA) and in vitro and in vivo analyses performed (Mooney et al. 1996, Bohl et al. 1998, Buurma et al. 1999). These approaches are basically a proof-of-principle to test whether cultured pulp cells can grow well and produce matrix on PGA, and whether the engineered pulp can be vascularized using in vivo study models. This approach reflected the emphasis on providing a three-dimensional structure for cells to attach to which simulates the in vivo environment. Using a tooth slice model, generation of well-vascularized pulp-like tissue has been reported (Cordeiro et al. 2008, Prescott et al. 2008).

Issues in cell-based pulp tissue engineering

The following questions must be considered when attempting to engineer and regenerate pulp tissue:

(i) vascularization: can the angiogenesis from the limited apical blood supply extend to the coronal end if the entire pulp is to be regenerated? (ii) New odontoblast formation: can the new odontoblasts form against the existing dentinal wall that has been chemically disinfected during the root canal procedures? (iii) New dentine formation: can the newly differentiated odonto- blasts produce new dentine and how much would they produce? (iv) Cell source: autologous cells are still the best cell source to avoid potential immune rejection. However, where can one find the cells needed for pulp regeneration in the clinical setting? These points will now be discussed in turn.

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Vascularization While vascularization is a universal issue for an engineered tissue, it is of special concern for pulp tissue engineering because of the lack of a collateral source of blood supply. It was considered that the use of angiogenic inducing factors such as vascular endothe- lial growth factor (VEGF) could enhance and accelerate pulp angiogenesis. Alternatively, the insertion of engi- neered pulp tissue may have to be separated into multiple steps to allow progressive vascularization (Huang et al. 2008). The choice of scaffold and the source of angiogenic factors have become integrated issues. Artificial synthetic scaffolds such as co-polymer of d,l-lactide and glycolide can be fabricated with impregnated growth factors such as VEGF and/or platelet-derived growth factor (Sheridan et al. 2000, Richardson et al. 2001, Peters et al. 2002, Kanematsu et al. 2004, Stiver et al. 2004, Sun et al. 2005). The size of apical opening would affect the ingrowth of blood vessels into the engineered pulp tissue. It is assumed that the larger the opening, the more likely that angiogenesis can occur. Immature teeth with open apices are therefore the best candidates for pulp tissue regeneration. It is a misconception to adapt the concept of engineering/regenerating bone for pulp tissue. Certain scaffolds that have osteo-inductive or conductive prop- erties and are suitable for bone regeneration, such as hydroxyapatite and tricalcium phosphate have been proposed as scaffolds for pulp regeneration. The misconception is based on the fact that dentine production has many aspects similar to bone forma- tion. However, it is important to recognize the key differences. An obvious one is the anatomic character- istics. Bone mass contains compact or trabecular bone and marrow, whereas dentine and pulp in a tooth have a rigid anatomic location. When regenerating pulp and dentine, the dentine should be located peripherally to the pulp, not within it. Therefore, the scaffold that carries the cells to regenerate pulp and dentine should not induce dentine formation randomly within the regenerated pulp.

New odontoblast formation To address the question whether new odontoblasts can form on the existing dentine walls, in vitro experiments have shown that by seeding DPSCs onto the existing dentine, some cells transformed into odontoblast-like cells with a cellular process extending into dentinal tubules (Huang et al. 2006). A tooth slice model has been utililzed and seeded SHED onto synthetic scaffolds

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of poly-l-lactic acid cast in the pulp chamber of the thin tooth slice. They observed odontoblast-like cells arising from the stem cells and localized against the existing dentine surface in their in vivo study model (No¨r 2006, Cordeiro et al. 2008). From these observations, it appears that stem cells seeded in the scaffold will be attracted to the dentinal wall, differentiate into odon- toblast-like cells and extend their cellular processes into the dentinal tubules. The mechanism behind this phenomenon has been speculated to be the released growth factors such as TGF-b by the dentine, which attracts and induces the differentiation of odontoblasts (Huang et al. 2006). Chemical disinfection of the root canal space may damage these embedded growth factors. Further investigation is needed to seek for ways to avoid this potential damage, and positively promote odontoblast-like colonization.

New dentine formation The next question is whether these newly formed odontoblast-like cells will make new dentine. In an in vivo study model, DPSCs were seeded onto dentine and the construct implanted into the subcutaneous space of immunocompromised mice. Deposition of reparative dentine-like structures by odontoblast-like cells was observed (Batouli et al. 2003). This finding suggests the possibility of forming additional new dentine on existing dentine if new odontoblasts can emerge. Huang G.T.-J., Shea L.D., Shi S. & Tuan R.S. (upubl. data) also demonstrated that new dentine-like or osteodentine structure can deposit onto the existing dentine throughout the entire canal wall in an in vivo pulp engineering/regeneration study model.

Cell source With respect to the cell source, there are several potential sources to obtain autologous cells for pulp/ dentine tissue regeneration: DPSC, SCAP and SHED. Immature third molars are one of the best sources for DPSCs and SCAP. The latter have been shown to be more potent dental stem cells than DPSCs in terms of their level of immaturity and potentiality. They give rise to odontoblast-like cells and make ectopic dentine in in vivo study models (Sonoyama et al. 2006) . SHED also produce ectopic dentine in vivo (Miura et al. 2003). The problem is the availability of this source. Banking personal teeth for future use appears to be a direction that must be explored and established to ensure this availability. Allogenic cells are an alternative and convenient source. The finding of the immunosuppres- sive capacity of mesenchymal stem cells to avoid

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immuno-rejection provides a great possibility that allogenic stem cells may be a good source (Pierdome- nico et al. 2005, Chen et al. 2006). However, in vivo studies to verify the long-term survival of transplanted allogenic dental stem cells are lacking.

Prospects

The above analysis points out the potential future fate of apexification procedures. Such procedures may no longer be the preferred first option to treat immature permanent teeth with nonvital pulps. Induced genera- tion and regeneration of vital tissues in the pulp space can thicken the root structure leading to a stronger tooth with a potentially reduced fracture risk. The progress of pulp/dentine regeneration so far has been promising and is likely to work in the not so distant future. There is some concern caused by the uncertainty as to how pulp regeneration would affect the future of endodontic practice (Murray et al. 2007b) . One may anticipate that to feasibly deliver stem cell-based endodontic therapy for pulp/dentine regeneration in endodontic practice, an uncomplicated clinical protocol would need to be established. If not, technology transfer to the commercial sector would be difficult (Rutherford

2007).

Acknowledgements

This work was supported in part by an Endodontic Research Grant from the American Association of Endodontists Foundation (G.T.-J.H.).

Reference

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doi:10.1111/j.1365-2591.2009.01581.x

doi:10.1111/j.1365-2591.2009.01581.x

Polymerization stress, flow and dentine bond strength of two resin-based root canal sealers

S. F. C. Souza 1,2 , A. C. Bombana 3 , C. Francci 2 , F. Gonc¸alves 2 , C. Castellan 2 & R. R. Braga 2

1 School of Dentistry, Federal University of Maranha˜o, Sa˜o Luiz, MA; Departments of 2 Dental Materials and 3 Restorative Dentistry University of Sa˜o Paulo, Sa˜o Paulo, SP, Brazil

Abstract

Souza SFC, Bombana AC, Francci C, Gonc¸alves F,

Castellan C, Braga RR. Polymerization stress, flow and dentine bond strength of two resin-based root canal sealers. International Endodontic Journal, 42, 867–873, 2009.

Aim To compare two resin-based root canal sealers (AH Plus and dual cure Epiphany) in terms of flow, polymerization stress and bond strength to dentine. Methodology Flow was evaluated by measuring the diameter of uncured discs of sealer (0.5 mL) after 7 min compression (20N) between two glass plates (n = 5). Polymerization stress was monitored for 60 min in 1-mm thick discs bonded to two glass rods (Ø = 5 mm) attached to a universal testing machine (n = 3). Bond strength was analyzed through micropush-out test (n = 10) and failure mode was examined with scan- ning electron microscope (100· and 2500·). Data

were statistically analyzed using the Student’s t-test (a = 0.05). Results Polymerization stress was 0.32 ± 0.07 MPa for Epiphany self-cure, 0.65 ± 0.08 MPa for Epiphany light-cure and zero for AH Plus (P < 0.05). Flow data and bond strength values were 30.9 ± 1.1, 28.6 ± 0.7 mm and 6.3 ± 5.3, 17.8 ± 7.5 MPa for Epiphany and AH Plus, respectively (P < 0.001). Failure mode was predominantly cohesive in the sealer for both materials. Conclusions Epiphany had higher flow and poly- merization stress and lower bond strength values to dentine than AH Plus. In view of these findings it can be implied that AH Plus would provide a better seal.

Keywords: apical gap, flow, micropush-out, poly- merization stress, root canal sealer.

Received 3 November 2008; accepted 5 March 2009

Introduction

Complete filling of the root canal system with biocom- patible and dimensionally stable filling materials is an important factor in achieving endodontic success (Sjo¨gren et al. 1990). Gutta-percha in combination with sealers of different chemical compositions has been widely used in clinical practice. However, filling com- pletely the root canals system remains a challenge despite the large number of techniques and materials available (Schwartz 2006). Adhesive bonding and resin cements developed for endodontic use have emerged as

Correspondence: Dra Soraia de Fa´tima Carvalho Souza, Faculdade de Odontologia, Universidade Federal do Maranha˜o (UFMA), Av. dos Portugueses s/n, Bacanga, Sa˜o Luis, MA 65085-580, Brazil (Tel.: +55 98 21098575; e-mail:

sosocarvalho@usp.br).

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a possibility to improve root canal filling (Weis et al. 2004). In 2004, a new adhesive root filling material, Epiphany Root Filling System, was patented by Pentron Clinical Technologies (Wallingford, CT, USA). This system contains a polyester-based thermoplastic root canal core material (Resilon; Resilon Research LLC, Madison, CT, USA), a dual-cure methacrylate-based sealer and a self-etching primer. This material can promote hybridization with the dentine substrate and a chemical bond with Resilon, improving resistance to bacterial leakage (Shipper et al. 2004, 2005) and root fracture (Teixeira et al. 2004a) due to a potential resin monoblock formation (Teixeira et al. 2004b). Neverthe- less, an ultrastructural evaluation revealed a weak link between Resilon and dentine (Tay et al. 2005a). Methacrylate-based sealers shrink during polymeriza- tion (Ferracane 2005), generating stress within the material and at the tooth-restoration interface that can

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lead to gap formation (Carvalho et al. 1996, Braga et al. 2002, De Munck et al. 2005). The magnitude of stress is influenced by several factors, such as composition and volume of the material and cavity configuration factor (factor-C) (Davidson & de Gee 1984, Davidson et al. 1984, Davidson & Feilzer 1997). In composite restora- tions, the use of low viscosity materials has been associated with a reduced incidence of marginal gaps at the tooth/restoration interface (Uno & Asmussen 1991, Peutzfeldt & Asmussen 2004) and better adapta- tion to cavity walls (Ferdianakis 1998, Fruits et al. 2002). On the other hand, viscosity is directly related to degree of conversion (Lovell et al. 1999, Sideridou et al. 2002) which, in turn, is a determinant factor on polymerization stress development (Braga & Ferracane 2002, Stansbury et al. 2005). The high C-factor situa- tion represented by the filling of root canals may originate high polymerization stresses (Goracci et al. 2004), exceeding bond strength to root dentine and causing debonding of the interface for stress relief (Tay et al. 2005b). Furthermore, resin sealer photoactivation for immediate coronal sealing hinders the resin viscous flow and increases stress build-up (Ferracane 2005), resulting in inappropriate bond strength or gap forma- tion between sealer and root dentine (Nagas et al. 2007). The aim of this study was to compare an epoxy- and a methacrylate-based root canal sealer in terms of several characteristics involved in apical gap formation. The null hypothesis was that AH Plus (Maillefer, Dentsply Ind. e Com. Ltda., Petro´polis, RJ, Brazil) or Epiphany (Pentron Clinical Technologies, Wallingford, CT, USA) would show no difference terms of flow, polymerization stress and dentine bond strength.

Materials and methods

Flow

According to ADA 57 Specification (American National Standard/American Dental Association, 2000), 0.5 mL of sealers was mixed and placed using a graduated syringe, on a glass plate (40 · 40 · 5 mm). After 180 ± 5 s another glass plate was placed on top of the sealer, followed by load application of 20 N. Then, 10 min after mixing, the load was removed and maximum and minimum diameters of compressed discs were measured with a digital caliper with a 0.01 mm resolution (Mitutoyo MTI Corporation, Tokyo, Japan). Results were recorded only if both diameters were uniform and were within 1.0 mm. Flow was calculated by averaging five specimens.

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Polymerization stress

Polymerization stress was determined using an estab- lished method (Condon & Ferracane 2000, Witzel et al. 2007, Gonc¸alves et al. 2008). One end of two glass rods (B 5 mm · 13 or 28 mm height) was sand-blasted with alumina (150–250 lm), silanated (RelyX Ceramic primer S; 3M ESPE, St Paul, MN, USA) and coated with a layer of unfilled resin (Adper Scotchbond Multi- purpose, bottle 3; 3M ESPE), which was exposed to the light source with 300 mW cm )2 for 40 s. The non- treated ends were attached to the opposite fixtures of a universal testing machine (Model 5565; Instron, Can- ton, MA, USA), and the distance between the treated surfaces was adjusted to 1.0 mm. The 28-mm rod was connected to a crosshead/load cell, whilst the 13-mm rod was connected to a stainless steel fixture containing a slot that allowed, when necessary the distal end of the light-curing guide to contact the rod opposite to the treated surface which was highly polished. Resin sealer (19.6 mm 3 ) was inserted between the treated glass surfaces and formed into a cylinder and excess was removed. An extensometer (Model 2630–101; Instron) was attached to the rods in order to monitor specimen height. The approximation of the glass rods due to composite shrinkage was registered by the extensom- eter and caused the crosshead to move in the opposite direction to restore the initial distance, with 0.01 lm accuracy. Therefore, the values registered by the load cell corresponded to the force necessary to maintain the initial height of the specimen in opposition to the contraction force exerted by the resin sealer (Fig. 1). Three specimens were tested in each experimental condition at 37 C, and force development was mon- itored for 60 min, starting 3 min after mixing. Exper- imental conditions were AH Plus, Epiphany self-cure (SC) and Epiphany light-cure (LC). Epiphany-LC was photoactivated (VIP Ju´ nior; BISCO, Schaumburg, IL, USA) 17 min after mixing with 475 mW cm )2 for 51 s (24 J cm )2 ), following manufacturer’s instructions. Maximum nominal stress (r, in MPa) was calculated by dividing the maximum contraction force [F (N)] by the cross-sectional area of the rods (A) as follows:

r ¼

FðNÞ

Aðmm 2 Þ

Micropush-out bond strengths

Twenty mandibular single-rooted human premolar teeth with straight root canals, anatomically similar

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Souza et al.

Physicomechanical properties of endodontic sealers

1 2 5 3 4
1
2
5 3
4

Figure 1 Schematic representation of the experimental set-up used for polymerization stress determination: (1) fixture conectect to the load cell; (2) long glass rod; (3) short glass rod; (4) stainless steel fixture with a slot to allow for the positioning of the light guide in contact with the glass rod; (5) extensometer.

dimensions, fully developed apices and patency foramen were collected after patient’s informed consent had been obtained under a protocol reviewed and approved by the Ethical Research Committee of Sa˜o Paulo University (protocol number, 177/05). Teeth were cleaned and the working length of each root was established with a size 15 K file (Dentsply Maillefer Ballaigues, Switzerland) 1.0 mm short of the apical foramen. Canals were prepared with a crown-down technique up to size 50 and irrigated with 0.5% NaOCl after every change of instrument. Five millilitres of 17% EDTA was used as final rinse to remove canal wall smear layer. EDTA solution was neutralized with 0.5% NaOCl and then the canal was rinsed with saline solution (15 mL) and dried with paper points. Prepared root canals were randomly (http://www. random.org) divided into two experimental groups (n = 10): AH Plus (Dentsply Ind. e Com. Ltda.) and Epiphany-SC (Pentron Clinical Technologies). Three disc slices of one-millimetre thick (±0.1 mm) were obtained after transverse sectioning (Isomet 1000 Precision Saw; Buehler Ltd., Lake Bluff, IL, USA) the apical 5.0 mm of each root under water cooling. The thickness of each root slice was measured by means of

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a digital caliper (Mitutoyo MTI Corporation, Tokyo,

Japan). The diameters of each apical and cervical slice

were photographed by a digital camera (Q-Color 5; Olympus America Inc., Center Valley, PA, USA)

attached to a stereomicroscope (SZ61; Olympus Amer- ica Inc., Miami, FL, USA) and was measured using Image J software (http://rsb.info.nih.gov/ij/; National

Institute of Health) under 25· magnification. Speci- mens with noncircular shape were discarded to avoid nonuniform stress distributions during testing, resulting

in approximately 25 slices per group. Endodontic sealers

were mixed according to manufacturer’s instructions

and used to fill the entire root canal space. Prior to filling with Epiphany sealer, root canal dentine was etched for

30

s with Epiphany primer. Specimens were stored for

72

h at 37 C and 100% relative humidity.

For the micropush-out test, a compressive load was

applied to the specimen via a cylindrical stainless steel punch attached to a universal testing machine (Kratos Dinamoˆmetros, Embu, SP, Brazil). For each specimen, a punch tip 0.2 mm smaller than its apical diameter was selected and positioned such that it touched only the sealer and did not stress the surrounding root canal walls. The apical aspect of the each specimen was positioned facing the punch tip. Loading was performed

at a crosshead speed of 0.5 mm min )1 until the sealer

was dislodged from the root slice. Tensile bond strength

of each slice was calculated as the force (N) of failure

divided by the bonded cross-sectional surface area and expressed in MPa (Patierno et al. 1996).

Failure mode analysis

For scanning electron microscope (SEM) observation (100· and 2500·, LEO Stereoscan 440, Electron Microscopy Ltd., Cambridge, UK) micropush-out spec- imens were cut longitudinally and root segments were covered with platinum (Coating System MED 020; BAL-TEC AG, Balzers, Liechtenstein). To estimate the percentage of free substrate the interface area was divided into eight segments. This approach, suggested by Fowler et al. (1992), was used to classify failure mode as: (75%); cohesive within sealer (£25%) adhesive-cohesive (>25% to <75%).

Statistical analysis

Data from bond strength to dentine, flow and polymer- ization stress were analyzed using the Student’s t-test. For the bond strength test each tooth derived one single value. The level of significance was fixed at 5%.

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Results

Table 1 summarizes average and SD of the micropush- out test and flow of both sealers. Epiphany presented significantly high flow than AH Plus (P < 0.001). A significant difference was detected between polymeri- zation stress for Epiphany-SC (0.32 ± 0.07 MPa) and Epiphany-LC (0.65 ± 0.08 MPa) as shown in Fig. 2 (P < 0.05). Epiphany-SC started to generate stress 20 min after mixing. Epiphany-LC was photoactivated after 17 min from the beginning of the test, when an abrupt increase on polymerization stress curve occurred. AH Plus revealed zero polymerization stress values during 60 min, and for this reason was excluded from statistical analysis. For the micropush-out test Epiphany-SC had lower values when compared with AH Plus (P < 0.001). Failure mode distribution is shown in Fig. 3: 79.2% cohesive within sealer and 20.8% adhesive for AH Plus, 78.3% cohesive within sealer and 21.7% adhesive- cohesive for Epiphany-SC.

Discussion

Apical gap formation is influenced by local factors such as substrate morphology (Wu et al. 1998, Ferrari et al.

Table 1 Mean values and standard deviations of bond strength to dentine and flow for AH Plus and Epiphany sealers

Groups

Micropush-out (MPa)

Flow (mm)

AH Plus

17.8 (7.5) a 6.3 (5.3) b

28.6 (0.7) b 30.9 (1.1) a

Epiphany

Different letters on the same column show statistically signif- icant differences (P < 0.001).

statistically signif- icant differences ( P < 0.001). Figure 2 Polymerization stress (MPa) as a function

Figure 2 Polymerization stress (MPa) as a function of time (s) of Epiphany self-cure (SC) and light-cure (LC).

International Endodontic Journal, 42, 867–873, 2009

International Endodontic Journal, 42 , 867–873, 2009 Figure 3 Failure mode distribution for experimental groups

Figure 3 Failure mode distribution for experimental groups (%).

2000, Mjo¨r et al. 2001), C-factor (Goracci et al. 2004, Tay et al. 2005b), and also material-related factors such as physical properties of sealers (i.e. flow, polymerization contraction) (Bergmans et al. 2005, Braga et al. 2005) and bond strength to dentine (Tagger et al. 2002, Bouillaguet et al. 2003). This study assessed the possible relationship between flow, polymerization stress and bond strength of AH Plus and Epiphany sealers with apical gap formation. The fact that no stress development was observed for AH Plus up to 60 min after mixing agrees with the manufacturer information that states a setting time of 8 h at 37 C. However, running the polymerization stress test for such long periods is impractical. Notwith- standing, this information is interesting for comparative purposes with the other sealer evaluated. For Epiphany, polymerization stress tests were performed for both curing modes: self-cured, relying only on the peroxide- amine reaction and dual-cured. Epiphany was tested in SC mode because clinically the light from photoactiva- tion does not reach the middle or apical root regions (Hiraishi et al. 2005). The increased polymerization time in SC mode allows materials to flow in a pre-gel state, which could provide stress relief at the dentine/ resin interface (Braga et al. 2002, Braga & Ferracane 2004), and be advantageous for this material. However, polymerization stress when light-curing was used (Epiphany-LC) doubled when compared with Epiph- any-SC (Fig. 2; P < 0.05). This finding is related to an increase in polymerization rate caused by light activa- tion. Nagas et al. (2007) suggested that a decreased polymerization time can adversely affect Epiphany bond strength to dentine. In fact, one could speculate that an

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Physicomechanical properties of endodontic sealers

(a) (b) (c) (d)
(a)
(b)
(c)
(d)

Figure 4 Representative scanning electron microscope (SEM) micrographs of failure mode for AH Plus (a and b) and Epiphany (c and d): (a) sealer cohesive failure showing dentine surface recovered by a thick organic matrix layer with different sizes fillers; (b) adhesive failure showing clean dentine surface only with small fillers and dentinal tubules with organic matrix tags; (c) sealer cohesive failure indicating dentine surface recovered by an organic matrix layer with granular small fillers, and major fillers with a thin plaque format, and also some empty spaces; (d) cohesive and adhesive failure demonstrating dentine surface covered by Epiphany primer and some sealers fragments with fillers closing total or partially dentinal tubules (pointer).

increased polymerization rate conferred by light activa- tion can restrict the chances for polymerization stress release during the pre-gel state (Tay et al. 2005b). In theory, total bond strength is the sum of the strengths of resin tags, hybrid layer and surface adhesion (Pashley et al. 1995). The low viscosity and hydrophilic nature of resin-based sealers in association with pressure caused by condensation technique allowed the sealer to infiltrate into dentinal tubules, forming long tags and secondary branchings (Bergmans et al. 2005, Tay et al. 2005a) In this study, both resin sealers differed in flow (P < 0,001; Table 1), and both of them exceeded specification 57 of American National Standard/American Dental Association (2000). Despite that, Tay et al. (2005a) showed in SEM and Transmis- sion Electron Microscope (TEM) the loss of integrity at dentine/Epiphany sealer and gutta-percha/AH Plus sealer interfaces. These gaps, presumably created by polymerization contraction forces (Tay et al. 2005b), suggest that hybrid layer and long tags do not guaran- tee the absence of gaps (Bergmans et al. 2005). Bond strength between endodontic cements and dentine may be an important property to provide a seal (Tagger et al. 2002). Micropush-out values for Epiphany were lower than for AH Plus (P < 0.001; Table 1). Epiphany polymerization stress may have

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contributed to its lower bond strength value. The amount of stress associated with shrinkage may result in separation of resin-based sealer and dentinal walls, and consequently, bond strength values of this inter- face would decrease (Hiraishi et al. 2005). In this study, bond strength results for Epiphany sealer are compa- rable with other experiments that showed values between 0.32 and 3.73 MPa (Gesi et al. 2005, Ungor et al. 2006, Fisher et al. 2007, Sly et al. 2007, Kaya et al. 2008, Lawson et al. 2008, Lee et al. 2008) though towards the high end range. Although filling the root canal only with the sealer does not accurately represent the clinical situation, this experimental model was chosen because it represents a worst case scenario, as polymerization stress development is directly related to the volume of shrinking material (Tay et al. 2005b). Moreover, by not using gutta-percha and resilon cones, it can be assured that the tested interface is comprised of sealer and dentine only. Epiphany-LC was not included in the micropush-out test because the study was designed to simulate the clinical conditions found at the apical third of the root canal, where the effect of light-curing is likely to be zero. It is reasonable to speculate that, when used in SC mode, the sealer does not totally polymerize. The incomplete polymerization can impair cement mechanical proper-

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ties and chemical stability (Braga et al. 2002). In fact, failure mode analysis revealed a high incidence of sealer cohesive failure for Epiphany (Figs 3 and 4). The integrity loss on dentine/Epiphany interface can be explained by comparing its bond strength to dentine with stress generated during the polymerization con- traction. Apparently, shrinkage stress was high enough to surpass bond strength (Bouillaguet et al. 2003, Tay et al. 2005a). The apparently negligible polymerization stress values determined in the mechanical test (Fig. 2) might be of a much higher magnitude in the root canal, where geometric shape and material confinement are obstacles for stress release. According to Tay et al. (2005b), C-factor of adhesive bonding root filling materials in root canals is highly unfavourable, chal- lenging the concept of total bonding in root canals.

Conclusion

The null hypothesis was rejected for the three variables analyzed. Epiphany had higher flow, lower bond strength to dentine and also developed higher poly- merization stress than AH Plus. Within the limitations of this laboratory study and in view of the results it can be speculated that, clinically, a better interfacial sealing could be expected with AH Plus. The higher bond strength to dentine obtained with AH Plus can be partially explained by its lower polymerization stress. Moreover, its higher viscosity compared with Epiphany did not seem to impair its bond strength.

Acknowledgements

This study was partially supported by CAPES (Coordenac¸a˜o de Aperfeic¸oamento de Pessoal de Nı´vel Superior) Institutional Qualification Program (PQI no.:

0090/03–4). The authors are grateful to Fla´via Rodri- gues for providing the polymerization stress test diagram.

References

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doi:10.1111/j.1365-2591.2009.01582.x

doi:10.1111/j.1365-2591.2009.01582.x

Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant

M. W. Pennington 1 , C. R. Vernazza 2 , P. Shackley 1,3 , N. T. Armstrong 1 , J. M. Whitworth 2 & J. G. Steele 2

1 Institute of Health and Society; 2 School of Dental Sciences, Newcastle University; and 3 Sheffield Vascular Institute, University of Sheffield, Sheffield, UK

Abstract

Pennington MW, Vernazza CR, Shackley P,

Armstrong NT, Whitworth JM, Steele JG. Evaluation of

the cost-effectiveness of root canal treatment using conven- tional approaches versus replacement with an implant. Inter- national Endodontic Journal, 42, 874–883, 2009.

Aim To evaluate the cost-effectiveness of root canal treatment for a maxillary incisor tooth with a pulp infection, in comparison with extraction and replace- ment with a bridge, denture or implant supported restoration. Methodology A Markov model was built to simu- late the lifetime path of restorations placed on the maxillary incisor following the initial treatment deci- sion. It was assumed that the goal of treatment was the preservation of a fixed platform support for a crown without involving the adjacent teeth. Conse- quently, the model estimates the lifetime costs and the total longevity of tooth and implant supported crowns at the maxillary incisor site. The model considers the initial treatment decisions, and the various subsequent

treatment decisions that might be taken if initial restorations fail. Results Root canal treatment extended the life of the tooth at an additional cost of £5–8 per year of tooth life. Provision of orthograde re-treatment, if the root canal treatment fails returns further extension of the expected life of the tooth at a cost of £12–15 per year. Surgical re-treatment is not cost-effective; it is cheaper, per year, to extend the life of the crown by replacement with a single implant restoration if orthograde endodontic treatment fails. Conclusion Modelling the available clinical and cost data indicates that, root canal treatment is highly cost- effective as a first line intervention. Orthograde re-treatment is also cost-effective, if a root treatment subsequently fails, but surgical re-treatment is not. Implants may have a role as a third line intervention if re-treatment fails.

Keywords: cost-effectiveness,

implant, Markov, root canal treatment.

decision

analysis,

Received 16 September 2008; accepted 17 March 2009

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Introduction

Clinical decisions could be consistent and straightfor- ward, if they were informed by unequivocal evidence, supported by clear and accepted guidelines, and if the recommended actions were universally acceptable to

Correspondence: Mark W. Pennington, MSc, PhD, Research Associate, Institute of Health and Society, Newcastle Univer- sity, 21 Claremont Place, Newcastle upon Tyne NE2 4AA, UK (Tel.: +44 191 222 3544; fax: +44 191 222 6043; e-mail:

mark.pennington@ncl.ac.uk).

International Endodontic Journal, 42, 874–883, 2009

patients and care providers. But few areas of practice are so clear-cut. Patients are not always equipped with the information they need to make rational decisions on their short and long-term care, and healthcare agencies might equally be ill-equipped to advise on best actions for the short and long term. As a consequence, patients may submit to the paternalistic decision- making of a healthcare professional (Kaba & Sooria- kumaran 2007) whose priorities may be expected to be objective, consistent and based on the same values as their own. But observations from medicine and dentistry suggest that the decisions of healthcare

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professionals themselves may be highly variable, even in the case of relatively simple interventions (Dome´- jean-Orliaguet et al. 2004, Lanning et al. 2005, van der Sanden et al. 2005, Calnan et al. 2007, Tickle et al. 2007), and influenced by a number of personal, educational and economic considerations (McColl et al. 1999, Brennan & Spencer 2006). The picture is complicated further in the case of complex interventions, and interventions that may not be the final solution within the lifetime of the patient. Here, the decision-making process may be limited to a consideration of the ‘next step’, and informed by short-term ‘success rates’, assessment of immediate costs, or of the willingness of the patient to pay for that individual step. Rarely is the decision- making process informed by a detailed understanding of the relative lifespan of alternative interventions or the ongoing costs, both financial and otherwise (White et al. 2006, Balevi 2008), which may flow from a particular treatment decision. Restorative dental treatments are an example of such an inter- vention, and if patients faced with treatment decisions, or healthcare providers stewarding finite resources are to make properly informed decisions, they must be presented with information on cost and outcome which they understand and which accounts for the long-term. The uncertainties inherent in modelling the costs of combinations of interventions over a lifetime require a fundamentally different approach to the use of evidence to that, with which most clinicians are comfortable. Decision analytic modelling provides a rational frame- work for decision making based on expected costs and outcomes (Raiffa 1968). Many decision analytic models are based on Markov modelling, a mathematical means of investigating stochastic or random events over time (Sonnenberg & Beck 1993). Such modelling lends itself well to the study of long-term medical conditions, defining a clear starting point or condition, and identifying a number of states into which the individual may or may not move at defined points in the future. The probability of remaining in the starting condition or moving to an alternative state is informed by best outcome and survival data, and the costs of initial and future interventions estimated from professional sources. Markov models are increasingly used in evaluating the long-term cost effectiveness of clinical interventions from the chemoprevention of prostatic cancer to the management of heart failure (Chan et al. 2008, Svatek et al. 2008, Takao et al. 2008).

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By contrast, the economic models applied to dentistry have generally been quite simple decision trees (Mil- eman & van den Hout 2003) or Markov models (Edwards et al. 1999) extrapolating over a fixed num- ber of years or the assumed lifetime of a specified intervention (for example, a dental restoration), rather than over the lifetime of the patient. Whilst previous publications have investigated the costs of dental treatments over a fixed time span (Bra¨gger et al. 2005), as far as the authors are aware, this report represents the first attempt to provide a definitive examination of the cost effectiveness of common dental interventions and look at all realistic options that flow from this over the lifetime of a patient. The starting point of the Markov model is a common clinical scenario; a damaged and irreversibly pulpitic maxillary central incisor tooth, where initial treatment options include root canal treatment and restoration, or extraction and prosthetic replacement. The model explores the long-term consequences and cost effectiveness of initial and subsequent decisions for individuals at different ages. The question at the heart of this investigation is whether root canal treatment and restoration of a damaged maxillary central incisor is a legitimate and cost-effective inter- vention over the lifetime of an adult patient, and in comparison with the alternatives of extraction followed by either a conventional or an implant- supported restoration.

Methods

Building the model

For this study, a Markov model was built with TreeAge decision analysis software (TreeAge Software Inc., Williamstown, MA, USA, http://www.treeage.com/ index.htm). The starting point was a damaged, irreversibly pulpitic maxillary central incisor in an otherwise healthy adult male of varying age. The loss of coronal tooth tissue was defined as sufficient to require resto- ration with a post-retained crown. Assuming that the patient requests some treatment to fill the space, and

from this starting position, the patient could occupy any of the six health states listed below at any given point in time, until the end of their life:

Tooth extracted with resin bonded bridge (RBB)

in situ

Tooth extracted with a conventional bridge (fixed

dental prosthesis, FDP) in situ

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Tooth extracted with removable partial denture (RPD) in situ

Tooth root canal treated (RoCT) with a post-

retained crown in situ (there may be repair or replace- ment of any of the parts of the restoration or root filling within this state)

Tooth extracted with an implant-supported single

crown (ISC) in situ (again this could be a first, second or

subsequent restoration)

An implant in situ prior to abutment connection

(the transitional state during osseointegration assum- ing there is no immediate loading)

Death of the patient. The model calculated the probability of the incidence of all significant mechanical and biological complica- tions that might arise in each of these states, over each 6 month period of the patients life, based on existing evidence (see ‘Outcome data’ later). A repair event or no event occurring meant that the simulated patient remained in the same restoration state, whereas complete failure resulted in transition to a different state (e.g. the event of root fracture would require extraction and replacement of the tooth with a pros- thesis of some description). The analysis was simplified by modelling the selec- tion of a bridge or denture prosthesis as a random parameter based on likely distributions in the UK population rather than a treatment choice. The simu- lation terminated when the patient reached 100 years of age or died (using age-related mortality probabilities– govt. actuaries dept., life tables 2002–2004, http:// www.gad.gov.uk/). The number of possible pathways through these various states in a lifetime is clearly massive. The initial treatment decision and then the

potential subsequent treatments necessitated by failure of a restoration are captured in the ten major strategies outlined in Fig. 1. Whilst these cannot capture every single possibility, they were considered the most likely 10 pathways by consensus of two senior clinical academics in Restorative Dentistry (JGS and JMW). Strategy 1 illustrates a decision to extract the irreversibly pulpitic tooth and to replace it with a conventional removable or fixed prosthesis, not an implant. The remaining nine strategies involved either retaining the tooth by root canal treatment, removing it and placing an implant or a combination of these. In comparing each of the 10 major strategies, the costs and expected outcomes of both the initial treat- ment strategy (first intervention) and supplementary interventions (second to fourth intervention) are pre- dicted. Estimations of cost and treatment longevity are central to the model. To examine fully the cost- effectiveness of three initial options (bridge/denture, implant, orthograde endodontics) the costs which might follow them are required. Clearly a RoCT is less expensive than an implant at the point of delivery but will the implant save money in the long term? To do this, it was necessary to model at least the second and third interventions and their costs and outcomes. It is not known what the patient might or should choose when the restoration fails, so all of the reasonable subsequent choices if that happened were considered and evaluated as different strategies. The strategy of placing an implant initially was also evaluated. One of these will be the most cost-effective. It was necessary to look at all of the likely second and third interventions if implants were to be given a fair comparison against RoCT.

Strategy

1st Intervention

2nd Intervention

3rd Intervention 4th Intervention

1 Extraction

Bridge/denture

1 Extraction Bridge/denture

2 One RoCT

Orthograde RoCT

Bridge/denture

2 One RoCT Orthograde RoCT Bridge/denture

3 RoCT then re-treatment

Orthograde RoCT

Orthograde RoCT

Bridge/denture

3 RoCT then re-treatment Orthograde RoCT Orthograde RoCT Bridge/denture
3 RoCT then re-treatment Orthograde RoCT Orthograde RoCT Bridge/denture

4 RoCT then surgery

Orthograde RoCT

Surgical RoCT

Bridge/denture

5 RoCT then Implant

Orthograde RoCT

First implant

Bridge/denture

5 RoCT then Implant Orthograde RoCT First implant Bridge/denture

6 RoCT/Implant/2nd Implant

Orthograde RoCT

First implant

2nd implant

Bridge/denture

7 RoCT/re-treatment/Implant

Orthograde RoCT

Orthograde RoCT

First implant

Bridge/denture

8 RoCT/Surgery/Implant

Orthograde RoCT

Surgical RoCT

First implant

Bridge/denture

9 Implant

First implant

Bridge/denture

9 Implant First implant Bridge/denture

10 Implant then 2nd implant

First implant

Second implant

Bridge/denture

10 Implant then 2nd implant First implant Second implant Bridge/denture

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Figure 1 Sequence of interventions in the ten treatment strategies.

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Cost-effectiveness analysis: data sources

Outcome data In order to function, the model was parameterized with information on expected treatment longevity/ failure rates, and likely maintenance needs of different treatment options. Extensive Searching of MEDLINE, EMBASE, DARE and Cochrane Library databases (from inception to June 2006) was undertaken for all papers with terms including failure, fracture, success, treatment, re-treatment, replacement, complications, survival, (meta)analysis and terms describing the tooth state such as root canal, endodont#, #apical. This was supplemented by systematically checking the references of all papers retrieved for further relevant studies. Meta-analyses were utilized, where available, otherwise parameters were chosen based on the size, quality, age and selection criteria of the study. In the very rare instances where no appropriate data were available, the expert opinions of two senior clinical academics in Restorative Dentistry (JGS and JMW) were sought to define the likely limits of parameters. Three meta-analyses were retreived on the survival of ISCs. The meta-analysis of Branemark implants (Lindh et al. 1998) was selected to parameterize implant survival as it differentiates between implant loss after loading and failure to osseo-integrate. A meta- analysis of prospective studies (Berglundh et al. 2002) provided data to parameterize complications in the implant states. However, the exclusion criteria limited the paper to a small number of studies. Hence, the analysis was judged less satisfactory than those reported by Lindh et al. (1998). The FDP state was parameterized using the most recent and largest meta- analysis (Tan et al. 2004). There are fewer reports on the survival and complication rates for RBBs and no meta-analyses were retrieved. The available data on RPDs is minimal. These states were parameterized from published individual trial or longitudinal studies where available. The heterogeneity of success criteria in reports on RoCT has defied meta-analysis to date (Creugers et al. 1993). Creugers analysis selected only three papers of which one (Mentink et al. 1993) was by far the largest, hence this report was prioritized when parameterizing the post-supported crown states. Rates of failure of root canal after re-treatment were taken from a 10-year Swedish study (Sjo¨gren et al. 1990) whilst rates of treatment failure following surgical endodontics were based on an evaluation of apical surgery (Buhler 1988).

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Costs For the purposes of this model, typical staff time and resource use for each procedure was estimated based on a UK National Health Service (NHS) secondary care setting. Staff costs were taken from published reference costs (Curtis 2006), and costs are in UK 2006 pounds. The base case analysis for this study assumes that all implant procedures were carried out by a senior specialist (consultant) dentist. All of the conventional dental procedures were costed at more junior specialist staff (Specialist Registrar or Senior House Officer) rates reflecting the more routine nature of such interven- tions. Staff costs were based on mid-band salaries and included overheads, training costs and administrative support. Costs and outcomes are discounted at 3.5% according to NICE guidelines for economic analyses. Mortality is parameterized using data for UK males (2002–2004 Government actuaries department). It is important to note that the costs used are based on standard data and represent the costs to the NHS, not the price that may be paid, for example in private practice where there are a range of additional consid- erations, such as profit margins and variations in overhead costs.

Cost-effectiveness analysis: assumptions

In order to develop an economic model such as this, a number of assumptions need to be made. Where possible these are supported by published evidence. The following assumptions were made for this model:

That the patient retains most of the dentition over

his/her lifetime (Kelly et al. 2000)

That the longevity of the restoration is proportional

to the lifetime benefit of the restoration to the patient

ISCs and crowned and root treated teeth provide the same Oral Health Quality of Life (OHQoL)

Apical surgery is undertaken alongside orthograde

re-treatment to enhance success rates, and not as a

response to a distinct clinical indication such as a cyst

RBBs, RPDs and conventional FDPs provide the

same OHQoL, inferior to that of the ISC or crowned tooth. This assumption infers that the retention of a tooth unit in the maxillary anterior region in the form of the original tooth or an implant is preferable to loss of a fixed platform (natural or artificial) for restora- tion. Whilst it is acknowledged that this is not universally the case, this was considered a reasonable working rule, which was necessary to allow the model to compare endodontic strategies with implant strat- egies

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A constant hazard rate is assumed for mechanical

and biological complications following an intervention

The same hazard rate applies to an event, such as

tooth fracture, in the post-supported crown states regardless of whether a surgical or nonsurgical end- odontic re-treatment had occurred. The exception to

this was the rate of root canal treatment failure for which there was available data (see above)

Probability of implant loss and peri-implantitis are

independent. These were modelled independently on the basis of data reported in the literature (Berglundh et al. 2002)

Results are presented for UK males only on the

assumption that dental costs and benefits are indepen- dent of gender. As life expectancy rather than gender dictates costs, results for females would be similar to those for a slightly younger cohort of males with the same life expectancy The literature consists predominantly of follow-up of patients treated in dental hospitals, or in specialist clinics in the case of implants. This may not accurately reflect outcomes achieved in primary-care settings, but robust data in these environments are generally lack- ing. However, sensitivity analysis allowed the cost variables related to hospital staff costs to be varied (see below).

Cost effectiveness: ratio calculation

The outcome measure used in the cost-effectiveness analysis is the total longevity of a fixed platform supported crown, both root canal treated and post- crowned natural tooth, and implant supported crowns. After reviewing the costs and longevity for all ten strategies and ranking them by cost, strategies that were clearly less cost effective (those that were ‘dominated’ or ‘extendedly dominated’, see results) were removed and the rest retained for the calculation of an incremental cost-effectiveness ratio (ICER). This widely used index of cost-effectiveness (Drummond et al. 2005) is the addi- tional financial cost divided by the additional effective- ness (in this case the prolonged longevity of the crown) of that strategy over the next cheapest alternative.

Cost-effectiveness analysis: sensitivity analysis

The key parameters (such as costs and survival) are all estimates and, by definition, likely to be imprecise. To allow for this, plausible ranges for key parameters (such as survival of restorations) were estimated by the academic dental authors, allowing one-way sensitivity

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analysis of the model to be undertaken for each of these parameters. This re-running of the model with different starting parameters illustrates the impact that the inevitable inaccuracies might have on the overall model. The overall costs of each strategy are clearly a product of the estimated dental procedure costs. Dental costs are considerably lower in eastern European countries but average wages and hence patient budgets are also likely to be lower. However, varying the costs of dental wages or implant components will influence the relative cost-effectiveness of each treatment strat- egy. The relative effect of decreasing component costs or increasing dental salaries is likely to be similar – implant costs will fall relative to alternative restorative procedures and implant strategies will be more cost- effective. We simulated three different potential cost environments to illustrate the impact of higher and lower wage costs and the impact of lower implant component costs.

Results

Table 1 shows both the expected total lifetime costs and the expected longevity of the root canal treated tooth and/or implant supported crowns for a male aged 35, 55 and 75 years, without inflation. The values have been ‘discounted’ to take account for change in perceived value with time, using standard measures recommended by NICE (http://www.nice.org.uk/

media/F13/6E/ITEM3FINALTAMethodsGuidePostCon-

sultationForBoardCover.pdf) and this partly accounts for the relatively low monetary values in all strategies. Crown longevity is the sum of the total lifetimes of root canal treated tooth and/or implant supported crowns at that site prior to failure and replacement with a bridge or denture. It is assumed that if no endodontic or implant treatment is provided there will still be a need over the lifetime to fill the space, with a cost consequence [statistically, unfilled anterior spaces are very rare in the UK (Kelly et al. 2000)]. The model predicts superior survival of the ISC over a conventional root canal treated tooth with a post- crown based on published evidence. After 20 years around 25% of root canal treated and re-treated teeth are predicted to have been lost, whereas 10% of first implants have failed, necessitating a further implant or replacement with a bridge or denture. Despite improved longevity, the implant based strategies still require more interim interventions if a two stage procedure is assumed.

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Table 1 Base case results – cost and total crown longevity for each strategy

Strategy

Male age 35 Cost (£) Longevity

Male age 55 Cost (£) Longevity

Male age 75 Cost (£) Longevity

1 (Extraction) 2 (One RoCT) 3 (RoCT then re-treatment) 4 (RoCT then Surgery) 7 (RoCT/re-treatment/Implant) 8 (RoCT/Surgery/Implant) 5 (RoCT then Implant) 6 (RoCT/Implant/2nd Implant) 9 (Implant) 10 (Implant then 2nd Implant)

731

0

649

0

540

0

805

15.81

717

12.62

597

7.1

828

17.29

730

13.56

601

7.41

847

17.51

746

13.66

611

7.43

1071

21.58

916

15.78

694

8

1079

21.59

924

15.78

701

8

1113

21.47

967

15.73

736

7.99

1140

21.85

983

15.88

741

8.02

1623

20.12

1570

14.96

1487

7.74

1717

21.73

1642

15.83

1527

8.01

1800 1600 1400 1200 1000 £ 800 600 Implant/2nd implant Implant 400 RoCT/Implant/2nd implant RoCT/Implant
1800
1600
1400
1200
1000
£
800
600
Implant/2nd implant
Implant
400
RoCT/Implant/2nd implant
RoCT/Implant
RoCT/Surg/Implant RoCT/re-treat/Implant
200
RoCT/Surg
RoCT/re-treat
One RoCT
Extraction
0
35
45
55
65
75
85
95
Age
Figure 2 Cumulative
35 years).
costs
of
each
strategy
(male
age

Figure 2 shows the cost accumulation (discounted) for each strategy over 65 years for a male aged 35 years. The significantly greater initial outlay on placing an implant is evident but slightly mitigated by lower ongoing costs, illustrated by the rather shallow curve. The ongoing costs of strategies five (RoCT/ Implant) and six (RoCT/Two implants) show the steepest gradient, due to a combination of relatively high failure rates of the first treatment (RoCT), and the high cost of the second treatment (implant).

Cost-effectiveness analysis

The 10 strategies model both the initial intervention and the possible subsequent interventions required to maintain a tooth or prosthesis at that site for the patient’s lifetime. To establish cost effectiveness these are ranked in order of cost and their longevity

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reviewed. When this was done, some strategies were clearly less cost-effective because they have poorer longevity but still cost more than others. They are said to be ‘dominated’. Strategies five (RoCT/Implant), nine (One Implant) and 10 (Two Implants) were dominated for patients at all ages analysed (35, 45, 55, 65, 75, 85) and have been excluded. The remaining strategies are each more effective than less expensive alternatives, but some are signifi- cantly more expensive than a comparator but only marginally more effective. It would not make sense to choose such a strategy if, by paying only a little more, we could get a much bigger increase in effectiveness, hence these strategies are excluded (they are said to be ‘extendedly dominated’). Both strategies involving a surgical endodontic re-treatment (strategies four and eight) fell in to this category at each age analysed. Whilst surgical endodontic re-treatment has a higher reported success rate than nonsurgical re-treatment in some studies, this has generally followed endodontic re-treatment. The overall increase in longevity, relative to the increased cost, is small. Additional crown years (longevity) can actually be achieved at a lower cost per year with implants. The results of the cost-effectiveness analysis are shown in Table 2. 1 Strategy 1 (No Treatment) is the least effective and the cheapest, and so this is the comparator for calculating the ICER for strategy two

1 The costs generated by the model are the expected future costs discounted to the present and not the actual costs faced by a patient if he/she was to receive each of the interventions in the strategy. We would expect many patients to die with an intact root treated tooth, only a proportion will go onto to receive subsequent interventions and the model presents the ‘average’ costs given the likelihood of failure of restorations undertaken.

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880

Table 2 Incremental cost-effectiveness ratios (ICERs) for non- dominated strategies over the age range 35–85

ICERs for males aged 35–85 (£)

Strategy

35

45

55

65

75

85

2 (One RoCT) 3 (RoCT then re-treatment) 7 (RoCT/re-treatment/Implant) 6 (RoCT/Implant/2nd Implant)

5

5

5

6

8

ED

15

15

14

13

11

12

57

67

84

111

158

241

252

383 654

1272 2813

6916

ED-extendedly dominated.

(One RoCT). The comparator for each subsequent strategy is the next best alternative after excluding dominated and extendedly dominated options. All the cost-effective strategies involve initial root treatment. Strategy 2 is expected to cost £5–8 more per year of longevity of the root treated tooth than replacement with a bridge or denture. The table reveals that patients who would choose othograde re-treatment should the root canal treatment fail (strategy three) can expect to extend the longevity of the root treated tooth at a cost per year of additional life of £11–£15 over and above the expected cost if a bridge or denture is fitted on failure of the root treated tooth. Patients who would choose an implant rather than a bridge or denture should the re-treatment fail (strategy 2) can expect to extend the longevity of fixed platform supported crown at a likely additional cost of £57–241 per year.

Sensitivity analysis

When each of the key parameters was altered over the limits of likely variation and the models re-run, the impact on the overall cost-effectiveness of each strategy was small, and no changes in the overall rankings were observed. General diffusion of implant technology is likely to lead to lower potential component costs and also more efficient provision by general dentists. The impact of halving all of the implant component costs, and re-costing implant procedures at lower professional rates (£50/hour instead of £87/hour) was examined. The impact of a higher wage setting (such as the US) was simulated by costing all procedures using the UK consultant rate (£87/hour) for dentists and by increas- ing labwork costs by 50%. The impact of a lower wage setting was examined by reducing all wage costs (dentists, assistants and hygienists) to 30% of the UK estimates and by reducing dental laboratory costs by 50%. Costs and ICERs for each scenario for nondom- inated strategies are presented for a 55-year-old male in Table 3. It can be seen that whilst the absolute effect of

International Endodontic Journal, 42, 874–883, 2009

higher or lower wage rates on overall costs is marked, the impact on ICERs is small. Unsurprisingly, lowering both wage rates and component costs only for implant procedures leads to a significant reduction in the costs of implant based strategies, but they are still more expensive than conventional treatment. Only when component costs are radically reduced to 10% of the current costs does an implant strategy (strategy five, RoCT/Implant) extendedly dominate an endodontic strategy (strategy three, two RoCTs), in this case for younger males below the age of 37 years.

Discussion

It is unrealistic to expect most dental restorations to last

for life (Richardson et al. 1999). Although data may be scarce, one systematic review estimated that 50% of all routine dental restorations may be anticipated to last between 10 and 20 years (Downer et al. 1999), whilst life-expectancy for women is now currently 80 years or more (http://www.statistics.gov.uk/cci/nugget.asp?id= 168). As our urban populations continue to age and expectations of dental function and aesthetics continue

to rise, patients, dentists and health planners need to recognize that the next intervention may not be the last, particularly in younger patients. Decisions made at

a fixed point in time may set individuals on a pathway

with long-term ramifications. The example considered in this study was a compro- mised, irreversibly pulpitic maxillary central incisor, with the starting expectation that very few would opt for no treatment at the point of presentation. The immediate choice facing the theoretical patient is whether to preserve the tooth by root canal treatment and a post-retained crown, or whether to have the tooth extracted and replaced with a prosthesis, includ- ing the possibility of a single implant. This decision may be influenced by patient and practitioner-based factors, including perceptions of ‘success’, the special interests of the practitioner, and the attitudes and financial considerations of the patient (Brennan & Spencer 2006, White et al. 2006). Debates on the merits of individual treatment decisions are not new and have been recognized clearly at the endodontic/implant interface, where strong arguments have been made on both sides that certain options are more likely to succeed or to be more economic at the point of delivery (Felton 2005, Trope 2005). But debates on ‘survival’ and immediate costs cannot always account for the lifetime implica- tions, including maintenance and repair, and costs of replacement after outright failure. A decision analytic

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Table 3 Impact of varying wages and implant component costs on cost-effectiveness (55 years old)

 

Base case

Cheaper implants

Higher wages

Lower wages

Strategy

Cost (£)

ICER (£)

Cost (£)

ICER (£)

Cost (£)

ICER (£)

Cost (£)

ICER (£)

1 (Extraction) 2 (One RoCT) 3 (RoCT then re -treatment) 7 (RoC T/re-treatment/Implant) 6 (RoCT/Implant/2nd Implant)

649

649

993

281

717

5

717

5

1088

8

315

3

730

14

730

14

1103

16

321

7

916

84

822

41

1242

63

451

59

983

654

848

254

1286

437

501

486

ICER, incremental cost-effectiveness ratio.

framework combines expected costs and expected benefits in a manner that aids decision making. In the absence of data on patient utility, it was assumed that benefits are proportional to the longevity of a root canal treated tooth or implant; the presentation of ICERs guides the decision according to the value placed on those benefits by the decision maker. For the clinician, the patient, the commissioner or the policy maker the model reported here gives a reason- ably strong guide to the general courses of action that are likely to be the most cost effective in this relatively common scenario. It suggests that root treatment in the first instance is a cost effective strategy, and that the lifetime costs are relatively low, even compared with extraction and replacement with a denture or bridge. Where root treatment fails, in general terms, ortho- grade re-root treatment is still a reasonably cost effective approach. The lifetime costs are a little higher, but still not a great deal higher, than extraction and bridge or denture placement. Following endodontic re-treatment with surgery was not cost effective in a typical presentation, though this does not rule-out the clinical need for surgery in the event of lesions requiring a biopsy, or the diagnosis of a lesion unlikely to heal by orthograde endodontic means. Implant placement is expensive, and is cost effective in this scenario only after endodontic treatment has failed twice. It is not cost- effective as an initial option. Of course these calcula- tions do not take into account the value that an individual patient may place on any given treatment. Markov modelling presents a valuable tool for examining such complex lifetime events. Central to the model is a body of survival and outcome data, which informs the probability of a patient remaining in a given health state or moving to a new health state at defined points in time. It allows extrapolation of the clinical data to estimate the expected costs and outcomes over the patient’s lifetime. The ICERs com- bine costs and outcome data in a manner which facilitates rational decision making at the level of the

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individual, the insurer or the state. It would be easy to misinterpret these findings as some sort of clinical guidance – they are explicitly not that. The model deals in probabilities spread across the generality of patients. Technical or patient issues will tip the balance in favour of one or other approach to treatment for individual patients. However, an understanding of costs and cost effectiveness may help the clinician to advise their patients about the long term costs of any given course of action, or to help insurers or health planners to decide on the basic treatment strategies that give the best value for money. For example, based on this evidence, a reasonable starting point for an insurer may be to provide high quality endodontic treatment, and perhaps to put a premium on high endodontic standards, in the first instance rather than funding implant provision as a first line treatment. The substantial body of evidence that defined the current model is available in the on-line Appendix S1. The literature was unable to provide the very best quality of evidence on all of the interventions consid- ered, so the model was informed by the best available evidence. It is likely that survival of restorations will vary widely according to patient characteristics and the skill of the dentist. The evidence for survival of implants and root treatments was meagre, though of reasonable quality. The weakest evidence related to the survival of partial dentures and bridges. This problem is of course not restricted to Markov modelling, and impacts on any attempt to conduct dental care on a base of evidence. Long-term, prospective clinical trials with large sample sizes and clearly defined outcome criteria are desper- ately needed (Torabinejad et al. 2007). The costs incorporated within the current model were specific to the state funded healthcare system currently operating in the UK. Clearly salary and labwork costs vary significantly in different countries and the impact on overall strategy costs is large. However, it is the relative costs between strategies rather than the actual values that are important. The

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relative impact of changing wage costs is surprisingly small. ICERs are changed, but not by an order of magnitude, and overall ranking of strategies remains the same. Hence recommendations based on the calculated ICERs are less susceptible to care costs in different settings. The sensitivity analysis, which dem- onstrated the stability of the strategy rankings to changes in event probabilities and costs, suggests the findings are robust.

Conclusions

Root canal treatment is an appropriate and cost- effective intervention to extend the life of a maxillary incisor tooth with a diseased pulp. Orthograde re-treatment is also cost-effective, but unless clinically indicated the benefits of additional apical surgery do not justify the additional cost. Increased longevity of the crown can be achieved at a lower cost per year with an implant. At current costs the role of implants is limited to a third line intervention if re-treatment fails.

Acknowledgements

The authors are grateful for the advice of Pelham Barton on the appropriate analysis of sequential treatment decisions, and the critical review and com- ments from Rob Anderson. This work was undertaken by Mark Pennington at Newcastle University without external financial support.

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Supporting Information

Additional Supporting Information may be found in the online version of this article:

Appendix S1. A detailed description of the model including all of the data sources used to parameterise it.

Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the correspond- ing author for the article.

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883
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doi:10.1111/j.1365-2591.2009.01583.x

doi:10.1111/j.1365-2591.2009.01583.x

Long-term sealing ability of Resilon apical root-end fillings

M. A. A. De Bruyne & R. J. G. De Moor

Department of Operative Dentistry and Endodontology, Dental School, Ghent University, Ghent University Hospital, Gent, Belgium

Abstract

De Bruyne MAA, De Moor RJG. Long-term sealing ability of Resilon apical root-end fillings. International Endodontic Journal, 42, 884–892, 2009.

Aim To evaluate ex vivo the long-term sealing ability of the SE Resilon Epiphany system as an apical root-end filling material. Methodology A total of 60 standardized horizontal bovine root sections were divided into three groups filled with either gutta-percha with AH 26, tooth-coloured mineral trioxide aggregate (MTA) or Resilon pellets with Epiphany SE, and submitted to capillary flow porometry at 48 h, 1 and 6 months to assess the minimum, mean flow and maximum pore diameters. Results of the different materials and results by material and time were analysed statistically using nonparametric tests; the level of significance was set at 0.05. Results Resilon had smaller pore diameters than gutta-percha and MTA at 48 h and smaller mean flow

and maximum pore diameters than gutta-percha and MTA at 1 month. At 6 months Resilon had larger minimum pore diameters than gutta-percha. Although not always statistically significant, the minimum, mean flow and maximum pore diameters of gutta- percha and MTA diminished with time. This was not the case for Resilon, where the same parameters increased. Conclusions All materials leaked at all times. Resi- lon performed better than gutta-percha and MTA in the short-term, but the seal of MTA and gutta-percha improved over time whereas the seal of Resilon deteriorated. It is critical to evaluate the performance of materials in the long-term contrary to most studies which are short-term.

Epiphany,

Keywords: capillary

leakage, Resilon, root-end filling, seal.

flow

porometry,

Received 14 October 2008; accepted 17 March 2009

884
884

Introduction

When orthograde root canal treatment is associated with post-treatment disease, surgical endodontics may be indicated. The procedure involves surgical debride- ment of pathological periradicular tissue, apical root- end resection, root-end cavity preparation and the placement of a root-end filling in an attempt to seal the root canal (Gutmann & Harrison 1994). The root-end filling should ideally produce a fluid-tight seal that

Correspondence: Dr M. A. A. De Bruyne, Department of Operative Dentistry and Endodontology, Dental School, Ghent University, Ghent University Hospital, De Pintelaan 185 P8, 9000 Gent, Belgium (Tel.: +32/9/332 58 35; fax: +32/9/332 38 51; e-mail: mieke.debruyne@UGent.be).

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prevents residual irritants and oral contaminants from exiting the root canal system and entering the perira- dicular tissues (Arens et al. 1998). An ideal root-end filling material would adhere and adapt to the walls of the root-end preparation, prevent leakage of micro-organisms and their toxins into the periradicular tissues, be biocompatible, be insoluble in tissue fluids and dimensionally stable and remain unaffected by the presence of moisture (Arens et al. 1998). It is generally accepted that the most fluid-tight apical seal possible is required for successful periapical healing (Hirsch et al. 1979). If the seal is not fluid-tight, microleakage may occur. Leakage of various root-end filling materials has been investigated widely, mainly using dye penetration methods. However, there are certain disadvantages in using the linear measurement

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Resilon root-end fillings

of dye penetration, including the destruction of the specimen, which makes further evaluation of samples impossible, and the lack of reproducible and compara- ble results (Schuurs et al. 1993, Wu & Wesselink

1993).

The reported pattern of leakage in endodontics differs according to the various techniques adopted (Wu et al. 2003). The fluid transport method was first reported by Greenhill & Pashley (1981) and adapted by Wu et al. (1993). This method investigates through-and-through voids and the result when using this technique indicates the diameter of the void. The dye penetration method investigates through-and-through as well as cul-de-sac voids and the result when using this technique indicates the length of the void rather than the diameter (Wu et al. 2003). Capillary flow porometry which was first introduced in dentistry in 2005 (De Bruyne et al. 2005) is also used to evaluate through-and-through voids. This technique is used in membrane and filter media testing to measure through pores (Jena & Gupta 2002), as does the fluid transport method. In contrast to the fluid transport method, which gives an indication on the diameter of the void, CFP provides exact information on the diameter of the minimum, mean flow and maxi- mum pore diameter at its most constricted part. The method has been approved by the American Society of Testing and Materials (1999) and was adapted suc- cessfully in collaboration with VITO (Flemish Institute for Technological Research, Mol, Belgium) to evaluate through pores in filled root canals or root sections (De Bruyne et al. 2005). The method also provides information on pore distribution. A variety of substances have been proposed as root- end filling materials including amalgam, gutta-percha, zinc oxide–eugenol cements, dentine bonding agents, glass–ionomer cements, mineral trioxide aggregate (MTA) and other restorative materials (Gutmann & Harrison 1994). MTA shows excellent biocompatibility (De Bruyne & De Moor 2004) and, in spite of the limited clinical research, is considered by many clinicians as a standard during apical surgery (Nicholson et al. 1991, Asrari & Lobner 2003, Pistorius et al. 2003, Sousa et al. 2004). After the introduction of grey MTA a tooth-coloured or white MTA was introduced (Matt et al. 2004, Tselnik et al. 2004). Gutta-percha has been used frequently as a root-end filling material in the past and often the filling material is exposed apically when no root-end filling is placed. The Epiphany endodontic obturation system (Pentron, Wallingford, CT, USA) consists of Resilon obturation material available in

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points and pellets, and a dual-cure, hydrophilic resin sealer. The Resilon points or pellets can be processed in the same way as gutta-percha. Recently, a self-etch (SE) version of this sealer was introduced. Resilon material is a formulation of polymers of polyester with fillers and radiopacifers in a soft resin matrix. The pellets are used with a delivery system (Obtura-Spartan, Fenton, MO, USA). The manufacturer claims that after curing the combination of obturation material and sealer will create a monoblock in the canal that effectively resists leakage. After periradicular surgery, the surface of the root-end filling is exposed to the periapical environment. Because of this exposure, decomposition of the material may occur and the seal of the filling may degrade. In order to obtain information on the performance of root-end filling materials on the long-term, the seal of root-end filling materials should be tested at different intervals after filling (Wu et al. 1998, De Bruyne et al. 2006). The purpose of this study was to evaluate the sealing ability of the SE Resilon-Epiphany system as a root-end filling material and to compare it with warm gutta- percha and white MTA in standard bovine root sections at 48 h and after 1 and 6 months.

Materials and methods

Preparation and filling of root sections

Roots of freshly extracted bovine incisors with an external diameter of approximately 7 mm were selected and prepared into standardized sections 3 mm high. The central pulp lumen was drilled to 2.5 mm in diameter. For this purpose, the sections which were verified to have a natural internal diameter smaller than 2.5 mm were fixed in a clamp. A bur of 2.5 mm in diameter which was secured in a fixed position was passed once through the lumen. Sixty of these sections were divided into three different groups and each group was filled according to the following scheme:

Group 1: warm gutta-percha (Obtura II, Obtura- Spartan) and AH 26 (Dentsply De Trey, Konstanz, Germany) (gutta-percha). Group 2: Pro-Root MTA Tooth-Colored Formula (Dentsply Tulsa, Tulsa, OK, USA) (MTA). Group 3: Resilon pellets (Pentron) (Obtura II delivery system; Obtura-Spartan) and Epiphany SE (Pentron) (Resilon). The root sections were rinsed with physiological saline solution, dried with paper points and air spray

International Endodontic Journal, 42, 884–892, 2009

885
885

Resilon root-end fillings

De Bruyne & De Moor

886
886

and placed on a glass plate on top of a strip of polyester. All materials were mixed and handled according to the manufacturer’s instructions and the root sections were filled. The filling materials were condensed with a plugger (RCPS 12P; Hu Friedy, Chicago, IL, USA) and excess material was removed. The root sections were kept for 24 h at a temperature of 37 C and 95–100% relative humidity and then immersed in demineralized water for 24 h before measurement. After the first capillary flow measurement at 48 h the root sections were removed from the capillary flow porometer and stored in demineralized water at a temperature of 37 C. They remained under these conditions except during the follow-up measurements that were under- taken at 1 and 6 months.

Measurement of capillary flow

Capillary flow porometry (CFP-1200-A; PMI, Ithaca, NY, USA) provides fully automated through pore anal- ysis. A wetting liquid (Galwick: 15.9 Dynes cm )1 , PMI) was used to fill the pores of the sample. Because the wetting liquid’s liquid/solid surface free energy is less than the solid/gas surface free energy, filling of the pores is spontaneous, but removal of the liquid from the pores is not. In order to remove the wetting liquid from pores and permit gas flow, pressure must be applied to the sample. The fully wetted sections were fixed in the sample chamber after which the sample chamber was sealed. Air was then allowed to flow into the chamber behind the sample. When the pressure reaches a point, it overcomes the capillary action of the fluid within the largest pore (maximum pore), and the sample’s bubble point pressure is identified. After determination of the bubble point pressure, the pressure is increased and the flow is measured until all pores are empty, and the sample is considered dry. At this time the smallest or minimum pore has been identified. The mean flow pore is described as follows: half of the flow through a dry sample is through pores having a diameter greater than the mean flow pore diameter. The other half of the flow is through pores having a diameter smaller than the mean flow pore diameter. Pressure in CFP ranges from 0 to 200 psi or 1.4 MPa and the pore size range that can be measured lies between 0.035 and 500 lm. The flow meters detect the presence of pores by sensing the increase in flow rate due to emptying of pores. Differential pressures and flow rates through wet and dry samples are measured. Application of differential pressure on excess liquid on the sample causes liquid displacement. Measurement of the volume of displaced liquid allows computation of

International Endodontic Journal, 42, 884–892, 2009

liquid permeability. The pore diameter (D) is derived from the following equation: D = 4 c cos h/p (c = surface tension of the wetting liquid, h = contact angle of the wetting liquid, p = differential pressure required to displace the wetting liquid from the pore) (Jena & Gupta 2003). All measurements were performed at VITO (Vlaamse Instelling voor Technologisch Onderzoek or Flemish Institute for Technological Research).

Statistical analysis

Results were analysed statistically using nonparametric tests. Comparisons were made between the leakage results of the different materials at 48 h, 1 and 6 months using Kruskal–Wallis tests; two by two analyses were performed by Mann–Whitney U-tests with Bonferroni correction. Comparisons between the leakage results of each material at the specified time intervals were completed using Friedman tests and two by two comparisons were carried out by Wilcoxon Signed Ranks tests with Bonferroni correction. The level of significance was set at 0.05.

Results

Measurements were obtained for each sample at each point in time, confirming the presence of through pores regardless of which root-end filling material was being tested. Exact values for minimum, mean flow and maximum pore diameters of each sample were obtained. The results of the study are summarized in Tables 1– 3. For reasons of completeness the range and median of minimum, mean flow and maximum pore diameters of gutta-percha and MTA as reported in De Bruyne et al. (2006) are repeated in Tables 1–3.

Leakage results at 48 h, 1 and 6 months

From the Kruskal–Wallis tests and the Mann–Whitney U-tests with Bonferroni correction the following results were obtained. At 48 h significant differences between the minimum (P < 0.001), mean flow (P < 0.001) and maximum (P < 0.001) pore diameters could be dem- onstrated. No significant differences between gutta-percha and MTA could be demonstrated but there were significant differences between gutta-percha and Resilon and between MTA and Resilon for minimum, mean flow and maximum pore diameters. At 48 h Resilon showed

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Resilon root-end fillings

Table 1 Range and median of minimum, mean flow and maximum pore diameters by root-end filling material at 48 h (lm)

 

Minimum

pore

diameter

Mean flow pore diameter (lm)

Maximum pore diameter (lm)

(lm)

Group

Filling material

Range

Median

Range

Median

Range

Median

1

GP + AH 26

0.075–0.355

0.1995

0.141–0.395

0.2630

0.177–1.714

0.4375

2

MTA

0.070–0.258

0.2210

0.183–0.925

0.2760

0.193–1.304

0.4440

3

Resilon

0.082–0.201

0.1165

0.100–0.272

0.1465

0.127–0.433

0.2140

MTA, mineral trioxide aggregate.

Table 2 Range and median of minimum, mean flow and maximum pore diameters by root-end filling material at 1 month (lm)

 

Minimum

pore

diameter

Mean flow pore diameter (lm)

Maximum pore diameter (lm)

(lm)

Group

Filling material

Range

Median

Range

Median

Range

Median

1

GP + AH 26

0.070–0.362

0.0875

0.106–0.455

0.2730

0.128–0.896

0.4410

2

MTA

0.070–0.330

0.2010

0.152–0.393

0.2880

0.162–0.854

0.4370

3

Resilon

0.069–0.198

0.1175

0.075–0.350

0.1525

0.088–0.432

0.2265

MTA, mineral trioxide aggregate.

Table 3 Range and median of minimum, mean flow and maximum pore diameters by root-end filling material at 6 months (lm)

 

Minimum

pore

diameter

Mean flow pore diameter (lm)

Maximum pore diameter (lm)

(lm)

Group

Filling material

Range

Median

Range

Median

Range

Median

1

GP + AH 26

0.069–0.199

0.1060

0.077–0.302

0.1315

0.104–0.418

0.2200

2

MTA

0.069–0.216

0.1055

0.084–0.346

0.1490

0.111–0.818

0.2455

3

Resilon

0.083–0.240

0.1335

0.095–0.340

0.1685

0.106–0.402

0.2380

MTA, mineral trioxide aggregate.

smaller pore diameters than gutta-percha and MTA. The range and median of minimum, mean flow and maximum pore diameters at 48 h are shown in Table 1. At 1 month there was no significant difference between the minimum pore diameters of the different materials, but significant differences between the mean flow (P < 0.001) and maximum (P < 0.001) pore diameters could be demonstrated. Concerning the mean flow and maximum pore diameters, no signifi- cant differences between gutta-percha and MTA could be demonstrated, but there were significant differences between gutta-percha and Resilon and between MTA and Resilon. At 1 month Resilon showed smaller mean flow and maximum pore diameters than gutta-percha and MTA. The range and median of minimum, mean flow and maximum pore diameters at 1 month are shown in Table 2. At 6 months a significant difference between the minimum pore diameters could be demonstrated

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(P < 0.05), but there were no significant differences between the mean flow and maximum pore diameters of the different materials. Concerning the minimum pore diameters, there was a significant difference between gutta-percha and Resilon. No significant differences between gutta-percha and MTA and between MTA and Resilon could be demonstrated. At 6 months Resilon showed larger minimum pore diameters than gutta-percha. The range and median of minimum, mean flow and maximum pore diameters at 6 months are shown in Table 3.

Leakage results by material

From the Friedman tests the following results were obtained. Concerning the minimum pore diameters there were significant differences between the different points in time for gutta-percha and MTA, but not for Resilon. Results of the two by two comparisons are summarized in Table 4. Statistically significant

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887
887

Resilon root-end fillings

De Bruyne & De Moor

Root-end

Two by two comparisons

filling

Friedman’s

48 h vs. 1 month

48 h vs. 6 months

1

month vs.

material

test

6

months

GP +

Minimum pore diameter Mean flow pore diameter Maximum pore diameter Minimum pore diameter Mean flow pore diameter Maximum pore diameter Minimum pore diameter Mean flow pore diameter Maximum pore diameter

*(P < 0.05) *(P < 0.001) *(P < 0.001) *(P < 0.01) *(P < 0.005)

 

>

AH 26

>

>

>

>

MTA

>

>

>

>

Resilon

 

Table 4 Summary of significant differ- ences (marked by an asterisk) between

minimum, mean flow or maximum

pore diameters at 48 h, 1 and 6 months and for two by two comparisons by material (> means the pore diameter is larger at the former than at the latter measurement)

888
888

MTA, mineral trioxide aggregate.

decreases in size were found between 48 h and 6 months for gutta-percha and MTA and between 1 and 6 months for MTA. Concerning the mean flow pore diameters there were significant differences between the different points in time for gutta-percha and MTA but not for Resilon. Results of the two by two comparisons are summarized in Table 4. Statistically significant decreases in size were found for gutta-percha and MTA between 48 h and 6 months and between 1 and 6 months. Concerning the maximum pore diameters there were significant differences between the different points in time for gutta-percha but not for MTA and Resilon. Results of the two by two comparisons are summarized in Table 4. Statistically significant decreases in size were found for gutta-percha between 48 h and 6 months and between 1 and 6 months.

Discussion

Capillary flow porometry generates highly reproducible and accurate data (Gupta & Jena 1999). Therefore, because of its nondestructive nature and following a previous study (De Bruyne et al. 2006) CFP was chosen as the evaluation method for the present study. It provides, as the first and only method in leakage research, exact data on pore diameters which can be compared statistically and gives an indication whether bacteria or their metabolites will be able to pass through the sample. This is in contrast to other methods, which only compare materials without giving any information on the size of pores. As such, the method can overcome the problem of limited repro- ducibility and comparability of conventional methods for evaluating leakage (Wu & Wesselink 1993). CFP uses a wetting liquid with a low surface tension such

International Endodontic Journal, 42, 884–892, 2009

that pores as small as 0.035 lm can be measured, which assures the detection of gaps of about 2 lm which were already observed between the root dentine and the Resilon primer. These gaps might be too small to be detected by, for example, bacterial penetration models (De-Deus et al. 2007). The relatively high pressures used during CFP may be a concern. It needs to be emphasized, however, that during the present study and during all previous studies none of the fillings were dislodged. Results from a pilot study also showed that no statistically significant differences were evaluated between measurements when samples were measured multiple times immedi- ately after each other (De Bruyne 2006). Apart from this the results from push-out tests revealed that micropush-out bond strengths of all materials tested were higher than the pressures used in the present study (Yan et al. 2006, Sly et al. 2007, Ureyen et al. 2008). This implies that the filling materials used in the present study will not be damaged during CFP. As the purpose of the study was to compare root-end filling materials, standardized root sections were essen- tial. Because human teeth are too small to be used to prepare standardized samples that are easy to handle, fix and evaluate in a reliable way, bovine teeth were used. As bovine teeth are easy to obtain and as the sections are large enough to adjust the central pulp lumen to the exact diameter, standardization is straight- forward. Consequently cavities of equal size could be filled with different materials and compared under the same conditions, although these differ from the clinical situation. From the study of Nakamichi et al. (1983) it appeared that no statistically significant difference was found in adhesion of various materials to human or bovine dentine. Because of the larger diameter and same height, the C-factor in the present samples will be lower

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