Basic Research—Technology
Effect of Root Dentin Conditioning on the
Pushout Bond Strength of Biodentine
Liz Paulson, BDS,* Nidambur Vasudev Ballal, BDS, MDS, PhD,* and Abhishek Bhagat, MSc†
Abstract
Introduction: Sodium hypochlorite (NaOCl) is the main
irrigant to clean root canals. Decalcifying agents are
advocated as additional means to condition the root
dentin. The aim of this study was to evaluate the effect
of alternating (EDTA) or continuous 1-hydroxyethane
1,1-diphosphonic (HEDP) chelation in conjunction with
NaOCl irrigation on the pushout bond strength of Bio-
dentine (Septodont, Saint Maur des Fosses, France).
Methods: Single root canals of 50 extracted, mature hu-
man teeth were divided into 5 groups (n = 10) and
enlarged using rotary instruments. Canals were irrigated
with 5 mL irrigant after each instrument and then with
5 mL after mechanical preparation as follows: 2.5%
NaOCl during and then 2.5% NaOCl, 17% EDTA, or
17% EDTA followed by 2.5% NaOCl after preparation.
Continuous chelation with 2.5% NaOCl/9% Dual Rinse
HEDP (Medcem GmbH, Weinfelden, Switzerland) during
and after preparation. The control group was irrigated
with water during and after preparation. Canals were
then filled with Biodentine. A horizontal section of
1.5-mm thickness was taken from the middle root third,
and a pushout bond test was performed. Data were
statistically analyzed using 1-way analysis of variance/
Tukey honest significant different test. Results:
The pushout bond strength of Biodentine was signifi-
cantly higher when the root canal was irrigated with
2.5% NaOCl/9% Dual Rinse HEDP (19.6  2.3 MPa)
than with NaOCl alone (15.5  1.5 MPa) or the
NaOCl/EDTA sequences (15.7  2.2 MPa and
16.9  2.9 MPa) (P < .05), which did not differ among
each other (P > .05). The lowest pushout bond
strength values were found with water irrigation
(11.5  0.5 MPa) (P < .05 to all other groups). Conclu-
sions: Irrigation with 2.5% NaOCl/9% Dual Rinse HEDP
significantly improved the pushout bond strength of Bio-
dentine to the root canal dentin. (J Endod 2018;-:1–5)
Key Words
Biodentine, dual rinse HEDP, EDTA, pushout bond
strength, smear layer, sodium hypochlorite
From the Departments of *Conservative Dentistry and Endodontics and †Dental Materials, Manipal College of Dental Sciences, Manipal Academy of Higher Edu-
cation, Manipal, Karnataka, India.
Address requests for reprints to Dr Nidambur Vasudev Ballal, Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal-
576 104, Manipal Academy of Higher Education, KA, India. E-mail address: drballal@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.04.009
JOE — Volume -, Number -, - 2018
T he essential part for
endodontic success is
proper cleaning of the
Significance
Irrigation with 2.5% NaOCl/9% Dual Rinse HEDP
can improve the pushout bond strength of Bio-
root canal system (1).
dentine to the root canal dentin.
Studies have shown that
large areas of root canal
walls remain untouched by hand and rotary instruments during canal preparation.
This shows the importance of cleaning and disinfecting the root canal system using
chemical means. To this end, the combined use of 2 or more irrigating solutions in
a specific sequence can be used to predictably achieve the goals of safe and optimal
irrigation.
During mechanical preparation, a smear layer is produced in the root canal
system on instrumented canal walls, whereas the noninstrumented area can be
covered by dentin mud and debris (2). Studies have shown that these entities
can impede sealer penetration into the dentinal tubules, thereby compromising
the seal of obturating materials (3). In some cases, the smear layer and debris
can be infected, thereby protecting the microorganisms within the dentinal tubules
and in isthmus areas (4). Furthermore, the infiltration of root canal irrigants and
intracanal medicaments into the dentinal tubules can be impeded (5), and micro-
leakage can occur.
Sodium hypochlorite (NaOCl) is the most widely used irrigant in endodontics
because of its potential to dissolve organic tissue as well as its antimicrobial properties
(6). In addition to NaOCl, the following chemical agents that aid in the elimination of the
smear layer and debris have been proposed and used in clinics: EDTA and its various
formulations, tetracycline, a mixture of a tetracycline isomer, an acid and a detergent,
organic acids such as maleic and citric acid, tannic acid, and 20% polyacrylic acid.
EDTA is a polyaminocarboxylic acid that is water soluble in a neutral or alkaline pH.
It is used in endodontics because of its chelating property whereby it interacts with cal-
cium ions present in dentin to form soluble chelates of calcium. It is the most widely
used chelating agent in endodontics (7). However, it has various drawbacks including
reduced efficacy in the elimination of the smear layer in the apical third (8), a reduction
in dentin microhardness (9), and cytotoxicity (10). Furthermore, it also reduces the
bond strength of resin cements (11), brings about a reduction in active chlorine
when combined with NaOCl (12), and forms a precipitate in combination with chlor-
hexidine (13).
Etidronic acid (also known as 1-hydroxyethane 1,1-diphosphonic [HEDP]) is a
biocompatible chelator that can be used in conjunction with NaOCl. It is a ‘‘soft’’
chelator that is less aggressive on dentin than EDTA (14). Studies have shown that it
has a weak chelating capacity when used alone (15). This property can be used to
the advantage of using NaOCl and HEDP as a single irrigant during and after root canal
Pushout Bond Strength of Biodentine 1
Basic Research—Technology
preparation. It was shown that a freshly mixed irrigant, containing HEDP
and NaOCl, dissolves the smear layer. The combination is also shown to
reduce the accumulation of hard tissue debris in the isthmus area (16).
Dual Rinse (9% HEDP) (Medcem GmbH, Weinfelden, Switzerland) is a
medical device (product approved for use in the root canal) based on
this chemistry. It comes in a capsule containing 0.9 g etidronate pow-
der, which should be mixed immediately with 10 mL of the NaOCl so-
lution of choice directly before treatment. This solution remains
useful for 1 hour with all the desired properties of NaOCl remaining
intact (17). Additionally, this combined solution of HEDP and NaOCl in-
hibits smear layer formation during instrumentation as well as condi-
tions the root canal wall for subsequent obturation (7, 18). A
mixture of HEDP and NaOCl can be used not only during root canal
instrumentation but also as a final irrigant.
Biodentine (Septodont, Saint Maur des Fosses, France) is a trical-
cium silicate developed by Septodont’s research group as a new range of
dental material that exhibits superior mechanical properties besides
biocompatibility and bioactivity. It is used as a dentin replacement ma-
terial whenever original dentin is damaged. Biodentine has a relatively
short setting time of around 12 minutes when compared with MTA,
which takes 3 to 4 hours to set (19). Biodentine is comprised of a highly
distilled tricalcium silicate powder that is prepared synthetically in the
laboratory and not from a clinker. Biodentine is known to show excel-
lent sealing ability with the aid of mineral tags into the dentin tubules
with excellent microleakage resistance, promoted by the lack of
shrinkage because of the resin-free formula (20). Considering the clin-
ical applications for tricalcium silicate cements, the marginal adaptation
as well as the bond strength of these materials with dentin plays a sig-
nificant role in clinical practice.
The pushout bond strength test evaluates the bond strength of a
restorative material to root canal dentin. It is a practical and reliable
method to evaluate the adaptation of a material to its surrounding
root dentin (21). Various studies have tested the pushout bond strength
of tricalcium silicate cements to root dentin after irrigation with various
regimens (22). Up to now, the effect of Dual Rinse on the bond strength
of Biodentine to root canal dentin has not been sufficiently investigated.
Hence, the aim of this study was to evaluate the effect of 17% EDTA, 9%
Dual Rinse HEDP, and 2.5% NaOCl when used with different irrigation
regimens on the pushout bond strength of Biodentine to the root canal
dentin.
The null hypothesis tested was that there is no significant differ-
ence in the pushout bond strength of Biodentine to root canal dentin
irrigated with 2.5% NaOCl, 2.5% NaOCl followed by 17% EDTA with
or without a final rinse of 2.5% NaOCl, 2.5% NaOCl/9% Dual Rinse
HEDP, and distilled water.
Materials and Methods
Sample Size Estimation
The number of samples included in this study was based on the
pushout bond strength of mineral trioxide aggregate to root canal
dentin treated with different irrigants (21). Based on this, the sample
size was estimated at a 95% confidence interval and with the power
of 80%, which resulted in 10 samples in each group.
Specimen Preparation
Ethical clearance was obtained for the use of extracted human
teeth for this study from the institutional review board (IEC 643/
2015). A total of 50 single-rooted human teeth were selected. Soft tissue
fragments and calcified debris on the specimens were removed using
ultrasonic scalers. The specimens were stored in a solution of 0.2%
sodium azide (Sigma-Aldrich, Steinheim, Germany) at 4 C until use.
2 Paulson et al.
Radiographs of specimens were taken from the buccal and mesial
aspect to confirm a straight, single canal with mature apices and without
any calcifications. The teeth were decoronated using a diamond disc
(Horico, Berlin, Germany). The working length was established by in-
serting a size 10-K file (Mani Inc, Tochigi Ken, Japan) into each root
canal until it was just visible at the apical foramen (observed using
magnifying loupes) and then subtracting 1 mm from the recorded
length. The apices of all the teeth were sealed with sticky wax to prevent
the flow of irrigants through them and to allow an effective reverse flow
of the irrigant to simulate a closed-end system. The specimens were then
randomly divided into 5 groups (n = 10) based on the irrigation
regimen.
Irrigation Regimen
The irrigation regimen was as follows:
1. The NaOCl group: 5 mL 2.5% NaOCl for 1 minute after each instru-
ment change / 5 mL 2.5% NaOCl for 1 minute / final rinse of
5 mL distilled water for 1 minute
2. The NaOCl/EDTA/NaOCl group: 5 mL 2.5% NaOCl for 1 minute after
each instrument change/ 5 mL 17% EDTA for 1 minute / 5 mL
2.5% NaOCl for 1 minute / final rinse of 5 mL distilled water for
1 minute
3. The NaOCl/EDTA group: 5 mL 2.5% NaOCl for 1 minute after each
instrument change/ 5 mL 17% EDTA for 1 minute / final rinse
of 5 mL distilled water for 1 minute
4. The Dual Rinse HEDP group: 5 mL 2.5% NaOCl/9% Dual Rinse HEDP
for 1 minute after each instrument change / 5 mL 2.5% NaOCl/9%
Dual Rinse HEDP for 1 min / final rinse of 5 mL distilled water for
1 minute
5. The distilled water group: 5 mL distilled water for 1 minute after each
instrument change / final rinse of 5 mL distilled water for 1 minute
Root canals were cleaned and shaped using the rotary ProTaper
system (Dentsply Sirona Endodontics, Tulsa, OK) according to the man-
ufacturer’s instructions up to a size of F3. Irrigation was performed us-
ing a 27-G side-vented needle (Vista Dental Inc, Racine, WI), which was
inserted 1 mm short of the working length. After the final irrigation
regimen, the root canals were dried with paper points (Dentsply Sirona
Endodontics).
Biodentine was then mixed according to the manufacturer’s in-
structions and placed in the canal using an amalgam carrier and
condensed with hand pluggers (Hu-Friedy, Chicago, IL). Obturated
roots were then radiographed in the buccolingual and mesiodistal di-
rections to ensure that the canals were densely obturated without any
voids. All the teeth were stored at 37 C in 100% humidity for 1 week
to allow for complete setting of Biodentine.
Pushout Bond Strength Measurement
Each root was embedded in cold cure acrylic (Dentsply India, Gur-
gaon, India) and sectioned horizontally in the middle third using a hard
tissue microtome (Leica Biosystems, Nussloch, Germany) under contin-
uous water cooling to obtain a slice of 1.5  0.1 mm thickness. The root
canal diameter as well as the height of each slice was recorded using a
digital caliper. The adhesion surface area was calculated by the
following equation: adhesion surface area (mm2) = D1 + D2/
2  p  h, where D1 and D2 are the largest and smallest canal diam-
eter, respectively, p is the constant 3.14, and h is the thickness of the
root slice. The pushout test was performed using a universal testing ma-
chine (Instron, Norwood, MA). The force was applied in the apicocoro-
nal direction at a crosshead speed of 1 mm/min using stainless steel
plungers of 0.6 mm positioned so that they contacted only the filling
JOE — Volume -, Number -, - 2018

material. The maximum force (F) applied at bond failure was recorded
in newtons The pushout bond strength was calculated in megapascals
using the following formula: pushout bond strength (MPa) = force
(N)/adhesion surface area (mm2). The data of the pushout
bond strength of Biodentine to root canal walls is presented as
means  standard deviations.
Fractographic Analysis
All samples from each group were subjected to stereomicroscopic
analysis (SZ61; Olympus, Tokyo, Japan) at 40 magnification for the
evaluation of bond failures.
The modes of bond failures were categorized as follows:
1. Adhesive failure between the root canal dentin wall and Biodentine
interface
2. Cohesive failure within the Biodentine
3. Mixed failure
Statistical Analysis
Statistical analysis was performed using SPSS Statistics Version
20.0 software (IBM Corp, Armonk, NY). Pushout bond strength data
were analyzed using 1-way analysis of variance with the post hoc Tukey
honest significant difference test. The chi-square test was performed for
the analysis of the bond failures. A P value <.05 was considered to be
statistically significant (95% confidence level).
Results
On intergroup comparison, group 4 (2.5% NaOCl/9% Dual Rinse
HEDP) showed significantly higher pushout bond strength
(19.6  2.3 MPa) when compared with other groups (P < .05). Group
5 had significantly lower pushout bond strength in comparison with all
other groups (11.5 MPa) (P < .05). There was no significant difference
among groups 1 (15.5  1.5 MPa), 2 (15.7  2.2 MPa), and 3
(16.9  2.9 MPa) (P > .05). Distilled water (control) showed the least
pushout bond strength (11.5  0.5 MPa) (Fig. 1).
Fractographic Analysis
The chi-square test showed that there was no significant differ-
ence among groups in terms of the distribution of failure rates
(P = .44). In group 1, the mode of bond failure was observed to
Figure 1. A box plot showing the pushout bond strength values of Biodentine
to root canal dentin treated with various irrigation regimens. The lines within
the box show the mean of each group. Different letters indicate significant dif-
ferences between groups.
JOE — Volume -, Number -, - 2018
Basic Research—Technology
be 50% cohesive and 50% mixed type. In group 2, 70% was cohesive
and 30% mixed type. In group 3, 60% was cohesive and 40% mixed
type. In group 4, 80% was cohesive and 20% mixed type. In group 5
(control), 10% was purely adhesive, whereas 80% was cohesive and
10% mixed type. Overall, in all the experimental groups, adhesive
failure was observed in 1 of 50 specimens (2%), cohesive failure
in 34 of 50 specimens (68%), and mixed type of failure in 15 of
50 specimens (30%) (Fig. 2).
Discussion
The present in vitro study evaluated the pushout bond strength of
Biodentine to root canal dentin when irrigated using different irrigation
protocols. The results showed that the use of various irrigation proto-
cols had a differential effect on the pushout bond strength of Biodentine.
This is in congruence with earlier studies (23, 24). Hence, the null
hypothesis has to be rejected.
In the current study, the pushout bond strength of Biodentine was
significantly higher when the root canal was irrigated with a combina-
tion of 2.5% NaOCl and 9% Dual Rinse HEDP (19.6  2.3 MPa). This is
in conjunction with the findings of Neelakantan et al (25).
The improved performance of HEDP could be attributed to the fact
that it has no adverse effect on the hydration properties of calcium sil-
icate cements (25). Also, smear layer removal by NaOCl and HEDP also
known as continuous chelation has been shown to be comparable with
that of EDTA (14). Hence, the current study showed that the removal of
the smear layer has a direct correlation with the adhesion of Biodentine
to the root canal dentin. Furthermore, an irrigating protocol using the
NaOCl + HEDP combination has been shown to be able to optimize the
bonding quality of Resilon/Epiphany (Sybron Endo, Glendora, CA) root
fillings (15). The lower pushout strength obtained in the specimens
treated with only 2.5% NaOCl (15.5  1.5 MPa) could be attributed
to the inferior smear layer removal property of NaOCl, thereby reducing
the bonding of Biodentine to the root canal walls. Also, studies have
shown that NaOCl interacts with calcium silicate cement, which, in
turn, can affect its adhesion (26).
EDTA has been shown to impart a negative influence on the hydra-
tion properties of calcium silicate cements because of its acidic nature
(27). This causes dissolution of the binding phase of the cement, which,
in turn, inhibits its adhesion to materials. This can occur if the final rinse
after the use of EDTA is insufficient resulting in some residual EDTA on
the root canal dentin, which may chelate the calcium ions released from
the tricalcium silicate cement during hydration, thereby disturbing the
formation of hydrated products (28). EDTA also decreases the hardness
and flexural strength of tricalcium silicate cements (29). Furthermore,
the sealing ability of tricalcium silicate cement was reported to reduce
when the final irrigation was performed using EDTA, which could have a
direct correlation to its adhesion to the root canal dentin. These could
be the reasons why the groups treated with NaOCl/EDTA
(15.7  2.2 MPa and 16.9  2.9 MPa) had poor bond strength
when compared with NaOCl/Dual Rinse HEDP in the present study.
Tricalcium silicate cements can be placed in the root canals using
hand files, pluggers, Lentulo spirals, and ultrasonic activation. In the
current study, Biodentine was condensed into the root canal using
hand pluggers because studies have shown that manual compaction
of calcium silicate cement resulted in more densely obturated root fill-
ings (30) with superior marginal adaptation compared with ultrasonic
activation.
Pane et al (31) concluded that pushout tests are commonly used
as a measure of the bond strength of root canal filling materials to the
root dentin. This test results in a shear stress at the dentin-cement inter-
face, which is comparable with the stress in clinical conditions. In the
Pushout Bond Strength of Biodentine 3
Basic Research—Technology
Figure 2. Representative stereomicroscopic images of the types of bond failures. (A) Adhesive failure, (B) cohesive failure, and (C) mixed failure.
current study, the dentin discs of 1.5 mm were used for the purpose of
pushout test measurement. Different authors have recommended
different thicknesses of dentin discs for the pushout test (32). However,
the use of thicker discs seems to increase the area of friction and may in
turn lead to an overestimation of the bond strength.
Analysis of the mode of bond failure, which was analyzed in the
current study, showed 61.3% cohesive type of bond failure. This is in
accordance with earlier studies (33, 34). This may be attributed to
the good adhesion of Biodentine to the root canal walls because of
its finer particle size, which, in turn, enhances the infiltration of the
cement into the dentinal tubules (22). It can also be attributed to its bio-
mineralization property through the formation of tags (35).
Conclusion
Within the limitations of this in vitro study, it can be concluded
that the pushout bond strength of Biodentine was differentially influ-
enced by the various irrigation regimens. Use of the combination of
2.5% NaOCl/9% Dual Rinse HEDP enhanced the bond strength of Bio-
dentine to the root canal dentin compared with the use of 2.5% NaOCl
alone, 2.5% NaOCl and 17% EDTA with or without a final rinse of 2.5%
NaOCl, and distilled water.
Acknowledgments
The authors thank Dr Matthias Zehnder, University of Zurich,
Switzerland, for his expertise and suggestions in this study.
The Dual Rinse used in this study was kindly supplied free of
charge by Medcem GmbH, Weinfelden, Switzerland.
The authors deny any conflicts of interest related to this study.
4 Paulson et al.
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