Biol Trace Elem Res
DOI 10.1007/s12011-013-9755-z
Correlation Between Endodontic Broken Instrument
and Nickel Level in Urine
Mohammad Ali Saghiri & Nader Sheibani & Franklin Garcia-Godoy &
Armen Asatourian & Peiman Mehriar & Mark Scarbecz
Received: 10 May 2013 / Accepted: 3 July 2013
# Springer Science+Business Media New York 2013
Abstract This study aims to evaluate the correlation be-
tween the presences of separated endodontic instrument in-
side the dental canal and the nickel (Ni) level in the urine
samples of subjected patients. Same-gendered and near-aged
participants were selected and were instructed to collect their
urine in sterile nickel-free plastic containers. The procedures
were carried out in the office, and samples were stored in
low-temperature cooler for 1 day and then they were trans-
ferred to the laboratory for electrothermal atomic absorption
spectrometry. The level of Ni was measured and the corre-
lation coefficient was calculated. Data were analyzed using t
tests, Pearson’s correlation coefficients, and linear regression
analysis, at a level of significance P<0.05. The statistical
analysis has showed significant difference in Ni level be-
tween endodontic and control groups (P<0.05). There was
no correlation between Ni level in urine and the age or time
period of broken instrument inside the canal; however, Ni
level of urine and the age of participants in experimental
group has demonstrated a positive correlation. The amount
of Ni element can be increased in the urine of patients who
have experienced broken endodontic instrument inside the
dental canal. However, there is no positive correlation be-
tween the remaining pieces of instruments inside the canal
and the elevation of nickel amount in urine during the tested
time period. This issue suggested that the aging of remaining
M. A. Saghiri : N. Sheibani
Department of Ophthalmology and Visual Sciences,
University of Wisconsin, school of Medicine and Public Health,
Madison, WI, USA
M. A. Saghiri (*) : A. Asatourian : P. Mehriar
Kamal Asgar Research Center, Encino, CA, USA
e-mail: saghiri@gmail.com
F. Garcia-Godoy : M. Scarbecz
Department of Bioscience Research, University of Tennessee
Health Science Center, Memphis, TN, USA
broken instrument inside the canal does not show any re-
markable concern regarding the Ni elevation in the urine
excreted by an individual.
Keywords Allergen . Broken instrument . Fatigue fracture .
NiTi rotary instrument . Nickel toxicity
Introduction
Nickel is considered as an essential trace element for human
and a component of some critical enzymatic systems with
daily intake of 100–600 μg [1]. With respect to this, nickel is
known as an allergen, and allergies from nickel-containing
dental alloys are mostly type IV hypersensitivity reactions
[2]. Although in theory a toxic reaction could be caused by
continuous exposure to nickel, but some studies showed no
relationship between nickel in dental alloys and toxic reac-
tions [3]. However, some recent publications have suggested
possible harmful effects of nickel-containing dental alloys on
oral mucosal cells and monocytes [4–6]. However, this alloy
has a long-standing history of success in dentistry, and no
remarkable biological effect has been reported [3]. Previous
authors have indicated that the mean values for serum Ni
concentration were <0.3 μg/L and the upper limits were
≤1.1 μg/L, while the mean reference values of Ni concentra-
tion in human urine were ≤2.0 μg/L and the upper limits
were ≤6.0 μg/L [7].
NiTi instruments are another instance of dental equip-
ments which have received much attention in recent years
due to their biocompatibility, corrosion resistance, shape
memory, and the superelasticity [8]. These advantages are
the main reasons for its predominant use in endodontic
which increases efficiently root canal cleaning and shaping
process [8–10]. Despite these all advantages, NiTi instru-
ments separation has been reported as a drawback of these
useful devices which can happen around 0.4 to 5 % [11].

Overuse of endodontic instruments is the frequent cause of
fracture [11], and the apical third of the root canal is a
common location for it [12–14].
In order to manage this disastrous clinical problem, vari-
ous methods have been utilized. Some authors have used
chemicals to dissolve the fractured portions of instrument
[15] while others have introduced more effective and con-
servative instruments and techniques including operating
microscope, fine ultrasonic tips, staging platforms [16, 17],
and the Instrument Removal System [18]. However, during
use of these instruments, some difficulties such as perfora-
tion, ledging, difficulty of usage in curved narrow roots,
excessive root canal dentin removal, and over extrusion of
the fractured piece can occur [19–21]. The well-judged de-
cision to remove or leave [22–24] the fractured instrument is
crucial. It is advisable to prevent removal when the fractured
instrument is close to curve in the canal [17] and particularly
when it has the least effect on prognosis [25]. Although there
is no evidence to support the effect of time of fracture on
prognosis, favorable prognosis is expected in well-debrided
canal with larger files in comparison with retained instru-
ment in early stages of canal debridement [26]. Bypassing
the fractured piece and incorporating it into root filling
proved successful and should be always considered as part
of treatment decision, particularly in minimally debrided
canals.
The present study evaluated the relationship between
endodontic broken instruments and urinary nickel level of
56 individuals (28 experimental and 28 control subjects).
The hypothesis was tested that in the patients who have
broken instruments in one of their teeth, the Ni level might
be elevated in the urine of these individuals. Also, the cor-
relation between the Ni level in the urine and the instrument
separation interval until the investigation time has been
evaluated as well.
Materials and Methods
Sample Collection
This retrospective cohort study was conducted on patients
with endodontic treatment history as the experimental sub-
jects and the same number of control individuals between fall
2007 and fall 2012. As part of the inclusion criteria for
control group, all the patients must have had at least near-
aged siblings with identical gender and no endodontic treat-
ment history. The exclusion criteria were applied to patients
with systemic diseases, medication intake, smoking or alco-
hol consumption, and presence of any metallic restoration
material such as amalgam or fixed prosthesis which was
checked through panoramic X-rays, as well as to those
patients having missing or extracted teeth (except for third
Saghiri et al.
molars) and individuals who were unwilling to participate
[27]. Same-gender and near-aged participants were selected
in order to reduce biological differences. The patients were
instructed to avoid consumption of a given list of foods rich
in nickel for 7 days before the next visit [27]. Sampling was
carried out in the office in order to collect uncontaminated
specimens. Patients were instructed to collect their urine in
sterile nickel-free, 50-mL plastic containers. They were also
advised to avoid wiping or rinsing the surfaces [28].
All the samples were transferred to the Chemical Analysis
Department of the Atomic Energy Organization, Tehran,
Iran, for electrothermal atomic absorption spectrophotome-
try (AA280Z GTA120, Varian, Mulgrave, Australia) with
0.01 μg/L accuracy limit [27] after they were kept in a
low-temperature freezer. Two 1-mL urine specimens were
collected from each container. The testing procedure was
repeated at the presence of discrepancy between nickel levels
of two specimens from every subject.
Statistical Analysis
Data was entered into an Excel Spreadsheet (Office 2010,
Microsoft, Redmond, WA, USA). Differences between each
endodontic subject and his/her control (n=28) was calculated
(endodontic−control) for age and for Ni level (endodontic−
control). As controls were non-endodontic-treated patients, the
number of years that a broken instrument remained in the canal
was zero. As such, for the purpose of analysis, the difference in
“instrument time” between each endodontic subject and
his/her control was the number of years during which the
broken instrument was in the canal of the endodontic subject.
The Kolmogorov–Smirnov goodness of fit test was used
to assess the normality of Ni values. Descriptive statistics
(means and standard deviations) were calculated for quanti-
tative variables and differences between endodontic subjects
and their controls were assessed using a two-sided paired t
test. Pearson’s correlation coefficients were calculated to
examine correlations between quantitative variables. Linear
regression analysis was used to assess the independent and
joint effects of age and instrument time on the differences in
Ni values between endodontic subjects and their controls.
Gender was not used in the analysis of Ni differences between
endodontic subjects and their controls, as each endodontic
subject was paired with a same-gender control.
All statistical analysis was done by using IBM SPSS
Statistics Version 20 (Armonk, NY, USA) and P values less
than 0.05 were considered to be statistically significant.
Results
The means±standard deviations of experimental and control
groups were 4.91±2.02 and 4.34±1.99, respectively (Table 1).
Broken Instrument and Nickel Level of Urine

Table 1 Means age, instrument time and Ni level of both endodontic Table 3 Regression analysis: difference in Ni level (endodontic−control),
and control groups (n=28) dependent; age difference and instrument time, independent (n=28 pairs)

Endodontic Control P valuea Model I Model II Model III

Ni level 4.91 4.34 0.005 Age difference 0.398 – 0.024

(2.02) (1.99) Instrument time – 0.231 0.220
Instrument time (years) 1.75 0.00 n/ab P for the regression 0.347 0.447 0.441
(.75) (0.0)
df 1,26 1,26 2,25
Age (years) 32.25 24.54 0.000
r2 0.034 0.022 0.063
(9.55) (6.21)
Percentage of subjects in endodontic 71.4 % Model I bivariate relationship between difference in Ni levels and
group with Ni>control instrument time, Model II bivariate relationship between difference in
a
Ni levels and age difference, Model III the result of regression between
Two-sided paired t test endodontic subjects and controls on both instrument time and age
b
Instrument time=0 for all control subjects difference
*P<0.05 (t test, regression coefficient significantly different from 0)
The Ni level was significantly higher in participants with
broken instrument in comparison with the control group which first was the difference in instrument time between endodontic
did not have any endodontic procedures. For the entire sample subjects and their controls. Since instrument time=0 for con-
(endodontic subjects and their controls, n=56), there was a trol subjects, the variable is the length of time that the instru-
positive correlation between Ni levels and age of broken in- ment has remained in the mouth of endodontic subjects. The
strument that was statistically significant (r=0.556, P<0.05). second independent variable was difference in age between
The within-group correlations between Ni levels and age were endodontic subjects and their controls (endodontic−control).
also positively correlated and statistically significant. For end- Thus, the regression analysis assessed whether the difference
odontic subjects, the correlation between Ni levels and age was in Ni levels between endodontic subjects and controls could be
r=0.524; for control subjects, the correlation was r=0.636. attributed to instrument time or the age difference between the
There was a small positive correlation between instrument time subjects. Models I and II presents the bivariate relationship
and Ni levels for the endodontic subjects (r=0.154), but it was between difference in Ni levels and instrument time and
not significantly different from zero (P>0.05) (Table 2). age difference, respectively. As noted in the table, the
Table 3 presents regression analysis from the data. The regression coefficient for instrument time is 0.231, which
dependent variable is not absolute Ni level but the difference is the predicted increase in Ni level for each additional
in Ni level between each endodontic subject and his/her control year of instrument time. The regression coefficient for age
(endodontic−control). There were two independent variables: difference was 0.398, which is the predicted difference in
Ni level between endodontic subjects and their controls, as
their age difference increased by 1 year. However, not the
Table 2 Pearson’s correlation coefficients between quantitative vari- coefficient was statistically different from zero, and the
ables. Correlations in all subjects and within-group amount of variance in Ni levels explained by the indepen-
dent variables is small. (r=0.034 for age, r=0.022 for
Ni Instrument time Age
instrument time).
All subjects (n=56) Model III presents the results of a regression in which the
Ni level n/a 0.556 difference in Ni levels between endodontic subjects and their
Instrument time n/a controls are regressed on both instrument time and age
Age difference. As shown in Table 3, neither regression coeffi-
Endodontic group (n=28) cient was significantly different from zero, and the P value
Ni level 0.154 0.524 for the regression equation (P=0.441) did not reach statistical
Instrument time 0.024 significance.
Age In summary, mean Ni level and age were greater in end-
Control group (n=28) odontic subjects compared to their controls. Additionally,
Ni level n/a 0.636 there was a positive correlation between age and Ni levels
Instrument time n/a within each group. However, the regression analysis indicated
Age
that the difference in Ni levels between endodontic subjects
and their controls could not be attributed to either instrument
P<0.05, two-tailed test time or the age difference between endodontic subjects and
n/a not applicable their controls.

Discussion
The present study was designed to evaluate the urinary nickel
in endodontic subjects with retained separated NiTi instrument
and to compare them with same-aged individuals without
endodontic treatment. Although we tried to justify inclusion
criteria, some limitation factors were unavoidable. In order to
avoid the limitations, all patients were instructed to avoid
consumption of a given list of foods rich in nickel for 7 days
before next visit. Sampling was carried out in the office in
order to collect uncontaminated specimens. Patients were
instructed to collect the urine in sterile nickel-free, 50-mL
plastic containers. They were also advised to avoid wiping or
rinsing the surfaces [28]. The mean age of the experimental
group samples was higher than the control group due to the
inclusion criteria of each group. In the experimental group, we
should have selected patients with broken instrument from an
endodontic treatment and in the control group without any
endodontic treatment and even metallic restorations which
made the sample selection very difficult. Although this differ-
ence in mean age might have influenced on statistical
methods, but in order to eliminate this, the sample size has
been increased to 28 specimens in each group.
A large amount of nickel in the blood is excreted through
feces unabsorbed; it comprises 90 % of total blood nickel. The
remaining 10 % is excreted through the urine. Kidney is the
main source of elimination of absorbed nickel [29]. In
unexposed people, the normal amount of nickel in the urine
is commonly reported between 2 and 6 μg/L [7], while some
authors have reported up to 50 μg/L [29]. Recent exposure to
nickel can be assessed from urinary and blood samples, and
concentration of nickel is the indicator of recent exposure to
nickel [30]. Indicator tissues which are more accessible for
nickel exposure measurements are urine, blood, and hair [28].
The present findings showed differences between urinary
nickel levels of the two groups. Endodontic subjects had
higher mean Ni levels than their controls. This finding shows
that Ni element derived from retained broken NiTi instru-
ment may have entered into systemic circulation, and con-
sequently into urine. However, this increase was within the
reference value of Ni concentration in urine. Previous ortho-
dontic studies have shown that orthodontic appliances might
increase the nickel levels of systemic urine in orthodontic
patients. Therefore, ions may enter into the systemic circu-
lation via orthograde route due to inadequate coronal seal of
restoration. A second possible mechanism for this exposure
may be through the periapical route. As this area is rich in
PDL vasculatures, nickel may enter into vessels and spread
through the systemic circulation and urine.
With increased age of participants, the urinary nickel levels
increased in either group. This increase may be attributed to
indirect contribution of environmental exposure sources. In
the modern world, urbanization has many consequences such
Saghiri et al.
as traffic and its effect on urinary nickel concentrations
[31, 32]. Also dietary habit and ingestion of drinking water
and food stuffs are significantly related to Ni urine level,
although Ni in water has a greater influence than food because
it is absorbed in higher extents [32].
There was not any positive correlation between instru-
ment time and Ni levels for the endodontic individuals. The
corrosion behavior of NiTi instruments may be influenced by
many factors. High acidity (PH <7) has especially adverse
effects on corrosion resistance of NiTi. Body fluids consist of
0.9 % NaCl and other minor amounts of salts which aggra-
vate corrosion of any metallic subject [33]. However, the
exposure of broken pieces to corrosive materials is limited
due to their entrapment by obturation materials.
Although this study has addressed the risk of increased level
of nickel element in the urine of patients with broken NiTi
instruments, but this increased amount was within the reference
value of Ni concentration in urine (2–6 μg/L), which was
presented by previous investigations. On the other hand, many
factors would influence the route of entering of this element
into the urinary system, such as the location of the broken piece,
whether or not the broken piece was surrounded by obturation
material, and the presence or lack of apical seal. In addition, the
need for elimination of environmental factors seems mandatory
in order to obtain more accurate results. This study setting
was carried out in an urbanized environment (Tehran, Iran).
For future work, researchers could have groups in other areas
with less indirect contributing factors for Ni exposure. As a
result, they may find the percentage of involvement of these
factors on Ni levels of urine in similar patients.
Conclusion
According to the outcomes of the present study, the following
conclusions have been drawn:
& The presence of a separated NiTi rotary endodontic in-
strument inside the dental canal can increase the Ni level
in urine excretion. However, this increase was within the
reference value of Ni concentration in urine.
& The time during or age of the broken instrument does not
have any remarkable effect on the amount of Ni element in
the urine. This issue suggests that either removal or
retaining of separated instrument cannot raise any concern
over the elevation of Ni level in the urinary excretion.
& The positive correlation between the age of participants
subjected for the study and the Ni level in urine has
demonstrated that in the course of time the level of Ni
can significantly increased in the urine. However, this Ni
elevation in urine is regardless of any accidental broken
instrument which an individual might experience in
his/her lifetime.
Broken Instrument and Nickel Level of Urine
Acknowledgments We are indebted to the late Professor Kamal
Asgar for the provision of laboratory facilities. Also, special thanks
go to Professor Hajar Afsar Ladjvardi, Dr. Amir Nazari and Ms. Neda
Bayati for all of their contributions to this research.
Conflict of Interest The authors affirm that they have no financial
affiliation or involvement with any commercial organization with direct
financial interest in the subject or materials discussed in this manuscript
and deny any conflicts of interest related to this study.
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