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Influence of root canal dressings and sealers on repair of apical

periodontitis after endodontic treatment


Fábio Luiz Camargo Villela Berbert, DDS, PhD,a Mário Roberto Leonardo, DDS, PhD,b
Léa Assed Bezerra Silva, DDS, PhD,c Mário Tanomaru Filho, DDS, PhD,a and Clóvis Monteiro
Bramante, DDS, PhD,d São Paulo, Brazil
UNIVERSITY OF THE STATE OF SÃO PAULO AND UNIVERSITY OF SÃO PAULO

Objective. The objective of this study was to evaluate the histopathologic response of periapical tissues after root canal treat-
ment of necrotic dog teeth with chronic apical periodontitis by using 2 calcium hydroxide–based root canal dressings and 2
root canal sealers.
Study design. Seventy-eight root canals were instrumented by using 5.25% sodium hypochlorite as the irrigating solution,
after which a calcium hydroxide paste (Calen/PMCC or Calasept) was placed for 30 days as a dressing. The root canals were
then filled by using cold lateral gutta-percha condensation and an endodontic sealer (Sealapex or AH Plus). After 360 days, the
animals were killed by anesthetic overdose; then, the teeth were histologically prepared, sectioned, and stained with hema-
toxylin and eosin for optical microscopic analysis of apical and periapical tissue repair.
Results. Statistical analysis showed that the poorest histopathologic results were observed in the Calasept/AH Plus group and
that the Sealapex sealer overall resulted in better apical repair than the AH Plus sealer. The histopathologic results of
Calen/PMCC paste with both AH Plus and Sealapex and Calasept paste with only Sealapex were statistically similar but were
different from the results of Calasept with AH Plus.
Conclusions. The results of this study in the dog showed differences in apical and periapical tissue repair of teeth with
chronic apical periodontitis by using 2 calcium hydroxide root canal dressings and 2 sealers. More research is necessary to
determine the best combination of dressings and sealers.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:184-9)

Chronic periapical lesions after root canal treatment most aerobic and anaerobic microorganisms. The
have been attributed to the persistence of bacterial antimicrobial effect of calcium hydroxide is attribut-
infection.1,2 Biomechanical preparation of teeth with able to its high alkalinity.7.8 Calcium hydroxide in
pulp necrosis and chronic apical periodontitis acts polyethylene glycol, mixed with small amounts of
especially on microorganisms located in the lumen of camphorated paramonochlorophenol, increases pene-
the root canal.3 Bacteria located in ramifications of the tration of root dentin. It also extends the period of
root canal system, especially in areas of cementum action8 due to the formation of calcium parachlorophe-
erosion,4,5 can only be reached with the topical appli- nolate.9
cation of antibacterial root canal dressings.6 The hermetic seal of root canals is also believed to be
Calcium hydroxide has been recommended as a root an important factor for successful endodontic treat-
canal dressing because of its antimicrobial action on ment. Sealapex sealer is outstanding for its biological
properties and for tissue mineralization around the
aAssistant Professor, Department of Endodontics, School of apical foramen after endodontic treatment of teeth with
Dentistry of Araraquara, University of the State of São Paulo, chronic periapical lesions.10 A new epoxy resin-based
UNESP, Araraquara, São Paulo, Brazil.
bProfessor, Department of Endodontics, School of Dentistry of
sealer, AH Plus, has shown biocompatibility with
Araraquara, University of the State of São Paulo, UNESP, apical tissues after root canal treatment of teeth with
Araraquara, São Paulo, Brazil. vital pulp.11
cProfessor, Department of Clinical Pediatrics, School of Dentistry of The purpose of this study was to evaluate the
Ribeirão Preto, University of São Paulo, USP, Ribeirão Preto, São histopathologic response of periapical tissues after root
Paulo, Brazil.
dAssistant Professor, Department of Endodontics, School of
canal treatment of dog teeth with pulpal necrosis and
Dentistry of Araraquara, University of the State of São Paulo, chronic apical periodontitis by using 2 calcium
UNESP, Araraquara, São Paulo, Brazil. hydroxide–based root canal dressings and 2 root canal
eProfessor, Department of Endodontics, School of Dentistry of sealers.
Bauru, University of São Paulo, USP, Bauru, São Paulo, Brazil.
Received for publication Aug 7, 2000; returned for revision Jan 5,
MATERIAL AND METHODS
2001; accepted for publication May 18, 2001.
Copyright © 2002 by Mosby, Inc. Seventy-eight root canals with completely formed
1079-2104/2002/$35.00 + 0 7/15/117803 apices in 6 mongrel dogs, aged 1 to 11⁄2 years, were
doi:10.1067/moe.2002.117803 used. The animals were first anesthetized with an intra-

184
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Berbert et al 185
Volume 93, Number 2

Fig 1. Radiograph of a dog’s mandible with periapical lesions. The sizes of the lesions are representative of all
lesions in the experiment.

venous injection of Nembutal (30 mg/kg body weight, camphorated paramonochlorophenol; S.S. White
pentobarbital sodium; Abbott Laboratórios do Brasil Artigos Dentários Ltda., Rio de Janeiro, Brazil) was
Ltda., São Paulo, Brazil). used as the root canal dressing in groups I and II, and
An access opening was made, and the pulp tissue was Calasept paste (Scania Dental AB, Knivsta, Sweden) in
removed. The teeth were left exposed to the oral envi- groups III and IV. These pastes were introduced into the
ronment for 7 days. The access openings were then root canal by using a threaded plunger syringe (S.S.
closed with a zinc oxide/eugenol-based cement (imme- White Artigos Dentários Ltda.). A long, 27-gauge needle
diate restorative material; Dentsply, Petrópolis, Brazil), (Becton Dickinson Ind. Cirúrgicas Ltda., Juiz de Fora,
and control radiographs were done every 15 days until MG, Brazil) was used for the Calen/PMCC paste, which
periapical radiolucent areas of similar sizes were was applied until it passed through the apical foramen, a
observed (Fig 1). After isolation with a rubber dam and state that was confirmed radiographically. The occlusal
disinfection with 0.3% iodoethanol (0.3% iodine in cavity was then sealed with zinc oxide–eugenol cement
70% alcohol), the root canals were instrumented by (immediate restorative material; Dentsply).
using the crown-down pressureless technique and the After 30 days, the root canal dressing was removed
irrigation was performed with abundant 5.25% sodium and the root canals were filled by using the lateral
hypochlorite (Instituto de Química da UNESP, condensation technique, with gutta-percha cones and
Araraquara, Brazil). The apical foramen was enlarged Sealapex endodontic sealer (Sybron Kerr Industria e
with sequential K-files (sizes #15 to #30) in the total Comercio Ltda., Guarulhos, SP, Brazil) for groups I and
length of the root. The apical delta was removed. III and AH Plus (Dentsply De Trey Gmbh, Konstanz,
Working length was established at 2 mm short of the Germany) for groups II and IV. The access opening was
radiographic apex. Instrumentation was performed restored with silver amalgam (Velvalloy; S.S. White
sequentially with K-files to size 70 to the working Artigos Dentários Ltda.) over a glass-ionomer base
length, confirmed radiographically, with irrigation (Vitremer, 3M Dental Products, St Paul, Minn). All 4
using 3.6 mL of 5.25% sodium hypochlorite solution at treatment combinations were tested in each animal.
every file change. After 360 days, the animals were euthanized with an
The teeth in each animal were randomly divided into anesthetic overdose. The maxilla and mandible were
4 experimental groups, so that all dressings and obtu- removed in each. The teeth were individually separated
ration methods could be tested in the same animal. and fixed in a buffer solution of sodium cacodylate
This resulted in 40 roots filled with AH Plus and 38 with saccharose and glutaraldehyde. The samples were
roots filled with Sealapex. Calen/PMCC paste (2.5 g demineralized with EDTA in a microwave oven
calcium hydroxide, 1 g zinc oxide p.a., 0.05 g (Continental Aw 42; B.S. Continental S.A. Utilidades
colophony, 2 mL polyethylene glycol 400, 0.04 g Domésticas, São Paulo, Brazil) and prepared for
186 Berbert et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
February 2002

Fig 2. Calen/PMCC-Sealapex: Complete sealing of the apical


opening with mineralized tissue. Periapical region with mild Fig 3. Calen/PMCC–AH Plus: Complete sealing of the apical
inflammatory infiltrate. opening with mineralized tissue.

histology. Thirty to 40 serial 6-µm-thick sections were dressings and sealers on apical periodontitis repair was
obtained from each root and stained with hematoxylin carried out with the nonparametric Kruskal-Wallis test
and eosin. and the 2-by-2 comparisons of the Dunn method.
A Zeiss binocular photomicroscope was used to
subjectively evaluate the following: (1) whether the RESULTS
level of the root canal filling was considered as slightly There was no significant difference in the apical level
short (1-2 mm), to the level of, or beyond the apical of the root canal fillings. Group III (Calasept and
opening; (2) whether closure of the apical opening with Sealapex) showed the best closure of the apical open-
mineralized tissue was absent/initial, partial, or ings, followed by groups I and II, with the poorest
complete; (3) whether inflammatory infiltrate was results observed in group IV (Calasept and AH Plus; P
absent/slight, moderate, or severe; (4) whether < .05). The least-inflammatory infiltrate was observed
cementum and dentin resorption was absent, only in groups I and III, in which Sealapex was used. Group
cement, or cement/dentin; (5) whether bone resorption II had some more inflammatory infiltrate, with the
was absent or present; and (6) whether periodontal poorest results observed in group IV (P < .05). The
ligament was normal or slightly thick, moderately apical periodontal ligaments were thinner in groups I
thick, or severely thick. The pathologists who evalu- and III (Sealapex) than in groups II and IV (AH Plus;
ated the specimens were calibrated and blinded to the P < .05). There were no statistical differences for the
groups being evaluated. Values of 0, 1, or 2 (best to cementum-dentin resorptions among the groups (P >
worst) were given to each parameter analyzed for .05; Figs 2-5).
statistical analysis. Within each group, there was a positive correlation of
Statistical analysis of the influence of root canal the intensity of the parameters analyzed and the final
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Berbert et al 187
Volume 93, Number 2

Fig 5. Calasept–AH Plus: Absence of sealing of apical


Fig 4. Calasept-Sealapex: Partial sealing of the apical opening.
opening. The periapical region showed severe bone destruc-
The periapical region showed moderate inflammatory infil-
tion and the presence of intense inflammatory infiltrate.
trate.

result. The overall results were calculated by adding apical closure and 75% partial closure after 90 days
the values of all parameters studied for each group and using AH Plus. It should be emphasized, however, that
then comparing groups. Analysis of these results these studies reported treatment of the root canals of
showed that the poorest histologic repair occurred in teeth with vital pulp.10,11 In the present study, a greater
group IV, which was statistically different from groups number of apical closures occurred with Sealapex than
I, II, and III (P < .05). with AH Plus. This difference is probably associated
with the solubility of Sealapex, leading to dissociation
DISCUSSION of Ca++ and OH–, providing antibacterial properties12
The results of this study showed that complete and enhancement of apical tissue mineralization.13
mineralized closure of the apical opening occurred in 3 Epoxy resin–based cements are highly insoluble.14 The
roots when Calasept paste and Sealapex were used and superiority of Sealapex over different root canal sealers
in 2 specimens when Calen/PMCC paste and Sealapex in cases of pulpal necrosis and chronic periapical
were used. By using a similar methodology, but with inflammations has been reported in other studies.10
Calen/PMCC applied for only 7 days, Tanomaru Filho In the 40 root canals in which AH Plus was used,
et al10 failed to obtain complete apical closure with severe inflammatory infiltrate was observed in 16 roots
Sealapex for 270 days. This difference is probably (40%), regardless of the dressing used. Conversely, in
attributable to the different time periods used in these 2 the 38 roots with Sealapex, severe inflammatory infil-
studies. trate occurred in only 3 (7.9%). These results are in
Complete apical closure occurred in only 1 case of agreement with those of Tanomaru Filho et al10 who
the 40 roots sealed with AH Plus (Calen/PMCC and reported a small incidence (5.26%) of severe inflam-
AH Plus). Leonardo et al11 obtained 12.5% complete matory infiltrate with Sealapex.
188 Berbert et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
February 2002

Table I. Frequency of samples and histopathologic findings, arranged according to the occurrences or intensity and
the experimental groups
Calen PMCC-Sealapex Calen/PMCC–AH Plus Calasept-Sealapex Calasept–AH Plus
Level of root canal filling Slightly short 12 14 11 12
To the level 3 2 3 2
Beyond 4 4 5 6
Closure of apical opening Complete 2 1 3 0
Partial 9 9 10 2
Absent 8 10 6 18
Inflammatory infiltrate Absent/slight 7 7 8 3
Moderate 10 5 10 9
Severe 2 8 1 8
Thickness of the periodontal Normal 8 1 10 0
ligament Moderately thick 8 13 6 13
Severely thick 3 6 3 7
Cementum-dentin resorption Absent 18 19 17 15
Only cement 0 0 2 2
Cement/dentin 1 1 0 3
Bone resorption Absent 12 16 14 6
Nondefined 0 0 0 0
Present 7 4 5 14

Assessing the effect of root canal dressings and tion and the application of a root canal dressing.6,10
occurrence of no or slight inflammatory infiltrate were The antimicrobial action of Sealapex is related to the
less frequent with Calen/PMCC paste (P < .05), dissociation of calcium and hydroxide ions, which is
regardless of sealer used. The dissociation of calcium responsible for maintaining a high pH of the tissues
hydroxide into calcium and hydroxide ions is respon- even after hardening due to its solubility.19,20 This
sible for increasing the pH of the root canal system, antimicrobial action associated with its biocompati-
making it unfavorable for bacterial growth. Other prop- bility13 could explain the more favorable results
erties of calcium hydroxide, such as an antiexudate obtained by Sealapex when used with a calcium
action,15 dissolution of necrotic tissue residues,16 and hydroxide dressing.
lipid A hydrolysis,17 may contribute to apical and peri-
apical repair.17 The high pH of the pastes used in this CONCLUSIONS
study as root canal dressings is dependent on the liber- • Sealapex showed better histopathologic results than
ation of hydroxide ions, which maintain this high pH did AH Plus (P < .05).
long enough to act on the microorganisms present in all • When compared with the results of the other groups in
of the root canal system.7 Calcium hydroxide paste, this study, the Calasept/AH Plus group showed the
containing a viscous vehicle, such as propylene glycol poorest histopathologic results (P < .05).
400, a component of the Calen/PMCC paste, has been • Calen/PMCC paste associated with the 2 sealers had
shown to be effective for the maintenance of the histopathologic results that were statistically similar
calcium hydroxide action, allowing a slow and to those with Calasept paste and Sealapex sealer.
extended release of calcium and hydroxyl ions for 60
days.6,9
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