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   Table of Contents - Current issue
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May-August 2020
Volume 10 | Issue 2
Page Nos. 83-171

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ORIGINAL ARTICLES  

The knowledge about vital pulp therapy of permanent teeth among Saudi internship dentists and dental students Highly accessed article p. 83
Mazen Doumani, Shahad Talea Almutairi, Naif Tami Talal Alshammari, Asma Naeem Alshami, Abdulaziz Saeed Alharbi, Adnan Habib
DOI:10.4103/sej.sej_84_19  
Introduction: The aim of this study was to assess the knowledge of Saudi internship dentists and dental students about the different types of vital pulp therapy (VPT) of permanent teeth. Materials and Methods: A comprehensive survey regarding different types of VPT were distributed either by E-mail or hard copies to internship dentists and clinical levels of dental students at seven different dental schools in Saudi Arabia. Descriptive statistics and Chi-square test were used to analyze the responses to the questions. Results: A total of 363 participants were included in this survey: 69.4% were male, and 30.6% were female. 27.3% of participants were internship dentists. About 74.4% of the participants believe that cone-beam computed tomography provides more accurate information about the root formation compared to conventional radiographs. About 44.4% of participants did not agree that sodium hypochlorite serves as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis and to help determine whether to proceed with partial pulpotomy, complete pulpotomy, or pulpectomy. 33.3% did not know that if mineral trioxide aggregate is substituted for calcium hydroxide in VPT procedures, similar time periods for apical maturation can be anticipated. There was no significant statistical difference among all examined groups regarding to knowledge and awareness about VPT. Conclusion: Within the limitations of this survey-based investigation among internship dentists and clinical levels' dental students, it was concluded that the participants had average knowledge about the different types and steps of VPT.
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Attitude and opinions of general dental practitioners, pedodontists, and endodontists toward regenerative endodontics in the Kingdom of Saudi Arabia p. 88
Mashael Al-Shahrani, Saeed Ali Al-Qahtani, Mona Al-Nefaie, Ghada Al-Enezi, Saad Al-Nazhan
DOI:10.4103/sej.sej_88_19  
Introduction: The aim of this survey study was to interpret the level of awareness, attitude, knowledge, and viewpoint toward regenerative endodontic treatments among general dental practitioners, pedodontists, and endodontists. Materials and Methods: A self-administered short questionnaire comprising 20 questions was circulated through WhatsApp mobile application among general dental practitioners, pedodontists, and endodontists of all the regions of the Kingdom of Saudi Arabia. The questionnaire consisted of four parts: demographic information, professional status, ethical opinions/beliefs, and information regarding clinical practice. The answers were tabulated and statistically analyzed. Results: A total of 311 duly filled-in questionnaires were received. The majority of the respondents were male (69.1%). Only one-third (38.3%) had received continued education in stem cells and/or regenerative dental treatments (P = 0.000). Two-thirds (75.6%) of the respondents were willing to save teeth/dental tissue and incorporate regenerative endodontic treatments in dental practice. The results suggested that one-third (33.8%) of the respondents were already using some kind of regenerative endodontic procedure in their clinical practices (P = 0.000). Conclusions: The level of awareness regarding the stem cell and regenerative dental procedures was low among the respondents in general.
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A comparative evaluation of sealing ability of three perforation repair materials using a field emission gun-scanning electron microscope p. 95
Saquib Mulla, Sharad Kamat, Santosh Hugar, Girish Nanjannawar, Nishita Kulkarni
DOI:10.4103/sej.sej_55_19  
Introduction: The study aimed to assess the sealing ability of Biodentine™, ProRoot mineral trioxide aggregate (MTA), and Super-EBA as furcation perforation repair materials using field emission gun-scanning electron microscope (FEG-SEM). Materials and Methods: Thirty-six extracted human permanent mandibular molar teeth were collected and cleaned. Standard access cavity preparation was made, and intentional perforation was created in each of the access cavity-prepared teeth using #12 round bur. The teeth were randomly divided into three groups each containing 12 teeth. The perforations were sealed as follows: Group A with Biodentine™, Group B with ProRoot MTA, and Group C with Super-EBA. The repair materials for all the three groups were evaluated for marginal adaptation using FEG-SEM. Data were statistically analyzed using one-way ANOVA and Tukey's honest significance test. Results: Quantitative FEG-SEM observations illustrated that the mean gap at the dentin–furcation repair material interface was as follows: Biodentine (3.01 ± 0.37 μm), ProRoot MTA (4.98 ± 0.68 μm), and Super-EBA (8.03 ± 0.68 μm). The difference between Biodentine™ and ProRoot MTA was not statistically significant (P > 0.05). Individually, Biodentine and ProRoot MTA showed statistically significant differences when compared to Super-EBA (P < 0.05). Conclusion: The sealing ability of ProRoot MTA and Biodentine™ as a repair material of furcation perforation was better than Super-EBA.
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Effect of chelating agents on the wettability of BioRoot RCS and AH Plus sealers p. 100
Poornika Gandhi, Nidambur Vasudev Ballal, Jijo Easo George, Sajan D George, Raj Kumar Narkedamalli
DOI:10.4103/sej.sej_82_19  
Introduction: To evaluate the effect of different chelating agents on the wettability of AH Plus and BioRoot RCS sealers on intraradicular dentin. Materials and Methods: Fifty single-rooted premolars were split longitudinally and divided into five groups according to irrigant regimen. Group 1: 2.5% sodium hypochlorite (NaOCl) – 17% ethylenediaminetetraacetic acid (EDTA); Group 2: 2.5% NaOCl – 7% maleic acid (MA); Group 3: 2.5% NaOCl – SmearOFF™ (containing chlorhexidine and EDTA); Group 4: 2.5% NaOCl – Dual Rinse® hydroxyethylidene diphosphonic acid (HEDP); Group 5: 2.5% NaOCl – distilled water. Specimens were treated with controlled volume of experimental sealers and subjected to contact angle measurement. Results: Wettability of both sealers on intraradicular dentin was found to be best with MA. For AH Plus sealer, wettability was better with SmearOFF™, followed by EDTA, Dual Rinse® HEDP, and distilled water. However, there was no statistical difference between SmearOFF™ and EDTA (P > 0.05). For BioRoot RCS, wettability was better with SmearOFF™ and EDTA, with the former showing better results (P < 0.001). This was followed by Dual Rinse® HEDP and distilled water. Conclusion: Within the limitations of the study, it can be concluded that MA when used as a final irrigant showed better wettability of both AH Plus and BioRoot RCS sealers compared to the other tested solutions.
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Effect of Irritrol™ endodontic irrigant and ethylenediaminetetraacetic acid in smear layer removal from instrumented human root canal dentine: A scanning electron microscopic analysis p. 106
Swastika Bhattacharya, Tina Puthen Purayil, Nidambur Vasudev Ballal, Kalyana Chakravarthy Pentapati
DOI:10.4103/sej.sej_94_19  
Introduction: Ethylenediaminetetraacetic acid (EDTA) is a chelating agent that is most widely used for smear layer removal. Irritrol™ is a novel endodontic irrigating solution that contains EDTA and chlorhexidine that can be used as a final irrigating agent which claims of being more efficient but less aggressive. The aim of the study was to evaluate and compare the effects of Irritrol and EDTA in smear layer removal from instrumented human root canal dentine. Materials and Methods: Thirty-nine extracted human single-rooted maxillary incisors were decoronated at the cementoenamel junction. Chemomechanical preparation was done using ProTaper Gold rotary instruments and intermittent irrigation of 2.5% sodium hypochlorite. Random division of the samples into three groups (n = 13) was done with Group A: Irritrol; Group B: 17% EDTA; and Group C: 0.9% saline solution. The samples were dehydrated, gold sputtered, and evaluated under scanning electron microscope. Statistical Analysis: Statistical analysis was performed using Kruskal–Wallis ANOVA with post hoc Conover test with a significance level of P = 0.05%. Results: It was demonstrated that 17% EDTA was significantly more effective in removal of smear layer than Irritrol in coronal, middle, and apical third of the root canal. Conclusions: 17% EDTA had better smear layer removal effect than Irritrol when used as a final irrigant.
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ProTaper Next files edge wear after conforming vestibular canals of maxillary molars: An in vitro study p. 111
Daniel Aracena, Sergio Marín, Eduardo Borie, Angella Aracena, Luis Bustos, Mario Guzmán
DOI:10.4103/sej.sej_95_19  
Introduction: The aim of this study was to evaluate the wear of ProTaper Next rotary files, X1, X2, and X3 after shaping 6, 10, and 14 maxillary molar vestibular canals. Materials and Methods: One hundred and sixty-two rotary files were divided into three groups according to the number of prepared canals, namely Group 1 (6 canals), Group 2 (10 canals), and Group 3 (14 canals). After canal preparation, files were embedded in resin molds, sectioned at 6 mm from the tip, and the wearied surface was microscopically evaluated. AutoCAD® software was used to measure the wear of edges in the different sections and multilevel mixed linear regression model to statistically analyze the data. Results: The files exhibited progressive wear as the number of uses increased. X2 and X3 files of Group 2 (10 canals) showed the highest wear, which decrease at 14 canals. Conclusions: X1, X2, and X3 files can shape until 10 canals without loss of their edge effectiveness.
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Influence of passive ultrasonic tip activation at different levels on the depth of sealer penetration: An in vitro study p. 116
Nurul Ain Ramlan, Dalia Abdullah, Timm Joyce Tiong, Diego Spreafico, Shalini Kanagasingam
DOI:10.4103/sej.sej_109_19  
Introduction: The aim of this study was to compare the effect between different levels of ultrasonic tip activation on the depth of epoxy resin-based sealer (AH plus) dentinal tubules penetration. Materials and Methods: Extracted single-rooted premolars (n = 60) were randomly allocated into three groups and instrumented following the same protocol. Group 1 (control), the sealer was mixed with 0.1% Rhodamine B dye and placed using size 20 K-file. In Group 2, the sealer was passively activated using ultrasonic tip (ISO 25) 10 s mesiodistally and buccolingually at 2 mm from the apex. In Group 3, the sealer was activated in a similar manner at 4 mm from the apex. Samples were sectioned horizontally at 2 mm, 4 mm, and 6 mm from the apex and analyzed using a stereomicroscope for tubular dentine sealer penetration. The cross-sectional area (μm2) was measured with software to get the percentage of sealer penetration, and presences of voids were recorded. Results: Significant lesser percentage of sealer penetration into the dentinal tubules was observed between the control group and both the experimental groups (P = 0.00) at 2 mm, 4 mm, and 6 mm from the apex. There was no significant difference in the percentage of sealer penetration into the dentinal tubules between both the experimental groups (P > 0.05). The presence of voids between all groups was not statistically significant (P > 0.05). Conclusion: Passive ultrasonic activation of sealer placement resulted in deeper sealer penetration into the dentinal tubules even at a higher level of tip activation (4 mm).
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Assessment of apical periodontitis in relation to quality of root canal fillings and coronal restorations in a Turkish subpopulation: A retrospective cone-beam computed tomography study p. 121
Seda Falakaloglu, Ceren Aktuna Belgin, Latife Altınok Uygun, Özkan Adigüzel
DOI:10.4103/sej.sej_114_19  
Introduction: This study aims to investigate the prevalence of apical periodontitis (AP) and relate the quality of root canal fillings (RCFs) and coronal restorations (CRs) with using cone-beam computed tomography (CBCT) in a Turkish subpopulation. Materials and Methods: A total of 824 CBCT scans were performed at the Dicle University Faculty of Dentistry between January 2015 and December 2017. The age, sex, root canal-treated teeth of each patient, quality of RCF and CR, and CBCT periapical index (CBCTPAI) scores of teeth were calculated and recorded. Data were statistically analyzed. Results: Among 333 patients, 152 (45.6%) patients were male and 181 (54.3%) were female. The mean age was 30.1 ± 5.3 years. The total number of endodontically treated teeth was 550, and 76.2% had AP. In 238 (43.3%) teeth with inadequate RCF, AP rate was 89.4%. There was a significant correlation between the density of the RCF and AP (P < 0.00). Inadequate restorations accounted for 177 teeth (32.2%), of which 10.1% (18) of the teeth were CBCTPAI 1. Of the 41 teeth with missing CR, 39 (95.1%) teeth showed signs of AP. A significant difference was found between CR and AP (P = 0.00). Conclusions: The RCF quality, adequate CR, and the type of CR are related to AP.
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Comparative evaluation of porosity distribution in root canals obturated with gutta-percha using single-cone technique and thermoplasticized technique p. 126
Tanya Sawhney, Ansu Ann Abraham, Karuna Y Mahabala, Madhura Sen, Srikant Natarajan, Nithin Thilak, Ashwin Rao, Anupama Nayak
DOI:10.4103/sej.sej_118_19  
Introduction: The objective of the study was to comparatively evaluate the porosity distribution in the root canals obturated using the single-cone technique and thermoplasticized technique. Materials and Methods: A total of 42 permanent single-rooted human extracted teeth were divided equally into two groups based on the technique employed: single-cone technique and thermoplasticized technique. Following postobturation restoration, void volume was analyzed by cone-beam computed tomography (CBCT) and void location was evaluated by microscopic method at three levels: coronal, middle, and apical. Independent Student't-test and Chi-square test were used for analyzing the obtained results. Results: On comparing the void volumes as seen in CBCT images between the two groups, the thermoplasticized technique showed greater but insignificant void volume (P = 0.18). When the association of the location of the void with the void area percentage was analyzed between the two techniques, significant associations were seen in the middle (P = 0.016) and the apical levels (P = 0.031). Conclusion: The single-cone technique showed a comparable seal with the thermoplasticized technique. Voids were predominantly seen at the sealer–cone interface and sealer–root canal wall interface for single-cone technique and in between the condensed gutta-percha for thermoplasticized technique.
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Cyclic fatigue resistance of three heat-treated nickel-titanium instruments at simulated body temperature p. 131
Tarek M Elsewify, Shehabeldin M Saber, G Plotino
DOI:10.4103/sej.sej_122_19  
Introduction: The aim of this study was to evaluate the cyclic fatigue resistance of three heat-treated nickel–titanium (NiTi) systems at simulated body temperature. Materials and Methods: Twelve instruments of similar apical diameter (#25) from three engine-driven NiTi instruments; WaveOne Gold (WOG), Hyflex EDM (HEDM), and M Pro system were tested for cyclic fatigue resistance at 37°C in simulated root canals with 60° angle of curvature and 5 mm curvature radius. All instruments were operated until fracture occurred. Mean and standard deviation of the time to fracture and fragment length were calculated, and statistical significance was set at 5%. The morphological characteristics of the fractured instruments were observed through scanning electron microscopy, and their chemical composition was determined using energy dispersive X-ray analysis (EDXA). Results: HEDM showed the highest resistance to cyclic fatigue at 37°C followed by WOG and M Pro instruments with a statistically significant difference. Scanning electron micrographs confirmed a predominantly ductile mode of fracture for all instruments. EDXA showed that WOG was composed of Ni (45.1 wt%) and Ti (37.0 wt%), HEDM was composed of Ni (52.9 wt%) and Ti (42.4 wt%), and M Pro was composed of Ni (49.7 wt%) and Ti (40.4 wt%). Conclusions: M Pro instrument showed the least cyclic fatigue resistance at 37°C compared to HEDM and WOG.
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Awareness, attitude, and practice of regenerative endodontic procedures among clinicians from different dental specialties p. 137
Mohamed Jamal, Summayah Khawaja, Sami Chogle
DOI:10.4103/sej.sej_131_19  
Introduction: This study assessed the opinions on and practice of regenerative endodontic procedures (REPs) among clinicians from different dental specialties. Materials and Methods: After the Institutional Review Board approval, 205 clinicians participated in a web-based survey and were asked about their educational level, professional status, opinion toward REPs, and preferred technique when performing REPs. Results: Although approximately 65% of participants were unsure or did not believe that there is enough evidence to support REPs, 78.2% believed that REPs are a better treatment option than apexification and 70.5% that they could be a future alternative to osseointegrated implants. The results also revealed variability in the preferred techniques to perform REPs, with 40.4% preferring the use of a mixture of antibiotics to disinfect the root canal space, whereas 20.2% preferred calcium hydroxide. Almost 66% were using ≥1 mg/mL of each antibiotic in the mixture, whereas 44.6% were using 0.1 mg/mL. Approximately 40% of participants used techniques that differ from the American Association of Endodontists' clinical considerations for REPs. Interestingly, attending a continuing dental education course (CDE) significantly reduced the participants' uncertainty toward REPs and increased their willingness to perform it themselves (P < 0.001). Conclusions: This survey revealed a positive attitude toward and general acceptance of REPs by dentists. It also showed considerable variability in techniques used to perform REPs. Conducting more CDE may increase the awareness of REPs among different dental specialties and reducing variability in techniques.
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Influence of kinematics on the cyclic fatigue of ProTaper Gold and WaveOne Gold p. 145
Nawaf S Hanbazaza, Tariq S Abuhaimed
DOI:10.4103/sej.sej_132_19  
Introduction: The aim of the study is to assess the difference in the dynamic cyclic fatigue resistance of ProTaper Gold (PTG) and WaveOne Gold (WOG) files tested in clockwise and counterclockwise continuous rotation against two different reciprocal motions. Materials and Methods: A total of 200 files were tested at 300 rpm. These files were divided into four groups according to direction and type of motion: (A) clockwise continuous rotation, (B) counterclockwise continuous rotation, (C) reciprocal motion with 150° counterclockwise and then 30° clockwise motion, and (D) reciprocal motion with 150° clockwise and then 30° counterclockwise motion. The files were operated in a stainless steel artificial canal with a 60° angle of curvature and a 5-mm radius. A continuous, axial oscillating motion was applied at one cycle/s. The number of cycles to failure (NCF) was recorded. The data were analyzed using two-way analysis of variance. Results: No significant difference in NCF was found between Groups A and B or between Groups C and D in all rotary systems used (P > 0.05). However, reciprocal motions exhibited higher cyclic fatigue resistance than continuous rotations (P < 0.05). Moreover, PTG showed higher cyclic fatigue resistance than WOG (P < 0.05). Conclusions: Reciprocal motions have increased cyclic fatigue resistance, but the direction of the motion had no effect on the fatigue life of the tested instruments. PTG files had higher resistance to cyclic fatigue than WOG files.
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Are endodontic abstracts of published randomized clinical trials reported adequately? p. 152
Fahd A Aljarbou, Fahad Alharbi, Hadi M Alamri
DOI:10.4103/sej.sej_143_19  
Introduction: The aim is to assess the randomized clinical trials reporting quality of abstract in two main endodontic journals and their adherence with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Materials and Methods: A hand search looking for all randomized clinical trials published in two endodontic journals; the International Endodontic Journal (IEJ) and the Journal of Endodontics (JOE) from 2012 to 2019; was carried out. A modified CONSORT abstracting checklist was followed and the data were analyzed descriptively. Results: A total of 140 abstracts gathered and distributed as 18% in the IEJ and 82% in the JOE. The overall mean score for reporting quality was 49.7%. There was 100% checklist score in authors' details, objectives, interventions, outcome, and conclusion. Deficient reporting in the randomization procedures, blinding, and allocation concealment was present in most of the abstracts. There was no mention of registrations and funding sources in any included abstract. Conclusions: The randomized clinical trials reporting quality of abstract in endodontic journals are suboptimal. More adherence to the CONSORT guidelines is recommended.
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CASE REPORTS Top

Multidisciplinary approach to the management of a subgingivally fractured anterior tooth using an aligner based esthetic orthodontic extrusion appliance – A case report p. 157
Gayathri Parthiban, Shweta Nagesh, Rupali Karale, Sumitra Reddy
DOI:10.4103/sej.sej_3_19  
Restoration of a subgingivally fractured tooth, especially at anterior esthetic zones, is still a great challenge for restorative dentists. This case report describes the management of a subgingivally fractured central incisor of a healthy 27 year old male patient using a conservative approach while maintaining esthetics throughout the treatment with the help of a clear aligner. An interdisciplinary approach was followed that included nonsurgical endodontic therapy followed by orthodontic extrusion, crown lengthening, and post-endodontic restoration with a custom cast post and porcelain-fused-to-metal crown. The tooth was asymptomatic clinically and radiographically at 1-year follow-up. This method can be an innovative solution to patients who demand instant resolution to their esthetic issues. The present case also reports management of relapse of orthodontically extruded tooth.
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Maxillary Central Incisor with Two Roots – A case report p. 162
Ebtissam M Al-Madi
DOI:10.4103/sej.sej_137_19  
Knowledge of the external and internal dental anatomy and its variations is a prime factor of success of endodontic therapy. The maxillary central incisor usually presents with one root canal system within one root. This report portrays an endodontic re-treatment of a maxillary central incisor of a healthy 38-year-old Saudi female patient with two canal systems and two roots presented to the clinic complaining of swelling and pus drainage. The case was initially misdiagnosed and not treated fully, however, correct diagnosis through detailed examination and evaluation, using tracing and imaging. Retreatment was done and the tooth was asymptomatic clinically and radiographically at 6 months follow-up.
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A multidisciplinary approach to an unusual cystic lesion of the maxilla – A case report p. 165
Farhana Omar, Tahir Yusuf Noorani, Huwaina Abd Ghani, Nik Rozainah Nik Abdul Ghani, Noor Hayati Abdul Razak, Nur Diyanah Ab Wahid
DOI:10.4103/sej.sej_38_19  
A large cyst in the maxilla in relation to a nonvital tooth is not a common occurrence. The present case report demonstrates an unusual case of a giant cyst in the right maxillary antrum region extending from the anterior to posterior right maxilla with no intraoral bony and soft tissue expansion of a healthy 31-year-old female. However, bone erosion was noted and integrity of important anatomical structures of the right maxillary sinus was affected. The adjacent teeth were nonvital without any evidence of root resorption. Conventional root canal treatment together with surgical enucleation of the affected teeth at 6 months follow-up resulted in the successful resolution of the cyst with complete bone regeneration.
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