Introduction: Endodontic infections are polymicrobial in nature. Enterococcus fecalis is the most common micro-organism isolated from failed endodontic cases. The constant increase in antibiotic resistant strains and side effects caused by synthetic drugs has prompted researchers to look for herbal alternatives since the gold standard for irrigation i.e., sodium hypochlorite (NaOCl) has many disadvantages. Objective: The present study was aimed to explore newer irrigation solutions, which would probably be as effective as NaOCl. Materials and Methods: Extracted human single rooted premolar teeth were biomechanically prepared, vertically sectioned, placed in tissue culture wells exposing the root canal surface to E. fecalis is grown on Mueller Hinton agar plates to form a biofilm for 6 weeks. At the end of 6 ^th week, all seven groups were treated with 3 ml of test solutions and control for 10 minutes and evaluated for E. fecalis growth and number of colony forming units. Results: Propolis, NaOCl and triphala showed no statistically significant difference, whereas all the other inter-group differences were statistically significant (Tukey's honest significant difference (HSD)) (P < 0.001). Conclusion: Propolis and triphala were found to be as efficacious as NaOCl. The use of herbal alternatives as root canal irrigation solutions might prove to be advantageous considering several unfavorable properties of NaOCl.

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Aim: To determine the prevalence of the number of root canals in permanent maxillary first and second premolars of a Saudi Arabian sub-population. Results will be compared to previous Asian studies. Materials and Methods: A total of 894 periapical radiographs of endodontically treated maxillary first and second premolars of 628 Saudi patients (268 males and 360 females) were viewed. The teeth were segregated into maxillary first premolars (463) and maxillary second premolars (431). The diagnostic, working length, master cone and final films with different angles were mounted, projected and, with the utilization of written clinical records, evaluated. Teeth with multiple canal systems were categorized according to whether the canals exited the root by common or separate apical foramen. Data was analyzed statistically using Chi-square test and professional t-test, by comparing pairs of groups with the significant level established at 5% (P < 0.05). Results: More than 90% of first maxillary premolar and more than 50% of the second maxillary premolar was found to have two canals. There was no significant difference between male (92%) and female (95%) in the distribution of the two root canals of the first maxillary premolar (t-test = 1.21, P value = 0.228), however, there was significant difference between the distributions of male (69.4%) and female (52.2%) of the two root canals within the second maxillary premolar (t-test = 3.75, P value = 0.000). Few teeth showed three canals. Conclusion: The number of root canals of the maxillary first premolar in Saudi population shows a higher incidence of two canals (93.6%) than previously reported. In addition, the figure is higher than most of the Asian countries.

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Objective: The aim of the study was to assess the radiographic quality of root fillings done by the undergraduate students. Materials and Methods: A sample of 258 clinical cases of patients who received root canal treatment from undergraduate students in the years 2010 to 2012 were selected, out of which 194 root fillings were assessed radiographically based on the following criteria; length and density of root filling. Root fillings were categorized as acceptable and unacceptable. Percentages and χ² test were used for statistical analysis. Results: From the 194 root fillings, 119 (61.35%) were having acceptable and 75 (38.65%) were having unacceptable root fillings. From the total 75 unacceptable root fillings, 49 (65.33%) had density problems, 11 (14.66%) were overfilled, and 15 (20%) were under filled. Chi-square test was done for statistical analysis; revealed no significant difference in the radiographic quality between anterior and posterior root fillings. Conclusion: The radiographic quality of root fillings done by undergraduate students was acceptable in 61.35% cases. Most common cause of unacceptable fillings was due to density problems compared to overfilling and under filling. Results from the study indicate that remedial measures have to be undertaken to improve training of undergraduate students in root canal treatment procedure.

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Mental nerve paraesthesia can occur as a result of a variety of reasons. Paraesthesia following endodontic treatment is an uncommon treatment complication. Causes of paraesthesia in the mental nerve region are reviewed and two cases involving endodontic treatment are discussed. In the first instance, a patient presented with difficulty in swallowing and severe pain localized to her right mandible, with numbness of her lower lip. Paraesthesia resolved quickly with endodontic treatment. In the second instance, a patient referred for treatment a mandibular second premolar developed profound paraesthesia in the distribution of the mental nerve after treatment. The local anesthetic used was 4% articaine by infiltration. CBCT imaging revealed two accessory mental foramen and slight extrusion of sealant into one of the neurovascular exits. Possible causes of paraesthesia are discussed in the light of the literature review. CBCT imaging may be useful in the diagnosis and management of these conditions.

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Radix entomolaris (RE) is considered to be an Asiatic trait. However, its prevalence in Indian population is found to be lower than in other Asian races. Nevertheless, its awareness and identification is vital to achieve endodontic success. This article presents a review on clinical approach and a case series on the detection and endodontic management of RE in mandibular first molars. Radix entomolaris was detected by identifying the presence of a double or extra root outline in the preoperative radiograph, modifying the access opening and closely inspecting the pulp chamber and was endodontically treated following cleaning, shaping, and obturation of the canals. Achieving the endodontic success in the presence of an RE requires knowledge about its prevalence, diagnosis, morphology, canal configuration, and clinical approach.

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The use of triple antibiotic paste (TAP) (mixture of ciprofloxacin, metronidazole and minocycline) as an intra-canal medicament have shown very encouraging results particularly in non-vital immature teeth associated with periradicular lesions. Hence, before opting for a surgical approach, a non-surgical approach can be thought of with extended use of TAP as intra-canal medicament, especially in patients who are phobic to invasive procedures. On the flip side, the use of TAP has few side-effects, of which one is the discoloration it can cause due to the presence of minocycline in the mix. The purpose of this article is to presents a case of coronal discoloration due to the use of TAP as an endodontic intra-canal medicament.

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Aim: The aim of this study was to compare the calcium hydroxide (Ca(OH) ₂ ) removal efficacy of the EndoActivator system with that of conventional irrigation with a syringe and hand file manipulation. Materials and Methods: A total of 44 extracted human single-rooted mandibular premolars were used. The root canal systems of all teeth were cleaned and shaped, then filled with Ca(OH) ₂ paste. The teeth were divided into two groups: Ca(OH) ₂ was removed using ethylenediaminetetraacetic acid (EDTA) and sodium hypochlorite (NaOCl) with hand filing and irrigation (Group 1) or the EndoActivator system (Group 2). Each tooth was split into two halves and examined under a scanning electron microscope. Results: Ca(OH) ₂ particles were completely removed at the coronal level in both experimental groups. More Ca(OH) ₂ particles were present in the apical third than in the middle-third in both groups. No significant interaction was observed between the two experimental groups or among the three examined levels (P > 0.05). Conclusion: Agitation with NaOCl and EDTA improved Ca(OH) ₂ removal only in the coronal third of the root canal. Use of the EndoActivator system did not improve the efficacy of Ca(OH) ₂ removal in the middle and apical thirds.

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Aim: The purpose of this in vitro study is to provide clinical data on the presence of the second canal in mandibular incisor teeth of Saudi Arabian Samples. Materials and Methods: Eighty extracted human mandibular incisors were collected from Saudi patients. The teeth were accessed by small round bur then placed in 5.25% sodium hypochlorite for 24 hours to dissolve the organic debris. Indian ink was injected inside the root canal systems under negative pressure. The teeth were decalcified in 5% nitric acid for three days then dehydrated in different concentrations of ethyl alcohol. Following the decalcification process, the teeth were cleared in methyl salicylate and evaluated according to Vertucci's classification. Result: Fifty six of both mandibular central and lateral incisor teeth (70%) had type I canal configuration (one main canal and one main apical foramen), while the remaining 30% of the sample (24 teeth) had a type III canal configuration (two separate canals and merged into one canal before exiting the tooth through single apical foramen). Conclusion : The incidence of two canals in mandibular incisor teeth is about one third of the examined Saudi Arabian samples with no difference between the centrals and laterals. The clinician should deal with these teeth as if they have two canals unless it is proved otherwise.

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Objective: We evaluated knowledge of technical aspects of non-surgical root canal treatment among general dentists in private dental clinics in Al-Madinah Al-Munawarah, Saudi Arabia. Materials and Methods: A questionnaire was distributed randomly to 70 general dental practitioners who were working in private dental centers. The response rate was 88.6%. Results: The results showed that only 3% of dentists were using rubber dams for isolation during endodontic treatment. The majority (59.7%) were using radiographs to determine the length. Also, 37% were using nickel-titanium (NiTi) rotary instruments to prepare the root canal. The lateral condensation technique with gutta percha points to fill the root canal was used by most respondents (77.5%). Conclusions: This study provides important data on endodontic treatment by general dental practitioners in Al-Madinah Al-Munawarah private dental centers. It shows a general lack of knowledge regarding the importance of using rubber dams as well as the new endodontic materials and methods. Continuing education programs to update their knowledge in the field of endodontics are essential.

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Aim: To evaluate and compare the antibacterial efficacy of Melaleuca alternifolia (tea tree oil), Curcumalonga (turmeric), 2% chlorhexidine (CHX), and 5% sodium hypochlorite (NaOCl) against Enterococcus faecalis. Materials and Methods: Agar plates were prepared using tryptone soya agar. Cultures of E. faecalis were grown in tryptone soya broth. Agar well diffusion method was performed and the plates were incubated at 37΀C for 24 h. The zones of inhibition were recorded. The readings were subjected to statistical analysis using analysis of variance (ANOVA) and Tukey's post hoc test. P-value was considered significant at P < 0.05. Results: Maximum antibacterial efficacy was exhibited by 2% CHX, followed by 5% NaOCl and C. longa with no statistically significant difference between them. It was followed by M. alternifolia (Tea tree oil). Ethanol and saline showed the least antibacterial action. Conclusion: According to the results of this study, C. longa and M. alternifolia can be used as an alternative root canal irrigant, although long-term in vivo studies are warranted.

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Aim: To evaluate the microleakage of a simplified etch-and-rinse adhesive bonded to pulp chamber dentin with water-wet bonding (WWB) or ethanol-wet bonding (EWB) with and without proanthocyanidins (PA) application. Materials and Methods: Total 88 non-carious extracted human molar teeth were sectioned horizontally to expose the pulp chambers 1.5 mm coronal to the cemento-enamel junction. After the pulp tissue extirpation, canal orifices were enlarged and the root ends were sealed. The samples were randomly divided equally into following four groups according to the four bonding techniques performed using Adper Single Bond 2 [SB] adhesive (1) WWB; (2) EWB; (3) WWB and PA application [WWB + PA]; (4) EWB and PA application [EWB + PA]. Composite resin restorations were performed in all the pulp chambers. Total 20 samples from each group were subjected to microleakage evaluation, and two samples per group were assessed under scanning electron microscope for interfacial micromorphology. Results: The least microleakage score was observed in group 2 (EWB) with similar results seen in group 4 (EWB + PA) (P = 0.918). Group 2 (EWB) showed significantly less microleakage than group 1 (WWB; P = 0.002) and group 3 (WWB + PA; P = 0.009). Group 4 (EWB + PA) also depicted significantly reduced microleakage as compared with group 1 (WWB; P = 0.001) and group 3 (WWB + PA; P = 0.003). Conclusion: The use of EWB technique in a clinically relevant simplified dehydration protocol significantly reduced microleakage in simplified etch-and-rinse adhesive, Adper Single Bond 2, bonded to pulp chamber dentin. Application of PA had no significant effect on the microleakage of the adhesive bonded with either WWB or EWB.

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Iatrogenic root perforations, which may have serious implications, occur in approximately 2-12% of endodontically treated teeth. Successful management of root perforations is dependent on early diagnosis of the defect, location of the perforation, choice of treatment, materials used, host response, and the experience of the practitioner. This report presents the successful management of an iatrogenic perforation in a tooth with radiographic evidence of pulp canal obliteration.

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Traumatized anterior teeth with sub-gingival crown fractures are a challenge to treat. The management of sub-gingival fractures includes exposing the cervical margin followed by appropriate coronal restoration. The treatment modalities, which involve exposing the cervical margin, are surgical crown lengthening and orthodontic extrusion. This paper reports a case of fractured maxillary anterior tooth at the sub-gingival level that was managed by forced orthodontic extrusion after endodontic treatment followed by esthetic rehabilitation, a much forgotten technique not utilized routinely yet conservative and cost-effective.

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Aim: The aim of our study is to elaborate a new cement based on Portland cement (PC), Modified Portland Cement (MPC) with modified chemical and physical properties that allow easier clinical manipulation and faster setting time than MTA^® and then to evaluate its cytotoxicity in vitro and its biocompatibility in vivo in comparison with MTA^® . Materials and Methods: Elaboration of MPC: Portland cement powder slenderly grinded to homogenize the particles, mixed with a radiopaque element and a setting time accelerator. A comparative in vitro study (MTS test) of the toxic effect of MTA^® and MPC with culture isolated from the calvaria of 18-day-old fetal Swiss OF1 mice are done. A comparative in vivo study of the biocompatibility of MTA^® and MPC: Under general anaesthesia, three holes (2.5 mm) were made in both the left and right femurs of six White New Zealand rabbits. In the first hole MPC is placed, in the second MTA^® and the third one is left empty (negative control group). Three weeks after implantation, two rabbits are sacrificed, then two other rabbits over six weeks and the last two after twelve weeks. The neck of the femur is trimmed and prepared for undecalcified histological studies. Mann-Whitney test was used to analyze the results. Results: The cell viability test according to the morphological observations suggested the biocompatibility of the two biomaterials tested. The in vivo test showed similar biocompatibility between MTA^® and MPC. Bone healing and minimal inflammatory response adjacent to MTA^® and MPC implants were observed at all experimental periods (3, 6 and 12 weeks), suggesting that both materials are well tolerated. Conclusion: This pilot comparative study of MTA^® and MPC showed no or very limited toxic effects of both cements in vitro and similar biocompatibility in vivo. However, additional in vivo and clinical studies should be done on MPC before it can be introduced in our clinical practice.

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Aim: To evaluate the cleanliness of rotary prepared root canals when the irrigation needle was placed at full or half the working length. Materials and Methods: Forty-five root canals were collected from extracted human teeth and divided into three groups each group of fifteen roots. Group 1: Root canals were instrumented using Profile® system and irrigated with 3% EDTA and 0.5% NaOCl. Group 2: Root canals were instrumented in the same manner as group 1 and irrigated with 18% EDTA and 5.25% NaOCl and the tip of the irrigation needle was introduced to the full working length. Group 3: Root canals were instrumented in the same manner as group 2 except that the tip of the irrigation needle was introduced half the working length. The roots were sectioned longitudinally and evaluated for smear layer at coronal, middle and apical thirds of the canals under SEM. The results were analyzed using the Kruskal-Wallis test. Results: No statistically significant difference was found in the distribution of the scores between all groups. However, the scores in the apical part of group 1were significantly higher than the middle and the coronal areas. Conclusion: The placement depth of irrigation needle or concentration of irrigants solutions has no influence on the cleanliness of rotary prepared canals.

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Aim : The purpose of this study was to comparatively evaluate the antibacterial property of various concentrations of green tea extracts and 2% chlorhexidine (CHX) against Enterococcus faecalis 0(E. faecalis) in vitro. Materials and Methods: The activity of green tea extract and CHX on E. faecalis was measured on agar plates using the agar diffusion method. In addition, the tube dilution method was used to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration of green tea extract against E. faecalis. Results: The MIC of green tea extract was found to be 3.5%. The zone of inhibition was found to be concentration dependent. The 2.5% concentration of green tea extract showed 20 mm zone of inhibition, while the 3% concentration demonstrated a 30 mm zone of inhibition. Two percent CHX showed 30 mm zone of inhibition. Conclusion: Three percent concentration of green tea extract showed an antibacterial activity equivalent to 2% CHX against E. faecalis.

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Aim: The aim of this study was to analyze the cytotoxicity of various volumes of 5.25% of sodium hypochlorite, 2% of chlorhexidine gluconate and mixture of a tetracycline isomer, an acid and a detergent (MTAD) by checking for hemolysis of human red blood corpuscles. Materials and Methods: A total volume of 100 μl of diluted red blood corpuscles obtained through centrifugation was added to three irrigating solutions (5.25% of sodium hypochlorite, 2% of chlorhexidine and MTAD) of six test tubes each. Individual irrigants per group were added in increasing volume starting from the second test tube keeping the first one as the control. After incubation for 3 min hemoglobin content was measured using an automated hemoanalyzer data was analyzed using one sample t-test. Results: Sodium hypochlorite is the most cytotoxic solution followed by MTAD and chlorhexidine. Conclusions: This study suggests that the three irrigating solutions do cause detrimental effects on the diluted red blood corpuscles. A great deal of care should therefore be exercised when using 5.25% sodium hypochlorite during endodontic irrigation.

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Aim: With the whole world looking at the eradication of existing infectious diseases and preventing any new infections, sterilization of instruments is significant to ensure optimal patient care. Infection preventions and controls are the most important components for providing a safe environment for patients and staff within a dental practice. Hence, the objective was to assess the level of knowledge, attitudes, and practices regarding the sterilization of endodontic files by the postgraduate (PG) students from the Department of Conservative Dentistry and Endodontics at dental colleges in Bangalore. Materials and Methods: A cross-sectional study was conducted among PG students of Conservative and Endodontics in Bangalore using a pretested questionnaire. Results: A total of 88% accepted endodontic files need to be sterilized and 60% reported that endodontic instruments can be used four or more times, but 44% practiced it. Interestingly, 74% reported that dental assistants are not trained for sterilization protocols. Conclusion : The study shows that although there is high knowledge and positive attitude regarding sterilization of endodontic files, but it is seldom practiced creating lacunae in motivation. To bridge this gap, frequent reinforcement is needed in the critical area of sterilization.

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Objectives: Using one rotary file can result in a faster canal preparation. This can be done with several file systems and endodontic motors. In the present study, a newly single file technique (one rotary file technique) with available rotary file systems is introduced. The aim of the present study was to evaluate centering ability and remaining dentin thickness of 2 rotary nickel-titanium systems (Mtwo versus RaCe) and instrumentation techniques (conventional versus one rotary file) by cone-beam computed tomography. Materials and Methods: A total of 76 mandibular molar teeth were selected and divided to 4 groups (n = 19 teeth with 57 canals). The teeth were mounted in resin and pre-instrumentation scans were prepared by Cone Beam Computed Tomography (CBCT). The canals instrumented with Mtwo and RaCe rotary files either in conventional or one rotary file technique (ORF). After cleaning and shaping of distal and mesial canals, post instrumentation scans were performed by CBCT in the same position as pre instrumentation scans. Centering ability and remaining dentin thickness were evaluated by Planmeca Romexis viewer. The data were analyzed with analysis of variance and post hoc t test (P < 0.05). Results: Mean centering ratios for Mtwo/conventional, Mtwo/ORF, RaCe/conventional and RaCe/ORF groups were assessed. At overall, there were no significant differences between instrument types and instrumentation techniques (P > 0.05). However, in a few cross-sections, conventional technique and/or RaCe showed higher centering ability. One rotary file technique with either RaCe or Mtwo was significantly faster than conventional technique (P = 0.02). There was no significant difference among groups regarding file fracture. Mesiolingual canals showed more transportation compared with mesiobuccal and distal canals. Conclusions: Both of the instrumentation systems and techniques produced canal preparations with adequate centering ratio. One rotary file technique prepared canal significantly faster than conventional technique.

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Objectives: The aim of the present research was to identify pulpitis through periapical radiography by applying edges as basis image features, the texture description and the artificial neural networks (ANNs). Materials and Methods: Input image data records of 10 molar and 10 canine teeth were used. The clinical diagnosis of interest cases were represented as normal pulp, reversible and irreversible pulpitis, and necrotic pulp. The following image processing steps were done. First, the data records were converted digitally and preprocessed as its original image using the Gaussian Filter to obtain the best smoothed intensity distribution. Second, the local image differentiation was used to produce edge detector operators, e(x,y) as the image gradient; ∇f(x,y) providing useful information about the local intensity variations. Third, these results were analyzed by using the texture descriptors to obtain digitally the image entropy, H. The fourth step, all were characterized by the ANNs. Results: The edge detection carried important information about the object boundaries of pulpal health and pain conditions in the dental pulp significantly. The image entropy which was identified, the diagnostic term, was obtained from texture descriptors in the segmentation regions where the curves of pulp states tent convergence with the normal pulp line from 4.9014 to 4.6843 decreasing to the reversible and the irreversible pulpitis line include the nectrotic pulp line from 4.6812 to 4.5926 and then inputting to the ANNs analysis at the same of mean square error around 0.0003. Conclusions: Referred to these results, the correlation of the image entropy and the ANNs analysis could be linearly classified with the critical point of 4.6827. Finally, it could be concluded that the direct reading radiography is better to be digitized in order to provide us the best choice for diagnosis validation.

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Introduction: Surgical and non-surgical endodontic treatment of involved teeth can necessitate prescription of analgesics and antimicrobials. The literature suggests confusion amongst practitioners regarding the need for adjunctive medication, mainly during non-surgical endodontic treatment, often leading to over-prescription. Aim: The aim of this study was to determine the current clinical practice of dentists participated in this study with respect to antibiotic and analgesic prescription patterns in their endodontic treatment management in Kuwait. Materials and Methods: Prescription patterns for antibiotics and analgesics were analyzed based on the responses to self-administered questionnaire (n = 169). Information was collected based on different clinical endodontic diagnostic scenarios. Statistical analysis was performed with SPSS software version 17.0 to determine relationships between prescription patterns, age, gender, and dental qualification (specialists and general dentists). Results: Ninety-two percent of dentists prescribed analgesics for the management of endodontic pain. While 16% prescribed antibiotics for severe dental pain; 62% prescribed antibiotics for acute apical abscesses. Significantly more male dentists prescribed antibiotics for dental pain than female dentists. No significant difference was found between general dental practitioners' and specialists' attitude toward drug prescriptions. Amoxicillin and ibuprofen were the most commonly prescribed medications. Conclusion: While the majority of dentists appeared to prescribe antibiotics and analgesics appropriately, some did not. This research confirmed previous studies and established a need for imparting information of evidence-based prescriptions protocols for the dentists surveyed in this study in Kuwait.

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Aims and Objectives: To evaluate the effectiveness of mineral trioxide aggregate (MTA) when used as a pulp capping agent in permanent teeth with carious exposure (≤1mm) after root formation is completed. Materials and Methods: Clinical follow-up was performed on 32 mandibular molars with deep occlusal caries, in patients in the age group range of 18 to 42 years. Carious pulpal exposures were treated by direct pulp capping with MTA, followed by a base of light cure glass ionomer cement and restored with amalgam. Clinical and radiographic examinations were carried out periodically at 1, 3, 6, 9, 12, 18 and 24 months. Results: After 24 months clinical and radiographic follow-up, it was found that 25 (out of 32) patients had successful outcome. However, two patients failed to return for evaluation after permanent restoration, and five patients exhibited clinical failure. Conclusions: Mineral trioxide aggregate was found to be an effective material when used for direct pulp capping in permanent teeth. However, further investigations with a larger sample size are needed to support these findings.

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This investigation presents a chart that can assist clinicians, in general and endodontists, in particular, in making the right decision when they are deciding, which rout to take; endodontic treatment to save the natural tooth or extraction and osseointegrated implant. Systematic review of the literature was used to investigate success rates of both endodontic therapy and extraction of the tooth and placement of an implant, with the intent of determining the superior treatment modality. The results demonstrated that both treatment modalities produced nearly similar success rates, with implants generally showing slightly higher success rates. It was concluded that endodontic treatment should first be given to save compromised natural tooth before pursuing extraction and implant. A protocol to assist clinicians in making the right decision to endodontically save or extract the offending tooth and replacement of implant is presented.

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