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ORIGINAL ARTICLE
Year : 2014  |  Volume : 32  |  Issue : 4  |  Page : 317-321
 

Comparison of Endoflas and Zinc oxide Eugenol as root canal filling materials in primary dentition


1 Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India
2 Department of Public Health Dentistry, Government Dental College, Shimla, Himachal Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Institute of Technology and Science, Ghaziabad, Uttar Pradesh, India
4 Department of Pedodontics and Preventive Dentistry, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India

Date of Web Publication17-Sep-2014

Correspondence Address:
Nivedita Rewal
Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sunder Nagar - 175 002, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.140958

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   Abstract 

Background: Zinc oxide eugenol has long been the material of choice of pediatric dentists worldwide, although it fails to meet the ideal requirements of root canal filling material for primary teeth. Endoflas, a mixture of zinc oxide eugenol, calcium hydroxide, and iodoform, can be considered to be an effective root canal filling material in primary teeth as compared with zinc oxide eugenol. This study was carried out to compare zinc oxide eugenol with endoflas for pulpectomy in primary dentition. Aim: The objective of the study was to compare clinically and radiographically success rates of zinc oxide eugenol with endoflas for the root canal filling of primary teeth at 3, 6, and 9 months. Design: Fifty primary molars were included in the study with 26 teeth in Group I (Endoflas) and 24 in Group II (zinc oxide eugenol). A single visit pulpectomy was carried out. Results: The overall success rate of zinc oxide eugenol was 83% whereas 100% success was found in the case of endoflas. The obtained results were compiled and subjected to statistical analysis using the chi-square test. The difference in the success rate between the two was statistically significant (P < 0.05). Conclusion: Endoflas has shown to have better results than zinc oxide eugenol. It should therefore be the material of choice for root canal treatment in deciduous dentition.


Keywords: Endoflas, pulpectomy, zinc oxide eugenol


How to cite this article:
Rewal N, Thakur AS, Sachdev V, Mahajan N. Comparison of Endoflas and Zinc oxide Eugenol as root canal filling materials in primary dentition . J Indian Soc Pedod Prev Dent 2014;32:317-21

How to cite this URL:
Rewal N, Thakur AS, Sachdev V, Mahajan N. Comparison of Endoflas and Zinc oxide Eugenol as root canal filling materials in primary dentition . J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2017 Oct 21];32:317-21. Available from: http://www.jisppd.com/text.asp?2014/32/4/317/140958



   Introduction Top


Pulpectomy is treatment of choice in view of saving the infected deciduous dentition. Zinc oxide eugenol has been widely used in pediatric dentistry since its discovery by Bonastre and its subsequent use in dentistry by Chisholm, [1] despite the disadvantages which have been reported in the literature time and again.

Important requisites of a root canal filling material for primary teeth are that it should resorb at the same rate as the roots of a primary tooth. [2],[3] It should be harmless to the periapical tissue and permanent tooth germ, resorb readily if pushed beyond the apex, be antiseptic, radioopaque, should not shrink, should adhere to the walls, not discolor the tooth, and must be easy to fill and remove, if required at any stage. [2],[3],[4],[5] Calcium hydroxide, vitapex, and metapex have been extensively used as root canal filling material in primary dentition despite various drawbacks that are associated with these materials.

The main disadvantage of calcium hydroxide as root canal filling material is that it has a tendency to resorb earlier than the physiological resorption of root of primary teeth. This creates a "hollow tube" effect wherein an unfilled root canal is permeated with tissue fluid that eventually becomes a site for infection. [6] Zinc oxide eugenol is resistant to resorption and eventually might result in a deflected successor. [7],[8] Moreover, it has limited antibacterial efficacy. [9],[10]

Endoflas (Sanlor and Cia. S. en C.S., Cali, Colombia), produced in South America, comprises of triiodomethane, zinc oxide eugenol, calcium hydroxide, barium sulfate, and iodine dibutylorthocresol with a liquid consisting of eugenol and paramonochlorophenol. [11] The rationale behind incorporating three materials zinc oxide eugenol, calcium hydroxide, and iodoform into endoflas was probably to compensate the disadvantage of one individual material with the advantages of the other.

Endoflas paste has the advantage of having the resorption limited to the excess material, which has been extruded. Resorption of the material does not occur within the canal. [11] Thus, the material is neither resistant to resorption nor does it result in the hollow tube effect. The manufacturers of endoflas paste claims that it has a broad spectrum of antibacterial efficacy. The material is hydrophilic and can be used in mildly humid canals. It has the ability to disinfect dentinal tubules and hard-to-reach accessory canals that cannot be disinfected or cleansed mechanically. In addition, the components of the material can be removed by phagocytosis making it resorbable. [12] Despite the numerous advantages that endoflas has over zinc oxide eugenol, it is still not the most widely employed material for root canal filling in a primary tooth.

The purpose of this study was to compare endoflas and zinc oxide eugenol clinically and radiographically after 3, 6, and 9 months postoperative period.


   Materials and Methods Top


The sample comprised of 50 primary molars from among patients aged 4-9 years attending the Department of Pedodontics and Preventive Dentistry. Ethical approval for the study was obtained from Institution Review Board of Himachal Dental Institute, Sunder nagar, India. The children and their caretakers were invited to participate in the study. Written consent was obtained from the parents/guardians before commencement of any procedure. The teeth having following signs and symptoms were included in the study: History of spontaneous pain, presence of an abscess or a fistula, gingival swelling, pain on percussion, and radiograph revealing interradicular radiolucency. Teeth having external/internal root resorption, extreme mobility, and a perforated pulpal floor were excluded from the study. The selected teeth were randomly divided into two groups of 26 (endoflas, Group I) and 24 (zinc oxide eugenol, Group II) teeth. Pulpectomies for both the groups were done by single investigator (NR). Clinical and radiographic evaluation was done after 3, 6, and 9 months postoperative period. Treatment was considered successful when there was absence of pain, redness, swelling, tenderness on percussion, and sinus or fistula. For radiographic evaluation, two investigators (NR and VS) were trained and calibrated. Intraexaminer reliability and interexaminer reliability were assessed by using kappa statistics. The kappa values were 0.87 and 0.93 for interexaminer and intraexaminer reliabilities, respectively. Radiographically, the treatment was considered successful in the case of a reduction in the size of interradicular radiolucency or the size remaining the same.

The procedure was carried out in a single visit using a rubber dam after administration of local anesthesia. The access to the chamber was obtained after removal of the carious tooth structure. The coronal pulp was removed with a spoon excavator. A radiograph was taken to confirm the working length. The working length was maintained 1 to 2 mm short of the radiographic apex to minimize the chance of over instrumentation apically and causing periapical damage. In case the unerupted permanent tooth bud was within the furcation area, the working length was limited to a level above the occlusal plane of the permanent tooth. However, if it was below the apices of the primary tooth, the entire length of the root was considered as the working length. H files were used to enlarge the canals till size 35. Irrigation was carried out using 2.5% sodium hypochlorite alternatively with saline. Root canal treatment in the primary dentition unlike the permanent dentition is more of chemo mechanical preparation owing to the tortuosity of the canals. Paper points were used for drying the canals. A lentulo spiral mounted on a slow speed hand piece was employed to introduce endoflas and zinc oxide eugenol into the root canals. The access cavity, postobturation was sealed with a thick paste of zinc oxide eugenol, and a radiograph was taken to determine the extent of the filling. The root canal filling was followed by placement of preformed stainless steel crown using a standard technique.

Data analysis

Data were analyzed using SPSS 11.5. The radiographic and clinical success rate of zinc oxide eugenol and endoflas were compared using the chi-square test. P < 0.05 was considered as statistically significant.


   Results Top


Fifty primary molars were endodontically treated in children ranging in the age group of 4-9 years. The selected teeth were randomly divided into two groups of 26 and 24 teeth and were filled with endoflas (Group I) and zinc oxide eugenol (Group II), respectively [Table 1]. Preoperative signs and symptoms were evaluated for pain, soft tissue, redness, mobility, intraoral swelling, draining sinus, and tenderness on percussion. Postoperative signs and symptoms and radiographic assessment of the size of the interradicular radiolucency were recorded after 3, 6, and 9 months [Figure 1] and [Figure 2].
Table 1: Age and gender wise distribution of the sample

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The preoperative and postoperative clinical signs and symptoms are tabulated [Table 2]. Statistically significant difference (P < 0.05) was seen between the two groups at postoperative 3 months follow-up for pain and tenderness. There were no extractions or failures in the endoflas group. In contrast, four teeth had to be extracted in the zinc oxide eugenol group 2 weeks postobturation.
Table 2: Comparison of clinical parameters preoperatively and postoperatively in Groups I and II

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Figure 1: Proeoperative and postoperative radiographs of tooth filled with endoflas: (a) Preoperative IOPA endoflas, (b) Immediate postoperative IOPA endoflas, (c) Postoperative IOPA at 3 months, (d) Postoperative IOPA at 6 months, and (e) Postoperative IOPA at 9 months

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Figure 2: Proeoperative and postoperative radiographs of tooth filled with zinc oxide eugenol: (a) Preoperative ZnOE, (b) Immediate postoperative IOPA, (c) Postoperative IOPA at 3 months, (d) Postoperative IOPA at 6 months and (e) Postoperative IOPA at 9 months

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At 9 months of follow up, the clinical success of zinc oxide eugenol was 83% owing to the four postoperative extractions, whereas there was complete clinical success of 100% in the endoflas group.

Radiographic assessment of the overfilled material revealed that out of the 12 overfilled canals in the endoflas group, resorption of the excess material was seen in 10 canals at 3-month follow-up period. However, complete resorption of the excess material was observed at the end of the 9-month follow-up. Overfilled zinc oxide eugenol was observed in 16 canals, and 4 teeth out of which were removed due to severe post-operative pain. Particles of the extruded zinc oxide eugenol were resorbed in four canals at 6 months. However, retention of the material was found in four canals at the end of 9-month evaluation period. Sixty percentage success was observed in teeth with excess filling material in zinc oxide eugenol compared with 100% success in teeth with overfilled endoflas [Table 3] and [Table 4].
Table 3: Comparison of postoperative success of teeth with excess filling material at 9 months in Groups I and II

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Table 4: Radiographic evaluation of resorption of excess filling material in Groups I and II

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Physiological resorption was seen in 14 and 12 teeth in the endoflas and zinc oxide eugenol group, respectively. The resorption of the filling material in endoflas was equal to the physiological resorption of the root in 100% cases. In the zinc oxide eugenol group, seven teeth (58.3%) revealed the slow resorption of the material whereas in five teeth (41.7%), the resorption of the material was equal to that of the physiological resorption of the root [Table 5].

Radiographically, the teeth were assessed for changes in the interradicular radiolucency. In endoflas, 100% decrease was seen in the size of interradicular radiolucency at the end of 9 months. In zinc oxide eugenol, a decrease of 45% was observed [Table 6]. The overall clinical and radiographic findings in this study reveal 83% success in zinc oxide eugenol compared with 100% success in the endoflas group [Table 7].
Table 5: Comparison of postoperative relative resorption of filling material with respect to root resorption
at 9 months in Groups I and II


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Table 6: Comparison of preoperative and postoperative interradicular radiolucency at 3, 6, and 9 months in Groups I and II

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Table 7: Overall success rate of the treatment at 3, 6, and 9 months in Groups I and II

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   Discussion Top


Pulpectomy since long has created a dilemma in the view of the clinician owing to the tortuosity of the canals of a primary molar. [13] Meticulous biomechanical preparation determines the success or outcome of root canal treatment in permanent teeth; however, the resorbable nature and antimicrobial properties of the filling material determine the success of pulpectomy in a primary tooth. Preparation of the root canal in a primary tooth is based mainly on chemical means rather than mechanical debridement. [14] Zinc oxide eugenol is the most commonly used material for pulpectomy of the primary teeth. [15] Despite the high success rates, zinc oxide eugenol does not meet all criteria required for an ideal root canal filling material. Various investigators [16],[17] have reported delayed resorption of extruded material, deflected or ectopic eruption of succedaneous tooth, anterior crossbite, and palatal eruption following zinc oxide eugenol pulpectomy.

This study reported immediate postoperative extractions in the zinc oxide eugenol group, which can be explained on the basis that zinc oxide eugenol is periapical irritant and utmost care should be taken not to force material past the apex. [18] Second, it has a limited antibacterial activity. [9] It is important that root canal filling material used in primary teeth should destroy the microorganisms in tissues as complete mechanical debridement is not possible due to the complexity of root canal system. [19]

In this study, retention of extruded zinc oxide eugenol in four canals was present at 9-month follow-up. In comparison, there was no retention of excess material in the teeth, which were filled with endoflas. The study observed that endoflas unlike any other material employed for pulpectomy resorbs at the same pace as the physiological resorption of root. This factor results in the resorption of the material limited to the excess extruded extraradicularly without showing any signs of resorption intraradicularly.

This study reported high clinical as well as radiographic success of endoflas over zinc oxide eugenol. Despite the drawbacks of zinc oxide eugenol, it is still the most widely employed root canal material for the primary teeth. One of the main drawbacks of this study was time constraint. More studies should be carried out with a longer follow-up period to gain knowledge about long-term effects and the success rate of endoflas.


   Conclusion Top


This study indicates that endoflas with a success rate of 100% is a much better material compared with zinc oxide eugenol and should be widely used as a root canal filling material for deciduous dentition considering the drawbacks of zinc oxide eugenol.

 
   References Top

1.Meeker HG, Linke HA. The antibacterial action of eugenol, thyme oil, and related essential oils used in dentistry. Compendium 1988;9:32, 34-5, 38 passim.  Back to cited text no. 1
    
2.Rifkin A. A simple, effective, safe technique for the root canal treatment of abscessed primary teeth. ASDC J Dent Child 1980;47:435-41.  Back to cited text no. 2
[PUBMED]    
3.Holan G, Fuks AB. A comparison of pulpectomies using ZOE and KRI paste in primary molars:A retrospective study.Pediatr Dent 1993;15:403-7.  Back to cited text no. 3
    
4.Fuks AB. Pulp therapy for the primary and young permanent dentitions. Dent Clin North Am 2000;44:571-96, vii.  Back to cited text no. 4
[PUBMED]    
5.Machida Y. Root canal obturation in deciduous teeth. Nihon Shika Ishikai Zasshi 1983;36:796-802.  Back to cited text no. 5
[PUBMED]    
6.Goldman M, Pearson AH. A preliminary investigation of the "Hollow Tube" theory in endodontics:Studies with neo-tetrazolium. J Oral Ther Pharmacol1965;1:618-26.  Back to cited text no. 6
[PUBMED]    
7.Sadrian R, Coll JA. A long-term follow-up on the retention rate of zinc oxide eugenol filler after primary tooth pulpectomy. Pediatr Dent 1993;15:249-53.  Back to cited text no. 7
    
8.Kennedy DB. Pediatric Operative Dentistry.Dental Practitioner Handbook No. 21. Bristol: John Wright and Sons; 1976. p. 232-9.  Back to cited text no. 8
    
9.Tchaou WS, Turng BF, Minah GE, Coll JA. Inhibition of pure cultures of oral bacteria by root canal filling materials. Pediatr Dent1996;18:444-9.  Back to cited text no. 9
    
10.Cox STJr, Hembree JHJr, McKnight JP. The bactericidal potential of various endodontic materials for primary teeth. Oral Surg Oral Med Oral Pathol1978;45:947-54.  Back to cited text no. 10
    
11.Fuks AB, Eidelman E, Pauker N. Root fillings with Endoflas in primary teeth: A retrospective study. J ClinPediatr Dent 2002;27:41-5.  Back to cited text no. 11
    
12.Moskovitz M, Sammara E, Holan G. Success rate of root canal treatment in primary molars. J Dent 2005;33:41-7.  Back to cited text no. 12
    
13.Fuks AB, Eidelman E. Pulp therapy in the primary dentition. Curr Opin Dent 1991;1:556-63.  Back to cited text no. 13
    
14.Rosendahl R, Weinert-Grodd A. Root canal treatment of primary molars with infected pulps using calcium hydroxide as a root canal filling. J ClinPediatr Dent 1995;19:255-8.  Back to cited text no. 14
    
15.Primosch RE, Glomb TA, Jerrell RG. Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States. Pediatr Dent 1997;19:118-22.  Back to cited text no. 15
    
16.Barker BC, Lockett BC. Endodontic experiments with resorbable pastes. Aust Dent J 1971;16:364-72.  Back to cited text no. 16
[PUBMED]    
17.Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent 1996;18:57-63.  Back to cited text no. 17
    
18.Erausquin J, Muruzábal M. Root canal fillings with zinc oxide-eugenol cement in the rat molar. Oral SurgOral Med Oral Pathol 1967;24:547-58.  Back to cited text no. 18
    
19.Garcia-Godoy F. Evaluation of an iodoform paste in root canal therapy for infected primary teeth. ASDC J Dent Child 1987;54:30-4.  Back to cited text no. 19
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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