|Year : 2016 | Volume
| Issue : 1 | Page : 55-59
A clinical and radiographic study of four different root canal fillings in primary molars
Alaa O Al-Ostwani, Bashier M Al-Monaqel, Mohamed K Al-Tinawi
Department of Pediatric Dentistry, Faculty of Dentistry, Damascus University, Damascus, Syria
|Date of Web Publication||2-Feb-2016|
Alaa O Al-Ostwani
Mazzeh Jabal, Villate Mottasela, Damascus
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Successful treatment of infected primary teeth aims to preserve the child's health. However, the complex morphology of primary root canals and the desire for shorter therapy sessions put the necessity to search for the ideal root canal paste. Aims: To evaluate pulpectomy of nonvital primary molars using four different root canal filling pastes zinc oxide and propolis (ZOP) as a new paste, endoflas-chlorophenol-free as a new paste free of chlorophenol, metapex paste, and zinc oxide and eugenol (ZOE) paste as a control paste. Materials and Methods: Pulpectomy of 64 nonvital primary molars were accomplished in 39 children aged 3-9 years. Teeth were randomly divided into four equal groups of 16 molars according to the type of root canal filling. Pulpectomy was performed in one stage using 5.25% sodium hypochlorite irrigation and stainless-steel crown for final restoration. Clinical and radiographic results were evaluated double-blindly for two periods of 6, 12 months. Data were analyzed using Chi-square/Fisher's exact test, and P-value was set as 0.05. Results: The four pastes achieved convergent clinical and radiographic success within the two observation periods (P > 0.05). ZOE paste was the slowest in its resorption. Conclusions: ZOP is a promising paste with its natural antibacterial component (propolis). ZOE paste had convergent efficacy to the other pastes.
Keywords: Antibacterial, primary molars, propolis, root canal filling
|How to cite this article:|
Al-Ostwani AO, Al-Monaqel BM, Al-Tinawi MK. A clinical and radiographic study of four different root canal fillings in primary molars. J Indian Soc Pedod Prev Dent 2016;34:55-9
|How to cite this URL:|
Al-Ostwani AO, Al-Monaqel BM, Al-Tinawi MK. A clinical and radiographic study of four different root canal fillings in primary molars. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2019 Jul 17];34:55-9. Available from: http://www.jisppd.com/text.asp?2016/34/1/55/175515
| Introduction|| |
Endodontic treatment of infected primary molars is a great challenge to the dentist. However, the complex anatomy of their root canals causes many difficulties in endodontic treatment,  and chemomechanical therapy is insufficient to disinfect all the bacteria from root canals. , Therefore, a filling paste should be both antibacterial and biocompatible with the periapical tissue; however, until present, there is no filling material that meets these requirements. ,,
Many studies used propolis for root canal irrigation  and direct pulp capping  as it has natural antibacterial , and biocompatible properties.  Therefore, it is necessary to evaluate its benefits in root canal filling.
Aims and objectives
To evaluate pulpectomy of nonvital primary molars using four different root canal filling pastes such as zinc oxide and propolis (ZOP) as a new paste, endoflas-chlorophenol-free (CF) as a new paste free of chlorophenol, metapex paste, and zinc oxide and eugenol (ZOE) paste as a control paste.
| Materials and Methods|| |
Pulpectomy of 64 primary molars were accomplished in 39 healthy children (19 females, 20 males) aged 3-9 years that attended the Department of Pedodontics and Preventive Dentistry at School of Dentistry, Damascus, Syria. The teeth were randomly divided into four equal groups of 16 molars according to the type of root canal filling paste such as ZOE, endoflas-CF, ZOP, and metapex. Inclusion criteria included the clinical presence of severe pain with redness besides the infected molar. On radiographic evaluation, there was discontinuing in lamina dura, limited furcation, or apical radiolucency. Exclusion criteria included the intake of antibiotics within 2 weeks before the treatment, presence of fistula, extensive root resorption, inadequate bone support, or hypermobility. After informed consent had been obtained from parents, pulpectomy was performed in one session. The tooth was anesthetized, isolated with rubber dam and caries were excavated. Access was gained to the pulp chamber using high-speed handpiece with round bur, and the coronal pulp was removed from the pulp chamber by a sharp excavator with sodium hypochlorite 5.25%. Then, the working length was determined by electronic apex locator (Dentaport ZX, J. Morita, Japan), the root canals were prepared manually using k-file up to size no. 30 with 5.25% hypochlorite sodium irrigation, and the tip of the irrigant needle did not exceed the first third of the root canal length to avoid pushing the irrigant solution beyond the apex. Distilled water was used for final irrigation, the canals were dried with paper point (size 25), then the filling paste was inserted in the root canals according to each group: ZOE, endoflas-CF, ZOP or metapex. Conventional ZOE paste consists of Zink oxide and Eugenol, (Fares, Damascus, Syria, License 0009). The powder of endoflas-CF paste was synthesized by adding 56.5% zinc oxide, 40.6% iodoform, 1.63% barium sulfate and 1.07% calcium hydroxide, and mixed with eugenol without adding chlorophenol [Figure 1]. The hydrolytic propolis of ZOP paste was extracted from raw Propolis. ZOP paste was synthesized by mixing 50% zinc oxide powder with 50% hydrolytic propolis, to form radiopaque paste with appropriate viscosity for filling the root canal (Syrian patent number/5918/[Al Ostowani Alaa Eldien]) [Figure 2]. Either of ZOP, ZOE, endoflas-CF paste was inserted into the root canal using lentulo spirals at low speed. Metapex (Meta Biomed/Korea) was available in performed syringe with disposable plastic needles to inject the paste into the root canal; after inserting the tape of the needle near the apex, and the paste was gently pressed into the canal pulling the tape back slowly until the canal was filled. After filling the root canals, a thin layer of the filling paste was put on the floor of pulp chamber, and a periapical radiograph was taken. If the canal was clearly under-filled, it was refilled again. However, if the canal was over-filled, the tooth was excluded from the sample. The pulp chamber and the access cavity were filled with restorative glass ionomer cement (Kavitan Pro, Spofa Dental, Czech Republic), and stainless steel crown (SSC) (3M/USA) was used for final restoration. The treated molars were evaluated clinically and radiographically for two periods of 6 and 12 months.
Criteria for success
The clinical success was based on the presence of normal mucosa without abnormal mobility, pain, or sensitivity to percussion. Radiographic success was associated with decrease in the size of radiolucency and the presence of bone regeneration. If the radiolucency remained stable without remarkable changes, the treatment was classified as suspected and required further observation. Treatment failure was classified into two degrees as (a) the radiolucency slightly increased in size, but it was separated from succeeding bud with adequate bone and (b) the radiolucency threatening the succeeding buds, so the tooth was extracted. The treated molars were evaluated double-blindly by three observers, and the result was determined by an agreement of at least two observers. Data were analyzed using Chi-square/Fisher's exact test (P < 0.05).
| Results|| |
The filling pastes achieved convergent clinical success rates within the two observation periods without significant differences between them (P > 0.05) [Table 1]. The filling pastes achieved convergent radiographic success rates within the two observation periods without significant differences between them (P > 0.05) [Table 2] and [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8] and [Figure 9]. The radiolucency in four cases of ZOE group remained stable without remarkable changes after 6, 12 months of observation and accompanied by slow resorption of ZOE paste compared with root resorption. ZOE resorption was slower than root resorption in 31.3% of cases. While ZOP resorption was corresponding with root resorption in 62.5% of the cases, both metapex and endoflas-CF were faster than root resorption in 56.3% of its cases [Table 3].
|Table 1: Clinical success rates according to the type of the filling paste and observation period|
Click here to view
|Table 2: Radiographic success according to the type of the filling paste and observation period|
Click here to view
|Table 3: Resorption of the fi lling pastes compared with root resorption|
Click here to view
| Discussion|| |
This study compared four root canal pastes in one stage pulpectomy. Apex locator was used to determine the working length of root canals instead of periapical radiograph because the root resorption usually changes the site of the orifices coronally,  and SSC crown was used in all cases to avoid micro-leakage.  However, the follow-up in this study was done only for 1 year, while many authors followed the treated primary teeth until their natural exfoliation. ,,
The suspected teeth were (25%) in ZOE group after 12 months of treatment that is similar to the result of Trairatvorakul and Chunlasikaiwan 2008 who found many suspected cases when used ZOE.  Moreover, ZOE resorption in this study was later than root resorption in 31.3% of cases which meets the results of Subramaniam and Gilhotra 2011  and Trairatvorakul and Chunlasikaiwan 2008  who explained the slow resorption of ZOE as its particles are resistant to the giant cells, so high concentrations of eugenol released from the remaining ZOE may affect the surrounding tissue and delay healing process. 
The clinical and radiographic success rate of endoflas-CF paste (free of chlorophenol) was 87.5% and 81.3% respectively after 12 months as similar as the radiographic success of endoflas FS (with chlorophenol) in Fuks et al. study 2002 (83%),  and Moskovitz et al. 2005 (79%).  In this study, the chlorophenol was eliminated from endoflas composition because it has fixation effect , which may affect the osteoblast cells. , Endoflas-CF resorption matched root resorption in 43.8% and was faster than root resorption in 56.3% of the cases, so endoflas-CF resorption was faster than endoflas FS (with chlorophenol) in other studies as it was corresponding with root resorption without washing out intraradicularly. ,,, This is because chlorophenol may have fixation effects on giant cells that are responsible for absorption of foreign objects. 
The success rate of metapex in this study (75%) was superior to the findings of Nakornchai study 2010 on vitapex (56%),  and similar to the success rate of metapex (72.5%) in Ramar and Mungara study 2010,  while it was lower than the success rate of metapex in Gupta and Das study 2011 who followed-up the treated molars only for 6 months,  the success rate of metapex in this study was lower than Subramaniam and Gilhotra study 2011 who considered the suspected cases as success and sealed the floor of the pulp chamber with ZOE  which may affect the treatment by releasing eugenol through the accessory canals (that exist in the floor of the pulp chamber) to the furcation region.  Metapex resorption in this study was faster than root resorption in 56.3% as similar as Ramar and Mungara study 2010,  Subramaniam and Gilhotra 2011,  and Trairatvorakul and Chunlasikaiwan 2008,  and the fast resorption of metapex causes voids in the canal which may permeate with periapical fluids and become stagnant and eventually nidus for infection and this is termed as "hollow tube effect." ,
The new ZOP paste achieved clinical success rate 93.8% and radiographic success rate 62.5% after 12 months without statistical differences with the other pastes, so ZOP success was acceptable in nonvital primary molars, ZOP resorption was corresponding with root resorption in 62.5% of cases, and faster than root resorption in 37.5%, so ZOP resorption was the most appropriate for comparing with the other pastes in this study.
| Conclusions|| |
In the limitations of this study, endoflas-CF paste as a root-canal filling for nonvital primary teeth had good efficacy. ZOP is a promising paste with its natural antibacterial component (propolis). ZOE paste had a convergent efficacy to the other pastes. Further longitudinal studies are required to assess the efficacy of the root canal filling pastes until natural exfoliation of the primary teeth.
We would like to thank Damascus University for supporting our research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McDonald RE, Avery DR, Jeffrey A. Treatment of deep caries, vital pulp exposure, and pulpless teeth. In: Mcdonald and Avery's Dentistry for the Child and Adolescent. 9 th
ed. Maryland Height, MO: Mosby-Elsevier; 2011. p.343-65.
Faria G, Nelson-Filho P, Freitas AC, Assed S, Ito IY. Antibacterial effect of root canal preparation and calcium hydroxide paste (Calen) intracanal dressing in primary teeth with apical periodontitis. J Appl Oral Sci 2005;13:351-5.
Ito IY, Junior FM, Paula-Silva FW, Da Silva LA, Leonardo MR, Nelson-Filho P. Microbial culture and checkerboard DNA-DNA hybridization assessment of bacteria in root canals of primary teeth pre- and post-endodontic therapy with a calcium hydroxide/chlorhexidine paste. Int J Paediatr Dent 2011;21:353-60.
Ozalp N, Saroglu I, Sönmez H. Evaluation of various root canal filling materials in primary molar pulpectomies: An in vivo
study. Am J Dent 2005;18:347-50.
Gupta S, Das G. Clinical and radiographic evaluation of zinc oxide eugenol and metapex in root canal treatment of primary teeth. J Indian Soc Pedod Prev Dent 2011;29:222-8.
Subramaniam P, Gilhotra K. Endoflas, zinc oxide eugenol and metapex as root canal filling materials in primary molars - A comparative clinical study. J Clin Pediatr Dent 2011;35:365-9.
Kosenko SV, Kosovich T. The treatment of periodontitis with prolonged-action propolis preparations (clinical x-ray research). Stomatologiia (Mosk) 1990;69:27-9.
Alafandy AS. Assessment of crude propolis as a direct pulp capping agent in primary and immature permanent teeth. Endod Pract Today 2014;8:199-206.
Toreti VC, Sato HH, Pastore GM, Park YK. Recent progress of propolis for its biological and chemical compositions and its botanical origin. Evid Based Complement Alternat Med 2013;2013:697390.
Markiewicz-Zukowska R, Borawska MH, Fiedorowicz A, Naliwajko SK, Sawicka D, Car H. Propolis changes the anticancer activity of temozolomide in U87MG human glioblastoma cell line. BMC Complement Altern Med 2013;13:50.
Mori GG, Nunes DC, Castilho LR, de Moraes IG, Poi WR. Propolis as storage media for avulsed teeth: Microscopic and morphometric analysis in rats. Dent Traumatol 2010;26:80-5.
Ballesio I, Campanella V, Gallusi G, Marzo G. Chemical and pharmacological shaping of necrotic primary teeth. Eur J Paediatr Dent 2002;3:133-40.
Seale NS. The use of stainless steel crowns. Pediatr Dent 2002;24:501-5.
Moskovitz M, Sammara E, Holan G. Success rate of root canal treatment in primary molars. J Dent 2005;33:41-7.
Fuks AB, Eidelman E, Pauker N. Root fillings with endoflas in primary teeth: A retrospective study. J Clin Pediatr Dent 2002;27:41-5.
Moskovitz M, Yahav D, Tickotsky N, Holan G. Long-term follow up of root canal treated primary molars. Int J Paediatr Dent 2010;20:207-13.
Trairatvorakul C, Chunlasikaiwan S. Success of pulpectomy with zinc oxide-eugenol vs calcium hydroxide/iodoform paste in primary molars: A clinical study. Pediatr Dent 2008;30:303-8.
Miyachi T, Tsutsui T. Ability of 13 chemical agents used in dental practice to induce sister-chromatid exchanges in Syrian hamster embryo cells. Odontology 2005;93:24-9.
Igbinosa EO, Odjadjare EE, Chigor VN, Igbinosa IH, Emoghene AO, Ekhaise FO, et al.
Toxicological profile of chlorophenols and their derivatives in the environment: The public health perspective. ScientificWorldJournal 2013;2013:460215.
Petel R, Moskovitz M, Tickotsky N, Halabi A, Goldstein J, Houri-Haddad Y. Cytotoxicity and proliferative effects of iodoform-containing root canal-filling material on RAW 264.7 macrophage and RKO epithelial cell lines. Arch Oral Biol 2013;58:75-81.
Nakornchai S, Banditsing P, Visetratana N. Clinical evaluation of 3Mix and vitapex as treatment options for pulpally involved primary molars. Int J Paediatr Dent 2010;20:214-21.
Ramar K, Mungara J. Clinical and radiographic evaluation of pulpectomies using three root canal filling materials: An in-vivo
study. J Indian Soc Pedod Prev Dent 2010;28:25-9.
Hashieh IA, Pommel L, Camps J. Concentration of eugenol apically released from zinc oxide-eugenol-based sealers. J Endod 1999;25:713s-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3]