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ORIGINAL ARTICLE
Year : 2019  |  Volume : 37  |  Issue : 3  |  Page : 297-302
 

Comparative evaluation of three obturation systems in primary molars – A randomized clinical trial


Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Sreekanth Kumar Mallineni
Department of Paedodontics and Preventive Dentistry, Narayana Dental College, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_276_18

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   Abstract 


Objectives: The objective of this study is to evaluate and compare the radiographic efficacy of the quality of obturation and to assess the number of voids and the obturation time in primary teeth using Pastinject™, disposable needle, and capillary tips. Materials and Methods: A total of 34 teeth with 103 canals were randomly divided into three groups using chit method, based on used application: Group 1: Pastinject™ (Micro-Mega, Besancon, France); Group 2: Disposable needle (23G short needle BD Discardit™, Becton Dickinson India Pvt. Ltd.), and Group 3: Capillary tips (Meta Biomed© Co. Ltd., China). All the groups were named based on obturation systems used. To compare the quality of obturation, the Chi-square test was used; to assess the number of voids, Kruskal–Wallis ANOVA test was used; and to evaluate the obturation time, post hoc Scheffe one-way ANOVA test was used. All P values having <0.05 were considered as statistical significant (P < 0.05). Kappa statistics were performed to check interexaminer reliability. Descriptive statistics were used for evaluation using SPSS (version. 21). Results: Capillary tips resulted in better optimal filled canals and less obturation time, compared to disposable needle and Pastinject (P < 0.001). There was no significant difference evident among three groups in relation to voids (P = 0.111). Conclusion: Capillary tip technique proved to be the most effective, yielding a higher number of optimally filled canals and minimal voids, combined with easier placement of the material into the canals when compared to Pastinject and disposable needle obturation.


Keywords: Obturation, primary molars, pulpectomy


How to cite this article:
Rajasekhar S, Mallineni SK, Nuvvula S. Comparative evaluation of three obturation systems in primary molars – A randomized clinical trial. J Indian Soc Pedod Prev Dent 2019;37:297-302

How to cite this URL:
Rajasekhar S, Mallineni SK, Nuvvula S. Comparative evaluation of three obturation systems in primary molars – A randomized clinical trial. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2019 Dec 9];37:297-302. Available from: http://www.jisppd.com/text.asp?2019/37/3/297/268180





   Introduction Top


Pulpectomy is a root canal procedure for the complete pulp tissue that is irreversibly infected or necrotic due to caries or trauma. Infected teeth should be treated and maintained in the dental arch as natural space maintainers, providing that they can be restored to function and remain free from the disease.[1] Due to the challenging task of complete debridement related to canal morphology and the proximity of the succedaneous tooth, the obturating material should be biocompatible and eliminate these residual pathogens.[2] The success of pulpectomy depends on the proper case selection, biomechanical preparation, and the type of obturating material used, as well as the technique for obturating the root canals and achievement of a good hermetic seal with minimum voids.[3],[4] Various filling techniques have been reported, such as the pressure syringe,[5] a premixed syringe,[6] the Lentulo spiral,[7],[8] and endoplugger.[5] Recently, a specially designed device called Pastinject paste carrier system was introduced that works similar to the Lentulo spiral and was reported to provide better placement of the obturating material, while eliminating voids and providing a high density of the obturating materials.[9],[10],[11] Studies available reported the placement of calcium hydroxide and root canal sealers in the permanent teeth, but there are not enough studies to evaluate its use as obturation technique in primary teeth. Bhandari et al.[12] established an obturation technique with a disposable needle which is a simple and economical, can be used with almost every filling material used for the purpose, and is easy to master with minimal chances of failure. Capillary tips are plastic tips that are provided with the Metapex/Vitapex syringe. These tips are also not been studied which are used regularly in routine practice.

Many of the studies [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] compared the success rate of different obturating materials used in the primary teeth. Nonetheless, there is scant literature on the in vivo evaluations of various obturating methods for root canals in the primary teeth. To the best of our knowledge, no studies have been reported comparing the efficacy of Pastinject™ (Micro-Mega, Besancon, France), disposable needle (23G short needle BD Discardit, Becton Dickinson India Pvt. Ltd.), and capillary tips (Meta Biomed © Co. Ltd., China) obturation techniques. Hence, the aim of the study was to compare the efficacy of these three obturation systems, in terms of quality of obturation, voids, and time taken for filling the root canals of primary mandibular teeth.


   Materials and Methods Top


Ethical approval was obtained from the Institutional Ethical Committee (214/A4/MDS/Diss/2015-16), Narayana Dental College and Hospital, Nellore, AP, India. The present study was conducted in children attending the department of pedodontics and preventive dentistry and those attending as a part of school dental health programs. Healthy children with at least one primary molar in mandibular arch indicated for pulpectomy of age 4-9 years were included in the study. The study design adopted was a prospective interventional, parallel, randomized, double-blind clinical trial with an allocation ratio of 1:1:1 of the total sample. There were no changes made after the trial commencement. Children attending the outpatient department of pedodontics and preventive dentistry participated were involved in the study. Only healthy children with Frankl's behavioral rating scale (4) were included in the study. Primary mandibular molar teeth with at least two-thirds of root length and absence of external or internal pathological root resorption or radiolucent area in the furcation or periapical region were included in the study. The clinical procedure was explained to the parent or guardian, followed by the assent from the children as well as informed consent from the parents obtained. Seventy primary mandibular molars were assessed for the eligibility, of which only 34 met the inclusion criteria and the remaining teeth were excluded. Each root canal was considered as a single unit.

A sample of 103 units was included after conducting a pilot study of 10 canals per each group. Consequently, a total of 103 canals were randomly divided into three groups and the random sequence was generated with chit method. Group 1: Pastinject™ (Micro-Mega, Besancon, France) consisting of 33 canals; Group 2: Disposable needle (23G short needle BD Discardit™, Becton Dickinson India Pvt. Ltd.) – 34 canals; and Group 3: Capillary tips (Meta Biomed © Co. Ltd., China) – 36 canals. An investigator blinded to the study design has enrolled the participants and assigned the participants into each group of the study.

Intervention

All the treatments were performed by the same operator in a single visit. In this study, the participants and assessing reviewers were blinded to the technique used for obturation. Due to the recognizable characteristics of the materials and techniques used in the study, they could not be blinded to the operator. After achieving adequate local anesthesia and rubber dam isolation, straight-line access was achieved using no. 4 round diamond bur. The pulp chamber was cleared of pulp tissue, and the canals were located using an endodontic probe. Pulp tissue was extirpated from the root canals using Barbed broaches, and working length was determined. Biomechanical preparation was performed till number 30 k size file, and the canals were copiously irrigated with 2% chlorhexidine and saline after each filing. Root canals were dried with paper points and prepared for obturation with zinc oxide eugenol (ZOE) using different carriers according to the respective groups.

Pastinject™ (Micromega, Mumbai, India) with a size corresponding to the size of last file used for preparation of the root canal was coated with a creamy mix of ZOE (powder/liquid ratio of 1:2, mixed on a cool glass slab) and was introduced into the root canal 1 mm short of radiographic working length/apex till adequate obturation was attained. Zinc oxide powder and liquid were introduced into the back end of the 2 ml syringe after removing the plunger, and mixing was accomplished using cement spatula till a creamy mix was obtained. Consequently, the plunger was introduced and pushed to check the flow of ZOE mix through the syringe tip. For Group 2, the tip of a 23G syringe needle was blunted using a trimmer bur, and for Group 3, 23G disposable needle tip was replaced with capillary tips. Disposable syringe needle/capillary tip was inserted into the canal right up to 1 mm short of the apical foramina taking the file stopper as a guide. Consequently, the material was gently pushed into the canal until the material flowed out of the canal orifice, and the needle/capillary tip was withdrawn gradually from the canal while maintaining pressure in the material.

After completion of the obturation, a thick paste of ZOE was placed and pushed into the canal orifices with the help of small wet cotton pellet. Then, the coronal seal was achieved using Fuji IX glass ionomer cement, and radiographs were taken immediately after the procedure. The time taken for obturation in minutes was also recorded with the same digital chronometer for all the techniques. The quality of obturation was rated based on criteria reported by Coll and Sadrian.[8] Radiographs were evaluated by two trained blinded examiners for checking the quality of obturation and presence/absence of voids. On completion of the study, data were formulated in the excel sheets, and statistical analysis was performed using SPSS (version. 20.0, IBM, Corp Chicago, IL, USA). All the groups were named as based on obturation system. Chi-square test and one-way-ANOVA test were used for the assessment of the number of the voids and quality of obturation. The post hoc test using one-way-ANOVA was used to evaluate obturation time. All the P values having <0.05 were considered as statistical significant (P < 0.05). Kappa statistics were performed to check interexaminer reliability. The children assessed for eligibility and those recruited for the study with randomization and allocation and study details were shown in [Figure 1].
Figure 1: Flowchart of study design in CONSORT format

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   Results Top


The assessment of canals with different obturation techniques showed that Group 3 (capillary tips) exhibited the highest number of optimally filled canals (63.9%), followed by Group 1 (Pastinject, 48.5%) and Group 2 (disposable needle, 41.2%). Although the highest number of underfilled canals was observed with Group 1 (Pastinject) (51.5%), followed by Group 2 (disposable needle, 26.5%) and Group 3 (capillary tips, 13.9%). On the other hand, the highest number of overfilled canals was observed in Group 1 (disposable needle, 32.3%), followed by Group 3 (capillary tips, 22.2%) and Group 1 (Pastinject, 0%), which was the least. Intergroup comparison for the quality of obturation showed a significant difference (P = 0.001) between Group 1 (Pastinject) and Group 2 (disposable needle), whereas highly significant difference (P < 0.001) was found between Group 1 (Pastinject) and Group 3 (capillary needle). Among disposable needle (Group 2) and capillary needle (Group 3), there was no significant difference (P = 0.153) observed [Table 1].
Table 1: Quality of obturation using three different techniques

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The highest number of voids was observed in canals filled with Pastinject (Group 1) and the least number of voids in the canals filled with capillary tips (Group 3). Overall, there were 24 voids in a total of 33 canals (72.7%) in Pastinject (Group 1), whereas in disposable needle (Group 2) obturation, there were 13 voids in a total of 35 canals (37.14%), and capillary tips (Group 3) showed 12 voids in 36 canals (33.3%). The highest percentage of voids was observed in the canals filled with Pastinject (Group 1) compared to disposable needle and finally the capillary tips (Group 3), as shown in [Table 2]. Chi-square tests showed that there was no significant difference among the three groups in relation to voids (P = 0.111).
Table 2: Comparison of voids in all three groups

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The minimum and maximum times taken for obturation of a single tooth with 3 canals using Pastinject (Group 1) were 9.67 min and 12.20 min, respectively, with a mean time of 10.71 min. With disposable needle (Group 2), the minimum and maximum times taken for obturation were 7.0 min and 8.85 min, respectively, with a mean time of 7.85 min. For capillary tips (Group 3), the corresponding values were 4.0 min and 6.60 min, respectively, with a mean time of 5.18 min [Table 3]. One-way ANOVA and post hoc Scheffe analysis was performed, and the results showed that all the three groups differ highly significantly from each other (P < 0.001).
Table 3: Average time taken for obturation using three different techniques

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   Discussion Top


In the present study, the ZOE paste was used as obturating material due to its universal usage and low cost, and many investigators have used ZOE for assessment.[13] It has beneficial properties such as the amount of the eugenol released at the periapical zone immediately after placement, i.e., 10−4 and falls to 10−6 after 24 h, reaching zero after 1 month. Within these concentrations, eugenol is said to have anti-infiammatory and analgesic properties that are beneficial after a pulpectomy procedure.[14] The outcome of the study was measured based on the quality assessment and a number of voids present in the canal.

In the present study, criteria for obturation quality were based on modifications of Coll and Sadrian.[8] Other criteria in the literature were reported by Memarpour et al.[15] The root canal filling was considered as acceptable if canal space appears radiopaque along the canal shape and was free of voids.[16] The ideal filling technique should possess a minimal number of voids, and the presence of voids may provide pathways for leakage in the obturating material. This could allow micro-organism regrowth, reinfection, and culture reversal, and there may be an increased risk of posttreatment disease, especially if there are several large voids.[17],[18]

In the present study, the highest percentage of underfilled canals and voids was observed with Pastinject (51.5%). None of the canals filled with this technique showed the overfilled quality of obturation. This can be attributed to the fact that Pastinject is a specially designed paste carrier with flattened blades, which improves material placed into the root canal, causing a lower occurrence of underfilled and overfilled canals. The results of the current study are inconsistent with the studies [9],[10],[19],[20] where Pastinject displayed improved placement of calcium hydroxide into the canals, exhibiting the highest number of optimal fillings and the minimum number of voids, compared to other techniques. Nonetheless, ZOE was used as an obturating material in the present study, while Ca(OH)2 was used in the former two studies and Endoflas was used in the latter study.

The highest number of optimal fillings and least number of voids were noticed with capillary tips (63.9%), compared to Pastinject and disposable needle techniques. These results are inconsistent with the study reported by Guelmann et al.,[21] in which Vitapex syringe technique displayed poor results, compared to NaviTip system in terms of the filling quality. The reason cited for the decreased quality of obturation was the thickness, and the limited flexibility of the plastic tip, due to which it is questionable if the tip, is able to reach the apex of all canals. In addition, difficulty to adopt a stopper and operator experience with the delivery system explains the reason for the decreased quality of obturation, which leaves uncertainty in the practitioners' mind, whether the material is expressed to the end of the canal or not. Nonetheless, despite the thickness and limited flexibility of the plastic tip, there was a better flow of the material into the canals, along with the ease of operation of this technique, in the current study. The results are comparable to the study described by Gibson et al.,[11] in which, placement of nonsetting Ca(OH)2 with capillary tips exhibited improved results, compared to the spirally filled technique of placement. The reason for improved results with capillary tips may be due to the safety of avoiding the danger of instrument separation observed with injectable tips, as they are single use units with improved access, while the use of this technique for obturation showed homogenous fill up to the desired depth in the primary root canals, in the current study, as the obturation starts from apex upward, leaving no room for entrapment of air and formation of voids.

In the current study, the highest number of overfilled canals was noticed with disposable needle obturation technique (32.3%) and less number of voids, when compared to Pastinject. These findings are consistent with Gandhi et al.[20] which may be related to the reduction in operator feel and displacement of the rubber stop during the filling procedure, with overfilling. In addition, the injectable system allows the easy deposition of the paste to the apex due to which there is a chance of inadvertent extrusion through the apex. Most of the canals filled with this technique had optimal filling quality (41.2%) and the least number of canals had underfilled quality of obturation (26.5%). The results are consistent with the studies [12],[22] where local anesthetic syringe showed satisfactory results for the length of root canal obturation, compared to the other techniques. Although, the results from present study are inconsistent with an in vitro study conducted by Memarpour et al.[15] The reason for this might be limited flexibility and the thicker tip of the needle used with the anesthetic syringe, which makes it difficult to reach the apex of the narrow, curved primary tooth canals that might lead to voids. In addition, entry of air into the cartridge during obturation leads to void formation. The discrepancy in the results among the studies probably reflects the differences in the type of teeth, sample size, needle thickness, and operator experience. However, in terms of the length of filling, Coll and Sadrian [8] stated that the success rate for the teeth filled to the apex was 89%, filled shortly of the apex was 87%, and overfill had 58%. However, Yacobi et al.[23] and Bawazir and Salama [4] reported that underfilled canals failed significantly compared to those filled completely after 12-month follow-up. Accordingly, in view of the findings of the present study, it can be stated that capillary tips, followed by Pastinject, would have better success rates in the long term and finally disposable needle technique of obturation when the length of obturation is considered in the case of ZOE. Prior in vivo and in vitro studies reported that eugenol in ZOE cement fixes cells, depresses cell respiration, and reduces nerve transmission upon direct contact. However, in direct contact with connective tissues, eugenol is an irritant. ZOE might form a temporary seal against the bacterial invasion.[24] ZOE has been found to cause only a slight-to-moderate inflammatory reaction within the 1st week in primate teeth. This reaction then declines to a mild, chronic inflammatory reaction with some reparative dentine formation (within 5–8 weeks) when cavities are deep.[25] To gain the trust and confidence of child patient in pediatric dental practice, it is essential to finish the treatment as early as possible.[26] However, all the prior observations in the literature reported with overfilled canals with ZOE paste.[8],[27],[28],[29],[30] Flaitz et al.[30] performed a radiographic evaluation of pulpal therapy for primary anterior teeth. Although the former had a moderately high success rate, those incisors treated with the latter procedure had a better prognosis. It may be the preferred treatment when the extent of pulpal involvement cannot be determined. Hence, in the current study, mean obturation time was also calculated for all the groups. The mean obturation time to obturate single tooth with three canals was higher with Pastinject technique (10.71 min), followed by disposable needle technique (7.85 min) and finally the capillary tip group (5.18 min). Therefore, in terms of the time taken to obturate the canals, capillary tips can be opted for obturation technique in clinical practice, as this has exhibited better results among all the three groups.

Limitations

In the present study, digital radiography which is two dimensional was used to assess the quality of obturation and the presence of voids. Three-dimensional images would have given a better assessment for these parameters. In the present study only, periapical radiographs were used for analysis. However, three-dimensional images are radiation and cost-effective. As this was an in vivo study, the sample size might be small to generalize the results to a larger population.


   Conclusion Top


Based on the results of the present study, it can be concluded that capillary tip technique proved to be the most effective, yielding a higher number of optimally filled canals with minimal voids, combined with easier placement of the material into the canals, compared to Pastinject and disposable needle obturation. However, further randomized clinical studies comparing these three techniques with larger sample sizes and longer follow-up periods are needed to substantiate the results of the present study.

Acknowledgments

We are grateful to all the schoolchildren and their parents for their participation in the present study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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