|Year : 2010 | Volume
| Issue : 1 | Page : 98-103
|Ex vivo evaluation of coronal and apical microbial leakage of root canal - Filled with gutta-percha or Resilon/Epiphany root canal filling material
Fabio de Almeida-Gomes1, Claudio Maniglia-Ferreira2, Marcelo de Morais Vitoriano2, Bruno Carvalho-Sousa3, Nadine Luisa Soares de Lima Guimaraes2, Roberto Alves dos Santos3, Eduardo Diogo Gurgel-Filho2, Marcia Maria de Negreiros Pinto Rocha4
1 Department of Endodontics, University of Fortaleza; and Department of Endodontics, University of Pernambuco, Brazil
2 Department of Endodontics, University of Fortaleza, Brazil
3 Department of Endodontics, University of Pernambuco, Brazil
4 Department of Microbiology, University of Fortaleza, Brazil
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|Date of Submission||16-Feb-2009|
|Date of Decision||21-Apr-2009|
|Date of Acceptance||01-Oct-2009|
|Date of Web Publication||27-Apr-2010|
| Abstract|| |
Objective: This ex vivo study compared coronal and apical microleakage of root canals filled with Resilon/Epiphany (RE) or gutta-percha/Grossman sealer (GP), using either lateral condensation (LC) or System B (SB) technique.
Materials and Methods: Specimens in eight experimental groups were obturated using the following materials and techniques: Groups 1 and 3 - GP and LC; groups 2 and 4 - GP and SB; groups 5 and 7 - RE and LC; groups 6 and 8 - RE and SB. Apical and coronal leakages were tested using bacterial methods. For coronal analysis, the number of days required for complete contamination of the root canals was recorded according to observation of the brain heart infusion broth turbidity for 15 weeks. For apical analysis, the teeth were cleaved and the leakage was measured at 30 days. Data were collected for each sample and analyzed statistically with the Chi-square and ANOVA tests.
Results: Leakage was found in all groups. The difference between filling materials, obturation techniques, and median time of leakage was not statistically significant for coronal ( P=0.847) and apical ( P=0.5789) leakages.
Conclusion: There were no differences between the different filling materials (gutta-percha/Grossman sealer and Resilon/Epiphany) and obturation techniques (lateral condensation and system B technique) in coronal or apical leakages.
Keywords: Root canal fillings, Resilon, gutta-percha, coronal leakage, apical leakage
|How to cite this article:|
de Almeida-Gomes F, Maniglia-Ferreira C, de Morais Vitoriano M, Carvalho-Sousa B, Guimaraes NS, dos Santos RA, Gurgel-Filho ED, Rocha MM. Ex vivo evaluation of coronal and apical microbial leakage of root canal - Filled with gutta-percha or Resilon/Epiphany root canal filling material. Indian J Dent Res 2010;21:98-103
The root filling is thought to be critical for the long-term outcome of root canal treatment. , A root filling may entomb the surviving bacteria, and prevent apical and coronal leakage, that is, stop influx of periapical tissue-derived fluid from nourishing the remaining microbiota and prevent re-infection of the root canal system.  Animal and human outcome studies have shown that the root filling materials and techniques used currently are not optimal , and fail to fulfill the desired requirements. , Therefore, the development and maintenance of a seal is desirable and considered to be a major prerequisite to improve the outcome of root canal treatment. One relatively recent approach to enhance the sealing ability of root fillings has been to apply adhesive concepts to endodontics. ,
|How to cite this URL:|
de Almeida-Gomes F, Maniglia-Ferreira C, de Morais Vitoriano M, Carvalho-Sousa B, Guimaraes NS, dos Santos RA, Gurgel-Filho ED, Rocha MM. Ex vivo evaluation of coronal and apical microbial leakage of root canal - Filled with gutta-percha or Resilon/Epiphany root canal filling material. Indian J Dent Res [serial online] 2010 [cited 2021 Jan 24];21:98-103. Available from: https://www.ijdr.in/text.asp?2010/21/1/98/62819
In 2004, a new core material, Resilon (Resilon Research LLC, Madison, CT, USA), in conjunction with an adhesive system (Epiphany, Pentron Clinical Technologies, Wallingford, CT, USA) was introduced to the market. This new thermoplastic-filled polymer core (polycaprolactone-based) has the potential to challenge gutta-percha, the 'gold standard', as a root filling core material.  Dentine adhesives can be applied as sealers either with gutta-percha  or bonded simultaneously to the intra-radicular dentine and to Resilon.  According to the manufacturer, the Resilon sealer bonds to the root-canal filling material and to dentine. Adhesion of the sealer to both gutta-percha and to dentine can improve the sealing properties of endodontic sealers, but the correlation between the dentine bond strength and microleakage is questioned.
Ideally, the root canal sealer should be capable of bonding simultaneously with the root canal dentine and Resilon. However, this new filling material must bond to the root dentine, which is less than ideal in terms of its cleanliness and surface characteristics.
Several leakage studies have been published, comparing this newly developed filling material with gutta-percha and conventional sealers. Using a fluid transport model, some authors have reported that Resilon and Epiphany are better at preventing fluid movement when compared to gutta-percha and AH Plus or AH26. , Some reports have concluded that there are no differences between the above-mentioned root filling materials when using the fluid filtration model. ,,
This study compares coronal and apical bacterial leakages in canals of single-rooted extracted human mandibular premolars filled with either gutta-percha and AH-Plus endodontic sealer or Resilon and Epiphany, using a continuous wave or a cold lateral condensation technique.
| Materials and Methods|| |
One hundred and forty single-rooted mandibular premolars of similar size and root shape were selected. The roots with open apices, cracks, and resorptive defects were excluded. The teeth were carefully cleaned with curettes to remove the soft tissue remnants and were stored in a 0.1% thymol solution at 58C, were obtained and used within 6 months of extraction.
The crowns of the teeth were sectioned at the cementoenamel junction by using water cooled diamond disks. The canal lengths were visually established by placing a size 15 K-file (Dentsply Maillefer, Ballaigues, Switzerland) into each root canal until the tip of the files were visible at the tip of the apical foramen. The working length was established 1mm short of the apex. The canal systems were instrumented to the working length with a size 50 K-file using a step-back technique. The coronal thirds of the roots were flared up to a size of a 4-2 Gates Glidden bur (Dentsply, Maillefer, Switzerland) (ISO size 70-150) using a low speed handpiece. The root canals were irrigated with 10ml of 2.5% NaOCl after the use of each file, throughout the preparation. The smear layer was removed with 10ml of 17% EDTA (Cana+, Septodont, France) for four minutes, followed by 10ml of 2.5% NaOCl. Finally, the root canals were flushed with 3ml saline solution and then dried with paper points.
The specimens were randomly divided into eight equal groups of fifteen samples each, setting aside ten teeth as negative and ten as positive controls [Table 1].
Group 1 and 3: Lateral condensation and gutta-percha
A medium nonstandardized gutta-percha cone (Konne Indϊstria e Comιrcio de Materiais Odontolσgicos, Belo Horizonte, Brazil) with a # 50 tip size was used as a master cone. The cone was trimmed to achieve a tugback at working length. It was lightly coated with an endodontic sealer (AH-Plus; Dentsply, Petrσpolis, Brazil), prepared according to the manufacturer's instructions, and placed into the root canal. All canals received 1.25ml of sealer picked up from the mixing pad and placed into the canal while rotating it counterclockwise. MF accessory gutta-percha points (Dentsply, Petrσpolis, Brazil) and a size C finger spreader (Dentsply Maillefer) were used for lateral condensation. A heated instrument was used to remove the excess gutta-percha from the coronal end.
Group 2 and 4: System B technique and gutta-percha
A medium nonstandardized gutta-percha cone (Konne) with a # 50 tip size was used as a master cone. All canals received 1.25ml of the sealer, picked up from the mixing pad and placed into the canal while rotating it counterclockwise (Buchanan, 1996). Following that, the cones were placed into the canals. A System B unit (model 1005; EIE/Analytic, Redmond, WA, USA) was used as recommended by the manufacturer and by Buchanan (1997). An FM plugger (EIE/Analytic) was pre-fitted to its binding point, which was 5mm short of the working length. System B, with an FM plugger, was set to 200 o C in touch mode, and the power was set at 8. The unit was driven through the master cone to plasticize the gutta-percha, followed by cold vertical condensation with a pre-fitted hand plugger (Dentsply Maillefer). The specimens were backfilled with thermoplasticized gutta-percha, and the System B unit was used to adapt and condense the secondary gutta-percha points.
Group 5 and 7: Lateral condensation and Resilon
A medium nonstandardized Resilon cone (Pentron Clinical Technologies, Wallingford, CT, USA) with a # 50 tip size was used as a master cone. The cone was trimmed to achieve a tugback at working length. A self-etching primer (Epiphany Primer, Pentron Clinical Technologies, Wallingford, CT, USA) was placed in the root canal using a paper point (Dentsply) soaked with primer. After 30 seconds, the excess primer was removed with paper points. The Epiphany sealer was placed in the canal with a lentulo spiral (Dentsply Maillefer), according to the manufacturer's instructions. A Resilon master cone was lightly coated with Epiphany sealer (Pentron) and placed into the root canal. Lateral condensation was achieved with a size C finger spreader and with FM nonstandardized accessory Resilon points (Pentron), which were initially placed not more than 1mm short of working length.
Group 6 and 8 system B technique with Resilon
After pretreatment with a self-etching primer (Epiphany Primer) as in the lateral condensation and Resilon group, a medium nonstandardized Resilon cone (Pentron) with a # 50 tip size was selected as the master cone. The cone was trimmed to achieve tugback at the working length and placed in the canal using the System B technique. The Epiphany sealer was placed into the canal with a lentulo spiral (Dentsply Maillefer). The master cone was then lightly coated with Epiphany sealer and placed into the root canal to working length. The FM System B heat carrier connected to the plugger (Kerr Analytic Endodontics, Glendora, CA, USA) was driven through the master Resilon cone to plasticize it. After that, cold vertical condensation was performed with a pre-fitted hand plugger. The specimens were backfilled with the thermoplasticized Resilon using the System B technique.
The negative control group consisted of ten roots, which were filled with gutta-percha and sealer and then completely coated with two layers of nail varnish. For the positive control samples, ten roots were prepared, but not filled.
Polymicrobial coronal leakage was tested using the method described by De Deus et al.  [Figure 1]. Two coats of nail varnish were applied to the external surface of all teeth, except for 2mm around the apical foramen, to prevent bacterial leakage through the lateral canals or other discontinuities in the cementum. All the roots were inserted in 1.5ml plastic Eppendorf tubes (Elkay, Shrewbury, MA, US). To achieve a good marginal seal of the system, the tooth-Eppendorf set was adapted, under pressure, to a rubber stopper, which was cut to a size small enough to enter a glass flask.
The interface between the root, Eppendorf tube, and rubber stopper was sealed with cyanoacrylate adhesive (Loctite 496, Henkel Ltda, Sγo Paulo, Brazil). The system was sterilized with ethylene oxide gas overnight, and then placed in a 9ml sterilized glass flask containing 4ml of sterile brain heart infusion broth (BHI, Difco Laboratories, Detroit, MI, US). About 2mm of the root apex was immersed in the broth. The external margin of the apparatus was sealed with cyanoacrylate adhesive and Parafilm M (Laboratory Film, American National Can, Chicago, Ill, US). For sterilization, the whole set was incubated at 37 o C for seven days.
To check the efficiency of the cyanoacrylate seal, 2ml of 1% sterile methylene blue dye was placed into the tube leading to the coronal portion of each sample. If the medium became blue, the seal was defective and the specimen was discarded. Human saliva to fill the Eppendorf reservoirs was collected every three days and mixed with the BHI broth at a 1:1 (v/v) ratio. The set was incubated at 37 o C and checked daily for the appearance of BHI broth turbidity during the next 15 weeks.
If turbidity occurred in a lower chamber, fluid from both the upper and the lower chambers was cultured on McConkey agar, and gram stains were performed to identify the organism. The time from inoculation to the moment when turbidity was observed was recorded, as well as the results of the culture and Gram staining.
For marginal leakage evaluation, the same external treatment, sterilization, and mounting apparatus were used. However, the broth in which the tooth apices were immersed was contaminated with an overnight culture of Enterococcus faecalis ass="ref" href="viewimage.asp?img=IndianJDentRes_2010_21_1_98_62819_u3.jpg" target="_blank" >[Figure 2].
The apparatus was incubated at 37oC for 30 days. The specimens were then carefully fractured longitudinally using a scalpel blade and a hammer.  After that, the filling material was removed. Each filling material was placed in 5ml of BHI (Difco) for seven days. On the seventh day, the culture (BHI) turbidity was evaluated; a turbid culture indicated contamination of the filling material. The nature and purity of the organism was determined by cultural morphology and microscopic analysis.
The data collected from each sample was entered into a spreadsheet and analyzed statistically using the SPSS for Windows (SPSS Inc., Chicago, III, US). The Chi-square and ANOVA tests were used to test the null hypothesis of no association between the time of coronal or apical leakage and filling material and filling technique. A P<0.05 was considered significant.
| Results|| |
Microbial penetration was found in all positive control specimens, but in none of the negative controls, which indicated that the leakage model was appropriate for the purposes of this study.
The results of coronal bacterial leakage are summarized in [Table 2] and [Figure 3]. All experimental groups had specimens that showed leakage. The difference between filling material, techniques, and median time of leakage was not statistically significant (P=0.847).
The results of apical bacterial leakage are summarized in [Table 3]. All experimental groups had specimens with apical bacterial leakage at 30 days. Of the 60 specimens analyzed, 18 had apical leakage. Specimens that were prepared using the lateral condensation technique had less leakage, regardless of the material used, but this difference was not statistically significant (P=0.5789).
| Discussion|| |
A stable and durable seal of the root canal system to prevent leakage through coronal restoration is an important prerequisite for long-term endodontic success. ,, Several ex vivo studies found that bacteria and bacterial elements leak along root fillings when exposed to the oral environment, which is a major cause of failure of root fillings. ,,
Bacterial leakage tests are frequently used to evaluate the sealing ability of endodontic sealers and filling techniques. The coronal leakage model described by De Deus et al.  was used in our study. The use of E. faecalis was based on the characteristics of human microbial flora and its frequent presence in failed endodontic cases. ,
Ricucci and Bergenholtz,  in a recent clinical investigation, showed that well-prepared and carefully filled root canals resist bacterial penetration even upon frank and longstanding oral exposure due to caries, fracture or loss of restorations. They showed that endodontic treatment may fail due to coronal leakage, and also that leakage takes longer to occur when the treatment is well performed. On the other hand, studies in vitro showed that coronal leakage occurs rapidly and leads to endodontic failure regardless of the type of material or technique used. , None of the endodontic sealers available in the market promote a hermetic seal at the dentine-material interface. 
When the Resilon/Epiphany system is used, the lack of an efficient seal may be explained by the fact that the resin in the root canal system has no stress relief, and that photopolymerization causes excessive bulk contraction.  This contraction of the resin moves toward the inner area of the root canal and becomes more evident with time. 
Immediate bulk contraction is about 3% and leads to loss of adaptation to the dentine wall  even when recommended canal cleaning protocols are strictly followed to promote better adhesion of the filling material. Irrigation with 2.5% NaOCl and 17% EDTA for three to four minutes eliminates the smear layer and prevents coronal leakage. 
One of the advantages of using adhesive sealers with bondable polymeric canal filling materials such as Resilon/Epiphany, is that they bond throughout the length of the root canal.  However, many authors, using different methods, found that coronal and apical leakages occur even with the use of resin cements and the Resilon/Epiphany system, ,,, which is in agreement with the findings of present study. Raina et al.  also found that Resilon/Epiphany, similar to gutta-percha/AH Plus, does not create a monoblock root filling and, therefore, leakage occurs.
No differences were found between immediate apical leakage in the groups of specimens filled with gutta- percha/Grossman cement or Resilon/Epiphany, which confirmed the findings reported by Paquι and Sirtes.  Moreover, the technique used did not affect the results. The filling techniques were used to achieve maximum material adhesion to the root canal walls. In the lateral condensation groups, a finger spreader was used to ensure that the accessory cones reached the maximum length, and this procedure was repeated until the cones filled up the entire space and could not be inserted into the cervical third anymore. In the System B groups, gutta-percha was plasticized and condensed against the root canal walls, which promoted excellent adhesion.
Although no statistical differences were found, the lateral condensation technique group had fewer specimens with apical leakage, regardless of the material used. However, the same was not seen when the other thirds were evaluated. A relevant fact is that bonding is further compromised in sclerotic dentine, which is often found in the apical third of adult teeth. 
All specimens with leakage in the cervical and middle thirds also had leakage in the other thirds. No specimens with cervical or middle third leakage were free of apical or middle third leakage, which characterizes the specimen's contamination or methodological failure.
Microleakage is a complex problem because of the several variables that affect it, such as root filling techniques,  the physical and chemical properties of sealers, and the presence or absence of a smear layer. 
Saleh et al.  showed that the resin cements available in the market behave differently. In the presence of a smear layer, the bond between dentine wall and resin cement is stronger, which delays leakage.
In this study, EDTA was used before filling to eliminate the smear layer. The Resilon/Epiphany group might have shown better results had the smear layer not been removed. Further studies should be conducted to develop more stable materials that may effectively prevent bacterial leakage. Material failure may actually be the main cause of bacterial leakage, as shown by different authors, even when anatomical changes suggest the use of thermoplasticizing techniques. ,
The superior quality of fillings using thermoplasticizing techniques may not be relevant clinically. Their results may be restricted to providing a better radiographic visualization of carefully prepared clinical cases.
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Fabio de Almeida-Gomes
Department of Endodontics, University of Fortaleza; and Department of Endodontics, University of Pernambuco
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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