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View of Comparative Evaluation of Effectiveness of Pre-Mixed Syringe and Incremental Technique as a Root Canal Obturating Technique in Primary Mandibular Second Molar – A Randomized Clinical Trial

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Comparative Evaluation of Effectiveness of Pre-Mixed Syringe and Incremental Technique as a Root Canal Obturating Technique in Primary

Mandibular Second Molar – A Randomized Clinical Trial

Dr. Ritesh Kalaskar

1*

, Dr. Hemraj Badhe

2

, Dr. Nilima Thosar

3

1 Government Dental College and Hospital, Dept. of Pediatric and Preventive Dentistry, Nagpur, India &

PhD Student, Sharad Pawar Dental College, Sawangi (M), DMIMS, Wardha, Nagpur, India 2 Government Dental College and Hospital, Dept. of Pediatric and Preventive Dentistry, Nagpur, India 3 Sharad Pawar Dental College and Hospital, Dept. of Pediatric and Preventive Dentistry, Wardha, Nagpur, India

*[email protected]

ABSTRACT

Introduction: Natural primary teeth are the best space maintainer; therefore every possible effort should be made retain carious and pulpally infected primary teeth until their exfoliation.

Aim: The current in vivo study is planned to evaluate and compare efficacy of two obturating technique: premixed syringe (vitapex syringe) with incremental technique.

Material and methods: Sixty primary second molar indicated for pulpectomy from 60 healthy children in the age group of 5-9 years were incorporated in the study. Sixty teeth were equally divided into two groups of 30 each: In group I, obturation was done by premixed syringe using vitapex whereas in group II, incremental technique was used for obturation using zinc oxide eugenol. Quality of obturation, presence or absence of voids, obturation time and clinical and radiographical success rate at 6 months follow-up was evaluated.

Result: Among the two groups maximum number of optimally filled root canals and minimal root canal with voids were observed with premixed syringe. Time needed for obturation was more with premixed syringe. The overall success rate of pulpectomy was more with premixed syringe than incremental technique.

Conclusion: The result suggests that both the techniques are equally effective for obturation of primary teeth.

Key words:

Incremental technique, obturation quality, pulpectomy, premixed syringe,

Introduction

Primary teeth are important for optimum oral health and should be maintained until their normal exfoliation time to provide proper guidance for the eruption of permanent teeth, to maintain arch length, for optimal mastication and to enhance esthetics as well as phonetics. Once the tooth becomes carious and involves pulp tissue causing necrosis of pulpal soft tissue, pulpectomy becomes the treatment of choice in primary teeth to preserve the arch integrity as natural tooth is the best space maintainer (Aylard & Johnson, 1987).

The term pulpectomy in primary teeth means removal of caries along with extirpation of inflamed or necrotic tissue and debris from the pulp chamber and root canal/canals followed by obturation of the root canal/canals using resorbable anti-microbial root canal filling material which provides hermetic seal. The aim of obturating the root canal system is to prevent recontamination of canal from either apical or coronal leakage and to isolate and neutralize any remaining pulpal tissue or bacteria in root canal/canals (Reddy & Fernandes, 1996).

For obturation of primary tooth root canal, various techniques have been described in the literature such as disposable syringe, insulin syringe, tuberculin syringe, NaviTip, pressure syringe, capillary tips, Jiffy tube, lentulo- spiral, bi-directional spiral, incremental technique (using endodontic pluggers) and past Inject (Nagarathna et al., 2018)(Hiremath & Srivastava, 2016). However, no technique is found to be ideal for obturation of primary teeth.

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Among these techniques, incremental and lentulo-spiral techniques are most commonly used for obturation of primary teeth. Each of the technique has some advantages and disadvantages. In incremental technique, a thick mix of zinc oxide-eugenol (ZOE) paste is placed into the canal using an endodontic plugger. Placing the paste in a narrow, apically curved canal is more difficult than in an apically wider canal. The endodontic pluggers are rigid and thus, the paste cannot be placed upto full working length of narrow, curved canals. Also, there is increased risk of large voids due to movement of the plugger (Memarpour et al., 2013). In endodontic pressure syringe, the standardized mixture is injected into the canals by inserting needle and withdrawing in 3 mm interval slowly from the canal. Overfilling is a common finding when obturating paste is applied through a pressure syringe (Memarpour et al., 2013). Lentulo-spiral mounted on a slow speedhandpiece is used to carry obturating paste in to the canal but instrument fracture and a tendency for extrusion beyond the apex are the main disadvantages of this technique (Memarpour et al., 2013). Bi-directional spiral is same as lentulo-spiral technique but it prevents the extrusion of material beyond the apical orifice. However, the highest numbers of voids are seen in canals filled with the lentulo- spiral and bi-directional spiral (Grover et al., 2013). Past inject have been used like lentulo-sprial and bi-directional spiral and is found to be more effective than both techniques. Mechanical Syringe gives poor obturating results (Mortazavi & Mesbahi, 2004). In Jiffy tube technique, an obturating material is back-loaded into the tube, then the tube tip is placed into the canal orifice and the material is expressed into the canal with a downward squeezing motion until the orifice appears visibly filled (Mortazavi & Mesbahi, 2004). Insulin syringe and disposable injection technique have their own disadvantages. A thick paste cannot be expressed through NaviTip.

Vitapex is a pre-mixed syringe device containing ready to use mixture of calcium hydroxide and iodoform as an obturating material in primary teeth. Till date no study has been conducted using pre-mixed syringe device (Vitapex) as an obturating technique evaluating the quality of obturation, presence or absence of voids and obturating time. Pre-mixed syringe offers numerous advantages over traditional obturating techniques of primary teeth such as ready to use sterile obtuarting paste, disposable tip prevent contamination of material, thin flexible disposable tip of needle allows obturating paste to flow easily in to the canal and pressure generated by the piston of syringe pushes the obturating paste into the canal.

Therefore, the study was planned to evaluate the efficacy of pre-mixed syringe device (Vitapex) and incremental technique as an obtuarting technique for primary teeth.

Materials and methods

Sixty healthy children in the age group of 5-9 years having at least one carious primary second molar reported to the department of pediatric and preventive dentistry were evaluated. Primary second molar fulfilling the inclusion and exclusion criteria of pulpectomy were included in a parallel, open ended randomized controlled trial and were divided into two groups:

Group I- teeth obturated with premixed syringe technique using calcium vitapex paste (Vitapex syringe) Group II- teeth obturated with incremental technique using zinc oxide-eugenol paste.

Inclusion criteria for pulpectomy were: restorable tooth, tooth with history of spontaneous pain/night pain (irreversible pulpities), tooth with signs of pulpal degeneration such as periapical abscess, sinus, pain on percussion, furcation involvement, periapical pathology not involving to the crypt of permanent successor and internal resorption (Figure 1A, B). Teeth with history of reversible pulpities, non- restorable tooth, tooth with periapical pathology involving the crypt of permanent successor, and external root resorption were excluded from the study.

Computerized generated sequence (block randomization sequence) was used to allocate the teeth to two groups of 30 each. After obtaining ethical clearance from institutional ethical committee, written and signed informed consents were taken from parents whose children were enrolled for the study.

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Figure 1:A- Pre-operative radiograph of Group I, B-Preoperative radiograph of Group II.

Procedure of pulpectomy:

One visit pulpectomy was performed by a single operator in all the selected teeth. After gaining local anesthesia (ICPA health product ltd, Ankleshwar, India), rubber dam (Hygenic, WhaldentInc, USA) was applied and straight line access to the first curve of the canal was obtained using diamond bur (Mani, Inc. burs, 8-3 Kiyohara Industries park, Utsunomiya, Taghigi, Japan). Pulp tissue was extirpated using barbed broach. By tactile sensation working length of the canal was adjusted. Intra oral periapical radiograph was taken to determine the final length of canal that was adjusted 1 mm short of the apex. Chemico-mechanical preparation of the canal was done using K files (Mani, Inc. 8-3 Kiyohara Industries park, Utsunomiya, Taghigi, Japan) up-to 35 size and 3% sodium hypochloride. Normal saline (BERYL Drugs ltd, Pritham, Dhar-MP, India) was used for copious irrigation of the canals. The root canals were then dried using absorbent paper points (DiaDent Group International, Rep. of Korea).

The root canals were obturated either by premixed syringe using metapex paste and incremental technique using zinc oxide-eugenol (ZOE) paste.

In premixed syringe group, the disposable needle of vitapex syringe was inserted one third into the funnel shaped prepared root canal. The tip was then gradually withdrawn, filling first the apical end of the canal and subsequently the remaining canal space. In incremental technique group, ZOE paste was filled in the canal with endodontic pluggers (Mani, Inc. Japan) in increment. Immediate post-operative radiographs were taken to evaluate quality of obturation (Figure 2A, B). The teeth were restored with glass ionomer cement (GC Fuji, Hassunama-Cho, Itabakshi-HU- Tokyo, Japan) followed by full coronal restoration using stainless steel crown (3M, New Zealand, Auckland).

Figure 2: A-Immediate post-operative radiograph showing root canal obturation in Group I, B-Immediate post-operative radiograph showing root canal obturation in Group II

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Quality of root canal obturation and voids was assessed by Coll and Sadrian criteria (Coll & Sadrian, 1996)

 Under filling (score 1) – Canal filled more than 2 mm short of the apex

 Optimal filling (score 2) – Canal filling ending at the radiographic apex or up to 2 mm short of apex

 Overfilling (score 3) – Any canal showing filling outside the root apex.

Voids were evaluated based on the presence/absence and their number in each third of root canal.

Mesio-buccal and distal canals were evaluated for quality obturation and voids as in majority of the cases mesio-lingual canal were overlapped on radiograph. Obturation time was recorded in both the groups in minutes.

The pulpectomized teeth were evaluated clinically and radiographically at 6 month interval. At 6 month follow up the pulpectomy was considered clinically successful if the tooth is asymptomatic without periapical abscess, sinus, mobility and pain on percussion. Radiographically the procedure was considered successful if the tooth shows no perapical pathology, furcation involvement and reduction in the size of any pathology if present at the start of treatment (Figure 3A, B).

Figure3: A-Six month follow-up radiograph with stainless steel crown in Group I, B- Six month follow-up radiograph with stainless steel crown in Group II

Chi-square test was used to compare the obturation quality. Fisher exact test was used to compare the presence or absence of voids and clinical and radiographic success of pulpectomy at 6 month follow-up.

Independent t-test was used to compare obturation time. Statistical significance was computed and P ≤ 0.05 was considered statistically significant.

Results

Approximately 64% and 40 % of the mesial-buccal root canals in group I and group II respectively were optimally filled. In group I, 66.7% of distal root canals were optimally filled as compared to 70% of distal root canals in group II (Table 1). In group I, 65% of root canals (mesial-buccal and distal) were optimally filled as compared to 55% of root canals in group II (Table 2). Approximately 40% of root canals in group I were having voids as compared to 53.3% of root canal in group II (Table 3). Clinical success rate of pulpectomy in group I was 96.7% as compared to 90% in group II. Similarly radiographical success rate of pulpectomy in group I and group II was 100% and 93.3% respectively (Table 4). The overall success rate of pulpectomy in group I and group II was 98.8% and 91.7% respectively (Table 5). In group I the average time required for obturation was 5.17 minutes whereas in group II the average time was 4.38 minutes (Table 6). For overall obturation quality and the time required for obturation, statistical significant difference was seen while no significant difference was observed for obturation quality of individual canals, voids and clinical or radiographical success.

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Tables

Table 1: Comparison of obturation quality among MB canal and D canal of group I and group II

Canal Groups Obturation quality

χ2 value p value Under filled Optimum filled Over filled

MB Group I 4 (13.3%) 19 (63.4%) 7 (23.3%)

5.658 0.059 (NS)

Group II 12 (40%) 12 (40%) 6 (20%)

D Group I 0 20 (66.7%) 10 (33.3%)

4.024 0.134 (NS)

Group II 3 (10%) 21 (70%) 6 (20%)

Chi-square test; NS: Non-significant; MB: Mesio-buccal; D: Distal

Table 2: Comparison of Obturation quality among group I and group II

Groups Obturation quality

χ2 value p value Under filled Optimum filled Over filled

Group I 4 (6.7%) 39 (65%) 17 (28.3%)

7.730 0.021*

Group II 15 (25%) 33 (55%) 12 (20%)

Chi-square test; * indicates significant difference at p≤0.05

Table 3: Comparison of voids among group I and group II

Groups Voids

χ2 value p value Present Absent

Group I 12 (40%) 18 (60%)

1.071 0.438 (NS)

Group II 16 (53.3%) 14 (46.7%)

Fisher exact test; NS: Non-significant

Table 4: Clinical and radiological success of pulpectomy at 6 month follow-up in group I and group II

Groups χ2 value p value

Failure Success

Clinical Group I 1 (3.3%) 29 (96.7%)

1.071 0.612 (NS)

Group II 3 (10%) 27 (90%)

Radiological Group I 0 (0.0%) 30 (100%)

2.069 0.472 (NS)

Group II 2 (6.7%) 28 (93.3%)

Fisher exact test; NS: Non-significant

Table 5: Overall success rate of pulpectomy between group I and group II

Groups χ2 value p value

Failure Success

Group I 1 (1.7%) 59 (98.8%)

2.807 0.207 (NS)

Group II 5 (8.3%) 55 (91.7%)

Fisher exact test; NS: Non-significant

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Table 6: Comparison of time required for obturation Group Mean Time

(minutes) Std. Deviation Difference t value p value

Group I 5.17 1.14

0.79 3.034 0.004*

Group II 4.38 0.84

Independent t test; * indicates significant difference at p≤0.05

Discussion

In primary teeth, the procedure of pulpectomy consists of removal or debridement of pulp tissue followed by preparation of canal space to receive a resorbable, antimicrobial obturating material. In the literature, there are many studies that evaluated the ideal obturating materials for primary teeth. However, studies evaluating the techniques of obturation are infrequent. Hence, the present study was done to compare the efficacy of pre-mixed syringe device (Vitapex) with incremental technique.

On overall comparison between the obturation techniques i.e. pre-mixed syringe device and incremental technique, significant difference was found in the quality of obturation (p<0.05). In both the techniques, optimal filling of canals was achieved in maximum number but premixed syringe showed significantly higher number of optimally filled canals. However, when individual canals were assessed, no statistical significant difference was observed. With pre-mixed syringe device more over-filled canals and less under-filled canals were seen when compared with incremental technique. This finding was in accordance to literature wherein a common drawback observed with syringe techniques of obturation was the higher incidence of overfilled canals (Serene et al., 1988). In most of the previous studies, syringe techniques were used due to its ease to expel and condense the material into the canals. However, various clinicians have observed that the needle tends to instill anxiety among children and disrupts their cooperation. Apart from the aforementioned barriers, cooperation of the child also deeply influences the overall quality of obturation.

Comparison of both techniques in terms of voids showed that voids were inevitable with both techniques, a consistent finding with earlier reports (Pandranki et al., 2017) (Subba Reddy & Shakunthala, 1997) (Guelmann et al., 2004) (Sari & Okte, 2008). It was observed that more uniform and dense root canal filling was achieved with pre-mixed syringe device. Pre-mixed syringe device technique showed 40% voids whereas incremental filling technique showed 53.3% voids but the difference was not statistically significant (p = 0.438). In the present study, assessment of the voids was done radiographically (intraoral periapical radiographs), which gave two dimensional view only, so it was not possible to find exact measurement and location of all the voids present which could be a drawback of our study. In a study by Dandashi et al., voids were measured with the help of anterior, posterior and lateral radiographs (Dandashi et al., 1993). Owing to its in vitro study design, multiple views were taken but in the present clinical study this assessment could not be performed. Presence of voids in the obturation is one predicament which might provide pathways for leakage and the possibility of microorganism and toxin retention, leading to post- treatment failures (Kositbowornchai et al., 2006). Factors that influence the location and size of the voids include the type, viscosity, and consistency of the paste, the method used to apply the paste and operator skill and experience (Kahn et al., 1997).

The overall clinical and radiographical success rate of the pulpectomized teeth, for recall evaluation was 98.8% and 91.7%. When both the techniques were compared for clinical success, pre-mixed syringe device technique showed (96.7%) more success than incremental technique (90%). Similar results were also seen in radiological evaluation where pre-mixed syringe device technique showed 100% success over incremental technique (93.3%). In this study, the radiological failure of pulpectomized teeth was less than clinical failure. Thus, not all

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teeth showing clinical failure showed radiographic failure. This result did not correspond with previous investigations carried out by Bawazir (Bawazir & Salama, 2006). The success of endodontic therapy cannot be determined alone by the quality of obturation on radiograph. It is necessary to follow up the patient on regular intervals for clinical and radiographic success.

To our surprise, when the time required for obturation was compared it was found that pre-mixed syringe device required more time than incremental technique. A significant difference (p=0.004) was found between these two techniques. The time taken for obturation influences the endodontic success since pediatric patients have a short attention span. Prolonged dental procedures may disrupt child cooperation. This was assessed in one study (Rajasekhar et al., 2019) wherein three techniques: Past inject, disposable needle and capillary tips were compared for the time for obturation. The observations showed significantly lesser time taken for syringe techniques of obturation which was contrary to this study.

Conclusion

The result of this study demonstrated that premixed syringe technique showed superior quality of obturation of primary teeth than incremental technique, however, it was relatively more time consuming. But other parameters like voids, clinical and radiographical success did not show any statistical significance. Hence, we can conclude that both the techniques are equally effective for obturation of primary teeth.

Conflict of interest

The authors have no conflicts of interest in connection with this study.

References

[1] Aylard, S. R., & Johnson, R. (1987). Assessment of filling techniques for primary teeth. Pediatric dentistry, 9(3), 195–198.

[2] Reddy, V. V., & Fernandes (1996). Clinical and radiological evaluation of zinc oxide-eugenol and Maisto's paste as obturating materials in infected primary teeth--nine months study. Journal of the Indian Society of Pedodontics and Preventive Dentistry, 14(2), 39–44.

[3] Nagarathna, C., Vishwanathan, S., Krishnamurthy, N. H., &Bhat, P. K. (2018). Primary Molar Pulpectomy Using Two Different Obturation Techniques: A Clinical Study. Contemporary clinical dentistry, 9(2), 231–

236.

[4] Hiremath, MC, Srivastava, P. (2016). Comparative evaluation of endodontic pressure syringe, insulin syringe, jiffy tube, and local anesthetic syringe in obturation of primary teeth: An in vitro study. Journal of Natural Science, Biology and Medicine; 7:130–135.

[5] Memarpour, M., Shahidi, S., & Meshki, R. (2013). Comparison of different obturation techniques for primary molars by digital radiography. Pediatric dentistry, 35(3), 236–240.

[6] Grover, R., Mehra, M., Pandit, I. K., Srivastava, N., Gugnani, N., & Gupta, M. (2013). Clinical efficacy of various root canal obturating methods in primary teeth: a comparative study. European journal of paediatric dentistry, 14(2), 104–108.

[7] Mortazavi, M., &Mesbahi, M. (2004). Comparison of zinc oxide and eugenol, and Vitapex for root canal treatment of necrotic primary teeth. International journal of paediatric dentistry, 14(6), 417–424.

[8] Coll, J. A., & Sadrian, R. (1996). Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatric dentistry, 18(1), 57–63.

[9] Serene, T. P., Vesely J., & Boackle, R. J. (1988). Complement activation as a possible in vitro indication of the inflammatory potential of endodontic materials. Oral surgery, oral medicine, and oral pathology, 65(3), 354–357.

[10] Pandranki, J., Chitturi, R. R., Vanga, N. R., & Chandrabhatla, S. K. (2017). A comparative assessment of

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different techniques for obturation with endoflas in primary molars: An In vivo Study. Indian journal of dental research: official publication of Indian Society for Dental Research, 28(1), 44–48.

[11] Subba Reddy W, Shakunthala B. (1997). Comparative assessment of three obturating techniques in primary molars: An in vivo study. Endodontology.9:13-16.

[12] Guelmann, M., McEachern, M., & Turner, C. (2004). Pulpectomies in primary incisors using three delivery systems: an in vitro study. The Journal of clinical pediatric dentistry, 28(4), 323–326.

[13] Sari, S., &Okte, Z. (2008). Success rate of Sealapex in root canal treatment for primary teeth: 3-year follow-up. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics, 105(4), e93–e96.

[14] Dandashi, M. B., Nazif, M. M., Zullo, T., Elliott, M. A., Schneider, L. G., &Czonstkowsky, M. (1993). An in vitro comparison of three endodontic techniques for primary incisors. Pediatric dentistry, 15(4), 254–

256.

[15] Kositbowornchai S, Hanwachirapong D, Somsopon R, Pirmsinthavee S, Sooksuntisakoonchai N. (2006).

Ex vivo comparison of digital images with conventional radiographs for detection of simulated voids in root canal filling material. International endodontic journal39:287‑92.

[16] Kahn, F. H., Rosenberg, P. A., Schertzer, L., Korthals, G., & Nguyen, P. N. (1997). An in-vitro evaluation of sealer placement methods. International endodontic journal, 30(3), 181–186.

[17] Bawazir, O. A., &Salama, F. S. (2006). Clinical evaluation of root canal obturation methods in primary teeth. Pediatric dentistry, 28(1), 39–47.

[18] Rajasekhar, S., Mallineni, S. K., &Nuvvula, S. (2019). Comparative evaluation of three obturation systems in primary molars - A randomized clinical trial. Journal of the Indian Society of Pedodontics and Preventive Dentistry, 37(3), 297–302.

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