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Abstract
A dog model was used to assess and compare in vivo
the efficacy of gutta-percha and AH26 sealer versus
Resilon with Epiphany primer and sealer [Resilon
A pical periodontitis is caused primarily by microorganisms or their by-products in
the root canal system (1–3). The aim of endodontic treatment is to prevent or
eliminate microbial challenge to the surrounding periodontal structures. Disinfecting of
“Monoblock” System (RMS)] filled roots in preventing the root canal space is achieved through mechanical and chemical means (4, 5) and if
apical periodontitis subsequent to coronal inoculation the microbial flora is controlled, predictable success will result (6 – 8).
with oral microorganisms. There were 56 vital roots in After the microbial control phase of endodontic therapy, a root canal filling is
the premolars of seven adult beagle dogs aseptically placed to seal the root canal system from the external environment. This filling should
instrumented, filled, and temporized. The roots were serve 3 principal functions: entombing most surviving bacteria; stopping the influx of
randomly divided into four experimental groups (Coro- periapical tissue-derived fluid from reaching surviving bacteria in the root canal system;
nal Leakage Model) and one negative control group and acting as a barrier, thereby preventing re-infection of the root canal (9). However,
and filled as follows: group 1—lateral condensation of the present root filling materials and techniques fail in all three requirements men-
gutta-percha and AH26 sealer (n ⫽ 12); group 2—ver- tioned above (10, 11).
tical condensation of gutta-percha and AH26 sealer Torabinejad et al. (12) examined the microbial coronal leakage of single-rooted
(n ⫽ 12); group 3—lateral condensation of RMS (n ⫽ extracted root-filled teeth and found that 50% of the teeth were contaminated along the
12); group 4 —vertical condensation of RMS (n ⫽ 10); whole length of the root filling after 19 and 42 days depending on the organism.
negative control (n ⫽ 10)— gutta-percha and AH26 Additional in vitro studies have confirmed the high leakage rate of gutta-percha and
sealer or RMS root fillings using lateral or vertical sealer root fillings within 30 days using either lateral or vertical condensation tech-
condensation techniques as in groups 1 to 4. Positive niques (13, 14).
control—57 additional premolar roots were instru- Coronal seal has been shown to be critical for periapical health after root canal
mented, infected and not filled (beginning of the En- treatment. Ray and Trope (15) recognized that the integrity of the coronal part of the
tombment Model experiment). The premolars in groups root canal system is paramount for success, and concluded that the technical quality of
1 to 4 were accessed again, inoculated with dental plaque the coronal restoration was significant and perhaps more important than the technical
scaled from the dog’s teeth, and temporized. This fresh quality of the root canal filling to ensure prevention or healing of apical periodontitis.
innoculum of microorganisms was repeated on two more Tronstad et al. (16) confirmed that the coronal restoration was critically important for
occasions at monthly intervals. The teeth in the negative success in endodontic therapy, but stated the technical quality of the root filling was also
control group were not accessed again and remained
highly significant.
undisturbed. On the 14-wk postcoronal inoculation, dogs
It appears that a root filling containing gutta-percha is the weak point in endodon-
were euthanized, and jaw blocks prepared for histologic
tic therapy (10 –14). Filling of the root canal with gutta-percha and sealer even by the
evaluation under a light microcope. Mild inflammation
most technically proficient operator will not result in a seal that is dependable. In fact
was observed in 82% (18 of 22) of roots filled with
as stated before, the coronal restoration is more likely the reason for success over the
gutta-percha and AH26 sealer that was stastistically more
long term than the gutta-percha fill. Many different materials have been proposed as
than roots filled with RMS (19% or 4 of 21) and roots in
root canal fillings, but none have replaced gutta-percha that is universally accepted as
the negative control (22% or 2 of 9) (McNemar paired
the gold standard filling material. Although gutta-percha has been used for a long time,
analysis, p ⬍ 0.05). The Resilon “Monoblock” System was
most agree that it would be advantageous to replace it with a filling material that
associated with less apical periodontitis, which may be
because of its superior resistance to coronal microleakage.
provides a superior seal (than gutta-percha) at all levels of the root canal system.
Adhesive resins have been used for many years in operative dentistry. In recent
years the seal and bond strength of these resins has been improved significantly (17).
Drs. Shipper, Trope and Teixeira are affiliated with the Resilon (Resilon Research LLC, Madison, CT), a thermoplastic synthetic polymer based
Department of Endodontics, University of North Carolina root canal filling material, has been developed that performs like gutta-percha, has the
School of Dentistry, Chapel Hill, NC. Dr. Roland R. Arnold is
Professor, Departments of Diagnostic Sciences and Periodon-
same handling properties, and for retreatment purposes may be softened with heat or
tology, and Director of Oral Microbiology, UNC School of dissolved with solvents like chloroform. Based on polymers of polyester, Resilon con-
Dentistry, Chapel Hill, NC. tains bioactive glass, bismuth oxychloride and barium sulfate. The sealer used is Epiph-
Address requests for reprints to Dr. Martin Trope, Department any Root Canal Sealant (Pentron Clinical Technologies, Wallingford, CT), which is a
of Endodontics, School of Dentistry, University of North Carolina,
Chapel Hill, NC, 27599; E-mail: martin_trope@dentistry.unc.edu.
dual curable dental resin composite sealer. This sealer when used with the Resilon
Copyright © 2005 by the American Association of filling material forms a bond to the dentin wall and the core material making the filling
Endodontists resistant to bacterial penetration (18). Thus, the Resilon core filling with Epiphany
Resilon and Epiphany sealer. The sealer was placed according to man- was replaced in the access cavity and the teeth were sealed with Fuji IX.
ufacturer’s instructions with a lentulo spiral instrument (Dentsply The innoculum of plaque and placement of the glass ionomer restora-
Maillefer, Johnson City, TN). An ISO size 40 Resilon master cone was tion in the experimental groups of the Coronal Leakage Model were
placed to length and a size 30 finger spreader (Dentsply Maillefer) was repeated monthly on two more occasions. Anaerobic cultures were
then inserted into the canal until resistance was felt. The space created obtained from pulp chambers in 14 randomly selected teeth (two teeth
was filled with a fine Resilon accessory point coated with Epiphany per dog) before the 2nd and 3rd stages of coronal inoculation of mi-
sealer. The process was repeated until it was felt that the canal was croorganisms and in 14 randomly selected teeth before root fillings in
completely filled. A sterile cotton pellet was placed in the access cavity the positive control group (two teeth per dog). The teeth in the negative
and the crown was temporized with a glass ionomer (Fuji IX) restora- control group were not accessed again and remained undisturbed. After
tion. 6 wk, all the teeth in the positive control group showed distinct areas of
radiolucencies (while the experimental and negative control groups did
Group 4: Vertical Condensation of Resilon—10 Roots not). The teeth in the positive control were used in a different experi-
After instrumentation the canals were rinsed with EDTA. The roots ment model (Entombment Model) and were also not accessed again
were prepared with the primer as in group 3. Roots were filled with an after root canal filling and coronal restorations had been placed. All
ISO size 40 Resilon master cone and Epiphany sealer using the contin- teeth, were examined each month to verify the integrity of the restora-
uous wave of condensation (System B) technique and backfilled with tions. Standardized radiographs utilizing pretreatment bite-blocks with
Resilon in an Obtura II system. The sealer was placed according to
Regisil 2⫻ bite registration material (Dentsply Caulk, Milford, DE)
manufacturer’s instructions with a lentulo spiral instrument. A sterile
were taken after the teeth were initially prepared. Additional radio-
cotton pellet was placed in the access cavity and the crown was tempo-
graphs were taken at 1, 3, and 6 months postoperatively and observed
rized with a glass ionomer (Fuji IX) restoration.
for apical periodontitis.
Negative Control—10 Roots A period of 14 wk had passed since the initial application of plaque
Roots were filled with gutta-percha and AH26 sealer or RMS using in the experimental teeth and 6 months for the control teeth, before the
lateral or vertical condensation techniques as in groups 1 to 4. The floor sacrifice of the dogs. Deep anesthesia was attained with the use of
of the access cavity was filled with Cavit (ESPE America Inc., Norristown, pentobarbital (iv administration), using a dosage of 30 mg/kg body
PA) (2-mm thick) and then a glass ionomer final restoration (Fuji IX) weight. The left and right common carotid arteries were then exposed
was placed coronally. and the jaws perfused with 4% neutral buffered formaldehyde. Jaw
blocks containing the treated teeth were resected, fixed in 10% phos-
Positive Control—57 Roots (beginning of the Entombment phate-buffered formalin, decalcified in 10% EDTA and embedded in
Model experiment) paraffin. and prepared for histologic evaluation. Serial longitudinal sec-
Roots were instrumented and irrigated with saline solution. A cot- tions of 5 to 7 microns in a mesio-distal orientation to include the entire
ton pellet coated with isologous plaque scaled from the dog’s teeth was root canal system and at least 1 mm of peripaical tissue were cut and
placed in the access cavity. A glass ionomer restoration (Fuji IX) was hematoxylin and eosin stained.
placed coronally. The periradicular tissues were examined histologically under a
After 14 wk, the teeth assigned in the experimental group were light microscope at ⫻10 magnification. The evaluators, one endodon-
accessed again and the cotton pellets removed. The pulp chambers in tist and one oral pathologist, were blinded to the treatment groups and
the experimental group were then inoculated with isologous plaque evaluated the histological sections according to the following predeter-
scaled from the dog’s teeth. A cotton pellet soaked in the dog’s plaque mined scale:
McNemar paired analysis was used to compare the incidence of inflam- Discussion
mation in the four experimental groups and the negative control (p ⬍ This in vivo study is a continuation of the evaluation of this new
0.05). RMS to assess if the superior bacterial leakage resistance found in our
in vitro model (18) is related to apical periodontitis, the disease of
Results interest in endodontics. While the RMS was clearly superior in the in
All dogs tolerated the operative procedures well throughout the vitro model, that model is unable to determine if the leakage found
observation period. There was no evidence of swelling or sinus tract relates to disease. This study was designed to assess if the apparent
associated with any of the treated teeth. One tooth fractured and was superiority of the material can be duplicated under physiologic func-
excluded from the study (two roots filled with gutta-percha and AH26 tional stresses and if a difference in the incidence of apical periodontitis
sealer). One root filled with RMS using the lateral condensation tech- could be determined.
nique was lost in histological sectioning. The overall results are sum- Twenty-two percent (2 of 9) of the negative control teeth that were
marized in Table 1. not challenged by coronal microorganisms showed mild inflammation
at the 6 month evaluation period. Both of the teeth that showed inflam- niques. However the incidence of apical periodontitis for the RMS was
mation were filled with gutta-percha and AH26 sealer. The inflammation significantly lower than the gutta-percha and sealer groups and was not
may have been the result of inflammatory stimulators other than bacte- different from the negative control group. Thus, we deduce that the low
ria, a break in the aseptic chain while performing the root canal treat- incidence of apical periodontitis in the roots filled with RMS is a result
ments or a break down in the coronal restorations over the 28-wk of a resistance to microbial penetration. This we feel is primarily be-
period. While it is disappointing that the negative control teeth showed cause of a superior seal of the material, although a possible antibacterial
some inflammation in roots after vital pulp therapy, the incidence is effect of the material itself cannot be discounted. Future studies will
much lower than if gutta-percha filled teeth are challenged by micro- evaluate the possible antibacterial effect of this material. Although sta-
organisms. tistical analysis was not performed between the RMS groups in this study
A previous study was performed by Friedman et al. (20) using the and the gutta-percha with Kerr sealer groups placed with a lentulo spiral
same experimental model with gutta-percha and Kerr sealer placed with instrument in the Friedman study (20), the results of this study are
a lentulo spiral and a lateral condensation technique. Two weeks after clearly superior to that of Friedman study (Table 2).
completion of the root canal therapy, they placed plaque coronally and Presently we are awaiting analysis of the roots in these dogs used to
found at a 14-wk histological evaluation (postplaque inoculation), mild assess entombment of remaining microorganisms in the root canal. We
inflammation in 67% of the roots. In this study we found mild inflam- feel that the results of this in vivo study in addition to the published in
mation in 82% of the roots filled with gutta-percha and AH26 sealer vitro study justify a prospective human outcome study that is presently
using a lateral or a vertical condensation technique. We did not find a ongoing at the Department of Endodontics, University of North Carolina.
statistical difference in apical inflammation between those roots filled
with a lateral or vertical gutta-percha technique. While the differences in
inflammation rates of Friedman et al. (20) and our study (67% versus Acknowledgment
82%) are unlikely to be statistically significant (Table 2), our higher This study was supported in part by the Endodontic Research
inflammation rate may be explained by the fact that we replaced the Grant of the American Association of Endodontists Foundation.
coronal microorganisms every month while in the Friedman study (20), The authors thank Eric Simmons (Department of Oral Micro-
they were placed at the beginning of the experiment and not replaced. biology, University of North Carolina, Chapel Hill, NC) for his assis-
We felt that replacing the microorganisms every month was important tance in culturing the microbiological specimens.
because this would more accurately simulate a clinical situation with a
lost or leaky coronal restoration where the filling of the root canal is References
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