BASIC RESEARCH – TECHNOLOGY

Mariana Barbosa de Almeida,

Effect of Vehicle and Agitation MSc,* Kauhanna Vianna de
Oliveira, MSc,*
Methods on the Penetration of Vinícius Rodrigues dos Santos,
MSc,† Wander Jos
e da Silva,
Calcium Hydroxide Paste in the PhD,† Fla
via Sens Fagundes
Tomazinho, PhD,*
Dentinal Tubules Flares Baratto-Filho, DDS,
MSc, PhD,* and
~o
Marilisa Carneiro Lea
Gabardo, PhD*

ABSTRACT
SIGNIFICANCE
Introduction: The aim of this ex vivo study was to analyze the effect of different vehicles
combined with agitation methods on the penetration of calcium hydroxide (CH) paste in the Regardless of the agitation
dentinal tubules. Methods: Sixty freshly extracted, single-rooted human premolars were techniques used, a viscous
prepared using WaveOne Gold (Dentsply Sirona, York, PA) and randomized into 6 vehicle as an adjuvant for
experimental groups (n 5 10) according to the vehicle and method of paste agitation as intratubular penetration of CH
follows: propylene glycol (PG) 1 Lentulo, PG 1 Lentulo 1 ultrasound, PG 1 Lentulo 1 sonic, paste is necessary, especially
distilled water (DW) 1 Lentulo, DW 1 Lentulo 1 ultrasonic, and DW 1 Lentulo 1 sonic. The at 5 mm from the root apex.
CH paste was manipulated with sodium fluorescein dye and was inserted to completely fill the
root canal. Two 1-mm thick sections at 2 mm and 5 mm from the apex of each root were
obtained. The sections were scanned using confocal laser scanning microscopy, and the
images were analyzed using ImageJ software (Bethesda, MD) to calculate the percentage
penetration and maximum penetration depth of CH paste. Statistical analysis was performed
using 1-way analysis of variance and Tukey honestly significant difference post hoc tests.
Results: No statistically significant differences between study factors at a distance of 2 mm
from the apex were observed (P . .05). However, at 5 mm, a significant difference between
the vehicles (P , .05) in percentage penetration was demonstrated with higher means for PG.
Conclusions: Vehicles interfered with the penetration of CH in the dentinal tubules at 5 mm
from the apex with better results for PG. (J Endod 2020;-:1–7.)

KEY WORDS
Calcium hydroxide; confocal microscopy; endodontics; fluorescent dyes

One of the main objectives of endodontic treatment is the control of infection caused by microorganisms
in the root canal system1,2. Once the infection is established, bacteria infiltrate the isthmus, apical deltas,
lateral canals, and root dentinal tubules where they cannot be completely eliminated by
chemomechanical preparation methods3,4. Hence, intracanal medications have been used to improve
the prognosis of endodontic treatment4,5 by eliminating treatment-resistant bacteria and/or treating
cases of persistent pain and/or exudates1. From the *School of Health Sciences,

,
Universidade Positivo, Curitiba, Parana
Calcium hydroxide (CH), 1 of the most commonly used medicaments in endodontics, is a highly
Brazil; and †Piracicaba Dental School,
alkaline substance with a pH of approximately 12.5–12.8. The principal actions of CH attributed to the
Universidade Estadual de Campinas,
dissociation of calcium (Ca21) and hydroxyl (OH2) ions include potentially antibacterial, tissue dissolution, Piracicaba, S~ao Paulo, Brazil
inhibition of tooth resorption, and induction of hard tissue deposition6–8. The dissociated ions diffuse
Address requests for reprints to Dr
through the dentinal tubules4, which can be explained by dentinal permeability governed by tubular ~o Gabardo, Rua Prof
Marilisa Carneiro Lea
anatomy, density, diameter, and length as well as the characteristics of the solute such as molecular Pedro Viriato Parigot de Souza, 5300,
weight9. Furthermore, the ionic diffusion of CH must exceed the buffering capacity of the dentin, attaining 81280-330, Curitiba, Parana
, Brazil.
adequate pH levels to destroy the microorganisms and to exert an antibacterial action within the dentinal E-mail address: marilisagabardo@gmail.
com
tubules7. 0099-2399/$ - see front matter
The vehicles for CH powder aggregate are primarily of 3 types: aqueous, viscous, and oily. The
Copyright © 2020 American Association
high molecular weights of the vehicles minimize the dispersion of the materials in the tissues and retain the of Endodontists.
paste in the desired area for a longer duration. With respect to viscosity, the lower the viscosity, the higher https://doi.org/10.1016/
the rate of ion dissociation, as evident with aqueous vehicles5. Conversely, viscous vehicles are water j.joen.2020.03.026

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soluble but provide a slower and prolonged
release of Ca21 and OH2 ions. Finally, oily
vehicles are not indicated because of the
difficulty in ensuring complete removal from the
root canal walls10.
Several authors have analyzed the
diffusion capacity of CH pastes in different
vehicles11,12. Research to analyze methods of
agitation, such as the sonic and ultrasonic
methods, to increase the penetration and
antimicrobial action on the dentinal tubules,
which would improve the performance through
enhanced physical effects, have been
proposed13.
Sonic and ultrasonic techniques are
currently used in endodontics for agitating
irrigating solutions14 and endodontic sealers15
as well as for the removal of intracanal
medications14,16. However, few studies have
analyzed the effects of agitation of intracanal
medications to increase the penetration13.
Galva~o et al17 evaluated the quality of
root canal CH fillings performed using a
Lentulo spiral and the EndoActivator (Dentsply
Sirona, York, PA) and reported that in most
evaluated cases a complete filling was not
obtained, with emphasis on the nonfilling of the
apical region, with any of the techniques used.
Confocal laser scanning microscopy
(CLSM) is an efficient method for analysis of the
penetration of drugs or endodontic sealers in
the dentinal tubules12,15,18,19, especially when
sodium fluorescein dye, the fluorescence
intensity of which is increased in the presence
of Ca21 ions18,20, is used.
Hence, the aim of this study was to
evaluate the effects of the type of vehicle,
aqueous (distilled water [DW]) or viscous
(propylene glycol [PG]), and the method of
agitating CH paste (sonic or ultrasonic) in the
root canal on the ability to penetrate the
dentinal tubules.
MATERIAL AND METHODS
Ethical Aspects
This research was approved by the institutional
research ethics committee (registration no.
2959418).
Sample Size Calculation
A study by Deniz Sungur et al12 that evaluated
the penetration area of CH paste in dentinal
tubules was used as a reference for sample
size estimation. The standard deviations of the
2 analyzed groups in this study were used.
The sample size calculation was
performed using SAS 9.4 software (SAS
Institute, Cary, NC) with a 95% confidence
interval for the analyzed variables. The test
power was determined to be 0.819 for the
number of samples included (n 5 60).
2 de Almeida et al.
Teeth Selection
Sixty freshly extracted, single-rooted human
premolars with completely formed apices were
obtained. Radiographs in the buccolingual and
mesiodistal directions were obtained, which
facilitated their inclusion. All specimens were
stored at 100% humidity during the
experimental period.
Experimental Procedures
The ideal amount of CH powder (Maquira,
Maringa
, Brazil), the required quantity of dye,
and the volume of each vehicle were
determined in an empirical pilot study
performed by manipulation and insertion of the
paste in 6 specimens. The proportion of the
constituents was considered ideal when the
consistency of the paste was homogeneous.
The specimens were divided according
to each type of vehicle (n 5 3). The proportion
of a Maxxion R glass ionomer cement dosing
shell (FGM, Joinville, Brazil) to 0.7 mL of the
liquid, which was measured using the
Eppendorf pipette (Eppendorf do Brasil Ltda,
Sa~o Paulo, Brazil), was adopted for both
groups.
Sodium fluorescein dye (Sigma-Aldrich,
St Louis, MO) mixed with the vehicles in the
amount equivalent to the tip of Explorer Probe
No. 5 (SS White Duflex, Rio de Janeiro, Brazil)
was added to the CH.
Sample Characterization
The crowns of the specimens were sectioned
using carborundum discs (Dentorium,
~o Paulo, Brazil) to obtain
Labordental Ltda, Sa
FIGURE 1 – An image with the markings made using ImageJ software. A indicates the circumference of the root canal
wall, B the circumference of the PPA, C the circumference of the TSA, and D the MDP of CH paste.
a standardized length of 12 mm. The root
canals were explored using size 10 K-files
(Dentsply Sirona), and the working length
(WL) was established 1 mm from the root
apex.
The root canal preparation at the WL
was performed using the WaveOne Gold
Medium (35/.06) (Dentsply Sirona) driven by
the X-Smart Plus Endo motor (Dentsply Sirona)
according to the manufacturer’s instructions.
When the instrument was advanced 3 mm
inside the root canal, irrigation using 5 mL
2.5% sodium hypochlorite (NaOCl) (Asfer
Indu
stria Química Ltda, Sa~o Caetano do Sul,
Brazil) in a disposable syringe (Injex Industrias
Ciru
rgicas Ltda, Ourinhos, Brazil) with an
Endo-Eze tip (Ultradent Products, South
Jordan, UT) was performed. Patency was
verified using size 10 K-files between 2
irrigation procedures.
After the completion of instrumentation,
the canals were irrigated according to the
protocol described by Vivan et al21 by filling the
root canal with 2 mL 2.5% NaOCl and agitating
with the ProfiNeo ultrasound (Dabi Atlante,
Ribeira~o Preto, Brazil) using the Irrisonic E1
insert (Helse Dental Technology, Santa Rosa
de Viterbo, Brazil) at a power of 10%, as
indicated by the manufacturer, for 20 seconds
followed by solution renewal. This cycle was
performed 3 times. The same process was
repeated using 2 mL 17% EDTA (Formula and
Action, S~ao Paulo, Brazil). Finally, the canal
was irrigated using 5 mL saline solution
(Eurofarma, Sa ~o Paulo, Brazil). After aspirating
the residual solutions using a 0.36-mm
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capillary tip (Ultradent Products), the canals
were dried using sterile absorbent paper
points (Dentsply Sirona).
Handling, Insertion, and Agitation of
the Pastes
The root apices were sealed using utility wax
(Lysanda, Sa ~o Paulo, Brazil) to avoid material
leakage. According to the vehicle and method
of paste agitation, the specimens (N 5 60)
were randomly allocated to the following 6
experimental groups (n 5 10): PG 1 Lentulo,
PG 1 Lentulo 1 ultrasound, PG 1 Lentulo 1
sonic, DW 1 Lentulo, DW 1 Lentulo 1
ultrasonic, and DW 1 Lentulo 1 sonic.
The vehicles were mixed with the dye
and were subsequently manipulated with CH.
All canals were filled with the corresponding
paste using a Lentulo size 1 (Dentsply Sirona)
at 900 rpm calibrated at the WL until it
appeared from the apex and up to the
remaining cervical line.
Ultrasonic agitation of the paste was
performed for 1 minute using the ProfiNeo with
the Irrisonic E1 insert at 10% power as
indicated by the manufacturer. Sonic agitation
was also performed for 1 minute using the
EndoActivator with the medium-activation tip
(25/.04). The access cavities were sealed
using a temporary filler (Villevie; Dentalville do
Brasil Ltda, Joinville, Brazil).
Specimen Preparation for Confocal
Laser Scanning Microscopic
Analysis
The specimens were embedded in a sticky
wax mold (Newwax; Technew Come
rcio e

stria Ltda, Rio de Janeiro, Brazil) affixed in
Indu
an acrylic stabilization holder and were
incubated at 37 C by immersion in water for 24
hours. Subsequently, each specimen was
sectioned perpendicular to the long axis using
a diamond disk mounted on the water-cooled
IsoMet 1000 Precision Cutter (Buehler, Lake
Bluff, IL) rotating at 100 rpm.
Two 1-mm thick sections of each tooth
were obtained at distances of 2 and 5 mm
from the root apex22. The sections were fixed
on glass slides for microscopic analysis.
CLSM
All sections were mounted on glass slides and
were scanned using a confocal laser scanning
microscope (Leica TCS-SP5; Leica
Microsystems, Mannheim, Germany)12. The
images were acquired under 5! magnification
and were analyzed using ImageJ software
(National Institutes of Health, Bethesda, MD)
calibrated at a 750-mm scale.
In each image, the circumference of the
root canal wall, the penetration area of the CH
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FIGURE 2 – A representation of data distribution for MPD in mm2 as a function of distances from the apex.
paste, and the total slice area were plotted difference between distances from the apex
using several software tools. The percentage (2 mm and 5 mm) was initially performed using
of paste penetration was determined by the Student t test. Thus, comparisons for the
calculating the difference between the response variable were performed between
penetration area of the CH paste (mm2) and the the study factors (vehicle and agitation
circumferential root canal area (mm2), dividing it technique) in isolation using 1-way analysis
by the total slice area (mm2), and multiplying it of variance followed by the Tukey honestly
by 100, as exemplified in the following formula: significant different post hoc test. Statistical
significance was defined for values with a
PPA  CRA
Pð100%Þ 5 ! 100 probability above 95% (a 5 0.05). SAS 9.4
TSA
software was used for all statistical
where P(100%) is the percentage of paste analyses.
penetration, PPA is the paste penetration area,
CRA is the circumferential root canal area, and RESULTS
TSA is the total slice area.
The maximum penetration depth A significant difference (P , .05) was observed
(MPD) of CH paste in micrometers was in the mean MPD between 2 mm and 5 mm,
determined by measuring the distance with higher values for the latter. The mean
between the edge of the root canal and the values are illustrated in Figure 2. When the
demarcation of the furthest penetration area. methods of agitation were evaluated, no
All the performed measurements are shown statistically significant differences (P . .05)
in Figure 1. were observed in the means for both P(100%)
and MPD.
A statistically significant difference in
Statistical Analysis P(100%) between the 2 vehicles was observed
Descriptive analysis was performed using at 5 mm, with the higher mean for PG. In
frequency measures for nominal and mean contrast, no statistically significant difference
variables and standard deviation for numeric was observed in the MPD between the 2
variables. The comparative analysis of the vehicles (P . .05). Regarding the apical third
TABLE 1 - The Mean 6 Standard Deviation for the percentage of Paste Penetration by Vehicle, Methods of Agitation,
and Distance from the Apex
Insertion and agitation
Vehicle L LU LS
Distance of 2 mm
DW 7.06 65.40A,a 5.47 65.93A,a 4.87 6 3.06A,a
PG 7.48 6 5.64A,a 8.97 6 4.30A,a 7.55 6 6.14A,a
Distance of 5 mm
DW 9.69 6 3.58A,a 5.81 6 3.93A,a 8.57 6 4.52A,a
PG 15.41 6 9.91B,a 14.72 6 8.62B,a 9.61 6 5.18B,a
DW, distilled water; L, Lentulo; LS, Lentulo 1 sonic; LU, Lentulo 1 ultrasound; PG, propylene glycol.
Means followed by different capital superscript letters represent a statistically significant difference between the 2 vehicles.
Means followed by different superscript lowercase letters show a statistically significant difference between the methods of
agitation.
CH Penetration in the Dentinal Tubules 3
TABLE 2 - Means 6 Standard Deviation for the Maximum Penetration Depth by Vehicle, Methods of Agitation, and
Distances from the Apex
Vehicle L LU
Distance of 2 mm
DW 4.98 6 3.81
PG 6.44 6 3.02
Distance of 5 mm
DW 7.07 6 3.08
PG 10.73 6 4.45
DW, distilled water; L, Lentulo; LS, Lentulo 1 sonic; LU, Lentulo 1 ultrasound; PG, propylene glycol.
(2 mm), no significant differences were found in
the same variables between the 2 vehicles
(P . .05).
The data obtained are illustrated in
Tables 1 and 2 and Figures 3 and 4.
DISCUSSION
Several authors have argued that root canal
reinfection and failure of endodontic treatment
may be associated with the presence of
microorganisms in the dentinal tubules3,23. The
high pH of CH may not be maintained in the
dentinal tubules because of the buffering effect
of the dentin, allowing bacterial proliferation24.
Therefore, an intratubular medicament with
MPD would be ideal12.
In this study, 2 widely used vehicles
were used for the handling of CH paste4,11,12,
and the agitation techniques used are currently
applied for the removal of remaining
intracanal medicaments from the root canal
walls, disinfection of dentinal tubules, and
FIGURE 3 – A representation of data distribution for P(100%) and MPD in mm2 as functions of methods of agitation and distances from the apex.
4 de Almeida et al.
Insertion and agitation
LS
7.50 6 7.78 4.76 6 2.01
6.97 6 2.57 4.92 6 2.90
8.72 6 4.00 6.64 6 3.26
10.27 6 3.27 7.30 6 2.91
penetration of intracanal medications
and endodontic sealers into the dentinal
tubules13–16.
In this study, the P(100%) and MPD of
CH paste with an aqueous and a viscous
vehicle combined with sonic and ultrasonic
agitation were analyzed. The findings showed
that at a distance of 2 mm from the apex, the
vehicle and agitation methods did not influence
CH penetration, whereas at 5 mm only the
vehicle interfered with the penetration ability.
Therefore, the hypothesis that no difference in
the penetration of medication into dentinal
tubules between different vehicles existed was
rejected. The null hypothesis in the case of
agitation methods was accepted.
CLSM was used to verify the
penetration ability of CH paste. This method is
more advantageous compared with scanning
electron microscopy and other methodologies
to evaluate the penetration of materials in the
root canal25. One reason being the
dehydration of root sections for analysis
leading to material loss and sample
deformation in a section for scanning electron
microscopic analysis18,19.
The use of a fluorescent dye for
visualization of the analyzed material is
indicated in CLSM18. In this study, sodium
fluorescein was used to determine the depth of
penetration of the paste in the dentinal tubules
because of its fluorescence intensity
relationship in the presence of Ca21 ions, and
in the absence of these ions, the opposite
effect is observed, facilitating the analyses20.
Various studies have used P(100%) and
MPD as parameters for evaluating the
penetration ability of a material. The MPD
measures the depth of penetration at 1 point,
whereas the P(100%) assesses the total
penetration in the root canal walls12,26. The
measurement of the entire area in which the
material had penetrated is required to define
the percentage of total penetration in the
dentinal tubules27. Hence, the PPA and TSA
were measured in this study as previously
described.
Different factors such as the
physicochemical properties of the materials28,
the anatomy of the tooth29, and the presence
of a smear layer30 may have an effect on the
penetration of endodontic medications and
sealers in the dentinal tubules26. Among these
factors, removal of the smear layer from the
root canal walls is indicated to achieve
complete material penetration30,31. In this
research, crown sectioning and root canal
instrumentation may have resulted in the
formation of the smear layer. Hence, 2.5%
NaOCl was followed by 17% EDTA, and both
materials were agitated using the ultrasound
technique according to the protocol described
by Vivan et al21 for better cleaning.
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FIGURE 4 – A representation of data distribution for P(100%) and MPD in mm2 as functions of vehicle and distances from the apex.

Previous research has not revealed any
significant difference between the use of DW
or PG in terms of P(100%) and the depth of
penetration of CH paste in the dentinal
tubules12. In our study, a statistically
significant difference was observed in the
percentage of penetration between these
vehicles at a distance of 5 mm, with higher
mean values for PG. However, in a previous
study that evaluated the diffusion capacity of
CH pastes, it was observed that the groups
that used DW and 2% chlorhexidine showed
higher dentin diffusion capacity compared
with the groups that used PG and 0.2%
chlorhexidine11.
In the present study, no statistically
significant difference was observed in the
P(100%) and MPD of CH pastes between the
vehicles and agitation methods in the 2-mm
root apex analysis. At 5 mm, no statistically
significant difference was observed in the
MPD. This may be related to the fact that the
apical region has fewer dentinal tubules with
smaller diameters, and the dentin is more
sclerotic, which renders adequate access to
the apex by the tip of the agitation
instruments more difficult, leading to the
introduction of lesser material in the root
apex22.
The use of ultrasonic agitation
techniques has shown positive results in
association with intracanal medications13 and
irrigating solutions14,16. Evidence has shown
that the dentin-disinfecting ability of CH in
bovine teeth is improved by the use of
ultrasonic agitation of the pastes, leading to a
stronger antimicrobial action in the dentinal
tubules because of greater penetration of the
intracanal medication13.
Several studies have reported optimum
penetration of endodontic sealers15 and
irrigating solutions22 combined with
EndoActivator use. However, no studies have
analyzed the efficacy of this device to agitate
intracanal medications aiming to increase the
penetration in the dentinal tubules.
In this study, no statistically significant
differences were found in the percentage of
penetration and MPD of CH paste between
Lentulo, ProfiNeo, and EndoActivator, both
2 mm and 5 mm from the root apex. The
results of a study corroborating these results
showed that agitating irrigating solutions using
the EndoActivator did not improve the
penetration of tricalcium silicate–based
endodontic sealer in the dentinal tubules15.
In this study, it was shown that CH
paste penetration can be effectively evaluated
ex vivo using CLSM. The sonic and ultrasonic
agitation methods did not provide greater
penetration of intracanal medication, but the
use of PG as a vehicle improved the results at
5 mm from the root apex, suggesting its clinical
use to enhance the properties of this material.
CONCLUSIONS
At a distance of 2 mm from the root apex, the
vehicle and the sonic or ultrasonic agitation of
CH paste did not affect the penetration in the
dentinal tubules. However, at 5 mm from the
root apex, only the vehicle interfered with the
outcome, with better results for PG. These
findings suggest the use of a viscous vehicle to
optimize the intratubular penetration of
intracanal medicaments.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.

REFERENCES
1. Gomes BP, Souza SF, Ferraz CC, et al. Effectiveness of 2% chlorhexidine gel and calcium
hydroxide against Enteroccocus faecalis in bovine root dentine in vitro. Int Endod J 2003;36
:267–75.

2. Cai M, Abbott P, Castro Salgado J. Hydroxyl ion diffusion through radicular dentine when calcium
hydroxide is used under different conditions. Materials (Basel) 2018;11:152.

3. Behnen MJ, West LA, Liewehr FR, et al. Antimicrobial activity of several calcium hydroxide
preparations in root canal dentin. J Endod 2001;27:765–7.

JOE
Volume -, Number -, - 2020 CH Penetration in the Dentinal Tubules 5

 4. Misra P, Bains R, Loomba K, et al. Measurement of pH and calcium ions release from different
calcium hydroxide pastes at different intervals of time: atomic spectrophotometric analysis. J Oral
Biol Craniofac Res 2017;7:36–41.

5. Athanassiadis B, Abbott PV, Walsh LJ. The use of calcium hydroxide, antibiotics and biocides as
antimicrobial medicaments in endodontics. Aust Dent J 2007;52(Suppl):S64–82.

6. Rehman K, Saunders WP, Foye RH, et al. Calcium ion diffusion from calcium hydroxide-
containing materials in endodontically-treated teeth: an in vitro study. Int Endod J 1996;29
:271–9.

7. Siqueira Jr JF, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: a critical
review. Int Endod J 1999;32:361–9.
8. Farhad A, Mohammadi Z. Calcium hydroxide: a review. Int Dent J 2005;55:293–301.

9. Nerwich A, Figdor D, Messer HH. pH changes in root dentin over a 4-week period following root
canal dressing with calcium hydroxide. J Endod 1993;19:302–6.
10. Fava LR, Saunders WP. Calcium hydroxide pastes: classification and clinical indications. Int
Endod J 1999;32:257–82.

11. Mori GG, Ferreira FC, Batista FR, et al. Evaluation of the diffusion capacity of calcium hydroxide
pastes through the dentinal tubules. Braz Oral Res 2009;23:113–8.

12. Deniz Sungur D, Aksel H, Purali N. Effect of a low surface tension vehicle on the dentinal tubule
penetration of calcium hydroxide and triple antibiotic paste. J Endod 2017;43:452–5.
13. Arias MP, Maliza AG, Midena RZ, et al. Effect of ultrasonic streaming on intra-dentinal disinfection
and penetration of calcium hydroxide paste in endodontic treatment. J Appl Oral Sci
2016;24:575–81.
14. Kirar DS, Jain P, Patni P. Comparison of different irrigation and agitation methods for the removal
of two types of calcium hydroxide medicaments from the root canal wall: an in-vitro study. Clujul
Med 2017;90:327–32.
15. El Hachem R, Le Brun G, Le Jeune B, et al. Influence of the EndoActivator irrigation system on
dentinal tubule penetration of a novel tricalcium silicate-based sealer. Dent J (Basel) 2018;6:45.

16. Tamil S, Andamuthu SA, Vaiyapuri R, et al. A comparative evaluation of intracanal calcium
hydroxide removal with hand file, rotary file, and passive ultrasonic irrigation: an in vitro study.
J Pharm Bioallied Sci 2019;11(Suppl 2):S442–5.

17. ~o T, Camargo B, Armada L, et al. Efficacy of three methods for inserting calcium hydroxide-
Galva
based paste in root canals. J Clin Exp Dent 2017;9:e762–6.

18. Jeong JW, DeGraft-Johnson A, Dorn SO, et al. Dentinal tubule penetration of a calcium silicate-
based root canal sealer with different obturation methods. J Endod 2017;43:633–7.
19. Gunes B, Yeter KY, Terlemez A, et al. Dentinal tubule penetration of endodontic sealers after
nonthermal plasma treatment: a confocal laser scanning microscopy study. Microsc Res Tech
2019;82:903–8.
20. Paredes RM, Etzler JC, Watts LT, et al. Chemical calcium indicators. Methods 2008;46:143–51.

21. Vivan RR, Duque JA, Alcalde MP, et al. Evaluation of different passive ultrasonic irrigation
protocols on the removal of dentinal debris from artificial grooves. Braz Dent J 2016;27:568–72.
22. Oliveira KV, Silva BM, Leonardi DP, et al. Effectiveness of different final irrigation techniques and
placement of endodontic sealer into dentinal tubules. Braz Oral Res 2017;31:e114.

23. Mohammadi Z, Shalavi S, Yazdizadeh M. Antimicrobial activity of calcium hydroxide in

endodontics: a review. Chonnam Med J 2012;48:133–40.

24. Cwikla SJ, Be
langer M, Giguere S, et al. Dentinal tubule disinfection using three calcium
hydroxide formulations. J Endod 2005;31:50–2.
25. Ordinola-Zapata R, Bramante CM, Graeff MS, et al. Depth and percentage of penetration of
endodontic sealers into dentinal tubules after root canal obturation using a lateral compaction
technique: a confocal laser scanning microscopy study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009;108:450–7.

26. Kara Tuncer A, Unal B. Comparison of sealer penetration using the EndoVac irrigation system
and conventional needle root canal irrigation. J Endod 2014;40:613–7.
27. Deniz Sungur D, Purali N, Cos gun E, et al. Push-out bond strength and dentinal tubule
Ë sealers used with coated core materials. Restor Dent Endod
penetration of different root canal
2016;41:114–20.

6 de Almeida et al. JOE
Volume -, Number -, - 2020

 28. Oks an T, Aktener BO, Sen BH, et al. The penetration of root canal sealers into dentinal tubule.
Ë
A scanning electron microscopic study. Int Endod J 1993;26:301–5.

29. Rouhani A, Ghoddusi J, Naghavi N, et al. Scanning electron microscopic evaluation of dentinal
tubule penetration of Epiphany in severely curved root canals. Eur J Dent 2013;7:423–8.
30. Kokkas AB, Boutsioukis ACh, Vassiliadis LP, et al. The influence of the smear layer on dentinal
tubule penetration depth by three different root canal sealers: an in vitro study. J Endod
2004;30:100–2.
31. Violich DR, Chandler NP. The smear layer in endodontics – a review. Int Endod J 2010;43:2–15.

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