Disinfection Of Root Canal System Research Articles

Antimicrobial Effectiveness of Different Root Canal Irrigants on Viablility of Root Canal Flora

Introduction: Cleaning and shaping of sophisticated root canal system plays an important role in the success of endodontic treatment. In addition to root canal instrumentation, irrigation also becomes a crucial aspect in the effective disinfection of root canal system. The chemical substances like acids, chelating agents, alkaline solutions, Sodium Hypochlorite (NaOCl), oxidative agents, and normal saline are used as root canal irrigants. But each irrigant has its own limitations. With the advent of novel materials and techniques, the search for the optimal root canal irrigant still continues. Aim: To evaluate and compare the antimicrobial effectiveness of various root canal irrigant solutions such as combination of 5.25% NaOCl and 2% Chlorhexidine gluconate, 2% Chlorhexidine gluconate, Miswak extract and normal saline for root canal irrigation. Materials and Methods: In this prospective observational study was conducted from February 2021 to April 2021, on 10 patients with persistent endodontic infection on single rooted teeth. After obtaining access to the root canals, paper points were inserted and the soaked paper points were placed immediately in a microtube with two mL of Reduced Transport Fluid (RTF) to obtain the bacterial suspension. The sensitivity of gram negative anerobic bacteria and E.faecalis to different irrigants was assessed with disc diffusion test and bacterial load was evaluated with Colony Forming Unit (CFU) assay. The study was analysed statistically using Kruskal-Wallis test and Dunn test (post-hoc test). Result: The results of disk diffusion method showed that the zone of inhibition for 2% chlorhexidine gluconate was 29 mm for gram negative anerobic bacteria and 22 mm for E.faecalis, and the zone of inhibition for Miswak extract was 8 mm for gram negative anerobic bacteria and 10 mm for E.faecalis. Gram negative anerobic bacteria on the culture plates treated with Miswak extract had 6.41 CFU/mL, and E.faecalis had 5.21 CFU/mL. Gram negative anerobic bacteria on the culture plates treated with normal saline had a CFU/mL of 6.77, and E.faecalis had a CFU/mL of 5.77. The antibacterial activity of miswak extract was lower than that of other irrigants. The normal saline lacked any antimicrobial qualities. Conclusion: The antibacterial effectiveness of the combination of 5.25% NaOCl and 2% Chlorhexidine gluconate was found to be higher than, 2% Chlorhexidine gluconate, Miswak extract and normal saline for root canal irrigation. A combination of 5.25% NaOCl and 2% Chlorhexidine gluconate can be used as a better choice over the other three irrigants.

Polymicrobial biofilm disinfection in maxillary and mandibular molars with varying access designs: A microbiological study

ABSTRACT Aim: The aim of the study is to evaluate and compare the effect of access cavity designs on the polymicrobial biofilm disinfection of root canal system. Methods: One hundred and twenty molar teeth were selected and randomly divided into four groups (n = 30) on the basis of access cavity design: traditional access cavity (TEC), contracted access cavity (CAC), truss access cavity (TAC), and caries-driven access cavity (CDAC). After access preparation, the samples were contaminated for 2 weeks to grow polymicrobial mature biofilm. Microbial sampling from the root canals was performed with sterile paper points before and after instrumentation to determine the bacterial load. The bacterial reduction was counted as CFU/ml and analyzed statistically. Results: Both maxillary and mandibular molars with different cavity designs showed significant decreased in the number of Enterococcus faecalis, Staphylococcus aureus, and Candida albicans postinstrumentation. TEC group showed significantly higher microbial reduction for all tested microorganisms than TAC and CDAC groups (P < 0.05). However, insignificant difference (P > 0.05) was observed between TEC and CAC and TAC and CDAC. Conclusion: In both maxillary and mandibular molars, complete elimination of microbes (E. faecalis, C. albicans, and S. aureus) could not be achieved with any access cavity design. Highest microbial reduction was achieved with TEC and lowest in CDAC. Both TEC and CAC resulted in equal microbial reduction and were superior to TAC and CDAC.

Clinical evidence of pulp Revascularization in necrosed and immature teeth: a literature review / Evidências clínicas da Revascularização pulpar em dentes necrosados e imaturos: uma revisão de literatura

Introduction: Endodontic treatment in teeth with incomplete root formation and necrotic pulp has been constantly studied and new approaches are being carried out, with revascularization being the most recent of them. Objective: This work is a literature review, which sought to elucidate the clinical aspects of pulp revascularization, about its longevity as a treatment modality. Methods: Articles from the last 7 years were used in the PUBMED, Scielo and VHL databases in English and Portuguese. Randomized clinical studies, clinical cases with follow-up, systematic reviews and meta-analysis were considered. Results and Discussion: Among the various recommendations, due to the clinical cases exposed, the importance of disinfection of root canal systems by the use of irrigating solutions with antimicrobial action, the use of intracanal medication, and calcium hydroxide can be used or the tri-antibiotic paste, both with the aim of eliminating bacteria present on dentin surfaces. Apical revascularization facilitates tooth root development, but it is uncertain how much root length and thickness, or apical closure, is achieved. However, regenerative techniques seem to have superior results, in these aspects, when compared to the Apexification technique. Among the clinical studies evaluated, it was observed that the revascularization technique with blood clot associated with the use of PRP and PRF as a scaffold was more effective for the longevity and success of the technique. Conclusion: After the reviewed articles, it can be concluded that the apical root closure technique, through the induction of the blood clot, is effective in enabling root strengthening and development, being safe, traumatic, and low cost and can be performed in any age, covering a significant number of patients with incomplete apex associated with pulp necrosis.

Antibacterial Effect of Longan Extract and Diode Laser Combination on Peptostreptococcus Species in Type 2 Diabetic Patients with Apical Periodontitis - A Pilot Study

Diabetes mellitus is a risk factor for developing periapical infections and increases resistance against pharmacotherapy. Microorganisms are the major cause for periradicular diseases. Peptostreptococcus spp. is the most common bacterial isolate from root canals of primary endodontic infections in diabetic patients. Herbal irrigants are being researched for its efficacy against root canal microorganisms owing to their resistance against commonly used irrigants and medicaments. Longan extract is known for its antimicrobial and antiglycemic action. Diode laser is a newer modality in the disinfection of root canal system. The aim of this study was to assess the antibacterial effect of longan extract (longan fruit extract) and diode laser on Peptostreptococcus species in type 2 diabetic patients with primary endodontic infections using PCR technique. Eleven subjects with type 2 diabetes requiring endodontic treatment were selected for the study based on convenience sampling for a period of 3 months. The preoperative root canal samples were collected after gaining access to the root canal system and initial instrumentation of root canals. Postoperative sample were obtained following a disinfection protocol using 3% NaOCl, 17% EDTA, longan extract as the final irrigant, followed by diode laser irradiation. Both the preoperative and postoperative samples were collected as per Moller’s criteria using sterile paper points. The mean percentage reduction following irrigation of the root canal with longan extract was 71.18% whereas diode laser showed 100% disinfection. In conclusion, the combination of longan extract and diode laser provides an effective mode of root canal disinfection in type 2 diabetic patients with apical periodontitis.

An Evaluation on the use of Photon-Induced Photoacoustic Streaming in Root Canal Treatment

Introduction: The main purpose of endodontic treatment is to retain the involved teeth in the oral cavity for as long as possible by the prevention and elimination of infection in the root canal system. Irrigation of the root canal after instrumentation is a fundamental component of endodontic treatment success. It is mainly aimed to achieve debridement, smear layer removal, and disinfection of the entire root canal system. Recently, Photon Induced Photoacoustic Streaming (PIPS), which is an activation technique based on the using of Er:YAG (2.940nm) laser equipped with PIPS tip at sub-ablative energy levels, has been used to achieve this goal. Objective: Evaluate the ability of PIPS technique in removing smear layer and remnants. Material and Method: Review and summarize studies evaluated the effect of PIPS in root canal treatment. Results: Several in-vitro studies has been evaluated the evidence to support the benefit of PIPS technique over the traditional and other laser agitation techniques as an efficient method regarding removal of smear layer, remnants disinfection of root canal system and its benefits in other procedures. Conclusion: Photon induced photoacoustic streaming in in-vitro studies seems to show better smear layer removal at coronal and middle thirds of root canal but not at the apical third, it has no superior effects compared with the other activation technique of endodontic solution

The usage of lasers in cleaning, shaping, and disinfection of root canal system

Since the laser was first used in endodontics in the 1970s, many studies have been conducted on this subject. This paper aims to summarize the studies about the effects of lasers in endodontics, which analyze the preparation and disinfection of the root canal system, postoperative pain, and the effect on the smear layer. The still-controversial question is; if lasers provide better results when used in tandem with conventional methods or alone. Another unknown factor is the side effects on teeth and surrounding tissues. With the increase in technology and knowledge in this field, developments are promising with different devices, laser tips, and wavelengths.

An Overview of the Antimicrobial Effect of Natural Irrigants in Disinfection of Root Canal System

The endodontic irrigants have an important role in eradicating microorganisms from the canal space to achieve a host manageable bioburden. The most important purpose for treating the root canal is to obtain an aseptic field and achieve the root canal system’s three-dimensional obturation. The irrigating solutions used in endodontics can irritate the periradicular region due to their cytotoxicity and would not remove the microorganism which has penetrated deeper into the dentinal tubule. Ph

INVESTIGATION OF ANTIBACTERIAL ACTIVITY OF ND: YAG - LASER AND STANDARD ENDODONTIC TREATMENT

Introduction: The microbial infection is one of the main causes of the dental pulp and periodontal diseases. Previously used methods for its elimination are not fully effective, and often some microorganisms in root canals (RC) remain unaffected after treatment. Another modern method for disinfection of root canal system is laser disinfection. Different types of lasers are used - Nd: YAG, Er: YAG, Diode laser. Purpose: The purpose of our study is to compare the antibacterial activity of ND: YAG laser and conventional endodontic therapy in the treatment of infected root canals. Materials and methods The study involved 36 teeth of patients diagnosed with pulp gangrene or chronic periapical periodontitis, requiring endodontic treatment. They were divided into two groups of 18 teeth each one. The teeth in both groups are prepared by Protaper Universal rotary instruments (Maillefer Instruments SA, Ballaigues, Switzerland). In group 1the root canals disinfection is performed with a Nd: YAG laser (source of Nd: YAG laser (1064 nm) is the AT Fidelis - Fotona d.d., Ljubljana laser system). In group 2 was used the following protocol of root canal disinfection: 2.5% sodium hypochlorite solution and 17% EDTA divided by irrigation with distilled water. Then a sterile paper point is placed in the root canals, and a microbiological sample is taken again. Results: In all compared pairs, there was no significantly different effect regarding the number of microorganisms. Conclusions: The disinfection rinsing method with NaOCl has the strongest antimicrobial effect in clinical studies (90% against all microbial isolates). The use of Nd: YAG laser independently is not always sufficient for root canal disinfection - the effect is about 66%.

Effect of Irrigants and Irrigating Devices on Disinfection of Root Canal System: A Systematic Review

Aim: The effective delivery of irrigants into the inaccessible areas of the root canal system is the prerequisite for a proper disinfection of the root canal system. Numerous activation devices that can provide effective delivery of the irrigant and aid in the success of the root canal treatment are available. The activation of irrigants has claimed to be effective in in vitro and clinical trials. Hence, the present systematic review aims to analyze the effect of irrigants and irrigating devices in disinfecting the root canal system. Materials and Methods: A literature search was undertaken in PubMed, Cochrane, Web of Science, and Scopus databases. The inclusion criteria included clinical trials, both in vivo and ex vivo. The exclusion criteria included animal studies, textbooks, review articles, and case reports. The patients who required endodontic treatment along with the activation of irrigants were chosen as participants for the review. Result: The search strategy screened around 132 articles, out of which only 10 were selected for the present systematic review. The risk of bias was calculated based on the following scores: 3, high; 2, moderate; and 1, low. In the present systematic review, four articles were categorized into low-risk bias, three articles were classified as moderate risk, and three articles belonged to the high-risk category. Conclusion: The present systematic review concluded that the use of a mechanical activation device along with the irrigant will help in better removal of the smear layer and debris from the root canal system, improving the cleanliness and helping achieve more successful endodontic treatment.

Antibacterial Effects of Erbium Chromium Laser along with/without Silver Nanoparticles in Root Canals Infected by Enterococcus faecalis.

This study investigates the antibacterial effects of erbium chromium laser at 2780 nm, silver nanoparticles, and erbium chromium along with silver nanoparticles on Enterococcus faecalis in comparison with sodium hypochlorite. In the present study, 90 extracted human single-rooted teeth were selected and standardized to a length of 15 mm. The canals were prepared by V-taper Gold rotary files and then incubated with E. faecalis for 21 days. The samples were divided into four experimental groups including hypochlorite sodium, silver nanoparticle, erbium chromium laser, and erbium chromium laser along with silver nanoparticle groups. Results showed that there was a significant reduction in colony count for all groups after interventions. Moreover, there was a significant reduction in the colony count for sodium hypochlorite group in comparison with another groups, and this group showed the highest reduction of colony count. There was a significant difference between silver nanoparticles and erbium chromium laser groups in colony count. According to the results, the silver nanoparticles offered strong antibacterial effects on E. faecalis and therefore can decrease bacterial colonies, while the use of the laser, despite the reduction of the bacterial colony, could not be sufficiently used for disinfection of root canal system.

Evaluation of Crack Propagation after Root Canal Preparation with Continuous and Reciprocating Files and Final Finishing with XP Endo Finisher - An In vitro Study.

Introduction:One of the disadvantages of stainless steel instruments used for root canal preparation is the lack of flexibility and shape memory. The invention of rotary instruments has been successful in overcoming these problems to a greater extent; however, some drawbacks still remain, one of which is vertical root fracture and the cause for it is microcracks formation in dentin, which in turn causes vertical root fracture. There are enough studies for microcracks using different rotary systems and this study compared microcracks with single as well as reciprocating files followed by final finishing with XP endo finisher. Apart from other studies, we used conefocal laser scanning microscope to assess microcrack propagation before and after instrumentation with each rotary system.Aim:To evaluate microcrack propagation in mandibular molars after root canal preparation with continuous and reciprocating file systems followed by final finishing with XP Endo finisher.Materials and Methods:Thirty mandibular molars indicated for the extraction due to periodontal causes were selected for this study. They were divided into three groups based on rotary systems used: Group A: ProTaper universal; Group B: ProTaper gold; and Group C: Waveone gold. All specimens were subjected to scanning before instrumentation to assess the presence of any existing cracks. Cone focal laser microscopic scanning is again repeated for each specimen after instrumentation with each rotary system and also after final finishing with XP Endo finisher.Statistical Analysis:One-way ANOVA is used.Results:Crack propagation is the highest with ProTaper universal and least with waveone gold. After final finishing of canals with XP Endo finisher, crack propagation observed was negligible.Conclusion:The success of root canal treatment depends on effective disinfection of root canal system. XP Endo finisher can be used as a final finishing file by considering its advantageous properties, moreover crack propagation with XP Endo finisher in an previously instrumented canal is negligible.

Antibacterial Efficacy of Muringa Seed Extract and Potato Peel Extract Against Enterococcus faecalis.

Background:Elimination of infection and prevention of reinfection should be the main goal in the treatment of apical periodontitis. The most challenging part of endodontics is the complete disinfection of root canal system. Herbal alternatives have emerged as the more biofriendly approach in root canal irrigation and disinfection.Aim and Objective:The aim of this study was to evaluate the antimicrobial efficacy of natural extracts like muringa seed and potato peel extract against Enterococcus faecalis.Materials and Methods:The antimicrobial activity was determined using agar diffusion test. The solutions were divided into three groups: Group I- Muringa seed extract, Group II- potato peel extract, and Group III-5.25% sodium hypochlorite. The zones of inhibition of growth were recorded. The strain used for this study was Enterococcus faecalis ATCC 29212.Results and Conclusion:Muringa seed extract (Group I) demonstrated the best result among the tested solutions. Although there was no significant difference between potato peel extract (Group II) and 5.25% sodium hypochlorite (Group III). Within the limitations of this study, herbal extracts tested has shown significant antimicrobial action against Enterococcus faecalis.

Comparative Evaluation of Fracture Resistance of Root Dentin Treated with Calendula Officinalis L. and Calcium Hydroxide as Intracanal Medicaments- An In vitro Study

Introduction: Intracanal Medicaments (ICMs) play a major role in disinfection of root canal system. The use of interappointment ICM during endodontic treatment may affect the mechanical properties of dentin which results in decreased fracture resistance of teeth. The use of synthetic medicament is associated with many limitations such as antibiotic overdose, side effects and cytotoxic reactions. In order to overcome this, recent research has been directed towards herbal ICMs with better efficacy and lesser side effects. Aim: To evaluate the effect of a novel herbal ICM Calendula officinalis L. (CO) on fracture resistance of root dentin in comparison to Calcium Hydroxide (CH). Materials and Methods: This in vitro study was conducted in the Department of Conservative Dentistry and Endodontics, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu. Thirty freshly extracted single rooted human premolar teeth were selected for the in vitro study and randomly assigned into three groups: Group 1: No medication (Control group) (n=10), Group 2: CH (n=10), Group 3: CO (n=10). The samples were decoronated and biomechanical preparation was done followed by placement of respective ICMs in the root canal space, sealed with glass ionomer cement and immersed in saline for a storage period of 7 and 14 days. Each group was subdivided into 5 teeth, depending on the storage period. After each storage period, ICMs were removed and samples were subjected to fracture resistance test using universal testing machine. Data were analysed using One-way Anova followed by Tukey HSD post-hoc test with level of statistical significance set at p<0.05. Results: On evaluation of compressive strength, CO group showed more fracture resistance compared to CH group on 7th day and no statistical significant differences were seen between CO and CH groups on 14th day. Conclusion: CO can be efficiently used as an alternative to CH because of its low toxicity and increased resistance to fracture.

Knowledge and practices of decontamination during root canal treatment by dentists in Jeddah

BackgroundThe periapical area is healed through disinfection of root canal system and reduction of microbial infection after root canal. PurposeTo assess the knowledge of dental practitioners about decontamination during root canal treatment and the techniques used in the government and private sectors of Jeddah, Saudi Arabia. Methods103 dental practitioners and interns from private and governmental sectors performing root canal treatment were included. To extract information, a questionnaire assessing knowledge and preferred techniques used in decontamination during root canals treatment was distributed. The association of variables was investigated using chi-square tests. ResultsThe findings reflected that 82.5% of subjects used rubber dam for isolation with significantly more practitioner in the governmental (95.2%) as compared to the private sector (27.8%). Chelating agents were used by 13.3% of the practitioners in government sector and 1% practitioners in private sector (1%). The most commonly used irrigant was sodium hypochlorite. Calcium hydroxide was used more frequently in the governmental sector (29.8%) than in the private sector (11.8%), as intracanal medicament. Mechanical irrigation devices were used by 2.4% of practitioners in the governmental sector only. ConclusionsThere is a significant difference in practicing root canal disinfection techniques among dentists in governmental and private sectors but no difference in degree of knowledge.

Anti-microbial Photo Dynamic Therapy (aPDT) in Endodontics: A Literature Review

Elimination of root canal pathogens is one of the main objectives for successful outcome of root canal treatment. Conventional chemo-mechanical debridement is not always successful in removing all bacteria. Adjunctive use of antimicrobial photodynamic therapy (aPDT) can be a used as a practical approach for successful elimination of all these bacteria. The aim of this review was to assess scientific literature that used various photosensitizers for bacterial reduction using aPDT methods. A search of the PubMed and Cochrane data bases using appropriate terms and keywords related to antimicrobial photodynamic therapy in endodontic disinfection was conducted. A hand search also was conducted in the preceding 5 years of several journals. Full texts of the selected articles were obtained and analyzed. A total of 177 articles published were identified at first stage of data extraction. After final screening, 41 articles were included in this review. This review summarizes the usage principles of aPDT and outlines the applications of aPDT in root canal disinfection procedures. It was concluded that aPDT should be used in conjunction with the conventional chemo mechanical debridement and disinfection of root canal system. It is critical to note that selection of photosensitizer dye, its correct delivery within the prepared root canal system, laser application with correct type of tips are predictors for successful outcome of this protocol of root canal disinfection.

Comparative evaluation of single-visit endodontic treatment with and without the use of iodine potassium iodide as an endodontic irrigant: In vivo study

Introduction: The root canal treatment in asymptomatic necrotic teeth in single visit has been an area of discussion for long. The purpose of this study was to compare the single-visit root canal treatment of asymptomatic nonvital mature mandibular molars with and without the use of 5% iodine potassium iodide (IKI) as an endodontic irrigant with the minimal use of postoperative medications. Materials and Methods: Sixty patients requiring root canal treatment on asymptomatic nonvital mandibular molars were included in the study and were randomly allocated into two groups of thirty each. In Group I, no IKI was used and in Group II, 5% IKI was used as an irrigant. The complete treatment was done in single visit. The occurrence of postoperative pain and swelling was noted at various time intervals. Results: Mann–Whitney U-test showed no statistically significant difference between the two groups regarding both the parameters. In Group I, 20% of patients experienced moderate-to-severe pain during the first 24 h (P = 0.25463) while only 10% of patients experienced moderate pain in Group II. In Group I, 20% of patients developed swelling after 24 h while none of the patients in Group II had any postoperative swelling (P = 0.09342). Conclusion: Irrigants with better disinfection properties, penetration, and quick action such as 5% IKI are important adjunct to complete the disinfection of root canal system in single-visit endodontics.

Comparative evaluation of micron- and nano-sized intracanal medicaments on penetration and fracture resistance of root dentin – An in vitro study

Intracanal medicaments play a vital role in disinfection of root canal system. The aim of this study was to evaluate intratubular penetration and fracture resistance of roots filled with micron- and nano-sized intracanal medicaments: calcium hydroxide (CH), nanocalcium hydroxide (NCH), chitosan (CS) and nanochitosan (NCS). Their antibacterial effect on E. faecalis was tested using agar diffusion method. NCH and NCS were prepared by precipitation method and ionic crosslinking respectively. NCH and NCS particles were spherical, with an average particle size of 102±11.3nm and 130±17.6nm respectively. The medicaments were filled in extracted human teeth. Depth of penetration of the medicaments into dentinal tubules at coronal (C), middle (M) and apical (A) thirds was measured. Fracture resistance of the teeth was evaluated after 1 week and 1-month intervals. NCH showed the highest depth of penetration (C ∼746.98μm, M ∼700.30μm, A ∼134.69μm). CS showed the highest fracture resistance, whereas no significant difference was found between other medicaments, at both the time intervals. NCH (8.07±0.06) and NCS (8.13±0.06) showed significantly higher zone of inhibition than CH (7.7±0.17) and CS (7.37±0.15). Under the conditions of this study, it can be concluded that NCH and NCS can be used as potential intracanal medicaments.

Evaluation of antibacterial efficacy of Chitosan, Chlorhexidine, Propolis and Sodium hypochlorite on Enterococcus faecalis biofilm : An in vitro study.

BackgroundLong term successful root canal treatment requires effective debridement and disinfection of root canal system. Persistent periradicular lesions are usually associated with Enterococccus faecalis. Prompt research for natural alternatives for irrigation is mainly due to the constant increase in antibiotic resistant strains and side effects caused by synthetic drugs. Sodium hypochlorite; the gold standard for irrigation has many disadvantages. Therefore, the present study was aimed to explore newer irrigants probably be as more effective and at the same time would be less irritating to the tissues than NaOCl.Material and MethodsNinety extracted human mandibular premolars were biomechanically prepared, vertically sectioned, placed in tissue culture wells exposing the root canal surface to E. faecalis to form a biofilm. At the end of 3rd week, all groups were irrigated with 3 ml of test solutions and control for 10 minutes. The samples were then scraped with a scalpel, inoculated on tryptone soy agar plates and incubated for 24 hours at 37ºC. The plates were then subjected to digital colony counter and evaluated for E. faecalisgrowth. The growth was statistically analysed by ANOVA & Post Hoc Tukey tests.ResultsChitosan + Chlorhexidine, NaOCl and Chlorhexidine showed no statistically significant difference, whereas all the other inter‑group differences were statistically significant (P<0.05).ConclusionsChitosan + Chlorhexidine, Chlorhexidine and Propolis were found to be as efficacious as sodium hypochlorite. The use of natural alternatives as root canal irrigation solutions might prove to be advantageous considering several unfavorable properties of NaOCl. Key words:Antibacterial efficacy, Chitosan, Enterococcus faecalis, Root canal irrigation.

Paradigm Shift from Stem Cells to Cell-Free Regenerative Endodontic Procedures: A Critical Review.

Regenerative endodontic procedures of immature teeth with necrotic pulp have become a part of therapeutic endodontic spectrum and are considered as an alternative to calcium hydroxide or mineral trioxide aggregate apexification. In last decade, numerous case reports and series with usage of cell-free approaches known as revascularization, revitalization, or maturogenesis have been published. This cell-free approach prevails in clinical regenerative endodontics because of its relative ease of performance, lower financial demands, and absence of complications such as tumorigenesis of used stem cells. In this article, the integral steps of cell-free treatment approaches such as source of stem cells, possible endogenous scaffolds, sources of growth factors, and width of apical foramen in the context of sufficient disinfection of root canal system and outcome of treatment are discussed. Despite not being a fully established treatment protocol, the achieved outcomes are promising regardless of it having a reparative character than a regenerative one.

Root canal treatment of permanent mandibular first molar with six root canals: a rare case

The awareness of internal dental morphology is an excessively critical step in management of endodontic therapy. [1] The mandibular first molar, the earliest permanent tooth to erupt is assumed to be the tooth that mostly creates need for root canal treatment. The most common root canal morphology of the mandibular first molar is the presence of two canals in the mesial root and one or two canals in the distal root.[2] However, the literature indicates a number of case reports on the anatomic alterations and the variations related to the mandibular first molars. Amazingly, Reeh[3] reported a case with seven canals, involving four canals in the mesial root and three canals in the distal root. The knowledge of such anatomic variations of root and root canals is an essential aspect in managing the degree of success of root canal treatment. Without an efficient exploration, a canal could be left unprepared and inaccurate disinfection of root canal system is inevitable, so the endodontic therapy may result in failure.[4]