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   Table of Contents - Current issue
Coverpage
July-December 2018
Volume 30 | Issue 2
Page Nos. 97-193

Online since Wednesday, December 5, 2018

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EDITORIAL  

Editorial Highly accessed article p. 97
Sanjay Miglani
DOI:10.4103/endo.endo_133_18  
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ORIGINAL ARTICLES Top

Phytomedicine: Herbal venture in green endodontics p. 98
Kuljit Kaur, Tarun Kumar, Sunandan Mittal, Renu Bansal
DOI:10.4103/endo.endo_115_17  
Introduction: Nature has bestowed a very rich botanical wealth. Antimicrobial agents of plant origin have enormous therapeutic potential. Azadirachta Indica (AI) & Aloe Barbadensis (AB) are the natural product that has gained interest in endodontics as irrigant due to their antibacterial effectiveness against several endodontic pathogens. Hence the purpose of this in vivo study was to compare the antimicrobial efficacy of herbal (Azadirachta Indica & Aloe Barbadensis) with conventional (Sodium Hypochlorite and Chlorhexidine Gluconate) irrigants in infected root canals. Methodology: One hundred and twenty five patients satisfying the inclusion criteria were selected. Before and after the root canal preparation, two canal samples were obtained by a harvesting method using a sterile paper point and then transferred for microbiological study. Results: The results of present study indicated that use of Sodium Hypochlorite showed greatest percentage reduction in Aerobic Microbial Load (87.58%) followed by Azadirachta Indica (82.24%), Chlorhexidine Gluconate (78.32%), Aloe Barbadensis (27.22%) and Distilled Water (15.73%). In anaerobic microbial load Azadirachta Indica showed greatest percentage reduction (78.43%) followed by Chlorhexidine Gluconate (78.12%), Sodium Hypochlorite (75.16%), Distilled Water (12.38%) and Aloe Barbadensis (-9.74%). Conclusion: The results of present study indicate that the number of post-irrigant positive cultures (CFU/ml) was significantly lower than the pre-irrigant cultures in all the groups.
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Effect of three different rotary instrumentation systems on crack formation in root dentin: An in vitro study p. 103
Esha Chandresh Vora, Rupinder Bhatia, Sandhya Tamgadge
DOI:10.4103/endo.endo_86_17  
Introduction: Biomechanical preparation (BMP) of root canal damages the root dentin which becomes a gateway to dentinal cracks and thereby causing failure of the treatment. Therefore, there is a need of best instruments to minimize the failure of endodontic treatment. Aims and Objective: The objective of this study is to compare the incidence of cracks observed in the root dentin after root canal preparation with three different rotary instrument systems. Material and Methods: Seventy-five freshly extracted permanent maxillary incisors were randomly selected. Teeth were divided into five groups (n = 15), Group 1 – Untreated (negative control group), Group 2 – BMP done with nickel–titanium K-files (positive control group), Group 3 – BMP done with ProTaper Universal files, Group 4 – BMP done with ProTaper Next files, and Group 5 – BMP done with HyFlex EDM files. Roots were sectioned horizontally at 2 mm, 4 mm, and 6 mm from the apex. All slices were then viewed under stereomicroscope. All findings were analyzed using Chi-square test. Observations and Results: In the apical third, Group 5 had maximum number of fracture cases while Group 4 had lesser number and Group 3 had the least. In the middle third, Group 3 had maximum number of fracture cases while Group 4 and Group 5 showed lesser number of fractures. In the cervical third, Group 3 and Group 4 showed equal and maximum number of fracture cases. Group 5 showed no fracture cases. Group 1 and Group 2 showed no fracture cases in all the root sections. Conclusion: Conventional hand instrumentation is the best as compared to rotary instrumentation. However, rotary systems render various benefits with an acceptable success in comparison to the conventional hand instrumentation. In our study, we found that HyFlex EDM rotary system was the best with least number of fracture as compared to other systems used.
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Evaluation of apical sealing ability of ActiV GP/glass ionomer sealer as a root filling material Highly accessed article p. 113
Souzan Ahmad Kassar, Adnan Asaad Habib, Mazen Deeb Doumani, Saleem Abdulrab, Hisham Alafif
DOI:10.4103/endo.endo_108_17  
Introduction: The aim of this in vitro study was to assess the sealing ability of ActiV GP/glass ionomer sealer and to compare it with sealing ability of Resilon/Real Seal and gutta-percha/AH Plus. Materials and Methods: Forty-five human mandibular premolars were randomly divided into three groups (15 canals each). Each canal was instrumented to a size 40, taper 6% using K3 NiTi rotary instruments. A smear layer was removed, and the teeth were filled using single cone technique with ActiV GP, Resilon/Real Seal, or lateral condensation with gutta-percha/AH Plus. The teeth then were immersed in 2% methylene blue solution for 24 h, longitudinally sectioned and examined under a stereomicroscope to evaluate the liner leakage of the dye in each group. The data were analyzed with descriptive statistical methods and Mann–Whitney test (P = 0.05). Results: The lowest mean of leakage was recorded in gutta-percha/AH Plus group. There was a statistically significant difference between gutta-percha/AH Plus group and the two other groups; ActiV GP group and Resilon group. Conclusion: Dye penetration examination showed that ActiV GP/GI sealer had weak sealing properties, Resilon/RealSeal system did not show superior sealing properties in comparison with gutta-percha/AH Plus sealer, and lateral condensation shows better sealing properties in comparison with single cone technique.
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Obturating the pink tooth: An in vitro comparative evaluation of different materials p. 119
Mahendra H Patel, Krushnangi Nitin Yagnik, Nishtha K Patel, Bhavika A Bhavsar
DOI:10.4103/endo.endo_90_17  
Aim: The aim is to evaluate the obturating potential of thermoplasticized gutta-percha, mineral trioxide aggregate (MTA), and Biodentine in simulated internal resorption cavities. Materials and Methods: Thirty human extracted teeth with single canal and mature apex were collected for the study. Access cavity was prepared in each. For all the teeth, standardized instrumentation was done to apical size of ISO #50 K stainless steel hand file. Following instrumentation, at the length of 6 mm short of working length, internal resorption cavity was simulated using Gates–Glidden drill, as the canal of the selected teeth was wide enough and thus widening of the canal occurred only at the desired working length. The teeth were radiographed to check internal resorption cavity. The teeth were randomly divided into three groups; ten teeth in each group. Samples were obturated as follows: Group 1 – thermoplasticized gutta-percha, Group 2 – MTA, and Group 3 – Biodentine. Samples were stored at room temperature for 48 h. After 48 h, samples were evaluated radiographically and microscopically using Dental Operating Microscope. Statistical analysis of the results was performed using Kruskal–Wallis test. Results: Results obtained were statistically significant. Conclusion: MTA and Biodentine showed better sealing than thermoplasticized gutta-percha.
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Incidence of C-shaped canal configuration in mandibular first premolars: A cone-beam computed tomography analysis p. 125
Parul Bansal, Vineeta Nikhil, Ayush Goyal, Sana Ali, Mariyam Hasnain
DOI:10.4103/endo.endo_113_17  
Aim: The endodontic literature reports considerable variations in the root canal morphology of mandibular first premolars, including variations in number of roots and root canals. Additionally C-shaped canal configuration has also been documented in some case reports. Thus, the aim of this study was to determine the incidence of C-shaped canal morphology in mandibular first premolars in an Indian population. Materials and Methodology: A total of 110 human mandibular left and right first premolars were collected. All teeth were subjected to CBCT exposures, made with the unit operating in continuous mode at 80 kV and 12 mA with an exposure time of 12s. CBCT images were analyzed using CS 3D Imaging Software 3.1 in the oblique cut. Result: Out of 110 teeth, five teeth (4.54%) presented with the C-shaped canal configuration. Conclusion: Limitations inherent in 2D imaging can be overcome by newer imaging techniques such as CBCT to better appreciate the variations in root canal anatomy.
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Accuracy of two different apex locators for working length determination during root canal retreatment of mandibular molars using two different retreatment files: An in vitro study p. 130
Ajay Chhabra, Ruhani Bhatia, Nisha Garg, Shruti Sharma, Aarushi Dogra, Ashu Jhamb
DOI:10.4103/endo.endo_88_17  
Aim: The aim of this study was to evaluate the accuracy of two different apex locators for working length determination during root canal retreatment of mandibular molars in an in vitro study. Method: Sixty extracted mandibular first molars with separate mesial canals and apical foraminae and one distal canal were selected. The mesiobuccal and distal canals were investigated; the length with the file tip at the major diameter was defined as the tooth length (TL). The canals were prepared with ProTaper files to 1 mm short of this and filled with gutta-percha and AH Plus sealer. One week later, the root fillings were removed using ProTaper and M2 retreatment files. Tooth length was remeasured and recorded as the retreatment tooth length (RTL). Then electronic measurements were taken at the major (electronic apex locator (EAL) major) and minor (EAL minor) foraminae with Root ZX and Apex ID apex locator as suggested by the instrument display. These lengths were compared with RTL and measurements 0.5 and 1 mm short of this distance. Results: For both canals, no significant difference was found between RTL and EAL major, and 0.5 mm short of RTL and EAL minor with Root ZX apex locator and protaper retreatment files. There were significant differences found between Apex ID apex locator with M2 retreatment files readings. Conclusion: Root ZX apex locator was more accurate as compared to Apex ID apex locator in determining the working length in teeth after removing the root canal obturating material.
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Evaluation of efficacy of Nd:YAG laser, ozonated water, and ultrasonic irrigation with 3% sodium hypochlorite for disinfection of root canal: An in vivo study p. 135
Dolly Rathod, Sanjyoy Mulay
DOI:10.4103/endo.endo_93_17  
Background: Root canal infection has multibacterial etiology. The success of the endodontic treatment is directly influenced by the elimination of microorganisms from infected root canals. Many authors have suggested that to eliminate bacteria from the root canals predictably, the adjuvant method or agent is recommended. Aims: The present study was conducted to evaluate and compare the efficacy of Nd:YAG laser, ozonated water, and ultrasonic irrigation using 3% sodium hypochlorite for disinfection of root canal. Methodology: In thirty single-rooted teeth, access opening and instrumentation till #25 file was done under rubber dam. The first sample was collected by introducing a sterile paper point for preoperative microbial sampling. Ten teeth in each group were treated with Nd:YAG laser, ozonated water, and ultrasonic irrigation using 3% sodium hypochlorite for disinfection of root canal. The second sterile paper point was placed to collect the postoperative sample. Paper points were put in a test tube containing transport medium and sent for microbiology laboratory. Results: According to the results of the present study, there was highly significant difference (P < 0.0001) in percentage reduction in all the three study groups. There was a statistically highly significant difference (P < 0.0001) in pre- and post-operative colony-forming units in samples treated with ultrasonic irrigation with 3% sodium hypochlorite (Group III). Conclusions: In the current study, ultrasonic irrigation with 3% sodium hypochlorite was the most effective treatment modality as compared to Nd:YAG laser and ozonated water for disinfection of root canal.
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CASE REPORTS Top

Canalis sinuosus mimicking root resorption lesion p. 140
Jaydeep Shashikumar Talim, Daniel Schechter, Rafael Roges, Ilan Rotstein
DOI:10.4103/endo.endo_103_17  
Anatomical variations in the premaxillary region, especially those involving neurovascular structures, can present a diagnostic challenge to a clinician. Correct diagnosis is crucial for treatment decision-making and prognosis assessment of nonsurgical and surgical procedures. Canalis sinuosus (CS) is an anatomical variation of the anterior superior alveolar nerve canal. Its diagnosis may sometimes be confusing, resulting in an inadequate treatment plan. Described is a case of a CS mimicking an external root resorption lesion. Cone beam computed tomography (CBCT) assisted in confirming the final diagnosis.
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Dysesthesia after endodontic treatment p. 144
Thomas Maly, Lisanne C Groeneveldt, Titiaan J Dormaar, Constantinus Politis
DOI:10.4103/endo.endo_116_17  
Whenever there is a close relationship between radix of mandibular teeth and inferior alveolar nerve (IAN), the IAN may be at risk during endodontic therapy. Overinstrumentation, overfilling irrigation fluids, as well as spread of infection, are the known causes of IAN damage. The following article regards two cases of IAN damage following endodontic therapy. In one case, surgical decompression with the use of piezosurgical techniques (Piezomed®) was performed, after which the pain and dysesthesia gradually subsided over the weeks following surgery. The second case was managed with medication only; the complaints reduced within 3 months. It is important to treat IAN damage as early as possible to achieve the best outcome.
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Complex endodontic-surgical management of dens invaginatus in multiple teeth associated with unusual morphology by using cone-beam computed tomography as a diagnostic aid p. 148
Amit Gandhi, Meenakshi Sood, Anshu Blaggana, Mandeep S Virdi
DOI:10.4103/endo.endo_123_17  
Dens invaginatus (DI) as a dental anomaly suggests a broad spectrum of morphologic variations and predisposes the tooth to decay and in intense invaginations to pulpitis and apical periodontitis. The involved tooth requires endodontic or combined endodontic-surgical treatment which often is complicated because of the abnormal morphology. As intraoral periapical radiographs provide insufficient information because of its two-dimensional nature, a cone-beam computed tomographic scan is recommended in complex cases with aberrant root canal anatomy that allows visualization of pathology in three dimensions. This article reports a case in which multiple teeth were involved with DI associated with open apex and periapical pathology which was successfully treated with endodontic and combined endodontic-surgical approach. The success of the present case suggest MTA as a preferable material to aid regeneration of the apical tissue in nonvital teeth with open apex and thus can be used in cases of DI.
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Management of an endodontic-periodontal lesion attributable to palatogingival groove p. 156
Tarun Kumar, Sunandan Mittal, Vanita Keshav, Harpreet Kaur
DOI:10.4103/endo.endo_74_17  
To describe the management of endodontic-periodontal lesion attributable to palatogingival groove extending from crown to root surface, contributing to severe periodontal breakdown in relation to maxillary central incisor. Palatogingival groove may act as a nidus of plaque accumulation and contribute to the pathogenesis of endodontic-periodontal lesions. The management of such lesions requires an integrated interdisciplinary approach with careful application of endodontic and periodontal surgical procedures. In the present case, the patient presented with advanced bone loss and negative pulpal response in relation to left maxillary central incisor. The etiology of such isolated periodontal lesion could be attributed to palatogingival groove as there was no history of endodontic pathology or trauma. The treatment plan included endodontic treatment followed by surgical exploration, elimination, and sealing of palatogingival groove using biodentine.
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Biradicular mandibular canine: A review and report of two cases p. 159
Akanksha Malik, Parul Bansal, Vineeta Nikhil, Digvijay Singh
DOI:10.4103/endo.endo_92_17  
Mandibular canine is generally considered to have one root and one canal, but it may possess two canals and even less frequently two roots and two or three canals. This article highlights the identification and endodontic management of two cases of a rare anatomical variation in mandibular canine with two roots and two canals.
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Endodontic management of radix entomolaris: Two case reports p. 163
P Ratnakar, Prahlad A Saraf, Thimmanagowda N Patil, Smita Karan
DOI:10.4103/endo.endo_94_17  
Mandibular first molars show most of the anatomical variations not only in the number of canals but also in the presence of number of roots and their morphology. The presence of additional root either lingually or buccally in addition to two roots is one of the complex morphological variations. Diagnosis, identification, and treatment of these variations need adequate knowledge of root and root canal anatomy and configurations which can contribute to the better outcome. This case report discusses the endodontic treatment of two mandibular first molars with a radix entomolaris (RE), which are rare macrostructures. The prevalence, the external morphological variations, and internal anatomy of the RE are described.
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Multidisciplinary approach in management of large-infected periapical cyst p. 166
Saida Ziada, Chebil Mohamed, Nesrine Tebbeb, Abdelmoumen Ehsen, Bagga Sana, Aguir Najet, Bhour Lotfi
DOI:10.4103/endo.endo_95_17  
Radicular cysts are the most commonly occurring cystic lesions in the oral cavity. The management of periapical localized cysts requires conventional nonsurgical root canal therapy. However, a multidisciplinary approach involving Endodontist and Oral surgeon holds the key to treat a large radicular cyst. This article aims to report a successful multidisciplinary management of a large-infected cyst, which was associated with maxillary central incisor with open apex.
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Surgical root repair of extensive invasive cervical resorption defects involving the cementoenamel junction: Two case reports p. 171
Ritu Sharma, Anuja Swami, BV Smitha
DOI:10.4103/endo.endo_98_17  
Extensive invasive cervical resorption (ICR) defects involving the cementoenamel junction has a poor periodontal, restorative, and structural prognosis. However, some patients may insist upon surgical restorative repair of these lesions. Two such treated cases are reported with 15 and 12 month follow–up, respectively. In one case, glass ionomer cement, and in the other case, composite resin with fiber post, were used for restoration, after thorough surgical debridement. Both the patients were available for close follow-ups and maintained scrupulous oral hygiene. In both cases, the teeth had poor prognosis due to high chance of tooth fracture and possible continued periodontal breakdown with bone loss. However, at the above-stated follow-up periods, the teeth remained asymptomatic, periodontally stable, and structurally intact. This supports that a surgical restorative treatment, of the extensive ICR lesion, may result in short-term success and tooth retention.
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Endodontic management of Type 2 dens in dente (DI) with talons cusp (DE): A rare case report p. 177
L Krishna Prasad, Bhagat S Tanwar
DOI:10.4103/endo.endo_118_17  
Dens invaginatus (DI or dens in dente) and Talons cusp or dens evaginatus are relatively rare developmental anomalies which affect the shape of teeth. DI is a deep surface invagination of the crown or root which is commonly detected on routine radiographic examination. Talon cusp is an additional cusp that projects predominately from the lingual surface of anterior teeth. These anomalies most commonly may be observed in the maxillary lateral tooth. Concurrently, the coexistence of these two anomalies in a single tooth is considered extremely rare. However, still in literature, there are a few reports cases available. This article is a case report of Talons cusp with DI involving maxillary lateral incisors in a 16-year-old patient.
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Single-visit apexification with Biodentine and platelet-rich fibrin p. 181
Nitin Khanduri, Deepak Kurup
DOI:10.4103/endo.endo_122_17  
Apexification is the process of induction of calcific barrier across the open apex or the continued apical development in an immature tooth with infected necrotic pulp. The presented case was of a 19-year-old male patient with discolored and fractured upper front left tooth and open apex. Immature permanent teeth pose difficulties during endodontic treatment because of the wide-open root apex and thin dentin walls. This article describes single-visit apexification using Biodentine, a new calcium silicate-based material as an apical barrier along with platelet-rich fibrin as internal matrix.
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Endodontic management of six canals in mandibular first molar p. 184
Parul Mour Agarwal, Sonali Taneja
DOI:10.4103/endo.endo_99_17  
Success in root canal treatment is achieved after meticulous mechanical and chemical cleansing of the pulp space succeeded by complete obturation of the root canal in its entire dimension. Pulp tissue remnants present in missed canals and spaces may compromise the treatment outcome. Therefore, it is important to diagnose the peculiar anatomy of such teeth during root canal treatment. This case report describes the diagnosis and successful endodontic management of an unusual mandibular first molar with three mesial and three distal canals.
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CASE SERIES Top

Usefulness of cone beam computed tomography in perplexing endodontic cases p. 187
Amandeep Kaur, Ajay Logani
DOI:10.4103/endo.endo_104_17  
Endodontic therapy entails maneuvers in a complex anatomy. Intraoral periapical (IOPA) X-rays aid in providing information regarding the root canal system and periapical area. It offers clinicians with a high-resolution, low radiation, cost-effective imaging modality, and continues to be the method of choice for endodontic imaging. However, it has an inherent limitation of being a two-dimensional (2D) representation of a three-dimensional (3D) object. This can sometimes lead to misinterpretation, especially in cases where there is a diagnostic dilemma. Cone beam computed tomography (CBCT) has been specifically developed for the maxillofacial imaging. It has been extensively used for imaging during pre-, intra-, and post-endodontic therapy. It provides additional information when the sign/symptoms and the 2D radiographic picture do not collaborate. This paper highlights three interesting cases in which IOPA X-rays failed to divulge accurate information. CBCT aided the clinician to arrive at a correct diagnosis and treatment planning, thereby protecting the patient from further unnecessary iatrogenic complications.
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