This study evaluated the effect of 17% EDTA and 7% maleic acid (MA) irrigation on microleakage of mineral trioxide aggregate (MTA) and Biodentine® (BD) used as root-end filling materials. 60 root samples were instrumented, resected, and filled with MTA or BD after irrigation with 17% EDTA, 7% MA, or saline (control). Microleakage was evaluated at 24 hours, 7 days, and 14 days. 7% MA removed smear layer better than 17% EDTA and resulted in less microleakage for both materials, especially BD. MTA showed better adaptation than BD when used with 17% EDTA. Overall, 7%

1. PRESENTED BY
Palani Selvi . K
PG - student
Dept. of Conservative Dentistry &
Endodontics
JOURNAL CLUB

2. BIOMECHANICAL
PREPARATION
3 DIMENSIONAL
OBTURATION
DISINFECTION
OF THE CANAL
SYSTEM
INTRODUCTION

3. Washingtonstudy
Apical Percolation Operative Errors Case Selection
63.5% 14.5% 22%
Incomplete obturation Root perforation Root resorption
Unfilled canal Gross overfilling Periodontal problem
Broken instruments

ENDODONTIC RETREATMENT

4. CONSIDERATIONS &CRITERIA FORCASESELECTION
IN ENDODONTIC RETREATMENT

5. • To eliminate diseased Tissues and obtain an apical seal to
prevent the ingress of Residual irritants into the
periradicular area.

6. INDICATIONS
FOR
SURGICAL
RETREATMENT
Irretrievable root canal
fillings
Calcified canals
Procedural errors
- Instrument
fragmentation
- Non negotiable ledging
- Over instrumentation &
apical fracture
Presence of dowels
Anatomic variations
Apical cyst
• Need for Biopsy
• Large inaccessible perforations
• Need to establish drainage
• Conventional treatment and
retreatment failed
• Conventional retreatment
impractical due to irretrievable
prosthetic restoration

9. ORGANIC
ACIDS
 The combination of EDTA and NaOCl is most commonly used for
the smear layer removal.
 17% EDTA is not efficient in removal of smear layer especially in
the apical third of the root canal system.
 It has also been reported to be cytotoxic.
7% maleic acid (MA) is a mild organic acid which has
shown to remove the smear layer significantly better
than 17% EDTA in apical third of root canal system
when used as a root canal irrigant.

10. RETRO
PREPARATION

11. ROOT END
FILLING
MATERIALS
Gartner and
Dom

12. ROOT END
FILLING
MATERIALS

13. • MTA prevents microleakage, is biocompatible, promotes
regeneration of the original tissues when place in contact
with periradicular tissues.
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999
MTA has been investigated as one of the best root end filling material in
endodontics.
• MTA provides a better seal than amalgam, IRM, and EBA
cement when used as a root-end filling material
Tang HM, Torabinejad M, Kettering JD. Leakage evaluation of root end filling materials using
endotoxin. J Endod 2002

14. Laurent et al. evaluated the genotoxicity, cytotoxicity,
and effects on target cells specific functions of BD.
They concluded that BD is a biocompatible material.
Induction of specific cell Responses to a Ca(3) SiO(5)-based posterior restorative
material. Dent Mater 2008;

17. Aim
 To evaluate the effect of 17% ethylenediaminetetraacetic acid
(EDTA) and 7% maleic acid (MA) irrigation on microleakage of
mineral trioxide aggregate (MTA) and Biodentine® (BD) when
used as a root-end filling material.

19. Sixty human anterior teeth were
decoronated and subjected to root
canal instrumentation.
3 mm of apical root portion was resected, and
root-end cavities were prepared using
ultrasonic tips. Teeth were then randomly
divided into two groups (n = 30).
Group 1 - Root End Cavity To
Be Filled With MTA;
Group 2 - Root End Cavity To
Be Filled With BD.
Each group was further divided into three
subgroups A, B, and C based on irrigation
regimen. About 5 mL of all irrigating
solutions were used for 1 min.
Group A - 17% EDTA
Group B - 7% MA
Group C - 0.9% saline.
After final irrigation, root-end
cavities were filled with
respective root end filling
material.
Specimens were then subjected to
microleakage analysis at 24 h, 7
days and 14 days using
GLUCOSE FILTRATION
TECHNIQUE.
SMEAR LAYER EVALUATION
6 central incisors were subjected to root
canal instrumentation and irrigation with
7% MA and 17% EDTA.
Then, these samples were analyzed
under the standard error of the
mean data was analyzed using
one-way ANOVA, Bonferroni test,
Mann–Whitney U-test and
Kruskal–Wallis test.

20. Sixty human
maxillary central
incisors with relative
similar extracted for
periodontal reasons
were selected.
Inclusion
criteria -
caries free, single
root canal, and
completely formed
apex
Exclusion
criteria -
open apex or
incompletely formed
apex, root
resorptions, cracks,
and endodontic
restorations).
Teeth were thoroughly
cleaned using
ultrasonics and stored
in 0.2% of sodium
azide at 4°C until the
experiment.
The crowns of all
teeth were
decoronated using a
diamond disc at the
CEJ so that the
coronal surface was
perpendicular to the
long axis of the root
and the remaining root
length was adjusted to
15 mm
SPECIMEN PREPARATION

21. ROOT CANAL
PREPARATION
The working length was
established by inserting a no. 10 K
file into each root canal until it
was just visible at apical foramen
(observed by magnifying loupes)
and by subtracting 1 mm from this
point.
The canal was enlarged
to size F3 using
ROTARY PROTAPER
FILES.
About 5 mL of 2.5%
NaOCl was used as
irrigant for 1 min
between each instrument
change.
Final irrigation was done
with 5 mL of distilled
water for 1 min, and the
canals were then dried
using paper points.

22. APICAL ROOT
RESECTIONS
Done by removing
3 mm of the apex
at a 90° angle to
the long axis of the
root with a
diamond bur
Under water coolant at
a high-speed. 3-mm
deep root-end cavities
were prepared using
the ultrasonic tip
(JT-4B size - 0.3 mm)
at a low power setting
using water coolant.
Cutting with the
ultrasonic tips
were performed
using back and
forth motion with
the tip enveloped
in water spray.

23. N= 60
GROUP C
0.9% SALINE
n=10
GROUP B
7% MALEIC
ACID
n=-10
GROUPA
17% EDTA
n=10
GROUP 2
BIODENTINE
(n=30)
GROUP 1
MTA (n=30)

24. • MTA and BD were mixed according to the manufacturer’s
instructions, and the root-end cavities were filled with the
respective material.
• A customized endodontic hand plugger was placed in the
root canal 3 mm short of root apex, which formed a coronal
matrix before filling with root-end material.
• Excess material from root-end cavity was removed with
wet cotton pellets, and the roots were kept in 100%
humidity at 37°C for 48 h.
• About 5 mL of all the irrigating solutions were used for 1 min
using a disposable syringe and 28 gauge needle.
• Final irrigation in all the groups was performed with 5 mL of
distilled water for 1 min.
• After final irrigation, root-end cavities were dried with paper
points.

25.  The coronal part of each root was glued to one end of a modified plastic dropper (in which both ends
were cut to accommodate specimen and the glass tube) using cyanoacrylate.
 Through other end, a glass tube of 15 cm in length was connected. A seal was obtained using
cyanoacrylate glue and sticky wax.
 The assembly was then placed in a sterile 5 ml glass bottle covered with paraffin sheet and sealed
with sticky wax.
 The tracer used was a 1 mol/L glucose solution (pH = 7.0), whose density was 1.09 × 103 g/L and
viscosity 1.18 × 10–3 Pas at 37°C.
 About 5 ml of glucose solution, containing 0.2% sodium azide (NaN3), was injected into the
modified dropper from glass tube until the top of the solution was 14 cm higher than the top of
specimen, which created a hydrostatic pressure of 1.5 kPa (15 cm H2O).
 The glass bottle contained 1 ml of 0.2% aqueous solution of NaN3, in which glucose that leaked
through the restored canal was collected.
GLUCOSE PENETRATION MODEL Evaluation of microleakage

26.  A 100-μL aliquot of the solution was drawn from the glass beaker using a micropipette
after 24 h, 7 days and 14 days.
 After drawing the sample, 100 μL of fresh 0.2% NaN3 was added to glass bottle reservoir
to maintain a constant volume of 1 mL.
 If there was any decrease in the volume in the control bottle due to evaporation, a
corresponding amount of sterile deionized water was added to the glass beaker.
 The sample was then analyzed with a glucose kit in a colorimeter at 500 nm wavelength.
 Two blinded independent evaluators conducted the colorimetric determination of glucose
concentration.
 The results of leakage in all groups were calculated as mmol/L from the respective optical
density observed in colorimeter.
Measurement of microleakage

27. Scanning electron microscopic analysis
Six human single-rooted maxillary
central incisors were selected and
prepared as mentioned previously.
Once the samples were prepared, they
were divided into two groups
(n = 3)
The apical segment were then split
into two halves using a straight
chisel and stored in deionized water
at 37°C
until standard error of the mean
analysis
Group 1- irrigated with 5 mL
of 17% EDTA solution for 1
min
Group 2 - irrigated with 5
mL of 7% MA solution for 1
min.
Finally, all the samples
were irrigated with 5 mL
of distilled water for 1
min.
The apical third of all the
samples were then
horizontally cut
Longitudinal grooves were prepared
on
the buccal and lingual surfaces of
each of the apical segment using a
diamond disc at a slow speed
without penetrating the
root canal
The specimens were dehydrated
using ascending grades of ethyl
alcohol and were then mounted on
metallic stubs, gold sputtered using
an ion sputter
Examined under scanning
electron microscope for
presence or absence of smear
layer.
Photomicrographs were taken
to observe the surface
morphology at ×1500
magnification and 10 KV

28. The images were
scored according to
the criteria given by
Torabinejad et al.

29. Stereomicroscopic
analysis
 Five representative samples from each group:
(a) 17% EDTA and MTA;
(b) 7% MA and MTA;
(c) 17% EDTA and BD;
(d) 7% MA and BD were selected
 Sectioned horizontally using diamond disc under water spray.
 The samples were then observed under stereomicroscope at ×10 magnification
for the marginal adaptation of root-end filling material to the root canal walls.

30. Statistical
analysis
 Statistical analysis for inter-group comparison was done using
one-way ANOVA and Bonferroni test, and that of intra-group
comparison was done using Mann–Whitney U-test and Kruskal–
Wallis test.
 In the smear layer evaluation, the inter-examiner’s reliability was
verified using the Kappa test.
 The level of statistical significance was set at P < 0.05.

31. MICROLEAKAGE
 In MTA group, saline (control) showed maximum leakage at all the time
intervals (P < 0.001) as compared to that of 17% EDTA and 7% MA.
There was no significant difference between 17% EDTA and 7% MA.
Bar graph demonstrating comparison of microleakage using different
irrigants in mineral trioxide aggregate group

32.  In BD group, saline (control group) showed the maximum leakage at all the time intervals (P <
0.001) as compared to that of 17% EDTA and 7% MA groups.
 There was a significant difference between 17% EDTA and 7% MA group at 48 h (P = 0.008),
7 days (P < 0.001) and 14 days (P = 0.002), with 17% EDTA demonstrating higher leakage
MICROLEAKAGE
Bar graph demonstrating comparison of microleakage using different irrigants in
Biodentine group

33. Bar graph demonstrating
comparison of microleakage
between mineral trioxide
aggregate and Biodentine at 48 h
 On intercomparison at different time, at 48 h in 17% EDTA group,
BD showed significant higher leakage than that of MTA (P <
0.001).
 However, in 7% MA (P = 0.172) and saline group (P = 0.65) there
were no significant difference between BD and MTA.

34. Bar diagram showing comparison of microleakage between
mineral trioxide aggregate and Biodentine at 7 and 14 days
At 7 and 14 days, 17% EDTA
(P< 0.001), 7% MA(P < 0.001),
and saline (P = 0.034) groups
demonstrated significant more
leakage in BD as
compared to MTAgroup

35. SMEAR
LAYER
EVALUATION
 Kappa test results for smear layer evaluation showed that there was no
statistical significant difference between the two examiners for both 7% MA
and 17% EDTA groups.
 About 7% MA was able to remove the smear layer better than 17% EDTA.
 There was no smear layer on root canal walls, and the tubules were open in
7% MA group.
 In 17% EDTA-treated specimens, tubules were partially obliterated with
smear layer.

36. STEREOMICROSCOPIC
EVALUATION
 Poor marginal adaptation of BD to root canal walls treated with
17% EDTA as compared to 7% MA.
 The adaptation of MTA to the root canal walls treated with 17%
EDTA and 7% MA was found to be good.
Stereomicroscope
photograph demonstrating
adaptation of root end filling
material to root-end cavity.
(a) 17% EDTA and MTA
(b) 7% MA and MTA
(c) 17% EDTA and BD
(d) 7% MA and Biodentine
A B
C D

37. • In this study, all irrigation groups both in MTA
and BD showed microleakage over time, but saline
demonstrated significant higher leakage than that
of 17% EDTA and 7% MA.
• No significant difference in the microleakage between 17%
EDTA and 7% MA group
• MTA was used as root-end filling material. This could be
attributed to the good adaptation of MTA to root canal
walls as reported by various studies.
Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties
of a new root-end filling material. J Endod 1995

38. • 17% EDTA and 7% MA, with 17% EDTA group
showing more leakage.
• Improper marginal adaptation of BD to root canal
walls treated with 17% EDTA.
• It has been reported that the adhesion of BD to the
root canal walls is most likely through the tag like
structures formed within the dentinal tubules
leading to micromechanical retention
Atmeh AR, Chong EZ, Festy F, Watson TF. Dentin-cement
interfacial interaction: Calcium silicates and polyalkenoates. J Dent Res2012
BIODENTINE
• Calcium and Silicon ion uptake into dentin leading to the
formation of tag like structures was higher in BD than
MTA
Han and Okiji
• Dentin in apical third of root canal system is sclerosed.
• In the presents tudy, in BD group, there may not have
been complete tag formation inside the apical sclerosed
root canal dentin which would have led to its
improper marginal adaptation.
Vasiliadis L, Darling AI, Levers BG. The amount and distribution of sclerotic human
root dentine. Arch Oral Biol 1983
MTA and IRM were significantly superior
to BD in terms of marginal adaptation
when used as root-end filling material.
Soundappan et al. J Dent 2014

39. Within the BD group, the 17% EDTA irrigation group showed more microleakage as
compared to that of the 7% MA group.
• Effective removal of smear layer in the apical third
of the root canal dentin by 7% MA when compared
to that of 17% EDTA ( SEM )
Present study
• Smear layer removal ability of 7% MA is better than 17%
EDTA, especially in the apical third of root canal system.
Ballal et al. J Endod 2009
• Postobturation apical seal following irrigation with 7% MA or 17% EDTA evaluated using
dye leakage under vacuum method was better with 7% MA than 17% EDTA.
• The authors attributed the minimal leakage with 7% MA irrigation due to its efficient smear
layer removal in the apical third.
Ballal et al. J Endod 2009

41. Hence, in the present study ultrasonic (US) retro tip was preferred to prepare
the root end cavity as US retro tips have many advantages over traditional
round bur. US retro tips produced cleaner, well-centered, and more conservative
root-end cavities.

42. In this study ,7% MA was used because it has been reported that, MA, when used at a
higher concentration than 7%, caused damage to the intertubular dentin
Time-dependent effects of EDTA on dentin structures. J.Endod 2002;
The irrigation time in the present study was set to 1 min because irrigation
with 17% EDTA for more than 1 min has shown to cause excessive
peritubular and intertubular dentinal erosion.
Time-dependent effects of EDTA on dentin structures. J.Endod 2002;

43. METHODS TO
EVALUATE SEALING
ABILITY OFROOTEND
FILLINGS
 Dye leakage
 Fluid filtration
 Bacterial penetration
 Radiolabelled isotopes
 Electromechanical tests
DYE PENETRATION TEST
• Advantages - simplicity and cost
effectiveness.
• Disadvantages - can lead to observers
bias, cannot be reproducible and
comparable.
Bacterial penetration
• Advantage- more relevant
• Disadvantage- maintaining asepsis
is critical
RADIOISOTOPE LABELING
AND ELECTROCHEMICAL
METHODS
• Radiation hazard and
require sophisticated materials
• Less frequently used
FLUID FILTRATION
ADVANTAGES- sensitive, nondestructive and reproducible
DISADVANTAGES- lack of standardization of the measurement
time, applied pressure, diameter of the tube containing the bubble,
and the length of the bubble

44. A new quantitative method using glucose for
analysis of endodontic leakage
Xu et al- Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;
• If the bacteria enter the root canal system from oral cavity, the bacteria
that
might have survived after root canal preparation and obturation could
multiply
and potentially lead to periapical inflammation.
• Hence, the use of glucose as a tracer in endodontic microleakage studies
would be more clinically relevant than using other tracers
ADVANTAGES
• Quantitative
technique
• Sensitive
• Nondestructive
• Clinically relevant.
GLUCOSE AS A TRACER
• small molecular size
• known nutrient for the
bacteria

45. • Compared glucose penetration and fluid filtration method for measuring leakage and
• Glucose penetration technique was more sensitive in detecting leakage along root fillings.
Shemesh et al.

46. Time Periods
For Evaluation
Of
Microleakage
• Leakage was evaluated at 48 h followed by 7days and 14 days
• They reported that microbial leakage was reduced significantly
as setting time increased from 4 h to 2 days or 1 week.
• There was no significant reduction in leakage when the setting
time was increased from 2 days to 1 week.
The maximum period for the assessment of leakage was taken as 14 days.
In accordance with Chogle et al
Intracanal assessment of mineral trioxide aggregate setting and sealing properties.
Gen Dent 2007

47. • Within the limitations of this study, it can be
concluded that MTA had a better sealing ability as
compared to that of BD when root-end cavities were
irrigated with 7% MA.