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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 46-54

Effect of different irrigation solutions and techniques on push-out bond strength of resin-based sealer


1 Demonstrator, Department of Endodontic, Faculty of Dentistry, Faros University, Alexandria, Egypt
2 Department of Endodontic, Faculty of Dentist, Tanta University, Tanta, Egypt

Date of Submission19-Dec-2018
Date of Acceptance10-Feb-2019
Date of Web Publication13-Jun-2019

Correspondence Address:
Ahmed E Elmessiry
Ministry of Health, Ahmed Barakat Street, Sidi-Beshr, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_45_18

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  Abstract 

Aim
To evaluate the effect of irrigation solutions [sodium hypochlorite (NaOCl), chlorhexidine (CHX), and normal physiological saline] and different irrigation techniques (conventional needle, EndoVac, and CanalBrush) on push-out bond strength of AH Plus resin-based sealer.
Materials and methods
Ninety mandibular freshly extracted premolars were selected and divided into three groups according to the irrigation solutions; group I: 5.25% NaOCl, group II: 2% CHX, group III: normal physiological saline solution. Then each group was subdivided into three subgroups according to the irrigation techniques; subgroup A: 27 G side beveled needle, subgroup B: EndoVac irrigating system, subgroup C: medium-sized CanalBrush (30/0.04). Root canals of all groups were prepared using ProTaper Universal Ni-Ti rotary system up to file F4 (40/0.06) and filled by single cone technique using AH Plus sealer. 2 mm thick horizontal sections from the coronal, middle and apical thirds of each root were sliced for the push-out bond strength measurement and tested using universal testing machine. Data were analyzed using one-way analysis of variance in a level of significance (P ≤ 0.05).
Results
The highest mean push-out bond strength values were recorded for EndoVac system followed by CanalBrush and Needle in all groups and at all root canal levels. In comparison of irrigation solutions in needle subgroup; the highest values were recorded for CHX and least for NaOCl at coronal and middle root levels. While in the apical section, the highest and least mean push-out bond strength values were recorded for CHX and saline respectively. Regarding EndoVac and CanalBrush; the highest push-out bond strength values were recorded for CHX followed by saline and NaOCl at all root canal levels.
Conclusions
Whenever root canal obturation using AH Plus sealer, it is preferred to use 2% CHX solution throughout and after instrumentation via EndoVac system for improved bond strength. The coronal sections showed higher bond strength than middle and apical sections.

Keywords: AH Plus, bond strength, CanalBrush, conventional needle, EndoVac


How to cite this article:
Elmessiry AE, Darrag AM, Ghoneim WM. Effect of different irrigation solutions and techniques on push-out bond strength of resin-based sealer. Tanta Dent J 2019;16:46-54

How to cite this URL:
Elmessiry AE, Darrag AM, Ghoneim WM. Effect of different irrigation solutions and techniques on push-out bond strength of resin-based sealer. Tanta Dent J [serial online] 2019 [cited 2021 Dec 7];16:46-54. Available from: http://www.tmj.eg.net/text.asp?2019/16/1/46/260281


  Introduction Top


An ideal root canal sealer should adhere firmly to both dentin and core filling materials[1],[2]. AH Plus is an epoxy-resin-based sealer that showed better long-term sealing ability compared to conventional sealers due to its reported expansion over time. It is biocompatible, radiopaque, has a short-setting time, low solubility, and good flow characteristics[3].

Factors affecting the adhesion of sealers to dentin include nature of root dentin in a specific tooth or even in different sites of the same root[4],[5], smear layer, chemical composition of irrigants and sealers, and their interaction with dentin[6]. Dentin surface treatment with different irrigation solutions causes shift in the chemical and structural architecture of the human dentin, which may change its permeability and solubility characteristics[7] and hence, affecting the adhesion of filling materials to dentin surfaces[8].

Sodium hypochlorite (NaOCl) is the most widely used irrigating solution in endodontics. It has a unique capacity to dissolve necrotic tissue and organic components of the smear layer. Chlorhexidine (CHX) had been suggested as an effective irrigating solution as it has a bactericidal effect due to its ability to precipitate and coagulate bacterial intracellular constituents[9].

The effectiveness of irrigants is associated with their direct association with the entire canal wall. However, this might not be achieved with conventional needle irrigation because of the complex nature of root canal anatomy[10]. Different irrigation activation techniques have been proposed to improve the efficacy of irrigation solutions within the root canal system. These techniques consist of activation with gutta-percha cones, lasers, brushes, the negative pressure irrigation technique, and sonic and ultrasonic devices[11].

EndoVac is a negative pressure irrigation system that was invented by John Schoeffel. The system generates negative pressure that draws irrigation solution apically via suction from the high volume evacuation of the dental unit. This system is composed of a master delivery tip (MDT), macrocannula, and microcannula[12]. CanalBrush is an endodontic microbrush molded entirely from polypropylene and can be used manually with a rotary action. However, it is more efficacious when attached to a contraangle handpiece running at 600 rpm[13].

Bond strength testing had become a popular method for determining the effectiveness of adhesion between endodontic materials and tooth structure[14]. Various tests are used to measure bond strength as tensile, micro-tensile, shear, micro-shear, and push-out strength testing. The push-out test is preferred to measure the bond strength as fracture occurs parallel to the dentine-bonding interface, making it a true shear test for parallel-sided samples[15],[16],[17].

To clean the root canal system, it is necessary to depend on both irrigating solutions and activation systems. However, both may have effect on adhesion of root canal sealers. Therefore, this study was made to evaluate the effect of different irrigating solutions and techniques on bond strength of AH Plus resin-based sealer to root canal dentin.


  Materials and Methods Top


Selection and preparation of samples

Ninety recently extracted, nearly straight, mature human lower premolars with single root canals were collected from the Outpatient Clinic of Oral Surgery Department, Faculty of Dentistry, Tanta University. The purpose of the present study was explained to the patients and informed consents were obtained to use their extracted teeth on the research according to the guidelines on human research published by the Research Ethics Committee at Faculty of Dentistry, Tanta University. Teeth were extracted mainly due to periodontal problems or orthodontic reasons from patients with age range 20–40 years old. All collected teeth were cleaned from soft tissues and calculus and stored in isotonic normal saline solution at room temperature to be used within 2 or 3 months after extractions[18].

Stainless steel k-file #15 (Dentsply Maillefer, Ballaigues, Switzerland) was introduced into each root canal until its tip was just visualized at the apical foramen to ensure the patency of the canal. Teeth fitting initial apical file #20 were selected to standardize the internal canal diameter. The working length (WL) was determined by measuring the length of k-file #15 from buccal cusp tip to apical foramen and subtracting 1 mm from that length[19].

Grouping of samples

Teeth were randomly divided equally into three groups according to the irrigation solutions used. Group I: 5.25% NaOCl (Clorox Co., 10th of Ramadan, Egypt), group II: 2% CHX (GLUCO-CHeX 2%, Cerkamed, Poland), group III: saline solution. Then each group was subdivided into three equal subgroups according to the irrigation techniques used: subgroup A: 27-G side beveled traditional needle (Jiangsu Jichun Medical Devices Co., China), subgroup B: EndoVac irrigation system (Discus Dental, Culver City, California, USA), subgroup C: medium-sized CanalBrush (Roeko Coltene/Whaledent, Germany).

Root canal instrumentation

In all samples, glide path shaping was achieved with rotary Pathfile (Dentsply Maillefer) instrument #3 (0.19 mm at the tip, 0.02 taper). Root canal preparation was performed by crown down technique using ProTaper (Dentsply Maillefer) Universal nickel titanium rotary system driven by x-smart endomotor (Dentsply Maillefer) with speed 300 rpm and torque 1.5–3 Nm up to F4 file (40/0.06).

Subgroup IA: root canal irrigation with 5.25% NaOCl solution using traditional needle. The root canal was irrigated using 27-G needle adjusted to 2 mm less than the WL with 1 ml of 5.25% NaOCl after each instrument. After completion of instrumentation, the canal received 3 ml of 5.25% NaOCl with the needle moving from 2 to 4 mm from WL in a constant motion for 30 s, irrigant was left undisturbed for 60 s, then irrigated for another 30 s with 3 ml of NaOCl solution and left undisturbed for 60 s[20].

Subgroup IB: root canal irrigation with 5.25% NaOCl solution using EndoVac system; according to the manufacturer's instructions, 1 ml of 5.25% NaOCl solution was delivered into the pulp chamber after each instrument by using MDT attached to the high suction and placed above the access opening to constantly deliver and evacuate any excess irrigant.

After the master apical file reached the WL, the canal was macroirrigated with 3 ml of 5.25% NaOCl using MDT while the macrocannula was constantly moved up and down for 30 s. Then, the canal full of irrigant was left undisturbed for 60 s. Then the cycle of microirrigation was initiated during which the pulp chamber was kept full of irrigant using MDT delivering 3 ml of 5.25% NaOCl solution while the microcannula was placed at the WL for 6 s, then positioned 2 mm short from the WL for 6 s. This up–down motion continued for 30 s. Then microcannula was withdrawn from the canal in the presence of sufficient irrigant for 60 s. Then, microcannula was reinserted at WL without replenishment to remove the remaining fluid[10].

Subgroup IC: root canal irrigation with 5.25% NaOCl solution using CanalBrush; root canal preparation and irrigation were performed by the same manner as in subgroup IA. Additionally, according to manufacturer's instructions, one medium-sized CanalBrush (30/0.04) attached to contraangle low-speed handpiece (NSK Ltd, Tokyo, Japan) was used for each canal and rotated at 300 rpm to WL for 30 s with up and down movements against root canal walls while canal was full of irrigant[21], then canal was finally irrigated with 3 ml 5.25% NaOCl solution for 30 s and left undisturbed for 60 s.

In subgroups IIA, IIB, and IIC: root canal preparation and irrigation were performed by the same manner as in subgroups IA, IB, and IC, respectively, but using 2% CHX instead of 5.25% NaOCl.

In subgroups IIIA, IIIB, and IIIC: root canal preparation and irrigation were performed similarly as in subgroups IA, IB, and IC, respectively, using saline solution instead of 5.25% NaOCl, as control groups.

Root canal obturation

After completion of preparation, all canals were dried with paper points (Dentsply Maillefer) size F4. Then filled with single cone technique with ProTaper Universal gutta-percha1 size F4 and AH Plus sealer (Dentsply Maillefer).

Preparation of roots for push-out bond strength testing

Crown of each tooth was removed by diamond disc (Dica, Dendia, USA) mounted to low-speed handpiece (NSK Ltd) under copious amount of water leaving root length 15 ± 1 mm[9]. Roots were vertically positioned and centered in cold cured colored acrylic resin blocks[22]. Each root block was sectioned horizontally using a circular diamond disk (Komet; Brasseler, Lemgo, Germany) at low speed with constant fresh cooling water. Sectioning was carried out in horizontal plane perpendicular to the long axis of the root canal into three equal sections (5 mm thickness) where the most apical 3 mm was discarded and the remaining 2 mm apically represented the apical section, then 2 mm thick slice was taken from the middle of the remaining sections to represent middle and coronal root canal thirds[23],[24].

Each specimen was carefully positioned on a custom made loading fixture and subjected to a compressive loading of 5 kN at a cross-head speed of 1 mm/min by three plungers (1, 0.5, and 0.35 mm) for coronal, middle, and apical sections, respectively, attached by a chuck to the universal testing machine (Instron Corp., Canton, Massachusetts, USA). Load was applied in an apico-coronal direction and failure was manifested by the appearance of a sudden drop along the load/time curve recorded by the testing machine and extrusion or debonding of obturation material from the root slice.

The push-out bond strength was calculated using the following formula:

Push-out bond strength in mega Pascals (MPa)=maximum load in Newton (N)/adhesion area (mm2).

The adhesion area was calculated by[25]:



where π=3.14, r1 is the coronal radius, r2 is the apical radius, and h is thickness of slice.


  Results Top


Mean ± SD of push-out bond strength values of three irrigation techniques at each root section for NaOCl, CHX, and saline are shown in [Table 1],[Table 2],[Table 3], respectively. In all groups, the highest mean push-out bond strength values were recorded for EndoVac followed by CanalBrush and needle at all root canal levels. Analysis of variance (ANOVA) test revealed statistical significant difference among tested irrigation techniques at all root canal levels. Tukey's test recorded statistical significant difference between EndoVac versus both subgroups needle and CanalBrush at all root canal levels (P < 0.001). Needle was statistically significant different than CanalBrush at all root canal levels except at apical third of NaOCl and CHX, coronal and apical thirds of saline.
Table 1 Mean±SD of push-out bond strength values of three irrigation techniques at each root section for sodium hypochlorite irrigation solution group

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Table 2 Mean±SD of push-out bond strength values of three irrigation techniques at each root section for chlorhexidine irrigation solution group

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Table 3 Mean±SD of push-out bond strength values of three irrigation techniques at each root section for saline irrigation solution group

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Comparison of irrigation solutions using needle at both coronal and middle sections [Table 4], the highest values were recorded for CHX, while NaOCl recorded the least mean push-out bond strength values. While in the apical section, the least mean push-out bond strength values were recorded for saline. One-way ANOVA demonstrated no statistical significant differences among irrigation solutions at coronal and middle sections (P > 0.05). However there was a statistical significant difference at the apical section. Tukey's test showed that, the statistical significant differences were between all tested solutions (P ≤ 0.05) except between NaOCl and saline.
Table 4 Mean±SD of push-out bond strength values of three irrigation solutions at different root canal levels for traditional needle subgroup

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Regarding EndoVac system, at all root canal levels, the highest mean push-out bond strength value was recorded for CHX followed by saline and NaOCl with statistical significant differences among groups using One-way ANOVA And Tukey's test recorded statistical significant differences between all tested groups (P ≤ 0.05) except between NaOCl and saline at all root sections [Table 5].
Table 5 Mean±SD of push-out bond strength values of three irrigation solutions at different root canal levels for EndoVac system subgroup

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Considering CanalBrush, all root canal levels showed similar results of a descending rank of mean values of push-out bond strength from groups CHX, saline, and NaOCl as shown in [Table 6]. One-way ANOVA revealed statistical significant differences among irrigation solutions in coronal and apical sections. Tukey's test recorded statistical significant differences between NaOCl versus CHX for apical section and CHX versus saline for coronal and apical sections.
Table 6 Mean±SD of push-out bond strength values of three irrigation solutions at different root canal levels for CanalBrush subgroup

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Comparison of push-out bond strengths between the three sections at each technique and each irrigation solution showed that coronal sections were associated by the highest mean of push-out bond strength values followed by middle and apical sections.

One-way ANOVA revealed statistical significant differences among root sections in all tested groups and subgroups. Where Tukey's test recorded statistical significant differences between all root canal levels (P ≤ 0.05) for all groups and subgroups, except between middle and apical sections in root canals irrigated with CHX solution using EndoVac system (P = 0.184).


  Discussion Top


The main objective of root canal obturation is to prevent leakage from oral cavity and periradicular tissues into root canal system[26]. AH Plus sealer was tested in this study as it has been widely used due to its acceptable physical properties, reduced solubility, apical sealability, microretention to root dentin, adequate biological performance[4], and it recorded high bond strength to root dentin[27].

Different irrigation solutions were used in the current study to examine their effect on push-out bond strength of AH Plus resin-based sealer. NaOCl is the most commonly used irrigant because it is a well-known antimicrobial, tissue-dissolving, and lubricating agent[28]. CHX has been used during endodontic therapy because of its lower toxicity, it is also an effective antimicrobial agent with substantivity[29],[30],[31].

Previous studies have shown that needle irrigation methods did not effectively debride the entire root canal apically. So, different irrigation activation techniques have been proposed to improve the efficacy of irrigation solutions within the root canal system which improve sealer penetration and retention of the filling material[32].

EndoVac is a novel irrigation system based on the negative apical pressure whereby the irrigant placed in the pulp chamber is sucked down the root canal and back up again through a thin needle with special design[10]. While CanalBrush is a machine-assisted agitation system used in a rotary action to remove debris from the canals[33] and enhances the flushing action of irrigants[34],[35]. Therefore, CanalBrush and EndoVac were used as irrigation activation techniques in this study.

Using extracted human teeth in the current study to simulate the clinical situations and several attempts have been made to ensure standardization of the experimental groups in the current study as single rooted teeth with similar apical diameter fitting initial file (size # 20) and rounded canal cross-section were selected.

The mechanical preparation in this study was performed in a crown down manner as it enhances irrigation penetration and maintains a reservoir of irrigant coronally[36]. ProTaper Universal rotary files were used up to F4 (40/0.06) which is adequate to accommodate a sufficient irrigant volume in both positive and negative pressure systems[37],[38]. Moreover, it allowed the microcannula with ISO size 32 of the EndoVac irrigation system to be used at the WL[10], and advance the medium-sized CanalBrush into the canal easily as recommended by Garip et al.[13] and Narmatha and Sophia[39].

A push-out bond strength test is one of the methods that measures the effectiveness of an endodontic obturation material[40]. This test design made it easy to align samples for testing and is less sensitive to small variations among specimens and to the variations in stress distribution during load application, allowed root canal sealers to be evaluated even when bond strengths are low[41] and fracture occurs parallel to the dentine-bonding interface[15],[16],[17] so it was used in this study.

Results showed that the best push-out bond strength values were recorded for EndoVac subgroup followed by CanalBrush and conventional needle subgroups for all groups at all root canal levels. These findings may be due to that EndoVac has proved to be more effective for debridement and cleaning of root canal dentinal walls as it allowed the delivery of the irrigant to the WL causing the irrigant to reflux and displacing the debris coronally[11],[42]. This was supported by Mendonça et al.[43]who revealed that EndoVac irrigation system resulted in significantly better smear layer and debris removal compared with conventional needle and CanalBrush and consequently a significantly higher percentage of sealer penetration than did conventional needle irrigation[44].

These results were agreed with results of a study conducted by Prasad et al.[24]who stated that bond strength was improved by using EndoVac than CanalBrush and conventional needle. Additionally, this was supported by other researches who reported that EndoVac system proved superiority in debris and smear layer debridement of the root canal system as compared to conventional needle irrigation[10],[45],[46],[47],[48],[49],[50]. No further studies disagree with these results.

The current findings showed that CanalBrush subgroup resulted in significantly better push-out bond strength values than conventional needle subgroup at coronal and middle root canal levels which was in agreement with Hegde and Arora[51] and Dumani et al.[52]. This is may be attributed to better canal debridement by CanalBrush as shown in a study by Rödig et al.[35] who reported that smear layer removal in the coronal part of canals was more effective with CanalBrush compared with conventional needle irrigation which improves bonding of AH Plus sealer. These were supported by several authors[13],[39],[53],[54],[55],[56] who proved that CanalBrush can remove smear layer more efficiently than conventional needle.

In contrast Protogerou et al.[57] and Mendonça et al.[43]concluded that the utilization of the CanalBrush did not contribute to produce cleaner dentinal walls. This controversy may be due to smaller canal preparation advocated in those studies up to file F3 (30/0.6) combined with the medium-sized CanalBrush (ISO: 30) which may led to a massive bristle deformation due to squeezing inside the proportionally narrow root canal and intense friction of brush against the walls.

On the other hand, there were no statistical significant differences between conventional needle and CanalBrush at apical section for all irrigation solutions, which may be due to little bristles' deformation of CanalBrush that slightly increase debris in the apical third which may adversely affect the bond strength[55],[58]. Also, no significant difference was found between them coronally for saline group due to larger distance between canal walls and CanalBrush, so both saline and CanalBrush failed to remove smear layer adhered to canal walls. While at middle canal level the difference was significant as the canal walls became closer to the brush which allows better mechanical action of brush with improved irrigant agitation. This was in agreement with Garip et al.[13].

Results in the present study also showed that CHX group resulted in better push-out bond strength values than saline and NaOCl groups. The positive effect on adhesion of materials has been attributed to the increase of surface energy and wetting ability of dentin by CHX which may favor resin infiltration into the dentinal tubule[59],[60]. Furthermore, CHX has been shown to inhibit the matrix metalloproteinases which can lead to collagen degradation, loss of structural integrity, and subsequently reduced bond strength. So, CHX resulting in improvement of the hybrid layer integrity and further resin dentin bond stability in a long-term period[61]. In addition, Santos et al.[62]theorized that CHX is a nonoxidizing agent that does not interfere with the resin adhesion system tested. This was in agreement with many studies[23],[63],[64],[65],[66],[67] which stated that CHX increased the bonding strength of AH Plus sealer.

The current findings revealed that utilizing NaOCl throughout instrumentation and as a final rinse had the least bond strength values than other groups. As NaOCl breaks down to sodium chloride and oxygen where the generation of oxygen bubbles at the resin dentin interface may oxidize collagen or other matrix components of dentin creating a layer of oxidized dentin causing strong inhibition of the interfacial polymerization of resin bonding materials and interferes with resin infiltration into tubules and intertubular dentin[59],[68],[69].

Furthermore, NaOCl is a deproteinizing agent that can degenerate dentin by collagen dissolution[70] that adversely affect adhesion of AH Plus sealer which depend on formation of covalent bonds between its open epoxide ring and any exposed amino groups in collagen[71],[72]. Also, deproteinization by NaOCl leads to a hydrophilic surface which does not favor the hydrophobicity of this sealer[63],[73].

The current results also showed that saline group sometimes resulted in better push-out bond strength values than NaOCl group. Same results showed by Rocha et al.[23] and Shokouhinejad et al.[65]as saline solution didn't have any adverse effect on dentin like NaOCl. But the difference between the two groups was statistically nonsignificant and this may be due to inability of saline to remove smear layer and debris which may affect the bond strength[23].

In the present study, results demonstrated that the bond strength values decreased in coronal to apical direction with significant difference between three sections. This result was comparable with the results of several studies showing that the adhesion of root sealers generally decreased in the coronal to apical direction[21],[74],[75],[76],[77].

This is probably due to inadequate volume or penetration of the irrigation and final rinse solutions into the apical portion of the root canal[78] and the consequent incomplete removal of the smear layer may decrease the penetration of sealer into dentinal tubules and may thereby affect adhesion in the apical region[79]. Additionally, decreasing tubule density from coronal to apical direction, which reduces sealer penetration into the smaller tubule diameter in the apical thirds[80]. Furthermore, Paqué et al.[81]reported that dentin in the apical third of root canal is more sclerosed than the coronal dentin.

In contrary, Mahdi et al.[82]revealed that the bond strength values were higher at apical root canal levels compared to the coronal sections. This contradiction may be attributed to the difference in the method of instrumentation where they used manual instrumentation until master apical file# 40/0.02 taper that produce very limited widening of the canal in the apical section, making it impossible to perform push-out tests without having a frictional component with the canal walls.


  Conclusions Top


Within the limitation of the present in-vitro study, the results suggest that: bond strength of AH Plus sealer to root canal dentin was affected by combined effect of both irrigation solutions and techniques. Using 2% CHX solution throughout and after instrumentation improved bond strength of AH Plus sealer to root canal dentin. Bond strength to root dentin was improved by using EndoVac system during irrigation rather than CanalBrush and needle. Coronal sections showed higher bond strength values than middle and apical sections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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