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Apical and periapical repair of dogs' teeth with periapical lesions after endodontic treatment with different root canal sealers.

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Api cal and pe ri a pi cal re pa ir of dogs’ te eth with pe ri a pi cal le si ons af ter

en do don tic tre at ment with dif fe rent root ca nal se a lers

Re pa ra ção api cal e pe ri a pi cal de den tes de cães com le são pe ri a pi cal crô ni ca

após tra ta men to en do dôn ti co uti li zan do di fe ren tes ma te ri a is ob tu ra do res

Má rio Ro ber to Le o nar do*

Antô nio Alber to Me de i ros Sal ga do** Léa Assed Be zer ra da Sil va*** Má rio Ta no ma ru Fi lho****

AB STRACT: The aim of this study was to eval u ate the api cal and periapical re pair af ter root ca nal treat ment of dogs’ teeth with pulp ne cro sis and chronic periapical le sion us ing dif fer ent root ca nal seal ers. Af ter periapical le sion in duc -tion, forty-four root ca nals of 3 dogs were sub mit ted to biomechanical prep a ra tion us ing 5.25% so dium hypochlorite as an ir ri gat ing so lu tion. A cal cium hy drox ide dress ing (Calen PMCC) was ap plied for 15 days and the root ca nals were filled us ing the lat eral con den sa tion tech nique with guttapercha points and Sealapex, AH Plus or Sealer Plus for seal -ing. Af ter 180 days, the an i mals were sac ri ficed by an es thetic over dose and the ob tained histological sec tions were stained with hematoxylin-eosin for op ti cal mi cro scopic anal y sis of the api cal and periapical re pair. The groups filled with Sealapex and AH Plus had better histological re pair (p < 0.05) than the group filled with Sealer Plus, that had un -sat is fac tory re sults.

DESCRIPTORS: Den tal ce ments; Root ca nal obturation; In juries; Periapical ab scess; Biocompatible ma te ri als.

RESUMO: O ob je ti vo do pre sen te es tu do foi ava li ar a re pa ra ção api cal e pe ri a pi cal pós-tra ta men to en do dôn ti co de den tes de cães com ne cro se pul par e re a ção pe ri a pi cal crô ni ca, em que se uti li za ram di fe ren tes ma te ri a is ob tu ra do res. Fo ram uti li za dos 44 ca na is ra di cu la res, nos qua is, após in du ção das le sões pe ri a pi ca is, foi efe tu a do o pre pa ro bi o me câ ni co em pre gan do-se como so lu ção ir ri ga do ra uma so lu ção de hi po clo ri to de só dio a 5,25%. Após cu ra ti vo de de mo ra com pas ta à base de hi dró xi do de cál cio (Ca len PMCC), man ti da no ca nal ra di cu lar du ran te 15 dias, os ca na is ra di cu la res fo ram ob tu ra dos pela téc ni ca clás si ca com ple men ta da pela con den sa ção la te ral ati va, em pre gan dose os ci men tos Se -a l-a pex, AH Plus ou Se -a ler Plus. De cor ri do o pe río do de 180 di-as, os -ani m-a is fo r-am mor tos e -as pe ç-as sub me ti d-as -ao pro ces sa men to la bo ra to ri al. Os cor tes his to ló gi cos ob ti dos fo ram co ra dos com he ma to xi li naeo si na. A aná li se his to pa to ló gi ca de monstrou que nos ca na is ra di cu la res ob tu ra dos com os ci men tos Se a la pex e AH Plus ocor reu me lhor repa -ra ção (p < 0,05) do que nos ca na is ob tu -ra dos com o Se a ler Plus, o qual mos trou re sul ta dos in sa tis fa tó ri os.

DESCRITORES: Ci men tos den tá ri os; Obtu ra ção do ca nal ra di cu lar; Le sões; Absces so pe ri a pi cal; Ma te ri a is bi o com pa tí ve -is.

INTRODUCTION

An intracanal dress ing has been in di cated for the treat ment of root ca nals with ne crotic pulp and chronic periapical le sions in or der to elim i nate mi -cro or gan isms of the root ca nal sys tem that were not re moved by biomechanical preparation1,4,8

. Cal -cium hy drox ide has been rec om mended as the intracanal dress ing of choice4,5,7,14

due to its antimicrobial ac tion and its ca pac ity to in ac ti vate the ef fects of Gram-neg a tive bac te ria endotoxin (LPS)10,11,12

pres ent on cell walls.

A her metic seal is also an im por tant fac tor for

the suc cess of api cal and periapical re pair in teeth with ne crotic pulp and chronic periapical le sions. For this, the sealer must not only have sat is fac tory physicochemical prop er ties, but must also have bi o log i cal prop er ties that al low or in duce api cal re -pair and min er al ized tis sue de po si tion. Among the seal ers stud ied, Sealapex (Kerr Corp., Romulus, USA) has pre sented ex cel lent biocompatibility2,15

. Even though it is rel a tively sol u ble af ter ap pli ca -tion, this does not af fect its seal ing property13

. In

*Cha ir man, Dis ci pli ne of Endo don tics; ****Adjunct Pro fes sor, Dis ci pli ne of Endo don tics – Scho ol of Den tistry of Ara ra qua ra, São Pa u lo Sta te Uni ver sity.

**Pro fes sor, Ca ru a ru Scho ol of Den tistry.

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fact, this rel a tive sol u bil ity al lows the ionic dis so ci a tion of cal cium hy drox ide from this sealer, con -trib ut ing to the in duc tion of api cal minerali -zation2,16

and an ti bac te rial action8

.

The resin-based ep oxy sealer AH Plus (Dentsply De Trey GmbH, Konstanz, Ger many) has shown sat is fac tory bi o log i cal re sults af ter root ca nal fill -ing in teeth with vi tal pulp6

. Sealer Plus, also a resin-based sealer, man u fac tured by Dentsply (Petrópolis, RJ, Brazil) is in an ex per i men tal phase. This sealer con sists of two pastes and con -tains cal cium ox ide.

Thus, the ob jec tive of this study was the com -par a tive eval u a tion of those 3 endodontic seal ers in the treat ment of dog root ca nals with chronic periapical le sions.

MA TE RIAL AND METHODS

The sec ond, third and fourth man dib u lar pre mol ars and the sec ond and third maxillary pre mol -ars of three mon grel dogs (aged 12 to 18 months; both sexes), to tal ing 44 roots, were se lected for treat ment and di vided into 3 groups.

The root ca nals were ini tially ex plored with no. 20 Kfiles (Dentsply Maillefer, Ballaigues, Swit -zer land) and the pulp was re moved with no. 30/40 Hedströen files (Dentsply Maillefer, Ballaigues, Swit zer land), de pend ing on the root ca nal di am e -ter. The root ca nals re mained ex posed to the oral cav ity for 7 days, in or der to al low bac te rial con -tam i na tion.

Af ter this pe riod, the pulp cham ber was cleaned and dried, cot ton pel lets were placed in the pulp cham ber and the co ro nal open ing was sealed with zinc ox ide-eugenol ce ment (Pulpo-San, S. S. White, Rio de Ja neiro, RJ, Brazil). Af ter 30 days, ra dio graphs were taken ev ery 15 days, ac cord ing to Le o nardo et al.9 (1993), un til radiolucent im ages

sug gest ing chronic periapical re ac tion were ob -served, which nor mally oc curs af ter 45-60 days.

Un der new an es the sia and rub ber dam place -ment, crown-down neu tral iza tion of the root ca nal sep tic/toxic con tent was per formed us ing K-files and 3.6 ml of 5.25% so dium hypochlorite af ter each in -stru ment. The teeth were in -stru mented 2 mm from the ra dio graphic apex. En large ment of the api cal fo -ra men was per formed up to a no. 30 file to the to tal tooth length. In this same ses sion, biomechanical prep a ra tion was per formed with Kfiles fol low ing clas -sic in stru men ta tion ac cord ing to Leal3 (1998), up to a

no. 70 in stru ment. A no. 30 file was re in serted to the to tal tooth length to re move pos si ble dentin chips taken to the apex dur ing in stru men ta tion. The root ca nals were dried and a 17% EDTA so lu tion was used with con tin u ous ag i ta tion with a K-file for 3 min utes and were again ir ri gated and dried with ster ile ab sor bent pa per points. A cal cium hy drox ide cam phor ated ρ-monochlorophenical intracanal dress ing (Calen PMCC, S. S. White Artigos Dentários Ltda., Rio de Ja neiro, RJ, Brazil) was used for 15 days. The co ro nal open ings were sealed with quick-set ting zinc ox ide-eugenol ce ment.

Af ter 15 days, un der an es the sia and rub ber dam place ment, the intracanal dress ing was re -moved with 0.5% so dium hypochlorite and a no. 70 file, and the root ca nals were dried with ster ile ab sor bent pa per points. A no. 30 file was again ap -plied to the to tal tooth length and the root ca nals were ir ri gated with 17% EDTA for 3 min utes. The mas ter gutta-percha cones (Tanari Ind., Manaus, AM, Brazil) were se lected and the root ca nals were sealed with Sealapex (Ta ble 1), AH Plus (Ta ble 2) or Sealer Plus (Ta ble 3) fol low ing the clas si cal tech nique com ple mented by ac tive lat eral con den sa -tion. The seal ers were ma nip u lated in equal parts (base and cat a lyst) un til a ho mog e nous color with clin i cal con sis tency was ob tained.

Root ca nal seal ing was ra dio graph i cally an a -lyzed and the co ro nal open ings were sealed with

TABLE 2 - AH Plus (ap pro xi ma te com po si ti on, ac cor -ding to Dentsply De Trey, Kons tanz, Ger many).

Paste A Paste B

Epoxy resins Amines

Calcium tungstate Calcium tungstate

Zirconium oxide Zirconium oxide

Silica Silica

Iron oxide pigments Silicone oil

TABLE 1 Se a la pex (ap pro xi ma te com po si ti on, ac cor -ding to Kerr Cor po ra ti on).

Base Catalyst

Cal ci um oxi de 54.0% Ba ri um sul fa te 40.0%

Ethyl to lu e ne

sul fo na mi de 32.0%

Poly(meth yle ne

-methylsa licy la te) re sin 30.0%

Zinc oxi de 14.0% Iso butyl sa licy la te 18.0%

Wa ter 0.01% Sub-mi cron si li ca 7.0%

Ti ta ni um di o xi de 4.0%

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sil ver amal gam (Velvalloy, S. S. White Artigos Dentários, Rio de Ja neiro, RJ, Brazil) con densed over a glass ionomer base (Vitremer, 3M do Brasil, Campinas, SP, Brazil).

Af ter 180 days, the an i mals were sac ri ficed by an es thetic over dose, the roots were fixed for histo logical anal y sis in so dium cacodylate and de min -er al ized with EDTA. The ob tained blocks w-ere cut se ri ally in 6-µm-thick sec tions and stained with hematoxylin-eosin.

The histopathological anal y sis re sults were eval u ated by the Mann-Whit ney test.

RE SULTS

Group I: Sealapex

The 10 roots sealed with Sealapex ce ment af ter 15 days of Calen PMCC intracanal dress ing showed the fol low ing histopathological char ac ter is tics: in the api cal ce men tum, the ce men tum la -cu nae were filled by nor mal con nec tive tis sue and the space fre quently de creased by min er al ized tis -sue for ma tion. Newly formed min er al ized tis -sue on the api cal fo ra men walls was ob served in di rect con tact with the seal ing ma te rial, to tally seal ing the fo ra men in 4 roots. Four of the 6 re main ing roots had ex ten sive min er al ized newly formed tis -sue that par tially sealed the api cal fo ra men with con nec tive tis sue invaginating the periapex. This in ter sti tial tis sue was nor mal and con tained col la -gen fi bers, fibroblasts, blood ves sels and sealer par ti cles (Fig ures 1 and 2). The api cal ce men tum sur face was reg u lar due to newly formed ce men -tum in pre vi ously re ab sorbed ar eas. The al ve o lar bone showed reg u lar trabeculae with osteocytes within the bone and os teo blasts at its sur face. The periapical re gion was slightly en larged in 5 roots, mod er ately en larged in 4 roots and se verely en -larged in 1 root.

Group II: AH Plus

From the 18 root ca nals that re ceived the Calen PMCC intracanal dress ing for 15 days and were sealed with AH Plus, 4 had to tal api cal seal ing with newly formed min er al ized tis sue and 12 had par -tial seal ing (Fig ure 3). No seal ing oc curred in 2 roots. The api cal ce men tum sur face was reg u lar with newly formed ce men tum in pre vi ously re ab -sorbed ar eas, with few cementoblasts and col la gen fi bers. The ce men tum la cu nae in the api cal re gion were fre quently empty or con tained nor mal con -nec tive tis sue in a few roots. The periapical re gion was slightly en larged in 11 spec i mens, mod er ately en larged in 5 and se verely en larged in 2 roots. In this re gion, the in flam ma tory in fil trate was mild and dif fuse in 14 roots, com posed of phagocytic mononuclear cells. Thin al ve o lar bone for ma tion was found sur round ing all of the api ces that were fre quently de nuded or with re duced os teo clasts on their sur face. In the roots in which the ma te rial

FIGURE 1 - Group I (Se a la pex) – bio lo gi cal se a ling of the apex with mi ne ra li zed tis sue de po si ti on (S). Mild and dif fu se in fil tra ti on of in flam ma tory cells in the api cal pe ri o don tal li ga ment clo se to the al ve o lar bone (H. E. -Olympus - 40 X).

TABLE 3 Se a ler Plus (ap pro xi ma te com po si ti on, ac cor -ding to Dentsply).

Base Catalyst

Calcium oxide Calcium oxide

Bismuth trioxide Bismuth trioxide

Calcium stearate Titanium dioxide

Epoxy resins Silicone oil

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was over filled to the periapical re gion, a fi brous cap sule sur rounded it, with no in flam ma tory cells.

Group III: Sealer Plus

In the 16 root ca nals from this group, which had a Calen PMCC intracanal dress ing for 15 days and were sealed with Sealer Plus, to tal api cal clo -sure was ob served in only 2 roots, par tial seal ing, in 8 roots and lack of seal ing, in 6 spec i mens. Among these 6 spec i mens, 4 were over filled. In the api cal ce men tum, the la cu nae were fre quently empty and en larged. The ce men tum sur face near the api cal fo ra men was re paired by newly formed tis sue and de marked by ba so philic lines. Some ar -eas of ce men tum re sorp tion per sisted lat er ally to the api cal fo ra men, es pe cially in the re gions near sec ond ary ca nals, with a mod er ate pres ence of ad ja cent in flam ma tory cells. The periodontal lig a -ment was mod er ately thicker in 7 roots and slightly thicker in 9. In this re gion, there was in -com plete re pair in 10 spec i mens, rep re sented by a

re duced quan tity of col la gen fi bers and fibroblasts. The in flam ma tory in fil trate was pre dom i nantly mononuclear and spread dif fusely around the apex, with a con sid er able num ber of con gested blood ves sels (Fig ures 4 and 5). The al ve o lar bone was de nuded or had oc ca sional os teo clasts on its sur face. In cases of over fill ing, there were in flam -ma tory cells with gi ant cells in di rect con tact with the ex truded sealer.

DIS CUS SION

The ideal root ca nal sealer should have ex cel -lent physicochemical prop er ties and bi o log i cal com pat i bil ity, be cause a sealer re mains in di rect con tact with api cal and periapical tis sues.

The re sults of the pres ent study show that Sealapex and AH Plus al lowed greater de po si tion of min er al ized tis sue than did Sealer Plus. The biocompatibility of Sealapex has al ready been am -ply eval u ated in teeth with vi tal pulp by Hol land, Souza2

(1985), Tag ger et al.16

(1988), and by

FIGURE 3 - Group II (AH Plus) – com ple te bi o lo gi cal sealing (S) of the root apex with de po si ti on of mi ne ra li zed tis sue. Mo de ra te pre sen ce of in flam ma tory cells on the api cal pe ri o don tal li ga ment (H. E. - Olympus - 40 X). FIGURE 2 - Group I (Se a la pex) – gre a ter mag ni fi ca ti on of

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Tanomaru Filho et al.17

(1998) in dog’s teeth with periapical le sions. Be cause AH Plus is a new sealer, there are few biocompatibility stud ies about it; how ever, cur rent re search shows that this ma te rial is biocompatible with api cal and periapical tis sues. Min er al ized tis sue for ma tion and lack of in flam ma -tion have also been reported6, pre sent ing re sults

sim i lar to those of the pres ent study.

On the other hand, Sealer Plus has not shown sat is fac tory bi o log i cal re sults. Its tis sue re sponse was sim i lar to that of AH 26 and Sealer 26, which have sim i lar chem i cal com po si tions.

In the cases in which the sealer was re stricted to the in te rior of the root ca nal, only root ca nals filled with Sealapex had de po si tion of min er al ized tis sue form ing a par tial or to tal seal in 100% of the cases. The same was not ob served with AH Plus nor with Sealer Plus.

In cases of over fill ing, the in flam ma tory re -sponse was sim i lar in root ca nals filled with AH Plus and Sealapex (p > 0.05), and was lesser than that ob served with Sealer Plus (p < 0.05).

In the pres ent study, fre quent ar eas of re paired ce men tum ab sorp tion were found, as well as the pres ence of cementoblasts and col la gen fi bers with Sealapex. Only 6 roots out of the 16 root ca nals filled with Sealer Plus showed re paired ce men tum.

The in sol u bil ity of Sealer Plus, as so ci ated with its ir ri tat ing ac tion, has prob a bly pro duced the per ma nent ac ti va tion of cel lu lar in flam ma tion, lead ing to the un sat is fac tory ef fects ob served in the api cal and periapical tis sues.

CON CLU SIONS

Based on the re sults ob tained in the histo pathological anal y sis of api cal and periapical tis -sues, we con clude that:

• The root ca nal se a lers Se a la pex and AH Plus sho wed sa tis fac tory tis sue res pon ses le a ding to the re pa ir of the api cal and pe ri a pi cal re gi ons. • Se a ler Plus sho wed un sa tis fac tory his to pat ho

-lo gi cal re sults and con si de ra ble tis sue ir ri tant ac ti on.

FIGURE 5 Group III (Se a ler Plus) – hig her magnifica tion of Fi gu re 4 shows mo de ra te and dif fu se in flam ma -tory in fil tra te (H. E. - Olympus - 100 X).

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REF ER ENCES

1. Chong BS, Pitt Ford TR. The role of in tra ca nal me di ca ti on in root ca nal tre at ment. Int Endod J 1992;25:97-106. 2. Hol land R, Sou za V. Abi lity of a new cal ci um hydro xi de root

ca nal fil ling ma te ri al to in du ce hard tis sue for ma ti on. J Endod 1985;11:535-43.

3. Leal JM. Pre pa ro bi o me câ ni co dos ca na is ra di cu la res – meios me câ ni cos. In: Le o nar do MR, Leal JM. Endo don tia: tra ta men to de ca na is ra di cu la res. 3a ed. São Pa u lo: Pa na -me ri ca na; 1998. p.367-88.

4. Le o nardo MR, Silva LAB. Medicação tópica en tre sessões, “curativo de demora” em biopulpectomia e necropulpecto -mia. In: Le o nardo MR, Leal JM. Endodontia: tratamento de canais radiculares. São Paulo: Panamericana; 1998. p.491-534.

5. Le o nar do MR, Alme i da WA, Sil va LAB, Utril la LS. Histo -pathological ob ser va ti ons of pe ri a pi cal re pa ir in te eth with ra di o lu cent are as sub mi tted to two dif fe rent met hods of root ca nal tre at ment. J Endod 1995;21:137-41.

6. Le o nar do MR, Sil va LAB, Alme i da WA, Utril la LS. Tis sue res pon se to an epoxy re sin-ba sed root ca nal se a ler. Endod Dent Tra u ma tol 1999;15:28-32.

7. Le o nar do MR, Sil va LAB, Ta no ma ru Fi lho M, Sil va RS. Re -le a se of for mal dehy de by 4 en do don tic se a -lers. Oral Surg Oral Med Oral Pat hol Oral Ra di ol Endod 1999;88:221-5. 8. Le o nar do MR, Sil va LAB, Ta no ma ru Fi lho M, Bo ni fá cio KC,

Ito IY. In vi tro eva lu a ti on of an ti mi cro bi al ac ti vity of se a lers and pas tes used in en do don tics. J Endod 2000;26:391-4.

9. Le o nar do MR, Sil va LAB, Le o nar do RT, Utril la LS, Assed S. His to lo gi cal eva lu a ti on of the rapy using a cal ci um hydro xi -de dres sing for te eth with in com ple tely for med api ces and pe ri a pi cal le si ons. J Endod 1993;19:348-52.

10. Sa fa vi KE, Ni chols FC. Effect of cal ci um hydro xi de on bac -te ri al li po poly sac cha ri de. J Endod 1993;19:76-8.

11. Sa fa vi KE, Ni chols FC. Alte ra ti on of bi o lo gi cal pro per ti es of bac te ri al li po poly sac cha ri de by cal ci um hydro xi de tre at -ment. J Endod 1994;20:127-9.

12. Sil va LAB, Nel sonFi lho P, Le o nar do MR, Ros si MA, Pan sa -ni CA. Effect of cal ci um hydro xi de on bac te ri al en do to xin in vivo. J Endod 2002;28:94-8.

13. Sle der FS, Lud low MO, Bo ha cek JR. Longterm se a ling abi -lity of a cal ci um hydro xi de se a ler. J Endod 1991;17:541-3. 14. Souza V, Bernabé PFE, Hol land R, Nery MJ, Mello W,

Otoboni Filho JA. Tratamento não-cirúrgico de dentes com lesões periapicais. Rev Bras Odontol 1989;46:39-46. 15. Tag ger M, Tag ger E. Pe ri a pi cal re ac ti on to cal ci um hydro xi

-de-con ta i ning se a lers and AH 26 in mon keys. Endod Dent Tra u ma tol 1989;5:139-46.

16. Tag ger M, Tag ger E, Kfir A. Re le a se of cal ci um and hydroxyl ions from set en do don tic se a lers con ta i ning cal ci um hydro -xi de. J Endod 1988;14:588-91.

17. Ta no ma ru Fi lho M, Le o nar do MR, Sil va LAB, Utril la LS. Effect of dif fe rent root ca nal se a lers on pe ri a pi cal re pa ir of te eth with chro nic pe ri ra di cu lar pe ri o don ti tis. Int Endod J 1998;31:85-9.

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TABLE 2 -  AH Plus (ap pro xi ma te com po si ti on, ac cor - -ding to Dentsply De Trey, Kons tanz, Ger many).
FIGURE 1 - Group I (Se a la pex) – bio lo gi cal se a ling of the apex with mi ne ra li zed tis sue de po si ti on (S)
FIGURE 4 -  Group III (Se a ler Plus) – par ti al bi o lo gi cal  sealing of the apex with lit tle de po si ti on of mi ne ra li zed tis sue

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