| Abstract | Svrha doktorskog rada bila je ispitati utjecaj fotodinamske terapije i biokeramičkoga punila korijenskih kanala na cijeljenje periapikalne lezije i pojavnost postoperativnih bolova nakon jednoposjetne revizije endodontskog liječenja. Pacijenti su metodom slučajnog odabira razvrstani u dvije skupine ovisno o završnom protokolu dezinfekcije korijenskih kanala: Skupina 1. UAI (ultrazvučno aktivirano ispiranje) + Fotodinamska terapija (engl. photodynamic therapy, PDT); Skupina 2. UAI (ultrazvučno aktivirano ispiranje). Ukupno je sudjelovalo 77 pacijenata, 38 u PDT skupini i 39 u UAI skupini. U svakoj skupini, kod polovice
ispitanika, korijenski kanali punjeni su biokeramičkim punilom (BioRoot RCS, Septodont, Francuska) (Podskupina A); a druga polovica punilom temeljenim na epoksi smoli AH Plus (AH Plus, Dentsply Sirona, Sjedinjene Američke Države) (Podskupina B). Kod svih pacijenata analizirana je pojavnost i intenzitet bolova s VAS skalom boli, po danima, 7 dana nakon završetka endodontskog liječenja zuba. Kod svih pacijenata napravljena je ciljana snimka zuba konusnom kompjuteriziranom tomografijom (eng. CBCT) prije i godinu nakon revizije endodontskog liječenja. Volumen inicijalne periapikalne lezije i lezije nakon 12 mjeseci
izračunat je softverom OnDemand3D. Dobiveni rezultati statistički su analizirani Fischerovim egzaktnim testom, Smirnov-Kolmogorovljevim i Mann-Whitney U testom uz razinu značajnosti od 0,05. Rezultati su pokazali značajno smanjenje volumena u svim ispitivanim skupinama, i to: PDT/AH+ 79,72% (p<0,05), PDT/BIO 89,58% (p<0,05), UAI/AH+ 86,98% (p<0,05), i UAI/BIO 86,95% (p<0,05). Između ispitivanih skupina nije bilo statistički značajne razlike u smanjenju volumena: PDT/AH+ i PDT/BIO (p=0,784), UAI/AH+ i UAI/BIO (p=0,458), PDT/BIO i UAI/BIO (p=0,458), PDT/AH+ i UAI/AH+ (p=0,970). Fotodinamska terapija nije pokazala superiornost u kliničkim uvjetima u odnosu na ultrazvučno aktiviranu irigaciju kao ni primijenjeni biokeramički materijal u odnosu na punilo temeljeno na epoksi smoli, kako u smanjenju periapikalne lezije, tako i u pojavnosti i intenzitetu postoperativne boli. |
| Abstract (english) | Aim: The aim of the clinical study was to examine the effect of photodynamic therapy (PDT) and bioceramic root canal filling on periapical lesion healing. Also, the influence of PDT and bioceramic filling on the occurrence and intensity of postoperative pain after a single visit endodontic treatment was examined.
Materials and methods: The study included patients with signs and symptoms of chronic apical periodontitis who required revision, according to the inclusion and exclusion criteria. Patients were divided into two basic groups depending on the type of final root canal disinfection protocol: Group 1. Ultrasonically activated irrigation (UAI) EDTA and 3% NaOCl + PDT (diode laser 660 nm, 100 mW); Group 2. Ultrasonically activated irrigation (UAI) EDTA and 3% NaOCl. In each group, half of the root canals samples were filled with bioceramic filling BioRoot RCS (BioRoot RCS, Septodont, Saint-Maur-des-Fossés, France), and the other half of the samples with epoxy resin-based filling AH Plus (AH Plus, Dentsply, Sirona, Charlotte, USA). Radiological volumetric assessment of periapical lesion healing was done by CBCT analysis by obtaining the exact lesion volume preoperatively and one year after revision. The randomization process was conducted using the Wheel Decide program (www.wheeldecide.com). The study was single-blinded, meaning that the patients were unaware of the group to which they were allocated. The clinical procedures were standardized for both groups. Root canal retreatment was performed under local anesthesia (Articain 4% with Epinephrine 1:100,000, one ampoule, Ubistesin™ forte, 3 M ESPE, Germany) and rubber dam isolation. The traditional access opening was performed under rubber dam isolation. All caries was removed using pearshaped diamond and round carbide burs under water coolant. In cases where there was a significant loss of coronal tooth structure, class I cavities were reconstructed using a composite material (Clearfill Majesty ES2 Classic, Kuraray America, Inc. Suite, USA). The working field was disinfected with 5% NaOCl. The root canal retreatment was performed with Rendo 1, 2, and 3 rotary files (MICROMEGA, Cedex, France) using an endomotor set at 300 rpm and 200 Ncm, according to the manufacturer's recommendations. During retreatment, the root canals were irrigated with 3% NaOCl (30 G needle, Steri Irrigation Tips, DiaDent; Netherlands). The retreatment was considered complete when no signs of remaining guttapercha were visible on the instruments or in the canal. The working length was determined and measured using a Kfile size #10 or #15 up to the apical foramen (value 0 on the apex locator) on Dualpex apex locator (MICROMEGA, Cedex, France). The canals were then instrumented up to the apical foramen using 2Shape 1 and 2 instruments (2Shape, MICROMEGA, Cedex, France) and 5 ml of 3% NaOCl per canal. Endomotor setup was 300 rpm and 200 Ncm. The presence of clean dentinal shavings, clear irrigant, and glassy smooth walls were the preferred indicators of adequate cleaning of the root canals. Additionally, apical cleaning was confirmed when clean dentinal debris was present at the tip of the rotary instrument.
After completion of instrumentation, the final disinfection protocol included: irrigation with 3 ml of 3% NaOCl for 30 s, followed by 3 ml of 15% ethylenediaminotetraacetic acid (EDTA) activated for 60 s, and finally, 3 ml of 3 % NaOCl activated for 30 s. All passive irrigation was performed using 30 G needle (30 G needle, Steri Irrigation Tips, DiaDent; Netherlands) and a 2 ml syringe. After each irrigation step and before the next irrigant, the excess irrigant in the root canal was aspirated using 30 G needle and a syringe.In Group 1 (UAI), EDTA and NaOCl irrigants in the final disinfection protocol were constantly activated using an EndoUltra device (MICROMEGA, Cedex, France) with an ultrasonic noncutting tip placed at 3 mm from the working length. The irrigant was delivered into the root canal, and the ultrasonic device was constantly activated, 30 s for NaOCl and 60 s for EDTA. During activation, irrigants were constantly delivered using 30 G needle and a syringe. In both groups the irrigants were activated in the same manner as explained but with the additional application of photodynamic therapy (PDT) after irrigation in Group 1. The PDT as applied using an HF diode laser (diode laser 660 nm, 100 mW 60 s/root canal, LASER HF COMFORT; HAGER&WERKEN, Duisburg, Germany) set at continuous mode. First, the PS, Toluidine blue (HF EndoPDT solution, Hager&Werken) was applied in the root canal and
distributed along the dentinal walls using a sterile hand Kreamer size #15. The dye was left in the canal for 60 s, then removed by rinsing the canal with 2 ml of sterile saline solution and dried with sterile paper points. Finally, the root canals were irradiated using a fiber tip (320 µm diameter), placed initially 2 mm from the working length, and then moved rotationally for 60 s with rotational motion from the apical to the coronal direction. In the same session, the root canals were obturated using an epoxy resinbased sealer (AH Plus, Dentsply Sirona, Germany) or bioceramic sealer (BioRoot RCS, Septodont, SaintMaurdesFossés, France) and guttapercha cones (MICROMEGA, Cedex, France) using a singlecone
obturation technique. The access cavity was temporarily sealed with a glass ionomer (Fuji IX; GC Corporation, Tokyo, Japan). Every patient received a visual analogue scale (VAS) questionnaire to record occurrence and pain intensity immediately after the retreatment and during the following seven days and analgesic consumption. The protocol was finished seven days after revision with permanent composite filling (Clearfill Majesty ES2 Classic, Kuraray America, Inc. Suite, USA).
Results: Results showed significant periapical lesion volume reduction in all groups: PDT/AH+ 79,72% (p<0,05), PDT/BIO 89,58% (p<0,05), UAI/AH+ 86,98% (p<0,05), i UAI/BIO 86,95% (p<0,05). There were no significant differences between the groups in terms of reduction of periapical lesion volume: PDT/AH+ vs PDT/BIO (p=0,784), UAI/AH+ vs UAI/BIO (p=0,458), PDT/BIO vs UAI/BIO (p=0,458), PDT/AH+ vs UAI/AH+ (p=0,970). Additional use of PDT after UAI did not contribute to the healing of periapical lesions. The intensity of postoperative pain was highest on the first day, but considering the median VAS values, this pain was minimal (median in the range from 0 to 1). Significant differences were recorded only in one comparison - UAI/AH+ and UAI/BIO on the fourth day (P=0.049), but this difference was also not clinically significant
because the median VAS was 0, while the difference related only to the measured ranges of minimum and maximum VAS values. In conclusion, the pain was of low intensity and equal between the groups.
Conclusion: The analysis showed that there was no statistically significant difference between the examined groups, photodynamic therapy did not show superiority in clinical conditions in relation to ultrasound-activated irrigation, nor did the applied bioceramic material in relation to filler based on epoxy resin. |
