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   Table of Contents - Current issue
Coverpage
September-December 2022
Volume 12 | Issue 3
Page Nos. 227-343

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REVIEW ARTICLES  

Root and root canal morphology of maxillary premolars in the Saudi population: A review of literature p. 227
Roqayah Aljuailan
DOI:10.4103/sej.sej_35_22  
Introduction: To achieve the desired treatment outcomes following root canal treatment, clinicians must have extensive knowledge of root and root canal morphology before commencing the treatment. Hence, this article aimed to review the studies performed on the root and root canal morphology of maxillary premolars in the Saudi population and to investigate sex differences and bilateral occurrence of the morphology of these teeth. Materials and Methods: A thorough search of MEDLINE/PubMed, Scopus, and Google Scholar databases was conducted. Nineteen studies concerning anatomical as well as case report studies were included and over 5120 permanent maxillary premolar teeth were evaluated in these studies. Results: Thirteen anatomic studies and six case reports included in this review examined root and/or root canal morphology of maxillary premolars in four provinces of Saudi Arabia. Various study methodologies have been implemented in these anatomic studies. The maxillary first premolars (MxFPs) showed two roots and two canals in an average of 63.2% and 92.2%, respectively. The majority of maxillary second premolars (MxSPs) had one root (84.4%) and two root canals (57.7%). Type IV canal configuration is the most frequent configuration in MxFP with an average of 64.4%, whereas Type I was seen in 47.1% of the MxSP. Conclusion: Both maxillary premolars showed anatomical diversity and this emphasizes the need for attention during endodontic management. In general, there are sparse studies on the Saudi population discussing the study's objectives and further studies are required for evaluating root and root canal morphology of maxillary premolars.
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Evolving trend of systematic reviews and meta-analyses in endodontics: A bibliometric study Highly accessed article p. 236
Galvin Sim Siang Lin, Jia Zheng Leong, Wen Xin Chong, Miko Chong Kha Chee, Chin Sheng Lee, Manahil Maqbool, Tahir Yusuf Noorani
DOI:10.4103/sej.sej_209_21  
Introduction: Endodontics is rapidly evolving with the emergence of various research publications. The present bibliometric study aimed to identify and analyze the trends of systematic reviews and meta-analyses in endodontics. Materials and Methods: An electronic literature search using Scopus® and Web of Science databases was performed from January 2001 till August 2021. Only systematic reviews and meta-analyses published in English were retrieved. The following parameters were recorded and analyzed: Title, citation counts, authors, year of publication, institutions, countries, journals, type of article, source of articles, thematic categories, keywords, and source of fundings. Data were analyzed using Microsoft Excel software, Visualization of Similarities viewer software, and SPSS software with a significance level set at P = 0.05. Results: Among the 149 articles included, the top-cited article was cited 184 times with 27 of them receiving more than 50 citations. 17 authors have contributed at least four publications, and most of the papers were published in 2020 (n = 26). Furthermore, the number of articles published increased substantially over the two decades (P < 0.05), but the citation counts decreased considerably (P < 0.05). The International Medical University Malaysia and the University of Hong Kong published the most articles, while Brazil was the most prolific country. The Journal of Endodontics published the most articles (n = 46) and more than half of the articles were published in Quartile 1 and Quartile 2 journals. The bulk of articles were published dealing with clinical or radiographic outcomes. Conclusion: This study revealed significant information on the trends of systematic reviews and meta-analyses in endodontics providing a comprehensive understanding and direction of future research.
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The usage of lasers in cleaning, shaping, and disinfection of root canal system p. 253
Taher Dr. Al Omari, Hamza El-Farraj, Hazem Mohammad Alzenate, Nahed Al Charabi, Rana Al Khatib, Ayfer Atav Ateş
DOI:10.4103/sej.sej_179_21  
Since the laser was first used in endodontics in the 1970s, many studies have been conducted on this subject. This paper aims to summarize the studies about the effects of lasers in endodontics, which analyze the preparation and disinfection of the root canal system, postoperative pain, and the effect on the smear layer. The still-controversial question is; if lasers provide better results when used in tandem with conventional methods or alone. Another unknown factor is the side effects on teeth and surrounding tissues. With the increase in technology and knowledge in this field, developments are promising with different devices, laser tips, and wavelengths.
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Implications of endodontic treatment in chemo-osteonecrosis of the maxillary jaw due to bisphosphonates. An updated review p. 261
Elena Bermudez-Bejarano, Aline Savariz Martins, Alberto Sierra Lorenzo, Ana Boquete Castro, Alejandro Peña López
DOI:10.4103/sej.sej_246_21  
Introduction: Chemo-osteonecrosis of the jaw can be caused by the pharmacodynamics of bisphosphonates and periapical-pulp physiopathology. Therefore, the objective of this study was to carry out a bibliographic review on endodontic treatment and chemo-osteonecrosis of the jaw and its recommendations. Materials and Methods: An electronic systematic review has been prepared in the PubMed and manual verification from 2005 to 2020, according to the 2020 Prism Guidelines and using inclusion and exclusion criteria, under the terms: “Bisphosphonate AND root canal therapy” and “Bisphosphonate associated osteonecrosis of the jaw AND endodontics.” Results: The 22 selected articles were divided into two differentiated blocks. The first one includes endodontic treatment in patients with bisphosphonate therapy and its relationship with maxillary chemo-osteonecrosis. The second includes recommendations to be followed in patients on bisphosphonate and root canal therapy. Conclusions: Patients who were administered intravenous or intraoral bisphosphonates for more than 4 years with associated risk factors are more predisposed to chemo-osteonecrosis of the jaw. Endodontics is safe compared to other traumatic procedures.
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ORIGINAL ARTICLES Top

Estimating the prevalence of COVID-19 disease and its effect among trainees in the endodontic postgraduate programs in the kingdom of Saudi Arabia: A web-based survey study p. 269
Fahd Alsalleeh, Sara Alaathy, Rand Alblaihed
DOI:10.4103/sej.sej_60_22  
Introduction: The coronavirus disease 2019 (COVID-19) pandemic had a profound impact on dental care and academic education. This survey investigated the prevalence of the COVID-19 pandemic, symptoms, and its impact among endodontic trainees in the Kingdom of Saudi Arabia. Materials and Methods: This cross-sectional web-based survey targeted all endodontic residents in Saudi Arabia. A 22-item questionnaire was distributed to a total of 197 participants. The questionnaire included questions related to demographic information, COVID-19 impact on endodontic postgraduate training, the incidence of testing positive, symptoms experienced, and infection control measures. Descriptive and analytic statistics (Chi-square or Fisher's exact test) were used for the analysis. The significance level was set at P ≤ 0.05. Results: A total of 125 residents completed the survey. During June and July of 2020, most residents (45% and 50%) were required to perform only urgent endodontic care. Among the 125 residents, 52.8% reported being tested for severe acute respiratory syndrome coronavirus 2. Of these 66 who were tested, 13.6% had positive results. Eight of the nine residents who tested positive were male. Muscle pain, loss of smell and taste, fever, and headache were the most reported symptoms. A nonsurgical root canal treatment was the most common endodontic procedure performed among those surveyed (100%, n = 125), followed by endodontic emergency (84.8%, n = 106), with surgical endodontic treatment being far less frequent (27.2%, n = 34). Enhanced infection prevention and control measures were common practices during the pandemic; almost half of the residents reported using an N95 respirator or equivalent face mask. Residents continued to provide urgent care during the pandemic, and the majority returning gradually to practice as they had before the COVID-19 pandemic by December 2020. Conclusion: This survey showed a relatively low prevalence of COVID-19 among endodontic residents compared with other frontline healthcare workers. More male residents tested positive COVID-19. A more effective protection measurement should be made available and accessible to endodontic residents to ensure their safety and prevent interruptions to their clinical training.
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Assessment of youth knowledge and attitude toward managing avulsed tooth across Saudi Arabia: A cross sectional study p. 277
Ruaa Alamoudi, Rana Alamoudi
DOI:10.4103/sej.sej_24_22  
Introduction: An increase in sports' participation especially with youth, increase the risk of dental trauma. Many studies around the world focus on the knowledge of parents, guardian, and teachers regarding emergency management of tooth avulsion. It is important to educate children and young adults about appropriate dental treatment. The aim of this study is to evaluate the knowledge and attitude of young adults regarding the emergency management of tooth avulsion. Materials and Methods: A cross-sectional descriptive study was conducted. The target group of this study was young adults aged from 11- to 19-years old in Saudi Arabia who read either Arabic or English. A questionnaire about tooth avulsion, mouthguards, and how to handle an avulsed tooth was sent electronically by Survey Legend tool. Access was made available until the desired sample size was reached. Results: About 390 questionnaires were collected. Subjects who received advice in dental trauma or who had previous experience with dental trauma either by suffering from the injury (P = 0.003) or witnessing it (P = 0.005) were more confident in managing future dental emergencies. Participants who had a first aid training course had significantly more correct answers. Conclusion: This study emphasizes the importance of youth education toward emergency management of tooth avulsion using different educational methods such as regular first aid training program to all middle and high school students. School students' knowledge and attitude for managing dental trauma are inadequate, and different educational strategies for middle and high schools' students are recommended.
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Cone-beam computed tomography evaluation of C-shaped root canal system in mandibular second molars in kuwaiti sub-population p. 283
Abdullah Jassim Alenezi, Saad Al-Nazhan, Nassr Al-Maflehi, Mazen A Aldosimani
DOI:10.4103/sej.sej_11_22  
Introduction: C-shaped root canal anatomical variations cause challenges in endodontics treatment. This study investigated the prevalence of C-shaped root canals in mandibular second molars in the Kuwaiti population using cone-beam computed tomography (CBCT). Materials and Methods: CBCT images of sound mature mandibular second molars of 247 Kuwaiti patients were collected from government dental centers. An endodontist and radiologist examined the images to determine the presence of C-shaped canals. They were evaluated at four levels (canal orifice, coronal, middle, and apical thirds of root). Data were collected and statistically analyzed. Results: One hundred and forty-nine scans and 199 teeth belonging to 62 males and 87 females aged 16–56 years were included. C-shaped canals were found in 26 (13.07%) cases and were more common in females. Females were more likely to have bilateral C-shaped canals (P < 0.05). C2 was the most frequent morphology type at the orifice and coronal levels (53.9%) and apical levels (38.5%). An uninterrupted “C” shape was seen in 4 teeth (15.39%). A lingual longitudinal groove with the buccal notch (groove Type II) was seen in 14 teeth (53.85%). Conclusion: The prevalence of C-shaped canals in the mandibular second molars of a Kuwaiti population was higher than studies performed in the Middle-East population. The morphology type of C-shaped canal in mandibular second molars varied between the root levels. Radicular groove with buccal notches was most frequently located on the lingual side.
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Effect of therapeutic fractionated radiotherapy on bond strength and interfacial marginal adaptation of Adseal, MTA Fillapex, and EndoSequence BC sealer: An in vitro study p. 289
Monika Khangwal, Ravinder Solanki, Hena Rahman
DOI:10.4103/sej.sej_21_22  
Introduction: The study aimed to assess the impact of fractionated radiation on push-out bond strength of sealer to dentin interface and on marginal adaptation of the sealer (Adseal, MTA Fillapex, and EndoSequence BC sealer) to irradiated dentin. Materials and Methods: Ninety maxillary central incisors were randomly divided into two groups: with irradiation (n = 45) and without (n = 45). All the samples to be radiated were exposed to fractionated dosage (60 Gy) through Co-60 gamma (1.17 and 1.33 Mev) photons. Specimens were prepared and subdivided into three subgroups (n = 15 each) according to assigned sealer Adseal, MTA Fillapex, and EndoSequence BC sealer. Later, the samples were sectioned into a 1 mm thick segment at each root third for bond strength and scanning electron microscope (SEM) analysis. SEM micrographs were analyzed with an ORION version 6 image analyzer. The percentage of failure mode after debonding was evaluated with a stereomicroscope. Bond strength data were analyzed using two-way analysis of variance and the Tukey's post hoc test. Results: Bond strength was significantly (P < 0.0001) decreased after radiotherapy (0.76 ± 0.12 Mpa) versus without radiation (0.93 ± 0.18 Mpa). Furthermore, when the pooled average of sealers was compared, significantly highest bond strength was perceived in Adseal (0.98 ± 0.18 Mpa) followed by EndoSequence BC (0.84 ± 0.13 Mpa). Coronal sections showed significantly (P < 0.0001) higher bond strength (0.99 ± 0.16 Mpa) compared to the middle (0.81 ± 0.14 MPa) and apical third (0.74 ± 0.12 Mpa). Qualitative SEM revealed a higher interfacial gap between sealer and irradiated radicular dentin. The percentage of mean change was recorded significantly high in MTA Fillapex (52%), then in EndoSequence BC (31%), and least was in Adseal (17%). Conclusions: Irradiated teeth resulted in consequential decreased adhesiveness and bond strength of dentin to root canal filling material. In addition, the highest bond strength was noticed in Adseal.
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Effect of different irrigation regimens on the wettability of Sealer Plus BC and AH Plus sealers on intraradicular dentin: An in vitro study p. 297
Archana Ambadas Chavan, Tina Puthen Purayil, Sajan Daniel George, Nidambur Vasudev Ballal
DOI:10.4103/sej.sej_25_22  
Introduction: Irrigants play a major role in eliminating bacteria and modify the wettability of radicular dentin, thus impacting its interaction with restorative materials. Hence, the aim of the current research was to evaluate and compare the effect of 17% ethylenediaminetetraacetic acid (EDTA) and 7% maleic acid (MA) on the wettability of Sealer Plus BC and AH Plus sealers. Materials and Methods: Thirty single-rooted premolars were decoronated and longitudinally sectioned to form 60 samples. The samples were then arbitrarily separated into three groups (n = 20) determined by the irrigation protocol: Group I (2.5% sodium hypochlorite [NaOCl] + 17% EDTA), Group II (2.5% NaOCl + 7% MA), and Group III (2.5% NaOCl + distilled water). Each group was then split into two subgroups (n = 10) based on the sealer utilized: Subgroup A (Sealer Plus BC sealer) and Subgroup B (AH Plus sealer). The sealers were mixed and placed on the samples. Contact angles of the sealers were determined with a goniometer. The intragroup and intergroup comparison was conducted by Two way-ANOVA test with a significance level of P < 0.01. Results: The wettability of both sealers was favorably influenced by the final irrigant rinse with 7% MA and 17% EDTA, although there was no statistical difference between both sealers in the MA group (P > 0.01). AH Plus demonstrated a better wettability than Sealer Plus BC in the EDTA group (P < 0.001). Both Sealer Plus BC and AH Plus sealers demonstrated lower contact angles on final irrigation with 7% MA in comparison to 17% EDTA. Conclusion: As a final irrigant, 7% MA increased the wettability of both Sealer Plus BC and AH Plus sealers compared to 17% EDTA.
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A questionnaire-based cross-sectional survey of Indian postgraduates and endodontists on awareness, attitude, and practice of using conventional syringe needle irrigation during root canal treatment p. 302
Kavalipurapu Venkata Teja, Sindhu Ramesh, Sahil Choudhari, Krishnamachari Janani, Jerry Jose, Kaligotla Apoorva Vasundhara
DOI:10.4103/sej.sej_26_22  
Introduction: Syringe needles of various gauges and vents have conventionally been used to irrigate the root canal system. This study aimed to collect data on the awareness, attitude, and practice among Indian postgraduates and endodontists of using conventional syringe needle irrigation (SNI) during root canal treatment. Materials and Methods: The survey was performed between January 2019 and December 2021. A total of 1000 printed forms and 1500 electronic questionnaires were shared with postgraduate students and endodontists across India. After validation by three national and two international experts, the survey with 35 questions was formulated. The survey contained 2 demographic-based, 13 awareness-based, 10 attitude-based, and 10 practice-based questions. The Chi-square test was used to assess the data (P < 0.05). Results: A total of 888 (35.5%) completed survey questionnaires were received (589 electronic and 299 printed). The respondents of the survey comprised 37% of postgraduate students and 63% of endodontic practitioners. In 24 out of the 35 questions, there was a statistical difference between postgraduate students and endodontists (P < 0.05). Ninety-one percent of the respondents were aware of the various SNI systems, while 7% were not much familiar and 2% were not aware. Sixty-six percent of the respondents strongly disagreed that SNI alone is sufficient for entire root canal disinfection, while 21% agreed to it. Eighty-eight percent of the respondents strongly agreed and 7% agreed that it is mandatory to activate the irrigant using agitation devices even after SNI, while 5% disagreed. Fifty-nine percent of the respondents used 30-gauge single side-vented closed-ended needles for conventional SNI, while 29% used needles for administration of local anesthesia. Conclusion: The awareness among the postgraduates and endodontists on SNI is moderate and the attitude is positive.
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Root canal morphology and incidence of isthmus in the mesial root canal of the mandibular first molar using cone-beam computed tomography of two different scanning modes p. 309
Mina Nabil Zaher, Mohamed Ibrahim Rabie, Hayam Yousef Hassan
DOI:10.4103/sej.sej_54_22  
Introduction: The mesial root of the mandibular molar is one of the most complex internal anatomies of human dentition. This study aimed to detect root canal morphology and the incidence of isthmus in the mesial root canal of the mandibular first molar using cone-beam computed tomography (CBCT) of different voxel size scanning modes compared to stereomicroscopic evaluation after teeth clearance. Materials and Methods: Sixty extracted mandibular first molars were collected, fixed in foam blocks, and scanned using CBCT with 150 and 400 μm voxel sizes. All the teeth were cleared and fixed in clear epoxy blocks for serial cross-sectioning from the apex, then examined using a stereomicroscope. Comparisons between cross-sectioned slices were achieved using Friedman's test (P ≤ 0.05). Results: There was a statistically significant difference between the cleared teeth, voxel sizes of 400 and 150 μm in the detection of the root canal and isthmus. Only voxel size 150 μm was able to detect the isthmus at 1 mm and 2.5 mm from the apex. Vertucci Types IV and II were the most common canal configurations reported, with a high incidence of isthmus at 4 mm and 5.5 mm from the apex. Conclusion: The 150 μm voxel size mode provides more accurate detection of the isthmus portion and root canal morphology. Vertucci Types IV and II were the most common canal configurations, and an isthmus with a high incidence was found at 4 mm and 5.5 mm from the apex of the mesial root of the mandibular first molar.
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Attitudes of dental practitioners from Northern Morocco on the prescription of antibiotics during endodontic treatment: A survey p. 316
Omar Khaloufi, Lauzan Haj Khalaf, Narjiss Akerzoul, Fatima Zohra Ibn Majdoub Hassani, Babacar Toure
DOI:10.4103/sej.sej_61_22  
Introduction: Nowadays, antibiotics are not correctly used among some dental practitioners. Thus, the misuse of antibiotics could lead to antibiotic resistance in the long run. The aim of this study was to evaluate the prescribing attitudes of dental practitioners in Northern Morocco when treating pulpal and periapical pathologies. Materials and Methods: This cross-sectional study involved 220 dental practitioners registered on the board of the National Council Order of Dentists of Morocco. A self-administered questionnaire, regarding the types of antibiotics used for endodontic treatment in healthy adult patients with endodontic pathological situations, was used and filled out via the E-mail addresses of practitioners chosen randomly. The data were analyzed with Jamovi (version 1.8.1). Quantitative variables were expressed as mean and standard deviation and qualitative variables as number and percentage. The Chi-square and the ANOVA tests were performed. The significance level was P < 0.05. Results: Forty percentage of dental practitioners prescribed amoxicillin as a first-line therapy for a patient who does not have a penicillin allergy and for patients with a penicillin allergy; azithromycin was the drug of choice prescribed by 41.1% of practitioners. The duration of prescription was 6.5 days ± 0.7. No statistically significant difference was noted regarding the duration of the prescription, in relation to age, sex, specialization, and country of graduation (P > 0.05). The acute apical abscess represents the pathology for which most antibiotics are prescribed. Practitioners aged between 24 and 35 years prescribe more than the oldest practitioners (P = 0.04). Antibiotics were also prescribed for the management of pulpitis and chronic apical periodontitis. The lowest prescription rates were noted among practitioners specializing in or having benefited from endodontic training. Conclusion: It emerges from this study that very few practitioners use antibiotics appropriately in treating pulpal and periapical pathologies. A real lack of knowledge has been noted with regard to indications, dosages, and duration.
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CASE REPORTS Top

Management of mandibular premolars with various C-shaped root canal configurations: A case series p. 322
Najma Abdulla Essa Al-Mahroos, Sara Abdulla Essa Al-Mahroos, Saad Al-Shahrani
DOI:10.4103/sej.sej_27_22  
C-shaped canal configuration poses a challenge to the clinician, both at the diagnostic and treatment levels. The present case series aims to describe the management of mandibular premolars that have various C-shaped configurations. Three healthy Saudi females were referred to the endodontic department for the management of premolars that appear unusual radiographically. The teeth response was normal to palpation and percussion. The cold test was negative for the concerned premolars. A diagnosis of either necrosis or previously initiated was established for the pulpal condition. The periapical tissues were diagnosed as normal/asymptomatic apical periodontitis. Modern endodontic tools such as a limited field of view cone-beam computed tomography, the dental operating microscope, and nickel–titanium files were used to negotiate, clean, and shape the root canal system. While EndoActivator sonic irrigant activation was used to effectively disinfect the uninstrumentable ramifications, thermo-plasticized gutta-percha in continuous-wave compaction technique was used to fill the root canal system. During a 12-month follow-up, the clinical and radiographic evaluation revealed no signs and symptoms and periapical healing of the lesion associated with the tooth in case #1. The other premolars were also free of signs and symptoms, with normal apical tissues.
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Multiple idiopathic invasive cervical root resorption p. 331
Prasannasrinivas Deshpande, Karthikeya Patil, Usha Hegde, M Aparna Vijayan
DOI:10.4103/sej.sej_12_22  
MICRR is a rare disease affecting more than 3 teeth at a time and is known to gradually involve other teeth. The etiology of this progressive disease is unknown and is usually detected as an incidental radiographic finding. This article reports one such case involving 5 teeth in a 25 year old healthy male patient who reported the chief complaint of discomfort and vague dull pain in the left mandibular posterior tooth for 3 months. Intraoral examination revealed initial occlusal pit caries on mandibular left first molar (#36) with grade I mobility, which was nontender on percussion with no vestibular findings. A panoramic radiograph showed a well defined radiolucent lesion in the cervical region on the mesial and distal surfaces of tooth #36 and the distal cervical areas of mandibular left first (#34) and second premolar (#35). Tooth #36 was extracted due to poor prognosis and subjected to histopathological investigation, scanning electron microscopy (SEM), and energy dispersive X ray (EDX or EDS) analysis. Histopathological evaluation showed cervical resorption with surface resorptive irregularities with vacuolar changes, and SEM revealed areas of lacunar resorption with irregular borders. Results of EDX analysis showed atomic % of calcium (CA) and phosphate (P) of 4.8% and 3.4%, respectively, with a CA: P ratio of 1.41:1.
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LETTERS TO EDITOR Top

Scanning electron microscope - The right tool for smear layer analysis? p. 338
Nidambur Vasudev Ballal
DOI:10.4103/sej.sej_10_22  
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Author's reply p. 339
Mohamed Jamal
DOI:10.4103/1658-5984.354839  
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An evidence-based discussion on herbal-based root canal disinfection: A letter to editor unrevealing the current scope and future perspective p. 340
Kavalipurapu Venkata Teja, Krishnamachari Janani, Jerry Jose, Galvin Sim Siang Liin
DOI:10.4103/sej.sej_45_22  
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NEWS Top

11th Saudi Endodontic Society International Conference p. 342
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7th Pan Arab Endodontic Conference p. 343
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