Introduction: Endodontic infections are polymicrobial in nature. Enterococcus fecalis is the most common micro-organism isolated from failed endodontic cases. The constant increase in antibiotic resistant strains and side effects caused by synthetic drugs has prompted researchers to look for herbal alternatives since the gold standard for irrigation i.e., sodium hypochlorite (NaOCl) has many disadvantages. Objective: The present study was aimed to explore newer irrigation solutions, which would probably be as effective as NaOCl. Materials and Methods: Extracted human single rooted premolar teeth were biomechanically prepared, vertically sectioned, placed in tissue culture wells exposing the root canal surface to E. fecalis is grown on Mueller Hinton agar plates to form a biofilm for 6 weeks. At the end of 6 ^th week, all seven groups were treated with 3 ml of test solutions and control for 10 minutes and evaluated for E. fecalis growth and number of colony forming units. Results: Propolis, NaOCl and triphala showed no statistically significant difference, whereas all the other inter-group differences were statistically significant (Tukey's honest significant difference (HSD)) (P < 0.001). Conclusion: Propolis and triphala were found to be as efficacious as NaOCl. The use of herbal alternatives as root canal irrigation solutions might prove to be advantageous considering several unfavorable properties of NaOCl.

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Aim: The purpose of this in vitro study is to provide clinical data on the presence of the second canal in mandibular incisor teeth of Saudi Arabian Samples. Materials and Methods: Eighty extracted human mandibular incisors were collected from Saudi patients. The teeth were accessed by small round bur then placed in 5.25% sodium hypochlorite for 24 hours to dissolve the organic debris. Indian ink was injected inside the root canal systems under negative pressure. The teeth were decalcified in 5% nitric acid for three days then dehydrated in different concentrations of ethyl alcohol. Following the decalcification process, the teeth were cleared in methyl salicylate and evaluated according to Vertucci's classification. Result: Fifty six of both mandibular central and lateral incisor teeth (70%) had type I canal configuration (one main canal and one main apical foramen), while the remaining 30% of the sample (24 teeth) had a type III canal configuration (two separate canals and merged into one canal before exiting the tooth through single apical foramen). Conclusion : The incidence of two canals in mandibular incisor teeth is about one third of the examined Saudi Arabian samples with no difference between the centrals and laterals. The clinician should deal with these teeth as if they have two canals unless it is proved otherwise.

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Aim: To determine the prevalence of the number of root canals in permanent maxillary first and second premolars of a Saudi Arabian sub-population. Results will be compared to previous Asian studies. Materials and Methods: A total of 894 periapical radiographs of endodontically treated maxillary first and second premolars of 628 Saudi patients (268 males and 360 females) were viewed. The teeth were segregated into maxillary first premolars (463) and maxillary second premolars (431). The diagnostic, working length, master cone and final films with different angles were mounted, projected and, with the utilization of written clinical records, evaluated. Teeth with multiple canal systems were categorized according to whether the canals exited the root by common or separate apical foramen. Data was analyzed statistically using Chi-square test and professional t-test, by comparing pairs of groups with the significant level established at 5% (P < 0.05). Results: More than 90% of first maxillary premolar and more than 50% of the second maxillary premolar was found to have two canals. There was no significant difference between male (92%) and female (95%) in the distribution of the two root canals of the first maxillary premolar (t-test = 1.21, P value = 0.228), however, there was significant difference between the distributions of male (69.4%) and female (52.2%) of the two root canals within the second maxillary premolar (t-test = 3.75, P value = 0.000). Few teeth showed three canals. Conclusion: The number of root canals of the maxillary first premolar in Saudi population shows a higher incidence of two canals (93.6%) than previously reported. In addition, the figure is higher than most of the Asian countries.

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Objective: This study aimed to investigate the bactericidal effect of silver nanoparticles (AgNPs) in reducing bacterial infection in root canal when used as intracanal medicament alone or in addition to the conventionally used calcium hydroxide (Ca(OH)₂). Materials and Methods: The root canals of 110 single-rooted teeth were cleaned, shaped, and sterilized. All groups, except for negative control, were inoculated with Enterococcus faecalis for 48 h. Then, teeth were divided into five groups according to the intracanal medicaments to be used. Group I (n = 30): Ca(OH)₂. Group II (n = 30): AgNP. Group III (n = 30): AgNP + Ca(OH)₂. Group IV (n = 10) was used as a positive control where the root canals were inoculated with E. faecalis and left without treatment. Group V (n = 10) was used as a negative control where the root canals were checked for the absence of bacterial growth. Specimens were incubated for 1 and 2 weeks. Pre- and post-medication samples were obtained by paper points, and the colony-forming units were counted. Results: Ca(OH)₂ resulted in a higher percentage of bacterial reduction in both 1 and 2 weeks of application (81.5% and 98%, respectively). AgNP was ineffective against E. faecalis with 32.9% bacterial reduction in 1 week and 56.5% after 2 weeks. Conclusion: It was concluded that the antibacterial effect of AgNP was lower than Ca(OH)₂ or combination of both materials.

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The aims of this paper were to review the studies that investigated the root and root canal morphology of permanent dentition in the Saudi Arabian population and to compare their results with the findings of international morphological studies conducted on other populations. An electronic search using the PubMed and Scopus databases was conducted using combination of the following keywords: "root canal morphology", "root morphology", "dental anomalies", and "Saudi Arabian population". In addition, all issues of the Saudi Dental Journal (since 1989) and Saudi Endodontic Journal (since 2011) were manually searched for relevant articles. Then, the reference lists of the articles were screened to identify further eligible publications. A total of 23 studies met the inclusion criteria and were subjected to data extraction and analysis. Variations from the normal root and canal morphology may occur in all populations including the Saudi Arabian population. Therefore, the clinicians must always take these variations in consideration during root canal treatment to ensure a successful treatment outcome.

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Objective: The aim of the study was to assess the radiographic quality of root fillings done by the undergraduate students. Materials and Methods: A sample of 258 clinical cases of patients who received root canal treatment from undergraduate students in the years 2010 to 2012 were selected, out of which 194 root fillings were assessed radiographically based on the following criteria; length and density of root filling. Root fillings were categorized as acceptable and unacceptable. Percentages and χ² test were used for statistical analysis. Results: From the 194 root fillings, 119 (61.35%) were having acceptable and 75 (38.65%) were having unacceptable root fillings. From the total 75 unacceptable root fillings, 49 (65.33%) had density problems, 11 (14.66%) were overfilled, and 15 (20%) were under filled. Chi-square test was done for statistical analysis; revealed no significant difference in the radiographic quality between anterior and posterior root fillings. Conclusion: The radiographic quality of root fillings done by undergraduate students was acceptable in 61.35% cases. Most common cause of unacceptable fillings was due to density problems compared to overfilling and under filling. Results from the study indicate that remedial measures have to be undertaken to improve training of undergraduate students in root canal treatment procedure.

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Objective: This study evaluated the quality of root canal treatment (RCT) and determined the prevalence of apical periodontitis (AP) in Al-Madinah Al-Munawwarah, Saudi Arabia. Materials and Methods: Panoramic radiographs of 630 patients (316 males and 314 females) who attended clinics at the Dental College of Taibah University seeking dental care for the first time between 2010and 2013 were assessed for the adequacy of RCT and presence of AP. Results: RCT of at least one tooth was found in 52.8% of the patients, with a significantly higher prevalence in females (28.4 vs. 24.4%; P = 0.012), and AP was found in 53.5% of the patients, with a significantly higher prevalence in females (31.9 vs 21.6%; P = 0.000). Conclusions: There was a significant correlation between AP and inadequate endodontic treatment. This study reveals the importance of improving RCT in Al-Madinah Al-Munawwarah.

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The knowledge of root canal system of different human teeth is a "road map" for the successful root canal treatment. Mandibular canine usually contains one root with a single root canal. Two-rooted mandibular canine is rare. This paper describes two cases of root canal therapy of permanent mandibular canine with two root canals and one apical foramen (Type II) in one root and canine with two separated roots. The clinicians must always suspect anatomical varieties and use all the available tools to diagnose and manage their cases.

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Studies on the anatomy of the root apex are an area of interest to the endodontist; they have reported that the position of the apical constriction, apical foramen and the cemento-dentinal junction varies across the tooth types. These anatomical apical landmarks are considered extension limits for root canal instrumentation and filling. Achieving an optimum working length is thought essential for successful root canal treatment, so adopting any of these landmarks is associated with certain risks and benefits. The variability in the position of the apical constriction and apical foramen, for example, complicates their clinical detection, while the cemento-dentinal junction is a histological landmark that cannot be detected clinically. The radiographic apex does not always coincide with the anatomic apex of the tooth. The pre-operative status of the pulp must be considered while obtaining the working length. Most prognostic studies agree that extending the root filling to within 2-3 mm of the radiographic apex is associated with favorable treatment outcomes.

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The use of triple antibiotic paste (TAP) (mixture of ciprofloxacin, metronidazole and minocycline) as an intra-canal medicament have shown very encouraging results particularly in non-vital immature teeth associated with periradicular lesions. Hence, before opting for a surgical approach, a non-surgical approach can be thought of with extended use of TAP as intra-canal medicament, especially in patients who are phobic to invasive procedures. On the flip side, the use of TAP has few side-effects, of which one is the discoloration it can cause due to the presence of minocycline in the mix. The purpose of this article is to presents a case of coronal discoloration due to the use of TAP as an endodontic intra-canal medicament.

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Objective: To determine the prevalence of pulp stones using cone-beam computed tomography (CBCT) and to explore any potential correlation between the occurrence of pulp stones with age, gender, tooth, arch, and tooth status. Material and Methods: CBCT scans of 428 patients comprising of 2982 teeth were retrospectively evaluated in the present study. All teeth were analyzed in sagittal, axial, and coronal plains by two examiners. The pulp stones were identified as the presence of a definite round or oval opaque or dense mass in the pulp cavity. The location of the involved tooth in terms of jaw and side and the status of involved tooth in terms of caries, restored, attrition, and periodontal disease were recorded. Statistical analysis was carried out by applying Chi-square tests with the Yates correction. Results: Out of a total of 428 individuals, pulp stones were identified in 50.93% of patients and 13.34% of teeth. The presence of pulp stones was more frequently encountered in males (58.89%) than in females (41.14%) and in individuals belonging to the fifth decade. First molars exhibited the highest incidence of pulp stones (P = 0.0090). No significant difference was observed when maxillary and mandibular arches and the sides were compared. The presence of pulp stones was high in carious, restored, attrited teeth and teeth with periodontal disease, when compared to the intact teeth (P < 0.05). Conclusion: Pulp stones were observed more frequently in molars and in nonintact teeth. Pulp stones occurred predominantly in males in the fifth decade irrespective of arch and side.

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Aim : The purpose of this study was to comparatively evaluate the antibacterial property of various concentrations of green tea extracts and 2% chlorhexidine (CHX) against Enterococcus faecalis 0(E. faecalis) in vitro. Materials and Methods: The activity of green tea extract and CHX on E. faecalis was measured on agar plates using the agar diffusion method. In addition, the tube dilution method was used to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration of green tea extract against E. faecalis. Results: The MIC of green tea extract was found to be 3.5%. The zone of inhibition was found to be concentration dependent. The 2.5% concentration of green tea extract showed 20 mm zone of inhibition, while the 3% concentration demonstrated a 30 mm zone of inhibition. Two percent CHX showed 30 mm zone of inhibition. Conclusion: Three percent concentration of green tea extract showed an antibacterial activity equivalent to 2% CHX against E. faecalis.

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Aim: The aim of this study was to compare the calcium hydroxide (Ca(OH) ₂ ) removal efficacy of the EndoActivator system with that of conventional irrigation with a syringe and hand file manipulation. Materials and Methods: A total of 44 extracted human single-rooted mandibular premolars were used. The root canal systems of all teeth were cleaned and shaped, then filled with Ca(OH) ₂ paste. The teeth were divided into two groups: Ca(OH) ₂ was removed using ethylenediaminetetraacetic acid (EDTA) and sodium hypochlorite (NaOCl) with hand filing and irrigation (Group 1) or the EndoActivator system (Group 2). Each tooth was split into two halves and examined under a scanning electron microscope. Results: Ca(OH) ₂ particles were completely removed at the coronal level in both experimental groups. More Ca(OH) ₂ particles were present in the apical third than in the middle-third in both groups. No significant interaction was observed between the two experimental groups or among the three examined levels (P > 0.05). Conclusion: Agitation with NaOCl and EDTA improved Ca(OH) ₂ removal only in the coronal third of the root canal. Use of the EndoActivator system did not improve the efficacy of Ca(OH) ₂ removal in the middle and apical thirds.

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Objectives: The aim of the study was to compare manual dynamic agitation with sonic agitation on removal of intra radicular Enterococcus faecalis (E. faecalis) biofilm. Material and Methods: Extracted mandibular premolars for orthodontic purpose were sectioned at cervical level and divided into three groups (n = 30). The root canals were instrumented using Protaper rotary instruments up to apical file F4. Roots were sterilized and E. faecalis bacteria were incubated within their root canal space for four weeks. Confirmation of biofilm was done using scanning electron microscopy and Gram staining. All groups were irrigated with side vented needle by using three percent sodium hypochlorite (NaOCl) for 60 seconds. Two experimental groups were agitated with manual dynamic agitation (with master gutta-percha cone) and sonic agitation (EndoActivator). Remaining bacteria were collected using sterile paper point, which were incubated inside brain-heart infusion (BHI) broth to check turbidity. The turbid broth was streaked on blood agar plate for colony counts. Result: Both experimental groups showed highly significant difference in their mean colony count when compared with control group; with P < 0.001. Conclusion: Passive sonic agitation with EndoActivator has proven to be the best irrigating system followed by manual dynamic agitation and conventional needle irrigation.

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Objective: We evaluated knowledge of technical aspects of non-surgical root canal treatment among general dentists in private dental clinics in Al-Madinah Al-Munawarah, Saudi Arabia. Materials and Methods: A questionnaire was distributed randomly to 70 general dental practitioners who were working in private dental centers. The response rate was 88.6%. Results: The results showed that only 3% of dentists were using rubber dams for isolation during endodontic treatment. The majority (59.7%) were using radiographs to determine the length. Also, 37% were using nickel-titanium (NiTi) rotary instruments to prepare the root canal. The lateral condensation technique with gutta percha points to fill the root canal was used by most respondents (77.5%). Conclusions: This study provides important data on endodontic treatment by general dental practitioners in Al-Madinah Al-Munawarah private dental centers. It shows a general lack of knowledge regarding the importance of using rubber dams as well as the new endodontic materials and methods. Continuing education programs to update their knowledge in the field of endodontics are essential.

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Aim: This study is aimed to evaluate the confidence level of undergraduate final year dental students in performing root canal treatment (RCT) and how it may affect their performance and perception regarding endodontics. Materials and Methods: A self-administered questionnaire was distributed to the final year dental students, at the University of Medical Sciences and Technology, Khartoum, Sudan (2013–2014). A total of 21 students were requested to participate voluntary and were asked to score their level of confidence using a 5-point Likert's scale. Results: Response rate was 100%, all the students (100%) stated that the requirements set were enough, and 66.7% rated endodontic as average in terms of difficulty. When rating the mean of self-confidence for performing RCT in the dentition, maxillary teeth (2.43 ± 0.51) followed by mandibular teeth (2.71 ± 0.64) were higher, whereas the molars were the least. Higher scores of self-confidence were in administrating local anesthesia (4.24 ± 0.70), followed by root canal shaping by hand instrument (3.76 ± 0.54). No association was found between overall confidence level and the number of performed RCT (P = 0.721). No association was found between overall confidence level of students who were subjected to instrument fracture and their frequency of fracture (P = 0.507), supervisor' reaction (P = 0.587), and willingness to specialize in endodontics (P = 0.530). Conclusion: Students displayed high confidence in performing basic endodontic and treating single-rooted teeth. More exposure is recommended to enhance the students' self-confidence.

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Aim: To evaluate and compare the regenerative potential of natural autologous scaffolds (blood clot and platelet rich fibrin [PRF]) with artificial scaffolds (commercially available collagen and poly-lactic-co-glycolic acid [PLGA] polymer) in inducing apexogenesis in necrotic immature permanent teeth. Materials and Methods: Necrotic immature permanent maxillary incisors with or without radiographic evidence of periapical lesion were included. Access opening was done under rubber dam isolation. Canal disinfection was done using minimal instrumentation, copious irrigation, and triple antibiotic paste as interappointment medicament for 4 weeks. After 4 weeks, asymptomatic teeth were divided into four groups on the basis of scaffolds used for revascularization procedure: Group I (blood clot); Group II (PRF); Group III (collagen); Group IV (PLGA). The clinical and radiographic evaluations of teeth were done at 6 and 12 months after the procedure and compared with baseline records. Result: Clinically, patients were completely asymptomatic throughout the study period. Radiographically, all cases showed improvement in terms of periapical healing, apical closure, root lengthening, and dentinal wall thickening. PRF and collagen gave better results than blood clot and PLGA in terms of periapical healing, apical closure, and dentinal wall thickening. Conclusion: Revascularization procedure is more effective and conservative over apexification in the management of necrotic immature permanent teeth. This study has shown that PRF and collagen are better scaffolds than blood clot and PLGA for inducing apexogenesis in immature necrotic permanent teeth.

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Aim: To determine the coronal leakage of various provisional restorations with and without intracanal medication over time after being exposed to human saliva. Materials and Methods: This study investigated Coltosol F, Cavit, Ketac Molar, and IRM as provisional restorative material. Calcium hydroxide and chlorhexidine were used as an intracanal medicament. Ninety-eight single rooted teeth were randomly selected and then mounted in an apparatus that isolated the crown portion of the tooth. Provisional restorative materials were placed in the access cavity following manufacturer guidelines after placement of intracanal medicament. Human saliva and brain heart infusion broth in 3:1 ratio were applied to the samples, incubated at 37°C, and results were tabulated over the course of 4 weeks by the appearance of turbidity in the lower part of the apparatus. Statistical Analysis: The data were statistically analyzed using proportional Z-test. The level of significance was set at 0.05. Results: Coltosol F and Cavit could significantly prevent the bacterial leakage up to a period of 7 days with a P value of 0.01 and 0.005, respectively. Bacterial recontamination was relatively less in the samples treated with intracanal medicaments up to 14 days. After 14 days, however, all materials leaked in over half of the samples. Conclusion: No provisional restorative material can be considered superior in providing a reliable seal after 14 days. Inter-appointments schedule should not extend beyond 2 weeks and after endodontic therapy final restoration should be completed within 1 week.

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Introduction: Rubber dam was introduced more than 150 years ago. It has been the standard of care, especially in endodontics. In spite of its advantages, dentists still refrain from using it. Hence, the objective of this study was to investigate the frequency of rubber dam usage among dental practitioners in Maharashtra, India. Materials and Methods: It was a cross-sectional study. The questions were regarding the usage of rubber dam in their practices which was answered by the dentists. A sample size of the study was 400. Questionnaire included eight questions and the last question was open-ended. Results: Dentists using the rubber dam in their daily practice were only 23.8%. Out of which, only 4.2% dentists use it in 100% of the cases. When the reason for not using the rubber dam was asked, 40% dentists said they do not use rubber dam because its time consuming, 37% do not use it due to patient compliance, 14% responded that it is expensive, and 9% were unsure of the technique. Conclusions: The low percentage of rubber dam usage in Maharashtra is not acceptable, and dentists should follow recommended standard of care. Dental schools should make it mandatory for students to use rubber dam in root canal treatments.

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The use of radiographs for working length determination is usual practice in endodontics. Exposing radiographs following the principles of the paralleling technique allows more accurate length determination compared to the bisecting-angle method. However, it has been reported that up to 28.5% of cases can have the file tip extending beyond the confines of the root canals despite an acceptable radiographic appearance. The accuracy of radiographic working length determination could be affected by the location of the apical foramen, tooth type, canal curvature and superimposition of surrounding structures. Variations among observers by virtue of training and experience may also influence the accuracy of the procedure. The interpretation of radiographs could be affected by film speed and viewing conditions, with the superiority of digital imaging over conventional radiography for working length determination remaining debatable. The combination of several methods is recommended for acquiring the most accurate working length.

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Radix entomolaris (RE) is considered to be an Asiatic trait. However, its prevalence in Indian population is found to be lower than in other Asian races. Nevertheless, its awareness and identification is vital to achieve endodontic success. This article presents a review on clinical approach and a case series on the detection and endodontic management of RE in mandibular first molars. Radix entomolaris was detected by identifying the presence of a double or extra root outline in the preoperative radiograph, modifying the access opening and closely inspecting the pulp chamber and was endodontically treated following cleaning, shaping, and obturation of the canals. Achieving the endodontic success in the presence of an RE requires knowledge about its prevalence, diagnosis, morphology, canal configuration, and clinical approach.

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Traumatized anterior teeth with sub-gingival crown fractures are a challenge to treat. The management of sub-gingival fractures includes exposing the cervical margin followed by appropriate coronal restoration. The treatment modalities, which involve exposing the cervical margin, are surgical crown lengthening and orthodontic extrusion. This paper reports a case of fractured maxillary anterior tooth at the sub-gingival level that was managed by forced orthodontic extrusion after endodontic treatment followed by esthetic rehabilitation, a much forgotten technique not utilized routinely yet conservative and cost-effective.

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Aim: With the whole world looking at the eradication of existing infectious diseases and preventing any new infections, sterilization of instruments is significant to ensure optimal patient care. Infection preventions and controls are the most important components for providing a safe environment for patients and staff within a dental practice. Hence, the objective was to assess the level of knowledge, attitudes, and practices regarding the sterilization of endodontic files by the postgraduate (PG) students from the Department of Conservative Dentistry and Endodontics at dental colleges in Bangalore. Materials and Methods: A cross-sectional study was conducted among PG students of Conservative and Endodontics in Bangalore using a pretested questionnaire. Results: A total of 88% accepted endodontic files need to be sterilized and 60% reported that endodontic instruments can be used four or more times, but 44% practiced it. Interestingly, 74% reported that dental assistants are not trained for sterilization protocols. Conclusion : The study shows that although there is high knowledge and positive attitude regarding sterilization of endodontic files, but it is seldom practiced creating lacunae in motivation. To bridge this gap, frequent reinforcement is needed in the critical area of sterilization.

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Aim: To evaluate and compare the volume percentage of root canals obturated with gutta percha (POV), with various techniques using spiral computed tomography (SCT). Materials and Methods: Forty-five mandibular first premolar teeth were instrumented using Race files and randomly divided into three groups of 15 teeth each (n = 15). The volume of root canal space was measured using SCT and the root canals were obturated as follows: Group 1-lateral condensation, Group 2-single-cone obturation and Group 3-thermoplasticized gutta-percha technique. The filled volume of root canals was measured using SCT and POV was calculated in total and at apical, middle and coronal third individually. The data was statistically analyzed using one-way ANOVA and Tukeys post hoc multiple comparison tests. Results: An intergroup comparison of the mean value of POV showed a statistically significant difference ( P < 0.05) in the middle third and in total when group 1 was compared to group 2. Conclusion: All the groups showed 100% POV at the apical third. Group 2 showed least POV at the middle third of the root canal.

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