6 Global Journal of Oral Science, 2020, 6, 6-11

E-ISSN-2414-2020 © 2020 Global Journal of Oral Science

Endomethasone as Root Sealer: The Current State of Art: A Systematic Review Supported with Case Reports

Comola Giorgio1,*, Marco E. Pasqualini2, Pasqualini Giulia3, Manenti Pierangelo4, Dal Carlo Luca5, Rossi Franco6 and Domenico Colombo6

1Universidad Alfonso X el Sabio (Madrid), Spain; 2Pivate Practice, Milan, Italy; 3Private Practice, Borgo Valsugana (TN), Italy; 4Private Practice, Bergamo, Italy; 5Private Practice, Venezia, Italy; 6Private Practice, Busto Arsizio (VA), Italy

Abstract: Objectives: Compare the root cements most used in endodontic therapy with emphasis on Endomethasone.

Materials and Methods: A review of the literature was carried on using the leading scientific databases in the time frame of the last 11 years, resulting in a total of 80 items of possible interest. Of these 15 items were kept with the purpose of analyze the following characteristics of endodontic cements: biocompatibility, adhesion, bacteriostatic / bactericidal activity, cytotoxicity, color variation, obturation and complications.

Results and Conclusions: From the research carried out was ensured that Endomethasone in root canal therapy may be a viable alternative to traditional filling with gutta-percha and root sealers.

Keywords: Endomethasone, Endodontic Treatment, Root Sealers.

The majority of root canals which require endodontic treatment has often an irregular shape. Such anatomical morphology makes it impossible to be perfectly adaptated within the same obturation solid and / or semisolid. The techniques with the sole gutta-percha (which provide a main cone carefully adapted to the apical tract and additional tips, rather than the use of high heat thermoplastic wave or continuous techniques with appropriate carriers) are valid for compact filling of the main part of the canal. However this will leave an interphase, otherwise minimal, due to the type of its material, which has no adhesive ability. It has been shown how the success of a good root canal therapy is due to the lack of secondary bacterial infiltrations, reason why the addition of an endodontic cement (which is capable of adhering chemically and micro-mechanically to the canal wall) is essential to ensure the clinical success. For a long time Endomethasone has been a valuable therapeutic material for an optimum sealing of the root canal, although in recent years there has been a remarkable evolution in the sealers. Today, however, the Endomethasone remains a solid option in the orthograde obturation of root canals.

MATERIALS AND METHODS

A literature review was made using a narrow reasearch criteria with the porpouse to include into the bibliograpy only significant results. A reaserch was

*Address correspondence to this author at the Universidad Alfonso X el Sabio (Madrid), Spain; Tel: +39 339 6897057; E-mail: drcomola@gmail.com

developed with the help of the largest database currently available on the computer side for scientific analysis. The list of used items was: the Core-Collection WOS (Web of Science) database, including all results from PubMed (MEDLINE), SciELO and specific search engine EBSCO Dentistry and Oral Science Source. The search term used was "ENDOMETHASONE" abbreviated with an asterisk in order to be able to include any hidden results. None of the Boolean operators of any kind were used, so have been excluded: AND, OR and NOT. A fundamental inclusion criteria was the reduction in the timeframe in articles between 2006 and 2017. WOS gave 49 results EBSCO 31, of these, after the reading of abstracts, were excluded all those who were not relevant because centered on the filling materials removal techniques for eventual retreatment or analysis which does not bring any relevant informations, reducing to a total of 15 items. Attempts have been made to include all aspects of interest about an endodontic concrete: biocompatibility, adhesion, bacteriostatic / bactericidal activity, cytotoxicity, color variation, three-dimensional fillings and possible complications or interactions with other products. Into the tables are compared most part of the endodontic cements used nowadays in endodontics: Endomethasone (A); Sultan (B); Sealapex (C); Diaket (D); Epiphany (E); AH26 (F); AH Plus (G); Apexit (H); PCS (I); PCS EWT (L); Tubli-Seal (M). Three clinical cases were presented, treated with the Endomethasone C (Septodont) use which has as its composition: hydrocortisone acetate 1,00g and as excipients: Diiodotimolo, Barium Sulfate, Zinc Oxide and Magnesium stearate qs 100g (CE0459). The

Endomethasone as Root Sealer Global Journal of Oral Science, 2020, Vol. 6 7

shaping of canals is obtained by identification with the apex of the sixth generation apex locator, action made possible by the apical permeability (Pattency Apical) obtained with K 08/10 ISO files. Then it proceeded to the instrumentation by means of a continuous rotary system with type files: Protaper Universal or with Endomat, with alternating movement [1], always with copious irrigation with sodium hypochlorite and EDTA. hydrocortisone acetate 1,00g and as excipients: Diiodotimolo, Barium Sulfate, Zinc Oxide and Magnesium stearate qs 100g (CE0459).

DISCUSSION

Given that the use of an endodontic cement is necessary in order to obtain a correct root canal treatment is advisable to investigate which one of the various options available on the market is the most appropriate (in order to achieve the best clinical outcome). Generally the scientific literature divides cements into two macro-categories: resin cements and eugenol cements. Among these the AH + (DENTSPLY) and the Endomethasone (Septodont) are two cements of particular interest, since widely used in clinical practice. Several are the tasks that had to perform an endodontic cement and many must be its features. Ideally it should be radiopaque, having a good adhesion to dentin, be fluid enough to penetrate into the ducts accessories, prevent the secondary microfiltration ensuring a good obturation, owning a modest antimicrobial activity, be biocompatible, not produce or at least not to favor the chromatic variation of the tooth [2]. Unfortunately, none of the materials which are commercially available fully meet the ideal criteria. It is the clinician who has to decide, considering the reconstructions that will be performed later on, which cement is the most appropriate to fill the endo-root canal, (pointing out that Endomethasone remains the substance that is closest to a hypothetical gold standard).

BIOCOMPATIBILITY AND EFFECTIVE ANTIMICROBIAL

Biocompatibility is an essential characteristic of any material that remains in the mouth of a patient. The inclusion of a paste with medicinal properties within the root canal has resulted in longer lasting results with better control of the clinical condition after endodontic treatment. In various studies it was demonstrated that some of the materials considered to be inert to the top, with excellent results in the unfortunate case of a root wall perforations as the MTA, are cytotoxic in time, on

the peri-radicular tissues [3]. In a comparative study of 2007 it has been shown as the normal inflammatory reaction of the human body wears off after only 30 days in contact with the Endomethasone without any recurrence [4]. The cytotoxicity induced by addition endoradicolari substances is variable, resin cements as AH + (which have always been considered "safe") actually show values significantly higher than those that would be expected.

AH + cytotoxic fact remains for more than two weeks in contact with the fibroblasts, the MTA, which is abundantly used for the closure of any perforations, continues to be detrimental to the cells even after 5 weeks, the Endomethasone instead exhausts its toxic capacity, which could be considered detrimental to ab initio, but at the same time the elimination of any bacteria, exactly after a week of persistence in peri radicular tissues [3]. It is important to emphasize its scarce inflammatory action in any situations of iatrogenia, such as the extrusion of material beyond the apex in the maxillary sinus. In a 5-year case report published in 2007, a 47 year old patient had a fair amount of Endomethasone in the maxillary sinus after scoring a root canal treatment, the same filling material was reabsorbed spontaneously and without causing noticeable symptoms in just over 48 months, thus avoiding any somewhat invasive surgery for its removal [5]. The fact that squeeze out a small part of the cement beyond the apex as a practice to get the perfect apical seal is a condition that causes some scientific controversies, on one side it is argued that it is the only way to get a true obturation, on the other there is a fear of irritating the peri-apical tissues. It can be noticed that with slightly biocompatible materials the cement leakage beyond the apex can lead to a chronic stimulus and to persist any leukocyte infiltrates in the connective tissue [6]. Although the extrusion beyond the apex with Endomethasone is often deprecated, in 2016 it was demonstrated that in the 4 years after the therapy, the reabsorption of excess can take place in physiological manner, for which reason the unintentional extrusion of small quantity of cement over the apical foramen can sometimes obtain a disinfection of the periapice [7]. The placement of the cement in the periapice level can be achieved by sprinkling the tip of a gutta-percha cone "pirate" led to work longitude, optionally repeating step prior radiographic control and instrumental. Obviously it is always recommended since the excess overfilling can lead to permanent damage such as, for example, paresthesia of the inferior alveolar nerve [8]. The percentage of eugenol

8 Global Journal of Oral Science, 2020, Vol. 6 Giorgio et al.

combined with the action of the corticosteroid contained confers to Endomethasone sedating and antimicrobial properties which are effective on a large spectrum and persistent over the time. Each cement is able to generate an area of bacterial inhibition, the greater this is much better the coverage and the therapeutic outcome will be. Analyzing the most widely sold commercial brands, the value of the greatest bacterial inhibition was found with the Endomethasone (that remains active even in a large percentage of periapical lesions which are treated with the intentional

extrusion beyond the apex material) [9]. If the eventual action of certain antibiotics is added to all this, some authors argue that it is effective against E. faecalis, considered the main cause of relapse in endodontics [10, 11] (Tables 1-3).

FILLING THREE-DIMENSIONAL

In addition to antimicrobial properties, the ADA (American Dental Association) has specified the characteristics that should have a cement to obtain a

Table 1: Area of Inhibition in mm3 of the Cements More Used in Endodontics

24h 48h 72h

Endometasone 35,50 +/- 1,29 33,50 +/-1,29 32,50 +/- 1,73

Sultan 31,25 +/- 1,50 30,50 +/-1,73 28,25 +/- 1,25

Sealapex 24,00 +/- 2,16 22,00 +/- 2,16 27,75 +/- 2,21

Diaket 22,75 +/-2,06 19,75 +/- 1,70 19,00 +/- 1,41

Epiphany 20,00 +/- 0,81 19,25 +/- 0,95 18,00 +/- 1,63

AH26 14,75 +/- 0,95 14,25 +/- 1,25

Bodrumlu E, Semiz M. Antibacterial activity of a new endodontic sealer against Enterococcus faecalis. Journal of the Canadian Dental Association 2006; 72(7): 637.

Table 2: Follow Up to 4 Years of the Presence of Endometasone over Apex

1-year follow-up 2-year follow-up >4-year follow-up Sealer Baseline n

Present Absent Present Absent Present Absent

Absent %

AH Plus 20 13 1 16 1 17 3 15

Apexit 15 7 2 8 0 10 5 33

Endomethasone 15 7 2 4 5 2 13 87

PCS 28 8 6 8 8 5 23 82

PCS EWT 21 9 5 9 10 6 15 71

Tubli -Seal 6 0 3 0 4 0 6 100

Ricucci D, Rocas IN, Alves FRF, Loghin S, Siqueira JF, Jr. Apically Extruded Sealers: Fate and Influence on Treatment Outcome. Journal of Endodontics 2016; 42(2): 243-9.

Table 3: Follow Up to 4 Years of the Recovery of the Periapical Granulomatoses Lesions

1-year follow-up 2-year follow-up >4-year follow-up Sealer Baseline n

Healed Healing Not healed Healed Healing Not healed Healed Not healed Healed %

AH Plus 18 4 6 1 11 3 2 14 4 78

Apexit 11 5 2 1 4 2 1 9 2 82

Endomethasone

9 2 2 2 2 3 1 8 1 89

PCS 21 4 1 4 5 2 4 14 7 67

PCS EWT 11 3 2 1 7 1 1 10 1 91

Tubli -Seal 5 2 1 0 2 1 0 4 1 80

Ricucci D, Rocas IN, Alves FRF, Loghin S, Siqueira JF, Jr. Apically Extruded Sealers: Fate and Influence on Treatment Outcome. Journal of Endodontics 2016; 42(2): 243-9.

Endomethasone as Root Sealer Global Journal of Oral Science, 2020, Vol. 6 9

sufficient fluidity to enable it to penetrate into the secondary ducts. Even if the Endomethasone does not observe neither the ADA nor the 57 standard ISO 6876 has been shown that these values do not affect in any way the final result of an obturation root [12]. In a vitro experiment (where the marginal microfiltration was evaluated) was tried to analyze, with a dye, the sealing capacity of each material after the same has been exposed to contaminants conditions that mimicked the oral cavity. Although with the Endomethasone a minimum microfiltration has been identified, it is important to emphasize that this result is more virtual than real. In fact, after an experiment with a highlighter dye, used to report any defects in the interphase closure, it has been noticed that with the presence of microfiltration the situation does not allow bacterial growth because the material has a broad-spectrum antimicrobial action [13]. A Brazilian study of 2012 under the auspices of Tufts University in Boston has once again shown that the sealing action of resin cements is in deficit and that the most reasonable results (90%) are obtained with the Endomethasone [14].

COLOR VARIATION AND CONTRAINDICATIONS TO THE USE DELL'ENDOMETHASONE

Before 2012, a study on the possibility that the root canal cements could affect the teeth color change had already been made, but it was only in that year that an analysis by spectrophotometer had established a real content. The endodontic cement residues should not remain inside the pulp chamber, however, some microparticles may remain nested and encourage a chromatic variation. The lower chromatic variation index is obtained with resin cements, despite that is statistically recognized that none of the cements offers an acceptable color stability if this persists in the pulp chamber area. For that reason is important to have a deep cleaning of that area in order to minimize the uptake of the chromogenic pigments that favour the tooth darkening [15]. Finally it is important to remember that the Endomethasone is still a eugenol-based material, which prevents the proper curing of resins; therefore is inadvisable the use of endoradicolari pins cemented with dual or self-curing cements with resinous matrices, since the adhesion to the walls is decidedly poor and compromised [16].

CASUISTRY

As an example of an alternative therapy here are showed three clinical cases particularly didactical

treated between 2007 and 2016. To each patient was given an informed consent signed before the teraphy. In these case the use of the dam is omitted because of the denial of the patient, despite that it was found that the therapeutic outcome doesn't depend on the presence of the last advised garrison since its main function is to act as a physical barrier to prevent the fall of tools and irrigating solutions in to the oral cavity [17, 18]. We emphasize that there has always been a modest intentional extrusion of a part of the material beyond the apex and that the same has been progressively and partially metabolized over time (Figures 1-10). CASE 1

Figure 1: Apical granuloma from incongruous Therapy (Year 2007).

Figure 2: The new endodontics beyond apex with Endomethasone.

10 Global Journal of Oral Science, 2020, Vol. 6 Giorgio et al.

Figure 3: Follow up (year 2010) Note the reduction of granulation and partial reabsorption of endodontic paste.

CASE 2

Figure 4: Apical granuloma out of 47 with presence of incongruous obturation.

Figure 5: Endodontic therapy completed with Endomethasone slightly above the apex, note the ectopy of the apex of the distal root.

Figure 6: After two months the radiographic appearance demonstrates the healing of peripical tissues.

CASE 3

Figure 7: Initial situation.

Figure 8: The condottometry of 47.

Figure 9: Endodontic treatment.

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Figure 10: To complete the ossification in zone 46 the placement of a plant and the resolution of the case with a mixed bridge.

CONCLUSIONS

Despite the market offers various materials for the orthograde filling for the canals treated the clinical results are sometimes conflicting. Filling with gutta-percha and sealer articular it's nowadays the most commonly used with excellent results, however it cannot be excluded, as an alternative therapy, the filling entirely realized with endomethasone which offers also in case of extrusion beyond the root apex, a safety apical seal and a moderate antimicrobial action peri radicular. Authors declare that they have no conflict of interest and did not receive funding for this study.

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Received on 14-02-2020 Accepted on 09-03-2020 Published on 13-03-2020 DOI: http://dx.doi.org/10.30576/2414-2050.2020.06.2 © 2020 Giorgio et al.; Licensee Global Journal of Oral Science. This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.