Root Canal Treatment Overfill Success Rate Systematic Review

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• Published: 29 December 2017

Clinical studies on core-carrier obturation: a systematic review and meta-analysis

BMC Oral Health volume 17, Article number:167 (2017) Cite this commodity

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Abstract

Background

This systematic review aimed to evaluate the clinical operation of core-carrier obturation in endodontic treatment.

Methods

Keywords of "(cadre carrier OR Thermafil) OR (cold lateral condensation OR lateral condensation) OR (warm vertical condensation OR vertical condensation) AND (obturation OR root culvert filling) AND clinical study" were searched for all obtainable publications up to year 2017 in the databases of PubMed, ScienceDirect, EMBASE, Scopus and Web of Scientific discipline. The success rate, curt-term postoperative pain, overfilling and adaptation of core-carrier obturation from clinical studies were selected. Reviews, laboratory studies, animal studies and irrelevant reports were excluded.

Results

1349 relevant articles were identified with 149 duplicated articles removed and 1173 irrelevant manufactures were excluded after screening. The titles and abstracts of the nineteen identified manufactures were screened in the systematic review. The full texts of remaining articles were retrieved with data extracted for meta-assay on the success rate, postoperative pain, overfilling and adaptation of obturation. The pooled success rate of cadre-carrier obturation was 83% (95% CI: 69%-91%). The pooled incidence of i-day and 7-24-hour interval brusque-term postoperative pain were 35% (95% CI: 15%-62%) and six% (95% CI: 1-35%). The pooled proportion of teeth with overfilling and adequate adaptation of the obturation material were 31% (95% CI: eighteen%-50%) and 85% (95% CI: 75%-91%), respectively.

Conclusions

The success rate of endodontic treatment using core-carrier obturation was 83%. Short-term postoperative pain was non uncommon (24%). Well-nigh teeth (85%) had adequate accommodation using core-carrier obturation material, only a considerable amount of teeth (31%) had overfilling.

Peer Review reports

Background

The debridement and neutralization of any tissue, bacteria or inflammatory products within the root culvert system is of import for endodontic success. The outcome of endodontic treatments does non rely on a proper disinfection process but, simply too on tight-sealed fillings of the canals equally barriers to foreclose re-infection. Therefore, root filling material is necessary to obturate the root culvert in fluid tight seal 3-dimensionally on the main canal as well as the accessory canals. The ideal root filling cloth should take inert properties, good adhesive ability and outcome in voids-free obturation forth the root canals. At present, the ideal root filling fabric is not available.

Since the introduction by Bowman in 1867, Gutta-percha has been the most unremarkably used solid cadre endodontic obturation cloth worldwide [1]. The root culvert was packed with this non-plastising gutta-percha in cold lateral compaction, which was gradually moved towards a thermoplastising rubber-like fabric aimed at increasing root culvert adaptability [2]. The cold lateral condensation technique is the most often used obturation techniques by general dentists, and it is used in many countries, such as Belgium [3], Hong Kong [4], India [5], Iran [six], Jordan [7], Kingdom of saudi arabia [8, 9], Turkey [10], Britain [11] and the USA [12]. One of the disadvantages of the cold lateral condensation technique is that gutta-percha cones practice not adapt properly to canal walls, particularly in the presence of irregularities in the canal, such as presence of isthmus, C-shaped morphology, resorptive defect and accessory canals. Inadequate adaptation poses microleakage of fluid along the obturated root canals. Clinicians and researchers looked for alternative obturation methods were reported [13, fourteen]. Contemporary endodontic obturation includes thermoplasticised techniques, such equally warm vertical condensation and core-carrier obturation. These obturation methods make use of heat to plasticise the gutta-percha for higher degree of homogeneity and better culvert adaptation [two, xiii, xv]. A survey in the The states reported that cadre-carrier obturation was the second most frequently used obturation method among full general dentists [12].

The Thermafil obturator as a simple obturation method for endodontic treatment was introduced by Johnson in 1978 [16]. It was the starting time core-carrier obturation technique that used heated blastoff-phase gutta-percha on a metal carrier prior to obturate the root canals. The materials of the core-carrier obturator continued to evolve from stainless steel, to titanium, plastic and crosslinked gutta-percha obturator. The number of clinicians, in particular general dentists, who favoured the use of core-carrier obturator was increasing [12, 17]. This written report was a systematic review to evaluate clinical success rate, short-term postoperative pain, overfilling and accommodation of the obturation textile using core-carrier obturation techniques in endodontic handling.

Methods

Literature search

A literature search was conducted to find descriptions using the five databases, which were MEDLINE database (PubMed), ScienceDirect, Excerpta Medica Database (EMBASE), Scopus and Web of Science. The keywords "(cadre carrier OR Thermafil) OR (cold lateral condensation OR lateral condensation) OR (warm vertical condensation OR vertical condensation) AND (obturation OR root canal filling) AND clinical written report" were used to search for all obtainable publications up to December 2017. Two authors of this study performed the literature search independently. They screened the titles and abstracts of the identified articles. Duplicate articles, reviews, laboratory studies, animal studies and irrelevant reports were excluded. The remaining manufactures were retrieved with total texts, which were assessed for the relevance to this systematic review. The references of all the articles were checked to identify additional pertinent articles. Information extraction and assay were performed and reviewed. Whatever disagreements on study inclusion, data extraction and assay were discussed with the tertiary author, until consensus was reached. The written report pattern of the selected studies were evaluated on their risks of bias according to the Cochrane Handbook for Systematic Reviews of Interventions (The Cochrane Collaboration Version v.1.0) [18].

Report selection

The assessment variables for clinical studies of endodontic treatment included the treatment success, curt-term postoperative pain, apical extrusion (overfilling) and quality (accommodation) of the root canal filling. Studies reporting core-carrier obturation alone or by comparing with other obturation methods were included in this review. The treatment success in this review was defined every bit both clinical success and radiographic success. The clinical success was the treated tooth without symptoms of tenderness towards percussion, hurting sensation, abscess and any endodontic-related symptoms. Radiographic success was resulted from absence of periapical radiolucency in intraoral radiographs. The short-term postoperative pain was divers as the pain encountered within 1 week from the time of obturation. In this study, we reported the postoperative pain in i day and after 7 days separately based on the results of selected studies. The overfilling of the obturation textile beyond the radiographic apex was evaluated. The adaptation of the obturation material was regarded as adequate when it was uniformly filled without visible voids or canal spaces in radiographic cess. There was no consensus in reporting the time used for obturation in the studies and a summary was performed without statistical assay [19, twenty].

Statistical analysis

The four cess variables including treatment success, brusk-term postoperative pain, overfilling and adaptation of obturation materials in endodontic treatment were extracted from each included study. Data were retrieved from tables, figures and the master text of the articles.

The pooled overall prevalence in the four assessment variables (pooled success charge per unit, pooled incidence of ane twenty-four hour period and 7 days short-term postoperative pain, pooled overfilling proportion and pooled proportion of adequate adaptation of the obturation material), separated meta analyses using logistic-normal random consequence model [21] were performed past the Stata procedure metaprop_one [22]. The weighting in the proportion interpretation was not explicit because parameter interpretation was an iterative procedure.

Although this review primarily aimed to evaluate the clinical performance of cadre-carrier obturation in endodontic treatment, near studies used common cold lateral condensation to compare core-carrier obturation. Thus, a direct comparison of the clinical performance of core-carrier obturation with common cold lateral condensation was also performed in this review. The pooled relative gamble (RR) in the four cess variables were analysed using meta-analysis with DerSimonian and Laird random furnishings method [23] past the Stata procedure metan [24] using the cold lateral condensation technique as the control group. In addition, comparison of the clinical performance of cadre-carrier obturation with other common obturation methods was conducted. Meta-analysis using logistic-normal random effect model for each common obturation method in success rate and postoperative pain was performed. Heterogeneity tests were performed for each meta-analysis for the reference. The Stata 13.1 software (StataCorp LP, College Station, TX, USA) was employed in the statistical analysis. The results were presented in forest plots and the tests were ready as two-tailed tests with the 0.05 significance level.

Results

The search identified 1349 potentially relevant manufactures in the 5 databases; 149 duplicated articles were removed. The titles and abstracts of 1200 publications were screened. After screening, 1173 papers were excluded because they were laboratory or animal studies, review papers, instance reports, data studies or irrelevant reports. Eight clinical studies of irrelevant obturation methods were excluded. The remaining xix publications of cadre-carrier obturation with full texts were retrieved. A manual search was performed on the references of these 19 papers and no additional reference was found. Therefore, 19 publications were included in this systemic review (Fig. 1). They were evaluated for their methodology and run a risk of bias (Table 1). Among these 19 studies, 11 papers reported the handling success [1, fifteen, 19, xx, 25,26,27,28,29,xxx,31], eight papers reported short-term (within 7 days) postoperative pain [17, 19, 25, 27, 28, 32,33,34], 11 papers reported overfilling [15, 17, 19, 20, 25, 27, 30, 35,36,37,38] and 7 papers reported the adequate accommodation of root canal filling [15, 20, 25, xxx, 35, 37, 38].

Fig. 1

Flowchart of the literature search

Full size prototype

Table i Summary of clinical studies on core-carrier obturation

Total size table

The pooled proportion of treatment success, incidence of short-term postoperative pain, overfilling and obturation quality (adequate adaptation) in teeth obturated with cadre-carrier obturators, were summarised in Fig. 2. 10 of the 11 papers reporting the treatment success reported the verbal success rate or the exact number of success cases for further meta-analysis. The pooled success charge per unit of cadre-carrier obturation was 83% (95% confidence interval (CI): 69%-91%; p < 0.01) which was significantly different from goose egg. 7 of the 8 studies reporting the exact 1 mean solar day and 7 days postoperative pain charge per unit or the exact number of postoperative pain cases for further meta-analysis. The pooled incidence of 1 day and 7 days short-term postoperative pain were 35% (95% CI: 15%-62%; p = 0.26) and 6% (95% CI: 1-35%; p = 0.01) respectively which was not statistical significantly different from zilch. The overall short-term postoperative nerveless within 1 calendar week was 24% (95% CI: fifteen%-36%; p < 0.01).

Fig. two

Meta-analysis of core-carrier obturation studies on handling success, incidence of curt-term postoperative hurting, overfilling and obturation quality

Full size epitome

Ten of the 11 studies reporting overfilling reported the exact overfilling rate or the verbal number of overfilling cases and six of the seven studies reporting adaptation of the obturation reported the verbal accommodation rate or the exact number of accommodation cases for further meta-analyses. The pooled proportion of teeth with overfilling and adequate adaptation of the obturation textile were 31% (95% CI: xviii%-50%; p = 0.04) and 85% (95% CI: 75%-91%; p < 0.01), respectively (Fig. ii).

The results of meta-analysis of the treatment success rate of cadre-carrier obturation versus cold lateral condensation extracted from the 6 selected studies [ane, 19, 20, 29,thirty,31] were presented in forest plots in Fig. 3. Studies reporting the cadre-carrier obturation lone were excluded from this assay. The forest plot showed no meaning difference in treatment success between core-carrier obturation and cold lateral condensation (RR = 1.01 with 95% CI: 0.96–ane.05; p = 0.75). Results of meta-analysis on two studies using warm vertical compaction [39, 40] constitute the treatment success charge per unit was 84% (95% CI: 77%-89). This treatment success rate was not significantly dissimilar from that of core-carrier obturation. Meta-analysis on four selected studies [17, 19, 32, 34] showed that the incidence of 1 day brusque-term postoperative pain (RR = 1.64 with 95% CI: 0.53–v.x; p = 0.forty) and two selected studies [32, 34] of vii days postoperative hurting (RR = 0.87 with 95% CI: 0.40–ane.89; p = 0.72) of cadre-carrier obturation were besides not significantly unlike from that of common cold lateral condensation. Likewise, the woods plot did not show significant differences in the overfilling (RR = 1.31 with 95% CI: 0.49–3.46; p = 0.59) and adequate accommodation (RR = 1.11 with 95% CI: 0.86-1.43; p = 0.43) between core-carrier obturation and cold lateral condensation of the selected studies (Fig. 3).

Fig. 3

Wood plots of cadre-carrier obturation versus cold lateral condensation according to treatment success, incidence of short-term postoperative pain, overfilling and obturation quality

Full size epitome

Three papers had reported the treatment or obturation time they all establish that the time required was significantly shorter using cadre-carrier obturation than cold lateral condensation [17, 20, 41]. Only one written report [xx] reported the comparing of mean obturation time betwixt cadre-carrier obturation and common cold lateral condensation. This study reported that the core-carrier obturation times were 21 min for multiple canals and 13 min for a unmarried canal, whereas the obturation times for lateral condensation were 28 min for multiple canals and 17 min for a single canal [20].

Discussion

The core-carrier obturation technique was getting more than popular in endodontic treatment, in particular for full general practitioners [12]. Laboratory studies of core-carrier obturation were numerous; however, they were performed using extracted teeth, mimicked molar models and plastic blocks, which were different from clinical settings. A systematic review for clinical studies on core-carrier obturation was therefore necessary merely was not found in literature. In this study, five common databases, including PubMed, ScienceDirect, EMBASE, Scopus and Web of Science databases, were used for literature search. Although there are 19 clinical studies on cadre-carrier obturation, the number of teeth assessed in this written report varied from 24 to 538. In that location are 8 studies with the number of teeth assessed less than 100. Among the 19 selected clinical studies, the detection bias and reporting bias are mostly low. Some of the clinical studies on core-carrier obturation institute in the databases had no details on how they randomised their samples. The "unclear" risk of bias on sample generation of randomisation revealed the need of better quality randomised clinical trials in this field. The initial aim of this review is to written report exploratory into the performance of the core-carrier obturation. Nevertheless, studies comparing core-carrier obturation with other obturation techniques, predominantly common cold lateral condensation technique, were identified. Therefore, this review also compared the clinical outcome of core-carrier obturation with cold lateral obturation technique. It is noteworthy that the number of the studies was pocket-sized. More studies are required to study the clinical outcomes including the success rate, incidence of postoperative pain, overfilling and quality of obturation.

Some studies evaluated the upshot of endodontic treatment based on radiograph [1, 20, 25, 26]. Radiograph was a 2-diemensional representation and it had limitations for evaluation. Information technology was suggested that iii-dimensional radiographic methods increased the diagnostic value on handling outcome [42, 43]. All the same the radiations dose was higher and need specialised equipment which may non be widely used in research purposes. The periapical radiograph method used was generally accepted by clinicians to assess healing progress and quality of obturation. In the radiographic cess of the selected studies, the observers were independent and were blinded in the treatment method [1, fifteen, 26, 28, 36, 38]. For the assessment of postoperative pain later endodontic handling, visual analogue scale [32] or likert scale [33] were used for grading the discomfort experienced past patients. These were reliable methods used for assessment of hurting for dental procedures [32].

Amidst all the independent variables, the almost important assessment for clinical protocol by operators was the success charge per unit. In this systematic review, the success rate of endodontic treatment using core-carrier obturation and using cold lateral condensation were not statistically significant. In this report, the success rates of warm vertical compaction and core-carrier obturation were not statistically significant. The core-carrier obturation could be a reasonable alternative to conventional technique without compromising the handling effect. However, only six studies were included in this analysis; the sample size and power of this analysis were limited. Even so the similar handling outcome between the 2 methods, the microleakage of obturation was hard to evaluate in clinical studies merely regarded as an important factor influencing the treatment outcome. Studies reported that core-carrier obturators produced higher gutta-percha/sealer ratio, thus reducing apical leakage, and less cytotoxic past-products disintegrated from sealer than in cold lateral condensation [44, 45]. Laboratory studies showed that no significant difference was institute in apical leakage between core-carrier obturation and common cold lateral condensation [46,47,48].

Another important aspect in assessing clinical protocol was postoperative pain which was a fundamental factor affecting patient satisfaction [49]. The results of this review found no pregnant difference in the postoperative hurting of cadre-carrier obturation and cold lateral condensation. The pooled effect of short-term postoperative pain in i solar day and seven days obturated with a cadre-carrier obturator were 35% and 6% respectively, which was comparable with that of cold lateral condensation with half-dozen% severe pain to 54% balmy post-obturation pain [50]. Extrusion of the obturation materials across the root apex could be a reason for the pain and discomfort [nineteen].

The adequate accommodation of cadre-carrier obturation compared with cold lateral condensation based on the ii clinical studies could non demonstrate significant difference [20, 37]. The method adopted was 2-dimentional radiographic assessment, which was inferior to the 3-dimentional assessment with cone beam computed tomography. It was plausible that the voids created by common cold lateral condensation during packing of gutta-percha with spaces left behind past spreader or shrinkage of sealer could increase the microleakage and thus affected the handling outcome. A study reported that cadre-carrier obturation had less sealer and more gutta-percha and facilitated adaptation of the filling material along the root canal spaces [44]. A recent written report reported that obturation by crosslinked gutta-percha core obturator consistently produced homogeneous obturation with lower incidences of voids compared with cold lateral condensation [51]. There was another written report demonstrated the improvement on retrievability in endodontic re-treatment by crosslinked gutta-percha obturator than plastic core one [52]. Some clinicians suggested that core-carrier obturation enabled gutta-percha tag formation inside the dentinal tubules, especially when the smear layer was removed by combined irrigations [53, 54]. There were significantly greater wedging forces on obturation with conventional cold lateral condensation than with cadre-carrier obturation. Dentists tended to exert forces to the spreader during obturation so as to increase the accommodation of the common cold lateral condensation. This should be avoided because this act increased the take chances of tooth fracture. Core-carrier obturation might induce less vertical forces on the root culvert and thus reduced the chance of root fracture after obturation. Therefore teeth with weakened remaining tooth structure or in doubtful prognoses, such as cracked teeth, might be ameliorate having core-carrier obturation than common cold lateral condensation.

A drawback of the core-carrier obturator was less control of the root canal filling, which should be confined within a root canal space [55]. The overfilling after obturation with the core-carrier was greater equally compared with cold lateral condensation [17, 20], while ane study reported the opposite [37]. The contradictory result of this report study [37] did not explain the reason of cold lateral status showed more overfilling than Thermafil over radiographic evaluation. Extrusion of gutta-percha or sealer might be influenced by a host'southward periapical tissues, apical patency, canal tapering and a patient response to the pain sensation [55], and some of these factors could not be evaluated with an in vitro study. The clinical implications of overfilling might induce undesirable pain and possible pooling of sealer in the apical portion of the canal. The risk of thermal trauma and extrusion trauma were two important problems for a clinician to consider when using thermoplasticised gutta-percha. A laboratory report institute that the temperature rise was below the disquisitional level that caused biological breakdown to periodontal attachment [56]. A laboratory report demonstrated that the likelihood of overfilling was associated with the canal tapering [55]. A study reported that the risk of overfilling could be reduced by using a pocket-size amount of sealer and obturating the canal with the master cone that correlated with the final file size [46]. The use of contemporary instrumentation instruments might let meliorate command of the core-carrier obturation within designated working length, and further studies should be performed.

It is generally accepted by clinicians that the treatment or obturation time required was significantly shorter using cadre-carrier obturation than cold lateral condensation [17, xx, 25]. However, the factors affecting the handling time are many. Operator skills and experience and complexity of the root canals system are two other important factors affecting the time for endodontic treatment [twenty]. A clinical study reported that the fourth dimension used for core-carrier obturation was shorter than that for common cold lateral condensation [19]. There were laboratory studies that reported similar results with used core-carrier obturation [17, twenty, 57]. The obturation time was not a variable related to the upshot of endodontic treatment, and thus was not reported in this study. However, information technology could exist an of import factor affecting dentists' option of obturation. Core-carrier obturation was a simpler thermoplastised technique than warm vertical condensation for mastering the skill. General dentists were generally satisfied and preferred to use cadre-carrier obturation because the chairside time can exist reduced [12, 25].

Endodontic treatment is a common dental treatment to save teeth from extraction. The success charge per unit of endodontic treatment was mostly high compared to dental implants [58, 59]. The long term survival charge per unit of compromised teeth that were endodontically treated was reported to be equally high as 83% to 98% [sixty]. The advance in materials and instruments had changed significantly regarding the protocols of endodontic treatment in recent decades. The use of thermoplasticised obturation could exist an culling to the traditional cold lateral condensation. It was easy and quick to primary the skills of the core-carrier obturation technique. However, overfilling could be a concern. More clinical trials on core-carrier obturation using updated materials and instrument were needed.

Conclusions

This systematic review plant the success rate of endodontic treatment using core-carrier obturation was 83%. Curt-term postoperative pain was non uncommon (24%). Most teeth (85%) had acceptable adaptation using core-carrier obturation material, simply a considerable corporeality of teeth (31%) had overfilling.

Abbreviations

CC:

Other cadre-carrier obturator

CI:

Confidence interval

CLC:

Cold lateral condensation

EMBASE:

Excerpta medica database

MEDLINE:

Medical literature assay and retrieval organization online / U.S. National Library of Medicine'due south life science database

NS:

Not significant

RR:

Relative risk

Southward:

Pregnant

TF:

Thermafil obturator

WVC:

Warm vertical compaction

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All co-authors declare no funding body, if any, in design, in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

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Affiliations

1. Kinesthesia of Dentistry, The University of Hong Kong, Hong Kong, SAR, Red china

   Amy Wai-Yee Wong, Samantha Kar-Yan Li, Chengfei Zhang & Chun-Hung Chu

2. Schoolhouse of Stomatology, Kunming Medical University, Yunnan, China

   Shinan Zhang

3. 3B53A, Prince Philip Dental Hospital, 34 Infirmary Road, Hong Kong, SAR, Prc

   Chun-Hung Chu

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Literature search, study inclusion, information extraction and chance assessment: AWYW, SZ, SKYL. Drafting manuscript: AWYW. Supervision and revising manuscript content: CHC, CFZ. All authors read and canonical the concluding manuscript.

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Correspondence to Chun-Hung Chu.

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Wong, A.WY., Zhang, South., Li, Due south.KY. et al. Clinical studies on core-carrier obturation: a systematic review and meta-analysis. BMC Oral Health 17, 167 (2017). https://doi.org/10.1186/s12903-017-0459-1

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• Received: 27 May 2016

• Accustomed: 14 Dec 2017

• Published: 29 December 2017

• DOI : https://doi.org/10.1186/s12903-017-0459-1

Keywords

• Thermafil
• Core carrier
• Obturation
• Endodontics
• Systematic review
• Meta-assay

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