INTRODUCTION:

Microbialbiofilms are considered the leading cause of root canal infections, and endodontic treatment's success depends on their elimination¹. One of the treatments for biofilm eradication is using medicaments². Root canal medicaments aim to kill or inhibit the growth of microorganisms between visits³.

The medicament still the gold standard to date in root canal treatment is calcium hydroxide (Ca(OH)₂)⁴. The material has antimicrobial activity, high alkaline properties, and can inhibit tooth resorption⁵. Calcium hydroxide has antibacterial solid properties by releasing highly reactive hydroxyl ions, which cause damage to the bacterial cytoplasmic membrane, protein lysis, and bacterial DNA⁶. Intracanal medication with Ca(OH)₂ complemented the instrumentation with irrigation and optimal disinfection of the root canal system⁷. Calcium hydroxide is also a pulpotomy agent used the inductive pulpotomy technique. This mechanism encourages the radicular pulp to heal and form the dentin bridge/hard tissue barrier⁸.

Before performing root canal obturation, the root canal wall must be clean of Ca(OH)₂residue. This residue in the root canal will affect the success of root canal treatment, as it can affect the adaptation of the sealer to the root canal surface. Some sealers have a brittle consistency and become granular when hardened after contact with Ca(OH)₂⁹. The residue also reduces the penetration of epoxy resin-based (AH26) and tricalcium silicate (BioRoot) based sealers into the dentinal tubules. Penetration of AH26 is lower than BioRoot. It cannot penetrate dentin in the apical third if the residue remains. It is due to BioRoot's pH, which tends to be alkaline (alkaline). Meanwhile, the AH26 sealer has an acidic or neutral pH, so it cannot penetrate the dentinal tubules when in contact with Ca(OH)_2, whose pH is alkaline¹⁰.

The agitation technique can altogether remove Ca(OH)₂. Commonly used are NaOCl, which can remove the organic smear layer, and EDTA with chelating agent properties, which can remove the inorganic smear layer. However, these liquids cannot remove Ca(OH)₂ completely. In some studies, the ultrasonic technique gives better results than other techniques¹¹. The development of instrumentation with a new nickel-titanium rotary endodontic file, XP Endo Finisher, has the advantage of a shape memory effect.⁷ Several studies of XPF have shown better results than other techniques, especially in curved root canals¹².

Currently, chitosan is being developed as an irrigation solution in endodontics. Chitosan has several remarkable properties, including good biocompatibility, biodegradability, mucoadhesion, and non-toxic¹³. It does not cause immunological reactions and does not cause cancer, so chitosan is often used in biomedical applications¹⁴. Chitosan is more studied in drug delivery systems because it shows better stability, simple and mild preparation methods, and includes various administration routes such as oral, nasal, ocular, and IV¹⁵. Chitosan can remove the smear layer without causing erosion of the intertubular dentin.The 0.2% chitosan, with 3 minutes, can remove the smear layer adequately with a lower erosion rate than EDTA¹⁶. The study by Vineeta showed that 0.2% chitosan performed better than 17% EDTA solution in removing Ca(OH)₂. It is due to an increase in the penetration of 0.2% chitosan into Ca(OH)₂vehicles, such as silicone oil. It causes better chelation than 17% EDTA in chelating calcium ions in water¹⁷. However, chitosan has a high molecular weight and high viscosity. Therefore, oligosaccharide chitosan has been developed with low molecular weight, higher solubility, and low viscosity¹⁸. This study assessed chitosan oligosaccharides as an irrigating fluid in removing Ca(OH)₂from root canal walls.

Material and Methods:

Material:

This research has passed the ethical clearance from the Faculty of Medicine, University of North Sumatra No. 07/KEPK/USU/2022. The sample consisted of 24 mandibular premolars extracted and cleaned manually of external debris and soft tissue residue. Then, the selection was put into a plastic container containing saline solution and left in a state of submersion at room temperature before being treated. The research was conducted from December 2021 to June 2022.

Preparation Sample and Root Canal Model:

The sample was cut at the cementoenamel junction with a carborundum disk bur. The samples were randomly divided into six groups of 4 pieces. Then, the root canal preparation was set, and the working length was 1 mm less than the tooth length¹⁹. Access the cavity with an endo access bur with a high-speed handpiece. The remaining pulp was extirpated using a barber broach. Root canal preparation using File #25 Taper 0.6 (AFTM Blue R3). The practice with the crown down technique. The speed of the endo motor is adjusted to the speed and torque according to the manufacturer's recommendations. Instrumentation of the root canal with a new instrument on each sample. Irrigation with 2.5% NaOCl, ultrasonic and XP Endo Finisher (FKG Dentaire SA Switzerland), saline irrigation, EDTA irrigation, and ultrasonic activation. Then the root canals were rinsed with saline and dried with paper points. The root canals were dried, calcium hydroxide was applied to the orifice boundaries throughout the work, temporarily filled, and then evaluated with a periapical X-ray. All samples were stored in an incubator at room temperature for seven days.

Scanning Electron Microscope Assay:

Examination of the cleanliness of the root canal using SEM (Hitachi, Japan) group determined 1 sample for microstructural imaging. The sample was coated with liquid gold with a thickness of (5-20nm). Then, the sample is placed in a vacuum chamber in the middle of the section. The height of the sample must follow the calibration standard. Then, the appliance is turned on with a power of 10kV 5. The sample is moved slowly to get the area photographed on the SEM screen. Furthermore, brightness, contrast, and focus are adjusted for a good picture.

Calculating the Residue Surface Area of Calcium Hydroxide:

After preparation, one sample from each group was taken, and the roots were sectioned longitudinally into two parts: buccal and lingual (palatal). The dentin walls were examined using a Scanning Electron Microscope (SEM) at 10x and 1000x magnification.10x magnification is to determine the location of the apical third of the root canal, and then perform 1000x magnification to observe the cleanliness of calcium hydroxide in the apical third of the root canal. For 1000x magnification, the image will be divided into nine observation areas assessed using the scoring method through double-blind observations made twice by different people. Measuring the residual level of calcium hydroxide in nine areas of compliance can be determined by using the Kuga score (2010), namely: 0 (no residue), 1(residue in a small amount of 20% of the surface), 2(residue in moderate amount, 20% to60% surface), 3(a large amount of residue, more than 60% surface)²⁰.

Statistical Analysis:

A paired T-test was carried out on the residual calcium hydroxide data to analyze the agreement between observers and then described. The normality test was assessed using the Shapiro Wilk test followed by the Kruskal Wallis and Mann-Whitney test to evaluate the SEM score, the difference in the ultrasonic value, and the XP Endo Finisher with the level of significance (p< 0.05).

RESULTS AND DISCUSSION:

The treatment was carried out for seven days using two groups of agitation techniques, namely: Group A (using ultrasonic agitation) consisting of Group A1 (calcium hydroxide cleaned with 2.5% NaOCl 5ml and 17% EDTA with ultrasonic agitation) and Group A2 (cleaning calcium hydroxide with NaOCl 2.5% 5ml and Chitosan Oligosaccharide 2% with ultrasonic agitation). A3 (Calcium hydroxide washed with 2% Chitosan Oligosaccharide with ultrasonic agitation). Group B (using XP Endo Finisher) consisted of Group B1 (Calcium Hydroxide was cleaned by placing the teeth for 30 seconds in water at 37C above the hotplate. Irrigated with 2.5% NaOCl 5ml and 17% EDTA with XP Endo Finisher instrumentation). Group B2 (Calcium hydroxide was cleaned by placing the teeth for 30 seconds in water at 37 C above a hotplate. Irrigation of 2.5% NaOCl 5ml and Chitosan Oligosaccharides 2% with XP Endo Finisher instrumentation was performed). Group B3 (Calcium Hydroxide was cleaned, and teeth were placed for 30 seconds in water at 37 C above the hotplate. Irrigated with 2% Chitosan Oligosaccharide with XP Endo Finisher instrumentation.

Figure 1 shows filling the medicament material (Ca(OH)2) in dental root canal treatment. (Ca(OH)2) enters from the cervix, middle, and musty. Meanwhile, Figure 2 shows the surface of the root canal wall after being given various irrigation solutions. Chitosan oligosaccharide irrigant with ultrasonic agitation can remove residual (Ca(OH)2) on the surface of the root canal wall, which is very good compared to the aspirator with XP Endo Finisher. Meanwhile, 2.5% NaOCl + 17% EDTA solution with ultrasonic agitation was better than agitation with XP Endo Finisher. These results align with the information in Table 1 and Figure 3. Table 1 shows the residual value scores in the treatment group with ultrasonic agitation and XP Endo Finisher. In the cervical, middle, and apex sections, the ultrasonic agitation group had a better ability to remove residues than the XP Endo Finisher group. The ability to remove residue (Ca(OH)2) in the middle and musty sections, respectively, showed a significant difference between the ultrasonic agitation group and the XP Endo Finisher (p<0.05). In the cervical part, there was no significant difference (p>0.05).

Table 1: Statistical analysis of residue (Ca(OH)2) in root canals of teeth after different irrigation solutions

Root canal	Groups	n	Mean ±SD	Frequency	*p-value
Cervical	A1	4	0,500±0,577	9%	0.206
	A2	4	0,500±0,577	9%
	A3	4	0,500±0,577	9%
	B1	4	0,750±0,500	14%
	B2	4	1,750±0,957	32%
	B3	4	1,500±1,291	27%
Middle	A1	4	1,000±0,817	15%	0.005
	A2	4	0,000±0,000	0%
	A3	4	1,000±0,000	15%
	B1	4	0,250 ±0,500	4%
	B2	4	2,250 ±0,957	35%
	B3	4	2,000±0,817	31%
Apical	A1	4	1,000 ±1,155	11%	0.016
	A2	4	0,500 ±0,577	6%
	A3	4	1,250±0,500	14%
	B1	4	1,000±1,155	11%
	B2	4	2,500±0,577	28%
	B3	4	2,750±0,500	31%

*Kruskal Wallis Test; Significance p<0.05; A1 (NaOCl 2,5% dan EDTA 17% denganagitasi ultrasonic); A2 (NaOCl 2,5% dan KitosanOligosakarida 2% denganagitasiultrasonik ); A3 (KitosanOligosakarida 2% denganagitasi ultrasonic); B1 (NaOCl 2,5% dan EDTA 17% menggunakan XP Endo Finisher); B2 (NaOCl 2,5% dan KitosanOligosakarida 2% menggunakan XP Endo Finisher); B3 (KitosanOligosakarida 2% menggunakan XP Endo Finisher)

Figure 3 shows that the ultrasonic agitation technique is better at removing residue (Ca(OH)2) than the XP endo finisher technique after being influenced by 2.5% NaOCl irrigation solution, 17% EDTA, and 2% chitosan oligosaccharides. The ultrasonic agitation technique generally removed up to 70% residue compared to the XP endo finisher agitation technique (30%) from all the root canal's cervical, middle, and apical parts. Table 2 shows that, statistically, the agitation effect of the two techniques showed a significant difference between the two parts of the root canal (p<0.05;0.020). Meanwhile, each section also showed a substantial difference in the cervical (p<0.05; 0.023), the Middle section had no significant difference (p>0.05;0.069), while the apical team showed significant differences (p<0.05;0.008).

The Ca(OH)₂currently used is Calcium hydroxide paste, namely UltraCal™ XS (UC), uniquely formulated aqueous and radiopaque, with a high pH.Ca(OH)₂ is chosen because it is commercially available and is generally used in clinical practice (Fig. 1). Ultracal XS consists of 35% by weight Ca(OH)₂, 2% by weight barium sulfate (BaSO₄), and other ingredients. Barium sulfate is added to Ca(OH)₂ to increase radiopacity. The particle size (diameter) of commercially available barium sulfate varies from the nanoscale (80-500nm) to microns (2m), depending on the manufacturing source. Previous studies have shown that BaSO₄ nanoparticles can improve X-ray contrast properties by increasing surface area and are more radiopaque than microparticles²¹. Adding barium sulfate thus increases the percentage of smaller particles at UC. The smaller particle geometry at UC also allows Ca(OH)₂particles to enter the exposed dentinal tubules. With aqueous properties, it has a low molecular weight and small particle size, so the Ca(OH)₂used is easy to penetrate and is located in the dentinal tubules²².

In this study, based on the Kruskal Wilis test, the cervical region was not statistically significant (p>0.05), while the middle and apical sections were statistically significant (p<0.05). In general, the more apical the tooth, the more influential the results, according to a study by Donnermeyer and Capar. Both studies assessed multiple irrigation instrumentation, including passive ultrasonic irrigation (PUI) and XP Endo Finisher. PUI was more efficient in removing Ca(OH)₂in apical thirds than in coronal thirds. It may be due to the small, intense circular fluid motion created around the instrument closer to the tip area than to the coronal tip of the device, with the irrigation portion more apically in the ultrasonic tip region. Coronal did not show significantly different results from all instrumentation, including PUI and XP Endo Finisher²³. Based on the study's results, it was found that using 2% oligosaccharide chitosan, either ultrasonic agitation techniques or XP Endo Finisher, has not removed Ca(OH)₂ultimately. The result of the score shows that the more cervical direction, the lower the score, which indicates better Ca(OH)₂removal.

Figure 2 reports that chitosan oligosaccharide irrigant with ultrasonic agitation can remove residual (Ca(OH)2) on the surface of the root canal wall, which is very good compared to the aspirator with XP Endo Finisher. Mean while, 2.5% NaOCl + 17% EDTA solution with ultrasonic agitation was better than agitation with XP Endo Finisher (Table 1). Chitosan oligosaccharide (COS) is an oligomer of β-(1 ➔ 4)-linked d-glucosamine with low molecular weight, higher solubility, and low viscosity²⁴. Chitosan oligosaccharides yielded 24.12% from 100 grams of chitin²⁵. This chitosan has non-toxic properties, good bioadhesive material, a broad-spectrum antibacterial effect²⁶, and an excellent chelating effect²⁷. With all these properties, chitosan oligosaccharides have become promising irrigation materials. It is known that the effectiveness of chelating agents is affected by concentration and time.

The higher the concentration, the shorter the time required. In this study, chitosan oligosaccharides were used only at a concentration of 2%, which was carried out for 3 minutes in the final irrigation. In the study of Silva et al., using chitosan with various concentrations and time, it was concluded that 0.2% chitosan in 3 minutes cleaned the smear layer efficiently with minimal dentin erosion²⁸. However, with the limitations of this study, the time variable for using chitosan oligosaccharides was within 3 minutes, with a concentration of 2% being the best. This research is a novel study of chitosan oligosaccharides in cleaning Ca(OH)₂, so further research is needed, especially in concentration and irrigation time.

Table 1 shows that the ultrasonic agitation group's cervical, middle, and apex sections had a better ability to remove residue than the XP Endo Finisher group.The ability to remove residue (Ca(OH)2) in the middle and musty sections, respectively, showed a significant difference between the ultrasonic agitation group and the XP Endo Finisher (p<0.05).In the cervical part, there was no significant difference (p>0.05). The 2.5% NaOCl irrigation solution and 2% chitosan oligosaccharides with ultrasonic agitation technique showed fewer residues on each part of the tooth: 0.5±0.577 (cervical), 0±0.000 (middle), and 0.5±0.500 (apical). In each tooth section, this treatment group showed superior results compared to the other treatment groups. Even in the middle and apical thirds, there was a significant difference in scores (p = 0.005< 0.05) and (p = 0.016< 0.05). Calcium-chelating agents have superior excretory results compared to non-calcium-chelating agents. One of the calcium-chelating agents is chitosan²¹. Chitosan can be a decalcifying agent. Due to the presence of an active hydroxyl group (-OH), an amino group (-NH2), or an amino acetyl group (-NHCOCH3), chitosan easily coordinates with metal ions and is also easy to degrade¹⁵. Calcium ions only form complexes with –NH2 groups in the chitosan molecular chain, but neither the hydroxyl nor acetyl groups are involved in the reaction. To strengthen the adsorption capacity of chitosan on calcium ions, many researchers have focused on modifying chitosan by improving the stability, physical and mechanical properties of chitosan materials, and the coordination ability of chitosan materials with metal ions²⁹.

The combination of NaOCl and chitosan seems more promising than NaOCl and 17% EDTA. A study by Vineeta showed that 0.2% chitosan worked better than 17% EDTA solution in removing Ca(OH)₂. It was due to an increase in the penetration of 0.2% chitosan into Ca(OH)₂vehicles, such as silicone oil. It caused better chelation than 17% EDTA in chelating calcium ions in water. Chitosan also can remove the smear layer without causing erosion of the intertubular dentin³⁰. Silva reported that 0.2% chitosan with 3 minutes of use could adequately remove the smear layer with lower erosion rates than EDTA²⁸.

In Table 2, it was reported that the effect of ultrasonic agitation to remove residue (Ca(OH)2) was better than that of XP Endo Finisher in root canals (p<0.05). A meta-analysis by Zhou in 2021 comparing Passive Ultrasonic Irrigation with XP Endo Finisher in cleaning medicaments showed that protocols using ultrasound were more effective than those using XP Endo Finisher in removing medicaments from single straight root canals. Regarding the anatomical area of the apical thirds of the root canal, PUI operates superior to the XP Endo Finisher. The file size, mechanism of action, and position of the PUI tip insertion can benefit ultrasound in straight single-root canals³¹. The ultrasonic tip file size was adjusted according to the intracanal diameter and the final height of the physiological foramen preparation. Before the root canal disinfection process, single straight canals are usually prepared to a length of 40/0.04. It balances cleaning effectiveness, anatomic enlargement, and the incident apical area risk³². However, the XP Endo Finisher size is size 25, with a nontapered instrument, so the XPF size may be less suitable for the foramen size than the PUI³³. However, in large canal spaces, one minute may not be enough for the XP Endo Finisher to dispense intracanal drugs efficiently. Meanwhile, they admitted that the contact time between the XP Endo Finisher file and the groove in straight root canals was too short³⁴.

Ultrasonic tip placement affects the effect of irrigation in endodontic treatment. Uzunoglu et al. reported that PUI reduced the amount of irrigant extrusion through the apex³⁵. In teeth with an open apex, Peeters et al. also revealed that using PUI during final irrigation resulted in virtually no apical extrusion of NaOCl in endodontic therapy³⁶. One explanation is that as the depth of insertion of the ultrasonic tip becomes more profound, the amount of debris and extrusion of irrigation also increases. Therefore, regarding efficiency and safety, using PUI is better than XP Endo Finisher in removing intracanal medicaments in straight single-root canals.

The study by Yaylali et al. demonstrated that PUI has the advantage of removing Ca(OH)₂from the apical thirds of the root canal³⁷. Irrigation in the apical thirds has difficulty achieving direct contact with the wall because the apical thirds have more lateral canals, apical ramifications, and isthmus than the coronal thirds and middle thirds. In addition to complex anatomical factors, the vapor lock phenomenon also prevents penetration of the irrigating solution into the apical thirds³⁸. PUI effectively eliminates vapor lock during endodontic irrigation of the apical thirds of the root canal³⁹. The PUI was significantly better than XPF in removing medicament from the apical thirds. NaOCl and EDTA have become the most commonly used irrigation solutions, dissolving organic substances, eliminating microbes, and cooling files. The combination of ultrasonic and NaOCl gave a synergistic effect on the elimination of bacteria³¹. Therefore, using NaOCl as an irrigation agent can increase the work efficacy of PUI. However, when NaOCl and EDTA are combined, the cleaning effectiveness of PUI is similar to that of XP Endo Finisher⁴⁰.

Conclusion:

The ultrasonic agitation technique removes residue (Ca(OH)2 more than the XP Endo Finisher technique. Chitosan Oligosaccharide 2% has a better effect on removing residue (Ca(OH)2 in root canals. In comparison, 2% NaOCl irrigation solution is better than 17% EDTA in removing debris (Ca(OH)2).

Conflict of Interest:

The authors declare no conflicts of interest.

References:

1. Umaiyal MP. Awareness of root canal treatment among people. Research Journal of Pharmacy and Technology. 2016; 9(7): 779-781. http://dx.doi.org/10.5958/0974-360X.2016.00149.9

2. Lavanya E, Antony S. Intracanal medicaments in revascularization-A review. Research Journal of Pharmacy and Technology. 2018; 11(6): 2672-2676. http://dx.doi.org/10.5958/0974-360X.2018.00495.X

3. Jhajharia K, Parolia A, Shetty KV, Mehta LK. Biofilm in endodontics: A review. Journal of International Society of Preventive and Community Dentistry. 2015; 5(1): 1-12. https://doi.org/10.4103/2231-0762.151956

4. Sastika DY, Abidin T, Agusnar H, Gani BA. Application of Calcium Hydroxide with Vehicles Relate to the pH Change, Calcium Ion Diffusion, Roughness, and Frequency of Chemical Compound in Root Canal. Research Journal of Pharmacy and Technology. 2022; 15(7): 2976-2982. http://dx.doi.org/10.52711/0974-360X.2022.00496

5. Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: a literature review - Part I. In vitro studies. Restorative dentistry and endodontics. 2014; 39(4): 241-52. https://doi.org/10.5395/rde.2014.39.4.241

6. Divya S, Sujatha S. An insight on the success of various pulpotomy medicaments in pediatric dentistry-a review of literature. Research Journal of Pharmacy and Technology. 2018; 11(6): 2647-2655. http://dx.doi.org/10.5958/0974-360X.2018.00491.2

7. Nagaraj N, Nesamani R, Sekar M, Pallavi S. Cone-beam Computed Tomography Evaluation of Non-surgical management of a Large Periapical Lesion using Calcium hydroxide intracanal medicament: A 1-year follow-up case report. Research Journal of Pharmacy and Technology. 2022; 15(10): 4701-4704.

8. Abiraamasri B, Gurunathan D. Comparison of ferric sulphate and calcium hydroxide as a pulpotomy agent. Research Journal of Pharmacy and Technology. 2018; 11(5): 1881-1883. http://dx.doi.org/10.5958/0974-360X.2018.00349.9

9. Özok AR, van der Sluis LW, Wu M-K, Wesselink PR. Sealing ability of a new polydimethylsiloxane-based root canal filling material. J Endod. 2008; 34(2): 204-207. https://doi.org/10.1016/j.joen.2007.11.005

10. Uzunoglu-Özyürek E, Erdoğan Ö, Aktemur Türker S. Effect of Calcium Hydroxide Dressing on the Dentinal Tubule Penetration of 2 Different Root Canal Sealers: A Confocal Laser Scanning Microscopic Study. J Endod. 2018; 44(6): 1018-1023. https://doi.org/10.1016/j.joen.2018.02.016

11. Torabinejad M, Khademi AA, Babagoli J, et al. A new solution for the removal of the smear layer. J Endod. 2003; 29(3): 170-5. https://doi.org/10.1097/00004770-200303000-00002

12. Elnaghy AM, Mandorah A, Elsaka SE. Effectiveness of XP-endo Finisher, EndoActivator, and File agitation on debris and smear layer removal in curved root canals: a comparative study. Odontology. 2017; 105(2): 178-183. https://doi.org/10.1007/s10266-016-0251-8

13. Gokilavani S, Vijayabharathi V, Parthasarathy R. Physico-chemical characteristics and antibacterial activity of chitosan extracted from shell of crab Paratelphusa hydrodromous. Asian Journal of Research in Pharmaceutical Science. 2014; 4(3): 125-128.

14. Jain V, Garg G, Patil U, Jain S. Recent perspectives of chitosan: A review. Research Journal of Pharmaceutical Dosage Forms and Technology. 2010; 2(3): 220-224.

15. Kumari GD, Raksha G, Deepak K, Anjana G, Mary CS. A Review on Chitosan Nanoparticle as a Drug delivery system. Asian Journal of Pharmaceutical Research. 2020; 10(4): 299-306. http://dx.doi.org/10.5958/2231-5691.2020.00051.9

16. Muxika A, Etxabide A, Uranga J, Guerrero P, De La Caba K. Chitosan as a bioactive polymer: Processing, properties and applications. Int J Biol Macromol. 2017; 105: 1358-1368. https://doi.org/10.1016/j.ijbiomac.2017.07.087

17. Skoskiewicz-Malinowska K, Kaczmarek U, Malicka B, Walczak K, Zietek M. Application of chitosan and propolis in endodontic treatment: A review. Mini Rev Med Chem. 2017; 17(5): 410-434. https://doi.org/10.2174/1389557516666160418122510

18. Roncal T, Oviedo A, de Armentia IL, Fernández L, Villarán MC. High yield production of monomer-free chitosan oligosaccharides by pepsin catalyzed hydrolysis of a high deacetylation degree chitosan. Carbohydr Res. 2007; 342(18): 2750-2756. https://doi.org/10.1016/j.carres.2007.08.023

19. Kasam S, Mariswamy AB. Efficacy of Different Methods for Removing Root Canal Filling Material in Retreatment - An In-vitro Study. Journal of Clinical and Diagnostic Research : JCDR. 2016; 10(6): Zc06-10. https://doi.org/10.7860/jcdr/2016/17395.7904

20. Hema BS, Chandu GS, Shiraguppi VL. Scanning Electron Microscopic Evaluation of Root Canal Surfaces Prepared with LightSpeed and Endowave Rotary System. Journal of Clinical and Diagnostic Research : JCDR. 2014; 8(12): Zc35-8. https://doi.org/10.7860/jcdr/2014/10034.5279

21. Ricker A, Liu-Snyder P, Webster TJ. The influence of nano MgO and BaSO4 particle size additives on properties of PMMA bone cement. International Journal of Nanomedicine. 2008; 3(1): 125.

22. Komabayashi T, Ahn C, Spears R, Zhu Q. Comparison of particle morphology between commercial-and research-grade calcium hydroxide in endodontics. J Oral Sci. 2014; 56(3): 195-199. https://doi.org/10.2334/josnusd.56.195

23. Donnermeyer D, Wyrsch H, Bürklein S, Schäfer E. Removal of calcium hydroxide from artificial grooves in straight root canals: sonic activation using EDDY versus passive ultrasonic irrigation and XPendo Finisher. J Endod. 2019; 45(3): 322-326. https://doi.org/10.1016/j.joen.2018.11.001

24. Shirsat ND, Momin S, Bandekar AA, Sayed U. Synthesis of Water Soluble Chitosan from Marine Waste and Its Application in Wet Wipes Formulations. Asian Journal of Research in Chemistry. 2012; 5(12): 1419-1423.

25. Chaudhry G-e-S, Thirukanthan C, Zin NAM, Sung YY, Muhammad TST, Effendy A. Antibacterial activity of Chito-oligosaccharides derived from Fish Scales. Research Journal of Pharmacy and Technology. 2022; 15(7): 3081-3085. https://doi.org/10.52711/0974-360X.2022.00515

26. Chaudhry GE, Thirukanthan CS, NurIslamiah KM, Sung YY, Sifzizul TSM, Effendy AWM. Characterization and cytotoxicity of low-molecular-weight chitosan and chito-oligosaccharides derived from tilapia fish scales. J Adv Pharm Technol Res. 2021; 12(4): 373-377. https://doi.org/10.4103/japtr.japtr_117_21

27. Sowjanya NT, Dhivya R, Meenakshi K, Vedhanayakisri K. Potential applications of chitosan nanoparticles as novel support in enzyme immobilization. Research Journal of Engineering and Technology. 2013; 4(4): 14.

28. Silva P, Guedes DFC, Nakadi FV, Pécora JD, Cruz‐Filho AMd. Chitosan: a new solution for removal of smear layer after root canal instrumentation. Int Endod J. 2013; 46(4): 332-338. https://doi.org/10.1111/j.1365-2591.2012.02119.x

29. Wei X, Chen S, Rong J, et al. Improving the Ca (II) adsorption of chitosan via physical and chemical modifications and charactering the structures of the calcified complexes. Polym Test. 2021; 98: 107192. https://doi.org/10.1016/j.polymertesting.2021.107192

30. Antunes PVS, Flamini LES, Chaves JFM, Silva RG, Cruz Filho AMd. Comparative effects of final canal irrigation with chitosan and EDTA. Journal of Applied Oral Science. 2019; 28 https://doi.org/10.1590/1678-7757-2019-0005

31. Zhou J, Liu T, Guo L. Effectiveness of XP-Endo Finisher and passive ultrasonic irrigation on intracanal medicament removal from root canals: a systematic review and meta-analysis. BMC Oral Health. 2021; 21(1): 1-15. https://doi.org/10.1186/s12903-021-01644-7

32. Al-dameh A. Root canal preparation with two different rotary systems: comparative study assessed by micro-computed tomography. University of Otago; 2011.

33. Tüfenkçi P, Yılmaz K. The effects of different endodontic access cavity design and using XP-endo Finisher on the reduction of Enterococcus faecalis in the root canal system. J Endod. 2020; 46(3): 419-424. https://doi.org/10.1016/j.joen.2019.11.011

34. Kfir A, Blau‐Venezia N, Goldberger T, Abramovitz I, Wigler R. Efficacy of self‐adjusting file, XP‐endo finisher and passive ultrasonic irrigation on the removal of calcium hydroxide paste from an artificial standardized groove. Australian Endodontic Journal. 2018; 44(1): 26-31. https://doi.org/10.1111/aej.12204

35. Uzunoglu E, Görduysus M, Görduysus Ö. A comparison of different irrigation systems and gravitational effect on final extrusion of the irrigant. Journal of Clinical and Experimental Dentistry. 2015; 7(2): e218. https://doi.org/10.4317/jced.52158

36. Peeters HH, Suardita K, Mooduto L, Gutknecht N. Extrusion of irrigant in open apex teeth with periapical lesions following laser-activated irrigation and passive ultrasonic irrigation. Iranian Endodontic Journal. 2018; 13(2): 169. https://doi.org/10.22037/iej.v13i2.17150

37. Yaylali IE, Kececi AD, Kaya BU. Ultrasonically activated irrigation to remove calcium hydroxide from apical third of human root canal system: a systematic review of in vitro studies. J Endod. 2015; 41(10): 1589-1599. https://doi.org/10.1016/j.joen.2015.06.006

38. Vera J, Arias A, Romero M. Effect of maintaining apical patency on irrigant penetration into the apical third of root canals when using passive ultrasonic irrigation: an in vivo study. J Endod. 2011; 37(9): 1276-1278. https://doi.org/10.1016/j.joen.2011.05.042

39. Agarwal A, Deore RB, Rudagi K, Nanda Z, Baig MO, Fareez MA. Evaluation of Apical Vapor Lock Formation and comparative Evaluation of its Elimination using Three different Techniques: An in vitro Study. The Journal of Contemporary Dental Practice. 2017; 18(9): 790-794. https://doi.org/10.5005/jp-journals-10024-2128

40. Espinoza I, Conde Villar AJ, Loroño G, Estevez R, Plotino G, Cisneros R. Effectiveness of XP-Endo Finisher and Passive Ultrasonic Irrigation in the Removal of the Smear Layer Using two Different Chelating Agents. Journal of Dentistry (Shiraz, Iran). 2021; 22(4): 243-251. https://doi.org/10.30476/dentjods.2021.86680.1204

Received on 21.12.2022 Modified on 18.05.2023

Research J. Pharm. and Tech 2023; 16(12):6008-6015.

DOI: 10.52711/0974-360X.2023.00975

Root Canal	Agitation Method	n	Mean±SD	*p-value	**p-value
Cervical	Ultrasonic	12	0,500±0,522	0,023	0.020
Cervical	XP Endo Finisher	12	1,333±0,985	0,023
Middle	Ultrasonic	12	0,667±0,651	0,069
Middle	XP Endo Finisher	12	1,500±1,168	0,069
Apical	Ultrasonic	12	0,917±0,793	0,008*
Apical	XP Endo Finisher	12	2,083±1,084	0,008*