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Table of Contents   
REVIEW ARTICLE  
Year : 2018  |  Volume : 21  |  Issue : 5  |  Page : 474-480
The influence of ProTaper and WaveOne on apically extruded debris: A systematic review and meta-analysis


1 Department of Oral Medical, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
2 Department of Orthodontics, Affiliated Hospital of Qingdao University, Qingdao, China
3 Department of Endodontics, Affiliated Hospital of Qingdao University; Department of Oral Medical, Qingdao University, Qingdao, China

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Date of Submission20-May-2018
Date of Decision31-Mar-2018
Date of Acceptance19-Jun-2018
Date of Web Publication17-Sep-2018
 

   Abstract 

Background: Apically extruded debris produced during root canal preparation can induce postoperative inflammation and subsequent failure of root canal treatment. Therefore, debris production must be reduced to improve the outcome of root canal treatment.
Aim: This study aimed to provide a theoretical basis for the improvement of root canal treatment by comparing the difference in the amount of apically extruded debris produced during the root canal preparation of extracted human teeth with ProTaper Universal (PTU), ProTaper Next (PTN), and WaveOne (WO).
Materials and Methods: On March 30, 2017, three researchers searched five electronic databases (PubMed/Medline, Cochrane, Science Direct Online, Embase, and Web of Science) with no time limitations. Only articles written in English were retrieved, and 150 articles were obtained. Then, the three researchers independently selected articles in accordance with previously established inclusion and exclusion criteria, and inconsistent results were discussed. Data were analyzed through meta-analysis for standardized mean difference (SMD).
Results: Eight studies met the inclusion criteria and were subjected to qualitative analysis. Four articles showed that PTU produced higher amounts of apical debris than WO; two articles showed that PTU produced lower amounts of apical debris than WO; and three articles showed that PTN produced lower amounts of apical debris than WO. Moreover, one article demonstrated that PTU produced higher amounts of apical debris than PTN. A meta-analysis showed that PTU and WO did not produce significantly different amounts of apically extruded debris: SMD = −0.26, Z = 0.50 (P > 0.05). PTU produced lower amounts of apically extruded debris than WO: SMD = −4.98, Z = 2.79 (P < 0.05). However, results were significantly heterogeneous among all the included studies (I2 = 97%). No significant difference was found between PTU and WO in the amounts of apically extruded debris: SMD = 0.47, Z = 1.06 (P > 0.05).
Conclusion: Currently available evidence shows that PTN can produce lower amounts of apical debris than WO (P < 0.05). Moreover, the amounts of apically extruded debris produced by PTU and WO are not significantly different (P > 0.05). Nevertheless, given the limited number of studies reviewed, a definitive conclusion cannot be reached.

Keywords: Apically extruded debris; meta-analysis; ProTaper Next; ProTaper Universal; WaveOne

How to cite this article:
Zhang C, Liu J, Liu L. The influence of ProTaper and WaveOne on apically extruded debris: A systematic review and meta-analysis. J Conserv Dent 2018;21:474-80

How to cite this URL:
Zhang C, Liu J, Liu L. The influence of ProTaper and WaveOne on apically extruded debris: A systematic review and meta-analysis. J Conserv Dent [serial online] 2018 [cited 2018 Oct 23];21:474-80. Available from: http://www.jcd.org.in/text.asp?2018/21/5/474/241202



   Introduction Top


Root canal therapy is a common treatment for periapical periodontitis and the irreversible inflammation or infected pulpal tissue. The success rate of root canal treatment ranges from 31% to 96%.[1],[2] Root canal therapy includes root canal preparation, cleaning, and finally obturation.[3],[4] A completely necrotic dental pulp provides a safe harbor for primarily anaerobic microbes and associated pathogens, given that no immune responses are produced in the absence of vascularity. Hence, only the complete cleaning, shaping, and obturation of the root canal will eliminate the source of periapical disease and create a microenvironment in which periapical lesions can remineralize. Therefore, the success of root canal therapy is based on thorough debridement, disinfection, and obturation.[5] The sentence means that root canal preparation is the first step in root canal treatment and plays a major role in the success of root canal treatment. Thorough debridement of the root canal space with instruments and irrigation solutions is important to improve the success of root canal therapy. Apically extruded debris consists of irrigation solutions, necrotic tissue, microorganisms, dentin particles, and pulpal fragments. The extrusion of debris into periapical tissues may cause postoperative inflammation and the short- or long-term failure of root canal therapy.[6],[7] However, no instruments or instrumental techniques can completely prevent debris production.[8] Although debris production cannot be completely avoided, the use of proper instruments or instrument techniques can reduce production rate.[9]

The Myers and Montgomery method is the most popular technique for the quantification of debris extrusion.[10] It suggested to re-evaluate apical dentinal plug as it can reduce the amount of apically extruded debris and irrigants and can prevent the overcombination between instrument and extruded materials.[10] This experimental model was previously used to prove that all manual or engine-driven instrumentation techniques generate apically extruded debris.[11],[12] Although no instrument or instrumentation technique can completely avoid the production of apically extruded debris, different instruments may produce different amounts of apically extruded debris. The amount of debris production can be influenced by the different operational principles and designs of the instruments. For example, most nickel–titanium (NiTi) instrument systems function in a crown-down manner with push–pull rotation filing movements. Next-generation NiTi files have an advantage in shaping and cleaning.[13] ProTaper (PT, Dentsply, Maillefer, Ballaigues, Switzerland) and WaveOne (WO, Dentsply, Maillefer, Ballaigues, Switzerland) are the two current instruments used for root canal preparation.

The PT system is characterized by the gradual tapering of each instrument and “progressive preparation” in the vertical and horizontal directions. The cross-section of the PT is similar to that of a reamer and possesses three cutting edges and a convex core9. ProTaper Next (PTN) is the most recent generation of shaping files. It has a unique center of rotation offset and center of mass. Wave motion travels along the active length of the PTN file. This design minimizes the engagement between the dentin and file, enhances the removal of apically extruded debris out of a root canal, and improves the flexibility of the files.[14],[15] The WO single-reciprocating file system simulates linear motion and reversed–balanced force. Whether PT and WO exhibit improved performance in terms of debris production remains unknown. Therefore, this study aimed to compare the effect of PT (include PTN and ProTaper Universal [PTU]) and WO on debris production during root canal preparation through previous studies searched from electronic database.


   Materials and Methods Top


Search strategy

Studies were searched from five electronic databases: PubMed, Cochrane, ScienceDirect online, Embase, and Web of Science by using Medical Subject Heading terms and other keywords in the following combinations: “Single-file” OR “file system” OR “WaveOne” OR “Reciproc” OR “single file endodontic” OR “reciprocating file” OR “reciprocating” OR “asymmetric movement” AND “Rotary file” OR “rotary instrument” OR “rotary nickel titanium” OR “rotary niti” OR “niti rotary instrument” OR “endodontic rotary file” OR “ProTaper” OR “Mtwo” OR “continuous movement” OR “continuous rotation” AND “debris extrusion” OR “apical debris extrusion” OR “apical extrusion of debris” OR “apically extruded debris” OR “apically extruded material.” The search was carried out on March 22, 2017; in PubMed, 31 articles were obtained with the keywords and randomized controlled trial or controlled clinical trial limitations; in Embase database, 23 results were obtained; in ScienceDirect online, 21 results were obtained; in Web of Science, 75 results were obtained; and in Cochrane database, no results were obtained. Finally 150 results were obtained, and then, they were selected under the following inclusion and exclusion criteria:

Inclusion criteria

  1. Original articles
  2. Teeth were extracted from humans who are over 18 years old
  3. The experiments which were randomized and controlled
  4. Experiments to evaluate the amount of apically extruded debris produced by WO and PT with or without other instrument
  5. In vitro or in vivo experiments
  6. Teeth with single root canal and apical foramen
  7. The length of teeth is similar
  8. The sample of each group is no <20
  9. Publication in English.


Exclusion criteria

  1. Articles studying instruments different from PT or WO were extracted
  2. Articles without sufficient data were excluded
  3. Articles involving the artificial teeth or retreatment teeth were excluded
  4. Articles studying the influence of irrigants on the apical extrusion of debris were extracted.


Data extraction

The amount of the apically extruded debris after the preparation of extracted human teeth using PT, PTU, PTN, and WO was extracted from all the included articles.

Analysis of the level of evidence

The evidence model was established based on the quality standards described in the guidelines used for reporting preclinical in vitro studies on dental materials applied for apically extruded debris.[16],[17],[18]

Statistical analysis

The standard deviation and average of apical debris extrusion of the eight articles were extracted to carry out the meta-analysis and review. The standardized mean difference (SMD) was used for the reason that the variable of interest was continuous. A random-effects model was also used because there was a high heterogeneity (values of I2 > 0.50). The results of the included studies are shown in a forest plot. A significance level of 0.5 was considered and the Review Management 5.3 software (Cochrane) was used to carry out this meta-analysis.

Initially, 150 articles were retrieved. However, 63 duplicated articles were removed. The titles and abstracts of the remaining articles were then screened. Inclusion and exclusion criteria were applied to the full texts of the remaining articles. Studies with clear information that met the inclusion criteria were included for complete analysis. At this stage, 21 articles were analyzed and 13 were excluded. The flowchart of article screening in the review process is shown in [Figure 1]. The exclusion criteria used are shown in [Table 1].
Figure 1: The flowchart of article screening in the review process

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Table 1: Excluded studies and reasons for the exclusions

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Study characteristics

Study characteristics (author, year, and country), tooth type, instrument working length, analysis, method, irrigation, confidence level, and P value were extracted from the included articles and are listed in [Table 2]. The qualities of the eight articles are shown in [Table 3]. The level of evidence is shown in [Table 4].
Table 2: Characteristics of the studies included in the systematic review

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Table 3: Qualities of evaluation

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Table 4: Classification of levels of evidence

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A total of 340 teeth were included in the selected studies. Among the eight included articles, four articles reported that PTU produced higher amounts of apical debris than WO; two articles reported that PTU produced lower amounts of apical debris than WO; and three articles reported that WO produced higher amounts of apical debris than PTN. Moreover, one article reported that PTU produced higher amounts of apical debris than PTN.

Meta-analysis of the amount of debris: ProTaper versus WaveOne

The results of this meta-analysis are presented in [Figure 2]. Results showed that the amounts of apical debris produced by PT and WO were not significantly different: SMD = −0.26, Z = 0.50 (P > 0.05), I2 = 94. PTN produced lower amounts of apical extrusion debris than WO: SMD = −4.98, Z = 2.79 (P < 0.05). However, results were significantly heterogeneous among studies (I2 = 97%). The amounts of apical debris produced by PTU and WO were not significantly different: SMD = 0.47, Z = 1.06 (P > 0.05). The trend in the amount of apical extrusion debris produced by different instruments was inferred from the evidence obtained through the meta-analysis. However, a definitive conclusion could not be reached given the limited number of studies reviewed.
Figure 2: Forest result of this meta-analysis

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   Discussion Top


This systematic review and meta-analysis addresses the influence of PT and WO on the production of apically extruded debris, which is one of the major reasons for posttreatment inflammation of symptomatic apical periodontitis.[31] Laboratory studies on different endodontic instruments are needed for the further development of endodontics. Rigorously designed studies could provide valid information for clinical research. This systematic review and meta-analysis initially obtained 150 articles that met the selection criteria. However, only eight results were selected after screening all retrieved articles on the basis of inclusion and exclusion criteria. All of the studies were performed in the laboratory, and study conditions were as similar as possible.

This systematic review and meta-analysis focused on the measurement of apical debris production by WO and PT during root canal preparation. All of the articles described comparable study groups (tooth type, root curvature, and canal length were similar across studies) to increase the probability that debris production was caused by instrumentation and not by root morphology. The studies demonstrated that many factors affect the production of apically extruded debris. These factors include the type of teeth; complexity of the root canal system; working length and technique of the instrument; extent of apical enlargement and dentin plug formation; type and amount of irrigant solution; and system of irrigation delivery.[18]

The eight included studies were conducted in different countries. Thus, tooth size (include tooth length, diameters, and volume size) differed across studies and may account for differences in outcomes. Articles from China, Turkey, and Iran all showed that PTU can produce higher amounts of debris than WO during root canal preparation.[32],[33],[34] Articles from India produced different answers: two articles showed that PTU produced lower amounts of debris than WO,[33],[35] whereas three articles showed that PTN produced lower amounts of debris than WO.[15],[36],[37] A German study showed that PT produced higher amounts of debris than WO.[38]

Tooth type differed across studies. Some studies were performed on anterior teeth, whereas others were performed on premolar teeth. One study was performed on incisor teeth. As a result, root canal systems differed across studies. Therefore, debris production may also differ across studies. A previous study has shown that root canal therapy is more likely to be successful when performed on anterior teeth than when performed on posterior teeth.[39] However, each study used the same tooth type and maintained similar working conditions; therefore, the consistency of the results should not be affected.

Working length is one of the factors that influence apical debris production. A working length of −1 mm from the apical foramen can significantly reduce the amount of apically extruded debris.[10],[37] All laboratory studies included in this review established this working length.

Irrigation can affect the amount of debris and the success of the root canal therapy.[40] From the laboratory studies included in the present review, all but two used distilled water,[33],[34],[35],[36],[37],[38] one used normal saline,[32] and one study used unknown irrigation.[15] The distilled water can avoid any factors that increase the weight of apical extruded debris. The author used the 0.9% NaOCl solution as the root canal irrigant which was used to avoid the generation of flocculent precipitates.

The studies included in this review utilized different methods to quantify the production of apically extruded debris. Six articles used the Myers and Montgomery method.[15],[34],[35],[36],[37],[38] The method used for the quantification of apically extruded debris was not stated in two articles.[32],[33] The Myers and Montgomery method has more advantages than other quantification methods because it allows the separate quantification of apically extruded debris and irrigant.[10] Despite its many advantages, this method has some drawbacks, such as the lack of an apical barrier. Furthermore, the sensitivity of the analytical balance is crucial to the accuracy of the Myers and Montgomery method given the small amount of apically extruded debris. The sample of the apically extruded debris could become hydrated through exposure to air moisture given that the Myers and Montgomery method does not control for environmental conditions.[41] Meanwhile, the drying technique used in the quantification method for apically extruded debris is influenced by external conditions, such as temperature and humidity.

The included studies were rated in accordance with their level of evidence. Quality standards were established on the basis of the information provided by the articles. No clinical study was included given that all the articles reported on laboratory studies, and the levels of evidence ranged from B (high) to D (low). Studies were rated as level B if the Myers and Montgomery method was used to quantify the amount of apically extruded debris; as level C if drying–freezing was applied; and as level D if another or an unknown quantification method was applied. Other factors considered were the use of natural teeth or not, the use of randomization or not, the use of a working length of −1 mm from the apical foramen or not, or the use of distilled water as an irrigant or not. The levels of the articles included in this meta-analysis ranged from B to C.

The eight studies included in this meta-analysis demonstrated that all root canal preparation techniques can produce apically extruded debris. However, different instruments for root canal preparation produced different amounts of debris.[42],[43] Given that apically extruded debris can cause inflammation after root canal treatment, measures, such as using a suitable irrigant or instrument, should be taken to reduce debris production.[10],[36]


   Conclusion Top


This meta-analysis showed that both of the PT (include PTU and PTN) and WO systems were associated with extruded debris, but PTN can produce lower amounts of apical debris than WO.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Lingshuang Liu
Department of Endodontics, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCD.JCD_82_18

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