|Year : 2019 | Volume
| Issue : 2 | Page : 54-60
Efficacy of XP-Endo finisher in removal of calcium hydroxide from root canal system: A systematic review
Shruti Kamath, Rajesh Shetty, Soumya Shetty, Nikhil Nighot, Karuna Ramnani, Dhananjay Bhujbal
Department of Conservative Dentistry and Endodontics, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||30-May-2019|
|Date of Acceptance||11-Sep-2019|
|Date of Web Publication||23-Dec-2019|
Dr. Shruti Kamath
A-1102, One Nation Society, Behind Swaraj Garden Hotel, Pimple Saudagar, Pune - 411 027, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Calcium hydroxide (CH) is widely used as an intracanal medicament between appointments to increase the number of canals free from bacteria. However, the remnant CH hinders the penetration of disinfectants and sealers into dentinal tubules and compromises the seal of the canal filling. Therefore, residual CH must be removed before permanent root canal obturation is completed. To analyze the efficacy of XP-endo finisher on the removal of CH medicament from root canal system. English language articles were retrieved from electronic biomedical journal databases. PubMed, Google Scholar, and ResearchGate were used to complete the search for all full-text articles available. The search was done till August 31, 2018. The last data search was conducted on September 1, 2018. All articles that were published in English were included. Only those articles that were published between January 1, 2011, and August 31, 2018, using XP-endo finisher were selected. The efficacy of XP-endo finisher on removal of CH medicament from root canal system. Total of 17 articles was identified through electronic database searching. After duplicate removal, and full-text reading, six articles qualified for qualitative synthesis in this systematic review. XP-endo finisher is proven to be more efficient in removing the CH medicament from root canal system.
Keywords: Calcium hydroxide, removal, XP-endo finisher
|How to cite this article:|
Kamath S, Shetty R, Shetty S, Nighot N, Ramnani K, Bhujbal D. Efficacy of XP-Endo finisher in removal of calcium hydroxide from root canal system: A systematic review. J Int Clin Dent Res Organ 2019;11:54-60
|How to cite this URL:|
Kamath S, Shetty R, Shetty S, Nighot N, Ramnani K, Bhujbal D. Efficacy of XP-Endo finisher in removal of calcium hydroxide from root canal system: A systematic review. J Int Clin Dent Res Organ [serial online] 2019 [cited 2020 May 24];11:54-60. Available from: http://www.jicdro.org/text.asp?2019/11/2/54/273756
| Rationale|| |
The ultimate goals of endodontic treatment are complete removal of bacteria, their by-products and pulpal remnants from infected root canals and the complete sealing of the disinfected root canals. Chemomechanical preparation is the first step to eliminate microorganism in the root canal system, but it alone is not sufficient to clean the root canal.,
Root canal instrumentation associated with irrigation is unable to achieve complete cleaning. The root canal system is a highly complex space, which impairs cleaning and disinfection procedures as well as the removal of root canal dressing. Despite technological advancements in instrumentation techniques and irrigation systems, clinicians may prefer to treat root canals in multiple sessions using an intracanal medicament to aid disinfection of the root canals.
Calcium hydroxide dressing (CH) has been used in dentistry for almost a century, and its advantages and disadvantages are well documented.,, CH is widely used as an intracanal medicament between appointments to increase the number of canals free from bacteria because of its antibacterial, therapeutic, biocompatible, and regenerative properties.,
CH is widely used to reduce bacteria in spite of its incapability to eradicate all endodontic microorganisms., It is also used in apexification procedures and to prohibit the resorption activity., CH paste is the medicament of choice during the treatment of internal root resorption. CH is widely used as it has antibacterial and anti-inflammatory properties, primarily due to the high pH value of the surrounding environment, approximately 12.5, after its dissolution.,
However, there are clinical concerns regarding the inability to completely remove the paste from the root canal system (Kenee et al., 2006, van der Sluis et al., 2007, Raὅdig et al., 2011, TaŞdemir et al., 2011, and Capar et al., 2014). Residual Ca(OH)2 may interfere with the ability of endodontic sealers to adapt to the canal wall and to enter the dentinal tubules, thus potentially allowing increased leakage (Lambrianidis et al. 1999, Kim and Kim 2002, and Barbizam et al. 2008). Therefore, complete removal of Ca(OH)2 paste prior to filling of the root canal system is desired. The complex anatomy of the root canal may not allow this elimination using our conventional materials.
XP-endo finisher (XP) (FKG Dentaire, La Chaux de Fonds, Switzerland) is a file based on the shape-memory principles of NiTi alloy, with a small core size 25 and no taper; It was designed to be used following root canal preparation till size 25 or more to clean complex morphologies and difficult to reach areas.
XP-endo finisher respects the original root canal anatomy and effectively cleans the irregular areas because of its reputed increased flexibility and its ability to expand to adapt to the root canal three-dimensionally. Under favor of these, properties previous studies reported that the XP effectively removed accumulated hard tissue debris and the smear layer from the root canal system.,
The XP-endo Finisher (FKG Dentaire; La Chaux-de-Fonds, Switzerland) is another novel NiTi-instrument system that has a C-shape in the apical half of the files.
This single file is ISO 25 in diameter, has no taper (25/.00) and expands up to 6 mm in diameter, or 100 times more than an equivalent-sized file. Unlike ordinary NiTi instruments, the shape of the XP-endo finisher alters with changes in temperature. Due to its metallurgy, the file changes from the M-phase to the A-phase when exposed to the temperature within the root canal. In the rotation mode, the A-phase shape enables the file to access and clean areas with memorized shape. The file can be returned to its original straight shape (M-phase) manually after it has cooled.,
The aim of this study is to thus evaluate the efficacy of XP-endo finisher in the removal of CH medicament from the root canal system, to have a better understanding of the material and to use these sealers in various clinical situations. In-depth knowledge of these properties will enhance a clinician's judgment and will result in predictable outcome and use of the material as and when required.
The aim of this study is to evaluate the efficacy of the XP-Endo® Finisher in removing Ca(OH)2 medicament from the root canal system.
What is the efficacy of XP-endo finisher files in the removal of CH medicament from the root canal system?
The objective is to to study the efficacy of XP-endo finisher files in the removal of CH medicament from root canal system.
- Articles in English language or those having a summary in English
- Studies published on January 1, 2011–September 31, 2018
- In vitro studies done in human extracted teeth
- Studies comparing the efficacy of XP-endo finisher file in the removal of CH medicament from root canal system.
- Review, case reports, abstracts, letters to editors, and editorials
- Studies published in languages other than English
- Review, abstract, letter to editorials, andin vivo studies are excluded
- Any studies are done before January 1, 2011.
| the Picos Guidelines That Were Selected Are|| |
P as the participants that were included, and this comprised of freshly extracted human teeth. I as the intervention where XP-endo finisher file was considered. C as comparison and this review did not aim to compare any of the parameters. O as the outcome where it was assessed to measure the amount of remaining CH in the root canal system. S as the study designs were includedin vitro studies. And, hence, the PICOS are mentioned below:
- P: Human extracted teeth
- I: XP-endo finisher file
- O: To measure the amount of remaining CH in the root canal system
- S: Study designin vitro studies.
| Information Sources|| |
English language articles were retrieved from electronic biomedical journal databases. PubMed, Google Scholar, and ResearchGate were used to complete the search for all full-text articles available. The search was done till August 31, 2018. The last data search was conducted on September 1, 2018.
| Search|| |
The following databases were searched on PubMed (the limits used were all full-text articles in English dated from January 1, 2011, to August 31, 2018) and Google Scholar. For the electronic search strategy, the following terms were used as keywords in several combinations [Table 1].
| Study Selection Process|| |
In vitro and comparative studies were selected; however, only articles where the efficacy of XP-endo finisher on the removal of CH from root canal system of freshly extracted human teeth were included. Using different search strategies from the above-mentioned keywords and their combinations; various electronic databases were searched. A total of 333 articles were identified through the database searching. These records were assessed for any duplicates, and 316 articles were removed. After a thorough reading of titles, 316 articles were excluded, and 17 articles were selected. These 17 articles were further screened for abstract reading and 11 articles were excluded and 6 were selected after reading the abstracts. Full texts for these six articles were obtained and were assessed for eligibility. All these six articles qualified and were selected. No exclusion was done after reading the full texts.
| Data Collection Process|| |
The data collection process was done according to the consultation approved by our expert. First, a Pilot Microsoft Excel Sheet was filled accordingly, and then the expert was consulted for further progress. According to the data collected and the records selected, the remaining Excel sheet was filled only with the data that were related to this study and retained [Figure 1].
| Data Items|| |
The headings under which the data were tabulated are study ID where the number of studies that were selected was mentioned number wise. Various articles were included and so was the name of the author and location as an important factor. The year of publication to mention and specify the fixed time interval that was selected. The study design was mentioned to specify the type of study design, for example, whether the study was in vitro, ex vivo or in situ. The sample Size was mentioned to specify the number of participants included in the study. Population/products were included and this comprised of freshly extracted human teeth. Intervention/exposure is the XP-endo finisher. The objective is to study the efficacy of XP-endo finisher files in the removal of CH from root canal system and the amount of remaining CH in percentage. The conclusion was mentioned according to the study's protocol and in the author's original words. The remark was expressed by the author of this systematic review.
In many areas of medicine, the amount of published information is increasing at an exponential rate, making it difficult for the clinician to condense the data to a manageable amount of valuable and useful information. Systematic reviews have been suggested as a remedy for this information overload. Such reviews are regarded as the highest level of evidence. Certain statistical methods, for example, meta-analysis, have also been introduced for the calculation of a more comprehensive summation of the compiled results from studies with small sample sizes. These findings would then serve as an authoritarian guide for evidence-based practice [Table 2].
Thus, conducting systematic reviews may provide reliable results that can be used for clinical decision making, especially when it is possible to perform a meta-analysis. This systematic review aimed to identify, evaluate, and synthesize allin vitro studies that met the prespecified eligibility criteria to answer the following research question: “What is the efficacy of XP-endo finisher files in the removal of CH medicament from root canal system as evaluated in experimentalin vitro studies?”
| Summary of Evidence|| |
Wigler et al. 2016, conducted a study to compare the efficacy of the XP-endo finisher file (XP) (FKG Dentaire, La Chaux de Fonds, Switzerland) to that of passive ultrasonic irrigation (PUI) and conventional syringe and needle irrigation (SNI) in the removal of CH paste from an artificial standardized groove in the apical third of root canals. The root canals of 68 mandibular incisors with single oval canals were prepared using Mtwo instruments (VDW GmbH, Munich, Germany) up to size 40.04 taper. Each tooth was split longitudinally, and in one half of the roots, a standardized groove was prepared in the apical part of the specimen. The grooves were filled with Ca(OH)2, and the root halves were reassembled. The roots were randomly divided into two control groups (n = 4) and three experimental groups (n = 20) according to the Ca(OH)2 methods used: XP, PUI, and SNI. The amount of remaining medicament was evaluated under X25 magnification using a four-grade scoring system. Kappa values were calculated for intra- and inter-observer agreement evaluation. The differences in the Ca(OH)2 scores among the different groups were analyzed using the Kruskal–Wallis test. None of the tested methods could completely clean the Ca(OH)2 from the artificial standardized groove in the apical third of the root canals. XP and PUI removed significantly more Ca(OH)2 than SNI (P < 0.001), with no significant differences between them (P = 0.238). They concluded that XP and PUI were more effective in removing Ca(OH)2 from artificial standardized grooves in the apical third of root canals than SNI.
Uygun et al. 2016, conducted a study to compare the efficacy of the XP-endo finisher and TRUShape 3D Conforming Files to conventional and ultrasonic irrigation techniques for removing CH from artificially created grooves on root canals. The study used 32 human mandibular premolar teeth, which were decoronated and instrumented up to ProTaper Universal F5 (Dentsply Maillefer; Ballaigues, Switzerland). The teeth were split longitudinally; two standardized grooves were prepared in the apical and coronal portions and filled with CH. Each tooth was reassembled with wax. The samples were stored at 100% humidity at 37°C for 1 week, after which the specimens were grouped and irrigated using needle irrigation, ultrasonic irrigation, XP-endo finisher through continuous irrigation or TRUShape 3D Conforming File through continuous irrigation. Two calibrated observers scored the amount of CH remaining, and the data were statistically analyzed using the Kruskal–Wallis and Mann–Whitney U-tests, (P < 0.05). Needle irrigation had the poorest scores (P < 0.001), while the XP-endo Finisher, TRUShape 3D Conforming File through continuous irrigation and ultrasonic irrigation groups had similar results in removing CH.
Kfir et al. 2012, conducted a study to compare the effectiveness of self-adjusting file (SAF), XP-endo finisher (XP), PUI, and conventional SNI in the removal of Ca(OH)2 from an artificial groove. Eighty mandibular incisors with single oval canals were prepared to size 40/0.04 and split longitudinally. A standardized groove was prepared in the apical third and filled with Ca(OH)2. The root halves were reassembled and divided into two control groups (n = 4) and four experimental groups (n = 18) according to the removal methods used. The amount of residual Ca(OH)2 was evaluated using a four-grade scoring system. The differences among the groups were analyzed using the Kruskal–Wallis test (P < 0.05). SAF, XP, and PUI removed significantly more Ca(OH)2 than SNI (P < 0.001), although there were no significant differences among them (P = 0.209). None of the tested methods could completely clean Ca(OH)2 from the groove.
Hamdan et al. 2017 conducted a study to to compare the efficacy of the PUI and the Xp-endo finisher (FKG-Dentaire, La-Chaux-de-Fonds, Switzerland) in removing the CH paste from root canals and the apical third. Sixty-eight root canals of single-rooted teeth were shaped using the BT-Race files (FKGDentaire, La-Chaux-de-Fonds, Switzerland). Ca(OH)2 was placed in all samples except for the negative control group (n = 4). Remaining teeth were randomly divided into three groups: G1-Xp (n = 30), G2-PUI (n = 30), and the positive control group (n = 4). The removal procedure consisted of three repeated 1 min cycles. Samples were split longitudinally, photos of halves were taken at ×6.4 magnification and were analyzed using the ImageJ-Software (The National Institutes of Health NIH, Bethesda, Maryland, USA) to calculate the percentage of surfaces with residual Ca(OH)2; the results were compared using the Wilcoxon-Mann–Whitney test. Photos of the apical thirds were taken at ×16 and ×40 magnifications and were scored by two examiners from 0 to 4. Scores of the apical third were compared using the Fisher's test. The Xp-endo finisher removed completely the Ca(OH)2 dressing from four teeth (13.33%) whereas the PUI in one tooth (3.33%). The mean values of the remaining Ca(OH)2 were (2.1% and 3.6%), respectively, and the difference was not statistically significant (P = 0.195). Both examiners found the Xp-endo finisher more efficient in the apical third, and the difference was significant; P = (0.025, 0.047), respectively.
Gokturk et al. 2017, conducted a study to investigate the ability of laser-activated irrigation (LAI), XP-endo finisher, CanalBrush (CB), Vibringe, PUI, and conventional syringe irrigation (SI) systems on the removal of CH from simulated root canal irregularities. The root canals of 105 extracted single-rooted teeth were instrumented using Reciproc rotary files up to size R40. The teeth were split longitudinally. Two of the three standard grooves were created in the coronal and apical section of one segment, and another in the middle part of the second segment. The standardized grooves were filled with CH, and the root halves were reassembled. After 14 days, the specimens were randomly divided into seven experimental groups (n = 15/group). CH was removed as follows: Group 1: beveled needle irrigation; Group 2: double side-vented needle irrigation; Group 3: CB; Group 4: XP-endo finisher; Group 5: Vibringe; Group 6: PUI; and Group 7: LAI. The amount of remaining CH in the grooves was scored under a stereomicroscope at ×20. Statistical evaluation was performed using Kruskal–Wallis and Bonferroni-Correction Mann–Whitney U-tests. Groups 1 and 2 were the least efficient in eliminating CH from the grooves. Groups 6 and 7 eliminated more CH than the other protocols; however, no significant differences were found between these two groups (P > 0.05). Nevertheless, none of the investigated protocols were able to completely remove all CH from all three root regions. LAI and PUI showed less residual CH than the other protocols from artificial grooves.
Keskin et al. 2017 conducted a study to The aim of this study was to evaluate the effect of supplementary use of XP-endo finisher file, passive ultrasonic activation (PUI), EndoActivator (EA), and CB on the removal of CH paste from simulated internal resorption cavities.
The root canals of 110 extracted single-rooted teeth with straight canals were prepared up to size 50. The specimens were split longitudinally, and standardized internal resorption cavities were prepared with burs. The cavities and root canals were filled with CH paste. The specimens were divided into five groups as follows: XP-endo finisher, EA, PUI, CB, and SI. The root canals were irrigated with 5.25% NaOCl and 17% EDTA for 2 min, respectively. Apart from the SI group, both solutions were activated using tested techniques for 1 min. The quantity of CH remnants on resorption cavities was scored. Data were analyzed using Kruskal–Wallis H and Mann–Whitney U-tests. XP-endo finisher and PUI removed significantly more CH than SI, EA, and CB (P < 0.05), showing no significant difference between them (P > 0.05). Differences among SI, EA, and CB were also nonsignificant (P > 0.05). None of the tested techniques render the simulated internal resorption cavities free of CH debris. XP-endo finisher and PUI were superior to SI, CB, and EA.
Few articles did not clearly mention the values of removal of CH from root canal system, which makes the interpretation difficult.
| Conclusion|| |
XP Endo finisher has been proven to be an efficient alternative to passive ultrasonics in the removal of CH medicament from root canal system.
In vitro studies have to be standardized to translate it into meaningful data for a clinician. Further studies, concentrating on “vehicle of CH” and its removal using various techniques of root canal system are required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kawashima N, Wadachi R, Suda H, Yeng T, Parashos P. Root canal medicaments. Int Dent J 2009;59:5-11.
Hülsmann M, Peters OA, Dummer PM. Mechanical preparation of root canals: Shaping goals, techniques and means. Endod Topics 2005;10:30-76.
Peters OA, Schönenberger K, Laib A. Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J 2001;34:221-30.
Martins Justo A, Abreu da Rosa R, Santini MF, Cardoso Ferreira MB, Pereira JR, Húngaro Duarte MA, et al.
Effectiveness of final irrigant protocols for debris removal from simulated canal irregularities. J Endod 2014;40:2009-14.
Sundqvist G. Pathogenicity and virulence of black-pigmented gram-negative anaerobes. FEMS Immunol Med Microbiol 1993;6:125-37.
Sathorn C, Parashos P, Messer H. Antibacterial efficacy of calcium hydroxide intracanal dressing: A systematic review and meta-analysis. Int Endod J 2007;40:2-10.
Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: A literature review – Part II.In vivo
studies. Restor Dent Endod 2015;40:97-103.
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. Restor Dent Endod 2014;39:241-52.
Athanassiadis B, Abbott PV, Walsh LJ. The use of calcium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics. Aust Dent J 2007;52:S64-82.
Siqueira JF Jr., Magalhães KM, Rôças IN. Bacterial reduction in infected root canals treated with 2.5% NaOCl as an irrigant and calcium hydroxide/camphorated paramonochlorophenol paste as an intracanal dressing. J Endod 2007;33:667-72.
Law A, Messer H. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. J Endod 2004;30:689-94.
Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: Systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e36-42.
Safavi KE, Nichols FC. Alteration of biological properties of bacterial lipopolysaccharide by calcium hydroxide treatment. J Endod 1994;20:127-9.
Bhuva B, Barnes JJ, Patel S. The use of limited cone beam computed tomography in the diagnosis and management of a case of perforating internal root resorption. Int Endod J 2011;44:777-86.
Kouassi M, Michaïlesco P, Lacoste-Armynot A, Boudeville P. Antibacterial effect of a hydraulic calcium phosphate cement for dental applications. J Endod 2003;29:100-3.
Yu DC, Schilder H. Cleaning and shaping the apical third of a root canal system. Gen Dent 2001;49:266-70.
Leoni GB, Versiani MA, Silva-Sousa YT, Bruniera JF, Pécora JD, Sousa-Neto MD, et al. Ex vivo
evaluation of four final irrigation protocols on the removal of hard-tissue debris from the mesial root canal system of mandibular first molars. Int Endod J 2017;50:398-406.
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;105:178-83.
Bortoluzzi EA, Carlon D Jr., Meghil MM, El-Awady AR, Niu L, Bergeron BE, et al.
Efficacy of 3D conforming nickel titanium rotary instruments in eliminating canal wall bacteria from oval-shaped root canals. J Dent 2015;43:597-604.
Peters OA, Arias A, Paqué F. A micro-computed tomographic assessment of root canal preparation with a novel instrument, TRUShape, in mesial roots of mandibular molars. J Endod 2015;41:1545-50.
Spångberg LS. Systematic reviews in endodontics – Examples of GIGO? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:723-4.
Moraes LC, Só MV, Dal Pizzol Tda S, Ferreira MB, Montagner F. Distribution of genes related to antimicrobial resistance in different oral environments: A systematic review. J Endod 2015;41:434-41.
Wigler R, Dvir R, Weisman A, Matalon S, Kfir A. Efficacy of XP-endo finisher files in the removal of calcium hydroxide paste from artificial standardized grooves in the apical third of oval root canals. Int Endod J 2017;50:700-5.
Uygun AD, Gündoǧdu EC, Arslan H, Ersoy İ. Efficacy of XP-endo finisher and TRUShape 3D conforming file compared to conventional and ultrasonic irrigation in removing calcium hydroxide. Aust Endod J 2017;43:89-93.
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. Aust Endod J 2018;44:26-31.
Hamdan R, Michetti J, Pinchon D, Diemer F, Georgelin-Gurgel M. The XP-endo finisher for the removal of calcium hydroxide paste from root canals and from the apical third. J Clin Exp Dent 2017;9:e855-60.
Gokturk H, Ozkocak I, Buyukgebiz F, Demir O. Effectiveness of various irrigation protocols for the removal of calcium hydroxide from artificial standardized grooves. J Appl Oral Sci 2017;25:290-8.
Keskin C, Sariyilmaz E, Sariyilmaz Ö. Efficacy of XP-endo finisher file in removing calcium hydroxide from simulated internal resorption cavity. J Endod 2017;43:126-30.
[Table 1], [Table 2]