Restor Dent Endod. 2021 Aug;46(3):e33 https://doi.org/10.5395/rde.2021.46.e33 pISSN 2234-7658·eISSN 2234-7666 Research Article Enhanced visualization of the root canal morphology using a chitosan- based endo-radiopaque solution Shashirekha Govind ,1* Amit Jena ,2 Satabdi Pattanaik ,1 Mahaprasad Anarasi ,3 Satyajit Mohapatra ,2 Vinay Shivagange 4 1Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Siksha ‘O’ Anusandhan Deemed to be University, Odisha, India 2Department of Conservative Dentistry and Endodontics, Sriram Chandra Bhanja Dental College & Hospital, Utkal University, Odisha, India 3Department of Conservative Dentistry and Endodontics, Hi-Tech Dental College & Hospital, Utkal University, Odisha, India 4Adult Restorative Dentistry - Endodontics, Oman Dental College, University Complutense of Madrid, Oman, Sultanate of Oman Received: Aug 26, 2020 ABSTRACT Revised: Dec 3, 2020 Accepted: Dec 9, 2020 Objectives: This study aimed to investigate the efficacy of ionic and non-ionic-based contrast Govind S, Jena A, Pattanaik S, Anarasi M, media (in vitro study) and the combinatorial effect of chitosan-based endo-radiopaque Mohapatra S, Shivagange V solution (CERS) (in vivo study) for visualization of the root canal anatomy. *Correspondence to Materials and Methods: In vitro study (120 teeth): The root canal of maxillary premolars Shashirekha Govind, BDS, MDS and molars (in vitro group 1 and 2 respectively, n = 60 each) were analyzed using 4 different Professor, Department of Conservative contrast media (subgroups: Omnipaque 350, Iopamidol, Xenetix 350, and Urografin 76;n = 15 Dentistry and Endodontics, Institute of Dental each) in combination with 5.25% sodium hypochlorite (NaOCl). Based on the results of the Sciences, Siksha ‘O’ Anusandhan Deemed to in vitro study, in vivo study (80 teeth) was done to compare Xenetix 350 + 5.25% NaOCl with be University, J-15, Khandagiri Marg, Dharam Vihar, Jagamara, Bhubaneswar, Odisha CERS (in vivo group 1 and 2 respectively, n = 40 each) on maxillary and mandibular premolars 751003, India. and molars. Two endodontists used radiovisiography to assess the depth of ingress and E-mail: [email protected] identify the aberrant root anatomy after access cavity preparation, and after initial cleaning and shaping of canals. Kruskal-Wallis test was used for in vitro comparison (p < 0.05), and Copyright © 2021. The Korean Academy of Conservative Dentistry Wilcoxon signed-rank test and Mann-Whitney U test for in vivo analysis (p < 0.01). This is an Open Access article distributed Results: In vitro study, Xenetix 350 + 5.25% NaOCl facilitated a significant higher visualization under the terms of the Creative Commons (p < 0.05). For in vivo study, CERS had a statistically significant depth of ingress (p < 0.01), Attribution Non-Commercial License (https:// and was efficient in identifying the aberrant root canal anatomy of premolars and molars. creativecommons.org/licenses/by-nc/4.0/) Conclusions: CERS facilitates better visualization of the root canal anatomy of human which permits unrestricted non-commercial use, distribution, and reproduction in any premolars and molars. medium, provided the original work is properly Keywords: Chitosan; Contrast media; Digital radiography; Root canal anatomy cited. Conflict of Interest No potential conflict of interest relevant to this article was reported. INTRODUCTION Author Contributions Accurate knowledge of the root canal anatomy, comprehensive assessment of radiograph Conceptualization: Govind S, Jena A. Data images, proper access to the canal orifices, thorough chemo-mechanical instrumentation, curation: Govind S, Anarasi M, Mohapatra S. Formal analysis: Govind S, Jena A, and 3-dimensional (3D) obturation is essential for a successful root canal therapy [1]. The Shivagange V. Funding acquisition: Govind genetic and ethnic variations in the root canal anatomy are fairly common, and they have https://rde.ac 1/12 Radiopaque solution for root canal system S, Jena A, Pattanaik S. Investigation: Govind been extensively discussed [2]. Thus, the internal root canal anatomy must be determined as S, Pattanaik S, Mohapatra S. Methodology: it is used as a basis for the course of endodontic therapy [3]. Govind S, Jena A, Pattanaik S, Anarasi M. Project administration: Govind S, Anarasi M, Mohapatra S. Resources: Govind S, Jena A, Conventional radiography is an indispensable tool for rapid chair-side visualization of the Anarasi M, Shivagange V. Software: Govind root canal anatomy, but 3D visualization is not achieved. Thus, methods that can enhance S, Jena A. Supervision: Govind S, Jena A. visualization are required. Barker et al. [4] first attempted to use an endogram to enhance Validation: Jena A, Mohapatra S, Anarasi M. the radiographic visualization of the root canals using contrast media but, the toxic lead- Visualization: Govind S, Jena A, Shivagange based elastomeric contrast media was difficult to remove from the root canals. Water-soluble S. Writing - original draft: Govind S, Jena A, contrast agents have been used with varying degrees of success [5,6]. Contrast media can Pattanaik S. Writing - review & editing: Govind S, Jena A, Shivagange V. be categorized into the ionic type (monomers: diatrizoic acid, iodic acid, and ioglicic acid and dimers: ioxaglic acid and iocarmic acid) and the non-ionic type (monomers: iohexol, ORCID iDs iopamidol, iobitridol, ioversol, iopromide, and iopentol and dimers: iotrol, iotrolan, and Shashirekha Govind iodixanol). The non-ionic type has lower osmolality and reduced chemotoxic effects and is https://orcid.org/0000-0003-4992-3087 Amit Jena better tolerated and less viscous than the ionic type [7]. https://orcid.org/0000-0002-4522-6519 Satabdi Pattanaik The Ruddle's solution is an iodinated ionic contrast media containing 5% sodium https://orcid.org/0000-0003-2686-9161 hypochlorite (NaOCl), 17% ethylenediaminetetraacetic acid (EDTA), and Hypaque (GE Mahaprasad Anarasi Healthcare, Chicago, IL, USA). NaOCl dissolves organic tissues and, enhances the ingress https://orcid.org/0000-0003-2270-7499 Satyajit Mohapatra of the radiopaque dye molecules into the root canal system. However, it should not be https://orcid.org/0000-0002-9461-9028 introduced forcefully [8]. Vinay Shivagange https://orcid.org/0000-0001-6372-0193 Chitosan is a natural polysaccharide prepared via the deacetylation of chitin and obtained from the shells of the crustaceans. It is an effective chelating agent similar to EDTA and has an antimicrobial property that prevents the growth of microorganisms in the root canal system [9-11]. Injectable radiopaque chitosan-based hydrogels have been used in endovascular therapies as sclerosing embolizing agents for the treatment of endoleaks and endovascular aneurysm repair [12,13]. Our research team formulated a chitosan-based endo- radiopaque solution (CERS), which was granted Indian patent [14]. Thus, the current study aimed to perform an in vitro comparison of 4 different contrast media introduced into the maxillary premolars and molars and in vivo comparison between Xenetix 350 + 5.25% NaOCl and CERS was conducted to visualize the root canal anatomy of the maxillary and mandibular premolars and molars. MATERIALS AND METHODS Chemicals The following chemicals were used in the experiment: Omnipaque 350 (non-ionic; GE Healthcare, Bengaluru, India), Iopamidol (non-ionic; Bracco Diagnostic Inc., Milan, Italy), Xenetix 350 (non-ionic; Guerbet, Hong Kong), Urografin 76 (ionic; Bayer, Madrid, Spain), chitosan (I-chess, Mumbai, India), and CERS, which is a mixture of 3% chitosan, iobitridol, and 100% acetone alcohol [14]. Sample size calculation The study was approved by the ethics committee of Siksha ‘O’ Anusandhan (Deemed to be University), Odisha, India (reference No. DMR/IMS-SH/SOA/16029). In vitro study was conducted over a period of 4 months (July 2016–October 2016) and the in vivo study was carried out during the period Jan 2017–March 2019 according to the STROBE statement (http://www.strobe-statement.org). The sample size was determined based on the results https://rde.ac https://doi.org/10.5395/rde.2021.46.e33 2/12 Radiopaque solution for root canal system from previous studies using G* power software, version 3.1.9 (available at http://www. gpower.hhu.de/en.html) [7,15]. With the level of significance and the power of test set at 5% and 80% respectively, the individual group sample size for in vitro was n = 60 (total 120 teeth) and for in vivo was n = 40 (total 80 teeth). In vitro experiment 1. Sample collection and preparation Extracted human maxillary premolars (group 1, n = 60) and molars (group 2, n = 60) with intact roots and mature apices were collected from the department of oral surgery according to the university guidelines. After extraction, the teeth were immersed in 5.25% NaOCl solution (Prime Dental Products Pvt Ltd., Thane, India) for 30 minutes to remove soft tissue remnants and stored in 0.2%thymol solution until use. The teeth in each group were divided (software: www.randomizer.org) into 4 subgroups (n = 15 each) according to the contrast media used (a) Omnipaque 350, (b) Xenetix 350, (c) Iopamidol, and (d) Urografin 76. Subsequently, the teeth were mounted on polyvinyl siloxane putty (President, Coltene/ Whaledent AG, Altstätten, Switzerland), and radiography in bucco-lingual and mesio-distal plane was performed using the digital radiovisiography (RVG) (CDR, FONA, Assago, Italy) and x-ray unit (X-Mind DC, Acteon, Italy) operating at 7 mA and 70 kv for 0.1 second.