Quantitative Assessment of the Efficacy of Sweeps Laser Activation Systems
Condition: Periapical Periodontitis; Polymerase Chain Reaction; Enterococcus Faecalis Infection
MeSH terms: Periodontitis; Periapical Periodontitis
Study type: Interventional

Summary: 
      Aim of the present study was to determine the intraradicular microbiota of previously root
      canal-treated teeth with apical periodontitis using droplet digital polymerase chain reaction
      (ddPCR) and to investigate the antibacterial effectiveness of different irrigation activation
      methods [ Sweeps laser and PUI group ] that will make classical chemomechanical preparation
      more effective. This superiority, parallel, randomized clinical trial was conducted in the
      clinic of the Endodontic Department, Faculty of Dentistry, Istanbul Medipol University,
      Istanbul. 30 patients with apical periodontitis (one tooth each) were randomly allocated into
      two groups according to the used (n=15, for each): the Sweeps laser group (A) or the vdw
      ultra group (B). Total bacterial loads, as well as the amount of Enterococcus faecalis
      (E.faecalis) were determined before (S1) and after (S2) chemomechanical preparation and
      finally, after intracanal medication (S3) by means of ddPCR.
    

Detailed description: 
      Eligibility criteria The study population consisted of 30 patients (aged 19-66 years)
      presenting to the endodontic clinic at Istanbul Medipol University Dental School, for
      nonsurgical endodontic treatment of teeth with apical periodontitis lesions. 30 teeth
      exhibiting clinical and radiographic evidence of chronic apical periodontitis lesions were
      included in this study. BT lab branded ELISA Kits (Shangai, China) were used to measure
      IL-1Beta levels. Radiographically, the diameter of the periapical radiolucency ranged from 2
      to 7 mm. Teeth with apical periodontitis had required treatment. Selected teeth had enough
      crown structure for adequate isolation with a rubber dam and showed an absence of periodontal
      pockets or attachment level deeper than 4 mm. Exclusion criteria were also applied, as
      follows: teeth from patients who had received antibiotics within the previous 3 months or who
      had any general disease, teeth that could not be properly isolated with rubber dam, teeth
      with absence of coronary sealing, teeth with periodontal pocket depth >4 mm; and teeth with
      crown/root fracture. Only one tooth was included from each patient.

      Root canal treatment procedures and sampling Rubber dam and an aseptic technique were used
      throughout the endodontic retreatment. After plaque removal and rubber dam isolation, the
      operative field was cleaned with 3% hydrogen peroxide and disinfected with 2.5% NaOCl
      solution. Then, all coronal restorations, posts and carious defects were removed and access
      preparation was completed when the root canal filling was properly exposed. Afterwards, the
      tooth (including the pulp chamber), clamp, and adjacent rubber dam were once again
      disinfected with 2.5% NaOCl, followed by inactivation with 10% sodium thiosulfate in order to
      avoid interference with bacteriological sampling. Sterility control samples (SR1) were taken
      from the tooth surface with a sterile Omni Swab (Whatman FTA, Sigma-Aldrich) with an
      ejectable head. Paper points were transferred to cryotubes containing phosphate buffered
      saline (PBS) solution stored at -20°C. In each case, a single root canal was sampled in order
      to confine the microbial evaluation to a single ecological environment. In multirooted teeth,
      the root with the periapical lesion was selected. If there were periapical lesions in all
      roots, the wider canal was selected.

      The working length (WL) was established 1-mm short of the apical foramen with an apex locator
      (Raypex6; VDW GmbH, Munich, Germany), and then periapical radiographs were taken to ensure
      that all filling material was removed. Irrigation with sterile saline solution was performed
      in order to remove any remaining materials and to moisten the canal prior to sample
      collection. Next, the canal was left filled with saline, and a small hand instrument was
      placed at the WL and used to gently file the canal walls. An initial microbiologic sample
      (S1) was taken from the root canal with sterile paper points consecutively placed at the WL.
      Three sterile paper points were inserted into the root canal for sampling. Each paper point
      was left in the canal for about 1 minute. Both the paper points and the endodontic hand
      instrument, without the handle, were transferred to cryotubes containing 300 μl of PBS
      solution stored at -20°C. The samples were transferred to genetic analysis laboratory for
      further analysis in cold chain.

      Root canals were prepared by using the ProTaper Next; Dentsply-Sirona, Ballaigues, İsviçre
      files and irrigated with 2.5% NaOCl. The canals were apically enlarged to size 35 (AS35) at
      the working length. Between each instrument change, the root canal was irrigated with 5 ml of
      2.5% NaOCl solution by using 30-gauge side-vented needle, which was placed 1 to 2 mm short of
      working length. Hence, a total of 30 mL of the irrigating solution was used. After
      instrumentation was completed, the smear layer was removed with 2 mL 17% EDTA, which was left
      in the canal for 3 min, followed by 2.5% NaOCl. The root canal was dried with sterile paper
      points and flushed with 2 ml of 10% sodium thiosulfate for 1 min to inactivate the NaOCl
      solution. Next, a sample (S2) was taken from the canals as described for S1. Following this,
      the NaOCl was agitated/activated as described below.

      Sweeps group: The SWEEPS fiber tip (25 µs ultra-short dual pulse mode-Auto SWEEPS mode) was
      inserted into the Er:YAG laser source (2,940 nm, 20 mJ per pulse, 15 Hz, 0.3 W power, and 50
      µs pulse frequency). The SWEEPS tip placed in the access cavity was kept in a stable
      position, and activation was performed in the SWEEPS mode using the same method with the same
      amount of irrigation solutions described for the PIPS group.

      PUI group: The irrigation solution was used by adapting an ultrasonic tip (IRRI S 21/25; VDW,
      Munich, Germany) to an ultrasonic device (VDW Ultra; VDW, Munich, Germany). The tip was
      activated a total of three times, with each cycle lasting 20 s and involving the use of 1 ml
      of 3% NaOCl. Then, 2 ml of 17% EDTA solution was activated for 1 min as describe above. The
      ultrasonic tip was placed 2 mm behind the working length without touching the canal walls.

      Finally, the canals in both groups were dried and rinsed with 2 mL 10% sodium thiosulfate for
      1 min. The post activation sample (S3) was obtained in the same way as the pre-activation
      sample was collected and sent for the PCR analysis. Completion of the root canal treatment
      proceeded with root filling using lateral condensation of gutta-percha. Access cavities were
      restored with composite resin, and a final radiograph was taken. All the root canal and
      microbial sampling procedures were performed by a single experienced endodontist. Total
      bacterial loads, as well as the amount of Enterococcus faecalis were determined before
      instrumentation, after instrumentation and use of the irrigation activation systems, by means
      of droplet digital polymerase chain reaction (ddPCR).

      Total bacterial loads, as well as the amount of Enterococcus faecalis were determined before
      instrumentation, after instrumentation and use of the intracanal medicaments, by means of
      ddPCR.

      Genomic DNA isolation and measurement of DNA concentration DNA was extracted using the QIAamp
      DNA Mini Kit (Qiagen, Germany) following the protocol recommended by the manufacturer. Before
      DNA isolation, samples (the tubes with paper points) were digested at 50-60°C BY vortexING
      for 30s in every 10 min in order to ensure disaggregation of all bacteria into the PBS
      solution. Afterwards, the paper points were aseptically removed from the suspension and, the
      bacterial suspension was pelleted by centrifugation for 10 min at 5000 g. The pellet was then
      resuspended in 180 µl buffer ATL supplied by QIAamp DNA Mini Kit (QIAGEN GmbH, Hilden,
      Germany) and 20 µl proteinase K (20 mg/ml) was added. Samples were incubated for 3 h at 56°C.
      Subsequently, total bacterial genomic DNA was isolated according to the protocol of the
      QIAamp DNA Mini Kit. The final volume of DNA solution of each sample was 150 μL and was taken
      into account during calculation. DNA concentration (absorbance at 260 nm) was determined with
      a spectrophotometer (Promega Quantifluor).

      Amplification of 16S rRNA genes Primers for Universal and Enterococcus 16S rRNA genes were
      designed in this study. After DNA extraction of samples with QIAamp DNA Mini Kit, 700-800 bp
      of 16S rRNA sequences were amplified by using universal E8F forward primer
      (5'-AGAGTTTGATCCTGGCTCAG-3') and universal E1115R reverse primer (5'-AGGGTTGCGCTCGTTG-3') 59.
      The final volume of PCR reactions for each isolated bacterial strain was adjusted to 25 µl.
      The amplification reactions of 16S rRNA genes were performed with the following conditions. 1
      cycle of predenaturation at 95°C for 3 minutes, 35 cycles of 95°C for 30 seconds, 55°C for 30
      seconds, and 72°C for 30 seconds which continue with a final extension step at 72°C for 10
      minutes.

      The PCR products were analyzed by electrophoresis using 2% agarose gel (containing ethidium
      bromide) in Tris/BoratE/EDTA (TBE) buffer, with gels being analyzed under ultraviolet light
      (at 140V for 20 minutes). Their images were visualized under ultraviolet illumination. In
      addition, the control and optimization of primers to be used for ddPCR was also done in
      conventional PCR.

      Purification and Sequencing of the 16S rRNA Gene After the PCR reactions, the purification of
      PCR products is done by hydrolyzing the excess primers and nucleotides with ExoSap-IT
      (Thermo, PN: 78201.1.ML) containing Exonuclease I and Alkaline Phosphatase enzymes. 2 µl of
      ExoSap-IT was mixed with 5 µl of PCR product for each sample. The ExoSap reaction is
      performed at 37 °C for 15 minutes (enzyme activation) followed by 15 minutes (inactivation)
      at 80 °C. Sequencing reactions were performed by using Bigdye™ Terminator v3.1 cycle
      sequencing kit (Thermo). The reactions were performed according to the kit manual for all
      isolated strains.

      After purification of the products with Exosap, the sequence reaction was performed with
      BigDye Terminator v3.1 Cycle Sequencing Kit (Thermo) under the following conditions. After
      the sequence PCR, BigDye products were purified by colon method. Zymo ZR DNA Sequencing
      Clean-up Kit (Zymo Research, USA) was used for this process. All samples were purified in
      accordance with the protocol given in the kit and executed on the 3130XL genetic analyzer.

      Droplet Digital PCR (ddPCR) Droplet Digital PCR (ddPCR) was performed using primers designed
      according to the 16S rRNA region specific to the total bacteria and Enterococcus faecalis
      species, after sequencing, absolute quantitation from the bacterial species found in the
      paper-point sample. Primer pairs were 16S-F-5'-AGGGAATCTTCSGCAATGGG-3' and
      16S-R-5'-ACGCCCAATAAATCCGGACA-'3 for total bacteria and ENT-F-5'-CGCTTCTTTCCTCCCGAGT-3' and
      ENT-R-5'-GCCATGCGGCATAAACTG-3' primer pairs for Enterococcus Faecalis. In the PCR reaction,
      amplicons amplified with unmarked primer pairs were analyzed by labeling with Eva-Green dye.
      For absolute quantitation of Enterococcus and total 16S rRNA, PCR was performed with two
      primer pairs from the same sample. 20 µL of PCR mix containing 10 µL of 2X ddPCR EvaGreen
      Supermix (Bio-Rad, cat. no. 1864034), 9 µL of nuclease-free water, 0.25 µL of both forward
      and reverse primer and 2 ng of DNA from each sample Thermal cycling conditions were: 95◦C for
      5 min, then 40 cycles of 95◦C for 30 s and 60◦C for 1 min and two final steps at 4◦C for 5
      minutes and 90◦C for 5minutes with a 4◦C infinite hold. After PCR was completed, the sealed
      plate was transferred into the plate holder of the QX200 Droplet Reader (Bio-Rad, cat. no.
      1864003).
    

Intervention name(s): sweeps laser to use irrigation activation; PUI to use irrigation activation
Intervention type(s): Other; Other
Intervention description(s): The SWEEPS fiber tip (25 µs ultra-short dual pulse mode-Auto SWEEPS mode) was inserted into the Er:YAG laser source (2,940 nm, 20 mJ per pulse, 15 Hz, 0.3 W power, and 50 µs pulse frequency). 3% NaOCl solution was activated in three periods of 20 s. Then, the same procedure was repeated with 2 ml of 17% EDTA solution.; The irrigation solution was used by adapting an ultrasonic tip (IRRI S 21/25; VDW, Munich, Germany) to an ultrasonic device (VDW Ultra; VDW, Munich, Germany). The tip was activated a total of three times, with each cycle lasting 20 s and involving the use of 1 ml of 3% NaOCl. Then, 2 ml of 17% EDTA solution was activated for 1 min as describe above. The ultrasonic tip was placed 2 mm behind the working length without touching the canal walls.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment