A New Approach for Controlling Hemostasis During Canal Treatment
Condition: Blood Contamination of Root Canal During Endodontic Therapy
Study type: Interventional

Summary: 
      The persistence of blood may significantly affect final sealing with the persistence of
      microleakage (Zmener et al. 2008, Roggendorf et al. 2007).

      In cases of copious bleeding from root canals, calcium hydroxide, anesthetic solution with
      1:50,000 epinephrine or ferric sulfate placed on a sterile paper cone, are recognized as
      effective hemostatic agents (Magnusson 1971, Kouri et al. 1969, Dannenberg 1974).

      The purpose of this study was to test the reduction of root canal bleeding in terms of
      significant percentage change for millimeters of blood in the canal at 2 different time
      points (baseline and after treatment with HybenX )
    

Detailed description: 
      A new device (HYBENX®, EPIEN Medical, Saint Paul, MN, USA) has been developed with the
      purpose of destroying dental biofilm. The material is a mixture of hydroxybenzenesulfonic
      acid (37%) and hydroxymethoxybenzene acids (23%), sulfuric acid (28%), and water (12%).

      This device has been successfully used in periodontology. Recent studies (Pini-Prato et al.
      2016a, Isola et al. 2017) have demonstrated the effectiveness of the oral tissue
      decontaminant material in the treatment of clinical cases showing acute periodontal abscess
      without the use of systemic or local antibiotics. Similar favorable effects were obtained in
      the treatment of peri-implant mucositis and peri-implantitis (Pini-Prato et al. 2016b, Lopez
      et al. 2016). In addition, a randomized controlled trial (RCT) also demonstrated beneficial
      effects of the material in the treatment of oral aphthae (Porter et al. 2009).

      Based on this scientific information, a clinical and microbiological study has been planned
      using the decontaminant device in cases of teeth with necrotic pulp with the aim to destroy
      the dental biofilm of root canals. The ability of the decontaminant device to immediately
      stop bleeding during canal instrumentation was found out accidentally during the procedures
      of this still unpublished trial.

      Due to this fact, the authors were interested in evaluating the coagulation property of the
      material. The purpose of this study was to test the reduction of root canal bleeding in terms
      of significant percentage change for millimeters of blood in the canal at 2 different time
      points (before and after treatment with HybenX ) A single center, participants and data
      analyst blind, two-arm, randomized, placebo controlled clinical trial study was performed
      following the CONSORT statement in the Endodontics Department, University Hospital Florence
      Careggi, Florence, Italy.

      The study population consisted of patients that were treated by Endodontics Department of the
      University Hospital of Florence Careggi, Italy. Subject inclusion criteria were: patients
      aged between 20 and 60 years, able and willing to sign a consent form, single-rooted teeth
      with necrotic pulp confirmed by electric vitality test, associated with healthy periodontium,
      physiologic sulcus depth (<3 mm), and absence of bleeding on probing of the involved teeth.

      Exclusion criteria were: patients with systemic diseases using anticoagulants, antibiotics,
      or anti-inflammatory therapies in the last 30 days, patients with allergy to sulfur in any
      form, and pregnancy. All subjects were informed of the nature and potential risks and
      benefits of their participation in the study. They also received information on the duration
      of the procedure, and the possible intraoperative and postoperative complications.

      Treatment The root canal therapy procedure was standardized and limited to one experienced
      endodontist (R.P.). Treatments were performed at the Endodontics Departments of the
      University Hospital of Florence Careggi, Italy, under local anesthesia using 1.8 mL
      mepivacaine hydrochloride (Optocaine; Molteni Dental SRL, Scandicci, Italy), and the teeth
      were isolated with rubber dams. After preparing the access cavity, the working length was
      determined with an electronic apex locator (Propex II Dentsply Maillefer Instruments,
      Ballaigues, Switzerland) with a size 10 k-file. Root canals were shaped using ProTaper
      Universal NiTi files (Dentsply Maillefer Instruments, Ballaigues, Switzerland) in the
      following sequence: S1, S2, F1, F2, F3 until each instrument reached the working length.
      After each instrument, the root canals were rinsed with NaClO (Niclor 5, Ogna, Italy) using a
      syringe with a side-vented 30 G needle. ProTaper NiTi instruments were driven with an
      endodontic motor (XSmart Endo Motor, Dentsply Maillefer Instruments, Ballaigues, Switzerland)
      with a 16:1 contrangle set up as suggested by the manufacturer.

      After the root canal, shaping was performed, and a first sterile paper point was introduced
      in the root canal, up to the working length, for 10 seconds to detect blood presence.

      With a caliber, on the sterile paper cone, the millimeters of blood present within the root
      canal were measured.

      Only the teeth that at this point showed 1 or more millimeters of blood within the root canal
      were included in the present study and randomized to the two experimental groups.

      Before further treatment, the teeth were allocated to an experimental (HybenX) or a control
      group (sterile saline solution) according to an uneven block randomization designed by the
      statistician (A.N.). For each tooth, a closed envelope was opened in a consecutive order,
      assigning the tooth to either the experimental or the control group HybenX was approved as a
      Class I CE medical device by the Italian Ministry of Health (no. 483768) on February 7, 2012.

      HybenX Group The material was introduced inside the root canal using the pre-dosed syringe
      for 20 seconds with a sterile paper point with and up and down movement up to the working
      length.

      Finally, the canal was rinsed with sterile water using a syringe with a side-vented 30 G
      needle 1 mm shorter than the working length.

      A second sterile paper point was introduced in the root canal, up to the working length, for
      10 seconds to detect the presence of blood and the millimeters of blood inside the root canal
      was measured again according the previous criteria.

      Statistical Analysis Data were analyzed using SAS Version 9.3 software (SAS Institute, Inc.,
      Cary, NC). A preliminary Levene's test was performed to verify the homogeneity of variance
      for the percentage change in the two groups.

      Since the two groups showed homogeneity of the variance a t-test was performed to verify the
      null hypothesis by using a type I error equal to 0.05.

      In order to confirm the firmness of the results a Wilcoxon non-parametric test was also
      carried out.
    

Intervention name(s): HybenX; Placebo control
Intervention type(s): Device; Other
Intervention description(s): The material was introduced inside the root canal using the pre-dosed syringe for 20 seconds with a sterile paper point with and up and down movement up to the working length.
Finally, the canal was rinsed with sterile water using a syringe with a side-vented 30 G needle 1 mm shorter than the working length.
A second sterile paper point was introduced in the root canal, up to the working length, for 10 seconds to detect the presence of blood and the millimeters of blood inside the root canal was measured again according the previous criteria.; The root canal was irrigated with sterile saline water with a syringe and a side-vented 30G needle activated for 20 seconds with a sterile paper point with and up and down movement up to the working length to ensure a flow of irrigant solution throughout the canal.
Finally, the canal was rinsed with sterile water using a syringe with a side-vented 30 G needle 1 mm shorter than the working length. A second sterile paper point was introduced in the root canal, up to the working length, for 10 seconds to detect the presence of blood and the millimeters of blood inside the root canal was measured again according the previous criteria.
Intervention MeSH terms: Hybenx
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: single center, participants and data analyst blind, two-arm, randomized, placebo controlled clinical trial study
Masking: Single (Participant)
Primary purpose: Treatment