Volumetric Assessment of Root Canal Obturation Using 3% Nano-Chitosan versus Zinc Oxide Eugenol (ZOE) and Iodoform-Calcium Hydroxide (Metapex), in Primary Root Canals Shaped with Rotary versus Manual Methods: A Preliminary In-Vitro Spiral CT Study

  • Elahe Babashahi Pediatric Dentistry Resident, Department of Pediatric Dentistry, School of Dental Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  • Maryam Mohmadi Kartalaie Assistant Professor, Department of Pediatric Dentistry, Kashan University of Medical Science, Kashan, Iran
  • Leila Basir Associated Professor, Department of Pediatric Dentistry, School of Dental Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  • Vahid Rakhshan Dentist, Private Practice, Tehran, Iran
Keywords: Chitosan, Primary Teeth, Pulpectomy, Root Canal Obturation


Objectives: In this study, chitosan was introduced and used as a substitute for pulpectomy obturation against conventional materials: zinc oxide eugenol (ZOE) and iodoform-calcium hydroxide (Ca(OH)2) compounds. Also, efficacies of rotary versus manual instrumentations were compared.

Materials and Methods: This preliminary in-vitro study was performed on 152 intact non-resorbed root canals of primary molars divided into rotary (n=78) versus hand-instrumentation (n=74) and also into ZOE (n=53), iodoform-Ca(OH)2 (n=50), and 3% nano-chitosan (n=49). Canals were cleaned/shaped using hand or rotary files. Canal spaces were measured using spiral computed tomography (CT). Canals were then obturated using the three materials. The percentages of obturation volume (POV) were estimated. Rotary and manual instrumentations were compared in terms of canal spaces before and after obturation. Three obturation materials were compared in terms of canal spaces after obturation (α=0.05).

Results: Average POVs of materials were 96.54% (ZOE), 97.87% (Metapex), and 74.74% (nano-chitosan; P=0.000). POV of chitosan differed from the other two (P=0.000) but the other two were similar (P=0.896). Average POVs were 91.46% (manual) and 88.51% (rotary); the difference was not significant (P=0.322). Pre-obturation spaces of canals for different methods were 3.89 mm3 (manual) and 3.26 mm3 (rotary); the difference was significant (P=0.013). Two-way ANCOVA showed a significant effect of materials (P=0.000) but not root length (P=0.585) or shaping methods (P=0.362) on POVs.

Conclusions: Nano-chitosan showed a considerable success rate but it still needs reformulation as it was weaker than the extremely successful commercial competitors.....


1. Moskovitz M, Sammara E, Holan G. Success rate of root canal treatment in primary molars. J Dent. 2005 Jan;33(1):41-7.
2. Crespo S, Cortes O, Garcia C, Perez L. Comparison between rotary and manual instrumentation in primary teeth. J Clin Pediatr Dent. 2008 Summer;32(4):295-8.
3. Thomas AM, Chandra S, Chandra S, Pandey RK. Elimination of infection in pulpectomized deciduous teeth: a short-term study using iodoform paste. J Endod. 1994 May;20(5):233-5.
4. Dean JA. Treatment of Deep Caries, Vital Pulp Exposure, and Pulpless Teeth, in Dean JA (editor). McDonald and Avery's Dentistry for the Child and Adolescent. Maryland Heights, Missouri, USA, Elsevier, 2015:221-53.
5. Bonow MLM, Guedes-Pinto AC, Bammann LL. Antimicrobial activity of drugs used in pulp therapy of deciduous teeth. Braz Endod J. 1996;1(1):44-8.
6. Leonardo MR, Silveira FF, Silva LA, Tanomaru Filho M, Utrilla LS. Calcium hydroxide root canal dressing. Histopathological evaluation of periapical repair at different time periods. Braz Dent J. 2002;13(1):17-22.
7. Queiroz AM, Nelson-Filho P, Silva LA, Assed S, Silva RA, Ito IY. Antibacterial activity of root canal filling materials for primary teeth: zinc oxide and eugenol cement, Calen paste thickened with zinc oxide, Sealapex and EndoREZ. Braz Dent J. 2009;20(4):290-6.
8. Bartelstone HJ. Radioiodine penetration through intact enamel with uptake by bloodstream and thyroid gland. J Dent Res. 1951 Oct;30(5):728-33.
9. Fuks AB, Kupietsky A, Guelmann M. Pulp therapy for the primary dentition, in Casamassimo P, Fields H, McTigue D, Nowak A (editors). Pediatric Dentistry: Infancy through Adolescence. Maryland Heights, Missouri, USA, Elsevier, 2013:333-51.
10. Nurko C, Garcia-Godoy F. Evaluation of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth. J Clin Pediatr Dent. 1999 Summer;23(4):289-94.
11. Gould JM. Root canal therapy for infected primary molar teeth-preliminary report. ASDC J Dent Child. 1972;39(4):269-73.
12. Wright KJ, Barbosa SV, Araki K, Spangberg LS. In vitro antimicrobial and cytotoxic effects of Kri 1 paste and zinc oxide-eugenol used in primary tooth pulpectomies. Pediatr Dent. 1994 Mar-Apr;16(2):102-6.
13. Holan G, Fuks AB. A comparison of pulpectomies using ZOE and KRI paste in primary molars: a retrospective study. Pediatr Dent. 1993 Nov-Dec;15(6):403-7.
14. Fuks A, Eidelman E, Pauker N. Root fillings with Endoflas in primary teeth: a retrospective study. J Clin Pediatr Dent. 2002 Fall;27(1):41-5.
15. Baumgartner JC, Rosenberg PA, Hoen MM, Lin LM. Treatment of endodontic infections, cysts, and flare-ups, in Baumgartner JC (editor). Ingle's Endodontics. Ontario, Canada: B.C. Decker Inc., 2009:690-713.
16. Roy PM, Harry P, Cailleux A, Allain P. Dangers of bismuth iodoform paraffin paste. Lancet. 1994 Dec;344(8938):1708.
17. Tharanathan RN, Kittur FS. Chitin--the undisputed biomolecule of great potential. Crit Rev Food Sci Nutr. 2003;43(1):61-87.
18. Ikeda T, Yanagiguchi K, Viloria IL, Hayashi Y. Relationship between lysozyme activity and clinical symptoms following the application of chitin/chitosan in endodontic treatment, in Muzzarelli RAA (editor). Chitosan Per Os: from Dietary Supplement to Drug Carrier. Crottammare, Italy, Atec Edizioni, 2000:275-92.
19. Peter MG. Applications and Environmental Aspects of Chitin and Chitosan. J Macromol Sci A. 1995;32(4):629-40.
20. Targino AG, Flores MA, dos Santos Junior VE, de Godoy Bené Bezerra F, de Luna Freire H, Galembeck A, et al. An innovative approach to treating dental decay in children. A new anti-caries agent. J Mater Sci Mater Med. 2014 Aug;25(8):2041-7.
21. Muzzarelli RAA. Chitins and Chitosans as Immunoadjuvants and Non-Allergenic Drug Carriers. Mar Drugs. 2010 Feb;8(2):292-312.
22. Dutta PK, Dutta J, Tripathi VS. Chitin and chitosan: chemistry, properties and applications. J Sci Ind Res. 2004;63(1):20-31.
23. Rabea EI, Badawy ME, Stevens CV, Smagghe G, Steurbaut W. Chitosan as antimicrobial agent: applications and mode of action. Biomacromolecules. 2003 Nov-Dec;4(6):1457-65.
24. Sun L, Du Y, Fan L, Chen X, Yang J. Preparation, characterization and antimicrobial activity of quaternized carboxymethyl chitosan and application as pulp-cap. Polymer. 2006 Mar;47(6):1796-804.
25. Song XL, Sun YY, Liu Y, Chen Q, Bi XX, Yu JT. [An in vitro evaluation of the effect of carboxymethyl chitosan and its composites against Enterococcus faecalis in the root canal]. [Article in Chinese]. Shanghai Kou Qiang Yi Xue. 2013 Jun;22(3):‎265-9‎.
26. Ueno H, Yamada H, Tanaka I, Kaba N, Matsuura M, Okumura M, et al. Accelerating effects of chitosan for healing at early phase of experimental open wound in dogs. Biomaterials. 1999 Aug;20(15):1407-14.
27. Matsunaga T, Yanagiguchi K, Yamada S, Ohara N, Ikeda T, Hayashi Y. Chitosan monomer promotes tissue regeneration on dental pulp wounds. J Biomed Mater Res A. 2006 Mar 15;76(4):711-20.
28. Schlueter N, Klimek J, Ganss C. Effect of a chitosan additive to a Sn 2+-containing toothpaste on its anti-erosive/anti-abrasive efficacy--a controlled randomised in situ trial. Clin Oral Investig. 2014 Jan;18(1):107-15.
29. Costa EM, Silva S, Pina C, Tavaria FK, Pintado MM. Evaluation and insights into chitosan antimicrobial activity against anaerobic oral pathogens. Anaerobe. 2012 Jun;18(3):305-9.
30. Uysal T, Akkurt MD, Amasyali M, Ozcan S, Yagci A, Basak F, et al. Does a chitosan-containing dentifrice prevent demineralization around orthodontic brackets? Angle Orthod. 2011 Mar;81(2):319-25.
31. Hayashi Y, Ohara N, Ganno T, Ishizaki H, Yanagiguchi K. Chitosan-containing gum chewing accelerates antibacterial effect with an increase in salivary secretion. J Dent. 2007 Nov;35(11):871-4.
32. Arnaud TM, de Barros Neto B, Diniz FB. Chitosan effect on dental enamel de-remineralization: an in vitro evaluation. J Dent. 2010 Nov;38(11):848-52.
33. Moghadas L, Shahmoradi M, Narimani T. Antimicrobial activity of a new nanobased endodontic irrigation solution: In vitro study. Dent Hypotheses. 2012;3(4):142-6.
34. Suzuki S, Masuda Y, Morisaki H, Yamada Y, Kuwata H, Miyazaki T. The Study of Chitosan-Citrate Solution as a Root Canal Irrigant: A Preliminary Report. J Oral Hyg Health. 2014;2:142.
35. Imani Z, Imani Z, Basir L, Shayeste M, Abbasi Montazeri E, Rakhshan V. Antibacterial Effects of Chitosan, Formocresol and CMCP as Pulpectomy Medicament on Enterococcus‎ faecalis, Staphylococcus aureus and Streptococcus‎ mutans. Iran Endod J. 2018 Summer;13(3):342-50.
36. Asokan S, Sooriaprakas C, Raghu V, Bairavi R. Volumetric analysis of root canal fillings in primary teeth using spiral computed tomography: an in vitro study. J Dent Child (Chic). 2012 May-Aug;79(2):46-8.
37. Huang TH, Ding SJ, Kao CT. Biocompatibility of various formula root filling materials for primary teeth. J Biomed Mater Res B Appl Biomater. 2007 Feb;80(2):486-90.
38. Keyes PH, Jordan HV. Periodontal lesions in the Syrian hamster. III. Findings related to an infectious and transmissible component. Arch Oral Biol. 1964 Jul-Aug;9:377-400.
39. Swanson K, Madison S. An evaluation of coronal microleakage in endodontically treated teeth. Part I. Time periods. J Endod. 1987 Feb;13(2):56-9.
40. Madison S, Swanson K, Chiles SA. An evaluation of coronal microleakage in endodontically treated teeth. Part II. Sealer types. J Endod. 1987 Mar;13(3):109-12.
41. Gillen BM, Looney SW, Gu LS, Loushine BA, Weller RN, Loushine RJ, et al. Impact of the quality of coronal restoration versus the quality of root canal fillings on success of root canal treatment: a systematic review and meta-analysis. J Endod. 2011 Jul;37(7):895-902.
42. Anbu R, Nandini S, Velmurugan N. Volumetric analysis of root fillings using spiral computed tomography: an in vitro study. Int Endod J. 2010 Jan;43(1):64-8.
43. Dandashi MB, Nazif MM, Zullo T, Elliott MA, Schneider LG, Czonstkowsky M. An in vitro comparison of three endodontic techniques for primary incisors. Pediatr Dent. 1993 Jul-Aug;15(4):254-6.
44. Silva PV, Guedes DF, Pécora JD, da Cruz-Filho AM. Time-dependent effects of chitosan on dentin structures. Braz Dent J. 2012;23(4):357-61.
45. Busscher HJ, Engels E, Dijkstra RJ, van der Mei HC. Influence of a chitosan on oral bacterial adhesion and growth in vitro. Eur J Oral Sci. 2008 Oct;116(5):493-5.
46. Kim HC, Kim HJ, Lee CJ, Kim BM, Park JK, Versluis A. Mechanical response of nickel-titanium instruments with different cross‐sectional designs during shaping of simulated curved canals. Int Endod J. 2009 Jul;42(7):593-602.
47. Schafer E, Zapke K. A comparative scanning electron microscopic investigation of the efficacy of manual and automated instrumentation of root canals. J Endod. 2000 Nov;26(11):660-4.
48. Silva LA, Leonardo MR, Nelson-Filho P, Tanomaru JM. Comparison of rotary and manual instrumentation techniques on cleaning capacity and instrumentation time in deciduous molars. J Dent Child (Chic). 2004 Jan-Apr;71(1):45-7.
49. Azar MR, Mokhtare M. Rotary Mtwo system versus manual K-file instruments: efficacy in preparing primary and permanent molar root canals. Indian J Dent Res. 2011 Mar-Apr;22(2):363.
50. Kleier DJ, Averbach R. Comparison of clinical outcomes using a nickel titanium rotary or stainless steel hand file instrumentation technique. Compend Contin Educ Dent. 2006 Feb;27(2):87-91; quiz 92, 112.
51. Makarem A, Ravandeh N, Ebrahimi M. Radiographic assessment and chair time of rotary instruments in the pulpectomy of primary second molar teeth: a randomized controlled clinical trial. J Dent Res Dent Clin Dent Prospects. 2014 Spring;8(2):84-9.
52. Peters OA, Peters CI, Schonenberger K, Barbakow F. ProTaper rotary root canal preparation: effects of canal anatomy on final shape analysed by micro CT. Int Endod J. 2003 Feb;36(2):86-92.
53. Hammad M, Qualtrough A, Silikas N. Evaluation of root canal obturation: a three-dimensional in vitro study. J Endod. 2009 Apr;35(4):541-4.
54. Barletta FB, de Sousa Reis M, Wagner M, Borges JC, Dall'Agnol C. Computed tomography assessment of three techniques for removal of filling material. Aust Endod J. 2008;34(3):101-5.
55. Reuben J, Velmurugan N, Kandaswamy D. The evaluation of root canal morphology of the mandibular first molar in an Indian population using spiral computed tomography scan: an in vitro study. J Endod. 2008 Feb;34(2):212-5.
How to Cite
Babashahi E, Mohmadi Kartalaie M, Basir L, Rakhshan V. Volumetric Assessment of Root Canal Obturation Using 3% Nano-Chitosan versus Zinc Oxide Eugenol (ZOE) and Iodoform-Calcium Hydroxide (Metapex), in Primary Root Canals Shaped with Rotary versus Manual Methods: A Preliminary In-Vitro Spiral CT Study. Front Dent. 16(1):45-54.
Original Article