LIST OF GRAPHS

COMPARISON OF THE POTENTIAL DISCOLOURATION EFFECT OF MTA ANGELUS, ENDOCEM MTA AND NEO MTA

ON NATURAL TEETH – AN IN VITRO STUDY

Dissertation submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

In partial fulfillment for the Degree of MASTER OF DENTAL SURGERY

BRANCH IV

CONSERVATIVE DENTISTRY AND ENDODONTICS MAY 2020

ACKNOWLEDGEMENT

I take this opportunity to sincerely thank my post graduate teacher and my guide Dr. C. S. Karumaran, M.D.S., Professor, Department of Conservative Dentistry and Endodontics, Ragas Dental College and Hospital, for his patience, perseverance in motivating, guiding and supporting me throughout my study period. His guidance, support, and constant encouragement throughout my study period helped me to finish my thesis.

My sincere thanks to Dr. R. Anil Kumar, M.D.S., Professor and HOD, Department of Conservative Dentistry and Endodontics, Ragas Dental College and Hospital, who helped me with his guidance, during my study period.

I extend my sincere thanks to Dr P. Shankar, M.D.S., Professor, Ragas Dental College and Hospital, for his guidance and encouragement during my study period.

I extend my sincere thanks to Dr. M. Rajasekaran, M.D.S.., Professor, Ragas Dental College and Hospital, for his encouragement, motivation, support and guidance all throughout my study period.

I would like to solemnly thank and be grateful to Dr. G Shankar Narayan, M.D.S., Dr. S.M. Venkatesan, M.D.S., for their constant support, guidance and encouragement throughout my propaganda.

I would like to thank Dr. B Venketesh, M.D.S., Dr. M. Sabari M.D.S, Dr.Arrvind Vikram, M.D.S. Readers, for all their help and support during my study period.

I would also like to thank Dr. C Nirmala, M.D.S., Dr. Shalini, M.D.S., Dr. V Sudhakar, M.D.S., Senior lecturers for their friendly guidance and support.

I also wish to thank the management of Ragas Dental College and Hospital, Chennai for their help and support.

I thank all my batchmates Dr. Anu Priya G, Dr. Anitha Varghese, Dr. Akshaya V B, Dr. Vinaya Madhuri B, Dr. Gayathri, Dr. Sai Swathi R, Dr, Suraj U, who had the patience to bear with me, my beloved seniors especially Dr. Nandhini Devi, Dr. Darlene Ann Johnson and juniors especially Dr. Azhagu Abirami, Dr. Roselin Stalin for their constant moral support, guidance patience, love and encouragement during my period.

Nothing like a friend in need is a friend indeed, I’m blessed to have my friends, Dr. Priyanka Venkatasubramaniam, Dr. Jayanthi, Dr. Mahalakshmi, Dr. Vijendranath for all the help, support and

encouragement they have given me.

I would like to extend my gratitude to my father Fabian Sebastian, my mother Judith Sebastian, my brother Benedict Roshan Sebastian my aunt Maria O’ Connor and my philanthropist Stephen Dinesh for their constant love, understanding, moral support and encouragement throughout these years without which I would not have reached so far.

My sincere thanks to Mr.K.Thavamani for his patience and support in DTP and Binding works. I extend my thanks to S.Venkatesan for his help in statistical work.

Above all, I am thankful to God, who always guides me and has given these wonderful people into my life.

SL.NO ABBREVIATIONS DESCRIPTION

1 MTA Mineral Trioxide Aggregate

2 GIC Glass Ionomer Cement

3 EDTA Ethylenediamine-tetraacetic acid

4 CEJ Cemento - enamel junction

5 SD Standard Deviation

6 IBM.SPSS International Business Machines Statistical Package for the Social Sciences

7 ANOVA Analysis of variance

CONTENTS

S. NO. INDEX PAGE.NO

1. INTRODUCTION 1

2. AIM AND OBJECTIVES 5

3. REVIEW OF LITERATURE 6

4. MATERIALS AND METHODS 23

5. RESULTS 30

6. DISCUSSION 37

7. SUMMARY 54

8. CONCLUSION 58

9. BIBLIOGRAPHY 61

10. ANNEXURES -

Table 1 MULTIPLE COMPARISONS OF THE GROUPS AT DIFFERENT INTERVALS BY ONE-WAY ANOVA

Table 2 REPEATED MEASURES OF ANOVA FOR BLOOD ONLY (∆E)

Table 3 PAIRWISE COMPARISONS OF BLOOD ONLY GROUP AT VARIOUS INTERVALS

Table 4 REPEATED MEASURES OF ANOVA FOR MTA ANGELUS (∆E)

Table 5 PAIRWISE COMPARISONS OF MTA ANGELUS GROUP AT VARIOUS INTERVALS

Table 6 REPEATED MEASURES OF ANOVA FOR ENDOCEM MTA (∆E)

Table 7 PAIRWISE COMPARISONS OF ENDOCEM MTA AT VARIOUS INTERVALS

Table 8 REPEATED MEASURES OF ANOVA FOR NEO MTA (∆E) Table 9 PAIRWISE COMPARISON NEO MTA GROUP AT VARIOUS

INTERVALS

LIST OF GRAPHS

S.NO. TITLE

Graph 1 REPRESENTING ∆E IMMEDIATE POSTOPERATIVE VALUES OF THE GROUPS

Graph 2 REPRESENTING ∆E DAY 1 VALUES OF THE GROUPS Graph 3 REPRESENTING ∆E 1 WEEK VALUES OF THE GROUPS Graph 4 REPRESENTING ∆E 2 WEEKS VALUES OF THE GROUPS Graph 5 REPRESENTING ∆E 3 WEEKS VALUES OF THE GROUPS Graph 6 REPRESENTING ∆E VALUES OF BLOOD ONLY GROUP

AT VARIOUS INTERVALS

Graph 7 REPRESENTING ∆E VALUES OF MTA ANGELUS GROUP AT VARIOUS INTERVALS

Graph 8 REPRESENTING ∆E VALUES OF ENDOCEM MTA GROUP AT VARIOUS INTERVALS

Graph 9 REPRESENTING ∆E VALUES OF NEO MTA GROUP AT VARIOUS INTERVALS

FIGURE 1 EXTRACTED HUMAN UPPER CENTRAL INCISORS FIGURE 2 DECORONATION OF TEETH AT CEJ

FIGURE 3 DIAMOND DISC FIGURE 4 HANDPIECE

FIGURE 5 ISO DIAMOND CYLINDRICAL BUR – SR -13 (MANI) FIGURE 6 SYRINGE (UNOLOK)

FIGURE 7 SALINE

FIGURE 8 SODIUM HYPOCHLORITE IRRIGATION SOLUTION 3%

(CHEMDENT)

FIGURE 9 DESMEAR 17% EDTA SOLUTION FIGURE 10 MICROPIPETTE

FIGURE 11 MTA (MICRO ANGELUS) FIGURE 12 ENDOCEM MTA (MARUCHI

FIGURE 13 NEO MTA PLUS (AVALON BIOMED)

FIGURE 14 GLASS IONOMER CEMENT TYPE IX (GC), MIXING PAD AND AGATE SPATULA

FIGURE 15 GLASS SLAB AND CEMENT SPATULA

FIGURE 16 PLASTIC INSTRUMENT FIGURE 17 CAVITY PREPARATION FIGURE 18 SPECTROPHOTOMETER

FIGURE 19 MANIPULATION OF MTA ANGELUS FIGURE 20 MANIPULATION OF ENDOCEM MTA FIGURE 21 MANIPULATION OF NEO MTA

FIGURE 22 BLOOD ONLY GROUP FIGURE 23 MTA ANGELUS GROUP FIGURE 24 ENDOCEM MTA GROUP FIGURE 25 NEO MTA GROUP

FIGURE 26 POST OPERATIVE SAMPLES

Introduction

Introduction

1

INTRODUCTION

Introduction of Mineral Trioxide Aggregate (MTA) as a root canal filling material in the year 1993 by Torabinejad, has continued to remain as a material of choice, widely reviewed and researched by the clinicians for various properties. Currently it is the most preferred and the choice of material for various clinical situations like pulpotomy, pulp capping, perforation management, root canal fillings and regenerative endodontic procedures. ¹

The basic composition of MTA is tricalcium silicate, tricalcium aluminate, calcium silicate and tetracalcium aluminoferrite which is similar to Portland cement. ² The initially formulated GMTA(which is grey in colour) had very few limitations and one among them is tooth discolouration when used in the coronal aspect. ³

To overcome this drawback, the manufacturers introduced a newer formulation called white MTA. The newer MTA has reduced Al2 O3, MgO and FeO when compared with grey MTA. This reduction in FeO resulted in less aluminoferrite phase which is the main constituent that is responsible for grey colour in GMTA. Nevertheless GMTA and WMTA contributes to the tooth discolouration. ^1,2,4–8

MTA has a pH around 12.5 and the ideal setting environment is alkaline. The setting time for grey and white MTA is 165 mins. ⁹ The prolonged setting time of the cement ¹⁰ is not an ideal property when used as a

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root end filling material, as it is in contact with blood and tissues which reduces the pH too. There is a drop in pH and results in washout of the material. ¹¹ This initiated in introducing newer cements with less setting time which was brought about by adjusting the original composition of the cement.¹² The ideal property of the MTA cement is not achieved when there is an interference with the setting time. When MTA is placed in contact with blood, discolouration occurs by haemolysis of the erythrocytes.⁴ Also altered pH influence the setting time and final set property of the MTA material.¹³ This is eliminated by newer introduction of MTA like MTA Angelus, Endocem MTA and Neo MTA.

MTA Angelus (Angelus, Londrina, Brazil) was launched in Brazil in 2001 and received FDA approval in 2011, making it available in the United States. MTA Angelus sets within 15 minutes of being prepared which is desirable with clinicians without worrying about MTA washout. The reduced setting time of MTA Angelus is due to the decreased concentration of calcium sulfate, which is the substance responsible for the longer setting time in the original formulation.

Due to the slow setting property of MTA [3-4 hours], calcium silicate based fast setting Endocem MTA material has been developed.¹⁴ Endocem MTA is non-miscible with liquid components, including blood and is ideal for use in clinical situations where bleeding is difficult to control.

Introduction

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Endocem MTA employs the pozzolanic reaction, possessing cementitious properties and known to reduce the setting time of Portland cement.¹⁴

Neo MTA Plus (Avalon Biomed Inc, Bradenton, FL), a new material similar to MTA has been marketed for use in pulpotomies as it does not discolour the tooth.¹⁵ MTA contains bismuth oxide which has been reported to discolour, this is replaced by tantalum oxide in Neo MTA. These radiopacifers were inert and showed no interference with the hydration of the material without phase changes and did not result in discolouration.¹⁵

Discolouration caused by MTA is exacerbated by its contact with blood.⁴

Most theories are related to:

 The presence of bismuth oxide in the WMTA formulation which causes the discolouration.¹⁶

 Collagen in dentin matrix, reacted with bismuth oxide, resulting in greyish discolouration.¹⁷

 The release of heavy metal ions from MTA is also reported to cause discolouration.

 The slow setting reaction of MTA permits the absorption and haemolysis of erythrocytes, resulting in material and subsequent tooth discolouration when in contact with blood.⁴

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This in vitro study was done to compare the potential discolouration effect of MTA Angelus, Endocem and Neo MTA since only few studies have been done on the discolouration potential.

Aim and Objectives

5

AIM AND OBJECTIVES

AIM:

The aim of this study is to compare the potential discoloration effect of MTA Angelus, Endocem and Neo MTA on natural teeth.

OBJECTIVES:

1. This study is designed to evaluate the discoloration potential of MTA when placed in contact with blood.

2. To compare the discoloration potential among MTA Angelus, Endocem and Neo MTA when placed in contact with blood using a

Spectrophotometer.

Review of Literature

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REVIEW OF LITERATURE

Van der Burgt and Plasschaert et al (1985)¹⁸ investigated the staining potential of different materials like Cavit, Durelon, Dycal, Fletcher’s cement, IRM, AH26-silver free, gutta-percha, Duo Percha, Fuji ionomer. and zinc phosphate cement by means of a visual method. The standards were arranged according to hue, value, and chroma as recommended by Munsell.

Seghi et al (1990)¹⁹ evaluated the effects of instrument-measuring geometry on color-difference assessments made on dental porcelains. The results indicate that a high degree of correlation can exist between color- difference measurements regardless of the design of the instrument-measuring geometry. This work suggests that the development of clinically useful devices need not be restricted to more traditional integrating-sphere-type designs and that more photometrically efficient alternative designs should be explored.

Mahmoud Torabinejad et al (1994)¹³ investigated mineral trioxide aggregate (MTA), as a potential alternative restorative material to the presently used materials in endodontics. Several in vitro and in vivo studies have shown that MTA prevents microleakage, is biocompatible, and promotes regeneration of the original tissues when it is placed in contact with the dental pulp or periradicular tissues. He described the clinical procedures for

Review of Literature

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application of MTA in capping of pulps with reversible pulpitis, apexification, repair of root perforations nonsurgically and surgically, as well as its use as a root-end filling material.

Thomas R. Pitt Ford et al (1995)²⁰ investigated the histologic response to intentional perforation in the furcations of mandibular premolars in seven dogs. In half the teeth, the perforations were repaired immediately with either amalgam or mineral trioxide aggregate; in the rest the perforations were left open to salivary contamination before repair. Results showed that the mineral trioxide aggregate is a far more suitable material than amalgam for perforation repair, particularly when used immediately after perforation.

Marin et al (1997)²¹ investigated tooth staining following pulpal haemorrhage. Samples of whole blood, erythrocytes, plasma and platelet concentrate and saline were individually placed in the pulp chambers of groups of five teeth and centrifuged twice daily for 25 min over a period of 3 consecutive days. He confirmed that the blood pigment responsible for the staining was found only in those samples containing erythrocytes. The tests done by Marin et al showed that, following haemolysis of erythrocytes within dentine, haemoglobin was found either intact or as one of the haematin molecules with no further breakdown of the haem structure and no evidence of any free ferric ions or haemosiderin.

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D.C.N. Chan et al (1999)²² studied the radiopacity of tantalum oxide in filled resins at varying percentage loadings. Ta₂O₅ nanoparticles were dissolved in methanol or powder forms were mixed into either glycerol dimethacrylate (GDMA) or a bisGMA and specimens were made in a split brass mold and compared with an aluminum step wedge (99.5% pure Al) and a dentin slice of the same thickness. The radiopacity increased significantly with tantalum loading and reached that of 70% enamel opacity.

Moir et al (2003)²³ describes the nature of Portland (calcium silicate-based) cements and outlines the manufacturing process and the quality

control procedures employed. Portland cement is essentially calcium silicate cement, which is produced by firing to partial fusion, at a temperature of approximately 1500°C, a well-homogenized and finely ground mixture of limestone or chalk (calcium carbonate) and an appropriate quantity of clay or shale. The composition is commonly finetuned by the addition of sand and/or iron oxide. Cement making is essentially a chemical process industry and has much in common with the manufacture of so-called heavy chemicals, such as sodium hydroxide and calcium chloride. Close control of the chemistry of the product is essential if cement with consistent properties is to be produced. This control applies not only to the principal oxides which are present but also to impurities, which can have a marked influence on both the manufacturing process and cement properties.

Review of Literature

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Asgary et al (2004)²⁴ compared the composition of white mineral trioxide aggregate (WMTA) and two different white Portland cements (WPCs). The samples were prepared and then imaged in a JEOL JSM6400 scanning electron microscope, equipped with an Oxford Instruments light element energy dispersive spectrometer detector for determining the elemental composition. The electron probe microanalysis showed that lime (CaO) and silica (SiO) were the dominant compounds in each case but with no detectable trace of bismuth oxide (BiO) in WPCs. He concluded that, there is no significant difference between the dominant compounds in both WMTA and WPCs except the presence of bismuth oxide in WMTA.

L. Turanli et al (2004)²⁵ studied the effect of three different natural pozzolans from Turkish deposits on the properties of blended cements produced by intergrinding cement clinker with a high volume of natural pozzolan (55 wt.% of the cementitious material). The particle size distribution of blended cements, setting time, heat of hydration, and compressive strength of blended cement mortars were determined. Experimental results showed that the hardness of the pozzolanic material strongly influenced the particle size distribution and the related properties of the blended cements by affecting the fineness of the components of the blended product. The early strength of the mortars was strongly affected by the particle size distribution of blended cements, whereas the strength development performance of the mortars was

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more related to the pozzolanic activity of the natural pozzolan present in the blended cement.

Ahmed Al-Kahtani et al (2005)²⁶ evaluated the seal created by varying depths of mineral trioxide aggregate (MTA) plugs placed in an orthograde fashion in five groups of 10 teeth. One group received a 2 mm thick orthograde apical plug of MTA, the second group a 5 mm apical MTA plug, and the third group a 2 mm apical MTA plug with a second 2 mm increment, 24 h later. The remaining portion of the canal in these groups was left unfilled. Group four received a 2 mm MTA plug that set for 24 h and the canal was then back-filled with gutta percha and eugenol based sealer. Group five was a positive control without an MTA plug. The apical seal was tested using a bacterial leakage model of Actinomyces viscosus. Results showed a statistically significant difference in only the 5 mm apical plug, which completely prevented bacterial leakage.

W. T. Felippe et al (2006)²⁷ evaluated the influence of mineral trioxide aggregate (MTA) on apexification and periapical healing of teeth in dogs with incomplete root formation and previously contaminated canals and to verify the necessity of employing calcium hydroxide paste before using MTA. He concluded that Mineral trioxide aggregate used after root canal preparation favoured the occurrence of the apexification and periapical healing. The initial use of calcium hydroxide paste was not necessary for

Review of Literature

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apexification to occur, and has shown to be strongly related to the extrusion of MTA and formation of barriers beyond the limits of the root canal walls.

Iwamoto et al (2006)²⁸ evaluated teeth clinically and histologically using white proroot MTA in direct pulp capping. white MTA were diagnosed as clinically successful, i.e. an absence of clinical symptoms and did not show evidence of periapical pathosis. Histologically dentin bridge had developed.

Iwamoto et al concluded that white ProRoot MTA was equally successful as calcium hydroxide when used for direct pulp capping in mechanically exposed teeth.

Song et al (2006)²⁹ observed that difference between white and gray MTA was the lack of iron ions in white MTA. the principal components of the gray-colored formula are tricalcium silicate, bismuth oxide, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, and calcium sulfate dehydrate, and the white-colored formula lacks the tetracalcium aluminoferrite. The fluxing agent is used for production of the white version to remove the ferrite phase during the clinkering process. Portland cement differed from MTA by the absence of bismuth ions and presence of potassium ions.

Bozeman et al (2006)³⁰ stated that crystal growth and elemental dissolution characteristics of gray Mineral Trioxide Aggregate (GMTA), white MTA (WMTA), and an experimental material, Dentalcrete, were compared.

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For part A, comparing amount and composition of surface crystal growth, twelve cylinders of each material were suspended in Phosphate Buffered Saline (PBS) solution without Ca. The crystals were analyzed by Scanning Electron Microscopy (SEM), X-ray Diffraction (XRD), and Inductively Coupled Plasma—Atomic Emission Spectroscopy (ICP-AES). For part B, three cylinders of each material were suspended in distilled, deionized water.

The water was analyzed by ICP-AES for Ca content at 24 h, 72 h, and 5, 7, 10, and 14 days. Data were analyzed using one-way ANOVA and Tukey test.

Both MTA materials released more Ca initially, followed by a decline and then rise in elution. GMTA produced the most surface crystal, which may be clinically significant. The crystals on GMTA and WMTA were chemically and structurally similar to hydroxyapatite (HA).

Lindsey et al (2007)³¹ determined the perceptibility and acceptability of tooth color differences using computer-generated pairs of teeth with simulated gingival displayed on a calibrated color monitor using appropriate signal detection theory methodology. Responses to tooth color differences (DE) were measured on each of the three principal axes of CIELAB color space (L*, a*, and b*). No group differences among subjects were found. All gave 50% match or acceptance points that averaged about 1.0 DE units in the L* and a* directions, and 2.6 units in the b* direction.

Kim-Pusateri et al (2009)³² evaluated the reliability and accuracy of 4 dental shade-matching instruments in a standardized environment. Four shade-

Review of Literature

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matching devices were tested: SpectroShade, ShadeVision, VITA Easyshade, and ShadeScan. Color measurements were made of 3 commercial shade guides (Vitapan Classical, Vitapan 3D-Master, and Chromascop). Shade tabs were placed in the middle of a gingival matrix (Shofu GUMY) with shade tabs of the same nominal shade from additional shade guides placed on both sides.

Measurements were made of the central region of the shade tab positioned inside a black box. For the reliability assessment, each shade tab from each of the 3 shade guide types was measured 10 times. For the accuracy assessment, each shade tab from 10 guides of each of the 3 types evaluated was measured once. Accuracy of devices was as follows: VITA Easyshade - 92.6%;

ShadeVision - 84.8%; SpectroShade - 80.2%; and ShadeScan - 66.8%.

Schembri et al (2010)³³ studiedPortland cement with a four to one addition of bismuth oxide marketed as mineral trioxide aggregate (MTA), which is used mainly as a dental material.Measurements of arsenic, lead, and chromium in hydrated gray and white Portland cement, ProRoot MTA, and MTA Angelus were conducted with graphite furnace atomic absorption spectrophotometry becauseheavy metal inclusion was a concern as MTA is in contact with hard and soft tissues. It was concluded that both MTAs released more arsenic than the amount specified. Portland cements and MTAs showed evidence of heavy metals in the acid-soluble form as well as leaching in deionized water and SBF. MTA contained levels of arsenic higher than the safe limit specified.

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Ilya Belobrov et al (2011)³⁴ describes the treatment of tooth discoloration caused by white MTA used for the management of a complicated crown fracture. A partial pulpotomy was performed with the use of WMTA after a complicated crown fracture of the upper right central incisor. Seventeen months later, upon access, the WMTA was completely discolored. the WMTA was removed because of tooth discoloration, and internal bleaching was performed. The toothremained vital, and adentin bridge was confirmed clinically and radiographically. He Concluded that WMTA used for vital pulp therapy in the esthetic zone may need to be reconsidered.

Daniel Felman et al (2013)⁴ characterized discoloration when white MTA was placed in the coronal aspect of the root canal ex vivo and the influence of red blood cells on this discoloration. Color was assessed using standardized digital photographs. All teeth discolored when restored with wMTA, which was most prominent in the cervical third of the crown. The presence of blood within the canal adjacent to the setting wMTA exacerbated the discoloration.

Ioannidis et al (2013)⁶ evaluated specific alterations in tooth colour with white and grey MTA when used to fill pulp chambers.Forty-five fully developed, intact, mandibular third molars were sectioned 1 mm below their cemento-enamel junction (CEJ). Their pulp chambers were chemo- mechanically debrided, and the specimens were randomly assigned into three

Review of Literature

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groups: Group 1–white MTAAngelus, Group 2– grey MTAAngelus and Group 3–negative control (unfilled). During the experimental period, specimens were immersed in vials containing distilled water up to the CEJ.

The discoloration was measured with a spectrophotometer and the data were transformed into values of the CIE L*a*b* colour system and ∆E values were obtained. He concluded that application of both grey and white MTA formulations induced a decrease in lightness and reduction in redness and yellowness in teeth. The present findings suggest that application of grey MTA in the aesthetic zone should be avoided, whilst white MTA should be used with caution when filling pulp chambers with the materials.

Ji-Hyun Jang et al (2013)³⁵ evaluated tooth discoloration after the use of mineral trioxide aggregate (MTA) and to examine the effect of internal bleaching on discoloration associated with MTA. He observed that the ProRoot and Angelus groups displayed increasing discoloration during a period of 12 weeks. The discoloration associated with ProRoot and Angelus was observed at the MTA-dentin interface and on the interior surface of the dentin. He concluded then ProRoot and Angelus caused tooth discoloration.

However, Endocem did not affect the contacting dentin surface. Removing the discolored MTA materials contributed more to resolving the tooth discoloration than post-treatment internal bleaching.

Marta Valles et al (2013)¹⁶ used five different calcium silicate cements namely ProRoot WMTA, Angelus WMTA, White Portland Cement

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[PC], PC with bismuth oxide, and Biodentine. They exposed each group of cements to combined environment of light and anaerobic condition and evaluated the color change in each specimens in different time period through spectrophotometer. From the results he concluded Biodentine and Portland cement demonstrated color stability than the other cements such as ProRoot WMTA, Angelus WMTA, White Portland with bismuth oxide.

Marina Angélica Marciano et al (2014)¹⁷ studied if the increase in radiopacity provided by bismuth oxide is related to the color alteration of calcium silicate-based cement. Calcium silicate cement was mixed with 0%, 15%, 20%, 30% and 50% of bismuth oxide (BO), determined by weight and Mineral trioxide aggregate was the control group. The assessments were performed using a spectrophotometer to obtain the ΔE, Δa, Δb and ΔL values.

He concluded that increase in radiopacity provided by bismuth oxide has no relation to the color alteration of calcium silicate-based cements.

Todd Berger et al (2014)³⁶ investigated the role of bismuth oxide, a constituent of contemporary mineral trioxide aggregate (MTA) materials, andits response to various solutions that may contribute to the potential discoloration. He observed thatall forms of ProRoot MTA showed discoloration and concluded that exposing MTA in various forms to a variety of liquids has determined that bismuth oxide in combination with other chemical moieties is the prime cause of staining.

Review of Literature

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Josette Camilleri et al (2014)³⁷ viewed that Immersion of white MTA and bismuthoxide in sodium hypochlorite resulted in the formation of a dark brown discoloration. This change was not observed in Portland cement. He concluded that Contact of white MTA and other bismuth-containing materials with sodium hypochlorite solution should be avoided.

Hannah Beatty et al (2015)³⁸ compared tooth discoloration between ProRootMTA, Biodentine, and EndoSequenceRoot Repair Material. She used bovine mandibular incisors and prepared them from the apical aspect after root resection. Canals were prepared with sequentially larger ParaPost drills coronal to the cementoenamel junction. Experimental materials were condensed into the crowns and the access sealed. Color was assessed at various times up to 2 months according to the CIE L*a*b* color space system and concluded that BioDentine and EndoSequence root repair material discolor bovine tooth structure to a perceptible degree. At 8 weeks, this was significantly more than ProRootMTA.

Josette Camilleri et al (2015)¹⁵ evaluated three materials namely Neo MTA Plus (Avalon Biomed Inc, Bradenton, FL), MTA Plus(Avalon Biomed Inc), and Biodentine (Septodont, Saint-Maur-des-Foss_es, France) that are used for pulpotomy procedures in immature permanent teeth to view their color stability in the presence of sodium hypochlorite. He compared the color stability using photography, spectrophotometry, and X-ray diffraction analysis. He concluded all materials used in the study are suitable to be used

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pulpotomy procedure of immature teeth as all the material produced calcium hydroxide as their byproduct in their early stage.but when comparing color stability Neo MTA Plus and Biodentine are suitable alternatives to MTA, and they do not exhibit discoloration.

BehnazEsmaeili et al (2015)³⁹ compared the discoloration potential of calcium enriched mixture cement, white mineral trioxide aggregate and calcium hydroxide, after placement in pulp chamber. The highest ΔE value belonged to WMTA group. They concluded that CEM cement may be the material of choice in the esthetic region, specifically pertaining to its lower colorchanging potential compared to WMTA.

Shin-Hong Kang et al (2015)³ compared the discolorationof these various MTA-based materials and concluded less discoloration was observed with ENDOCEM Zr and RetroMTA which contain zirconium oxide than with ProRoot MTA and MTA Angelus which contain bismuth oxide

ZohrehKhalilaket al (2015)⁴⁰ The aim of this in vitrostudy was to compare discoloration induced by tooth colored mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement in extracted human teeth. Color measurement was carried out by spectrophotometry and observed that tooth discoloration was similarly detectable with both of the two experimental materials.

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Marta Valles et al (2015)⁴¹ assessed the color stability of teeth restored coronally with WMTA or Biodentine under artificial light. In this invitro study he prepared cavities on coronal tooth and restored with WMTA + composite, Biodentine + composite, or composite alone. Color was assessed spectrophotometrically at 6 time points (initial, 1 week, 2 weeks, 1 month, 3 months, and 6 months), and color difference values were calculated. He concluded teeth treated with WMTA exhibited discoloration, whereas those treated with Biodentine maintained color stability throughout the study.

Christian A. Dettwiler et al (2016)⁴² viewed to investigate the discoloration potential of different endodontic cements, dressings, and irrigants used in dental traumatology. The specimens were selected and the cavities were filled with a range of endodontic materials,sealed with composite and stored in physiological saline. The color of the labial enamel surface was measured with a spectrophotometer at 7 time intervals. After 12 months, significant staining was observed among the endodontic cements only in the Portland cement group with additional bismuth oxide and other commercially available calcium silicate cements containing bismuth oxide were not significantly discolored. He concluded that the presence of bismuth oxide in calcium silicate cements was not shown to be a reliable predictor for tooth discoloration.

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Noushin Shokouhinejad et al (2016)⁴³compared the discoloration potential of MTA namely ProRoot MTA (Dentsply Tulsa Dental Products, Tulsa, OK) and calcium silicate based material such as Biodentine (Septodont, Saint Maur des Foss_es, France), OrthoMTA (BioMTA, Seoul, Korea), and EndoSequence Root Repair Material (ERRM; Brasseler, Savannah, GA) in the presence or absence of blood. He concluded all materials showed discoloration in the presence of blood butbiodentine and ERRM showed significantly less tooth discoloration in the absence of blood.

Yoldas et al (2016)¹ evaluated and compared the discoloration potential of 3 different tricalcium cements using a bovine tooth model. He used 4 groups namely BioAggregate, Biodentine, mineral trioxide aggregate Angelus, and only blood.Crowns separated from the roots and materials have been placed to the standardized cavities on the lingual surfaces of the crowns, and their contact with blood has been provided. The color values of the samples were measured with a digital tooth shade before the placement of the materials, after the placement of the materials, in the 24th hour, in the first week, in the first month, in the third month, and in the first year. Results showed all groups displayed increasing discoloration during a period of the first year. The ‘‘only blood group’’ showed the highest color change values, and it was followed as Bio-Aggregate, mineral trioxide aggregate Angelus, and Biodentine, respectively. He finally concluded that Biodentine is found to have the least discoloration potential among the tested materials.

Review of Literature

21

Marina Angelica Marciano et al (2017)⁴⁴ investigated the addition of variable amounts of zinc oxide to inhibitdental discoloration caused by mineral trioxide aggregate.He used MTA Angelus andMTA with additions of 5%, 15%, and 45% zinc oxide in weight were tested the set cements using a combination of scanning electronmicroscopy, energy dispersive spectroscopy, and x-raydiffraction. The pH and calcium ion releasewere measured after 3 hours, 24 hours, and 28 days.Dental discoloration in contact with the cements wasmeasured after 24 hours, 28 days, and 90 days. The results showed addition ofZnO did not alter significantly the radiopacity, settingtime, volume change, pH, and biocompatibility compared with MTA Angelus. He concluded the addition of 5%, 15%, or 45% zinc oxide to MTAAngelus inhibits dental discoloration without modifyingthe radiopacity, setting time, volume change, pH, andbiocompatibility.

Bansode et al (2018)⁴⁵ reviewed tricalcium silicate based cements like MTA though initially introduced as root end filling materials, have found wide acceptance in other treatment modalities like pulp capping, pulpotomies, apexification, perforation repairs because of their biocompatibility, sealing abilities etc. At the same time its limitations like longer setting time, difficult handling characteristics, potential to cause tooth discoloration have led to the exploration of modifications of the material. This article reviews a newer modification ‘Pozzolan Dental Cement’ which has been evaluated and compared with the existing tricalcium silicate-based cement.

22

Ivan Odler et al (2019)⁴⁶ studied the hydration, setting and hardening of Portland cement. There are various factors that determine the mechanism of PC setting reaction. He has studied the chemistry in depth and given and overview of the cement.

Jiménez-Sánchez et al (2019)⁴⁷ studied the physicochemical parameters with those of ProRoot MTA White (Pro) and NeoMTA Plus.

Setting time was assessed according using a scanning electron microscope.

Bioactivity evaluation in vitro was carried out, by soaking processed cement disk in simulated body fluid (SBF) during 168 h. HP showed shorter initial setting time compared to Pro and Neo and produce a quick and effective bioactive response in vitro in terms of phosphate phase surface coating formation which improved the outcome of vital pulp therapy.

Materials and Method

23

MATERIALS AND METHODS

ARMAMENTARIUM AND MATERIALS

1. 40 Extracted Human Upper Central Incisors 2. Diamond disc

3. Handpiece

4. ISO Diamond Cylindrical Bur – SR -13 (Mani) 5. Saline

6. Syringe (Unolok)

7. Sodium hypochlorite irrigation solution 3% (Chemdent) 8. 17% EDTA solution (Desmear)

9. Human Blood 10. Micropipette

11. MTA Angelus (Angelus) 12. Endocem MTA (Maruchi) 13. Neo MTA plus (Avalon Biomed) 14. Glass ionomer cement Type IX (GC)

24 15. Mixing pad and Agate spatula 16. Glass slab and Cement spatula 17. Plastic instrument

18. Spectrophotometer (Vita Easyshade Compact)

25

FLOW CHART ILLUSTRATING THE METHODOLOGY OF THE STUDY

All the 40 teeth’s root were removed and crowns were retained for the study.

A 3mm depth cavity was prepared with a cylindrical bur (SR-13) on the palatal surface of the teeth.

40 extracted upper central incisors were collected.

The teeth were cleaned with pumice, rinsed and dried.

The teeth are then place in 3% sodium hypochlorite solution for 30 mins, dried and placed in 17% EDTA

solution for another 2 mins for smear layer removal.

The teeth are divided into 4 groups

26

4 GROUPS

BLOOD ONLY n=10

BLOOD + MTA ANGELUS

n=10

BLOOD + ENDOCEM MTA

n=10

BLOOD + NEO MTA n=10

The access cavity of all the teeth were restored with Type IX GIC.

A preoperative shade was taken before placement of the respective materials and an immediate postoperative shade was taken using a

spectrophotometer.

The shade was checked after 1 day

The shade was checked after 1 week

The shade was checked after 2 weeks

The shade was checked after 3 weeks

27

SELECTION AND PREPARATION OF THE SAMPLES:

BLOOD COLLECTION:

5ml blood was collected by venipuncture from a volunteer in an anticoagulant spray coated tube that were sterile.

PROCEDURE:

40 extracted central incisors were collected. The teeth were cleaned with pumice, rinsed with running water and dried. The crowns were separated from their roots with a diamond disc. The crowns were retained for the study.

A cylindrical bur was used to prepare a cavity on the lingual surface of the teeth of 3mm depth. The teeth were then rinsed and placed in 3% sodium hypochlorite solution for 30 mins followed by 17% EDTA solution for 2 mins for smear layer removal. The teeth were then rinsed and randomly divided into 4 groups:

Group A - Blood only;

Group B – Blood + MTA Angelus;

Group C – Blood + Endocem MTA;

Group D – Blood + Neo MTA

An initial shade was obtained using a spectrophotometer for all the teeth. Each tooth was filled with blood using a micropipette, followed by their

respective group material and their access cavity were restored with

28

Type IX GIC. In Group A, the cavities were filled only with 2.0μL blood followed by GIC restoration. In Group B, the cavities were filled with 0.5μL blood followed by MTA Angelus using a plastic instrument and restored with GIC. MTA Angelus was mixed as per the manufacturer’s instructions and placed within the cavity with the plastic instrument. In Group C, the cavities were filled with 0.5μL blood, then Endocem MTA was mixed and placed in the cavity with a plastic instrument followed by GIC restoration. In Group D, the cavities were filled with 0.5μL blood followed by Neo MTA, which was mixed and placed within the cavity with a plastic instrument. After which the access cavities were restored with type IX GIC. An immediate postoperative shade was obtained with the Spectrophotometer. The samples were then stored in tap water at room temperature. Each group’s shade was measured after one day, 1 week, 2 weeks and 3 weeks. ∆E values were obtained from the samples and analysed.

∆E Measurements:

The Spectrophotometer is a device used to measure the shade of the tooth. The conducting end is placed on the middle third of the tooth’s labial surface and the device is activated to measure the ∆E value. This value

consists of L (Lightness), c (chroma), h (hue) measurements.

L*c*h = ∆E

29 Statistical Analysis:

One -way ANOVA (analysis of variance) – to assess significant differences between the tested materials.

Bonferroni multiple - comparison test

Figures

FIGURE 1: EXTRACTED HUMAN UPPER CENTRAL INCISORS

Figures

FIGURE 2: DECORONATION OF TEETH AT CEJ

FIGURE 3: DIAMOND DISC

FIGURE 4: HANDPIECE

FIGURE 5: ISO DIAMOND CYLINDRICAL BUR – SR -13 (MANI)

Figures

FIGURE 6: SYRINGE (UNILOK)

FIGURE 7: SALINE

FIGURE 8: SODIUM HYPOCHLORITE IRRIGATION SOLUTION 3% (CHEMDENT)

FIGURE 9: 17% EDTA SOLUTION (DESMEAR)

Figures

FIGURE 10: MICROPIPETTE

FIGURE 11: MTA (MICRO ANGELUS)

FIGURE 12: ENDOCEM MTA (MARUCHI)

FIGURE 13: NEO MTA PLUS (AVALON BIOMED)

Figures

FIGURE 14: GLASS IONOMER CEMENT TYPE IX (GC), MIXING PAD AND AGATE SPATULA

FIGURE 15: GLASS SLAB AND CEMENT SPATULA

FIGURE 16: PLASTIC INSTRUMENT

FIGURE 17: CAVITY PREPARATION

Figures

FIGURE 18: SPECTROPHOTOMETER

FIGURE 19: MANIPULATION OF MTA ANGELUS

FIGURE 20: MANIPULATION OF ENDOCEM MTA

Figures

FIGURE 21: MANIPULATION OF NEO MTA

FIGURE 22: BLOOD ONLY GROUP

FIGURE 23: MTA ANGELUS GROUP

FIGURE 24: ENDOCEM MTA GROUP

FIGURE 25: NEO MTA GROUP

Figures

A

B

C

FIGURE 26: POSTOPERATIVE SAMPLES D

Results

Results

30

RESULTS

The study was designed to evaluate the discolouration potential of newer and improvised MTA materials when it comes in contact with blood and to compare the discolouration potential among them. The discolouration in teeth were measured with a spectrophotometer and the obtained ∆E values were analysed with the IBM.SPSS statistics software 23.0 Version.

To find the significance difference one-way ANOVA was used and for repeated measures, ANOVA with Bonferroni test was used for multiple comparison.

The experimental groups were divided into four groups:

Group A – Blood only

Group B – Blood +MTA Angelus Group C – Blood + Endocem MTA Group D – Blood + Neo MTA

Table 1 represents the multiple comparison test analysis for the materials used and measured at various intervals by one-way ANOVA. The table shows the mean and SD of each group at measured intervals. The immediate postoperative p value is 0.421(p>0.05), Group A(Blood only) shows a mean value [21.39±1.34], Group B (MTA Angelus) shows a mean value [20.20±4.37], Group C ( Endocem MTA) shows a mean value

31

[21.57±0.77] and Group D (Neo MTA) shows a mean value [21.90±1.15].

After day 1 the p value is 0.445(p>0.05), Group A shows a mean value of [21.35±1.38], Group B shows a mean value of [22.67±4.28], Group C shows a mean value of [21.40±0.80] and Group D shows a mean value of [21.50±1.09]. The p value after one week is 0.364(p>0.05), Group A shows a mean value of [22.63±1.37], Group B shows a mean value of [22.59±3.79], Group C shows a mean value of [21.86±0.74] and Group D shows a mean value of [21.03±1.11]. After two weeks the p value is 0.264(p>0.05), Group A shows a mean of [23.09±1.32], Group B shows a mean value of [22.79±3.89], Group C shows a value of [22.16±0.75] and Group D shows a mean value of [22.32±1.27]. After three weeks the p value is 0.316(>0.05), Group A shows a mean of [23.88±1.26], Group B shows a mean value of [22.94±3.89], Group C shows a mean value of [22.22±0.75] and Group D shows mean value of [22.17±1.33].

Table 2 represents the repeated measures of ANOVA for Blood only [Group A] (∆E). It shows a p value of 0.005 (P < 0.01) that is statistically highly significant. The immediate postoperative measurement shows a mean value of [21.39±1.34], day 1 shows a mean value of [21.88±1.38], after 1 week shows a mean value of [22.63±1.37], after 2 weeks a mean value of [23.09±1.32] and after 3 weeks it shows a mean value of [23.61±1.26].

Results

32

Table 3 shows pairwise comparison of blood only group at different intervals. p value for all the group is 0.0005. The mean difference is significant at the 0.05 level. The p value comparing immediate postoperative with day 1 is 0.055, comparing with one week shows a value of 0.083, comparing with two weeks shows a value of 0.104, comparing with three weeks a value of 0.140. The p value comparing day 1 with one week is 0.073, comparing with two weeks is 0.091, comparing with three weeks is 0.121. The p value comparing one week with two weeks is 0.045 and comparing with three weeks is 0.080. The p value comparing two weeks with three weeks is 0.049.

Table 4 shows repeated measures of ANOVA for MTA Angelus [Group B] (ΔE). p value is 0.064 which is not statistically significant. The statistical significance is at p>0.01. The immediate postoperative measurement shows a mean value of [20.20 ±4.37], day 1 shows a mean value of [20.53±4.28], after 1 week a mean value of [20.97±3.79], after 2 weeks mean value of [21.12±3.89], after 3 weeks mean value of [21.25±3.89].

Table 5 shows pairwise comparison of MTA Angelus group at different intervals. The p value comparing immediate postoperative with day 1 value is 0.053, compared after one week is 0.054, compared after two weeks is 0.014, compared after three weeks is 0.002. The p value comparing day 1 value with one week is 0.717, with two weeks is 0.137 and compared with three weeks is 0.015. The p value comparing one week with two weeks is 1.00,

33

comparing with three weeks is 0.016. The p value comparing two weeks with three weeks is 0.675. The mean difference is significant at the 0.05 level.

Table 6 shows repeated measures of ANOVA for Endocem MTA [Group C] (ΔE). p value is 0.0005 which is highly statistically significant at the level of p<0.01. The immediate postoperative measurement shows a mean value of [21.57 ±0.77], day 1 shows a mean value of [21.84±0.80], after 1 week shows a mean value of [22.02±0.74], after 2 weeks shows a mean value of [22.16±0.75], after 3 weeks shows a mean value of [22.22±0.75].

Table 7 shows the pairwise comparison of Endocem MTA at different intervals. The p value comparing the immediate postoperative value with day one is 0.003, comparing with one week’s value is 0.0005, comparing with two weeks is 0.0005, comparing with three weeks is 0.0005. The p value comparing day 1 with one week is 0.077, comparing with two weeks is 0.006 and comparing with three weeks is 0.024. The p value comparing one week with two weeks is 0.066, comparing with three weeks is 0.023. The p value comparing two weeks with three weeks is 1.000. The mean difference is significant at the 0.05 level.

Table 8 shows repeated measures of ANOVA for Neo MTA [Group D] (ΔE). The p value is 0.003, that is highly statistically significant at p<0.01 level. The immediate postoperative measurement shows a mean value of [21.90 ±1.15], after day 1 the mean value is [22.08±1.09], after one week the

Results

34

mean value is [22.18±1.11], after two weeks the mean value is [22.32±1.27]

and after 3 weeks the mean value is [22.36±1.33].

Table 9 shows the pairwise comparison of Neo MTA group at different levels. The p value comparing immediate postoperative value with day one shows value of 0.025, comparing with one week shows a value of 0.033, comparing with two weeks shows a value of 0.115 and comparing with three weeks shows a value of 0.142. The p value comparing day 1 with one week shows a value of 0.026, comparing with two weeks shows a value of 0.121 and comparing with three weeks shows a value of 0.149. The p value comparing one week with two weeks shows a value of 0.130 and that comparing with three weeks is 0.158. The p value comparing two weeks with three weeks is 0.031. The mean difference is significant at the 0.05 level.

Graph 1, represents the ∆E mean values of immediate postoperative measurement of all the groups.

Graph 2, represents the ∆E mean values after day 1 measurement of all the groups.

Graph 3, represents the ∆E mean values after one week measurement of all the groups.

Graph 4, represents the ∆E mean values after two weeks measurement of all the groups.

35

Graph 5, represents the ∆E mean values after three weeks measurement of all the groups.

Graph 6, represents the ∆E mean values of the blood only group at various intervals.

Graph 7, represents the ∆E mean values of MTA Angelus group at various intervals.

Graph 8, represents the ∆E mean values of Endocem MTA group at various intervals.

Graph 9, represents the ∆E mean values of Neo MTA group at various intervals.

From table 1 and graphs 1-5, it is inferred that all the tested groups showed discolouration.

From table 2, 3 and graph 6, the results showed that, though the Blood Only group showed minimal discolouration initially, it exhibited maximum discolouration potential at the end of three weeks.

Table 4, 5 and graph 7 showed that an immediate increase in discolouration potential of MTA Angelus was seen after one day, that gradually increased after a week and sustained the discolouration till the third week.

Results

36

Table 6, 7 and graph 8 showed that Endocem MTA showed minimum discolouration initially after placement. Its discolouration was very minimal compared to all the other tested groups. The discolouration gradually increased and remained the same in 2^nd and 3^rd week. Over all it showed minimum discolouration potential when compared to other groups at the end of 3^rd week.

Table 8, 9 and graph 9 showed that Neo MTA exhibited the least discolouration potential when measured at different intervals. Compared to the other tested groups, it showed minimum discolouration initially and at the end of 3weeks.

Tables and Graphs

Tables and Graphs

Multiple comparison by Oneway ANOVA

N Mean S.D F-

value

P- value Blood only 10 21.39 1.34

∆E IMMEDIATE

POST OP

MTA

Angelus 10 20.20 4.37

0.962 0.421 # Endocem

MTA 10 21.57 0.77

Neo MTA 10 21.90 1.15

Blood only 10 21.35 1.38

MTA 10 22.67 4.28

∆E 1 DAY Angelus

0.912 0.445#

Endocem

10 21.40 0.80

MTA

Neo MTA 10 21.50 1.09

Blood only 10 22.63 1.37

MTA 10 22.59 3.79

∆E AFTER 1 WEEK

Angelus

1.093 0.364#

Endocem

10 21.86 0.74

MTA

Neo MTA 10 21.03 1.11

Blood only 10 23.09 1.32

MTA 10 22.79 3.89

∆E AFTER 2 WEEKS

Angelus

1.381 0.264 # Endocem

10 22.16 0.75

MTA

Neo MTA 10 22.32 1.27

Blood only 10 23.88 1.26

MTA 10 22.94 3.89

∆E AFTER 3 WEEKS

Angelus

1.97 0.136 # Endocem

10 22.22 0.75

MTA

Neo MTA 10 22.17 1.33

No Statistical Significance at P < 0.05 level

TABLE 1: MULTIPLE COMPARISONS OF THE GROUPS AT INTERVALS BY ONE-WAY ANOVA

REPEATED MEASURES OF ANOVA FOR BLOOD ONLY (∆E)

Mean S.D F-value P-value

Pre OP 21.16 1.35

210 0.0005 **

Immediate

Post OP 21.39 1.34

Day 1 21.88 1.38

After 1 week 22.63 1.37 After 2

weeks 23.09 1.32

After 3

weeks 23.61 1.26

** Highly Statistical Significance at P < 0.01 level

TABLE 2: REPEATED MEASURES OF ANOVA FOR BLOOD ONLY (∆E)

Tables and Graphs

Pairwise Comparisons

(I) DeltaE

MD (I- J)

Std.

Error P-value

95% C.I Lower Bound

Upper Bound

Pre OP

Immediate post

OP -.230^* .026 .0005 -.333 -.127

Day 1 -.720^* .071 .0005 -1.001 -.439 After 1 Week -1.470^* .101 .0005 -1.870 -1.070 After 2 Weeks -1.930^* .123 .0005 -2.416 -1.444 After 3 Weeks -2.450^* .159 .0005 -3.080 -1.820

Immediate Post OP

Day 1 -.490^* .055 .0005 -.706 -.274 After 1 Week -1.240^* .083 .0005 -1.569 -.911 After 2 Weeks -1.700^* .104 .0005 -2.113 -1.287 After 3 Weeks -2.220^* .140 .0005 -2.772 -1.668

Day 1

After 1 Week -.750^* .073 .0005 -1.040 -.460 After 2 Weeks -1.210^* .091 .0005 -1.571 -.849 After 3 Weeks -1.730^* .121 .0005 -2.209 -1.251 After 1

week

After 2 Weeks -.460^* .045 .0005 -.639 -.281 After 3 Weeks -.980^* .080 .0005 -1.296 -.664 After 2

weeks After 3 Weeks -.520^* .049 .0005 -.714 -.326

* The mean difference is significant at the 0.05 level.

TABLE 3: PAIRWISE COMPARISONS OF BLOOD ONLY GROUP AT VARIOUS INTERVALS

Repeated measures of ANOVA for MTA angelus (∆E)

Mean S.D F-value P-value

Pre OP 19.66 6.12

4.199 0.064 # Immediate

Post OP 20.20 4.37

Day 1 20.53 4.28

After 1 week 20.97 3.79

After 2 weeks 21.12 3.89

After 3 weeks 21.25 3.89

** Highly Statistical Significance at P < 0.01 level

TABLE 4: REPEATED MEASURES OF ANOVA FOR MTA ANGELUS (∆E)

Tables and Graphs

Pairwise Comparisons

(I) DeltaE MD

(I- J)

Std.

Error

P- value

95% C.I Lower Bound

Upper Bound

Pre OP

Immediate

post OP -.540 .606 1.000 -2.936 1.856 Day 1 -.870 .628 1.000 -3.353 1.613 After 1 Week -1.310 .774 1.000 -4.371 1.751

After 2

Weeks -1.460 .744 1.000 -4.400 1.480 After 3

Weeks -1.590 .743 .914 -4.526 1.346

Immediate Post OP

Day 1 -.330 .084 .053 -.664 .004 After 1 Week -.770 .197 .054 -1.550 .010

After 2

Weeks -.920^* .190 .014 -1.672 -.168 After 3

Weeks -1.050^* .167 .002 -1.712 -.388

Day 1

After 1 Week -.440 .192 .717 -1.200 .320 After 2

Weeks -.590 .179 .137 -1.296 .116 After 3

Weeks -.720^* .151 .015 -1.318 -.122

After 1 week

After 2

Weeks -.150 .079 1.000 -.463 .163 After 3

Weeks -.280^* .059 .016 -.514 -.046 After 2

weeks

After 3

Weeks -.130 .056 .675 -.351 .091

* The mean difference is significant at the 0.05 level.

TABLE 5: PAIRWISE COMPARISONS OF MTA ANGELUS GROUP AT VARIOUS INTERVALS

Repeated measures of ANOVA for Endocem MTA (∆E)

Mean S.D F-value P-value

Pre OP 21.48 0.74

66.395 0.0005 **

Immediate

Post OP 21.57 0.77

Day 1 21.84 0.80

After 1 week 22.02 0.74

After 2

weeks 22.16 0.75

After 3

weeks 22.22 0.75

** Highly Statistical Significance at P < 0.01 level

TABLE 6: REPEATED MEASURES OF ANOVA FOR ENDOCEM MTA (∆E)

Tables and Graphs

Pairwise Comparisons

(I) DeltaE MD

(I-J)

Std.

Error P- value

95% C.I Lower Bound

Upper Bound

Pre OP

Immediate post OP -.090 .041 .814 -.251 .071 Day 1 -.360^* .065 .006 -.618 -.102 After 1 Week -.540^* .040 .0005 -.698 -.382 After 2 Weeks -.680^* .059 .0005 -.914 -.446 After 3 Weeks -.740^* .067 .0005 -1.005 -.475

Immediate Post OP

Day 1 -.270^* .045 .003 -.447 -.093 After 1 Week -.450^* .022 .0005 -.538 -.362 After 2 Weeks -.590^* .046 .0005 -.771 -.409 After 3 Weeks -.650^* .060 .0005 -.888 -.412

Day 1

After 1 Week -.180 .049 .077 -.374 .014 After 2 Weeks -.320^* .059 .006 -.554 -.086 After 3 Weeks -.380^* .085 .024 -.718 -.042 After 1

week

After 2 Weeks -.140 .037 .066 -.287 .007 After 3 Weeks -.200^* .045 .023 -.377 -.023 After 2

weeks After 3 Weeks -.060 .048 1.000 -.248 .128

* The mean difference is significant at the 0.05 level.

TABLE 7: PAIRWISE COMPARISONS OF ENDOCEM MTA AT VARIOUS INTERVALS

Repeated measures of ANOVA for Neo MTA (∆E)

Mean S.D F-value P-value

Pre OP 21.78 1.14

7.751 0.003 **

Immediate

Post OP 21.90 1.15

Day 1 22.08 1.09

After 1

week 22.18 1.11

After 2

weeks 22.32 1.27

After 3

weeks 22.36 1.33

** Highly Statistical Significance at P < 0.01 level

TABLE 8: REPEATED MEASURES OF ANOVA FOR NEO MTA (∆E)

Tables and Graphs

Pairwise Comparisons

(I) DeltaE MD

(I-J)

Std.

Error P- value

95% C.I Lower Bound

Upper Bound

Pre OP

Immediate

Post OP -.120 .101 1.00

0 -.519 .279

Day 1 -.300 .114 .402 -.749 .149

After 1 Week

-.400 .115 .107 -.857 .057 After 2

Weeks

-.540 .154 .098 -

1.147 .067 After 3

Weeks

-.580 .172 .125 -

1.262 .102

Immediate Post

OP

Day 1

-

.180^* .025 .001 -.279 -.081 After 1

Week

-

.280^* .033 .000

5 -.409 -.151

After 2 Weeks

-.420 .115 .081 -.876 .036 After 3

Weeks

-.460 .142 .150 -

1.020 .100

Day 1

After 1 Week

-.100 .026 .057 -.202 .002 After 2

Weeks

-.240 .121 1.00

0 -.720 .240

After 3 Weeks

-.280 .149 1.00

0 -.869 .309

After 1 week

After 2 Weeks

-.140 .130 1.00

0 -.655 .375

After 3 Weeks

-.180 .158 1.00

0 -.806 .446

After 2

weeks After 3

Weeks

-.040 .031 1.00

0 -.161 .081

* The mean difference is significant at the 0.05 level.

TABLE 9: PAIRWISE COMPARISON NEO MTA GROUP AT VARIOUS INTERVALS

VALUES OF THE GROUPS

GRAPH 2: REPRESENTING ∆E DAY 1 VALUES OF THE GROUPS

Neo MTA MTA angelus Endocem MTA

Blood only 0.00

4.00 8.00 12.00 16.00 20.00

24.00

∆E Immediate Post OP

Neo MTA MTA angelus Endocem MTA

Blood only 0.00

4.00 8.00 12.00 16.00 20.00 24.00

∆E 1 Day

MEAN MEAN