Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
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Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : ZC19 - ZC23 Full Version

Comparison of Sealing Efficiency of Mineral Trioxide Aggregate and Biodentine used in Perforation Repair in Acidic and Neutral Environments- An In-vitro Study

Published: July 1, 2021 | DOI:
Güney Mustafa Yüzer, Sadullah Kaya

1. Research Assistant, Department of Endodontics, Dicle University, Diyarbakir, Turkey. 2. Professor, Department of Endodontics, Dicle University, Diyarbakir, Turkey.

Correspondence Address :
Güney Mustafa Yüzer,
Research Assistant, Department of Endodontics, Dicle University, Diyarbakir, Turkey.


Introduction: Furcation perforation is one of the complications that occur during endodontic treatment due to anatomical differences or iatrogenic causes. Repairing the perforation with a biocompatible material eliminates the connection with the gingival sulcus and positively affects the prognosis. The sealing ability of the repair materials is very important and is affected by the conditions of the environment in which they are applied.

Aim: To compare the sealing efficiency of Mineral Trioxide Aggregate (MTA) (Angelus, Londrina, PR, Brazil) and Biodentine (Septodont, Saint Maur des Fosses, France) materials used in the repair of furcation perforations in acidic and neutral environments.

Materials and Methods: This in-vitro experimental study was carried out in the Department of Endodontics at Dicle University Faculty of Dentistry, Diyarbakir, Türkiye and Dicle University Science and Technology Application and Research Center from 10th June 2020 to 22nd July 2020. A total of 96 mandibular molars were used in the study. The specimens were randomly divided into two equal groups (n=48). When the perforations were repaired with MTA and Biodentine materials, each group was divided into four subgroups (n=12). These subgroups were kept in Phosphate Buffered Saline (PBS) and Acetic Acid (AA) solutions for different periods of time from 4 or 34 days, and all groups were immersed in methylene blue solution. The dye penetration level of the divided sections was examined under a stereomicroscope (Leica, Wetzlar, Germany). Microleakage data of all groups were statistically analysed using Kolmogorov Smirnov, Shapiro Wilk’s and Mann-Whitney U Test. Statistical significance was set at 0.05, it was stated that there was a significant difference when p-value <0.05.

Results: The short-term (4 days) microleakage level of biodentine material in the AA environment was significantly lower than that of MTA material (p-value=0.005). There was no statistically significant difference between the materials in terms of long-term (34 days) microleakage levels in the AA environment (p-value >0.05). The long-term microleakage level in PBS environment of biodentine material was significantly lower than that of the AA environment (p-value=0.008).

Conclusion: Lower microleakage levels were observed in the neutral environment than the acid environment with both MTA and biodentine during both holding periods.


Acetic acid, Dye penetration, Phosphate buffered saline, Stereomicroscope

Furcation perforation can be expressed as the enlargement of the pulp chamber of the tooth from the pulp floor to the Periodontal Ligament (PDL) space. Inflammation, gingival enlargement, or resorption of the bone structure may occur in that area due to perforation. There are surgical or non-surgical treatment options for perforation. If it is repaired with a biocompatible material with sealing property without any delay in the intervention, the prognosis of the tooth is usually excellent (1).

MTA is one of the materials preferred most by researchers due to its excellent biocompatibility, sealing ability, and antimicrobial properties (2). Although it was a material originally used to repair perforations, today it is used in vital pulp therapy as root end filling material, in devital teeth with open apex as an apical plug, in the treatment of dentine hypersensitivity and in regenerative endodontic treatment (3),(4). However, it has some disadvantages including long setting time, the difficulty of manipulation, causing discolouration of the tooth structure and high cost (5).

Biodentine (Septodont, Saint Maur des Fosses, France), a new calcium silicate-based restorative cement, has recently been released. It is a fast-setting restorative material that can be used in the same practices as MTA (6). This calcium silicate-based product was first released in 2009 and was originally designed as a “dentin replacement” material. Biodentine has wide areas of use in endodontic treatments as retrograde filling material in root perforations, apexification, resorptive lesions, and endodontic surgery and in restorative dentistry as dentin replacement material. The material was actually formulated with the improvements in MTA based cement technology and some of the properties of these types of cement, such as physical nature and manipulation ability (7).

The environment in which a material exists may affect its marginal adaptation to dentin, microleakage, and the microstructure and surface morphology of the material (8). It was reported that pH changes in the surrounding tissues due to pre-existing inflammation during the use of the material might affect the physical and chemical properties of the materials (9).

Many researchers have investigated the properties of MTA and biodentine, such as compressive strength, micro crack formation, marginal adaptation to dentine and impermeability, they compared the advantages of these materials over each other (2),(8),(9),(10). However, the effect of pH level on the physical and chemical properties of the materials in the areas they contact during an application is still controversial. In clinical practice, furcation perforations that occur during treatment or pre-exist may be accompanied by an inflammation in the adjacent periradicular tissue. This can alter the pH levels, and therefore, the properties of the material applied.

The aim of this study was to compare the sealing properties of biodentine and MTA using a dye penetration model for quantitative analysis of microleakage following exposure to acidic and neutral environments.

Material and Methods

This in-vitro experimental study, approved by Dicle University Faculty of Dentistry Ethics Board (Protocol no: 2019/31), was conducted in Department of Endodontics at (Dicle University Faculty of Dentistry, Diyarbakir) Türkiye and Dicle University Science and Technology Application and Research Center from 10th June 2020 to 22nd July 2020.

Inclusion criteria: A total of 96 double-rooted mandibular molars that were extracted due to periodontal reasons were used.

Exclusion criteria: Teeth with a large decay extending into the furcation area, whose roots were not separated from each other or whose furcation levels were not the same as the other teeth were excluded.

Sample size calculation: In this study, 96 specimens were included, which were divided into four subgroups with 12 specimens in each group, considering a margin of error of 5% for microleakage, with a confidence level of 95% and a theoretical study power of 99% (11).


The selected teeth were cleaned with soft brush and distilled water to remove debris and blood stains and were preserved in saline solution until study procedure.

After the crown lengths of the teeth were shortened to 5 mm coronal to the cementoenamel border by using a high speed bur, endodontic access cavities were prepared. After access opening, perforations were created in the furcation areas of the teeth under water cooling with round burs of 1.4 mm diameter.

The specimens were randomly divided into two groups based on repair materials: Group A with MTA (n=48) and Group B with biodentine (n=48). The specimens in both the groups were also randomly divided into four subgroups based on storage environment and holding period (n=12). After the perforation areas were covered with the relevant materials, the endodontic access cavities were restored with composite filling material. Group A1 and Group B1 were exposed for four days to PBS solution that mimics the neutral environment (pH 7.4). Group A2 and Group B2 were exposed for four days to an AA solution buffered to pH 4.5. Group A3 and Group B3 were exposed to PBS for 34 days, while Group A4 and Group B4 were kept in PBS solution, which mimics the neutral environment, for 30 days following a period of four days in the AA solution (11).

Cotton pellets were soaked in the solutions (AA or PBS) previously used between the roots of the teeth before the repair in the groups, and the pellets were placed under the perforation area of the furcation sites to reproduce the inside of the mouth. The specimens were then placed in styrofoam, and the perforation areas were covered with the repair materials. It was removed from the styrofoam after it hardened according to the manufacturer’s instructions. Gauze pads soaked in the relevant solutions based on their groups were placed between the roots in a way to come into contact with the furcation areas of the teeth taken out from the styrofoam. Afterwards, the specimens in all groups were placed in 15 mL falcon tubes with cap to ensure the continuity of the humid environment. The relevant groups (Group A3 and Group B3) of the specimens to be followed for a long period were kept in the PBS solution for 34 days for that purpose, and the solutions were replaced at 5-day intervals (11). The groups (Group A4 and Group B4) to be exposed to the AA solution were kept in the solution for four days, and the pads which were soaked in the AA solution were removed. The same specimens were kept in the PBS solution by replacing the solution at 5-day intervals for 30 days. The specimens to be followed for a short period (Group A1, B1, A2 and B2) were kept in the PBS/AA solution for four days. All specimens were kept stable at 37°C in the incubator (Nüve Incubator EN 055, Ankara, Turkey) during the holding period.

All study groups kept in the incubator for the specified periods were removed out of the tubes, washed with distilled water, and cleaned up from the solutions. Dried specimens were dyed with two-coat nail polish covering all surfaces, except the surrounding area of 2 mm to the perforation area to prevent possible leakage from the apical foramen or the microcracks on the surface. All specimens were immersed in 50 mL of 1% methylene blue solution together with their own groups, and they were kept in the solution for 24 hours (12).

The specimens were rinsed with distilled water for 15 minutes to remove excess dye. The molars were fixed to 2×4 cm wooden blocks, and they were then divided into two in the buccolingual direction using the Isomet (Iso-Met® 1000 Precision Saw, Buehler Ltd., Illinois, EUA) device in a way to include the furcation area.

The images of the sections obtained from the specimens were recorded under a stereomicroscope (Leica, Wetzlar, Germany) at X20 magnification (Table/Fig 1). The level of dye penetration in the recorded images was measured using the Motic Images Plus version 3.0 (Motic Inc., Ltd., Hong Kong, China) software. During the measurement, the level of dye penetration in the area from the bottom of the perforation area to the coronal of the tooth was identified in mm on both walls, and the mean value of these measurements was provided.

Statistical Analysis

The study data were analysed using the Statistical Package for the Social Sciences (SPSS) (SPSS, Chicago, IL, USA) version 21.0 software. The Kolmogorov Smirnov Test or the Shapiro-Wilk Test was used to analyse the results of the normal distribution of the variables. The Mann-Whitney U test was used in case the variables were not obtained from the normal distribution while evaluating the differences between the groups. As the variables were not obtained from the normal distribution, the Wilcoxon Test was used while evaluating the difference between two dependent variables. A p-value of 0.05 was considered significant.


Comparison of the Materials According to the Storage Environments and the Periods

The short-term microleakage level of biodentine material in the AA environment (Group B2) was significantly lower than that of MTA material (Group A2) (p-value=0.005). There was no statistically significant difference between the materials in terms of short-term microleakage level in the PBS environment (Group A1 and B1) (p-value >0.05).

There was no statistically significant difference between the materials in terms of long-term microleakage levels in the (Group A3, B3, A4 and B4) PBS and AA environments (p-value >0.05) (Table/Fig 2).

Comparison of the Environments According to the Repair Materials and the Periods

The short-term (Group A1) and long-term (Group A3) microleakage levels of MTA material in the PBS environment were significantly lower than those of the AA environment (Group A2 and A4) (p-value <0.05).

There was no statistically significant difference between the environments in terms of the short-term microleakage levels of biodentine material (p-value >0.05). However, the long-term microleakage level in the PBS environment (Group A3 and B3) was significantly lower than that of the AA environment (group A4 and B4) (p-value <0.05) (Table/Fig 3).

Comparisons of the Periods According to the Repair Materials and the Storage Environments

There was no statistically significant difference was observed between short-term (Group A1, A2) and long-term (Group A3, A4) of the microleakage levels of MTA material in the PBS and AA environments (p-value >0.05).

There was no statistically significant difference between the periods in terms of the microleakage levels of biodentine material in the PBS environment (p-value >0.05). On the other hand, the short-term (Group B2) microleakage level of biodentine material in the AA environment was significantly lower than the long-term (Group B4) microleakage level (p-value=0.045) (Table/Fig 4).


Perforation is a pathological connection between the root canal system and the surrounding periodontal tissues. It may develop during pathological processes, such as caries and internal/external resorption, or may occur during endodontic treatment and intracanal post implementations (13). Perforation is one of the reasons for endodontic treatment failure. This pathological connection causes an inflammatory reaction in the tissue with which it comes into contact, and it significantly affects the long-term prognosis of teeth (14),(15). Therefore, perforation areas should be repaired with a suitable material. Today, furcation repair materials preferred most are bioactive substances such as MTA and biodentine. Many in-vitro and in vivo studies have shown that the sealing ability and biocompatibility of MTA is superior to conventional materials (1),(16). MTA has high pH and radiopacity levels (17). However, MTA has some disadvantages, such as the length of the initial setting time (3-4 hours), difficulty in using (depending on water/powder ratio), and high cost (5). On the other hand, biodentine, which is a calcium silicate-based restorative cement, is a fast setting restorative material that can be used in the same practices as MTA (18).

An important factor affecting the success in the repair of perforations is the sealing property of the materials used (19). An ideal material should provide complete sealing. The sealing ability of MTA has been investigated in different in-vitro studies using dye penetration method or fluid filtration technique (20),(21). In the present study, biodentine was used by considering this situation, and the sealing ability of biodentine was compared with MTA which suggested better sealing results compared to other traditional materials in the literature review.

In many studies comparing biodentine and MTA, it was indicated that there was no statistically significant difference between the two materials in microleakage level (22),(23),(24). However, in a study, it was reported that biodentine provided better results compared to MTA, although the results were not statistically significant in repairing furcation perforations (25). On the other hand, some studies suggested that MTA was superior to biodentine in prevention against microleakage when used to repair perforations (26),(27). The results of the present study suggested that there was no significant difference in microleakage levels between MTA and biodentine used to cover the perforation areas within the neutral pH range.

The environment where the material is applied may change marginal adaptation to dentine, microleakage, and the microstructure and surface morphology of the material (28). Changes in the pH of the relevant tissues due to a pre-existing inflammation during the implementation may affect the physical and chemical properties of these materials (29). The surface of the unset repair material applied to the area to repair furcation perforations may be exposed to a lower pH (30). Torabinejad M and Chivian N, stated that MTA could remain unset when applied to a highly inflamed perforation area and that the inflammation area surrounding a tooth may have an acidic pH level of as low as 5.5-5.6 (31). Moreover, Nilforoushan MR and Sharp JH, reported that lithium salts in the environment, including sodium chloride, had a significant effect on the chemical reactions of calcium silicate-based materials (32). Therefore, it can be assumed that environmental factors such as acidic pH or the types of ion in the environment may affect the setting reactions of MTA. It was also reported that the surface hardness of MTA deteriorated in an acidic environment (33). Elnaghy AM observed that a significant change occurred in the microstructure of biodentine and MTA exposed to different pH levels and stated that the surface microhardness, compressive strength, and the binding affinity of the repair material and dentine changed. As suggested by the results of the study by Elnaghy AM, MTA may be more sensitive than biodentine to environments with acidic pH (34). The results of the studies in which the changes in the physical and chemical properties of the materials exposed to different pH levels were reported showed that biodentine seemed a more suitable option in an acidic environment compared to MTA (33),(35). However, there are still limited data in the literature regarding the effect of low pH on biodentine. In the present study, repair materials with changing physical and chemical properties in the acid environment were evaluated about microleakage in light of this information. The results of the present study were similar to other studies in the literature, and biodentine had a better sealing property in environments with low pH levels than MTA (33),(35).

After the study groups were exposed for three days to environments with pHs of 4.4, 5.4, 6.4, and 7.4, Saghiri MA et al., filled retrograde cavities with MTA and evaluated microleakage using bovine serum albumin. The highest microleakage level was observed at pH 4.4, followed by pH 5.4, 6.4, and 7.4, respectively. They stated that a significantly longer period of time was required for leakage to occur in the samples stored at higher pH levels (36). In the present study, MTA coming into contact with pH 7.4 PBS solution mimicking the neutral environment showed more sealing ability than MTA samples coming into contact with pH 4.5 AA solution. Our study results were similar to the results of the study by Saghiri MA et al., Roy CO et al., who compared the sealing ability of retrograde filling materials, and reported that the contact of MTA with an acid environment did not affect its sealing ability and that when the Calcium Phosphate Cement (CPC) matrix was used, the sealing property of MTA in the acidic environment increased (36),(37). The use of a CPC matrix, acid with a different type and not buffered, and the short exposure time (24 hours) of MTA to acidic solutions may be the reason for the inconsistency with the results of our study.

In a study comparing the solubility of MTA and biodentine materials in environments with different pH levels, Pushpa S et al., reported that acidic pH (pH 4.4) increased the solubility of both materials. They directly correlated the sealing potential and dimensional changes of an endodontic repair material with its solubility that might leave gaps supporting bacterial colonisation and its penetration into periapical tissues (38). Accordingly, we can suggest that acidic pH negatively affects the sealing properties of MTA and biodentine. The results of our study were in line with this inference.

Agrafioti A et al., evaluated the sealing ability and morphological microstructure of biodentine compared to MTA in dentine discs after storage in an acidic environment. In the 3rd month measurements, there was statistically significantly superior sealing property with MTA kept in PBS solution than biodentine that was kept under the same conditions. However, when the materials were stored in an acidic environment, no statistically significant difference was observed in the 3rd month measurements. Moreover, they reported that the exposure of biodentine to an acid environment increased its sealing ability over time (39). In the present study, the long-term storage condition was determined to be 34 days, and it was observed that coming into contact with the acid environment during this period negatively affected the sealing property of both materials. There was no significant difference between the sealing properties of the two materials kept for a long time in both environments. The differences between studies may result from different types of acid used and different levels of pH, the fact that the prepared solutions were not buffered, varying periods of contact with the solutions, and different techniques used for microleakage examination. Studies evaluating the microleakage of biodentine and MTA have been compared in (Table/Fig 5).

Elnaghy AM, examined the microstructure of MTA in environments with different pH levels using a scanning electron microscope, and in the images obtained, they showed that the microstructure changed towards acidic pH levels and a shift from amorphous weakly crystalline superficial gel structure containing spherical particles and microchannels to pores with laminated cross-stratified structures occurred (34). Moreover, in another study, they found compatible results of the compressive strength of biodentine and MTA following exposure to different pH levels with the findings of microhardness values (40). The compressive strength of the tested materials decreased significantly following exposure to low pH levels, and biodentine, as in micro-hardness, had higher compressive strength and showed more resistance to acidic environment compared to MTA. It is suggested that the development of a hybrid layer on dentine interface space using calcium silicate based materials in an acidic environment may be impaired (33). The results of our present study suggested that the low sealing property of the repair materials kept in an acidic environment compared to the neutral environment may result from defects in the development of this hybrid layer caused by the acidic environment. It may be proposed that the sealing properties of the materials change together with the changes in the microstructure.


The main limitation of the study was that the microleakage was examined with a stereomicroscope. This method, which allows for two dimensional inspection, may interfere with the exact calculation of the microleakage volume.


Both long-term and short-term contact of MTA with PBS showed better sealing properties compared to that with AA. In biodentine, on the other hand, there was no difference when came into contact with short-term storage environments. The molars coming into contact with PBS during the long-term presented better sealing properties. Low pH levels adversely affected the sealing properties of both materials; however, in the presence of inflammation, biodentine may be preferred to repair an area of perforation as it provides better results in terms of microleakage. The current study evaluates the microleakage volume in two dimensions and we think that the use of micro CT for future research can prevent this limitation in volume evaluations.


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DOI and Others


Date of Submission: Jan 26, 2021
Date of Peer Review: Mar 31, 2021
Date of Acceptance: Jun 18, 2021
Date of Publishing: Jul 01, 2021

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Jan 30, 2021
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