Print version ISSN 1678-7757
J. Appl. Oral Sci. vol.19 no.2 Bauru Mar./Apr. 2011
Luciana Malheiro de BritoI; Cláudia de Moura CarreiraII; Denise Pontes RaldiIII; José Luiz Lage-MarquesIV; Sandra Márcia HabitanteIII; Wilson Abraão SaadIII
IDDS, MSc of Endodontics, Postgraduate Program in Dentistry, Department of Dentistry, University of Taubaté, Taubaté, SP, Brazil
IIDDS, MSc, PhD of Endodontics, Postgraduate Program in Dentistry, University of São Paulo, São Paulo, SP, Brazil
IIIDDS, MSc, PhD, Professor of Postgraduate Program in Dentistry, Department of Dentistry, University of Taubaté, Taubaté, SP, Brazil
IVDDS, MSc, PhD, Associated Professor of Endodontics, Department of Dentistry, University of São Paulo, São Paulo, SP, Brazil; Endodontics Coordinator of the Postgraduate Program in Dentistry, Department of Dentistry, University of Taubaté, Taubaté, SP, Brazil
Nitric oxide (NO) has been considered a key molecule in infammation.
OBJECTIVE: The aim of this study was to evaluate the effect of treatment with L-NAME and sodium nitroprussiate, substances that inhibit and release NO, respectively, on tissue tolerance to endodontic irrigants.
MATERIAL AND METHODS: The vital dye exudation method was used in a rat subcutaneous tissue model. Injections of 2% Evans blue were administered intravenously into the dorsal penial vein of 14 male rats (200-300 g). The NO inhibitor and donor substances were injected into the subcutaneous tissue in the dorsal region, forming two groups of animals: G1 was inoculated with L-NAME and G2 with sodium nitroprussiate. Both groups received injections of the test endodontic irrigants: acetic acid, 15% citric acid, 17% EDTA-T and saline (control). After 30 min, analysis of the extravasated dye was performed by light absorption spectrophotometry (620 nm).
RESULTS: There was statistically signifcant difference (p<0.05) between groups 1 and 2 for all irrigants. L-NAME produced a less intense infammatory reaction and nitroprussiate intensifed this process.
CONCLUSIONS: Independently of the administration of NO inhibitors and donors, EDTA-T produced the highest irritating potential in vital tissue among the tested irrigating solutions.
Key words: Nitric oxide. Infammation. Root canal irrigants.
Chemical substances should act without being aggressive to the pulp and periapical tissues. Considering that the chemical substances used during chemomechanical preparation of root canals can extrude to the periapical region, and that the chemical agents used are tissue irritatings, it is important to know the consequences of their contact with vital tissues, in order to minimize postoperative complications. All substances that come into contact with vital tissues require previous biocompatibility tests.
When a tissue is damaged, a normal protective response is set off: inflammation. The inflammatory response starts by the release of chemical mediators, produced by the cells of the affected tissue, which promote vasodilation and increase theblood flow, resulting in an accumulation of liquid and blood cells. The vasodilation phenomenon occurs as a result of the action of a substance produced in the endothelium, denominated endothelium derived relaxation factor (EDRF)4. Palmer, Ferrige and Moncada15 (1987) and Ignarro, et al.8 (1987) suggested that this factor was nitric oxide (NO) because of the similarities in their physicochemical characteristics.
In 1992, the scientifc journal Science11 recognized the importance of this substance in various areas of Medicine, and named it the "Molecule of the Year". Since then, a increased number of studies on NO and its metabolites have progressively allowed an understanding of some of its main biological functions: participation in the immunological system, neurotransmission and vasodilation5,13. Furthermore, a variety of cardiovascular and cerebral problems and infammatory and infectious diseases may be related to a high or low NO level in the organism6.
NO is synthesized by the enzyme nitric oxide synthase (NOS), which is present in a variety of different cell types, or is induced by an external mechanism, such as immunological and infammatory stimuli5. Dental pulp presents the potential to produce NO, since NOS is present in endothelial cells, odontoblasts, nerve tissues, white blood cells and vascular smooth muscles10. Analyzing NOS production, NO has been found to be synthesized in root cysts26 and infamed periapical tissues3,18, playing a decisive role in the regulation of chronic, periapical infection25.
After obtaining good results with inhibitory substances on cells removed from periapical cysts, Takeichi, et al.24 (1999) suggested the use of NO inhibitors in the root canal as a pharmacological treatment for periapical lesions.
There are several studies correlating NO with endodontic sealers or periapical lesions3,18,20,24, but only one relating it to chemical irrigant substances16. Laboratory determination of NO is complex, and characterization of its specific activators and inhibitors constitutes a new challenge to the understanding and treatment of various diseases.
The solutions commonly used in the final irrigation of endodontic therapy are citric acid and EDTA12,21, and more recent research has also suggested acetic acid22. The use of these irrigants has been extensively studied12,21,23. It would be interesting to accelerate the healing process, in order to obtain a better control of the infammatory process, and to provide more comfort to the patient. Thus, the aim of this study was to evaluate the effects of the treatment with L-NAME and sodium nitroprussiate, substances that block and release NO, respectively, in connective tissue infammation caused by acetic acid, citric acid, EDTA-T irrigants.
MATERIAL AND METHODS
This study was approved by the Ethics Committee of the Dental School of the University of Taubaté, Brazil (protocol 07/ 2005).
The following endodontic irrigants, prepared at Formula & A<ao pharmacy (Sao Paulo, SP, Brazil), were evaluated:
-17% EDTA-T (ethylenediaminetetraacetic acid disodium- tergentol) - The salt EDTA was weighed (17 g), diluted in 100 mL of tergentol and the pH was adjusted to 7.3 with sodium hydroxide solution.
-15% citric acid - The salt (Merck S.A., São Paulo, SP, Brazil) was weighed, diluted in deionized, and the pH was adjusted to 1.0 using pH meter (B371; Micronal, São Paulo, SP, Brazil).
-10% acetic acid - 10 g of 2-hydroxypropane tricarboxylic acid was diluted in (qsp) 100 mL of bidistilled water.
-Saline solution (used as control).
L-NAME (NG-nitro-L-arginine methyl ester) and sodium nitroprussiate were purchased from Tocris Cookson Inc.(St. Louis, MO, USA).
Vital dye exudation technique
The experiment was performed according to the technique proposed by Udaka, et al.27 (1970). Fourteen male Wistar rats (Rattus novergicus, albinus), weighing between 200-300 g, were obtained from the Animal Care Facility of the Araraquara Dental School, São Paulo State University, Brazil. They were kept in cages, in a suitable environment, at the Pharmacological Laboratory of the Medical School of the University of Taubaté, Brazil.
The animals were anesthetized with intraperitoneal administration of Thiopentax® (0.3 mL for every 100 g/rat) in the lateral caudal region. After, 2% Evans vital blue dye (Sigma Chemical Co., St. Louis, MO, USA) was injected intravenously in the dorsal penial vein, at the dose of 20 mg/kg of body weight. A suffcient period was waited to ensure that the dye injection had been successfully administered (around 3 h) observing the blue stain in the irises of the rats. After that, the dorsal region was shaved and the animals were randomly divided into 2 groups (n=7):
Group 1: at four predetermined sites in the dorsal region of the rats, 0.1 mL of L-NAME, a NO inhibitor (30 mg/kg dissolved in 5 mL of saline solution), was injected into the subcutaneous tissue. Afterwards,0.1 mL of each tested solution (EDTA, citric acid, acetic acid and saline) was injected in each point.
Group 2: at four predetermined sites in the subcutaneous tissue, 0.1 mL of sodium nitroprussiate, a NO donor (4 mg/kg dissolved in 40 mL of saline), was injected into the subcutaneous tissue. Afterwards, 0.1 mL of each tested solution (EDTA, citric acid, acetic acid and saline) was injected in each point.
The substances were used in a system of rounds, in such a way that the same animal would receive the three irrigants, in addition to the control solution. Concomitantly with NO inhibitor or donor substances, the irrigants were applied, according to their respective groups.
After 30 min the animals were sacrifced by anesthetic overdose (Thiopentax®- 0.6 mL for every 100 g body weight) and their dorsal skins were excised using an iron ring with an active tip (3 cm in diameter), with a safety margin of 20 mm beyond the bluish colored edema haloes formed by the medication.
The tissue obtained was fragmented, immersed in 10% formalin and kept in water at 37ºC for 72 h for complete extraction of the dye. After 72 h, the resulting solutions were subjected to spectrophotometric analysis (Cary 50 Bio UV Visible Spectrophotomer; Varian Inc., San Francisco, CA, USA) at 620 nm wavelength (maximum absorbance capacity of the Evans blue dye), and calibrated for optical density reading, according to the evaluation criteria of the irritating potential of substances proposed by Nagem-Filho and Pereira14 (1976) (Figure 1).
The obtained data were examined for the adherence to the normality curve and submitted to statistical analysis by the Kruskal-Wallis test for individual comparison at a level of signifcance of 5% (p<0.05).
The data presented in the Table 1 defne the irritating potential of the irrigants (acetic acid, citric acid, EDTA-T and saline) correlating them with the treatment with sodium nitroprussiate and L-NAME, substances that release and inhibit NO, respectively.
Table 1 shows the dye absorbance means and their correlation with the irritating potential of the irrigants used and the standard deviations. Analysis of the solutions by spectrophotometry showed lower light absorbance by the irrigants in the group in which NO inhibitor (L-NAME) was used. There were statistically signifcant differences (p<0.05) among the irrigants in each group when the NO inhibitor and donor substances were compared.
Endodontic intervention produces an infammatory reaction which, depending on the intensity, can interfere in the repair and healing process, and consequently in the control of the infammation21. Over the last few years, a large number of studies have considered NO as a key molecule in infammatory processes. The action of NO can vary, depending on the source and quantity of produced5,13.
In this study, it can be observed that the administration of a NO releasing agent (sodium nitroprussiate) produced an intensifcation of the infammatory process. On the other hand, the application of NO blocking substance (L-NAME), was able to reduce signifcantly the infammatory reaction.
When chemical substances are used during endodontic treatment, it may inadvertently extrude to the periapical region and promote an acute initial infammation. For this reason, it was opted to evaluate the irrigants in vital tissues. Another decisive factor on this regard was the results of Takeichi, et al.24 (1999), who suggested the use of NO inhibitors in the root canal as a pharmacological treatment for periapical lesions. It motivates the evaluation of chemical substances and their correlation with NO, a fact that had not been studied previously.
In order to quantify the irritating potential of a substance inoculated in vivo, the method proposed by Udaka, et al.27 (1970), has frequently been used. This was based on the evaluation of the exudate produced due to the increase in vascular permeability, as a result of the irritating potential of the tested substances, and which were inferred by the spectrophotometric measurements of the extravasated vital dye. Thus, the method is useful not only to quantify the infammatory exudates elicited by phlogistic agents2,19,21, but also to evaluated the effcacy of antiinfammatory drugs7,9. The vital dye exudation technique was conducted as previously described14,21,27.
Nagem-Filho and Pereira14 (1976) established complementary evaluation criteria for the vital dye exudation technique. The absorbance values (A620), which translate the amount of dye exudate proportionally, relative to the irritating potential of the tested substances, were divided into 4 degrees: not signifcant, discrete, moderate and severe. Comparing the table of absorbance values (A620) proposed by Nagem-Filho and Pereira14 (1976) to the values obtained in this study (Table 1), it can be observed that, for both NO inhibitor and donor substances, EDTA-T presented a higher irritating potential in vital tissues than the other irrigants. However, it is important to emphasize that this analysis was performed in the initial stage of infammation.
Some studies1,17,28 have described that the ideal concentration of EDTA ranging from 10% and 17%. Citric acid concentration at 15% was chosen based on a previous study12 that evaluated the demineralizing effect of this solution at 5%, 10%, 15% and 25%.
Although all endodontic irrigants in the sodium nitroprussiate group (G2) presented a higher irritating potential than in the L-NAME group (G1), the acetic acid solution and particularly EDTA-T presented a greater irritating potential. Citric acid and saline showed similar results and were less aggressive than the other two solutions in contact with vital tissues.
EDTA and citric acid have been used in Dentistry for years and have wide clinical applicability. The considerations in the literature about their irritating potential suggest that independently of the solution used, it should be applied in a safe manner, with caution, due to its action on periapical tissues12,21. However, studies related to acetic acid are new, and further studies should be conducted as regards its biocompatibility.
It is well known that the action of NO in immunoregulation is present in infammation and in the autoimmunity mechanisms3,5,13,18. Therefore, further investigations regarding the determination of specifc activators and inhibitors of NO synthesis constitutes a new challenge to the understanding and treatment of various diseases. As there are not so many studies in dentistry showing the role of NO in the infammatory process, further investigations are needed to produce relevant knowledge in this area that can be clinically applicable in Endodontics.
Based on the conditions established by the experiment, it can be concluded that:
1. Sodium nitroprussiate and L-NAME changed the inflammatory reaction produced by tested irrigants.
2. The infammatory reaction was more intense in the group submitted to treatment with sodium nitroprussiate.
3. In the group in which the NO inhibitor (L-NAME) was administered, there was a reduction in the infammatory process.
4. Independently of the administration of NO inhibitor or donor substances, EDTA-T had the highest irritating potential in vital tissue among the tested irrigating solutions.
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Profa Dra Denise Pontes Raldi
Rua Expedicionário Ernesto Pereira, 110
12020-330 - Taubaté - SP - Brasil
Received: June 1, 2009
Modifcation: April 30, 2010
Accepted: May 21, 2010