INTRODUCTION

Root perforation is any condition be it pathologic or accidental exposure that leads to direct communication between pulp cavity and periodontal tissues as a result of reabsorption, iatrogenic, or dental caries [1, 2]. Root perforation is believed to be one of the most unprecedented accidents that happen during endocrine treatment subsequently several prominent clinicians and endodontic subspecialties see this condition as challenging. Mangala and Pawar (2020, P.658) note that having a very pleasing and tasteful condition requires one to maintain functional and characteristic Dentition [3]. However, on the course of endodontic treatment, many unprecedented situations can happen such as punching of the root water divider. Wavdhane et al. (2020, P.4) acknowledge how difficult is the repair of perforation by a dentist [4].

As Mangala and Pawar (2020, P.658) highlight, endodontic treatment’s main objective is to make sure that all microorganisms present within the root cavity/canal are cleaned and also the root trench framework is sealed viably [3]. However, endodontic punctures cause the epithelium to be multiplied, damage the periodontal accessibility, bone problems, and bacterial invasion, which can subsequently lead to an inevitable loss of teeth. Furcation punctures are believed to be the major iatrogenic challenges capable of triggering endodontic diseases [3]. Root canal treatment (RCT) is a procedure that encompasses many steps even more dependable and yet one of the most problematic procedures. It is imperative to assess root canal systems and also the presence of confluence apices, estimate distance towards root end, and check for symmetry between bilateral teeth. Therefore, it is important to fix these punctures with the most appropriate materials to achieve successful treatment.

Several materials have been introduced to treat problems related to the root aperture but despite the effort, none of the materials was shown to restore punctured furcations appropriately. The materials were namely; Glass Ionomer concrete, Zinc Phosphate concrete, Light Cure Glass Ionomer, Amalgam, Indium Foil, Cavit, and Calcium hydroxide, among others [3]. The challenges faced by these materials are they do not seal the correspondence hidden tissues and the root hole. Therefore, advanced materials were needed to break the current gap that exists when it comes to puncturing, including Mineral Trioxide Aggregate (MTA), Glass Ionomer Cement (GIC), and Biodentine. Alghamdi and Aljahdali (2019, P.471) and Alazrag et al. (2020) emphasize that the ideal perforation repair material should be characterized by biocompatibility, radiopaque, proper sealing, not absorbable, and allow for easy manipulation [1, 5]. The purpose of this systematic review is to establish the efficacy and clinal properties of MTA, Biodentine, and GIC in repairing root perforations.

MATERIALS AND METHODS

This systematic review utilized the Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The focused question is: which material is the most effective in repairing root perforations between MTA, Biodentine, and GIC?

Search Strategy

The search was performed to find quality articles that can be used to provide quality information about the repairing of root perforations. The information was searched in different databases such as Google Scholar, ProQuest, and PubMed. Various keywords were used during the search. They include “root perforation,” “biodentine,” repair material,” “Glass Ionomer Cement,” and “Mineral Trioxide Aggregate.”

Inclusion Criteria

The inclusion criteria entailed various conditions that the selected articles were supposed to meet. First, all studies included were in the English language, with a timeframe of between 2019 and 2021. Second, studies that were carried out on animals and human beings were considered for review. Third, before any article could be selected, it must address either biodentine, Glass Ionomer Cement, or Mineral Trioxide Aggregate, or all of them. Finally, only full-text articles were eligible to be considered for review.

Exclusion Criteria

The first exclusion criteria entailed articles that focused on other repair materials without mentioning biodentine, Glass Ionomer Cement, or Mineral Trioxide Aggregate. The second element of exclusion is studies that concentrated on the different clinical applications of repair materials without a clear focus on root perforation. The strategy was to ensure that the selected articles are relevant and provide the needed information to establish facts related to MTA, GIC, and biodentine. Finally, other articles that were not considered include commentary articles, surveillance reports, and perspectives.

All studies selected were evaluated to determine whether they meet the inclusion criteria. Some articles were assessed by reading the abstract and establishing where the summary provided captures the keywords of the topic. Other articles were investigated in-depth since their topics were not descriptive enough to reveal all the details discussed in those materials. Furthermore, the references used in the studies were examined to establish whether they are from reputable databases and written by acknowledged professionals. Most importantly, all articles selected for review were peer-reviewed. This move was meant to guarantee that only reputable and reliable data can be used to accomplish the objectives of this systematic review. The relevance of each article was examined and studies that satisfied the set criteria for inclusion were scheduled for review. After screening, a total of 20 articles were picked from a pool of 150 studies. The PRISMA flowchart in Figure 1 below displays the eligibility criteria for the exclusion and inclusion of articles based on relevance.

Bias Risk Assessment

A bias risk assessment was conducted on all the selected articles utilizing the Cochrane risk of a bias assessment tool. This form of bias assessment is based on five domains that include reporting, attrition, performance, selection, and other bias. Therefore, the assessment of bias is done as a verdict of high, low, or unclear. Table 1 below shows the Cochrane risk of bias assessment. Table 2 shows the overall risk of bias judgment.

RESULTS AND DISCUSSION

The exploration conducted resulted in twenty studies that met the inclusion and exclusion criteria. In total, 150 articles matched the search approach based on the picked keywords. However, after the removal of duplicate records 100 articles were selected for screening, out of which 60 studies were excluded. At this point, 40 articles were eligible for assessment since they were full articles. Out of the 40 studies, 5 qualified to be included in the qualitative synthesis.  Specifically, these studies focused on MTA, GIC, and biodentine, and how they are used in root perforation. The studies collected articles include In-vivo studies, In-vitro studies, retrospective clinical studies, and randomized controlled trials (RTC). The majority of the articles addressed more than one element of interest. For instance, some articles compare biodentine and GIC, others compared MTA and GIC, while others compared biodentine and MTA. Other studies addressed either MTA, GIC, or biodentine, while other articles compared either GIC, MTA, or biodentine with other materials used for root perforation. Table 3 below shows a summary of the studies (Table 3).