Biomarkers in Apical Periodontitis

March 26, 2026 updated by: Sevda Durust Baris, Kırıkkale University

Effects of Different Irrigation Activation Techniques on Pro-inflammatory Cytokine and Proteolytic Enzyme Levels in Teeth With Chronic Apical Periodontitis

Aim: To evaluate the effects of three different irrigation activation techniques-conventional syringe irrigation (CSI), ultrasonic irrigation (UI), and SWEEPS (Shock Wave Enhanced Emission Photoacoustic Streaming)-on the levels of proinflammatory cytokines (Tumor Necrosis Factor Alpha (TNF-α), interleukin-1beta (IL-1β)) and proteolytic enzymes matrix metalloproteinase-9 (MMP-9) in teeth with chronic apical periodontitis.

Methodology: Sixty-six male patients (aged 18-35) with single-rooted teeth, previous root canal treatment (at least 4 years ago), and periapical lesions (<1 cm, PAI score 3 or 4) were included. Sample size was determined by G*Power (Power=0.90, α=0.05). Following local anesthesia and rubber dam isolation, endodontic access was performed under a dental operating microscope. After removing old filling material and completing root canal preparation with Reciproc R25/R50 files, patients were randomly assigned into three groups (n=22 each): (1) CSI (30G needle), (2) UI (EMS miniPiezon), and (3) SWEEPS (Er:YAG laser, 2940 nm). Periapical exudate samples were collected using sterile paper points (2 mm beyond the apex for 60s) at the first visit (pre-treatment) and the second visit (one week post-medication with calcium hydroxide). Samples were analyzed via ELISA for TNF-α, IL-1β, and MMP-9 levels.

Statistical Analysis: Data were analyzed using IBM SPSS 20. Percent changes in biomarker levels were evaluated using the Kruskal-Wallis test for inter-group comparisons and the Wilcoxon test for intra-group (pre- vs. post-treatment) comparisons. Linear regression was used to identify effective factors (group, age, gender, tooth type). Significance was set at (p < 0.05).

Keywords: Apical periodontitis, SWEEPS, Ultrasonic activation, Cytokines, MMP-9, Endodontics.

Study Overview

Status

Not yet recruiting

Conditions

Detailed Description

The sample size was calculated using G*Power v3.1 (Heinrich Heine University, Düsseldorf). Based on a significance level of 0.05 and a power of 0.90, it was determined that 18 samples per group were sufficient. Accounting for potential dropouts, a total of 66 patients are planned for inclusion.

Inclusion Criteria:

Male patients aged 18-35.Chronic apical periodontitis in maxillary or mandibular incisors, canines, or single-rooted/single-channeled premolars.History of root canal treatment performed at least 4 years ago.Presence of a periapical lesion (<1 cm) with an Orstavik PAI score of 3 or 4.Ethical compliance will be ensured through informed consent; patients will be briefed on the study, and those willing to participate will sign a voluntary informed consent form. Patient demographics (name, age, gender), contact information, tooth number, and clinical symptoms/findings will be recorded in case report forms (CRF).

Exclusion Criteria:

Patients requiring antibiotic prophylaxis, those with diabetes or hematological diseases, or those who have used antibiotics/anti-inflammatory drugs within the last month. Pregnant patients, teeth with heavy plaque/calculus, gingival redness/bleeding, severe gingivitis, generalized periodontitis, or periodontal pocket depths >3 mm. Teeth with sinus tracts, internal/external resorption, swelling, or pain on palpation will also be excluded. Treatment Protocol Local anesthesia [1.8 mL 4% articaine HCl with 1:100,000 epinephrine (Ultracain DS Forte)] will be administered. Teeth will be isolated using a rubber dam (OpalDam, Ultradent). Asepsis will be maintained using 30% H₂O₂ and 2.5% NaOCl (Werax). Following access cavity preparation, the coronal third of the gutta-percha will be removed using #3 and #4 Gates Glidden drills. All procedures will be performed under high magnification using a dental operating microscope (Carl Zeiss Meditec AG).Working length (WL) will be determined with an electronic apex locator (Morita Root ZX Mini). Canal instrumentation will be completed using Reciproc R25 and R50 files (VDW) at WL. If gutta-percha remnants are radiographically visible, additional preparation will be performed with large-sized hand K-files. Canals will be irrigated with 2 mL of 2.5% NaOCl after each file change using a 30-gauge side-vented needle (NaviTip). Recapitulation will be performed to maintain apical patency.To inactivate NaOCl, 0.5% sodium thiosulfate will be used, followed by 5 mL of saline. The smear layer will be removed with 5 mL of 17% EDTA and a final 5 mL saline rinse. Patients will be randomly assigned to three final irrigation groups (n=22 per group) using an online randomizer (www.randomizer.org). Conventional Syringe Irrigation (CSI): 10 mL of 2.5% NaOCl applied for 1 minute using a 30G needle placed 1 mm short of WL. Ultrasonic Irrigation Activation (UI): 10 mL of 2.5% NaOCl applied using an ultrasonic device (EMS miniPiezon) and a K-file tip (#25) at 50% power with up-and-down motions for 1 minute. SWEEPS (Shock Wave Enhanced Emission Photoacoustic Streaming): Er:YAG laser (LightWalker AT, Fotona) at 2940 nm, 50 μs pulse duration, H14 handpiece, SWEEPS mode (0.3 W, 15 Hz, 20 mJ). A 600 μm fiber tip (PIPS 600/9) will be held stationary in the access cavity while 10 mL of 2.5% NaOCl is activated in four 15-second cycles.Following the first session, calcium hydroxide medication will be applied, and the access cavity will be sealed with sterile Teflon tape and zinc phosphate cement. One week later, at the second session, isolation and asepsis will be repeated, and second periapical exudate (PAE) samples will be collected before completing the root canal treatment and permanent composite resin restoration.

Periapical Sampling Procedure : After final irrigation, canals will be dried with sterile paper points. Sampling will be performed using #20 sterile paper points placed 2 mm beyond the apical foramen for 60 seconds. The apical 4 mm of the paper point will be cut with sterile scissors and placed into a sterile Eppendorf tube. This process will be repeated three times.ELISA Analysis Samples stored at -80°C will be thawed and 300 μL of Dulbecco's Phosphate Buffered Saline (DPBS, pH 7.2) will be added to each tube. Samples will be vortexed at 25 Hz for 1 minute. Tissue homogenization will be performed using an ultrasonic homogenizer (Sonics Vibra-cell) for 1 minute, followed by centrifugation at 5000 rpm for 5 minutes at +4°C. TNF-α, IL-1β, and MMP-9 levels will be measured using ELISA kits at 450 nm absorbance.

Statistical Analysis Data will be analyzed using IBM SPSS Statistics v20. Linear regression analysis will identify factors (treatment group, gender, tooth number, age) influencing the percentage change in biomarkers. If data are not normally distributed, the Wilcoxon test will be used for pre- vs. post-treatment comparisons, and the Kruskal-Wallis test for inter-group comparisons. Age distribution will be analyzed via Kruskal-Wallis, and gender/tooth distribution via the Chi-square test. Significance is set at (p < 0.05).

Study Type

Observational

Enrollment (Estimated)

66

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

  • Name: Sevda DURUST BARIS, Asst. Prof.
  • Phone Number: +905079396652
  • Email: s.baris@kku.edu.tr

Study Contact Backup

Study Locations

  • Turkey (Türkiye)
    • Kırıkkale
      • Kırıkkale, Kırıkkale, Turkey (Türkiye), 71100
        • Kırıkkale University, Faculty of Dentistry
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult

Accepts Healthy Volunteers

Yes

Sampling Method

Non-Probability Sample

Study Population

The study population consists of male patients aged 18-35 years diagnosed with chronic apical periodontitis in single-rooted teeth with a history of prior root canal treatment and periapical lesions (PAI 3 or 4).

Description

Inclusion Criteria:

  • Male patients aged 18-35 years.
  • Presence of chronic apical periodontitis in maxillary or mandibular incisors, canines, or single-rooted/single-channeled premolars.
  • History of root canal treatment performed at least 4 years ago.
  • Presence of a periapical lesion smaller than 1 cm.
  • Periapical Index (PAI) score of 3 or 4 according to Orstavik classification.

Exclusion Criteria:

  • Need for antibiotic prophylaxis
  • Diabetes
  • Hematological disorders
  • Use of antibiotics or anti-inflammatory drugs within the last month.
  • Excessive plaque and tartar
  • Gum redness or bleeding
  • Severe gingivitis
  • Widespread periodontitis
  • Periodontal pocket depths exceeding 3 mm.
  • Presence of sinus fistula (bleeding).
  • Presence of internal or external root resorption.
  • Pain on palpation of teeth
  • Swelling
  • Pregnancy during treatment.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
SWEEPS Group
22 participants. Method: Retreatment using SWEEPS activation. Collection of PAE samples.
US Group
22 participants. Method: Retreatment using US activation. Collection of PAE samples.
CSI Group
22 participants. Method: Retreatment using CSI activation. Collection of PAE samples.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Proinflammatory Cytokine Levels (TNF-α and IL-1β)
Time Frame: Baseline and 7. days
The primary outcome is the reduction in the levels of proinflammatory cytokines TNF-α and IL-1β in periapical exudate samples, measured by Enzyme-Linked Immunosorbent Assay (ELISA). Results will be expressed in pg/mL or concentration units provided by the ELISA kit to evaluate the effectiveness of the three different irrigation activation techniques (CSI, UI, and SWEEPS) in reducing periapical inflammation.
Baseline and 7. days

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Proteolytic Enzyme Levels (MMP-9)
Time Frame: Baseline and 7.days
The secondary outcome is the change in the levels of Matrix Metalloproteinase-9 (MMP-9) in periapical exudate samples, analyzed via ELISA. This measure aims to evaluate the impact of different irrigation protocols on the proteolytic activity associated with tissue destruction in chronic apical periodontitis.
Baseline and 7.days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Kırıkkale University

Investigators

  • Principal Investigator: Sevda DURUST BARIS, Asst. Prof., Kirikkale University Faculty of Dentistry

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

March 30, 2026

Primary Completion (Estimated)

July 27, 2026

Study Completion (Estimated)

September 28, 2026

Study Registration Dates

First Submitted

March 18, 2026

First Submitted That Met QC Criteria

March 26, 2026

First Posted (Actual)

April 1, 2026

Study Record Updates

Last Update Posted (Actual)

April 1, 2026

Last Update Submitted That Met QC Criteria

March 26, 2026

Last Verified

March 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 2025/14-2025.10.17

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

UNDECIDED

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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