Oscillatory pattern of sonically powered endodontic files

Expert consensus on irrigation and intracanal medication in root canal therapy

Chemical cleaning and disinfection are crucial steps for eliminating infection in root canal treatment. However, irrigant selection or irrigation procedures are far from clear. The vapor lock effect in the apical region has yet to be solved, impeding irrigation efficacy and resulting in residual infections and compromised treatment outcomes. Additionally, ambiguous clinical indications for root canal medication and non-standardized dressing protocols must be clarified. Inappropriate intracanal medication may present side effects and jeopardize the therapeutic outcomes. Indeed, clinicians have been aware of these concerns for years. Based on the current evidence of studies, this article reviews the properties of various irrigants and intracanal medicaments and elucidates their effectiveness and interactions. The evolution of different kinetic irrigation methods, their effects, limitations, the paradigm shift, current indications, and effective operational procedures regarding intracanal medication are also discussed. This expert consensus aims to establish the clinical operation guidelines for root canal irrigation and a position statement on intracanal medication, thus facilitating a better understanding of infection control, standardizing clinical practice, and ultimately improving the success of endodontic therapy.

Is XP-endo Finisher a better treatment option for its efficacy against intracanal bacteria for post-treatment apical periodontitis cases than EndoActivator?

To investigate the efficacy of the supplementary use of a rotary agitation method [XP-endo Finisher (XPF)] and sonically-activated irrigation [EndoActivator (EA)], using droplet digital PCR (ddPCR) on reducing the bacterial load in previously root canal treated teeth with apical periodontitis. Twenty patients with post-treatment apical periodontitis were allocated into two groups according to the irrigation activation method used: XPF and EA group. Total bacterial loads, as well as the amount of Enterococcus faecalis (E. faecalis) were determined before (S1) and after (S2) chemomechanical preparation, and after final irrigation activation (S3) by means of ddPCR. The bacterial copy numbers were compared between groups using the Friedman test (Nonparametric Repeated Measures ANOVA). When the groups were examined in terms of gender, age, number of root canals, periapical index score, sterility control total bacteria (SCTB), S1- and S2-total bacteria copy number, it was found that there was no statistical difference between the XPF group and the EA group (p > 0.05). Subsequent activation (S3) resulted in a significant microbial reduction in both XPF and EA groups, both of which reduced significantly more bacteria than chemomechanical instrumentation (S2) (p < 0.0001). On the contrary, S3-total bacteria copy number of the EA group was lower than the XPF group (p < 0.0147). There was no statistical difference between the XPF group and the EA group in terms of E. faecalis copy number (p > 0.05). Although both the XPF and the EA optimised the antibacterial efficiency of chemomechanical preparation in previously root canal-treated teeth with apical periodontitis, a lower total bacterial copy number was achieved with the EA application than the XPF application.

Advances in the Role of Sodium Hypochlorite Irrigant in Chemical Preparation of Root Canal Treatment

Irrigation of root canal system is of great significance to the success of endodontic treatment, where sodium hypochlorite (NaOCl) is the most widely used irrigant in chemical preparation. NaOCl functions by eliminating bacterial biofilms and dissolving organic tissue, which may vary according to several factors such as the microbiology of root canal infection and the concentration of the irrigant. It has been proposed that the effectiveness of NaOCl could be enhanced via several methods, including heating the irrigant, applying in conjunction with certain reagents, or activating by agitation techniques. Despite its antibacterial and tissue-dissolving capacities, NaOCl should be used with caution to avoid detrimental effect due to its cytotoxicity and negative effect on dentin properties. In this narrative review, we discussed the factors that affect the properties of NaOCl, the methods to improve its efficacy, and the side effects that might occur in clinical practice.

A simple predictable triple protocol for the management of double-curved canals (Case report of three cases)

Double-curved canals, despite their rarity, pose a great challenge to complete endodontic treatment, and the difficulty lies in negotiating these canals and reaching their apex, whereas the greatest difficulty lies in their shaping, disinfection, and obturation. Conventional methods require excessive preflaring to the level of the first curvature to facilitate access and handling of the second one. Modern technologies facilitate dealing with these cases without compromising the dental tissues, metal alloys have become more flexible, and activation techniques have made it possible to deliver irrigants deeper. The triad of minimum shaping with tactile-controlled activation technique, hybrid irrigation, and sealing with bioceramics constitute an integrated and effective method to deal with these cases, and this protocol was used in the following three cases.

In vitro evaluation of efficacy of two endodontic sonic-powered irrigant agitation systems in killing single-species intracanal biofilms

OBJECTIVE

To evaluate the efficacy of two sonic-powered irrigation systems, EDDY and EndoActivator, in killing intracanal biofilms.

METHODS

Eighty-three instrumented, autoclaved single-rooted human premolars were inoculated with Enterococcus faecalis (ATCC-29212) for 21 days to generate mature, single-species biofilms. The teeth were devided into four groups: irrigation with saline (N = 11); irrigation with 2% NaOCl without agitation (N = 24); irrigation with 2% NaOCl with agitation by the EndoActivaor (N = 24); irrigation with 2% NaOCl with agitation by the EDDY (N = 24). Colony-forming unit (CFU) counts and XTT assay were used to evaluate bacterial load. Additional teeth were split into root-halves for fluorescence staining to examine the percentages of live/dead bacteria in the dentinal tubules present in different canal locations (coronal, mid-root and apical portions).

RESULTS

Agitation of 2% NaOCl by EDDY or EndoActivator reduced bacteria load more proficiently than the use of 2%NaOCl without agitation (p < 0.05). No significant difference was detected between the two sonic-powered irrigant agitation systems (p > 0.05). Confocal laser scanning microscopy indicated that both devices had better intratubular bacteria killing efficacy than the use of 2% NaOCl only in all parts of the canal space (p < 0.05), with no significant difference detected between EDDY and EndoActivator (p > 0.05). Elimination of intracanal and intratubular bacteria were less efficient in the apical portion of the canal space for all experimental groups.

CONCLUSION

The two sonic-powered irrigant activation systems demonstrated comparable intracanal bacteria reduction efficacy when 2% NaOCl was used for disinfecting E. faecalis biofilms in single-rooted teeth.

CLINICAL SIGNIFICANCE

With the use of 2% NaOCl as irrigant, the EDDY and EndoActivator sonic-powered irrigant agitation systems have improved and equivalent intracanal bacteria reduction efficacy but are incapable of completely killing all bacteria that resided within the dentinal tubules of root canals.

Evaluation of two shaping systems and two sonic irrigation devices in removing root canal filling material from distal roots of mandibular molars assessed by micro CT

AIM

To compare two preparation systems and two sonic irrigation devices during the removal of root filling material from oval distal canals of extracted mandibular molars.

METHODOLOGY

The distal canals in 40 extracted mandibular molars were shaped using the ProTaper Next system (Dentslpy Sirona, Ballaigues, Switzerland), filled with Gutta Percha X2 (Dentsply Sirona), along with AH Plus sealer (Dentsply De Trey, Konstanz, Germany) and randomly divided into two groups (n = 20) according to volume of initial filling, preparation diameter and working length. One group was retreated using the Reciproc system (VDW, Munich, Germany), and the other using the 2Shape system (Micro-Mega, Besançon, France). A micro-CT scan was taken after the initial root filling and after retreatment to evaluate the volume of filling material remnants. The teeth were divided into four groups to test the supplementary effect of two sonic irrigation devices on removing filling material: Eddy (VDW) and MM1500 (Micro-Mega). In the first and second groups, 2Shape was followed subsequently by MM1500 and Eddy; in the third and fourth groups, Reciproc was followed by MM1500 and Eddy. A third micro-CT was taken to compare the remaining root filling material in all groups. Wilcoxon's signed rank tests, Mann-Whitney and Kruskal-Wallis tests were used for statistical analysis.

RESULTS

No significant difference was found for the volume of filling material removed between the Reciproc and 2Shape in the entire canal (P = 0.355). The volume dropped significantly from its initial value after removing the bulk of the root filling by 95.8% (from 4.71 to 0.22 mm³ ) with the 2Shape (P < 0.001) and by 94.0% (from 5.05 to 0.33 mm³ ) with the Reciproc (P < 0.001). Sonic activation significantly decreased the residual volume of filling material remnants by 3.21% (P = 0.013) in the first group, 1.38% (P = 0.012) in the second group, 1.83% (P = 0.008) in the third group and 1.83% (P = 0.012) in the fourth group. At the end, the percentage of residual material was not significantly different among the groups in the entire canal (P = 0.163).

CONCLUSION

In the distal oval canals of extracted mandibular molar teeth, there was no significant difference between the 2Shape and Reciproc systems in removing gutta-percha/sealer. Sonic activation with MM1500 and Eddy significantly improved filling material removal.

Antibacterial efficacy of an endodontic sonic-powered irrigation system: An in vitro study

OBJECTIVE

To evaluate the efficacy of EDDY, a new sonic-powered irrigation system, in reducing intracanal bacteria load.

METHODS

Thirty-eight instrumented, autoclaved single-rooted human premolars were inoculated with Enterococcus faecalis (ATCC-29212) for 21 days. Two teeth were used as negative control without bacterial contamination. For the bacteria-inoculated teeth, 6 were used as positive control without irrigation. The remaining 30 teeth were randomly divided into 2 groups (N = 15), using 3% NaOCl as irrigant: (A) 30-gauge syringe needle irrigation (SNI), (B) EDDY (VDW, Munich, Germany). Twelve teeth per group and 4 teeth in the positive control were evaluated for bacterial reduction using MTT assay. The remaining teeth were split for BacLight LIVE/DEAD staining to examine the percentages of live/dead bacteria present in the dentinal tubules from different canal locations (coronal, mid-root and apical portions of the canal space) using confocal laser scanning microscopy (CLSM).

RESULTS

MTT assay indicated that both SNI and EDDY significantly reduced overall intracanal bacterial load compared with the positive control, with no significant difference between the two techniques. CLSM indicated that EDDY had better intratubular bacterial killing efficacy than SNI in the coronal and mid-root portions of the canal space only but not in the apical portion. In all canal locations (coronal, mid-root apical), both systems failed to eliminate bacteria that proliferated deep within the dentinal tubules.

CONCLUSION

With the use of 3% NaOCl, sonic-powered irrigant activation with EDDY tips did not provide additional advantage over SNI in killing Enterococcus faecalis from deep intraradicular dentin.

CLINICAL SIGNIFICANCE

Both the sonic-powered root canal irrigant activation system and syringe needle irrigation can reduce intracanal bacteria load but are incapable of completely killing all bacteria that resided deep within the dentinal tubules of root canals infected with Enterococcus faecalis.

Pressure alteration techniques in endodontics- a review of literature

The triad of biomechanical preparation, pulp space sterilization and three-dimensional obturation is the hallmark of endodontic success. Complete disinfection of the pulp space cannot be achieved with most sophisticated instrumentation techniques. The role of irrigants in obtaining this goal cannot be underestimated. Optimal irrigation is based on the combined use of two or several irrigating solutions, in a specific sequence. Today's irrigation armamentarium presents a diverse variety of tools and techniques that can assist the practitioner in reducing bacteria and debris within the canal system. However, currently there is no universally accepted standard irrigation technique. The aim of this article is to review armamentarium and various irrigants in endodontic practice.

A comparative scanning electron microscopic investigation of the efficacy of manual and automated instrumentation of root canals

The cleaning effectiveness of automated and manual root canal instrumentation was investigated with the aid of a scanning electron microscope. Hand instrumentation was performed with K-Flexofiles used in a reaming working motion and according to the step-back technique and with Hedstrom files used in a filing motion. Automated preparation was performed with the KaVo-Endo Flash device featuring torque-limited rotation using K-Flexofiles, as well as with the mechanical ProFile system using rotary nickel-titanium instruments. Twelve teeth each with either straight or curved root canals were instrumented to size 40. After cracking the roots longitudinally (n = 120), the amount of debris and smear layer were quantified on the basis of a numerical evaluation scale (1 through 5). Comparison of manual instrumentation with the automated KaVo-Endo Flash resulted in an equivalent degree of canal cleaning. Complete cleanliness was not achieved by any of the techniques and devices investigated. Best instrumentation results, especially in curved canals, were obtained with rotary ProFile instruments.

Effect of air inlet ring opening on sonic handpiece performance

This study investigated the effect of air inlet ring opening on the oscillatory pattern of the MM 1500 sonic handpiece and files. The oscillatory pattern of the driver head and files in air and under load was determined microscopically. The results showed that a critical opening of the air inlet ring was necessary to elicit oscillation of the driver head and sonic file. The driver oscillated in an elliptical manner, the displacement of which varied with air inlet ring opening. When operated in air the file exhibited an elliptical movement which was influenced by different design, length and thickness. This action was constrained under load and replaced by a longitudinal action of the same dimension for all files which appeared to have an efficient cutting action. This work shows that air inlet ring opening increases oscillation of the driver head once a critical opening has been reached and that clinical loading does not constrain the cutting action of the file.

Cleaning of oval canals using ultrasonic or sonic instrumentation

This study investigated the effect of direction of file oscillation on the amount of debris and smear remaining within oval canals. Sixty-five lower premolars were allocated to six experimental groups (n = 10) and one control group (n = 5). Canals were prepared using Gates Glidden burs and hand instruments. Preparations were completed using either an ultrasonic size 15 K file or a sonic size 15 shaper file. Three preparation techniques were used: (a) file oscillation toward oval recesses within the canal, (b) file oscillation at right angles to the recesses, and (c) rotational movement of handpiece. Canals were examined under the scanning electron microscope and blindly scored for debris and smear layer. Log linear analysis revealed no significant difference (p > 0.05) between sonic or ultrasonic instrumentation as to debris or smear layer remaining. File oscillation directed toward oval recesses left the least amount of debris (p < 0.05). Smear layer remained unaffected by all techniques.

Variations in stroke rate and loading using hand sonic or ultrasonic instrumentation

An in vitro model system was developed to investigate the stroke rate and loading during hand, sonic, or ultrasonic instrumentation. The model system consisted of a mandibular molar tooth attached to a strain gauge and interface to a computer. Ten clinicians instrumented the distal canal of lower molar teeth. Stroke rates used and loads applied were measured using different sized files with the three different preparation techniques. There was no significant difference in stroke rates between different file sizes (p > 0.05) within the same generator, however, stroke rate for hand was significantly slower than for sonic or ultrasonic (p < 0.01). Loading of the canal wall rose with increase in file size which was significant for hand (p < 0.01) and sonic (p < 0.05) but not ultrasonic (p > 0.05). There was a tendency for loading to be higher with hand instrumentation, this however was not significant (p > 0.05).

Ultrasound in dentistry. Part 2--Periodontology and endodontics

Ultrasound in the kHz frequency range is used widely in clinical dentistry. The most common uses are in the fields of periodontology and endodontics. The ultrasonic scaler works by the vibratory chipping action of the oscillating tip and is assisted by the presence of cavitational activity in the associated cooling water. When assessing clinical studies it is often difficult to interpret results from different workers due to the lack of standardization of the ultrasonic scaler. Operators should be aware of the oscillatory pattern of different instruments. Endosonics utilizes an ultrasonically oscillating endodontic file to clean and shape the root canal prior to obturation. The cleaning ability of such files is assisted by the occurrence of acoustic microstreaming forces. The endosonic file is prone to constraint when it contacts the canal wall which alters its oscillatory pattern. Clinical techniques should be modified to reduce this problem.

Streaming patterns produced around endosonic files

Acoustic microstreaming is known to be an important phenomenon associated with the use of clinically available endosonic systems. However, it has proved difficult to calibrate its pattern and effectiveness around the oscillating file. An in-vitro model system consisting of slow setting plaster was developed to demonstrate the activity of streaming around both ultrasonically and sonically activated files. For ultrasonic files, streaming occurred mainly in front of and behind the file, in contrast to the sonic file, where the plaster was disturbed evenly around it. With both types of file most activity occurred around the file tip, and became reduced towards the driver. Streaming patterns associated with the ultrasonic device were found to be dependent on the power setting of the instrument and whether the side of the file was constrained or lightly touched. The sonic device produced a large disturbance around the freely oscillating tip. Under load this streaming occurred along the whole length of the file, and was unaffected by constraint. This investigation demonstrated that streaming does occur with the instruments currently available, although it is dependent on their operating conditions. Clinical users of such equipment should be aware of the characteristic three-dimensional patterns of streaming that occur around these endosonic files, in order to maximize their efficiency.

Canal markings produced by endosonic instruments

It has been recognised that ultrasonic files leave a diagonal pattern within the canal following endosonic instrumentation. There is confusion on the causative factor on the production of these marks. Furthermore there is little information about the marks produced by sonic files. An in vitro system consisting of highly polished dentin discs demonstrated that the ultrasonic K-file made a diagonal pattern that was an imprint of the cutting edges of the file. The sonic files produced different markings which were the result of their longitudinal and transverse motion. Root canals of extracted teeth were prepared with these instruments and similar grooves were observed. The ultrasonic K-file had diagonal grooves in the coronal and middle third of the root canal but longitudinal marks in the apical third. The rispisonic and shaper files produced debris even in the presence of NaOCl. This debris was formed into discrete parallel bands. Both longitudinal and transverse grooves were present and the canal had many other scratches similar to those seen with the dentin discs. There were differences between the marks produced by either ultrasonic or sonic endosonic instruments but it is unknown whether this influences the long term prognosis of the root canal therapy.

In vitro comparison of the cytotoxicity of twelve endodontic materials using a new technique

An in vitro method for the cytotoxicity testing of endodontic materials is described which aims to simulate the clinical situation. Materials can be tested in the presence or absence of a compacted layer of dentine chips mimicking the periapical dentine plug. A total of twelve materials were tested. In the absence of dentine, Kloroperka, Biocalex, Diaket and Endomethasone were slightly cytotoxic; AH26 with and without silver, Sealapex, Tubliseal and Kerr's pulp canal sealer were moderately cytotoxic, while Forfenan, Spad and Kri paste were strongly cytotoxic. In the presence of dentine the cytotoxicity of these materials was considerably reduced, with the exception of Endomethasone, Forfenan, Spad and Kri paste. The method provides a satisfactory alternative to implantation testing and is an inexpensive and reproducible test system in which dentine can be incorporated.