Clinical Research

In Vivo Efficacy of Three Different Endodontic Irrigation Systems for Irrigant Delivery to Working Length of Mesial Canals of Mandibular Molars
Hugo Roberto Munoz, DDS, MA, and Karla Camacho-Cuadra, DDS
Introduction: Many in vitro studies have debated over the ability of different irrigant delivery and/or agitation systems to reach the apical third of curved root canals; however, little is known about irrigant penetration in vivo. Therefore, the purpose of this study was to compare the efficacy of the conventional endodontic irrigation needle, passive ultrasonic irrigation (PUI), and a negative pressure system for irrigant delivery to working length (WL) of mesial canals of mandibular molars. Methods: Thirty mesial canals of 30 vital mandibular first or second molars were randomly assigned into 3 groups (n = 10): (1) Monoject syringe with 27-gauge needle; (2) PUI with IrriSafe tip; and (3) EndoVac system. All canals were treated following the same preparation protocol to size 35/0.04 by using 5.25% NaOCl as irrigant during preparation procedure. Before obturation, canals were irrigated with 1 mL of a radiopaque solution by using the assigned irrigation system, and a digital radiograph was taken by using a parallel technique. With the aid of image editing software the distance between WL and maximum irrigant penetration was measured. Results: Mean distances for Monoject, PUI, and EndoVac groups were 1.51 mm, 0.21 mm, and 0.42 mm, respectively. Analysis of variance test showed statistically significant differences between groups (P < .001). Tukey honestly significant difference test showed statistically significant differences between the Monoject group and the other 2 groups (P < .001) but no significant differences between PUI and EndoVac groups (P = .06). Conclusions: PUI and EndoVac are more effective than the conventional endodontic needle in delivering irrigant to WL of root canals. (J Endod 2012;38:445–448)


Key Words
Apical third, conventional endodontic irrigation needle, EndoVac, irrigation systems, passive ultrasonic irrigation, PUI

ne of the goals of conventional endodontic treatment is to remove vital or necrotic pulp tissue and to minimize the amount of irritants that could be present inside the root canal system; therefore, cleaning and disinfection of root canals are essential to achieve endodontic success (1, 2). Endodontic irrigating solutions are used to dissolve pulp tissue and remove dentin debris, smear layer, and bacteria (3, 4). However, complete debridement of the root canal system has become a true clinical challenge, mainly because of morphologic irregularities such as lateral canals, ramifications, and apical deltas (5). In fact, despite the good success rates of endodontic treatment, it is widely accepted that cleaning and shaping procedures do not completely eliminate all bacteria present in the root canal (6). Moreover, additional complications arise during the preparation of narrow curved canals, especially when the curvature angle is higher than 25 (7). Currently, different irrigation techniques and devices are being used to improve the disinfection of root canal system; the conventional endodontic irrigation syringe and needle is the most widely used because it is very easy to manipulate, and there is good control of needle depth and volume of irrigant delivered (8). However, its safety has been questioned because of the positive pressure used to introduce the irrigant into the canal, which could extrude the solution to the periapex, resulting in severe tissue damage and postoperative pain (9, 10). Passive ultrasonic irrigation (PUI) was introduced to increase the effectiveness of canal disinfection by agitating the irrigant solution previously placed inside the canal. An ultrasonic tip is activated in the canal up to working length (WL) and is moved passively in an up-and-down motion to ensure it did not bind with the root canal walls. It has been shown that PUI is significantly more effective at reducing bacterial amount from the root canals when compared with conventional endodontic needle irrigation, although it does not completely eliminate bacteria from the root canals (11–13). EndoVac (Discus Dental, Culver, CA) is a negative pressure irrigation system that has been designed to safely deliver irrigant solutions into the apical portion of the canal. This device consists of a master delivery/suction tip, a macrocannula, and a microcannula that are connected to a vacuum line. When using this system, the irrigant is delivered into the pulp chamber by the master delivery tip and is driven by negative pressure into the root canals with the aid of the macrocannula and microcannula (14, 15). To achieve the goal of endodontic therapy, an effective irrigation technique should be implemented to facilitate the penetration of the irrigant solution to the apical third of the canals without forcing it to the periapical tissues (10, 16, 17). Therefore, the purpose of this study was to compare in vivo the efficacy of the conventional endodontic irrigation syringe and needle, PUI, and a negative pressure system for irrigant delivery to WL of mesial canals of mandibular molars.

From the Postgraduate Endodontic Department, School of Dentistry, Universidad de San Carlos de Guatemala, Guatemala City, Guatemala. Address requests for reprints to Hugo Roberto Munoz, Of. 102, Edificio M4, Ciudad Universitaria, Zona 12, Guatemala City, Guatemala. E-mail address: 0099-2399/$ - see front matter Copyright ª 2012 American Association of Endodontists. doi:10.1016/j.joen.2011.12.007

JOE — Volume 38, Number 4, April 2012

Irrigant Delivery to Working Length


IRR20/25.42 Æ 0.05). canals were irrigated with 1 mL of Iohexol (Omnipaque. Merignac. Tukey honestly significant difference post hoc comparisons were also performed. and (3) negative pressure irrigation system (EndoVac [Discus Dental. a blinded calibrated observer measured the distance between WL and maximum irrigant penetration (Fig.001). irrigant solution was ultrasonically agitated with IrriSafe tip #20/25 (ref. Finally. GE Healthcare. Cork.Clinical Research Materials and Methods This study was conducted following the requirements of the Ethic Committee of the National Institute of Science and Technology regarding research involving human tissues. In addition for PUI group. 446 Munoz and Camacho-Cuadra JOE — Volume 38. Mesial canals selected for the study were randomly assigned into 3 different groups (n = 10): (1) conventional endodontic syringe/needle irrigation (Monoject group). Ireland) contrast medium with the same needle also placed at 2 mm short of WL. Munich. Nakanishi Inc. Mean. Tokyo. All teeth were anesthetized with 1.06) (Table 1). All canals were irrigated with 2 mL of 5. One mesial canal was selected from each tooth. 1). Number 4. All mesial canals were prepared with new Mtwo rotary files (VDW.001). Analysis of variance test was performed to establish statistically significant differences between groups (P < . WI). a digital x-ray image was obtained for each tooth with parallel technique at the same angle and exposition as the WL image to ensure minimum distortion between the 2 images. Germany) to size 35/0. For Monoject and PUI groups. Finally. 3). France) placed inside the canal at WL with an up-and-down motion during 30 seconds.5. Samples for this study were obtained from 30 first and/or second vital mandibular molars with root canal treatment indication. After rubber dam isolation. Statistical Analysis Values are presented as distances in millimeters. No significant difference was observed between the PUI and the EndoVac groups (P = . with 2 separate and completely developed roots. Analysis of variance test showed statistically significant differences between groups (P < . WL was confirmed with a digital x-ray with parallel technique by using a Schick CDR-holder (Schick Technologies Inc. 2). and 2 mL of 5. Morita. and maximum/minimum values are presented for each group.25% NaOCl was delivered into the canal.43 mm. J. Final irrigation protocol for each experimental group. Japan) tip (PUI group). 1 mL of Iohexol contrast medium was delivered during 30 seconds into the pulp chamber with the master delivery tip and suctioned with the microcannula placed at WL. Racine. a Monoject syringe with a 27gauge side-vented needle was placed 2 mm short of WL. without radiographic evidence of periapical pathology and root resorption. Results Longest distances between WL and maximum irrigant penetration were observed in the Monoject group. NY). Japan). Shortest distances were observed in the PUI group with a mean distance of 0. and with a mesial root with at least 25 curvature angle. (2) PUI with an IrriSafe (NSK. Satelec Acteon Group.30 mm.25% NaOCl between each file during the whole preparation procedure that was delivered with a Monoject syringe with a 27-gauge side-vented needle (Vista Dental Products. With the contrast medium inside the canal.21 Æ 0. Schick Technologies Inc). For EndoVac group. With the aid of image editing software (Dicom 4. cavity access was done on each tooth. Written informed consent was obtained from each of the patients participating in the study.25 mm (Fig. followed by the EndoVac group with a mean distance of 0. and WL was determined with #10 K-file and the use of an electronic apex locator (RootZX II. 2 mL of NaOCl was delivered into the pulp chamber with the master delivery tip and suctioned with the macrocannula placed in the cervical and medium thirds of the root canal. Tukey honestly significant post hoc tests showed significant statistical differences between the Monoject group and the 2 other groups (P < . April 2012 . A different final irrigation protocol was performed for each group (Fig. Culver City.04 following manufacturer’s suggested sequence. CA] group). Figure 1. standard deviation. Long Island City.000 epinephrine by inferior alveolar nerve block injection.51 Æ 0. with a mean distance of 1.8 mL 2% prilocaine with 1:100.

this needle size is appropriate for canals prepared up to 35 apical file size to allow the needle to reach the last 2 mm of WL (28. NJ) has been used in some endodontic research because it can be dissolved in water to form a radiopaque solution with similar physical characteristics to sodium hypochlorite. 33). monomeric. and because the root canal behaves as a closed tube system. all mesial canals used in this study were prepared to a standardized 35/0. 28. Number 4. 27).5 mm deeper into the canal (8. Iohexol (Omnipaque) was used as contrast medium. however. and bacteria that are within the root canal system (2. 29). because it has a 0. A conventional endodontic syringe with a 27-gauge Monoject needle was used in this study.32-mm diameter (14.04 caliber with the Mtwo (VDW) rotary system. nontoxic solution. because there are studies that have shown that this needle allows the release of the irrigant solution from 1–1. 25). During ultrasonic irrigant activation. Many studies have demonstrated that ultrasonic irrigant activation is more efficient than conventional needle in removing remnants of pulp tissue and dentin debris from root canals (4. 15). Sodium hypochlorite was used during the whole preparation procedure to allow the hydrolysis of organic tissue present in the pulp chamber and root canal systems. Measurement of distance (mm) from WL to maximum contrast medium penetration (sample from the Monoject group). However.Clinical Research Figure 2. Irrigant Delivery to Working Length 447 . Diatrizoate sodium powder (Hypaque. 30. their use in dentistry has been limited. 19) and might account for the limited irrigant penetration into the apical third with the conventional endodontic needle in this study. According to previous data.25% NaOCl. and water-soluble iodide solution also with similar density and viscosity as 5. 19. It also has been shown that PUI is more effective in reducing bacteria when compared with conventional needle or even with the EndoVac system (13). Princeton. Moreover. Iohexol has the advantage of being a low-osmolality agent (Hypaque osmolality has been reported to be more than twice higher) that it is readily available in a sterile. and in contrast enhancement for brain computed tomography (22. results from this study showed that irrigant solution only penetrates from 0–1. It is well known that a good irrigation technique up to the apical portion is essential to achieve adequate removal of tissue. JOE — Volume 38. 16). with a high incidence of isthmuses between them (18). 21). because most of them are narrow and curved. It is widely used for angiocardiographic studies. Therefore. However. This situation has been previously described as the vapor lock effect (2. because it is a non-ionic. It has been demonstrated that this chemical reaction leads to the formation of small bubbles of ammonia and carbon dioxide. 32. 13. The conventional irrigation needle was placed 2 mm short of WL in all canals used in this research. In the present study.1 mm deeper than the tip of the needle. April 2012 24. Mean distances between WL and maximum irrigant penetration in mesial canals of mandibular molar with different irrigation systems. such as viscosity and density (20. these bubbles get trapped in the closed end of the tube. 23). thoracic and lumbar myelography. this apical diameter also allowed the penetration of the EndoVac microcannula up to WL. previous studies have shown that traditional irrigation methods are effective to disinfect the coronal and middle thirds of the root canals but are much less effective for the apical third (20. pyrogen-free. In contrast to Hypaque. Other studies have also shown that conventional needle irrigation leaves large amount of debris clogged in the irregularities of the root canal system (4. 31). the file oscillation allows the irrigant to Figure 3. PUI. 26. 4. This is in accordance with the present study because it was found that conventional endodontic syringe/needle system does not efficiently deliver irrigant solution into the apical third. Discussion The purpose of this study was to compare in vivo the efficacy of the conventional endodontic irrigation syringe. debris. Radiographic contrast media are widely used in medicine. and a negative pressure system for irrigant delivery to WL of mesial canals of mandibular molars. Amersham Health. These canals were selected because of their anatomic characteristics.

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