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Bettina Basrani


Chemical Disinfection of
the Root Canal System


Endodontic Irrigation

Bettina Basrani

Endodontic Irrigation
Chemical Disinfection of the
Root Canal System

Bettina Basrani
Department of Dentistry
University of Toronto

ISBN 978-3-319-16455-7 ISBN 978-3-319-16456-4 (eBook)
DOI 10.1007/978-3-319-16456-4

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This book is dedicated:
To my father, Enrique, for leaving his fingerprints of endodontic
passion in my life
To my mother, Clarita, and mother-in-law, Enid, for being my
dearest and most unconditional fans
To my husband, Howard, for helping me, every day, in
becoming a better person
To my children, Jonathan and Daniel, for teaching me what life
is really about
To my coworkers, Shimon, Cal, Anil, Andres, Gevik, and Pavel,
for being my second family
Finally, to my students for making me a better teacher


Dr. Some attention is also paid to the influence that mechanical root canal preparation has in impeding or promoting their thera- peutic effect. technologies that have shown promise in avoiding the potential risks associated with sodium hypochlorite use. the mechanical removal of necrotic tissue and microorganisms from the root canal system and the irrigation of the root canal system with chemical agents. Research has shown that despite the nature and design of the instruments used in the mechanical preparation of the system. limitations. Over the years. has proven itself to be consistently effective. With an eye to the future. Its treatment therefore must be directed at eliminating or. as well as address the presence of tissue and microorganisms at sites in the system that mechanical preparation could not reach.Foreword Apical periodontitis is an infectious disease related to the presence of microorganisms in the root canal system of teeth. significant reduction in the concentrations of tissue and microorganisms in complex root canal systems can only be achieved when irrigation of the sys- tem is an integral part of the treatment undertaken. has recruited a panel of prominent authors to discuss the merits. reducing the infecting micro- biota. Basrani has also included chapters concerned with evolving technologies in the field of supplemental root canal disinfection. exceeding sodium hypochlorite’s effectiveness in tissue and micro- bial reduction. in some instances. to supplement removal of tissue and microorganisms from areas of the system that were mechanically prepared. The treatment of apical periodontitis has historically been based upon two pillars. a noted authority in root canal irrigation. vii . Because of the toxic nature of sodium hypochlorite. Basrani. Dr. to levels that allow healing to occur. at the very least. In this textbook. sodium hypo- chlorite. Advances in microbiology have identified the nature and complexity of the infecting microbiota and the abil- ity of some of its members to collectively survive under the harshest of condi- tions. Its effectiveness is a product of its concentration and the manner in which it is introduced into the root canal system. different irrigants have been used in endodontic treatment. and safety of the various sodium hypochlorite delivery systems currently being used in endodontic treatment. but only one. while achieving and. both of these factors pose a potential risk to the patient if tissues surrounding the tooth are inadvertently exposed to the agent during use.

this textbook is a must-read for all clinicians who include endodontics as an integral part of their dental practice. DDS. Canada Calvin D. MS.viii Foreword In view of the importance of irrigation of the root canal system in its broadest form. Torneck. to the outcome of endodontic treatment. FRCD(C) . ON. Toronto.

Shimon Friedman and Dr. After a couple of meetings together. I felt like a dream came true. I am so proud of being part of such a prestigious group of researchers and remarkable group of human beings. Dr. the big difference is that. However. Jesus D. and microbiologist. Tjadehane and Dr. I was invited work with a periodon- tist. Marcantoni. under the wise guidance of Dr. Today. We start by analyzing the main etiologi- cal factors of apical periodontitis in Chapter 1. the disinfection research is reaching for new horizons with the leading research of Dr. and chlorhexidine (CHX) was the “new” topical drug at that time. In Chapter 2 Dr. and (c) both chemically disinfect the surface (medicaments and irrigants). why not for endodontics? This is how my irrigation pathway began in 1995. and Manoel D. and that path opened to new amazing and unexpected routes. We wondered: if CHX is used for periodontics. we seal the canal as tridimensionally as possible. I was able to complete my PhD and published in vitro papers on the use of CHX as an intracanal medicament and other papers on the mixture of CHX with calcium hydroxide with my new supervisors Dr. Pécora. I have been working on endodontic irrigation for close to 20 years.Preface When I was invited by Springer International Publishing to edit a book in irrigation. as endodontists. we recognized how much peri- odontics and endodontics have in common: (a) similar etiological factor of the diseases (bacterial-/biofilm-related causes). (b) similar treatments (both disciplines mechanically clean the tooth surface either with curettes or end- odontic files). Calvin Torneck and the inquisitive minds of the residents who went through our program. Finally. Anil Kishen and his lab. Dr. Canete. Piovano. Even though we have new and sophisticated file systems in the market. and Dr. Luis Chaves de Paz explains the importance of the biofilms in causing endodontic diseases. While doing my PhD at Maimonides University in Buenos Aires. When we recognized the similarity in the procedure. the key to endodontic success is based on chemical disinfection. ix . Chemical disinfection of the root canal system is now the bread and butter of modern endodontic therapy. this motivation and interest in irrigation research brought me to Canada to continue this line of investigation with the research group at the University of Toronto. Argentina. who became my initial mentors. Versiani. Marco A. while in periodontal treatment this step is difficult to achieve. This book is intended to convey the most recent challenges and advances in cleaning the root canal. we started to analyze the medicaments that periodontal therapy applied. Sousa-Neto.

We then have Dr Jorge Vera in Chapter 7 describ- ing how patency file may (or may not) affect irrigation efficacy Chapters 8 to 14 are dedicated to each irrigation technique written by experts in each of these fields: Dr. Zvi Metzger and Anda Kfir for SAF. Anibal R. thank you! Toronto. Dr. Chap. Canada Bettina Basrani . Zahed Mohammadi and Dr. Two chapters are dedicated to modern and current points of interest. Diogenes and Nikita B. Rôças describ- ing the details on intracanal medications (Chap.M. Gary Glassman and Karine Charara for apical negative pressure. Mexico. Drs. John Nusstein for sonic and ultrasonics. van der Sluis explained in detail why the irrigants do not reach the apical part of the canal and what we can do to improve irrigation dynam- ics. 15) describing the use of antibiotics in endodontics and Professor José F. Two chapters are dedicated to inter-appointment therapy. Lin J. Peru. Paul Abbott (Chap. Carlos Eduardo da Silveira Bueno and Chap.18 on irrigation in the era of revascularization by Dr. Dr. Greece. Siqueira Jr and Isabela N. Israel. and Dr. In Chapter 5. To all of them. In Chapter 3 on irrigation dynamics was written by Dr. Australia. Wang Z. ON. Chapter 6 Dr Gary Glassman describes accidents and mishaps during irrigation. Gevik Malkhassian and I put together the most common irrigant solutions used in endodontics along with the pros and cons of their use. 16). and Holland. Ruparel. 17 on irrigation in the era of re-treatment written by Dr. USA. we have Chapter 4 Drs. France. Iran. For the more academic-oriented readers. Christos Boutsioukis and Lucas W. Canada. explain dental anatomy in great detail. Drs. with Dr. Rodrigo Sanches Cunha and Dr. and Haapasalo M described different methods on studying irrigation. Drs. Pierre Matchou for manual dynamic technique. Anil Kishen and Anie Shersta for photo activation disinfection.x Preface with distinctive studies on microCT. Ma J. Dr. to my coauthors. Gao Y. Shen Y. David Jaramillo for PIPS. The collaborators of this textbook are bringing their expertise and knowledge from Brazil. The vision of this book would never have been possible without the dedi- cation and hard work of this astounding team of scientists with such different backgrounds but with the same enthusiasm for endodontic disinfection. Amir Azarpahazoo and Zahed Mohammadi for ozone.

for granting me the 6-month sab- batical to focus on this project. and divided his time between academics and clinical practice. and your motivated and enthusiastic responses were always encouraging. as I follow in his steps. I want to recognize my family. patience. I also want to thank Dean Haas. Clarita. Without your presence in my life. He never stopped working.Acknowledgments I would like to start by thanking Springer International Publishing for giving me the wonderful opportunity of editing a textbook on chemical disinfection of the root canal system. Faculty of Dentistry. finishing his last one on his death bed. Finally. You are the ones who make us better teachers. I would not be able to be the person that I am today. It was a great pleasure to invite you to participate in this project. who inspire us to give our best. and mother-in-law. my beloved and precious husband. I should say: he never stopped doing what he loved. Damian Basrani and his family always have a special place in my heart. My brother Dr. And to my beautiful children. for being as enthusiastic as I am in every- thing they do. xi . He lived in Buenos Aires. and the ones who I also dedicate this book to. the ones who challenge us. I want to thank my mother. and feel him guiding me in spirit in all that I do. Now. Professor Emeritus Dr. I have to start by thanking my father. I want to conclude by thanking all my students. Thanks for your expertise and dedication. dividing my own time between aca- demics and clinical practice. Jonathan and Daniel. University of Toronto. Argentina. for showing me what a life of an endodontist looks like. from the undergraduate to graduate program and participants in lectures and workshops. Calvin Torneck for the thoughtful writing of the preface. and I have a deep appreciation to the whole endodontic department of the faculty of dentistry for their motivation and constant support. while he wrote six textbooks in endodontics. I appreciate the trust. thanks for being there for me. Enid Alter for listening and understanding when sometimes I think that life is overpowering. Special thanks to Warrena Wilkinson for editing some of the chapters and Dr. Enrique Basrani. Secondly. always. Howard. and knowledge they demonstrated throughout the whole process. Gratitude goes to the collaborators of this book.


. Sousa-Neto 3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics . . . Chávez de Paz 2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography . 117 Gary Glassman 7 The Role of the Patency File in Endodontic Therapy . 221 Zahed Mohammadi and Amir Azarpazhooh xiii . . . . . . . . . . . . Yuan Gao. . . . Versiani. . . . . . . . . . . 15 Marco A. . . . van der Sluis 4 Research on Irrigation: Methods and Models . . . . Jingzhi Ma. . . . . Jesus D. . . . . 99 Bettina Basrani and Gevik Malkhassian 6 Complications of Endodontic Irrigation: Dental. . . . . Pécora. . . . . . . . . 65 Ya Shen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Christos Boutsioukis and Lucas W. 1 Luis E. . .Contents 1 Microbial Biofilms in Endodontics . . 149 Pierre Machtou 9 Apical Negative Pressure: Safety. . . . . . . . . . . . . . . . . 137 Jorge Vera 8 Manual Dynamic Activation (MDA) Technique . . . . . . . . . . . . Nusstein 11 Continuous Instrumentation and Irrigation: The Self-Adjusting File (SAF) System . . and Legal . . . . . . 157 Gary Glassman and Karine Charara 10 Sonic and Ultrasonic Irrigation . . . . . Zhejun Wang. . . . . . . . . . . . . . . . . . . . . and Markus Haapasalo 5 Update of Endodontic Irrigating Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . .M. . . . . . . . . . . . . . and Manoel D. . . . . . Medical. . . James Lin. 199 Zvi Metzger and Anda Kfir 12 Ozone Application in Endodontics . . . . . . . . . . 173 John M. . . . . . . . . . Efficacy and Efficiency . . . . . . . . . . . . .

. Ruparel 19 Conclusion and Final Remarks . . . . . . . . . . . . Rôças 17 Disinfection in Nonsurgical Retreatment Cases . . . . . . . . . . . . . . . . .xiv Contents 13 Irrigation of the Root Canal System by Laser Activation (LAI): PIPS Photon-Induced Photoacoustic Streaming . . . . and Isabela N. . . . . . . . . . . . . . . . . . . . . 315 . . . . . . . 253 Zahed Mohammadi and Paul V. . . . . . . . . . . . . . . . . . . . . . . 285 Rodrigo Sanches Cunha and Carlos Eduardo da Silveira Bueno 18 Irrigation in Regenerative Endodontic Procedures . . . . . . . . . . 237 Anil Kishen and Annie Shrestha 15 Local Applications of Antibiotics and Antibiotic-Based Agents in Endodontics . . . 267 José F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 David E. Diogenes and Nikita B. . . Abbott 16 Intracanal Medication . . . . . . . . . . 313 Bettina Basrani Index . . . Jaramillo 14 Photodynamic Therapy for Root Canal Disinfection . . . . . . Siqueira Jr. . . . . . . . . . . . . . . . . . . 301 Anibal R. . . . . . . . . . . . . . . . . . . .

DMD Adjunct Professor of Dentistry. University of Toronto. RCDC (F). PhD Department of Endodontics.Sc. USA xv . Amsterdam. MSc. Abbott. MS. FRCD(C) Department Restorative Dentistry. Department of Dentistry. The Netherlands Karine Charara. Faculty of Dentistry. Sweden Carlos Eduardo da Silveira Bueno. Canada Bettina Basrani. DDS. University of Texas Health Center at San Antonio. TX. Toronto. MB. PhD. University of Toronto. College of Dentistry. WA. FIADT Department of Endodontics. DDS. Brazil Anibal R. PhD Associate Professor. Academic Centre for Dentistry Amsterdam (ACTA). University of Manitoba. Montréal. PhD Endodontics. Diogenes. MSc. Gothenburg. São Leopoldo Mandic Centre for Dental Research. ON. Canada Private Practice. Chávez de Paz. PhD. Endodontics Program. Director M. Toronto. FRACDS(Endo). The Swedish Academy for Advanced Clinical Dentistry. FRCD(C) Division of Endodontics. Clinique Endodontique Mont-Royal. Canada Rodrigo Sanches Cunha. MSc. MS. BDSc. MDS. DDS. QC. DDS. Université de Montréal. DDS. QC. Lunenfeld-Tanenbaum Research Institute.Contributors Paul V. Mont-Royal. MSc. ON. Campinas. Canada Christos Boutsioukis. San Antonio. ON. MSc. Faculty of Health Sciences. SP. PhD Faculty of Dentistry. DDS. The University of Western Australia. Canada Dental Public Health and Endodontics. Faculty of Dentistry. Toronto. Nedlands. School of Dentistry. DDS. and Clinician Scientist. Mount Sinai Hospital. Canada Luis E. PhD Department of Endodontology. Australia Amir Azarpazhooh. Winnipeg.

Toronto. MSD Iranian Center for Endodontic Research (ICER). Toronto. DMD Department of Endodontology. DDS. DMD. MSc. DDS. Tel Aviv. China Pierre Machtou. Israel Anil Kishen. PhD Department of Stomatology. Tel Aviv University. Houston. Dental School of Ribeirao Preto. Faculty of Dentistry. Canada David E. MDS. Vancouver. Jamaica Private Practice. University of British Columbia. Shahid Beheshti University of Medical Sciences. ON. DDS. University of Texas Health Science Center at Houston. FRCD(C) Assistant Professor. The Goldschlager School of Dental Medicine. BC. DDS. Canada Zvi Metzger. TX. DMD Department of Endodontology. PhD Department of Endodontics and Operative Dentistry. DDS Department of Endodontics. DDS. Discipline of Endodontics. Kingston. West China Stomatological College and Hospital Sichuan University. DDS. Huazhong University of Science and Technology. PhD Department of Restorative Dentistry. ON.R. Tongji Medical College. PhD Endodontie. UFR d’Odontologie Paris 7-Denis Diderot. Canada Jingzhi Ma. FRCD(C) Associate in Dentistry. USA Anda Kfir. DDS. University of Toronto. OH. Toronto. BDS Department of Endodontics. P. Chengdu. Tel Aviv University. School of Dentistry. Israel Zahed Mohammadi. Research Institute of Dental Sciences. Canada Adjunct Professor of Dentistry. Vancouver. Tongji Hospital. Nusstein. Columbus. Paris Ile de France. Iran John M. Wuhan. Department of Endodontics. Graduate. USA Jesus D. PhD. Department of Oral Biological and Medical Sciences. MSc. China Gary Glassman. University of British Columbia. Canada James Lin. Ribeirao Preto. MS. P. Brazil . Tehran. FRCD(C) Division of Endodontics. France Gevik Malkhassian. University of Toronto. DDS. Faculty of Dentistry. Department of Oral Biological and Medical Sciences.xvi Contributors Yuan Gao. University of Sao Paulo. PhD Division of Endodontics. Canada Markus Haapasalo. DDS. University of Technology. The Goldschlager School of Dental Medicine. Faculty of Dentistry. Pécora. Toronto. The Ohio State University College of Dentistry. BC.R. Tel Aviv. Endodontic Specialists. ON. University of Toronto. Jaramillo. ON. MSc. Facility of Dentistry. MS Division of Endodontics. Faculty of Dentistry.

Brazil Zhejun Wang. Department of Oral Biological and Medical Sciences. Faculty of Dentistry. DDS. Ribeirao Preto. Groningen. University Medical Center Groningen.Contributors xvii Isabella N. Siqueira Jr. MSc. Brazil Nikita B. USA Ya Shen. PhD Department of Endodontics. PhD. PhD Department of Restorative Dentistry. DDS. Canada Annie Shrestha. Mexico Marco A.M. Faculty of Dentistry. MSc. PhD Department of Restorative Dentistry. Dental School of Ribeirao Preto. University of Toronto. MSc. DDS. Canada . DDS. DDS. PhD Division of Endodontics. University of Sao Paulo. PhD Department of Conservative Dentistry. BDS Faculty of Dentistry. Vancouver. University of Tlaxcala Mexico. Faculty of Dentistry. SP. van der Sluis. University of Sao Paulo. Ruparel. ON. RJ. PhD PostGraduate Program in Endodontics. Brazil Lucas W. Estácio de Sá University. The Netherlands Manoel D. Ribeirao Preto. Versiani. DDS Department of Endodontics. Vancouver. Canada José F. Rôças.. Toronto. MSc. Estácio de Sá University. Puebla. Faculty of Dentistry. University of British Columbia. San Antonio. BC. Puebla. University of British Columbia. Rio de Janeiro. PhD Division of Endodontics. Dental School of Ribeirao Preto. Rio de Janeiro. RJ. PhD PostGraduate Program in Endodontics and Molecular Microbiology Laboratory. Department of Endodontics. MSc. Sousa-Neto. DDS. DDS. MS. University of Texas Health Center at San Antonio. DDS. BC. Department of Oral Biological and Medical Sciences. Brazil Jorge Vera. TX.

Bacterial growth and division then leads to the colonization of the surrounding area and the maturation of the biofilm. PhD face and it is strictly regulated in response to Endodontics. A greater understanding of biofilm processes should lead to novel. Chávez de Paz Abstract Microorganisms colonizing different sites in humans have been found to grow predominantly in complex structures known as biofilms.). Endodontic Irrigation: Chemical Disinfection of the Root Canal System. Chávez de Paz. 33].paz@gmail. this topic is still under © Springer International Publishing Switzerland 2015 1 B. MS.chavez. In nature. The initial stage of biofilm formation includes the attachment of bacteria to the substratum. Introduction are embedded in a self-produced extracellular matrix which bind cells together [17. Sweden environmental conditions [33]. The environment in a biofilm is not 30]. agents. 18. DDS. DOI 10. bacteria are able to live either as Biofilms have major clinical relevance as they independent free-floating cells (planktonic state) provide bacteria with protective environments or as members of organized surface-attached against stresses. Basrani (ed.E. Microbial Biofilms in Endodontics 1 Luis E. and antibiotics [31. The Swedish Academy for Advanced Clinical Dentistry.1007/978-3-319-16456-4_1 . The implications of this mode of microbial growth in the context of endodontic infections are discussed in this chapter. immune responses. Biofilms are dynamic systems with attributes of both primordial multicellular organisms and represent a protected mode of growth that allows cells to survive. the bacteria in multispecies biofilms are not randomly distributed. Gothenburg. but rather are orga- nized to best meet their requirements. antibacterial microbial communities called biofilms. effective control strategies for endodontic biofilm control and a resulting improvement in patient management. Although there is an initial understanding on the mechanisms of biofilm formation in root canals and its associated resistance to clinical antimicrobial regimens. it is now well estab- lished that biofilm formation is a developmental process that begins when a cell attaches to a sur- L. e-mail: luis. After several Biofilms are composed of microorganisms that decades of intense research.

Although there is no as dental plaque. 16. Oral biofilm formation serves generally agreed upon mechanism to account not only to aid in retention of bacteria in the oral for this broad resistance to antimicrobials. rods.1 and 1. also known cides [13. In the initial phase. and fila. 24. when sections were viewed by transmission Formation of Microbial Biofilms electron microscopy. cavity. co-adhesion with other organisms is achieved by specific interspecies interactive mechanisms . Fig. tal process that begins when a cell attaches to a ies using scanning electron microscopy have surface.E. The bio. a “clean” surface is coated with environmental elements. but also results in their increased survival the extent of the problem in endodontics is [34.1 Initial stages of biofilm formation. 83]. 46]. 1. At the second stage.2). dense aggregates of cocci and rods embedded in an extracellular matrix Formation of a bacterial biofilm is a developmen- were observed along the walls [61]. 1. been confirmed by examinations of extracted teeth with periapical lesions [71]. and within the biofilm. The formation of microbial biofilms shown microcolonies of cocci. For example. exopolymers. while stud. irreversible adhesion occurs by association of specific cell components such as pili. 74. In the following stage. main parts: (a) the initial interactions of cells film mode of growth contributes to resistance to with the substrate and (b) growth and develop- host defenses. there are ment of the biofilm (see Figs. In root canals of teeth. 35]. a plank- tonic cell that approaches the coated surface initiates adhesion by adjusting a number of regulatory mechanisms known as surface sensing. Schematic outlining the general approaches of initial cellular interaction of planktonic cells with coated substrates.2 L. Chávez de Paz One of the most relevant features of oral formed subpopulations of cells that are pheno- bacteria is their intrinsic ability to continuously typically highly resistant to antibiotics and bio- form complex biofilm communities. Lastly. includes several steps that can be divided in two ments on root canal walls [59. etc. biofilms have considerable. flagella.

28. 47]. Image sections showing reconstructed three-dimensional biofilm Monolayers of cells adhered to a images at a magnification of surface ×100. the now active communities. second and third images show subsequent stages of biofilm formation at day 3 and 5. between the two surfaces and also helped by the tioning polymeric matrix or “conditioning film” sticky exopolymers secreted by the cells. When the first As depicted in Fig. gravitation. This is trostatic interactions [21]. This is partly due to surface floating cell (cell in planktonic state) is deposited appendages overcoming the repulsive forces on a substratum coated with an organic condi. Conditioning films are composed by hydrophilic exopolymers have a complex and constituents of the local environment like water. respectively. ing growth some cells will be detaching from the sion of the cell to the substrate becomes biofilm over time [6. 3. albumin. Biofilms were stained with LIVE/DEAD stain. salt ions.1). the second part of the bacterial cells arrive. tional cells adhering to the biofilm [37]. Double layers. 3D images show confocal images of biofilm formation by oral bacteria at 1. formation of isms appear green micro-colonies Continuous growth and maturation Biofilms initiate formation when a free. and 7 days of growth. Specific interactions an overall dynamic process where many microor- with bacterial surface structures such as flagella ganisms co-adhere to one another and interact in and pilus are also important in the initial forma. 1. . dynamic structure [22]. Bottom image shows the fourth stage of biofilm formation at day 7. 1. Consequently dur- tion of a biofilm. The next step is when the adhe. initial Upper image shows the first differentiation of micro-colonies stage of biofilm growth at day 1. Damaged organisms appear red and undamaged organ. Development of a biofilm occurs as film resulting from physical interactions such as a result of adherent cells replicating and by addi- Brownian motion.2 Biofilm growth and maturation. formation of a biofilm comprises its growth and ible contact between the cell and the conditioning development. irreversible. or elec. or fibronectin. respectively.2. resulting in live and dead bacteria appearing as green or red. These (Fig. 1. respectively. Vertical expansion.1 Microbial Biofilms in Endodontics 3 Fig. 8. 5. there is a weak and revers. diffusion.

71]. The extracellular matrix is the backbone of the biofilm and it is very complex in Biofilm bacteria usually have an increased resis. age of the biofilm [80. There are. It would produced adhesive substances will provide the seem that resistance is dependent in multiple fac- proper prerequisites for the survival of microbes. not only physical and adhesive stability to the Biofilms formed by oral bacteria are more biofilm. a fact that will affect the oral bacteria in the mouth. doxycycline. bacteria have been observed respond to stress. Svensäter and Bergenholtz [83] pro. and In 2004. . These aggregations viability of susceptible root canal strains in of microorganisms have been observed adhered planktonic cultures was found to be considerably to the inner walls of complex apex anatomies and increased when the same strains were exposed to accessory canals [61. As it is illustrated in Fig. tors such as the substrate. 26]. The inflam. in some cases up to charides. differentiation of cells that actively walls. microenvironment. Chávez de Paz Biofilms Developed in Root Canals planktonic cells [46.000-fold greater than that of the same microor. Microorganisms have been found to formed by bacteria isolated from infected root colonize by adhering to dentine walls in all the canals to alkaline stress [12]. The pulp chamber by oral organisms following the physical protection is mainly related to the pulp tissue inflammatory breakdown. nucleic acids. three-dimensional architecture that interconnects cillin. but they also form the scaffold for the resistant to chlorhexidine. it is reasonable to assume that biofilms formed in root As surface-associated microbial communities are canals will also share the same resistant proper- the main form of colonization and retention by ties as oral bacteria. occasionally mass in the inflammatory lesion per se [61. biofilm matrix. This observation could explain how the inflammatory lesion front serves as a fluid Physical Barrier to the Penetration source for bacterial biofilm detachment and colo. When these biofilm the same alkaline stress in biofilms. 1. host-derived proteins be multiple. 75]. impaired penetration of antibiotics through the matory lesion frontage will then move succes. and differentiation of cells with to detach from inner root canal surfaces and a very high persistent phenotype. however. The to assume that biofilms also form in root canals high resistance capacity of biofilm communities having the same properties as the parent commu. and lipids. from root canal bacteria was shown in a series of nities colonizing the enamel and cementum sur.4 L. communities are formed on surfaces located The reasons for the increased resistance of beyond the reach of mechanical removal and the bacteria when forming a biofilm are believed to effects of antimicrobials. a posed a hypothesis for biofilm formation in root number of known mechanisms that account for canals.E. the extension of the root canals. proteins. extracellular polymeric substances (EPS) provide ganisms living in liquid suspension [27. of Antimicrobials in Biofilms nization of other remote sites in the root canal. 71]. and currently. 81]. this broad resistance and can be divided in two ably initiated just after the first invasion of the main groups: (a) physical and (b) acquired. amine fluoride. it is not unreasonable overall prognosis of root canal treatments. In this study. there is no generally from remaining necrotic tissues and bacterially agreed upon specific mechanism(s). Interestingly.3. experiments that tested the resistance of biofilms faces [10]. Biofilm formation in root canals is prob. 38]. The 1. Therefore. its composition. amoxi. and metronidazole than and organizes cells in biofilms [26]. wide ranging between polysac- tance to antimicrobial agents. The main barrier that will hinder the penetration of antibiotics into the biofilm is the extracellular Resistance to Antimicrobials matrix [7. sively towards the apex providing the fluid acquired resistance is divided into three subcate- vehicle for the invading organisms so these can gories: differentiation of cells with low metabolic multiply and continue attaching to the root canal activity.

sections of the biofilm. cells are in different phys- Due to the physical protection provided by the iological states. Because of enzymes that may prevent formation and/or the marked diversity of EPS – inclusive of activate dispersal of biofilms [45].1 Novel biofilm matrix components recently found and under current research Biofilm matrix component Biofilm-forming species Reference Exopolysaccharide Bacillus subtilis (NCIB3610) [7] Poly-gamma-DL-glutamic acid B. The illustration depicts different mechanisms of resistance by biofilm bacteria. may be dead or lysing. 70. S. Cells at the base of the film. depending on the species involved – it is not sur- prising that this slimy substance delays consider- ably the diffusion of antimicrobials [81]. 1. and L. homeostatic. This novel research on matrix of the varied molecular-complex components components will provide evidence for the identi- that influences the developmental. 80]. aureus [66] Amyloid fibers of the protein TasA B. monocytogenes [55. it has been directly observed a profound and Dormancy retardation in the delivery of a penicillin antibi- otic from penetrating a biofilm formed by a It has been observed that throughout the various betalactamase-positive bacterium [3]. Some exam- glycoproteins. fication and application of matrix-degrading and defensive processes in biofilms.1. a subpopu- lation of persister cells may also develop (black cells) (4) Table 1.1 Microbial Biofilms in Endodontics 5 Fig. aureus [87] Extracellular protein. Slow or incomplete penetra- tion of antimicrobials through the matrix (1). monocytogenes [39] BAP proteins S. intense research is ongoing that example. and insoluble ples of novel biofilm matrix components that are hydrophobic polymers. . while those near aim to target the identification of novel matrix the surface may be actively growing [19. Concentration gradients of metabolites and waste will form zones where subpopulations of bacteria are differentiated. subtilis (RO-FF-1) [79] Poly-N-acetyl glucosamine (PNAG) S. subtilis [72] Protein BapL L. 91] Critical to matrix function is the distribution components. MabA Lactobacillus rhamnosus [88] Extracellular DNA (eDNA) Bacillus cereus. aureus. proteoglycans. These subpopulations have different antimicrobial resistance capacities depending on their metabolic activity (dormant cells labeled blue) (2) or if they develop an active stress response mechanism (red cells) (3). for biofilm matrix. Finally. For State of Nutrient Deprivation example. among other components currently studied are listed in Table 1.3 Mechanisms of resistance by biofilm bacteria.

65]. do not reactivate in short time periods even under sine pentaphosphate. also a profound effect on the ability of E. The data produced by this study showed response. depending on the spatial location of the From the perspective of the persisting root cells within the community [81. the reactivation of dor.6 L. unlike cells in planktonic culture. adaptive example. These improved understanding of the alar. This phenomenon is correlated metabolic perspective. 68. forced to enter a state of dormancy by exposing vironments where nutrients are scarce. Weiser infection caused by bacteria possibly located in et al. This phenomenon was not observed for cells away from biosynthesis and reproduction [40. and maintain stable biofilms [15]. 41].E. One such mechanism involves the stringent after 2 h. the stationary phase of growth [64. local environmental conditions [69. from the tibility [32. alarmones guanosine tetraphosphate and guano. strategy of biofilm bacteria to resist stressful Furthermore. collectively known as (p) optimal conditions. that significantly differ in their antibiotic suscep- voke periapical inflammation. a mechanism that may account as a in root-filled teeth for at least 12 months [58. Biofilm cultures of oral isolates of Streptococcus ticular this dormant state is hypothesized to be anginosus and Lactobacillus salivarius were common in biofilms that are formed in microen. 96]. a global bacterial response to nutritional that biofilm cells exhibit a slow physiological stress that is mediated by the accumulation of the response and. (p)ppGpp plays the difference in physiology between the biofilm an important role for low-nutrient survival of E. Chávez de Paz However. ease revealed recurrent disease after 12 years. 67]. with differences in chemical concentration gradi- mant cells will render biofilm bacteria able to ents that create unique microenvironments within contribute to the persistence of inflammation. This observation highlights ppGpp [25. 54]. and their mechanisms including genetic altera- rounding the area of a lateral canal providing evi. faecalis may facilitate the iden- tification of pathways that could be targeted to Bacteria within biofilms differ in their pheno- control persistent infections by this organism. mutations. and sto- dence on the persistence of an intraradicular chastic gene expression. the alarmone system (p)ppGpp has conditions. There is canal flora. Biofilm cells were then exposed to a “reac- cells to antimicrobials. type. For biofilm communities. pneumoniae that switched between a pheno- . it is reasonable to assume that such now consistent evidence that has proven the pres- dormant cells might “wake up” at some point in ence of subpopulations of cells within biofilms time and resume their metabolic activity to pro. a recent case report of a tooth that was variability allows the cells to respond to their adequately treated and showed no signs of dis. the cultures were dominated by tion have developed efficient adaptive regulatory undamaged cells that were metabolically inac- mechanisms to modify their metabolic balance tive. after 96 h. and planktonic cultures and also confirms the faecalis. This dormant After the starvation period the number of meta- physiological state related to the general stress bolically active cells decreased dramatically to response and associated survival responses may zero and their cell membrane integrity was kept offer an explanation for the resistance of biofilm intact. described two distinct phenotypic variants dentinal tubules [90]. faecalis to form. the majority of time cells in biofilms The above hypothesis on the reactivation of are in a dormant state that is equivalent to cells in biofilm cells was tested in a recent study [14]. but even Bacteria under the stress of nutrient depriva. Simultaneously. Numerous studies have investigated the creation Histopathologic and histobacteriologic analyses of these phenotypically different subpopulations showed a heavy dentinal tubule infection sur. Thus. in S. Formation of Phenotypically mone mechanisms underlying biofilm formation Different Subpopulations and survival by E. in a planktonic state that were rapidly reactivated 73]. develop. 85]. treated root canals of teeth [14]. 97]. an organism that is known to withstand slower physiological response of biofilm cells prolonged periods of starvation and remain viable [53. For example. In par. tivation period” with fresh nutrients. genetic recombination. tions. such as them to nutrient deprivation for 24 h in buffer. For example.

of biofilm bacteria to resist exposure to antimi- tors from the environment [76]. reacted concurrently to the toxin–antitoxin genes [42]. the formation of subpopulation resistance [51]. the absence of glucose in the culture medium. patterns expression of toxins drives bacteria reversibly of physiologic adaptation by members of the into the slow-growing. (b) capable to adhere but was better adapted to evade are capable of rapid adaptation.1 Microbial Biofilms in Endodontics 7 type with the ability to adhere and coexist among [48. This result lends in Biofilms support to the hypothesis that the reorganization of subpopulations of cells in multispecies bio. In this case. these cells have only were accentuated by changes in the environmen. These differences has been dissipated. This distinct spa. streptococ. where physiological differences are rence and the mechanism(s) involved in their in play. would cus. which triggered the appear- polysaccharide expression. has been demonstrated to occur in multi. there was a significant variation in the films [42]. decreased oxygen bacterial population to high doses of a single levels correlated with an increase in capsular antimicrobial agent. lowing exposure to lethal doses of antibiotics and Currently. when cocultured. coli bio- of glucose. In addition. such persister cells represent a recal- in their production of capsular polysaccharide citrant subpopulation that will not die and are having the inflammation-resistant phenotype an capable of initiating a new population with nor- increased production of up to two to six times mal susceptibility once the antibacterial effect more capsular polysaccharide. In the context of root canal bacteria. been reported to occur after the exposure of a tal concentration of oxygen. ance of persister cells exhibiting multiple drug Interestingly. 49]. This with Escherichia coli suggests that persister cells was shown using four root canal bacterial isolates are regulated by the expression of chromosomal that. the exact description of the sta- tus of a microorganism can be complex especially Groups of cells have been found to persist fol. (c) are in a dor- the host immune response during inflammation mant state. multiple drug-tolerant community to the glucose-deprived medium phenotypes by “shutting down” antibiotic targets were observed. Thus. The previous discussion relative to the capacity films is also important for survival to stress fac. although one hypothesis species biofilms by root canal bacteria [11]. These persister cells (a) may represent eukaryotic cells and a phenotype that was less cells in some protected part of their cell cycle. and lactobacilli were found predominating in explain how organisms are able to survive and the upper levels of the biofilms. The metabolic activity was con. Of interest is the fact grammed cell death in response to the stimulus that both phenotypes of S. glucose shows a clear reorganization of the com- munity in order to satisfy their members’ meta- bolic pathways in order to enable the long-term Methods to Study Bacteria persistence of the community. However. to application of calcium hydroxide [12]. The frequency of persister occur- in biofilms. pneumoniae differed [49]. the for- centrated in the upper levels of the biofilms. crobials indicates the importance of studying the physiological state of bacteria with respect to their potential level of activity in the disease pro- Bacterial Cells That Persist cesses. [50]. in chronic infections such as apical periodontitis. a variety of microscopic in situ meth- new growing populations appear in the culture ods have been developed to identify subpopula- . as rise of the alkaline levels due cies with high glycolytic demands. ment measures. To date. It has also been proposed that the 3D structure of the biofilms. or (d) are unable to initiate pro- or invasive infection [94]. operon HipA seems to be responsible for toler- Although the overall cell viability of the four. ance to ciprofloxacin and mitomycin C in species community was not affected by the lack stationary-phase planktonic cells and E. remain in the environment until the effects of tial organization in biofilms grown in the lack of noxious stimuli have dissipated. mation of such persisting populations that are while at lower levels the metabolism of cells was capable of surviving imposed endodontic treat- considerably decreased. appearance are unclear. Subpopulations of spe.

usually called and scanning mode allows higher magnifications confocal laser scanning microscopy (CLSM). metabolic activity. Scale bars: 5 labeled with LIVE/DEAD. The LSM technique. Observation of bio. David viability. 1. EM provides resolution and bacterial cells in biofilms. branes.4 LSM and SEM techniques. is that it requires the sample to be dehydrated prior to its analysis. a fluorescent marker of cell and 2 μm (SEM images are courtesy of Dr. Chávez de Paz Fig. 1. environment (Fig.4).8 L. however. green represents cells with intact cell mem. Some of these methods magnification to offer a more detailed insight into include molecular markers to study cell mem. The branes. while red represents cells with damaged mem- film features by laser scanning microscopy and SEM. Jaramillo) tions and assess the physiological status of sample [92]. The panel below shows ultrastructure of biofilms panel above shows 3D reconstruction of biofilm structures formed on apex of teeth as imaged by SEM. backs of this technique. in combi. analysis of the tool for three-dimensional in situ imaging of elemental composition in specific regions of the microbial communities [9]. SEM and LSM The invention of laser scanning microscopy (LSM) in the 1980s caused a revolution in light Electron microscopy (EM) in the transmission microscopy. nowadays the most important and indispensable nation with specific detectors. the ultrastructure of the biofilm as well as its brane integrity. is of fixed and dehydrated samples and. The LSM technique . One of the main draw- cation of stress encoding genes. or the identifi.E.

they may assume a status of cultivation [1]. culture the tracking of ribosome-associated changes in techniques have been the standard method used activity levels and subcellular localization at the to assess bacterial viability. natural habitat [2]. moribund. Once the living bac- single-cell level [2]. question. LSM allows the can be of great advantage to investigate distribu- volumetric and structural quantification of multi. Finally. quiescent. viable cells approximates the number of colony- tion with rRNA FISH (see below) would allow forming units. most often 16S but also 23S criminate use of terms that are used to assess non- rRNA. conceptually and do not reflect the actual knowl- nucleotide probes targeting 16S rRNA have been edge of the exact viability state of the organism in developed for specific detection of different bac. composition. for identification of single cells in their viable states. tats. Very recently. it is possible to to visualize and identify bacteria from periapical analyze the structure. The is the hybridization of oligonucleotide probes to extent of this problem is reflected in the indis- ribosomal RNA. Sequences of oligo. or nique allows the specific detection and viable cells are present that have lost their ability enumeration of biofilm subpopulations in situ in to form colonies [95]. One of the main disadvantages of LSM. Furthermore. and proxies of general metabolic activity and of the resuscitable [62]. viable but not cultur- tein factories of all cells. biofilm models using CLSM-FISH cific color probes. lesions of asymptomatic root-filled teeth [82]. inhibited. Since ribosomes are the pro. their numbers are good able. or more essential nutrients required for the film [1]. and processes using a variety of spe. sublethally damaged. such as cases where slightly tools in modern microbiology as it allows visual. Up to date a number of studies low metabolic activity similar to stationary-phase have demonstrated the direct use of CLSM-FISH planktonic growth for the majority of time [65]. damaged organisms are present [4]. 23]. Furthermore. tion of species in multispecies biofilms. such as dead. microhabi. growth of some bacteria in the sample [93]. [62]. Many of these terms are used physiological state of cells. Markers of Cell Viability structure of the biofilm is difficult. where the number of foreseen that the application of SRM in combina.1 Microbial Biofilms in Endodontics 9 is mainly used to visualize multiple features in terial species and can be found in online different channels that are spectrally resolved. this problem of LSM has been overcome with the Viability of bacteria is conventionally defined as advent of super-resolution microscopy (SRM). The most frequent application of FISH undetectable by regular culture techniques. injured. By databanks. however. the metabolic prop- erties of these bacterial isolates were then used to rRNA Fluorescence In Situ infer the potential roles of these and related Hybridization (FISH) microorganisms in a clinical context. starved. resting. FISH has been used means of this imaging procedure. Under some circumstances. . It is viability is growth on plates. channel signals in four dimensions [63]. In root canal infections. if the bacte- their natural environment without the need for ria exist in a biofilm. In endodontics. activity. on biofilm cultures growing in different surfaces The bacteria in such low active states may be [11. The common method to assess bacterial tion limits of common light microscopy [60]. however. dormant. This high-throughput microscopy tech. the labora- ization of specific subpopulation of cells while tory growth media employed are deficient for one maintaining unaltered the 3D structure of the bio. the capacity of cells to perform all cell functions SRM encompasses a suite of cutting-edge necessary for survival under given conditions microscopy methods able to surpass the resolu. such methods may The combination of FISH with confocal laser underrepresent the number of viable bacteria for scanning microscopy is one of the most powerful a variety of reasons. is that the information captured from detailed ultra. terial cells from root canals were isolated after growth on specific substrate.

It is likely that these in vivo stains. Biofilm basic CTC-positive cells and the CFU count can be research that focuses to test novel antibiofilm obtained. such as oral infections clinical measures. Along the years. These indicators are based mostly on other bacteria in this model. will bridge the gap from the lab to the clinic. Although the permanently altered.E. so that the affinity of an . managing the ondary biofilm formation in root canals is to effects of the native microbiota. It is also easier to exclude est years. The tetrazolium the prospective view for them to be applied to salts INT and CTC are often used as markers of fight root canal biofilms. replace the conditioning film with repelling sub- Oral infections including periodontitis and stances that will alter the chemical composition endodontic infections have been modeled in the of the substrates [36]. 1. infections. administer and monitor. a in root canal therapy is the mechanical removal good correlation between the number of INT/ with instrumentation and irrigation. most of them have been developed with tetrazolium chloride (CTC). of our understanding of chronic infections and cent red by stain with PI) and intact cells (fluores. Both models have fluorescent molecules. Up until now.5. Most of these strategies are summa- bolic functions. antibiofilm approaches arise from basic science razolium chloride (INT) and 5-cyano-2. However. Once a surface has been oral cavity of antibiotic-treated rats or in mouse artificially conditioned.3-ditolyl research. 89]. SYTO-9 and propidium iodide (PI). 84. rial interactions that influence oral diseases [43]. Chávez de Paz A number of viability indicators that can be former model is a closer representation of the assessed at the single-cell level without culturing disease.10 L. in some cases. the most bacterial respiratory activity. which can be detected been useful in revealing some of the interbacte- with epifluorescence microscopy or laser scan. have been developed to prevent biofilm forma- Alternative fluorescent probes to test bacterial tion and to eliminate established biofilm-related viability are those that target specific cell meta. strategies allows the characterization and effect of antimicrobials on specific biofilm properties. different therapeutic strategies odontic infections [44]. Although the majority of these 2-(4-iodophenyl)-3-(4-nitrophenyl)-5-phenyl tet. Advances in in vivo models will make it possible The LIVE/DEAD kit tests the integrity of the in the future to observe the events of human cell membrane by applying two nucleic acid infections in detail. Surface Coating modeling polybacterial infections presents spe- cific challenges such as establishing a mixed A reasonable approach to prevent or reduce sec- infection and. including apical periodontitis. This fluorescent probe has been used to assess the viability of root canal strains ex vivo [10] and to Antibiofilm Strategies determine the autoaggregation and coaggregation of bacteria isolated from teeth with acute end. which biofilm models will help improve the resolution can simultaneously detect dead/injured (fluores. such as the tetrazolium salts rized in Fig. there is a great need of experimental models that will closely mimic in vivo features of the disease. cent green by staining with SYTO-9) [5]. the wound infection model is easier to cells have gained increased popularity in the lat. ning microscopy. With these relatively simple methods. as well as viability common and efficient antibiofilm strategy used [20]. The validation of these new strategies will likely In Vivo Models for Biofilm Testing require efficient translational collaborations between basic research and clinical practice To better understand the pathogenesis of human before these strategies can be included in future polybacterial diseases. its properties become skin wound infections [56.

may get exhausted. one of the main objectives and strategies for disease control. Schematic outlining the general approaches for antibiofilm strategies currently used and under research organism for a native or a conditioned surface problems with this method to prevent biofilm can vary greatly depending on the molecules in formation is that the coating at some point in time the new conditioning film [52. It is clear that endodontic infections are caused 78]. the development of a coated been shown to prevent or reduce bacterial adhe. surface modifications have may stop. Hence. commensal organisms. In the bio. For example. surface that prevents bacterial colonization for sion and biofilm formation by the incorporation long periods remains still a challenge. . However. Several studies have reported Concluding Remarks that surface preconditioning with biocides has the potential to prevent bacterial adhesion [57. Further research in basic micro- [36]. 77]. and their root canal isolates in an in vitro biofilm model eukaryotic hosts. of antimicrobial products into surface materials and by modifying the surface’s physicochemical properties [29. Biofilm research in endodontics is still an In a recent study it was shown that a surface open field of research that should greatly contrib- coating with a solution of benzalkonium chloride ute into a better understanding of the mechanistic diminished biofilm formation by oral bacteria in behind the complex interplay between patho- a dentin disk model and by a consortium of three genic agents. Benzalkonium chloride was found to exhibit biological processes such as the molecular basis an overall 70-fold reduction in the biofilm bio. In parallel.5 Antibiofilm strategies. 1. it was also found nections may lead to an improvement of treat- that NaOCl (1 %) also had good effects in reduc. ment regimens and also may identify new ing biofilm formation.1 Microbial Biofilms in Endodontics 11 Fig. come. it was shown that biocides can by multispecies biofilms and that the interactions increase the cell wall charge of bacteria and between different organisms can contribute to therefore reduce their ability to attach and form apical periodontitis progress and clinical out- biofilms [78]. its antibiofilm effect medical industry. 86]. and biological effect of these host–bacterial con- mass accumulation. thus.

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the so-called Carabelli’s cusp. PhD the first author to provide a comprehensive M. Pécora. Sousa-Neto Abstract The primary goals of endodontic treatment are to debride and disinfect the root canal space to the greatest possible extent and to seal the root canal system as effectively as possible. MSc.D. from the University of Vienna. Treating complex and anomalous anatomy requires knowledge of the internal anatomy of all types of teeth before undertaking endodontic therapy. A Brief History of the First Studies has been done in relation to the root canal anatomy on Root Canal Anatomy and its remarkable influence on the endodontic procedures. MSc. such as X-ray comput. and Manoel D. PhD description of the number and location of root Department of Restorative Dentistry. canals. DDS. This chapter is focused on the complexity of root canal anatomy and discusses its relationship on the understanding of the principles and problems of shaping and cleaning procedures. Basrani (ed. appropriate to take a brief look to the past. Authors erized tomography [1–5]. PhD (*) Although the Hungarian dentist and professor Department of Restorative Dentistry. Sousa-Neto. aiming to establish or maintain healthy periapical tissues. Dental School of Ribeirao Preto. DDS. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. it would be advanced imaging systems. three-dimensional imaging of teeth using microcomputed tomography has been used to reveal the internal anatomy of the teeth to the clinician. However. Update in Root Canal Anatomy of Permanent Teeth Using 2 Microcomputed Tomography Marco [6].A. Brazil [6]. University of Sao Paulo. György Carabelli. to whom endodontics is greatly indebted. Pécora. he reproduced some illustrations of sectioned © Springer International Publishing Switzerland 2015 15 B.D. Brazil surface of the mesiopalatal maxillary molar cusp e-mail: marcoversiani@yahoo. he was also J. should be always revisited. M. Versiani. a lot of research work that preceded this new image-processing techno- logical era. s/n Bairro Monte Alegre. Recently. University of Sao Paulo. to understand the contem- Since the first attempts of using contemporary porary approaches regarding this issue. was eternized in the dental literature by his Avenida do Café. Dental School of Ribeirao Preto. description of an additional cusp on the palatal Ribeirao Preto 14049-904. DOI 10.1007/978-3-319-16456-4_2 . MSc. Jesus D. Anatomie des Mundes Ribeirao Preto. SP. Versiani. In his textbook.). DDS.

Spalteholz developed a process in which organs Greene Vardiman Black published the first could be made translucent and stained using dif- edition of his classic book [8] in which he sys. made up of 1 part small-piece collodion to 8 fied the percentage values concerning the number parts of pure acetone. and closely examining field modified and simplified the Spalteholz’s them in connection with the descriptions given. on blocks of chalk. Then. external morphology of all groups of teeth. obtain a metal model of its internal anatomy. and replicas of the more subtle ography [21–32]. the teeth were washed again. However. anoptically transparent embedding material that According to him. were also used to tematic study on the root canal anatomy in which obtain a model of the root canal space. this method renders the sur- photomicrographs in which impressive pictures rounding hard tissues transparent through demin- of histological sections of human teeth demon. it was possible to which was vulcanized later into teeth. Some researchers in the endodontic to be studied into view. . methods did not fit for the study of a large num- At the beginning of the twentieth century. This process was based on tematized the dental terminology and detailed the dehydration of the removed organs and the use of internal and external anatomy of the teeth. digital radiography [33–35]. Okumura speci- tion. cinnabar [15]. (70 °C) into the canal space in which. and China ink [16]. canal system. after com. Fischer [11] obtained better results filling the percentage number of root canals in all groups approximately 700 teeth with a collodion solu. A few years later.” method employing this “clearing technique” In 1894. such as paraffin [12]. After decalcifi- tooth overheating and the replicas were obvi. especially those near the apical fora. full replica of the root canal system. gelatin-containing [9]. Thirty improved techniques for injecting different mate- years later. The collodion solution was and divisions of the main root canal in 1. cation. from the (diaphanization) for the study of the root canal University of Zürich. providing a technique [19]. teeth detailing the root canal system and the ramifications fractured easily. Mühlreiter [7] published the first sys. Professor Alfred Gysi. His phology of approximately 3. Fisher deeply In the following decades. at this point. In and the patient’s age and published details about 1908.000 teeth [17. Basically.A. teeth was sectioned in all planes and the internal In 1914. the German anatomist Werner anatomy described in details. such as strated the complexity of the root canal system molten Wood’s metal [14]. In later years. he used the demineralizing method. Nevertheless. conventional radi- was fragile. and vulcanite samples mounted the finer branches of the root canal system. in vivo and ex vivo methods such as three- men. The specimens were washed in running water and main limitation of this method was that it led to placed in 50 % hydrochloric acid. packing and pressing softened natural rubber. rials. plete tooth decalcification. the methodologi. He established a cor- stated that “a canal-anastomosis system can be relation between the presence of ramifications found in some roots and is not rare” [10]. method consisted in the injection of molten metal Basically. of teeth [17]. ber of teeth. omy were predominantly based on sectioning After considering that the available research techniques. eralization after injecting fluid materials.339 able to penetrate all the branches of the root canal teeth using dye injection and diaphanization system and harden in 2 or 3 weeks. the hardened collodion solution dimensional wax models [20]. After a few decades. organic ously incomplete as the metal could not penetrate debris removed. 18]. Hess corroborated his results Despite these methodological drawbacks. Versiani et al.16 M. the morphology of studied ramifications and little lateral canal the root canal system was described by several branches. “anatomy is not to be learned had the same refractive index as the tissue of the from books alone. published a collection of anatomy. performing some histological preparations by Preiswerk was one of the first researchers who carrying out serial sections. into the root cal approaches for studying the root canal anat. but also by bringing the parts organ itself. ferent colors [13]. Professor Walter Hess developed his Preiswerk introduced the “modeling technique” own technique and studied the root canal mor- for the study of the root canal anatomy [10].

authors stated that “applications of dinal and transverse cross sectioning. nificant discrepancy in the results. were obtained. elaborated the sections. providing a 3D model of therefore. the teeth at the same time [64]. 47. which rebuilt. as well as. superimposed. surface. these techniques have shown root canals were estimated using a computerized potential for endodontic research and have been video image-processing program. The invention of X-ray computed tomography (CT) brought a significant In 1986. 39.” This radiographic of the root canal system is reduced because they volume interpolation method from two-dimen- provide only a two-dimensional image of a three. this computer-based method was niques do not allow for the three-dimensional improved by decreasing the cross-sectional analysis of the external and internal anatomy of thickness of the root [75–79]. the volume and diameters of the Without doubt. CT assisted imaging in the field of endodontic produces a two-dimensional map of X-ray research. and an accurate computerized method for 3D visualization of image of the root canal as a whole cannot be the root canal before and after instrumentation obtained because of the large thickness of the was introduced [74]. perimeter.2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 17 resin injection [36–38]. this technique in the fields of research and edu- scopic approaches in assessing the morphology cation are very promising. endodon. radiographic a mathematically determined three-dimensional methods with radiopaque contrast media [60]. celluloid. Furthermore. caused by technological computer-processing The accuracy of radiographic methods. from known angles. the canal anatomy [71–73]. these tech.” They adapted a tech. limitations. tooth sectioning on different planes canal. 68]. Then. area. macroscopic evaluation the injection of a contrast medium into the root [27. micrographs of wax. 41–46]. a new specimens are also destroyed. 40]. Briefly. morphology [67. subject. computer. absorption into a two-dimensional slice of the tics needed “a model for studying canal mor. This is achieved by taking a series of phology before. and micro. essentially some of them may provide questionable data. According to these authors. diameter. step forward in diagnostic medicine [70]. or 1 mm. these sections were transferred to a graphics niques. Subsequently. microscopy evaluation [43–45. [69] introduced computer. and the thickness of sec- for the Study of Root Canal tions and material loss were found to influence Anatomy the obtained results [79]. To maxi- . 48]. or after endodontic X-ray projections through the slice at various therapy on actual teeth. produce irreversible changes in the speci. and volume of the canal. clearing techniques [49–59]. Despite a sig- used successfully over many years [62]. the X-ray absorption of objects [70] for the evaluation of the root map is computed. resin. after three-dimensional map is produced [5]. decalcification and clearing tech. and mens [65] and many artifacts [66] which. and scanning electron microscopy [61]. Mayo et al. Five cross-sectional images sections [64]. It may be pointed out also used in further studies to evaluate the root that in the process of making the sections. Some years later. From this data. during. These inherent These computerized methods allowed the limitations have repeatedly been discussed. longitu. development of 3D models of the root as well as encouraging the search for new methods with the measurements of parameters such as distance. improved possibilities [62]. contour. sional radiographs taken in different angles was dimensional structure [63]. a canals of single-rooted premolars. it was still a Computational Methods destructive technique. By combining all six views. (3D) representation of the canals was obtained. cannot accurately reflect the canal the root with the image of the canal system. angles around an axis perpendicular to the slice. at intervals of root canals with wood metal. however. six radiographs of each tooth were taken [39. Despite the improvements achieved with this newer approach. Modeling techniques with the of the mesial root of mandibular first molars removal of all surrounding tissues from casts of before and after canal preparation. By taking a number of slices. nique that allowed three-dimensional imaging From this set of projections.

using an isotro- similar terminologies. 116]. the scanners were designed to take resolution (0. 68. the image of the shell of a Biomphalaria glabrata Application of micro-CT technology to end- snail was produced. medical CT in Endodontics systems need to use a limited dose of relatively low-energy X-rays (≤125 keV). 95]. inadequate software.6 mm). ments) [80. optical increased resolution at a cost in X-ray coherence tomography [96]. [3] indicated to model smaller objects [115]. microcomputer tomography. it has been considered the most for research. micro-CT technology employs four allow a proper analysis. signal-to-noise ratio to compensate for the Elliott and Dover [2] developed the first high. entitled Microcomputed Tomography: An This also meant that the machine was smaller in Advanced System for Detailed Endodontic design compared to the human version and was Research [3]. they Like conventional medical tomography. 67. and instrumentation and obturation. Nielsen et al. bility of CT imaging in endodontics. and using a resolution of 12 μm. whereas a typical digital image mm and high-efficiency detectors [80]. 115] (Fig. Besides.” In this of root canal anatomy [63. they concluded that CT had advantage of the fact that the items being studied only a limited usefulness in endodontics as do not move and are not harmed by X-rays. despite the pic resolution of 127 μm. X-ray evaluated the reliability of micro-CT in the recon- microcomputed tomography (micro-CT) has also struction of the external and internal anatomy of been denominated as microcomputed tomogra. However. assessing the mor- phy. tuned-aperture (b) X-ray focal spots are smaller providing computed tomography (TACT) [94. onance microscopy [87–93]. they use relatively large scale in [115].A. 3D object that later can be used to recreate a vir- to obtain as much data as possible given these tual model without destroying the original model requirements. micro- must also acquire their data rapidly because the CT also uses X-rays to create cross sections of a patient should not move during scanning. these (c) X-ray detectors are finer and more densely digital image systems were hampered mainly by packed which increases resolution at a cost in insufficient spatial resolution and slice thickness detection efficiency. device. cone beam CT (CBCT) [97–114]. four maxillary first molars. achieved images were not detailed enough to Basically. The term “micro” in this new odontic research was recognized only 13 years device was used to indicate that the pixel sizes of after its development and described in a paper the cross sections were in the micrometer range. Tachibana and Matsumoto [1] were slice image is composed of voxels (volume ele- the first authors to suggest and evaluate the feasi. Versiani et al. Therefore. effective at penetrating dense materials. three-dimensional images of the internal . Then. and volumetric or output. is composed of pixels (picture elements). magnetic res. Authors concluded that impossibility of employing micro-CT for in vivo micro-CT had “potential as an advanced system human imaging. mize their effectiveness in differentiating tissues The Micro-CT Technology while minimizing patient exposure. study. but also provides the foundation as important and accurate research tool for the study an exciting interactive educational tool. Because of Because micro-CT is mostly used in nonliving high costs. for the study of root canal anatomy [3. 4]. 2. X-ray microtomography. Further improvements in optimizations in comparison to conventional CT digital image systems have been used to evaluate [80]: the root canal anatomy in either ex vivo or in vivo conditions using nondestructive tools such as (a) It uses high-energy X-rays which are more conventional medical CT [81–86]. (d) It uses longer exposure times increasing the A decade after the CT scanner was created. a CT In 1990. Nowadays. and a low spatial objects.1).18 M. In this article. loss in signal from the diminished output and resolution X-ray microcomputed tomographic efficiency of the source and detectors. high-resolution phological changes in the root canal after X-ray tomography.

sive. and a detector array – coupled to a digital charge- tive image software that allowed the alignment of couple device camera – records attenuated inten- pre. [4] demonstrated the feasibility of this tech. thorough discussion is beyond the scope of this nology using a resolution of 38. development of virtual reality techniques for end. with voxel sizes related to the morphological analysis of the root decreasing to less than 40 μm [4.e. resolution.and post-image volumes. i. while the object rotates Therefore. Authors concluded that micro-CT and researching. the technique is not previously cleaned tooth fits inside the field of . the only preparation that is abso- given that scanning and reconstruction proce. visualiza- CT as a methodological tool was also tion.. 2.1 Three-dimensional cross section of the coronal arranged in a two-dimensional grid that makes up a third of a mandibular second molar root (a) illustrating the picture. 2.2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 19 a b c Voxel Pixel Fig. the tooth attached to the sample stage (Fig. an understanding of basic princi- the morphological characteristics of the root ples is desirable to ensure a better comprehension canal before and after different steps of root canal of its potential as a tool for endodontic teaching treatment. Voxel stands for volumetric element.2b). the equipment is expen- sented in a format previously unattainable [3]. sities of the X-ray beam. suitable for clinical use. They are the smallest unit of information and external structures of the teeth were also pre. 117]. a motorized high- rendered images and slices. The word pixel three-dimensional equivalent of a pixel and the tiniest dis- stands for picture element. micro-CT significance in the detailed study of canal involves gathering projection data of the tooth anatomy in endodontics because it offered a from multiple directions. Later. and a et al. The source sends X-ray radiation through the root canal preparation [62. The lection. 116–119]. If many projections are nondestructive reproducible technique that could recorded from different viewing angles of the be applied quantitatively as well as qualitatively same tooth.7 μm to evaluate text. obtura. contributing to the precision sample rotation stage. software resources for reconstruction. and computing odontic teaching. in-depth knowledge of dedicated software. improvements in the speed of data col. each projection image will contain for two. technology would offer the possibility of learning A typical micro-CT scanner consists of a tooth morphology by interactive study of surface. and it is the difference between pixel (b) and voxel (c). However. and the complexity of the technical proce- With further developments of the micro-CT dures requires a high learning curve and an scanners. a detection array. microfocus X-ray source. and image quality yielded technical procedures related to the micro-CT greater accuracy compared with the first studies methodology with the aim to evaluate aspects using computational methods. the reliability of micro. Dowker canal anatomy are a complicated subject. 2. and analysis of the root canal anatomy demonstrated in the quantitative assessment of [122]. At this stage. lutely necessary for scanning is to ensure that the dures take considerable time. micro-CT has gained increasing on its own axis (Fig.2a). ment of the root canal system [116]. Conversely. a system control mechanism. using innova.and three-dimensional accurate assess. Every digital image is made up tinguishable element of a 3D object of pixels. different information about its internal structure. tion [120]. and retreatment [121].

as in the study resolution. which can be visualized (Fig. Authors cor- images are then subjected to image segmentation related the shape of the root canals to the using dedicated software. for educa- . 2. through the tooth. 2. niques [62. flat-field correction. After recording the X-ray images. [125]. the resulting of frames. number of the internal anatomy of the teeth. and a detector(s) that mea. and structured model index. Peters et al. 119. However. type of filter. 2. micro-CT was used by different groups to Concerning the tooth.3a) is then used as input for a reconstruc.3d) improve the further 3D reconstruction of the or analyzed using different software.. data collection. is controlled by a contours after image segmentation can be used to software – the system control mechanism – which create 3D models with the help of interpolation allows setting up these parameters in order to algorithms. image segmentation is for detailing the root canal geometry of 12 the process of assigning a label to every pixel in maxillary molars regarding volume. Belgium) micro-CT ated by the object. Common elements of micro-CT: (a) X-ray source. Image segmentation is corresponding roots of five maxillary molars a manual or automatic procedure that can remove scanned at a resolution of 33 μm. while the object rotates on through which the X-rays pass. [116] something that is more meaningful and easier to evaluated the potential and accuracy of micro-CT analyze. Using Micro-CT tion algorithm.20 M. The The result of image segmentation is a set of seg- entire operation of the scanner. Kontich. its own axis (b) view and does not move during the scan [80]. the different radiographic evaluate geometrical changes in root canals after densities of the enamel. share certain visual characteristics [124]. When applied to a stack of images. based on the two-dimensional projection tool for the analysis of the root canal anatomy images (Fig.3b) [123]. the the unwanted structures from the image based on real potential for the analysis of several quantita- the object density. More precisely. a b Fig. rotation angle. The source sends X-ray radiation device. exposure. 2. and root canal preparation with different instruments and tech- facilitate the segmentation procedures (Fig. Versiani et al. dentin. Then.2 Inside view of the chamber of a SkyScan sures the extent to which the X-ray signal has been attenu- 1174 v2 (Bruker-microCT. including X-ray ments that collectively cover the entire image. and a detector array records attenuated an object attached to the sample stage to be imaged intensities of the X-ray beam. tooth. an image as such that pixels with the same label diameter. This algorithm computes a three- dimensional image of the internal anatomy of the The first attempt to use micro-CT as a quantitative tooth. etc. 2. surface area. as well as. the projec- tion data of the tooth from multiple directions Evaluation of Root Canal Anatomy (Fig.3c). rotation step. 126–129].A. The resulting volumetric was done by Bjørndal et al. The goal of segmentation is to tive parameters using micro-CT was reported in simplify the representation of an image into the following year [116].

and isthmuses [147. mandibular first . 157. 136. facilitate its segmentation which can be used to create 3D rithm which computes a 3D image of the internal anatomy models (d) of the tooth. based on the 2D projection images (b). 139. and 2. it took molars [161–165. C-shaped canals in mandibular lished in indexed journals in English language premolars [136–138] and molars [145.2. 2. two-rooted mandibular canines [68] and published. 131]. 2. 152. The main results of the studies pub. 130. Most of the micro-CT studies on root canal 144]. 148– are summarized in Tables 2. four-rooted maxillary second molar evaluating the root canal anatomy started to be [67]. mandibular canines [63]. 160].3 The projection data of the tooth from multiple different radiographic densities of the tooth tissues (c) directions (a) is used as input for a reconstruction algo.2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 21 a b c d Root canal space Dentin Enamel Fig. 2. 167–170]. radicular grooves [134. Though. 143. 146. The tional purposes [64. 159]. 140. canal in the mesiobuccal root of maxillary first 133]. three-rooted over 18 years for the micro-CT scanners gain mandibular premolars [135.1. premolars [141].4. 153. 144] and molars accessibility [3] and the first in-depth studies [154–156]. anatomy evaluated anatomical variations present Other authors evaluated the anatomical configu- in specific groups of teeth. 158. such as the second ration of conventional mandibular incisors [132.3.

98 mm3. Oval-shaped canal anatomy of 80 μA. voxel size: 16. long and shallow RG extended beyond the coronal third of the root (in radicular grooves (RG) one specimen. short RG at the coronal third.31 mm. major and minor diameters.64.59 ± 0. The mean area. surface area. canal anatomy of 80 μA. respectively. 3. Lateral and furcation canals were observed mostly in the cervical third.2 % Leoni et al.52 ± 3. From a proximal view.or oval-shaped configuration of the canal in the apical third of both groups of teeth Gu 2011 (China) [134] To investigate the Siemens Inveon (n.43 and 0. 13. Vertucci’s types I and III were the most prevalent canal configurations.88 mm. a cross-sectional teardrop-like canal was observed). voxel RG were classified into type I (n = 3). .11. The mean distance from the root apex to the major apical foramen mandibular canines was 0.16 to single-rooted 0.83 mm2. invagination. RG were located at mesial (n = 3). and SMI were 0.7 μm) root.r. 31 % of the samples had no accessory canals.16 ± 11. and type III in maxillary lateral (n = 3).4 mm2. and in both (n = 1) aspects of the root Versiani et al. Versiani et al. respectively n.1 Micro-CT studies on the root and root canal morphology of incisors and canines 22 Authors Aim Scanner specifications Main conclusions Almeida et al. 0. voxel size: 22. respectively Versiani et al.36 ± 0. voxel size: 19.A.6 μm) foramen varied considerably and its major diameter ranged from 0.72 mm. type II anatomical features of size: 15 μm) (n = 5). distal (n = 6). Mean major and minor diameters of the canal 1 mm short (n = 100) of the foramen were 0.31 mm2. From a buccal view.70 ± 0. The average roundness represented a flat.27 ± 0.86. no straight lingual root (n = 14) with two roots occurred. 2013 (Brazil) [63] To investigate the root SkyScan 1174 v2 (50 kVp. The area of the root canal in both teeth increased gradually in the coronal direction. Bifurcation was located in both apical (44 %) and middle (58 %) thirds of the canal anatomy of 80 μA. and two distinct canals Location of the apical foramen tended to the mesiobuccal aspect of both roots. In both views. perimeter. 2013 (Brazil) [132] To investigate the root SkyScan 1174 v2 (50 kV. roundness.35 ± 0. 2014 (Brazil) [133] To investigate the root SkyScan 1174 v2 (50 kV.14 mm. not reported M. long and deep RG associated with a complex root canal system (C incisors (n = 11) shaped.72 ± 0. volume.09.85 ± 0.9 μm) however. and 3.6 μm) canals in the apical third were not uncommon and were more prevalent in the mandibular incisors type III anatomy. S-shaped roots were found in 21 % of the specimens.87 to 3. however.Table 2.33 ± 4.69 ± 0.r. most of the incisors had no accessory canals.36 mm and 0. SMI ranged from 1.25 mm. and additional root/canal). No (n = 100) and lateral difference was observed in the comparison of the morphometric parameter (n = 100) incisors analyzed between central and lateral incisors. 8 new types were described. 1. no curvature toward the lingual or buccal direction mandibular canines occurred in either roots.. The incidence of 2 or more root canals at the apical third was (n = 340) 3. Accessory canals were observed only at mandibular central the apical third. form factor. Mean volume and area of the canals were 11.5 ± 16. 63. The location of the apical canal anatomy of 80 μA. 2011 (Brazil) [68] To investigate the root SkyScan 1174 v2 (50 kVp.44 mm3 and 71. Vertucci’s type III configuration represented 92 % of the samples. voxel size: 19. 0.

It was not (China) [136] morphology of C-shaped voxel size: 37 μm) possible to define the canal configurations in the middle and apical canal third by just mandibular first premolars with assessing the morphology of coronal canal. and interrupted by non-C-shaped canal. C-shaped mandibular first premolars had a groove on the mandibular first premolars with size: 38 and 30 μm) external root surface.7 %.98 ± 1..3 %) and distal (69. and a (n = 1) premolars prominent vertical root groove on buccal surface. 69 % of (China) [141] of the lingual canal in mandibular (80 kVp. The greatest first premolars with Vertucci’s type voxel size: 14. Overall.36 mm.5 % and (China) [139] the root canal and the groove in (80 kVp. If one RG C-shaped mandibular first voxel size: 15 μm) was present (n = 125).7 to 14. Canal system had a C-shaped morphology through the majority of the mid-canal system. [135] mandibular first (n = 1) and second The mandibular second premolar exhibited a single root. 102 sections (China) [138] and groove configuration in voxel size: 15 μm) exhibited a mesial groove.r.94 mm. Corresponding canals 2008 (Canada) the root and canal morphology of voxel size: 30 μm) divided in the middle to apical third of the root. 2012 To investigate the root and canal Scanco μCT-20 and No C-shaped canals were found in teeth without RG.24° and 43. C-shaped groove (RG) canals were found in 29 specimens (19.2 %) root walls Gu et al.r.5 % of the specimens. 500 μA.2 Micro-CT studies on the root and root canal morphology of premolars Authors Aim Scanner specifications Main conclusions Cleghorn et al.r. if two premolars (n = 148) with radicular RGs were present (n = 15). Two canals and bifurcations were dominant at the middle and apical third. 2008 To investigate the root and canal Scanco μCT-80 (n.r. respectively. the minimum thickness occurred at the lingual aspect of groove (RG) the mesial (67. a single apical foramen. Detection and instrumentation of a second canal (n = 86) and without (n = 54) of a bifurcation located further apically may be a difficult task radicular groove (RG) by accessing the morphology of canal orifices Fan et al. another groove was located on the distobuccal side. C-shaped canals was observed in 29 teeth (19. The wall thickness C-shaped mandibular first decreased at increasing distances from the CEJ.2 % of premolars with RG. The complexity of canal systems in mandibular premolars may be determined by the severity of the RGs Li et al. radicular groove (RG) Seventy furcation canals were observed and 57 were located in C-shaped premolars Gu et al. 155 RGs were observed in 140 premolars.9 mm. Mandibular first premolar exhibited three distinct. 2013 To investigate the relation between Siemens Inveon Mean root length was 12...39°.r. the location was mostly on the mesiolingual side of the root. respectively (continued) 23 . The morphology of C-shaped canals was classified as continuous. The prevalence of furcation grooves was 85. separate roots. The maxillary first premolars (n = 42) wall thickness of the buccal roots was buccopalatally asymmetric Li et al. (n = 146) and without (n = 181) semilunar. 2 Table 2. The mean groove length was 3. which terminated in a single apical foramen Fan et al. voxel 66.6 %) and 107 cross sections.. Most of them (69. Buccal and lingual walls were thicker than premolars (n = 148) with radicular the distal and mesial walls. continuous combined with semilunar. 18. 2013 To investigate the furcation grooves Scanco μCT-80 (n. 500 μA. lingual canals began at the middle third and the remainder at the apical third. 2012 To evaluate the anatomical aspects Siemens Inveon The lingual canal orifice was located at the middle-apical third with severe angle. Shallow and deep RGs were found on 37. To investigate unusual variations in Feinfocus 160 (n.6 %) and 107 cross sections. C-shaped canals were identified in (China) [137] morphology of C-shaped μCT-80 (n. The root length ranged from 9. 2013 To investigate the wall thickness Siemens Inveon (n..4 %) were located in the Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography (China) [140] in the buccal root of bifurcated voxel size: 36 μm) coronal and middle thirds of the buccal roots.97 μm) angles “a” [curvature at the beginning of the lingual canal] and “b” [lingual canal curvature] V canal configuration (n = 26) were 65. A prominent furcation canal was present.

2013 To investigate the canal Siemens Inveon The shape of the canal orifice was classified as oval (84.97 μm) identified as types I (65. and triangular (1.A.7 % of the teeth and most of them (92.2 %). and apical delta were observed n.4 %).7 %). Accessory canals were present in 35.r. fusion of canals. Ten specimens did not fit Vertucci’s classification. Versiani et al.7 %). (7. To evaluate the applicability of SkyScan 1072 Mesiobuccal (MB) canal area was greater than distobuccal (DB) canal.1 %) apical foramens was observed mostly laterally (77. Micro-CT images 2013 (Brazil) micro-CT and iCat CBCT system (50 kVp.2 (continued) 24 Authors Aim Scanner specificationsMain conclusions Liu et al.Table 2.9 %). Complexities of the root canal systems such as the presence of with Vertucci’s type IX canal furcation canals. not reported M.7 %) located in the apical third.6 %).2 % of mandibular premolars with radicular grooves. III (2. et al. Apical delta and intercanal communications were present in 6.0 %).8 % of teeth Marca et al. two (28. canal trifurcation in the apical rooted maxillary premolars (n = 16) third. small orifices at the configuration (n = 16) pulp chamber level. 500 μA. Root canal configuration was premolars (n = 115) voxel size: 14. flattened ribbon shaped (China) [142] morphology of mandibular first (80 kVp. voxel size: revealed more details than CBCT including the presence of 3 and 2 canals in the middle [143] to study the anatomy of three. eight shaped (7. and VII (0. . or four (6. 80 μA. oval-shaped canals at the apical level. three (14.1 % and 3.6 %). 34 × 34 × 42 μm) third of the MB and DB root of one specimen. respectively. V (22.3 %). lateral canals. The presence of one (50.8 %).5 % of the samples. voxel Most of them had a triangle-shaped pulp chamber in which the distance between the MB (Brazil) [144] anatomy of mandibular premolars size: 18 μm) and L canals was the largest. and differences in cross-sectional canal shapes in different levels of the root Ordinola-Zapata To describe the morphometric SkyScan 1174 v2 Type IX configuration was found in 15.4 %). 2013 aspects of the external and internal (50 kVp. Mesial invagination of the root was observed in 27.0 %).

.82. Mandibular first molars had more isthmuses with separate and of mandibular first (n = 70) mixed morphological types.) C-shaped canals varied in shape at different levels. 16 had a type II configuration. in which 94 samples had only 1 isthmus.. 1/5 of specimens showed 4 or more canals. voxel size: n.73 and 0. V.19 to 0. A total of 115 main and 41 accessory second molars (n = 44) foramina were observed. and 6 round orifices (n = 44) Fan et al. voxel size: n. voxel size: 37 μm) 107 molars (85 %) had isthmuses in the apical 5 mm of mesial roots... suggesting that the debridement of these canals mandibular second molars would be more demanding than type II (canals continue on their own pathway to (n = 54) the apex). 2007 To investigate the Scanco μCT-20 (n.r. or VI) or 3 (i. voxel size: n. The development of a device for contrast medium radiography in detecting introduction into anatomically complex root canal systems might lead to a useful C-shaped canals in clinical diagnostic tool mandibular second molars (n = 30).r.3 Micro-CT studies on the root and root canal morphology of mandibular molars Authors Aim Scanner specifications Main conclusions Cheung et al. with most of them occurring within 2 mm from the apex Fan et al. (China) [146] ways to negotiate the root 14 a type III configuration. 2010 To investigate the Scanco μCT-80 (n.07 to 0. 14 mesiobuccal-distal. using a contrast medium (continued) 25 . Prevalence of accessory and [145] C-shaped mandibular lateral canals ranged from 11 to 41 %. respectively Fan et al. voxel size: 30 μm) Most of the samples had 2 (i.r.r. and 13 isthmuses in the mesial root samples had 2. The total number of canal system of C-shaped the orifices was 83 including 8 continuous C-shaped.. type II.r. while second molars had more isthmuses with sheet and second (n = 56) molars connections Fan et al. None of the orifices was (China) [148] morphology of C-shaped found at the level of the CEJ..1 % were located within 3 mm below the CEJ. Canal bifurcation was (n = 54) observed in the apical 4 mm of 17 teeth. C1 and C2 configurations radiography in detecting were prevalent in types I (mesial and distal canals merge into one before exiting) C-shaped canals in and III (separated canals) teeth.r.32 mm and from 0.e. with a mean form factor of 0. To investigate the apical Scanco μCT-20 (n.) C1 (uninterrupted “C”) and C2 (shape resembled a semicolon) configurations (China) [149] predictability of the always have narrow isthmuses closed to the groove.r. type VIII) root 2007 (China) canal morphology of canals. 1/4 of the orifices were found 1 mm below CEJ. and 6 a type IV configuration. 41 oval.r. 2009 To investigate effective Scanco μCT-20 (n. C-shaped canal system in mandibular molars might be predicted according to the radiographic appearance Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography Fan et al. 14 mandibular second molars flat.. The total (China) [147] morphology of the number of isthmuses was 120. 2 Table 2.) The contrast medium helped to discern the C-shaped canal anatomy in (China) [150] predictability of the mandibular second molars.10 mm. 2004 To investigate the Scanco μCT-20 (n..e. IV.r.r. The diameters of the main and accessory foramina ranged from 0. 2004 To investigate the canal Scanco μCT-20 (n. voxel size: n.) 8 teeth had a continuous C-shaped orifice (type I). mandibular second molars while 98.

respectively..r. while 25 roots showed a pattern of sections with and without isthmus. Grooves two-rooted (n = 25) could be observed between adjacent orifices.r.. web.Table 2. The lingual edge of the three.3 (continued) 26 Authors Aim Scanner specifications Main conclusions Fan et al.. In 65 % of the 3-rooted teeth. In type III (n = 28). which blocks the view of the canal. mandibular first molars mesial root contained a type 2-2 root canal configuration. affecting the classification of (DSR) in detecting the canal anatomy. 2009 To investigate the GE Explore Locus SP (n. 2010 To investigate the root GE Explore Locus SP (n. which would prevent contrast media from mandibular second molars entering this area (n = 30). Type 1-1 canal occurred more frequently in the DL and DB roots. . such as the X-ray-projecting angulation and (China) [151] predictability of the digital the degree to which the contrast medium is distributed within the canal system. 32 teeth had isthmus mandibular first molars somewhere along its length.A. 2006 To investigate the Scanco μCT-20 (n. voxel size: C-shaped canals were assigned as follows: in type I (n = 32). The prevalence of an isthmus was higher at the apical 4. Furcation canals were not observed M.r.r. respectively. or ribbon (China) [153] isthmuses in mesial roots of 15 μm) connecting the individual canals.r. This discrepancy could be the result of incomplete cleaning C-shaped canals in in the apical canal merging 6-mm level in the 20. Symmetry of the mesial canal and distal canal was second molars (n = 98) present along the root. 2008 To investigate the Scanco μCT-20 (n. but not in the coronal portion Gu et 39-year-old age group (up to 81 %) Gu et al. Seven out of 32 roots had a continuous isthmus (n = 36) from coronal to apical end. The distal canal may have a large isthmus across the furcation area. voxel size: The morphology of the isthmuses includes the presence of fin. The (China) [154] canal configuration in 21 μm) third root usually curved severely in the proximal view.. the incidences of lateral canals were 65 % and 40 %. In type II (n = 38).) It was observed that some factors. canals merged into (China) [152] morphology and canal wall 11 × 11 × 500 μm/30 × 30 × 100 μm) one major canal before exiting at the apical foramen. subtraction radiography could change the shape and size of canal images.(n = 20) and orifice might form a dentinal shelf. thickness at different levels separated mesial and distal canals were located at the mesial part and distal part of C-shaped mandibular of the root. voxel size: n. using a contrast medium Gao et al. In mesial and distal roots of three-rooted molars. Differences in the minimum canal wall thickness were observed in the apical and middle portion. separate mesial and distal canals were evident. Versiani et al. voxel size: Pulp floors with two mesial and two distal orifices were frequent (n = 16). which commonly made the mesial and distal canals asymmetrical. In the apical third.

voxel size: The length of DL roots was shorter than the DB and mesial roots. Types V and I were the most (n = 22) common configurations of the canal in the mesial and distal roots. voxel size: 17 roots had isthmuses in one or more sections of the apical third. respectively (Schneider method). ML.99 mm in central view. Secondary curvature three. 2011 To investigate the root GE Explore Locus SP (n.25 to 1.r. The morphology of the isthmuses varied between teeth and within the same tooth (continued) Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 27 .0 μm) 17 roots with isthmuses had a continuous isthmus from coronal to the apical end. voxel size: In the 3-rooted molars. the mean angle and radius of the DL canals were 59. the mean degrees of curvature in the MB and ML canals (China) [155] canal curvature in 21 μm) were 24. [158] mesial root of mandibular The other 3 roots showed sections with and without isthmuses.25 % in the apical 5 mm of the root canals.K.36 portals of exit was observed in the apical 0.. ML. respectively.53 μm) In the apical third of the distal root. 2010 To investigate the root GE Explore Locus SP (n. and #45.r. 2013 To investigate the canal n.06°). The MB.41 × 12.1 % of the distal roots. In the mesial and distal roots. The percentage first molars (n = 20) of sections showing isthmuses ranged from 17. In proximal view. DB.(n = 20) and was rare in the mesial root. (n.17 mm in proximal view and 26.39°.) at the apical third of the 12. It was suggested that the initial apical mandibular first molars file for a DL canal should be 2 sizes smaller than that for a DB canal.35 mm.5 × 12. the mean thickness of dentin on the mandibular first molars furcation side ranged from 0. 2 Gu et al.34° and 22. respectively. The buccal (China) [156] canal morphology in 21 μm) and lingual canal walls were thicker than the distal and mesial for MB.25 to 50.5 mm of the roots Mannocci et al. DL. (USA) [157] morphology of the 11.. The mean angle of the second curvature was approximately twice mandibular first molars that of the primary one. and three. To investigate the isthmus GE Testing Lab (100 kVp. Isthmuses were found along the length of all of the mesial roots (100 %) and within 9.04° and 6. voxel size: Mean distance from the mesial to distal orifices at the pulpal floor was 4.. Only 4 out of 2005 (U.73 and 3. Using Pruett method. The frequency of S-shaped canals was 60 % of the two-rooted (n = 25) DB canals. an average of 3.17° and 20. The distal wall of the MB/ML canal and the mesial wall of the DB two-rooted (n = 25) and DL canals were the thinnest zones.5 × 25.r.47 mm. and MB/ML canals should be instrumented to a mean size of #55. #40.r. and DB canals were mostly oval. the DL canal exhibited the greatest degree of curvature (32.(n = 20) and DB canals. while the DL canals were relatively rounder Harris et al.21 × 17. respectively. The curvature in the DL canals had a more severe angle and smaller radius in the proximal view Gu et al.

3 (continued) 28 Authors Aim Scanner specifications Main conclusions Min et al. Versiani et al.91 % of the pulp chamber floors were within 3 mm below the CEJ. 2006 To investigate the Scanco μCT-20 (n. 2-.r. 0. and 0.r. while the buccolingual diameters were 0.54. not reported M. 0. To evaluate the morphology SkyScan 1076 (n. and 4-mm levels were 2011 (Brazil) of the canal and the 0.22. respectively. The volume of the apical third ranged from 0. and 0.49. Six teeth with a C-shaped canal (n = 44) system showed non-C-shaped chamber floors. Types II and III were mandibular second molars observed in 16 and 14 teeth. The (China) [159] morphology of the pulp location of grooves was usually 4 mm below the CEJ.27.35. the canal configuration was similar to those present in conventional mandibular molars with separated roots.4 mm3 n.r.A. and apical third of the mesial 0..55. In type II teeth. in the MB canal and 0. 0.35 in the ML [160] presence of isthmus at the canal.) 90. there was a large MB-D orifice and a small ML orifice Villas-Boas et al.3.r. 0. 0. 0.54 in the MB canal and 0. 27 teeth second molars (n = 60) presented complete or incomplete isthmuses at the 1-mm apical level. . respectively. voxel size: 18 μm) The median mesiodistal diameter (in mm) at the 1-.Table 2. 3-. respectively. In type III teeth. 0. 4-mm level. root of mandibular first and The presence of isthmuses was more prevalent at the 3.02 to 2.6 in the ML canal.41. and 0. Eight teeth had a chamber floor of C-shaped continuous C-shaped orifice and type I canal configuration. voxel size: n.3.

5 %. voxel size: more canals. Fifty-seven percent (8 out of 14) of maxillary canals in the MB root of second molar MB root had 2 canals exiting as 2 or more foramina maxillary first (n = 13) and second (n = 14) molars Gu et al.5 × 39. roots of maxillary first 15.6 %). III. but similar from those acquired using CBCT and micro-CT in size: 20 μm) system (Kodak 9000). the most common configurations were types molars (n = 154) II (23 %). 114 μA. 27.. 2 Table 2.r. Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography Twenty (17. voxel IV (Weine’s configuration) were observed in 39. moderate in the DB canals. Using Vertucci’s classification.5 % of the samples. 73. and 17.3 %).8 μm) 15 MB roots had a completely independent second canal. 2012 To evaluate the reliability Hitachi MCT100-MFZ A second canal in the MB root was observed in 60.4 % roots presented additional canals. and apical thirds were 40. VI (13.) respectively. Korea) [162] minimum-intensity size: 31. II (23 %).0 μm) the P canals.. VII (5.5 %).2 % of roots had multiple apical foramina. The curvatures increased in the apical third when accessory canals are present. and VIII (0.8 %). Eleven roots showed 6 new adjunct to evaluate the configuration types.9 %). 49. III (10.6 %. The incidences of root of maxillary first intercanal communication in the coronal. Intercanal morphology of the MB communications were found in all roots having multiple canals. while 9 had 3 canals. voxel 24 roots had a single canal. voxel was different compared to digital radiography.5. detecting a second canal size: n. 2011 (South To evaluate the use of SkyScan 1172 (n. II. MB roots had 2 canals. 53 roots had projection technique as an 2 canals that joined into 1 or had 1 canal that divided into 2. The most prevalent configurations were Weine’s types III (32. particularly in MB and DB canals (continued) 29 . 2013 (South To investigate the canal SkyScan 1172 (100 kVp. 100 μA.9.7 %) roots had 12 new configuration types Lee et al. 1999 To analyze the correlation THX1430 GKV (n.4 Micro-CT studies on the root and root canal morphology of maxillary molars Authors Aim Scanner specifications Main conclusions Bjørndal et al.5 × 19. 94 roots had two canals and 19 roots had three or Korea) [164] configuration in the MB 100 μA. it was verified that the number of canals determined with micro-CT (USA) [161] of radiography. V (9. 82.7 %)..r.5 % of the samples. respectively Hosoya et al. middle. of which 69 % determining the number of (9 out of 13) exited as 2 or more foramina. voxel Curvatures were most pronounced in the MB canals. IV (19.9 μm) and IV (15 %). and least in Korea) [165] curvature in maxillary first size: 19.3 %). 2006 (South To evaluate the root canal SkyScan 1072 (n. There was a strong correlation between the shape of the canals and the root components.2 % of the MB roots. In all maxillary first molars.6 %. 2013 To evaluate the reliability Scanco VivaCT 40 Using human cadavers. (Denmark) [125] between the shapes of the voxel size: 33 μm) Authors suggested that 3D volumes generated by micro-CT technology would constitute a outer surface of the root platform for preclinical training in fundamental endodontic procedures and the canal in maxillary molars (n = 5) Domark et al.r.r. Multiple canals were observed in 76. Detection of the second canal was higher for micro-CT and dental CT than the in the MB root of other diagnostic tools maxillary first molars (n = 86) Kim et al. CBCT. and (Japan) [163] of different methods in (65 kVp. molars (n = 110) and 44. (70 kVp. Types I. 15.1. Accessory canals within the apical third were present in almost half of the MB molars (n = 46) canals and nearly a quarter of the DB canals.

which presented (Brazil) [67] morphology of four. In 5 teeth (21 %).r. the configuration of the root canal in the apical third.5 % of the samples. No furcation canals were observed. . 17. 37 %) followed by types I (single root of maxillary first canal. and apical delta was observed in 12 % of the molars (n = 25) roots.3 %. while 14 roots had two canals that either joined into one canal. voxel size: n. two had completely independent MB canals. not reported M. 56 % of the sample presented an irregular quadrilateral-shaped orifice configuration. 80 μA. An independent canal was observed in 42 % of roots. the SMI. tapered (15 %).A.. II (2 MB canals that joined.2 % of the roots had 2 canals.15 ± 0. the volume. molars (n = 46) 10. In 18 roots with multiple canals. 2012 To investigate the canal SkyScan 1174 v2 Most of the roots presented straight with 1 main canal. and 6. The morphology frequencies of apical constrictions were parallel (35 %). Three separated apical foramina and apical delta were present in 20 % of the samples Verma and Love 2011 To investigate the canal SkyScan 1172 (80 kVp.5 × 39 μm) common configuration was type III (2 distinct MB canals. Intercanal communications were found in 55 % of the roots located in all areas of the roots. voxel 2 canals in 24 % of the sample. voxel 65.57 mm. a second molars (n = 30) canal had its origin some distance down the orifice. Versiani et al. Types II and III (Weine’s (New Zealand) [169] configuration of the MB 85 μA.r.6 μm) configurations that could not be classified by Weine’s or Vertucci’s classification systems. 28.6 % of the samples (n = 90) n. and delta (12 %) and second molars (n = 40) Park et al. however. and completely separated canals in 33.3 %.3 %). 2011 To investigate the canal HMX225 ACTIS4 Single root canals were observed in 44. The mean distance from the pulp chamber floor to the furcation was 2.9 %). 6. Accessory canals were of maxillary first molars size: n. 40 and 30 % of the roots had root of maxillary first 11. IV (1 MB canal that split into 2. A single apical foramen was found in 37 % of the samples. while the 35 % had a 2011 (USA) [166] morphology of the palatal (n. Two roots had three canals with separate orifices.r.3 % had 1 canal. 80 % of the roots had 2 canals. canal of maxillary first single (19 %). Accessory canals were rooted maxillary second size: 22. while root of maxillary first 19. while 2 foramina were present in 23 % of the samples. molars (n = 20) respectively. voxel canals in 22. except the MB root.r.) observed in 76. (Italy) [168] configuration of the MB 98 μA.r.5 %) Somma et al. incomplete separation of root (Japan) [170] anatomy of the MB root (100 kVp. voxel size: Communications between canals were found mainly in the coronal and middle thirds.4 (continued) 30 Authors Aim Scanner specifications Main conclusions Meder-Cowherd et al. voxel size: classification) were the most prevalent configuration.6 μm) located mostly in the apical third of the roots.1 × 19. or showed multiple intercanal communications Versiani et al. Isthmus and intercanal connections were observed in different regions of the same root. 2009 To investigate the canal SkyScan 1072 (100 kVp. 75 μA.Table 2. or one canal divided into two or multiple canals. (50 kVp. To evaluate the apical Siemens Micro-CAT II 65 % of the specimens had no constriction in the apical 1–3 mm. and V (3 canals. Multiple foramina and accessory canals were found in 17 roots.1 × 38 μm) accessory canals and loops were mainly found in apical third. 28.4 %). The most Korea) [167] configuration of the MB size: 19.5 % had 3 canals. and the surface area of the root canals Yamada et al. 2009 (South To investigate the canal SkyScan 1072 (n. flaring (18 %). No difference was observed between roots by considering their length.) constriction.5 × 19.

(g) [182]. or irregular the shape of the accessory foramen was more shaped [242].56. 181]. with 1 signifying a circle. oval. and 2.High frequency of apical root curvature to the disto-buccal direction Dens evaginatus(p) . form factor is calculated by the equation (4. and Previous results using these parameters in single- perimeter.A/ and location of accessory.Average length: 22. 2. objects results in smaller values of form factor.Large midroot canal diameter . the presence and roundness. lateral. 171.Average length: 22 mm 4 canals(g) C-shaped(p) Talon cusp(r) Apical curvature(s) Lateral incisor . these same parameters can sectional forms throughout the root canal [63]. In contrast. 3D analysis was applied description of these cross-sectional appearances qualitatively to evaluate the number and configu- using two morphometric parameters: form factor ration of the main canal. flat. (i) [172–174]. and furcation . (k) [187]. in the same root may have impact on the selected dreds of slices at once. 2. Roundness is defined as 4. (e) [177–179]. References: (a) [171].Average length: 26. ranges from 0 to 1. (c) [175]. Elongation of individual conventional methods were taken from measur. (h) [192].4.6.5 mm or less from the apex and 94. 61] on root canal anatomy using eter. micro-CT evaluation allow a mathematical In the earlier studies.9 % were approximately 2 canals(b) Two-rooted(i) 1. extracted from selected references.5 mm Central incisor Two-rooted(l) Radicular groove(m) Fusion/gemination(n) 2 canals(e) 1 canal 3 canals(f) Dens invaginatus(o) .2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 31 Normal 3D models anatomy(a) Variations Anomalies Clinical remarks(u) . and maxillary molars [166]. (q) [191].A total of 79. a qualita.p.Root canal cross-section is usually oval-shaped 1 canal 2 canals(h) Dens invaginatus(t) . (m) [186].0 mm or less away 1 canal 3 canals(c) Radicular groove(j) . as well as.7. ing some parameters such as area. which may canals of mandibular second molars [145] lead to inaccurate results.4 % of the lateral canals has a mean diameter less than an size 4 canals(d) Fusion/gemination(k) 10 K-file . ment. Form factor was also used to describe that tively classified as round. (o) [32]. (s) [193]. 195] premolars [142]. where “A” is the area and “dmax” is Summarized data for canal numbers and its varia. the canal shape has been also qualita. The sented in Figs. round than that of the main foramen in C-shaped tive evaluation is always subjective. acquired from a few cross sections of rooted canines have demonstrated different cross- the root. (p. This is an important data as different canal shapes nology using automatic computer tools in hun.5. 2.7 % of all foramina were located approximately 0.A)/ The quantitative morphological data of the P2. diameter. (b) [172–174]. (t) [194]. (n) [189]. 2. be easily measured by means of micro-CT tech. (u) [50. where “A” and “P” are object area and perim- first studies [41. respectively.[dmax]2). (j) [186].4 Morphology of the permanent maxillary ante. (r) (d) [176]. (p) [190]. The value of roundness tions. are pre. rior teeth. Despite its applicability.8a). Algorithms used in (Fig.5 mm Canine Fig. 2. (f) [180. (l) [188]. Based on cross sections of chemomechanical protocol on root canal treat- the root. the major diameter. [183–185].

Often a dentinal bridge is present in the pulp chamber that divides the root into 2 canals . 7 canals(g) Hypertaurodontism(r) 2 or 3 root canals. (k) [203].In cross-section at the CEJ.2 or 3 canals can occur in a single root . (l) [204]. they may persist as 2 separate canals Two-rooted(g) .Most incisors have a single root . (h) [68].The root canal system is wider buccolingually than mesiodistally 1 canal 2 canals 3 canals(c) Dens invaginatus(o) . (d) [213]. which makes the canal. because this tooth often has 2 canals . (f) [199]. (m) [205].The palatel canal usually is slightly larger than 2 canals 1 canal 3 canals(b) Gemination/fusion(m) the buccal canal Dens evaginatus(n) .7 mm Central or lateral incisor . a lingual shoulder must be removed 1 canal 2 canals(b) 3 canals(d) Two-rooted(h) to gain access to the entrance of a second canal .The 2nd molar usually has one canal in each root.A concavity exists on the distal aspect of the MB root. it may have 2 or 3 MB canals.There are 2 MB canals in majority of cases 1 canal(d) .32 M.In two-rooted canines.A. (e) [209].6 mm Canine Fig.5 mm Second premolar . (d) [197].Average length: 21. Versiani et al.Teeth with fused roots occasionally have only 2 canals (buccal and palatal) of equal length and diameter . and apical deltas. (u) [212]. 195] Normal Second most 3D models anatomy(a) frequent(a) Variations Anomalies Clinical remarks(i) . (g) [200]. (r) [210]. 3 canals 4 canals 2 canals(j) Four-rooted(t) 1 or 2 DB canals.The 2 canals usually join and exit through a single Gemination/fusion(e) 1 canal 2 canals 3 canals(c) Dens invaginatus(f) apical foramen. (i) [50. to develop well-controlled condition. (t) [67]. Besides.Generally.Palatal and MB roots contain 1 (most commom). 171. 2. (e) [214]. 3D analysis shaping had a greater effect on the changes that using micro-CT algorithms allows also for the occurred during preparation than did the instru- calculation of volume and surface area [116]. (o) [207].Incidence of furcation groove on the palatal aspect of the buccal root has been reported as between 62 % and 100 % . which makes this wall thin .6 Morphology of the permanent mandibular anterior teeth.The lingual wall is almost slit-like compared with the larger buccal wall. (i. References: (a) [171]. (f) [215]. (n) [206].8 mm First molar . 171.Location of the MB2 canal varies greatly 5 canals(e) C-shaped(p) . (v) [50.The palatal root often curves buccally at the apical third 4 canals 3 canals 6 canals(f) Four-rooted(q) . (b) [68]. (p) [208].5 Morphology of the permanent maxillary poste. the palatal orifice is wider buccolingually and kidney-shaped because of the mesial concavity of the root Furcation groove(l) . these mor- tions in canal geometry before cleaning and phological data should be taken into account in . or 2 palatal canals 5 canals(k) Hypertaurodontism(u) . (h) [201].Average length: 25.Average length: 20. 2.6 mm First premolar . wider buccolingually than mesiodistally . 195] canals. Nowadays. but. 1 canal(i) Gemination/fusion(s) however.Average length: 20.Average length: 20 mm Second molar Fig. References: (a) [171].Removal of the lingual shoulder is critical. the 3 roots are grouped closer together and are sometimes fused . . considering clinical significance of such parameters has been that the main role of laboratory-based studies is emphasized by studies demonstrating that varia. Normal Second most 3D models anatomy(a) frequent(a) Variations Anomalies Clinical remarks(v) . (s) [211]. (b. The mentation techniques [119].The root canal is narrow mesiodistally but usually very broad buccolingually .Canal cross-section is oval-shaped. (g) [216]. while DB have 1 or 2 canals 8 canals(h) . j) [202]. [198].Average length: 20. (c) [133]. (q) rior teeth. c) [196].

(t) [231]. which makes the dentin 5 canals(g) Gemination/fusion(z) wall very thin 4 canals 3 canals 6 canals(h) Isthmuses(aa) .It usually has 2 roots.Average length: 21 mm .The distal surface of the mesial root and the mesial surface Apical curvature(y) of the distal root have a concavity. .The lingual canal.Multiple accessory foramina may be present in the Middle mesial(ad) furcation area. (ae) [218]. (af) [35]. (p) [228]. (s) [135]. (w) [233]. 195] [227]. (q) [229]. (r) [230]. (z) terior teeth.The root canal is more often oval than round 3 canals(d) C-shaped(s) . References: (a) [171]. 2.The root canal system is wider buccolingually than Radicular groove(m) mesiodistally C-shaped(n) 3 canals(b) .Average length: 22. tem. changes in the canal geometry . (ad) [238]. (ai) [148.7 Morphology of the permanent mandibular pos. 171. (ac) [237]. (c) [217]. (v) [232].3 mm Gemination/fusion(v) Second premolar .2.6 mm First premolar Two rooted(r) .The lingual canal.8 mm Second molar Fig. (aa) [147]. demonstrating the qualitative and quantitative (b) Frontal and (c) lateral views of 3D models of a man. (y) [35]. although the most prevalent configurations are 3 and 4 canals Apical curvature(af) . (i) [223]. with 2 or 3 Radix(w) canals in the mesial root and 1. a b c Fig.Average length: 21.2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 33 Normal Second most 3D models anatomy(a) frequent(a) Variations Anomalies Clinical remarks(ak) . tends to diverge from (e) the main canal at a sharp angle 1 canal 2 canals 4 canals Dens evaginatus(t) 5 canals(f) Taurodontism(u) .At the cervical third is oval-shaped and tends to become 1 canal 2 canals Dens evaginatus(o) round at the middle and apical thirds 4 canals(c) Dens invaginatus(p) .The root canal system is extremely variated. (m) [139]. when present. (ab) [236]. First molar Middle distal(ae) . (d) [235]. (u) [220]. (e) [219].The 2 mesial orifices are located closer together 1 canal(j) Gemination/fusion(ag) . (o) (aj) [241]. (h) [222]. 149]. 2. (x) [234]. [239]. (b) [144]. (f) [220].The canal morphology may present many variation . (g) [221]. (j) [224].A variation in root morphology is the presence of 3 canals 4 canals 2 canals(k) Isthmuses(ah) C-shaped canal 5 canals(l) C-shaped(ai) . (n) [136]. (k) [225]. or 3 canals in the distal root Taurodontism(x) .It may have 1 to 5 canals. when present. tends to diverge from the Gemination/fusion(q) main canal at a sharp angle . (ag) [240].The apices of this tooth often are close to the Middle mesial(aj) mandibular canal . but occasionally it has 3.8 (a) Two-dimensional micro-CT cross section of dibular canine root canal before (green) and after (red) the cervical third of a maxillary first molar root showing preparation with a conventional multiple-file rotary sys- the 2D parameter measurements of the four root canals.Average length: 19. (ah) [147]. (ak) [50. (l) [226].The presence of root canal isthmuses averages 55% in the 7 canals(i) Three-rooted(ab) mesial root and 20 % in the distal root C-shaped(ac) .

In order to circumvent limitations gener- similarities should be taken into consideration ated by the unpredictable anatomical configura- during the root canal preparation as it might tions of the root canal. Preparation of oval-. several instruments and techniques have been developed and are properly detailed in this book. a b c Fig. 153.34 M. 126–129. isthmuses.or cylinder-like areas may also be packed with dentin debris gen- geometry of an object. 246]. and to counterbalance the suboptimal debride- tion quality. shaped cross-sectional root canals using different Another interesting 3D parameter that can be instruments has shown to leave unprepared exten- evaluated using micro-CT is the so-called struc. necrotic pulp tissue and biofilms [242. 243]. The Influence of Root Canal efficient irrigation solutions and protocols are Anatomy on Irrigation Procedures required to provide fluid penetrability to such an extent as to accomplishing a microcirculation Advances with micro-CT analysis brought new flow throughout the intricate root canal anatomy perspectives on the overall mechanical prepara. 68.A. where S is the object surface area disinfecting effects of instruments and irrigants before dilation and S’ is the change in surface may be additionally hampered in the presence of area caused by dilation. as well complexity of the root canal system. the canal space assumes a pivotal role in treat- 116] (Fig. These hard-to-reach grinding. disinfection procedures more predictable. A recent study has shown a ment because it acts mechanically and chemi- large discrepancy between the minimum and cally on remnants of necrotic pulp tissue and maximum values of SMI in the comparison of the bacterial communities colonizing the main canal root canal thirds in a same tooth [63]. making cleaning and compromise the treatment outcome. tools in acting within the anatomical complexity ies might demonstrate the effect of canal anatomy of the root canal [81. SMI is derived as 6. preventing the irrigant flow into them as well as face area. The SMI is determined by erated and pushed therein by endodontic instru- an infinitesimal enlargement of the surface. 2. to the convexity of the structure. sions or recesses which can harbor remnants of ture model index (SMI). respec. 244].V)/S2). Versiani et al. 119. confirming the inability of shaping ment quality obtained by currently available . 67. and fications.9 Three-dimensional micro-CT models of the red) with single-file reciprocating systems. 245. flattened-. canals connected by isthmus (c).9). sphere have SMI values of 0. or irregular- 243. and apical deltas. 118. intercanal connections. c). rami- object volume. that is. An ideal plate. Ideally.8b. and 4. fins. The ((S’. by neutralizing its efficacy [247. accessed and cleaned by conventional techniques ventional techniques such as radiographs or [147. From left to mesial root system of 8 mandibular molars presenting right. 158. undilated complex anatomy such as accessory canals. SMI is impossible to achieve using con. These dis. interfering with disinfection by both the change in volume is related to changes of sur. cylinder. [243]. V is the initial. and describes the plate. 243]. rather than the variable of interest [63. the amount of non- as. 68. This parameter has been used to assess root canal Based on the aforementioned assumptions. 248] (Fig. 3. 2. as the results of such stud. 243. 168. which cannot be properly tively. while ments. geometry three-dimensionally in anatomical spreading and flushing the irrigant throughout studies of different groups of teeth [63. 2. after preparation (in prepared canal surface areas (in green) also increases the sample selection. it is possible to observe that with the increase of the regular (a) and irregular (b) tapered root canals.

to the irri- of the root canal space. Below: same cross sec- I root canal configuration molar. 2. solution or the root canal areas effectively Using micro-CT. such as the volume of the (Fig. 245. . 2. subsequently to the injection of a path. 68. 119. but they are unable to show of the irrigant within the root canal space some critical factors. A comprehensive An ideal experimental model should allow a quantification of irrigant-free areas can also be reliable in situ volumetric quantitative evaluation calculated and correlated. 244. canal preparation. It includes artificially created of the root canal system [63.2 Update in Root Canal Anatomy of Permanent Teeth Using Microcomputed Tomography 35 a b c d Middle third cross-sections Apical third cross-sections Fig. several experi. tion (in white) and irrigant-free areas (in black) after glide gation technique (d). the correlated to the full root canal volume and with destructive approach of these methods stands for the presence of some anatomical irregularity or its major drawback.1. spreadability of the irrigant. Micro-CT technology may also and in vivo use of radiopaque solutions [254– overcome several limitations displayed by the 256]. root canal preparation (c). the presence of dentin debris that may avoid the tion of the root canal is unknown.10). computational fluid dynamics (CFD) [251–253]. for example. irrigation. limitations of different irrigation protocols. 2. fluid activation system. histological cross sections [250]. Recently.2. tions of the root in different levels showing the root canal omy (in green) prior to treatment (a) and after glide path space (in black) before preparation and the contrast solu- (b). technique for the three-dimensional assessment tion protocols. as it provides three-dimensional quan- ing and shaping procedures which cannot other. 67. These methodological approaches provide conventional methods on the study of root canal valuable information about the quality of clean. and ultrasonic irrigation contrast solution (in black). offering a deeper and gant delivery method. and 2. since the preoperative condi.3. micro-CT has gained increasing signif- mental models have been used to understand the icance in endodontics as it offers a reproducible intracanal effect of irrigants by different irriga. Besides. 2. 248] in different groups of teeth (Tables 2.4). Original root canal anat. titative volumetric and two-dimensional mapping wise be obtained. grooves [249]. and ultrasonic passive irri. the volume of irrigant can be touched by the irrigant [257].10 Three-dimensional micro-CT models of a type in blue after each preparation step. In laboratory-based studies. Irrigant-free areas are shown technology in the mechanical enlargement of the comprehensive understanding on capabilities and root canal space [246].

36 M.A. Versiani et al.

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An interdisciplin- Medical Center Groningen. Boutsioukis. the flow developed inside the root canal system. so syringe irrigation is frequently used just as a control regarded a priori not C. DOI 10.M. it is still recommended for use lications primarily aim to evaluate new irrigation [51. their practices [31].W. this chapter will also discuss the physi- cal properties of commonly used irrigants. University advantages and limitations. van der Sluis.M. be totally replaced by other delivery techniques Gustav Mahlerlaan 3004. MSc.1007/978-3-319-16456-4_3 . Amsterdam 1081 LA. PhD (*) effective and unnecessary bias is introduced. Therefore. entrapment and removal of air bubbles. DDS. The Netherlands any time soon. DDS. a recent survey indicated that techniques. The Netherlands ary approach combining endodontics and fluid © Springer International Publishing Switzerland 2015 45 B.). this chapter will focus e-mail: c. most pub- irrigation systems. In addition to the equipment used clinically (syringes and needles). It Department of on the specific aspects of syringe irrigation that L.boutsioukis@acta. 76]. PhD need to be optimized and will also highlight its Department of Conservative Dentistry. Essential background knowledge on fluid dynamics will also be provided. ing root canal treatment dates back more than Over the years. In fact. forces applied on the root canal wall. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. Academic Centre seems rather unlikely that syringe irrigation will for Dentistry Amsterdam (ACTA). Introduction approximately half of the responding AAE mem- bers only used conventional syringe irrigation in Irrigant delivery by a syringe and a needle dur. Despite its long history and the optimize the various parameters related to this development of newer and more sophisticated technique has diminished. Groningen. Syringe Irrigation: Blending Endodontics and Fluid Dynamics 3 Christos Boutsioukis and Lucas W. the interest to investigate and a century [91]. An interdisciplinary approach involving well- established methods from the field of fluid dynamics can provide new insights into the mechanisms involved in cleaning and disinfection of the root canal system by this method. Nowadays. van der Sluis Abstract Syringe irrigation remains a widely used irrigant delivery method dur- ing root canal treatment. Basrani (ed. irrigant refreshment. and the anatomical chal- lenges faced by syringe irrigation.

ganisms/biofilms.. sion. been investigated by interdisciplinary approaches tion of interaction with the targeted material. decreases [44. and the dura. chemical disruption At the moment. relative importance of each one of these effects ganisms and inactivation of endotoxin. a process and also elsewhere in this book. gravity. i. In areas point of view. initial delivery and penetration. thus exerting the mechanical effect. the active irrigant and require its penetration to the chemical effect can only be exerted by chemi. The chemical effect strongly depends medical field are anything but uncommon. most of the aims and objectives mentioned in but this process is markedly slower than convec- this list can be grouped together since they are tion. there is no consensus on the or inactivation of biofilms. dentin debris cess of root canal treatment. This way.g. 65.46 C. detachment and removal of microor. i. the random movement of particles in a fluid. system is also of utmost importance for an opti- mum chemical effect. Fluids are substances that can- chemically active and inert irrigants (e.. unless the irrigant comes into close contact with like pressure difference. and concentration gra- effects: dients [104]. mechanical dis. Applications of fluid dynamics in the bio- [45. apart from the 59. Both effects are pri- and of the smear layer by the active chemical marily produced by the flow of a chemically component(s) of the irrigant. 34]. they include both liquids and gases. flow seem justified. • The chemical effect. or buoyancy [4.. This list has been termed convection. temperature. An upon the concentration of the active component(s) increasing number of challenging problems have of the irrigant.g. so the concentration and air flow in the respiratory system [23. 64. and Fluid dynamics is the study of fluids in motion dentin debris from the root canal system via and the subsequent effects of the fluids upon the forces applied by the flowing irrigant. 88. van der Sluis dynamics will be employed.e. Thus. involving fluid dynamics. Thus. saline) [42. 54. 45. as both have the ability to flow [113]. (chemical and mechanical) for the overall suc- lution of pulp tissue remnants. sive role of microorganisms in the development irrigant transport may still take place by diffu- of apical periodontitis [57.e. killing of microor. A flow is Evidently. 30. 75. undoubtedly because of the deci. 78. However. pulp tissue remnants. not withstand any attempt to change their shape water. 99]. Irrigants can reach the sites of interest prefer- Redefining the Aims ably by the flow developed during delivery (or during agitation). 71. full extent of the root canal system. no mechanical effect is exerted by diffusion. most commonly used irri. Clearly. . 90]. 117].M. disso. efforts cally active solutions (e. refined several times in the past but has always the irrigant applies forces on the targeted mate- reflected the clinician’s and microbiologist’s rial. when at rest. either solid surfaces or interfaces Mechanical effects can be exerted by both with other fluids. particles (molecules/ions) are transported quickly gation can be found in every endodontic textbook and efficiently by the fluid motion. include blood flow in the cardiovascular system gants are rapidly consumed. Boutsioukis and L. 114]. and this can be achieved by • The mechanical effect. frequent refresh- ground knowledge on fluid dynamics will also be ment of the irrigant in all areas of the root canal provided to facilitate comprehension. sodium to obtain additional insight and optimize irrigant hypochlorite). Notable examples During the interaction. understanding the fluid dynamics of root canal ruption. both effects cannot take place caused by the action of externally applied forces. while flowing. of the root canal where a flow cannot be created. the area of contact. In addition. the targeted microorganisms and tissue remnants 7. boundaries. 79]. Moreover. irrigation. and its rate is further affected by the size of actually realized by two simultaneous but distinct the particles. and essential back.W.. chemically active The traditional long list of aims of root canal irri.

86. All syringes have a Luer Lock threaded fitting (arrow) . 56. 66. 42. in order to detach/disrupt microorganisms/biofilm. This lack of the size of the syringe used. however. debris. 3. 24. Although little attention has been put on experimental evidence [29. (Chemical effect) • Application of force on the root canal wall (wall shear stress). this can affect the scientific data may still be reflected on the way tactile force needed to irrigate at a certain flow this procedure is described in endodontic text. Elementary fluid dynamics can provide books as well as taught in dental schools. syringes of vari- syringe irrigation has been attributed to its inabil. variations have been found among endodontists During syringe irrigation. this results the basic aims of root canal irrigation can be from the definition of pressure. 24. the clinician cannot draw reliable • Flow of the irrigant to the full extent of the conclusions about the pressure.1 Syringes of variable capacity (from top to bot- • Restriction of the flow within the constraints tom: 20. 5 and 2. and tissue remnants. of the root canal system and prevention of irri. able capacity ranging from 1 to 20 mL have been ity to deliver the irrigant into all the parts of the suggested for use (Fig. in order to retain a high concentration of its active component(s) at the sites of interest and compensate for their rapid consumption (applicable only to chemically active irrig- ants). 117]. it falls The remainder of this chapter will focus on clearly within the scope of fluid dynamics and the first three aims. the limited performance of In order to perform irrigation. (Mechanical effect) Fig.1) [2. A cli- tissue remnants.5 mL) used for root canal irrigation. 84]. rate [8]. where pressure is built up (Text Box 3. 82. a clinician applies in the way they perform syringe irrigation ex vivo tactile force to the syringe plunger. even if the actually developed pres- Based on such an interdisciplinary approach. safety aspects will be dis- especially microfluidics. Wide an explanation for this effect. For example. Consequently. in order to come in close contact with microorganisms/biofilm. (Flow) • Frequent refreshment of the irrigant. microscale flow of a liquid (irrigant) inside an (Safety) [11] irregularly shaped domain of very small dimen- sions (root canal system). For the same reason. 3. but without strong 93. 82. This force [8]. The need to investigate cussed in more detail in a separate chapter. Larger syringes restated briefly as follows: are more difficult to depress and control. and dentin debris been coupled nician will need to apply different amounts of with detailed numerical and experimental evalua. debris. carry them away and provide lubrication for the instruments. sure inside the syringe is identical. size are used. complicated root canal system.1). 94]. experiments on the removal of microorganisms. and tis- sue remnants. Only recently have the abundant data from is transmitted to the irrigant into the syringe. force and will feel different levels of difficulty tion of the irrigant flow to provide new insights to push the plunger when syringes of a different into root canal cleaning and disinfection. in detail the flow of the irrigants inside the root canal has been stressed repeatedly [2. 46. 12. Syringes nated this aspect of root canal irrigation for decades.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 47 Root canal irrigation can be viewed as the gant extrusion towards the periapical tissues. 93. root canal system and subsequently to the canal orifice. speculations have domi. 29.

These nee- inside the syringe barrel remains considerably dles mainly differ in the presence of an open or higher than the ambient pressure around the tip of closed tip and one or more outlets (Fig. also reproduced in several publications is that Flow rate delivery of the irrigant at high flow rate is errone- The flow rate (Q) of an irrigant is defined ously termed forceful delivery or delivery under as: pressure.5). (see Text Box 3. So.W. minute. 37. the flow rate through a needle is reasonable compromise between less-frequent described by the equation: refilling and ease of use. 50. pressure acts A common mistake among clinicians which is perpendicular to the boundary [67].1) is always neces- needle. the flow rate through a smaller needle syringe plunger and A is the cross-sectional will be much less than through a larger needle.48 C. Evidently. . The irrigant flow rate is syringe. Because of the very high pressures developed inside the syringe. Assuming a laminar flow (see Text A 5-mL syringe has been recommended as a Box 3. which can also be estimated clinically. Δt In addition. for the same pressure where F is the tactile force applied to the difference. syringe or the root canal).1 pressure difference drives the irrigant through the Pressure needle and into the root canal. but the flow rate would still be low. 56. Thus. the pressure [13. in most cases.g. several types of needles have been used to deliver irrigants into the root canals While depressing the plunger. because a significant pressure drop frequently expressed in mL/s or mL/min occurs along the needle. 3.25 mL/s even when combined with fine irriga- 128m L tion needles [8]. Pressure acts uniformly other words. Using a very large syringe combined ΔV with a fine-diameter needle would require a large Q= tactile force.. 3. The irrigant flow rate is F proportional to this difference. mL/s nor “pressure” is an appropriate term to describe is more relevant to clinical practice. 38.M.2). Boutsioukis and L. μ is the viscosity of the irrigant dle during irrigation [8]. a larger pressure difference is in all directions. since how fast the irrigant is delivered. 112. This Text Box 3. it must be emphasized that the pres- where ΔV is the volume of the irrigant sure of the irrigant delivered inside the root canal delivered in the root canal within a time is always much lower than the pressure inside the period Δt [67]. 95. In area of the plunger. a Luer where D is the internal diameter of the Lock threaded fitting (Fig. neither “force” (1 mL/s = 60 mL/min). and L the length of the needle [103]. In an irrigant confined required to achieve the same flow rate through a by solid boundaries (e. but is also affected P= by the size of the needle and several other param- A eters (Text Box 3. Over the years. van der Sluis the needle (which is nearly atmospheric).1). 10]. This syringe can be p D 4 ΔP used to reach flow rates at least up to 0. Such informa- irrigation rarely continues for a whole tion can only be provided by the flow rate [8. the needle diame- ter influences the flow rate much more than Needles the other parameters. ΔP is the pressure difference along sary to avoid accidental detachment of the nee- the needle. 115].20– Q= 0. and that is why The pressure (P) developed inside the syringe irrigation is categorized as a positive- syringe barrel is defined as: pressure technique [21]. the wall of the smaller needle. 66.3).

diameter Metric External diameter (mm) (mm) Instrument Gauge size size (mm) Min Max Min size 21 0.370 0.33 0.30 0. beveled (b).254 0.232 50 27 0.600 0.25 0.1:2001 and corresponding size of end- odontic instruments ISO 9626:1991/Amd.500 0.133 35 30 0.50 0.80 0.36 0.349 0. and ences in tip design.60 0.490 80 23 0. 3.1 Medical needle specifications according to ISO 9626:1991/Amd.184 40 28 0.673 0.114 25 Nonexisting instrument sizes were rounded up to the next available size. and multi-vented (f)]. closed-ended needles: side-vented (d).298 0. double-side-vented (e).40 0. The multi-vented needle is not com- notched (c).133 40 29 0.420 0.317 60 25 0. mercially available at the moment for use with a syringe.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 49 a b c d e f Fig. the actual sizes may be different to some extent due to inevitable variations during the machining procedures (tolerances) .133 30 31 0.320 0.2 Various types of 30G needles used for root canal views and magnifications were used to highlight differ- irrigation [open-ended needles: flat (a).1:2001 (Medical needles) Int. Even if the nominal size of an instrument and a needle are the same.351 0.267 0. Variable Reprinted with permission from Elsevier (Ref.400 0.530 0.830 0.800 0.324 0. [13]) Table 3.

the root canal behaves mostly like . the use of finer. 103. but not between the demanding task. the apical part of root canals is an unlikely event meter as the standard metric unit to express nee. mainly because they can reach farther Viscosity into the canal. 92. as dle size already recommended by the ISO for it will be discussed further on. More recently. 49. even in wide root canals. 113]. because these two ing irrigation. 24. m r= 87.5. the liquids are miscible. like a stretched membrane. 82.W. irrigant and air) is Apart from the equipment (syringe and needle). 113]. The origin of ical properties. The surface tension of endodontic irrigants in contact and other factors. The effect of needle type irrigant to motion [67. It depends on the pair of fluids tions. 27. 103. face tension. 55] or seem to conform well to the relevant ISO specifi. found to behave as if it were under tension. 117]. Surface tension Physical Properties of Irrigants The interface between two immiscible fluids in contact (e. 100] and on dissolution of pulp tissue [97].g. large needles (21–25G) were com- monly employed for irrigant delivery [20.2 odontic instruments could greatly assist clinical Density procedures [9]. Viscosity describes the resistance of the 14. 113]. The adoption of the milli. Density (ρ) is defined as: In the past. The net effect of these forces is for very similar to those of distilled water [41. Boutsioukis and L. even to working length (WL) [6. these properties are fluid.. mainly density and viscosity such tension at an interface is due to the (Text Box 3.1) and of NaOCl to dissolve pulp tissue [25. such as the (Text Box 3. advocated. Irrigant Flow During Syringe while density and viscosity affect the flow in all Irrigation cases. 113]. agents or surfactants [58. more than a decade [52]. the “gauge” units cannot be cium from dentin [116] or to remove the smear directly compared to the size of instruments and layer [26. where m is the mass of a certain quantity of diameter needles (28G. However. the effect of surface tension is important only at the interface between two immiscible flu. van der Sluis Similarly to all other medical needles. 19. the ability of common chelators to remove cal- cation [9]. In addition. 69. 105] the interface to contract and it is called sur- because most irrigants are sparse aqueous solu. the flow of irrigants is also affected by their phys.2) [67. Such needles could hardly penetrate V beyond the coronal third of the root canal. Box 3.50 C.M. It has been underlined that dur- irrigant and the dentinal fluid. 113]. However. together with the definition of wall shear stress. Such an interface is formed between and uniformly tapered root canal can be a very the irrigant and an air bubble. bubble entrapment in obturation materials. 102]. 36. A more and size on root canal irrigation will be discussed elaborate definition will be given in Text in more detail further on. 62]. Evaluating irrigant flow even in a simple straight ids [58. and the development of a color code corresponding to that of the end- Text Box 3.2) and its decrease by wetting agents temperature and the presence of wetting (surfactants) have also been studied extensively. provided that certain guidelines are followed. Recent studies have con- sizes of irrigation needles are most frequently firmed that surfactants do not enhance the ability described by the “gauge” system (Table 3. For commonly intermolecular attractive forces within each used endodontic irrigants. 30G or 31G) has been the irrigant and V is its volume [67. under the assumption that they may have a sig- nificant effect on irrigant penetration in dentinal tubules and accessory root canals [1.

becomes turbulent. a the far more effective mixing [34]. the flow becomes unsteady. 96. character- entrapped apically [12. which ing syringe irrigation has not been verified exper. An unsteady flow changes are random. 77. Turbulent flows are also character- The type of flow occurring within the ized by substantially more effective mix- root canal depends primarily on the bal. these results eddies until it is dissipated and converted have not been verified in experiments. . 47. a closed apical foramen Re = m results in a significantly more complicated flow pattern and adds considerable obstacles for irrig. 77. and characteristic length ies in the past. as pointed out by Tay ru D et al.53–0. Laminar and turbulent flow 111]. The kinetic unrealistic. [101]. and momentum are very effectively irrigant. In such a case. 113]. 109. so in ex vivo and in vitro experiments the apical foramen should be sealed four parameters influencing the flow: fluid [10. 73. According to (not to be confused with the more stable computer simulations. and chaotic. In the case Reynolds number increases further than of root canal irrigation. 109]. Visualizations of turbulent syringe irrigation could have been mistaken for flows reveal rotational flow structures turbulence in the past due to limitations of the of various sizes. 60. into thermal energy. When the irrigant is delivered at tia forces are dominant over viscous very low flow rates (~0. At low Reynolds numbers. but it of characteristic properties that distin- remains laminar [10. even if no air bubbles are and the flow remains laminar. except adjacent to solid surfaces needle. velocity scale (υ). ing than laminar flows because of the ance between the inertia (driving) forces eddying motions.26 mL/s).4). smoothly over time. It is likely that the formation of vortices generally vary along the three spatial (Text Box 3. flow rate (0. Moreover. 63. giving rise to doubt about the scale (D). but it is not necessarily tur. As a consequence. 18. guish them from laminar flows. However. a higher.3). ity with position and/or time. 60. turbulence would greatly a critical value (usually taken to be assist irrigant penetration and refreshment due to around 2200–3000 for flows in pipes). and viscous (frictional) forces affecting the mass. This dissipation results in increased energy losses asso- Text Box 3. a steady laminar flow is developed within [39. iner- imentally yet. contrary to previ. they are highly unsteady and bulent. ized by a smooth variation of the veloc- Fluid flows are broadly categorized into lami.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 51 a closed-ended system. and this Reynolds number (Re). from both sides. At higher flow rates (up to at least Turbulent flows possess a number 0. If the nar and turbulent ones (Text Box 3. 80]. the complicated series of events leads to a development of turbulence inside root canals dur. which combines can be an important advantage for certain chemical or biological applications [34]. called turbulent eddies visual assessment in real time. validity of their results. 111]. radical change of the flow.79 mL/s) may lead energy is continuously transferred from to the development of turbulence mostly close to large eddies to progressively smaller the tip of the needle [10].4) and the unsteady flow during directions. In fact. 101]. This seemingly minor detail density (ρ) and viscosity (μ). heat. viscous ant penetration compared to a root canal open forces are dominant over inertia forces.01 mL/s) through a 30G forces. 58. They ous reports [56]. 77. This balance is expressed by the exchanged [39.3 ciated with turbulent flows [39. characteristic has been overlooked in many experimental stud. the root canal. yet clinically vortices – see Text Box 3. 12. however. unpredictable.

and taper have only a lim. [13]) [open-ended needles: flat (a). (Fig. double-side- (right) of irrigant velocity in the apical part of a size 45. 113]. ited influence [12–16.W. and multi-vented (f)]. the open-ended and the closed. The jet formed by the flat and bev- eled needle is slightly more intense and extends further apically than that of the notched needle The type of the needle has also a substantial [13.52 C.3a–c). 3.2 3. A jet is a high-velocity fluid stream beveled. the A vortex is a relatively stable rotating insertion depth of the needle. Jet In the case of the open-ended needles (flat. vented. 109]. The irrigant mainly follows of needles can be categorized into two main a curved path around the tip and then towards groups. closed-ended needles: side-vented (d). the jet is formed while other parameters such as needle insertion near the apical side of the outlet (the one proxi- depth.4 extent. apically to their tip nozzle [103. and the flow rate. namely. beveled (b). It should be dis. 109]. to some Text Box 3. root canal size. position. A series of counterrotating ended [13]. All needles are posi- 0. Reverse tinguished from the eddies formed in turbu. and a b c d e f 18 14 11 7. ent types of needles. van der Sluis the outlet determines the orientation and. according to computer simulations Reprinted with permission from Elsevier (Ref. 3.3d–e). canal wall. tioned at 3 mm short of WL and are colored in red. which Vortex depends on the geometry of the root canal. flow structure [103. Boutsioukis and L.06 tapered root canal during syringe irrigation by differ. the jet appears to break up gradually.4) vortices are formed apically to the tip. double-side-vented). effect on the basic flow pattern developed in the When closed-ended needles are used (side- root canal during syringe irrigation (Fig. notched). the intensity of the jet. All needles create a jet (Text Box 3. Their size. Based on the needle and it is directed apically with a slight diver- design and the resulting flow. flow towards the canal orifice occurs near the lent flows. 3.3 Time-averaged contours (left) and vectors (c). vented (e). extend- at their outlet.6 0 Fig. the jet is very intense and forced out of a small-diameter opening or extends along the root canal. 113]. but the exact position and shape of ing almost to the WL.M. 3. and notched . the available types gence (Fig. mal to the tip for the double-side-vented needle). Within a certain distance. the coronal orifice.3).

needle is not commercially available at the although in this case.5 %) flows out through the proximal irrigant refreshment is achieved apically to a outlet. several small jets are formed by Even when an optimal flow rate is attained. 93]. The most intense jets flow and apical refreshment (Fig. while size 35 combined with 0. A similar effect gation many years ago [37. while very low velocities are noted api. and in order for significant effect on the extent of apical irrigant a 30G needle to reach this position. 24.02 taper) may pres- Under the same conditions. [16]. (73 % of the total flow) are formed through the Apical enlargement to size 30 leads to effec- pair of outlets most proximal to the tip.05–0. Interestingly. since clarified the limitations in the irrigant refresh. The distal outlet of the double. Therefore. so irrigant penetration refreshment [15. apical size 30 or 35 is required.06 taper. The type of needle also appears to have a placed within 1 mm from WL. tion to allowing needle placement closer to WL side-vented needle has only a minor influence [2]. 13–16.4) [14. If a multi-vented ended needles are more efficient than open-ended needle were to be used for syringe irrigation. 65]. it appears to develop a distinct flow pat. closed-ended needles ent an advantage over the usual tapered ones in are always less effective in exchanging the irrig. 3. irrigant exchange apically to its tip is very lim- ment apically to closed-ended needles and clearly ited [13]. 0. a minimum exchange. 25. and the requirements of the obtura- various types of closed-ended or between various tion technique should also be taken into account types of open-ended needles [13. it ones [56. Furthermore. 24. Most of tive exchange 2 mm apically to an open-ended the flowing irrigant is directed towards the canal needle when combined at least with 0. aration size or taper also improves irrigant cantly towards the apex. 3. the possibility of iatro- ited differences have been detected between genic errors. these needles need to be 45. 19. Very lim. 109. but an optimal flow A special case of closed-ended needle is the rate (0. 117]. resistance to root fracture. taper results into significant irrigant refreshment almost 3 mm apically to the needle [15. irre- depth. 112]. an increase in the prep- tex to the next. suggested for root canal irri. the ant apically than open-ended needles. while further increase of the various parts of the root canal system is a crucial size or taper has only a minimal additional effect requirement for an adequate chemical effect [29.01 mL/s). It has been found that hardly any irrigant (93. a minimally tapered root proven their inferiority [10. 49]. 66]. 3. 48]. tern (Fig. However. 48]. 0.06 cally to the tip [13]. 48. [15. it doesn’t provide any important closed-ended needle when irrigating at a very advantage [13. 16.06 taper orifice.5) [15. 48. 1 mm apically to the needle [10]. farther compared to the closed-ended ones [109]. Although this has been noted for the open-ended needles. 38.06 taper does not allow adequate irrigant dicularly to the canal wall. Despite spective of other parameters (Fig. irrigant exchange in the at least 0. 33. it appears Irrigant Refreshment that irrigant exchange occurs almost 1 mm api- cally to their tip in a root canal of size 30 and As already mentioned. refreshment always extends moment. recent studies have would also have to be placed almost at WL. low flow rate (~0. 16. Regarding the closed-ended needles. Earlier reports argued that closed. and flow rate. root canal shape. 47]. A general trend has been well-documented in It has been reported that a dead-water or the literature that needle placement closer to WL stagnation zone may exist apically to the tip of . 112]. Increasing the flow rate also seems to have a on the overall flow pattern because most of the similar effect. the fact that irrigant can flow from one vor. 18.26 mL/s) can provide refreshment up to multi-vented needle. terms of irrigant refreshment [16]. the velocity decreases signifi.3f). in addi- becomes slower. it the irrigant exiting the needle from the outlets seems that root canal preparation to apical size proximal to the tip and they are directed perpen. However. thus. canal preparation (size 60.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 53 number may differ according to needle insertion results in more efficient irrigant exchange. when deciding the instrumentation strategy. 109].

However. visual evaluation of dye clearance that was ment takes place [35. and streamlines (right) in the apical tions. van der Sluis Fig. Needles are colored in red.26 mL/s). 0. according to computer simula- and vectors (middle). [14]) ended (top) and an open-ended needle (bottom) positioned closed-ended needles. no areas in the main root canal where the irrigant dles and the flow rate used. even if near WL in these cases.4 Triads of time-averaged velocity contours (left) at 1–5 mm short of WL.06 tapered root canal for a closed.1 mL/s) through closed-ended needles posi. 74. Reprinted and modified part of a size 45. Boutsioukis and L. 3. This zone has been employed has only a very limited ability to detect observed while irrigating at a medium flow rate irrigant flow and true exchange. 95]. studies using high-speed imaging combined with tioned 3–5 mm short of WL. More detailed (~0.54 C. it is possible that a is completely stagnant during syringe irrigation zone of inadequate refreshment may indeed exist at an optimal flow rate (0.M. Given the limited computer simulations have shown that there are irrigant exchange apically to closed-ended nee. where no irrigant refresh. the real-time closed-ended needles are positioned at 3 mm . with permission from Elsevier (Ref.W.

ment have been obtained from experiments and Increasing the flow rate. canal treatment. [15. delivering additional computer simulations of simple straight root .5 Triads of time-averaged velocity contours (left) various sizes and tapers. 109]. 3. such areas exist when the needle Most of the data on irrigant flow and refresh- is placed too far away from WL [12–16. to WL could help to improve refreshment in these ant exchange within the time limitations of a root cases [14. 92. the flow may be very slow volume of irrigant or inserting the needle closer near WL. 16]) at 3 mm short of WL in the apical part of root canals of short of WL. according to computer simula- and vectors (middle) and streamlines (right) for a closed.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 55 Fig. tions. 93]. Needles are colored in red. Reprinted and modified ended (top) and an open-ended needle (bottom) positioned with permission from Wiley (Refs. not being able to ensure adequate irrig. However. 19.

16]. On the other hand. many root canals are Wall Shear Stress curved in reality. individual layers of infinitely small thick- sive enlargement. frictional forces occur indirectly by Nguy and Sedgley [69]. iso- can be assumed that if needles are positioned lated microorganisms. fine-diameter nee. The latter find.W. 24].M.5 needles widely available nowadays can facili. its resistance to motion and could be ing irrigation [8]. Nonetheless. also called as the velocity canal and is also necessary for refreshment cor- gradient (du/dy. thus. so it determines the mechanical effect. Larger needles also dy increase the risk of wedging and irrigant extru- sion [81]. this way they satisfy better ness. who between the flowing irrigant and root canal walls. flowing irrigant and between flowing irrig- In addition to improving irrigant exchange in ant and root canal walls tend to resist its severely curved root canals. The develop- proportional to the difference of the veloc- ment of an effective reverse flow improves irrig- ity (u) between the adjacent irrigant layers ant refreshment in the apical part of the root close to the wall. and dentin debris detached from the walls du t =m by the shear stress [15. a curva. evaluated the removal of bioluminescent plank. It removal of dentin debris. there are no quantitative data on flow rate is used. In order to explain this phenome- dles can reach further and earlier even into non. or biofilm from root canal within 1–3 mm short of WL in a curved root walls. according to the equation: flow carries away microorganisms. finer-diameter The viscosity of the irrigant (μ) describes needles require more effort by the clinician dur. These forces give rise to wall shear stress (Text tonic bacteria. which is of particular interest to irriga- ture up to 24°–28° according to Schneider’s tion because it can detach material from the root method [89] doesn’t seem to create additional canal wall. 29. the overall distribution of wall shear canal. the wall shear stress is flow compared to a finer needle. Wall shear stress and viscosity tate placement near WL in many cases. which can slide over each other. Based on their results. As the requirements for irrigant refreshment [14]. the relative mechanical effect. Box 3. Small size (30G or 31G) flexible irrigation Text Box 3. the irrigant is considered to consist of straight root canals without the need of exces. 82]. .5). provided that a closed-ended the minimum shear stress required for the needle is placed at 1 mm short of WL [69]. it has been verified in ex vivo studies from the wall tend to move faster than the that finer needles result into improved irrigant ones closer to the wall and a shear stress is exchange and cleaning [24. the layers farther away Indeed. even in Frictional forces occurring within a severely curved canals. a G F t = larger needle occupies more space inside the A root canal and leaves less space for the reverse For most irrigants. Boutsioukis and L. Moreover. tissue remnants. tissue rem- nants. G gant towards the canal orifice. The effect of root canal cur- vature on irrigant exchange has been studied During irrigant flow. motion. the reverse from the wall). obstacles for irrigant flow even when a low At the moment. Shear stress (τ) is defined as the true even when positioned at the same insertion force (F) required to slide one layer of the depth as larger needles [19. ing curvature apically to their tip is limited. in many cases they have already stress can be useful mainly for comparisons of bypassed most of the curvature and the remain. where y is the distance onally to the needle tip. Evidently. the irrigant moves. but this is developed. van der Sluis canal.56 C. fluid over another divided by the area of ing probably relates to the space available contact between the two layers (A): around the needle for the reverse flow of the irri.

two needle. Reprinted (b). and multi-vented (f)].06 ing to computer simulation. 115]. performance of the side-vented and double-side- Regarding the open-ended needles. depend. An area of slightly increased shear stress is also identified opposite to the distal outlet of the double-side-vented Similarly to the developed irrigant flow. Only half of the root canal tapered root canal during syringe irrigation using various wall is shown to allow simultaneous evaluation of the types of needles [open-ended needles: flat (a). 113] dles (side-vented and double-side-vented) lead Obviously. [13]) . Needles are colored in red. but but limited near their tip. and notched (c). 3. which develop local maxima regarded as a measure of its internal fric. the closed-ended nee- ing mainly on temperature [67. irrigants with higher viscosity to almost twice as high maximum shear stress. but has only a minimum influence on basic wall shear stress patterns can be distin. closed-ended needles: side-vented with permission from Elsevier (Ref. outlet.6 Time-averaged distribution of shear stress on (d). the overall stress pattern [13]. on the wall facing the they will also resist flow and require more needle outlet (the proximal outlet for the dou- effort to deliver ble-side-vented needle) [13].6) [13]. This orientation in the debridement of the root canal area is approximately symmetrical around the [49. the multi-vented needles show a slightly a b c d e f Fig. 3. on the side of the root canal wall not facing the tion. double-side-vented (e). On the other hand. The unidirectional guished during syringe irrigation (Fig. 103. 0. beveled needle position. Being a special case of closed-ended needle and is slightly smaller for the beveled and needles. accord- the root canal wall in the apical part of a size 45.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 57 notched needles. will develop a higher wall shear stress. an area of vented needles has also been reported in ex vivo increased shear stress is developed apically to studies that investigated the influence of needle the needle tip. It is a property of the irrigant. in the region of jet breakup.

49]. the area affected the root canal space. Reprinted and modi- the WL in a size 45.W. 3. no data are available on the effect of irrigant flow rate on wall shear stress. Needles are colored in red. a favorable reverse flow is by maximum shear stress becomes larger. so the irrigant veloc. van der Sluis Fig. [14]) different pattern. Apical Vapor Lock Currently. it could be hypothesized that mentioned above. it has been dem- that an increase in the flow rate results in a direct onstrated that air bubbles may be entrapped in the increase in wall shear stress. overenthusiastic enlargement of the root canal further than a certain size or taper may in fact reduce the mechanical effect of irrigation.M. It must maximum shear stress decreases as needles also be emphasized that wall shear stress may move away from WL or with increasing size or lead to the detachment of biofilm. The the root canal wall as possible (Fig. and canal during syringe irrigation. apical part of the root canal during syringe irriga- . as on these findings. root canal size. advantageous to move the needle inside the root Needle insertion depth. it appears outlets [13]. Boutsioukis and L.7). at the same time. Only half of the root canal wall is the root canal wall for the a closed-ended (left) and an shown to allow simultaneous evaluation of the needle open-ended needle (right) positioned at 1–5 mm short of position. or dentin debris from the root canal wall. 3. but it is not enough to ensure their removal from ity decreases. because more space is available for the nants.7 Time-averaged distribution of shear stress on computer simulation. Based on Most of the experiments and simulations already the definition of wall shear stress (Text Box 3. 0. so that the limited taper do not seem to affect the distribution of area of high wall shear stress affects as much of wall shear stress to a large extent [14–16]. Consequently. it is very likely (single-phase system).06 tapered root canal.5) described in this chapter have assumed that the and the relation of the flow rate to the velocity root canal is completely filled with a liquid distribution in the root canal [10].58 C. but the stress is mainly concentrated on the tip of the needle. Based needed to carry them towards the canal orifice. according to fied with permission from Elsevier (Ref. Maximum wall shear stress can Optimum debridement seems to be achieved be up to seven times more than the other types of only in a limited part of the root canal wall near needles. Recently. reverse flow of the irrigant. tissue rem- taper. irrespective of other param- a very limited area opposite to the many needle eters [13–16.

108]. 3. In addi- tion. 73. 109. So. closed-ended root canals (sealed apical foramen) ing syringe irrigation. with the irrigant towards the coronal orifice (arrows) are ant was delivered through a 30G closed-ended needle at a of minor importance because they cannot block irrigant flow rate of 0. to result into a smaller apical vapor lock. it appears that the ex vivo cleaning effi- no need for the use of negative pressure systems ciency of syringe irrigation in the main root canal or agitation techniques to reach this goal [17]. [17]) Only large bubbles occupying completely a part of the tion and totally block irrigant penetration in that Earlier studies probably overestimated the fre- area (Fig. an entrapped bubble can be easily removed during syringe irrigation either by brief insertion Anatomical Challenges of a closed-ended needle to WL or by increasing the flow rate to 0. use of an open. Smaller bubbles floating in the irrigant or moving computer simulations and in vitro experiments. 40.8). according to (stars).26 mL/s. The blue surface depicts penetration to any part of the root canal. The formation and extent as compared to open-ended ones [28. sumed apical vapor lock without demonstrating eral: an increase in the flow rate. and enlargement of the root canal all seem two cases [12.3 Syringe Irrigation: Blending Endodontics and Fluid Dynamics 59 Fig. In view of these recent findings. 0. 98. it appears that Despite earlier claims [28.083 or 0. phase system (irrigant – air) (Text Box 3. A more likely explanation is the ended needle. modified with permission from Wiley (Ref. its presence. 107. as explained above. 40.260 mL/s.8 Bubble entrapment (vapor lock) in the apical apical root canal should be considered a vapor lock part of size 50. of apical vapor lock is dependent on the same 101] should not be directly attributed to the pre- parameters that affect irrigant penetration in gen. 101. Reprinted and the air-irrigant interface in the computer simulations.04 tapered root canals. a phenomenon also termed apical quency and importance of apical vapor lock by vapor lock [17. insertion of the needle closer to large differences in irrigant flow between these WL. may be similar even to that of ultrasonic activation. The irrig. 3. The presence positioning the needles too far away from WL of an air bubble results in the formation of a two. bubble the poorer performance of syringe irrigation in entrapment doesn’t seem to be a major issue dur. 28.6). 113]. . 101]. and irrigating only at a very low flow rate. there seems to be Overall.

the importance of • Closed-ended needles need to be placed at irrigant penetration into dentinal tubules in the 0–1 mm short of WL. the irrigant flow phase system. However. 113]. 35 combined with increased taper. 70]. when an air bubble [53]. The presence of an air bubble in the to augment both the chemical and the mechan- canal is a noteworthy exception to this statement. Boutsioukis and L. Currently. tooth orienta. surface tension has no effect on adequate agitation. factors influencing the healing of apical periodonti- tis and especially the role of the biofilm structure. 32. 104. which could force the irrigant the irrigant flow [58.6). irrigant penetration to WL. anatomic even in such a case. 113]. . laterally into the grooves. a [85]. 104]. In a single- tations [22. the debridement and disinfection of the root canal system. to allow In most cases of syringe irrigation. a recently published randomized occupies part of the root canal during irri- controlled clinical trial showed that an optimized gation. sur- indicates that a more effective lateral cleaning may face tension effects become significant. gravity also gives radiographic success rate as the combination of the rise to buoyancy. Clinical studies have corroborated these limi- single-phase system is studied. because of buoyancy (Text Box 3. if the usual patient • Root canals need to be enlarged to size 30 or positions during treatment are taken into account. or abovementioned point of maximum insertion. a two-phase system is formed (irrig- syringe irrigation protocol still resulted in the same ant – air). tion has no significant effect in the resulting flow • A relatively high flow rate (~0. Recent Summary: Clinical Tips studies have shown that irrigant flow created by syringe irrigation cannot penetrate farther than a • Syringe irrigation using 5-mL syringes and few micrometers from the tubule entrance [110] fine needles (at least 30G) presents several and diffusion is very slow even under ideal condi. and isthmuses To the contrary. the needle should be moved decade of life [106]. cavities. oriented root canal is the most challenging case ment. In such case. It could be negligible compared to the dynamic pres- speculated that flow into narrow spaces connected sure developed due to the flow itself.W. 68.60 C.25 mL/s) seems [11–13]. Irrigant penetration inside dentinal tubules also seems to be a challenge [43. 83]. tions [110. this can still be achieved eas- irregularities may pose additional challenges for ily during syringe irrigation [17]. Nevertheless. but and a relatively high flow rate. Syringe irrigation seems unable to remove hard tissue debris or soft tissue remnants from the Text Box 3. However.M. for the removal of an entrapped air bubble. apical part of the root canal remains unclear • Open-ended needles can be placed at 2–3 mm because of the inevitable dentinal sclerosis that short of WL. even horizontal orientation. placement of a fine needle very close to WL.and two-phase systems ular molars ex vivo [3. which always forces the same protocol with ultrasonic activation [61]. gravity affects the irrigant developed by syringe irrigation in such compli- flow through hydrostatic pressure. blocks most patent tubules as early as the third • During irrigation. longitudinally inside the root canal up to the A tooth may have a maxillary. advantages. In to the main root canal is very much dependent on addition. A maxillary- Such technique includes adequate canal enlarge. which is cated geometries has not been studied.6 isthmus between the mesial root canals of mandib- Single. 118]. mandibular. 58. This bubble upwards [5. not be directly translated to a better treatment out- since irrigant and air are immiscible and come. 72] or from artificial If a root canal is assumed to be com- grooves and cavities in the apical part of the canal pletely filled with a liquid (irrigant). Moreover. van der Sluis provided that an optimum technique is used [3]. so further research is warranted to clarify the form an interface [5. ical effects of irrigation.

1. Boutsioukis C. Valero J. . 2010. 23. Comparison tion radiographic study. 2010. cleaning and shaping of root canals: a digital subtrac- 6. Verhaagen B. p. 2010. Versluis M. K. van der Sluis LWM. Kastrinakis J Endod. 2014. Calarza M. Bouillaguet S. Versluis M. Looney SW. van der Sluis LWM. 17–199. Zehnder M. Gogos C. J Endod. Boutsioukis C. Souza E. dynamics model to the study of root canal irrigation. Abou-Rass M. Kaufman B. 2007.3:60–3. 2010.43:393–403. The effects of decreasing Kastrinakis E. of the effect of two endodontic irrigation protocols on 19. Boutsioukis C. Lambrianidis T. Mechanical effectiveness of root canal irri- 11. & 9626:1991/Amd 1:2001 specification. Cambridge: Cambridge University Press. Heilborn C. 2009.47:191–201. J Endod. J Calif Dent Assoc. Verhaagen B. ment of irrigant penetration and renewal during the ogy. An in vitro evaluation of the 7. Evans GE.53:524–6. Wesselink P. Lambrianidis T. Boston: Artech House.30:105–16. Boutsioukis C. 2014. Kidd B. 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Lin. J. West China Stomatological College and Hospital 2199 Wesbrook Mall. Faculty of Wuhan. 3rd section. Department of Oral and Technology. PhD • J. P.R. PhD (*) BC. Zhejun Wang. Dentistry. Canada Division of Endodontics. Irrigation is also the only way to impact those areas of the root canal wall not touched by mechanical instrumentation. 610041. Yuan Gao. A variety of different study models have been used in endodontic research on irrigation. It has several different functions and goals depending on the type of the irrigant used: irrigation reduces friction between the instru- ment and dentin. Tongji Hospital. DDS. China Dentistry.). Gao. PhD Medical College. No. Ma. Last but not least. Shen. DDS. Jingzhi Ma. China e-mail: markush@dentistry. Wang. P. Research on Irrigation: Methods and Models 4 Ya Shen. University of British © Springer International Publishing Switzerland 2015 65 B. DDS. MSc. and exchange of irrigants in the highly complex root canal anatomy. 1095 Jiefang Avenue Biological and Medical Sciences. Huazhong University of Science Division of Endodontics. BC V6T 1Z3. irrigation acts against root canal biofilms. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. Faculty of Department of Endodontics and Operative Dentistry. 14. DDS. Tongji Z. 430030. Department of Oral Y.1007/978-3-319-16456-4_4 . improves the cutting effectiveness of the files.R. poor penetration of the irrigant. Vancouver. PhD Y. and Markus Haapasalo Abstract Irrigation is regarded by many as being the most important part of root canal treatment. Haapasalo. and dis- solves organic and inorganic matter. It also cools the tooth and the file. Progress in the search for better irrigants and irrigant delivery is necessary. DDS. One of the issues is how to make a rational choice for a study model that is relevant for the question at hand. M. Sichuan University. James Lin. The factors that remain a challenge in the irrigation and disinfection of the root canal include biofilm resistance.ubc. FRCD(C) Department of Stomatology. DDS. This article presents an overview of the methods and models that have been used in endodontic literature to study irrigation. University of British Columbia. Chengdu. it has a washing effect and removes loose debris and bacteria from the canal. DOI 10. Canada Ren Min Nan Road. Basrani (ed. Vancouver. PhD Biological and Medical Sciences.

during. and debris removal. Similar This article presents an overview of the various results were reported also by Siqueira et al. by instrumentation combined with saline irriga- tic biofilms. it is difficult to predictably reach this to successful root canal treatment. tissue remnants. irrigation. and large lateral isms. In another study the authors reported that We attempt to explain how differences in experi. and (micro)bio. for example. 50 % of the biofilm bacteria and remove these biofilms. microbiological. and clinical tation reduced the number of bacteria. It fulfills several goal [2–4] because of the complex structure of important mechanical. microorganisms. such as fins. tion. and after instrumentation. In a study by Dalton et al. Instrumentation of the root canal system must always be supported by irrigation to system must always be supported by effective remove pulp tissue remnants and dentin debris. developments such as computational fluid dynamic The results showed that while progressive filing models help to interpret and better explain the out. Optimal irrigation is based on research using ment. a variety of in vitro biofilm models are that mechanical instrumentation and saline irriga- currently used in endodontic research. were significantly more effective than saline in as well as to provide cutting-edge information on reducing bacterial counts in the root canal [28]. Shen et al.66 Y. In order to simulate this in vivo In 1981. [26]. isthmuses. lenge for irrigation may be the areas untouched by and to kill planktonic and biofilm microorgan- the files. Factors cases. limited tissue-dissolving ability. Also large areas in oval and flat canals may taken place with introduction of new irrigating remain untouched despite careful instrumentation. mechani- penetration. and sampled for microbial growth from the order to predict safe and effective irrigation. irrigated with saline solu- models that closely replicate in vivo scenarios in tion. CFU counts of bacteria have been of all vital or necrotic tissue. solutions and equipment. and standardized irrigation canals were prepared. The efficacy of an irrigation system Without irrigation. chemical. Instrumentation of the root canal films [5–7]. reproducible. none of the studies and help with the design of new strategies. Although this could be accomplished by optimal chemomechanical instrumenta- Safe and effective irrigation is of central importance tion [1]. the most important phases in endodontic treat- omy. Byström and Sundqvist [25] reported situation. to the apical and uninstrumented regions of the Several irrigating solutions also have antimicrobial canal space. recent developments. techniques resulted in germ-free canals. Different . using irrigation. the root reliable. However. Although many new developments have canals. in ca. [8–12]. New canals before. Nevertheless. Models Employing Teeth Challenges of Root Canal Irrigation and Dentin Blocks The goal of endodontic therapy is the removal Traditionally. the root canal system and the resistance of bio- logical functions. accumulation of this debris is dependent on its ability to deliver the irrigant causes instruments to rapidly become ineffective. used as the gold standard method for evaluat- and microbial by-products from the root canal ing the effectiveness of disinfection. there is currently no These areas contain tissue remnants and biofilms solution or method that predictably results in which only can be removed by chemical means completely cleaned root canals [13–24]. tion greatly reduced bacterial numbers in the to study how irrigation and instrumentation can kill infected root canal. 1–5 % sodium hypochlorite (NaOCl) solutions mental methods may affect the reported behavior. to dissolve necrotic tissue and biofilm. bacteria could still be detected in the canals that remain a challenge with irrigants include poor after four appointments. to clear the debris from the canals activity against bacteria and yeasts. and cal instrumentation has been considered one of exchange in the highly complex root canal anat. by both rotary and stainless steel hand instrumen- comes of ex vivo. Introduction system. [27] factors that need to be considered when developing who reported a 90 % reduction in bacteria counts models to study the effect of irrigation on endodon. A bigger chal.

both of these meth- A traditional way of measuring the antimicrobial ods have considerable shortcomings. 43]. Furthermore. the dentin block/extracted tooth model has the planktonic killing tests can predict the ranking also weaknesses. Bacteria in known concentra. tions (CFU/mL) are incubated for different time Chemical interactions between the media and the periods in disinfecting solutions such as NaOCl disinfecting agents are not known. CFU counting [37. used to determine the effectiveness of systemic often unidentified growth phases. which is still ies. The use of effectiveness of endodontic irrigants and dis. or a mixed erly standardized and reported. This invites several confounding factors. However. and a study comparing the effectiveness of disinfect. and cultured on solid conclusions from the size of the zones of inhibi- media.4 Research on Irrigation: Methods and Models 67 experimental designs have been employed. 40. planktonic studies give much too dentin canals was not verified. There are several reasons for the differ. tion or from the oral cavity is incubated in the direct contact tests with planktonic bacteria can. the extent of of the effectiveness of the same agents in biofilms bacterial growth on the root canal wall and in the [35]. the information obtained Despite the seemingly simple design. antibiotics against specific bacteria. which can greatly impact the results. if the microbes have been grown The use of teeth or dentin blocks in in vitro and in a liquid culture for some time. In several studies. tion to the effect of the same agent in vivo in the ing the CFUs after a period of growth [29–31]. Therefore. When the experimental conditions are prop. different kinds must be interpreted with great caution. (2) bacteria to these agents. Therefore. However. and (3) in vivo studies. bacteria were exposed to the disinfectants a valid method for that purpose. After the incubation period. single species. the pH of the ex vivo studies of endodontic disinfection is an broth drops. and chlorhexidine (CHX) of various concentra. The effort to bring the experimental conditions closer activity of many disinfecting agents such as cal. Often a pH. there are no studies that would assist in drawing tions. In several stud. In addition. diluted. to the in vivo reality of the root canal than direct cium hydroxide and NaOCl is dependent on the contact tests with planktonic bacteria. Although useful ing studies with planktonic bacteria to results information has been obtained from these stud- obtained using killing in biofilms indicated that ies. on accepted standardization of the methods. such as E. the agar diffusion method to test the antimicro- infecting solutions has been with direct contact bial activity of endodontic materials is not based tests in test tubes. ria for direct contact tests [35]. faecalis. root canal space for 1 day to several weeks [37– not replicate the in vivo conditions and the results 44]. 38. biofilms are ex vivo studies using contaminated root canals in today recommended instead of planktonic bacte- extracted teeth. microbiological samples are taken for culture and ing agents against bacteria in simple in vitro kill. Nevertheless. the results from agar diffusion studies does not reliably from different studies have shown considerable reflect the in vitro or in vivo antimicrobial activ- variation. the results can bacterial flora obtained from an endodontic infec- be expected to be more constant. sampled. for example. ity of endodontic antimicrobial agents and should ences in different studies. this should are non-standardized exposure conditions and the not be confused with agar diffusion tests that are use of microbial cultures which are at different. often even several pH steps. The agar diffusion test and CFU counting method have traditionally been used to measure In Vitro: Direct Contact Tests the effectiveness of endodontic disinfecting solu- tions [28–31]. which leaves some . optimistic picture of the sensitivity of root canal including (1) direct contact tests in vitro. The two main reasons not be used anymore [36]. However. while still in their growth medium [29. Unfortunately. root canal. The culture medium In Vitro/Ex Vivo: Use contains a variety of compounds that may inhibit of Extracted Teeth the activity of the antibacterial substances [32– 34]. of treatment procedures are completed. which allows for count. 30].

43. This could be possible Within the first hours. room for error. To balance the differences sample collecting instrument. but time required to collect a large enough group of their effect on biofilm bacteria is questionable. or by aspirating the sample fluid In Vivo Models from the root canal. for example. In addition. These results make ent irrigating solutions and other disinfecting it easy to understand the wide variation of the agents has often been done by culturing the bac- results in many of the earlier studies with dentin teria at various stages of the experiment or anti- blocks and extracted teeth. To increase the between study groups. Recent solutions or irrigation technologies are intro- studies with young and old biofilms grown from duced. relevant in vitro and were sensitive to NaOCl. such as the maxillary cen. Although there are many challenges facing tionary phase. Furthermore. 45. Another important aspect its early stages. 44]. but animal mostly planktonic and in either the exponential or studies nowadays face strict ethical consider- stationary growth phase. the biofilms became very resistant candidates for the in vivo studies. temperature. In some in vitro studies. a large sample size is possibility of also obtaining some of the “hid- usually required. chlorhexidine. Sampling Methods biofilms from six different donors all became resistant to the three disinfecting agents between Comparison of the antimicrobial effect of differ- 2 and 3 weeks of growth [44]. suited for planktonic bacteria and bacteria that chemistry of the tooth and the periapical area. agitation of sample fluid by sonic ficult to do because of increasing costs and the or ultrasonic energy has been used [56–58]. which again is dependent on time of study in the search for optimal treatment proto- growth. the bacteria are likely to be to some extent in animal studies. den” microbes. to these same agents. cols. biofilm formation is in ations and high cost.000 times more resistant to disinfecting agents [48–52]. In vivo studies also have ethical limita. that real environmental factors are present. are only loosely attached to biofilm. [47] showed that in animal experiments is that the anatomy of the planktonic bacteria in the starvation phase can be root canal system is different from human teeth 1. 46]. It is clear. and ex vivo models with strict control of confounding iodine for the first 2 weeks of growth [41. Portenier et al. By select. commonly used sampling methods are best These include anatomy. which makes these studies dif. many of these factors show great lect bacteria from a biofilm. paper variation from one tooth to another. However. points and files only go where files used for ing only certain teeth. host defense. tral incisors. this should be the ultimate type of maturity. Sampling of the microbes has been done by paper points. the impact of some factors such as Untouched areas are likely left untouched by the anatomy is reduced. they cannot readily be tested by an exten- oral bacteria have shown that the biofilm bacteria sive in vivo study. However. however. nutrients. factors should be used in screening for the best After 3 weeks. end- odontic files. than the same bacteria in the exponential or sta. with paper points is unlikely to effectively col- film. Sampling tissue exudate. the whole dentin block . In with the bacteria and frequency of nutrient patients. it is not possible to have exchange show great variation [40. standardized infections. in the same concentrations. the time of incubation tions which in vitro studies often do not have. Another key factor affecting bacte. biofilms grown from different sources showed the same pattern of resistance. patients. and “natural” bio. in vivo studies on endodontic irrigation and dis- rial sensitivity is biofilm formation and biofilm infection. Shen et al. type and frequency of nutrient addition.68 Y. The CFU measurement pro- vides information on the amount of viable bacte- Studies done in vivo have the great advantage ria one is able to collect in the sample. In addition. microbial treatment [53–55]. Instead. that when new irrigating and the substrate (surface to attach to). instrumentation have created the path and space.

This raises great differences with statistical significance concerns about the validity of laboratory studies between different groups [29. reason for this may be that the dynamics (speed) of killing planktonic bacteria by different agents typically results in differences in CFUs of even Uninstrumented Parts of the Root several logarithmic steps [29. This approach ing. espe- cally significant differences. 31. inherent variations due to the method row root canals. tact tests using planktonic cultures often show “free-floating” microbes [68.”) . In the main root canal. It is well documented that in make it difficult or impossible to obtain statisti. The uninstrumented onstrated the ability of multiple bacteria to form surfaces should therefore always be regarded as Fig. biofilm which is touched by the instruments is Culturing method only detects those bacteria likely to be removed. The based on cultures. The preoperative canal system is Artendo Enterprises Inc. and in these locations have a better chance of surviv- infected dentin [39. Residual bacteria are commonly found in brings promising advantages for the study of the such hard-to-reach spaces and in lateral canals antimicrobial effectiveness of irrigating solutions and dentin canals. 62. 41. the against microbes in endodontic biofilms.1 Root canal anatomy of maxillary first molar and shown in red. If with the root canal wall to be effective. are not touched by the instru- staining has been employed to quantitate the kill. by the mechanical action. although some of the bac- that are able to grow and form colonies on solid terial cells may become embedded within the laboratory media and whose growth requirements smear of tissue [75]. 4. ments [70–74] (Fig. confocal cially in the apical third but also in ribbon-shaped laser scanning microscopy together with viability and oval canals. is indicated by green (Courtesy “Visual Endodontics/ computed tomography. Biofilm microbes show much greater resis- Results obtained by culturing from direct con. pulverized. culturing from the root canal (in vivo biofilms) is a very different situation and is com. root canal.1). and cultured in an effort a biofilm architecture on root canal walls [65– to capture all microbes in the specimen [59. 31. 60]. Canal System However. The irrigating solutions must be in direct contact plicated by a number of confounding factors. In vitro studies have dem. 35. 69]. Therefore. microbes ing of bacteria in the biofilm. 4. biofilms are supported by the culture medium and growth on the uninstrumented areas remain undisturbed atmosphere selected. 64]. 44. Recently. many teeth 35–53 % of the canal wall area. tance to antimicrobial agents than planktonic. 67]. the post-instrumentation shape of the canal the effects of instrumentation as revealed by micro. This is the differences in killing root canal bacteria are particularly important in the apical part of nar- not great. 63]. 61]. Contrary to this.4 Research on Irrigation: Methods and Models 69 has been frozen.

The Gram-negative organisms were both detected. limitations of the identified between the canals and the isthmi. a method was presented to quantita. In study emphasized that debris accumulation can light of the well-documented challenges in . the Netherlands) incidence of canal isthmi varies depending on the with side-vented needle irrigation (SNI) in the type of tooth [76]. which may result in Johnson et al. Another study [77] ated isthmi had to be less than one-quarter of the showed that the highest prevalence of isthmus in diameter of the unshaped canals along the canal mandibular first molars is 4–6 mm from the apex.70 Y. despite rigorous irrigation. of Isthmus Areas In an in vivo situation. Both micro-CT include that it only can be used on instrumented canal spaces and uninstrumented extracted teeth and that it can detect inorganic but isthmus regions are cleared of soft tissue debris not organic matter. gation during and after instrumentation was not Therefore. ally be prepared after completed chemomechani- tion and irrigation in the root canal system. and biofilms from the untouched areas can only Such packed debris may have a negative impact be done on chemical means. with the highest preva. of completely patent isthmi or partially obliter- lence at the 3-mm level [78]. entire length of the isthmus of a tooth. 30 % of the original canal system was filled treated 2 years later [94]. 80]. Gram-positive and with hard tissue debris after preparation. It showed that initially been treated 10 years earlier and then re- ca. root canal system. In mesiobuccal root of maxillary first molars using one study the prevalence of isthmi ranged from 17 a closed canal model. entrapment and a vapor lock effect at its api- niques are able of reaching all irregularities of the cal end [84–86] during irrigation [12. dentists must irri. device or the conventional SNI technique. contaminated. Thus. which often results in gas Modern instruments and instrumentation tech. Removing necrotic tissue. root level [6]. which had ments without any irrigation [79].2). cal preparation. multi- sue debris into isthmus areas of mesial roots of species biofilm was recently demonstrated in the mandibular molars using rotary ProTaper instru. [80]. 81–89]. 4. Even copious irri- ter and (in high concentration) detach biofilms. debris. Isthmus areas (connections between ment from the apical part of the canal walls with two root canals in the same root) in posterior teeth the use of a syringe delivery technique [90–92]. that neither technique could completely remove tively assess accumulation and removal of inor. Sodium hypochlorite on the sealability of root canals and reduce the is the only irrigant that can dissolve organic mat. Histological sections showed Recently. Shen et al. sufficient use of sodium hypochlorite able to prevent or remove the debris packed into is important in order to obtain maximal cleaning the isthmus area between the main root canals effect in the whole canal. removal of dentin debris and tissue remnants. variable. Studies designed to simulate a closed root canal gate the uninstrumented areas to remove debris system have demonstrated incomplete debride- and biofilms. However. levels (i. sured. [93] compared debridement effi- survival of microorganisms and only partial cacies of a sonic irrigation technique (Vibringe.e. The Cavex Holland BV. the chemical to the same extent using the sonic irrigation effects on soft tissues by NaOCl cannot be mea. be an undesired consequence of instrumentation. The tooth selection in this to 50 % in the apical 5 mm of the mesial root of study was that the mesiodistal isthmus width mandibular first molars. are challenging to irrigate. A study evaluated the packing of hard tis. the debris from the canal or isthmi. and age [77]. A significant ganic debris in molar teeth instrumentation and difference between the two methods was only irrigation [79. Consequently. the canal is like a closed-end channel.8 mm from the anatomical apex) Use of micro-CT in endodontic research has from which histological sections would eventu- made it easier to study the effects of instrumenta. 1–2. the accu- mulation of dentin debris seems to occur and restrict cleaning and disinfecting the areas Models to Study Cleaning blocked by the debris (Fig. Therefore. The presence of a complex. Haarlem. effectiveness of disinfection..

Mechanical The bulk of root dentin is traversed by the dentin cleaning/disinfection means the removal of some canal (dentinal tubules).4 Research on Irrigation: Methods and Models 71 Fig. 4. faecalis sis of non-surgical endodontic treatment. showed that irrigating the canal with sodium the effect of endodontic irrigants and locally used hypochlorite (after removing the smear layer) antibacterial agents in standardized bovine dentin rendered the dentinal tubules bacteria-free only blocks infected with test bacteria. Ørstavik and Haapasalo [98] investigated ples. Some other studies have shown that bac- Dentin Canals teria can penetrate dentinal tubules to depths of 200 μm or more [99. 102]. The cross sections are shown before instrumentation (left) and after instrumenta- tion (right). whereas Escherichia coli penetrated approximately 600 μm. Bacteria have been of the infected root canal wall dentin. 100] (Fig. Several 200 μm is not achieved with any of the contem- different approaches have been used to study the porary instruments [101. canal lumen and dentin canals. The authors to a depth of 130 μm from the canal lumen. shown to be present in dentinal tubules in most complete uniform enlargement of a root canal by teeth with apical periodontitis [95–97]. 4. effect of irrigation on microbes inside the dentin [103]. Berutti et al. Note the presence of accumulated hard b tissue debris in the ribbon- shaped isthmus area after instrumentation (the four cross sections on the right) c d obtaining the desired cleanliness. infected the entire length of the tubules. However.2 Micro-computed tomographic cross sections a of mesial root canals of four mandibular molars treated with rotary NiTi instruments (a–d).3). using bacterial culture from dentin sam- canals. E. this area can reported that bacteria colonized the main root have a negative impact on the long-term progno. .

The results and temperature on the penetration of NaOCl indicated that instrumentation and irrigation with into dentinal tubules was recently studied [106]. At all depths of the mined by the bleaching of the stain and mea- root canals and for all techniques used. Maximum penetration of . and the differences from the main root canal.25 % sodium hypochlorite as found only in a few dentinal tubules even after a intracanal irrigants associated with hand and prolonged period of incubation [98. and deep penetration chanical action immediately after the instrumen. dense. a burs of different diameters in order to evaluate standardized three-dimensional in vitro model the presence of bacterial cells inside the dentinal for quantitative assessment of bacterial viability tubules following the biomechanical procedures. and 5. Shen et al. The depth of penetration of NaOCl was deter- rial cells from the root canal. incubated The effect of concentration. a b Fig. The results showed NaOCl was shown to be the most effective irrig.5. No differ. Such a rotary instrumentation techniques against E. 104]. penetration after 20-min found.4). but the relative ences between the different hypochlorite concen. allows predictable.3 A scanning electron microscope (SEM) image of Enterococcus faecalis in dentinal tubules in cross-sectional (a) and longitudinal (b) view (Courtesy “Visual Endodontics/Artendo Enterprises Inc.25 % sured by light microscopy. followed by 2. [54] investigated the efficacy of SEM studies have both shown that bacteria are 0. 105].72 Y. The reliably measure the effects of disinfecting agents samples collected from the root canals with paper by culture or by confocal laser scanning micros- points were obtained just after biomechanical copy (CLSM). 4. and temperature.5 % NaOCl. a dentin model that preparation in order to evaluate the chemicome. and plated onto BHI agar.”) Berber et al. effect of the three factors was much smaller than trations in cleaning the main root canals were expected. saline only removed more than 95 % of the bacte. of bacteria would be most useful for the study of tation. Therefore. in dentin by CLSM after infection and disinfec- The samples obtained with each bur were placed tion of the dentinal tubules was developed [64]. fae.5. that the ability of sodium hypochlorite to pen- ant solution tested when dentinal tubules were etrate dentinal tubules was dependent on time. histological sections between penetration by 1 and 6 % NaOCl were stained with the Brown and Brenn method and rather small (Fig. 2. concentration. time of exposure. For instance. 5. low level of dentin infection makes it difficult to calis within root canals and dentinal tubules. Although dentin in most teeth with apical exposure was only twice (not ten times) as much periodontitis is infected by bacteria invading as after 2-min exposure. analyzed. 4. into brain–heart infusion (BHI) broth. Recently. at 37 °C. The dentin samples were obtained using endodontic disinfection [100.

[34] studied the potential tor of IPI and CHX than dentin matrix [34]. are important differences between type I col- Dentin matrix (3 % w/v). citric acid) showed no inhibitory activity. inhibitory effect of bovine dentin matrix (col. with earlier reports which have shown that IPI Several studies have reported that dentin was more susceptible to dentin than to organic weakens the antibacterial effectiveness of cal. demineralized dentin (pretreated with EDTA or etrate into the tubules. This may be citric acid treatment [34]. dentin inhibited the bacteria could therefore also be attributed the activity of CHX more than untreated den- to their invasion into the dentinal tubules where tin powder but less than purified dentin matrix. iodine potassium iodide. Portenier et al. In summary. dentin is a complex cells surviving after 24 h of incubation with the chemical and anatomical environment that needs medicaments in the given concentrations. . Dentin to be carefully considered when designing stud- matrix was a slightly less effective inhibitor of ies looking at the effects of irrigation. It can caments by dentin. 4. but on CHX its effect was stron- was used for 20 min at 45 °C in coronal and mid. was a potent inhibi. compounds. 33]. and through different production and purifica- tor of both CHX and IPI. caused by the difficulty of the solutions to pen. faecalis tion methods. and skin collagen on was stronger than with skin collagen but weaker the antibacterial activity of 0. When IPI was tested. which mostly consists lagen products obtained from different sources of purified dentin collagen. or the microbial biomass be speculated that rinsing with EDTA or citric in the tubules [33].4 Depth of penetration (in vitro) of sodium hypochlorite in various concentrations and at different temperatures into dentin canals in 2 min (left) and 20 min (right) 300 μm was seen when 6 % sodium hypochlorite IPI than dentin. Together with the observation that dentin treated lagen). they are better protected from endodontic medi. This is in accordance root dentin. demineralized dentin powder (treated with EDTA or citric acid caused inhibition that with EDTA or citric acid). The survival of first used to dissolve the apatite. During chemomechanical acid before irrigation with disinfecting agents preparation of the root canal.4 Research on Irrigation: Methods and Models 73 200 2 min 400 20 min Penetration depth (µm) Penetration depth (µm) 150 300 20 °C 37 °C 100 200 45 °C 50 100 0 0 1% 2% 4% 6% 1% 2% 4% 6% %NaOCl %NaOCl Fig. with most E. whereas the opposite was true for cium hydroxide. exposing collagen indicated that skin collagen is a weaker inhibi- fibers.2 % iodine potassium iodide (IPI) solution. use of chelating might weaken the effect of CHX but strengthen agents and acids results in selective removal of the effect of IPI. this indicates that there 0. 33].02 % CHX and than with dentin matrix. ger than that of dentin.1/0. When EDTA or citric acid was sodium hypochlorite [32. inactivation of the medi. No difference was detected between EDTA and caments than in the main canal. and CHX [32. Comparative experiments have inorganic dentin components.

irregular. Histological sections of extracted teeth have estimated the layer to be up to 5 μm thick have indicated that the lateral canals are not com. The narrowing of the root canal apically (toward the Use of any kind of metallic instrument in the root) poses a similar barrier. The lat. Such narrow orifices create a surface tension bar- rier that does not allow adequate mixing between Smear Layer the irrigant and the liquid within the canal.05–0. 119]. Any fluid flowing root canal results in a smear layer wherever the down the accessory canals from the root canal instrument comes into contact with the root will be laminar flow. the smear layer is a com- still contained vital or necrotic pulp tissue and plex mixture of inorganic and organic particles. microbes in the lateral canals gation needle is likely to follow the path created remain one possible reason for posttreatment by the endodontic instruments. 4. with inorganic particles of 0.15 μm diameter pletely cleaned and. Others lesions. turbulent flow will be not be canal wall [111. 112] (Fig. As the irri- lateral canals. 114]. a b Fig. and granu- inherent at such small “pipe” diameters. delivery of irrig- endodontic disease. bacteria [109]. ants to areas covered by the smear layer is usually The small number of studies on irrigant action unproblematic except perhaps in the most apical in lateral or accessory canals is probably due to canal. (needle too big in size or apical canal not suffi- ficult to determine. Essentially. 100 μm to a common minimum of 10 μm [107]. 4. and. Consequently. as the accessory to the coronal or middle parts of the root canal canal position and status before treatment are dif. with diameters ranging from over irrigant penetration [88. Irrigation with the needle introduced only the difficulty of such studies. they often [115–117]. amorphous. pulp tissue. where lar layer with a deeper part that can penetrate up edge effects and viscosity become the major fac. after root filling. Shen et al. bacteria and fungi [118. 108]. The penetra- tors affecting fluid dynamics [76. blood cells.5). in infected completely and predictably clean and disinfect canals. there is a need ciently enlarged) will result in incomplete removal for standardized models that simulate accessory of the smear layer in the apical root canal. to 40 μm into the dentinal tubules.5 Instrumented canal wall (a) with smear layer and (b) after removal of the smear layer by NaOCl and EDTA Lateral Canals canals. Models of artificially created lateral canals in cleared teeth or an epoxy resin have Accessory (lateral) canals branch from the main recently been developed to evaluate efficacy of root canal.74 Y. tion is hypothesized to be the result of capillary eral canals may contain bacteria/bacterial biofilm action and adhesive forces between the dentinal which may cause lateral. 110]. periradicular bone tubules and the smear layer [113. . As long as there is no method to proteins. Smear layer is achievable due to the very low Reynolds numbers a 1–2-μm-thick.

It has been developed for the testing of the antimicro. This allows the film studies of irrigation have closely examined the to be first grown on a substrate (e. thus min.g.g. 39].. Therefore. Newer membranes. irri. glass. It has been established studies are increasingly utilizing novel experi. that the development and structural organization mental models. the results obtained from score-based between studies and experiments. e. and an inter- penetrant inorganic fraction (around 70 wt%). and poor exchange of irrigants in such as the available nutrients and the substratum the highly complex root canal system [107. Therefore. which is mainly collagen. for the analysis. These include against bacteria in biofilms has not been stan- score-based conventional SEM examination or dardized. computa. attributed to the diversity of the microbial growth ducible. the testing of antimicrobial agents the smear layer removal in vitro. However. resentative biofilm model for application in imizing human bias. due to the different chem- gating solutions. may not represent a true indi- els. polycarbonate or glass. 123]. 130]. The structure and susceptibility of biofilms to sure time often very short [38. istry of the substrate. where the biofilm has attached to [41. these of the antimicrobial agent. calls for relevant in vitro mod. Therefore. or plastic. the factors that remain a challenge Biofilm Substrate. a number of parame- tional routines able to automatically extract ters need to be considered in the design of a rep- quantitative data of dentin morphology. been reported that HA coated with type I collagen bial effectiveness and strategies of irrigation. further efforts must be phase. Type I collagen is the major Irrigation is complementary to instrumentation in organic component (90 %) of dentin. many in vitro biofilm models have cation of the bacteria–substrate interaction. biofilm models.. 20 wt%). which exists both within the collagen fibrils (intrafibrillarly mineralized) and between Measuring Antibacterial Activity fibers (interfibrillarly mineralized) on a nano- metric scale [128]. The latter is composed primarily of hydroxyapa- New Models to Study Irrigation tite (HA). 121]. and then removed and placed in a defined amount ciency. Studying end. Biofilm experiments on their response to antimicrobial agents. An improved understanding of of a biofilm are influenced by the chemical nature the challenges by microbial biofilms by new of the substrate [127]. 108]. disinfectants shows considerable differences However. expo. The Progress in the search for safe and more effective majority of endodontic studies on biofilm have irrigant delivery and agitation systems for root been conducted by allowing cells to grow on canal irrigation is therefore necessary. small overall antimicrobials are affected by a number of factors volume [126]. Therefore.4 Research on Irrigation: Methods and Models 75 Various methods have been used to evaluate However.. Certain bacte- face great challenges in their effort to eliminate ria can attach to type I collagen in dentin [97] the biofilm from the root canal. Calcium ions chelated from irrigation studies. activity of the same optical microscopy techniques [120. but unlike in the previous decades. the Surface in the irrigation and disinfection of the root canal to Attach to include biofilm resistance [124. although facilitating the removal of pulp tissue and/or small amounts of several non-collagenous pro- microorganisms. provided an excellent substrate for multi-species . the available irrigants teins are also present in dentin. e. the root canal have been quantified by atomic absorption spectrophotometry [122. 42]. and procedures utilized directed to the development of. through the expression of surface adhesins and odontic microorganisms adhered to surfaces for form biofilms [129. Not surprisingly. 125]. irrigant penetration [39] and concentration [27]. membrane) same variables associated with irrigation effi. Dentin is a composite research models and designs is likely to help us material made up of an organic fraction (around to better eliminate biofilm infections in the future.g. which may be conventional SEM studies are not always repro.

On the other hand. this or any other model does not simu.”) coiled spiral forms which probably represent Treponema a b Fig. of the colonizing cells and the production of However. The abundant growth of oral spiral forms tion of the various irrigating solutions. [42] reported standard shape of the discs makes it possible to that biofilms formed on surfaces preconditioned . Therefore.6) [39]. 4. grow biofilms with consistent characteristics. keep in mind that several additional local factors film model for studies of in vitro endodontic bio. Shen et al.6 (a) Scanning electron micrograph of a 3-week. Chávez de Paz et al. (Fig. ssp. the and virulence. signaling molecules that control cell physiology late dentin microanatomy. a b Fig. (b) Several tightly Endodontics/Artendo Enterprises Inc. 4. Chemical similar. (a) Biofilm grown on the hydroxy- apatite disc without collagen coating. 42]. 4. (b) Biofilm grown on a hydroxyapatite disc coated with collagen biofilm growth (Fig. it is important to model has the potential to serve as a standard bio. can be seen in the biofilm (Courtesy “Visual old biofilm with mixed bacterial flora. survived in the collagen-treated HA biofilm than The biofilm substratum (surface where it is in the HA model in the medicament groups and a attached to) influences both the initial adhesion thicker biofilm was observed (Fig. However.6) in this multi-species in vitro biofilm conclusions from in vitro biofilm models must be has not been described previously. More bacteria drawn with caution.76 Y. in the root canal environment may affect the func- films.7) [39. 4. 4.7 Scanning electron micrograph of a cross section of 3-week-old biofilms. ity with the teeth/dentin and the excellent growth which has proven difficult when using dentin as of the multi-species biofilm indicate that this the biofilm substrate.

It was recently reported trated stabilized chlorine dioxide with various [144] that a surface coating with a solution of concentrations of irrigants commonly used in BAK greatly reduced biofilm formation by oral endodontic treatment protocols. dia. ized suspensions of Streptococcus sanguinis. The teeth were bacteria in a dentin disc model and in an in vitro coated with mucin. [46] grew E. tion by the incorporation of antimicrobial prod- The levels of dehydrogenase and esterase enzyme ucts into surface materials and by modifying activities of biofilm cells on collagen-coated sur. biofilm model. 139]. ria after breakdown of temporary or permanent lation represents one possibility how the sub. Actinomyces viscosus. Bhuva et al. an uncoated surface. Peptostreptococcus micros. Such documented metabolic downregu. Streptococcus The “infected extracted tooth biofilm” model intermedius. Benzalkonium chloride (BAK) is a cationic ment for human teeth in scientific research [132]. faecalis biofilms. Its antibacterial potential relies on the biofilm” model system and used this model to changes provoked on the ionic resistance of the compare the bactericidal activity of concen. faecalis were generated on membrane filter discs . standardized root halves. lis. However. and incubated anaerobically. faeca. than those formed on clean polystyrene sur. and therefore much more resistant to 1 % NaOCl on a collagen-coated surface than on the effects of chemomechanical treatment. with apical periodontitis are typically much older. [133] developed a “bovine tooth proteins. These differences can be explained by a pared root canal walls (for 72 h) of longitudinally selection of cells that adhere exclusively to the sectioned. restorations is an unfortunately common chal- strate surface condition may influence bacterial lenge to the outcome of root canal treatment. effects of different irrigation protocols on the face [131].4 Research on Irrigation: Methods and Models 77 with collagen showed a more patchy structure canal walls of extracted single-rooted teeth [45]. Bovine dentin has a higher mean value of tubules per Single-species biofilm models have been the millimeter but the difference in the diameter of most prevalent in endodontic and microbio- individual tubules is not significant [134]. although the proportion of Surface modifications are known to prevent removed cells was still high. [146] tested studies have focused on dentin permeability a variety of irrigants against five different fac- [135–137] and effects of the therapeutic agents ultative and obligate anaerobic single-species applied directly on the exposed dentin which may biofilms grown on membrane filter discs. E. cell membranes [143]. Fusobacterium nucleatum. and often uses a single-species biofilm on the root E. the physicochemical properties of the surface faces were much lower than on uncoated surfaces [140–142]. Several logic research [145]. The mechanisms or reduce bacterial adhesion and biofilm forma- behind these changes are not fully understood. Biofilm formation by oral bacte- [42]. physiology. the biofilms grown level may influence the stress response in bio. and Prevotella Mono. Fusobacterium nuclea- tum. faecalis biofilms on pre- faces. be dependent on the number and diameter of the Single-species biofilms of Prevotella interme- dentin tubules [138. Antibiofilm coatings can alter root canal surface Various hard tissues such as bovine teeth properties and thus interfere with bacterial adhe- have been used in an attempt to find a replace. inoculated with standard. Peptostreptococcus micros. Scanning weakly hydrophobic tracks created by surface electron microscopy was used to measure the oxidation on the collagen–substratum inter. Biofilms found in teeth In this study. in this study are not as resistant as the true in vivo film bacteria when exposed to antimicrobials. Spratt et al. sion. polymicrobial biofilms. detergent expressing a high affinity to membrane Lundström et al.and Multi-species Biofilms nigrescens. as the length of occurring at the collagen–substratum interface incubation was only 2 days. It is possible that such phenomena E. and Lactobacillus paracasei showed a much with greater substrate adhesion and dentinal tubule higher number of viable cells after exposure to penetration. Streptococcus gordonii.

However. 157]. [149] also investigated a showed that the effectiveness of a particular root canal disinfectant on dual-species biofilms. they are bically. 5. mutans bio- agitation improved the antimicrobial properties films and the dual-species biofilms. The results indicated that both also possible that the antimicrobial resistance is CHX and NaOCl were effective at killing all of related to the amount of biofilm biomass rather the organisms tested. Chávez de Paz [158] investi- ied according to the agent and species. F. faecalis. with regard to time. or 10 % iodine [146]. The biofilm features such as maturation and extracel- organisms in the dual-species biofilms included lular polymeric substance are more important S. This model has the advan. faecalis or a mixture of disruption and bactericidal effects of root canal bacteria from human dental root canal infections irrigants on single. faecalis biofilms. In a simi. The resistance of dual-species biofilms to 2 days is also a weakness of this model. nucleatum. 151]. which may explain the greater against E. bovine dentin discs. faecalis with or without Streptococcus mutans on the contact time. The The organisms tested were facultative and anaer. Du et al. or 10 min. 2. vehicle. Short-term incubation for only 1 min. compared to Spratt et al. Sterile bovine dentin discs Bryce et al.and dual-species biofilms to form 1. their co-association in dual-species loidal silver. the test agent. The an identical number of polystyrene pegs that fit limitations include lack of substrate similar to into the wells [150. maturation status of the cells in biofilms is a pos- obic bacteria. however. agent was dependent on the type of organism and E. the species.2 and 0. The Gram-negative obligate anaerobe necessary to better simulate interactions that take species were more susceptible to cell removal place. The effect of mechanical agitation sible reason for their higher resistance [152]. 0. and Porphyromonas in the susceptibility between the single-species gingivalis were grown on nitrocellulose mem. This may also be regarded as an indication that chlorhexidine. [146]. Biofilm gated the ability of four root canal bacteria to . It is was also tested. Over the past than Gram-positive facultative anaerobes. The development of in vitro multi-species bio- respectively. sanguinis. faecalis and multi-species biofilms on biofilm resistance. it biofilm model for 24 h. parable to that of the dual-species biofilms. biofilm research in endodontics has used majority of the cells were killed after the first both single-species [155. The results exposure. in root canal biofilms.g. branes for 72 h and exposed to NaOCl. The results of root canal isolates. mutans biofilms was com- nitrocellulose membranes was examined [147]. faecalis biofilm and the multi-species biofilm. and the duration of chlorhexidine. showed that there were only small differences E. e. in biofilms were formed in an active attachment tage of at least some level of standardization.4 at detailed composition. nucleatum.and 3-week-old biofilms.25 % sodium hypochlorite. although the results varied than the bacterial interactions in the biofilms. 540 nm) for the S. The years. model. Mechanical biomass than the single-species S. treated with various concentrations of NaOCl for terial species. The resistance to NaOCl on single-species biofilms grown for 10 days on of single-species S. [154] evaluated the in vitro killing activ- in this study the biofilm has been grown for ten ity of modified nonequilibrium plasma with CHX instead of 2 days. Shen et al. [148] investigated the relative were incubated with E. and these were incubated anaero. This model consisted of is easily reproducible and allows large quantities a standard 96-well microtiter plate and a lid with of test assays to be performed at one time. concentration. which may of the chemical substances tested using a biofilm explain the highest sensitivity [153]. faecalis biofilms contain less mechanical agitation of the irrigant. The ratio of each in determining the biofilm resistance than its organism was 1:2 (absorbance of 0. However. E. NaOCl was 30-fold higher than in single-species lar study the effect of NaOCl and chlorhexidine E. or iodine for 1. and Single-species E. Jiang et al. Recently. 156] and multi-species minute of exposure.78 Y. film models is challenging. The biofilms were then dentin and the limited number of different bac. models [39. sanguinis and F. Biofilms of S. sanguinis and F. EDTA. (incubated for 48 h in an anaerobic cabinet) and disruption and cell viability were influenced by subjected to 15-min or 1-h incubation with col..2 % biofilms. the extent var. nucleatum.

so that the ability to strong evidence of a significant difference in the survive or adapt to nutritional and other changes levels of bactericidal activity associated with within mature biofilms remains an important the type of irrigant for all five bacterial species aspect of the ecology of biofilm microbes. nuclea. The species tested were able to form stable bio. micros were not significant. gordonii were most abundant. The tested. A necrotic tional. cacy of disinfecting agents. root canal represents a challenging environment munities. access to nutrients and certain key elements such and E. The infecting agents at different stages of maturation. four groups and rinsed for 3 min with 15 mL however.4 Research on Irrigation: Methods and Models 79 establish a multi-species biofilm community and they can best survive by activating various stress- to characterize the main structural. 159]. Streptococcus gordonii. the results are likely tum and P. bacteriocins and where they often have limited Lactobacillus salivarius. biofilms (from 2 days to 12 weeks) to two differ- A bovine tooth biofilm model system was ent types of CHX preparations for 1. sali. however. Levels of antibacterial activity by NaOCl results from this study [41] demonstrated that if were significantly higher than by stabilized chlo. Biofilms were harvested and spiral. The biofilms formed in rich affects the outcome of antimicrobial treatment. Permanent which were 2 weeks old and younger were much bovine incisors were coated with mucin more sensitive to the antibacterial agents than and anaerobically inoculated with standard. Fusobacterium nuclea. The differences for F. the biofilms over time.. that nutrients can produce changes of irrigant. Teeth were randomly divided into effects of the environment. composi. faecalis which were grown together in a as iron. viscosus. “viable but non-culturable” (VBNC) state [157]. while resulted in significantly smaller biofilm volumes. only occasionally have longer times up to several A high proportion of viable cells (>90 %) was months been used [41. The physiological state of bacteria greatly film communities. medium generally showed continuous growth However. or Prevotella of cells and better protect them against harmful nigrescens. sanguinis. faecalis. [133] for the test. 160]. Peptostreptococcus micros. 43]. 38. by Shen et al. The results of this study indicated that biofilms ing of different irrigation protocols. nigrescens. biofilms grown for 3 weeks or more. or 10 min. only young biofilms of a few hours or even up to rine dioxide (ClO2) for S. 2 weeks are used to assess the antibacterial effi- and P. such plated on selective media. e. Bacteria the antibacterial efficacy of endodontic irrigants and other antibacterial materials.g. [41]. Suspensions of the four survival strategies such as reduced metabolic microorganisms were mixed in equal proportions activity or in extreme situation transform into the to create the mixed-species biofilm inoculums. Biofilm bacteria are frequently encountered in New evidence of the effects of oral biofilm challenging ecological environments in which maturation on resistance to disinfecting agents . This will force the bacteria to use various miniflow cell system. and physiological features of their com. A. during which E. It can be ized suspensions of Streptococcus sanguinis. who exposed young and old varius. It is therefore important to understand the maturation curve of each biofilm model used Physiological Status of the Biofilm and use mature biofilms when evaluating. environments that dictate the metabolic activities tum. to give a far too optimistic picture of their effec- tiveness. speculated that mature biofilms develop localized Actinomyces viscosus. community structure of biofilms formed in a rich The importance of oral biofilm age and nutrition medium did not change considerably over the on biofilm behavior was recently demonstrated 120-h period. It must be recognized. and S. compared the susceptibility of the biofilms to dis- related with high metabolic activity of cells. L. The clinical isolates from infected root in which bacteria face toxic substances such as canals included Actinomyces naeslundii. The results provided as variations in pH [161]. 3. developed by Lundström et al. the absence of glucose have been grown for 1–7 days [37. in most published studies. and biofilm growth was cor. Few studies have generally observed. within the environment of mature biofilms. responding mechanisms [67.

The two stains differ in their ability tance occurred similarly between 2 and 3 weeks to penetrate normal and damaged bacterial cells. duration of incubation) [169]. laser scanning microscope scans of 3-week-old multi. acknowledged to be the continuing presence of teria to antibacterial agents. the resistance of bacteria was observed in all six The two-component BacLight staining has biofilms and with all three disinfecting agents. The primary of biofilm maturation. damaged allowing penetration of the propidium odontic disinfecting agents against biofilm bacte. Multi-species bacteria within the root canal system [109. the development of biofilm resis. It is a rapid and relatively easy-to- agents exert their antibacterial effect by different use test. A histopathological investigation reported grown for up to 8 weeks on collagen-coated HA biofilm structures in the great majority (74 %) of discs. the the two methods of bacterial detection in order to results from these experiments will give too opti. media. was presented by Stojicic et al. the cases of posttreatment apical periodontitis [168]. of biofilm maturation for all three agents. who. 5-cyano-2. After 1. and it yields both viable and total counts mechanisms. live bacteria with intact membranes result emphasizes the importance of understand. The As a result. (a) Live bacteria (green).8 Three-dimensional constructions of confocal 3 min. supposing that their membrane is which is used for testing the effectiveness of end.3- dine for 1 or 3 min. examined the have been a focus of interest in endodontic effect of the source of biofilm bacteria.4 % iodine potassium iodide. Shen et al. the level research for a long time [161–165]. biofilms were exposed to 1 % NaOCl. 2. 4. 166– biofilms from plaque bacteria of six donors were 169]. there has been little emphasis on this fluorescence (Fig. cause of posttreatment apical periodontitis is ing agent on the susceptibility of the biofilm bac. whereas dead bacteria ing the maturation timeline of each biofilm model fluoresce red. iodine stain. teria can be sensitive to culture conditions (tem- tern of the effect of biofilm age (maturation) on perature. and LIVE/ 1. It gained popularity because of its several potential is of interest that although the three disinfecting advantages.and 2-week-old biofilms were moderately or DEAD BacLight staining have been used to very sensitive to the tested disinfecting agents.2 or A variety of methods such as autoradiog- 0. 4. counting can only detect bacteria that are able to After 3 weeks of growth. One recent study [157] important aspect in the research on endodontic examined cell culturability and viability using biofilms. The bac- same agents and exposure times. So far. and (c) a combination of live and dead bacteria species biofilms after treatment with CHX-Plus® for . The same pat. or 2 % chlorhexi. Traditional colony which killed 20–99 % of the biofilm bacteria. and the type of disinfect. fluoresce green (SYTO9). 3. (b) dead bacteria (red). using Persistent and recurrent apical periodontitis the design described earlier [41]. of the presence of the VBNC bacteria under a b c Fig. With short biofilm maturation times.8). 0. evaluate microbial viability.80 Y. which is responsible for the red ria. the biofilms became initiate cell division at a sufficient rate to form much more resistant to the same agents and only colonies and whose growth requirements are 10–30 % of the bacteria were killed using the supported by the culture medium used. or 8 weeks of growth. 4. The results showed that all ditolyl-tetrazolium chloride (CTC). traditional colony count. better understand bacterial behavior in a multi- mistic picture of the ability of the antibacterial species biofilm and to examine the possibility agents to kill bacteria in the biofilms. raphy. [44]. in one step.

despite the fluid/nutrient ing during phase III when nutrient addition was exchange. as indicated by the assumed that a static rather than dynamic biofilm staining. glycoproteins. The number and proportion of live application. Fluid flow is considered to be a prin- bacteria in biofilm were assessed both by cultur. be examined at any given time. and they can be Viability staining thus seemed to better reflect used as a high-throughput system for biofilm the true viability of the biofilm bacteria than cul. after which trols the flow rate of the medium. more frequent access of such models are that numerous biofilms can to fresh nutrients while still inside the biofilm. The results strongly indicated that oral true situation of biofilms in the root canal. Inaccessible Root Canal Areas the results of this study may have an impact on the interpretation of results of cultural studies on Inaccessible regions of the root canal system (e. whereas in and out of the root canal. it does not create shear forces that would have but it took 4 weeks for the CFU counts to return more than a minimal effect on the developing (several logarithmic steps) close to the original biofilms in the root canal.4 Research on Irrigation: Methods and Models 81 long-lasting nutrient deprivation. it can be CFU numbers. The growth medium is passed through the nutrient-deprivation phase (phase II) with just cell with the aid of a peristaltic pump.g.. However. Interestingly. model is a more realistic representation of the nal 95 %. Cell viability. The grooves were packed with used to grow dynamic biofilms. an exudate may move during phase II (nutrient deprivation). fins. It has a transparent chamber of fixed species biofilm was grown from plaque bacteria depth through which the growth medium flows. It ing and by confocal laser scanning microscopy provides nutrient exchange [171]. This was followed by a 9-week voir. 173]. cipal determinant of biofilm structure [170]. improved from 75 % close to the origi. accessory canals. Digital photo- system is one of the most utilized in dynamic bio. film models. the bacteria could growth and maturation. 177] and in extracted human fresh culture medium. and affects the dis- the experiment. The multi. on collagen-coated hydroxyapatite discs in BHI The inlet tubing supplies growth medium and the broth for 3 weeks (phase I) with a weekly addi. The results showed that the CFU persal of cells from the biofilm [174]. In a tooth counts dropped more than four logarithmic steps with apical periodontitis. This fluid exchange the viability staining and confocal micros. The flow cell dentin debris followed by irrigation. graphs were then taken and evaluated for the . Such in vitro devices are teeth [178–180]. The key characteristics be recovered by renewed. Therefore. which con- one monthly addition of nutrients. and isthmi) cannot be examined by conventional microbiological sam- pling methods. and other nutri- copy indicated only a 25 % drop in viability. the CFU counts started increas. provides proteins. If this is the situation of in vivo biofilms in root canals with limited nutrition available to the bacteria. bacteria in a multi-species biofilm grown under The static model represents biofilms that have nutrient deprivation remained viable but became used up much of the available nutrients during unculturable. outlet tubing drains the medium to a waste reser- tion of nutrients. Prefabricated the biofilm was reactivated again by weekly flow cell systems are available commercially or additions of fresh BHI medium for 4 weeks they can be custom-made based on any particular (phase III). root canal. turing during the long starvation phase. The efficacy of passive ultrasonic Biofilms: Static Versus Dynamic irrigation at cleaning uninstrumentable recesses of the root canal system has been using artificially A number of different in vitro devices can be created grooves in both simulated root canals in used to grow biofilms under continuous flow of plastic blocks [176. root canal microbiology/biofilms in vivo. influences den- using a LIVE/DEAD viability stain throughout sity and strength [172. analysis [175]. the flow rate is likely to be so low that changed back from once a month to once a week. ents to the bacteria growing as a biofilm in the Interestingly.

[181] using extracted teeth with an artificial apical groove published a stan. Inside the groove. Shen et al. 182. Irrigation with a predictable. Recently. the opening of the outside the groove than inside. After growing the polymicrobial biofilm inside Experience has shown. A new dentin infection model was recently after 4 weeks of growth. a antibacterial irrigating solutions and other materi- thick layer of biofilm was detected in the canals als. while no statisti. or SAF. Before treatment. 4. faecalis the use of SAF system rather than after the rotary into the dentinal tubules using a series of centrifu- file or hand K-file (3. medium in the root canals of extracted teeth. 4. Before centrifugation.9). even after several weeks of incubation. (a) Infected dentin treated with sterile . (b) dentin treated laser scanning microscope images of E. Lin et al. Teeth were randomly are great variations from one area to another [99. faecalis-infected with 2 % NaOCl for 3 min shows moderate killing.9 Three-dimensional reconstructions of confocal water showing almost no dead bacteria. and (c) dentinal tubules treated by different concentrations of dentin treated with 6 % NaOCl for 3 min shows high level sodium hypochlorite (NaOCl) for 3 min. the split number of dentin canals are invaded by bacteria halves were reassembled in a custom block. significantly more bacteria were removed (Fig. For all gations at low and moderate speed [64. 26. 19. Each tooth with an oblong canal was teria in dentin canals have been based on culturing split longitudinally and a 0. Areas inside and outside the groove the proportion of bacteria after exposure to various were examined using SEM. and there ating an apical vapor lock. Root surface cement was removed before the the groove.2-mm-wide groove methods in which bacteria are grown in a liquid was placed in the apical 2–5 mm of the canal. by forcing E. amount of residual debris. 185] groups. that only a low the canal under anaerobic condition. The study demonstrated that none of centrifugation to allow liquid (and bacterial) flow the instrumentation techniques with irrigation through the tubules.82 Y. stained with of killing viability staining. however. particularly those in biofilms. This dentin infection model a b c Fig. bacteria. heavy presence of bacteria has was done using 10 mL of 3 % NaOCl and 4 mL been difficult. Improved Models to Study Biofilms dardized biofilm model to quantify the efficacy of in Dentin Canals hand. Producing comparable dentin infections a conventional rotary NiTi file. This biofilm model represents a potentially the irrigation techniques on the visual cleanliness useful tool for future studies of root canal clean- of the artificial grooves rather than the removal of ing in hard-to-reach areas. cre. rotary nickel–titanium and self-adjusting file (SAF) instrumentation in biofilm bacteria Earlier approaches to establish the presence of bac- removal. dentin canals was enlarged by NaOCl and citric cally significant differences were found outside acid. a developed by producing a much more standardized smaller area remained occupied by bacteria after infection deep in the dentin.98 %). 183].25.25. It should be emphasized was able to remove all bacteria from the studied though that these studies assessed the efficacy of area. divided into three treatment groups using a K-file. making it challenging to determine 17 % EDTA. 184.

cements. ent irrigants. but it is also potentially more toxic studies have also demonstrated a great difference in to periapical tissue [195–197] in case of extru- sensitivity to disinfecting agents between young sion. but it also establishes dissolve organic substances and thus to dissolve a predictable presence of bacteria and model to pulp fragments and debris is well known and quantitatively measure. studies of infected dentin. There are a couple of methods to species biofilm model has been used instead of a evaluate the dissolution in an in vitro study. exposure. One of the limi. Negative controls with sterile water showed [186]. rat connective tissue [190]. cult to determine the end point of complete dis- Killing experiments using planktonic cultures solution of the tissue because of the large number often show differences of even several logarithmic of bubbles (resulting from the saponification steps between different medicaments or times of reaction) attached to the sample surface. activities. In one study [199] the authors reported (sealers. The such as microhardness and roughness have also new standardized dentin infection model is a prom. even in pure culture. the dynamics of bacterial kill. Porcine muscle tissue [186–188]. fixed time has been used instead. E. number found in non-treated biofilms in which bovine pulp [193]. used to determine the dissolution ability of differ- tations of these studies so far is that only a single. been reported after long-term exposure to sodium ising approach to study dentin disinfection not only hypochlorite in concentrations of 2. The new dentin infection model with the in the solutions. faecalis survives the impact of centrifuga. time but also on the surface area of the exposed onstrated between endodontic irrigation solutions tissue [189]. Changes in dentin mechanical properties and mature biofilms in dentin canals [185]. such as the amount of available high resolution of CLSM and viability stain makes chlorine after completed dissolution [189] or the it possible to detect significant differences even amount of hydroxyproline in the residual tissue within the same logarithmic step. Tissues from a number of different staining and CLSM.5 and 5. bovine muscle tissue [192]. The ability of sodium hypochlorite to ment for the bacteria to grow.25 % by irrigating solutions but also by any material [198]. while the modulus of elasticity was not affected during this time. However. and significant differences have been dem.5 % NaOCl infected dentin. However. one of the shortcomings . and contact another. On the other hand. is not a sensitive exposure. 185]. pig pala- tion as the number of dead cells was similar to the tal mucosa [191]. caused a significant drop in flexural strength. rabbit that E. measuring the changes in growth. for example. The stronger effect. it is diffi- endodontic infections. The loss of calcium ions appears to be dependent on both Sodium hypochlorite (NaOCl) is the most com. unlike in cultural after incubation with the solution [194]. and pig pulp [194] have been centrifugation was not used [184]. The percentage of killing The effectiveness of sodium hypochlorite of bacteria has been consistent from one study to relies on its concentration. this is not the case. 184. sources have been used in studies assessing the ing after exposure to a variety of disinfecting tissue-dissolving ability of sodium hypochlorite agents. One polymicrobial biofilm model. etc. way is to measure the time of visualizing the end faecalis is commonly found in persistent cases of point of sample dissolution. liver [189]. the NaOCl concentration (5 % showing the great- monly used solution in endodontic irrigation est amount of decalcification) and the exposure because of its antimicrobial and tissue-dissolving time [201]. and cally the differences are within 10–50 % units only. Other authors found a decline of Dissolution of Organic Matter both flexural and elastic strength after a 2-h sub- in the Root Canal mersion of dentin bars in NaOCl [200]. High concentration NaOCl has a and materials in these studies [64.4 Research on Irrigation: Methods and Models 83 not only provides a natural dentin canal environ. Other methods have used different enough method to reliably detect small differences approaches. Therefore. volume. using fluorescent viability documented. the samples have been weighed before and after Culturing.) placed on the surface of that a 24-min exposure time to 2. and typi. on the other hand. In biofilms.

ago as a safe method to effectively irrigate the The active compound in NaOCl is the chlorine. CA). and evaluation method. System demonstrated the by far fastest tissue dis- Some studies have used powdered dentin which solution. Negative pressure irrigation was in vitro environment. However. Despite a general active agent to hypochlorite was first shown by consensus that increased temperature enhances Cameron [205] who demonstrated that the addi- the effectiveness of hypochlorite solutions. hypochlorite penetration into the results showed that the Multisonic Ultracleaning surrounding root dentin is much more limited. NaOH-stabilized NaOCl has been suggested to the Multisonic Ultracleaning System (Sonendo have a stronger tissue-dissolving effect com- Inc. in order to lower its surface tension and improve There are several ways to improve the effi. in models used in many of the studies of the uses sound energy to create cavitation within the effect on dentin properties by NaOCl and other solution to remove soft tissue and bacteria inside solutions is that the natural anatomy/structure root canals. [193] tions on tissue dissolution has been suggested found no improvement in pulp tissue dissolution to be important [188]. process of powdering may remove some of the the Piezon Master 700 ultrasonic system. Shen et al. It should be noted that the mechanisms involved are not completely these investigations were all performed in the understood [13]. has been developed for pared with the standard preparation [207]. solutions on dentin. 202]. The system reason for this is that the OCl−/HOCl equilibrium . tissue-dissolving effectiveness of the Multisonic Dentin bars cut from the root dentin are usually Ultracleaning System with conventional methods devoid of the cement layer. of mechanical agitation of the hypochlorite solu. pared with similar solutions without surfactant. thus allowing rapid of irrigation using NaOCl in concentrations rang- penetration of the solutions through the entire ing from 0. ing forces caused by ultrasound on the ability of The differences may be due to the study design hypochlorite to dissolve tissue [188]. lution increased with a higher concentration and Therefore. Tissue dissolution was more than eight has been exposed to the irrigating solutions. integrity of the root dentin is preserved before the Sodium hypochlorite has a relatively low sur- exposure are needed to secure a realistic under. and tension by 15–20 %. Jungbluth et al. Results may therefore not introduced to endodontic treatment several years be directly extrapolated to the clinical situation. rela. 22. pulp in a shorter time than regular sodium hypo- perature) with the same efficacy [22]. The times faster than the second fastest device tested. a novel technology. tion of the surface modifiers enhanced the ability tively few articles have been published of the topic of sodium hypochlorite to dissolve organic mate- [20. These canals. addition of surfactant would lower the surface ture of the solutions. Some investigators [204] have pro- standing of the effects of endodontic irrigating posed adding a surfactant to sodium hypochlorite. However. The effect of the surface prolonged working time [13]. Haapasalo et al. Preheating low-concentration solu.84 Y. the rate of tissue disso- possibly allowing more dramatic effects to occur. rial. [186] tested the dissolution tions improves their tissue-dissolving capacity ability of three different brands of sodium hypo- with no effect on their short-term stability.5 to 6 % and at different temperatures thickness of the dentin pieces. [206] and Clarkson et al. irrigation devices tested. The impact chlorite at the same concentration. In reality in the (21 and 40 °C) of the irrigating solution. Also. The study emphasized by NaOCl solutions containing surfactant com- the great impact of violent fluid flow and shear. its ability to penetrate the principal canal. new models where the structural temperature of the NaOCl solution. lateral cacy of hypochlorite in tissue dissolution. The root canal. Laguna Hills. face tension. Recently. The include increasing the pH [17] and the tempera. Clarkson et al. and tubules of dentin and predentin. most apical canals. chlorite available in Australia and reported that systemic toxicity is lower compared with the the products with surfactants dissolved porcine higher-concentration solutions (at a lower tem. ultrasonic activation. For all hydroxyapatite protection around collagen fibers. [203] compared the of dentin is often changed before the exposure. The cleaning of the root canal system.

However. [88] developed a model that used artificially created lateral canals and cleared Clinical trials and laboratory experiments are teeth to evaluate the efficacy of irrigant penetra. SACs to measure the width of the isthmus prior to tooth were filled with necrotic bovine pulp tissue. However. is extremely valuable. This limitation could be explained by the tion of the physical processes that dominate the osmotic drawing effect described by Pashley flow field. Burleson et al. diameters ranging from 10 to 200 μm [107].2 mm from cases of pulp necrosis and apical and/or lateral the 1. The gap between these studies may be narrowed sure irrigation efficiently reached the entire root by a class of experiments that give specific infor- canal system up to working length in all samples mation of the underlying physical processes. [211] to com.4 Research on Irrigation: Methods and Models 85 adjusts itself exceedingly fast in non-stabilized Gutarts et al. tation. but did not mention of depth of irrigant delivery. The The teeth were prepared with a hand/rotary tech- largest diameter was smaller than the mean diam.” This kind of in vivo studies simulated accessory canals had no effect on tis. Models De Gregorio et al. Such experiments often require mathematical tion demonstrated limited effect in the lateral abstraction of the clinical setting and the isola- canals. in endodontic research to improve understanding . Computational etration of irrigant into lateral canals than fluid dynamics (CFD) is a relatively new approach negative pressure irrigation. These studies used a 60-s activation time Simulated accessory root canals (SACs) of 0. The effect of several irrigation and activa. however. mm diameter were placed at defined angles and Molar teeth were used but no attempt was made positions in the mid-canal and apical area. nique followed by 1 min of ultrasonic irrigation. that epoxy resin is a completely different material from human dentin. [83] goal of the treatment. Significantly cleaner canals and pare the efficacy of passive ultrasonic irrigation isthmi were found in teeth cleaned with ultra- with that of sonic irrigation. In conclusion. The selection. it is important to acknowledge in vitro studies for practical and ethical reasons. both important and complement each other in tion. film/necrotic tissue by a hand/rotary technique ing the quantitative assessment of necrotic pulp versus a hand/rotary/ultrasound technique in tissue dissolution in simulated accessory canals the mesial roots of necrotic. processes to be developed and then applied to vation has demonstrated significantly more pen. Therefore. This allows a general model of these et 3-mm apical levels. and caution should be exer- cised when extending conclusions to the clinical Mathematical Virtual Simulation situation. providing evidence for the development of best tion systems on the penetration of NaOCl into clinical practice. 210]. debridement efficacy of hand/rotary canal prepa- A study of 100 permanent molars revealed ration versus a hand/rotary/ultrasound technique that 79 % had lateral/accessory foramina with in mesial root canals of vital mandibular molars. Both studies reported debris only in results showed that the location or angulation of “very narrow isthmi. [212]. passive ultrasonic acti. were evaluated for periodontitis should be considered an important percentage of tissue removal. molars in vivo. taken every 0. specific circumstances [214]. bridging the gap artificial lateral canals and to working length in a between the clinical reality and the well- closed system was evaluated using the model controlled in vitro experiments is challenging. human mandibular was developed by Al-Jadaa et al. A model allow. [213]. although it is difficult to compared the effectiveness of removal of bio- achieve with current procedures. However.2. [82] compared the in vivo solutions [207].5-μm cross sections. disinfection of lateral canals in 0. Transparent root sonic irrigation than with hand/rotary instrumen- canal models were made from epoxy resin. control of con- sue dissolution by passive ultrasonic irrigation founding factors is often more difficult than in the (PUI). apical negative pressure irriga. tested. eters reported for the main apical foramen [208– After extraction and histological preparation. The results showed apical negative pres.

tigations [214]. four tur- ments. lead to potential numerical errors in CFD results once the numerical model is validated by experi. The results showed and wall shear stress on the root canal wall. Time Frame: 4. The selection of the most suitable turbulence model for a particular 2. k-ω] were used to simulate root canal irrigation line. it can be used to mathematically simulate bulent models [low Reynolds k-ε.93101e+002 application is still an open question because no single model is accepted universally as being superior to others and applicable to all cases [216]. reverse engineering techniques based on micro- ics. In a study by Gao et al. CFD is the science that focuses on predicting CT images of the real model. Root canal irrigation which are practically impossible to measure in vivo because of the size and anatomy of the root canals.. 4. Following this fluid flow and related phenomena by solving the approach.86 Y. [108]. theoretic model of the instrumented canal was obtained by fluid dynamics. the use of an unsuitable turbulence model may hand. velocity distribution of irrigant flow in vari. with some being designed purely for one type of flow regimen [216]. In this study. 4. and CFD solutions can only be as accurate as the physical models on which they Fig. such as the stream. all of that the SST k-ω turbulence model appeared . The precise CAD solid ways: experimental fluid dynamics.10 Particle tracking during irrigation simulated by are based [217]. on the other ies. facilitated for detailed CAD reconstruction of the Fluid flow is commonly studied in one of three needle and its opening. [218]. was developed and validated [79]. transitional flow k-ω.g. studying flow with low Re. “safety-designed” needle the CFD model. CFD can be used to evaluate and and transitional flow shear stress transport (SST) predict specific parameters. based on the geometry and physical characteris- tics of an in vitro model of syringe irrigation. Shen et al. the transparent simulated canal enabled the observa- tion of the flow during irrigation and the direct visual assessment of the magnitude of the “dead water” zone. geometry) of real-world processes are used 2. In CFD stud- fluid flow. thus providing useful references for the CFD model.04041e-002 CFD has been used to show turbulence in the temperature canal during irrigation with different injection velocities [11. Each model has its strengths and weak- nesses. have the advantage of physical realism. Recently. Physical data (e.10). The needle is a machine provided constant irrigant velocity for side-vented. renormalization group k-ε. low Reynolds various conditions and perform parametric inves. a three- dimensional CFD model of root canal irrigation. a CFD model was obtained that rep- mathematical equations that govern these pro. wall flow pressure. 215]. and computational fluid dynam. veloc- ity. licated the in vitro irrigation model with a great cesses. Numerical and experimental approaches degree of similarity and incorporated all of its play complementary roles in the investigation of geometry and physical parameters. The Instron mechanical testing a computational fluid dynamics model. 108. Experimental studies.93100e+002 in CFD models. because these turbulent models are suitable for ous parts of the root canal. Accurate measurements of nee- dle parameters performed on SEM micrographs of fluid dynamics in the root canal (Fig.

and were sensed by the pressure transducer.g. 218]. such velocity of the file because of the shape of the as the canal geometry (shape and dimension). It provide qualitative insight and quantitative mea- also makes possible to observe and measure flow surements that may be useful for understanding characteristics of the flow region [108. the apical pressure range is similar. The main advantage of sure irrigation in this study showed excellent this setup was that the recording speed was not agreement with the range of pressures calculated restricted by the amount of light emitted from for simulated irrigation at 6 mL/min using CFD fluorescent particles and the recordings could be analysis with the SST k-ω model in a previous made both at high recording speeds and for a pro. [222] measured tribution of pressure and velocity and turbulent the flow around a rotary file more generally to parameters). Koch et al. The CFD lated by a CFD model. tooth method.. apex propagated through the incompressible fluid [221] developed an unsteady CFD model to eval. CFD allows examination of a large demonstrate quantitative fluid velocity measure- number of locations in the region of interest and ments using the fluorescent particle PIV tech- yields a comprehensive set of flow parameters nique in an in vitro study. Particle Image Velocimetry Particle image velocimetry (PIV) is a well. CA). In this micro-PIV loscope (BK Precision. needle inside the root canal. the dis. light to facilitate recording by a high-speed cam.4 Research on Irrigation: Methods and Models 87 to be the most suitable for the problem investi. by reflecting with few if any well-founded answers. and the irrigant flow rates. e. the file. provid- setup. CFD modeling also offers the flex. It can needle tip design. PIV is an experimental tool that may be valu- diameters and placement depth of the needle. The authors com. Recently. the complex fluid dynamics and transport pro- cesses in root canal irrigation and for validating CFD models in dental research. Pressure waves generated at the root simulated root canals [220]. size. in comparison . [223] for a similar needle design and good agreement with the velocity field as calcu. Recently. The results showed that high-speed pressure measurements calculated in this CFD imaging experiments together with PIV analysis study are converted into the pressure units used by of the flow inside a simulated root canal have Park et al. Irrigation Pressure in the Apical Canal established technique outside endodontics for the measurement of fluid flow characteristics in a Apical pressure during irrigation is an important specific environment. an objective lens with a small depth of ing 250 measurements per second. The study found that for analysis. If the minimum and maximum apical longed time.. Small lateral displacements of the nee- gated. A strain gage signal conditioner was connected to pared the detailed flow field resulting from CFD the pressure transducer to sample the pressure and micro-PIV was performed to assess the measurements. The tooth was placed in an airtight formed in the past to visualize and analyze the custom fixture coupled to a piezoresistive pressure action of endodontic irrigation systems inside transducer. during root canal irrigation using an in vitro human High-speed imaging experiments have been per. Small tracer particles are question in clinical endodontics. fluid velocities can be much higher than the ibility of easily modifying the parameters. the able to researchers in root canal irrigation. Boutsioukis et al. Micro-PIV is a modification of PIV to sure transducer model to measure apical pressure access the small scales of microfluidic devices. The range of focus and a continuous light source were used apical pressures generated during positive pres- instead of a laser sheet. [223] developed a piezoresistive pres- era [219]. The uate the effect of off-center positioning of the pressure range of the setup was −258 to 258 mmHg. Yorba Linda. flow field. While many data are difficult to extract dle inside the canal had a limited effect on the in the in vitro irrigation system (e.g. unsteady. and the output was sent to an oscil- validity of the CFD model. even though the flow was study range was 8–12 mmHg [108]. yet it is an area added to a fluid and visualized. Park et al. study [108].

Wall Shear Stress/Wall Velocity 227–232]. CFD studies have canal walls were very low (0–0. Different needle types have been proposed to increase the efficiency of syringe irrigation [8. to 5–15 mmHg in the direct measurement study with residual collagen increased from the apex [223]. the new method of direct measure. 4. A recent study [108] investigated the effect of irrigation needle tip design on irrigant Biofilm and smear layer are removed by both the flow pattern by using the CFD model (Fig. tion.11). single side-opening needle was used with the In summary. but will depend on the flow 3 or 5 mm from the apex.88 Y. needles (beveled. A closed-end. The dimensional streamlines in the CFD models pro- authors reported that the efficacy of the removal vide a snapshot of the current state of the velocity of the collagen film was improved by increasing vectors in a three-dimensional view. There is potential to use this method to assess the safety of current and new irrigating Needle Design conditions and techniques.7 m/s) compared evaluated the effect of root canal taper [224] and to that within the needle lumen (~7 m/s) and var- apical preparation size [225] on irrigant flow ied as a function of needle tip design. irrigant velocities on velocity gradient at the wall. and changing the field such as velocity distribution. and predict the orientation of the side-opening of the needle exchange of root canal irrigant as a whole in vari- [227]. Apical inside a root canal during final irrigation. The pressure was highest with the beveled needle and results indicated that an increase in root canal lowest with the side-vented closed-end needle. Irrigant flow in a minimally tapered approaching zero for the side-vented closed-end root canal with a large apical preparation size needle. decreasing the apical wall pressure might have a [226]. . The bacterial biofilm for irrigant extrusion through the apex. A similar finding has been The results indicate that improving safety by reported in an ex vivo study by Huang et al. who undertook a systematic evaluation of negative impact on the effectiveness of irrigation the influence of canal size and geometry and irri. side-vented open-end. Wall shear stress is a difficult parameter to and side-vented closed-end needles) were placed measure directly. the flow on the oppo- shear stress while reducing the risk for irrigant site side to the vent/opening was very low. preparation size. increasing visualize features of the measured flow velocity the volume of irrigant used. extrusion. taper improved irrigant replacement and wall For the side-vented needles. Complete removal was not achieved ment of apical pressure seems reproducible and in any of the samples. represents a direct approach to validating CFD estimations. Shen et al. The three- was simulated using dyed rattail collagen. helping to the apical size and taper of the canal. This result is in accordance with an ear- also showed better irrigant replacement and wall lier study which showed that the root canal sur- shear stress and reduced the risk for irrigant face facing the side vent of the needle was extrusion than in canals with a smaller apical significantly cleaner than the opposite side [226]. The percentage of canal surface coverage ous parts of the root canal. the computational fluid dynamics direction of the single side-opening location models enable estimation of the pressure and fixed in all of the tests on single-rooted extracted thereby provide an assessment of the risk factors teeth with single canals. in some areas of the canal and emphasize the gant volume on the fraction of simulated biofilm importance of continuing research on needle tip (a biomolecular film) removed. design. chemical action and physical shear stress on the The results showed that when different types of canal wall generated by fluid flow during irriga. Thus. coronally. notched.

J Endod. J Endod. The developed in recent years and used for a vari. Wing K. models that ing capacity of mechanical endodontic instruments best can reproduce the in vivo conditions activated by the ENDOflash system. and used in endodontic research on irrigation. Irrigation has several key functions. (b. 2003. During the past few years. Histologic analysis of the clean- each research problem. Generally. Ørstavik D.4 Research on Irrigation: Methods and Models 89 a b c d Fig. c) low magnification. Root canal morphology ideal irrigation model for all purposes.16:498–504. (a. and removal of the biofilms. Ørstavik D. Trope M. da Cruz-Filho AM. J Endod. Baratto-Filho F.11 (a–d) SEM of two different needle tip designs. Card SJ. Today. Fariniuk LF. Skidmore AE. Reduction of intracanal bacteria using nickel–tita- but the full potential of biofilm experimenta.32:778–84. Shuping GB. Several J Endod. Sjögren U. Oral Surg Oral challenge continues for the development more Med Oral Pathol. Bjorndal AM. Factors safety. d) high magnification Conclusions accurate and realistic models to study and Instrumentation and irrigation are the most improve the effectiveness and safety of root important parts of root canal treatment. effectiveness of increased apical enlargement in reduc- ing intracanal bacteria. should be preferred. the most important of which are tissue dissolution. 1990. kill- ing of microorganisms. 2. de will hopefully help to optimize the models for Sousa-Neto MD. Apical irrigation poses a special References challenge with regard to effectiveness and 1.29:651–3. Sigurdsson A. Trope M.26:751–5. canal irrigation. ety of experimental purposes. as there is still no 5. Hägglund B. Sigurdsson A. the of the human mandibular first molar. tion has not yet been fully exploited. Sundqvist G.28:779–83. new different irrigation models have been 3. Future research 4. . 2000. 4. nium rotary instrumentation and various medications. 2002. 1971. a variety of affecting the long-term results of endodontic treat- ex vivo biofilm models have been developed ment.

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Water Sci lis. Int Endod electron microscopic follow-up study. Gambarini G.30:778–81. Wu MK.38:593–6. J. The effect of and behavior of Pseudomonas aeruginosa biofilms. Sjögren U. asymptomatic human teeth with therapy. Influence of hydrodynamics and nutrients on endodontic disinfecting solutions against young and biofilm structure. 177. in vitro biofilm model.4 Research on Irrigation: Methods and Models 95 159. Defining the normal bacterial flora of the oral 2005. Sörlin S. Clegg MS. Umea: an artificial standardized groove in the apical root University of Umea. editor. Influence of infected dentin. cance of injured indicator bacteria in drinking water. Wang Z. Int 167. Kahnberg KE. Lin J. Growing and 161. 2004. Int Endod J. Aas JA. Wesselink PR. and Desulfovibrio sp. induced deformation and detachment phenomena. Costerton JW. Liu Y. Canepari influence of fluid shear and AICI3 on the mate- P. Dissolution of 2001. Clarkson RM. 1990. . J Endod. 2012. association with 182. Haapasalo M. 2005.38:948–53. ing by human polymorphonuclear leukocytes in 179. Pathogenicity of Actinomyces israelii and removing artificially placed dentine debris from root Arachnia propionica: experimental infection in canals in resin blocks during ultrasonic irrigation. Oral Microbiol Immunol. Wesselink PR. Lee SJ. water on bacteria invading dentinal tubules. Sundqvist G. 2004. J tions on apical dentin biofilms in vitro. cavity. Stoodley P. 163. Wesselink PR.21:277–82. 178. Confocal laser scanning microscopy is appro- Science Technology. Sjögren U. The Aust Dent J.43:5721–32. Sundqvist G. Bacteria on the apical Endod J. The effi- Sundqvist G. Dunsmore BC. Endod J.39:472–6. The eval- 166. Haapasalo M. Merritt JH. Siqueira Jr JF. Shen Y. 1998. 2008. 1:19S–28. Macfarlane R. rotary nickel–titanium Endod J. Ricucci D. Lleo MM. Nagayoshi M. Dodds I. canal using different irrigation methodologies. J Clin Microbiol. Purevdorj B.36:1277–88. Lopes HP.40:52–7. J Endod. Wilson S. hydrodynamics and cell signaling on the structure 184. 2001. Heim S.16:580–8. Haapasalo M. 2002. J Appl Microbiol. 175. Int of biofilm removal with hand. 171. A comparative study lesions: a scanning electron microscopy study. J Endod. Stoodley P.68:4457–64. Olsen I. 2007. Kadouri DE.38:1376–9. EX265 biofilms. J Appl Microbiol. Lewis D. Metabolic response of biofilm to 186. 2002. Nishihara clinical and histopathologic findings.32:434–7. Podlich H.184:6739–45. Terashita M. FE. porcine incisor pulps in sodium hypochlorite solu- 173. Sundqvist ultrasonic irrigation to remove artificially placed G. 1988. Wang Z. In: McFeters GA. Shen Y. van der Sluis LW. 2013. No. Effectiveness of HM. Nair PNR. root surfaces of untreated teeth with periradicular 181. odontitis: study of prevalence. 180. Jacobsen A. Bacteriological studies of necrotic den. Moraes IG. PR. Siqueira Jr JF.85 Suppl old Enterococcus faecalis biofilms in dentin canals. Stoodley P. McFeters GA. 176. Madison: RB. Biofilms and apical peri. Stoodley P. from twenty-four patients. Purevdorj tions of varying compositions and concentrations. J Endod. B. Odontological Dissertations. 2006.37:607–12. Curr Protoc Microbiol. Technol. Graeff MS. Histologic investigation of root canal-treated tine debris from the apical root canal during passive teeth with apical periodontitis: a retrospective study ultrasonic irrigation. van der Sluis LW. 2001.43:113–20. O’Toole GA. Dewhirst analyzing static biofilms. Lappin-Scott 185. ing solutions in dentin.39:658–63. Intraradicular bacteria and fungi in cacy of ultrasonic irrigation to remove artificially root-filled. as determined by proteome analysis. 183. Happonen RP.

De Figueiredo JA. Effects of calcium sonic ultracleaning system and sodium hypochlorite. 2012. Gulabivala K. p. Endod. Rossi-Fedele G. 215.131:67–71. Evans GE. J Endod. Aust lution property of sodium hypochlorite. Ng YL. Attin T. Hasselgren G. Ruse ND. J Am Dent gation in simulated accessory canals: impact Assoc. 2007. J Am Dent Assoc. Clancy C.38:372–5. Zehnder M. Int Endod J. van Ertbruggen C.96 Y. Wu H.34:39–42. Olsson B. DH. Uitto VJ. tissue dissolving capability of sodium hypochlorite. Siqueira EL. Zehnder M. Frank W. 2010. Toxicity of concentrated sodium hypochlorite used 212. 204. Gulabivala Haapasalo M. Sayin TC.30:792–5. 1985. A preliminary report. Scand J Oral Surg Oral Med Oral Pathol. 2009. Knowles J. Yee FS.34:113–9. Shen Y. Cengiz T. Flow in antibacterial properties.31:364–8. The effects of sodium hypo.V. Validation of CFD 203. Paranjpe as an endodontic irrigant. Gilbertson M. Int Endod 196. 2010. Paqué F. high pH: effects on soft tissue and dentin. Dent J. 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Schroten H. predictions of flow in a 3D alveolated bend with Khakpour M. lution of necrotic porcine muscle tissue. 2001. Mehra P.41:399–405. 216. Thoma K. Turbulence modeling in 201. Deniz D. Clarkson RM. 200. Cytotoxic effects of NaOCl on vital tissue. Moorer WR. 175.55:41–54. 2004. 2008. Stenvall H. 1997.88:406–11. J. 2012. Zehnder M. elastic modulus. dine digluconate gel. J Endod. Brandt J. Physiol of irrigant sequence on mechanical properties of Meas. Jungbluth H. J Endod. Three-dimensional numeric simula- K. Zehnder 190. St. Kalayci S. activation systems on the penetration of sodium Liewehr F. Gozukara H. Eppendorf K. Endod. Dagli F. The dentino-canal junction. Okino LA. Kuttler Y. Harrison JW. Smith ML. Efficacy of different irrigation and 197. Factors promoting the pulp. Sener B. Canal debridement and disinfec- 1988.37:693–6. J Endod. Pashley EL. Aust Endod 218. Stabilizing sodium hypochlorite at J. 2005. 205. Ari H. J Endod. Microscopic investigation of root apexes. 1956. 206. 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Hülsmann M. Particle imaging velocimetry—a practical guide.21:277–80. Otogoto J. Kavitha S. Influence of irrigating unsteady Computational Fluid Dynamics model.43:909–16. 227. J Endod. Smith NA.4 Research on Irrigation: Methods and Models 97 219. Int Endod J. Verhaagen B. Nordmeyer S. 226. Lakshminarayanan canal taper on the irrigant flow: evaluation using an L. Ng YL. 1976. Rosenberg PA. Berlin: Springer. Olsen FK. film ex vivo model to evaluate the influence of canal Wesselink PR. An in vitro model root canal: flow around a polymer rotary fin. Yamada H. 2009. flow visualization. Versluis M. Gogos C. tube luminometer. Gliksberg J. Yamamoto A. Raffel M. Int Endod J. vitro particle image velocity measurements in a 229. Kuroiwa A. Kasahara E.48:79–83. 1–448. Laser-activated dimensions and irrigation variables on the efficacy irrigation of the root canal: cleaning efficacy and of irrigation. Shen Y. 2010. J Endod. Rödig T. Endod Top. Versluis M. Boutsioukis C. effect of irrigation using trial-manufactured washing 224. Willert C. extent of irrigant flow beyond the needle tip during 230. Apical pressure and and probes. 2006. Goldman M.39:511–5.33:746–8. Gomathi NS. 2014. Koch JD. 2013. Scanning electron microscope study of a new speed imaging. Huang TY. Kahn FH. needle. 1979. Boutsioukis C. Complications cal preparation size on irrigant flow in root canals during root canal irrigation. 232. Int Endod J. Kastrinakis E. Goldman LB. Int needle-tip designs in removing bacteria inoculated Endod J. evaluation of the irrigating characteristics of ultra- ishing file. Garces D. Oral Surg 222. Grady J. sonic and subsonic handpieces and irrigating needles 223. Van der Sluis LW.16:27–63. J Endod. 221. J Endod. Kastrinakis E. Haapasalo M. The effect of api. 2008. Versluis M. Irrigant flow in the tic treatment. Int Endod J. positive pressure irrigation in an in vitro root canal Yamaguchi H. 1995. root canal: experimental validation of an unsteady 228. In Oral Med Oral Pathol. Gao L. Park E. Gogos C. 2nd ed. PS. into instrumented root canals measured using single- 225. Kumar V. Boutsioukis C. Jap J Conserv Dent. Verhaagen B. van der Sluis LW. de Groot SD. Kronman JH. Kronman JH. Kompenhans evaluated using an unsteady computational fluid J. A bio-molecular 220. Clausen H. 2010. irrigation method in endodontic treatment.42:1077–83. Maeda M. Wereley S. Anzai M. p. Versluis M. Van der Sluis LW. dynamics model. Goldman LB. . Vinothkumar TS. Goldman M. 2007.40:412–6. The model. Verhaagen B.41:60–71. 2010. 2007.49:64–70. 2009. Verhaagen B. J Endod. Lin Computational Fluid Dynamics model using high.43:874–81. The effect of root 231.43:393–403.2:257–60. van der Sluis LW. New method of irrigation during endodon- Kastrinakis E. Gulabivala K. Wu MK.

ventional instrumentation [35. it is impos- sible to predictably eradicate intraradicular infection with mechanical instrumentation alone. DDS.Basrani@dentistry.1). particles that are cut from the canal wall are car- Toronto. strategy for successful treatment. irrigants are required to be used as an important addition in the disinfection process. University of Toronto. Faculty of Dentistry. Basrani (ed.utoronto. University of Toronto. Update of Endodontic Irrigating Solutions 5 Bettina Basrani and Gevik Malkhassian Abstract Successful root canal therapy depends on thorough debridement of pulpal tissue. reach favorable outcomes in endodontic infection management requires the recognition of the prob. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. in canal with a round cross section. the dentine Faculty of Dentistry. DOI 10. dentin structure.1007/978-3-319-16456-4_5 . cleaning. MSc. DDS. 348C-124 Edward Street. PhD (*) is important to mention here that more than 35 % Associate Professor. ON. This chapter analyzes the main irrigating solutions used during the endodontic treatment and their actions and interactions among them. It is well known that shaping. The principle to and dentin constituents. The goal of endodontic treatment is to prevent or In endodontic disinfection. Currently. The anatomical challenge can be divided into and obturating the root canal system provide the complexity of the root canal system. Explanation of their mechanism of action and effect on dentin structure and on biofilm is also described. ON M5G1G6. G. Malkhassian. MSc. Paque et al. 5.). FRCD(C) showed explained that when rotary files are used Assistant Professor. Apical periodontitis is an challenges which are important to be recognized inflammatory process in the periradicular tissues the anatomical challenge and the microbiological caused by microorganisms in the infected root challenge [42]. there are two main cure apical mulate debris in isthmus areas.Sc. and infective microorganisms. dentin debris. A clinical protocol is proposed at the end of the chapter. RCDC (F). Basrani. of the root canal surface is left untouched by con- Endodontics Program. Toronto. Therefore. Root canal is an enclosed complex space with intricate configurations and apical constriction it B. Director M. 2): lem and the removal of the etiological factors. Canada © Springer International Publishing Switzerland 2015 99 B. Discipline of Endodontics. Canada Also. canal [84]. Anatomical Complexities (also see Chap. 64] (Fig. common instrumentation techniques accu- e-mail: Bettina.

and mechanical.2). (Courtesy of Dr Gagliardi. Type I include to soften and dissolve organic and inor- collagen is the major protein of intertubular den. or penetration of the bio- tained and packed in the file’s flute space. M Middle. 67].2 SEM of dentin structure showing irregularities of dentin tissue advance disinfection techniques like chitosan nanoparticles and photoactivation disinfection ried coronally by the flutes of the file. debris was most probably actively packed into the area with the least resistance. biological. Dentin Constituents The effectiveness of antimicrobial irrigants is known to be compro- mised under in vivo conditions [77]. before (in green) and after (in red) in a lower molar. Lateral view of representative 3D recon. Malkhassian C P M T N A Fig. In recent studies it has been reported that dentin powder. drill. A Apical. ganic tissues. disruption. in a manner can also be neutralized by the dentin constitu- similar to that of a common mechanical spiral ents [77].100 B. and dissolve smear observed in the peritubular dentin. mak- ing dentin disinfection a challenging step (Fig. and access.1 MicroCT scan of pre. This removal is apparently less effective The microbiological challenge is well covered when the file has no dentine wall on one side. and biological objec- . the film should be our disinfection aim [43]. tives: chemical. Versiani and Sousa-Neto) structions of the internal anatomy of a mesial roots of a is a porous configuration with dentinal tubules that allow bacterial invasion and adherence. as in Chap. the dentin is a complex structure. 1. and lubricate the canal. 5. and dentin matrix can inhibit the antibacterial effect of commonly used irrig- ants [29. whereas no collagen fibrils are layer during instrumentation. 66. It is important to understand that the is the case of a canal adjacent to an isthmus. endodontic problem is a biofilm-related diseases Rather than being carried coronally or being con. Basrani and G. 5.and post-instrumentation mandibular molar. serum albumin. namely into the Endodontic irrigants have three major objec- isthmus [62]. chemical objectives cally. Mechanical objectives include to rinse out debris Dentin Structure Physiologically and anatomi. prevent the formation of a smear tin (90 %). Note the amount of walls not touch by canal preparation C Coronal. Interestingly. The structure layer once it has formed. it has been also reported that even the antibacterial effect of Fig. the instruments. 5.

5 Update of Endodontic Irrigating Solutions 101

tives are related to their antiseptic and nontoxic
effects such as efficacy against anaerobic faculta-
tive microorganisms (planktonic and biofilms),
ability to inactivate endotoxin, nontoxic and non-
caustic, and little potential to cause anaphylaxis.
The ideal irrigating solution to disinfect the
root canal system should be a biocompatible
bactericidal agent, tissue solvent, lubricant, and
smear layer remover capable of physically
flushing debris, with sustained effect but with-
out affecting the physical properties of the
The irrigating solutions in endodontics can be
classified as antimicrobial solutions, chelating
solutions (strong or weak), combinations (anti-
bacterial and chelating solutions combined), and Fig. 5.3 Percentage of responders who utilize each irrig-
solutions with detergent. ant as their primary disinfectant agent (Reproduced with
permission JOE [17])
Antimicrobial effects: antiseptic solutions,
topical antibiotics, bacteriostatic solutions, and
bactericidal solutions.

Antiseptic Solutions

Sodium Hypochlorite

Surveys from around the world [17, 23, 94]
reported that sodium hypochlorite is the most
common irrigating solution used in endodontics.
Figure 5.3 shows the percentage of responders
who utilize each irrigant as their primary disin-
fectant agent in a survey by the American
Association of Endodontists. It is an effective
antimicrobial and proteolytic agent [48, 49],
excellent organic tissue solvent [60], and lubri-
cant with fairly quick effects. NaOCl is both an
oxidizing agent and a hydrolyzing agent. Fig. 5.4 Schematic drawing of NaOCl mechanism of
Commercial sodium hypochlorite solutions are action (Reproduced with permission from [20])
strongly alkaline and hypertonic and typically
have nominal concentrations of 10–14 % avail- Estrela [20] reported that sodium hypochlorite
able chlorine. exhibits a dynamic balance:

Mode of Action 1: Saponification reaction:
Sodium hypochlorite has a pH of 11. Figure 5.4 Sodium hypochlorite acts as an organic and fat
shows the schematic interaction of the mecha- solvent that degrades fatty acids and trans-
nism of action of NaOCl (Reproduced with forms them into fatty acid salts (soap) and
permission from Estrela et al., Brazilian glycerol (alcohol), reducing the surface ten-
Endodontic Journal). sion of the remaining solution.

102 B. Basrani and G. Malkhassian

2: Neutralization reaction: 1. The velocity of dissolution of the bovine
Sodium hypochlorite neutralizes amino acids pulp fragments was directly proportional to
by forming water and salt. With the exit of the concentration of the sodium hypochlo-
hydroxyl ions, the pH is reduced. rite solution and was greater without the
3: Hypochlorous acid formation: surfactant.
When chlorine dissolves in water and it is in 2. Variations in surface tension, from beginning
contact with organic matter, it forms hypo- to end of pulp dissolution, were directly pro-
chlorous acid. It is a weak acid with the chemical portional to the concentration of the sodium
formula HClO that acts as an oxidizer. hypochlorite solution and greater in the solu-
Hypochlorous acid (HOCl−) and hypochlorite tions without surfactant. Solutions without
ions (OCl−) lead to amino acid degradation surfactant presented a decrease in surface ten-
and hydrolysis. sion and those with surfactant an increase.
4: Solvent action: 3. In heated sodium hypochlorite solutions, dis-
Sodium hypochlorite also acts as a solvent, solution of the bovine pulp tissue was more
releasing chlorine that combines with protein rapid.
amino groups (NH) to form chloramines 4. The greater the initial concentration of the
(chloramination reaction). Chloramines sodium hypochlorite solutions, the smaller the
impede cell metabolism; chlorine is a strong reduction of its pH (Estrela).
oxidant and inhibits essential bacterial
enzymes by irreversible oxidation of SH
groups (sulfhydryl group) [20]. Volume
5: High pH: Volume is more critical for disinfection than its
Sodium hypochlorite is a strong base concentration. Frequent exchange with fresh
(pH > 11). The antimicrobial effectiveness of NaOCl is important and the use of large amount
sodium hypochlorite, based on its high pH of irrigant compensates for the low concentra-
(hydroxyl ion action), is similar to the mecha- tion. It should be kept in mind that the NaOCl
nism of action of calcium hydroxide. The high will inactivate its components very fast, so fresh
pH interferes in cytoplasmic membrane integ- irrigating solution should be added to the canal
rity due to irreversible enzymatic inhibition, system constantly. (Please see chapter on irriga-
biosynthetic alterations in cellular metabo- tion dynamics to learn more about the volume.)
lism, and phospholipid degradation observed
in lipidic peroxidation [20]. Time
How long does NaOCl need to kill bacteria? This
question can be misinterpreted in the literature.
Concentration Some articles will show bacterial killing in 30 min
In the literature, it can be found that NaOCl can when 0.5 % NaOCl is used, while higher concen-
be used in a concentration that ranges from 0.5 to trations will need only 30 s to do the same job.
6 %. It was proven that the lower and higher con- Interpretation of results needs to be taken with
centrations are equally efficient in reducing the caution because it will depend on the methods
number of bacteria in infected root canal system used to test the time. It is important to remember
but the tissue-dissolving effect is directly related that the presence of organic matter, inflammatory
to the concentration [26]. exudates, tissue remnants, and microbial biomass
Grossman observed pulp tissue dissolution consumes NaOCl and weakens its effect.
capacity and reported that 5 % sodium hypochlo- The chlorine ion, which is responsible for the
rite dissolved this tissue in between 20 min and dissolving and antibacterial capacity of NaOCl,
2 h. The dissolution of bovine pulp tissue by is unstable and consumed rapidly during the first
sodium hypochlorite (0.5, 1.0, 2.5, and 5.0 %) phase of tissue dissolution, probably within
was studied in vitro under different conditions 2 min [57], which provides another reason for
(Estrela). It was concluded that: continuous replenishment. This should especially

5 Update of Endodontic Irrigating Solutions 103

be considered in view of the fact that rotary root a microscopic view of stained root section treated
canal preparation techniques have expedited the by 1 % sodium hypochlorite for 2 min (Published
shaping process. The optimal time that a hypo- with permission).
chlorite irrigant at a given concentration needs to
remain in the canal system is an issue yet to be Effect on Biofilms
answered [96]. Clegg et al. [12] demonstrated that 6 % NaOCl
was the only agent capable of both physically
Effect on the Dentin removing artificial biofilm and killing bacteria.
As it was stated before, the dentin is composed of There was a dose-dependent effect of NaOCl
22 % organic material by weight. Most of this against bacteria, as higher concentrations were
consists of type I collagen, which contributes more antibacterial. Figure 5.6 illustrates the
considerably to the mechanical properties of the effect of different irrigants on dentin biofilm
dentin. NaOCl solutions may affect mechanical elimination. In summary, 3 % and 6% NaOCl
dentin properties via the degradation of organic showed absence of biofilm, 1 % NaOCl showed
dentin components. disruption of biofilm, and 2 % CHX showed
intact biofilm (Fig. 5.6).
Depth of Penetration
The depth of NaOCl penetration varied between Limitations
77 and 300 μm, and it depends on concentration, Unfortunately, even though NaOCl has many
time, and temperature [99]. Figure 5.5 illustrates ideal properties, it has some limitations such as
being toxic [39, 48] (see more details in Chap. 7),
nonsubstantive, ineffective in smear layer
removal and corrosive. It may cause discolor-
ation [40] and has unpleasant odor. When NaOCl
is used as a final rinse, bonding of the sealer to
the dentin may be altered [72].

Clinical Recommendation
NaOCl in concentrations between 2.5 and 6 %
should be used during the whole cleaning and
shaping procedure. Pulp chamber should be used
as a reservoir of fresh irrigant. Once the mechani-
cal preparation is finished and a master apical file
is determined, the protocol of irrigation should
Fig. 5.5 A microscope view of stained root section
treated by 1 % sodium hypochlorite for 2 min (arrow) start with the activation of fresh NaOCl in each
(Reproduced with permission [99]) canal [27].

a b c d

Fig. 5.6 (a) Scanning electron micrograph (SEM) of with 6 % NaOCl. No bacteria are visible (original magni-
bacteria-free dentin on negative control specimen (origi- fication ×5,000). (d) SEM of dentin section treated with
nal magnification ×3,000). (b) SEM of positive control 2 % CHX. The biofilm is intact with no visible disruption
reveals cocci, rods, and filamentous organisms (original (original magnification ×5,000) (Reproduced with per-
magnification ×5,000). (c) SEM of dentin section treated mission from JOE [12])

104 B. Basrani and G. Malkhassian

Chlorhexidine Gluconate (CHX) [6] Time and concentration of CHX can influence
the antibacterial substantivity and the conclu-
Molecular Structure sions are inconsistent. Some studies demon-
CHX is a strongly basic molecule with a pH strated that 4 % CHX has greater antibacterial
between 5.5 and 7 that belongs to the polybigua- substantivity than 0.2 % after 5 min application
nide group and consists of two symmetric four- (332). Other studies stated that CHX should be
chlorophenyl rings and two biguanide groups left for more than 1 h in the canal to be adsorbed
connected by a central hexamethylene chain. by the dentin [50]. Komorowski et al. [45] sug-
CHX digluconate salt is easily soluble in water gested that a 5-min application of CHX did not
and is very stable [25]. induce substantivity, so the dentin should be
treated with CHX for 7 days. However, when
Mode of Action Paquette et al. [63] and Malkhassian et al. [55] in
Chlorhexidine, because of its cationic charges, is their in vivo studies medicated the canals with
capable of electrostatically binding to the nega- either liquid or gel forms of CHX for 1 week,
tively charged surfaces of bacteria [14], damag- neither of them could achieve total disinfection.
ing the outer layers of the cell wall and rendering Therefore, residual antimicrobial efficacy of
it permeable [33, 36, 37]. CHX is a wide- CHX in vivo still remains to be demonstrated.
spectrum antimicrobial agent, active against
gram-positive and gram-negative bacteria and Chlorhexidine as an Endodontic
yeasts [16]. Irrigant
Depending on its concentration, CHX can CHX has been extensively studied as an end-
have both bacteriostatic and bactericidal effects. odontic irrigant and intracanal medication, both
At high concentrations, CHX acts as a detergent in vivo (Barbosa, Linkgog, Manzur, Paquette,
and exerts its bactericidal effect by damaging the Malkhassian) and in vitro [4, 5, 9, 10, 51, 56].
cell membrane and causes precipitation of the The antibacterial efficacy of CHX as an irrigant
cytoplasm. At low concentrations, CHX is bacte- is concentration dependent. It has been demon-
riostatic, causing low-molecular-weight sub- strated that 2 % CHX has a better antibacterial
stances (i.e., potassium and phosphorous) to leak efficacy than 0.12 % CHX in vitro ([10]). When
out from the cell membrane without the cell being comparing its effectiveness with NaOCl, contro-
permanently damaged. versial results can be found. NaOCl has an obvious
advantage over CHX with the dissolution capacity
Substantivity of organic matter that CHX lacks; therefore, even
Due to the cationic nature of the CHX molecule, though in vitro studies suggest some advantages
it can be absorbed by anionic substrates such as with the use of CHX, as soon as organic and dental
the oral mucosa and tooth structure [54, 73, 92]. tissue is added, NaOCl is clearly preferable.
CHX is readily adsorbed onto hydroxyapatite The antibacterial effectiveness of CHX in
and teeth. Studies have shown that the uptake of infected root canals has been investigated in sev-
CHX onto the teeth is reversible [34]. This revers- eral in vivo studies. Investigators [70] reported
ible reaction of uptake and release of CHX leads that 2.5 % NaOCl was significantly more effec-
to substantive antimicrobial activity and is tive than 0.2 % CHX when the infected root
referred to as substantivity. This effect depends canals were irrigated for 30 min with either of the
on the concentration of CHX. At low concentra- solutions.
tions of 0.005–0.01 %, only a constant mono- In a controlled and randomized clinical trial,
layer of CHX is adsorbed on the tooth surface, the efficacy of 2 % CHX liquid was tested against
but at higher concentrations, a multilayer of CHX saline using culture technique. All the teeth were
is formed on the surface, providing a reservoir of initially instrumented and irrigated using 1 %
CHX which can rapidly release the excess into NaOCl. Then either 2 % CHX liquid or saline
the environment as the concentration of CHX in was applied as a final rinse. The authors reported
the surrounding environment decreases [19]. a further reduction in the proportion of positive

5 Update of Endodontic Irrigating Solutions 105

cultures in the CHX group. Their results showed 2. When maximal antimicrobial effect is desirable
a better disinfection of the root canals using CHX as a final rinse after EDTA to further facilitate
compared to saline as a final rinse [95]. disinfection and to improve dentin bonding
In a recent study, the antibacterial efficacy of (where relevant) [30].
2 % CHX gel was tested against 2.5 % NaOCl in
teeth with apical periodontitis, with the bacterial Decalcifying Agents
load assessed using real-time quantitative poly- Debris is defined as dentin chips or residual vital
merase chain reaction (RTQ-PCR) and colony- or necrotic pulp tissue attached to the root canal
forming units (CFU). The bacterial reduction in wall. Smear layer was defined by the American
the NaOCl group was significantly greater than Association of Endodontists in 2003 as a surface
the CHX group when measured by RTQ- film of debris retained on the dentin or other sur-
PCR. Based on culture technique, bacterial faces after instrumentation with either rotary
growth was detected in 50 % of the CHX group instruments or endodontic files; it consists of
compared to 25 % in the NaOCl group [93]. On dentin particles, remnants of vital or necrotic
the other hand, another study based on this culture pulp tissue, bacterial components, and retained
technique revealed no significant difference irrigants. While it has been viewed as an impedi-
between the antibacterial efficacy of 2.5 % NaOCl ment to irrigant penetration into dentinal tubules,
and 0.12 % CHX liquid when used as irrigants there is still a controversy about the influence of
during the treatment of infected canals [80]. smear layer on the outcome of endodontic treat-
In a recent systematic review, Ng et al. [59] ment. Some researchers emphasize the impor-
demonstrated that abstaining from using 2 % tance of removing the smear layer to allow
CHX as an adjunct irrigant to NaOCl was associ- irrigants, medications, and sealers to penetrate
ated with superior periapical healing. into the dentinal tubules and improve disinfec-
Unlike NaOCl, CHX lacks a tissue-dissolving tion. On the other hand, other researchers focused
property. Therefore, NaOCl is still considered the on keeping the smear layer as a protection for
primary irrigating solution in endodontics. bacterial invasion, apical and coronal microleak-
age, bacterial penetration of the tubules, and the
Allergic Reactions to Chlorhexidine adaptation of root canal materials. The majority
Allergic responses to CHX are rare, and there are of the conclusions on smear layer are based on
no reports of reactions following root canal irri- in vitro studies. A recent clinical study by Ng
gation with CHX [2, 39]. The sensitization rate et al.[59] found that the use of EDTA signifi-
has been reported in several studies to be approx- cantly increased the odds of success of retreat-
imately 2 % [47]. However, some allergic reac- ment cases by twofold.
tions such as anaphylaxis, contact dermatitis, and The chelating agents can be classified as strong
urticaria have been reported following direct con- or weak. Strong chelating agents are EDTA, citric
tact to mucosal tissue or open wounds [18, 65, acid, and chitosan nanoparticles, while weak che-
74, 81]. lating agent is HEBP or etidronate.

The limitations of using CHX as a primary and sole Ethylenediaminetetraacetic Acid
endodontic irrigant are the following: the inability
to dissolve organic matter, no action on smear Ethylenediaminetetraacetic acid, widely abbre-
layer, and minor effect on biofilm disruption. viated as EDTA, is an aminopolycarboxylic
acid, and a colorless, water-soluble solid.
Clinical Recommendations EDTA is often suggested as an irrigant because
The clinical recommendation to use CHX during it can chelate and remove the mineralized
endodontic treatment: portion of the smear layer. It is a polyami-
1. In teeth with open apices or perforation where nocarboxylic acid with the formula
there is a risk to extrude NaOCl. [CH2N(CH2CO2H)2]2. Its prominence as a che-

106 B. Basrani and G. Malkhassian

lating agent arises from its ability to sequester The effect of chelators in negotiating narrow,
di- and tricationic metal ions such as Ca2+ and tortuous, calcified canals to establish patency
Fe3+. After being bound by EDTA, metal ions depends on both canal width and the amount of
remain in solution but exhibit diminished active substance available, since the deminer-
reactivity. alization process continues until all chelators
have formed complexes with calcium [38, 98].
History Therefore, studies should be read with caution
The compound was first described in 1935 by because one study can show demineralization up
Ferdinand Munz, who prepared the compound to a depth of 50 μm into the dentin [38], but other
from ethylenediamine and chloroacetic acid. reports demonstrated significant erosion after
Chelating agents were introduced into endodon- irrigation with EDTA [89, 91]. The sequence in
tics as an aid for the preparation of narrow and which root canal wall dentin is exposed to NaOCl
calcified root canals in 1957 by Nygaard-Østby and EDTA has an impact on the level of dentin
[38]. Today, EDTA is mainly synthesized from erosion on the main root canal wall.
ethylenediamine (1, 2-diaminoethane), formalde- In the study reported by Qian et al. [69] no ero-
hyde (methanal), and sodium cyanide [38]. sion was detected when demineralizing agents
were used as a final rinse after NaOCl. However,
Mode of Action the erosion of peritubular and intertubular dentin
On direct exposure for extended time, EDTA was detected when EDTA was used first followed
extracts bacterial surface proteins by combining by 5.25 % NaOCl.
with metal ions from the cell membrane which EDTA had a significantly better antimicrobial
can eventually lead to bacterial death [38]. effect than saline solution. It exerts its strongest
Chelators such as EDTA form a stable complex effect when used synergistically with NaOCl
with calcium. When all available ions have been [32, 78].
bound, equilibrium is formed and no further dis-
solution takes place; therefore, EDTA is self-lim- Interaction Between CHX and NaOCl
iting [38]. The combination of NaOCl and CHX produces
a change of color and a precipitate. The reaction
Applications in Endodontics is dependent of the concentration of NaOCl. The
EDTA alone normally cannot remove the smear higher the concentration of NaOCl, the larger the
layer effectively; a proteolytic component, such precipitate is if 2 % CHX is used [7] (Fig. 5.7).
as NaOCl, must be added to remove the organic Furthermore, concerns have been raised that the
components of the smear layer [22]. For root color change may have some clinical relevance
canal preparation, EDTA has limited value alone causing staining of the tooth. Also the resulting
as an irrigation fluid [22]. EDTA is normally used precipitate might interfere with the seal of the
in a concentration of 17 % and can remove the root canal obturation. Basrani et al. [7] evalu-
smear layer when in direct contact with the root ated the chemical nature of this precipitate and
canal wall for less than 1 min. reported the formation of 4-chloroaniline (PCA).
Although citric acid appears to be slightly Furthermore, a recent study [44] (Fig. 5.8) using
more potent at similar concentration than EDTA, TOF-SIMS analysis showed the penetration
both agents show high efficiency in removing of PCA inside dentinal tubules. PCA has been
the smear layer. In addition to their cleaning shown to be toxic in humans with short-term
ability, chelators may detach biofilms adhering exposure, resulting in cyanosis, which is a mani-
to root canal walls [28]. This may explain why festation of methemoglobin formation. The inter-
an EDTA irrigant proved to be highly superior to action should be avoided by using EDTA or other
saline in reducing intracanal microbiota despite irrigants after NaOCl and before CHX or alterna-
the fact that its antiseptic capacity is relatively tively, the canals can be dried using paper points
limited [28]. before the final rinse [98].

Note irregular precipitate on surface (green chlorine. of CHX group [44] Interaction Between CHX and EDTA on the results. in addition to chlorine. 5. ucts. did a study to determine whether the precipitate involves the chemical degradation of CHX. the higher the amount of precipitate [7] a b c 50 µm 50 µm 50 µm 24 400 50 20 40 300 16 12 30 200 8 20 100 4 10 0 0 0 total ClC6H4H2N+ + ClC6H4CH2N2+ + Cl. They concluded that . so a group of investigators [70] (Fig. (a) ‘‘Total’’ shows raw image.10e+5 mc:57 tc:4. 5.0 % CHX. into Dentinal tubules (yellow lyzed by High-spatial-resolution TOF-SIMS images of arrows). 5. The Interaction Between EDTA and NaOCl precipitate was produced and redissolved in a Investigators [24] studied the interactions known amount of dilute trifluoroacetic acid.5 Update of Endodontic Irrigating Solutions 107 Fig.28e+7 mc:24 tc:1. (b) Positive ion of CHX group. ClC6H4 H2N+ + ion distribution in longitudinal sections of dentin: Pulp ClC6H4CH2N2+ show distribution of PCA and CHX space is on topmost and dentin bottom-most in each breakdown products. and Cl _+ 37Cl_ show distribution of image.8 Dentin treated with CHX and NaOCl and ana. CHX was found to form a salt with The combination of CHX and EDTA produces a EDTA rather than undergoing a chemical reaction white precipitate.+ 37Cl- mc:473 tc:1. Based between EDTA and NaOCl.03e+5 Fig. the extension of PCA and CHX breakdown prod.9).7 Interaction between different concentrations of NaOCl and 2. Note that the higher the concentration of NaOCl. (c) Negative ion arrows).

A weak chelating agent. irrigation with EDTA for crobial activity [98]. this combi- remove the NaOCl with large amount of EDTA. copious amounts of NaOCl should be administered to wash out remnants HEBP of the EDTA. EDTA is used once the cleaning and shaping is completed Etidronic acid. 5. In an alternating irrigating regimen.10 (Prado et al. therefore. 5. In modern endodontics. Basrani and G. It can be ultrasonically acti. lose its tissue-dissolving capacity. suffering from osteoporosis or Paget’s disease It should be taken into consideration that a rise and was suggested as a substitute for traditional on the temperature of EDTA is not desirable. we need to be careful to (HEBP) or etidronate [86].108 B.9 Endodontic access cavities containing CHX mixed with various irrigants. with virtually Any collagen and/or other proteins left no free chlorine detected in the combinations. and collagen can be tion to a similar extent as with the conventional important for the binding of bacteria. (b) NaOCl. This irrigant has the ability to remove the smear layer similar to that Clinical Recommendations of EDTA or citric acid. but EDTA caused NaOCl to tion may produce dentin erosion [69]. this suggests that EDTA and NaOCl exposure to sodium hypochlorite [83]. Note that NaOCl and EDTA cause CHX to form a precipitate (Reproduced with permission from [70]) EDTA retained its calcium-complex ability when be applied at this time. Because NaOCl and EDTA as 1-hydroxyethylidene-1. and (c) EDTA. nation reduces AHTD and prevents smear layer EDTA will leave a layer of collagen on the sur. It is considered the unique chela- can work at their best. resorption.5 % Figure 5. exposed by EDTA would be removed by a short Clinically. When EDTA is heated tor that can be mixed with NaOCl without inter- from 20 to 90°. has been used in medicine for patients vated for better penetration in dentinal tubules. the calcium-binding capacity fering with its antimicrobial property [98].) showed a visual NaOCl/9 % etidronic acid (HEBP). the NaOCl/HEBP . Note that larger concentra- mixed with NaOCl. decreases [97]. Besides. that the tissue dissolution ability of NaOCl is not EDTA can be activated for a couple of seconds to diminished when mixed with HEBPT also known improve penetration. anatomical irregularities. a use of NaOCl during instrumentation followed final rinse with a low concentration of NaOCl can by EDTA [52]. Consequently. formation during rotary root canal instrumenta- face of the root canal lumen. (a) Water. has been aspect of different interactions between com. a substance that prevents bone for around 1 min. should be used separately. Malkhassian a b c Fig. proposed to eliminate debris impaction in the monly used irrigants (Fig. A recent report has shown 1 min should be used to remove smear layer. such as 2. chelators due to fewer effects observed on dentin Chelators have a temperature range wherein they structure [85].10). 1-bisphosphonate may interact negatively. and it can be mixed with After NaOCl was used throughout the cleaning NaOCl without any loss of the NaOCl antimi- and shaping procedure.

however. a 10 °C temperature rise during ultrasonic activation was insufficient to increase the reac- Effect of Temperature tion rate.wikipedia. in situ heating of NaOCl is rec. liquid that are the consequence of forces acting upon the liquid. the generation soon as the irrigant touches the root canal system. ultrasonic rinse with a chelating agent [1]. This can be done by from 20 to 90 °C will decrease the calcium- activating ultrasonic or sonic tips to the NaOCl binding capacity of EDTA and citric acid from inside the root canal for a couple of Heating ommended by some authors. Cavitation is the formation of vapor cavities in a respectively [97]. Increasing the temperature of low-concentration NaOCl solutions improves their immediate EDTA + Heat tissue-dissolution capacity [98]. it was demonstrated that as of the solution will be enhanced.[53] state that the efficacy of NaOCl on the ing and after instrumentation. and exposure time. replacing the final dentin is improved by refreshment.10 Visual aspect of a b c the interactions between the following: (a) 5. When subjected to higher pressure. It usually occurs when a liquid is subjected to rapid changes that cause the forma. Cameron [11] reported that an increase . 219 to 154 and from 195 to 30 mg CaO/g. to our knowledge. ture range at which they work best. the voids The use of ultrasonic energy to enhance the effi- implode and can generate an intense shockwave cacy of irrigants is a new trend in clinical end- http://en. In this investiga- tion.16 % NaOCl and 2 % CHX. JOE 2007 [68]) solution could be used as a single irrigant dur. (c) 17 % EDTA and 2 % CHX (Reproduced with permis- sion from Prado et al. heated hypochlorite solutions remove organic The ultrasonic activation and heat production debris from dentin shavings more efficiently. activation. Furthermore. of heat and the possibility of cavitation may not the temperature reaches the body temperature be beneficial. Macedo odontics. Chelators have a clear tempera- [98]. While the streaming syringes. (b) 0. et al. Therefore. 5. CHX + Heat tion of cavities where the pressure is relatively low.5 Update of Endodontic Irrigating Solutions 109 Fig. there are no clinical studies available at this point to sup- NaOCl + Heat port the use of heated NaOCl. of chelating agents with an ultrasonic tip are There are various devices to preheat NaOCl also of questionable value.25 % NaOCl and 2 % CHX. However.

5. contact angle. indicating the presence of pylene glycol + citric acid PCA or another aromatic amine. the result was a • Tetraclean: 50 mg/mL doxycycline + polypro- yellow end product. there is no need in endodontic irigants to the NaOCl solution was ultrasonically activated add detergents (see Dynamics chapter for more for 30 s without replenishment. BioPure MTAD and Tetraclean cipitate. Figure 5. vis. and wetting behavior of the 80) [89. It is mixed as a liquid and powder irrigant. 91]. These findings • MTAD: 3 % doxycycline hyclate + 4. In 2009. is an aqueous with Detergents solution of 3 % doxycycline. 4. NaOCl/CHX pre. introduced by Torabinejad and Johnson [90] at Combinations and Solutions Loma Linda University in 2003. and 2.11 Tubes with PCA and the NaOCl/CHX precipitate turned yellow after heating them to 45°. agent.25 % might be clinically relevant because PCA has citric acid + Tween 80 been shown to be toxic. • SmearClear: EDTA + detergents therefore indicating that there is no aromatic • Chlor-XTRA: NaOCl + detergents amine present.0 % CHX at 45 °C were yellow. indicating that no oped. 89. 91]. Malkhassian Fig. surface tension only clinical practice as a final rinse after completion affects the flow when 2 immiscible (incapable of of conventional chemomechanical preparation mixing) fluids are present. it is not recommended to elevate the tem- perature of the CHX [8]. Because the dentin is [75. MTAD. our details). Considering that CHX • QMiX: CHX + EDTA + detergent can break down to form PCA by exposure to heat. when CHX that was • CHX-Plus: CHX + detergents heated to 45 °C was diazotized. and a detergent have been devel- or heated at 37 °C turned white. However. MTAD has been recommended in always affect the flow.110 B. However. indicating that the amine (PCA) was present [8] in the intracanal temperature from 37 to 45 °C hydrophilic and dentinal tubules always contain occurred close to the tip of the instrument when water.11 shows that the end products of the PCA. indicating that an aromatic amine was present in Two new irrigants based on a mixture of antibiot- all samples. and 0. Even though density and viscosity prior to use. a broad-spectrum antibiotic. . 91]. Basrani and G.25 % citric acid. both the smear layer and organic tissue from the infected root canal system [89.5 % polysorbate 80 detergent (Tween cosity. These irrigants are capable of removing aromatic was present. CHX at room temperature ics. group (Basrani) published a paper showing that Some added detergents in the market are: CHX at room temperature and at 37 °C did not result in a yellow end product when diazotized. citric acid. a demineralizing The irrigant flow can be affected by density.

Krause et al. Tetracyclines inhibit alone. 79]. protein binding. used as an intracanal irrigant before placing Doxycycline. [15] EDTA as a decalcifying agent.N-trimethylammonium bromide). 6. A study using extracted human hypochlorite was used throughout the cleaning teeth contaminated with saliva showed that and shaping. 88].N. QMiX Earlier in vitro research on MTAD showed contains a CHX analog.3 % NaOCl as a root canal irrigant and MTAD as a final rinse was significantly Protocol more effective against E. 41]. [46]. 5. 87.5 Update of Endodontic Irrigating Solutions 111 Tetraclean (Ogna Laboratori Farmaceutici. It is effective against Aa. when a low concentration of NaOCl (1. Torabinejad et al. for MTAD and 50 mg/5 ml for Tetraclean) and using bovine tooth sections. and 7 positions.25 % NaOCl was more effective than MTAD propylene glycol for Tetraclean). intermedia and affects fect the root canal system and remove the smear both gram-positive and gram-negative (more layer. and Tween 80 together 1 ml of MTAD in a canal for 5 min and rinsing may have a synergistic effect on the disruption it with an additional 4 ml of MTAD as the final of the bacterial cell wall and on the cytoplasmic rinse [79]. Mode of Action All tetracyclines are derivatives of four-ringed Clinical Trials nucleus that differ structurally in regard to the Malkhassian et al. in disinfection of the teeth. Shabahang and in the removal of canal wall smear layers and Torabinejad [76] showed that the combina. metabo. 88]. 5. P. faecalis than other QMiX is suggested as a final rinse. The two irrigants differ in the concen.25 % NaOCl vent the formation of PCA. and irrigants [15. It is recommended to be used at the end of instrumentation. debris. In contrast to the Muggio. it is intended as found that MTAD was effective in killing E. Italy) is a combination product similar previously mentioned studies.[55] in a controlled clinical chemical groups at 2. pletely remove the smear layer is enhanced riostatic antibiotic. The effectiveness of MTAD to com- gram-negative effect). (N-cetyl- its antimicrobial efficacy over conventional N. showed that the kind of detergent (Tween 80 for MTAD. If sodium regimens [75]. citric acid. triclosan. trial of 30 patients reported that the final rinse These derivatives exhibit different characteris. in disinfection of dentin disks inoculated with E. Smear Layer Removal QMiX In two studies. . canal irrigation. it is one of the but no significant difference between these two new combination products introduced for root solutions was reported [87. after NaOCl irri- Antibacterial Efficacy gation. with MTAD did not reduce the bacterial counts tic such as absorption. saline can rinse out NaOCl to pre- MTAD was more effective than 5. MTAD was developed as a final rinse to disin- aga. poly. a antimicrobial irrigant as well as to be used faecalis up to 200× dilution. and the degree of activity against chemomechanical preparation using NaOCl susceptible organism [31]. later research to MTAD. faecalis [76. membrane. and P. capnocytoph.gingivalis. protein synthesis by reversibly binding to the 30S subunit of bacterial ribosome in susceptible Protocol for Use bacteria.3 %) is tetracycline may also have a bactericidal effect. tion of 1. Tetracycline is a bacte. but in high concentrations. suggested less than optimal antimicrobial tration of antibiotics (doxycycline 150 mg/5 ml activity of MTAD [21. the efficacy of MTAD or EDTA in the removal of the smear layer was confirmed. excretion. QMiX was introduced in 2011. in infected canals beyond levels achieved by lism. According to the patent (195).

Dry with paper points and obturate of dentin slurry has the potential to inhibit most current antimicrobials in the root canal system. Ferrer-Luque CM. decreased significantly the number of live bacteria 3. or antibiotics (MTAD) lacked an effective tion. 30 sec with fresh solution per canal. Baca P. [58] showed that QMiX a. solutions against the young biofilm. Basrani and G. CHX. 1 min or was less effective than 6 % NaOCl and similar to b. 6 % NaOCl for approx. using an open-canal design. Recommended irrigation protocol for root canal imental model.5–5 % NaOCl throughout the instrumenta- 12 times more biofilm bacteria than 1 % NaOCl tion procedure until final shape of the canal is (P < 0. when the dentin was infected 2.5–5. Antibacterial Efficacy and Effect on Biofilms Disinfection Protocol Suggested Stojicic et al.40(12):1999–2002. sonic or laser activation) for old E. Contact Dermatitis. Malkhassian Smear Layer Removal (P < 0. Moreover. Endovac). the ability of two pH versions of QMiX on Dissolution ability is mandatory for an appropri- removal of canal wall smear layers and debris ate eradication of biofilms attached to the dentin. providing also cleaner dentin surfaces Antibacterial efficacy of calcium hydroxide. Joyce AP. Further clinical research from independent investigators is needed to corroborate the findings.112 B. intraorally. QMiX. compared the antibacterial effects 2. Ordinola-Zapata et al. or 1 %NaOCl in bactericidal action. They concluded that several chelat- Stojicic et al. faecalis biofilms in dentin canals using approx. Wang et al. Autegarden JE. QMiX and 2 % NaOCl killed up to 1. Arias-Moliz MT. Pecquet C. antibiofilm activity. Six percent NaOCl to enhance apical irrigation without extrusion and QMiX were the most effective disinfecting (ex. Bayrou O. iodine com- of a sodium hypochlorite/etidronic acid irrigant solu- pounds. 2014. with the exception equally well as EDTA. achieved (adequate size and taper). The irrigant solutions 4 % perace. etc.40:215–7. 2. QMiX and 1 % steps are the most commonly used: NaOCl killed all planktonic E. Morgental et al. Huet S.25 % sodium hypochlorite 1999. Ordinola-Zapata R. cetrimide. [13] examined of sodium hypochlorite and 4 % peracetic acid.01) or 2 % CHX (P < 0. Leynadier F. P < 0. tic acid and 2. were more effective than 2 % NaOCl and 2 % 5. 1min (activation and/or apical was the most effective followed by QMiX. in biofilms. According to c. it appears that the presence d. whereas 4. Baker NE. maleic acid. Buxton TB. Final rinse options: CHX. faecalis and plaque bacteria in 5 s. Smear layer removal (EDTA. a novel dentin infection model and confocal 3. Apical negative pressure devices are optional laser scanning microscopy. studies. Both negative pressure optional).25 % NaOCl as the main rinse. Ruiz- Linares M. J Endod.001). in a laboratory exper. the efficacy of QMiX against treatment: Many protocols are suggested in the Enterococcus faecalis and mixed plaque bacteria modern endodontic literature. Clinical Trials mental QMiX versions are as effective as 17 % The efficacy and biocompatibility of QMiX were EDTA in removing canal wall smear layers after demonstrated via nonclinical in vitro and ex vivo the use of 5. Citric acid. iodine . The following in planktonic phase and biofilms. Anaphylactic shock after application of chlorhexidine to unbroken skin. QMiX removed smear layer on intraorally infected dentin.) against the 3-week-old biofilm. Dai et al. the two experi. Fresh NaOCl for approx.05). [82] investigated the effectiveness ing agents containing antimicrobials could not of smear layer removal by QMiX using scanning remove nor kill significantly biofilms developed electron microscopy. Within the limita- tions of an open-canal design. Alcohol or their in vitro study. Antimicrobial activity (QMiX). Activation and heating of the fresh NaOCl of different disinfecting solutions on young and (such as ultrasonic.05. [61] found References that several endodontic irrigants containing anti- microbial compounds such as chlorhexidine 1. [82] assessed. Liewehr FR.

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V. there have been many irrigating agents that have been used to achieve this objective. Historically. Complications of Endodontic Irrigation: Dental. Department of 1964 questioned the need to culture [3. Canada lish endodontic biofilm as the cause of apical e-mail: gary@rootcanals. Kingston. University of Technology. This chapter will outline the complications and sequelae that poten- tially can occur if sodium hypochlorite is accidentally extruded past the apex and into the periradicular tissues. and equipment to identify all varieties of ago. © Springer International Publishing Switzerland 2015 117 B. debride necrotic tis- sue from the root canal space.1007/978-3-319-16456-4_6 . Sodium hypochlorite. FRCD(C) researchers like Bender and Seltzer who by Associate in Dentistry. and by the mid-1920s. Sundqvist reestablished the impor- Adjunct Professor of Dentistry. Jamaica tance of the endodontic microflora [5] and began the scientific path of discovery that would estab- Private Practice. Glassman. Endodontics.). Toronto. Endodontic Specialists. Medical. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. periodontitis [6]. the importance of microbiota and their symbiotic association within the root canal system. Graduate. the legal and ethical implications with respect to the use and delivery of sodium hypochlorite during endodontic treatment will also be discussed. tech- endodontic microbial control over a century niques. Toronto. ON. as microbiology assay methods improved. 4]. 6 and Legal Gary Glassman Abstract The objective of endodontic treatment is to treat and/or prevent apical periodon- titis. still remains the irrigant of choice to break down the organic tissue of the dental pulp. DDS. to date. The mechanism of action of the irrigation accident will be detailed as well as preventative measures that can be employed to avoid such occurrences in addition to suggested treat- ment recommendations should such an accident occur. Black [1] recognized the significance of endodontic pioneers lacked the methods. Canada Fortunately. the early G. DOI 10. Microbial Control: History obtaining a “negative culture” prior to obtura- tion was axiomatic [2]. These shortcom- ings adversely affected the reasoning of many G. Unfortunately. University of Toronto. Basrani (ed. In addition. Faculty of Dentistry. and confirm negative bacteria cultures. Sodium hypochlorite while being an excellent endodontic irrigant can also cause devas- tating complications if extruded past the apex into the periradicular tissues.

Although (1) maxillary sinus incidents [11]. The study also included the intra. it lacked [12]. (2) severe pain chlorhexidine effectively kills biofilm. described. only 6 % NaOCl could pre- 5. At the root of the problem is a broad misunder- capable of addressing the problems associated standing of the reasons NaOCl is extruded from with endodontic biofilm. further noted that one + Control + Intact 100 of the serious clinical consequences of using − Control − Absent 0 NaOCl is the passage of some of the solution From Clegg [8] through the foramina. is extremely cytotoxic and should be used 1 % NaOCl + Disrupted 90 judiciously and with caution in endodontic treat- 1 % NaOCl/ + Disrupted 0 ment.25 % NaOCl. when diluted with saline at a ratio possibility of forceful apical extrusion and of 1:1. to date. (6) one of the basic objectives of endodontic treat. Twenty-eight years after this warning. (3) cellulitis [13].1 While 3 and 6 % NaOCl could eliminate bio. therefore. Pashley coauthored In 2005. this chapter the apical foramen. Pashley et al. This finding immediately prompted intraosseous infusion [10]. In a classical study. when an irrigation needle is wedged into a canal during irrigation. thus failing to achieve [14]. Glassman Table 6. and (8) acute kidney injury [18]. produced 96. Pashley et al. in a one-of-a-kind clinical devastating effects on living tissue. as Pashley using NaOCl during endodontic treatment. His findings conclusively proved that 6 % NaOCl is required Complications from NaOCl extrusion includes to achieve both objectives (Table 6.3 % hemolysis of an reported that care was taken to insure that no irri- RBC sample. mats reported they felt the needle was wedged in sible for complete hydrolysis of biofilm produces the canal [19]. however. 6 % NaOCl is infection [17]. the chemical characteristic respon. gation needle was wedged into the walls. Even the suggestion that NaOCl. in a survey of NaOCl: Cytotoxicity the diplomats of the American Board of Endodontics. will only affect necrotic tissue should be 2 % CHX + Intact 0 abandoned. (7) secondary ment – debridement. and the affected Presence of Biofilm Culture Solution bacteria status growth (%) areas ulcerated after 24 h. (5) permanent facial disfigurement [15].” Pashley et al.000. which sometimes occurs when the needle is momentarily wedged tightly Microbial Control: Biofilm and NaOCl into the canal during irrigation.25 % NaOCl during canal prepara. yet in . Hypaque (a radiopaque dye) was used as 1985 study. First. It is generally believed that will only address complications associated with apical extrusion of NaOCl happens. Second.25 % NaOCl. two stud- ies disagree with this belief.118 G. Clegg to investigate the most currently available endodontic irrigation solutions so as to determine their ability to both eradicate biofilm and prevent NaOCl: Complications its regrowth on dentinal walls [8]. warned: 6 % NaOCl − Absent 0 “NaOCl. sion incident – direct intravenous injection via tion [7]. the only known endodontic irrigant. while a very effective proteolytic sol- 3 % NaOCl − Absent 20 vent. [9] investigated the an irrigating solution [20]. By default. at some MTAD dilution. The intradermal injections vent regrowth of the biofilm resulted in immediate hemorrhage within the SEM entire area of solution contact.1). It is important to note effect on red blood cells (RBC) and found that that the Hypaque investigators were aware of the 5. Nair reported an abundance of biofilm another publication that identified a far simpler within the root canal system after using copious and more dangerous cause of the NaOCl extru- amounts of 5. only 20 % of the responding diplo- Unfortunately. permanent nerve damage [16]. dermal injection effect using a rat model and film from the dentinal walls. (4) life-threatening events the ability to hydrolyze it.

but if an irrigant can escape the apical ing root canal irrigation. Regarding nonvital teeth: “When the Hypaque did extend into the periapical tissues in teeth with necrotic pulps. Salzgeber used a radi- opaque dye (Hypaque) as an endodontic irrigant delivered judicially and cautiously via a non-binding needle during canal preparation and final irrigation. due to tissue reaction ecchymosis involving (A) one or both eyelids and (B) upper with NaOCl.2. and Legal 119 both vital and nonvital teeth. a find. 6. 6. almost no ecchymosis is would feel some degree of postoperative pain or apparent at or near the right alar lobule.” It symptoms of the NaOCl incident so rare? is important to note that the Boutsioukis’ et al.1 In a unique clinical study. four months superficial to the involved root apex virtually ever affected. why isn’t the facial area directly review was published in July 2013. Medical. sometimes regardless of the pulp’s vitality. Gondim et al. Boutsioukis et al. Currently available foramen as easily as demonstrated in Fig. Considering the and other areas like the cheek are never affected. 6.6 Complications of Endodontic Irrigation: Dental.1). Despite careful delivery. the dye extended into the apical tissues.1. it seems reasonable that many patients Fig. In July 2013. [23] NaOCl: Reviewing the Extrusion published an extensive 16-page review paper Incident that included 105 references and examined 40 case histories and stated: “There is a lack of clin- A typical NaOCl extrusion is characterized in ical studies focusing on irrigant extrusion dur- Fig. and this discomfort following traditional endodontic irri.3a. 6. post-op pain is likely a consequence. [21] (From Salzgeber and never includes the cheek area [18] (With permission from Brilliant [20]) Saudi Journal of Kidney Diseases and Transplantation) . Curiously. 6. it seemed to respect no Fig. 6. yet cally significant fact [21]. and lower lips beginning at the angle of the mouth but (C) ing supported by Gondim et al. proved this to be a statisti. 6. case reports provide limited data on the possible then why are these characteristic signs and factors that may influence irrigant extrusion. Hypaque was noted (Fig. tissue toxicity of even the smallest amount of This is apparent again with the patient shown in NaOCl.” In a situation as shown here. ecchymosis is apparent up to the super palpebral vein (arrow in “A”) and down to the angle of the mouth [22].2 are usually always affected.2 The pathognomonic appearance of a NaOCl boundaries and occupied a random portion of the rarefied extrusion incident typically includes hemifacial edema and area. treated tooth (upper right lateral incisor). apical extrusion of the face in Fig. Furthermore. while very specific other parts of a b c Fig. is the area directly superficial to the apex of the gation.

Finally. such as occurs when the apex ex vivo studies [24–26]. 6. (c) The area between the hemorrhagic effect of NaOCl infusion. veins. The article immediately following Boutsioukis’ Periapical tissues and bone provide resistance July 2013 review was one of the three ex vivo to apical extrusion as well as non-patent canals. (b) The course of the anterior facial vein.120 G. and. by design. Glassman a b c Fig. studies published between April 2013 and May If quantities of periapical extrusion occurred 2014 [24–26]. he stated sinus and may not be covered with bony lamina the following: “The protocol for this study was dura or even the schneiderian membrane [30].” the root tips may project into the maxillary Furthermore. two of a tooth is extruding into the maxillary sinus extremely important case histories [27. the method flaw and the case histories will be examined in detail. The maxillary sinus is uniquely located in the ing regarding “irrigan[t] extrusion. although drains blood from the teeth to the pterygoid plexus of the the right superior palpebral vein (red arrow) shows the veins in the infratemporal fossa. in Desai’s discussion. The model used most likely corre- gator with Pashley was Zhu [10]. Interestingly. (Figs. It is understood that in clinical situations of direct intravenous injection via intraosseous several factors might decrease the extent to infusion. 28] were with no apical covering or restriction. most importantly – an uncommon connection ance of NaOCl infusion resulting from the treatment of [40] – with the superior alveolar vein(s) that normally the maxillary right lateral incisor. to a canal that is open to atmo- was not referenced in any of Boutsioukis’ spheric pressure. there- fore. likely occur. yet normal directly with the nasal cavity and consequently . greater method flaw obviously due to the investigator’s adverse treatment reactions associated with lack of knowledge regarding the more recent full-strength sodium hypochlorite would most findings of Pashley et al. the ostium maxillae communicate extrusion through an unrestricted. the midface area eyelids and the angle of the mouth is unaffected because just below the eyelids and upper lip is virtually unaffected the malar fat pad and the zygomatic muscles cover the (From Witton and Brennan [22]).3 (a) The classical pathognomonic facial appear.” not included in the Boutsioukis’ review. described their novel theory apex. b & c with Permission from SybronEndo) bral veins of the eyelids. the review criti. and their work lates. thus hiding any hemorrhagic effect anterior facial vein and its tributaries including the palpe. Additionally. the alveolar bone surrounding in vitro study was to compare the relative safety these apices becomes thinner to the point where of various intracanal irrigation systems. designed to maximize the possibility of irrigant Furthermore. With age. the superior and inferior labia before Pashley et al. The principle investi. These ex vivo studies contained a clinically such as reported in this article.” while in immediate vicinity to the apices of maxillary fact Desai stated: “The specific aim of this teeth. which these systems extrude solutions. Maxillary Sinus Considerations cizes the ex vivo study by Desai and Himel [29] as not specifying a research hypothesis or aim.

on her way home from the endodontic treatment. [31].6 mL/ never before described sequelae resulting from min. In lary molar region where she had received end- summary. this unique with a different outcome. a decongestant.6 Complications of Endodontic Irrigation: Dental.” When the patient was questioned about the tooth and congestion of the associated maxillary procedure. Each experiment used single straight-rooted the extruded NaOCl via the endodontic access teeth with open apical foramen exposed to normal opening. the treatment appeared unremarkable having been properly prepared and obturated. 6. Medical. NaOCl relationship offers no resistance to fluid extrusion was inadvertently injected into the maxillary during endodontic irrigation. The pan- One of the earliest case histories of NaOCl oramic view (Fig. was referred to a slower delivery rate of 7 mL/min.04 and also irrigated with an open-ended has been reported [33]. Sleiman. thesia. The authors described a routine endodontic Referring to Fig. on the posterior wall and aggravate[d] the dam- Except for a mild soreness associated with the age. revealed that the maxillary first molar had been lier [30]. and while the sion escape from the root canal system as in the radiographic appearance of the molar region case of the maxillary sinus situation described ear. The percent patient with a chief complaint concerning an extrusion was very similar: Boutsioukis ≈60 % uncomfortable feeling relative to her right maxil- and Desai (larger apical size) recorded ≈70 %. 29] used similar methods and materi. . treated endodontically. root-canal procedure that made NaOCl stagnate and Motrin were prescribed for seven days. Provided the root Kavanagh and Taylor [32] reported a similar case canal is fully patent during treatment. the only exception noted radiographi- Maxillary Sinus: NaOCl Incident – cally was a vague appearance of something Case Reports unusual within the maxillary sinus.06 and irri.” and Other case reports were not so favorable. This vague appearance resulted in a CBCT scan. just that the patient fossa. she reported that during the treatment.5 (red arrow). Two previously cited sinus resulting in acute severe facial pain and studies [25. The tooth was eventually extracted three gated with open-ended (NaviTip) needles placed months after the hospital procedure.4b) revealed areas of bone loss. resulting in the need to admit the patient atmospheric pressure. a at WL – 1 mm with a delivery rate of 15.4a) revealed that tissue filled extruded into the maxillary sinus reported a rela. an area rich with several complex nerves indicated the taste of NaOCl in his throat during leaving the cranium. Amoxicillin. the canals were shaped to a #35/. the patient made a full recovery. Treating the extrusion event consisted has been reported to cause permanent nerve dam- of flushing sterile water through the palatal canal age [16]. it of the maxillary first molar and out the maxillary could be the position of the patient during the sinus via the ostium. for a Caldwell-Luc procedure under general anes- ment. In the Boutsioukis’ experi. clinical examination was normal. Desai’s canals were shaped larger to a the extrusion of NaOCl into the maxillary sinus #50/. 6. Sleiman postulated that “Potentially. and that exposure to NaOCl treatment. who maintains a (NaviTip) needles placed at WL – 1 mm but at a practice limited to endodontics. and Legal 121 normal atmospheric pressure. part of the anterior boarder of the infratemporal matic physiological response. During routine treat- root canal system and maxillary sinus anatomical ment of an upper right second bicuspid. A tively benign reaction. 6. the authors stated: “The close examination of the posterior maxillary sinus expected deleterious sequelae were not seen” wall (Fig. The apical foramen permits a very high irrigant extru. half the volume of the affected maxillary sinus. A futile attempt was made to aspirate als. her nose as a liquid was dripping internally. both studies found that an unrestricted odontic treatment several months earlier. Recently. swelling. sinus and a brownish material expressed when she “had a chlorine taste in her throat arising from blowing his nose. it must be noted treatment that resulted in the extrusion event and that the posterior wall of the maxillary sinus forms did not report any needle binding nor any dra.

6. A few of the many abun. plus the otic ganglion and chorda tympani (Yellow Arrows). Today’s imaging technology portion of the anterior boarder protecting the infratemporal can. Lebanon) of Dr. 6. After viewing the CBCT results.4 (a) Panoramic CBCT scan demonstrates half of CBCT scan of same maxillary sinus demonstrates areas of the maxillary sinus associated with endodontically treated the posterior wall that are nonexistent (Courtesy of Dr. Maxillary Sinus: NaOCl Incidents – Treatment and Prevention These three cited cases represent the spectrum of morbidity associated with extruding NaOCl into Fig. even the most seemingly inconse- (inferior alveolar. therefore. unknown conse- fossa. Beirut. the patient was referred to an otorhinolaryngologist for additional examination and treatment. In addition to the pterygoid venous plexus. tooth which is filled with inflammatory tissue (Courtesy Philippe Sleiman. (b) Sectional the strange chlorine type liquid began to drip from her nose.5 (Red arrow) The posterior maxillary sinus wall is a critical anatomical feature because it forms a significant the maxillary sinus. Philippe Sleiman. quences of extruding NaOCl into the maxillary temporal fossa contains the following nerves: mandibular sinus. Beirut. Lebanon). Glassman a b A B C Fig. buccal). quential incidents involving extrusion of NaOCl dant sinusoid spaces are identified throughout the maxilla into the maxillary sinus must be approached with .122 G. and has revealed heretofore. lingual. Nothing of further consequence was reported. the infra.

the anterior facial vein is positioned more cumorbital ecchymosis is not uncommon. It face (Fig. 6.1 irrigant from the chamber to full working length. dermal injection findings. how. Regarding of NaOCl Extrusion: A Problem prevention. since demonstrates a vascular connection via superficial nasal part of it is not hidden under the malar fat pad. 6.6b) [28]. most importantly.4b. Desai concluded: “This study con. nor in the case of most NaOCl incidents [34. 6. only the right side is affected. apparent venous connection between the orbits as shown Most edematous and hemorrhagic effects of published in (a). That doesn’t happen. unique case.6 Complications of Endodontic Irrigation: Dental. Very spe- Pressure] system. The literature universally suggested anti. If that was the root cause of the NaOCl inci- In concluding his case study. the study conducted by Desai was modeled to simulate a The facial appearance resulting from injecting root without any resistance to apical extrusion. However. all of the “One of the safest options that we currently have at superficial tissue should be ecchymotic and even- our disposal is the EndoVac [Apical Negative tually ulcerate.6a) [27] or both sides of the of the root-canal system using the microcannula. canal does not agree with the 1985 Pashley intra- illary sinus. in this NaOCl incidents are hemifacial.” [20]. a consultation with an otorhinolaryngologist may be appropriate Pathognomonic Appearance in cases involving the maxillary sinus. Sleiman opined: dent. allows us to be certain that no chemicals can go biotic and anti-inflammatory therapeutic treatment beyond the limits of the root-canal space. which is designed specifically to cific parts of the face and neck are profoundly deliver fresh irrigant all along the root-canal sys. affected by ecchymosis: (1) the upper and lower tem and. as previously mentioned. Accordingly.6 (a) Upper left cuspid from Mehra et al. from the CBCT images presented in Fig. Although bilateral cir. 6. 6. There is no permission of Elsevier) . this case clearly toward the medial area of the face. then according to Pashley in 1985. it is apparent that in some cases. (b) common facial vein which is apparent (Reproduced with Upper right cuspid from Hülsmann [28]. and Legal 123 caution. to clean the last 3 mm eyelids on one (Fig. (2) the angle of the mouth a b Fig.” ever. thus. the entire veins (arrow) between both left and right circumorbital course of the anterior facial vein from the circumorbital venous complexes suggesting that the NaOCl followed veins to where it courses under the mandible joins the the venous connection across the bridge of the nose. Consider a hypotheti- cluded that the EndoVac did not extrude irrigant cal situation whereby excessive amounts of after deep intracanal delivery and suctioning the NaOCl exceed the Hypaque extrusion in Fig. and NaOCl beyond the apical termination of the root balanced to atmospheric as may occur in the max. cause any serious or even minor damage. Medical. [27]. 35].

6. If NaOCl is extruded above a specific pressure gradient through patient’s maxillary right lateral incisor.7) [36].4b. air would enter the venous system. [37] initiated by it exhibits the full course of the anterior facial . a radiopaque substance (iodoform paste) was injected into a lower second premolar and was forced out the apical foramen. Twenty-seven years later. the veins (Fig. At first it formed into a disorga- nized periapical mass similar to the appearance reported by Salzgber. and a source of air. occur [40]. 6. which would result in a fatal cardiac embolism. specifically (in most cases) the muscular fibers cover the anterior facial vein anterior facial vein and its associated complex of (Fig. Their study determined that when the air pressure inside the root canals was increased by using intracanal needles. not area of the malar fat pad despite almost all of the middle.6b is very unique because the 1963 study by Rickles et al. a new theory hypothesized that the upper eyelid to the angle of the mouth and beyond NaOCl extrusion incident is not the result of to the heart and the entire vascular system. [36]. Manisali [39] reported an unusual case of canal overfilling (Fig. 6. the inferior alveolar canal clearly shown posi- lower face and neck being affected tioned below the wavy line. it Pathognomonic Appearance could enter a vein connected directly to the ante- of NaOCl Extrusion: A New Theory rior facial vein and then spread through the venous complex affecting all areas extending from the In 2013 [10].” A year prior to the Davies and Campbell paper. 6. They specifically stated that “For air embolism to occur there must be an open vessel.124 G. albeit rare. are never affected (Fig.6b and 6. specifically the between the anterior facial vein and the maxillary cheek. except where it crosses the bridge produced a well-defined wavy line extending dis- of the nose to include left circumorbital area as in tally. Manisali opined that the paste could have Fig. A careful examination of Fig. a gradient between extravascular and intravascular pressure. and work (Fig. 6. (3) some.3c). 6.8). it formed a second irregular mass that The ecchymotic pattern of this severe NaOCl incident is classically hemifacial. Bone tissue is very vascular…. upper eyelid. Davies and Campbell [38] reported three fatalities resulting from air entering the vascular system during implant surgery. cheek would not be affected because the cheek fat sue alone.7 Upper right cuspid from de Sermeño et al.3b). Note the classical absence of ecchymosis in the entered and coursed its way through a vein. teeth does. 6.3b). but rather its direct injection into the pad (malar fat pad) and some of the zygomatic venous system. but then within a few mil- Fig. It is clearly the superior palpebral times the inferior boarder of the mandible only vein that is part of the anterior facial venous net- on the affected side (Figs. b). This theory evolved from The case shown in Fig. 6. The injecting excessive NaOCl into the periapical tis. 6. 6. therefore masking the hemorrhage. Glassman a fatal case history caused by air entering the cir- culatory system through the root canal space. limeters. A direct vascular connection (4) while other parts of the face.6a.7). In this unique case report.3a shows an ecchymotic threadlike line extending across the only on the affected side (Fig. 6.

When viewed in its entirety. uptake was measured over 30 min. in this case. the apical foramen. the initially resembles the disorganized extrusion of Hypaque paste overfill initially respects no boundaries upon leaving in Fig. He used the lower first premolar of temic circulation [48–56]. the interosseous (IO) tered another problem while investigating the space has been used to provide a reliable and safe uptake of ambient air by a healthy periodontal method for allowing the introduction into sys- ligament [41].6a In 1928. 6. Medical.10 shows a young healthy dogs (Fig.6a). 47].1. the inferior alveolar canal venous complex from the eyelids to the area where apical foramen prepared to 0. The blood pressure in these spaces is collapse easily. this figure shows over.9a) and bonded a commercially available device used by the mili- 21-gauge needle into a root canal space with an tary and civilian medical personnel to establish . sure [46. Figs. ted line). and rule or 25 % of normal mammalian blood pres- they connect directly to veins. 6. den by the malar fat pad. the anterior facial vein is posi.3a includ.7 both share the pathognomonic characteristics of Fig. approximately 30 mmHg.9b). Schoeffel encoun. then it becomes well organized as if a second mass (white arrow). 6. 6. 6. Except for the inclusion of the other eye. veins across the bridge of the nose (black arrow Medullary bone contains thousands of small non- Fig. to 175 mmHg above atmospheric pressure.6a and 6. Both circumorbital areas apparent in Figs. also known as the ¼ ory – but medullary sinusoids do not collapse. Intraosseous Injection ing the absence of ecchymosis in the cheek area. no tioned more laterally than usual and thus not hid.8 From Manisali et al. 6. but a few millimeters below the initial overfill. Since 1934. 6. thus possibly nullifying the the. One apparent flaw in the theory is the collapsible sinusoids that drain into larger veins fact that veins lack the elasticity of arteries and [43–45]. Figure 6. 6.6 Complications of Endodontic Irrigation: Dental. it courses under the mandible and joins the jugular and although the root canal space was pressurized vein.7 are connected via a complex of superficial space be considered a non-collapsible vein [42].80 mm (Fig. and Legal 125 a b Fig. appears again as another running inside a blood vessel as it extends distally above random mass then forms into a well-organized wavy line. Also note worthy is the faint radiopacity con- tures. (b) This line is not within the inferior alveolar canal (dot- fill of iodoform paste which exhibits several unusual fea. [39]. Drinker proposed that the intraosseous and 6. (a) The apical overfill of paste (black arrow) necting the two masses.

A injected directly into the anterior facial vein .” Additionally. Quoting from theory of a direct intravenous injection. it serves as a heuristic device. War Medicine. Under the correct conditions. the simplest solution is that NaOCl was e. Fig. later in 2013 rapid access to the venous system. This case resulted from the inad- vertent injection of NaOCl instead of lidocaine into an anatomical area where a section of the anterior facial vein complex is located – the patient’s right infraorbital space. pp. (b) Tooth after extraction demonstrating apical termination opened Pathognomonic Appearance to 0. Tocantins et al. history. 6. 6. Infusion of drugs or other flu- ids into the marrow (intraosseous infusion) results in rapid transmission of such fluids into the vascu- lar system. Schoeffel’s observations in 1980 seem in conflict with Rickles findings.2 are indistinguishable from the classical endodon- tic NaOCl extrusion incident. 6.126 G. the IO route is used routinely in dentistry to effect pro- found anesthesia [57]. 222–25 (1944).711: “It has (Fig. since he was using a model using a pressure gradient (170 mmHg).10 FAST device for interosseous infusion becomes apparent again at the angle of the mouth is easily explained by Pashley et al. 6. in this case system is available via bone marrow sinuses. but the fact that the ecchymosis skips the cheek area and Fig. the FAST patent application 5. Glassman New and Simple Instrument for Administration of a Fluids Through Bone Marrow.360. not medullary sinusoids. the NaOCl extru- sion was not the result of extrusion via the root canal system. See. This method of infusion can be quite important when the patient has very low blood pressure or collapsed veins. intraosseous injection can occur when the pres- sure gradient exceeds approximately 30 mmHg [10].8 mm of NaOCl Extrusion: A New Theory – Support The Peck Case History Although the pathognomonic features in Fig. constructing an ex vivo model as either “open” or “closed” b ignores the very well-established medullary bone space anatomy and physiology relative to the cir- culatory system.g. Accordingly. however.3b). Although Occam’s razor proves noth- long been recognized that access to the vascular ing.. [55]. his observations were correct because the pressure approximated a healthy and intact periodontal ligament. The significant ecchymosis in the lower eyelid is understandable according to Pashley’s 1985 findings. Turkel and Bethell.9 (a) Radiograph of 21-gauge needle bonded into the root canal of live dog (From Schoeffel [41]).

compliant” (atmospheric pressure) or high com- tion in the venous drainage must exist that directs pliant (incompressible) [24–26]. the pressure gradient factor involves its bone spaces that are so abundant in both arches. With the publi- the blood flow away from the pterygoid plexus of cation of Zhu et al. This is the first report demonstrating that tors influence this issue: canal configuration. own subset of contributory factors including (1) rate of delivery. Due to the immediate facial swelling and hemorrhage. the dental profession the veins. Three conditions must occur together before an More recent ex vivo studies consider the pressure intravenous injection can occur: (1) the apical resistance at the apical foramen to be either “low foramen must be patent. pen simultaneously in order to produce a NaOCl nosis of acute kidney injury secondary to renal incident: a patent apex. A few days after the event. [10] paper. it is still a rare event. and access to and pressure exceeding the speculate that direct tubular epithelial injury intraosseous space. Park et al. in 2013. Periapical pressure presents occurred as a result of sodium hypochlorite expo. three basic factors must hap- nephrological evaluation that resulted in the diag. study show that it is quite easy to exceed capil- lowed its natural course toward the heart. ous (IO) fluid delivery method and now must dal pressure of approximately 30 mmHg [10]. Khan et al. unusual vasculature anat- tubular injury. reevaluate safe periapical pressure gradients at Excluding wedging the needle in the root canal the apical foramen by including the interseptal system. apical pressure produced with different 30-gauge and both cited venous blood pressure as a possi. opined: “The data of the present ent flow rates varying from 1 to >8 mL/min. and position of irrigation needle. (2) location of the irrigation nee- dle relative to the apical foramen. The . the patient was referred for As previously stated. many fluid Although the long-term consequences of NaOCl dynamic studies modeled their experiments on extrusion have been reported to vary from benign the premise that “The apical foramen was simu- to life-threatening. and (5) the use of and Flow Rate positive or negative apical pressure. rate. the most confusion because several basic subfac- sure.6 Complications of Endodontic Irrigation: Dental. two recent peer-reviewed articles appeared in the In an ex vivo study. (2) an anatomical varia. open and side-vented irrigation needles located at ble threshold pressure gradient to be avoided [58. WL – 1 mm from the apical termination at differ- 59]. irrigant delivery nosis to consider after systemic sodium hypochlo. Accordingly.” and alarming insight regarding the systemic effects of a NaOCl extrusion. [59] evaluated the April 2013 issue of the Journal of Endodontics. The nephrologists reported: “We omy. and Legal 127 complex near the inferior palpebral vein and fol. lary pressure when the needle is close to the This recent case history also provides a new working length even at low flow rates. Pathognomonic Appearance Periapical Pressure Gradient: of NaOCl Extrusion: Multivaried Historical Misconceptions Factors Until the recent Zhu et al. omy and physiology of the periapical region. and universal misunderstanding of the anat- rite exposure during a dental procedure” [18]. type ATN [acute tubular necrosis] is an important diag. and (3) the periapical pressure gradient has come to realize the efficacy of the intraosse- must communicate with and exceed the sinusoi. Medical. Why? lated as a rigid and impermeable wall” [60–64]. (4) Irrigation Needle Position design of the irrigation needle. Interestingly. (3) size and Periapical Pressure Gradient: shape of the canal relative to the irrigation. the patient was directed Pathognomonic Appearance immediately to visit the emergency department of of NaOCl Extrusion – Periapical the nearest hospital. Pressure urine microscopy showed the presence of granular casts.

11 Apical pressures Averaged irrigant pressure at apical forman were calculated at a constant 338 at 15. at various working length backflow. ence between the 0. Irrigant was delivered at rates that round and tapered canals.12. resistance to backflow is a direct result of the tioned their irrigation needles. Glassman Fig. their variables (position or rate of delivery) dle is .6 mL/min.12).07 mm in diameter (the differ- depth of insertion (Figs. regardless of needle needle is .31 needles produced the left canal has limited area for backflow while .6 mL/min. “clinically realistic” delivery rate (15.11 and 6. Note: all pressures recorded exceed 150 normal intraosseous pressure.31 and 0. [63] employed a similar shape #45/. in critical areas of the Periapical Pressure Gradient: root canal.6 mL/min.065 mm2 while the same area for a 0. The recorded pres. 263 Mean apical pressure (mm Hg) The variables were the depth of needle insertion 225 (WL −1 to −5 mm). the apically directed pressure Noting that the thickness of a normal human hair increased proportionate to either the flow rate or is approximately . >0 mmHg pressure proportionate to the rate of In the mandibular molar mesial root in Fig.31 nee- cases.128 G. 6.030 mm2 or 216 % less surface area.13 pressure needles produced increasing apical demonstrates root canal variations at WL – 1 mm. this illustrates that the slightest variation in size or depth of irrigation needles. [63] and one had an outside diameter of 0. [63]) 113 75 Side-vented 38 Intraosseous pressure 0 –5 –4 –3 –2 –1 WL Needle position (mm) Khan study used an ex vivo canal initially shaped virtually identical apical pressure. configuration. the models were not representa- sures are illustrated in Fig. Flat (From Boutsioukis et al.38 mm (Vpro Khan et al. Canal Size Khan et al. 6. In both between the canal walls and the tip of a 0. and Vpro StreamClean) while The models used by Boutsioukis et al. All positive tive of the true biological situation. Boutsioukis needle produced dramatically higher apical pres- et al. 188 Flat or Side-vented.31 mm (Max-i- Probe. Figure 6.13a. irrigant delivery. NaviTip. and needle configuration . 6.02. was consistent.38 produced similar results. The three 0. three Backflow Resistance – Canal Shape had an outside diameter of 0. [59] used four different needle types Periapical Pressure Gradient: for delivery irrigant via positive pressure. The area available for backflow but at constant flow rate 15. 6. thus proving that building their computerized model and posi. but the 0. [59] were configured as perfectly EndoSafe).06 and finally to #40/. apical pressure. also 30-gauge total surface area available for the irrigant to open or side-vented.38 needle).) by using 300 an Unsteady Computational Fluid Dynamics Model.06 when sure at the same flow rates. Although their data varied from 1 to >8 mL/min.38 to #35/. can have profound effects on the final Backflow Resistance – Needle vs.

Max-i-Probe.0 5. [59] and Goode et al.0 6.0 2. sure group = EndoVac microcannula and macro cannula.02 at apical seat. and (d) needle position = WL – or exceed the interosseous (IO) pressure. above illustrate different backflow scenarios: (a) mesial ing with the findings that backflow space affects apical root lower molar. Medical. cal termination of a root canal model created according to In the case of positive pressure.and intercanal configurations shown mesial root lower molar . and Vpro Stream Clean. 6. regardless of irrigant flow rates.5 1. 6.13 Apical configurations at WL – 1 mm. and (c) pressure. (c) canal preparation #30/.5 mL/min. the negative pressure tioned closer than WL – 4 mm].0 4.0 3. Conversely. directly proportionate to increased flow rate. 1 mm [except macro cannula which could not be posi. Needle designs tested: (1) groups produced a consistent. [79]) a b c Fig. (2) apical negative pres. At a flow rate (b) WL = 17 mm.6 Complications of Endodontic Irrigation: Dental. the intra. the apical pressure was the following parameters: (a) material = polycarbonate.12 A digital manometer was connected to the api. and Legal 129 600 Apical pressure (mm) Hg 500 vs Delivery rate WL = –1 mm 400 300 Vpro endoSafe 200 Max-i-probe NaviTip Vpro stream clean 100 EndoVac micro EndoVac macro IO 0 –100 –200 –300 0.0 8.0 Rate = mL/minute Fig. 35 mmHg (microcannula) and ≈ − 250 mmHg (macro NaviTip. negative pressures ≈ − positive pressure group = Vpro EndoSafe.0 7. cannula) (From Khan et al. (b) maxillary central incisor. In keep.06 followed exceeding 3. all positive pressure needles met by #40/.

it is imperative to note that Subjective Pressure Factors since no specific treatment can reverse the initial damages caused due to NaOCl [67]. [58] stated: onstrating the subjective nature of irrigant deliv- “When the 30-gauge side-vented closed-ended ery techniques. thus dem- and mesiolingual canals converge in the apical onstrating the highly subjective nature of clini- millimeter. et al.35 + 0. The previously reported in the Park experiment. It is also important to canal at this point will follow the path of least note that even though Boutsioukis et al.” Incident The next section will describe treating the NaOCl Periapical Pressure Gradient: incident. the Rickles and Joshi [37] reported intravenous air investigators noted: “When the needles were emboli arising from dental procedures as causing . a large lateral fin is apparent binding would be physically impossible.13b.31 mm diameter) placed at the periapical pressure. the diameter vasculature infusion.41–0. However. 6. in an earlier exper- paragraph. Unlike the findings of of irrigant delivery varied from 1. and from the discussion in the previous seous pressure. according to the actual preparation lary anterior root in Fig.06 mm) thus leaving free space of mination was not rigid and impermeable. without binding of the needle tip. 6. the profession had not been of the root canal would be 0. Additionally. However. both genders practicing as either endodontists ferent results even when all other parameters or general dentist and determined that their rates remain constant. and clini- dibular molars to #35/. in this situation. The thus producing a sizeable increased backflow more likely scenario is that the operating clini- escape area. These needles panion canal could offer a backflow escape route. Park et al. heterogeneous group of clinicians that included tomical configurations produce profoundly dif. In the maxil. The investiga.31 mm) and thus making it Recalling that Davies and Campbell [38] and impossible for binding to occur. every one of their demonstrated the irregularities of the root canal apical pressures recording exceeded the intraos- system. [66] surveyed a insignificant physical differences in internal ana. tors prepared the mesiobuccal canals of man. until Zhu −1 mm from WL during one phase of the experi. Furthermore. then entire com.130 G. Hess [65] conclusively “clinically realistic” flow rate.10 mm (0. it is apparent that the most seemingly iment Boutsioukis et al. canal shape. but if this “fin” could be placed at this level in the root canal is part of an isthmus complex.41 mm aware that the tissue surrounding the apical ter- (0. although the canal geometry vs. needle was placed at 1 mm from the working length. placed at 1 mm from the apex. Accordingly. Irrigant flow directed down either cal irrigation methods.” using the same needle and pressure.06 and used 30-gauge cian’s subjective delivery technique each affected irrigation needles (0. again dem- results using human teeth. discussed experiments all proved that flow rates. Glassman its companion canal demonstrates a fin that obvi. emphasis A further interesting observation was also must be placed on prevention. 0. when reporting their min when using a 30-gauge needle. included the 30-gauge blunt open-ended It is easy to see how two very different apical (FlexiGlide) needle and the 30-gauge side- pressures could be recorded from the same root vented closed-ended (ProRinse) needle. is basically round. the size of the irrigation needle. explained the interosseous route of ment. the apical pressure was unpredictable and oscillated between low and moderate apical Preventing the NaOCl Endodontic pressures. both the mesiobuccal needles encountered root curvatures. [64] resistance up the companion canal rather than reported an irrigant flow of 15.6 mL/min as a being forced apically. only two needles ously increases the backflow area.13c. In mesial root lower molar in cian experienced the sensation of binding as the Fig.2 to 48 mL/ Boutsioukis and Khan. however. irrigation needle depth. at WL – 1 mm.

Khan. dosing. Each under pressure. Medical. Bradford opined in (A) Results: “No needle design or As previously stated. [68] study that examined periapi. post-extrusion treatment is directed and (B) Discussion: “Vacuum rather than air toward preventing further deterioration. 18]: Bradford’s method.12 using a closed system. Desai study. for example. it is important to examine the Treatment of the NaOCl Extrusion Bradford et al. canals. Physiological and systemic concerns must be (Desai. Italy) . aller- sure as means of delivering irrigants to the apical gies to medications. Inform the patient regarding the nature of the meaning not only that irrigants could not be incident including the possible risks and forced out of the root canal system but that exu. 6. using a totally open apex and equal. 33. respiratory embarrassment. the following general recom- expelled during any test. no irrigant was on. Accordingly. In the Khan study in mendations are summarized from six sources Fig. 69. and so ized atmospheric pressure. side effects. sidered including severity of the incident. all pressures using apical negative pressure recordings were less than zero 1. and Gondim). renal damage. 6. Baumgartner. In the evaluated on an individual basis. 6.6 Complications of Endodontic Irrigation: Dental. the initial damage from a gauge proved safe to use in either round or ovoid NaOCl extrusion incident cannot be reversed.14). complications. Hospitalization is required in all cases of the periapical area (Fig. 70. Incident cal pressures produced via air delivery. Filippo Santarcangelo. respiratory embarrassment or uncontrolled a b Fig. and so termination under various clinical scenarios on. regardless of stage of instrumentation” therefore. and Legal 131 patient death. Bari.” basis because a multitude of factors must be con- Several studies have examined vacuum pres. date from the apical area can be aspirated from 2. modeled after [28. may be a superior means for incident must be evaluated on a case-by-case canal drying.14 (a) A large palatal lesion filled with purulent exudate is aspirated (b) using apical negative pressure via the root canal system of associated central incisor (Courtesy of Dr.

NaOCl tooth extraction. the clinician succeeding decades. it is recommended that through the apical foramina and produce a pain. Antibiotics are not always required but are NaOCl. hold) information when. and all that was needs and on the basis of those needs. this author’s. without the need to 5. Glassman hemorrhage or when the need for intrave. That all-inclu. CBCT could not rationally engage in a conversation technology. and procedures for use in their own offices. tence. sequelae including at least one life-threatening 3. Pelka concluded his case history: reserved in cases of high risk or evidence of “Because of this fact and the number of reported secondary infection. John Ingle published the first quite vague about exactly what the patient needs modern and extremely well-referenced endodon. the American Association of Endodontists has a position statement on its website entitled: “Informed Consent Guidelines” [73]. or sinus procedures must be should not be used as an irrigation solution dur- assessed.” As of this writing. editor’s. mation provided to the patient before endodontic 10. and technology have advanced into the that permits clinicians to tailor (and even with- ultramodern age characterized by NiTi instru. Further treatment like surgical intervention. warm mouth rinses will ing the often morbid dangers relative to the stimulate blood flow. culturing techniques. The publication would be followed by NaOCl apical therapeutic privilege itself can vary from state to . the 4. Pain control can range from local anesthesia event [14] and some reports of permanent facial to analgesics. endodontics materials. Careful Informed Consent reading of this position paper does not mention a word about the NaOCl extrusion incident. but only when.” Nine years later. reduce swelling. digital radi. draft forms known about NaOCl extrusion in a single sen. it is Fifty years ago. nerve damage [16]. Without such written consent. In just the last two years. After the first day. ing endodontic therapy. guidelines are not to be considered legal advice. Daily recall is required to monitor recovery. but their use reactions of NaOCl into the normal written infor- is controversial. to know. cases. “Care must be taken not to seat the needle Recognizing that state statutes regarding tightly in the canal or the solution may be forced informed consent vary. members consult their state statutes when devel- ful apical periodontitis. the oping their own informed consent forms. profession has learned that the direct intraosse- lary sinus is involved or a nephrologist if the ous infusion route can deliver NaOCl directly urine appears unusually dark. Use external cold compresses for one day to wedge a needle into the root canal [10]. it’s beyond patient discomfort and distress. the obligation to warn the patient about the use of 8. and the realization that Becker’s about therapeutic options and consequences. it is very important to include the adverse 9. Corticosteroids are often given. extrusion case histories that included severe nous medications is indicated. Despite the professions’ knowledge concern- 6. endodontic microscope. closure would so upset a patient that he or she ography. and it ends with a statement: “These tic textbook: Endodontics [71]. must also understand the therapeutic privilege methods. or publisher’s professional recovery occurred in a few days” [72].132 G. sive work of the day explained the use of silver Members should consider their own particular points.” swelling and bleeding into the tissue causing the Like the AAE’s position statement. treatment. In the field to offer legal advice. its dis- mentation. That said. it has failed to heed 7. NaOCl extrusion incident. into the circulatory system. “However. Refer to an otolaryngologist when the maxil. the authors described facial association where you practice or reside. A copy first published NaOCl report of apical extrusion of your state statute can be obtained from your through the apex of an upper second premolar attorney or by writing to the local county bar was published. electronic apex locators.

American Standard. Conclusion by-state basis when considering all aspects of In light of the cytotoxicity of the sodium informed consent. every practicing dentist must consult his or her own attorney on a state. help in explaining the concept of intraosseous fluid deliv- chlorite into the root canal for irrigation and ery and the intracanal fluid dynamics that affect periapical pressure as well as his assistance in organizing the logic debridement. cuss that product with the patient. I am grateful for his was a simple syringe to introduce sodium hypo. on failure to warn. has medical science progressed to the degree of specialization that the doctor has the duty to sim. Orange. beginning with postoperative pain [21].ca) produced graph- sodium hypochlorite extrusion is uncommon. hypochlorite (NaOCl). the The first is entitled: “Legal and Ethical Myths EndoVac would be the preferred alternative About Informed Consent” [74]. The second is device. the venous system after scrutinizing the Bradford study the device utilized for irrigation in the root canal [68] and the associated references. While the occurrence of Dr. under any analysis of product liability law. John Schoeffel.ovidiu. Rochelle based his ants to safely reach the apical one third in opinion on the Johnson v. lesser risk device? An example Khan study [59] but were mentioned in Goode [79] as of such a newer medical device recently described unpublished results. working length without causing their undue tor to warn the patient. Note and Acknowledgement Figure 11: The pressures recorded for the macro cannula were not reported in the ply select the new. By the Need For The Doctor To Simply Make The Apical negative pressure devices such as Best Decision For The Patient? The entire text can the EndoVac have been shown to enable irrig- be read at this website [77]. the EndoVac system is also advanta- relieve the manufacturer of a duty to warn the ulti. originally envisioned the concept of NaOCl traveling in ery system for endodontic irrigation. 4th 56 (2008) case that recognized the cal vapor lock (air entrapment at the apical “sophisticated user” doctrine as a defense to both one third) as well as remove tissue and bacte- negligence and shift product liability claims based ria throughout the root canal system [80–82]. In the alternative to an informed consent docu. in the peer review literature is the EndoVac (Kerr Dr. geous in its ability to deliver irrigants safely to mate user (patient) and places the duty on the doc. Medical. It is superior in that. often state-by-state basis [76]. but don’t tell the whole truth: does not sacrifice treatment efficacy and eliminates The Therapeutic Privilege is it ever justified?” the risk of severe debilitating injury that can occur [75]. Goode coauthored the Khan study [59]. This does not imply that NaOCl can or ment dealing with the NaOCl extrusion incident. Alternatively. endodontic treatment. . followed. 80. voluminous amounts and help overcome api- Inc. Rochelle’s opinion is extrusion into the periapex [29. Rochelle states that the Johnson Apart from being able to avoid air entrap- case is the latest in a trend of decisions that act to ment. should be excluded as an endodontic irrigant. CA) deliv.6 Complications of Endodontic Irrigation: Dental. its extrusion from the ilege. an important and standard part of path and graphics for this chapter. thereby avoiding NaOCl incidents. in order to arrive at a correct from sodium hypochlorite extrusion from positive and proper informed consent document relative pressure. The University of Washington School of root canal will affect the periapical tissue and Law maintains a convenient resource regarding may cause the patient a series of complica- informed consent laws in the United States on a tions of variable clinical significance.” to the NaOCl incident. 43 Cal. as quoted in Disinfection of Root Canal Systems long as manufacturer’s recommendations are [78]: “that doctor has the affirmative duty to dis. inventor and royalty recipient (SybronEndo) Endodontics. an ABOTA [American Board of Trial in fact. Accordingly. What this does imply Has The Doctor’s Duty To Warn Been Replaced is that it must be delivered safely. and Legal 133 state as exemplified in two different opinions. Ovidiu Cioanu (www. Previously. (SybronEndo/Kerr Endodontics) of the EndoVac system. 83]. for a minimal cost. has published an opinion entitled: chemical debridement. ics 4 B and C. including the therapeutic priv. its use is essential to achieve adequate Advocates]. Rochelle. it entitled: “Don’t lie.

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163.wikifoundry.38: 82. . Microsc Res J. Meisel A. Ribeiro EM. 81.38:633–8. Comparison of the informedconsent. J Endod. Silva-Sousa YTC. Don’t lie but don’t tell the whole truth: the and smear removal in flattened root canals after use therapeutic privilege is it ever justified? Ghana Med of different irrigant agitation protocols. doctors-duty-to-warn-been-replaced-by-the-need. Gosier J. 79. Jung I-Y. 2010. Nielsen BA. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Lee C-Y. Disinfection of root canal systems: the irrigation devices when used with either positive or treatment of apical periodontitis. and_research/guidelines_and_position_statements/ 80. Khan S.109:479–84. but the other states are listed on new apical negative pressure irrigating system with the left]. 77. Becket GL. Zangari D. Ames: Wiley. Malentacca A. 2012. myths about informed consent. Souza-Gabriel AE. conventional irrigation needles in the root canals. http://rochellegriffith.41(7):636–41.33:611–5. Efficacy and safety of various active 78. Legal and ethical Endod. Arch Intern Med. Lee S-J. 83. 2008. Sousa-Neto MD. 2013. 2007. The sequelae of acci. http://www. negative pressure: an in vitro study. EndoVac system to needle irrigation of root canals. Eid AA. 76. http://uwtortswikimiller. Fabiani C. Kuczewski M. Glassman 72. Edwin AK. Wall shear stress effects of root apex. Lorencetti KT. 2014. California [Note to reader: Opening this website will Kim E. 1974. J Dent. Silva SRC. Kim H-K. different endodontic irrigation techniques and sys- 73. Cohenca tems. Lajolo C. Craig Baumgartner J. 1622–6.156(22):2521–6. Uccioli U.aae. Borer R. Oral Surg. Cohen S. Goode N.136 G. Tech.75:781–90. Tay FR. J 74. Susin dentally injecting sodium hypochlorite beyond the LF.pdf. Debris 75. endovac-use-in-root-canals. Comparison of the cleaning efficacy of a open on California. Shin Pashley DH. 1996. Niu LN.42(4):156–61. to-simply-make-the-best-decision-for-the-patient. 2012.

lack of proper studies showing its ability to improve cleaning of the complex anatomy of the root canal sys- tem in the apical third. Vera. Histological sections of the apical thirds of teeth that were appropriately cleaned with the use of this procedure and then examined usually show remnants of organic tissue and biofilm. Madrid 4920-101 2A seccion Gabriel Pastor. Using a small K file inserted passively and intentionally by 1 mm through the fora- men is advocated by some investigators and clinicians as an important proce- dure designed to help the cleaning and shaping process. Puebla either from organic tissue that was not properly 72420. higher incidence of postoperative pain. DOI 10. and limited information on the influence of the use of the patency file on the prognosis of the root canal treatment. The objective of this chapter is to analyse the current lit- erature that addresses the use of the patency file in endodontic therapy. Mexico removed during the chemo-mechanical prepara- e-mail: jveraro@yahoo. as well as to the apical third. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. The Role of the Patency File in Endodontic Therapy 7 Jorge Vera Abstract The use of a patency file in endodontics remains a controversial issue. DDS areas may develop or perpetuate apical periodon- Department of Endodontics. Detractors of the use of the patency file have con- cerns with the increased extrusion of debris and irrigants through the fora- tion of the canal or by getting nutrients from © Springer International Publishing Switzerland 2015 137 B. Puebla. Elimination action of irrigants and the instruments used to shape the canals [16]. titis if they are able to get sufficient nutrients. Introduction of organic tissue and reduction of the microbial bio-burden remain a difficult task. Microorganisms residing in these complex J.). University of Tlaxcala Mexico. especially in Proper debridement of the root canal system is the apical third of the root canal system because essential when attempting to obtain favourable of anatomical irregularities that compromise the long-term prognosis in Basrani (ed.1007/978-3-319-16456-4_7 . to aid in delivering irrigating solutions to “hard to reach areas” of the root canal system. This procedure is even cited as an important step in achieving clinical success.

1 (a.2). 7. 7. because (i) there are no studies showing its efficacy in terms of cleaning and shaping.2 Patency obtained in a two-canal right second trolled studies showing if using it would improve lower premolar the prognosis of endodontically treated teeth. Vera Fig. either vital teeth or teeth with infected pulp and periapical periodontitis (Fig. 16 out of 24 33 % taught the use of a size 15 K file. The authors ing the patency concept. b) A patency file is a small K file inserted a b 1 mm through the foramen (Courtesy of Fernando Durán-Sindreu) periradicular tissues. which should be kept free of packed debris. and . One popular method of avoiding accumula- tion of tissue and debris is by using a patency file. thus preventing ledge formation. it has been established that to suc- cessfully clean this apical area. students. 12. At the time of the survey. conducted a survey in which they got back 48 Concerning the size of the file used in the responses indicating that only 50 % of the schools schools using patency.3). 11. only one published study has their undergraduate students.1 and 7. as well as keeping the foramen open in case drainage is needed from the periapical tissues [24]. the size 10 K file was the were teaching the use of the patency file to their most popular file used (42 % of respondents). This has been described in numerous texts and articles as using a small 10 K file which is inserted passively and intentionally by 1 mm through the foramen. irrigants should be able to penetrate to the full length of the root canal. and most importantly (iii) there are no con- Fig. The patency file would ideally prevent dentin chips from being compacted into the apical por- tion of the root canal and from blocking access to this area for instruments and irrigants [1]. The use of a patency file remains controver- sial. allowing them to release their by-products [21. 7. 7. and perhaps perforations in this cru- cial area [5. blockages. 31] (Figs. however.138 J. (ii) periradicular tissues may be irri- tated. 7. programs were teaching the use of patency to Until now. 27] Therefore. Nineteen out of 36 assessed the prevalence of teaching apical schools that had a graduate program were teach- patency in US dental schools [8].

3 (a. In their study. modifying its shape in curved canals. Photographic slides of pared superimposed digital images obtained the foramen were taken after the use of every before and after treatment. The study com- evaluated ex vivo the apical transportation caused pared transportation to those similar groups in by #10. another ex vivo study found that when a size 08 K-Flexofile or a size 10 stainless steel reamer was used. found in the majority of the 102 mesiobuccal Irrigating. Transportation was shown in 18 of the found that using a patency file helped in main- 30 specimens. By contrast. and #25 K files in 30 human which patency files were not used and then com- maxillary lateral incisors. Another question addressed com. They further stated that because the ments against the use of the patency file. and Cleaning the Root canals of maxillary and mandibular molars [30]. Some authors have evaluated the influence of the 10 K patency files were employed after the use of patency file on the transportation of the apical root each instrument with the balanced force tech- canal or the foramen. the purpose of the Furthermore. (55. Popular foramen commonly exits laterally from the apex. Canal System The authors evaluated root canal transportation at the major foramen by comparing photographs On Apical Transportation before and after instrumentation. Patency was maintained throughout the cleaning and shaping procedure. Thus. (c) Two-year follow-up another 25 % recommended the use of a larger in five cases in one of the treatment groups size 20 K file. . #15. The authors not only instrument. Gutierrez et al.7 The Role of the Patency File in Endodontic Therapy 139 a b c Fig. b) Treatment of a left second lower premolar. Similar results were obtained by Tsesis et al.5 %). responses included concerns regarding the pro. Goldberg and Massone [13] nique or the Lightspeed system. They proved that transportation taining working length but also reported no dif- occurred even after the use of the small 10 K file ferences in the degree of apical transportation. [41]. it would not be uncommon that the patency file jection of debris into the periapical tissues with would lean to one of the walls of the apical fora- concomitant irritation and the lack of proof of an men. increased success rate. 7. proved that a cemen- present literature review is to dissect studies tum layer could fracture at the apex after penetra- addressing the use and contraindications for the tion of a 15 K file through the main foramen [15]. patency file in endodontics. no transportation was Role of the Patency File in Shaping. #20.

just as it was shown in a previous study of Root Canals assessing extrusion [20]. tonic bacteria. The authors assessed the that they can dissolve organic tissue. irrigation was done with 3 ml of anatomy. Lambrianidis et al. In phase attached to the dentin in the very complex apical one of the study. in the reported extrusion in 9/17 specimens after the use periapical lesions in nonvital teeth. solution Claritrast 300 (ioversol 678 mg/mL) . Through the Apical Foramen not blocking the foramen when using ex vivo specimens would not mimic the in vivo situation. kill plank- extrusion of the irrigant without any instrumenta. In a recent in vivo study using a radiopaque clinically postoperative pain after root canal ther. would probably push a larger amount of NaOCl These are examples of how variable the results and debris through the foramen because of the can be when determining this sensitive issue. Further compar- [19] used thirty-three human maxillary incisors ative studies with strictly controlled variables in their study in which debris and irrigant were should address the influence of a patency file on measured after being extruded into a glass vial. debris extrusion through the foramen. It is not All root canals were instrumented to the apical clear if the use of a patency file would lead to constriction with the step-back technique. However. “pumping” action of hand files. the irrigant was the canals were irrigated again.140 J. The study detected at the apex and. placing the needle at the entrance of the that irrigants (Hypaque) could not reach the api- canal and injecting without pressure after estab. In vivo. differences in the experimental design between the vapour lock effect present in a closed system published ex vivo studies as well as differences would result in different intra-canal hydrody- with what would be in vivo clinical situations namics [39]. root canal anatomy. In addition. of the 10 K file for patency from phase one and in Instrumentation techniques used at that time all specimens from phase two. They also showed that if the canals 15 K-Flexofile were used as patency files. They found more extrusion when the constriction remained intact and concluded that with more instrumentation. in some instances. ants to be extruded through the foramen. extrusion of debris/irrigants alter the anatomy of the apical root canal in a way occurs frequently in vitro. the use of a patency irrigant used per canal was 10 ml. the apical constriction was further packing debris in the apical third of the complex enlarged and the measurement was done again. but a more debris/irrigants being extruded through the patency file was not used. By contrast. com- because the kind of extrusion reported ex vivo parative studies in vivo have not been carried out would lead to postoperative pain and flare-ups in to prove such a statement. cal third of human root canals that contained vital lishing apical patency. Salzgeber and Brilliant showed [29] NaOCl. that could affect clinical results. In phase two. Another study used a colour-changing reagent Irrigants should be able to reach the apical third in acrylic receptacles in contact with the root tips with enough concentration and contact time so of maxillary molars [9]. Clinically. and disturb or eliminate biofilms tion technique used to flare the canals. the vast majority of cases in vivo. Concerning the extrusion of debris through the allowing for a larger amount of debris and irrig- foramen during cleaning and shaping procedures. the formation of an apical plug Role of the Patency File on Irrigant could have helped prevent the extrusion of the Penetration into the Apical Third irrigant. size 10 and tissue in vivo. then were flared to small apical sizes. Conclusions From these results we could con- Two studies have shown that even without the clude that using a small patency file should not use of a patency file. After this pro. make it difficult to extrapolate the results of extrusion from ex vivo studies to clinical reality. The total volume of apical foramen. Vera On Extrusion of Irrigants and Debris apy occurs with very low incidence. file helps to maintain working length and to avoid cedure.

4 Mixture of a radiopaque solution and NaOCl used as an irrigating solution. and both roots of maxillary sured. 7. demon- after the use of every rotary instrument. mesial roots of measuring between 19 and 21 mm) was mea- mandibular molars. ing action of NaOCl or the presence of an apical ogy was used [45]. (a) Passive irrigation without the use of a patency file delivering the solution at 2 mm from the WL. and anterior teeth (buccal roots of maxillary molars. but not in group two. 7.25 % NaOCl. the apical 2 mm of 43 large root canals (palatal mated in density and viscosity to that of NaOCl roots of maxillary molars. apical patency was not maintained throughout ing the shaping and cleaning procedure with a the cleaning and shaping procedure.7 The Role of the Patency File in Endodontic Therapy 141 mixed with 5. 40 human root canals considered small dibular molars with one canal. apical patency was maintained dur. (b) After the use of a patency file and passive ultrasonic irrigation . A blinded cali. the root canals compared to those teeth where In group one. 2 mm of the treated roots. ing pulp tissue in the apical anatomy that was not dure compared to the group where it was not [42] removed adequately by the combination of the (Fig. which was approxi. cleaning and shaping technique and the dissolv- In a different study where the same methodol.4). A 27-G side-vented needle was inserted to first premolars) were irrigated with the solution 2 ml from the WL with gentle in and out move- to within 2 ml from the working length (WL) ments and maintaining apical patency. cluded that the low flow rate used was not very brated reader determined the presence or absence efficient in delivering the irrigant into the apical of the radiopaque irrigating solution in the apical 2 mm when a patency file was not used. Then. the lack of penetration showed that there was significantly more irrigant of the irrigant deep into the apical 2 mm could after the use of PUI when a patency file had been have been caused by the presence of the remain- used throughout the cleaning and shaping proce. Statistical analysis In both of these studies. It was con- 10 K file. penetration of irrigants into gas bubble or vapour lock effect as proven in a b Fig. strated a higher incidence of the mixture of passive ultrasonic irrigation (PUI) was used in NaOCl/radiopaque solution in the apical 2 mm of both groups for 1 min at the end of the procedure. distal roots of man- alone.

but not in the other The Use and Effect of the Patency two groups also consisting of both small and File in Cleaning of the Root Canals large canals.5). It was surprising to note that. the gas radiopaque solution could also vary the density. Furthermore. bubble could grow larger in size because of the and especially its viscosity and surface contact reaction of the irrigant with organic tissue [14]. Apical patency was maintained with a 10 K file in two groups (small and big canals). angle. when short of the radiographic apex and avoiding present.25 % NaOCl and the radiopaque solution Claritrast 300. its influence root canal is still not demonstrated and will be on the presence of large gas bubbles in the middle discussed further in the following section of this and cervical third of human root canals in vivo chapter. Some other articles have described this vapour lock effect in closed-ended canals/tubes. was evaluated in another study [43]. at least under the conditions of Besides the role of the patency file in the pen. 7. 25. the consistent presence of these bubbles in the mid- dle and cervical thirds would limit the contact of NaOCl with organic tissue and microorganisms attached to the dentin and hiding in isthmuses and areas where there would be more gas than irrigant during the cleaning and shaping proce- dure. when a patency file was not used. 7.5 A small K file used short of the foramen. Whether this in vivo etration of irrigants into the difficult-to-reach api. the aforementioned studies. some studies have tested the importance of Then. other authors have doubted the pres. thus However. compared to only in 25 % when the 10 K file was used to maintain patency. Some authors have recommended the during every step of the cleaning and shaping proper working length to be determined 1–2 mm procedure.142 J. ence of a vapour lock if a high enough flow is used while irrigating and by also using an Conclusions Using a patency file appears to open-ended needle that should be positioned help irrigants penetrate into the apical 2 mm of closer to the WL [6]. when compared to NaOCl by itself. No position of the irrigant by mixing NaOCl with a patency (Courtesy of Fernando Durán-Sindreu) . which had been tested in Concerning cleaning and shaping of the apical pilot studies to dissolve pulp tissue efficiently. The advantages and risks the complex anatomy of human root canals both involved in irrigating in such a way will be dis. However. Fig. Even though the importance of such bubbles may not be much concerning the pene- tration of the irrigants into the apical third. canal. in large and small canals and to prevent gas accu- cussed in another chapter of this book. the gas bubbles in the middle/cervical third appeared in 40 % of the cases. Furthermore. favouring the apical vapour lock effect [6]. Irrigation was also done using a in Teeth with Vital Pulps mixture of 5. third. Vera some in vitro studies [39]. a calibrated reader evaluated the presence apical patency during the preparation of the root of gas bubbles in radiographs that were taken canal. but they were not easy to break. preventing irrigating solutions from reaching their apex [10]. 26] (Fig. these gas bubbles could move in the root patency [17. mulation in them. some studies have mentioned the possibility that the change in com. penetration really improves the “cleaning” of the cal anatomy in human root canals.

tic instruments should still prevent this accidental lary first premolar to be extracted for non. men” or “slightly short” of the foramen [37].7 The Role of the Patency File in Endodontic Therapy 143 These authors question and criticize the need the region (Fig. WL was established 1. of the buccal root of a maxil. 7. apex.7). and not necessarily The injury that this procedure could potentially all of them. The use of a patency file signal is displayed on the screen and then with- in such situations could destroy the connective drawing it until the display shows “at the fora- tissue.6. Note the apical deltas with undis. Furthermore. The pulp was vital and the canals that the use of an electronic apex or foramen loca- were instrumented before extraction. In light of this terminology. One disadvantage of not for a patency file in cases with vital pulp and using a patency file in noninfected teeth is the actually state that it is contraindicated in cases possibility of being blocked out or losing working where there is a clean wound in the apical pulp length during instrumentation of the root canal. Conclusion The use of a patency file in teeth with noninfected root canals has not proven histologi- cally to aid in cleaning and shaping procedures. 7. as well as indications established 1. showing multiple foramens (Courtesy of Ronald turbed vital tissue (Courtesy of Domenico Ricucci) Ordinola-Zapata) . 7.7 Distal and mesial roots of a mandibular molar the radiographic apex. and the working length was The vast majority of studies. Rotary NiTi tor helps determine the ideal position in space for files were employed. The pulp was vital and the root canals were instrumented before extraction with NiTi rotary instruments and NaOCl used as the irrigant. Interesting discussions on the matter remain academic and possibly without sufficient scientific background to support or avoid the use of this procedure. experience and proper use of endodon- is shown Fig.6 Buccal root of a maxillary first premolar. A photomicrograph depicting this situation However.5 mm short of Fig. which is differentiate that the maintenance of apical important in modern root canal therapy. it has been shown clearly restorability. impairing or delaying wound healing. The section shows an apical delta with recommend advancing the file until the “long” undisturbed vital tissue. irrigating solution. to properly use a device. 1 % NaOCl was used as the the determination of the optimal working length. a patency patency will prevent the blockage of one of the file should be used at least once per root canal. it is important to Therefore.5 mm short of the radiographic for the use of different brands of apex locators. because of the complex anatomy of inflict on the periapical tissues and the possibility that further use of the patency file two or three more times throughout the shaping and cleaning procedure could increase that injury in a clinically significant manner remain unknown. procedure. tissue. foramens with dentin chips. 7. Fig.

proper elimination of the bac. Whether dures that are accomplished differently [36]. therefore. Pain and Flare-Ups sory canals and other foramens present in the same root (Fig. and the use or lack of use of the patency file. attempting to finish the instrumentation tech- nique “short” of the foramen. However. cate differences from the immunological. This case presents evi- achieving patency with a small file is necessary to dence against the concept that patency files are ensure the proper use of apex locators. therefore canal with files bigger than the file used to clean apical patency and apical cleaning are two proce. Because way but where a patency file had not been used. performing this procedure really helps clean the The presence of bacteria in the cementum canal in such a way remains to be demonstrated in canal [4] is of concern for some authors when histological studies. a bacterial biofilm was demonstrated in a network inflammatory responses in humans.. smear layer humans and animal studies would probably indi. as shown in the mentioned study. 7. of apical ramifications. This would be a difficult task since patency was maintained throughout the proce- such histology studies could not be performed in dures. expected to be able to disrupt apical biofilms in vivo.144 J. or. Furthermore. removal. from single cases or from a study where no com- tin root canal walls and projected in the filling parison could be made to cases treated in a similar material in all segments of the root canal. shows that in vivo. Nevertheless. at least. 26]. debris and/or bacteria were present in cerning the possible role of the patency file in the main foramina in 8 of 13 cases. incidence of postoperative pain [32]. these in vivo observations have not been able to demonstrate such a concept [3]. and ultrasonic agitation of chlorhexidine. it would have to be instrumented. however. Vera Whether the use of a patency file in such teeth out the use of patency. The Influence of the Use maintaining one foramen open with the use of the of a Patency File on Postoperative patency file may not help in the cleaning of acces. increasing the there were no teeth that were instrumented with. of the large amount of apical ramifications that remained infected. a speculative issue that warrants further histologi. patency should be in Teeth with Necrotic Pulps used only to help maintain proper working length and Apical Periodontitis and to avoid packing debris in the apical foramen but that cleaning of the apical foramen be achieved Some questions have arisen concerning the ability with bigger size files [36]. proper compari- affects healing of the periradicular tissues remains sons could not be made. the root canal in its apical portion [35]. with the use of 5 % NaOCl. in part caused by the file extruding a larger terial bio-burden and tissue may not depend on amount of contaminated debris. Remnants onstrated [44]. some authors have recommended that File in Cleaning of the Root Canals when pulp necrosis is present. In this study. foraminas when evaluated histologically. masses of amorphous material that it is important to note that the histological informa- included dentin shavings and infected necrotic tion that has been mentioned was obtained either masses were observed to be packed into the den. The Use and Effect of the Patency Therefore. In another recent case report in which apical cal research. irrigants. in the study by Controversial results have been presented con- Vera et al. whether Conclusions The use of a patency file has not been the use of a patency file is by itself capable of proven to aid in the cleaning of accessory canals/ cleaning these difficult areas has not been dem. However. Other authors have even of the patency file to truly clean the foramen. This clearly causing damage to the periapical tissues [25. all specimens. Since dentinal chips [19]. . For recommended cleaning the divergent cementum that. or contained remnants of organic tissue.7). after treating human of tissue and biofilm remain in these “hard to reach teeth in vivo and with the use of a patency file in areas” despite the use of the patency file. and.

The working length was confirmed and patients were asked about the occurrence of carefully with the use of apex locators. NaOCl was postoperative pain and its severity. wider canals. . when analysing different variables. undergone root canal therapy and who had been However. patency cases. ing working length determination (in many cases being accidental) had no influence on the inci. Only #30 for small canals and to sizes 25–40 in bigger or undergraduate students were used as operators. In fact. degree. isms into the periapical tissues [18]. cases of re-treatment. and all ration was performed 1 mm short of the root apex teeth were filled in one appointment. [2]. used as the irrigant between all instruments. data from 627 teeth that needed to be retreated and the master apical files used varied from #20 to endodontically or that had necrotic pulps. api- immune and inflammatory system in the perira. the no patency group. The did not require any treatment (mild). apical patency was confirmed to the radio. Some studies or articles have ing and shaping procedures with a size 10 K file.7 The Role of the Patency File in Endodontic Therapy 145 The use of a patency file is considered by formed by Arias et al. using criteria as to whether the discomfort carried out with 2. including with the NaOCl present in the root canal after the presence or absence of vitality. They were also graphic root end with a small file after each larger asked to rate the discomfort as mild. or the pain did for each variable involved in the study. There was also had inter-appointment pain or swelling. some clinicians as being a non-harmful biologic and length of postoperative pain were compared event because of the great capabilities of the between two groups. not subside with analgesics (severe). All 17 operators were endodontists with at least 5 when there was preoperative pain present. statistically and showed no differences in pain ysed information from 2. In this study. the pain was incidence of postoperative pain was calculated relieved with analgesics (moderate). and statis.000 patients who had between the patency and the no patency groups. also shown how well these tissues tolerate the use but not in the other group that consisted of 150 of the file throughout the cleaning and shaping teeth in which special care was taken to avoid using procedures. or mandibular arch. in a retrospective study. [33] evaluated the incidence of use of Gates-Glidden drills (Dentsply Maillefer) postoperative pain. Half of ber of days in which pain persisted was more in the the patients that were treated had reported having patency group (up to 3 days more). The incidence. 121 teeth patency did not influence the occurrence of post. or file. asked to record the presence or absence of post- Then. Some other diagnostic factors. Maintaining apical patients responded to the questionnaires. the num- years of practice limited to endodontics. After the tical analysis was applied.5 % NaOCl as the irrigant. They collected and examined and K-Flexofile instruments (Dentsply Maillefer). not to increase the incidence of pain or flare-ups A prospective study on the influence of the when used even in teeth with necrotic pulps or in patency file on post-endodontic pain was per. Conclusions The use of a patency file appears dence of postoperative pain or swelling. penetration postoperative pain when compared to the non- through the foramen with small instruments dur. The cleaning and shaping procedures were severe. preoperative irrigation. endodontic pain and its duration. The shaping procedures were performed with the Siqueira et al. The more postoperative pain in the lower teeth when other half of the analysed patients reported no patency was maintained. thus showing that the use of patency pain. were taken into consideration. were designated as the patency group and 115 as operative pain or flare-ups. cal patency was maintained throughout the clean- dicular tissues [28]. Patients were with master apical files ranging from #35 to #60. The results were analysed [40]. Torabinejad et al. collected and anal. and the location of the tooth in the maxillary would not contaminate or inoculate microorgan. and in nonvital teeth the pain or complications after the cleaning and cases where patency was maintained showed less shaping procedure. one study has shown that any instrument longer than the determined working contaminated patency files could be disinfected length. moderate. Apical prepa. For example. In one group of 150 teeth. some interesting findings were obtained diagnosed as having teeth with necrotic pulps.

the prognosis of teeth when cases were discussed until an agreement was using or not using a patency file. between every instrument used months. the use of a patency file is findings seem to indicate. well-controlled studies that have assessed the Concerning tooth survival [23]. [22] investigated the factors involved in the until extraction as measured in months. of course. In those cases that presented discomfort ies that have compared the use of a patency file but where no radiographic evidence of a radiolu. Vera The Influence of the Patency File the fact that the use of a patency file was not on Prognosis compared to those cases reaching proper working length where patency was not maintained. Cleaning and shaping were done with before becoming blocked.21:154–8. including tenderness to tially and then not using the patency file any percussion or palpation. However. which needed to be 2. Both pre-calibrated observers were initially does seem to have an impact on the prog- experienced endodontists who were blinded to nosis and survival of endodontically treated teeth. Therefore. sectional tomography odontic therapy. radiographic assessment to detect the presence or absence of radiolucent Conclusions There are not many scientific stud- lesions. versus achieving patency ini- factors were evaluated. Achievement of patency at the canal termi. ration. and. further. tooth . NaOCl at 2. get blocked late during the cleaning and shaping ate students and follow-ups were performed up to procedures may have been cleaned well enough 2–4 years. J factor went hand in hand with achieving proper Endod. Al-Omari MA. the To some clinicians. de la Macorra close to the apical terminus. It is important to enlarge the canal. 1995. no studies have compared. Azabal M. Ng interest was extraction of the tooth and the time et al. length is not achieved are associated with lower odontic therapy [5. patency at the apical secondary root canal treatment in which radio. Being able to reach the foramen was used. the AAE glossary of terms. versus not using it. This 1. concluded that the reason may be that canals that All teeth were treated by endodontic postgradu. In However. the authors for secondary root canal treatment (re-treatment). between instruments throughout the cleaning and In the follow-up appointments. there are few success rates [34. and agree with previ- extremely important. 46]. References nus was found to be one of the significant prognostic factors for root canal treatment. it was maintained by was concluded that achieving patency at the api- placing a small file size 8 or 10 to 0. Arias A. that teeth where proper working that its use may increase the success rate of end. many clinical shaping procedure. thus not affecting the the use of many different systems and hand files. It but if patency was achieved. under con- cases where no agreement was achieved. the quality of the resto. in terms of success in end- cent lesion was present. the conditions that improved periapical healing were analysed care- fully. prognosis or survival of those teeth and roots. Dummer PM. terminus and blockage of the canal during treat- graphic follow-ups were performed in 1170 roots ment did not have prognostic value when they for primary root canal therapy and in 1314 roots were analysed together. Then. the trolled situations. but not after that period. Interestingly.5–5 % was used as tained with a small 10 K file going 1 mm long the irrigant. the treatment procedures used in the cases.146 J. the event of influence of the patency file in prognosis. Relationship between postendodontic pain. When periapical status of teeth following primary or entered into the same model. Some clinicians even claim ous studies. 38]. Canal blockage and debris extrusion with eight preparation techniques. as described in reached on the outcome.5 mm past the cal terminus reduced tooth loss within the first 22 apical terminus. despite JC. ysis was performed. Hidalgo JJ. and then statistical anal. The minimal size to which to note that no comparison was done between canals were prepared was a size 30 and flared to teeth where patency was achieved and then main- different tapers. extension of canal cleaning.

An in vivo evaluation of J. II. Fate of the tissue in lateral Indian J Dent Res.44:583–609. J. Apr 1994. Why it is so important. Tay instruments. São Paulo: Santos. Mann V. Incidence of microscopic study. canals and apical ramifications in response to patho- 10. Rocas IN. 2009. 2005. Firenze: Il Tridente. J of debris extruded apically by conventional filing and Endod. Iacono S. Dezan Junior ment. Sanchez JA. 2011. S. Int 23. 5th ed. patency files. file and apical extrusion of sodium hypochlorite. Mercadé M. 4. 2003. 2004. J Endod. 1991. Souza RA. CV Mosby: St Louis. Siqueira JF. 2009. J Endod. complex network of apical ramifications as the cause 20. The balanced force technique. Versluis M. Gulabivala K. 2005. Vera J. Literature review. Fernando MV. Cleaning and shaping the root canal.16:498–504. Arnold M. 31. How 2002. Clin N Am. Siqueira Jr JF. Int Endod ration techniques in United States dental schools. Zhang P. editors. J Endod. Int Endod J.28:510–1.1111/iej. 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cost-effective. passive irrigation followed by some type of activation technique has proved to be effective to reduce bacteria counts. amounts [37]. NaOCl must be used in large role to help eradicate intracanal bacteria [7]. Paris Ile de France. Data on the efficiency of current activation systems are inconclusive. 90 % of them use it as the primary irrigant [15]. MS. In bacterial infection of the root canal system. But.machtou@gmail. and convenient method to perform irrigant agitation at the end of the shaping procedure. according to experimental available data. the apical third appears to be the most difficult area to clean [32]. nothing is as treat apical periodontitis which is the result of a efficient as sodium hypochlorite (NaOCl) [42]. Furthermore. implying that P. Therefore.). be in contact with the tissues [38]. Machtou. So far. Nevertheless. 27]. it is a fast. following chemomechan- ical preparation. DDS. It is Diderot. despite long efforts to develop new be mechanically agitated [26]. When it comes to The aim of endodontic treatment is to prevent or select an endodontic irrigant. the clinical goal is to reduce apical periodontitis are located in the last apical 2 ml [25. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. complete sterilization of extent of the root canal space since the bacteria the root canal systems is currently impossible to involved in the development and continuation of achieve. It has a recent survey among AAE members. safe. PhD irrigant penetration and exchange with the Endodontie. UFR d’Odontologie Paris 7-Denis syringe are not easy to occur in this area. Basrani (ed. Manual Dynamic Activation (MDA) Technique 8 Pierre Machtou Abstract Highest canal disinfection has to be achieved in endodontics in order to expect a predictable successful outcome. more than been shown that using an antiseptic irrigant dur. NaOCl has to penetrate the full mentation techniques. and be exchanged irrigation devices and solutions and new instru. until a new activation protocol has proven to be the best and although MDA may be perceived by some clinicians as laborious. so far. Static Versus Dynamic Irrigation at best the threshold of the bacterial load to allow the host defenses to repair [33]. France obvious that a better knowledge of the behavior e-mail: Prpierre.1007/978-3-319-16456-4_8 .com © Springer International Publishing Switzerland 2015 149 B. Therefore. DOI 10. ing chemo-mechanical preparation plays a major To be effective. [2].

Yana of air (or gas bubbles) is entrapped in the apical [41] in an in vivo study was the first to distinguish part of the canal and restricts or blocks irrigant the two different modalities of the irrigation pro. Boutsioukis et al. Surprisingly. At this stage. a so-called vapor lock effect admit that total irrigation of the root canal is has been recently described when the irrigating clinically feasible at the end of the shaping proce- solution is delivered with the syringe. lock does not exist in all situations and the inser- both parameters being related with the tion of a fine needle close to the working length is depth of penetration of the endodontic able to prevent or remove it. This result was needle expected as shown in an earlier study using digi- tal subtraction to assess irrigant penetration and renewal during the final irrigation regimen [6].2). 1974 [22] and precisely described by Machtou tion of both terms is required: [23] (Fig. However. [5] has shown that the vapor tion of the taper and the size of the canal. a clear defini. 8. and vol- The root canal is similar to a closed system. needle tip design.1a–d) who recommended. However. 8. a recent study by – The exchange of irrigant which is a func. Machtou of root canal irrigation is needed and all current before irrigating the canal for the first time. the needle tip insertion depth was the The Vapor Lock Effect main factor affecting irrigant penetration fol- lowed by apical taper. 39]. In this study. 28. that the tip of the root • Static (the term “passive” is inappropriate must be closed with soft modeling wax prior to because it implies the result of an action) irri. a column research tends toward this goal. any investigation (Fig. 31. this cess: static (or passive) irrigation and dynamic phenomenon has first been mentioned by Luks in (or active) irrigation. In fact. dure with static irrigation either with the syringe a b c d Fig. As a result.1 (a–d) Vapor lock phenomenon: penetration of the needle and extent of penetration of irrigant (Hypaque) in a closed system (1980) .150 P. 36. geometry [19]. penetration [11. for rele- vance of in vitro studies. 8. This vapor lock phe- gation occurs when the solution is delivered nomenon can be described as the difficulty of dis- with the syringe and depends on the depth of persion and mixing of irrigant in a confined penetration of the irrigating needle. • Dynamic irrigation includes two parts: Removal of an apical vapor lock may be chal- – The penetration depth of the irrigant during lenging so additional techniques like activation the use of any type of instrument which is a or the use of apical negative pressure (ANP) are function of the size of the instrument and considered useful adjuncts to overcome the prob- the motion applied to the instrument lem [18. it is possible to in such a situation. and ume of the irrigant. 31].

a general agreement exists about the ben- efit of using irrigant activation at the end of the canal preparation which appears to improve canal cleaning and disinfection in comparison with syringe delivery [6]. hydrody. a repeated use of a patency file after each final goal is to distribute and exchange irrigants active shaping instrument helps break up the gas into the intricacies of the apical anatomy. reach the apical portion of . But. different evaluation methodolo- gies. Indeed. intermittent passive ultrasonic on endodontic irrigation. ing procedure to agitate the irrigating solution namic activation (RinsEndo). Manual dynamic irrigation can be performed with hand files [14].2 Tooth model with closed apex using soft model. plastic finishing and enable it to involve the entire length of the file (PFF). It is the apical progression of the instru- ment that moves irrigant beyond the tip. Hence. During canal shap- tional agitation of the solution is needed if the ing. several activation techniques and irrigant further and further apically. 8. mainly plastic and extracted teeth. photoacti. sonic fitting tapered master cone at the end of the shap- irrigation (EndoActivator. reciprocating movement used allows the solution ing wax (1980) to involve the entire canal space (Fig. 41] or ANP. All these techniques and with the canal walls. But. 16]. obviously. It must be realized that MDA starts early during canal preparation when the first scouting hand file is placed inside the canal. whatever the activation technique. it must be remembered that agitation is a critical factor to help distribute and exchange the solution within the canal space and enhance antiseptic and solvent effectiveness.8 Manual Dynamic Activation (MDA) Technique 151 devices have been extensively tested and com- pared. the vertical Fig. But addi. root canal [23]. amount of irrigant is small. devices are available including manual dynamic In 1980. disinfection. at this stage of the procedure. brushes [18]. Vibringe). continuous ultrasonic irrigation author to propose the systematic use of a well- (CUI). MDA is a simple yet cost- vated disinfection (PAD). 23. self-adjusting file (SAF). the and a fine needle [6. and elimination patency files are factors that allow the delivery of of biofilm. it made sense for the irrigation (IPUI). following a series of investigations activation (MDA). and once the working length has been reached. results are inconclusive because of different models. and laser activation effective way to help the irrigant to get in contact (Er: YAG. 8. different apical sizes. The fre- Manual Dynamic Activation quency of replenishment of the coronal irrigant Technique with the syringe along with the progressive shap- ing of the root canal and the repeated use of For better cleaning. or a well-fitting tapered gutta-percha point.3a–c). bubbles and moves fresh irrigant into the apical last millimeters [39] mixing it with the stagnant solution of the “dead zone” [6. passive ultrasonic irrigation (PUI). but it is currently impossible to interpret their results and draw reliable conclusions from the literature. different tapers. PIPS). and different volumes and time.

Finally. [1].4). In the Saber Sel and Hashem [30] and Andrabi et al. and ment efficacies of MDA and ANP in mesial root the frequency of the strokes creates turbulences of the mandibular first molars with narrow isthmi and enhances diffusion by shear stresses. the Safety irrigator. It when using MDA but not ANP. MDA on smear layer removal were confirmed by ies to compare ANP (EndoVac) and MDA.152 P. efficiency of ANP was the result of wall shear MDA facilitates the mixing of fresh solution with stresses [17]. Yana) the canal. [21] who the stagnant solution in the apical millimeters [6]. Using a well-matching GP cone and the canal walls. Huang et al. and dislodge the vapor lock effect. (b) Working length determination with K ≠ 15 file. Machtou a b c Fig. 8. first experiment. 8. CUI being the most effective technique in agitation of the master cone was significantly this study. compared MDA with tapered and non tapered The efficiency of the technique was confirmed gutta-percha cones. the good debridement tive hydrodynamic effect (Fig. debris. Bronnec et al. [35] compared canal and isthmus debris debride- ing the in-and-out movement of the GP cone. Results showed that a sealed including MDA did not alter the mineral level of apical foramen adversely affected debridement root dentine surface. [20] who used a Continuous Ultrasonic Irrigation (CUI) and ANP dyed collagen biofilm model showed that manual found. For the authors. . canal debridement efficiency In 2013. In contrast. a the same model McGill et al. Moreover. [6]. the use cantly less effective than MDA although another of MDA in a well-shaped canal with sufficient study using scanning electron microscopy (SEM) apical taper produced very cleaned apical regions could not find a difference between the two meth. Good results of walls [40]. (c) Dynamic irrigation after ≠1#5 file use (irrigant used: Hypaque) (Courtesy of Dr Y. [24] found that the factor described in detail by Machtou [23] and hydrodynamic device RinsEndo® was signifi.3 (a) Preoperative X-ray. The and closed apices. the authors [21] empha- more effective in removal of stained collagen sized the importance of the reflux space between from canal surfaces than static irrigation. by several studies. Jiang et al. It was shown that both tech- presence of a thin reflux space between the cone niques did not completely remove debris from and the canal walls is critical to allow the irrigant the isthmus region although ANP removed more to flow back along the cone and induce an effec. In a recent SEM study. and the absence of smear layer in severely curved ods in the removal of debris from the root canal canals of mandibular molars [9]. One group conducted a series of stud. The same group generates higher intracanal pressure changes dur. Capar and Aydinbelgehave [8] had was tested for both techniques in a closed and an shown that final irrigation activation protocols open system [28].

Following the same agitation protocol. but. the canal is filled with 1 ml of EDTA delivered with a 30 gauge NiTi needle (either Navy tip from Ultradent or Stropko NiTi Flexi-Tips from SybronEndo or CanalPro Flex-Tips from Coltene/Whaledent).4 GP cone agitation. until a with an accurate use of the MDA technique. it is noteworthy to notice that in a successful outcome. A final flush is per- formed with 3 ml of NaOCl. So far. a chlorhexidine-based solution with a Some other studies can be found where MDA weak chelator and surfactant. A snug fit is sought after at the work- ing length. 4. new activation protocol has proven to be the . the resistance of the periapical followed by some types of activation tech- tissues plays a role in limiting the occurrence of nique has proved to be effective to reduce extrusion. in endodontics in order to expect a predictable tem). may alternatively and different activation systems are compared replace both EDTA and NaOCl for final irriga- [12. 29]. This protocol has proven very effective in removing the smear layer and producing very Fig. 34]. According to avail. • After suction of the primary irrigant NaOCL. 8. and 1 mm the same protocol is repeated using 50 in and out strokes during 30 s. Therefore. A 1 min be interpreted with caution. • Manual agitation of the master cone is started with an up and down motion and a 2 mm amplitude at a frequency of 100 strokes during approximately 1 min (Fig. • The canal is flushed with 1 ml of NaOCl. and disruption of vapor lock cleaned canals in the apical area [9]. 13]. passive irrigation clinical situation. the product efficiency. 1 ml of EDTA is delivered with the irrigating needle to flush out debris. as stated earlier.5a–b). After that. • Then 1 ml is trimmed at the tip of the cone in order to get tug-back 1 ml shorter than the canal terminus. However. their results must tion of the root canal system [10. 8.8 Manual Dynamic Activation (MDA) Technique 153 MDA Mode of Use • A well-matching GP master cone whose taper is slightly less than the taper of the canal is selected. Irrigant extrusion can be prevented intracanal bacteria counts. able data [3. but further The main concern during irrigant activation is scientific data is needed to support and validate the risk of apical extrusion. reflux space. agitation protocol is recommended. all tested devices included MDA appear to extrude some irrigant except ANP Conclusion which is the safest (but ANP should be seen more Highest canal disinfection has to be achieved as a delivery device rather than an activation sys. QMix (Dentsply). EDTA is then suc- tioned to eliminate any residual chelating action.

10. Aust Endod Sci. Wu H.76:893–6. Review of contemporary irrigant agitation tech- ment of irrigant penetration and renewal during the niques and devices. 2010. Versluis M. J Endod. Cuenin PR. Microsc Res Tech. Heilborn C. Efficacy of several con. Boutsioukis C. Factors 16. Jiang LM. film ex-vivo model to evaluate the influence of canal 8. and convenient method to per. of ultrasonic and conventional methods of irrigant 3. Boutsioukis C. Mishra SK. Surface change of root canal dimensions and irrigation variables on the efficacy of dentin after the use of irrigation activation protocols: irrigation. der Sluis LW. of the effect of 0. Cohenca N.35:891–5. Kumar A. Gosier J. Aydinbelge HA. Khechen K. Effect of EDTA. sonic. Development and validation of a three- a systematic review. Caron G. Tay FR. J. Gillen B. Eames I. de Gregorio C. 20.55:307–12. The 7. 2009. dimensional computational fluid dynamics model of 5. Bacteriologic evaluation fluid mechanics of root canal irrigation.35:791–804. Goode N. A bio-molecular 1983. 2015. Verhaagen B. Gulabivala K. Haapasalo M. J Endod. Tay FR. Desai P. Kastrinakis E. Eijsvogels LM. Tay 6. Loushine BA. 2009.41:636–41. 1992. . Baumgartner JC. T. Eid AA. The effect of replacement. Gilbertson M. Effectiveness of different final irrigant activation 2012. it is a fast. Wimmer CE. endodontic therapy. J Endod. Physiol Meas. Gutmann JL. Lak B. 18. J Dent. Nham K. Zhou X.39:131–6. centrations of sodium hypochlorite for root canal irri. Kastrinakis E. Dai L.41:60–71. van der Sluis LW.5 (a.43:663–72.38:37–40. Irrigation trends ex vivo. Mines P. and ultrasonic References activation on the penetration of sodium hypochlo- rite into simulated lateral canals: an in vitro study. Bronnec F.38:838–41. 11. Anderson A. Psimma Z. Lasers Med scanning electron microscopic study. Stock CJ. Dutner J. Niu LN. Andrabi SM. Druttman AC. on removal of canal wall smear layer and debris. flow rate and agitation technique on irrigant extrusion 15. 2014. 13. Comparison of the cleaning efficacy 9. Himel V. 2012. J Endod. Gu LS. 1989. 2009. Shen Y. J Endod. safe. effective. Boutsioukis C. 2010.18:605–12. Oral Surg Oral Med Oral Pathol. 1.22:174–8. J Endod.31:R49–84. Meire MA. Byström A. Capar ID. 12. 19. Ruse affecting irrigant extrusion during root canal irrigation: ND. based irrigant activation methods in removing debris diaminetetraacetic acid and SmearClear: an in vitro from simulated root canal irregularities. Ling J. Int Endod J. Siddiqui S.154 P. Machtou Fig. 2008. J Endod. Comparative safety of various intra- 2. Kim JR.30:831–5. bers: a web-based survey. Choi KK. canal irrigation systems. Int Endod J. J Endod. LF. 2014. 2013. doi:10. The form irrigant agitation at the end of the root effect of QMix. Sundqvist G. van microanalysis. Int Endod J. Gulabivala K. Int Endod J. Li B. Lambrianidis root canal irrigation. Pashley DH. Int Endod tems. Ng YL. Ng YL.46(5):99–618.36:1361–6.12176. Formation and removal of apical vapor lock dur. Pashley D. Alam S. J Endod. 2009. Pashley DH. Susin LW. electron microscopy and an energy-dispersive X-ray 21. Huang TY. Khan S. Efficacy of laser- vation on smear layer removal efficacy of ethylene. 14. P.5 percent sodium hypochlorite in 2010.47:191–201. some clinicians as laborious. De Moor RJ. Effect of manual dynamic acti. Machtou P.1111/ among American Association of Endodontists mem- iej. cost. Deleu E. Wesselink P. Psimma Z. van der Sluis 17. Ex vivo assess. Khan S. Cisneros R. Tewari RK. FR. J. Wall shear stress effects of ing syringe irrigation: a combined experimental and different endodontic irrigation techniques and sys- Computational Fluid Dynamics approach. Machtou of different final irrigation techniques. Gao Y. Estevez R. 4. 8. Bronnec F. final irrigation regimen.35:1282–7. 2013.47:487–96.37:80–4. canal irrigant. an experimental antibacterial root canal preparation. b) Clinical MDA technique: agitation of the GP a b cone with a 2 mm amplitude best and although MDA may be perceived by protocols on smear layer removal in curved canals. 2013. 2013. 2011.35:545–9. Bouillaguet S. An in vitro comparison gation. Int Endod J.

Bortolo MV. ment using manual dynamic agitation or the EndoVac 39. J Endod. Susin L.41:602–8.75:781–90. Mordan N. Weller RN. 1971. 2004. study of sodium hypochlorite as an in vitro endodon- Weller RN. p. Philadelphia: JB 33. 1977. 34. Gu L. Lazzari EP.7:226–9. Rôças IN. smear removal in flattened root canals after use of dif. The novel irrigant. Tay of a collagen ‘bio-molecular film’ from an ex vivo FR. Factors promoting the positive-pressure irrigant delivery. Int Endod J. Wesselink PR. J Endod. 36:745–50. Johnson B.U. Stojicic S. 94. Root canal debride. Duarte MA. Luks S. Bryan T. Schoeffel GJ. Masters thesis. Clinical implications and Lippincott.37:1272–5. ferent irrigant agitation protocols. 2010.26:92. 1991. Crit Rev Oral Biol Oral Pathol. Braz Dent final irrigation activation techniques on smear layer J. 42. Susin L. 38.8 Manual Dynamic Activation (MDA) Technique 155 22.45:363–71. Paris. Med. McGill S. 1989. M. Senia ES.15:348–81. Machtou P. Arias A. Rosen S. Susin L. in permanent teeth with periapical lesions.43:1001–12. Schoeffel GJ. Ribeiro EM. Bramante CM. Antibacterial and smear layer removal ability of a 24. 2011.15:187–96. Liu Y. Olsen I. 37. Parente JM. 2008. 2012. Loushine RJ. The EndoVac method of endodon. An in vivo comparative study of the penetra- 31. ing cleaning and shaping procedures using the B. Vera J. Scanning electron Endod J. Wimmer C. Int Endod J. Vivan RR. Saber Sel D. Yana Y. Moraes IG. Quantitative 28. Yoon JC. Moorer WR. Pashley DH. Kerekes K. Looney SW. Romero M. Efficacy of different conventional irrigation for debris removal. 2008. Investigations sur l’irrigation en endodon.32: Oral Surg Oral Med Oral Pathol. der Sluis LW. J Endod. Nair PNR. Siqueira Jr JF. Tay FR. 2010. 1974. Zehnder M. 41. Debris and 2012. Silva SR.31:96–103. The SD. J Endod. Practical endodontics. microscopy of bacteria in the apical part of root canals 36. 2006. tie. 32. Parente JM. Marshall JF. Gu LS. Hashem AA. Tay FR. tron microscopy analysis of RinsEndo system and 30. Madden RM. . Boston.21:305–9. Sousa-Neto MD. 96. The solvent action of sodium hypochlorite on 27. Haapasalo Université Paris 7. on irrigant penetration into the apical two millime- 29. sodium hypochlorite on pulp tissue of extracted teeth. 1980. tion of sodium hypochlorite in root canal systems dur- tic irrigation: safety first. Dent Today. J Endod. Lorencetti KT. J Endod.34:1291–301. Int Endod J. technique and sonic instrumentation. Shen Y. Pathogenesis of apical periodontitis and fixed and unfixed necrotic tissue. procedures. Canal and isthmus debridement efficacies of two model. 1982. Thèse de doctorat en sciences odontologiques. Hernández EM. Silva-Sousa YT. Scanning elec- 2012. efficacy of dynamic irrigation using a commercially 35. The solvent action of Boston University. Loushine RJ. Gulabivala K.3:194–6. available system (RinsEndo) determined by removal Ricucci D. QMiX. Trepagnier CM. Pashley DH. Qian W. ters of large root canals: an in vivo study.38:1340–3.43:1077–90. Oral Surg Oral Med the causes of endodontic failures. et al. Ng YL. Effect of maintaining apical patency tem. Root canal irrigants. Int 25. 40. Int Endod J. tissue dissolving capability of sodium hypochlorite. van for final irrigation in a closed system and an open sys. Souza-Gabriel AE. Effect of vapor lock on root canal Dent Traumatol. Endod Zhang K. microbiology of bacterial persistence after treatment 23. 2010. tic irrigant. 2010.47:558–61. Tanomaru-Filho M. 1979. debridement by using a side-vented needle for 26. 2007. 82–5. Microsc Res Tech. irrigant agitation techniques in a closed system. 389–98. removal. Molven O.

QC. Canada e-mail: gary@rootcanals. © Springer International Publishing Switzerland 2015 157 B. University of Université de Montréal. DMD Associate in Dentistry. Adjunct Professor of Dentistry. In order for an endodontic irrigant delivery system to be mechanically effective and satisfy the objective of endodontics. G. FRCD(C) (*) K. without the risk of apical extrusion. a column of gas develops at the apical one third of the root canal (apical vapour lock). Glassman. Jamaica Private Practice.). In very short order. Montréal. The conundrum that the clinician faces is to safely and effec- tively deliver the irrigants to the apical terminus. DDS. Basrani (ed. the organic component of pulpal tissue con- sumes NaOCl rapidly as the reaction of hydrolysis occurs forming water and releasing ammonia and carbon dioxide as the by-products. hopefully for the lifetime of the patient. ON. Currently. DOI 10. The objective of end- odontic treatment is to prevent and/or treat apical periodontitis. Canada University of Technology. Canada Private Practice. Kingston. Canada Toronto. Endodontics.1007/978-3-319-16456-4_9 . the irrigant of choice to achieve this objective is full-strength sodium hypochlorite (NaOCl). During endodontic irrigation. it must reach the apical terminus. Apical Negative Pressure: Safety. create a current along the root canal wall and have the ability to remove debris. ON. break the apical vapour lock and allow constant exchange of irrigant and thereby continual hydrolysis of pulpal tissue by the NaOCl. This chapter will outline the scientific evidence surrounding apical neg- ative pressure as a safe and reliable method to deliver irrigants to the apical terminus. Toronto. Endodontic Specialists. QC. Mont-Royal. thereby satisfying the objectives of endodontic treatment. Department of Adjunct Professor of Dentistry. Faculty of Dentistry. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. Graduate. tissue and bacterial contaminants. Clinique Endodontique Mont-Royal. Charara. Efficacy and Efficiency 9 Gary Glassman and Karine Charara Abstract The objective of dentistry is to prevent oral disease and retain the natural dentition.

microbes and their by-products could result in persistent periradicular inflammation [4]. 3]. supply of fresh irrigation solution into the root and if a significant quantity of a toxic irrigant canal. 8]. may result in supe. Root canal irrigation systems can be divided During root canal treatment. the Vibringe ment depends on a number of factors. the potential to experience a NaOCl accident gation when compared with intermittent irriga- increases [7]. against the root canal wall when the irrigant niques and machine-assisted irrigation tech. successful irrigation and and the EndoActivator (Dentsply Tulsa Dental decontamination of the root canal system to the Specialties). such as lateral/accessory canals. Taking into consideration that surviving the cleaning and shaping procedures. based on apical negative pres- the root canal can be very challenging and must sure (SybronEndo). chloride (responsible for dissolving the organic adjuvant techniques. the canal is filled several times the irrigation solution to reach the apex. Manual irrigation techniques include Negative pressure refers to a situation in which the positive-pressure syringe fitted with a vari. pressure is exerted into two categories: manual irrigation tech. With debris and bacteria frequently tion devices. Successful endodontic treat. solution is delivered into the root canal space. the endodontic care. after each activation cycle. The presence of persistent deltas. Glassman and K. the Rinsendo (Air Techniques). Manual and Machine-Assisted Apical Negative Pressure Irrigation Techniques Pressure is defined as a force per unit area. results and reduce the time required for final irri- sue. isthmuses and organisms [2. inaccessible areas such as isthmuses. the continu- sible the solution may enter the periapical tissues ous flush techniques provide an uninterrupted [6]. This can be a source of post-operative pain. the irrigant is injected in the root canal the needle may not be reached by the irrigant [5]. After traditional nickel– are whether the irrigation systems can deliver the titanium instrumentation and syringe-assisted irrigant to the apical terminus and whether the irrigation. Unless the needle of a positive-pressure irrigate root canal systems: the continuous and delivery system is placed close to the apex. proper instrumentation. Delivering an endodontic irrigant with a needle Continuous and Intermittent and a syringe may be unpredictable. accessory canals and the root canal terminus not be reached with mechanical instrumentation. irrigant is capable of debriding areas that could fins. space with a syringe and the irrigant solution can When the needle is placed to a depth that allows then be activated. With the intermittent flush tech- portion of the canal from the apex to the end of nique. including (Vibringe). Charara The Challenge of Endodontic agitation using a gutta-percha point. thereby not Flushing Techniques allowing the irrigant to reach root canal anasto- moses and the apical one third of the principal Two flushing methods are currently employed to canals.158 G. not be discounted from providing high-quality based on multisonic pressure wave formation. This technique can provide more effective such as NaOCl is injected into the periapical tis. Inversely. the GentleWave (Sonendo). a continuous rior root canal cleaning [3. the intermittent. may remain filled with residual debris and micro. unstable and quickly consumed. niques [9]. Two important factors that should apices and in areas such as isthmuses and lateral be considered during the process of irrigation and accessory canals [1]. an enclosed volume has lower pressure than its ety of needle designs and the manual-dynamic surroundings. Machine- Debridement assisted irrigation techniques include sonics and ultrasonics. to the traditional syringe tissues and NaOCl’s antibacterial property) is and needle commonly used. it is pos. flow of irrigant would make intuitive sense. . plastic rotary F File (Plastic Endo). as well as newer systems such Adequate debridement of the apical one third of as the EndoVac.

thereby drawing and on a fairly frequent basis when they use a vacuum delivering the irrigant passively to the apex [9]. tion system has three active component parts tive pressure to prevent the contamination of the (Fig. If the pipeline were posi. It is attached snugly Fig. All these diameter of ISO size of 0. plastic macrocannula (Fig. needle. The MDT accommodates a syringe of irri- sea and the pipeline’s wall breaks off. has a 0. This prevents microorganisms from result in treatment complications [6. 9. Oil pipelines also employ nega.1). clear plastic tubing to the high-speed suction of phology of the root canal system. Negative pressure is also seen in medical The EndoVac system delivers the chosen irrigant quarantine situations where an isolation room passively to the apex [5. 9. the macrocannula and the microcan- In a situation where the pipeline is under the nula. As such. cleaner.9 Apical Negative Pressure: Safety.1 Micro-CT images of a maxillary molar demonstrate the root canal complexity (Courtesy Dr. into a multiport adaptor which in turn is inserted prehensive review of an apical negative-pressure into the high-volume suction [13]. Ronald Ordinala Zapata) .2): the Master Delivery Tip (MDT) environment in the event of a rupture.35 mm. inter-canal and intra-canal communica. creating a potentially connected to clear plastic tubing which inserts hazardous spill. This chapter will provide a com. while irrigant is simultaneously delivered The EndoVac system was developed to safely and to the pulp chamber directed towards an axial predictably deliver irrigant to the apical terminus. The macrocannula is used to draw irrigant by way of suction from the cham- The EndoVac System ber to the coronal and middle segments of the canal. 9. such as the dental unit via the multiport adaptor. rocannula or microcannula is connected via tion solution into the inherent anatomy and mor. 9. addresses the problem of irrigation penetration taminated air is through an opened door or win. The isthmuses. the EndoVac MDT can simultaneously deliver and evacuate system.4) has an external tions.55 mm and an internal anatomic irregularities make disinfection of the diameter of ISO size of 0. seawater gant. curvatures and oval-shaped canals. any excess irrigant that may flow over from the pulp chamber. Efficacy and Efficiency 159 Many people use a negative-pressure device have the ability to suction.02 taper and is Apical negative-pressure systems for irrigation meant for single use only. The EndoVac apical negative-pressure irriga- ical personnel. 10] and positively will have negative pressure so the outflow of con. which is expressed through a 20-gauge will flood the pipeline. It is made of root canal extremely challenging [10] (Fig. blue translucent plastic. escaping and makes it safer for patients and med. the system for endodontic irrigation. (Fig.3). 9. wall and never towards a canal orifice. There is also a plastic suction hood tively pressurised. The mac- thereby allowing a better penetration of the irriga. their contents would explode attached around the 20-gauge needle which is and leak into the ocean. 11. past the apex into the periapical tissue which may dow. 12].

04 taper or larger. nal diameter of ISO size of 0.160 G.5) and is used in an up-and-down peck. The micro. A non-tapered prepara- instrumentation. Both the macro- holes adjacent to its closed end. the macrocannula is connected to the high-volume suction of the dental chair attached to the autoclavable aluminium handpiece and the via the multiport adaptor (Courtesy Dr.6) tion can also be considered. It is used to remove enlarged with endodontic files to ISO size 35 the gross debris and tissue left behind during with 0. These holes act as sure that pulls fresh irrigant from the chamber. allowing the reaction of hydrolysis to continu- cal part of the canal when it is positioned at ally occur. 100 μ in diam. 9. the microcannula and the Master Delivery Tip (MDT) accommodates different sizes MDT are connected via clear plastic tubing.02. the cannula and out through the suction hose. the root canal to 40/0. end and should be taken to the full working ing motion. fingerpiece and is used for irrigation of the api. During irrigation. The microcannula (Fig. The macrocannula. Glassman and K. The size of 0. laterally positioned offset irrigant to prevent overflow. The tubes are of syringes filled with irrigant. the MDT delivers irrigant less-steel microcannula of zero taper has four to the pulp chamber and siphons off the excess sets of three laser-cut. John Schoeffel) microcannula is attached to an autoclavable aluminium to an autoclavable aluminium hand piece working length. a constant flow of fresh irrigant is deliv- cannula is attached to an autoclavable aluminium ered by negative pressure to working length. The microcannula has a closed (Fig. in this situation the contains 12 microscopic holes and is capable of manufacturer recommends an enlargement of evacuating debris to full working length [14]. filters to prevent the clogging of the internal down the canal to the tip of the cannula. 9.20 mm.32-mm-external-diameter stain. cannula and microcannula exert negative pres- eter and spaced 100 μ apart.2 The components of the EndoVac system: the fingerpiece. Charara Fig. Thus. 9. while irrigant is simultaneously length to aspirate irrigants and debris. The delivered passively to the pulp chamber in the microcannula can be used in canals that are manner mentioned above. into lumen of the microcannula which has an inter. .

5) (Courtesy Kerr Endodontics (SybronEndo).32-mm-external-diameter stainless-steel microcannula of zero taper has four sets of three laser-cut. 100 μ in diameter and spaced 100 μ apart (Courtesy Dr.3 Master Delivery Tip (MDT) composed of a 20-gauge needle and luer lock connectors to connect to the syringe and the high-volume suction of the dental Fig.9 Apical Negative Pressure: Safety. Efficacy and Efficiency 161 Method of Use Irrigation begins during rotary instrumentation.5 Autoclavable handpiece for the macrocannula chair (Courtesy Kerr Endodontics (SybronEndo). 9. California) Fig. 9. 9. laterally positioned offset holes adjacent to its closed end. John Schoeffel) . California) California) Fig. 9. 9.4 The macrocannula is made of blue translucent plastic and it is attached to an autoclavable aluminium handpiece (Fig. Orange.6 The ISO size of 0. (Courtesy Kerr Endodontics (SybronEndo). Orange. The MDT delivers fresh irrigant to the access opening when each instrument is changed in the hand piece. A normal Monoject syringe may be used to replenish the irrigant in the pulp chamber during instrumentation. This removes instrumentation debris and exchanges irrigant deep within the pulp chamber as subse- quent files are brought closer and then finally to Fig. Orange. Using the MDT is optional during access and the instrumentation phases of root canal treatment.

If a shortcut is made and this step is not completed for the full 30 s in each canal. is then added for the third and final time for never direct the flow of irrigant towards a another 10 s. the mac. Delicately guide the microcannula to full work- ing length by holding the fingerpiece. The NaOCl is added with the MDT to the pulp chamber for 10 s (Fig. Continue to deliver copious NaOCl with the MDT while the macrocannula is moving up and down the canal. The the microcannula if it won’t stay in the canal on its own NaOCl is added for another 10 s after which the (Courtesy Kerr Endodontics (SybronEndo). to be charged (soaked) with fresh NaOCl for 60 Following complete instrumentation. 9. but at the end of this time period. Use a ruler to position the rubber stopper that is placed on the microcannula or score the microcannula with an indelible marker (Fig.162 G. Glassman and K. 9. California) during instrumentation. When using the MDT. Charara working length. This step can also be performed with the microcannula should it get blocked. If it does.8 Once the microcannula is placed at full working seconds to allow the gas bubbles formed by length. The first micro cycle allows the organic com- rocannula is used in each canal for 30 s in a short up-and-down pecking motion as close as possible to working length. canal’s orifice as the pressure of irrigant expres. The fin- gerpiece is then released and the tubing is stabilised. The next step involves three micro cycles. the clinician may leave it in place and proceed with irrigant delivery via the MDT.7). The NaOCl direct the irrigant flow against a chamber wall.7 Remove the cap of the microcannula.8). the microcannula is removed by the fingerpiece sion has the potential of causing an irrigation as the MDT continues to deliver NaOCl to the accident in straight and wide canals even when pulp chamber as to not allow its removal from the needle is not placed directly in the orifice the canal just being treated. 9. then remove the plastic tubing from the aluminium handle. then the microcannula used in the next step may get blocked and slow down the irrigation process. irrigant flow is stopped again to allow the gas California) . After 10 s the irrigant flow is stopped for just a couple of Fig. The use of Fig. Use the provided rubber stopper or a marker to indicate working the macrocannula in the final irrigation protocol length (Courtesy Kerr Endodontics (SybronEndo). They are called micro cycles because the micro- cannula is now used at full working length to remove debris from the canal lumen and isthmus areas. Observe the mac- rocannula for continuous flow and that it does not become blocked with debris. 9. will remove the gross debris and tissue left behind Orange. s. Orange. Put a slight bend on hydrolysis to be purged from the canal. This allows the canal or canal. place a syringe of water tightly at the end and express the water through the handle and macrocannula to dislodge the blockage. always bubbles to be purged from the canal. This is carefully done over the sink and not over the patient.

9. As mentioned. the root canal system after instrumentation with cately guided to full working length. EDTA is rotary files [16–21]. The microcannula is again deli. using apical negative pressure compared to the col using the EndoVac system. Efficacy and Efficiency 163 ponent of the smear layer to be removed in addi. and then the microcannula is objective of root canal treatment and remains a removed allowing the canal to be charged for 60 challenge especially in the apical portion of the s. When compared to 60 s.9 Apical Negative Pressure: Safety. The second micro cycle using Several studies were carried out to evaluate the EDTA removes the inorganic component of the EndoVac system’s ability to remove debris within smear layer. The third micro cycle is the same as microorganisms from the root canal by mechanical the first micro cycle. There is no better way to dry the root canals walls and a statistically cleaner result using api- than to delicately guide the microcannula to full cal negative-pressure irrigation in closed root working length for just a moment. this third micro cycle will allow the control to reach the last millimetre of the root canal. NaOCl to enter the dentinal tubules via osmosis Some in vitro and in vivo studies have demon- and dissolve the remaining tissue and microbiota strated greater removal of debris from the apical [15]. this will remove the inorganic canal and within the isthmuses and lateral and component of the smear layer and expose the accessory canals. In an in vivo lowed by one or two paper points. Now that the smear layer has been removed traditional syringe and side-vented needle irriga- from the root canal walls by the first two micro tion. The canal(s) is study of 22 teeth by Siu and Baumgartner. Debris Removal tion to any fine debris left behind during instrumentation. Debridement is the elimination dentinal tubules in preparation for the third of organic and inorganic substances as well as micro cycle. Refer to Fig. while Shin Fig. use of traditional needle irrigation. 9. the EndoVac system has demonstrated better cycles. less now ready for obturation.9 for a debris remained at 1 mm from working length flow chart illustrating the final irrigation proto. two purges and a charge for and/or chemical means [22]. canal systems with sealed apices. This is fol. Debridement is a principal added for 10 s.9 Final irrigation protocol using EndoVac system .

164 G. cal groove comparable to an ovoid apical canal sure resulted in less debris remaining at 1. Moreover. an error that in vitro root canal model may be caused by robust could easily cause the microcannula to clog and bubble formation during irrigant delivery. evidence of low wall shear stress values causes a itive outcomes discussed above. A score between 0 and 3 was given to in a closed system and an open system. it was each specimen: 0 = the groove is empty. When compared several devices to activate the irriga- comparing root canal debridement using manual. Once the irrigation regimen was dynamic agitation (using a well-fitted gutta. They 3. fluid-dynamic challenges inherent in closed root while 35 % had less than half filled with debris canal systems [25. This will reduce the incidence the volume of irrigant delivered apically was sig. within the canal by the microcannula [28]. To avoid this complication. found in an in vitro study of 69 teeth com. but debris and 3 = the complete groove is filled with did not adversely affect results when the EndoVac debris. if the macrocannula is used according to by negative pressure [18]. This One study is not in agreement with those pos. creat. To enhance cleanliness of the root with the macrocannula should it also become canal system.5 mm from working length [18. EndoVac system has the ability to clogged during its use (Fig. tion solution. The specimens irrigated with the system was used. A recent study demonstrated that nula is introduced. the microcannula can be debris remained with the EndoVac system at wiped with a 2 × 2 gauze or air and water can be 1 mm from the working length and in isthmuses blown into it to unclog it. However. A weaker capacity of the EndoVac sys- same period [18] and resulted in significantly tem to remove apical debris could be attributed more debris removal at 1 mm from working to the minimal turbulence intensity produced length than did needle irrigation. failed system to significantly clean more debris from a to follow the manufacturer’s instructions by fail- mechanically inaccessible recess of the curved ing to use the critical macrocannula. This can also be done [18. The model negative pressure that these methods both resulted was made of a single tooth root in which an api- in clean root canals but that apical negative pres. Apical negative-pressure EndoVac system had their groove completely irrigation is an effective method to overcome the filled with debris (score 3) 65 % of the time. to remove dentin debris from artificially made paring traditional needle irrigation with apical grooves in standardised root canals. Glassman and K. the clinician will experience liquid flow phenomenon that is well known in decreased or complete arrest of irrigant flow. 20. completed. the macro- avoids air entrapment in the apical third [21] and cannula’s main purpose is to remove as much promotes a regular replenishment of the irrigant debris as possible before the smaller microcan- apically [21]. 9. nula will continue to work even if several holes tion of the irrigation solution in the apical end of are blocked. It is important to note that Jiang et al. 26]. Charara et al. men adversely affected debridement efficacy 2 = more than half of the groove is filled with when manual-dynamic agitation was used. the negative pressure decrease. ran a minimum physical interaction between the irrig- study and evaluated the EndoVac system’s ability ant and the root canal walls [29]. become ineffective. 1 = less found that the presence of a sealed apical fora. The ability of the EndoVac [17]. of it clogging as long as the macrocannula is nificantly higher than the volume delivered by used according to the manufacturer’s recommen- conventional syringe needle irrigation within the dation. 21]. This vacuum action the manufacturer’s instructions. When the microcannula is ing higher wall shear stresses by a two-phase air– blocked by debris.10). Less rectify the situation. The microcan- enhances the volume of solution and the circula. its effectiveness will the root canal. To other industrial debridement systems [27]. than half of the groove is filled with debris. 24]. they viewed the grooves through a percha cone in an up-and-down motion in the stereomicroscope to evaluate the residual dentin canal) or the EndoVac system for final agitation debris. This absence of . Complete safely deliver irrigant to working length [18] by clogging of the microcannula happens very pulling the irrigant into the canal and removing it rarely. 23.5 and was created and packed with dentin debris. Jiang et al.

9 Apical Negative Pressure: Safety, Efficacy and Efficiency 165

Fig. 9.10 If either cannula
becomes clogged, try
unclogging it by attaching the
back end of either the
fingerpiece or handpiece onto
a syringe filled with water.
Push the plunger; in most
instances the hole(s) is
immediately cleared
(Courtesy Kerr Endodontics
(SybronEndo). Orange,

interaction may explain the difficulty of the irri- for mineralised tissue formation and the repair
gation solution to reach the root canal’s lateral process [30], the study [30] suggests that EndoVac
canals and anastomoses [5]. may overcome the need for intra-canal medica-
tion. Further research is required to evaluate this
potential. Using apical negative pressure with
Microbial Control NaOCl also decreases the risk of drug resistance,
tooth discoloration and allergic reactions often
The effective removal of organic and inorganic seen with the administration of antibiotics [32,
tissues would logically allow better access and 33]. A recent randomised controlled clinical trial
elimination of endodontic pathogens, responsible [34] compared the antimicrobial effectiveness of
of apical periodontitis, localised in the root canal EndoVac system and the traditional positive-
system. pressure syringe and needle for irrigation. From
Hockett et al. tested the ability of apical the 16 mandibular molar treated with the conven-
negative-pressure irrigation to remove a thick bio- tional method, negative culture was found in 67 %
film of E. faecalis in mesial roots of mandibular compared to 100 % among the apical negative-
molars, finding that these specimens rendered pressure irrigation group. A second clinical study
negative cultures after 48-h incubation, while [35] demonstrated a higher frequency of obtain-
some of those irrigated using traditional positive- ing negative culture with EndoVac system com-
pressure irrigation were positive at 48 h [29]. One pared to a syringe with regular needle. Unlike
in vivo dog study found that apical negative- Cohenca et al. [34], Pawar et al. [35] did not reach
pressure irrigation with 2.5 % NaOCl resulted in significance between the two clinical groups.
similar bacterial reduction than the use of apical However, Pawar et al. added an overriding codicil
positive-pressure irrigation combined with seven in their discussion: “The original EndoVac proto-
days of intra-canal medication which was the tri- col recommends using a concentration of 5.25 %
ple antibiotic paste [30]. The triple antibiotic NaOCl. Almost all studies investigating the effi-
Trimix (metronidazole, ciprofloxacin and mino- cacy of EndoVac have used NaOCl at concentra-
cycline) has been utilised for pulpal regeneration/ tions ranging from 2.5 to 6 %. The use of 0.5 %
revascularisation in teeth with incompletely NaOCl [a 1,000 % dilution from the manufactur-
formed apices [31]. The antibiotic medication is er’s instructions] in this study could be considered
applied in regeneration cases to safely kill bacte- responsible for the lack of significant differences
ria. Since the triple antibiotic versus the use of in antimicrobial efficacy between EndoVac irriga-
EndoVac with NaOCl was statistically equivalent tion and standard irrigation” [35].

166 G. Glassman and K. Charara

Smear Layer Removal the smear layer in the apical one third [45]. A
possible explanation for this is that both tech-
The smear layer is created when the dentinal niques reach full working length of instrumented
walls of the root canal system interact with end- canals, eliminate the apical vapour lock at the
odontic instruments [36]. The smear layer is apex and hence allow adequate irrigant replace-
comprised of inorganic and organic material such ment [44, 45]. When evaluating irrigation of the
as dentin filings and pulp tissue remnants [37]. apical one third, the phenomenon of apical
This deposit can be penetrated by bacteria and vapour lock should be considered [26, 46, 47].
may offer protection to biofilms adhering to the
root canal walls [38]. Furthermore, the smear
layer interferes with the tight adaptation of cur- Apical Vapour Lock
rently used root canal sealers to dentinal walls
and may therefore promote microleakage [39]. Since roots are surrounded by the periodontium,
Torabinejad et al. [40] suggested that the removal unless the root canal foramen is open, the root
of the smear layer decreases bacteria and canal behaves like a close-ended channel. This
improves adaptation of obturation materials to produces an apical vapour lock that resists dis-
the canal walls. Another study showed that the placement during instrumentation and final irri-
smear layer produced during root canal prepara- gation, thus preventing the flow of irrigant into
tion promotes adhesion and colonisation of P. the apical region and adequate debridement of
nigrescens [41] to the dentin matrix and might the root canal system [48, 49]. Apical vapour
increase the likelihood of canal reinfection. lock also results in gas entrapment at the apical
Removing the smear layer reduces the potential one third [9]. During irrigation, NaOCl reacts
for microleakage [19, 42] and improves sealer with organic tissue in the root canal system, and
penetration in dentinal tubules [43]. When manu- the resulting hydrolysis liberates abundant quan-
facturer’s recommendations are followed, tities of ammonia and carbon dioxide [50]. This
EndoVac system delivers a sufficient volume of gaseous mixture is trapped in the apical region
irrigants which enables to remove smear layer and quickly forms a column of gas into which
[19, 44, 45] (Fig. 9.11). further fluid penetration is impossible. Extension
Compared to passive ultrasonic irrigation, api- of instruments into this vapour lock does not
cal negative-pressure irrigation and manual- reduce or remove the gas bubble [13], just as it
dynamic irrigation are more efficient in removing does not enable adequate flow of irrigant.
The phenomenon of apical vapour lock has
been confirmed in studies in which roots were
embedded in a polyvinyl siloxane impression
material to restrict fluid flow through the apical
foramen, simulating a close-ended channel [26].
The results in these studies were found to be an
incomplete debridement of the apical part of the
canal walls with the use of a positive-pressure
syringe delivery technique [26]. Micro-CT scan-
ning and histological tests conducted by Tay
et al. have also confirmed the presence of apical
vapour lock [26]. In fact, studies conducted with-
out ensuring a close-ended channel cannot be
regarded as conclusive on the efficacy of irrigants
and the irrigant system [51–53]. The apical
Fig. 9.11 SEM of a clean root canal wall where the
smear layer has been removed (Courtesy Dr. Arianna vapour lock may also explain why in a number of
Gomez-Perez) studies investigators were unable to demonstrate

9 Apical Negative Pressure: Safety, Efficacy and Efficiency 167

a clean apical third in sealed root canals [65]. The results were similar to another study
[54–56]. [66] where EndoVac system was compared to the
In a paper published in 1983, Chow deter- traditional syringe irrigation and the ProUltra®
mined that traditional positive-pressure irrigation PiezoFlowTM ultrasonic irrigation needle
had virtually no effect apical to the orifice of the (Dentsply Tulsa, Tulsa, OK, USA). EndoVac sys-
irrigation needle in a closed root canal system tem left significantly less calcium hydroxide
[57]. Fluid exchange and debris displacement compared to the traditional syringe irrigation and
were minimal. Equally important to his primary provided better results than PiezoFlowTM, but the
findings, Chow set forth an infallible paradigm difference was not statistically significant [66].
for endodontic irrigation: “For the solution to be Although the EndoVac system improves the
mechanically effective in removing all the parti- removal of calcium hydroxide, the apical portion
cles, it has to: (a) reach the apex; (b) create a cur- of the canal was not completely free of intra-
rent (force); and (c) carry the particles away” canal medicament. Therefore, the use of the mas-
[57]. The apical vapour lock and consideration ter apical file in combination with the EndoVac
for the patient’s safety have always prevented the system may result in better removal of calcium
thorough cleaning of the apical 3 mm. It is criti- hydroxide [66].
cally important to determine which irrigation
system will effectively irrigate the apical third, as
well as isthmuses and lateral canals [10], and do Sodium Hypochlorite Incidents
it in a safe manner that prevents the extrusion of
irrigant. In light of the cytotoxicity of the sodium hypo-
chlorite, its extrusion from the root canal will
affect the periapical tissue and may cause the
Calcium Hydroxide Removal patient a series of complications of a variable
clinical significance, beginning with the a post-
As stated previously, the debridement of the root operative pain [7].
canal system consists of elimination of organic, Although a devastating endodontic NaOCl
inorganic and microbial components, thus incident is rare [67], the cytotoxic effects of
accomplished by mechanical instrumentation NaOCl on vital tissue are well established [68].
supported by various irrigation regimens and The associated sequelae of NaOCl extrusion have
placement of intra-canal medication. Calcium been reported to include life-threatening airway
hydroxide is a commonly used intra-canal medi- obstructions [69], facial disfigurement requiring
cament [58] that has antimicrobial activity proven multiple corrective surgical procedures [70], per-
to contribute to bacterial endotoxin neutralisation manent paraesthesia with loss of facial muscle
[59] and to periapical repair [60]. However, to control [71] and tooth loss [72].
provide a maximum interface between the root Although the exact aetiology of the NaOCl
canal walls and the filling material, calcium incident is still uncertain, based on the evidence
hydroxide has to be removed [61]; otherwise, the from actual incidents and the location of the asso-
bond strength [62] of the sealer and its penetra- ciated tissue trauma, it would appear that an
tion into the dentinal tubules could be reduced intravenous injection might be the main cause.
[63]. Conventional methods for irrigation have The patient shown in Fig. 9.12 [73] demonstrates
demonstrated limited capacity to remove calcium a widespread area of tissue trauma that is in con-
hydroxide from the apical third of the root canal trast to the characteristics of NaOCl incident
[64]. A scanning electron microscopic evaluation trauma reported by Pashley [68]. This extensive
of longitudinally sectioned canines demonstrated trauma, particularly involving the pattern of
that EndoVac system performs better than the tra- ecchymosis around the eye, could only have
ditional syringe irrigation in removing calcium occurred if the NaOCl had been introduced intra-
hydroxide from the apical one third of root canals venously to a vein close to the root apex through

168 G. Glassman and K. Charara

use is essential to achieve adequate chemical
debridement. What this does imply is that it must
be delivered safely.


With traditional root canal irrigation, clinicians
must be careful when determining how far an irriga-
tion needle is placed into the canal. Recommendations
for avoiding NaOCl incidents include not binding
the needle in the canal, not placing the needle close
to working length and using a gentle flow rate when
using positive-pressure irrigation [75]. In contrast,
the EndoVac system pulls irrigant into the canal to
working length and irrigant and debris is removed
by negative pressure. Apical negative pressure has
been shown to enable irrigants to safely reach the
apical one third and help overcome apical vapour
lock [18, 20].
Apart from being able to avoid air entrapment,
Fig. 9.12 Clinical aspect of emphysema related to
the EndoVac system is also advantageous in its
extravasation of the sodium hypochlorite solution during
endodontic treatment, with ecchymosis and severe swell- ability to deliver irrigants safely to working
ing of the right side of the face. These symptoms appeared length without causing their undue extrusion into
after a root canal treatment of the upper right canine the periapex [14, 18, 76], thereby avoiding
(Reproduced with permission from Elsevier)
NaOCl incidents. It is important to note that it is
possible to create positive pressure in the pulp
which extrusion of the irrigant occurred and the canal if the MDT is misused, which would create
irrigant then found its way into the venous com- the risk of a NaOCl incident. The manufacturer’s
plex. This would require positive pressure api- instructions must be followed for correct use of
cally exceeding the venous pressure, for which the Master Delivery Tip by never directing
the mean value is 5.88 mmHg [12]. In other towards the orifice of a canal.
words, NaOCl extrusion into the venous system In order to compare the safety of six current
is more susceptible to occur when the apical pres- intra-canal irrigation delivery devices, an in vitro
sure of irrigant is greater than 5.88 mmHg. One test was conducted using the worst-case scenario of
in vitro study, where a positive-pressure needle apical extrusion, with neutral atmospheric pressure
irrigation technique was used to mimic clinical and an open apex [14]. The study concluded that
conditions and techniques, demonstrated that the the EndoVac system did not extrude irrigant even
apical pressure generated easily exceeds the after deep intra-canal delivery and suctioning of the
value of normal venous pressure [74]. The results irrigant from the chamber to full working length,
of this study suggested that a combination of fac- whereas other devices did. The EndoActivator
tors is necessary for a severe NaOCl accident to extruded only a very small volume of irrigant, the
occur. The hypothesis that involves intravenous clinical significance of which is not known.
infusion of extruded NaOCl into the facial vein Mitchell and Baumgartner tested irrigant
via non-collapsible venous sinusoids within the (NaOCl) extrusion from a root canal sealed with a
cancellous bone has been suggested [12]. permeable agarose gel [11]. Significantly less
This does not imply that NaOCl can or should extrusion occurred using the EndoVac system
be excluded as an endodontic irrigant; in fact, its compared with positive-pressure needle irriga-

9 Apical Negative Pressure: Safety, Efficacy and Efficiency 169

tion. A well-controlled study by Gondim et al. assessed by micro computed tomography. Int Endod
J. 2001;34:221–30.
found that patients experienced less post-operative
3. Cano V, Nair PNR, Henry S, Vera J. Microbial status
pain, measured objectively and subjectively, when of apical root canal system of human mandibular first
apical negative-pressure irrigation was performed molars with primary apical periodontitis after “one-
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Pathol Oral Radiol Endod. 2005;99:231–52.
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extrusion of sodium hypochlorite using different root
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up to working length: an in vitro study. J Endod.
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A scanning electron microscopic a case report. The solvent action of of various calcium hydroxide removal techniques.30:110–2. Khademi AA. Mechanisms of antimicrobial hypochlorite extrusion during root canal treatment. Fabiani 61. Oral Radiol Endod. Int J Heat Mass Transf. 2009. 2006. Radiol Endod. Bakland LK. Oral Surg Oral Med Oral Pathol.35:891–5. Gürel M.31:96–103. Karabucak B. Maden M. Herrera H. Erdemir A. Aust Endod J. J Endod. in vitro study.29:233–9. gation. 2010. Efficacy and safety of various active irrigation ide intracanal medication on apical seal. rite extrusion during root canal treatment. 51. Alacam T. Hellstein J. 74. Torabinejad M. Kayaoglu 1985. Health Dent Prod Rep. 2005. Kenee DM. 1987. hydroxide. An experimental study 62. Efficacy and Efficiency 171 47. Petschelt A. 64. Berutti E. Senia ES. Boutsioukis C.33:186–93. Effect of EDTA. Koçak MM.9 Apical Negative Pressure: Safety. 2002. 2004. Kastrinakis Bonetti Filho I. de Sermeño RF. lowing accidental subcutaneous extrusion of sodium 55.48:5150–65.39:93–9. Zangari D. Averbach RE. and nerve damage caused by sodium hypochlorite: 56. An ex vivo evaluation of a new root canal irri. chlorite at different temperatures. Estevez R. J Endod. Silva RA. Birdsong NL. pressure: an in vitro study. Johnson JD. Allemang JD. Complications during root based root canal dressing on periapical repair in dogs: canal irrigation–literature review and case reports. 1971. Serper A. J Endod. Marini R. Cho Y. Wu MK. 59. Uzun O. E. 71. Güngüneş H. Int a histological study. Tanomaru-Filho M. Pesse AV. Effect of a calcium hydroxide. Dhir VK. J Endod. Mehdipour O. 1996.101:402–4. Hahn W.108:e46–9. Int Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Hülsmann M. Seux R. and CanalBrush agitation techniques: an water disinfection. Leonardo MR. 2012. Koçak S.39:472–6. Lopes HP. Belli S. Türker SA. 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Cytotoxic effects of NaOCI on vital tissue efecto ultrasonic irrigation.206:263–4. Int Endod J. Oral Surg Oral Med Oral Pathol Endod J. 63.36:875–9. Bowden JR. Brennan PA. Malentacca A. Güler E.9:475–9. Kim YO. type of irrigant and Educ Dent. 2013. J Endod. Silva LAB. Gambarini G. Alouini Z. Dentinal tubule penetration of root Cohenca N. model.101:104. Chow TW. Comparison 50. J Endod. da Silva LA. 65. Hislop WS. Endod J. Kim SK. When irrigation leads to litigation.38:1622–6. Water Res. activity of calcium hydroxide: a critical review.31:533–5. A quantitative assessment of efficacy 49. sonic. Anatomy 52. J Endod. Kleier DJ.28:544–6. threatening airway obstruction secondary to hypochlo- 54. Tinaz AC. Int Endod devices when used with either positive or negative J. Compend Contin PR. Usman N. 73. rite into simulated lateral canals: an in vitro study. Int Endod J. Mechanical effectiveness of root canal irri. Rosen S. van der Sluis LWM. and ultrasonic canal sealers after root canal dressing with calcium activation on the penetration of sodium hypochlo. flushing method on removing artificially placed den. 2007. 2010. Uccioli U. Pashley EL. Leonardo MR. 2009. root canal dentin. J Endod.106:e80–3. Med Oral Pathol Oral Radiol Endod. 2009. Yücel A. Br Dent J. gation technique with intracanal aspiration. Linden WJ. Wesselink of sodium hypochlorite accidents. Permanent mimic musculature 2004. medications for root canal treatment on bonding to channels. sodium hypochlorite on pulp tissue of extracted teeth. Siqueira JF. C. Van der Sluis LWM. Wesselink PR. The effect of various concentrations of final irrigation techniques in removal of calcium of sodium hypochlorite on the ability of MTAD to hydroxide.25:431–3. instrument size on root canal debridement. 2000. 53.102:680–5. Tissue damage after sodium 58. Kinetics and mechanisms of of calcium hydroxide removal by self-adjusting file. Marshall FJ. 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A review of the concepts. kill bacteria. The question is if that goal is truly mesial root of a mandibular first molar (Fig. is unable to clean and disinfect the root canal system as well as an activated irrigant. Hess’s original findings on the com- placing obturating materials. all of the removal of vital or necrotic tissue. Room 3058. Postle Hall. 10. one can see on these overlays (Fig. Columbus. This chapter reviews the use of ultrasonic. Nusstein. OH 43210. With modern sci. achievable utilizing the standard techniques we are one sees nice round canal preparations at the 1 mm currently taught. systems.M. Basrani (ed. and mechanisms will be presented as well as review of the pertinent literature to justify the use of activated end- odontic irrigants. Almost 100 years ago. the results we anticipate. Introduction these facts. DDS. microorgan. and sonic-activated irriga- tion to improve the cleaning and disinfecting of the root canal system. we have been reminded of irrigation has taken on a new importance and why there has been an increase in the research on irriga- tion. USA The ability of an irrigant to dissolve pulp tis- e-mail: Nusstein. DOI 10. However. Irrigation works at a level that endodontic J. These findings are the reason why entific technology.1).edu sue. 12th Ave. Sonic and Ultrasonic Irrigation 10 John M. However..).1@osu. current research has shown that needle-delivered irrigation. laser. irregularities. 305 W. Nusstein Abstract Cleaning and shaping of the root canal with the use of irrigants is a funda- mental principle of endodontic therapy. The ultimate goal is plexity of root canal anatomy have been recon- the complete removal and disinfection of the root firmed.3). Hess [76] apical level. walls of the canals are not touched during cleaning isms. As one looks at a cross section of the canal space.1007/978-3-319-16456-4_10 .2) that even The goal of root canal cleaning and shaping is the with our improved NiTi file systems. and their by-products and provide space for and shaping. 10. and remove smear layer are © Springer International Publishing Switzerland 2015 173 B. According to work by Peters [126]. Unfortunately the traditional Division of Endodontics. although effective. 10. a great deal of tissue is left showed us the challenges dentists face in cleaning behind in the isthmus and along the canal wall the root canal system (Fig. MS files cannot reach. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. The Ohio State University use of needle-only irrigation may not be achieving College of Dentistry.

M. 10.2 Micro CT scans of canals following rotary file instrumentation (red) overlaid preoperative scans (green) [126] well known and reported in the literature. root canal with standard needle irrigation (using ers. Nusstein Fig.1 Hess [76] intricacies of canal anatomy a b c Fig.174 J. Research has shown that the preparation sodium hypochlorite – NaOCl) and even . 10. Some (hand files and/or rotary NiTi files) of an infected irrigants are better suited for some jobs than oth.

138. 69. the use of ultrasonics in root the isthmuses and canal ramifications [28]. 82. mentation techniques [16. canal system. ultrasound removes more tissue from the canal film. The ultrasonically energized file was a benefit if the needle cannot reach the apex of reported to rapidly instrument the canal wall the root canal but a drawback if it does (potential more efficiently with less operator fatigue.10 Sonic and Ultrasonic Irrigation 175 complete cleaning of the root canal system. preparation and debridement in root canal ther- Open-ended or beveled needles deliver fluid at a apy. This endosonic method. lateral canals. 67. 170]). 38. Of that group. Unfortunately. method of instrumentation did not support the This pressure may be of benefit in cleaning the claims of Martin and Cunningham [107] that canal walls by dislodging material such as bio.3 Cross section of mesial root of mandibular molar demonstrating remaining tissue following root canal preparation utilizing NiTi rotary files [73] Ultrasonic Activation placement of calcium hydroxide greatly reduces Richman [128] first reported the application of the number of viable bacteria in the canal [29. Also. 73. these cases were treated without untoward post- Removal of biofilm is also limited. 39. The irrigation accident). 74. 142. canal therapy held great promise. The side-ported needles “ultrasonically activated” irrigant facilitated allow solution to only reach about 1 mm past the cleansing and disinfecting actions within the root end of the tip and still have similar risks and ben. Cunningham [48–50. 30. Shen et al. when antibacterial effects were evaluated. 22. Martin and have also been described in the endodontic litera. A survey conducted by Dutner et al. Martin and Cunningham [106] concluded have their maximum velocity at the site of the that endosonic root canal preparation was supe- port and the energy dissipates apically. [140] Other studies of ultrasound as a primary also calculated the fluid pressure of the irrigant. 94. and its effect on extrusion of from the canal walls. fluid wall pressure) 92. ously shown that traditional needle irrigation no difference was found between the two instru- fails to clean isthmuses. Activation of the endodontic irri. velocity. it does not eliminate all of them. 154] found no difference in tissue removal are all affected by the fluid flow rate placed into between ultrasound and hand instrumentation. disinfection. 121. instrumentation was not found to be superior to gant appears to be a necessary step in the more hand instrumentation. These studies [52. Of course the three dynamic parameters than hand instrumentation. [65] on the use of irrigants and adjunctive devices to aid irriga- tion found that almost 50 % of respondents use some type of irrigation aid. The studies evaluated the efficacy of the quicker pace than side-vented needles. efits of the open-ended needles. 60]. 46. [140] described how the velocity use of ultrasound as a primary method of canal of fluid flow is affected by the needle design. its ability to eliminate bacte- increase in velocity may aid in removing debris ria from the canal. 132. This is shaping. The flow characteristics of various size and In a series of articles published in the end- shaped needles (open-ended versus side-vented) odontic literature from 1976 to 1985. 151. The overall per- de-sacs to any extent ([15. especially in operative sequelae. formance of ultrasound as a primary method of 112. 53. Fig. and cul. rior to hand preparation in mechanical and chem- ended/beveled needles deliver irrigation solution ical debridement. research has continu. However. There was also a reported . He used a Cavitron® 31. The side-ported needles debris. 144. 48 % used ultrasonics and 34 % utilized some form of sonic (subsonic) activation. Open. (fluid flow pattern. and final canal about 1–2 mm past the end of the needle. Shen et al. the needle. ultrasonics in endodontics. 10. 125. ultrasonic dental unit and concluded that since 145]. 104–109] reported on the ture.

there was no statistically significant differ- an object requires dissolving a contaminant ence between ultrasonic and hand instrumentation (removing substance/object from a wall and put. This detection system monitored the When an ultrasonic wave is projected in liq. This collapse creates a pressure. These spheres were illuminated so waves continue. ° C and pressures that exceed 500 atmo. ultrasonic cavitation implosion effect is incredi- Martin and Cunningham [106] attributed the bly effective in doing this. Combined with small gas bubbles set into oscillation by the fluc- these effects of cavitation is a dispersal of physi. Additionally. It was also . were divided into four groups and instrumented powered shockwaves that dissipate repeatedly at either by hand or ultrasonically (Cavi-Endo®). The canals.M. The cavitation implo- success of ultrasonic instrumentation to the inter.tmasc. However. Forty extracted maxillary anterior teeth violent implosion. when either water or sodium hypochlorite was ting it into solution) and then displacing the satu.5 % sodium hypochlorite 30 kHz). layer using a scanning electron microscope spheres. negative pressure is created and causes the tion bubbles. tuating pressure field generated by the ultrasonic cal energy which leads to physical acoustic file. which vigor. a process known as cavitation. The authors con- rated layer of the contaminant so that fresh cluded that acoustic streaming was more impor- cleaning solution can come in contact with the tant to cleaning than cavitation.” The irrigating solution achieves gation alone.000 ~ 30. com) [21. tion system. These terms were combined effect of the ultrasonic instrument. light produced by the violent collapse of cavita- uid. cavitation. Cleaning ated. because the rapid vortex-like motion associated ously agitates the irrigating solution. The group looked at transient cavitation (sound wave) streaming. cessible through conventional means such as irri- gistic system. duced when a scaler tip was inserted into the unit. Nusstein increase risk in straightening and perforating unsaturated surface of the contaminant. as an irrigating solution. derived from the ultra-high-frequency oscillation When the amount of remaining debris was evalu- of the ultrasonic tip/file placed in a fluid. The oscillatory acoustic streaming. [2] investigated the phenomena of cavita- and acoustic streaming. It was determined that transient cavita- the implosion travel at speeds over 500 mph tion did not occur with the Cavi-Endo® unit and within the fluid and this current is called acoustic endosonic files. The authors defined the involved in ultrasonic instrumentation. The implosions radiate high. As the ultrasonic streaming. as described by Martin and vacuum effect which cleans irregularities in Cunningham [106].000 times per second (25– using either water or 2. They called this interaction the “syner. sion effect is especially effective on unsmooth action of the ultrasonic energy and the irrigating and out of reach surfaces that are normally inac- solution. is defined as with the vibrating file can also be associated with resonant or stable cavitation. its active biological-chemical effects when it To gain an insight into the mechanisms undergoes ultrasonation. a rate of 25. Ahmad primary effects of ultrasound as being cavitation et al. This acoustic streaming using a photometric-sensitive image intensifica- purportedly enhances cleansing and disinfection. A rectangular container filled with liquid to fracture. used as an irrigating solution. the implosion of cavita. In this initial study. eventually collapsing in a detected. cavitation was pro- streaming (www.176 J. 157]. methylene blue dye and a dispersed film of poly- Cavitation creates bubbles that oscillate in the styrene spheres was used to detect acoustic projected ultrasonic waves. these bubbles grow larger and that patterns of acoustic streaming could be become very unstable. with the phenomenon of canals and kills microorganisms. The teeth were split lon- tion bubbles creates temperatures that exceed gitudinally and evaluated for presence of a smear 5. Transient cavitation was tion and acoustic streaming as seen within the said to occur when the ultrasonic energy creates a root canal space. the authors bubble which grows to a certain point and then combined the phenomenon of resonant or stable collapses. Acoustic streaming can also be The endosonic files produced acoustic streaming. The shock waves that are generated by (SEM).

[2]. Twenty extracted maxillary anterior teeth were divided into two groups and instrumented with the sec- ond group using a modified technique in which a #15 endosonic file was allowed to freely vibrate Fig. The authors concluded that cavita- files generated relatively greater acoustic stream. resulting in enhanced cleansing action. and a superim. Smaller root canals. hydrodynamic shear stress was proportional to erated by the #15 and 20 endosonic files. 10. The authors defined acoustic stream- ing as the generation of time-independent. The power generated by the files was estimated by measur- ing the transverse displacement amplitudes that were produced. the velocity of which increased with mechanism in root canal debridement. as he concluded that cavi- cleaner surfaces. Canals instrumented sound in root canal treatment. 10. The authors concluded that the tation had little if any bearing on the debridement . His results agreed with the modified method were found to exhibit with Ahmad et al. [166] also investigated the mechanisms of ultra- firmed by Jiang et al. The results showed endosonic file [3] that each file generated an acoustic streaming field comprised of a primary field consisting of rapidly moving eddies in which the fluid element freely vibrating file produced hydrodynamic oscillated about a mean position. the direction of rotation of the fluid deduced that since streaming velocity was high- elements in each eddy was opposite to that of its est at the apical tip of the file. steady unidirectional circulation of fluid in the vicinity of a small vibrating object. [3] continued the investigation of ultrasonic debridement by examining acoustic streaming. In another investigation into the mechanisms ported from the apical to coronal end of the file. different size files were studied at different power settings. Using the same method to detect acoustic streaming as described in the previous study [2]. These results were later con. tion should not be regarded as an important ing. of ultrasound.4). relatively slow.10 Sonic and Ultrasonic Irrigation 177 concluded that the recommended technique of ultrasonic instrumentation did not produce suffi- cient acoustic streaming to effectively clean the canal. Fluid was generally trans. [4] examined the The streaming velocity was greatest at the apical effects of acoustic cavitation in debridement of and least at the coronal end of the file. a concentration of immediate neighbor. Dampening of the files may have caused the limitation in the production of acoustic streaming in the constricted canal system. Ahmad et al. the file (Fig.5). Ahmad et al. time-independent flow (Fig. the authors primary field. Therefore. Walmsley increased power. shear stresses large enough to remove debris and posed secondary field consisting of patterns of the smear layer from the walls of the root canal. In the streaming velocity. The secondary field showed stresses in the vicinity of the tip facilitated symmetrical longitudinal flows on both sides of debridement. 10. Transverse displacement ampli- tude was defined as half of the total distance moved by the pinpoint of light that appeared as a thin transverse line when a file oscillated. This Approximately four clusters of eddies were gen. [83].4 Photo of acoustic streaming around a size 15 at working length for 5 min.

178 J.M. Nusstein

ever, Jiang et al. [83] and Macedo et al. [97]
showed that, within a simulated root canal sys-
tem, cavitation did occur around the tip of an
ultrasonically activated file, but that canal size (in
relation to the file size) did impact the amount of
cavitation produced.
Ahmad et al. [5] also reported that ultrasonic
files can generate acoustic streaming both in the
free field and in a small channel. Higher-velocity
streaming was observed when smaller size files
were employed and when the file was precurved
(for curved canals). Light file-wall contact did
not totally inhibit streaming, while severe file-
wall contact inhibited movement of the file and,
as a result, no streaming was observed. The
positions and length scales of the streaming vor-
tices appeared to be influenced by the presence
of boundaries. In the free field, two rows of vor-
tices were situated along the sides of the file
(Fig. 10.6a), while in the small channel, the vor-
tices were positioned above the surface of the
file (Fig. 10.6b). These results indicated that it is
possible for acoustic streaming to occur in a
confined space, as in a root canal, provided that
severe file-wall contact is avoided. They recom-
mended that allowing the file to freely vibrate
during some stage of treatment should be car-
Fig. 10.5 Depiction of the waves generated around the ried out in order to generate streaming in the
vibrating ultrasonic file (ACTEON North America/
Clinical Research Dental)
root canal.
Roy et al. [133] used sonoluminescence as
an indicator of transient cavitation activity and
activity of ultrasound. This conclusion was based photographic analysis was utilized as a means
on his postulation that although the displacement for detecting steady streaming, microstream-
amplitudes of the vibrating file were adequate to ing, and stable cavitation with ultrasonic files.
produce cavitation, the streamlined shape of the Measurements failed to indicate any strong cor-
endosonic file was not conducive to generating a relation between registered driving power and
sound pressure field large enough to produce the propensity to produce transient cavitation.
cavitation. Walmsley [167] also concluded that Files that were pitted or possessed salient edges
because of the transverse nature of the vibration were very effective at generating transient cavita-
pattern of the activated file, the effectiveness of tion. When observed, transient cavitation activ-
ultrasonic instrumentation is limited by the ity generally occurred near the tip of the straight
dampening of the file against the root canal wall. file, provided the wall loading did not inhibit
Acoustic streaming is an effective mechanism in file motion. In all cases studied, steady acoustic
disrupting debris within the canals but is reduced streaming and stable cavitation were observed
when loading occurs against canal walls. Also, to varying degrees, depending on the amount of
the synergistic activity of ultrasound and the irri- file to wall contact. Although the imposition of
gating solution does not take place when the file file-wall contact served to inhibit the production
is not allowed to vibrate freely. Recently how- of transient cavitation, this action had relatively

10 Sonic and Ultrasonic Irrigation 179

Fig. 10.6 (a) Acoustic a b
streaming as generated
around a free-moving file and
(b) within a simulated root
canal space [5]

little effect on the ability of a file to produce a trical current (AC) from the ultrasonic generator is
nominal level of streaming, microstreaming, and first converted into an alternating magnetic field
stable cavitation. They concluded that it was not through the use of a coil of wire inside the ultra-
prudent to ascribe enhanced cleaning effects to sonic handpiece. The alternating magnetic field is
any one phenomenon, for it is likely that sev- then used to induce mechanical vibrations at an
eral factors are involved to varying degrees ultrasonic frequency in resonant strips of nickel or
depending on the local conditions of application. other magnetostrictive material that are attached to
Boutsioukis et al. [26] confirmed that an ultra- the surface to be vibrated [45]. Because magneto-
sonically activated file contacts the root canal strictive materials behave identically to a magnetic
wall at least 20 % of time during activation. They field of either polarity, the frequency of the electri-
reported that the depth of penetration of the file, cal energy applied to the transducer (coiled wire)
the power utilized to activate the file, and the is half of the desired output frequency. This form
size of the root canal preparation all affected the of ultrasonic generation requires two transforma-
amount of contact. However, they did report that tions of energy: electrical to magnetic and mag-
cavitation in the fluid was detected even though netic to mechanical. During these energy
there was file-wall contact. transformations, heat is generated as energy is lost.
Therefore, the efficiency of this type of generator
is affected (as low as 50 %) and cooling measures
Ultrasonic Energy Generation are required to dissipate the heat generated. The
frequency at which magnetostrictive generators
There are two main types of ultrasonic energy gen- operate is also limited. Due to size restrictions,
erators used in dentistry which differ in their mode they operate below 30 KHz [45]. To increase the
of operations. The magnetostrictive generator uti- frequency would require enlarging the wire coils
lizes the principle of magnetostriction in which and resonant metal strips, as well as increase the
certain materials expand and contract when placed need for cooling, to the point of clinical
in an alternating magnetic field. Alternating elec- infeasibility.

180 J.M. Nusstein

The piezoelectric generator, on the other hand, terms can and will be used interchangeably in the
converts AC electrical energy directly into dental literature and that they represent the same
mechanical energy through the use of the general technique.
piezoelectric effect. When electrical energy is Research into PUI/UAI has looked at the abil-
applied to ceramic piezoelectric materials (i.e., ity of the technique to remove tissue and debris,
barium titanate or lead zirconate titanate), there is bacteria, biofilm, calcium hydroxide and other
a conversion and amplification of electrical medicaments, and smear layer. Research has also
energy into mechanical energy by way of vibra- looked at the impact of using PUI/UAI in curved
tion of the material within the ultrasonic hand- canals, the use of a smooth instrument versus an
piece. This vibration is then directly transmitted endodontic file, and the effects the size of the
into the ultrasonic tip. This method allows piezo- instrument and canal preparation size have on
electric transducers to operate well into the cleaning/debridement results. In general, PUI/
megahertz frequency range. Piezoelectric gener- UAI consists of the use of a size 15 or 20
ators are more efficient (95 %) than magneto- endodontic-type file or wire attached to an ultra-
strictive units due to the fact that magnetostrictive sonic handpiece from which ultrasonic energy is
units require the two conversions of energy [45]. supplied. The depth of the file within the canal
and the manner in which irrigating solution is
supplied during the process has also been
Passive Ultrasonic Irrigation (PUI)/ evaluated.
Ultrasonically Activated Available products that a clinician can utilize
Irrigation (UAI) to provide PUI/UAI include file-holder tips
(Brasseler). These tips allow for the insertion of a
The terminology for the activation of irrigat- hand file (k-type file, r-type file, spreader, etc.) or
ing fluids in root canals can be a bit confusing. a specially designed hand file-type inserts (dia-
Weller et al. [168] compared the efficacy of ultra-
sonics as a primary method of instrumentation
and as an adjunct to hand instrumentation versus
hand instrumentation alone. The authors con-
cluded that ultrasonic instrumentation is not an
alternative to hand cleaning but acts as an aid to
increase debridement efficacy after hand instru-
mentation. In this study, the ultrasonic instrument
was still used as an adjunct in canal prepara-
tion. Later research [12, 36, 69, 74, 82, 94, 112]
looked at the use of ultrasonic instrumentation
in a more passive manner, that is, it was utilized
after hand instrumentation and without the intent
to enlarge, instrument, or impact the walls of
the root canal. Thus, the term passive ultrasonic
irrigation (PUI) came to be. The “passive” por-
tion indicated no active or intentional removal
of dentin. Unfortunately, even though no intent
is made to contact or alter the root canal walls,
contact of the oscillating ultrasonic instrument
on the wall occurs (see above). Due to this, the
phrase ultrasonically activated irrigation (UAI)
was recently suggested by Boutsioukis et al. [26].
Unfortunately the reader must be aware that these Fig. 10.7 Brasseler file holder E12 (Brasseler)

10 Sonic and Ultrasonic Irrigation 181

UAI per canal (using NaOCl as an irrigant) signif-
icantly improved the cleanliness of the isthmuses
of the mesial roots of mandibular molars in vitro
at the 1 and 3 mm levels from the canal apex.
Metzler and Montgomery [112] found similar
results using 2 min of PUI/UAI. Cameron [36]
also reported that canals had less tissue and
debris following the use of EDTAC/NaOCl and
1.5 min of PUI/UAI in vitro. These studies were
followed up by Haidet et al. [74] and Archer et al.
[12] who studied the use of 3 min of PUI/UAI
per canal in vivo following hand instrumentation
Fig. 10.8 Satelec Acteon Irrisafe™ tips. Note serrated and found that isthmus and canal cleanliness was
wire with non-cutting sides and irrigation port near attach-
ment hub (Satelec) significantly improved at the levels 1–3 mm from
the apex as compared to needle irrigation with
Utilizing ex vivo models with artificially pre-
pared grooves, different preparation tapers, and
lateral canals filled with dentin debris, various
studies have shown that PUI/UAI improved
debris removal from the hard-to-reach areas.
Fig. 10.9 Satelec Sonofile with no irrigation port (Tulsa Looking at the influence of the size of the canal
Dental Products) preparation on cleaning with PUI/UAI, Lee et al.
[92, 93] and van der Sluis et al. [162] reported
mond coated, fluted, smooth-sided, etc.) and that the greater the taper of the canal, the more
secured for use in the canal (Fig. 10.7). Also debris that is removed with the PUI/UAI file.
available is the Irrisafe™ ultrasonic tip (Fig. 10.8) Rödig et al. [129, 130], however, found that api-
produced by Satelec Acteon which comes in dif- cal size had no impact on canal cleanliness when
ferent lengths and diameters and includes a port utilizing PUI/UAI. This result contradicted find-
for the delivery of irrigating fluid, and the ings that larger apical preparations improved the
Sonofile tips (Fig. 10.9) by Satelec which are efficacy of NaOCl [79]. In another study, van der
similar to the Irrisafe™ files but without the irri- Sluis [163] reported that a smooth wire (such as a
gation port. finger plugger placed in a file holder) could
remove debris as well as a file design. This sup-
ported the previous work of Cameron [34] and
Debris and Smear Layer Removal Goodman et al. [69]. Jiang et al. [84] reported
that the direction the ultrasonic file oscillated
The effectiveness of PUI/UAI following canal may affect cleaning. They stated that improved
preparation to remove tissue and debris has been results were achieved when the vibration was
extensively studied. In general, PUI/UAI has directed at the site of a groove to be cleaned. In
been reported to be more effective than simple terms of irrigant penetration, several studies have
syringe and needle irrigation. As previously looked at the ability of PUI/UAI to improve the
stated, Weller et al. [168] was the first to report dispersement of an irrigant into lateral canals. De
on the benefits of ultrasonic activation of irrigant Gregorio et al. [55] reported that irrigant pene-
following hand instrumentation. They reported trated artificially made lateral canals much better
that the combination was superior to either tech- when PUI/UAI was utilized than needle irriga-
nique alone. Goodman et al. [69] and Lev at al. tion or negative pressure irrigation. Spoorthy
[94] reported that the addition of 3 min of PUI/ et al. [148] reported similar results. Al-Jadaa

182 J.M. Nusstein

et al. [8] reported similar results (improved debris of a large area of canal wall are evaluated and,
removal from artificial lateral canals) between often, different conditions can appear on the
PUI/UAI and needle irrigation when controlling same image. This makes grading of the images
for the increase in temperature of the NaOCl difficult and potentially unreliable depending on
irrigant (approximately 30 ° C) caused by the the evaluators and the number of images
ultrasonic activation. evaluated.
Clinically, these studies can be translated into The amount of irrigant, delivery method, and
improved canal cleanliness in the areas generally delivery time of irrigants has also been evaluated.
untouched by hand and/or rotary files, i.e., Intermittent flushing is a more popular method as
isthmuses, lateral canals, canal fins, and cul-de- compared to external continuous flushing for
sacs. In vivo research has indicated that isth- PUI/UAI. A new method for continuous irriga-
muses and canals are more thoroughly cleaned tion utilizing an ultrasonically activated needle
when PUI/UAI is utilized following canal prepa- was developed and will be discussed later in the
ration [12, 74, 112]. Empirically, this increased chapter. The intermittent flushing process encom-
ability to remove debris and tissue should lead to passes the use of an irrigating needle/syringe
improved clinical outcomes. An initial study by which is utilized to initially fill the root canal and
Liang et al. [95], evaluating 86 patients 10–19 access opening with irrigant and then replenish
months after root canal treatment, showed an the irrigant after applications of ultrasonic energy
improvement in the reduction and resolution of within the canal. This technique is more time
apical pathosis following the use of PUI/UAI consuming due to the stop-and-go process. The
compared to needle irrigation. However, the dif- need to replenish the irrigant is due to the fact
ference was not found to be significant. More that dentin debris, tissue, bacteria, and biofilm
research with longer follow-up times is needed. saturate the irrigating solution and increase the
In terms of smear layer removal, results have viscosity of the solution to the point where no
varied with slightly more studies indicating that ultrasonic activity may occur in the solution. This
PUI/UAI helps remove smear layer. These varied effect was reported by Weller [168] and Moorer
results may be due to the use of different types and Wesselink [115]. Research has shown that
and concentrations of irrigants. When NaOCl refreshing NaOCl during PUI/UAI increases the
was utilized alone, studies have reported almost reaction of NaOCl [98, 161] and improves clean-
complete smear layer removal from various lev- ing of canals. These studies also indicated that an
els of the root canal [7, 33, 34, 35, 81, 159]. increase in the time of exposure of the canals to
These studies, again, utilized various concentra- PUI/UAI improved cleanliness in ex vivo
tions of NaOCl, ranging from 0.5 to 12 %, and models.
different exposure times to the ultrasonic energy Continuous flushing of irrigant, as achieved
(10 s to 5 min). When NaOCl was combined with by utilizing the Irrisafe™ tips with its irrigation
EDTA, the research has shown a marked improve- ports, requires a delivery system that is able to
ment in smear layer removal [11, 20, 66, 90]. direct irrigant into the tooth and allow for replace-
Several studies, however, did not find PUI/UAI to ment of saturated or contaminated irrigant.
be very effective in removing smear layer even Ideally the irrigant replacement should occur to
when NaOCl and EDTA were utilized [1, 42, 44, the level of root canal apex. Also, the formation
134, 156]. The use of water as an irrigant has of aerosol as the irrigant contacts the coronal
been reported not to enhance smear layer removal aspect of the ultrasonic file may lead to patient
with the addition of PUI/UAI ([33, 34, 75, 159]). exposure to the NaOCl beyond the rubber dam or
This would indicate that the cavitation and acous- by inhalation. Unfortunately research has shown
tic streaming effects alone cannot account for that with this type of system the time of exposure
smear layer removal. The difficulty in studying plays a more critical factor since extra time is
smear layer removal is that it relies on the assess- needed to completely flush the canals in a rather
ment of SEM images. Only very small portions uncontrolled manner [64, 121]. Lev et al. [94]

10 Sonic and Ultrasonic Irrigation 183

reported that, in terms of cleaning, 1 min of PUI/ results when comparing the use of straight, pre-
UAI per canal was equivalent to 3 min per canal bent, and NiTi ultrasonic files placed within
for canal cleanliness, but that 3 min provided 1 mm of the apex of straight and curved canals. In
cleaner isthmuses when utilizing a continual this study, the use of the NiTi file resulted in bet-
flushing system. Further research into the effect ter debris removal and less transportation versus
of time is needed when more standard PUI/UAI the straight and precurved stainless steel files/
techniques are developed. The size of the end- wires.
odontic access opening may also play a factor in
the ability of the irrigant to reach the canal.
However, no research has looked at this. Bacteria/Biofilm Removal
Studies looking at the use of PUI/UAI to
remove either calcium hydroxide or other paste The removal or reduction in the number of bacte-
fillers from root canals have given mixed results. ria within the root canal system is one of the pri-
Complete removal of a medicament is necessary mary goals of endodontic therapy. The utilization
since there is a potential to prevent sealing of the of ultrasonically activated irrigation to achieve
canal due to interference with the filling material this goal has been researched. A large number of
by the remaining paste [47, 77, 102]. The addi- studies have reported a significant reduction in the
tion of PUI/UAI to remove calcium hydroxide number of bacteria (as measured by colony form-
and Ledermix was found to improve overall ing units – CFU’s) following the use of PUI/UAI
removal, but did not assure complete removal of [6, 16, 32, 60, 81, 103, 146, 147, 158] when com-
all material [131]. Wisemann et al. [169] reported pared to needle irrigation. Only one study failed
similar results. Capar et al. [37] reported that to show an improvement in CFU reduction [143].
PUI/UAI removed significantly more calcium The above studies concentrated on the reduc-
hydroxide from artificial grooves in the apical tion of free bacteria (planktonic) and not the
third of the root canal as compared to needle irri- removal of biofilm. The impact of PUI/UAI on
gation. Complete removal of the paste was not removing biofilms has also been evaluated, but to
achieved. a lesser extent. Bhuva et al. [17] reported no
The impact of canal curvature on the effective- improvement in removal when utilizing an artifi-
ness of PUI/UAI has also been reported. cially produced biofilm of E. faecalis. Shen et al.
Significantly improved cleaning of canals and [140] reported an increase in killing of artificial
isthmuses occurred at the apical 5 mm in curved biofilm when PUI/UAI was utilized with
canals versus needle irrigation [69, 82, 112, 135]. chlorhexidine on dentin discs. Case et al. [40]
Malki et al. [100] report that the flow of irrigant reported similar results when testing ozone – PUI/
beyond the ultrasonic file tip was not affected by UAI helped reduce E. faecalis biofilm. Gründling
curvature of the canal. Ahmad et al. [5] and et al. [71] reported that PUI/UAI helped reduce E.
Lumley et al. [96] reported improved efficacy faecalis biofilm only when NaOCl was used as an
when pre-bent files were utilized for PUI/ irrigant. Joyce et al. [86] looked at the mechanism
UAI. Amato et al. [10] reported better cleaning of of action of ultrasonics on biofilm and stated that
artificially made lateral canals in teeth with PUI/ PUI/UAI caused deagglomeration of the biofilm
UAI in both straight and curved canals as com- via the cavitation effect.
pared to needle irrigation. However, better clean-
ing was observed in the straight canals. This
could be due to the fact that the ultrasonic file Safety
was placed within 1 mm of the apex and con-
tacted the inner wall of the canal at the curvature The potential risk of extrusion of debris and irrig-
and the outer wall near the apex therefore leading ant during the use of PUI/UAI has been evalu-
to diminished or restricted ultrasonic activation ated. Malki et al. [100] reported that fluid
of the irrigant. Al-Jadaa et al. [9] reported similar movement and cleaning extends 3 mm beyond

Research utilizing the commercial tips has ing times of 1 min per canal with 5. [28] from the apex. Munoz et al. The Piezoflow tip is a 25-gauge. [150] and Mitchel et al. However extrusion did occur when the file was placed within 1 mm of the apex. [73]. this group irrigants in the canals and the problems reported prepared and cleaned the mesial root canals simi- with continuous flushing.12) and Vista ous ultrasonic irrigation (CUI). tures and reduction of CFU’s compared to canal ment became an issue. stained. been rather limited and has looked at the efficacy . 10. Malentacca et al. [12] on mandibular Burleson et al. Piezoflow™ Ultrasonic tip (Fig. In vivo studies by Haidet preparation alone with needle irrigation (NaOCl). [73] published the first study (Fig.13). This did not include any time utilized to replenish Using necrotic mandibular molars. CUI in necrotic mandibular molars. of binding of the needle.04) than 1–2 mm short of PUI/UAI in the literature. reported less apical extrusion of irrigant versus needle irrigation. [74] and Archer et al. This 3 min technique lar to Gutarts et al. Tasdemir et al. [28] utilized the same device/ molars utilized 3 min cleaning cycles per canal. [39].10). Dental Products StreamClean™ Flo-thru tip Gutarts et al. vital mandibular molar mesial roots. 10. technique to look at in vivo biofilm removal. [73] and extracted. lead to the development of an ultrasonically acti. blunt-ended stainless steel needle. when the PUI/UAI file was kept at 3 and 5 mm Carver et al. Currently there are two products commer- vated irrigating needle which could simultane. et al. These issues to needle irrigation (Fig.184 J. Continuous Ultrasonic This study was followed by Carver et al. in NiTi tube with external serrations.10 CUI system used by Gutarts et al. [39] Irrigation (CUI) who looked at the in vivo removal of planktonic bacteria using the same treatment technique and As PUI/UAI was reported to improve the cleanli. 165] stated that maintaining apical patency is important to allow irrigant to reach the canal apex during PUI/UAI. [99] reported no extrusion of irrigant out the root apex Fig. No reports have been made of sodium Placement of the needle was no deeper within the hypochlorite accidents occurring during the use prepared canals (size 30/. 10. 10. Vera et al. mandibular molar. Tambe et al. and irrigat. This group ness of root canals and canal isthmuses. Another problem that was pre. [164. while the Their in vivo results indicated cleaner canals and StreamClean™ tip is a 30-gauge blunt-ended canal isthmuses within 3 mm of the canal apex. using this customized ultrasonic tip (Fig.11). Nusstein the ultrasonic file tip. Burleson et al.25 % NaOCl. cially available for clinical use to provide CUI: ously activate and replenish irrigant deep within Dentsply Tulsa Dental Specialties ProUltra® the canals. [116] reported that the use of PUI/UAI does transport irrigant solution to the apex of the root canal. They reported significantly cleaner canals and viously noted was the potential for straightening isthmuses following the use of CUI as compared of curved canals and file breakage. the issue reported a significant increase in negative cul- of time for the technique and irrigant replenish. This system was designated continu.M. [113] both reported more extrusion of irrigant and debris out the apex of the root canal following the use of PUI/UAI as compared to needle irrigation. A 25-gauge needle was utilized and 15 ml of irrigant was delivered over the 1 min of continuous ultrasonic activation. 10. how- ever. [153]. could add almost 15 min of treatment time to a and sectioned the roots from the apical 1–3 mm.

[41] reported that CUI same system but attaching suction to the ultra- with the Piezoflow™ tip was more effective than sonic tip and placing irrigant in the pulp chamber PUI/UAI in getting irrigant into lateral canals.13 Vista Dental StreamClean™ Flo-thru tip Piezoflow™ Ultrasonic tip (Dentsply Tulsa Dental) (Vista) and safety of CUI. In terms of safety. set-up) extruded more irrigant UAI. resulted in significant irrigant extrusion beyond Curtis and Sedgley [51] also reported cleaner the apex when placed within 5 mm of the apex.10 Sonic and Ultrasonic Irrigation 185 Fig. canals at the 1–3 mm level from the apex using Placement beyond this length does not follow the the StreamClean™ tip compared to needle irriga. hydroxide better than needle irrigation. 10. However. Castelo-Baz et al. Utilizing this tion. tip cleaned canals and isthmuses better than nee. Desai and Piezoflow™ tip removed pulp tissue significantly Himel [61] reported that the use of CUI (using better than needle irrigation and PUI/ the Burleson et al. [173] reported that differences in debris removal with the CUI with the Piezoflow™ tip removed calcium Piezoflow™ tip over needle irrigation. [99] reported that the use of the Piezoflow™ tip dle irrigation in extracted mandibular molars.12 Dentsply Tulsa Dental Specialties ProUltra® Fig. 2006) Fig. [78] reported no out the root apex than needle irrigation. Pafford .e.11 Photomicrograph of cross section at the 2. (similar to the EndoVac system by SybronEndo) Malentacca et al. Malentacca et al. (b) CUI group (magnifica- tion: 40 ×) (Burleson Master’s thesis. manufacturer’s recommendations. 10.0 mm B level – (a) Needle irrigation group (magnification: 100 ×). Yücel et al. 10. i. Yoo et al. [99] reported that CUI with the proved to be extremely safe [99].. extrusion of debris [172] reported that CUI with the StreamClean™ irrigant past the canal apex. Howard et al.

M. 10. issues have arisen in and Brilliant [137] reported that radiopaque dye terms of potential damage to the root canal wall infused irrigant extruded out the apex of vital and dentin. Nusstein [118] reported. the debate over an (similar to ultrasonics). disinfection. in a clinical study using the maintained with a size 10 file during NiTi rotary prototype Piezoflow™ tip. of PUI/UAI. Vapor lock is reported to occur due to preparation size. Since there are multiple unfortunate ing the use of CUI in vital and necrotic posterior reports of NaOCl accidents in the literature. No sodium hypochlorite accidents have may presume that the in vivo status of the root been reported in the literature during the use of canal system is open unless it becomes blocked a CUI system. [155] reported Laser-Activated Irrigation (LAI) that this effect occurred in the root canal and therefore apical cleaning was impossible Activation or agitation of root canal irrigants via (Fig. little or no intra. 10. [164] explained that irrigant can reach of the laser tip. overheating of the root and periodontium.186 J. This phenomenon may be a factor the use of lasers is a relatively new concept in that can be controlled in the lab by either sealing endodontics. access around the canal curvatures.14). [63]. Arrow shows that the fluid reaches the apex of the root in an open system . Boutsioukis et al.14 Apical bubble due to vapor lock [155]. and the size Vera et al. and smear open versus closed system remains. clinically. However. the apex of a root (in vivo) when apical patency is Fig. with dentin or tissue debris and patency is not Debate has developed if ultrasonic activation maintained. [55] and Tay et al. one teeth. De Gregorio et al. Previous work with laser has the apex of an extracted tooth or by maintaining focused on direct canal cleaning and shaping patency. necrotic teeth during hand filing preparation. using an open-ended needle and the root end being enclosed by the boney socket temporarily increasing fluid flow rate of the irrig- which results in gas entrapment at its closed end ant within the root canal. It was first reported in the engi- neering literature by Dovgyallo et al. increasing apical vapor lock. However.or preparation of canals with or without the utilization postoperative treatment pain during and follow. during irrigation. [24] reported that actually is capable of cleaning the apical portions vapor lock can be removed by increasing the of the root canal due to a phenomenon known as depth of needle penetration. Salzgeber layer removal.

Zhu et al. removal of the biofilm or bacteria. The vaporized water reducing CFUs. but the difference in cleaning compared to ilar to that of PUI/UAI and CUI and hence the needle irrigation was not significant. the cleaning effect of LAI is very sim. is that the laser tip is not placed within the root De Groot et al. Matsumoto et al. [171] also reported expanded forming a void (bubble) as the irradia. in the literature for a similar process is photon. Er:YAG laser. but not complete collapse resulting in acoustic waves which trav. [110] detailed the chlorhexidine) to remove E. 10. irrigating fluids. Deleu et al. laser was superior to PUI/UAI in a similar model. better results with needle irrigation versus the use tion continued and heated more water on the of LAI. the bubble began to shrink.Cr:YSGG (erbium. NaOCl. Kaptan et al. firmed by Blanken et al. They reported that this ter at removing E. cussed) which result in cleaning of the canal by [88] reported an improvement in calcium hydrox- shearing debris off the walls (Fig. tation.15 Development of cavitation bubble 750 μs following activation of laser [57] . most studies utilizing LAI the effects of using an Er. Another term seen hydroxide remained in the canals. Peters et al. [56] reported LAI with an Er:YAG canal but only placed at the canal orifice [62].15). SEM when compared to PUI/UAI and sonic agi- sion of gas bubbles) effects. In terms of bacte. [136] reported the addition of LAI that improved and Matsumoto et al. [13] also reported superior debris disinfecting potential of LAI. who utilized an the effects of irrigating solutions (EDTA. [57]. have shown an improvement in the removal of chromium-yttrium-scandium-garnett) laser on artificially placed biofilms of E. Zhu et al. also benefitted from the use of LAI. [174] found no improvement canal (water in their study) instantly vaporized with LAI (versus needle irrigation) in terms of (1 μs) next to the laser tip. but the reported increased disinfection with the use of pressure of the surrounding fluid caused a violent LAI compared to PUI/UAI. [117] reported improved diate fluid movement after each laser pulse and biofilm removal from dentin discs viewed under they visualized cavitation (expansion and implo. It is these waves (as previously dis. Yavari et al. [59] reported that the use of Er:YAG laser with a induced photoacoustic streaming (PIPS). They stated that there was imme. ide paste removal following the use of Er:YAG Therefore. [110]. [139] found that LAI was bet- inner surface of the void.10 Sonic and Ultrasonic Irrigation 187 Blanken and Verdaasdonk [19] first reported ria/biofilm removal. [127] pulse ceased. faecalis biofilm. plain tip was the best method to remove dentin ference in this technique over the LAI techniques debris from artificially prepared canal grooves. 10. This work was con. Seet et al. removal utilizing Er:YAG LAI for 1 min in the Fig. eled through the fluid-acoustic streaming Debris/material removal from root canals has (Fig. De Moor et al. Calcium term laser-activated irrigation. cavitational effects by stating that the fluid in the However. Numerous studies have looked at the cleaning/ Arslan et al.16). 10. [18]. [174] and Sahar-Helft et al. When the laser compared to sonic agitation. LAI. faecalis. The dif. faecalis from dentinal tubules expansion occurred for 700 μs. Ordinola-Zapata et al.

Moon et al. 10. 10. Sonic devices generally oscillate at a frequency of 20–20. Peeters tion. The major sys- tems available to produce sonic/subsonic agita- tion are the Micromega® Sonic Air®1500 Fig.Cr:YSGG LAI. especially after a 60 s size. The Vibringe® irrigation system consists of and Mooduto [123] reported that. PUI/UAI utilizing intermittent flushing and irrig. [58] looked at both mer tips (Dentsply Tulsa Dental Specialties) seen Er:YAG and Er.188 J. (Fig.000 Hz. The Er. disposable.000 Hz (manufacturer data). root canal and access opening via needle irriga- Safety of LAI has also been evaluated. The Sonic Air® 1500 unit is an air-driven ant replacement. apical 2–5 mm of the root canal using the same the EndoActivator® system with attached poly- type of model.3 °C was found on the external root surface. and 190 Hz. [72] reported that the temperature increase. application. 10. Sonic Activation Efficacy of sonic/subsonic activation of irrigants has been evaluated as a manner to improve over- all canal cleanliness.18.Cr:YSGG LAI for 60 s in canals prepared to a Rispi-Sonic® files are stainless steel and have size 30 file as compared to shorter durations of barbs along the length of the file in a spiral design LAI and smaller canal preparations. in vivo.) seen in Fig.19.17b).02.Cr:YSGG LAI with EDTA resulted in That handpiece accepts one of three different cleaner dentinal tubules. s5/. DiVito et al. The removal and hence sealer penetration into the tips agitate the irrigating solution placed in the dentinal tubules. By definition. was minimal (less than 4 °C) after use of an Er:YAG laser to perform LAI and an average increase of only 1. 175. Nusstein was no extrusion of a radiopaque-infused irrigant beyond the apex of the treated tooth following Er. 100. [62] as well as agitate the irrigant solution with the reported that the combination of Er:YAG LAI handpiece with an attached Rispi-Sonic® file (Medidenta International Inc. This file is designed to cut dentin Removing smear layer.500 to 3. The EndoActivator® is a battery-operated Suardita [124] also reported that the combination portable handpiece with a 3-speed electric motor.V. [84] to be 160.) seen in Fig.M. sonic frequency is anything in the audible hearing range of a human.17.Cr:YSGG LAI in removing in Fig. internally. 10.16 Laser activated irrigation (healthmantra. and 167 Hz. Irrigant is delivered and refreshed inter- with EDTA produced very clean dentinal walls mittently via needle delivery and not by the hand- with little smear layer remaining. The size of the canal preparation was 35/. Peeters and piece. [114] reported et al. also found to impact the effectiveness of the laser Operating frequencies were reported by Jiang to remove smear layer. and polymer tips (15/. These fre- Nd:YAG LAI with either NaOCl or EDTA quencies are different from the manufacturer equaled the effect of EDTA alone for smear layer reported frequencies of 33. there a battery-operated plunger and thumb ring which . Guidotti et al. of Er. 10. and the Vibringe® sonic irrigation dentin debris and found that both were equal to system (Vibringe B. Peeters and Suardita [124] device that produces vibrations ranging from reported cleaner canals following the use of 1. The polymer tips are smooth sided.04).04. De Moor et al.

it was inferior to Fig. of varying size ting irrigant to the canal apex in variously tapered.18 EndoActivator® system with polymer tips agitation (sonic) had the second greatest effect (Dentsply Tulsa Dental) (more than increasing the temperature of the solution). as well difference in cleanliness to the flow velocity of .10 Sonic and Ultrasonic Irrigation 189 Fig.17 (a) Micromega® a b Sonic Air® 1500 handpiece. [54] found that sonic activation with the EndoActivator® equaled the effective- ness of PUI/UAI in getting irrigant solution into lateral canals 2–4. but was inferior to PUI/UAI. (b) Rispi-Sonic® file (Micromega) as removal of pastes (mainly calcium hydroxide) and smear layer removal. movement. 10. [111] stated that PUI/ is placed into a disposable.19 Vibringe irrigation system (Vibringe) PUI/UAI and EndoVac® (SybronEndo) for the same role. [55] reported that the EndoActivator® was superior to needle irrigation in getting irrigating solution to the apex of the root canal preparation and into lateral canals. lateral canals. The group attributed the canal walls. has provided rather mixed results with sonic activation of irrigants. 10. They found that the taper of the attached. Stojicic et al. [129] reported that use of the Vibringe® resulted in a cleaner apical 1/3 of the Debris and Smear Layer Removal canal as compared to needle irrigation alone. PUI/UAI was superior over the entire Research into the improved cleaning of the root length of the root canal. 10 ml. In a later study. However. to needle irrigation in both straight and curved canals. UAI was superior to the EndoActivator® in get- An endodontic irrigating needle. As the irrigant is delivered into the root preparation had no impact on the irrigant canal. [149] reported on the effect sonic agitation of NaOCl has on dissolution of tissue. Merino et al. the thumb ring is activated causing vibra. de Gregorio et al. However. depending on the root canal preparation. The reported fre. Rödig et al. 10. tion of the irrigating needle.5 mm from the root apex when EDTA was used. De Gregorio et al. and isthmuses. Sabins et al. They reported that increasing the concentration of the NaOCl had the greatest impact and that Fig. [135] reported that sonic irrigant activation (using a MicroMega® 1500 system) improved canal cleanliness over needle irrigation alone. Research on debris removal has shown that quency of agitation is 150 Hz (manufacturer both Vibringe® and EndoActivator® are superior data). is curved canals. nylon syringe.

removed when only NaOCl was utilized. There was no dif- was equivalent between PUI/UAI and ference in calcium hydroxide removal. [120]. Grischke et al. fae- utilizing 5. nificantly improved smear layer removal when [152] found no difference in removal of E. Calcium hydroxide and other paste and sealer Neither technique could remove all the bacteria. [68] and Khaleel et al. The reported that using Vibringe® cleaned canals and group reported that the EndoActivator® scored isthmuses filled with artificial collagen to the poorly in removing the sealer with PUI/UAI pro- same degree as needle irrigation although there viding better results. removal have also been evaluated utilizing sonic Pasqualini et al. but inferior to PUI/UAI. especially in the Removal of bacteria from the root canal sys- coronal portion of the canal. They reported that sonic activation with 4 mm of the root canal compared to needle irri. faecalis- EDTA. and EndoActivator® agitation of 5 % NaOCl was . Tardivo et al. [27] reported that the use of the canals with EndoActivator®. Uroz-Torres reported better results with the EndoActivator® et al. [23] EndoActivator® was similar to needle irrigation compared fluorescent dye-labeled sealer pen.25 % NaOCl over PUI/UAI 3–8 mm calis between the EndoActivator® and PUI/UAI from the root apex in an SEM study. Goode et al. Paragiola et al. flow velocity with sonic activation prevented They found that the use of the EndoActivator® removal of debris from artificial grooves along resulted in more complete removal of the pastes as the canal wall. Brito et al. Doxypaste. [89] In removing smear layer.M. Chou et al. [119] to remove calcium hydroxide from root canals.190 J. Neither technique. Rödig et al. Johnson et al. faecalis counts in extracted teeth. sonic activation has also studied the efficacy of the EndoActivator® also had mixed results. Blank-Goncalves tem has been evaluated utilizing a number of et al. Kanter et al. Mancini et al. [160] reported no differences between and PUI/UAI (similar results) than needle irriga- needle irrigation and the use of EndoActivator® tion. using similar artificially activation. irrigation but inferior to PUI/UAI. while Goode’s group reported no difference in removing smear layer when using EDTA and between the techniques (EndoActivator® versus NaOCl. Bolles et al. the Micromega® 1500 and EndoActivator® sys- gation with 17 % EDTA. infected plastic root canal models to determine tors did not improve sealer penetration (therefore the removal efficacy of several irrigating tech- smear layer removal was absent) in the apical niques. They stated that no smear layer was needle irrigation). (Irrisafe™ system) from the root canal system. of EndoActivator® and Vibringe® on 17 % Townsend and Maki [158] utilized E. [43] evaluated removal contaminated root canals. In curved canals. [70] evaluated debris and cleaned lateral canals better than PUI/ the use of the EndoActivator® to remove set AH UAI and needle irrigation. Odontopaste®. [85] Plus sealer from artificial grooves in roots. were some differences at various levels of the was able to remove all of the sealer from the canals. [101] tems were similar in results and superior to needle reported that the use of the EndoActivator® sig. [20] also showed improved smear layer irrigation techniques including sonic activa- removal with activation of EDTA in curved tion. reported that 30 s of of Ledermix®. Calcium EndoActivator®. debris removal compared to needle irrigation. Nusstein the irrigant during activation/agitation – a lower Pulpdent® (calcium hydroxide) from root canals. reported that the use of EndoActivator® was Both groups reported that no irrigation tech- superior to needle irrigation in removing smear nique could remove all of the material. [87] reported that hydroxide was found to be the most difficult the use of the EndoActivator® removed more product to remove. [130] reported that the addition of PUI/ UAI or EndoActivator® to activate the irrigants Bacteria and Biofilm Removal (NaOCl and EDTA) in curved canals resulted in superior smear layer removal. (NaOCl as the irrigant) in reducing artificially etration in dentinal tubules following the use placed E. They reported that the use of the activa. grooves. Khaleel layer. however.

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this simple concept. Such canal with rotary files to the extent that a thin irri. Unfortunately. there would be no round cross section. Tel Aviv University. the irrig. The effective cleaning of oval canals enables more effective disinfection and better obturation than can be achieved with rotary files. The Role of Irrigants in Endodontic gation needle can be inserted to a working length Treatment would always provide clean. straight canals with a ant cleans” was always true.zvi@gmail. 59. which may If the simple idea that “the file shapes. 72. including its cross section. Shaping a result in oval canals [23. The Goldschlager concept provides adequate cleaning of the whole School of Dental Medicine. Endodontic Irrigation: Chemical Disinfection of the Root Canal System. Ramat Aviv. Continuous Instrumentation and Irrigation: The Self-Adjusting 11 File (SAF) System Zvi Metzger and Anda Kfir Abstract The recently introduced self-adjusting file (SAF) system is the first of its kind. As an instrumentation device it adapts itself to the shape of the canal. fails to deliver the desired need for special irrigation systems. Z. be effective in narrow. DMD Furthermore. Kfir. 99]. Basrani (ed.). DOI 10. Its scrubbing effect is also useful in the final stage of retreat- ment as well as in the treatment of root canals of immature teeth. the assumption that the above Department of Endodontology. as opposed to most rotary file systems that machine the canal to the shape of the file. 100]. canals represent 24 % of the total number of root canals. The SAF system is a no-pressure irrigation system combined with an added mechan- ical scrubbing effect. 77. performing continuous and simultaneous instrumentation and irriga- tion. Tel Aviv 69978.andakfir@gmail. Combined with its effective irriga- tion. ready-to-fill canals. 58. Israel canal has led to an oversimplified approach to root e-mail: the incidence of oval canals can reach 90 % [29. canal treatment: one only has to machine the canal dr. and in certain types of teeth. The SAF system removes a uniform dentin layer from all around the canal as opposed to rotary files which are using excessive removal of sound dentin in attempt to include the whole canal within the to a certain shape to accommodate a similarly © Springer International Publishing Switzerland 2015 199 B. DMD (*) • A. it allows a new concept of minimally invasive endodontics. 50. Metzger.1007/978-3-319-16456-4_11 .

This random The Self-Adjusting File (SAF) circular position also allows the asymmetrical tip of the file to negotiate curvatures that may be The SAF is the first file that does not have a solid found in the root canal. (Fig. reaching a buccolingual diameter that “the notion that ‘the file shapes. such a oval canals” [23]. should do so at random. When the SAF enters delivers a continuous flow of irrigant through the the canal during the inbound pecking motion. by either (a) affecting the flow or motion of the irrigant at given time points of the The RDT Handpiece Head procedure or by (b) adding a scrubbing effect to a continuous flow of the irrigant. It transforms the rotation 60. tube. it hollow file [39. a 1. This com- files in such canals not only fails to clean the buccal pressibility also enables the file to adapt to the and/or lingual “fins” or the isthmus between canals shape of the cross section of the canal [39. 66.5 mm SAF will even with passive ultrasonic irrigation [66]. 81] and sonic and ultrasonic irrigant acti. 89]. 35.000 rpm. tains a clutch mechanism that allows the SAF to rotate slowly when not engaged in the canal but that completely stops the rotation once the file is The Self-Adjusting File (SAF) System engaged with the canal walls. 68. 11. 95]. The dis.000 The self-adjusting file system is a shaping and vibrations/min.1). flattened file cannot rotate while it is in the canal These limitations of syringe and needle irriga.4 mm and con- file system represents the second approach. to conclude buccolingually. 11. 53–57]. 0. titanium rotary files. RDT heads may be metal core. when the SAF is disen- RDT handpiece head and an irrigation pump that gaged from the canal walls. The action of rotary file can be inserted into (Fig. When inserted into an oval canal with a particles [63. with different circular positions. 25. 69. thus ensuring uniform treatment of the canal walls [53–56.3) has a dual included negative pressure irrigation systems [36. be compressed mesiodistally and thus spread Such findings led De-Deus et al. The file is extremely com- Studies indicate that the effective cleaning of pressible. 11. (Fig.5 mm SAF diameter may oval canals is a challenge that is beyond the ability be compressed into a root canal that only a #20 K of syringe and needle irrigation. and the operator uses pecking cleaning system designed for minimally invasive motions when using the SAF. mechanical function. This will occur even if the cleans’ represents wishful thinking rather than an operator is not aware that the canal is oval. of the micromotor into a trans-line in-and-out vation systems [9. 53– but also actively packs these recesses with dentin 56]. Free rotation of the endodontic treatment. 43]. The micromotor is operated at 5. 74. The irrigant is thus expected titanium lattice with a rough outer surface. such that a 1. The system consists of a file should occur at the outbound portion of self-adjusting file that is operated with a special every pecking stroke. Kfir shaped master cone. The first group The RDT handpiece head (Fig. 11. as opposed to the symmetrically centered ing the whole endodontic treatment to preparing a tips that may be found in all conventional nickel- space to accommodate a master cone may be small.2 mm mesiodistal diameter. at least in the case of the name “self-adjusting file. 78. 73. 67] that are difficult to remove.2). The file is designed as a hollow tube.3). irrigation methods that are designed to overcome this barrier. 53–57]. The new self-adjusting vibration with an amplitude of 0. which results in 5. and is operated with in-and-out vibrations that tion led to a search for and introduction of new are created by the RDT handpiece head. hence established scientific fact. the irrigan