You are on page 1of 8

CONTINUING EDUCATION

CONTINUING EDUCATION Volume 36 No.6 Page 84 Endodontic Disinfection: The Sonic Advantage Authored by Clifford J.

Volume 36 No.6 Page 84

CONTINUING EDUCATION Volume 36 No.6 Page 84 Endodontic Disinfection: The Sonic Advantage Authored by Clifford J.

Endodontic Disinfection:

The Sonic Advantage

Authored by Clifford J. Ruddle, DDS

Upon successful completion of this CE activity, 2 CE credit hours may be awarded.

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage Effective Date: 2/01/16 Expiration Date: 2/01/20 About the Author

Endodontic Disinfection:

The Sonic Advantage

Effective Date: 2/01/16 Expiration Date: 2/01/20

About the Author

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage Effective Date: 2/01/16 Expiration Date: 2/01/20 About the Author

Dr. Ruddle is founder and director of Advanced Endodontics, an international educational source located in Santa Barbara, Calif. He is an assistant professor of graduate endodontics at Loma Linda University and the University of California, Los Angeles; an associate clinical professor at the University of California, San Francisco; and an adjunct assistant professor of endodontics at the University of the Pacific School of Dentistry. As an inventor, he has designed and developed several instruments and devices that are widely

used internationally. He offers endodontic

education through lectures, clinical articles, training manuals, videos, and DVDs. He maintains a private practice in Santa Barbara. He can be reached at (800) 753-3636 or via endoruddle.com.

Disclosure: Dr. Ruddle has a financial interest in products he designs and develops, including the EndoActivator System (Dentsply Sirona).

ENDODONTIC OBJECTIVES A LEO will invariably heal following an extraction because this procedure not only removes the tooth, but importantly serves to eliminate 100% of the contents of the root canal system. Like the extraction, the biological objectives for endodontic treat- ment are to remove all the pulp and bacteria when present (and their related irritants) from the root canal system. Treatment is directed toward making a correct diagnosis, isolating the tooth, and preparing an effective access cavity. Importantly, any given canal is manually reproduced, secured, and shaped to facilitate both 3-D cleaning and filling root canal systems. Certainly, end- odontically treated teeth should be properly restored to protect against hopeless fracture and achieve a coronal seal (Figure 3). Further influencing 3-D disinfection, one must recognize that the files utilized to prepare canals produce debris and do not clean into the uninstrumentable portions of a root canal system (Figure 4). This debris (or smear layer) is oftentimes a cocktail containing dentinal mud, pulpal remnants, and, when present, micro-organisms. Importantly, a smear layer serves to limit or completely block the exchange of an irrigant into the uninstru- mentable aspects of the root canal system. In the noble quest toward complete 3-D cleaning or disinfection, many reagents, devices, and methods have been advocated and utilized. 3 This article will emphasize the importance of active irrigation.

I n the United States alone, more than 100,000 dentists per-

form tens of millions of operative, restorative, and recon-

structive procedures on an annual basis. Certainly, these

dental procedures are primarily directed toward eliminating carious lesions, aesthetically restoring teeth, and functionally moving patients toward optimal oral health. However, it is well recognized that repeated dental procedures on the same tooth potentially contribute to irreversible pulpal injury. Pul- pal breakdown originates within an anatomical space that commonly exhibits infinite configurations along its length. As such, the endodontic treatment challenge is 3-D disinfection. Root canal systems contain branches that communicate with the attachment apparatus furcally, laterally, and often terminate apically into multiple portals of exit (POEs). 1 Con- sequently, any opening from the root canal system to the peri- odontal ligament should be thought of as a POE through which potential endodontic breakdown products may pass (Figure 1). Radiographically, it is fundamental to associate that a lesion of endo dontic origin (LEO) arises secondary to pulpal breakdown and forms adjacent to any given POE. Improvement in endo- dontic treatment occurs with the recognition that anatomy matters and that 3-D disinfection of the root canal system is cen- tral to predictably successful endodontics (Figure 2). 2

Active Irrigation

Using the best technologies, active irrigation serves to initiate fluid hydrodynamics, resulting in shear wall forces that wipe surfaces clean. There is increasing evidence to support that fluid activation, in both minimally or more fully shaped canals, plays a strategic role in exchanging irrigant, which in turn serves to disinfect into all aspects of the root canal system, including lateral canals, loops, fins, webs, anastomoses, and dentinal tubules. 2-4 The greatest focus today is on how to safely, effectively, and efficiently activate any given reagent to maximize the hydrodynamic phenomenon. The most important reagents for activation are solutions of 6% sodium hypochlorite (NaOCl) and 17% ethylenediaminetetraacetic acid (EDTA), recognizing that other final rinse solutions are available.

Active Irrigation Methods There are 3 primary methods that have been shown to exchange an intracanal irrigant into all aspects of the root canal system— namely, acoustic energy, light energy, and mechanical energy. 3 Although acoustic and light-based technologies are intriguing, their widespread adoption into the marketplace is limited, as both these technologies are priced from several thousand to tens of thousands of dollars. The following will describe a mechanical technology for 3-D disinfection that best combines

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage a b Figure 1. This graphic demonstrates that Figure

Endodontic Disinfection: The Sonic Advantage

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage a b Figure 1. This graphic demonstrates that Figure
a b
a
b

Figure

1.

This

graphic

demonstrates

that

Figure 2a. A preoperative

film

of

a maxil-

Figure 2b. A recall image reveals excellent heal-

lesions

of

endodontic

origin

(LEOs)

arise

lary first bicuspid. Note a gutta-percha cone

ing and confirms the importance of shaping

secondary to pulpal breakdown and form

tracing a sinus tract to a LEO.

canals, 3-D disinfection, and treating root canal

adjacent to portals of exit.

 

systems.

scientific evidence, effectiveness, and affordability. The EndoActivator (Dentsply Sirona) is validated by more than a dozen scientific, peer-reviewed articles. Furthermore, it is used by nearly 50,000 international dentists and is readily affordable in North America at a cost of about $500 for the introductory kit and less than $2 per patient.

ENDOACTIVATOR SYSTEM The EndoActivator is a mechanical system that comprises a handpiece and variously sized polymer tips (Figure 5). This sonically driven system has been engineered to safely activate various intracanal reagents and vigorously produce the hydrodynamic phenomenon. As we will see, this technology provides a safer and more effective method to disinfect a root canal system compared to ultrasonic technology. 4-6 When the directions for use are followed, research continues to show that the EndoActivator system is able to remove the smear layer, debride into the uninstrumentable portions of the root canal system, and dislodge biofilms within long, narrow, and highly curved canals of molar teeth (Figure 6). 6-10

Sonic Handpiece The sonic handpiece has been designed to be cordless, contra- angled, and ergonomic, and it is used to mechanically drive strong and flexible polymer EndoActivator tips. When the handpiece is activated, the power defaults to 10,000 cpm, which research has shown significantly promotes all aspects of 3-D disinfection. 4,6,7 Depending on use, a new, single lithium battery is periodically replaced to ensure optimal performance. For infection control, custom protective barrier sleeves have been designed to easily slide over the entire handpiece. After use, it is important to not autoclave or submerge the handpiece in

cleaning solutions; rather, remove the barrier sleeve and simply wipe down the handpiece with a mild detergent.

EndoActivator Tips The EndoActivator tips have an easy snap-on/snap-off design and are color-coded yellow, red, and blue to approximately correspond to file sizes 20/02, 25/04, and 30/06, respectively. The tips are made from a noncutting, medical-grade polymer, are strong and flexible, and are 22 mm long with orientational depth gauge rings positioned at 18, 19, and 20 mm. The EndoActivator tips are disposable, single-use devices that should not be autoclaved. Autoclaving an EndoActivator tip reduces the elasticity of the tip, which decreases its back-and-forth movement and performance. The EndoActivator tip selected is placed over the barrier-protected driver and is simply snapped on to secure its connection to the handpiece (Figure 7). Tip Selection In well-prepared canals, it is easy to select a tip that fits loosely to within 2.0 mm of working length. 1,11 When a tip is too big for any given prepared canal, its back-and-forth movement will be restricted or dampened, limiting its ability to agitate a solu- tion. Research has shown that vibrating the tip, in combination with moving the tip up and down in short 2.0 to 3.0 mm verti- cal strokes, synergistically produces a powerful hydrodynamic phenomenon. 4,6,7 Scientific evidence supports that this specific technique optimizes debridement, eliminates the smear layer, and disrupts biofilms (Figure 6). 6-10

Clinical Protocol

Following shaping procedures, re-irrigate and flush the root canal space with a solution of 6% NaOCl, then suction to remove this reagent. Next, flood the pulp chamber with a 17% EDTA solution

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage and use the EndoActivator to agitate this intraca- nal

Endodontic Disinfection: The Sonic Advantage

and use the EndoActivator to agitate this intraca- nal solution for 60 seconds. This process should be repeated for each canal or until the fluid in the pulp chamber is clinically observed to be clear. Follow- ing the use of 17% EDTA, vacuum and remove this reagent. Irrigate with a solution of 6% NaOCl and use the EndoActivator to agitate this intracanal solu- tion for 30 seconds (Figure 8). When the clinical pro- cedure has been completed, the single-use activator tip and barrier sleeve should be discarded. To better understand the clinical use of the EndoActivator, animations, clinical ops, and published articles are available at endoruddle.com.

Mechanism of Action

In a well-shaped and fluid-filled canal, the hydrodynamic phenomenon results when a vibrating tip generates fluid activation and intracanal waves. 3,4,9,11 Random waves fracture, resulting in the formation of bubbles that oscillate within any given reagent. These bubbles expand, become unstable due to heat and pressure, then collapse and implode. Each implosion generates up to 30,000 shockwaves that serve to powerfully penetrate, break up potential biofilms, and wipe surfaces clean. 4 This phenomenon is regularly visualized clinically as the action of the EndoActivator tip frequently produces a cloud of debris within a fluid-filled pulp chamber.

THE SONIC ADVANTAGE

The EndoActivator is a sonic technology that has been shown to be superior to ultrasonic technol- ogy utilized for 3-D disinfection. 3,4,6 The follow- ing will look at the distinct sonic advantages that independently and synergistically influence fluid activation.

a b
a
b

Figure 3a. (Left) A preoperative

film

demonstrates a failing central incisor with a gutta-percha point tracing a sinus tract to a lateral LEO. (Right) Following dis- assembly and 3-D cleaning, a working film demonstrates master cone fit.

Figure 3b. (Left) This working film image demonstrates the downpack. Note the filled lateral canal associated with the laterally positioned LEO. (Right) A 25-year recall film demonstrates 3-D endodontics, osseous repair, and the restored tooth.

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage and use the EndoActivator to agitate this intraca- nal

Figure 4. This graphic shows residual tis- sue following shaping, while the inset image depicts a file generating debris, resulting in a blocked lateral canal.

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage and use the EndoActivator to agitate this intraca- nal

Figure 5. The EndoActivator System (Dentsply Sirona) is designed to safely and vigorously exchange intracanal reagents into all aspects of the root canal system.

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage and use the EndoActivator to agitate this intraca- nal
CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage and use the EndoActivator to agitate this intraca- nal

Figure 6. SEM images provide evidence

Figure

7.

A

preselected

EndoActivator

that the EndoActivator System can clean

tip

is

placed

over

a

protective

barrier

root canal systems. (Courtesy of Dr. Grégory

and

snapped

onto

the

handpiece

for

Caron; Paris, France.)

clinical use.

 

breakage. To clarify, when ultrasonic energy is used for 3-D disin- fection, high frequency sinusoidal waves are produced with low amplitude, meaning less useful energy. On the contrary, sonic technology produces a high tip amplitude about 60 times greater than ultrasonic technology (Figure 9). Research shows this ampli- tude maximizes hydrodynamics and 3-D disinfection. 3-7,12-14

Amplitude and Frequency Amplitude is the maximum value of back and

forth displacement of a vibrating tip. Frequency is the interval of time it takes a vibrating tip to move through one complete back-and-forth displacement cycle. In general, the higher the frequency, the lower the amplitude. Certain dis- tributors market activating metal insert tips at high ultrasonic frequencies for endodontic 3-D disinfection. However, an ultra- high frequency requires an ultralow amplitude to mitigate tip

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage Noncutting Tips Sonic technology drives highly flexible, noncut- ting,

Endodontic Disinfection: The Sonic Advantage

Noncutting Tips Sonic technology drives highly flexible, noncut- ting, polymer tips that absolutely maintain the anatomical integrity of the final preparation. 4,14 On the contrary, all ultrasonically driven instru- ments are manufactured from metal alloys. Appreciate that ultrasonically driven instru- ments are either active and have cutting edges, or are nonactive in that their cutting edges have been reduced or eliminated. Regardless, any active or nonactive metal-driven ultrasonic insert tip that contacts dentin will cut dentin and generate its own smear layer. Of greatest concern, vibrating any metal tip—even precurved—around a canal curvature invites ledges, apical transportations, lateral perforations, or broken instruments (Figure 10). 14,15

Continuous Movement

Any vibrating tip will almost certainly con- tact dentin because of the various dimensions and curvatures of any given final preparation. Research has shown that when a sonically driven polymer tip is constrained against a dentinal wall, the tip advantageously continues to display a large displacement amplitude. 12 To validate this phenomenon, simply turn on the EndoActi- vator handpiece, purposefully constrain, at any level, the moving tip, and note that the tip will continue to vigorously move! On the contrary, constrain a vibrating ultrasonic insert tip and note the tip movement will be sharply reduced or the tip will not move at all. 13 It is appreciated that a loss of tip movement will compromise the exchange of irrigant.

CLOSING COMMENTS

a b Figure 8a. This clinical image shows the EndoActivator in use. Note the power- ful
a
b
Figure 8a. This clinical image shows the
EndoActivator in use. Note the power-
ful activation of fluid and appreciate the
suborifice potential for 3-D cleaning.
Figure 8b. This image depicts a simulated
root canal system. The EndoActivator tip
is used with a gentle pumping motion to
enhance the exchange of irrigant.
a b
a
b
Figure 9a. This image illustrates a sinusoi- dal wave of ultrasonic energy propagating along a metal
Figure 9a. This image illustrates a sinusoi-
dal wave of ultrasonic energy propagating
along a metal screw-on tip. Note the high
frequency and ultralow amplitude.
Figure 9b. This image illustrates a sinusoi-
dal wave of sonic energy propagating along a
polymer snap-on tip. Note the low frequency
and ultrahigh amplitude.
a
b

Discounting radicular fractures, the sum of all endodontic failures is directly related to bacterial infection due to deficiencies in primary

Figure 10a. In this plastic S-block, vibrating

a metal insert tip around canal curvatures predisposes to ledges, an apical transporta-

tion, and a broken insert tip.

Figure 10b. In this plastic S-block, vibrating a polymer and noncutting EndoActivator tip maintains the anatomical integrity of the final preparation.

treatment. As such, 3-D disinfection is central to predictably successful treatment. Clinicians should be skeptical and dismiss marketing claims that state ultrasonic technology for 3-D disinfection is faster and somehow better; it is well known that activating metal insert tips at a high speed is dangerous. In the current state of 3-D disinfection, the

EndoActivator is an effective, affordable, and scientifically proven technology that uses safe, flexible, and noncutting polymer tips. Catch the sonic wave and recognize that a clean root canal system is an opening for 3-D obturation and long- term success (Figure 11).F

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage References 1. Schilder H. Cleaning and shaping the root

Endodontic Disinfection: The Sonic Advantage

References 1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. Figure 11.
References
1.
Schilder H. Cleaning and shaping the root canal. Dent Clin North Am.
Figure 11. A long-term recall
radiographic image demon-
strates
a
lone
palatal root
1974;18:269-296.
2.
Ruddle CJ. Predictably successful endodontics. Dent Today.
2014;33:104-107.
successfully serving as
a peer abutment under a
6-unit splint.
3.
Ruddle CJ. Endodontic triad for success: the role of minimally invasive
technology. Dent Today. 2015;34:76-80.
4.
Ruddle CJ. Endodontic disinfection: tsunami irrigation. Endodontic
Practice. 2008;11:7-15.
5.
Desai P, Himel V. Comparative safety of various intracanal irrigation
systems. J Endod. 2009;35:545-549.
6.
Kanter V, Weldon E, Nair U, et al. A quantitative and qualitative analysis
of ultrasonic versus sonic endodontic systems on canal cleanliness
and obturation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
11.
2011;112:809-813.
Albrecht LJ, Baumgartner JC, Marshall JG. Evaluation of apical debris
removal using various sizes and tapers of ProFile GT files. J Endod.
7.
Caron G, Nham K, Bronnec F, et al. Effectiveness of different final
irrigant protocols on smear layer removal in curved canals. J Endod.
2004;30:425-428.
12.
2010;36:1361-1366.
Walmsley AD, Lumley PJ, Laird WR. Oscillatory pattern of sonically
powered endodontic files. Int Endod J. 1989;22:125-132.
  • 8. Shen Y, Stojicic S, Qian W, et al. The synergistic antimicrobial effect by mechanical agitation and two chlorhexidine preparations on biofilm bacteria. J Endod. 2010;36:100-104.

  • 9. Arslan D, Guneser MB, Dincer AN, et al. Comparison of smear layer removal ability of QMix with different activation techniques. J Endod. 2016;42:1279-1285.

    • 10. Bryce G, MacBeth N, Ng YL, et al. An ex vivo evaluation of the efficacy of dynamic irrigation using the EndoActivator. Poster presented at: British Endodontic Society Spring Scientific Meeting; March 2010; London, England.

    • 13. Lumley PJ, Walmsley AD, Laird WR. Streaming patterns produced around endosonic files. Int Endod J. 1991;24:290-297.

    • 14. Neuhaus KW, Liebi M, Stauffacher S, et al. Antibacterial efficacy of a new sonic irrigation device for root canal disinfection. J Endod. 2016;42:1799-1803.

    • 15. Ruddle CJ. Nonsurgical endodontic retreatment. In: Cohen S, Burns RC, eds. Pathways of the Pulp. 8th ed. St. Louis, MO: Mosby; 2002:875-929.

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage POST EXAMINATION INFORMATION To receive continuing education credit for

Endodontic Disinfection: The Sonic Advantage

POST EXAMINATION INFORMATION

To receive continuing education credit for participation in this educational activity you must complete the program post examination and receive a score of 70% or better.

Traditional Completion Option:

You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page). All information requested must be provided in order to process the program for credit. Be sure to complete your “Payment,” “Personal Certification Information,” “Answers,” and “Evaluation” forms. Your exam will be graded within 72 hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailed to the address provided.

Online Completion Option:

Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not previously purchased the program, select it from the “Online Courses” listing and complete the online purchase process. Once purchased, the program will be added to your User History page where a Take Exam link will be provided directly across from the program title. Select the Take Exam link, complete all the program questions and Submit your answers. An immedi- ate grade report will be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting the form, your Letter of Completion will be provided immediately for printing.

General Program Information:

Online users may log in to dentalcetoday.com any time in the future to access previously purchased programs and view or print letters of completion and results.

POST EXAMINATION QUESTIONS

  • 1. According to this article, it is well recognized that repeated dental procedures on the same tooth potentially contribute to irreversible pulpal injury. a. True

b. False

  • 2. Any opening from the root canal system to the periodontal ligament should be thought of as a portal of entry through which potential endodontic breakdown products may pass. a. True

b. False

  • 3. There is no evidence to support that fluid activation, in both minimally or more fully shaped canals, plays a strategic role in exchanging irrigant. a. True

b. False

  • 5. Proper infection control protocol for the sonic handpiece includes autoclaving the instrument.

a. True

b. False

  • 6. Research has shown that vibrating the tip, in combination with moving the tip up and down in short 2.0 to 3.0 mm vertical strokes, synergistically produces a powerful hydrodynamic phenomenon.

a. True

b. False

  • 7. With ultrasonic energy: the higher the amplitude, the lower the frequency. a. True

b. False

  • 4. The EndoActivator (Dentsply Sirona) is a mechanical system that, when used, provides a safer and more effective method to disinfect a root canal system compared to ultrasonic technology. a. True

b. False

  • 8. Research has shown that, when a sonically driven polymer tip is constrained against a dentinal wall, the tip advantageously continues to display a large displacement amplitude.

a. True

b. False

CONTINUING EDUCATION

CONTINUING EDUCATION Endodontic Disinfection: The Sonic Advantage PROGRAM COMPLETION INFORMATION If you wish to purchase and

Endodontic Disinfection: The Sonic Advantage

PROGRAM COMPLETION INFORMATION

If you wish to purchase and complete this activity traditionally (mail or fax) rather than online, you must provide the information requested below. Please be sure to select your answers carefully and complete the evaluation information. To receive credit you must answer at least 6 of the 8 questions correctly.

Complete online at: dentalcetoday.com

TRADITIONAL COMPLETION INFORMATION:

Mail or fax this completed form with payment to:

Dentistry Today

Department of Continuing Education

100 Passaic Avenue Fairfield, NJ 07004 Fax: 973-882-3622

PAYMENT & CREDIT INFORMATION:

Examination Fee: $40.00

Credit Hours: 2

Note: There is a $10 surcharge to process a check drawn on any bank other than a US bank. Should you have addi-

tional questions, please contact us at (973) 882-4700.

o I have enclosed a check or money order. o I am using a credit card. My credit card information is provided below.

o American Express

o Visa

o MC

o Discover

Please provide the following (please print clearly):

PERSONAL CERTIFICATION INFORMATION:

Last Name

(PLEASE PRINT CLEARLY OR TYPE)

First Name

Profession / Credentials

License Number

Street Address

Suite or Apartment Number

City

State

Zip Code

Daytime Telephone Number With Area Code

Fax Number With Area Code

E-mail Address

ANSWER FORM: VOLUME 36 NO. 6 PAGE 84

Please check the correct box for each question below.

  • 1. o b. False

o a. True.

  • 2. o b. False

o a. True.

  • 3. o b. False

o a. True.

  • 4. o b. False

o a. True.

  • 5. o b. False

o a. True.

  • 6. o b. False

o a. True.

  • 7. o b. False

o a. True.

  • 8. o b. False

o a. True.

Exact Name on Credit Card

Credit Card #

Expiration Date

Signature

This CE activity was not developed in accordance with AGD PACE or ADA CERP standards. CEUs for this activity will not be accepted by the AGD for MAGD/FAGD credit.

PROGRAM EVAUATION FORM

Please complete the following activity evaluation questions. Rating Scale: Excellent = 5 and Poor = 0 Course objectives were achieved. Content was useful and benefited your clinical practice. Review questions were clear and relevant to the editorial. Illustrations and photographs were clear and relevant. Written presentation was informative and concise. How much time did you spend reading the activity and completing the test? What aspect of this course was most helpful and why?

What topics interest you for future Dentistry Today CE courses?