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Neuhaus 2016
Neuhaus 2016
Abstract
Introduction: Passive ultrasonic irrigation (PUI) is the
most widespread method used to activate irrigation so-
lutions. Concerns have been raised that PUI is less effec-
R oot canal infections
are caused by a variety
of mainly anaerobic gram-
Significance
Passive sonic irrigation at 6000 Hz seems to
perform equal to or better than passive ultrasonic
tive in curved root canals and is not passive at all. Our positive bacteria (1). A
irrigation.
aim was to compare a novel passive sonic irrigation persistent intraradicular
(PSI) device (6000 Hz) with PUI and manual irrigation presence of bacteria after
(MI) with respect to their efficiency in removing different chemomechanical treatment is considered to be a possible cause of endodontic failure
endodontic microorganisms from curved and straight (2). Although facultative anaerobes such as Streptococcus gordonii, Fusobacterium
root canals. Methods: We performed 2 experiments nucleatum, and Actinomyces oris have been isolated in primary endodontic infections
as follows. In a 3-day infection model, we included 8 (3), the persistence of Enterococcus faecalis (4) or Candida albicans (5) has been
groups of single or dual microbial species that were associated with persistent periapical lesions and the need for endodontic retreatment.
rinsed with 0.9% sodium chloride using PSI, PUI, or Sodium hypochlorite is considered a suitable disinfecting irrigation solution, but it has
MI. Colony-forming units (CFUs) were counted after in- been shown that ultrasonic activation of sodium hypochlorite (NaCl) enhances its effec-
cubation, and log10 transformations were performed for tiveness (6). Nowadays, passive ultrasonic irrigation (PUI) seems to be the predomi-
statistical comparisons. In a 21-d infection model, we nant activation method for endodontic irrigation solutions (7). The main reason for
tested the same irrigation protocols on 4 groups of mi- the additional effectiveness via ultrasound has been shown to be caused by acoustic
croorganisms and used 1.5% sodium hypochlorite as streaming effects that increase wall shear stress and enhance rupturing of intraradicular
an irrigant. Infection control samples were taken at biofilm (8). However, several limitations have been identified that impose procedural
day 0, 3, 5, and 7 after treatment and were subsequently problems when using ultrasonic activation. Wall contact with the oscillating instrument
reincubated. Results: Using sodium chloride as an irri- dampens the energy and constrains the file movement (9). Therefore, in curved root
gant, the amount of reduction in CFUs compared with canals, ultrasonic instruments are less likely to oscillate freely. It has been shown
the negative control was approximately 3 log10 units that even in straight root canals an ultrasonic instrument comes into contact with the
for PSI at 6000 Hz, 2 log10 units for PUI, and 1 log10 wall during at least 20% of the working time (10). Furthermore, although ultrasonic
unit for MI. PSI reduced the microorganism CFUs signif- irrigation instruments usually possess a noncutting design, they are made of a metal
icantly better than PUI. Using sodium hypochlorite led to alloy that is harder than root dentin, and, therefore, their use risks changing root canal
a significant reduction in microorganism CFUs even with morphology. Consequently, Boutsioukis et al (10) suggested that PUI be replaced by
MI. After 3 days, compared with MI, microorganism re- ultrasonically activated irrigation.
growth significantly reduced after PSI and PUI treat- In order to avoid the detrimental effects caused by ultrasonic activation, activating
ment, but in these groups, in at least half of the the irrigation solution with sonically driven noncutting plastic tips was suggested.
samples, microorganisms were detectable after 7 days. Among the devices using this technique, the EndoActivator (Dentsply, Tulsa, OK) device
Conclusions: PSI at 6000 Hz might be at least equal appears to be the best-documented system (11). The principle is to use a polyamide tip
to PUI with respect to reduction of the microbial load to activate the solution and thus to prevent active cutting of the root canal walls or open-
in curved and straight root canals. (J Endod 2016;- ing of the apical constriction. Passive sonic activation at low frequency was shown to be
:1–5) inferior to PUI with respect to bringing irrigation solution to the apex in variously
tapered and curved canals (12). Furthermore, using simulated lateral canal models,
Key Words no difference in cleaning efficacy was detected between PUI and passive sonic activation
Disinfection, oral bacteria, root canal, sonic irrigation, at low frequency (13). The maximum frequency of the aforementioned sonic irrigation
ultrasonic irrigation system was measured to be 190 Hz (14).
From the *Department of Preventive, Restorative and Pediatric Dentistry and †Laboratory of Oral Microbiology, Department of Periodontology, School of Dental
Medicine, University of Bern, Bern, Switzerland.
Address requests for reprints to Dr Klaus W. Neuhaus, Department of Preventive, Restorative and Pediatric Dentistry, School of Dental Medicine, University of Bern,
Freiburgstrasse 8, CH 3010, Bern, Switzerland. E-mail address: klaus.neuhaus@zmk.unibe.ch
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.08.024
TABLE 1. Median Log10 Colony-forming Units (Interquartile Range) after Different Irrigation Protocols
Microorganisms PSI PUI MI Control
S. gordonii 2.78*,† (0.99) 2.93† (1.3) 4.23† (0.47) 5.36 (0.67)
A. oris 4.08† (0.36) 4.58† (0.33) 5.29† (0.22) 6.39 (0.23)
F. nucleatum 2.38† (2.07) 4.07*,† (1.85) 4.93* (1.52) 5.88 (1.35)
S. gordonii/A. oris 4.23† (0.45) 4.58† (0.28) 5.42† (0.45) 6.55 (0.28)
S. gordonii/F. nucleatum 3.76† (0.51) 4.96‡,† (0.51) 4.99† (0.33) 6.65 (0.19)
E. faecalis 2.97*,† (0.4) 3.84† (0.75) 4.68* (0.24) 6.47 (2.1)
C. albicans 1.74† (0.94) 3.26† (0.58) 3.68† (0.14) 4.67 (0.2)
Retreatment isolates 3.46† (0.27) 3.96† (0.45) 4.64† (0.27) 5.88 (0.23)
MI, manual irrigation; PSI, passive sonic irrigation at 6000 Hz; PUI, passive ultrasonic irrigation.
Superscript symbols indicate pair-wise comparisons to the boxes to the right in the same row.
*P < .05.
†
P < .01.
‡
Nonsignificant.
of the irrigation solution. It could be argued that the greater effect of PSI
4
compared with PUI was because a larger amount of irrigation solution
was used and is inherent in methods that use continuous flushing versus
2 intermittent flushing. However, in the group with manual irrigation,
even more rinsing solution was used than in the PSI and PUI groups.
0
Therefore, the effect is likely attributable to hydrodynamic effects.
Control PSI PUI MI In this study, both straight and curved root canals were tested. The
irrigation methods
main obstacle of the efficacy of ultrasonic devices appears to be the cur-
vature of the root canals. It has been shown that cavitation effects occur
mainly at a freely oscillating tip of an ultrasonic instrument ‘‘depending
B Curved canals on the wall contact’’ (24). Consequently, because in curved root canals
8 ** it is usually not possible to avoid wall contact, the cleaning effect of PUI
**
** through cavitation is restricted (10). This has been shown in studies
** examining debris removal using ultrasonic irrigation. A less pro-
6 **
** nounced effect was found beyond the root canal curvature, whereas
in straight portions of the root canals debris removal was better (25,
log10 cfu
4 26). Still, any activation is better than no activation for cleaning the
apical portion of curved root canals (26). In our study, as expected,
2
‘‘curvature’’ was a significant variable for treatment outcome (reduction
of bacterial counts). However, even in curved canals, sonic activation at
6000 Hz performed significantly better than ultrasonic irrigation or
0 manual irrigation in the short-term infection experiment. This was
Control PSI PUI MI
true for bacteria that are associated with primary endodontic infections
irrigation methods (groups 1–5) as well as for microorganisms associated with endodon-
tic retreatment.
Figure 1. Log10 CFUs after different irrigation protocols in (A) straight canals This study also included a long-term experiment with 21 days of
and (B) curved canals. **P < .01.
root canal infection. The rationale was that after 3 days of incubation,
a young biofilm and planktonic microorganisms would be expected,
Ultrasonic activation is supposed to support the endodontic but after 21 days of incubation, many of the microorganisms might
irrigation protocol. There are several possible reasons for the greater be located within dentinal tubules. Thus, we wanted to measure the
effectiveness of PUI compared with manual irrigation. First, the irriga- in-depth cleaning effect by incubating the roots after the irrigation pro-
tion solution becomes activated because of the implosion of microcavi- cedure for another 7 days in order to allow regrowth of microorganisms
tation bubbles and hydrodynamic effects. PUI has been shown to clean that survived the cleaning procedure, presumably in dentinal tubules.
root canal walls from the smear layer, debris, and bacteria better than We wanted to follow a clinical protocol as closely as possible, which
manual irrigation (21). A second effect that has been described derives is why only a final rinsing with 1 mL NaCl solution but no inactivation
from a heating effect in the root canal. Part of the energy is transformed of NaOCl with sodium thiosulfate was performed. Quantitatively, we
to heat energy, which leads to an intracanal temperature of 45 C (22). did not detect a statistical difference between PSI and PUI after irrigation
The thermal effect might be advantageous when used in combination with NaOCl, but both methods performed significantly better than
with NaOCl (23). Whether or not PSI at 6000 Hz is able to heat the irri- manual irrigation in a long-term infection model.
gation solution is the object of ongoing research. The novel PSI device at 6000 Hz seemed to reduce bacteria at least
Clinically, a difference between the novel sonic devices operating as well as PUI and thus might represent an interesting option for inclu-
at 6000 Hz compared with PUI with the IrriS (VDW, Munich, Germany) sion into endodontic irrigation protocols. In a survey among American
TABLE 2. Median Log10 Colony-forming Units after Different Irrigation Protocols, Differentiated by Group of Microbial Species and Root Curvature
PSI PUI MI Control
Microorganisms Straight Curved Straight Curved Straight Curved Straight Curved
S. gordonii 2.78 2.96 2.92 3.72 4.25 4.03 5.04 5.24
A. oris 4.02 4.39 4.56 4.71 5.28 5 6.42 6.26
F. nucleatum 1.60 2.39 2.9 4.31 4.62 4.93 5.28 6.3
S. gordonii/A. oris 4.03 4.32 4.46 4.7 5.4 5.2 6.46 6.69
S. gordonii/F. nucleatum 3.65 3.8 5.08 4.84 5 4.98 6.58 6.7
E. faecalis 2.98 3.42 3.85 3.86 4.66 4.82 5.54 7.57
C. albicans 1.7 1.78 3 3.54 3.61 3.68 4.62 4.7
Retreatment isolates 3.45 3.51 3.85 4.26 4.53 4.66 5.89 5.78
Curved, curvature >25; MI, manual irrigation; PSI, passive sonic irrigation at 6000 Hz; PUI, passive ultrasonic irrigation.