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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 39-42

Comparative evaluation of efficacy of three different irrigation activation systems in debridement of root canal isthmus: An in vitro study


1 Department of Conservative Dentistry and Endodontics, MIDSR Dental College, Latur, Mahatrashtra, India
2 Department of Conservative Dentistry and Endodontics, M. A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Mahatrashtra, India

Date of Web Publication25-May-2017

Correspondence Address:
Shruti Ishwar Hariramani
Department of Conservative Dentistry and Endodontics, MIDSR Dental College, Vishwanathpuram, Ambejogai Road, Latur, Mahatrashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_4_17

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  Abstract 

Objective: The purpose of this study was to evaluate the effectiveness of different irrigation activation devices in removing debris from the isthmus area of mandibular molars.
Materials and Methods: A total of 50 extracted human mandibular molars were selected, and access cavity was prepared. After determining the working length, instrumentation was done till ProTaper F2 with simultaneous irrigation with 5.25% NaOCl and 17% ethylenediaminetetraacetic acid. Later, the samples were divided into five groups containing ten samples each, that is, Endo-Irrigator Plus, EndoActivator, passive ultrasonic irrigation (PUI), manual dynamic activation (MDA), and control group. About 5.25% NaOCl was used for irrigation activation. Mesial roots were sectioned 4 mm from the apex and observed under a stereomicroscope at ×× 10 magnification for the presence of debris.
Results: The Endo-Irrigator Plus demonstrated the least amount of debris followed by EndoActivator, PUI, MDA, and then control. There was statistically significant difference between the first three groups and MDI and control. However, there was no statistically significant difference between the first three groups.
Conclusion: In this study, none of the devices were able to remove the debris completely. Nevertheless, Endo-Irrigator Plus, EndoActivator, and PUI could be used as effective irrigation activation devices.

Keywords: EndoActivator; Endo-Irrigator Plus; irrigant efficacy; isthmus; passive ultrasonic irrigation.


How to cite this article:
Gadaalay S, Hariramani SI, Dhore P, Kale A, Agrawal M, Doshi S. Comparative evaluation of efficacy of three different irrigation activation systems in debridement of root canal isthmus: An in vitro study. Endodontology 2017;29:39-42

How to cite this URL:
Gadaalay S, Hariramani SI, Dhore P, Kale A, Agrawal M, Doshi S. Comparative evaluation of efficacy of three different irrigation activation systems in debridement of root canal isthmus: An in vitro study. Endodontology [serial online] 2017 [cited 2019 Nov 20];29:39-42. Available from: http://www.endodontologyonweb.org/text.asp?2017/29/1/39/207004


  Introduction Top


Successful endodontic therapy depends on correct diagnosis, effective cleaning, shaping and disinfection of the root canals, and adequate obturation.[1] Biomechanical preparation of this system to render it void of organic debris and microorganisms is challenging. Since instrumentation alone cannot achieve total elimination of bacteria and debris in all canals, effective irrigant delivery is a prerequisite for it.[2]

The fact that proportionally large areas of the main root canal wall remain untouched by the instruments, have been proven by various studies using advanced techniques available. This is due to the complex root anatomy present, especially, in the apical area such as isthmuses, accessory canals, fins, and deltas that provide an ideal space for tissue debris, microbes, and their by-products, emphasizing the importance of chemical means for cleaning and disinfecting all areas of the root canal.[3]

However, these irrigants must be brought into direct contact with the entire canal wall for effective action, as the traditional needle irrigation technique delivers solutions no more than 0–1.1 mm beyond the needle tip.[4],[5] Furthermore, the phenomenon of vapor lock that results in trapped air in the apical third of root canals, also hinder the exchange of irrigants and affect the debridement efficacy of irrigants. That is why different irrigant delivery devices and activation system have been proposed to increase the flow and distribution of irrigating solutions within the root canal system such as EndoActivator, Irrisafe, EndoVac, and photon-induced photoacoustic streaming.

Endo-Irrigator Plus (K-Dent Dental System) is a novel irrigation activation device based on the concept of continuous warm activated irrigation and evacuation system. This system consists of inbuilt suction and heater with positive and negative pressure tips which are to be used with warmed sodium hypochlorite at a temperature of 45°C.[6]

EndoActivator (Dentsply, Tulsa Dental) uses sonic activation of the irrigants comprising a portable handpiece and three types of disposable flexible polymer tips of different sizes that do not cut root dentin. Cavitation and acoustic streaming significantly improves the debridement and disruption of the smear layer and biofilm.[7]

Passive ultrasonic irrigation (PUI) (Irrisafe – Acteon, UK), first used by Weller et al.[8] in 1980, utilizes ultrasonic wave energy that is transmitted from a file or smooth oscillating wire to the irrigant. Manual dynamic activation (MDA) is a simple and cost-effective technique which involves repeated insertion of a well-fitting gutta-percha cone in short, vertical strokes to hydrodynamically displace and agitate an irrigant by producing eddy currents.[9]

The purpose of this in vitro study is to evaluate the cleaning efficacy of Endo-Irrigator Plus, EndoActivator, PUI, and MDA. The null hypothesis was that there is no significant difference in the debris removal efficacy among the four irrigation protocols tested.


  Materials and Methods Top


Fifty extracted human mandibular molars were selected for the study. Access cavity preparation was done and patency was established. Working length (WL) was obtained by viewing #10 K-file from the apex. The initial glide path was prepared with hand files #15 and #20 K. The ProTaper rotary system was used for canal preparation, and each canal was prepared up to an apical preparation of F2 size, to allow adequate cleaning and penetration of the solution to the apical one-third area. Irrigation was done with 5.25% NaOCl in between each file using 30-gauge side-vented needle. After the completion of instrumentation, final irrigation of the samples was done with 17% ethylenediaminetetraacetic acid (1 ml) and 5.25% NaOCl (3 ml) followed by normal saline (3 ml). Then the teeth were randomly divided into five groups containing ten samples each. The irrigation activation was carried out for 1 min in all the samples except the control group.

  • Group 1: Endo-Irrigator Plus – After the final irrigation, 5.25% warm sodium hypochlorite heated to 50°C is placed into the canal with the help of positive pressure tips for coronal one-third and negative pressure tips for the apical area. Irrigation was accompanied by simultaneous evacuation
  • Group 2: EndoActivator – The canals and pulp chambers were filled with 5.25% NaOCl. The EndoActivator sonic handpiece was set at 10,000 cpm and a size no. 25/0.04 taper activator tip was passively inserted in the canal within 2 mm of the WL. The tip was moved in short 2–3 mm vertical strokes
  • Group 3: PUI – Final rinse with 5.25% NaOCl activated with #20 tip, which was driven by an ultrasonic device with power set at 5 for 1 min at 1 mm from the WL
  • Group 4: MDA – The canals and pulp chambers were filled with 5.25% NaOCl. Repeated insertion of a well-fitting gutta-percha cone to WL. 100 strokes per min is the recommended rate at which activation was performed
  • Group 5 (Control): No activation of the irrigant was done in this group.


After the irrigation activation, distal roots were separated, and mesial roots were sectioned longitudinally 4 mm from the apex. Isthmus cleanliness was checked with stereomicroscope at ×20 magnification. These images were analyzed under ImageJ Software (National Institutes of Health, Bethesda, Maryland, USA).

Statistical analysis was performed with one-way ANOVA followed by Tukey's post hoc test. The scoring criteria were as follows:

  • Score 1 – Clean root canal walls, only a few small debris particles
  • Score 2 – Few small agglomeration of debris
  • Score 3 – Many agglomerations of debris covering <50% of the root canal wall
  • Score 4 – More than 50% of the root canal wall covered with debris
  • Score 5 – Complete or nearly complete root canal walls covered with debris.



  Results Top


The mean percentages of debris removal in isthmus area were highest in case of Group 1; Endo-Irrigator Plus (2.7 ± 0.82) followed by Group 2; EndoActivator (3.5 ± 0.70), Group 3; PUI (3.6 ± 1.07), and Group 4; MDA (4.0 ± 0.81) as compared to control group (Group 5), that is, 4.2 ± 0.78. Results are shown in [Table 1] and graph.
Table 1: Mean and standard deviation values of experimental groups

Click here to view


When the groups were compared using ANOVA followed by Tukey's post hoc test, there was statistically significant difference between Groups 1, 2, 3 and Groups 4, 5 (P < 0.05). However, there was no statistically significant difference between Groups 1, 2, and 3 [Table 2].
Table 2: Mean and standard deviation values of experimental groups

Click here to view



  Discussion Top


Riddling of endodontic irrigants into the complicated root canal system is very important for successful endodontic treatment. It depends on the diameter of the prepared canal, coronal enlargement, the type and volume of irrigant, and irrigant delivery system.[10] The use of various ultrasonic, sonic, and PUI devices, and techniques have been reported to improve tissue removal, more vigorous irrigation of lateral canals, and additional removal of canal bacteria.[11]

In this study, four different irrigation/agitation techniques were selected for comparison of their isthmus debridement efficacy in the mesial root of mandibular molars. EndoActivator is a sonic activation system while PUI works on the dynamics of ultrasonics. MDA acts by physically displacing, folding, and cutting the fluid under “viscously dominated flow” in the root canal system while Endo-Irrigator Plus acts on the principle of active negative pressure and supplies warm irrigant into the root canal system using a single-use 30-gauge side-vented needle. The incidence of isthmus in mesial roots of the mandibular first molar at 3–4 mm from apex is 80%, especially type IV. This may affect surgical as well as nonsurgical endodontic procedures.[12] Therefore, mandibular molars were selected for this study.

It was observed from the study that, at 4 mm from the apex, the three irrigation systems were statistically different from MDA and control group in removing the debris from the isthmus area. These results coincide with the study carried out by Kanter et al.[13] and Al-Obaida et al.,[14] in which they found that the sonic irrigation was significantly better than the control group in removing loose debris at 3 mm from the radiographic apex. Similar results were obtained by Khaord et al.[15] and Mozo et al.[16] who concluded that PUI is more effective than conventional syringe and needle irrigation in eliminating pulp tissue and dentin debris. This is because ultrasound creates a higher speed and flow volume of the irrigant in the canal during irrigation, thereby eliminating more debris.

The results of this study also coincide with the study by Jensen et al.[17] where there was no statistically significant difference between sonic and ultrasonic agitation systems. While in other study carried out by Khalap et al.,[18] it was concluded that sonic activation is superior to ultrasonic activation in debris removal. The reason they cited was that PUI creates acoustic microstreaming which produces sufficient shear stresses to dislodge debris from instrumented canals. Along the length of an activated ultrasonic file, it has multiple nodes and antinodes.[19] However, it also creates the undesirable dampening effect of the amplitude of its characteristic nodes and antinodes pattern, especially when the instrument touched the lateral walls of a shaped canal. Whereas in sonic agitation, the movement of the vibratory sonic instrument was not influenced by lateral wall contact.[20] Literature regarding Endo-Irrigator Plus shows recent study by Neelakantan et al.[6] where the pulp tissue removal capacity of this device was better than MDA and PUI. This result could be attributed to the increase in the volume and temperature of the irrigant, continuous replenishment of fresh solution, and the ability to place the needle tip 1 mm short of the WL.


  Conclusion Top


Within the limitations of this in vitro study, it was concluded that Endo-Irrigator Plus had superior cleaning efficacy (least remaining debris), followed by EndoActivator and then PUI. Further comparative studies are required to assess the efficiency of this novel irrigant system with the other activation systems available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in endodontics. Br Dent J 2014;216:299-303.  Back to cited text no. 1
    
2.
Schilder H. Cleaning and shaping the root canal. Dent Clin North Am 1974;18:269-96.  Back to cited text no. 2
    
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Peters OA, Schönenberger K, Laib A. Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J 2001;34:221-30.  Back to cited text no. 3
    
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Heard F, Walton RE. Scanning electron microscope study comparing four root canal preparation techniques in small curved canals. Int Endod J 1997;30:323-31.  Back to cited text no. 4
    
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Chow TW. Mechanical effectiveness of root canal irrigation. J Endod 1983;9:475-9.  Back to cited text no. 5
    
6.
Neelakantan P, Devaraj S, Jagannathan N. Histologic assessment of debridement of the root canal isthmus of mandibular molars by irrigant activation techniques ex vivo. J Endod 2016;42:1268-72.  Back to cited text no. 6
    
7.
Ruddle CJ. Endodontic disinfection: Tsunami irrigation. Endod Pract 2008;11:7-15.  Back to cited text no. 7
    
8.
Weller RN, Brady JM, Bernier WE. Efficacy of ultrasonic cleaning. J Endod 1980;6:740-3.  Back to cited text no. 8
    
9.
McGill S, Gulabivala K, Mordan N, Ng YL. The efficacy of dynamic irrigation using a commercially available system (RinsEndo) determined by removal of a collagen 'bio-molecular film' from an ex vivo model. Int Endod J 2008;41:602-8.  Back to cited text no. 9
    
10.
Carver K, Nusstein J, Reader A, Beck M.In vivo antibacterial efficacy of ultrasound after hand and rotary instrumentation in human mandibular molars. J Endod 2007;33:1038-43.  Back to cited text no. 10
    
11.
Klyn SL, Kirkpatrick TC, Rutledge RE.In vitro comparisons of debris removal of the EndoActivator system, the F file, ultrasonic irrigation, and NaOCl irrigation alone after hand-rotary instrumentation in human mandibular molars. J Endod 2010;36:1367-71.  Back to cited text no. 11
    
12.
Mannocci F, Peru M, Sherriff M, Cook R, Pitt Ford TR. The isthmuses of the mesial root of mandibular molars: A micro-computed tomographic study. Int Endod J 2005;38:558-63.  Back to cited text no. 12
    
13.
Kanter V, Weldon E, Nair U, Varella C, Kanter K, Anusavice K, 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 2011;112:809-13.  Back to cited text no. 13
    
14.
Al-Obaida M, Al-Ahmari M, Al-Maflehi N. A comparison of the cleaning efficacy of ProRinse syringe needle, ProUltra PiezoFlow TM, and EndoActivator irrigation techniques using software program ImageJ. Saudi Endod J 2015;5:20-5.  Back to cited text no. 14
  [Full text]  
15.
Khaord P, Amin A, Shah MB, Uthappa R, Raj N, Kachalia T, et al. Effectiveness of different irrigation techniques on smear layer removal in apical thirds of mesial root canals of permanent mandibular first molar: A scanning electron microscopic study. J Conserv Dent 2015;18:321-6.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Mozo S, Llena C, Forner L. Review of ultrasonic irrigation in endodontics: Increasing action of irrigating solutions. Med Oral Patol Oral Cir Bucal 2012;17:e512-6.  Back to cited text no. 16
    
17.
Jensen SA, Walker TL, Hutter JW, Nicoll BK. Comparison of the cleaning efficacy of passive sonic activation and passive ultrasonic activation after hand instrumentation in molar root canals. J Endod 1999;25:735-8.  Back to cited text no. 17
    
18.
Khalap ND, Kokate S, Hegde V. Ultrasonic versus sonic activation of the final irrigant in root canals instrumented with rotary/reciprocating files: An in-vitro scanning electron microscopy analysis. J Conserv Dent 2016;19:368-72.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Plotino G, Pameijer CH, Grande NM, Somma F. Ultrasonics in endodontics: A review of the literature. J Endod 2007;33:81-95.  Back to cited text no. 19
    
20.
Singh N, Chandra A, Tikku AP, Verma P. A comparative evaluation of different irrigation activation systems on smear layer removal from root canal: An in-vitro scanning electron microscope study. J Conserv Dent 2014;17:159-63.  Back to cited text no. 20
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