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Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 7-10

Efficacy of the EndoActivator system used throughout the endodontic cleaning and shaping procedure to disinfect root canals infected with Candida albicans

Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication25-May-2017

Correspondence Address:
Fahd Alsalleeh
Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-7212.207010

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Objective: The purpose of the present investigation was to analyze the effectiveness of using the EndoActivator™ (EA) system (DENTSPLY Tulsa Dental Specialties, Tulsa, OK) throughout the cleaning and shaping process to disinfect root canals contaminated with Candida albicans .
Materials and Methods: Forty-six extracted human single-rooted teeth were selected. Except for those used as negative controls, the teeth were standardized and then infected with C. albicans . Infected teeth were randomly divided into four experimental irrigation protocol groups (n = 10); normal saline, normal saline with EA activation, 6% sodium hypochlorite (NaOCL), or 6% NaOCL with the EA activation. Three teeth were left untreated to serve as positive controls. Teeth not included in control groups were instrumented with ISO Profile rotary files (DENTSPLY-Tulsa Dental, York, PA). In groups that utilized the EA, the irrigant was activated throughout the procedure.
Results: All samples of the positive control and saline groups showed C. albicans growth. The negative controls had no growth and NaOCL alone groups showed one sample growth. When the EA was used with NaOCL, three samples showed C. albicans growth.
Conclusion: EA activation throughout the procedure did not add any benefit to disinfect root canal system against C. albicans .

Keywords: Fungal infection; root canal disinfection; sonic activation.

How to cite this article:
Alsalleeh F. Efficacy of the EndoActivator system used throughout the endodontic cleaning and shaping procedure to disinfect root canals infected with Candida albicans. Endodontology 2017;29:7-10

How to cite this URL:
Alsalleeh F. Efficacy of the EndoActivator system used throughout the endodontic cleaning and shaping procedure to disinfect root canals infected with Candida albicans. Endodontology [serial online] 2017 [cited 2022 Jul 5];29:7-10. Available from: https://www.endodontologyonweb.org/text.asp?2017/29/1/7/207010

  Introduction Top

Removal of microbial infected root canal system requires effective chemomechanical debridement to treat or prevent apical periodontitis.[1],[2] However, the root anatomy often harbors microorganism in areas; isthmi, fins, and lateral canal that difficult to be reached by the traditional protocol of cleaning and shaping.[3],[4]

In recent years, new innovations have been developed and brought to market in an attempt to more effectively reduce the microbial load in the root canal space. One such item is the EndoActivator ™ (EA) (DENTSPLY Tulsa Dental Specialties, Tulsa, OK). The EA is a handheld portable device that agitates solutions sonically and can be fitted with three types of disposable polymer tips of different sized at different speeds; 2000–10,000 cycles/min. The manufacturer recommendations are to activate irrigation solution used for 30 s as a final rinse.

Many studies have documented the presence of fungi in endodontic infections, and its role in the etiology of periradicular lesions.[5],[6],[7] It was reported that 21% of infected root canals contain Candida albicans.[8] A pure culture of C. albicans was found to be the causative factor of an acute apical abscess.[9] These reports support that C. albicans are involved in the etiology of persistent periradicular lesions. Previous studies had evaluated the effectiveness of commonly used root canal irrigants against C. albicans including sodium hypochlorite (NaOCL) and chlorhexidine. It appeared that C. albicans is more resistant to these irrigating solutions.[10] One report indicated that NaOCL and chlorhexidine were equally effective against C. albicans.[11]

EA has been tested on the elimination of bacteria from root canal system. It was reported that the EA did not enhance the ability of standard needle irrigation to eliminate cultivable bacteria from root canals.[12] Another report indicated that the use of EA for 30 s of irrigation solution appeared to be slightly more efficacious in disinfecting the root canal compared with a standard irrigation regimen.[13] It is yet unknown the influence of EA to eliminate infected root canals contain C. albicans. Furthermore, the EA studies have been done using the manufacturers' recommendations in conjunction with conventional needle irrigation. However, the use of the EA throughout treatment in a nonconventional activation protocol may improve the effectiveness in disinfection when compared to conventional needle irrigation. Therefore, the purpose of the current study is to analyze the effectiveness of the EA use throughout the cleaning and shaping process in disinfecting root canals contaminated with C. albicans.

  Materials and Methods Top

Sample selection

Forty-six freshly extracted human single-rooted teeth, with an unknown history, were collected for this study. Teeth were placed into 6% NaOCL solution (Clorox, Oakland, CA) for 24 h to remove any stains. Radiographs were taken to confirm morphology, and the incisal edge of teeth was shaped with diamond bur to standardized length of 20 mm. Standard lingual access was performed using round bur #6. The working length was established with a #10/2 K-file (Dentsply Maillefer, Switzerland) to the apex subtracting 1 mm from the length. Afterward, the foramen was sealed with a fast set epoxy resin. A glide path was completed to a #25/2 K-file. The teeth were autoclaved and then inoculated with 1 mL of C. albicans wild strain CA42 (formerly known as SC5314) at 1 × 106 cells/mL every other day for 1 week and allowed to incubate aerobically at 37°C. Three teeth were not infected with C. albicans and served as negative control.

Root canal cleaning and shaping protocol

Teeth were randomly divided into four experimental groups each comprised ten teeth per group and treated according to the irrigation protocols as follows:

  • Group (1): Normal saline
  • Group (2): Normal saline alongside passive sonic activation utilizing the EA
  • Group (3): 6% NaOCL
  • Group (4): 6% NaOCL alongside passive sonic activation utilizing the EA.

Three teeth were left untreated and served as positive controls. All teeth (except control groups) were instrumented with ISO Profile rotary files (DENTSPLY-Tulsa Dental, York, PA) in sequential order (25/04–40/04) and recapitulated with a #25/2 K-file. One milliliter of respective irrigant was used between each file and a final rinse of 1 mL of 17% EDTA and saline in Group 1 and 2 or 6% NaOCL in Group 3 and 4. In groups that utilized the EA, the irrigant was activated at 10,000 cpm for 5 s between each file, and 10 s following each respective final rinse using a 20/0.04 tip, placed 1 mm short of the working lengths. Group 3 and 4, following the final rinse, received a rinse with 4% sodium thiosulfate to deactivate the NaOCl samples.

Sample processing and evaluation

All teeth were then flushed with 15 mL of sterile saline, and canals were dried with sterile absorbent paper points. A small amount of saline solution was introduced into canals, and new sterile paper points were introduced and left inside for 30 s. Paper points were transferred and plated on fresh Sabouraud 4% dextrose agar (Difco Laboratories, Detroit, MI, USA). The plates were incubated at 37°C for 48 h and evaluated for the growth of C. albicans visually. Pairwise comparison and Tukey's analysis of mean differences were conducted with significance level set at the 0.05 level. Data were calculated using SPSS software version 18.0 (SPSS Inc., Chicago, USA).

  Results Top

All samples of the positive control and saline groups (Group 1 and 2) regardless of EA usage showed C. albicans growth. The negative controls had no C. albicans growth. Group 3, using NaOCL alone, showed one sample with C. albicans growth. Within Group 4, NaOCL plus EA, three samples showed C. albicans growth. A pairwise comparison and Tukey's analysis indicated the difference between Group 3 and 4 was significant (P < 0.000). The summary of results is shown in [Table 1].
Table 1: Number of samples tested positive for Candida albicans growth

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  Discussion Top

From a clinical endodontic perspective, several technological advances in irrigation systems failed to be adopted due to complexity and difficulty of use, regardless of their effectiveness. Instead, clinicians showed interest using an irrigation protocol based on its practicality. EA has been introduced alongside claims that it is an easy to use and effective sonic adjunct to disinfect root canal system. EA is purported to deliver sonic waves in irrigating solutions, which will enhance disinfection of the root canal system. However, current evidence suggested that EA, used as recommended by the manufacturer, was not better than conventional syringe irrigation protocol.[12] Therefore, the current study has aimed to utilize the EA activation system throughout the cleaning and shaping phase and hoped to improve disinfection using ex vivo root canal system. To the best of our knowledge, this is the first report to evaluate the influence of EA in eliminating infected root canals containing C. albicans.

Results herein indicate that conventional cleaning and shaping alone produced a better outcome in disinfecting canals from C. albicans infection. Another study utilizing EA to remove bacteria in simulated canals had a similar outcome.[14] One study used an Enterococcus faecalis infection model and compared the intracanal disinfection performance of three different irrigation techniques including the EA system. The importance of chemomechanical preparation in reducing bacterial load was confirmed, but no significant differences were found in the three techniques, which performed similarly.[15] Clearly in the current study, sonic activation with EA device after throughout chemomechanical procedures did not improve disinfection against C. albicans.

Few researchers have shown that sonic activation of irrigation solutions, utilizing EA, improved disinfection protocol compared to conventional syringe methods.[16] However, it is widely accepted that ultrasonic irrigation provides a better outcome to disinfect root canal system when compared to EA.[17] One reason might be that EA is not powerful enough to disrupt microbial biofilms.[18] The amplitude of EA tip was 1 mm compared to 75 μm found with ultrasonic file.[17]

C. albicans was chosen due to its involvement in the etiology of persistent periradicular lesions.[8],[19] NaOCL is a potent irrigant with a broad-spectrum antimicrobial activity. High pH of NaOCL interferes with the cytoplasmic membrane integrity and causes biosynthetic alterations in cellular metabolism attributing to its antimicrobial nature.[20] Several studies have indicated that NaOCL was very effective against C. albicans[21],[22],[23] which the results herein confirmed.

  Conclusion Top

Under the condition of the current study, conventional cleaning and shaping using syringe irrigation alone resulted in better disinfection of the root canal system against C. albicans. EA activation throughout the procedure did not add any benefit, and its use is unwarranted.


I would like to thank Drs. Chris Wieseman and Eric Wilbur, for the assistance to conduct experiments. I also thank Ms. Heide Thompson for editing the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30:297-306.  Back to cited text no. 1
Waltimo T, Trope M, Haapasalo M, Ørstavik D. Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing. J Endod 2005;31:863-6.  Back to cited text no. 2
Gutarts R, Nusstein J, Reader A, Beck M.In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod 2005;31:166-70.  Back to cited text no. 3
Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod 2000;26:751-5.  Back to cited text no. 4
Nair PN, Sjögren U, Krey G, Kahnberg KE, Sundqvist G. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: A long-term light and electron microscopic follow-up study. J Endod 1990;16:580-8.  Back to cited text no. 5
Waltimo TM, Sirén EK, Torkko HL, Olsen I, Haapasalo MP. Fungi in therapy-resistant apical periodontitis. Int Endod J 1997;30:96-101.  Back to cited text no. 6
Egan MW, Spratt DA, Ng YL, Lam JM, Moles DR, Gulabivala K. Prevalence of yeasts in saliva and root canals of teeth associated with apical periodontitis. Int Endod J 2002;35:321-9.  Back to cited text no. 7
Baumgartner JC, Watts CM, Xia T. Occurrence of Candida albicans in infections of endodontic origin. J Endod 2000;26:695-8.  Back to cited text no. 8
Matusow RJ. Acute pulpal-alveolar cellulitis syndrome. III. Endodontic therapeutic factors and the resolution of a Candida albicans infection. Oral Surg Oral Med Oral Pathol 1981;52:630-4.  Back to cited text no. 9
Sen BH, Safavi KE, Spångberg LS. Antifungal effects of sodium hypochlorite and chlorhexidine in root canals. J Endod 1999;25:235-8.  Back to cited text no. 10
Sen BH, Akdeniz BG, Denizci AA. The effect of ethylenediamine-tetraacetic acid on Candida albicans. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:651-5.  Back to cited text no. 11
Huffaker SK, Safavi K, Spangberg LS, Kaufman B. Influence of a passive sonic irrigation system on the elimination of bacteria from root canal systems: A clinical study. J Endod 2010;36:1315-8.  Back to cited text no. 12
Pasqualini D, Cuffini AM, Scotti N, Mandras N, Scalas D, Pera F, et al. Comparative evaluation of the antimicrobial efficacy of a 5% sodium hypochlorite subsonic-activated solution. J Endod 2010;36:1358-60.  Back to cited text no. 13
Townsend C, Maki J. An in vitro comparison of new irrigation and agitation techniques to ultrasonic agitation in removing bacteria from a simulated root canal. J Endod 2009;35:1040-3.  Back to cited text no. 14
Brito PR, Souza LC, Machado de Oliveira JC, Alves FR, De-Deus G, Lopes HP, et al. Comparison of the effectiveness of three irrigation techniques in reducing intracanal Enterococcus faecalis populations: An in vitro study. J Endod 2009;35:1422-7.  Back to cited text no. 15
Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. Review of contemporary irrigant agitation techniques and devices. J Endod 2009;35:791-804.  Back to cited text no. 16
Jiang LM, Verhaagen B, Versluis M, van der Sluis LW. Evaluation of a sonic device designed to activate irrigant in the root canal. J Endod 2010;36:143-6.  Back to cited text no. 17
Stamos DE, Sadeghi EM, Haasch GC, Gerstein H. An in vitro comparison study to quantitate the debridement ability of hand, sonic, and ultrasonic instrumentation. J Endod 1987;13:434-40.  Back to cited text no. 18
Waltimo TM, Sen BH, Meurman JH, Ørstavik D, Haapasalo MP. Yeasts in apical periodontitis. Crit Rev Oral Biol Med 2003;14:128-37.  Back to cited text no. 19
Mohammadi Z. Sodium hypochlorite in endodontics: An update review. Int Dent J 2008;58:329-41.  Back to cited text no. 20
Ferguson JW, Hatton JF, Gillespie MJ. Effectiveness of intracanal irrigants and medications against the yeast Candida albicans. J Endod 2002;28:68-71.  Back to cited text no. 21
Waltimo TM, Orstavik D, Sirén EK, Haapasalo MP.In vitro susceptibility of Candida albicans to four disinfectants and their combinations. Int Endod J 1999;32:421-9.  Back to cited text no. 22
Mohammadi Z, Asgary S. A comparative study of antifungal activity of endodontic irrigants. Iran Endod J 2015;10:144-7.  Back to cited text no. 23


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