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Figure 8. Irreversible musculature atrophy This does not imply that NaOCl can or should be excluded as an endodontic irrigant; in fact, its use is critical, as has been discussed in this article. What this does imply is that it must be safely delivered. Safety First To compare the safety of six current intracanal irrigation delivery devices, an in vitro test was conducted using the worstcase scenario of apical extrusion, with neutral atmospheric pressure and an open apex. 97 The study concluded that the EndoVac did not extrude irrigant after deep intracanal delivery and suctioning of the irrigant from the chamber to full working length, whereas other devices did. The EndoActivator extruded only a very small volume of irrigant, the clinical significance of which is not known. Figure 9. Comparative extrusion of irrigant using irrigation devices 100 Extrusion of irrigant (%) 80 60 40 20 0 MicroCannula MacroCannula EndoActivator Max-I-Probe Positive Pressure Ultrasonic RinsEndo Mitchell and Baumgartner Irrigation tested system irrigant used(NaOCl) extrusion from a root canal sealed with a permeable agarose gel. 109 Significantly less extrusion occurred using the EndoVac system compared with positive pressure needle irrigation. A well-controlled study by Gondim et al found that patients experienced less postoperative pain, measured objectively and subjectively, when apical negative pressure irrigation was performed (EndoVac) rather than apical positive pressure irrigation. 110 The use of apical negative pressure needle irrigation results in safer delivery of sodium hypochlorite, and less post-operative pain. Efficacy In vitro and in vivo studies have demonstrated greater removal of debris from the apical walls and a statistically cleaner result using apical negative pressure irrigation in closed root canal systems with sealed apices. In an in vivo study of 22 teeth by Siu and Baumgartner, less debris remained at 1 mm from working length using apical negative pressure compared to use of traditional needle irrigation, while Shin et al found in an in vitro study of 69 teeth comparing traditional needle irrigation with apical negative pressure that these methods both resulted in clean root canals but that apical negative pressure resulted in less debris remaining at 1.5 mm and 3.5 mm from working length. 46, 99,111 When comparing root canal debridement using manual dynamic agitation or the EndoVac for final irrigation in a closed system and an open system, it was found that the presence of a sealed apical foramen adversely affected debridement efficacy when manual dynamic agitation was used, but did not adversely affect results when the EndoVac was used. Apical negative pressure irrigation is an effective method to overcome the fluid dynamic challenges inherent in closed canal systems. 112 Apical negative pressure irrigation results in greater removal of debris and a cleaner result at working length. Microbial Control Hockett et al tested the ability of apical negative pressure to remove a thick biofilm of Enterococcus faecalis, finding that these specimens rendered negative cultures obtained within 48 hours while those irrigated using traditional positivepressure irrigation were positive at 48 hours. 94 Figure 10 shows a scanning electron microscope image of decontaminated dentinal tubules after use of apical negative pressure irrigation with sodium hypochlorite and use of EDTA. Figure 10. SEM of decontaminated dentinal tubules Courtesy of Dr. Jeffrey L. Hockett and Dr. Nestor Cohenca 8 www.ineedce.com
One study found apical negative pressure irrigation resulted in similar bacterial reductions to use of apical positive pressure irrigation and a triple antibiotic in immature teeth. 113 In a study comparing the use of apical positive pressure irrigation and a triple antibiotic that has been utilized for pulpal regeneration/revascularization in teeth with incompletely formed apices (Trimix=Cipro, Minocin, Flagyl) versus use of apical negative pressure irrigation with sodium hypochlorite, it was found that the results were statistically equivalent for mineralized tissue formation and the repair process. 114 Using negative apical pressure and sodium hypochlorite also avoids the risk of drug resistance, tooth discoloration, and allergic reactions. 115,116 Conclusion Since the dawn of contemporary endodontics, dentists have been syringing sodium hypochlorite into the root canal space and then proceeding to place endodontic instruments down the canal in the belief that they were carrying the irrigant to the apical termination. Biological, SEM, light microscopy, and other studies have proven this belief to be in error. Sodium hypochlorite reacts with organic material in the root canal and quickly forms micro gas bubbles at the apical termination that coalesce into a single large apical vapor bubble with subsequent instrumentation. Since the apical vapor lock cannot be displaced via mechanical means, it prevents further sodium hypochlorite flow into the apical area. Additionally, acoustic microstreaming and cavitation are limited to liquids and have no effect inside the vapor lock. The only method yet discovered to eliminate the apical vapor lock is to evacuate it via apical negative pressure. This method has also been proven to be safe because it always draws irrigants to the source via suction—down the canal and simultaneously away from the apical tissue in abundant quantities. 117 When the proper irrigating agents are delivered safely to the full extent of the root canal terminus, thereby removing 100% of organic tissue and 100% of the microbial contaminants, success in endodontic treatment may be taken to levels never seen before. References 1 Friedman S,MorC.Thesuccess ofendodontictherapy—healing and functionality. J Calif Dent Assoc. 2004;32(6):493–503. 2 Orstavik D, Pittford T. Essential endodontology: prevention and treatment of apical periodontitis. 2nd ed. Ames, IA: Blackwell Munksgaard Ltd; 2008:1. 3 Ricucci D, Siqueira JF Jr. Biofilms and apical periodontitis: study of prevalence and association with clinical and histopathologic findings. J Endod. 2010;36(8);1277-88. 4 FabriciusL,DahlenG,SundqvistG,etal.Influenceofresidual bacteria on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected monkey teeth. Eur J Oral Sci. 2006;114:278-85. 5 Siqueira JF Jr, Rocas IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod. 2008;34:1291-301. 6 Wong R. Conventional endodontic failure and retreatment. Dent Clin North Am. 2004;48:265-89. 7 Basmadjian-Charles CL, Farge P, Bourgeois DM, Lebrun T. Factors influencing the long-term results of endodontic treatment: a review of the literature. Int Dent J. 2002;52:81-6. 8 Nair PN, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99:231-52. 9 Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. Review of contemporary irrigant agitation techniques and devices. J Endod. 2009;35(6):791-804. 10 Peters OA. Current challenges and concepts in the preparation of root canal systems: A review. J Endod. 2004;30:559-67. 11 Siqueira JF, de Uzeda M, Fonseca MEF. A scanning electron microscope evaluation of in vitro dental tubules penetration by selected anaerobic bacteria. J Endod. 1996;22:308-10. 12 Haapasalo M. In vitro infection and disinfection of dentinal tubules. J Dent Res. 1987;66:1375-79. 13 Gomes BP, Pinheiro ET, Gade-Neto CR, et al. Microbiological examination of infected dental root canals. Oral Microbiol Immunol. 2004;19:71-6. 14 Orstavik D, Haapasalo M. Disinfection by endodontic irrigants and dressings of experimentally infected dentinal tubules. Endod Dent Traumatol. 1990;6:142-9. 15 Nakajo K, Komori R, Ishikawa S, et al. Resistance to acidic and alkaline environments in the endodontic pathogen Enterococcus faecalis. Oral Microbiol Immunol. 2006;21:283-8. 16 de Gregorio C, Estevez R, Cisneros R, Paranjpe A, Cohenca N. Efficacy of different irrigation and activation systems on the penetration of sodium hypochlorite into simulated lateral canals and up to working length: An in vitro study. J Endod. 2010;36(7):1216-21. 17 Basson N, Tait C. Effectiveness of three root canal medicaments to eliminate Actinomyces israelii from infected dentinal tubules in vitro. S A Dent J. 2000;56:499-501. 18 Kruse A, Hellmich N, Luebbers HT, Grätz KW. Neurological deficit of the facial nerve after root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(2):e46-8. 19 Paragliola F, Franco V, Fabiani C, et al. Final rinse optimization: Influence of different agitation protocols. J Endod. 2010;36(2):282-5. 20 Zehnder M. Root canal irrigants review. J Endod. 2006;32:389-98. 21 Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod. 2004;30:785-7. 22 Haikel Y, Gorce F, Allemann C, et al. In vitro efficiency of endodontic irrigation solutions on protein desorption. Int Endod J. 1994;27:16-20. 23 Spratt DA, Pratten J, Wilson M, et al. An in vitro evaluation of the antimicrobial efficacy of irrigants on biofilms of root canal isolates. Int Endod J. 2001;34:300-7. www.ineedce.com 9
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