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Recent advances in endodontic irrigation devices

CONTAINS DETAILS ABOUT VARIOUS IRRIGATION DEVICES USED IN ENDODONTICS

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Recent advances in endodontic irrigation devices

  1. 1. RECENT ADVANCES IN IRRIGATION DEVICES DR. ANUPRABHA SHRIVASTAVA PG-2nd YR DEPT. OF CONSERVATIVE DENTISTRY & ENDODONTICS 1
  2. 2. CONTENTS  Manual irrigation devices  Machine assisted irrigation devices  Safety irrigator  SAF  NaoCl accident  Comparative evaluation of all devices  Concluding remarks 2
  3. 3. 3
  4. 4. MANUAL AGITATION TECHNIQUES A) SYRINGE IRRIGATION  It is the most common and conventional set of irrigation techniques.  It involves dispensing of an irrigant into a canal through needles/cannulae of variable gauges, either passively or with agitation by moving the needle up and down the canal space without binding it on the canal walls.  The needle/cannula should remain loose inside the canal so that it allows the irrigant to reflux and causes more debris to be displaced coronally, while avoiding the extrusion of the irrigant into periapical tissues. 4
  5. 5.  Some of these needles are designed to dispense an irrigant through their most distal ends, whereas others are designed to deliver an irrigant laterally through closed-ended, side-vented channels.  The latter design has been proposed to improve the hydrodynamic activation of an irrigant and reduce the chance of apical extrusion.5
  6. 6.  Advantage of syringe irrigation is that it allows good control of needle depth and the volume of irrigant that is flushed through the canal.  Disadvantage is that it is 1. Difficult to standardize fluid flow rate. 2. Inaccessible canal extensions likely to harbor debris and bacteria. 3. Mechanical flushing action created by conventional hand-held syringe needle irrigation is relatively weak. 6
  7. 7. IRRIGATION TECHNIQUE • Disposable plastic syringes of 2.5 or 5 ml capacity with 27 gauge blunted needles are useful for endodontic irrigation. 7
  8. 8. • The needle should be bent to an obtuse angle, to reach the canals of posterior as well as anterior teeth. • 8
  9. 9.  If needle does not bind, the solution should be ejected from the syringe with little or no pressure on the plunger. 9
  10. 10.  Most of the residual irrigating solution may be removed from the root canal by holding the needle of the syringe in the canal and withdrawing the plunger slowly.  Compressed air must not be used for drying the root canal because tissue emphysema may result if an air bubble penetrates the periapical tissue.  Drying should be done with absorbent points. 10
  11. 11. DIFFERENT IRRIGATING NEEDLES USED o Beveled tip. o Monoject tip. o Safe ended tip. BEVELED NEEDLE: o In beveled needle irrigant is forced apically. 11
  12. 12. MONOJECT TIPS: o Advantage of passing irrigant to the Side. SAFE ENDED TIP: o Best tip advantage of passing irrigant to the side. 12
  13. 13. ADVANCED IRRIGATING NEEDLE Max I Probe Needle or Pro Rinse 13
  14. 14.  Max I probe is basically closed ended, side vented needle. ADVANTAGE :  Prevents extrusion of irrigating solution into periapical tissue 14
  15. 15.  Grossman recognized the need for adequate enlargement of the root canal to improve irrigation efficacy in 1943.  It has been reported that hand-held syringe needle irrigation is less effective when the canal is enlarged to less than size 40 at the apex. (Wu MK et al, 1995)  Therefore, clinicians need to balance the mechanical efficacy of irrigation via canal enlargement. This leads to inadvertent reduction in radicular dentin thickness and subsequent weakening of the root structure. 15
  16. 16. NEEDLE IN ROOT CANAL. INJECTION OF IRRIGATING SOLUTION. 16
  17. 17. B) BRUSHES  Brushes are not directly used for delivering an irrigant into the canal spaces.  They are adjuncts for debridement of the canal walls or agitation of root canal irrigant.  A 30-gauge irrigation needle covered with a brush (NaviTip FX; Ultradent Products Inc, South Jordan, UT) was introduced commercially.  A study reported improved cleanliness of the coronal third of instrumented root canal walls irrigated and agitated with the NaviTip FX needle over the brushless type of NaviTip needle. (Al-Hadlaq SM et al, 2006) 17
  18. 18.  Nevertheless, the differences in the apical and middle thirds were not statistically significant.  The results might have been improved if the brush-covered needle was mechanically activated so that it can perform active scrubbing action against.  But, friction created between the brush bristles and the canal irregularities might result in the dislodgement of the radiolucent bristles in the canals that are not easily recognized by clinicians, even with the use of a surgical microscope. 18
  19. 19. NAVITIP FX NEEDLE WITH BRUSH 19
  20. 20.  Keir et al in early 1990s, performed a study and used Endobrush for improved canal debridement.  The Endobrush (C&S Microinstruments Ltd, Markham, Ontario, Canada) is a spiral brush designed for endodontic use that consists of nylon bristles set in twisted wires with an attached handle and has a relatively constant diameter along the entire length.  In that study the bristles of the brush were claimed to extend to the non instrumented canal walls and into the fins, cul-de-sacs, and isthmi of the canal system to remove trapped tissue and debris. 20
  21. 21.  However, the Endobrush could not be used to full working length because of its size, which might lead to packing of debris into the apical section of the canal after brushing. ENDOBRUSH 21
  22. 22. C) MANUAL DYNAMIC IRRIGATION  An irrigant must be in direct contact with the canal walls for effective action.  However, it is often difficult for the irrigant to reach the apical portion of the canal because of the so-called vapor lock effect.  Research has shown that gently moving a well fitting gutta-percha master cone up and down in short 2-3 mm strokes (manual dynamic irrigation) within an instrumented canal can produce an effective hydrodynamic effect and improve the displacement of any given reagent.  It has demonstrated that manual dynamic irrigation was significantly more effective than an automated dynamic irrigation system (RinsEndo Du¨ rr Dental Co, Bietigheim-Bissingen, Germany) and static irrigation. (McGill S, 2008) 22
  23. 23.  Several factors could have contributed to the positive results of manual-dynamic irrigation: 1) A well fitted gutta-percha point in the canal might generate higher intracanal pressure during pushing movements, leading to forcing of irrigant to the untouched canal surfaces. 2) The frequency of push-pull motion of the gutta-percha point (3.3 Hz, 100 strokes per 30 seconds) is higher than the frequency (1.6 Hz) of positive-negative hydrodynamic pressure generated by RinsEndo, possibly generating more turbulence in the canal. 3) The push-pull motion of the gutta-percha point allows better mixing of the fresh unreacted solution with the spent, reacted irrigant. 23
  24. 24.  Although manual-dynamic irrigation is simple and cost- effectiveness, the laborious nature of this hand-activated procedure still hinders its application in routine clinical practice.  Therefore, there are a number of automated devices designed for agitation of root canal irrigants. 24
  25. 25. MACHINE ASSISTED IRRIGATION A) ROTARY BRUSHES  Ruddle used a micro brush attached to rotary handpiece.  The brush includes a shaft and a tapered brush section. The latter has multiple bristles extending radially from a central wire core.  This micro brush rotates at about 300 rpm, causing the bristles to deform and go into the irregularities of the preparation & displace residual debris out of the canal in a coronal direction. 25
  26. 26.  However, this product has not been commercially available since the patent was approved in 2001.  Commercially available endodontic microbrush is Canalbrush (Coltene Whaledent, Langenau, Germany).  This is highly flexible and is molded entirely from polypropylene.  It might be used manually with a rotary action. However, it is more efficacious when attached to a contra-angle handpiece running at 600 rpm. 26
  27. 27. B) CONTINUOUS IRRIGATION DURING ROTARY INSTRUMENTATION: QUANTEC - E  Continuous irrigant agitation during active rotary instrumentation would generate: 1) Increased volume of irrigant. 2) Increase irrigant contact time. 3) Greater depth of irrigant penetration inside the root canal.  The Quantec-E irrigation system (SybronEndo, Orange, CA) is attached to the Quantec-E Endo System. 27
  28. 28.  It uses: 1. Pump console. 2. Two irrigation reservoirs. 3. Tubing to provide continuous irrigation during rotary instrumentation.  Quantec-E irrigation did result in cleaner canal walls and more complete debris and smear layer removal in the coronal third of the canal walls.  However, these advantages were not observed in the middle and apical thirds of the root canal. 28
  29. 29. C) SONIC IRRIGATION FREQUENCY AND OSCILLATING PATTERN OF SONIC INSTRUMENTS  Tronstad et al were the first to report the use of a sonic instrument for endodontics in 1985.  Sonic irrigation is different from ultrasonic irrigation in that 1) It operates at a lower frequency (1–6 kHz) 2) Produces smaller shear stresses . 3) Generates significantly higher amplitude or greater back-and- forth tip movement.  Moreover, the oscillating patterns of the sonic devices are different compared with ultrasonically driven instruments. 29
  30. 30.  When the movement of the sonic file is constrained, the sideway oscillation disappears. This results in a pure longitudinal file oscillation.  This mode of vibration has been shown to be particularly efficient for root canal debridement. 30
  31. 31. EFFECT OF SONIC IRRIGATION CONVENTIONAL MORE RECENT Rispisonic file Endoactivator (Medidenta International, (Dentsply Tulsa Dental Inc, Woodside, NY) Specialties, Tulsa, OK) 31
  32. 32.  The Rispisonic files have a non uniform taper that increases with file size.  Because they are barbed, these files might inadvertently engage the canal wall and damage the finished canal preparation during agitation.  Endoactivator consists of a portable handpiece and 3 types of disposable polymer tips of different sizes that are easily attached (snap-on) to the handpiece (A) ENDOACTIVATOR WITH THE LARGE (BLUE) PLASTIC TIP. (B) SAME TIP IN SONIC MOTION. 32
  33. 33.  These tips are claimed to be strong and flexible and do not break easily.  Because they are smooth, they do not cut dentin.  It does not deliver new irrigant to the canal but it facilitates the penetration of the irrigant in the canal.  A recent study have indicated that the use of endoactivator facilitates irrigant penetration and mechanical cleansing compared with needle irrigation, with no increase in the risk of irrigant extrusion through the apex. (Townsend C et al, 2009) 33
  34. 34. VIBRINGE  Vibringe (Vibringe BV, Amsterdam, The Netherlands) is a new sonic irrigation system that combines battery-driven vibrations (9000 cpm) with manually operated irrigation of the root canal.  Vibringe uses the traditional type of syringe/needle delivery but adds sonic vibration. 34
  35. 35. D) ULTRASONICS  Ultrasonic devices were first introduced in endodontics by Richman.  Ultrasonic energy produces higher frequencies (25- 30 kHz) than sonic energy but low amplitudes.  They operate in transverse vibration.  Two types of ultrasonic irrigation are available for use.  The first type is simultaneous ultrasonic instrumentation and irrigation (UI), and the second type is referred to as passive ultrasonic irrigation (PUI) operating without simultaneous instrumentation. 35
  36. 36.  UI is shown to be less effective than PUI. This can be explained by a reduction of acoustic streaming and cavitation.  In UI, the file contacts the root canal wall, so the oscillations are dampened and becomes too weak to maintain acoustic streaming.  For proper acoustic streaming, the ultrasonic file should move freely in the canal without making contact with the canal wall.  A canal size of at least 30-40 file is required to maintain free oscillation. (Irrigant can also penetrate more easily into apical part).  Disadvantage of UI is difficult to control the cutting of dentin during ultrasonic preparation which can result in apical perforation & irregular canal shapes. 36
  37. 37.  PUI was first described by Weller et al.  The term passive does not adequately describe the process, since it is infact active.  The term passive relates to non cutting action of ultrasonically activated file.  The active streaming of the irrigant, increases its potential to contact a greater surface area of the canal wall. 37
  38. 38.  After the canal has been shaped to MAF, a small file or a smooth wire is introduced at the centre of the canal, as far as the apical region.  Canal is then filled with irrigating solution, and ultrasonically oscillating file activates the irrigant.  Using this non cutting methodology, the potential to create aberrant shapes within root canals are reduced to a minimum. 38
  39. 39.  Ultrasonics is not able to effectively get through the apical vapor lock in the apical 3 mm of the canal.  It has been shown that once a sonic or ultrasonically activated tip leaves the irrigant and enters the apical vapor lock, acoustic microstreaming and/or cavitation becomes physically impossible which is not the case with the apical negative pressure irrigation technique. (Nielsen BA et al, 2007)  This is because acoustic microstreaming or cavitation is only possible in fluids/liquids, not in gases.  Ultrasonics can help in debridement of anastomoses between double canals, isthmuses, and fins. 39
  40. 40. CONTINUOUS ULTRASONIC IRRIGATION  Chlorine, which is responsible for the dissolution of organic tissues and the antibacterial property of NaOCl, is unstable and is consumed rapidly during the first phase of tissue dissolution, probably within 2 minutes.  Therefore, an improved delivery system that is capable of continuous replenishment of root canal irrigants is highly desirable.  Recently, a needle-holding adapter to an ultrasonic handpiece has been developed by Nusstein. (Nusstein J, 2005) 40
  41. 41.  During ultrasonic activation, a 25-gauge irrigation needle is used instead of an endosonic file.  The unique feature of this needle-holding adapter is that the needle is simultaneously activated by the ultrasonic handpiece, & at the same time maintains a continuous flow of fresh irrigant.  This technique resulted in: 1. Greater reduction in colony forming units. 2. Reduction in time required for irrigation. 41
  42. 42. INTERMITTENT FLUSH ULTRASONIC IRRIGATION  In intermittent flushed ultrasonic irrigation, the irrigant is delivered to the root canal by a syringe needle.  The irrigant is then activated with the use of an ultrasonically oscillating instrument.  The root canal is then flushed with fresh irrigant to remove the dissolved remnants from the canal walls. 42
  43. 43. E) PRESSURE ALTERNATING DEVICES 1) ENDOVAC ANP SYSTEM  In the EndoVac system (Discus Dental, Culver City, CA), has three components: 1. Master delivering tip 2. Macro cannula 3. Micro cannula 43
  44. 44.  Master delivering tip simultaneously delivers and evacuates the irrigant from the pulp chamber. 44
  45. 45.  The plastic macro cannula has a size 55 open end with a .02 taper and is attached to a titanium handle.  It is used to suction irrigant from the chamber to the coronal and middle segments of the canal. 45
  46. 46.  The ISO size 0.32 stainless steel micro cannula has 4 sets of 3 laser-cut, laterally positioned, offset holes (total 12 holes) adjacent to its closed end.  The holes are 100 microns in diameter and spaced 100 microns apart. 46
  47. 47.  This is attached to a finger-piece for irrigation of the apical part of the canal by positioning it at the working length.  The micro cannula can be used in canals that are enlarged to size 35/.04 or larger.  The Master Delivery Tip (MDT) is connected to a syringe of irrigant.  The macro cannula or micro cannula is connected via tubing to the high-speed suction of a dental unit.  During irrigation, the MDT tip delivers irrigant to the pulp chamber and siphons off the excess irrigant to prevent overflow.47
  48. 48.  The cannula in the canal simultaneously exerts negative pressure that pulls irrigant from its fresh supply in the chamber, down the canal to the tip of the cannula, into the cannula, and out through the suction hose.  Thus, a constant flow of fresh irrigant is being delivered by negative pressure to working length.  ADVANTAGE: 1. Avoid air entrapment. 2. Avoid undue extrusion. 3. Maintains a gentle flow rate. 48
  49. 49.  Apical negative pressure has been shown to enable irrigants to reach the apical third and help overcome the issue of apical vapor lock.  In a comparing the Endoactivator, passive ultrasonic, the F file, the manual dynamic max-i-probe, the pressure ultrasonic, and the endovac, only the endovac was capable of cleaning 100% of the isthmus area. (Klyn SL et al, 2010) 49
  50. 50. MICROBIAL CONTROL:  Hockett et al (2008) tested the ability of apical negative pressure to remove a thick biofilm of Enterococcus faecalis.  He found that the cultures were negative with ANP within 48 hours while those irrigated using traditional positive pressure irrigation were positive. SEM OF DECONTAMINATED DENTINAL TUBULES AFTER USE OF ANP 50
  51. 51. 2) THE RINSENDO SYSTEM  RinsEndo irrigates the canal by using pressure-suction technology.  Its components are a handpiece, a cannula with a 7 mm exit aperture, and a syringe carrying irrigant. 51
  52. 52.  The handpiece is powered by a dental air compressor and has an irrigation speed of 6.2 ml/min & (1.6 Hz amplitude).  Periapical extrusion of irrigant has been reported with this device. RINSEENDO FITS LEADING HANDPIECE COUPLINGS RINSEENDO HANDPIECE WITH DISPOSABLE CANNULAS AND SPLASH PROTECTOR 52
  53. 53. RINSEENDO IS PREPARED FOR THE TREATMENT 53
  54. 54. SAFETY IRRIGATOR  It is an irrigation/evacuation system that apically delivers the irrigant under positive pressure through a thin needle with a lateral opening, and evacuates the solution through a large needle at the root canal orifice. 54
  55. 55. SELF ADJUSTING FILE  It has a hollow thin walled cylinder composed of a thin nickel-titanium lattice.  It is compressible and adjusts to the anatomy of the root canal.  SAF operates with a continuous flow of irrigant (5ml/min) running through the instrument.  The vibrating movement of SAF within the irrigant facilitates its cleaning and debriding effects. 55
  56. 56.  Root canals vary greatly in their cross-sectional anatomy, and oval, flat, and C-shaped canals are commonly found  SAF is designed to efficiently prepare root canals that do not have a round cross section because the compressible file adapts its shape to the canal anatomy.  It is operated with a modified KaVo handpiece that generates in and out vibrations with 5000vibrations/min and 0.4mm amplitude.  A VATEA irrigation unit is used to deliver a constant flow of irrigant. 56
  57. 57. 57
  58. 58. SODIUM HYPOCHLORITE INCIDENT  Sodium hypochlorite (NaOCl) incident is a rare event.  Its sequelae includes: 1) Ecchymosis 2) Widespread tissue trauma 3) Tooth loss 4) Facial disfigurement 5) Permanent paresthesia 6) Loss of facial muscle control 7) Irreversible muscle atrophy 8) Life-threatening airway obstruction 58
  59. 59. IRREVERSIBLE MUSCULATURE ATROPHY WIDESPREAD TISSUE TRAUMA 59
  60. 60.  Although the exact etiology of the NaOCl incident is still uncertain, based on the evidence from actual incidents, it would appear that an intravenous injection may be the cause.  In case of extrusion, if the vein is close to the root apex, the irrigant can find its way into the venous complex.  This would require positive pressure apically that exceeded venous pressure (10 mm of Hg).  And so, NaoCl must be safely delivered. 60
  61. 61. COMPARATIVE EXTRUSION OF IRRIGANT USING IRRIGATION DEVICES (Gary Glassman, 2011) 61
  62. 62. OTHER TECHNIQUES OF ROOT CANAL DISINFECTION 1) LASERS  It has been documented in several studies that CO2, Argon, Nd:YAG, Er:YAG laser has the ability to remove smear layer and debris.  A new endodontic side firing spiral tip (RCLase; Lumenis, Opus Dent, Israel) overcomes the disadvantage of the straight emission of the laser beam, and thus claims to enable cleaning of the root canal walls laterally. 62
  63. 63. 2) PHOTO ACTIVATED DISINFECTION  It includes PDT/LAT i.e photo dynamic therapy or light activated therapy. Light of Photosensitizer Oxygen based free specific wavelength Activation radical formed (tolonium chloride) Multiple Targets Membrane damage Genetic damage Enzyme inactivation  Optic fibre may be used to direct the irradiation to the intended side of application.63
  64. 64.  Advantage of PDT: 1. Wide spectrum of anti microbial activity. (also act on antibiotic resistant strains) 2. Minimal chance of giving rise to resistant microbial population.  It is dual selective i.e only those cells which have selectively accumulated the photosenstizer or which have endogenously produced photosensitizer will be affected upon radiation.  Low intensity light and the non toxic photo sensitizer both are harmless. 64
  65. 65. 3) INTRALIGHT UV DISINFECTION  UV light is used for disinfection.  Intralight consist of an intracanal UV illuminator shaped in the form of an endodontic file.  It proides uniform circumferential illumination of the root canal with 254nm UV light.  It is used as a supplemental disinfection after NaOCl irrigation, otherwise the bacteria in the inner layer of biofilm may be protected by UV light which is absorbed by outer layer bacterias. 65
  66. 66. 4) SUPER OXIDIZED WATER  Also known as “electro chemicaly activated” water in Russia & “oxidative potential water” in Japan.  Its basically saline that is electrolysed to produce: superoxidized water, hypochlorous acid and free chlorine radical.  The solution at anode is harvested as anolyte, & that at cathode as catholyte.  It is available as Sterilox.  It has been tested for its ability to remove smear layer, root canal debridement & killing bacteria. 66
  67. 67. 5) HEAL OZONE  Ozone is triatomic oxygen or trioxygen.  It is found in stratosphere at a concentration of 1-10 ppm. It is created from & destroyed into molecular oxygen.  It acts as antimicrobial agent in gaseous/ aqueous form.  The strongest acid produced by acidogenic bacteria is pyruvic acid. Ozone decarboxylate it into acetic acid.  This acetic acid encourages remineralization. 67
  68. 68. Ozone attacks Glycolipids, Glycoproteins, amino acids & inhibits enzymatic control Increases cell membrane permeability Ozone enters the cell Immediate functional cessation 68
  69. 69. CONCLUDING REMARKS  Effective irrigant delivery and agitation are prerequisites for successful endodontic treatment.  There is a need to determine how these devices are perceived in terms of their practicality and ease of use. 69
  70. 70. REFERENCES  Pathways of the pulp ,cohen, 6th & 9th edition  Endodontics, ingle,6th edition.  Endodontic practice, Grossman , 11th edi. & 12th edi.  Lisha G, Kim JR. review of contemporary irrigant agitation techniques and devices. J Endod 2009:35(6):791-804.  Safety and Efficacy Considerations in Endodonti Irrigation :A Peer-Reviewed Publication Written by Gary Glassman, 2011 70
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