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Th is course waswritten for dentists,dental hygienists,and assistants

P e n n W e l l i s a n A D A C E R P r e c o g n i z e d p r o v i d e iA D A C E R P I s a s e r v ic e o f t t i e A m e r i c a n O e f f l a l A s s o c ia t io n to a s s is t d e n t a l p r o f e i s k m a i s inI d e n t i f y in g n u a l i ty p i o v l d e r i of c o n t in u i n g d e n t i l e i o t a t l o n AD A C E S P d o e s n o t a p p r o v e

A D A C E - R - P ' I S S S S S S S ' " * " * " ' f i i i l c o u r s e s 0 1 I n s t m t t o r s , n or d o e s it i m p l y a c c e p t a n ce of c r e d i t h o u r sb y b o a r d s o f d e n t i s t r yC o n c e r n s or c o m p l a i n ts a b o u l a C E p r o v u fe r m a y b e d i r e c t e d lo l l i i p r o v i d e r o r t o A D A ( E R Pa t w w w a d a o r g / g o t o / c e r p CE ineedCG.comThe Academy ol DentalTherapmitlcs and Slomalolojy

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Educational O bjectivesTh e overall goal of this article is to provide the reader withinformation on endodontic irrigation.On completion of this course, the reader will be able to:1 . List and describe the challenges for successful endodon-

tic treatment2 . List and describe the different types of root canal irrig-ants, their relative advantages and disadvantages3 . List and describe root canal irrigation systems4 . Describe and explain a sodium hypochlorite incident5 . List and describe the steps that can be taken to avoid a

sodium hypochlorite incident.AbstractEndodontic treatment is a predictable procedure withhigh success rates. Success depends on a number of fac-tors, including appropriate instrumentation, successfulirrigation and decontamination of the root canal space tothe apices and in areas such a s isthmuses. These steps mustbe followed b y complete obtu ration of the root canals, andplacement of a coronal seal, prior to restorative treatment.Several irrigants and irrigation systems are available, allof which behave differently and have relative advantagesand disadvantages. Common root canal irrigants includesodium hypochlorite, chlorhexidine gluconate, alcohol,hydrogen peroxide and ethylenediaminetetraacetic acid(EDTA). In selecting an irrigant and technique, consid-eration mu st be given to their efficacy and safety.IntroductionWith the introduct ion of modern techniques, end-odon tic success rates of up to 98% are being achieved. 'Th e ul t imate goal of endodon tic t reatment pe r s e is theprevention or treatment of apical periodontitis suchthat the re is comp lete healing and an absence of infec-tion , ' while the overall long-term goal is the placemen tof a definitive, clinically successful restoration andpreservation of the tooth. For these to be achieved,appropriate instrumentation, irrigation and decon-tamination, and root canal obturation must occur,as well as attainment of a coronal seal. There is clearevidence that apical periodontitis is a biofilm-induceddisease. ' A biofilm is an aggregate of microorga nismsin which cells adhe re to each other an d/ or to a surface.Th ese adherent cells are frequently e mb edded withina self-produced matrix of extracellular polymeric sub-stance. Th e presence of microorganisms em bedded ina biofilm and growing in the root canal system is a keyfactor for the development of periapical lesions.' '^' ''Additionally, the root canal system has a complexanatomy that consists of arborizations, isthmuses, and

The challenge for successful endodontic treatment halways been the removal of vital and necrotic remnants pulp tissues, debris generated during instrumentation, tdentin smear layer, microorganisms, and microtoxins frothe root canal system .'F ig u r e 1 . R o o t c a n a l c o m p l e x

I

C o u r t e s y o f O r . C h a r l e s J . G o o d i s . I n : M a n d i b u l a r M o l a r E n d o d o n t ic T r e a t m e n t .

Even with the use of rotary instrumentation, the nickel-titnium instruments currently available only act on the centrbody of the root canal, resulting in a reliance on irrigatito clean beyond what may be achieved by these instrments. '" In addition, EnXerococcus jaecalis and Actinorrisraeliiwhich are both implicated in endodontic infectas well as in endodontic failurepenetrate deep into tdentinal tubules, making their removal through mechanicinstrumentation impossible." '- Finally, Enterococcus faecommonly expresses multiple drug resistance,'^''''^ furthcomplicating treatment.Therefore, a suitable irrigant and irrigant delivery sytem are essential for efficient irrigation and the success endodontic therapy.'^ Not only should root canal irriganbe effective for dissolution of the organic component of tdental pulp, they must also effectively eliminate bactercontamination and remove the smear layerthe organic ainorganic layer that is created on the wall of the root canduring in strum entation. T he ability to deliver irrigants to troot canal terminus in a safe manner without causing harmthe patient is as important a s the efficacy of those i rrigantsRoot Canal Irrigants

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rial decontamination. Th e desired attributes of a root canalirrigant include the ability to dissolve necrotic and pulpaltissue, bacterial decontamination and a broad antimicrobialspectrum, the ability to enter deep into the dentinal tubules,biocompatibility and lack of toxicity, the ability to dissolveinorganic material and remove the smear layer, ease of use,and m oderate cost.Table 1. Desirable root canal irrigant attributes

Bacterial decontaminationBroad spectrum antimicrobial activityAbility to enter deep into dentinal tubulesAbility to dissolve necrotic tissueAbility to dissolve inorganic materialSafetyBiocompatibilityLack of toxicityEase of useModerate cost

Root canal irrigants currently in use include hydrogenperoxide, sodium hypochlorite, ethylenediaminetetraace-tic acid (ED TA ), alcohol, and chlorhexidine gluconate.C^lhlorhexidine gluconate offers a wide antimicrobial spec-trum, the main bacteria associated with endodontic infec-t ions [Enterococcus faecalis and Actinomyces israelii) aresensitive to it, and it is biocompatible with no tissue toxicityfor the periapical or surrounding tissues.'' Chlorhexidinegluconate, however, lacks the ability to dissolve necrotictissue, which limits its usefulness. Hydrogen peroxide asa canal irrigant helps to remove debris by the physical actof irrigation as well as throu gh effervescing of the solution .However, while an effective an tibacterial irrigant, hydrogenperoxide also does not dissolve necrotic intracanal tissue,and exhibits toxicity to the surrounding tissues. Cases ofissue damage and facial nerve damage have been reported

lowing use of hydrogen peroxide as a root canal irrigant.'"canal irrigants also have antimicrobial activ-y, but will not dissolve necrotic tissue.

Cblorhexidine gluconateSodium hypochloriteAlcoholHydrogen peroxide ; D T A

The irrigant that satisfies most of the requirements for

organic components of the smear layer. "'^'^ It also killssessile endodontic pathogens organized in a biofilm.'''''The re is no other root canal irrigant that can meet all theserequireme nts, even with the use of method s such as lower-ing the pH,"-'-' increasing the temperature,-'*-'''"'"'- oradding surfactants to increase the wetting efficacy of the ir-rigant. However, although sodium hypo chlorite appearsto be the most d esirable single endodontic irrigant, it cannotdissolve inorganic dentin particles and thus cannot preventthe formation of a smear layer during instrumentation. '

Calcifications hindering mechanical preparation arefrequently encountered in the canal system, further com-plicating treatment. Demineralizing agents such as EDTAhave therefore been recommended as adjuvants in rootcanal therapy.-'"'"Thus, in contemporary endodontic prac-tice, dual irrigants such as sodium hypochlorite (NaOCl)with ED TA are often used as initial and final rinses to cir-cumvent the shortcomings of a single irrigant. '"'"''' Theseirrigants must be brought into direct contact with the entirecanal wall surfaces for effective action,-'"'" " particularly forthe apical portions of small root canals.''

The combination of sodium hypochlorite and EDTAhas been used worldwide for antisepsis of root canal sys-tems. The concentration of sodium hypochlorite used forroot canal irrigation ranges from 2.5% to 6%, dependingon the country and local regulations; it has been shown,however, tha t tissue hydrolyzation is greater at the higherend of this range, as demonstrated in a study by Hand etal comparing 2.5% and 5.25% sodium hypochlorite. Thehigher concentration may also favor superior microbialoutcomes."" N aO Cl has a broad antimicrobial spectrum,-"including but not limited to Enterococcus faecalis. Sodiumhypochlorite is also second to none among irrigating agentsthat dissolve organic matter. E DT A is a chelating agent thataids in smear layer removal and increases dentin perme-ability,^'^'which will allow further irrigation with NaOClto penetrate deep into the dentinal tubules.''"'

T h e c o m b in a t i o n o f s o d iu m h y p o c h lo r i te a n d EDTA h asbeen used wor ldwide fo r an t iseps is o f r oo t cana l sys tems.

General Safety PrecautionsRegardless of which irrigant and irrigation system is em-ployed, and particularly if an irrigant with tissue toxicity isused, there are several general precautions that must be fol-lowed. A rubber dam m ust be used and a good seal obtainedto ensure that no irrigant can spill from the pulp chamberinto the oral cavity. If deep caries or a fracture is presentadjacent to the rubber dam on the tooth being isolated, atemporary sealing material must be used prior to perform-ing the procedure to ensure a good rubber dam seal. It is alsoimportant to protect the patient's eyes with safety glasses

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It is very important to note that while sodium hypochlo-rite has unique properties that satisfy most requ irements fora root canal irrigant, it also exhibits tissue toxicity tha t can re-sult in damage to the adjacent tissues, including nerve dam-age should sodium hypochlorite incidents occur during canalirrigation. Furtherm ore, Salzgeber reported in the 1970s thatapical extrusion of an endodon tic irrigant routinely occurredin vivo;*^ this highlights the importance of using devices andtechniques that minimize or prevent this. Sodium hypochlo-rite incidents are further discussed later in this article.

Regard less of which i rr igant and i rr igat ion system is used,a rubber dam must be used and a good seal obta ined.

Irrigant Delivery SystemsRoot canal irrigation systems can be divided into two catego-ries: manual agitation techniques and machine-assisted agita-tion techn iques.' Manual irrigation includes positive pressureirrigation, which is commonly performed with a syringe anda side-vented needle. Machine-assisted irrigation techniquesinclude sonics and ultrasonics, as well as newer systems suchas the EndoVac (Discus Dental, Culver City, CA), whichdelivers apical negative pressure ( ANP) irrigation,'"' the plas-tic rotary F File (Plastic Endo, Lincolnshire, IL),''"'"* theVibringe (Vibringe BV, Amsterdam, The Netherlands),'*'the RinsEndo (Air Techniques Inc., NY) ,' and the Endo-Activator (Dentsply Tulsa Dental Specialties, Tulsa, OK ).'Two important factors that should be considered duringthe process of irrigation are whether the irrigation systemcan deliver the irrigant to the whole extent of the root canalsystem, particularly at the apical third, and whether the ir-rigant is capable of debriding areas that could not be reachedwith mechanical instrumentation, such as lateral canals andisthmi. When evaluating irrigation of the apical third, thephenomenon of apical vapor lock should be considered.'"'''^Apical Vapor LockSince roots are surrounded by the periodontium , and unlessthe root canal foramen is open, the root canal behaves likea close-ended channel. This produces an apical vapor lockeffect tha t resists displacement during instrumen tation andfinal irrigation, thus preventing the flow of irrigant intothe apical region and adequate debridement of the canalsyste m." '''' Apical vapor lock also results in gas entrap men tat the apical third.'During irrigation, sodium hypochloritereacts with organic tissue in the root canal system, andthe resulting hydrolysis liberates abundant quantities ofammonia and carbon dioxide." This gaseous mixture istrapped in the apical region and quickly forms a columnof gas into which further fluid penetration is impossible.Extension of instruments into this vapor lock does not re-

Apica l vapor lock prevents the f low of i r r igant in tothe apica l reg ion of roots and a lso resul ts in gas

e n t r a pme n t a t th e a p ica l t h i r d .

The phenomenon of apical vapor lock has been confirmin studies where roots were embedded in a polyvinylsiloxa(PVS) impression material to restrict fluid flow through tapical foramen, simulating a close-ended channel. The resin these studies was incomplete debridement of the apicpart of the canal walls with the use of a positive pressusyringe delivery technique."''*''"" Micro-CT scanning ahistological tests conducted by Tay et al have also confirmthe presence of apical vapor lock.*"" In fact, studies conducwithout ensuring a close-ended channel cannot be regardas conclusive on the efficacy of irrigants and the irrigan t sy^gjjj 61,62.63 Yj^g apical vapor lock may also explain why, inumber of studies, investigators were unable to dem onstraa clean apical th ird in sealed root canals.''""''=''F ig u r e 2 a . C l o s e - e n d e d c h a n n e l F ig u r e 2 b . O p e n - e n d e d c h a n

C o u r t e s y o f D r . F r a n i < i i n T a y

In a paper published by Chow in 1983, based on researhe determined that traditional positive pressure irrigatihad virtually no effect apical to the orifice of the irrigatineedle in a closed root canal system.*'' Fluid exchange adebris displacement were minimal. Equally important to primary findings. Chow set forth an infallible paradigm endodontic irrigation: "For the solution to be mechanicaeffective in removing all the particles, it has to: (a) reach tapex; (b) create a current (force); and (c) carry the particaway."*"' The apical vapor lock and consideration for the ptient's safety have always prevented the thorough cleaningthe apical 3 mm. It is critically important to determine whirrigation system will effectively irrigate the apical thirdwell as isthmi and lateral canals,"' and in a safe manner thprevents the extrusion of irrigant.

An e f fec t ive i r r iga n t m ust reach the apex, c rea te a cu r re

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Manual Agitation TechniquesBy far the most common and conventional set of irrigationlechniques, manual irrigation involves dispensing of an ir-rigant into a canal through needles/cannulae of variablegauges, either passively or with agitation by moving theneedle up and down the canal space without binding it onthe canal walls. Th is allows good control of needle depth andthe volume of irrigant that is flushed through the canal.''"However, the closer the needle tip is positioned to the apicaltissue, the greater the chance of apical extrusion o fthe irrig-, j (. 6768 'pj^jg must be avoided; if sodium hypochlorite wereto extrude past the apex there is a chance that a catastrophicaccident could occur.''*'Manual-Dynaniiic IrrigationManual dynamic irrigation involves gently moving a well-fit-ting gutta-percha master cone up and down in short 2 mm to3 mm strokes within an instrumented canal, thereby produc-ing a hydrodynamic effect and significant irrigant exchange.'"Recent studies have shown that this irrigation technique issignificantly more effective than an automated-dynamic ir-rigation system and static irrigation.''"'''F ig u r e 3 . M a n u a l D y n a m ic M a x - I - P r o b e ' *

Machine-Assisted Ag itation Systems

Sonic IrrigationSonic activation has been shown to be an effective methodfor disinfecting root canals, operating at frequencies of 1-6kHz.'''"* There are several sonic irrigation devices on themarket. The Vibringe allows delivery and sonic activationof the irrigating solution in one step. It employs a 2-piecesyringe with a rechargeable battery. The irrigant is soni-cally activated, as is the needle that attaches to the syringe.The EndoActivator System is a more recently introducedsonically driven canal irrigation system. ' ' " It consists of aportable handpiece and three types of disposable polymertips of different sizes. Th e Endo Activator has been reportedto effectively clean debris from lateral canals, remove the

F i g u r e 4 . S o n i c i r r i g a t i o n s y s t e m s

UltrasonicsUltrasonic energy produces higher frequencies than sonicenergy but low amplitudes, oscillating at frequencies of 2 5 -30 kHz.'''"'' Two types of ultrasonic irrigation are availablefor u s e . The first type is simultaneous ultrasonic instrumen-tation and irrigation (UI), and the second type is referredto as passive ultrasonic irrigation operating without simul-taneous irrigation (PUI). The literature indicates that it ismore advantageous to apply ultrasonics after completion ofcanal preparation rather than as an alternative to conven-tional instrumentation."-"" PUI irrigation allows energyto be transmitted from an oscillating file or smooth wire tothe irrigant in the root canal by means of ultrasonic waves.'There is consensus that PUI is more effective than syringeneedle irrigation in removing pulpal tissue remnants anddentin debris."""*" This may be due to the much highervelocity and volume of irrigant Bow that are created in thecanal during ultrasonic irrigation.''*' PUI has been shownto remove the smear layer; there is a large body of evidencewith different con cen trations of NaOCl."'""'"'''"'"' In addi-tion, numerous investigations have demonstrated that theuse of PUI after hand or rotary instrumentation results ina significant reduction of the number of bacteria,' *'*'''"' orachieves significantly better results than syringe needle ir-rigation.''^'"''*'

Studies have demon strated that effective delivery of irri-gants to the apical third can be enhanced by using u ltrasonicand sonic devices."'*'''"'"''^ However, some recent studieshave shown that once a sonic or ultrasonically activated tipleaves the irrigant and enters the apical vapor lock, acous-tic microstreaming and/or cavitation becomes physicallyimp ossible ," which is not the case with th e apical negativepressure irrigation technique.*"'"'

Consider the erroneous idea that acoustic microstream-ing or cavitation that occurs during PU I can clean any p artof the apical portion filled with gas (apical vapor lock).Acoustic microstreaming is defined as the m ovement o fluidalong cell mem branes, which occurs as a result ofthe ultra-sound energy creating mechanical pressure changes within

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This process (cavitation) results from the creation and col-lapse of microbubbles in the liquid. Acoustic microstream-ing or cavitation is only possible in fluids/liquids, not ingases. Therefore, as previously mentioned, it is physicallyimpossible for acoustic microstreaming and/or cavitationto disrupt theap ical vapor lock.."'

Oth er studies have shown that sonic or ultrasonic activa-tion might allow a better removal of pulpal tissue rem nantsand debris from isthmi and fins.'*"*'Although ultrasonicscan effectively clean debris and bacteria from th e root canalsystem, they still have the drawback of not being able toeffectively get throug h th e apical vapor lock in the apical 3mm ofthe canal.

Ultrasonics can effectively clean debris and bacteria fromthe root canal system, but cannot ef fect ively get throu ghtheap ica l vapor lock .

The Plastic R otary F FileAlthough sonic or ultrasonic instrum entation is more effec-tive in removing residual canal debris than rotary endodonticfiles'*' and irrigation solutions are often unable to removethis during endodontic treatment, many clinicians still donot incorporate it in their endodontic instrument armamen-tarium. The common reasons given for not using sonic orultrasonic filing are that it can be time consuming to set up,an unwillingness to incur the cost ofthe equipm ent, and lackof awareness ofthe benefits of thisfinal nstrumentation stepin endodontic treatment.

It is for these reasons that an endodontic polymer-basedrotary finishing file was developed. This new, single-use,plastic rotary file has a unique file design with a diamondabrasive embedded into a nontoxic polymer. The F File willremove dentinal wall debris and agitate the sodium hypochlo-rite without further enlarging the canal.Pressure Alternation DevicesRinsEndo irrigates the canal by using pressure-suctiontechnology. Its components are a handpiece, a cannula witha 7 mm exit aperture, and a syringe carrying irrigant. Thehandpiece is powered by a dental air compressor and has anirrigation speed of 6.2 ml/min. Research has shown that ithas promising results in cleaning the root canal system, butmore research is required to provide scientific evidence forits efficacy. Periapical extrusion of irrigant has been reportedwith this device.''*''"Figure 5. RinsEndo

The EndoVac Apical Negative Pressure SystemThe EndoVac apical negative pressure irrigation system hthree components: The Master Delivery Tip, MacroCannuand MicroCannula. The Master Delivery Tip simultaneousdelivers and evacuates the irrigant. The M acroCannula is usto suction irrigant from the chamber to the coronal and m iddsegments ofthe canal. The MacroCannula or MicroCannuis connected via tubing to the high-speed suction of a denunit. Th e Master Delivery Tip is connected to a syringe ofrigant and the evacuation hood is connected via tubing to thigh-speed suction of a dental unit.^''The plastic MacroCanula has an ISO size 0.55 mm diameter open end with a .taper and is attached to a Handpiece for gross, initial flushof the coronal and mid-length parts of the root canal. TMicroCannula contains 12 microscopic holes and is capableevacuating debris to full working length.'*' The ISO size 0.mm diameter stainless steel MicroCannula has four sets three laser-cut, laterally positioned, offset holes adjacent to closed end, 100 microns in diameter and spaced 100 microapart. This is attached to a Fingerpiece for irrigation ofthe acal part ofthe canal when it is positioned at the working lengThe MicroCannula can be used in canals that are enlargwith endodonticfiles o ISO size #35/.O4 or larger.Figure 6a. EndoVac Mu lt i-Port Adap ter

Figure 6b. EndoVac Ins trum en ts

Master Del ivery Tip

MacroCannula

Mkr oC annu la w i t h ven t i ng

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During irrigation, the Master Delivery Tip delivers irrigantto the pulp chamber and siphons off the excess irrigant toprevent overflow. Both the MacroCannula and MicroCan-nula exert negative pressure th at pu lls irrigant from its freshsupply in the cham ber, down the canal to the tip of the can-nula, into the cannula, and out through the suction hose.Th us , a constant flow of fresh irrigant is being delivered bynegative pressure to working length. A recent study showedthat the volume of irrigant delivered was significantly higherthan the volume delivered by conventional syringe needleirrigation during the same time period,'"' and resulted insignificantly more debris removal at 1 mm from the workinglength than did needle irrigation. During conventional rootcanal irrigation, clinicians must be careful when determin-ing how far an irrigation needle is placed into the canal.Recommendations for avoiding NaOCl incidents includenot binding the needle in the canal, not placing the needleclose to working length, and using a gentle flow rate whenusing positive pressure irrigation.'"* With the EndoVac, incontrast, irrigant is pulled into the canal at working lengthand removed by negative pressure. Apical negative pres-sure has been shown to enable irrigants to reach the apicalthird and help overcome the issue of apical vapor lock.'"' '''In addition, with respect to isthmus cleaning, although it isnot possible to reach and clean the isthm us area with instru-ments, it is not impossible to reach and totally clean theseareas with NaOCI when the method of irrigation is safeand efficacious. In studies comparing the EndoActivator,'""passive ultrasonic,'"" the F File,'"" the Manual DynamicMax-I-Probe, '""'"' the Pressure Ultrasonic,'^and the En-doVac,"" only the EndoVac was capable of cleaning 100% ofthe isthmus area.

The EndoVac uses neg at ive pressure, pu l ls i r r iga nti n to the cana l to work ing l eng th andremoves i t w i t h su c t i o n .Apart from being able to avoid air entrapm ent, the EndoVacsystem is also advantageous in its ability to safely deliverirrigants to working length without causing their undueextrusion into the periapex,^*''" thereby avoiding sodiumliypochlorite incidents. It is important to note that it ispossible to create positive pressure in the pulp canal if theMaster Delivery Tip is misused, which would create therisk of a sodium hypochlorite incident. The manufacturer'sinstructions must be followed for correct use of the MasterDelivery Tip .Sodium Hypochlorite IncidentsAlthough a devastating endodontic sodium hypochlorite (Na-OCl) incident is a rare event,'"-the cytotoxic effects of sodiumliypochlorite on vital tissue have been well established.""Theassociated sequelae of NaOC l extrusion have been reported to

urement requiring multiple corrective surgical procedures,""permanent paresthesia with loss of facial muscle control,*'and the least significant consequencetooth loss. '""T a b l e 2 . P o t e n t ia l s e q u e l a e o f s o d iu m h y p o c h l o r it e e x t r u s io n t h r o u g h t h e a p e x

E c c h y m o s i sW i d e s p r e a d t is s u e t r a u m aT o o t h l o ssF a c i a l d i s f i g u r e m e n tP e r m a n e n t p a r e s th e s i aL o s s of f a c i a l m u s c l e c o n t r o lI r r e v e r s i b le m u s c l e a t r o p h yL i f e - t h r e a t e n i n g a i r w a y o b s t r u c t i o n

Although the exact etiology of the NaOCl incident isstill uncertain, based on the evidence from actual incidentsand the location of the associated tissue trauma, it wouldappear that an intravenous injection may be the cause. Th epatient shown in Figure 7 demonstrates a widespread areaof tissue traum a that is in contrast to the characteristics ofsodium hypochlorite incident trauma reported by Pash-ley.'"""' This extensive trauma, and particularly involvingthe pattern of ecchymosis around the eye, could only occurif the sodium hypochlorite were introduced intravenously toa vein close to the root apex throu gh which extrusion of theirrigant occurred, and the irrigant then found its way intothe venous complex. This would require positive pressureapically that exceeded venous pressure (10 mg of Hg). Inone in vitro study, which used a positive pressure needle ir-rigation technique to realistically mimic clinical conditionsand techniqu es, the apical pressure generated was found tobe 8 times higher than the normal venous pressure. '""Figure 7. Widespread tissue trauma

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Figure 8. Irreversible musculature atrophy

This does not imply that NaOCl can or should be excludedas an end odo ntic irrigant; in fact, its use is critical, as has b eendiscussed in this article. What this does imply is that it mustbe safely delivered.Safety FirstTo compare the safety of six current intracanal irrigation de-livery devices, an in vitro test was conducted using the wo rst-case scenario of apical extrusion, with neutral atmosphericpressure and an open apex. '" Th e study con cluded that theEn do Vac did n ot ex trude irrigant after d eep intracanal de-livery and suctioning of the irrigant from the chamber to fullworking length, whereas other devices did. Th e EndoA ctiva-tor extruded only a very small volume of irrigant, the clinicalsignificance of which is not k now n.Figure 9. Comparative extrusion of irriga nt using irriga tion devices

100

Mitchell and Baumgartner tested irrigant (NaOCl) extrusionfrom a root canal sealed with a permeable agarose gel." " Sig-nificantly less extrusion occurred using th e En do Vac systemcomp ared w ith positive pressure needle irrigation. A well-con-

when apical negative pressure irrigation was performed (Edo Vac) rather tha n apical positive pressure irrigation.""

The use of apical negative pressure needle irrigationresults in safer delivery of sodium hypochlorite, and les

post-operative pain.EfficacyIn vitro and in vivo studies have demo nstrated greater removof debris from the apical walls and a statistically cleaner resusing apical negative pressure irrigation in closed root cansystems with sealed apices. In an in vivo study of 22 teeth Siu and B aumgartner, less debris remained at 1 mm froworking length using apical negative pressure comp ared to uof traditional needle irrigation, while Shin et al found in anvitro study of 69 teeth comparing traditional needle irrigatiwith apical negative pressure that these meth ods b oth resultin clean root canals but that apical negative pressure resultin less debris remaining at 1.5 m m and 3.5 m m from workilength. '" '" '" ' When comparing root canal debridement usiman ual d yna mic ag itation or the E nd o Vac for final irrigatiin a closed system and an open system, it was found that presence of a sealed apical foramen ad versely affected deb ridmen t efficacy w hen m anual dyn amic agitation was used, bu t dnot adversely affect results wh en th e En do Vac was used. A pinegative pressure irrigation is an effective method to overcothe fluid dyna mic challenges inh erent in closed canal systems

Apical negative pressure irrigation results in greaterremoval of debris and a cleaner result at w orking lengthMicrobial ControlHockett et al tested the ability of apical negative pressureremove a thick biofilm of Enterococcus faecalis, finding tthese specimens rendered negative cultures obtained with48 hours while those irr igated using tradit ional posit ivpressure irr igation were posit ive at 48 hours. ' ' ' Figure shows a scanning electron microscope image of decontamnated dentinal tubules af ter use of apical negative pressuirr igation with sodium hypochlorite and use of EDTA.Figure 10. SEM of decontam inated den tinal tubules

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One study found apical negative pressure irrigationresulted in similar bacterial reductions to use of apical posi-tive pressure irrigation and a triple antibiotic in immatureteeth.'" In a study comparing the use of apical positivepressure irrigation and a triple antibiotic that has beenutilized for pulpal regeneration/revascularization in teethwith incompletely formed apices (Trimix=Cipro, Minocin,Flagyl) versus use of apical negative pressure irrigation withsodium hypochlorite, it was found that the results were sta-tistically equivalent for mineralized tissue formation and therepair process."'' Using negative apical pressure and sodiumhypochlorite also avoids the risk of drug resistance, toothdiscoloration, and allergic reactions.'"'"'

ConclusionSince the dawn of contemporary endodontics, dentists havebeen syringing sodium hypochlorite into the root canalspace and then proceeding to place endodontic instrumentsdown the canal in the belief that they were carrying theirrigant to the apical termination. Biological, SEM, lightmicroscopy, and other studies have proven this belief to bein error. Sodium hypochlorite reacts with organic materialin the root canal and quickly forms micro gas bubbles atthe apical termination that coalesce into a single large apicalvapor bubble with subsequent instrumentation. Since theapical vapor lock cannot be displaced via mechanical means,it prevents further sodium hypochlorite flow into the apicalarea. Additionally, acoustic microstreaming and cavitationare limited to liquids and have no effect inside the vaporlock. The only method yet discovered to eliminate the apicalvapor lock is to evacuate it via apical negative pressure. Thismethod has also been proven to be safe because it alwaysdraws irrigants to the source via suctiondown the canaland simultaneously away from the apical tissue in abun-dant quantities."' When the proper irrigating agents aredelivered safely to the full extent of the root canal terminus,thereby removing 100% of organic tissue and 100% of themicrobial contaminants, success in endodontic treatmentmay be taken to levels never seen before.

References1 Friedman S, Mor C. The success of endodo ntic therapy healing

and functionality./ Ca/i/Den iAssoc. 2004;32(6):493 503.2 Orstavik D, Pittford T. Essential endod ontolog y: 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 andhistopathologic findings. J Endod. 2010;36(8);1277-88.

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procedures. / Endoii. 2008;34:1291-301.6 Wo ng R. Conventional endo don tic failure and retreatment.

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24 Clegg MS , Vertucci FJ, Walker C, B elanger M, Britto LR.The effect of exposure to irrigant solutions on apical dentinbiofilms in viiro.] Endod. 2006;32(5):434-7.25 Cotter JL, Fader RC, Lil ley C, Hemdon DN. Chemicalparam eters, antimicrobial activities, and tissue toxicity of 0.1and 0.5% sodium h ypochlorite solutions. Antimicrob Agents

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59 Albrecht LJ, Baumgartner JC, Marshall JG. Evaluationof apical debris removal using various sizes and tapers ofProFile G T files. / Endod. 2004;30:425-8.

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64 Fuk um oto Y, Kikuchi I, Yoshioka T, Kobaya shi C, Suda H.An ex vivo evaluation of a new root canal irrigation techn iquewith intracanal aspiration. Int Endod J. 2006;39(2):93-9.

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and nerve damage caused by sodium hypochlorite: a casereport. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2008;106(3):e80-3.

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71 McG ill S, Gulabivala K, Mord an N, Ng YL. Th e efficacyof dynamic irrigation using a commercially availablesystem (RinsEndo) determined by removal of a collagen'bio-molecular film' from an ex vivo model. Int Endod ].20()8;41:602-8.

72 Hu ang TY, Gulabivala K, Ng Y-L. A bio-molecu lar film ex-vivo mo del to evaluate the influence of canal dim ension s andirrigation variables on the efficacy of irrigation. Int Endod].2008:41:60-71.

73 Pitt W G . Removal of oral biofilm by sonic phe nom ena . Amy De nt. 2005:18:345-52.

74 Ahm ad M, Pit t Ford TR, Grum LA. Ultrasonic debridem entof root canals: an insight into the mechanisms involved. /Endod. 1987:13:93-101.

75 Ruddle GJ. Endodontic disinfection: tsunami irrigation.Endod Pract. 2008:7-15.

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cleanin g. / Endod. 1980:6:740-3.78 Sabins RA, Johnson JD, Hellstein JW. A comparison ofth e

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79 G oo dm an A, Reader A, Beck M, Melfi R, Me yers W.An in vitro comparison of the efficacy of the step-backtechnique versus a s tep-back/ul trasonic tech nique in hum anmandibu lar m olars . / Endod. 1985:11:249-56.80 Gam eron JA. TTie synergistic relationship betwe enultrasound and sodium hypochlorite: a scanning electronmicroscope evaluation. 7 Endod. 1987:13:541-5.

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86 Gunningham W T, M art in H, Forrest W R. Evaluation of rootcanal debridement by the endosonic ultrasonic synergisticsystem. Oral Surg Oral Med Oral Pathol. 1982:53:401-4.87 Gunningha m W T, M art in H, Pelleu GB Jr., Stoops DE. Acomparison of antimicrobial effectiveness of endosonic andhand root canal therapy. Oral Surg Oral Med Oral Pathol.1982:54:238-41.

88 Spoleti P, Siragusa M, Spoleti MJ . Bacteriological evaluatio nof passive ultrasonic activation. / Endod. 2003:29:12-4.

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107 Hlsmann M, RdigT, Nordmeyer S.Complications duringroot canal. Endo Topics. 2009; 16:27-63.108 Bou tsioukis C, Verhaagen B, Versluis M , K astrinakis E,Wesselink PR, van der Sluis PR. Evaluation of irrigantflow in the root canal using different needle types by anunsteady computational fluid dynamics model. / Endod.2010;36(5):875-97.

109 Mitchell RP, Yang SE, Baum gartner JC . C om parison ofapical extrusion of NaOCl using the EndoVac or needleirrigation of root canals. / Endod. 2010;36(2):338-41.

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113 Cohe nca N, H ellbom C, Johnson JD , Flores DS , Ito Ida Silva LA. Apical negative pressure irrigation versconventional irrigation plus triantibiotic intracanal dression root canal disinfection in dog teeth. Oral Surg Oral MOral Pathol Oral Radiol Endod. 2010;109(l):e42-6.

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Author ProfileG a r y G l a ss m a n D D S , F R C D (Dr. Gary Glassman graduated frothe University of Toronto Schoof Dentistry in 1984 and graduatfrom the Endodontology Prograat Temple University in 1987 whehe received the Louis I. GrossmStudy Club Award for academand clinical proficiency in En

odontics. The author of numerous publications. Dr. G laman lectures globally on endodontics and is on staff at tUniversity of Toronto, Faculty of Dentistry in the gradudepa rtmen t of endodontics. Gary is a Fellow of the RoCollege of Dentists of Canada, and the endodontic edifor Oral Health dental journal. He maintains a private pratice, Endo dontic Specialists, in Toro nto, On tario, CanaHe can be reached throug h his website www .rootcanals.DisclaimerThe author of this course has no commercial ties with sponsors or the providers of the unrestricted educatiogrant for this course.

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Questions

2 7 . M a n u a l d y n a m i c ir r ig a t i o n p r o d u c e sa. a hydrodynamic effectb. effervescencec. significant irrigant exchanged. a ande

2 8 . S o n i c a c t i v a t i o n h a s b e e n s h o w n t o b ea n e f f e c t i v e r o o t c a n a l i r r i g a t i o n m e t b o d ,o p e r a t i n g a t f r e q u e n c i e s o f .a. 1-6 kHzb . 2-7 kHzc. 3-8 kHzd. none of the above

2 9 . U l t r a s o n i c e n e r g y .a. produces higher frequencies than sonic energyb. produces low amplitudesc. results in oscillations at frequencies of 25-30 kHzd. all of the above

3 0 . T h e l i t e r a t u r e i n d i c a t e s t b a t it is m o r ea d v a n t a g e o u s t o a p p l y u l t r a s o n i c sa. as an alternative to conventional instrumentationb. after completion of canal preparationc. after initial root canal preparationd. a ande

3 1 . P a s s i v e u l t r a s o n i c i r r i g a t i o n .a. operates without .simultaneous irrigationb. allows energy to be transm itted from an oscillating

file or smooth wire to the irrigantc. is the only type of ultrasonic irrigationd. a a n d b

3 2 . P a s s i v e u l t r a s o n i c i r r i g a t i o n .a. effectively removes pulpal tissue remnantsb. effectively removes dentin debrisc. results in a significant reduction of the number of

bacteriad. all of the above

3 3 . S t u d i e s b a v e d e m o n s t r a t e d t b a t e f fe c ti v ed e l i v e r y of i r r i g a n t s t o t b c a p i c a l t b i r d c a nb e e n b a n c e d b y u s i n g d e v i c e s .a. ultrasonicb. sonicc. air abrasiond. a a n d b

3 4 . A c o u s t i c m i c r o s t r e a m i n g is d e n e d a st b e m o v e m e n t o f .a. sound along cell membranesb. fluids along cell membranesc. gases along cell membranesd- all of the above

3 5 . O n c e a sonic o r ultrasonically activated ti pleaves t b e i r r igan t a n d en te rs t b e ap ica l vaporlock, beco mes physically impos sible .

3 6 . U l t r a s o n i c s .a. can effectively clean ba cteria from th e root canalsystem

b. can effectively dean debris from the root canalsystem

c. cannot effectively get through the apical vapor lockd. all of the above

3 7 . is a c o m m o n r e a s on g i ve n fo rn o t u s i n g s o n i c o r u l t rason ic f i l ing .a. The time required for set-upb. An unwillingness to incur the equipment costsc. Lack ofawarenessofthe benefits of this fina l

instrumentation stepd. all of the above

3 8 . S o n i c o r u l t r a s o n i c a c t i v a t io n m i g h ta l low a b e t t e r r e m o v a l o f .a. pulpal tissue remnantsb . debris from isthmic. debris i 'om insd. all of the above

3 9 . A n a p i c a l n e g a t i v e p r e s s u r e s y s t e mc o n t a i n s a .a. Master D elivery Tipb . MaaoCarmulac. MicroCannulad. all of the above

4 0 . A p r e s s u r e a l t e r n a t i o n d e v i c e c o n s i s t s o fa. a handpieceb . a cannula with a 7 mm exit aperturec. a syringe carrying irrigantd. all of the above

4 1 . W i t b a n a p i c a l n e g a t i v e p r e s s u r e s y s t e m ,t b e c a n n u l a e i n t b e c a n a l .a. exert negative pressureb . pull irrigant from its fresh supply in the

chamber, down the canal to the tip of thecannula

c. pull irrigant into the cannula and out through thesuction hose

d alloftheabove4 2 . A p i c a l n e g a t i v e p r e s s u r e b a s b e e n s b o w n

t o .a. enable irrigants to reach the apical thirdb . help overcome th e issue of apical vapor lockc. remove the risk of sodium hypochlorite incidentsd. alloftheabove

4 3 . A s o d i u m b y p o c h l o r i t e i n c i d e n t o c c u r sw h e n t b e i r r i g a n t .a. extrudes through th e root canal foramenb . is at a concentration above 3%c. is mixed with a second inigantd. alloftheabove

4 4 . R e c o m m e n d a t i o n s fo r a v o i d i n g s o d i u m

c. using a gentle lo w ated. alloftheabove4 5 . . _ is a s e q u e l a of a s o d i u m

b y p o e b l o r i t e i n c i d e n t .a. Life-threatening airway obstructionb. Permanent paresthesiac. Facial disfigurementd. alloftheabove

4 6 . B a s e d o n t b e e v i d e n c e f r o m a c t u a ls o d i u m b y p o e b l o r i t e i n c i d e n t s a n d t h el o e a t i o n of t h e a s s o c i a t e d t i s s u e t r a u m ai t w o u l d a p p e a r t h a t a n m a y b et b e e a u s e .a. anatomical anomalyb. intravenous injectionc. arterial injectiond. aandb

4 7 . I n a n i n v i t ro st u d y c o m p a r i n gi n t r a c a n a l i r r i g a t i o n d e l i v e r y d e v i c e s , ot b e u s e o f a d e v i c e u s i n g r e s u l tin n o e x t r u s i o n a t t h e a p e x .a. ultrasonicsb. apical positive pressurec. apical negative pressured. sonics

4 8 . T b e p r e s e n c e o f a s e a l e d a p i c a l f o r a mw a s s b o w n i n o n e s t u d y t o adverse ly a fd e b r i d e m e n t e f f i c a c y w h e n w au s e d .a manual dynamic agitationb. apical negative pressurec. waterd. alloftheabove

4 9 . T b e o n l y m e t b o d y e t d i s c o v e r e d t oe l i m i n a t e t b e a p i c a l v a p o r l o c k is toe v a c u a t e i t v ia .a, apical positive pressureb. apical negative pressurec, acoustic microstreamingd. alloftheabove

5 0 . P r o p e r r o o t c a n a l ir r i g a t i o n s b o u l d rin .a. safe delivery of the irrigating agent(s)

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ANSWER SHEETSafety and Efficacy C on side rat ion s in End od on t ic I r r iga t ionN ame :Ad d r e s s :C i t y :Te l ephon e : H ome ( )

Ti t le :E-mail:S ta te :O f f i c e ( )

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C o u n t r y :L i e R en ew a l D a t e :

Requirements for successful completion ofthe course and t o obta in den tal con t inuing educat ion credi ts: 1) Read the e nt i re course. 2) Co mplete al lin format ion above. 3 ) Co mplete answer sheets in ei ther pen or p e n c i l . 4 ) Mark only on e answer for each quest ion. 5 ) A score of 7 0 % o n this test will earnyou 3 C E credits. 6 ) Co mplete the Course Evaluation below. 7) Ma ke check paya ble to PennWell Co rp. F or Questions Call 216.398.7822E d u c a t i o n a l O b j e c t iv e s

1 . L i s t a n d d e s c r i b e t h e c h a l l e n g e s f o r s u c ce s s f u l e n d o d o n t i c tr e a t m e n t2 . L i s t a n d d e s c r i b e t f i e d i f f e r e n t t y p e s o f r o o t c a n a l i r i g a n t s , t h e i r r e l a t i v e a d v a n t a g e s a n d d i s a d v a n t a g e s3 . L i s t a n d d e s c r i b e r o o t c a n a l i r r i g a t i o n s y s t e m s4 . D e s c r ib e a n d e x p l a in a s o d i u m h y p o c h l o r it e i n ci d e n t5 . L i s t a n d d e s c r ib e t h e s t ep s t h a t c a n b e t a k e n t o a v o i d a s o d i u m h y p o c h f o r i t e i n c id e n t

C o u r s e E v a l u a t io nP l ea s e e v a l u a t e t h i s c o u r s e by r e s p o n d i n g t o t h e f o l lo w i n g s t a t e m e n t s , u s i n g a s c a le o f E x c e l le n t = 5 t o P o o r = 0 .1 , W e r e t h e i n d i v i d u a l c o u r s e o b j e ct iv e s m e t / O b j e c t i v e ! ) : Yes No O b j e c t ii /e 3 : Yes No

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2 . T o w h a t e x t e n t w e r e t h e c o u r s e o b j e c ti v e s a c c o m p i i s h e d o v e r a l l?3 . P l e as e r a t e y o u r p e r s o n a l m a s t e r y o f t h e c o u r s e o b j e a i v e s .4 . H (m w o u l d y o u r a t e t h e o b j e c ti v e s a n d e d u c a t i o n a l m e t h o d s ?5 . H o w d o y o u r a t e th e a u t h o r ' s g r a s p o f t h e t o p ic ?6 . P l e a s e r a t e th e i n s t r u n o r ' s e f f e c t i v e n e s s .7 . W a s t h f o v e r a l l a d m i n i s t r a t i o n o f t h e c o u r s e e f fe c t i v e ?8 . D o y o u f e f t h a t t h e r e f er e nc e s w e r e a d e q u a t e ?9 . W o u l d y o u p a r t i ci p a t e in a s i m i l a r p r o g r a m o n a d i f fe r e n t t o p ic ?

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1 1 . W a s t h e r e a n y s u b j e c t m a t t e r y o u f o u n d c o n f u s in g ? P l e a s e d e s c ri b e .

1 2 . W h a t a d d i t io n a l c o n t i n u i n g d e n t a l e d u c a t i o n t o p ic s w o u l d y o u l ik e t o s e e?

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