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Eficacia en La Irrigacion PDF
Eficacia en La Irrigacion PDF
3 CE credits
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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 3 CE credits.
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Educational Objectives
The overall goal of this article is to provide the reader with
information on endodontic irrigation.
On completion of this course, the reader will be able to:
1. List and describe the challenges for successful endodontic treatment
2. List and describe the different types of root canal irrigants, their relative advantages and disadvantages
3. List and describe root canal irrigation systems
4. Describe and explain a sodium hypochlorite incident
5. List and describe the steps that can be taken to avoid a
sodium hypochlorite incident.
Abstract
Endodontic treatment is a predictable procedure with
high success rates. Success depends on a number of factors, including appropriate instrumentation, successful
irrigation and decontamination of the root canal space to
the apices and in areas such as isthmuses. These steps must
be followed by complete obturation of the root canals, and
placement of a coronal seal, prior to restorative treatment.
Several irrigants and irrigation systems are available, all
of which behave differently and have relative advantages
and disadvantages. Common root canal irrigants include
sodium hypochlorite, chlorhexidine gluconate, alcohol,
hydrogen peroxide and ethylenediaminetetraacetic acid
(EDTA). In selecting an irrigant and technique, consideration must be given to their efficacy and safety.
Introduction
With the introduction of modern techniques, endodontic success rates of up to 98% are being achieved.1
The ultimate goal of endodontic treatment per se is the
prevention or treatment of apical periodontitis such
that there is complete healing and an absence of infection,2 while the overall long-term goal is the placement
of a definitive, clinically successful restoration and
preservation of the tooth. For these to be achieved,
appropriate instrumentation, irrigation and decontamination, and root canal obturation must occur,
as well as attainment of a coronal seal. There is clear
evidence that apical periodontitis is a biofilm-induced
disease.3 A biofilm is an aggregate of microorganisms
in which cells adhere to each other and/or to a surface.
These adherent cells are frequently embedded within
a self-produced matrix of extracellular polymeric substance. The presence of microorganisms embedded in
a biofilm and growing in the root canal system is a key
factor for the development of periapical lesions.4,5,6,7
Additionally, the root canal system has a complex
anatomy that consists of arborizations, isthmuses, and
cul-de-sacs that harbor organic tissue and bacterial
contaminants.8
2
Even with the use of rotary instrumentation, the nickel-titanium instruments currently available only act on the central
body of the root canal, resulting in a reliance on irrigation
to clean beyond what may be achieved by these instruments.10 In addition, Enterococcus faecalis and Actinomyces
israeliiwhich are both implicated in endodontic infections
as well as in endodontic failurepenetrate deep into the
dentinal tubules, making their removal through mechanical
instrumentation impossible.11,12 Finally, Enterococcus faecalis
commonly expresses multiple drug resistance,13,14,15 further
complicating treatment.
Therefore, a suitable irrigant and irrigant delivery system are essential for efficient irrigation and the success of
endodontic therapy.16 Not only should root canal irrigants
be effective for dissolution of the organic component of the
dental pulp, they must also effectively eliminate bacterial
contamination and remove the smear layerthe organic and
inorganic layer that is created on the wall of the root canal
during instrumentation. The ability to deliver irrigants to the
root canal terminus in a safe manner without causing harm to
the patient is as important as the efficacy of those irrigants.
It is very important to note that while sodium hypochlorite has unique properties that satisfy most requirements for
a root canal irrigant, it also exhibits tissue toxicity that can result in damage to the adjacent tissues, including nerve damage should sodium hypochlorite incidents occur during canal
irrigation. Furthermore, Salzgeber reported in the 1970s that
apical extrusion of an endodontic irrigant routinely occurred
in vivo;45 this highlights the importance of using devices and
techniques that minimize or prevent this. Sodium hypochlorite incidents are further discussed later in this article.
Manual-Dynamic Irrigation
Manual dynamic irrigation involves gently moving a well-fitting gutta-percha master cone up and down in short 2 mm to
3 mm strokes within an instrumented canal, thereby producing a hydrodynamic effect and significant irrigant exchange.70
Recent studies have shown that this irrigation technique is
significantly more effective than an automated-dynamic irrigation system and static irrigation.9,71,72
Figure 3. Manual Dynamic Max-I-Probe
Ultrasonics
Ultrasonic energy produces higher frequencies than sonic
energy but low amplitudes, oscillating at frequencies of 2530 kHz.9,76 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 operating without simultaneous irrigation (PUI). The literature indicates that it is
more advantageous to apply ultrasonics after completion of
canal preparation rather than as an alternative to conventional instrumentation.9,20,77 PUI irrigation allows energy
to be transmitted from an oscillating file or smooth wire to
the irrigant in the root canal by means of ultrasonic waves.9
There is consensus that PUI is more effective than syringe
.
needle irrigation in removing pulpal tissue remnants and
dentin debris.78,79,80 This may be due to the much higher
velocity and volume of irrigant flow that are created in the
canal during ultrasonic irrigation.9,81 PUI has been shown
to remove the smear layer; there is a large body of evidence
with different concentrations of NaOCl.9,80,82,83,84 In addition, numerous investigations have demonstrated that the
use of PUI after hand or rotary instrumentation results in
a significant reduction of the number of bacteria,9,85,86,87 or
achieves significantly better results than syringe needle irrigation.9,84,88,89
Studies have demonstrated that effective delivery of irrigants to the apical third can be enhanced by using ultrasonic
and sonic devices.79,81,90,91,92 However, some recent studies
have 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,93 which is not the case with the apical negative
pressure irrigation technique.46,94
Consider the erroneous idea that acoustic microstreaming or cavitation that occurs during PUI can clean any part
of the apical portion filled with gas (apical vapor lock).
Acoustic microstreaming is defined as the movement of fluids
along cell membranes, which occurs as a result of the ultrasound energy creating mechanical pressure changes within
the tissue. Cavitation is defined as the formation and collapse of gas- and vapor-filled bubbles or cavities in a fluid.
5
This process (cavitation) results from the creation and collapse of microbubbles in the liquid. Acoustic microstreaming or cavitation is only possible in fluids/liquids, not in
gases. Therefore, as previously mentioned, it is physically
impossible for acoustic microstreaming and/or cavitation
to disrupt the apical vapor lock..56
Other studies have shown that sonic or ultrasonic activation might allow a better removal of pulpal tissue remnants
and debris from isthmi and fins.79,81 Although ultrasonics
can effectively clean debris and bacteria from the root canal
system, they still have the drawback of not being able to
effectively get through the apical vapor lock in the apical 3
mm of the canal.
MacroCannula
Figure 5. RinsEndo
MicroCannula with venting
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when apical negative pressure irrigation was performed (EndoVac) rather than apical positive pressure irrigation.110
100
80
60
40
20
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
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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 suctiondown 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
2
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Endod. 2008;34:1374-7.
95 Gutarts R, Nusstein J, Reader A, Beck M. In vivo
debridement efficacy of ultrasonic irrigation following handrotary instrumentation in human mandibular molars. J
Endod. 2005;3:166-170.
96 Pouch D, Bohne W, et al. Cleaning qualities of Rinsendo: an
in vitro study. Eur Cells Mater. 2007;13:7.
97 Desai P, Himel V. Comparative safety of various intracanal
irrigation systems. J Endod. 2009;35(4):545-9.
98 Hlsmann M, Hahn W. Complications during root canal
irrigation: literature review and case reports. Int Endod J.
2000;33:186-93.
99 Shin SJ, Kim HK, Jung IY, Lee CY, Lee SJ, Kim E.
Comparison of the cleaning efficacy of a new apical negative
pressure irrigating system with conventional irrigation
needles in the root canals. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2010 Mar;109(3):479-84.
100 Klyn SL, Kirkpatrick TC, Rutledge RE. In vitro comparisons
of debris removal of the EndoActivator System, the F File,
ultrasonic irrigation, and NaOCl irrigation alone after handrotary instrumentation in human mandibular molars. J
Endod. 2010;36(8):1367-71.
101 Susin L, Parente JM, Loushine RJ, et al. Canal and isthmus
debridement efficacies of two irrigant agitation techniques in
a closed system. Int Endod J. 2010;43(12):1077-90.
102 Mehdipour O, Kleier DJ, Averbach RE. Anatomy of
sodium hypochlorite accidents. Compend Contin Educ Dent.
2007;28(10):544-6.
103 Pashley EL, Birdsong NL, Bowman K, Pashley DH.
Cytotoxic effects of sodium hypochlorite on vital tissue. J
Endod. 1985;11:525- 8.
104 Bowden JR, Ethunandan M, Brennan PA. Life-threatening
airway obstruction secondary to hypochlorite extrusion
during root canal treatment. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2006;101(3):402-4.
105 Markose G, Cotter CJ, Hislop WS. Facial atrophy following
accidental subcutaneous extrusion of sodium hypochlorite.
Br Dent J. 2009;206(5):263-4.
106 Linden J. When Irrigation Leads to Litigation. Dental
Products Report. Sept. 2010, 75-81.
107 Hlsmann M, Rdig T, Nordmeyer S. Complications during
root canal. Endo Topics. 2009;16:27-63.
108 Boutsioukis C, Verhaagen B, Versluis M, Kastrinakis E,
Wesselink PR, van der Sluis PR. Evaluation of irrigant
flow in the root canal using different needle types by an
unsteady computational fluid dynamics model. J Endod.
2010;36(5):875-97.
109 Mitchell RP, Yang SE, Baumgartner JC. Comparison of
apical extrusion of NaOCl using the EndoVac or needle
irrigation of root canals. J Endod. 2010;36(2):338-41.
110 Gondim E Jr., Setzer F, dos Carmo CD, Kim S. Postoperative
pain after the application of two different irrigation devices
in a prospective randomized clinical trial. J Endod.
2010;36;(8):1295-1301.
111 Siu C, Baumgartner JC. Comparison of the debridement
efficacy of the EndoVac irrigation system and
conventional needle root canal irrigation in vivo. J Endod.
12
2010;36(11):1782-5.
112 Parente JM, Loushine RJ, Susin L, Gu L, Looney SW, Weller
RN, et al. Root canal debridement using manual dynamic
agitation or the EndoVac for final irrigation in a closed system
and an open system. Int Endod J. 2010;43(11):1001-12.
113 Cohenca N, Heilborn C, Johnson JD, Flores DS, Ito IY,
da Silva LA. Apical negative pressure irrigation versus
conventional irrigation plus triantibiotic intracanal dressing
on root canal disinfection in dog teeth. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2010;109(1):e42-6.
114 da Silva LA, Nelson-Filho P, da Silva RA, et al.
Revascularization and periapical repair after endodontic
treatment using apical negative pressure irrigation versus
conventional irrigation plus triantibiotic intracanal dressing
in dogs teeth with apical periodontitis. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2010;109(5):779-87.
115 Eickholz P, Kim TS, Brklin T, et al. Nonsurgical periodontal
therapy with adjunctive topical doxycycline: a double-blind
randomized controlled multicenter study. J Clin Periodontol.
2002;29:108-17.
116 de Paz S, Perez A, Gomez M, Trampal A, Dominguez
Lazaro A. Severe hypersensitivity reaction to minocycline. J
Invest Allergol Clin Immunol. 1999;9:403-4.
117 Schoeffel GJ. The EndoVac method of endodontic irrigation:
Part 4, Clinical Use. Dent Today. 2009;28(6):64, 66-67.
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Questions
68%
78%
88%
98%
fungal
viral
biofilm-induced
all of the above
cul-de-sacs
arborizations
isthmuses
all of the above
isthmi
central body
lateral body
all of the above
Actinomyces israelii
Candida albicans
Enterococcus faecalis
a and c
Bacterial decontamination
A broad antimicrobial spectrum
The ability to enter deep into dentinal tubules
all of the above
Chlorhexidine gluconate
Hydrogen peroxide
Sodium hypochlorite
all of the above
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polyalkenoic acid
sodium hypochlorite
saline
chlorhexidine gluconate
remineralizing agent
dilutant
demineralizing agent
b and c
never
rarely
routinely
always
18. Root canal irrigation systems are available that work using _______.
a.
b.
c.
d.
dessication
hydrolysis
cross-linking
none of the above
an open-ended channel
a close-ended channel
multiple isthmuses
all of the above
Histological tests
Micro-CT scans
Radiographs
a and b
apical 3 mm
lateral 3 mm
apical 5 mm
lateral 5 mm
mechanical irrigation
manual irrigation
hydrodynamic theory irrigation
all of the above
13
Questions
a hydrodynamic effect
effervescence
significant irrigant exchange
a and c
1-6 kHz
2-7 kHz
3-8 kHz
none of the above
ultrasonic
sonic
air abrasion
a and b
14
acoustic microstreaming
cavitation
cell death
a and/or b
a handpiece
a cannula with a 7 mm exit aperture
a syringe carrying irrigant
all of the above
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3. EndoVac MicroCannula
Complete Apical
Debridement & Disinfection
at Working Length
Maximum microbial control
using a 0.32 mm cannula
and negative pressure to
safely draw irrigants to the
apical termination and create
a vortex-like cleaning of the
apical third.