|Year : 2021 | Volume
| Issue : 3 | Page : 122-127
Root canal cleaning effectiveness with passive ultrasonic irrigation: A comparative in vitro study between Irrisafe and EndoUltra tip
Erlando Sartiono1, Bernard Iskandar1, Aryadi1, Widijanto Sudhana2
1 Department of Conservative Dentistry, Universitas Trisakti, Jakarta, Indonesia
2 Public Health, Faculty of Dentistry, Universitas Trisakti, Jakarta, Indonesia
|Date of Submission||15-Feb-2021|
|Date of Decision||13-Apr-2021|
|Date of Acceptance||13-Aug-2021|
|Date of Web Publication||18-Oct-2021|
Department of Conservative Dentistry, Faculty of Dentistry, Trisakti University, Jakarta.
Source of Support: None, Conflict of Interest: None
Background: Root canal irrigation has an important role in removing pulp tissue, dentine debris, and microorganisms in root canals. Passive ultrasonic irrigation (PUI) Irrisafe is a high-frequency wired ultrasonic device, which is usedto obtain cleanliness of root canal from cavitation and acoustic streaming. EndoUltra is a high-frequency wireless ultrasonic device. It has advantages in terms of its ease of application. However, further research is needed to identify the variations in effectiveness between PUI Irrisafe and EndoUltra tip for dentine debris cleanliness. Objective: The aim of this study was to determine the effectiveness between the activation of PUI Irrisafe and EndoUltra tip on the dentine debris cleanliness of the apical third of a root canal. Methods: This experimental study was carried out on 50 mandibular premolar teeth with a single root canal from extracted teeth. The teeth were irrigated with 5% NaOCl with the activation of EndoUltra # 20/02 (15 and 30 s), with 5% NaOCl with the activation of the PUI tip Irrisafe # 20/02 (15 and 30 s), or with conventional irrigation (30 s). The assessment of the dentine debris score was assessed by two observers using a scanning electron microscope (SEM). Analysis of the results used the Kruskal—Wallis and Mann—Whitney U tests. Results: Differences in median cleanliness scores for the apical third of the root canal from the Irrisafe group, the EndoUltra group, and conventional group had a Kruskal—Wallis test value of P = 0.005. The results showed that there were significant differences (P < 0.05) in five groups. Conclusion: PUI activation with the EndoUltra tip had a better effectiveness on the dentine debris cleanliness of the apical third of a root canal than the Irrisafe tip at 15 and 30 s.
Keywords: Dentine debris cleanliness, EndoUltra, Irrisafe, passive ultrasonic irrigation
|How to cite this article:|
Sartiono E, Iskandar B, Aryadi, Sudhana W. Root canal cleaning effectiveness with passive ultrasonic irrigation: A comparative in vitro study between Irrisafe and EndoUltra tip. Sci Dent J 2021;5:122-7
|How to cite this URL:|
Sartiono E, Iskandar B, Aryadi, Sudhana W. Root canal cleaning effectiveness with passive ultrasonic irrigation: A comparative in vitro study between Irrisafe and EndoUltra tip. Sci Dent J [serial online] 2021 [cited 2021 Nov 27];5:122-7. Available from: https://www.scidentj.com/text.asp?2021/5/3/122/328423
| Background|| |
The success of a root canal treatment depends on the dentist’s ability to clean and disinfect the root canals. Root canal irrigation plays an important role in removing pulp tissue, dentin debris, and microorganisms from the root canal by inserting an irrigation needle to a depth of 1—2 mm from the working length., Irrigation solutions with antibacterial properties that are often used in root canal irrigation include sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA). The benefits of sodium hypochlorite include its ability to dissolve vital and necrotic tissue, it has a good antibacterial effect, and it is nontoxic., However, EDTA is a chelating agent that removes inorganic debris, such as smear layers, and prepares the root canal for filling.
High concentrations of sodium hypochlorite are able to remove biofilm containing Enterococcus faecalis in 1 min. Activation is needed to improve the penetration of the sodium hypochlorite., An ultrasonic file activation is performed to clean root canals over a frequency range of 20—30 kHz, beyond human hearing. The use of this tool still has the disadvantage of damaging the dentin structure when it is applied, especially in curved root canals.,
Previous study showed that irrigation followed by activation of passive ultrasonic irrigation (PUI) with Irrisafe tips had a higher level of dentine debris cleanliness than conventional irrigation. Similar results have been reported by the literature, in which PUI was applied for 30 s and 60 s and resulted in significantly better root canal cleanliness compared to that seen with conventional irrigation techniques. Several studies have examined the differences in the effectiveness of ultrasonic devices in the removal of dentin debris in the apical third of a root canal. EndoUltra wireless ultrasonic device with higher frequency (40 kHz) than Irrisafe (30 kHz) has advantages in terms of its ease of application. This study aimed to identify differences in the effectiveness of dentine debris cleanliness between the PUI Irrisafe and EndoUltra tip in the apical third of root canals.
| Materials and Methods|| |
This study was a laboratory research experiment conducted at the Dental Hospital of Universitas Trisakti and Universitas Negeri Jakarta (UNJ) in June 2019. The samples for this study included mandibular premolar teeth with a deviation of the root canal by 20°—30° [Figure 1]A and 1B. Examinations of the samples of mandibular premolar teeth were obtained after approval by the Dental Research Ethics Committee, Faculty of Dentistry, Trisakti University (No.330/S2-Sp/KEPK/FKG/11/2019). The inclusion criteria of the study were mandibular premolar teeth with a root canal deviation of 20°—30° with a tooth length ≥ 18 mm [Figure 2]A. The exclusion criteria of the study were teeth with root fractures, teeth with root caries, teeth with an abfraction, and premolars with resorption in the root area.
|Figure 2: (A) Tooth length determination. (B and C) Decoronization of sample. (D) Determination length of k-file. (E) Working length determination|
Click here to view
After obtaining research approval, periapical radiographs were taken from the mesiodistal and buccolingual viewpoints to ensure that the tooth had a single root canal with a 20°—30° deviation. The decoronization of the teeth was performed using a fissure diamond bur and flat edge wheel diamond to obtain the same root lengths of 15 mm [Figure 2]B and 2C. This was followed by measuring the working length using a k-file (Dentsply Maillefer, Ballaigues, Switzerland) size # 10 by inserting the k-file until it could be seen at the apical foramen, then 1 mm was subtracted [Figure 2]D and 2E. The outer apical third of the roots were covered using a composite resin to prevent irrigation fluid from leaking from the apical foramen. Tooth preparations were performed using the rotary file ProTaper Next (Dentsply Maillefer) size # 30 (7%). The root canal was irrigated with 2.5 mL of 5% sodium hypochlorite for 30 s and then rinsed with distilled water using a disposable syringe and a 30-gauge side venting irrigation needle when the instrument was changed [Figure 3]. The teeth were randomly divided into five groups (n = 10 per group) and the final irrigation technique was treated with an ultrasonic activation device (Satelec Acteon, Merignac, France) [Figure 4]A and 4B followed by scanning electron microscope (SEM) testing (Geol JSM-6060VL, Westmont, Illinois). The SEM is a tool of assessment that uses electrons to obtain cleanliness from the apical third of the root canal. The cleanliness assessments of the apical third of the root canal with the SEM are shown in [Table 1]. The results were recorded and evaluated by the two scorers after signing an agreement following intra-examiner correlation with Kappa Agreement Test (0.91). Data were analyzed by using the Statistical Package for the Social Sciences (SPSS) software program, version 19.0 (SPSS, Chicago, Illinois) with the Kruskal—Wallis analysis.
|Figure 4: (A) PUI activation with Irrisafe tip. (B) EndoUltra activation|
Click here to view
| Results|| |
The results of the Kruskal—Wallis analyses showed that there was a significant difference between the conventional group and the PUI Irrisafe tip and EndoUltra groups on the apical third cleanliness of the root canals ([Table 2]; P < 0.05). The median (min—max) value in the PUI Irrisafe 15 and 30 s group was 2 (1—3) [Figure 5]A, the EndoUltra 15 s was 2 (1—3), the EndoUltra 30 s was 1 (1—3) [Figure 5]B, and the conventional treatment was 3 (2—4) [Figure 5]C. The results in the table show that the EndoUltra 30 s has the smallest score in the group [Figure 6].
|Table 2: Kruskal—Wallis test results for the cleanliness of the apical third|
Click here to view
|Figure 5: (A) No smear layer and the dentine tubule were opened (score 1). (B) A few smear layers and some dentin tubules were opened (score 2). (C) Homogeneous smear layer covered the root canal and only a few dentine tubules were opened (score 3)|
Click here to view
| Discussion|| |
Long periods of irrigation without activation need approximately 1 min to eliminate bacteria. Therefore, shorter periods of activation are needed to reduce the working time for patient comfort. On the basis of our findings [Table 2], ultrasonic activation of sodium hypochlorite for 15 s or 30 s shows good levels of cleanliness with no significant differences in the cleanliness on the apical third of the root canal dentin wall. These results agree with the previous results which reported no significant differences in the cleanliness of the apical third of the root canal dentin wall after sodium hypochlorite activation with an ultrasonic device for 30 and 60 s.
The degree of the apical third curvature of the root canal in the inclusion criteria of our sample affected the level of cleanliness on the apical third of the root canal wall during the cleaning stage. The application of an ultrasonic device on the apical third wall of the root canal with a 33° curvature shows the ability to attain good cleanliness levels compared to conventional irrigation techniques. Cleanliness was achieved by an ultrasonic activation system that allows hydrodynamic flow.
The previous study has shown there was significantly better cleanliness produced by PUI activation on the dentin debris compared with conventional irrigation techniques., The ultrasonic frequency ranges were between 20 and 40 kHz, which were effective in generating cavitation and acoustic streaming. The cavitation movement generated from the ultrasonic tip, which creates an acoustic streaming motion, enhances the cleaning ability in root canals compared to conventional irrigation.,
The PUI activation transmits vibrations from the file to ultrasonic waves in the irrigation solution producing acoustic streaming and cavitation in the irrigation solution, which breaks the vapor lock in the root canal. In this study, the EndoUltra activation device at 40 kHz had better hygienic which obtained greater cavitation value from greater vibration on the apical third of the root canals compared to Irrisafe at 30 kHz. Greater cavitation used in cleaning a root canal can improve the effect of acoustic streaming, which produces better cleanliness of the root canal.
In this study, tests were carried out using an SEM with × 1000 magnification to identify the dentin structures on the apical third of the root canals. Usually, × 500 to × 2000 magnification was used to identify dentin structures in root canals. The images produced by the SEM are black and white three-dimensional images.,
Overall, this study showed that the Irrisafe and EndoUltra PUI tips were more effective in removing smear layers and opening dentinal tubules compared to conventional irrigation on the apical third of the root canal walls at 15 and 30 s.
Activation of the sodium hypochlorite solution with ultrasonic vibrations can create positive and negative bubble pressures in the solution’s molecules when in contact with the tissue, then increases the effectiveness of sodium hypochlorite on the root canal cleanliness. The sodium hypochlorite molecule becomes unstable and decompresses. The energy released by sodium hypochlorite is part of the detergent effect. The sodium hypochlorite solution with PUI activation has been shown to increase the enhanced dissolving effect on organic and inorganic tissues of the root canal walls when compared to conventional irrigation.,
According to the research, this study used a single root canal premolar with a range of length and curvature on the apical third, also used a 5% sodium hypochlorite irrigation solution, which has become the gold standard in dissolving organic and inorganic tissues to reduce bias that may occur during research.
This study used SEM examination tools to identify the level of cleanliness of the root canal dentine debris with a magnification of × 1000 to × 2000. The × 1000 magnification is enough to identify the cleanliness of the apical third of the root canal from the dentine debris.,, We used the SEM with the aim of identifying three-dimensional details and topographical images of certain surface areas. The weakness of the SEM is that it can only evaluate part of an area with a certain surface area, so it is difficult to perform SEM examinations on intact tooth structures. In this study, the tooth section evaluations were carried out using a chisel and mallet, based on a previous study, to facilitate the SEM examination on small surface areas.
The clinical application of the research results for the Irrisafe and EndoUltra ultrasonic devices is to shorten the working time required for root canal debridement. The application of the EndoUltra device with a wireless system can make it easier for operators to perform root canal treatments. Further research is needed to determine the level of cleanliness of the root canals as this study was limited by the number of teeth, the activation devices, and equipment.
| Conclusion|| |
The EndoUltra tip had a better effectiveness on cleaning dentine debris in the apical third of the root canal than the Irrisafe tip over the same duration.
Financial support and sponsorship
Conflicts of interest
The authors whose names are listed immediately below certify that they have no affiliation with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent — licensing arrangements), or non-financial interest (such as personal or professional relationship affiliation, knowledge or belief) in the subject matter or materials discuss in this manuscript.
| References|| |
Basrani B, Peters OA, Peters CI. Cleaning and shaping the root canal system. In: Hargreaves KM, Cohen S, editors. Pathways of the pulp. 11th ed. St Louis, MO: Mosby; 2016. pp. 209-79.
Tanomaru-FIlho M, Torres FF, Chávez-Andrade GM, Miano LM, Guerreiro-Tanomaru JM. Intermittent or continuous ultrasonically activated irrigation: Micro-computed tomographic evaluation of root canal system cleaning. Clin Oral Investig 2016;20:1541-6.
Mohammadi Z, Abbott PV. The properties and applications of chlorhexidine in endodontics. Int Endod J 2009;42:288-302.
Mohammadi Z, Giardino L, Mombeinipour A. Antibacterial substantivity of a new antibiotic-based endodontic irrigation solution. Aust Endod J 2012;38:26-30.
Mohammadi Z, Shalavi S, Jafarzadeh H. Ethylenediaminetetraacetic acid in endodontics. Eur J Dent 2013;7:135-42. [Full text]
Neuhaus KW, Liebi M, Stauffacher S, Eick S, Lussi A. Antibacterial efficacy of a new sonic irrigation device for root canal disinfection. J Endod 2016;42:1799-803.
Dhingra A, Mangat P, Miglani A, Kalkhande S, Bhullar HK. To evaluate the effect of two passive ultrasonic irrigation methods on removal of dentin debris from root canal systems using computational fluid dynamics study model. Int J Contemp Dent Med Rev2015;7:1-7.
Mozo S, Llena C, Chieffi N, Forner L, Ferrari M. Effectiveness of passive ultrasonic irrigation in improving elimination of smear layer and opening dentinal tubules. J Clin Exp Dent 2014;6:e47-52.
Nair U, Natera M, Koscso K, Pillai P, Varella C, Pileggi R. Comparative evaluation of three different irrigation activation on debris removal from root canal systems. Int J Dent Sci 2009;9:1-6.
Choudhary OP, Priyanka . Scanning electron microscope: Advantages and disadvantages in imaging components. Int J Curr Microbiol App Sci 2017;6:1877-82.
van der Sluis LW, Versluis M, Wu MK, Wesselink PR. Passive ultrasonic irrigation of the root canal: A review of the literature. Int Endod J 2007;40:415-26.
Pereira ES, Peixoto IF, Nakagawa RK, Buono VT, Bahia MG. Cleaning the apical third of curved canals after different irrigation protocols. Braz Dent J 2012;23:351-6.
Plotino G, Cortese T, Grande NM, Leonardi DP, Di Giorgio G, Testarelli L, et al
. New technologies to improve root canal disinfection. Braz Dent J 2016;27:3-8.
Dashtimoghadam E, Johnson A, Fahimipour F, Malakoutian M, Vargas J, Gonzalez J, et al
. Vibrational and sonochemical characterization of ultrasonic endodontic activating devices for translation to clinical efficacy. Mater Sci Eng C Mater Biol Appl 2020;109:110646.
de Haan K, Ballard ZS, Rivenson Y, Wu Y, Ozcan A. Resolution enhancement in scanning electron microscopy using deep learning. Sci Rep 2019;9:12050.
Mohammadi Z, Shalavi S, Giardino L, Palazzi F, Asgary S. Impact of ultrasonic activation on the effectiveness of sodium hypochlorite: A review. Iran Endod J 2015;10:216-20.
Puspita D, Djuanda R, Evelyna A. The differences in hygiene of the apical third root of the smear layer using ultrasonic and sonic activation system. SONDE 2019;4:24-32.
Ozyurek T. Comparison of the smear layer removal ability of four different final activation techniques after retreatment procedures: A SEM investigation. Turkish Endod J2017;2:10-16.
Dhanyakumar NM, Shivanna V, Garg S. SEM evaluation of smear layer formation after using three different nickel titanium rotary instruments-endowave, k3 and ProTaper: An in vitro
study. Endodontology 2010;22:26-36.
Ahuja P, Nandini S, Ballal S, Velmurugan N. Effectiveness of four different final irrigation activation techniques on smear layer removal in curved root canals: A scanning electron microscopy study. J Dent (Tehran) 2014;11:1-9.
Castagna F, Rizzon P, da Rosa RA, Santini MF, Barreto MS, Duarte MA, et al
. Effect of passive ultrassonic instrumentation as a final irrigation protocol on debris and smear layer removal: A SEM analysis. Microsc Res Tech 2013;76:496-502.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]