Advances in Endodontic Irrigation
In George Orwell’s satirical Animal Farm utopia, it was said that “all animals are equal, but some animals are more equal than others.”
In George Orwell’s satirical Animal Farm utopia, it was said that “all animals are equal, but some animals are more equal than others.” Similarly, while every procedural step is important, when it comes to root canal therapy, it might be argued that endodontic cleaning and disinfection are the most equal animals of all — because if these early critical steps prove unsuccessful, the outcome is also likely to be poor.
Fortunately, recent advances have allowed greater predictability in cleaning and disinfection. To gain insights into how these developments affect clinical care, we caught up with Reid V. Pullen, DDS, FAGD, a board-certified endodontist practicing in Brea, California. Pullen, who heads the Root Canal Academy Boot Camps, points to the challenges inherent in today’s more conservative endodontic preparations, which preserve as much pericervical dentin and tooth structure as possible. “The newer irrigation systems seek to address the problem of removing pulp tissue, biofilm and microbes from smaller spaces by creating a turbulent stream of sodium hypochlorite, ethylenediaminetetraacetic acid and distilled water,” he notes. “The irrigant’s aggressive acoustic streaming action can, in many cases, remove pulp tissue more effectively than standard needle irrigation.”
While acknowledging the high success rates achievable with proper canal cleaning, shaping and passive needle irrigation, Pullen poses the question, “Can we do better? Can we improve our success rate so that 10 to 20 patients out of 100 aren’t experiencing failures?” Noting the variety of new approaches, he observes that “clinicians can choose from sonic or ultrasonic activation. There is negative apical pressure and concurrent ultrasonic and negative apical pressure, as well as laser-activated irrigation that sends photons into the irrigant, causing thousands upon thousands of vapor bubbles to form and collapse, producing a shock wave that flows throughout the canal system. In addition, one approach uses multisonic sound waves to loosen and remove pulp tissue and canal remnants. All of these technologies act to dynamically move the irrigant throughout the canal system, whereas with standard needle irrigation, the irrigant is allowed to passively ‘sit and digest.’”
The chief advantage is that activated systems make debriding and disinfecting the root canal system easier and faster. And in concert with the advanced metallurgy of today’s shaping files, in some cases the tooth can be accessed and shaped within minutes, Pullen reports. “The main disadvantages include increased cost, training, flow implementation, and apical bleeding,” he says. “All of these can be addressed and solved, but it takes grit to purchase, learn, and incorporate one or more of these new irrigation systems into your everyday workflow.”
Pullen also concedes that dynamic irrigation has not completely replaced standard needle irrigation in his practice, noting he still utilizes needle irrigation in case apical bleeding occurs during the activated irrigation debridement process. “I firmly believe that even with these new irrigation systems, root canal therapy requires skill,” he asserts. “The clinician still needs to locate all of the canals, negotiate them to the apical third, and then shape, clean and obturate the canal system to create a three-dimensional hermetic seal. Activated irrigation is just one component of the ‘clean, shape, and pack’ triad.”
Ultimately, does the evidence show that activated irrigation actually improves debridement? Pullen responds affirmatively, stating, “In my opinion, yes. If you review the studies and compare activated irrigation — sonic, ultrasonic, laser-activated, and multisonic sound wave — with standard needle irrigation, you will see improvements in pulp tissue debridement and microbial removal.”
And if you subscribe to that thinking, this might just make these newer activated technologies the most equal animals on the endodontic farm.
From Decisions in Dentistry. May 2023;9(5):46.