irrigant delivery systems

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IRRIGANT DEL IVERY SYSTEMS AND

TECHNIQUES

DR. A. Vimal Kumar

Department of Conservative dentistry and

Endodontics

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INTRODUCTION

Removal of vital and necrotic remnants of pulptissues, microorganisms, and microbial toxinsfrom the root canal system is essential forendodontic success (Siqueria JF et at, Wong et al

DCNA 2004).

Although this might be achieved throughchemomechanical debridement it is impossibleto shape and clean the root canal completely(Gurtarts et al , Svec TA, JOE 1997)

Even with the use of rotary instrumentation , the nickel-titanium instruments currently available only act on thecentral body of the canal, leaving canal fins, isthmi, andcul-de-sacs untouched after completion of the

preparation(Haga et al, Gutierrez JH et al OOO 1968). 2


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These areas might harbor tissue debris, microbes, and their by-products (Hess W.

Vertucci FJ et al OOO 1984), which might prevent close adaptation of the obturation

material (Wollard RR, JOE 1976)and result in persistent periradicular inflammation

DEFINITION :

Irrigation is

def ined as washing out a body

cavity or wound with water or

a medicated fl uid (COHEN)

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Therefore, irrigation is an essential part of root canal

debridement because it allows for cleaning beyond

what might be achieved by root canal

instrumentation alone .


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Objectives

Biologicfunction

Related to antimicrobial effect

Mechanicalobjectives

Flushing out debris

Lubricating the canal

Dissolving organic andinorganic tissue

Bleaching (Basrani et al)

Opening of lateral andaccesory canals

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IDEALREQUIREMENTSOFANIRRIGANT(ZEHNDERM. ROOTCANALIRRIGANTS. J ENDOD2006)

Effective germicide and fungicide

Non irritant

Remain stable in solution

Prolonged antimicrobial effect

Be active in presence of blood, serum

Low surface tension

Not interfere with repair of periapical tissues

Not stain tooth structure

Capable of inactivation in a culture medium

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Not induce cell mediated immune response

Be able to remove smear layer and to disinfect underlying

dentinal tubules

Non antigenic, non toxic and non carcinogenic

Have no adverse effects on physical properties of exposed

dentin and sealing ability of filling materials

Have convenient application and economical

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However, there is no one unique irrigant that can meet all these requirements, even with the

use of methods such as lowering the pH (Cotter JL, Bloomfield et al), increasing the temperature

(Sirtes G, JOE 2005), as well as addition of surfactants to increase the wetting efficacy of the

irrigant (Lui JN JOE 2003).

Thus, in contemporary endodontic practice, dual irrigants such as sodium hypochlorite

(NaOCl) with ethylene diamine tetra acetic acid (EDTA) or chlorhexidine (CHX) are oftenused as initial and final rinses to complement the shortcomings that are associated with the

use of a single irrigant.

More importantly, these irrigants must be brought into direct contact with the entire canal

wall surfaces for effective action (Al-Hadlaq SM JOE 2006), particularly for the apical portions

of small root canals.

This can be achieved by means of a proper irrigant delivery system.7


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Concept of germ theory became significant in latter half of

19 th century

1859- Taft recommended frequent syringing of root canal

1940s American Endodontic Society estsblished

Till early 1980s syringe with needle only

Endobrushin 1980s (Kier et al)

Sonic(Tronstad et al-1985) and Ultrasonic (Richmand 1957

but commercial unit in 1980 by Martin et al)

1993Rotary Niti instruments

Ruddle brush, canal brush (Coltene)2001

Pressure altering devices- Endovac (Schoefffel GJ 2008)

Rinse Endo (Hauser et al2007)

Self adjusting files- (Continuous irrigation)-Z.Metzger- 2010

Lasers

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IRRIGATION DEVICES AND TECHNIQUES

MANUAL

Syringe irrigation

with needles/

cannulas

(end/side vent)

Brushes

(Endobrush,

Navitip FX)

Manual Dynamic

Agitation

(hand activated

well fitting gutta

percha

MACHINE ASSISTED

Rotary brushes

(Ruddlebrush,

Canalbrush)

Continuous irrigation

during rotaryinstrumentation

(Quantec-E)

Sonic

(Rispisonic file,

Endoactivator)

Ultrasonic

Pressure

alternating

devices

(EndoVac,

Rinse Endo)

JOE

Volume 35, Number 6, June 2009


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MANUAL AGITATION TECHNIQUES

Syringe Irrigation with Needles/Cannulas

Efficient method of irrigant delivery before the advent ofpassive ultrasonic activation (Van der Sluis LW et al IEJ 2006).

Still widely accepted by both general practitioners and

endodontists.

The technique involves dispensing of an irrigant into a canal

through needles/cannulas of variable gauges, either passivelyor with agitation.

Delivered by distal ends of syringe or by side vented needle

that improves hydrodynamic activation of an irrigant and

reduced apical extrusion(Hauser V, IEJ 2007)

Needle/cannula should remain loose inside the canal during

irrigation.

Advantages :Easy control of the depth of needle penetration within the

canal and

The volume of irrigant that is flushed through the canal . 10


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DISADVANTAGES

Mechanical flushing relatively weak

Thorough canal debridement difficult (Nair PN, Henry S

OOO 2005)

Irrigation solution delivered only 1mm below the tip of

needle

Penetration depth and efficacy of the irrigant is limited

Canal size should at least be enlarged to a size of 40 at

apex (Wu MK, Wesselink PR OOO 1995)

Enlargement with negative consequences of inadvertent

reduction in radicular dentin thickness and subsequent

weakening of root structure (Lertchirakan V, JOE 2003)11


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Plastic syringes for irrigation

Different sizes (1-20 ml)

Luer-Lok design

Modificationsof needles

A) Bevelled

B) MonojectC) Safe ended

(A) (B) (C )


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Modifications of needles

Bending the tip Flexiglide needle

27-31 gauge recommended

should not bind in the canal

easily controlled

not enough flushing action

deliver solution only 1 mm deeper

than the tip of the needle

Oral Surg Oral Med Oral Pathol 1977; 44:30612


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Different Irrigating needles:

MAX-I-PROBE(dentsply, TULSA)

NiTi Superflex : Provides maximumflexibility

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BRUSHES

Not used directly used as adjuncts only

Recently Navitip FX (Ultradent)- 30 gauge needle with

brush was introduced

Better debridement than Navitip (Al Hadlaq SM JOE

2006) in coronal

Middle and apical third no significant difference

Endobrush (Keir at al) used in brushing and rotary

motion provided improved debridement

DISADVANTAGES

Frictioncause dislodgement of bristles

Cannot be used to full working length

Can cause apical packing of debris

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MANUAL-DYNAMICIRRIGATION

HAND ACTIVATED WELL FITTING GUTTA PERCHA

The use of apically fitting Gutta Percha cones in an up and down motion

at the working length facilitating the penetration of solution in the

canal

Research has shown that gently moving a well-fitting gutta-percha

master cone up and down in short 2- to 3-mm strokes

(manualdynamic irrigation) within an instrumented canal can

produce an effective hydrodynamic effect and significantly improve

the displacement and exchange of any given reagent.(Machtou .P

and Caron .G Paris VII University, Paris, France: Masters thesis;

2007).

Later confirmed by Mc Gill et al and Huang et al. Manual dynamic

agitation better than RinsEndo16


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Principles:

1. changes in intracanal pressure

2. frequency of 3.3Hz, 100 strokes per 30 seconds

3. viscously dominated flow (mixing of fresh

solution with the spent, reacted irrigant)

It removes the effect of vapor lock

17Dent Today 2008;27:82,84,8687


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MACHINE-ASSISTEDAGITATIONSYSTEMS

ROTARY BRUSHES :

Ruddle-rotary hand piece attached micobrush

Consists of shaft and a tapered brush

Commercially- CANAL Brush

(coltene whaledent)

Highly flexible- made of poly propylene

Used attached to a contra angled hand piece at 600

rpm

Weise at al showed that canal brush is effective in

removing debris along with an irrigant

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Ruddle brush

Canal brush


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SELF ADJUSTING FILE

Primarily introduced as an endodontic file

Also can be considered as an irrigation device, due to its hollow

file configuration

Irrigant delivered through a rotating hub to which a silicone tube

is attached.

Special irrigation unit(VATEA, ReDent, Israel) or any physio

dispenser type unit can be used to deliver a constant flow of

irrigant at 5 ml/min.

This maintains continuous flow of irrigant.

No positive pressure created due to open metal latticeirrigants

escape freely

No risk of irrigant transportation beyond apical foarmen (Metzger

JOE 2009). Efficient in removing debris in coronal, middle apical third.20


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SONICIRRIGATION

Frequency and Oscillating Pattern of Sonic Instrument :

Tronstad et al first introduced1985

Generates significantly higher amplitude and greater back and forth tip movement.

Operates at a lower

frequency (1-6 kHz) Produce smaller shear

stresses

Sonic instruments

differs from ultrasonic

When movement of sonic

file is constrained sidewayoscillation disappears,resulting in purelongitudinal file oscillation

Oscillatingpatterns

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ENDOACTIVATOR

Conventionally done by Rispisonic file used

Non uniform taper, barbed tips may damage

prepared canal walls

Endoactivator was introduced to overcome (DentsplyTulsa Dental Specialties, Tulsa, OK)

Consists of a portable hand piece and 3 types of

disposable , safe non cutting polymer tips of

different sizes

Effectively clean debris from lateral canals, remove

smear layer and dislodge chimps of bio film within

curved canals of molars (Caron G 2007)

Mechanism of action:

Hydro dynamic phenomenonvibrating and movingthe tip up and down in short vertical strokes

10,000 cycles per minute optimize debridement

and dislodge smear layer

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ADVANTAGES

Disposable tips

Smooth do not cut dentin

Strong , flexible do not breakeasily

DISADVANTAGES

Not as powerful as ultrasonic

Polymer tips radiolucent

Cannot be detected if breaks incanal

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Vibringe is a new sonic irrigation system

Battery driven vibrations 9000 cpm with

manually operated irrigation of root canal.

Cordless

Precisely fits in its specially designed disposable

10 ml syringes

Active ingredient is delivered in a pulsatingmanner directly into the root canal via a standard

needle and is activated at a frequency of 150 Hz

Any type of irrigation can be used

Rdiger et al. (2010): debridement by using

vibringe has been found more effective than

conventional syringe irrigations.

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VIBRINGE (VIBRINGE B.V. AMSTERDAM)


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cavitationAcousticstreaming


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ULTRASONIC IRRIGATION WITH INSTRUMENTATION

Studies on endosonic systems have shown that teethprepared ultrasonically with UI devices have

significantly cleaner canals than teeth prepared by

conventional root canal filing alone(Stamos et al JOE

1987)

Other studies failed to demonstrate superiority of UI

(Ahmed et al JOE 1987).

This may be attributed to the constraint of vibratory

motion and cleaning efficacy of an Ultrasonic file in a

non flared root canal space (Ruddle CJ et al 2002)27


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OTHER DISADVANTAGES

Difficult to control the cutting of dentin, and shape of root canal

Strip perforation and

Highly irregular- shaped canals

Therefore, UI is not generally perceived as an alternative to conventional

hand instrumentation

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PASSIVE ULTRASONIC IRRIGATION

WELLER et al(1980) first used the term

Non cutting technology

PUI an irrigation scenario where there was

no instrumentation, planing, or contact of the

canal walls with an endodontic file or

instrument (Jensen SA JOE 1999).

Energy transmitted from an oscillating file or

a smooth wire

Smooth wire induces acoustic streaming and

cavitation of the irrigant (Ahmad M ,JOE 1987)

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IRRIGANTAPPLICATIONMETHODSDURINGPUI

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Two flushing methods during PUI

CONTINUOUS flush ofirrigant from ultrasonic

hand piece

Intermittent flushtechnique by using syringe

delivery


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CONTINUOUSULTRASONICIRRIGATION

Recently, a needle-holding adapter to an ultrasonic

handpiece has been developed by Nusstein

25 gauge irrigation needle used instead of endosonic

file

Irrigant delivered by intravenous tubing connected

via a Leur-Lok to an irrigation delivery syringe

Needle is simultaneously activated by an ultrasonichand piece

Thus irrigant supplied continuously

Produces significantly cleaner canals and isthmi in

both vital and necrotic teeth in 1 minute (Burleson et

al JOE 2007)

Reduces Colony-forming units(CFU) counts in

infected molars (Carver K et al JOE 2007)

Reduced time for ultrasonic irrigation 31

PRO ULTRA PIEZO FLOW Ultrasonic

Irrigation Needle


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Irrigant is delivered to the root canal by a syringe needle.

Then activated with the use of an ultrasonically oscillating

instrument.

The root canal is then flushed with fresh irrigant to remove the

dislodged or dissolved remnants from the canal walls.

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INTERMITTENT FLUSH ULTRASONIC IRRIGATION


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IRRISAFE (SATELEC)

Designed for the safe removal of the

smear layer, dentin debris and

bacteria from the root canal.

IrriSafe instruments are used during

Passive Ultrasonic Irrigation (PUI)

with NaOCl.

IrriSafe is small, parellel-shaped and

non cutting (bluntended).

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Removal of Pulpal Tissues and Dentin Debris

PUI more effective than syringe needle irrigation due

to high velocity and the volume of irrigation (CameronJA, JOE 1987)

Oscillation of the file adjacent to canal irregularities

might also have removed more debris from these hard-

to-reach locations (Lumley PJ et al , JOE 1992).

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Removal of Smear Layers

PUI with water did not remove smear layer

(Cameron JA et al , JOE 1983)

PUI with 3% NaOCl complete smear layer

removal (Cameron et al, Alacam and Huque et al)

Smear layer effectively removed from apical,

middle and coronal third when used with NaOCl

and EDTAC (Guerisoli et al)

But Cheung and Stock et alshowed that smear

layer cannot be removed completely in apical

third by PUI with 1% NaOCl for 10 seconds or

with NaOCl and EDTA combinations.

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Removal of Bacteria

Significant bacterial reduction is seen (Cunningham

WT et al OOO 1982)

Better than syringe needle

May be attributed to two factors

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de-agglomeration ofbacterial biofilms via the

action of acoustic

Streaming

Cavitation might have produced

temporary weakening of the cellmembrane, making the bacteria

more permeable to NaOCl.

VAPOR LOCK EFFECT


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VAPOR LOCK EFFECT

Air entrapment by an advancing liquid front in closed-end micro

channels is a well-recognized physical phenomenon(Bankoff SB

AICHE J 1958)The ability of a liquid to penetrate these closed-end

channels is dependent on the contact angle of the liquid and the

depth and size of the channel.

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Under all circumstances, these closed-end microchannels will eventually be

flooded after sufficient time (hours to days) (Pesse AV, Int J 2005).

This phenomenon of air entrapment and the time frame in which complete

flooding occurs has practical clinical implications when irrigants aredelivered by using syringe needles from the coronal or middle third of a root

canal.

Because endodontic irrigation is performed within a time frame of minutes

instead of hours or days, air entrapment in the apical portion of the canal

might preclude this region from contact or disinfection by the irrigant.

Simple way to eliminate air lock is by dynamic Gutta percha activation(Mc

Gil l I EJ 2008, Huang TY IEJ 2008)38


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PRESSURE ALTERNATION DEVICES

Irrigants cannot reach the apical portion due to air

entrapment when needle tips are placed far away

Conversely if placed close to the foramen it may

result in severe iatrogenic damage

Concomitant irrigant delivery and aspiration via the

use of pressure alternation devices provide a

plausible solution to this problem.

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EARLY EXPERIMENTAL PROTOCOLS

No instrument technologyby Lussi et al

No canal enlargement

Debridement achieved solely with the use of low concentration

NaOCl, by altering subambient pressure fields.

This created bubble implosion and hydro dynamic turbulence

facilitating penetration

Proved to be better than conventional syringe needle irrigation

(Lussi et al 2004)

But , the technique was not considered safe in in vivo animal

studies and did not proceed to human clinical trials.

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Another experimental irrigation system was introduced by

Fukumoto et al.

Consists of an injection needle, aspirating needle attached

to the apex locator (Root ZX).

Aspiration pressure at -20 kPa

Coronally placed injecting needle and aspirating needle at

2 mm from apex gave reliable effects.

Significant importance is the irrigant reaches the apical

delta

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ENDOVAC (DISCUS DENTAL CULVER CITY CA)


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ENDOVAC (DISCUSDENTAL, CULVERCITY, CA)

Endovac system is based on a negative pressure approach whereby the irrigant is placed in the pulp

chamber is sucked down the root canal and back up again through a thin needle with a special design.

A macrocannula (# 55) or microcannula (#32) is connected via tubing to a syringe of irrigant and the

high-speed suction of a dental unit

Endovac system lowers the risks associated with irrigation close to the apical foramen considerably.

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The EndoVac System.

(A) Macro cannula with

hand piece

(B) Micro cannula with

finger piece

(C) Master delivery tip

(D) Tip of micro

cannula


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ADVANTAGES

Another advantagegood apical cleaning at

1mm level due to reverse flow of irrigants

(Nielsen BA, JOE 2007) and avoids air

entrapment

More volume of fluid is irrigated than

conventional syringe technique

Strong anti bacterial effect when

hypochlorite is used

Can be used for gross, course andmicroscopic debridement

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Safety:Less apical extrusion risk using the EndoVac system

compared with needle irrigation

J Endod. 2010 Feb;36(2):338-41

Efficacy:Better debridement 1 mm from working length using the EndoVac system

compared with needle irrigation

J Endod 2007;33:611-615

SUCCESS:Negative apical pressure irrigation system EndoVac results insignificantly less postoperative pain & necessity for analgesic medication

than a conventional needle irrigation protocol using the Max-i-Probe

J Endod 2010;36:1295-1301

RINSE ENDO (AIRTECHNIQUES, MELVILLE, NY)


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Titanium handpiece with a specially designed single-use

cannula with a 7 mm long aperture.

The long aperture eliminates blockage, enabling the

irrigation solution to reach and disinfect all portions of

the canal.

The pressure created by Rinsendo irrigation is lower

than the pressure created by a syringe during manual

irrigation.

Rinsendo employs exclusive, patented pressure suction

technology.

In the pressure phase, 65 l of rinsing solution

oscillating at a frequency of 1.6 Hz are automatically

drawn from the attached syringe and aspirated into the

canal.

In the suction phase, the used solution and air are

aspirated back.

Pressure suction cycles changes approximately 100

times per min


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Manufacturer claims that it is efficient in cleaning the

apical third.

But a higher risk of apical extrusion was observed byHauser V et al (IEJ 2007)

Mc Gill et al and Huang et al. confirmed that Manual

dynamic agitation better than RinsEndo

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HEATEDIRRIVACIRRIGATIONSYSTEM

The Heated IrriVac root canal irrigation system is designed

to provide rapid, thorough root canal cleaning. All -in-one

handpiece dispenses fresh, heated sodium hypochlorite

through an irrigation needle and removes spent irrigant and

dissolved tissue from the top of the canal through suction.

The handpiece has a corrosion-resistant titanium head with a

plastic handle and push-button control for precise solution

dispensing.

Irrigation solution is provided from a low pressure

regulated, 250-ml bottle and is heated in the handpiece

tubing just before dispensing the solution..

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ENDO IRRIGATOR

The Endo-Irrigator is a six-bottle micro-irrigation

system that provides fingertip controlled,

instantaneous, purge-free delivery of up to six

different irrigating solutions, including sodium

hypochloride.

The handpiece control or remote touch pad allows

the doctor or assistant to select from one solution

to the next with the touch of a button, without

leaving the field.

Built-in heater allows the delivery of heatedirrigating solutions for improved chemical

reactions. It reportedly improves procedure safety

and efficiency while also decreasing procedure

time (Nelson BA).

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COMPARATIVE SAFETY OF VARIOUS INTRACANAL


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COMPARATIVE SAFETY OF VARIOUS INTRACANAL

IRRIGATION SYSTEMS (PRANAV DESAI AND VAN HIMEL,

2009)

Endo Vac did not extrude irrigant after deep intracanal delivery and

suctioning the irrigant from the chamber to full working length.

Endo Activator had a minimal, although statistically insignificant, amount

of irrigant extruded out of apex.

Manual, Ultrasonic and Rinsendo groups had significantly greater

amounts of extrusion compared with EndoVac and EndoActivator groups.

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CONCLUSION

Irrigation has a key role in successful endodontic treatment.

Despite the plethora of studies on the effectiveness of various endodontic irrigation

regimens, it is noteworthy that no well- controlled clinical study is available in the

current endodontic literature.

From a practical point of view, no evidence based study is available to date that

attempts to correlate the clinical efficacy of these devices with improved treatment

outcomes.

Thus, the question of whether these devices are really necessary remains unresolved.

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