• Users Online: 24
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 29-32

Effect of different irrigation activation techniques on the amount of apical debris extrusion


Department of Endodontics, Faculty of Dentistry, Zonguldak Bülent Ecevit University, Zonguldak, Turkey

Date of Submission26-Oct-2019
Date of Acceptance10-Jan-2019
Date of Web Publication13-Jun-2019

Correspondence Address:
Uygar Hizarci
Department of Endodontics, Faculty of Dentistry, Zonguldak Bülent Ecevit University, 67600 Zonguldak
Turkey
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_38_18

Rights and Permissions
  Abstract 

Aim
This study compared the amount of debris extrusion of different irrigation activation techniques.
Materials and methods
Sixty single rooted maxillary incisor human teeth with single and straight canals were used. The crowns were flattened to obtain a standardized working length. The specimens were placed into Eppendorf tubes to collect the debris. The root canals were instrumented using the ProTaper Next system. The specimens were randomly divided into four equal groups in terms of the irrigation activation techniques; group I, no activation; group II, manual dynamic agitation; group III, passive ultrasonic irrigation; and group IV, Xp-endo Finisher. A total of 10 ml of distilled water was used during the irrigation procedures of each specimen. The tubes were stored in incubator for 5 days. The amount of debris extrusion was calculated by subtracting the initial weight from the final weight of the tube. The distribution of the data was examined using the Shapiro–Wilk test. Mann–Whitney U- test was used for post-hoc group comparisons.
Results
Debris extrusion was recorded for all specimens. The no activation group demonstrated significantly less amount of debris extrusion compared to all activation groups (P < 0.05). No differences were found between other groups (P > 0.05). The mean values for manual dynamic agitation, passive ultrasonic irrigation, and Xp-endo Finisher groups were found as 0.00114733 g, 0.00091733 g, and 0.00100 g, respectively.
Conclusion
Although activation techniques caused a higher amount of debris extrusion, their benefits and limitation of in-vitro conditions to reflect clinical situations should be well considered.

Keywords: apical debris extrusion, irrigation activation, manual dynamic agitation, passive ultrasonic irrigation, Xp-endo finisher


How to cite this article:
Hizarci U, Koçak S, Sağlam BC, Koçak MM. Effect of different irrigation activation techniques on the amount of apical debris extrusion. Tanta Dent J 2019;16:29-32

How to cite this URL:
Hizarci U, Koçak S, Sağlam BC, Koçak MM. Effect of different irrigation activation techniques on the amount of apical debris extrusion. Tanta Dent J [serial online] 2019 [cited 2021 Dec 7];16:29-32. Available from: http://www.tmj.eg.net/text.asp?2019/16/1/29/260279


  Introduction Top


The incidence of extruded debris, which ranges between 1.4 and 16%[1], may cause inflammation and finally postoperative pain[2]. Flare-up and postoperative pain, which may occur as a result of unexpected debris extrusion, are undesirable clinical conditions for both patients and clinicians[3]. Therefore, the occurrence of less debris extrusion may minimize postoperative reactions and increase the patient comfort after appointment.

Conventional needle irrigation is a commonly used technique during irrigation of root canals[4],[5]. The main limitation of conventional needle irrigation is lack of delivering the solutions no further than 0–1.1 mm beyond its tip[6]. Additionally, the conventional needle irrigation is insufficient for cleaning of the complex anatomy including isthmus, fins, lateral and accessory canals[7]. To obtain a well-cleaned root canal, irrigants should be in contact with the whole surface[8]. For this purpose, various irrigation activation techniques were developed to increase the efficacy of irrigation solutions[9].

A well-fitted gutta-percha cone is used in repeated insertion motion to the working length for the manual dynamic activation (MDA) during activation. For the activation of irrigant, the cone is applied with short strokes[10]. The activation of irrigant with the passive ultrasonic irrigation (PUI) is an acceptable technique which removes debridement and provides an efficient canal disinfection. PUI refers to an irrigation protocol where in a non-cutting ultrasonically activated file is agitated in the canal without contacting the walls[11].

A novel nickel–titanium (NiTi) rotary finishing file, XP-endo Finisher (XPF) file, has been introduced for irrigation activation. The alloy of XPF, NiTi Max-Wire, increases the flexibility[12]. The file was reported to improve the effectiveness of final irrigation after root canal instrumentation[13]. The curved bulb of file expands to a diameter of 6 mm which is 100 times of a corresponding sized file[12],[14].

This study compared the amount of apical debris extrusion after performing different irrigation activation techniques prepared with rotary NiTi instruments.


  Materials And Methods Top


All patients are informed and signed a consent for approval for using their extracted teeth in this research according to ethical guidelines of Faculty of Dentistry, Zonguldak Bülent Ecevit University, Zonguldak, Turkey. Sixty extracted single rooted maxillary incisor human teeth with single and straight canals were used. Soft tissue remnants were removed by periodontal curettes and all specimens were stored in sterile saline solution until use. A reference point was created by flattening the top of the buccal cusps and the access cavities were prepared. A size 15-K file (Dentsply Maillefer, Ballaigues, Switzerland) was used to control the canal patency until the tip was visible at the apical foramen and 1 mm was subtracted from this length to determine the working length. The amount of debris was collected by an experimental setup described by Myers and Montgomery[15]. To obtain the initial weight, the Eppendorf tubes were weighed for three times using an analytic balance (Radwag, Radom, Poland) with 10−4 accuracy after removal of the covers, and averaged. The teeth were inserted into the previously created holes on the cover.

A 27-G needle was placed alongside the tooth to balance the air pressure and both were fixed to the cover with cyanoacrylate to create the test setup. The test setup was placed in the Eppendorf tube, and the tube was fitted into a vial which was covered with aluminum leaf to prevent the seeing during instrumentation. All preparations were performed by a single operator, using ProTaper Next rotary files (Dentsply Maillefer) to a size X4 using a crown down technique in a sequence of PU SX, PN X1, X2, X3, and X4. The setting of endodontic motor was selected as 300 rpm rotation speed and 200 gram-centimeter torque. When the instrumentation was completed, the test setup was removed. A volume of 5 ml distilled water was used between files.

The specimens were randomly divided into four groups as follows (n = 15):

  1. Group I (no activation): final irrigation was applied with 5 ml distilled water without any additional agitation.
  2. Group II (MDA): distilled water was activated with the ProTaper X4 gutta-percha point (ProTaper Next Gutta-Percha Points, Size X4; Dentsply Maillefer) for 1 min The gutta-percha cone was inserted 1 mm shorter than the working length.
  3. Group III (PUI): distilled water was activated with ultrasonic device (VDW Ultra, VDW GmbH, Münich, Germany) and ultrasonic tip (length/ISO 25/25) which was placed 1 mm short of the working length. It was activated at a frequency cycle of 28–36 kHz after the last irrigation for 1 min.
  4. Group IV: distilled water was activated with XPF (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) (size/25, Taper/00) which was set at 800-rpm speed and 1- Ncm torque and applied for 1 min. The file was inserted 1 mm shorter than the working length.


The remaining debris on the apical root surface was irrigated into the tube. The tubes were held in an incubator at 70°C for 5 days to vaporize the distilled water. The tubes, including the extruded debris were weighed for three times, averaged and this value was recorded as the final weight. Finally, amount of extruded debris was calculated by subtracting the initial weight from the final weight including the debris.

The normal distribution of data was evaluated with the Shapiro–Wilk test. The comparison between parameters was analyzed with the Kruskal–Wallis test. The failure of normality of data prompted the application of the Bonferroni-adjusted Mann–Whitney U- test for post-hoc group comparisons. P values less than 0.05 were considered significant for all tests.


  Results Top


Debris was recorded in all specimens. The no activation group demonstrated significantly less amount of debris extrusion compared to all activation groups (P < 0.05). However, no significant differences were found between other groups (P > 0.05). The mean values and standard deviations for all groups are listed in [Table 1].
Table 1 Mean weights and SD of apically extruded debris by activation techniques

Click here to view



  Discussion Top


The extruded debris was associated with periapical tissue inflamation and postoperative pain[1]. Therefore, less debris extrusion may reduce postoperative pain after root canal treatment[16]. The effects of different instrumentation techniques, instrumentation systems, and instrumentation kinematics on apical debris extrusion were previously well evaluated[17]. However, irrigation technique and activation of the irrigant may also cause extrusion of debris. Thus, we evaluated the effect of different irrigation activation techniques on apical debris extrusion.

The debris was collected using a common experimental model. This model does not mimic the periapical tissues and the absence of apical pressure may be a limitation of the experimental setup[3]. However, the model provides a standardization in methodology, develops well-controlled conditions, and allows reliably comparison of certain factors[18].

When the chemomechanical preparation was applied with conventional needles, irrigation could not reach to 40–60% of the canal walls[19]. It has also been noted that the traditional irrigation solutions are capable of advancing the needle tip by as much as 1 mm deeper distance, which is inadequate for canal irrigation[20]. Thus, activation procedure is required to increase the efficacy of the irrigant.

The MDA technique requires a matched gutta-percha cone, which may be defined as a relatively inexpensive method. The MDA technique allows the penetration of irrigation solution into the dentinal tubules comparable to PUI activation[21]. However, this technique has limited activity to eliminate the apical vapor lock[22]. Ribeiro et al.[23] reported that PUI was more successful in terms of debris removal compared to needle irrigation, MDA, PUI system. In a previous study, PUI was compared with conventional irrigation and the less apical debris flow was detected for activation with PUI[24]. This contrary finding to our results could be related to the difference in irrigation solutions used. The distilled water was used instead of sodium hypochlorite to highlight the possible effect of the activation techniques and to eliminate misleading results due to the crystallization of irrigant. In the present study, MDA technique demonstrated relatively higher debris extrusion compared to other activation methods without any significance. A recent clinical study reported that MDA technique caused more postoperative pain than conventional needle irrigation, sonic activation, and PUI techniques after root canal treatment at the first 24 h[25]. This result may be related to higher amount of debris extrusion as recorded in the present study.

Irrigation using a conventional needle may create an apical vapor lock which significantly limits the irrigant exchange at the apical third of the root canal system[26]. Irrigation activation systems have been developed to overcome this situation. Additionally, activation/agitation techniques provide superior root canal cleanliness[27]. In the present study, the lowest debris extrusion was recorded in the nonactivated group. The reason for this result may be related to the fact mentioned in the previous studies in which they reported that the conventional irrigation is insufficient for the removal of debris from the root canal irregularities and the fact that it cannot provide adequate cleaning on the root canal walls. Although no statistically significant difference was found, apical debris extrusion was observed in all activation groups.

XPF has been described as a spoon-shaped form, which makes cleaning more effective in root canal irregularities that cannot be reached during instrumentation. Due to the shape, shaking of the solution through the canal by moving up and down is required. This makes it more efficient to clean the canals, because it comes into contact with the canal walls mechanically[14].

The irrigation with the XPF was found more effective than conventional needle irrigation for removal of debris and smear layer[28], and showed superior cleaning efficacy compared to PUI[29]. A relatively higher amount of debris extrusion for the XPF group than the PUI group may be associated with mechanical activation of the XPF and more effective cleaning of the apical third[30].


  Conclusion Top


All techniques caused apical extrusion of debris. Although, activation techniques caused a higher amount of debris extrusion, their benefits in clinical practice and limitations of in-vitro conditions to reflect clinical conditions should be well considered.

Acknowledgements

This manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Siqueira JFJr, Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod 2002; 28:457–460.  Back to cited text no. 1
    
2.
Ruiz-Hubard EE, Gutmann JL, Wagner MJ. A quantitative assessment of canal debris forced periapically during root canal instrumentation using two different techniques. J Endod 1987; 13:554–558.  Back to cited text no. 2
    
3.
Tanalp J, Güngör T. Apical extrusion of debris: a literature review of an inherent occurrence during root canal treatment. Int Endod J 2014; 47:211–221.  Back to cited text no. 3
    
4.
Uroz-Torres D, González-Rodríguez MP, Ferrer-Luqe CM. Effectiveness of the endo-activator system in removing the smear layer after root canal instrumentation. J Endod 2010; 36:308–311.  Back to cited text no. 4
    
5.
Zmener O, Pameijer CH, Serrano SA, Palo RM, Iglesias EF. Efficacy of NaviTip FX irrigation needle in removing post instrumentation canal smear layer and debris in curved root canals. J Endod 2009; 35:1270–1273.  Back to cited text no. 5
    
6.
Munoz HR, Camacho-Cuadra K. In vivo efficacy of three different endodontic irrigation systems for irrigant delivery to working length of mesial canals of mandibular molars. J Endod 2012; 38:445–448.  Back to cited text no. 6
    
7.
Mancini M, Cerroni L, Iorio L, Armellin E, Conte G, Cianconi L. Smear layer removal and canal cleanliness using different irrigation systems (EndoActivator, EndoVac, and passive ultrasonic irrigation): field emission scanning electron microscopic evaluation in an in vitro study. J Endod 2013; 39:1456–1460.  Back to cited text no. 7
    
8.
Zehnder M. Root canal irrigants. J Endod 2006; 32:389–398.  Back to cited text no. 8
    
9.
Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. Review of contemporary irrigant agitation techniques and devices. J Endod 2009; 35:791–804.  Back to cited text no. 9
    
10.
McGill S, Gulabivala K, Mordan N, Ng YL. The efficacy of dynamic irrigation using a commercially available system (RinsEndo) determined by removal of a collagen 'biomolecular film' from an ex vivo model. Int Endod J 2008; 41:602–608.  Back to cited text no. 10
    
11.
Weller RN, Brady JM, Bernier WE. Efficacy of ultrasonic cleaning. J Endod 1980; 6:740–743.  Back to cited text no. 11
    
12.
FKG XP-Endo Finisher Technical Guide. La Chaux-deFonds. Switzerland: FKG; 2018. 1–16.  Back to cited text no. 12
    
13.
Bao P, Shen Y, Lin J, Haapasalo M. In vitro efficacy of XP-endo Finisher with 2 different protocols on biofilm removal from apical root canals. J Endod 2017; 43:321–325.  Back to cited text no. 13
    
14.
Trope M, Debelian G. XP-3D Finisher™ file the next step in restorative endodontics. Endodontic Practice US 2015; 8:22–24.  Back to cited text no. 14
    
15.
Myers GL, Montgomery S. A comparison of weights of debris extruded apically by conventional filling and Canal Master techniques. J Endod 1991; 17:275–279.  Back to cited text no. 15
    
16.
Koçak MM, Çiçek E, Koçak S, Saǧlam BC, Yılmaz N. Apical extrusion of debris using ProTaper Universal and ProTaper Next rotary systems. Int Endod J 2015; 48:283–286.  Back to cited text no. 16
    
17.
Kustarci A, Akdemir N, Siso SH, Altunbas D. Apical extrusion of intracanal debris using two engine driven and step-back instrumentation techniques: an in-vitro study. Eur J Dent 2008; 2:233–239.  Back to cited text no. 17
    
18.
Versiani MA, Pécora JD, Sousa-Neto MD. Microcomputed tomography analysis of the root canal morphology of single-rooted mandibular canines. Int Endod J 2013; 46:800–807.  Back to cited text no. 18
    
19.
Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod 2000; 26:751–755.  Back to cited text no. 19
    
20.
Ram Z. Effectiveness of root canal irrigation. Oral Surg Oral Med Oral Pathol 1977; 44:306–312.  Back to cited text no. 20
    
21.
Generali L, Campolongo E, Consolo U, Bertoldi C, Giardino L, Cavani F. Sodium hypochlorite penetration into dentinal tubules after manual dynamic agitation and ultrasonic activation: a histochemical evaluation. Odontology 2018; 106:454–459.  Back to cited text no. 21
    
22.
Agarwal A, Deore RB, Rudagi K, Nanda Z, Baig MO, Fareez MA. Evaluation of apical vapor lock formation and comparative evaluation of its elimination using three different techniques: An in vitro Study. J Contemp Dent Pract 2017; 18:790–794.  Back to cited text no. 22
    
23.
Ribeiro EM, Silva-Sousa YT, Souza-Gabriel AE, Sousa-Neto MD, Lorencetti KT, Silva SR. Debris and smear removal in flattened root canals after use of different irrigant agitation protocols. Microsc Res Tech 2012; 75:781–790.  Back to cited text no. 23
    
24.
Shetty VP, Naik BD, Pachlag AK, Yeli MM. Comparative evaluation of the amount of debris extruded apically using conventional syringe, passive ultrasonic irrigation and EndoIrrigator Plus system: an in vitro study. J Conserv Dent 2017; 20:411–414.  Back to cited text no. 24
    
25.
Topçuoǧlu HS, Topçuoǧlu G, Arslan H. The Effect of Different Irrigation Agitation Techniques on postoperative pain in mandibular molar teeth with symptomatic irreversible pulpitis: a randomized clinical trial. J Endod 2018; 44:1451–1456.  Back to cited text no. 25
    
26.
Tay FR, Gu LS, Schoeffel GJ, Wimmer C, Susin L, Zhang K, et al. The effect of vapor lock on root canal debridement using a side-vented needle for positive- pressure irrigant delivery. J Endod 2010; 36:745–750.  Back to cited text no. 26
    
27.
Lee SJ, Wu MK, Wesselink PR. The efficacy of ultrasonic irrigation to remove artificially placed dentine debris from different-sized simulated plastic root canals. Int Endod J 2004; 37:607–612.  Back to cited text no. 27
    
28.
Wigler R, Dvir R, Weisman A, Matalon S, Kfir A. Efficacy of XP-endo finisher files in the removal of calcium hydroxide paste from artificial standardized groove in the apical third of oval root canals. Int Endod J 2017; 50:700–705.  Back to cited text no. 28
    
29.
Turkaydin D, Demir E, Basturk FB, Sazak Övecoglu H. Efficacy of XP-Endo Finisher in the removal of triple antibiotic Paste from immature root canals. J Endod 2017; 43:1528–1531.  Back to cited text no. 29
    
30.
Hamdan R, Michetti J, Pinchon D, Diemer F, Georgelin-Gurgel M. The XP-Endo Finisher for the removal of calcium hydroxide paste from root canals and from the apical third. J Clin Exp Dent 2017; 9:e855–e860.  Back to cited text no. 30
    



 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials And Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed2980    
    Printed127    
    Emailed0    
    PDF Downloaded330    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]