A Comparative Assessment of Three Different Irrigating Systems in Root Canal Treatment: An In vitro Study.

BACKGROUND: Exact diagnosis, efficient cleaning, shaping as well as disinfection of the root canals lead to successful root canal treatment. The present study compared three different irrigating systems in root canal treatment.
METHODOLOGY: Sixty recently extracted permanent mandibular molars were classified into four groups: Group I, II, III, and IV with 15 teeth each. Group I comprised Endo-Irrigator Plus system. Group II comprised EndoActivator, Group III utilized passive ultrasonic irrigation (PUI), and Group IV was control, in which no activation of the irrigant was done. Stereomicroscope (X20) magnification was used for checking isthmus cleanliness. The scoring criteria were divided into score 1-5 depending on the amount of debris in root canal walls.
RESULTS: The mean ± standard deviation debris removal score in Group I was 2.6 ± 0.80, in Group II was 3.8 ± 0.72, in Group III was 3.9 ± 1.06, and in Group IV was 4.2 ± 0.82. The difference was significant (P < 0.05).
CONCLUSION: Authors found that Endo-Irrigator Plus exhibited better cleaning efficacy followed by EndoActivator and PUI. Copyright:

INTRODUCTION

The motive of endodontic therapy is complete elimination of root canal debris. Exact diagnosis, efficient cleaning, shaping as well as disinfection of the root canals lead to successful root canal treatment.[1] Obturation of root canals is the final step of endodontic therapy. Aim of root canal therapy is to bring tooth into the healthy and functional state.[2] Biomechanical preparation removes organic debris and microorganisms from pulp canals. Complete removal of bacteria and debris is essential to ensure successful therapy which is augmented by the selection of proper instruments as well as irrigants.[3]

Irrigating solutions flush debris, dissolve tissue, and disinfect root canal system. It should be nontoxic, adequate flowable, and should reach to exact working length (WL). It should also possess the property of adequate flow, and amount of irrigating solution should be enough to be effective in debriding the complete canal system.[4]

There are numerous irrigation devices available in the market. Endo-Irrigator Plus System comprised suction having positive and negative pressure tips that work at the temperature of 45°C. Thus, system follows the principle of continuous warm activated irrigation and evacuation. EndoActivator is based on the concept of cavitation and acoustic streaming which comprised disposable flexible polymer tips of variable sizes. It is three in types. This is effective in the removal of smear layer. Passive ultrasonic irrigation (PUI) uses ultrasonic wave energy transmitted to the irrigant from a file or smooth oscillating wire.[5] The present study compared three different irrigating systems in endodontic treatment.

METHODOLOGY

This in vitro study was conducted after obtaining ethical approval from concerned committee. For this study, we selected sixty recently extracted permanent mandibular molars. Endodontic treatment was started following all standardized procedures. Access cavity preparation was done, and with #10 K-file, WL was obtained. ProTaper rotary system was used for canal preparation up to an apical preparation of F2 size. 30G needle was used for irrigation with 5.25% NaOCl. Final irrigation was done with 1 ml of 17% ethylenediaminetetraacetic acid and 3 ml of 5.25% NaOCl followed by 3 ml (normal saline). Following this, samples were classified into different groups. Group I comprised Endo-Irrigator Plus system. In this group, 3 ml of 5.25% NaOCl was heated up to 50°C was inserted with positive pressure tips for coronal one-third and negative pressure tips for the apical area. Group II comprised EndoActivator, in which 5.25% NaOCl was used as an irrigant. The EndoActivator sonic handpiece activator tip was passively inserted in the canal within 2 mm of the WL. Vertical strokes of 2–3 mm were given from the tip of handpiece. Group III utilized PUI, in which 5.25% NaOCl solution was activated with #20 tip driven by an ultrasonic device at 1 mm from the WL. Group IV was control, in which no activation of the irrigant was done. Each group had 15 samples. Following this, mesial roots were sectioned longitudinally 4 mm from the apex. Stereomicroscope (X20) magnification was used for checking isthmus cleanliness. The scoring criteria were divided into score 1–5 depending on amount of debris in root canal walls. Score 1 showed clean root canal walls, score 2 comprised few small agglomeration of debris, score 3 comprised many agglomerations of debris covering <50% of the root canal wall, score 4 was >50% of debris covering the root canal walls, and score 5 showed debris completely or nearly completely covering root canal walls. Analysis of the results was done using SPSS software version 16.0 (IBM, Armonk, New York).

RESULTS

Table 1 shows the type of irrigation activation systems. Each group had 15 samples.

Table 1

Distribution of samples into various study groups

Groups	Group I	Group II	Group III	Group IV
Method	Endo-Irrigator Plus System	EndoActivator	Passive ultrasonic irrigation	Control
n	15	15	15	15

Each group had 15 samples

Table 2 shows that mean ± standard deviation (SD) debris removal score in Group I was 2.6 ± 0.80, in Group II was 3.8 ± 0.72, in Group III was 3.9 ± 1.06, and in Group IV was 4.2 ± 0.82. The difference was significant (P < 0.05).

Table 2

Debris removal in isthmus area in all groups

Groups	Mean	SD	P
Group I	2.6	0.80	0.021
Group II	3.8	0.72
Group III	3.9	1.06
Group IV	4.2	0.82

SD: Standard deviation

DISCUSSION

Apical one-third root canals are the area where penetration of irrigants is challenging. An effective irrigant should come in direct contact with the entire canal wall surfaces. It is evident that most of the instruments do not reach every part of the root canal system; hence, there is a need for irrigating solution that can reach in those areas. Isthmuses, accessory canals, fins, and deltas are the areas because of complex root anatomy remain untouched by instruments and thus provide space for debris, microbes, and by-products.[6] Numerous irrigation delivery and agitation systems are available in the market for root canal irrigation. Diffusion of irrigating solutions in root canals depends on the diameter and coronal enlargement of canal, the type and volume of irrigant, and irrigant delivery system. Ultrasonic, sonic, PUI devices, and techniques are found to be beneficial in the removal of tissue, effective irrigation of lateral canals, and complete bacterial removal.[7] The present study compared three different irrigating systems in root canal treatment.

In the present study, we recruited sixty teeth which were divided into four groups. Group I comprised Endo-Irrigator Plus System, Group II comprised EndoActivator, Group III utilized PUI, and Group IV was control. Gadaalay et al.[8] compared Endo-Irrigator Plus, PUI, EndoActivator, manual dynamic activation, and control group in fifty extracted human mandibular molars. Debris removal score was compared in all groups. It was observed that Group 1 had 2.7 ± 0.82, Group 2 had 3.5 ± 0.70, Group 3 had 3.6 ± 1.07, and Group 4 had 4.0 ± 0.81. The result of the study showed a significant difference between different groups.

We found that mean ± SD debris removal score in Group I was 2.6 ± 0.80, in Group II was 3.8 ± 0.72, in Group III was 3.9 ± 1.06, and in Group IV was 4.2 ± 0.82. Khalap et al.[9] in their study found that sonic activation is superior to ultrasonic activation in debris removal. Authors suggested that PUI bring out the removal of debris from instrumented canals through acoustic microstreaming, which produces sufficient shear stresses.

Saini et al.[10] compared efficacy of NaviTip, Max I Probe, and EndoVac in removal of debris from the root canal. They observed least amount of mean percentage debris with EndoVac followed by Max I probe and NaviTip. The difference between the groups found to be significant (P < 0.05). It was evident from the results that 3.5 mm level showed relatively less amount of debris as compared 1.5 mm level, though EndoVac irrigation system revealed nonsignificant difference (P < 0.05).

Al-Obaida et al.[11] found that the sonic irrigation was significantly better than the control group in removing loose debris at 3 mm from the radiographic apex. Heilborn et al.[12] evaluated the cleaning efficiency of EndoVac system with the Max-I-Probe and found that Max-I-Probe system was least effective in debris removal as compared to EndoVac system; however, no significant difference was found between groups at 3 mm level. The limitation of the study is that only three irrigating systems were compared.

CONCLUSION

Authors found that Endo-Irrigator Plus exhibited better cleaning efficacy followed by EndoActivator and PUI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.