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CONTINUING EDUCATION

Volume 36 No.6 Page 84

Endodontic Disinfection:
The Sonic Advantage
Authored by Clifford J. Ruddle, DDS

Upon successful completion of this CE activity, 2 CE credit hours may be awarded.

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment
and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.
CONTINUING EDUCATION

Endodontic Disinfection: ENDODONTIC OBJECTIVES


A LEO will invariably heal following an extraction because this
The Sonic Advantage procedure not only removes the tooth, but importantly serves
to eliminate 100% of the contents of the root canal system. Like
the extraction, the biological objectives for endodontic treat-
Effective Date: 2/01/16 Expiration Date: 2/01/20 ment are to remove all the pulp and bacteria when present (and
their related irritants) from the root canal system. Treatment is
directed toward making a correct diagnosis, isolating the tooth,
and preparing an effective access cavity. Importantly, any given
About the Author canal is manually reproduced, secured, and shaped to facilitate
Dr. Ruddle is founder and director of Advanced
both 3-D cleaning and filling root canal systems. Certainly, end-
Endodontics, an international educational source odontically treated teeth should be properly restored to protect
located in Santa Barbara, Calif. He is an assistant against hopeless fracture and achieve a coronal seal (Figure 3).
professor of graduate endodontics at Loma Linda
University and the University of California, Los
Further influencing 3-D disinfection, one must recognize that
Angeles; an associate clinical professor at the the files utilized to prepare canals produce debris and do not
University of California, San Francisco; and an clean into the uninstrumentable portions of a root canal system
adjunct assistant professor of endodontics at
the University of the Pacific School of Dentistry.
(Figure 4). This debris (or smear layer) is oftentimes a cocktail
As an inventor, he has designed and developed containing dentinal mud, pulpal remnants, and, when present,
several instruments and devices that are widely micro-organisms. Importantly, a smear layer serves to limit or
used internationally. He offers endodontic
education through lectures, clinical articles,
completely block the exchange of an irrigant into the uninstru-
training manuals, videos, and DVDs. He maintains a private practice in Santa mentable aspects of the root canal system. In the noble quest
Barbara. He can be reached at (800) 753-3636 or via endoruddle.com. toward complete 3-D cleaning or disinfection, many reagents,
Disclosure: Dr. Ruddle has a financial interest in products he designs and develops,
devices, and methods have been advocated and utilized.3 This
including the EndoActivator System (Dentsply Sirona). article will emphasize the importance of active irrigation.

Active Irrigation

I
n the United States alone, more than 100,000 dentists per- Using the best technologies, active irrigation serves to initiate
form tens of millions of operative, restorative, and recon- fluid hydrodynamics, resulting in shear wall forces that wipe
structive procedures on an annual basis. Certainly, these surfaces clean. There is increasing evidence to support that fluid
dental procedures are primarily directed toward eliminating activation, in both minimally or more fully shaped canals, plays
carious lesions, aesthetically restoring teeth, and functionally a strategic role in exchanging irrigant, which in turn serves to
moving patients toward optimal oral health. However, it is disinfect into all aspects of the root canal system, including
well recognized that repeated dental procedures on the same lateral canals, loops, fins, webs, anastomoses, and dentinal
tooth potentially contribute to irreversible pulpal injury. Pul- tubules.2-4 The greatest focus today is on how to safely, effectively,
pal breakdown originates within an anatomical space that and efficiently activate any given reagent to maximize the
commonly exhibits infinite configurations along its length. As hydrodynamic phenomenon. The most important reagents for
such, the endodontic treatment challenge is 3-D disinfection. activation are solutions of 6% sodium hypochlorite (NaOCl) and
Root canal systems contain branches that communicate 17% ethylenediaminetetraacetic acid (EDTA), recognizing that
with the attachment apparatus furcally, laterally, and often other final rinse solutions are available.
terminate apically into multiple portals of exit (POEs).1 Con-
sequently, any opening from the root canal system to the peri- Active Irrigation Methods
odontal ligament should be thought of as a POE through which There are 3 primary methods that have been shown to exchange
potential endodontic breakdown products may pass (Figure 1). an intracanal irrigant into all aspects of the root canal system
Radiographically, it is fundamental to associate that a lesion of namely, acoustic energy, light energy, and mechanical energy.3
endodontic origin (LEO) arises secondary to pulpal breakdown Although acoustic and light-based technologies are intriguing,
and forms adjacent to any given POE. Improvement in endo their widespread adoption into the marketplace is limited,
dontic treatment occurs with the recognition that anatomy as both these technologies are priced from several thousand
matters and that 3-D disinfection of the root canal system is cen- to tens of thousands of dollars. The following will describe a
tral to predictably successful endodontics (Figure 2).2 mechanical technology for 3-D disinfection that best combines

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CONTINUING EDUCATION

Endodontic Disinfection: The Sonic Advantage


a b

Figure 1. This graphic demonstrates that Figure 2a. A preoperative film of a maxil- Figure 2b. A recall image reveals excellent heal-
lesions of endodontic origin (LEOs) arise lary first bicuspid. Note a gutta-percha cone ing and confirms the importance of shaping
secondary to pulpal breakdown and form tracing a sinus tract to a LEO. canals, 3-D disinfection, and treating root canal
adjacent to portals of exit. systems.

scientific evidence, effectiveness, and affordability. The cleaning solutions; rather, remove the barrier sleeve and simply
EndoActivator (Dentsply Sirona) is validated by more than a wipe down the handpiece with a mild detergent.
dozen scientific, peer-reviewed articles. Furthermore, it is used
by nearly 50,000 international dentists and is readily affordable EndoActivator Tips
in North America at a cost of about $500 for the introductory kit The EndoActivator tips have an easy snap-on/snap-off design
and less than $2 per patient. and are color-coded yellow, red, and blue to approximately
correspond to file sizes 20/02, 25/04, and 30/06, respectively.
ENDOACTIVATOR SYSTEM The tips are made from a noncutting, medical-grade polymer,
The EndoActivator is a mechanical system that comprises a are strong and flexible, and are 22 mm long with orientational
handpiece and variously sized polymer tips (Figure 5). This depth gauge rings positioned at 18, 19, and 20 mm. The
sonically driven system has been engineered to safely activate EndoActivator tips are disposable, single-use devices that should
various intracanal reagents and vigorously produce the not be autoclaved. Autoclaving an EndoActivator tip reduces
hydrodynamic phenomenon. As we will see, this technology the elasticity of the tip, which decreases its back-and-forth
provides a safer and more effective method to disinfect a root movement and performance. The EndoActivator tip selected is
canal system compared to ultrasonic technology.4-6 When the placed over the barrier-protected driver and is simply snapped
directions for use are followed, research continues to show on to secure its connection to the handpiece (Figure 7).
that the EndoActivator system is able to remove the smear Tip Selection
layer, debride into the uninstrumentable portions of the root In well-prepared canals, it is easy to select a tip that fits loosely
canal system, and dislodge biofilms within long, narrow, and to within 2.0 mm of working length.1,11 When a tip is too big
highly curved canals of molar teeth (Figure 6).6-10 for any given prepared canal, its back-and-forth movement will
be restricted or dampened, limiting its ability to agitate a solu-
Sonic Handpiece tion. Research has shown that vibrating the tip, in combination
The sonic handpiece has been designed to be cordless, contra- with moving the tip up and down in short 2.0 to 3.0 mm verti-
angled, and ergonomic, and it is used to mechanically drive cal strokes, synergistically produces a powerful hydrodynamic
strong and flexible polymer EndoActivator tips. When the phenomenon.4,6,7 Scientific evidence supports that this specific
handpiece is activated, the power defaults to 10,000 cpm, technique optimizes debridement, eliminates the smear layer,
which research has shown significantly promotes all aspects and disrupts biofilms (Figure 6).6-10
of 3-D disinfection.4,6,7 Depending on use, a new, single lithium
battery is periodically replaced to ensure optimal performance. Clinical Protocol
For infection control, custom protective barrier sleeves have Following shaping procedures, re-irrigate and flush the root canal
been designed to easily slide over the entire handpiece. After space with a solution of 6% NaOCl, then suction to remove this
use, it is important to not autoclave or submerge the handpiece in reagent. Next, flood the pulp chamber with a 17% EDTA solution

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Endodontic Disinfection: The Sonic Advantage


and use the EndoActivator to agitate this intraca- a b
nal solution for 60 seconds. This process should be
repeated for each canal or until the fluid in the pulp
chamber is clinically observed to be clear. Follow-
ing the use of 17% EDTA, vacuum and remove this
reagent. Irrigate with a solution of 6% NaOCl and
use the EndoActivator to agitate this intracanal solu-
tion for 30 seconds (Figure 8). When the clinical pro-
cedure has been completed, the single-use activator
tip and barrier sleeve should be discarded. To better Figure 3a. (Left) A preoperative film Figure 3b. (Left) This working film image
understand the clinical use of the EndoActivator, demonstrates a failing central incisor demonstrates the downpack. Note the filled
animations, clinical ops, and published articles are with a gutta-percha point tracing a sinus lateral canal associated with the laterally
tract to a lateral LEO. (Right) Following dis- positioned LEO. (Right) A 25-year recall film
available at endoruddle.com. assembly and 3-D cleaning, a working film demonstrates 3-D endodontics, osseous
demonstrates master cone fit. repair, and the restored tooth.
Mechanism of Action
In a well-shaped and fluid-filled canal, the
hydrodynamic phenomenon results when a
vibrating tip generates fluid activation and
intracanal waves.3,4,9,11 Random waves fracture,
resulting in the formation of bubbles that oscillate
within any given reagent. These bubbles expand,
become unstable due to heat and pressure, then
collapse and implode. Each implosion generates
up to 30,000 shockwaves that serve to powerfully
penetrate, break up potential biofilms, and wipe Figure 4. This graphic shows residual tis- Figure 5. The EndoActivator System
sue following shaping, while the inset image (Dentsply Sirona) is designed to safely and
surfaces clean.4 This phenomenon is regularly depicts a file generating debris, resulting in vigorously exchange intracanal reagents
visualized clinically as the action of the a blocked lateral canal. into all aspects of the root canal system.
EndoActivator tip frequently produces a cloud
of debris within a fluid-filled pulp chamber.

THE SONIC ADVANTAGE


The EndoActivator is a sonic technology that has
been shown to be superior to ultrasonic technol-
ogy utilized for 3-D disinfection.3,4,6 The follow-
ing will look at the distinct sonic advantages that
independently and synergistically influence fluid
activation.
Figure 6. SEM images provide evidence Figure 7. A preselected EndoActivator
Amplitude and Frequency that the EndoActivator System can clean tip is placed over a protective barrier
Amplitude is the maximum value of back and root canal systems. (Courtesy of Dr. Grgory and snapped onto the handpiece for
clinical use.
forth displacement of a vibrating tip. Frequency Caron; Paris, France.)
is the interval of time it takes a vibrating tip to move through breakage. To clarify, when ultrasonic energy is used for 3-D disin-
one complete back-and-forth displacement cycle. In general, fection, high frequency sinusoidal waves are produced with low
the higher the frequency, the lower the amplitude. Certain dis- amplitude, meaning less useful energy. On the contrary, sonic
tributors market activating metal insert tips at high ultrasonic technology produces a high tip amplitude about 60 times greater
frequencies for endodontic 3-D disinfection. However, an ultra- than ultrasonic technology (Figure 9). Research shows this ampli-
high frequency requires an ultralow amplitude to mitigate tip tude maximizes hydrodynamics and 3-D disinfection.3-7,12-14

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CONTINUING EDUCATION

Endodontic Disinfection: The Sonic Advantage


Noncutting Tips a b
Sonic technology drives highly flexible, noncut-
ting, polymer tips that absolutely maintain the
anatomical integrity of the final preparation.4,14
On the contrary, all ultrasonically driven instru-
ments are manufactured from metal alloys.
Appreciate that ultrasonically driven instru-
ments are either active and have cutting edges, or
are nonactive in that their cutting edges have been
reduced or eliminated. Regardless, any active or
nonactive metal-driven ultrasonic insert tip that Figure 8a. This clinical image shows the Figure 8b. This image depicts a simulated
contacts dentin will cut dentin and generate its EndoActivator in use. Note the power- root canal system. The EndoActivator tip
ful activation of fluid and appreciate the is used with a gentle pumping motion to
own smear layer. Of greatest concern, vibrating suborifice potential for 3-D cleaning. enhance the exchange of irrigant.
any metal tipeven precurvedaround a canal
curvature invites ledges, apical transportations, a b
lateral perforations, or broken instruments
(Figure 10).14,15

Continuous Movement
Any vibrating tip will almost certainly con-
tact dentin because of the various dimensions
and curvatures of any given final preparation.
Research has shown that when a sonically driven
polymer tip is constrained against a dentinal Figure 9a. This image illustrates a sinusoi- Figure 9b. This image illustrates a sinusoi-
wall, the tip advantageously continues to display dal wave of ultrasonic energy propagating dal wave of sonic energy propagating along a
a large displacement amplitude.12 To validate along a metal screw-on tip. Note the high polymer snap-on tip. Note the low frequency
frequency and ultralow amplitude. and ultrahigh amplitude.
this phenomenon, simply turn on the EndoActi-
vator handpiece, purposefully constrain, at any a b
level, the moving tip, and note that the tip will
continue to vigorously move! On the contrary,
constrain a vibrating ultrasonic insert tip and
note the tip movement will be sharply reduced
or the tip will not move at all.13 It is appreciated
that a loss of tip movement will compromise the
exchange of irrigant.

CLOSING COMMENTS
Discounting radicular fractures, the sum of
Figure 10a. In this plastic S-block, vibrating Figure 10b. In this plastic S-block, vibrating
all endodontic failures is directly related to a metal insert tip around canal curvatures a polymer and noncutting EndoActivator tip
bacterial infection due to deficiencies in primary predisposes to ledges, an apical transporta- maintains the anatomical integrity of the final
treatment. As such, 3-D disinfection is central tion, and a broken insert tip. preparation.
to predictably successful treatment. Clinicians should be EndoActivator is an effective, affordable, and scientifically
skeptical and dismiss marketing claims that state ultrasonic proven technology that uses safe, flexible, and noncutting
technology for 3-D disinfection is faster and somehow better; polymer tips. Catch the sonic wave and recognize that a clean
it is well known that activating metal insert tips at a high root canal system is an opening for 3-D obturation and long-
speed is dangerous. In the current state of 3-D disinfection, the term success (Figure 11).F

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CONTINUING EDUCATION

Endodontic Disinfection: The Sonic Advantage


References Figure 11. A long-term recall
1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. radiographic image demon-
1974;18:269-296. strates a lone palatal root
2. Ruddle CJ. Predictably successful endodontics. Dent Today. successfully serving as
a peer abutment under a
2014;33:104-107.
6-unit splint.
3. Ruddle CJ. Endodontic triad for success: the role of minimally invasive
technology. Dent Today. 2015;34:76-80.
4. Ruddle CJ. Endodontic disinfection: tsunami irrigation. Endodontic
Practice. 2008;11:7-15.
5. Desai P, Himel V. Comparative safety of various intracanal irrigation
systems. J Endod. 2009;35:545-549.
6. Kanter V, Weldon E, Nair U, et al. A quantitative and qualitative analysis
of ultrasonic versus sonic endodontic systems on canal cleanliness
and obturation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 11. Albrecht LJ, Baumgartner JC, Marshall JG. Evaluation of apical debris
2011;112:809-813. removal using various sizes and tapers of ProFile GT files. J Endod.
7. Caron G, Nham K, Bronnec F, et al. Effectiveness of different final 2004;30:425-428.
irrigant protocols on smear layer removal in curved canals. J Endod. 12. Walmsley AD, Lumley PJ, Laird WR. Oscillatory pattern of sonically
2010;36:1361-1366. powered endodontic files. Int Endod J. 1989;22:125-132.
8. Shen Y, Stojicic S, Qian W, et al. The synergistic antimicrobial effect by 13. Lumley PJ, Walmsley AD, Laird WR. Streaming patterns produced around
mechanical agitation and two chlorhexidine preparations on biofilm endosonic files. Int Endod J. 1991;24:290-297.
bacteria. J Endod. 2010;36:100-104. 14. Neuhaus KW, Liebi M, Stauffacher S, et al. Antibacterial efficacy of
9. Arslan D, Guneser MB, Dincer AN, et al. Comparison of smear layer a new sonic irrigation device for root canal disinfection. J Endod.
removal ability of QMix with different activation techniques. J Endod. 2016;42:1799-1803.
2016;42:1279-1285. 15. Ruddle CJ. Nonsurgical endodontic retreatment. In: Cohen S, Burns RC,
10. Bryce G, MacBeth N, Ng YL, et al. An ex vivo evaluation of the efficacy eds. Pathways of the Pulp. 8th ed. St. Louis, MO: Mosby; 2002:875-929.
of dynamic irrigation using the EndoActivator. Poster presented at: British
Endodontic Society Spring Scientific Meeting; March 2010; London,
England.

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Endodontic Disinfection: The Sonic Advantage


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POST EXAMINATION QUESTIONS


1. According to this article, it is well recognized that repeated 5. Proper infection control protocol for the sonic handpiece
dental procedures on the same tooth potentially contribute includes autoclaving the instrument.
to irreversible pulpal injury. a. True b. False
a. True b. False
6. Research has shown that vibrating the tip, in combination
2. Any opening from the root canal system to the periodontal with moving the tip up and down in short 2.0 to 3.0 mm
ligament should be thought of as a portal of entry through vertical strokes, synergistically produces a powerful
which potential endodontic breakdown products may pass. hydrodynamic phenomenon.
a. True b. False a. True b. False
3. There is no evidence to support that fluid activation, in both
minimally or more fully shaped canals, plays a strategic role 7. With ultrasonic energy: the higher the amplitude, the lower
in exchanging irrigant. the frequency.
a. True b. False a. True b. False

4. The EndoActivator (Dentsply Sirona) is a mechanical 8. Research has shown that, when a sonically driven
system that, when used, provides a safer and more polymer tip is constrained against a dentinal wall, the tip
effective method to disinfect a root canal system compared advantageously continues to display a large displacement
to ultrasonic technology. amplitude.
a. True b. False a. True b. False

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CONTINUING EDUCATION

Endodontic Disinfection: The Sonic Advantage


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