Professional Documents
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Endodontic Disinfection:
The Sonic Advantage
Authored by Clifford J. Ruddle, DDS
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
Active Irrigation
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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
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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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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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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