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ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 20-25

A comparison of the cleaning efficacy of ProRinse® syringe needle, ProUltra® PiezoFlow TM , and EndoActivator® irrigation techniques using software program ImageJ


1 Department of Restorative Dental Sciences, King Saud University, Riyadh, Saudi Arabia
2 Senior Registrar, Endodontist, Ministry of Health, Tabuk, Saudi Arabia
3 Department of Preventive Dental Sciences, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication12-Jan-2015

Correspondence Address:
Mohammed Al-Ahmari
Senior Registrar, Endodontist, Ministry of Health, Tabuk
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.149082

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  Abstract 

The purpose of this ex vivo study was to evaluate the efficacy of three different irrigation techniques, ProRinse® syringe needle, ProUltra® PiezoFlow TM , and EndoActivator®, in cleaning the canals and isthmuses of human mandibular molars using a software program ImageJ. Materials and Methods : A custom-made metal cube was used to create a sealed canal system. Eighty extracted mandibular molars were randomly divided into four equal groups. Teeth were mounted; sectioned at 2, 4, and 6 mm; and reassembled into the metal cube. Chemo-mechanical preparation was done for all teeth. The teeth were divided into four groups for final debridement: Group 1 (control group) received only needle irrigation, group 2 used the ProRinse® syringe needle with 5% NaOCl irrigation within a 1-mm working length, group 3 used ProUltra® PiezoFlow TM ultrasonic agitation for 30 seconds, and group 4 used the EndoActivator® system to agitate for 30 seconds. All groups received a final irrigation with 5% NaOCl in each canal. Specimens were evaluated by digital image capture with a stereomicroscope. Statistical analysis was completed using an ANOVA test and Tukey's test. Results: The results showed no statistically significant difference in canal or isthmus cleanliness between the four groups. However, there was a statistically significant difference (P < 0.05) in isthmus cleanliness in group 4 at the 4-mm level. Conclusions: EndoActivator® produced a good result in isthmus cleaning at the 4-mm level.

Keywords: EndoActivator®, metal cube, ProRinse;, ProUltra® PiezoFlow TM , root canal irrigation


How to cite this article:
Al-Obaida M, Al-Ahmari M, Al-Maflehi N. A comparison of the cleaning efficacy of ProRinse® syringe needle, ProUltra® PiezoFlow TM , and EndoActivator® irrigation techniques using software program ImageJ. Saudi Endod J 2015;5:20-5

How to cite this URL:
Al-Obaida M, Al-Ahmari M, Al-Maflehi N. A comparison of the cleaning efficacy of ProRinse® syringe needle, ProUltra® PiezoFlow TM , and EndoActivator® irrigation techniques using software program ImageJ. Saudi Endod J [serial online] 2015 [cited 2019 Oct 19];5:20-5. Available from: http://www.saudiendodj.com/text.asp?2015/5/1/20/149082


  Introduction Top


Root canal treatment is not an easy procedure to do due to the presence of a complex canal and root morphology. Isthmuses, accessory canals, fins, and deltas that provide an ideal space for tissue debris, microbes, and their by-products are difficult to clean. [1] Removal of these products is very important for successful outcome. [2] Instrumentation of the root canal using hands or nickel-titanium instruments alone will not remove all debris. [3],[4],[5] Therefore, irrigation must be used to help the root canal instruments to clean what might be left in the irregular root canal system. [6],[7] In addition, and for better results, the used irrigants must be brought into direct contact with the entire canal wall surfaces, particularly the apical third. [8]

Different devices such as ProRinse® syringe needle, ProUltra® PiezoFlow TM , and EndoActivator® have been developed as agitation systems for effective delivery of root canal irrigant. [9],[10],[11] Their use after cleaning and shaping of the root canal has been claimed to significantly reduce the bacterial colony-forming units' counts resulting in improvement of the canal and isthmus cleanliness. [12],[13]

The purpose of this ex vivo study was to evaluate the efficacy of three different irrigation techniques, ProRinse® syringe needle, ProUltra® PiezoFlow TM , and EndoActivator®, in cleaning the canals and isthmuses of human mandibular molars using a software program ImageJ.


  Materials and methods Top


Specimen preparation

Eighty extracted human mandibular molars with mesial root curvatures of less than 25 degrees were selected. The degree of root canal curvature was determined according to the method of Schneider. [14] The mesial wall was painted with nail varnish to distinguish between the mesial and distal cusps after embedding [Figure 1] a.
Figure 1: Specimen mounted in resin, and the mesial wall is stained with nail paint [left]; Specimen after sectioning that shows the boundary of the mesial wall after painting [right] (a). Metal cube disassembled (b). Metal cube assembled (c). Specimen mounted in resin and 2-mm sections measuring 2 mm, 4 mm, and 6 mm areas for sectioning (d). Isomet saw with a 0.50-mm-thick diamond blade (Buehler) for specimen sectioning (e)

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The apical part of the root was covered with nail polish to prevent blockage of the apical area with resin after embedding. After standard access opening was made in each tooth, a No. 10 Flex-R file (Miltex, York, PA, USA) was inserted in the root canal until the tip of the file was visible at the apical foramen. The working length (WL) was determined by the subtraction of 1mm from the total length.

Each mesial canal was instrumented until a Profile GT No. 20/.06 file (Dentsply, Tulsa Dental, York, PA, USA) could be inserted to the full WL. Irrigation was done with saline only. The access opening was sealed with a moist cotton pellet and utility wax (Carmel Industries, Quebec, Canada).

To allow for a more precise visualization of the root apex during sectioning, the teeth were embedded into a custom-made metal cube at the level of the cemento-enamel junction using Coldpac Ortho resin (The Motloid Company, Chicago, IL, USA) [Figure 1] b. A self-curing resin (The Motloid Company, Chicago, IL, USA) was used for each specimen. After the resin had set, the embedded specimens were removed from the cube.{Figure 1}

Specimen sectioning

The mounted specimens were sectioned at 2, 4, and 6 mm from the apex [Figure 1] c and d of the root using an Isomet low-speed saw with a 0.50-mm-thick diamond blade (Buehler, Lake Bluff, IL, USA) [Figure 1] e. The blade was irrigated with IsocutPlus Fluid (Buehler, Lake Bluff, IL, USA) and water according to the manufacturer's recommendations.{Figure 1}

Canal preparation

After sectioning, the specimens were reassembled in the metal cube. A groove was cut in the wall of the metal cube to helpfully reassemble the specimen, and all external sides were firmly tightened. The utility wax and cotton pellet were removed, and a hand file was used to verify WL and proper assembly. Following coronal flaring with Gates Glidden drills (Dentsply, York, PA, USA), the canals were prepared using ProFile 0.04 rotary files (Dentsply, Tulsa Dental, Johnson City, TN, USA) in a crown-down technique to a master apical file size No. 40. Between each rotary file, 0.5 mL of 5% NaOCl was used to irrigate each canal using a 30-gauge regular needle. After final instrumentation, each canal was irrigated with 2 mL of 5% NaOCl and dried with paper points. Each canal was then irrigated with 2 mL of 17% ethylene diamine tetra-acetic acid (EDTA) and dried before final irrigation with 2 mL 5% NaOCl. All canals were dried, and the access was sealed with a moist cotton pellet and utility wax.

Method of evaluation

Each specimen was then disassembled, and images of the coronal aspect of each section were obtained using a digital camera (Olympus DP71; Olympus, Tokyo, Japan) attached to a stereomicroscope (Olympus SZX16; Olympus, Tokyo, Japan) at the highest magnification to allow for a complete view of the canals and isthmus [Figure 2] a-d. The full color images were viewed on a monitor, and the mouse was used to trace the outline of the root canal, isthmuses, and the remaining debris [Figure 2] e.
Figure 2: A stereomicroscope captured images of the specimen at different levels (a). Digital images of a specimen section at the 6-mm leveldemonstrating canal and isthmus debris (b-d). Initial canal access only (b). Post-cleaning and shaping (c).Post experimental treatment (d). The mouse was used to trace the outline of the canals, isthmuses, and remaining debris (e). ImageJ software was used to compute the canal cleanliness

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Debris was defined as any material that was present on the canal walls and in the canal lumen or isthmus. The software program ImageJ (National Institutes of Health, v1.44a) was used to calculate the area of the root canals, isthmuses, and the amount of debris present. To calculate the canal cleanliness, the area of remaining debris was divided by the total area of the canal or isthmus to yield a percentage.

Final debridement

The specimen sections were reassembled into the metal cube, and each tooth was randomly assigned to one of the four experimental groups. Each group was treated according to the manufacturer's directions.

Group 1 (n = 20): was the control group (root canal was not touched after the initial cleaning and shaping) and received conventional needle irrigation only. The needle was introduced into the canal 0.5 mm short of WL without wedging and evacuated with light hand pressure.

Group 2 (n = 20): A ProRinse® side-vented needle and a conventional syringe (Dentsply, Tulsa Dental, Johnson City, TN, USA) were inserted into the root canal 0.5 mm short of WL and then backed up approximately 0.5 mm from the WL. The canals and pulp chamber were irrigated with 2 mL (1 mL in each canal) of 5% NaOCl, using a 30-gauge regular needle for 30 seconds.

Group 3 (n = 20): The canals and pulp chamber were filled with 2 mL of 5% NaOCl. The ProUltra® PiezoFlow TM Ultrasonic Irrigation Needle (Dentsply, Tulsa Dental, Johnson City, TN, USA) was passively inserted into the canals and set to stop 1-mm short of the binding, which was no more than 75% of the WL. The needle was never being taken to the apex. The tip was attached to an ultrasonic hand piece. The Booster was set to power level No. 5, and the file was circumferentially worked along the dentinal walls in a cyclic axial motion (up and down) for 30 seconds using an ultrasonic unit and a 30-gauge regular needle with 2 mL 5% NaOCl solution.

Group 4 (n = 20): The canals and pulp chambers were filled with 2 mL of 5% NaOCl before treatment. The EndoActivator® (Advanced Endodontics, Santa Barbara, CA, USA) sonic hand piece was set at 10,000 cpm, and a size No. 15/0.02 taper activator tip was passively inserted in the canal within 2 mm of the WL. The tip was moved in short 2-3 mm vertical strokes for 30 seconds. All experimental groups received a final irrigation with 2 mL 5% NaOCl in each canal using a 30-gauge regular needle.

After drying the canals with paper points, the specimens were removed from the metal cube, disassembled, and evaluated for debris as previously mentioned using software program ImageJ. Percent cleanliness was calculated for each canal and isthmus immediately after instrumentation and after the use of the experimental final debridement technique. The percent change in debris amount was statistically analyzed using a repeated measures analysis of variance (ANOVA) and Tukey's test. The significance level was P < 0.05.


  Results Top


A comparison of canal and isthmus cleanliness using ANOVA is shown in [Figure 3] a and b. There was no statistically significant difference in canal or isthmus cleanliness when the EndoActivator®, ProUltra® PiezoFlow TM , or ProRinse® needle was used as an adjunct to aid in canal debridement compared with conventional irrigation alone (control group). None of the three treatment groups demonstrated a significant difference (P > 0.05, Tukey's test) from the control group. However, there was a significant difference (P < 0.05, Tukey's test) in the EndoActivator® group at 4-mm apical level after the experiment in cleaning efficacy of the isthmus.
Figure 3: Comparison of canal and isthmus cleanliness post-cleaningand shaping versus post-experimental treatment. (a) Percentage ofcanal cleanliness of each experimental group at the 2, 4, and 6 mmlevels post-cleaning and shaping pre- and post-experimental treatment(Post). (b) Percentage of isthmus cleanliness of each experimentalgroup at the 2, 4, and 6 mm levels post-cleaning and shaping pre- and post-experimental treatment (Post). *Statistically signifi cant differences between levels (P < 0.05)

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  Discussion Top


A custom-designed metal cube (K-Kube) was used in this study, which was based on the techniques of Bramante et al. [15] and Ψrstavik et al. [16] The K-Kube was designed to allow a tooth to be sectioned and then reassembled to recreate an intact root canal system. This affords the opportunity to evaluate not only canal and isthmus anatomy but also the effect of irrigation on residual debris while using each tooth as its own control. Thus, the K-Kube enabled the evaluation of experimental irrigation adjuncts in a sectioned tooth for the first time. [10]

Deep penetration of endodontic irrigants into the complicated root canal system is very important for successful endodontic treatment. It depends on the diameter of the prepared canal, the type of irrigant and irrigant delivery system. In this study, three different irrigant systems were evaluated. None of them demonstrated a significant difference from the control group. Similar findings were reported by Howard et al. [17] who found no significant differences in canal and isthmus cleanliness after final irrigation with ProUltra® PiezoFlow TM . In addition, Adcock et al. [11] reported that significantly less debris was present in the isthmus with the use of ProUltra® PiezoFlow TM . Both results were compared with conventional needle irrigation using a 30-G side-vented needle. Variations in irrigation volumes and types of irrigants used could explain these apparent disparities.

A significant difference in the EndoActivator® group at 4-mm apical level was reported in this study. This was different than the report of Uroz-Torres et al. [18] who found that the EndoActivator® system did not enhance the removal of smear layer as compared with conventional Max-I-Probe irrigation with NaOCl and EDTA. The difference in results could be related to the examined area and method of evaluation. Computer software was used in this study, whereas scanning electron microscope was used in Uroz-Torres et al. study. Meanwhile, de Gregorio et al., [19] by using ultrasonic and sonic (EndoActivator®) activation in simulated lateral canals, found better irrigation in the apical third (at 4.5 and 2 mm from WL) than with traditional needle irrigation alone.

There was a higher overall standard deviation concerning isthmus cleanliness as compared with canal cleanliness. This was probably due to the variation in isthmus width not only within each tooth but also between different samples. The narrow isthmuses consistently demonstrated the most residual debris both after cleaning and shaping and after treatment with the experimental irrigation adjuncts.

The reason for performing the instrumentation of the canal until size 40 is because the irrigation will not be effective when the canal is not larger than size 40, [20] and irrigant extrusion will decreased as needles moved away from WL or when the apical size was increased. [21]

The use of various ultrasonic, sonic, and passive ultrasonic irrigation devices and techniques have been reported to improve tissue removal, more vigorous irrigation of lateral canals, and additional removal of canal bacteria. [10] However, there are obvious considerations and limitations in the use of these devices in curved canals. [22] This is related to the metal cannula tips, which were represented in this study in the ProUltra® PiezoFlow TM system.


  Conclusion Top


EndoActivator® produced a good result in isthmus cleaning at the 4-mm level. Further study is required to test and improve the different irrigation systems.


  Acknowledgement Top


The authors gratefully acknowledge Dr. Faisal Al-Onaizan for providing the material from the US, and Badriah Al-Ahmari, the wife of Dr. Mohammed Al-Ahmari, for her support to him and her assistance in data entry. The authors thank Mr. Bong D. Tuazon and Ms. Jasmin Flores for their technical expertise in the preparation the specimens and Mrs. Jeannette Gonzales Quinsay for her great effort in the capture of the images using the stereomicroscope.

 
  References Top

1.
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99.  Back to cited text no. 1
    
2.
Siqueira JF Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod 2008;34:1291-301.  Back to cited text no. 2
    
3.
Walton RE. Histologic evaluation of different methods of enlarging the pulp canal space. J Endod 1976;2:304-11.  Back to cited text no. 3
    
4.
Schafer E, Zapke K. A comparative scanning electron microscopic investigation of the efficacy of manual and automated instrumentation of root canals. J Endod 2000;26:660-4.  Back to cited text no. 4
    
5.
Tan BT, Messer HH. The quality of apical canal preparation using hand and rotary instruments with specific criteria for enlargement based on initial apical file size. J Endod 2002;28:658-64.  Back to cited text no. 5
    
6.
Svec TA, Harrison JW. Chemomechanical removal of pulpal and dentinal debris with sodium hypochlorite and hydrogen peroxide vs normal saline solution. J Endod 1977;3:49-53.  Back to cited text no. 6
    
7.
Gulabivala K, Patel B, Evans G, Ng YL. Effects of mechanical and chemical procedures on root canal surfaces. Endod Top 2005;10:103-22.  Back to cited text no. 7
    
8.
Al-Hadlaq SM, Al-Turaiki SA, Al-Sulami U, Saad AY. Efficacy of a new brush-covered irrigation needle in removing root canal debris: A scanning electron microscopic study. J Endod 2006;32:1181-4.  Back to cited text no. 8
    
9.
Nielsen BA, Craig Baumgartner J. Comparison of the EndoVac system to needle irrigation of root canals. J Endod 2007;33:611-5.  Back to cited text no. 9
    
10.
Klyn SL, Kirkpatrick TC, Rutledge RE. In vitro comparisons of debris removal of the EndoActivator system, the F file, ultrasonic irrigation, and NaOCl irrigation alone after hand-rotary instrumentation in human mandibular molars. J Endod 2010;36:1367-71.  Back to cited text no. 10
    
11.
Adcock JM, Sidow SJ, Looney SW, Liu Y, McNally K, Lindsey K, et al. Histologic evaluation of canal and isthmus debridement efficacies of two different irrigant delivery techniques in a closed system. J Endod 2011;37:544-8.  Back to cited text no. 11
    
12.
Carver K, Nusstein J, Reader A, Beck M. In vivo antibacterial efficacy of ultrasound after hand and rotary instrumentation in human mandibular molars. J Endod 2007;33:1038-43.  Back to cited text no. 12
    
13.
Burleson A, Nusstein J, Reader A, Beck M. The in vivo evaluation of hand/rotary/ultrasound instrumentation in necrotic, human mandibular molars. J Endod 2007;33:782-7.  Back to cited text no. 13
    
14.
Schneider SW. A comparison of canal preparations in straight and curved root canals. Oral Surg Oral Med Oral Pathol 1971;32:271-5.  Back to cited text no. 14
    
15.
Bramante CM, Berbert A, Borges RP. A methodology for evaluation of root canal instrumentation. J Endod 1987;13:243-5.  Back to cited text no. 15
    
16.
Ørstavik D, Pitt Ford T. Essential endodontology: Prevention and treatment of apical periodontitis. 2 nd ed. Ames: Blackwell Munksgaard Ltd; 2008.  Back to cited text no. 16
    
17.
Howard RK, Kirkpatrick TC, Rutledge RE, Yaccino JM. Comparison of debris removal with three different irrigation techniques. J Endod 2011;37:1301-5.  Back to cited text no. 17
    
18.
Uroz-Torres D, Gonza ' lez-Rodrý,guez MP, Ferrer-Luque CM. Effectiveness of the EndoActivator System in removing the smear layer after root canal instrumentation. J Endod 2010;36:308-11.  Back to cited text no. 18
    
19.
de Gregorio C, Estevez R, Cisneros R, Heilborn C, Cohenca N. Effect of EDTA, sonic, and ultrasonic activation on the penetration of sodium hypochlorite into simulated lateral canals: An in vitro study. J Endod 2009;35:891-5.  Back to cited text no. 19
    
20.
Grossman LI. Irrigation of root canals. J Am Dent Assoc 1943;30:1915-7.  Back to cited text no. 20
    
21.
Psimma Z, Boutsioukis C, Kastrinakis E, Vasiliadis L. Effect of needle insertion depth and root canal curvature on irrigant extrusion ex vivo. J Endod 2013;39:521-4.  Back to cited text no. 21
    
22.
Ahmad M, Pitt Ford TJ, Crum LA. Ultrasonic debridement of root canals: Acoustic streaming and its possible role. J Endod 1987;13:490-9.  Back to cited text no. 22
    


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