ABSTRACT
http://dx.doi.org/10.1590/1678-775720160286
An
i n v i t r o
ev al u at i o n o f v ar i o u s i r r i g at i o n
t echniques for t he rem oval of double ant ibiot ic
past e from root canal surfaces
Hakan GOKTURK1, Ismail OZKOCAK1)HY]L%8<8.*(%ø=12VPDQ'(0ø52
1- Gaziosmanpasa University, Faculty of Dentistry, Department of Endodontics, Tokat, Turkey. 2- Gaziosmanpasa University, Faculty of Medicine, Department of Biostatistics, Tokat, Turkey.
Corresponding address: Hakan Gokturk - Department of Endodontics - Faculty of Dentistry - Gaziosmanpasa University - 60100 - Tokat - Turkey - Phone: +90-356-212 42 22 - ext-4015 - Fax: +90-356 212 42 25 - e-mail: [email protected]
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bj ect ive: The aim of t his st udy was t o invest igat e t he effect iveness of convent ional syringe irrigat ions, passive ult rasonic irrigat ion ( PUI ) , Vibringe, CanalBrush, XP- endo Finisher, and laser- act ivat ed irrigat ion ( LAI ) syst em s in rem oving double ant ibiot ic past e'$3IURPURRWFDQDOV0DWHULDODQG0HWKRGV2QHKXQGUHG¿YHH[WUDFWHGVLQJOHURRWHG
t eet h w er e inst r um ent ed. The r oot s w er e split longit udinally. Thr ee st andar d gr ooves w ere creat ed and covered w it h DAP. The root s w ere dist ribut ed int o seven groups: Group 1, beveled needle irrigat ion; Group 2, double side- vent ed needle irrigat ion; Group 3, CanalBrush; Group 4, XP- endo Finisher; Group 5, Vibringe; Group 6, PUI ; Group 7, LAI . The am ount of rem aining DAP was scored under a st ereom icroscope. Result s: Group 4,
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difference was found bet w een Group 7 and Group 6. No differences w ere found bet w een groups in t he apical region eit her, except for t he com parisons bet ween groups 7 and 2, and groups 2 and 3. Conclusions: None of t he invest igat ed prot ocols w ere able t o com plet ely rem ove t he DAP from t he grooves. The Vibringe and XP- endo Finisher syst em s show ed result s sim ilar t o t hose of convent ional needle irrigat ion.
Ke yw or ds: Endodont ics. Lasers. Sodium hypochlorit e. Therapeut ic irrigat ion. Ult rasonic t herapy.
I N TROD UCTI ON
The m ain goal of r oot canal t r eat m ent is t o enlar ge t he r oot canal sy st em and t o elim inat e and discharge bact eria from it . For t his purpose, num er ous inst r um ent s, ir r igat ion solut ions, and m edicam ent s have been used12. Chem om echanical SUHSDUDWLRQ LV RIWHQ VHOHFWHG DV WKH ¿UVW RSWLRQ
t o achieve t he goal of elim inat ing t he int racanal bact er ial populat ion. Alt hough chem om echanical preparat ion reduces t he bact eria populat ion, none of t he cont em porar y t echniques can com plet ely clean t he root canal syst em16. Therefore, int racanal
m edicam ent s are used t o elim inat e and/ or reduce t he num ber of bact eria from t he canal22.
Calcium hydroxide ( CH) is w idely used as an in t r acan al m ed icam en t b et w een ap p oin t m en t s
t o enhance t he incidence of bact eria free canals. CH has t herapeut ic propert ies, is biocom pat ible, inhibit s ost eoclast ic act ivit y, can dissolve organic t issue, and has regenerat ive propert ies5,28. Despit e WKHVHDGYDQWDJHV&+LVLQVXI¿FLHQWLQFRPSOHWHO\
rem oving bact eria from root canals20.
An t i b i o t i c p a st e s a r e a n o t h e r e x a m p l e o f in t r acan al m ed icam en t . Tr ip le an t ib iot ic p ast e
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and m inocycline) or double ant ibiot ic past e ( DAP)
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com m only used as int racanal m edicam ent s in cases in w hich CH cannot alleviat e t he sym pt om s9,30.
Pr e v i o u s i n v e s t i g a t i o n s a g r e e t h a t t h e m edicam ent should be com plet ely rem oved from
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penet rat ion of sealers or cem ent s int o t he root canal dent in walls, as t hey act as a physical barrier along t he sealer/ dent in int erface1,14. Furt herm ore, clinical
concent rat ions of CH, DAP, and TAP can lead t o a
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t i ssu es1 1 a n d a r e cy t o t o x i c t o h u m a n d en t a l
pulp st em cells19. Thus, t he com plet e rem oval of
m edicam ent s from t he root canal is an im port ant st ep in successful root canal t reat m ent .
The m ost com m only used t echnique for t he r em oval of m edicam ent s is r ecapit ulat ion of t he
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lengt h ( WL) follow ed by copious ir r igat ion w it h et hylenediam inet et raacet ic acid ( EDTA) and sodium h y p och lor it e ( NaOCl)2 4. Pr ev iou s st u d ies h av e
report ed t hat t he passive ult rasonic irrigat ion ( PUI ) and phot on- induced phot oacoust ic st ream ing ( PI PS) t echniques rem oved m ore m edicam ent t han t he convent ional needle irrigat ion syst em2,4,8.
The XP- endo Finisher ( FKG, Dent air e SA, La Chaux- de- Fonds, Swit zerland) is a newly int roduced shape- m em ory NiTi inst rum ent . This inst rum ent ’s
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on t he irregular area of t he root canal syst em ; t his is achieved by providing an expanded reach ( 6 m m
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Ho w e v e r, i t i s u n k n o w n w h e t h e r XP- e n d o Finisher or CanalBrush can rem ove DAP from t he root canal wall. Therefore, t he aim of t his st udy was
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irrigat ions, CanalBrush, XP- endo Finisher, Vibringe, PUI , and laser- act ivat ed irrigat ion ( LAI ) syst em s
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grooves in t he root canal. The null hypot heses were t hat t he rem oval of DAP was not affect ed by t he [ 1] sect ion of root canal ( t hird) or t he [ 2] irrigat ion t echniques.
M ATERI AL AN D M ETH OD S
This st udy was review ed and approved by t he Tokat Clinical Resear ch Et hics Com m it t ee of t he
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KAEK 225) .
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h u m an an t er i o r t eet h w er e sel ect ed t h r o u g h buccolingual and m esiodist al radiographs, aft er
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apex, and no signs of int ernal/ ext ernal resorpt ion. The t eet h w ere short ened using a diam ond disc under wat er cooling, and each t oot h was given a
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( Mani I nc., Tochigi, Japan) . Canals w ere prepared
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Germ any) and a t orque- cont rolled m ot or ( Silver
Recipr oc; VDW, Munich, Ger m any ) t o a m ast er
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root canals were irrigat ed wit h 10 m L of 2.5% NaOCl
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t hen t hey w ere placed in Eppendorf vials ( Labosel,
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m at erial ( Clinical Zet aplus soft ; Zherm ack, Badia Polesine, I t aly) . Aft er t he im pression m at erial was fully set , t he root s w ere grooved w it h a diam ond disk and split longit udinally w it hout dam aging t he inner layer of dent ine around t he canal. A num ber 1S cav it r on t ip ( Acet on, Mer ignac, France) w as
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w hich w ere 3 m m in lengt h, 0.5 m m in dept h, and 0.2 m m in w idt h, and w ere locat ed 2–5 m m from t he apex for apical sect ions, 11- 14 m m from t he apex for coronal sect ions, and 7- 10 m m from t he apex in t he opposit e par t of t he m iddle sect ion ( Figure 1) . The phot ographs w ere t aken using a st ereom icroscope ( Zeiss St em i 2000- C; Carl Zeiss Microlm aging, Göt t ingen, Germ any) equipped w it h a digit al cam era ( AxioCam ERc5s, Germ any) at 20X
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w ere irrigat ed w it h 5 m L 17% EDTA ( I m icryl Lt d., Konya, Turkey) for 60 sec. and 5 m L 2.5% NaOCl for 60 sec. Then, t he t eet h w ere agit at ed w it h a t oot h brush t o rem ove debris and t he sm ear layer. The root canal was dried w it h paper point s.
Eq u al am o u n t s o f ci p r o f l ox aci n ( Bi o f ar m a,
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I st anbul, Turkey) w ere m ixed w it h dist illed wat er at a liq u id / p ow d er r at io of 1 : 3 b ased on t h e form ulat ions used in t he st udy by Hoshino, et al.15 (DFK RI WKH JURRYHV ZDV ¿OOHG ZLWK '$3 E\ D PRGL¿HG VSUHDGHU DQG VWHUHRPLFURVFRS\ ZDV XVHG WR FRQ¿UP WKDW WKH JURRYHV ZHUH IXOO\ ¿OOHG ZLWK '$3 7KHQ ZKLOH WDNLQJ FDUH WR DYRLG ZD[ÀRZLQWRWKHURRWFDQDOWKHURRWKDOYHVZHUH
r eassem bled w it h w ax , and all t he r oot s w er e rem ount ed int o Eppendorf vials. Next , t hey w ere
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The access cavit ies were t em porarily sealed ( Cavit , ESPE GMBH, Seefeld, Germ any) and st ored at 37° C w it h 100% relat ive hum idit y for 2 w eeks. Aft er t his period, specim ens were random ly divided int o seven experim ent al groups ( n= 15) .
For t he rem oval of DAP in all 7 groups, an R40
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w ere used t o obt ain a space for irrigat ion needles and inst rum ent s.
G1 ( Bev eled Needle) : Th e r oot can als w er e irrigat ed w it h 10 m L 2.5% NaOCl for 2 m in w it h a 27- gauge beveled dent al irrigat ion needle ( Ayset , Adana, Turkey) . The t ip of t he needle was insert ed 1 m m short of t he WL.
dent al, Siauliai, Lit huania) was used ( rat her t han a 27- gauge beveled dent al irrigat ion needle) .
G3 ( CanalBrush) : The root canals were irrigat ed w it h 5 m L 2. 5% NaOCl and t hen br ushed w it h a m edium size CanalBr ush ( Colt ene/ Whaledent Gm bHCo. KG, Langenau, Ger m any ) at 600 r pm
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insert ed 1 m m short of t he WL and was m oved around in sm all vert ical m ovem ent s.
G4 ( XP- endo Finisher) : The irrigat ion prot ocol was t he sam e as t hat in G3 w it h t he except ion t hat t he XP- endo Finisher ( FKG, Sw it zerland) was used at 800 rpm w it h 1 Ncm for 1 m in ( rat her t han t he CanalBrush) .
G5 ( Vibringe) : A 10 m L 2.5% NaOCl solut ion w as d eliv er ed an d son ically act iv at ed v ia t h e Vibringe syst em ( Vibringe B. V. Corp, Am st erdam , Net herlands) for 2 m in. The needle t ip was placed 1 m m short of t he WL.
G6 ( PUI ) : Passive ult rasonic irrigat ion ( PUI ) was perform ed using an I rrisafe ult rasonic t ip ( size 25, 0.00 t aper ) ( Act eon, France) , w hich was dr iven by an u lt r ason ic dev ice ( New t r on P5 ; Sat elec, Act eongroup, France) 1 m m short of t he WL. A 10 m L 2.5% NaOCl solut ion cont inuously delivered at
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t he unit . I t was act ivat ed at a pow er set t ing of 5 for 1 m in.
G7 ( LAI ) : The irrigat ion prot ocol was t he sam e as t hat in G3 w it h t he except ion t hat an Er: YAG laser ( Kavo Key 3+ , KaVo, Biberach, Ger m any ) w it h a 2940 nm wavelengt h was used for 1 m in w it h endodont ic t ips. The laser param et ers w ere
1 W, 10 Hz, and 100 m J. When t he irrigant in t he root canal dropped or vaporized, t he canal space
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The t ot al volum e of irrigant for each specim en
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approxim at ely 0.08 m L s- 1 except for G6 ( PUI ) . The
irrigant was delivered int o t he canal wit h a 30- gauge double side- v ent ed needle ( i dent al, Lit huania) except for G1 ( beveled needle) . The root canals w ere dried w it h paper point s, and t he root halves w ere separat ed so t hat digit al phot ographs could be t aken of t he canal walls as described above.
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w er e cod ed b ef or e ev alu at ion t o en su r e t h at t he evaluat or s w er e blinded t o t heir ident it ies. Th e am ou n t of DAP r em ain in g in t h e g r oov es was evaluat ed by t w o dent ist s using a num er ic evaluat ion scale as described by van der Sluis, et al.32 ( 2007) . The scoring syst em was as follow s:
score 0, t he groove is ent irely em pt y; score 1, DAP is present in less t han 50% of t he groove; score 2, m ore t han 50% of t he groove is covered w it h DAP; and score 3, t he groove is com plet ely covered w it h DAP ( Figure 2) . Before scoring, t he 2 exam iners assessed 30 random ly select ed specim ens t oget her for calibrat ion purposes. I n t he case of discrepant scores, a consensus was reached by discussion.
An aly ses w er e con du ct ed u sin g com m er cial soft ware ( I BM SPSS St at ist ics 19, SPSS I nc., I BM Co., Som ers, New York, USA) . The kappa t est was used t o det erm ine int erexam iner agreem ent . The Kruskal-Wallis and Mann-Whit ney U t est s were used t o com pare t he rem aining DAP scores. Result s were
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RESULTS
Resu lt s of t h e t w o ex am in er s w er e in good agreem ent ( kappa value= 0.907) . Figure 3 show s t he dist ribut ion of scores according t o t he regions. No irrigat ion prot ocols could com plet ely rem ove all
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found bet w een t oot h r egions in t er m s of past e rem oval, and m ore residues w ere observed in t he apical region ( Figure 3) (p<05) . The Kruskal-Wallis
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t he groups for apical, m iddle, and coronal t hirds (p> 05) , except for t he XP- endo Finisher ( G4) and PUI ( G6) (p<05) . The XP- endo Finisher ( G4) , LAI
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differences w ere found bet w een t hese groups in t he coronal region (p> 05) ( Figure 4) . LAI ( G7) was
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and PUI groups (p> 05) ( Figure 5) . I t was quit e
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Figure 2- Images of scores: (A) Score 0; (B) Score 1; (C) Score 2; (D) Score 3
Figure 3- Distribution of scores according to regions
Figure 4- The distribution of scores for double antibiotic paste removal in the coronal third. Different letters denote
no difference was found bet w een groups (p> 05) except for t he com parisons bet w een LAI ( G7) and double side needle ( G2) and bet w een CanalBrush ( G3) and double side needle ( G2) (p< 05) ( Figure 6) .
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Vibringe syst em ( G5) and t he beveled needle ( G1) or double side needle ( G2) for all segm ent s (p> 05) .
D I SCUSSI ON
To our k now ledge, no st udy hav e com par ed t he effect iveness of needle irrigat ion, t he XP- endo Finisher and CanalBr ush in r em ov ing DAP fr om
sim ulat ed lat eral irregularit ies on root canal walls. Result s of t his st udy indicat e t hat no differ ence was found bet w een t oot h regions in t erm s of past e
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accept ed. The rem oval of DAP was not affect ed by t he root canal t hirds. How ever, LAI was superior t o double side- needle irrigat ion in rem oving DAP at all t hirds of t he root , and t herefore, t he second hypot hesis is rej ect ed.
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t h e elim in at ion of som e sy m p t om s, an d t h u s, an t ibiot ic past es ar e u sed as an alt er n at iv e9 , 3 0
due t o t heir good ant im icrobial and biocom pat ible p r op er t ies1 1 , 1 5 , 3 1. On e of t h e m ost w id ely u sed
ant ibiot ic past es is TAP, w hich consist s of equal p o r t i o n s o f m et r o n i d azo l e, ci p r o f i ox aci n , an d m inocycline. How ever, TAP alw ay s causes t oot h discolorat ion2. I n one st udy, researchers rem oved
m inocycline from t he TAP, and developed DAP, which
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Alt hough ant ibiot ic past es have been successfully u se d i n e n d o d o n t i c p r o ce d u r e s, t h e y sh o u l d
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obt urat ion t o avoid t heir negat ive effect s, such as t oot h discolorat ion, cyt ot oxic effect s, and t he prevent ion of sealer or cem ent penet rat ion t o root dent in1,2,19. How ever, it is im possible t o com plet ely
rem ove ant ibiot ic past es from t he root canal using convent ional irrigat ion prot ocol2- 4,6,23.
There are lim it ed dat a about t he effect of t he ir r igat ion pr ot ocol on t he r em oval of DAP fr om t he root canal. Akçay, et al.2 ( 2014) invest igat ed
t he effect iveness of PI PS and an EndoAct ivat or Syst em in rem oving DAP and TAP from root canal irregularit ies in t he coronal and apical part s of a root canal syst em . They report ed t hat PI PS was superior for t he rem oval of DAP and TAP, regardless o f t h e g r o ov e l o cat i o n , w h en co m p ar ed w i t h t he EndoAct ivat or and needle ir r igat ion gr oups. Anot her st udy by Arslan, et al.4 ( 2014) invest igat ed
t h e ef f ect iv en ess of dif f er en t ir r igan t s w it h or w it hout ult rasonic act ivat ion in rem oving TAP from sim ulat ed root canal irregularit ies. They report ed t hat PUI w it h 1% NaOCl w as super ior t o ot her irrigat ion t echniques in rem oving TAP. These result s are sim ilar t o t he result s obt ained in t his st udy.
A pr ev ious st udy by Ber k hoff, et al.6 ( 2014)
com pared positive pressure irrigation, EndoActivator, PUI , and EndoVac from root canal syst em s by t he radiolabeled t echnique; t hey concluded t hat t here was no difference in labeled TAP rem oval am ong groups. These result s are not consist ent w it h t hose
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variables in t he st udy design, such as ( i) t he used m edicam ent , ( ii) t he irrigat ion solut ion’s volum e, and/ or ( iii) m easurem ent t echnique. I n a previous st udy, it was revealed t hat m inocycline ( a com pound of TAP) binds t o calcium ions via chelat ion t o form
Figure 5- The distribution of scores for double antibiotic paste removal in the middle third. Different letters denote
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Figure 6- The distribution of scores for double antibiotic paste removal in the apical third. Different letters denote
an insoluble com plex29. How ever, a m or e r ecent VWXG\UHSRUWHGQRVLJQL¿FDQWGLIIHUHQFHVEHWZHHQ
DAP an d TAP r em ov al f r om ar t if icially cr eat ed grooves2.
I n t h is st u dy, w e u sed a r ot ar y in st r u m en t syst em ( XP- endo Finisher) w it h 2.5% NaOCl as an
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t hat act ivat ion of irrigant w it h a rot ary inst rum ent
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grooves; however, t his was not st at ist ically different f r om con v en t ion al sy r in g e ir r ig at ion . A st u d y conduct ed by Capar, et al.8 ( 2014) report ed t hat t he
use of t he Self-Adj ust ing File ( SAF) syst em rem oved si g n i f i can t l y m o r e CH f r o m si m u l at ed l at er al irregularit y in t he apical t hird of root canals t han t he convent ional syringe irrigat ion. I n line w it h t he result s of t he aforem ent ioned st udy, Akm an, et al.3 KDYHVKRZQWKDW6$)VLJQL¿FDQWO\LPSURYHG WKHUHPRYDORIP7$3PHWURQLGD]ROHFLSURÀR[DFLQ
and cefaclor) from root canals when com pared wit h convent ional sy r inge ir r igat ion. Unlike r ot ar y or hand inst rum ent s, SAF adapt s channels in t hree dim ensions, and also allow s for copious irrigat ion
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Sim ilarly, t he superior abilit y of PUI in rem oving int racanal m edicam ent from t he root canals was at t ribut ed t o it s higher velocit y of irrigat ion solut ion
ÀRZ32 and it s fresh irrigant replacem ent propert ies
during t he procedure33.
Can alBr u sh is a h ig h ly f lex ib le en d od on t ic br ush m ade of poly pr opy lene. Accor ding t o t he m anufact urer, it helps clean areas of t he root canal
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n o st u d y h a s co m p a r ed t h e ef f ect i v en ess o f CanalBr ush on t he r em oval of ant ibiot ic past es.
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difference was found bet w een CanalBrush and PUI on t he rem oval of CH from root canal surfaces7.
On t h e ot h er h an d , Gr isch k e, et al.1 3 ( 2 0 1 4 ) LQYHVWLJDWHGWKHHI¿FDF\RIIRXUGLIIHUHQWLUULJDWLRQ
sy st em s i n r em o v i n g r o o t ca n a l sea l er f r o m sim ulat ed irregularit ies on t he root canal wall, and report ed t hat PUI is m ore effect ive t han CanalBrush.
Th e Vib r in g e sy st em ( Vib r in g e B. V. Cor p, Net h er l an d s) i s a d ev i ce t h at p r ov i d es so n i c act ivat ion of irrigat ion solut ions. This device uses
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st r eam in g in t h e r oot can al an d oper at es at a low er frequency ( 2–3 kHz)25. Rodig, et al.25 ( 2010) UHSRUWHGWKDW38,UHPRYHGVLJQL¿FDQWO\PRUHGHEULV
from t he canal irregularit ies t han did t he syringe irrigat ion and Vibringe Syst em . Johnson, et al.18
( 2012) r epor t ed t hat Vibr inge w as not super ior t o side- vent ed needle irrigat ion w hen com paring
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n o sig n if ican t d if f er en ces b et w een Vib r in g e – beveled needle and Vibringe – double side needle for DAP rem oval for all t he segm ent s. However, few
st udies in t he lit erat ure exam ine t he effect iveness of Vibringe on t he rem oval of m edicam ent s from t he root surface, and t herefore, furt her invest igat ions are needed on t his t opic.
Sahar - Helft , et al.2 7 ( 2 0 1 5 ) inv est igat ed t he HI¿FDF\ RI WKUHH LUULJDWLRQ SURWRFROV SRVLWLYH
pressure irrigat ion, PUI , and LAI ) on sm ear- layer rem oval from hum an t eet h w it h SEM. An Er: YAG laser at a wavelengt h of 2940 nm ( t o 0.5 W, 50 m J, 10 HZ) was used for 60 sec in t he LAI group. They report ed t hat LAI w it h Er: YAG rem oved t he sm ear layer from t he ent ire root canal wall bet t er
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observed in a previous st udy2. Alt hough t he laser
param et ers in t his st udy are different from t hose
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are consist ent w it h t he lit erat ure. We found t hat LAI rem oved m ore DAP from t he root canal surface t han t he ot her t echniques.
Despit e t he fact t hat ant ibiot ic m edicam ent s are com m only used in revascularizat ion and root canal t reat m ent s, t here are no st andardized applicat ion t im es. Er, et al.9 ( 2007) used TAP for int racanal
dressing for up t o 12 weeks in root canal t reat m ent . I n revascularizat ion t reat m ent , t he past es are left in t he canal for different periods ( 1- 11 w eeks)21.
Therefore, fut ure st udies are needed t o t horoughly invest igat e t he applicat ion t im e on t he r em oval capacit y.
Th i s st u d y sh ow ed t h at t h e g r oov e i n t h e apical sect ion gave w orse result s t han t he coronal and m iddle sect ions, regardless of t he irrigat ion prot ocol. These result s are sim ilar t o t hose obt ained by Arslan, et al.4 ( 2014) . I n cont rast , Rodig, et al.26
( 2010) observed superior result s in t he apical t hird,
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published result s m ay be due t o t he diam et er of apical preparat ion, volum e of irrigant , and irrigat ion prot ocol used bet w een t hese st udies.
Th e design of t h is st u dy h as been u sed by several ot her invest igat ions4,8,13,25,26,32. However, few
st udies are invest igat ing t he rem oval of DAP from
DUWL¿FLDOO\FUHDWHGJURRYHV2. Alt hough t he sim ulat ed
lat eral irregularit ies do not represent t he com plex st ruct ure of a nat ural root canal syst em , t he groove m odel has it s advant ages, w hich include allow ed discrim inat ion bet w een m echanical rem oval of t he
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as well as high int raobserver reproducibilit y26. The
m aj or lim it at ion of t his st udy is t he result s obt ained from in vit ro condit ions. Thus, fut ure st udies should
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condit ions.
CON CLUSI ON
None of t he invest igat ed t echniques w ere able
st a n d a r d g r o o v e s. H o w e v e r, l a se r - a ct i v a t e d irrigat ion and PUI m ay be preferred for t he rem oval of DAP. The Vibringe and XP- endo Finisher syst em s gave sim ilar result s t o t hose of convent ional needle irrigat ion.
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