Turning endodontic irrigation upside down – literally

As dental professionals, it is our duty to provide the highest quality of patient care, regardless of the treatment.

Greg Goldfaden, DMD

For more on this topic, go to www.dentaleconomics.com and search using: endodontic irrigation, Dr. Greg Goldfaden.

As dental professionals, it is our duty to provide the highest quality of patient care, regardless of the treatment. This is particularly true with root canal irrigation and disinfection.

In my years of practice, I have tested every irrigation system and solution. All of them have their pros and cons. Some use ultrasonics to stimulate the flow of irrigants into lateral canals. Newer irrigation solutions claim efficacy without potentially harmful, caustic side effects. Despite the claims of all the systems and solutions, no irrigant can get the canal cleaner and eradicate endodontic biofilm better than sodium hypochlorite (NaOCl).The question remains: how do we best take advantage of the antimicrobial properties of NaOCl, while also mitigating the risk of a damaging irrigation accident to the patient?

The easiest way to mitigate risk is to avoid the use of systems or devices that rely on "positive pressure irrigation" in the apical portion of the root canal. Standard syringe-based irrigation is not a treatment option in my protocol. Three treatment options that have been proven as safe and effective apical irrigation include ultrasonics (multiple manufacturers), a negative pressure delivery/evacuation system called the EndoVac (Discus Dental, Culver City, Calif.), and to a more limited degree, some hard-tissue laser devices (Waterlase, Biolase, Irvine, Calif.).

The Biolase laser technology works on the principle of hydrophotonic energy through the energy of ultra small droplets of water. These energized water molecules remove organic debris and bacteria inside the root canal that is usually caused by heat or vibration, and have been shown to penetrate deep into dentinal tubules without damaging the internal tooth structure. The laser should still be used in conjunction with endodontic irrigating solutions to allow for tissue dissolution.

When discussing ultrasonic irrigation, it is important to distinguish between delivery of irrigants and activation of irrigants that have already been delivered. Ultrasonic irrigation is an effective method of activating predelivered irrigants to facilitate bacterial disinfection deeper into dentinal tubules.

This brings us back to the issue of patient safety, which becomes a function of how the irrigants were delivered initially. If apical positive pressure delivery is used prior to ultrasonic activation, then efficacy may be compromised as delivery will likely occur short of working length. To maximize the antimicrobial effects of my ultrasonic activation while keeping patient safety in mind, I use the EndoVac system to safely draw irrigants to full working length prior to activation. This gives me the best possible combination of safety and efficacy.

The EndoVac system does things "opposite" of how they’ve always been done. Rather than using positive pressure (i.e., squirting bleach into the canal), EndoVac uses suction to pull irrigants down the root canal, into a set of cannulas, and then safely up and away into the Hi-Vac suction unit - a phenomenon known as "negative apical pressure."

Negative apical pressure has completely changed the game. Safety is no longer an issue because I no longer deliver sodium hypochlorite via potentially dangerous positive pressure methods. I passively deliver it at the coronal opening, and it is then pulled down along the walls of the canal using patented MacroCannula and MicroCannula technology.

Irrigants cannot get past the suctioning holes of the unique cannulas, so the risk of apical extrusion is eliminated. This apical negative pressure also helps to eradicate bacteria and biofilm in a much more effective manner than with traditional positive pressure delivery systems. Because the biofilm is eliminated, the healing process is expedited. A recent in vivo study from Brazil showed that patients treated with EndoVac had significantly less post-operative pain when compared to those treated with traditional methods.

I treat every patient with the EndoVac system. As mentioned, NaOCl is the best irrigant available to dentists for killing E. faecalis biofilm. The EndoVac is the first and only system that has enabled us to safely deliver NaOCl to the final few mm of the root canal. (Side note: To reach full WL, the EndoVac MicroCannula requires a minimum preparation size of #35. I can do this quickly, safely, and easily with LightSpeedLSX NiTi rotary instruments. LSX instruments excel in the apical third because they effectively debride this space without the need to over enlarge the mid and coronal aspects of the canal.)

Aside from the obvious safety advantages of using an apical negative pressure system (EndoVac), there are also compelling antimicrobial benefits that may allow for single-visit endodontics, which is important as economic pressures force clinicians to carefully consider chair time and treatment time.

Recent research confirms, "…the results demonstrated that reliable disinfection can be achievable with efficient and safer irrigation delivery systems, such as the EndoVac system, and that the use of intracanal antibiotics might not be necessary."

Single-visit treatments for the general dentist and endodontist have obvious economic advantages – and it is entirely possible thanks to the efficacy of an apical negative pressure system. To think that root canal irrigation, of all things, could have a dramatic positive effect on the economy of your practice; it’s worth taking a closer look.

References at www.dentistryiq.com. Use search word: Goldfaden.

Dr. Greg Goldfaden is in private practice in Aventura, Fla., specializing in endodontics. President of the North Dade Miami Beach Dental Society for 2010-’11, he received his DMD from the University of Florida in 2003, and his Certificate of Advanced General Studies in endodontics from Boston University Goldman School of Dental Medicine in 2005. Reach him via e-mail at grg5050@aol.com.

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