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Dental tribune | June 16-22, 2008 Clinical 5

Improving endodontic success through use of the EndoVac irrigation system

By Gregori M. Kurtzman, DDS, MAGD, DICOI

The endodontic triadLong-term success endodonti-

cally is not due to a single factor but relates to three aspects of treatment, what you may call an “endodontic triad.” This is composed of instru-mentation, disinfection and obtura-tion. These three components of the triad are interwoven and required for success.

Instrumentation alone does not ready the canal system for obtura-tion, and disinfection is key to aug-menting the process and optimizing the obturation process. But what is referred to when we mention dis-infection of the canal system? Dis-infection comprises removal of the residual tissue in the canal system and the associated bacteria through flushing the canal system with irri-gating solution. The key is to remove as much residual tissue as possible. The more thorough the irrigation process, the lower the remaining bacterial level.

The intricacies of the canal anat-omy, with its fins, lateral canals and apical deltas, make it impossible for the instrumentation of the canals to reach all of the fine aspects of the anatomy. Irrigation of the canal sys-tem thus permits removal of residual tissue in the canal anatomy that can-not be reached by instrumentation of the main canals.

Cleansing the canal No matter what obturation mate-

rial is used, how well the sealer adheres to the canal walls is impor-tant. Smear layer can play a factor, which may prevent sealer penetra-tion into the dentinal tubules. The frequency of bacterial penetration through teeth obturated with intact smear layer (70%) was significantly greater than that of teeth from which the smear layer had been removed (30%). Removal of the smear layer enhanced sealability, as evidenced by increased resistance to bacterial penetration.1 The incidence of apical leakage was reduced in the absence of the smear layer, and the adapta-tion of gutta-percha was improved no matter what obturation method was used later.2-4

What is used to obturate the canals is important, however the manner in which the canal was prepared prior to obturation also determines how well the canal is sealed when therapy is completed. Rotary instru-mentation with NiTi files has shown less microleakage than hand instru-ment prepared canals irrespective of what was used to obturate the canal.5 The machining of the canal walls with NiTi rotary instruments provides smoother canal walls and shapes that are easier to obturate than can be achieved with stainless steel files. The better the adapta-

tion of the obturation material to the instrumented dentinal walls, the less leakage is to be expected along the entire root length. The better the canal walls are prepared, the more smear layer and organic debris is removed, which is beneficial to root canal sealing.

Final smear layer removal is best achieved by irrigating the canals with NaOCL (sodium hypochlorite) followed by 17% EDTA solution.6 Whereas, the NaOCL dissolves the organic component of the smear layer exposing the dentinal tubules

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Fig. 1: Comparison of positive (left) and apical negative (right) pressure with regard to endodontic irrigation.

See Improving, Page 6

lining the canal walls. EDTA, a chelating agent, dissolves the inor-ganic portion of the dentin, opening the dentinal tubules. Utilization of the two irrigants following instru-mentation will permit removal of more organic debris further into the tubules, increasing resistance to bacterial penetration once the canal is obturated.7,8

Studies suggest that regu-lar exchange and the use of large amounts of irrigant should maintain the antibacterial effectiveness of the NaOCl solution, compensating for

the effects of concentration.9 So it seems that volume is more critical to canal disinfection during treat-ment than the concentration of the irrigant.10

Clinical Dental tribune | June 16-22, 20086

Positive pressure vs. apical negative pressureIrrigation as it relates to endodon-

tic treatment involves placement of an irrigating solution into the canal system and its evacuation from the tooth. Traditionally, this involved placement of an end-port or side-port needle into the canal and express-ing solution out of the needle to be suctioned coronally. This creates a positive pressure system with force created at the end of the needle, which may lead to solution being forced into the periapical tissues. As some irrigating solutions such as

sodium hypochlorite have the poten-tial to cause tissue injury that may be extensive, when encountering the

periapical tissue and its communica-tion with tissue spaces, positive pres-sure irrigation has its risks. Chow was able to show as early as 1983 that positive pressure irrigation has little or no effect apical to the needle’s orifice.11 This is highlighted in his paradigm on endodontic irrigation,

“For the solution to be mechanically effective in removing all the particles, it has to: (a) reach the apex, (b) cre-ate a current force and (c) carry the particles away.”

An apical negative pressure irriga-tion system, on the other hand, does not create a positive force at the nee-dle’s tip, so potential accidents can be eliminated. In an apical negative pressure irrigation system, the irriga-tion solution is expressed coronally, and suction at the tip of the irrigation needle at the apex creates a current flow down the canal toward the apex and is drawn up the needle. But true apical negative pressure only occurs when the needle (cannula) is utilized to aspirate irrigants from the apical termination of the root canal. The apical suction pulls irrigating solu-tion down the canal walls toward the apex, creating a rapid, turbulent current force toward the terminus of the needle. Haas and Edson found, “The teeth irrigated with negative apical pressure had no apical leak-age. While the teeth irrigated with positive pressure leaked an over-age of 2.41 mL out of 3 mL.”12 A recent study by Fukumoto found that [apical] negative pressure irrigation resulted in less extrusion of irrigant than did positive pressure irrigation when both needles were placed 2 mm from working length (Fig. 1).13

EndoVac endodontic irrigation systemDesigned by Dr. G. John Schoeffel

after almost a decade of research, the EndoVac irrigation system (Dis-cus Dental, Culver City, Calif.) was developed as a means to irrigate and remove debris to the apical constric-ture without forcing solution out the apex into the periapical tissue. The system utilizes apical negative pres-sure through the office’s high volume evacuation system, permitting thor-ough irrigation with high volumes of irrigation solution.

The EndoVac system consists of a Hi-Vac adapter assembly that con-nects to the high volume evacuation hose in the dental operatory at one end and has a “T” connector at the other end (Fig. 2). The “T” connec-tor permits a Master Delivery irri-gation-suction tip with a disposable syringe filled with irrigation solution

ImprovingFrom Page 5

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Fig. 2: Hi-Vac hose assembly with connector to office high volume suction (black end) and “T” connector (red/white end).

Fig. 3: EndoVac Master Delivery (irrigation-suction) tip on a disposable syringe.

Fig. 4: EndoVac MacroCannula on the titanium handpiece.

Fig. 5: EndoVac MicroCannula in the fingerpiece and close-up showing the blunt end with multiple lateral micro holes.

Fig. 7: Obturation of apical anatomy following irrigation with the EndoVac system demonstrating apical deltas. (Courtesy of Dr. Richard Rubinstein, Farmington Hills, Mich.)

Fig. 8: Bifurcation in the apical 1 mm obturated following irrigation with the EndoVac system. (Dr. Gregori M. Kurtzman, Silver Spring, Md.)

Fig. 9: Obturation of apical anatomy following irrigation with the EndoVac system demonstrating lateral anatomy. (Courtesy of Dr. Richard Rubinstein, Farmington Hills, Mich.)

Clinical Dental tribune | June 16-22, 20088

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(Fig. 3) and either a MacroCannula (Fig. 4) or MicroCannula (Fig. 5) to be attached and used simultane-ously during treatment. The plastic MacroCannula is placed on a tita-nium handpiece, which is attached to tubing that connects to the “T” connector. This is used for coarse debris removal. The MicroCannula is a metal suction tip available in either 25 or 31 mm lengths with 12 micro holes in the terminal 0.7 mm of the tip, permitting removal of par-ticles that are 100 microns or smaller to the apical constricture. This tip fits into a metal finger piece and is connected to the “T” connector via tubing. The turbulent current forces

developed by the MicroCannula rap-idly flow to the micro holes at the terminus, which can be placed as close as 0.2 mm from the full work-ing length. The vacuum formed at the tip of the MicroCannula is able to achieve each of Chow’s objectives in his irrigation paradigm.

The system comes packed in a single-use package that contains a

the canal system. The EndoVac irri-gation system, as Nielsen and Baum-gartner demonstrated, is able to bet-ter clean at the apex where other irrigation methods and systems have not been able to do as thorough a job (Figs. 7–9).

EndoVac techniqueFollowing removal of the chamber

roof and exposure of the pulp, the Master Delivery Tip is used to pro-vide frequent and abundant irriga-tion as the orifices are identified and explored. During instrumentation, the Master Delivery Tip is placed coronally to provide fresh irrigation

Master Delivery Tip, a MacroCan-nula, a MicroCannula and tubing assembly (Fig. 6).

Nielsen and Baumgartner found that the volume of irrigant delivered with the EndoVac system was signifi-cantly more than the volume deliv-ered with needle irrigation over the same amount of time.14 Further, they reported significantly better debride-ment 1 mm from working length for the EndoVac system compared with needle irrigation.

Since one of the laws of physics states “only one object can occupy a space at a time,” if the tissue remnants can be removed from the lateral canals, apical deltas and fins within the canal system, these areas can be filled with obturation materi-al, providing a better seal and inhib-iting bacterial migration throughout

Fig. 6: EndoVac single-use pack.

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solution and aid in debris removal that is brought coronally as the rotary file is used in the canal (Fig. 10). The benefit of the Master Delivery Tip is that with a single tip at the tooth’s access, visibility is not blocked and large volumes of irrigation solution can be utilized. The MacroCannula is utilized to remove coarse debris after instrumentation and is used in combination with the Master Deliv-ery Tip, which delivers the irrigating solution. Apical negative pressure is created as irrigating solution is drawn down the canal toward the apex as it is expressed from the Master Deliv-ery Tip and then drawn down to and

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Clinical Dental tribune | June 16-22, 200810

up through the MacroCannula (Fig. 11). The MicroCannula is taken to full working length and moved 2 mm with an up and down action every six seconds as each canal is flushed. This up and down action removes micro-gas bubbles formed during tissue hydrolysis. The MicroCannula

is used with a combination of three rinses using NaOCL (6%) and EDTA (17%).

The EndoVac will work in any canal configuration shaped at least to a size 35 with a 0.04 taper or greater (Fig. 12). To prevent plug-ging of the fine holes in the apical

terminus, do not use the MicroCan-nula until thorough irrigation has been accomplished with the Macro-Cannula and all instrumentation has been completed.

ConclusionInstrumentation, disinfection and

obturation are important aspects of rendering quality endodontic care. Yet, the instruments we use to pre-pare the canal, be they hand or mech-anized are unable to reach all aspects of the canal system. Irrigation is key to cleaning and disinfecting those areas that the instrument cannot reach. The EndoVac irrigation sys-tem with its apical negative pressure is able to more thoroughly remove the micro debris at the apical con-stricture, thereby providing a better environment to be filled with sealer.

A complete list of references is available from the publisher.

Fig. 10: Master Delivery Tip being used to provide constant irrigation as the canal is instrumented. Fig. 11: Use of the EndoVac MacroCannula.

Fig. 11: Use of the EndoVac MacroCannula.

About the author

Gregori M. Kurtzman, DDS, MAGD, DICOIDr. Gregori M. Kurtzman is in

private practice in Silver Spring, Md., and is a former Assistant Clin-ical Professor at the University of Maryland School, Baltimore Col-lege of Dental Surgery, Department of Endodontics, Prosthetics and Operative Dentistry. He has lec-tured both nationally and interna-tionally on the topics of restorative dentistry, endodontics and dental implant surgery and prosthetics. He has had numerous journal arti-cles published in peer-reviewed publications. He is a consultant and evaluator for several dental com-panies. He has earned fellowships in the Academy of General Den-tistry, the International Congress of Oral Implantologists, the Pierre Fauchard Academy and the Ameri-can College of Dentists and master-ships in The Academy of General Dentistry and the Implant Pros-thetic Section of the International Congress of Oral Implantologists. He can be contacted at: dr_kurtz-man@maryland-implants.com.