Endo Tribune Middle East & Africa No. 5, 2017
Cleaning is the key / All roads lead south
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DTMEA_No.5. Vol.7_ET.indd
www.dental-tribune.me
PUBLISHED IN DUBAI
September-October 2017 | No. 5, Vol. 7
Cleaning
is key
ENDO
TRIBUNE
The World’s Endodontic Newspaper Middle East & Africa Edition
By Aws Alani, UK
Completely disinfecting the canal
system is challenging when all factors are considered. If we are looking
at the nano level there are approximately 76,000 dentinal tubules per
square millimetre of dentine. Each
of which can harbour a colony of
bacteria. Then there may be inaccessible anatomy such as lateral canals,
apical deltas or fins. These are factors
that need considering outside of canal curvatures that may or may not
be entirely visible in the plane of the
radiograph. It is clear that outside of
the contact our files make with the
walls of the root canal there needs to
be chemical disinfection to further
reduce bacterial load. Irrigants disinfect as well as lubricate instruments
and they dissolve the pulp. Sodium
hypochlorite has been the mainstay
irrigant for decades.
During the 1980s, Bystrom and colleagues investigated the effect of mechanical instrumentation with and
without adjunctive use of hypochlorite. They found, unsurprisingly so,
that when compared to pure mechanical instrumentation, the use
of hypochlorite in combination with
hand filing significantly reduced bacterial load. As such chemomechanical instrumentation was shown to be
crucial for endodontic success. They
compared irrigation with saline, 0.5
% and 5 % hypochlorite over a sequence of 5 appointments. Interestingly they found no difference in the
reduction of bacterial load between
0.5 and 5 % hypochlorite. Despite
what was likely to be a comprehen-
sive protocol for these teeth, 7 of the
15 specimens in this study still had
bacteria that they could grow at the
end of treatment. The presence of
cultivable bacteria does not necessarily mean we have failure—it merely
means that there may be a cohort
of bacteria that have resisted treatment. Mechanical instrumentation
does reduce bacterial load by itself—
this is by way of physical removal of
tissues where bacteria reside, while
also facilitating the dispersal of the
irrigant into the canal. Siquiera and
colleagues found that enlarging the
canal from size 30 to 40 resulted in
a significant decrease in endodontic
pathogens.
It seems that irrigation and instrumentation are both highly interrelated in canal disinfection. Take
washing your car for instance, purely
covering it with soapy water and
rinsing won’t remove the motorway
bugs and bird produced projectiles.
A good scrubbing with a sponge is
needed, or if you are really serious
about cleaning, a pressure washer!
This begs a further question—how
would your patients feel if they
knew that, more or less, the same or
very similar liquid they use to clean
bathroom suites is the same that we
use to clean the inside of their teeth?
On recent evidence of a dentist to
the “stars” appearance on national
TV not much—he advocated using
charcoal to whiten teeth, which you
may be able to buy from your local
petrol station for barbecues.
Annareichel/Shutterstock.com
Hypochlorite is an effective bactericidal but does not remove the smear
layer. The smear layer is a mix of
organic material (protein, pulp remnants, saliva, microorganisms) with
an inorganic components consisting of minerals from the dentine.
The smear layer prevents bacteria
residing in the dentinal tubules from
being exposed to the irrigant as well
as reducing the contact between the
dentine and sealant during obtura-
ÿPage A2
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[2] =>
DTMEA_No.5. Vol.7_ET.indd
A2
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 5/2017
◊Page A1
tion. Hence, utilising EDTA to remove
the smear layer prior to obturation
but after completion of preparation
and instrumentation is sensible. A
penultimate rinse with EDTA then a
final rinse with hypochlorite prior to
drying has been advocated heavily in
the literature.
Bacteria and the biofilms
Unlike what we once thought, bacteria do not tend to just sit alone and
remote from each other. If only they
were this antisocial and could be
picked off one by one! Bacteria join
forces and create symbiotic groups,
share resources and protect each
other from external influence. This
is commonly known as a “biofilm”,
which has a thin but robust layer
of mucilage that adheres to a solid
surface housing the community
of microorganisms. They not only
share resources, they also share information that promote each other’s
survival through RNA or DNA. As the
majority of bacteria will be encapsulated in this layer, purely irrigating without disrupting this layer is
inefficient. The word disrupting is
a bit kind really—it needs to be destroyed to reveal all its contents and
expose it to the bleach for chemical
action. It is the methods of disruption of the canal biofilm that has
seen a lot of development over the
last 10 years or so. Much in the same
way a pressure washer can clean that
more quickly and efficiently than a
sponge, energising the disinfectant
results in improved cleanliness.
Energising the irrigant
This can take many forms. The
simple and straightforward form
ensures appropriate exchange of
the fluid and displacement into the
recesses where airlocks may reside.
This can be achieved through applying a GP point into the prepared canal to displace and disperse.
Ultrasonic irrigation transmits energy by an oscillating instrument. This
results in two different phenomena.
Cavitation is the growth and subsequent collapse of small gas bubbles
due to a drop in pressure. Acoustic
streaming is the bulk movement of
fluid when pressure waves are projected, resulting in vortex motion
around a fast moving oscillating instrument. This results in shear stresses to tear the biofilm apart.
Keeping the canal clean
Once irrigated and prepared, the clinician has a choice—to obturate or
to dress. Some may argue that the
canal is cleanest at the end of instrumentation and that for convenience,
obturating in a one visit arrangement is the best option. As we know,
not all bacteria are removed or killed
during treatment. Dressing the canal
with calcium hydroxide may continue the process of eradication of
the residual microorganisms over a
2-week period. The choice between
the two schemes sometimes boils
down to the presenting factors of
the case. Where a tooth is difficult to
instrument, has a large lesion or is
quite obviously chronically infected
with a history of pain, then dressing
may be more of a consideration. If a
tooth is treated in a de novo manner
and treatment goals are achieved
with no history of pain then a single
visit treatment could be utilised.
The goal of obturation is to seal the
canal system to prevent any reinfection and entomb any bacteria
not eradicated by chemomechanical debridement. If the obturation
is through the apex, this can have
significant implications. GP through
the apex can carry bacteria outwith
of the canal and exacerbate symptoms. A foreign body reaction could
also develop.
We also have to remember that
a beautiful obturation of a canal
achieved without rubber dam and
utilising saline or local anaesthetic
irrigation is sub-standard treatment.
It can be difficult to assess the “quality” of treatment when a radiograph
of a “failed” tooth is examined in this
context. Indeed, an obturation that
is short of the radiographic apex
having been treated under rubber
dam and with copious amounts of
irrigation is more likely to be successful than the previous scenario.
Attributing too much significance to
the radiographic appearance of the
obturation is short-sighted. Indeed,
Katebzadeh and colleagues in the
late ‘90s witnessed healing in the
absence of obturation where teeth
where instrumented and irrigated
optimally under isolation. Sealants
are also antibacterial and aide filling
the voids between the GP and the
canal system. One further option
would be to provide a sub-seal to
each of the canal orifices. This can be
achieved by removal of 1 mm of GP
and packing a good thick mix of IRM
packed with a plugger.
Covering the cusps
The provision of a coronal restoration (if provided optimally) can
improve the coronal seal while also
structurally protecting the underlying tooth tissue. Due to endodontic
treatment, resulting in reduction
of tissue bulk and stiffness the risk
of fracture increases. Where both
mesial and distal margins have not
been breached and the access cavity
is confined to the occlusal surface,
a crown restoration may not be required. Once a margin is breached
the tooth is more likely to flex and
result in cracks or fractures. A commonly asked question, “When
should the crown be provided? Soon
after the root canal treatment or
when the treatment has proven to
be successful?” If the success of endodontic treatment is significantly
in doubt then this should be communicated to the patient and a well
compacted direct restoration may
be the best option, otherwise an onlay or if tooth tissue is significantly
reduced, a crown should be provided
soon after completion.
Conclusion
Bacteria are public enemy number
one in dentistry. Disinfecting the
root canal system by irrigating in
combination with mechanical instrumentation is key to success in
root canal therapy. Preventing further re-infection or persistence of
residual bacteria after the formal
stages of treatment through dressing initially and a quality coronal seal
subsequently is as important as the
root canal therapy.
Editorial note: The article was published in Roots Magazine International 2/2017
Aws Alani, UK
He is a Consultant in Restorative Dentistry
at Kings College Hospital in London, UK.
He can be contacted at:
awsalani@hotmail.com.
www.restorativedentistry.org
All roads lead south
By Dr Alfredo Iandolo, Italy
As usual in the human anatomy,
root canals come in all forms and
sometimes develop in very random
structures. Luckily, pre-bendable
nickel titanium (NiTi) files allow us
to prepare and clean the canal in
next to no time. In this article, we will
compare three different endodontic cases, you will quickly fi nd that
a thorough and efficient root canal
preparation is easy with the right set
of instruments—regardless of the
shape of the canal itself.
Reading endodontic case reports,
you sometimes get the impression
that root canals always spot an extreme, double curved morphology.
With the latest technology and treatment auxiliaries the endodontic
world has to offer, you should, of
course, feel confident to take on even
the most unusual shapes of canals.
Would not it be nice though to have
a universal, flexible NiTi file system
that allows you to prepare all sorts
of canals, whether they are S- or Jshaped or lead straight down to the
apex? In Italy, we say “tutte le strade
portano a Roma”. For a well-versed
endo expert “all root canals lead to
the apex is just as true—you only
have to know how to use your equipment the right way”.
Fig. 1: Pre-operative radiograph of case 1
Case 1:
Straight down to business
A 48-year-old female patient introduced to our surgery complaining of
pain caused by chewing in the maxillary left side. We quickly found that
the necrotic pulp of tooth 24 caused
the complaint. The pre-operative
radiograph showed a deep caries as
well as a medium-sized periapical lesion (Fig. 1).
The root canals were positioned in a
comparatively straight, almost parallel way with hardly any curvature.
Quick preparation with a reduced
sequence of NiTi files consequently
should be possible in that particular
case, as there were no contraindications to a root canal therapy in general.
To provide a clean and dry operating field, dental dam was applied
to isolate tooth 24 for the following
treatment. First of all, we handfiled
the main canals up to ISO 10 size. We
were thus able to create a suitable
glide path, before the actual preparation took place.
In our endodontic practice, we normally use the latest generation of
nickel titanium files by Swiss dental specialist COLTENE for cleaning
Fig. 2: Specially hardened surface of the HyFlex EDM file
under the microscope
and shaping the canal. As the name
already indicates, the HyFlex EDM
is a “highly flexible” NiTi file, which
proves to be incredibly fracture resistant. In close cooperation with
leading universities and international endo-specialists, the renowned
research department of the innovative provider of endo equipment developed a literally sharp solution for
their instruments. To come up with
a new, powerful tool they employed
a clever idea that is widely used in
other industry branches to dentistry.
The abbreviation “EDM” stands for
a specific manufacturing process
named “electrical discharge machining”. Spark erosion improves the cutting performance of the instrument
as it produces a unique surface in
the file. You can compare this kind
of refinement with the serrated edge
of a kitchen knife you use for cutting
bread to make bruschetta (Fig. 2).
Due to its special material properties, the file is virtually unbreakable
and predestined for dentists who require fast and reliable results using a
reduced file sequence.
With the HyFlex EDM, we were able
to prepare the root canal system
in the blink of an eye. Access was
quickly gained with the HyFlex 25/.12
Orifice Opener (Fig. 3). For the main
procedure we used only one univer-
Fig. 3: Cutting in the canal using a HyFlex
EDM 25/.12 Orifice Opener.
sal file that saved a
lot of time during
the treatment. For a
quick and thorough
preparation, a size
25 file with variable
taper was applied
in the common
single length technique. The shaping
took only a couple
of minutes and we
were able to navigate the instrument
swiftly through the
canal in a soft pecking motion (Fig. 4).
Even when a bit
more pressure was
put on the file it neither blocked nor got
stuck in the dentine.
To obtain the ideal
chemomechanical
cleansing we then
irrigated the canal
several times for a
total of at least 30
minutes. Following
the classic irrigation
Fig. 4: HyFlex protocol, we used
EDM OneFile
intracanal heated sodium hypochlorite
(Iandolo technique), 17 % EDTA solution and 2 % chlorhexidine digluconate solution to remove all debris
and possible irritants from the canal.
After eradicating the infection, we
dryed the canal with the corresponding paper points size 25. The last step
was to create a proper seal to prevent
microorganisms from reentering
the root canal system and thus protect the root from future recontamination. A bioactive 3-in-1 obturation
material was applied in a special
technique as described in the following case to ensure that all lateral and
side canals were filled. The postoperative radiograph after the treatment
most notably showed a lateral canal
in the apical third as well as an isthmus between the main canals, which
got both filled safely (Fig. 5). The result was a tight, durable seal of the
whole root canal system, as the final
radiograph reflected (Fig. 6).
Case 2:
3-D obturation technique
In our second case, a 65-year-old
female patient was referred to our
practice with chief complaint of pain
in the right side mandible. The radiograph showed defects in two teeth:
in tooth 45, an insufficient former
root canal treatment had led to a periapical lesion. In the neighbouring
molar, a deep restoration was clearly
visible. Tooth 46 was therefore diagnosed with a necrotic pulp (Fig. 7).
Again, the HyFlex EDM helped us to
shape the canal effectively without
transporting or changing the natural
path of the root canal. After gaining
access with the orifice opener, we
once again used the HyFlex OneFile
to get to the apex. A few finishing
touches were provided with the help
of a 40/.04 EDM file.
Obturating all portals of exit turned
out to be particularly challenging in
our second case, therefore a modified three-dimensional obturation
technique was applied using GuttaFlow bioseal. The 3-in-1 obturation material combines fluid gutta-percha with a suitable sealer at
room temperature and bioceramics
in an automix syringe (Fig. 8). This
composition results in an easy to
handle material with excellent flow
properties and working times of 10
to 15 minutes. What we call threedimensional obturation technique
is, in fact, an efficient and reliable
way to fill even complex root canal
structures.
ÿPage A3
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DTMEA_No.5. Vol.7_ET.indd
Fig. 8: 3-in-1 obturation material GuttaFlow bioseal
◊Page A2
Figs. 5 & 6: Postoperative radiographs, case 1
First, we warm the gutta-percha using system B heat source. For our
purpose, we decrease the temperature to 130 degrees from the average 200 degrees, as this totally suffices. Penetration depth is reduced
to 3 seconds as well compared to the
usual 5 seconds with a heat carrier to
4 millimetres from working length.
This way the GuttaFlow does not set,
but keeps a sticky consistency, which
allows us to push it further down the
canal with a plugger, if necessary.
However, with our new technique
the gutta-percha itself does not have
to get inside the accessory canals, as
the bioceramic sealer will already
flow into any hidden canals.
In previous test settings, you can see
that the modified obturation technique allowed the sealer to advance
deeper inside lateral canals in comparison to a traditional single cone
technique (Fig. 9). Inserting the obturation material with more speed also
generates higher pressure: you do
not have to reach the desired working length in one go, but can use
another stroke until you reach the
desired length. The sealer sets only
around 2 minutes earlier than normal with the reduced heat settings
and fast penetration. Thanks to 3-D
obturation, you let the sealer do its
job in areas which are hard to reach,
while it gets pushed further down
into the canal by the slightly melted
guttapercha on top. The fine white
line in the postoperative radiograph
of tooth number 45 showed the obturated small lateral canal leading
away from the main canal (Fig. 10).
Moreover, in the follow-up session,
we noted that healing of the affected
teeth 45 and 46 had already taken
place. The bioactive components
of the obturation material further
added to the regeneration process,
as they stimulated the rebuilding of
bone and dentine tissue, which was
a favourable side effect to the actual
sealing of the canal (Fig. 11).
Case 3:
Severe double curvature
to finish off
Last but not least, we come to the
extraordinary S-shaped canal as
mentioned in the introduction. With
strong curves it is always good to
know that NiTi files with a so-called
“controlled memory” (CM) effect can
be prebent like classic stainless steel
files, but do not bounce back. Using
their unique material properties,
you can work comparatively stressfree, even under difficult conditions.
This time, the patient with the rath-
Fig. 7: Pre-operative radiograph of teeth 45 and 46,
case 2
Fig. 10: Postoperative radiograph case 2 showing an obturated small lateral canal
er challenging canal anatomy was
a 40-year-old female patient with
complaints in her right side mandible. In our analysis, the clinical diagnosis revealed an irreversible pulpitis
in tooth 47. The radiograph indicated
that we needed to get around a very
sharp angle in the mesial root (Fig.
12); endo specialists know how distant molars are notorious for their
winding root canal system! We used
the following sequence to get to the
length very quickly without straightening the canal at all:
HyFlex EDM 25/.12, 10/.05 and the
afore-mentioned HyFlex EDM OneFile 25/~ (Figs. 4 , 13, 14). The flexible
files can even find their way around
tricky anatomies and are virtually
unbreakable. They move perfectly
in the centre of the canal, therefore I
have never come across any perforations or ledges during my numerous
treatments so far. After using “CM”treated NiTi files, they can be quickly
regenerated by autoclaving and are
ready for their next application until
they reach the end of their life cycle
by displaying an uneven, bent shape.
As long as they are not unwound
they can be re-used safely, otherwise
they have to be discarded.
After drying and successfully obturating the canal, we were able to dismiss the patient with a very promising prognosis. The immediate
postoperative radiograph showed
the naturally formed, filled mesial
canal with its striking double curvature at the end (Fig. 15). We are very
glad that even in more challenging
cases like the present one we can rely
on the versatility of the latest generation of rotary instruments.
Conclusion
The latest generation of nickel titanium files adapt easily to all shapes
of root canals thanks to heir flexible
Dr Alfredo Iandolo, Italy
Dr Alfredo was awarded Doctor of Dental Medicine by the University of Naples Federico
II in 2006. As Professor A.C. he has continued speaking on endodontic courses at his
home university since 2014. Iandolo is a certified member of the ESE (European Society
of Endodontics) as well as an active member of the SIE (Italian Society of Endodontics)
and AIOM (Italian Academy of Microdentistry). As winner of the “Riitano Award” 2016
for best research in Endodontics Iandolo is a regular speaker at national and international congresses. The inventor of the Iandolo Gauging File (IG-File) and a new protocol
in irrigation activation is widely published both nationally and internationally.
Dr Alfredo Iandolo
Via A. Ammaturo 126 B
I-83100 Avellino, Italy
iandoloalfredo@libero.it
A3
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 5/2017
Fig. 11: Follow-up four months later
Fig. 13: HyFlex EDM 25/.12 Orifice Opener
design and unusual cutting power.
Whatever way you choose to reach
the apex, prebendable NiTi files like
the HyFlex EDM help you to follow
Fig. 9: In vitro comparison of single cone technique (left) to improved
3-D obturation (right)
Fig. 12: Pre-operative radiograph case 3,
tooth 47
Fig. 15: Postoperative radiograph
case 3 showing a severe double curvature in the mesial root
Fig. 14: HyFlex EDM 10/.05
the natural path of the root canal and
quickly remove debris for chemical
cleansing and long-term obturation
of the various root canal structures.
The extremely fracture resistant files
are literally “cutting edge” technology, which make an excellent travel
companion on virtually every road.
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