Endo Tribune U.S. No. 3, 2012
Endodontists support U.S. troops with care packages / Improving endodontic success through use of the EndoVac irrigation system / Harvard alums honor Dr. Alvin Krakow / Industry
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[1] =>
ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
april 2012 — Vol. 7, No. 3
www.dental-tribune.com
Improving endodontic success through
use of the EndoVac irrigation system
By Gregori M. Kurtzman, DDS, MAGD,
FACD, FPFA, FADI, DICOI, DADIA
L
ong-term success endodontically 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 instrumentation, disinfection and
obturation. These three components of
the triad are interwoven, and success requires careful attention to all three.
Instrumentation alone does not prepare the canal system for obturation,
and disinfection is key to augmenting
the process and optimizing the obturation process. But what is referred to
when we mention disinfection of the
canal system? Disinfection comprises
removal of the residual tissue in the canal system and the associated bacteria
through flushing the canal system with
irrigating 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, 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
system thus permits removal of residual
tissue in the canal anatomy that cannot
be reached by instrumentation of the
main canals.
Cleansing the canal
No matter what obturation material is
used, how well the sealer adheres to the
canal walls is important. Smear layer
can play a factor that may prevent sealer
Fig. 1: Comparison of positive (left) and apical negative (right) pressure with regard to
endodontic irrigation. Photos/Provided by Dr. Gregori M. Kurtzman
penetration into the dentinal tubules.
The frequency of bacterial penetration
through teeth obturated with intact
smear layer (70 percent) was significantly greater than that of teeth from
which the smear layer had been removed
(30 percent). 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, and
the adaptation of gutta-percha was improved no matter what obturation method was used later.2–4
What is used to obturate the canals
is important, but the manner in which
the canal was prepared prior to obturation also determines how well the canal
is sealed when therapy is completed.
Rotary instrumentation with NiTi files
has shown less microleakage than handinstrument-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
adaptation of the obturation material to
the instrumented dentinal walls, the less
Fig. 2: EndoVac Multi-Port Adapter (blue)
connected to HVE suction line and to the
Master Delivery Tip syringe. A separate line
connects to the MacroCannula or MicroCannula suction tip.
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.
Smear layer removal is best achieved
by irrigating the canals with NaOCL (sodium hypochlorite) followed by 17 percent EDTA solution.6 The NaOCL dissolves
the organic component of the smear
layer, exposing the dentinal tubules lin” See IRRIGATION, page 4
Endodontists support U.S. troops with care packages
W
orking with Operation
Support Our Troops —
America, one of the largest
volunteer-based military
support organizations in the country, the
American Association of Endodontists is
encouraging dental professionals and patients to donate items for care packages,
monetary gifts or a letter to U.S. troops.
With support from Henry Schein
Dental/Henry Schein Cares, the AAE
had a booth at the Hynes Convention
Center for attendees to submit their
donations to the cause during the AAE
Annual Session in Boston, which was
held April 18 to 21.
Military dentists work in special conditions, usually maintaining the oral
Photo/stock.xchng
health of soldiers on military bases, but
they are frequently transferred and also
get deployed. The AAE wishes to recog-
nize these individuals, as well as their
families and veterans with an ongoing
Support the Troops initiative.
“We want our troops to know we appreciate everything they do for our country,” said AAE President Dr. William T.
Johnson. “Many of our members, including myself, are serving or have served in
the armed forces, and we hope that our
actions will help make life a little easier
for them. We invite the entire dental
community to join us in supporting our
hardworking troops.”
In addition to Operation Support Our
Troops — America, the AAE lists several
military organizations and causes to support. To learn more, visit www.aae.org/
supportthetroops, or contact the AAE at
supportthetroops@aae.org.
(Source: AAE)
[2] =>
NEWS
B2
Endo Tribune U.S. Edition | April 2012
Harvard alums honor Dr. Alvin Krakow
Dr. Jeffrey Linden gathered several former students of Dr. Alvin Krakow, a beloved endodontics professor at the Harvard School of Dental Medicine (HSDM),
to celebrate their mentor with a lecture
and a dinner last fall.
Linden spoke to endodontics postdoctoral residents about ultrasonic endodontics. He dedicated the lecture to the late
Dr. Cyril Gaum, a colleague and friend of
Krakow’s. Dr. John Schoeffel, who traveled
from California for the event, also spoke.
Attendees included Dr. Robert White,
assistant professor and director of endodontics programs and advanced graduate training in endodontics at HSDM; and
Dr. Lawrence Rubin and Dr. Shepard Goldstein, both lecturers on restorative dentistry and biomaterials sciences at HSDM.
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid e.seid@dental-tribune.com
Dr. Marilyn
Steinert Lyons,
from left, and
Dr. Jeffrey
Linden were
among those
celebrating
Dr. Alvin Krakow
last fall at the
Harvard
School of
Dental
Medicine.
Photo/Dr. John
(Source: Harvard Dental Bulletin)
AD
ENDO TRIBUNE
Schoeffel
Group Editor
Robin Goodman r.goodman@dental-tribune.com
Editor in Chief ENDO Tribune
Frederic Barnett, DMD BarnettF@einstein.edu
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Published by Dental Tribune America
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All rights reserved.
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Editorial Board
Frederic Barnett, Editor in Chief
Dr. Roman Borczyk
Dr. L. Stephen Buchanan
Dr. Gary B. Carr
Prof. Dr. Arnaldo Castellucci
Dr. Joseph S. Dovgan
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Dr. Vladimir Gorokhovsky
Dr. Fabio G.M. Gorni
Dr. James L. Gutmann
Dr. William “Ben” Johnson
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Dr. John Nusstein
Dr. Ove A. Peters
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John D. West
Tell us what you think!
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[3] =>
[4] =>
B4
IRRIGATION
“ IRRIGATION, Page 1
ing the canal walls. EDTA, a chelating
agent, dissolves the inorganic portion of
the dentin, opening the dentinal tubules.
Alternating between the two irrigants as
the instrumentation is being performed
will permit removal of more organic debris farther into the tubules, increasing
resistance to bacterial penetration once
the canal is obturated.7,8
Studies suggest that regular 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 treatment than
the concentration of the irrigant.10
Positive vs. negative apical pressure
Irrigation as it relates to endodontic
treatment involves placement of an irrigating solution into the canal system and
its evacuation for the tooth. Traditionally,
this involved placement of an end-port
or side-port needle into the canal and expressing 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
potential to cause tissue injury that may
be extensive when encountering the periapical tissue and its communication with
tissue spaces, positive pressure 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) create a current force
and (c) carry the particles away.”
An apical negative pressure irrigation
system, on the other hand, does not create a positive force at the needle’s tip, so
potential accidents can be eliminated. In
an apical negative pressure irrigation system, the irrigation 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 solution 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 leakage. While the teeth irrigated with positive pressure leaked an
overage of 2.41 mL out of 3 mL.”12 A recent
study by Fukumoto found using [apical]
negative pressure less extrusion of irrigant than needle irrigation (positive pressure) when both were placed 2 mm from
working length.13
Fig. 3: Master Delivery Tip filled with irrigation solution and attached to the EndoVac
Multi-Port Adapter via the suction tubing.
Fig. 4: Master Delivery Tip (irrigation-suction) tip on a disposable syringe.
system, permitting thorough irrigation
with high volumes of irrigation solution.
The EndoVac system consists of MultiPort Adapter (MPA) assembly that connects to the high volume evacuation
hose in the dental operatory (Fig. 2). To
this connects the Master Delivery Tip
(irrigation and suction together) with a
disposable syringe filled with irrigation
solution (Figs. 3,4). Either a MacroCannula or MicroCannula is attached and used
simultaneously with the Master Delivery
Tip during treatment. The plastic MacroCannula is placed on a handpiece, which
is attached to tubing that connects to the
MPA via a separate line. This is used for
coarse debris removal. The MicroCannula is a metal suction tip available in
either 21, 25 or 31 mm lengths with 12 micro holes in the terminal 0.7 mm of the
tip, permitting removal of particles that
are 100 microns or smaller to the apical
constricture. This tip fits into a metal
fingerpiece and is connected to the MPA
in the HVE via tubing. The turbulent current forces developed by the MicroCannula rapidly flows to the micro holes at
the terminus, which can reach within 0.2
mm of full working length. Quite simply, the vacuum formed at the tip of the
MicroCannula is able to achieve each of
Chow’s objectives in his irrigation paradigm.
Nielsen and Baumgartner found that
the volume of irrigant delivered with
the EndoVac system was significantly
more than the volume delivered with
needle irrigation over the same amount
of time.14 Further, they reported significantly better debridement 1 mm from
working length for the EndoVac system
compared with needle irrigation.
EndoVac technique
Fig. 5: Master Delivery Tip being used to provide constant irrigation as the canal is instrumented.
EndoVac endodontic irrigation system
Designed by Dr. G. John Schoeffel after
almost a decade of research, the EndoVac
irrigation system (Axis|SybronEndo, Anaheim, Calif.) was developed as a means to
irrigate and remove debris to the apical
constricture without forcing solution out
the apex into the periapical tissue. The
system utilizes apical negative pressure
through the high-volume evacuation
Endo Tribune U.S. Edition | April 2012
Fig. 6: Use of the EndoVac MacroCannula and Master Delivery Tip.
Following removal of the chamber roof
and exposure of the pulp, the Master
Delivery Tip is used to provide frequent
and abundant irrigation as the orifices
are identified and explored. During instrumentation, the Master Delivery Tip is
placed at the coronal to provide fresh irrigation solution and aid in debris removal
that is brought coronally as the rotary file
is used in the canal (Fig. 5). 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 Delivery
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 Delivery Tip and then is drawn
up the MacroCannula (Fig. 6). The MacroCannula 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 rinse
cycles using NaOCL (6 percent) and EDTA
(17 percent).
The EndoVac will work in any canal
configuration shaped at least to a size
35 with a 0.04 taper or greater (Fig. 7). To
prevent plugging of the fine holes in the
apical terminus, do not use the MicroCannula until thorough irrigation has
been accomplished with the MacroCannula and all instrumentation has been
completed.
[5] =>
IRRIGATION
Endo Tribune U.S. Edition | April 2012
Conclusion
B5
Gregori M. Kurtzman,
Instrumentation, disinfection and obturation are important aspects of rendering quality endodontic care. Yet the
instruments we use to prepare the canal,
be they hand or mechanized, 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 system, with its
apical negative pressure, is able to more
thoroughly remove the micro debris at the
apical constricture, thereby providing a
better environment to be filled with sealer.
DDS, MAGD, FACD, FPFA,
FADI, DICOI, DADIA is in
private general practice
in Silver Spring, Md., and
a former assistant clinical
professor at University of
Maryland. He has lectured internationally on
the topics of restorative
dentistry,
endodontics
and implant surgery and
prosthetics,
removable
and fixed prosthetics and
periodontics, and he has
more than 240 published
Please refer to Roots North America Edition, Vol. 2, No. 1, for a longer version of this
article, which includes discussion on the safety of positive vs. negative pressure irrigation.
References
1.
2.
3.
4.
Behrend GD, Cutler CW, Gutmann JL.: An
in-vitro study of smear layer removal and
microbial leakage along root-canal fillings.
Int Endod J. 1996 Mar; 29(2):99–107.
Karagoz-Kucukay I, Bayirli G.: An apical
leakage study in the presence and absence
of the smear layer. Int Endod J. 1994
Mar;27(2):87–93.
Saunders WP, Saunders EM.: Influence of
smear layer on the coronal leakage of Thermafil and laterally condensed gutta-percha root fillings with a glass ionomer sealer. J Endod. 1994 Apr;20(4):155–158.
Gencoglu N, Samani S, Gunday M.: Dentinal
wall adaptation of thermoplasticized gutta-percha in the absence or presence of
smear layer: a scanning electron microscop-
articles. He has earned fellowship in the AGD, AAIP, ACD, ICOI, Pierre
Fauchard, ADI, mastership in the AGD and ICOI and diplomat status
in the ICOI and American Dental Implant Association (ADIA). He has
been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006. He may be contact-
Fig. 7: Use of the MicroCannula of the EndoVac system showing placement of
the tip in the apical root end.
5.
6.
7.
ic study. J Endod. 1993 Nov;19(11): 558–562.
Von Fraunhofer JA, Fagundes DK, McDonald NJ, Dumsha TC.: The effect of root canal preparation on microleakage within
endodontically treated teeth: an in vitro
study. Int Endod J. 2000 Jul;33(4):355–360.
Behrend GD, Cutler CW, Gutmann JL.: An
in-vitro study of smear layer removal and
microbial leakage along root-canal fillings.
Int Endod J 1996 Mar;29(2):99–107.
Clark-Holke D, Drake D, Walton R, Rivera E,
Guthmiller JM.: Bacterial penetration
through canals of endodontically treated
teeth in the presence or absence of the
smear layer. J Dent. 2003 May;31(4):275–281.
8.
9.
10.
ed at drimplants@aol.com.
Vivacqua-Gomes N, Ferraz CC, Gomes BP,
Zaia AA, Teixeira FB, Souza-Filho FJ.: Influence of irrigants on the coronal microleakage of laterally condensed gutta-percha root
fillings. Int Endod J. 2002 Sep;35(9):791–795.
Siqueira JF Jr, Rôças IN, Favieri A, Lima KC.:
Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1%,
2.5%, and 5.25% sodium hypochlorite. J Endod. 2000 Jun;26(6):331–334.
Baker NA, Eleazer PD, Averbach RE, Seltzer
S.: Scanning electron microscopic study of
the efficacy of various irrigating solutions.
J Endod. 1975 Apr;1(4):127–135.
11.
12.
13.
14.
Chow TW.: Mechanical effectiveness of root canal irrigation. J Endod. 1983 Nov;9(11):475–479.
Haas S, Edson D.: Negative apical pressure
with the EndoVac system. Poster presented at American Association of Endodontists 2007 Annual Session, April 25–28;
Philadelphia, PA.
Fukumoto Y, Kikuchi I, Yoshioka T, Kobayashi C, Suda H. An ex vivo evaluation of a new
root canal irrigation technique with intracanal aspiration. Int Endo J 2006;39:93–99.
Nielsen BA, Craig Baumgartner J.: Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007
May;33(5):611–615.
AD
[6] =>
industry
B6
Endo Tribune U.S. Edition | April 2012
Roydent offers new 12.5 C-File Axis Dental
• Twisted to the tip
To negotiate calcified ca• Larger sizes ideal
nals, you need the right file
for high calcification in
at the right size and the right
the coronal third
stiffness. That’s why Roy• Non-cutting tip
dent Dental Products has infollows canal curve
creased its C-File offering to
Roydent C-Files are
encompass a 12.5, a 15 and an
available in 06, 08,
assorted pack (all available in
10, 15 and assorted
21 mm and 25 mm).
packs 6-10 (21 mm
The 12.5 size is available exand 25mm).
clusively from Roydent and
For more informaallows you to make a half step
tion, contact Roydent
between sizes 10 and 15. These
Dental Products, 608
C-Files help you to gain access
to even the trickiest canals.
Roydent has added a new 12.5 C-File to its offerings. Photo/Roydent Dental Products Rolling Hills Drive,
Johnson
City,
TN
Features of the files include
37604,
(800)
992-7767,
www.roydent.com.
the following:
• Extra stiffness is ideal for gaining
• Heat-tempered
access to calcified canals
(Source: Roydent Dental Products)
• Stainless steel for increased stiffness
• Sharp edges
ProPoint: ‘A single-cone,
one-step obturation device’
By Fred Michmershuizen, Managing Editor
In an interview,
Emil Jachmann,
CEO of EasyEndo, discusses
ProPoint
selfsealing endodontic points, which
are an alternative to gutta-percha.
What is the history of Easy-Endo?
Emil Jachmann
Formed six years
ago under the name DRFP Ltd., EasyEndo is a materials research company
established to capitalize on its development of polymer technology to improve
the performance of medical devices.
How long have you been with the company?
I have been chief executive for two years,
and I have considerable experience in
technology commercialization and medical devices.
What is different about the ProPoint and
what advantages does this product offer
to the practitioner?
Uniquely, the Easy-Endo ProPoint endodontic points are self-sealing. The hydrophilic polymer technology that is
incorporated into the ProPoints ensures
the devices expand radially once in the
root canal, thereby forming a positive
seal to reduce the chance of bacteria
re-appearing in the canal. It is a singlecone, one-step obturation device. Due
to its simplicity of use, the points also
allow dental practitioners to complete
predictable root canal procedures more
quickly and with a higher degree of confidence.
Is this product more about new chemistry? Or a different technique?
ProPoints are made from an entirely
ProPoint endodontic points are available from Easy-Endo. Photos/Easy-Endo
new material and probably represent
the first major advancement in materials science for root canal treatment in
well over 100 years. It is not necessary
to adopt any new technique when using ProPoints. Neither are there any
additional equipment costs — dentists
simply use the canal preparation tools
and techniques that they have already
perfected.
Will this product have more appeal for
specialists? Or for GPs?
ProPoints are equally applicable to specialist or GPs who are keen to improve
the performance of their procedures and
to complete obturation more quickly.
What else should clinicians know?
In late 2010, ProPoint received FDA approval, and during 2011 the product
was pilot marketed to dentists in the
Boston area. The American dentists
who have used the ProSmart system
now report that they will never return
to their previous obturation material.
ProPoints are available in a variety of
sizes and tapers. Clinicians will find
that ProPoints are far more precisely
matched to their file system than current products.
Is there anything you would like to add?
In 2011, Easy-Endo won the Medical Design Excellence Award (MDEA) for the
dental equipment, instruments and
supplies category. The MDEA competition, the premier international awards
program for the medical technology
community, recognized the technological innovation, ease-of-use and
end-user benefits the ProPoint offers.
The ProPoint product has been in use in
the UK and EU for several years, where
hundreds of dentists have been treating
thousands of patients with exceptional
success rates. We look forward to entering the US market.
More information about Easy-Endo
ProPoint endodontic points is available at
www.pro-smart.com.
merges with
SybronEndo;
company
‘poised for
growth’
If coming together is a beginning and
working together is success, then Axis
SybronEndo is poised for continued
growth by implementing several key improvements
made possible by the
merger of
Axis Dental and SybronEndo.
“Working together. By Design. Poised
for growth by investing in dentistry,” is
how the recent merger of Axis Dental and
SybronEndo is being described in a recent
press release. According to the relase, Axis
SybronEndo offers the following:
• Instruments designed to work together. Now, Axis SybronEndo offers a
full spectrum of rotary and endodontic
instruments for dentists who demand
exceptional performance from products
designed for the way they practice.
• Increased local support. Axis SybronEndo has doubled its sales force, which
means dentists will experience a higher
level of local support. The company has
also invested in training to provide the
ultimate in technical expertise from a
dedicated sales specialist.
• Customized Solutions. Axis SybronEndo now offers rotary and endodontic
solutions designed to work together to
maximize both procedure efficacy and
efficiency while minimizing inventory.
“Axis Dental and SybronEndo have
always shared a common objective: To
win and keep your business by providing
exceptional products and outstanding
service,” said Axis SybronEndo President
Perry Lowe. “We remain dedicated to this
objective now that we are operating as
one company committed to providing
products designed to work together to
improve clinical outcomes and productivity for our customers.”
Through 2012 and beyond, Axis SybronEndo will continue to help dentists succeed by providing best-in-class local technical support and a portfolio of innovative
products designed to work together.
Axis SybronEndo, a division of Sybron
Dental Specialties, a Danaher company, is
poised for continued growth as a proven
leader in dentistry. With its dedicated
employees and distribution partners, the
company is passionate and focused on
achieving results through strong relationships promoted by a proactive, enthusiastic and responsive approach to business.
Closely aligned with top clinicians and
industry leaders, it’s the company’s intent
to remain the company of choice for dental professionals everywhere.
(Source: Axis SybronEndo)
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