EndoActivator from Tulsa Dental

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1 EndoActivator from Tulsa Dental

2 Irrigation-EndoActivator EndoActivator System did not enhance the removal of smear layer as compared with conventional Max-I-Probe irrigation with NaOCl and EDTA. Uroz-Torres et al JOE Feb 2010 no statistically significant difference in canal or isthmus cleanliness among groups 1 F file for 30 seconds, group 2 EndoActivator for 30 seconds, group 3 ultrasonic irrigation for 30 seconds, and group 4 irrigation with 6% NaOCl within 1 mm of WL. Klyn et al JOE Aug 2010 Thirty seconds of NaOCl subsonic agitation with EndoActivator slightly more effective in reducing bacterial load in the root canal compared with NaOCl irrigation alone. Pasqualini et al, JOE Aug 2010 no significant difference in the ability of sonic group and control group to eliminate cultivable bacteria from root canals. Huffaker et al JOE Aug 2010

3 EndoVac form Discus Dental apical negative pressure irrigation Macro cannula ISO size #55/.02 Micro cannula ISO size #32/.02

4 EndoVac cont. negative apical pressure irrigation device can result in a significant reduction of postoperative pain levels in comparison to conventional needle irrigation. Gondim et al JOE Aug 2010 sodium hypochlorite irrigation with the EndoVac system can be considered as a promising disinfection protocol in immature teeth with apical periodontitis, suggesting that the use of intracanal antibiotics might not be necessary. da Silva et al JOE May 2010 apical enlargement to ISO #40 with a 0.04 taper will allow for tooth structure preservation and maximum volume of irrigation at the apical third. Brunson et al JOE Apr 2010 significantly less extrusion risk using the EndoVac system compared with needle irrigation Mitchell et al JOE Feb 2010

5 Passive Ultrasonic Irrigation Acoustic Streaming is the rapid movement of fluid in a circular or vortex-like motion around a vibrating file Shear flow caused by acoustic microstreaming produces shear stresses along the root canal wall, which can remove debris and bacteria from the wall Cavitation can be defined as the creation of new bubbles or the expansion, contraction and/or distortion of preexisting bubbles producing a focus of energy leading to intense sound and damage

6 PUI PUI is more effective than syringe irrigation in removing remnants of pulp tissue and dentine debris significant increase in dissolving capacity of organic material by NaOCl, when agitated by ultrasound or when the temperature rises because of ultrasound. Moorer & Wesselink 1982 Cunningham& Balekjian 1980, Cameron 1988, Ahmad 1990 significant reduction of bacteria or shows significantly better results than syringe irrigation Martin 1976, Collinson & Zakariasen 1986, Ahmad1989, Sjogren & Sundqvist 1987, Huque et al. 1998, Spoleti et al. 2003, Weber et al min use of the ultrasonic needle after hand/rotary instrumentation resulted in significantly cleaner canals and isthmuses in the mesial roots of mandibular molars. Gutarts et al JOE 2005 addition of ultrasonic irrigation was 7 times more likely to yield a negative culture. Carver et al JOE 2007

7 After cleaning and shaping a small file or ultrasonic tip loose in canal activated for 30 secs- 60secs PUI

8 Rinsendo from AirTechniques RinsEndo -hydro-dynamic rinsing of root canals by delivering an active ingredient in a pulsating manner (.65ml at 1.6Hz)

9 Rinsendo cont. Hydrodynamic rinsing demonstrated an improvement over conventional methods in terms of dentine penetration of a dye marker. A higher risk of apical extrusion with the RinsEndo-system was evident. Hauser et al IEJ 2007

10 Vibringe Passive ultrasonic irrigation is more effective than the Vibringe System or syringe irrigation in removing debris. The Vibringe demonstrated significantly better results than syringe irrigation in the apical root canal third. Rodig et al JOE 2010

11 Comparisons Conventional irrigation vs final irrigant activation by the EndoActivator vs EndoVac =There was no evident antibacterial superiority of any of the irrigation techniques evaluated in the present in vitro model. Brito PR et al JOE Oct 2009 In the penetration of an endodontic irrigant into dentinal tubules: control = K-file = gutta-percha < EndoActivator = Plastic Endo < PUI. Ultrasonic agitation of final rinse justified. Paragliola et al JOE 2010 Manual, Ultrasonic, and Rinsendo groups had significantly greater amount of extrusion compared with EndoVac and EndoActivator. Ultrasonic irrigation is more effective than syringe irrigation or RinsEndo in removing debris from artificial extensions in straight root canals. Rodig et al IEJ Jul 2010 final rinse with gutta-percha agitation and the EndoActivator group final rinse showed significantly better smear layer removal in the apical third then manual irrigation or Rinsendo. Caron et al JOE Aug 2010

12 Comparisons cont. No difference in canal or isthmus cleanliness among, group 1 F file for 30 seconds, group 2 EndoActivator for 30 seconds, group 3 ultrasonic irrigation for 30 seconds, and group 4 irrigation with 6% NaOCl within 1 mm of WL. Klyn et al JOE Aug 2010 The EndoVac irrigation system demonstrated limited activation of the irrigant into lateral canals but reached the working length more. In contrast, PUI group demonstrated significantly more penetration of irrigant into lateral canals but not up to the working length. de Gregorio et al, JOE Jul 2010

13 Conclusions Activation good Sonic better than irrigation alone but EndoVac gets more irrigant to apex PUI gets more into lateral canals and isthmus Some combination of PUI and EndoVac probably the ideal.

14 Obturation MTA based sealer Great biologic response as pulp capping agent and root end filling material Now as a sealer

15

16 MTA Tricalcium silicate Bismuth oxide Dicalcium silicate Tricalcium aluminate Tetracalcium aluminoferite Calcium sulfate dihydrate Just add water plus 3 hours Crystals of Calcium Oxide Amorphous structure 33% calcium 49% phosphate 2% carbon 3% chloride 6% silica

17 MTA Properties Torabinejad et al 1995 ph of 10.2 to 12.5 (3 hours) Hydrophilic Radioopaque Setting time 2h 45min Compressive strength similar to IRM Solubility similar to IRM Increases the production of both pro and anti-inflammatory cytokines by odontoblasts Koh et la 1997, 1998 Mitchhell et al 1999 Seals similar to super EBA, Amalgam, IRM at root end Sets in the presence of blood

18 Mechanism of action??? Tricalcium oxide + tissue fluids = Calcium hydroxide ph conducive -anti-inflammatory -induces hard tissue formation Odontoblast stimulation pro healing??

19 MTA Histology

20 MTA based sealer The sealing ability of MTAS was similar to that of PCS MTA sealer released calcium ions in solution that encouraged the deposition of calcium phosphate crystals. Camilleri J IEJ Jul 2010 ProRoot (Dentsply) and MTA-Angelus (Angelus) produced similar responses in the pulp when used for pulp capping in intact, caries-free teeth. IEJ Jan 2009 Endo CPM Sealer presented biological potential. Characteristics of the inflammatory reaction were equivalent to those produced by MTA. Scarparo et al JOE Jul 2010

21 But not of that matters Revascularization of necrotic pulp Regeneration of teeth

22 Revascularization

23 6 months

24 18 month

25 24 months later

26 Revascularization Nygaard-Ostby 1950 s and 1960 s Bauchs and Trope 2004 Chueh and Huang 2006

27 Revascularization WE NEED 3 THINGS Disinfection of the canal Matrix or Scaffold to encourage tissue in growth Bacterial tight seal

28 Common Features of Reported Pulpal Revascularization Young patients/immature teeth/open apex No instrumentation Irrigation with NaOCl Triple antibiotic paste Placement of CaOH may prevent revascularization Blood clot scaffold Restoration Follow up

29 Disinfection Sodium Hypochlorite 20ml Triple antibiotic paste described by Hoshino et al ciprofloxacin, metronidazole, and minocycline paste -lentulo spiral to place paste into canal cotton pellet and Cavit However, sodium hypochlorite irrigation with the EndoVac system can be considered as a promising disinfection protocol in immature teeth with apical periodontitis, suggesting that the use of intracanal antibiotics might not be necessary. da Silva et al JOE May 2010

30 Blood Clot Scaffold 2-4 weeks later Cavit and cotton pellet removed Flushed with NaOCl 10ml Poke apex with a file to stimulate bleeding to 3mm below CEJ Wait 15 minutes to confirm clot formation

31 Coronal Seal MTA placed on blood clot 3-4mm thick Wet cotton pellet Cavit Wait at least a day Confirm MTA set and bond a coronal restoration over the MTA.

32 What kind of tissue is it? Intracanal cementum like cellular cementum Intracanal bone Some PDL around the above Wang X et al, JOE Jan 2010

33 Tooth Regeneration Newly established cell lines from mouse oral epithelium regenerate teeth when combined with dental mesenchyme Takahashi C et al In Vitro Cellular and molecular Biology-animal AUG 2010

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