DOI: 10.7860/JCDR/2015/14455.

6804
Original Article

Comparison of Penetration of Irrigant

Dentistry Section
Activated by Traditional Methods with A
Novel Technique
Pavan Kumar Kanumuru1, Sujatha Gopal Sooraparaju2, Karthik Roy Konda3,
Surya Kumari Nujella4, Bala Kasi Reddy5, Siva Ram Penigalapati6

ABSTRACT - Sonic activation with Endo activator, Group III Ultrasonic

Introduction: The effectiveness of irrigation depends upon activation with ultrasonic tips and Group IV - Activation using
various irrigation activation methods & devices used. reciprocation movement. All the samples were examined under
a stereomicroscope and irrigant penetration was evaluated by
Aim: To compare and evaluate the penetration of irrigant upto
means of penetration of ICS.
working length and into simulated lateral canals using four
different irrigation activation techniques. Results: Group III and Group IV resulted in better penetration
of ICS into lateral canals at 2mm and 4mm depth (p<0.001),
Materials and Methods: The root canals of 60 single-rooted
when compared with Group I and II. At lateral canals 6mm all
teeth were instrumented using the proTaper rotary system.
the groups except Group I, had shown 100 % penetration.
After decalcification of each sample tooth, three simulated
lateral canals were created at 2mm, 4mm and 6mm levels Conclusion: The activation of irrigant using reciprocation was
from the root apex using a 06-size C+ le. After clearing the able to achieve penetration of irrigating contrast solution both
samples they were randomly assigned into four experimental up to the working length and into lateral canals. Hence the
groups (n=15) and 1ml of Irrigating Contrast Solution (ICS) was clinical significance of this method of irrigant activation is that
delivered into all samples and then it is activated with 4 different it can be used for effective penetration of irrigants both upto
methods Group I-Conventional syringe and needle, Group II working length and into lateral canals.

Keywords: Irrigating contrast solution, Reciprocation, Simulated

lateral canals, Sonicactivation, Ultrasonic activation

Introduction the comparison of penetration of irrigant activated by traditional

Thorough disinfection of the root canal system is considered a key methods with the activation by using reciprocating movement.
requirement for successful root canal treatment. Traditionally it is
accomplished by a combination of instrumentation and irrigation MATERIALs AND METHODS
[1]. Thus the outcome of endodontic treatment depends upon The present study was conducted in MNR Dental College and
mechanical instrumentation and effectiveness of irrigating solutions Hospital Sanga reddy in the year 2015. Sixty human single-
[2]. Microorganisms remain in the root canal despite of cleaning rooted maxillary teeth with straight root canals were selected.
and shaping procedures. This is because of complexities in root Teeth were kept in 4% NaOCl (sodium Hypochlorite) for 2 hours,
canal morphology consisting of isthmuses, lateral canals, fins, and any visible calculus removed ultrasonically. The teeth were
and deltas which harbour bacteria, debris and necrotic tissue [2]. radiographed in both buccolingual and mesiodistal direction to
Regardless of the instrumentation technique, 35% or more of the verify the presence of single canal. They were decoronated at the
root canal surfaces remains uninstrumented [3]. Hence the ability of cemento enamel junction and examined under dental operating
the irrigant to penetrate into areas not instrumented by mechanical microscope to confirm the presence of single canal. The patency
instrumentation is critical for debridement and disinfection of the of the root canals was obtained using a size 10 K-le (Maillefer,
root canal system. There is a clear correlation between lateral Ballaigues, Switzerland). The root canals were instrumented using
canals obturation and healing of periapical lesions [4]. However, the ProTaper rotary system in the sequence of Sx, S1, S2, F1, F2,
in order to ll lateral canals, these should be thoroughly cleaned and F3. After each file 1.5ml of 5.25% NaOCl was delivered using
[5]. Therefore mechanical instrumentation along with chemical a 27-gauge side port Monojet needle for 30 seconds.
disinfection will result in better canal cleanliness [6]. After the instrumentation, teeth were subjected to modied
Currently, a variety of irrigation techniques and devices like clearing protocol described by Venturi et al., [12]. Teeth were
ultrasonic, endovac are being used to improve the disinfection of submerged in 5% nitric acid for 36 hours, for decalcification, with
root canal system. However, the conventional endodontic irrigation the solution being replenished every 8 hours. After completeness
syringe and needle is the most widely used delivery system. Chow of decalcification the teeth were cleaned under tap water for 3
showed that the efficacy of apical irrigation is directly related to the minutes, to remove any traces of acid, if presented. Lateral canals
depth of insertion of the needle, which in some cases presents a were then created inserting 06C+files at 2mm, 4mm and 6mm
challenge to the clinician [7]. Ultrasonic and Sonic devices effectively from apex the buccal and lingual walls perpendicularly to the
deliver irrigants to the apical third [8-10]. Sonic activation produces external surface. Samples were then dehydrated by subjecting to
mechanical oscillation, mainly at the tip of the le, with frequency 60% ethyl alcohol for 12 hours followed by 80% for 1 hour and
ranging from 1 to 6 KHz, whereas Ultrasonic activation produces 96.6% for 1 hour. Finally they were cleared and stored in 99.9%
transverse vibrations with high frequencies but low amplitude [11]. methyl salicylate [Table/Fig-1]. Thus a total of 360 simulated lateral
However, the safety of these methods has yet to be evaluated. canals were created, with two lateral canals at each depth i.e. at
Hence in the present study a novel method of activation of irrigant 2, 4 and 6 mm in every sample. Then they were mounted in rubber
using reciprocating motion was done. The present study aimed at based impression material to mimic the presence of surrounding

44 Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): ZC44-ZC47

www.jcdr.net Pavan Kumar Kanumuru et al., Efficacy of Various Irrigant Activation Devices

hydrodynamic activation of the irrigant and reduces the chance of

apical extrusion[14].
Group II: Sonic activation group: After the ICS was delivered
by positive pressure irrigation at 2 mm from the working length,
activation was done using Endoactivator [] set at 10,000 cycles
per minute with a 25/.04 tip inserted 2 mm short of working length
for 30 sec.
Group III: Ultrasonic activation group: Ultrasonic activation was
performed using a stainless steel, noncutting, and ultrasonic Irri
Safe size 20 le mounted on a Suprasson Newtron XS ultrasonic
[Table/Fig-1]: Specimens of cleared tooth: a) Direct observation; b) Observation
under stereomicroscope at 30X magnification unit []. After the delivery of ICS into the canal the le was inserted
passively 2 mm short of the working length and was activated for
a period of 30 seconds using a power setting of ve.
Group IV: Irrigant activation with Reciprocating motion: In this
method after ICS was delivered into the canal, 25/.02 RACE file
was used with ES-100 endomotor in reciprocation motion (back
and forth movement) till the working length for 30 seconds. This
novel reciprocating motion uses a large counter clockwise rotation
and a smaller clockwise rotation that resembles a safe reverse
balance force manual motion. During reciprocation movement
file gradually follows the canal and simultaneously carries the
irrigant into continuously tapering funnel shaped canal.
[] DentsplyMaillefer
[] Satelec Aceton Group

Evaluation criteria
All the specimens were observed under stereomicroscope at 30X
magnification with eye piece lense 10X and objective lense 3X and
feild size of 6.57 mm for evaluation of irrigant penetration [Table/
Fig-2]. Samples were scored on the basis of penetration of ICS up
to the working length and into simulated lateral canals [6] [Table/
Fig-3].

[Table/Fig-2]: Stereomicroscopic pictures of samples: Group I (Conventional Scoring criteria Working length Lateral canals
syringe activation); Group II (Sonic activation); Group III (Ultrasonic); and Group IV
Present If penetration till working length If penetration >50%
(Reciprocation)
Absent No penetration If penetration < 50%
periodontal tissues. [Table/Fig-3]: Scoring criteria for evaluation of Irrigant Penatration
The cleared specimens were divided into 4 groups with 15
teeth per group (n=15). Irrigating Contrast Solution (ICS) was Scoring was performed at all the three levels independently. A total
prepared by mixing 40% of Indian ink with 60% of NaOCl of 360 lateral canals per group (90 lateral canals at each level that
(5.25%) in the ratio of 2:3 [13]. This solution enhances the is at 2mm, 4mm and 6 mm from the apex) were assessed. All
visibility of irrigant penetration. One ml of ICS was delivered samples were scored by two trained evaluators who were blinded
into all samples and then activated by four different methods; for group assignment pertaining to each sample.
conventional syringe, sonic, ultrasonic and reciprocation.
The depth of penetration of the contrast solution into the Statistical Analysis
lateral canals and up to the working length was used as a All the analysis was done using SPSS version 18. A p-value of
means to evaluate the penetration of the irrigants. <0.05 was considered statistically significant. Comparison of
Group I: Conventional Syringe irrigation with Manual irrigant penetration among the study groups was done using Chi-
Agitation: In this group samples were irrigated with positive square test [Table/Fig 4].
pressure irrigation using 25 mm, 30 gauge side vented needle,
the syringe being placed 2 mm short of the working length, and 1 Results
ml of ICS was delivered for a period of 30 s by moving the syringe ICS penetration upto working length and into lateral canals at
up and down in the canal. This method of activation creates the 2mm, 4mm and 6mm depth when activated by different methods
Group p-value
I II III IV
N % N % N % N %
Working Length Absent 6 40.0% 0 .0% 0 .0% 0 .0% 0.004; Sig
Present 9 60.0% 15 100.0% 15 100.0% 15 100.0%
6mm Absent 14 46.6% 0 .0% 0 .0% 0 .0% <0.001; Sig
Present 16 53.3% 30 100.0% 30 100.0% 30 100.0%
4mm Absent 22 73.3% 12 40.0% 0 .0% 3 10.0% <0.001; Sig
Present 8 26.6% 18 60.0% 30 100.0% 27 90.0%
2mm Absent 30 100.0% 16 53.3% 0 .0% 6 20.0% <0.001; Sig
Present 0 .0% 14 46.6% 30 100.0% 24 80.0%
[Table/Fig-4]: Satistical evaluation of groups for irrigant penetration. p-value of < 0.05 was considered as statistically significant

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 Pavan Kumar Kanumuru et al., Efficacy of Various Irrigant Activation Devices www.jcdr.net

(Group I conventional, Group II sonic, Group III ultrasonic and This method will cause hydrodynamic activation of irrigant and
Group IV reciprocation) were evaluated. A p-value of < 0.05 was allows the irrigant to reflux, prevents the extrusion of the irrigant
considered as statistically significant. into periapical tissue and displaces the debris coronally [22]. The
There was significant penetration of ICS till the working length in results in the study showed that there was no penetration of ICS
all the groups except in the Group I (Conventional) which showed into lateral canals particularly at the apical third. This might be
penetration only in the 60% of the samples. In lateral canals at related to the presence of gases in the apical region forming a
6mm the Groups II, III and IV have shown penetration of ICS in vapour lock into which further uid penetration is difficult [23].
all the samples whereas in Group I (Conventional) penetration of In group II the sonic activation of the irrigant has been used. The
ICS was seen only in 53.3 % of sample size. In lateral canals at results show that sonic activation is superior to needle irrigation
4mm Group III ultrasonic activation had shown penetration of ICS but inferior to ultrasonic activation. These results are also in
in 100 % of canals followed by Group IV reciprocation in 90% accordance with reports of other studies by Castelo-Baz et al.,
of canals, Group II sonic activation in 60% of canals and Group Spoorthy et al., de Gregorio [13,19,24].
I only in 26.6% of the canals. In lateral canals at 2mm Group III Passive Ultrasonic Irrigation was first described by Weller et al.,
ultrasonic activation had shown penetration of ICS in 100 % of However the term passive is a misnomer as it was named after
canals followed by Group IV reciprocation (80%), Group II sonic noncutting action of the ultrasonically activated le, but as it is in
(46.6%) and Group I (0%) [Table/Fig 5]. fact active. PUI transmits acoustic energy from an oscillating le
to irrigant in the root canal. In group III Ultrasonic activation was
done. In this technique, the ultrasonic tip is placed in the centre
of canal without any intention to instrument, plane or contact the
canal walls with the le. Results showed that ICS penetrated into
all the lateral canals. The efficacy of PUI for irrigant penetration
into the lateral canals may be due to the le oscillation that has
the potential to create acoustic streaming and cavitation effects,
which allows the irrigant to ow into the irregularities accessing
untouched areas [10]. The effectiveness of the PUI system achieved
in this study is in accordance with the studies by Bronnec et al.,
2010, de Gregorio, Jensen et al., [1,24,25].
[Table/Fig-5]: Graph showing the penetration of ICS up to working length and into
In group IV, a novel method of irrigant activation by reciprocation
lateral canal at 2mm,4mm and 6mm depth, when activated by different methods
movement was used. Results obtained in the study showed its
efficacy is inferior to ultrasonic activation but superior to sonic
DISCUSSION activation. This method had shown the penetration of ICS into
Effectiveness of irrigation is ensured only when irrigant comes in lateral canals present even in the apical third. This was because
contact with entire root canal system. Several delivery systems of the churning effect of reciprocating movement which carried
and new agitation devices developed for better distribution of the ICS to the working length and into lateral canals. The RACE
irrigant throughout canal system which results in improved canal (Reamer with Alternating Cutting Edges), system which was used
cleanliness. Hence it is benecial to agitate the irrigant after passive in reciprocation has a combination of a triangular section with
irrigation, regardless of level of needle insertion, volume of solution alternating cutting edges ensures more space for the irrigant, which
used or apical taper of the preparation [11]. allows the adequate swirling of irrigant and efficient penetration. As
The classic laboratory techniques for the evaluation of root anatomy the non cutting tip was used, it ensured sure guidance/centering
and irrigant distribution include clearing of teeth and injection of an of the file in the canal and can be safely used at the apex even
opaque material (India ink or dyes). Currently, this is the accepted for 30 sec. As 2% taper file was used it was loosely fitting and
method by which three-dimensional irrigant penetration can be did not cause any apical transportation. The results of this study
assessed in an extracted tooth [15-18]. Viscosity and surface show that activating irrigant with file remaining essentially loose
tension play a role in the penetration of the irrigants within the inside the main body of the canal, after shaping systematically
root canals. The viscosity and surface tension of ICS is almost brought solution to the apical end of the canal. It is hypothesized
similar to that of NaOCl [19]. Hence in the present study, irrigant that the tapered preparation probably gave reux space allowing
penetration was assessed by clearing the tooth and observing the the irrigating solution to ow up and down along the file, with the
extent of penetration of ICS up to working length and into lateral solution being displaced outward when the file is inserted at length
canals. However, in the previous study for assessment irrigant and owing inward when it is removed. In previous studies irrigant
penetration by de Gregorio et al., a sample size of 20 cleared teeth penetration using different activation devices such as ultrasonics
(n=20) per group were evaluated and study by Spoorthy et al., and endoactivator were compared. But till date no study has
sample size of 16 teeth (n=16) per group were evaluated. But in evaluated the irrigant penetration using reciprocation motion for
the present study sample size of 15 teeth (n=15) per group were irrigant activation.
evaluated. This is because the sample size was selected based Though the ultrasonic activation had shown the best results during
on the results of pilot study which have shown a highly statistical the activation unintentional contact of the ultrasonic tip to canal
significant difference between the groups. wall may occur due to the dimensions and complex geometry of
When using side vented syringe, irrigant penetration was limited the root canal system [26]. Apart from damping of the le motion
only 1 to1.5 mm apical to the needle tip for all ow rates tested and reduction of the cleaning efficacy [27,28], such contact
[20]. Hence, when using side vented syringe, the needle should be could also lead to uncontrolled removal of dentin [29]. However,
placed within 1mm from working length to ensure fluid exchange. to date, the le-to-wall contact during ultrasonic activation or its
This recommendation, although physically correct, is biologically effect on le oscillation has not been fully evaluated. Since the
unsafe because intracanal pressure produced by small-diameter efficacy of irrigant agitation is inversely proportional to the extent
needles can reach up to 400550 KPa which can contribute to the of wall contact of an irrigant delivery or agitation device it is difficult
possibility of extrusion of irrigant into periradicular tissues [20,21]. to standardize the positioning of the ultrasonically activated
In group - I (conventional), irrigant activation was done using 29 instrument in the centre of the root canal and to standardize the
gauge side vented needle by moving up and down in the canal. displacement amplitude as a small constraint in the canal. This will

46 Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): ZC44-ZC47

www.jcdr.net Pavan Kumar Kanumuru et al., Efficacy of Various Irrigant Activation Devices

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PARTICULARS OF CONTRIBUTORS:
1. Professor, Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana, India.
2. Professor and HOD, Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana, India.
3. Postgraduate Student, Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana, India.
4. Reader, Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana, India.
5. Senior Lecturer, Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana, India.
6. Senior Lecturer, Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Karthik Roy Konda,
MNR Dental College, Sangareddy, Medak District, Telangana-522094, India. Date of Submission: Apr 13, 2015
E-mail: [email protected] Date of Peer Review: Jun 09, 2015
Date of Acceptance: Sep 14, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Nov 01, 2015

Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): ZC44-ZC47 47