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Volume 5, Issue 2

Journal home page:

http://www.journalijiar.com

RESEARCH ARTICLE
Comparative evaluation of the efficacy of EndoActivator, ProUltra and Canal brush with conventional needle
irrigation without chemically active adjunct in removing calcium hydroxide from root canals: a scanning
electron microscopic study.

Malik Sartaj1, Riyaz Farooq2, Aamir Rashid3 Ankush Sangra4 and Fayaz Ahmad5.
1. Post Graduate scholar, Department of conservative dentistry and endodontics.
2. Professor/Principal Dean, Govt Dental College Srinagar.
3. Associate Professor, Department of conservative dentistry and endodontics.
4. Post Graduate scholar, Department of conservative dentistry and endodontics.
5. Assistant Professor, Department of conservative dentistry and endodontics.

*Corresponding Author
Malik Sartaj
………………………………………………………………………………………………………
Abstract:
Calcium hydroxide, the most commonly used intracanal medicament, should be completely removed from
root canal walls before obturation, otherwise it may hinder the penetration of root canal sealers and affect the proper
fluid tight seal. Canal shape and method of application had an impact on the residual calcium hydroxide remaining.
Application with a lentulo spiral has been found to be more homogenous and deeper in tubules than injection of
Ca(OH)2 paste. Different techniques have been introduced to improve removing of calcium hydroxide from root
canal system. But till date none of the techniques was able to completely remove calcium hydroxide. The aim of this
study was to compare the cleaning efficacy of EndoActivator, Canal brush and ProUltra in removing calcium
hydroxide from root canal walls.

Key Words: Calcium hydroxide, irrigation, EndoActivator, ProUltra, intracanal medicament, canal brush.
………………………………………………………………………………………………………
Introduction
Calcium hydroxide remains the medication of choice for root canals treated in more than one visit. It inhibits
the growth of bacteria between appointments.it is routinely recommended as intra canal medicament for teeth with
periapical lesions. It needs to be filled homogeneously and densely into the whole length of canal to achieve
maximal benefits.1Among the several placement methods lentulospiral is the most efficient and commonly use
placement method.2,3 All inter appointment dressing placed inside the canal needs to be removed before obturating
with gutta-percha because the residual Ca(OH) 2 may interact with the root canal sealer and interfere with its sealing
ability and increase microleakage. Various methods and/or irrigation substances have been proposed for removal of
CH dressing. Studies have showed that irrigation with sodium hypochlorite alone is not efficient to remove
CHmedication.4Among the several irrigation protocols studied, the best removal of CH is achieved by
instrumentation and EDTA followed by NaOCl. 5 The elimination may be carried out by mechanical and chemical
means simultaneously. So the most frequently described method for removal of Ca(OH)2 from the root canal is
instrumentation of the root canal with the master apical file in combination with copious irrigation of sodium
hypochlorite (NaOCl) and EDTA .6,7 However, it has been reported that removal of Ca(OH)2 from the apical root
canal wall, when this method is used, is difficult. When Ca(OH)2 is removed from the main canal with a file,
remnants will remain in canal extensions or irregularities. Further Ni-Ti instruments and NaOCl with passive
ultrasonic irrigation have been found to remove Ca(OH) more effectively from the root canal. 6,8Ultrasonic and sonic
activation of irrigants have been found to be very beneficial during irrigation. 9,10The Canal Brush (Roeko Canal
Brush™, Coltène/Whaledent,Germany) is an endodontic microbrush recently introduced. This highly flexible
microbrush is molded entirely from polypropylene and can be used manually with a rotary action. However, the

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brush was more efficient when operated at 600rpm in a contra-angle handpiece. 8Therefore, the present study was
designed to evaluate the effectiveness of Sonic, Ultrasonic and Canal Brush technique in removing Ca(OH) from the
root canal system by using the scanning electron microscope (SEM).

Materials and methods:-

Ninety freshly extracted human single-rooted teeth were used in this study. Following extraction the teeth
were stored for two days at room temperature in 3% NaOCl to remove organic debris. Subsequently they were
scaled with ultrasonic, washed with distilled water for the removal of any calculus or soft tissue debris and then
immersed in 10% formalin solution until use. The crowns of the teeth were removed 14mm from the apex to
standardize their length. A size 10K-file was placed in the canals until it was visible at the apical foramen. The
working lengths were determined by subtracting1mm from this measurement. Canal preparation was performed
using an electric engine (X-Smart, Dentsply Maillefer) with constant speed of 250 rpm and rotational force of
1.6N.cm, at the working length. All roots were prepared using ProTaper rotary system (Dentsply, Maillefer,
Switzerland) to a # F4 (#40, 6% apical third taper) instrument as the MAF. Teeth were irrigated with 5mL 2.5%
NaOCl and 5mL 17% EDTA for1minute for final flush to remove smear layer. After completing the
instrumentation, thecanals were dried with paper points. Eighty teeth were filled with calcium hydroxide paste
(Metapaste, Metadent Co., Chongju, Korea) by using a lentulo spiral (Dentsply Maillefer), according to the
manufacturer’s instructions. Five teeth were left as positive and five as negative controls. The coronal 3 mm of all
the canals were sealed with Cavit. All specimens were kept in a closed box, with the roots placed in moist
environment for 7 days at room temperature. After this period, the coronal access was opened and the canal was
irrigated with 5 mL of2.5% NaOCl solution. The teeth were randomly assigned into four experimental groups (n
=20). According to the rotary instrument and final irrigating solution used for removal of CH residues: G-1;
EndoActivator, G-2; ProUltra, G-3; Canal brush and G-4; Needle irrigation only. In all irrigation is done with 2.5%
NaOCl. The solutions were aspirated with a green Navi tip point (Ultradent), and dried with absorbent paper points.
The remaining teeth served as positive (n =5) and negative (n =5) controls. Teeth were split along their long axis in a
buccolingual direction using a surgical chisel. For SEM analysis, the specimens were dehydrated, fixed on
aluminum stubs, sputter-coated with gold, and examined with a scanning electron microscope at 10 kV
(JEOL,Tokyo, Japan) at 100X magnification. Three previously calibrated examiners evaluated the cleanliness of
root canal walls, by assigning each specimen with a score. The scoring procedure was performed by 2 calibrated and
blinded evaluators who were trained in the evaluation procedure using the following 5-grade scale. 11
Score 1: 80%–100% removal of Ca(OH)2 (total cleanliness)
Score 2: 60%–80% removal of Ca(OH)2 (great cleanliness)
Score 3: 40%–60% removal of Ca(OH)2 (partial cleanliness)
Score 4: 20%–40% removal of Ca(OH)2 (light cleanliness)
Score 5: 0%–20% removal of Ca(OH)2 (no cleanliness)

Figure 1.Scanning electron microscopic images representative of scores attribution.

Statistical Analysis
Statistical analysis was performed by Statistical Package for Social Sciences (SPSS) 11.5 software (SPSS Inc.,
Chicago, IL, United States). Data were expressed as mean and standard deviations. The differences between
techniques were evaluated by Mann-Whitney U test. The level of significance was set at P< 0.001.

Results
The results of the study are shown in Table 1. Remnants of medicament were found in all experimental teeth
and none of the groups showed complete removal of Ca(OH) 2 dressing. The positive control teeth showed complete
coverage of their canal walls with Ca(OH)2 as opposed to negative controls with total cleanliness. Each device was
compared with the conventional irrigation needle group. However, a statistically significant difference between the
groups can be shown (P < .001) using the analysis of variance test. Group 1; EndoActivator was found to be
statistically significant cleaner from all other groups, both at apical as well as coronal level. There was no significant
difference Pro Ultra and Canal brush in the removal of calcium hydroxide from root canal in cervical (P=0.67) and

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apical(P=0.51) part of canal. Group 4; needle irrigation shows higher scores of calcium removal than any other
group.
Table 1: Mean score of dentine debris or Ca(OH)2 removal from root canal by different methods.
Group n Apical area Coronal area
Mean SD Mean SD
Endoactivator (G-1) 20 0.6 0.09 0.2 0.01
Pro ultra(G-2) 20 2.01 0.32 1.7 0.1
Canal brush(G-3) 20 2.30 0.2 1.4 0.08
Neddle irrigation(G-4) 20 3 0.02 3 0.6

3.5

2.5

Series 1
1.5
Series 2
1

0.5

0
Category 1 Category 2 Category 3 Category 4
Figure 2.Bar graph showing distribution of scores for devices in coronal (series 2) and apical third (series 1)

Discussion
Residual Ca(OH) 2 influences the setting mechanism of various types of root canal sealers and therefore
should be removed before obturation of root canals. Calcium hydroxide pastes are not easily removed from root
canal walls. The aim requires new devices with high effectiveness and easy handling for clinical application. Many
factors can influence removing calcium hydroxide from root canal wall like master apical file, size of needle for
irrigation delivery, length of time devoted to irrigation and system that is used for canal irrigation. 12, 13The procedure
used in this study for the removal of the intra canal medicament is the standard protocol employed widely in clinical
practice. In the present scanning electron microscopic study, the main goal was to evaluate the effectiveness of
conventional needle irrigation in comparison with the EndoActivator, ProUltra Piezo Flow systems and Canal brush
in combination with 0.5% NaOCl and 18% EDTA in removing calcium hydroxide from root canal walls. Many
methods have been used for evaluation of residual debris or calcium hydroxide on canal walls like scoring method,
scanning electron microscopy , volumetric analysis by spiral CT and longitudinal sectioning and steromicroscopy,
photo graphic imaging and blind examination by observers. 6,14 We choose the scanning electron microscope for
evaluating the cleanliness of root canal walls surfaces because many investigators showed that the use of the
scanning electron microscope is a reliable method in examining and evaluating the removal of Ca(OH) 2 from the
root canal walls when using different instrumentation and irrigation systems. 15,16,17 Sonic and ultrasonic irrigation
were reported to improve removal of the smear layer in the apical third of curved root canals compared with
conventional irrigation.17Moreover, EDTA has been considered more effective than NaOCl in the removal of
inorganic substances such as the smear layer and Ca(OH) 2.15Canal brush has been introduced as a new device to

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assistant in irrigation and removal of smear layer from root canal walls. In our study, the Canal Brush was used with
a contra-angle hand piece running at 600rpm. The results indicate that EndoActivator with NaOCl as irrigant was
more effective in removal of Ca(OH)2 paste from root canal walls in the coronal as well as apical areas than
ProUltra ultrasonic activation ,canal brush or by means of needle delivery of NaOCl. The efficiency in eliminating
Ca(OH)2 from root canals by the EndoActivatorin combination with irrigation may be caused by its primary
function, which has been reported to produce vigorous intra canal fluid agitation through acoustic streaming and
cavitations.17,18The results of Ultrasonic activation of ProUltra with hypochlorite were better than the results of
irrigation by means of syringe delivery of NaOCl indicating that the extra capacity to remove matter from the root
canal of ultrasonic activation with NaOCl as irrigant. The use of passive ultrasonic irrigation is based on the
transmission of energy from an ultrasonically oscillating instrument to the irrigant in the root canal. In this
experiment, the use of PiezoFlow created relatively cleaner root canal walls in the coronal and middle thirds than in
the apical one compared with conventional needle irrigation. Sodium hypochlorite as irrigant is more effective in
removing dentine debris from the root canal during passive ultrasonic activation. 19, 20This is in agreement with results
of the previous studies done by Balvedi RP, Sami Alturaiki et al and Maalouf L et al. 13, 17, 21Observations of our study
are opposite to those of van der Sluis et al.19In our study, EndoActivator in combination with irrigant removed more
Ca(OH)2 medication than the Pro Ultra and Canal Brush system.

Conclusion
None of the techniques used in this study removed the inter-appointment root canal medicaments effectively.
However, the EndoActivator shows better results in removing Ca(OH) 2 than other experimental techniques. Further
studies should be undertaken with other techniques of root canal preparation and irrigating solutions to evaluate the
removal of intra canal dressing from the root canal walls.

References
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14. Lambrianidis T, Margelos J, Beltes P. Removal efficiency of calcium hydroxide dressing from the root canal. J
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