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IRRIGANT DEL IVERY SYSTEMS AND
TECHNIQUES
DR. A. Vimal Kumar
Department of Conservative dentistry and
Endodontics
1
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INTRODUCTION
Removal of vital and necrotic remnants of pulptissues, microorganisms, and microbial toxinsfrom the root canal system is essential forendodontic success (Siqueria JF et at, Wong et al
DCNA 2004).
Although this might be achieved throughchemomechanical debridement it is impossibleto shape and clean the root canal completely(Gurtarts et al , Svec TA, JOE 1997)
Even with the use of rotary instrumentation , the nickel-titanium instruments currently available only act on thecentral body of the canal, leaving canal fins, isthmi, andcul-de-sacs untouched after completion of the
preparation(Haga et al, Gutierrez JH et al OOO 1968). 2
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These areas might harbor tissue debris, microbes, and their by-products (Hess W.
Vertucci FJ et al OOO 1984), which might prevent close adaptation of the obturation
material (Wollard RR, JOE 1976)and result in persistent periradicular inflammation
DEFINITION :
Irrigation is
def ined as washing out a body
cavity or wound with water or
a medicated fl uid (COHEN)
3
Therefore, irrigation is an essential part of root canal
debridement because it allows for cleaning beyond
what might be achieved by root canal
instrumentation alone .
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Objectives
Biologicfunction
Related to antimicrobial effect
Mechanicalobjectives
Flushing out debris
Lubricating the canal
Dissolving organic andinorganic tissue
Bleaching (Basrani et al)
Opening of lateral andaccesory canals
4
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IDEALREQUIREMENTSOFANIRRIGANT(ZEHNDERM. ROOTCANALIRRIGANTS. J ENDOD2006)
Effective germicide and fungicide
Non irritant
Remain stable in solution
Prolonged antimicrobial effect
Be active in presence of blood, serum
Low surface tension
Not interfere with repair of periapical tissues
Not stain tooth structure
Capable of inactivation in a culture medium
5
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Not induce cell mediated immune response
Be able to remove smear layer and to disinfect underlying
dentinal tubules
Non antigenic, non toxic and non carcinogenic
Have no adverse effects on physical properties of exposed
dentin and sealing ability of filling materials
Have convenient application and economical
6
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However, there is no one unique irrigant that can meet all these requirements, even with the
use of methods such as lowering the pH (Cotter JL, Bloomfield et al), increasing the temperature
(Sirtes G, JOE 2005), as well as addition of surfactants to increase the wetting efficacy of the
irrigant (Lui JN JOE 2003).
Thus, in contemporary endodontic practice, dual irrigants such as sodium hypochlorite
(NaOCl) with ethylene diamine tetra acetic acid (EDTA) or chlorhexidine (CHX) are oftenused as initial and final rinses to complement the shortcomings that are associated with the
use of a single irrigant.
More importantly, these irrigants must be brought into direct contact with the entire canal
wall surfaces for effective action (Al-Hadlaq SM JOE 2006), particularly for the apical portions
of small root canals.
This can be achieved by means of a proper irrigant delivery system.7
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Concept of germ theory became significant in latter half of
19 th century
1859- Taft recommended frequent syringing of root canal
1940s American Endodontic Society estsblished
Till early 1980s syringe with needle only
Endobrushin 1980s (Kier et al)
Sonic(Tronstad et al-1985) and Ultrasonic (Richmand 1957
but commercial unit in 1980 by Martin et al)
1993Rotary Niti instruments
Ruddle brush, canal brush (Coltene)2001
Pressure altering devices- Endovac (Schoefffel GJ 2008)
Rinse Endo (Hauser et al2007)
Self adjusting files- (Continuous irrigation)-Z.Metzger- 2010
Lasers
8
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IRRIGATION DEVICES AND TECHNIQUES
MANUAL
Syringe irrigation
with needles/
cannulas
(end/side vent)
Brushes
(Endobrush,
Navitip FX)
Manual Dynamic
Agitation
(hand activated
well fitting gutta
percha
MACHINE ASSISTED
Rotary brushes
(Ruddlebrush,
Canalbrush)
Continuous irrigation
during rotaryinstrumentation
(Quantec-E)
Sonic
(Rispisonic file,
Endoactivator)
Ultrasonic
Pressure
alternating
devices
(EndoVac,
Rinse Endo)
JOE
Volume 35, Number 6, June 2009
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MANUAL AGITATION TECHNIQUES
Syringe Irrigation with Needles/Cannulas
Efficient method of irrigant delivery before the advent ofpassive ultrasonic activation (Van der Sluis LW et al IEJ 2006).
Still widely accepted by both general practitioners and
endodontists.
The technique involves dispensing of an irrigant into a canal
through needles/cannulas of variable gauges, either passivelyor with agitation.
Delivered by distal ends of syringe or by side vented needle
that improves hydrodynamic activation of an irrigant and
reduced apical extrusion(Hauser V, IEJ 2007)
Needle/cannula should remain loose inside the canal during
irrigation.
Advantages :Easy control of the depth of needle penetration within the
canal and
The volume of irrigant that is flushed through the canal . 10
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DISADVANTAGES
Mechanical flushing relatively weak
Thorough canal debridement difficult (Nair PN, Henry S
OOO 2005)
Irrigation solution delivered only 1mm below the tip of
needle
Penetration depth and efficacy of the irrigant is limited
Canal size should at least be enlarged to a size of 40 at
apex (Wu MK, Wesselink PR OOO 1995)
Enlargement with negative consequences of inadvertent
reduction in radicular dentin thickness and subsequent
weakening of root structure (Lertchirakan V, JOE 2003)11
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Plastic syringes for irrigation
Different sizes (1-20 ml)
Luer-Lok design
Modificationsof needles
A) Bevelled
B) MonojectC) Safe ended
(A) (B) (C )
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Modifications of needles
Bending the tip Flexiglide needle
27-31 gauge recommended
should not bind in the canal
easily controlled
not enough flushing action
deliver solution only 1 mm deeper
than the tip of the needle
Oral Surg Oral Med Oral Pathol 1977; 44:30612
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Different Irrigating needles:
MAX-I-PROBE(dentsply, TULSA)
NiTi Superflex : Provides maximumflexibility
14
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BRUSHES
Not used directly used as adjuncts only
Recently Navitip FX (Ultradent)- 30 gauge needle with
brush was introduced
Better debridement than Navitip (Al Hadlaq SM JOE
2006) in coronal
Middle and apical third no significant difference
Endobrush (Keir at al) used in brushing and rotary
motion provided improved debridement
DISADVANTAGES
Frictioncause dislodgement of bristles
Cannot be used to full working length
Can cause apical packing of debris
15
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MANUAL-DYNAMICIRRIGATION
HAND ACTIVATED WELL FITTING GUTTA PERCHA
The use of apically fitting Gutta Percha cones in an up and down motion
at the working length facilitating the penetration of solution in the
canal
Research has shown that gently moving a well-fitting gutta-percha
master cone up and down in short 2- to 3-mm strokes
(manualdynamic irrigation) within an instrumented canal can
produce an effective hydrodynamic effect and significantly improve
the displacement and exchange of any given reagent.(Machtou .P
and Caron .G Paris VII University, Paris, France: Masters thesis;
2007).
Later confirmed by Mc Gill et al and Huang et al. Manual dynamic
agitation better than RinsEndo16
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Principles:
1. changes in intracanal pressure
2. frequency of 3.3Hz, 100 strokes per 30 seconds
3. viscously dominated flow (mixing of fresh
solution with the spent, reacted irrigant)
It removes the effect of vapor lock
17Dent Today 2008;27:82,84,8687
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MACHINE-ASSISTEDAGITATIONSYSTEMS
ROTARY BRUSHES :
Ruddle-rotary hand piece attached micobrush
Consists of shaft and a tapered brush
Commercially- CANAL Brush
(coltene whaledent)
Highly flexible- made of poly propylene
Used attached to a contra angled hand piece at 600
rpm
Weise at al showed that canal brush is effective in
removing debris along with an irrigant
18
Ruddle brush
Canal brush
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SELF ADJUSTING FILE
Primarily introduced as an endodontic file
Also can be considered as an irrigation device, due to its hollow
file configuration
Irrigant delivered through a rotating hub to which a silicone tube
is attached.
Special irrigation unit(VATEA, ReDent, Israel) or any physio
dispenser type unit can be used to deliver a constant flow of
irrigant at 5 ml/min.
This maintains continuous flow of irrigant.
No positive pressure created due to open metal latticeirrigants
escape freely
No risk of irrigant transportation beyond apical foarmen (Metzger
JOE 2009). Efficient in removing debris in coronal, middle apical third.20
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SONICIRRIGATION
Frequency and Oscillating Pattern of Sonic Instrument :
Tronstad et al first introduced1985
Generates significantly higher amplitude and greater back and forth tip movement.
Operates at a lower
frequency (1-6 kHz) Produce smaller shear
stresses
Sonic instruments
differs from ultrasonic
When movement of sonic
file is constrained sidewayoscillation disappears,resulting in purelongitudinal file oscillation
Oscillatingpatterns
21
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ENDOACTIVATOR
Conventionally done by Rispisonic file used
Non uniform taper, barbed tips may damage
prepared canal walls
Endoactivator was introduced to overcome (DentsplyTulsa Dental Specialties, Tulsa, OK)
Consists of a portable hand piece and 3 types of
disposable , safe non cutting polymer tips of
different sizes
Effectively clean debris from lateral canals, remove
smear layer and dislodge chimps of bio film within
curved canals of molars (Caron G 2007)
Mechanism of action:
Hydro dynamic phenomenonvibrating and movingthe tip up and down in short vertical strokes
10,000 cycles per minute optimize debridement
and dislodge smear layer
22
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ADVANTAGES
Disposable tips
Smooth do not cut dentin
Strong , flexible do not breakeasily
DISADVANTAGES
Not as powerful as ultrasonic
Polymer tips radiolucent
Cannot be detected if breaks incanal
23
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Vibringe is a new sonic irrigation system
Battery driven vibrations 9000 cpm with
manually operated irrigation of root canal.
Cordless
Precisely fits in its specially designed disposable
10 ml syringes
Active ingredient is delivered in a pulsatingmanner directly into the root canal via a standard
needle and is activated at a frequency of 150 Hz
Any type of irrigation can be used
Rdiger et al. (2010): debridement by using
vibringe has been found more effective than
conventional syringe irrigations.
24
VIBRINGE (VIBRINGE B.V. AMSTERDAM)
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cavitationAcousticstreaming
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ULTRASONIC IRRIGATION WITH INSTRUMENTATION
Studies on endosonic systems have shown that teethprepared ultrasonically with UI devices have
significantly cleaner canals than teeth prepared by
conventional root canal filing alone(Stamos et al JOE
1987)
Other studies failed to demonstrate superiority of UI
(Ahmed et al JOE 1987).
This may be attributed to the constraint of vibratory
motion and cleaning efficacy of an Ultrasonic file in a
non flared root canal space (Ruddle CJ et al 2002)27
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OTHER DISADVANTAGES
Difficult to control the cutting of dentin, and shape of root canal
Strip perforation and
Highly irregular- shaped canals
Therefore, UI is not generally perceived as an alternative to conventional
hand instrumentation
28
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PASSIVE ULTRASONIC IRRIGATION
WELLER et al(1980) first used the term
Non cutting technology
PUI an irrigation scenario where there was
no instrumentation, planing, or contact of the
canal walls with an endodontic file or
instrument (Jensen SA JOE 1999).
Energy transmitted from an oscillating file or
a smooth wire
Smooth wire induces acoustic streaming and
cavitation of the irrigant (Ahmad M ,JOE 1987)
29
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IRRIGANTAPPLICATIONMETHODSDURINGPUI
30
Two flushing methods during PUI
CONTINUOUS flush ofirrigant from ultrasonic
hand piece
Intermittent flushtechnique by using syringe
delivery
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CONTINUOUSULTRASONICIRRIGATION
Recently, a needle-holding adapter to an ultrasonic
handpiece has been developed by Nusstein
25 gauge irrigation needle used instead of endosonic
file
Irrigant delivered by intravenous tubing connected
via a Leur-Lok to an irrigation delivery syringe
Needle is simultaneously activated by an ultrasonichand piece
Thus irrigant supplied continuously
Produces significantly cleaner canals and isthmi in
both vital and necrotic teeth in 1 minute (Burleson et
al JOE 2007)
Reduces Colony-forming units(CFU) counts in
infected molars (Carver K et al JOE 2007)
Reduced time for ultrasonic irrigation 31
PRO ULTRA PIEZO FLOW Ultrasonic
Irrigation Needle
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Irrigant is delivered to the root canal by a syringe needle.
Then activated with the use of an ultrasonically oscillating
instrument.
The root canal is then flushed with fresh irrigant to remove the
dislodged or dissolved remnants from the canal walls.
32
INTERMITTENT FLUSH ULTRASONIC IRRIGATION
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IRRISAFE (SATELEC)
Designed for the safe removal of the
smear layer, dentin debris and
bacteria from the root canal.
IrriSafe instruments are used during
Passive Ultrasonic Irrigation (PUI)
with NaOCl.
IrriSafe is small, parellel-shaped and
non cutting (bluntended).
33
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Removal of Pulpal Tissues and Dentin Debris
PUI more effective than syringe needle irrigation due
to high velocity and the volume of irrigation (CameronJA, JOE 1987)
Oscillation of the file adjacent to canal irregularities
might also have removed more debris from these hard-
to-reach locations (Lumley PJ et al , JOE 1992).
34
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Removal of Smear Layers
PUI with water did not remove smear layer
(Cameron JA et al , JOE 1983)
PUI with 3% NaOCl complete smear layer
removal (Cameron et al, Alacam and Huque et al)
Smear layer effectively removed from apical,
middle and coronal third when used with NaOCl
and EDTAC (Guerisoli et al)
But Cheung and Stock et alshowed that smear
layer cannot be removed completely in apical
third by PUI with 1% NaOCl for 10 seconds or
with NaOCl and EDTA combinations.
35
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Removal of Bacteria
Significant bacterial reduction is seen (Cunningham
WT et al OOO 1982)
Better than syringe needle
May be attributed to two factors
36
de-agglomeration ofbacterial biofilms via the
action of acoustic
Streaming
Cavitation might have produced
temporary weakening of the cellmembrane, making the bacteria
more permeable to NaOCl.
VAPOR LOCK EFFECT
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VAPOR LOCK EFFECT
Air entrapment by an advancing liquid front in closed-end micro
channels is a well-recognized physical phenomenon(Bankoff SB
AICHE J 1958)The ability of a liquid to penetrate these closed-end
channels is dependent on the contact angle of the liquid and the
depth and size of the channel.
37
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Under all circumstances, these closed-end microchannels will eventually be
flooded after sufficient time (hours to days) (Pesse AV, Int J 2005).
This phenomenon of air entrapment and the time frame in which complete
flooding occurs has practical clinical implications when irrigants aredelivered by using syringe needles from the coronal or middle third of a root
canal.
Because endodontic irrigation is performed within a time frame of minutes
instead of hours or days, air entrapment in the apical portion of the canal
might preclude this region from contact or disinfection by the irrigant.
Simple way to eliminate air lock is by dynamic Gutta percha activation(Mc
Gil l I EJ 2008, Huang TY IEJ 2008)38
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39
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PRESSURE ALTERNATION DEVICES
Irrigants cannot reach the apical portion due to air
entrapment when needle tips are placed far away
Conversely if placed close to the foramen it may
result in severe iatrogenic damage
Concomitant irrigant delivery and aspiration via the
use of pressure alternation devices provide a
plausible solution to this problem.
40
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EARLY EXPERIMENTAL PROTOCOLS
No instrument technologyby Lussi et al
No canal enlargement
Debridement achieved solely with the use of low concentration
NaOCl, by altering subambient pressure fields.
This created bubble implosion and hydro dynamic turbulence
facilitating penetration
Proved to be better than conventional syringe needle irrigation
(Lussi et al 2004)
But , the technique was not considered safe in in vivo animal
studies and did not proceed to human clinical trials.
41
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Another experimental irrigation system was introduced by
Fukumoto et al.
Consists of an injection needle, aspirating needle attached
to the apex locator (Root ZX).
Aspiration pressure at -20 kPa
Coronally placed injecting needle and aspirating needle at
2 mm from apex gave reliable effects.
Significant importance is the irrigant reaches the apical
delta
42
ENDOVAC (DISCUS DENTAL CULVER CITY CA)
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ENDOVAC (DISCUSDENTAL, CULVERCITY, CA)
Endovac system is based on a negative pressure approach whereby the irrigant is placed in the pulp
chamber is sucked down the root canal and back up again through a thin needle with a special design.
A macrocannula (# 55) or microcannula (#32) is connected via tubing to a syringe of irrigant and the
high-speed suction of a dental unit
Endovac system lowers the risks associated with irrigation close to the apical foramen considerably.
43
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44
The EndoVac System.
(A) Macro cannula with
hand piece
(B) Micro cannula with
finger piece
(C) Master delivery tip
(D) Tip of micro
cannula
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45
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ADVANTAGES
Another advantagegood apical cleaning at
1mm level due to reverse flow of irrigants
(Nielsen BA, JOE 2007) and avoids air
entrapment
More volume of fluid is irrigated than
conventional syringe technique
Strong anti bacterial effect when
hypochlorite is used
Can be used for gross, course andmicroscopic debridement
46
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47
Safety:Less apical extrusion risk using the EndoVac system
compared with needle irrigation
J Endod. 2010 Feb;36(2):338-41
Efficacy:Better debridement 1 mm from working length using the EndoVac system
compared with needle irrigation
J Endod 2007;33:611-615
SUCCESS:Negative apical pressure irrigation system EndoVac results insignificantly less postoperative pain & necessity for analgesic medication
than a conventional needle irrigation protocol using the Max-i-Probe
J Endod 2010;36:1295-1301
RINSE ENDO (AIRTECHNIQUES, MELVILLE, NY)
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48
Titanium handpiece with a specially designed single-use
cannula with a 7 mm long aperture.
The long aperture eliminates blockage, enabling the
irrigation solution to reach and disinfect all portions of
the canal.
The pressure created by Rinsendo irrigation is lower
than the pressure created by a syringe during manual
irrigation.
Rinsendo employs exclusive, patented pressure suction
technology.
In the pressure phase, 65 l of rinsing solution
oscillating at a frequency of 1.6 Hz are automatically
drawn from the attached syringe and aspirated into the
canal.
In the suction phase, the used solution and air are
aspirated back.
Pressure suction cycles changes approximately 100
times per min
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Manufacturer claims that it is efficient in cleaning the
apical third.
But a higher risk of apical extrusion was observed byHauser V et al (IEJ 2007)
Mc Gill et al and Huang et al. confirmed that Manual
dynamic agitation better than RinsEndo
49
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HEATEDIRRIVACIRRIGATIONSYSTEM
The Heated IrriVac root canal irrigation system is designed
to provide rapid, thorough root canal cleaning. All -in-one
handpiece dispenses fresh, heated sodium hypochlorite
through an irrigation needle and removes spent irrigant and
dissolved tissue from the top of the canal through suction.
The handpiece has a corrosion-resistant titanium head with a
plastic handle and push-button control for precise solution
dispensing.
Irrigation solution is provided from a low pressure
regulated, 250-ml bottle and is heated in the handpiece
tubing just before dispensing the solution..
50
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ENDO IRRIGATOR
The Endo-Irrigator is a six-bottle micro-irrigation
system that provides fingertip controlled,
instantaneous, purge-free delivery of up to six
different irrigating solutions, including sodium
hypochloride.
The handpiece control or remote touch pad allows
the doctor or assistant to select from one solution
to the next with the touch of a button, without
leaving the field.
Built-in heater allows the delivery of heatedirrigating solutions for improved chemical
reactions. It reportedly improves procedure safety
and efficiency while also decreasing procedure
time (Nelson BA).
51
COMPARATIVE SAFETY OF VARIOUS INTRACANAL
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COMPARATIVE SAFETY OF VARIOUS INTRACANAL
IRRIGATION SYSTEMS (PRANAV DESAI AND VAN HIMEL,
2009)
Endo Vac did not extrude irrigant after deep intracanal delivery and
suctioning the irrigant from the chamber to full working length.
Endo Activator had a minimal, although statistically insignificant, amount
of irrigant extruded out of apex.
Manual, Ultrasonic and Rinsendo groups had significantly greater
amounts of extrusion compared with EndoVac and EndoActivator groups.
52
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CONCLUSION
Irrigation has a key role in successful endodontic treatment.
Despite the plethora of studies on the effectiveness of various endodontic irrigation
regimens, it is noteworthy that no well- controlled clinical study is available in the
current endodontic literature.
From a practical point of view, no evidence based study is available to date that
attempts to correlate the clinical efficacy of these devices with improved treatment
outcomes.
Thus, the question of whether these devices are really necessary remains unresolved.
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