Endodontic Irrigation Chemical disinfection of the root canal

system

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Editor
Bettina Basrani
Department of Dentistry
University of Toronto
Toronto
Canada

ISBN 978-3-319-16455-7 ISBN 978-3-319-16456-4 (eBook)

DOI 10.1007/978-3-319-16456-4

Library of Congress Control Number: 2015945163

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This book is dedicated:
To my father, Enrique, for leaving his fingerprints of endodontic
passion in my life
To my mother, Clarita, and mother-in-law, Enid, for being my
dearest and most unconditional fans
To my husband, Howard, for helping me, every day, in
becoming a better person
To my children, Jonathan and Daniel, for teaching me what life
is really about
To my coworkers, Shimon, Cal, Anil, Andres, Gevik, and Pavel,
for being my second family
Finally, to my students for making me a better teacher
Foreword

Apical periodontitis is an infectious disease related to the presence of

microorganisms in the root canal system of teeth. Its treatment therefore must
be directed at eliminating or, at the very least, reducing the infecting micro-
biota, to levels that allow healing to occur. Advances in microbiology have
identified the nature and complexity of the infecting microbiota and the abil-
ity of some of its members to collectively survive under the harshest of condi-
tions. The treatment of apical periodontitis has historically been based upon
two pillars, the mechanical removal of necrotic tissue and microorganisms
from the root canal system and the irrigation of the root canal system with
chemical agents, to supplement removal of tissue and microorganisms from
areas of the system that were mechanically prepared, as well as address the
presence of tissue and microorganisms at sites in the system that mechanical
preparation could not reach. Research has shown that despite the nature and
design of the instruments used in the mechanical preparation of the system,
significant reduction in the concentrations of tissue and microorganisms in
complex root canal systems can only be achieved when irrigation of the sys-
tem is an integral part of the treatment undertaken. Over the years, different
irrigants have been used in endodontic treatment, but only one, sodium hypo-
chlorite, has proven itself to be consistently effective. Its effectiveness is a
product of its concentration and the manner in which it is introduced into the
root canal system. Because of the toxic nature of sodium hypochlorite, both
of these factors pose a potential risk to the patient if tissues surrounding the
tooth are inadvertently exposed to the agent during use.
In this textbook, Dr. Basrani, a noted authority in root canal irrigation, has
recruited a panel of prominent authors to discuss the merits, limitations, and
safety of the various sodium hypochlorite delivery systems currently being
used in endodontic treatment. Some attention is also paid to the influence that
mechanical root canal preparation has in impeding or promoting their thera-
peutic effect. With an eye to the future, Dr. Basrani has also included chapters
concerned with evolving technologies in the field of supplemental root canal
disinfection, technologies that have shown promise in avoiding the potential
risks associated with sodium hypochlorite use, while achieving and, in some
instances, exceeding sodium hypochlorite’s effectiveness in tissue and micro-
bial reduction.

vii
viii Foreword

In view of the importance of irrigation of the root canal system in its

broadest form, to the outcome of endodontic treatment, this textbook is a
must-read for all clinicians who include endodontics as an integral part of
their dental practice.

Toronto, ON, Canada Calvin D. Torneck, DDS, MS, FRCD(C)

Preface

When I was invited by Springer International Publishing to edit a book in

irrigation, I felt like a dream came true. I have been working on endodontic
irrigation for close to 20 years. While doing my PhD at Maimonides
University in Buenos Aires, Argentina, I was invited work with a periodon-
tist, Dr. Piovano, and microbiologist, Dr. Marcantoni, who became my initial
mentors. After a couple of meetings together, we recognized how much peri-
odontics and endodontics have in common: (a) similar etiological factor of
the diseases (bacterial-/biofilm-related causes), (b) similar treatments (both
disciplines mechanically clean the tooth surface either with curettes or end-
odontic files), and (c) both chemically disinfect the surface (medicaments and
irrigants). However, the big difference is that, as endodontists, we seal the
canal as tridimensionally as possible, while in periodontal treatment this step
is difficult to achieve.
When we recognized the similarity in the procedure, we started to analyze
the medicaments that periodontal therapy applied, and chlorhexidine (CHX)
was the “new” topical drug at that time. We wondered: if CHX is used for
periodontics, why not for endodontics? This is how my irrigation pathway
began in 1995, and that path opened to new amazing and unexpected routes.
I was able to complete my PhD and published in vitro papers on the use of
CHX as an intracanal medicament and other papers on the mixture of CHX
with calcium hydroxide with my new supervisors Dr. Tjadehane and Dr.
Canete. Finally, this motivation and interest in irrigation research brought me
to Canada to continue this line of investigation with the research group at the
University of Toronto, under the wise guidance of Dr. Shimon Friedman and
Dr. Calvin Torneck and the inquisitive minds of the residents who went
through our program. Today, the disinfection research is reaching for new
horizons with the leading research of Dr. Anil Kishen and his lab. I am so
proud of being part of such a prestigious group of researchers and remarkable
group of human beings.
Chemical disinfection of the root canal system is now the bread and butter
of modern endodontic therapy. Even though we have new and sophisticated
file systems in the market, the key to endodontic success is based on chemical
disinfection. This book is intended to convey the most recent challenges and
advances in cleaning the root canal. We start by analyzing the main etiologi-
cal factors of apical periodontitis in Chapter 1, and Dr. Luis Chaves de Paz
explains the importance of the biofilms in causing endodontic diseases. In
Chapter 2 Dr. Marco A. Versiani, Jesus D. Pécora, and Manoel D. Sousa-Neto,

ix
x Preface

with distinctive studies on microCT, explain dental anatomy in great detail. In

Chapter 3 on irrigation dynamics was written by Dr. Christos Boutsioukis and
Lucas W.M. van der Sluis explained in detail why the irrigants do not reach
the apical part of the canal and what we can do to improve irrigation dynam-
ics. For the more academic-oriented readers, we have Chapter 4 Drs. Shen Y,
Gao Y, Lin J, Ma J, Wang Z, and Haapasalo M described different methods
on studying irrigation. In Chapter 5, Dr. Gevik Malkhassian and I put together
the most common irrigant solutions used in endodontics along with the pros
and cons of their use. Chapter 6 Dr Gary Glassman describes accidents and
mishaps during irrigation. We then have Dr Jorge Vera in Chapter 7 describ-
ing how patency file may (or may not) affect irrigation efficacy Chapters 8 to
14 are dedicated to each irrigation technique written by experts in each of
these fields: Dr. Pierre Matchou for manual dynamic technique, Drs. Gary
Glassman and Karine Charara for apical negative pressure, Dr. John Nusstein
for sonic and ultrasonics, Drs. Zvi Metzger and Anda Kfir for SAF, Drs. Amir
Azarpahazoo and Zahed Mohammadi for ozone, Dr. David Jaramillo for
PIPS, and Dr. Anil Kishen and Anie Shersta for photo activation disinfection.
Two chapters are dedicated to inter-appointment therapy, with Dr. Zahed
Mohammadi and Dr. Paul Abbott (Chap. 15) describing the use of antibiotics
in endodontics and Professor José F. Siqueira Jr and Isabela N. Rôças describ-
ing the details on intracanal medications (Chap. 16).
Two chapters are dedicated to modern and current points of interest, Chap.
17 on irrigation in the era of re-treatment written by Dr. Rodrigo Sanches
Cunha and Dr. Carlos Eduardo da Silveira Bueno and Chap.18 on irrigation
in the era of revascularization by Dr. Anibal R. Diogenes and Nikita
B. Ruparel.
The vision of this book would never have been possible without the dedi-
cation and hard work of this astounding team of scientists with such different
backgrounds but with the same enthusiasm for endodontic disinfection. The
collaborators of this textbook are bringing their expertise and knowledge
from Brazil, Iran, Peru, Mexico, Canada, Australia, USA, Israel, France,
Greece, and Holland. To all of them, to my coauthors, thank you!

Toronto, ON, Canada Bettina Basrani

Acknowledgments

I would like to start by thanking Springer International Publishing for giving

me the wonderful opportunity of editing a textbook on chemical disinfection
of the root canal system. I appreciate the trust, patience, and knowledge they
demonstrated throughout the whole process. I also want to thank Dean Haas,
Faculty of Dentistry, University of Toronto, for granting me the 6-month sab-
batical to focus on this project, and I have a deep appreciation to the whole
endodontic department of the faculty of dentistry for their motivation and
constant support. Special thanks to Warrena Wilkinson for editing some of
the chapters and Dr. Calvin Torneck for the thoughtful writing of the
preface.
Gratitude goes to the collaborators of this book. It was a great pleasure to
invite you to participate in this project, and your motivated and enthusiastic
responses were always encouraging. Thanks for your expertise and
dedication.
Finally, I want to recognize my family. I have to start by thanking my
father, Professor Emeritus Dr. Enrique Basrani, for showing me what a life
of an endodontist looks like. He lived in Buenos Aires, Argentina, and
divided his time between academics and clinical practice, while he wrote
six textbooks in endodontics, finishing his last one on his death bed. He
never stopped working. I should say: he never stopped doing what he
loved. Now, as I follow in his steps, dividing my own time between aca-
demics and clinical practice, and feel him guiding me in spirit in all that I
do. Secondly, I want to thank my mother, Clarita, and mother-in-law, Enid
Alter for listening and understanding when sometimes I think that life is
overpowering. My brother Dr. Damian Basrani and his family always have
a special place in my heart. Howard, my beloved and precious husband,
thanks for being there for me, always. Without your presence in my life, I
would not be able to be the person that I am today. And to my beautiful
children, Jonathan and Daniel, for being as enthusiastic as I am in every-
thing they do.
I want to conclude by thanking all my students, from the undergraduate to
graduate program and participants in lectures and workshops. You are the
ones who make us better teachers, the ones who challenge us, who inspire us
to give our best, and the ones who I also dedicate this book to.

xi
Contents

1 Microbial Biofilms in Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . 1

Luis E. Chávez de Paz
2 Update in Root Canal Anatomy of Permanent
Teeth Using Microcomputed Tomography . . . . . . . . . . . . . . . . . . 15
Marco A. Versiani, Jesus D. Pécora,
and Manoel D. Sousa-Neto
3 Syringe Irrigation: Blending Endodontics
and Fluid Dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Christos Boutsioukis and Lucas W.M. van der Sluis
4 Research on Irrigation: Methods and Models . . . . . . . . . . . . . . . 65
Ya Shen, Yuan Gao, James Lin, Jingzhi Ma, Zhejun Wang,
and Markus Haapasalo
5 Update of Endodontic Irrigating Solutions . . . . . . . . . . . . . . . . . 99
Bettina Basrani and Gevik Malkhassian
6 Complications of Endodontic Irrigation:
Dental, Medical, and Legal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Gary Glassman
7 The Role of the Patency File in Endodontic Therapy . . . . . . . . 137
Jorge Vera
8 Manual Dynamic Activation (MDA) Technique . . . . . . . . . . . . 149
Pierre Machtou
9 Apical Negative Pressure: Safety, Efficacy and Efficiency . . . . 157
Gary Glassman and Karine Charara
10 Sonic and Ultrasonic Irrigation . . . . . . . . . . . . . . . . . . . . . . . . . . 173
John M. Nusstein
11 Continuous Instrumentation and Irrigation:
The Self-Adjusting File (SAF) System . . . . . . . . . . . . . . . . . . . . 199
Zvi Metzger and Anda Kfir
12 Ozone Application in Endodontics . . . . . . . . . . . . . . . . . . . . . . . 221
Zahed Mohammadi and Amir Azarpazhooh

xiii
xiv Contents

13 Irrigation of the Root Canal System by Laser

Activation (LAI): PIPS Photon-Induced
Photoacoustic Streaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
David E. Jaramillo
14 Photodynamic Therapy for Root Canal Disinfection . . . . . . . . 237
Anil Kishen and Annie Shrestha
15 Local Applications of Antibiotics and Antibiotic-Based
Agents in Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Zahed Mohammadi and Paul V. Abbott
16 Intracanal Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
José F. Siqueira Jr. and Isabela N. Rôças
17 Disinfection in Nonsurgical Retreatment Cases . . . . . . . . . . . . . 285
Rodrigo Sanches Cunha and Carlos Eduardo da Silveira Bueno
18 Irrigation in Regenerative Endodontic Procedures . . . . . . . . . . 301
Anibal R. Diogenes and Nikita B. Ruparel
19 Conclusion and Final Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Bettina Basrani

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Contributors

Paul V. Abbott, BDSc, MDS, FRACDS(Endo), FIADT Department of

Endodontics, School of Dentistry, The University of Western Australia,
Nedlands, WA, Australia
Amir Azarpazhooh, DDS, MSc, PhD, FRCD(C) Division
of Endodontics, Department of Dentistry, and Clinician Scientist,
Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital,
Toronto, ON, Canada
Dental Public Health and Endodontics, Faculty of Dentistry,
University of Toronto, Toronto, ON, Canada
Bettina Basrani, DDS, MSc, RCDC (F), PhD Associate Professor,
Director M.Sc. Endodontics Program, Faculty of Dentistry, University of
Toronto, Toronto, ON, Canada
Christos Boutsioukis, DDS, MSc, PhD Department of Endodontology,
Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam,
The Netherlands
Karine Charara, DMD Adjunct Professor of Dentistry, Université de
Montréal, Montréal, QC, Canada
Private Practice, Clinique Endodontique Mont-Royal, Mont-Royal, QC,
Canada
Rodrigo Sanches Cunha, DDS, MSc, PhD, FRCD(C) Department
Restorative Dentistry, Faculty of Health Sciences, College
of Dentistry, University of Manitoba, Winnipeg, MB, Canada
Luis E. Chávez de Paz, DDS, MS, PhD Endodontics, The Swedish
Academy for Advanced Clinical Dentistry, Gothenburg, Sweden
Carlos Eduardo da Silveira Bueno, DDS, MSc, PhD Faculty
of Dentistry, São Leopoldo Mandic Centre for Dental Research,
Campinas, SP, Brazil
Anibal R. Diogenes, DDS, MS, PhD Department of Endodontics,
University of Texas Health Center at San Antonio,
San Antonio, TX, USA

xv
xvi Contributors

Yuan Gao, DDS, PhD Department of Endodontics and Operative

Dentistry, West China Stomatological College and Hospital Sichuan
University, Chengdu, P.R. China
Gary Glassman, DDS, FRCD(C) Associate in Dentistry, Graduate,
Department of Endodontics, Faculty of Dentistry, University of Toronto,
Toronto, ON, Canada
Adjunct Professor of Dentistry, University of Technology, Kingston, Jamaica
Private Practice, Endodontic Specialists, Toronto, ON, Canada
Markus Haapasalo, DDS, PhD Division of Endodontics,
Department of Oral Biological and Medical Sciences, Faculty
of Dentistry, University of British Columbia, Vancouver, BC, Canada
David E. Jaramillo, DDS Department of Endodontics, University of Texas
Health Science Center at Houston, School of Dentistry, Houston, TX, USA
Anda Kfir, DMD Department of Endodontology, The Goldschlager
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
Anil Kishen, PhD, MDS, BDS Department of Endodontics,
Facility of Dentistry, University of Toronto, Toronto, ON, Canada
James Lin, DDS, MSc, FRCD(C) Division of Endodontics, Department of
Oral Biological and Medical Sciences, Faculty of Dentistry, University of
British Columbia, Vancouver, BC, Canada
Jingzhi Ma, DDS, PhD Department of Stomatology, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, P.R. China
Pierre Machtou, DDS, MS, PhD Endodontie, UFR d’Odontologie
Paris 7-Denis Diderot, Paris Ile de France, France
Gevik Malkhassian, DDS, MSc, FRCD(C) Assistant Professor,
Discipline of Endodontics, Faculty of Dentistry, University of Toronto,
Toronto, ON, Canada
Zvi Metzger, DMD Department of Endodontology, The Goldschlager
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
Zahed Mohammadi, DMD, MSD Iranian Center for Endodontic
Research (ICER), Research Institute of Dental Sciences, Shahid
Beheshti University of Medical Sciences, Tehran, Iran
John M. Nusstein, DDS, MS Division of Endodontics, The Ohio
State University College of Dentistry, Columbus, OH, USA
Jesus D. Pécora, DDS, MSc, PhD Department of Restorative Dentistry,
Dental School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto,
Brazil
Contributors xvii

Isabella N. Rôças, DDS, MSc, PhD PostGraduate Program

in Endodontics and Molecular Microbiology Laboratory, Faculty
of Dentistry, Estácio de Sá University, Rio de Janeiro, RJ, Brazil
Nikita B. Ruparel, MS, DDS, PhD Department of Endodontics,
University of Texas Health Center at San Antonio, San Antonio, TX, USA
Ya Shen, DDS, PhD Division of Endodontics, Department of Oral
Biological and Medical Sciences, Faculty of Dentistry, University of British
Columbia, Vancouver, BC, Canada
Annie Shrestha, PhD, MSc, BDS Faculty of Dentistry, Department
of Endodontics, University of Toronto, Toronto, ON, Canada
José F. Siqueira Jr., DDS, MSc, PhD PostGraduate Program
in Endodontics, Faculty of Dentistry, Estácio de Sá University,
Rio de Janeiro, RJ, Brazil
Lucas W.M. van der Sluis, DDS, PhD Department of Conservative
Dentistry, University Medical Center Groningen, Groningen, The
Netherlands
Manoel D. Sousa-Neto, DDS, MSc, PhD Department of Restorative
Dentistry, Dental School of Ribeirao Preto, University of Sao Paulo,
Ribeirao Preto, Brazil
Jorge Vera, DDS Department of Endodontics, University of Tlaxcala
Mexico, Puebla, Puebla, Mexico
Marco A. Versiani, DDS, MSc, PhD Department of Restorative Dentistry,
Dental School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto,
SP, Brazil
Zhejun Wang, DDS, PhD Division of Endodontics, Department of Oral
Biological and Medical Sciences, Faculty of Dentistry, University of British
Columbia, Vancouver, BC, Canada
 Microbial Biofilms in Endodontics
1
Luis E. Chávez de Paz

Abstract
Microorganisms colonizing different sites in humans have been found to
grow predominantly in complex structures known as biofilms. Biofilms
are dynamic systems with attributes of both primordial multicellular
organisms and represent a protected mode of growth that allows cells to
survive. The initial stage of biofilm formation includes the attachment of
bacteria to the substratum. Bacterial growth and division then leads to the
colonization of the surrounding area and the maturation of the biofilm.
The environment in a biofilm is not homogeneous; the bacteria in
multispecies biofilms are not randomly distributed, but rather are orga-
nized to best meet their requirements. The implications of this mode of
microbial growth in the context of endodontic infections are discussed in
this chapter. Although there is an initial understanding on the mechanisms
of biofilm formation in root canals and its associated resistance to clinical
antimicrobial regimens, this topic is still under investigation. A greater
understanding of biofilm processes should lead to novel, effective control
strategies for endodontic biofilm control and a resulting improvement in
patient management.

Introduction are embedded in a self-produced extracellular

matrix which bind cells together [17, 18, 30].
In nature, bacteria are able to live either as Biofilms have major clinical relevance as they
independent free-floating cells (planktonic state) provide bacteria with protective environments
or as members of organized surface-attached against stresses, immune responses, antibacterial
microbial communities called biofilms. agents, and antibiotics [31, 33]. After several
Biofilms are composed of microorganisms that decades of intense research, it is now well estab-
lished that biofilm formation is a developmental
process that begins when a cell attaches to a sur-
L.E. Chávez de Paz, DDS, MS, PhD face and it is strictly regulated in response to
Endodontics, The Swedish Academy for Advanced
Clinical Dentistry, Gothenburg, Sweden environmental conditions [33].
e-mail: [email protected]

© Springer International Publishing Switzerland 2015 1

B. Basrani (ed.), Endodontic Irrigation: Chemical Disinfection of the Root Canal System,
DOI 10.1007/978-3-319-16456-4_1
2 L.E. Chávez de Paz

One of the most relevant features of oral formed subpopulations of cells that are pheno-
bacteria is their intrinsic ability to continuously typically highly resistant to antibiotics and bio-
form complex biofilm communities, also known cides [13, 16, 24, 46]. Although there is no
as dental plaque. Oral biofilm formation serves generally agreed upon mechanism to account
not only to aid in retention of bacteria in the oral for this broad resistance to antimicrobials,
cavity, but also results in their increased survival the extent of the problem in endodontics is
[34, 35]. In root canals of teeth, biofilms have considerable.
been confirmed by examinations of extracted
teeth with periapical lesions [71]. For example,
when sections were viewed by transmission Formation of Microbial Biofilms
electron microscopy, dense aggregates of cocci
and rods embedded in an extracellular matrix Formation of a bacterial biofilm is a developmen-
were observed along the walls [61], while stud- tal process that begins when a cell attaches to a
ies using scanning electron microscopy have surface. The formation of microbial biofilms
shown microcolonies of cocci, rods, and fila- includes several steps that can be divided in two
ments on root canal walls [59, 74, 83]. The bio- main parts: (a) the initial interactions of cells
film mode of growth contributes to resistance to with the substrate and (b) growth and develop-
host defenses, and within the biofilm, there are ment of the biofilm (see Figs. 1.1 and 1.2).

Fig. 1.1 Initial stages of

biofilm formation. Schematic
outlining the general
approaches of initial cellular
interaction of planktonic
cells with coated substrates.
In the initial phase, a “clean”
surface is coated with
environmental elements. At
the second stage, a plank-
tonic cell that approaches the
coated surface initiates
adhesion by adjusting a
number of regulatory
mechanisms known as
surface sensing. In the
following stage, irreversible
adhesion occurs by
association of specific cell
components such as pili,
flagella, exopolymers, etc.
Lastly, co-adhesion with
other organisms is achieved
by specific interspecies
interactive mechanisms