|Year : 2020 | Volume
| Issue : 4 | Page : 424-430
|Comparison of the efficacy of CanalBrush, EndoActivator, and Passive Ultrasonic Irrigation on the removal of triple antibiotic paste from root canal walls: An in vitro study
Santosh Kumar1, Kavisha Desai2, Aparna Palekar2, Baswaraj Biradar2, Ananjan Chatterjee3, Khushboo Kumari3
1 Department of Conservative Dentistry and Endodontics, Patna Dental College & Hospital, Patna, Bihar, India
2 Department of Conservative Dentistry and Endodontics, Rural Dental College, Pravara Institute of Medical Sciences (PIMS), Loni, Maharashtra, India
3 Department of Oral Pathology, Buddha Institute of Dental Sciences & Hospital, Patna, Bihar, India
|Date of Submission||08-Jan-2020|
|Date of Decision||10-Apr-2020|
|Date of Acceptance||12-Apr-2020|
|Date of Web Publication||06-Aug-2020|
Dr. Santosh Kumar
Department of Conservative Dentistry and Endodontics, Patna Dental College & Hospital, Bankipur, Ashok Rajpath, Patna, Bihar.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study was to compare the efficacy of CanalBrush (CB), EndoActivator (EA), and Passive Ultrasonic Irrigation (PUI) on the removal of triple antibiotic paste (TAP) from root canal walls. Materials and Methods: Thirty-six extracted human single-rooted teeth were prepared using ProTaper Universal rotary files (DentsplyMaillefer, Ballaigues, Switzerland) up to size F5. The root canals were filled with TAP, and after 21 days, roots were randomly assigned to three groups (n = 10) according to irrigation regimens used: CB, EA, and PUI. In three teeth, TAP was not removed (positive controls), and the other three teeth were not filled with TAP (negative controls). The roots were sectioned, and the amount of TAP remaining was evaluated at the mesial halves of each tooth at ×30 magnification under a stereomicroscope using a 4-grade scoring system. Data were evaluated using the Kruskal–Wallis and Mann–Whitney U tests. Results: There were significant differences among the experimental groups according to the different parts of the root canals (P < 0.05). At the apical and middle third, EA and PUI groups removed more TAP than CB group; however, there was a statistically significant difference only between CB and PUI groups (<0.01 at apical third and <0.05 at middle third). At the coronal third, there was no statistically significant difference between all the three groups (P > 0.05). Conclusion: PUI led to superior results compared to CB in the middle and apical thirds. There was no significant difference between EA and PUI techniques.
Keywords: CanalBrush, EndoActivator, ultrasonic irrigation
|How to cite this article:|
Kumar S, Desai K, Palekar A, Biradar B, Chatterjee A, Kumari K. Comparison of the efficacy of CanalBrush, EndoActivator, and Passive Ultrasonic Irrigation on the removal of triple antibiotic paste from root canal walls: An in vitro study. J Int Soc Prevent Communit Dent 2020;10:424-30
|How to cite this URL:|
Kumar S, Desai K, Palekar A, Biradar B, Chatterjee A, Kumari K. Comparison of the efficacy of CanalBrush, EndoActivator, and Passive Ultrasonic Irrigation on the removal of triple antibiotic paste from root canal walls: An in vitro study. J Int Soc Prevent Communit Dent [serial online] 2020 [cited 2020 Sep 22];10:424-30. Available from: http://www.jispcd.org/text.asp?2020/10/4/424/291448
| Introduction|| |
The root canal treatment involves the generation of an environment free of bacteria in the root canal space. This can be accomplished by chemo-mechanical preparation of the canal using various instruments and irrigating solutions. Although it leads to decrease in bacterial count, it does not completely eliminate them from the root canal system. The polymicrobial nature of root canal infection advocates the use of intracanal medicaments in the reduction of bacterial population. Calcium hydroxide (CH) is the most common intracanal medicament that has high alkalinity. This high pH of CH changes the biologic properties of the lipopolysaccharide component in the cell wall of gram-negative species and inactivates the mechanisms of membrane transportation, which leads to bacterial cell death. However, it is suggested that effect of CH is questionable due to various factors such as increased bacterial adhesion to dentin, buffering capacity of dentine, presence of biofilm, and necrotic tissue. Also, it is said to reduce the flexural strength of dentin. Considering these shortcomings, finding an alternative intracanal medicament would be beneficial.
One of the most potent intracanal medicaments is a mixture of metronidazole, ciprofloxacin, and minocycline––the triple antibiotic paste (TAP) described by Hoshino et al. Several studies have shown that TAP when applied to root canal walls leads to its efficient sterilization. Its antimicrobial and biocompatible properties create suitable environment for tissue revascularization. TAP has also shown successful results when treatment with CH dressing failed to eliminate symptoms. An in vitro study showed that compared to CH, the TAP is highly effective against Enterococcus faecalis. These reports show the popularity of TAP as an intracanal medicament and in regenerative endodontic procedures.
Regenerative endodontic procedure includes disinfection of root canal space with TAP medicament, followed by its removal, and followed by placement of mineral trioxide aggregate. However, it has been proclaimed that TAP has a lethal effect on the stem cells derived from the apical papilla. Also, it has been said to have an effect on sealer penetration and tooth discoloration. Thus, this paste should be completely cleared away from the root canal walls to suppress its effects.
Conventionally, syringe irrigation with sodium hypochlorite solution has been used to remove TAP., However, this does not lead to thorough cleaning of complex root canal anatomy. Devices for irrigation delivery to increase the flow and distribution have recently been recommended.
The CanalBrush (CB) (Roeko Canal Brush, Coltène/Whaledent, Langenau, Germany) is a highly flexible endodontic microbrush, which is molded entirely from polypropylene. It is used manually with a rotary action.
The EA system (Dentsply, Tulsa, Oklahoma) is a cordless, battery-powered, sonically driven irrigant activation system. It is designed to produce vigorous agitation of intracanal solutions.
Passive Ultrasonic Irrigation (PUI) (Acteon Group Ltd, Merignac, France) uses a stainless steel file to agitate the irrigating solution previously placed inside the canal. It is gently moved inside out not touching the canal walls.
| Background and Objectives|| |
The objective of the study was to compare the efficacy of CB, EA, and PUI on the removal of TAP from root canal walls.
The null hypotheses were that the removal of TAP was not affected by the using the following:
- Irrigation technique
- Different parts of the root canal system.
| Materials and Methods|| |
Setting and design
Thirty-six single-rooted, non-carious human teeth with similar sizes and completed apices were selected. The sample size was calculated online using Raosoft software. Soft tissues and calculus were mechanically removed from the root surface with a periodontal scaler. Buccolingual and mesiodistal radiographs were taken to confirm the presence of a single canal, an intact apex and no signs of internal or external resorption. The teeth were stored in 4°C distilled water until use. The teeth were decorated 12 mm from the apex to standardize the root length using a diamond disk under water coolant.
The root canals were shaped with ProTaper Universal rotary files (DentsplyMaillefer, Ballaigues, Switzerland) up to F5 with 2 mL of 3% sodium hypochlorite (NaOCl) between each file. Prepared canals were irrigated with 5-mL NaOCl, followed by 5 mL of 17% EDTA to remove the smear layer. The canals were then dried with paper points (DentsplyMaillefer).
TAP was prepared by mixing equal proportions (1 g) of metronidazole, ciprofloxacin, and minocycline (Research-Lab Fine Chem Industries, Mumbai, India) with distilled water (1 mL) (powder:liquid ratio of 3:1) on a glass slab with a stainless steel spatula [Figure 1]. A Lentulo spiral was used to carry and spread the medicament in the canal space until it was in view at the apical foramen. The openings of the root canals were sealed momentarily with a cotton pellet and Cavit (ESPE, Seefeld, Germany). The teeth were stored in an incubator at 37°C with 100% humidity for 21 days.
The specimens were split into three experimental groups (n = 10) and positive and negative control groups (n = 3) using a simple random sampling method. A lottery approach was made in which each specimen in the sample was numbered from 1 to 36 in a consequent manner. These specimens were mixed in a bowl and were randomly chosen to be divided into the experimental and control groups. This allocation and implementation of the randomization was carried out by an individual who was unaware of the groups and was not related to the field of dentistry. In the positive control group, no irrigation protocol was followed. In the negative control group, root canals were not filled with TAP.
Group 1: CB [Figure 2]A: A CB with a tip diameter of 0.30 mm in a handpiece set at 600rpm was placed 1 mm from the working length. 10 mL of 3% NaOCl was agitated for 1 min in a gentle up and down motion.
Group 2: EndoActivator (EA) [Figure 2B]: An EA handpiece with a red (25/04) tip set at 10,000 cycles per minute was inserted 1 mm from the working length. 10 mL of 3% NaOCl was infused into the canal and agitated for 1 min.
Group 3: PUI [Figure 2C]: A size 15K, 0.02 taper ultrasonic file was connected to an adaptor of a Satelec P5 Newtron XS ultrasonic system handpiece (Acteon Group, Merignac, France) at power setting 6 and was inserted 1 mm deficient of working length without brushing the walls, enabling it to vibrate freely. 10 mL of 3% NaOCl was passively agitated for 1 min.
After the final irrigation, 5-mL distilled water was used to flush away remaining NaOCl from the root canals which were then dried with paper points. Two longitudinal grooves were prepared on the buccal and lingual surfaces of each root using a fine diamond disc, avoiding penetration into root canal. The two halves of the root were separated using a hammer and chisel. Thus, 20 specimens were obtained from each group.
| Outcomes|| |
Determination of the remaining triple antibiotic paste
The amount of TAP remaining was evaluated at mesial halves of each root (n = 10). The distal halves were discarded. Images of the coronal (8–12 mm from apex), middle (4–8 mm from apex), and apical (0–4 mm from apex) thirds of root canal surfaces were acquired using a digital camera mounted on a stereomicroscope (Zeiss Stemi 2000-C, Carl Zeiss MicroImaging, Göttingen, Germany) at ×30 magnification and transferred to the computer. The remaining medicament at each third of root canal was evaluated by two registered endodontists in a blind manner using a four-grade scoring system described by van der Sluis et al. as follows [Figure 3]:
- Score 0: The canal was empty
- Score 1: TAP was present in less than half of the canal
- Score 2: TAP covered more than half of the canal
- Score 3: The canal was completely filled with TAP
The κ test was used to analyze interexaminer agreement. Statistical analysis was performed with the Kruskal–Wallis and Mann–Whitney U tests using Statistical Package for the Social Sciences (SPSS) software program (IBM SPSS, Chicago, Illinois). The level of statistical significance was set at 95% confidence (P < 0.05).
| Results|| |
The κ test showed that the interexaminer agreement was 92.7%. The positive control group showed that the canal walls were completely filled with TAP. The negative control group showed no TAP on the root canal walls. The score allotted to the amount of TAP removed at different parts of root canal system is shown in [Table 1] and [Table 2]. There were significant differences among the experimental groups according to the different parts of the root canals (P < 0.05) [Table 3].
|Table 1: Distribution of the triple antibiotic paste removal scores at different parts of the root canals (n = 10)|
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|Table 2: Mean with standard deviation values for the removal of triple antibiotic paste|
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At the apical third
There was a highly significant difference between CB and PUI groups (P < 0.01). In EA group, better results were obtained than CB group, but it was not statistically significant. Also, in PUI group better results were obtained than EA group, but it was not statistically significant.
At the middle third
There was a significant difference between CB and PUI group (P < 0.05). In EA group, better results were obtained than CB group, but it was not statistically significant. Also, in PUI group better results were obtained than EA group, but it was not statistically significant.
At the coronal third
There was no significant difference between all three groups (P > 0.05).
Overall comparison of each group
There was a very highly significant difference between CB and PUI group (P < 0.001) and a significant difference between CB and EA group (P < 0.05). However, no significant difference was found between EA and PUI group [Graph 1].
| Discussion|| |
Remnants of intracranial medicaments left on the dentinal walls could reduce the sealing ability of the root canal sealers. The amount of residue left can be evaluated using various methods such as digital photographs, stereomicroscope, scanning electron microscope, micro-computed tomographic imaging, and spiral computed tomographic imaging. In this study, a stereomicroscope was used at ×30 magnification, and the remnants were evaluated using a 4-grade scoring system similar to that used in previous study. Based on the results, the amount of TAP removed was significantly affected by both the irrigation techniques used and the different parts of the root canal system. Thus, both the null hypotheses were rejected.
Microorganisms play a significant role in the development of pulpoperiapical lesions. Various instrumentation techniques, irrigation protocols, and intracanal medicaments have been used to reduce the bacterial count. Due to the polymicrobial nature of the infection, different antibiotic combinations have been used to treat the diverse flora. A mixture of metronidazole, ciprofloxacin, and minocycline appears to be promising. Metronidazole is of nitroimidazole group. It has a broad spectrum of activity against protozoa and is toxic to anaerobic bacteria. Ciprofloxacin is a synthetic fluoroquinolone having bactericidal activity. In addition, metronidazole and ciprofloxacin can generate fibroblasts. Minocycline is a tetracycline derivative, which inhibits collagenases and matrix metalloproteinases and increases the level of interleukin-10, an anti-inflammatory cytokine.
In previous studies, TAP has been used successfully for the treatment of large periapical lesions. TAP has a significant potential to eradicate bacterial biofilm, which is a critical step in regenerative endodontics. When used in low concentrations such as 1, 0.1, or 0.01mg/mL, it possesses the ability to eradicate E. faecalis colonies with no side effect on the viability of the stem cells in the apical papilla. Also, as an intracanal medicament, it has led to an increase in dentin thickness and root length.
TAP has been left in the root canal up to 21 days in the previous studies. To simulate a similar clinical condition, in this study, TAP was left into the root canal up to 21 days. Discoloration due to presence of minocycline in TAP has been reported., Minocycline chelates calcium ions to form insoluble complexes that remain in calcifying tissues. This report was confirmed in this study as TAP containing minocycline discolored the root canal walls.
In the apical and middle third, PUI was more effective than CB in removing TAP. PUI relies on an ultrasonically oscillating instrument, which transfers energy to the irrigation solution inside the root canal which results in acoustic streaming or cavitation. This micro streaming causes more dentine debris to be removed from canal walls. Probably the same mechanism is responsible for effective removal of TAP. PUI is said to generate higher velocity of irrigant flow. Reports have shown that fresh irrigant replacement also improves its efficacy. The smaller tip used for PUI allowed free movement in the apical region, with consequent increase in hydrodynamic flow.
It is believed that a brush-covered irrigation needle will aid in removing debris from the root canal because it is flexible and the bristles may extend into the uninstrumented canal irregularities, into fins, cul-de-sacs, and isthmuses and remove the trapped tissue and debris. However, studies have evaluated the effectiveness of CB in removing antibiotic paste from root canal system and found antibiotic remnants to be packed mainly in the apical third of the root canal in nearly all specimens., Grischke et al. reported from their investigation that PUI is more effective than CB. A similar situation was noticed in this study.
It has been suggested that the use of PUI for 3–5 min with NaOCl concentrations of 3% or 5% is sufficient for the complete removal of the smear layer in instrumented root canals. Wiseman et al. found that PUI repeated three times with 20s intervals was more effective than sonic irrigation. This result could be due to the fact that sonic frequency ranges are much lower than ultrasonic irrigation, and therefore the acoustic microstreaming would be lower, as would be the cleaning efficacy. This study’s results were inconsistent with the above findings, may be because a different irrigation duration, and regime was applied.
| Conclusion|| |
According to the findings of this study, it can be concluded that the different irrigation protocols significantly influence the removal of TAP from the root canal walls. Within limitations of the study, PUI led to superior results compared to CB in the middle and apical thirds. There was no significant difference between EA and PUI techniques.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical policy and institutional review board statement
Patient declaration of consent
Data availability statement
| References|| |
Gorduysus M, Nagas E, Torun OY, Gorduysus O A comparison of three rotary systems and hand instrumentation technique for the elimination of Enterococcus faecalis
from the root canal. Aust Endod J 2011;37:128-33.
Yücel AÇ, Gürel M, Güler E, Karabucak B Comparison of final irrigation techniques in removal of calcium hydroxide [Internet]. Aust Endod J 2013;39:116-21.
Mohammadi Z, Dummer PM Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endod J 2011;44:697-730.
Pai ARV, Pai S, Thomas M, Bhat V Effect of calcium hydroxide and triple antibiotic paste as intracanal medicaments on the incidence of inter-appointment flare-up in diabetic patients: An in vivo
study [Internet]. J Conserv Dent 2014;17:208.
Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al
antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125-30.
Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in situ
. Int Endod J 1996;29:118-24.
Taneja S, Kumari M Use of triple antibiotic paste in the treatment of large periradicular lesions. J Investig Clin Dent 2012;3:72-6.
Adl A, Shojaee NS, Motamedifar M A comparison between the antimicrobial effects of triple antibiotic paste and calcium hydroxide against Entrococcus faecalis
. Iran Endod J 2012;7:149-55.
Ruparel NB, Teixeira FB, Ferraz CC, Diogenes A Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. J Endod 2012;38:1372-5.
Kim JH, Kim Y, Shin SJ, Park JW, Jung IY Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: A case report. J Endod 2010;36:1086-91.
Topçuoğlu HS, Düzgün S, Ceyhanlı KT, Aktı A, Pala K, Kesim B Efficacy of different irrigation techniques in the removal of calcium hydroxide from a simulated internal root resorption cavity. Int Endod J 2015;48:309-16.
Bryce G, MacBeth N, Gulabivala K, Ng YL The efficacy of supplementary sonic irrigation using the EndoActivator® system determined by removal of a collagen film from an ex vivo model. Int Endod J 2018;51:489-97.
Munoz HR, Camacho-Cuadra K In vivo
efficacy of three different endodontic irrigation systems for irrigant delivery to working length of mesial canals of mandibular molars. J Endod 2012;38:445-8.
van der Sluis LW, Wu MK, Wesselink PR The evaluation of removal of calcium hydroxide paste from an artificial standardized groove in the apical root canal using different irrigation methodologies. Int Endod J 2007;40:52-7.
Thakur DA, Patil S, Gade V, Jogad N, Gangrade A, Sinkar R Comparative scanning electron microscopy evaluation of canal brushing technique, sonic activation, and master apical file for the removal of triple antibiotic paste from root canal (in vitro
study). Contemp Clin Dent 2015;6:517-21.
Wiseman A, Cox TC, Paranjpe A, Flake NM, Cohenca N, Johnson JD Efficacy of sonic and ultrasonic activation for removal of calcium hydroxide from mesial canals of mandibular molars: A microtomographic study. J Endod 2011;37:235-8.
Mohammadi Z, Jafarzadeh H, Shalavi S, Yaripour S, Sharifi F, Kinoshita JI A review on triple antibiotic paste as a suitable material used in regenerative endodontics. Iran Endod J 2018;13:1-6.
Ferreira MB, Myiagi S, Nogales CG, Campos MS, Lage-Marques JL Time- and concentration-dependent cytotoxicity of antibiotics used in endodontic therapy. J Appl Oral Sci 2010;18:259-63.
Parhizkar A, Nojehdehian H, Asgary S Triple antibiotic paste: Momentous roles and applications in endodontics: A review. Restor Dent Endod 2018;43:e28.
Vijayaraghavan R, Mathian VM, Sundaram AM, Karunakaran R, Vinodh S Triple antibiotic paste in root canal therapy. J Pharm Bioallied Sci 2012;4:S230-3.
do Couto AM, Espaladori MC, Leite APP, Martins CC, de Aguiar MCF, Abreu LG A systematic review of pulp revascularization using a triple antibiotic paste. Pediatr Dent 2019;41:341-53.
Tawfik H, Abu-Seida AM, Hashem AA, Nagy MM Regenerative potential following revascularization of immature permanent teeth with necrotic pulps. Int Endod J 2013;46:910-22.
Lenherr P, Allgayer N, Weiger R, Filippi A, Attin T, Krastl G Tooth discoloration induced by endodontic materials: A laboratory study. Int Endod J 2012;45:942-9.
Kahler B, Rossi-Fedele G A review of tooth discoloration after regenerative endodontic therapy. J Endod 2016;42:563-9.
Mozo S, Llena C, Forner L Review of ultrasonic irrigation in endodontics: Increasing action of irrigating solutions. Med Oral Patol Oral Cir Bucal 2012;17:e512-6.
Jiang LM, Verhaagen B, Versluis M, Langedijk J, Wesselink P, van der Sluis LW The influence of the ultrasonic intensity on the cleaning efficacy of passive ultrasonic irrigation. J Endod 2011;37:688-92.
Jiang LM, Verhaagen B, Versluis M, van der Sluis LW Influence of the oscillation direction of an ultrasonic file on the cleaning efficacy of passive ultrasonic irrigation. J Endod 2010;36:1372-6.
van der Sluis LWM, Maikel PJ, Verhaagen B, Macedo R, Wesselink PR Study on the influence of refreshment/activation cycles and irrigants on mechanical cleaning efficiency during ultrasonic activation of the irrigant [Internet]. J Endod 2010;36:737-40.
Gorduysus M, Yilmaz Z, Gorduysus O, Atila B, Karapinar SO Effectiveness of a new canal brushing technique in removing calcium hydroxide from the root canal system: A scanning electron microscope study. J Conserv Dent 2012;15:367-71.
Garip Y, Sazak H, Gunday M, Hatipoglu S Evaluation of smear layer removal after use of a canal brush: An SEM study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e62-6.
Grischke J, Müller-Heine A, Hülsmann M The effect of four different irrigation systems in the removal of a root canal sealer. Clin Oral Investig 2014;18:1845-51.
Urban K, Donnermeyer D, Schäfer E, Bürklein S Canal cleanliness using different irrigation activation systems: A SEM evaluation. Clin Oral Investig 2017;21:2681-7.
Neelakantan P, Ounsi HF, Devaraj S, Cheung GSP, Grandini S Effectiveness of irrigation strategies on the removal of the smear layer from root canal dentin. Odontology 2019;107: 142-9.
[Figure 1], [Figure 2], [Figure 3], [Graph 1]
[Table 1], [Table 2], [Table 3]
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