endodontic triad for success - · pdf filepotentially exchange intracanal irrigants into all...

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Authored by Clifford J. Ruddle, DDS

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Volume 34 No. 5 Page 76

Endodontic Triad for Success The Role of Minimally Invasive Technology

CONTINUING EDUCATION

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For more than 50 years, there has been universalagreement that the triad for endodontic success isshaping canals, cleaning in 3 dimensions, and filling root

canal systems. Further, it is globally accepted that 3-Ddisinfection is central to success and has traditionally requireda well-shaped canal. Yet, the concept of minimally invasiveendodontics (MIE) has ignited a discussion between proponentsof well-shaped canals and those who advocate more minimallyprepared canals. Although well intended, this shaping shiftalone will never fulfill the biological objectives for success. Toforward the concept of MIE will require a new future that’s notabout the past, but takes the past into account. The way forwardto better respect the concept of MIE requires minimallyinvasive technology (MIT) that strategically optimizes 3-Ddisinfection and filling root canal systems.

This article will examine each pillar that supports theendodontic triad for success and focus on the current and futuretechnologically driven methods that will better enable 3-Dcleaning and filling root canal systems. The intention of thisarticle is to invite everyone to pause, pump the brakes, andthoughtfully reflect on how each pillar, individually and in

combination, serves to influence the biological objectives forpredictably successful endodontics.

SHAPING CANALSThe only current reason to skillfully negotiate, secure, and fullyshape any given canal is to create sufficient space to hold aneffective reservoir of reagent that, upon activation, can bepotentially exchanged into all aspects of the root canal system.Even with this long-standing knowledge regarding theimportance of the shape, ongoing debate and lingeringcontroversy continues as to the minimal mechanicalrequirements that enable any given preparation and its relatedroot canal system to be 3-D cleaned and filled (Figure 1).Throughout the decades, 2 philosophical points of view haveemerged for shaping more restrictive canals.

One widely adopted point of view emphasizes smaller terminaldiameters and wider apical tapers, while maximizing remainingdentin in the body of the same canal.1 Traditionally, a finishedpreparation is confirmed to have a terminal diameter equivalent toa size 25 file and an apical one-third taper of 10% when eachsequentially larger-sized file uniformly steps back out of the canalin 0.5-mm increments (Figure 2). However, in longer, narrower, andmore curved canals, or in roots that exhibit deep externalconcavities, an apical one-third taper of 10% may be anatomicallyinappropriate (Figure 3). In these instances, it has been shown thata narrower taper of 8% can also safely clean curved canals and theirrelated root canal systems.2

The other time-honored preparation method emphasizes theimportance of enlarging the terminal diameter of virtually anypreparation, regardless of its actual anatomical size, to at least a size40 file.3 Emphasis is on working larger D0 diameter files short oflength, developing an apical box, and producing a taperedpreparation of 4% or 6%. Yet, blocks, ledges, and apical trans-portations can result when working larger-sized—and hencestiffer—files to length, especially in longer, narrower, and moreapically curved canals.4Further, caution should be exercised whenshaping canals that exhibit deeper external root concavities, asoverpreparing the body of these canals thins roots and predisposesto iatrogenic events. Appreciate that a size 30/06 or 40/06 fixedtapered file has a large D16 diameter of 1.26 mm or 1.36 mm,respectively (Table 1).

The international body of research on shaping canals hastraditionally demonstrated that preparations must bedeveloped to minimal mechanical parameters in order topotentially exchange intracanal irrigants into all aspects of theroot canal system. Further, Albrecht et al5 have shown that a20/10 preparation is equally clean to a 40/06 preparation(Figure 4). From the evidence, it could be said that that these 2

Endodontic Triad for SuccessThe Role of Minimally InvasiveTechnology

About the Author

Dr. Ruddle is founder and director of Ad vancedEndodontics, an international educational source, inSanta Barbara, Calif. He is an assistant professor ofgraduate endodontics at Loma Linda University andUniversity of California, Los Angeles, an associateclinical professor at University of California, SanFrancisco, and an adjunct assistant professor of

endodontics at University of the Pacific School of Dentistry. As an inventor,he has designed and developed several instruments and devices that arewidely used internationally. He is well known for providing superb endodonticeducation through his lectures, clinical articles, training manuals, videos, andDVDs. He maintains a private practice in Santa Barbara. He can be reachedat (800) 753-3636 or endoruddle.com.

Disclosure: Dr. Ruddle has a financial interest in products on which hecollaborates, which include the ProTaper, WaveOne, and Endo Activator Systems(DENTSPLY Tulsa Dental Specialties).

Effective Date: 05/01/2015 Expiration Date: 05/01/2018

schools of thought have defined the boundaries for final shapesthat can be theoretically cleaned and filled. In spite of theseboundaries, there is emerging advocacy that champions moreminimally prepared canals, while failing to address how thisalone can 3-D clean and fill these canals and their related rootcanal systems.6

To objectively compare commercially available files and theshapes they cut, it would be wise to first review the anatomy ofhuman teeth. With exceptions, the vast majority of teeth rangefrom 19 to 25 mm in overall length. Most clinical crowns are about10 mm, and most roots range from 9 to 15 mm in length. If we dividethe root into coronal, middle, and apical one-thirds, then each thirdis between 3 and 5 mm in length, or on average 4 mm (Figure 5).This means the most important aspect of a file is that portion of itsactive length that actually extends below the orifice. With so muchmisinformation, it is informative to compare the cross-sectionaldiameters of different brands and designs of files along their activeportion from D1 to D12 (Tables 1 and 2).

Another critical consideration that will influence the terminaldiameter and taper of the preparation, and hence disinfection, iswhether the file has a fixed or variably tapered design along itsactive portion. Table 1 provides information regarding files withdifferent D0 diameters and fixed tapered designs; examples of themore popular North American brands with this design includeProFile, GT, and Vortex (DENTSPLY Tulsa Dental Specialties[DTDS]); TF Adaptive files (Axis|SybronEndo), and EndoSe quence(Brasseler USA). As was previously stated, caution should beexercised if the decision is to carry a file with a larger D0 diameterand 6% fixed tapered design to the full working length.

File brands that have a variably or progressively tapereddesign over the active portion of a single file were first introducedin North America by DTDS. Table 2 provides information andspecific examples of legally sold file brands with this design, which

include Tru Shape, ProTaper NEXT (PTN), ProTaper Universal(PTU), ProTaper Gold (PTG), and WaveOne (all DTDS). For example,a PTU/PTG 25/08 F2 Finishing file has a fixed taper of 8% from D1 to D3, then a decreasing percentage tapered design from D4 toD16. With respect for the concept of MIE, the F2 has a D16diameter of 1.05 mm versus an alarming 1.53 mm if this same filehad a fixed taper of 8% over the entire length of its active portion(Figure 6).

Hence, the concept of MIE is commercially driving 3viewpoints and related technologies. One viewpoint advocatesminimally preparing can als using smaller-sized, fixed, or de -creasing percentage tapered file de signs. However, profoundlymore meaningful and central to success is MIT that canexquisitely clean root canal systems, in either fully prepared orminimally prepared canals. Min imally prepared canals and theirrelated root canal systems that can actually be disinfected will,in turn, require advancements in MIT and materials that canpredictably fill root canal systems. MIT that focuses on 3-Ddisinfection and filling root canal systems are the breakthroughfor MIE and the future of endodontics.

3-D DISINFECTIONLike the extraction, endodontic treatment should be directedtoward removing all the pulp, bacteria when present, and relatedirritants from the root canal system. Further influencing 3-Ddisinfection is to recognize that the files utilized to prepare canalsproduce a smear layer, which is oftentimes a cocktail containingdentinal mud, pulpal remnants, and micro-organisms, whenpresent. Im portantly, this smear layer serves to limit or block theexchange of an irrigant into the uninstrumentable aspects of theroot canal system.7 In the quest toward complete 3-D disinfection,many reagents, devices, and methods have been advocated.

One of the more traditional methods has included

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Endodontic Triad for Success

Figure 1. These radiographic imagesdemonstrate this MB system contains a loop,an anastomosis, and divides apically into 4portals of exit.

Figure 2. This graphic illustrates a traditional stepback preparation that has a 10% taperlimited to the apical one-third.

Figure 3. This post-treatment film reveals 3flowing multiplanar shapes and 6 filled portalsof exit. Note the furcal canal.

dispensing various reagents from a handheldsyringe, utilizing a preferred gauge cannula.More recently, many so-called final rinsesolutions have come to market to presumablybetter eliminate mi cro-organisms. Throughoutthe years, other disinfection methods emerged,including heating reagents, utilizing ionto-phoresis, pumping an apically trimmed gutta-percha master cone in a well-shaped andfluid-filled canal, employing negative pressureirrigation/vacuum devices, activating re agentswith ultrasonic metal insert tips or sonicnonmetal insert tips, and energizing reagentswith soft- and hard-tissue lasers.

Importantly, there has been significantinterest in biofilms and their role in endodonticprognosis. A biofilm is a structured communityof bacteria enclosed in a protective, stickypolysaccharide matrix that can adhere to anyroot canal surface. Further, planktonic—or free-floating organisms within biofilm fragments—have been observed to disrupt, drift, andreattach to any surface within the root canalsystem, including dentinal tubules.8 Logically,3-D cleaning procedures should be directedtoward disrupting any given bio film, breakingup this matrix, and moving this infected massinto solution so it can be eliminated from theendodontic space.

Active irrigation is intended to initiate fluidhydrodynamics and holds significant promise toimprove disinfection. There is increasingendodontic evidence to support that fluid activation plays astrategic role in cleaning and disinfecting all as pects of the rootcanal system, including dentinal tu bules, lateral can als, fins, webs,and anastomoses.2,9-11The greatest focus today is on how to safelyactivate any given solution to maximize the hydrodynamicphenomenon in both well-shaped and minimally prepared canals.There are several emerging methods that are receiving attentionand are purported to effectively activate an intracanal solution.

Hydrodynamic DisinfectionThe EndoActivator system (DTDS) is comprised of a cordlesshandpiece and variously sized polymer tips (Figure 7a). Thistechnology utilizes sonic energy to drive a preselected tip, whichin turn activates various intracanal reagents, producing avigorous hydrodynamic phenomenon in well-shaped canals. Astrong, flexible, and noncutting vibrating tip generates fluid

activation and intracanal waves, which then fracture, creatingbubbles that oscillate within any given solution (Figure 7b).These bubbles expand and become unstable, then collapse andimplode. Each implosion produces shockwaves that dissipate at25,000 to 30,000 times per second.9

Shockwaves serve to powerfully penetrate, break up biofilmswhen present, and wipe surfaces clean. Implo ding bubblesdesirably increase the temperature and further generatesignificant pressure on an intracanal irrigant, which in a smallanatomical space, serves to promote surface cleaning.8-9 Duringuse, the action of the Endo Activator tip frequently produces acloud of debris that can be observed within a fluid-filled pulpchamber. Research has shown this technology is able to removethe smear layer, debride into the deep lateral anatomy, anddislodge biofilm clumps within curved mesial canals of molarteeth (Figure 7c).2,10-11

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Table 1. Fixed Tapered File Design

Table 2. Variably Tapered File Design

Another powerful method to eradicate microbes utilizesphotoactivated disinfection (PAD). Clinically, this techniqueinvolves dispensing a photosensitizer dye, such as toloniumchloride, into a well-shaped canal. The assumption with PAD isthat the intracanal reagent can reach and target bacteria by bindingto or entering any given microbial cell. Professor Gulabivala andhis team at the Eastman Dental Institute have shown that this canbe facilitated utilizing the EndoActivator.12 A low-power diodelaser then emits light and creates a cascade of energy transfer in thephotosensitizer, which in turn, releases singlet oxygen. Singletoxygen is a protoplasmic poison, causes lethal damage, andimplodes the marked bacterial invaders.8

The challenge is to activate any given reagent so it willpenetrate, reach, and kill bacteria. Compounding the challenge toeliminate biofilms is that they have the ability to hide within ananatomically complex space, and this is further complicated in thatthey are protected by their own secretions. On the horizon, theToronto group led by professor Anil Kishen13has been working on

advanced disinfection strategies for cleaning the uninstrumentableportions of the root canal system. This work is focusing on utilizingantibacterial nanoparticles, antimicrobial photodynamic therapy,and laser-assisted root canal disinfection methods.

3-D Disinfection in Minimally Prepared CanalsNew, minimally invasive 3-D disinfection technologies haverecently come to market that do not require canal preparationas traditionally advocated. At the Arizona Center for LaserDentistry, Dr. Enrico DiVito and his team14 ingeniouslydeveloped Photon Induced Photoacoustic Stream ing (PIPS)(Figure 8). This laser-activated disinfection method often onlyre quires any given canal be prepared to a size 20 file. The uniquetapered and striped PIPS tip is placed stationary in the pulpchamber only. When activated, PIPS creates nonthermalphotoacoustic shockwaves, which travel 3 dimensionally, eveninto the anatomically complex apical regions. Scien tificevidence confirms PIPS eliminates both planktonic and bio film

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Figure 4. Although problematic, the apicalbox preparation has been traditionally advocated to prepare a canal with a widerapical diameter and narrower taper.

Figure 5. This graphic illustrates the conceptof mentally dividing roots into thirds. Figure 6. A ProTaper Gold (PTG) Finishing file

(DENTSPLY Tulsa Dental Specialties [DTDS])better respects the concept of minimallyinvasive endodontics compared to a same-sized file with a fixed tapered design.

Figure 7a. The EndoActivator system (DTDS)is designed to safely and vigorouslyexchange intracanal reagents into the rootcanal system anatomy.

Figure 7b. This image shows theEndoActivator initiating vigorous fluid activation.

Figure 7c. SEM images provide evidence thatthe EndoActivator system can clean root canalsystems. (Courtesy of Dr. Grégory Caron; Paris,France.)

a b c

contaminates and sterilizes more than 1,000 µmdeep into the dentinal tubules, withoutdamaging root canal morphology.15

Another 3-D disinfection technology that isimminently coming to market has beendeveloped by Sonendo, commercially termedGentleWave (Figure 9). In this method, an accesscavity is prepared and more restrictive canals arecatheterized to a size 15 file, or in more opencanals, no instrumentation is required at all.Subsequently, the GentleWave handpiece isconnected to the cavosurface of an endodonticallyaccessed tooth. Treatment reagents flow throughthis closed system, creating multisonic energy inthe form of specific wide spectrum wavelengthsusing different frequencies. Collaborative re -search has shown that this disinfection methodcan 3-D clean a canal, the lateral anatomy, andrelated dentinal tubules.16

FILLING ROOT CANAL SYSTEMSVirtually all obturation methods scientificallyvalidated, utilized, and reported have beenanalyzed within the preparation boundariespreviously identified. Specifically, warm gutta-percha 3-D filling methods can be effectivelyutilized in virtually any well-shaped canal (Figure 10).17The most popular methods includevertical condensation, single-wave condensation,and carrier-based obturation. At this moment of endodonticdevelopment and financial practicality, only a single-conetechnique or a syringeable extrusion method exists for filling aminimally prepared canal. It would be wise to recall theavalanche of endo dontic failures that resulted when single cones,silver points, and carrier-based obturators were utilized inunderprepared canals.4

To date, there is no mainstream method to predictably fill anygiven minimally prepared or essentially noninstrumented canal.Certainly, work has been and is being done utilizing differentmaterials, technologies, and methods. However, when the CEO ofa company that has developed noninstrumentation 3-Ddisinfection technology was asked how a dentist could predictablyand 3-D fill such a minimally prepared canal, he stated, “Getanything you can to length that will produce a white line on aradio graph and the insurance company will pay.” This tongue-in-cheek answer readily acknowledges that there is a need to perfecta method to more predictably 3-D fill underprepared, minimallyprepared, or canals not prepared at all.

The FutureDr. Nathan Li and his team at Health dent recently developedsystem-based gutta-percha master cones (GPMCs) for well-shaped canals prepared with the most popular file brands. TheseGPMCs offer superior sizing and formulation and willimminently be launching through DTDS. Fortu itously,Healthdent’s proprietary methods represent a breakthrough byproviding an ex tended heat wave through the GPMC. Fur ther,Health dent’s work in nanotechnology is leading to thedevelopment of methods to revolutionize carrier-basedobturation as we know it. Addtion ally, regenerative efforts havefocused on developing a game-changing method to 3-D fill rootcanals and their related systems, whether minimally shaped ornot shaped at all (Figure 11). This recent work is showingpromise to unlock a new future for MIE.

The above mentioned innovations—namely, methods to fillminimally prepared canals or canals not prepared at all—areabsolutely essential in order to truly bring in a new era of betterfulfilling the concept of MIE, which in turn will redefine the

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Figure 8. An SEM image provideshistological evidence that the PhotonInduced Photoacoustic Streaming method 3-D cleans canal surfaces, tubules, and root canal system anatomy.

Figure 9. Evidence has shown thatGentleWave technology (Sonendo) canremove the smear layer, eliminate tissue,and clean deep into the dentinal tubules.

Figure 10. This post-treatment film demonstrates that effective access isessential to identify, shape, and fill these 5 root canal systems.

Figure 11. These µCT images illustrate thatadvanced technologies are essential to fullytreat root canal systems. (Courtesy of Dr.Frank Paque; Zurich, Switzerland.)

triad for endodontic success. MIE is not simply an argumentabout the size of the access cavity, or whether the canal shouldbe a certain dimension at any given level. The concept of MIEmust also focus on the necessity of eliminating vital or necrotictissue from avascular root canal systems during and after pulpdeath. Minimally invasive canal preparation alone is not MIEwhen primary treatment fails, requiring, at times, coronaldisassembly, nonsurgical retreatment, surgical correction, orextraction.4

CLOSING COMMENTS There is significant change coming, yet again, to the specialtyfield of endodontics. Regardless of how compelling any giventechnology and method is, it only represents a truebreakthrough if all endodontic mandates can be predictablyaccomplished utilizing existing available technologies. So-called minimally invasive files systems are meaningless unlesstheir commercial introduction and advocacy are accompaniedby affordable companion technologies that offer genuinepotential to better fulfill the endodontic triad for success. Untilthen, we would all be wise to recall Dr. Schilder’s clarion cry,“Make yourself the patient, and you will have the answer.”F

References1. Schilder H. Cleaning and shaping the root canal. Dent Clin

North Am. 1974;18:269-296.2. Caron G, Nham K, Bronnec F, et al. Effectiveness of different

final irrigant activation protocols on smear layer removal incurved canals. J Endod. 2010;36:1361-1366.

3. Baugh D, Wallace J. The role of apical instrumentation in rootcanal treatment: a review of the literature. J Endod.2005;31:333-340.

4. Ruddle CJ. Nonsurgical endodontic retreatment. In: Cohen S,Burns RC, eds. Pathways of the Pulp. 8th ed. St. Louis, MO:Mosby; 2002:875-929.

5. Albrecht LJ, Baumgartner JC, Marshall JG. Evaluation of apicaldebris removal using various sizes and tapers of ProFile GTfiles. J Endod. 2004;30:425-428.

6. Clark DJ. Reclaiming endodontics and reinventing restorative,part 1. Dent Today. 2010;29:112-116.

7. Haapasalo M, Orstavik D. In vitro infection and disinfection ofdentinal tubules. J Dent Res. 1986;66:1375-1379.

8. Lambrechts P, Huybrechts B, Moisiadis P, et al. Photoactivateddisinfection (PAD): paintball endodontics. Endo Tribune.2006;1:1-24.

9. Gutarts R, Nusstein J, Reader A, et al. In vivo debridementefficacy of ultrasonic irrigation following hand-rotaryinstrumentation in human mandibular molars. J Endod.2005;31:166-170.

10. Kanter V, Weldon E, Nair U, et al. A quantitative and qualitativeanalysis of ultrasonic versus sonic endodontic systems oncanal cleanliness and obturation. Oral Surg Oral Med OralPathol Oral Radiol Endod. 2011;112:809-813.

11. Ruddle CJ. Endodontic disinfection: tsunami irrigation.Endodontic Practice. 2008;11:7-16.

12. Bryce G, MacBeth N, Ng YL, et al. An ex vivo evaluation of theefficacy of dynamic irrigation using the EndoActivator. Posterpresented at: British Endodontic Society Spring ScientificMeeting; March 13, 2010; London, England.

13. Kishen A. Advanced therapeutic options for endodonticbiofilms. Endodontic Topics. 2010;22:99-123.

14. DiVito E, Peters OA, Olivi G. Effectiveness of the erbium:YAGlaser and new design radial and stripped tips in removing thesmear layer after root canal instrumentation. Lasers Med Sci.2012;27:273-280.

15. Peters OA, Bardsley S, Fong J, et al. Disinfection of root canalswith photon-initiated photoacoustic streaming. J Endod.2011;37:1008-1012.

16. Haapasalo M, Wang Z, Shen Y, et al. Tissue dissolution by anovel multisonic ultracleaning system and sodiumhypochlorite. J Endod. 2014;40:1178-1181.

17. Schilder H. Filling root canals in three dimensions. Dent ClinNorth Am. November 1967:723-744.

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POST EXAMINATION QUESTIONS

1. One widely adopted point of view emphasizes smallerterminal diameters and wider apical tapers, whilemaximizing remaining dentin in the body of the samecanal. a. True b. False

2. It has been shown that a narrower taper of 4% canalso safely clean curved canals and their related rootcanal systems. a. True b. False

3. With exceptions, the vast majority of teeth range from19 to 25 mm in overall length. Most clinical crowns areabout 10 mm and most roots range from 9 to 15 mm inlength.

a. True b. False

4. Planktonic—or free floating organisms within biofilmfragments—have been observed to disrupt, drift, andreattach to any surface within the root canal system,including dentinal tubules. a. True b. False

5. There is no scientific evidence in the endodonticliterature to support that fluid activation plays a strategicrole in cleaning and disinfecting all aspects of the rootcanal system, including dentinal tubules, lateral canals,fins, webs, and anastomoses. a. True b. False

6. Another powerful method to eradicate microbesutilizes photoactivated disinfection. Clinically, thistechnique involves dispensing a photosensitizer dye,such as tolonium chloride, into a well-shaped canal. a. True b. False

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7. Scientific evidence confirms Photon InducedPhotoacoustic Streaming eliminates both planktonicand biofilm contaminates and sterilizes more than1,000 µm deep into the dentinal tubules, withoutdamaging root canal morphology. a. True b. False

8. To date, there is no mainstream method to predictablyfill any given minimally prepared or essentiallynoninstrumented canal. a. True b. False

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