| Abstract|| |
Aim: The purpose of this in vitro study was to evaluate the cleaning efficacy of NaviTip, Max-i-Probe and Endovac in removal of debris from the root canal at 1.5 and 3.5 mm from the apex.
Materials and Methods: Forty single-rooted teeth were divided into four groups according to the root canal irrigation system (EndoVac, NaviTip, Max-i-Probe, and control). Instrumentation was done using ProFile 0.06 taper series to MAF #40. Root canals were irrigated after each file size with 1 ml of 5% NaOCl. For final irrigation 5 ml of 5% NaOCl and 17% ethylenediaminetetraacetic acid (EDTA) was used. Each group was irrigated with a different irrigation device. Four micron thick serial sections were prepared at 1.5 and 3.5 mm from the apical level and photographs were taken for the analysis. The influence of the irrigation system was evaluated using a one-way analysis of variance (ANOVA) test and unpaired t-test (P < 0.05).
Results: Endovac showed significantly least amount of mean percentage debris followed by Max-i-probe and NaviTip at both levels (P < 0.05). In all the experimental groups, significantly less amount of mean percentage debris was seen at 3.5 mm level than at 1.5 mm level (P < 0.05). However, the difference was statistically insignificant in case of Endovac irrigation system group.
Conclusions: Amongst all the experimental groups, Endovac removed significantly more debris followed by Max-i-probe and NaviTip at both levels.
Keywords: Debris removal; Endovac; irrigation system; light microscope; Max-i-Probe; NaviTip
|How to cite this article:|
Saini M, Kumari M, Taneja S. Comparative evaluation of the efficacy of three different irrigation devices in removal of debris from root canal at two different levels: An in vitro study. J Conserv Dent 2013;16:509-13
|How to cite this URL:|
Saini M, Kumari M, Taneja S. Comparative evaluation of the efficacy of three different irrigation devices in removal of debris from root canal at two different levels: An in vitro study. J Conserv Dent [serial online] 2013 [cited 2019 Dec 7];16:509-13. Available from: http://www.jcd.org.in/text.asp?2013/16/6/509/120959
| Introduction|| |
The ultimate goal of endodontic therapy should be to return the involved teeth to a state of health and function.  Instrumentation of the root canal system is recognized as being one of the most important stages in root canal treatment.  The debris created during root canal instrumentation should be removed from the dentine surface of the canal wall and the dentine tubules.
Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue, and disinfecting the root canal system.  An effective irrigation delivery system is required for the irrigants to reach the working length. Such a delivery system should have adequate flow and volume of irrigant to the working length to be effective in debriding the complete canal system. ,
Conventional irrigation with a syringe and needle remains widely accepted. However, it has been demonstrated that the flushing action of syringe irrigation to remove debris from root canal irregularities is not sufficient. ,,, It has also been seen in a previous study that when conventional syringe needle was used, the irrigating solution was delivered only 1 mm deeper than the tip of the needle. 
To overcome the drawback of irrigation with conventional needles, flexible needles like NaviTip (Ultradent Products Inc., South Jordan, UT) have been introduced. It is a flexible, stainless steel cannula that easily navigates curved canals and provides controlled delivery to the apex.
Max-i-Probe (Dentsply International, York, PA) is a very commonly used manual irrigation system. It has a closed end irrigating probe with side-port dispersal that creates an upward flushing motion. The closed, round end reduces risk of apex damage. Kahn and others  in their study found that Max-i-Probe was more effective in irrigation than the conventional needles routinely used. Klyn and others  found that Max-i-Probe was as effective as EndoActivator TM system, the F file TM and ultrasonic irrigation in canal and isthmus cleanliness.
Recently, Endovac (Discus Dental, Culver City, CA), a novel device for root canal irrigation has been introduced. It is a unique commercially available negative pressure irrigation system that claims to deliver irrigant to the apical portion of the root canal system in a safe and effective manner. Nielsen and Baumgartner  found that Endovac system showed significantly better debridement at 1 mm from working length compared with needle irrigation. However, a study by Jiang and others  found that Endovac was not superior to the other irrigaton techniques like manual dynamic activation, the safety irrigator system and continuous ultrasonic irrigation system used in their study. In another study by Pawar and others  Endovac irrigation system did not provide any added advantage over standard irrigation in obtaining microbe free root canals.
Till date no study has compared the debris removal efficacy of these three irrigation devices together. The purpose of this study was to evaluate and compare the cleaning efficacy of NaviTip, Max-i-Probe, and Endovac in removal of debris from the root canal at two different levels.
| Materials and Methods|| |
For this study, 40 single rooted permanent teeth with mature apices were collected and were immediately stored in 10% formalin.
The crown portion of all teeth was removed and the coronal part of the root was trimmed to 17 mm in length from the root apex. To resemble the clinical situation, a closed system was created by coating each root with soft modeling wax. A shallow horizontal groove was made in the coronal one-third of each root for mechanical retention and then placed in a plastic container filled with a rubber base impression material to mimic periodontal support.
The coronal portion was flared using ProFile orifice shapers (Dentsply Maillefer, Ballaigues, Switzerland). The working length was established by inserting a size 15 k file into the canal until the tip of the file was just visible at the apical foramen and then deducting 1 mm from that length. Root canals allowing introduction of an instrument exceeding size 20 were excluded. The 40 specimens were randomly divided into three experimental groups (n = 30) and one control group (n = 10). Group 1: Endovac (n = 10) (Discus Dental, Culver City, CA), Group 2: NaviTip (n = 10) (Ultradent Products Inc., South Jordan, UT), Group 3: Max-i-Probe (n = 10) (Dentsply International, York, PA), and positive control: (n = 10) No irrigation was done during instrumentation.
The root canals were instrumented using a ProFile 0.06 taper series to MAF #40. After each file size, the root canal was irrigated with 5% NaOCl solution. For final irrigation, 17% ethylenediaminetetraacetic acid (EDTA) followed by 5% NaOCl was used. To maintain patency, recapitulation was done by inserting a #10 stainless steel hand file 0.5 mm beyond the working length. The rotary files were changed after being used in six samples.
Irrigation in all the groups was done with respective irrigation devices as per manufacturer's instructions. Irrigation was done after each instrument change and also after instrumentation was completed. Standardized volume of irrigant was used for all the three devices. The rate of irrigant flow was standardized to 1 ml over a period of 30 s.
The teeth were removed from the impression material and marked on the external surface of the root at 1.5 and 3.5 mm from the apical foramen with a scalpel. A one-fourth round bur was used to deepen the marks by creating a shallow groove. The teeth were fixed with formalin for 24 h and then decalcified in a specific solution (7% nitric acid-formalin decalcification solution) in decalcifying unit for 7 days. The decalcified roots were cut at the shallow grooves formed at the 1.5 and 3.5 mm level from the apex by using a microtome and serial sections of 4 micron thickness were prepared. After staining with hematoxylin and eosin stain by following standard protocol, sections were then mounted on glass slides.
These mounted sections were observed under optical microscope at original magnification ×100. Image analysis software was used to analyze and calculate the amount of debris remaining in the root canal space in microns per pixels. The amount of debris remaining in each root canal was quantified as a percentage of the root canal lumen area. Then the mean were calculated and subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) version 17. One-way analysis of variance (ANOVA) with post hoc analysis (least square difference) was applied to see the significance among the various groups and at different levels. Unpaired t-test was used to see the significance in one particular group at different sites.
| Results|| |
The results of the study showed that all experimental groups showed significantly less debris than the control group at both 1.5 and 3.5 mm level. No difference was observed between experimental groups when all groups (experimental and control) were compared. However, when experimental groups were compared with each other, without considering the control group, a statistically significant difference was found between them.
Amongst all the experimental groups, Endovac showed significantly (P < 0.05) least amount of mean percentage debris followed by Max-i-probe and NaviTip at both levels [Table 1]. Max-i-probe showed significantly less debris than NaviTip at both the levels (P < 0.05). In all the experimental groups, significantly less amount of mean percentage debris was seen at 3.5 mm level than at 1.5 mm level (P < 0.05). However, the difference was statistically insignificant in case of Endovac irrigation system group. [Figure 1] illustrates remaining root canal debris of experimental groups and positive control at 1.5 mm and 3.5 mm from the apical foramen.
|Table 1: Intergroup comparison of mean percentage debris at both the levels, that is, 1.5 and 3.5 mm|
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|Figure 1: Remaining root canal debris of experimental groups and positive control at 1.5 mm (a) and 3.5 mm (b) from the apical foramen with ×100 magnifi cation are shown in the figure; (A) Endovac irrigation system, (B) NaviTip group, (C) Max-i-Probe, and (D) Control group|
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| Discussion|| |
It is important that the irrigants must be brought into direct contact with the entire canal wall surfaces for effective action particularly in the apical portions of root canals because of the typically challenging complexity of the root canal morphology.  For the irrigants to reach the apical region there must be an effective delivery system. Various irrigation delivery and agitation systems have been developed for effective root canal irrigation.
While testing the effect of irrigation and fluid dynamics, one should take into consideration the presence of the periradicular tissues surrounding the root surface, preventing passive extrusion of irrigant and creating a closed canal system. ,, Clinically, this means that the irrigants always exit the canal coronally and not apically or laterally. Therefore to resemble the clinical situation, a closed system was created by coating each root with soft modeling wax. This coating sealed the apical foramen and lateral canals.
For determining debris removal efficacy of various irrigaton devices, scanning electron microscopy has been used by various authors. , Tay and others  pointed out that it was difficult to use scanning electron microscopy for examining the apical 0.5-1 mm of the canal walls and suggested using light microscopy for critically examining the canal cleanliness (i.e., debris retention) at the different canal levels. Therefore in this study, light microscopy was used to evaluate debris remaining after irrigation with three different devices.
We recognize that anatomy is a very difficult variable to standardize. Moreover, variation in apical enlargement might influence the fluid flow and the amount of remaining debris after mechanical instrumentation. To overcome these variables the root canals allowing introduction of an instrument exceeding size 20 were excluded and the Master Apical File (MAF) and the rotary instrument taper were standardized. This approach minimized the difference in remaining debris or cleaning efficacy after the mechanical instrumentation.
In this study, Endovac irrigation system group was found to show significantly less debris than NaviTip and Max-i-Probe group at both 1.5 and 3.5 mm levels. The effectiveness of Endovac system in producing clean canals at both the levels might be attributed to its apical negative pressure approach. The apical negative pressure pulls the irrigant down the canal walls towards the apex, creating a rapid turbulent current force towards the terminus of the microcannula. The orifices of the microcannula provide a portal of exit for canal debris in closed end canal systems.  This mechanism helps it to overcome the vapor lock, thus enabling effective irrigation. On the other hand NaviTip and Max-i-Probe were not able to remove debris that effectively. This could be explained by the fact that both NaviTip and Max-i-Probe are positive pressure irrigation devices due to which they are unable to eliminate the vapor lock effect seen in the apical part of root canal in a closed system. Studies have demonstrated that the presence of an apical vapor lock adversely affects debridement efficacy when using positive pressure irrigation. , According to Tay and others  , in the closed system, irrigant extrusion beyond 1-1.5 mm of Max-i-Probe (side-venting needle) generates a liquid film along the air bubble-canal wall interface. Fluid stagnation in this ''dead water zone'' fails to provide adequate irrigant replacement, resulting in gross debris retention in this region.
Our results are consistent with the findings of Ribeiro and others  who reported Endovac to remove significantly more debris than NaviTip. Saber and Hashem  in their study found that Endovac was significantly better in removing debris than NaviTip in the apical third of the root canal.
Heilborn and others  in their study compared the EndoVac system to the Max-i-Probe for root canal cleaning efficacy and found that Endovac system performed better than Max-i-Probe. However, in their study, no significant difference was found between groups at 3 mm level.
This could be due to a different methodology used in their study to assess debris. Similarly, Howard and others  in their study compared the debris removal efficacy of EndoVac, PiezoFlow, and Max-i-Probe in mandibular molars and found that there was no statistically significant difference in canal cleanliness among all groups at 2 and 4 mm from working length. In another study, Nielsen and Baumgartner  reported that at 1 mm level, significantly less debris was found in the Endovac group. However, at 3 mm level, no significant difference was found between Endovac and ProRinse needle (side vented needle).
Even though both NaviTip and Max-i-Probe are positive pressure irrigation device, but still Max-i-Probe in our study was able to remove significantly more debris. This may be due to the reason that Max-i-Probe has a laterally perforated needle which develops a laterally directed hydraulic pressure within the root canal. This mechanism allows the removal of the debris from the wall surfaces. In comparison to this, NaviTip is an end port needle. Kahn and others  found that Max-i-Probe was the most effective instrument used to clear dye from the simulated canals. They related this to its design. It has a blunt tip with the lumen ~2 mm from the tip. Expression of fluid through the lumen creates turbulence. The turbulent motion enabled the dye used in their study to be removed more effectively. Pavlović and Živković in their study found that laterally perforated needles for irrigation allows more efficient cleaning of root canal walls as compared to end vented needles (conventional needles).
Intragroup comparison of all groups at 1.5 and 3.5 mm showed more debris at 1.5 mm level than at 3.5 mm and the difference was statistically significant except in Endovac group. The effectiveness of EndoVac system at producing clean canals at both the levels might be attributed to elimination of vapor lock.
Our findings are consistent with the findings by Susin and others.  They found that apical negative pressure irrigation technique with the placement of the EndoVac microcannulas to working length resulted in clean instrumented canal spaces at all the 10 canal levels between 1 and 2.8 mm of the apex and the difference was statistically insignificant. Heilborn and others  in their study found all the negative pressure irrigation samples to be 100% clean both at 1 or 3 mm from working length.
Within the parameters of this in vitro study, it was found that apical negative-pressure irrigation has the potential to achieve better root canal cleaning at both 1.5 and 3.5 mm level than positive pressure irrigation. Clinical controlled trials are warranted to corroborate the impact of clean canals obtained with apical negative pressure irrigation and the outcome of treatment.
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Department of Conservative Dentistry and Endodontics, Institute of Technology and Science Centre for Dental Studies and Research, Delhi-Merrut Road, Ghaziabad, Uttar Pradesh - 201 206
Source of Support: None, Conflict of Interest: None