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    Endodontic Sonic and Ultrasonic Irrigant Activation: John M. Nusstein

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    Endodontic Sonic and Ultrasonic Irrigant Activation: John M. Nusstein

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    ultrasonic device

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    Endodontic Sonic and Ultrasonic Irrigant Activation: John M. Nusstein

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    AnindyaNoviaPutri
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    Clinical Dentistry Reviewed (2018) 2:22

    https://doi.org/10.1007/s41894-018-0037-1

    TECHNIQUES

    Endodontic sonic and ultrasonic irrigant activation

    John M. Nusstein1

    Received: 18 September 2018 / Accepted: 26 September 2018 / Published online: 15 October 2018
    © Springer Nature Switzerland AG 2018

    Abstract
    The ultimate goal of cleaning and shaping of the root canal system is the complete
    removal of the necrotic or vital tissue and disinfection of the root canal space for
    the placement of obturating materials. The process can be improved with the use of
    irrigant activation by:

    – Ultrasonic activation
    – Laser activation
    – Sonic activation

    Keywords  Ultrasonic · Sonic · Laser · Root canal cleaning · Disinfection

    Quick reference/description

    A fundamental principle of endodontic therapy is cleaning and shaping of the root


    canal with the aid of irrigants. The ultimate goal of cleaning and shaping of the root
    canal system is the complete removal of the necrotic or vital tissue and disinfection
    of the root canal space for placement of obturating materials. Cleaning and disin-
    fecting can be improved with the use of irrigant activation by:

    – Ultrasonic activation
    – Laser activation
    – Sonic activation

    * John M. Nusstein
    Nusstein.1@osu.edu
    1
    The Ohio State University College of Dentistry, 305 W. 12th Ave, Columbus, OH 43210, USA

    13
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    Page 2 of 7 Clinical Dentistry Reviewed (2018) 2:22

    Indications

    Cleaning of the root canal system.


    Complete removal of vital or necrotic tissue, microorganisms and their
    by-products.
    Disinfection of the root canal space.
    Removal of debris and smear layer.

    Materials/instruments

    Ultrasonic file
    File holder tips (Brasseler)
    Irrisafe ultrasonic tip
    Satelec Sonofile
    Sodium hypochlorite
    Dentsply Tulsa Dental Specialities ProUltra Piezoflow Ultrasonic tip
    Erbium-chromium-yttrium-scandium-garnett (Er,Cr:YSGG) laser
    Erbium-doped yttrium aluminum garnet (Er:YAG) laser
    Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser
    Micromega Sonic Air 1500 handpiece with an attached Rispi-Sonic file
    Dentsply Tulsa Dental Specialities EndoActivator system with attached polymer tips
    Vibringe sonic irrigation system
    Sonendo Gentlewave system

    Procedure

    Activation of the endodontic irrigant is an essential step in the complete cleaning


    of the root canal system. It can be performed with the use of ultrasonic, laser and
    sonic activation [1, 2].

    • Ultrasonic activation.
      Ultrasonics is widely used in root canal therapy. Ultrasonically activated
    irrigants are used for cleansing and disinfection within the root canal system.
    The primary effect of ultrasonic activation depends on cavitation and acoustic
    streaming.
      Cavitation usually develops after the ultrasonic energy has created a bub-
    ble that grows to a certain point and collapses generating a pressure vacuum
    effect. This effect helps in cleaning the irregularities in the canals and killing
    microorganisms.

    13
    Clinical Dentistry Reviewed (2018) 2:22 Page 3 of 7  22

    Fig. 1  Depiction of the waves


    generated around the vibrating
    ultrasonic file (ACTEON North
    America/Clinical Research
    Dental)

      An oscillatory motion of the ultrasonic instrument agitates the irrigant


    resulting in enhanced cleaning and disinfection (Fig. 1).

    Passive ultrasonic irrigation (PUI)/ultrasonically activated irrigation (UAI)

    PUI/UAI is more effective than simple syringe and needle irrigation and aids in
    debris and smear layer removal.

    For PUI/UAI, size 15 or 20 endodontic-type file or wire is attached to an ultrasonic


    handpiece. File holder tips (Brasseler) are used. These tips allow for the insertion of
    a hand file (k-type file, r-type file, spreader, etc.) or a specially designed hand file-
    type inserts (diamond coated, fluted, smooth-sided, etc.) and are secured for use in
    the canal. Irrisafe™ ultrasonic tip produced by Satelec Acteon comes in different
    lengths and diameters and includes a port for the delivery of irrigating fluid. The
    Sonofile tips by Satelec are similar to the Irrisafe™ files but without the irrigation
    port (Fig. 2) [3, 4].

    13
    22 
    Page 4 of 7 Clinical Dentistry Reviewed (2018) 2:22

    Fig. 2  a Brasseler file holder E12 (Brasseler), b Satelec Acteon Irrisafe™ tips. Note serrated wire with
    non-cutting sides and irrigation port near attachment hub (Satelec). c Satelec Sonofile with no irrigation
    port (Tulsa Dental Products)

    Effectiveness of PUI/UAI depends upon:

    – The time of exposure


    – The size of the endodontic access opening
    – The impact of canal curvature

    PUI/UAI irrigation can be of two types:

    – Intermittent flushing
    – Continuous ultrasonic irrigation (CUI)

    Intermittent flushing

    The intermittent flushing involves use of an irrigating needle/syringe that is utilized


    to fill the root canal initially and then replenish the irrigant after applications of
    ultrasonic energy within the canal.

    Continuous ultrasonic irrigation (CUI)

    CUI involves continuous flushing of the activated irrigant in the canal. To pro-
    vide CUI, Dentsply Tulsa Dental Specialties ­ProUltra® Piezoflow™ Ultrasonic
    tip (25-gauge, blunt-ended stainless steel needle) (Fig. 3a) is used. A non-needle
    delivery system that utilizes a “multi-sonic” delivery and activation of irrigant in
    ­ entleWave® system by S
    the canals is the G ­ onendo® (Fig. 3b).

    13
    Clinical Dentistry Reviewed (2018) 2:22 Page 5 of 7  22

    ­ roUltra® Piezoflow™ Ultrasonic tip (Dentsply Tulsa Den-


    Fig. 3  a Dentsply Tulsa Dental Specialties P
    tal), b ­Sonendo® ­Gentlewave® unit and handpiece (dentaltown.com)

    Irrigant agitation

    • Laser-activated irrigation (LAI).


      In LAI activation or agitation of root canal irrigants is done via use of lasers.
    The fluid in the canal is instantly vaporized (1 μs) next to the laser tip resulting
    in cavitation.
      As the irradiation continues, the vaporized water expands forming a bub-
    ble. This expansion occurs for 700  μs. When the laser pulse stops, the bubble
    begins to shrink, but the pressure of the surrounding fluid causes a violent col-
    lapse resulting in acoustic waves which result in cleaning of the canal by shear-
    ing debris off the walls (Fig. 4) [5].
    • Sonic activation.
      Sonic devices oscillate at a frequency of 20–20,000 Hz.
      The major systems available to produce sonic/subsonic agitation are the
    ­Micromega® Sonic ­ Air®1500 handpiece with an attached Rispi-Sonic® file
    (Medidenta International Inc.) seen in (Fig. 5); the ­EndoActivator® system with
    attached polymer tips (Dentsply Tulsa Dental Specialties) seen in (Fig. 6a); and
    the ­Vibringe® sonic irrigation system (Vibringe B.V.) seen in (Fig. 6b).
      Sonic activation of irrigants helps in:
    – Improved cleaning of the root canal walls, lateral canals, and isthmuses.
    – Removal of pastes and sealers (mainly calcium hydroxide).
    – Removal of smear layer.
    – Removal of bacteria from the root canal system.

    13
    22 
    Page 6 of 7 Clinical Dentistry Reviewed (2018) 2:22

    Fig. 4  Laser-activated irrigation
    (healthmantra.com)

    Fig. 5  a ­Micromega® Sonic ­Air® 1500 handpiece. b Rispi-Sonic® file (Micromega)

    Fig. 6  a ­EndoActivator® system with polymer tips (Dentsply Tulsa Dental), (b) vibringe irrigation sys-
    tem (Vibringe)

    13
    Clinical Dentistry Reviewed (2018) 2:22 Page 7 of 7  22

    Pitfalls and complications

    • Complications of PUI/UAI/CUI/Sonic activation include:


    – Added time of procedure.
    – Need for irrigant replenishment with PUI/UAI and Sonic techniques.
    – Potential risk of extrusion of debris and irrigant.
    • The transverse nature of the vibration pattern of the activated file and the effective-
    ness of ultrasonic debridement is limited by the dampening of the file against the
    root canal wall.
    • Complications of LAI include:
    – Potential damage to the root canal wall dentin.
    – Overheating of the root and periodontium.
    – Access around the canal curvatures.
    – The size of the laser tip.

    Further Reading
    1. Nusstein J (2015) Sonic and ultrasonic irrigation. In: Basrani B (ed) Endodontic irrigation - chemi-
    cal disinfection of the root canal system. Springer, Cham, pp 173–197
    2. van der Sluis LW, Versluis M, Wu MK, Wesselink PR (2007) Passive ultrasonic irrigation of the
    root canal: a review of the literature. Int Endod J 40:415–426
    3. Layton G, Wu WI, Selvaganapathy PR, Friedman S, Kishen A (2015) Fluid dynamics and biofilm
    removal generated by syringe-delivered and two ultrasonic-assisted irrigation methods: a novel
    experimental approach. J Endod 41:884–889
    4. Chou K, George R, Walsh LJ (2014) Effectiveness of different intracanal irrigation techniques in
    removing intracanal paste medicaments. Aust Endod J 40:21–25
    5. Kaptan F, Karapinar-Kazandag M, Kayahan MB, Bora T, Bayirli G (2012) Potential of an Er: yAG
    laser in the removal of calcium hydroxide from root canals. Photomed Laser Surg 30:250–254

    13

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