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Title Sonic Irrigation Leads to Improved Sealer Penetration When Compared to Conventional Irrigation in Non-Surgical Root Canal Therapy
Clinical Question When performing initial non-surgical root canal therapy, does sonic irrigation activation compared to conventional needle irrigation improve or worsen sealer penetration of dentinal tubules?
Clinical Bottom Line Sonic irrigation may increase tubular dentin sealer penetration in coronal and middle thirds of teeth that undergo initial non-surgical root canal therapy. A systematic review and meta-analysis demonstrate that sonic irrigation has a statistically significant increase in sealer penetration compared to conventional irrigation, especially in teeth that are single-rooted. More studies are needed to identify its effectiveness in the apical third or in teeth with curved apical thirds. Use of sonic irrigation can easily be adapted into clinical practice by the clinician and patient as the increase in procedural time for the clinician is minimal and there is no additional cost to the patient.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 36463149Tan/ 202217 studies: 9 for qualitative synthesis, 8 for quantitative synthesisSystematic Review & Meta-Analysis
Key resultsBoth total percentage of sealer penetration (TPSP) and maximum sealer penetration depth (MSPD) were significantly increased in the coronal third and middle third when using sonic irrigation (SI) compared to conventional needle irrigation (CNI). At a 95% CI, TPSP and MSPD were as follows: Coronal third (WMD: 8.09, 95% CI 2.78–13.40, P < 0.003; WMD: 165.32, 95% CI 128.85–201.80, P < 0.00001), Middle third (WMD: 8.81, 95% CI 5.76– 11.87, P < 0.00001; WMD: 132.98, 95% CI 68.71–197.25, P < 0.0001). As for the Apical third, no significant differences were found in TPSP between the two groups, (WMD: 4.73, 95% CI − 2.34–11.80, P = 0.19), but SI significantly enhanced MSPD over that of CNI (WMD: 121.46, 95% CI 86.55–156.38, P < 0.00001). Chi-squared tests revealed a 0-75% heterogeneity score for percent of sealer penetration and 44-90% heterogeneity score for depth of sealer penetration with higher scores for the apical third. The lower heterogeneity scores indicate that the null hypothesis can be rejected, and the higher heterogeneity scores indicates the need for additional sensitivity and standardization in future studies to increase accuracy of the data.
#2) 34148161Ates/ 202164 single-rooted extracted human mandibular incisors Randomized Controlled Trial
Key resultsWhile there were no significant differences (P > 0.05) amongst the conventional endodontic needle, EndoActivator (sonic irrigation activator), Er,Cr: YSGG laser, and XP-endo Finisher groups 2 mm away from the apex for total percentage of sealer penetration (TPSP), maximum sealer penetration depth (MSPD), and sealer penetration area (SPA), there were significant differences (P < 0.05) found 5 mm away from the apex. The EndoActivator method showed increased TPSP, MSPD, and SPA values (respectively, 64.48 ± 19.96; 1.19 ± 0.28; 2.56 ± 2.07) compared to the conventional endodontic needle method (respectively, 59.77 ± 17.41; 1.12 ± 0.39; 1.54 ± 0.77). The P values for the parameters TPSP, MSPD, and SPA are, respectively, P = 0.001, P = 0.029, and P = 0.0001.
#3) 23611397Bolles/ 201350 single-rooted human teethRandomized Controlled Trial
Key resultsTPSP and MSPD were significantly less at 1mm (<40% and <250 μm, respectively) compared to 5mm (Saline control = ~18% and ~450 µm, but all other groups >50% and >500 µm, respectively) (P < .0125) for all irrigation methods (saline control, 17% EDTA followed by 6% NaOCl (conventional irrigation), EndoActivator and Vibringe). The EndoActivator and Vibringe groups also had significantly greater TPSP at the 5-mm level than the saline control group (p < 0.0125) but not the conventional irrigation group. The use of a sonic activation, whether with EndoActivator or Vibringe, did not improve sealer penetration when compared to conventional irrigation in this study.
Evidence Search “dentinal tubule penetration irrigation conventional sealer”
Comments on
The Evidence
Tan’s systematic review and meta-analysis provided a broad overview of many randomized controlled trials and found that total percentage of sealer penetration (TPSP) and maximum sealer penetration depth (MSPD) were increased in coronal and middle thirds of the tooth compared to the apical third with the use of sonic irrigation (SI) over conventional irrigation (CNI). The inclusion and exclusion criteria were appropriate for the study, though there are limitations due to the large range of heterogeneity scores and low power due to a small sample size. Ates’ randomized controlled trial had a single-operator and all samples were appropriately randomized for experimentation. Results coincided with those of Tan’s in that TPSP and MSPD were significantly enhanced with the use if SI over CNI away from the apical region (5 mm). However, Ates’ results did not show a difference between the two types of methods at the apical region (2 mm). The limitations of this study were that data was only collected at 2 mm and 5 mm away from the apex instead of the length of the whole root, and the authors performed limited statistical analyses for the data. Bolles’ randomized controlled trial also had a single-operator, and robust statistical analyses were performed on the data. However, results contradict the first two studies in that no significant improvement in sealer penetration were observed using SI at the 1-mm or 5-mm levels. The limitations of this study were that the authors did not specify how samples were randomized, did not report raw data or confidence intervals, and the only evaluated results at 1 mm and 5 mm away from the apex. Common amongst all articles was the result that there is significantly less sealer penetration in the apical third region: there may be a ceiling effect due to the anatomic lowered density and narrower size of dentinal tubules at the apical third. While the Bolles article did not show an effect, the systematic review, which included results from both Ates and Bolles articles, showed a significant enhancement with the use of SI. Due to the small sample sizes of the Ates and Bolles studies, there is a high probability that there was not enough power to discern the differences. Thus, there seems to be a benefit to using SI, albeit a small improvement.
Applicability In clinical endodontics, cleaning and shaping of root canals have strong effects on treatment outcomes. The source of apical infection is usually coronally-sourced and the density and size of dentinal tubules in the coronal portion is greater than the apical portion of the root canal system. The systematic review was appropriately carried out with a suitable study design; however, the randomized controlled trial's internal validity is compromised due to a higher level of methodological bias. The data presented in these articles suggest that there is increased sealer penetration from apical to coronal with the use of sonic irrigation, though the effect may be small based on the discrepancies in the results. Since the increase in procedural time for the clinician to use SI is minimal and there is no additional cost to the patient, the use of SI seems beneficial. However, the data has limited external validity as the findings cannot be extrapolated to teeth with multiple roots or curved apices.
Specialty/Discipline (Endodontics)
Keywords sonic activation, sonic agitation, sonic irrigation, dentinal penetration, conventional irrigation, sealer penetration, dentinal tubule penetration
ID# 3545
Date of submission: 10/25/2023spacer
E-mail machj@livemail.uthscsa.edu
Author Janice Mach, DMD
Co-author(s) Rachel Kurcz, DDS
Co-author(s) e-mail kurcz@livemail.uthscsa.edu
Faculty mentor/Co-author Nikita Ruparel, DDS, MS, PhD
Faculty mentor/Co-author e-mail ruparel@uthscsa.edu
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