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Article

Removal of Accumulated Hard Tissue Debris (AHTD) from Root Canals with an Electric Current Device: A MicroCT Preliminary Report

by
Manuele Mancini
1,
Giovanni Cianconi
1,
Rossella Bedini
2,
Raffaella Pecci
2,*,
Luigi Cianconi
1 and
Guido Pasquantonio
1
1
Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
2
National Center of Innovative Technologies in Public Health, Italian National Institute of Health (Istituto Superiore di Sanità, ISS), 00161 Rome, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2022, 12(4), 1969; https://doi.org/10.3390/app12041969
Submission received: 4 January 2022 / Revised: 9 February 2022 / Accepted: 9 February 2022 / Published: 14 February 2022
(This article belongs to the Section Applied Dentistry and Oral Sciences)
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Versions Notes

Abstract

:
In modern endodontics, removal of accumulated hard tissue debris (AHTD) from root canals is requested. In the last decade, different irrigating solutions and activation methods have been successfully tested. Sonic activation has been shown to be effective in the removal of AHTD. Electric current has been tested before in restorative dentistry, but not in endodontics. An experimental electric current delivering device was compared in the removal of AHTD, using microCT analyses. Fifteen single-rooted teeth were shaped with TruNatomy system endodontic files and divided into three groups: negative control group: specimens underwent no activation; EA group: specimens were activated with EndoActivator (EA); EB group: specimens were activated with ElectroBond (EB). The 2D images, 3D images and morphometric analysis from the microCT showed a statistically significant increased AHTD removal when EB was used. Results of the present preliminary study showed that the irrigant activation with ElectroBond is encouraging when compared to EndoActivator along the entire root canal system. The AHTD was significantly statistically reduced, validating the clinical use of electric fields in endodontics.

1. Introduction

The main objectives of root canal treatment are three-dimensional cleaning, shaping and obturation of the root canal system, comprehensively enunciated in 1974 by Herbert Schilder [1]. Successful endodontic treatment depends on the elimination of pulp residues, bacteria and their byproducts, from both the main canal system and the accessory endodontic anatomy (dentinal tubules, lateral canals, isthmuses, cul-de-sacs and fins) [2,3,4]. During the root canal instrumentation, a residual including organic and inorganic components, known as accumulated hard tissue debris (AHTD), is produced [5]. This debris is regarded as an undesired side effect of shaping procedures as it may harbor microorganisms from disinfecting irrigants and may also interfere with root filling materials, preventing their adaptation into hard-to-reach areas.
It is universally accepted that the removal of AHTD increases disinfection and promotes the penetration of irrigants and intracanal medication, as well as ameliorating the adaptation of the filling materials to the walls of the root canal system [6,7]. At present, the removal of both organic and inorganic layers can only be obtained with different irrigating solutions [8,9]. Irrigation plays an essential role in cleaning and disinfecting the main root canal as well as isthmuses as these areas are frequently inaccessible to endodontic instruments [10]. However, irrigation is often ineffective in the removal of AHTD from the anatomical complexities of the root canal system [11,12]. The reviews of literature show that various chemicals have been used as irrigants [4,9,13,14,15]. Sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic acid (EDTA) are the recommended irrigating solutions because they are able to dissolve organic/necrotic tissue (NaOCl) and inorganic debris (EDTA), respectively [9]. The development of new mechanical instrumentation and innovative techniques has decreased the overall time of the shaping phase at the expense of the time irrigating solutions may be active in the endodontic system [16,17]. Unfortunately, using only irrigating solutions cannot ensure necessities [18]. Therefore, to enhance their efficacy, various manual and machine-assisted agitation techniques have been offered, including brushes; hand-activated files or gutta-percha cones; and laser, sonic and ultrasonic systems [19]. Sonic activation and passive ultrasonically activated irrigation are two techniques that claim to improve the irrigant’s effectiveness [20,21,22,23]. The EndoActivator (EA) (Dentsply Sirona, Ballaigues, Switzerland) is a sonically driven irrigant activation system designed to produce vigorous intracanal fluid agitation that has been shown to increase the efficacy of irrigation better than traditional needle irrigation [21]. In the last decade, in restorative dentistry, the application of an electric current with an experimental device has been shown to be effective in improving the shear bond strength (SBS) of dental adhesives to dentine [24]. Moreover, it reduces nanoleakage as it enhances resin infiltration into the demineralized collagen matrices of acid-etched dentin [25,26].
In endodontics, electric current has never been tested before. The electric current delivering device should create an electric potential difference between the endodontic tooth substrate and the ionic irrigating solution inside the root canal producing a constant electric flow. The removal of AHTD should be improved during root canal treatment, and the activation with electric current has never been tested before with endodontic irrigating solutions; therefore, the aim of the present study was two-fold: to investigate the effectiveness of electricity in the removal of AHTD and to compare electricity to a well-known irrigating activation system, sonic technology.

2. Materials and Methods

2.1. Sample Selection

This preliminary study was approved by the Ethics in Research Committee of the Centre of Health Sciences of the University of Rome “Tor Vergata”, Italy (register No 25–30–29). Fifteen single-rooted teeth extracted for orthodontic reasons from young adult patients between 15 and 25 years old were selected. Teeth met the following inclusion criteria: no carious lesions, cracks, resorptions or previous restorative and endodontic treatment. Only teeth with intact and mature root apices and similar length (20–22 mm) were selected. Teeth were then radiographed buccolingually and mesiodistally. Teeth with root canal curvatures greater than 5° or calcified root canals were discarded. The degree of root canal curvature was calculated according to Schneider’s method. After extraction, teeth were stored in a solution of 2% thymol in distilled water at room temperature and used within one week. Inclusion and exclusion criteria were verified under a 20× magnification laboratory microscope (Stemi DV4 Spot; Carl Zeiss, Oberkochen, Germany). After the access cavity was created, a #15 K-file (Dentsply Sirona) was inserted into the canal until the instrument tip was barely visible at the apical foramen and the working length was established 1 mm shorter than that point. The apices of the teeth were sealed with a resin-based composite material (SDR flow+, Dentsply Sirona) with the aim of simulating clinical conditions to prevent passive extrusion of the irrigant, creating a closed-end system [27]. The specimens were stabilized in a dedicated device, ProTrain (Simit Dental, Mantova, Italy), to standardize the operative procedures (Figure 1). A single endodontist was selected for all treatment procedures to eliminate interoperator variability and procedural bias.

2.2. Root Canal Preparation

All teeth were shaped with TruNatomy (Dentsply Sirona) rotary instruments in an endodontic motor (XSmart Plus, Dentsply Sirona) at 500 rpm and 1,5 N-cm torque in continuous rotation following the manufacturer’s recommendation. A TruNatomy Orifice Modifier (#20/0.06) and TruNatomy Glider (#17/0.03) were initially used. Then a TruNatomy Prime Shaping File (#26/0.04) was used until the working length (WL) was reached. Instruments were used according to the manufacturer’s instruction. The pulp chamber and root canal were irrigated with 5 mL at 5.25% NaOCl, before inserting any instruments. The irrigant solution was renewed after each instrument with preheated NaOCl solution at 37° delivered with a disposable plastic syringe with a 30-G needle (Navitip; Ultradent, South Jordan, UT, USA).

2.3. Final Irrigation Protocol

Fifteen specimens were randomly divided into three groups:
  • Negative Control Group (n = 5): Specimens were shaped and not subjected to final irrigant activation.
  • EndoActivator Activation Group (n = 5) (EA Group): Specimens were irrigated with 5 mL of NaOCl at 5.25% preheated using TruNatomy irrigation needle (Dentsply Sirona). To sonically activate the irrigating solution, EndoActivator (Dentsply Sirona) was used. The EndoActivator is a sonically driven canal activation system. It is presented with a portable handpiece and disposable noncutting polymer tips. It has been shown to significantly better remove debris when compared to conventional syringe irrigation and passive ultrasonic irrigation (PUI). The smooth polymer tips have the advantage of being noncutting, hence reducing the risk of iatrogenic damage. The propylene tip was inserted at 1 mm from working length, and then the irrigant was activated for 2 × 30 s at 10.000 cpm using the size 15.02 taper EndoActivator with the highest frequency (166 Hz). The tip was passively inserted with an in-and-out movement in the root canal. Then, the specimen was rinsed with 3 mL of saline solution for 30 s. Finally, the root canal was irrigated with 5 mL 17% EDTA for 30 s and sonically activated with the same procedures used for NaOCl.
  • Electric Current Activation Group (n = 5) (EB Group): The specimen was irrigated with 5 mL of NaOCl at 5.25% preheated using TruNatomy irrigation needle (Dentsply Sirona). For the electric current activation, ElectroBond (Patent No. WO03/002014 PCT/IB02/02565, Rome, Italy) was used. ElectroBond delivered a direct current (DC) between the endodontic dentin (working as cathode) and the irrigating solution (working as anode) [14]. The tested ElectroBond automatically induced an electric flow over 20 μA throughout the irrigating solution through the endodontic dentine during the application procedure. To permit electricity conduction under in vitro conditions, the tooth to be tested was surrounded by a transmitting medium inside the ProTrain (Figure 1).

2.4. MicroCT Scanning Procedures

To our knowledge, three suggested methodologies of analysis for evaluating the cleanliness and the residual debris after root canal treatment can be used: confocal laser scanning microscopy (CLSM), field emission scanning microscopy (FESEM) and micro computed tomography (microCT). In the present study, microCT was chosen because FESEM requires preparation of the specimens (sputter coating and critical point drying), causing macroscopic artifacts and consequential bias. At the same time, SEM analysis allows a two-dimensional analysis of a restricted area of root canal surface, limiting the statistical analysis. CLSM is a useful technique in endodontics that avoids the drawbacks of FESEM, but it is not in accordance with the aim of our research. MicroCT imaging is a nondestructive and reproducible technology leading to very thin sections and a true three-dimensional reconstruction of an object. In particular, microCT imaging has been increasingly used to investigate endodontic anatomical features such as apical transportation, centering ratio and the volumetric changes of instrumented root canals. As a nondestructive technique, microCT enhanced our experimental protocol because it allowed us to analyze samples before and after the endodontic activations. After root canal shaping, all specimens of the three groups were scanned by a SkyScan 1072 microCT scanner (Bruker micro-CT, Kontich, Belgium) at 100 kV, 98 mA, 7.32 µm isotropic resolution, 180° rotation around vertical asses, total amount of 2 frames with 1 mm thick aluminum filter. The two-dimensional images were reconstructed using the CT-Analyser (V1.16; Bruker micro-CT, Kontich, Belgium) software used for image processing and analysis. The volume of AHTD (mm3) for the entire root canal system as well as from the different root thirds (coronal, middle and apical) were obtained by using the three-dimensional analysis tool. Specimens of EA group and EB group were scanned after the activation of the irrigating solution using the previously described parameters. Control negative specimens were not scanned because they were not subjected to irrigant activation, and thus the endodontic volume was not modified [9].

3. Results

Kappa test results, with a significance set at 0.5, showed good intra- and interexaminer agreement, with values of 0.90 and above for the different groups. From the microCT analyses, two-dimensional images, three-dimensional images and morphometric parameters were obtained. Two-dimensional images were analyzed to obtain slice-by-slice information along the entire length of the root. Those images showed the presence of AHTD in every slice, before and after the irrigating solution activation. The 2D images, corresponding to a slice (coronal, middle or apical) of a representative sample for each group, are shown in Figure 2 and Figure 3, where the AHTD accumulation areas are circled in red. The three-dimensional images of the root canals, obtained with the transparent effect of the dental tissues, were processed in order to highlight the residues of AHTD colored in red to highlight their presence. The 3D images obtained, with transparency effect, are shown in Figure 4 and Figure 5, where the distribution along the entire root canal of AHTD residues can be observed, before and after the treatment corresponding to the group shown. Figure 4 and Figure 5 show the efficacy of the activation methods: the presence of red (more or less intense in chroma) highlights the presence/absence of AHTD. Specimens of EB group showed a reduced presence of red (less AHTD) than the EA group specimens. This result was shown by all the observed samples, while the figures display only representative samples for each group. The obtained quantitative morphometric data, reported in Table 1 and Table 2, confirm the visual results shown in 3D images. In EA group specimens, the volume of AHTD in the endodontic system before activation is 4.35%, decreasing to 1.87% after irrigant activation with EA. In EB group specimens, the volume of AHTD in the endodontic system before activation is 4.29%, decreasing to 0.40% after irrigant activation, confirming a statistically significant better result than the activation with EA.

4. Discussion

The smear layer hinders the successful disinfection and three-dimensional filling of the root canal system, as suggested by Economides et al. [28]. Shaping root canals is challenging due to their anatomy even if new endodontic instruments are yearly launched on the market. In fact, more than 50% of the root canal surfaces remain untouched by mechanical instrumentation [29]. Moreover, packing debris into canal irregularities by reciprocating and/or rotary instrumentation has been described [30]. However, to the best of the authors’ knowledge, this is the first study to evaluate the effects of electric current in AHTD removal. AHTD is produced during the chemo-mechanical shaping of root canal systems.
To date, there is no clinical consensus that the removal of the smear layer improves the clinical treatment outcome of root canal treatment [31]. Nevertheless, removal of AHTD and smear layer provides better cleaning and disinfection of the root canal system, increasing the adaptation of root filling materials [6,32,33]. The aims of the present study were to investigate the effectiveness of an electric current device and to compare it to endodontic sonic activation (EA) of irrigating solutions. Results showed the efficacy of electric fields in the activation of endodontic irrigants and AHTD removal in the final irrigation. Any comparison to the use of electric fields in endodontics cannot be exerted because no research has ever been published before. On the contrary, the use of electric current has been already applied in restorative dentistry. In fact, authors have shown that the application of electric current on etch-and-rinse and self-etching adhesive systems significantly increases resin impregnation and the hybridization of dentine [24,25]. Moreover, Pasquantonio et al. [26] have investigated the use of ElectroBond in simplified etch-and-rinse adhesives, showing that the application of electric current improves the shear bond strength (SBS) to dentin, reducing nanoleakage [8]. Endodontic irrigation and, more importantly, irrigant activation are crucial to further improve canal cleanliness and disinfection of the entire root canal system. Activation of endodontic irrigating solutions has been investigated during the last few decades, leading to the conclusion that it increases the removal of the smear layer [34]. Many authors have shown that EA is efficient in reducing the smear layer in the endodontic system. In fact, it has been shown that EA was more efficient in removing the smear layer in coronal and middle thirds than in the apical third [35], in accordance with the results of Haupt et al. [36] who evaluated the effectiveness of different activation techniques on debris and smear layer removal in curved root canals. Sonic agitation (EA and EDDY system) performed significantly better than syringe irrigation (SI), without a significant difference to PUI. This result is in agreement with the results of Urban et al. [37].
MicroCT has been introduced in the last few decades in experimental procedures as a nondestructive method [38]. In endodontics, microCT has been widely used in the study of endodontic anatomy [39], shaping of root canal system [5,10,12,27] and sealing ability of different materials [27,40,41,42,43,44,45]. Smear layer removal has been usually evaluated using scanning electron microscopy (SEM and FESEM). Unfortunately, this evaluation method has an important drawback: only a small portion of the endodontic surface can be analyzed and compared, leading to bias. Recently, microCT has been used to assess AHTD. Rodig et al. [46] evaluated the reduction in AHTD in isthmus-containing mesial root canals of mandibular molars by sonically and ultrasonically activated irrigation and compared results to manual irrigation using microCT imaging.
According to previous reports [5,27,47,48,49], none of the tested irrigation protocols was able to clean the isthmus of mesial root canal systems of mandibular molars from debris. In the present study, no significant differences were observed between final irrigation protocols regarding the removal of AHTD. Mancini et al. [34] evaluated the effectiveness of different irrigating systems in removing the smear layer from endodontic walls from the apex to the coronal third. They compared the efficacy of EndoActivator, EndoVac (EV), PUI and laser activated irrigation (LAI) methods in removing the smear layer at 1, 3, 5 and 8 mm from the apex. However, it should be noted that in their study, in order to increase the volume flow of irrigants at the WL, the different groups were shaped to a ProTaper F4 (apical dimension 40, taper 6%). The authors concluded that the EV and EA methods performed significantly better than the rest of the groups at 1, 3, 5 and 8 mm and 3, 5 and 8 mm from the apex, respectively. Overall, activating irrigation solutions significantly improved smear layer removal in the apical third of the canal. [34].
In contrast to our findings, many studies have confirmed that irrigant activation with sonic devices (EA-EDDY) performed better than others irrigant activation protocols [49,50]. Urban et al., in an in vitro study, using scanning electron microscopy, evaluated the efficacy of different final irrigation activation methods (manual irrigation, EndoActivator, PUI, EDDY) in removing debris and smear layer in the apical, middle and coronal portions of straight root canals. All activation methods created clean canal walls concerning residual debris, but none of the activation methods completely removed debris and smear layer. All activation methods were superior compared to manual irrigation regarding debris removal. EDDY and PUI obtained significantly better smear layer scores compared to manual irrigation. However, these results can be attributed to several factors: SEM allows evaluating only limited areas of the canal wall with only a two-dimensional analysis of debris and smear layer. Moreover, only NaOCl was used as an intracanal irrigant. Finally, it should be noted that the preparation of the root canals was performed with Reciproc R40 (VDW) instruments [37]. In a recent investigation by Plotino et al., in artificial root canals and irregularities, they evaluated the efficacy of different sonic and ultrasonic devices in the removal of debris from canal irregularities in artificial root canals irrigated with sodium hypochlorite or EDTA. The results showed no statistically significant differences between NaOCl and EDTA; therefore, it seems that the mechanical movement of the liquid is more important than the chemical action for the removal of debris. Both sonic and ultrasonic activation demonstrate a good efficiency for dentin debris removal. The only limitation of this study may have been the use of a transparent resin model of the root canal [51].
These differences encountered from the above-mentioned results and the findings of our preliminary investigation are most probably due to the different methodology of research. First of all, in our study, we used the TruNatomy shaping system, a new rotary instrument recently introduced in the clinical practice [52]. As it is the first study based on TruNatomy and microCT, it is difficult to compare our results with others. Secondly, following the concept of “minimally invasive endodontic treatment”, the instrument shaping the apical third was the TruNatomy Prime (26/.04), which is smaller than the one used in other studies that have enlarged the apical third to a size 40/.06. A wider apical preparation increases the irrigant solution flow and facilitates more efficient fluid dynamics and turbulence. Surprisingly, analyzing images and volumetric data obtained with the microCT, our results have shown unexpected accumulation of AHTD at the apical level after canal shaping and irrigant activation with EA (Figure 2 and Figure 4). On the contrary, the activation with the ElectroBond showed a significant removal of AHTD from the coronal, middle and apical thirds of the root canal (Figure 3 and Figure 5).
The accumulation of AHTD at the apical level is in accordance with the hypothesis formulated by other authors. Kanaan et al., in an in vitro study, hypothesized the possibility that the use of an acid solution (in our study, 17% EDTA) may have caused the erosion of a thin layer of dentin and the sonic activation (EA) of the plastic tip may have detached the eroded layer that accumulated as AHTD at the apical level [53]. Rius et al., in an in vitro study evaluating the smear layer formation with different activation systems, found that the sonic activation (EDDY) generated the greatest amount of smear layer and AHTD, especially at the apical level [54].
The results of the present preliminary study, obtained by the qualitative and quantitative analyses from the microCT nondestructive method, are encouraging. Within the limits of the present study due to a reduced number of specimens and testing different validated activation methods, authors can conclude that further studies are needed to validate the use of electric fields in clinical endodontics.

Author Contributions

Conceptualization, M.M., L.C. and G.P.; methodology, M.M., R.B. and L.C.; software, R.B., R.P.; validation, M.M. and R.B.; formal analysis, R.B. and R.P.; investigation, G.C. and G.P.; data curation, R.B. and R.P.; writing—original draft preparation, M.M., G.C., R.P.; writing—review and editing, M.M., R.B., R.P., L.C.; supervision, M.M., R.B., L.C. and G.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Applsci 12 01969 g001 550
Figure 1. ProTrain and its exploded view.
Figure 1. ProTrain and its exploded view.
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Figure 2. EA group—slice evaluation of ATHD: (a) before (image left) and after (image right) activation at middle third; (b) before (image left) and after (image right) activation at apical third.
Figure 2. EA group—slice evaluation of ATHD: (a) before (image left) and after (image right) activation at middle third; (b) before (image left) and after (image right) activation at apical third.
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Figure 3. EB group—slice evaluation of ATHD: (a) before (image left) and after (image right) activation at middle third; (b) before (image left) and after (image right) activation at apical third.
Figure 3. EB group—slice evaluation of ATHD: (a) before (image left) and after (image right) activation at middle third; (b) before (image left) and after (image right) activation at apical third.
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Figure 4. EA group—3D evaluation of ATHD before (image left) and after (image right) irrigant activation.
Figure 4. EA group—3D evaluation of ATHD before (image left) and after (image right) irrigant activation.
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Figure 5. EB group—3D evaluation of ATHD before (image left) and after (image right) irrigant activation.
Figure 5. EB group—3D evaluation of ATHD before (image left) and after (image right) irrigant activation.
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Table
Table 1. EA group—volume (mm3) of AHTD before and after the irrigant activation.
Table 1. EA group—volume (mm3) of AHTD before and after the irrigant activation.
SkyScan 1072—ISSBefore Irrigant ActivationAfter Irrigant Activation
Volume of shaped root canal (mm3)8.0717 ± 0.00028.0717 ± 0.0002
Volume of AHTD (mm3)0.3507 ± 0.00010.1506 ± 0.0008
Table
Table 2. EB group—volume (mm3) of AHTD before and after the irrigant activation.
Table 2. EB group—volume (mm3) of AHTD before and after the irrigant activation.
SkyScan 1072—ISSBefore Irrigant ActivationAfter Irrigant Activation
Volume of shaped root canal (mm3)7.3745 ± 0.00087.3745 ± 0.0008
Volume of AHTD (mm3)0.3162 ± 0.00090.0289 ± 0.0008
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Mancini, M.; Cianconi, G.; Bedini, R.; Pecci, R.; Cianconi, L.; Pasquantonio, G. Removal of Accumulated Hard Tissue Debris (AHTD) from Root Canals with an Electric Current Device: A MicroCT Preliminary Report. Appl. Sci. 2022, 12, 1969. https://doi.org/10.3390/app12041969

AMA Style

Mancini M, Cianconi G, Bedini R, Pecci R, Cianconi L, Pasquantonio G. Removal of Accumulated Hard Tissue Debris (AHTD) from Root Canals with an Electric Current Device: A MicroCT Preliminary Report. Applied Sciences. 2022; 12(4):1969. https://doi.org/10.3390/app12041969

Chicago/Turabian Style

Mancini, Manuele, Giovanni Cianconi, Rossella Bedini, Raffaella Pecci, Luigi Cianconi, and Guido Pasquantonio. 2022. "Removal of Accumulated Hard Tissue Debris (AHTD) from Root Canals with an Electric Current Device: A MicroCT Preliminary Report" Applied Sciences 12, no. 4: 1969. https://doi.org/10.3390/app12041969

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