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20 14 년 월2
석 사 학 위 논 문
박 성 환
2014년 2월 석 사 학 위 논 문
A c ompar i s onofc l e ani nge f f i c i e nc y ofvar i ousi r r i gat i onme t hods
조선대학교 대학원
치 의 학 과
박 성 환
A c ompar i s onofc l e ani nge f f i c i e nc y ofvar i ousi r r i gat i onme t hods
여러 가지 근관 세척 방법에 따른 세척 효율의 비교
2 0 14 년 2 월 2 5 일
조선대학교 대학원
치 의 학 과
박 성 환
A c ompar i s onofc l e ani nge f f i c i e nc y ofvar i ousi r r i gat i onme t hods
지도교수 황 호 길
이 논문을 치의학 석사학위신청 논문으로 제출함.
2 01 3 년 1 0 월
조선대학교 대학원
치 의 학 과
박 성 환
박성환의 박사학위논문을 인준함.
위원장 조선대학교 교수 김 재 덕 인 위 원 조선대학교 교수 민 정 범 인 위 원 조선대학교 교수 황 호 길 인
2 0 13 년 11 월
조선대학교 대학원
CONTENTS
Abstract···iv
Ⅰ.Introduction···1
Ⅱ.MaterialsandMethods···3
Ⅲ.Results···6
Ⅳ.Discussion···8
Ⅴ.Conclusion···10
References···11
-ii-
TABLE LEGEND
Table1.Smearlayerscores···6
FI GURE LEGENDS
Figure1.SEM imagesandascaleusedtoevaluatesamplecleanliness.···5
Figure2.Therepresentativemicrographsofeachgroups.···6
Figure3.Bardiagrammesshowingmeansmearlayerscore.···7
-iv-
국문초록
여러 가지 근관 세척 방법에 따른 세척 효율의 비교
박성환
지도교수 황호길 조선대학교 대학원 치의학과
본 연구에서는 음파 근관세척 기구인 EndoActivator와 초음파 근관세척 기구인 CK file의 근관 내 도말층 제거 능력을 평가하고 더 나아가 기존의 수동 세척법과 비교하 여 차이가 있는지 알아보고자 하였다.근첨이 완성되고,근관의 만곡이 없는 사람의 단 근치 60개를 준비하였다.실험과정의 표준화를 위해 치관부를 절단하고 #25,#40 WaveOneTM Ni-Tifile,#50 K file을 순차적으로 사용하여 근관확대를 시행하였으며 각 확대 과정 후에는 1ml의 2.5% NaOCl로 세척하였다.근관확대 완료 후,3개의 군 으로 나누어 최종세척을 시행하였다.첫 번째 그룹은 기존의 manualneedleirrigation 으로 근관세척을 시행하는 대조군으로 설정하였고,두 번째 그룹은 EndoActivator와 전용 #25polymertip을 사용하여 세척액이 채워진 근관 내에서 음파 근관 세척법을 적용하였고,세 번째 그룹은 #25CK file로 세척액이 채워진 근관 내에서 초음파 근관 세척법을 적용하였다.최종세척과정에는 5 ml의 17% EDTA와 5ml의 2.5% NaOCl 이 사용되었다.근관 건조 후 치근을 절단하여 노출된 근관의 내면을 주사전자현미경 으로 관찰하였다.독립된 두 명의 조사자가 현미경 하에서 얻은 이미지를 통해 근관 내 상아질 벽에서의 도말층 제거 정도를 평가하였다.분석 결과,치근단 3mm 부위에 서 EndoActivator와 CK file을 사용한 두 실험군 모두 대조군에 비해 유의적으로 높은 도말층 제거 결과를 보였으며 두 실험군 간에는 유의적인 차이를 보이지 않았다.
I .I nt r oduc t i on
The ultimate objectives of endodontic treatment is to eliminate the microorganismsandpreventtherecontamination in rootcanalsystem.1Toachieve theseobjectives,mechanicalandchemicalpreparationmethodsofrootcanalsystem areessentialprocedures.2
The preparation of the root canalis performed almost by hand and rotary instrumentation techniques.Theaim ofthisinstrumentation isto shapethecanal, removeinfecteddentin,andfacilitatesatisfactory delivery ofirrigantstotheapical anatomy,whilemaintaining thepatency oftheentirecanalsystem and preserving theintegrityofthetooth.3Severalnew kindsofnickel-titanium(Ni-Ti)filesystems have been introduced. One of these systems, WaveOneTM (Dentsply Mailefer, Switzerland)isdesignedtoprepareandcleantherootcanalscompletely with only oneinstrument.4
During root canalinstrumentation,a layer of organic and inorganic material calledthesmearlayercouldbeformed.Thesmearlayerispotentiallyinfected,and itsremovalallowseffectivepenetration ofintracanalmedications into thedentinal tubules and a better interface between the filling materialand the root canal walls.2,5Attheapicalthird portion ofrootcanal,cleanlinessiscriticaldueto the limited space,low permeability6 and complex anatomicalconfiguration.7 Forthese reasons,a variety ofchemicalagentshavebeen used conventionally as irrigating agents such as sodium hypochlorite (NaOCl)10and 17% Ethylenediaminetetraacetic acid (EDTA).11However,conventionalmanualirrigation method isnoteffectivein the apical area of the root canal.12 Recently,emphasis has been devoted to hydrodynamicirrigationmethods,consistingofsonicorultrasonicfluidactivationin pre-shapedcanals.Thesesystemspromotefluidcirculationthroughvibration.9,10,12,13
TheEndoActivator(Dentsply,Tulsa,OK)issonicdeviceandithasbeenshown to safely clean the canalsystem,including lateralcanals,fins,and isthmus,by activating the irrigants with a flexible,noncutting and 3 differentsized(#15,#25,
#35)polymertip.7,8 Mechanicaloscillations are produced mainly atthe tip ofthe
-2-
activatorwith afrequency ranging from 1to10kHz.TheCK file(B&L Biotech, Korea)isarelatively new deviceon themarket.Itisconnected tohand pieceof ultrasound generator via 90〫 or 120〫 file holder and generate acoustic micro-streaming of the irrigants by using ultrasonic energy. This device is compatible with both EMS system and SATELEC system,and the tips are composed of4 differentsize(#20,#25,#30,#35).According to the manufacturer's recommendation, 10% of maximum energy of engine is suitable for efficient cleaning ofthe rootcanal,and proper acting depth is 3 mm subtracting from workinglengthofthecanal.
The objective of this study was to compare the effectiveness of the EndoActivator and CK file on removing the smear layer after mechanical instrumentationandirrigationwithEDTA andNaOCl.
Ⅱ.Mat e r i al sandMe t hods
1.SampleSelection
Sixty intact,single-rooted and straight human teeth with mature apex were collected for this study.Allteeth were radiographed in a bucco-lingualand a mesio-distaldirection toconfirm single,straightcanalmorphology.Theteethwere storedin0.9% physiologicsalineat4℃ afterextraction.
2.Mechanicalpreparation ofrootcanals
Allteeth were decoronated atthecementoenameljunction with a diamond disk forsimpleprocedures.Afterdecoronation,lengthsoftheroots weremeasured by passively placing a #10 K-filein thecanaluntilthetip oftheinstrumentvisibly penetrated.The actualworking length was calculated by subtracting 1 mm from this measurement.15The apices were sealed with melted sticky wax to close the apical foramens in order to simulate in vivo condition which is not allowed escaping irrigantsthrough theapex ofeach roots.16,17Theteeth wereinstrumented with #25WaveOneTM fileto theworking length first,and then,irrigated 1 mlof 2.5% NaOClby manualirrigation method.Theirrigantwasdelivered in a 10 ml syringe,with a 27-gauge side-vented needle.Secondly,#40 WaveOneTM file was usedtotheworkinglengthandfinally#50K-filewasusedtoexpandandconfirm the foramen diameter.Consequently,apicalsize was standardized in #50.After completion ofinstrumentation,the teeth were randomly divided into three groups with20teethineach.
3.Finalirrigation procedures
(1)Group1:Manualneedleirrigationgroup
The canals were irrigated and maintained with 2.5 mlof17% EDTA for 1 minutewithnoactivation.Andthen,thecanalswereirrigatedagainwith2.5mlof 17% EDTA.Afteraspiration,thecanalswereirrigatedandmaintainedwith 2.5ml of2.5% NaOClfor30secondswith no activation,followed by irrigating with 2.5
-4- mlof2.5% NaOCl.
(2)Group2:ActivatedirrigationwithEndoActivator(EA)
Thecanalswereirrigatedwith2.5mlof17% EDTA andsonically activatedfor 1minuteby EndoActivatorwith #25sizedpolymertip.And then,thecanalswere irrigated again with 2.5 mlof 17% EDTA.After aspiration,the canals were irrigated with 2.5 mlof2.5% NaOCland sonically activated for30 seconds by EndoActivatorwith #25 sized polymertip,followed by irrigating with 2.5 mlof 2.5% NaOCl.
(3)Group3:ActivatedirrigationwithCK file(CK)
Theirrigationwascarriedoutwithasimiarprotocolasgroup2usingCK file. Thecanals wereirrigated with 2.5 mlof17% EDTA and ultrasonically activated for1 minute by CK file with #25 sized tip.And then,the canals were irrigated again with 2.5mlof17% EDTA.Afteraspiration,thecanalswereirrigated with 2.5mlof2.5% NaOClandultrasonically activatedfor30secondsby CK filewith
#25sizedtip,followedbyirrigatingwith2.5mlof2.5% NaOCl.
4.Sectioning oftherootsandpreparationforSEM
Aftermechanicalandchemicalpreparation,allrootsweredriedwithpaperpoint. And then,to preventinvasion ofdebris into the canal,#50 Gutta-percha cones were fitted.To getprecise samples for SEM,severalsectioning procedure was accomplished.Firstly,longitudinalgrooves were made with a diamond disk on buccalandlingualsurfaceoftheroot.Secondly,horizontalgroovewasmadeon 3 mm from apex oftheroots.Finally,therootweresplitwith chiselto get3mm sized cross-sectioned samples ofapex area,and the remnants were discarded.18 Eachsamplewasdehydratedandview withaSEM (S4700,Hitachi,Japan).
5.SEM evaluation andstatisticalanalysis
Allsampleswereviewedatlow magnificationinordertoobserveoverallimage. The micrographs ofthe mostrepresentative three areas ofeach samples were
obtained ata ×1000 magnification.Total180 micrographs were scored blindly by twoindependentevaluatorstomeasuretheamountofsmearlayerusing a4-step scaleasfollows;(0)alltubulesvisible,(1)morethan 50% oftubulesvisible,(2) lessthan 50% oftubulesvisible,and (3)notubulesvisible(Figure1).15Thedata wereanalyzed by meansoftheKruskal-Wallistestand Mann-Whitney test.The levelofsignificancewassetatp< 0.05.
(a)Score0 (b)Score1 (c)Score2 (d)Score3
Figure1.SEM imagesandascaleusedtoevaluatesamplecleanliness.
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Ⅲ.Re s ul t s
TherepresentativemicrographsofeachgroupsarepresentedinFigure2andthe resultsforsmearlayerremovalintheapical3mm aresummarizedinTable1and Figure3.
Figure 2.The representative micrographs ofeach groups.(a)Group 1 :Manual needleirrigation.(b)Group2:ActivatedirrigationwithEndoActivator.(c)Group3 :ActivatedirrigationwithCK file.
Table1.Smearlayerscores
Figure3.Bardiagrammesshowingmeansmearlayerscore.
*:p< 0.05
The results showed thatthe groups treated with EndoActivator(Group 2)and CK file(Group 3)had significantly effectivein removing smearlayerthan group treatedwithmanualneedleirrigation(Group1)(p < 0.05).However,therewasno significantdifferencebetweengroup2andgroup3.
-8-
I V.Di s c us s i on
Irrigationoftherootcanalsystem isafundamentalpartofendodontictreatment. The efficacy of irrigation depends on how effectively it can remove debris in canals.19 And also,the infiltration ofthe irrigantwithin the apicalthird ofroot canals depends on theircomplex anatomy and removalofthe smearlayerfrom thesecomplexcanalsystem.
Conventionally,manualirrigation method has been used in chemicalpreparation within rootcanal.However,recently,severalstudies revealed the imperfection of manualirrigation method in removing smear layer.Ram20 reported that during manualirrigation,theirrigating solution passesonly 1mm deeperthan thetip of the needle.Chow21 reported that,by manualirrigation,though adequate time and volumeconsuming,therewasalimitation in contentableremovalofdebrisin root canals.
Activation of NaOCl and EDTA with a sonic or ultrasonic devices during chemicalpreparation appeared to improve the smear layer removaland cleaning capability of the irrigants.22 Comparing the effectiveness of these two different activating deviceisstillacontroversialsubject.23Rodig etal24found nodifference in smear layer removal between the EndoActivator and ultrasonic activating method.Also,Jensen et al25 reported that when the acting time of devices is increased, there was no significant difference between sonic and ultrasonic activation method atcleaning rootcanals.However,Sabin etal26,Stamos etal27 reported that there was a correlation between acoustic streaming velocity and frequencyofdevice,andtherethough,theyclaimedthatultrasonicactivatingsystem ismoreeffectiveinremovingsmearlayerthansonicactivatingsystem.
In thepresentstudy,theresultsshowed thatin group 2and 3,theremovalof smearlayerwassignificantly greaterthan group1.Betweengroup2andgroup3, group 3 (CK file)showed slightly betteroutcome than group 2 (EndoActivator) but,therewasnosignificantdifference.
Despitetheeffortsto standardizetherootcanalsystem,widevariation ofeach
canalmorphologywasstilldifficultvariabletocontrol.Theoriginalsizeofacanal mayinfluencetheamountofproducingsmearlayer,andsequentiallyitcouldeffect thedebridementefficacyoftheinstrument.
In this study, WaveOneTM Ni-Ti file was used in mechanical preparing instrument of the canals. In comparison with other mechanical preparing instrument,thenumberofinstrumentisdecreaseduptooneortwo,andthereby, necessary timeforpreparation isdecreased.Simultaneously,thetimeavailablefor irrigation and chemicaldebridementofthe rootcanalsystem is also reduced.In thisregard,changingmechanicalpreparationsystem mayaffectirrigationefficiency andresultofstudy.
A variousanalyzing methodshavebeen described toevaluatethecleanlinessof rootcanalsystem.In this study,the cleanliness ofrootcanalwas evaluated by twoindependentevaluatorandtheyscoredSEM images.Atthispoint,problemsof quantifyng the cleanliness of root canal system could be occur. To obtain objectivity of results, further studies are required to quantify the level of cleanlinessofrootcanalsystem.
-10-
V.Conc l us i on
In conclusion,both activating devices,EndoActivator and CK file were more effective in removing smearlayerfrom the apical3 mm ofthe rootcanalthan manual irrigation method. With evidence of this results, activating irrigation methods using sonic or ultrasonic devices should be clinically considered for obtainingidealcleanlinessofapicalarea.
Re f e r e nc e s
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