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References 1. Baratto-Filho F, Fariniuk LF, Ferreira EL, Pecora JD, Cruz-Filho AM, Sousa- Neto MD. Clinical and macroscopic study of maxillary molars with two palatal roots. Int Endod J. 20xb 2010 May 19. 3. Desai P, Himel V. Comparative safety of various intracanal irrigation systems. J Endod. 2009 Apr;35(4):545-9. 4. Mitchell RP, Yang SE, Baumgartner JC. Comparison of apical extrusion of NaOCl using the EndoVac or needle irrigation of root canals. J Endod. 2010 Feb;36(2):338-41. Epub 2010 Jan 19. 5. Nielsen BA, Craig Baumgartner J. Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007 May;33(5):611-5. Epub 2007 Mar 26. 6. Abarajithan M, Dham S, Velmurugan N, Valerian-Albuquerque D, Ballal S, Senthilkumar H. Comparison of Endo- vac irrigation system with conventional irrigation for removal of intracanal smear layer: an in vitro study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Sep; 112(3):407-11. Epub 2011 Jun 12. 7. Siu C, Baumgartner JC. Comparison of the debridement efficacy of the Endo- Vac irrigation system and conventional needleroot canal irrigation in vivo. J Endod. 2010 Nov;36(11):1782-5. Epub 2010 Sep 16. 8. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Sur- gery Oral Medicine and Oral Pathology. 1984; 58(5): 589–599. 9. Evans M, Davies JK, Sundqvist G, Figdor D. Mechanisms involved in the resistance of Enterococcus faeca- lis to calcium hydroxide. Int Endod J 2002;35:221–8. 10. Baumgartner JC, Falkler WA. Bacte- ria in the apical 5 mm of infected root canals. J Endod 1991;17:380–3. 11. Hockett JL, Dommisch JK, Johnson JD, Cohenca N. Antimicrobial efficacy of two irrigation techniques in tapered and nontapered canal preparations: an in vitro study. J Endod. 2008 Nov; 34(11):1374-7. Epub 2008 Sep 3. 12. Heilborn C, Reynolds K, Johnson JD, Cohenca N. Cleaning efficacy of an api- cal negative pressure irrigation system at different exposure times. Quintessence Int. 2010 Oct;41(9):759-67. 13. Saber Sel-D, Hashem AA. Efficacy of different final irrigation activation techniques on smear layer removal. J Endod. 2011 Sep;37(9):1272-5. Epub 2011 Jul 16. 14. Gondim E Jr, Setzer FC, Dos Carmo CB, Kim S. Postoperative pain after the application of two different irrigation devices in a prospective randomized clinical trial. J Endod. 2010 Aug;36(8): 1295-301. Epub 2010 Jun 19. 22 page 21DTß 2 Repeat previous step again. 3 Again deliver NaOCl for 10 seconds - BUT - instead of purging, quickly remove the Mi- croCannula while the MDT con- tinues to deliver NaOCl. This is referred to as “charging” the canal. 4 Let the NaOCl work for at least 60 seconds (passive wait) before proceeding to the next step. 5 Place MicroCannula to full WL and deliver EDTA from MDT for 10 seconds, leaving the canal filled (charged) with EDTA for 60 seconds. 6 Place MicroCannula to full WL and deliver NaOCl from MDT for 10 seconds. Stop delivery and watch for Micro- Cannula to suction (purge) all NaOCl from the canal. 7 Repeat previous step for another 10 seconds. 8 Repeat again, but after delivery for 10 seconds remove the MicroCannula im- mediately before removing the MDT, leaving the canal filled (charged) with NaOCl. 9 Let the NaOCl work for at least 60 seconds before proceeding to the next step. While waiting, fitting of a gutta- percha point is optional. 10 Place MicroCannula to full WL for at least three seconds. 11 Confirm canal is dry or continue drying with paper points. An alternative sequence can be followed to shorten the time if the final irrigation is done at the same time in both canals (Fig 4). Both canals were obturated in the same visit with gutta-per- cha and Sealapex (SybronEndo) using the Elements Obturation Units (SybronEndo) for continu- ous wave of condensation. The complexity of the root canal anatomy can be seen in the final X-ray (Fig 5). Patient was seen after one week for a final composite fill- ing and she reported she had not experienced any pain since the obturation. Discussion Indispensable procedures such as the correct location of the canals, thorough debridement, efficient cleaning, precise obturation and good restoration are paramount for the success of the root canal treatment. Vertucci reported that a consid- erable number of failures could be assigned to anatomical vari- ations, such as the presence of canals not usually found8 . Other authors, although they agree with Vertucci’s re- port, also consider most of the failures related to an inefficient cleaning. It is generally believed that the major cause of failure is the survival of microorganisms in the apical portion of the root- filled tooth9,10 . Therefore, many studies have been done to see which system can clean better this api- cal portion. Recent studies have shown that the apical negative- pressure irrigation system En- doVac (SybronEndo) is more ef- fective in removing smear layer from the apical third resulting in significantly less debris and consequently producing better disinfection at the apical third of root canals than current ir- rigation methods using positive pressure or conventional nee- dle irrigation5,6,7,11 . Heilborn et al.12 also showed in their histo- logic study that the apical neg- ative-pressure irrigation sys- tem EndoVac has the potential to achieve significantly better root canal cleaning at the apical third of root canals and in less volume and exposure time than required with traditional posi- tive-pressure irrigation. Saber and Hashem13 compared the smear layer removal after final irrigant activation with apical negative pressure (ANP), man- ual dynamic agitation (MDA), and passive ultrasonic irrigation (PUI). They concluded that final irrigant activation with ANP and MDA resulted in better removal of the smear layer than with PUI or PI. Another concerned when cleaning the apical third is the extrusion of irrigation solution beyond the apical constric- tion resulting in post-operative pain. It is known that Sodium hypochlorite can cause severe tissue irritation and necrosis if extruded into the periodon- tal ligament space. Therefore, many studies were done and different delivery techniques were discussed to reduce this potential risk. Desai and Himel3 concluded in their study that the EndoVac did not extrude irrigant after deep intracanal delivery and suctioning the ir- rigant from the chamber to full working length. Mitchell et al.4 showed in their study signifi- cantly less extrusion risk using the EndoVac system compared with needle irrigation. Gondim et al.14 concluded that the use of a negative apical pressure irri- gation device can result in a sig- nificant reduction of postopera- tive pain levels in comparison to conventional needle irrigation. In the present clinical case it is possible to see in the final X-ray the complexity of the root canal system and the obturation extended to the ramifications in the apical third. It is also impor- tant to explain that a question- naire was used before and after the re-treatment to evaluate the post-operative pain and no post- operative pain was registered. Conclusion Endodontic success is fully de- pendent on an efficient cleaning of the root canal system mainly in its apical portion. EndoVac is an important tool in this process because it has not only the potential to achieve significantly better root canal cleaning at the apical third of root canals but also result in a significant reduction of postoperative pain. The reason I use the Endo- Vac is because I believe that “In a root canal treatment I would trust in my eyes, my tactile sense and also in the EndoVac. EndoVac delivers the irrigant in spaces where I cannot see or even feel. This fabulous product came to revolutionise not only the whole of endodontic irriga- tion but also the definition of a successful treatment.” DT Fig. 1 Fig. 2 Fig. 5 Fig. 3 Fig. 4 Clinical About the author Dr Daniela Mancuso BDS, MSc, PhD, Specialist in both Endodontics (in Brazil) and Prosthodontics (in Bra- zil and in the UK) is Clinical Lecturer at Queen Mary University of London (UK), at University of Warwick (UK) and also Invited Professor at Sao Paulo State University (Brazil). She is also part of the multidisciplinary team at the Windsor Centre for Advanced Dentistry, UK and at CastleView Den- tal, UK. November 12 - 18, 2012United Kingdom Edition