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today Ontario Dental Meeting 07 May

exhibitors4 2015 ASM — May 7, 2015 n Successful endodontic treatment depends upon maximal debridement and disinfection of the entire root canal system. The root canal system must be shaped to a convenience form that per- mits adequate cleaning and disinfection byeliminationofmicrobes.1 The literature is clear that as much as 35 percent or more of the root canal systemremainsuntouchedbyanyinstru- mentationtechnique.Essentiallynofiling technique allows instruments to sculpt all canal walls and remove infected den- tin.2 To decrease the bacterial load and achieve better debridement, irrigation protocolsareusedpriortoobturation. The efficacy of the irrigants to decon- taminatecanalwallshasseensignificant improvements recently. Both negative and positive apical pressure irrigation techniques have been surpassed by ultrasonically activated irrigants, photo- activateddisinfectionandlaser-activated irrigantsintheirabilitytoimproveclean- linessofthecanalsystem.3,4 Inparticular,theEr:YAG(Lightwalker Er:YAG& Nd:YAG dental laser, National Dental Inc., Barrie, Ontario) has shown to be effective at removing debris and the smear layer from canal walls.3,4 A final application of the Er:YAG laser to thesodiumhypochloritealreadypresent within the canal, after standardized instrumentation, can result in improved cleaning of the canal walls with a higher quantity of open tubules (Fig. 1) in com- parison to results without the use of the laser.3,4 A new application of Laser-Activated Irrigation (LAI) has been recently intro- duced. Photon Induced Photoacoustic Streaming(PIPS™)usesanErbium2,940 laser to pulse extremely low energy lev- elsoflaserlighttogenerateaphotoacous- tic shockwave, which streams irrigants throughouttheentirerootcanalsystem.5 Using extremely short bursts of peak power, laser energy is directed down into the canal and the action actively pumpsthetissuedebrisoutofthecanals while cleaning, disinfecting and steril- izing each main canal, lateral canals, dentinal tubules and canal anastomoses to the apex. This movement of irrigant is achieved without the need to place the radialandstrippedlasertip(PIPStip,Fig. 2) into the canal itself, as with other con- ventionalhandandultrasonicsystems. Thetipisheldstationaryinthecoronal aspect of the access preparation only. With the irrigant occupying the entire root canal system, the shock wave cre- ated by PIPS travels in all directions dur- ing activation and effectively debrides and removes organic tissue remnants. Through this laser-activated turbulent flow phenomenon, clinicians following the PIPS protocol are not required to place the tip into each canal, thus elim- inating the need to enlarge and remove more tooth structure to deliver standard needle irrigation to the smaller andmoredelicateapical anatomy, commonly seen in the apical one third. The results are canal convenience forms that are more conservative, min- imally invasive and biomimetic (Fig. 3), preventing the unnecessary removal of toothstructure. Unlike other laser-activated irrigant techniques, PIPS is not a thermal event, rather subablative. Properly executed, PIPScreatesturbulentphotoacousticagi- tation of irrigants that move fluids three dimensionallythroughouttherootcanal systemevenasfarastheapicalterminus, distant from the radial stripped tip loca- tion. By activating the tip in the access cavityandoutsidetherootcanalsystem, the extremely low energy needed to activate the unique PIPS tip (20 mJs or less) is below the threshold of ablation for dentin. Ledging and thermal effects that have plagued the widespread use of otherlasersystemsiscompletelyavoided at the energy levels used by the PIPS technique.5,6 Recent testing, performed at the Uni- versity of Tennessee by Dr. Adam Lloyd, chairmanofthedepartmentforendodon- tics, objectively confirmed the improved cleaninganddebridementoforganicand inorganic tissue left by instrumentation. Microcomputed tomography scans were used to assess before and after volumet- ricchangeintheinternalintagliooflower first molars treated with PIPS protocol (Fig. 4). Sequential slicing beginning at 6 mm from the apex and moving down to the last 2 mm demonstrated that all sliceimagesshowedsignificantimprove- mentsafterPIPS. The importance of these findings is far reaching. PIPS now offers the den- tistalesstechnique-sensitive,minimally invasive and time-reducing method for irrigatingandpreparingendodonticroot canal systems. Because PIPS has demon- strated its ability to decontaminate and debride areas that files and instrumenta- tion cannot reach, success rates rise and retreatmentforpastfailuresispossible.7 PIPS is also helpful in locating and helpingnegotiatecalcifiedcanals.PIPSis avaluableadditionaltoolinthetreatment of endodontics regardless of the shaping andobturationsystemused. Laser technology used in endodontics during the past 20 years has under- gone an important evolution. Research inrecentyearshasbeendirectedtoward producing laser technologies (such as impulses of reduced length, radial-firing and stripped tips) and techniques (such as LAI and PIPS) that are able to simplify  Fig. 1: Left, apical third of root treated with PIPS. Note clean surfaces without any thermal damage. Right, SEM of apical third showing extremely clean dentin tubules post PIPS with no sign of thermal dam- age. (Photos/Provided by Enrico Divito, DDS ) PIPS with laser-activated irrigation laser use in endodontics andminimizetheundesir- able thermal effects on the dentinal walls, using lower energies in the pres- enceofchemicalirrigants. EDTA has proved to be the best solution for the LAItechniquethatactivates the liquid and enhances its cleaning of the smear layer. The use of a laser (PIPS) to activate sodium hypochlor- ite increases its antimicrob- ialactivity. Finally, using the cor- rect protocol, the PIPS technique reduces the thermal effects and exerts both a stronger cleaning and bactericidal action, because of its streaming of fluids initiated by the pho- tonicenergyofthelaser.Fur- ther studies are currently underway to validate LAI andPIPStechniqueasinnov- ativetechnologiesinmodern endodontics. ÿ References 1. ClarkD,KhademiJA.“Casestudiesinmod- ern molar endodontic access and directed dentin conservation” DentClin NorthAm. 2010:54:275–289. 2. PetersOA,SchonenbergerK,LaibA.Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro- computed tomography. International EndodonticJournal. 3. GeorgeR,MeyersIW,WalshLJ(2008)Laser activationofendodonticirrigantswithim- provedconicallaserfibertipsforremoving smear layer in the apical third of the root canal.JEndod34:1524–1527
4. 4. de Groot SD, Verhaagen B, Versluis M, Wu MK,WesselinkPR,vanderSluisLW(2009) Laser-activated irrigation within root can- als: cleaning efficacy and flow visualiza- tion.IntEndodJ42:1077–1083. 5. Li Z., Code JE., Van De Merwe WP. Er:YAG Laserablationofenamelanddentinofhu- man teeth: determination of the ablation rates at various fluences and pulse repeti- tion rates. Lasers in Surgery and Medicine. 1992,12:625–630. 6. Majaron B, Lukac M, Sustercic D, et al. ThresholdandefficiencyanalysisinEr:YAG laser ablation of hard dental tissue. Proc SPIE.1996;2922:233–242. 7. DiVito, E., O.A. Peters, and G. Olivi, Effect- iveness of the erbium:YAG laser and new designradialandstrippedtipsinremoving the smear layer after root canal instru- mentation. Lasers Med Sci, 2012. 27(2): p. 273–280. By Enrico Divito, DDS  Fig. 2: Left, close-up of tapered and stripped PIPS tip used for laser-activated irrigation. Right, position of the laser tip in the PIPS technique: steady in the pulp chamber and does not enter canal.  Fig. 3: Left, pre-treatment. Right, post-treatment ob- turation after PIPS. Tooth instrumented to a #25/06 tapper. Note the conservative convenience form maintaining more original anatomy of root canal system and reducing the need to use larger file sizes conserving more dentin tooth structure.  Fig. 4: Left, mandibular molar canal system showing isthmus before (A, red canal) PIPS laser- activated irrigation. Areas of organic tissue and debris from instrumentation have been completely eliminated, as highlighted by post-PIPS image (B, green canal). Right, mandibular molar with canal preparation to a size 30/.04 (A, green canal) obtur- ated with nano-particle BC Sealer (Brasseler USA, Savannah, Ga.) and single cone obturation (B, blue). About the author Dr. Enrico DiVito formed his dental prac- ticein1980inScottsdale,Ariz.In2004,he formedtheArizonaCenterforLaserDent- istry. He is the founder and director of the state-accredited Arizona School of Dental Assisting (ASDA). In addition to teaching atASDA,DiVitoisalsoaclinicalprofessor at the Arizona School of Dentistry and Oral Health and is helping to create its de- partmentoflaserdentistry.Heearnedhis undergraduatedegreefromArizonaState Universityin1980andisagraduateofthe UniversityofthePacific,ArthurA.Dugoni SchoolofDentistrywithhonors,receiving severalclinicalexcellenceawards.Hecan be reached at edivito@azcld.com. Here in Toronto Learn more about the LightwalkerEr:YAG& Nd:YAG dental laser intheNationalDental Inc. booth, No. 1028, in the exhibit hall. Photoacoustic shockwave with irrigant debrides areas of root canal files can’t reach

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