Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2017-05-12, 10:07:48 | version 1.38.0
16 exhibitors 2017 ASM — May 4, 2017 PIPS with laser-activated irrigation Photoacoustic shockwave with irrigant debrides areas of canal that files can’t reach By Enrico Divito, DDS 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 permits adequate cleaning and disinfection by elimination of microbes.1 The literature is clear that as much as 35 percent or more of the root canal system remains untouched by any instrumentation technique. Essen- tially no filing technique allows instru- ments to sculpt all canal walls and remove infected dentin.2 To decrease the bacterial load and achieve better debridement, irrigation protocols are used prior to obturation. The efficacy of the irrigants to decontaminate canal walls has seen significant improvements recently. Both negative and positive apical pres- sure irrigation techniques have been surpassed by ultrasonically activated irrigants, photo-activated disinfec- tion and laser-activated irrigants in their ability to improve cleanliness of the canal system.3,4 In particular, the Er:YAG (Light- walker Er:YAG& Nd:YAG dental laser, National Dental Inc., Barrie, Ontario) has shown to be effective at remov- ing debris and the smear layer from canal walls.3,4 A final application of the Er:YAG laser to the sodium hypochlor- ite already present 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 comparison to results without the use of the laser. 3,4 A new application of Laser- Activated Irrigation (LAI) has been recently introduced. Photon Induced Photoacoustic Streaming (PIPS™) uses an Erbium 2,940 laser to pulse extremely low energy levels of laser light to generate a photoacoustic shockwave, which streams irrigants throughout the entire root canal sys- tem.5 Using extremely short bursts of peak power, laser energy is directed down into the canal and the action actively pumps the tissue debris out of the canals while cleaning, disin- fecting and sterilizing 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 radial and stripped laser tip (PIPS tip, Fig. 2) into the canal itself, as with other con- ventional hand and ultrasonic sys- tems. The tip is held stationary in the cor- onal aspect of the access preparation 5 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 By Enrico Divito, DDS ) 5 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. Here in Toronto Learn more about the Lightwalker Er:YAG & Nd:YAG dental laser in the National Dental Inc. booth (No. 424) in the exhibit hall. only. With the irrigant occupying the entire root canal system, the shock wave created by PIPS travels in all direc- tions during activation and effect- ively 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 eliminating the need to enlarge and remove more tooth structure to deliver standard needle irrigation to the smaller and more deli- cate apical anatomy, commonly seen in the apical one third. The results are canal convenience forms that are more conservative, minimally invasive and biomimetic (Fig. 3), pre- venting the unnecessary removal of tooth structure. Unlike other laser-activated irri- gant techniques, PIPS is not a thermal event, rather subablative. Properly executed, PIPS creates turbulent photoacoustic agitation of irrigants that move fluids three dimensionally throughout the root canal system even as far as the apical terminus, distant from the radial stripped tip location. By activating the tip in the access cavity and outside the root canal system, 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 other laser systems is completely avoided at the energy levels used by the PIPS technique.5,6 Recent testing, performed at the University of Tennessee by Dr. Adam Lloyd, chairman of the department for endodontics, objectively confirmed the improved cleaning and debride- ment of organic and inorganic tissue left by instrumentation. Microcom- puted tomography scans were used to assess before and after volumetric change in the internal intaglio of lower 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 demon- strated that all slice images showed significant improvements after PIPS. The importance of these findings is far reaching. PIPS now offers the dentist a less technique-sensitive, minimally invasive and time-reducing method for irrigating and pre- paring endodontic root canal systems. Because PIPS has demonstrated its ability to decontam- inate and debride areas that files and instru- mentation cannot reach, success rates rise and retreatment for past fail- ures is possible.7 PIPS is also helpful in locating and helping negotiate calcified can- als. PIPS is a valuable additional tool in the treatment of endodon- tics regardless of the shaping and obturation system used. 5 Fig. 3: Left, pre-treatment. Right, post-treatment obturation 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. 5 Fig. 4: Left, mandibular molar canal system show- ing isthmus before (A, red canal) PIPS laser-activated irrigation. Areas of organic tissue and debris from in- strumentation 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) obturated with nano-particle BC Sealer (Brasseler USA, Savannah, Ga.) and single cone obturation (B, blue). About the author Laser technology used in endodontics dur- ing the past 20 years has undergone an important evolution. Research in recent years has been directed toward produ- cing laser technologies (such as impulses of reduced length, radial- firing and stripped tips) and tech- niques (such as LAI and PIPS) that are able to simplify laser use in endodontics and minimize the undesirable thermal effects on the dentinal walls, using lower ener- gies in the presence of chemical irrigants. EDTA has proved to be the best solution for the LAI tech- nique that activates the liquid and enhances its cleaning of the smear layer. The use of a laser (PIPS) to activate sodium hypochlorite increases its antimicrobial activ- ity. Finally, using the correct proto- col, the PIPS technique reduces the thermal effects and exerts both a stronger cleaning and bac- tericidal action, because of its streaming of fluids initiated by the photonic energy of the laser. Fur- ther studies are currently under- way to validate LAI and PIPS tech- nique as innovative technologies in modern endodontics. References are available from the publisher on request Dr. Enrico DiVito formed his dental prac- tice in 1980 in Scottsdale, Ariz. In 2004, he formed the Arizona Center for Laser Dentistry. He is the founder and director of the state-accredited Arizona School of Dental Assisting (ASDA). In addition to teaching at ASDA, DiVito is also a clinical professor at the Arizona School of Dentistry and Oral Health and is helping to create its department of laser dentistry. He earned his undergraduate degree from Arizona State University in 1980 and is a graduate of the University of the Pacific, Arthur A. Dugoni School of Dentistry with honors, receiving several clinical excellence awards. He can be reached at ndivito@azcld.com.