Conclusions

Instrumentation and irrigation are the most important parts of root canal treatment. Irrigation has several key functions, the most important of which are tissue dissolution, killing of microorganisms, and removal of the bioÞlms. Apical irrigation poses a special challenge with regard to effectiveness and safety. During the past few years, a variety of ex vivo bioÞlm models have been developed and used in endodontic research on irrigation, but the full potential of bioÞlm experimentation has not yet been fully exploited. Several new different irrigation models have been developed in recent years and used for a variety of experimental purposes. Future research will hopefully help to optimize the models for each research problem. Generally, models that best can reproduce the in vivo conditions should be preferred. Today, as there is still no ideal irrigation model for all purposes, the challenge continues for the development more

accurate and realistic models to study and improve the effectiveness and safety of root canal irrigation.

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The goal of endodontic treatment is to prevent or cure apical periodontitis. Apical periodontitis is an inßammatory process in the periradicular tissues caused by microorganisms in the infected root canal [84]. It is well known that shaping, cleaning, and obturating the root canal system provide the strategy for successful treatment. The principle to reach favorable outcomes in endodontic infection management requires the recognition of the problem and the removal of the etiological factors.

B. Basrani, DDS, MSc, RCDC (F), PhD (*)

Associate Professor, Director M.Sc.

Endodontics Program, Faculty of Dentistry,

University of Toronto, 348C-124 Edward Street,

Toronto, ON M5G1G6, Canada

e-mail: Bettina.Basrani@dentistry.utoronto.ca

G. Malkhassian, DDS, MSc, FRCD(C)

Assistant Professor, Discipline of Endodontics,

Faculty of Dentistry, University of Toronto,

Toronto, ON, Canada

In endodontic disinfection, there are two main challenges which are important to be recognized the anatomical challenge and the microbiological challenge [42].

The anatomical challenge can be divided into complexity of the root canal system, dentin structure, and dentin constituents.

Anatomical Complexities (also see Chap. 2): Root canal is an enclosed complex space with intricate conÞgurations and apical constriction it is important to mention here that more than 35 % of the root canal surface is left untouched by conventional instrumentation [35, 64] (Fig. 5.1). Also, common instrumentation techniques accumulate debris in isthmus areas. Paque et al. showed explained that when rotary Þles are used in canal with a round cross section, the dentine particles that are cut from the canal wall are car-

P

T

N

C

M

A

Fig. 5.1 MicroCT scan of preand post-instrumentation in a lower molar. Note the amount of walls not touch by the instruments. Lateral view of representative 3D reconstructions of the internal anatomy of a mesial roots of a

mandibular molar, before (in green) and after (in red) canal preparation C Coronal, M Middle, A Apical, (Courtesy of Dr Gagliardi, Versiani and Sousa-Neto)

Fig. 5.2 SEM of dentin structure showing irregularities of dentin tissue

ried coronally by the ßutes of the Þle, in a manner similar to that of a common mechanical spiral drill. This removal is apparently less effective when the Þle has no dentine wall on one side, as is the case of a canal adjacent to an isthmus. Rather than being carried coronally or being contained and packed in the ÞleÕs ßute space, the debris was most probably actively packed into the area with the least resistance, namely into the isthmus [62].

Dentin Structure Physiologically and anatomically, the dentin is a complex structure. Type I collagen is the major protein of intertubular dentin (90 %), whereas no collagen Þbrils are observed in the peritubular dentin. The structure

is a porous conÞguration with dentinal tubules that allow bacterial invasion and adherence, making dentin disinfection a challenging step (Fig. 5.2).

Dentin Constituents The effectiveness of antimicrobial irrigants is known to be compromised under in vivo conditions [77]. In recent studies it has been reported that dentin powder, serum albumin, and dentin matrix can inhibit the antibacterial effect of commonly used irrigants [29, 66, 67]. Interestingly, it has been also reported that even the antibacterial effect of advance disinfection techniques like chitosan nanoparticles and photoactivation disinfection can also be neutralized by the dentin constituents [77].

The microbiological challenge is well covered in Chap. 1. It is important to understand that the endodontic problem is a bioÞlm-related diseases and access, disruption, or penetration of the bioÞlm should be our disinfection aim [43].

Endodontic irrigants have three major objectives: chemical, biological, and mechanical. Mechanical objectives include to rinse out debris and lubricate the canal; chemical objectives include to soften and dissolve organic and inorganic tissues, prevent the formation of a smear layer during instrumentation, and dissolve smear layer once it has formed; and biological objec-