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Removal of accumulated hard tissue debris from mesial root of mandibular molars evaluated using micro-CT - a systematic review and network meta-analysis

Evidence-Based Dentistry (2021)Cite this article

A Correction to this article was published on 25 March 2022

Abstract

Aim The aim of this systematic review and network meta-analysis was to identify the best irrigant activation technique (IAT) for the removal of accumulated hard tissue debris (AHTD) from the mesial root of mandibular molars evaluated using micro-CT studies.

Methods The research question was based on the PICO format. Four electronic databases - PubMed, Scopus, Embase and Web of Science - were searched for articles up to June 2020. Selected articles were assessed for bias using the Joanna Briggs Institute Critical appraisal tool. The network meta-analysis using a fixed-effects model and SUCRA ranking were performed. The quality of the evidence was assessed using the CINeMA framework.

Results Eleven studies were included for qualitative synthesis while seven were included for quantitative synthesis. The risk of bias of all included articles was low. The results based on SUCRA values revealed the IAT shock wave-enhanced emission photoacoustic streaming (100%) resulted in the greatest reduction of the volume of AHTD from mesial roots of mandibular molars. Ranking of the other IATs was as follows: photon-induced photoacoustic streaming (87%), laser-activated irrigation (79.3%), XP EndoFinisher (71.2%), ultrasonically activated irrigation (59.6%), apical negative pressure (42.3%), EasyClean (37.4%), EDDY (26.2%), EndoActivator (24.2%), self-adjusting file (11.6%) and needle irrigation (11.3%).

Conclusion None of the IATs rendered the root canals completely free of AHTD. The laser-activated irrigation groups fared better than all other interventions in reducing AHTD from the mesial roots of mandibular molars. The confidence rating ranged from low to high for indirect evidence and moderate to high for mixed evidence. Results must be interpreted with caution due to the laboratory nature of the included studies.

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References

  1. Paqué F, Laib A, Gautschi H, Zehnder M. Hard-tissue debris accumulation analysis by high-resolution computed tomography scans. J Endod 2009; 35: 1044-1047.

  2. Bergenholtz G, Spångberg L. Controversies in endodontics. Crit Rev Oral Biol Med 2004; 15: 99-114.

  3. Nair P N, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after "one-visit" endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: 231-252.

  4. Brito P R, Souza L C, Machado de Oliveira J C et al. Comparison of the effectiveness of three irrigation techniques in reducing intra-canal Enterococcus faecalis populations: an in vitro study. J Endod 2009; 35: 1422-1427.

  5. Gu L-S, Kim J R, Ling J, Choi K K, Pashley D H, Tay F R. Review of contemporary irrigant agitation techniques and devices. J Endod 2009; 35: 791-804.

  6. Paqué F, Boessler C, Zehnder M. Accumulated hard tissue debris levels in mesial roots of mandibular molars after sequential irrigation steps. Int Endod J 2011; 44: 148-153.

  7. Paqué F, Al-Jadaa A, Kfir A. Hard-tissue debris accumulation created by conventional rotary versus self-adjusting file instrumentation in mesial root canal systems of mandibular molars. Int Endod J 2012; 45: 413-418.

  8. Susila A, Minu J. Activated irrigation vs. conventional non-activated irrigation in endodontics - a systematic review. Eur Endod J 2019; 4: 96-110.

  9. Kim Y, Perinpanayagam H, Lee J K et al. Comparison of mandibular first molar mesial root canal morphology using micro-computed tomography and clearing technique. Acta Odontol Scand 2015; 73: 427-432.

  10. Gu L, Wei X, Ling J, Huang X. A microcomputed tomographic study of canal isthmuses in the mesial root of mandibular first molars in a Chinese population. J Endod 2009; 35: 353-356.

  11. Kiefer C, Sturtz S, Bender R. Indirect comparisons and network meta-analyses. Dtsch Arztebl Int 2015; 112: 803-808.

  12. Tonin F S, Rotta I, Mendes A M, Pontarolo R. Network meta-analysis: a technique to gather evidence from direct and indirect comparisons. Pharm Pract (Granada) 2017; 15: 943.

  13. Roever L, Biondi-Zoccai G. Network meta-analysis to synthesize evidence for decision making in cardiovascular research. Arq Bras Cardiol 2016; 106: 333-337.

  14. Leucht S, Chaimani A, Cipriani A S, Davis J M, Furukawa T A, Salanti G. Network meta-analyses should be the highest level of evidence in treatment guidelines. Eur Arch Psychiatry Clin Neurosci 2016; 266: 477-480.

  15. Hutton B, Salanti G, Caldwell D M et al. The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions: Checklist and Explanations. Ann Intern Med 2015; 162: 777-784.

  16. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In Aromataris E, Munn Z (eds) Joanna Briggs Institute Reviewer's Manual. JBI Centre: The Joanna Briggs Institute, 2017.

  17. Saletta J M, Garcia J J, Carames J M M, Schliephake H, da Silva Marques D N. Quality assessment of systematic reviews on vertical bone regeneration. Int J Oral Maxillofac Surg 2019; 48: 364-372.

  18. Hu D, O'Connor A M, Wang C, Sargeant J M, Winder C B. How to Conduct a Bayesian Network Meta-Analysis. Front Vet Sci 2020; 7: 271.

  19. Veroniki A A, Mavridis D, Higgins J P T, Salanti G. Characteristics of a loop of evidence that affect detection and estimation of inconsistency: a simulation study. BMC Med Res Methodol 2014; 14: 106.

  20. Krahn U, Binder H, König J. A graphical tool for locating inconsistency in network meta-analyses. BMC Med Res Methodol 2013; 13: 35.

  21. Chaimani A, Salanti G. Using network meta-analysis to evaluate the existence of small-study effects in a network of interventions. Res Synth Methods 2012; 3: 161-176.

  22. Nikolakopoulou A, Higgins J P T, Papakonstantinou T et al. CINeMA: An approach for assessing confidence in the results of a network meta-analysis. PLoS Med 2020; DOI: 10.1371/journal.pmed.1003082.

  23. Papakonstantinou T, Nikolakopoulou A, Higgins J P T, Egger M, Salanti G. CINeMA: Software for semi automated assessment of the confidence in the results of network meta-analysis. Campbell Syst Rev 2020; DOI: 10.1002/cl2.1080.

  24. Lloyd A, Uhles J P, Clement D J, Garcia-Godoy F. Elimination of intracanal tissue and debris through a novel laser-activated system assessed using high-resolution micro-computed tomography: a pilot study. J Endod 2014; 40: 584-587.

  25. Versiani M A, Alves F R, Andrade-Junior C V et al. Micro-CT evaluation of the efficacy of hard-tissue removal from the root canal and isthmus area by positive and negative pressure irrigation systems. Int Endod J 2016; 49: 1079-1087.

  26. Keleş A, Alçin H, Sousa-Neto M D, Versiani M A. Supplementary steps for removing hard tissue debris from isthmus-containing canal systems. J Endod 2016; 42: 1677-1682.

  27. Chan R, Versiani M A, Friedman S et al. Efficacy of 3 supplementary irrigation protocols in the removal of hard tissue debris from the mesial root canal system of mandibular molars. J Endod 2019; 45: 923-929.

  28. Leoni G B, Versiani M A, Silva-Sousa Y T, Bruniera J F, Pécora J D, Sousa-Neto M D. Ex vivo evaluation of four final irrigation protocols on the removal of hard-tissue debris from the mesial root canal system of mandibular first molars. Int Endod J 2017; 50: 398-406.

  29. Rödig T, Koberg C, Baxter S, Konietschke F, Wiegand A, Rizk M. Micro-CT evaluation of sonically and ultrasonically activated irrigation on the removal of hard-tissue debris from isthmus-containing mesial root canal systems of mandibular molars. Int Endod J 2019; 52: 1173-1181.

  30. Linden D, Boone M, De Bruyne M, De Moor R, Versiani M A, Meire M. Adjunctive steps for the removal of hard tissue debris from the anatomic complexities of the mesial root canal system of mandibular molars: a micro-computed tomographic study. J Endod 2020; 46: 1508-1514.

  31. Freire L G, Iglecias E F, Cunha R S, Dos Santos M, Gavini G. Micro-computed tomographic evaluation of hard tissue debris removal after different irrigation methods and its influence on the filling of curved canals. J Endod 2015; 41: 1660-1666.

  32. Silva E J N L, Carvalho C R, Belladonna F G et al. Micro-CT evaluation of different final irrigation protocols on the removal of hard-tissue debris from isthmus-containing mesial root of mandibular molars. Clin Oral Investig 2019; 23: 681-687.

  33. Verstraeten J, Jacquet W, De Moor R J G, Meire M A. Hard tissue debris removal from the mesial root canal system of mandibular molars with ultrasonically and laser-activated irrigation: a micro-computed tomography study. Lasers Med Sci 2017; 32: 1965-1970.

  34. Yang Q, Liu M W, Zhu L X, Peng B. Micro-CT study on the removal of accumulated hard-tissue debris from the root canal system of mandibular molars when using a novel laser-activated irrigation approach. Int Endod J 2020; 53: 529-538.

  35. Macedo R G, Verhaagen B, Wesselink P R, Versluis M, van der Sluis L W M. Influence of refreshment/activation cycles and temperature rise on the reaction rate of sodium hypochlorite with bovine dentine during ultrasonic activated irrigation. Int Endod J 2014; 47: 147-154.

  36. Nagendrababu V, Jayaraman J, Suresh A, Kalyanasundaram S, Neelakantan P. Effectiveness of ultrasonically activated irrigation on root canal disinfection: a systematic review of in vitro studies. Clin Oral Investig 2018; 22: 655-670.

  37. Elemam R F, Pretty I. Comparison of the success rate of endodontic treatment and implant treatment. ISRN Dent 2011; 2011: 640509.

  38. Weller R N, Niemczyk S P, Kim S. Incidence and position of the canal isthmus. Part 1. Mesiobuccal root of the maxillary first molar. J Endod 1995; 21: 380-383.

  39. Caldwell D M, Dias S, Welton N J. Extending treatment networks in health technology assessment: how far should we go? Value Health 2015; 18: 673-681.

  40. Chaimani A, Caldwell D M, Li T, Higgins J P T, Salanti G. Chapter 11: Undertaking network meta-analyses. In Higgins J P T, Thomas J, Chandler J et al. (eds) Cochrane Handbook for Systematic Reviews of Interventions version 6.0. Chichester: John Wiley & Sons, 2019.

  41. Jurič I B, Anić I. The use of lasers in disinfection and cleanliness of root canals: a review. Acta Stomatol Croat 2014; 48: 6-15.

  42. Blanken J W, Verdaasdonk R M. Cavitation as a working mechanism of the Er,Cr:YSGG Laser in endodontics: a visualization study. J Oral Laser Appl 2007; 7: 97-106.

  43. de Groot S D, Verhaagen B, Versluis M, Wu K, Wesselink P R, van der Sluis L W. Laser-activated irrigation within root canals: cleaning efficacy and flow visualization. Int Endod J 2009; 42: 1077-1083.

  44. Verhaagen B, Boutsioukis C, van der Sluis L W, Versluis M. Acoustic streaming induced by an ultrasonically oscillating endodontic file. J Acoust Soc Am 2014; 135: 1717-1730.

  45. Chen J E, Nurbakhsh B, Layton G, Bussmann M, Kishen A. Irrigation dynamics associated with positive pressure, apical negative pressure and passive ultrasonic irrigations: a computational fluid dynamics analysis. Aust Endod J 2014; 40: 54-60.

  46. Mikulik R, Naji A, van der Hoeven R, Tsesis I, Rosen E, Jaramillo D E. Efficacy evaluation of a cordless ultrasonic unit in achieving reduction of bacterial load within a root canal system as compared to a conventional ultrasonic unit and negative pressure irrigation. Evid-Based Endod 2019; 4: 2.

  47. Schoeffel G J. The EndoVac method of endodontic irrigation: part 2 - efficacy. Dent Today 2008; 27: 82-87.

  48. Uroz-Torres D, González-Rodríguez M P, Ferrer-Luque C M. Effectiveness of the EndoActivator system in removing the smear layer after root canal instrumentation. J Endod 2010; 36: 308-311.

  49. Suman S, Verma P, Prakash-Tikku A, Bains R, Kumar-Shakya V. A comparative evaluation of smear layer removal using Apical Negative Pressure (EndoVac), Sonic Irrigation (EndoActivator) and Er:YAG laser - an in vitro SEM study. J Clin Exp Dent 2017; DOI: 10.4317/jced.53881.

  50. Andrade-Junior C V, Batista R M, Marceliano-Alves M, Alves F R F, Silva E J N L. Efficacy of a new activation device in irrigant penetration into simulated lateral canals. Eur Endod J 2016; 1: 1-4.

  51. Urban K, Donnermeyer D, Schäfer E, Bürklein S. Canal cleanliness using different irrigation activation systems: a SEM evaluation. Clin Oral Investig 2017; 21: 2681-2687.

  52. Kanaan C G, Pelegrine R A, da Silveira Bueno C E, Shimabuko D M, Valamatos Pinto N M, Kato A S. Can irrigant agitation lead to the formation of a smear layer? J Endod 2020; 46: 1120-1124.

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Authors and Affiliations

  1. Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Meenakshi Ammal Dental College & Hospital, Meenakshi Academy of Higher Education and Research (MAHER), No.1, Alapakkam Main Road, Maduravoyal, Chennai, 600095, Tamil Nadu, India

    Velmurugan Natanasabapathy, Buvaneshwari Arul, Vignesh Srinivasan, Sneha Susan Santosh & Aishwarya Vasudevan

  2. Department of Orthodontics, Faculty of Dentistry, Meenakshi Ammal Dental College & Hospital, Meenakshi Academy of Higher Education and Research (MAHER), No.1, Alapakkam Main Road, Maduravoyal, Chennai, 600095, Tamil Nadu, India

    Selva Arockiam

  3. Department of Periodontology and Oral implantology, Faculty of Dentistry, Meenakshi Ammal Dental College & Hospital, Meenakshi Academy of Higher Education and Research (MAHER), No.1, Alapakkam Main Road, Maduravoyal, Chennai, 600095, Tamil Nadu, India

    Ambalavanan Namasivayam

  4. Department of Conservative Dentistry & Endodontics, Faculty of Dental Sciences, Sri Ramachandra Institute of Higher Education and Research, Chennai, 600116, Tamil Nadu, India

    Kandaswamy Deivanayagam

  5. Department of Conservative Dentistry and Endodontics, Sri Venkateswara Dental College and Hospital, Chennai, 600130, Tamil Nadu, India

    M. R. Srinivasan

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Contributions

Velmurugan Natanasabapathy: conceptualisation; data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualisation; roles/writing - original draft; writing - review and editing. Buvaneshwari Arul: data curation; formal analysis; investigation; methodology; project administration; supervision; validation; visualisation; writing - review and editing. Vignesh Srinivasan: data curation; formal analysis; investigation; methodology; project administration; supervision; validation; visualisation; writing - review and editing. Sneha Susan Santosh: data curation; formal analysis; investigation; methodology; visualisation; roles/writing - original draft; writing - review and editing. Aishwarya Vasudevan: data curation; formal analysis; investigation; methodology; visualisation; roles/writing - original draft; writing - review and editing. Selva Arockiam: methodology; resources; software; validation; visualisation. Ambalavanan Namasivayam: formal analysis; supervision; validation; writing - review and editing. Kandaswamy Deivanayagam: formal analysis; supervision; validation; writing - review and editing. M. R. Srinivasan: formal analysis; supervision; validation; writing - review and editing

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Natanasabapathy, V., Arul, B., Srinivasan, V. et al. Removal of accumulated hard tissue debris from mesial root of mandibular molars evaluated using micro-CT - a systematic review and network meta-analysis. Evid Based Dent (2021). https://doi.org/10.1038/s41432-021-0207-x

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