|Year : 2021 | Volume
| Issue : 3 | Page : 149-154
Antimicrobial Efficacy of Sonic v/s Ultrasonic Activation on Disinfection of Root Canal System: An In Vitro Study
Shruthi H Attavar1, Mithra N Hegde1, Veena Shetty2
1 Department of Conservative and Endodontics, A B Shetty Memorial Institute of Dental Sciences, NITTE (Deemed to be University), Deralakatte, Mangalore, India
2 Department of Microbiology, K S Hegde Medical College NITTE (Deemed to be University), Deralakatte, Mangalore, India
|Date of Submission||25-Nov-2020|
|Date of Decision||16-Mar-2021|
|Date of Acceptance||29-Mar-2021|
|Date of Web Publication||2-Nov-2021|
Shruthi H Attavar
Department of Conservative and Endodontics, A B Shetty Memorial Institute of Dental Sciences, NITTE (Deemed to be University), Deralakatte, Mangalore - 575018
Source of Support: None, Conflict of Interest: None
Introduction: The key for long-term success in root canal therapy is the effective debridement with chemical irrigants before obturation. The purpose of this study was to compare the antimicrobial effect of sodium hypochlorite and chlorhexidine along with activation using sonic and an ultrasonic device in teeth when used in teeth infected with Enterococcus faecalis. Material and Method: A total of 90 single rooted mandibular premolar were infected with E. faecalis and placed in the incubator for 24 hours .The specimens were divided into six groups as follows: Group I: positive control; Group II: negative control; Group III: sodium hypochlorite + passive ultrasonic activation for 20, 40, and 60 seconds; Group IV: chlorhexidine + passive ultrasonic activation; Group V: sodium hypochlorite + endoactivator; and Group VI: chlorhexidine + endoactivator activation. After disinfection, dentinal shavings were collected using H file and subcultured in brain heart infusion agar (BHI) broth further streaked in brain heart agar plates to check the colony counting. Result: Bonferroni post hoc test was done to compare the significant difference between different experimental groups. Group III showed a significant difference in the antimicrobial activity compared to Group IV, V, and VI with P < 0.05. One-way analysis of variance (ANOVA) analysis was done to analyze the intergroup comparison of the bacterial count at various time intervals (20, 40, and 60 seconds). It was observed that there was a statistically significant difference with P < 0.01 between the time interval of different experimental groups. Conclusion: Within the limitation of this study, sodium hypochlorite along with passive ultrasonic irrigation showed a reduction in E. faecalis count compared to the other irrigating protocols used in the study and the results were statistically significant.
Keywords: Chlorhexidine, endo activator, passive ultrasonic activation, E. faecalis, sodium hypochlorite
|How to cite this article:|
Attavar SH, Hegde MN, Shetty V. Antimicrobial Efficacy of Sonic v/s Ultrasonic Activation on Disinfection of Root Canal System: An In Vitro Study. Dent Hypotheses 2021;12:149-54
|How to cite this URL:|
Attavar SH, Hegde MN, Shetty V. Antimicrobial Efficacy of Sonic v/s Ultrasonic Activation on Disinfection of Root Canal System: An In Vitro Study. Dent Hypotheses [serial online] 2021 [cited 2021 Nov 29];12:149-54. Available from: http://www.dentalhypotheses.com/text.asp?2021/12/3/149/329759
| Introduction|| |
The removal of microorganisms, toxins, and their irritants from the infected root canal system determines the success of endodontic treatment so as to best obtain a host-manageable bioburden. The disinfection of root canal system by chemomechanical preparation plays an critical role in reducing the bacterial load. The mechanical instrumentation of the root canal along with the synergetic effect of antimicrobial property of irrigants enhances the elimination of microorganisms. The mechanical preparation of the root canal system is an essential phase since it aims to facilitate the easy flow of irrigants within the canal space.
E faecalis is gram-negative facultative anaerobic cocci found in 4% to 40% of primary endodontic infection and nine times more likely in failed root canal cases. The prevalence of E faecalis in root filled teeth with periradicular lesions is from 24% to 77%.
Sodium hypochlorite is a potent antimicrobial agent introduced by Walker in the year 1936. It is used in the concentration between 05% and 6%. The most important property of sodium hypochlorite is that it dissolves the organic pulp tissue and collagen. Chlorhexidine gluconate a bisguanide derivative shows its antimicrobial property by destroying the microbial cell wall and attacks the bacterial cytoplasm causing coagulation of intracellular components. The application of a final irrigating solution that remains active not only at the time of application but also over a fairly long period of time thereafter stands as one strategy for preventing bacterial recolonization or eliminating the bacteria that persist after the root canal treatment.
Traditionally, irrigants were delivered into the root canal using syringe and metal needles of various sizes and tip design. Clinically, this method was ineffective because irrigants could not penetrate into peripheral areas such as fins, isthmus, and deltas. In an attempt to improve the penetration and efficacy of irrigants, various mechanical devices have been developed to enhance the cleaning efficacy of the root canal system.
Alternatively, different solution agitation methods and devices have been proposed to increase effectiveness of irrigating solutions, including agitation with hand files, plastic instruments, and sonic and ultrasonic devices. Sonic activation generates mechanical oscillation, mainly at the file tip, at 1 to 6000 Hz frequency, while ultrasonic devices generate microstreaming along the file with 40,000 to 45,000 Hz frequency.
Passive ultrasonic irrigation was first described by Weller et al. in 1980. The term “passive” does not adequately describe the process, as it is in fact active; however, when it was first introduced, the term “passive” related to the “noncutting” action of the ultrasonically activated file. passive ultrasonic irrigation (PUI) relies on the transmission of acoustic energy from an oscillating file or smooth wire to an irrigant in the root canal. The energy is transmitted by means of ultrasonic waves and can induce acoustic streaming and cavitation of the irrigant.
The synergetic effect of sodium hypochlorite and chlorhexidine along with ultrasonic activation and endoactivator in disinfection of the root canal system has not been evaluated. Therefore, the aim of the present study is to determine the efficacy of sonic v/s ultrasonic device in eradication of E. faecalis from the root canal system.
| Material and Method|| |
Sample size determination was done based on 5% level of significance and 80% power effect size of 0.4. The total sample size for six groups is 90, that is, 25, in each group.
Selection and standardization of specimen
Ninety noncarious single rooted mandibular premolars were collected and sterilized according to occupational safety hazard (OSHA) regulation. The presence of single root was confirmed radiographically using digital radiograph. The exclusion criteria were teeth with open apex, resorption, caries, and fractured roots. The crown of all teeth was sectioned using high speed carbide disk at the level of cemento enamel juntion (CEJ). Working length was determined using size 15 k file (Dentsply Sirona) 1 mm short of the apical foramen. Cleaning and shaping of the root canal was done with the protaper gold rotary file system using the crown down technique till file size F 3 (Dentsply Sirona). The apical foramen was sealed using epoxy resin to prevent bacterial leakage.
The tooth samples were sealed in a plastic pouch and sterilized using ethylene oxide sterilization.
Cultivation of E. faecalis and specimen contamination
A suspension of 50 mL of E. faecalis [American type culture collection (ATCC) 29212] was incubated in 5 mL of brain heart infusion agar (BHI) broth at 37°C for 24 hours. The concentration of the inoculum was adjusted to McFarland scale, which corresponds to the concentration of 3 × 108 cells/mL and optical density (OD) of 550 nm. The root canal of all teeth was inoculated with the bacterial strain of E faecalis using sterile insulin syringe and incubated for 21 days at 37°C.
Group I: N = 15–Positive control group − Brain heart infusion broth with inoculation of E. faecalis
Group II: N = 15–Negative control − Brain heart infusion broth without inoculation of E. faecalis
Group III: N = 15–Sodium hypochlorite + Passive ultrasonic activation (Irrisafe tips, Aceteon Satelec)
Subgroup A: N = 5–5 mL of 3% sodium hypochlorite (Vensons, India) + Passive ultrasonic − activation − 20 seconds
Subgroup B: N = 5–5 mL of 3% sodium hypochlorite (Vensons, India) + Passive ultrasonic activation − 40 seconds
Subgroup C: N = 5–5 mL of 3% sodium hypochlorite (Vensons, India) + Passive ultrasonic activation − 60 seconds
Group IV: N = 15–Chlorhexidine + Passive ultrasonic activation (Irrisafe tips, Aceton Satelec)
Subgroup A: N = 5–5 mL of 2% chlorhexidine (DC Chlor, Red Gold Mines) + Passive ultrasonic − 20 seconds
Subgroup B: N = 5–5 ml of 2% chlorhexidine (DC Chlor, Red Gold Mines) + Passive ultrasonic − 40 seconds
Subgroup C: N = 5–5 mL of 2% chlorhexidine (DC Chlor, Red Gold Mines) + Passive ultrasonic − 60 seconds
Group V: N = 15–Sodium hypochlorite + Endoactivator (Dentsply Sirona) activation
Subgroup A: N = 5–5 mL of 3% sodium hypochlorite (Vensons, India) + Endoactivator − 20 seconds
Subgroup B: N = 5–5 mL of 3% sodium hypochlorite (Vensons, India) + Endoactivator − 40 seconds
Subgroup C: N = 5–5 mL of 3% sodium hypochlorite (Vensons, India) + Endoactivator − 60 seconds
Group VI: N = 15–Chlorhexidine + Endoactivator activation
Subgroup A: N = 5–5 mL of 2% chlorhexidine (DC Chlor, Red Gold Mines) + Endoactivator − 20 seconds
Subgroup B: N = 5–5 mL of 2% chlorhexidine (DC Chlor, Red Gold Mines) + Endoactivator − 40 seconds
Subgroup C: N = 5–5 mL of 2% chlorhexidine (DC Chlor, Red Gold Mines) + Endoactivator − 60 seconds
After disinfection of the root canal, the dentinal shavings were collected using H file (Dentsply Sirona) and placed in BHI broth in a micro tube and incubated for 24 hours. The samples were streaked on brain heart infusion agar plate and incubated at 37°C for 24 hours [Figure 1].,
Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) 23.0 software for windows. The quantitative data obtained from the mean colony forming unit of the Bonferroni post hoc test was done to compare the significant difference between different experimental groups. One-way analysis of variance (ANOVA) was done to analyze the intergroup comparison of the bacterial count at various time intervals (20, 40, and 60 seconds).
| Results|| |
A pairwise comparison was done using Bonferroni post hoc test to analyze the level of significance between groups activated with different time intervals (20, 40 and 60 sec) [Table 1]. P < 0.05 was considered statistically significant. Bonferroni post hoc test was done to compare the significant difference between different experimental groups [Table 2]. Group III showed a significant difference in the antimicrobial activity compared to Group IV,V, and VI with P < 0. 05.
|Table 1 Pairwise comparison of log10 CFU of bacteria between different time intervals|
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|Table 2 Pairwise comparison of log10 CFU of bacteria between different study groups|
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One-way ANOVA analysis was done to analyze the intergroup comparison of the bacterial count at various time intervals (20, 40, and 60 seconds) [Table 3]. It was observed that there was a statistically significant difference with P < 0.01 between the time interval of different experimental groups. Bonferroni post hoc test was done to compare the bacterial count between the groups at different time intervals [Table 4]. The results of the study showed that there was no statistical significant difference in group group III activated for duration of 20 and 40 sec, but there was a statistically significant difference between groups activated for 20 and 60 seconds with P value of 0.02. In Group IV, there was a statistically significant difference between activation time of 20 seconds when compared to 40 and 60 seconds with P value of 0.02 and 0.04, respectively, but there was no statistically significant difference between activation time of 40 and 60 seconds. In Group V, there was a statistically significant difference between groups irrigated for 20, 40, and 60 seconds. In Group VI, there was no statistical significance between groups irrigated for 20 and 40 seconds, but there was a significant difference between groups irrigated between 40 and 60 seconds.
|Table 3 Comparison of log10 CFU of bacteria between different study groups at each time interval|
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|Table 4 Comparison of log10 CFU of bacteria between different time intervals in each study groups|
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| Discussion|| |
The aim of endodontic treatment is the elimination of bacteria and the prevention of reinfection. This is accomplished by effective mechanical instrumentation and the use of irrigants and intracanal disinfectants. Sodium hypochlorite is the most effective antimicrobial solution; the property is attributed to the presence of hypochlorous acid. Chlorhexidine is a biguanide with a broad spectrum antimicrobial activity against both gram-positive and gram-negative organisms with the property of substantivity.
Passive ultrasonic activation is one of the predominant irrigation regimens in endodontic practise with the advantage of acoustic streaming that removes the intraradicular biofilm by increasing the shear stress on the walls of the root canal. Endoactivator is a sonic device that operates at a frequency of 1 to 8 kHz with the flexible plastic tips that do not stop when it comes in contact with root canal wall, and hence it can be used in curved canals.
Among irrigant agitation equipment, sonic and ultrasonic devices have been extensively tested (De Gregorio et al. 2009, Gu et al. 2009, Gulabivala et al. 2010). Sonic activation generates mechanical agitation primarily on the tip of files, whereas ultrasonic activation generates microstreaming around the file and a secondary acoustic streaming (Ahmad et al. 1987, De Gregorio et al. 2009, Gu et al. 2009, Gulabivala et al. 2010). Ex vivo studies in root canal systems with restricted flow through the apical foramen, which better simulates fluid flow in clinical conditions (Tay et al. 2010), revealed that penetration of solutions is enhanced by ultrasonics and, to a lesser degree, sonic activation (De Gregorio et al. 2009, Paragliola et al. 2010, Sainz-Pardo et al. 2014).
In the present study, a long-term incubation of E. faecalis for 21 days was done since a short duration of 3 days would lead to the formation of young planktonic cells compared to 21 days incubation that leads to the penetration of microorganisms into dentinal tubules. Since we focused on the in-depth penetration of irrigants into the dentinal tubule, a long duration of incubation was selected.
In this study, the activation time was used at an interval of 20, 40, and 60 seconds. As a general rule, the greater the time of activation, the greater the canal cleanliness [Table 1]. Ultrasonic activation of NaOCl from 30 seconds to 1 minute for each canal with three cycles of 10 to 20 seconds (with constant irrigant renewal) seems to be a sufficient to obtain cleaned canals at the end of the preparation. Sodium hypochlorite along with passive ultrasonic activation, that is, Group III, showed an increased antimicrobial activity compared to the Group IV, V, and VI and the results were statistically significant [Table 2]. One of the reasons could be the higher frequency of 30,000 Hz and lower amplitude of 11 mm that during oscillation causes shear stress in root canal walls. The bacterial cell walls get teared off due to this high velocity and energy produced by the ultrasonic device. Furthermore, these ultrasonic devices can cause degassing of the solution and decomposition of molecules. In addition to these factors, the ultrasonic wave that vibrates in the irrigating solution can convert sound energy into heat, which leads to heat generation and increases in the temperature. In general, it is believed that sonic activation is seemingly less effective than the use of ultrasound as a more velocity fluid stream is induced with the latter. Furthermore, instrument size, tip diameter, instrument taper, confinement of the instrument within the canal, and the type of irrigants have an influence on the cleaning and disinfection efficacy associated with enhanced fluid streaming.
The present study also evaluated the effect of sodium hypochlorite in disinfection of root canal system and it was shown that it had a better antimicrobial efficacy compared to chlorhexidine. This can be attributed to the fact that sodium hypochlorite, when it comes in contact with organic debris, leads to the formation of hypochlorous acid that interferes with the oxidizing sulfhydryl group of the bacterial enzyme, thus disrupting the microbial metabolism and killing of bacterial cells. It has been demonstrated that ultrasonic activation of sodium hypochlorite dramatically enhances the effectiveness of cleaning the root canal space. Besides, it greatly increases the flow of liquid and improves both the solvent and antibacterial capacities and the removal effect of organic and inorganic debris from root canal walls.
| Conclusion|| |
Within the limitation of this study, sodium hypochlorite along with passive ultrasonic irrigation showed a reduction in E faecalis count compared to the other irrigating protocols used in the study and the results were statistically significant.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sonarkar SS, Singh S, Podar R, Kulkarni G, Purba R. An in vivo
comparison of the antibacterial efficacy of photoactivated disinfection, diode laser, and 5% sodium hypochlorite in root canal disinfection. J Conserv Dent 2018;21:205-9.
] [Full text]
Rôças IN, Siqueira JFJr. Comparison of the in vivo antimicrobial effectiveness of sodium hypochlorite and chlorhexidine used as root canal irrigants: a molecular microbiology study. J Endod 2011;37:143-50.
Abbaszadegan A, Khayat A, Motamedifar M. Comparison of antimicrobial efficacy of IKI and NaOCl irrigants in infected root canals: an in vivo study. Iran Endod J 2010;5:101-6.
Hulsmann M, Peters OA, Dummer P. Mechanical preparation of root canals: shaping goals, techniques and means. Endod Topics 2005;10:30-76.
Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis
: its role in root canal treatment failure and current concepts in retreatment. J Endod 2006;32:93-8.
Byström A, Sundqvist G. Bacteriologic evaluation of the effect of 0.5 percent sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol 1983;55:307–12.
Haapasalo M, Shen Y. Irrigation in endodontics. Dent Clin N Am 2010;54:291–312.
Pedullà E, Genovese C, Messina R, La Rosa GRM, Corsentino G, Rapisarda S, Arias-Moliz MT, Tempera G, Grandini S. Antimicrobial efficacy of cordless sonic or ultrasonic devices on Enterococcus faecalis-infected root canals. J Investig Clin Dent 2019;10:1-5.
Berber BV, Gomes A, Sena NT. Efficacy of various concentrations of NaOCl and instrumentation techniques in reducing Enterococcus faecalis
within root canals and dentinal tubules. Int Endod J 2006;39:10-7.
Shenoy A, Mandava P, Bolla N, Raj S, Kurien J, Prathap MS. Antibacterial efficacy of sodium hypochlorite with a novel sonic agitation device. Indian J Dent Res. 2013;24:537-41.
Ghivari SB, Bhattacharya H, Bhat KG, Pujar MA. Antimicrobial activity of root canal irrigants against biofilm forming pathogens − an in vitro
study. J Conserv Dent 2017;20:147-51.
] [Full text]
Ahangari Z, Samiee M, Yolmeh MA, Eslami G. Antimicrobial activity of three root canal irrigants on Enterococcus faecalis
: an in vitro study. Iran Endod J 2008;3:33-7.
Plotino G, Grande NM, Mercade M et al.
Efficacy of sonic and ultrasonic irrigation devices in the removal of debris from canal irregularities in artificial root canals. J Appl Oral Sci 2019;27:1-6.
de Castro FP, Pinheiro SL, Duarte MA, Duque JA, Fernandes SL, Anchieta RB, da Silveira Bueno CE. Effect of time and ultrasonic activation on ethylenediaminetetraacetic acid on smear layer removal of the root canal. Microsc Res Tech 2016;79:1062-8.
Hage W, De Moor RJG, Hajj D, Sfeir G, Sarkis DK, Zogheib C. Impact of different irrigant agitation methods on bacterial elimination from infected root canals. Dent J (Basel) 2019;7:1-6.
Darda S, Madria K, Jamenis R, Heda A, Khanna A, Sardar L. An in-vitro evaluation of effect of EDTAC on root dentin with respect to time. JIOH 2014;6:22-7.
Pedulla E, Genovese C. Antimicrobial efficacy of cordless sonic or ultrasonic devices on Enterococcus faecalis
-infected root canals. J Investig Clin Dent 2019;10:1-5.
Hage W, Moor R. Impact of different irrigant agitation methods on bacterial elimination from infected root canals. 2019;64:2-9.
Maden M, Ertuğrul İF, Orhan EO, Erik CE, Yetiş CÇ, Tuncer Y, Kahriman M. Enhancing antibacterial effect of sodium hypochlorite by low electric current-assisted sonic agitation. PLoS One 2017;12:1-9.
[Table 1], [Table 2], [Table 3], [Table 4]