Endo onties

THE IMPORTANCE OF CHEMOMECHANICAL PREPARATION

OF THE ROOT CANAL

GEORGE G. STEWART, A.B., D.D.S., PHILADELPHIA, PA.

R OOT canal therapy may be divided into three phases: ehemomechanical

preparation, microbial control, and obturation of the root canal. Each
of these phases is important for the eventual healing of the supporting tissues
of the tooth. Of these, chemomeehanical preparation is probably the most
important single entity, for as the root canal is enlarged we help to reduce the
number of microorganisms that may be present and also remove the debris in
which they can grow. Then, too, as we increase the internal diameter of the
canal, we also increase the space available for a greater volume of medication.
The enlarged canal is also simpler to obturate with a properly condensed
root canal filling.
This phase of treatment has been emphasized by most reputable endo-
dontists, but it has been neglected by those who treat endodontic cases only
occasionally, and too much reliance is placed upon drugs alone12 ‘9 4-8
To determine more accurately the importance of cleansing and enlarging
the root canal in endodontics, the following study was devised.

Method
Patients were carefully selected who required endodontic therapy of one
or more maxillary anterior teeth. Preference was given to those teeth that
showed radiographic evidence of periapical pathosis and in which the pulp
chamber was exposed to the saliva of the mouth. The pulp tissue had to have
marked putresence or show evidence of microbial activity when a culture was
taken.
Those teeth which were selected were treated as follows: The tooth was
carefully isolated, using a rubber dam. Following this, the entire area was
swabbed with untinted tincture of Metaphen and then washed with alcohol.
Using sterile materials, the pulp chamber was opened further and carefully
irrigated with 0.5 CC. of 3 per cent hydrogen peroxide, followed by 0.5 CC. of
sodium hypochlorite (Zonite). Barbed broaches were then used to remove
whatever pulp tissue would adhere to them. This was followed by irrigation
with hydrogen peroxide and sodium hypochlorite, as just described. The next
993
step was to select the lar+gest rea.mcr that could reach the apical region of the
tooth and manipulate the instrument within the canal to loosen any debris
that may have been cl.inging to the wall surfaces. After removal of the in-
strument, the @anal was irrigated as before. The file of the same number was
then inserted and this time the walls of the canal were planed, to further
remove pulp remnants and smooth the sur-faces. The canal again was irrigated
2,s described previously. The next,-sized reamer was then selected and the
l)rocedurc wn.8 repeated.
After each instrument was used in the canal, the irriga.ting solutions were
used to flush out the loosened materials. l<ilCh canal treated was enlarged to
a XO. 6 or 7 instrument before enlargement was considered adequate. Tn the
case of younger teeth with wider canals, a ‘No. 8 or 9 instrument was used
before completion. irrigation was continued, following the last instrument,
until the solutions coming from the canal were clear of all debris.
The canal. was then carefully dried with sterile, absorbent points until no
moisture was evident. At this time, an absorbent point was inserted in the
canal until the apical tissues were reached. The point was permitted to
remain in this position for approximately one minute; then it was removed
and placed in a culture tube containing brain-heart infusion broth, and in-
cubated for one week at 3F C.
A small. pell& of dry; sterile cott,on was then inserted in the chamber.
This was covered with gutta-pcrcha and t.he seal was then completed with an
outer layer of cement.
At the second visit, the tooth was again isolated and treated as before.
After the seal was removed, before any further solutions were applied to the
wdl surfaces of the canal, another cult,ure was taken. Tf the test culture
taken at the first visit was free o-f growth, and if the tooth and surrounding
tissues were free from discomfort, the canal was prepared for filling. If,
however, there was any tenderness or swelling or if a fistula had failed 1.0
close, even though the first culture had been negative, a culture was again
taken. If the previous culture had been positive for growth, the canal was
enlarged one additional insl.rument size and again carefully irrigated and
dried before reculturing. When it was deemed safe, the ,c:lnal WBS again
sealed, without medication.
Before root canal filling, il.8 il. routine measure 0 f caution, t.he wall surfaces
were freshened with the last-sized instrument used, and repeated irrigations
were instituted. The canal was then carefully dried and seaded by la,teral con-
densation, as described by (Yrrossrnan.”

Results
Of the fifty teeth thus treated, forty-seven, or 94 per cent, were free of
bacterial growth, as tested, after the initial instrumentation and irrigation.
However, when the canals were cultured on the second visit, before instru-
mentation, only thirty-eigbt teeth, or 76 per cent, were 1Iree of bacterial growth.
This would indicate a possible error of ‘18 per cent between the first and second
 CHEMOMECHANICAL PREPARATION OF ROOT CANAL 995

cultures. It is also interesting to note that those canals which had been positive
for growth on the first cul.ture were all free of growth on the second and third
culture examinations.
Discussion
The results of this study indicate that approximately 76 per cent of the
canals treated as described did yield two successive growth-free cultures.
These results compare favorably with those of Auerbach,l who, using a some-
what similar method of study, was able to demonstrate 78 per cent growth-
free cultures of the canals treated.
The 94 per cent figure of growth-free cultures after the original instru-
mentation is, in all probability, misleading. Even though the canal was dried
with absorbent points, there may have been enough chlorinated soda remain-
ing to inhibit growth. It is conceivable also that, immediately following in-
strumentation, the number of organisms remaining on the walls of the canal
were so few that, in sampling via culture technique, an insufficient number was
obtained to produce growth in a culture tube.

A. u. G.

Fig. 1: -A, Uefore treatment. 6, After root filling. (N&c collateral canal.) C, After six
mxlths. (Note repair of tissues in area of collateral canal.)
In the above case, the first culture was free of growth. The second culture w&s positive
three days after the canal was filled. The clinical signs before filling, however, were favorable.

The increase in the number of positive cultures, as found in the second

testing, could have been due, however, to contamination during culture proce-
dure, or to an increase in the microbial count of those organisms that managed
to survive the original cleansing procedure.
As noted, the primary function of the irrigating solutions used in this
study was to flush out loosened debris. Chlorinated soda solutions, as shown
by Grossma.n,” are effective in digesting necrotic pulp tissues. The repeated
irrigations might hel.p, then, in removing necrotic tissues--areas inacecssibIe
to the regular root canal. instruments. This probabiy was the situation in, the
case shown in Pig. :I.
It is important to note that the negative culture should be used merely as
an indication of potential bacterial destruction, and not as a definite sign that
su~eess in therapy must fol.low. The ultimate criteria for success are clinical
responses : freedom from pain and swelling, closing of a fistula (if present),
healthy appearance of the supporting tissues, and radiographic avidence of
bone healing i.f periapicd patbosis had been present.

A. R. c.
Fig. 2.---A, Ikfore treatment. B, After root Ming. 0, Six months after treatment.
‘I%<~ ahovn case Aemonstrntod two growth-free cultures.

The twelve teeth which showed growth in the second culture tube but not
in the first all appeared to be clinically healthy after root canal filling. This
may be due to several factors :
1. There may have been a False positive culture--a result of con-
tamination.
2. The additional cleansing and irrigation before obturation may
have eliminated the remaining organisms from within the canal.
3. The root canal cement (Grossman’s) which was used to line
tbe canal as part of the obturation has antimicrobial activity, and
may have further reduced or eliminated the remaining organisms.
4. The seal of the canal may have been adequate, in itself, to
prevent organisms or their toxins from leaving the canal. These
additional factors were sufficient, either singly or collectively, to
bring the healing potential of the tissues to a point of dominance.
Pathologists and physiologists3 have recognized the fact that if a tissue
has the ability to heal, it will heal only if and when the irritants that prevent
 CHEMOMECHANICAL PREPARATION OF ROOT CANAL 997

healing are reduced to within the physiologic limits of repair of the given
tissue. The rate and degree of healing will be directly proportionate to the
reduction of irritation and the potential healing capacity of the tissue. The
dentist can thus help a tooth and its surrounding tissues to health by eliminat-
ing or reducing the irritants that would prevent healing.
The excellent clinical results obtained after thorough chemomeehanical
cleansing should indicate its importance in root canal therapy. Medication
beyond this point is not treatment per se, but merely an adjunct to successful
treatment.
Summary
1. The results of a clinical study to determine the importance of thorough
cleansing of the root canal are reported.
2. Although I do not wish to leave the impression that medication of the
root canal is unimportant, for I do use medicaments (including antibiotics)
where indicated, no medication other than irrigating solutions was used in this
study.
3. The findings indicate that the culture, although important, is not the
determining factor for success or failure in therapy.
4. Thorough chcmomeehanical cleansing of the canal is one of the most
important phases of root canal therapy.

R,eferences
1. Auerbach, M. B.: Antibiotics vs. Instrumentation in Endodontics, New York Dent. J.
19: 225-228. 1953.
2. Bender, I. B., anb Seltzer, S.: The Probability of Error of the Negative Culture With
the Use of Combinations of Antibiotics in Endodontic Treatment, ORAL SURG.,
ORAL MED., AND Okm PATII. 7: 1311-19, 1954.
3. Cahn, L. R.: Oral Infections: The Evaluation of Their Treatment, ORAL SURG., ORAL
MED.,AND ORAL PATII.~: 125%1266,1954.
4. Coolidge, E. D.: Endodontia, Philadelphia, 1950, Lea & Febiger, p, 113.
5. Grossman, L. I.: Irrigation of Root Canals, J. Am. Dent. A. 30: 1917-1.7, 1943.
6. Grossman, L. I.: Root Canal Therapy, ed. 3, Philadelphia, Lea & Febiger, pp. 199, 219,
296 -.
7. Stewart, G. G.: An Improved Antibiotic-Antihistamine Compound for Root Canal
Medication (D.C.P.), J. Dent. Med. 9: 174-179, 1954.
8. Stevvart, G. 0.: Determination of the Approximate Volumes of Medication Used in
Endodontic Treatment, J. D. Res. 27: 24-26, 1948.
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