HK DJ

Hong Kong Dental Journal 2004;1:52-7

FEATURED ARTICLE

Sterilization in root canal treatment: current advances

Robert Pong-Yin Ng, BDS, MSc, MClinDent, MRD RCSEd, Adv Dip Endodont, FRACDS, LDS RCSEng
ABSTRACT Sterilization of root canal is an important step in the treatment to prevent the development of or to resolve any periradicular pathology. Conventionally, mechanical and chemical means have been used to clean the root canal systems. Various novel agents or technologies have been recently available to supplement or replace the current methods of root canal debridement. This article reviews some of these emerging technologies and assesses their efficacy.

Introduction
Bacteria were first implicated in the causation of pulpal and periradicular diseases by van Leeuwenhoek in the 17th century 1. Since then, studies have confirmed and elucidated the role of bacteria in the etiology of these diseases 2-7. Other microbiologic studies have suggested that the presence of intraradicular bacteria is an important factor affecting the success rate of endodontic treatment 8,9. On the basis of the evidence available, preserving the sterility or sterilization of the root canal system will increase the likelihood of success of root canal treatment. To maintain a sterile root canal system, asepsis should be observed during endodontic treatment and provision of the definitive coronal restoration. When treating an infected root canal, the process of cleaning and shaping could be viewed as a key step of root canal treatment 10. The root canal system is complex and accessory features, such as fins, cul de sacs, and intercanal communications 11,12, are colonized by microorganisms once the tooth becomes infected. Bacteria have also been identified in dentinal tubules, halfway through the root dentine of infected teeth 13. Nair 14 reported seeing mainly loose clumps of bacteria suspended in the canal lumen after examining the root canal flora under transmission electron microscopy. Self-aggregates of monobacterial morphotypes and coaggregates of different bacterial
Assistant Professor in Conservative Dentistry, Faculty of Dentistry, The University of Hong Kong, Prince Philip Dental Hospital, 34 Hospital Road, Hong Kong Correspondence to: Dr. Robert Pong-Yin Ng Tel : 2859 0287 Fax : 2559 9013 e-mail : rpyng@hkucc.hku.hk

morphotypes were also found adhering to teeth. The interbacterial spaces were occupied by an amorphous material, spirochetes, and hyphal-like structures that were suggestive of fungi 14. Costerton et al 15 used the term biofilm to describe this clustering of bacteria. Bacteria within a biofilm have increased resistance to a variety of external hostile influences, such as the host defense responses, antibiotics, antiseptics, and shear forces, compared with isolated bacterial cells 16. Once bacteria have established themselves in the root canal system, they are difficult to eradicate by chemical or mechanical means. Furthermore, dentine can reduce the antimicrobial properties of irrigating and intracanal solutions 17,18. Miller 1 stated that there was a large diversity of endodontic microflora, but not all of them could be detected by culturing. Using culture techniques, Sundqvist 6 recovered up to 12 different strains of bacteria from each infected root canal, whereas Fabricius 7 recovered between 8 and 15 strains in primates. The use of molecular techniques in microbial identification has allowed more microorganisms to be detected, such as spirochetes 19 and other uncultivable species 20,21. The mean number of taxa recovered per sample using a combination of cultural and molecular analyses was approximately 20. Certain bacteria, such as Enterococcus faecalis, and certain fungi, such as Candida albicans, have been shown to be resistant to antibiotics 22 and to commonly used root canal medicaments, such as calcium hydroxide 23-25. These microorganisms can survive in root canals after seemingly adequate cleaning and shaping, and both E faecalis 26,27 and C albicans 28 have been associated with the failure of root canal treatment. Although other resistant organisms might be present in root canals, they would not be identifiable by culturing.

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A combination of mechanical cleaning and chemical disinfection is commonly used to prepare root canals; however, infected root canals are not always sterilized using these methods 9. This article introduces some of the recent developments in the identification of new agents or technologies to sterilize infected root canals. These developments can be divided into three groups: irrigating solutions, root canal preparation techniques, and adjunctive therapy.

because of its acidity and high oxidation-reduction potential. This solution has been reported to efficiently remove the smear layer and debris when it is used to irrigate the root canal 37. Both electrolyzed neutral water and oxidative potential water are claimed to be harmless to humans 35,37 and are probably similar to ECA water. Another group of researchers have also found ECA anolyte and catholyte to be effective in removing the smear layer and debris from the root canals 38. A recently introduced irriganta mixture of tetracycline, acetic acid, and Tween 80 detergent (MTAD)was designed to be used as a final root canal rinse before obturation 39. It seems that MTAD has some advantages over conventional irrigants and solutions used in root canal treatment. For example, MTAD is effective in removing the smear layer along the whole length of the root canal 40 and in removing organic and inorganic debris 41, and did not produce any signs of erosion or physical changes in dentine 42, whereas a mixture of 5.25% sodium hypochlorite and 17% ethylenediamine tetraacetic acid (EDTA) did 39. In particular, MTAD mixture is effective against E faecalis 43-45 , and it is also less cytotoxic than a range of endodontic medicaments, including eugenol, hydrogen peroxide (3%), EDTA, and calcium hydroxide paste 46. The physical properties of dentine are not affected when MTAD is used for 5 minutes, as recommended by the clinical protocol. In contrast, sodium hypochlorite and EDTA have been shown to adversely affect the strength of dentine in vitro 47-49. Further independent studies on MTAD are needed to confirm its properties.

Irrigating solutions
Irrigants are used during root canal preparation to help lubricate canal walls, soften dentine, remove debris and smear layer, dissolve organic matter, kill microorganisms, and clean areas inaccessible to endodontic instruments 29. Sodium hypochlorite solution has many of these desired properties and is widely used as an irrigant in a range of concentrations 30. This irrigant, however, is toxic to the host and, if accidentally extruded into periradicular areas, it can cause acute pain, extensive destruction of tissues, and severe inflammation 31. Electrochemically activated (ECA) water has been found to be biocompatible and effective in wound cleansing 32. Two types of ECA solutions can be produced from tap water and a saline solution using a flow-through electrolytic module 32. The first is an anolyte that has antimicrobial properties, a high oxidation potential, and a pH value ranging from 2 to 9. The other is a catholyte that acts like a detergent, has a high reduction potential, and is alkaline. Electrochemically activated water exists in a metastable state that contains a variety of free radicals, molecules, and ions. Biocidal agents, such as hydrogen peroxide, sodium hydroxide, and ozone, are also present in ECA water. After 48 hours, the solution will return to a stable inactive state. Marais and Brzel 33 showed that using ECA in dental unit water lines could effectively eliminate biofilms and control bacterial counts. Electrochemically activated water is more effective than sodium hypochlorite solution in smear layer removal 32. Nevertheless, when the anolyte and catholyte were used individually to irrigate infected root canals, results of antimicrobial effectiveness tests were disappointing compared with 3.5% sodium hypochlorite 34. A group of Japanese researchers have evaluated a solution called electrolyzed neutral water, which is produced by a proprietary electrolysis machine. This solution has a pH close to 7 and possesses some bactericidal or growth-inhibitory effect against a selection of endodontic pathogens in vitro 35. Other researchers have evaluated an ECA solution termed oxidative potential water 36, which is claimed to be highly antimicrobial

Root canal preparation techniques

Removing debris and microorganisms from the root canal systems is an important step in treatment. Conventionally, this has been performed either mechanically by endodontic files using different techniques, or chemically by a range of irrigants and intracanal solutions. Complete sterilization has been difficult to achieve 50-52, especially in the apical areas. The noninstrumentation technique (NIT), introduced in the past decade 53, is a novel method of root canal debridement that uses the principle of controlled cavitation. The access cavity and root canal system are sealed off under reduced atmospheric pressure using specialized equipment. Rapidly alternating pressure fields (30-90 MPa, 25 Hz) are then generated, resulting in the production of macroscopic and microscopic cavitation bubbles (diameter, 5-50 m) within the sodium hypochlorite irrigant 54. The vapor-filled bubbles then collapse, thereby creating hydrodynamic turbulence 53. Extrusion of irrigant
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is avoided because the pressure of the entire system is below atmospheric pressure 53. With a vacuum-filling method (using the same machine), the root canals can be dried and filled with a sealant 54. Nevertheless, NIT cannot enlarge the canal or remove the infected dentine 55. Similar in vitro results have been obtained with NIT and with the conventional step-back technique of lateral condensation 54 . A second generation NIT machine has achieved superior root canal debridement 56 and obturation 57 results in vitro. The quality of root fillings performed by the second generation NIT are equivalent to that of conventional mechanical obturation, as detected by radiography 58. The proportion of filled root canal was similar when comparing NIT and sealer with hand instrumentation and warm vertical compaction of guttapercha 59. Attin et al 60 showed that there was more debris in the apical region of the root canal when NIT was used in vivo than when conventional methods were used. Furthermore, it was hypothesized that under clinical conditions, the efficacy of NIT might be reduced; thus, other problems should be resolved before NIT can be used clinically 60. The use of lasers for various endodontic applications has been investigated since 1971 61. Different types of lasers have been investigated for their efficacy in root canal shaping and sterilization; removal of the smear layer and debris; and sealing of dentinal tubules in the root canal wall. Lasers using carbon dioxide or krypton fluoride have been assessed, as have those using yttrium-aluminum-garnet (YAG)for example, in combination with neodymium (Nd:YAG); holmium (Ho:YAG); erbium (Er:YAG); and erbium with chromiumyttrium-scandium-gallium-garnet (Er,Cr:YSGG). Multiple drawbacks have prevented the widespread use of lasers in clinical endodontics. For example, the carbon dioxide laser could not be delivered into the root canal system through a suitable fiberoptic system, and the Nd:YAG laser was poorly absorbed by the dentine 62. Furthermore, the excessive heat generated by these lasers is deemed to be the major limiting factor against clinical acceptance in endodontic treatment 61. The American Association of Endodontists has warned that the heat could potentially damage the periodontium or char the root canal dentine 63. The magnitude of heat generated depends on a number of variables, such as the type of laser, power setting, mode of energy delivery, presence of water spray, and the type of target tissue 62. Excimer lasers, including the krypton fluoride laser, generate very little heat but carry the risk of genetic mutation because the wavelength of operation is close to the absorption peak of DNA 64. Erbium lasers, which emit radiation at a wavelength similar to that of the absorption peak of water, have been

considered suitable in the ablation of dentine, because the heat they produce is not too excessive 62. Both Er:YAG 65 and Nd:YAG 66 lasers have also been used to shape root canals. Generally, after laser irradiation, root canal walls can be rough and uneven 61; consequently, improvements in the fiber tip and in the delivery method are necessary. Shoji et al 67 used a water-cooled cone-shaped irradiation tip and an Er:YAG laser to enlarge simulated root canals that were bored into a bovine dentine block. They reported that the canal walls were free of debris and smear layer. Others have reported that the temperature rise at the root surface is between 0 C and 5 C in more than 95% of extracted teeth when a Ho:YAG laser is used to enlarge the root canal 68. Nevertheless, further development and testing are required to determine the ideal parameters for different endodontic applications before any lasers can be used clinically 61. A recently introduced Er,Cr:YSGG laser (Waterlase; Biolase, San Clemente [CA], US) has been claimed to possess hydrokinetic effects: according to Rizoiu et al 69, hydrokinetic effects can be created from photons interacting with water above and at interface of the tissue, thereby removing hard tissue without thermal side-effects. It has been claimed that this laser can be used to perform root canal shaping without local anesthesia 70, because the infected pulpal tissue and dentine would be anesthetized and ablated by the laser. Furthermore, by using a series of three flexible fiberoptic tips with small dimensions (200-400 m), this laser can clean and shape the root canal, as well as prepare it for obturation. Although the Waterlase has been granted approval for use on hard tissues (i.e. teeth) by the United States Food and Drug Administration, only clinical reports on this product have been published. Further scientific research is needed on the safety and efficacy of Waterlase.

Adjunctive therapy
Various agents or treatment modalities have been used to enhance the root canal cleaning and shaping ability of conventional methods. Adjunctive therapy primarily aims at improving the removal of viable microorganisms, the smear layer, and debris from the root canal system. Using an Nd:YAG laser, Altamura et al 71 found that smear layer and debris removal was effective at a lower power level of 2 W, 100 mJ energy, and 20 Hz pulse rate than 4 to 5 W. Indeed, Crespi et al 72 found that at a certain power setting, the Nd:YAG laser could clear the root canals of debris; however, it might be difficult to clean the entire canal surface because the laser can emit radiation only in a straight line 61. The antimicrobial effect of the Er:YAG laser was investigated by Stevanovic et al 73, whose results

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indicated a considerable reduction of the bacterial count in the root canals. Still, the conditions and the period of incubation might have introduced bias, and the two bacterial species tested were not common endodontic pathogens. It also seems that selecting the correct laser setting is paramount to avoid causing any collateral damage to the surrounding tissues 61. Ozone has proved to be effective in treating root caries 74. This gas is a powerful oxidative agent and a highly potent bactericidal 75. A novel ozone-delivery system (HealOzone; CurOzone USA Inc., Aurora, Canada) was reported to cause a considerable reduction of microbial colony forming units associated with root caries 76. It would be difficult, however, to sterilize the entire root canal system by the perfusion of ozone gas. For example, Hems et al 77 showed that ozone gas had no effect on E faecalis biofilms. Although ozone dissolved in water had some bactericidal effect on E faecalis, this solution was not as effective as sodium hypochlorite 77. It has also been claimed that ozone dissolved in oil is antimicrobial 78, but many questions must be answered before this solution can play a role in clinical endodontics. For example, the fluid dynamics and surface tension of ozone oil requires further investigation to determine whether ozone can be delivered into the apical region and accessory features (including the lateral canals and the infected dentinal tubules). The chemical stability of ozone oil also needs to be studied to find out whether it can be inactivated by materials present in the root canal system, including the dentine. In addition, it is important to establish how completely and easily the oil can be removed from the root canal system prior to obturation, because oil residue may adversely affect the obturated root canal by interacting with the guttapercha and sealer, or with the bonding of the newer resinbased obturation materials, such as Resilon (Resilon Research LLC, Madison, Connecticut, US) and Epiphany (Pentron Clinical Technologies, Wallingford, Connecticut, US) 79. In lethal photosensitization, microorganisms are sensitized by a photoactive agent that releases bactericidal radicals when stimulated by light of an appropriate wavelength. This technique, termed photoactivated disinfection (PAD), shows promising results for planktonic organisms associated with dental caries 80, periodontal disease 81, and root canal infection 82. In PAD, a photoactive agent (tolonium chloride) is applied to the infected area and left in situ for a short period. The agent binds to the cellular membrane of bacteria, which will then rupture when activated by a laser source emitting radiation at an appropriate wavelength (e.g. 635-nm radiation emitted by SaveDent; Denfotex Light Systems Ltd., Inverkeithing, United Kingdom). The light is transmitted into the root

canals at the tip of a small flexible optical fiber that is attached to a disposable handpiece. The laser emits a maximum of only 100 mW and does not generate sufficient heat to harm adjacent tissues. Furthermore, tolonium chloride dye is biocompatible and will not stain dental tissue. The data quoted by the manufacturer suggest that this PAD system has antimicrobial efficacy 83. Lethal photosensitization of Streptococcus intermedius biofilms in root canals is unable to achieve a total kill rate when a combination of a helium-neon laser and tolonium chloride are used 84. In contrast, irrigation with sodium hypochlorite (3%) eliminated the entire bacterial population 84. The difference could be because the optical fiber was not properly introduced into the root canals, and so the light could not transmit through the tooth structure. Thus, PAD might not be able to achieve a 100% kill rate in infected root canals that have complex anatomic features and colonized by polymicrobial biofilms of varying properties 84. Still, PAD can currently be considered a useful adjunct to conventional root canal treatment. The Endox system (Lysis S.r.I., Nova Milanese, Italy) can sterilize the root canal by emitting high-frequency electrical impulses. The manufacturer has claimed that Endox could completely eliminate the pulp and bacteria from the entire root canal system, including the lateral canals 85. In addition, many other advantages have been claimedfor example, the reduced treatment time and its safety. Endox seems to be popular among dentists in Germany, Italy, and Spain, and numerous research reports have been published in German and Spanish, although only an abstract in English is available 86. Further, accessible scientific evidence is required before Endox can be widely accepted by the international dental community.

Conclusion
Many new materials and methods have recently been introduced to improve root canal debridement and to achieve root canal sterilization. Some of the new treatment modalities have been marketed to dentists, with the claim that it is possible to sterilize an infected root canal system in one appointment. In theory, these endodontic treatments should be able to treat all types of cases, and the use of intracanal agents, such as calcium hydroxide, would not be necessary. However, bearing in mind the complex anatomy of the root canal system and the ability of microorganisms to survive under adverse conditions, it might be premature to believe that the total sterilization of the root canal system could be readily achieved. In the age of evidence-based dentistry, it is advisable to wait until quality independent data are available to support the use of such new technologies 87.
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References
1. 2. Miller WD. An introduction to the study of the bacterio-pathology of the dental pulp. Dent Cosmos 1894;36:505-28. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9. Mller J. Microbiological examination of root canals and periapical tissues of human teeth. Methodological studies. Odontol Tidskr 1966; 74(Suppl):S1-380. Torneck CD. Reaction of rat connective tissue to polyethylene tube implants. I. Oral Surg Oral Med Oral Pathol 1966;21:379-87. Torneck CD. Reaction of rat connective tissue to polyethylene tube implants. II. Oral Surg Oral Med Oral Pathol 1967;24:674-83. Sundqvist G. Bacteriologic status of necrotic dental pulps [dissertation]. Ume, Sweden: Umea University; 1967. Fabricius L. Oral bacteria and apical periodontitis. An experimental study in monkeys [dissertation]. Gteberg, Sweden: University of Gteberg; 1982. Engstrm B. The significance of enterococci in root canal treatment. Odontol Revy 1964;15:87-105. Sjgren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30:297-306. Klevant FJ, Eggink CO. The effect of canal preparation on periapical disease. Int Endod J 1983;16:68-75. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99. Alavi AM, Opasanon A, Ng YL, Gulabivala K. Root and canal morphology of Thai maxillary molars. Int Endod J 2002;35:478-85. Shovelton DS. The presence and distribution of microorganisms within non-vital teeth. Br Dent J 1964;117:101-7. Nair PN. Light and electron microscopic studies of root canal flora and periapical lesions. J Endod 1987;13:29-39. Costerton JW, Geesey GG, Cheng KJ. How bacteria stick. Sci Am 1978;238:86-95. Jenkinson HF, Lappin-Scott HM. Biofilms adhere to stay. Trends Microbiol 2001;9:9-10. Haapasalo HK, Sirn EK, Waltimo TM, rstavik D, Haapasalo MP. Inactivation of local root canal medicaments by dentine: an in vitro study. Int Endod J 2000;33:126-31. Portenier I, Haapasalo H, Rye A, Waltimo T, rstavik D, Haapasalo M. Inactivation of root canal medicaments by dentine, hydroxylapatite and bovine serum albumin. Int Endod J 2001;34: 184-8. Jung IY, Choi B, Kum KY, et al. Identification of oral spirochetes at the species level and their association with other bacteria in endodontic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:329-34. Rolph HJ, Lennon A, Riggio MP, et al. Molecular identification of microorganisms from endodontic infections. J Clin Microbiol 2001; 39:3282-9. Munson MA, Pitt-Ford TR, Chong B, Weightman A, Wade WG. Molecular and cultural analysis of the microflora associated with endodontic infections. J Dent Res 2002;81:761-6. Dahln G, Samuelsson W, Molander A, Reit C. Identification and antimicrobial susceptibility of enterococci isolated from the root canal. Oral Microbiol Immunol 2000;15:309-12. rstavik D, Haapasalo M. Disinfection by endodontic irrigants and dressings of experimentally infected dentinal tubules. Endod Dent Traumatol 1990;6:142-9. Waltimo TM, Sirn EK, rstavik D, Haapasalo MP. Susceptibility of oral Candida species to calcium hydroxide in vitro. Int Endod J 1999; 32:94-8. Waltimo TM, rstavik D, Sirn EK, Haapasalo MP. In vitro 26. 27.

3.

28. 29.

4. 5. 6. 7.

30. 31. 32. 33. 34.

8. 9.

10. 11. 12. 13. 14. 15. 16. 17.

35.

36. 37. 38.

39. 40.

41.

18.

42.

19.

43. 44.

20.

45.

21.

46. 47.

22.

23.

48.

24.

49.

25.

susceptibility of Candida albicans to four disinfectants and their combinations. Int Endod J 1999;32:421-9. Molander A, Reit C, Dahln G, Kvist T. Microbiological status of root-filled teeth with apical periodontitis. Int Endod J 1998;31:1-7. Sundqvist G, Figdor D, Persson S, Sjgren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:86-93. Waltimo TM, Sirn EK, Torkko HL, Olsen I, Haapasalo MP. Fungi in therapy-resistant apical periodontitis. Int Endod J 1997;30:96-101. Sundqvist G, Figdor D. Endodontic treatment of apical periodontitis. In: rstavik D, Pitt Ford TR, editors. Essential endodontology. Oxford: Blackwell Science Ltd; 1998:242-77. Clarkson RM, Moule AJ. Sodium hypochlorite and its use as an endodontic irrigant. Aust Dent J 1998;43:250-6. Pashley EL, Birdsong NL, Bowman K, Pashley DH. Cytotoxic effects of NaOCl on vital tissue. J Endod 1985;11:525-8. Marais JT. Cleaning efficacy of a new root canal irrigation solution: a preliminary evaluation. Int Endod J 2000;33:320-5. Marais JT, Brzel VS. Electro-chemically activated water in dental unit water lines. Br Dent J 1999;187:154-8. Marais JT, Williams WP. Antimicrobial effectiveness of electrochemically activated water as an endodontic irrigation solution. Int Endod J 2001;34:237-43. Horiba N, Hiratsuka K, Onoe T, et al. Bactericidal effect of electrolyzed neutral water on bacteria isolated from infected root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:83-7. Hata G, Uemura M, Weine FS, Toda T. Removal of smear layer in the root canal using oxidative potential water. J Endod 1996;22:643-5. Hata G, Hayami S, Weine FS, Toda T. Effectiveness of oxidative potential water as a root canal irrigant. Int Endod J 2001;34:308-17. Solovyeva AM, Dummer PM. Cleaning effectiveness of root canal irrigation with electrochemically activated anolyte and catholyte solutions: a pilot study. Int Endod J 2000;33:494-504. Torabinejad M, Khademi AA, Babagoli J, et al. A new solution for the removal of the smear layer. J Endod 2003;29:170-5. Torabinejad M, Cho Y, Khademi AA, Bakland LK, Shabahang S. The effect of various concentrations of sodium hypochlorite on the ability of MTAD to remove the smear layer. J Endod 2003;29:233-9. Beltz RE, Torabinejad M, Pouresmail M. Quantitative analysis of the solubilizing action of MTAD, sodium hypochlorite, and EDTA on bovine pulp and dentin. J Endod 2003;29:334-7. Machnick TK, Torabinejad M, Munoz CA, Shabahang S. Effect of MTAD on flexural strength and modulus of elasticity of dentin. J Endod 2003;29:747-50. Shabahang S, Pouresmail M, Torabinejad M. In vitro antimicrobial efficacy of MTAD and sodium hypochlorite. J Endod 2003;29:450-2. Shabahang S, Torabinejad M. Effect of MTAD on Enterococcus faecalis-contaminated root canals of extracted human teeth. J Endod 2003;29:576-9. Torabinejad M, Shabahang S, Aprecio RM, Kettering JD. The antimicrobial effect of MTAD: an in vitro investigation. J Endod 2003; 29:400-3. Zhang W, Torabinejad M, Li Y. Evaluation of cytotoxicity of MTAD using the MTT-tetrazolium method. J Endod 2003;29:654-7. Grigoratos D, Knowles J, Ng YL, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endod J 2001;34:113-9. Sim TP, Knowles JC, Ng YL, Shelton J, Gulabivala K. Effect of sodium hypochlorite on mechanical properties of dentine and tooth surface strain. Int Endod J 2001;34:120-32. Rajasingham R, Knowles JC, Ng YL, Sobhani O, Rahbaran S, Gulabivala K. The effect of root canal irrigation with sodium hypochlorite and EDTA on tooth surface strain. Int Endod J 2004;36: 932 [Abstract].

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Sterilization in root canal treatment

50. Dalton BC, rstavik D, Phillips C, Pettiette M, Trope M. Bacterial reduction with nickel-titanium rotary instrumentation. J Endod 1998; 24:763-7. 51. Siqueira Junior JF, Lima KC, Magalhaes FA, Lopes HP, de Uzeda M. Mechanical reduction of bacterial population in the root canal by three instrumentation techniques. J Endod 1999;25:332-5. 52. Evans GE, Speight PM, Gulabivala K. The influence of preparation technique and sodium hypochlorite on removal of pulp and predentine from root canals of posterior teeth. Int Endod J 2001;34: 322-30. 53. Lussi A, Nussbcher U, Grosrey J. A novel noninstrumented technique for cleansing the root canal system. J Endod 1993;19:549-53. 54. Lussi A, Messerli L, Hotz P, Grosrey J. A new non-instrumental technique for cleaning and filling root canals. Int Endod J 1995; 28:1-6. 55. Portmann P, Lussi A. A comparison between a new vacuum obturation technique and lateral condensation: an in vitro study. J Endod 1994;20:292-5. 56. Lussi A, Portmann P, Nussbcher U, Imwinkelried S, Grosrey J. Comparison of two devices for root canal cleansing by the noninstrumentation technology. J Endod 1999;25:9-13. 57. Lussi A, Imwinkelried S, Stich H. Obturation of root canals with different sealers using non-instrumentation technology. Int Endod J 1999;32:17-23. 58. Lussi A, Suter B, Fritzsche A, Gygax M, Portmann P. In vivo performance of the new non-instrumentation technology (NIT) for root canal obturation. Int Endod J 2002;35:352-8. 59. Ardila CN, Wu MK, Wesselink PR. Percentage of filled canal area in mandibular molars after conventional root-canal instrumentation and after a non-instrumentation technique (NIT). Int Endod J 2003; 36:591-8. 60. Attin T, Buchalla W, Zirkel C, Lussi A. Clinical evaluation of the cleansing properties of the noninstrumental technique for cleaning root canals. Int Endod J 2002;35:929-33. 61. Kimura Y, Wilder-Smith P, Matsumoto K. Lasers in endodontics: a review. Int Endod J 2000;33:173-85. 62. Khabbaz MG, Makropoulou MI, Serafetinides AA, Papadopoulos D, Papagiakoumou E. Q-switched versus free-running Er:YAG laser efficacy on the root canal walls of human teeth: a SEM study. J Endod 2004;30:585-8. 63. Position statement: use of lasers in dentistry. Chicago: American Association of Endodontists; 2000. 64. Pini R, Salimbeni R, Vannini M, Barone R, Clauser C. Laser dentistry: a new application of excimer laser in root canal therapy. Lasers Surg Med 1989;9:352-7. 65. Mazeki K, Kojy R, Saito K, Funato A, Matsumoto K. Morphological study on preparation of root canal orifices by Er:YAG laser. Journal of Japan Endodontic Association 1998;17:185-9. 66. Levy G. Cleaning and shaping the root canal with a Nd:YAG laser beam: a comparative study. J Endod 1992;18:123-7. 67. Shoji S, Hariu H, Horiuchi H. Canal enlargement by Er:YAG laser using a cone-shaped irradiation tip. J Endod 2000;26:454-8. 68. Deutsch AS, Cohen BI, Musikant BL. Temperature change at the root surface when enlarging a root canal with a holmium:YAG (Ho:YAG) laser, using six different fiber-optic sizes. Gen Dent 2004;52:222-7.

69. Rizoiu I, Kohanghadosh F, Kimmel AI, Eversole LR. Pulpal thermal responses to an erbium,chromium:YSGG pulsed laser hydrokinetic system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 86:220-3. 70. Chen WH. YSGG laser root canal therapy. Dent Today 2002;21:74-7. 71. Altamura C, Majori M, Bedini R, Filippini P. Evaluation of Nd:YAG laser effects on root canal walls. J Oral Laser Applications 2003; 3:67-72. 72. Crespi R, Lando G, Covani U. Cleaning root canals with Nd:YAG laser: an in vivo study. J Oral Laser Applications 2003;3:27-31. 73. Stevanovic M, Petrovska M, Stevanovic M, Mirceva M. Bactericidal effects of Er:YAG laser irradiation in root canals. J Oral Laser Applications 2004;4:43-6. 74. Holmes J. Clinical reversal of root caries using ozone, double-blind, randomised, controlled 18-month trial. Gerodontology 2003;20: 106-14. 75. Baysan A, Lynch E. Effect of ozone on the oral microbiota and clinical severity of primary root caries. Am J Dent 2004;17:56-60. 76. Baysan A, Whiley RA, Lynch E. Antimicrobial effect of a novel ozone-generating device on micro-organisms associated with primary root carious lesions in vitro. Caries Res 2000;34: 498-501. 77. Hems RS, Spratt DA, Ng YL, Gulabivala K. An in vitro evaluation of the ability of ozone to kill Enterococcus faecalis [Abstract]. Int Endod J 2002;35:86. 78. Ozonated oils from Pearlywhites Ltd. HealOzone website: http:// www.the-o-zone.cc/oils01.htm. 79. Shipper G, rstavik D, Teixeira FB, Trope M. An evaluation of microbial leakage in roots filled with a thermoplastic synthetic polymer-based root canal filling material (Resilon). J Endod 2004; 30:342-7. 80. Burns T, Wilson M, Pearson GJ. Sensitisation of cariogenic bacteria to killing by light from a helium-neon laser. J Med Microbiol 1993; 38:401-5. 81. Sarkar S, Wilson M. Lethal photosensitization of bacteria in subgingival plaque from patients with chronic periodontitis. J Periodontal Res 1993;28:204-10. 82. Poh YJ, Ng YL, Spratt D, Gulabivala K, Bhatti M. Lethal photosensitisation of root canal Fusobacterium nucleatum isolates [Abstract]. Int Endod J 2000;33:74. 83. Williams JA, Pearson GJ, Colles MJ, Wilson M. The effect of variable energy input from a novel light source on the photoactivated bactericidal action of toluidine blue O on Streptococcus mutans. Caries Res 2003;37:190-3. 84. Seal GJ, Ng YL, Spratt D, Bhatti M, Gulabivala K. An in vitro comparison of the bactericidal efficacy of lethal photosensitization or sodium hypochlorite irrigation on Streptococcus intermedius biofilms in root canals. Int Endod J 2002;35:268-74. 85. Endox Endodontic System website: http://www.endox.com/ indexeng.htm. 86. Haffner C, Benz C, Mehl A, Folwaczny M, Hickel R. High-frequency current in endodontic therapy: an in-vitro study [Abstract]. J Dent Res 1999;78(Special Issue):117. 87. Position statement: new technologies/materials. Chicago: American Association of Endodontists; 2004.

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