Abstract
BackgroundEx vivo and in vitro studies have demonstrated the effectiveness of some irrigation protocols in reducing the bacterial load in the root canal system. However, standardized protocols have not yet been defined for the real clinical context due to many irrigation procedures available.ObjectiveTo evaluate the clinical endodontic protocols and limitations of irrigating solutions in the disinfection of the root canal system in patients with apical periodontitis.MethodsPubMed, Scopus, Embase, Web of Science, and Cochrane databases were searched for randomized controlled trials (RCT) published until January 2021. Hand searching was also performed. Studies focused on evaluating the effectiveness of irrigating solutions and/or irrigation activation methods in reducing the bacterial load in the root canal system were considered. The Cochrane risk-of-bias tool for randomized trials (RoB2) was used to assess the quality of the studies.ResultsFour hundred and twenty eight published articles were identified. After removing the duplicate studies and analyzing full texts, seven RCTs were selected. Two studies compared pure NaOCl with some combination of NaOCl with HEDP and MTAD. Two studies analyzed the antibacterial efficacy of NaOCl and chlorhexidine (CHX). Three studies compared conventional needle irrigation with different irrigation activation methods (PUI, XP-endo finisher, F-file activator, EndoVac activator). The review attained a satisfactory methodology. The main results of each included study were described.DiscussionActivation methods provide significantly higher biofilm reduction than conventional needle irrigation methods. Combinations of NaOCl with different chelating agents were ineffective in terms of antimicrobial, but it could potentially increase the risk of irrigant extrusion. However, the irrigating protocols were not carefully detailed, especially those regarding the irrigants application time or total volume. The existing literature lacks high-quality studies. The level of evidence is moderate.ConclusionsThe available data is too heterogeneous to compare and identify the superiority of specific valuable irrigation protocols in each clinical context. Application time, volume, and activation methods should be standardized to determine the optimal irrigating procedures to reduce the bacterial load and ensure higher predictability of the endodontic treatment.Systematic Review Registration(https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=218555), PROSPERO registration: CRD42020218555.
Highlights
Apical periodontitis (AP) is a periapical inflammatory response caused by a bacterial infection of the dental pulp [1]
The reduction of the bacterial load to a level below the one required to assure healing [5] is achieved by combining root canal preparation and disinfection, while the entombment of the low concentration of the surviving bacteria is achieved through proper sealing [6]
The literature search strategy was based on the following key words: ((root canal therapy[MeSH Terms]) OR apical periodontitis OR OR (Dental Pulp Cavity[MeSH]) OR) AND ((sodium hypochlorite[MeSH Terms]) OR naocl OR OR CHX OR edetic acid OR mtad OR hedp OR etidronic acid OR EDTA OR Ethylenediaminetetraacetic acid OR saline OR citric acid) AND (irrigant∗ OR irrigation OR rinse OR disinfect∗ OR OR OR OR ultrasonic∗ OR OR Application time OR Volume OR Percentage OR passive activation OR ultrasonic activation) AND
Summary
Apical periodontitis (AP) is a periapical inflammatory response caused by a bacterial infection of the dental pulp [1]. The prevalence of AP ranges from 16 to 86% and increases with age [2] This inflammation is characterized by a complex interplay between microbial tissue invasion and host defense [3]. The defense mechanism keeps the microbial infection in the root canal system, thereby preventing its spread beyond the apical foramen, but the permanence of bacteria in the pulpal tissues leads to pulpal pathology and periapical inflammation [4]. The reduction of the bacterial load to a level below the one required to assure healing [5] is achieved by combining root canal preparation and disinfection, while the entombment of the low concentration of the surviving bacteria is achieved through proper sealing [6]. Ex vivo and in vitro studies have demonstrated the effectiveness of some irrigation protocols in reducing the bacterial load in the root canal system. Standardized protocols have not yet been defined for the real clinical context due to many irrigation procedures available
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