Thought On Spectacular Cleansing of Extremely Complex Pulpal Anatomy

What we see in this most complicated of cases is the ability of the laser activated irrigation systems to evidently create enough agitation of the irrigants to leave a space that can be subsequently filled with at least some flowable sealer and possibly gutta percha. In its description of usage in this particular case, it was stated that neither the the NITi instruments nor the tip of the laser were able to come close to the apices implying that the laser’s impact was effective at a distance of several millimeters. This can be looked at as both an advantage and something to her wary of.

The advantage is that the removal of bacteria and pulp tissue does not need the direct contact of the laser to be effective beyond the physical tip, not requiring what would be in this case an extremely tortuous path. On the other hand, the precautions noted with at least one high energy irrigation systems includes not using it when open apices are present or in close proximity to sinuses. Also noted is the production of blood emanating periodically after its usage, a sign that indicates its disruptive power beyond the confines of the root. I interpret this effect as a requirement for caution if for example the apices of the tooth being treated is in close proximity to the inferior alveolar nerve.

I am certainly impressed as is everyone else that any material was able to be deposited throughout the length of an unbelievably tortuous canal pathway, but I have also learned over the years to question the possibility of unintended consequences. We know the precautions regarding the implementation of acoustic agitation including the extravasation of periapical blood resulting from such activity and its worth questioning whether or not the same potential exists with laser activation.

In such a complex pulpal configuration as is so impressively displayed, it would seem unlikely that periapical damage would occur, but consider the possibility in a case with far simpler anatomy, near sinuses or where the inferior alveolar nerve is in close proximity to the apices of the roots. I am neither an advocate or detractor in the use of laser activated irrigation systems, but I am well acquainted with the unintended consequences that can occur when rapidly adopting new technologies, rotary NiTi that led to instrument separation resulting in the adoption of centered shaping that has been documented to produce inadequate debriding of oval canals and thin isthmuses being an example.

At a minimum, as Dr. Short has pointed out, we need reliable data that confirms that the employment of whatever new technologies are adopted produce higher success rates or at least comparable success rates done faster, less expensively and quicker. Without that data, any decisions on what to uses are based on unsubstantiated information, prior teachings that were not subject to critical analysis and probably most significantly marketing.

For those who might object to this post, what specifically would be the objections?

• The need for data that supports the claims of superior results?
• The challenge that something that looks genuinely impressive should even need proof of effectiveness?
• The bringing up of the possibility of unintended consequences that should not be dismissed?

There is nothing radical in these requests. They are part of the scientific method and should be adopted with enthusiasm. In that light my guiding principle is to employ systems that are as simple as possible without being simplistic. That includes instrumentation systems that are virtually immune to breakage that in turn give the dentists the freedom to apply these instruments vigorously against all the canal walls resulting in superior debridement and reuse of the instruments providing great cost savings. It should be noted that the direct physical application of the instruments against the canal walls by 30o oscillating relieved stainless steel reamers at a frequency of approximately 60 cycles per second has been documented by the French study I have previously posted to be more effective at debridement than the three rotary systems it was compared to. Does this make the 30o oscillating system superior in outcomes. No. There is no evidence to that effect. However, there is no evidence regarding the superiority of any other approach.

Given this state of affairs, the old maxim of safer faster and less expensive still holds and cuts through all the marketing attempts to sway dentists to buy so many expensive innovations that lack sufficient evidence to justify their purchase. To illustrate this point graphically in terms of appreciating the simplified approach of 30o oscillations of relieved stainless steel reamers please observe the result I attained in a root that had curves in three planes.

This tooth was given to me several years ago at one of our 2 day workshops almost as a joke. Nevertheless, I thought I would give it a try using the 30o oscillating techniques we teach. Knowing the reamers are virtually immune to breakage because of their use with such short arcs of motion I negotiated to the apex using first a 06/02, followed by a10/02, a 15/02 relieved stainless steel reamer and then a 20/02 relieved stainless steel reamer. I stepped back a mm and instrumented to a 25/02, stepped back another mm to a 30 and finally stepped back another mm to a 35/02. All done with the 30o oscillating handpiece. The canal was cleansed by a direct contact of the instruments against all the walls of the canal while at the same time activating the irrigants at about 60 cycles per second and driving those irrigants into intimate contact with the canal walls.

The result speaks for itself and the energy utilized in this method of instrumentation and irrigation is confined to the canal anatomy. There is no action at a distance with the possibility of unintended consequences. I cannot make any claims that it is superior, but for sure its simplicity implies greater predictability.

Regards, Barry