Photoactivated disinfection (PDA): paintball

endodontics. Rationale, applications and instructions for

use

: Prof. Paul Lambrechts
Catholic University of Leuven, Faculty of Medicine,
Department of Conservative Dentistry & Endodontics
in collaboration with: Bart Huybrechts, Panagiotis Moisiadis, Lars Bergmans, Daniela Mattar, Wim Teughels, Martine Pauwels, Bart
Van Meerbeek & Marc Quirynen, Belgium
Restorative dentistry is evolving from extension for prevention to adhesion for retention in order to
maintain pulp vitality and reduce the dental countdown. From various sources (caries, leaking
restorations, trauma, and microcracks), bacteria end up in the dentinal tubules and produce lactic
acids, proteolytic enzymes and endotoxins. They infect and digest the surrounding dentin, and
eventually can reach the dental pulp, possibly evolving into pulpitis and, in most cases, pulp necrosis.
Nowadays, treatment of dentinal caries involves assessing the level of tooth decay and removing the
infected dentin in a minimally invasive manner to try to prevent endodontic treatment. When
irreversible pulp damage has occurred, endodontic treatment should be minimally invasive as well, so
as to not weaken the remaining tooth. Therefore, inactivation of all colonizing pathogens is the
ultimate aim in dentistry, rather than removing all diseased tissue.
This is consistent with what is also happening in the medical field (killing etiological agents rather than
treating symptoms). Caries should be diagnosed with smart detection systems like Diagnodent
(KaVo) and treated with a combination of mechanical, physical and chemical methods to reach those
sheltered microorganisms (Fig. 1a-f). This also includes the use of micro drills with micropreparation
so as not to unnecessarily destroy teeth, as well as diamond-tipped sonics or ultrasonics in proximal
areas. Magnification in surplus is mandatory to modern minimally invasive dentistry. Air abrasion
technology is used to treat fissures and stained grooves (Fig. 2a-c). Lasers have some potential, but
still present problems such as charring, cracking, crazing, thermal decomposition, collateral damage
and carbonization of hard tooth tissues and even thermal deleterious effects to the surrounding
tissues.

Figs.1a-f Caries should be diagnosed with smart detection systems (such as Diagnodent, Kavo) and treated with a combination of mechanical,
physical and chemical methods to reach sheltered microorganisms

Figs.2a-c Air abrasion techniques are used to treat fissures and stained grooves
The photoactivated disinfection (PAD) concept
Recently, the photoactivated disinfection (PAD) concept has been introduced into modern
dentistry. PAD is a unique combination of a photosensitizer solution and low-power laser light (Fig.
3a-c). The photosensitizer, which is mostly colored, adheres to or gets absorbed by microbial cells.
In this perspective, the metaphor of microbial terrorist soldiers getting hit by paintball bullets is
appropriate. To win the war against these terrorists, though, a bullet of paint will not be sufficient.
The low-power laser will hit the marked targets and inactivate those microbial invaders.
Today, the fundamental mechanism of this "dual-cure" killing is not fully understood. Hypothetically,
the photosensitizer binds to microbial cell walls or even enters cells. Laser light activates the
photosensitizer and creates a cascade of energy transfer and variable chemical reactions in which
singlet oxygen and free radicals play an important role. Thus, the results of this laser activation are
cracks in the cell wall (implosion of cells), crucial protein degradement, organel demolishment,
inactivation of their virulence factors (eg, toxins) and even DNA damage. The huge advantage of this
action mechanism is that it's quite impossible for the organism to create resistance against it.


Figs.3 a, b PAD combines a photosensitizer solution and low-power laser light.
c. Low-power laser handpiece irradiating a mandibular premolar mounted in a glass bottle. This image
shows the penetration capacity of low-power laser light

Another advantage is the time aspect. Usually, sodium hypochlorite, antibiotics and other weapons
against microbial threats need a lot of time to inactivate their targets. PAD needs a maximum of 150
seconds. And finally, PAD only works where it should: at the infected site, not elsewhere in the human
body. From this perspective, the indications for PAD in the whole world of medicine are legio,
regarding growing resistance of all types of bacteria against all types of antimicrobials nowadays.
In dentistry, this new concept is finding its way in carious dentin disinfection, in managing root canal
infections and in reducing the bacterial load in periopockets.
Depending on dentin preparation techniques (drill, air abrasion, ultrasonics, laser, NiTi root canal
rotaries), tooth substrate and dentin conditions will vary. A smear layer covers intact dentinal tubules;
both can be invaded by microorganisms. To get back to the previous metaphor, the coronal or
radicular dentinal tubules are the protective mountains in which terrorist combatants wait their turn
while sheltered by the smear layer.
Figures 1a-f show an example in cariology of a molar with deep stained occlusal fissures. Removal of
only denatured dentine (dentin where all structure has been lost) is necessary. After this stage, the
area that is not denatured, though highly infected, could be treated with a PAD technique followed by
remineralizing materials applied prior to restoring the tooth with materials that seal the cavity, such as
glass ionomer cements.
Enterococcus faecalis is often seen as the true pathogenic nuisance in endodontics as a result of its
high resistance to the endodontic treatment protocol and its high potential to invade dentinal tubules.
When one removes the smear layer and opens the tubules, one opens the treasure chamber to one of
the most hard-to-get microorganisms in endodontics. Thus, smear layer removal is crucial and even
mandatory to endodontic treatment success.
Figures 4a-o show a step-by-step endodontic retreatment using the PAD procedures to disinfect root
canals and anastomoses before final obturation.

Figs.4a-g Step-by-step endodontic treatment using PAD to disinfect root canals and anastomoses before final obturation
How does PAD work?
Certain photoactive agents are taken up by bacteria preferentially, with the agent residing in the
proximity of or becoming attached to the cell wall. Some may even enter microorganisms. All bacteria
have the potential to be targeted, though some combinations between certain sensitizers and certain
organisms are more successful than others. Healthy human tissue will not be affected.
PAD techniques use low power lasers to elicit a photochemical reaction in a photosensitizer, which in
turn exerts a lethal effect on particular cells, such as bacteria. PAD is basically a lethal laser
photosensitization. Photosensitizers alone in the right doses are not toxic to bacteria. Low power
(diode) laser energy in itself is, again, not particularly lethal to bacteria but is useful for photochemical
activation of oxygen-releasing dyes. Singlet oxygen, a protoplasmic poison released from dyes, causes
lethal membrane, organel and DNA damage to microorganisms.



Figs.4 h-k Step-by-step endodontic treatment using PAD to disinfect root canals and anastomoses before final obturation

Figs.4 l-o Step-by-step endodontic treatment using PAD to disinfect root canals and anastomoses
Several factors affect the results created using PAD. These include the type of dye used, the dye
concentration, the dose of radiation applied and the species of microorganism involved.
Dyes
Over 400 different photoactive dyes are known. Some of them are already used in dentistry:
o Toloniurn chloride (Toluidine Blue 0 or TBO)
Aqueous solution
Sodium phosphate buffer
Peak absorption 633 nm
Dye concentration 12-100 mg/ml. These are empirically derived values, but further research is
needed for an optimalization of the concept.
Radiation dose of typically 40 J/cm
2

Temperature of the dye is also an unknown factor and deserves further research
Long-term safety proven (oral carcinoma staining protocols with much higher doses,
eg, Orascreen)
Experience in dentistry: evidence based
o Methylene Blue Peak absorption 670 nm
o Rose Bengal Peak absorption 550 nm
o Aluminum disulphonated phthalocyanine Peak absorption 675 nm
o Parphyrin conjugates Different peak absorptions
o Polylysine conjugates Different peak absorptions
o Chlorine conjugated dyes Different peak absorptions
PAD can be obtained with more than 400 photoactive substances, combined with different laser
devices. Ten kinds of blue, purple and green dyes are the most effective and popular, mainly of the
phenylmethane family. Blue seems to work the best and is best documented.
Much work has been done on PAD with TBO by the British research group of M. Wilson, J. Williams, G.
Pearson, J. Dobson, S. Sarkar, T. Burns, J. Pratten, A. MacRobert, N. Komerik, M. Bhatti, and S.
Bonsor, and by the Australian group of L. Walsh and M. Lee.
Radiation dose
Several visible red semiconductor diode lasers are available (Fig. 3a):
o SaveDent diode laser (Denfotex Light Systems Ltd., Scotland), now commercially available as
Aseptim PAD (SciCan, Germany): 635 nm, 50-100 mW with TBO + customized emitters.
o Ceralase PDT diode laser (CeramOptic, Germany): 662 nm, 0.5 W with chlorine dyes.
o Biolitec diode laser (Biolitec AG, Germany): 665 nm with chlorine dyes.
Radiation doses are typically related to time, power, and energy density:
o 40 J/cm
2

o Power 100 mW
o Time 120-150 sec.
Species of microorganism
Virtually all microbial organisms can be inactivated by the right kind of PAD. In general, due to cell
wall properties, Gram positive pathogens are more sensitive to PAD than their Gram negative
counterparts. With PAD using TBO, this difference is marginal due to its cationic nature.
In the dental world, work has been done on periopathogens like Porphyromonas gingivalis,
Actinobacillus actinomycetem comitans, Fusobacterium nucleatum, Streptococcus sanguinis, B.
forsythus, Campylobacter rectus and Eikenella corrodens. All experiments showed significant kill rates.
These rates were stronger in planktonic than in biofilm mode. There is a consistent lack of in vivo
research.
S. sobrinus, Lactobacillus casei, Actinomyces viscosus, and Veillonella spp.,
main cariogenic microorganisms can also be inactivated by PAD. Even in biofilms on carious dentine,
kill rates of S. mutans were significant. Again, these rates were stronger in planktonic than in biofilm
mode. There is a consistent lack of in vivo research.
In the endodontic literature, E. faecalis, S. intermedius, F. nucleatum, P. micros and P.
intermedia have been investigated regarding their sensitivity to PAD. All showed significant reductions
in viable counts. Again, sufficient in vivo research lacks, but is underway.
PAD applications in dentistry
Regarding the microbial nature and the locoregional character of oral diseases, the locoregional aspect
of orodental pathology, upcoming therapy-resistant species, and decreasing efficiency of almost all
antibiotics, orodental PAD applications are legio, including:
o PAD can be applied effectively for killing Gram positive bacteria, Gram negative bacteria, fungi and
viruses.
o PAD can kill bacteria in complex biofilms such as subgingival plaque, which are typically resistant to
the action of microbial agents.
o PAD can be made more species-specific by tagging the dye with monoclonal antibodies.
For disinfection purposes, PAD is effective for:
o Root canals (Enterococcus faecalis, Streptococcus intermedius, Fusobacterium nucleotum,
Peptostreptococcus micros, Prevotella intermedia)
o Perio pockets and mucosal diseases (Porphyromonas gingivalis, Actinobacillus
actinomycetemcomitans, Fusobacterium nucleatum, Streptococcus sanguinis, Bacteroides
forsythus, Campylobacter rectus and Eikenella corrodens)
o Sites of per-implantitis
o Deep carious lesions (Streptococcus Mutans, Streptococcus sobrinus, Lactobacillus casei,
Actinomyces viscosus and Veillonella spp.)
o Viral and fungal diseases, like oral herpes and Candidosis.
PAD can be used effectively in carious lesions and root canals since visible light transmits well across
dentin (Fig. 3c).
The research group of Gavin Pearson (London) conducted a study of S. mutans in a planktonic
environment. When exposed to PAD for 30s contact time with the dye and 60s exposure at 60 mW
with the laser, 99% of the S. mutans was killed. Further in vivo studies on biofilms on carious dentin
showed a similar, almost complete reduction of bacteria.
Different studies on cariogenic and endodontic species in biofilm modes suggested high potential for
PAD as an adjunct in the routine disinfection protocol. Further research must be done to confirm or
deny this thesis.
PAD safety
PAD using TBO sensitizer and low-power diode laser light has proven to be a safe combination. It is
already commercially available in Europe, and American FDA approval for endodontic use is coming in
the near future. Several safety issues have been examined:
o PAD does not give rise to deleterious thermal effects for adjacent tissues.
o PAD treatment does not cause sensitization and killing of adjacent human cells such as fibroblasts
and keratinocytes.
o Neither the dye nor the reactive oxygen species produced from it are toxic to the patient.
o Until today, bacteria are not able to produce resistant strains to the photoactive agent.
o TBO is used in much higher concentrations for screening purposes for malignancies of the oral
mucosa and oropharynx. It does not exert toxic effects at the low concentrations used in the PAD
technique.
Microbiological assessment
Quantitative vs. qualitative
All microbial assessments mentioned above were counts of viable microorganisms. This kind of
research only takes into account the quantitative aspect, ie, the result of PAD. Other ways of
assessing endodontic microbes could be very valuable.
Our team had another idea of visualizing the action of PAD. We used a Fe-ESEM (Field emission-
Environmental Scanning Electron Microscope, Figs. 5a, b) to assess the qualitative rather than the
quantitative aspect of lethal PAD. A Fe-ESEM is an SEM that allows us to examine microorganisms and
microbial biofilms on a dentin substrate. It does not require high vacuum, dehydration and fixation of
the sample, giving the opportunity to examine wet objects in their native state. This enables us to
visualize bacteria in situ, embedded in their own extracellular matrix and in real time. The effects of
different disinfective concepts (like sodium hypochlorite and PAD) can be clearly seen.

Figs.5a,b A Field emission-Environmental Scanning Electron Microscope (Fe-ESEM) was used to assess the
qualitative aspect of lethal PAD
Figures 6a, b show a 1-day matured biofilm of Enterococcus faecalis that appears "out of focus." In
fact the image is representational of a biofilm because it accurately shows how bacteria are embedded
in their own juices extracellular matrix proteins. Half an hour later, you could take another image
and see how the bacteria have doubled. The reason that these images don't have the "classic" sharp
look of SEM bacteria is that they are not "fixed" and dried.
Our research group had a special interest in the Enterococcus faecalis because it is sheltered in its
biofilm in the dentinal tubules and bonded to the dentin by "adhesion interactions." This adhesive
layer consists of extracellular polysaccharide matrices, strings and ropes that allow them to adhere to
surfaces and to other bacteria.
One could ask whether it is a true pathogen or just a nuisance. The challenge is to first reach, second
penetrate, and finally kill these clumps of colonies and biofilms with our irrigants and PAD. Publications
of this ESEM research will be available soon.

Figs.6a, b A 1-day microfilm of E. faecalis appears out of focus, but actually represents how bacteria are
embedded in their own juices
Recently a frightening paper appeared in the endodontic literature, illustrating dramatically the
inability to eliminate microorganisms in a onevisit cleaning, shaping and obturation protocol. Nair's
photomicrographs show sequential transverse sections at varying distances in the corono-apical
direction from the apical portion of a necrotic non-instrumented and non-obturated distal root. As the
images illustrate, the main canal contains microorganisms, the accessory canals are clogged with
bacteria and both bacteria (filamentous and coccus forms) and yeast are clearly visible. In the apical
area of newly obturated root canals, lots ofbacteria are left and hiding. This illustrates the need for
more pronounced shaping for cleaning and disinfection protocols followed by a three-dimensional
obturation.
Advances in the disinfective protocol are multifactorial: good aseptive control, proper cleaning of the
canal which is only possible by proper shaping of it, good tissue resolving, smear layer degrading and
bacteriotoxic irrigants at the right concentration and temperature supplemented with ultrasound-
activated instruments and new technology like PAD. Finally, a three-dimensional obturation and a
perfect coronal seal are mandatory to endodontic success.
Biofilm issues
A biofilm is a structured, heterogenous community of bacterial cells enclosed in a self-produced
polymeric matrix and adherent to inert or living surfaces.
The life cycle of a biofilm includes five phases: (1) attachment of bacteria to a substrate; (2) colony
forming; (3) growing to a monolayer stage;(4) differentiating to a mature biofilm;
and (5) detachment into clumps and/or a swarming phenomenon or "seeding dispersal."
A biofilm is a 3-D community of bacteria attached to a surface. It has the following characteristics:
o Fluid interactions (communication by fluid interactions through channels and pores)
o Channels/pores (the same channels we need to use to penetrate the biofilm with disinfectants and
reach the organisms at the center)
o Complex, heterogenous structure
o Cell-to-cell communication
o Protective mechanisms
o High resistance potential
Bacteria in biofilm mode are much more resistant and tolerant to antimicrobials compared to their
planktonic counterparts because:
o They can survive in a hostile environment.
o Their channels for circulation of nutrients and waste products can create ideal properties for each
species involved.
o They exhibit different gene expression patterns.
o A biofilm gives rise to planktonic bacteria, which enables rapid multiplication and dispersion.
o They are organized communities with functional heterogeneity.
The multicellular characteristics of biofilms contribute to their survivability. Their resistance
mechanisms are based upon:
1. Penetration depth. The outer bacteria are easily killed, but the inner ones cannot be
approached. Inner layers of biofilm cells have more time to initiate stress response. The
corpses of dead outer bacteria can even function as a protective shield that can even be
improved by certain irrigants, such as sodium hypochlorite and hydrogen peroxide. Outer
layers of biofilm cells absorb damage.
2. Altering the metabolism. Limited access to nutrients can turn certain bacteria into a
starving/slow-growing state. Nutrient depletion creates zones of altered activity. These
microorganisms will not be equally sensitive to routine disinfection because as they do not
take up nutrients they also do not take up irrigants.
3. Heterogeneity in the metabolism. Not all bacteria in a biofilm have the same metabolism.
Some can survive and are responsible for culture reversal.
4. Altering the fenotype. This means a biologically programmed response to growth on a
surface(not to limited nutrient access!). This means that different genes will be expressed in
planktonic versus biofilm bacteria.
5. Heterogeneity in the fenotype. Some are killed, some survive. "Persistor" cells may be present
in higher numbers.
One can think of biofilms as static, but they are not. These biofilm structures are viscoelastic.
Hydrodynamic forces - turbulent flow of liquids can lead to shear induced adherence failure, but
only after a time. They are fairly resistant, so how much flow and penetration of irrigants do we need
until they are finally dislodged?

Figs.7a, b RinsEndo (Durr Dental, Germany)
To dislodge a biofilm, we need active long-term agitation. The SonicCare tooth brush uses a similar
principle: acoustic streaming and agitation to attempt to remove plaque biofilm. If we want to disturb
any biofilm, we must do it actively.
Several devices can help us win the battle against biofilms. Ultrasound-driven instruments are just
one example. Figures 7a, b show theRinsEndo device (Durr Dental, Bietigheirn Bissingen, Baden-
Wurttemberg, Germany), which has a compressed air-driven dynamic root canal irrigation system for
vigorous controlled flushing. It uses an alternating "flushing/suctioning" action to actively flush the
root canal system. However, the needle insertion must be well controlled because it is an "active"
rather than passive irrigation system.
NaOCl vs. PAD
Not only does NaOCl kill bacteria, it dissolves organic material and membranes. Concentration (0.5-
5%), diffusion time, temperature and contact time are important.
NaOCl is a fairly corrosive liquid and cannot be applied for a long time when using the type of sensitive
Fe-ESEM equipment used in our research. When 1 minute of NaOCl 2.5% was applied to a 2-day-old
biofilm of S. anginosus, good viable count reduction was noted. Similar tests done with 6 day
incubated biofilm of S. anginosus showed similar results. Likewise, similar tests done with 2 day
incubated E. faecalis (2 min. NaOCl 2.5%) showed good but not complete results. Some E.
faecalis still remain embedded deeper in the polysaccharide layer and can cause re-growth. In the
case of those particular bacteria you need 15-20 minutes contact time in order to penetrate and
dissolve the biofilm to its complete depth.
Is PAD an alternative or an adjunct?
Figures 6a, b show a biofilm with E. faecalis, where exposure to the dye/laser PAD combination
resulted in a substantial though not complete reduction of intact organisms. Hypothetically, this could
be explained by the dye not penetrating to the full depth of the biofilm. Like NaOCl, the effectiveness
depends on how well the dye diffuses into the biofilm and the contact and activation time. Ultimately,
this all depends on how well you can deal with smear layer removal and have the TBO enter the
tubules. The better you remove it, the better the penetrating power you have for PAD.
Studies of bacteria in biofilms subjected to PAD showed an 88% to 99% kill depending on the type of
microorganism. If the original number of bacteria in the canal was 10 million (for example), a 99%
reduction would still leave 100,000 bacteria in the tubules. If you do not entomb these remaining
bacteria with a good endodontic seal, you may still get failure due to regrowth of these remaining
bacteria. A failing coronal seal will also evolve into contamination of the obturation and ultimately into
treatment failure.
Different bacteria also show different levels of susceptibility to PAD. That is because the complex
structure of the biofilm means that different bacteria may be protected by being located in deeper
layers of the biofilm, or have resisting properties because of their location and interaction with other
organisms.
What does this mean for endo treatment?
During endo treatment we need to neutralize microorganisms and their by-products. Finally sealing
the tooth and preserving as much healthy tissue as possible will lead to treatment success. We need
to do this successfully while at the same time working in a minimally invasive and effective manner.
We all know that the ideal situation is complete cleaning and sealing of the canal system. The problem
is the complex anatomy of the root canal system, which does not always allows us to do this.
Even most reknown endodontists fail to prepare all root canal surfaces. Prof Paul Lambrechts and Prof
Lars Bergmans worked with Prof Pierre Machtou and Prof Clifford Ruddle. The latter two prepared a
pre-scanned mandibular molar mesial root. After preparation, the roots were returned to Prof
Lambrechts. Again they were scanned and matched to the images before instrumentation. Though
they were nicely prepared and tapered, there were still anastomotic regions that could not be reached
through thorough shaping. To reach these areas, additional tools are needed: active rinsing,
ultrasonics, agitating devices and other methods.
Figures 8a-d show a horizontally sectioned mesial root with two canals, one each prepared
with K3 and ProTapers. The canals were nicely centered and shaped but there were still lateral areas
that were not encompassed by the preparations, as well as the interconnection of the isthmuses.
Preparing the canals with this technique can actually push debris into the isthmus and lateral areas.
This makes rinsing these isthmuses and lateral areas almost impossible. The bacteria can then
multiply in these areas, every half an hour. That is a major problem.

Figs. 8a-d Horizontally sectioned mesial root with two canals, one each prepared with K3 and ProTaper files
So how do we deal with these organisms that have sheltered themselves in the dentin tubules and
have culture reversal potential? Though debatable, Nair's study showed through apical surgery that a
mandibular molar, presenting initially with primary apical periodontitis, still harbors lots of micro-
organisms following thorough instrumentation, filling and then surgery of the root eight months after
treatment.
A photomicrograph of the transverse section of the resected root apex showed incomplete obturation
of both canals connected by a debris-filled wide isthmus that was just as wide as the prepared canals.
TEMs of the bacterial masses in these isthmuses showed islands of "fibro-dentinal structures," the pulp
and dentin debris that was pushed into the isthmus during preparation of the MB and ML canals. The
bacteria are protected by this debris layer. TEM of a necrotic accessory canal in the area showed
numerous filamentous and cocci bacteria embedded in an extracellular matrix.
Are we losing the fight? Do we feel uncomfortable seeing these results?
Optimizing endodontic treatment
The problem has only one solution: optimizing the whole concept of a successful endodontic
treatment, but most urgent, optimizing the disinfection protocol. Better cleaning of the root canal is
only possible when irrigants can get to the right site, which means shaping in function of cleaning.
Besides shaping, smear layer management is very important. Without the removal of all dentin debris,
a totally clean canal system is impossible. Active irrigation is mandatory to this aim. When the root
canal system is as clean as possible, a perfect endodontic and coronal seal must be accomplished.
Prof Lambrechts proposes the following:

Fig 9a,b Once the root canal preparation is finished and an ultrasonic instrument is used in a root canal
system filled with NaOCI, a cloud of debris will appear. It must be aspirated and the canal filled again with
NaOCI until the irrigant stays clear
1. Place a rubber dam and disinfect tooth and rubber dam.
2. Create straight line access to the pulp chamber; immediately soak it with sodium hypochlorite.
3. Shape the coronal third, removing a huge bacterial load.
4. Determine the proper working length using ISO size 06, 08, and 10 files, bathing in a NaOCl-
soaked canal with electronic and radiographic techniques.
5. Inspect the canal system (looking for isthmuses and anastomoses).
6. Start canal preparation. Use NaOCl throughout the whole procedure.
7. I use hand microdebriders to try to clean hardly accessible areas. But the more we try to clean
them this way, the more we realize how difficult they are to clean. We need more.
8. Use ultrasonics instead. The super-elastic NiTi smooth probe (EMS) ESI Endo Soft Instrument
number DT-069 is an absolute must-have. You use this flexible tip ultrasonically (25,000-
40,000 Hz) at moderate power for the activation of irrigants in canals, without removing any
peripheral root canal dentin. This is an "inactive" instrument because it is totally smooth and
without flutes; therefore, it does not alter your preparation. It creates cavitation effects,
micro-acoustic streaming, as well as primary and secondary streaming. When the root canal
preparation is finished and this instrument is used in a root canal system filled with NaOCl, a
cloud of debris will show up in the NaOCl(Figs. 9a, b, arrow). This cloudy irrigant has to be
aspirated and the canal filled again. One has got to keep on doing this procedure until the
irrigant stays clear and no clouds appear anymore. Use of NaOCl on pulp tissue (without some
form of agitation assistance) is a slow process, requiring 30 minutes (depending on
concentration and temperature). Dr Ruddle has a similar instrument that is being developed (a
biofilm disruptor) called the EndoActivator (patent pending, Fig. 10a-c). It is a battery-driven
small handpiece that activates a nylon fiber and has three speeds. It is used with a pumping
(in and out) motion. It can also be used to enhance the penetration of the TBO solution when
PAD is used. Further research on this device is required.
9. Aspirate the canals dry rather than use a large number of paper points. Why? Because paper
points can smear the suspended bacteria and debris against the canal walls and plug the
isthmuses again rather than removing the debris that is now in suspension by means of
aspiration.
10. Use 20% citric acid solution to dissolve the smear layer together with the smearplugs and
fibro-dentinal structures in the anastomotic areas. This assists penetration of the TBO dye
afterwards.
11. Apply TBO (lt does not stain the tooth blue! It looks like light-blue colored water, Fig. 4h).
Agitate the solution in the canal with an ESI Endosoft DT-069 or Ruddle's EndoActivator. It
needs 60sec. contact time. Apply the laser fiber. Agitate the fiber in and out and move it as
close as you can to the isthmuses. Keep the fiber in for 120-150 sec/per canal. Then rinse the
canal again with NaOCl to flush out the killed bacteria and remnants. The new Aseptim
PAD unit (SciCan) has disposable tips of two types(caries and endo, Fig. 3b). The tips consist
of a laser focusing lens and a length of fiberoptic (endo tip is longer).
12. Remove the TBO dye with an alcohol rinse and aspiration, which also serves as a canal drying
agent. We want to remove the liquids from the canal and dentinal tubules. Use paper points
for a final dry, taking care not to leave paper point fibers in the canals.
13. A Ca(OH)
2
inter-appointment dressing is not necessary after PAD treatment; the canals can be
filled immediately after completion of the PAD and drying phase. I believe in single-
appointment treatment with the exception of cases of obvious acute periradicular symptoms.
In those cases, common sense tends us to lean over to a two-step endodontic treatment
although there is no evidence that a one-step endodontic treatment using PAD on teeth with
obvious acute periradicular pathology has lower outcome results than a two-step approach
using Ca(OH)
2
. Further research is required. Is it difficult to remove the Ca(OH)
2
? I use the
Durr's RinsEndo to remove the Ca(OH)
2
with the dynamic rinsing and flushing action of NaOCl
and the device. I also use CHX as a rinse as well; it may be "overkill," but I prefer this
method.
14. Fill as usual with a good obturation technique. I use the Thermafil technique. This technique
has been the subject of some criticism, but this was due to the fact that it was used with poor
shaping procedures. When used with a well shaped canal, many clinicians say it works well.
The cross sections and microCT scans of Thermafil obturations show very nice results. I use
Topseal sealer (an epoxy resin-based sealer like AH Plus) inserted only at the orifice and just
below. I do not fill the entire canal with sealer because Thermafil (being a "top-down" filling
technique) would extrude too much of this sealer during placement. I cut the carriers off with
a ThermaCut bur.
15. Take care of good coronal seal as usual.

Fig. 10 a-c Clifford Ruddle's EndoActivator (patent pending) is a biofilm disruptor
Root canal system obturation
Thermafil
Intensive in vitro analysis of the mandibular molar mesial root fill using Thermafil with computer
reconstruction illustrates the ability to isolate where the carriers are located, where the sealer was
located and how well the gutta-percha filled the isthmus (Fig. 11). This type of obturation technique
can give excellent results, but only when performed in combination with a proper cleaning and shaping
regimen. Bacteria can escape from the apex of the tooth, but we have our host defense system to
help us. Our immune system has the ability to summon macrophages, neutrophils and PMNs to deal
with those bacteria that may be exposed to it.

Fig. 11 Microfocus CT image of a root-filled molar. Thermafil has been used to obturate the root canal system three-
dimensionally
Anastomotic and tubular entombment of bacteria
Future developments in endodontics can be expected in optimization of three-dimensionally stable
sealers. They provide superior flow and seal throughout the root canal system and also provide good
adaptation and long-term stability.
Such a candidate for intratubular penetration is EndoRez from Ultradent. This is a UDMA resin filler,
using a two-phase automixing tip with an injectable resin filler NaviTip. Its features include:
o Hydrophilic
o Methacrylate based (UDMA)
o Superior flow
o Simplified application
o Excellent infiltration capacity
In an in vitro study of Endo Rez, we used a plastic carrier as a gutta-percha cone substitute to drive
the EndoRez sealer into the radicular dentin tubulesof a prepared anterior maxillarycanal. The tooth
was dissolved in 30% hydrochloric acid for 36 hours to remove the inorganic component. NaOCl 2.5%
was used for 10 minutes to remove the organic component. What remains is the canal obturation with
the filling material in place and dentinal resin tags, if they are present.
Photomicrographs showed thousands of spaghetti-like resin tags that had flopped over (they were no
longer supported by the surrounding dentin, Fig. 12a). These tags were an astounding 1,000 to 1,500
microns long! They were completely polymerized and continuous. The resin tags perfectly correlated
with the size and shape of the tubules, even down to the tubule branching. If there were any bacteria
in these tubules, they would certainly have been entombed in the material. If you cannot kill the
bacteria, entomb them by radial penetration (Fig. 12b).

Fig. 12 a, b Entombing bacteria: After Endo Rez sealer was driven into the radicular dentinal tubules of a
prepared maxillary canal, photomicrography show thousands of spaghetti-like resin tags flopped over, no
longer supported by the surrounding dentin
The drawback with resin-based systems, however, is the polymerization shrinkage. They shrink
approximately 4% to 6%. This can result in severing of the material in the tubules from the core
material and gap formation along the periphery. If this gap is re-infected, the case can fail. Therefore
more work is needed to reduce the polymerization shrinkage so that this gap is minimized or
eliminated.
Conclusion
Although extensive consistent evidence lacks, PAD seems to have high potential for disinfection
of root canals. Mandatory to a benefit of adjunctive PAD treatment, all steps of the routine
endodontic treatment should be followed carefully. PAD cannot replace shaping, cleaning, smear layer
and biofilm management, but could go hand in hand with a perfect routine endodontic treatment to
improve outcome. This is consistent with the concept of minimally invasive endodontics.

Tolonium chloride in the root canal system of a mandibular molar.
Note the laser tip (not irradiating) in a canal