industry |

Laser-activated
®
irrigation with PIPS
The power of better irrigation
Author: Dr Ralf Schlichting, Germany

Why endodontics?
species against antimicrobial agents.10 In
Bacterial infections of the root canal system advanced stages of apical periodontitis, you can
are one of the main causes of apical therefore always refer to an infectious disease
periodontitis.1 The infection usually enters triggered by biofilm.11 With regard to the
through the dentinal tubules. Carious lesions, preferably complete removal of bacteria from
leaky fillings, leaky dental implants, hairlines, the canal system and the dentinal tubules, the
traumas, or erosion may be the cause of canal increased resistance of the bacteria embedded
system infections.2 For the primary and for the in biofilm, together with the extremely strong
secondary infection as well, an intra-radicular adhesion due to the extra-poly- saccharide
mixed bacterial flora was proven.3 The median matrix, is one of the essential problems in
bacterial count for the primary infection was 4.6 endodontic treatment. In summary, bacteria are
x 107 colony forming units (CFU) per apex.4 For the main cause of apical periodontitis.12 The
persistent infec- tions, 5.4 x 104 CFU per apex purpose of any endodontic therapy must
were determined.5 Bac- teria may enter very therefore be the extensive eradication of
deeply into the dentinal tubules and ramifications microorganisms, infected tissue residues, and
of the root canal system.6 Colonies of E. faecalis, infected dental hard tissue from the canal system
for example, can be found up to 500 µm away and dentinal tubules.13
from the main canal (Fig. 1). 7 The bacteria
within the infected canal system appear either Antimicrobial treatment concept
in plankton form, i.e. swimming in tissue fluid8,
or rela- tively “organised” in the so-called To meet this requirement as best as possible, it
“biofilm”. This is a conglomerate of various is necessary to comply with a strict antimicrobial
bacterial species, which or- ganise themselves in treat- ment concept. This includes the imperative
an extra-polysaccharide matrix that adheres applica- tion of a dental dam, the removal of
tightly to the canal walls and the den- tinal potentially in- fected dental restorations and
tubules (Fig. 2).9 The almost symbiotic interrela- scrupulously exact caries excavation as well as
tions among the bacteria within the biofilm the preparation of a dentin-adhesive tight pre-
results in a much higher resistance of the endodontic buildup. The preparation of the
individual bacterial correct access cavity facilitates all

Fig. 1: Bacterial infection of

dentinal tubules. Source: Prof.
V. Kaitsas. Fig. 2: Biofilm.
Source:
Prof. V. Kaitsas.

laser
Fig. 1 Fig. 2 2 2016 21
 Fig. 3: Correctly prepared
access cavity of the upper
molar.
Figs. 4a & b: Upper molars after
reciprocal preparation, irrigation
with 5 % NaClO and 17 % EDTA,
PUI and thermoplastic obturation.
Fig. 5: Surface after laser
treatment in dry canal with end
Fig. 3 Fig. 4a Fig. 4b Fig. 5 firing tip; Er:YAG laser at 75 mJ,
15 Hz, 1.1 W,
and 300 micron.57

work steps following the pre-endodontic build- seems to be one of the main advantages of reciprocal movements. Another
up. The direct correlation between the correctly advantage over fully rotating systems is the effective and thus more rapid
prepared endodontic access cavity and the canal preparation.21 Because of the improved mechanical properties of
success of end- odontic therapy has been verified reciprocal file systems, the preparation
(Fig. 3).14 After hav- ing applied the access cavity
and prepared the coro- nal root canals, we
measure the length of the root canal and
determine the working length. Given the
development of electrometric measurement
systems in the past years, electrometric length
determination is the measure of choice for this
purpose.15

Chemomechanical preparation

As already mentioned above, bacterial infections

of the root canal system are the main cause of
apical periodontitis.16 Solely preparing the root
canals me- chanically does not lead to sufficient
reduction of mi- crobial contamination. It was
shown that major parts of the canal were not even
attended to mechanically by means of mechanical
preparation using rotating instruments.17 The
combination of mechanical prepa- ration, activated
irrigation by means of antimicrobial and tissue-
resolving agents as well as the application of
antimicrobial medication between the treatment
sessions may reduce bacterial contamination of the
canal system considerably.18

Mechanical preparation

Mechanical root canal preparation, depending on

the available anatomy of the canal, may be
performed with either manual instruments or
rotating nickel- titanium instruments. Compared
to manual instru- ments, the use of rotating
instruments leads to considerably improved
results with regard to the preparation geometry
and the preservation of the original topography of
the canal.19 The introduction of a novel preparation
pattern, i.e. reciprocal prepara- tion movements,
facilitates an even better mechani- cal preparation.
Besides the reduced risk of fracture20, better
alignment of the files in the canal system and the
resulting predictable and repeatable preparation
can be limited to a few debris generated by the mechan- ical preparation,
file sizes, depending on consisting of die dentin chips, bac- teria, infected
the available canal tissue, organic particles etc.23 Espe- cially with the
anatomy. This makes rotating or reciprocal preparation, this debris is
handling easier for the positively pressed into the dentinal tubules and
attending doctor and compacted by the rotational movement. The
his/her team. smear layer thus prevents intra-canal antimicrobial
agents and drugs from entering into the dentinal
C tu- bules and sub-canals.24 The combination of
h sodium hypochlorite (NaClO) and ethylene
e diamine tetra- acetate (EDTA) is the gold
m standard for the chemical reduction of intra-
i canal microorganisms to this day and has been
c proven in many research studies. The
a combination of both solutions and the
l mechanical preparation makes it possible to
p reduce contamina- tion of root canals by the
r factor of 100 to 1,000.25 NaClO has an excellent
e antimicrobial effect against most of the
p microorganisms that are significant in
a endodontics.26 With regard to the tissue-
r resolving effect, NaClO is clearly superior to all
a other known irrigation solutions.27 This tissue-
ti lytic, effect com- bined with the excellent
o antimicrobial effectiveness, are key factors to
n accomplish comprehensive bacte- rial reduction in
— the root canal system. Concentra- tions between
1 per cent and 5.25 per cent are dis- cussed. The
i higher the concentration, the quicker the lysis of
r the tissue.28 Because of the rapid inactivation of
r NaClO when it contacts organic tissue, a large
i quantity of irrigation fluid of at least 10 ml per
g canal is required.29 Heating the NaClO increases
a the effec- tiveness of the irrigation solution in
ti the canal sys-
o
n
s
o
l
u
ti
o
n
s

The irrigation
solutions applied to
reduce bacterial
contamination must
fulfill various tasks in
the root canal
system:22
1. Antibacterial
effectiveness against
a broad micro- bial
spectrum
2. Destruction of biofilm
3. Dissolution of potentially infected tissue
4. Removal of the smear layer

The smear layer is

Fig. 6: PIPS ® the irradiated tissue.37 Nd:YAG lasers function at a
tip.
wavelength of 1,064 nm, diode lasers within a range
between 810 nm and

Fig. 6

tem.30 Furthermore, you can improve the

effective- ness by a longer reaction time.31

Ethylene diamine tetra-acetate (EDTA) serves

to remove the smear layer mentioned above.
Irrigation with approx. 5 ml of EDTA in a
concentration of 17 per cent leads to the complete
removal of the smear layer within one minute.32
The reason why this effect is so important is that
antimicrobial agents like e.g. NaClO can react
deeply in the dentinal tubules only after the smear
layer was removed. We should also mention that
the effectiveness of EDTA against fungi like e.g.
Candida albicans has been proven (Fig. 4).33 The
anti- microbial effect of EDTA is of rather minor
impor- tance.34 The combination of the two
described irriga- tion solutions is still the gold
standard. Please refer to the related technical
literature for more detailed in- formation.

Laser in endodontics

In the past decades, lasers were established

in endodontics.35 Laser is the abbreviation of
light am- plification by stimulated emission of
radiation. They are electromagnetic waves with a
high-energy den- sity. In endodontics, lasers of
different wavelengths are used. By photothermal
and partly photomechan- ical effects, laser
radiation can unfold its bactericidal effect,
depending on the wavelength and the asso-
ciated absorption in the irradiated tissue. Mostly
be- cause of heating and the subsequent change
of the osmotic gradient within the bacterial cell
wall, the cell dies.36 Lasers used in endodontics
so far differ in their wavelengths, which again
have critical influ- ence on the interaction with
980 nm, and burn (Fig. 5).42
erbium lasers at
2,780 nm Matusomo et al. explain that, due
(Er,Cr:YSGG) and to the linear emission of the laser
2,940 nm beam, on the one hand consis- tent wall
(Er:YAG). contact was impossible and on the
other hand, because of the heat
First reports on formation, emission over the apex had to
the application of be avoided, making the work in the
Nd:YAG lasers in apical third considerably harder. 43 When
the root canal comparing the disinfecting effect of
were published in Nd:YAG lasers with “tradi- tional”
1984 already.38 In disinfection using NaClO and
this procedure, ultrasound, DeMoore et al. arrived at
special endodontic the conclusion that the Nd:YAG laser
optical fibers were has no advantage in this respect.44 The
used which could effects described for the Nd:YAG laser
emit the laser light apply to the diode laser as well.
only linearly. For
this reason, the Two different wavelengths are
optical fiber had differentiated for erbium lasers: 2,780
to be moved in nm for Er,Cr:YSGG and 2,940 nm for
spi- rals in the Er:YAG lasers. These wavelengths have
canal to reach as their maximum absorption in water and
many canal hydroxy- apatite.45 When erbium laser
sections as radiation hits the dental hard tissue
possible. At 15 Hz directly, the water contained in the tissue
and 100 mJ, the evaporates immediately and dental hard
antibacterial effect tissue is ab- lated “gently” with only
may then reach minimal thermal effects.46 With regard
up to 1,000 µm39 to endodontics, experimental studies
and enter deeply with erbium lasers proved the removal
into the dentinal of the smear layer to be more effective
tubules. than by other types of la- sers and
endodontic irrigation solutions.47
Compared to Further- more, the canal walls were free
that, the reduction from debris and smear layer and had
of bacteria using mostly open dentinal tubules.48 Be-
NaClO was cause of the linear emission of the laser
proven to a depth beam by the optical fiber and due to the
of only 100 µm.40 cumbersome handling, the canal walls
How- ever, the were cleaned imperfectly.49
linear emission
and the high To resolve these limitations, special
energy density in endodontic so-called “side-firing” tips
connection with were developed, which are intended to
the work in the emit irradiation laterally and apically
dry canal had det- sealed:50 Unfortunately, a construction-
rimental effects. related re-
The antibacterial
effect is lower in
curved canals
because of the
linear emission of
laser radiation.41 In
addition, heat of
up to 38°C
developed in the
canal, which may
cause the dental
hard tissue to
 industry |

quirement for the application was the minimum

Fig. 7
preparation size of ISO 60, which resulted in the
un- necessary sacrifice of dental hard tissue.
Because of the apical sealing, the apical
cleaning effect was only low.

Laser Activated Irrigation (LAI)—

a revolution nimisation ofthe risk of irrigation fluid Fig. 7: Cavitation. Luther et al.
beingextruded (Fig. 6).56 2001.
How can the major advantages of erbium laser
ra- diation be maintained without having to
PIPS® is the abbreviation of Photon Initiated
accept the application-related drawbacks? In
Pho- toacoustic Streaming. In this procedure, the
2007, Blanken et al. described for the first time
PIPS® tip is inserted only into the pulp cavity
the intra-canal appli- cation of a pulsed erbium
filled with irriga- tion fluid. The pulsed laser
laser in the canal lumen filled with NaClO.51 beam generates shock- waves in the irrigation
They observed a few interesting effects: Each fluid and cavitation effects in the whole root
laser pulse caused great acceleration of the fluid canal system, intended to create a cleaning
in the root canal. At the same time, they proved effect in the entire canal system, including
a strong cavitation effect in the root canal.52 Both isthmuses, lateral canals and deep down into the
effects combined resulted in vitro in a cleaning den- tinal tubules, which is superior to any of the
effect, which is superior to the passive ultrasonic previous techniques. The almost complete
ir- rigation (PUI), the previous gold standard of elimination of bac- teria, smear layer, and biofilm
clean- ing.53 LAI in root canals, however, had was proven in the in vi- tro experiment for NaClO
some disad- vantages too. and for EDTA.57 No indica- tion of irrigation fluid
being extruded was noticed.58
Irrespective of the laser tip design, sometimes a
lot of irrigation fluid was extruded through the What does the mechanism leading to this
apical constriction. This extrusion was superior cleaning effect look like? When the laser
significantly higher than in conventional pulse starts, the rapid heating of the irrigation
irrigation systems.54 Addition- ally, the formation fluid causes an ex- panding vapor bubble to form.
of gas bubbles because of the laser pulse may The more the vapor bubble expands, the more it
cause the irrigation fluid to vanish from the cools down, leading fi- nally to its implosion.
respective canal section completely, which again
may cause thermal damage of dental hard This affects the root canal in the following
tissue.55 ways:
1. The volume changes of the vapor bubble
PIPS®—the evolution of revolution lead to heavy movement of the fluid in the root
canal.59
In 2010, DeVito presented a novel tip design 2. The implosion of the bubble is a high-energy
for the first time, combining all advantages of process. Shockwaves with large amplitudes
erbium laser radiation, Laser Activated Irrigation and “micro-jets” develop. Shear stress builds
(LAI) and the mi- up near surfaces (primary cavitation).60

AD

laser
2 2016 23
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3. In addition to the primary cavitation, The manufacturer recommends the

secondary cavitation processes are caused by fol- lowing settings for PIPS®: 50 µS
the formation of subsequent, smaller bubbles pulse length, 10 to 20 Hz and 0.15 to
(Fig. 7).61 0.5 W, i.e. peak powers of 400 W up to
1,000 W are achieved with each pulse
These laser-induced effects depend on the absorp- due to the inter- action with irrigation
tion spectrum of the endodontic irrigation fluid. Air/water spray is not required.
medium. That means: The better a certain medium These settings triggered the shockwaves
absorbs the laser radiation, the better is the and the strong current of irrigation fluid
primary and the secondary cavitation effect. as described above.63 The temperature of
NaClO 5.3 , the root surface increased by only 1.5 °C
EDTA 17 and water have almost with the PIPS® activated for 20 to 40
the same absorption spectrum.62 s.64 Clinical application should
follow the manufacturer’s instructions.
Wavelengths that are badly absorbed
by the irrigation fluid may cause At the end of the preparation,
damage to the root canal walls, dentinal irrigation with 17 EDTA is performed
tubules, or even the periodontal to remove the smear layer. The pulp
ligament. This is one of the key cavity should be flooded with EDTA.
differences between the two erbium Then the PIPS® tip is inserted into the
wavelengths. The absorption co- orifice and activated for 30 seconds
efficient of Er:YAG at 2,940 nm is (Fig. 9). After rinsing interme- diately
almost twice as high as that of with saline solution, rinsing with
Er,Cr:YSGG. The PIPS® system NaClO is performed. This is followed by
operates exclusively at the wavelength ac- tivating the NaClO twice for 30
of Er:YAG of 2,940 nm. seconds respectively with a break of
30 seconds between the intervals. A
The PIPS® tip design is also a key sufficient quan- tity of fluid in the
influ- ence on the effectiveness of orifice is important in this procedure.
cleaning: It is a 9 mm long tip with a If necessary, the assistant
diameter of 600 µm, the apical 3 mm
of which are not sheathed
with polyamide and have a tapered Fig. 8 needs to add irrigation fluid continuously.
end (Fig. 6). The lacking sheath of
the apical
3 mm results in better lateral emission. The tip
is connected to the laser source (LightWalker®,
Fotona, Slovenia) via a special endodontic
handpiece. The free axial flexibility facilitates
the application even in difficult anatomic
situations (Fig. 8).
Fig. 8: Fotona LightWalker® and
PIPS® handpiece.
Fig. 9: PIPS® tip in orifice.

Fig. 9

24 laser
2 2016
 industry |
The research as well PIPS®, PUI, and sonic
results regarding activation of irrigation fluids. After
PIPS® so far the laser-acti- vated irrigation with
have been PIPS®, all the samples were free from
promising. One calcium hydroxide, 24 per cent still
study compared showed residues in case of PUI.67 The
the bacterial removal of E. faecalis from artificially
reduction as well infected root canals using PIPS® and
as the biofilm the sole irrigation with saline solution
removal between without activation was the subject
PUI and PIPS® matter of another study. The remarkable
in vitro. The result ofthis study was the complete
application of removal of E. faecalis from all canals
PIPS® re- sulted in the PIPS® group, in which the
in the reduction preparation was effected only to the
of bacterial Pro Taper® F1 file.68 This study may
contamination be an in-
by 99.5 , the
significantly
better reduction
of bio- film, and
the significantly
greater number
of sam- ples that
are free from
bacteria.65 In
another study,
Jaramillo et al.
compared the
removability of
biofilm applying
various
techniques to
activate the
irriga- tion.
Besides PIPS®
(LightWalker®,
Fotona, Slovenia),
these were the
passive
ultrasonic
irrigation (PUI)
and sonic
activation
(EndoActivator).
The laser-in-
duced irrigation
with PIPS® was
significantly
supe- rior to all
other techniques
as regards
removing the
biofilm (Fig.
10).66 Another
study deals with
the re-
movability of
calcium
hydroxide from
root canals. The
authors compared

laser
2 2016 25
dicator that minimally invasive canal Fig. 10: Dentinal tubules after PIPS®
preparation might be possible because of the application. Jaramillo et al. 2010.
good cleaning ef- fect of PIPS®, certainly
always depending on the an- atomic situation.

PIPS®—the force awakens

The eradication of microorganisms and
tissue from the root canal system must be the Fig. 10
goal ofevery endodontic therapy. Complete
removal of bacterial contamination was
considerably. PIPS® will be in any case a clear
achieved only rarely so far due to complex
evolu- tion in endodontic treatment. Only the
anatomic canal structures and technol- ogy-
future can show whether the introduction of PIPS®
related limitations. The development of PIPS® to
will revolu- tionise endodontology in a similar
reduce bacteria by laser-induced activation of ir-
way as the intro- duction of NiTi files. However,
rigation fluid could have the crucial advantage
the force of laser-in- duced irrigation has
over all currently known therapeutic procedures.
awakened._
The re- search results have been promising so
far, but fur- ther studies should and will be
Editorial note: Initially published by dental
conducted, in partic- ular invivo studies, to
journal edition 01/2016. A list of references
consolidate the positive trend. All endodontic
is available from the publisher.
treatment steps must be imple- mented in the
therapy using PIPS®. However, the su- perior
cleaning effect of PIPS® seems to realise two
key advantages for dentists specialising in end-
odontics:
1. Improved cleaning effect of the canal
systems, which will result in an improved
success rate of endodontic therapies.
2. More substance-friendly preparation because
contact
of the better cleaning effect. This preserves the
dental material, which again influences the
Dr Ralf Schlichting
fracture be- havior of endodontically treated
Specialist in endodontics
teeth directly.
Dr.-Hans-Kapfinger Straße 30
94032 Passau
The integration of PIPS® into a strictly
www.endo-dontie.de
antibacterial endodontic treatment concept might
improve the therapeutic success of endodontic
therapies again
Kurz & bündig

Bei PIPS® (Photon Induced Photoacoustic Streaming) handelt es sich um eine photoakustische Spülmethode. Durch die Energie eine
Laser induzierten Effekte sind vom Absorptionsspektrum des endodontischen Spülmediums abhängig, das bedeutet, je besser die Ab

PIPS® ist ebenso wirksam als abschließende Spülung im Vorfeld der Obturation. Zur Anwendung von PIPS® in Ihrer Praxis benötigen