NEGATIVE PRESSURE IRRIGATION SYSTEM A REVIEWINTRODUCTION Endodontics has seen major developments and innovations in rotary instruments, ultrasonics, imaging, and biocompatibility of filling materials over the past two decades. But the innovations in irrigating the canal have shown slow development. However, today we have seen a developmental surge in advanced irrigation technology1. The ultimate goal of endodontics treatment is to clean the root canal system. The apical third of the system is the most critical area to clean as this anatomy is highly complex network of canal space, Deltas, and fins. The apical third of the root canal system contains over 98% of the canal ramifications2.The mechanical instruments we use are limited in cleaning the apical third of the system. In a research it was shown that only 35% of the canal space walls have actually been contacted by the instruments3. The instruments are helping in creating a pathway in the canal system, through which the solutions are allowed to flow. So we most probably depend on the action of these chemical agents to clean the complex canal space4. The classic technique of positive pressure needle irrigation does not allow the solutions to reach the full length of the canal system effectively. The important aspect in order to clean the apical area is to have a solution to create the current force, and reach the apex and take the particles away from the apex. But these things are not present in classic technique5.The apical negative pressure irrigation has changed the perspective of apical irrigation. This technique allows the chemical solutions to reach the full working length of the canal space. The negative pressure is used to pull the chemical solution from the reservoir to the working length using high speed suction. The high speed suction at the tip of cannulas drives the negative pressure current force. If the cannula gets blocked or the suction force is disturbed, no solution would be present in the apex. This is due to the dependent nature of the technology on the suction force to deliver the solution to the working length of the canal space.This review of the negative pressure apical irrigation will show a descriptive difference with the positive pressure irrigation, technology used, how it is one of the most advanced canal cleansing, minimisation of risks and maximisation of effectiveness and the clinical impact.OBJECTIVE OF IRRIGATIONThe endodontic treatment has always kept its priority to eliminate or to prevent apical infection. Instruments are made to shape the canals to their convenience and irrigants are injected to clean the canals. Irrigation of root canal has been aiming to eradicate the organic and inorganic contaminants. Chemical irrigants and physical devices are being applied in order to achieve the effective irrigation. The ability of the root canal irrigation system is very much dependent on the effectiveness of irrigants and the mechanical function of the irrigation technique. Conventional positive apical needle irrigation has shown difficulties to improve the delivery of irrigants into the apical third of the root canal. This had been proved by Nair et al.,6 who showed biofilms were found in mandibular molars even after the procedure of conventional irrigation. Mechanical instrumentation of the apical third becomes challenging due to the presence of fins, lateral canals, apical deltas7,8. The irrigants injected into the canal usually kills biofilm in laboratory studies. Hence, it appears that debris developed during instrumentation gets compacted against the apical anatomy, fins and isthmus and made the irrigants hard to reach the apical most part of the root canal, especially when positive irrigation is carried out. In order to avoid such consequences, the need for the irrigation technique, that could avoid the accumulation of debris or remove the debris accumulated, developed. Hence the negative pressure irrigation techniques which sucks the debris in root canal is created. Fig.2 shows the difference in technique in both negative and positive pressure irrigation.APICAL NEGATIVE PRESSURE IRRIGATION SYSTEMThe EndoVac system (Fig.1.) uses suction technique to clear out the debris and promote the flow of the irrigant solution to reach the apical third of the root canal9. This suction pressure creates a movement of the chemical solutions placed in the chamber of the device. The chamber is located in the master delivery tip all way to the end of the canal where the tip of the micro cannulae is placed.The EndoVac system uses two steps to remove the debris. In the first step, a macro cannulae (0.55 mm diameter) is placed to the middle third to eliminate gross debris and pulp remnants. In the second step, a micro cannulae (0.32 mm diameter) is used at the full working length to remove the minute debris10. Therefore, appropriate apical enlargement to a minimum of a size 0.35 file must be created to ensure that the micro cannulae tip (0.32 mm) reaches the apical terminus. Fig.3A and Fig.3B shows the macro cannulae and micro cannulae respectively.EndoVac system has the advantage to eliminate the debris formed from instrumentation and also the necrotic pulp remnants by using a safe delivery o the irrigants to the full working length in the root canal without the risk of apical extrusion11,12. Several researches have reported the advantages in EndoVac system comparing the other irrigation techniques, such as risk free procedure from the extrusion of apex, improved cleaning quality13,14,15,16. The researches conducted by various authors in their report, showed the advantages of the EndoVac system which improved the cleansing of the apical one third as observed by histological sections12,16,17. Nielsen and Baumgartner17, using extracted teeth with vital pulps, showed improved cleaning efficacy of EndoVac system at 1 mm from the working length in comparison to conventional irrigation. The authors also showed that the volume of irrigant delivered by the EndoVac system was at least 3 times higher, compared to conventional needle irrigation. These results were confirmed in an in-vivo study where the EndoVac system showed a higher ability to clean the apical one third of vital pulp root canals.APICAL NEGATIVE PRESSURE IN PREVENTING EXTRUSION OF THE IRRIGANTSIrrigants are helpful in achieving the goal of cleanliness21,22. But certain irrigants could be extruded into the periapical tissues, which would lead to unwanted complications such as inflammation, hematoma and sometimes necrosis could also occur23,24,25. Hence, it is necessary to reduce the risks associated in root canal irrigation that would benefit the patient more26. In a study, Desai and Himel26, Brown et al.27, Myers and Montgomery28, and Roy and Laurence29, reported that the positive pressure irrigation could result in extrusion of apical root canal. But, Desai and Himel26, Fukumoto et al.30, and Mitchell31 demonstrated that negative pressure irrigation could be reducing the periapical extrusion. Desai and Himel researched the EndoActivator, Ultrasonic needle irrigation and RinsEndo. In EndoActivator, volume of extruded irrigants was very less comparing ultrasonic needle irrigation and RinsEndo. Hence, concerning extrusion negative pressure irrigation is comparatively safe. Apical negative pressure irrigation irrigated the root canal system effectively to the fullest of the working length32. This is due to the design of the micro cannulae, which avoids the vapour lock effect. However, the negative pressure irrigation could not completely activate the irrigants in the non-instrumented areas.IRRIGATION OF CURVED ROOT CANALSRoot canals are curved structures33, which makes them more difficult in accessing and cleaning. This difficulty is due to the contact between the device needles and canal walls. So, bending the instrument to follow the canal structure becomes a necessary, however, it could compromise the irrigation greatly34. Rodig et al.35, and Amato et al.36 , reported that the curvature reduced the cleaning efficiency of several irrigation techniques. But CUI and PUI reaches the working length in curved canals. This is due to the sufficient force exerted at the tip of the instrument to overcome the vapour lock effect. As a result, both exhibit an increase in penetration of the irrigants into the lateral canal and apical third of the canal37-40. Fig. 4. Shows the mode of operation of CANUI – A new concept of irrigation.In a study, Abarajithan et al,19 reported that apical negative pressure irrigation and positive pressure irrigation were equally effective in eliminating the smear layer from the coronal amped middle third of the root canals, while in the apical third the EndoVac system performed significantly better than the needle irrigation. Their results are ordinary considering their usage of large sized apical areas to improve the irrigant flow to the root canals. The difference in smear layer removal at all levels was significant and better than the positive irrigation. The reason behind this finding is due to failure of positive irrigation to avoid vapour lock effect in closed canal system20.Several studies have compared the effectiveness of both positive and negative apical pressure irrigation techniques16,18. Currently no differences between the treatments were found. This could be explained on the basis of the usage of single rooted teeth on these studies which were lacking the complex anatomy of the apical root canal. Also, single rooted teeth could be cleaned easily than the posteriorly positioned teeth. This would certainly explain the absence of difference in efficacy between the positive and negative pressure techniques in clinical settings. The challenge in endodontics treatment is the cleaning of complex regions in root canals. Considering this, the negative apical pressure has a slight advantage over the conventional methods in in-vivo researches.Though negative pressure irrigation would improve the irrigant volumes, contact with the root canal walls, mainly in the uninstrumented areas, which would increase the disinfection and debridement, it is still the questionable debate about the exposure and volume of irrigants in improving the effectiveness of cleansing in the root canal.CONCLUSIONThe study has exhibited that the EndoVac system has a slight upper hand over the conventional positive method. Hence, the negative apical pressure system’s improved cleaning ability would result in remarkable improvements in the treatment of complex regions in root canal. However, many studies are needed to be done in order to achieve this in real clinical settings.REFERENCES1. Nielsen BA, Baumgartner JC. Comparison of the EndoVac system to needle irrigation of root canal. J Endod. 2007;33(5):611-615.2. Kim S, Kratchman S. 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