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The Internohonol Journal Ot Perjodonhcs £ Restorative Denlisi 289 288 The InternoHonol Journal ot PerJodonhcs £ Restorative DenlisI 289 Effect of Calculus and Abstract The role of supragingivol irrigotion in Irrigator Tip Design on the treatment of gingivitis is clear'"^; Depth of Subgingival This study oddressed three foctors however, the ability of subgingivol ir- Irrigation thot moy affect the penetratian af rigation ta improve the periadontal medicaments inta periadontol pock- stotus of patients with periodontitis re- ets: calculus, ejection site pressure, mains cantroversial.^"* Theoretically, ond irrigatar tip design. Ejection site delivery of antimicrobial solutions to pressure far the Mox-i-Probe, the suppress putotive periodontal path- Ytadent ond Water-Pik tips were de- ogens could represent a supplemen- termined with a variant of Bernoullis' tal procedure to enhance mechoni- equation. Depth of irrigont penetra- cal instrumentation. However, the fol- tion was determined by delivering lowing principles must be considered disclosing salutian supragingivotly before irTigction theropy is integrated ond subgingivolly. Following irriga- into treotment regimens: ¡1) drugs tion, assessed teeth were extracted must be delivered to the site of dis- and the percentage af packet pen- ease activity, ¡2} ontibocterial solu- Jeffrey R. Larner, DDS, MS' etratian by the dye was calculated. tions must be used ot bactericidal Gary Greenstein, DDS, M5' The Max-I-Probe and Viodent tips concentrotions, ond ¡31 medicaments had significantly greoter penetration than did the Water-File tip. Further- must be present long enough to more, calculus deposits reduced irri- work.' The latter two foctors can be gation penetration in deep pockets regulated by adjusting drug concen- (7 ta W mm¡. Ejection site pressures trations, selecting substantive medi- af the three tips ronged fram 0.10 to caments, ond odministering irrigotion 4.80 psi. The ejection site pressure of therapy frequently. the Mox-I-Frabe side-port delivery The ability of clinicians and po- system was lawer thon that af the tients to deliver drugs ta the base of other two systems. Results indicated pockets hos been evaluated. Inves- thot subgingivol calculus, Irrigator tip tigators reported that supragingivol design, and plocement of the tip af- irrigation achieves secondary subgin- fect the depth to which drugs con be givol penetration of pockets to ap- delivered subgingivolly. proiiimotely ane holf the probing (Int J Periodont Rest Dent 1993; depth.^''^ In contrast, subgingival ir- } 3:289-297.) rigation viflfh o syringe, Pik Pocket (Teledyne), or o connula attached to a jet irrigotor results in penetrotion of irrigonts ta about 80% of deep prob- ing depths.'"'^ Although insertion of irrigating devices into pockets en- hances penetratian of irrigonts, these devices still fail to deliver fluids con- sistently to the bose of deep pockets, where loss of attachment occurs. ' Private Practice 226B East Main Street Therefore, odditional information is PO Box 365 needed regarding factors thot influ- Snellville, Géorgie 30278 ence the extent to which drugs are • Private Proctice 900 W. Main Street projected subgingivolly. Freehold, New Jersey 07728 Volume 13, Number 3, IV93 290 To clarify possible determinants of Ejection site pressure drug penetration, this study was un- dertaken to ascertain if imgator tip The mean discharge rate (mL/s) for design, ejection site pressure, or cal- the three tips was determined by col- culus influence the effectiveness of lecting dischorged water for eoch tip subgingival irrigation. Supragingival for 30 seconds in a groduated cyl- and subgingival devices were eval- inder. The volume was divided by the uated, because both result in subgin- discharge time, A technique devised gival penetration of medicaments, by Lugassy et aP was used to as- certain the average ejection velocity for each tip. Irrigating tips were held Methad and materials at 45 degrees during the evaluation, Two related siudies were conducted. which permitted the maximum dis- Ejection site pressures were deter- tonce that a stream could travel. This mined in vitro for three irrigotor tips, information was used to calculate and the depth of dye penetration into ejection site pressure with a variant of pockets was assessed histometrical- Bernoulli's equation:''' ly. The fallawing imgator tips were evaluoted: o 24-gouge Mox-I-Prabe 10 I imgationI cannuias: |A| WF,- [MIP) side-port cannula (Smith & 11 MIP; |C| VIA Nephew), o Water-Pik (WP) irrigation = p. + ^Y^ + Q (G) [H,] tip [Teledynel with an internal dia- meter of 0,955 mm (both were con- where G = gravitational constant; fV, nected to o Water-Pik pumpi, and a = height of the tank; /-^ = height of 23-gauge Viadent (VIA) end-port the ejection tip; P, = pressure at ejec- cannula (Viadent) attached to the tion point; P.J — pressure within the gually, A reference notch was cut Viadent pump (Fig 1|, Settings 2 system; Vj = velocity within the sys- using a YA round bur ot the gingival through 10 for the Woter-Pik unit and tem; VJ = velocity at the ejection margin, where probing measure- 1 through 5 for the Viadent unit were point; and Q — density of water. ments were performed. used to determine clinical and me- Erythrosin solution was used to chanical charocteristics of the irtiga- stoin the roots, (Red Cote, John O, Subgingival irrigotion tion tips. These settings correlated to Butler.) It was diluted with woter at a less thon 20 psi, as indicated by the Five patients requiring extraction of 29 dye-water ratio of 1:4 ond delivered monufocturer. perlodontolly hopeless teeth were into pockets with the three tips The selected for this study. Selected teeth Water-Pik unit was allowed to dis- ¡]l were periodontally hopeless; (2} charge at setting 4 and the Viadent exhibited hypermobility that allowed pump at setting 3, because these set- simple forcep extraction; and ¡3} had tings delivered equivalent amounts of received no scaling or root planing solution (MIP ond VIA delivered 0,26 in the lost 6 months. mL/s and WP delivered 2.6 mL/s), After administration of local on- Both devices provided on irrigotion force of less than 20 psi. esthetic, a Michigan O tip was used wifh gentle manual probing force to measure probing depths at six sites on each tooth: mesially, distally, and at midroot, both buccally and lin- The Iriterrotionol Joumol ol PenodonticE S Reslorative Dentislry 291 Pig 2 Ptocement oí MIP into gingivai pocket with reference notch on imgotion cannula ¡3 mm irom ejection tip} at the gingival margin. Fig 3 Surface landmarks on extracted teeth: (A) reference notch ¡gingival mor- ginj; (B) reference groove (apical extent af dye penetratian/; (C] coronal limit ai cannective tissue ottochment 13, Number 3, 1993 292 Teeth were randomly irrigated with one of the three tips. The WP was placed at the gingival morgin at ap- proximately 45 degrees to the tooth and each site wos irrigated for 1 sec- ond, while MIP and VIA were placed 3 mm into the sulcus and each of fhe sites was irrigated for 1 0 seconds (Fig 2¡ Precise subgingival placement was facilifoted by placement of a notch an the cannula 3 mm from the ejection site orifice. During extroction, forcep beoks were placed at the cementoenomel junction, avoiding the stain on root surfoces. Teeth were rinsed in cold water to remave blood and debris, ond o reference groove correspond- ing to the apical extent of dye pen- etration was cut circumferential ly Fig 4 Extracted tooth previausly irrigoted Fig 5 Extracted tooth previously irrigated oround the tooth with o '/i round bur. with WP irrigation cannula: (A) enamel with MIP cannuia. (A) reference groove; Extracted teeth were immersed in a projections; (B) reference groove fapicot (B| coronal limit of connective tissue at- extent of dye penetration/; (C) coronal tachment; {C] calculus; (D) pocket 4% oqueous toluidine blue solution limit of connective tissue attachment; depths, 4 to 6 mm, with no catcuius pres- to stain the connective tissue and [D] calculus. ent; (E) pocket depths, 4 to 6 mm with calculus present were fixed in a 2% glutaraldehyde. Dye penetration was determined at six surfaces per tooth (midbuccal ond midlingual surfaces and the line angles of the mesiobuccol, mesio- lingual, distobuccal, and distolinguol surfaces). The following measure- ments were recorded with a dial cal- iper: from reference notch (gingival margin) to reference groove (opical extent of dye penetration) and from reference notch to the coronal limit of connective tissue attachment (Fig 3). The meon percentage of dye pen- etration was calculated for each root. Vertical measurements taken at six separóte sites around each tooth were converted into percentages. Subsequently, a mean percentage of Fig 6 Extracted tooth previously irrigated penetration was calculated for all with VIA cannula. (A) reference groove; (B) coronol limit of connective tissue at- teeth within each group. tachment; (C) pocket depths, 7 to 10 mm with calculus present; (D) pocket depths, 4 to 6 mm with colculus present The International Journal ot Periodonlicä S ReslorolK/e Dentistiv 293 To facilitate o comparison of the Table 1 Discharge rate and averoge velocity ability of different tips to deliver med- icaments into moderate and deep Mean rate Mean averoge velocity pockets associated with periodontitis, Machine Setting [mL/s) (ft/s)- probing depth measurements were divided into two groups: 4 to 6 mm Water-Pik 2 2.33 and 7 to 10 mm. These groups were 4 2,60 further subdivided into colculus and 4.13 23.26 noncolculus groups for all three irri- 6 gator tips. Roots were ossessed vis- 8 5.60 ually to determine if calculus was 10 7.33 present on the root surfaces. If o root Max-I-Probe 2 0.20 surface hod visibly detectable cal- 4 0,26 culus, it was ploced in the calculus 6 0.40 4.41 group [Figs 4 to 6). Roots with no 8 0.56 calculus were placed m the noncal- 10 0.73 culus group.
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