10.59987/ads/2024.1.49-54
A new testing device (Endocator, Endocator Inc, Aptos, CA, USA) has been recently developed to assess presence of remaining organic debris inside canals , In the present study the reliability of the device was assessed in vitro by checking the risk of possible cross-contamination during the sampling procedure. Five new syringes were used for sampling procedure in five artificial canals which had been previously filled with organic and inorganic debris (contaminated canals). The recorded Endocator measurement were noted as Group 0. Other five new syringes were used for sampling procedures in artificial canals in which no instrumentation, debridement or filling with debris had been performed (untouched canals). The recorded Endocator measurement were noted as Group A (sterile syringes). In Group B (non-sterile syringes) the sampling procedure in the untouched canals was repeated by using the same 5 syringes previously used for sampling in the contaminated canals. In all cases procedure precisely followed the instruction of use (IFU) provided by the manufacturer. . Descriptive analysis was performed to determine mean and standard deviation (SD) of the findings for the 3 groups. Paired T-test with Bonferroni correction was executed to find out significant differences (p&lt;0.05) between the 3 groups. Results showed that ,even if the canals were same and all well cleaned, Group B provided significantly higher mean values than Group A (p&lt;0.05). In Group O canals (non-cleaned, contaminated canals) mean values were significantly higher than the other two groups (p&lt;0.05) . Results showed a potential risk that even a minimal cross-contamination can significantly affect Endocator measurements due to the high sensitivity of the system. Therefore, authors suggested to use a new sterile syringe for each sampling procedure and proposed manufacturer should write this recommendation in the IFU (Instruction of Use) of the product.
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In vitro evaluation of a new endodontic device for assessment of canal cleanliness
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In vitro evaluation of a new
endodontic device for assessment
of canal cleanliness

Randolph Cross1                                                                                Authors
Gianluca Gambarini2                                                                            Randolph Cross - Private practice,
                                                                                               Watsonville, Ca, USA
1
    Private practice, Watsonville, Ca, USA                                                     Gianluca Gambarini - Sapienza
2
    Sapienza University of Roma, Italy                                                         University of Roma, Italy

Corresponding author: Gianluca Gambarini
gianluca.gambarini@uniroma1.it

Abstract
A new testing device (Endocator, Endocator Inc, Aptos, CA, USA) has been re-
                                                                                               License
cently developed to assess presence of remaining organic debris inside canals ,
                                                                                               This work is licensed under a Creative
In the present study the reliability of the device was assessed in vitro by checking           Commons Attribution-NonCommercial-
the risk of possible cross-contamination during the sampling procedure. Five new               NoDerivatives 4.0 International License.
syringes were used for sampling procedure in five artificial canals which had been
previously filled with organic and inorganic debris (contaminated canals). The re-             Authors contributing to Annali di
corded Endocator measurement were noted as Group 0. Other five new syringes                    Stomatologia agree to publish
                                                                                               their articles under the Creative
were used for sampling procedures in artificial canals in which no instrumenta-
                                                                                               Commons Attribution-NonCommercial-
tion, debridement or filling with debris had been performed (untouched canals).                NoDerivatives 4.0 International License,
The recorded Endocator measurement were noted as Group A (sterile syringes).                   which allows third parties to copy and
In Group B (non-sterile syringes) the sampling procedure in the untouched ca-                  redistribute the material providing
nals was repeated by using the same 5 syringes previously used for sampling in                 appropriate credit and a link to the
the contaminated canals. In all cases procedure precisely followed the instruction             license but does not allow to use the
                                                                                               material for commercial purposes and to
of use (IFU) provided by the manufacturer. . Descriptive analysis was performed
                                                                                               use the material if it has been remixed,
to determine mean and standard deviation (SD) of the findings for the 3 groups.                transformed or built upon.
Paired T-test with Bonferroni correction was executed to find out significant differ-
ences (p<0.05) between the 3 groups. Results showed that ,even if the canals were              How to Cite
same and all well cleaned, Group B provided significantly higher mean values than              R Cross, G Gambarini.
Group A (p<0.05). In Group O canals (non-cleaned, contaminated canals) mean val-               In vitro evaluation of a new endodontic
                                                                                               device for assessment of canal
ues were significantly higher than the other two groups (p<0.05) . Results showed
                                                                                               cleanliness.
a potential risk that even a minimal cross-contamination can significantly affect              Annali Di Stomatologia, 15(1), 49-54.
Endocator measurements due to the high sensitivity of the system. Therefore, au-               https://doi.org/10.59987/ads/2024.1.49-54
thors suggested to use a new sterile syringe for each sampling procedure and
proposed manufacturer should write this recommendation in the IFU (Instruction
of Use) of the product.
Key words: canal cleanliness, testing device, endodontic

Copyright: authors retain copyright of the article

Introduction
In the last decades there has been a lot of progress in materials and techniques for
the endodontic treatment, aiming at improving performance and clinical outcomes (1-4).
The major innovation in the shaping and cleaning procedures, has been the widespread
and consolidated clinical use of nickel-titanium (Niti) rotary instrumentation as the golden
standard for canal preparation, and, more recently, the introduction of innovative propri-
etary heat treatments in the manufacturing process. Such innovations result in more flex-
ible and resistant NiTi instruments (5-6), which allow to simplify canal shaping by making
it easier and faster to perform. Moreover, they minimize iatrogenic errors and overall
improve safety and efficiency of the shaping procedure also in complex canals (7-8).
Besides these improvements, innovations have been proposed also in the root canal
cleaning procedures, mainly related to the development of new irrigating solutions and
devices to activate irrigants inside canals (9-12). However, such improvements so far
had a smaller impact on the quality of the procedure and on the treatment outcome. In
recently published reviews there is no evidence about superiority of these new cleaning



10.59987/ads/2024.1.49-54                                                                                                  49
     In vitro evaluation of a new endodontic device for assessment of canal cleanliness

     procedures and devices when compared to traditional           vide a strong clinical recommendation through objective
     syringe irrigation with sodium hypochlorite and ethyl-        measurements, checking when root canal cleaning is
     enediaminetetraacetic acid (EDTA) (13). Proper canal          satisfactory completed. It consists of a dedicated swab
     cleaning and disinfection is influenced by many factors       (Endotester) and a luminometer (Endocator) as shown
     including canal complexities, presence of biofilm, differ-    by figs 1-2. Endotester is containing the swab and the re-
     ences between composition of pulp remnants, iatrogenic        agent for testing the amount of debris inside a root canal
     errors which may lead to incomplete or unsatisfactory         (fig.2) , by using a methodology which utilizes an enzyme
     debridement and disinfection of the endodontic space          cycling method, based on a combination of luminescent
     (14-18). Even if some antibacterial effect can be pro-        reactions from firefly luciferase, pyruvate, orthophos-
     vided by proper canal obturation by entombing bacte-          phate dikinase (PPDK) and pyruvate kinase (PK). The
     ria (19-20), poor cleaning is likely the main factor which    luminescence is measured by Endocator and provides
     negatively affects both the short and long-term outcome       a quantitative analysis, or the above-mentioned reac-
     of the treatment.                                             tions induced by organic and inorganic debris. This new
     In clinical practice endodontists have to face a big chal-    device has been evaluated by the authors in previous
     lenge. While it is relatively easy to decide when to end      in vitro research (25) with promising results, even if the
     shaping procedures (usually when working length is            procedure must be properly performed to avoid errors
     reached by a Niti rotary instrument with adequate tip size    which could affect performance, including false positive
     and taper), clinicians have little or no clue when to end     or negative results. Therefore, in the present study the
     the final cleaning procedure. Besides visualization under     reliability of the device was assessed in vitro by check-
     magnification, which may reveal only huge amount of           ing the risk of possible cross-contamination during the
     left debris, and visualization of debris, blood or exudates   sampling procedure.
     on paper points used to dry the canal, clinicians have
     no devices to verify quality of cleaning (21). in the last    Methodology
     decade new devices and techniques like fluorescence-          Ten transparent resin training blocks (fig.3) for root canal
     based imaging or spectroscopy have been developed             obturation (SystemB blocks, Kerr, Glendora, CA, USA)
     to provide clinical hints and help in detecting residual      were selected and randomly divided into two groups of
     bacteria and/or debris after cleaning and shaping proce-      5 each. The use of transparent blocks allowed to visu-
     dure are completed (22-24), but none of them so far has       ally check the procedure, including proper insertion of
     been successfully commercialized or gained popularity         the sampling needle and visual (macroscopic) check of
     amongst practitioners. To become effective and widely         presence of debris which could interfere with results.
     used in clinical practice such devices should be simple,      Each block consisted in one artificial curved canal with
     rapid to use, reliable and cost effective. A new testing      dimensions already designed (taper .06 and apical size
     device (Endocator, Endocator Inc, Aptos, CA, USA) has         25) for root canal filling (Fig 3), thus reducing any bias
     been recently developed to fulfill these requirements         related to production of additional debris or any artificial
     (fig.1) and assess presence of remaining organic debris       contamination generated by NiTi rotary instrumentation.
     inside canals (25). Ideally, the new device should pro-       Sample size was selected by using Power Analysis and




     Figure 1.                                                     Figure 2.



50                                                                                                    10.59987/ads/2024.1.49-54
R. Cross et al.

calculated from results obtained after 4 preliminary mea-     part to collect the liquid inside the tube and then inserted
surements, by choosing a power of 80% and a 0.05 alpha        to the full length to mix the sample solution with the re-
type error (G*Power, Heinrich-Heine-Universität Düssel-       leasing surfactant reagent. A correct mixing of the two
dorf, Düsseldorf, Germany). Since sample calculation          components was then provided by shaking the Endotest-
showed that 3 specimens could be sufficient to provide        er casing for at least 10 seconds and checked by visual-
significant data (effect size = 1.48), a total number of 5    izing the dissolution of the luminescent reagent within
artificial transparent block was chosen for each group.       the sample solution. As the last step, the Endotester was
Five new syringes were used for sampling procedure            inserted into the Endocator to measure the generated
in five transparent training blocks which had been pre-       luminescence, and results where quickly displayed af-
viously filled with organic and inorganic debris (artifi-     ter 10 seconds. Overall, each sampling and measuring
cially contaminated canals). The recorded Endocator           procedure was completed in less than 1 minute and was
measurement were noted as Group 0. Other five new             performed by one trained operator to eliminate intra-
syringes were used for sampling procedures in artificial      examiner variables. Three consecutive samples were
canals in which no instrumentation, debridement or filling    taken for each block to assess consistency of results
with debris had been performed (untouched canals). The        The device allows to display results using to 2 different
recorded Endocator measurement were noted as Group            measuring scales, in which the higher the score the high-
A (sterile syringes). In Group B (non-sterile syringes)       er is the amount of organic material collected. RLU is a
the sampling procedure in the untouched canals was            continuous scale, with values ranging from 0 to more
repeated by using the same 5 syringes previously used         than 600000, while ES shows values from 0 to 100. In the
in the contaminated canals. In all cases the sampling         IFU, the following clinical correlation was provided only
procedure precisely followed the instruction of use (IFU)     for ESE values : 0-30 is clean, 31-60 is contaminated,
provided by the manufacturer. A sterile irrigation syringe    and 61-100 is dirty. On the contrary,no information about
with sterile 27-gauge needle containing 1 ml of distilled     the correlation between the two scales was provided by
water was inserted into the artificial canal, injecting the   the manufacturer. The Endoscore (ES) is suggested only
solution and then agitating it with a slight up and down      to briefly simplify clinical evaluation of canal cleanliness
motion of the needle. Then, after inserting the needle 3-4    by proposing a division in the three above mentioned
mm from the apex, the irrigating solution was collected       categories , which are not being precisely or directly cor-
and transferred to the Endotester.                            related to RLU results. RLU results are more precise and
After removing the swab stick from the main body of En-       accurate, and consequently in the present study statisti-
dotester and the collected sample liquid (one/two drops)      cal analysis was performed only using them. Descriptive
was released by the needle inside the upper part of the       analysis was performed to determine mean and standard
tube main body (fig 4). Injection was easy to perform but     deviation (SD) of the findings for the 3 groups. Paired T-
attention was paid since a too small amount or a too big      test with Bonferroni correction was executed to find out
amount of liquid may interfere with results, by diluting or   significant differences (p<0.05) between the 3 groups .
concentrating the amount of debris. Then swab stick was       Statistical analysis was undertaken using SPSS (SPSS,
inserted inside the casing, initially moved in the upper      v25.0 for Windows, SPSS Inc Chicago, IL, USA




Figure 3.                                                     Figure 4.



10.59987/ads/2024.1.49-54                                                                                                    51
     In vitro evaluation of a new endodontic device for assessment of canal cleanliness

     Table 1. Descriptive analysis. ES (Endoscore). RLU (Relative Luminescence Unit). Group 0 (dirty blocks, clean syringe),

         Measurement unit

               Group                                                             0

               Sample                            1st                    2nd                                 3rd

                                    1       100/192932              100/113568                          100/88764

                                    2       100/198885              100/102934                          100/95411


            Resin block             3       100/679199              100/213908                         100/110980

                                    4       100/488916              100/113515                          100/70267

                                    5       100/310117               100/98766                          100/90457

            Sample Mean                    100/374009.8            100/128538.2                        100/91175.8

             Sample SD                      0/208497.0               0/48165.8                          0/14608.7

        Overall group Mean                                                 100/197907.9

         Overall group SD                                                   0/173224.9




     Results                                                      ine diphosphate (ADP) and adenosine monophosphate
                                                                  (AMP) present inside canals. In the past ATP monitoring
     All Measurements, mean and standard deviation (SD)           technology has been used in determining cleanliness lev-
     values for groups 0 (dirty blocks, clean syringe), A         els, allowing rapid and accurate measurements of organic
     (clean blocks, clean syringe) and B (clean blocks, dirty
                                                                  residues by detecting ATP using luciferase, even if with
     syringe), consecutive samples (1st, 2nd, 3rd) and resin
                                                                  some risks of bias (25). Therefore, Endocator technology
     blocks (1, 2, 3, 4, 5) are reported in Table 1. A signifi-
                                                                  uses an improved new ATP + ADP + AMP monitoring sys-
     cant difference was noted between Group A (sterile
                                                                  tem which can analyze a greater range of organic resi-
     syringes) and Group B (non-sterile syringes) . Even if
                                                                  dues with increased sensitivity and precision. However,
     the canals were same and well cleaned, Group B pro-
                                                                  such higher sensitivity may more easily produce varia-
     vided significantly higher mean values than Group A
                                                                  tions and errors in the measurements due to inadvertent
     (p<0.05). Group O canals (non-cleaned, contaminated
                                                                  contamination or errors in the sampling technique, which
     canals) mean values were significantly higher than the
                                                                  is the most critical step in the procedure.
     other two groups (p<0.05). Group 0 showed highest
                                                                  The monitoring technology is a simple, easy to perform
     values 100/197907.9±0/173224.9, followed by Group B
                                                                  step which allows objective measuremenst and is mini-
     84.3/32352.4±21.4/39095.1 showing that not only dirty
                                                                  mally influenced by operators’ skills. On the contrary
     blocks, but also contaminated syringes used on clean
                                                                  the sampling procedure is more subjective and can be
     blocks could lead to ES/RLU values corresponding to
                                                                  influenced by many factors, including the risk of cross-
     dirty canal. On the other hand, Group A expressed the
                                                                  contamination. For example the dentists could use a
     lowest values 24.9/201.1±8.5/123.5, showing that col-
                                                                  syringe to collect the liquid for evaluation of the initial
     lecting a sample from a clean resin block with a clean sy-
                                                                  presence of debris (first measurement after starting of
     ringe could lead to values corresponding to clean chan-
                                                                  the procedure) and then use the same syringe to col-
     nel even if a small amount of organic residue was always
                                                                  lect the liquid for final evaluation of the cleaning results
     detected. Considering the 3 consecutive samples, each
                                                                  (second measurement). A similar situation could also
     group expressed a decreasing trend, which is related to
                                                                  happen when dentists check only final canal debride-
     the fact that each sampling procedure adds some new
                                                                  ment, but results provided by Endocator are not good,
     irrigant and provides some agitation of the solution.
                                                                  thus suggesting further cleaning procedures. After per-
                                                                  forming such improved cleaning, dentists may check
     Discussion                                                   again canal cleanliness (second measurement) by us-
     The new testing device is based on a method producing        ing the same syringe used for the first measurement.
     a given amount of luminescence, which is directly related    All these clinical situation may lead to some contamina-
     to the amounts of adenosine triphosphate (ATP), adenos-      tion and reduce reliability of the system. It is intuitive
                                                                  that initially the syringe should be a sterile one, while


52                                                                                                   10.59987/ads/2024.1.49-54
      R. Cross et al.

   A (clean blocks, clean syringe) and B (clean blocks, dirty syringe). SD (Standard Deviation).

ES/RLU

                             A                                                                   B

    1st          2nd                     3rd                        1st                2nd                         3rd

  38/456       41/457                  26/176                  100/82652            97/16461                    78/4707

  37/333       25/175                  18/108                 100/113421           100/24409                    70/2798

  30/270       24/168                   16/96                   96/15131             64/1916                     25/157

  24/168       20/140                   14/84                  100/98756           100/32277                    73/3080

  26/182       19/114                   15/90                  100/72432            94/14733                    68/2356

 31/281.8    25.8/210.8               17.8/110.8              99.2/76478.4         91/17959.2                 62.8/2619.6

 6.3/118.3    8.8/139.7                4.8/37.5               1.8/37679.7         15.3/11364.8                21.5/1638.2

                        24.9/201.1                                                         84.3/32352.4

                          8.5/123.5                                                        21.4/39095.1




      same concept may not be so intuitive when applied to a              where 0 corresponds to a properly cleaned canal without
      second measurement in the same clinical case. More-                 any organic material and 100 to a non-cleaned canal.
      over, no recommendation is provided by manufacturer                 The ES scale is meant to be used in clinical practice with
      about syringes. Hence, the purpose of this study was                a simplified range of values as described in IFU: 0-30
      to assess the risk of cross-contamination with syringe,             clean, 31-60 contaminated, and 61-100 dirty. In the pres-
      and to assess whether this risk could significantly affect          ent study, even if number of specimens was low, varia-
      measurements and promote the use of a new syringe                   tions in the measurements in a few cases due to inad-
      for each sampling procedure, even if in the same tooth              vertent contamination were able to wrongly differentiate
      in the same clinical procedure                                      a cleaned canal into a contaminated canal, according to
      Results of the present study showed that the risk of                the proposed ES scale. RLU is a continuous scale, with
      cross contamination is significant. Clean, non-instru-              wider values ranging from 0 to more than 600.000, which
      mented canals were properly assessed by the method-                 is probably more precise and useful for vitro or clinical
      ology showing only a minimal quantity of residual debris            studies. However, manufacturer provided no information
      (probably derived from manufacturing) in a very precise             about the correlation between RLU values and canal
      and reliable way when a new sterile syringe was used.               cleanliness in vivo.
      On the contrary second measurements of the same                     Hence, we may conclude that there is a significant risk
      sample using a syringe who had been previously slightly             that even a minimal cross-contamination can signifi-
      contamined ( being used for sampling in a canal full of             cantly affect Endocator measurements due to the high
      debris) provided significantly different results and canals         sensitivity of the system. Therefore, authors recommend
      were evaluated as partially or poorly cleaned. This is ob-          clinicians to use a new sterile syringe for each sampling
      viously related to the high sensitivity of the Endocator,           procedure and suggest manufacturer to write this recom-
      and to the presence of residual debris in the needle or in          mendation in the IFU (Instruction of Use) of the product.
      the syringe previously used. In fact in a previous study
      performed by authors to determine precision and reliabil-           References.
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      10.59987/ads/2024.1.49-54                                                                                                            53
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