Received Date : 25-Sep-2012

Accepted Article Accepted Date : 03-May-2013

Article type : Review

Apical extrusion of debris: A literature review of an inherent occurrence during root

canal treatment

J. Tanalp1 & T. Gngr2

Department of Endodontics, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey

Running title: Apical extrusion of debris

Keywords: Apical extrusion, debris, endodontic treatment, irrigation

Correspondence:

Assoc. Prof.Dr Jale Tanalp,

Yeditepe University, Faculty of Dentistry, Bagdat Caddesi 238 Goztepe, Istanbul, Turkey

Phone: +902163636044

e-mail: jale.tanalp@yeditepe.edu.tr

Fax: +902163636211

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/iej.12137

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 Abstract
Accepted Article Extrusion of intracanal debris as well as irrigants is a common occurrence during root canal

treatment and no instrument or technique has thoroughly solved this problem. Since flare-ups

may arise with any irritation directed towards periapical tissues, a shaping or irrigation

technique should minimize the risk of apical extrusion, even though it may not be prevented.

There has been a rapid evolution of root canal instruments and irrigation systems through the

last decade and many have been assessed for their debris extrusion potential. The purpose of

this review was to identify publications regarding the evaluation of debris, bacteria and

irrigant extrusion during root canal treatment. A PubMed, Ovid and Medline search was

conducted using the keywords apical extrusion, debris extrusion and endodontic

treatment. The literature search extended over a period of more than 30 years up to 2012.

Content of the review was limited to apical extrusion of debris and irrigants, extrusion of

liquid by irrigation methods and bacterial extrusion. Issues relevant to apical extrusion were

obtained by further search in the reference sections of the retrieved articles. The review

provides an update on the current status of apical extrusion.

Introduction

Chemomechanical preparation of the root canal system is one of the major

prerequisites of contemporary root canal treatment. The procedure encompasses not only

canal shaping but also the usage of intracanal irrigants to provide optimal cleanliness and

disinfection within the root canal system. Although various methodologies have been

introduced, one inherent problem related with all root canal shaping and cleaning procedures

is the extrusion of intracanal debris and irrigants into the periradicular tissues.

Chapman et al. (1968) were the first to verify the expulsion of infective material from

the root canal system during instrumentation. Van de Visse & Brilliant (1975) then attempted

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 to compare apical extrusion of debris in root canals with or without irrigation. They
Accepted Article concluded that irrigation was a procedure that facilitated the extrusion of intracanal debris

periapically and that instrumentation without irrigants resulted in no collectible debris. The

authors also stated that the amount of debris was correlated with the length of the root canal.

This was a preliminary study that successfully demonstrated the formation of the worm of

necrotic debris as described by some (Seltzer & Naidorf 1985). However, irrigation is one of

the indispensable components of successful root canal treatment and other inherent risks are

likely to ensue without irrigation. Therefore, the selection of a methodology that would

decrease the amount of extrusion rather than completely eliminate the use of irrigants is more

logical.

It is the common opinion of most authors that the extrusion of some debris is

inevitable during root canal instrumentation and a methodology that completely avoids this

phenomenon has not been developed. There have been many studies on extrusion with

attempts made to quantitate the debris as well as liquid and bacteria extruded by various

techniques. A review of the literature reveals that the large number of apical extrusion

investigations carried out in the past decade, have not yet been included in a review. The

intention of this article is to make a general summary of the apical debris extrusion concept in

the field of root canal treatment. Prior to starting the review, it is noteworty to mention that

the concept of apical extrusion should not only be limited to debris or liquid forced into

periapical tissues during mechanical instrumentation. There are also other types of apical

irritations during root canal treatment that may disrupt the integrity of periapical structures,

such as extrusion of filling materials, intracanal medicaments or root canal instruments.

Extrusion of intracanal material may be in the form of filling materials, necrotic pulp tissue,

bacteria or irrigants (Huang et al. 2007). Generally speaking, extrusion of cleaning,

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 medication or filling materials beyond the apical terminus into the surrounding tissues may
Accepted Article result in delayed healing or even treatment failure because of a foreign body reaction (Ng et

al. 2008).

The topic of apical extrusion will be reviewed in terms of debris, liquid and bacterial

extrusion to specify and limit the spectrum of the analysis. However, the authors share the

view that any sort of apical irritation should be taken into consideration when one is

attempting to understand the aetiological factors that lead to the development of a periapical

response and hamper the healing process. It is also noteworthy to mention that during

endodontic procedures, extrusion occurs through the combination of several factors, e.g.

instrumentation is always associated with extrusion of debris and extrusion of irrigant will

also result in the extrusion of bacteria. Therefore, it may be more rational to consider the

extrusion phenomenon holistically, rather than separately.

An initial search was conducted in PubMed, Ovid and Medline search engines by

inserting keywords apical extrusion, and endodontics. One hundred and ten articles in

English were retrieved in PubMed whereas over 3000 articles were displayed in Ovid and

Medline, covering a wide range of topics including endodontics, orthodontics and oral

surgery. This necessitated a limitation and specification of the analysis and further filtering

was used so that only articles relevant to apical debris, irrigant and bacterial extrusion caused

by root canal shaping instruments, influence of apical constriction on extrusion, as well as

irrigation potential of recently introduced methodologies and devices were included in the

search. Articles displayed using the same keywords and related to extrusion of MTA during

apical placement, extrusion of obturating materials, complications such as paresthesia

following overfilling, sodium hypochlorite accidents and intrusive and extrusive traumatic

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 luxations orthodontic luxations and extrusion of filling materials during retreatment were
Accepted Article excluded. Thirty-four articles were included by this selection. Another search was conducted,

this time by using the keywords, apical extrusion, debris and endodontics. Six

additional articles were retrieved, some related with extrusion of debris and others including

the effect of needle type and negative pressure. The retrieved articles were reviewed and

issues relevant to apical extrusion (flare-up etc.) were also searched for a more

complementary analysis of the topic. Meanwhile, the reference lists of the retrieved articles

were checked to identify further relevant literature, where necessary. Overall, 60 articles were

included up to 2012.

Clinical and biological relevance of apical extrusion

One of the most significant complications related with or that occurs as a consequence

of apical extrusion during root canal procedures is inter-appointment flare-ups and post-

operative pain that is an undesirable occurrence both for the patient and the practitioner.

Siqueira (2003) has drawn attention to the fact that some type of balance exists between

microbial aggression and host-defence in asymptomatic chronic periradicular lesions. The

author further emphasized that in case microorganisms are extruded apically during

chemomechanical preparation, the balance will be disrupted with the periradicular tissues

being challenged by more irritants and an acute reaction will ensue to reastablish the balance

(Siqueira 2003).

During mechanical instrumentation, the number and virulence of the extruded

microorganisms are the decisive and critical factors that determine the extent of the

periradicular reaction. It has further been indicated that though the qualitative factor is not

under the control of the practitioner, quantitative factors may be controlled by selecting

techniques such as crown-down instrumentation to provide a gradual approach to the canal

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 terminus. This allows the control of the amount of irritants propelled periapically (Siqueira
Accepted Article 2003).

Although the presence of virulant microorganisms is a critical causative factor in the

occurrence of flare-ups, it is also accepted that contaminated as well as noncontaminated

dentine and pulp tissue may have the potential to initiate an inflammatory reaction. A good

example of this is the report by Seltzer et al. (1968) where noncontaminated dentine chips

forced beyond the apical foramen during overinstrumentation distended the apical collagen

fibres of the periodontal ligament. Torneck (1967) also demonstrated that sterile connective

tissue fragments placed in the subcutaneous tissue of white rats, and coming in contact with

vital connective tissue of the same specimen produced inflammatory reactions. The presence

of immunoglobulins formed against altered tissue proteins acting as antigens as well as mast

cells capable of degranulation to release vasoactive amines have also been demonstrated

(Naidorf 1985, Torabinejad et al. 1985).

Seltzer & Naidorf (1985) commented that a quiescent chronic inflammatory periapical

lesion may give a violent inflammatory reaction after the initiation of root canal treatment.

Also, cell mediated or humoral immunological phenomena may ensue due to foreign

materials introduced into the periradicular connective tissue. All these aforementioned reports

indicate that all types of physical or chemical irritation that may disrupt the integrity and

balance of periradicular tissues may have the potential to initiate a periapical reaction. It

appears that the confinement of canal preparation within the root canal space is of critical

value from multiple perspectives, among which prevention of the initiation of an

inflammatory and immunologic reaction is the most important. However, clinical cases

display variations that might necessitate the selection of different approaches. In teeth with

vital pulps, instrumentation 1-2 mm. short of the apical foramen and preservation of a vital

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 apical pulp stump may enhance the healing procedure expected thereafter. However;
Accepted Article specifically in teeth with necrotic pulps and periapical lesions, leaving intact tissues apically

may result in the harbouring of microorganisms, leading to the persistance of the periapical

lesion (Wu et al. 2006). Also, dentine chips and pulp tissue compacted into the apical region

may cause apical blockage and interfere with the working length (Souza 2006).

It has thus been proposed that the apical foramen should be penetrated with a file of

adequate size to prevent accumulation in this region procedure referred to as apical patency

(Buchanan 1987). It has been suggested that the selection of an apical patency file that is not

adjusted to the apical portion rather than one that binds to the foramen will offer less risk in

terms of extrusion (Souza 2006). Nevertheless; it is one of the major tasks of the dental

practitioner to avoid or minimize irritation of the periapical tissues during root canal

treatment, including one that might be caused by apical patency files. Consequently,

confirmation of apical patency must be achieved so as to cause minimal irritation on

periradicular structures.

Methodologies and experimental designs used in apical extrusion studies

With the intention of quantitatively examining debris that might be extruded into

periapical tissues during root canal shaping, laboratory experimental set-ups have been

designed. The system that has received the most attention and has been adopted by most

studies pertaining to apical extrusion of debris is the one described by Myers & Montgomery

(1991). This system consists of a rubber stopper through which the instrumented root is

forced and secured, a glass vial where the extruded debris or irrigants are collected and a

flask made of glass into which the vial is placed. A 25 gauge needle is also placed within the

rubber stopper to balance internal and external pressures. The debris collecting apparatus has

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 shown variations in different studies. While glass vials have been selected by some, others
Accepted Article have preferred the use of aluminium crowns suspended beneath the tooth by wires (Fairbourn

et al. 1987). Eppendorf tubes are also conventional means of debris collection (Tanalp et al.

2006). Self-curing acrylic is one means of stabilizing the root while suspended in the

Eppendorf. The rubber stopper with the tooth is secured into the mouth of the flask so that the

apex remains suspended. Two points are of importance during the conduction of such studies.

Firstly, the assembly where the tooth is placed should be secured to prevent any movement

which might disrupt the standardization of the instrumentation procedure. Also, the flask

should be shielded using a rubber dam so that the operator performing the procedure is not

able to see the root he or she is working on. This approach simulates a clinical working

environment where the operator is dependent on working length determined by radiographs

or apex locators without seeing the root canal space. It also prevents bias by the practitioner.

The methodology comprises weighing the collecting tubes prior to and after instrumentation

using a precise microbalance and calculation of the extruded debris by subtracting the initial

weight from the post-instrumentation weight. Since debris as well as irrigants may also be

extruded apically, the extruded liquid needs to be evaporated by storage in an incubator.

When the amount of extruded liquid is measured, a calibrated tube serving as a guide with

increments of 0.5 mL can be placed next to the collecting tube; thus the amount of extruded

liquid can be calculated, as well (Myers & Montgomery 1991). Additionally, the collecting

flask or vial can be filled with various solutions such as 0.9% NaCl. A calibrated injector

(e.g. insulin injector) can be used through the ventilation needle space to collect and measure

the amount of extruded irrigant. This methodology has generally been preferred by authors

who attempted to quantitate the amount of extruded irrigant, apart from debris (Tinaz et al.

2005, Er et al. 2005, Kustarci et al. 2008a, Mohammadi 2009).

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 Lyophilization (dry freezing), a chemical procedure by which excess liquid can be
Accepted Article evaporated, has been used by some authors (Tanalp et al. 2006). It has been speculated that

slight variations in room temperature and moisture are prevented in lyophilization process

due to the closed environment. Following a standardized dehydration and weighing protocol

is essential as the weight of the sample might increase due to hydration from moisture in the

air as the sample is being weighed (Fairbourn et al. 1987). Weighing procedures are repeated

3 times, sometimes more, and an average value is taken for more precision.

Another methodology used is the filter column suction system used by Ruiz-Hubard

et al. (1987). Standardized acrylic endodontic teaching models containing both straight and

curved root canals with periapical wells are used in this system. In order to collect debris

produced during cleaning and shaping, models are cross sectioned through the apical wells

using a low-speed diamond saw. Following instrumentation, irrigation and drying, root canals

are filled. The reason why experimental root canals are filled in this methodology is the

prevention of the debris in the periapical well from being pushed backward. The collected

debris is introduced into a filter column suction system, containing a Milli-pore plastic filter.

Accurate weight of the filters is previously calculated. After debris introduction, the filters

are exposed to heat in an oven for the elimination of moisture and the amount of extrusion is

calculated by subtracting the previously recorded filter weight from the weight of the debris

and filter. Advantages of using simulated root canals in acrylic models include the adjustment

of the canals to any desired size, shape or curvatures providing a consistent model. They also

eliminate any variation between dentine of each individual tooth by using a standardized

structure. On the other hand, acrylic models lack pulp tissue, three-dimensional curves and

canal irregularities, and a natural apical constriction. Therefore, they are unable to make a

precise representation of what occurs in clinical circumstances. Some authors also drew

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 attention to the fact that heat generated with rotary instruments may soften the resin material
Accepted Article and adversely affect the reliability of the experimental system (Kum et al. 2000).

Several common statements have been made by authors as criticism of the

experimental methodology used for debris collection. For example, no periapical tissues that

may act as a natural barrier against apical extrusion are present in some laboratory models.

Even if some sort of simulation is provided, the structure and condition of the tissues as well

as pulpal status cannot be standardized. This has well been demonstrated by Salzgeber &

Brilliant (1977) who used a radiopaque material to delineate apical penetration in vivo. The

authors concluded that the solution was confined to the root canal space in teeth with vital

pulps whereas in teeth with necrotic pulps and teeth with periapical lesions, the solution

seemed to disperse randomly into the periapical lesions. Also, the radiopaque material used

as an irrigant reached the endpoint of the preparation sooner in teeth with necrotic pulps than

in teeth with vital pulps. As understood from the aforementioned study, the pulpal status as

well as the condition of the periapical tissues cannot be mimicked. The pressure at the

periapex cannot be simulated either. Some suggestions have been made for the simulation of

the periodontal ligament to better represent clinical conditions. Hachmeister et al. (2002)

suggested the use of floral foam to simulate the resistance of the periapical tissues to pressure

exerted from within the root canal space. On the other hand, this methodology has also been

criticised as foam may absorb irrigant and debris (Altundasar et al. 2011).

It has also been stated that variations in the microhardness values of dentine may

affect the results of studies in which human teeth are used. (Tanalp et al. 2006) In teeth with

lower hardness, debris may be extruded more readily into the periapical tissues. Another

point to draw attention to is that different irrigating solutions such as sodium hypochlorite or

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 bidistilled water may be selected in experimental studies. The extrusion potential of different
Accepted Article irrigants may also affect the results of the studies and the development of an experimental

model using irrigants selected during routine endodontic procedures seems more logical and

reflects clinical conditions more precisely.

Other shortcomings of currently used methodologies for evaluation of debris

extrusion can be summarized as follows: It is impossible to ensure that the collecting devices

are not contaminated or additionally affected and loaded by sources other than the apically

extruded debris during instrumentation. The amount of extruded material that is calculated is

extremely low, often in fractions of a mg or g. There is always the possibility of additional

influence by touching of the devices by fingers or even pollution by contents from the

environment in which the specimens are preserved. Even contact of moist fingertips to the

steel crown or contamination from other unpredictable sources may alter the weight by

several g. These additional parameters cannot be standardized nor prevented and there is no

means by which they can be differentiated and measured when extremely low weights are

being taken into consideration.

Another important issue is the standardization of the size of the apical foramen.

Although this factor has been taken into consideration in some studies by ensuring an even

distribution between the experimental groups by measuring apical diameters (Al Omari &

Dummer 1995, Hinrichs et al. 1998, Beeson et al. 1998), others have not taken this parameter

into consideration and only preferred standardization by inserting a certain size of file into the

root canal until it slightly protruded through the foramen, which is a rather subjective

methodology.

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 Furthermore, procedure to dry samples is also a weak part of experimental
Accepted Article methodologies, which may show variations according to time, constancy of the moisture and

heat of the storage environment. It is not possible to ensure that an identical amount of

evaporation has occurred for all samples and drying is therefore a critical issue that should be

meticulously evaluated to make improvements in traditional study designs. During the drying

procedure, it is not only the water content but also the irrigants that should be evaporated.

Crystals of sodium hypochlorite or other irrigants are likely to remain which might adversely

affect the reliability of the experimental methodology. Sodium crystals that cannot be

separated from debris may cause considerable alteration of the results. The discrepancy

between the weights of extruded materials reported by different authors is a clear indication

of the challenges of the standardization. The residue that remains after the evaporation of the

liquid is highly dependent upon the irrigation method used.

During laboratory investigations evaluating apical extrusion, one important factor is

lacking, which is the vital pulp tissue that may remain within lateral canals and apical

ramifications. It is quite likely that this remaining tissue may later be inflamed and infected

and cause periradicular disease (Ricucci & Siqueira 2010). In serial sections of human teeth,

lateral canals and apical ramifications were observed in 75% of teeth. In teeth with pulp

exposure by caries, the tissue in lateral canals and apical ramifications remained vital as long

as the pulp tissue in the main canal was vital. When pulpal necrosis reached this level, the

tissues within these lateral canals were partially or completely necrotic. The authors drew

attention to develop methodologies to effectively disinfect these regions. It is practically

impossible to simulate this parameter under laboratory conditions.

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 All the aforementioned techniques and methodologies are based on the quantitative
Accepted Article measurement of debris, liquid or bacteria. On the other hand, extrapolating apical extrusion

on a quantitative basis only may not be a rational approach as it lacks the accomplishment of

a qualitative analysis on the content of extruded material. It is quite likely that a smaller

amount of extruded material may have a higher potential of initiating a periapical response

due to a bacterial content of high virulence and antigenic characteristics compared with an

extruded material of high quantity, yet lacking the specific threshold value of irritation.

Furthermore; variations in terms of measured debris are observed between researchers even

when the same methodology is used, explaining the confounding of multiple factors in

experimental settings, resulting in questionable results.

A recent article introduced a point conductivity probe to measure irrigant extrusion

and a vial system incorporating a valve to adjust pressure and a magnetic stirrer, to resemble

a clinical condition and mimic periapical pressure. Although this system warrants further

research to determine its reliability, it holds promise to overcome the weakness of previous

investigations where extrusion might be overemphasized due to the lack of imitation of

periapical tissues (Psimma et al. 2012).

Other studies investigating extrusion have evaluated ex-vivo the number of bacteria

extruded apically after root canal instrumentation. (Er et al. 2005, Kustarci et al. 2008 a,

Mohammedi 2009, Ghivari et al. 2012). E faecalis is generally selected as the biological

marker in these studies. It is a nonfastidious, easy-to-grow aerobic bacterium of significant

clinical importance that is relavant in studies applying a bacteriological assessment method

(Er et al. 2005). The test apparatus used in this experimental methodology resembles those of

studies evaluating apically extruded debris quantitatively, with rubber stoppers through which

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 experimental teeth are forced. Rubber stoppers are fitted on top of vials used as collective
Accepted Article containers. The collecting vials are filled with sodium chloride (0.9%). Contamination is

performed by using a pure culture of E. Faecalis (ATCC 29212) grown in brain-heart

infusion broths. The number of colony forming units has to be standardized for each sample.

Root canals are completely filled with E. Faecalis suspension by sterile pipettes accompanied

by hand instrumentation to carry the bacteria down the whole length of the root canals.

During instrumentation, irrigation is performed with 0.9% saline solution to rule out the

antibacterial activity of other irrigants. Before the beginning of and after the end of

laboratory tests, an amount of (0.1 mL) NaCl solution is collected from the experimental vials

in order to count the bacteria, then the suspension is incubated in brain- heart agar at 37C for

24 h. Colonies of bacteria are counted and the results are given as number of colony forming

units (CFU).

The following comments or criticism can be made in relation to bacterial extrusion

studies from a clinical point of view: they are indeed helpful methodologies because they

show resemblance to clinical circumstances where bacteria are the predominating factors

governing the process or long-term success of root canal treatment. E. faecalis is a good

species to select as it is a type of bacteria the endodontic literature has specifically focused on

in recent years due to its resistant characteristics. On the other hand, these studies evaluate

apical extrusion phenomenon only from a bacteriological point of view. Apical reactions are

likely to ensue even when sterile tissue fragments are forced into periradicular tissues and act

as antigens. They are not able to evaluate the virulence or pathogenic characteristics of the

extruded bacteria; they rather provide numerical information which is then extrapolated to the

clinical circumstances. Since no antibacterial irrigant is used, the effect of this important

constituent of chemomechanical preparation is completely ruled out. There is also no means

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 by which the bodys defense mechanism is taken into account in laboratory based
Accepted Article methodology. Nevertheless, these studies are good attempts to mimic clinical conditions and

may be further developed to reveal a more favorable resemblance to clinical circumstances

by the inclusion of other variables.

Irrespective of the technique used, some variables such as canal diameter, angle and

distance of canal curve from the orifice and the radius of curvature are important factors that

should be recorded while allocating specimens into groups when extracted teeth are selected.

The introduction of innovative irrigation systems creating a negative pressure at the

apical portion of canals has held promise for the prevention of irrigant extrusion.

Concurrently, there have been alterations in study designs for evaluating the degree of liquid

extrusion caused by these systems. An example of these new methodologies is the one

described by Mitchell et al. (2010) where the experimental teeth are embedded in 0.2%

agarose gel. A colour change to purple occurs as sodium hypochlorite is extruded into the gel.

The gel is photographed after irrigation and the area of the colour change is expressed in

Pixels using Adobe Photoshop 7 (Adobe, San Jose, CA, USA). The gel system is designed to

simulate periapical tissues, which has generally been a weak point of the majority of

extrusion studies. Although it is a good attempt to simulate in vivo conditions, the authors

summarized the shortcomings of this design by stating that the density of the gel cannot be

correlated with that of an intact periodontium or a periapical lesion where a constant density

is not expected. Furthermore; the gel possesses a porous nature and the extrusion affected

area expands with time as long as the pH remains above 9. Although the authors have tried to

overcome this limitation by aspirating irrigants and drying the canal after each cycle, the

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 degree to which this is accomplished remains questionable. Residual sodium hypochlorite is
Accepted Article always likely to remain, which may cause the persistence of the pH above a certain limit.

Overview of extrusion studies

A survey of literature reveals that there has been a continuous interest to evaluate

endodontic instruments and techniques in terms of apical extrusion over the years. As stated

previously, the unreliable characteristics of the study designs prevent definite conclusions on

extrusion to be drawn. Nevertheless, the following section summarizes the factors that impact

on extrusion.

Extrusion studies involving only hand techniques for root canal shaping

Prior to studies by Beeson et al. (1998) and Reddy & Hicks (1998), extrusion studies

focused on different hand instruments, sonic and ultrasonic techniques for preparing root

canal spaces. Following the study by Van de Visse & Brilliant (1975) who reported the

significance of irrigation in apical extrusion, several authors attempted to evaluate the

extrusion levels of different manual preparation techniques as well as sonic and ultrasonic

systems (Ruiz Hubard et al (1987, Fairbourn et al 1987).

Al-Omari & Dummer (1995) compared 8 different hand-instrumentation methods and

suggested that techniques involving a filing (linear) motion caused significantly more

blockages and extruded significantly more apical dentine debris. Their results were also

consistent with other studies showing the tendency for cervical flaring and crown-down

techniques to produce less apical extrusion (Fairbourne et al. 1987, Ruiz-Hubard et al. 1987,

Mc Kendry 1990)

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 Extrusion studies using sonics and ultrasonics
Accepted Article Martin & Cunningham (1982) suggested that ultrasonic instrumentation extruded less

material than hand instrumentation. On the other hand; in a clinical study assessing post-

instrumentation pain and flare-ups, no significant difference existed between endosonic and

conventional instrumentation, showing that from laboratory studies, results cannot be directly

extrapolated to clinical circumstances (Martin & Cunningham 1982) and controversial results

may be obtained when trying to correlate laboratory studies to clinical findings. In another

study, sonic canal preparation produced the lowest amount of debris extrusion whereas

conventional technique the highest (Fairbourn et al. 1987).

Extrusion studies on nickel-titanium rotary instruments (debris, liquid and bacteria)

Profile .04 Taper Series 29 System (Tulsa Dental Products, Tulsa, OK, USA) was first

assessed in terms of debris evaluation by Beeson et al. (1998) and compared with K-files. It

was proposed that specific features of this system would encourage coronal displacement of

debris, rather than apical. Later, the ProFile Series 29 was compared with other Ni-Ti

instruments such as Lightspeed (Reddy & Hicks,1998), NT McXIM (Hinrichs et al, 1998),

Quantec 2000 and PowR (Ferraz et al. 2001) and Race and Flexmaster (Zarrabi et al, 2006) .

The system generally yielded lower extrusion compared to other systems. Furthermore; the

system has also been evaluated in terms of extrusion potential at different speeds of rotation

(Bidar et al. 2004). Even at a high speed, the instrumentation system produced lower

extrusion compared to hand instrumentation. The less aggressive morphological

characteristics of the system and the requirement for the utilization of multiple instruments

before reaching the apical terminus might have accounted for the relatively lower extrusion

levels observed with the Profile .04 Taper Series 29 System.

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 ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) has also been the topic of a
Accepted Article variety of investigations pertaining to apical extrusion. In extrusion studies incorporating

ProTaper, the system has been compared to ProFiles and K-Flexofiles (Azar& Ebrahimi,

2005) and System GT (Dentsply Maillefer) from a bacteriological point of view (Er et al,

2005). No differences in terms of extrusion were noted in these studies compared to other

systems tested.

On the other hand, ProTaper was found to extrude significantly more debris compared

to ProFile and HERO Shaper in other studies (Tanalp et al, 2006, Logani & Shah, 2008). The

ProTaper system was also compared to K3 system (Kustarci et al 2008c, Madhusudhana et

al. 2010) and Mtwo (Madhusudhana et al. 2010, Tasdemir et al, 2010). Kustarci et al (2008c)

reported that ProTaper extruded significantly more debris compared to K3 whereas

Madhusudhana et al. (2010) determined no significant difference. Tasdemir et al (2010), on

the other hand, reported that ProTaper extruded significantly higher amount of apical debris

compared to other systems tested, one of which was MTwo.

MTwo, a rotary system that engages a step-back approach was also assessed by

Froughreyhani et al. (2011) and was determined to extrude significantly more debris than

Race.

Kutarc et al. (2008a,2008b) evaluated K3, Race (FGK, La Chaux-de-Fonds,

Switzerland) and Flexmaster (VDW, Munich, Germany) from two different perspectives in

two extrusion studies, one related with debris and one with bacterial extrusion. In both

studies, hand instrumentation resulted in more debris and bacterial extrusion. No differences

were noted between the groups in terms of debris extrusion. On the other hand, in the

bacterial extrusion study, manual technique caused significantly more bacteria compared to

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 the engine driven groups, which presents a good example of how results might differ with
Accepted Article different study designs.

Influence of apical diameter and patency on extrusion

In the majority of extrusion studies, the standardization of apical diameter is

performed by inserting a file of a specific size until it protrudes through the foramen. This is a

rather subjective means of standardization though it is generally believed to provide patency

of the apical foramen and provide consistency among samples in terms of the diameter of the

apical region. Some studies preferred to make a more detailed analysis and examined apical

regions (major and minor foramina) under a stereomicroscope (Fairbourn et al.1987, Myers

& Montgomery 1991).

Al-Omari & Dummer (1995) determined no correlation between weight of debris

extruded and parameters of canal shape, one of which was apical diameter. Hinrichs et al.

(1998) also concluded that factors such as canal length, curvature, and foramen size had no

influence on the amount of debris extruded.

Lambrianidis et al. (2001) evaluated the extrusion concept in terms of the

maintenance of apical patency during instrumentation. An interesting finding described as

paradoxical by the authors was the greater amount of extrusion that occurred when the apical

constriction remained intact. Tnaz et al. (2005), on the other hand found a contradictory

result and concluded that more debris was extruded with an increase in apical diameter. A

laboratory study concluded that NaOCl extruded into a simulated periradicular space without

apical debridement nor use of patency files and injection of the irrigant without pressure

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 (Camoes et al. 2009). This demonstrates how easily endodontic irrigants reach the apical
Accepted Article third and extrude into the periradicular tissues.

Influence of working length on extrusion

In most studies on extrusion, the influence of the working length has not been the

main target of the investigation; however, it has been further evaluated to provide additional

complementary information. Some studies concluded that filing to the foramen resulted in

more debris extrusion compared to 1 mm shorter than the foramen (Martin & Cunningham

1982, Myers &Montgomery 1991,Beeson et al. 1998).

Influence of canal curvature on extrusion

The majority of studies on extrusion have used single rooted teeth with relatively

straight root canals of less than 5-10 degrees of curvature. On the other hand, it is quite likely

that the practitioner will be faced with severely curved roots in clinical practice. Leonardi et

al, (2007) focused on roots with greater curvatures and determined no significant differences

between slight and moderate curvatures, nor any difference between the evaluated techniques

in terms of debris extrusion.

Influence of instrument pitch design on extrusion

The influence of pitch design of a specific instrument, NRT files (MANI Inc, Tochigi,

Japan) was assessed by Elmsallati (2009) with short, medium and long pitch designs. The

results showed that the short pitch design extruded less debris than the medium and long

ones.

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 Influence of irrigant needle type on extrusion
Accepted Article In general, studies on apical extrusion utilize conventional needles of various gauges.

Altundaar et al. (2011) drew attention to the type of irrigation needles used. ProTaper in

combination with a regular needle extruded the greatest amount of irrigant and side-vented

irrigation needles seemed to have a lowering effect on irrigant extrusion.

Debris and liquid extrusion studies on reciprocating instruments

De-Deus (2010), reported no difference between conventional ProTaper Universal

technique and Single File ProTaper F2 in terms of debris extrusion. Brklein (2012) on the

other hand, concluded that full-sequence rotary instrumentation was associated with less

debris extrusion compared to reciprocating single-file systems.

Studies on extrusion potential of irrigation methodologies and devices

Although traditional needles are widely used by many practitioners, there are

continuous attempts to facilitate the flow mechanism and even distribution of irrigants within

the root canal space as well as to provide additional safety.

The use of a reservoir of irrigation in the coronal access cavity and passive insertion

of the needle have been shown to provide safer treatment procedure, decreasing the

likelihood of considerable amounts of liquid being pushed periapically (Brown et al. 1995).

The idea of aspirating the delivered solution back from the root canal space has been

proposed by some authors (Fukumoto et al.2006).

Although provision of safe irrigation is extremely important, it is undeniable that the

irrigation solution is expected to provide optimal cleanliness especially in the apical portion

of the root canal system. It has also been proposed by some that traditional needles are

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 ineffective in cleaning the apical third (Boutsiokis et al. 2009). Manual dynamic irrigation
Accepted Article incorporating the application of a gutta-percha cone in short, gentle strokes to

hydrodynamically activate the irrigant (McGill et al. 2008) and the EndoVac system (Discus

Dental, Culver City, CA, USA), an apical negative pressure irrigation device are two

methodologies that have gained attention. Supportive statements were made by some authors

for Endo-Vac, indicating that it resulted in less irrigant extrusion (Desai & Himel. 2009,

Mitchell et al., 2010, Mitchell et al, 2011) and reduced post-operative pain (Gondim et al.

2010) . However, the accumulated data is limited and further long-term clinical trials are

warranted to better establish these methodologies in routine care.

Conclusions

This review article summarizes the results of apical extrusion studies. In general, the

clinical relevance and scientific reliability of the reported studies are questionable and

difficult to draw out definite conclusions. Apical extrusion should not solely be the decisive

factor in the selection of a specific methodology since there are also other parameters that

determine the clinical success of root canal treatment. On the other hand, prevention of all

types of damage and irritation to surrounding tissues is one of the major clinical

responsibilities of a practitioner. Caution must be exercised in the selection and utilization of

instruments, specifically taking into consideration the diagnosis of the clinical case.

Within the limitations of the evaluated studies, it can be concluded that rotary

instruments used in a crown-down manner seem to produce less extruson than hand

instruments used conventionally. Also, simple modifications in irrigation methodologies by

selecting side-vented needles may be advantageous for the prevention of apical extrusion.

Negative pressure creating irrigating devices also seem promising though meticulous care

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 should be taken to prevent complications such as the clogging of delivery tips. Reciprocating
Accepted Article movement is a recent concept which has not been evaluated extensively in terms of debris

extrusion and warrants further research.

It appears that there is a tendency to develop extrusion study designs and set-ups,

which better resemble in vivo conditions and inclusion of other important parameters, such as

the apical pressure. Once these methodologies are more strongly established, more credible

information regarding extrusion will result.

References

Altundasar E, Nagas E, Uyanik O, Serper A (2011) Debris and irrigant extrusion potential of

2 rotary systems and irrigation needles. Oral Surgery Oral Medicine Oral Pathology Oral

Radiology and Endodontology 112, e31-5. Epub 2011 Jul 20.

Al-Omari MAO, Dummer PMH (1995) Canal blockage and debris extrusion with eight

preparation techniques. Journal of Endodontics 21, 154-8.

Azar NG, Ebrahimi G (2005) Apically-extruded debris using the ProTaper system (2005)

Australian Endodontic Journal 31, 21-3.

Beeson TJ, Hartwell GR, Thornton JD, Gunsolley JC (1998) Comparison of debris extruded

apically in straight sanals: Conventional filing Versus Profile .04 Taper Series 29. Journal of

Endodontics 24, 18-22.

Bidar M, Rastegar AF, Ghaziani P, Namazikhah MS (2004) Evaluation of apically extruded

debris in conventional and rotary instrumentation techniques. Journal of Californian Dental

Association 32, 665-71.

This article is protected by copyright. All rights reserved.

 Boutsiokis C, Lambrianidis T, Kastrinakis E (2009) Irrigant flow within a prepared root canal
Accepted Article using various flow rates: a computational fluid dynamics study. International Endodontic

Journal 42, 14455.

Brown DC, Moore BK, Brown CE Jr, Newton CW (1995) An in vitro study of apical

extrusion of sodium hypochlorite during endodontic canal preparation. Journal of

Endodontics 21, 587-91.

Buchanan LS (1987) Working length and apical patency: the control factors. Endodontic

Report. 1987 Fall-Winter:16-20.

Brklein S, Schfer E (2012) Apically extruded debris with reciprocating single-file and full

sequence rotary instrumentation systems. Journal of Endodontics 38, 850-2.

Camoes ICG, Salles MR, Fernando MVM,Freitas LF, Gomes CC (2009) Relationship

between the size of patency file and apical extrusion of sodium hypochlorite. Indian Journal

of Dental Research 4, 426-30.

Chapman CE, Collee JG, Beagrie GS (1968) A preliminary report on the relation between

apical infection and instrumentation in endodontics. Journal of the British Endodontic Society

12, 7-11.

De-Deus G, Brando MC, Barino B, Di Giorgi K, Fidel RA, Luna AS (2010) Assessment of

apically extruded debris produced by the single-file ProTaper F2 technique under

reciprocating movement. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and

Endodontology 110, 390-4.

Desai P, Van Himel (2009) Comparative safety of various intracanal irrigation systems.

Journal of Endodontics 35, 545-9.

Elmsallati EA, Wadachi R, Suda H (2009) Extrusion of debris after use of rotary nickel

titanium files with different pitch: A pilot study. Australian Endodontic Journal 35, 65-9.

This article is protected by copyright. All rights reserved.

 Er K, Smer Z, Akpinar KE (2005) Apical extrusion of intracanal bacteria following use of
Accepted Article two engine-driven instrumentation techniques. International Endodontic Journal 38, 871-6.

Fairbourn DR, McWalter GM, Montgomery S (1987) The effect of four preparation

techniques on the amount of apically extruded debris. Journal of Endodontics 13, 102-8.

Ferraz CCR, Gomes NV, Gomes BPFA, Zaia AA, Teixeira FB, Souza Filho FJ (2001) Apical

extrusion of debris and irrigants using two hand and three engine driven instrumentation

techniques. International Endodontic Journal 34, 354-8.

Froughreyhani M, Lotfi M, Rahimi S, Shahi S, Milani AS , Mehanfar N (2011) Evaluation of

the amount of apically extruded debris using Mtwo and RaCe systems-An in vitro study.

African Journal of Biotechnology 10, 19637-40.

Fukumoto Y, Kikuchi I, Yoshioka C, Kobayashi C, Suda H (2006) An ex-vivo evaluation of

a new root canal irrigation technique with intracanal aspiration. International Endodontic

Journal 39, 93-9.

Ghivari SB, Kubasad GC, Deshpande P (2012) Comparative evaluation of apical extrusion of

bacteria using hand and rotary systems: An in vitro study. Journal of Conservative Dentistry

15, 32-5.

Gondim E Jr, Setzer FC, Dos Carmo CB, Kim S (2010) Postoperative Pain after the

application of two different irrigation devices in a prospective randomized clinical trial.

Journal of Endodontics 36, 1295-301.

Hachmeister DR, Schindler WG, Walker WA, Thomas DD (2002) The sealing ability and

retention characteristics of mineral trioxide aggregate in a model of apexification. Journal of

Endodontics 28, 386-90.

Hinrichs RE, Walker WA, Schindler WG (1998) A comparison of amounts of apically

extruded debris using handpiece-driven nickeltitanium instruments systems. Journal of

Endodontics 24, 1026.

This article is protected by copyright. All rights reserved.

 Huang X, Ling J, Wei X, Gu L (2007) Quantitative evaluation of debris extruded apically by
Accepted Article using ProTaper Universal Tulsa Rotary System in endodontic retreatment. Journal of

Endodontics 33, 1101-5.

Kum K, Spangberg L, Cha BY, Il-Young J, Seung-Jong L, Chan-Young L (2000) Shaping

ability of three Profile rotary instrumentation techniques in simulated resin root canals.

Journal of Endodontics 26, 716-23.

Kustarci A, Akpnar KE, Sumer Z, Er K, Bek B (2008a) Apical extrusion of intracanal

bacteria following use of various instrumentation techniques. International Endodontic

Journal 41, 106671.

Kustarci A, Akpinar KE, Er K (2008b) Apical extrusion of intracanal debris and irrigant

following use of various instrumentation techniques. Oral Surgery Oral Medicine Oral

Pathology Oral Radiology and Endodontology 105, 257-62.

Kustarci A, Akdemir N, Siso SH, Altunbas D (2008c) Apical Extrusion of Intracanal Debris

Using Two Engine Driven and Step-Back Instrumentation Techniques: An In-Vitro Study.

European Journal of Dentistry 2, 233-9.

Leonardi LE, Atlas DM, Raiden G (2007) Apical extrusion of debris by manual and

mechanical instrumentation. Brazilian Dental Journal 18, 16-9.

Lambrianidis T, Tosounidou E, Tzoanopoulou M (2001) The effect of maintaining apical

patency on periapical extrusion. Journal of Endodontics 27, 696-8.

Logani A, Shah N (2008) Apically extruded debris with three contemporary NiTi

instrumentation systems: An ex vivo comparative study. Indian Journal of Dental Research

19, 182-5.

Madhusudhana K, Mathew VB, Reddy NM (2010) Apical extrusion of debris and irrigants

using hand and three rotary instrumentation systems- An in vitro study. Contemporary

Clinical Dentistry 1, 234-6.

This article is protected by copyright. All rights reserved.

 Martin H, Cunningham WT (1982) The effect of endosonic and hand manipulation on the
Accepted Article amount of root canal material extruded. Oral Surgery Oral Medicine Oral Pathology 53,

611-3.

Martin H, Cunningham WT (1982) An evaluation of post-operative pain incidence following

endosonic and conventional root canal therapy. Oral Surgery Oral Medicine Oral Pathology

54, 74-6.

McGill S, Gulabivala K, Mordan N, Ng YL (2008) The efficacy of dynamic irrigation using a

commercially available system (Rinsendo) determined by removal of a collagen bio-

molecular filmfron an ex vivo model. International Endodontic Journal 41, 602-8.

McKendry DJ (1990) Comparison of balanced forces, endosonic and step-back filing

instrumentation techniques: quantification of extruded apical debris. Journal of Endodontics

16, 24-7.

Mitchell RP, Yang S, Baumgartner JC (2010) Comparison of apical extrusion of NaOCl

using the EndoVac or needle irrigation of root canals. Journal of Endodontics 36, 338-41.

Mitchell RP, Baumgartner JC, Sedgley CM (2011) Apical extrusion of sodium hypochlorite

using different root canal irrigation systems. Journal of Endodontics 37, 1677-81.

Mohammedi Z (2009) In vitro evaluation of apical extrusion of bacteria following use of new

rotary instrumentation system. NewYork State Dental Journal 75, 28-30.

Myers GL, Montgomery S (1991) A comparison of weights of debris extruded apically by

conventional filing and Canal Master techniques. Journal of Endodontics 17, 275-9.

Naidorf IJ (1985) Endodontic flare-ups: Bacteriological and immunological mechanisms.

Journal of Endodontics 11, 462-4.

Ng Y-L, Mann V, Rahbaran S, Lewsey J, Gulabivala K (2008) Outcome of primary root

canal treatment: systematic review of the literature- Part 2. Influence of clinical factors.

International Endodontic Journal 41, 6-31.

This article is protected by copyright. All rights reserved.

 Psimma Z, Boutsioukis C, Vasiliadis L, Kastrinakis E (2012) A new method for real-time
Accepted Article quantification of irrigant extrusion during root canal irigation ex vivo. International

Endodontic Journal. Accepted manuscript online: 8 NOV 2012 02:50AM EST | DOI:

10.1111/iej.12036

Reddy SA, Hicks ML (1998) Apical extrusion of debris using two hand and two rotary

instrumentation techniques. Journal of Endodontics 24, 180-3.

Ricucci D, Siqueira JF Jr (2010) Fate of the tissue in lateral canals and apical ramifications in

response to pathologic conditions and treatment procedures. Journal of Endodontics 36, 1-15.

Ruiz-Hubard EE, Gutmann JL, Wagner MJ (1987) A quantitative assessment of canal debris

forced periapically during root canal instrumentation using two different techniques. Journal

of Endodontics 13, 554-8.

Salzgeber RM, Brilliant JD (1977) An in vivo evaluation of the penetration of an irrigating

solution in root canals. Journal of Endodontics 3, 394-8.

Seltzer S, Soltanoff W, Sinai I (1968) Biologic aspects of endodontics.3. Periapical tissue

reactions to root canal instrumentation. Oral Surgery 26, 534-46.

Seltzer S, Naidorf IJ (1985) Flare-ups in endodontics: etiological factors. Journal of

Endodontics 11, 472-8.

Siqueira Jr. JF (2003) Microbial causes of endodontic flare-ups. International Endodontic

Journal 36, 453-63.

Siqueira JF, Roas IN (2004) Polymerase chain reaction-based analysis of microorganisms

associated with failed endodontic treatment. Oral Surgery Oral Medicine Oral Pathology

Oral Radiology and Endodontology 97, 85-94.

Souza RA (2006) The importance of apical patency and cleaning of the apical foramen on

root canal preparation. Brazilian Dental Journal 17,, 6-9.

This article is protected by copyright. All rights reserved.

 Tanalp J, Kaptan F, Sert S, Kayahan B, Bayirl G (2006) Quantitative evaluation of the
Accepted Article amount of apically extruded debris using 3different rotary instrumentation systems. Oral

Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology 101, 250-7.

Tasdemir T, Er K, Celik D, Aydemir H (2010) An in vitro comparison of apically extruded

debris using three rotary instrumentation systems. Journal of Dental Sciences 5, 121-5.

Tinaz AC, Alacam T, Uzun O, Maden M, Kayaoglu G (2005) The effect of disruption of

apical constriction on periapical extrusion. Journal of Endodontics 31, 533-5.

Torabinejad M, Eby WC, Naidorf IJ (1985) Inflammatory and immunological aspects of the

pathogenesis of human periapical lesions. Journal of Endodontics 11, 479-88.

Torneck CD (1967) Reaction of rat connective tissue to pyethylenetube implants, Part II. Oral

Surgery 24, 674-83.

Van de Visse J, Brilliant JD (1975) Effect of irrigation on the production of extruded material

at the root apex during instrumentation. Journal of Endodontics 1, 243-6.

Wu MK, Dummer PMH, Wesselink PR (2006) Consequences and strategies to deal with

residual post-treatmentroot canal infection. International Endodontic Journal 39, 343-56.

Zarrabi H, Bidar M, Jafarzadeh H (2006) An in vitro comparative study of apically extruded

debris resulting from conventional and three rotary (ProFile, Race, Flexmaster)

instrumentation techniques. Journal of Oral Sciences 48, 85-8.

This article is protected by copyright. All rights reserved.