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Effects of subgingival irrigation on bacteremia following scaling and root planing.

The purpose of this study was to determine the effects of professional subgingival irrigation, together with subsequent patient administered home marginal irrigation, on the incidence of bacteremia after scaling and root planing (Sc/RP). A total of 60 periodontal maintenance patients were assigned to either Group 1: subgingival irrigation, with 0.12% CHX and daily marginal irrigation with 0.04% CHX; Group 2: subgingival irrigation with 0.12% CHX and daily marginal irrigation with water; Group 3: subgingival and daily marginal irrigation with water; Group 4: Non-irrigation (control). Patients entered the study after receiving a thorough periodontal maintenance appointment including a complete examination, Sc/RP, and standard oral hygiene instruction. Blood samples were taken at the 3-month visit before and after Sc/RP. Microbiological culturing was done using the Septi-Chek system, selective and non-selective media. Results from 54 patients showed that bacteremia was detected prior to Sc/RP in 2 patients and after Sc/RP in 10 patients. No significant effect by treatment regimens on post Sc/RP bacteremia could be detected. The organisms isolated included Eubacterium lentum, Propionibacterium acnes, Streptococcus species, Neisseria species, Candida albicans, Staphylococcus species, and un-identified Gram-negative rods.

Adult↗

Irrigation with 0.06% chlorhexidine in naturally occurring gingivitis. II. 6 months microbiological observations.

In an examiner blind positive/negative controlled 6-month study, the efficacy of supragingival irrigation with 0.06% chlorhexidine gluconate on the marginal and subgingival microflora in naturally occurring gingivitis was evaluated. The 222 patients enrolled in the study were assigned to one of four groups: Group 1: Once daily irrigation with 300 ml water followed by irrigation with 200 ml 0.06% chlorhexidine gluconate (experimental); Group 2: Twice daily rinsing with 15 ml 0.12% chlorhexidine (positive control); Group 3: Once daily irrigation with 500 ml water (irrigation control) and Group 4: Sodium fluoride dentifrice for normal oral hygiene only (negative control). All groups received the same sodium fluoride dentifrice for tooth brushing. All patients received a supra- and subgingival oral prophylaxis after baseline examination and at the end of the investigation. Plaque samples were analyzed from 105 patients at baseline, 93 patients at 3 months and 88 patients at 6 months. The 6-months results demonstrated that, when compared with tooth brushing alone, adjunctive supragingival irrigation with 0.06% chlorhexidine gluconate was most effective by significantly reducing (P less than or equal to 0.008) both log10 CFU and % of Gram-negative anaerobic rods and black-pigmented Bacteroides. Chlorhexidine rinse also significantly (P less than or equal to 0.008) reduced log10 CFU of black-pigmented Bacteroides at 6 months. Both chlorhexidine regimens significantly (P less than or equal to 0.008) increased the % of Gram-positive facultative cocci compared to water irrigation at 3 months. Water irrigation had a limited effect on any of the assessed bacterial groups (log10 CFU and %).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone.

BACKGROUND: Recent studies have suggested that high-pressure irrigation may have adverse effects on bone. However, the use of low-pressure irrigation may not remove all adherent bacteria from bone. The type of irrigating solution may be an important factor in the removal of adherent bacteria with pulsatile lavage. In this study, we compared the effects of various irrigating solutions on the number and function of osteoblasts and osteoclasts and we examined the effectiveness of these solutions in removing adherent bacteria from bone. METHODS: To examine the effect of irrigating solutions on the number and activity of osteoblasts, we isolated calvarial cells from newborn C57BI/6 mice and exposed the cells to equivalent concentrations of ethanol, povidoneiodine, liquid soap, antimicrobial wash (50 U/L of bacitracin), or chlorhexidine gluconate, for two, ten, or twenty minutes. The cells were then cultured in the presence of bone-nodule-enhancing medium (beta-glycerophosphate and ascorbic acid) for twenty-one days. The medium was changed every three or four days. Mineralized nodules were stained with alizarin red S, and osteoblasts were stained with a histochemical stain for alkaline phosphatase. Osteoclasts were identified with tartrate-resistant acid-phosphatase staining. In a second experiment, canine cortical tibiae were contaminated with Staphylococcus aureus for six hours and subjected to different irrigating solutions with or without low-pressure lavage. Bacterial colony-forming units were quantitated under each set of conditions. RESULTS: Each solution resulted in a time-dependent decrease in the number of calvarial osteoblasts and osteoclasts compared with that in the controls. The 1% soap solution resulted in greater preservation of both alkaline-phosphatase activity and bone-nodule formation than did the other solutions. Moreover, the soap solution preserved the number of osteoclasts to the greatest extent. The povidone-iodine and chlorhexidine-gluconate solutions resulted in the largest decline in bone-nodule formation, alkaline-phosphatase activity, and number of osteoclasts. Low-pressure pulsatile lavage with the soap solution removed the most bacteria from the contaminated tibia when compared with either the soap solution alone or low-pressure irrigation with saline solution. CONCLUSIONS: Our findings suggest that certain solutions may be more effective in removing bacteria from bone than mechanical irrigation with saline solution alone. Among the various solutions examined, the soap solution preserved the number and activity of osteoblasts the most. Low-pressure lavage with the soap solution resulted in the greatest removal of adherent bacteria from bone.

Animals↗

The role of lipids on sorption characteristics of freshwater- and wastewater-irrigated soils.

The soil lipid fraction can play an important role in the sorption of organic compounds. In this study, the impact of the lipid fraction of freshwater- and wastewater-irrigated soils on the sorption of non- and relatively polar compounds was assessed. Lipid analyses revealed a clear difference between the two lipid fractions. The lipid extract from the wastewater-irrigated soil was consistent with mainly straight paraffinic chain materials; the lipid extract from freshwater-irrigated soil, on the other hand, exhibited stronger signals of aromatics, double bonds, ester, ether, and methyl, in addition to a smaller contribution from methylene protons. Our data suggest that lipid removal induced a stronger increase in the soil's sorption affinity for solutes capable of polar interactions such as atrazine (2-chloro-4-ethylamino-6-isopropylamino-1,3,5-triazine) and chlorotoluron (N'-(3-chloro-4-methylphenyl)-N,N-dimethylurea) as compared to phenanthrene. Moreover, the level of increase in sorption affinities due to lipid removal was much higher for the freshwater-irrigated soil than for its wastewater-irrigated counterpart, even though the level of lipids in the freshwater-irrigated soil was half that in the wastewater-irrigated one (6 vs. 11% of the total organic C). The higher level of polar functionalities, such as ether and ester moieties, in the lipid fraction from the freshwater-irrigated soil suggests that these extractable compounds compete successfully with the polar solutes (atrazine and chlorotoluron) for specific binding sites in the soil organic matter (SOM). It appears that the composition of the lipid fraction may be a key consideration in unraveling the sorption of organic molecules in soils.

Adsorption↗

Influence of various irrigation fluids on serum enzyme patterns following transurethral resection of the prostate.

Serum levels of a variety of enzymes were determined preoperatively and repeatedly postoperatively in a comprehensive biochemical study of 60 patients undergoing transurethral resection of the prostate (TURP). These patients were divided into four groups depending on the type of fluid used for irrigation during TURP. Prostatic acid phosphatase (PAP, analysed by radio-immunoassay) in serum showed a marked postoperative increase but wide inter-individual variation in all groups. It returned to normal within 24 to 48 hours. When water was used for irrigation, similar but less pronounced increases were observed for serum lactate dehydrogenase (LD, LD-1) and aminotransferases (ASAT, ALAT). This is interpreted as being due to an influx of irrigating fluid into the general circulation from the bladder through opened veins, by absorption from a perivesical accumulation or, in the case of PAP, also from the prostatic wound. The enzyme increases (other than PAP) may be due to their release from haemolysed red cells in the bladder or in a perivesical fluid accumulation, which conjecture is supported by the marked increase also seen in plasma haemoglobin. When iso-osmolar fluids were used for irrigation signs of haemodilution, such as a postoperative decrease in serum sodium, were observed. Several of the variables studied may be used as markers to indicate the quantity of irrigating fluid absorbed during resection. Plasma haemoglobin, serum LD (or LD-1) in connection with water irrigation, serum sodium in connection with iso-osmolar fluid irrigation and serum PAP, regardless of the type of irrigating fluid used, are some practical suggestions for such markers.

Acid Phosphatase↗

[A study of incidence of bacteriuria according to bladder irrigation in patients with indwelling catheters].

The Purpose of this study is for clinical nurses to be aware of the significance of prevention against bacteriuria caused form foley catheterization, through probing variables related to the occurrence of bacteriuria which appears as the most frequent occurring infection, and try to lower bacteriuria by applying to nursing care at the clinical. For this study 46 patients with catheterization and the closed drainage system were sampled and investigated from among patients at Intensive Care Unit in Two hospitals affiliated to K University in Seoul. Those patients sampled had not shown bacteriuria before foley catheterization. The research design is to explore the effectiveness of prevention against bacteriuria in accordance with bladder irrigation and no bladder irrigation. Especially, the frequency of occurrence of bacteriuria examined so as to compare the effectiveness of bladder irrigation depending on the type of foley catheter between 2-lumen foley catheter and 3-lumen foley catheter. The results Were as follows. 1. The occurrence of bacteriuria in patient with bladder irrigation was 21.7%, while in patient without bladder irrigation 26.1%. 2. The occurrence of bacteriuria in patient without bladder irrigation according to duration of indwelling catheter, was 4.3% after 48 h, 8.7% after 72 h and 21.7% after 96 h. 3. In case of 2-lumen foley catheter the occurrence of bacteriuria in patient with bladder irrigation was 0% after 72 h, and 4.35% after 96 h. In case of 3-lumen foley catheter, the occurrence of bacteriuria in patient with bladder irrigation was 13% after 48 h, 8.7% after 72 h and 4.3% after 96 h. 4. The occurrence of bacteriuria according to duration of catheterization was 8.7% after 48h, 8.7% after 72 h and 15.2% after 96 h. In sex, female was 35% and male 15.4%. 5. The occurrence of bacteriuria according to mental state was 15% in clear state, while 29.6% in mental disorder. 6. In regard to a kind of microorganism induced bacteriuria, Gram negative bacteria was 63.7%, Gram positive bacteria 36.3%.

Bacteriuria↗

Nondiseased dentinal root surface following citric acid or tetracycline hydrochloride conditioning: a scanning electron microscopic study on the effects of ultrasonic irrigation before and after root conditioning.

The scanning electron microscope was used to evaluate the effects of ultrasonic irrigation before and after root conditioning. Six groups of five specimens each received saline irrigation; ultrasonic irrigation; saline irrigation followed by root conditioning with either citric acid or tetracycline hydrochloride; or ultrasonic irrigation followed by root conditioning with either citric acid or tetracycline hydrochloride. After immersion in citric acid or tetracycline hydrochloride solutions, root dentin was rinsed again with saline or irrigated ultrasonically. Control specimens exhibited an amorphous, irregular surface smear layer. Ultrasonic irrigation, citric acid, and tetracycline hydrochloride were effective in removing the smear layer. Use of ultrasonic irrigation before and after acid application improved the exposure of dentinal fibrils.

Acid Etching, Dental↗

Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study.

BACKGROUND: Capsular contracture remains one of the most commonly reported complications in aesthetic and reconstructive breast patients. Previous in vitro studies from the authors' laboratory have recommended a new triple antibiotic povidone-iodine irrigation (2000) and subsequently a triple antibiotic non-povidone-iodine-containing irrigant (2001) to optimize broad-spectrum coverage of various bacteria implicated in capsular contracture; however, the clinical efficacy of these in vitro studies remains unproven. The purpose of this study was to determine the clinical efficacy for the previously reported triple antibiotic breast irrigation. The cost-effectiveness of universal application of irrigation solutions in breast prosthesis surgery was analyzed as well. METHODS: Patients undergoing aesthetic and reconstructive breast implant procedures were treated with a standardized operative technique, including the use of triple antibiotic breast irrigation by a single surgeon. Capsular contracture was assessed using a simplified Baker scale and graded by two independent caregivers to maximize objectivity and consistency. Additional complications were also recorded, including reoperation. Patient charges for antibiotic irrigation and reoperation for contracture were determined and compared. RESULTS: A total of 335 patients operated on since 1997 were evaluated prospectively. They ranged in age from 18 to 86 years, and the mean follow-up was 14 months (range, 6 to 75 months). The rate of grade III/IV capsular contracture in the study groups was 1.8 percent for patients undergoing primary breast augmentation. Patients undergoing augmentation-mastopexy had a grade III/IV contracture rate of 0 percent. Breast reconstruction patients had a 9.5 percent rate of grade III/IV contracture. CONCLUSIONS: Triple antibiotic breast irrigation is clinically associated with a low incidence of capsular contracture compared with other published reports, and its clinical efficacy supports previously published in vitro studies. Application of triple antibiotic irrigation is recommended for all aesthetic and reconstructive breast procedures and is cost effective.

Adolescent↗

Subgingival irrigation--an adjunct to periodontal therapy. Current status and future directions.

Science, in the search for truth, is dynamic and constantly changing. Periodically, an innovative idea such as subgingival irrigation emerges, which needs to be tested and retested. If the results are statistically and clinically meaningful, it then can be incorporated into treatment and maintenance regimes. This article addresses advantages and limitations of subgingival irrigation as it pertains to the treatment of patients with periodontitis. The subject is controversial, because while the role of supragingival irrigation is being recognized in the treatment of gingivitis, the status of subgingival irrigation in periodontitis therapy still needs further clarification. Four major themes are addressed within this text: (1) to explore the biologic rationale for subgingival irrigation, since treatment decisions must be based upon scientific data and not upon empiricisms; (2) to place in perspective the ability of subgingival irrigation (which also will be referred to as irrigation or lavage) to enhance periodontal health by assessing data from controlled studies; (3) to encourage use of subgingival irrigation as an adjunct to conventional therapy, in certain situations; and (4) to discourage bad execution of a good idea, because if limitations of lavage are not recognized, therapists may engage in ineffective treatment.

Chlorhexidine↗

[The management of bleeding following transurethral prostatic resection by local irrigation with a thrombin solution].

The clinical value of local irrigation of thrombin was studied in 30 patients with urethral bleeding following transurethral prostatic resection. A thrombin solution consisting of 25,000 units of thrombin in 500 ml of saline was irrigated in 20 patients through the especially designed three-way balloon catheter at a speed of 8.3 ml/min for five hours after the operation while sterile saline was irrigated in the same manner in 10 patients as a control. The hemostatic effect of thrombin solution was evaluated as excellent in 2 patients (10%), good in 5 (25%), moderate in 6 (30%), and poor in 2 (10%) with 5 drop outs (25%) in the thrombin irrigating group. In the control group, the effect of irrigation was evaluated as good in 1 patient (10%), moderate in 4 (40%), poor in 2 (20%), and unable to be estimated in 2 (20%) with 1 drop out (10%). Therefore the rate of overall effectiveness was 65% in the thrombin irrigating group and 50% in the control group and volume of postoperative blood loss was 0.58 ml/g X hour and 0.62 ml/g X hour, respectively. Though almost all of the patients in both groups showed a moderate elevation of fibrinogen in serum, there was no adverse effect considered to be caused by thrombin irrigation. The local irrigation of the thrombin solution is a useful method and safe in the management of bleeding following transurethral prostatic resection.

Aged↗

[The local cooling effect of anterior chamber irrigation on the blood-aqueous barrier].

Local cooling effect on the breakdown of the blood-aqueous barrier (BAB) following anterior chamber irrigation, including additional direct irritation of the iris, was evaluated fluorophotometrically. The rabbit anterior chamber was irrigated with simulated aqueous humor (S-MA 2) the temperature of which was maintained at 35 degrees C or 10 degrees C. The fluorophotometry was performed before and 4, 24, 48 hours and 7 days after irrigation for 30 or 60 minutes. The temperature changes in the anterior chamber, retrolental vitreous body and posterior retina were also measured with a thermocouple during irrigation at 10 degrees C. The temperature of the anterior chamber and the retrolental vitreous fell to 15.0 degrees C and 28.2 degrees C, respectively, within 30 minutes after starting irrigation, whereas the temperature drop in the posterior retina was only 2.0 degrees C after 60 min. At 4 hours after 60-minute irrigation, the breakdown of the BAB was greater than following 30-minute irrigation. There was no significant difference in the BAB breakdown between eyes irrigated at 10 degrees C and 35 degrees C.

Animals↗

Intra-operative saline irrigation of the peritoneal cavity in experimental post-traumatic peritonitis.

A trial of intra-operative saline irrigation of the peritoneal cavity for the prevention of peritonitis was conducted in an animal model. Following abdominal missile injury with intestinal perforation, 43 anaesthetized pigs were operated on an randomly assigned to three treatment groups. In two of the groups intraperitoneal irrigation with 3 litres of saline solution was performed during the operation, using a jet technique in one group. A control group of pigs received no irrigation. The effect of irrigation was evaluated with quantitative bacteriologic studies of peritoneal exudate and peritoneal biopsy specimens. Continuous anaesthesia and assisted ventilation were used and the post-trauma observation period was 3 days. The average bacterial density in the peritoneal exudate decreased by more than 99% in all treatment groups during the operation, but increased to more than the pre-irrigation level during the observation period. Irrigation did not result in significantly greater elimination of the bacterial population. The mortality was not lower in irrigated animals than in the controls. Intra-operative saline irrigation thus did not prevent peritonitis in this experimental model.

Animals↗

Subgingival irrigation instruction and utilization in dental hygiene curricula.

PURPOSE: The purpose of this study was to assess subgingival irrigation instruction in accredited dental hygiene programs in the United States; specifically, the number of programs providing instruction; teaching methods used; delivery systems taught didactically and/or clinically; the amount of student clinical experience provided; clinical patient selection criteria; and specific irrigation solutions used. METHODS: A 17-item questionnaire was mailed in January 1989 to 197 accredited dental hygiene programs. Frequency distributions were used to describe the data. RESULTS: A response rate of 85% (N = 167) was obtained after two mailings. One hundred twenty-four dental hygiene programs (74%) provide subgingival irrigation information in their curriculum. Data revealed that although student experiences with subgingival irrigation delivery agents and systems vary greatly, a majority of schools teach the utilization of chlorhexidine delivered via motorized irrigation systems. Students who provide subgingival irrigation usually do so in selected areas for specific patients. CONCLUSIONS: Results from the survey indicate that a majority of dental hygiene programs provide some form of subgingival irrigation instruction, although educational content, experience, and placement of instruction within the two-year curricula varied. Based on these findings, dental hygiene educators may elect to develop standards for teaching subgingival irrigation in their programs.

Curriculum↗

A chairside microbiological evaluation using the BANA test after a single subgingival irrigation with 1.64% SnF2 solution combined with subgingival scaling.

In this study, the adjunctive effects of subgingival irrigation by 1.64% stannous fluoride after subgingival scaling were evaluated in 10 patients with moderate periodontal disease. Three pockets related to single rooted teeth, each in a separate quadrant were monitored in each patient. After proper subgingival scaling, one pocket was irrigated by 1.64 SnF2, the other pocket by saline and the third pocket was left without irrigation. Subgingival plaque samples were evaluated by BANA test and clinical indices were taken at baseline, immediately after subgingival scaling with and without adjunctive subgingival irrigation using SnF2 and saline, and one week after treatment. The results were compared at the different time intervals and it was found that 1.64% SnF2 irrigation after subgingival scaling gave the best clinical indices and least microbiological values using the BANA test throughout the study, followed by subgingival scaling together with saline irrigation, which were better than subgingival scaling without irrigation only right after irrigation, and was insignificantly different from scaling after one week.

Adult↗

A literature review: oral irrigation therapy. The adjunctive roles for home and professional use.

It is now recognized that there are several different types of periodontal infections. As we learn more about the cause of these diseases, it becomes obvious that we have treatment options. A successful choice of procedures for each individual depends on an accurate diagnosis based on comprehensive data collection of clinical and microbiological findings. Treatment choices include a non-surgical phase which consists of plaque removal, plaque control, scaling, root planing, and the use of chemical agents. For complete debridement of deep pockets, furcations or areas with root surface irregularities, surgical access may be necessary. When considering drug therapy, it must be noted that systemic antibiotics may be necessary to suppress those subgingival periodontal pathogens which have the ability to invade the tissue and resist other methods of eradication. Removal or alteration of pathogenic flora is mandatory to improve a patient's periodontal health. The extensive use of supragingival irrigation as an adjunct for treating gingivitis has led to the interest in subgingival irrigation as a possible adjunct for treatment of periodontal diseases. Targeted lavage and subgingival delivery of effective antimicrobial agents show potential as supplemental office procedures or as a component of a home oral hygiene regime. Additional research is needed to develop more efficacious chemotherapeutic substances than are currently available and to further define the optimum application of each. Substantive medicaments that react specifically against periodontopathic organisms are essential. Exact frequency and duration of professionally-applied and self-administered subgingival irrigation need to be determined for maximum results. Further investigation is required to establish the potential role of adjunctive irrigation and antimicrobial therapy in the treatment of periodontitis. Yet, another important application of irrigation has been recognized. Recently, the American Heart Association revised its guidelines for the prevention of bacterial endocarditis. The amendments to the dentistry sections have been approved by the Council on Dental Therapeutics of the American Dental Association. Included in this text is the recommendation that as an adjunct to antibiotic prophylaxis, sulcular irrigation with chlorhexidine may be useful for those patients considered high risk and/or have poor oral hygiene. Irrigation therapy is undergoing extensive scrutiny in the scientific research community. Presently, considerable conclusive evidence exists to suggest that adjunctive irrigation may play an important role in controlling gingivitis and periodontitis. The overwhelming challenge for any and all successful periodontal therapy will always remain dependent on patient compliance to regular professional and home care.

Anti-Bacterial Agents↗

Effects of subgingival chlorhexidine irrigation on peri-implant maintenance.

PURPOSE: To evaluate the effect of irrigation with 0.06% chlorhexidine (PerioGard) (CHX) using a powered oral irrigator (Water Pik) with a special subgingival irrigating tip (Pik Pocket Subgingival Tip) compared to rinsing with 0.12% chlorhexidine gluconate once daily. MATERIALS AND METHODS: Following a prophylaxis, patients were randomly assigned to an irrigation or a rinse group. The following clinical parameters were measured at baseline and at the 3-month end of the study: Modified Gingival Index (MGI), Plaque Index (PI), Bleeding Index (BI), and Calculus Index (CI). Also, a Stain Index (SI) was measured at 3 months. RESULTS: Patients irrigating with diluted CHX showed a statistically significant reduction (P < 0.05) from their baseline in the MGI, PI, BI, and CI scores at 3 months. In the rinse group both MGI and BI showed statistically significant reduction from their baseline (P < 0.05) at 3 months. The rinse group showed a nonsignificant (P > 0.05) increase from baseline in CI and a nonsignificant decrease in PI. Intergroup comparisons showed that CHX irrigation produced statistically significantly greater reductions than CHX rinsing in the PI, MGI, and SI. The irrigation group also showed a greater reduction in BI and CI than the rinsing group but these differences were not statistically significant (P = 0.12). The results of this study suggest that use of diluted 0.06% CHX when used in a powered irrigator may be a valuable adjunct to oral health in patients with implants.

Adult↗

[Evaluation of blood loss and absorption of irrigating fluid in transurethral resection of the prostate].

A questionnaire was sent to all Danish departments performing transurethral resection of the prostate (TUR-P) concerning the use of irrigating fluids and methods to estimate peroperative blood loss and absorption of irrigating fluid. Fifty-six of 60 departments used glycine as an irrigant. Seventeen percent of the departments measured blood loss peroperatively (HemoCue). Only two departments (3%) measured absorption of irrigating fluid quantitatively by the expired breath ethanol method. The other departments estimated blood loss and absorption of irrigant from the colour of the irrigating fluid. From studies of the literature we suggest the use of sorbitol/mannitol as irrigating fluid instead of glycine, as this may have fewer adverse effects, and we recommend quantitative measurements of blood loss and absorption of irrigating fluid to minimise the potentially dangerous consequences of TUR-P.

Blood Loss, Surgical↗

[The effect of root canal irrigation and variance of apical foramen pressure by use of casing aspiration needle system in vitro].

The authors introduced casing aspiration needle system (CANS) to irrigating root canal. The effect of root irrigation on removing canal debris and the variance of apical foramen pressure on extracted teeth were compared between the conventional irrigation and CANS irrigation. The results indicated that the effect of root canal irrigation by CANS was much better than the conventional method (P < 0.01). CANS irrigation didn't produce pressure to apical foramen during root canal irrigation. However, in the conventional method, with irrigation needle inserted deeper and deeper in root cancal the pressure of apical foramen gets higher and higher.

Humans↗