Manual Dynamic Activation (MDA)

Technique
8
Pierre Machtou

Abstract
Highest canal disinfection has to be achieved in endodontics in order to
expect a predictable successful outcome. So far, following chemomechan-
ical preparation, passive irrigation followed by some type of activation
technique has proved to be effective to reduce bacteria counts. Data on the
efficiency of current activation systems are inconclusive. Therefore, until
a new activation protocol has proven to be the best and although MDA
may be perceived by some clinicians as laborious, it is a fast, cost-effective,
safe, and convenient method to perform irrigant agitation at the end of the
shaping procedure.

Static Versus Dynamic Irrigation at best the threshold of the bacterial load to allow
the host defenses to repair [33]. When it comes to
The aim of endodontic treatment is to prevent or select an endodontic irrigant, so far, nothing is as
treat apical periodontitis which is the result of a efficient as sodium hypochlorite (NaOCl) [42]. In
bacterial infection of the root canal system. It has a recent survey among AAE members, more than
been shown that using an antiseptic irrigant dur- 90 % of them use it as the primary irrigant [15].
ing chemo-mechanical preparation plays a major To be effective, NaOCl must be used in large
role to help eradicate intracanal bacteria [7]. amounts [37], be in contact with the tissues [38],
Nevertheless, despite long efforts to develop new be mechanically agitated [26], and be exchanged
irrigation devices and solutions and new instru- [2]. Furthermore, NaOCl has to penetrate the full
mentation techniques, complete sterilization of extent of the root canal space since the bacteria
the root canal systems is currently impossible to involved in the development and continuation of
achieve. Therefore, the clinical goal is to reduce apical periodontitis are located in the last apical
2 ml [25, 27]. But, according to experimental
available data, the apical third appears to be the
most difficult area to clean [32], implying that
P. Machtou, DDS, MS, PhD irrigant penetration and exchange with the
Endodontie, UFR d’Odontologie Paris 7-Denis syringe are not easy to occur in this area. It is
Diderot, Paris Ile de France, France obvious that a better knowledge of the behavior
e-mail: Prpierre.machtou@gmail.com

© Springer International Publishing Switzerland 2015 149

B. Basrani (ed.), Endodontic Irrigation: Chemical Disinfection of the Root Canal System,
DOI 10.1007/978-3-319-16456-4_8
150 P. Machtou

of root canal irrigation is needed and all current before irrigating the canal for the first time, a column
research tends toward this goal. However, Yana of air (or gas bubbles) is entrapped in the apical
[41] in an in vivo study was the first to distinguish part of the canal and restricts or blocks irrigant
the two different modalities of the irrigation pro- penetration [11, 28, 31, 36, 39]. Surprisingly, this
cess: static (or passive) irrigation and dynamic phenomenon has first been mentioned by Luks in
(or active) irrigation. At this stage, a clear defini- 1974 [22] and precisely described by Machtou
tion of both terms is required: [23] (Fig. 8.1a–d) who recommended, for rele-
vance of in vitro studies, that the tip of the root
• Static (the term “passive” is inappropriate must be closed with soft modeling wax prior to
because it implies the result of an action) irri- any investigation (Fig. 8.2). This vapor lock phe-
gation occurs when the solution is delivered nomenon can be described as the difficulty of dis-
with the syringe and depends on the depth of persion and mixing of irrigant in a confined
penetration of the irrigating needle. geometry [19].
• Dynamic irrigation includes two parts: Removal of an apical vapor lock may be chal-
– The penetration depth of the irrigant during lenging so additional techniques like activation
the use of any type of instrument which is a or the use of apical negative pressure (ANP) are
function of the size of the instrument and considered useful adjuncts to overcome the prob-
the motion applied to the instrument lem [18, 31]. However, a recent study by
– The exchange of irrigant which is a func- Boutsioukis et al. [5] has shown that the vapor
tion of the taper and the size of the canal, lock does not exist in all situations and the inser-
both parameters being related with the tion of a fine needle close to the working length is
depth of penetration of the endodontic able to prevent or remove it. This result was
needle expected as shown in an earlier study using digi-
tal subtraction to assess irrigant penetration and
renewal during the final irrigation regimen [6]. In
this study, the needle tip insertion depth was the
The Vapor Lock Effect main factor affecting irrigant penetration fol-
lowed by apical taper, needle tip design, and vol-
The root canal is similar to a closed system, and ume of the irrigant. As a result, it is possible to
in such a situation, a so-called vapor lock effect admit that total irrigation of the root canal is
has been recently described when the irrigating clinically feasible at the end of the shaping proce-
solution is delivered with the syringe. In fact, dure with static irrigation either with the syringe

a b c d

Fig. 8.1 (a–d) Vapor lock phenomenon: penetration of the needle and extent of penetration of irrigant (Hypaque) in a
closed system (1980)
8 Manual Dynamic Activation (MDA) Technique 151

devices have been extensively tested and com-

pared, but it is currently impossible to interpret
their results and draw reliable conclusions from
the literature. Indeed, results are inconclusive
because of different models, mainly plastic and
extracted teeth; different evaluation methodolo-
gies; different tapers; different apical sizes; and
different volumes and time. But, whatever the
activation technique, it must be remembered that
agitation is a critical factor to help distribute and
exchange the solution within the canal space and
enhance antiseptic and solvent effectiveness.
Hence, a general agreement exists about the ben-
efit of using irrigant activation at the end of the
canal preparation which appears to improve canal
cleaning and disinfection in comparison with
syringe delivery [6].
Manual dynamic irrigation can be performed
with hand files [14], brushes [18], or a well-fitting
tapered gutta-percha point. It must be realized
that MDA starts early during canal preparation
when the first scouting hand file is placed inside
the canal. It is the apical progression of the instru-
ment that moves irrigant beyond the tip, and once
the working length has been reached, the vertical
Fig. 8.2 Tooth model with closed apex using soft model- reciprocating movement used allows the solution
ing wax (1980) to involve the entire canal space (Fig. 8.3a–c).
But, obviously, at this stage of the procedure, the
and a fine needle [6, 23, 41] or ANP. But addi- amount of irrigant is small. During canal shap-
tional agitation of the solution is needed if the ing, a repeated use of a patency file after each
final goal is to distribute and exchange irrigants active shaping instrument helps break up the gas
into the intricacies of the apical anatomy. bubbles and moves fresh irrigant into the apical
last millimeters [39] mixing it with the stagnant
solution of the “dead zone” [6, 16]. The fre-
Manual Dynamic Activation quency of replenishment of the coronal irrigant
Technique with the syringe along with the progressive shap-
ing of the root canal and the repeated use of
For better cleaning, disinfection, and elimination patency files are factors that allow the delivery of
of biofilm, several activation techniques and irrigant further and further apically.
devices are available including manual dynamic In 1980, following a series of investigations
activation (MDA), intermittent passive ultrasonic on endodontic irrigation, it made sense for the
irrigation (IPUI), continuous ultrasonic irrigation author to propose the systematic use of a well-
(CUI), passive ultrasonic irrigation (PUI), sonic fitting tapered master cone at the end of the shap-
irrigation (EndoActivator, Vibringe), hydrody- ing procedure to agitate the irrigating solution
namic activation (RinsEndo), plastic finishing and enable it to involve the entire length of the
file (PFF), self-adjusting file (SAF), photoacti- root canal [23]. MDA is a simple yet cost-
vated disinfection (PAD), and laser activation effective way to help the irrigant to get in contact
(Er: YAG, PIPS). All these techniques and with the canal walls, reach the apical portion of
152 P. Machtou

a b c

Fig. 8.3 (a) Preoperative X-ray. (b) Working length determination with K ≠ 15 file. (c) Dynamic irrigation after ≠1#5
file use (irrigant used: Hypaque) (Courtesy of Dr Y. Yana)

the canal, and dislodge the vapor lock effect. It when using MDA but not ANP. The same group
generates higher intracanal pressure changes dur- [35] compared canal and isthmus debris debride-
ing the in-and-out movement of the GP cone, and ment efficacies of MDA and ANP in mesial root
the frequency of the strokes creates turbulences of the mandibular first molars with narrow isthmi
and enhances diffusion by shear stresses. The and closed apices. It was shown that both tech-
presence of a thin reflux space between the cone niques did not completely remove debris from
and the canal walls is critical to allow the irrigant the isthmus region although ANP removed more
to flow back along the cone and induce an effec- debris. For the authors, the good debridement
tive hydrodynamic effect (Fig. 8.4). Finally, efficiency of ANP was the result of wall shear
MDA facilitates the mixing of fresh solution with stresses [17]. In contrast, Jiang et al. [21] who
the stagnant solution in the apical millimeters [6]. compared MDA with tapered and non tapered
The efficiency of the technique was confirmed gutta-percha cones, the Safety irrigator,
by several studies. Huang et al. [20] who used a Continuous Ultrasonic Irrigation (CUI) and ANP
dyed collagen biofilm model showed that manual found, CUI being the most effective technique in
agitation of the master cone was significantly this study. Moreover, the authors [21] empha-
more effective in removal of stained collagen sized the importance of the reflux space between
from canal surfaces than static irrigation. Using a well-matching GP cone and the canal walls, a
the same model McGill et al. [24] found that the factor described in detail by Machtou [23] and
hydrodynamic device RinsEndo® was signifi- Bronnec et al. [6]. In a recent SEM study, the use
cantly less effective than MDA although another of MDA in a well-shaped canal with sufficient
study using scanning electron microscopy (SEM) apical taper produced very cleaned apical regions
could not find a difference between the two meth- and the absence of smear layer in severely curved
ods in the removal of debris from the root canal canals of mandibular molars [9]. Good results of
walls [40]. One group conducted a series of stud- MDA on smear layer removal were confirmed by
ies to compare ANP (EndoVac) and MDA. In the Saber Sel and Hashem [30] and Andrabi et al. [1].
first experiment, canal debridement efficiency In 2013, Capar and Aydinbelgehave [8] had
was tested for both techniques in a closed and an shown that final irrigation activation protocols
open system [28]. Results showed that a sealed including MDA did not alter the mineral level of
apical foramen adversely affected debridement root dentine surface.
8 Manual Dynamic Activation (MDA) Technique 153

MDA Mode of Use

• A well-matching GP master cone whose taper

is slightly less than the taper of the canal is
selected. A snug fit is sought after at the work-
ing length.
• Then 1 ml is trimmed at the tip of the cone in
order to get tug-back 1 ml shorter than the
canal terminus.
• After suction of the primary irrigant NaOCL,
the canal is filled with 1 ml of EDTA delivered
with a 30 gauge NiTi needle (either Navy tip
from Ultradent or Stropko NiTi Flexi-Tips
from SybronEndo or CanalPro Flex-Tips from
Coltene/Whaledent).
• Manual agitation of the master cone is started
with an up and down motion and a 2 mm
amplitude at a frequency of 100 strokes during
approximately 1 min (Fig. 8.5a–b). After that,
1 ml of EDTA is delivered with the irrigating
needle to flush out debris. EDTA is then suc-
tioned to eliminate any residual chelating
action.
• The canal is flushed with 1 ml of NaOCl, and
1 mm the same protocol is repeated using 50 in and
out strokes during 30 s. A final flush is per-
formed with 3 ml of NaOCl.

This protocol has proven very effective in

removing the smear layer and producing very
Fig. 8.4 GP cone agitation, reflux space, and disruption
of vapor lock cleaned canals in the apical area [9].
Following the same agitation protocol, QMix
(Dentsply), a chlorhexidine-based solution with a
Some other studies can be found where MDA weak chelator and surfactant, may alternatively
and different activation systems are compared replace both EDTA and NaOCl for final irriga-
[12, 29], but, as stated earlier, their results must tion of the root canal system [10, 34]. A 1 min
be interpreted with caution. agitation protocol is recommended, but further
The main concern during irrigant activation is scientific data is needed to support and validate
the risk of apical extrusion. According to avail- the product efficiency.
able data [3, 4, 13], all tested devices included
MDA appear to extrude some irrigant except ANP Conclusion
which is the safest (but ANP should be seen more Highest canal disinfection has to be achieved
as a delivery device rather than an activation sys- in endodontics in order to expect a predictable
tem). However, it is noteworthy to notice that in a successful outcome. So far, passive irrigation
clinical situation, the resistance of the periapical followed by some types of activation tech-
tissues plays a role in limiting the occurrence of nique has proved to be effective to reduce
extrusion. Irrigant extrusion can be prevented intracanal bacteria counts. Therefore, until a
with an accurate use of the MDA technique. new activation protocol has proven to be the
154 P. Machtou

Fig. 8.5 (a, b) Clinical MDA

technique: agitation of the GP
a b
cone with a 2 mm amplitude

best and although MDA may be perceived by protocols on smear layer removal in curved canals.
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11. de Gregorio C, Estevez R, Cisneros R, Heilborn C,
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