REVIEW ARTICLE

Anastasios Retsas, Christos Boutsioukis

An update on ultrasonic irrigant activation

KEY WORDS
acoustic streaming, cavitation, irrigation, ultrasonic activation

ABSTRACT
Ultrasonic irrigant activation is the most widely used supplementary irrigation method. It relies on
the oscillation of an instrument at ultrasonic frequency while surrounded by irrigant, which results
in heating of the irrigant, intense streaming and, under certain conditions, cavitation. A variety of
ultrasonic files, tips, wires and needles have been used for this purpose. The efficacy of ultrasonic
activation depends on the size of the instrument, the power setting and the direction of oscil-
lation. Sodium hypochlorite, ethylenediaminetetraacetic acid (EDTA) and chlorhexidine are the
most commonly activated irrigants and they can be delivered either simultaneously or between
activation periods. This method appears very effective in the removal of pulp tissue remnants
and hard tissue debris from the root canal. However, there is conflicting information regarding its
antimicrobial effect and there seems to be no improvement in the treatment success rate, at least
in single-rooted teeth. Instrument-to-wall contact appears inevitable under clinical conditions and
may result in oscillation dampening and removal of small amounts of dentine. Ultrasonic instru-
ments may fracture during use because of fatigue. Irrigant extrusion through the apical foramen
is very limited except when the irrigant is continuously delivered and activated by an ultrasonic
needle. Electromagnetic interference with pacemakers is unlikely to occur. Important knowledge
gaps still exist, so ultrasonic activation is a topic of interest for future studies.

Introduction disinfection of those areas, a variety of irrigant

agitation or activation methods have been pro-
Irrigation of the root canal system with antimi- posed, the most widely used one being ultrasonic
crobial solutions is one of the most essential steps activation6,7,11.
during root canal treatment1,2. Its effect is based Despite its wide use, only a few reviews have
on the chemical ability of irrigants to kill micro- tried to summarise the available evidence. An
organisms, disrupt biofilm and dissolve tissue extensive overview was published in 200711 but
remnants when they come in close contact with a large number of new studies have come to light
them, and on the mechanical flushing created by since then. More recent reviews included only a
the flow3-5. Syringe irrigation remains the most small number of studies without any appraisal12
popular way to deliver the irrigant6,7 but it is only or limited their interest to very specific outcomes
effective in the main root canal8. The flow is rela- and types of studies13-15, as required in systematic
tively weak8 and thus unable to penetrate into reviews. The aim of this narrative review was to
remote areas and anatomical irregularities8-10, as address the topic broadly, and summarise and criti-
explained in more detail elsewhere in this spe- cally appraise the current evidence on ultrasonic
cial issue. In order to improve the cleaning and irrigant activation.

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Retsas/Boutsioukis Ultrasonic irrigant activation

Fig 1a to c
(a) Ultrasound
device with an
attached Irrisafe file
(Acteon Satelec,
Merignac, France).
(b) File positioned
inside the root
canal. (c) Activa-
tion of sodium
hypochlorite.

a b c

Nomenclature An additional topic of ongoing debate is

whether this technique should be called ‘activa-
Although ultrasonics was introduced in endo- tion’ or simply ‘agitation’. ‘Agitation’ is a broader
dontics in 195716, its use for irrigant activation term and refers to stirring of the irrigant in order to
independent of instrumentation was proposed create a flow, and transport the irrigant to various
much later, in 198017. The goal was to enhance areas inside the root canal. Several irrigation meth-
the antimicrobial activity of irrigants but this early ods, including ultrasonics, are able to agitate the ir-
protocol advocated intentional file-to-wall contact rigant, albeit to varying degrees. ‘Activation’ of the
through lateral pressure and circular movements irrigant, on the other hand, implies an enhance-
in order to maximise the effect17. Subsequent ment of the chemical activity beyond what can be
studies revealed that wall contact dampened the achieved by optimising the concentration gradient
oscillation and actually limited the effect of ultra- near reaction sites and it is arguably much harder
sonic activation18-20, so the protocol was gradu- to achieve. Such enhancement could take place
ally modified to discourage wall contact. The term around ultrasonic instruments under certain condi-
‘passive activation’ seems to have appeared in the tions due to sonochemical effects26-28 (see below),
literature in 199921 and was used to distinguish thereby justifying to some extent the term ‘ultra-
this method from earlier ‘active’ ultrasonic instru- sonic activation’.
mentation techniques; no intentional instrumenta-
tion or planing should take place and wall contact
should be avoided instead of sought. Despite the Mechanisms of action
obvious contradiction between ‘passive’ and ‘ac-
tivation’, these terms survived for a long time and Ultrasonic activation relies on the oscillation of
the technique became widely known as ‘passive an instrument inside an irrigant-filled root canal
ultrasonic irrigation’ or PUI11. During this time the (Fig 1)11,29. The instrument is driven at one end by
theory of ‘passive activation’ was repeatedly chal- an ultrasonic handpiece at a frequency of approxi-
lenged as new information became available about mately 25 to 32 kHz29. In order to maximise effi-
file-to-wall contact and inadvertent removal of ciency and energy transfer the instrument must be
dentine10,22-25. Eventually, it was suggested that driven at resonance mode, so a different driving fre-
the term ‘passive’ should be abandoned and the quency is required for each ultrasonic instrument29.
technique should be named ‘ultrasonic irrigant ac- Modern ultrasound devices are able to probe the
tivation’ or UIA, in order to reflect the most recent attached instrument and determine the optimum
experimental evidence23, but so far the adoption driving frequency within a predetermined range
of this new terminology has been rather slow. through a feedback system which operates briefly

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 Retsas/Boutsioukis Ultrasonic irrigant activation

at the start-up of the oscillation29. An adequate Fig 2 Ultrasonic

instruments oscillate
mechanical coupling between the handpiece and primarily along
the instrument is also important for efficient en- the direction of
the handpiece (red
ergy transfer, otherwise energy may be dissipated arrows). A much
in unwanted vibrations30; damaged or defective smaller oscillation
takes place in a per-
instrument holders can cause such problems31. pendicular direction
Driving results in a transverse oscillation mainly (blue arrows).
along the direction of the handpiece; a much
smaller oscillation takes place in a direction per-
pendicular to the first one (Fig 2)29,30. Several
nodes (areas with zero oscillation amplitude) and
antinodes (areas with maximum oscillation ampli-
tude) appear along the instrument29,30, with the
largest oscillation amplitude always at its the free
end18,29,32. It is interesting that tapered instru- oscillation of the instrument, the geometry of the
ments, like ultrasonic K-files, show a gradual root canal and the physical properties of the irri-
decrease in the antinode amplitude from the free gant35. This flow is actually the superimposition of
end towards the handpiece, while non-tapered two components:
instruments, like Irrisafe files (Acteon Satelec, Mer- • The oscillatory component, which follows the
ignac, France), have almost equal amplitude at all direction of motion of the instrument.
antinodes29,30. The oscillation pattern may be dif- • The steady component, which is the result of
ferent during start-up due to the operation of the complicated interactions within the irrigant
feedback system29. Pre-bending of the instrument, very close to the instrument (boundary lay-
which is often done during clinical use, may also ers). The steady component forms two steady
affect the oscillation29. jets of irrigant continuously flowing away from
Instrument oscillation, in turn, drives the sur- the instrument along the direction of oscil-
rounding irrigant and induces a complicated lation irrespective of the direction of the file
three-dimensional flow inside the root canal33-35. motion (Fig 3)35. This component is also named
The flow pattern depends on the geometry and ‘acoustic streaming’36.

Jet Jet

Outer Inner
boundary boundary
layer layer

Entrainment
a b c

Fig 3a to c (a) Acoustic streaming around an ultrasonic file oscillating in a large water tank. Reprinted from van der Sluis
et al11 © 2007 International Endodontic Journal, with permission from John Wiley and Sons. (b) Schematic drawing of the
streaming along the file. Reprinted with permission from van der Sluis et al11 © 2007 International Endodontic Journal, with
permission from John Wiley and Sons. (c) Cross-section of the double boundary layer and the steady jets (red arrows) gener-
ated by an ultrasonically oscillating wire (grey circle) according to theory. The grey double arrow indicates the main oscillation
direction. Reprinted and modified with permission from Verhaagen et al35 , © 2014, Acoustic Society of America35.

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2 μs 6 μs 10 μs 14 μs 18 μs

Fig 4 Transient cavitation bubbles in the wake of an Irrisafe file (Acteon Satelec, Merignac, France) oscillating inside a large
water tank as captured by a high-speed camera. Courtesy of Dr Bram Verhaagen and Prof Luc van der Sluis.

Early studies on ultrasonic activation18,37,38 only length scale is much smaller than the radius of
considered the steady component of the flow curvature in most root canals43.
(acoustic streaming) even though both compo- The rapid motion of an ultrasonic instrument
nents coexist and may contribute to the cleaning and the resulting pressure changes in the irrigant
and disinfection of the root canal. The oscillatory may also give rise to acoustic cavitation27,28, which
component is stronger and dominates the flow is the formation, behaviour and collapse of bubbles
close to the instrument, so it may lead to intense under an applied oscillating pressure44. When the
agitation of the irrigant and more effective mech- amplitude of the oscillating pressure is small, bub-
anical cleaning in that area due to the high shear bles remain almost stable for relatively long periods
stress developed, but it diminishes rapidly with of time and their wall vibrates in response to the
distance. Even though the steady component is pressure changes in the surrounding irrigant with-
weaker near the instrument, it diminishes at a much out collapsing. This ‘stable cavitation’ may enhance
lower rate, so it becomes dominant farther away local streaming44 but bubbles can also impede the
from the instrument35. This component may be streaming28,35 and even create a ‘vapor lock’ in
responsible for irrigant transport into remote loca- certain parts of the root canal system45, thereby
tions of the root canal system28,35. It is noteworthy hindering cleaning and disinfection.
that an oscillatory flow can be created under vari- Under more extreme pressure changes, bub-
ous conditions even by an instrument oscillating at bles can grow and collapse rapidly (transient or
much lower frequency (sonic agitation) but acous- inertial cavitation) (Fig 4), thereby emitting power-
tic streaming is only created if the instrument oscil- ful shockwaves44. Bubble collapse near a wall also
lates at a small amplitude compared to its diameter leads to the formation of a high-velocity irrigant jet
and at sufficiently high frequency; these require- that is directed towards the wall44 and can further
ments are met during ultrasonic activation but not enhance surface cleaning due to the high shear
during sonic agitation35. stress applied to the wall46. In addition, during
The flow created around ultrasonic instruments the collapse the pressure and temperature inside
seems to improve irrigant exchange and increase the bubble also increase rapidly by several orders
the reaction rate of sodium hypochlorite inside the of magnitude44 and may produce sonochemical
root canal39,40. It is more intense along the direc- effects47. Although definitive evidence is lacking,
tion of oscillation compared to other directions, various chemical reactions between irrigants and
so areas of the root canal along this direction are bacteria or tissue in root canals may be accelerated
cleaned more effectively41. Moreover, the intensity under these conditions26-28.
of the flow is increased during start-up, due to the The formation and collapse of transient cavi-
unsteady file oscillation resulting from the oper- tation bubbles inside root canals and their con-
ation of the feedback system29, which is also ben- tribution to cleaning and disinfection have been
eficial for cleaning42. Regarding the apical extent debated for decades11,19,48,49. Early studies had
of the flow, it is limited to 2 to 3 mm apically to the failed to detect such bubbles and had concluded
instrument and it does not seem to be affected by that their formation inside root canals is unlikely
root canal curvature because the typical streaming under clinically realistic conditions19. Subsequent

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 Retsas/Boutsioukis Ultrasonic irrigant activation

studies showed that currently available ultrasound Fig 5a to c Dif-

ferent types of
devices can produce transient cavitation inside ultrasonic instru-
straight artificial canals, but the bubbles always ments used for
irrigant activation
collapse towards the instruments instead of the (a) K-file (Acteon
root canal wall27,42. Moreover, in order to produce Satelec, Merignac,
France). (b) Irrisafe
such bubbles, sufficiently large and preferably file (Acteon Satelec,
non-tapered instruments must be allowed to oscil- Merignac, France).
late unimpeded at large amplitudes, which requires (c) Smooth wire
(Endo Soft Instru-
high power settings27,28,45,50,51. Under these con- ment [ESI], Electro
ditions, transient cavitation seems to contribute to Medical Systems,
Nyon, Switzerland).
mechanical cleaning45. However, these results can-
not be directly extrapolated to the clinical setting
because there may not be always enough space a b c

for large ultrasonic instruments (size ≥ 25) to oscil-

late freely in all root canals and there are limits
to the power settings that can be used clinically
Types of ultrasonic instruments
due to instrument fracture and inadvertent dentine
removal (see below). Therefore, even though tran- A variety of different ultrasonic files, tips, wires and
sient cavitation can take place inside root canals needles have been proposed for irrigant activation
under certain conditions, its precise contribution (Fig 5). Smooth wires were originally suggested
to root canal cleaning has yet to be determined. for this purpose in order to avoid unwanted den-
Part of the kinetic energy transferred to the tine removal17. Such wires are still in use22,59-61
instrument and irrigant is inevitably converted and they are made from a tapered or non-tapered
to heat and increases the temperature of the ir- stainless steel or nickel-titanium (NiTi) rod with a
rigant52-54. The maximum overall temperature circular cross-section. Ultrasonic K-files, similarly
rise in mature permanent teeth ex vivo has been to hand-operated K-files, are made by twisting
estimated as 4°C after 30 seconds of activation53 a conical (2% taper) stainless-steel blank with a
and 7.7°C after 180 seconds of activation54. These square cross-section, which results in relatively
temperature levels seem to be below the threshold sharp edges along the instrument in order to serve
for heat-induced bone tissue damage55 and, due their primary design purpose, i.e. efficient dentine
to the low thermal conductivity of dentine56, it cutting rather than irrigant activation. The more
is likely that the temperature at the external root recently introduced Irrisafe files (Acteon Satelec)
surface is even lower. Although increasing the tem- are an adaptation of the K-files to the requirements
perature of sodium hypochlorite has been linked of irrigant activation. They have almost no taper,
to improved tissue dissolution and antimicrobial a larger pitch, rounded edges, and a blunt tip in
effect57,58, the temperature rise during ultrasonic an effort to minimise or even prevent uninten-
activation cannot fully account for the observed tional removal of dentine62. The in-vitro debride-
effects31. Nevertheless, it must be emphasised ment efficacy of fluted and non-fluted instruments
that the measurements reported above reflect the appears to be similar63,64. Ultrasonically oscillating
volume-averaged temperature of a relatively large needles have also been developed to allow simul-
amount of irrigant over long periods of time (sev- taneous delivery of the irrigant deep inside the root
eral seconds); rapid local temperature variations canal and ultrasonic activation65-67. These needles
occurring near collapsing cavitation bubbles can- are also made of stainless steel or NiTi, their tip
not be recorded by these methods31 and could design resembles that of needles used for syringe
still have a significant effect on chemical reactions irrigation and they can be connected to a syringe
inside the root canal, as already mentioned. while being attached to the ultrasonic handpiece.
Ultrasonic K-files and Irrisafe files appear to be

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NR Instrument size
16 16
U/S needle NR
50
Smooth wire
12 12 30
Studies Irrisafe 25

Studies
K-file 20
8 8 15
10

4 4

(30G) (25G)
0 0
10 15 20 25 30 50 NR 20 25 30 35 40 45 50 60

Ultrasonic instrument size Apical root canal size

Fig 6 Type and size of the ultrasonic instruments used for Fig 7 Size of the ultrasonic instruments used in root canals
irrigant activation (corresponding gauge sizes of the ultra- of various apical sizes in the studies included in a recent sys-
sonic [U/S] needles are provided in parenthesis) in the stud- tematic review14. There seems to be no apparent correlation
ies included in a recent systematic review14. Ultrasonic K-files between the apical size of the root canal and the size of the
and Irrisafe files appear to be almost equally popular, while instrument. NR, not reported. Reprinted and modified from
smooth wires and ultrasonic needles are used less frequently. Căpută et al14 © 2019, with permission from Elsevier.
NR, not reported. Reprinted and modified from Căpută et
al14 © 2019, with permission from Elsevier.

almost equally popular in studies evaluating ultra- unobstructed oscillation is at least 250 to 360 μm
sonic activation, while smooth wires and ultrasonic even under ideal conditions; even more space may
needles are used less frequently (Fig 6)14. be required for larger instruments (size ≥ 25). Thus,
in many cases there may not be enough space,
and smaller instruments should be preferred. Such
Technique parameters instruments are also more frequently used in pub-
lished experimental studies but their choice is not
The efficacy of ultrasonic activation is known to be based on an estimation of the available space in
influenced by a number of operating parameters the apical third of the root canal; there seems to be
but currently there seems to be no consensus on no apparent correlation between the apical size of
the most effective activation protocol. For instance, the root canal and the size of the ultrasonic instru-
conflicting information has been reported regard- ment chosen for irrigant activation (Fig 7)14. In
ing the optimum size of the ultrasonic instrument addition, sufficient space for relatively free oscilla-
that should be used in a certain root canal29,38,68. tion is very rarely available until instrumentation is
Larger instruments may create a more intense flow completed so ultrasonic activation before or during
than smaller instruments when oscillating at the instrumentation makes little sense. Space limita-
same amplitude in the absence of any confinement tions become even more pressing in curved canals
because they displace a larger volume of irrigant, because the curvature itself can also obstruct oscil-
but the presence of the root canal wall increases lation. Ultrasonic instruments should be pre-bent
the complexity of this process. Taking into account to follow the path of the root canal in such cases
the limited apical extent of the flow created by and this seems to reduce wall contact and improve
an ultrasonic instrument and the cleaning efficacy cleaning59,68.
in that area43, the instrument should be placed Streaming around ultrasonic instruments is
within 2 to 3 mm from working length and enough more intense along the direction of oscillation35
space should be available at that level for both and this has a direct effect on cleaning41. However,
the instrument and its ‘free’ oscillation. A reason- the importance of the oscillation direction has been
able approximation of the tip oscillation amplitude ignored in most published studies14. Clinically, it is
for small ultrasonic instruments (size 15 or 20) is advisable to slightly rotate the handpiece around
50 to 80 μm29,50, so the total space required for the canal axis in order to direct the streaming to

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NR Cycles
12 16
U/S needle NR
Smooth wire >3
Irrisafe 12 3
Studies

Studies
K-file 2
8 1

4
4

NR
0 0
0 10 20 30 40 50 60 70 80 90 100 <10 10 15 20 30 45 60 90 >90 NR
Power setting (% of maximum power) Duration of activation per cycle (s)

Fig 8 Power setting used for different types of ultrasonic Fig 9 Number of irrigant activation cycles and duration of
instruments during irrigant activation in the studies included activation per cycle for sodium hypochlorite in the studies
in a recent systematic review14. NR, not reported; U/S, ultra- included in a recent systematic review14. NR, not reported.
sonic. Reprinted and modified from Căpută et al14 © 2019, Reprinted and modified from Căpută et al14 © 2019, with
with permission from Elsevier. permission from Elsevier.

various areas and especially to fins and isthmuses, ultrasonically oscillating needles72. However, these
whenever possible. However, pre-bent instruments recommendations are often ignored in published
and space limitations could hinder such handpiece ex-vivo and in-vitro studies (Fig 8)14.
rotation. Interestingly, a number of ex-vivo and During irrigant activation of sodium hypochlor-
in-vitro studies have opted to direct the oscillation ite the available chlorine is consumed rapidly40 and
towards the area of interest, thereby maximising droplets of irrigant are splashed out of the root
the observed cleaning effect, even though this is canal, thereby reducing the amount of irrigant
rarely feasible in vivo14. inside the canal27. Hence, frequent replenishment
The power setting of the ultrasound device also with fresh irrigant is needed. The irrigant can be
affects irrigant activation50. In general, a higher delivered continuously during activation in the
power setting results in larger oscillation ampli- pulp chamber and coronal third of the root canal
tude, more intense flow and improved cleaning50 through the ultrasonic handpiece or by a syringe
but the effect is nonlinear, possibly due to the oper- and needle or in the apical third of the root canal
ation of the feedback system. Although details on through an ultrasonically oscillating needle. How-
the mapping of this system are proprietary infor- ever, it may be difficult to keep track of the total
mation and rarely disclosed by the manufacturers, amount of irrigant delivered by these methods.
it is likely that the feedback system also adjusts Alternatively, activation can be interrupted and the
the driving amplitude during start-up according irrigant can be delivered in the apical third through
to the power setting selected and the initial load a syringe and needle. Currently, intermittent irri-
applied to the instrument. The presence of irrigant gant delivery and ultrasonic activation appears to
around the instrument, contact with dentine and be more widely used (Fig 9)14. This method allows
even the rubber stop used to mark the desired precise control of the depth of irrigant delivery and
insertion depth increase the load29,35 and probably the volume of the delivered irrigant. In addition,
trigger an increase in the driving amplitude that repeated start-up of the oscillation increases the
may compensate to some extent for the dampen- cleaning efficacy compared to continuous activa-
ing effect of the load. Manufacturers of ultrasound tion for the same period of time42,73,74. Thus, even
devices and instruments recommend using around if the irrigant is delivered by a method allowing
30% to 35% of the maximum available power for continuous activation, it is preferable to apply ac-
ultrasonic files or wires62,69-71 and 30% to 50% for tivation for several shorter periods rather than a

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single longer period because the number of start- be to combine short activation periods with long
ups is more important that the total activation rest periods and ample refreshment of the solution.
time74,75. Chlorhexidine has no pulp tissue or hard tissue
dissolving effect per se2,82 and its antimicrobial
effect against polymicrobial biofilms in vitro is also
Which irrigants should be activated? much weaker than sodium hypochlorite79,80,83,84.
Therefore, if chlorhexidine is used as an irrigant, its
Ultrasonic activation can augment both the chem- chemical effect is limited and activation is required
ical and the mechanical effect of irrigation76. The in order to boost the mechanical cleaning effect.
intense streaming can agitate the solution in the Ex-vivo studies have confirmed that ultrasonic
main root canal and ensure that it is refreshed in activation increases the antimicrobial efficacy of
the areas where active molecules and ions react chlorhexidine85,86. A similar rationale applies to
with various substrates (e.g. near the root canal inert irrigants such as saline and distilled water,
wall). The steady irrigant jets formed along the which have no chemical effect whatsoever; acti-
oscillation direction can also deliver molecules and vation provides clear benefits also in these cases14.
ions further away to remote areas of the root canal
system that would otherwise be reached only by
diffusion35. Moreover, heating of the irrigant in Clinically relevant outcomes
situ may accelerate some chemical reactions57,58.
Streaming and cavitation also increase the shear Ultrasonic irrigant activation does not seem to pro-
stress applied to root canal walls, which is respon- vide a significant advantage over syringe irrigation
sible for the mechanical cleaning effect35,76. in the main root canal, provided that the canal is
Sodium hypochlorite, the most widely used enlarged adequately and the needle is inserted
irrigant6,7,77, is also the irrigant most frequently close to working length during syringe irrigation8.
activated by ultrasonic instruments in experimen- Several ex-vivo studies could not detect any dif-
tal studies14. Its activation seems to augment the ference between the two methods regarding the
removal of pulp tissue remnants and hard tissue removal of pulp tissue remnants, hard tissue debris,
debris and, in some cases, also its antimicrobial or biofilm from the main root canal under these
action14. The observed improvement can be attrib- conditions, especially when sodium hypochlorite
uted to both chemical and mechanical effects. was used as irrigant87-90. Likewise, a randomised
Therefore, if ultrasonic activation is to be applied, controlled clinical trial that evaluated healing of ap-
NaOCl is the irrigant that makes the most sense to ical periodontitis in teeth with a single root canal
activate inside the root canal. and relatively simple anatomy also showed no dif-
Ethylenediaminetetraacetic acid (EDTA), a ference between syringe irrigation and ultrasonic
commonly used chelator6, is also often activated in activation91. Nevertheless, ultrasonic activation may
the literature14. Such activation is not justified from improve the cleaning of uninstrumented oval exten-
the smear-layer-removal point of view because the sions, fins, isthmuses and accessory canals although
smear layer is only formed on a part of the main very limited information is available regarding its
root canal78 that is easily accessible by both instru- antimicrobial effect in those areas (Table 1)14,59,61.
ments and irrigants. It could be justified as a way Ultrasonic activation seems to outperform
to deliver EDTA deeper in uninstrumented parts sonic agitation by earlier devices regarding the
of the root canal system where it may have an removal of pulp tissue remnants92, hard tissue
effect on biofilm79,80 or on accumulated hard tis- debris34 and biofilm93, but other studies compar-
sue debris10. However, the inevitable temperature ing it to more recent sonic devices have found no
increase reduces its calcium binding capacity, thus difference94,95. It also seems to be more effective
activation may be counterproductive in this case81. than manual dynamic agitation, at least in straight
A possible way to circumvent this problem could root canals65,92,93. Regarding lasers, a number of

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 Retsas/Boutsioukis Ultrasonic irrigant activation

Table 1 Overview of the findings of a recent systematic review14 that compared syringe irrigation and ultrasonic irrigant ac-
tivation (UIA) regarding various outcomes. The numbers indicate how many of the included studied came to each conclusion.
Numbers inside the parentheses show in how of many of these studies the protocol favoured one of the compared groups
resulting in bias of the same direction as the conclusion.

Outcome UIA better No difference Syringe irrigation better Total

(favoured UIA) (favoured syringe) (favoured syringe) studies
Healing of apical periodontitis 0 (0) 1 (0) 0 (0) 1
Antimicrobial effect 10 (5) 8 (1) 1 (0) 19
Removal of pulp tissue remnants 8 (3) 0 (0) 0 (0) 8
Removal of hard tissue debris 17 (4) 3 (1) 0 (0) 20

UIA, ultrasonic irrigant activation.

studies have found no difference between ultra- (Fig 10)23. Even more frequent multi-point wall
sonic activation, laser activated irrigation (LAI) and contact and greater dampening can be expected in
photon-initiated photoacoustic streaming (PIPS) curved root canals and under clinical conditions20.
concerning the removal of hard tissue debris or A small ex-vivo study reported differences in the
biofilm when these methods are combined with performance of ultrasonic activation in straight
sodium hypochlorite96-98, but LAI has also been and curved canals60 that could be attributed to
reported as more effective99. oscillation dampening because of wall-contact.
Increasing the power setting could ameliorate
the dampening but there are manufacturer rec-
Limitations ommended limits to the maximum power setting
that should be used for irrigant activation (see
Wall contact and oscillation dampening above), probably to prevent instrument fracture.
Thus, instrument-to-wall contact and oscillation
Even though all current protocols recommend that dampening seem inevitable during clinical applica-
ultrasonic instruments should not touch the root tion of ultrasonic activation. Nevertheless, these
canal wall during activation11, this appears to be phenomena are often meticulously prevented dur-
impossible even under ideal conditions. Wall con- ing in-vitro experiments, which probably leads to
tact seems to occur very frequently (~94% of the overestimation of the various positive effects.
total activation time) even when activation takes
place inside wide straight root canals under opti-
Dentine removal
mum access, stability and visibility conditions dur-
ing a bench-top laboratory experiment and it is Instrument-to-wall contact can also result in unin-
independent of any conscious operator effort to tentional removal of small amounts of dentine and
prevent it23. In addition, it increases as the ap- in root canal transportation during irrigant activa-
ical root canal size decreases23, thus being an tion, especially when ultrasonic K-files are used.
even greater problem in unprepared or minimally This was suspected10,22 and later demonstrated
shaped root canals. ex vivo or in vitro in both straight24 and curved
Wall contact increases the load on the instru- root canals (Fig 11)25,59. These unwanted effects
ment dramatically and compensation by the feed- appear to be time-dependent and no specific type
back system may not be able to fully restore the of ultrasonic instrument can prevent them com-
oscillation. Measurements have shown that even a pletely24,25, although pre-bending the instrument
very light single-point contact (6 g) can reduce the before use in curved canals could reduce them59.
oscillation amplitude by 30% to 50% depending Nevertheless, the clinical significance of these find-
on the part of the instrument to which it is applied ings is still unclear.

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at middle of at end of
at first antinode working part working part
Contact: none at tip (dc = 0 mm) (dc = 3 mm) (dc = 8 mm) (dc = 16 mm)
Driven end 0 0 0 0 0

Position along
file (mm) 5 5 5 5 5

10 10 10 10 10

15 15 15 15 15

20 20 20 20 20
Tip
–30 –15 0 15 30 –30 –15 0 15 30 –30 –15 0 15 30 –30 –15 0 15 30 –30 –15 0 15 30

Amplitude (μm)

Fig 10 Oscillation patterns of a size 15 21-mm ultrasonic K-file in a very light single-point contact (6 g) with a caries excava-
tor at different positions along its length (black arrows) as recorded by a laser scanning vibrometer. The position of the file
at rest is indicated in blue. The red dotted line indicates the non-contact oscillation pattern (control). The outer black lines
that define the ‘envelope of motion’ of the ultrasonic file are marked with circles and asterisks. A reduction of 30% to 50%
in the tip oscillation amplitude was noticed in all contact cases compared to non-contact, except when contact was made at
the driven end of the file (not shown). dc, contact distance from the file tip. Reprinted and modified from Boutsioukis et al23
© 2013 International Endodontic Journal, with permission from John Wiley and Sons.

Group A Group B Group C Group D cause of ultrasonic file fracture seems to be cyclic
(K-file) (Irrisafe) (Smooth wire) (Control) fatigue due to repeated alternating bending rather
than cavitation-induced damage100,101. Fractures
appear more often near the first antinode away
from the tip, at a location approximately 2 mm
from the tip, which coincides with the maximum
bending moment101. Interestingly, files seem to
fracture much faster when oscillating freely in air
than inside water (0.37 vs. 82.15 seconds)101 and
file-to-wall contact inside a root canal may delay
30 s 60 s 30 s 60 s 30 s 60 s 30 s 60 s the fracture even longer100. It could be hypoth-
esised that dampening of the oscillation because
Fig 11 Three-dimensional reconstructions of micro-computed
tomography scans depicting the root canal wall of curved of water and wall contact may contribute to these
molar root canals after preparation (yellow) and the amount of differences100. It is difficult to determine a ‘safe-
dentine removed by different ultrasonic instruments (red) after
30 seconds and 60 seconds of irrigant activation. Reprinted
usage period’ for ultrasonic files based on the
and modified from Retsas et al25 © 2016, with permission available evidence because their fracture is likely
from Elsevier.
to be a multi-factorial process. For example, a
parameter widely believed to influence fractures
Instrument fracture is the power setting but this is based on clinical
observations rather than studies. In any case, the
Ultrasonic instruments, especially files, tend to remaining part of a broken ultrasonic file has a
fracture during use and although the retrieval of larger active tip that can cut dentine more aggres-
the separated part from the root canal is usu- sively. Therefore, broken files should not be used
ally easier than that of hand or rotary files, it for irrigant activation even if their remaining
still requires additional time and effort. The main length is sufficient.

124 ENDO EPT 2019;13(2):115–129

 Retsas/Boutsioukis Ultrasonic irrigant activation

Irrigant extrusion Conclusions

Intermittent ultrasonic activation does not Ultrasonic irrigant activation does not seem to
appear to cause any measureable irrigant extru- provide any obvious practical advantage during
sion through the apical foramen even at high treatment, perhaps with the exception of retreat-
power settings102, which could be explained by ment cases where the superior debridement could
the primarily lateral flow created by ultrasonic assist with the identification of untreated parts of
instruments and the absence of a significant flow the root canal system. To the contrary, it requires
component with an apical direction35,43. In addi- additional equipment (instruments) and time and
tion, no sodium hypochlorite accidents have been entails certain risks (e.g. instrument fracture).
reported so far with this method103. However, the Therefore, its wide adoption (24% to 45%) by
irrigant needs to be delivered into the root canal both general dental practitioners and specialists
prior to or during activation, usually by a syringe in various countries6,7 could be largely attributed
and needle, and it could be extruded through to the widespread perception that it improves the
the apical foramen during this process. Significant debridement and disinfection of the root canal
extrusion has also been reported during continu- and thus the treatment outcome. This perception
ous delivery and activation by ultrasonically oscil- may have originated from the promising find-
lating needles61. ings of early studies on the removal of pulp tissue
remnants or hard tissue debris11 and was prob-
ably amplified by marketing strategies of various
Electromagnetic interference
manufacturers. However, the link between widely
Ultrasound devices are sources of electromag- studied surrogate endpoints such as the removal of
netic radiation, so, in theory, they could interfere pulp tissue remnants or hard tissue debris and the
with the operation of cardiac pacemakers and primary outcome of interest, i.e. healing of apical
implanted cardioverter defibrillators104. However, periodontitis, remains largely theoretical. Conse-
even when ultrasonic scalers or piezoelectric sur- quently, it could be argued that ultrasonic activa-
gical units are used at maximum power there tion may have been adopted prematurely based on
seems to be no interference105-107 or very light insufficient evidence.
interference108 with the operation of the pace- Current evidence suggests that ultrasonic acti-
makers and defibrillators in vitro. Clinical stud- vation is indeed a very effective way to debride the
ies have also failed to detect any adverse effects root canal but it is still unclear whether it reduces
on the operation of cardioverter defibrillators the microbial load and there is no proof that the
implanted in patients109,110. Some contradictory effective debridement is actually translated into an
in-vitro findings111 were later attributed to inter- increased success rate14. Therefore, from a clin-
ference with the telemetry unit, which is known ical point of view it makes little sense to apply it
to occur in some cases109, and not with the pace- with the aim of improving the healing of apical
maker itself110,112. Given the fact that the power periodontitis, at least during the initial treatment
setting recommended for ultrasonic irrigant acti- of single-rooted teeth91. However, it can be a very
vation is much lower than the power used in these useful method in order to debride root canals in
studies, it is unlikely that activation will have any order to facilitate subsequent treatment steps, for
effect on implanted pacemakers or defibrilla- example during retreatments.
tors. Nevertheless, a minimum distance of 20 cm Despite the abundance of studies on this
between all parts of the ultrasound device and the topic, there are still important knowledge gaps.
pacemaker/defibrillator is advisable108. The vast majority of studies have used extracted
single-rooted teeth with simple anatomy. Very lit-
tle attention has been drawn to teeth with multi-
ple root canals and complex anatomy, especially

ENDO EPT 2019;13(2):115–129 125

Retsas/Boutsioukis Ultrasonic irrigant activation

regarding the ability of ultrasonic activation to 12. Mozo S, Llena C, Forner L. Review of ultrasonic irrigation
in endodontics: increasing action of irrigating solutions.
eliminate multi-species biofilms or to improve the Med Oral Patol Oral Cir Bucal 2012;17:e512–e516.
success rate14. In addition, there is no consensus 13. Nagendrababu V, Jayaraman J, Suresh A, Kalyanasundar-
am S, Neelakantan P. Effectiveness of ultrasonically activat-
on the optimum activation protocol and most of ed irrigation on root canal disinfection: a systematic review
the suggested protocols have been developed and of in vitro studies. Clin Oral Investig 2018;22:655–670.
14. Căpută PE, Retsas A, Kuijk L, Chávez de Paz LE, Bout-
fine-tuned in order to optimise the removal of pulp sioukis C. Ultrasonic irrigant activation during root canal
tissue remnants or hard tissue debris rather than treatment: a systematic review. J Endod 2019;45:31–44.
biofilm. Finally, there is limited information con- 15. Moreira RN, Pinto EB, Galo R, Falci SGM, Mesquita AT.
Passive ultrasonic irrigation in root canal: systematic review
cerning the possible adverse effects. Therefore, and meta-analysis. Acta Odontol Scand 2019;77:55–60.
ultrasonic irrigant activation remains a topic of 16. Richman RJ. The use of ultrasonics in root canal therapy
and root resection. Med Dent J 1957;12:12–18.
interest for future studies. 17. Weller RN, Brady JM, Bernier WE. Efficacy of ultrasonic
cleaning. J Endod 1980;6:740–743.
18. Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic debride-
ment of root canals: acoustic streaming and its possible
role. J Endod 1987;13:490–499.
Acknowledgements 19. Ahmad M, Pitt Ford TR, Crum LA, Walton AJ. Ultrasonic
debridement of root canals: acoustic cavitation and its
The authors thank Prof Fridus van der Weijden, relevance. J Endod 1988;14:486–493.
20. Walmsley AD, Williams AR. Effect of constraint on the oscil-
Dr Bram Verhaagen and Prof Luc van der Sluis for latory pattern of endosonic files. J Endod 1989;15:189–184.
providing some of the figures used in this review. 21. Jensen SA, Walker TL, Hutter JW, Nicoll BK. Comparison
of the cleaning efficacy of passive sonic activation and
passive ultrasonic activation after hand instrumentation
in molar root canals. J Endod 1999;25:735–738.
22. Mayer BE, Peters OA, Barbakow F. Effects of rotary
References instruments and ultrasonic irrigation on debris and smear
layer scores: a scanning electron microscopic study. Int
1. Haapasalo M, Endal U, Zandi H, Coil JM. Eradication of Endod J 2002;35:582–589.
endodontic infection by instrumentation and irrigation 23. Boutsioukis C, Verhaagen B, Walmsley AD, Versluis M,
solutions. Endod Topics 2005;10:77–102. van der Sluis LW. Measurement and visualization of file-
2. Zehnder M. Root canal irrigants. J Endod 2006;32: to-wall contact during ultrasonically activated irrigation in
389–398. simulated canals. Int Endod J 2013;46:1046–1055.
3. Chow TW. Mechanical effectiveness of root canal irriga- 24. Boutsioukis C, Tzimpoulas N. Uncontrolled removal
tion. J Endod 1983;9:475–479. of dentin during in vitro ultrasonic irrigant activation.
4. Gulabivala K, Patel B, Evans G, Ng YL. Effects of mech- J Endod 2016;42:289–293.
anical and chemical procedures on root canal surfaces. 25. Retsas A, Koursoumis A, Tzimpoulas N, Boutsioukis C.
Endod Topics 2005;10:103–122. Uncontrolled removal of dentin during in vitro ultra-
5. Boutsioukis C, van der Sluis LWM. Syringe irrigation: sonic irrigant activation in curved root canals. J Endod
blending endodontics and fluid dynamics. Chapter 3. 2016;42:1545–1549.
In: Basrani B (ed). Endodontic irrigation: Chemical dis- 26. Tiong TJ, Price GJ. Ultrasound promoted reaction of Rho-
infection of the root canal system. New York: Springer, damine B with sodium hypochlorite using sonochemical
2015:45–64. and dental ultrasonic instruments. Ultrason Sonochem
6. Dutner J, Mines P, Anderson A. Irrigation trends among 2012;19:358–364.
American Association of Endodontists members: a web- 27. Macedo RG, Verhaagen B, Fernandez Rivas D, et al.
based survey. J Endod 2012;38:37–40. Sonochemical and high-speed optical characterization
7. Willershausen I, Wolf TG, Schmidtmann I, et al. Survey of cavitation generated by an ultrasonically oscillating
of root canal irrigating solutions used in dental practices dental file in root canal models. Ultrason Sonochem
within Germany. Int Endod J 2015;48:654–660. 2014;21:324–335.
8. Boutsioukis C. Internal tooth anatomy and root canal irri- 28. Macedo R, Verhaagen B, Rivas DF, Versluis M, Wesse-
gation. In: Versiani MA, Basrani B, Sousa-Neto MD (eds). link P, van der Sluis L. Cavitation measurement during
The root canal anatomy in permanent dentition. New sonic and ultrasonic activated irrigation. J Endod 2014;40:
York: Springer, 2019:303–321. 580–583.
9. Nair PN, Henry S, Cano V, Vera J. Microbial status of ap- 29. Verhaagen B, Lea SC, de Bruin GJ, van der Sluis LW, Walms-
ical root canal system of human mandibular first molars ley AD, Versluis M. Oscillation characteristics of endodontic
with primary apical periodontitis after “one-visit” endo- files: numerical model and its validation. IEEE Trans Ultrason
dontic treatment. Oral Surg Oral Med Oral Pathol Oral Ferroelectr Freq Control 2012;59:2448–2459.
Radiol Endod 2005;99:231–252. 30. Lea SC, Walmsley AD, Lumley PJ. Analyzing endosonic
10. Paqué F, Boessler C, Zehnder M. Accumulated hard tissue root canal file oscillations: an in vitro evaluation. J Endod
debris levels in mesial roots of mandibular molars after 2010;36:880–883.
sequential irrigation steps. Int Endod J 2011;44:148–153. 31. Al-Jadaa A, Paque F, Attin T, Zehnder M. Necrotic pulp
11. van der Sluis LW, Versluis M, Wu MK, Wesselink PR. Pas- tissue dissolution by passive ultrasonic irrigation in
sive ultrasonic irrigation of the root canal: a review of the simulated accessory canals: impact of canal location and
literature. Int Endod J 2007;40:415–426. angulation. Int Endod J 2009;42:59–65.

126 ENDO EPT 2019;13(2):115–129

 Retsas/Boutsioukis Ultrasonic irrigant activation

32. Walmsley AD. Ultrasound and root canal treatment: 53. Cameron JA. The effect of ultrasonic endodontics on the
the need for scientific evaluation. Int Endod J 1987;20: temperature of the root canal wall. J Endod 1988;14:
105–111. 554–559.
33. Duck PW, Smith FT. Steady streaming induced between 54. Zeltner M, Peters OA, Paqué F. Temperature changes
oscillating cylinders. J Fluid Mech 1979;91:93–110. during ultrasonic irrigation with different inserts and
34. Jiang LM, Verhaagen B, Versluis M, van der Sluis LW. modes of activation. J Endod 2009;35:573–577.
Evaluation of a sonic device designed to activate irrigant 55. Eriksson AR, Albrektsson T. Temperature threshold levels
in the root canal. J Endod 2010;36:143–146. for heat-induced bone tissue injury: a vital-microscopic
35. Verhaagen B, Boutsioukis C, van der Sluis LW, Ver- study in the rabbit. J Prosthet Dent 1983;50:101–107.
sluis M. Acoustic streaming induced by an ultrasonically 56. Brown WS, Dewey WA, Jacobs HR. Thermal properties of
oscillating endodontic file. J Acoust Soc Am 2014;135: teeth. J Dent Res 1970;49:752–755.
1717–1730. 57. Sirtes G, Waltimo T, Schaetzle M, Zehnder M. The effects
36. Yasui K. Acoustic cavitation and bubble dynamics. Singa- of temperature on sodium hypochlorite short-term stabil-
pore: Springer International Publishing, 2018:37–97. ity, pulp dissolution capacity, and antimicrobial efficacy.
37. Lumley PJ, Walmsley AD, Laird WR. Streaming patterns J Endod 2005;31:669–671.
produced around endosonic files. Int Endod J 1991;24: 58. Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo M.
290–297. Tissue dissolution by sodium hypochlorite: effect of
38. Ahmad M, Roy RA, Kamarudin AG. Observations of concentration, temperature, agitation, and surfactant.
acoustic streaming fields around an oscillating ultrasonic J Endod 2010;36:1558–1562.
file. Endod Dent Traumatol 1992;8:189–194. 59. Al-Jadaa A, Paqué F, Attin T, Zehnder M. Acous-
39. Macedo RG, Wesselink PR, Zaccheo F, Fanali D, van der tic hypochlorite activation in simulated curved canals.
Sluis LW. Reaction rate of NaOCl in contact with bovine J Endod 2009;35:1408–1411.
dentine: effect of activation, exposure time, concentra- 60. Amato M, Vanoni-Heineken I, Hecker H, Weiger R.
tion and pH. Int Endod J 2010;43:1108–1115. Curved versus straight root canals: the benefit of acti-
40. Macedo RG, Verhaagen B, Wesselink PR, Versluis M, vated irrigation techniques on dentin debris removal.
van der Sluis LW. Influence of refreshment/activation Oral Surg Oral Med Oral Pathol Oral Radiol Endod
cycles and temperature rise on the reaction rate of so- 2011;111:529–534.
dium hypochlorite with bovine dentine during ultrasonic 61. Malentacca A, Uccioli U, Zangari D, Lajolo C, Fabiani C.
activated irrigation. Int Endod J 2014;47:147–154. Efficacy and safety of various active irrigation devices
41. Jiang LM, Verhaagen B, Versluis M, van der Sluis LW. when used with either positive or negative pressure: an
Influence of the oscillation direction of an ultrasonic file in vitro study. J Endod 2012;38:1622–1626.
on the cleaning efficacy of passive ultrasonic irrigation. 62. Acteon-Satelec. Tip book. 2015. Available at: http://
J Endod 2010;36:1372–1376. support-acteon-equipment.com/download-file.php?
42. Jiang LM, Verhaagen B, Versluis M, Zangrillo C, Cucko- id=2221. Accessed 7 July 2016.
vic D, van der Sluis LWM. An evaluation of the effect 63. van der Sluis LW, Wu MK, Wesselink PR. A comparison
of pulsed ultrasound on the cleaning efficacy of passive between a smooth wire and a K-file in removing arti-
ultrasonic irrigation. J Endod 2010;36:1887–1891. ficially placed dentine debris from root canals in resin
43. Malki M, Verhaagen B, Jiang LM, et al. Irrigant flow blocks during ultrasonic irrigation. Int Endod J 2005;38:
beyond the insertion depth of an ultrasonically oscillating 593–596.
file in straight and curved root canals: visualization and 64. Munley PJ, Goodell GG. Comparison of passive ultrasonic
cleaning efficacy. J Endod 2012;38:657–661. debridement between fluted and nonfluted instruments
44. Brennen CE. Cavitation and bubble dynamics, 1st edn. in root canals. J Endod 2007;33:578–580.
New York: Oxford University Press, 1995:1–290. 65. Jiang LM, Lak B, Eijsvogels LM, Wesselink P, van der
45. Robinson JP, Macedo RG, Verhaagen B, et al. Cleaning Sluis LWM. Comparison of the cleaning efficacy of
lateral morphological features of the root canal: the role different final irrigation techniques. J Endod 2012;38:
of streaming and cavitation. Int Endod J 2018;51(Sup- 838–841.
pl 1):e55–e64. 66. Goode N, Khan S, Eid AA, et al. Wall shear stress effects
46. Ohl CD, Wolfrum B. Detachment and sonoporation of of different endodontic irrigation techniques and systems.
adherent HeLa-cells by shock wave-induced cavitation. J Dent 2013;41:636–641.
Biochim Biophys Acta 2003;1624:131–138. 67. Curtis TO, Sedgley CM. Comparison of a continuous
47. Suslick KS. Sonochemistry. Science 1990;247:1439–1445. ultrasonic irrigation device and conventional needle ir-
48. Martin H, Cunningham W. Endosonic endodontics: the rigation in the removal of root canal debris. J Endod
ultrasonic synergistic system. Int Dent J 1984;34:198–203. 2012;38:1261–1264.
49. Lumley PJ, Walmsley AD, Laird WR. An investigation into 68. Lumley PJ, Walmsley AD. Effect of precurving on the
cavitational activity occurring in endosonic instrumenta- performance of endosonic K files. J Endod 1992;18:
tion. J Dent 1988;16:120–122. 232–236.
50. Jiang LM, Verhaagen B, Versluis M, Langedijk J, Wes- 69. Electro Medical Systems (EMS) Piezon® Systems: Oper-
selink P, van der Sluis LW. The influence of the ultrasonic ation instructions, 2012:30–35. Available at: https://
intensity on the cleaning efficacy of passive ultrasonic www.ems-dental.com/sites/default/files/documents/
irrigation. J Endod 2011;37:688–692. FB-439_3_ed_2012-06_Piezon%20instruments.com-
51. Halford A, Ohl CD, Azarpazhooh A, Basrani B, Fried- pressed_4.pdf. Accessed 16 May 2018.
man S, Kishen A. Synergistic effect of microbubble 70. NSK. Tip guide, 2017:1–30. Available at: http://www.
emulsion and sonic or ultrasonic agitation on endodontic uk.nsk-dental.com/pdf/catalog/oralcare/tip_guide.pdf.
biofilm in vitro. J Endod 2012;38:1530–1534. Accessed 16 May 2018.
52. Cunningham WT, Martin H, Forrest WR. Evaluation of 71. Acteon-Satelec. User manual, 2018. Available at:
root canal debridement by the endosonic ultrasonic syn- https://www.acteongroup.com/en/uploads/media/
ergistic system. Oral Surg Oral Med Oral Pathol 1982;53: default/0001/01/a264bc99fb3e386a7d8e6269957ff-
401–404. c225bc2efb3.pdf. Accessed 16 May 2018.

ENDO EPT 2019;13(2):115–129 127

Retsas/Boutsioukis Ultrasonic irrigant activation

72. Dentsply International. ProUltra PiezoFlow ultrasonic 88. Klyn SL, Kirkpatrick TC, Rutledge RE. In vitro compari-
irrigation needle: Technique card, 2012. Available at: htt- sons of debris removal of the EndoActivator system, the
ps://www.dentsplysirona.com/content/dam/dentsply/ F file, ultrasonic irrigation, and NaOCl irrigation alone
pim/manufacturer/Endodontics/Irrigation__Activation/ after hand-rotary instrumentation in human mandibular
Ultrasonics/ProUltra_PiezoFlow_Ultrasonic_Irrigation_ molars. J Endod 2010;36:1367–1371.
Needle/ProUltra-PiezoFlow-Ultrsonic-Irrigation-Needle- 89. Adcock JM, Sidow SJ, Looney SW, et al. Histologic evalu-
70ebtmh-en-1402. Accessed 16 May 2018. ation of canal and isthmus debridement efficacies of two
73. van der Sluis LWM, Gambarini G, Wu MK, Wesselink PR. different irrigant delivery techniques in a closed system. J
The influence of volume, type of irrigant and flushing Endod 2011;37:544–548.
method on removing artificially placed dentine debris 90. Howard RK, Kirkpatrick TC, Rutledge RE, Yaccino JM.
from the apical root canal during passive ultrasonic irri- Comparison of debris removal with three different irriga-
gation. Int Endod J 2006;39:472–476. tion techniques. J Endod 2011;37:1301–1305.
74. van der Sluis LW, Vogels MP, Verhaagen B, Macedo RG, 91. Liang YH, Jiang LM, Jiang L, et al. Radiographic heal-
Wesselink PR. Study on the influence of refreshment/ac- ing after a root canal treatment performed in single-
tivation cycles and irrigants on mechanical cleaning effi- rooted teeth with and without ultrasonic activation
ciency during ultrasonic activation of the irrigant. J Endod of the irrigant: a randomized controlled trial. J Endod
2010;36:737–740. 2013;39:1218–1225.
75. van der Sluis LWM, Wu MK, Wesselink P. Comparison of 2 92. Varela P, Souza E, de Deus G, Duran-Sindreu F, Mercadé
flushing methods used during passive ultrasonic irrigation M. Effectiveness of complementary irrigation routines in
of the root canal. Quintessence Int 2009;40:875–879. debriding pulp tissue from root canals instrumented with
76. van der Sluis L, Boutsioukis C, Jiang LM, Macedo R, Ver- a single reciprocating file. Int Endod J 2019;52:475–483.
haagen B, Versluis M. Root canal irrigation. In: Chávez 93. Mohmmed SA, Vianna ME, Penny MR, Hilton ST, Mor-
de Paz L, Sedgley CM, Kishen A (eds). The root canal dan N, Knowles JC. A novel experimental approach to
biofilm. New York: Springer, 2015:259–302. investigate the effect of different agitation methods using
77. Eleazer PD, Gilbert GH, Funkhouser E, et al. Techniques sodium hypochlorite as an irrigant on the rate of bacterial
and materials used by general dentists during endodontic biofilm removal from the wall of a simulated root canal
treatment procedures: findings from The National Den- model. Dent Mater 2016;32:1289–1300.
tal Practice-Based Research Network. J Am Dent Assoc 94. Neuhaus KW, Liebi M, Stauffacher S, Eick S, Lussi A.
2016;147:19–27. Antibacterial efficacy of a new sonic irrigation device for
78. Sen BH, Wesselink PR, Türkün M. The smear layer: a root canal disinfection. J Endod 2016;42:1799–1803.
phenomenon in root canal therapy. Int Endod J 1995;28: 95. Conde AJ, Estevez R, Loroño G, Valencia de Pablo Ó,
141–148. Rossi-Fedele G, Cisneros R. Effect of sonic and ultrasonic
79. Tawakoli PN, Ragnarsson KT, Rechenberg DK, Mohn D, activation on organic tissue dissolution from simulated
Zehnder M. Effect of endodontic irrigants on biofilm grooves in root canals using sodium hypochlorite and
matrix polysaccharides. Int Endod J 2017;50:153–160. EDTA. Int Endod J 2017;50:976–982.
80. Busanello FH, Petridis X, So MVR, Dijkstra RJB, Sharma 96. Verstraeten J, Jacquet W, De Moor RJG, Meire MA. Hard
PK, van der Sluis LWM. Chemical biofilm removal capacity tissue debris removal from the mesial root canal system of
of endodontic irrigants as a function of biofilm structure: mandibular molars with ultrasonically and laser-activated
optical coherence tomography, confocal microscopy and irrigation: a micro-computed tomography study. Lasers
viscoelasticity determination as integrated assessment Med Sci 2017;32:1965–1970.
tools. Int Endod J 2019;52:461–474. 97. De Meyer S, Meire MA, Coenye T, De Moor RJ. Effect
81. Zehnder M, Paqué F. Disinfection of the root canal of laser-activated irrigation on biofilms in artificial root
system during root canal re-treatment. Endod Topics canals. Int Endod J 2017;50:472–479.
2011;19:58–73. 98. Passalidou S, Calberson F, De Bruyne M, De Moor R,
82. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution Meire MA. Debris removal from the mesial root canal
capacity of currently used and potential endodontic irri- system of mandibular molars with laser-activated irriga-
gants. J Endod 2004;30:785–787. tion. J Endod 2018;44:1697–1701.
83. Ruiz-Linares M, Aguado-Pérez B, Baca P, Arias-Moliz 99. de Groot SD, Verhaagen B, Versluis M, Wu MK, Wes-
MT, Ferrer-Luque CM. Efficacy of antimicrobial solutions selink PR, van der Sluis LW. Laser-activated irrigation
against polymicrobial root canal biofilm. Int Endod J within root canals: cleaning efficacy and flow visualiza-
2017;50:77–83. tion. Int Endod J 2009;42:1077–1083.
84. Stojicic S, Shen Y, Haapasalo M. Effect of the source of 100. Ahmad M, Roy RA. Some observations on the breakage
biofilm bacteria, level of biofilm maturation, and type of of ultrasonic files driven piezoelectrically. Endod Dent
disinfecting agent on the susceptibility of biofilm bacteria Traumatol 1994;10:71–76.
to antibacterial agents. J Endod 2013;39:473–477. 101. Verhaagen B. Root canal cleaning through cavitation
85. Niazi SA, Clark D, Do T, et al. The effectiveness of enzy- and microstreaming (PhD Thesis). Enschede, The Neth-
mic irrigation in removing a nutrient-stressed endodontic erlands: Physics of Fluids Group, University of Twente
multispecies biofilm. Int Endod J 2014;47:756–768. 2012:94–98.
86. Cherian B, Gehlot PM, Manjunath MK. Comparison 102. Boutsioukis C, Psimma Z, Kastrinakis E. The effect of flow
of the antimicrobial efficacy of octenidine dihydro- rate and agitation technique on irrigant extrusion ex vivo.
chloride and chlorhexidine with and without passive Int Endod J 2014;47:487–496.
ultrasonic irrigation: an in vitro study. J Clin Diagn Res 103. Boutsioukis C, Psimma Z, van der Sluis LWM. Factors
2016;10:ZC71–ZC77. affecting irrigant extrusion during root canal irrigation: a
87. Bhuva B, Patel S, Wilson R, Niazi S, Beighton D, Man- systematic review. Int Endod J 2013;46:599–618.
nocci F. The effectiveness of passive ultrasonic irrigation 104. Pisano P Jr, Mazzola JG, Tassiopoulos A, Romanos GE.
on intraradicular Enterococcus faecalis biofilms in extract- Electrosurgery and ultrasonics on patients with implant-
ed single-rooted human teeth. Int Endod J 2010;43: able cardiac devices: evidence of side effects in the dental
241–250. practice. Quintessence Int 2016;47:151–160.

128 ENDO EPT 2019;13(2):115–129

 Retsas/Boutsioukis Ultrasonic irrigant activation

105. Brand HS, Entjes ML, Nieuw Amerongen AV, van der 109. Patel D, Glick M, Lessard E, Zaim S. Absence of in vivo
Hoeff EV, Schrama TA. Interference of electrical dental effects of dental instruments on pacemaker function.
equipment with implantable cardioverter-defibrillators. Br Oral Surg Oral Med Oral Pathol Oral Radiol Endod
Dent J 2007;203:577–579. 2005;99:430 (abstract).
106. Gomez G, Jara F, Sánchez B, Roig M, Duran-Sindreu F. 110. Maiorana C, Grossi GB, Garramone RA, Manfredini R,
Effects of piezoelectric units on pacemaker function: an Santoro F. Do ultrasonic dental scalers interfere with
in vitro study. J Endod 2013;39:1296–1299. implantable cardioverter defibrillators? An in vivo investi-
107. Dadalti MT, da Cunha AJ, de Araújo MC, de Moraes LG, gation. J Dent 2013;41:955–959.
de Andrade Risso P. Electromagnetic interference of 111. Roedig JJ, Shah J, Elayi CS, Miller CS. Interference of car-
endodontic equipments with cardiovascular implantable diac pacemaker and implantable cardioverter-defibrillator
electronic device. J Dent 2016;46:68–72. activity during electronic dental device use. J Am Dent
108. Lahor-Soler E, Miranda-Rius J, Brunet-Llobet L, Sabaté Assoc 2010;141:521–526.
de la Cruz X. Capacity of dental equipment to interfere 112. Crossley GH, Poole JE. More about pacemakers. J Am
with cardiac implantable electrical devices. Eur J Oral Sci Dent Assoc 2010;141:1053.
2015;123:194–201.

Anastasios Retsas, DDS, MSc

Department of Endodontology, Academic Centre for Dentis-
try Amsterdam (ACTA), University of Amsterdam and Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands.

Christos Boutsioukis, DDS, MSc, PhD

Department of Endodontology, Academic Centre for Dentis-
try Amsterdam (ACTA), University of Amsterdam and Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands.

Anastasios Retsas Christos Boutsioukis

Correspondence to:
Dr Christos Boutsioukis, Department of Endodontology, Academic Centre for Dentistry Amsterdam (ACTA), University
of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, The Netherlands.
E-mail: [email protected]

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