Review Article
Ultrasonic Irrigant Activation during Root Canal
Treatment: A Systematic Review
Petruţ a E. C
a, DDS, MSc,* Anastasios Retsas, DDS, MSc,* Lydwien Kuijk, DDS,†
aput

Luis E. Ch avez de Paz, DDS, MS, PhD,‡ and Christos Boutsioukis, DDS, MSc, PhD*
Abstract
Introduction: The aim of this study was to systemati-
cally review the evidence on the cleaning and disinfec-
tion of root canals and the healing of apical
periodontitis when ultrasonic irrigant activation is
applied during primary root canal treatment of mature
permanent teeth compared with syringe irrigation.
Methods: An electronic search was conducted of the
Cochrane Library, Embase, LILACS, PubMed, SciELO,
and Scopus databases using both free-text key words
and controlled vocabulary. Additional studies were
sought through hand searching of endodontic journals
and textbooks. The retrieved studies were screened by
2 reviewers according to predefined criteria. The
included studies were critically appraised, and the ex-
tracted data were arranged in tables. Results: The elec-
tronic and hand search retrieved 1966 titles. Three
clinical studies and 45 in vitro studies were included
in this review. Ultrasonic activation did not improve
the healing rate of apical periodontitis compared with
syringe irrigation after primary root canal treatment of
teeth with a single root canal. Conflicting results were
reported by the in vitro microbiological studies. Ultra-
sonic activation was more effective than syringe irriga-
tion in the removal of pulp tissue remnants and hard
tissue debris based on both clinical and in vitro studies.
Ultrasonic activation groups were possibly favored in 13
studies, whereas syringe irrigation groups may have
been favored in 3 studies. Conclusions: The level of
the available evidence was low, so no strong clinical rec-
ommendations could be formulated. Future studies
should focus on the antimicrobial effect and healing of
apical periodontitis in teeth with multiple root canals.
(J Endod 2019;45:31–44)
Key Words
Apical periodontitis, cleaning, disinfection, irrigation,
root canal, ultrasonic activation
From the *Department of Endodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amster-
dam, The Netherlands; †Private Practice, Amsterdam, The Netherlands; and ‡Private Practice, Stockholm, Sweden.
Address requests for reprints 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, Netherlands. E-mail address: c.boutsioukis@acta.nl
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.09.010
JOE — Volume 45, Number 1, January 2019
I rrigation is an essential
part of root canal treat-
ment because it enhances
Significance
This review summarized and appraised published
studies comparing ultrasonic irrigant activation
the debridement and
and syringe irrigation, 2 widely used methods,
disinfection of areas insuf-
regarding the cleaning and disinfection of root ca-
ficiently cleaned by instru-
nals and the healing of apical periodontitis.
ments (1, 2). Irrigation is
mainly performed by a
syringe and a needle (3, 4), but this simple method is unable to clean remote areas
of the root canal system (5). Thus, several more elaborate methods have been devel-
oped (6).
Ultrasonic irrigant activation is probably the most widely used adjunct method (3),
and it has been compared with syringe irrigation in a large number of studies (7). How-
ever, very few attempts have been made to summarize the available evidence. An earlier
study (7) reviewed 54 articles on this topic, but more than 100 new experimental
studies have been published since then. Very few studies were included in a subsequent
review without any appraisal (8). A more recent systematic review (9) focused only on
the in vitro antimicrobial effect of ultrasonic activation against Enterococcus faecalis
in comparison with all other irrigation techniques, and many of the included studies
used unreliable experimental models. Therefore, the aim of this study was to systemat-
ically review and critically analyze the evidence on the cleaning and disinfection of root
canals and the healing of apical periodontitis when ultrasonic irrigant activation is
applied during primary root canal treatment of mature permanent teeth compared
with syringe irrigation.
Materials and Methods
This systematic review was reported in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses statement (10).
PICO Question
In adult patients with fully formed permanent teeth in need of primary endodontic
treatment (P), does ultrasonic irrigant activation (I) in comparison with syringe irriga-
tion (C) result in improved healing of apical periodontitis (primary outcome), a stron-
ger antimicrobial effect, or better removal of pulp tissue remnants or hard tissue debris
(secondary outcomes) from the root canal system?
Ultrasonic Irrigant Activation 31
Review Article
Literature Search
Appropriate free-text key words and controlled vocabulary terms
were initially extracted from 10 key articles and were used in a series of
pilot electronic searches. The key terms were further enriched as addi-
tional terms came up, and the electronic search was repeated each time.
An example of the final search strategy is shown in Table 1.
The electronic search strategy was adapted and applied to 6 data-
bases: the Cochrane Library (1995 onward), Embase (1947 onward),
LILACS (1982 onward), PubMed (1950 onward), SciELO (1997 on-
ward), and Scopus (1970 onward). Articles from the inception of these
databases until June 2016 (4th week) were considered. Moreover, all
issues of 7 endodontic journals were hand searched: International
Endodontic Journal (1967 onward); Journal of Endodontics (1975
onward); Oral Surgery, Oral Medicine, Oral Pathology, Oral Radi-
ology, and Endodontology (1948–2011); Dental Traumatology
(formerly Endodontics and Dental Traumatology, 1985 onward);
Australian Endodontic Journal (1982 onward); Endodontic Topics
(2002–2016); and ENDO—Endodontic Practice Today (2007 on-
ward). The International Clinical Trials Registry Platform Search Portal,
ISRCTN registry, and ClinicalTrials.gov were searched for ongoing or
recently completed clinical trials. Gray literature was searched through
OpenGrey (http://www.opengrey.eu) and Grey Literature Report
(http://www.greylit.org/). A complementary search took place on
March 2018 (1st week).
Furthermore, the search was enriched with references from the
relevant chapters of 5 endodontic textbooks (11–16). In addition,
the reference lists of all full-text articles selected after the screening
and relevant previously published reviews (7, 8, 17) were hand
searched for relevant titles not already identified. No language
restriction was applied to any of the searches.
Study Selection
Abstracts were obtained for all the titles identified during the
searches. In cases in which an abstract was not available, a full-text
copy was obtained and evaluated instead. Two reviewers (P.E.C. and
A.R.) screened titles and abstracts (or full-text copies) independently
to select clinical or in vitro studies applying ultrasonic irrigant activa-
tion and exclude completely off-topic articles; reviews; case reports;
comment letters; letters to the editor; books; surveys; conference ab-
stracts; animal studies; studies evaluating only instrumentation; studies
on irrigant flow or penetration; studies on the apical extrusion of debris
or irrigants; and studies on the removal of medicaments, root canal
filling, and subsequent procedures or retreatment. In cases of disagree-
ment, the studies were included in the next step for eligibility
assessment.
Full-text copies were obtained for all titles remaining after
screening. Articles not in English were translated. The reviewers evalu-
ated the full-text articles to determine eligibility and excluded articles
that met any of the following criteria:
1. Not treating human permanent teeth with fully formed apices
2. Using cleared teeth (applicable only to in vitro studies)
3. Not simulating an apically closed system (applicable only to in vitro
studies)
4. Not evaluating root canal cleaning, disinfection, or healing of apical
periodontitis
5. Different/not standardized instrumentation in the compared groups
6. Not including a group with syringe irrigation
7. Not including a group with ultrasonic irrigant activation
8. Not using commonly used irrigants (eg, using radiopaque solutions,
dyes/inks, or their mixtures with other irrigants)
9. Using high-vacuum scanning electron microscopy (SEM) to evaluate
debris/smear layer removal from single-rooted teeth
Disagreements between the 2 reviewers at this stage were resolved
by discussion with a third reviewer (C.B.).
Quality Assessment
Eligible studies were critically analyzed independently by 2 re-
viewers (P.E.C. and A.R.) according to a predetermined list of require-
ments (Supplemental Table S1 is available online at www.jendodon.
com). These requirements were based on published guidelines for sys-
tematic reviews of clinical studies (18) and factors that could possibly
affect irrigation (19). Major sources of bias and the main direction of
the possible bias were also identified. Disagreements at this stage were
resolved through arbitration by a third reviewer (C.B.). The checklist
was further processed to calculate a summary score for each study
based on the number of requirements that were satisfied, and the quality
of the studies was rated as low (score <50%), medium (score 50%–
75%), or high (score >75%).
Data Extraction and Synthesis of Evidence
Predetermined data (Supplemental Table S2 is available online at
www.jendodon.com) were extracted in duplicate from each study
(P.E.C. and A.R.) and arranged into data tables. Disagreements during
data extraction were resolved through discussion with a third reviewer
(C.B.). Because of the extensive variability in the study protocols, the
lack of information about the effect size, and the nonnormal distribution
of the data in most studies, a meta-analysis was not feasible; a narrative
synthesis of the available evidence was conducted instead. Study quality
ratings and indications about possible bias in favor of 1 of the compared

TABLE 1. An Example of the Electronic Search Strategy (Adapted for PubMed)

Number Search strategy Results
#1 “root canal*” OR tooth OR teeth OR endodontic* 234,185
#2 root canal [MeSH Terms] OR tooth [MeSH Terms] 86,943
#3 irriga* OR rins* OR flush* OR clean* 234,216
#4 sodium hypochlorite/administration[MeSH Terms] OR therapeutic irrigation/ 6,502
instrumentation[MeSH Terms] OR therapeutic irrigation/methods[MeSH Terms] OR
root canal irrigants/administration and dosage [MeSH Terms]
#5 ultrasonic* OR ultrasound* OR endosonic* OR activat* OR agitat* OR oscillat* OR 2,154,735
vibrat* OR energ* OR PUI OR UAI OR CUI OR CUAI OR IUAI
#6 acoustic OR streaming OR microstreaming OR micro-streaming OR cavitati* 140,745
#7 Acteon OR Satelec OR Suprasson OR Newtron OR 00 Electro Mechanical Systems00 OR 18,207
EMS OR NSK OR Irrisafe OR 00 ProUltra PiezoFlow00 OR Streamclean OR Enac
#8 (#1 OR #2) AND (#3 OR #4) AND (#5 OR #6 OR #7) 1,266

32 C
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groups were taken into account in the synthesis of the evidence and the
formulation of the conclusions and clinical recommendations.
Results
The combined electronic and hand searches resulted in 1966
unique titles. After screening of the titles and abstracts, 240 titles
were selected by at least 1 reviewer for full-text evaluation. The publi-
cation years ranged from 1980 to 2018. The articles were written in En-
glish (n = 221), Chinese (n = 8), Portuguese (n = 5), French (n = 3),
German (n = 1), Persian (n = 1), and Spanish (n = 1).
Full-text evaluation according to the eligibility criteria resulted in
the exclusion of 14 clinical studies and 178 in vitro studies
(Supplemental Table S3 is available online at www.jendodon.com).
Three clinical studies and 45 in vitro studies were finally included in
the systematic review (Fig. 1). The reviewers’ agreement before discus-
sion was 94.2% (Cohen k = 0.85). All included articles were written in
English. The studies were further categorized according to the out-
comes of interest as follows:
1. Healing of apical periodontitis (n = 1)
2. Antimicrobial effect (n = 19)
3. Removal of pulp tissue remnants (n = 8)
4. Removal of hard tissue debris (n = 20)
Quality Assessment
A summary of the quality assessment of the included studies is pre-
sented in Table 2. None of the included studies met all of the criteria.
Figure 1. A flowchart of the literature search and the selection process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
statement (10).
JOE — Volume 45, Number 1, January 2019
Review Article
Study Design, Specimen Selection, Randomization, and
Instrumentation. A priori sample size calculation was reported
only in 2 of the 48 included studies (65, 66); therefore, it is possible
that some of the studies that found no significant difference between
the 2 methods actually made a type II error. Eight articles did not
specify the type of teeth included in the experiments, 21 articles did
not standardize their length, and another 21 articles did not provide
information about root canal curvature. Moreover, several studies
that included the isthmus area in the evaluations did not balance the
groups in regard to its presence, position, and dimensions (n = 6,
n = 7, and n = 10, respectively). The age of the teeth (donors) was
unknown in all but 1 of the studies on the antimicrobial effect of the
irrigation methods (35); this parameter determines the amount of scle-
rotic dentin (68) and could have affected the infection/disinfection pro-
cedures (69).
Six studies did not describe random allocation of the specimens to
the different groups (21, 23, 26, 27, 34, 48), so their findings may have
been affected by selection bias. Furthermore, 6 studies tried to establish
baseline equality of the compared groups after randomization by
statistical testing of preoperative anatomic parameters (20, 40, 41,
43, 63, 65), an approach of questionable validity (70, 71).
All included studies applied the same instrumentation protocol in
the compared groups and standardized the apical size, but 4 studies did
not specify the root canal taper. Nonetheless, only 9 studies ensured a
strictly standardized final root canal shape in all specimens.
Irrigation. Three studies did not clarify the irrigant delivery method
used during ultrasonic activation (26, 34, 38). Information about the
needle type, size, or insertion depth was lacking in a number of
Ultrasonic Irrigant Activation 33
 34

Review Article
TABLE 2. Quality Assessment of the Included Studies
Design, selection
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of specimens, Assessment Overall

Category Study Type randomization Instrumentation Irrigation of results quality
Healing of apical Liang et al, 2013 (20) Clinical 5/7 2/3 13/16 3/5 Medium
periodontitis
Antimicrobial effect Spoleti et al, 2003 (21) In vitro 1/6 1/3 3/16 3/5 Low
Bhuva et al, 2010 (22) In vitro 2/6 2/3 12/16 3/5 Medium
No brega et al, 2011 (23) In vitro 1/6 2/3 5/16 2/5 Low
Peters et al, 2011 (24) In vitro 3/6 2/3 14/16 2/5 Medium
Case et al, 2012 (25) In vitro 2/6 2/3 8/16 2/5 Low
Cachovan et al, 2013 (26) In vitro 2/6 2/3 10/16 2/5 Medium
Hubbezoglu et al, 2014 (27) In vitro 2/6 2/3 3/16 2/5 Low
Juric et al, 2014 (28) In vitro 2/7 2/3 12/16 1/5 Medium
Niazi et al, 2014 (29) In vitro 2/6 2/3 12/16 2/5 Medium
Neelakantan et al, 2015 (30) In vitro 4/6 2/3 1/16 2/5 Low
Neelakantan et al, 2015 (31) In vitro 3/6 2/3 4/16 2/5 Low
Al-Mahdi & Balto, 2016 (32) In vitro 3/6 2/3 8/16 2/5 Medium
Cherian et al, 2016 (33) In vitro 4/6 2/3 11/16 4/5 Medium
Neuhaus et al, 2016 (34) In vitro 2/6 2/3 9/16 1/5 Low
Pladisai et al, 2016 (35) In vitro 5/6 1/3 14/16 4/5 High
Toljan et al, 2016 (36) In vitro 2/6 2/3 11/16 2/5 Medium
Bao et al, 2017 (37) In vitro 3/6 2/3 13/16 2/5 Medium
Cheng et al, 2017 (38) In vitro 3/6 2/3 14/16 2/5 Medium
Maden et al, 2017 (39) In vitro 3/6 2/3 15/16 2/5 Medium
Removal of pulp tissue Gutarts et al, 2005 (40) Clinical 4/8 2/3 9/16 4/5 Medium
remnants Burleson et al, 2007 (41) Clinical 3/8 2/3 9/16 4/5 Medium
Adcock et al, 2011 (42) In vitro 2/6 2/3 12/16 4/5 Medium
Al-Ali et al, 2012 (43) In vitro 4/6 2/3 11/16 2/5 Medium
Curtis & Sedgley, 2012 (44) In vitro 3/5 2/3 13/16 4/5 High
Yoo et al, 2013 (45) In vitro 3/6 2/3 9/16 2/5 Medium
Vinhorte et al, 2014 (46) In vitro 2/5 2/3 6/16 3/5 Low
Neelakantan et al, 2016 (47) In vitro 3/8 2/3 8/16 2/5 Low
Removal of hard tissue debris Lee et al, 2004 (48) In vitro 1/5 2/3 13/16 3/5 Medium
de Groot et al, 2009 (49) In vitro 3/4 3/3 13/16 4/5 High
de Moor et al, 2009 (50) In vitro 4/5 3/3 10/16 3/5 Medium
van der Sluis et al, 2009 (51) In vitro 1/4 3/3 14/16 1/5 Medium
de Moor et al, 2010 (52) In vitro 4/5 3/3 10/16 3/5 Medium
Jiang et al, 2010 (53) In vitro 3/4 3/3 13/16 2/5 Medium
Jiang et al, 2010 (54) In vitro 3/4 3/3 9/16 1/5 Medium
Klyn et al, 2010 (55) In vitro 3/6 2/3 5/16 2/5 Low
JOE — Volume 45, Number 1, January 2019

Ro€ dig et al, 2010 (56) In vitro 3/4 2/3 13/16 3/5 Medium
Ro€ dig et al, 2010 (57) In vitro 4/5 2/3 13/16 4/5 High
van der Sluis et al, 2010 (58) In vitro 1/4 3/3 15/16 2/5 Medium
Amato et al, 2011 (59) In vitro 2/4 1/3 8/16 3/5 Medium
Howard et al, 2011 (60) In vitro 2/6 2/3 10/16 2/5 Medium
Jiang et al, 2012 (61) In vitro 3/4 3/3 14/16 2/5 High
Arslan et al, 2014 (62) In vitro 3/5 2/3 11/16 4/5 Medium
Thomas et al, 2014 (63) In vitro 2/6 2/3 6/16 3/5 Low
Deleu et al, 2015 (64) In vitro 3/4 3/3 8/16 2/5 Medium
Leoni et al, 2016 (65) In vitro 4/6 2/3 10/16 3/5 Medium
Duque et al, 2017 (66) In vitro 4/7 2/3 11/16 2/5 Medium
Kamaci et al, 2018 (67) In vitro 4/6 2/3 8/16 4/5 Medium
The numbers indicate how many of the requirements were met by each study. Low <50%, medium 50%–75%, and high >75%.

studies (ultrasonic activation group: n = 9, n = 5, and n = 19 and
syringe irrigation group: n = 13, n = 6, and n = 13, respectively).
One study reported irrigant delivery through a 35-G needle (25), which
is likely an error. Five studies reported differences in these parameters
between the compared groups (37, 42, 44, 45, 60), which may have
introduced bias in the comparisons (72, 73). It is noteworthy that 3
studies used very large needles (<27G) for syringe irrigation (26,
35, 41), which deviated from current clinical standards. Even though
needles of the same size were also used in the ultrasonic activation
groups, this choice possibly limited the insertion depth of the needle
and the resulting irrigant penetration (72, 74, 75), leading to
overestimation of the ultrasonic activation effect.
Several studies did not mention the volume of at least 1 irrigant or
its flow rate (ultrasonic activation group: n = 10 and n = 23 and syringe
irrigation group: n = 4 and n = 16, respectively). In addition, these pa-
rameters often differed between the 2 groups (n = 11 and n = 11,
respectively) despite their importance for irrigant penetration (76,
77) and root canal cleaning (78–80).
One study did not describe the type of ultrasonic file/tip used (27),
7 studies did not provide details about its size, and 17 studies did not
mention its insertion depth. Activation was applied to rather narrow
root canals in some cases (apical size $20), which may have increased
the chance of file-to-wall contact, oscillation dampening (81–83), and
inadvertent dentin removal (84). Two studies applied ultrasonic activa-
tion also during instrumentation (20, 23), which is likely to have
amplified these effects.
At least 23 different ultrasound devices produced by 14 manufac-
turers were used in the included studies, whereas 4 studies omitted this
information (30, 55, 59, 63). Even though only 1 device was used per
study, this wide variation hindered comparisons between studies.
Currently, there is no evidence that identical power settings on
different devices correspond to the same file oscillation amplitude,
which has a pronounced effect on irrigant streaming and cleaning
(85). Furthermore, the power settings actually used in the included
studies were also not identical, and they ranged from 10%–100% of
the maximum power (Fig. 2E) although manufacturers recommend
up to 30%–35% when ultrasonic files are used for irrigant activation
(86–89) and approximately 30%–50% when ultrasonically
oscillating needles are used (90). Nine studies did not report this crit-
ical parameter.
The number of activation cycles also varied widely (Fig. 2F), and
because of the strong effect of the oscillation startup on irrigant stream-
ing and root canal cleaning (53), it may have influenced the perfor-
mance of ultrasonic activation even if the total activation time
remained constant. Four studies did not clarify this parameter (23,
27, 30, 31), and 1 of them also did not report the duration of each
cycle (27).
Forty-three studies did not standardize the primary direction of ul-
trasonic file/tip oscillation, which has a pronounced effect on cleaning
(54). In addition, 4 of the studies that standardized it (48, 51, 58, 61)
always directed the oscillation toward the areas of interest, thereby
maximizing the observed effect. Such optimization is clinically
unrealistic, so these studies possibly overestimated the cleaning efficacy.
The irrigant contact time differed between the syringe irrigation
and ultrasonic activation groups in 12 studies regarding sodium hypo-
chlorite (NaOCl) and 2 studies regarding EDTA, whereas relevant infor-
mation was missing from 19 and 2 studies, respectively. A common
finding in several studies was that, in order to balance the contact
time between the compared groups, the irrigant was delivered at a
much lower flow rate in the syringe group (28, 31, 33, 36, 37, 49,
58) or less irrigant was delivered in the ultrasonic activation group
(22, 29, 34). Both of these differences introduced bias in the
JOE — Volume 45, Number 1, January 2019
Review Article
comparisons and could have been avoided by simply adding a rest
period after irrigant delivery in the syringe irrigation group.
Overall, the ultrasonic activation and syringe irrigation groups
were irrigated under identical conditions (except for the activation cy-
cles) only in 3 of 48 studies (24, 39, 65); all other studies either did not
provide enough information or reported deviations in the irrigation
protocol between the compared groups, which may have introduced
bias in the comparisons. It is noteworthy that indications that
ultrasonic activation groups were potentially favored were found in
13 studies, whereas corresponding indications in favor of the syringe
irrigation groups were found in 3 studies.
Outcome Assessment. Only 22 of 48 studies performed either
blinded or observer-independent evaluation of the outcome in order
to reduce the detection bias. Eleven studies used unsuitable statistical
tests (28, 32, 34, 47, 48, 51, 53, 54, 58, 61, 64); parametric tests
were often used to analyze ordinal data, or tests assuming
independent groups were used to analyze repeated measurements on
the same specimens. One study included an exploratory statistical
analysis without adjustment of the alpha level to account for multiple
pairwise comparisons (34); therefore, this analysis was excluded
from the review. Thirty-four studies did not report exact P values,
and 46 studies did not provide any indication about the magnitude of
the difference between the 2 methods (eg, effect size); the latter hin-
dered quantitative synthesis through meta-analysis.
Synthesis of Evidence
Study Design, Specimen Selection, and Instrumentation.
The main aim of all 48 studies was to compare different irrigation
methods. Other aims were to compare irrigants (n = 5), irrigation/acti-
vation protocols (n = 7), types of teeth (n = 2), or instrumentation pro-
tocols (n = 1). Regarding study design, 1 study was a 2-arm
randomized controlled clinical trial with a parallel group design
(20); 2 clinical studies also included 2 independent groups of patients
who received treatment, but the teeth were later extracted and evaluated
ex vivo (40, 41); and 45 studies used extracted teeth allocated to
independent groups (n = 34), reused for repeated experiments
(n = 10), or both (n = 1). The sample size ranged from 5 to 43
specimens per group/subgroup (median = 13). Thirty-six studies
included specimens with a single root/single root canal, whereas 14
studies included molars. Most studies used specimens with straight
root canals (n = 17); 3 studies included curved root canals, and 7
studies included both straight and curved root canals. The apical size
ranged between 20 and 60 (median = 35) and the taper between
0.00 and 0.10.
Irrigation. Most studies applied ultrasonic activation after instru-
mentation, but 2 studies activated the irrigant also during instrumenta-
tion (20, 23). Thirty-nine studies chose to deliver the irrigants in the
apical part of the root canal either intermittently through a syringe
and needle before each activation cycle (n = 32) or continuously
through an ultrasonically activated needle (n = 7). Twelve studies deliv-
ered the irrigants continuously in the pulp chamber or in the coronal
third of the root canal either through the ultrasonic handpiece
(n = 9) or through a syringe and needle (n = 4).
Open-ended needles were used in 18 studies for intermittent sy-
ringe delivery of the irrigant in the root canal, whereas 9 studies used
closed-ended needles. Their size varied between 25 G and 31 G with
the most widely used sizes being 30 G (n = 16) and 27 G (n = 11),
and they were generally inserted to 1–2 mm from the working length
(WL). Ultrasonically oscillating needles used for continuous delivery
and activation were open-ended in all cases and either 25 G (n = 4)
or 30 G (n = 3) in size. In general, needles of the same type and
Ultrasonic Irrigant Activation 35
Review Article

Figure 2. An overview of irrigant activation protocols used in the included studies. (A) The volume of irrigants delivered before/during ultrasonic activation in
each root canal. (B) The flow rate of each irrigant delivered before/during ultrasonic activation. (C) The size and type of the ultrasonic files/tips used for irrigant
activation (corresponding gauge sizes of the ultrasonically oscillating [U/S] needles are provided in parentheses). (D) The size of the ultrasonic files/tips used in
root canals of various apical preparation sizes. (E) The power setting used for different types of ultrasonic files/tips during irrigant activation. (F) The number of
irrigant activation cycles and the duration of activation per cycle for NaOCl. NR, not reported.

size were used, and they were inserted to the same depth in the syringe
irrigation groups, except for 5 studies that reported differences (37, 42,
44, 45, 60).
NaOCl in concentrations of 1%–10%, EDTA in concentrations of
15%–17%, and physiologic saline were the most frequently used irri-
gants (n = 46, n = 21, and n = 14, respectively) and also the ones
most frequently activated (n = 44, n = 7, and n = 8, respectively).
Distilled/tap water, chlorhexidine 2%, octenidine 0.1%, and a mixture
of NaOCl and etidronic acid were used less frequently. The total volume
of irrigant delivered per root canal in the ultrasonic activation groups
ranged from 1.5–200 mL for NaOCl, 1–15 mL for EDTA, and 1–6 mL
for saline (Fig. 2A). The flow rate ranged between 0.006 and 1.1 mL/
s (Fig. 2B). Matching irrigant volumes and flow rates were used in
the syringe irrigation groups in 37 and 37 studies, respectively.
The most commonly used ultrasonic files/tips were K-files
(n = 19) and Irrisafe (Acteon Satelec, Merignac, France) files
(n = 15). Smooth wires and ultrasonically oscillating needles were
also used (n = 7, and n = 7, respectively). The most widely used sizes
were 15 and 20 (Fig. 2C). The root canal size did not seem to influence
the choice of these parameters (Fig. 2D). Ultrasonic files/tips were usu-
ally inserted to 1 mm from the WL (n = 24), whereas fewer studies in-
serted them to the WL (n = 1) or to 2 mm from the WL (n = 7). The
power settings ranged from 10%–100% of the maximum power
(Fig. 2E); the number of activation cycles varied between 1 and 12,
and each cycle lasted for 0.1–180 seconds (Fig. 2F), resulting in a total
activation time between 1.2 and 180 seconds.
The total contact time (the sum of delivery, activation, and any rest
time) ranged between 30 and 300 seconds for NaOCl and between 60
and 195 seconds for EDTA in the ultrasonic activation groups. The cor-
responding ranges were 13–420 seconds and 60–180 seconds in the
syringe irrigation groups. Further details on the irrigation protocols
of individual studies are available in Supplemental Table S4–S6
(available online at www.jendodon.com).
Healing of Apical Periodontitis (Primary Outcome). Only 1
randomized controlled clinical trial (20) provided information on the
primary outcome. Healing of apical periodontitis after primary root

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TABLE 3. A Summary of the Methodology and the Results of the Studies That Evaluated the Healing of Apical Periodontitis or the Removal of Pulp Tissue Remnants
Specimens Delivery in Area of Superior Group favored
Study Type (outcome) (curvature) n Size/taper Irrigants U/S group Assessment interest group by protocol Study quality
Liang et al, Clinical (healing Single rooted 41 40/.00 NaOCl, EDTA Needle CBCT — — Ultrasonics Medium
2013 (20) of apical (straight +
periodontitis) curved)
Gutarts et al, Clinical Mandibular 15 30/.04 NaOCl U/S needle Histologic Apical third Ultrasonics* Ultrasonics Medium
2005 (40) (pulp tissue) molar roots sections
(straight +
curved)
Burleson et al, Clinical Mandibular 20 30/.04 NaOCl U/S needle Histologic Apical third Ultrasonics Ultrasonics Medium
2007 (41) (pulp tissue) molar roots sections
(straight +
curved)
Adcock et al, In vitro Mandibular 10 40/.04 NaOCl, EDTA U/S needle Histologic Apical third Ultrasonics* Unclear Medium
2011 (42) (pulp tissue) molar roots sections
(NR)
Al-Ali et al, In vitro Molar roots 20 40/.04 NaOCl, EDTA Needle Histologic Apical third Ultrasonics Ultrasonics Medium
2012 (43) (pulp tissue) (curved) sections
Curtis & In vitro Single rooted 19 36/.04 NaOCl, EDTA U/S needle Histologic sections Apical third Ultrasonics Unclear High
Sedgley, (pulp tissue) (straight)
2012 (44)
Yoo et al, 2013 In vitro Mandibular 15 35/.06 NaOCl, Needle Histologic Apical third — Ultrasonics Medium
(45) (pulp tissue) molar roots saline U/S needle sections Ultrasonics* Unclear
(curved)
Vinhorte In vitro Single rooted (NR) 10 25/.08 NaOCl Needle Histologic Apical third Ultrasonics Unclear Low
et al, (pulp tissue) sections
2014 (46)
Neelakantan In vitro Mandibular 10 25/.08 NaOCl, EDTA, Needle Histologic sections Apical third Ultrasonics Unclear Low
et al, 2016 (pulp tissue) molars (NR) distilled
(47) water

CBCT, cone-beam computed tomography; NaOCl, sodium hypochlorite; NR, not reported; U/S, ultrasonic.
*Significant differences were detected only in some of the tested areas. Other areas showed no difference.
Ultrasonic Irrigant Activation

Review Article
37
 38

Review Article
C
aput
a et al.

TABLE 4. A Summary of the Methodology and the Results of the Studies That Evaluated the Antimicrobial Effect
Delivery Group
Specimens in U/S Species Incubation Superior favored by Study
Study Type (curvature) n Size/taper Irrigants group inoculated period Sampling Assessment group protocol quality
Spoleti et al, In vitro Single rooted + 10 50, 35/NR Saline Needle Multiple 3d Root half Culture Ultrasonics Unclear Low
2003 (21) molar roots (NR)
Bhuva In vitro Single rooted (NR) 12 30/.09 NaOCl Needle E. faecalis 3d — SEM (root half) — Syringe Medium
et al, 2010
(22)
 brega
No In vitro Single rooted 10 50/.05 NaOCl, EDTA Needle E. faecalis 20 d Paper point Culture — Unclear Low
et al, 2011 (straight)
(23)
Peters et al, In vitro Single rooted (NR) 20 20/.07 NaOCl Needle Multiple 21 d File + paper Culture — — Medium
2011 (24) (in situ) point + histology
(apical third)
Case et al, In vitro Single rooted (NR) 14 35/.06 Saline Needle E. faecalis 14 d File Culture — Unclear Low
2012 (25)
Cachovan In vitro Single rooted 25 40/.04 Saline NR E. faecalis NR Paper point Culture Ultrasonics Unclear Medium
et al, 2013 (straight)
(26)
Hubbezoglu In vitro Single rooted (NR) 10 30/.09 NaOCl Needle E. faecalis 1d Paper point Culture — Unclear Low
et al, 2014
(27)
Juric et al, In vitro Single rooted (NR) 20 30/.09 NaOCl U/S handpiece E. faecalis 10 d File + Culture Ultrasonics Ultrasonics Medium
2014 (28) syringe
Niazi et al, In vitro Single rooted (NR) 5 30/.09 NaOCl Needle Multiple 14 d Paper point Culture — Syringe Medium
2014 (29) Chlorhexidine Ultrasonics*
Saline Ultrasonics*
Neelakantan In vitro Single rooted (NR) 25 35/.04 NaOCl Needle E. faecalis 28 d Dentin Culture — Unclear Low
et al, 2015 shavings + CLSM
(30) (root half)
Neelakantan In vitro Single rooted (NR) 20 25/.06 NaOCl + HEDP Needle E. faecalis 28 d Dentin Culture — Ultrasonics Low
et al, 2015 NaOCl, EDTA shavings + CLSM — Unclear
(31) NaOCl, EDTA† (root half) — Unclear
Saline — Ultrasonics
Al-Mahdi & In vitro Single rooted 19 40/.04 NaOCl Needle E. faecalis 21 d Paper point Culture — Ultrasonics Medium
Balto, 2016 (straight + Saline + SEM Ultrasonics*
(32) curved)
Cherian et al, In vitro Single rooted 12 50/NR Chlorhexidine Needle E. faecalis 7d Dentin Culture Ultrasonics Ultrasonics Medium
2016 (33) (straight) Octenidine shavings Ultrasonics
JOE — Volume 45, Number 1, January 2019

Neuhaus et al, In vitro Single-rooted, 6 25/.08 NaOCl, saline NR Multiple 21 d Paper point Culture — Unclear Low
2016 (34) premolar +
molar roots
(straight
+ curved)
Pladisai et al, In vitro Single rooted 12 60/NR NaOCl Needle E. faecalis 21 d Dentin Culture Ultrasonics Ultrasonics High
2016 (35) (straight) shavings +
paper point
 Review Article
canal treatment in single-rooted teeth with straight or moderately
curved root canals irrigated with or without ultrasonic activation was
Medium

Medium

Medium

Medium
evaluated by cone-beam computed tomographic scans 10–19 months
after treatment (recall rate = 82%). The study quality was medium.
No significant difference was found between the syringe irrigation
and the ultrasonic activation groups despite indications that the irriga-
Ultrasonics

Ultrasonics
Unclear

Unclear

tion protocol favored the ultrasonic activation group (Table 3).

—

Antimicrobial Effect (Secondary Outcome). All 19 studies

were conducted in vitro and included specimens with a single root/sin-
gle straight root canal or molar roots with a single straight root canal.
Ultrasonics
Ultrasonics
Ultrasonics
Ultrasonics
Ultrasonics
Syringe

Two studies also included a number of specimens with curved root ca-
—

nals. The root canals were usually inoculated with a single species
(n = 14), often E. faecalis, but 4 studies tried to create a multispecies
biofilm, and 1 study established a polymicrobial infection in situ. The
(root half)

incubation period varied between 1 and 28 days (median = 20.5 days).

Culture

Culture

Culture

Seventeen studies used culture-based techniques to quantify the

SEM

antimicrobial effect; samples were usually obtained by paper points

(n = 9), files (n = 5), or syringes (n = 2), but 5 studies collected dentin
shavings and 1 study obtained root halves as samples. Two studies used
paper point

confocal laser scanning microscopy to quantify the remaining biofilm

shavings
syringe

mass and the percentage of “dead” bacterial cells on root halves. Three
Dentin
File +

File +
—

studies used SEM and scored the presence of biofilm on the root canal
CLSM, confocal laser scanning microscopy; HEDP, 1-hydroxyethane 1,1-diphosphonic acid or etidronic acid; NR, not reported; SEM, scanning electron microscopy; U/S, ultrasonic.

wall. Finally, 1 study examined histologic sections from the apical third
and quantified the percentage of the root canal perimeter covered by
bacteria. Most studies were ranked as medium quality.
Ten studies reported that ultrasonic activation was more effective
28 d

28 d

21 d
1d

either in all subgroups/areas tested (n = 8) or in some of them (n = 2),

but in 5 of these studies, there were indications that this method was
favored by the irrigation protocol. Eight studies could not detect any dif-
ference between ultrasonic activation and syringe irrigation; the irriga-
E. faecalis

E. faecalis

E. faecalis
Multiple

tion protocol appeared to favor syringe irrigation in 1 of them. One

study reported that syringe irrigation was more effective in some of
the subgroups tested, without clear indications of favoring this method
(Table 4).
U/S handpiece

NaOCl, saline U/S handpiece

+ needle

Removal of Pulp Tissue Remnants (Secondary Outcome).

Needle

NR

Two clinical studies and 6 in vitro studies provided information about

*Significant differences were detected only in some of the tests/examined areas. Other areas showed no difference.

this outcome. Most of the studies in this category included molar teeth,
except for 2 studies that included specimens with a single root/single
sterile water
NaOCl, EDTA,

root canal. Four studies mentioned that the specimens had curved
NaOCl†

root canals. After instrumentation and irrigation, the apical third of

NaOCl
Saline

the specimens was processed for histologic analysis, and the area occu-
pied by pulp tissue remnants within the main root canal or the isthmus
was quantified on sections examined under an optical microscope.
Most studies were ranked as medium quality.
30/.09

40/.06

40/.04

30/.09

All 8 studies concluded that ultrasonic activation was superior to

syringe irrigation either in all subgroups/areas tested (n = 5) or in
some of them (n = 3), but 3 of the studies appeared to have favored
In vitro Single rooted (NR) 12

15

In vitro Single rooted (NR) 11

the ultrasonic activation groups (Table 3).

In vitro Single rooted (NR)

Removal of Hard Tissue Debris (Secondary Outcome). All

NR (straight)

20 studies on the removal of hard tissue debris were conducted

in vitro. Fifteen studies included specimens with a single root/single
root canal, whereas 6 studies included molar root canals. Three studies
reported the inclusion of specimens with curved root canals. Most
Different irrigation/activation protocols.

studies used the “split-tooth” model and scored the removal of manu-
In vitro

ally packed hard tissue debris from artificially created grooves and de-
pressions along the root canal. Four studies evaluated the removal of
hard tissue debris packed during instrumentation in the main root
Bao et al, 2017

Maden et al,

canals and in the isthmus of molar specimens that were presectioned

Cheng et al,
2016 (36)

2017 (38)

2017 (39)
Toljan et al,

at 2–3 levels and reassembled. Evaluation always took place under a

(37)

stereoscopic microscope or SEM, except for 1 study that used

micro–computed tomographic imaging to quantify the volume of
†

JOE — Volume 45, Number 1, January 2019 Ultrasonic Irrigant Activation 39

 40

Review Article
C
aput
a et al.

TABLE 5. A Summary of the Methodology and the Results of the Studies That Evaluated the Removal of Hard Tissue Debris
Group
Specimens Size/ Delivery in Area of Superior favored by
Study Type (curvature) n taper Irrigants U/S group Assessment interest group protocol Study quality
Lee et al, In vitro Single rooted (NR) 8 50/.05 NaOCl U/S handpiece Stereomicr. Groove Ultrasonics Unclear Medium
2004 (48)
de Groot In vitro Single rooted 20 35/.06 NaOCl Needle Stereomicr. Groove Ultrasonics Ultrasonics High
et al, 2009 (straight)
(49)
de Moor In vitro Single rooted 20 40/.06 NaOCl Needle Stereomicr. Groove Ultrasonics Unclear Medium
et al, 2009 (straight)
(50)
van der Sluis In vitro Single rooted (NR) 20 20/.10 NaOCl U/S handpiece† Stereomicr. Groove Ultrasonics Ultrasonics Medium
et al, 2009 Needle† Ultrasonics
(51)
de Moor In vitro Single rooted 20 40/.06 NaOCl Needle Stereomicr. Groove Ultrasonics Unclear Medium
et al, 2010 (straight) Needle Ultrasonics
(52)
Jiang et al, In vitro Single rooted 20 30/.06 NaOCl Needle† Stereomicr. Groove Ultrasonics Ultrasonics Medium
2010 (53) (straight)
Jiang et al, In vitro Single rooted 20 30/.06 NaOCl Needle† Stereomicr. Groove Ultrasonics Unclear Medium
2010 (54) (straight)
Klyn et al, In vitro Mandibular molar 10 40/.04 NaOCl, water U/S handpiece + Stereomicr. Canal + — Unclear Low
2010 (55) roots (straight + needle isthmus
curved) (apical +
middle third)
€ dig et al,
Ro In vitro Single rooted 10 35/.02 NaOCl U/S handpiece Stereomicr. Groove Ultrasonics Unclear Medium
2010 (56) (straight)
€ dig et al,
Ro In vitro Single rooted 10 30, 40, 50/.02 NaOCl U/S handpiece Stereomicr. Groove, Ultrasonics Unclear High
2010 (57) (straight) depressions
van der Sluis In vitro Single rooted (NR) 20 30/.06 NaOCl Needle Stereomicr. Groove Ultrasonics Ultrasonics Medium
et al, 2010
(58)
Amato et al, In vitro Single rooted 6 45/NR NaOCl Needle Stereomicr. Canal wall, Ultrasonics Unclear Medium
2011 (59) (straight) depressions
Molars (curved) 6 45/NR NaOCl —
Howard In vitro Mandibular molar 10 40/.04 NaOCl, EDTA U/S needle Stereomicr. Canal + — Unclear Medium
et al, 2011 roots (NR) isthmus
JOE — Volume 45, Number 1, January 2019

(60) (apical third)

Jiang et al, In vitro Single rooted 20 40/.02 NaOCl U/S needle Stereomicr. Groove Ultrasonics Syringe High
2012 (61) (straight)
Arslan et al, In vitro Single rooted (NR) 6 40/.06 NaOCl Needle Stereomicr. Groove — Syringe Medium
2014 (62)
Thomas et al, In vitro Mandibular molar 16 40/.06 NaOCl, EDTA Needle Stereomicr. Canal + Ultrasonics Unclear Low
2014 (63) roots (NR) isthmus
(apical third)
Deleu et al, In vitro Single rooted 20 30/.06 NaOCl Needle Stereomicr. Groove Ultrasonics Unclear Medium
2015 (64) (straight)
 Review Article
remaining hard tissue debris after final irrigation. Most studies were
ranked as medium quality.
Medium

Medium

Medium
Seventeen studies reported that ultrasonic activation was more
effective than syringe irrigation either in all cases (n = 15) or in
some of the groups/areas tested (n = 2), but in 4 of these studies, there
were indications that ultrasonic activation groups were favored. Three
studies could not detect any difference between the 2 methods, but the
Unclear

Unclear

irrigation protocol appeared to favor syringe irrigation in 1 of them

—

(Table 5).
Ultrasonics*
Ultrasonics

Ultrasonics

Discussion
Most of the available information on ultrasonic irrigant activation
still originates from in vitro studies, which are frequently quoted to sup-
port the use of this method (7–9). In order to provide a comprehensive
answer to the PICO question and highlight possible inconsistencies
middle third)
(apical +
isthmus

between different types of studies, both clinical and in vitro studies

Complete

Canal +

Groove

were included in this review although they represent different levels

of evidence. The type of each study was clearly identified in the
summarizing tables, and it was also taken into account during the
synthesis of the evidence.
A number of studies were excluded because of internal validity is-
Stereomicr.
Micro-CT

sues such as nonstandardized instrumentation, which may affect irri-

SEM

gant penetration (75, 91, 92) and the cleaning and disinfection of
the root canal (80, 93, 94). In addition, studies on debris or smear
layer removal from single-rooted teeth under high-vacuum SEM were
excluded because of the fundamental methodological limitations of
this method (1, 95, 96). External validity issues were also regarded
as reasons for exclusion. Animal teeth present anatomic differences
Micro-CT, micro–computed tomography; NR, not reported; SEM, scanning electron microscopy; Stereomicr, stereoscopic microscope; U/S, ultrasonic.
Needle

Needle

Needle

from human teeth (97, 98), and artificial root canals and cleared
human teeth have a more hydrophobic surface compared with
natural dentin, which may affect irrigant penetration (99). Liquids
such as radiopaque solutions and dyes are not used commonly as irri-
gants and may behave differently inside the root canal (99). Moreover,
the clinical relevance of in vitro studies that did not simulate an apically
Dist.water

closed system is questionable (100).

NaOCl,
NaOCl

NaOCl

Incomplete reporting and standardization of the irrigation and

activation protocols within studies along with wide variation in the pro-
tocols between studies were 2 important findings of this review. The
*Significant differences were detected only in some of the tested areas. Other areas showed no difference.

introduction of unnecessary confounders to the experiments may

have favored 1 of the groups, and differences between studies may
25/.08

35/.04

50/.05

have affected the overall performance of the irrigation methods even

if the comparisons within each study remained valid. Ideally, meta-
regression could provide some insight on the effect of each parameter
on the outcomes of interest (101), but such an approach was not
10

10

15

feasible here primarily because of incomplete reporting.

Healing of apical periodontitis is undoubtedly the primary
Mandibular molar

Mandibular molar
roots (straight)
roots (curved)

outcome of interest in clinical endodontics. Nevertheless, surrogate

Single-rooted
(straight)

end points or markers are frequently used instead in experimental

studies. The key role of microbial biofilms in the development of pulpal
and periapical disease (102) renders the reduction of the intracanal mi-
crobial load the most relevant surrogate marker. This marker appears
to predict healing, at least to some extent (103). Other frequently used
Various irrigation/activation protocols.

surrogate markers, such as the removal of pulp tissue remnants or hard

In vitro

In vitro

Kamaci et al, In vitro

tissue debris, may have an indirect effect on healing by removing nutri-

ents or improving the access of irrigants to microbes (5, 104–107), but
their actual contribution to the healing of apical periodontitis remains
Duque et al,

unclear.
2016 (65)

2017 (66)

2018 (67)
Leoni et al,

The effectiveness of ultrasonic activation seems to differ depending

on the outcome evaluated. Almost all studies, clinical and in vitro,
agreed that ultrasonic activation is more effective than syringe irrigation
regarding the removal of pulp tissue remnants and hard tissue debris,
†

JOE — Volume 45, Number 1, January 2019 Ultrasonic Irrigant Activation 41

Review Article
but only around half of the in vitro studies found a superior antimicro-
bial effect and the clinical trial could not detect any improvement in the
healing of apical periodontitis. This apparent discrepancy remained
even when only studies using specimens with a single root canal were
considered or when lower-quality studies or studies not using NaOCl
were excluded (sensitivity analysis). It is possible that the wide variation
in the irrigation protocols may have influenced the performance of the
methods in some of the studies. Furthermore, microbiological studies
are technically more demanding compared with the pulp tissue or hard
tissue removal studies, so it may have been difficult to demonstrate sig-
nificant differences. In addition, the methodology used to measure the
effect of the compared irrigation methods against single-species biofilm
models in vitro is oversimplified, so these studies may have not repre-
sented sufficiently the in vivo effect of the compared irrigation methods.
On the other hand, it is also possible that the removal of pulp tissue rem-
nants or hard tissue debris may not be reliable predictors of healing, so
their value as surrogate markers may be questionable. Finally, the clin-
ical trial (20) may have incorrectly accepted the null hypothesis (no dif-
ference between the compared irrigation methods) because of an
inadequate sample size (type II error) since a power analysis was not
conducted.
Future in vitro studies should focus on specimens with multiple
root canals that could reveal further differences in the effectiveness of
the 2 irrigation methods. Moreover, the research interest should shift
from the removal of hard tissue debris to the antimicrobial effect,
and more standardized protocols should be used. The use of multispe-
cies biofilm models as well as in situ confocal laser scanning micro-
scopy could enhance the clinical relevance of the findings. Finally,
more clinical trials evaluating healing of apical periodontitis both in
teeth with a single root canal and, primarily, in teeth with multiple
root canals are also needed.
Conclusions
Intermittent ultrasonic irrigant activation did not improve the heal-
ing rate of apical periodontitis compared with syringe irrigation after
primary root canal treatment of teeth with a single root canal. Neverthe-
less, this finding was based on a single medium-quality randomized
clinical trial. It remains unclear whether ultrasonic activation can
reduce the microbial load further than syringe irrigation in vitro, but
it is more effective in the removal of pulp tissue remnants based on
both clinical and in vitro studies. It is also more effective in the removal
of hard tissue debris in vitro. Ultrasonic activation groups were
possibly favored in 13 studies, whereas syringe irrigation groups may
have been favored in 3 studies. The overall level of the available evidence
was low, so no strong clinical recommendations could be formulated.
Acknowledgments
The authors thank their colleagues who helped with the trans-
lation of non-English articles.
The authors deny any conflicts of interest related to this study.
Supplemental Material
Supplementary material associated with this article can be found in
the online version at www.jendodon.com (https://doi.org/10.1016/j.
joen.2018.09.010).
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JOE — Volume 45, Number 1, January 2019

SUPPLEMENTAL TABLE S1. Quality Requirements during Critical Appraisal of
Included Studies
Study design, specimen selection, and randomization
1. Sample size calculation a priori
2. Type of teeth
3. Length
4. Curvature
5. Presence, position, and dimensions of isthmus
6. Age of the teeth/patients
7. Diagnosis
8. Random allocation to different groups
Instrumentation
9. Identical standardized instrumentation in all groups/
subgroups compared
10. Apical root canal size and taper
11. Root canal geometry completely standardized after
instrumentation
Irrigation
12. Irrigants used: type and concentration
13. Needle: type and size (syringe irrigation group)
14. Needle insertion depth (syringe irrigation group)
15. Duration of irrigant delivery/rest (syringe irrigation
group)
16. Volume of irrigant delivered (syringe irrigation group)
17. Irrigant flow rate (syringe irrigation group)
18. Ultrasound device (model and manufacturer)
19. Ultrasonic file/tip: type, size, length
20. Ultrasonic file/tip: insertion depth
21. Oscillation direction standardized
22. Duration of activation
23. Power setting
24. Volume of irrigant delivered (ultrasonic activation
group)
25. Duration of irrigant delivery/rest (ultrasonic activation
group)
26. Irrigant flow rate (ultrasonic activation group)
27. Irrigation protocols identical in the compared groups
except for activation cycles
Assessment of results
28. Blinded/observer-independent assessment of the re-
sults
29. Data summary (descriptive statistics) or complete raw
data
30. Suitable statistical tests
31. Exact P values
32. Effect size/confidence interval of difference between
the groups
JOE — Volume 45, Number 1, January 2019
Review Article
SUPPLEMENTAL TABLE S2. Data Extracted from Included Studies
First author name and year of publication
Study design
Aim of the study
Outcome measures
Irrigation methods/systems used in each group
Sample size per group
Type of teeth, length, curvature (angle, radius), isthmus
details (presence, position, length, width), age of teeth/
patients, diagnosis
 Apical end point of instrumentation (distance from apical
foramen)
 Working length
 Apical root canal size and taper
 Number of instruments used
 Irrigants used (type and concentration)
 Irrigation protocol during instrumentation
 Syringe irrigation group: type and size of needle, insertion
depth, volume of each irrigant delivered, duration of de-
livery/rest, flow rate
 Ultrasonic activation group: method of irrigant delivery,
type and size of needle (if syringe irrigation was employed
for delivery), insertion depth, volume of each irrigant
delivered, duration of delivery/rest, flow rate, method of
activation (continuous/intermittent), ultrasound device
(model and manufacturer), power setting, ultrasonic file/tip
(type, size, length, insertion depth), oscillation direction,
number of activation cycles and duration of each cycle,
duration of rest
 Irrigation protocol after the main experiments (if any) in
order to deactivate/flush out irrigants
 Method of assessment of the results
 Area of interest
 Data summary (mean/median, standard deviation/inter-
quartile range, frequencies, etc)
 Statistically significant differences and P values
 Effect size/95% confidence interval of the difference be-
tween the groups
 Data normally distributed (yes/no)
 Conflict of interest
Additional data from clinical studies
 Follow-up period
 Recall rate
Additional data from microbiological studies
 Species inoculated
 Incubation period
 Verification of biofilm formation (in some specimens) (yes/
no)
 Confirmed infection in all specimens (yes/no)
 Sampling method
 Detection method
Ultrasonic Irrigant Activation 44.e1
Review Article
SUPPLEMENTAL TABLE S3. Excluded Studies after Full-text Evaluation
Excluded studies Criteria
1. Weller RN, Brady JM, Bernier WE. Efficacy of ultrasonic cleaning. J Endod 1980;6:740–743. 4, 5
2. Moorer WR, Wesselink PR. Factors promoting the tissue dissolving capability of sodium hypochlorite. Int Endod J 1
1982;15:187–196.
3. Cameron JA. The use of ultrasonics in the removal of the smear layer: a scanning electron microscope study. J 3, 5, 9
Endod 1983;9:289–292.
4. Cameron JA. The use of ultrasound and an EDTA-urea peroxide compound in the cleansing of root canals. An 3, 9
SEM study. Aust Dent J 1984;29:80–85.
5. Delzangles B. Endodontic irrigation. Survey of effectiveness. Inf Dent 1986;68:1435–1445. 3, 9
6. Alaçam T, Demirtola N, Misirligil A, et al. In vivo comparison of antimicrobial effectiveness of conventional and 5
ultrasound activated irrigation techniques in root canal therapy. Bull Tokyo Dent Coll 1987;28:19–22.
7. Apap M, Thorin C. Role of synergy, instrumentation, irrigation, vibrations in endodontics. Rev Fr Endod 1, 3, 9
1987;6:29–43.
8. Cameron JA. The synergistic relationship between ultrasound and sodium hypochlorite: a scanning electron 3, 5, 9
microscope evaluation. J Endod 1987;13:541–545.
9. Cameron JA. The use of 4 per cent sodium hypochlorite, with or without ultrasound, in cleansing of 1, 9
uninstrumented immature root canals; SEM study. Aust Dent J 1987;32:204–213.
10. Nun~ ez de Uribe Echevarrıa N, Badanelli P, Martınez Berna A, Uribe Echevarrıa J. Elimination of the smear layer 3, 9
with ultrasonic apparatus and various irrigating solutions. Rev Esp Endodoncia 1987;5:1–9.
11. Cameron JA. The use of ultrasound for the removal of the smear layer. The effect of sodium hypochlorite 3, 5, 6, 9
concentration; SEM study. Aust Dent J 1988;33:193–200.
12. Lumley PJ, Walmsley AD, Laird WR. An investigation into cavitational activity occurring in endosonic 1, 3, 4, 6, 8
instrumentation. J Dent 1988;16:120–122.
13. Maquin M, Laurent-Maquin D. Qualitative evaluation of the efficiency of new mechanized endodontic technics: 3, 6, 9
macroscopic and microscopic studies. Inf Dent 1988;70:1223–1236.
14. Ciucchi B, Khettabi M, Holz J. The effectiveness of different endodontic irrigation procedures on the removal of 9
the smear layer: a scanning electron microscopic study. Int Endod J 1989;22:21–28.
15. Druttman AC, Stock CJ. An in vitro comparison of ultrasonic and conventional methods of irrigant replacement. 1, 4
Int Endod J 1989;22:174–178.
16. Metzler RS, Montgomery S. The effectiveness of ultrasonics and calcium hydroxide for the debridement of 3, 5, 6
human mandibular molars. J Endod 1989;15:373–378.
17. Ahmad M. Measurements of temperature generated by ultrasonic file in vitro. Endod Dent Traumatol 4, 6
1990;6:230–231.
18. Ahmad M, Ford TRP, Crum LA, Wilson RF. Effectiveness of ultrasonic files in the disruption of root canal bacteria. 1
Oral Surg Oral Med Oral Pathol 1990;70:3:328–332.
19. Abbott PV, Heijkoop PS, Cardaci SC, Hume WR, Heithersay GS. An SEM study of the effects of different irrigation 3, 9
sequences and ultrasonics. Int Endod J 1991;24:308–316.
20. Petschelt A, Dobler J. High volume vs. activated root canal irrigation. Dtsch Zahnarztl Z 1991;46:285–287. 3, 7, 9
21. Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation. J 9
Endod 1992;18:605–612.
22. Briseno BM, Wirth R, Hamm G, Standhartinger W. Efficacy of different irrigation methods and concentrations of 3
root canal irrigation solutions on bacteria in the root canal. Endod Dent Traumatol 1992;8:6–11.
23. Wang ZM. The bactericidal efficiency of ultrasonic in the root canal. Zhonghua Kou Qiang Yi Xue Za Zhi 6
1992;27:12–15, 61.
24. Cheung GS, Stock CJ. In vitro cleaning ability of root canal irrigants with and without endosonics. Int Endod J 3
1993;26:334–343.
25. Cameron JA. Factors affecting the clinical efficiency of ultrasonic endodontics: a scanning electron microscopy 3, 6, 9
study. Int Endod J 1995;28:47–53.
26. Cameron JA. The choice of irrigant during hand instrumentation and ultrasonic irrigation of the root canal: a 3, 9
scanning electron microscope study. Aust Dent J 1995;40:85–90.
27. Kahn FH, Rosenberg PA, Gliksberg J. An in vitro evaluation of the irrigating characteristics of ultrasonic and 1, 4
subsonic handpieces and irrigating needles and probes. J Endod 1995;21:277–280.
28. Yoshida T, Shibata T, Shinohara T, et al. Clinical evaluation of the efficacy of EDTA solution as an endodontic 5, 6
irrigant. J Endod 1995;21:592–593.
29. Siqueira JF Jr, Machado AG, Silveira RM, et al. Evaluation of the effectiveness of sodium hypochlorite used with 6
three irrigation methods in the elimination of Enterococcus faecalis from the root canal, in vitro. Int Endod J
1997;30:279–282.
30. Tu€rku€ n M, Cengiz T. The effects of sodium hypochlorite and calcium hydroxide on tissue dissolution and root 9
canal cleanliness. Int Endod J 1997;30:335–342.
31. Huque J, Kota K, Yamaga M, et al. Bacterial eradication from root dentine by ultrasonic irrigation with sodium 5, 9
hypochlorite. Int Endod J 1998;31:242–250.
32. Jensen SA, Walker TL, Hutter JW, Nicoll BK. Comparison of the cleaning efficacy of passive sonic activation and 3
passive ultrasonic activation after hand instrumentation in molar root canals. J Endod 1999;25:735–738.
33. Hata G, Hayami S, Weine FS, Toda T. Effectiveness of oxidative potential water as a root canal irrigant. Int Endod J 3, 5, 9
2001;34:308–317.
34. Marais JT, Williams WP. Antimicrobial effectiveness of electro-chemically activated water as an endodontic 6
irrigation solution. Int Endod J 2001;34:237–243.
35. Guerisoli DM, Marchesan MA, Walmsley AD, et al. Evaluation of smear layer removal by EDTAC and sodium 5, 7, 9
hypochlorite with ultrasonic agitation. Int Endod J 2002;35:418–421.
36. Mayer BE, Peters OA, Barbakow F. Effects of rotary instruments and ultrasonic irrigation on debris and smear 3, 9
layer scores: a scanning electron microscopic study. Int Endod J 2002;35:582–589.
(continued )

44.e2 C
aput
a et al. JOE — Volume 45, Number 1, January 2019

 Review Article
SUPPLEMENTAL TABLE S3. (continued )
Excluded studies Criteria
37. Al-Kilani MG, Whitworth JM, Dummer PM. Preliminary in vitro evaluation of Carisolv as a root canal irrigant. Int 1, 9
Endod J 2003;36:433–440.
38. Peng B, Chen SL, Fan B, et al. Clinical evaluation and laboratory study of ultrasonic irrigation of the root canal. 3, 4
Zhonghua Kou Qiang Yi Xue Za Zhi 2003;38:192–194.
39. Sabins RA, Johnson JD, Hellstein JW. A comparison of the cleaning efficacy of short-term sonic and ultrasonic 3
passive irrigation after hand instrumentation in molar root canals. J Endod 2003;29:674–678.
40. Ferreira RB, Alfredo E, Porto de Arruda M, et al. Histological analysis of the cleaning capacity of nickel-titanium 3
rotary instrumentation with ultrasonic irrigation in root canals. Aust Endod J 2004;30:56–58.
41. Gulabivala K, Stock CJ, Lewsey JD, et al. Effectiveness of electrochemically activated water as an irrigant in an 7, 8
infected tooth model. Int Endod J 2004;37:624–631.
42. Lee SJ, Wu MK, Wesselink PR. The efficacy of ultrasonic irrigation to remove artificially placed dentine debris 1, 6
from different-sized simulated plastic root canals. Int Endod J 2004;37:607–612.
43. van der Sluis LW, Wu MK, Wesselink PR. A comparison between a smooth wire and a K-file in removing artificially 1, 6
placed dentine debris from root canals in resin blocks during ultrasonic irrigation. Int Endod J 2005;38:593–596.
44. van der Sluis LW, Wu MK, Wesselink PR. The efficacy of ultrasonic irrigation to remove artificially placed dentine 6
debris from human root canals prepared using instruments of varying taper. Int Endod J 2005;38:764–768.
45. Weber CD, McClanahan SB, Miller GA, et al. The effect of passive ultrasonic activation of 2% chlorhexidine or 4, 5
5.25% sodium hypochlorite irrigant on residual antimicrobial activity in root canals. J Endod 2003;29:562–564.
46. Passarinho-Neto JG, Marchesan MA, Ferreira RB, et al. In vitro evaluation of endodontic debris removal as 3
obtained by rotary instrumentation coupled with ultrasonic irrigation. Aust Endod J 2006;32:123–128.
47. Tinaz AC, Karadag LS, Alaçam T, Mihçioglu T. Evaluation of the smear layer removal effectiveness of EDTA using 3, 9
two techniques: an SEM study. J Contemp Dent Pract 2006;7:9–16.
48. van der Sluis LW, Gambarini G, Wu MK, Wesselink PR. The influence of volume, type of irrigant and flushing 6
method on removing artificially placed dentine debris from the apical root canal during passive ultrasonic
irrigation. Int Endod J 2006;39:472–476.
49. Lui JN, Kuah HG, Chen NN. Effect of EDTA with and without surfactants or ultrasonics on removal of smear layer. 3, 9
J Endod 2007;33:472–475.
50. Munley PJ, Goodell GG. Comparison of passive ultrasonic debridement between fluted and nonfluted 3
instruments in root canals. J Endod 2007;33:578–580.
51. Zhuang GH, Liu QC, Liu QY, et al. Effect of ultrasonic root canal irrigation on different diameters of root canal 3, 9
preparation through SEM. J Dalian Med Univ 2007;29:268–270, 273.
52. Carver K, Nusstein J, Reader A, Beck M. In vivo antibacterial efficacy of ultrasound after hand and rotary 5
instrumentation in human mandibular molars. J Endod 2007;33:1038–1043.
53. Ferreira RB, Marchesan MA, Silva-Sousa YT, Sousa-Neto M. Effectiveness of root canal debris removal using 3, 6
passive ultrasound irrigation with chlorhexidine digluconate or sodium hypochlorite individually or in
combination as irrigants. J Contemp Dent Pract 2008;9:68–75.
54. Al-Jadaa A, Paque  F, Attin T, Zehnder M. Acoustic hypochlorite activation in simulated curved canals. J Endod 1
2009;35:1408–1411.
55. Al-Jadaa A, Paque  F, Attin T, Zehnder M. Necrotic pulp tissue dissolution by passive ultrasonic irrigation in 1
simulated accessory canals: impact of canal location and angulation. Int Endod J 2009;42:59–65.
56. Chopra S, Murray PE, Namerow KN. A scanning electron microscopic evaluation of the effectiveness of the F-file 3, 9
versus ultrasonic activation of a K-file to remove smear layer. J Endod 2008;34:1243–1245.
57. Goel S, Tewari S. Smear layer removal with passive ultrasonic irrigation and the NaviTip FX: a scanning electron 3, 9
microscopic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:465–470.
58. Kuah HG, Lui JN, Tseng PS, Chen NN. The effect of EDTA with and without ultrasonics on removal of the smear 3, 9
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71. Tardivo D, Pommel L, La Scola B, et al. Antibacterial efficiency of passive ultrasonic versus sonic irrigation. 3
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93. Malki M, Verhaagen B, Jiang LM, et al. Irrigant flow beyond the insertion depth of an ultrasonically oscillating 6
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97. Bhardwaj A, Velmurugan N, Sumitha, Ballal S. Efficacy of passive ultrasonic irrigation with natural irrigants 5, 7
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98. Capar ID, Aydinbelge HA. Surface change of root canal dentin after the use of irrigation activation protocols: 4
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102. Kaya BU, Keçeci AD, Gu € ldaş HE. Investigation of root canal debridement efficacy of low temperature 3, 9
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103. Mancini M, Cerroni L, Iorio L, et al. Smear layer removal and canal cleanliness using different irrigation systems 9
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104. Paiva SS, Siqueira JF Jr, Ro 5
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107. Shenvi S, Kumar BS. An in vitro study to compare the effectiveness of F-fle with ultrasonically activated K-fle to 3, 6, 9
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110. Andrabi SM, Kumar A, Zia A, et al. Effect of passive ultrasonic irrigation and manual dynamic irrigation on 9
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112. Çapar ID, 9
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114. de Almeida AP, Souza MA, Miyagaki DC, et al. Comparative evaluation of calcium hypochlorite and sodium 1
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115. Freire LG. Hard-tissue debris removal after different final irrigation methods and its influence on the filling of 6
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116. Ghinzelli GC, Souza MA, Cecchin D, et al. Influence of ultrasonic activation on photodynamic therapy over root 6, 8
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117. Guo X, Miao H, Li L, et al. Efficacy of four different irrigation techniques combined with 60 C 3% sodium 3, 9
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120. Kobayashi Y, Hayashi M, Yoshino F, et al. Passive ultrasonic irrigation in the presence of a low concentration of 1, 6
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131. Tang ZY, Jiang SY, Wang H, Lan BF. Clinical one-visit root treatment with nickel-titanium rotary instrument and 5, 6
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132. Wang J, Gao Y, Wang QS, et al. Research on cleaning rate of the C-shaped canal treated by manual or rotary 3
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133. Wang Y, Huang X. Comparative antibacterial efficacy of photodynamic therapy and ultrasonic irrigation 1, 3, 6
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134. Xavier F, Nevares G, Albuquerque DS, et al. Analysis of the effect of ultrasonic agitation on the cleaning of root 3, 6, 9
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135. Xhevdet A, Stubljar D, Kriznar I, et al. The disinfecting efficacy of root canals with laser photodynamic therapy. J 3
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137. Da Costa Lima GA, Aguiar CM, Ca ^ mara AC, et al. Comparison of smear layer removal using the Nd:YAG laser, 6, 9
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138. Freire LG, Iglecias EF, Cunha RS, et al. Micro-computed tomographic evaluation of hard tissue debris removal 6
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139. Guerreiro Tanomaru JM, Cha vez Andrade GM, de Faria NB Jr, et al. Effect of passive ultrasonic irrigation on 6
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140. Hou MH, Chen M, Li L, et al. Flushing methods, temperature and flushing time of sodium hypochlorite affect 3, 9
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142. Khaord P, Amin A, Shah MB, et al. Effectiveness of different irrigation techniques on smear layer removal in 3, 9
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143. Layton G, Wu WI, Selvaganapathy PR, et al. Fluid dynamics and biofilm removal generated by syringe-delivered 1
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144. Leichtweis AL, Melo TAF, Kunert GG. Analysis of the time required for dissolving the pulp tissue according to 1, 3, 6
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145. Metri M, Hegde S, Dinesh K, et al. Comparative evaluation of two final irrigation techniques for the removal of 4
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148. Schmidt TF, Teixeira CS, Felippe MC, et al. Effect of ultrasonic activation of irrigants on smear layer removal. J 9
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149. Silva KT, Boeno N, Oliveira SD, et al. Effect of endodontic irrigation, with or without ultrasound, in removing 6, 7
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150. Tang Z, Wang H, Jiang S. Clinical study of single-visit root canal treatment with a nickel-titanium (Ni-Ti) rotary 5
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152. Tennert C, Drews AM, Walther V, et al. Ultrasonic activation and chemical modification of photosensitizers 7
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153. Wang Y, Xiao S, Ma D, et al. Minimizing concentration of sodium hypochlorite in root canal irrigation by 1, 3, 6
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154. Alves FR, Andrade-Junior CV, Marceliano-Alves MF, et al. Adjunctive steps for disinfection of the mandibular 6
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156. Ayranci LB, Arslan H, Akcay M, et al. Effectiveness of laser-assisted irrigation and passive ultrasonic irrigation 6, 9
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158. Castro FP, Pinheiro SL, Duarte MA, et al. Effect of time and ultrasonic activation on ethylenediaminetetraacetic 1
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159. Hertel M, Sommer K, Kostka E, et al. Outcomes of endodontic therapy comparing conventional sodium 5
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161. Khalap ND, Kokate S, Hegde V. Ultrasonic versus sonic activation of the final irrigant in root canals 3, 6, 9
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170. Conde AJ, Estevez R, Lorono G, et al. Effect of sonic and ultrasonic activation on organic tissue dissolution from 4
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172. Endo MM, Estrela CRA, Alencar AHG, et al. Antibacterial action of red and green propolis extract in infected 3
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173. Estevez R, Conde AJ, Valencia de Pablo O, et al. Effect of passive ultrasonic activation on organic tissue 4
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174. Gartenmann SJ, Thurnheer T, Attin T, Schmidlin PR. Influence of ultrasonic tip distance and orientation on 1, 3, 6
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175. Kamble AB, Abraham S, Kakde DD, et al. Scanning electron microscopic evaluation of efficacy of 17% 3, 6, 9
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178. Lu CH, Zhong Q. Comparison of antimicrobial activity of Er,Cr: YSGG laser and ultrasonic irrigation in root canal 6
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179. Middha M, Sangwan P, Tewari S, Duhan J. Effect of continuous ultrasonic irrigation on postoperative pain in 4, 5
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180. Mohmmed SA, Vianna ME, Penny MR, et al. Confocal laser scanning, scanning electron, and transmission 1
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182. Priyank H, Pandey V, Bagul A, et al. Evaluation of 4% sodium hypochlorite in eliminating enterococcus faecalis 6
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183. Schiavotelo TCL, Coelho MS, Rasquin LC, et al. Ex-vivo smear layer removal efficacy of two activated irrigation 9
techniques after reciprocating instrumentation in curved canals. Open Dent J 2017;11:512–519.
184. Sun CW, Zhu YQ. Elimination of Entercoccus faecalis with different disinfection methods in root canals in vitro. 7
Shanghai Kou Qiang Yi Xue 2017;26:134–138.
185. Toyota Y, Yoshihara T, Hisada A, Yawaka Y. Removal of smear layer by various root canal irrigations in primary 1, 3, 9
teeth. Pediatr Dent J 2017;27:8–13.
186. Urban K, Donnermeyer D, Scha € fer E, Bu
€ rkklein S. Canal cleanliness using different irrigation activation systems: 9
a SEM evaluation. Clin Oral Investig 2017;21:2681–2687.
187. Vasconcelos LRSM, Midena RZ, Minotti PG, et al. Effect of ultrasound streaming on the disinfection of flattened 3
root canals prepared by rotary and reciprocating systems. J Appl Oral Sci 2017;25:477–482.
188. Verstraeten J, Jacquet W, De Moor RJG, Meire MA. Hard tissue debris removal from the mesial root canal system 6
of mandibular molars with ultrasonically and laser-activated irrigation: a micro-computed tomography study.
Lasers Med Sci 2017;32:1965–1970.
189. Jamleh A, Suda H, Adorno CG. Irrigation effectiveness of continuous ultrasonic irrigation system: an ex vivo 9
study. Dent Mater J 2018;37:1–5.
190. Malentacca A, Uccioli U, Mannocci F, et al. The comparative effectiveness and safety of three activated 2
irrigation techniques in the isthmus area using a transparent tooth model. Int Endod J 2018;51(suppl 1):e35–e41.
191. Mancini M, Cerroni L, Iorio L, et al. FESEM evaluation of smear layer removal using different irrigant activation 9
methods (EndoActivator, EndoVac, PUI and LAI). An in vitro study. Clin Oral Investig 2018;22:993–999.
192. Nakamura VC, Pinheiro ET, Prado LC, et al. Effect of ultrasonic activation on the reduction of bacteria and 5
endotoxins in root canals: a randomized clinical trial. Int Endod J 2018;51(suppl 1):e12–e22.

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SUPPLEMENTAL TABLE S4. A Summary of the Irrigation and Activation Protocols Used in the Studies That Evaluated the Healing of Apical Periodontitis or the Removal of Pulp Tissue Remnants
Size/ Delivery method, Total volume (mL), Ultrasonic tip type, Power Activation Total Group favored
Study Type (outcome) taper maximum depth flow rate (mL/s) size, max depth (%) time contact time by protocol
C
aput
a et al.

Liang et al, 2013 Clinical 40/.00 Needle, 2 mm NaOCl: 22 mL, — — — NaOCl: 140 s Ultrasonics
(20) (healing of apical 0.2 mL/s EDTA: 60 s
periodontitis) EDTA: 2 mL,
0.03 mL/s
Needle, 2 mm NaOCl: 22 mL, Irrisafe 20, 2 mm 40 NaOCl: 7$10 s NaOCl: 180 s
0.2 mL/s EDTA: 60 s
EDTA: 2 mL,
0.03 mL/s
Gutarts et al, 2005 Clinical 30/.04 Needle, NR NaOCl: 16 mL, — — — 64 s Ultrasonics
(40) (pulp tissue) 0.25 mL/s
U/S needle, NR NaOCl: 17 mL, U/S needle 25 G, NR 100 1$60 s NR
0.25 mL/s*
Burleson et al, 2007 Clinical 30/.04 Needle, NR NaOCl: 16 mL, — — — 64 s Ultrasonics
(41) (pulp tissue) 0.25 mL/s
U/S needle, NR NaOCl: 17 mL, U/S needle 25 G, NR 100 1$60 s NR
0.25 mL/s*
Adcock et al, 2011 In vitro 40/.04 Needle, 1 mm NaOCl: 15 mL, — — — NaOCl: 60 s Unclear
(42) (pulp tissue) 0.25 mL/s EDTA: 60 s
EDTA: 15 mL,
0.25 mL/s
U/S needle, NR NaOCl: 15 mL, U/S needle 25 G, NR 36 NaOCl: 1$60 s NaOCl: 60 s
0.25 mL/s EDTA: 1$60 s EDTA: 60 s
EDTA: 15 mL,
0.25 mL/s
Al-Ali et al, 2012 In vitro 40/.04 Needle, NR NaOCl: 10 mL, — — — NaOCl: 120 s Ultrasonics
(43) (pulp tissue) 0.08 mL/s EDTA: 120 s
EDTA: 3 mL,
0.05 mL/s
Needle, NR NaOCl: 10 mL, Irrisafe 25, NR 50 NaOCl: 1$30 s NaOCl: 150 s
0.08 mL/s EDTA: 1$30 s EDTA: 150 s
EDTA: 3 mL,
0.05 mL/s
Curtis & Sedgley, In vitro 36/.04 Needle, 1 mm NaOCl: 10 mL, — — — NaOCl: 120 s Unclear
2012 (44) (pulp tissue) 0.08 mL/s EDTA: 60 s
EDTA: 5 mL,
0.08 mL/s
U/S needle, 1 mm NaOCl: 10 mL, U/S needle 30 G, 50 NaOCl: 2$60 s NaOCl: 120 s
0.08 mL/s 1 mm EDTA: 1$60 s EDTA: 60 s
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EDTA: 5 mL,
0.08 mL/s
Yoo et al, 2013 (45) In vitro 35/.06 Needle, NR NaOCl: 6 mL, — — — NaOCl: 60 s Ultrasonics
(pulp tissue) 0.1 mL/s Saline: NR
Saline: NR
Needle, NR NaOCl: 6 mL, K-file 15, 0 mm 25 NaOCl: 1$60 s NaOCl: 120 s
0.1 mL/s Saline: NR
Saline: NR
U/S needle, NR NaOCl: 6 mL, U/S needle 30 G, NR 25 NaOCl: 1$60 s NaOCl: 60 s Unclear
0.1 mL/s Saline: NR
Saline: NR
JOE — Volume 45, Number 1, January 2019

Vinhorte et al, 2014 In vitro 25/.08 Needle, NR NaOCl: 1 mL, NR — — — NR Unclear

(46) (pulp tissue) Needle, NR NaOCl: 1 mL, NR Smooth wire NR, 30 1$60 s NR
1 mm
Neelakantan et al, In vitro 25/.08 Needle, 2 mm NaOCl: 15 mL, — — — NaOCl: NR Unclear
2016 (47) (pulp tissue) 0.11 mL/s* EDTA: 120 s
EDTA: 3 mL, Distilled water:
0.03 mL/s* NR
Distilled water:
5 mL, 0.03 mL/s*
Needle, 2 mm NaOCl: 15 mL, NR Irrisafe NR, NR 21 NaOCl: 3$30 s NaOCl: NR
EDTA: 3 mL, NR EDTA: 1$60 s EDTA: 120 s
Dist. water: 5 mL, Distilled water: Distilled water:
NR 1$60 s NR
NaOCl, sodium hypochlorite; NR, not reported; U/S, ultrasonic.
The information presented here regarding the removal of pulp tissue remnants reflects only the final irrigation protocol after instrumentation. The maximum insertion depth is reported as the distance from the working length. All values are given per root canal. Power is reported as the
percentage of the maximum power. The main parameter considered to favor 1 of the compared groups is shown in bold font.
*The flow rate was reported only for a part of the irrigant delivery in this group.
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SUPPLEMENTAL TABLE S5. A Summary of the Irrigation and Activation Protocols Used in the Studies That Evaluated the Antimicrobial Effect
Delivery method, Total volume (mL) and Ultrasonic tip type, Power Activation Total contact Group favored
Study Type Size/taper maximum depth flow rate (mL/s) size, maximum depth (%) time time by protocol
Spoleti et al, 2003 (21) In vitro 50, 35/NR Needle, NR Saline: NR — — — NR Unclear
C
aput
a et al.

Needle, NR Saline: NR K-file 20, NR NR 1$10 s NR

Bhuva et al, 2010 (22) In vitro 30/.09 Needle, 1 mm NaOCl: 6 mL, 0.05 mL/s — — — 120 s Syringe
Needle, 1 mm NaOCl: 4 mL, 0.05 mL/s K-file 15, NR 25 2$20 s 120 s
 brega et al, 2011
No In vitro 50/.05 Needle, NR NaOCl: NR — — — NaOCl: NR Unclear
(23) EDTA: 1 mL, 0.01 mL/s EDTA: 180 s
Distilled water: 5 mL, Distilled water: NR
NR
Needle, NR NaOCl: NR K-file 10, NR NR NaOCl: NR$15 s NaOCl: NR
EDTA: 1 mL, 0.01 mL/s EDTA: 1$15 s EDTA: 195 s
Peters et al, 2011 (24) In vitro 20/.07 Needle, NR NaOCl: 5 mL, 0.17 mL/s — — — 60 s —
Needle, NR NaOCl: 5 mL, 0.17 mL/s Smooth wire 15, 1 mm 50 1$30 s 60 s
Case et al, 2012 (25) In vitro 35/.06 Needle, NR Saline: 5 mL, 0.04 mL/s — — — 120 s Unclear
Needle, NR Saline: NR K-file 15, NR NR 4$30 s 240 s
Cachovan et al, 2013 In vitro 40/.04 Needle, 1 mm Saline: 5 mL, 0.08 mL/s — — — 60 s Unclear
(26) NR Saline: 5 mL, NR K-file 15, 1 mm 33 1$60 s NR
Hubbezoglu et al, In vitro 30/.09 Needle, NR NaOCl: NR — — — 180 s Unclear
2014 (27) Needle, NR NaOCl: NR NR NR NR NR
Juric et al, 2014 (28) In vitro 30/.09 Needle, 2 mm NaOCl: 5 mL, 0.08 mL/s — — — 60 s Ultrasonics
U/S handpiece NaOCl: 10 mL, 0.17 mL/s K-file 15, 2 mm NR 1$60 s 60 s
Niazi et al, 2014 (29) In vitro 30/.09 Needle, 1 mm NaOCl: 6 mL, 0.05 mL/s — — — 120 s Syringe
Needle, 1 mm NaOCl: 4 mL, 0.05 mL/s K-file 15, NR 25 2$20 s 120 s
Needle, 1 mm Chlorhexidine: 6 mL, — — — 120 s
0.05 mL/s
Needle, 1 mm Chlorhexidine: 4 mL, K-file 15, NR 25 2$20 s 120 s
0.05 mL/s
Needle, 1 mm Saline: 6 mL, 0.05 mL/s — — — 120 s
Needle, 1 mm Saline: 4 mL, 0.05 mL/s K-file 15, NR 25 2$20 s 120 s
Neelakantan et al, In vitro 35/.04 Needle, NR NaOCl: NR — — — NR Unclear
2015 (30) Needle, NR NaOCl: NR Irrisafe NR, NR NR NR$30 s NR
Neelakantan et al, In vitro 25/.06 Needle, NR NaOCl + HEDP: 5 mL, — — — 360 s Ultrasonics
2015 (31) 0.01 mL/s
Needle, NR NaOCl + HEDP: 5 mL, Irrisafe NR, NR NR 8$30 s 360 s
0.04 mL/s
Needle, NR NaOCl: NR — — — NaOCl: 240 s Unclear
EDTA: NR EDTA: 120 s
Needle, NR NaOCl: NR Irrisafe NR, NR NR NaOCl: NR$30 s NaOCl: 240 s
EDTA: NR EDTA: NR$30 s EDTA: 120 s
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Needle, NR NaOCl: NR (delivered — — — NaOCl: 240 s

twice) EDTA: 120 s
EDTA: NR
Needle, NR NaOCl: NR Irrisafe NR, NR NR NaOCl: NR$30 s NaOCl: 240 s
EDTA: NR EDTA: NR$30 s EDTA: 120 s
Needle, NR Saline: 5 mL, 0.01 mL/s — — — 360 s Ultrasonics
Needle, NR Saline: 5 mL, 0.04 mL/s Irrisafe NR, NR NR 8$30 s 360 s
Al-Mahdi & Balto, In vitro 40/.04 Needle, 1 mm NaOCl: 6 mL, 0.05 mL/s — — — 120 s Ultrasonics
2016 (32) Needle, 1 mm NaOCl: 6 mL, 0.05 mL/s K-file 15, 1 mm 35 1$60 s 180 s
Needle, 1 mm Saline: 6 mL, 0.05 mL/s — — — 120 s
Needle, 1 mm Saline: 6 mL, 0.05 mL/s K-file 15, 1 mm 35 1$60 s 180 s
JOE — Volume 45, Number 1, January 2019

Cherian et al, 2016 (33) In vitro 50/NR Needle, 1 mm Saline: 5 mL, NR — — — Saline: NR Ultrasonics
Chlorhexidine: 4 mL, Chlorhexidine: 120 s
0.03 mL/s
Needle, 1 mm Chlorhexidine: 4 mL, K-file 15, 1 mm 25 2$20 s 120 s
0.05 mL/s
Needle, 1 mm Saline: 5 mL, NR — — — Saline: NR
Octenidine: 4 mL, Octenidine: 120 s
0.03 mL/s
Needle, 1 mm Octenidine: 4 mL, K-file 15, 1 mm 25 2$20 s 120 s
0.05 mL/s
Neuhaus et al, 2016 In vitro 25/.08 Needle, 0 mm NaOCl: 6 mL, NR — — — NR Unclear
(34) Saline: 1 mL, NR
NR NaOCl: 3 mL, NR Irrisafe NR, 1 mm 20 NaOCl: 3$20 s NR
Saline: 1 mL, NR
Pladisai et al, 2016 (35) In vitro 60/NR Needle, 1 mm NaOCl: 15 mL, 0.06 mL/s — — — 240 s Ultrasonics
Needle, 1 mm NaOCl: 15 mL, 0.06 mL/s Irrisafe 20, 1 mm 29 3$20 s 300 s
Toljan et al, 2016 (36) In vitro 30/.09 Needle, 1 mm NaOCl: 20 mL, 0.25 mL/s — — — 80 s Unclear
U/S handpiece NaOCl: 20 mL, 0.67 mL/s K-file 15, 1 mm NR 1$30 s 30 s
Needle, 1 mm NaOCl: 11 mL, 0.24 mL/s — — — 45 s Ultrasonics
U/S handpiece NaOCl: 30 mL, 0.67 mL/s K-file 15, 1 mm NR 1$45 s 45 s
Bao et al, 2017 (37) In vitro 40/.06 Needle, 1 mm NaOCl: 1.5 mL, 0.02 mL/s — — — NaOCl: 90 s —
EDTA: 4 mL, 0.03 mL/s EDTA: 120 s
Sterile water: 1 mL, Sterile water: 30 s
0.03 mL/s
Needle, 1 mm NaOCl: 1.5 mL, 0.02 mL/s K-file 20, 1 mm 15 NaOCl: 1$60 s NaOCl: 90 s
+ pulp chamber EDTA: 4 mL, 0.03 mL/s EDTA: 120 s
Sterile water: 1 mL, Sterile water: 30 s
0.03 mL/s
Needle, 1 mm NaOCl: 1.5 mL, 0.02 mL/s — — — NaOCl: 90 s Ultrasonics
EDTA: 4 mL, 0.03 mL/s EDTA: 120 s
Sterile water: 1 mL, Sterile water: 30 s
0.03 mL/s
Needle, 0 mm NaOCl: 1.5 mL, 0.05 mL/s K-file 20, 1 mm 15 NaOCl: 3$20 s NaOCl: 90 s
EDTA: 4 mL, 0.03 mL/s EDTA: 120 s
Sterile water: 1 mL, Sterile water: 30 s
0.03 mL/s
Cheng et al, 2017 (38) In vitro 40/.04 Needle, 1 mm Saline: 5 mL, 0.08 mL/s — — — 60 s Unclear
NR Saline: 5 mL, 0.08 mL/s K-file 25, 1 mm 20 1$60 s 60 s
Needle, 1 mm NaOCl: 5 mL, 0.08 mL/s — — — 60 s
NR NaOCl: 5 mL, 0.08 mL/s K-file 25, 1 mm 20 1$60 s 60 s
Maden et al, 2017 (39) In vitro 30/.09 Needle, 2 mm NaOCl: 5 mL, 0.08 mL/s — — — NaOCl: 60 s —
Saline: 5 mL, 0.08 mL/s Saline: 60 s
Ultrasonic Irrigant Activation

U/S handpiece NaOCl: 5 mL, 0.08 mL/s K-file 20, 2 mm 40 1$60 s NaOCl: 60 s
+ needle, NR Saline: 5 mL, 0.08 mL/s Saline: 60 s
HEDP, 1-hydroxyethane 1,1-diphosphonic acid or etidronic acid; NR, not reported; U/S, ultrasonic.
The maximum insertion depth is reported as the distance from the working length. All values are given per root canal. Power is reported as the percentage of the maximum power. The main parameter considered to favor 1 of the compared groups is shown in bold font.

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SUPPLEMENTAL TABLE S6. A Summary of the Irrigation and Activation Protocols Used in the Studies That Evaluated the Removal of Hard Tissue Debris
Ultrasonic tip type,
Delivery method, Total volume (mL) and size, maximum Power Activation Total contact Group favored
Study Type Size/taper maximum depth flow rate (mL/s) depth (%) time time by protocol
C
aput
a et al.

Lee et al, 2004 (48) In vitro 50/.05 Needle, 1 mm NaOCl: 50 mL, 0.12 mL/s — — — 420 s Unclear
U/S handpiece NaOCl: 200 mL, 1.11 mL/s K-file 15, 1 mm 30 1$180 s 180 s
de Groot et al, 2009 In vitro 35/.06 Needle, 1 mm NaOCl: 4 mL, 0.08 mL/s — — — 50 s Ultrasonics
(49) Needle, 1 mm NaOCl: 4 mL, 0.13 mL/s Irrisafe 20, 1 mm 70 1$20 s 50 s
de Moor et al, 2009 In vitro 40/.06 Needle, 1 mm NaOCl: 4 mL, 0.20 mL/s — — — 20 s Unclear
(50) Needle, 1 mm NaOCl: NR Irrisafe 20, 1 mm 70 1$20 s NR
van der Sluis et al, In vitro 20/.10 Needle, 1–2 mm NaOCl: 6 mL, 0.1 mL/s — — — 60 s Ultrasonics
2009 (51) U/S handpiece NaOCl: 45 mL, 0.25 mL/s Smooth wire 15, 70 1$180 s 180 s
1 mm
U/S handpiece NaOCl: 22.5 mL, 0.25 mL/s Smooth wire 15, 70 1$90 s 90 s
1 mm
Needle, 1–2 mm NaOCl: 6 mL, 0.1 mL/s Smooth wire 15, 70 3$20 s 120 s
1 mm
Needle, 1–2 mm NaOCl: 6 mL, 0.1 mL/s Smooth wire 15, 70 3$60 s 240 s
1 mm
de Moor et al, 2010 In vitro 40/.06 Needle, 1 mm NaOCl: 4 mL, 0.20 mL/s — — — 20 s Unclear
(52) Needle, 1 mm NaOCl: NR Irrisafe 20, 1 mm 70 1$20 s NR
Needle, 1 mm NaOCl: NR Irrisafe 20, 1 mm 70 3$20 s NR
Jiang et al, 2010 In vitro 30/.06 Needle, 1 mm NaOCl: 4 mL, 0.08 mL/s — — — 48 s Ultrasonics
(53) Needle, 1 mm NaOCl: 4 mL, 0.08 mL/s Irrisafe 20, 1 mm 40 1$10 s 58 s
Needle, 1 mm NaOCl: 4 mL, 0.08 mL/s Irrisafe 20, 1 mm 40 12$0.7 s 58 s
Needle, 1 mm NaOCl: 4 mL, 0.08 mL/s Irrisafe 20, 1 mm 40 12$0.4 s 58 s
Needle, 1 mm NaOCl: 4 mL, 0.08 mL/s Irrisafe 20, 1 mm 40 12$0.1 s 58 s
Jiang et al, 2010 In vitro 30/.06 Needle, 1 mm NaOCl: 4 mL, NR — — — NR Unclear
(54) Needle, 1 mm NaOCl: 4 mL, NR Irrisafe 20, NR 70 1$10 s (toward NR
groove)
Needle, 1 mm NaOCl: 4 mL, NR Irrisafe 20, NR 70 1$10 s NR
(perpendicular)
Klyn et al, 2010 (55) In vitro 40/.04 Needle, 1 mm NaOCl: 3 mL, NR — — — NR Unclear
Needle, 1 mm NaOCl: 3 mL, NR K-file 20, NR NR NaOCl NaOCl: NR
+ U/S handpiece Water: NR + water: 1$30 s Water: 30 s
€ dig et al, 2010
Ro In vitro 35/.02 Needle, 1 mm NaOCl: 20 mL, 0.08 mL/s — — — 240 s Unclear
(56) U/S handpiece NaOCl: 20 mL, 0.17 mL/s K-file 15, 1 mm 25 1$120 s 120 s
€ dig et al, 2010
Ro In vitro 30, 40, 50/.02 Needle, 1 mm NaOCl: 30 mL, 0.11 mL/s — — — 270 s Unclear
(57) U/S handpiece NaOCl: 30 mL, 0.17 mL/s K-file 15, 1 mm 25 1$180 s 180 s
van der Sluis et al, In vitro 30/.06 Needle, 1 mm NaOCl: 6 mL, 0.05 mL/s — — — 120 s Ultrasonics
2010 (58) Needle, 1 mm NaOCl: 6 mL, 0.10 mL/s Irrisafe 20, 1 mm NR 3$20 s 120 s
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Amato et al, 2011 In vitro 45/NR Needle, 1 mm NaOCl: 6 mL, NR — — — NR Unclear

(59) Needle, 1 mm NaOCl: 6 mL, NR Smooth wire 15, NR 3$20 s NR
1 mm
Howard et al, 2011 In vitro 40/.04 Needle, 1 mm NaOCl: 16 mL, NR — — — NaOCl: NR Unclear
(60) EDTA: 2 mL, NR EDTA: NR
U/S needle, NR NaOCl: 15 mL, 0.25 mL/s U/S needle 25 G, NR 50 1$60 s 60 s
Jiang et al, 2012 In vitro 40/.02 Needle, 1 mm NaOCl: 6 mL, 0.1 mL/s — — — 60 s Syringe
(61) U/S needle, 1 mm NaOCl: 3 mL, 0.1 mL/s U/S needle 30 G, 40 1$30 s 30 s
1 mm
Arslan et al, 2014 In vitro 40/.06 Needle, 1 mm NaOCl: 6 mL, 0.1 mL/s — — — 60 s Syringe
(62) Needle, 1 mm NaOCl: 6 mL, 0.09 mL/s* Smooth wire 15, 25 1$60 s NR
1 mm
JOE — Volume 45, Number 1, January 2019

Thomas et al, 2014 In vitro 40/.06 Needle, NR NaOCl: 8 mL, NR — — — NaOCl: NR Unclear
(63) EDTA: 4 mL, NR EDTA: NR
Needle, NR NaOCl: 8 mL, NR Irrisafe NR, 2 mm NR NaOCl: 4$30 s NaOCl: NR
EDTA: 4 mL, NR EDTA: 2$30 s EDTA: NR
Deleu et al, 2015 In vitro 30/.06 Needle, 1 mm NaOCl: 4 mL, 0.30 mL/s — — — 13 s Unclear
(64) Needle, NR NaOCl: NR Irrisafe 20, 1 mm 50 1$20 s NR
Leoni et al, 2016 In vitro 25/.08 Needle, 2 mm NaOCl: 5.5 mL, 0.08 mL/s* — — — NR —
(65) Needle, 2 mm NaOCl: 5.5 mL, 0.08 mL/s* Smooth wire 20, 10 3$20 s NR
2 mm
Duque et al, 2017 In vitro 35/.04 Needle, 2 mm NaOCl: 6 mL, 0.1 mL/s — — — 60 s Unclear
(66) Needle, 2 mm NaOCl: 6 mL, NR Smooth wire 20, 20 3$20 s NR
2 mm
Kamaci et al, 2018 In vitro 50/.05 Needle, 2 mm NaOCl: 4 mL, 0.1 mL/s — — — NaOCl: 40 s Unclear
(67) Distilled water: 1 mL, Distilled water:
NR NR
Needle, 1 mm NaOCl: 4 mL, 0.1 mL/s K-file 20, 2 mm 50 NaOCl: 1$20 s NaOCl: 40 s
+ pulp chamber Distilled water: 1 mL, Distilled water:
NR NR
NaOCl, sodium hypochlorite; NR, not reported; U/S, ultrasonic.
The maximum insertion depth is reported as the distance from the working length. All values are given per root canal. Power is reported as the percentage of the maximum power. The main parameter considered to favor 1 of the compared groups is shown in bold font.
*The flow rate was reported only for part of the irrigant delivery in this group.
Ultrasonic Irrigant Activation

Review Article
44.e13