Photomedicine and Laser Surgery

Volume 33, Number 6, 2015

ª Mary Ann Liebert, Inc.
Pp. 330–337
DOI: 10.1089/pho.2015.3903

Efficacy of Needle, Ultrasonic, and Endoactivator

Irrigation and Photon-Induced Photoacoustic
Streaming in Removing Calcium Hydroxide
from the Main Canal and Isthmus:
An In Vitro Micro-Computed Tomography
and Scanning Electron Microscopy Study

Dongxia Li, DDS,1,2 Shan Jiang, MDS,2 Xingzhe Yin, MDS,2,3 Jeffrey Wen Wei Chang, MDS,2
Jie Ke, DDS, PhD,1 and Chengfei Zhang, DDS, PhD 2

Abstract

Objective: The aim of this in vitro study was to use high-resolution micro-computed tomography (micro-CT)
and scanning electron microscopy (SEM) to compare the efficacy of four irrigation techniques [needle, ultra-
sonic, EndoActivator, and photon-induced photoacoustic streaming (PIPS)] in removing calcium hydroxide
(Ca[OH]2) from the root canal and isthmus of maxillary premolars. Methods: Twenty-four maxillary first
premolars were selected based on the presence of isthmus regions on micro-CT scans. Root canals were
instrumented with an F2 file using ProTaper rotary instruments and filled with Ca(OH)2 paste. Samples were
stored at 37C and 100% humidity for 1 week and randomly divided into four groups (n = 6 each), according to
irrigation technique. Samples were scanned with micro-CT before instrumentation, after Ca(OH)2 filling, and
after irrigation. Ca(OH)2 reduction in the coronal, middle, and apical thirds and in the isthmus were assessed
with three-dimensional image analysis. Next, specimens were split longitudinally, and canal walls were ex-
amined with SEM for Ca(OH)2 residues. Data were statistically evaluated with the Kruskal–Wallis and Mann–
Whitney tests ( p = 0.05). Results: The PIPS and ultrasonic groups showed greater Ca(OH)2 reduction in the
apical third and higher cleanliness of the isthmus than the EndoActivator and needle irrigation groups
( p < 0.05). Ca(OH)2 residue scores in the PIPS and ultrasonic groups were significantly lower than those in the
EndoActivator and needle groups in all regions of the root canals ( p < 0.05). There was no significant difference
between PIPS and ultrasonic groups ( p > 0.05), or between EndoActivator and needle groups ( p > 0.05).
Conclusions: PIPS and ultrasonic irrigation more effectively removed Ca(OH)2 from the main canal and
isthmus in maxillary premolars than did EndoActivator or needle irrigation.

Introduction (Ca[OH]2) paste, a widely used intracanal medicament, has

T he persistent presence of microorganisms and their
byproducts in the root canal system causes pulpal in-
fection, necrosis, and, eventually, periapical pathosis.1 Che-
mical root canal disinfection based on irrigation and
intracanal dressing to obtain clean root canals and to elimi-
nate bacteria prior to final obturation is a fundamental step
for successful root canal therapy.2 Calcium hydroxide
been thoroughly tested for its excellent antimicrobial activity
and biocompatibility.3–5 To maximize the antimicrobial po-
tential of Ca(OH)2, the root canal must be temporarily filled
with Ca(OH)2 paste for several weeks.6–8 Prior to final root
canal obturation, the Ca(OH)2 within the root canal must be
completely removed. If not removed, Ca(OH)2 residues can
affect the quality of root canal obturation by reducing the
sealing ability of endodontic sealers, increasing apical

1
Department of Stomatology, Air Force General Hospital of the PLA, Haidian District, Beijing, China.
2
Comprehensive Dental Care, Endodontics, Faculty of Dentistry, The University of Hong Kong, Prince Philip Dental Hospital, Sai Ying
Pun, Hong Kong, China.
3
VIP Dental Service & Geriatric Dentistry, School and Hospital of Stomatology, Peking University, Haidian District, Beijing, China.

330
EFFICACY OF CA(OH)2 REMOVAL WITH IRRIGATION
leakage, and forming calcium eugenolate by reacting with
zinc oxide and eugenol-based endodontic cements, hamper-
ing penetration of endodontic sealer into the canal wall dentin
tubules.9–11 Various irrigation techniques have been em-
ployed to resolve this problem.12–16 Clinically, use of a
master apical file combined with copious irrigation is the
most common technique for removing Ca(OH)2.17 However,
removal of Ca(OH)2 from intracanal irregularities such as
isthmus areas is extremely difficult with this technique.17,18
Researchers and clinicians have worked to solve this
clinical dilemma over the past few decades. Ultrasonic and
EndoActivator (Dentsply Tulsa Dental Specialties, Tulsa,
OK) irrigation systems have been developed as adjunct
procedures to enhance the removal of Ca(OH)2 remnants
after needle irrigation.19 Because of its activation of irri-
gants and its clinical availability, ultrasonic irrigation is now
commonly used. However, the effectiveness of ultrasonic
irrigation in removing Ca(OH)2 varies greatly depending
upon the irrigating solution and paste vehicle used.16,19
Recently, photon-induced photoacoustic streaming
(PIPS), a laser-activated approach, has shown more effi-
ciency in fluid interchange and in removing debris from root
canal systems than other techniques.20–22 PIPS generates
peak power spikes and intensive shockwaves in water with
minimal thermal effect, using low-energy levels and short
(50 ls) pulse rates. Divito et al. reported that PIPS resulted
in significantly better root canal debridement than traditional
irrigation techniques.20 Contaminated isthmus areas, which
harbor bacteria and serve as an intracanal medicaments
reservoir, account for many endodontic treatment failures.23
Theoretically, PIPS photoacoustic streaming can travel three
dimensionally wherever fluid is present in the root canal, to
effectively debride the entire root canal system with place-
ment of the tip into the coronal portion only.20 This ad-
vantage may enable PIPS to clean isthmus regions better
than conventional irrigation techniques. To our knowledge,
no studies have investigated the effectiveness of PIPS in
removing Ca(OH)2 residues from the isthmus areas of root
canals.
The aim of this in vitro study was to use high resolution
micro-computed tomography (micro-CT) and scanning elec-
tron microscopy (SEM) to evaluate the effectiveness of
four different irrigation techniques (PIPS, ultrasonic, Endo-
Activator, and needle) in removing Ca(OH)2 residues
from the main root canals and isthmus areas of premolar
teeth.
Materials and Methods
Sample collection and selection
Approval for this study was obtained from the Research
Ethics Committee, Chinese PLA Air Force General Hospi-
tal. Thirty-two freshly extracted maxillary first premolars
were randomly selected from the native Chinese population.
Teeth were extracted for reasons not related to this study.
Samples with immature apical foramina, endodontic treat-
ment, non-carious cervical lesions, or root fracture were
excluded. All samples were rinsed with tap water and stored
in neutral-buffered formalin solution until further use. Soft
tissues and dental calculus were removed by hand with a
periodontal scaler. All samples were scanned with micro-CT
(Skyscan, Aartselaar, Belgium) at an isotropic resolution of
331
20 lm. The X-ray tube was operated at 80 kV and 100 mA.
Image slices were reconstructed and 24 samples containing
an isthmus, according to Weller’s criteria, were selected for
further study.23
Root canal instrumentation
A conventional access cavity was prepared and an end-
odontic explorer was used to detect the pulp chamber
anatomy and canal orifices. A size 10 K-file (Dentsply
Maillefer, Ballaigues, Switzerland) was introduced into the
canal until the file tip reached the apical foramen, to es-
tablish apical patency. The working length was registered as
0.5 mm shorter than the length to the foramen. The canals
were instrumented with size 15 and size 20 hand files. Next,
the canals were instrumented with ProTaper rotary instru-
ments (Dentsply Maillefer, Ballaigues, Switzerland) ac-
cording to manufacturer’s instructions; the final instrument
was an F2 file. A 30 gauge blunt-tip needle (Terumo Cor-
poration, Leaven, Belgium) was used to fill the root canal
with 3% sodium hypochlorite solution irrigant. Pulp cham-
ber and root canals were filled with irrigating solution dur-
ing canal instrumentation. The canals were flushed with
3 mL of 3% sodium hypochlorite solution between instru-
ments. After instrumentation, 6 mL of 17% ethylenediami-
netetraacetic acid (EDTA) solution was used to irrigate the
canal for 3 min as the final rinse. The irrigation solution in
the pulp chamber was aspirated and the canals were dried
with paper points.
Intracanal Ca(OH)2 filling
Sterile Ca(OH)2 is a radiopaque, water-soluble root canal
medicament with 8.33 wt% barium sulfate (Nordiska Den-
tal, Angelholm, Sweden). Ca(OH)2 paste was injected into
the root canal until paste was extruded from the apical fo-
ramen. Lentulo spiral fillers (Dentsply Maillefer) were used
to pack the slurry into the canals. A cotton pellet was placed
over Ca(OH)2 paste and the coronal access cavities were
sealed with Cavitron temporary filling material (GC, Tokyo,
Japan). The root apex was covered with sticky wax to rep-
licate the surrounding periodontal tissues and their effect on
the dynamics of the irrigating solution. All samples were
stored at 37C and 100% humidity for 1 week.
Removal of Ca(OH)2
After removing the temporary coronal filling material,
Ca(OH)2 was removed by a standard protocol, including an
F2 instrument and 3 mL of 3% sodium hypochlorite
(NaOCl) irrigating solution via a 30 gauge needle at 1 mm
short of the working length of the canal. The samples were
then randomly divided into the following four groups of six
each, according to irrigation protocol. All operating proce-
dures were performed by the same endodontist.
Group 1: Needle irrigation
Each root canal was irrigated with 6 mL of 3% NaOCl
solution for 60 sec using a 30-gauge blunt-tip needle (Ul-
tradent, South Jordan, UT) situated 1 mm short of the
working length. Irrigating solution was delivered at a flow
rate of 6 mL/min.
332
Group 2: EndoActivator irrigation
Each root canal was irrigated with EndoActivator for
60 sec (setting: headpieces 10,000 cycles per min). A sonic
tip (size 20, taper 0.02) was inserted into the canal and
agitated 2 mm short of the working length without touching
the walls. The root canal was filled with 2 mL of 3% NaOCl,
and then activated by EndoActivator for 20 sec. The pro-
cedure was repeated three times.
Group 3: Ultrasonic irrigation
Each root canal was irrigated with an ultrasonic device
for 60 s (setting: E mode 25% power) (EMS, Le Sentier,
Switzerland). An ultrasonic tip (size 20, taper 0.02) was
inserted into the canal and agitated 2 mm short of the
working length. The root canal was filled with 2 mL of 3%
NaOCl solution, and then activated by the ultrasonic device
for 20 sec. The procedure was repeated three times.
Group 4: PIPS irrigation
Each root canal was irrigated with an Er.YAG laser (Fi-
delis AT, Fotona, Ljubljana, Slovenia; 2940 nm wavelength,
0.3 W, 15 Hz, and 20 mJ without water or air) for 60 sec. A
14 mm long, 300 lm diameter quartz tip was used. The root
canal was filled with 2 mL of 3% NaOCl solution, then the
laser tip was put into the coronal part of the canal and acti-
vated for 20 sec. When the irrigant in the coronal reservoir
dropped, the pulp chamber was refreshed with 3% NaOCl
solution. Three 20 sec activation procedures were performed.
Micro-CT scan and measurement
All samples were scanned with micro-CT three times:
before instrumentation (scan 1), after Ca(OH)2 filling (scan
2), and after irrigation (scan 3). Image data processing was
performed with MeVisLab 2.6.1 software package (MeVis
Medical Solution AG, Bremen, Germany). The region of
interest (ROI) was selected from the cementoenamel junc-
tion (CEJ) layer to the root apex layer. The CEJ layer was
defined as where enamel occupied half of the tooth perim-
eter in cross-section.24 Image data from scans 2 and 3 were
registered and used to evaluate Ca(OH)2 removal in the
coronal two thirds of the root. Image data from scans 1 and 2
were registered and used to segment Ca(OH)2 in the isthmus
region before irrigation. Image data from scans 1 and 3 were
registered and used to segment residual Ca(OH)2 in the
isthmus region after irrigation.
SEM evaluation
After canal irrigation, two longitudinal grooves were
prepared with a diamond disc, one on the buccal and one on
the lingual surface of the root. Next, the root was longitu-
dinally split with a bone hammer. Samples were dehydrated
step by step with absolute alcohol, dried at the critical point,
and sputter-coated with gold (Magnetron Ion Sputter Metal
Coating Device, Msp-2S, IXRF System, Inc. MA, Japan).
The presence of Ca(OH)2 remnants in the coronal, middle,
and apical thirds of each sample were assessed with SEM
(Hitachi, Tokyo, Japan; magnification 1000 · ). Two cali-
brated examiners evaluated the cleanliness of the root canal
walls according to the following scoring system: 0, no res-
LI ET AL.
idue; 1, small amount of residue (covering £ 20% of the
surface); 2, moderate amount of residue (covering 20–60%
of the surface); 3, large amount of residue (covering > 60%
of the surface).25
Statistical analysis
Data were analyzed with repeated-measures Kruskal–
Wallis and Mann–Whitney–Wilcoxon U tests. All analyses
were conducted using SPSS software (SPSS 20.0 for Win-
dows, SPSS, Chicago, IL). The level of significance was
defined as p < 0.05.
Results
Micro-CT imaging study and quantitative evaluation
In the coronal third of the root canal, the mean reduction in
volume of Ca(OH)2 after irrigation with needle, Endo-
Activator, ultrasonic, and PIPS was 94.24 – 9.84%, 98.54 –
1.55%, 100.00 – 0.00%, and 100.00 – 0.00%, respectively. In
the middle third of the root canal, the four groups showed a
similar trend, but the mean Ca(OH)2 reduction percentages
were all less than in the apical third. There were no significant
differences among the four groups in Ca(OH)2 reduction in
the coronal and middle thirds of the root canal (both p > 0.05).
In the apical third, ultrasonic irrigation and PIPS eliminated a
higher percentage of Ca(OH)2 than did needle and En-
doActivator irrigation ( p < 0.05) (Table 1). There was no
significant difference between the ultrasonic and PIPS groups
( p > 0.05), or between the needle and EndoActivator groups.
However, none of the techniques completely eliminated
Ca(OH)2 from the apical third of the root canal (Fig. 1).
The mean Ca(OH)2 volume reductions in the canal isth-
mus regions with each removal technique are shown in
Table 2. Ultrasonic and PIPS irrigation were more effective
than the needle and EndoActivator irrigation ( p < 0.05)
(Table 2, Fig. 2). There was no significant difference be-
tween the ultrasonic and PIPS groups ( p > 0.05) or between
the needle and EndoActivator groups ( p > 0.05).
SEM observation and quantitative evaluation
SEM images representative of Ca(OH)2 residues in the
coronal, middle, and apical thirds of the root canals in each
group are shown in Fig. 3. Root canals in the ultrasonic and
PIPS groups generally had less Ca(OH)2 residue than did
those in the needle and EndoActivator groups. Within each
group, Ca(OH)2 residues were present in the following order:
apical > middle > coronal. None of the methods completely
eliminated Ca(OH)2 from the apical-third canals. Figure 4
Table 1. Mean Percentage of Ca(OH)2 Volume
Reduction in the Main Canal with Irrigation
Group Coronal Middle Apical
Needle 94.24 – 9.84 87.92 – 6.91 29.25 – 4.72II
EndoActivator 98.54 – 1.55 89.55 – 9.70 34.02 – 5.33II
Ultrasonic 100.00 – 0.00 99.66 – 0.82 96.44 – 7.62I
PIPS 100.00 – 0.00 99.81 – 0.46 96.68 – 9.65I
I–II
Ranking: there were significant differences ( p < 0.05) in the
means between subgroups with different ranks.
PIPS, photon-induced photoacoustic streaming.
EFFICACY OF CA(OH)2 REMOVAL WITH IRRIGATION 333

FIG. 1. Three-dimensional reconstruction of micro-CT scans showing Ca(OH)2 in the apical third of root canal before and
after irrigation. Needle (A1, before irrigation; A2, after irrigation), EndoActivator (B1, before irrigation; B2, after irriga-
tion), ultrasonic (C1, before irrigation; C2, after irrigation), and photon-induced photoacoustic streaming (PIPS) (D1, before
irrigation; D2, after irrigation).

shows SEM images representative of the assigned residue
scores. Ca(OH)2 residue scores in each region of the root
canal in each treatment group are summarized in Table 3. In
all areas of the root canal, ultrasonic and PIPS irrigation were
more efficient than EndoActivator and needle irrigation in
removing Ca(OH)2 (all p < 0.05). There was no significant
difference between ultrasonic and PIPS groups ( p > 0.05) or
between needle and EndoActivator groups ( p > 0.05).
Discussion
Application of Ca(OH)2 paste to disinfect the entire root
canal system, especially irregular areas such as the isthmus
regions and apical deltas, greatly contributes to the success
of endodontic treatment.26 Ca(OH)2 paste in its flowable
form can penetrate canal irregularities, which increases the
difficulty of subsequent Ca(OH)2 removal.27 It has been
clearly shown that residual Ca(OH)2 present in the main root
canal and/or its isthmus prior to final canal obturation
compromises hermetic root canal sealing by root canal
filling materials.28 Therefore, complete removal of Ca(OH)2
is crucial. However, conventional irrigation techniques such
as needle irrigation do not effectively remove Ca(OH)2 from
the isthmus area and apical delta.29 In the present study, we
compared currently available devices (EndoActivator, ul-
trasonic, and PIPS) with needle irrigation to determine ap-
propriate protocols for removing Ca(OH)2 from the main
root canal and isthmus.
Based on micro-CT data analysis, we found that ultrasonic
and PIPS irrigation were superior to EndoActivator and needle
irrigation in removing Ca(OH)2 from the isthmus regions of
the root canal of maxillary premolars. This finding supports
that of a previous study, which found that PIPS eliminated
significantly more organic debris from the canal isthmus than
did needle irrigation.21 PIPS was developed as a novel laser
agitation irrigation technique to clean and debride the root
canal system after instrumentation. PIPS employs Erbium:
yttrium-aluminum-garnet (Er:YAG) laser energy at sub-
ablative parameters (lower power 0.3 W, 20 mJ at 15 Hz) with
a newly designed radial and stripped tip to create peak power
spikes.20,22 Er:YAG laser energy exhibits the highest absorp-
tion by water and hydroxyapatite of any laser, causing three-
dimensional agitation of fluid throughout the root canal.20
Additionally, Er:YAG laser can produce cavitation effects
through formation of explosive vapor bubbles, enhancing the
effectiveness of Ca(OH)2 and debris removal from intricate
anatomy, including the subcanals and isthmus regions.30
Most endodontists recommend a final ultrasonic irrigation
as a routine step in root canal cleaning. This additional step
results in more efficient debridement in the isthmus region
than the needle technique alone.31 Similarly, the present
study showed that ultrasonic irrigation produced a cleaner

Table 2. Mean Percentage of Ca(OH)2 Volume Reduction in the Canal Isthmus with Irrigation
Needle EndoActivator Ultrasonic PIPS
II II I
(%)Volume reduction 81.60 – 6.20 85.30 – 2.90 99.83 – 0.42 99.97 – 0.07I
I–II
Ranking: there were significant differences ( p < 0.05) in the means between subgroups with different ranks.
PIPS, photon-induced photoacoustic streaming.
334 LI ET AL.

FIG. 2. Micro-CT images of Ca(OH)2 in the isthmus region before and after irrigation. Needle (A1, before irrigation; A2,
after irrigation); EndoActivator (B1, before irrigation; B2, after irrigation); Ultrasonic (C1, before irrigation; C2, after
irrigation) and photon-induced photoacoustic streaming (PIPS) (D1, before irrigation; D2, after irrigation).

FIG. 3. Scanning electron microscopic (SEM) images of Ca(OH)2 residues in the coronal, middle, and apical third of root
canal after irrigation with four different irrigation techniques. Needle (A1, coronal third; A2, middle third; A3, apical third),
EndoActivator (B1, coronal third; B2, middle third; B3, apical third), Ultrasonic (C1, coronal third; C2, middle third; C3,
apical third), and photon-induced photoacoustic streaming (PIPS) (D1, coronal third; D2, middle third; D3, apical third).
EFFICACY OF CA(OH)2 REMOVAL WITH IRRIGATION 335

FIG. 4. Scanning electron microscopic (SEM) images representative of Ca(OH)2 residue scores. (A) Score 0, absence of
Ca(OH)2 residue; (B) Score 1, small amount of Ca(OH)2 residue (covering £ 20% of the surface); (C) Score 2, moderate
amount of Ca(OH)2 residue (covering 20–60% of the surface); and (D) Score 3, large amount of Ca(OH)2 residue (covering
> 60% of the surface).

root canal surface than other techniques, with less Ca(OH)2
remaining in the main canal and isthmus areas. Ultrasonic
vibration activates irrigants and enhances fluid movement
and exchange.32 The highly mobile irrigant molecules can
penetrate the irregular isthmus region and remove Ca(OH)2
located there. Continuous delivery of fresh irrigant and
prolonged ultrasonic activation may have synergistic
cleaning effects. However, the optimal parameters of the
combination need further study.
Micro-CT revealed no difference in Ca(OH)2 volume
reduction among the four irrigation groups in the coronal
and middle thirds of the root canal. Needle, EndoActivator,
ultrasonic, and PIPS irrigation all effectively removed
Ca(OH)2 from the coronal and middle thirds of the root
canal of the maxillary premolars. However, in the apical
third, the PIPS and ultrasonic groups had significantly
higher Ca(OH)2-removal percentages than did the En-
doActivator and needle groups. A possible explanation for
this difference in the case of PIPS is that the system gen-
erates a strong and significant photoacoustic shock wave,
which could enhance three-dimensional spreading of irri-
gants into the apical third. The higher efficacy of ultrasonic

Table 3. Mean Ca(OH)2 Residue Scores in the Root Canal After Irrigation
Group Coronal Middle Apical Overall
Needle 1.54 – 0.70II 2.08 – 0.56II 2.54 – 0.45II 2.06 – 0.48II
EndoActivator 1.38 – 0.54II 1.58 – 0.56II 2.50 – 0.42II 1.82 – 0.41II
Ultrasonic 0.71 – 0.29I 0.92 – 0.13I 1.67 – 0.46I 1.10 – 0.23I
PIPS 0.58 – 0.30I 0.92 – 0.47I 1.38 – 0.44I 0.96 – 0.29I
I-II
Ranking: there were significant differences ( p < 0.05) in the means between subgroups with different ranks.
PIPS, photon-induced photoacoustic streaming.
336
irrigation likely resulted from transmission of ultrasonic
energy to the irrigant, producing high shear stress in the root
canal system.22 In contrast, needle irrigation and Endo-
Activator did not clean the apical third or the isthmus areas
effectively, even when their tips were placed close to the
root apex. It has been reported that trapped air in the apical
area creates a vapor lock and block, which prevents fluid
movement and exchange.29 Unlike PIPS and ultrasonic ir-
rigation, neither needle nor EndoActivator irrigation can
produce adequate fluid movement to suck air from the apical
region or destroy the dead block. Furthermore, the needle
delivers irrigants no further than 1 mm beyond the needle
tip, and therefore the apical third is inaccessible for flush-
ing.33,34 EndoActivator, delivering insufficient volume of
irrigants to the apical area and lacking cavitation, resulted in
low efficiency of Ca(OH)2 removal.35,36
Although micro-CT has been widely used in dentistry and
has several distinct advantages, including the non-destructive
nature of the imaging, the lack of sample staining prepara-
tion needed, and the rapid speed of data acquisition, one
disadvantage is its poor assessment of less radiopaque ma-
terials and tissues; such as the smear layer and Ca(OH)2
particles on the root canal wall. SEM reveals the detailed
morphology of the root canal surface and allows quantifi-
cation of radiolucent materials present on the root canal
wall.37 Therefore, we used SEM (1000 · ) to observe and
categorize Ca(OH)2 removal from the root canal wall with a
four scale scoring system, which has been described previ-
ously and was well calibrated in a series of studies.25
Ca(OH)2 residue scores in the PIPS and ultrasonic groups
were significantly lower than those in the EndoActivator and
needle groups in the coronal, middle, and apical thirds of the
root canals. These SEM results were not completely con-
sistent with the micro-CT findings. SEM imaging revealed
that PIPS and ultrasonic irrigation removed Ca(OH)2 sig-
nificantly more thoroughly than EndoActivator or needle
irrigation in the coronal and middle thirds of the root canal,
whereas micro-CT showed no difference among the four
groups in Ca(OH)2 volume reduction in these regions.
Micro-CT did not reveal the difference, because the tech-
nique is not sensitive enough to reveal Ca(OH)2 particles.
Notably, our study showed that no irrigation technique
completely eliminated Ca(OH)2 from the entire canal sys-
tem. This finding is in agreement with those of previous
studies.19,38 Because the PIPS tip was placed in the orifice
area, the irrigant flow generated might not have been strong
enough to travel into the apical third, because of declining
fluid flow capacity. Alternatively, the energy of PIPS may
not have been sufficient to activate irrigant flow in the apical
third.39 Similarly, acoustic microstreaming and/or cavitation
significantly decreases or disappears when the activated tip
leaves the irrigant and enters the apical vapor lock.40
Therefore, more effective methods of completely cleaning
the apical portion need to be developed.
Conclusions
In summary, PIPS and ultrasonic irrigation techniques
more effectively removed Ca(OH)2 from the main canal and
isthmus areas in maxillary premolars than did En-
doActivator or needle irrigation, but did not completely
remove Ca(OH)2 from the apical third of the root canal.
LI ET AL.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Chengfei Zhang
Comprehensive Dental Care, Endodontics
Faculty of Dentistry
The University of Hong Kong
Prince Philip Dental Hospital
34 Hospital Road
Sai Ying Pun
Hong Kong SAR, 999077
China
E-mail: zhangcf@hku.hk