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50]

Original Article

Comparative evaluation of efficacy of three different irrigation

activation systems in debridement of root canal isthmus: An
in vitro study
ABSTRACT
Objective: The purpose of this study was to evaluate the effectiveness of different irrigation activation devices in removing debris from the
isthmus area of mandibular molars.
Materials and Methods: A  total of 50 extracted human mandibular molars were selected, and access cavity was prepared. After
determining the working length, instrumentation was done till ProTaper F2 with simultaneous irrigation with 5.25% NaOCl and 17%
ethylenediaminetetraacetic acid. Later, the samples were divided into five groups containing ten samples each, that is, Endo‑Irrigator Plus,
EndoActivator, passive ultrasonic irrigation (PUI), manual dynamic activation (MDA), and control group. About 5.25% NaOCl was used for
irrigation activation. Mesial roots were sectioned 4 mm from the apex and observed under a stereomicroscope at ×× 10 magnification for the
presence of debris.
Results: The Endo‑Irrigator Plus demonstrated the least amount of debris followed by EndoActivator, PUI, MDA, and then control. There was
statistically significant difference between the first three groups and MDI and control. However, there was no statistically significant difference
between the first three groups.
Conclusion: In this study, none of the devices were able to remove the debris completely. Nevertheless, Endo‑Irrigator Plus, EndoActivator,
and PUI could be used as effective irrigation activation devices.

Key words: EndoActivator; Endo‑Irrigator Plus; irrigant efficacy; isthmus; passive ultrasonic irrigation.

INTRODUCTION
Successful endodontic therapy depends on correct
diagnosis, effective cleaning, shaping and disinfection of
the root canals, and adequate obturation.[1] Biomechanical
preparation of this system to render it void of organic debris
and microorganisms is challenging. Since instrumentation
alone cannot achieve total elimination of bacteria and debris
in all canals, effective irrigant delivery is a prerequisite for
it.[2]
The fact that proportionally large areas of the main root
canal wall remain untouched by the instruments, have
been proven by various studies using advanced techniques
available. This is due to the complex root anatomy present,
especially, in the apical area such as isthmuses, accessory
canals, fins, and deltas that provide an ideal space for tissue
debris, microbes, and their by‑products, emphasizing the
importance of chemical means for cleaning and disinfecting
all areas of the root canal.[3]
Sunanda Gadaalay, Shruti Ishwar Hariramani,
Praveen Dhore, Anita Kale, Madhuri Agrawal,
Saurabh Doshi1
Department of Conservative Dentistry and Endodontics, MIDSR
Dental College, Latur, 1Department of Conservative Dentistry
and Endodontics, M. A. Rangoonwala College of Dental
Sciences and Research Centre, Pune, Mahatrashtra, India
Address for correspondence: Dr. Shruti Ishwar Hariramani,
Department of Conservative Dentistry and Endodontics,
MIDSR Dental College, Vishwanathpuram, Ambejogai Road,
Latur, Mahatrashtra, India.
E‑mail: drshrutihariramani@gmail.com

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How to cite this article: Gadaalay S, Hariramani SI, Dhore P, Kale A,

DOI:
Agrawal M, Doshi S. Comparative evaluation of efficacy of three different
10.4103/endo.endo_4_17 irrigation activation systems in debridement of root canal isthmus: An
in vitro study. Endodontology 2017;29:39-42.

© 2017 Endodontology | Published by Wolters Kluwer - Medknow 39

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Gadaalay, et al.: Efficacy of three different irrigation activation systems
However, these irrigants must be brought into direct
contact with the entire canal wall for effective action,
as the traditional needle irrigation technique delivers
solutions no more than 0–1.1 mm beyond the needle tip.[4,5]
Furthermore, the phenomenon of vapor lock that results in
trapped air in the apical third of root canals, also hinder the
exchange of irrigants and affect the debridement efficacy
of irrigants. That is why different irrigant delivery devices
and activation system have been proposed to increase the
flow and distribution of irrigating solutions within the root
canal system such as EndoActivator, Irrisafe, EndoVac, and
photon‑induced photoacoustic streaming.
Endo‑Irrigator Plus (K‑Dent Dental System) is a novel irrigation
activation device based on the concept of continuous warm
activated irrigation and evacuation system. This system
consists of inbuilt suction and heater with positive and
negative pressure tips which are to be used with warmed
sodium hypochlorite at a temperature of 45°C.[6]
EndoActivator (Dentsply, Tulsa Dental) uses sonic activation
of the irrigants comprising a portable handpiece and three
types of disposable flexible polymer tips of different sizes
that do not cut root dentin. Cavitation and acoustic streaming
significantly improves the debridement and disruption of the
smear layer and biofilm.[7]
Passive ultrasonic irrigation (PUI) (Irrisafe – Acteon, UK),
first used by Weller et al.[8] in 1980, utilizes ultrasonic wave
energy that is transmitted from a file or smooth oscillating
wire to the irrigant. Manual dynamic activation (MDA) is a
simple and cost‑effective technique which involves repeated
insertion of a well‑fitting gutta‑percha cone in short, vertical
strokes to hydrodynamically displace and agitate an irrigant
by producing eddy currents.[9]
The purpose of this in vitro study is to evaluate the cleaning
efficacy of Endo‑Irrigator Plus, EndoActivator, PUI, and MDA.
The null hypothesis was that there is no significant difference
in the debris removal efficacy among the four irrigation
protocols tested.
MATERIALS AND METHODS
Fifty extracted human mandibular molars were selected for
the study. Access cavity preparation was done and patency
was established. Working length (WL) was obtained by
viewing #10 K‑file from the apex. The initial glide path was
prepared with hand files #15 and #20 K. The ProTaper rotary
system was used for canal preparation, and each canal was
prepared up to an apical preparation of F2 size, to allow
40 Endodontology / Volume 29 / Issue 1 / January-June 2017
adequate cleaning and penetration of the solution to the
apical one‑third area. Irrigation was done with 5.25% NaOCl
in between each file using 30‑gauge side‑vented needle.
After the completion of instrumentation, final irrigation of
the samples was done with 17% ethylenediaminetetraacetic
acid (1 ml) and 5.25% NaOCl (3 ml) followed by normal
saline (3 ml). Then the teeth were randomly divided into
five groups containing ten samples each. The irrigation
activation was carried out for 1 min in all the samples except
the control group.
• Group 1: Endo‑Irrigator Plus – After the final irrigation,
5.25% warm sodium hypochlorite heated to 50°C is
placed into the canal with the help of positive pressure
tips for coronal one‑third and negative pressure tips
for the apical area. Irrigation was accompanied by
simultaneous evacuation
• Group 2: EndoActivator – The canals and pulp chambers
were filled with 5.25% NaOCl. The EndoActivator sonic
handpiece was set at 10,000 cpm and a size no. 25/0.04
taper activator tip was passively inserted in the canal
within 2 mm of the WL. The tip was moved in short
2–3 mm vertical strokes
• Group 3: PUI – Final rinse with 5.25% NaOCl activated
with #20 tip, which was driven by an ultrasonic device
with power set at 5 for 1 min at 1 mm from the WL
• Group 4: MDA – The canals and pulp chambers were filled
with 5.25% NaOCl. Repeated insertion of a well‑fitting
gutta‑percha cone to WL. 100 strokes per min is the
recommended rate at which activation was performed
• Group 5 (Control): No activation of the irrigant was done
in this group.
After the irrigation activation, distal roots were separated,
and mesial roots were sectioned longitudinally 4 mm from the
apex. Isthmus cleanliness was checked with stereomicroscope
at ×20 magnification. These images were analyzed under
ImageJ Software  (National Institutes of Health, Bethesda,
Maryland, USA).
Statistical analysis was performed with one‑way ANOVA
followed by Tukey’s post hoc test. The scoring criteria were
as follows:
• Score 1 – Clean root canal walls, only a few small debris
particles
• Score 2 – Few small agglomeration of debris
• Score 3 – Many agglomerations of debris covering <50%
of the root canal wall
• Score 4 – More than 50% of the root canal wall covered
with debris
• Score 5 – Complete or nearly complete root canal walls
covered with debris.
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Gadaalay, et al.: Efficacy of three different irrigation activation systems

RESULTS In this study, four different irrigation/agitation techniques

The mean percentages of debris removal in isthmus area were
highest in case of Group 1; Endo‑Irrigator Plus (2.7 ± 0.82)
followed by Group 2; EndoActivator (3.5 ± 0.70), Group 3;
PUI (3.6 ± 1.07), and Group 4; MDA (4.0 ± 0.81) as compared
to control group (Group 5), that is, 4.2 ± 0.78. Results are
shown in Table 1 and graph.
When the groups were compared using ANOVA followed
by Tukey’s post hoc test, there was statistically significant
difference between Groups 1, 2, 3 and Groups 4, 5 (P < 0.05).
However, there was no statistically significant difference
between Groups 1, 2, and 3 [Table 2].
were selected for comparison of their isthmus debridement
efficacy in the mesial root of mandibular molars. EndoActivator
is a sonic activation system while PUI works on the dynamics
of ultrasonics. MDA acts by physically displacing, folding,
and cutting the fluid under “viscously dominated flow” in
the root canal system while Endo‑Irrigator Plus acts on the
principle of active negative pressure and supplies warm
irrigant into the root canal system using a single‑use 30‑gauge
side‑vented needle. The incidence of isthmus in mesial
roots of the mandibular first molar at 3–4 mm from apex
is 80%, especially type IV. This may affect surgical as well as
nonsurgical endodontic procedures.[12] Therefore, mandibular
molars were selected for this study.

DISCUSSION It was observed from the study that, at 4 mm from the apex,
the three irrigation systems were statistically different from
Riddling of endodontic irrigants into the complicated root MDA and control group in removing the debris from the
canal system is very important for successful endodontic isthmus area. These results coincide with the study carried
treatment. It depends on the diameter of the prepared canal, out by Kanter et al.[13] and Al‑Obaida et al.,[14] in which they
coronal enlargement, the type and volume of irrigant, and found that the sonic irrigation was significantly better than
irrigant delivery system.[10] The use of various ultrasonic, the control group in removing loose debris at 3 mm from the
sonic, and PUI devices, and techniques have been reported radiographic apex. Similar results were obtained by Khaord
to improve tissue removal, more vigorous irrigation of lateral et al.[15] and Mozo et al.[16] who concluded that PUI is more
canals, and additional removal of canal bacteria.[11] effective than conventional syringe and needle irrigation in
eliminating pulp tissue and dentin debris. This is because
Table 1: Mean and standard deviation values of experimental ultrasound creates a higher speed and flow volume of the
groups
irrigant in the canal during irrigation, thereby eliminating
DIFFERENT IRRIGATION ACTIVATION Mean more debris.
SYSTEM Std. Deviation
4.5 4.2
4
4 The results of this study also coincide with the study by
3.5 3.6
3.5 Jensen et  al.[17] where there was no statistically significant
2.7
3
difference between sonic and ultrasonic agitation systems.
2.5
2 While in other study carried out by Khalap et al.,[18] it was
1.5
0.82
1.07
0.81 0.788
concluded that sonic activation is superior to ultrasonic
1 0.7
0.5
activation in debris removal. The reason they cited was
0 that PUI creates acoustic microstreaming which produces
Endoirrigator Endoactivator Passive Manual Control
plus ultrasonic
sufficient shear stresses to dislodge debris from instrumented
canals. Along the length of an activated ultrasonic file, it has
multiple nodes and antinodes.[19] However, it also creates
the undesirable dampening effect of the amplitude of its
Table 2: Mean and standard deviation values of experimental
groups characteristic nodes and antinodes pattern, especially when
Groups n Mean±SD F P,
the instrument touched the lateral walls of a shaped canal.
significance Whereas in sonic agitation, the movement of the vibratory
Endo‑Irrigator Plus (Group 1) 10 2.7±0.82 4.624 0.003, sonic instrument was not influenced by lateral wall contact.[20]
Endoactivator (Group 2) 10 3.5±0.70 significant Literature regarding Endo‑Irrigator Plus shows recent study
Passive ultrasonic 10 3.6±1.07 by Neelakantan et al.[6] where the pulp tissue removal capacity
activation (Group 3)
of this device was better than MDA and PUI. This result could
Manual agitation (Group 4) 10 4.0±0.81
Control – no activation 10 4.2±0.788
be attributed to the increase in the volume and temperature
(Group 5) of the irrigant, continuous replenishment of fresh solution,
SD: Standard deviation and the ability to place the needle tip 1 mm short of the WL.

Endodontology / Volume 29 / Issue 1 / January-June 2017 41

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Gadaalay, et al.: Efficacy of three different irrigation activation systems
CONCLUSION
Within the limitations of this in vitro study, it was concluded
that Endo‑Irrigator Plus had superior cleaning efficacy
(least remaining debris), followed by EndoActivator and
then PUI. Further comparative studies are required to assess
the efficiency of this novel irrigant system with the other
activation systems available.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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