963295 PRD Primary Dental Journal

Key words Learning Objectives Authors

Root canal system, biofilm, sodium
hypochlorite, EDTA solution, agitation
•• To understand the aims of contemporary
cleaning of the root canal system
•• To have knowledge of the various
endodontic cleaning solutions and
techniques
•• To appreciate the importance of
effective and safe cleaning of the root
canal system
Justin J. Barnes BSc (Hons), BDS
(Hons), MFDS RCPSGlasg, MClinDent,
MRD (Endo) RCSEd
Specialist in Endodontics, Belfast, UK
Igor R. Blum DDS (Hons), PhD,
Dr Med Dent, MSc, MFDS RCS (Eng),
MFDS RCS (Edin), FDS (Rest Dent) RCS,
FFGDP(UK), FCGDent, PGCHE, FHEA,
LLM (Medico-Legal)
Reader in Primary Dental Care & Advanced General
Dental Practice; Faculty of Dentistry, Oral &
Craniofacial Sciences, King’s College London, UK;
Consultant & Specialist in Restorative Dentistry, King’s
College Hospital Dental Institute

Justin J. Barnes, Igor R. Blum

Prim Dent J. 2020;9(4):24-30

Contemporary cleaning of the

root canal system
Abstract
This article provides a contemporary synopsis of effective cleaning of the root
canal system, an essential stage of root canal treatment. It provides a clinical
update on the current state of knowledge on cleaning of the root canal system,
and presents an outline of essential theory and practical tips for achieving
effective and safe cleaning of the root canal system.

Introduction periodontitis or, if it has already

The dentine-pulp complex is microbe-free
under normal healthy conditions.
Microbes from the oral microbiota can
invade the dentine-pulp complex if there
is a breach of the protective enamel or
cementum. Pathways include dental
caries, traumatic fractures, cracks, tooth
surface loss, root resorption, iatrogenic
procedures, and poorly fitting
restorations. Once inside the dentine-
pulp complex, these microbes initially
cause inflammation of the pulp (known
as ‘pulpitis’). If left untreated, reversible
pulpitis can progress to irreversible
pulpitis, which can in turn progress to
partial and complete necrosis of the
pulp, deeper invasion by the microbes,
and then inflammation of the
periradicular tissues (known as ‘apical
periodontitis’, ‘periapical periodontitis’
or ‘periodontitis of endodontic origin’).
Root canal treatment of the diseased pulp
is carried out to prevent apical
occurred, to treat apical periodontitis.
Root canal treatment has several stages
which can be categorised as shaping,
cleaning and filling. Cleaning root canals
is carried out simultaneously with shaping
root canals, and is then followed by
filling root canals. In a tooth with
irreversible pulpitis, the coronal portion
of the root canal system has become
invaded by microbes. In these cases,
the objective of cleaning is to remove
the inflamed pulp tissue and microbes
(Figure 1) with the intention of preventing
microbial contamination of the apical
portion of the root canal system and
development of apical periodontitis.
In a tooth with apical periodontitis, most
portions of the root canal system have
become invaded by microbes. In these
cases, the objective of cleaning is to
remove as many of these microbes and
as much of the necrotic pulp tissue as
possible with the intention of promoting
healing of inflamed periapical tissues.

© The Author(s) 2020. Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2050168420963295

24 Pr i ma r y De n ta l J ou r n a l journals.sagepub.com/home/PRD

Figure 1:  Cleaning the mesial root canals of a mandibular first molar: (left) inflamed
pulp, (middle) sodium hypochlorite in root canals, (right) clean and dry root canals
There is a diverse range of terminology
in the field of endodontics. With regards
to cleaning the root canal system,
examples of commonly interchangeable
terminology include ‘chemical
preparation’, ‘chemical debridement’,
‘irrigation’, and ‘disinfection’. The term
‘cleaning’, as used by Schilder,1 is used
throughout this paper for consistency of
terminology.
Aim of cleaning the root
canal system and
complicating factors
As dentists, we set out to control
microbes that have invaded the root
canal system so that the balance can be
shifted from infection-related disease to
healing and healthy dental and
periradicular tissues. Achieving this aim
is complicated by several factors:
1. The complex and intricate anatomy of
root canal systems
2. The complex nature in which
microbes grow and adhere to the
root canal walls
3. The formation of smear and debris
during shaping of root canals
The anatomy of the root canal system is
usually very small, delicate, and
complex; root canals are not straight
tubes with a circular cross-section. The
complex anatomy may include lateral
root canals, fins, webs, anastomoses,
isthmi, apical deltas, and root canals
which have an ovoid, ribbon, or
C-shaped cross section. In 1842,
Carabelli2 was the first to publish on
root canal anatomy. In 1925, Hess and
Zürcher3 demonstrated the complexities
of root canal anatomy using a
vulcanised-rubber demineralised-tooth
technique. Modern micro-CT studies4,5
continue to reveal the complexities of
Vol. 9 N o . 4 De c em b er 2020
the root canal system (Figure 2).
The complex anatomy may:
•• Contain biofilm and remnants of pulp
tissue in teeth affected by endodontic
disease6
•• Become clogged with smear layer
and hard tissue debris in teeth
undergoing root canal treatment7,8
•• Be inaccessible to hand and machine-
driven files9,10
•• Be inaccessible to cleaning solutions
which cannot easily flow into these
areas
Figure 2a:  Micro computed tomography
scan showing root canal anatomy of a
maxillary molar
Courtesy of Sophie Parker, Endo Reality Ltd
Figure 2b:  Micro computed tomography
scan showing isthmus connecting two
root canals
Adapted with permission from Oxford University
Press, courtesy of Shanon Patel
Microbes that invade the root canal
system do not simply float as single
cells inside the main root canals; they
exist in the form of a biofilm and may
invade all parts of the root canal
system.11 Endodontic biofilms are
complex communities of microbes,
predominantly bacteria, that stick to root
canal walls and each other, and are
embedded in a self-produced protective
slime of extracellular polymeric
substances (Figure 3). Biofilms are
difficult to remove, and highly resistant
to antimicrobial agents and the host
defense system.
Figure 3:  Scanning electron microscope
image of an in vivo biofilm in a root
canal x300 magnification
Adapted with permission from Oxford University
Press, courtesy of Sadia Niazi
A smear layer and hard tissue debris
may be generated by the cutting
action of endodontic instruments on
dentine. The smear layer is composed
of organic (pulp tissue remnants and
microbes) and inorganic (dentinal
‘mud’) debris which may coat the
surface of the root canal wall and
penetrate the dentinal tubules. Debris
can also be compacted into complex
anatomy which may interfere with the
flow and effectiveness of cleaning
solutions.11
Taking into account the above
complications, the aims of contemporary
cleaning of root canal systems are to
disrupt and kill biofilms, dissolve and
flush out pulpal tissue, and remove
smear and debris. Ideally, this should be
applicable to all of the root canal
anatomy, but realistically it applies to as
much of it as is practicable. It would be
a similar feat to removing crunchy sticky
peanut butter from the rough porous
surface of toast.
25
 Contemporary cleaning of the root canal system
Cleaning solutions
A variety of endodontic cleaning
solutions have been studied and
reviewed in the literature.13-15 Solutions
have included sodium hypochlorite,
ethylenediaminetetraacetic acid (EDTA),
citric acid, chlorhexidine gluconate,
iodine potassium iodide, hydrogen
peroxide, saline and local anaesthetic.
Sodium hypochlorite fulfills many of the
properties of an ideal endodontic
cleaning solution (Table 1). It is a highly
effective antimicrobial and antibiofilm
agent, and it can dissolve organic matter
including inflamed pulp tissue, necrotic
pulp remnants, biofilm, and the organic
component of the smear layer. There is
no widespread agreement on the
optimal concentration, temperature,
volume, delivery time, soak time, and
timing of use (i.e. final rinse) of sodium
hypochlorite. Despite this, there is
general agreement that sodium
hypochlorite should be frequently
replenished to maintain an effective
concentration of its active components to
compensate for their rapid
inactivation.16,17 Most suppliers provide
commercially available sodium
hypochlorite solutions at concentrations
of 2%, 3% or 6% (Figure 4). These are
licensed for use in endodontics and are
considered more appropriate to use than
household bleach. Disadvantages of
sodium hypochlorite include foul taste,
Table 1
Ideal properties of an
endodontic cleaning
solution
•  Antimicrobial and antibiofilm
•  Able to dissolve organic tissue
•  A
 ble to remove the smear layer and
hard tissue debris
•  Low cost
•  Adequate shelf-life and stability
•  Easy to use
•  Low surface tension
•  Non-caustic to periodontal tissues
•  Non-staining
•  D
 oes not significantly alter the
composition and mechanical
properties of dentine
26 Pr i ma r y De n ta l J ou r n a l
Figure 4:  Examples of sodium
hypochlorite solutions at 3%
concentration
Figure 5:  Examples of EDTA solution at
17% concentration
ability to bleach and damage clothing,
inability to remove the inorganic
component of the smear layer, tissue
toxicity, and it may have a negative
effect on dentine elasticity and flexural
strength.18
It has been suggested in the literature
that ethylenediaminetetraacetic acid
(EDTA) solution at a concentration of
17% (Figure 5) should be used to
remove the inorganic component of
the smear layer and open the dentinal
tubules. When used in root canals,
EDTA solution binds calcium ions within
dentine, holding on to them as soluble
calcium chelates, which can then be
flushed out. EDTA does not dissolve
organic matter and has no or limited
antimicrobial and antibiofilm activity. It is
therefore advisable that EDTA solution is
used in conjunction with sodium
hypochlorite as a penultimate or final
rinse. There is no widespread agreement
on the optimal volume and delivery time
of EDTA solution.
It has also been suggested that other
antimicrobial solutions may be used as
final rinse or an alternative to sodium
hypochlorite.13,15 Chlorhexidine
gluconate (CHX) solution may be useful
in situations where sodium hypochlorite
is unsuitable to use, for example,
patients who have an allergy to
household bleach; however, CHX may
also cause an allergic reaction. Other
disadvantages of CHX solution include
its inability to dissolve organic and
inorganic tissue, and that it does not
effectively disrupt biofilm.19
Care should be taken when alternating
cleaning solutions as negative
interactions may occur. Sodium
hypochlorite loses its tissue dissolving
capacity when combined with EDTA
solution.20 A toxic and carcinogenic
precipitate, parachloranaline, forms
when CHX solution is combined with
sodium hypochlorite.21 It is therefore
advisable not to mix solutions or
repeatedly alternate them during
treatment.
Cleaning techniques
Simply flooding root canals with cleaning
solution is not considered the most
effective way to clean the root canal
system. Cleaning solutions should be
replenished and agitated to promote
exchange of fresh and active solution
throughout the root canal system, in
particular, the complex anatomy and
apical portion of root canals. This is
particularly important in light of the
recent trends in minimally invasive
dentistry with conservative access cavities
and less tapered preparations (e.g.
TruNatomy, Dentsply Sirona, Ballaigues,
Switzerland). The root canal system may
be cleaned manually or by utilising an
assisting device. Ideally, the technique
used should be effective, safe, evidence-
based, easy to use, and affordable. The
literature is replete with studies which
have compared the various techniques
and devices.22,23 It is difficult to draw
reliable conclusions due to a lack of
a standardised research protocols to
investigate the in vivo impact on clinical
outcome.24,25 It should also be pointed
out that several devices have now been
discontinued from the market.
Manual cleaning
Manual cleaning of the root canal
system is low cost and convenient.
It involves delivering fresh cleaning
solution into root canals using positive
pressure via a side-venting needle
(Figure 6) and syringe, and then
manually agitating the solution. Manual
agitation techniques may include:
•• Gently pumping the needle in and out
of the root canal when delivering the
cleaning solution
•• ‘Gutta-percha pumping ‘also known
as ‘manual dynamic activation’:26
deliver fresh cleaning solution into the
root canal; insert a well-fitting gutta-
percha point into the root canal 1-2
mm short of the working length; and
then gently move or ‘pump’ the point
Figure 6a:  Examples of side-venting
needles
Figure 6b:  TruNatomy irrigation
needle (Dentsply Sirona, Ballaigues,
Switzerland). Flexible plastic needle with
two-sided vent
Vol. 9 N o . 4 De c em b er 2020
Figure 7:  ‘Gutta-percha pumping’ manual agitation
in and out of the root canal using
locking tweezers (Figure 7)
•• A technique described by Dr Cliff
Ruddle:27 the index finger and thumb
are placed on wings of the syringe
with the plunger sitting in the palm of
the hand. This facilitates gentle
pushing and pulling on the plunger
which allows solutions to be delivered
into and vacuumed out of the root
canal
Device-assisted cleaning
Various techniques and devices may be
used to facilitate intermittent or
continuous replenishment and agitation
of cleaning solutions. These include:
•• Sonic agitation: This involves
inserting a sonically-activated single-
use flexible non-cutting polymer tip
(e.g. EndoActivator tip, Dentsply
Sirona; or Eddy tip, VDW GmbH,
Munich, Germany) into the root canal
to agitate fresh cleaning solution.
The sonic energy causes a
hydrodynamic phenomenon which
results in ‘intracanal waves’.28 The
sonic energy may be generated
from a battery-operated handpiece
(e.g. EndoActivator, Dentsply Sirona;
Figure 8) or airscaler handpiece,
which can generate up to 10,000
cycles per minute
•• Ultrasonic agitation: This involves
inserting an ultrasonically-activated
Figure 8:  EndoActivator device and tip
(Dentsply Sirona, Tulsa, OK, USA)
Adapted with permission from Oxford University
Press
small-sized hand file or a specialised
non-cutting ultrasonic file/tip (e.g.
IrriSafe, Acteon Group, Merignac
cedex, France) into the root canal to
agitate fresh cleaning solution. The
ultrasonic energy causes rapid
movement of the cleaning solution
around the file/tip (known as
‘acoustic stream’) and the formation
and implosion of vapour bubbles in
the cleaning solution (known as
‘cavitation’).29 Ideally, the file/tip
should be able to move freely and not
touch or cut dentine. If the file/tip
touches the root canal walls, this may
dampen the energy and/or create
more of a smear layer
•• Multisonic agitation:
(GentleWave system, Sonendo Inc,
Laguna Hills, CA, USA). A unit stores,
degasses, and optimises the
concentration of sodium hypochlorite,
27
 Contemporary cleaning of the root canal system
EDTA solution, and distilled water.
These cleaning solutions are
sequentially delivered and removed
via a specialist handpiece which sits
on a temporarily sealed occlusal
platform. The cleaning solutions hit a
specialised tip inside the pulp
chamber which induces cavitation
bubbles and a broad-spectrum of
sound waves. The reported benefits
of this system are that it requires
minimal shaping of root canals and
that there is a continuous
replenishment of fresh cleaning
solutions. The reported disadvantages
include time to set up the platform,
cost, and that it should not be used in
certain cases (e.g. roots that are in
close proximity to the maxillary sinus,
open apices, and external root
resorption communicating with the
root canal)
•• ‘Apical negative pressure
irrigation’: (EndoVac system, Kerr
Dental, Orange, CA, USA). This
involves simultaneously delivering
fresh cleaning solution into the pulp
chamber and drawing the solution
apically using suction via a macro-
cannula and then micro-canula
inserted to working length. The
reported benefits of this system are
continuous replenishment of fresh
sodium hypochlorite into the apical
portion of the root canal, and minimal
risk of cleaning solution being forced
into the periapical tissues. The
reported disadvantages include
clogging of the cannula with debris,
and cost. A systematic review
concluded that there is insufficient
evidence to claim general superiority
of apical negative pressure cleaning
system versus using a syringe30
Several other adjunctive techniques and
devices have been suggested for
cleaning the root canal system. Although
there have been positive in vitro results,
there have been calls for further
validated in vivo studies. These include:
•• Laser activated therapy:31
Examples include photo-induced
photoacoustic streaming (PIPS) and
shock wave-enhanced emission
photoacoustic streaming (SWEEPS).
These involve delivering laser pulses
into the pulp chamber to induce
cavitation bubbles and shock waves
within the cleaning solution
28 Pr i ma r y De n ta l J ou r n a l
•• Photodynamic therapy:32 This
involves delivering a photosensitizer
dye into the root canal which is then
irradiated with a specific wavelength
of light to kill microbes and disrupt
biofilm
•• Ozone therapy:33 This involves
delivering ozone gas via a dedicated
handpiece with a silicone cup
Practical tips on cleaning the
root canal system
It is essential that cleaning is carried out
in an effective way that achieves the
stated aims; that is, disrupting and killing
biofilms, dissolving and flushing out pulp
tissue, and removing smear and debris. It
is also essential that cleaning is carried
out in a safe way that minimises the risk
of iatrogenic error, for example, cleaning
solution being delivered directly or forced
out of the root canal into the periapical
tissues or microbes being iatrogenically
transmitted into root canals.
The following steps are a guide to
achieving effective and safe cleaning of
the root canal system:
  1. Apply a well-fitting rubber dam.
This will reduce the risk of saliva
contamination of the root canal
system, and cleaning solution
entering the patient’s oropharynx.
  2. Use goggles/visors, aprons,
gloves, and any other applicable
enhanced personal protective
equipment. This will aid infection
control and reduce the risk of
solutions staining clothing or
splashing the eyes and skin of the
patient and dental team.
  3. Label syringes. This will ensure the
dental team know what solution is
being delivered into the root canal
system.
  4. Use a narrow-gauge (gauge 30),
closed-ended, side-vented needle.
This will reduce the risk of extrusion
of solution into the periapical
tissues.
  5. Screw the needle on to the syringe
with a Luer-lock design. This will
ensure a secure connection and
reduce the risk of leakage of
solution on to the patient and their
clothing or the dentist and dental
nurse.
  6. Apply a bend or an endodontic
stop to the needle to measure the
Figure 9:  Forefinger, not thumb, is being
used to apply gentle pressure to the
syringe plunger
Adapted with permission from Oxford University
Press.
depth of delivery, which should be
at least 1 mm short of the working
length. This will reduce the risk of
extrusion of solution into the
periapical tissues.
  7. Insert the needle gently into the root
canal without binding it within the
root canal. This will reduce the risk
of extrusion of solution into the
periapical tissues.
 8. Apply gentle pressure to the
plunger of the syringe. Consider
using a forefinger rather than a
thumb to apply gentle pressure
(Figure 9). This will reduce the risk
of extrusion of solution into the
periapical tissues.
  9. Deliver fresh cleaning solution after
each file is withdrawn from the root
canal. This will ensure there is fresh
active solution and reduce the risk
of the root canal system becoming
blocked with debris.
10. During the process of shaping root
canals, agitate the solution by
gently moving the needle up and
down within the root canal, and
then insert a small-sized hand file
(ISO size 10).
11. When the process of shaping root
canals has been completed, deliver
fresh solution into the root canals,
and then agitate the solution
manually or using a device.
12. Throughout treatment, the primary
cleaning solution should be sodium
hypochlorite.
13. If using EDTA solution or another
solution as a penultimate or final
rinse, the root canal should be
rinsed with saline and/or
thoroughly dried with sterile paper
points before and after their use.
Iatrogenic (nosocomial)
infections
Microbes may be iatrogenically
transmitted into the root canal system
via contaminated gloves, instruments,
and materials. Skin commensal
bacteria have been identified in
endodontic infections.34 The following
infection control measures are
advisable to reduce transmission of
pathogens:
•• Correct hand hygiene:35
handwashing with soap and water or
handrubbing with an alcohol-based
formulation
•• Correct donning, use, and doffing
of personal protective equipment
(Figure 10)
•• Disinfection of tooth and
environmental surfaces. It is
advisable that once rubber dam has
been placed, the tooth surface and
rubber dam sheet are disinfected
using an appropriate cleaning
solution36
•• Sterilization and disinfection of
instruments, devices, and equipment.
It is advisable to use presterilized
files, needles, and paper points; and
to disinfect gutta-percha points in
sodium hypochlorite prior to filling
root canals
Figure 10:  The use of personal
protective equipment decreases the risk
of iatrogenic microbial transmission into
the root canal system
•• Removal of infected debris from the
flutes of files to prevent cross-
contamination between root canals
if treating a multirooted tooth or
simultaneously treating multiple teeth37
•• Changing gloves frequently
throughout endodontic procedures,34
in particular, after taking
intraoperative radiographs
•• Use of high-speed vacuums/suction to
minimize droplets and splatter
Summary points
•• Endodontic disease is a biofilm-
mediated infection. Biofilms can be
challenging to disrupt and kill
•• Root canal anatomy is usually
complex and can be challenging to
clean
•• Shaping root canals creates a smear
layer and hard tissue debris, which
can complicate cleaning the root
canal system
•• Contemporary cleaning of the root
canal system aims to disrupt and kill
biofilms, dissolve and flush out pulp
tissue, and remove smear and debris
from ideally all of the root canal
anatomy, but realistically as much of
it as is practicable
•• Contemporary cleaning solutions
continue to be sodium hypochlorite
and EDTA solution
•• Effective cleaning is achieved
by frequently delivering fresh
cleaning solution into the root canal
system and then agitating the
solution manually and/or with
a device
•• Controlling infection is key: this not
only applies to existing root canal
infections, but also to preventing
iatrogenic endodontic infections
Acknowledgements
The author would like to thank Dr Sadia Niazi,
Dr Sophie Parker, Dr Shanon Patel, and Oxford
University Press who kindly gave permission to
reproduce material.

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