doi:10.1111/iej.

12648

Impact of needle insertion depth on the removal of

hard-tissue debris

R. Perez1, A. A. Neves2, F. G. Belladonna3, E. J. N. L. Silva4, E. M. Souza5, S. Fidel1,

M. A. Versiani6, I. Lima7, C. Carvalho4 & G. De-Deus4
1
Department of Dental Clinics, Rio de Janeiro State University, Rio de Janeiro; 2Department of Pediatric Dentistry and
Orthodontics, Federal University of Rio de Janeiro, Rio de Janeiro; 3Department of Endodontics, Fluminense Federal University,
oi, Rio de Janeiro; 4Department of Endodontics, Grande Rio University, Duque de Caxias, Rio de Janeiro; 5Department of
Niter

Dentistry II, Federal University of Maranh~ao, S~ ao; 6Department of Restorative Dentistry, Dental School of
ao Lu
ıs, Maranh~
Ribeir~
ao Preto, University of S~ ao Paulo; and 7Nuclear Engineering Program, Federal University of Rio de Janeiro,
ao Paulo, S~
Rio de Janeiro, Brazil

Abstract matched images of the canals, before and after prepa-

Perez R, Neves AA, Belladonna FG, Silva EJNL,
Souza EM, Fidel S, Versiani MA, Lima I, Carvalho C,
De-Deus G. Impact of needle insertion depth on the removal
of hard-tissue debris. International Endodontic Journal, 50,
560–568, 2017.
Aim To evaluate the effect of depth of insertion of an
irrigation needle tip on the removal of hard-tissue
debris using micro-computed tomographic (micro-CT)
imaging.
Methodology Twenty isthmus-containing mesial
roots of mandibular molars were anatomically
matched based on similar morphological dimensions
using micro-CT evaluation and assigned to two
groups (n = 10), according to the depth of the irriga-
tion needle tip during biomechanical preparation: 1
or 5 mm short of the working length (WL). The
preparation was performed with Reciproc R25 file (tip
size 25, .08 taper) and 5.25% NaOCl as irrigant. The
final rinse was 17% EDTA followed by bidistilled
water. Then, specimens were scanned again, and the
ration, were examined to quantify the amount of
hard-tissue debris, expressed as the percentage vol-
ume of the initial root canal volume. Data were com-
pared statistically using the Mann–Whitney U-test.
Results None of the tested needle insertion depths
yielded root canals completely free from hard-tissue
debris. The insertion depth exerted a significant influ-
ence on debris removal, with a significant reduction
in the percentage volume of hard-tissue debris when
the needle was inserted 1 mm short of the WL
(P < 0.05).
Conclusions The insertion depth of irrigation nee-
dles significantly influenced the removal of hard-tissue
debris. A needle tip positioned 1 mm short of the WL
resulted in percentage levels of hard-tissue debris
removal almost three times higher than when posi-
tioned 5 mm from the WL.
Keywords: hard-tissue debris, insertion depth, irri-
gation, micro-CT, Reciproc, side-vented needle.
Received 18 July 2015; accepted 7 April 2016

in an infected root canal system, may contain bacte-

Introduction
An important step for successful root canal treatment
is the removal of organic and inorganic debris that,
Correspondence: Gustavo De-Deus, Department of Endodon-
tics, Grande Rio University, Duque de Caxias, Av. Henrique
Dodsworth, 85, Apto 808, Lagoa, Rio de Janeiro 22061-
030, Brazil (e-mail: endogus@gmail.com).
ria and serve as a nidus for reinfection (Versiani et al.
2016). This goal can be achieved by the combination
of mechanical preparation with chemical irrigation to
control or eliminate the causative agents of apical
periodontitis (Kahn et al. 1995, Lee et al. 2004).
However, large areas of untouched canal
walls (Peters et al. 2001) and accumulation of hard-
tissue debris in fins, isthmuses, irregularities and ram-
ifications have been reported by several authors as an

560 International Endodontic Journal, 50, 560–568, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd

undesirable effect of mechanical preparation (Paqu
e
et al. 2009, De-Deus et al. 2015, Versiani et al.
2016). Therefore, thorough irrigation of the root
canal system is of utmost importance to remove
infected debris (Haapasalo et al. 2010, Boutsioukis
et al. 2014).
The main limitation of current irrigation techniques
is the difficulty of spreading and flushing the solution
in limited and narrow anatomical structures of the
root canal system such as isthmuses or fins (Versiani
et al. 2015). The effectiveness of the fluid dynamics of
the irrigating solution during chemomechanical
preparation relies on many variables, such as canal
anatomy, the delivery system, volume, flow and type
of irrigation agent, as well as the type and diameter
of the irrigation needle (Abou-Rass & Piccinino 1982,
Kahn et al. 1995). Despite extensive research on irri-
gation and agitation techniques, the conventional syr-
inge and needle is still the most commonly used
irrigation method (Shen et al. 2010, Thomas et al.
2014). In this technique, replenishment and
exchange of irrigants depend upon the depth of nee-
dle, which may also affect the removal of accumu-
lated hard-tissue debris (Abou-Rass & Piccinino 1982,
Chow 1983, Albrecht et al. 2004, Sedgley et al.
2005, Hsieh et al. 2007). However, it remains uncer-
tain which should be the ideal needle penetration
depth to achieve a safe and effective debridement
strategy and to establish evidence-based guidelines for
root canal irrigation.
Recently, several authors have focused on the
study of accumulated hard-tissue debris in recesses,
isthmuses, irregularities and ramifications using
micro-computed tomographic (micro-CT) imaging
(Paqu
e et al. 2009, 2011, 2012, Robinson et al.
2013, De-Deus et al. 2015, Versiani et al. 2016);
however, none of them evaluated the effect of the
insertion depth of the needle tip on the removal of
hard-tissue debris. Hence, the present study was
designed to assess the effect of the position of the irri-
gation needle tip on the removal of hard-tissue debris
in mesial root canals of mandibular molars using
micro-CT. Micro-CT imaging allows monitoring the
accumulation and removal of radiopaque structures
in the main space of the root canal and its recesses
and isthmuses during and after instrumentation
(Robinson et al. 2012, De-Deus et al. 2014, 2015)
whilst preserving sample integrity. The hypothesis
tested was that the insertion depth of the irrigation
needle tip does not have a significant impact on the
removal of hard-tissue debris.
© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
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Perez et al. Needle depth and hard-tissue debris removal
Materials and methods
Sample size estimation
An a priori Wilcoxon–Mann–Whitney test was
selected from the t-tests family in G*Power 3.1 soft-
ware for Mac (Heinrich Heine, Universit€ at D€
usseldorf).
Based on data from a previous study evaluating hard-
tissue debris accumulation after irrigation procedures
(Versiani et al. 2016), the effect size for this study
was established (=1.87). An alpha-type error of 0.05,
power beta of 0.95 and allocation ratio N2/N1 of 1
were also specified. A total of 18 samples (nine per
group) were indicated as the ideal size required for
observing significant differences.
Specimen selection
This study was revised and approved by the Ethics
Committee, Nucleus of Collective Health Studies (pro-
tocol n° 2223 – CEP/HUPE). One-hundred and six
human mandibular first and second molars with mod-
erately curved mesial roots (10–20°) were selected
from a pool of extracted teeth and stored in a 0.1%
thymol solution at 5 °C. Digital radiographs taken in
a buccolingual direction were used to calculate the
angle of the curvature using AxioVision 4.5 software
(Carl Zeiss Vision GmbH, Hallbergmoos, Germany),
according to Schneider’s method (Schneider 1971).
The teeth were pre-scanned in a micro-CT device
(SkyScan 1173; Bruker micro-CT, Kontich, Belgium)
using an isotropic resolution of 70 lm at 70 kV and
114 mA to obtain a pre-treatment outline of the root
canals. Following Fan et al. (2010), 20 specimens
with mesial roots with isthmuses type I (narrow sheet
and complete connection existing between two
canals) or III (incomplete isthmus existing above or
below a complete isthmus) were selected. Then, the
specimens were scanned again at an increased isotro-
pic resolution of 14.16 lm through 360° rotation
around the vertical axis with a rotation step of 0.5°,
camera exposure time of 7000 milliseconds and frame
averaging of 5, using a 1.0-mm-thick aluminium fil-
ter. The acquired images were reconstructed into
cross-sectional slices with NRecon v.1.6.9 software
(Bruker micro-CT) using standardized parameters for
beam hardening (40%), ring artefact correction (10)
and similar contrast limits. The volume of interest
was selected to extend from the furcation level to the
apex of the root, resulting in the acquisition of 700–
800 transverse cross sections per tooth.
International Endodontic Journal, 50, 560–568, 2017 561

Needle depth and hard-tissue debris removal Perez et al.
Subsequently, mesial roots were matched to create
two groups of 10 roots each based on the root canal
configuration, three-dimensional (3D) morphologic
aspects of the canals (volume and surface area),
degree of curvature and root length. One root from
each group was randomly assigned to one of the two
groups (n = 10) according to the insertion depth of
the irrigation needle: 1 or 5 mm short of the working
length (WL). After checking for normality assumption
(Shapiro–Wilk test) and homogeneity (Levene’s test)
of the groups with respect to root canal volume and
surface area, degree of curvature and root length,
anatomical matching between groups was statistically
confirmed (P > 0.05; independent samples t-test).
Root canal preparation
A single experienced operator performed all proce-
dures. After access cavity preparation, the WL was
determined by passing a size 10 K-file (Dentsply
Maillefer, Ballaigues, Switzerland) through the major
foramen and withdrawing it 1.0 mm. Next, the apical
foramen of each root was sealed with hot glue and
embedded in polyvinyl siloxane to create a closed-
ended system (Susin et al. 2010). A glide path was
established by scouting a stainless steel size 15 K-file
(Dentsply Maillefer) up to the WL. Then, root canals
were prepared with Reciproc R25 file size 25, .08
taper (VDW, Munich, Germany), powered by an elec-
tric motor (VDW Silver motor; VDW) according to the
manufacturer’s instructions. Each instrument was
used to enlarge four root canals, and four waves of
instrumentation were performed to prepare each root
canal. The WL was reached in the fourth wave for all
canals.
Throughout the biomechanical preparation, a total
of 30 mL 5.25% NaOCl was delivered at a flow rate
of 2 mL min 1 by a VATEA peristaltic pump
(ReDent-Nova, Ra’anana, Israel) connected to a 30-
gauge side-vented needle (Max-i-Probe; Dentsply
Rinn, Elgin, IL, USA) placed without binding up to 1
or 5 mm short of the WL, according to each group.
Each root canal was irrigated with 2 mL NaOCl after
access and glide path procedures, respectively. Then,
3 mL NaOCl was used after each wave of instrumen-
tation and 1 mL NaOCl after patency. After prepara-
tion, an additional rinse with 10 mL NaOCl was
performed, followed by 5 mL 17% EDTA (pH = 7.7)
delivered at a flow rate of 1 mL min 1 for 5 min.
Finally, a 5-min 5-mL rinse with bidistilled water was
used in the final irrigation to flush out the EDTA.
562 International Endodontic Journal, 50, 560–568, 2017
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Thus, the overall volume of irrigant solutions per
canal was 40 mL, in a total time of 25 min (Fig. 1).
Irrigant aspiration was performed at the level of root
canal orifices with a SurgiTip (Ultradent Products
Inc., South Jordan, UT, USA) attached to a high-speed
suction pump. Then, canals were dried with absor-
bent paper points (Dentsply Maillefer), imaged again
with a micro-CT system and reconstructed with the
same parameters used in pre-treatment scans.
Quantitative three-dimensional analysis
The image stacks of the specimens after preparation
were rendered and co-registered with their respective
preoperative data sets using an affine algorithm of the
3D Slicer 4.4.0 software (available from http://
www.slicer.org) (Fedorov et al. 2012). Matched
images of the canals were examined to calculate vol-
ume using the ImageJ software v.1.49 (Schneider
et al. 2012). Then, quantification of hard-tissue debris
was undertaken as described previously (Neves et al.
2014) and expressed as the percentage volume of the
initial root canal volume for each specimen. Debris
was considered as the material with density similar to
dentine in regions previously occupied by air in the
nonprepared root canal space and quantified by inter-
section between images before and after canal instru-
mentation (Robinson et al. 2012, De-Deus et al.
2014). Subsequently, colour-coded pre- and postoper-
ative root canal models and debris were rendered and
qualitatively evaluated using the plugins 3D Viewer
and 3D Object Counter, respectively, in the ImageJ
software (Schmid et al. 2010, Schneider et al. 2012).
Statistical analysis
Data regarding the accumulated hard-tissue debris cre-
ated after root canal preparation were calculated as the
percentage volume of the initial root canal volume and
input for statistics. Data were skewed (Shapiro-Wilk
test) and, therefore, compared using Mann–Whitney
U-test, with the alpha-type error set at 0.05.
Results
Irrigation of the root canals using the needle tip
1 mm short of the WL left a mean of 0.92% (1.68)
of the total root canal system volume filled with accu-
mulated hard-tissue debris. On the other hand, after
irrigation using the needle tip 5 mm short of the WL,
2.43% (2.22) of the total canal volume was filled
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 13652591, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.12648 by Cochrane Japan, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Perez et al. Needle depth and hard-tissue debris removal

1 mm 5 mm

Access Access

2 mL 2 mL

Glide path Glide path

2 mL 2 mL

R25 first wave R25 first wave

3 mL 3 mL

Patency Patency
1 mL 1 mL

R25 second wave R25 second wave

3 mL 3 mL

5.25% NaOCl Patency 5.25% NaOCl Patency

1 mL 1 mL

R25 third wave R25 third wave

3 mL 3 mL

1 mL Patency 1 mL Patency

3 mL R25 fourth wave 3 mL R25 fourth wave

1 mL Patency 1 mL Patency

10 mL 10 mL
5.25% NaOCl 5.25% NaOCl
5 mL 5 mL
17% EDTA 17% EDTA
5 mL 5 mL
Bidistilled water Bidistilled water

Figure 1 Flow chart for the experimental irrigation sequence. The only difference between groups was the insertion depth of
the irrigation needle: 1 or 5 mm short of WL.

with accumulated hard-tissue debris. The difference

between the groups was significant (Mann–Whitney
U-test, P = 0.019) (Table 1).
Representative 3D models and cross-sectional slices
in Figs 2 and 3 show the distribution of the accu-
mulated hard-tissue debris after root canal prepara-
tion irrigated with the needle tip positioned at 1 or
5 mm short of the WL in mesial roots of mandibular
molars.
Discussion
It was hypothesized that dentine particles cut from
the canal walls by rotary instruments were actively
packed into soft-tissue remnants within the root canal
space and became more resistant to removal by con-
ventional syringe-and-needle irrigation (Paqu
e et al.
2009, 2012, Endal et al. 2011). This packed debris
may potentially interfere with disinfection by

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 560–568, 2017 563

Needle depth and hard-tissue debris removal Perez et al.
Table 1 Mean, standard deviation (SD), median, range and confidence intervals (CI) of the preoperative data and total % vol-
ume of accumulated hard-tissue debris after instrumentation
Needle’s depth Initial volume (mm3)
1 mm short of the WL
Mean (SD) 4.87 (1.99)
Median (min-max) 5.00 (1.79–7.70)
95% CI 3.45–6.30
5 mm short of the WL
Mean (SD) 4.96 (2.25)
Median (min-max) 4.89 (1.72–8.38)
95% CI 3.35–6.57
P-value 0.932
preventing irrigant flow and neutralizing the antibac-
terial effects of the irrigating solution (Paqu
e et al.
2012). Therefore, debris generated during mechanical
preparation must be removed by the flushing of the
irrigant solution. However, it has been demonstrated
that several factors may affect the efficiency of irriga-
tion during chemomechanical preparation (Abou-Rass
& Piccinino 1982). In the present study, the insertion
depth of the irrigation needle was chosen as an inde-
pendent variable to be tested on the reduction of
accumulated hard-tissue debris, considering the lack
of information on this subject in the literature, using
a micro-CT methodological approach. Additionally,
mesial roots of mandibular molars were selected
because of the high incidence of isthmuses in compar-
ison with roots from other teeth groups (Weller et al.
1995, Mannocci et al. 2005, Harris et al. 2013),
which makes their debridement a laborious challenge.
Several authors have advocated that irrigation pro-
cedures must provide an effective debridement of the
root canal space (Chow 1983, Sedgley et al. 2005,
Hsieh et al. 2007, Boutsioukis et al. 2010); however,
the literature has limited information associating nee-
dle insertion depth and debris removal. Earlier studies
using destructive methodological approaches reported
that the proximity of the irrigation needle to the apex
played an important role in the removal of debris
(Brown & Doran 1975, Abou-Rass & Piccinino 1982,
Chow 1983). Similarly, Sedgley et al. (2005) showed
that needle depth had a significant effect on mechani-
cal removal of bacteria from within the root canal
space. A previous computational fluid dynamics study
evaluating the effect of needle insertion depth on irri-
gant flow recommended that side-vented needles
should be positioned within 1 mm to the WL if possi-
ble because the irrigant replacement reached the WL
only when the side-vented needle was placed at this
position (Boutsioukis et al. 2010).
564 International Endodontic Journal, 50, 560–568, 2017
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Initial surface area (mm2) % volume of debris
69.37 (19.01) 0.92 (1.68)
68.37 (43.71–103.47) 0.30 (0–5.52)
55.76–82.97 0.28–2.12
66.46 (17.57) 2.43 (2.22)
67.29 (35.84–98.57) 1.55 (0.30–6.39)
53.89–79.03 0.84–4.01
0.727 0.019
More recently, several studies evaluating the accu-
mulation of hard-tissue debris in recesses, isthmuses,
irregularities and ramifications using micro-CT have
been published (Paqu
e et al. 2009, 2011, 2012,
Robinson et al. 2013, De-Deus et al. 2015, Versiani
et al. 2016). This technology quantified the accumu-
lation and removal of radiopaque debris in various
areas of the root canal system (Robinson et al.
2012, De-Deus et al. 2014, 2015). This is a nonde-
structive technology that enables the same speci-
mens to be assessed after different treatment steps to
observe both quantitatively and qualitatively hard-
tissue debris. A disadvantage of this method is that
it is not possible to analyse remaining soft tissue
(Paqu
e et al. 2009). Overall, previous micro-CT stud-
ies revealed that sequential or supplementary irriga-
tion procedures during or after root canal
preparation resulted in less hard-tissue debris in isth-
mus-containing root canal systems, which is in
accordance with the present results. In this study, a
significant reduction in the volume of hard-tissue
debris was observed when the needle tip was placed
1 mm short of the WL, thus rejecting the tested
hypothesis. In contrast, root canals in which the
needle was 5 mm short of the WL exhibited almost
a three-fold increase in the percentage volume of
debris. However, both irrigation protocols did not
succeeded in rendering mesial root canal systems
free from hard-tissue debris. Thus, in conventional
syringe–needle irrigation, optimization of the irriga-
tion process can be related to the depth of needle
penetration (Siu & Baumgartner 2010).
In the current study, a 30-G side-vented needle
was used in both groups. This needle has a lumen on
the lateral surface located 2 mm from the blunt tip
and produces lower apical pressure than an open-end
needle (Boutsioukis et al. 2007); however, its closed
end is important to avoid inadvertent displacement of
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Perez et al. Needle depth and hard-tissue debris removal

Figure 2 Different views of a 3D rendering of the mesial root canal system of a given mandibular molar (a) before and (b) after
root canal preparation with Reciproc R25 instrument and irrigated with the needle positioned 1 mm short of the WL. Pre- and
postoperative root canal anatomy is depicted in green and red colours, respectively. (c) Superimposition of the accumulated
hard-tissue debris (blue areas) over the original canal anatomy (in grey). (d) Representative cross-sectional images of the coro-
nal, middle and apical thirds of the mesial root (from above to below), showing the presence of accumulated debris in the
mesial canal system after preparation (yellow arrows).

NaOCl into the periapical tissues. Although the irri-
gating solution used with conventional open-end
syringe–needle technique does not reach more than
1 mm apically from the needle tip (Ram 1977), it has
been reported that 42% of endodontists in North
American had at least one accident with NaOCl
extrusion (Kleier et al. 2008). Consequently, the dee-
per the needle penetration, the higher is the risk of
irrigant extrusion (Psimma et al. 2013). This long-
standing background explains why some professionals
avoid reaching the WL whilst irrigating with NaOCl
solution. The use of a penetration depth far from the

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 50, 560–568, 2017 565
 13652591, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.12648 by Cochrane Japan, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Needle depth and hard-tissue debris removal Perez et al.

(a) (d)

(b)

(c)

Figure 3 Different views of a 3D rendering of the mesial root canal system of a given mandibular molar (a) before and (b) after
root canal preparation with Reciproc R25 instrument and irrigated with the needle positioned 5 mm short of the WL. Pre- and
postoperative root canal anatomy is depicted in green and red colours, respectively. (c) Superimposition of the accumulated
hard-tissue debris (blue areas) over the original canal anatomy (in grey). (d) Representative cross-sectional images of the coro-
nal, middle and apical thirds of the mesial root (from above to below), showing the presence of accumulated debris in the
mesial canal system after preparation (yellow arrows).

WL may be protective against apical extrusion, how-
ever, according to the present results, this will result
in a significantly greater amount of remaining hard-
tissue debris in isthmus-containing mesial roots of
mandibular molars.
To help disseminate the concept of close-to-WL irri-
gation as demonstrated by the present study, it is
important to avoid incidents with NaOCl solution,
such as using low flow rate and pressure of irrigant
delivery and preventing the binding of the needle to
the canal walls, as it can act like a piston, forcing the
solution beyond the apex. Moreover, the use of a side-
vented type irrigation needle allows an upward turbu-
lent motion around and beyond the end of the probe,
which thoroughly irrigates the root canal system and
prevents solution and debris from being extruded
through the apical foramen (Kahn et al. 1995, Saini
et al. 2013).

566 International Endodontic Journal, 50, 560–568, 2017 © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd

Conclusions
Neither irrigation approach succeeded in rendering
the isthmus-containing mesial root canal system free
from accumulated hard-tissue debris; however, the
depth of needle insertion significantly influenced the
removal of hard-tissue debris. The needle tip posi-
tioned 1 mm short of the WL resulted in percentage
levels of hard-tissue debris removal almost three times
higher than when positioned at the 5 mm level.
Within the conditions of this study, it may be con-
cluded that the closer the needle is to the WL, the
more efficient is the removal of hard-tissue debris.
This outcome emphasizes that the choice of an ade-
quate needle positioned at an appropriate level is an
important step to optimize the overall quality of the
irrigation procedure.
Conflict of interest
The authors have stated explicitly that there are no
conflict of interests in connection with this article.
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