Original Article

Antimicrobial efficacy of sodium hypochlorite, saline,

and Er, Cr:YSGG laser‑assisted disinfection in root
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canal treatment of primary molars: An in vivo study

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Neha Chauhan, Gyanendra Kumar, Mridula Goswami, Smriti Johar, Abha Sharma1
Department of Pediatric and Preventive Dentistry, Maulana Azad Institute of Dental Sciences, 1Department of Microbiology, Govind
Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India

ABSTRACT Address for correspondence:

Aim: The aim of the study was to compare the
antimicrobial efficacy of sodium hypochlorite
(NaOCl), Saline, and Er, Cr:YSGG laser‑assisted
disinfection through microbiological analysis
in root canal treatment of primary molars.
Materials and Methods: Forty‑five primary teeth
were selected for this study as per the inclusion
and exclusion criteria in the age group of 4–8 years
and then randomly allocated to Three Groups  A,
B, and C. In Group A, during root canal treatment,
irrigation was done using NaOCl, in Group  B,
laser‑assisted disinfection was done using Er,
Cr:YSGG laser, and in Group C, saline was used as
an irrigating agent. This was followed by obtaining
pre‑ and postirrigation samples from the canals for
microbiological investigation in all the groups. Data
analysis was performed using Statistical Package
for the Social Science‑21 (SPSS‑21). Results: NaOCl
was more effective against aerobic bacteria while Er,
Cr:YSGG laser was more effective against anaerobic
bacteria when used for disinfection in root canal
treatment. There was a significant difference among
the three groups (P > 0.05). Conclusion: The study
showed that NaOCl and Er, Cr:YSGG laser have
antimicrobial effects when used for disinfection in
root canal treatment of primary teeth. Moreover,
the study also shows that Er, Cr:YSGG laser may be
used as a valuable tool for laser‑assisted disinfection
in root canal treatment of primary teeth.
KEYWORDS: Antimicrobial, Er, Cr:YSGG laser,
irrigating agent
Dr. Neha Chauhan,
Department of Pedodontics and Preventive Dentistry, Maulana
Azad Institute of Dental Sciences, New Delhi, India.
E‑mail: nc000006@gmail.com
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DOI:
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microbial antigens entering into the pulp. Proceeding
infection within the tooth causes necrosis, apical
periodontitis, entire root canal system gets invaded
by bacteria. Root canal treatment is therefore
indicated in the primary teeth with aims to purify
the root canals from infection and to keep the
teeth in the mouth until the age they normally
fall off. The rationale for preserving the primary
dentition is the relief of pain, the function of
chewing and speech, improvement of appearance,
the arch length, and maintenance of a healthy oral
environment.
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of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new
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How to cite this article: Chauhan N, Kumar G, Goswami M,

Johar S, Sharma A. Antimicrobial efficacy of sodium hypochlorite,
Introduction saline, and Er, Cr:YSGG laser‑assisted disinfection in root canal
treatment of primary molars: An in vivo study. J Indian Soc Pedod
Dental caries in the teeth of infants and children is Prev Dent 2023;41:70-5.
represented as one of the most prevalent dental
Submitted: 24‑Feb‑2023 Revised: 12‑Apr‑2023
problems.[1] Pulpitis from carious lesions or leaking
Accepted: 17‑Apr‑2023 Published: 01-Jun-2023
filling through the dentinal tubules is caused by

70 © 2023 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
 Chauhan, et al.: Primary molar root canal disinfection: A comparative study
Endodontic infections being polymicrobial in nature
are dominated by obligate anaerobic bacteria.
Studies indicate 69% facultative anaerobes and 70%
Gram‑positive bacteria in the infected root canals with
the two most prevalent species being Peptostreptococcus
and Streptococcus spp. are reported.[2] Effective
elimination of infection from the root canal system
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became the objective of endodontic treatment of teeth
with necrotic pulp and periapical lesions.
In the treatment of endodontic infection, irrigation can play
an important role in the elimination of microorganisms
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 06/10/2023
from the root canal. Irrigants are used during the
endodontic treatment to flush out loose debris, dissolve
organic matter in the canal, lubricate the dentinal walls,
and be antimicrobial.[3] Several irrigation solutions have
been recommended for use in combination with root
canal preparation such as Sodium Hypochlorite (NaOCl),
Chlorhexidine, MTAD, Aqueous Ozone, Saline, Nd:
YAG laser, Er: YAG laser, Er, Cr:YSGG laser.
In the present study, root canal disinfection was
performed using NaOCl, Saline, and Er, Cr:YSGG
laser in primary molars. One of the most commonly
used irrigating agents during instrumentation in
primary teeth has been NaOCl. It is a proteolytic
agent which has a wide range of activity against
several endodontic microorganisms. It has
excellent tissue‑dissolving ability and hemostatic
properties.[4] Some of its disadvantages include bad
odor and taste, cytotoxicity,[5,6] deteriorative effects on
the mechanical and chemical properties/composition
of dentine.[7,8] Furthermore, due to its highly irritant
nature for periapical tissues, researchers have
developed alternative irrigants.
Recently, new disinfection approaches have been
suggested, and one of these includes the use of laser.
Several types of lasers are being used such as Nd:
YAG laser (1064 nm), Er: YAG laser (2940 nm) and Er,
Cr:YSGG laser  (2780  nm). The Erbium Laser having
high affinity with water, shallow depth of tissue
penetration, and no thermal damage makes it an ideal
laser for use in pediatric patients.[9] The aim of the
present study was to compare the antimicrobial efficacy
of NaOCl, Saline, and Er, Cr:YSGG laser‑assisted
disinfection through microbiological analysis in root
canal treatment of primary molars.
The null hypothesis of the study was that the
antimicrobial efficacy of Er, Cr:YSGG laser‑assisted
disinfection is no better than that of irrigation with
NaOCl and saline.
Materials and Methods
A total of 45 children aged 4–8  years participated
in the study in the Department of Pedodontics and
Preventive Dentistry at Maulana Azad Institute
of Dental Sciences, New  Delhi. The present study
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January-March 2023 |
was a randomized controlled trial carried out after
obtaining prior approval from the Ethical Committee
of the Institution with approval number‑MAIDS
committee/2016/3260. The sample size was estimated
using the following formula.
n = σ2 (Zα + Zβ) 2/d2
Where, n = Sample size, Zα = 1.96 value of the standard
normal variate corresponding to level of significance
alpha 0.0500. Power of the study  =  0.8000, Zβ = 0.84
d  =  Difference between the two mean standard
deviation assumed to be equal for both groups.
The teeth were divided equally into the following
three groups of 45 primary molar teeth each by block
random allocation as shown below based on inclusion
and exclusion criteria.
Total sample size (n) = 45 children (age group = 4–8 years)
The sample was divided into three groups based on the use of irrigating agents
GROUP I GROUP II GROUP III
2.5% NaOCl Er,Cr:YSGG laser irradiation Saline
(15 children) (15 children) (15 children)
Inclusion and exclusion criteria
The children aged between 4 and 8 years were included
in the study with positive parental informed consent.
Primary molars infected with either abscess, sinus tract
or with signs of irreversible pulpitis were included.
Radiographically, the teeth showing interradicular or
periapical radiolucency and with less than two‑thirds
of root resorption were enrolled. Teeth with abnormal
anatomy and calcified canals, with unrestorable
crowns or with evidence of extensive internal/
external pathological root resorption were excluded.
Patients who presented with any systemic disorder or
medically compromising conditions or had received
antibiotics 2  weeks before microbial sampling were
excluded from the study.
Clinical procedures
Tooth isolation was done by rubber dam after local
anesthesia administration and cleaned with pumice.
Access opening was done using a high‑speed
handpiece and canals were located under dental
operating microscope. Shaping and cleaning the canals
were done with sterile Kerr files and Hedstrom files.
Pre‑  and postirrigation samples were collected in
all three groups with paper points sterilized using a
glass bead sterilizer and transported to Microbiology
Laboratory, Department of Microbiology, Govind
Ballabh Pant Institute of Postgraduate Medical
Education and Research, New Delhi, for estimating the
number of bacteria in suspension  (as colony‑forming
unit [CFU]/ml). Bacteria were cultured on blood agar
and MacConkey agar bacterial culture medium and
incubated under aerobic and anaerobic conditions. The
71
 Chauhan, et al.: Primary molar root canal disinfection: A comparative study
bacterial count was done after 24–48  h of incubation
using the semi‑quantitative technique (Standard loop
method). Root canal treatment was completed after
taking the sample from root canal in the same visit.
Group  A  ‑  During instrumentation, irrigation was
done with 2.5% NaOCl.
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Group  B  ‑  During instrumentation, irrigation was
done with normal saline followed by Er, Cr:YSGG
laser irradiation (2W, 2780 nm) at the end with radial
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firing tip RF‑T2, 200 µm in diameter and 25 mm length
for 60 s. The tip was introduced up to 4–5  mm from
the radiographic apex. Er, Cr:YSGG laser tip was
continuously moved from apical to the cervical third
for 15 s against each wall  (mesial, distal, buccal, and
lingual) for a total of 60 s using a slow up‑and‑down
motion within the canal. The following parameters
were used: 2W, 20 pulses/s, 50% water and 50% air as
shown in Figures 1‑4.
Group  C  ‑  During instrumentation, irrigation was
done with saline.
Figure 1: Rubber dam application over deep carious tooth
Figure 3: Laser‑assisted irrigation with Er, Cr:YSGG laser
72 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January-March 2023 |
The data were entered into MS Excel and statistically
analyzed using SPSS-PC-21.0 version (IBM, Inc.
Virginia, United States) Chi‑square test was used
for categorical variables. McNemar test was used to
compare the colony count from pre‑ to postirrigation
phase. The level of statistical significance was set at
P < 0.05.
Results
In Group  A  (NaOCl group), a significant difference
was seen for aerobic and anaerobic bacterial count
from preirrigation to postirrigation phase. In
Group  B  (Er, Cr:YSGG laser), a significant difference
was seen for aerobic and anaerobic bacterial count
from preirrigation to postirrigation phase while in
Group C (saline), no significant difference was seen for
aerobic and anaerobic bacterial count from preirrigation
to postirrigation phase. The semi‑quantitative method
was used for the bacterial count.
A significant difference was seen in the aerobic colony
count among three study groups after irrigation with
respective irrigating agents as P <  0.05 as shown in
Table 1. Postirrigation sodium hypochloride (Group A)
was found to be most effective followed by Er,
Cr:YSGG laser  (Group  B) and saline  (Group  C) was
found ineffective against aerobic colonies.
The significant difference was seen in the anaerobic
colony count among three study groups after irrigation
with respective irrigating agents as P < 0.05 as shown
in Table 2. Postirrigation, Er, Cr:YSGG laser (Group B)
a b
Figure 2: (a) Pre-irrigation sample collection with paper points, (b)
Transport media containing Pre-irrigation sample
a b
Figure 4: (a) Post-irrigation sample collection with paper points, (b)
Transport media containing Post-irrigation sample
 Chauhan, et al.: Primary molar root canal disinfection: A comparative study

Table 1: Intergroup comparison of aerobic colony necessary for complete disinfection. A  large number
count (postirrigation) of substances have been used as root canal irrigants
Aerobic (CFU/mL) Total,
which include normal saline, citric and phosphoric
n (%) acids, ethylenediaminetetraacetic acid, proteolytic
>10 ,3
>10 ,
4
>10 ,
5
No growth,
n (%) n (%) n (%) n (%) enzymes, NaOCl, sodium hydroxide, urea, potassium
NaOCl 2 (13.3) 1 (6.7) 2 (13.3) 10 (66.7) 15 (100.0)
hydroxide, hydrogen peroxide, chlorhexidine
Er, Cr: 4 (26.7) 2 (13.3) 0 9 (60.0) 15 (100.0)
gluconate, and lasers.[11] Our study aimed to compare
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YSGG laser the antimicrobial efficacy of NaOCl, Er, Cr:YSGG laser,

Saline 1 (6.7) 6 (40.0) 5 (33.3) 3 (20.0) 15 (100.0) and saline as irrigating agent in root canal treatment of
Total 7 (15.6) 9 (20.0) 7 (15.6) 22 (48.9) 45 (100.0) primary molars.
P 0.014*
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*P< 0.05 statistically significant, CFU = Colony‑forming unit;
NaOCI = Sodium hypochlorite
Table 2: Intergroup comparison of anaerobic
colony count (postirrigation)
Anaerobic (CFU/mL)
>102, >103, >104, >105, No growth,
n (%) n (%) n (%) n (%) n (%)
NaOCl 0 3 (20.0) 2 (13.3) 2 (13.3) 8 (53.3)
Er, Cr: 0 1 (6.7) 1 (6.7) 0 13 (86.7)
YSGG
laser
Saline 1 (6.7) 5 (33.3) 1 (6.7) 5 (33.3) 3 (20.0)
Total 1 (2.2) 9 (20.0) 4 (8.9) 7 (15.6) 24 (53.3)
P 0.032*
*P< 0.05 statistically significant, CFU = Colony‑forming unit;
NaOCI = Sodium hypochlorite
was found to be most effective followed by
NaOCl  (Group  A), and saline  (Group  C) was found
ineffective against anaerobic colonies.
Discussion
Dental caries is represented as one of the most prevalent
dental problems in children mainly affecting primary
teeth. When compared to the permanent teeth, primary
teeth have thinner enamel and dentin, wider dentinal
tubules and higher and larger pulp chamber. All of these
factors may lead to early involvement of pulp in primary
teeth as compared to permanent teeth.[10] Considering
the fast progression of caries in primary teeth, and
consequently the pulp damage due to the pulpal tissue
contamination by bacteria and their derived toxins,
endodontic treatment becomes imperative.
Treating the primary teeth endodontically is considered
highly complicated as the primary teeth exhibit bizarre
canal geometry, features such as furcal connections
and horizontal anastomoses which is uncommon in
permanent teeth.[10] Successful endodontic treatment is
dependent on many factors, such as a precise diagnosis,
thorough cleaning, a disinfection protocol achieved
with the help of various intracanal medicaments and
irrigation solutions followed by obturation of the pulp
space and adequate final restoration.
Over the years studies have shown that
chemo‑mechanical preparation of root canals is
In Group  A, 2.5% NaOCl was introduced as an
irrigating agent for the root canal treatment of primary
molars. 2.5% NaOCl  (Group  A) showed significant
antibacterial activity against both aerobic and anaerobic
bacteria. When comparing the antimicrobial activity of
Total, NaOCl against aerobic bacteria, significant reductions
n (%)
were obtained when the preirrigation bacterial count
was compared with the postirrigation bacterial count.
15 (100.0) These findings were in accordance with studies done
15 (100.0) by Vianna et al., Rôças and Siqueira, Sonarkar et al.[12‑14]
15 (100.0)
Considering the studies done by Wang et  al.,[15]
45 (100.0)
Arnabat et al. (2010)[16] and Schoop et al.,[17] Er, Cr:YSGG
Waterlase™  (2780  nm) irradiated at 2W at the end
with radial firing tip laser 200  µm in diameter and
25 mm in length for 60 s was introduced for the root
canal disinfection of primary molars. Er, Cr:YSGG
laser  (Group  B) showed significant antibacterial
activity against both aerobic and anaerobic bacteria.
These findings were in accordance with studies done
by Kasić et al.[18] Cheng et al.[19] Licata et al.[20]
Sterile normal saline 0.9% has been conventionally
used to irrigate and clean the root canal since the dawn
of endodontics. It is isotonic to the body fluids and is
universally accepted as the most common irrigating
solution in all endodontic and surgical procedures. It is
also found to have no side effects, even if pushed into
the periapical tissues, hence safer to use in pediatric
patients and thereby used in the study as one of the
irrigating agent in root canal treatment. Agarwal
et  al. compared the antimicrobial efficacy of saline,
aqueous ozone, and green tea as an irrigating agents
in pulpectomy procedures and found that saline has
limited antimicrobial efficacy.[21] In our study, no
significant difference was found between pre‑  and
postirrigation CFU in the saline group for aerobic
as well as anaerobic bacteria. Our findings are in
conjunction with the studies carried out by Josic et al.
and Hendi et al.[22,23]
Intergroup comparison of postirrigation CFUs of
aerobic bacteria had shown a significant reduction
in Group  A and B and it was not significant for
Group  C  (P  =  0.014). Furthermore, the intergroup
comparison of anaerobic CFUs postirrigation for each
group showed significant reduction in Group A and B
and nonsignificant for Group C (P = 0.032).

Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January-March 2023 | 73
 Chauhan, et al.: Primary molar root canal disinfection: A comparative study
In the present study, it was also seen that root canal
disinfection using NaOCl is more effective against
aerobic bacteria whereas Er, Cr:YSGG laser‑assisted
disinfection is more effective against anaerobic bacteria.
Kouchi et al.[24] demonstrated that bacteria are capable
of invading the periluminal dentin up to a depth of
1100  µm. On the other hand, chemical disinfectants
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penetrate no more than 130  µm into the dentin as
indicated by Berutti et  al.[25] In addition, curved root
canals or canal branching can act as potential obstacles
for penetration of conventional root canal irrigants.
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The utilization of lasers helps to overcome this issue,
as already discussed by Schoop et al.  (2009).[26]  The
high penetration depth of the Er, Cr:YSGG laser in
the dentinal tissue seems to be the most appropriate
explanation for the effective antibacterial activity. One
possible explanation for this kind of light propagation
is given by Vaarkamp et al.[27] and Kienle et al.[28] These
authors have described the ability of enamel prisms
and dentine tubules to scatter light within dental
hard tissues. In addition, the micropulse generated by
Er, Cr:YSGG laser is responsible for the penetration
of energy of about 3  µm into the water to achieve
expansion of intratubular water and the collapse of
water vapor as deep as 1000  µm or more, which is
capable of producing acoustic waves strong enough
to disrupt intratubular bacteria. This penetration into
dentin may provide additional advantages for the use
of laser over conventional methods of disinfection,
such as NaOCl irrigation, in cases where there is
limited access of the agent to the interstices of the
root canal system may limit antimicrobial activity.[29]
The use of flexible fiber tips allows the irradiation
of even narrow or curved root canals. Arnabat et  al.
showed that Er, Cr:YSGG Waterlase™ laser at 2W for
60 s operating at 20 Hz was as effective as 5% NaOCl
and more efficient than Er, Cr:YSGG laser at 1W
for 120 s, 60 s, 30 s, and 2W for 30 s, when applied
for measuring its bactericidal effect in root canals
experimentally colonized with Enterococcus faecalis.
Furthermore, the output power of 2W results in no
carbonization or melting of the root canal walls, and
the resulting temperature increase is not high enough
to damage surrounding tissues.[16] Er, Cr:YSGG
Waterlase™ (2780 nm) irradiated at 2W at the end with
radial firing tip laser 200 µm in diameter and 25 mm
in length for 60 s were taken as laser settings in our
study.[30] However, extra care should be taken while
using laser‑assisted root canal disinfection in primary
teeth because of the peculiar anatomy of the roots
and apices (open or absorbed) as well as the different
penetration depth of the mid‑infrared radiation. One
of the limitations in the study while using laser was
the laser tips being very fragile and should be handled
with care, especially when used on children. The
operator should be trained enough to use the laser
on pediatric patients as it requires proper knowledge
of the operator as well as the cooperation of patient.
Direct vision of the laser is harmful to eyes and can
lead to ocular damage and therefore protective eye
74 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January-March 2023 |
wears were required for the operator, assistant, and
patient. In addition, the Pediatric Dentist must adapt
behavior management techniques along with the
skills to use new laser technologies to provide efficient
dental care to the pediatric patients.[31]
Our results suggest that the Er, Cr:YSGG laser may be
a valuable tool for root canal disinfection of primary
molars. In the present study, negative culture was
obtained in 9 samples when anaerobic bacterial count
was done in preirrigation cases. This might have
occurred due to improper paper point sampling,
sensitivity during transportation and bacterial culture
techniques that provided the inability to culture
anaerobic bacteria in 9 samples.[26] As this was a time
bounded study, a minimum sample size was taken.
For more elaborate results, a larger sample size is
recommended.
Conclusion
The present study assessed the antimicrobial efficacy
of NaOCl, saline, and Er, Cr:YSGG laser‑assisted
disinfection in root canal treatment of primary molars.
The antimicrobial efficacy in reducing the aerobic
bacterial count is seen highest with NaOCl followed by
Er, Cr:YSGG laser. Whereas, the antimicrobial efficacy
in reducing the anaerobic bacterial count is seen highest
with Er, Cr:YSGG laser followed by NaOCl. Saline was
found to be an ineffective irrigating agent in reducing
the aerobic as well as anaerobic bacteria in root canal
treatment of primary molars. Our study suggests that
the Er, Cr:YSGG laser may be used as a valuable tool
for root canal disinfection of primary molars.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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