doi:10.1111/iej.
13108
Penetration depth of irrigants into root dentine
after sonic, ultrasonic and photoacoustic
activation
K. M. Galler1,†, V. Grubmu € ller1,†, R. Schlichting2, M. Widbiller1
M. Wo€ lflick , K.-A. Hiller
1 1
& W. Buchalla1
1
Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg; and 2Private Practice,
Passau, Germany
Abstract
Galler KM, Grubmu € ller V, Schlichting R, Widbiller
M, Eidt A, Schuller C, Wo € lflick M, Hiller K-A,
Buchalla W. Penetration depth of irrigants into root dentine
after sonic, ultrasonic and photoacoustic
International Endodontic Journal, 52, 1210–1217, 2019.
Aim To compare penetration depths of endodontic
irrigants into the dentinal tubules of extracted teeth
when using several activation methods.
Methodology The root canals of 90 extracted
human teeth were prepared to size 40, .06 taper. The
straight and round-shaped root canals were dis-
tributed randomly into six groups, and final irrigation
was performed with EDTA and sodium hypochlorite
as follows: (I) manual dynamic activation, (II) Ultra-
sonic, (III) Sonic, (IV) PIPS (photon-induced photoa-
coustic streaming, (V) SWEEPS (shock-wave enhanced
emission photoacoustic streaming) and (0) control
without final irrigation or activation. Subsequently,
methylene blue was inserted into the canals and acti-
vated according to the groups (I–V). Teeth were
Correspondence: Kerstin M. Galler, Department of Conserva-
tive Dentistry and Periodontology, University Hospital
Regensburg, Franz-Josef-Strauß Allee 11, 93053 Regens-
burg, Germany (Tel.: +49941 9446024; fax: +49941
9446025; e-mail: kerstin.galler@ukr.de).
†
Authors contributed equally to this work.
1210 International Endodontic Journal, 52, 1210–1217, 2019
, A. Eidt1, C. Schuller1,
sectioned horizontally, imaged under a light micro-
scope, and dye penetration depths were measured in
six sections per tooth and 24 points on a virtual clock-
face per section. Data were analysed statistically by
nonparametric tests for whole teeth and separately for
activation.
coronal, middle and apical thirds.
Results Penetration of dye into the dentinal tubules
was lowest for the controls. Median penetration depths
amounted to 700–900 lm for groups I–V with differ-
ences in the apical thirds between group I and the other
test groups. Minimum penetration depths were signifi-
cantly greater for PIPS in the apical thirds (P ≤ 0.046).
Conclusions Greater penetration depths occurred
in the apical thirds for ultrasonic, sonic and laser-
induced activation compared to manual dynamic acti-
vation. PIPS was associated with deeper penetration
of irrigants. The novel SWEEPS mode did not increase
irrigant penetration.
Keywords: disinfection, EDTA, laser, root canal,
sodium hypochlorite, ultrasonic.
Received 1 August 2018; accepted 28 February 2019
Introduction
Pulpitis, pulpal necrosis and subsequent periradicular
lesions are induced by opportunistic infections of the
dental pulp and root canals with oral commensal
microorganisms. Thus, the primary goal of root canal
treatment is cleaning and disinfection of the canal
system and reduction of microorganisms. With
mechanical preparation alone, more than one-third of
the canal surface may remain untouched by
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

endodontic instruments (Peters et al. 2001, Paque
et al. 2010) resulting in insufficient debridement. Fur-
thermore, instrumentation of canal walls creates a
smear layer and the accumulation of dentine debris
in surface irregularities. Irrigation plays a crucial role
during treatment, as it enables chemical dissolution of
remnant pulp tissue, removal of debris and smear
layer and mechanical detachment of the biofilm
(Zehnder 2006). The apical third of the canal system
typically has a complex morphology (Vertucci1984)
and is therefore particularly difficult to clean (Foschi
et al. 2004).
Traditional irrigation during root canal treatment
with a syringe and needle is associated with only lim-
ited penetration beyond the main canal into dentinal
tubules (Ram 1977). In order to increase the efficacy
of irrigants, general activation techniques have been
developed. Passive ultrasonic irrigation (PUI) uses an
oscillating file in the canal after shaping to induce
acoustic microstreaming (>25 kHz). Its rapid move-
ment enables penetration into noninstrumented areas
and enhances shear stress on tissue remnants and
biofilm (Jiang et al. 2011, Bryce et al. 2018). Sonic
devices work similarly, but generally use flexible tips
and operate at lower frequencies (<20 kHz). Sonic
activation appears to be more effective than needle
irrigation alone (de Gregorio et al. 2010, R€ odig et al.
2010, Bryce et al. 2018); however, ultrasonic activa-
tion has been reported to be superior regarding pene-
tration to working length and into lateral canals (de
Gregorio et al. 2010). More recently, laser-activated
irrigation based on the activation of irrigants by med-
ium-infrared lasers (2780 and 2940 nm) has gained
increasing attention in endodontics. The radiation
emitted by the laser is strongly absorbed by water-
based solutions. The effect of laser activation is
achieved by cavitation where vapour bubbles are
formed at the fibre tip, which expand and then col-
lapse. These changes in size lead to a distinct fluid
movement. The consecutive collapse of the bubbles
generates localized shock waves and lead to a distinct
fluid movement. Furthermore, subsequent laser pulses
induce secondary cavitation bubbles, which result in
acoustic streaming of the solution throughout the
entire canal system (Blanken et al. 2009, Matsumoto
et al. 2011).
An example of laser-induced activation is PIPS
(photon-induced photoacoustic streaming), performed
by a pulsed Er:YAG laser (Divito et al. 2012). It uses
low pulse energies (10 or 20 mJ) with a short pulse
length (50 ls), resulting in high peak powers and
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Galler et al. Activation of irrigants
efficient cavitation (Verstraeten et al. 2017). Laser-
activated irrigation has been reported to be more
effective than syringe-based irrigation but also more
effective than ultrasonic activation regarding the
removal of smear layer and debris (De Moor et al.
2010, Guidotti et al. 2014, Deleu et al. 2015). How-
ever, a recent study (Verstraeten et al. 2017) reported
that differences regarding hard tissue debris removal
in the mesial roots of mandibular molars between
laser and ultrasonic activation of irrigants were evi-
dent but not significant. The latest development
regarding laser-activated irrigation in endodontics is
SWEEPS (shock-wave enhanced emission photoacous-
tic streaming), which uses an Er:Yag laser and a fibre
tip that is placed inside the pulp chamber, the differ-
ence, however, is the pulse of the laser light. The
SWEEPS mode uses pulses to create a series of bub-
bles, which are timed to appear such that secondary
bubbles lead to a collapse of existing bubbles, result-
ing in shock waves and enhanced photoacoustic
streaming. Up to now, data from independent
research on SWEEPS activation have not been
published.
The overarching aim of this study was to assess
whether newly developed methods of activation are
more effective than commonly used techniques. The
objective was to compare several methods of activa-
tion for endodontic irrigants including ultrasonic,
sonic, PIPS and SWEEPS in their ability to penetrate
into dentinal tubules.
Materials and methods
Preparation of teeth
Ninety single-rooted human teeth extracted for
orthodontic reasons (age range 14–20 years) with
straight and round-shaped root canals were selected
and stored in 0.5% chloramine T-hydrate (Carl Roth,
Karlsruhe, Germany). Twenty-four hours prior to
experimentation, the teeth were transferred to ultra-
pure water (Barnstead Smart2Pure, Thermo Fisher Sci-
entific, Waltham, MA, USA). Access cavities were
prepared with a diamond bur (Endo Access Bur, Dents-
ply Sirona, Ballaigues, Switzerland), the canal orifice
was localized by scouting with a size 10, .06 taper
C-pilot file and enlarged with Nos. 2 and 3 Gates-Glidden
burs (Dentsply Sirona). The entrance was covered with
a foam pellet, and the walls of the access cavity were
treated with dentine bonding agent (Scotchbond
Universal, 3M ESPE, Seefeld, Germany) according to
International Endodontic Journal, 52, 1210–1217, 2019 1211
 Activation of irrigants Galler et al.
the manufacturer’s instructions. Access cavities were
filled with bulk fill composite resin (SDR flow+, Dents-
ply Sirona) and extended coronally in order to create a
reservoir of 6 mm in height, necessary for the laser-
based activation methods. To ensure standardized
access cavities, a new cone-shaped access cavity was
then prepared with a diamond bur (FG/type palatal,
Henry Schein Dental, Langen, Germany).
For root canal preparation, a glide path was pre-
pared with hand files size 08, .02 taper to size 20,
.02 taper (K-files, VDW, Munich, Germany). Working
length was determined as patency length minus
1 mm. The apical region of each root was covered
with a layer of heavy-body condensation silicone
impression material (Panasil tray Soft Heavy, Ketten-
bach, Eschenburg, Germany) to avoid extrusion of
irrigating solutions (Widbiller et al. 2017). Root
canals were instrumented in a crown-down manner
with rotary files (Protaper Next X1–X4 and X-Smart
Plus Motor, Dentsply Sirona) to size 40, .06 taper.
Canals were irrigated with 5% sodium hypochlorite
(NaOCl, SPEIKO, M€ unster, Germany), pre-heated to
60 °C, with a volume of 1 mL between files. NaOCl
was removed with paper points, and teeth were stored
in ultrapure water before final irrigation. The irriga-
tion solutions for final irrigation were NaOCl (5%,
60 °C), ultrapure water (room temperature) and
EDTA (17%, room temperature). The protocol for final
irrigation was established as follows:
1. NaOCl (5 mL, 1 min)
2. Ultrapure water (5 mL, 1 min)
3. EDTA (5 mL, 1 min), activation for 30 s
4. Ultrapure water (5 mL, 1 min)
5. NaOCl (5 mL, 1 min), activation for 30 s, resting
phase 30 s, activation for 30 s
After a rinse with ultrapure water, the canal was
filled with 1% methylene blue (Sigma-Aldrich, Stein-
heim, Germany), which was activated for 30 s with
the respective activation method as defined by the test
group in order to visualize the penetration depth of
the last irrigant. Subsequently, the canal was dried
with paper points and teeth were stored dry until fur-
ther use. Teeth were randomly divided into five test
groups (I–V) and one control group (0), where activa-
tion was performed as follows:
(I) Manual Dynamic Activation (MDA): needle irriga-
tion with manual up- and down-movement of the
needle inside the canal (NaviTip 30 ga, Ultradent,
K€oln, Germany)
(II) Passive Ultrasonic Irrigation: IRRI K 25/25 (VDW
GmbH, Munich, Germany and the appendant
1212 International Endodontic Journal, 52, 1210–1217, 2019
ultrasonic device (VDW.ULTRA, VDW) at 25%
intensity
(III) EDDY (Sonic Activation): EDDY (Polyamide tip,
VDW)
(IV) PIPS (Photon-Induced Photoacoustic Streaming):
20 mJ, 15 Hz, 0.30 W, SSP Mode, air/water
turned off (FOTONA, Ljubljana, Slovenia)
(V) SWEEPS (Shock-Wave Enhanced Emission Pho-
toacoustic Streaming) 20 mJ, 15 Hz, 0.30 W,
SWEEPS Mode, air/water turned off (FOTONA)
(0) Control: Final irrigation only with 1 mL of 5%
NaOCl without activation
Sectioning and light microscopy
Cross sections of the teeth were prepared using a cir-
cular saw (Leitz 1600, Ernst Leitz Wetzlar, Wetzlar,
Germany) under constant water flow at 600 rpm
with a feed speed of 0.5 mm s 1 at a thickness of
300 lm. Sections were numbered consecutively and
collected selectively from the coronal, middle and api-
cal third of the root. Two nonconsecutive sections per
third were chosen and placed under a light micro-
scope with a corresponding camera system and soft-
ware (Zeiss AXIO LAB A1 and ZEN core
v2.0.66.1000, Jena, Germany). Images were taken,
uploaded into Fiji software (Schindelin et al. 2012),
and a virtual clock face was placed over each image.
Along 24 exactly spaced lines of the clock face, the
penetration depth of methylene blue dye was deter-
mined visually by two examiners, and the median
penetration depth was calculated. Figure 1 shows rep-
resentative images after staining and sectioning. Fif-
teen teeth were prepared in each group resulting in a
total of 540 sections.
Penetration depths of methylene blue into the
dentinal tubules were a surrogate measure for the
penetration of sodium hypochlorite during the last
step of activation. Median penetration depths as well
as 25–75% quantiles were calculated and depicted for
the entire canal and separately for coronal, middle
and apical regions. Additionally, the minimally
achievable penetration depths were calculated. The
minimum penetration depth was determined in each
section, and median values as well as quantiles of
these values from all sections were calculated.
Data analysis
Medians and 25–75% quantiles were calculated for
whole canals per group as well as for the coronal,
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 1 Representative images of methylene blue penetration into root canal dentine after different activation methods in
coronal, middle and apical sections. Scale bar: 1000 lm.
medial and apical tooth segments per group. Data
were analysed statistically by nonparametric tests
(Mann–Whitney U) on an a = 0.05 level of signifi-
cance (SPSS, version 23.0, SPSS Inc., Chicago, IL,
USA).
Results
For controls without final irrigation, the median pene-
tration depth of dye as a surrogate for sodium
hypochlorite for all teeth was 445.8 lm which was
significantly lower compared to all other groups. The
median penetration depths for whole canals (Fig. 2a)
from highest to lowest were EDDY (985.5 lm) > PIPS
(961.5 lm) > PUI (823.8 lm) > MDA (775.0 lm) >
SWEEPS (722.0 lm), with significantly lower pene-
tration depths for SWEEPS compared to PIPS
(P = 0.026). The minimally achievable penetration
depth (Fig. 2b) was greatest for PIPS (526.5 lm) with
significant differences compared to EDDY (310.5 lm,
P = 0.013), MDA (336.0 lm, P = 0.016) and
SWEEPS (365.0 lm, P = 0.026).
The separate evaluation of median penetration
depths in the coronal, middle and apical regions
(Fig. 3a) revealed a decline in irrigant penetration
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Galler et al. Activation of irrigants
depth from coronal to apical. In coronal and middle
sections, the various activation methods achieved sim-
ilar results; however, differences became apparent api-
cally. The greatest median penetration depths were
observed for PIPS coronally and apically (1246.8 and
657.5 lm, respectively) and for EDDY in the middle
sections (985.5 lm). PIPS was associated with signifi-
cantly deeper penetration in the apical sections com-
pared to needle irrigation (260.3 lm, P = 0.006),
and also to SWEEPS (332.1 lm, P = 0.02). Consider-
ing the minimally achievable penetration depths, PIPS
achieved the greatest penetration depths in the middle
and particularly in the apical sections (364.0 lm vs.
32.0–102.0 lm for other groups) with significant dif-
ferences compared to all other groups (P ≤ 0.046).
Discussion
This laboratory study aimed to compare penetration
depths of final irrigation solutions into the dentinal
tubules of extracted human teeth after application of
various modes of activation. Compared to controls
with neither EDTA nor activation, the test groups
were associated with deeper penetration of irrigants,
which can be expected due to the ability of EDTA to
International Endodontic Journal, 52, 1210–1217, 2019 1213
 Activation of irrigants Galler et al.

Figure 2 (a) Median penetration depths with 25–75% quantiles for the tested activation methods (n = 15). (b) Minimally
achievable penetration depths with 25–75% quantiles. The dotted line indicates the median (a) and minimal (b) penetration
depth for controls. Asterisks indicate significant differences (P ≤ 0.05) between groups.

Figure 3 (a) Median penetration depths with 25–75% quantiles for the tested activation methods, depicted separately for coro-
nal, middle and apical sections. (b) Minimally achievable penetration depths with 25–75% quantiles. The dotted line indicates
the median (a) and minimum (b) penetration depth for controls; coronal (c), middle (m) and apical (a) level. Asterisks indicate
significant differences (P ≤ 0.05) between groups.

remove smear layer from the canal walls (Teixeira
et al. 2005). The smaller but still measurable ingress
of irrigant in the controls might be explained by the
large preparation size of the canals in combination
with thorough irrigation; it appears that the smear
layer reduces but not fully prevents influx of liquid
into the tubules. Furthermore, due to the limited age
range of the patients from which the teeth were
collected, sclerotic dentine or limited penetration
depths due to other physiological or pathological
changes were not expected. Differences between the
test groups were negligible in coronal and middle sec-
tions, where manual dynamic activation achieved
similar results compared to sonic, ultrasonic and laser
activation with PIPS and SWEEPS. However, differ-
ences become obvious in apical sections. Since

1214 International Endodontic Journal, 52, 1210–1217, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

ramifications and lateral canals are frequently present
in apical areas (Vertucci 1984), their cleaning is more
important for successful treatment. Penetration depths
after manual dynamic activation were as low as the
controls, but markedly greater with PIPS, EDDY and
PUI. Thus, activation of irrigants appears to be benefi-
cial especially in the apical area, where the trans-
portation of irrigants into the dentinal tubules is
impeded not only by anatomical conditions such as
reduced number of tubules with smaller diameters
and sclerotic dentine (Carrigan et al. 1984), but also
by accessibility. In that respect, PIPS might be advan-
tageous, as it does not depend on the insertion depth
of a file or probe, such as with other agitation tech-
niques tested in this study.
Interestingly, the minimum penetration depths per
section were significantly greater for PIPS compared
to all other tested methods. Regarding the fact that in
histological studies, the median penetration depth of
bacteria into dentinal tubules reaches 390 lm (Kakoli
et al. 2009), this increased penetration depth and
antibacterial effect inside the dentinal tubules might
be clinically relevant. Increased penetration after acti-
vation in apical sections might also be due to a reduc-
tion or elimination of an apical vapour lock, which
impedes irrigant penetration to working length and
can be managed better after sonic and ultrasonic acti-
vation compared to manual dynamic agitation (Agar-
wal et al. 2017). On the other hand, this study
revealed that the new SWEEPS mode was not able to
achieve increased penetration depths compared to the
other activation methods, but appeared inferior in api-
cal sections, especially regarding minimally achievable
values. Thus, the introduction of a modified laser
pulse did not lead to enhanced performance. One can
speculate that the change in pulse and the generation
of secondary bubbles, given the geometrical con-
straints inside the root canal, might induce counter
currents which actually hinder irrigant flow. It also
seems that the SWEEPS mode was brought onto the
market without thorough testing and comparison to
PIPS. Since there is no data on SWEEPS in the litera-
ture, these results cannot be related to other findings.
Some of the results observed in this study are co-
determined by the experimental design. The teeth that
were chosen for the experiments were single-rooted
teeth with relatively round canals and simple canal
geometry. The benefit of this choice is comparability
and reproducibility of penetration depth in different
teeth due to the similar root canal anatomies. Pre-
sumably, the differences between groups will be more
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Galler et al. Activation of irrigants
evident in more complex root canal systems. The
canal preparation to a size 40, .06 taper was selected
to enable easy penetration of the irrigants and might
be considered a medium to large preparation (de Gre-
gorio et al. 2013). The irrigation protocol prior to the
rinse with EDTA and activation of NaOCl was thor-
ough considering volume, concentration and fluid
temperature. Both higher concentration as well as
pre-heating of sodium hypochlorite have been shown
to increase the efficacy of disinfection as well as tissue
dissolution (Sirtes et al. 2005). The use of EDTA, a
chelator which binds calcium, to remove the smear
layer and the subsequent rinse with sodium
hypochlorite, which will now penetrate more easily
into the dentinal tubules, has been advocated (Sen
et al. 1995, Violich & Chandler 2010). These factors
likely contributed to the large penetration depths in
controls as well as in test groups in coronal and mid-
dle sections. In the present experiments, methylene
blue was used to display penetration depths as an
indirect indicator for the ingress of sodium hypochlo-
rite. Various designs for this type of study can be
found, where fluorescently labelled irrigants (Akcay
et al. 2017) or sealers (Chaudhry et al. 2017, Uzuno-
€ urek et al. 2017, Bharti et al. 2018) have
glu-Ozy€
been used in combination with confocal microscopy.
Pilot experiments with fluorescent dyes and methy-
lene blue exhibited advantages for the latter, as den-
tine shows intense autofluorescence. Penetration
depths of methylene blue observed in this study are in
line with other findings; comparable studies of sealer
penetration after irrigation show similar penetration
depths into dentine as well as significantly superior
sealer penetration at greater distances from the apex
(Akcay et al. 2017, Chaudhry et al. 2017, Uzunoglu-
€ urek et al. 2017, Bharti et al. 2018). In order to
Ozy€
exclude errors during the analysis of penetration
depths, the same two examiners performed this task
together. Whereas one examiner determined the start
and end-point of each line segment, the second exam-
iner verified the correct procedure. The actual mea-
surement of line segments was based on software.
Conclusion
Thorough irrigation of straight, large canals in
extracted teeth with simple root canal geometries
enabled penetration in coronal and middle sections
but faced limitations in apical areas. Activation of irri-
gants increased penetration depths apically, where
PIPS was associated with segments of deeper
International Endodontic Journal, 52, 1210–1217, 2019 1215
 Activation of irrigants Galler et al.
penetration, followed by EDDY and PUI. SWEEPS, on
the other hand, did not show benefits compared even
to manual dynamic activation.
Conflict of interest
The authors have stated explicitly that there are no
conflicts of interest in connection with this article.
References
Agarwal A, Deore RB, Rudagi K et al. (2017) Evaluation of
apical vapor lock formation and comparative evaluation of
its elimination using three different techniques: an in vitro
study. Journal of Contemporary Dental Practice 18, 790–4.
Akcay M, Arslan H, Mese M et al. (2017) Effect of photon-
initiated photoacoustic streaming, passive ultrasonic, and
sonic irrigation techniques on dentinal tubule penetration
of irrigation solution: a confocal microscopic study. Clinical
Oral Investigations 21, 2205–12.
Bharti R, Tikku AP, Chandra A, Shakya VK, Yadav S.
(2018) Depth and percentage of resin-based sealer pene-
tration inside the dentinal tubules using EndoVac,
EndoActivator, Navi tip FX irrigation system: a confocal
laser scanning microscope study. Journal of Conservative
Dentistry 21, 216–20.
Blanken J, De Moor RJ, Meire M et al. (2009) Laser induced
explosive vapor and cavitation resulting in effective irriga-
tion of the root canal. Part 1: a visualization study. Lasers
in Surgery and Medicine 41, 514–9.
Bryce G, MacBeth N, Gulabivala K et al. (2018) The efficacy
of supplementary sonic irrigation using the EndoActiva-
torâ system determined by removal of a collagen film from
an ex vivo model. International Endodontic Journal 51,
489–97.
Carrigan PJ, Morse DR, Furst ML et al. (1984) A scanning
electron microscopic evaluation of human dentinal tubules
according to age and location. Journal of Endodontics 10,
359–63.
Chaudhry S, Yadav S, Talwar S et al. (2017) Effect of
EndoActivator and Er, Cr:YSGG laser activation of Qmix,
as final endodontic irrigant, on sealer penetration: a confo-
cal microscopic study. Journal of Clinical and Experimental
Dentistry 9, e218–22.
De Moor RJ, Meire M, Goharkhay K et al. (2010) Efficacy of
ultrasonic versus laser-activated irrigation to remove artifi-
cially placed dentin debris plugs. Journal of Endodontics 36,
1580–3.
Deleu E, Meire MA, De Moor RJ (2015) Efficacy of laser-
based irrigant activation methods in removing debris from
simulated root canal irregularities. Lasers in Medical Science
30, 831–5.
Divito E, Peters OA, Olivi G (2012) Effectiveness of the
erbium:YAG laser and new design radial and stripped tips
1216 International Endodontic Journal, 52, 1210–1217, 2019
in removing the smear layer after root canal instrumenta-
tion. Lasers in Medical Science 27, 273–80.
Foschi F, Nucci C, Montebugnoli L et al. (2004) SEM evalua-
tion of canal wall dentine following use of Mtwo and Pro-
Taper NiTi rotary instruments. International Endodontic
Journal 37, 832–9.
de Gregorio C, Estevez R, Cisneros R et al. (2010) Efficacy of
different irrigation and activation systems on the penetra-
tion of sodium hypochlorite into simulated lateral canals
and up to working length: an in vitro study. Journal of
Endodontics 36, 1216–21.
de Gregorio C, Arias A, Navarrete N et al. (2013) Effect of
apical size and taper on volume of irrigant delivered at
working length with apical negative pressure at different
root curvatures. Journal of Endodontics 39, 19–24.
Guidotti R, Merigo E, Fornaini C et al. (2014) Er:YAG 2,940-
nm laser fiber in endodontic treatment: a help in removing
smear layer. Lasers in Medical Science 29, 69–75.
Jiang LM, Verhaagen B, Versluis M et al. (2011) The influ-
ence of the ultrasonic intensity on the cleaning efficacy of
passive ultrasonic irrigation. Journal of Endodontics 37,
688–92.
Kakoli P, Nandakumar R, Romberg E et al. (2009) The effect
of age on bacterial penetration of radicular dentin. Journal
of Endodontics 35, 78–81.
Matsumoto H, Yoshimine Y, Akamine A (2011) Visualization of
irrigant flow and cavitation induced by Er:YAG laser within a
root canal model. Journal of Endodontics 37, 839–43.
Paque F, Balmer M, Attin T et al. (2010) Preparation of
oval-shaped root canals in mandibular molars using
nickel-titanium rotary instruments: a micro-computed
tomography study. Journal of Endodontics 36, 703–7.
Peters OA, Schonenberger K, Laib A (2001) Effects of four
Ni-Ti preparation techniques on root canal geometry
assessed by microcomputed tomography. International
Endodontic Journal 34, 221–30.
Ram Z (1977) Effectiveness of root canal irrigation. Oral Sur-
gery Oral Medicine Oral Pathology Oral Radiology and
Endodontology 44, 306–12.
R€odig T, Bozkurt M, Konietschke F et al. (2010) Comparison
of the Vibringe system with syringe and passive ultrasonic
irrigation in removing debris from simulated root canal
irregularities. Journal of Endodontics 36, 1410–3.
Schindelin J, Arganda-Carreras I, Frise E et al. (2012) Fiji:
an open-source platform for biological-image analysis. Nat-
ure Methods 9, 676–82.
Sen BH, Wesselink PR, T€ urk€un M (1995) The smear layer: a
phenomenon in root canal therapy. International Endodon-
tic Journal 28, 141–8.
Sirtes G, Waltimo T, Schaetzle M, Zehnder M (2005) The
effects of temperature on sodium hypochlorite short-term
stability, pulp dissolution capacity, and antimicrobial effi-
cacy. Journal of Endodontics 31, 669–71.
Teixeira CS, Felippe MC, Felippe WT (2005) The effect of
application time of EDTA and NaOCl on intracanal smear
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

layer removal: an SEM analysis. International Endodontic
Journal 38, 285–90.
€ urek E, Karaaslan H, T€
Uzunoglu-Ozy€ urker SA et al. (2017)
Influence of size and insertion depth of irrigation needle
on debris extrusion and sealer penetration. Restorative Den-
tistry and Endodontics 43, e2.
Verstraeten J, Jacquet W, De Moor RJG et al. (2017) Hard
tissue debris removal from the mesial root canal system of
mandibular molars with ultrasonically and laser-activated
irrigation: a micro-computed tomography study. Lasers in
Medical Science 32, 1965–70.
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Galler et al. Activation of irrigants
Vertucci FJ (1984) Root canal anatomy of the human per-
manent teeth. Oral Surgery Oral Medicine Oral Pathology
Oral Radiology and Endodontology 58, 589–99.
Violich DR, Chandler NP (2010) The smear layer in endodon-
tics—a review. International Endodontic Journal 43, 2–15.
Widbiller M, Eidt A, Hiller K-A, Buchalla W, Schmalz G, Gal-
ler KM (2017) Ultrasonic activation of irrigants increases
growth factor release from human dentine. Clinical Oral
Investigations 21, 879–88.
Zehnder M (2006) Root canal irrigants. Journal of Endodontics
32, 389–98.
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