Various Irrigation Agitation Techniques and devices used in endodontics till date.

1. Irrigation
Agitation
Techniques
&
Devices
PRESENTED BY
DR. HIMANII THAWALE
JR-II

2. CONTENTS
Introduction
Classification
Manual Irrigation system
Machine assisted Irrigation system
Recently Introduced Irrigation Agitation System
Conclusion
References

3. INTRODUCTION
• Removal of vital and necrotic remnants of pulp
tissues, microorganisms, and microbial toxins
from the root canal system is essential for
endodontic success.
• Although this might be achieved through
chemo-mechanical debridement, it is impossible
to shape and clean the root canal completely.
Siqueira JF Jr, Roˆ c¸as IN. Clinical implications and microbiology of bacterial
persistence after treatment procedures. J Endod 2008;34:1291–301

4. • Even with the use of rotary instrumentation, the nickel-titanium instruments
currently available only act on the central body of the canal, leaving canal
fins, isthmi, and cul-de-sacs untouched after completion of the preparation.
Wong R. Conventional endodontic failure and retreatment. Dent Clin North Am 2004;48:265–89.

5. Therefore, irrigation is an essential part of root canal
debridement because it allows for cleaning beyond what
might be achieved by root canal instrumentation alone.
Basmadjian-Charles CL, Farge P, Bourgeois DM, Lebrun T. Factors influencing the long-term results of endodontic treatment: a review of the
literature. Int Dent J 2002; 52:81–6.

6. • There is no one unique irrigant that meets the ideal requirement of root canal
irrigants.
• In our contemporary endodontic practice, dual irrigants such as sodium
hypochlorite (NaOCl) with ethylenediaminetetraacetic acid (EDTA) or
chlorhexidine (CHX) are often used as initial and final rinses to complement the
shortcomings that are associated with the use of a single irrigant.
Walton RE. Histologic evaluation of different methods of enlarging the pulp canal space. J Endod 1976;2:304–11

7. • More importantly, these irrigants must be brought into direct contact with the
entire canal wall surfaces for effective action particularly for the apical portions of
small root canals.
• To accomplish these objectives, there must be an effective delivery system of
irrigation devices so that the irrigant reaches the working length.
• Throughout the history of endodontics, endeavors have continuously been made
to develop more effective irrigant delivery and agitation systems for root canal
irrigation.
Haga CS. Microscopic measurements of root canal preparations following instrumentation. J Br Endod Soc 1968;2:41–6.

8. • Today’s irrigation armamentarium presents a diverse variety of tools and
techniques that can assist the practitioner in reducing bacteria and debris
within the canal system.
• However, currently there is no universally accepted standard irrigation
technique.
Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on results of mechanical preparation of root
canals. Oral Surg Oral Med Oral Pathol 1968; 25:108–16.

9. CLASSIFICATION
Manual
Agitation
Techniques
Machine-
Assisted
Agitation
Techniques

10. Brushes
Manual Agitation
Techniques
Manual Dynamic
Agitation
Syring irrigation
with needles/
cannuals
1) Endo
Brush
2) Navi Tip
FX
1) End
venting
2)
SideVenting
Hand
activated
well fitted
gutta percha

11. Continuous irrigation
during rotary
instrumentation
Quantec- EMachine
assisted
agitation
Techniques
Rotary brushes
- Ruddle brush
- Canal Brush
Sonic
- Risponic File
- Endo Activator
Ultrasonic
Pressure alterating Devices.
- Endo Vac
- Rinse Endo

12. MANUAL AGITATION TECHNIQUES

13. • Manual irrigation system using needles is still
widely accepted by both general practitioners
and endodontists.
• In this technique the dispensing of an irrigant
into a canal through needles/cannulas of variable
gauges, either passively or with agitation.
• The agitation might be achieved by moving the
needle up and down the canal space.
SYRINGEIRRIGATIONWITHNEEDLES/CANNULAS
Kahn FH, Rosenberg PA, Gliksberg J. An in vitro evaluation of the irrigating characteristics of ultrasonic and subsonic handpieces and irrigating needles and probes. J Endod 1995;21:277–80

14. • Irrigation tip gauge and tip design can have a significant impact on the
irrigation flow pattern, flow velocity, depth of penetration, and
pressure on the walls and apex of the canal.
• 27 gauge needle is the preferred needle tip size for routine endodontic
procedures.
• Several studies have shown that the irrigant has only a limited effect
beyond the tip of the needle because of the dead-water zone or
sometimes air bubbles in the apical root canal, which prevent apical
penetration of the solution.
van der Sluis LW, Gambarini G, Wu MK, Wesselink PR. The influence of volume, type of irrigant and flushing method on removing artificially placed dentine debris
from the apical root canal during passive ultrasonic irrigation. Int Endod J 2006;39: 472–6.

15. Factors that have been shown to improve the efficacy of syringe
needle irrigation include
 Closer Proximity Of The Irrigation Needle To The Apex
 Larger Irrigation Volume
 Smaller-gauge Irrigation Needles
 Slow Irrigant Delivery In Combination With Continuous Hand
Movement Will Minimize Naocl Accidents.
Goldman M, Kronman JH, Goldman LB, Clausen H, Grady J. New method of irrigation during endodontic treatment. J Endod 1976;2:257–60.

16. (A) Flat(B) Beveled (C)
Notched
Open-ended tips express irrigant out at the
end toward the apex and consequently
increase the apical pressure within the
canal
Needle tip design
Open Ended
Open Ended Closed Ended
Falk KW, Sedgley CM. The influence of preparation size on the mechanical efficacy of root canal irrigation in
vitro. J Endod 2005;31:742–5

17. (D) side vented (E) double side vented ( (F)
multivented
Close Ended
Create more
pressure on
the walls
Allows the
irrigant to
reflux
Causes more
debris to be
displaced
coronally
Reduce the
chance of
apical
extrusion.

18. MAX-I- PROBE
• Max-I-probe is a modified design of regular manual irrigation
needles with a well-rounded, close tip and side-port dispersal.
• The dispersal of the irrigating solution through the side-port in
the cannula creates a unique upward turbulent motion,
which thoroughly irrigates the root canal preparation
but prevents solution and debris from being expressed through
the

19. • Micheal s et al 2000, evaluated the effectiveness of 3 kinds of EDTA salts and
NaOCl delivered alternately by using a Monoject syringe with a 27-gauge
needle reported that the debridement properties of the solutions were
adequate in the coronal two thirds of the canals but were less effective in the
apical third.
• Even after EDTA and NaOCl irrigation was performed with a specially
developed side-vented, closed-end needle that was placed within 1mmof the
working length, abundant smear layer remained in the apical region of the

20. • Nevertheless, the mechanical flushing action created by conventional
hand-held syringe needle irrigation is relatively weak.
• After conventional syringe needle irrigation, inaccessible canal extensions
and irregularities are likely to harbor debris and bacteria, thereby making
thorough canal debridement difficult.

21. • Brushes are adjuncts that have been
designed for debridement of the canal walls
or agitation of root canal irrigant.
• Recently, a 30-gauge irrigation needle
covered with a brush (NaviTip FX;
Ultradent Products Inc, South Jordan, UT)
was introduced commercially.
BRUSHES

22. Solaiman et al 2006, reported improved cleanliness of the coronal third of
instrumented root canal walls irrigated and agitated with the NaviTip FX needle
over the brushless type of NaviTip needle. Nevertheless, the differences in the
apical and middle thirds were not statistically significant.
The results might have been improved if the brush-covered needle was
mechanically activated in an active scrubbing action during the irrigation process
to increase the efficiency of the brush.

23. • Friction created between the brush bristles and the canal irregularities might
result in the dislodgement of the radiolucent bristles in the canals that are not
easily recognized by clinicians, even with the use of a surgical microscope.
• It could not be used to full working length because of its size, which might
lead to packing of debris into the apical section of the canal after brushing.
Disadvantage
Keir DM, Senia ES, Montgomery S. Effectiveness of a brush in removing postinstrumentation canal debris. J Endod 1990;16:323–7.

24. • Research has shown that gently moving a well-fitting
gutta-percha master cone up and down in short 2- to
3-mm strokes (manual dynamic irrigation) within an
instrumented canal
• Can produce an effective hydrodynamic effect and
significantly improve the displacement and exchange
of any given reagent.
Manual Dynamic Irrigation
Pesse AV, Warrier GR, Dhir VK. An experimental study of the gas entrapment process in closed-end microchannels. Int J Heat Mass Transfer 2005;48:5150–65. Review Article 802 Gu

25. Studies by McGill et al and Huang et al (2008) demonstrated that manual-
dynamic irrigation was significantly more effective than an automated-
dynamic irrigation system (RinsEndo; Du¨ rr Dental Co, Bietigheim-
Bissingen, Germany) and static irrigation. Several factors have contributed
to the positive results of manual-dynamic irrigation:
(1) The push-pull motion of a well fitting gutta-percha point in the
canal might generate higher intracanal pressure changes during
pushing movements, leading to more effective delivery of irrigant
to the ’’untouched’’ canal surfaces.

26. 2) The frequency of push-pull motion of the gutta-percha point (3.3
Hz, 100 strokes per 30 seconds) is higher than the frequency (1.6 Hz)
of positive-negative hydrodynamic pressure generated by
RinsEndo, possibly generating more turbulence in the canal.
3) The push-pull motion of the gutta-percha point probably acts by
physically displacing, folding, and cutting of fluid under ‘‘viscously-
dominated flow’’ in the root canal system. The latter probably allows
better mixing of the fresh unreacted solution with the spent, reacted
irrigant.

27. Advantage
• Simplicity and cost-effectiveness
Disadvantage-
The laborious nature of this hand-activated procedure still hinders its
application in routine clinical practice.
• .

29. MACHINE ASSISTED AGITATION SYSTEMS

30. Continuous irrigation
during rotary
instrumentation
Quantec- EMachine
assisted
agitation
Techniques
Rotary brushes
- Ruddle brush
- Canal Brush
Sonic
- Risponic File
- Endo Activator
Ultrasonic
Pressure alterating Devices.
- Endo Vac
- Rinse Endo

31. • A rotary handpiece–attached microbrush has been used by Ruddle to
facilitate debris and smear layer removal from instrumented root canals.
• The brush includes a shaft and a tapered brush section. The latter has
multiple bristles extending radially from a central wire core.
• During the debridement phase, the micro brush rotates at about 300 rpm,
causing the bristles to deform into the irregularities of the preparation. This
helps to displace residual debris out of the canal in a coronal direction
ROTARY BRUSHES

32. Canal Brush (Coltene Whaledent, Langenau,
Germany)
• This highly flexible micro brush is molded entirely from
polypropylene and might be used manually with a rotary
action.
• It is more efficacious when attached to a contra-angle
handpiece running at 600 rpm
• A recent report by Weise et al 2007 , showed that the use of
the small and flexible Canal Brush with an irrigant removed
Weise M, Roggendorf MJ, Ebert J, Petschelt A, Frankenberger R. Four methods for cleaning simulated lateral extensions of curved root canals: a
SEM evaluation. Int Endod J 2007;40:991–2.

33. • Self-contained fluid delivery unit that is attached to the
Quantec-E Endo System.
• It contains
- Pump Console,
- 2 Irrigation Reservoirs,
- Tubing To Provide Continuous Irrigation
During
Rotary Instrumentation
Continuous Irrigation During Rotary Instrumentation

34. • Ideally, continuous irrigant agitation during active rotary instrumentation would
generate an
- Increased volume of irrigant
- Increase irrigant contact time,
- Facilitate greater depth of irrigant penetration inside the root canal.
This results in more effective canal debridement compared with syringe needle
irrigation.

35. .147.151
• These speculations, however, were not supported by the work of Setlock et al.
• Compared with needle irrigation, Quantec-E irrigation did result in cleaner canal
walls and more complete debris and smear layer removal in the coronal third of
the canal walls.
However, these advantages were not observed in the middle and apical thirds of
the root
canal.
• This is also confirmed by Walters et al, who found that there was no significant
difference between standard syringe needle irrigation and irrigation with the
Quantec-E pump.
Setlock J, Fayad MI, BeGole E, Bruzick M. Evaluation of canal cleanliness and smear layer removal after the use of the Quantec-E irrigation system and syringe:
a comparative scanning electron microscope study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:614–7.

36. SONIC IRRIGATION SYSTEMS

37. Sonic Irrigation System
Tronstad et al(1985) - First to report the use of a sonic instrument for
endodontics
Rispisonic
file
Vibringe
system
ENDO
ACTIVATOR

38. • Conventionally, sonic irrigation is performed by using a
Rispisonic file attached to a MM 1500 sonic handpiece
(Medidenta International, Inc, Woodside, NY) after canal
shaping.
• These files have a nonuniform taper that increases with file size.
• Because they are barbed, these files might inadvertently engage
the canal wall and damage the finished canal preparation during
agitation.
Rispisonic file

39. • Irrigation device that combines manual delivery
and sonic activation of the solution.
• The Vibringe is a cordless handpiece that fits in a
special disposable 10-mL Luer-Lock syringe that is
compatible with every irrigation needle.
• The Vibringe allows delivery and sonic activation
of the irrigating solution in one step.. The irrigant
is sonically activated, as is the needle that attaches
VIBRINGE SYSTEM

40. Rodig et al 2010 compared the efficiency of a sonic device (Vibringe), syringe
irrigation, and passive ultrasonic irrigation in the removal of debris from
simulated root canal irregularities and concluded that Ultrasonic irrigation
removed debris significantly better from the artificial canal irregularities than
the Vibringe System and syringe irrigation ( P < .0001). The Vibringe System
demonstrated significantly better results than syringe irrigation in the apical
part of the root canal ( P = .011).

41. The EndoActivator System (Dentsply Tulsa Dental Specialties, Tulsa, OK) is a
more recently introduced sonically driven canal irrigation system .
It consists - Portable handpiece and
- 3 types of disposable polymer tips of different sizes.
ENDOACTIVATOR

42. Endoactivator Tips
• Snap-on/snap-off design
• Color-coded yellow, red, and blue to approximately correspond to file
sizes 20/02, 25/04, and 30/06, respectively.
• Made from a noncutting, medical-grade polymer, are strong and flexible,
and are 22 mm long with orientational depth gauge rings positioned at 18,
19, and 20 mm.
• Tips are disposable, single-use devices that should not be autoclaved..

44. In a well-shaped and fluid-filled canal, the
hydrodynamic phenomenon results when a
vibrating tip generates fluid activation and
intracanal waves
Random waves fracture, resulting in the
formation of bubbles that oscillate within any
given reagent
These bubbles expand, become unstable due to
heat and pressure, then collapse and implode
Each implosion generates up to 30,000
shockwaves that serve to powerfully penetrate,
break up potential biofilms, and wipe surfaces
clean

45. In general, the higher the frequency Lower the amplitude.
when ultrasonic energy is used for 3D disinfection, high frequency sinusoidal
waves are produced with low amplitude, meaning less useful energy.
On the contrary, sonic technology produces a high tip amplitude about 60 times
greater than ultrasonic technology
Advantages of sonic system

46. Sonic System
Noncutting
Sonic technology drives highly flexible,
noncutting, polymer tips that
absolutely maintain the anatomical
integrity of the final preparation.
Ultrasonic system
All ultrasonically driven instruments are
manufactured from metal alloys.
Of greatest concern, vibrating any metal
tip, even precurved, around a canal
curvature invites ledges, apical
transportations, lateral perforations, or
broken instruments

47. Mancini et al 2016 reported that EndoActivator System (Dentsply
Tulsa Dental Specialties, Tulsa, OK) was significantly more
efficient than PUI and the control groups in removing the smear
layer at 3, 5, and 8 mm from the apex.
JOE — Volume 39, Number 11, November 2013

48. ULTRASONIC IRRIGATION AGITATION SYSTEMS

49. • Richman in 1957 introduced ultrasound to endodontics as a means of canal
debridement.
• Martin et al in 1980, designed first ultrasonic unit commercially available for
endodontic
use.
• Weller et al was the first to describe Passive Ultrasonic Irrigation
Types of ultrasonic irrigation
Combination of
simultaneous
ultrasonic
instrumentation
and irrigation (UI).
Passive Ultrasonic
Irrigation (PUI),
Operates Without
Simultaneous
Instrumentation
History

50. Several studies have failed to demonstrate the superiority of UI as a primary
cleaning and shaping technique.
These results might be attributed to
1) The constraint of vibratory motion and cleaning efficacy of an ultrasonic file
within the nonflared root canal space (In addition, it is difficult to control the
cutting of dentin during UI and hence the shape of the prepared root canal.)
2) Strip perforations as well as highly irregular-shaped canals were frequently
produced
Therefore, UI is not generally perceived as an alternative to conventional hand
Ultrasonic Irrigation
(UI)

51. Passive Ultrasonic Irrigation
• The term PUI was first used by Weller et al. in
1980 to describe irrigation without simultaneous
instrumentation.
• This non-cutting technology reduces the potential
for creating aberrant shapes in the root canal
system.

52. •Energy is transmitted
from an oscillating file or a
smooth wire to the irrigant
in the root canal by means
of ultrasonic waves.
These waves induces
acoustic streaming and
cavitation of the irrigant
This produces a
disagglomeration of
bacteria biofilms in the root
canal by the action of the
acoustic current
Gives rise to planktonic
bacteria that are more
susceptible to the
bactericidal activity of
NaOCl
Cavitation may also
produce a temporary
weakening of the cell
membrane making bacteria
more permeable to NaOCl
Mechanis
m of
Action

54. • Recently, Nusstein in US patented a a needle-holding
adapter to an ultrasonic handpiece .
• During ultrasonic activation, a 25-gauge irrigation needle is
used instead of an endosonic file.
• The unique feature of this needle-holding adapter is that the
needle is simultaneously activated by the ultrasonic
handpiece, while an irrigant is delivered from an intravenous
tubing connected via a Luer-lock to an irrigation-delivering
syringe.
Continuous Ultrasonic Irrigation

55. Intermittent Flush Ultrasonic Irrigation
• In intermittent flushed ultrasonic irrigation, the irrigant is delivered to the root
canal by a syringe needle.
• The irrigant is then activated with the use of an ultrasonically oscillating
instrument. The root canal is then flushed with fresh irrigant to remove the
dislodged or dissolved remnants from the canal walls.
• The amount of irrigant flowing through the apical region of the canal can be
controlled because both the depth of syringe penetration and the volume of
irrigant administered are known. This is not possible with the use of the

56. Mozo et al 2014, compared the ability to eliminate debris and open
dentinal tubules of different ultrasound irrigation procedures and
concluded that Passive ultrasonic activation of the irrigation with
Irrisafe tips was the most effective procedure for eliminating the debris
and opening up dentinal tubules, especially in the apical third.
J Clin Exp Dent. 2014 Feb; 6(1): e47–e52.

57. PRESSURE ALTERNATING DEVICES

58. ENDO VAC SYSTEM RINSE ENDO SYSTEM
Pressure Alternating Devices

59. • Three different components of EndoVac system:
- The Master Delivery Tip (MDT)
- The Macro Cannula And
- The Micro Cannula .
• They are used separately (or together) in 4 discrete
phases of root canal preparation and final irrigation:
access opening, canal preparation, macro irrigation,
and micro irrigation.
ENDOVAC SYSTEM

60. Principle Of Endovac System
The process begins immediately after all canals are located
and working lengths are confirmed.
Accordingly, the MDT is used with orifice expansion
instruments to apply and evacuate large quantities of
NaOCl
After completion of all rotary preparations, a micro-
hurricane of NaOCl is created inside the root canal by
using the macro cannula which creates a pressure-washing
effect along the walls of the root canal system.
This micro-hurricane lasts for 20 seconds while at least 15 to
20 mL of irrigation solution are added via the MDT and
continues the macro evacuation process in coronal two
third of root canal.
Significant microscopic debris still remains in the apical one
third that must be removed via the micro cannula.

61. The micro cannula is placed at full working length, and
irrigant cascading down the walls,
The last of the organic debris begins its hydrolysis,
releasing ammonia and carbon dioxide gas.
This serves to “insulate” the residual tissue from further
contact with the NaOCl solution.
In order to eliminate/evacuate these micro-bubbles, it is
necessary for the clinician to lift the micro cannula
coronally 2 mm every 6 seconds, then return it to the full
working length for 6 more seconds
This is done for a total of 30 seconds during the final
micro evacuation phase.

63. Venumbaka et al 2018, evaluated and compared the apical extrusion of
irrigant and depth of irrigant penetration into dentine using the
EndoVac irrigating system and manual irrigation system in primary
molar teeth and he concluded that the EndoVac irrigation system
demonstrated better efficacy compared to manual irrigation system
with less apical extrusion and better depth of irrigant penetration into
dentine.
The Journal of Clinical Pediatric Dentistry, 2018, 42(5):355-360

64. Rinse Endo System
The RinsEndo system irrigates the canal by using pressure-suction technology
developed by Durr Dental Co.
Its components are - Handpiece,
- Cannula with a 7 mm exit aperture,
- Syringe carrying irrigant.
The handpiece is powered by a dental air compressor and has an irrigation
speed of 6.2 ml/min.
Hauser V, Braun A, Frentzen M. Penetration depth of a dye marker into dentine using
a novel hydrodynamic system (RinsEndo). Int Endod J 2007;40:644–52.

65. During the suction phase, the used solution and air are extracted from the root
canal and automatically merged with fresh rinsing solution. The pressure-suction
cycles change approximately 100 times per minute.
With this system, 65 mL of a rinsing solution oscillating at a frequency of 1.6 Hz is
drawn from an attached syringe and transported to the root canal via an adapted
cannula

66. McGill et al , evaluated the effectiveness of RinseEndo system in a split
tooth model. They found to be less effective in removing the stained
collagen from root canal walls when compared with manual-dynamic
irrigation by hand agitation of the instrumented canals with well-fitting
gutta-percha points.

67. RECENTLY INTRODUCED IRRIGANT
AGITATION TECHNIQUES

68. EASY CLEAN
SYSTEM
70
SAFETY
IRRIGATOR
Recently Introduced Irrigant Agitation Techniques
VATEA
SYSTEM
LASER
ACTIVATED
IRRIGATION
GENTLE
WAVE SYSTEM

69. Safety Irrigator
It is an irrigation/evacuation system that apically
delivers the irrigant under positive pressure
through a thin neede containing lateral opening and
evacuates the solution through large needle at root
canal orifice.
It features a large coronal evacuation tube, enabling
the user to safely irrigate and evacuate
simultaneously. It fits any standard leur lock

70. • This negative pressure device comes with fully assembled and fitted
with side vented irrigation needle for added safety.
• This system was tested in vitro to evaluate the removal of dentin debris
from artificially made grooves in standardized root canals and showed
that there was no significant difference among the manual dynamic
activation, the safety irrigator and apical negative pressure irrigation.

71. The VATEA system is an irrigation device which is
an integral part of Self Adjusting file rotary system
(SAF).
The VATEA system is a self-contained, fluid
delivery unit intended to be attached to dental
handpieces to deliver irrigation during endodontic
procedures.
VATEA SYSTEM:-

72. During the endodontic treatment, irrigation
solution is pumped from the VATEA's 400 ml
reservoir.
The irrigant is delivered via a disposable silicone
tube to the endodontic file.
The operator can adjust the flow rate from 1-10
ml/min by using the -/+ push buttons located on
the control panel.
The flow of irrigant is toggled using a foot pedal.

73. LASER ACTIVATED IRRIGATION

74. The first use of laser in endodontics was reported by Weichman and Johnson in 1971.
Laser energy may be used to activate irrigant solutions in different ways
At bulk flow level
Laser Activated
Irrigation
At Molecular Level
Photo Activated
Disinfection
Laser activated irrigation (LAI) is based on the creation of specific cavitation
phenomena and acoustic streaming in intracanal fluids as a result of
photothermal and photomechanical effects

75. Carbon dioxide (CO2),
9600 and 10 600 nm
Potassium titanyl
phosphate (KTP), 532 nm;
Diode, 635 to 980 nm;
Neodimium:yttrium
aluminium garnet
(Nd:YAG), 1064 nm;
Erbium, chromium: yttrium
scandium galium garnet
(Er,Cr:YSGG), 2780 nm
Erbium: yttrium
aluminium garnet
(Er:YAG), 2940 nm;
The laser wavelengths described for cleaning and disinfecting the root canal system
are:

76. Most commonly used laser for endodontic disinfection.
Antimicrobial effect of the Nd:YAG is based on thermal heating of the bacterial
environment and local heating inside bacteria (through chromophores inside
bacteria sensitive to the laser light)
The advantage of this laser is its significant bactericidal effect up to 1 mm into
the dentine.
Moritz et al. found 99.16% reduction of bacterial numbers (Enterococcus
faecalis and Escherichia coli) in inoculated root canals after Nd:YAG irradiation.
Nd:YAG laser

77. Since Nd:YAG laser irradiation is well absorbed in melanin and dark pigmented
tissues and poorly in water, it is not as effective against nonpigmented bacteria and
bacterial biofilms and therefore higher energy densities are required to induce a
lethal thermal effect.
At present, safety parameters for the Nd:YAG laser are 15 Hz, 100 mJ, and 1.5 W,
four times for 5 to 10 seconds, with an interval of 20 s .
Antibacterial effect of Nd:YAG laser has never been shown to be superior to
conventional NaOCl irrigation . Bergman et al. concluded that Nd:YAG laser
irradiation is not an alternative but a possible adjunct to existing protocols for root
Drawbacks

78. • Diode lasers emit radiation within the visible (mostly 660 nm) and
infrared (810 to 980 nm) range of the electromagnetic spectrum.
• Due to the higher absorption coefficient in water (0.68 cm-1), diode
lasers have lower penetration depth into the dentine (up to 750 µm)
compared to Nd:YAG laser .
• In a study by Bago et al. the effect of a diode laser (985 nm, 2 W, 3x20 s)
against E. faecalis biofilm was similar to the use of 2.5% NaOCl for 60 s.
DIODE
LASERS

79. Erbium lasers are commonly used for the
agitation of intracanal water-based fluids.
The strong absorption of the Erbium
laser energy (at low settings of 50-75
mJ) in water and NaOCl
causes vaporization and formation of large
elliptical vapour bubbles
cause a volumetric expansion of up to 1,600
times the original volume of an irrigant with
high intracanal pressure which drives the
fluid out of the canal.
The bubbles implode after 100 to 200
microseconds, creating pressure which
sucks fluid back into the canal: inducing
secondary cavitation effect
Er:YAG and Er,Cr:YSGG
lasers

80. De Moor et al. and De Groot et al. showed a higher efficiency of LAI with
Er,Cr:YSGG and Er:YAG (75 mJ, 20 Hz, 1.5 W, 4 x 5 s) and 2.5% NaOCl in
the removal of dentine debris from the apical part of the root canal
compared to conventional irrigation or Passive ultrasonic irrigation
J Endod. 2010 Sep;36(9):1580-3.

81. If the Er:YAG laser is used at low settings (20 mJ, 15 Hz) and ultra-short laser
pulses (50 µs), intracanal cavitations and shockwaves are created as a result of
photoacoustic and photomechanical effects. This phenomenon is called photon
induced photoacoustic streaming (PIPS).
Compared to the LAI, where intracanal conical side-firing fibre tips are
positioned 5 mm from the apex, PIPS uses a tapered 600 µm wide side-firing
stripped tip which is kept at the entrance of the root canal and used with

82. When using lasers inside the root canal, several limitations
have to be taken into consideration.
Firstly, the laser light is emitted in a straight line from the tip of an
optical plain-ended fibre or a laser guide with a divergence angle of
only 18 to 20 degrees.
Moreover, the root canal preparation as well as retreatment
procedures with laser and plain fibres is dangerous in curved root
canals because of the risk of creating ledges and perforations
Another limitation is the safe use of lasers in the root canal, especially
thermal damage of periradicular tissues through the open apical
foramen may occur when using the erbium lasers at ablative settings

83. Photoactivated Disinfection
• It is a laser induced photochemical disinfection or sterilization of hard and soft tissues
which is based on the activation of a nontoxic photosensitizer by low laser energy.
• As a result of the interaction between the phothosensitizer and the laser light,
singlet oxygen (1O2) is formed out of molecular oxygen (3O2)
which causes damage to the bacterial membrane and to its DNA

84. • Various combinations of light sources (diode laser at 630nm, 660nm and
670nm; Helium: Neon laser) & Dyes (methylene blue, tolonium chloride)
have been investigated and are commercially available.
In an in vivo study of Garcez at al. 2010, a combination of
polyethylenimine chlorine and a diode laser (40 mW, 4 min,
energy: 9.6 J), was used successfully for the eradication of multi-
drug resistant microorganisms.
J Endod. 2010 Sep;36(9):1463-6.

85. Souza et al. 2010 investigate the antibacterial effects of photodynamic
therapy (PDT) with methylene blue (MB) or toluidine blue (TB) (both
at 15 μg/mL) as a supplement to instrumentation/irrigation of root
canals experimentally contaminated with Enterococcus faecalis and did
not find a significant additional effect of the aPDT compared to
chemomechanical instrumentation with either methylene blue or
toluidine blue and 660 nm diode laser (40 mW).

86. Limitation
• Discoloration of teeth due to penetration of dye in
dentinal tubules.
• Limited diffusion of the photosensitizer into intracanal
irregularities, dentinal tubules and into the biofilm with
restricted production of reactive oxygen species (ROS)
will interfere with the efficacy of a PDT in root canal
disinfection

87. Gentle Wave System
• The GentleWave® System (Sonendo, Inc., Laguna
Hills, CA), is an innovative and unrivaled method
designed to create “ultraclean” canals in order to
overcome current limitations and challenges.
• The GentleWave™ System is capable of removing all
tissue, smear layer, biofilm, and bacteria from the
tubules to a very deep level that is not typically seen
in traditional endodontic treatment.
•

88. Features and Benefits :-
1. Haapasalo et al.152 (2014) demonstrated that the tissue dissolution efficacy of
the GentleWave® System is at least eight times greater than that of conventional
irrigation systems, ultrasonic irrigation, and EndoVac
2. The GentleWave System results in negative pressure and zero extrusion at the
apex.
3. To use the GentleWave System, the teeth have to be only minimally
instrumented e.g.: siz e 15/04.

89. • The resulting fluid dynamics, multisonic sound waves, and sono-
chemistry, enable the treatment fluids to penetrate and reach complex
areas such as apical-thirds, isthmi, lateral fins, dentinal tubules, and
other anastomoses.
• This cleaning system composes of a portable treatment unit with a
single-use sterile handpiece. Irrigant solutions of NaOCl, distilled
water and EDTA are included in this cleaning system.
4. Recent clinical study shows that only 3% of the patients experience
moderate post-treatment pain, and 97% of successful healing in the
teeth treated with the GentleWave System at 12months

90. The EC system is composed of a 25/.04 ABS plastic instrument designed to
mechanically activate the irrigant and combines reciprocating motion with
an ‘‘aircraft wing’’ design.
The system cleans by agitation of the irrigation solution and also by
mechanical drag of adhered debris.
Because a mechanical movement is involved, the agitation action occurs
along the whole length of the instrument unimpeded by contact of the
instrument with canal walls.
EASY CLEAN
SYSTEM

91. Kato et al 2016, compared the efficacy of passive ultrasonic irrigation
(PUI) versus a new activation system using reciprocating motion
(EasyClean [EC] and they concluded that activating the irrigant with
a reciprocating system (EC) promoted more effective debris removal
from the more apical regions of the root canal when compared with
PUI
J Endod 2017 Feb;43(2):326-331.

92. CONCLUSION

93. • Effective irrigant delivery and agitation are prerequisites for successful
endodontic treatment.
• Technological advances during the last decade have brought to fruition
new agitation devices that rely on various mechanisms of irrigant transfer,
soft tissue debridement, and, removal of smear layers.
• Overall, they appeared to have resulted in improved canal cleanliness
when compared with conventional syringe needle irrigation.

94. • In addition, from a practical point of view, no evidence based study is available
to date that attempts to correlate the clinical efficacy of these devices with
improved treatment outcomes.
• Thus, the question of whether these devices are really necessary remains
unresolved.
• There is a need to determine from a practice management perspective how these
devices are perceived in terms of their practicality and ease of use..

95. 1. Li-sha Gu. Review of Contemporary Irrigant Agitation Techniques and Devices. JOE — Volume 35, Number 6, June 2009,791.
2. L. W. M. van der Sluis. The influence of volume, type of irrigant and flushing method on removing artificially placed dentine
debris from the apical root canal during passive ultrasonic irrigation. International Endodontic Journal, 39, 472–476, 2006.
3. V. Hauser. Penetration depth of a dye marker into dentine using a novel hydrodynamic system (RinsEndo). International
Endodontic Journal, 40, 644–652, 2007.
4. M.K.Wu. A primary observation on the preparation and obturation of oval canals. International Endodontic Journal, 34, 137-
141, 2001.
5. Michael S. O’Connell. A Comparative Study of Smear Layer Removal Using Different Salts of EDTA. JOURNAL OF
ENDODONTICS VOL. 26, NO. 12, DECEMBER 2000.
6. Melvin Goldman. New method of irrigation during root canal treatment. JOE, Vol.2, No.3, Sept 1976.
7. Solaiman M. Al-Hadlaq. Efficacy of a New Brush-Covered Irrigation Needle in Removing Root Canal Debris: A Scanning
Electron Microscopic Study. JOE — Volume 32, Number 12, December 2006, 1181.
REFERENCES

96. 8) Jarbas Gonçalves Passarinho-Neto. In vitro evaluation of endodontic debris removal as obtained by
rotary instrumentation coupled with ultrasonic irrigation. Aust Endod J 2006; 32: 123–128.
9) S.-J. Lee. The efficacy of ultrasonic irrigation to remove artificially placed dentine debris from different sized simulated
plastic root canals. International Endodontic Journal, 37, 607–612, 2004.
10) M. Hülsmann & W. Hahn. Complications during root canal irrigation – literature review and case reports. International
Endodontic Journal,33, 186–193, 2000.
11) Y. Fukumoto. An ex vivo evaluation of a new root canal irrigation technique with intracanal aspiration. International
Endodontic Journal, 39, 93–99, 2006.
12) Benjamin A. Nielsen. Comparison of the EndoVac System to Needle Irrigation of Root Canals. JOE — Volume 33,
Number 5, May 2007..10
13) ENDODONTIC DISINFECTION The Sonic Advantage by Clifford J. Ruddle, DDS.
14) Passive ultrasonic irrigation of the root canal: a review of the literature L. W. M. van der Sluis1 , M. Versluis2 , M. K. Wu1
& P. R. Wesselink1

97. 15)Ronald A. Sabins. A Comparison of the Cleaning Efficacy of Short-Term Sonic and
Ultrasonic Passive Irrigation after Hand Instrumentation in Molar Root Canals. JOURNAL OF
ENDODONTICS VOL. 29, NO. 10, OCTOBER 2003.
16) S.-J. Lee. The effectiveness of syringe irrigation and ultrasonics to remove debris from simulated
irregularities within prepared root canal walls. International Endodontic Journal, 37, 672–678, 2004.
17) Rubin Gutarts. In Vivo Debridement Efficacy of Ultrasonic Irrigation Following Hand-Rotary
Instrumentation in Human Mandibular Molars. JOE—Volume 31, Number 3, March 2005.