MANUAL AGITATION TECHNIQUES
A) SYRINGE IRRIGATION
It is the most common and conventional set of irrigation
It involves dispensing of an irrigant into a canal through
needles/cannulae of variable gauges, either passively or with
agitation by moving the needle up and down the canal space
without binding it on the canal walls.
The needle/cannula should remain loose inside the canal so that it
allows the irrigant to reflux and causes more debris to be
displaced coronally, while avoiding the extrusion of the irrigant
into periapical tissues.
Some of these needles are designed to dispense an irrigant through
their most distal ends, whereas others are designed to deliver an
irrigant laterally through closed-ended, side-vented channels.
The latter design has been proposed to improve the hydrodynamic
activation of an irrigant and reduce the chance of apical extrusion.5
Advantage of syringe irrigation is that it allows good control of
needle depth and the volume of irrigant that is flushed through the
Disadvantage is that it is
1. Difficult to standardize fluid flow rate.
2. Inaccessible canal extensions likely to harbor debris and bacteria.
3. Mechanical flushing action created by conventional hand-held
syringe needle irrigation is relatively weak.
• Disposable plastic syringes of 2.5 or 5 ml capacity with 27
gauge blunted needles are useful for endodontic irrigation.
• The needle should be bent to an obtuse angle, to reach the
canals of posterior as well as anterior teeth.
If needle does not bind, the solution should be ejected from the
syringe with little or no pressure on the plunger.
Most of the residual irrigating solution may be removed from the
root canal by holding the needle of the syringe in the canal and
withdrawing the plunger slowly.
Compressed air must not be used for drying the root canal
because tissue emphysema may result if an air bubble
penetrates the periapical tissue.
Drying should be done with absorbent points.
DIFFERENT IRRIGATING NEEDLES USED
o Beveled tip.
o Monoject tip.
o Safe ended tip.
o In beveled needle irrigant is forced apically.
o Advantage of passing irrigant to the Side.
SAFE ENDED TIP:
o Best tip advantage of passing irrigant to the side.
ADVANCED IRRIGATING NEEDLE
Max I Probe Needle
Max I probe is basically closed ended,
side vented needle.
Prevents extrusion of irrigating solution
into periapical tissue
Grossman recognized the need for adequate enlargement of the
root canal to improve irrigation efficacy in 1943.
It has been reported that hand-held syringe needle irrigation is less
effective when the canal is enlarged to less than size 40 at the
(Wu MK et al, 1995)
Therefore, clinicians need to balance the mechanical efficacy of
irrigation via canal enlargement. This leads to inadvertent reduction
in radicular dentin thickness and subsequent weakening of the root
NEEDLE IN ROOT CANAL.
INJECTION OF IRRIGATING SOLUTION. 16
Brushes are not directly used for delivering an irrigant into the
They are adjuncts for debridement of the canal walls or agitation of
root canal irrigant.
A 30-gauge irrigation needle covered with a brush (NaviTip FX;
Ultradent Products Inc, South Jordan, UT) was introduced
A study 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.
(Al-Hadlaq SM et al, 2006)
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 so that it can perform active scrubbing
But, 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.
Keir et al in early 1990s, performed a study and used Endobrush
for improved canal debridement.
The Endobrush (C&S Microinstruments Ltd, Markham, Ontario,
Canada) is a spiral brush designed for endodontic use that
consists of nylon bristles set in twisted wires with an attached
handle and has a relatively constant diameter along the entire
In that study the bristles of the brush were claimed to extend to
the non instrumented canal walls and into the fins, cul-de-sacs,
and isthmi of the canal system to remove trapped tissue and
However, the Endobrush 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.
C) MANUAL DYNAMIC IRRIGATION
An irrigant must be in direct contact with the canal walls for effective
However, it is often difficult for the irrigant to reach the apical portion
of the canal because of the so-called vapor lock effect.
Research has shown that gently moving a well fitting gutta-percha
master cone up and down in short 2-3 mm strokes (manual dynamic
irrigation) within an instrumented canal can produce an effective
hydrodynamic effect and improve the displacement of any given
It has demonstrated that manual dynamic irrigation was significantly
more effective than an automated dynamic irrigation system
(RinsEndo Du¨ rr Dental Co, Bietigheim-Bissingen, Germany) and
(McGill S, 2008)
Several factors could have contributed to the positive results of
1) A well fitted gutta-percha point in the canal might generate
higher intracanal pressure during pushing movements, leading to
forcing of irrigant to the untouched canal surfaces.
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 allows better
mixing of the fresh unreacted solution with the spent, reacted
Although manual-dynamic irrigation is simple and cost-
effectiveness, the laborious nature of this hand-activated
procedure still hinders its application in routine clinical practice.
Therefore, there are a number of automated devices designed for
agitation of root canal irrigants.
MACHINE ASSISTED IRRIGATION
A) ROTARY BRUSHES
Ruddle used a micro brush attached to rotary handpiece.
The brush includes a shaft and a tapered brush section. The latter
has multiple bristles extending radially from a central wire core.
This micro brush rotates at about 300 rpm, causing the bristles to
deform and go into the irregularities of the preparation &
displace residual debris out of the canal in a coronal direction.
However, this product has not been commercially available since
the patent was approved in 2001.
Commercially available endodontic microbrush is Canalbrush
(Coltene Whaledent, Langenau, Germany).
This is highly flexible and is molded entirely from polypropylene.
It might be used manually with a rotary action. However, it is more
efficacious when attached to a contra-angle handpiece running at
B) CONTINUOUS IRRIGATION DURING
QUANTEC - E
Continuous irrigant agitation during active rotary
instrumentation would generate:
1) Increased volume of irrigant.
2) Increase irrigant contact time.
3) Greater depth of irrigant penetration inside the root canal.
The Quantec-E irrigation system (SybronEndo, Orange, CA) is
attached to the Quantec-E Endo System.
1. Pump console.
2. Two irrigation reservoirs.
3. Tubing to provide continuous irrigation during rotary
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.
C) SONIC IRRIGATION
FREQUENCY AND OSCILLATING PATTERN OF SONIC
Tronstad et al were the first to report the use of a sonic instrument
for endodontics in 1985.
Sonic irrigation is different from ultrasonic irrigation in that
1) It operates at a lower frequency (1–6 kHz)
2) Produces smaller shear stresses .
3) Generates significantly higher amplitude or greater back-and-
forth tip movement.
Moreover, the oscillating patterns of the sonic devices are
different compared with ultrasonically driven instruments.
When the movement of the sonic file is constrained, the sideway
oscillation disappears. This results in a pure longitudinal file
This mode of vibration has been shown to be particularly
efficient for root canal debridement.
EFFECT OF SONIC IRRIGATION
CONVENTIONAL MORE RECENT
Rispisonic file Endoactivator
(Medidenta International, (Dentsply Tulsa Dental
Inc, Woodside, NY) Specialties, Tulsa, OK)
The Rispisonic files have a non uniform taper that increases with
Because they are barbed, these files might inadvertently engage
the canal wall and damage the finished canal preparation during
Endoactivator consists of a portable handpiece and 3 types of
disposable polymer tips of different sizes that are easily attached
(snap-on) to the handpiece
(A) ENDOACTIVATOR WITH THE LARGE (BLUE)
PLASTIC TIP. (B) SAME TIP IN SONIC MOTION.
These tips are claimed to be strong and flexible and do not break
Because they are smooth, they do not cut dentin.
It does not deliver new irrigant to the canal but it facilitates the
penetration of the irrigant in the canal.
A recent study have indicated that the use of endoactivator
facilitates irrigant penetration and mechanical cleansing
compared with needle irrigation, with no increase in the risk of
irrigant extrusion through the apex.
(Townsend C et al, 2009)
Vibringe (Vibringe BV, Amsterdam, The Netherlands) is a new
sonic irrigation system that combines battery-driven vibrations
(9000 cpm) with manually operated irrigation of the root canal.
Vibringe uses the traditional type of syringe/needle delivery but
adds sonic vibration.
Ultrasonic devices were first introduced in endodontics by
Ultrasonic energy produces higher frequencies (25- 30 kHz) than
sonic energy but low amplitudes.
They operate in transverse vibration.
Two types of ultrasonic irrigation are available for use.
The first type is simultaneous ultrasonic instrumentation and
irrigation (UI), and the second type is referred to as passive
ultrasonic irrigation (PUI) operating without simultaneous
UI is shown to be less effective than PUI. This can be explained
by a reduction of acoustic streaming and cavitation.
In UI, the file contacts the root canal wall, so the oscillations are
dampened and becomes too weak to maintain acoustic streaming.
For proper acoustic streaming, the ultrasonic file should move
freely in the canal without making contact with the canal wall.
A canal size of at least 30-40 file is required to maintain free
oscillation. (Irrigant can also penetrate more easily into apical
Disadvantage of UI is difficult to control the cutting of dentin
during ultrasonic preparation which can result in apical
perforation & irregular canal shapes.
PUI was first described by Weller et al.
The term passive does not adequately describe the process, since
it is infact active.
The term passive relates to non cutting action of ultrasonically
The active streaming of the irrigant, increases its potential to
contact a greater surface area of the canal wall.
After the canal has been shaped to MAF, a small file or a smooth
wire is introduced at the centre of the canal, as far as the apical
Canal is then filled with irrigating solution, and ultrasonically
oscillating file activates the irrigant.
Using this non cutting methodology, the potential to create
aberrant shapes within root canals are reduced to a minimum.
Ultrasonics is not able to effectively get through the apical vapor
lock in the apical 3 mm of the canal.
It has been shown that once a sonic or ultrasonically activated tip
leaves the irrigant and enters the apical vapor lock, acoustic
microstreaming and/or cavitation becomes physically impossible
which is not the case with the apical negative pressure irrigation
(Nielsen BA et al, 2007)
This is because acoustic microstreaming or cavitation is only
possible in fluids/liquids, not in gases.
Ultrasonics can help in debridement of anastomoses between
double canals, isthmuses, and fins. 39
Chlorine, which is responsible for the dissolution of organic
tissues and the antibacterial property of NaOCl, is unstable and is
consumed rapidly during the first phase of tissue dissolution,
probably within 2 minutes.
Therefore, an improved delivery system that is capable of
continuous replenishment of root canal irrigants is highly
Recently, a needle-holding adapter to an ultrasonic handpiece has
been developed by Nusstein.
(Nusstein J, 2005) 40
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,
& at the same time maintains a continuous flow of fresh irrigant.
This technique resulted in:
1. Greater reduction in colony forming units.
2. Reduction in time required for irrigation.
INTERMITTENT FLUSH ULTRASONIC
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
The root canal is then flushed with fresh irrigant to remove the
dissolved remnants from the canal walls.
E) PRESSURE ALTERNATING DEVICES
1) ENDOVAC ANP SYSTEM
In the EndoVac system (Discus Dental, Culver City, CA), has
1. Master delivering tip
2. Macro cannula
3. Micro cannula
Master delivering tip simultaneously delivers and evacuates the
irrigant from the pulp chamber.
The plastic macro cannula has a size 55 open end with a .02 taper
and is attached to a titanium handle.
It is used to suction irrigant from the chamber to the coronal and
middle segments of the canal.
The ISO size 0.32 stainless steel micro cannula has 4 sets of 3
laser-cut, laterally positioned, offset holes (total 12 holes) adjacent
to its closed end.
The holes are 100 microns in diameter and spaced 100 microns
This is attached to a finger-piece for irrigation of the apical part of
the canal by positioning it at the working length.
The micro cannula can be used in canals that are enlarged to size
35/.04 or larger.
The Master Delivery Tip (MDT) is connected to a syringe of
The macro cannula or micro cannula is connected via tubing to
the high-speed suction of a dental unit.
During irrigation, the MDT tip delivers irrigant to the pulp
chamber and siphons off the excess irrigant to prevent overflow.47
The cannula in the canal simultaneously exerts negative pressure
that pulls irrigant from its fresh supply in the chamber, down the
canal to the tip of the cannula, into the cannula, and out through
the suction hose.
Thus, a constant flow of fresh irrigant is being delivered by
negative pressure to working length.
1. Avoid air entrapment.
2. Avoid undue extrusion.
3. Maintains a gentle flow rate.
Apical negative pressure has been shown to enable irrigants to
reach the apical third and help overcome the issue of apical vapor
In a comparing the Endoactivator, passive ultrasonic, the F file,
the manual dynamic max-i-probe, the pressure ultrasonic, and the
endovac, only the endovac was capable of cleaning 100% of the
(Klyn SL et al, 2010)
Hockett et al (2008) tested the ability of apical negative pressure
to remove a thick biofilm of Enterococcus faecalis.
He found that the cultures were negative with ANP within 48
hours while those irrigated using traditional positive pressure
irrigation were positive.
SEM OF DECONTAMINATED DENTINAL TUBULES
AFTER USE OF ANP
2) THE RINSENDO SYSTEM
RinsEndo irrigates the canal by using pressure-suction
Its components are a handpiece, a cannula with a 7 mm exit
aperture, and a syringe carrying irrigant.
The handpiece is powered by a dental air compressor and has an
irrigation speed of 6.2 ml/min & (1.6 Hz amplitude).
Periapical extrusion of irrigant has been reported with this
RINSEENDO FITS LEADING
RINSEENDO HANDPIECE WITH
AND SPLASH PROTECTOR
It is an irrigation/evacuation system that apically delivers the
irrigant under positive pressure through a thin needle with a
lateral opening, and evacuates the solution through a large needle
at the root canal orifice.
SELF ADJUSTING FILE
It has a hollow thin walled cylinder composed of a thin
It is compressible and adjusts to the anatomy of the root
SAF operates with a continuous flow of irrigant (5ml/min)
running through the instrument.
The vibrating movement of SAF within the irrigant facilitates
its cleaning and debriding effects.
Root canals vary greatly in their cross-sectional anatomy,
and oval, flat, and C-shaped canals are commonly found
SAF is designed to efficiently prepare root canals that do
not have a round cross section because the compressible
file adapts its shape to the canal anatomy.
It is operated with a modified KaVo handpiece that
generates in and out vibrations with 5000vibrations/min and
A VATEA irrigation unit is used to deliver a constant flow of
Although the exact etiology of the NaOCl incident is still
uncertain, based on the evidence from actual incidents, it would
appear that an intravenous injection may be the cause.
In case of extrusion, if the vein is close to the root apex, the
irrigant can find its way into the venous complex.
This would require positive pressure apically that exceeded
venous pressure (10 mm of Hg).
And so, NaoCl must be safely delivered.
COMPARATIVE EXTRUSION OF IRRIGANT
USING IRRIGATION DEVICES
(Gary Glassman, 2011)
OTHER TECHNIQUES OF ROOT
It has been documented in several studies that CO2, Argon,
Nd:YAG, Er:YAG laser has the ability to remove smear layer and
A new endodontic side firing spiral tip (RCLase; Lumenis, Opus
Dent, Israel) overcomes the disadvantage of the straight emission
of the laser beam, and thus claims to enable cleaning of the root
canal walls laterally.
2) PHOTO ACTIVATED DISINFECTION
It includes PDT/LAT i.e photo dynamic therapy or light activated therapy.
Light of Photosensitizer Oxygen based free
specific wavelength Activation radical formed
Membrane damage Genetic damage Enzyme
Optic fibre may be used to direct the irradiation to the intended side of application.63
Advantage of PDT:
1. Wide spectrum of anti microbial activity. (also act on antibiotic
2. Minimal chance of giving rise to resistant microbial population.
It is dual selective i.e only those cells which have selectively
accumulated the photosenstizer or which have endogenously
produced photosensitizer will be affected upon radiation.
Low intensity light and the non toxic photo sensitizer both are
3) INTRALIGHT UV DISINFECTION
UV light is used for disinfection.
Intralight consist of an intracanal UV illuminator shaped in the
form of an endodontic file.
It proides uniform circumferential illumination of the root canal
with 254nm UV light.
It is used as a supplemental disinfection after NaOCl irrigation,
otherwise the bacteria in the inner layer of biofilm may be
protected by UV light which is absorbed by outer layer bacterias.
4) SUPER OXIDIZED WATER
Also known as “electro chemicaly activated” water in Russia &
“oxidative potential water” in Japan.
Its basically saline that is electrolysed to produce: superoxidized
water, hypochlorous acid and free chlorine radical.
The solution at anode is harvested as anolyte, & that at cathode as
It is available as Sterilox.
It has been tested for its ability to remove smear layer, root canal
debridement & killing bacteria.
5) HEAL OZONE
Ozone is triatomic oxygen or trioxygen.
It is found in stratosphere at a concentration of 1-10 ppm. It is
created from & destroyed into molecular oxygen.
It acts as antimicrobial agent in gaseous/ aqueous form.
The strongest acid produced by acidogenic bacteria is pyruvic
acid. Ozone decarboxylate it into acetic acid.
This acetic acid encourages remineralization.
Effective irrigant delivery and agitation are prerequisites for
successful endodontic treatment.
There is a need to determine how these devices are perceived in
terms of their practicality and ease of use.
Pathways of the pulp ,cohen, 6th & 9th edition
Endodontics, ingle,6th edition.
Endodontic practice, Grossman , 11th edi. & 12th edi.
Lisha G, Kim JR. review of contemporary irrigant agitation
techniques and devices. J Endod 2009:35(6):791-804.
Safety and Efficacy Considerations in Endodonti Irrigation :A
Peer-Reviewed Publication Written by Gary Glassman, 2011