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 Table of Contents  
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 29-32

Effect of different irrigation activation techniques on the amount of apical debris extrusion

Department of Endodontics, Faculty of Dentistry, Zonguldak Bülent Ecevit University, Zonguldak, Turkey

Date of Submission26-Oct-2019
Date of Acceptance10-Jan-2019
Date of Web Publication13-Jun-2019

Correspondence Address:
Uygar Hizarci
Department of Endodontics, Faculty of Dentistry, Zonguldak Bülent Ecevit University, 67600 Zonguldak
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tdj.tdj_38_18

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This study compared the amount of debris extrusion of different irrigation activation techniques.
Materials and methods
Sixty single rooted maxillary incisor human teeth with single and straight canals were used. The crowns were flattened to obtain a standardized working length. The specimens were placed into Eppendorf tubes to collect the debris. The root canals were instrumented using the ProTaper Next system. The specimens were randomly divided into four equal groups in terms of the irrigation activation techniques; group I, no activation; group II, manual dynamic agitation; group III, passive ultrasonic irrigation; and group IV, Xp-endo Finisher. A total of 10 ml of distilled water was used during the irrigation procedures of each specimen. The tubes were stored in incubator for 5 days. The amount of debris extrusion was calculated by subtracting the initial weight from the final weight of the tube. The distribution of the data was examined using the Shapiro–Wilk test. Mann–Whitney U- test was used for post-hoc group comparisons.
Debris extrusion was recorded for all specimens. The no activation group demonstrated significantly less amount of debris extrusion compared to all activation groups (P < 0.05). No differences were found between other groups (P > 0.05). The mean values for manual dynamic agitation, passive ultrasonic irrigation, and Xp-endo Finisher groups were found as 0.00114733 g, 0.00091733 g, and 0.00100 g, respectively.
Although activation techniques caused a higher amount of debris extrusion, their benefits and limitation of in-vitro conditions to reflect clinical situations should be well considered.

Keywords: apical debris extrusion, irrigation activation, manual dynamic agitation, passive ultrasonic irrigation, Xp-endo finisher

How to cite this article:
Hizarci U, Koçak S, Sağlam BC, Koçak MM. Effect of different irrigation activation techniques on the amount of apical debris extrusion. Tanta Dent J 2019;16:29-32

How to cite this URL:
Hizarci U, Koçak S, Sağlam BC, Koçak MM. Effect of different irrigation activation techniques on the amount of apical debris extrusion. Tanta Dent J [serial online] 2019 [cited 2021 Dec 7];16:29-32. Available from: http://www.tmj.eg.net/text.asp?2019/16/1/29/260279

  Introduction Top

The incidence of extruded debris, which ranges between 1.4 and 16%[1], may cause inflammation and finally postoperative pain[2]. Flare-up and postoperative pain, which may occur as a result of unexpected debris extrusion, are undesirable clinical conditions for both patients and clinicians[3]. Therefore, the occurrence of less debris extrusion may minimize postoperative reactions and increase the patient comfort after appointment.

Conventional needle irrigation is a commonly used technique during irrigation of root canals[4],[5]. The main limitation of conventional needle irrigation is lack of delivering the solutions no further than 0–1.1 mm beyond its tip[6]. Additionally, the conventional needle irrigation is insufficient for cleaning of the complex anatomy including isthmus, fins, lateral and accessory canals[7]. To obtain a well-cleaned root canal, irrigants should be in contact with the whole surface[8]. For this purpose, various irrigation activation techniques were developed to increase the efficacy of irrigation solutions[9].

A well-fitted gutta-percha cone is used in repeated insertion motion to the working length for the manual dynamic activation (MDA) during activation. For the activation of irrigant, the cone is applied with short strokes[10]. The activation of irrigant with the passive ultrasonic irrigation (PUI) is an acceptable technique which removes debridement and provides an efficient canal disinfection. PUI refers to an irrigation protocol where in a non-cutting ultrasonically activated file is agitated in the canal without contacting the walls[11].

A novel nickel–titanium (NiTi) rotary finishing file, XP-endo Finisher (XPF) file, has been introduced for irrigation activation. The alloy of XPF, NiTi Max-Wire, increases the flexibility[12]. The file was reported to improve the effectiveness of final irrigation after root canal instrumentation[13]. The curved bulb of file expands to a diameter of 6 mm which is 100 times of a corresponding sized file[12],[14].

This study compared the amount of apical debris extrusion after performing different irrigation activation techniques prepared with rotary NiTi instruments.

  Materials And Methods Top

All patients are informed and signed a consent for approval for using their extracted teeth in this research according to ethical guidelines of Faculty of Dentistry, Zonguldak Bülent Ecevit University, Zonguldak, Turkey. Sixty extracted single rooted maxillary incisor human teeth with single and straight canals were used. Soft tissue remnants were removed by periodontal curettes and all specimens were stored in sterile saline solution until use. A reference point was created by flattening the top of the buccal cusps and the access cavities were prepared. A size 15-K file (Dentsply Maillefer, Ballaigues, Switzerland) was used to control the canal patency until the tip was visible at the apical foramen and 1 mm was subtracted from this length to determine the working length. The amount of debris was collected by an experimental setup described by Myers and Montgomery[15]. To obtain the initial weight, the Eppendorf tubes were weighed for three times using an analytic balance (Radwag, Radom, Poland) with 10−4 accuracy after removal of the covers, and averaged. The teeth were inserted into the previously created holes on the cover.

A 27-G needle was placed alongside the tooth to balance the air pressure and both were fixed to the cover with cyanoacrylate to create the test setup. The test setup was placed in the Eppendorf tube, and the tube was fitted into a vial which was covered with aluminum leaf to prevent the seeing during instrumentation. All preparations were performed by a single operator, using ProTaper Next rotary files (Dentsply Maillefer) to a size X4 using a crown down technique in a sequence of PU SX, PN X1, X2, X3, and X4. The setting of endodontic motor was selected as 300 rpm rotation speed and 200 gram-centimeter torque. When the instrumentation was completed, the test setup was removed. A volume of 5 ml distilled water was used between files.

The specimens were randomly divided into four groups as follows (n = 15):

  1. Group I (no activation): final irrigation was applied with 5 ml distilled water without any additional agitation.
  2. Group II (MDA): distilled water was activated with the ProTaper X4 gutta-percha point (ProTaper Next Gutta-Percha Points, Size X4; Dentsply Maillefer) for 1 min The gutta-percha cone was inserted 1 mm shorter than the working length.
  3. Group III (PUI): distilled water was activated with ultrasonic device (VDW Ultra, VDW GmbH, Münich, Germany) and ultrasonic tip (length/ISO 25/25) which was placed 1 mm short of the working length. It was activated at a frequency cycle of 28–36 kHz after the last irrigation for 1 min.
  4. Group IV: distilled water was activated with XPF (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) (size/25, Taper/00) which was set at 800-rpm speed and 1- Ncm torque and applied for 1 min. The file was inserted 1 mm shorter than the working length.

The remaining debris on the apical root surface was irrigated into the tube. The tubes were held in an incubator at 70°C for 5 days to vaporize the distilled water. The tubes, including the extruded debris were weighed for three times, averaged and this value was recorded as the final weight. Finally, amount of extruded debris was calculated by subtracting the initial weight from the final weight including the debris.

The normal distribution of data was evaluated with the Shapiro–Wilk test. The comparison between parameters was analyzed with the Kruskal–Wallis test. The failure of normality of data prompted the application of the Bonferroni-adjusted Mann–Whitney U- test for post-hoc group comparisons. P values less than 0.05 were considered significant for all tests.

  Results Top

Debris was recorded in all specimens. The no activation group demonstrated significantly less amount of debris extrusion compared to all activation groups (P < 0.05). However, no significant differences were found between other groups (P > 0.05). The mean values and standard deviations for all groups are listed in [Table 1].
Table 1 Mean weights and SD of apically extruded debris by activation techniques

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  Discussion Top

The extruded debris was associated with periapical tissue inflamation and postoperative pain[1]. Therefore, less debris extrusion may reduce postoperative pain after root canal treatment[16]. The effects of different instrumentation techniques, instrumentation systems, and instrumentation kinematics on apical debris extrusion were previously well evaluated[17]. However, irrigation technique and activation of the irrigant may also cause extrusion of debris. Thus, we evaluated the effect of different irrigation activation techniques on apical debris extrusion.

The debris was collected using a common experimental model. This model does not mimic the periapical tissues and the absence of apical pressure may be a limitation of the experimental setup[3]. However, the model provides a standardization in methodology, develops well-controlled conditions, and allows reliably comparison of certain factors[18].

When the chemomechanical preparation was applied with conventional needles, irrigation could not reach to 40–60% of the canal walls[19]. It has also been noted that the traditional irrigation solutions are capable of advancing the needle tip by as much as 1 mm deeper distance, which is inadequate for canal irrigation[20]. Thus, activation procedure is required to increase the efficacy of the irrigant.

The MDA technique requires a matched gutta-percha cone, which may be defined as a relatively inexpensive method. The MDA technique allows the penetration of irrigation solution into the dentinal tubules comparable to PUI activation[21]. However, this technique has limited activity to eliminate the apical vapor lock[22]. Ribeiro et al.[23] reported that PUI was more successful in terms of debris removal compared to needle irrigation, MDA, PUI system. In a previous study, PUI was compared with conventional irrigation and the less apical debris flow was detected for activation with PUI[24]. This contrary finding to our results could be related to the difference in irrigation solutions used. The distilled water was used instead of sodium hypochlorite to highlight the possible effect of the activation techniques and to eliminate misleading results due to the crystallization of irrigant. In the present study, MDA technique demonstrated relatively higher debris extrusion compared to other activation methods without any significance. A recent clinical study reported that MDA technique caused more postoperative pain than conventional needle irrigation, sonic activation, and PUI techniques after root canal treatment at the first 24 h[25]. This result may be related to higher amount of debris extrusion as recorded in the present study.

Irrigation using a conventional needle may create an apical vapor lock which significantly limits the irrigant exchange at the apical third of the root canal system[26]. Irrigation activation systems have been developed to overcome this situation. Additionally, activation/agitation techniques provide superior root canal cleanliness[27]. In the present study, the lowest debris extrusion was recorded in the nonactivated group. The reason for this result may be related to the fact mentioned in the previous studies in which they reported that the conventional irrigation is insufficient for the removal of debris from the root canal irregularities and the fact that it cannot provide adequate cleaning on the root canal walls. Although no statistically significant difference was found, apical debris extrusion was observed in all activation groups.

XPF has been described as a spoon-shaped form, which makes cleaning more effective in root canal irregularities that cannot be reached during instrumentation. Due to the shape, shaking of the solution through the canal by moving up and down is required. This makes it more efficient to clean the canals, because it comes into contact with the canal walls mechanically[14].

The irrigation with the XPF was found more effective than conventional needle irrigation for removal of debris and smear layer[28], and showed superior cleaning efficacy compared to PUI[29]. A relatively higher amount of debris extrusion for the XPF group than the PUI group may be associated with mechanical activation of the XPF and more effective cleaning of the apical third[30].

  Conclusion Top

All techniques caused apical extrusion of debris. Although, activation techniques caused a higher amount of debris extrusion, their benefits in clinical practice and limitations of in-vitro conditions to reflect clinical conditions should be well considered.


This manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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