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Year : 2018  |  Volume : 12  |  Issue : 1  |  Page : 31-35

Comparıson of calcıum hydroxıde removal effıcacy of dıfferent irrıgatıon systems and photon–Induced photoacustıc streamıng technıque

1 Department of Endodontics, Faculty of Dentistry, Recep Tayyip Erdogan University, Rize, Turkey
2 Department of Pedodontics, Faculty of Dentistry, Recep Tayyip Erdogan University, Rize, Turkey
3 Department of Prosthodontics, Faculty of Dentistry, Recep Tayyip Erdogan University, Rize, Turkey
4 Department of Endodontics, Faculty of Dentistry, Karadeniz Technical Universty, Trabzon, Turkey

Date of Web Publication27-Jun-2018

Correspondence Address:
Dr. Banu Aricioglu
Department of Endodontics, Faculty of Dentistry, Recep Tayyip Erdogan University, Rize
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdl.jdl_8_18

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Aim: The aim of this study is to determine the effectiveness of the irrigation techniques including Vibringe Sonic Irrigation, passive ultrasonic irrigation (PUI), photon-induced photoacoustic streaming (PIPS), and conventional needle irrigation (CNI) used to remove the calcium hydroxide (CH) from the artificial groove. Subjects and Methods: Ninety-four teeth extracted human mandibular premolars having single root and linear canal were instrumented with ProTaper system up to size 50. As a standard groove model was designed in the apex of the root's half part. The samples were divided into four experimental groups (n = 21). The techniques were applied for experimental groups as Vibringe (Group 1), PUI (Group 2), PIPS (Group 3), and CNI (Group 4). The residual amount of CH was measured with a stereomicroscope at × 15 magnification by scoring system. The obtained data were statistically analyzed by Kruskal–Wallis and Mann–Whitney U-tests (P < 0.001). Results: CH residues in Group 3 (PIPS) and Group 2 (PUI) were statistically significantly lower than those in Group 1 (Vibringe) and Group 4 (CNI) (P < 0.001). There was no statistically significant difference either between PIPS and PUI groups (P > 0.001) or between Vibringe and CNI groups (P > 0.001). Conclusions: PUI and PIPS techniques could remove but not clean up CH residues from the artificial grooves. In addition, the sonic irrigation technique through the Vibringe device was similar to CNI method in the effectiveness of removal of CH in root canal apices.

Keywords: Calcium hydroxide, endodontics, photon-induced photoacoustic streaming, sonic, Vibringe

How to cite this article:
Aricioglu B, Arslan I, Duymus ZY, Çelik D. Comparıson of calcıum hydroxıde removal effıcacy of dıfferent irrıgatıon systems and photon–Induced photoacustıc streamıng technıque. J Dent Lasers 2018;12:31-5

How to cite this URL:
Aricioglu B, Arslan I, Duymus ZY, Çelik D. Comparıson of calcıum hydroxıde removal effıcacy of dıfferent irrıgatıon systems and photon–Induced photoacustıc streamıng technıque. J Dent Lasers [serial online] 2018 [cited 2023 Jun 10];12:31-5. Available from:

  Introduction Top

Root canal disinfection requires chemomechanical and mechanical preparation with the root canal irrigants and the intracanal medications.[1] For intracanal medication, calcium hydroxide (CH) is popular; however, ıt has been shown that the root canal should be cleaned up from CH since its residual constitutes a risk for the hermetic obturation of the root canal.[2]

The present study can make contributions to the assessment of such alternating methods (Vibringe, erbium-doped yttrium aluminum garnet photon–induced photoacoustic streaming [Er-YAG-PIPS], passive ultrasonic irrigation [PUI], and conventional needle irrigation [CNI]) with respect to their achievement level to remove CH. In this case, typically the null hypothesis showed that there is no difference between these methods.

  Subjects and Methods Top

Local ethical committee approval was obtained from the Ethical Review Committee under the Research Foundation at the Medical Faculty of XXX University (2017/07) to start our research study. The sample was selected among ninety-four extracted human mandibular premolars with single rooted and canals. To ensure standardization, the crowns of the selected teeth were cut, out and in this procedure, a diamond disc was used together with a speedy handpiece under water-cooling to make each's length equal at 16 mm. Endodontic working length (WL) was calculated 0.5-mm shorter.

The rotary instruments were established on the roots including the brand of Protaper (Dentsply Maillefer) and its guidelines were truly applied that the level of apical file up to F5 (size 50, 0.05 taper) was chosen as master. The root canals were prepared with the irrigation with sodium hypochlorite (NaOCl) solution (2-mL, 2.5%) with the help of an injection having a 27G needle that was side vented (NaviTip; Ultradent, South Jordan, UT, USA) in every time when the instrument altered.

For tooth fixation, the redesigned Eppendorf vials (Eppendorf-Elkay, Shrewsbury, MA, USA) were used with the substance made of silicone (Optosil; Heraeus Kulzer, Hanau, Germany). Along with their buccal and lingual sides, all the teeth were longitudinally incised using a diamond disk by irrigating with lots of water and without entering into the canal. A small chisel was required to cut each root in half vertically in parallel with the canal and a 4-mm long, 0.2-mm wide, 0.5-mm deep standard groove in one canal wall that was 2–6-mm high from the apex to imitate the uninstrumented part of the canal corresponding to the apical third.[3] A toothbrush was used to remove debris from the root halves and grooves. On the one hand, five of the remaining teeth were unfilled with CH as the control group or the negative part of experiment and on the other hand, another five were filled with CH utilizing as the positive control group with no removal procedure. At the last stage, ethylenediaminetetraacetic acid (EDTA) (5-mL, 17%) and NaOCl (5-mL, 2.5%) were utilized to clean for 1 min and the distilled water (10 mL) to rinse the canals and then sterilized paper points to dry them.

CH paste (Kalsin, Spot Dental, A.Ş. İzmir, Turkey) was applied to the grooves. The half roots were faintly glued with Scotch Super Glue gel (3M, St Paul, MN, USA) for adaptation. Afterward, the specimens were reassembled inside the vials. A cotton pellet tamped access cavities with temporary filling material (Coltosol F, Coltene Whaledent, Swıtzerland). Those were stored in an incubator at 37°C in 100% humidity for 7 days. Four groups in the experiment (n = 21 for each) were randomly selected from 84 teeth prepared in the way above-mentioned.

The identified groups in the experiment are as follows:

  • Group 1 – Vibringe sonic irrigation group

  • To take CH out of the artificial groves, the Vibringe device was attached to a 27G side-vented needle (Navi-Tip; Ultradent, South Jordan, UT, USA). It was performed by the back and forth movement without any touch on the walls and 1 mm short from the WL during the 60s agitation of EDTA (6-mL, 17%).

  • Group 2 – PUI group

  • An ultrasonic device (EMS, Geneva, Switzerland) was used to agitate EDTA (6-mL, 17%) at medium power setting in a passive manner for each root canal. A volume of 2 mL of that solution and a smooth ultrasonic file (size 15) (Various U file; Nakanishi, Inc. Tochigi, Japan) were advanced into a depth 1 mm short of WL without any touch on the walls along with the 20-s activation. This procedure was repeated three times during all the time of the 60-s agitation of EDTA (6-mL, 17%). The time was stopped during the refill of the injector.

  • Group 3 – Er-YAG-PIPS group

  • In this group, the laser irradiation protocol was performed by an Er: YAG laser (Fidelis AT; Fotona, Ljubljana, Slovenia) system using 14 mm in length and 300 μm in diameter tapered with a stripped sheath fiber tip with 2940-nm wavelength; at 0.3W, 15 Hz, and 20 mJ and 50 μs pulse duration without air or water. The tip was placed into the pulp chamber and EDTA (6-mL, 17%) was activated for 20 s. Three activations were performed to make total activation time 60 s. The time was stopped during the refill of the injector.

  • Group 4: CNI group

  • EDTA (2-mL, 17%) was applied with the 27G side vented needle with up and downmotion without binding to the root canal walls and 1-mm shorter from the WL. The procedure was repeated three times, and total time was fixed of the 60 s. The time was stopped during the refill of the injector.

    Finally, the samples from the cases in the experimentation were irrigated with 5-mL of distilled water and wiped dry by sterilized paper points to prevent further irrigant action.

Image evaluation

The teeth's roots were dismantled to observe the residual amounts of CH. The stereomicroscope of digital camera (Zeiss Stemi 2000 C; Carl Zeiss, Jena, Germany) provided digital images at × 15 magnification which were downloaded to the computer afterward. The sequence of all the pictures was randomized. To evaluate the observations of CH that remained after irrigation was made in the artificial grooves, the scoring system using the scores given freely by three calibrated examiners that were similar to the one used in a study [4] was presented such below [Table 1].
Table 1: Scoring system

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Statistical analysis

Digital images were analyzed by the observers 1 week later and then Kappa test was made to find out the consistency between the examiners. The observations in CH scores for each group were statistically analyzed using Kruskal–Wallis and Mann–Whitney U-tests at a significance level of 95% or P = 0.05. SPSS 20.0 software (SPSS Inc. Chicago, IL, USA) were used in all statistical analyses made.

  Results Top

According to the Kappa test made, the interexaminer agreement was (0.701 ≤ Kw ≤ 0.811) and the intraobserver reproducibility was (0.808 ≤ Kw ≤ 0.904) [Table 2]. The score results of CH residues in the artificial grooves are shown in [Figure 1]. There is a statistically significant difference between the positive and negative control groups (P< 0.05). “No residue” or zero score was not observed for all the groups. The Mann–Whitney U-tests estimated that the removals are greater in PIPS and PUI techniques than those in Vibringe and CNI methods (P< 0.001). Yet, there was no statistically significant difference between the techniques of PIPS and PUI (P > 0.001). In addition, there was a small difference between the methods of CNI and Vibringe, but it was not statistically significant (P > 0.001).
Table 2: Frequency distribution of residual calcium hydroxide score by experimental groups

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Figure 1: Stereomicroscope images (×15) of calcium hydroxide residues. (a) Score 3 (more than 60% of the surface covered) (b) score 2 (20%–60% of the surface covered), (c) score 1 (up to 20% of the surface covered), (d) score 0 (negative control group)

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  Discussion Top

CH is a popular, common substance to use as a medicine for the root canals. Notwithstanding that, when the residues of CH are not all cleaned from the walls, it may lead to a problem about the effecting of the cements into the tubules.[5] In this case, for dissolution of the inorganic substances such as CH material the EDTA chelators solution may be conveniently used for much effectiveness in cleaning CH particles from the root canals along with rotary and ultrasonic instruments, and hence, it was applied in the present study in parallel with the literature.

This research was designed in consistent with the groove model.[6] Among its advantages is a standard size and position of the grooves as well as an evaluation standardized by high-quality intraexaminer reproducibility and sound interexaminer agreement. However, the standard, artificial grooves cannot reflect more complicated system of root canals. With this, it should bear in mind that the removal of CH from isthmuses or oval extensions in vivo can be harder than that from the artificial models used in the experiment.

In this study, Vibringe sonic sytem, PUI, and Er: YAG-PIPS irrigation activation methods were used with EDTA to remove CH from an artificial groove created in straight root canals in comparison with needle irrigation. The main finding of this study was that none of the techniques completely remove the medication. The PIPS and PUI were statistically superior than the Vibringe sonic irrigation and CNI techniques in removing CH. Therefore, the null hypothesis that there is no difference between various techniques is rejected.

In PUI, a thin, smooth tip is applied into the canal filled with irrigant solutions and is activated using ultrasound; so that acoustic microstreaming occurs around the instrument producing agitation of the irrigant solution.[7] Some studies reported that the PUI was shown to be more effective than the CNI for the removal of CH and significantly lower amount of CH remnants was found in the root canal compared with Endoactivator sonic irrigation.[8],[9] To date, there has been no study evaluating the Vibringe sonic system to remove CH from the root canal systems. Based on the results of this study, PUI removed significantly more CH from the artificial groove than the sonically activated Vibringe system and CNI. Sonic irrigation was found to be similar to the needle irrigation. A more effective removal of CH with PUI compared with Vibringe sonic activation could be due to the higher driving frequency of ultrasound in comparison to the sonic device. In the sonic systems, low displacement amplitude (1.2 ± 0.1 mm) of the tip used may cause inadequate fluid movement and low cavitation effect which is known as vapor lock effect and the low energy used is insufficient in this overcurrent.[10] However, in the Vibringe System, nonergonomic design as huge adapted syringe system, which is necessary to apply the constantly maximum same force to activate the system, may be difficult to use for the clinician and shorten activation. All these reasons may explain the failure of the removal canal medicament in the sonic devices.

Among the agitation/activation methods, PIPS differently includes photoacoustic and photomechanical phenomena. By the contrast with other irrigation techniques, the laser tip is unnecessary to advance up to the canal terminus because of the cavitation bubbles supporting to clean the apical area.[11] These study results match up with the findings that, as Li et al. reported, are lower CH residues observed in the groups treated by PIPS and PUI techniques than those in the groups applied by the endoactivator sonic and conventional needle groups in the whole root canals and no other difference was found between the groups.[12]

On the other hand, Arslan et al.[13] suggested that PIPS technique was dominant over PUI in removing CH residues. Furthermore, they showed that all intracanal medicaments could be removed completely by PIPS technique. This difference may be due to their CH paste that includes water and scoring system they used. So that, in the glycerine, CH crystals can more readily and easily be separated into smaller molecules. It has been known the passive diffusion to the dentin tubules depends on the concentration of the solution. Thus, the mixture made with glycerin penetrates the dentin tubules better than water does.[14] For this reason, in the studies that used the CH powder with distilled water, the medicament can be removed more easily from the root canals with irrigation devices.

  Conclusions Top

According to the current experimental study, the techniques were applied to test the irrigation systems of the tooth's root canals, yet none of them managed to clean up CH from the artificial or model grooves in linear canals in the apical area. Nevertheless, it can be concluded from a comparative analysis that PUI and PIPS methods are more effective than CNI and Vibringe techniques and Vibringe system is similar to CNI in effectively cleaning the canals in the apical area.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ingle JI. Ingle's Endodontics. 6th ed. BC Decker INC, Hamilton: PMPH-USA; 2008.  Back to cited text no. 1
Erdemir A, Ari H, Güngüneş H, Belli S. Effect of medications for root canal treatment on bonding to root canal dentin. J Endod 2004;30:113-6.  Back to cited text no. 2
Wu MK, R'oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:739-43.  Back to cited text no. 3
Kuga MC, Tanomaru-Filho M, Faria G, Só MV, Galletti T, Bavello JR, et al. Calcium hydroxide intracanal dressing removal with different rotary instruments and irrigating solutions: A scanning electron microscopy study. Braz Dent J 2010;21:310-4.  Back to cited text no. 4
Hosoya N, Kurayama H, Iino F, Arai T. Effects of calcium hydroxide on physical and sealing properties of canal sealers. Int Endod J 2004;37:178-84.  Back to cited text no. 5
Lee SJ, Wu MK, Wesselink PR. The effectiveness of syringe irrigation and ultrasonics to remove debris from simulated irregularities within prepared root canal walls. Int Endod J 2004;37:672-8.  Back to cited text no. 6
Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR, et al. Review of contemporary irrigant agitation techniques and devices. J Endod 2009;35:791-804.  Back to cited text no. 7
Arslan H, Akcay M, Capar ID, Saygili G, Gok T, Ertas H, et al. An in vitro comparison of irrigation using photon-initiated photoacoustic streaming, ultrasonic, sonic and needle techniques in removing calcium hydroxide. Int Endod J 2015;48:246-51.  Back to cited text no. 8
Wiseman A, Cox TC, Paranjpe A, Flake NM, Cohenca N, Johnson JD, et al. Efficacy of sonic and ultrasonic activation for removal of calcium hydroxide from mesial canals of mandibular molars: A microtomographic study. J Endod 2011;37:235-8.  Back to cited text no. 9
Jiang LM, Verhaagen B, Versluis M, van der Sluis LW. Evaluation of a sonic device designed to activate irrigant in the root canal. J Endod 2010;36:143-6.  Back to cited text no. 10
de Groot SD, Verhaagen B, Versluis M, Wu MK, Wesselink PR, van der Sluis LW, et al. Laser-activated irrigation within root canals: Cleaning efficacy and flow visualization. Int Endod J 2009;42:1077-83.  Back to cited text no. 11
Li D, Jiang S, Yin X, Chang JW, Ke J, Zhang C, et al. Efficacy of needle, ultrasonic, and endoactivator irrigation and photon-induced photoacoustic streaming in removing calcium hydroxide from the main canal and isthmus: An in vitro micro-computed tomography and scanning electron microscopy study. Photomed Laser Surg 2015;33:330-7.  Back to cited text no. 12
Arslan H, Capar ID, Saygili G, Gok T, Akcay M. Effect of photon-initiated photoacoustic streaming on removal of apically placed dentinal debris. Int Endod J 2014;47:1072-7.  Back to cited text no. 13
Alaçam T, Yoldaş HO, Gülen O. Dentin penetration of 2 calcium hydroxide combinations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:469-72.  Back to cited text no. 14


  [Figure 1]

  [Table 1], [Table 2]


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