Research Article

Comparative evaluation of canal cleanliness using three

different irrigation agitation methods
M. Meenapriya, K. Anjaneyulu*

ABSTRACT

Background: Different techniques and irrigant delivery devices have been proposed to increase the effect of chemical
disinfection within the root canal system and to improve canal cleanliness following mechanical instrumentation. Aim: The
aim of the study was to do a comparative evaluation of the cleanliness of the canal using EndoActivator (Dentsply Sirona),
modified Waterpik tooth floss, Finishing File, and without any agitation. Materials and Methods: Single root canals of
extracted human anterior teeth were used. Root canals were prepared. Irrigation was performed using 3% sodium hypochlorite
and 17% ethylenediaminetetraacetic acid solution. Samples were divided into four equal groups, according to the irrigation
activation techniques: (a) EndoActivator (Dentsply Sirona) (b) modified Waterpik tooth floss with EndoActivator tip,
(c) Finishing File (Neoendo Healthcare India Pvt. Ltd.), and (d) without any agitation (control). Roots were cross-sectioned
longitudinally, and the canal walls were subjected to scanning electron microscopy. The presence of smear layer at coronal,
middle, and apical levels was evaluated. Results: The Finishing File (Neoendo Healthcare India Pvt. Ltd.) performed better
than the EndoActivator (Dentsply Sirona) and modified Waterpik tooth floss in the debridement of coronal to the apical
thirds of the root canal. In the coronal third, modified Waterpik tooth floss was effective in the debridement of the root
canal. Similarly, in the middle and the apical thirds, Finishing File (Neoendo Healthcare India Pvt. Ltd.) was effective in the
debridement of the root canal. Conclusion: Finishing File scored the best in debris removal compared to the other irrigation
activation systems. However, none of the irrigation activation systems were able to debride the root canal completely.

KEY WORDS: Agitation, Canal cleanliness, Debridement, EndoActivator (Dentsply Sirona), Scanning electron microscope

INTRODUCTION canal remain untouched by the instruments. This is due

Cleaning and shaping of the root canal is the main
components of successful root canal treatment. Cleaning
is influenced by proper removal of debris and smear layer.
Irrigation which is considered as an essential part of root
canal debridement is done to ensure cleaning in areas
that were not touched by mechanical instrumentation.
These irrigants must have direct contact with the entire
canal wall for effective action.[1]
The microorganisms play an important role in
the pathogenesis of pulp and periapical diseases.
The root canal therapy requires elimination of
microorganisms and their byproducts and prevention of
its reinfection.[2] Proportionally, larger areas of the root
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to the complex root canal anatomy present, especially
in the apical areas such as isthmus, accessory canals,
fins, and deltas which provide ideal space for debris.[3]
EndoActivator (Dentsply Sirona) uses sonic activation
of the irrigants comprising a portable handpiece and
three types of disposable flexible polymer tips of
different sizes that do not cut root dentin. Cavitation
and acoustic streaming significantly improve the
debridement and disruption of the smear layer and
biofilm. The EndoActivator (Dentsply Sirona) seems
to have a minimal account of irrigant extruded out of
the apex compared to other irrigation devices, and the
frequency of extrusion depends on apical preparation
size. It has been shown to increase the efficacy of
irrigation better than traditional needle irrigation.[3-5]
Waterpik Power Flosser is an activation device used
for flossing the interdental areas. It has a mechanism

Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and
Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr. Anjaneyulu, Department of Conservative Dentistry and Endodontics, Saveetha Dental College
and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road,
Chennai - 600 077, Tamil Nadu, India. E-mail: anji.tmdch@gmail.com

Received on: 21-06-2019; Revised on: 23-07-2019; Accepted on: 27-08-2019

Drug Invention Today | Vol 12 • Special Issue 1 • 2019 57

 M. Meenapriya and K. Anjaneyulu

of action very similar as that of the EndoActivator
(Dentsply Sirona); moreover, the tips of the
EndoActivator (Dentsply Sirona) and those of the
Power Flosser system are interchangeable.
The Finishing File (Neoendo Healthcare India Pvt.
Ltd.) just requires your electric slow-speed handpiece,
the type that can be used with nickel-titanium files.
The Finishing File is made of non-toxic polymer and
has two opposing flutes that run the entire length of
the file. The flutes agitate the residual sidewall debris,
and when in the canal with the irrigation solution, the
fluid dynamics of the flutes spinning create a pump
that extracts debris out of the canal. The Finishing
File (Neoendo Healthcare India Pvt. Ltd.) is the
only product that agitates and extracts debris out
of the canal. Finishing Files (Neoendo Healthcare
India Pvt. Ltd.) all come in size 20, with .04 taper, and
in lengths of 21 mm, 25 mm, and 31 mm.
Therefore, this study compares the efficacy of
EndoActivator (Dentsply Sirona), modified Waterpik
tooth floss, and the Finishing File (Neoendo
Healthcare India Pvt. Ltd.) in the debridement of the
coronal, middle, and the apical thirds of the root canal.
MATERIALS AND METHODS
Sample Selection
Twenty extracted human single-rooted teeth were
selected for this study. Access opening of the root
canal was done on the palatal side of the teeth.
In Group 3, the root canal was agitated with Finishing
File (Neoendo Healthcare India Pvt. Ltd.) along
with the use of irrigants such as 5  ml of sodium
hypochlorite and EDTA [Figure 3a and b]. Neoendo
Finishing File of size 20, 4% taper, and length 21 mm
was used for the present study. The Finishing File was
used along with the contra-angle handpiece at a speed
of 600–900 rpm.
In Group  4, the root canal was not subjected to any
agitation.
Each irrigating solution was delivered using a needle
in a passive up and down motion, inserted to within
2 mm of the apex.
Specimen Processing and Evaluation
The specimens were then longitudinally sectioned,
using a serrated laboratory diamond disk to groove
the buccal and lingual of each root. A  15 blade was
tapped with a mallet along the groove to separate the
halves [Figure 4a-c]. During sectioning, care was
taken to avoid penetration into the canal space. Each
half was viewed with a scanning electron microscope
[Figure 5]. Three photographs for each specimen were
taken at 2000× to visualize the coronal, middle, and

Root Canal Instrumentation

The working length was determined using a size 15 file a b
to the apex. The root canals of teeth in all the groups Figure 1: (a and b) EndoActivator (Dentsply Sirona)
were instrumented using crown-down technique to
the working length. During instrumentation, all four
experimental groups were irrigated with 1  ml of
NaOCl between each file. The teeth were randomly
distributed into four groups.

Final Irrigation
On completion of the canal preparation, each specimen
received a final irrigation with 5 ml of NaOCl and 5 ml
of ethylenediaminetetraacetic acid (EDTA), with each a b
irrigant being activated according to their assigned group. Figure 2: (a and b) Modified Waterpik tooth floss

In Group 1, EndoActivator (Dentsply Sirona) served

as the irrigation device. This was used along with the
irrigants such as 5 ml of sodium hypochlorite and 5 ml
of EDTA [Figure 1a and b].

In Group  2, modified Waterpik tooth floss with

EndoActivator tip served as the irrigation device.
This was agitated inside the root canal with the use a b
of irrigants such as 5 ml of sodium hypochlorite and Figure 3: (a and b) Finishing File (Neoendo Healthcare
EDTA [Figure 2a and b]. India Pvt. Ltd.)

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 M. Meenapriya and K. Anjaneyulu

apical portion of the root canal system. The areas root canal and there was very less debris removal in
examined for each sample were standardized using the middle thirds of the root canal [Figures 9-11 and
parameters. A  digital photograph of the coronal, Table 1].
middle, and apical thirds was taken of each half of
each specimen.[6] Group 3 reveals the better debridement of root canal
compared to the other irrigation activation systems.
The following scoring criteria were used in the Least debris removal was in the middle thirds of the
previous studies:
• Score 1: Clean canal wall, only very few debris
particles
• Score 2: Few small conglomerations, <25% of the
canal wall covered
• Score 3: Many conglomerations, 25–50% covered
• Score 4: 50–70% of the canal wall covered
• Score 5: Complete or nearly complete.

RESULTS
The groups were scored according to the scoring
criteria and the results were analyzed.

Group  1 reveals less debris removal in the coronal

thirds of the root canal and highest in the middle thirds
of the root canal [Figures 6-8 and Table 1]. Figure 6: Sample 1 coronal third
Group  2 reveals that the debridement of root canal
was more on the coronal and the apical thirds of the

a b

c Figure 7: Sample 1 middle third

Figure 4: (a-c) The cross-section of the tooth longitudinally
using serrated diamond disk

Figure 5: The scanning electron microscope Figure 8: Sample 1 apical third

Drug Invention Today | Vol 12 • Special Issue 1 • 2019 59

 M. Meenapriya and K. Anjaneyulu

root canal and highest in the coronal thirds of the root apical thirds of the root canal [Figures 15-17 and
canal [Figures 12-14 and Table 1]. Table 1].

Group  4 reveals the highest debris removal in the Based on the debridement in the coronal, middle, and
coronal and the middle thirds of the root canal and the apical thirds of the root canal, the following results
there was minimal debridement of root canal in the were obtained [Table 2 and Graph 1].

Table 1: The efficacy of different agitation devices in

debris removal
Agitation S1 S2 S3 S4 S5 Mean
devices used
EndoActivator (Dentsply Sirona)
Coronal 4 3 4 4 4 3.8
Middle 1 1 2 1 2 1.4
Apical 2 2 2 3 2 2.2
Modified Waterpik tooth floss
Coronal 1 1 1 1 1 1.2
Middle 5 4 5 5 5 4.8
Apical 1 1 1 1 2 1.2
Finishing File (Neoendo Healthcare India Pvt. Ltd.)
Coronal 2 1 2 2 2 1.8
Middle 1 1 1 2 1 1.2
Apical 1 2 1 2 1 1.4
No agitation
Coronal 1 2 2 1 1 1.4
Middle 1 2 2 1 1 1.4
Apical 5 4 5 5 5 4.8 Figure 11: Sample 2 apical third

Figure 9: Sample 2 coronal third Figure 12: Sample 3 coronal third

Figure 10: Sample 2 middle third Figure 13: Sample 3 middle third

60 Drug Invention Today | Vol 12 • Special Issue 1 • 2019

 M. Meenapriya and K. Anjaneyulu
Figure 14: Sample 3 apical third
Figure 15: Sample 4 coronal third
In the debridement of the coronal thirds of the root
canal, modified Waterpik tooth floss was efficient
compared to the EndoActivator (Dentsply Sirona) and
Finishing File.
In the debridement of the middle thirds and apical
thirds of the root canal, Finishing File (Neoendo
Healthcare India Pvt. Ltd.) was efficient when
compared to the EndoActivator (Dentsply Sirona) and
modified Waterpik tooth floss.
No group demonstrated the complete debridement of
the root canals.
DISCUSSION
This study focused on the canal cleanliness using three
different agitation techniques. In this study, Finishing
File demonstrated better efficiency in the debridement
of the root canals compared to the other irrigation
activation systems used. Although disinfection and
debridement of the root canal are an essential part
during the root canal treatment procedures, none of
the irrigation activation systems showed complete
Drug Invention Today | Vol 12 • Special Issue 1 • 2019
Figure 16: Sample 4 middle third
Figure 17: Sample 4 apical third
Graph 1: The debris removal in the coronal, middle, and
apical thirds of the root canal
debridement of the root canal in the coronal, middle,
and the apical thirds. The present study also reveals
that, in the coronal thirds, modified Waterpik tooth
floss was effective in debridement, whereas in the
middle and the apical thirds of the root canal, Finishing
File served as better system.
A study conducted for the smear layer removal in the
apical thirds of the mandibular molars revealed that
the EndoActivator (Dentsply Sirona) was efficient
in removing the smear layer, compared to the other
irrigation systems. Comparing the sonic, ultrasonic,
and the manual dynamic activation, sonic irrigation was
61
 M. Meenapriya and K. Anjaneyulu
Table 2: The debridement of coronal, middle, and apical thirds of the root canal
Agitation devices EndoActivator (Dentsply Modified Waterpik
used Sirona) tooth floss
Coronal 3.8
Middle 1.4
Apical 2.2
the most effective method.[7] Comparison of the seven
different agitation techniques in removing smear layer
and debris removal showed that significantly sonic
activation was efficient, but there was no significant
result for the smear layer removal.[8] No irrigation
activation systems were significantly efficient in
the removal of smear layer and debris in the apical
thirds of the root canals.[9] Smear layer removal
ability of different final activation techniques showed
that the Irrisafe removed more smear layer than the
conventional irrigation and the efficiency was better
in the apical thirds of the root canal than the middle
and the coronal thirds.[10]
Evaluation of the smear layer removal efficiency using
the EndoActivator (Dentsply Sirona) and EndoUltra
Activator Systems showed that the EndoUltra had
better efficiency comparatively, but there was no
complete removal of the smear layer from the apical
thirds.[11] Radiographically, passive ultrasonic irrigation
and conventional manual irrigation showed similar
efficiency in root canal cleaning, but the passive
ultrasonic irrigation showed better efficiency with
intermittent flushing.[12] Compared to the manual
irrigation methods, passive ultrasonic irrigation and
EndoVac system showed better efficiency in the main as
well as the lateral canals in the study conducted for the
canal cleanliness using different agitation systems.[13] In
artificial root canals, the sonic and ultrasonic activation
systems were used in the areas of canal irregularities.
When the time of activation increases, the dentin debris
removal increases. No significant differences were
found out than the eddy systems.[14]
In a study conducted for the influence of ultrasonic
activation in association with different final irrigants
on intracanal smear layer, ultrasound (US) can aid
EDTA and QMix in the middle thirds of the root canal
and QMix in the apical thirds of the root canal.[15] For
removing the triple antibiotic paste in the coronal,
middle, and apical thirds of the root canal using the
master file, sonic activation, and canal brush, different
systems served as better efficiency when compared
to the others in each part of the root canal.[16] The
use of auxiliary devices during irrigation to increase
the ability of chelating agent was performed with
ultrasonic activation which showed best performance
when used with QMix.[17] US when used with EDTA
also showed best performance when used in cleaning
the post-space.[18] Similar studies were conducted for
the debris and smear layer removal, dentinal tubule
62
Finishing File (Neoendo No agitation
Healthcare India Pvt. Ltd.)
1.2 1.8 1.4
4.8 1.2 1.4
1.2 1.4 4.8
penetration with novel tricalcium silicate-based sealer
using various irrigation activation systems.[19,20]
CONCLUSION
This study demonstrated the cleanliness of the canal
using three different agitation methods. All the
irrigation activation systems showed different degrees
of effectiveness in the removal of debris from the
root canal. Finishing File (Neoendo Healthcare India
Pvt. Ltd.) showed better debridement of root canal
comparatively. No irrigation system demonstrated the
complete debridement of the root canal. Therefore,
there is a need for the better irrigation protocols for
the complete debris removal in the coronal, middle,
and the apical thirds of the root canal.
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Source of support: Nil; Conflict of interest: None Declared
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