International Endodontic Journa ,105-111
Ultrasound and root canal treatment: the need for scientific
evaluation
A. D, W AhMSLEY Department of Dental Prosthetks, Birmingham Dental School, University of
Birmingham, St Chad's Queensway, Birmingham
Summary. Ultrasound has recently been intro-
duced into endodontics to aid in the biomeclianical
preparation of the root canal. Although there are
numerous investigations into the clinical efficacy of
the endosonic system, there has been a poor under-
standing of the possible role of the biophysical
aspects of ultrasound. Such areas where clarifi-
cation is required are the possible roles of cavitation
and acoustic microstreaming together with the
'synergistic' effect of the combined use of ultra-
sound and irrigant (usually sodium hypochlorite).
Furthermore the oscillation of the file within the
root canal may be prone to the load applied to it and
this will greatly affect its efficiency. The present
article aims to clarify these areas and to provide a
guide to some of the biophysical terms used within
the ultrasound discipline. Further investigations
are required however to understand fully the action
of the instrument, and it is hoped that this article
will provide a basis for a scientific appraisal of
endosonics.
Introduction
Ultrasonics is used commonly in dentistry in
the form of a scaling instrument to remove
deposits from the teeth (Suppipat 1974).
Recently this instrument has been adapted for
use in endodontic procedures. This develop-
ment began with the work of Martin (1976)
and Cunningham et al. (1982a) and has been
termed 'endosonics'. Its use has increased
rapidly in popularity especially over the last
decade (Nehammer & Stock 1985, Stamos et
al. 1985).
Most of the published work on the
endosonic instrument has been directed to-
wards its clinical effectiveness usirig histologi-
cal (Cunningham et al. 1982a, Langeland
et al. 1985), bacteriologieal (Martin 1976,
Correspondence: Dr A.D. Walmsiey, Department
of Dental Prosthetics, Birmingham Dental School,
University of Birmingham, St Chad's Queensway,
Birmingham B4 6NN, UK.
Cunningham et al. 1982b) and microscopic
techniques (Martin et al. 1980b, Cunningham
& Martin 1982, Cameron 1983). This has
centred on its comparison with hand instru-
mentation into the cleaning and filing
efficiency in biomechanical preparation of the
root canal. The majority of investigators indi-
cated the superiority of the instrument over
conventional methods particularly in relation
to its speed of operation (Nehammer & Stock
1985), filing action (Martin et al. 1980a, b) and
the use of an irrigant (Cunningham et al.
1982a). Other studies have suggested that,
foUowing hand or ultrasonic instrumentation,
there is no difference in either the efficacy of
each technique (Weller et al. 1980) or in the
appearance of the root canals (Cymerman et al.
1983). One study has shown that both sonic
and ultrasonic devices were not as effective in
the elimination of bacteria from the root canal
as conventional hand instrumentation
(Barnettrta/. 1985). However the incidence of
postoperative pain following endosonic prep-
aration is less than that experienced following
conventional root canal therapy (Martin &
Cunningham 1982).
The majority of researchers, although
aware of the possible roles of the biophysical
aspects of ultrasound, have not investigated
them. This includes both the roles of cavi-
tation and acoustic microstreaming together
with the 'synergistic' effect of the combined
use of ultrasound and irrigant (usually sodium
hypochlorite). Furthermore there is confusion
over the pattern of oscillation of the tip of the
file as it moves within the root canal. These
factors are complicated further by the range of
instruments available, many of which use dif-
fering methods of ultrasound production.
The present article aims to clarify areas of
confusion that are present and to provide a
guide to some of the biophysical terms used
105
106 A. D. Walmsley
within the ultrasound discipline. In addition
certain areas will be identified where further
investigations are required to understand fully
the action of the instrument and so provide a
basis for a scientific appraisal of endosonics.
The areas of dental interest in endosonics
may be considered under the following head-
ings; production of ultrasound oscillations;
cavitation; acoustic microstreaming, and role
of irrigant. Each of these aspects will be
considered in further detaii.
Production of ultrasound oscillations
Ultrasound is sound energy with a frequency
above the limit of human hearing (usually
taken as 20 kHz) and consists of a wide spec-
trum of frequencies ranging from the kHz to
the MHz range. The higher MHz frequencies
are employed in general medicine, while it is
the kHz range (20-50) that is normally used in
dentistry.
Early work on endosonics (Martin 1976)
resulted in the development of an instrument
which was essentially a direct adaptation of the
ultrasonic sealer utilising the phenomenon of
magneto-striction (electrotnagnetic energy
converted to mechanical energy) to produce
oscillatory action ofafile.During operation an
irrigant solution (sodium hypochlorite) was
passed through a separate channel from a
reservoir over the oscillating file. Other
instruments have also been designed using
piezoelectric principles (crystal deformation
converted to mechanical oscillations), and a
further group of mechanically oscillating
devices was developed with a range of sonic
instruments operating in the arbitrary sonic or
hearing range (i.e. < 20 kHz). Unlike the
ultrasonic instruments, sonic devices rely on
the passage of pressurized air through the
instrument handpiece to produce oscillation of
the working tip. Two such types of these
instruments are in current use; those operating
at around i-A kHz or 16-20 kHz.
The majority of endosotiic instruments
oscillate with a maximum displacement ampli-
tude (half peak to peak excursion) along the
main longitudinal axis of the instrument (Fig.
la). However, the endodontic file is inserted
near to the end of the main instrument and is
set at an angle of 60-90° to the main longi-
todinal axis of the instrument. Accordingly,
(bl
Fig. 1. (a) Diagrammatic representation of anendo-
sonic instrument showing the main longitudinal
oscillation (L)occurring along the main axis. The file
is at right angles to the main instrument and subse-
quently a transverse oscillation (T) is set up along its
length, (b) The transverse oscillation of the file con-
sists of antinodes (A) where the greatest oscillation
occurs and nodes (N) where minimal oscillation
occurs. The tip of the file is unconstrained and
exhibits a large oscillation.
during operation the file wili oscillate in a
transverse rather than longitudinal manner
(Fig. Ib). This type of oscillation sets up a
characteristic pattern of nodes, where little or
no displacement occurs, and antinodes where
maximum displacement of the file is present.
As the working dp of thefileis unconstrained
the greatest displacement from rest will occur
at this position. The arrangement of the node-
antinode pattern and the displacement ampli-
tudes will he dependent however on the fre-
quency at which the instrument is being
driven, together with the design and type of
file employed. It may be expected therefore
that different machities together with different
files may exhibit different patterns of oscil-
lation. This occurrence has been demon-
strated previously within ultrasonic scaling
instruments (Walmsley et al. 1986b).
Two types of file designs are used with the
endosonic instrtiment. The geometry of the
K-files equates with the measurements and

dimensions of normal hand instruments. The
diamond-coated files have been specially
designed for use with the instrument. Both are
inserted into the driver and expected to pro-
duce a standard oscillatory pattern. It is not
unreasonable to deduce however that a'ny
change in length or thickness of the file will
affect the nature of the oscillatory pattern, a
topic that is currently under investigation.
Afinalconsideration on the oscillatingfileis
that the nodes are also points at which the
greatest mechanical strain occurs. Therefore
prolonged use of thefilemay result in fracture
of the file due to metal fatigue. If such fracture
were to occur it is likely to present at the node
nearest to the tip as this will have the greatest
strain placed on it. Obviously the fracture of
instruments may have serious chnical conse-
quences and such probiems of instrument
fracture have already been reported (ChenaiJ
&Teplitsky 1985).
Filing action
The instrument is designed primarily to file
mechnically the wails of the root canal. Hand
instruments are used generally in a longi-
tudinai direction,filingbeing achieved by con-
tact of the instrument with the walls of the
canal on its withdrawal. The endosonic file
however oscillates transversely and this may
result in irregular cutting of the dentine.
However such oscillation of the file within the
root canal will be dependent upon another
important factor, namely the load applied to
the file.
During operation of the endosonic instru-
ment most of the energy is delivered in the
longitudinal mode along the main axis of the
instrument. There is, however, an energy
phase change where some of the longitudinal
energy is converted into the transverse mode
along the length of the oscillatingfile(Fig. la).
The energy contained in this transverse mode
is low and consequently the file can be pre-
vented from oscillating if a small load is
applied. The reduction in oscillation ampli-
tude will be dependent upon the magnitude of
the load and its point or area of application.
However it is unlikely that the loading will
effect the longitudinal oscillation of the main
instrument. In this respect it is possible that
such loading may account for the occasional
Ultrasound and root canal treatment 107
inefficiency of the system when negotiating
constrictions or curved canals (Goodman et al.
1985), although workers suggest that the
instrument can file curved canals adequateiy
(Chenail & Tepiitsky 1985). Furthermore, as
explained earlier, the greatest displacement
amplitude will occur at the tip with the
greatest filing action occurring at the apical
third. Initially thefilewili be loaded within the
canai which wili result in a small osciilation at
the apex. However as thefiieenlarges the canal
then the apical oscillation will slowly increase.
This may potentially lead to over flaring of
the apex (zipping) and this may explain the
occurrence of zipping previously reported
when using such instruments (Stamos et al.
1985).
Cavitation
During operation of the endosonic file, water
or an irrigant such as sodium h3^ochlorite is
passed over the oscillating tip. It is suggested
that cavitation generated by movement of the
file occurs within this water supply, and this is
claimed to be one of the main beneficial effects
of the endosonic instrument (Martin 1976,
Cunningham ff a/. 1982a, b).
The term cavitation or 'cavitational activity'
encompasses all of the linear and non-linear
oscillatory motions of gas and/or vapour-filled
bubbles in an acoustic field. These motions
may vary within one acoustic cycle from stable
cavitation, where bubbles are oscillating with-
out fragmentation, to transient cavitation,
where there is rapid growth and collapse of the
bubble (Flynn 1964, Nyborg 1977, Williams
1983). These bubbles are powered by the
energy from the incident ultrasonicfield.Most
of the energy released from their oscillations is
converted irreversibly into heat and hydro-
dynamic shear fields which are able to disrupt
biological tissues (Nyborg 1977, Williams
1983). Transient cavitation is the more violent
form where supersonic contraction of the
bubbles generates large shock waves, together
with the development of extremely high tem-
peratures and pressures within the bubble
(Noitingk & Neppiras 1950). This may result
in pyrolytic breakdown of water and the pro-
duction of free radicals (H and OH) which
may pose a significant biological hazard by
108 A. D. Walmsley
reacting with biological tissues (El' Piner
1964).
Cavitational activity as described above can
readily be demonstrated within the cooling
water supply of the ultrasonic sealer
(Walmsley et al. 1986a). In this situation the
'damaging' effects of cavitation are useful
during scaling procedures to remove solid
deposits from tooth surfaces (Walmsley et al.
1984).
Although it is theoretically possible that
transient cavitational activity may occur with
the endosonic instrument, it is unlikely that
sufficiently high sound pressure fields occur
around the oscillating file. The broad oscillat-
ing tip of the ultrasonic sealer produces a high
sound pressure field enabling cavitational
activity to occur. Although oscillating at simi-
lar displacement amplitudes the narrow and
more streamlined endosonic file is less able to
generate a sound pressurefieldlarge enough to
produce transient cavitation.
Preliminary results on the measurement of
cavitational activity occurring around the
endosonic file have suggested that little or no
transient cavitation is occurring (Ahmad et al.
1986). However further conclusive studies are
necessary in this respect, particularly due to
the emphasis placed on cavitation and its
beneficial effects when using the endosonic
system (Martin 1976, Cunningham 1982a, b).
Acoustic microstreaming
When a wire oscillating at a relatively low dis-
placement amplitude is immersed in a liquid,
complex steady-state (non-oscillatory)
streaming patterns are formed close to the
wire. This is a second order effect of the sound
field and is termed acousting microstreaming
(Nyborg 1965). The characteristic pattern of
these flows of liquid is shown diagrammati-
cally in Fig. 2 and consists of inner and outer
vortices (adapted from Hoitzmark et al. 1954).
The dimension of the inner vortices is approx-
imately 4|xm in water at an ultrasonic fre-
quency of 20 kHz. These snnall dimensions
mean that the velocity gradients (i.e. the rate of
change of velocity with distance) and hence
the hydrodynamic shear stresses are large even
though the actual streaming velocities which
produce them are relatively low (of the order
of a few centimetres per second). Therefore
Fig. 2. A diagrammatic representation of the
acoustic microstreamingfieldthat may be generated
around the tip ofa transversely oscillating ultrasonic
(endosonic) file (F) (adapted from Hoitzmark et al.
1954). The dimension of the inner vortices (V) is
about 4 (im at an ultrasonic frequency of 20 kHz.
any biological material that enters these
streaming fields will be subjected to large
shear stresses and may possibly be damaged.
It has been previously shown that acoustic
microstreaming may disrupt deoxyribonucleic
acid (Williams 1974), disaggregate bacteria
(Williams & Slade 1971), inactivate enzymes
(Kashkooli et al. 1980) and produce a variety
of effects in many biological systems (Rooney
1972). Furthermore it has also been demon-
strated that both human erj'throcytes and
platelets may be disrupted by microstreaming
fields both in vitro and in vivo (Williams et al.
1970, Williams 1977).
The oscillating file in the endosonic system
will also produce streaming fields along its
length, with the greatest shear stress being
generated around points of maximum dis-
placement such as the tip of the file and the
antinodes along its length (Williams et al.
1970). These streaming fields are iikely
to be responsible for many of the beneficial
effects attributed to the use of endosonics
(Cunningham etal. 1982a) and will be import-
ant in moving the associated irrigant around
the root canal. However the efficiency of such
forces will he dependent upon the amount of
damping which occurs when the instrument is
working within the canal. The phenomenon of
acoustic microstreaming and its potential

beneficial cleaning effects are an important
area for further investigation in endosonics.
Role of irrigant
An essential part of many of the endosonic
systems is the role of the irrigant that flows
over the oscillating file (Cunningham et at.
1982a). The most widely used irrigant appears
to be sodium hypochlorite with a concen-
tration varying from 1 to 5.5 per cent (Martin,
1976, Cunningham et at. 1982a, Cameron
1983, Langeland et al. 1985,, Griffiths & Stock
1986). However, some endosonic instruments
have not been designed to be resistant to the
corrosive nature of sodium hypochlorite, and
their manufacturers therefore recommend
water.
The optimal concentration of sodium
hypochlorite appears to be around 2-3 per
cent (Cunningham et al. 1982a, Griffiths &
Stock 1986) and this is sufficient to act as both
a lubricant and a bactericidal solution. The
action of the irrigant and the biophysical
effects of the ultrasound (cavitation, acoustic
microstreaming, thermal) are presumed to be
'synergistic' (Martin 1976).
Initial studies have shown that the hypo-
chlorite solution is more effective when used in
conjunction with the endosonic system com-
pared with its use with hand instrumentation
(Cunningham et al. 1982a, Langeland et al.
1985). Furthermore hs'pochlorite solution at a
concentration of 2.6 per cent appears to be a
superior irrigant when compared with the use
of Solvidont (bisdequaiinium acetate) or water
(Griffiths & Stock 1986).
The frictional contact between the canal
wall and the oscillating file produces heat
which will in turn warm the hypochlorite and
enhance its activity (Cunningham et al. 1980,
1982a, b). In addition the role of acoustic
microstreaming produced by the oscillating
file may further enhance the activity of the
hypochlorite solution by moving it around the
canal continuously, disaggregating bacteria
and removing debris from the walls. Such
actions of the ultrasound will of course be
dependent upon the oscillating nature of the
file within the canal. If there is appreciahle
loading for instance then the 'synergistic'
action of endosonics will be severely limited.
Ukmsound and root canai treatment 109
Furthermore it is not clear whether the irri-
gant solution reaches the oscillating tip within
the canal and whether there is sufficient circu-
latory movement and replenishment of the
solution during operation, with recent evi-
'dence suggesting that the irrigant is slow to
provide apical irrigation (Krell & Johnson
1986).
Conclusion
Certain characteristics of the action of endo-
sonics have been identified. However further
investigations are needed to improve the
understanding of its operation. These may be
summarized as follows:
(i) The file oscillates in the transverse
mode exhibiting points of maximum
displacement (antinodes) and points of
minimum displacement (nodes). The
greatest oscillation of the file occurs at
the tip. Such oscillation may vary with
both the instrument power setting and
between different instruments. The
oscillation of the file merits further
research.
The file's efficiency is reduced by the
load applied to it and further work is
needed to evaluate this effect during
root canal therapy.
If a filing action is to be the primary
way of using the instrument, then it
may require redesigning to produce a
longitudinal osciilation which is not
prone to the effects of such loading,
(ii) Present evidence suggests that little
if any of the destructive effects of
cavitation are present during instru-
ment operation.
(iii) Acoustic microstreaming will be effec-
tive during use of the endosonic system.
This is achieved by the continual move-
ment of irrigant around the canal which
may potentially disrupt/disaggregate
bacteria and debris thus cleaning the
canal walls. Its effectiveness will depend
upon the oscillation of thefilewithin the
root canal and will be reduced as loading
occurs.
(iv) The role of the irrigant appears to be
important in increasing the effectiveness
of the system. The irrigant of choice is a
2-3 per cent solution of sodium hypo-
no A.D. Walmsley
chlorite. Although the soiution is effec-
tive when used alone its activity appears
to be increased when passed over the
oscillating wire. However the effective-
ness of the endosonic system in irri-
gating the entire length of the canal
(especiaily the apicai third) requires
further consideration.
Acknowledgements
The author wishes to thank Professor W.R.E.
Laird and Dr A.R. Wiiliams for their assist-
ance in the preparation of this paper.
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