Skip to main content
SpringerLink
Log in

Clinical and microbiological effects of ultrasonically activated irrigation versus syringe irrigation during endodontic treatment: a systematic review and meta-analysis of randomized clinical trials

  • Original Article
  • Published:
Odontology Aims and scope Submit manuscript

Abstract

This study aimed to systematically review clinical and microbiology-related effects of ultrasonically activated irrigation (UAI) compared to syringe irrigation (SI) during endodontic treatment. Electronic databases searching and manual searching were conducted. Only randomized clinical trials (RCTs) were included comparing UAI to SI. The RoB 2.0 Cochrane tool was used for risk-of-bias (RoB) assessment. The main outcomes were postoperative pain, treatment failure, and microbiology-related outcomes. Qualitative and quantitative analyses, wherever applicable, were performed. Risk ratios (RR) and [standardized] mean differences {[S]MD} were calculated for dichotomous and continuous outcomes, respectively. Certainty of evidence (CoE) was assessed using GRADE tool. Ten RCTs were included. UAI reduced pain incidence within the first 24 h (RR 0.50, 95% CI 0.35–0.71, 308 teeth) and microbial counts (SMDpooled − 0.40, 95% CI [− 0.78, − 0.02], I2 = 0%, 126 teeth) than SI in non-vital teeth with apical periodontitis (AP). Both groups, however, had similar effects regarding pain intensity, lipopolysaccharide amounts, and the incidence of rescue-analgesic intake, treatment failure, and microbial presence (p > 0.05). CoE ranged from low to very low. Very limited evidence suggests that UAI could reduce postoperative-pain risk within the first 24 h and microbial counts for non-vital teeth with AP compared to SI. Most meta-analyses, however, are based on very few studies, mostly low-powered, with an overall very-low-to-low CoE. Further well-designed, larger RCTs are, thus, required.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12

Similar content being viewed by others

References

  1. Siqueira JF Jr, Rôças IN. Bacterial pathogenesis and mediators in apical periodontitis. Braz Dent J. 2007;18:267–80.

    Article  PubMed  Google Scholar 

  2. Ricucci D, Siqueira JF. Biofilms and apical periodontitis: study of prevalence and association with clinical and histopathologic findings. J Endod. 2010;36:1277–88.

    Article  PubMed  Google Scholar 

  3. Martinho FC, de Rabello DGD, Ferreira LL, Nascimento GG. Participation of endotoxin in root canal infections: a systematic review and meta-analysis. Eur J Dent. 2017;11:398–406.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J. 1997;30:297–306.

    Article  PubMed  Google Scholar 

  5. Nair PNR. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med. 2004;15:348–81.

    Article  PubMed  Google Scholar 

  6. Siqueira JF Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod. 2008;34:1291–301.

    Article  PubMed  Google Scholar 

  7. Haapasalo M, Shen Y, Ricucci D. Reasons for persistent and emerging post-treatment endodontic disease. Endod Topics. 2011;18:31–50.

    Article  Google Scholar 

  8. Hong CY, Lin SK, Kok SH, Cheng SJ, Lee MS, Wang TM, Chen CS, Lin LD, Wang JS. The role of lipopolysaccharide in infectious bone resorption of periapical lesion. J Oral Pathol Med. 2004;33:162–9.

    Article  PubMed  Google Scholar 

  9. Estrela C, Holland R, Estrela CR, Alencar AHG, Sousa-Neto MD, Pécora JD. Characterization of successful root canal treatment. Braz Dent J. 2014;25:3–11.

    Article  PubMed  Google Scholar 

  10. Căpută PE, Retsas A, Kuijk L, de Paz LEC, Boutsioukis C. Ultrasonic irrigant activation during root canal treatment: a systematic review. J Endod. 2019;45:31–44.

    Article  PubMed  Google Scholar 

  11. Decurcio DA, Rossi-Fedele G, Estrela C, Pulikkotil SJ, Nagendrababu V. Machine-assisted agitation reduces postoperative pain during root canal treatment: a systematic review and meta-analysis from randomized clinical trials. J Endod. 2019;45:387–93.

    Article  PubMed  Google Scholar 

  12. Ruksakiet K, Hanák L, Farkas N, Hegyi P, Sadaeng W, Czumbel LM, Sang-ngoen T, Garami A, Mikó A, Varga G, Lohinai Z. Antimicrobial efficacy of chlorhexidine and sodium hypochlorite in root canal disinfection: a systematic review of randomized controlled trials. J Endod. 2020;46:1032–41.

    Article  PubMed  Google Scholar 

  13. Nair PNR, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99:231–52.

    Article  PubMed  Google Scholar 

  14. van der Sluis LW, Versluis M, Wu MK, Wesselink PR. Passive ultrasonic irrigation of the root canal: a review of the literature. Int Endod J. 2007;40:415–26.

    Article  PubMed  Google Scholar 

  15. Gu L, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. Review of contemporary irrigant agitation techniques and devices. J Endod. 2009;35:791–804.

    Article  PubMed  Google Scholar 

  16. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod. 2004;30:559–67.

    Article  PubMed  Google Scholar 

  17. Tay FR, Gu L-S, Schoeffel GJ, Wimmer C, Susin L, Zhang K, Arun SN, Kim J, Looney SW, Pashley DH. Effect of vapor lock on root canal debridement by using a side-vented needle for positive-pressure irrigant delivery. J Endod. 2010;36:745–50.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Paqué F, Boessler C, Zehnder M. Accumulated hard tissue debris levels in mesial roots of mandibular molars after sequential irrigation steps. Int Endod J. 2011;44:148–53.

    Article  PubMed  Google Scholar 

  19. Boutsioukis C, van der Sluis LW. Syringe irrigation: blending endodontics and fluid dynamics. In: Basrani B, editor. Endodontic irrigation: chemical disinfection of the root canal system. New York: Springer; 2015. p. 45–64.

    Chapter  Google Scholar 

  20. De-Deus G, Belladonna FG, Silva EJNL, Marins JR, Souza EM, Perez R, Lopes RT, Versiani MA, Paciornik S, Neves AA. Micro-CT evaluation of non-instrumented canal areas with different enlargements performed by NiTi systems. Braz Dent J. 2015;26:624–9.

    Article  PubMed  Google Scholar 

  21. Martins JNR, Marques D, Silva EJNL, Caramês J, Versiani MA. Prevalence studies on root canal anatomy using cone-beam computed tomography imging: a systematic review. J Endod. 2019;4:372–86.

    Article  Google Scholar 

  22. Haapasalo M, Shen Y, Qian W, Gao Y. Irrigation in endodontics. Dent Clin North Am. 2010;54:291–312.

    Article  PubMed  Google Scholar 

  23. Dutner J, Mines P, Anderson A. Irrigation trends among American Association of Endodontists members: a web-based survey. J Endod. 2012;38:37–40.

    Article  PubMed  Google Scholar 

  24. Virdee SS, Ravaghi V, Camilleri J, Cooper P, Tomson P. Current trends in endodontic irrigation amongs general dental practitioners and dental schools within the United Kingdom and Ireland: a cross-sectional survey. Br Dent J. 2020. https://doi.org/10.1038/s41415-020-1984-x.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Yaylali IE, Kececi AD, Kaya BU. Ultrasonically activated irrigation to remove calcium hydroxide from apical third of human root canal system: a systematic review of in vitro studies. J Endod. 2015;41:1589–99.

    Article  PubMed  Google Scholar 

  26. Virdee SS, Seymour DW, Farnell D, Bhamra G, Bhakta S. Efficacy of irrigant activation techniques in removing smear layer and debris from mature permanent teeth: a systematic review and meta-analysis. Int Endod J. 2018;51:605–21.

    Article  PubMed  Google Scholar 

  27. Nagendrababu V, Jayakumar J, Suresh A, Kalyanasundaram S, Neelakantan P. Effectiveness of ultrasonically activated irrigation on root canal disinfection: a systematic review of in vitro studies. Clin Oral Investig. 2018;22:655–70.

    Article  PubMed  Google Scholar 

  28. Moreira RN, Pinto EB, Galo R, Falci SGM, Mesquita AT. Passive ultrasonic irrigation in root canal: systematic review and meta-analysis. Acta Odontol Scand. 2019;77:55–60.

    Article  PubMed  Google Scholar 

  29. Johnson KL. A comparison of the effectiveness of three irrigation methods in the removal of bacteria from root canals following instrumentation [Dissertation]. Chapel Hill, USA: University of North Carolina; 2011. https://cdr.lib.unc.edu/concern/dissertations/j96021477. Last Accessed 8 Aug 2021

  30. Liang YH, Jiang LM, Jiang L, Chen XB, Liu YY, Tian FC, Bao XD, Gao XJ, Versluis M, Wu MK, van der Sluis L. Radiographic healing after a root canal treatment performed in single-rooted teeth with and without ultrasonic activation of the irrigant: a randomized controlled trial. J Endod. 2013;39:1218–25.

    Article  PubMed  Google Scholar 

  31. Tang Z, Wang H, Jiang S. Clinical study of single-visit root canal treatment with a nickel-titanium (Ni–Ti) rotary instrument combined with different ultrasonic irrigation solutions for elderly patients with chronic apical periodontitis. Biomed Mater Eng. 2015;26(Suppl 1):s311–8.

    PubMed  Google Scholar 

  32. Jain A, Bahuguna R, Kashyap S, Ali A. Incidence of post endodontic pain after single visit root canal treatment with manual, rotary and rotary instruments with ultrasonic cleaning: a comparative study. Saudi J Oral Dent Res. 2017;4:102–9.

    Article  Google Scholar 

  33. Middha M, Sangwan P, Tewari S, Duhan J. Effect of continuous ultrasonic irrigation on postoperative pain in mandibular molars with nonvital pulps: a randomized clinical trial. Int Endod J. 2017;50:522–30.

    Article  PubMed  Google Scholar 

  34. Nakamura VC, Pinheiro ET, Prado LC, Silveira AC, Carvalho APL, Mayer MPA, Gavini G. Effect of ultrasonic activation on the reduction of bacteria and endotoxins in root canals: a randomized clinical trial. Int Endod J. 2018;51(Suppl 1):e12–22.

    Article  PubMed  Google Scholar 

  35. Topcuoğlu HS, Topcuoğlu G, Arslan H. The effect of different irrigation agitation techniques on postoperative pain in mandibular molar teeth with symptomatic irreversible pulpitis: a randomized clinical trial. J Endod. 2018;44:1451–6.

    Article  PubMed  Google Scholar 

  36. Orozco EIF, Toia CC, Cavalli D, Khoury RD, Cardoso FGR, Bresciani E, Valera MC. Effect of passive ultrasonic activation on microorganisms in primary canal infection: a randomized clinical trial. J Appl Oral Sci. 2020;28:e20190100.

    Article  PubMed  Google Scholar 

  37. de Aveiro E, Chiarelli-Neto VM, de-Jesus-Soares A, Zaia AA, Ferraz CCR, Almeida JFA, Marciano MA, Gomes BPFA. Efficacy of reciprocating and ultrasonic activation of 6% sodium hypochlorite in the reduction of microbial count and virulence factors in teeth with primary endodontic infection. Int Endod J. 2020;53:604–18.

    Article  PubMed  Google Scholar 

  38. Ballal NV, Gandhi P, Shenoy PA, Dummer PMH. Evaluation of various irrigation activation systems to eliminate bacteria from the root canal system: a randomized controlled single blinded trial. J Dent. 2020;99:103412.

    Article  PubMed  Google Scholar 

  39. Verma A, Yadav RK, Tikku AP, Chandra A, Verma P, Bharti R, Shakya VK. A randomized controlled trial of endodontic treatment using ultrasonic irrigation and laser activated irrigation to evaluate healing in chronic apical periodontitis. J Clin Exp Dent. 2020;12:e821–9.

    Article  PubMed Central  PubMed  Google Scholar 

  40. Gündoğar M, Sezgin GP, Kaplan SS, Özyürek H, Uslu G, Özyürek T. Postoperative pain after different irrigation activation techniques: a randomized, clinical trial. Odontology. 2021;109:385–92.

    Article  PubMed  Google Scholar 

  41. Silva EJNL, Rover G, Belladonna FG, Herrera DR, De-Deus G, Fidalgo TKS. Effectiveness of passive ultrasonic irrigation on periapical healing and root canal disinfection: a systematic review. Br Dent J. 2019;227:228–34.

    Article  PubMed  Google Scholar 

  42. Susila A, Minu J. Activated irrigation vs conventional non-activated irrigation in endodontics—a systematic review. Eur Endod J. 2019;3:96–110.

    Google Scholar 

  43. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Loannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62:e1–34.

    Article  PubMed  Google Scholar 

  44. Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

    Article  PubMed  Google Scholar 

  45. McGrath S, Zhao X, Steele R, Thombs BD, Benedetti A, DEPRESsion Screeing Data (DEPRESSD) Collaboration. Estimating the sample mean and standard deviation from commonly reported quantiles in meta-analysis. Stat Methods Med Res. 2020;29:2520–37.

    Article  Google Scholar 

  46. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (2021) Cochrane handbook for systematic reviews of interventions version 6.2 (updated February 2021). Cochrane: Available from www.training.cochrane.org/handbook. Accessed 10 Aug 2021.

  47. Manfredi M, Figini L, Gagliani M, Lodi G. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst Rev. 2016;12:CD005296.

    PubMed  Google Scholar 

  48. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:869.

    Article  Google Scholar 

  49. Pildal J, Hróbjartsson A, Jørgensen KJ, Hilden J, Altman DG, Gøtzsche PC. Impact of allocation concealment on conclusions drawn from meta-analyses of randomized trials. Int J Epidemiol. 2007;36:847–57.

    Article  PubMed  Google Scholar 

  50. Siqueira JF, Rôças IN. Diversity of endodontic microbiota revisited. J Dent Res. 2009;88:969–81.

    Article  PubMed  Google Scholar 

  51. Rogers GB, Marsh P, Stressmann AF, Allen CE, Daniels TVW, Carroll MP, Bruce KD. The exclusion of dead bacterial cells is essential for accurate molecular analysis of clinical samples. Clin Microbiol Infect. 2010;16:1656–8.

    Article  PubMed  Google Scholar 

  52. Teles AM, Manso MC, Loureiro S, Silva R, Madeira IGC, Pina C, Cabeda JM. Effectiveness of two intracanal dessings in adult Portuguese patients: a qPCR and anaerobic culture assessment. Int Endod J. 2014;47:32–40.

    Article  PubMed  Google Scholar 

  53. Siqueira JF Jr, Rôças IN. Polymerase chain reaction–based analysis of microorganisms associated with failed endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:85–94.

    Article  PubMed  Google Scholar 

  54. Sathorn C, Parashos P, Messer HH. How useful is root canal culturing in predicting treatment outcome? J Endod. 2007;33:220–5.

    Article  PubMed  Google Scholar 

  55. Chen JE, Nurbakhsh B, Layton G, Bussmann M, Kishen A. Irrigation dynamics associated with positive pressure, apical negative pressure and passive ultrasonic irrigations: a computational fluid dynamics analysis. Aust Endod J. 2014;40:54–60.

    Article  PubMed  Google Scholar 

  56. Vier FV, Figueiredo JAP. Prevalence of different periapical lesions associated with human teeth and their correlation with the presence and extension of apical external root resorption. Int Endod J. 2002;35:710–9.

    Article  PubMed  Google Scholar 

  57. Salzgeber RM, Brilliant JD. An in vivo evaluation of the penetration of an irrigating solution in root canals. J Endod. 1977;3:394–8.

    Article  PubMed  Google Scholar 

  58. Seltzer S. Pain in endodontics. J Endod. 1986;12:505–7.

    Article  PubMed  Google Scholar 

  59. Siqueira JF Jr, Barnett F. Interappointment pain: mechanisms, diagnosis, and treatment. Endod Topics. 2004;7:93–109.

    Article  Google Scholar 

  60. Glennon JP, Ng Y-L, Setchell DJ, Gulabivala K. Prevalence of and factors affecting postpreparation pain in patients undergoing two-visit root canal treatment. Int Endod J. 2004;37:29–37.

    Article  PubMed  Google Scholar 

  61. Ng Y-L, Glennon JP, Setchell DJ, Gulabivala K. Prevalence of and factors affecting post-obturation pain in patients undergoing root canal treatment. Int Endod J. 2004;37:381–91.

    Article  PubMed  Google Scholar 

  62. Arias A, de la Macorra JC, Hidalgo JJ, Azabal M. Predictive models of pain following root canal treatment: a prospective clinical study. Int Endod J. 2013;46:784–93.

    Article  PubMed  Google Scholar 

  63. Law AS, Nixdorf DR, Aguirre AM, Reams GJ, Toromasi AJ, Manne BD, Harris DR, National Dental PBRN Collaborative Group. Predicting severe pain after root canal therapy in the national dental PBRN. J Dent Res. 2015;94:37–43.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Endodontics, Faculty of Dentistry, Cairo University, 11 ElSaraya Street, ElManyal, Cairo, 11553, Egypt

    Noha Tawfik Ali, Randa Mohamed El-Boghdadi, Ahmed Mohamed Ibrahim & Suzan Abdul Wanees Amin

Authors
  1. Noha Tawfik Ali
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Randa Mohamed El-Boghdadi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ahmed Mohamed Ibrahim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Suzan Abdul Wanees Amin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Suzan Abdul Wanees Amin.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ali, N.T., El-Boghdadi, R.M., Ibrahim, A.M. et al. Clinical and microbiological effects of ultrasonically activated irrigation versus syringe irrigation during endodontic treatment: a systematic review and meta-analysis of randomized clinical trials. Odontology 110, 419–433 (2022). https://doi.org/10.1007/s10266-021-00671-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10266-021-00671-8

Keywords

Search

Navigation