Efficacy of Needle Irrigation, EndoActivator, and Photon-initiated Photoacoustic Streaming Technique on Removal of Double and Triple Antibiotic Pastes

Published:April 14, 2014DOI:



      Photon-induced photoacoustic streaming (PIPS) is a novel technique used for the removal of material on root canal walls, such as bacteria and the smear layer. This study evaluated the efficacy of needle irrigation, the EndoActivator System (Dentsply Tulsa Dental Specialties, Tulsa, OK), and PIPS on the removal of antibiotic pastes from an artificial groove created in a root canal.


      Root canal preparation was performed up to size #40 on 84 extracted single-rooted teeth using ProTaper rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland). The specimens were then split longitudinally, and 2 standardized grooves were prepared in the coronal and apical part of each segment. Double (DAP) and triple antibiotic pastes (TAP) were placed in the grooves for 4 weeks, and the root halves were reassembled. Needle irrigation, the EndoActivator System, and PIPS were used for the removal of DAP and TAP. The root segments were disassembled, and the amount of remaining antibiotic pastes was evaluated under a stereomicroscope at 20× magnification using a 4-grade scoring system. The data were evaluated statistically using Mann-Whitney U tests with a 95% confidence level (P = .05).


      PIPS removed significantly more antibiotic pastes than the EndoActivator and needle irrigation (P < .001). The EndoActivator was superior to needle irrigation in removing antibiotic pastes (P < .001). There were no statistically significant differences between DAP and TAP and between coronal and apical thirds in their removing from artificially created grooves (P > .05).


      PIPS was more effective in removing both DAP and TAP from artificial grooves in root canals than the EndoActivator System and needle irrigation. The EndoActivator was also more effective than needle irrigation. It is difficult to completely remove antibiotic pastes from root canals.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Endodontics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bezgin T.
        • Yilmaz A.D.
        • Celik B.N.
        • et al.
        Concentrated platelet-rich plasma used in root canal revascularization: 2 case reports.
        Int Endod J. 2014; 47: 41-49
        • Er K.
        • Kustarci A.
        • Ozan U.
        • et al.
        Nonsurgical endodontic treatment of dens invaginatus in a mandibular premolar with large periradicular lesion: a case report.
        J Endod. 2007; 33: 322-324
        • Sato I.
        • Ando-Kurihara N.
        • Kota K.
        • et al.
        Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in situ.
        Int Endod J. 1996; 29: 118-124
        • Hoshino E.
        • Kurihara-Ando N.
        • Sato I.
        • et al.
        In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline.
        Int Endod J. 1996; 29: 125-130
        • Thibodeau B.
        • Teixeira F.
        • Yamauchi M.
        • et al.
        Pulp revascularization of immature dog teeth with apical periodontitis.
        J Endod. 2007; 33: 680-689
        • Gomes-Filho J.E.
        • Duarte P.C.
        • de Oliveira C.B.
        • et al.
        Tissue reaction to a triantibiotic paste used for endodontic tissue self-regeneration of nonvital immature permanent teeth.
        J Endod. 2012; 38: 91-94
        • Kim J.H.
        • Kim Y.
        • Shin S.J.
        • et al.
        Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: a case report.
        J Endod. 2010; 36: 1086-1091
        • Miller E.K.
        • Lee J.Y.
        • Tawil P.Z.
        • et al.
        Emerging therapies for the management of traumatized immature permanent incisors.
        Pediatr Dent. 2012; 34: 66-69
        • Iwaya S.I.
        • Ikawa M.
        • Kubota M.
        Revascularization of an immature permanent tooth with apical periodontitis and sinus tract.
        Dent Traumatol. 2001; 17: 185-187
        • Hargreaves K.M.
        • Diogenes A.
        • Teixeira F.B.
        Treatment options: biological basis of regenerative endodontic procedures.
        J Endod. 2013; 39: S30-S43
        • Ruparel N.B.
        • Teixeira F.B.
        • Ferraz C.C.
        • et al.
        Direct effect of intracanal medicaments on survival of stem cells of the apical papilla.
        J Endod. 2012; 38: 1372-1375
        • Akcay M.
        • Arslan H.
        • Yasa B.
        • et al.
        Spectrophotometric analysis of crown discoloration induced by various antibiotic pastes used in revascularization.
        J Endod. 2014; 40: 845-848
        • DiVito E.
        • Lloyd A.
        ER: YAG laser for 3-dimensional debridement of canal systems: use of photon-induced photoacoustic streaming.
        Dent Today. 2012; 31: 4-7
        • DiVito E.
        • Peters O.A.
        • Olivi G.
        Effectiveness of the erbium:YAG laser and new design radial and stripped tips in removing the smear layer after root canal instrumentation.
        Lasers Med Sci. 2012; 27: 273-280
        • Peeters H.H.
        • Suardita K.
        Efficacy of smear layer removal at the root tip by using ethylenediaminetetraacetic acid and erbium, chromium: yttrium, scandium, gallium garnet laser.
        J Endod. 2011; 37: 1585-1589
        • Peeters H.H.
        • Mooduto L.
        Radiographic examination of apical extrusion of root canal irrigants during cavitation induced by Er,Cr:YSGG laser irradiation: an in vivo study.
        Clin Oral Investig. 2013; 17: 2105-2112
        • Zhu W.
        • Zhu X.
        • Huang G.T.
        • et al.
        Regeneration of dental pulp tissue in immature teeth with apical periodontitis using platelet-rich plasma and dental pulp cells.
        Int Endod J. 2013; 46: 962-970
        • Tawfik H.
        • Abu-Seida A.M.
        • Hashem A.A.
        • et al.
        Regenerative potential following revascularization of immature permanent teeth with necrotic pulps.
        Int Endod J. 2013; 46: 910-922
        • Utneja S.
        • Garg G.
        • Arora S.
        • et al.
        Nonsurgical endodontic retreatment of advanced inflammatory external root resorption using mineral trioxide aggregate obturation.
        Case Rep Dent. 2012; 2012: 624-792
        • Arslan H.
        • Capar I.D.
        • Saygili G.
        • et al.
        Efficacy of various irrigation protocols on the removal of triple antibiotic paste.
        Int Endod J. 2013; ([Epub ahead of print])
        • Alfredo E.
        • Souza-Gabriel A.E.
        • Silva S.R.
        • et al.
        Morphological alterations of radicular dentine pretreated with different irrigating solutions and irradiated with 980-nm diode laser.
        Microsc Res Tech. 2009; 72: 22-27
        • Pedulla E.
        • Genovese C.
        • Campagna E.
        • et al.
        Decontamination efficacy of photon-initiated photoacoustic streaming (PIPS) of irrigants using low-energy laser settings: an ex vivo study.
        Int Endod J. 2012; 45: 865-870
        • van der Sluis L.W.
        • Wu M.K.
        • Wesselink P.R.
        The evaluation of removal of calcium hydroxide paste from an artificial standardized groove in the apical root canal using different irrigation methodologies.
        Int Endod J. 2007; 40: 52-57
        • Estrela C.
        • Holland R.
        • Bernabe P.F.
        • et al.
        Antimicrobial potential of medicaments used in healing process in dogs' teeth with apical periodontitis.
        Braz Dent J. 2004; 15: 181-185
        • Nair P.N.
        On the causes of persistent apical periodontitis: a review.
        Int Endod J. 2006; 39: 249-281
        • Athanassiadis B.
        • Abbott P.V.
        • Walsh L.J.
        The use of calcium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics.
        Aust Dent J. 2007; 52: S64-S82
        • Bystrom A.
        • Claesson R.
        • Sundqvist G.
        The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals.
        Endod Dent Traumatol. 1985; 1: 170-175
        • Kusgoz A.
        • Yildirim T.
        • Er K.
        • et al.
        Retreatment of a resected tooth associated with a large periradicular lesion by using a triple antibiotic paste and mineral trioxide aggregate: a case report with a thirty-month follow-up.
        J Endod. 2009; 35: 1603-1606
        • Taneja S.
        • Kumari M.
        Use of triple antibiotic paste in the treatment of large periradicular lesions.
        J Investig Clin Dent. 2012; 3: 72-76
        • Banchs F.
        • Trope M.
        Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol?.
        J Endod. 2004; 30: 196-200
        • Petrino J.A.
        • Boda K.K.
        • Shambarger S.
        • et al.
        Challenges in regenerative endodontics: a case series.
        J Endod. 2010; 36: 536-541
        • Lee S.J.
        • Wu M.K.
        • Wesselink P.R.
        The effectiveness of syringe irrigation and ultrasonics to remove debris from simulated irregularities within prepared root canal walls.
        Int Endod J. 2004; 37: 672-678
        • van der Sluis L.W.
        • Wu M.K.
        • Wesselink P.R.
        A comparison between a smooth wire and a K-file in removing artificially placed dentine debris from root canals in resin blocks during ultrasonic irrigation.
        Int Endod J. 2005; 38: 593-596
        • van der Sluis L.W.
        • Wu M.K.
        • Wesselink P.R.
        The efficacy of ultrasonic irrigation to remove artificially placed dentine debris from human root canals prepared using instruments of varying taper.
        Int Endod J. 2005; 38: 764-768
        • Rodig T.
        • Vogel S.
        • Zapf A.
        • et al.
        Efficacy of different irrigants in the removal of calcium hydroxide from root canals.
        Int Endod J. 2010; 43: 519-527
        • Kanter V.
        • Weldon E.
        • Nair U.
        • et al.
        A quantitative and qualitative analysis of ultrasonic versus sonic endodontic systems on canal cleanliness and obturation.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 112: 809-813
        • Blank-Goncalves L.M.
        • Nabeshima C.K.
        • Martins G.H.
        • et al.
        Qualitative analysis of the removal of the smear layer in the apical third of curved roots: conventional irrigation versus activation systems.
        J Endod. 2011; 37: 1268-1271
        • Rodig T.
        • Dollmann S.
        • Konietschke F.
        • et al.
        Effectiveness of different irrigant agitation techniques on debris and smear layer removal in curved root canals: a scanning electron microscopy study.
        J Endod. 2010; 36: 1983-1987