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Ultrasonically Activated Irrigation to Remove Calcium Hydroxide from Apical Third of Human Root Canal System: A Systematic Review of In Vitro Studies

      Highlights

      • The current evidence points out that ultrasonically activated irrigation removes more calcium hydroxide (Ca[OH]2) from the apical third of the root canal than conventional syringe irrigation.
      • The current evidence indicates that ultrasonically activated irrigation removes more Ca(OH)2 from the apical third of the root canal than apical negative pressure irrigation.
      • The review detected no evidence describing the superiority of ultrasonically activated irrigation over the other irrigation techniques investigated.

      Abstract

      Introduction

      The aim of this systematic review was to summarize the outcomes of in vitro studies comparing ultrasonically activated irrigation versus other irrigation techniques for removing calcium hydroxide (Ca[OH]2) from the apical third of root canals.

      Methods

      The research question was developed according to the PICO strategy. A comprehensive literature search was performed. The Medline, Embase, and TRIP electronic databases were searched. A hand search of the reference lists of identified articles was performed to isolate relevant articles. Two reviewers critically assessed the studies against our inclusion and exclusion criteria. Evaluation of the risk of bias of the studies was performed independently by the 2 reviewers.

      Results

      After study selection, 62 were assessed for eligibility. Of these, 9 met the inclusion criteria and were included in the systematic review. Because considerable heterogeneity was found in the methodologies, it was not possible to combine the results of studies in a meta-analysis. Ultrasonically activated irrigation was found to be superior to syringe irrigation and apical negative pressure irrigation, but insufficient evidence was found to indicate its superiority over the other irrigation techniques such as sonically activated irrigation, the Self-Adjusting File, (ReDent-Nova, Ra'anana, Israel) and the RinsEndo, (Dürr Dental, Bietigheim, Germany).

      Conclusions

      On the basis of available evidence, we determined the effectiveness of ultrasonically activated irrigation compared with syringe and apical negative pressure irrigation. Because of the small sample sizes, low number of included studies, and limitations, further research is needed to confirm our results.

      Key Words

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      References

        • Sathorn C.
        • Parashos P.
        • Messer H.
        Antibacterial efficacy of calcium hydroxide intracanal dressing: a systematic review and meta-analysis.
        Int Endod J. 2007; 40: 2-10
        • Law A.
        • Messer H.
        An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments.
        J Endod. 2004; 30: 689-694
        • Itoh A.
        • Higuchi N.
        • Minami G.
        • et al.
        A survey of filling methods, intracanal medications, and instrument breakage.
        J Endod. 1999; 25: 823-824
        • Safavi K.E.
        • Nichols F.C.
        Alteration of biological properties of bacterial lipopolysaccharide by calcium hydroxide treatment.
        J Endod. 1994; 20: 127-129
        • Safavi K.E.
        • Nichols F.C.
        Effect of calcium hydroxide on bacterial lipopolysaccharide.
        J Endod. 1993; 19: 76-78
        • Hasselgren G.
        • Olsson B.
        • Cvek M.
        Effects of calcium hydroxide and sodium hypochlorite on the dissolution of necrotic porcine muscle tissue.
        J Endod. 1988; 14: 125-127
        • Chala S.
        • Abouqal R.
        • Rida S.
        Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 112: e36-e42
        • Nowicka A.
        • Lipski M.
        • Parafiniuk M.
        • et al.
        Response of human dental pulp capped with biodentine and mineral trioxide aggregate.
        J Endod. 2013; 39: 743-747
        • Bottcher D.E.
        • Hirai V.H.
        • Da Silva Neto U.X.
        • et al.
        Effect of calcium hydroxide dressing on the long-term sealing ability of two different endodontic sealers: an in vitro study.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: 386-389
        • Calt S.
        • Serper A.
        Dentinal tubule penetration of root canal sealers after root canal dressing with calcium hydroxide.
        J Endod. 1999; 25: 431-433
        • Kim S.K.
        • Kim Y.O.
        Influence of calcium hydroxide intracanal medication on apical seal.
        Int Endod J. 2002; 35: 623-628
        • Margelos J.
        • Eliades G.
        • Verdelis C.
        • et al.
        Interaction of calcium hydroxide with zinc oxide-eugenol type sealers: a potential clinical problem.
        J Endod. 1997; 23: 43-48
        • Ricucci D.
        • Langeland K.
        Incomplete calcium hydroxide removal from the root canal: a case report.
        Int Endod J. 1997; 30: 418-421
        • Nandini S.
        • Velmurugan N.
        • Kandaswamy D.
        Removal efficiency of calcium hydroxide intracanal medicament with two calcium chelators: volumetric analysis using spiral CT, an in vitro study.
        J Endod. 2006; 32: 1097-1101
        • Yu D.C.
        • Schilder H.
        Cleaning and shaping the apical third of a root canal system.
        Gen Dent. 2001; 49: 266-270
        • 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
        • Sagsen B.
        • Ustun Y.
        • Aslan T.
        • et al.
        The effect of peracetic acid on removing calcium hydroxide from the root canals.
        J Endod. 2012; 38: 1197-1201
        • Salgado R.J.
        • Moura-Netto C.
        • Yamazaki A.K.
        • et al.
        Comparison of different irrigants on calcium hydroxide medication removal: microscopic cleanliness evaluation.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: 580-584
        • Lambrianidis T.
        • Margelos J.
        • Beltes P.
        Removal efficiency of calcium hydroxide dressing from the root canal.
        J Endod. 1999; 25: 85-88
        • Turker S.A.
        • Kocak M.M.
        • Kocak S.
        • et al.
        Comparison of calcium hydroxide removal by self-adjusting file, EndoVac, and CanalBrush agitation techniques: an in vitro study.
        J Conserv Dent. 2013; 16: 439-443
        • Kenee D.M.
        • Allemang J.D.
        • Johnson J.D.
        • et al.
        A quantitative assessment of efficacy of various calcium hydroxide removal techniques.
        J Endod. 2006; 32: 563-565
        • Capar I.D.
        • Ozcan E.
        • Arslan H.
        • et al.
        Effect of different final irrigation methods on the removal of calcium hydroxide from an artificial standardized groove in the apical third of root canals.
        J Endod. 2014; 40: 451-454
        • Rodig T.
        • Hirschleb M.
        • Zapf A.
        • et al.
        Comparison of ultrasonic irrigation and RinsEndo for the removal of calcium hydroxide and Ledermix paste from root canals.
        Int Endod J. 2011; 44: 1155-1161
        • Arslan H.
        • Akcay M.
        • Capar I.D.
        • 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: 246-251
        • Kaptan F.
        • Karapinar-Kazandag M.
        • Kayahan M.B.
        • et al.
        Potential of an Er:YAG laser in the removal of calcium hydroxide from root canals.
        Photomed Laser Surg. 2012; 30: 250-254
        • Khaleel H.Y.
        • Al-Ashaw A.J.
        • Yang Y.
        • et al.
        Quantitative comparison of calcium hydroxide removal by EndoActivator, ultrasonic and ProTaper file agitation techniques: an in vitro study.
        J Huazhong Univ Sci Technolog Med Sci. 2013; 33: 142-145
        • 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
        • Bramante C.M.
        • Pinheiro B.C.
        • Garcia R.B.
        • et al.
        Efficacy of the NaviTip FX irrigation needle in removing calcium hydroxide from root canal.
        J Clin Exp Dent. 2012; 4: e226-e229
        • da Silva J.M.
        • Junior C.V.A.
        • Zaia A.A.
        • et al.
        Microscopic cleaness evaluation of the apical root canal after using calcium hydroxide mixed with chlorhexidine, propylene glicol, or antibiotic paste.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 111: 260-264
        • Faria G.
        • Kuga M.C.
        • Ruy A.C.
        • et al.
        The efficacy of the Self-Adjusting File and ProTaper for removal of calcium hydroxide from root canals.
        J Appl Oral Sci. 2013; 21: 346-350
        • Tasdemir T.
        • Celik D.
        • Er K.
        • et al.
        Efficacy of several techniques for the removal of calcium hydroxide medicament from root canals.
        Int Endod J. 2011; 44: 505-509
        • Mohammadi Z.
        • Dummer P.M.
        Properties and applications of calcium hydroxide in endodontics and dental traumatology.
        Int Endod J. 2011; 44: 697-730
        • van der Sluis L.W.
        • Versluis M.
        • Wu M.K.
        • et al.
        Passive ultrasonic irrigation of the root canal: a review of the literature.
        Int Endod J. 2007; 40: 415-426
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Higgins J.P.
        • Green S.P.
        Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 (updated March 2011) The Cochrane Library.
        John Wiley & Sons, Ltd, Chichester, UK2011
        • Kumar A.R.
        • Rao C.V.
        • Parameswaran A.
        • et al.
        Scanning electron microscopic and energy dispersive spectrometric investigations on the effect of XeCl excimer laser on human dentin with smear layer.
        J Oral Rehabil. 2002; 29: 1003-1009
        • Estrela C.
        • Sousa-Neto M.D.
        • Guedes O.A.
        • et al.
        Characterization of calcium oxide in root perforation sealer materials.
        Braz Dent J. 2012; 23: 539-546
        • Lottanti S.
        • Gautschi H.
        • Sener B.
        • et al.
        Effects of ethylenediaminetetraacetic, etidronic and peracetic acid irrigation on human root dentine and the smear layer.
        Int Endod J. 2009; 42: 335-343
        • Ahmetoglu F.
        • Simsek N.
        • Keles A.
        • et al.
        Efficacy of self-adjusting file and passive ultrasonic irrigation on removing calcium hydroxide from root canals.
        Dent Mater J. 2013; 32: 1005-1010
        • Yucel A.C.
        • Gurel M.
        • Guler E.
        • et al.
        Comparison of final irrigation techniques in removal of calcium hydroxide.
        Aust Endod J. 2013; 39: 116-121
        • Alturaiki S.
        • Lamphon H.
        • Edrees H.
        • et al.
        Efficacy of 3 different irrigation systems on removal of calcium hydroxide from the root canal: a scanning electron microscopic study.
        J Endod. 2015; 41: 97-101
        • Aminoshariae A.
        • Kulild J.
        Master apical file size—smaller or larger: a systematic review of microbial reduction.
        Int Endod J. 2015; 48: 639-647
        • de Vos R.J.
        • Windt J.
        • Weir A.
        Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review.
        Br J Sports Med. 2014; 48: 952-956
        • Abi-Rached G.P.
        • Herrera D.R.
        • Zaia A.A.
        • et al.
        Efficacy of ethylene-diamine-tetra-acetic acid associated with chlorhexidine on intracanal medication removal: a scanning electron microscopy study.
        Microsc Res Tech. 2014; 77: 735-739
        • Arslan H.
        • Gok T.
        • Saygili G.
        • et al.
        Evaluation of effectiveness of various irrigating solutions on removal of calcium hydroxide mixed with 2% chlorhexidine gel and detection of orange-brown precipitate after removal.
        J Endod. 2014; 40: 1820-1823
        • Masudi S.M.
        • Azhar L.
        • Awang R.A.R.
        • et al.
        Removal efficiency of calcium hydroxide intracanal medicament using two irrigation solutions.
        Intern Med J. 2014; 21: 106-109
        • Vineeta N.
        • Gupta S.
        • Chandra A.
        Retrievabilty of calcium hydroxide intracanal medicament with Chitosan from root canals: an in vitro CBCT volumetric analysis.
        J Conserv Dent. 2014; 17: 454-457
        • Nainan M.T.
        • Nirupama D.
        • Benjamin S.
        Comparison of the efficacy of ethylene diamine tetraacetic acid and maleic acid in the removal of three calcium hydroxide intra-canal dressings: a spiral computerized tomography volumetric analysis.
        J Conserv Dent. 2013; 16: 56-60
        • Arslan H.
        • Topcuoglu H.S.
        • Karatas E.
        • et al.
        Effect of the smear layer in the removal of calcium hydroxide from root canal walls.
        J Conserv Dent. 2012; 15: 113-117
        • Ballal N.V.
        • Kumar S.R.
        • Laxmikanth H.K.
        • et al.
        Comparative evaluation of different chelators in removal of calcium hydroxide preparations from root canals.
        Aust Dent J. 2012; 57: 344-348
        • Rao S.A.
        • Manasa N.
        Effect of irrigants using ultrasonics on intracanal calcium hydroxide removal—an in vitro comparative evaluation.
        Braz J Oral Sci. 2012; 11: 52-55
        • da Silva J.M.
        • Silveira A.
        • Santos E.
        • et al.
        Efficacy of sodium hypochlorite, ethylenediaminetetraacetic acid, citric acid and phosphoric acid in calcium hydroxide removal from the root canal: a microscopic cleanliness evaluation.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 112: 820-824
        • Naaman A.
        • Kaloustian H.
        • Ounsi H.F.
        • et al.
        A scanning electron microscopic evaluation of root canal wall cleanliness after calcium hydroxide removal using three irrigation regimens.
        J Contemp Dent Pract. 2007; 8: 11-18
        • Berkhoff J.A.
        • Chen P.B.
        • Teixeira F.B.
        • et al.
        Evaluation of triple antibiotic paste removal by different irrigation procedures.
        J Endod. 2014; 40: 1172-1177
        • Chou K.
        • George R.
        • Walsh L.J.
        Effectiveness of different intracanal irrigation techniques in removing intracanal paste medicaments.
        Aust Endod J. 2014; 40: 21-25
        • Amin S.A.
        • Seyam R.S.
        • El-Samman M.A.
        The effect of prior calcium hydroxide intracanal placement on the bond strength of two calcium silicate-based and an epoxy resin-based endodontic sealer.
        J Endod. 2012; 38: 696-699
        • Bolhari B.
        • Shokouhinejad N.
        • Masoudi A.
        The effect of calcium hydroxide on the bond strength of resilon/epiphany self-etch and assessment of calcium hydroxide removal techniques: an ex-vivo study.
        J Dent (Tehran). 2012; 9: 150-155
        • Wiseman A.
        • Cox T.C.
        • Paranjpe A.
        • 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: 235-238
        • Phillips M.
        • McClanahan S.
        • Bowles W.
        A titration model for evaluating calcium hydroxide removal techniques.
        J Appl Oral Sci. 2015; 23: 94-100
        • Faria G.
        • Viola K.S.
        • Kuga M.C.
        • et al.
        Effect of rotary instrument associated with different irrigation techniques on removing calcium hydroxide dressing.
        Microsc Res Tech. 2014; 77: 642-646
        • Kamal A.
        • Behnaz G.
        • Marjan H.
        • et al.
        Compare the effectiveness of manual technique and rinsendo system in the irrigation of Ca(OH)2 from root canals.
        Res J Med Sci. 2013; 7: 9-12
        • De Faria-Junior N.B.
        • Keine K.C.
        • So M.V.
        • et al.
        Residues of calcium hydroxide-based intracanal medication associated with different vehicles: a scanning electron microscopy evaluation.
        Microsc Res Tech. 2012; 75: 898-902
        • Gorduysus M.
        • Yilmaz Z.
        • Gorduysus O.
        • et al.
        Effectiveness of a new canal brushing technique in removing calcium hydroxide from the root canal system: a scanning electron microscope study.
        J Conserv Dent. 2012; 15: 367-371
        • Kuga M.C.
        • Campos E.A.
        • Faria-Junior N.B.
        • et al.
        Efficacy of NiTi rotary instruments in removing calcium hydroxide dressing residues from root canal walls.
        Braz Oral Res. 2012; 26: 19-23
        • Nikhil V.
        • Singh V.
        • Singh S.
        Relationship between sealing ability of Activ GP and Gutta Flow and methods of calcium hydroxide removal.
        J Conserv Dent. 2012; 15: 41-45
        • Kuga M.C.
        • Tanomaru-Filho M.
        • Faria G.
        • et al.
        Calcium hydroxide intracanal dressing removal with different rotary instruments and irrigating solutions: a scanning electron microscopy study.
        Braz Dent J. 2010; 21: 310-314
        • Victorino F.R.
        • Bramante C.M.
        • Zapata R.O.
        • et al.
        Removal efficiency of propolis paste dressing from the root canal.
        J Appl Oral Sci. 2010; 18: 621-624
        • Contardo L.
        • De Luca M.
        • Bevilacqua L.
        • et al.
        Influence of calcium hydroxide debris on the quality of endodontic apical seal.
        Minerva Stomatol. 2007; 56: 509-517
        • Lambrianidis T.
        • Kosti E.
        • Boutsioukis C.
        • et al.
        Removal efficacy of various calcium hydroxide/chlorhexidine medicaments from the root canal.
        Int Endod J. 2006; 39: 55-61
        • Goldberg F.
        • Alfie D.
        • Roitman M.
        Evaluation of the incidence of transportation after placement and removal of calcium hydroxide.
        J Endod. 2004; 30: 646-648
        • Tatsuta C.T.
        • Morgan L.A.
        • Baumgartner J.C.
        • et al.
        Effect of calcium hydroxide and four irrigation regimens on instrumented and uninstrumented canal wall topography.
        J Endod. 1999; 25: 93-98
        • Porkaew P.
        • Retief D.H.
        • Barfield R.D.
        • et al.
        Effects of calcium hydroxide paste as an intracanal medicament on apical seal.
        J Endod. 1990; 16: 369-374
        • Ferreira M.
        • Simoes R.
        • Carrilho E.
        Removal of calcium hydroxide of the root canal: conventional irrigation vs sonic.
        Rev Port Med Dent Cir Maxilofac. 2014; 55: 97-101
        • Al-Garni S.
        • Al-Shahrani S.
        • Al-Nazhan S.
        Evaluation of calcium hydroxide removal using EndoActivator system: an in vitro study.
        Saudi Endod J. 2014; 4: 13-17
        • Song Y.
        • Ma J.Z.
        • Wang R.Y.
        • et al.
        Calcium hydroxide removal in curved root canals with apical transportation in vitro.
        J Huazhong Univ Sci Technolog Med Sci. 2014; 34: 608-611
        • Goode N.
        • Khan S.
        • Eid A.A.
        • et al.
        Wall shear stress effects of different endodontic irrigation techniques and systems.
        J Dent. 2013; 41: 636-641
        • Balvedi R.P.
        • Versiani M.A.
        • Manna F.F.
        • et al.
        A comparison of two techniques for the removal of calcium hydroxide from root canals.
        Int Endod J. 2010; 43: 763-768
        • Böttcher D.E.
        • Rahde N.M.
        • Grecca F.S.
        Calcium hydroxide removal: effectiveness of ultrasonic and manual techniques.
        Rev Odonto Cienc. 2012; 27: 152-155
        • Ma J.Z.
        • Shen Y.
        • Al-Ashaw A.J.
        • et al.
        Micro-computed tomography evaluation of the removal of calcium hydroxide medicament from C-shaped root canals of mandibular second molars.
        Int Endod J. 2015; 48: 333-341
        • Maalouf L.
        • Zogheib C.
        • Naaman A.
        Removal efficiency of calcium hydroxide dressing from the root canal without chemically active adjuvant.
        J Contemp Dent Pract. 2013; 14: 188-192
        • Topcuoglu H.S.
        • Duzgun S.
        • Ceyhanli K.T.
        • et al.
        Efficacy of different irrigation techniques in the removal of calcium hydroxide from a simulated internal root resorption cavity.
        Int Endod J. 2015; 48: 309-316
        • Silva L.J.
        • Pessoa O.F.
        • Teixeira M.B.
        • et al.
        Micro-CT evaluation of calcium hydroxide removal through passive ultrasonic irrigation associated with or without an additional instrument.
        Int Endod J. 2015; 48: 768-773
        • Ma J.
        • Shen Y.
        • Yang Y.
        • et al.
        In vitro study of calcium hydroxide removal from mandibular molar root canals.
        J Endod. 2015; 41: 553-558
        • de Souza Batista V.E.
        • Junior J.F.
        • de Faria Almeida D.A.
        • et al.
        The effect of offset implant configuration on bone stress distribution: a systematic review.
        J Prosthodont. 2015; 24: 93-99
        • Nienkemper M.
        • Handschel J.
        • Drescher D.
        Systematic review of mini-implant displacement under orthodontic loading.
        Int J Oral Sci. 2014; 6: 1-6