Eggmann et al.

BMC Oral Health (2020) 20:102

https://doi.org/10.1186/s12903-020-01088-5

RESEARCH ARTICLE Open Access

Sonic irrigant activation for root canal

disinfection: power modes matter!
Florin Eggmann1*, Yvonne Vokac2, Sigrun Eick3 and Klaus W. Neuhaus1,4

Abstract
Background: Sonic irrigant activation has gained widespread popularity among general dentists and endodontists
alike in recent years. This in vitro study aimed to evaluate the impact of three power modes of a sonic activation
device (EDDY) on its antimicrobial effectiveness in infected root canals.
Methods: The root canals of straight, human roots (n = 120) were prepared to size 40/.06. In a short-term infection
experiment, the root canals were inoculated with different microbial species for three days. The following irrigation
protocols, using 4 ml of normal saline as irrigant, were performed: negative control, manual rinsing, sonic irrigant
activation at power modes “low”, “medium” and “high”. In a second, long-term experiment, testing the same irrigation
protocols, inoculation lasted 21 days and sodium hypochlorite was used as irrigant. Sequential infection control
samples were assessed using culture assays. The statistical analysis included one-way analysis of variance of log10-scaled
counts of colony-forming units (CFU) with post-hoc comparisons using Bonferroni corrections and Chi2 tests (α = 0.05).
Results: In the short-term experiment, the sonic irrigation protocols decreased the number of CFUs by 1.88 log10 units
compared with the negative control (p < 0.001). The power modes “medium” and “high” achieved the most effective
reduction of the microbial load. In the long-term experiment, microbial regrowth occurred after 7 days unless the
device was used at its highest power setting.
Conclusions: The power modes of the sonic irrigation device have a significant impact on the effectiveness for
endodontic disinfection. The sonic irrigation device should always be used at the highest power setting in order to
maximize its antimicrobial effectiveness.
Keywords: Endodontic disinfection, Oral bacteria, Sonic activation, Needle irrigation, Sodium hypochlorite

Background The uninstrumented portions of the root canal system

Apical periodontitis is a disease caused by endodontic and anatomical complexities, such as accessory canals, ap-
biofilms [1]. To achieve a favorable treatment outcome, ical ramifications, fins and isthmus areas, can harbor tissue
it is crucial to eliminate or significantly reduce the mi- debris as well as microorganisms and their deleterious by-
crobial load within the root canal system and to prevent products in spite of thorough chemomechanical disinfec-
any recontamination after the treatment [2, 3]. However, tion [1]. Supplementary irrigation methods such as irri-
the root canal system has an intricate anatomy, and root gant activation techniques are therefore needed to
canal instrumentation with rotary files leaves, on aver- enhance the elimination of endodontic biofilms [5].
age, 60% of the root canal wall surface untouched [4]. Ultrasonic irrigant activation is the most commonly used
supplementary irrigation method [6]. However, file-to-wall
* Correspondence: florin.eggmann@unibas.ch contact of ultrasonic instruments, all but unavoidable under
1
Department of Periodontology, Endodontology and Cariology, University clinical conditions, may lead to the inadvertent removal of
Center for Dental Medicine, UZB, University of Basel, Mattenstrasse 40,
CH-4056 Basel, Switzerland small amounts of dentin and significant oscillation dampen-
Full list of author information is available at the end of the article ing [7, 8]. Compared with ultrasonic activation, sonic
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
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Eggmann et al. BMC Oral Health (2020) 20:102 Page 2 of 9

irrigation devices operate at lower frequencies. EDDY After shaping the root canals, the external root surfaces
(VDW GmbH, Munich, Germany), a flexible, non-cutting of the apices were conditioned for 15 s with a phosphoric
polyamide tip that is coupled to an air scaler handpiece, is acid etchant (Ultra-Etch, Ultradent Products Inc. South
used with sonic activation at a frequency of 5000 Hz to 6000 Jordan, UT, USA), which was rinsed off with water for 15 s.
Hz [9]. Sonic activation with soft polymer tips promises to A multimode adhesive (Scotchbond Universal, 3 M Oral
be an alternative irrigant activation technique without the Care, St. Paul, MN, USA) was applied actively with a micro-
risk of unintentional dentin removal, [10] and in vitro evi- brush for 20 s, then the adhesive was gently air dried for 5
dence suggests that the antimicrobial efficacy of sonic activa- s. The apices were closed with resin-based composite (Telio
tion with EDDY is, at least, on par with ultrasonic irrigant CS Inlay, Ivoclar Vivadent AG, Schaan, Principality of
activation in straight and curved root canals [11]. Liechtenstein). Light curing of the adhesive and the resin-
Previous studies on the disinfection effectiveness of irriga- based composite was performed with a polymerization light
tion acitivation with EDDY employed the sonic device at the at an irradiance of 1200 mW/cm2 (Bluephase [high power
highest power mode of the air scaler handpiece [11]. Some mode], Ivoclar Vivadent AG) and as short a distance be-
dental practitioners may, however, use EDDY with air scaler tween the tip of the light probe and the adhesive/resin-
handpieces set at lower power modes in order to reduce irri- based composite as feasible for 10 s and 30 s, respectively.
gant spray mist during activation (VDW GmbH, oral com- The roots were stored in deionized water at 4 °C until fur-
munication). In ultrasonic irrigant activation, the power ther use. Prior to the microbial contamination procedure,
setting influences the file oscillation amplitude, which, in the roots were autoclaved in water for 20 min at 121 °C
turn, has a pronounced effect on irrigant streaming and (Laboklav ECO, SHB Steriltechnik AG, Detzel Schloss/
cleaning effectiveness [12]. Whether or not different power Satuelle, Germany).
settings have a similar impact on the effectiveness of sonic
irrigant activation has not yet been investigated.
The aim of this in vitro study was therefore to assess, Short-term infection experiment
through microbiological testing, if different power modes Microbial contamination
affect the antimicrobial effectiveness of sonic irrigation ac- The following microorganisms were separately precul-
tivation with the EDDY device. tured and suspended for 18 h:

Methods 1. Enterococcus faecalis ATCC 29212

Selection and preparation of roots 2. Candida albicans ATCC 76615
One hundred and twenty mature, straight roots (root curva- 3. Streptococcus gordonii ATCC 10558 and
ture radius < 15° [13]) of maxillary front teeth, single-rooted Actinomyces oris ATCC 43146
maxillary premolars, and palatal roots of maxillary molars
were selected from a pool of extracted human permanent Thirty autoclaved roots were randomly allocated to
teeth stored in a 1% aqueous solution of chloramine-T. The each group of microorganisms and inoculated for
roots had neither resorptive defects nor fracture lines. The three days at 37 °C. Groups 1 and 2 were cultured
local Ethics Committee denied the need for a formal ap- under aerobic conditions. Group 3 was cultured with
proval for using irreversibly anonymized teeth and issued a 10% CO2. Tryptic soy agar (TSA) plates with 5%
written declaration of no-objection. All donors had given sheep blood were used for the cultivation of the mi-
their verbal informed consent to the use of their extracted, croorganisms. Then, suspensions of E. faecalis ATCC
anonymized tooth/teeth for research purposes. 29212 and C. albicans ATCC 76615 were prepared
To remove the periodontal tissue, the roots were in a 0.9% sodium chloride solution (McFarland 4),
immersed in 3% (w/v %) sodium hypochlorite (NaOCl) which was then diluted, at a ratio of 1:9, with a
for 10 min. The working lengths were determined using brain-heart infusion broth (Oxoid Limited, Basing-
a 10/.02 K file (C-PILOT, VDW GmbH, Munich, stoke, UK). Wilkins-Chalgren anaerobe broth (Oxoid
Germany). The working length was defined as 0.5 mm Limited) supplemented with 5 mg/l β-nicotinamide
shorter than the length at which the instrument was first adenine dinucleotide sodium salt (NAD) (Sigma-Al-
visible at the apical foramen under 2.5x magnification. drich, St. Louis, MO, USA) was used for the suspen-
After confirmation of canal width by reassuring passive sion of S. gordonii ATCC 10558 and A. oris ATCC
fit and gauging with a 20./02 K file, root canal shaping 43146 (mixed at a ratio of 1:2). The nutrient broths
was performed with a reciprocating single-file system were renewed daily. At the beginning of the micro-
(RECIPROC #40, VDW GmbH); the rinsing solutions, biological experiments, sterility was monitored by
used alternately during the shaping of the root canals, sampling and culturing on TSA plates under both
were 3% (w/v %) NaOCl and 17% (w/v %) ethylenedi- aerobic and anaerobic conditions as described above.
aminetetraacetic acid. Cultivation was performed over 4 days.
Eggmann et al. BMC Oral Health (2020) 20:102 Page 3 of 9

Irrigation protocols tubes filled with 1 ml 0.9% NaCl. The tubes were vor-
Normal saline, i.e., a solution of 0.9% w/v of sodium texed for 20 s and sonicated in an ultrasonic bath before
chloride, was used as irrigation solution. The root canals, 0.1 ml of the solution was dispersed on TSA plates. Incu-
inoculated with microorganisms, were subjected to the bation of E. faecalis ATCC 29212 and C. albicans ATCC
following irrigation protocols: 76615 was performed for 2 days. Incubation of S. gordonii
ATCC 10558 and A. oris ATCC 43146 lasted 7 days. After
1. Negative control (n = 6): no treatment the incubation periods, the number of colony-forming
2. Manual rinsing (n = 6): manual irrigation, 4 ml units was determined by using an automated colony coun-
irrigation solution ter (aCOLyte, Synbiosis, Cambridge, UK).
3. Power mode “low” (n = 6): sonic irrigant activation
with a polyamide tip (6000 Hz; EDDY, VDW Long-term infection experiment
GmbH) coupled to an air scaler (SONICflex, KaVo Thirty autoclaved roots were inoculated with S. gordonii
Dental GmbH, Biberach, Germany), 3 × 20 s, 4 ml ATCC 10558 and A. oris ATCC 43146. The incubation
irrigation solution (3 ml for continuous irrigation period lasted three weeks at 37 °C with 10% of CO2. Apart
during activation, 1 ml as a final rinse) from the irrigation solution, the irrigation protocols were
4. Power mode “medium” (n = 6): sonic irrigant analogous to those in the short-term infection experiment.
activation with a polyamide tip (6000 Hz; EDDY, NaOCl (1.5% w/v) was used as irrigation solution instead
VDW GmbH) coupled to an air scaler (SONICflex, of 0.9% NaCl. One ml of 0.9% NaCl was only used for the
KaVo Dental GmbH), 3 × 20 s, 4 ml irrigation final rise. A rest period of 60 s was added after NaOCl de-
solution (3 ml for continuous irrigation during livery in the manual rinsing group to standardize irrigant
activation, 1 ml as a final rinse) contact time across all groups. Immediately after the irri-
5. Power mode high (n = 6): sonic irrigant activation gation protocol, a microbiological sample was collected
with a polyamide tip (6000 Hz; EDDY, VDW with a sterile paper point as described above. Thereafter,
GmbH) coupled to an air scaler (SONICflex, KaVo the root canals were filled with nutrient broth and they
Dental GmbH), 3 × 20 s, 4 ml irrigation solution (3 were incubated at 37 °C as described above. Microbio-
ml for continuous irrigation during activation, 1 ml logical samples were collected from the root canals after 3,
as a final rinse) 5 and 7 days. The samples were processed following the
same procedures as in the short-term infection experi-
The power modes “low”, “medium” and “high” corre- ment. A qualitative dichotomous analysis was performed
sponded to the markings “1”, “2” and “3”, respectively, on to assess the presence of viable microorganisms after incu-
the SONICflex air scaler handpiece. The respective ampli- bation periods of 0, 1, 4 and 7 days.
tudes within the excitation unit of the handpiece were
120 ± 15 μm, 160 ± 15 μm and 240 ± 15 μm according the Statistical analysis
manufacturer (Ulrike Nagorr, KaVo Dental GmbH, writ- Statistical analyses were performed with SPSS 24.0 (IBM
ten communication). All irrigants were delivered by SPSS Statistics, Chicago, IL, USA). Statistical analyses
single-use syringes with a capacity of 10 ml (Omnifix Luer based on log10-scaled microbial counts (total colony
Solo, B. Braun Medical AG, Sempach, Switzerland). In the forming units ([CFU]) for the short-term experiment.
manual rinsing group (group 2) and for the final rinse in Data were compared using a one-way analysis of vari-
groups 3–5, side-vented Gauge 30 irrigation needles (Irri- ance (ANOVA) with post-hoc comparisons of groups
gation Probe, KerrHawe SA, Bioggio, Switzerland) were using Bonferroni corrections. For the long-term infec-
inserted to working length. The sonic irrigation tips, like- tion experiment, the Chi2 test was employed. The level
wise, were placed at working length. The sterile single-use of significance was set at α = 0.05.
EDDY tips were replaced for the irrigant activation of each
root. For continuous irrigation during sonic activation, the Results
side-vented needle was placed within the coronal third of Short-term infection experiment
the root canal. All endodontic procedures were performed No contamination of the samples occurred throughout
by one operator (YV) throughout the study, and all irri- the duration of the experiment. All irrigation protocols
gants that were used were at room temperature. with sonic activation significantly reduced the number of
viable microorganisms, E. faecalis and Candida albicans.
Counting of colony-forming units The order of magnitude of the reduction of CFUs of E.
Sterile paper points (R40, RECIPROC Paper Points, faecalis was 1.82 log10 units for all sonic activation pro-
VDW GmbH) that matched the taper of the file used for tocols (groups 3–5) compared with the negative control
root canal preparation were placed in each root at work- (group 1) (p < 0.001), and 1.20 log10 units compared with
ing length for 30 s. The paper points were then placed in the manual irrigation group (group 2) (p ≤ 0.006). No
Eggmann et al. BMC Oral Health (2020) 20:102 Page 4 of 9

statistically significant difference was observed between

the manual irrigation protocol and the negative control
group (p = 0.37). The different power modes showed no
statistically significant differences (p = 1.00). The order of
magnitude of the reduction of CFUs of Candida albicans
was 1.83 log10 units for all sonic activation protocols
(groups 3–5) compared with the negative control (group 1)
(p < 0.001), and 1.31 log10 units compared with the manual
irrigation group (group 2) (p < 0.001). Statistically signifi-
cant differences were neither observed between the manual
irrigation protocol and the negative control group (p =
0.93) nor between the different power modes (p = 1.00).
In comparison with the negative control group, all irri-
gation protocols significantly reduced the number of S.
gordonii and A. oris: the order of magnitude of the re-
duction of CFUs was 2.72 log10 units for the sonic acti-
vation power mode “medium” (p < 0.001), 2.03 log10
units for the sonic activation power mode “high” (p < Fig. 1 Log10 units of CFUs of Candida albicans after different
0.001) and 1.21 log10 units for the sonic activation power irrigation protocols. “Low”, “medium” and “high” refer to respective
the power mode of the air scaler handpiece used for sonic irrigation
mode “low” (p < 0.001). The manual irrigation protocol with the EDDY device. **,## indicate p < 0.05
reduced the number of CFUs by 0.69 log10 units com-
pared with the negative control group (p = 0.022). Over-
all, the sonic irrigation protocols decreased the number infection experiment, bacterial regrowth was completely
of CFUs by 1.30 log10 units compared with the manual stunted exclusively in root canals that had been irrigated
irrigation protocol. Among the sonic irrigation proto- with the sonic irrigation device employed at the highest
cols, the power mode “medium” obtained the most sub- power setting.
stantial CFU reduction: it decreased the number of Recent in vitro studies have shown that, compared with
CFUs by 1.51 log10 units compared with the power manual irrigation, the sonic irrigation device EDDY im-
mode “low” (p < 0.001) and by 0.69 log10 units compared proves the dentin debris removal from artificial canal ir-
with the power mode “high” (p = 0.020). The power regularities [14], the removal of calcium hydroxide from
mode “high” reduced the number of CFUs by 0.82 log10 artificial grooves in the root canal of maxillary incisors [9],
units compared with the power mode “low” (p < 0.004), the removal of remnants of sealer and guttapercha [15]
Figs. 1, 2 and 3 show detailed results of the short-term
infection experiment.

Long-term infection experiment

No contamination of the samples occurred throughout
the duration of the experiment. After three weeks of in-
cubation with S. gordonii and A. oris, no bacteria could
be cultivated from the samples taken immediately after
irrigation with NaOCl. The addition of nutrient broth
and incubation at 37 °C led to bacterial regrowth in all
root canals after 7 days except for those that had been ir-
rigated with sonic activation at the highest intensity
(power mode “high”). Detailed results of the long-term
infection experiment are provided in Fig. 4.

Discussion
This in vitro investigation showed that the power modes
of a sonic irrigation device have a significant impact on
the antimicrobial efficacy in root canals. In the short- Fig. 2 Log10 units of CFUs of E. faecalis after different irrigation
term infection experiment, the two higher power modes protocols. “Low”, “medium” and “high” refer to respective the power
mode of the air scaler handpiece used for sonic irrigation with the
achieved a more substantial reduction of viable microor-
EDDY device. **,## indicate p < 0.05
ganisms than the lowest power mode. In the long-term
Eggmann et al. BMC Oral Health (2020) 20:102 Page 5 of 9

that study and the present investigation reveals that the

order of magnitude of CFU reductions are, in some cases,
more than one logarithmic step apart even though the
overall trend is qualitatively similar in both studies. For in-
stance, Neuhaus et al. [11] reported median log10 CFU
counts of 4.03 for the S. gordonii and A. oris co-culture,
2.98 for E. faecalis and 1.7 for C. albicans after sonically ac-
tivated irrigation of straight root canals. In the present in-
vestigation, on the other hand, the log10 CFU counts in the
group with sonic irrigant activation at the highest power
setting were 5.16 for the S. gordonii and A. oris co-culture,
5.30 for E. faecalis and 4.94 for C. albicans in the short-
term infection experiment.
In this study, microorganisms were used that are fre-
quently found in infected root canal and that have the po-
tential to invade radicular dentin [19]. The in vitro study
of Neuhaus et al. [11] found regrowth of C. albicans and
Fig. 3 Log10 units of CFUs of S. gordonii and A. oris after different
irrigation protocols. “Low”, “medium” and “high” refer to respective
E. faecalis in all samples after seven days, i.e. some viable
the power mode of the air scaler handpiece used for sonic irrigation microorganisms that evaded detection – presumably in
with the EDDY device. **,##,§§,$ indicate p < 0.05 dentinal tubules - immediately after irrigation remained in
the root canal system. No microbial regrowth occurred in
the long-term infection experiment in the roots that were
and the median dye penetration depths in dentinal tubules infected with S. gordonii and A. oris [11]. In that study,
of apical root sections [16]. However, considering the piv- however, the sonic irrigation was always performed at the
otal etiopathogenetic role of endodontic biofilms in periapi- highest power setting [11]. The present investigation re-
cal disease, the reduction of the microbial load within root vealed that microbial regrowth of S. gordonii and A. oris
canal systems is arguably the most relevant surrogate marker occurred in all samples apart from those that had been
in experimental irrigation studies [17]. Although microbio- sonically irrigated at the highest power setting. The irriga-
logical studies are fraught with some methodological difficul- tion protocols and microbiological assays were carried out
ties, the endodontic microbiological status can, at least to in an analogous manner in both studies. However, in the
some degree, predict healing of apical periodontitis [18]. study of Neuhaus et al. [11], the root canals were shaped
The setup of the present study is comparable to a previ- with a reciprocating file size 25/.08 and both straight and
ous in vitro study which indicated that, in straight and curved roots were included in the long-term infection ex-
curved root canals, sonic irrigation with EDDY surpasses periment. Contrary to this, the tooth sample of the present
manual syringe irrigation in terms of antibacterial efficacy study included only straight roots and the root canals were
[11]. However, an in-depth comparison of the results of prepared with a reciprocating file size 40/.06. The

Fig. 4 Bacterial regrowth (log10 units of CFUs, black bars) after irrigation with 1.5% NaOCl (d0, day 0) and after re-incubation and provision of
nutrient broth (d1, day 1; d4, day 4, d7, day 7). “Low”, “medium” and “high” refer to respective the power mode of the air scaler handpiece used
for sonic irrigation with the EDDY device. “Manual” stands for the manual rinsing group
Eggmann et al. BMC Oral Health (2020) 20:102 Page 6 of 9

increased apical enlargement and the absence of curved In the present investigation, an established in vitro
roots provided favorable conditions for improved irrigant model with extracted teeth with closed-end root canals
delivery to the apical part of the main root canal and more was used in order to have a standardized and reproducible
unimpeded oscillation of the EDDY tip in the present setup and to replicate in vivo scenarios as closely as pos-
study [7, 20, 21]. These advantages notwithstanding, the sible [5, 11]. It is important to give due consideration to
EDDY device employed at the two lower power settings the inherent strengths and limitations of this model and
was insufficiently efficacious in eliminating residual micro- the microbiological methods that were employed.
organisms. This underlines that sonic irrigant activation Decoronated roots were used for this in vitro study in
should be performed at the highest power mode even if order to increase the level of standardization and to en-
the conditions for root canal disinfection seem favorable. sure a straightline access and adequate visual control of
Data from a previous in vitro study which assessed the irrigation needles and EDDY tips during the irrigation
how effective sonic irrigant activation with EDDY was procedures. However, the use of decoronated roots might
against E. faecalis suggest that EDDY is more efficient have influenced the irrigation protocols and thus the
than syringe needle irrigation against intratubular bac- microbiological findings. For example, coronal tooth sub-
terial in all portions of the root [22]. Yet, EDDY does stance or restoration material can sometimes compromise
not maintain its antibacterial superiority in dentinal tu- the straight access to the root canal orifice and the result-
bules beyond a depth of 100 μm [22]. Considering the ing interference between the crown and the EDDY tip is
limited reach of sonically activated irrigants in dentinal likely to affect the oscillation behavior of the latter.
tubules, it has been argued that the concentration of The root curvature affects the effectiveness of activation
NaOCl is more important than sonic irrigant activation methods that rely on the insertion of an instrument in the
to eliminate bacteria residing in dentinal tubules [22]. root canal [5, 20]. To decrease the potential for confound-
The present investigation confirms that sonic irrigant ac- ing, the study material comprised exclusively of roots with
tivation with EDDY, employed at the highest power set- no pronounced curvatures. Moreover, as in the majority
ting, outperforms the antimicrobial effect of manual of in vitro studies, single roots with a simple anatomy
syringe irrigation but, in contrast to the studies of Hage were used in the present investigation. Micro-computed
et al. [23] and Zeng et al. [22], no viable microorganism tomography data suggest, however, that in the complex
were found even after an extended re-incubation period mesial root canal systems of mandibular molars sonic irri-
of seven days. In addition to different microbiological as- gant activation does not improve the removal of accumu-
says and variations in the irrigation protocols, the differ- lated hard-tissue debris compared with conventional
ent makeup of tooth samples may account, at least to manual irrigation [10]. Whether or not the same holds
some degree, for these conflicting microbiological re- true for the antimicrobial efficacy remains currently un-
sults. In the studies of Hage et al. [23] and Zeng et al. clear. Interestingly, a recent in vitro study that used a stan-
[22] exclusively single-rooted premolars were used dardized isthmus model reported that laser-activated
whereas the sample of the present study included anter- irrigation and sonic irrigant activation with EDDY
ior teeth, premolars and palatal roots of maxillary mo- achieved the most thorough removal of a biofilm-
lars. Premolars are frequently extracted in adolescence mimicking hydrogel [26]. Corroborating microbiological
and early adulthood for orthodontic reasons. The anter- evidence for this finding is, however, lacking for the time
ior teeth and molars contained in the sample of the being. Further studies are, therefore, necessary to evaluate
present study, by contrast, were likely to come predom- if the results of the present investigation are replicable in
inately from older patients with tooth loos resulting teeth with multiple root canals, curved roots or more
from periodontal disease. It is thus reasonable to assume complex root canal anatomies.
that the average age of the teeth in the samples of these Endodontic infections are caused by multispecies bio-
studies were different. The degree of root dentin scler- films. This in vitro investigation, however, used microbial
osis increases with advancing age, and consequently bac- monocultures and two-species co-cultures, consisting of
terial infection of dentinal tubules is less pronounced in microorganisms commonly found in infected root canals,
older teeth [17, 24]. This may influence the antimicro- to assess the effectiveness of different irrigation protocols.
bial effect of irrigation protocols [17, 24]. A tentative Therefore, the results of this study are not directly translat-
conclusion that can be drawn based on the results of the able to situations where multispecies biofilm are present.
studies which assessed the antibacterial efficacy of the Biofilm formation and maturity have a determining influ-
EDDY device is that sonic irrigant activation is advanta- ence on the antimicrobial effectiveness of irrigation proto-
geous compared with manual syringe irrigation but cases cols [5]. While biofilms grown from oral bacteria are quite
with severe intratubular infection may still require ad- susceptible to antimicrobial agents within the first two
junct measures such as the use of higher NaOCl concen- weeks of growth, more mature biofilms are more resistant
trations and prolonged exposure times [22, 23, 25]. and so the same antimicrobial agents are considerably less
Eggmann et al. BMC Oral Health (2020) 20:102 Page 7 of 9

effective after three weeks [27]. The present study used two deemed the preferable approach for better comparability.
different maturation timelines for the biofilm models in The sonic irrigation tip, too, was inserted to working
order to take account of the different degrees in biofilm re- length and remained there during activation despite the
sistance. In line with methodological recommendations, the fact that the manufacturer recommends moving the sonic
microbial purity of the contaminated roots was strictly irrigation tip carefully up and down with vertical motions.
monitored throughout the experiments to rule out any con- The manufacturer’s recommendation was deliberately dis-
tamination [5]. The extent of microbial growth on the root regarded because, again, manually carrying out vertical
canal walls and in dentinal tubules was not assessed by motions in a standardized way was considered unfeasible.
microscopic imaging or histology. Nevertheless, the micro- The irrigant that was used in the short-term infection
biological results of negative controls provided a framework experiment differed from the one used in the long-term
that allowed to quantitatively evaluate the effect of different infection experiment. This restricts the comparability of
irrigation protocols. the results of the two experiments and needs to be taken
Conclusive evidence indicating which microbiological sam- into consideration when contrasting these results. In the
pling method is best suited for irrigation studies is currently short-term infection experiment, normal saline was used
lacking [5]. Paper points allow straightforward sampling from as irrigant in order to asess the microbial load reduction
within the main root canal lumen whereas sampling that can be achieved through fluid dynamics alone. Bio-
methods using dentin debris may yield more illuminating films at this stage of maturation are highly susceptible to
insight into dentinal tubule disinfection [5]. The microbio- potent antimicrobial irrigants such as sodium hypochlor-
logical approach of the present investigation was developed ite and, consequently, relevant differences in the effect-
to remedy some of the shortcomings of paper point sam- iveness of different irrigations protocols would likely not
pling [28]. As a response to a scarcity of nutrients and other have been detectable with culture assays if sodium hypo-
adverse conditions for life, some microorganisms enter a vi- chlorite had been used. It is essential to bear in mind,
able but non-culturable state. The reintroduction of nutrients though, that normal saline was chosen simply to avoid
recovers the metabolic activity, albeit quite slowly for some falling below the microbiological detection threshold. In
oral bacteria, which can take up to three days for their reacti- clinical cases, it is crucial to use an effective antimicro-
vation [29]. The provision of nutrient broth and sequential bial and proteolytic agent as main irrigant regardless of
microbiological sampling over an incubation period that the stage of root canal infection.
lasted one week ensured that slow and lagged microbial re- Clinical treatment trials are needed to assess whether the
growth was detectable in the present investigation. differences in antimicrobial efficacy observed in the present
Syringe irrigation was chosen as control group because investigation have a measurable impact on patient-centered
it is the most popular irrigation method among general outcomes such as healing of apical periodontitis. The pre-
dental practitioners and endodontists alike [6, 30]. To dictive validity of in vitro irrigation studies for clinical out-
overcome some of the limitations of syringe irrigation come parameters is limited. For instance, although a
with side-vented needles [21, 31], the root canals in this substantial body of in vitro evidence suggests that ultrasonic
study were shaped with a file that achieved an apical en- irrigant activation is more effective than syringe irrigation,
largement of an ISO size 40 and a taper of .06 along the there is a paucity of clinical evidence for the benefit of ultra-
most apical millimeters. In addition, small needles, sonic irrigant activation in primary root canal treatment of
Gauge size 30, that allowed placement at working length teeth with a single root canal [17].
without binding were used to facilitate adequate irrigant
delivery to the full extent of the main root canal and to Conclusions
improve irrigant exchange through an effective reverse Within the limitations of this in vitro study, it can be con-
flow [9, 31–33]. It is, however, important to bear in cluded that the power modes of the sonic irrigation device
mind that the irrigant flow of side-vented needles is EDDY have a significant impact on its effectiveness for
nonuniform and the mechanical cleaning effect thus root canal disinfection. Lower power settings compromise
tends to concentrate on the areas of the root canal walls the antimicrobial effectiveness and they need, therefore, to
next to the vent [33]. The orientation of the side-vent be avoided. In order to reduce the microbial load within
during irrigation was not monitored in the present in- the root canal system as effectively as feasible, the hand-
vestigation. Furthermore, the tip of the needle remained piece that is used to drive the sonic irrigation tip ought to
at working length for the whole duration of the irriga- be employed at its highest power setting at all times.
tion even though up and down movement of needles is
likely to be advantageous in terms of mechanical clean- Abbreviations
ing. However, as standardized vertical movements of the ANOVA: Analysis of variance; A. oris: Actinomyces oris; C. albicans: Candida
albicans; CFU: Total colony forming units; E. faecalis: Enterococcus faecalis;
needles were not possible in the setup of this study, irri- NAD: β-nicotinamide adenine dinucleotide sodium salt; NaOCl: Sodium
gation with the needle static at working length was hypochlorite; S. gordonii: Streptococcus gordonii; TSA: Tryptic soy agar
Eggmann et al. BMC Oral Health (2020) 20:102 Page 8 of 9

Acknowledgements 8. Retsas A, Koursoumis A, Tzimpoulas N, Boutsioukis C. Uncontrolled removal

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KWN and SE developed the conception and design of this study. SE and YV 11. Neuhaus KW, Liebi M, Stauffacher S, Eick S, Lussi A. Antibacterial efficacy of a new
acquired the experimental data. KWN and SE performed the data analysis. FE, KWN, sonic irrigation device for root canal disinfection. J Endod. 2016;42:1799–803.
SE and YV interpreted the data. FE and KWN drafted the manuscript. FE, KWN, SE 12. Jiang L-M, Verhaagen B, Versluis M, Langedijk J, Wesselink P, van der Sluis
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Funding 13. Schneider SW. A comparison of canal preparations in straight and curved
The work was funded by the participating departments. root canals. Oral Surg Oral Med Oral Pathol. 1971;32:271–5.
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Testarelli L. Efficacy of sonic and ultrasonic irrigation devices in the removal
Availability of data and materials
of debris from canal irregularities in artificial root canals. J Appl Oral Sci.
The datasets used and/or analyzed during the current study are available
2019;27:e20180045.
from the corresponding author on reasonable request.
15. Kaloustian MK, Nehme W, El Hachem C, Zogheib C, Ghosn N, Mallet JP,
et al. Evaluation of two shaping systems and two sonic irrigation devices in
Ethics approval and consent to participate removing root canal filling material from distal roots of mandibular molars
The local Ethics Committee denied the need for a formal approval for using assessed by micro CT. Int Endod J. 2019;52:1635–44.
irreversibly anonymized teeth. All donors had given their verbal informed 16. Galler KM, Grubmüller V, Schlichting R, Widbiller M, Eidt A, Schuller C, et al.
consent to the use of their extracted, anonymized tooth/teeth for research Penetration depth of irrigants into root dentine after sonic, ultrasonic and
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Sigrun Eick is a member of the editorial board for BMC Oral Health, but 19. Stauffacher S, Lussi A, Nietzsche S, Neuhaus KW, Eick S. Bacterial invasion
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Author details Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111:529–34.
1
Department of Periodontology, Endodontology and Cariology, University 21. Boutsioukis C, Gogos C, Verhaagen B, Versluis M, Kastrinakis E, Van der Sluis
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CH-4056 Basel, Switzerland. 2Private practice, Zurich, Switzerland. 3Laboratory evaluated using an unsteady computational fluid dynamics model. Int
of Oral Microbiology, Department of Periodontology, School of Dental Endod J. 2010;43:874–81.
Medicine, University of Bern, Bern, Switzerland. 4Department of Preventive, 22. Zeng C, Willison J, Meghil MM, Bergeron BE, Cutler CW, Tay FR, et al.
Restorative and Pediatric Dentistry, University of Bern, Bern, Switzerland. Antibacterial efficacy of an endodontic sonic-powered irrigation system: an
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Received: 15 January 2020 Accepted: 25 March 2020 23. Hage W, de Moor RJG, Hajj D, Sfeir G, Sarkis DK, Zogheib C. Impact of
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