JOURNAL OF ENDODONTICS

Copyright 2003 by The American Association of Endodontists

Printed in U.S.A.
VOL. 29, NO. 10, OCTOBER 2003

A Comparison of the Cleaning Efficacy of ShortTerm Sonic and Ultrasonic Passive Irrigation after
Hand Instrumentation in Molar Root Canals
Ronald A. Sabins, DDS, MS, James D. Johnson, DDS, MS, and John W. Hellstein, DDS, MS

sonically cleaned canals and those cleaned by hand filing with

regard to cleanliness.
Acoustic streaming, as described by Ahmad et al. (7), has been
shown to produce sufficient shear forces to dislodge debris in
instrumented canals. When files were activated with ultrasonic
energy in a passive manner, this acoustic streaming was sufficient
to produce significantly cleaner canals in human maxillary teeth
than those produced by hand filing alone. They deducted that to
maximize acoustic streaming for debridement purposes, the best
results were to have a freely vibrating file of small size subjected
to a high-power setting on the ultrasonic unit. The smaller file
would be less likely to contact the canal walls and reduce the
acoustic-streaming effect. They found greater removal of debris
and smear layer in the apical third of canals because of more
intense magnitude and velocity at the apical end of the file.
Lev et al. (8) compared the cleaning ability of ultrasonics and a
step-back technique. They concluded that a 3-min ultrasonic stepback technique produced a significantly cleaner isthmus between
canals in the mesial roots of mandibular first molars. Their study
also looked at a 1-min ultrasonic step-back technique. The 1-min
technique was not significantly better than hand filing for removing debris.
Hiadet et al. (9) found that step-back preparation followed by 3
min of ultrasonic preparation provides superior cleanliness at both
the apical 1-mm level and in the isthmus compared with step-back
preparation alone. Archer et al. (10) found that step-back preparation followed by 3 min of ultrasonics resulted in significantly
cleaner canals and isthmuses in mandibular molars compared with
step-back preparation alone. The ultrasonic instrumentation was
performed by placing the file 1-mm short of the working length
and activating the ultrasonic unit for 3 min using a push-pull
circumferential motion.
Torabinejad (11) described a passive step-back instrumentation
technique where ultrasonic files were used as part of the instrumentation technique. Ultrasonic files were used 1-mm short of
resistance, and used circumferentially, not allowing the tip to
penetrate into dentin. The ultrasonic files were alternated with
K-type files. The final step used the #15 ultrasonic file 1- to 2-mm
short of the working length for 1 to 2 min before the final irrigation
with NaOCl.
Cameron (12) found, under the conditions of his study, that the
most effective regimen for smear layer and debris removal, at 1, 5,
and 10 mm from the apical seat, was a 1-ml rinse of EDTAC after

A total of 100 maxillary molar canals were hand

instrumented to a master apical file size #35 and
flared to a size #60 file. The canals were randomly
divided into 5 groups of 20 each. Group 1 received
no further treatment. Groups 2 and 3 received passive sonic irrigation for 30 and 60 s, respectively.
Groups 4 and 5 received passive ultrasonic irrigation for 30 and 60 s, respectively. The roots were
split longitudinally and photographed with a digital
camera. The apical portion of the root was magnified to 100. A debris score was calculated for the
apical 3 and 6 mm. The debris score was calculated as a percentage of the total area of the canal
that contained debris as determined by pixels in
Adobe Photoshop 5.0. Passive sonic or ultrasonic
irrigation, for as little as 30 s, resulted in significantly cleaner canals than hand filing alone. Ultrasonic passive irrigation produced significantly
cleaner canals than passive sonic irrigation, when
sonic and ultrasonic passive irrigation were compared with only each other.

Cleansing and shaping the canals is a well-known fundamental

necessity for the success of any root-canal treatment (1). Obtaining
the cleanest canal possible before obturation is one of the goals of
endodontic treatment. The activation of endodontic files by ultrasonic or sonic energy has been shown, in some studies, to be
effective in both cleaning and shaping of root-canal systems.
Richman (2) first introduced ultrasonics as a means of canal
debridement. Martin et al. (3) demonstrated the ability of ultrasonically activated K-type files to cut dentin. In another study, the
same authors showed that canals that were cleaned and shaped with
ultrasonic instrumentation were significantly cleaner than those
instrumented with conventional root-canal filing (4).
Stamos et al. (5) showed that canals were significantly cleaner
at the 1-mm level, after the use of ultrasonics and 2.6% NaOCl,
than those cleaned using hand instrumentation alone. Tronstad et
al. (6) evaluated sonic activation of files to shape and cleanse
canals. Their results showed no significant difference between
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Debris Removal Using Passive Sonic and Ultrasonic Irrigation

each instrument size, followed by two 30-s exposures to ultrasound

plus EDTAC, and then four 30-s exposures to ultrasound plus 4%
sodium hypochlorite.
Other studies have found conflicting results for the increased
efficacy and advantages of sonic or ultrasonic instrumentation as
the primary instrumentation technique (1317). When sonic or
ultrasonic files are used in small, curved canals, they may bind,
which then restricts their vibratory motion and cleaning efficiency
(18).
Jensen et al. (19) proposed a technique for canal debridement
that called for passively activating a sonic or ultrasonic file inside
the canal after hand instrumentation. Passive activation meant that
there was no attempt to instrument, plane, or contact the canal
walls with the file. This technique was used to try to maximize
acoustic-streaming effects. They showed that 3 min of passive
sonic or ultrasonic activation significantly reduced debris levels in
canals after hand instrumentation. No significant difference in
cleaning efficiency was found between sonically and ultrasonically
activated files.
Krell et al. (20) found that for endosonic files that were binding
in the canal, 1 min of activation was insufficient to allow irrigant
to penetrate to the tip of the file. They emphasized the need to use
smaller endosonic files for 2 min, instead of 30 s. They also stated
that when there were fewer coronal-canal obstructions, there was
faster penetration of irrigant through the entire length of the canal
because the file could move freely within the canal. The files in
their study were not used in a passive manner but to cut dentin and
prepare the canal.
Using 3 min of sonic or ultrasonic irrigation in each canal of a
molar with four canals would add 12 min to the endodontic
procedure. Would 30 to 60 s of passive sonic or ultrasonic irrigation be enough time to effectively remove debris that remained
after hand filing? The shorter sonic or ultrasonic irrigation time
would allow a reduction in preparation time while removing additional debris.
The purpose of this study was to determine if sonic or ultrasonic
irrigation applied in a passive manner for 30 to 60 s could significantly reduce the amount of debris in the root canals of maxillary
molars after hand instrumentation, and thus allow for a decrease in
canal preparation time.
MATERIAL AND METHODS
A total of 100 canals from extracted human molars were used.
Access preparations were made and patency established by passing
a #10 K-file beyond the apex of all canals. Working lengths were
determined by subtracting 1 mm from the length at which the #10
file first appeared at the apical foramen. Coronal flaring was
achieved by using #2 through #4 Gates Glidden drills. The canals
were then instrumented to a #35 Flex-O-File (Maillefer Dentsply,
Tulsa, OK) to the established working length using the balancedforce technique. Step-back flaring was accomplished by subtracting 0.5 mm from each successively larger file size up to a #60 file.
One milliliter of 5.25% sodium hypochlorite was used between

675

each file size as an irrigant, with 5 ml used as a final rinse. For all
rinses, a 10-ml syringe (Excelint International Co., Los Angeles,
CA) with a 27-gauge, slotted needle (Monoject, Sherwood Medical, St. Louis, MO) was placed as far as possible into the canal
without having the needle bind in the canal.
One operator who was experienced with this method of instrumentation prepared all canals. After hand instrumentation, the
canals were filled with 5.25% sodium hypochlorite and randomly
divided into 5 groups of 20 canals each.
Group 1 served as the control group. The control group consisted of 20 canals that received no further treatment, except a final
rinse of 5 ml of 5.25% NaOCl. The canals were dried with paper
points after the final rinse and sealed with a cotton pellet and Cavit
(ESPE, Seefeld, Germany).
Group 2 received passive sonic irrigation for 30 s using a MM
1500 sonic handpiece (Medidenta International Inc., Woodside,
NY) with a size 1 Rispisonic file (Medidenta International Inc.)
placed 2-mm short of the working length with NaOCl still in the
canal. Passive activation, or irrigation, meant that there was no
attempt made to instrument, plane, or contact the canal walls with
the file, and every attempt was made to keep the file centered in the
canal so that it would not touch the canal walls.
Group 3 received passive sonic irrigation for 60 s, in the same
manner as group 2, except the irrigation time was increased to 60 s.
Group 4 received passive ultrasonic irrigation for 30 s using a
Mini-endo ultrasonic unit (EIE/Analytic, San Diego, CA) with a
#15 ultrasonic file set at the manufactures recommended power
setting. The file was placed 2-mm short of the working length and
activated for 30 s with NaOCl still in the canal.
Group 5 received passive ultrasonic irrigation for 60 s, in the
same manner as group 4, except the activation time was increased
to 60 s. After activation of the sonic or ultrasonic files, the canals
were rinsed again with 5 ml of 5.25% NaOCl, dried with paper
points, and sealed with a cotton pellet and Cavit.
With the aid of a surgical operating microscope (Global Surgical
Corp., St. Louis, MO), a longitudinal groove was cut in the root using
the end of a 557 bur (Henry Schein, Melville, NY). The roots were
removed from the crowns and then split by placing a #15 surgical
blade (Henry Schein, Port Washington, NY) in the groove and striking
the blade with a small mallet. Images of the split roots were made
using a Nikon N90S DCS 420 digital camera (Nikon Corp., Tokyo,
Japan) at a 1:1 setting. The images were transferred to a computer with
Adobe Photoshop 5.0 software (Adobe Systems Inc., San Jose, CA)
and enlarged to 100 the original size. Lines were superimposed over
the canals at 0, 3, and 6 mm from the apical constriction.
The debris in each canal was traced and the total number of
pixels occupied by the debris was reported by using the histogram
function in the software program. The outline of the canal was then
traced and the same feature of the software reported the total pixels
occupied by the canal. Percentage of debris was calculated by
dividing the pixels of debris by the total pixels representing the
entire area of the canal. Percentage of debris was calculated for
both the 0- to 3-mm and the 3- to 6-mm areas for each canal.

TABLE 1. Mean percentage of remaining debris

Level

Control
(Group 1)

Sonic Irrigation
30 s (Group 2)

Sonic Irrigation
60 s (Group 3)

Ultrasonic Irrigation
30 s (Group 4)

Ultrasonic Irrigation
60 s (Group 5)

03 mm
36 mm

36.70
23.91

20.69
11.57

19.74
11.87

11.95
8.41

15.43
7.97

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Sabins et al.

Journal of Endodontics

hand

FIG 2. Typical canal after 30 s of passive sonic irrigation after hand

instrumentation.

FIG 3. Typical canal after 60 s of passive sonic irrigation after hand

instrumentation.

FIG 4. Typical canal after 30 s of passive ultrasonic irrigation after

hand instrumentation.

FIG 1. Typical
instrumentation.

canal

with

debris

remaining

after

Vol. 29, No. 10, October 2003

Debris Removal Using Passive Sonic and Ultrasonic Irrigation

677

FIG 6. Comparison of sonic and ultrasonic passive irrigation of

canals (left) versus canals that received no sonic or ultrasonic passive irrigation after hand instrumentation (right).

examples that illustrate the debris left by the various methods and
times used in this study.
DISCUSSION
FIG 5. Typical canal after 60 s of passive ultrasonic irrigation after
hand instrumentation.

ANOVA and Tukeys honest significance difference post hoc

tests were run on the data to determine significant differences
between the groups. Additionally, the four treatment groups were
analyzed to incorporate the factorial design to compare the sonic
method to the ultrasonic method. SPSS 11.0 statistical software
(SPSS Inc., Chicago, IL) was used for all statistical analysis.
RESULTS
Table 1 gives the mean values of the percentage of remaining
debris for all groups at both the 0- to 3-mm and the 3- to 6-mm
levels. Both the sonic and ultrasonic groups showed significantly
less debris than the control group (p 0.001). Treatment groups
did not differ among themselves (no difference between sonic and
ultrasonic irrigation) when all groups were compared.
But when the ultrasonically irrigated groups were compared
directly to the sonically irrigated groups, without considering the
control group, it was found that the ultrasonically irrigated groups
had significantly less debris at both the 0- to 3-mm and the 3- to
6-mm levels than the sonically irrigated groups (p 0.05).
There was a main effect for the level (3-mm versus 6-mm, p
0.001) with less debris at the 3- to 6-mm level and for the irrigation
method (sonic versus ultrasonic, p 0.047). Means for the irrigation methods are 15.96% for sonic irrigation versus 10.94% for
ultrasonic irrigation; but there were no significant interactions.
Thus, irrigation method (sonic versus ultrasonic) had a statistically
significant effect on the outcome, which was not differentially
influenced by distance or time.
There was no significant difference between 30 s and 60 s of
irrigation for either irrigation method. Figures 1 to 6 are typical

The sonic or ultrasonic activation of files in this study was

considered passive because there was no attempt to remove dentin
from the walls of the canals. The files were not moved after
activation started, except in an attempt to keep the files centered in
the canals.
Thirty seconds of ultrasonic or sonic activation produced
cleaner canals than hand filing alone. This seems beneficial to the
success of endodontic treatment and only adds 2 min to the
procedure in a molar with four canals. The findings of this study
contrast to those found by Lev et al. (8), who found that 1 min of
ultrasonic step-back was not significantly better than hand filing in
removing debris.
If an ultrasonic unit with a file adapter was not available, a
provider could substitute a less expensive sonic unit and still
achieve cleaner canals with less debris than when no sonic irrigation was used. Sonic energy operates at a lower frequency (1 8
kHz) than that of ultrasonics (25 40 kHz). When placed in the
small, curved canals of a maxillary molar, there is a certain amount
of dampening that occurs with all files, if they touch the canal
walls. This dampening may explain the results that the more
powerful ultrasonics removed more debris than the less powerful
sonic activation. However, when the sonics were applied for a
longer time, as in the Jensen et al. (19) study, there was no
significant difference seen in the remaining debris for the two
techniques.
This study found the 3- to 6-mm region of the canal to be cleaner
than the more apical 0- to 3-mm region. This is in contrast to the
findings of Ahmad et al. (7). They found that the apical regions of
the canal, where the file tip had greater magnitude of movement
and velocity, were the cleanest portions of the canal. This may be
because of the level that the irrigation needle reached during
irrigation with NaOCl or time required for irrigant to reach the
entire length of the canal (20).

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Journal of Endodontics

The sonic handpiece causes greater horizontal amplitude at the

tip of the file and tends to bind more than the ultrasonic file. This
occasional binding made no noticeable marks on the canal walls.
Another benefit of shorter sonic or ultrasonic passive irrigation
time is that the operator has less time in which to have to maintain
the file in the center of the canal to prevent it from touching the
canal walls.
Because the sonic or ultrasonic files should not contact the canal
walls to prevent a dampening effect, use of a smooth sonic or
ultrasonic file would seem to be a benefit. The smooth files would
prevent the instrument from potentially damaging the finished
canal preparation in the event that the file inadvertently touched the
canal wall during passive irrigation.
The method of determining the percentage of debris used in this
study removes the subjectivity of some previous studies where
evaluators gave canals a score of no, light, moderate, or heavy for
the amount of remaining debris. This method gives the amount of
remaining debris as a percentage of the total area of the canal, thus
making a better comparison of the different techniques used.
No attempt was made in this study to evaluate smear-layer
removal, or the effect of other irrigants on debris and smear-layer
removal with sonics or ultrasonics. Also, this study did not evaluate the cleaning of the isthmus between canals.
CONCLUSION
Passive activation of endodontic files for irrigation with NaOCl
with sonic or ultrasonic energy in canals, for as little as 30 s after
hand instrumentation, produced canals with significantly less debris than canals instrumented by hand files alone. Passive use of
ultrasonic files with NaOCl irrigation produced significantly
cleaner canals than did the passive use of sonic files with NaOCl
irrigation.
The views expressed in this article are those of the authors and do not
necessarily reflect the official policy or position of the Department of the Navy,
Department of the Army, Department of Defense, or the U.S. Government.
The authors are military service members. This work was prepared as part
of their official duties. Title 17 U.S.C. 105 provides that copyright protection
under this title is not available for any work of the United States Government.
Title 17 U.S.C. 101 defines a United States Government work as a work
prepared by a military service member or employee of the United States
Government as part of that persons official duties.
The authors thank Dr. Mark E. Cohen, Naval Dental Research Institute,
Great Lakes, IL, for his help with statistical analysis.
Dr. Sabins is a former resident, Advanced Specialty Education Program in
Endodontics, Naval Postgraduate Dental School, Bethesda, MD. He is currently the staff endodontist, Branch Dental Clinic, Naval Air Station, Whidbey
Island, WA. Dr. Johnson is the former program director, Advanced Specialty
Education Program in Endodontics, and is currently chair, Research Department, Naval Postgraduate Dental School. Dr. Hellstein is a former faculty
member, Oral and Maxillofacial Pathology Department, Naval Postgraduate

Dental School, and is currently associate professor, Oral Pathology, Radiology, and Medicine Department, University of Iowa College of Dentistry, Iowa
City, IA.
Address requests for reprints to James D. Johnson, Endodontics Department, Naval Postgraduate Dental School, National Naval Dental Center, 8901
Wisconsin Avenue, Bethesda, MD 20889-5602.

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