doi:10.1111/j.1365-2591.2007.01243.

REVIEW

Passive ultrasonic irrigation of the root canal: a review of the

literature

L. W. M. van der Sluis1, M. Versluis2, M. K. Wu1 & P. R. Wesselink1

1
Department of Cariology Endodontology Pedodontology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The
Netherlands; and 2Physics of Fluids group, Science and Technology, University of Twente (UT), Enschede, The Netherlands

Abstract The taper and the diameter of the root canal were found to
be important parameters in determining the efficacies of
van der Sluis LWM, Versluis M, Wu MK, Wesselink PR.
Passive ultrasonic irrigation of the root canal: a review of the literature.
dentine debris removal. Irrigation with sodium
International Endodontic Journal, 40, 415–426, 2007.
hypochlorite is more effective than with water and
ultrasonic irrigation is more effective than sonic irrigation
Ultrasonic irrigation of the root canal can be performed in the removal of dentine debris from the root canal. The
with or without simultaneous ultrasonic instrumentation. role of cavitation during PUI remains inconclusive. No
When canal shaping is not undertaken the term passive detailed information is available on the influence of the
ultrasonic irrigation (PUI) can be used to describe the irrigation time, the volume of the irrigant, the penetration
technique. In this paper the relevant literature on PUI is depth of the instrument and the shape and material
reviewed from a MEDLINE database search.Passive properties of the instrument. The influence of irrigation
ultrasonic irrigation can be performed with a small file or frequency and intensity on the streaming pattern as well
smooth wire (size 10–20) oscillating freely in the root as the complicated interaction of acoustic streaming with
canal to induce powerful acoustic microstreaming. PUI the adherent biofilm needs to be clarified to reveal the
can be an important supplement for cleaning the root underlying physical mechanisms of PUI.
canal system and, compared with traditional syringe
Keywords: biofilm, cleaning, dentine debris, irrigation,
irrigation, it removes more organic tissue, planktonic
bacteria and dentine debris from the root canal. PUI is review, root canal, ultrasound.
more efficient in cleaning canals than ultrasonic Received 5 September 2006; accepted 7 December 2006
irrigation with simultaneous ultrasonic instrumentation.
PUI can be effective in curved canals and a smooth wire
can be as effective as a cutting K-file.
Introduction Peters 2004, Naı¨r et al. 2005).
Irregularities of the root canal wall in
With the endodontic procedures at our disposal it is
particular are a major concern, including
impossible to shape and clean the root canal completely.
oval extensions, isthmuses and apical
This is mainly due to the complex anatomy of the root
deltas (Wu & Wesselink 2001, Ricucci &
canal system (Ricucci & Bergenholtz 2003,
Bergenholtz 2003, Peters 2004, Naı¨r et al.
2005). In fact, within oval canals only 40%
Correspondence: L. W. M. van der Sluis, Department of of the apical root canal wall area can be
Cariology Endodontology Pedodontology, ACTA, Louwesweg contacted by instruments when a rotating
1, 1066 EA Amsterdam, The Netherlands (Tel.: technique is used (Wu et al. 2003).
+31 20 5188651; fax: +31 20 6692881; e-mail: l.vd.sluis@ Therefore, irrigation is an essential part of
acta.nl).
a root canal treatment as it allows for
cleaning beyond the root canal instruments.

ª 2007 International Endodontic Journal International Endodontic Journal, 40, 415–426, 2007 415
 Passive ultrasonic irrigation: a review of the literature van der Sluis et al.

The goal of irrigation is to remove pulp tissue UI the file is intentionally brought into
and/or microorganisms (planktonic or biofilm) contact with the root canal wall. UI has
from the root canal system (Haapasalo et al. 2005). been shown to be less effective in
Irrigation should also remove smear layer and removing simulated pulp tissue from the
dentine debris that occur following root canal system or smear layer from the
instrumentation of the root canal (Baugh & root canal wall than PUI (Weller et al.
Wallace 2005). The efficacy of irrigation depends 1980, Ahmad et al. 1987a). This can be
on the working mechanisms of the irrigant and the explained by a reduction of acoustic
ability to bring the irrigant in contact with those streaming and cavitation (Ahmad et al.
elements, materials and structures within the canal 1987a). As the root canal anatomy is
system, which have to be removed (Rosenfeld et complex (Peters 2004) an instrument will
al. 1978, Chow 1983). Sodium hypochlorite never contact the entire root canal wall
(NaOCl) is widely used as an endodontic (Wu et al. 2003). Thus, UI could result in
disinfectant that is effective because it can uncontrolled cutting of the root canal wall
dissolve organic tissue, can kill microorganisms, without effective cleaning.
act as a lubricant and is nontoxic (Haapasalo et al. Passive ultrasonic irrigation was first described by
2005). However, chlorine, which is responsible for Weller et al. (1980). The term ‘passive’ does not
the dissolving and antibacterial capacity of adequately describe the process, as it is in fact active;
NaOCl, is unstable and is consumed rapidly during however, when it was first introduced the term ‘passive’
the first phase of tissue dissolution, probably related to the ‘noncutting’ action of the ultrasonically
within 2 min (Moorer & Wesselink 1982); activated file. PUI relies on the transmission of acoustic
therefore continuous replenishment is essential. energy from an oscillating file or smooth wire to an
Ultrasonic devices were first introduced irrigant in the root canal. The energy is transmitted by
in Endodontics by Richman (1957). means of ultrasonic waves and can induce acoustic
Ultrasonically activated files have the streaming and cavitation of the irrigant (Ahmad et al.
potential to prepare and debride root canals 1987a,b, Ahmad et al. 1988, Lumley et al. 1991, Ahmad
mechanically. The files are driven to et al. 1992, Roy et al. 1994). After the root canal has been
oscillate at ultrasonic frequencies of 25–30 shaped to the master apical file (irrespective of the
kHz that are beyond the limit of human preparation technique used), a small file or smooth wire
hearing. The files operate in a transverse (for example size 15) is introduced in the centre of the
vibration, setting up a characteristic pattern root canal, as far as the apical region. The root canal is
of nodes and anti-nodes along their length then filled with an irrigant solution and the ultrasonically
(Walmsley 1987, Walmsley & Williams oscillating file activates the irrigant. As the root canal has
1989). already been shaped, the file or wire can move freely and
Unfortunately, it proved to be difficult to the irrigant can penetrate more easily into the apical part
control the cutting of dentine during of the root canal system (Krell et al. 1988) and the
ultrasonic preparation, with the result that cleaning effect will be more powerful
it is impossible to control the shape of the (Ahmad et al. 1987a,b,1988,1992, Lumley et al. 1991,
prepared root canal and apical perforations Roy et al. 1994). Using this noncutting methodology, the
and irregular shapes were produced (Stock potential to create aberrant shapes within the root canal
1991, Lumley et al. 1992). will be reduced to a minimum. A file larger than size 15
On the other hand it has been shown that or 20 will only oscillate freely in a wide root canal. A
ultrasonically driven files are effective for size 25 file may in fact produce less acoustic streaming
the ‘irrigation’ of root canals. Two types of than a size 15 and 20 file (Ahmad et al. 1987b).
ultrasonic irrigation have been described in Consequently, using a file larger than size 20 may be
the literature: one where irrigation is considered fundamentally different from the basic
combined with simultaneous ultrasonic principle of PUI. The cleaning efficacy of PUI implies
instrumentation (UI) and another without the effective removal of dentine debris, microorganisms
simultaneous instrumentation, so called (planktonic or in biofilm) and organic tissue from the root
passive ultrasonic irrigation (PUI). During canal. Because of the active streaming of the irrigant its

416 International Endodontic Journal, 40, 415–426, 2007 ª 2007 International Endodontic Journal
 van der Sluis et al. Passive ultrasonic irrigation: a review of the literature

potential to contact a greater surface area of the canal Different frequencies, intensities and
wall will be enhanced. displacement amplitudes of the files were
The purpose of this review is to evaluate the literature used in the various studies. Whether these
on PUI, to provide a description of the mechanism and its parameters influenced the results reported
effects and to evaluate if PUI is more effective in is not known. Other variables that are
cleaning the root canal than syringe irrigation. encountered in laboratory research, e.g. the
difference in preoperative status of the
teeth, storage media and storage time may
Materials and methods
also have an influence on the outcome.
The literature search used the MEDLINE database which However, their effect is unknown.
goes back to 1965. Reference lists of potentially relevant
articles and review articles were also screened for the
Results
search strategy. The following combinations of keywords
were used for the search strategy: The results of the review are divided into
• ‘ultrasound irrigation root canal’ two parts. The first part describes the
• OR ‘ultrasonic irrigation root canal’ mechanism of PUI and the second part the
• OR ‘passive ultrasonic irrigation’ effects of PUI.
• OR ‘ultrasound NaOCl’
• OR ‘ultrasonic cavitation root canal’ Mechanism of passive ultrasonic irrigation
• OR ‘ultrasonic acoustic streaming root canal’ • OR
‘ultrasonic bacteria root canal’ Frequency and intensity
• OR ‘ultrasonic biofilm root canal’. An ultrasonic device converts electrical
Care was taken to include only studies that addressed energy into ultrasonic waves of a certain
‘passive’ ultrasonic irrigation; studies using UI were frequency by magnetostriction or by
excluded. It appeared that there is little consensus about piezoelectricity. On one hand,
the terminology of ultrasonic irrigation in the literature. magnetostriction is generated by the
For example, PUI occasionally was mentioned, whilst in deformation of a ferromagnetic material
fact UI was meant. Such discrepancies potentially had a subjected to a magnetic field; on the other
considerable influence on the interpretation of the results hand piezoelectricity is the generation of
of PUI. The papers were screened independently by two stress in dielectric crystals subjected to an
reviewers (M-K. W. and L.S.). The quality of the papers applied voltage. Piezoelectricity was used
was assessed including an evaluation of the study design in the studies of Goodman et al. (1985),
and statistical tests. Some papers were categorized as Ahmad et al. (1992, 1993), Cheung &
observational studies. These studies describe in detail Stock (1993), Lee et al. (2004a,b) and van
acoustic streaming patterns, cavitation or displacement der Sluis et al. (2005a,b, 2006). Only one
amplitudes of the file or wire (Ahmad et al. 1987a,b, pilot study was undertaken to compare
Cameron 1987a,b, Lumley et al. 1988, Cameron 1988, devices using magnetostriction or
Ahmad 1989, Walmsley & Williams 1989, Ahmad 1990, piezoelectricity at different intensities,
Lumley et al. 1991, Ahmad et al. 1992, 1993, Lumley & however, no conclusive evidence was
Walmsley 1992, Roy et al. 1994, Cameron 1995, Lea et provided (Cameron 1995).
al. 2004). Moreover, three review articles on ultrasonic The properties of the ultrasonic material
irrigation cleaning were included: Walmsley (1987), determine the frequency of the oscillating
Walmsley et al. (1991) and Stock (1991). instrument, which in dental practice, is
The search resulted in a total of 74 articles of which 20 fixed at 30 kHz. The intensity or energy
were excluded because they did not correspond with the flux, expressed in units of Watt cm )2, of the
inclusion criteria, one because of insufficient oscillating instrument can be adjusted by
methodology (Teplitsty et al. 1987). The articles where the power setting. Frequency and intensity
the term ‘UI’ was used instead of ‘PU’ are listed in Table do play a role in the transmission of energy
1. from the ultrasonically oscilla-

ª 2007 International Endodontic Journal International Endodontic Journal, 40, 415–426, 2007 417
 Passive ultrasonic irrigation: a review of the literature van der Sluis et al.

Table 1 Articles which were not included because they dealt with vibrating membranes or wires, which arise
ultrasonic instrumentation and not passive ultrasonic irrigation from the frictional forces between a
boundary and medium carrying vibrations
Cunningham et al. (1982), Barnett et al. (1985), of circular frequency (Leighton 1994).
Chenail & Teplitsky (1985), Langeland et al. (1985), Griffiths & Stock Several papers have confirmed that
(1986), Krell & Johnson (1988), Biffi & Rodrigues (1989), Haidet et al.
(1989), Rodrigues & Biffi (1989), Walker & del Rio (1989), Archer et al.
acoustic microstreaming occurs during PUI
(1992), Baumgartner & Cuenin (1992), Briseno et al. (1992), Lumley et al. (Ahmad et al. 1987a,b, Walmsley 1987,
(1992, 1993), Panighi & Jacquot (1995), Guerisoli et al. (2002), Siqueira et Walmsley & Williams 1989, Lumley et al.
al. (2002),
1991, Walmsley et al. 1991, Ahmad et al.
Walters et al. (2002)
1992, 1993, Lumley et al. 1993, Roy et al.
ting file to the irrigant but a full 1994) (Fig. 1). The streaming pattern
understanding of the mechanism is still corresponds to the characteristic pattern of
lacking. A higher frequency should in nodes and antinodes along the length of the
principle oscillating file.
result in a The
higher displacement
streaming amplitude is at
velocity of its maximum at
the irrigant, the tip of the
as will be file, probably
addressed causing a
later. This directional flow
in turn to the coronal
results in a part of the root
more canal (Ahmad et
powerful al. 1987a).
acoustic When the file
streaming. touches the root
Increasing canal wall at an
the antinode a
intensity greater reduction
does not result in a linear increase of the in displacement amplitude will occur
displacement amplitude of the oscillating compared with when it touches at a node
file (Ahmad et al. 1987a, Walmsley & (Walmsley & Williams 1989, Lumley et al.
Williams 1989, Lea et al. 2004). However, 1993). When the file is unable to vibrate
this observation is taken from studies that freely in the root canal, acoustic
investigated the oscillation of the file in microstreaming will become less intense,
free air. Therefore, a direct relationship however, it will not stop completely
with acoustic microstreaming could not be (Ahmad et al. 1988, 1992, Lumley et al.
established. 1991, 1993, Roy et al. 1994). The resultant
Acoustic streaming acoustic microstreaming depends inversely
Acoustic streaming is the rapid movement on the surface area of the file touching the
of fluid in a circular or vortex-like motion root canal wall.
around a vibrating file (Walmsley 1987). In curved canals, pre-shaping the file will result in
The acoustic streaming that occurs in the more powerful acoustic microstreaming (Ahmad et al.
root canal during ultrasonic irrigation has 1992, Lumley et al. 1992, Lumley & Walmsey 1992). A
been described as acoustic microstreaming. pre-shaped file shows the same pattern of nodes and
This is defined as the streaming which antinodes as a straight file both in air and in the confined
occurs near small obstacles placed within a geometry of a root canal (Lumley & Walmsley 1992).
sound field, near small sound sources,

418 International Endodontic Journal, 40, 415–426, 2007 ª 2007 International Endodontic Journal
 van der Sluis et al. Passive ultrasonic irrigation: a review of the literature

The intensity of the acoustic microstreaming is directly liquid through tensile forces induced by high-speed flows
related to the streaming velocity. The equation that in first or flow gradients. These bubbles expand and then rapidly
approximation describes the streaming velocity is xe20 collapse producing a focus of energy leading to intense
v¼ ; ð1Þ a sound and damage, e.g. pitting of ship propellers and
pumps. Acoustic cavitation can be defined as the creation
where v is the liquid streaming velocity, x is 2p times the
of new bubbles or the expansion, contraction and/or
driving frequency, e0 is the displacement amplitude and a
distortion of pre-existing bubbles (so-called nuclei) in a
the radius of the wire. Following equation 1 it can be
liquid, the process being coupled to acoustic energy
concluded that the thinner the file, the higher the
(Leighton 1994). Cavitation is beneficially used in
frequency and the greater the displacement amplitude of
industrial ultrasound cleaning (Moholkar et al. 2004),
the file, the higher the streaming velocity and the more
megasonic chip cleaning (Kern 1990), lithotripsy (Church
powerful the acoustic microstreaming will be. Whether
1989) and even by small shrimp to stun prey (Versluis et
this equation will also hold for the complicated nonlinear
al. 2001). In this review the term cavitation refers to
streaming pattern during PUI remains to be shown.
acoustic cavitation.
The shear flow caused by acoustic microstreaming
According to Roy et al. (1994), two types of cavitation
produces shear stresses along the root canal wall, which
could occur during PUI of root canals: stable cavitation
can remove debris and bacteria from the wall. The shear
and transient cavitation. Stable cavitation could be
stress is expressed in the following equation (Ahmad et
defined as linear pulsation of gas-filled bodies in a low
al. 1988):
amplitude ultrasound field. Transient cavitation occurs
when vapour bubbles undergo highly energetic pulsations
(Fig. 2). When the acoustic pressures are high enough, the
bubbles can be inertially driven to a violent collapse,
radiating shock waves and generating high internal gas
pressures and temperatures. The energy at the collapse
point is in some cases sufficient to dissociate the gas
molecules in the bubble, which recombine radiatively to
produce light, a process known as sonoluminescence
(Crum 1994, Brenner et al. 2002). In the studies of
Ahmad et al. (1988), Lumley et al. (1993) and Roy et al.
(1994), sonoluminescence was used to detect transient
cavitation.
Transient cavitation only occurs when
the file can vibrate freely in the canal or
when the file touches lightly
(unintentionally) the canal wall (Lumley et
Figure 1 Acoustic streaming around a file in free water (left) and al. 1993, Roy et al. 1994). Increased
a schematic drawing (right). (intentional) contact with the canal wall, as
V gxe20 in UI, excludes transient cavitation. The
s ¼ gc_ ¼ g ¼ ; ð2Þ d ad surface property of the file is important for
the enhancement of cavitation (Roy et al.
where g the kinematic viscosity of the liquid, V the 1994). In their study a smooth file with
streaming velocity (from equation 1) and d the boundary sharp edges and a square cross-section
layer thickness. This equation is an approximation and it produced significantly more transient
remains to be shown whether it is applicable to the cavitation than a normal K-file. The sharp
typical, more complex, flow conditions of the root canal. edges could have induced so-called edge
cavitation. The transient cavitation was
Cavitation and cavitational microstreaming visible at the apical end and along the
length of the file. When the file came in
Cavitation in the fluid mechanical context can be contact with the canal wall, stable
described as the impulsive formation of cavities in a cavitation was affected less than transient

ª 2007 International Endodontic Journal International Endodontic Journal, 40, 415–426, 2007 419
 Passive ultrasonic irrigation: a review of the literature van der Sluis et al.

cavitation and was mainly seen at the

midpoint of the file (Roy et al. 1994). A
pre-shaped file brought into a curved canal
is more likely to produce transient
cavitation rather than a straight file (Roy et
al. 1994). Other researchers claim that
cavitation provides only minor benefit in
ultrasonic irrigation, or that it does not
occur at all (Walmsley 1987, Ahmad et al.
1988, Lumley et al. 1988).
Figure 2 Left: Glass root canal model allowing optical
access to the vibrating file for high-speed visualization of
ultrasonic irrigation. Middle: File in operation captured at

microseconds timescale displaying both transient and inertial cavitation phenomena and in addition local streaming
patterns (only visible in video mode). Right: A high-speed recording of a noncutting K-file is shown, displaying
vigorous microstreaming and collapsing cavitation bubbles.
Figure 3 Dentine debris packed in oval shaped root canal after syringe irrigation (left) and clean oval canal after 3 min of
PUI (right).
The effects and use of PUI root canal. Removal of EDTA before the injection of 2
mL NaOCl in the root canal was not mentioned. EDTA
PUI versus syringe irrigation
inactivates the NaOCl and it is possible that this had an
After shaping the root canal, cleaning can be completed
influence on the outcome.
with PUI or a final flush of syringe irrigation. From the
studies where PUI and syringe irrigation were compared,
PUI with NaOCl as irrigant
it can be concluded that PUI is more effective in
During PUI, NaOCl removes significantly more smear
removing remnants of pulp tissue and dentine debris
layer or bacteria from artificial smear layer, pulp tissue or
(Goodman et al. 1985, Cameron 1987a, Metzler &
dentine debris from the root canal than water (Cameron
Montgomery 1989, Cheung & Stock 1993, Lee et al.
1987b, Metzler & Montgomery 1989, Cheung & Stock
2004b, Gutarts et al. 2005, Passarinho-Neto et al.
1993, Heard & Walton 1997, Tu¨rku¨n & Cengiz 1997,
2006) and planktonic bacteria (Sjo¨gren & Sundqvist
Huque et al. 1998, van der Sluis et al. 2006). The
1987, Huque et al. 1998, Spoleti et al. 2003, Weber et al.
significant increase in dissolving capacity of organic
2003) (Fig. 3). In the studies by Goodman et al. (1985),
material by NaOCl, when NaOCl is agitated by
Cheung & Stock (1993), Spoleti et al. (2003), Gutarts et
ultrasound (Moorer & Wesselink 1982) or when the
al. (2005), Passarinho-Neto et al. (2006), the working
temperature rises because of ultrasound (Cunningham &
volume of the experimental irrigant was standardized
Balekjian 1980, Cameron 1988, Ahmad 1990) can be an
between the groups. In all these studies NaOCl was used
explanation for the enhanced performance of NaOCl.
as the irrigant except the study of Spoleti et al. (2003) and
When a greater concentration of NaOCl is used the
Weber et al. (2003), where sterile saline and
efficacy appears to increase (Tu¨rku¨n & Cengiz 1997,
chlorhexidine and NaOCl was used respectively.
Huque et al. 1998).
In the study of Mayer et al. (2002) no significant
difference was found between PUI and syringe irrigation
in dentine debris removal from the root canal. Before
activating ultrasonically the NaOCl, EDTA was left in the

420 International Endodontic Journal, 40, 415–426, 2007 ª 2007 International Endodontic Journal
 van der Sluis et al. Passive ultrasonic irrigation: a review of the literature

Removal of bacteria methodology is that only a very small part of the root
The PUI results in a significant reduction of bacteria canal can be evaluated and this is often not standardized.
(Martin 1976, Collinson & Zakariasen 1986, Ahmad
1989), or shows significantly better results than syringe PUI in curved canals
irrigation (Sjo¨gren & Sundqvist 1987, Huque et al. 1998, The PUI can also be effective in curved canals (Goodman
Spoleti et al. 2003, Weber et al. 2003). Only in the study et al. 1985, Metzler & Montgomery 1989, Jensen et al.
of Siqueira et al. (1997) the difference was not 1999, Sabins et al. 2003, Gutarts et al. 2005) and the best
significant. In the study by Huque et al. (1998), PUI with result is obtained when the file is pre-bent (Ahmad et al.
12% NaOCl as irrigant almost completely removed 1992, Lumley & Walmsley 1992). In the studies of
different types of planktonic bacteria from a parallel- Goodman et al. (1985), Metzler & Montgomery (1989),
sided canal by a streaming effect through the dentinal Jensen et al. (1999), Sabins et al. (2003), Gutarts et al.
tubules. (2005), the apical portion of the root canal was examined,
Studies on the antibacterial effect of PUI have focused i.e. below the curve. When compared with syringe
on the removal of planktonic bacteria through the flushing irrigation (Goodman et al. 1985, Metzler & Montgomery
effect. The physical mechanisms describing the effect of 1989, Gutarts et al.
ultrasonic irrigation on biofilms in the root canal are 2005) PUI performed significantly better.
unknown, although cavitation has shown to be able to
destroy or even remove a biofilm (Ohl et al. PUI and the cleaning of the isthmus
2006). Some studies specifically evaluated the cleaning efficacy
of PUI in the isthmus which runs between two canals.
Removal of the smear layer Their results confirm a significantly cleaner isthmus when
Studies on smear layer removal by PUI are inconclusive. PUI is used compared with syringe irrigation (Goodman
However, the various studies selected different types and et al. 1985, Metzler & Montgomery 1989, Gutarts et al.
concentrations of irrigant solution. When 3% NaOCl was 2005), which demonstrates that PUI has the potential to
used Cameron (1983) found complete removal of smear remove pulp tissue and dentine debris from remote areas
layer with 3 and 5 min of PUI; the results were confirmed of the root canal system untouched by endodontic
in a subsequent study (Cameron 1987b). Alac¸am (1987) instruments.
could completely remove the smear layer after 3 min of
PUI with 5% NaOCl and Huque et al. (1998) after 20 s Ultrasonic versus sonic irrigation
PUI with 12% NaOCl. A 5% NaOCl solution during 3 Sonic irrigation is different from ultrasonic irrigation
min PUI could remove more smear layer than 0.5% because it operates at a lower frequency. For sonic
NaOCl from the apical and middle part of the root canal application the frequencies ranges from 1000 to 6000 Hz.
(Tu¨rku¨n & Cengiz 1997). Consequently, following equation 1, the streaming
Cheung & Stock (1993) could not completely remove the velocity of the irrigant will be lower. Moreover, the
smear layer using 10 s PUI with 1% NaOCl, although oscillating patterns of the sonic instruments are different.
PUI was significantly better than syringe irrigation. In the They have one node near the attachment of the file and
studies of Ciucchi et al. (1989) and Abbott et al. (1991) one antinode at the tip of the file. When the movement of
ultrasound did not enhance the removal of the smear layer the sonic file is constrained, the sideway movement will
when EDTA or a combination of EDTA and NaOCl was disappear, but will result in a longitudinal vibration
used as irrigant. On the other hand, PUI could (Lumley et al. 1996).
significantly improve the smear layer removal of Savlon Two studies report that PUI removed more dentine
(0.03% chlorhexidine, 0.3% cetrimide). PUI with water as debris from the root canal than sonic irrigation (Stamos et
irrigant is unable to remove the smear layer (Cameron al. 1987, Sabins et al. 2003), whilst in one study no
1983, 1987b, Heard & Walton 1997, Tu¨rku¨n & Cengiz significant difference was found (Jensen et al. 1999). In
1997, Huque et al. 1998). All studies show increased the study by Jensen et al. (1999), however, pre-shaping of
removal of the smear layer primarily from the coronal the files was not mentioned and this may explain their
part of the root canal wall rather than the apical part, findings. The positive relationship between streaming
except for one study (Tu¨rku¨n & Cengiz 1997). velocity and frequency can explain the higher efficiency
All these studies used the SEM technique to investigate of PUI versus sonic irrigation.
the presence of smear layer. A disadvantage of this

ª 2007 International Endodontic Journal International Endodontic Journal, 40, 415–426, 2007 421
 Passive ultrasonic irrigation: a review of the literature van der Sluis et al.

Heating of irrigant and root surface during PUI the root canal system is more likely to be influenced by
Cameron (1988) reported a rise of the intracanal time than by the volume used (Druttman & Stock 1989).
temperature from 37 to 45 C close to the tip of the This is confirmed by a study of Passarinho-Neto et al.
instrument and 37 C away from the tip when the irrigant (2006), where 5 min of PUI removed more dentine debris
was ultrasonically activated for 30 s without from the root canal than 1 min using a continuous flow of
replenishment. A cooling effect from 37 to 29 C was NaOCl, when the volume was the same in both groups.
recorded when the irrigant was replenished with a When the irrigant is injected in the root canal by a
continuous flow of irrigant. The temperature of the syringe, the amount of irrigant flowing through the apical
irrigant was 25 C. The external temperature stabilized at region of the canal can be controlled because both volume
32 C during a continuous flow of the irrigant and reached and depth of syringe penetration are known, this is not
a maximum of 40 C in 30 s without continuous flow. possible using the continuous flush from the handpiece.
Ahmad (1990) reported a mean rise of temperature of 0.6 The apical flow is important because frequent
C during a continuous flow of irrigant. The initial replenishment of NaOCl is essential.
temperature of the irrigant was 20 C. A rise of
temperature within these ranges will not cause Irrigation time
pathological temperature rises in the periodontal The influence of irrigation time on the efficacy of PUI is
ligament. not clear. One study claimed an increased removal of the
smear layer after 5 min of PUI as opposed to 3 min
(Cameron 1983). In the study of Sabins et al. (2003), no
PUI parameters
significant difference was found between 30 and 60 s of
Taper of the file and diameter of the root canal PUI in dentine debris removal from the root canal. In
The taper and diameter of the root canal have an influence their study, instead of a continuous flow of NaOCl during
on the efficacy of PUI in dentine debris removal from the PUI, the NaOCl was injected in the root canal by a
root canal. In the studies by Lee et al. (2004a) and van der syringe and not refreshed during the ultrasonic activation
Sluis et al. (2005b), 3 min of PUI with 2% NaOCl was of NaOCl.
performed in each canal. From their results, it can be
concluded that within certain limits (size 20, taper 0.04 to PUI with a smooth wire
size 20, taper 0.10) the greater the taper the more dentine A smooth wire is as effective as a normal cutting file in
debris can be removed. dentine debris removal during PUI (van der Sluis et al.
Application of irrigant during PUI 2005a). It seems preferable to use a smooth wire during
Two flushing methods can be used during PUI, namely a PUI because it does not intentionally cut into the root
continuous flush of irrigant from the ultrasonic handpiece canal wall and it may, therefore, prevent aberrant root
or an intermittent flush method using syringe delivery canal shapes or perforation of the (apical) root (Mayer et
(Cameron 1988). In the intermittent flush method, the al. 2002). Several studies (Weller et al. 1980, Cameron
irrigant is injected into the root canal by a syringe, and 1983, Goodman et al. 1985, Cameron 1987a,b, Tu¨rku¨n
replenished several times after each ultrasonic activation. & Cengiz 1997, Mayer et al. 2002, Gutarts et al. 2005)
During ultrasonic activation, an ultrasonically oscillating have used smooth wires, and demonstrated their
instrument (file or smooth wire) will activate the irrigant effectiveness during PUI. The smooth wire used in the
in the root canal such that microorganisms, dentine debris study by Gutarts et al. (2005) was in fact a hollow
and organic tissue will be detached from the root canal ultrasonically activated needle through which the irrigant
wall and be absorbed or dissolved in the irrigant (Weller was delivered into the root canal.
et al. 1980, Moorer & Wesselink 1982). Hereafter, the
root canal is flushed with 2 mL of fresh irrigant to remove
Discussion
the remnants from the root canal. Both flushing methods
were equally effective in removing dentine debris from Acoustic microstreaming or cavitation play an important
the root canal in an ex vivo model when the irrigation role in the efficacy of PUI. However, the details
time was set at 3 min (van der Sluis et al. concerning those mechanism have not been clarified. An
2006). accurate description of the streaming pattern of the
Druttman & Stock (1989) concluded that using a irrigant ‘in the root canal’ during PUI for instance is still
continuous flush of irrigant, the irrigant replacement in

422 International Endodontic Journal, 40, 415–426, 2007 ª 2007 International Endodontic Journal
 van der Sluis et al. Passive ultrasonic irrigation: a review of the literature

not available. Therefore, the exact physical mechanisms Conclusion

responsible for the efficacy of PUI remain uncertain.
Based on this literature review it is concluded that PUI
In some of the studies large standard deviations have appears to be an adjunctive treatment for cleaning the root
been reported, indicating a substantial variation in the canal system and that PUI is more effective than syringe
efficacy of PUI. An explanation could be that it is irrigation. More research is needed to clarify the
difficult to standardize the positioning of the underlying physical mechanisms through which PUI
ultrasonically activated instrument in the centre of the exerts its efficacy.
root canal and to standardize the displacement amplitude
as a small constraint in the canal will change the
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