Basic ResearchTechnology

In Vitro Comparisons of Debris Removal of the

EndoActivatorTM System, the F FileTM, Ultrasonic Irrigation,
and NaOCl Irrigation Alone after Hand-rotary
Instrumentation in Human Mandibular Molars
Steven L. Klyn, DDS,* Timothy C. Kirkpatrick, DDS, and Richard E. Rutledge, DDS
Abstract
Introduction: The purpose of this in vitro study was
to compare the debris removal efficacy of the EndoActivatorTM system, the F fileTM, ultrasonic irrigation, or 6%
NaOCl irrigation alone in human mandibular molars
after hand-rotary instrumentation. Methods: A custom
brass cube (K-Kube) was used to create a sealed canal
system, allowing each tooth to serve as its own control.
Forty extracted mandibular molars were randomly
divided into 4 equal experimental groups. Each tooth
was mounted, sectioned at 1, 3, and 5 mm from the
working length, and then reassembled into the KKube, and the mesial roots were similarly prepared by
using hand-rotary instrumentation. For final debridement, group 1 used F file for 30 seconds, group 2
used EndoActivator system for 30 seconds, group 3
used ultrasonic irrigation for 30 seconds, and group
4 used irrigation with 6% NaOCl within 1 mm of
working length. All groups received a final irrigation
with 6% NaOCl in each canal. Specimens were evaluated at 1, 3, and 5 mm from the working length for
cleanliness by capturing a digital image with a stereomicroscope. All specimens had the percent cleanliness for
each canal and isthmus calculated both before and after
final debridement. Statistical analysis was completed
by using a repeated-measures analysis of variance
with Tukey post hoc tests. Results and Conclusions:
The results showed no statistically significant difference
in canal or isthmus cleanliness among the 4 groups, but
there was a statistically significant difference (P < .001)
in canal cleanliness between the 1-mm level versus the
3-mm and 5-mm levels for all of the groups. (J Endod
2010;36:13671371)

Key Words

he prevention or treatment of apical periodontitis is the ultimate goal of endodontic

therapy (1). Complete debridement of the root canal system is complicated by the
presence of a complex system of isthmuses, accessory canals, fins, and deltas that can
provide ideal locations for harboring debris (2). The residual debris within the canal
system can be composed of bacteria, other microorganisms and their by-products, vital
and necrotic pulp tissue, smear layer, and biofilm. Although mechanical instrumentation and the use of irrigants within the canal have shown effectiveness, complete cleanliness of these inaccessible areas is difficult to achieve (36). Studies have shown that
incomplete canal debridement can lead to a decrease in endodontic success (7, 8).
To aid in the removal of debris and the disinfection of the canal system, the use of
various intracanal irrigants and techniques has been advocated (9, 10). No single
solution or technique has been found to achieve complete canal debridement, but
the use of ultrasonics as an adjunct to cleaning and shaping has shown increased
canal cleanliness. Archer et al (11) compared step-back instrumentation alone with
step-back instrumentation followed by ultrasonic irrigation and showed significantly
cleaner canals and isthmuses at 1, 2, and 3 mm from the apex with the use of ultrasonics. Other studies have confirmed the effectiveness of ultrasonic irrigation on the
removal of debris from within the canals and isthmuses (1216).
Ultrasonic irrigation has the potential for continued prepping or cutting of the
canal walls during its use after cleaning and shaping. Canal deviation, apical zipping,
and even root perforations can occur while using an ultrasonically activated file within
a curved canal during irrigation. These potential problems have led researchers to the
development of new techniques based on ultrasonic technology. By using a modified
ultrasonically charged irrigation needle, Burleson et al (17) showed a significant
improvement in canal cleanliness at the apex and within the isthmuses of the mesial
roots of mandibular molars without undue canal deviation.
Two systems to aid in the debridement of the canal system were recently introduced, the EndoActivator System (Advanced Endodontics, Santa Barbara, CA) and
the F file (Plastic Endo, Buffalo Grove, IL). Both systems use noncutting plastic or polymer tips to enhance root canal debridement after instrumentation. The tips do not
actively engage the dentin walls, thus preventing further enlargement of the canals.
The purpose of this in vitro study was to compare the effectiveness of the F file, the
EndoActivator System, ultrasonic irrigation, and 6% NaOCl irrigation alone in removing
canal and isthmus debris in human mandibular molars.

EndoActivator, F file, irrigation, K-Kube, ultrasonics

From the *Department of Endodontics, 10th Dental Squadron, United States Air Force Academy, Colorado; and Department of Endodontics, Wilford Hall Medical
Center, Lackland Air Force Base, Texas.
Address requests for reprints to Timothy C. Kirkpatrick, DDS, Program Director, Endodontics Residency, Wilford Hall Medical Center, 59th Dental Training Squadron/
SGDTN, 2450 Pepperrell St, Lackland AFB, TX 78236. E-mail address: timothy.kirkpatrick@us.af.mil.
0099-2399/$0 - see front matter
Copyright 2010 Published by Elsevier Inc. on behalf of the American Association of Endodontists.
doi:10.1016/j.joen.2010.03.022

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Materials and Methods
Specimen Preparation
Forty extracted human mandibular molars with mesial root curvatures less than 25 degrees were selected and stored in 0.5%
chloramine-T before use. The buccal and lingual cusps were flattened
to provide a reproducible reference point during instrumentation
(Fig. 1C).
After standard access openings were made, working length (WL)
was determined by inserting a #10 Flex-R file (Miltex, York, PA) until
the tip of the file was visible at the apical foramen and subtracting 1
mm. Each mesial canal was instrumented until a Profile GT #20/.06
file (Dentsply-Tulsa Dental, York, PA) could be inserted to the WL. Irrigation was with saline only. The access opening was sealed with a moist
cotton pellet and Cavit (3M ESPE, St Paul, MN), making sure the Cavit
extended into the orifice of the distal canal. The distal root was amputated, and Triad gel (Dentsply Trubyte, York, PA) was used to seal the
apical foramina on the mesial roots and the distal root orifice to prevent
mounting resin from entering these areas.
To allow more precise visualization of the root apex during
sectioning, the apical 2 mm of the mesial roots was dipped in methylene
blue. The teeth were then embedded into a custom-made metal cube (KKube) at the level of the cementoenamel junction by using VariKleer
resin (Buehler, Lake Bluff, IL) (Fig. 1A, B, E, F). Each specimen was
cured by using a pressure pot of warm water at 20 psi for 30 minutes.
After the resin had set, the embedded specimens were removed from the
cube and stored in 100% humidity.
Specimen Sectioning
The mounted specimens were sectioned at 2, 4, and 6 mm from
the apex (Fig. 1D) of the root by using an Isomet low-speed saw with
a 0.30-mm-thick diamond blade (Buehler). The blade was irrigated
with Isocut Plus Fluid (Buehler) and water according to the manufacturers recommendations.

Three 2-mm-thick sections were used for evaluation and scoring:

section 1, apex to 1 mm coronal to WL; section 2, 13 mm coronal to
WL; and section 3, 35 mm coronal to WL.

Canal Preparation
After sectioning, the specimens were reassembled into the K-Kube,
and all external hex bolts were firmly tightened. The Cavit and cotton
pellet were removed, and a hand file was used to verify WL and proper
assembly. Following coronal flaring with Gates Glidden drills (Dentsply,
York, PA), the canals were prepared with ProFile 0.04 rotary files
(Dentsply-Tulsa Dental) using a crown-down technique to a master
apical file size #40. Between each rotary file, 0.5 mL of 6% NaOCl
was used to irrigate each canal by using a 30-gauge Max-i-ProbeTM
(Dentsply). The Max-i-Probe was inserted until resistance was felt
and then backed up approximately 0.5 mm. After final instrumentation,
each canal was irrigated with 2 mL of 6% NaOCl and dried with a capillary tip (Ultradent, South Jordan, UT) and paper points. Each canal was
then irrigated with 2 mL of 17% ethylenediaminetetraacetic acid and
dried before final irrigation with 2 mL 6% NaOCl. All canals were
then dried and the access was sealed with a moist cotton pellet and Cavit.
Method of Evaluation
Each specimen was then disassembled and images of the coronal
aspect of each section were made by using a digital camera (Olympus
DP71; Olympus, Tokyo, Japan) attached to a stereomicroscope
(Olympus SZX16) at the highest magnification to allow complete view
of the canals and isthmus. The full color images were viewed on a Cintiq
21 UX (Wacom Co Ltd, Saitama, Japan) monitor, and an interactive pen
was used to trace the outline of the root canal, isthmuses, and remaining
debris (Fig. 2). Debris was defined as any material present on the canal
walls and in the canal lumen or isthmus. The software program Image J
(National Institutes of Health, v1.39a) was used to calculate the area of
the root canals, isthmuses, and amount of debris present. In order to

Figure 1. Specimen preparation. (A) K-Kube disassembled; (B) K-Kube assembled; (C) specimen preparation; (D) specimen mounted in resin and 2-mm sections
measured; (E) sectioned specimen partially reassembled in K-Kube; (F) specimen fully mounted in K-Kube with access for instrumentation. (This figure is available
in color online at www.aae.org/joe/.)

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Figure 2. Digital images of a specimen section at the 5-mm level demonstrating canal and isthmus debris. (A) Initial canal access only; (B) post cleaning and
shaping; (C) post experimental treatment. An interactive pen was used to trace the outline of the canals, isthmuses, and remaining debris as shown in (D). Image J
software was used to compute the canal cleanliness. (This figure is available in color online at www.aae.org/joe/.)

calculate the canal cleanliness, the area of remaining debris was divided
by the total area of the canal or isthmus to yield a percentage. The
percentage of canal debris present was subtracted from 1 to determine
the percent of canal cleanliness.

Final Debridement
The specimen sections were reassembled into the K-Kube, and
each tooth was randomly assigned to 1 of 4 experimental groups.
Each group was treated according to the manufacturers directions
and then dried with a capillary tip.
In group 1, the canals and chamber were filled with 2 mL of 6%
NaOCl, and the F file (size #20/0.04 taper) was passively inserted
into the canal with an electric slow-speed handpiece set at 600 rpm
and a torque of 132 g/cm. The file was circumferentially worked along
the dentinal walls with a cyclic axial motion (up and down) for
30 seconds.
In group 2, the canals and chamber were filled with 2 mL of 6%
NaOCl before treatment. The EndoActivator sonic handpiece was set
at 10,000 cpm, and a size #15/0.02 taper activator tip was passively inserted to within 2 mm of the WL and used in a pumping action to move
the EndoActivator tip in short, 23 mm vertical strokes for 30 seconds.
In group 3, the canals and chamber were filled with 2 mL of 6%
NaOCl, and a 30K PEC Endosonic size #20 file (Dentsply) was passively
inserted into the canals. The file was circumferentially worked along the
dentinal walls with a cyclic axial motion (up and down) for 30 seconds
using an ultrasonic unit set at a consistent low power and water
irrigation.
In group 4, each specimen had a Max-i-Probe inserted to within 1
mm of WL, and both the canals and chamber were filled and irrigated
with 2 mL (1 mL in each canal) of 6% NaOCl.
JOE Volume 36, Number 8, August 2010

All groups received a final irrigation with 2 mL 6% NaOCl in each

canal. After drying with a capillary tip and paper points, the specimens
were removed from the K-Kube, disassembled, and evaluated as before
for debris. Percent cleanliness was calculated for each canal and
isthmus immediately after instrumentation and after using the experimental final debridement technique. The percent change in debris
was statistically analyzed by using a repeated-measures analysis of
variance with Tukey post hoc tests (significance level, P < .05).

Results
A comparison of canal and isthmus cleanliness is shown in Fig. 3.
There was no statistically significant difference in canal or isthmus
cleanliness with the F file, EndoActivator, or ultrasonics when used as
an adjunct to aid in canal debridement compared with irrigation alone
with NaOCl. All 4 treatment groups demonstrated a statistically significant difference (P < .001) in canal cleanliness at 3 and 5 mm from
the WL (>99.4%) than at 1 mm from the WL (>97.3%).

Discussion
This study introduced the custom-designed K-Kube (Fig. 1A, B),
which was based on the technique of Bramante et al (18) with the addition of a compression component. Compressing the parallel sections
within each specimen effectively eliminated the 0.3-mm kerf created
by each saw blade cut. The K-Kube allows a tooth to be sectioned
and then reassembled to recreate an intact root canal system. This
affords the opportunity to evaluate not only canal and isthmus anatomy
but also the effect of irrigation on residual debris while using each tooth
as its own control. Thus, the K-Kube enabled the evaluation of experimental irrigation adjuncts in a sectioned tooth for the first time.

Comparison of Debris Removal by 4 Different Systems

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Basic ResearchTechnology
Mean Percentage of Canal Cleanliness

Mean Percentage of Canal Cleanliness

Comparing Experimental Groups (+1 SD)

Comparing Levels (+1 SD)

105.0%
103.0%
101.0%
99.0%
97.0%
95.0%
93.0%
91.0%
89.0%
87.0%
85.0%

105.0%

*
*

100.0%
95.0%
90.0%
85.0%
1 mm 3 mm 5 mm 1 mm 3 mm 5 mm 1 mm 3 mm 5 mm 1 mm 3 mm 5 mm
1 mm

3 mm

5 mm

1 mm

Post Clean & Shape

*
*

3 mm

5 mm

F File

Post Experimental

F File

Ultrasonics

EndoActivator

Max-i-Probe

EndoActivator
Post Clean & Shape

Mean Percentage of Isthmus Cleanliness

Ultrasonics

Max-i-Probe

Post Experimental

Mean Percentage of Isthmus Cleanliness

Comparing Levels (+1 SD)

Comparing Experimental Groups (+1 SD)

110.0%

110.0%

100.0%

100.0%

90.0%

90.0%

80.0%

80.0%

70.0%

70.0%
60.0%

60.0%
1 mm

3 mm

5 mm

Post Clean & Shape

F File
EndoActivator

1 mm

3 mm

5 mm

Post Experimental
Ultrasonics
Max-i-Probe

1 mm 3 mm 5 mm 1 mm 3 mm 5 mm 1 mm 3 mm 5 mm 1 mm 3 mm 5 mm

F File

EndoActivator

Post Clean & Shape

Ultrasonics

Max-i-Probe

Post Experimental

Figure 3. Comparison of canal and isthmus cleanliness post cleaning and shaping versus post experimental treatment. (A) Percentage of canal cleanliness of each
experimental group at the 1-, 3-, and 5-mm levels. (B) Percentage of canal cleanliness of all 4 experimental groups individually at the 1-, 3-, and 5-mm levels. (C)
Percentage of isthmus cleanliness of each experimental group at the 1-, 3-, and 5-mm levels. (D) Percentage of isthmus cleanliness of all 4 experimental groups
individually at the 1-, 3-, and 5-mm levels. *Statistically significant differences between levels (P < .001).

In this study, conventional cleaning and shaping alone resulted in

greater than 94% canal cleanliness and greater than 74% isthmus cleanliness. The addition of an irrigation adjunct resulted in improved canal
and isthmus cleanliness at all levels, regardless of the technique used.
Most of the remaining debris was found in the apical 1 mm of the canal
or isthmus. These results were consistent with previous studies in
regards to canal cleanliness but were better than previous studies in
regards to isthmus cleanliness after conventional cleaning and shaping
alone (1113, 15, 17, 19).
There was a higher overall standard deviation concerning isthmus
cleanliness as compared with canal cleanliness. This was probably due
to the variation in isthmus width not only within each tooth but also
between 2 different samples. The narrow isthmuses consistently demonstrated the most residual debris both after cleaning and shaping and
after treatment with the experimental irrigation adjuncts.
Recent studies with various ultrasonic, sonic, and passive ultrasonic irrigation devices and techniques have shown improved tissue
removal (20), more vigorous irrigation of lateral canals (21), and additional removal of canal bacteria (22). Other recent studies have also
shown that the use of various irrigating solutions not only improves
smear layer removal (23), but alters the physicochemical properties
of dentin that influence the adherence and biofilm formation of Enterococcus faecalis to dentin (24). In this study, there was no statistically
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Klyn et al.

significant difference in canal or isthmus cleanliness with the F file,

EndoActivator, or ultrasonics when used as an adjunct to aid in canal
debridement compared with irrigation alone with NaOCl. The additional
irrigation with NaOCl produced the same statistical improvement in
canal and isthmus cleanliness and might best be explained by the fact
that a 30-gauge Max-i-Probe can be inserted to WL when the canal is
prepared to an ISO size 40 (25). This needle deep irrigation was
more important in improving canal and isthmus cleanliness than the
use of any of the adjunct devices tested (2529). Although this study
evaluated debris removal and not the actual removal of bacteria,
improved debris removal should correlate with improved bacterial
control.
In conclusion, the present in vitro study demonstrated that needle deep irrigation with NaOCl was as effective as 3 irrigation adjuncts
in canal and isthmus cleanliness utilizing the K-Kube technique. Clinical
trials to investigate a correlation between irrigation adjunct devices and
improved clinical outcomes are needed to validate the use of these
devices (30).

Acknowledgments
The authors gratefully acknowledge Dr Anneke Bush for her
statistical support and interpretation and Griffin M. Perry for his
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Basic ResearchTechnology
technical expertise. This article is the work of the United States
government and may be reprinted without permission. Opinions
expressed herein, unless otherwise specifically indicated, are those
of the authors. They do not represent the views of the Department of
the Air Force or any other department or agency of the United States
government.

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