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REVIEW ARTICLE OPEN

Expert consensus on irrigation and intracanal medication in

root canal therapy
Xiaoying Zou1,2, Xin Zheng 3, Yuhong Liang4, Chengfei Zhang5, Bing Fan6, Jingping Liang7, Junqi Ling8, Zhuan Bian6, Qing Yu9,
Benxiang Hou10, Zhi Chen 6, Xi Wei 8, Lihong Qiu11, Wenxia Chen12, Wenxi He13, Xin Xu 3, Liuyan Meng6, Chen Zhang14,
Liming Chen15, Shuli Deng16, Yayan Lei17, Xiaoli Xie18, Xiaoyan Wang1, Jinhua Yu 19, Jin Zhao20, Song Shen2, Xuedong Zhou3 ✉ and
Lin Yue1 ✉

Chemical cleaning and disinfection are crucial steps for eliminating infection in root canal treatment. However, irrigant selection or
irrigation procedures are far from clear. The vapor lock effect in the apical region has yet to be solved, impeding irrigation efficacy
and resulting in residual infections and compromised treatment outcomes. Additionally, ambiguous clinical indications for root
canal medication and non-standardized dressing protocols must be clarified. Inappropriate intracanal medication may present side
effects and jeopardize the therapeutic outcomes. Indeed, clinicians have been aware of these concerns for years. Based on the
current evidence of studies, this article reviews the properties of various irrigants and intracanal medicaments and elucidates their
effectiveness and interactions. The evolution of different kinetic irrigation methods, their effects, limitations, the paradigm shift,
current indications, and effective operational procedures regarding intracanal medication are also discussed. This expert consensus
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aims to establish the clinical operation guidelines for root canal irrigation and a position statement on intracanal medication, thus
facilitating a better understanding of infection control, standardizing clinical practice, and ultimately improving the success of
endodontic therapy.

International Journal of Oral Science (2024)16:23 ; https://doi.org/10.1038/s41368-024-00280-5

INTRODUCTION For example, mechanical preparation by the movement of rotary

The core concept of root canal therapy is to control the infection files may not be able to follow the irregularities of the root canal
in the root canal system by eradicating the existing infection and wall, thus leaving the untouched area of the root canal surface up
preventing any reinfection.1 However, the anatomical complexity to more than 1/3–1/2.2 The anatomical factors of the root canal
of the root canal system and the diversity of root canal infections system and the limitations of instrumentation will undoubtedly
limit the efficacy of various strategies, such as mechanical lead to infection retention within the root canal.3 In literature, the
instrumentation and irrigation, in eliminating root canal infections. complications of root canal treatment have been extensively

1
Department of Cariology and Endodontology, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for
Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of
Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental Materials, Beijing, China; 2Center of Stomatology, Peking University
Hospital, Beijing, China; 3State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & West China Hospital of
Stomatology, Sichuan University, Chengdu, China; 4Department of Emergency, Peking University School and Hospital of Stomatology & National Center of Stomatology &
National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital
Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental Materials, Beijing, China;
5
Restorative Dental Sciences, Endodontics, Faculty of Dentistry, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China; 6State Key Laboratory of Oral & Maxillofacial
Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan
University, Wuhan, China; 7Department of Endodontics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai
Jiao Tong University; National Clinical Research Center for Oral Diseases; National Center for Stomatology; Shanghai Key Laboratory of Stomatology, Shanghai, China;
8
Department of Operative Dentistry and Endodontics, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University & Guangdong Provincial Key Laboratory
of Stomatology , Guangzhou, China; 9State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, National Clinical Research Center for Oral Diseases, Shaanxi
Key Laboratory of Oral Diseases, Department of Operative Dentistry & Endodontics, School of Stomatology, The Fourth Military Medical University, Xián, China; 10Center for
Microscope Enhanced Dentistry, Beijing Stomatological Hospital, Capital Medical University, Beijing, China; 11Department of Endodontics, School of Stomatology, China Medical
University, Shenyang, China; 12College & Hospital of Stomatology, Guangxi Medical University, Nanning, China; 13Department of Stomatology, Air Force Medical Center, The Air
Force Medical University, Beijing, China; 14Department of Endodontics, Beijing Stomatological Hospital, School of Stomatology, Capital Medical University, Beijing, China;
15
Department of Endodontics, Guiyang Stomatological Hospital, Guiyang, China; 16Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine,
Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University,
Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China; 17Department of Endodontics, the Affiliated Stomatological Hospital of
Kunming Medical University, Kunming, China; 18Department of Endodontology, Hunan Xiangya Stomatological Hospital, Central South University, Changsha, China; 19Institute of
Stomatology, Nanjing Medical University & Department of Endodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China and 20Department of
Endodontics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
Correspondence: Xuedong Zhou ([email protected]) or Lin Yue ([email protected])
These authors contributed equally: Xiaoying Zou, Xin Zheng

Received: 5 November 2023 Revised: 22 December 2023 Accepted: 3 January 2024

 Expert consensus on irrigation and intracanal medication in root canal. . .
Zou et al.
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discussed, and the effectiveness of mechanical preparation has The efficacy of conventional syringe irrigation is affected by the
been questioned, which was once overinterpreted.4 The infected depth the irrigation needle tips enter, the distance the irrigant
root canal is a dead space favorable for bacterial growth and penetrates apically to the needle, and the vapor lock effect.13 The
proliferation and a blind spot for host immunity due to the effectiveness of conventional irrigation is often unsatisfactory.
interruption of blood supply.1 There are three forms of infection in Thus, various instruments have been developed and used to
the canal system. (1) A mixture of suspended microorganisms and activate the irrigants to maximize the debridement of complex
their metabolites, tissue debris and exudates, and foreign bodies. root canal systems. In addition, more advanced techniques have
These infectious substances occupy the main, lateral, and been developed to augment physical kinetic energy to the liquid
accessory root canals, isthmus, and apical delta.5 (2) in the root canal by increasing the shear force on the root canal
Microorganisms-formed biofilms adhered to the surface of the wall and activating the irrigants to improve the effect of chemical
root canal wall, and various bacteria in the microenvironment, disinfection.
causing inflammation and even drug resistance.6 (3) Microorgan-
isms and toxins enter in dentinal tubules of the root canal wall,
with an invasion depth of 200–1 000 μm.7–9 These diversity of root TYPE OF IRRIGANTS
canal infections raises the difficulty in root canal debridement. The Current clinically used irrigants
consequence is that the residual microorganisms can sustain the Sodium hypochlorite (NaOCl). The aqueous solution is a strong
infection state in the root canal, inducing persistent periapical oxidant, which is alkaline and used as a disinfectant and
tissue inflammation, and leading to root canal therapy failure.10 household bleach. NaOCl is the most widely used root canal
Mechanical preparation is fundamental in shaping the canal irrigation chemical due to its bactericidal and unique organic
into a funnel and facilitating irrigation and obturation, but tissue-dissolving ability. NaOCl dissolves organic substances
insufficient in canal cleaning and debridement. Thus, more through three reactions: Degrading fatty acids into fatty acid salts
endeavors have been made on chemical cleaning and disinfec- and glycerol through saponification; Neutralization of amino acids
tion, including root canal irrigation and intracanal medication. to produce water and salt by neutralization reactions; Interference
Chemical agents are used to inhibit or kill the remaining with microbial cell metabolism by chloramination of chlorine and
microorganisms in the infected root canal after mechanical amino groups.14 Since plaque biofilms, residual pulp tissue, and
preparation, especially in the wall of the root canal, the lateral dentin are mainly organic tissues, NaOCl can exert a proficient
accessory root canal, the isthmus, and the apical delta, which are tissue-dissolving effect on these tissues and improve the
complex anatomical regions that cannot be reached by instru- debridement effect of the unprepared areas. In addition, NaOCl
mentation. Although various root canal irrigants and methodol- has a broad antibacterial spectrum that can more effectively
ogies have been practiced in clinics, no single irrigant meets all remove the infection in the root canal.15 Its main mode of action is
the requirements for effective root canal cleaning safely and hydrolyzation to form hypochlorous acid, which is further
without side effects. The critical problem, vapor lock in the apical decomposed into new ecological oxygen to denigrate bacterial
region, has yet to be solved either by conventional syringe proteins, interfere with the oxidative phosphorylation of bacterial
irrigation or by various kinetic energy irrigation systems. There is biofilm and the synthesis of bacterial DNA, and thus exerts a
no clear protocol or operation guideline for irrigation procedures broad-spectrum bactericidal effect. The concentrations of NaOCl
in dental practice. Due to the ineffectiveness of root canal used in the clinic are 0.5%–8.25%. Over 2.5% NaOCl solution can
preparation, in the early 20th century, aldehydes and phenolics dissolve organic tissues, and with the increase of concentration,
were advocated to seal the root canal to achieve the goal of temperature, volume, and time, the bactericidal effect and tissue
disinfection.11 With technological advances and updated knowl- dissolution ability are gradually boosted. At the same time, its
edge, modern root canal therapy recommends thorough root irritation, causticity, and cytotoxicity to tissues are also increased.
canal debridement by mechanical preparation and chemical Root canal irrigation with NaOCl often follows root canal
irrigation. Root canal dressing agents have gradually faded, so mechanical preparation and can be used as the final irrigation
the current medicaments and medication methods have changed after instrumentation. A rubber dam must be placed during the
considerably. Nevertheless, the clinical indications for root canal treatment to protect the gingiva and oral mucosa. Extrusion of
medication are unclear, and the dressing protocols are not NaOCl solution from the apical foramen may cause periapical
standardized. tissue damage, which has to be avoided.
Based on the above-mentioned clinical concerns, there is an
urgent need to refine the principles, objectives, medicament Ethylenediamine tetraacetic acid (EDTA). EDTA is a calcium
selection, operating instruments and techniques, and clinical chelator that can remove minerals from the smear layer and
procedures of root canal irrigation and medication and debris on the root canal wall. The smear layer not only hinders the
establish an expert consensus to better guide root canal contact between the chemical irrigants and the root canal wall but
infection control. This expert consensus aims to establish the also provides a living environment for the growth of bacteria.
clinical operation standards for root canal irrigation and Clinically, EDTA is often applied in combination with NaOCl
medication based on the current evidence obtained from solution (≥2.5%) to remove the smear layer on the root canal wall.
in vitro and in vivo studies. NaOCl can dissolve organic components and eliminate bacteria.
EDTA forms a complex with calcium ions in hydroxyapatite to
dissolve inorganic components, such as dentin debris, thereby
THE PIVOTAL ROLE OF ROOT CANAL IRRIGATION IN MODERN cleaning the root canal wall and opening the dentine tubules,
ENDODONTIC THERAPY facilitating the chemical molecules in the irrigant to penetrate the
Irrigation is regarded as an important part of root canal treatment. dentin tubules to exert an antibacterial effect in the deep
Irrigants are delivered into the root canal by needle or other tools locations. EDTA unceasingly softens the root canal wall and
during root canal instrumentation and irrigation. The irrigants can should not be used as a final irrigation.
dissolve and remove infectious substances in the root canal, on
the surface of the root canal wall, and within the dentinal tubules Chlorhexidine (CHX). CHX solution has a stable, long-acting,
of the root canal wall. The chemicals contained in irrigation can kill broad-spectrum antimicrobial property against Gram-positive
or inhibit infectious microorganisms in the root canal, dissolve and Gram-negative bacteria, and fungi. CHX in low concentration
necrotic pulp tissue, neutralize toxins, remove the smear layer, and (0.2%) can enter the cell through the interaction with phospho-
serve as lubricants.12 lipids on the surface of the cell membrane, increase the

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 Expert consensus on irrigation and intracanal medication in root canal. . .
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3
permeability of the cell wall, cause a large amount of potassium ● Fill the pulp chamber and root canal with irrigants before the
and phosphorus loss in the cell, and change the osmotic balance first step of root canal treatment, always keeping the root
in and out of the cell. High concentration of chlorhexidine solution canal system under irrigant immersion.
(2%) reacts directly with the cytoplasmic contents, resulting in ● Frequent and extensive root canal irrigation should be
bacterial death.16 As a cationic surfactant, CHX can be adsorbed performed during mechanical preparation, with 2 mL of
on the surface of negatively charged substances in the cell wall of irrigant per canal between file replacements.
bacteria containing acidic proteins and can be slowly released by ● A total of 10–20 mL of irrigant is used for each root canal
chelating with calcium ions in the root canal wall.16 On the other during the whole mechanical preparation.
hand, its chelation with calcium ions in the root canal wall can ● The needle should be inserted as deep into the root canal as
slowly release the active ingredient of CHX,17 so that its possible at 2 mm from the working length. It should not be
bacteriostatic activity can be retained in the root canal system inserted too tightly, which may cause poor reflux and the
for up to 12 weeks,18 thus suppressing bacterial proliferation and irrigant and debris extrusion beyond the apical foramen.
exerting a long-term antibacterial effect.15 CHX is suitable for the ● The needle should be moved longitudinally in the canal with
final irrigation of severely infected root canals and retreatment up and down motion in a small range, and gently push the
cases.12 However, CHX has no tissue-dissolving ability and cannot syringe plunger. Do not apply excessive force apically.27
remove the smear layer, so it cannot replace NaOCl and EDTA in ● The syringe should have a Luer Lock threaded fitting to avoid
clinical practice. the needle falling off and the irrigants splashing due to
excessive pressure during irrigation, which may cause skin
Ethanol. 95% ethanol can be used as the final irrigation solution injuries or the patient clothes bleaching.
for root canals. Its strong volatility can quickly and effectively take
away the water in the system and dry the root canal. It can also The efficacy of conventional syringe irrigation is limited,
reduce the surface tension of the root canal wall, which is depending on needle insertion depth into the root canal, the
conducive to the sealer entering the complicated root canal diameter and shape of the needle, and the root canal width,
structures and dentin tubules during the root canal filling process curvature, and taper.28,29 Because the root canals are closed-
and improve the sealing effect. ended cavities, the air bubbles entrapped at the apical part of the
root canal can block irrigant penetration in this area, called the
Hydrogen peroxide. 3% Hydrogen peroxide has was in root canal vapor lock phenomenon.30 Due to the vapor lock effect, sufficient
irrigation in history, but the evidence supporting its effectiveness infection debridement in the apical region is impossible using
is scarce. Its bactericidal effect on Enterococcus faecalis is weak.19 conventional syringe irrigation alone.
Thus, hydrogen peroxide is no longer recommended as a routine
root canal irrigant. Mechanical agitation irrigation
In order to enhance the irrigant penetration and refreshment in
Interaction between irrigants the apical part of the root canal, a gutta-percha or a file matching
NaOCl and EDTA solution. The tissue-dissolving capacity of NaOCl the root canal size is proposed in clinical practice. The vapor lock
decreases when combined with EDTA solution, with no free effect can be disrupted by manual agitation so that fresh irrigants
chlorine detected in the combinations.20 can enter the apical segment of the root canal and improve the
cleaning effect.13 Due to the low efficiency of manual agitation,
NaOCl and CHX. When combined, they react with each other to motorized agitation instruments and equipment have emerged.
produce a brown precipitate containing para-chloraniline (PCA). Most of them are made of NiTi alloy with excellent elasticity. The
The precipitate can block dentinal tubules and is difficult to instruments inserted into the root canal are driven by a powered
remove.21,22 Therefore, the interaction should be avoided. In case motor to rotate continuously to improve the flushing effect of the
NaOCl and CHX are used together, irrigation with water should be liquid flow. The specially designed spoon-shaped instruments can
conducted to remove the residual NaOCl solution before CHX also take advantage of their extensibility to expand and deform
is used. during movement to adapt to the irregular shape of the root canal
and even directly touch the canal wall to remove the adhesions on
CHX and EDTA. Although CHX solution does not react chemically the canal wall.31 At present, such devices include XP-endo
with EDTA solution when mixed, it forms a salt that is insoluble in Finisher, M3-Max, etc. The XP-endo Finisher was found to be
water and appears as a white precipitate.23 superior to conventional syringe irrigation in removing the smear
layer, dentin debris, and bacterial biofilm in the root canal.32,33
Another agitation instrument is the Finisher GF brush, a final
DEVELOPMENT OF CLINICAL ROOT CANAL IRRIGATION agitation file in the Gentlefile system made of six strands of
METHODS AND TECHNIQUES stainless-steel flexible wires. Under the centrifugal effect produced
Conventional syringe irrigation by 6500 rpm high-speed rotation, the wires are spread out to
A 5 mL syringe is the most commonly used instrument for root whip, scrape and smooth the root canal wall, and activate irrigants
canal irrigation. With this syringe, the flow rate can reach at least by mechanical agitation,34,35 thus improving the root canal
0.20–0.25 mL/s,24 and the irrigant penetration can be 1–2 mm debridement effect of sodium hypochlorite.36 The Gentlefile
apically to the needle tip within the root canal. The needles have system’s unique design can produce a “tornado” effect, which
various specifications, mainly differing in the presence of an open can guide the irrigants into the apical part and suck the liquid and
or closed end, the diameter, and the outlet numbers. The debris back to the orifice direction, providing new ideas and
recommended diameters are 30 gauge needles (0.298–0.320 mm methods to solve the irrigation challenges. The problem with
outside diameter, corresponding to a 30# file). There are two main mechanical agitation is that irrigants may extrude the apical
types of needle end openings: open-ended (flat/ bevelled/ foramen and cause some postoperative pain.37,38
notched) and close-ended (side-vented/ double side-vented/
multi-vented).25 The needle with the lateral opening is more Physical energizing irrigation
conducive to the coronal reflux of the irrigant, which can Physical kinetic energy can be applied to the irrigants in the root
effectively reduce the amount of irrigant pushed out beyond canal to change the flow pattern, increase the flushing intensity,
the apical foramen.26 Key points and precautions of syringe improve the wall shear stress, and activate the chemical
irrigation are: composition of the irrigants, which can promote the irrigants to

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4
enter the complex of the root canal system and further exert the smaller than that of ultrasound. Therefore, although the acoustic
biochemical effects. It’s also known as kinetic energy irrigation. streaming effect produced by sonic irrigation is weaker than that
The physical kinetic energy includes ultrasonic and sonic energy, of ultrasonic irrigation in theory, a desired irrigation effect may still
positive and negative pressure, laser, etc. How liquid energy is be obtained in practice.18 The first-generation EndoActivator,
converted by various physical kinetic energy and its effects differ. which appeared in 2010, is a low-frequency sonic device that
operates at 160 Hz, 175 Hz, and 190 Hz.50 Li et al. compared the
Ultrasonic irrigation. Ultrasonics was first introduced in endo- smear layer cleaning effect of ultrasound and EndoActivator on
dontics by Richman.39 The range of frequencies of the ultrasonic the root canal wall.51 It was shown that the first-generation
device was between 25 000 and 40 000 Hz.40 Under ultrasound EndoActivator achieved a smear layer cleaning effect similar to
activation, the irrigants form a circular or vortex-like motion that ultrasound in the middle and upper root canal segments. It was
rolls rapidly, which is the effect of acoustic streaming.41 The shear better than ultrasound in the apical part. However, the bacterial
stress generated by acoustic streaming along the root canal wall inhibition ability in the deep dentinal tubules of EndoActivator
facilitates the removal of tissue and biofilm attached to the root was not as good as that of PUI.51 In order to improve the acoustic
canal wall and suspended debris and bacteria in the canal. In streaming effect, the second generation EndoActivator appeared
addition, the bubbles in the liquid caused by the acoustic in 2023, which increased the vibration frequency to 300 Hz.
streaming continue to grow and become unstable, eventually However, the high-frequency sonic device EDDY, which came out
collapse in a violent implosion. The strong shock wave and in 2015, has a frequency of 5 000–6 000 Hz. Studies have shown
instantaneous high flow rate generated by the explosion of that EDDY has a better debridement effect on dentin debris and
bubbles are conducive to the removal of infectious substances, smear layer than low-frequency sonic device (EndoActivator).52 Liu
which is known as the cavitation effect.41 The early ultrasonic et al. showed that Eddy could achieve a similar antibacterial effect
irrigation method is active ultrasonic irrigation (AUI). In the in dentin tubules as ultrasound in the middle and upper root
process of irrigation, the ultrasonic file acts on the root canal wall canals.53 However, neither high-frequency nor low-frequency
and cuts the dentin, which may cause damage to the root canal sonic activation showed a good effect on removing the bacteria
wall.42 On the other hand, because the ultrasonic file attaches to in the root canal, especially in the deep dentinal tubules of the
the root canal wall, the acoustic streaming effect cannot be apical root canal wall.
generated, which may limit the effectiveness of ultrasonic
irrigation. The concept of Passive Ultrasonic Irrigation (PUI) was Negative pressure irrigation. The combination of positive-pressure
first proposed by Weller et al. in 1980, defined as the “non-cutting” irrigation and negative-pressure suction in the root canal allowed
movement form of the ultrasonic file.43 It means that the the irrigants to reach the apical region without extruding the
ultrasonic file does not touch the root canal wall, so it does not apical foramen.54 The representative product is EndoVac. The
remove it, thus avoiding the problems of AUI mentioned above.41 working tip of the EndoVac was not allowed to enter the apical
PUI only transfers energy through the vibration of the ultrasonic part until the canal was prepared to 35#,55 and its effect of
file into the liquid and utilizes significant acoustic streaming and irrigation in the apical area is better than that of the traditional
cavitation effects to achieve debridement.44 Clinically, a 15–25# positive pressure irrigation.56 Launched in 2015, the GentleWave is
ultrasonic file or a special ultrasonic tip without a cutting edge is designed to clean and disinfect complex root canal systems using
placed in the root canal 1–2 mm short from the working length, multi-frequency sound waves to form enriched cavitation micro-
which can clean the apical part well.45 Still, irrigants may be bubbles and broad-spectrum sound fields. The pulp chamber
extruded beyond the apical foramen if the ultrasonic file is too sealing device should be used to create a positive pressure
close to the apex. Additionally, the ultrasonic file is suggested to flushing and negative pressure suction environment after the
be placed above the curvature of the root canal to avoid excessive specially designed working head enters the pulp chamber, and
contact with the root canal wall, perforation, or instrument the irrigant in the pulp chamber can be sucked out while pushing
separation.46 it into the root canal at the same time. The negative pressure
There are two common modes of PUI, namely continuous and formed at the apex avoids the extrusion of the irrigant into the
intermittent irrigation. With continuous irrigation, the irrigant is apical foramen.57 The GentleWave system can also improve the
continuously flowing to irrigate the root canal simultaneously organic tissue solubilization of sodium hypochlorite,58 and its
during ultrasonic activation. The other method was to inject bacterial biofilm removal effect was better than that of ultrasound
irrigants into the root canal, then insert an ultrasonic file, and in the central root canal and isthmus.59
intermittently irrigate the static irrigant in the root canal. Each root
canal was ultrasonically activated three times, 20 s each time, for a Laser activated irrigation. The use of lasers in endodontic
total of 1 min. After each PUI, 2 mL of the canal was irrigated with treatment began in 1971. With the development of optical fiber
a syringe, and the irrigant was refreshed. transmission systems, laser has been widely used in endodontics
in the 1990s. The erbium (Er) family laser is considered the most
Sonic irrigation. Tronstad et al. first reported the sonic devices in suitable type for laser activation irrigation, including Er: YAG laser
endodontic treatment.47 The sound waves generated mechanical (2940 nm) and Er, Cr: YSGG laser (2780 nm). Erbium laser has a
vibration of the liquid in the root canal, broke the vapor lock effect high affinity for water and hydroxyapatite, which can produce a
at the root apex through the acoustic streaming and made the strong activation effect and shock wave during irrigation. Fast flow
irrigating fluid smoothly enter the apical area to achieve root canal and high shear stress were induced on the root canal wall. Laser
cleaning. The sonic activation has a lower driving frequency but a can also produce reactive oxygen to destroy biofilms and directly
greater amplitude than ultrasound devices. The tips used in the accelerate bacterial death. The most significant feature of the
current sonic irrigation equipment are made of soft polymeric Erbium laser is its remote bactericidal efficacy. However, the root
materials and can be inserted into the middle or lower segments canal’s complex and variable anatomical structure will gradually
of the curved root canal.48 Studies have shown that when the decrease its optomechanical effectiveness from the coronal to the
ultrasonic tip is constrained by the root canal wall, the amplitude apical part. Photon-initiated photoacoustic streaming (PIPS) is
will be significantly reduced, and its acoustic streaming will be another laser activation irrigation system developed from the
significantly weakened. However, if constrained, the sonic tip can traditional erbium laser. The principle of its application in root
still produce longitudinal vibration with large amplitudes.49 In canal irrigation is to transmit low energy (20–50 mJ) with an
addition, acoustic streaming can be generated along the working extremely short pulse (50 μs), which generates a sustained and
tip’s length, and the acoustic streaming’s attenuation degree is intense shock wave, causing violent movement of the irrigant in

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the root canal.60 Studies have shown that PIPS can promote effect of the whole root canal system, which is conducive to
irrigant penetration into dentinal tubules,61 and achieve a better the entry and attachment of filling materials.
disinfection effect than ultrasound.62 However, in vitro studies
have shown that a small amount of irrigant may extrude the apical Combining multiple irrigants is recommended to achieve
foramen,63 it is still unclear whether it will cause clinical complementary or enhanced root canal cleaning. At the same
postoperative pain. In addition, laser-activated irrigation is not time, attention should be paid to the incompatibility and
widely used in clinical practice because it requires expensive laser interaction of chemical agents.
equipment.

ATTITUDE TOWARD INTRACANAL MEDICATION

RECOMMENDED CLINICAL PROCEDURES OF ROOT CANAL The primary objective of intracanal medication is to eliminate
IRRIGATION IN ROOT CANAL TREATMENT microbial and toxin burden within the root canal after mechanical
Root canal irrigation should be performed under rubber dam preparation and irrigation. Introduction of antimicrobial and
conditions and a microscope. Rubber dams can separate the disinfecting chemical agents into the root canal can directly
operation area from the internal environment of the oral cavity, impede or eradicate microorganisms, neutralize toxins, modulate
avoid contamination of the operation area, improve the operation environmental pH, and create favorable biological conditions for
efficiency, and prevent complications such as the irritation of the periapical tissue repair and regeneration.69,70
oral mucosa by flushing irrigants and the accidental ingestion of From 1891 to the early 20th century, due to limited resources
irrigants.1,64 Using a microscope can help the clinician better and inadequate understanding of root canal mechanical prepara-
observe the movement of the irrigating solution in the root canal tion and irrigation techniques, scholars endeavored to achieve
and accurately judge the cleanliness of the root canal. The basic root canal disinfection by encapsulating potent volatile drugs like
principle of root canal irrigation strategy is irrigation before formaldehyde and phenol within the root canal. Commonly
starting instrumentation, frequent and abundant irrigation, and employed root canal disinfectants included formaldehyde phenol,
irrigation throughout the treatment. The following procedures are camphor para-chlorophenol, camphor phenol, etc.71,72 During this
recommended. period, multiple medication applications were necessary in
conjunction with sampling and cultivation within the canals until
● After entering the pulp chamber, NaOCl solution is injected bacterial testing results indicated sterility prior to root canal
first to fill in the pulp chamber and root canal, then obturation.73 However, using intracanal medicaments alone is
identification of orifice locations and root canal negotiation insufficient for optimal therapeutic outcomes without adequate
were performed. root canal preparation, as revealed by numerous studies.74,75
● During access cavity and root canal mechanical preparation, Furthermore, the medications mentioned above exhibit potent
copious NaOCl irrigation is recommended until the instru- cytotoxicity and poor biocompatibility. They can induce damage
mentation is completed. to periodontal fibers and impede periapical tissue healing,74
● Irrigation with 2.50%–5.25% NaOCl solution (2 mL/root canal) potentially leading to systemic allergies in severe cases.11 There-
between each file is recommended during the instrumenta- fore, their utilization is currently not recommended in clinical
tion process.65 practice.65,76–78 Over the past 30 years, advancements in root
● After the mechanical instrumentation, the irrigant amount for canal cleaning and sealing techniques have led to more effective
final irrigation should be more than 5 mL/root canal. The infection control within the root canal. Consequently, the demand
apical size of the infected root canal is generally suggested to for intracanal medication has gradually decreased. It is now
be prepared to at least 30# in order for a 30 G irrigation needle recognized that interappointment medication may augment
to reach sufficient depth and ensure effective action of effectiveness while increasing the risk of reinfection between visits.
irrigants in the apical third region, as well as achieve optimal According to clinical studies and systematic analysis on non-
removal of pulp tissue, debris, and infectious substances in the infected root canals, there is no statistically significant difference in
apical region.25,66,67 effectiveness between single-visit and multiple-visit root canal
● The root canal should be irrigated before medication or therapy when evaluating indicators, such as periapical bone
obturation. The sequence of final irrigation is as follows: NaOCl density,79 healing rate of lesions,80 and postoperative pain.81
(2.50%–5.25%) for 1 min, EDTA (17%) for 1 min to remove the Therefore, using intracanal medicaments for non-infected root
smear layer, and final NaOCl is reintroduced in the root canal canals is not recommended. However, it is still advisable to use
system for 30 s to penetrate further into the opened dentinal appropriate medications to manage symptoms, control infection,
tubules that now have been cleared of smear layer to inhibit and evaluate prognosis in cases of severe root canal infections.82–85
the bacteria.25 To ensure the irrigant’s penetration into the These drugs should prioritize biocompatibility, stable physicochem-
root canal, the chemical irrigant can be activated by kinetic ical properties, and degradability. Highly bactericidal pastes are
energy irrigation, such as ultrasonic, sonic, laser, negative recommended as they require direct contact with the root canal
pressure irrigation, or mechanical agitation. The protocol is as walls to create a physical barrier sealing off the pulp cavity.
follows: The irrigant is refreshed three times in each root canal,
and ultrasonic irrigation is performed for 20 s within the
irrigant filled in the pulp chamber and root canal system for TYPES OF INTRACANAL MEDICAMENTS
1 minute to increase the effect of the chemical irritant. Pay The ideal intracanal medicaments should have the following
attention to the water irrigation between the two irrigants to characteristics: (1) Strong antimicrobial abilities, neutralizing
avoid mutual reactions. toxins, and sustained disinfection capability. (2) Permeability and
● For severely infected root canals, especially those with sinus flowability. (3) Formation of a physical-chemical barrier within the
tracts or purulence or retreatment cases, 2% chlorhexidine can root canal. (4) Excellent biocompatibility, reducing inflammation in
be used as the final irrigant. However, NaOCl or EDTA in the periapical tissues without causing additional irritation to the apical
root canal should be replaced with water first.24,68 tissue. (5) Not interfering with the repair, induction of healing and
● Before root canal obturation, 95% ethanol can be used to rinse hard tissue formation in periapical tissues. (6) Easy removal.
the root canal, with 3 mL/root canal. With the rapid evapora- Currently, available drugs in clinical practice have not yet met all
tion of ethanol, water can be taken away to obtain the drying these requirements.

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 Expert consensus on irrigation and intracanal medication in root canal. . .
Zou et al.
6
Calcium hydroxide (Ca(OH)2) counts within the root canal and prevents colonization when used
It is an extensively researched and widely utilized disinfectant for as an intracanal medication for 1 week.104 However, clinical trials
root canals, exhibiting potent antibacterial activity by releasing have reported no statistically significant difference in antibacterial
hydroxyl ions in water to create an alkaline environment. It exerts effects between chlorhexidine and calcium hydroxide after one or
bactericidal effects through cell membrane disruption, protein two weeks of intracanal application. Meanwhile, the capacity of
denaturation, and DNA damage. Moreover, it effectively neutra- chlorhexidine to reduce endotoxin levels within the root canal is
lizes bacterial endotoxins on the root canal walls and promotes weaker than calcium hydroxide.105 There is still controversy
tissue healing by counteracting acidic substances generated regarding the effectiveness of combining chlorhexidine with
during inflammation.86,87 Clinical studies have demonstrated that calcium hydroxide, and the results of various studies are
calcium hydroxide can significantly reduce the number of inconsistent. In vitro experiments have shown that this combina-
cultivable bacteria within the root canal.88,89 Additionally, it tion effectively eliminates E. faecalis, surpassing the antibacterial
promotes mineralized tissue formation and facilitates the repair effects of calcium hydroxide alone,106 and it can also reduce
of periapical hard tissues. It is commonly utilized as an intracanal bacterial types and quantities in initially infected root canals.107
medicament for treating periapical lesions in immaturely devel- However, clinical trials have found no statistically significant
oped teeth and preventing/treating inflammatory root resorp- difference in antibacterial effects between using these two
tion.87,90–92 Nevertheless, the limitations of calcium hydroxide as substances or using only calcium hydroxide.108 There is insuffi-
an intracanal medication are primarily due to (1) poor antibacterial cient evidence to suggest that chlorhexidine used alone or in
effects against specific pathogens like E. faecalis and Candida combination with calcium hydroxide has superior effects com-
albicans;93,94 (2) dentin’s ability to buffer the high pH environment pared to calcium hydroxide alone.
produced by calcium hydroxide, affecting its antibacterial activity
in vitro;95 (3) limited volatility of calcium hydroxide,96 making it Antibiotics
challenging to target microorganisms in areas such as apical Throughout the history of root canal treatment, antibiotics used
deltas and isthmuses;97,98 (4) slow onset of action and removal as intracanal medicaments have attracted attention several
difficulty.87 Studies have shown inconsistent results regarding the times. However, to this day, they have not become mainstream
impact of calcium hydroxide paste on tooth fracture resis- due to their insufficient effectiveness and the potential for
tance.99,100 Some research indicates that prolonged application bacteria resistance caused by antibiotics. Triple antibiotic paste
of calcium hydroxide paste to root canal walls can reduce dentin’s (TAP), consisting of metronidazole, minocycline, and ciproflox-
three-point bending strength and fracture resistance, possibly due acin, is an effective antibiotic formulation. These antibiotics
to its strong alkalinity and water solubility leading to the loss of complement each other in terms of antimicrobial efficacy,
organic and inorganic components in dentin.99,100 According to providing a broad spectrum of antibacterial activity with deep
reports, oil-based calcium hydroxide (such as Vitapex) has a slow penetration and long-lasting effects. In vitro studies have
release. It does not significantly impact tooth fracture resistance,99 demonstrated that TAP exhibits superior microbial clearance
making it suitable for relatively long-term (2–4 weeks) use. against infected dental pulp compared to calcium hydroxide and
Calcium hydroxide remains the preferred agent for intracanal 2% chlorhexidine gel.109 TAP is commonly used in regenerative
medication at present. endodontic treatment,110 typically applied for two weeks. Its use
Calcium hydroxide is powdered and can be formulated into in conventional root canal therapy has not been observed. The
various types of intracanal medication by combining it with drawbacks of TAP include (1) Minocycline can cause tooth
different solvents. An ideal formulation should possess good discoloration; (2) Complete removal from the root canal is
flowability and permeability while not affecting or promoting the challenging; (3) It only effectively targets metabolically active
dissociation of calcium hydroxide ions, as its action depends on microorganisms; (4) Antibiotic resistance may occur. Therefore, in
pH value and direct contact. Solvents are classified into aqueous, 2016, the European Society of Endodontology statement still
viscous, and oily based on their viscosity and ability to facilitate recommends using calcium hydroxide as an intracanal medica-
calcium hydroxide dissociation. Among them, water-based tion in regenerative endodontic treatment.
solvents are commonly used. Calcium hydroxide powder is
typically mixed with physiological saline to form a paste, or pre- Corticosteroids
made water-based calcium hydroxide can be used for better The glucocorticoids, as steroid hormones, possess anti-
flowability and ion release capability. An oil-based calcium inflammatory and anti-allergic effects. They can reduce the release
hydroxide medication like Vitapex may be chosen if long-term of inflammatory mediators, decrease capillary permeability,
medication is required.99 However, doubts exist regarding the alleviate edema and exudation, and relieve inflammation in
disinfection efficacy of viscous or oily calcium hydroxide periapical tissues.111 The use of corticosteroids should be limited
formulations due to their significant inhibition of hydroxyl ion to the minimum effective dose and shortest duration in order to
dissociation and release. Calcium hydroxide is commonly achieve treatment goals while minimizing adverse reactions in
combined with radiopaque agents such as barium sulfate, multiple body systems, including cardiovascular, digestive, hema-
bismuth carbonate, iodoform, etc., to enhance its X-ray opa- tologic, endocrine, and immune systems.112 In root canal therapy,
city,101,102 facilitating the evaluation of intracanal medication corticosteroids are commonly combined with antibiotics to
quality using X-ray images. effectively reduce swelling and pain caused by acute apical
periodontitis and postoperative discomfort.113 Currently available
Chlorhexidine (CHX) corticosteroid-antibiotic pastes include Septomixine, Pulpomixine,
It belongs to the category of cationic antimicrobial agents and and Ledermix paste. Septomixine and Pulpomixine contain
exhibits a broad-spectrum antibacterial activity. The commonly neomycin and neomycin B, respectively, but they have limited
employed clinical formulation is 0.2%–2.0% chlorhexidine gluco- antibacterial activity against bacteria causing root canal infec-
nate gel, which can be utilized independently or in conjunction tions.114 On the other hand, Ledermix paste contains 1%
with calcium hydroxide.12 However, the efficacy of chlorhexidine triamcinolone acetonide and 3% demeclocycline, which has anti-
as a standalone intracanal medication remains uncertain. In vitro inflammatory effects that help reduce root resorption and
studies have demonstrated that chlorhexidine exhibits superior promote apical healing.115,116 The use of steroids for intracanal
antibacterial efficacy compared to calcium hydroxide, effectively medicaments is limited due to their side effects, including
eliminating E. faecalis biofilm at a concentration of 2%.103 In vivo immunosuppression,117 tooth discoloration,118 and drug
investigations have revealed that chlorhexidine reduces bacterial interactions.119

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 Expert consensus on irrigation and intracanal medication in root canal. . .
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7
INDICATIONS AND NON-INDICATIONS FOR INTRACANAL persist, a thorough analysis should be conducted to identify
MEDICATION any deficiencies in the root canal cleaning process or the
Indications for calcium hydroxide paste as an intracanal presence of extra-radicular infections, other diseases, or
medication issues.123,124 This analysis will help develop targeted infection
control strategies for subsequent steps or consider modifying
the treatment plan. It is advised to consider an alternative
● Severe root canal infection: clinical signs of severe root canal treatment plan rather than repeating the same medication for
infection include a sinus tract, active exudation, swelling, pain more than three visits.125,126
to palpation and percussion, and extensive radiological
periapical tissue lesions.

CONSEQUENCES AND TREATMENT OF INTRACANAL

● Can not complete root canal cleaning, shaping, and obturation in MEDICAMENT EXTRUSION
a single visit: Patients may require treatment to be completed in Extrusion of calcium hydroxide beyond the apical foramen can
multiple visits due to various systemic and local factors, including induce inflammation in periapical tissues, developing iatrogenic or
but not limited to systemic diseases (such as diabetes and chemical apical periodontitis, ultimately failing root canal therapy.127
cardiovascular diseases), advanced age with reduced treatment However, research has also demonstrated that incorporating radio-
tolerance, restricted mouth opening, temporomandibular joint paque agents influences the impact of calcium hydroxide on the
disorders, or oral and maxillofacial injuries. healing process of periapical lesions beyond the apical foramen.128
● Observing infection control’s effectiveness during treatment is Using a paste containing barium sulfate affects the regeneration of
crucial for evaluating prognosis and determining treatment periapical tissues, potentially due to an immune response triggered
plans. Intracanal medicaments offer a short-term window to by barium sulfate,129 and its promotion of osteoclast differentiation
assess changes in symptoms and judge the success of infection leading to bone resorption.130 Furthermore, a case report study
control, providing valuable information for clinical diagnosis and suggests that the extrusion of calcium hydroxide does not influence
treatment strategies. the healing of periapical lesions.131 Calcium hydroxide paste without
● In teeth with internal or external resorption, intending to radiopaque agents can be completely absorbed, while paste with
perform treatment for rescuing the tooth. added barium sulfate cannot even after complete tissue healing in
● In immature permanent teeth with open apices, plan to perform periapical regions.131 Existing research on the consequences and
apexification or regenerative endodontic treatment. outcomes of intracanal medication extrusion remains insufficient.
Therefore, when applying calcium hydroxide, intentionally exceeding
the apical foramen should be avoided.
Non-indications for intracanal medication In cases where calcium hydroxide exceeds the apical foramen,
treatment options include (1) regular monitoring through X-rays
and clinical examination to evaluate periapical healing and
● For non-infected root canals, completing the root canal medication absorption; (2) administration of anti-inflammatory
therapy in a single visit is advocated. or analgesic drugs to alleviate pain or swelling; (3) if persistent
● In the case of adult permanent teeth with periapical lesions symptoms, infection, or damage to adjacent structures (such as
and root resorption leading to an open apex, intend to maxillary sinuses or mandibular nerve canal) occur, endodontic
perform apical barrier treatment. microsurgery should be performed for cleaning purposes.

POSITION STATEMENT ON INTRACANAL MEDICATION IN

CLINICAL PROTOCOL FOR USING CALCIUM HYDROXIDE AS AN MODERN ENDODONTIC THERAPY
INTRACANAL MEDICATION IN ROOT CANAL TREATMENT This article presents a statement on intracanal medication in
contemporary endodontic therapy:

● Perform final irrigation and dry the root canal thoroughly. ● For teeth with vital pulp where the root canals are not
● Radiopaque calcium hydroxide paste is recommended for infected, the primary focus of root canal therapy is to strictly
facilitating X-ray examination. To ensure easy removal of follow the infection control principles: meticulous sterilization
medicaments from the root canal, it is preferable to use water- of instruments and materials, use of a rubber dam for isolation
based agents. The medication should be precisely injected or during treatment, thoroughly cleaning the root canals, and
introduced throughout the entire final working length (FWL) completely obturating the root canal system. Intracanal
of the root canal to achieve maximal disinfection. medication is not essential, and completing root canal
● Using glass ionomer cement (GIC) to seal the crown entrance. treatment in a single visit is encouraged.
● Immediate X-ray imaging is suggested, to examine the quality ● For infected root canals with periapical lesions caused by pulp
of intracanal medicaments, which provides a predictive infection and necrosis and cases of root canal retreatments,
reference for controlling infection and guiding communica- especially those with extensive apical lesions, severe swelling,
tion with patients about treatment procedures and prognosis. and pain, presence of sinus tracts, or active exudation,
● The sealing period for root canal therapy is 1–2 weeks.65,120 intracanal medication is needed to reduce bacteria and toxin
● Medicament removal: Water-based calcium hydroxide can be load in the root canal system. The interappointment period of
removed by irrigation, and it is recommended to use dynamic intracanal medication provides a window of opportunity for
irrigation under microscope.44,121 Irrigation needle with bristle the assessment of the effect of infection control.
brush (NaviTip FX), XP-endoFinisher, M3-Max, and Finisher GF ● The intracanal medicaments should consist of a radiopaque
Brush can be used for agitation during root canal irriga- agent and fill the entire root canal system to establish a robust
tion,32–34,122 which enhances the effectiveness and efficiency physical barrier. Additionally, it should tightly seal the coronal
of removing medicaments. access to prevent any potential leakage from the crown.
● In general, intracanal medication is typically performed 1–2 Immediate evaluation of the intracanal medication by X-ray
times during interappointment visits.12 If symptoms and signs imaging is suggested.

International Journal of Oral Science (2024)16:23

 Expert consensus on irrigation and intracanal medication in root canal. . .
Zou et al.
8
Overall, adequate mechanical preparation and irrigation are the 19. Wang, D., Gao, X. & Shen, S. [Comparison of antimicrobial efficacy of four
primary measures for controlling root canal infection during root endodontic irrigants using an in vitro model infected by Enterococcus faecalis].
canal therapy, while intracanal medication is a supplementary Zhonghua Kou Qiang Yi Xue Za Zhi 42, 223–224 (2007).
approach. 20. Grawehr, M., Sener, B., Waltimo, T. & Zehnder, M. Interactions of ethylenedia-
mine tetraacetic acid with sodium hypochlorite in aqueous solutions. Int. Endod.
In summary, chemical irrigation is essential in infection control,
J. 36, 411–417 (2003).
and medication is supportive for persistent infection, especially 21. Rossi-Fedele, G., Doğramacı, E. J., Guastalli, A. R., Steier, L. & de Figueiredo, J. A. P.
teeth with sinus tract, during root canal therapy. The irrigation and Antagonistic interactions between sodium hypochlorite, chlorhexidine EDTA,
medication protocols for apexification or regenerative endodontic and citric acid. J. Endod. 38, 426–431 (2012).
procedures should refer to the corresponding expert consen- 22. Cintra, L. T. A. et al. The use of NaOCl in combination with CHX produces
sus.110 Given the intricate nature of root canal anatomy and the cytotoxic product. Clin. Oral. Investig. 18, 935–940 (2014).
diverse range of infections encountered, it is imperative to 23. Rasimick, B. J., Nekich, M., Hladek, M. M., Musikant, B. L. & Deutsch, A. S. Inter-
develop safer and more effective irrigants, innovate more practical action between chlorhexidine digluconate and EDTA. J. Endod. 34, 1521–1523
and feasible operating techniques and procedures, and develop (2008).
24. Basrani, B. Endodontic Irrigation. Chemical Disinfection of the Root Canal Sys-
smaller and more affordable equipment for root canal irrigation.
tem (Springer International Publishing AG, 2015).
With advancements in techniques for cleaning root canals, the 25. Boutsioukis, C. & Arias-Moliz, M. T. Present status and future directions—irri-
focus on intracanal medicaments is becoming secondary. The gants and irrigation methods. Int. Endod. J. 55(Suppl 3), 588–612 (2022).
emergence of next-generation antimicrobial peptides, nanoparti- 26. Boutsioukis, C. et al. Evaluation of irrigant flow in the root canal using different
cles, and other drugs/formulations may bring about fundamental needle types by an unsteady computational fluid dynamics model. J. Endod. 36,
changes in intracanal medication and revolutionize the proce- 875–879 (2010).
dures and concepts underlying root canal therapy. Nonetheless, 27. European Society of Endodontology. Quality guidelines for endodontic treat-
the ultimate objective of root canal therapy remains unaltered: ment: consensus report of the European Society of Endodontology. Int. Endod. J.
controlling infection to preserve the affected tooth maximally. 39, 921–930 (2006).
28. Boutsioukis, C. et al. The effect of needle-insertion depth on the irrigant flow in
the root canal: evaluation using an unsteady computational fluid dynamics
model. J. Endod. 36, 1664–1668 (2010).
ADDITIONAL INFORMATION
29. Boutsioukis, C. et al. The effect of apical preparation size on irrigant flow in root
Competing interests: The authors declare no competing interests. canals evaluated using an unsteady Computational Fluid Dynamics model. Int.
Endod. J. 43, 874–881 (2010).
30. Blanken, J., De Moor, R. J. G., Meire, M. & Verdaasdonk, R. Laser induced
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