doi:10.1111/iej.
12137
REVIEW
Apical extrusion of debris: a literature review of an
inherent occurrence during root canal treatment
J. Tanalp & T. Güngör
Department of Endodontics, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey
Abstract
Tanalp J, Güngör T. Apical extrusion of debris: a literature
review of an inherent occurrence during root canal treatment.
International Endodontic Journal, 47, 211–221, 2014.
Extrusion of intracanal debris as well as irrigants is a
common occurrence during root canal treatment, and
no instrument or technique has thoroughly solved
this problem. Because flare-ups may arise with any
irritation directed towards periapical tissues, a shap-
ing or irrigation technique should minimize the risk
of apical extrusion, even though it may not be
prevented. There has been a rapid evolution of root
canal instruments and irrigation systems through the
last decade, and many have been assessed for their
debris extrusion potential. The purpose of this review
was to identify publications regarding the evaluation
Introduction
Chemomechanical preparation of the root canal sys-
tem is one of the major prerequisites of contemporary
root canal treatment. The procedure encompasses not
only canal shaping but also the usage of intracanal
irrigants to provide optimal cleanliness and disinfec-
tion within the root canal system. Although various
methodologies have been introduced, one inherent
problem related to all root canal shaping and cleaning
procedures is the extrusion of intracanal debris and
irrigants into the periradicular tissues.
Correspondence: Assoc. Prof. Dr Jale Tanalp, Yeditepe Univer-
sity, Faculty of Dentistry, Bagdat Caddesi 238 Goztepe, Istanbul,
Turkey (Tel.: +902163636044; fax: +902163636211;
e-mail: jale.tanalp@yeditepe.edu.tr).
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
of debris, bacteria and irrigant extrusion during root
canal treatment. A PubMed, Ovid and MEDLINE
search was conducted using the keywords “apical
extrusion”, “debris extrusion” and “endodontic treat-
ment”. The literature search extended over a period
of more than 30 years up to 2012. Content of the
review was limited to apical extrusion of debris and
irrigants, extrusion of liquid by irrigation methods
and bacterial extrusion. Issues relevant to apical
extrusion were obtained by further search in the
reference sections of the retrieved articles. The review
provides an update on the current status of apical
extrusion.
Keywords: apical extrusion, debris, endodontic
treatment, irrigation.
Received 25 September 2012; accepted 3 May 2013
Chapman et al. (1968) were the first to verify the
expulsion of infective material from the root canal
system during instrumentation. Van de Visse &
Brilliant (1975) then attempted to compare apical
extrusion of debris in root canals with or without
irrigation. They concluded that irrigation was a pro-
cedure that facilitated the extrusion of intracanal
debris periapically and that instrumentation without
irrigants resulted in no collectible debris. The authors
also stated that the amount of debris was correlated
with the length of the root canal. This was a preli-
minary study that successfully demonstrated the
formation of the ‘worm’ of necrotic debris as described
by some (Seltzer & Naidorf 1985). However, irrigation
is one of the indispensable components of successful
root canal treatment and other inherent risks are
likely to ensue without irrigation. Therefore, the selec-
tion of a methodology that would decrease the
International Endodontic Journal, 47, 211–221, 2014 211
 Apical extrusion of debris Tanalp & Güngör
amount of extrusion rather than completely eliminate
the use of irrigants is more logical.
It is the common opinion of most authors that the
extrusion of some debris is inevitable during root
canal instrumentation and a methodology that com-
pletely avoids this phenomenon has not been devel-
oped. There have been many studies on extrusion
with attempts made to quantitate the debris as well
as liquid and bacteria extruded by various techniques.
A review of the literature reveals that the large
number of apical extrusion investigations carried out
in the past decade has not yet been included in a
review. The intention of this article is to make a gen-
eral summary of the apical debris extrusion concept
in the field of root canal treatment. Prior to starting
the review, it is noteworthy to mention that the con-
cept of apical extrusion should not only be limited to
debris or liquid forced into periapical tissues during
mechanical instrumentation. There are also other
types of apical irritations during root canal treatment
that may disrupt the integrity of periapical structures,
such as extrusion of filling materials, intracanal
medicaments or root canal instruments. Extrusion of
intracanal material may be in the form of filling
materials, necrotic pulp tissue, bacteria or irrigants
(Huang et al. 2007). Generally speaking, extrusion of
cleaning, medication or filling materials beyond the
apical terminus into the surrounding tissues may
result in delayed healing or even treatment failure
because of a foreign body reaction (Ng et al. 2008).
The topic of apical extrusion will be reviewed in
terms of debris, liquid and bacterial extrusion to spec-
ify and limit the spectrum of the analysis. However,
the authors share the view that any sort of apical irri-
tation should be taken into consideration when one is
attempting to understand the aetiological factors that
lead to the development of a periapical response and
hamper the healing process. It is also noteworthy to
mention that during endodontic procedures, extrusion
occurs through the combination of several factors, for
example, instrumentation is always associated with
extrusion of debris and extrusion of irrigant will also
result in the extrusion of bacteria. Therefore, it may
be more rational to consider the extrusion phenome-
non holistically, rather than separately.
An initial search was conducted in PubMed, Ovid
and MEDLINE search engines by inserting keywords
‘apical extrusion’ and ‘endodontics’. One hundred and
ten articles in English were retrieved in PubMed,
whereas over 3000 articles were displayed in
Ovid and MEDLINE, covering a wide range of topics
212 International Endodontic Journal, 47, 211–221, 2014
including endodontics, orthodontics and oral surgery.
This necessitated a limitation and specification of the
analysis and further filtering was used, so that only
articles relevant to apical debris, irrigant and bacterial
extrusion caused by root canal shaping instruments,
influence of apical constriction on extrusion, as well
as irrigation potential of recently introduced method-
ologies and devices were included in the search.
Articles displayed using the same keywords and
related to extrusion of MTA during apical placement,
extrusion of obturating materials, complications
such as paraesthesia following overfilling, sodium
hypochlorite accidents and intrusive and extrusive
traumatic luxations, orthodontic luxations and extru-
sion of filling materials during retreatment were
excluded. Thirty-four articles were included by this
selection. Another search was conducted, this time
using the keywords, ‘apical extrusion’, ‘debris’ and
‘endodontics’. Six additional articles were retrieved,
some related to extrusion of debris and others includ-
ing the effect of needle type and negative pressure.
The retrieved articles were reviewed and issues
relevant to apical extrusion (flare-up, etc.) were also
searched for a more complementary analysis of the
topic. Meanwhile, the reference lists of the retrieved
articles were checked to identify further relevant
literature, where necessary. Overall, 59 articles were
included up to 2012.
Clinical and biological relevance of
apical extrusion
One of the most significant complications related to or
that occurs as a consequence of apical extrusion
during root canal procedures is interappointment
flare-ups and postoperative pain that is an undesirable
occurrence both for the patient and the practitioner.
Siqueira (2003) has drawn attention to the fact that
some type of balance exists between microbial aggres-
sion and host defence in asymptomatic chronic perira-
dicular lesions. The author further emphasized that in
case microorganisms are extruded apically during
chemomechanical preparation, the balance will be
disrupted with the periradicular tissues being chal-
lenged by more irritants and an acute reaction will
ensue to re-establish the balance (Siqueira 2003).
During mechanical instrumentation, the number
and virulence of the extruded microorganisms are the
decisive and critical factors that determine the extent
of the periradicular reaction. It has further been indi-
cated that although the qualitative factor is not under
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

the control of the practitioner, quantitative factors
may be controlled by selecting techniques such as
crown-down instrumentation to provide a gradual
approach to the canal terminus. This allows the con-
trol of the amount of irritants propelled periapically
(Siqueira 2003).
Although the presence of virulent microorganisms
is a critical causative factor in the occurrence of flare-
ups, it is also accepted that contaminated as well as
noncontaminated dentine and pulp tissue may have
the potential to initiate an inflammatory reaction.
A good example of this is the report by Seltzer et al.
(1968) where noncontaminated dentine chips forced
beyond the apical foramen during overinstrumenta-
tion distended the apical collagen fibres of the peri-
odontal ligament. Torneck (1967) also demonstrated
that sterile connective tissue fragments placed in the
subcutaneous tissue of white rats and coming in
contact with vital connective tissue of the same speci-
men produced inflammatory reactions. The presence
of immunoglobulins formed against altered tissue
proteins acting as antigens as well as mast cells capa-
ble of degranulation to release vasoactive amines has
also been demonstrated (Naidorf 1985, Torabinejad
et al. 1985).
Seltzer & Naidorf (1985) commented that a quies-
cent chronic inflammatory periapical lesion may give
a violent inflammatory reaction after the initiation of
root canal treatment. Also, cell-mediated or humoral
immunological phenomena may ensue due to foreign
materials introduced into the periradicular connective
tissue. All these aforementioned reports indicate that
all types of physical or chemical irritation that may
disrupt the integrity and balance of periradicular
tissues may have the potential to initiate a periapical
reaction. It appears that the confinement of canal
preparation within the root canal space is of critical
value from multiple perspectives, amongst which
prevention of the initiation of an inflammatory and
immunological reaction is the most important. How-
ever, clinical cases display variations that might
necessitate the selection of different approaches. In
teeth with vital pulps, instrumentation 1–2 mm short
of the apical foramen and preservation of a vital
apical pulp stump may enhance the healing proce-
dure expected thereafter. However, specifically in
teeth with necrotic pulps and periapical lesions, leav-
ing intact tissues apically may result in the harbour-
ing of microorganisms, leading to the persistence of
the periapical lesion (Wu et al. 2006). Also, dentine
chips and pulp tissue compacted into the apical
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Tanalp & Güngör Apical extrusion of debris
region may cause apical blockage and interfere with
the working length (Souza 2006).
It has thus been proposed that the apical foramen
should be penetrated with a file of adequate size to
prevent accumulation in this region, a procedure
referred to as apical patency (Buchanan 1987). It has
been suggested that the selection of an apical patency
file that is not adjusted to the apical portion rather
than one that binds to the foramen will offer less risk
in terms of extrusion (Souza 2006). Nevertheless, it is
one of the major tasks of the dental practitioner to
avoid or minimize irritation of the periapical tissues
during root canal treatment, including one that might
be caused by apical patency files. Consequently, con-
firmation of apical patency must be achieved so as to
cause minimal irritation on periradicular structures.
Methodologies and experimental designs
used in apical extrusion studies
With the intention of quantitatively examining debris
that might be extruded into periapical tissues during
root canal shaping, laboratory experimental set-ups
have been designed. The system that has received the
most attention and has been adopted by most studies
pertaining to apical extrusion of debris is the one
described by Myers & Montgomery (1991). This
system consists of a rubber stopper through which
the instrumented root is forced and secured, a glass
vial where the extruded debris or irrigants are col-
lected and a flask made of glass into which the vial is
placed. A 25-gauge needle is also placed within the
rubber stopper to balance internal and external
pressures. The debris collecting apparatus has shown
variations in different studies. Whilst glass vials have
been selected by some, others have preferred the use
of aluminium crowns suspended beneath the tooth by
wires (Fairbourn et al. 1987). Eppendorf tubes are
also conventional means of debris collection (Tanalp
et al. 2006). Self-curing acrylic is one means of stabi-
lizing the root whilst suspended in the Eppendorf.
The rubber stopper with the tooth is secured into
the mouth of the flask so that the apex remains
suspended. Two points are of importance during the
conduction of such studies. First, the assembly where
the tooth is placed should be secured to prevent any
movement that might disrupt the standardization of
the instrumentation procedure. Also, the flask should
be shielded using a rubber dam so that the operator
performing the procedure is not able to see the root
he or she is working on. This approach simulates a
International Endodontic Journal, 47, 211–221, 2014 213
 Apical extrusion of debris Tanalp & Güngör
clinical working environment where the operator is
dependent on working length determined by radio-
graphs or apex locators without seeing the root canal
space. It also prevents bias by the practitioner.
The methodology comprises weighing the collecting
tubes prior to and after instrumentation using a
precise microbalance and calculation of the extruded
debris by subtracting the initial weight from the post-
instrumentation weight. Because debris as well as
irrigants may also be extruded apically, the extruded
liquid needs to be evaporated by storage in an incubator.
When the amount of extruded liquid is measured, a
calibrated tube serving as a guide with increments of
0.5 mL can be placed next to the collecting tube;
thus, the amount of extruded liquid can be calculated
as well (Myers & Montgomery 1991). Additionally,
the collecting flask or vial can be filled with various
solutions such as 0.9% NaCl. A calibrated injector
(e.g. insulin injector) can be used through the ventila-
tion needle space to collect and measure the amount
of extruded irrigant. This methodology has generally
been preferred by authors who attempted to quanti-
tate the amount of extruded irrigant, apart from
debris (Er et al. 2005, Tinaz et al. 2005, Kustarci
et al. 2008a, Mohammadi 2009).
Lyophilization (dry freezing), a chemical procedure
by which excess liquid can be evaporated, has been
used by some authors (Tanalp et al. 2006). It has
been speculated that slight variations in room temper-
ature and moisture are prevented in lyophilization
process due to the closed environment. Following a
standardized dehydration and weighing protocol is
essential as the weight of the sample might increase
due to hydration from moisture in the air as the sam-
ple is being weighed (Fairbourn et al. 1987). Weigh-
ing procedures are repeated 3 times, sometimes more,
and an average value is taken for more precision.
Another methodology used is the filter column
suction system used by Ruiz-Hubard et al. (1987).
Standardized acrylic endodontic teaching models
containing both straight and curved root canals with
periapical wells are used in this system. To collect
debris produced during cleaning and shaping, models
are cross sectioned through the apical wells using a
low-speed diamond saw. Following instrumentation,
irrigation and drying, root canals are filled. The
reason why experimental root canals are filled in this
methodology is the prevention of the debris in the
periapical well from being pushed backward. The
collected debris is introduced into a filter column
suction system, containing a Millipore plastic filter.
214 International Endodontic Journal, 47, 211–221, 2014
Accurate weight of the filters is previously calculated.
After debris introduction, the filters are exposed to
heat in an oven for the elimination of moisture and
the amount of extrusion is calculated by subtracting
the previously recorded filter weight from the weight
of the debris and filter. Advantages of using simulated
root canals in acrylic models include the adjustment
of the canals to any desired size, shape or curvatures
providing a consistent model. They also eliminate any
variation between dentine of each individual tooth
using a standardized structure. On the other hand,
acrylic models lack pulp tissue, three-dimensional
curves and canal irregularities and a natural apical
constriction. Therefore, they are unable to make a
precise representation of what occurs in clinical
circumstances. Some authors also drew attention to the
fact that heat generated with rotary instruments may
soften the resin material and adversely affect the reliabil-
ity of the experimental system (Kum et al. 2000).
Several common statements have been made by
authors as criticism of the experimental methodology
used for debris collection. For example, no periapical
tissues that may act as a natural barrier against
apical extrusion are present in some laboratory
models. Even if some sort of simulation is provided,
the structure and condition of the tissues as well as
pulpal status cannot be standardized. This has well
been demonstrated by Salzgeber & Brilliant (1977)
who used a radiopaque material to delineate apical
penetration in vivo. The authors concluded that the
solution was confined to the root canal space in teeth
with vital pulps, whereas in teeth with necrotic pulps
and teeth with periapical lesions, the solution seemed
to disperse randomly into the periapical lesions. Also,
the radiopaque material used as an irrigant reached
the end-point of the preparation sooner in teeth with
necrotic pulps than in teeth with vital pulps. As
understood from the aforementioned study, the pulpal
status as well as the condition of the periapical tissues
cannot be mimicked. The pressure at the periapex
cannot be simulated either. Some suggestions have
been made for the simulation of the periodontal liga-
ment to better represent clinical conditions. Hachmei-
ster et al. (2002) suggested the use of floral foam to
simulate the resistance of the periapical tissues to
pressure exerted from within the root canal space. On
the other hand, this methodology has also been
criticized as foam may absorb irrigant and debris
(Altundasar et al. 2011).
It has also been stated that variations in the
microhardness values of dentine may affect the results
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

of studies in which human teeth are used (Tanalp
et al. 2006). In teeth with lower hardness, debris may
be extruded more readily into the periapical tissues.
Another point to draw attention to is that different
irrigating solutions such as sodium hypochlorite or
bidistilled water may be selected in experimental stud-
ies. The extrusion potential of different irrigants may
also affect the results of the studies and the develop-
ment of an experimental model using irrigants
selected during routine endodontic procedures seems
more logical and reflects clinical conditions more
precisely.
Other shortcomings of currently used methodolo-
gies for evaluation of debris extrusion can be summa-
rized as follows: it is impossible to ensure that the
collecting devices are not contaminated or addi-
tionally affected and loaded by sources other than the
apically extruded debris during instrumentation. The
amount of extruded material that is calculated is
extremely low, often in fractions of a mg or lg. There
is always the possibility of additional influence by
touching of the devices by fingers or even pollution
by contents from the environment in which the speci-
mens are preserved. Even contact of moist fingertips
to the steel crown or contamination from other
unpredictable sources may alter the weight by several
lg. These additional parameters cannot be standard-
ized nor prevented, and there is no means by which
they can be differentiated and measured when
extremely low weights are being taken into consid-
eration.
Another important issue is the standardization of
the size of the apical foramen. Although this factor
has been taken into consideration in some studies by
ensuring an even distribution between the experimen-
tal groups by measuring apical diameters (Al-Omari &
Dummer 1995, Beeson et al. 1998, Hinrichs et al.
1998), others have not taken this parameter into
consideration and only preferred standardization by
inserting a certain size of file into the root canal until
it slightly protruded through the foramen, which is a
rather subjective methodology.
Furthermore, procedure to dry samples is also a
weak part of experimental methodologies, which may
show variations according to time, constancy of the
moisture and heat of the storage environment. It is
not possible to ensure that an identical amount of
evaporation has occurred for all samples, and drying
is therefore a critical issue that should be meticu-
lously evaluated to make improvements in traditional
study designs. During the drying procedure, it is not
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Tanalp & Güngör Apical extrusion of debris
only the water content but also the irrigants that
should be evaporated. Crystals of sodium hypochlorite
or other irrigants are likely to remain which might
adversely affect the reliability of the experimental
methodology. Sodium crystals that cannot be sepa-
rated from debris may cause considerable alteration of
the results. The discrepancy between the weights of
extruded materials reported by different authors is a
clear indication of the challenges of the standardiza-
tion. The residue that remains after the evaporation
of the liquid is highly dependent upon the irrigation
method used.
During laboratory investigations evaluating apical
extrusion, one important factor is lacking, which is
the vital pulp tissue that may remain within lateral
canals and apical ramifications. It is quite likely that
this remaining tissue may later be inflamed and
infected and cause periradicular disease (Ricucci &
Siqueira 2010). In serial sections of human teeth,
lateral canals and apical ramifications were observed
in 75% of teeth. In teeth with pulp exposure by
caries, the tissue in lateral canals and apical ramifi-
cations remained vital as long as the pulp tissue in
the main canal was vital. When pulpal necrosis
reached this level, the tissues within these lateral
canals were partially or completely necrotic. The
authors drew attention to develop methodologies to
effectively disinfect these regions. It is practically
impossible to simulate this parameter under labora-
tory conditions.
All the aforementioned techniques and methodolo-
gies are based on the quantitative measurement of
debris, liquid or bacteria. On the other hand, extrapo-
lating apical extrusion on a quantitative basis only
may not be a rational approach as it lacks the accom-
plishment of a qualitative analysis on the content of
extruded material. It is quite likely that a smaller
amount of extruded material may have a higher
potential of initiating a periapical response due to a
bacterial content of high virulence and antigenic
characteristics compared with an extruded material of
high quantity, yet lacking the specific threshold value
of irritation. Furthermore, variations in terms of
measured debris are observed between researchers
even when the same methodology is used, explaining
the confounding of multiple factors in experimental
settings, resulting in questionable results.
A recent article introduced a point conductivity
probe to measure irrigant extrusion and a vial system
incorporating a valve to adjust pressure and a
magnetic stirrer, to resemble a clinical condition and
International Endodontic Journal, 47, 211–221, 2014 215
 Apical extrusion of debris Tanalp & Güngör
mimic periapical pressure. Although this system
warrants further research to determine its reliability,
it holds promise to overcome the weakness of previ-
ous investigations where extrusion might be overem-
phasized due to the lack of imitation of periapical
tissues (Psimma et al. 2012).
Other studies investigating extrusion have evalu-
ated ex vivo the number of bacteria extruded apically
after root canal instrumentation (Er et al. 2005, Kust-
arci et al. 2008a, Mohammadi 2009, Ghivari et al.
2012). Enterococcus faecalis is generally selected as the
biological marker in these studies. It is a nonfastidi-
ous, easy-to-grow aerobic bacterium of significant
clinical importance that is relevant in studies applying
a bacteriological assessment method (Er et al. 2005).
The test apparatus used in this experimental method-
ology resembles those of studies evaluating apically
extruded debris quantitatively, with rubber stoppers
through which experimental teeth are forced. Rubber
stoppers are fitted on top of vials used as collective
containers. The collecting vials are filled with sodium
chloride (0.9%). Contamination is performed using a
pure culture of E. faecalis (ATCC 29212) grown in
brain–heart infusion broths. The number of colony-
forming units (CFU) has to be standardized for each
sample. Root canals are completely filled with E. fae-
calis suspension by sterile pipettes accompanied by
hand instrumentation to carry the bacteria down the
whole length of the root canals. During instrumenta-
tion, irrigation is performed with 0.9% saline solution
to rule out the antibacterial activity of other irrigants.
Before the beginning of and after the end of labora-
tory tests, an amount of (0.1 mL) NaCl solution is
collected from the experimental vials to count the
bacteria and then the suspension is incubated in
brain–heart agar at 37 °C for 24 h. Colonies of bacte-
ria are counted, and the results are given as number
of colony-forming units.
The following comments or criticism can be made
in relation to bacterial extrusion studies from a clini-
cal point of view: they are indeed helpful methodolo-
gies because they show resemblance to clinical
circumstances where bacteria are the predominating
factors governing the process or long-term success of
root canal treatment. E. faecalis is a good species to
select as it is a type of bacteria the endodontic litera-
ture has specifically focused on in recent years due to
its resistant characteristics. On the other hand, these
studies evaluate apical extrusion phenomenon only
from a bacteriological point of view. Apical reactions
are likely to ensue even when sterile tissue fragments
216 International Endodontic Journal, 47, 211–221, 2014
are forced into periradicular tissues and act as
antigens. They are not able to evaluate the virulence
or pathogenic characteristics of the extruded bacteria;
they rather provide numerical information, which is
then extrapolated to the clinical circumstances.
Because no antibacterial irrigant is used, the effect of
this important constituent of chemomechanical prep-
aration is completely ruled out. There is also no
means by which the body’s defence mechanism is
taken into account in laboratory-based methodology.
Nevertheless, these studies are good attempts to
mimic clinical conditions and may be further devel-
oped to reveal a more favourable resemblance to
clinical circumstances by the inclusion of other
variables.
Irrespective of the technique used, some variables
such as canal diameter, angle and distance of canal
curve from the orifice and the radius of curvature are
important factors that should be recorded whilst allo-
cating specimens into groups when extracted teeth
are selected.
The introduction of innovative irrigation systems
creating a negative pressure at the apical portion of
canals has held promise for the prevention of irrigant
extrusion. Concurrently, there have been alterations
in study designs for evaluating the degree of liquid
extrusion caused by these systems. An example of
these new methodologies is the one described by
Mitchell et al. (2010) where the experimental teeth
are embedded in 0.2% agarose gel. A colour change
to purple occurs as sodium hypochlorite is extruded
into the gel. The gel is photographed after irrigation,
and the area of the colour change is expressed in
Pixels using Adobe Photoshop 7 (Adobe, San Jose,
CA, USA). The gel system is designed to simulate peri-
apical tissues, which has generally been a weak point
of the majority of extrusion studies. Although it is a
good attempt to simulate in vivo conditions, the
authors summarized the shortcomings of this design
by stating that the density of the gel cannot be corre-
lated with that of an intact periodontium or a periapi-
cal lesion where a constant density is not expected.
Furthermore, the gel possesses a porous nature and
the extrusion affected area expands with time as long
as the pH remains above 9. Although the authors
have tried to overcome this limitation by aspirating
irrigants and drying the canal after each cycle, the
degree to which this is accomplished remains ques-
tionable. Residual sodium hypochlorite is always
likely to remain, which may cause the persistence of
the pH above a certain limit.
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

Overview of extrusion studies
A survey of literature reveals that there has been a
continuous interest to evaluate endodontic instru-
ments and techniques in terms of apical extrusion
over the years. As stated previously, the unreliable
characteristics of the study designs prevent definite
conclusions on extrusion to be drawn. Nevertheless,
the following section summarizes the factors that
impact on extrusion.
Extrusion studies involving only hand techniques
for root canal shaping
Prior to studies by Beeson et al. (1998) and Reddy &
Hicks (1998), extrusion studies focused on different
hand instruments, sonic and ultrasonic techniques for
preparing root canal spaces. Following the study by
Van de Visse & Brilliant (1975) who reported the
significance of irrigation in apical extrusion, several
authors attempted to evaluate the extrusion levels of
different manual preparation techniques as well as
sonic and ultrasonic systems (Fairbourn et al. 1987,
Ruiz-Hubard et al. 1987).
Al-Omari & Dummer (1995) compared eight differ-
ent hand instrumentation methods and suggested
that techniques involving a filing (linear) motion
caused significantly more blockages and extruded
significantly more apical dentine debris. Their results
were also consistent with other studies showing the
tendency for cervical flaring and crown-down tech-
niques to produce less apical extrusion (Fairbourn
et al. 1987, Ruiz-Hubard et al. 1987, McKendry
1990).
Extrusion studies using sonics and ultrasonics
Martin & Cunningham (1982a) suggested that ultra-
sonic instrumentation extruded less material than
hand instrumentation. On the other hand, in a clini-
cal study assessing post-instrumentation pain and
flare-ups, no significant difference existed between
endosonic and conventional instrumentation, show-
ing that from laboratory studies, results cannot be
directly extrapolated to clinical circumstances (Martin
& Cunningham 1982b) and controversial results may
be obtained when trying to correlate laboratory stud-
ies to clinical findings. In another study, sonic canal
preparation produced the lowest amount of debris
extrusion, whereas conventional technique the high-
est (Fairbourn et al. 1987).
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Tanalp & Güngör Apical extrusion of debris
Extrusion studies on nickel–titanium rotary instruments
(debris, liquid and bacteria)
ProFile .04 Taper Series 29 System (Dentsply Tulsa
Dental Products, Tulsa, OK, USA) was first assessed in
terms of debris evaluation by Beeson et al. (1998)
and compared with K-files. It was proposed that spe-
cific features of this system would encourage coronal
displacement of debris, rather than apical. Later, the
ProFile Series 29 was compared with other Ni-Ti
instruments such as Lightspeed (Reddy & Hicks
1998), NT McXIM (Hinrichs et al. 1998), Quantec
2000 and PowR (Ferraz et al. 2001) and Race and
FlexMaster (Zarrabi et al. 2006). The system generally
yielded lower extrusion compared with other systems.
Furthermore, the system has also been evaluated in
terms of extrusion potential at different speeds of rota-
tion (Bidar et al. 2004). Even at a high speed, the
instrumentation system produced lower extrusion
compared with hand instrumentation. The less
aggressive morphological characteristics of the system
and the requirement for the utilization of multiple
instruments before reaching the apical terminus
might have accounted for the relatively lower extru-
sion levels observed with the ProFile .04 Taper Series
29 System.
ProTaper (Dentsply Maillefer, Ballaigues, Switzer-
land) has also been the topic of a variety of investiga-
tions pertaining to apical extrusion. In extrusion
studies incorporating ProTaper, the system has been
compared with ProFiles and K-Flexofiles (Azar &
Ebrahimi 2005) and System GT (Dentsply Maillefer)
from a bacteriological point of view (Er et al. 2005).
No differences in terms of extrusion were noted in
these studies compared with other systems tested.
On the other hand, ProTaper was found to extrude
significantly more debris compared with ProFile and
HERO Shaper in other studies (Tanalp et al. 2006,
Logani & Shah 2008). The ProTaper system was also
compared with K3 system (Kustarci et al. 2008c,
Madhusudhana et al. 2010) and Mtwo (Madhu-
sudhana et al. 2010, Tasdemir et al. 2010). Kustarci
et al. (2008c) reported that ProTaper extruded signifi-
cantly more debris compared with K3, whereas
Madhusudhana et al. (2010) determined no signifi-
cant difference. Tasdemir et al. (2010), on the other
hand, reported that ProTaper extruded significantly
higher amount of apical debris compared with other
systems tested, one of which was Mtwo.
Mtwo, a rotary system that engages a step-back
approach, was also assessed by Froughreyhani et al.
International Endodontic Journal, 47, 211–221, 2014 217
 Apical extrusion of debris Tanalp & Güngör
(2011) and was determined to extrude significantly
more debris than Race.
Kustarci et al. (2008a,b) evaluated K3, Race (FGK,
La Chaux-de-Fonds, Switzerland) and FlexMaster
(VDW, Munich, Germany) from two different perspec-
tives in two extrusion studies, one related to debris
and the other to bacterial extrusion. In both studies,
hand instrumentation resulted in more debris and
bacterial extrusion. No differences were noted
between the groups in terms of debris extrusion. On
the other hand, in the bacterial extrusion study, man-
ual technique caused significantly more bacteria com-
pared with the engine-driven groups, which presents
a good example of how results might differ with differ-
ent study designs.
Influence of apical diameter and patency on
extrusion
In the majority of extrusion studies, the standardiza-
tion of apical diameter is performed by inserting a file
of a specific size until it protrudes through the fora-
men. This is a rather subjective means of standardiza-
tion although it is generally believed to provide
patency of the apical foramen and provide consistency
amongst samples in terms of the diameter of the
apical region. Some studies preferred to make a more
detailed analysis and examined apical regions (major
and minor foramina) under a stereomicroscope
(Fairbourn et al. 1987, Myers & Montgomery 1991).
Al-Omari & Dummer (1995) determined no correla-
tion between weight of debris extruded and parame-
ters of canal shape, one of which was apical diameter.
Hinrichs et al. (1998) also concluded that factors
such as canal length, curvature and foramen size had
no influence on the amount of debris extruded.
Lambrianidis et al. (2001) evaluated the extrusion
concept in terms of the maintenance of apical patency
during instrumentation. An interesting finding des-
cribed as paradoxical by the authors was the greater
amount of extrusion that occurred when the apical
constriction remained intact. Tinaz et al. (2005), on
the other hand, found a contradictory result and
concluded that more debris was extruded with an
increase in apical diameter. A laboratory study con-
cluded that NaOCl extruded into a simulated perira-
dicular space without apical debridement nor use of
patency files and injection of the irrigant without
pressure (Camoes et al. 2009). This demonstrates how
easily endodontic irrigants reach the apical third and
extrude into the periradicular tissues.
218 International Endodontic Journal, 47, 211–221, 2014
Influence of working length on extrusion
In most studies on extrusion, the influence of the
working length has not been the main target of the
investigation; however, it has been further evaluated
to provide additional complementary information.
Some studies concluded that filing to the foramen
resulted in more debris extrusion compared with
1 mm shorter than the foramen (Martin & Cunning-
ham 1982a,b, Myers & Montgomery 1991, Beeson
et al. 1998).
Influence of canal curvature on extrusion
The majority of studies on extrusion have used single
rooted teeth with relatively straight root canals of
<5–10 degrees of curvature. On the other hand, it is
quite likely that the practitioner will be faced with
severely curved roots in clinical practice. Leonardi
et al. (2007) focused on roots with greater curvatures
and determined no significant differences between
slight and moderate curvatures nor any difference
between the evaluated techniques in terms of debris
extrusion.
Influence of instrument pitch design on extrusion
The influence of pitch design of a specific instrument,
NRT files (MANI Inc, Tochigi, Japan), was assessed by
Elmsallati et al. (2009) with short-, medium- and
long-pitch designs. The results showed that the short-
pitch design extruded less debris than the medium
and long ones.
Influence of irrigant needle type on extrusion
In general, studies on apical extrusion utilize conven-
tional needles of various gauges. Altundasar et al.
(2011) drew attention to the type of irrigation needles
used. ProTaper in combination with a regular needle
extruded the greatest amount of irrigant, and side-
vented irrigation needles seemed to have a lowering
effect on irrigant extrusion.
Debris and liquid extrusion studies on
reciprocating instruments
De-Deus et al. (2010)reported no difference between
conventional ProTaper Universal technique and
single-file ProTaper F2 in terms of debris extrusion.
Bürklein & Schäfer (2012) on the other hand,
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

concluded that full-sequence rotary instrumentation
was associated with less debris extrusion compared
with reciprocating single-file systems.
Studies on extrusion potential of irrigation
methodologies and devices
Although traditional needles are widely used by many
practitioners, there are continuous attempts to facili-
tate the flow mechanism and even distribution of
irrigants within the root canal space as well as to
provide additional safety.
The use of a reservoir of irrigation in the coronal
access cavity and passive insertion of the needle have
been shown to provide safer treatment procedure,
decreasing the likelihood of considerable amounts of
liquid being pushed periapically (Brown et al. 1995).
The idea of aspirating the delivered solution back
from the root canal space has been proposed by some
authors (Fukumoto et al. 2006).
Although provision of safe irrigation is extremely
important, it is undeniable that the irrigation solution
is expected to provide optimal cleanliness especially in
the apical portion of the root canal system. It has also
been proposed by some that traditional needles are
ineffective in cleaning the apical third (Boutsiokis
et al. 2009). Manual dynamic irrigation incorporating
the application of a gutta-percha cone in short, gentle
strokes to hydrodynamically activate the irrigant
(McGill et al. 2008) and the EndoVac system (Discus
Dental, Culver City, CA, USA), an apical negative
pressure irrigation device, are two methodologies that
have gained attention. Supportive statements were
made by some authors for EndoVac, indicating that it
resulted in less irrigant extrusion (Desai & Himel
2009, Mitchell et al. 2010, 2011) and reduced post-
operative pain (Gondim et al. 2010). However, the
accumulated data are limited and further long-term
clinical trials are warranted to better establish these
methodologies in routine care.
Conclusions
This review article summarizes the results of apical
extrusion studies. In general, the clinical relevance
and scientific reliability of the reported studies are
questionable and difficult to draw out definite conclu-
sions. Apical extrusion should not solely be the deci-
sive factor in the selection of a specific methodology
because there are also other parameters that deter-
mine the clinical success of root canal treatment. On
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Tanalp & Güngör Apical extrusion of debris
the other hand, prevention of all types of damage and
irritation to surrounding tissues is one of the major
clinical responsibilities of a practitioner. Caution must
be exercised in the selection and utilization of instru-
ments, specifically taking into consideration the
diagnosis of the clinical case.
Within the limitations of the evaluated studies, it
can be concluded that rotary instruments used in a
crown-down manner seem to produce less extrusion
than hand instruments used conventionally. Also,
simple modifications in irrigation methodologies by
selecting side-vented needles may be advantageous for
the prevention of apical extrusion. Negative pressure
creating irrigating devices also seem promising
though meticulous care should be taken to prevent
complications such as the clogging of delivery tips.
Reciprocating movement is a recent concept that has
not been evaluated extensively in terms of debris
extrusion and warrants further research.
It appears that there is a tendency to develop extru-
sion study designs and set-ups, which better resemble
in vivo conditions and inclusion of other important
parameters, such as the apical pressure. Once these
methodologies are more strongly established, more
credible information regarding extrusion will result.
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