Apical debris extrusion following photon-induced photoacoustic streaming, high-power laser, and other irrigation techniques: A systematic review

OBJECTIVE: To summarize, critically analyze, compare, and synthesize existing data on apical debris extrusion associated with sonic irrigation, passive ultrasonic irrigation (PUI), apical negative pressure (ANP), high-power laser (HPL), and photon-induced photoacoustic streaming (PIPS), as well as conventional irrigation techniques (CIT). METHODS: This systematic review was registered in PROSPERO and conducted in accordance with PRISMA 2020 guidelines. Eligibility criteria were defined based on the PICOS framework, including studies that assessed apical extrusion of debris using at least one of the following irrigation techniques: sonic, PUI, ANP, HPL, or PIPS. A comprehensive search strategy was employed across PubMed, Scopus, Embase, and Web of Science™ databases. Data were summarized, the risk of bias was assessed using the QUIN tool, and the certainty of evidence was rated using GRADE. RESULTS: A total of 364 studies were identified, of which 12 met the inclusion criteria. Most studies presented a low to moderate risk of bias, while the overall certainty of evidence was rated as very low. HPL and PIPS resulted in greater apical extrusion of debris compared to CIT. In contrast, ANP demonstrated less apical extrusion than CIT. The PUI and sonic techniques yielded mixed results, with some studies showing greater debris extrusion and others reporting comparable outcomes to CIT. CONCLUSION: While ANP was associated with less apical extrusion of debris, HPL and PIPS were found to increase debris extrusion relative to CIT. Both sonic and PUI techniques exhibited similar levels of extrusion to CIT.