Comparative Evaluation of the Effectiveness of Root Canal Preparation After Irrigation Using Endodontic Needle and Inertial Cavitation: A Randomized Controlled Trial
Phase: NA
Conditions: Root Canal Treatment, Post Operative Pain
Sponsor: Lumendo AG

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PROTOCOL 
(Clinical Investigation Plan) 
 
 
Comparative evaluation of the effectiveness of root canal preparation after 
irrigation using endodontic needle and inertial cavitation: A randomized 
controlled trial 
 
 
 
 
Protocol version: 1.0 
 
Protocol Date: 27.01.2022 
 
 
 
 
 

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SPONSOR SIGNATURE PAGE  
The Sponsor have approved the Protocol (CIP) version 1.0 dated 27.01.2022 and confirm 
hereby to conduct the investigation according to the Protocol (CIP), the current version of 
the World Medical Association Declaration of Helsinki, ISO14155 norm, ICH-GCP as far as 
applicable, and the local legally applicable requirements. 
 
Sponsor:                             Lumendo AG (CHE-165.176.923),  
                                            Chemin du Closel 5,  
                                            1020 Renens, 
                                            Switzerland 
 
Mark Bispinghoff, CTO 
 
 
Place/Date 
 
Signature 
 
 
Andreas Schmocker, CEO 
 
 
Place/Date 
 
Signature 
 
 
Co-Investigator: Prof. Dr. Dr. h.c. Mutlu ÖZCAN, Honorary Professor 
İstanbul Medipol Universitesi, Kavacık Mah. Ekinciler Cad. No: 19/1/1 34810 Beykoz, 
İstanbul, Turkey 
 
Prof. Mutlu ÖZCAN 
 
 
Place/Date 
 
Signature 
 
 
 

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INVESTIGATOR STATEMENT 
I have read and understood this Protocol (CIP) version 1, dated 27.01.2022 and agree that it 
contains all necessary details for carrying out the study described and in conformance with 
Good Clinical Practices (GCPs) and applicable regulatory requirements. I agree to conduct 
the investigation according to the Protocol, the current version of the World Medical 
Association Declaration of Helsinki, ISO 14155 norm, ICH-GCP and the local legally applicable 
requirements. I agree to maintain the confidentiality of all information received or 
developed in connection with the protocol.  
 
Site:                                     İstanbul Medipol Universitesi,  
                                             Diş Hekimliği Fakültesi,  
                                             Haliç Yerleşkesi,  
                                             Atatürk Bulv. No:27,  
                                             34083, Unkapanı,  
                                             Fatih/istanbul Türkiye 
 
Principal Investigator: Assoc. Prof. Dr.Tan Fırat EYÜBOĞLU 
 
Tan Fırat EYÜBOĞLU 
Printed Name of Principal Investigator 
 
 
Signature of Principal Investigator 
 
 
Place/Date 
 
 
 

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TABLE OF CONTENT 
Introduction ..................................................................................................................... 6 
Objectives and hypothesis ................................................................................................. 7 
STUDY PROTOCOL ............................................................................................................. 7 
1. Sponsor: ...................................................................................................................... 7 
2. Principal Investigator .................................................................................................... 8 
3. Preparation of the Investigation:.................................................................................... 8 
3.1. 
Ethical Considerations: ........................................................................................... 8 
3.2. 
Investigational device ............................................................................................. 8 
3.2.1. General description of the investigational device ........................................................ 8 
3.2.2. 
Traceability and accountability of the investigational device ................................... 9 
3.2.3. 
Intended purpose of the investigational device ..................................................... 9 
3.2.4. 
Intended patient’s population ............................................................................. 9 
3.3. 
Study Design and Setting ........................................................................................ 9 
3.3.1. 
Patient Population: ............................................................................................. 9 
3.3.1.1. Sample Size Calculation ....................................................................................... 9 
3.3.1.2. Pilot Study ....................................................................................................... 10 
3.3.1.3. Inclusion Criteria: ............................................................................................. 10 
3.3.1.4. Exclusion Criteria: ............................................................................................. 10 
3.3.1.5. Withdrawal Criteria: ......................................................................................... 11 
3.4. 
Diagnosis ............................................................................................................ 11 
3.5. 
Randomization and Blinding ................................................................................. 11 
4. Patient information and informed consent to participate: .............................................. 12 
5. Confidentiality: .......................................................................................................... 12 
6. Clinical Procedures ..................................................................................................... 12 
6.1. 
Endodontic procedures ........................................................................................ 12 
6.2. 
Post-endodontic pain assessment ......................................................................... 13 
7. Concomitant Treatments ............................................................................................ 13 
8. Schedule ................................................................................................................... 13 
9. Reporting of Unexpected Serious Adverse Events, Serious Adverse Events and Adverse 
Events ........................................................................................................................... 14 
10. 
Premature Termination of the Study...................................................................... 15 
11. 
Statistical Analysis ................................................................................................ 15 
12. 
Financing and Insurance ....................................................................................... 15 
12.1. 
Reimbursement of Patients' Expenses ................................................................... 15 

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12.2. 
Insurance for Patients .......................................................................................... 15 
13. 
Publications policy ............................................................................................... 15 
14. 
References .......................................................................................................... 15 
 
 
 

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Comparative evaluation of the effectiveness of root canal preparation after irrigation using 
endodontic needle and inertial cavitation: A randomized controlled trial 
Introduction 
Postoperative pain after root canal treatment is a clinical challenge influenced by host-dependent 
(preoperative pain, occlusal trauma) (Glennon et al. 2004, Yu 2004) and operator-dependent factors 
(chemical, mechanical or microbiological factors) (Siqueira & Barnett 2004). It is mainly attributed to 
the extrusion of infected debris into the periapical area. (Siqueira JF 2003). Although the incidence of 
postoperative pain was reported to be around 40% of cases, it can reach 80% within the first 24 
hours after the treatment (Pak & White 2011). While host-dependent factors cannot be influenced, 
the operator-dependent factors such as instrumentation materials, shaping kinematics, irrigation 
material and method can be controlled to minimize or avoid postoperative pain (Tanalp and Gungor 
2014, Mostafa et al. 2020). 
Chemo-mechanical debridement of the root canal system is important to achieve an optimal 
disinfection and shaping of the root canal and is a prerequisite for a successful treatment outcome 
(Topcuoglu et al. 2018, Eyuboglu & Özcan 2019). Optimal shaping and disinfection require both 
mechanical and chemical debridement as large areas of the root canal system were shown to remain 
untouched even after the completion of root canal shaping (Brito et al. 2009, Howard et al. 2011). 
The comparison of root canals using micro computed tomography before and after root canal 
treatment also presented non-prepared areas within the root canal system and shortcomings of 
mechanical shaping (Peters et al. 2001). Therefore, root canal irrigation, the chemical part of the 
debridement, plays a key role in optimally disinfecting the root canal system, especially on these 
untouched areas (Versiani et al. 2016, Estevez et al. 2017). However, there is no single, ideal 
irrigation solution that can penetrate the entirety of the root canal structure. This is not sufficiently 
improved by increasing the temperature, lowering pH, or increasing wettability. To this end, new 
irrigation solutions have been proposed such as combining sodium hypochlorite (NaOCl) with 
ethylenediaminetetraacetic acid (EDTA) as initial or final irrigation solution (Zehnder 2006). 
Endodontic needles with differently shaped tips and designs are the most common way to deliver the 
irrigation solutions into the root canal system (Boustsioukis et al. 2010). However, irrigation using 
endodontic needles does not remove all debris especially within the canal extensions at the apical 
third of the root canal system due to limited fluid penetration (Tay et al. 2010, Chan et al. 2019). 
Different devices or methods for agitation or activation of the irrigation solution have been 
introduced to increase the efficacy of the irrigation solution within the root canal system and thus 
create optimal disinfection (Gu et al. 2009, Dutner et al. 2012, van der Sluis et al. 2015). 
During ultrasonically activated irrigation (UAI) the irrigation solution is activated with a noncutting 
oscillating tip within the root canal system (Boustsioukis et al. 2013). Acoustic microstreaming, a 
unidirectional circulation of fluid, is created by UAI. During the acoustic microstreaming, transient 
(inertial) cavitation was observed (Macedo et al. 2014). Inertial cavitation can only be created under 
the right physical conditions within the root canal system (Flynn (1975)a, Flynn (1975)b, Birkin et al. 
2011). There are several reasons for the disappearance of acoustic microstreaming within the root 
canal such as airlock formation in the apical third of the canal (de Gregorio et al. 2009, Peeters et al. 

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2013) or the oscillating tip getting stuck in the apical third thereby obstructing the oscillating 
movement (Jensen et al. 1999). 
In order to overcome such problems, a  novel medical device “EndoClean” (Lumendo AG, Renens, 
Switzerland) has been developed that generates hydraulic cavitation to clean root canals deeper and 
more effectively than other systems described above. This method overcomes the problem of the 
stagnation plane formation (around 1-2 mm in front of a syringe [Gulabivala et al.,2010), permitting 
the irrigation solution to access deeper into the root canal system and thus providing a fast and 
efficient way of cleaning the root canal. 
It is known that extrusion of irrigation solution may damage the periapical tissues and cause 
postoperative pain (George & Walsh 2008). Although there are data presenting similar amount of 
irrigation solution extrusion between UAI and manual irrigation (Mitchell et al. 2011), no data 
regarding the short term (postoperative pain) effects of the novel device, EndoClean, is available. For 
this reason, a pilot clinical study for EndoClean is planned. 
Objectives and hypothesis 
The primary objective of this randomized controlled trial is to compare the postoperative pain 
intensity levels in patients with asymptomatic teeth diagnosed for non-surgical orthograde root canal 
treatment that are disinfected during the root canal treatment procedure by manual irrigation with 
sodium hypochlorite (NaOCl) solution or EndoClean. The secondary objective is to evaluate, if 
EndoClean could be used safely during root canal treatment as an alternative approach to manual 
irrigation. The null hypothesis is that there will not be a significant difference in postoperative pain 
intensity levels between patients who will undergo root canal treatment with manual irrigation with 
NaOCl or EndoClean. 
 
STUDY PROTOCOL  
The "Clinical Investigation" complies with the requirements of the World Medical Association 
Declaration of Helsinki (2013) and ISO 14155:2020 (Clinical investigation of medical devices for 
human subjects - Good Clinical Practice). 
1. 
Sponsor: 
Lumendo AG (CHE-165.176.923), Chemin du Closel 5, 1020 Renens, Switzerland 
(https://www.lumendo.ch/) by its authorized representitives: 
 
CTO: 
Mark Bispinghoff 
Cell: +41 78 700 95 98 
E-mail: mark.bispinghoff@lumendo.ch  

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CEO: 
Andreas Schmocker 
Cell: + +41 76 363 10 63 
E-mail: andreas.schmocker@lumendo.ch  
 
Clinical Affairs Manager:  
Elena Migacheva  
Cell: +41 76 205 55 25 
E-mail: elena.migacheva@lumendo.ch 
2. 
Principal Investigator 
Name-Surname Tan Fırat EYÜBOĞLU 
Institution: Istanbul Medipol University, Faculty of Dentistry, Department of Endodontics 
Address: Atatürk Bulv. No:27, 34083, Unkapanı, Fatih, Istanbul / TURKEY 
Phone: 05304636059 
E-mail: tfeyuboglu@yahoo.com 
3. 
Preparation of the Investigation: 
3.1. 
Ethical Considerations: 
The ethical considerations of the "Clinical Investigation" are based on the Declaration of Helsinki 
(2013). The approval by the "Ethics Committee" is the prerequisite for the start of the "Clinical 
Investigation". 
3.2. 
Investigational device 
3.2.1. General description of the investigational device 
Endoclean generates hydraulic cavitation within the root canal. The cavitation provides a strong 
erosive effect that allows the removal of bacteria, smear layer, pulp tissue and dental debris based 
on mechanical action only. Endoclean intends to overcome the disadvantages of chemical irrigation 
system that either cannot fully reach all parts of the root canal system,is very cumbersome to use 
and is highly toxic to the surrounding tissue. It further intends to reduce the number and extend of 
mechanical filing steps, thus firstly reducing the overall treatment time andsecondly reducing the 
complication risk ofextensive mechanical filing. 
 

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Endoclean is applied following conventional access cavity preparation, pulp removal, glide path 
preparation and root canal length measurement. The Endoclean tip needs to reach within 3 mm from 
the apex. Accordingly, in very narrow canals minimal shaping is required. Endoclean is applied for 60 
seconds in every root canal in an up-and-down movement. 
 
3.2.2. Traceability and accountability of the investigational device 
Traceability will be controlled during and after the investigation period by means of the lot number 
of the device. Only one device will be used in this study. The lot number of the device used in each 
finished clinical case will be included in the case report and recorded in a datasheet specifically-
designed for that purpose. 
 
The device will be delivered directly to the Site by Lumendo staff. The device will be stored and 
transported according to the regulations written in the instructions. 
 
After completion of the study the used device will be returned to Lumendo by Lumendo staff or 
express shipping. 
 
3.2.3. Intended purpose of the investigational device 
Endoclean is intended to clean and remove bacteria, smear layer, pulp tissue, and dental debris from 
the root canal during root canal treatment. 
 
3.2.4. Intended patient’s population 
Intended patients profile include individuals in need of root canal treatment (endodontic treatment), 
most commonly due to progressed tooth decay, faulty fillings, or tooth trauma which has resulted in 
an infection in the pulp and root of the tooth. The patients are otherwise in relatively good health, do 
not suffer from unrelated acute conditions or diseases and the chronic diseases, if present, are 
properly managed. 
3.3. Study Design and Setting 
The protocol of this prospective, 2-arm, randomized controlled clinical trial and consent forms for the 
patients will be approved by the ministry of health and ethics committee of the university. The study 
will be registered on www.clinicaltrials.gov. The study will be following the Consolidated Standards of 
Reporting Trials (CONSORT) guidelines (Moher et al. 2010). All patients will be informed about the 
nature of the study, the treatment procedures, evaluation process, benefits, and the potential risks 
before they will be asked to sign a written consent form. The enrolment of patients will be executed 
from the outpatient clinic of Department of Endodontics, Faculty of Dentistry, Istanbul Medipol 
University, Turkey. 
3.3.1. Patient Population: 
3.3.1.1. Sample Size Calculation 
In order to determine the number of samples, power analysis was performed using the G*Power 
(v3.1.9.2) program. The power of the study is expressed as 1-β (β = probability of type II error). Based 
on the postoperative 6th-hour pain measurements in the article by D. Liapis et al.*, the mean for 

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Group I was 13.9 SD:16.2; When the mean for Group II was taken as 4.9 SD: 7.3, the effect size (d) 
was found to be 0.716 in the calculation made to obtain 90% power at the α=0.05 level. Accordingly, 
it was calculated that there should be at least 42 people in each group and 84 people in total. 
Considering that there may be losses during the study process (20%), it was decided to take at least 
50 people in each group. 
3.3.1.2. Pilot Study 
10 patients will be involved in a pilot study. There will be 5 patients in each group: manual final 
irrigation and EndoClean device. Pilot study will be conducted for two reasons. The first reason is to 
ensure the safety of the device for clinical use. Thesecond reason is to conduct an accurate power 
analysis and therefore, a sample group for the full clinical study. A full clinical investigation will be 
performed once the pilot study is done, and which will be powered according to the outcome of the 
pilot study. 
3.3.1.3. Inclusion Criteria: 
1. Physical status classification system described was used for patients’ recruitment. 
Healthy patients, who were classified by the American Society of Anaesthesiologists 
(ASA) as ASA I and II 
2. Patients with the age of 18 and over 
3. Patients who were diagnosed as in need of non-surgical orthograde root canal 
treatment of an asymptomatic tooth 
4. Tooth without signs of previously initiated Root Canal Therapy 
 
3.3.1.4. Exclusion Criteria: 
1. Pregnant and lactating females 
2. Patients with chronic periodontal diseases 
3. Patients with sensitivity or adverse reactions to any medication or materials that 
were used throughout the treatment procedure 
4. Patients with acute periapical periodontitis 
5. Patients with acute periodontal abscess 
6. Patients who could not abide by the follow-up time 
7. Patients who used analgesics 1-week prior or antibiotics 1-month prior to treatment 
8. Uncooperative patients 
9. Teeth that cannot be made functional nor restored or difficult to access teeth with 
no importance (wisdom teeth) 
10. Teeth with poor prognosis, for example, due to deep root caries or big root 
resorption 
11. Teeth with 4 mm periodontal pocket depth 
12. Teeth with an inaccessible root end 
13. Teeth with apical resorption or a radiologically not clearly defined apex 
14. Fractured teeth 
15. Teeth with immature or open apices 
16. Teeth with root apices extending into the maxillary sinus 

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17. Teeth with external resorption communicating with the pulp 
3.3.1.5. Withdrawal Criteria: 
Subjects may be withdrawn from the study at the discretion of the Investigator or Sponsor due to a 
safety concern or if judged non-compliant with trial procedures. 
A subject must be withdrawn from treatment if one of the following applies: 
• 
Subject chooses to withdraw from the study at any time; 
• 
Intolerable adverse effects; 
• 
Other circumstances that would endanger the health of the subject if he/she were to 
continue his/her participation in the trial. 
3.4. Diagnosis 
The patient's dental and medical history, demographic data (age, gender) are recorded and a 
thorough clinical examination, as well as radiological examination, is performed. During clinical 
examination, the relevant tooth, and surrounding tissues, as well as adjacent lymph nodes, are 
examined. Percussion and palpation tests, and periodontal probing of the relevant tooth are 
performed. A cold test (Roeko Endo-Frost, Coltène/Whaledent Langenau, Germany) is used to assess 
sensitivity. Periapical radiographs (KODAK RVG 5100, Carestream Health, Rochester, NY, USA) are 
produced with a paralleling technique for evaluation of periradicular tissues (exposure time: 0.16 s, 
exposure dose: 1.22 mGy). All findings of patients will be recorded in patients’ charts.  
After being trained by a blinded investigator, all participants will be asked to grade their pain 
intensity level on a horizontal Visual Analogue Scale (VAS) before the treatment procedure. This scale 
is a horizontal 100 mm bar, marked in every 10mm with two ends. One end (0) indicated “no pain” 
and the other end (10) indicated “worst pain possible”. Categorization of pain scores is as follows: 0-
4 mm = No Pain, 5-44 mm = Mild Pain, 45-74 mm = Moderate Pain, 75-100 mm = severe pain. After 
grading the pain level, the distance between the marked point and the “no pain” endpoint will be 
measured with a ruler to calculate the pain intensity level. Clinical and radiological findings consistent 
with the asymptomatic tooth with nonvital pulp tissue with the preoperative pain intensity scores in 
the category of “no pain” will be included in the study. (Eyuboglu & Kim 2020). 
3.5. Randomization and Blinding 
The patients will be randomly assigned to one of the two groups based on the irrigation protocol 
(Group 1-named “CONI” (conventional irrigation), and Group 2- named “INCA” (inertial cavitation)). 
To rule out the potential influence of the tooth type (molar, nonmolar) on postoperative pain, 
stratified randomization will be performed (Nagendrababu & Gutmann 2017). Blocks with different 
sizes of 2, 4 and 6 and an allocation ratio of 1:1 will be prepared (https://www.randomizer.org). 
All allocations containing the unique randomization number and group name (CONI or INCA) will be 
concealed in opaque sealed envelopes which will be marked with the abbreviations “M” (molar) and 
“NM” (non-molar). 

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Due to the nature of the study, both patient and the operator could not be blinded to the treatment 
protocol. However, the data collector will be blinded to the objectives and the design of the study. 
4. 
Patient information and informed consent to participate:  
All patients participating in the study have to be informed in oral form by the Investigator. 
Additionally, patients will receive an information form, on which they shall give their written 
consent to participate in the investigation. This form will be countersigned by the Investigator and 
the Patient. 
5. 
Confidentiality: 
Data will be collected with a browser-based electronic data capture system. No personal data such 
as name, address, date of birth will be collected with this system. The data will be accessible to the 
sponsor within this system. The identification codes, used by the "Investigator" to put the results of 
the study in a certain relation, have to be kept confidential by the Investigator after completion of 
the study. 
6. 
Clinical Procedures 
6.1. 
Endodontic procedures 
All treatment procedures will be performed in a single visit by a single treatment provider. It will be 
assured that the operation room is quiet and isolated throughout the whole process to avoid any 
outside interference. Patients will be made comfortable and informed about the steps of the 
procedure a second time right before commencing the treatment protocol. Patients will be also 
reminded that they will get the necessary treatment even if they decline from the study and should 
not feel compelled to participate the study for a proper treatment. All root canal treatments will be 
performed using a dental loupe with a magnification of 4.50X (EyeMag Pro F; Carl Zeiss). 
Each tooth will be anaesthetized with 2 mL local anaesthetic solution containing 40 mg/mL articaine 
hydrochloride and 12 mg/mL epinephrine hydrochloride (Ultracaine DS Forte; Aventis Pharma). After 
isolating the tooth with a rubber dam (Hygenic Dental Dam Kit; Coltene/Whaledent Gmbh  &  Co.kg,  
Langenau,  Germany) the operation field will be disinfected using 5.25% NaOCl solution (Wizard; 
Rehber Chemistry) soaked cotton rolls.  
After the access cavity preparation, a #10 C-File (MMC file, Coltene-Micro-Méga, Besançon, France) 
will be introduced into the root canal for scouting. Coronal flaring of root canals will be performed 
using a nickel-titanium flaring file (One Flare; Coltene-Micro-Méga) with an electric endodontic 
motor (Dual Move, Coltene-Micromega). Working length determination will be performed with a #10 
C-file (MMC file, Coltene-Micro-Méga) and glidepath preparation will be completed with a One G 
(Coltene-Micro-Méga). The shaping of the root canals will be performed using One Curve (#25/0.06, 
Coltene-Micro-Méga). If further shaping of the canal will be needed 2 Shape F35 (#35/0.06) (Coltene-
Micro-Méga) files will be used according to apical canal lumen. All rotary files will be used according 

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to the manufacturer’s instructions. The filing protocols and files used will be recorded in the patient 
file. 
In Group 1, 2 mL of NaOCl solution will be used after each file as an irrigation solution. After the 
shaping of the root canal is completed final irrigation with a 31G double side vented tip is performed 
in each canal using 2.5 mL of 5% EDTA (Wizard; Rehber Chemistry) for 1 minute, 2.5 mL of 5.25% 
NaOCl for 30 seconds and 5 mL of saline solution for 30 seconds respectively.  
In Group 2, 2 mL of NaOCl solution will be used after each file as an irrigation solution. After the 
shaping of the root canal is completed, the NaOCl solution is removed from the root canal with 2.5 
mL saline solution using a syringe with a 31G needle. EndoClean tip is introduced into the root canal, 
always maintaining a distance of at least 3mm from the apex. The EndoClean device is used for 60 
seconds for each root canal. 
In both groups, following root canal preparation, a matching gutta-percha cone (#25/0.06 or 
#35/0.06) (MM GP Points, Coltene-Micro-Méga) is introduced into the root canal coated with a 
calcium silicate-based root canal sealer (BioRoot RCS; Lancester PA, USA). Single-cone technique is 
used to fill the root canals. 
Total-etch technique is used to restore the coronal part of each tooth. The cavities are etched with 
35% H3PO4 for 15 seconds before a single layer application of an adhesive material (Adper Single 
Bond 2; 3M ESPE). After photopolymerization (Elipar S10, 3M ESPE) of the adhesive material for 20 
seconds, a flowable bulk-fill composite material (Estelite, BulkFill Flow, Tokuyama Dental, Tokyo, 
Japan) is used to restore the coronal cavity incrementally with a thickness of 4 mm for every layer. 
Each layer is photopolymerized for 20 seconds. 
6.2. 
Post-endodontic pain assessment 
After the treatment, all participants will be provided with analgesics (75 mg diclofenac sodium) 
(Voltaren SR 75 mg, Novartis, Kurtköy, İstanbul) and will be advised to use them if needs be and 
record the time of use. A pain intensity evaluation diary including VAS diagrams with their respective 
follow-up evaluation times will be provided to each participant to mark their pain. All participants 
will be contacted on their follow-up time to remind them to mark their pain intensity scores. Pain 
intensity of patients will be evaluated at 6h, 24h, 48h, 72h and 1 week after the completion of root 
canal treatment as previously described. Any complication such as paraesthesia, acute exacerbations, 
flare-ups, swellings will be also recorded on patients’ charts. Patients who fail to abide by the follow-
up time will be traced via phone, e-mail or SMS to determine the possible reasons for dropout. 
7. 
Concomitant Treatments 
Medications given to patients are to be documented 
8. 
Schedule 
The duration of the investigation and the post-assessment has to be justified. 

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Study duration:  
Step 1. Patients enrollement: 2 months 
Step 2. Treatment duration: 1 visit to dentist 
Step 3. Follow-up period: 1 week 
Flow chart of the study: 
Investigation Periods 
Consent (ICF) 
Screening 
Treatment  
Follow-up 
Visit 
1  
On-site 
2 
On-site 
3 
4 
5 
6 
7 
On-site 
Time (hour, day, week) 
-1 week 
0 
6 hours 
24 hours 
48 hours 
72 hours 
1 week 
Patient consent (ICF) 
x 
 
 
 
 
 
 
Demographics 
x 
 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
 
In- /Exclusion Criteria 
x 
x 
 
 
 
 
 
Dental Examination 
x 
 
 
 
 
 
x 
X-ray 
 
x 
 
 
 
 
 
Randomization 
 
x 
 
 
 
 
 
Medical device application 
 
x 
 
 
 
 
 
Concomitant Therapy, 
x 
x 
x 
x 
x 
x 
x 
(Serious) 
Adverse 
Events, 
Adverse device effects 
x 
x 
x 
x 
x 
x 
x 
Pain intensity 
 
 
x 
x 
x 
x 
x 
Pain 
intensity 
diary 
dispensing 
 
x 
 
 
 
 
 
Pain intensity diary collection 
 
 
 
 
 
 
x 
 
9. 
Reporting of Unexpected Serious Adverse Events, Serious Adverse Events and Adverse Events 
Unexpected Serious Adverse Events and Serious Adverse Events must be reported to the sponsor 
within 24 hours after awareness of the event by the Investigator. Unexpected Serious Adverse Events 
must be reported to the Ethics Committee and Regulatory Authority within identified timeline as per 
the regulations. 

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10. Premature Termination of the Study 
If excessive pain will be experienced by three concomitant patients the study will be terminated. 
11. Statistical Analysis 
Statistical analysis will be defined on later stage. It is a pilot study with exploratory statistics. 
12. Financing and Insurance 
12.1. 
Reimbursement of Patients' Expenses 
The Sponsor shall provide the materials used for the patients. 
12.2. 
Insurance for Patients 
Insurance will be provided by the Sponsor. A copy of the certificate is filed in study site file and the 
sponsor file. 
13. Publications policy 
The study results are communicated to the sponsor after termination and evaluation of the study by 
E-Mail. To healthcare professionals, the public, and other relevant groups not participating directly in 
the study, the results are being presented via publication. It is not planned to use professional writers 
or to grant public access to the full protocol, participant-level dataset, and statistical code. 
The decision to submit the report for publication as well as the ultimate authority over any of the 
activities lies with the Sponsor. 
The trade secrets of the medical device are to be protected at all times. 
14. References 
1. Glennon JP, Ng Y-L, Setchell DJ, Gulabivala K (2004) Prevalence of and factors affecting post 
preparation pain in patients undergoing two-visit root canal treatment. International 
Endodontic Journal 37, 29–37. 
2. Yu CY (2004) Role of occlusion in endodontic management: report of two cases. Australian 
Endodontic Journal 30, 110–5. 
3. Siqueira JF Jr, Barnett F (2004) Interappointment pain: mechanisms, diagnosis, and 
treatment. Endodontic Topics 7, 93–109. 
4. Siqueira JF Jr (2003) Microbial causes of endodontic flare-ups. International Endodontic 
Journal 36, 453–63. 
5. Pak JG, White SN (2011) Pain prevalence and severity before, during, and after root canal 
treatment: a systematic review. Journal of Endodontics 37, 429–3. 

Protocol version 1.0                                                                                                             Page 16 of 17 
Protocol date: 27.01.2022 
 
Confidential 
6. Tanalp, J., & Güngör, T. (2013). Apical extrusion of debris: a literature review of an inherent 
occurrence during root canal treatment. International Endodontic Journal, 47(3), 211–221. 
7. Mostafa MEHAA, El-Shrief YAI, Anous WIO, et al. (2019). Postoperative pain on endodontic 
irrigation using 1.3% versus 5.25% sodium hypochlorite in mandibular molars with necrotic 
pulps: A randomized double‐blind clinical trial. International Endodontic 53, 154-66. 
8. Topçuoğlu HS, Topçuoğlu G, Arslan H (2018) The Effect of Apical Positive and Negative 
Pressure Irrigation Methods on Postoperative Pain in Mandibular Molar Teeth with 
Symptomatic Irreversible Pulpitis: A Randomized Clinical Trial. Journal of Endodontics, 44, 
1210–15. 
9. Eyuboglu TF, Özcan M (2019) Postoperative pain intensity associated with the use of 
different 
nickel-titanium 
shaping 
systems 
during 
single-appointment 
endodontic 
retreatment: a randomized clinical trial. Quintessence International 50, 2–12 
10. Brito PR, Souza LC, Machado de Oliveira JC, et al. (2009) Comparison of the effectiveness of 
three irrigation techniques in reducing intracanal Enterococcus faecalis populations: an in 
vitro study. Journal of Endodontics 35, 1422–7. 
11. Howard RK, Kirkpatrick TC, Rutledge RE, Yaccino JM (2011) Comparison of debris removal 
with three different irrigation techniques. Journal of Endodontics 37, 1301–5. 
12. Peters OA, Schonenberger K, Laib A (2001) Effects of four Ni-Ti preparation techniques on 
root canal geometry assessed by micro computed tomography. International Endodontic 
Journal 34, 221–30. 
13. Versiani MA, Alves FR, Andrade-Junior CV, et al. (2016) Micro-CT evaluation of the efficacy of 
hard-tissue removal from the root canal and isthmus area by positive and negative pressure 
irrigation systems. International Endodontic Journal 49, 1079–87. 
14. Estevez R, Conde AJ, Valencia de Pablo O, et al. (2017) Effect of passive ultrasonic activation 
on organic tissue dissolution from simulated grooves in root canals using sodium 
hypochlorite with or without surfactants and EDTA. Journal of Endodontics 43, 1161–5. 
15. Zehnder M (2006) Root canal irrigants. Journal of Endodontics 32, 389–98. 
16. Boutsioukis C, Verhaagen B, Versluis M, Kastrinakis E, Wesselink PR, van der Sluis LW (2010) 
Evaluation of irrigant flow in the root canal using different needle types by an unsteady 
computational fluid dynamics model. Journal of Endodontics 36, 875–9. 
17. Tay FR, Gu LS, Schoeffel GJ et al. (2010) Effect of vapor lock on root canal debridement by 
using a side-vented needle for positive-pressure irrigant delivery. Journal of Endodontics 36, 
745–50. 
18. Chan R, Versiani MA, Friedman S et al. (2019) Efficacy of 3 supplementary irrigation protocols 
in the removal of hard tissue debris from the mesial root canal system of mandibular molars. 
Journal of Endodontics 45, 923–9. 
19. Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR (2009) Review of contemporary irrigant 
agitation techniques and devices. Journal of Endodontics 35, 791–804. 
20. Dutner J, Mines P, Anderson A (2012) Irrigation trends among American Association of 
Endodontists members: a web-based survey. Journal of Endodontics 38, 37–40. 
21. van der Sluis L, Boutsioukis C, Jiang LM, Macedo R, Verhaagen B, Verlsuis M (2015) Root 
canal irrigation. In: Chavez de Paz LE, Sedgley CM, Kishen A, ed. The Root Canal Biofilm, 1st 
edn. Berlin-Heidelberg, Germany: Springer. pp. 256-302. 
22. Boutsioukis C, Psimma Z, van der Sluis LWM (2013) Factors affecting irrigant extrusion during 
root canal irrigation: a systematic review. International Endodontic Journal 46, 599–618. 

Protocol version 1.0                                                                                                             Page 17 of 17 
Protocol date: 27.01.2022 
 
Confidential 
23. Macedo R, Verhaagen B, Rivas DF, Versluis M, Wesselink P, van der Sluis L (2014) Cavitation 
measurement during sonic and ultrasonic activated irrigation. Journal of Endodontics 40, 
580–3. 
24. Flynn HG (1975)a Cavitation dynamics: I. Free pulsations and models for cavitation bubbles. 
The Journal of the Acoustical Society of America 58, 1160–70. 
25. Flynn HG (1975)b Cavitation dynamics: I. A mathematical formulation,” Journal of the 
Acoustical Society of America 57, 1379–96. 
26. Birkin, P.R, Offin, DG, Vian, CJB, Leighton, TG, Maksimov, A.O (2011) Investigation of 
noninertial cavitation produced by an ultrasonic horn. The Journal of the Acoustical Society of 
America, 130, 3297–308. 
27. de Gregorio C, Estevez R, Cisneros R, Heilborn C, Cohenca N (2009) Effect of EDTA, sonic, and 
ultrasonic activation on the penetration of sodium hypoclorite into stimulated lateral canals: 
an in vitro study. Journal of Endodontics; 35, 891–95. 
28. Peeters, H. H., & Gutknecht, N. (2013). Efficacy of laser-driven irrigation versus ultrasonic in 
removing an airlock from the apical third of a narrow root canal. Australian Endodontic 
Journal, 40, 47–53. 
29. Jensen, SA, Walker, TL, Hutter, JW, & Nicoll, BK (1999). Comparison of the cleaning efficacy of 
passive sonic activation and passive ultrasonic activation after hand instrumentation in molar 
root canals. Journal of Endodontics, 25, 735–8. 
30. Gulabivala, K., Ng, Y.-L., Gilbertson, M., & Eames, I. (2010). The fluid mechanics of root canal 
irrigation. Physiological Measurement, 31(12), R49–R84. 
31. George R, Walsh LJ (2008) Apical extrusion of root canal irrigants when using Er:YAG and Er, 
Cr:YSGG lasers with optical fibers: an in vitro dye study. Journal of Endodontics 34, 706–8. 
32. Mitchell RP, Baumgartner JC, Sedgley CM (2011) Apical extrusion of sodium hypochlorite 
using different root canal irrigation systems. Journal of Endodontics 37, 1677–81. 
33. Moher D, Hopewell S, Schulz KF et al. (2010) CONSORT 2010 explanation and elaboration: 
updated guidelines for reporting parallel group randomised trials. BMJ 340, c869. 
34. Eyuboglu TF, Kim HC (2020) When to install the endodontic post? First visit with root canal 
filling versus a separate second visit for post-restoration: A randomized controlled trial. 
Journal of Oral Rehabilitation 47, 1247-53. 
35. Nagendrababu V, Gutmann JL (2017) Factors associated with postobturation pain following 
single-visit nonsurgical root canal treatment: a systematic review. Quintessence International 
48, 193–208. 
36. Friedman S (2002) Considerations and concepts of case selection in the management of post-
treatment endodontic disease (treatment failures. Endodontic Topics 1(1):54–78