1 Volume 24 2025 e254250 Original Research Braz J Oral Sci. 2025;24:e254250http://dx.doi.org/10.20396/bjos.v24i00.8674250 ¹ Graduate Program in Dentistry, ATITUS Educação, Passo Fundo, RS, Brazil. 2 Undergraduate Program in Dentistry, ATITUS Educação, Passo Fundo, RS, Brazil. Corresponding author: Rafael Sarkis-Onofre Graduate Program in Dentistry – ATITUS Educação Senador Pinheiro, 304/ Rodrigues/ 99070-220 Passo Fundo, Rio Grande do Sul, Brazil. E-mail address: rafael.onofre@ atitus.edu.br Editor: Dr. Altair A. Del Bel Cury Received: August 9, 2023 Accepted: November 19, 2024 Use of the gentlewave system in endodontics: scoping review Daiana Jacobi Lazzarotto¹ , Mayara Colpo Prado1 , Lara Dotto2 , Rafael Sarkis-Onofre1* Aim: The objectives of this scoping review are to map the evidence available in the literature on using the GentleWave System (GWS) in endodontic treatments and to identify knowledge gaps. Methods: Searches were conducted in PubMed, Scopus and Web of Science. We included randomized and non-randomized clinical trials, cohort studies, case series and cross-sectional studies that evaluated or reported using the GWS. In vitro studies assessing the GWS versus a control group were included. Studies were independently selected by two researchers based on eligibility criteria. Two reviewers each extracted data from half of the included studies. The following data were extracted: study design, purpose, number of study groups, sample size and sample type, analyzed outcome, outcome measurement and main results. A descriptive analysis of the data was performed. Results: Twenty-seven studies were included. In vitro studies were the most frequent study design (85.2%). Of these studies, 13 evaluated root canal disinfection. The general results demonstrated that the GWS produces results superior to the observed comparison groups. Only four studies were conducted in humans (13.8%): three prospective clinical studies and one randomized clinical trial. However, the results of these studies seem to demonstrate that the GWS is a promising treatment. Conclusion: Available evidence demonstrates that knowledge about GWS is still very limited. Although most of the studies in our review demonstrated that the GWS performed better than or similar to other observed systems, caution should be exercised regarding its clinical recommendation, as evidence of its superiority comes only from in vitro studies. Keywords: Endodontics. Review. Root canal preparation. Root canal therapy. https://orcid.org/0009-0009-3235-8377 https://orcid.org/0000-0003-1094-8148 https://orcid.org/0000-0003-1535-4736 https://orcid.org/0000-0002-1514-7879 2 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Introduction Endodontic diseases often result from the evolution of dental caries and are the main reasons for seeking dental care1-4. Eliminating necrotic tissue and bacteria is a crucial step of endodontic therapy and provides a better chance of achieving success and obtaining a favorable treatment prognosis5. The chemical–mechanical preparation is a step of endodontic treatment and aims to disinfect the root canal system6,7. For this procedure, it is necessary to shape the root canal system with either manual or mechanized instruments and to use sonic and ultrasonic devices associated with irrigation solutions. These solu- tions aim to improve the removal of microorganisms from root canal systems5. Auxiliary solutions are used as decalcifying substances to remove the smear layer and open and expose the dentinal tubules for penetration of irrigants and intracanal medication8,9. However, even after adequate chemical–mechanical preparation, current tech- niques and instruments still cannot ensure that canals are free of bacteria10. The permanence of microorganisms can result from several factors and anatomical complexities, such as curvatures, isthmuses and anastomoses, lateral canals, api- cal ramifications and canals of different formats, considered challenging to access by endodontic instruments11. Cases with these complexities depend mainly on the effects of irrigating solutions and intracanal medications for complete cleaning and disinfection12. Recently, a new device known as the GentleWave System (GWS) (Sonendo, Laguna Hills, CA, USA) was developed to clean root canals. The system works through a handpiece positioned on the occlusal surface of the already accessed tooth, and it is activated from a computer console. In addition, the system contains a tech- nology called multisonic ultra-cleaning, which is based on the energy generated by various wavelengths of sound over a wide frequency range. The irrigant solutions and chelating agents (3% sodium hypochlorite, distilled water and 8% ethylene- diamine tetraacetic acid—EDTA) are associated with the sonic movement. The machine alternates the flow of irrigation fluid, which interacts with the stationary liquid inside the pulp chamber, creating a shear force that causes hydrodynamic cavitation, forming microbubbles13. The GWS features a built-in suction that removes fluid and residual debris through a negative pressure created inside the root canal system, promoting crown–apex cleaning10,14. Furthermore, according to the manufacturer, the canals can be treated with minimal instrumentation and do not need to be enlarged beyond the ISO 15 size, thus preserving the tooth structure14,15. Although some articles have been published over the last several years discussing the use of the GWS system, its introduction to the market is still very recent, and a better understanding of it is still necessary. In addition, no systematic literature search has been performed to map the available evidence and identify knowledge gaps. Therefore, a scoping review is an appropriate method since it is designed to 3 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 map and evaluate characteristics and evidence of a given subject based on broad research questions16. Thus, this study aimed to conduct a scoping review to map the available evidence on the use of the GWS and identify gaps in knowledge to guide future research on this technology. Materials and Methods The design of this study was based on the recommendations of Peters et al.16 (2020). The study protocol is available on the Open Science Framework platform through the https://osf.io/n5vhb/ link, and the reporting of the study is based on the PRISMA-ScR17. Eligibility criteria Concept The concept of interest was human and in vitro studies using the GWS, regardless of the outcome. Context For human studies, no restrictions were applied regarding the patient’s age, study setting, endodontic technique used or outcome measured. For in vitro studies, no restrictions were applied regarding the laboratory analysis performed. Additionally, we included studies published in English, Spanish and Portuguese since 2014, the year the technology was developed. Types of participants The included human studies involved patients of any age who underwent endodon- tic treatment, regardless of the reason for treatment, tooth group, preparation tech- nique and filling technique. It was only necessary that the GWS was used during the treatment. For in vitro studies, any dental group was considered, regardless of the preparation and filling technique used, and it was only necessary that the GWS was used during treatment and had a comparator group. Types of sources of evidence Randomized and non-randomized clinical trials, retrospective and prospective cohort studies, case series and cross-sectional studies that evaluated or reported the use of the GWS were included. Furthermore, any in vitro study assessing the use of GWS versus a control group, regardless of the purpose of the study or the analy- sis performed, was included. Search Searches were performed in electronic databases (PubMed, Scopus and Web of Science) restricted from January 1, 2014 (year of technology development), to 4 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 September 1, 2022. The search strategy was developed based on terms of the PubMed MeSH and adapted to the other databases (Table 1). References of included studies were analyzed to identify additional studies. Table 1. Search strategy PubMed “Root Canal Therapy”[Mesh] OR “Root Canal Therapy” OR “Canal Therapies, Root” OR “Canal Therapy, Root” OR “Root Canal Therapies” OR “Therapies, Root Canal” OR “Therapy, Root Canal” OR “Root Canal Treatment” OR “Endodontic Treatment” AND “Gentlewave” OR “Multisonic Ultracleaning” SCOPUS “Root Canal Therapy” OR “Canal Therapies, Root” OR “Canal Therapy, Root” OR “Root Canal Therapies” OR “Therapies, Root Canal” OR “Therapy, Root Canal” OR “Root Canal Treatment” OR “Endodontic Treatment” AND “Gentlewave” OR “Multisonic Ultracleaning” Web of Science (((((((((ALL=(Root Canal Therapy)) OR ALL=(Canal Therapies, Root)) OR ALL=(Canal Therapy, Root)) OR ALL=(Root Canal Therapies)) AND ALL=(Therapies, Root Canal)) OR ALL=(Therapy, Root Canal)) OR ALL=(Root Canal Treatment)) OR ALL=(Endodontic Treatment)) AND ALL=(Gentlewave)) OR ALL=(Multisonic Ultracleaning) Screening The studies were selected using the Rayyan web platform (https://www.rayyan.ai/), where duplicate studies were removed. Initially, a pilot test was conducted to test the agreement in the selection of studies between the two reviewers (DJL and MCP) involved in this phase. The references were randomly selected using the Excel program (Microsoft Corporation, Redmond, WA, USA). Then, the two researchers independently evaluated the articles, first analyzing the titles and abstracts for the presence of the eligibility criteria. These articles were classified as “include,” “exclude,” or “undefined.” Then, the evaluation of the full texts of the articles classified as “include” and “undefined” was conducted independently by the same two reviewers. Discrepancies in selecting titles/abstracts and full texts were resolved through discussion. In case of disagreement, the opinion of a third reviewer (RSO) was obtained. Data collection A standardized data extraction form was created using Excel. First, 10% of the included studies were randomly selected in Excel to test the data extraction process and ensure consistency in interpreting the items. Next, the pilot test was conducted through discussion between the reviewers involved in this study phase. Subsequently, two reviewers (DJL and MCP) each extracted data from half of the included studies, and a third reviewer (RSO) checked the consistency of the data. The following data were extracted: study design, purpose of the study, analyzed outcome, how the outcome was measured and main results. The number of study 5 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 groups, sample size and sample used (e.g., assessed dental group—molar, printed root canals) were also collected. Data analysis Analyses were conducted in Excel. Descriptive data analysis was performed, consid- ering the study design separately. Data were summarized in tables and figures. Results The search resulted in the identification of 177 studies. Forty-eight duplicates were removed, resulting in 129 articles. After analyzing the titles and abstracts, 102 articles were removed. Twenty-seven studies were assessed for eligibility through their full texts, and two articles were excluded (see Supplementary Material). After analyzing references from other studies, two additional articles were included. Thus, 27 studies were included in this scoping review. Figure 1 presents a flowchart depicting study selection. Twenty-three (85.2%) studies were classified as in vitro and four (14.8%) as human studies. Table 2 presents the characteristics of in vitro studies. The sample size ranged from one to 900, and only one study evaluated 900 models of 3D-printed root canals; the majority (64.0%) of studies used molar teeth. Thirteen studies (56.5%) tested canal disinfection and measured different outcomes and used different ver- ification methods. Most of these studies demonstrated that the GWS was superior to the systems used for comparison10,18-23. In four studies, there was no difference between the GWS and the compared groups24-27, and, in two studies, the GWS was shown to be inferior8,28. Three articles evaluated the effectiveness of removing filling material (gutta-percha, cement and calcium hydroxide29-31), and, in only one study, the GWS failed to remove the filling material completely31. Even the first published study on the GWS, which evaluated its effectiveness at tissue dissolution, demonstrated that the system dissolved tissues at a significantly faster rate than conventional irrigation devices32. Several studies evaluated other outcomes. Wang et al.33 (2016) demonstrated that the GWS caused minimal erosion in root dentin, as did the NaOCl group, followed by final irrigation with EDTA. In another study, the anatomy of the dentin of the root canal wall was examined using scanning electron microscopy, and a wide variety of struc- tures, especially in the middle and apical regions, were observed to have no remnants of organic tissue or dentin34. One study found that the GWS and Endovac irrigations were not associated with apical extrusion14. Three other studies evaluated apical pressure while using the GWS and employed the same analysis method. Ordinola-Zapata et al.35 (2021) reported that the GWS produced negative pressure, and closed needles gener- ated lower apical pressure than open needles. According to Chen et al.36 (2021), a larger apical size did not result in higher apical pressure than smaller sizes for needle irrigation, and the GWS and negative pressure during irrigation contrib- 6 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Id en tif ic at io n of s tu di es v ia d at ab as es a nd re gi st er s Id en tif ic at io n of s tu di es v ia o th er m et ho ds Re co rd s id en tif ie d fr om : Ci ta tio n se ar ch in g (n = 3 ) Re co rd s re m ov ed be fo re s cr ee ni ng : Du pl ic at e re co rd s re m ov ed (n = 3 ) Re co rd s id en tif ie d fr om da ta ba se s: Pu bm ed (n = 2 9) W eb o f S ci en ce (n = 2 4) Sc op us (n = 1 4) Re po rts s ou gh t f or re tri ev al (n = 3 ) Re po rts s ou gh t f or re tri ev al (n = 2 7) Re co rd s sc re en ed (n = 1 29 ) Re co rd s ex cl ud ed (n = 1 02 ) Re po rts a ss es se d fo r e lig ib ili ty (n = 3 ) Re po rts a ss es se d fo r e lig ib ili ty (n = 2 7) Re po rts n ot re tri ev ed (n = 0 ) Re po rts n ot re tri ev ed (n = 0 ) Re po rts e xc lu de d: In v itr o st ud y w ith ou t co m pa ra to r ( n = 1) Re po rts e xc lu de d: In v itr o st ud y w ith ou t co m pa ra to r ( n = 2) Identification Screening Included St ud ie s in cl ud ed in re vi ew (n = 2 7) Fi gu re 1 . S tu dy s el ec tio n flo w d ia gr am 7 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Ta bl e 2. C ha ra ct er is tic s an d re su lts o f t he in v itr o st ud ie s in cl ud ed . St ud y St ud y de si gn St ud y gr ou ps N Ti ss ue us ed O bj ec tiv e O ut co m e O ut co m e m ea su re m en t Re su lt Ch ar ar a K et a l. 20 16 In v itr o 18 16 M ol ar s To e va lu at e ap ic al e xt ru si on d ur in g tre at m en t w ith G en tle W av e sy st em , op en c on ve nt io na l 3 0- G n ee dl e or En do va c in ro ot c an al s en la rg ed to di ff er en t d im en si on s w ith a nd w ith ou t ap ic al c on st ric tio n. Ap ic al e xt ru si on Ex tr us io n fr eq ue nc y an d av er ag e ex tr ud ed m as s th ro ug h th e ap ic al ex tr us io n m ea su rin g de vi ce - ai rt ig ht c ha m be r Ro ot c an al tr ea tm en t w ith G en tle W av e Sy st em a nd ir rig at io n w ith E nd ov ac w as no t a ss oc ia te d w ith e xt ru si on . E xt ru de d irr ig at io n m as s us in g th e op en -e nd ed 30 -G n ee dl e de pe nd ed o n th e ca na l t yp e an d en la rg em en t. Ch an R e t a l. 20 19 In v itr o 3 24 M ol ar s To a ss es s th e effi ca cy o f t he G en tle W av e sy st em in c om pa ris on w ith in te rm itt en t an d co nt in uo us u ltr as on ic al ly ac tiv at ed irr ig at io n in th e re m ov al o f a cc um ul at ed ha rd ti ss ue d eb ris in ro ot c an al s an d is th m us es w ith in m es ia l r oo ts of m an di bu la r m ol ar s us in g m ic ro – co m pu te d to m og ra ph ic im ag in g. Re m ov al o f ac cu m ul at ed h ar d tis su e de br is in ro ot c an al s an d is th m us es M ic ro –c om pu te d to m og ra ph ic im ag in g G en tle W av e sy st em a ch ie ve d gr ea te r effi ca cy in th e re m ov al o f a cc um ul at ed ha rd ti ss ue d eb ris fr om th e m es ia l r oo t ca na l s ys te m o f m an di bu la r m ol ar s co m pa re d w ith c on tin uo us u ltr as on ic b ut no t i nt er m itt en t u ltr as on ic . T he e ffi ca cy of c on tin uo us u ltr as on ic a nd in te rm itt en t ul tra so ni c w as c om pa ra bl e. Ch en B e t a l. 20 21 In v itr o 27 1 M ol ar s To e xa m in e th e ef fe ct o f a pi ca l s iz e on th e ap ic al p re ss ur e by p os iti ve a nd ne ga tiv e pr es su re s yr in ge -n ee dl e an d m ul tis on ic n eg at iv e pr es su re ir rig at io n. Ap ic al p re ss ur e Pr es su re tr an sd uc er La rg e ap ic al s iz e of th e ca na l d id n ot re su lt in h ig he r a pi ca l p re ss ur e va lu es c om pa re d to s m al l s iz es fo r s yr in ge -n ee dl e irr ig at io n an d m ul tis on ic n eg at iv e pr es su re ir rig at io n, re ga rd le ss o f d ife re nt c an al a na to m ie s. Ch oi H W e t a l 20 19 In v itr o 3 39 M ol ar s To c om pa re d is in fe ct io n an d th e bi ofi lm re m ov al e ffi ca cy o f t he G en tle W av e sy st em w ith p as si ve ul tra so ni c ac tiv at io n m et ho d. Di si nf ec tio n an d th e bi ofi lm re m ov al e ffi ca cy H is to lo gi ca l t is su e pr oc es si ng . M od ifi ed Br ow n an d Br en n st ai ne d se ct io ns a nd H em at ox yl in a nd E os in st ai ne d se ct io ns w er e vi su al iz ed u si ng a st er eo m ic ro sc op e. Th e G en tle W av e Sy st em d em on st ra te d si gn ifi ca nt ly g re at er re du ct io n in b io fil m w ith in th e m es ia l r oo ts o f m an di bu la r m ol ar s an d m es io bu cc al ro ot s of m ax ill ar y m ol ar s th an th os e tre at ed w ith co nv en tio na l r ot ar y in st ru m en ta tio n an d pa ss iv e ul tra so ni c ac tiv at io n pr ot oc ol . Co ag ui la -L le re na H e t a l. 20 22 a In v itr o 2 22 M ol ar s To a ss es s bi ofi lm re m ov al e ffi ca cy of G en tle W av e Sy st em a nd p as si ve ul tra so ni c irr ig at io n. Bi ofi lm re m ov al effi ca cy Q ua nt ita tiv e re al -ti m e po ly m er as e ch ai n re ac tio n (q PC R) a nd 1 6S ri bo so m al RN A ge ne s eq ue nc in g (n ex t-g en er at io n ae qu en ci ng — N GS ). Ba ct er ia l r ed uc tio n in m es ia l r oo ts of m an di bu la r m ol ar s pr ep ar ed w ith pa ss iv e ul tra so ni c irr ig at io n w as s im ila r t o th os e pr ep ar ed w ith a G en tle W av e sy st em . Th e re du ct io n es tim at ed th at b ot h gr ou ps w er e eq ui va le nt . Co nt in ue 8 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Co nt in ua tio n Cr oz et a BM et a l. 20 20 In v itr o 2 20 M ol ar s Effi ca cy to re m ov e re m ai ni ng fi lli ng m at er ia ls fr om o va l-s ha pe d ro ot c an al s Ef fe ct iv en es s of re m ov in g re m ai ni ng fi lle r m at er ia ls Sc an ni ng e le ct ro n m ic ro sc op e an d M ic ro -C T Sc an ni ng G en tle W av e sy st em a nd p as si ve ul tra so ni c irr ig at io n w er e ab le to re du ce th e re m ai ni ng fi lli ng m at er ia l vo lu m e. N on e of th es e te ch ni qu es co m pl et el y re m ov ed a ll re m ai ni ng fil lin g m at er ia l. Pa ss iv e ul tra so ni c irr ig at io n sh ow ed a b et te r p er fo rm an ce by re m ov in g. Da sh S e t a l 20 20 In v itr o 5 75 Pr em ol ar s To c om pa re th e ef fe ct iv en es s of er bi um : y ttr iu m –a lu m in um –g ar ne t la se r, G en tle W av e irr ad ia tio n, ph ot od yn am ic th er ap y, an d so di um hy po ch lo rit e in s m ea r l ay er re m ov al an d de nt in p er m ea bi lit y w ith a sc an ni ng e le ct ro n m ic ro sc op e. Sm ea r l ay er re m ov al an d de nt in pe rm ea bi lit y Sc an ni ng e le ct ro n m ic ro sc op e Al l t es te d ag en ts a re e ff ec tiv e in s m ea r re m ov al a t c or on al , m id dl e, a nd a pi ca l th ird , h ow ev er , i t w as fo un d th at E r:Y AG la se r-a ct iv at ed c on ve nt io na l r oo t c an al pr ep ar at io n w as c om pa ra tiv el y effi ci en t in c le an in g th e sm ea r l ay er a nd o pe ni ng de nt in al tu bu le s. H aa pa sa lo M et a l 2 01 6 In v itr o 4 4 M ol ar s To m ea su re th e ap ic al p re ss ur e by th e G en tle W av e Sy st em Ap ic al p re ss ur e Pr es su re tr an sd uc er Th e G en tle W av e sy st em pr od uc ed lo w er a pi ca l p re ss ur e th an sy rin ge ir rig at io n un de r a ll ex pe rim en ta l co nd iti on s. H aa pa sa lo M et a l 2 01 4 In v itr o 5 6 Pi ec es of b ov in e m us cl e tis su e As se ss ti ss ue d is so lu tio n Ef fe ct iv en es s in tis su e di ss ol ut io n Ti ss ue d is so lv ed a s ju dg ed v is ua lly in le ss th an 5 m in ut es Th e G en tle W av e sy st em u se d w ith so di um h yp oc hl or ite (N aO Cl ) a t d iff er en t co nc en tra tio ns d is so lv ed ti ss ue a t a si gn ifi ca nt ly fa st er ra te w he n co m pa re d w ith th e co nv en tio na l i rr ig at io n de vi ce s ex am in ed u nd er th e co nd iti on s in th e pr es en t s tu dy . Ja ra m ill o DE et a l. 20 21 In v itr o 3 24 M ol ar s To e va lu at e th e effi ca cy o f a m ul tis on ic te ch no lo gy fo r t he d eb rid em en t o f v ita l an d ne cr ot ic p ul p tis su es in fr es hl y ex tra ct ed h um an m an di bu la r m ol ar te et h co m pa re d to u nt re at ed te et h. Effi ca cy o f a m ul tis on ic te ch no lo gy fo r t he de br id em en t o f vi ta l a nd n ec ro tic pu lp ti ss ue s Ex am in ed u nd er th e m ic ro sc op e th e pr es en ce of p ul p tis su e re m na nt s e ba ct er ia Th e G en tle W av e sy st em c om bi ne d w ith m in im al in st ru m en ta tio n w as e ff ec tiv e fo r r em ov al o f v ita l a nd n ec ro tic p ul p tis su e fr om th e ro ot c an al s ys te m a nd in ac ce ss ib le a re as . Co nt in ue 9 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Co nt in ua tio n Li u H e t a l. 20 22 In v itr o 90 90 0 3D p rin te d ro ot c an al m od el s To e va lu at e th e effi ca cy o f d iff er en t irr ig at io n te ch ni qu es in th e re m ov al of v ar io us c al ci um h yd ro xi de [C a( O H )2 ] a nd b ar iu m s ul fa te [B aS O 4] fo rm ul at io ns fr om th re e is th m us es in 3- di m en si on al (3 D) p rin te d m ol ar ro ot ca na l m od el s. Re m ov al o f re si du al m at er ia l fr om th e th re e is th m us es o f t he pr in te d m od el s. M ea n re m ov al ti m es w er e re co rd ed fr om a ct iv at io n of ir rig at io n pr oc ed ur es to co m pl et io n of re m ov al Th e G en tle W av e sy st em re m ov ed al l m at er ia ls fa st er th an P ie zo Fl ow , w he re as O pe n- en de d irr ig at io n ne ed le 5m L/ m in a nd 1 5m L/ m in , Do ub le -s id e- ve nt ed ir rig at io n ne ed le 5m L/ m in , E nd oU ltr a N iT i a ct iv at or ti p fa ile d to re m ov e al l m at er ia ls fr om th e is th m us es . P ur e Ca (O H )2  a nd th e m ix tu re w ith B aS O 4  pa st e in th e pr op or tio n 8: 1 w er e re m ov ed in le ss ti m e th an th e ot he r m ix tu re s by th e G en tle W av e sy st em , Pi ez oF lo w a nd O pe n- en de d ne ed le irr ig at io n sy st em s us in g 15 m L/ m in . M a J et a l. 20 15 In v itr o 3 30 M ol ar s To e va lu at e th e re m ov al o f c al ci um hy dr ox id e [C a( O H )2 ] As se ss m en t o f ca lc iu m h yd ro xi de [C a( O H )2 ] re m ov al fr om ch an ne ls ro ot M ic ro -C T sc an s w er e ac qu ire d fo r ea ch s pe ci m en a ft er in st ru m en ta tio n an d be fo re a nd a ft er th e re m ov al o f c al ci um hy dr ox id e [C a( O H )2 ] Al l 2 0 m es ia l c an al s of th e G en tle W av e sy st em w er e co m pl et el y fr ee o f c al ci um hy dr ox id e [C a( O H )2 ] a ft er c le an in g M ol in a B et a l. 20 15 In v itr o 3 45 M ol ar s To c om pa re th e de br id em en t effi ca cy o f t he G en tle W av e sy st em w ith a tr ad iti on al m et ho d fo r c le an in g ro ot c an al s Th e effi ca cy o f tis su e de br is re m ov al fr om ro ot ca na ls Pe rc en ta ge o f d eb ris re m ai ni ng in th e ro ot ca na l s pa ce th ro ug h cr os s se ct io ns w ith ph ot om ic ro gr ap hs Ge nt le W av e Sy st em s ho w ed a si gn ifi ca nt ly gr ea te r c le an in g ca pa ci ty an d re du ct io n in re si du al d eb ris w ith in th e m es io bu cc al a nd m es io lin gu al c an al s of m an di bu la r m ol ar s an d th e m es io bu cc al ca na ls o f m ax illa ry m ol ar s th an th os e cl ea ne d co nv en tio na lly . Pa rk S Y et a l. 20 20 In v itr o 6 66 M ol ar s To a ss es s th e effi ca cy o f d iff er en t fi na l ro ot c an al ir rig at io n ac tiv at io n m et ho ds in re m ov in g de br is a nd s m ea r l ay er s in th e ap ic al a nd m id dl e po rt io ns o f r oo t ca na ls d ur in g re tre at m en t. Re m ov in g de br is an d sm ea r l ay er s in th e ap ic al a nd m id dl e po rt io ns of ro ot c an al s Sc an ni ng e le ct ro n m ic ro sc op ic Th e G en tle W av e sy st em s ho w ed a m or e op tim al c le an in g effi ca cy o f t he ro ot c an al de br is b ut d id n ot d iff er s ig ni fic an tly w ith th e te st ed p as si ve u ltr as on ic o r s on ic irr ig at io n m et ho d. Co nt in ue 10 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Co nt in ua tio n O rd in ol a- Za pa ta R et a l 2 02 2 In v itr o 2 22 In ci so rs To a ss es s th e effi ca cy o f a n on ‐ in st ru m en ta tio n te ch ni qu e to d is in fe ct ro ot c an al s in fe ct ed b y a hu m an d en ta l pl aq ue ‐d er iv ed m ul tis pe ci es b io fil m . Ef fe ct iv en es s in th e di si nf ec tio n of ro ot c an al s in fe ct ed b y m ul tis pe ci es bi ofi lm . Cu ltu re a nd 1 6S rR N A ge ne s eq ue nc in g Si gn ifi ca nt s hi ft s in c om po si tio n w er e ob se rv ed fo llo w in g cl ea ni ng b y us in g bo th re gi m en s (c on ve nt io na l t ec hn iq ue an d th e no n- in st ru m en ta tio n te ch ni qu e -G en tle W av e Sy st em ) b ut th e im pa ct of th is c ha ng e w as g re at er fo llo w in g a co nv en tio na l c le an in g te ch ni qu e. O rd in ol a- Za pa ta R et a l. 20 21 In v itr o 6 12 M ol ar s To e va lu at e th e ap ic al p re ss ur e ge ne ra te d by 2 e nd od on tic ir rig at io n ne ed le s an d th e G en tle W av e sy st em in lo w er m ol ar s. Ap ic al p re ss ur e Cu rr en t ( m A) fr om th e pr es su re tr an sd uc er Cl os e- en de d ne ed le s ge ne ra te d le ss a pi ca l pr es su re th an o pe n- en de d ne ed le s. Ir rig at io n in du ce d le ss a pi ca l p re ss ur e in m es ia l t ha n in d is ta l r oo t c an al s. T he G en tle W av e sy st em pr oc ed ur e pr od uc ed n eg at ive a pi ca l p re ss ur e. Va nd ra ng i P . 20 16 In v itr o 4 40 M ol ar s To e va lu at e th e pe ne tra tio n de pt h of s od iu m h yp oc hl or ite (N aO Cl ) i n de nt in al tu bu le s us in g th e G en tle W av e sy st em v er su s ul tra so ni c ag ita tio n De pt h of s od iu m hy po ch lo rit e pe ne tra tio n in to de nt in al tu bu le s Ex am in ed a nd im ag ed w ith a s te re o m ic ro sc op e Ge nt le W av e Sy st em d em on st ra te d at le as t fo ur ti m es d ee pe r c le an in g in th e ap ic al re gi on th an a ct iv e ul tra so ni c sy st em a nd w as ef fe ct iv e th ro ug ho ut th e ro ot c an al s ys te m . Ve la rd i J P et a l. 20 22 a In v itr o 5 60 Pr em ol ar s To c om pa re th e ef fe ct ive ne ss o f t he Ge nt le W av e sy st em a nd p as si ve ul tra so ni c irr ig at io n in re m ov in g lip op ol ys ac ch ar id es fr om in fe ct ed ro ot ca na ls a fte r m in im al ly in va si ve te ch ni qu es an d co nv en tio na l in st ru m en ta tio n. Ef fe ct ive ne ss in re m ov in g lip op ol ys ac ch ar id es fro m in fe ct ed ro ot ca na l LA L as sa y (K Q CL te st ) G en tle W av e sy st em w as th e m os t e ff ec tiv e pr ot oc ol a ga in st li po po ly sa cc ha rid es in in fe ct ed ro ot c an al s us in g m in im al ly in va si ve te ch ni qu es a nd c on ve nt io na l in st ru m en ta tio n te ch ni qu es . Ve la rd i J P et a l. 20 22 b In v itr o 5 60 Pr em ol ar s To e va lu at e th e ef fe ct iv en es s of th e G en tle W av e Sy st em a nd p as si ve ul tra so ni c irr ig at io n in re m ov in g En te ro co cc us fa ec al is li po te ic ho ic ac id fr om in fe ct ed ro ot c an al s w ith a m in im al ly in va si ve a nd c on ve nt io na l in st ru m en ta tio n te ch ni qu e. Ef fe ct iv en es s in re m ov in g En te ro co cc us fa ec al is lip ot ei ch oi c ac id fr om in fe ct ed ro ot ca na ls Sa m pl es w er e cr yo ge ni ca lly g ro un d fo r in tra ra di cu la r l ip ot ei ch oi c ac id (L TA ) a na ly si s. LT A w as q ua nt ifi ed w ith a n LT A EL IS A ki t e nz ym e- lin ke d im m un os or be nt a ss ay k it G en tle W av e Sy st em + m in im al ly in va si ve te ch ni qu e an d co nv en tio na l in st ru m en ta tio n te ch ni qu e w er e th e m os t ef fe ct iv e pr ot oc ol s ag ai ns t E . f ae ca lis LT A, w ith n o di ff er en ce b et w ee n th em . W an g Z et a l. 20 16 In v itr o 7 35 M ol ar s To e xa m in e th e le ve l o f e ro si on in ro ot de nt in c au se d by d iff er en t i rr ig at io n m et ho ds a nd p ro to co ls Le ve l o f e ro si on in ro ot d en tin En er gy -d is pe rs iv e X- ra y sp ec tro sc op y an d sc an ni ng e le ct ro n m ic ro sc op ic im ag es . Sc an ni ng e le ct ro n m ic ro sc op y sh ow ed ca na l w al l e ro si on w he n an a dd iti on al fi na l irr ig at io n w ith N aO Cl w as d on e. N aO Cl fo llo w ed b y fin al E DT A irr ig at io n pe rf or m ed ei th er b y sy rin ge n ee dl e or th e G en tle W av e Sy st em c au se d m in im al d en tin e ro si on . Co nt in ue 11 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Co nt in ua tio n W an g Z et a l. 20 18 In v itr o 2 24 Pr em ol ar s To e xa m in e ro ot c an al w al l a na to m y in p re m ol ar te et h cl ea ne d by a no ni ns tr um en ta tio n m et ho d af te r #1 0 K- fil e pa te nc y ex am in at io n Ex am in e ro ot ca na l w al l an at om y Sc an ni ng e le ct ro n m ic ro sc op ic Ro ot c an al w al l d en tin in p re m ol ar s cl ea ne d w ith G en tle W av e sy st em sh ow ed a w id e st ru ct ur al v ar ie ty , es pe ci al ly in th e m id dl e an d ap ic al re gi on . N o or ga ni c tis su e re m na nt s or d en tin d eb ris w er e de te ct ed . I n th e co nt ro l g ro up u nt re at ed te et h, ti ss ue re m na nt s co ve re d m os t o f t he de nt in s ur fa ce . W rig ht C R et a l. 20 19 In v itr o 3 30 M ol ar s Ef fe ct iv en es s of th e re m ov al o f re si du al o bt ur at io n m at er ia l ( gu tta - pe rc ha a nd s ea le r) Ef fe ct iv en es s of fil lin g m at er ia l re m ov al Di gi ta l r ad io gr ap hs in th e bu cc ol in gu al a nd m es io di st al a ng le s an d po st re tre at m en t m ic ro –c om pu te d to m og ra ph ic s ca ns N on e of th e irr ig at io n pr ot oc ol s as se ss ed c ou ld c om pl et el y re m ov e re si du al o bt ur at io n m at er ia l fr om th e ro ot c an al s ys te m . B ot h th e si de -v en te d ne ed le a nd G en tle W av e sy st em g ro up s w er e ab le to re m ov e m or e re si du al o bt ur at io n m at er ia l t ha n th e En do Va c gr ou p; h ow ev er , t he d iff er en ce s w er e no t s ig ni fic an t Zh an g D et a l. 20 19 In v itr o 2 20 M ol ar s To d et er m in e th e ef fe ct iv en es s of tw o irr ig at io n an d cl ea ni ng s ys te m s in re m ov in g m ul tis pe ci es o ra l b io fil m s fr om ro ot c an al s. Ef fe ct iv en es s of ir rig an t a nd ro ot c an al sy st em c le an in g in re m ov in g m ul tis pe ci es o ra l bi ofi lm s fr om ro ot ca na ls Q ua nt ita tiv e re al -ti m e PC R an d ba ct er ia l c ul tu re Bo th g ro up s, G en tle W av e Sy st em a nd Ul tra so ni c Sy st em , s ho w ed re du ce d ba ct er ia l D N A. G en tle W av e sh ow ed a m or e co ns ta nt a nd s ig ni fic an tly g re at er re du ct io n of to ta l m ic ro bi al D N A th an Pi ez oF lo w U ltr as on ic 12 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 uted to improved safety compared to positive pressure. This result corroborates a study by Haapasalo et al.37 (2016), in which the GWS was shown to create negative pressure in the apical foramen during root canal cleaning, regardless of the size of the canal instrumentation. Table 3 presents the characteristics and results of the human studies included. Three were classified as prospective clinical studies, and one was a randomized clinical trial. These studies had sample sizes between 36 and 77. Three studies evaluated molar teeth, and only one article considered premolars. Three articles evaluated the success rate based on signs, symptoms and radiographic evalua- tions. Of these, two articles considered the same sample but used different fol- low-up times: 6 and 12 months. The GWS had a healing success rate of 97.4% after 6 months38 and 97.3% after 12 months39. In the other study, treatment with the GWS considerably reduced periapical lesions, with a success rate of 97.7% at the 12-month reassessment13. Of all included studies, only one was a randomized clinical trial40. The study compared the use of the GWS to endodontic treatment with conventional irri- gation and evaluated the incidence and intensity of postoperative pain using a pain scale. The study found no significant difference in the incidence or inten- sity of pain with the two methods. However, patients on both evaluated sys- tems that were evaluated reported a significant decrease in pain within 6 hours of treatment. 13 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Ta bl e 3. C ha ra ct er is tic s an d re su lts o f t he in cl ud ed h um an s tu di es . St ud y St ud y de si gn St ud y gr ou ps N Ti ss ue us ed O bj ec tiv e O ut co m e O ut co m e m ea su re m en t Re su lt G rig sb y D Jr e t a l. 20 20 H um an , Ra nd om iz ed cl in ic al tr ia l 2 36 Pr em ol ar s or M ol ar s To d et er m in e if th e G en tle W av e sy st em s ig ni fic an tly de cr ea se s th e in ci de nc e an d in te ns ity o f po st op er at iv e pa in . In ci de nc e an d in te ns ity of p os to pe ra tiv e pa in 0- 10 0 nu m er ic al ra tin g sc al e (N RS )-4 1 fo r p ai n Th er e w as n o si gn ifi ca nt d iff er en ce in th e in ci de nc e or in te ns ity o f p os to pe ra tiv e G en tle W av e sy st em a nd e nd od on tic tre at m en t w ith c on ve nt io na l s id e- ve nt ed n ee dl e irr ig at io n an d ul tra so ni c ac tiv at io n. H ow ev er , b ot h gr ou ps re po rt ed a s ta tis tic al ly s ig ni fic an t de cr ea se in p ai n w ith ti m e 6- ho ur po st tre at m en t t im e po in t. Si gu rd ss on A e t a l. 20 16 a H um an , Pr os pe ct iv e Cl in ic al St ud y 1 77 M ol ar s To e va lu at e he al in g ra te s of m ol ar s af te r ro ot c an al tr ea tm en t em pl oy in g th e G en tle W av e sy st em Cu m ul at iv e su cc es s ra te o f h ea lin g Cl in ic al s ig ns a nd sy m pt om s an d si gn s of a pi ca l p er io do nt iti s th ro ug h ra di og ra ph s In th is s ix -m on th c lin ic al s tu dy , t he cu m ul at iv e su cc es s ra te o f h ea lin g w as 97 .4 % w he n pa tie nt s w er e tre at ed w ith th e G en tle W av e sy st em . Si gu rd ss on A e t a l. 20 16 b H um an , Pr os pe ct iv e Cl in ic al St ud y 1 75 M ol ar s To e va lu at e he al in g ra te s of m ol ar s 12 m on th s af te r en do do nt ic th er ap y us in g th e G en tle W av e sy st em Cu m ul at iv e su cc es s ra te o f h ea lin g Cl in ic al s ig ns a nd sy m pt om s an d si gn s of a pi ca l p er io do nt iti s th ro ug h ra di og ra ph s In th is 1 2- m on th p ro sp ec tiv e m ul tic en te r cl in ic al s tu dy , t he G en tle W av e sy st em sh ow ed a h ig h le ve l o f s uc ce ss a ft er a 12 -m on th fo llo w -u p, 9 7. 3% . Si gu rd ss on A e t a l 20 18 H um an , Pr os pe ct iv e Cl in ic al St ud y 1 44 M ol ar s To re po rt th e re su lts of a g ro up o f p at ie nt s w ith s ig ni fic an t pe ria pi ca l l es io ns w ho w er e tre at ed an d ev al ua te d in tw o pr os pe ct iv e, m ul tic en te r, si ng le - ar m , n on -s ig ni fic an t ris k cl in ic al s tu di es . Cu m ul at iv e su cc es s ra te o f h ea lin g Cl in ic al s ig ns an d ra di og ra ph ic ev al ua tio ns Tr ea tm en t o f s iz ab le p er ia pi ca l l es io ns w ith th e G en tle W av e sy st em p ro ce du re re su lte d in a s uc ce ss ra te o f 9 7. 7% a t 12 -m on th re -e va lu at io n. 14 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Discussion This study is the first to use a complete knowledge synthesis method to improve understanding of the available evidence on using the GWS. The main result was that the evidence regarding the use of this technology is still limited, since most of the included studies were in vitro, and there were only four clinical studies of the GWS. However, some aspects should be highlighted: 1) most in vitro studies demonstrated the superiority of GWS compared to other methods, mainly for clean- ing and disinfection of the root canal10,18-23; 2) a significant portion of the remaining in vitro studies and the only randomized clinical trial included in this scoping review revealed similar results between the GWS and its comparators14,24-27,31,33,36,40; and 3) most of the clinical studies included did not establish a control group, which hinders a clear understanding of the GWS. In vitro studies are performed to simulate biological conditions in the laboratory, providing researchers with information useful for the development of further stud- ies. These studies have been widely used to test new materials and therapeutic or preventive procedures within the field of dentistry, especially in endodontics41. However, in vitro studies have some limitations, such as the difficulty of extrapolat- ing results to human beings42. Despite the caution needed when interpreting in vitro studies, the available evidence seems to demonstrate that the GWS is a promising treatment. However, it is important to note that the GWS works through a hand- piece positioned on the occlusal surface of the already accessed tooth. This condi- tion requires the system to reach the occlusal position, which is problematic if the patient has restricted mouth opening capability and is probably difficult to simulate in in vitro studies. Regardless, in vitro studies are performed to assess the reduction of bacterial DNA and the dissolution of organic matter, although it is impossible for them to reproduce a clinical scenario and its associated challenges. Only four clinical studies were identified in this review. Only one was a random- ized clinical trial40, which is considered the ideal study design for testing health interventions43, and the other three were prospective clinical studies13,38,39. Grigsby et al.40 (2020) showed no significant difference in the incidence or intensity of pain after using irrigant solutions with the GWS versus conventional irrigation. The other three clinical studies did not include a control group13,38,39, which makes it impossible to compare the results produced using the GWS with those produced with other instrumentation systems. This fact corroborates the conclusion that the evalu- ation of the GWS is still in the very early stages. Recently, a narrative review describing the results of the GWS in endodontic treat- ment was published. In general, the results demonstrated that the GWS promoted the reduction of bacterial DNA, faster dissolution of organic matter and greater penetration of sodium hypochlorite into dentinal tubules44. However, narrative reviews do not use explicit and systematic criteria for the search and critical anal- ysis of the literature, making it difficult for other researchers to reproduce their results. Searching for sources does not involve the application of a predetermined and specific strategy and is often less comprehensive. Furthermore, the selection of studies and interpretation of information may be influenced by the subjectiv- 15 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 ity of the authors and selection bias45. The present study performed a scoping review, which mapped the main concepts of the GWS. A scoping review examines the extent, scope and nature of investigations, summarizes and disseminates the investigation data systematically, reproducibly and transparently and identifies gaps in existing research46. It is essential to note that the GWS is expensive, reaching up to 70,000 USD47, and this may make the development of clinical studies unfeasible, especially because they are already considered more expensive than other types of studies. How- ever, the success rate of the GWS seems to be similar to that of other root canal instrumentation systems, which may not justify the use of this technology and the development of new studies. Thus, analyses that consider the cost-effectiveness of the GWS are still necessary for a better understanding of the viability of its use. Maybe the cost of the GWS explains why only four studies used the GWS in patients. In addition, it is necessary to train personnel to use the system since dentistry schools teach only the conventional methods for endodontic treatment. As a result, few professionals can apply this new technology. This study has some important limitations. First, a search in the gray literature was not conducted because it was understood that the technology is still in the very early stages; therefore, articles on the subject were expected to be indexed in the searched databases. Second, data extraction was not performed in duplicate, but prior training of the researchers was performed to reduce possible errors. Knowledge about mechanized systems to aid chemical–mechanical preparation contributes to the success of endodontic therapy. This process is essential for bio- film removal and root canal disinfection. In the future, more randomized clinical tri- als should be performed to compare the GWS with two or more root canal cleaning systems, and they should consider cost-effectiveness analyses during study develop- ment. Furthermore, clinical studies already published on the subject must continue their follow-ups to obtain long-term evidence. In conclusion, the evidence available on the GWS is mostly based on in vitro studies and four clinical studies and demonstrates that knowledge about using the technol- ogy is still very limited. Caution should be exercised regarding the clinical recommen- dation of the GWS, as evidence of its superiority comes only from in vitro studies, and there is still no evaluation of its cost-effectiveness, which seems essential due to its high cost compared to other systems available on the market. Funding Statement and Acknowledgments MCP is funded by the ATITUS Education and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES). RSO is funded in part by Meridional Foun- dation (Passo Fundo, Brazil). The funders had no role in the study design, data collec- tion and analysis, or manuscript publication. Conflict of Interest Statement The authors deny any conflicts of interest related to this study. 16 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 Data Sharing Data, analytical code, or other materials will be shared upon request. Author Contribution Daiana Jacobi Lazzarotto – Data curation, Methodology, Writing-review & editing. Mayara Colpo Prado - Data curation, Methodology, Writing-review & editing. Lara Dotto - Data curation, Methodology, Writing-review & editing. Rafael Sarkis Onofre – Conceptualization, Project administration, Supervision, Writing-original draft. All authors actively participated in the manuscript findings, revised, and approved the final version. References 1. Dye BA. Global periodontal disease epidemiology. Periodontol 2000. 2012 Feb;58(1):10-25. doi: 10.1111/j.1600-0757.2011.00413.x. 2. Franciscatto GJ, Brennan DS, Gomes MS, Rossi-Fedele G. Association between pulp and periapical conditions and dental emergency visits involving pain relief: epidemiological profile and risk indicators in private practice in Australia. Int Endod J. 2020 Jul;53(7):887-94. doi: 10.1111/iej.13293. 3. Jin LJ, Lamster IB, Greenspan JS, Pitts NB, Scully C, Warnakulasuriya S. Global burden of oral diseases: emerging concepts, management and interplay with systemic health. Oral Dis. 2016 Oct;22(7):609-19. doi: 10.1111/odi.12428. 4. Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors. J Dent Res. 2017 Apr;96(4):380-7. doi: 10.1177/0022034517693566. 5. Peters OA, Peters CI. Cleaning and shaping of the root canal system. In: Hargreaves KM, Berman LH. Cohen’s pathways of the pulp. 10th ed. Saint Louis: Mosby; 2010. 6. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-96. 7. Soares CJ, Rodrigues MP, Faria-E-Silva AL, Santos-Filho PCF, Veríssimo C, Kim HC, et al. How biomechanics can affect the endodontic treated teeth and their restorative procedures?. Braz Oral Res. 2018 Oct;32(suppl 1):e76. doi: 10.1590/1807-3107bor-2018.vol32.0076. 8. Crozeta BM, Chaves de Souza L, Correa Silva-Sousa YT, Sousa-Neto MD, Jaramillo DE, Silva RM. Evaluation of passive ultrasonic irrigation and gentlewave system as adjuvants in endodontic retreatment. J Endod. 2020 Sep;46(9):1279-85. doi: 10.1016/j.joen.2020.06.001. 9. Dotto L, Sarkis Onofre R, Bacchi A, Rocha Pereira GK. Effect of root canal irrigants on the mechanical properties of endodontically treated teeth: a scoping review. J Endod. 2020 May;46(5):596-604.e3. doi: 10.1016/j.joen.2020.01.017. 10. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave system. J Endod. 2015 Oct;41(10):1701-5. doi: 10.1016/j.joen.2015.06.018. 17 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 11. Siddique R, Nivedhitha MS. Effectiveness of rotary and reciprocating systems on microbial reduction: a systematic review. J Conserv Dent. 2019 Mar-Apr;22(2):114-22. doi: 10.4103/JCD.JCD_523_18. 12. Siqueira Junior JF, Rôças IDN, Marceliano-Alves MF, Pérez AR, Ricucci D. Unprepared root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral Res. 2018 Oct;32(suppl 1):e65. doi: 10.1590/1807-3107bor-2018.vol32.0065. 13. Sigurdsson A, Garland RW, Le KT, Rassoulian SA. Healing of periapical lesions after endodontic treatment with the gentlewave procedure: a prospective multicenter clinical study. J Endod. 2018 Mar;44(3):510-7. doi: 10.1016/j.joen.2017.12.004. 14. Charara K, Friedman S, Sherman A, Kishen A, Malkhassian G, Khakpour M, et al. Assessment of apical extrusion during root canal irrigation with the novel gentlewave system in a simulated apical environment. J Endod. 2016 Jan;42(1):135-9. doi: 10.1016/j.joen.2015.04.009. Epub 2015 Nov 4. 15. Hargreaves KM, Berman, LH. Cohen’s pathways of the pulp. 12th ed. United States: Elsevier Health Sciences; 2022. 16. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil, H. Scoping reviews. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI; 2020. [cited 2023 July 18]. Available from: https://synthesismanual.jbi.global. 17. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018 Oct;169(7):467-73. doi: 10.7326/M18-0850. 18. Choi HW, Park SY, Kang MK, Shon WJ. Comparative analysis of biofilm removal efficacy by multisonic ultracleaning system and passive ultrasonic activation. Materials (Basel). 2019 Oct;12(21):3492. doi: 10.3390/ma12213492. 19. Jaramillo DE, Arriola AR. Histological evaluation of multisonic technology for debridement of vital and necrotic pulp tissues from human molar teeth. An observational study. Appl Sci. 2021;11(22):11002. doi: 10.3390/app112211002. 20. Vandrangi P. Evaluating penetration depth of treatment fluids into dentinal tubules using the GentleWave® system. Dentistry. 2016;6:366. doi: 10.4172/2161-1122.1000366. 21. Velardi JP, Alquria TA, Alfirdous RA, Corazza BJM, Gomes APM, Silva EG, et al. Comparison of GentleWave system and passive ultrasonic irrigation with minimally invasive and conventional instrumentation against LPS in infected root canals. Sci Rep. 2022 Mar;12(1):4894. doi: 10.1038/s41598-022-08835-4. 22. Velardi JP, Alquria TA, Alfirdous RA, Griffin IL, Tordik PA, Martinho FC. Efficacy of GentleWave System and passive ultrasonic irrigation with minimally invasive and conventional instrumentation technique against enterococcus faecalis lipoteichoic acid in infected root canals. J Endod. 2022 Jun;48(6):768-74. doi: 10.1016/j.joen.2022.01.021. 23. Zhang D, Shen Y, de la Fuente-Núñez C, Haapasalo M. In vitro evaluation by quantitative real-time PCR and culturing of the effectiveness of disinfection of multispecies biofilms in root canals by two irrigation systems. Clin Oral Investig. 2019 Feb;23(2):913-20. doi:10.1007/s00784-018-2515-x. 24. Chan R, Versiani MA, Friedman S, Malkhassian G, Sousa-Neto MD, Leoni GB, et al. Efficacy of 3 supplementary irrigation protocols in the removal of hard tissue debris from the mesial root canal system of mandibular molars. J Endod. 2019 Jul;45(7):923-9. doi:10.1016/j.joen.2019.03.013. 25. Coaguila-Llerena H, Ordinola-Zapata R, Staley C, Dietz M, Chen R, Faria G. Multispecies biofilm removal by a multisonic irrigation system in mandibular molars. Int Endod J. 2022 Nov;55(11):1252-61. doi: 10.1111/iej.13813. 18 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 26. Dash S, Ismail PM, Singh J, Agwan MA, Ravikumar K, Annadurai T. Assessment of effectiveness of erbium:yttrium-aluminum-garnet laser, gentlewave irradiation, photodynamic therapy, and sodium hypochlorite in smear layer removal. J Contemp Dent Pract. 2020 Nov;21(11):1266-9. 27. Park SY, Kang MK, Choi HW, Shon WJ. Comparative analysis of root canal filling debris and smear layer removal efficacy using various root canal activation systems during endodontic retreatment. Medicina (Kaunas). 2020 Nov;56(11):615. doi: 10.3390/medicina56110615. 28. Ordinola-Zapata R, Mansour D, Saavedra F, Staley C, Chen R, Fok AS. In vitro efficacy of a non-instrumentation technique to remove intracanal multispecies biofilm. Int Endod J. 2022 May;55(5):495-504. doi: 10.1111/iej.13706. 29. Liu H, Shen Y, Wang Z, Haapasalo M. The ability of different irrigation methods to remove mixtures of calcium hydroxide and barium sulphate from isthmuses in 3D printed transparent root canal models. Odontology. 2022 Jan;110(1):27-34. doi: 10.1007/s10266-021-00628-x. 30. Ma J, Shen Y, Yang Y, Gao Y, Wan P, Gan Y, et al. In vitro study of calcium hydroxide removal from mandibular molar root canals. J Endod. 2015Apr;41(4):553-8. doi: 10.1016/j.joen.2014.11.023. 31. Wright CR, Glickman GN, Jalali P, Umorin M. Effectiveness of gutta-percha/sealer removal during retreatment of extracted human molars using the GentleWave System. J Endod. 2019;45(6):808-12. doi: 10.1016/j.joen.2019.02.009. 32. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod. 2014 Aug;40(8):1178-81. doi: 10.1016/j.joen.2013.12.029. 33. Wang Z, Maezono H, Shen Y, Haapasalo M. Evaluation of root canal dentin erosion after different irrigation methods using energy-dispersive x-ray spectroscopy. J Endod. 2016 Dec;42(12):1834-9. doi: 10.1016/j.joen.2016.07.024. 34. Wang Z, Shen Y, Haapasalo M. Root canal wall dentin structure in uninstrumented but cleaned human premolars: a scanning electron microscopic study. J Endod. 2018 May;44(5):842-8. doi: 10.1016/j.joen.2018.01.014. 35. Ordinola-Zapata R, Crepps JT, Arias A, Lin F. In vitro apical pressure created by 2 irrigation needles and a multisonic system in mandibular molars. Restor Dent Endod. 2021 Feb;46(1):e14. doi: 10.5395/rde.2021.46.e14. 36. Chen B, Shen Y, Ma J, Haapasalo M. Effect of apical size on apical pressure during syringe- needle and multisonic negative pressure irrigation. Odontology. 2021 Jul;109(3):625-31. doi: 10.1007/s10266-020-00586-w. 37. Haapasalo M, Shen Y, Wang Z, Park E, Curtis A, Patel P, et al. Apical pressure created during irrigation with the GentleWave™ system compared to conventional syringe irrigation. Clin Oral Investig. 2016 Sep;20(7):1525-34. doi: 10.1007/s00784-015-1632-z 38. Sigurdsson A, Le KT, Woo SM, Rassoulian SA, McLachlan K, Abbassi F, et al. Six-month healing success rates after endodontic treatment using the novel GentleWave™ System: The pure prospective multi-center clinical study. J Clin Exp Dent. 2016 Jul;8(3):e290-8. doi: 10.4317/jced.52779. 39. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel GentleWave System: a prospective multicenter clinical study. J Endod. 2016 Jul;42(7):1040-8. doi: 10.1016/j.joen.2016.04.017. 40. Grigsby D Jr, Ordinola-Zapata R, McClanahan SB, Fok A. Postoperative pain after treatment using the gentlewave system: a randomized controlled trial. J Endod. 2020 Aug;46(8):1017-22. doi: 10.1016/j.joen.2020.04.004. 19 Lazzarotto et al. Braz J Oral Sci. 2025;24:e254250 41. Freire MCM, Pattussi MP. [Types of studies]. In: Estrela C. [Scientific methodology. Science, teaching and research]. 2ª ed. São Paulo: Artes Ciência, Ensino e Pesquisa Médicas; 2005. 42. Pound P, Ebrahim S, Sandercock P, Bracken MB, Roberts I, Reviewing Animal Trials Systematically (RATS) Group. Where is the evidence that animal research benefits humans? BMJ. 2004 Feb;328(7438):514-7. doi: 10.1136/bmj.328.7438.514. 43. Friedman LM, Furberg CD, DeMets DL, Reboussin DM, Granger CB. Fundamentals of clinical trials. 5th ed. New York: Springer; 2015. 44. Coaguila-Llerena H, Gaeta E, Faria G. Outcomes of the GentleWave system on root canal treatment: a narrative review. Restor Dent Endod. 2022 Feb;47(1):e11. doi: 10.5395/rde.2022.47.e11. 45. Chalmers I, Altman D. Systematic reviews. BMJ Publishing Group; 1995. 46. Coelho TP, Rezende CP, Sousa MCVB, Pereira CEO, Mendonça SAM. [Comparison and analysis of the use of systematic review and scoping review in the area of patient care in pharmacy]. Res Soc Devel. 2021;10(12):e08101219915. Portuguese. doi: 10.33448/rsd-v10i12.19915. 47. Atlas Resell Management. Garden City, Idaho, USA; 2023. [cited 2023 Feb 28]. Available from: https://atlasresell.com/blogs/news/sonendo-gentlewave-the-new-wave-of- endodontics-technology-and-safety-1.