Smear layer management in endodontics: An update on commonly available materials

The effects of three endodontic irrigants and two types of laser on a smear layer created by hand instrumentation were evaluated in vitro in the middle and apical thirds of root canals. Sixty human mature extracted mandibular premolar teeth with a single root canal and a closed apex were distributed randomly into five groups of 12 teeth each. Whilst cleaning and shaping up to a size 60 master apical file with a step-back technique, the root canals were irrigated with 3 mL of 5.25% NaOCL and 3% H2O2, alternately, between each file size. Group 1 (G1) were control specimens that were irrigated with a final flush of 17% EDTA. The teeth in group 2 (G2) were irrigated with a final flush of 6% phosphoric acid, and group 3 (G3) with 6% citric acid. In the specimens of group 4 (G4) the root canals were irradiated with a carbon dioxide (CO2) laser, and specimens of group 5 (G5) were irradiated using an Er:YAG laser. The teeth were split longitudinally and prepared for examination by scanning electron microscopy. Control specimens (G1) showed clean root-canal walls with open dentinal tubules in the middle one-third, but in some specimens thick smear layer was observed in the apical one-third. Specimens irrigated with a final flush of 6% phosphoric acid (G2) or 6% citric acid (G3) were cleaner than with 17% EDTA, showing very clean root canal surfaces in the middle one-third but in the apical one-third the smear layer was not completely removed, especially at the openings of the dentinal tubules. The specimens irradiated with the CO2 laser (G4) showed clean root-canal walls with the smear layer absent, charred, melted, recrystallized and glazed in both middle and apical thirds. The root-canal walls of the specimens irradiated with the Er:YAG laser (G5) revealed an absent smear layer with open dentinal tubules in the middle and apical thirds. Statistical analysis showed no significant difference in the cleanliness of root-canal wall between G1 and G2, and G1 and G3. However, there were statistically significant differences (P < 0.01) between G1 and G4, and G1 and G5 in the cleanliness of the middle and apical one-thirds of the root canals. Irrigation with 17% EDTA, 6% phosphoric acid and 6% citric acid did not remove all the smear layer from the root-canal system. In addition, these acidic solutions demineralized the interbular dentine around tabular openings, which became enlarged. The CO2 laser was useful in removing and melting the smear layer on the instrumented root-canal walls and the Er:YAG laser was the most effective in removing the smear layer from the root-canal wall.

The aim of the present in vitro study was to compare the effectiveness of passive ultrasonic irrigation (PUI), sonic irrigation, and mechanic dynamic activation on the removal of debris and smear layer from primary mandibular second molars during pulpectomy. Mesial roots of 48 primary mandibular second molars were prepared with an R-motion 21 mm file (30/0.04) (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland), irrigated with 1% sodium hypochlorite (NaOCl) and 17% ethylenediaminetetraacetic acid (EDTA), and divided into four groups (n = 24 canals) according to the final irrigation activation technique: control group without activation, PUI with Ultra-X (Eighteeth, Changzhou, China), mechanical activation with XP-endo Finisher (FKG), and sonic irrigation with EQ-S (Meta Biomed, Chungcheongbuk-do, Korea). The roots were split longitudinally and analyzed using scanning electron microscopy (SEM). The presence of debris and smear layer was assessed using a 5-grade scoring scale with 200× and 1000× magnification, respectively. The Kruskal-Wallis and Friedman tests were used for data analysis. The activation of the irrigant significantly improved debris and smear layer removal (p < 0.001). There was no significant difference between Ultra-X, XP-endo Finisher, and EQ-S (p > 0.05). No activation technique was able to completely eliminate debris and smear layer from the root canals of primary mandibular second molars. During pediatric pulpectomy, the irrigation protocol must include activation of the irrigation solutions using either ultrasonic, sonic, or mechanical activation techniques to enhance the removal of debris and smear layer for a better prognosis. During root canal treatment on primary teeth, the clinician must incorporate an activation technique in the irrigation protocol to enhance the removal of debris and smear layer and increase the success of the treatment.

The primary objective of endodontic therapy is to thoroughly disinfect the root canal system. The smear layer formed during instrumentation presents a substantial impediment to optimal root canal disinfection, as it provides a medium for bacterial proliferation, hinders the penetration of disinfecting agents, and creates a physical barrier that undermines the efficacy of root canal sealers by obstructing the interface between the obturating core material and the dentinal tubules. Consequently, the removal of the smear layer is of utmost importance. This in vitro study assessed the efficacy of 20% N-acetyl-cysteine (NAC) and 17% ethylenediaminetetraacetic acid (EDTA) in removing the smear layer from root canal dentine. Ninety-two single-rooted teeth were instrumented and divided into two groups: 20% NAC for 1 minute, and 17% EDTA for 1 minute. Following irrigation, the samples were analyzed using scanning electron microscopy (SEM) to evaluate smear layer removal in the coronal, middle, and apical thirds of the root canals. No statistically significant difference was observed between 20% NAC and 17% EDTA in their ability to remove the smear layer across all sections of the root canal. 20% NAC demonstrates smear layer removal capability comparable to 17% EDTA as a final irrigant.

To assess the chemical and microstructural characteristics of dentine after the use of two irrigation protocols and correlate this with the antimicrobial properties of hydraulic calcium silicate cement (HCSC) sealers and changes to the dentine structure/chemistry after sealer placement. Two irrigation protocols - Protocol A using 2% NaOCl used 5mL/5min and Protocol B with 2% NaOCl (5mL/5min) followed by 17% EDTA (5mL/3min) - were used to prepare dentine. The chemical and microstructural changes following irrigation were assessed by scanning electron microscopy (SEM), energy dispersive spectroscopy (EDS) and Fourier transform infrared (FT-IR) spectroscopy (n=5) on dentine obtained from the mid-root and coronal parts of extracted human teeth. Four sealers (AH Plus, BioRoot, MTA Fillapex, TotalFill) were characterized by SEM/EDS (n=3). The ability of the sealers to eradicate intratubular Enterococcus faecalis biofilms was assessed by live/dead dye and confocal laser scanning microscopy to measure the percentage of living cells. The effect of combined irrigation and root filling on dentine was assessed by SEM and EDS analysis (n=5). Statistical analysis was undertaken using one-way anova and a number of post hoc tests to detect intergroup differences. The F-test was used for comparison of variances in the microbiology testing. The use of NaOCl alone left the smear layer intact, with traces of chlorine remaining on dentine. The use of BioRoot sealer restored the calcium levels of dentine which had been depleted by the irrigation with EDTA. BioRoot exhibited antimicrobial properties against intratubular bacteria even in the presence of smear layer (Protocol A). Smear layer removal improved the bactericidal effect of all sealers and Ca2+ leaching. The use of a chelating agent was important for the intratubular sealer penetration for AH Plus but not the other sealers. The removal of smear layer was necessary for penetration of AH Plus into the dentinal tubules. BioRoot was a more effective sealer in reducing the bacterial load in the dentinal tubules than the other materials tested and the presence of smear layer did not affect its activity.

Cross-sections of resin-dentin interfaces were etched with an argon-ion beam to make their substructure detectable by scanning electron microscopy. The dentin adhesive systems were categorized morphologically into three groups, and an attempt was made to clarify their adhesive mechanism. The first group of products removed the smear layer. The argon-ion bombardment clearly disclosed a hybrid or resin-impregnated dentin layer. It is hypothesized that conditioning with acidic or chelating agents demineralized the dentin surface-layer to a certain depth, leaving behind a collagen-rich mesh-work. Hydrophilic monomers are then believed to alter this collagen-fiber arrangement in a way that facilitates penetration of the adhesive resin, resulting in a mechanical, intermingled link between collagen and the adhesive resin. The second group preserved the smear layer. In this case, the dentinal tubules were obliterated with globular particles at their orifices and remained patent underneath these smear plugs. This type of adhesive system aims at the incorporation of the smear layer into the hydrophilic monomers, which have an affinity for the organic and/or inorganic components of the underlying dentin. Finally, a third, small group only partly dissolved the smear layer, creating a thin resin-impregnated dentin layer and a resin-impregnated smear plug. This study clearly showed that the application of recent adhesive systems induced structural changes in the dentin surface morphology, creating a retentive interface, called the inter-diffusion zone, between the deep, untouched dentin layers and the composite filling material. This resin-dentin interdiffusion zone offers bonding sites for copolymerization with the resin composite and, concurrently, might have protective potential for the pulp tissues.

Aim: The aim of this study was to compare the efficacy of 980 nm diode laser and QMix 2in1 solution (DENTSPLY Tulsa Dental Specialties) alone and in combination, for smear layer removal from the root canals. Background: Smear layer is an amorphous layer formed on root canal walls following instrumentation. This layer should be removed as it can harbor bacteria and bacterial products and prevents the penetration of intracanal medicaments into the dentinal tubules. Irrigation agitation techniques have been proposed recently to remove smear layer from root canals more efficiently. The diode laser has the potential for irrigant activation and studies are needed to establish their efficacy for smear layer removal especially from apical thirds of canals. Methods: Forty extracted single-rooted permanent human teeth were used. Root canals were prepared to full working length using manual K-files (MANI) till 40K. Prepared teeth were divided into four groups (n=10): Group 1, no irrigation; Group 2, QMix 2in1 solution; Group 3, diode laser; Group 4, QMix 2in1 in combination with a diode laser. The roots were split longitudinally and prepared for scanning electron microscopic (SEM) investigation. The split roots were examined for remaining smear layer at the coronal, middle, and apical portion of each canal under a scanning electron microscope (JSM5910, JEOL, Japan) at 1000x magnification. Results: Smear layer removal was scored according to Guttman rating system for remaining smear layer scores (Gutmann et al.). Diode laser in combination with QMix solution had the least smear layer scores. Conclusions: Diode laser irradiation in combination with QMix 2in1 solution effectively removes smear layer from apical thirds of root canals.

The purpose of this systematic review of meta-analysis was to compare the effectiveness of removing the smearing layer using EDTA versus Chitosan (Ch) and Chitosan nanoparticles (Ch-NPs). A search was performed in four electronic databases (Web of Science, PubMed, Scopus, and Cochrane). The included studies were assessed by two reviewers using Joanna Briggs Institute's critical appraisal checklist for the quasi-experimental studies. Outcomes obtained by scanning electron microscopy (SEM) and conventional methods were presented as standardized mean differences alongside 95% confidence intervals. Seven investigations employed 212 single-root teeth. In the apical section (p = .317, 95% CI = -0.820 to 0.266, Tau2 = 0.387), middle segment (p = .914, 95% CI = -1.019 to 0.912, Tau2 = 1.027), and coronal segment (p = .277, 95% CI = -1.008 to 0.289, Tau2 = 0.378). This meta-analysis found no difference between Ch, Ch-NPs, and EDTA in removing the smear layer in the three segments. This systematic review is designed to show evidence related to the PICO question, in which our outcome is smear layer removal and not the clinical success of such a treatment. RESEARCH HIGHLIGHTS: The study aimed to compare the effectiveness of chitosan and chitosan nanoparticles with ethylenediaminetetraacetic acid (EDTA) in removing the smear layer, a layer of debris and organic material on the tooth surface, through a systematic review and meta-analysis. The removal of the smear layer is crucial for successful dental treatments, as it enhances the adhesion of restorative materials and improves the penetration of antimicrobial agents into dentinal tubules. The researchers conducted a systematic review and meta-analysis, searching various databases of electron microscopy results for relevant in vitro studies comparing the effects of chitosan or chitosan nanoparticles with EDTA on smear layer removal. The results encourage further exploration of chitosan and chitosan nanoparticles for clinical use in dentistry, while considering their specific applications and long-term effects.

This study evaluated the removal of debris and smear layer after post space preparation using different irrigations and passive ultrasonic agitation. Sixty human premolars were decoronated and post space prepared after endodontic therapy. The samples were then randomly divided into three experimental groups (Groups A, B, C) and one control group (Group D) with fifteen samples in each group. Groups A and B samples were treated with 10% citric acid and 17% ethylenediamintetraacetic acid (EDTA), respectively and passive ultrasonic agitation was done, rinsed with sodium hypochlorite and finally flushed with saline. Group C samples were conditioned with 36% phosphoric acid and then rinsed with saline. The control group was treated with 3% sodium hypochlorite, passive ultrasonic agitation done and flushed with saline. The samples were sectioned and evaluated for debris and smear layer removal under scanning electron microscope. 10% citric acid showed the best removal of smear layer when compared with 17% EDTA and 36% phosphoric acid, but was not statistically significant (p>0.05). The difference in scoring for debris and smear layer removal in the coronal, middle and apical third of post space of experimental groups in comparison with control group was statistically significant (p<0.001).

The aim of this research was to evaluate, under the scanning electron microscope, the role of different parameters and angles of incidence of the Nd:YAG laser on the morphology of the radicular dentine. Irradiation of dentine with Nd:YAG laser removes smear layer and promotes its fusion and recrystallization, thus decreasing permeability. Forty-eight human maxillary canines were randomly divided in four groups of 12 teeth each, according to the following parameters of irradiation: 1 Wand 10 Hz; 1 Wand 20 Hz; 3 Wand 10 Hz; 3 Wand 20 Hz. Two teeth of each group were split longitudinally and the laser was applied perpendicularly to the root canal. Specimens were observed under the SEM, and the morphological alterations in dentine were recorded. The increase of power and frequency of the laser produced more structures that characterize the irradiation of dentine by Nd:YAG laser, such as globular formations, melting and glazing, and ebullitions. Such structures were especially frequent when 3 Wand 20 pps were used as parameters. The removal of the smear layer produced root canals with more dentinal tubules visible under the SEM. The increase in power and frequency of the Nd:YAG laser irradiation produced more visible morphological alterations than the lower settings. The removal of the smear layer increased the number of visible dentinal tubule openings.

The present study was designed to analyze the structures of dentinal tubules by confocal microscopy. Undecalcified ground sections of human teeth were stained with alizarin red in 0.1% KOH aqueous solution, and examined by confocal microscopy. Alizarin red stained dentinal tubules, interglobular dentine, granular layer of Tomes, and the surface of dentine. Interglobular dentine was seen between the outer and middle layers of coronal dentine. At the outer layer of coronal dentine, the dentinal tubules were thin and showed numerous branches. At the middle layer of coronal dentine, dentinal tubules displayed two types. The type I tubules are the dentinal tubules that do not show any nodular structures and the type II tubules are the dentinal tubules that appear bamboo-like with many nodules. In the cross section through the type II tubules, the nodules appeared as fine circular tubules surrounding the dentinal tubules. The circular tubules of nodules adhered to one side of the dentinal tubules. When the fluorescence images were compared with the images taken by transmission light mode, the fluorescence of dentinal tubules was seen at the inner surface of dentinal tubules, and the fluorescence of nodules was seen at interface between peritubular and intertubular dentine. Most of the dentinal tubules were of the type II tubules in the teeth from older individuals, whereas the type II tubules were scarce in the teeth from younger individuals. At the inner layer of coronal dentine, the dentinal tubules have no nodules and branches were scarce. The dentinal tubules of radicular dentine were different from those of coronal dentine. Most of the dentinal tubules were the type I tubules. Numerous fine branches were seen at the outer and middle layers of radicular dentine. No interglobular dentine was seen in the root except at the cervical part, and the granular layer of Tomes was also positive with alizarin red. At the cervical part of the root, interglobular dentine was present and the dentinal tubules displayed types I and II.

Biological and chemical properties of new multi-functional root canal irrigants.

Background: Endodontic treatment objectives comprise eliminating or decreasing bacterial load inside the complex endodontic space. Removing the smear layer and debris becomes mandatory to achieve good three-dimensional (3D) cleaning. Aim: This study assesses the difference in smear layer removal using the 3D cleaning technique and traditional syringe needle irrigation. The 3D cleaning technique includes the ultrasonic activation of intracanal-heated NaOCl. Materials and Methods: Our current study used single-rooted human mandibular premolar teeth to test the earlier-mentioned technique (n = 30). Initially, an endodontic access cavity was performed. Consequently, specimens were randomly distributed into three study groups according to irrigation protocol. The groups were Group 1, where the traditional syringe needle irrigation system was applied; Group 2, where the 3D cleaning technique was performed; and Group 3, in which teeth remained uncleaned as it was regarded as the control group. Once the experiment was completed, the teeth were decoronated at the cementoenamel junction (CEJ) and examined using scanning electron microscopy (SEM). Debris and smear layers were viewed in 1000× magnification and scored. Results: Statistical analysis was performed with a standard statistical software package (SPSS, version 28.0; SPSS IBM, Armonk, NY, USA). Data were analyzed with a nonparametric analysis of variance (Kruskal−Wallis ANOVA) among the groups tested and among the thirds of the canals. The level of significance was set at p < 0.05. A statistically significant (p < 0.05) lower mean smear layer and debris score was observed in both study groups compared to the control group. Group 2 showed better results compared to Group 1. Conclusions: The present study concluded that the 3D cleaning technique is an effective irrigation method for removing debris and smear layers. Future research, such as CLSM (Confocal Laser Scanning Microscopy) and Histological study, should be employed to confirm this study’s conclusion.

Introduction:Enlargement of the root canal may potentially affect efficient smear layer (SL) removal. The aim of the present in vitro study was to compare SL removal following canal preparation with two different sizes/tapers by means of scanning electron microscopy (SEM). Methods and Materials: A total of 50 extracted human mandibular premolars were decoronated. The teeth were randomly divided into two experimental groups (n=20) and two negative control groups. In groups 1 and 2 the sizes of master apical file (MAF) were #25 and 40, respectively. Coronal part of the canals were flared with #2 Piezo drills in group 1 and sizes #2 to 6 in group 2. Finally FlexMaster NiTi rotary instruments were used to complete canal preparation (25/0.04 and 35/0.06 in groups 1 and 2, respectively). The irrigation protocol consisted of 10 mL of 17% ethylenediaminetetraacetic acid (EDTA) for 1 min followed by 10 mL of 5.25% NaOCl for 3 min. The patency of dentinal tubules was evaluated under SEM with Hülsmann scores. Data were analyzed with the Kruskal-Wallis and Mann-Whitney U tests. Results:The number of patent dentinal tubules in coronal third of the group 1 was significantly more than group 2 (P<0.001). However, this difference was not significant for the middle and apical segments. There was a significant difference in the number of patent dentinal tubules between coronal, middle and apical thirds (P<0.05). Conclusion:Increasing the canal preparation size did not lead to better cleanliness of the canal walls and more efficient smear layer removal.

To compare the smear layer and debris removal effectiveness of four root canal irrigation protocols as well as their effectiveness in removing remaining soft tissues in curved root canals. The mesiobuccal and mesial root canals of 107 extracted human maxillary and mandibular molars were instrumented using Mtwo rotary NiTi instruments then randomly divided into four groups according to a final rinse protocol: Group 1 (n = 28) - manual agitation of 1% NaOCl and 15% EDTA; Group 2 (n = 26) - CanalBrush agitation of 1% NaOCl and 15% EDTA; Group 3 (n = 26) - 3% H(2) O(2) alternated with 1% NaOCl; Group 4 (n = 27) - passive ultrasonic agitation of 1% NaOCl and 15% EDTA. All irrigation protocols were performed in a closed system. Eleven roots per group were prepared and histologically stained (H&E) to assess percentage of remaining pulpal tissues in the apical thirds. The remaining specimens were split longitudinally and examined under scanning electron microscope at ×2000 magnification to assess smear layer and debris removal. Image Pro Plus 6.0 software was used to analyse smear layer and remaining pulp tissue. Debris presence was scored by two blinded investigators using a five-point scale. Data were analysed using Univariate analysis of variance (GenStat 13, α = 0.05). CanalBrush and passive ultrasonic irrigation were equally effective with significantly less smear layer and debris than manual agitation and H(2) O(2) alternated with NaOCl (P < 0.05). The H(2) O(2) alternated with NaOCl protocol was significantly more effective in removing pulp tissue remnants in the apical level than manual agitation (P = 0.009) and passive ultrasonic irrigation (P = 0.01). CanalBrush was as effective as passive ultrasonic irrigation in smear layer and debris removal. Alternating H(2) O(2) with NaOCl was effective in removing soft tissues from root canal complexities. Further studies are required to evaluate effectiveness of this regimen taking into account irrigant volume differences and effect of root canal system configuration.

Aim: This study compared smear-layer and debris removal using with three different application times of 17% EDTA and 7% maleic acid irrigation agents.&#x0D; Methodology: Fifty-two maxillary and mandibular single-rooted teeth were divided randomly into seven groups (n = 8 each, control group n = 4). Three groups received 17% EDTA and three received maleic acid (1, 5, 10 min). Canals were prepared using nickel-titanium rotary files. Smear-layer and debris removal were evaluated in the coronal, middle, and apical thirds of the teeth using scanning electron microscopy, and results were analyzed compared using Mann–Whitney U tests.&#x0D; Results: Maleic acid removed the smear layer (coronal and middle: p&lt;0.01; apical: p&lt;0.05) and debris (all p&lt; 0.05) more effectively than EDTA in terms of 1 min application period. Effectiveness did not differ significantly with 10-min applications.&#x0D; Conclusions: Final irrigation with 7% maleic acid is more efficient than 17%EDTA in the removal of smear layer and debris from the coronal, middle and apical third of the root canal system in application within 1 min. &#x0D; How to cite this article: Kaya S, Adıgüzel Ö, Ganidağlı Ayaz S. Effectiveness of Three Different Application Times of 17% EDTA and 7% Maleic Acid Irrigation Agents on the Removal of Debris and Smear Layer: A Scanning Electron Microscope Study. Int Dent Res 2011;2:48-54.&#x0D; Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.