The Journal of the Australian Society of Endodontology Inc.

and the Australian and New Zealand Academy of Endodo ntists

Aust Endod J 2009; 35: 1317

ORIGINAL RESEARCH

Effect of 17% EDTA and MTAD on intracanal smear layer removal: A scanning electron microscopic study
Mohammad Ali Mozayeni, DDS, MSD1; Ghasem Hossein Javaheri, DDS, MSD2; Pardis Poorroosta, DDS, MSD2; Mohammad Asna Ashari, DDS, MSD2; and Homan Hossein Javaheri, DDS3
1 Department of Endodontics, Iranian Center for Endodontic Research, Shaheed Beheshti University of Medical Sciences, Dental School, Tehran, Iran 2 Department of Endodontics, Shaheed Beheshti University of Medical Sciences, Tehran, Iran 3 Dental Research Center Shaheed Beheshti University of Medical Sciences, Tehran, Iran

Keywords EDTA, MTAD, Smear layer removal. Correspondence Homan H. Javaheri DDS, Dental Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran. Email: drjavaheri@sbmu.ac.ir doi:10.1111/j.1747-4477.2007.00111.x

Abstract
The purpose of this study was to determine the effectiveness of MTAD as the nal irrigant to remove the smear layer, compared with that of 17% EDTA, both following root canal irrigation with 5.25% sodium hypochlorite (NaOCl). Fifty-ve extracted maxillary and mandibular single-rooted human teeth were prepared by a crown-down technique using rotary 0.04 and 0.06 taper nickeltitanium les. 5.25% sodium hypochlorite was used as the intracanal irrigant. The canals were then treated with 5 mL of one of the following solutions as nal rinse: 5.25% sodium hypochlorite, 17% EDTA or MTAD. The presence or absence of smear layer in the coronal, middle and apical portion of each canal was examined with a scanning electron microscope. The results showed that MTAD is an effective nal rinse solution for removing the smear layer in canals irrigated with sodium hypochlorite. When 17% EDTA was used as a nal rinse, the smear layer was removed from the middle and coronal thirds of canal preparations, but it was less effective in the apical third of the canals.

Introduction
The smear layer associated with endodontic instrumentation is a thin layer that covers the prepared canal walls and occludes the orices of the dental tubules. The smear layer is an amorphous structure composed of inorganic and organic substances (1,2). There have been numerous debates about leaving or removing the smear layer. In spite of the controversy regarding its effect on apical microleakage (35), eliminating it has many benets. The presence of this smear layer prevents penetration of intracanal medication into the irregularities of the root canal system and the dentinal tubules and also prevents complete adaptation of obturation materials to the prepared root canal surfaces (6). Controversy also exists about how best to remove the smear layer. The most debated elements of smear layer removal are volume of irrigation and contact time. Smear layer removal may facilitate the opening of dentinal tubules for intracanal medication action and allow better

adhesion of the root canal lling material (7). Therefore, endodontic treatment should not be limited to the removal of pulp remnants and the widening of root canals, but should also focus on smear layer removal. Ultrasonic instruments, lasers and chelating agents have been recommended for chemical and mechanical debridement during root canal treatment for the removal of the smear layer (810). stavik and Haapasalo (11) showed the importance of the removal of smear layer and the presence of patent dental tubules in decreasing the time necessary to achieve disinfection. Bystrom and Sundqvist (12) also have shown that the presence of a smear layer can inhibit or signicantly delay penetration of antimicrobial agents, such as intracanal irrigants and medications into the dentinal tubules. The purpose of this study was to determine the effectiveness of MTAD as a nal irrigant to remove the smear layer compared with that of 17% EDTA, both after the use of 5.25% sodium hypochlorite (NaOCl) as the root canal irrigant.
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Materials and methods

Fifty-ve extracted maxillary and mandibular singlerooted non-carious human teeth were used for this study. After cleaning, they were immersed in an isotonic saline solution. To facilitate splitting of the roots after preparation, a longitudinal buccolingual groove and two circumferential grooves were cut at the middle and apical thirds of the teeth, avoiding penetration of the root canals. After preparing a conventional access preparation for each tooth, a #10 FlexoFile (Dentsply Maillefer, Johnson City, TN, USA) was inserted into the canal until just visible at the apex to determine patency. One millimetre was subtracted from this measurement and this was the working length. Rotary instrumentation was performed with Hero 642 0.06 and 0.04 taper rotary les (MicroMega, Besancon, France) in a crown-down fashion to a standardised master apical le #40, while the canal was irrigated with 1 mL of 5.25% NaOCl between les. The teeth were divided randomly into two experimental groups of 25 teeth each and a negative control group of ve teeth. To determine the effect of experimental and control solutions as a nal rinse on the surface of instrumented root canals, the canals were treated with 5 mL of one of the following solutions: 1. 5.25% NaOCl (negative control) 2. 17% EDTA (AriaDent, Tehran, Iran) 3. MTAD (BioPure, Dentsply, TulsaDental, OK, USA) a solution containing a mixture of a tetracycline isomer, an acid and a detergent. Table 1 shows the distribution of samples. After instrumentation, each canal was initially irrigated with 1 mL of one of the solutions. To ensure a uniform and direct contact of each irrigant with the root canal walls, a #15 barbed broach was wrapped with cotton and soaked in the same solution and placed to the working length. After 4 min, the wrapped broach was moved up and down 45 times, and then each canal was irrigated with a further 4 mL of this solution as a nal rinse. The total exposure time to the nal solution was approximately 5 min. The canals were then irrigated with 10 mL of sterile distilled

water and dried with paper points. The teeth were split longitudinally, and half of each tooth was placed in a 2% glutaraldehyde solution for 24 h. The other half of each tooth was discarded. The xed specimens were rinsed three times with a sodium cacodylate-buffered solution (0.1 M, pH 7.2), incubated in osmium tetroxide for 2 h, dehydrated with ascending concentrations of ethyl alcohol (30100%) and placed in a desiccator for at least 24 h. Each specimen was mounted on an aluminium stub and coated with 30 mm of gold palladium and examined under a scanning electron microscope (XLC30 Phillips) at magnication 2500. The specimens were coded and examined by examiners who were unaware of the specimens history. Two investigators scored the presence or absence of smear layer on the surface of the root canal or in the dentinal tubules at the coronal, middle and apical portion of each canal according to the following criteria used by Torabinejad et al. (8): 1. No smear layer: no smear layer on the surface of the root canals; all tubules were clean and open. 2. Moderate smear layer: no smear layer on the surface of root canal, but tubules contained debris. 3. Heavy smear layer: smear layer covered the root canal surface and the tubules.

Results
Removal of smear layer from the surfaces of root canals revealed the presence of more abundant and larger dentinal tubules in the coronal third of the root canals compared with those seen in the middle and apical thirds of the root canal system. The surfaces of samples in group A (negative control) were all covered with a heavy layer of debris throughout each canal (Fig. 1). Comparison of remaining debris in groups B and C in the coronal and middle thirds of the canals showed no signicant difference. (Table 2, Figs 2,3). The dentinal tubules in the apical third of canals treated with MTAD were signicantly cleaner than those treated with EDTA (P < 0.05) (Table 2, Figs 2,3).

Discussion
Table 1 Solutions used during and after root canal preparation Irrigating solution during root canal preparation 5.25% NaOCl 5.25% NaOCl 5.25% NaOCl Final solution for removal of the smear layer 5.25% NaOCl 17% EDTA MTAD

Group A (n = 5) [negative control] B (n = 25) C (n = 25)

The data were evaluated statistically with the Mann-Whitney and Chisquare with 5% level of signicance.

The purpose of this study was to evaluate the effectiveness of MTAD as a nal irrigant to remove the smear layer compared with that of 17% EDTA, both following irrigation with 5.25% NaOCl. It seems benecial to remove the smear layer from the entire root canal system. Current methods of smear layer removal include chemical, ultrasonic and laser techniques, none of which are totally effective or have received universal acceptance (6,8). Torabinejad et al. showed that MTAD is an effective

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Effect of 17% EDTA and MTAD

(a)

Figure 1 Presence of the smear layer on the surface of the coronal of a root canal irrigated with 5.25% NaOCl and a nal rinse of the same solution (original magnication 2500).

(b)

Table 2 P values for smear layer removal between group B and C Canal level Coronal Middle Apical *P < 0.05 P value P = 0.671 P = 0.695 P = 0.038*

solution for the removal of the smear layer and does not signicantly change the structure of the dentinal tubules when used as a nal irrigant in conjunction with 5.25% NaOCl as a root canal irrigant (8). The entire canal length was utilised to test the efcacy of the solutions in all segments of the root including the apical third. The canals in this investigation were prepared with a crown-down technique using rotary nickeltitanium instruments. This technique is an effective method to prepare root canals with rotary instruments. The use of the rotary les creates a signicant amount of smear layer (13). The apical portion of each canal was enlarged to a size 40 le to allow adequate cleaning and penetration of the solution to the apical third of each root canal. To remove the smear layer, irrigating solutions should dissolve both organic and inorganic components. When EDTA is alternately used with 5.25% NaOCl, the smear layer is removed in the middle and coronal thirds of canal preparations, but this combination is less effective in the apical third (14). This is probably because of inadequate volume and/or penetration of the solution into the apical portion of the canal during irrigation. Our experiment corroborated these ndings. The placement of MTAD with a cotton-wrapped barbed broach allows intimate contact of the solution even in the apical region of the canals and improves debridement of the entire root canal wall.

(c)

Figure 2 Instrumentation of a root canal with 5.25% NaOCl as root canal irrigant and treatment with 5 mL of 17% EDTA as a nal rinse in the coronal (a), middle (b) and apical (c) portions of the root canal (original magnication 2500).

The results showed that NaOCl was an ineffective irrigant to remove the smear layer. These ndings are similar to those observed in previous investigations (8,15), which also showed that these irrigants are not able to remove both organic and inorganic components of the smear layer. Gettleman et al. (16) showed that a contact time of 3 min with 17% EDTA was effective for smear layer
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Effect of 17% EDTA and MTAD

M. A. Mozayeni et al.

(a)

Torabinejad et al. (19) showed that the effectiveness of MTAD to completely remove the smear layer is enhanced when low concentrations of NaOCl are used as an intracanal irrigant before the use of MTAD as a nal rinse. This combination and sequence do not seem to signicantly change the structure of the dentinal tubules. The cleaning action of the EDTA solution was less efcient near the apex and the smear scores increased. These results are consistent with recent ndings (20,21). Ultrasonic irrigation was not used in this study, because ultrasound in association with EDTA does not appear to enhance the chelating capability (22).

(b)

Conclusions
Based on the results of this investigation, it seems that MTAD is an effective solution for the removal of the smear layer when used as a nal rinse. When 17% EDTA was used as the nal rinse, the smear layer was removed from the middle and coronal thirds of canal preparations, but this combination seemed less effective in the apical third of the canals.

References
(c)

Figure 3 Instrumentation of a root canal with 5.25% NaOCl as root canal irrigant and treatment with 5 mL of MTAD as nal rinse resulted in the removal of the smear layer in the coronal (a), middle (b) and apical (c) portions of the root canal (original magnication 2500).

removal. Calt and Serper (17) demonstrated that 10-mL irrigation with 17% EDTA for 1 min was effective in removing the smear layer, but a 10-min application caused excessive peritubular and intertubular dentinal erosion. Increasing contact time and concentration of EDTA from 10% to 17%, as well as using a pH of 7.5 versus pH of 9.0, have been shown to increase demineralisation of dentin (18).
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