Basic ResearchTechnology

Calcium Loss From Root Canal Dentin Following EDTA,

EGTA, EDTAC, and Tetracycline-HCl Treatment With or
Without Subsequent NaOCl Irrigation
T. Cem Sayin, DDS, PhD,* Ahmet Serper, DDS, PhD,* Zafer C. Cehreli, DDS, PhD,
and Sukru Kalayci, PhD
Abstract
The aim of this study was to determine the extent of
calcium removal on root canal dentin after 17% EDTA,
17% EGTA, 15% EDTAC, and 1% tetracycline-HCl treatment; with or without subsequent use of 2.5% NaOCl.
Extracted single-rooted human teeth were bisected longitudinally and the root halves (n 100) were isolated
with nail varnish, leaving the root canal exposed. The
samples were immersed in the test solutions for 1 and
5 minutes, after which the amount of calcium ion
(Ca2) release into the solutions was determined by
flame photometry. Regardless of treatment time, all
single (treatment solution only) and combined (treatment solution with subsequent NaOCl application) irrigation regimens removed significantly more Ca2
than control treatment (distilled water). Compared with
other groups, treatment with 17% EDTA and 17%
EDTA 2.5% NaOCl resulted in the maximum amount
of Ca2 removal from root canal dentin (p 0.05). All
combined-treatment groups except 17% EGTA 2.5%
NaOCl removed significantly more Ca2 than their
single-treatment versions (p 0.05). Within each test
group, extending the treatment time to 5 minutes resulted in significantly more Ca2 removal (p 0.05). (J
Endod 2007;33:581584)

Key Words
Calcium, chelating agent, dentin, endodontics, flame
photometry

From the *Department of Endodontics and the Department of Pediatric Dentistry, Faculty of Dentistry, Hacettepe
University, Ankara, Turkey; and the Department of Chemistry,
Faculty of Arts and Science, Gazi University, Ankara, Turkey.
Address requests for reprints to Dr. T. Cem Sayin, Department of Endodontics, Faculty of Dentistry, Hacettepe University, Sihhiye 06100, Ankara, Turkey. E-mail address: cemsayin@
yahoo.com.
0099-2399/$0 - see front matter
Copyright 2007 by the American Association of
Endodontists.
doi:10.1016/j.joen.2006.12.010

JOE Volume 33, Number 5, May 2007

urrent methods of cleaning and shaping root canals produce a smear layer that
covers the instrumented walls. At present, irrigation is considered the best method
for the removal of tissue remnants and the smear produced during root canal preparation, as well as for reducing adherence of microorganisms to dentin (1, 2). Complete
removal of the smear layer requires use of chelating agents followed by tissue solvents,
because no single solution is capable of providing both effects alone (3). Accordingly,
alternating the use of ethylenediaminetetraacetic acid (EDTA) and sodium hypochlorite
(NaOCl) solutions has been advocated as an effective irrigation regimen to remove the
organic and inorganic remnants (4-8), and has gained wide acceptance (9).
The calcium ions (Ca2) present in hydroxyapatite crystals are one of the main
inorganic elements of dentin (10). It has been reported that some chemicals used for
endodontic irrigation are capable of causing alterations in the chemical composition of
dentin (11-14). Any change in the Ca2 ratio may change the original proportion of
organic and inorganic components, which in turn changes the microhardness, permeability, and solubility characteristics of dentin (12), and may also adversely affect the
sealing ability and adhesion of dental materials such as resin-based cements and root
canal sealers to dentin (12, 15-17). Indeed, dentin adhesion depends on the presence
of residual Ca2 on the bonding area (17, 18), and there is evidence that partial
depletion of surface Ca2 may significantly reduce the bond strength of some adhesive
materials (16, 17, 19).
Previous studies have shown that EDTA, used either alone or in combination with
NaOCl irrigation, decreases the Ca/P ratio of root dentin significantly (13, 14). EDTA is
well known as a Ca2 chelating agent, and not only can extract Ca2 ions from dentin,
but can even produce demineralization lesions following extended contact with dentin,
including nonmineral areas near the surface (20). When used alone, NaOCl may (13)
or may not (14) decrease the Ca/P ratio of superficial root dentin, depending on the
concentration of the solution (14). Recently, 1% solutions of ethylene glycol-bis-[2aminoethyl ether]-N,N,N=N=-tetraacetic acid (EGTA), 1,2-cyclohexane-diaminetetraacetic acid (CDTA), and citric acid (pH 1.0) were also shown to extract significant
amounts of Ca2 from root canal dentin (21). However, their demineralizing effect in
clinically relevant concentrations and with regard to application time has remained
uninvestigated.
Consequently, the aim of this study was to determine the extent of calcium removal
from root canal dentin after 17% EDTA, 17% EGTA, 15% EDTA 0.1% cationic
surfactant, cetavlon [cetyltrimethyl ammonium bromide (EDTAC), and 1% tetracyclineHCl treatment, with or without subsequent use of 2.5% NaOCl.

Materials and Methods

Test Solutions
The irrigation solutions tested were 2.5% NaOCl, 17% EDTA (ethylenediaminetetraacetic acid), 15% EDTAC, 17% EGTA, and 1% tetracycline hydrochloride. All chemicals were obtained from Sigma Chemical Co. (St. Louis, MO). The test solutions were
freshly prepared in laboratory conditions. The pH of EDTA, EDTAC, and EGTA solutions
was adjusted to 7.5 by addition of NaOH.

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TABLE 1. Calcium release values (ppm) from root canal dentin following 1-minute treatment with the test solutions
Group

Treatment

Mean

Median

SD

Min

Max

1
2
3
4
5
6
7
8
9
10

NaOCl
EDTA
EGTA
EDTAC
Tetracycline-HCL
EDTA NaOCl
EGTA NaOCl
EDTAC NaOCl
Tetracycline-HCL NaOCl
Distilled water

84.35
296.56
217.82
270.79
76.92
530.75
223.18
296.88
218.93
36.00

84.31
296.67
217.48
270.74
89.75
533.53
228.78
296.97
216.77
33.33

0.31
3.68
2.68
3.24
40.83
35.65
38.34
8.95
5.52
3.44

83.92
292.22
213.18
265.00
7.69
458.38
150.39
284.26
213.67
33.33

84.79
302.22
223.93
275.04
125.64
592.49
273.57
307.86
230.04
40.00

Max, maximum; Min, minimum; SD, standard deviation.

Experimental Procedures
Fifty peridontally involved, single-rooted human teeth were extracted and stored in distilled water at 4C for a maximum of 2 months.
Before experiments, soft tissues covering the root surfaces were removed with gauze and a fine brush. The crowns were removed at the
cementoenamel junction using a high-speed bur under water cooling.
The apical portions of the roots were removed in the same manner so as
to obtain standardized root specimens of 10 mm length. The roots were
then bisected longitudinally, and the pulp tissue was removed with a
toothbrush. All root halves (n 100) were dehydrated in a sterilizer at
120C until they reached a fixed weight, as verified by consistent readings using a precision scale (Sartorius, Gotingen, Germany; precision
0.0001 g). Thereafter, the specimens were covered with two consecutive layers of nail varnish, leaving the root canal surface exposed.
The samples were randomly distributed into the following treatment groups:
Group 1: 2.5% NaOCl
Group 2: 17% EDTA
Group 3: 17% EGTA
Group 4: 15% EDTAC
Group 5: 1% Tetracycline-HCl
Group 6: 17% EDTA 2.5% NaOCl
Group 7: 17% EGTA 2.5% NaOCl
Group 8: 15% EDTAC 2.5% NaOCl
Group 9: 1% Tetracycline-HCl 2.5% NaOCl
Group 10: Distilled water (negative control)

at 1 minute, and the treatment was further extended to 5 minutes, after

which another 0.1-ml sample was taken for 5-minute readings. In
groups 2 to 5, separate specimens (n 10 each) were used for 1- and
5-minute treatments, respectively. At the end of treatments, 0.1 ml of
solution was obtained from each bath for Ca2 analysis. Then, the same
samples (in groups 2 to 5) were further immersed in 2.5% NaOCl and
subjected to either 1- or 5-minute treatment (groups 6 to 9). For each
specimen, the same amount of solution was removed from the bath. The
synergistic effect of both treatments (groups 6 to 9) was then calculated
by taking the sum of Ca2 readings.
The Ca2 level of each group was determined by flame photometry. Accordingly, the flame photometer (Jenway PFP7, Milano, Italy) was
calibrated using standard calcium solutions (100 and 500 ppm), which
enabled conversion of emission signals into a standard measurement
graph in terms of ppm. Following calibration, the treated samples (0.1
ml each) were aspirated into the flame photometer, and the emission
signals were recorded. Conversion of the values into ppm was accomplished using the calibration graph.
Statistical comparisons between the test groups for both 1- and
5-minute treatments were carried out using Kruskal Wallis analysis of
variance and Conover tests (22) with values of p 0.05 considered
significant. Comparisons within each group with respect to treatment
periods and those between single and combined use of test materials
versus time were made with the Mann-Whitney U test and the Wilcoxon
signed ranks test at the same level of significance.

Results

In each group, the specimens were immersed in a magnetic stirrer

bath containing 10 ml of test solution for 1 and 5 minutes. In groups 1
and 10, the same samples (n 10) were used for 1- and 5-minute
treatments. Accordingly, 0.1 ml of solution was aspirated from the bath

The mean calcium release values from root canal dentin after 1and 5-minute treatments with the test solutions are presented in Tables
1 and 2, respectively. Regardless of treatment time, all single (treatment
solution only) and combined (treatment solution with subsequent
NaOCl application) irrigation regimens (groups 1-5 and 6-9, respectively) removed significantly more Ca2 than control treatment (Tables
1 and 2, p 0.05). Compared with other groups, treatment with 17%

TABLE 2. Calcium release values (ppm) from root canal dentin following 5-minute treatment with the test solutions
Group

Treatment

Mean

Median

SD

Min

Max

1
2
3
4
5
6
7
8
9
10

NaOCl
EDTA
EGTA
EDTAC
Tetracycline-HCL
EDTANaOCl
EGTANaOCl
EDTACNaOCl
Tetracycline-HCL NaOCl
Distilled Water

84.45
294.44
230.69
272.13
50.77
697.69
565.29
298.97
223.14
35.33

84.38
294.44
229.96
272.41
53.85
713.87
570.32
301.05
223.18
33.33

0.29
1.89
5.02
2.11
19.37
104.72
123.16
4.44
9.44
3.22

84.04
291.11
223.93
268.83
23.08
479.19
346.36
291.52
202.61
33.33

84.92
297.78
239.86
275.52
74.36
809.83
743.90
304.23
234.90
40.00

Max, maximum; Min, minimum; SD, standard deviation.

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Sayin et al.

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Basic ResearchTechnology
EDTA (group 2) and 17% EDTA 2.5% NaOCl (group 6) resulted in
the maximum amount of Ca2 removal from root canal dentin (p
0.05). For 1-minute treatment, there was no significant difference between the Ca2 release values of tetracycline-HCl and 2.5% NaOCl (p
0.05). With regard to treatment time, a ranking for Ca2 removal was
obtained as follows:
Single Use
1 minute: EDTA EDTAC EGTA tetracycline-HCL NaOCl
distilled water
5 minutes: EDTA EDTAC EGTA NaOCl tetracycline-HCL
distilled water
Combined Use
1 minute: EDTANaOCl EDTACNaOCl EGTANaOCl
tetracycline-HCLNaOCl NaOCl distilled water
5 minutes: EDTANaOCl EGTANaOCl EDTACNaOCl
tetracycline-HCL NaOCl NaOCl distilled water
All combined treatment groups except group 7 (17% EGTA
2.5% NaOCl) removed significantly more Ca2 than their single versions, regardless of application time (Wilcoxon signed ranks test, p
0.05). Within each test group, extending the treatment time to 5 minutes
resulted in significantly more Ca2 removal (Mann-Whitney U test, p
0.05).

Discussion
To precisely assess the amount of released Ca2, accuracy of the
applied technique is of great importance. Methods such as atomic absorption spectrometry, flame photometry, complexometric titration
with EDTA, or inductively coupled plasma-atomic emission spectroscopy (ICP-AES) are all suitable measurement techniques, provided that
calibration is accomplished precisely (14, 23-25). Flame photometry
(also known as flame emission spectroscopy) is a highly sensitive
atomic emission method for the detection of metal salts such as Ca2
and is used extensively for clinical, biologic, and environmental analysis
(26-28). Quantitative analysis is performed by measuring the flame
emission of solutions containing the metal salts. Solutions are aspirated
into the flame. The hot flame evaporates the solvent, atomizes the metal,
and excites a valence electron to an upper state. Light is emitted at
characteristic wavelengths for each metal as the electron returns to the
ground state. Optical filters are used to select the emission wavelength
monitored for the analyte species. Comparison of flame emission intensities of unknowns to either that of standard solutions, or to those of an
internal standard, allows quantitative analysis of the analyte metal in the
sample solution.
In the present study, the root canals were not prepared prior to
analysis; thus, no smear was present on the dentin surface. The rationale
behind omitting this step was to enable measurement of Ca2 loss that
occurred solely on intact root dentin, whereas avoiding any possible
contamination of readings that could have been caused by the Ca2
incorporated into the loosely bound smear (13, 14, 21). Furthermore,
adhesive restoration of endodontically treated teeth generally involves
the pulp chamber, whose mineral content is adversely affected by exposure to endodontic irrigants (29), and this region generally does not
contain smear because of the conservative nature of endodontic access
cavity preparation (30). To incorporate smear into the measurements,
more research may be required to determine the durations at which
irrigants could completely remove the surface smear before interacting
with the dentin substrate. However, it is tempting to speculate that the

JOE Volume 33, Number 5, May 2007

time-dependent demineralization effect of the irrigation regimens tested

herein may be reduced in the clinical situation by the presence of smear.
The rationale behind using 2.5% NaOCl was to test a low yet commonly used concentration of NaOCl on Ca2 removal. Despite different
methodologies used, our results confirm and extend previous work
(14), which demonstrated a significant decrease in the Ca2 level of
dentin following 2.5% NaOCl treatment. The same study also reported a
nonsignificant decrease for 15-minute 5.25% NaOCl treatment, compared with control treatment. Because 5.25% NaOCl was not tested in
the present study, no comparison can be made. However, the high
concentration of NaOCl used in that study could have affected the inorganic material, preventing further dissolution of the dentin, or it may
have dissolved the organic components, leaving a smear layer with high
mineral content (5, 31). It is noteworthy to mention herein that although NaOCl is not a chelating agent, the extent of Ca removal by 2.5%
NaOCl was similar to or significantly greater than that of tetracycline-HCl
at 1 and 5 minutes, respectively. Moreover, the combined use of EDTA,
EDTAC, and tetracycline-HCl with NaOCl removed more Ca2 than did
their single versions, indicating that 2.5% NaOCl may facilitate alteration
of the chemical composition of root canal dentin.
In the present study, the pH of test solutions except NaOCl was
adjusted to 7.5. Studies have shown that EDTA and EGTA demonstrate
optimal effects at neutral pH and cause less alteration (i.e., erosion,
excessive ion removal) on radicular dentin (32, 33). The pH of NaOCl
was not adjusted, as it is known to be effective at basic pH.
Previous studies have compared different concentrations of EDTA
with several other irrigants, showing that EDTA presents similar (21) or
more potent (14) effects on Ca extraction from dentin. In the present
study, treatment with 17% EDTA and 17% EDTA 2.5% NaOCl resulted
in the maximum amount of Ca2 removal from root canal dentin, and
this effect was increased by extended application time. When EDTA is
used as an irrigant alone, the organic matrix of dentin is the limiting
factor on the dissolution of dentin (17), because it accumulates on the
canal surface, thereby preventing further dissolution (17, 34). Subsequent application of NaOCl may facilitate further exposure of the inorganic material on EDTA-decalcified dentin substrate through removal of
the organic matrix (13, 17), and thus increase the demineralizing effect,
as shown herein.
Although the time-dependent demineralizing potential of single
and combined use of the tested irrigants was shown in the present study,
the effects of such calcium removal on the adhesion of endodontic
sealers and adhesive cements remains to be studied in detail. Also of
importance is how these irrigation regimens might influence the microhardness of root canal dentin. These studies are now underway.

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JOE Volume 33, Number 5, May 2007