Basic ResearchTechnology
Effect of EDTA with and without Surfactants or
Ultrasonics on Removal of Smear Layer
Jeen-Nee Lui, BDS, MDS, MRD. Hong-Guan Kuah, BDS, MDS, MRD,
and Nah-Nah Chen, BDS, MDS, MS
Abstract
This study compared the in vitro efficacy of Smear Clear
(Sybron Endo, CA), a 17% ethylenediaminetetraacetic
acid (EDTA) solution with surfactants, to 17% EDTA,
with and without the use of ultrasonics, in removal of
the smear layer. Seventy-five extracted teeth, randomly
distributed into 5 test groups, were prepared by using
ProFile rotary instruments (Dentsply Maillefer, Bal-
laigues, Switzerland) and subjected to different final
irrigating regimes; group A, 1% sodium hypochlorite;
group B, 17% EDTA; group C, 17% EDTA with ultra-
sonics; group D, Smear Clear; and group E, Smear Clear
with ultrasonics. Samples were examined under the
scanning electron microscope and scored for debris and
smear layer removal. Statistical analysis showed that
groups D and E did not perform significantly better than
groups B and C. Group C performed significantly better
than group B. Addition of surfactants to EDTA in Smear
Clear did not result in better smear layer removal. The
use of ultrasonics with 17% EDTA improved smear layer
removal. (J Endod 2007;33:472 475)
Key Words
Ethylenediaminetetraacetic acid, irrigation, smear layer,
surfactants, ultrasonics
From the Department of Restorative Dentistry, National
Dental Centre, Singapore.
Address requests for reprints to Dr. Jeen-Nee Lui, National
Dental Centre, 5, Second Hospital Avenue, Singapore 168938,
Republic of Singapore. E-mail address: lui.jeen.nee@
ndc.com.sg
0099-2399/$0 - see front matter
Copyright 2007 by the American Association of
Endodontists.
doi:10.1016/j.joen.2006.12.007
472 Lui et al.
T he aim of endodontic treatment is the elimination of microorganisms from the root
canal system and the prevention of reinfection. To achieve this objective, root canals
are cleaned before root filling using mechanical instrumentation, supplemented with
irrigants and intracanal medications. After mechanical preparation, an amorphous,
irregular layer known as the smear layer is formed on root canal walls (1). The smear
layer contains remnants of ground dentine; pulp tissue and odontoblastic processes;
and, in infected teeth, bacteria (1).
Possible deleterious effects may occur if the smear layer is not removed during
root canal treatment. Microorganisms remaining in the smear layer after the instru-
mentation of an infected root canal space can survive and reinfect the canal (2, 3). The
smear layer has also been shown to hinder the penetration of intracanal disinfectants
(4) and sealers (57) into dentinal tubules and has the potential of compromising the
seal of the root filling (8 10). Although it has been suggested that an intact smear layer
may prevent initial bacterial penetration of dentinal tubules (11), degradation of the
smear layer after treatment may contribute to leakage and reinfection of the root canal
space. It has been shown that removal of the smear layer reduced the leakage of bacteria
through the root canal system after root filling (12). Although not substantiated in
clinical trials, it would appear prudent to remove the smear layer before root filling an
instrumented canal.
The use of chemicals, ultrasonics, and lasers, in combination or alone, has been
evaluated for removal of the smear layer with varying results. Currently, a final irrigation
sequence with a chelating agent, such as ethylenediaminetetraacetic acid (EDTA), and
sodium hypochlorite (NaOCl) is recommended to remove the inorganic as well as
organic components of the smear layer (13). It has been reported that smear layer
removal is less predictable in the apical region as compared with the coronal and
middle third of the root (3, 14, 15). This could be attributed to comparatively smaller
apical canal dimensions hindering the penetration of irrigants and resulting in limited
contact between canal walls and the irrigants.
Possible methods to increase the penetration of irrigating solutions into the apical
third of the root canal and dentinal tubules include the use of ultrasonics and the
addition of surfactants to irrigating solutions. The use of ultrasonics employs an acous-
tic streaming effect (16), and it has been shown that the use of a small oscillating file is
able to transport irrigants into the apical parts of the root canal (17). This could be
beneficial in transporting chelating agents and improving smear layer removal in the
apical root canal. Intimacy of an irrigating solution to the dentinal walls depends on the
wettability of the solution on solid dentine, which is in turn dependent on a low surface
tension (18). The surface tension of an irrigating solution can be reduced with the
addition of surfactants (19), and therefore, in theory, translate to better cleaning effi-
ciency in the root canal. Smear Clear (SybronEndo, Orange, CA) is a product recently
introduced for removal of the smear layer. It is a 17% EDTA solution with 2 additional
proprietary surfactants. Although it may be speculated that irrigation with Smear Clear
would be more efficient compared with EDTA, there have been no published studies to
date of the effectiveness of Smear Clear in the removal of the smear layer. The aim of this
study was to compare the in vitro efficacy of Smear Clear to 17% EDTA, with and without
the use of ultrasonics, in the removal of the smear layer in the apical third of the
instrumented root canal.
JOE Volume 33, Number 4, April 2007

Materials and Methods
Sample Selection
Extracted intact mature human premolars with single canals of
curvatures less than 30 (20) were collected and stored in saline (Bax-
ter, NSW, Australia). The teeth were radiographed from the buccal and
mesial aspects to ensure closed apices and similar root canal widths.
Seventy-five selected teeth were decoronated to standardized root
lengths of 12 mm and randomly distributed into 5 groups of 15 teeth.
This sample size was calculated based on a desired power of 80% for the
study.
Root Canal Instrumentation
The specimens were instrumented with .04 ProFile rotary files
(Dentsply Maillefer, Ballaigues, Switzerland) using a crown-down tech-
nique, with the final apical preparation completed with Flex-O hand files
(Dentsply Maillefer) to a master apical file size 40. The working length
was determined by deducting 1 mm from the length recorded when a
#10 K file that was placed through the apical foramen of each specimen
was pulled back until the tip of the file just disappeared. During instru-
mentation, the canals were irrigated with 1 mL of 1% NaOCl (Milton,
Procter & Gamble, NSW, Australia) between every instrument change.
Final Irrigation Sequence
After instrumentation, teeth in different groups underwent a dif-
ferent final irrigation sequence. The solutions were introduced into the
canals by using a 27-gauge needle to within 1 to 2 mm of the working
length. For groups using ultrasonics, #15 K files placed 1 to 2 mm from
the working length were ultrasonically activated by using the Suprasson
P-50 machine (Satelec, Merignac Cedex, France) at a power setting of 2.
The final irrigating sequences were as follows: (1) group A, 5 mL of 1%
NaOCl for 1 minute followed by 5 mL of 1% NaOCl; (2) group B, 5 mL of
17% EDTA (Pulpdent EDTA Solution; Pulpdent, Watertown, MA) for 1
minute followed by 5 mL of 1% NaOCl; (3) group C, 5 mL of 17% EDTA
for 1 minute with ultrasonics followed by 5 mL of 1% NaOCl; (4) group
D, 5 mL of Smear Clear for 1 minute followed by 5 mL of 1% NaOCl; and
(5) group E, 5 mL of Smear Clear for 1 minute with ultrasonics followed
by 5 mL of 1% NaOCl.
Scanning Electron Microscope Evaluation
The teeth were grooved along the buccal and lingual surfaces by
using a diamond disc at low speed and split longitudinally with a chisel
and mallet into two halves. The specimens were dried, mounted on
metallic stubs, gold sputtered, and evaluated under a scanning electron
microscope (SEM) (SEM 5600; JEOL Ltd., Tokyo, Japan) at magnifica-
tions of 1,000 and 3,000 at the apical and middle levels. Serial SEM
photomicrographs were taken of the canal walls at 2 and 6 mm from the
apical foramen of each specimen.
Figure 1. Representative SEM photomicrographs. Specimens with (A) smear score 0 and debris score 0, (B) smear score 1 and debris score 1, and (C) smear score
2 and debris score 2
JOE Volume 33, Number 4, April 2007
Basic ResearchTechnology
TABLE 1. Smear layer and debris scoring
Score Observation
Smear score
0 All dentinal tubules are open and no smear
layer present
1 Some dentinal tubules are open with smear
layer covering some of the openings of the
dentinal tubules
2 All dentinal tubules are covered by smear layer
Debris score
0 No debris present
1 Few debris particles present
2 Large amount of debris present
Two examiners who were blinded to specimen groups scored the
SEM photomicrographs separately. Before the scoring proper, both
examiners assessed the first 20 specimens together for calibration pur-
poses. Intra- and interexaminers reliability was verified by using the
kappa test. The amount of debris and smear layer present was scored,
and frequencies of the scores were subject to statistical evaluation using
the chi-square test. Smear layer and debris scoring is shown in Table 1.
Results
Examiner Calibration
Intraexaminer and interexaminer agreement evaluated with the
kappa test for the first 20 samples, significance set at 0.5, showed
satisfactory values of 0.9 and above for each category.
Smear Layer and Debris Removal
Representative SEM photomicrographs are shown in Figure 1A-C.
The results for smear layer and debris scores in each group are pre-
sented in Figures 2 and 3 respectively.
Group A performed significantly worse than the rest of the groups
with respect to smear layer and debris removal at both apical (2 mm)
and midroot (6 mm) levels. At 2 mm from the apex, group C was
significantly better than group B at debris and smear removal (p
0.05), and group C was significantly better than group D in smear
removal (p 0.05). Other than with group A, there was no significant
difference between the rest of the groups.
At the 6-mm level, the majority of samples in the groups, except for
group A, had a smear score of 0. There was no significant difference
between groups B, C, D, and E with respect to smear and debris removal.
Discussion
In this study, we attempted to evaluate methods to improve the
removal of smear layer in the apical third of the canal. The significant
EDTA With and Without Surfactants 473
Basic ResearchTechnology
Figure 2. Smear score distribution at 2 mm and 6 mm levels from the apex
difference found with use of NaOCl alone and the rest of the groups with
respect to smear layer removal is in accordance with other studies that
have shown that NaOCl is not effective in removing the smear layer (15,
21). The better results we achieved in smear and debris removal at the
6-mm level compared with the 2-mm level in all samples regardless of
the type of chelating agent or technique used emphasizes the difficulty in
thoroughly debriding the apical region of the root canal as previously
reported (3, 14, 22, 23).
The use of a higher concentration of NaOCl in this study may have
resulted in lower debris scores, although this remains speculative.
Yamada and coworkers (3) found 5.25% NaOCl effective in removing
all debris in the canal when used as an irrigant during instrumentation
and as a final flush but did not compare these results with lower con-
centrations of NaOCl. A comparison of 0.5%, 1.0%, 2.5%, and 5.25%
NaOCl found all concentrations equally effective in removal of loose
superficial debris from the root canal but ineffective in removal of the
smear layer (24).
Surface tension may be defined as the force between molecules
that produces a tendency for the surface area of the liquid to decrease.
This force tends to inhibit the spread of a liquid over a surface or limit
its ability to penetrate a capillary tube (18). Reducing surface tension of
endodontic solutions improves their dentine wetting ability (25) and
improves their flow into narrow root canals (26). It may be speculated
that reduction of surface tension of an endodontic irrigating solution by
addition of surfactants should improve its efficacy in the narrow apical
region of the root canal. However, our experiments showed that the
surfactants in Smear Clear did not improve its performance in smear
layer removal compared to EDTA alone. Recently, it was shown that
reducing the surface tension of endodontic chelator solutions did not
improve their calcium chelating ability and that the addition of a wetting
agent to a chelator solution is unnecessary (27). In vivo, root canals are
Figure 3. Debris score distribution at 2 mm and 6 mm levels from the apex
474 Lui et al.
usually wet, and the surface tension of endodontic solutions may not
play a large role (28).
In our study, ultrasonics was used only after the completion of
instrumentation and during the final irrigation sequence so that the file
was activated passively and with minimal contact with the canal wall.
Higher-velocity acoustic streaming had been observed when smaller
size files were used, and there was minimal file-wall contact (16). At 2
mm from the apex, specimens irrigated with EDTA and ultrasonics
(group C) scored significantly better than specimens irrigated with
EDTA and NaOCl without ultrasonics (group B) for debris and smear
removal (p 0.05). This may be attributed to the ability of ultrasonics
to deliver irrigants to the apical region of the root canal (17). Although
irrigation with Smear Clear and ultrasonics (group E) had more spec-
imens with smear score 0 and 1 compared with irrigation with Smear
Clear alone (group D), the difference was not significant. It has been
previously noted that reduction of surface tension in irrigants used
during instrumentation may actually cause an increased penetration of
smear material into dentinal tubules (29). The authors speculated that
use of surface active agents during instrumentation may encourage
deeper packing of smear material into dentinal tubules via capillary
action and fluid dynamics (29).
Based on the results in our study, a 1-minute application of ultra-
sonic irrigation with 17% EDTA followed by a final flush of NaOCl was
very successful in obtaining clean, smear free walls in instrumented and
relatively straight root canals. This protocol can be easily achieved in
clinical practice, except in cases in which curved root canals may pose
problems in placement of the ultrasonic file to within 1 to 2 mm of the
root apex. Recently, it was shown that use of an ultrasonically activated
irrigation needle for irrigation after completion of hand/rotary cleaning
and shaping significantly improved canal and isthmus cleanliness in the
apical 3 mm of mesial root canals of mandibular molars despite the
JOE Volume 33, Number 4, April 2007

needle depth being 4 to 5 mm short of the apical preparation (30).
Application of this technology to the removal of smear layer in curved
canals appears promising, but further studies will be required to deter-
mine its effectiveness.
Conclusion
The use of ultrasonics with 17% EDTA improved smear layer re-
moval in the apical region of the canal. However, the addition of sur-
factants to EDTA in Smear Clear did not result in better smear layer
removal compared with EDTA alone.
Acknowledgments
The authors thank Dr. Chan Yiong Huak from the Biostatistics
Unit, Yong Loo Lin School of Medicine, National University of Sin-
gapore, for assistance in statistical analysis.
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