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10]

Review Article

The smear layer in endodontic: To keep or remove – an

updated overview
Ruaa A. Alamoudi
Department of Conservative Dentistry, Division of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Abstract During mechanical preparation, the use of hand or rotary instruments results in the production of
considerable amount of smear layer. The smear layer consists of two parts: a supercial layer that covers
the dentinal wall and a smear plug which occludes that dentinal tubules. Researchers had reached to
different conclusions on the importance of removing or maintaining this layer. Removing the smear layer
allows for more cleaning and disinfecting root canal walls and better adaptation of root canal filling
materials. However, the presence of smear layer can act as a seal to the dentinal tubules and minimize the
ability of bacteria and its toxins from penetrating the dentinal tubules. The ability to remove smear layer
depends primarily on chemomechanical preparation. There are three main methods to remove smear layer:
chemically, mechanically (ultrasonically), laser, or combinations. No one single irrigant has the ability to kill
microorganisms, dissolve organic tissues, and demineralize smear layer. Thus, alternating between organic
and inorganic solvents and the use of different methods and techniques have been recommended. Indeed,
there is little relevance attributed to the influence of smear layer on the clinical treatment outcomes.
Moreover, there is critical lack of clinical studies to determine the role of smear layer since all previous
studies were carried out on laboratory based. Further experimental model with a longitudinal observational
characteristic should be applied.

Keywords: Chemomechanical instrumentation, irrigating solutions, outcome, smear layer

Address for correspondence: Dr. Ruaa A. Alamoudi, Department of Conservative Dentistry, Division of Endodontics, Faculty of Dentistry, King Abdulaziz
University, P.O. Box: 1119, Jeddah 21431, Saudi Arabia.
E‑mail: ralamoudi1@kau.edu.sa

INTRODUCTION of smear layer on instrumented root canals was first

During mechanical preparation, the use of hand or rotary
files for instrumentation will result in the production of
considerable amount of mineralized debris what is called
smear layer. Eick et al.[1] were the first who identified the
smear layer using scanning electron microscope (SEM)
and found that smear layer is made from different size
of particles ranging from <0.5 to 15 µm. The presence
reported by McComb and Smith in 1975. [2] They
showed that this layer is made of remnants of dentin,
odontoblastic processes, necrotic or viable pulp tissues,
and bacteria. Lester and Boyde[3] reported that smear layer
is a mineralized collagen matrix made up of entrapment
of organic matter within inorganic dentin. Other studies
showed that the smear layer has an amorphous granular
and irregular particle under SEM.[4‑6]

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DOI:
10.4103/sej.sej_95_18 How to cite this article: Alamoudi RA. The smear layer in endodontic:
To keep or remove – an updated overview. Saudi Endod J 2019;9:71-81.

© 2019 Saudi Endodontic Journal | Published by Wolters Kluwer ‑ Medknow 71

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Alamoudi: Smear layer
The smear layer consists of two parts: a superficial layer
that covers the dentin surface and a smear plug that
occludes the dentinal tubules. Mader et al.[7] showed that
this superficial layer consists of a thin layer of mineralized
tissue and is about 1–2 µm in thickness. Goldman et al.[8]
agreed with a previous study and reported that the smear
layer is about 1 µm. Brännström and Johnson[9] reported
that the thickness of smear layer could range between 2 and
5 µm in thickness. Other studies reported that the smear
plug is about 40 µm.[4,7,10‑12] and can reach up to 110 µm.[13]
Variation in the thickness of smear layer depends on
whether the dentin was instrumented in wet or dry field
and the type and sharpness of the cutting instruments.[14,15]
The increase in the centrifugal forces resulted from the
proximity of the endodontic instrument to the dentin
wall forms a thicker and more resistant smear layer,[16] thus
Gates‑Glidden and postdrills produce more and greater
volume of smear layer than that produced by hand‑filing.[17]
Several studies explain the phenomenon of tubular packing.
Brännström and Johnson[9] and Mader et al.[7] reported
that smear plug occurred due to the rotational movement
of the burs and rotary instruments leading to scattering
of the smear debris and subsequently plugged inside the
tubules. Meanwhile, Cengiz et al.[12] advocated that it could
be due to the sucking force of the capillary resulting in an
adhesion between the smear layer and the dentinal tubules.
Other factors such as whether the dentin is wet or dry
during instrumentation[14,15,18] and the cutting efficiency of
the instruments determine the thickness of smear layer.
THE SIGNIFICANCE OF SMEAR LAYER
Researchers have reached to different conclusions on
the importance of removing or leaving this layer. Some
authors advocated the significance of removing the smear
layer since it contains necrotic tissue, bacteria, and its
by‑products.[2,5,19‑21] This content can act as a reservoir for
further microbial irritants[22] and may serve as a substrate
for microorganisms[23] to survive, multiply,[24] and then
proliferate deeply inside the dentinal tubules.[25‑29] Although
several studies reported the presence of microorganisms
inside the dentinal tubules after chemomechanical
preparation,[30‑32] Brännström[33] advocated that these
microorganisms inside the dentinal tubules can easily be
destructed once the smear layer is removed. Meryon and
Brook[29] also reported the negligible effect of smear layer
on the penetration ability of three microorganisms.
In addition, the smear layer can minimize the ability of
disinfecting agents to penetrate the dentinal tubules.[2,5,19,20,34]
Other studies showed that it can also minimize the ability
of intracanal medicaments to penetrate deeply.[7,29,35]
72 Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019
These findings contradicted with that of Haapasalo and
Ørstavik[36,37] who reported that removing the smear layer
may allow liquid‑camphorated monochlorophenol solution
to completely disinfect the dentinal tubules. Yet, it failed
to eradicate Enterococcus faecalis with calcium hydroxide.
Therefore, smear layer can delay but did not completely
eliminate the effect of disinfectant agent or intracanal
medicament.
Furthermore, Okşan et al.[38] stated that smear layer decreases
the ability of sealer to penetrate the dentinal tubules and
adhere properly. Gençoğlu et al.[39] stated that smear layer
minimizes the ability of gutta‑percha to adapt well to canal
wall regardless of the condensation techniques used; cold
laterally or thermoplastic vertically. Their studies were in
accordance with that of Gutmann[40] who also reported that
thermoplastic gutta‑percha adapted well to canal wall after
smear layer removal regardless of the presence of sealer.
Smear layer acts as a sealing barrier between the canal wall
and root filling materials and may compromise the ability
to form a satisfactory seal.[3,17,41‑44] Several authors advocated
that smear layer is a loosely nonhomogeneous adherent
structure that can easily dislodged from the underlying
dentin and potentially lead to bacterial contaminant and
leakage between the filling material and the dentinal
walls.[7,29,45] A study by Pashley et al.[46] showed the presence
of a microchannel between the root filling material and
dentinal wall in the presence of smear layer which is between
1 and 10 µm in thickness. These channels may negatively
affect the apical and coronal seal and they may disintegrate
leaving voids in poorly filled root canal, consequently
altering the root canal treatment outcome.[42,47‑71]
Conversely, other investigators advocated the importance
of maintaining the smear layer after canal preparation, and
some studies provide strong evidence to prove that smear
layer acts as a seal to the dentinal tubules and minimizes
bacterial and its toxin from invasion by altering dentinal
permeability.[72‑76] Pashley[77] reported that the presence of
a smear layer may limit bacteria present in the infected
canal to enter the dentinal tubules in case of inadequate
canal disinfection or recontamination of the canal between
treatment sessions. However, a study by Williams and
Goldman[27] reported that this layer cannot act as a complete
barrier and its presence could only delay bacterial invasion.
Another study by Madison and Krell[47] using a chelating
agent, ethylenediaminetetraacetic acid (EDTA) solution,
found no difference in the leakage properties regardless of
the presence of smear layer. This study was in accordance
with that of Chailertvanitkul et al.[59] who found the same
result. However, a major disadvantage of these studies is
that the experiments did not mimic the clinical condition
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Alamoudi: Smear layer
and were undertaken using cross‑sectional root models or
dentin discs. This limitation was overcome by a study of
Drake et al.[75] who evolved a more clinically relevant model
using extracted human teeth to examine the effect of smear
debris on bacterial retention on canal wall. They suggested
that smear layer formed during mechanical instrumentation
can prevent bacterial colonization of root canals as it limits
bacterial penetration into dentinal tubules.
A systematic review and meta‑analysis by Shahravan et al.[78]
tested whether removal of the smear layer can prevent
the leakage of root‑filled teeth, 54% of the comparisons
stated no significant effect with or without smear layer
removal, 41% advocated toward the removal of smear
layer in order to prevent leakage, and 5% reported keeping
it. They concluded that smear layer removal can promote
an excellent fluid‑tight seal, while other factors such as
type of the sealer or the filling technique cannot produce
significant effects.
THE EFFECT OF INSTRUMENTATION
TECHNIQUE ON THE AMOUNT OF SMEAR LAYER
Though little research highlight the effect of different
instrumentation techniques and materials on the amount of
smear layer remaining in the dentinal wall, it is well known
that mechanical preparation produces considerable amount
of smear layer. Endodontic hand files such as K‑reamers
and K‑files created similar surfaces compared to rotary
files.[79] Meanwhile, postburs and Gates‑Glidden showed
a higher volume in producing smear debris compared to
hand instruments.[17]
A study by Poggio et al.[80] demonstrated the effect of two
different nickel‑titanium (NiTi) rotary systems on the
amount of smear layer debris present in the middle and
apical third of the root canal: Reciproc (VDW GmbH,
Munich, Germany) and Mtwo rotary files (VDW, Munich,
Germany). Mtwo group presented significantly less smear
layer and promoted more clean canal walls compared to
Reciproc group. A recent study by Kar et al.[81] compared the
amount of smear debris remained after using two multifile
rotary systems  (MTwo and Silk MANI, INC, Tochigi,
Japan) and two single‑file rotary systems  (F6 Skytaper,
KometBrasseler GmbH & Co., Lemgo, Germany and
NeoNiTi, Neolix Creative Dental Instruments, Châtres-
la-Forêt, France). The result of this study showed that F6
Skytaper single‑file rotary instrument had the maximum
cleaning efficacy followed by Mtwo multifile rotary
instrument in the apical area of root canals. This result may
be attributed to the fact that both instruments share similar
file design, i.e. S‑shaped cross section with two sharp cutting
Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019 73
edges, small core diameter, and greater chip space. Another
study reported no significant difference in the amount of
smear layer between canals with different tapers: 30/0.02
files and 30/0.4 files.[82]
THE EFFECT OF SMEAR LAYER ON THE
BONDING EFFICACY OF DIFFERENT
ENDODONTIC OBTURATION MATERIALS
Several studies demonstrate the importance of smear layer
removal and its effect on material‑to‑dentin bond strength,
which promotes fluid‑tight seal and minimized leakage.
White et al.[41,83] reported effective penetration of different
endodontic sealers and root filling materials into dentinal
tubules after removal of the smear layer. They also reported
that Roth 801, AH26, pHEMA, and silicone sealers
extended consistently inside the dentinal tubules when the
smear layer was removed. This study was in accordance with
that of Sonu et al.[84] which showed that removal of smear
layer allows AH plus sealer to penetrate deeply into the
dentinal tubules at cervical and middle thirds of the root.
Sisodia et al.[85] advocated that removal of smear layer helps
in better resistance to bacterial penetration and less leakage
along Apexit Plus (Vivadent, Schann, Lichtenstein)  root
canal sealer. However, few other investigations contradicted
the effect of smear layer on bond strength. Goldberg et al.[49]
reported that smear layer did not produce any difference
on the sealing ability of Ketac‑Endo (ESPE. GmbH,
Seefeld, Germany)and Tubliseal endodontic sealers (Kerr
Italia S.p.A., Salerno, Italy). Another study by Saleh et al.[86]
showed that removing the smear layer did not necessitate
the improvement of bacterial resistance to penetrate along
different types of sealers.
METHODS TO REMOVE THE SMEAR LAYER
The ability to clean effectively an endodontic space and
remove smear layer depends primarily on chemomechanical
preparation. Several aspects related to the smear layer
removal have been discussed in the last decade, such as
the use of different chelating agents, the volume and
concentration of the solution used, the interaction between
chelators and other irrigants, the ideal time effective
to eliminate smear layer without causing an extensive
destruction to the dentin matrix, and the influence of
ultrasonic agitation. The following three main methods
are used to remove smear layer: chemically, mechanically,
laser, or combination.
Sodium hypochlorite
This solution is well known to dissolve organic tissues[20,87,88]
and kill microorganisms. Meanwhile, it lacks the ability to
remove smear layer.[8,89‑91]
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Alamoudi: Smear layer
Chlorhexidine
This solution has been considered a substantive antibacterial
agent through its excellent long‑lasting adherence to dentin
wall, but it did not show any dissolving capability to organic
material or removing effect to smear layer.[92]
Chelating agents
These agents interact with calcium ions which are present
in the dentin wall and form soluble calcium chelates. EDTA
acids are considered one of the most common chelating
irrigants in endodontics. McComb et al. reported that
application of EDTA resulted in effective opening to the
dentinal tubules with very little superficial smear debris.[93]
Another study showed that 17% EDTA can decalcify
dentin up to a depth of 20–30 µm in 5 min.[94] However,
Fraser[95] reported that the chelating effect of EDTA
was almost neglected in the apical part of root canals.
Furthermore, the use of 24% EDTA gel was believed to
prevent the extrusion of the material to periapical tissues
compared to liquid form, increase the permeability of
dentin, and enhance the cleaning ability.[96]
Different materials were added to EDTA to enhance its
effect. RC‑Prep (Premier Dental Products, Plymouth
Meeting, PA, USA) is an EDTA product with urea
peroxide to enhance the floating effect of smear debris
out of the root canal.[97] However, this product contains
a wax that remains on canal walls and decreases the
hermetic seal between canal wall and filling material.[98]
Many other studies have advocated that paste‑type EDTA
did not eliminate the smear layer as effective as liquid
type. Another recent investigation examined the addition
of surfactants to liquid EDTA to minimize the surface
tension and enhance the cleaning efficacy; however, no
additional result was noted.[99] Quaternary ammonium
bromide (cetrimide or Cetavlon) is another solution that
has been added to EDTA solutions. Fehr and Nygaard[100]
recommended the addition of 0.84 g of a quaternary
ammonium bromide (Cetavlon or cetrimide) to transform
EDTA to EDTAC. Cetrimide reduces the surface tension
and increases the penetrating capacity of the solution.
Goldberg and Abramovich[19] reported the presence of
smooth canal surface and regular dentinal tubules with
the use of EDTAC. However, Frithjof et al.[94] reported
no difference in the behavior of EDTA and EDTAC.
The ideal working time of EDTAC is recommended
to be <15 min and no further chelating effect could be
expected after this period.[101] Smear Clear® (SybronEndo,
Orange, CA, USA) is a recently introduced chelating
agent that contains 17% EDTA solution, cetrimide,
and two additional surfactants  (polyoxyethylene and
isooctylcyclohexyl). A study by Dua and Uppin[102] showed
74 Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019
that final irrigation with either 17% EDTA solution or
Smear Clear followed by 1% sodium hypochlorite (NaOCl)
was effective in removing the smear layer in coronal and
middle thirds. However, Smear Clear was more effective
when compared with 17% EDTA solution in the apical
third.
Another chelating agent called Bis‑dequalinium‑acetate
(BDA) consists of a dequalinium compound and an oxine
derivative. This agent has been known for its ability to
remove smear debris throughout the entire length of root
canal.[103,104] It has been reported that this agent has a low
surface tension, less toxic, and well tolerated by periodontal
tissues. Commercial forms of BDA, Solvidont (De Trey,
A.G., Zurich, Switzerland) and Salvizol  (Ravens Gmbh,
Konstanz, Germany), were introduced in the 1980s and
have both inorganic and organic debridement actions.[105‑109]
Kaufman et al.[103] showed that Salvizol had better cleaning
effect compared to EDTA. Meanwhile, Berg et al.[90]
demonstrated less patent dentinal tubules using Salvizol
compared to EDTA.
Another chelator is ethylene glycol‑bis (ß‑aminoethyl
ether)‑N, N, N¢, N¢‑tetraacetic acid (EGTA). It showed to
bind more specifically to calcium ions.[110] Calt and Serper[111]
compared the effects of EGTA to EDTA on the removal
of smear layer and found that this layer was completely
eliminated using EDTA solution although it caused more
destruction and erosion to the peritubular and intertubular
dentin, while EGTA was not as efficient as EDTA in the
apical area of root canals.
Tetracycline (including tetracycline hydrochloride,
minocycline, and doxycycline) is a broad‑spectrum
antibiotic. Tetracycline can act as a calcium chelator
because of its low pH.[112] A study by Barkhordar et al.[113]
showed that 100 mg/ml of doxycycline hydrochloride was
sufficient in eliminating smear layer. Haznedaroğlu and
Ersev[114] showed no difference between 1% tetracycline
hydrochloride and 50% citric acid in removing smear
layer though tetracycline showed less demineralization to
peritubular dentin than citric acid. Recently, Torabinejad
et al.[115] introduced a solution containing a mixture of
a tetracycline isomer, an acid, and a detergent called
MTAD™. This solution is an excellent irrigant for the
removal of smear layer and killing microorganisms.[115‑118]
Organic acids
Citric acid is an organic acid that demonstrates its
effectiveness in removing smear layer.[119‑121] It has been
reported that citric acid eliminates smear layer much better
than other acids such as polyacrylic acid, lactic acid, and
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Alamoudi: Smear layer
phosphoric acid.[122] Wayman et al.[20] reported that 10%
citric acid produces the best effect in removing smear
layer compared to higher concentration of citric acid
(25% and 50%). A study by Machado et al.[123] compared
the effectiveness of smear layer removal when either 17%
EDTA or 10% citric acid was used. They found that sealer
penetrates the dentinal tubules equally with both chelating
solutions. pH and time of exposure[124] are the main factors
to determine the amount of removal.
Polyacrylic acid is another type of organic acid that can
be used as a chelating solution. Studies by McComb and
Smith[2,93] compared the effect of commercial liquid EDTA
preparation (REDTA) to 5%, 10%, and 20% polyacrylic
acid and reported that there is no difference between all
solutions in eliminating or even preventing the formation
of smear layer. Although 40% polyacrylic acid (Durelon™
liquid and Fuji II liquid) is an effective potent solution, it
should not be applied for more than 30 s to avoid extensive
damage of the dentin surface.[125]
Moreover, Bitter[126] introduced 25% tannic acid irrigant as a
root canal‑chelating solution and reported that it produces
clean smooth canal wall. However, Sabbak and Hassanin[127]
contradicted previous findings and reported that tannic
acid increases the organic cohesion. Their explanation was
because of the presence of collagen cross‑linking between
smear layer and dentin.
Chitosan
Chitosan is a biopolymer derived by the partial deacetylation
of chitin obtained from crustacean shells. A study by
Geethapriya et al.[128] advocated that combination of
chitosan‑EDTA (1:1) exhibits excellent smear layer removal
with less erosion to the coronal and middle thirds of the
root compared to 17% EDTA alone. This study was in
accordance with previous studies, which had reported the
ability of chitosan/chitosan nanoparticles to eliminate
smear layer and inhibit bacterial recolonization when used
as a final irrigant during root canal treated on dentin.[129,130]
Silva et al.[131] recommended using 0.2% chitosan for 3 min
to remove the smear layer without causing dentinal erosion.
COMBINATION BETWEEN DIFFERENT
SOLUTIONS
No one single irrigant has been yet found to act as an
antimicrobial agent, a tissue dissolvent, and a smear layer
demineralizer. Thus, alternating between organic and
inorganic solvents has been advised.[5,121,132]
Different studies recommended the sequential application
of NaOCl and EDTA during chemomechanical
Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019 75
preparation[5,12,41,91] to help eliminating microorganism
and remove soft‑tissue debris and smear layer. Goldman
et al.[88] tested the result of using single irrigant or various
combinations to thoroughly clean the entire root canal. The
result showed that the most effective final rinse was when
10 mL of 17% EDTA was applied into the canal followed
by 10 mL of 5.25% NaOCl as a final rinse. Brännström
et al.[4] confirmed that this mixture has the ability to remove
most of the smear debris without extensive opening to the
dentinal tubules or erosion to peritubular dentin.
Sequential irrigation with either NaOCl and MTAD or with
NaOCl and EDTA produces similar effect in the ability of
bacteria to penetrate filled canals.[133] However, NaOCl and
MTAD mix can demineralize dentin faster than NaOCl
and EDTA.[134]
QMix is an endodontic irrigant recently introduced to
remove smear layer and kill microorganisms. It contains
EDTA, chlorhexidine  (CHX), and a detergent. Stojicic
et al.[135] reported that alternating between NaOCl and QMix
was superior to CHX and MTAD in killing microorganisms
and removing smear layer.
Another study by Yamada et al.[5] showed that combination
of 25% citric acid and NaOCl solution can result in crystal
precipitation.
Ultrasonic smear removal
Several previous studies related to smear layer removal were
conducted in straight wide root canal. Meanwhile, most
of the human teeth present some degree of curvature.
Achieving smear layer removal in a curved apical third is
difficult and challenging. A  continuous flow of irrigant
solution activated by an ultrasonic delivery system
was advised in order to produce a highly clean canal
surface.[10,35,45,136,137] Martin and Cunningham[138] advocated
the use of a biotechnological approach using ultrasound
in order to produce canal with effective debridement and
disinfection. This was achieved by a handpiece and an
instrument file that were both energized by ultrasound.
Their technique explained the highly intense magnitude and
velocity applied on endodontic file. Later, Ahmad et al.[139,140]
reported that the free movement of ultrasonic tip inside the
root canal produced an intense acoustic streaming effect
that enhances the cleaning efficacy and the direct physical
contact of the instrument to the canal walls may reduce
the effect. Lumley et al.[141] also showed the importance of
using a small‑sized instrument to maximize microstreaming
effect, leading to cleaner wall. Prati et al.[142] advocated that
the best smear layer removal was achieved with the use
of ultrasonic activation. A  recent study by Kowsky and
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Alamoudi: Smear layer
Naganath[143] concluded that the application of EndoVac
system could enhance smear layer removal at the apical
portion of curved canals.
Several studies showed the significant effect of ultrasonic
delivery system   with different irrigation solutions in
cleaning canal wall. Walker and del Rio[144,145] reported
no significant difference between the different types
of irrigation solutions. Tap water gives the same result
compared to NaOCl when used with  ultrasonic irrigation.
Cameron[18] showed that 2%–4% NaOCl irrigant with
ultrasonic energy can eliminate smear debris, compared
to other irrigations. Ahmad et al.[139] claimed that modified
ultrasonic instrumentation with low concentration of 1%
NaOCl removed smear layer debris more efficiently and
produced clean apical region. Yeung et al.[146] showed that
a combination of 5  mL of 17% EDTA with the endo
activator eliminated smear layer from a curved apical third
of root canals more efficiently.
Furthermore, Cameron[10] reported that the best time
period for removing smear layer using ultrasonic is 3–5‑min
activation compared to 1 min to ensure smear‑free canal
walls.
A recent systematic review and meta‑analysis done
by Virdee et al.[147] concluded that irrigant activation
techniques – passive ultrasonic irrigation, sonic
irrigation, apical negative pressure, and manual dynamic
activation – improve intracanal cleanliness and smear
layer removal compared to conventional needle irrigation.
Therefore, it is recommended to be used throughout
root canal preparation. However, no individual technique
showed superiority than another.
These findings were contradicted by other studies which
showed ultrasonic system’s inefficiency to eliminate smear
layer.[148‑150] Researchers who found the cleaning effects
of ultrasonic system to be effective used this technique
at the end of chemomechanical preparation and after
completion of hand instrumentation.[18,137,139] Moreover,
Baumgartner and Cuenin[151] reported that irrigation with
NaOCl and ultrasonic did not enhance smear layer removal
from root canal walls. Guerisoli et al.[152] also reported that
the use of ultrasonic irrigation did not add any additional
effect to smear layer removal and the use of 15% EDTAC
with either distilled water or 1% NaOCl was found to be
more effective to achieve the desired result. In addition,
a study by Ahmetoglu et al.[153] evaluated the effectiveness
of different irrigation devices, namely passive ultrasonic
irrigation, apical negative pressure irrigation (EndoVac),
and conventional needle irrigation systems on smear layer
76 Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019
removal. The results found that removal of smear layer
depends primarily on the solution used and not on the
irrigation system.
Laser removal
Lasers have many applications in dentistry. In endodontics,
it was used to eliminate the smear layer and vaporize tissues
in the main straight root canal till the apex.[154‑156] The
effectiveness of laser energy was based on several aspects
such as the anatomy of the root canal, power level of
the laser machine, the duration of exposure to laser light,
the absorption ability of dental tissues, and the distance
between the tip of the laser and the targeted tissue.[157‑160]
Although application of laser during endodontic treatment
is safe,[161] yet it has some limitations since it cannot access
small curved canal spaces with the large straight probes
that are provided.
D e d e r i ch e t   a l . [ 1 5 7 ] a n d Te w f i k e t   a l . [ 1 5 9 ] u s e d
neodymium–yttrium‑aluminum‑garnet  (Ne:YAG) laser
and showed that different changes occur on the surface
of dentin ranging from no effect to actual melting and
recrystallization of the underlying dentin. Takeda et al.
[154‑156]
advocated the use of erbium: YAG (Er:YAG) laser
to remove the smear layer. It resulted in effective smear
layer removal without causing any side effect to the dentin;
melting, charring, or vaporization that can be associated with
other types of laser. Kimura et al.[162] confirmed the positive
effect of using Er:YAG laser on the smear layer. Other
studies showed the use of different types of lasers such as
argon laser,[160,163] argon fluoride laser,[164] and carbon dioxide
laser.[158] They all give the same pattern of dentin disruption.
Moreover, Saraswathi et al.[165] reported that 940 nm diode
laser irradiation of root dentin along with NaOCl and
EDTA irrigation resulted in better removal of smear layer
without significant additional loss of mineral content. Yet,
another study[166] aimed to demonstrate the effectiveness
of different techniques and lasers on smear layer removal
using‑ NaOCl, 17% EDTA, MTAD, Nd:YAG, or Er:YAG.
They reported that smear layer removal by EDTA solution
demonstrated the best irrigation technique in all regions,
and the effect of EDTA was statistically significant in the
coronal and middle thirds only compared to MTAD. Thus,
although alternative materials and techniques were used to
improve smear layer debridement, still the combination of
EDTA and NaOCl remains the best technique.
THE EFFECT OF SMEAR LAYER ON THE
OUTCOME OF ROOT CANAL THERAPY
Violich and Chandler [167] concluded that removing
smear layer allowed for a more thorough cleaning and
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Alamoudi: Smear layer
disinfecting of root canal wall and better adaptation of
filling materials. Yet, there are no clinical trials to support
this. Until today, no study has shown the long‑term
outcome of the effect of removing smear layer. Only one
study by Nischith et al.[168] showed that smear layer removal
increases the long‑term apical seal and further success of
the root canal therapy, leading to improve the outcome.
Other clinical trials performed on primary teeth have been
found. The complex morphology of the root canal system
of posterior primary teeth and the close relationship of
the apex to the developing permanent tooth buds make
mechanical instrumentation alone difficult to eliminate
the infected tissue and microorganisms, especially in the
apical area to avoid damaging of the permanent tooth
bud.[169] For that, further investigation with randomized
controlled clinical trials should be performed to
demonstrate the effect of smear layer into the root canal
treatment outcome.
Indeed, there is little relevance attributed to the influence
of smear layer on clinical treatment outcomes and a major
lack of clinical studies to determine the role of smear
layer since all previous studies were carried out based on
laboratory. Further experimental model with a longitudinal
observational characteristic should be applied.
CONCLUSION
Upon mechanical root canal preparation, organic and
inorganic debris are formed and named smear layer. This
layer contains necrotic tissue and microorganisms that
overlay the canal walls. This layer limits the penetration
ability of disinfecting agents and intracanal medicaments
into the dentinal tubules and compromises the adherence
of filling materials to canal wall.
Different methods have been used to remove smear layer
including chemical, mechanical, and laser which were
applied aiming to enhance the cleaning effect to canal wall,
yet no single method has been obtained universally to clean
throughout the entire length of root canals. However, if
the smear layer is required to be eliminated, the ultimate
method to be used is sequential application of EDTA and
NaOCl solutions.
Conflicting studies exist with regard to the benefit
of maintaining or eliminating the smear layer before
filling root canals. The data presented demonstrate the
importance of removing the smear layer to enhance the
adaptation of filling materials and proper disinfection of
the canal system. Since new sealer and core materials have
recently been introduced, further researches are necessarily
Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019 77
to point out the role of the smear layer in the outcome of
treatment through conducting a clinical trial.
Moreover, it has been reported that using SEM to study
the smear layer is not trustworthy and reproducible. The
magnification used in different studies differed broadly,
making the result inconsistent.[170]
Further investigations should be conducted to determine
the effect of chelating solution on an uninstrumented canal
wall since there are 35% of dentin surface untouched after
mechanical instrumentation as reported by Peters et al.[171]
It is also important to understand the change that occurs
to the root dentin after the application of chelating agent.
Moreover, research about the thickness of demineralization
layer occurred by chelating agent is lacking and further
research is indicated in this field.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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