Basic Research—Technology
Efficacy of Different Final Irrigation Activation Techniques
on Smear Layer Removal
Shehab El-Din Saber, BDS, MSc, PhD, and Ahmed Abdel Rahman Hashem, BDS, MSc, PhD
Abstract
Introduction: Different techniques and irrigant delivery
devices have been proposed to increase the flow and
distribution of irrigating solutions within the root canal
system. The aim of this study was to compare smear layer
removal after final irrigant activation with apical nega-
tive pressure (ANP), manual dynamic agitation (MDA),
and passive ultrasonic irrigation (PUI). Methods: Forty
single-rooted human mandibular premolars were
decoronated to a standardized length of 16 mm. They
were cleaned and shaped by using ProTaper system to
size F4 and NaOCl 2.5%. The specimens were divided
into 4 equal groups (n = 10) according to the final irriga-
tion activation technique: group 1, passive irrigation (PI);
group 2, apical negative pressure (ANP) (EndoVac);
group 3, manual dynamic activation (MDA); and group
4, passive ultrasonic irrigation (PUI). Samples were split
longitudinally and examined under scanning electron
microscope for smear layer presence. Results: PI and
PUI had the highest smear scores, with no significant
differences between them. This was followed by MDA
and finally ANP, which showed the statistically signifi-
cant lowest mean score at P # .05. Conclusions: Final
irrigant activation with ANP and MDA resulted in better
removal of the smear layer than with PUI or PI. (J Endod
2011;37:1272–1275)
Key Words
EndoVac, irrigant activation, manual dynamic activa-
tion, passive ultrasonic irrigation, root canal irrigation,
smear layer
From the Endodontic Department, Faculty of Dentistry, Ain
Shams University, Cairo, Egypt.
Address requests for reprints to Dr Ahmed Abdel Rahman
Hashem, Endodontic Department, Faculty of Dentistry, Ain
Shams University, 79 Abou Bakr El-Sedeek St, Heliopolis, Cairo,
Egypt. E-mail address: endohashem@gmail.com
0099-2399/$ - see front matter
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.06.007
1272 Saber and Hashem
I rrigation is an essential part of root canal debridement. It allows for cleaning beyond
what might be achieved by root canal instrumentation alone (1, 2). It helps by killing
microorganisms, flushing debris, and removing the smear layer from the root canal
system (3). Smear layer prevents the penetration of intracanal medicaments into dentinal
tubules and influences the adaptation of filling materials to canal walls (4). It consists of
organic and inorganic substances, including fragments of odontoblastic processes,
microorganisms, their by-products, and necrotic materials (4, 5). The alternate use of
sodium hypochlorite (NaOCl), a deproteinizing agent, and ethylenediaminetetraacetic
acid (EDTA), a calcium-chelating agent, has been recommended for its efficient removal
(6, 7). These irrigants must be brought into direct contact with the entire canal wall for
effective action (8). During conventional needle irrigation, replenishment and fluid
exchange do not extend much beyond the tip of the irrigating needle (9, 10). Vapor
lock that results in trapped air in the apical third of root canals might also hinder the
exchange of irrigants and affect the debridement efficacy of irrigants (11). That is why
different techniques and irrigant delivery devices have been proposed to increase the
flow and distribution of irrigating solutions within the root canal system (12).
The EndoVac system (Discus Dental, Culver City, CA) is an apical negative pressure
(ANP) irrigation device designed to deliver irrigating solutions to the apical end of the
canal system and suction out debris (13). It has been shown to introduce a higher flow
of irrigant and produce better debridement 1 mm from working length when compared
with needle irrigation (14). In addition, this system has been shown to extrude less
irrigant and, therefore, have less risk of a NaOCl incident (15). Manual dynamic acti-
vation (MDA) has been described as a cost-effective technique for cleaning the walls of
the entire root canal. It involves repeated insertion of a well-fitting gutta-percha cone to
working length of a previously shaped canal. The gutta-percha cone is applied in short,
gentle strokes to hydrodynamically displace and activate an irrigant (16). Gu et al (12)
hypothesized that this technique might be useful in breaking the air bubble located at the
apical 0–2 mm of the canal. Passive ultrasonic irrigation (PUI) refers to an irrigation
protocol in the presence of an ultrasonically activated file, which is noncutting or con-
tacting the canal walls (17). It has been shown to be more effective than syringe needle
irrigation in removing pulpal tissue remnants and dentin debris (18, 19), bacterial
reduction (20, 21), and smear layer removal (22, 23).
The aim of this study was to compare smear layer removal after final irrigant acti-
vation with ANP, MDA, and PUI. The null hypothesis tested was that there is no difference
in smear layer removal by using different final irrigant activation protocols.
Materials and Methods
Selection and Preparation of the Specimens
Forty human single-rooted mandibular premolars with straight single canals and
mature apices extracted for orthodontic reasons were selected for this study. They were
stored at 4 C in saline supplemented with 0.02% sodium azide and used within 1 month
after extraction. To standardize canal instrumentation, the crowns were removed, and
the roots were adjusted to a standardized length of 16 mm. A closed canal system was
prepared according to Tay et al (11). The cementum of each root was coated with tray
adhesive. The root apex was covered with hot, flexible glue that was allowed to solidify
before the root was inserted into a clear polyvinylsilicone-filled Plexiglas tube. Working
length (WL) was set at 15 mm, and instrumentation was performed by using the Pro-
Taper rotary nickel-titanium system (Dentsply Maillefer, Ballaigues, Switzerland) until
JOE — Volume 37, Number 9, September 2011

finishing file #4 (40/0.6). During instrumentation, 1 mL 2.5% NaOCl
was used at each change of file.
Classification of the Specimens
Specimens were divided into 4 equal groups according to the tech-
nique used during final irrigation.
In passive irrigation group (PI), a final irrigation sequence of 5 mL
2.5% NaOCl, followed by 5 mL 17% EDTA, was used to remove the
smear layer. Solutions were delivered by a syringe and a 30-gauge nee-
dle (NaviTip; Ultradent, South Jordan, UT) that was inserted as deep
apically as possible without binding.
In ANP group, specimens were irrigated by using the EndoVac
system according to a modified protocol from that described by Nielsen
and Baumgartner (14), in which only 2 micro-irrigation cycles were
used, the first with 2.5% NaOCl and the second with 17% EDTA.
In MDA group, 2.5% NaOCl followed by 17% EDTA was each acti-
vated for 1 minute. The canals were flooded with the irrigant, and push-
pull strokes were performed manually to the WL by using a size 40/6%
taper gutta-percha cone at an approximate rate of 100 strokes per
minute for 30 seconds. Irrigation with 2.5 mL followed. This was
repeated for another cycle by using new gutta-percha, with total irriga-
tion volume of 5 mL.
In PUI group, 2.5% NaOCl and 17% EDTA were each activated for 1
minute by using #25/0.00 taper SS noncutting ultrasonic tip (IrriSafe;
Satelec, Acteon, Merignac, France) at 1 mm from the WL. The tip was
operated by a piezoelectronic unit (Pmax XS; Satelec) at power setting
5. The canal was irrigated with 2.5 mL after 30 seconds of ultrasonic
activation, with total volume of 5 mL per irrigant.
Finally, the specimens were irrigated with 5 mL sterile distilled
water, dried, temporarily sealed, and stored separately in labeled bottles
containing 10% formaldehyde as a fixative for any remaining soft tissue
debris.
Scanning Electron Microscopy Examination
Teeth were split longitudinally in a buccolingual direction accord-
ing to Parente et al (3), resulting in 20 specimens per group. Each spec-
imen was dehydrated in graded series of ethanol solutions, critical point
dried, mounted on stubs, gold-sputtered, and examined under scanning
electron microscopy (SEM) (Philips SEM 515, Eindhoven,
Netherlands). Three blinded observers scored the amount of remaining
smear layer at the coronal, middle, and apical regions of both root
halves of each specimen, with a 5-level score system described previ-
ously (24). The presence of smear layer was evaluated from images
at 1000 magnification by using the following scores: 1, smear layer
is completely absent; most tubules are patent and debris-free (coronal
third and middle third) or occluded with sclerotic casts (apical third);
2, smear layer covering >25% of the canal wall and dentinal tubules; 3,
smear layer evident in 25%–50% of the canal surface and tubules; 4,
smear layer evident in 50%–75% of the canal surface and tubules;
Basic Research—Technology
and 5, smear layer covering 75%–100% of the canal surface and
tubules. Two photographs were taken of each canal third of each spec-
imen.
Statistical Analysis
SEM images were assessed 3 times in random order by all
observers at 1-week intervals, each time without knowledge of the
previous results. Weighted coefficient kappa (Kw) was used to measure
interobserver reproducibility between observers separately for each
time period and to measure intraobserver reproducibility between
time periods separately for each observer. This was done to validate
the subjective findings. Data were presented as mean and standard devi-
ation (SD) values. Kruskal-Wallis test was used to compare between
final irrigation techniques. Mann-Whitney U test was used for pairwise
comparisons between techniques. Friedman test was used to compare
between root canal thirds. Wilcoxon signed rank test was used for pair-
wise comparisons between root canal thirds. The significance level was
set at P # .05. Statistical analysis was performed with SPSS 16.0 statis-
tical package for Windows (Chicago, IL).
Results
There was excellent intraobserver (Kw value, 0.96) and interob-
server (Kw value, 0.95) reproducibility for the smear scores.
Comparison between Irrigation Activation Techniques
As regards total mean scores of all canal thirds (Table 1), PI and
PUI had the highest smear scores, with no significant differences
between them. This was followed by MDA and finally ANP, which showed
the statistically significant lowest mean score.
At the apical and coronal thirds, PI and PUI had the highest smear
scores, with no significant differences between them. MDA and ANP
recorded the least smear scores, with no significant differences between
them.
At the middle third, PI had the highest smear scores, followed by
PUI and MDA, with no significant differences between them. Finally, ANP
had the statistically significant least smear scores. Figure 1 shows exam-
ples of smear layer removal in the coronal, middle, and apical thirds for
all groups.
Comparison between Canal Thirds
As regards intragroup comparison (Table 2), the highest scores
were recorded in the apical third, followed by the middle and the
coronal thirds, and this was observed in all groups.
Discussion
Currently, several techniques and systems are available and
reported to improve final irrigation before obturation (9). The aim of

TABLE 1. Means and SD Values and Results of Comparison between Smear Layer Scores for Different Activation Techniques
ANP MDA PUI PI

Segment Mean SD Mean SD Mean SD Mean SD P value

b b a a
Apical 1.43 0.51 1.89 0.33 3.58 1.00 3.50 0.71 <.001*
Middle 1.56c 0.63 2.00b 0.76 2.07b 1.07 2.50a 0.71 <.001*
Coronal 1.21b 0.43 1.17b 0.35 2.00a 0.39 2.00a 0.00 .007*
Total 1.38d 0.34 1.93c 0.22 2.29b 0.75 2.44b 0.51 <.001*
Means with different superscript letters are statistically different according to Mann-Whitney U test.
*Significant at P # .05.

JOE — Volume 37, Number 9, September 2011 Efficacy of Different Final Irrigation Activation Techniques on Smear Layer Removal 1273
Basic Research—Technology

Figure 1. Representative SEM micrographs showing selected samples from the apical, middle, and coronal segments representing the different irrigant activation
techniques. ANP (EV) group (A–C) showing a highly clean canal surface with patent dentinal tubules in the coronal and middle thirds, with little debris and some
smear plugs in the apical third. MDA group (D–F) showing similar findings in the coronal and middle thirds, with a high percentage of the canal wall covered by
a thin smear layer in the apical third. PUI group (G–I) showing a clean wall with few smear plugs in the coronal third, less patent tubules with more smear plugs in
the middle third, and a thick smear layer with few patent tubules in the apical third. PI group (K–M) showing similar findings in the coronal and middle thirds, with
more debris in the apical third.

this study was to compare the effectiveness of 3 techniques (ANP, MDA,
and PUI) that are different in their theory and mode of application.
In the current study, root canal instrumentation was performed
with rotary nickel-titanium instruments, which create significant smear
layers (5); this would be more challenging for the agitation techniques
tested. Apical preparation was extended to size 40/0.06 file to allow
adequate penetration of solutions to the apical third of each root canal
(25). An ex vivo closed-end canal model was used. It more accurately
simulates in vivo situations, in which there is possible gas entrapment
inside the root canal, and the tooth’s foramen and outer surface are
sealed by the periodontal ligament and further embedded in alveolar
bone (11). Irrigating times of 1 minute each for NaOCl and EDTA solu-
tions were selected after canal preparation, because this seemed clini-
cally practical (23). All solutions were refreshed after 30 seconds to
clear the debris and avoid exhaustion (26).
Results of this study showed that as regards total mean scores of all
canal thirds, PI and PUI had the highest smear scores, with no signifi-
cant differences between them. This was followed by MDA and finally
ANP, which showed the statistically lowest mean scores.
The relatively higher smear scores achieved with PUI might be due
to the size of the tip (25/00), which might be very small for these larger
canals (40/06). Also, the power setting used (5) might be weak to allow
a proper acoustic streaming with this small tip. This is in agreement with
Jiang et al (27), who found that a higher ultrasonic intensity results in

TABLE 2. Means and SD Values and Results of Comparison between Smear Layer Scores at the 3 Segments with Each Irrigant
ANP PUI MDA PI

Segment Mean SD Mean SD Mean SD Mean SD

a
Apical 1.56 0.51 3.58 1.00 1.89 0.33 3.50 0.71
Middle 1.43 0.63 2.07b 1.07 2.00 0.76 2.50 0.71
Coronal 1.21 0.43 1.17c 0.39 1.88 0.35 2.00 0.00
P value .121 <.001* .939 .156
Means with different superscript letters are statistically significantly different according to Wilcoxon signed rank test.
*Significant at P # .05.

1274 Saber and Hashem JOE — Volume 37, Number 9, September 2011

higher amplitude of oscillation and, consequently, enhances the clean-
ing efficacy of PUI.
The efficiency of MDA might be attributed to several reasons. The
first is the selection of gutta-percha cone that was corresponding to the
canal preparation size and taper. This ensured that air inside the apical
third of the canal was displaced by the gutta-percha cone when the latter
was inserted to WL. Second reason is the tapered canal preparation,
which gave reflux space, allowing the irrigating solution to flow up
and down along the cone, with the solution being displaced outward
when the cone is inserted at length and flowing inward when it is
removed (28). Third reason is changing the gutta-percha cones on
solution refreshment. This excluded the possibility of impregnation of
tissue debris on the gutta-percha cone surface and generation of
a new smear on repeated rubbing against the canal walls.
The EndoVac system’s effectiveness at producing clean dentinal
surfaces might be attributed to its ANP approach. Placement of the mac-
rocannula at middle–apical third of the canal, followed by the placement
of the microcannula to WL as recommended by the manufacturer,
enables the irrigant to be suctioned in sufficient volume and flow to
remove smear layers and displace debris. In addition, the orifices of
the microcannula provide a portal of exit for canal debris in closed-
end canal systems (3).
Results also showed that ANP and MDA had the lowest smear
scores in the apical third, with no statistical difference between them.
A possible explanation for this is that both techniques reach full WL
of instrumented canals and hence allow adequate irrigant replacement
(29), which is not possible or recommended with conventional needle
irrigation or ultrasonic agitation devices. This is in agreement with Tay
et al (11), who demonstrated clean instrumented canal spaces in the
presence of apical gas entrapment in a closed system with MDA and
ANP, and Susin et al (30), who found no differences in the percentage
of canal spaces occupied by debris between ANP and MDA at all canal
levels in a simulated closed canal system.
Although the ability of PUI to remove the smear layer has been
reported previously (22, 31), our results showed no difference
between PUI and PI. This is in agreement with other studies (32–34)
that demonstrated that PUI did not completely remove smear layers
from the apical third of canal walls.
The null hypothesis tested was rejected because differences were
found in smear layer removal after using different irrigant activation
protocols. Within the limitations of this study, it can be concluded
that final irrigant activation with ANP and MDA resulted in better
removal of the smear layer than with PUI or PI.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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