ARTICLE IN PRESS
Basic Research—Technology
Effectiveness of Different Final Irrigant Activation Protocols
on Smear Layer Removal in Curved Canals
Gregory Caron, DDS,* Khan Nham, DDS,† Francois Bronnec, DDS,* and Pierre Machtou, DDS*
Abstract
Introduction: A final flush with chelating agents and
antiseptic irrigating solutions is needed to remove the
smear layer. The improvement of these protocols is
possible by using specific delivery and agitation tech-
niques. This study examined the effect of different final
irrigation regimens and methods of activation on smear
layer removal in curved canals after root canal instru-
mentation. Methodology: Mesial root canals of 50 ex-
tracted mandibular molars were prepared using
ProTaper rotary files (Dentsply Maillefer, Ballaigues,
Switzerland) and 3% NaOCl. Teeth were then allocated
to two control groups and four experimental groups (n
T he ultimate goal of endodontic treatment is to control the microbial factor in
= 10) for final irrigation as follows: no-activation group
(final rinse with a 27-gauge needle and 17% EDTA/3%
NaOCl), manual-dynamic activation group (final rinse
17% EDTA/3% NaOCl + gutta-percha agitation),
automated-dynamic activation group (final rinse 17%
EDTA/3% NaOCl + RinsEndo [Dürr Dental GmbH & Co
KG, Bietigheim-Bissingen, Germany]), and sonic-
activation group (final rinse 17% EDTA/3% NaOCl + En-
doactivator [Advanced Endodontics, Santa Barbara,
CA]). All mesial roots were split with a new approach
to allow visualization of every third of the canal, partic-
ularly the apical third. The samples were prepared for
scanning electron microscopic observation to assess
the smear layer removal. Blind scoring was performed
by two calibrated observers using a five-score scale.
The differences in smear layer scores between the exper-
imental groups were analyzed with the Kruskal-Wallis
test and the Mann-Whitney U test. The level of signifi-
cance was set at p = 0.05. Results: Very high levels
of root canal cleanliness (#score 3) were found for
each test group with activation. For the middle and
apical third, the no-activation group was significantly
less effective than the three other activation groups (p
< 0.05). The manual-dynamic activation group (final
rinse 17%EDTA/3%NaOCl + gutta-percha agitation)
and the sonic-activation group (final rinse 17%EDTA/
3%NaOCl + Endoactivator) showed significantly better
smear layer removal (p < 0.05) in comparison with the
From the )Department of Endodontics and Restorative Dentistry, School of Dentistry, University, Paris, France; and †Department of Surface Physico-Chemistry,
ENSCP, Paris, France.
Supported in part by the Association de formation en Endodontie Appliquée.
Address requests for reprints to Dr Gregory Caron, 5 rue Garanciere 75006 Paris , France. E-mail address: greg.hypomoclion@gmail.com.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.03.037
JOE — Volume -, Number -, - 2010
other test groups in the apical third. Conclusion: Root canal cleanliness benefits
from solutions activation (especially sonic activation and manual-dynamic activation)
in comparison with no activation during the final irrigation regimen. (J Endod
2010;-:1–6)
Key Words
Automated-dynamic activation, final irrigation, manual-dynamic activation, smear
layer, sonic activation
complex root canal anatomy, especially in the apical one third (1). This objective
is achieved by combining instrument-based preparation (manual or mechanical)
with antiseptic irrigating solutions followed by three-dimensional obturation of the
root canal system. The gold standard irrigant is still sodium hypochlorite, which can
be associated with EDTA to offer bactericidal, solvent, and chelating actions all in
one. This combination offsets the drawbacks of the instrument-based preparation,
particularly the creation of debris (2) and the smear layer (3). The smear layer is poten-
tially infected, and its removal allows more efficient penetration of intracanal medica-
tions into the dentinal tubules and a better interface between the filling material and the
root canal walls (4).
The literature reports generally show that regardless of the instrumentation and
irrigation techniques, the effectiveness of irrigating solutions remains limited in the
apical one third of a prepared canal. This is particularly true for curved root canals
(5, 6) and even on single-rooted teeth (7, 8). Therefore, the improvement of
irrigating protocols is essential during root canal treatment in order to achieve
better cleaning efficiency especially in the very complex apical area.
Currently, several techniques and systems are available and reported to improve
final irrigation before obturation (9). Among these protocols passive ultrasonic irriga-
tion has shown promising results on debris (10) and smear layer removal (11).
However, there are little published scientific data comparing the new and
emerging devices and methods for disinfection with a conventional syringe irrigation.
First, a fully tapered and apically trimmed nonstandardized gutta-percha master cone
could be used in a well-prepared canal as a cost-effective mechanical agitator. A gentle
pumping with short vertical strokes has been shown to promote disinfection (12, 13).
Another recently released device, the RinsEndo irrigation system (Dürr Dental GmbH &
Co KG, Bietigheim-Bissingen, Germany), delivers solutions at a flush-through rate of 6.2
mL/min using pressure-suction technology for intracanal activation (1.6 Hz). This
device generates a mechanical action that is able to produce a hydrodynamic exchange
circuit (13, 14). Finally, the Endoactivator system (Advanced Endodontics, Santa
Barbara, CA) has been purported to improve disinfection. This device uses
Final Irrigant Activation Protocols for Smear Layer Removal in Curved Canals 1
 ARTICLE IN PRESS
Basic Research—Technology
a cordless sonic handpiece to activate strong, highly flexible polymer
tips. Noncutting tips have tapers and terminal diameters that closely
match the dimensions of the final root canal preparation (15). Mechan-
ical oscillations are produced mainly at the tip of the activator with
a frequency ranging from 1 to 10 kHz.
The purpose of this study was to assess smear layer removal effi-
ciency after using gutta-percha master cone or RinsEndo or the Endoac-
tivator in comparison to conventional final irrigation using a 27-gauge
needle. The null hypothesis was that there is no difference in smear layer
removal between final irrigation with no activation and final irrigation
with activation.
Materials and Methods
The study was conducted on 50 freshly extracted mature human
mandibular molar teeth with two separate mesial canals. None of the
teeth had received restorative or endodontic treatment before extrac-
tion. After extraction, the teeth were conserved in a solution of physio-
logic saline to avoid damaging the pulp tissue and then stored at 4 C
(16). Each individual tooth was then photographed and x-rayed to visu-
alize the root canal anatomy and confirm that each canal curved at more
than 20 (17).
After cutting a four-wall access cavity, the full lengths of the mesio-
buccal and mesiolingual canals were determined when a #08 K-type file
could be visualized at the apical foramen. Both the mesial and distal
roots were sealed with melted wax to close the apical foramen (18).
The aim was to prevent the irrigants from escaping through the apex
in order to simulate in vivo conditions (19). The two mesial root canals
were prepared using the Protaper Universal rotary files system (Dents-
ply Maillefer, Ballaigues, Switzerland) following the protocol described
by Machtou and Ruddle (20) in which the apical one-third taper of the
finished preparation is approximately 10%. All the canals were
prepared so that the finished size of each apical foramen ranged
between 0.20 mm and 0.30 mm in diameter. A medium nonstandar-
dized gutta-percha master cone (Henry Schein, Melville, NY) was fitted
in each canal to the full working length, and then the tooth was x-rayed.
After each instrument, the expending preparation was flooded by
passively irrigating 0.5 mL of 3% sodium hypochlorite (Parcan; Septo-
dont, Saint-Maur-des-Fosses, France) into the canal using a 27-gauge
needle (Monoject; Tyco Kendall, Hampshire, UK) loosely inserted as
far as possible without binding. A #10 K-type patency file was used to
maintain apical patency and move debris into suspension followed by
flushing the canal again with 0.5 mL of fresh irrigant. All procedures
were performed by the same operator (GC).
The teeth were randomly divided into four experimental groups (n
= 10) and two control groups. The negative controls (n = 5) received
no final irrigation regimen after fitting of the master cone. The positive
controls (n = 5) were immersed for 5 minutes in a bath of 17% EDTA
followed by an immersion for 5 minutes in a bath of 3% NaOCl after the
splitting process.
Final Irrigation Protocols
No-activation Group. After suctioning away the intracanal surplus
of NaOCl with the 27-gauge needle, 1 mL of 17% EDTA (Largal Ultra;
Septodont, Saint-Maur-des-Fossés, France) was flushed into each canal
and was left in place for 1 minute per canal. All canals were then flushed
with 3 mL of 3% sodium hypochlorite, which was left in place for 30
seconds per canal.
Manual-dynamic Activation Group. After suctioning away the
intracanal surplus of NaOCl with the 27-gauge needle, 1 mL of 17%
EDTA was flushed into each canal. This solution was activated by using
a gutta-percha cone as previously described for 1 minute in each canal.
2 Caron et al.
The frequency of activation used was 100 push-pull strokes per minute
(12). The canals were then flushed with 3 mL of a 3% solution of
sodium hypochlorite. This solution was then activated for 30 seconds
per canal using the pumping master cone method.
Automated-dynamic Activation Group. After optimally
preparing the canal, surplus NaOCl was suctioned away with the
27-gauge needle. Following the manufacturer’s instructions, each canal
was flushed with 1 mL of 17% EDTA using the RinsEndo system for 1
minute per canal. Each canal was then flushed with 3 mL of a 3% solu-
tion of sodium hypochlorite delivered via the RinsEndo system for 30
seconds in each canal.
Sonic-activation Group. After optimally preparing the canal,
surplus NaOCl was suctioned away with the 27-gauge needle. Each canal
was then irrigated with 1 mL of 17% EDTA using the 27-gauge needle.
This intracanal solution was activated with either a red (25/04) or blue
(35/04) EndoActivator tip at a speed of 10 kHz for 1 minute per canal.
Each canal was then flushed with 3 mL of 3% sodium hypochlorite. This
solution was then activated using either the red or blue EndoActivator tip
for 30 seconds per canal.
After activation, the action of the sodium hypochlorite was stopped
by syringing in 3 mL of physiologic saline solution per canal (ie, 6 mL for
each tooth in the four test groups). All the samples were then placed in
a solution of physiologic saline and stored at 4 C until proceeding with
the sectioning protocol.
Sectioning of the Teeth and Preparation for SEM
The teeth were sectioned in two halves; only the mesial root was
kept for further study. Two horizontal grooves were made using a Frios
diamond-cutting disk (Microsaw; Dentsply Friadent, Mannheim,
Germany) mounted on a surgical dental handpiece to separate the
mesial root into thirds (the apical third, the middle third, and the
coronal third). This step was performed using a surgical microscope.
Colored gutta-percha cones were fitted and used as markers to best
gauge groove depth. The objective was to avoid any intrusion of the
cutting disc into the canals, which would pollute the samples by splat-
tering cutting debris into the root canal system. To avoid any contami-
nation, coronal thirds were discarded because there was a bigger gap
between the gutta-percha markers and the prepared walls of the canal.
This gap compromised vision and increased the possibility of the cutting
disc inadvertently introducing debris into this region of the canal.
The apical and middle one thirds of the canal were then
sectioned in the longitudinal plane with a precision diamond bur
(889 Model; Komet, Paris, France). A continuous supply of air was
delivered to improve vision and cutting precision, which eliminated
the potential of introducing debris into this region of the canal.
Each third was vertically split by applying slight pressure to an enamel
chisel into the longitudinal groove. Each sample was dehydrated in
graded series of ethanol solutions, critical point dried, coated with
gold, and viewed with a scanning electron microscope (Hitachi
S2500,Verrieres-le-buisson, France) at 15 kV (Fig. 1).
SEM Evaluation and Statistical Analysis
Each fragment was first viewed at low magnification (30) by the
operator (GC) and another trained dentist with SEM studies (KN) in
order to gain an overview of the sample. Image acquisition on the
most typical zones of the sample was performed at a magnification of
1,000 to assess the presence of smear layer. The images were blindly
assessed by two practitioners with no inside knowledge of the operative
procedures and who were fully conversant with qualitative analysis on
root canal images produced by scanning electron microscopy (PM,
FB). Analysis began using the scale described in Hülsmann et al
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 ARTICLE IN PRESS
Figure 1. Four different apical sample fragments highlighting the reproducibility and preservation of the apical one-third samples using our experimental protocol.
Magnification: 30.
(21), but the significant lack of sensitivity in the best scores prompted
us to refine the system, as follows (Fig. 2): score 1: no smear layer and
dentinal tubules open, score 2: small amounts of scattered smear layers
and dentinal tubules open, score 3: thin smear layer and dentinal
tubules partially open (characteristic image of crescent), score 4:
partial covering with a thick smear layer, and score 5: total covering
with a thick smear layer.
First, the full set of samples was independently evaluated by two
observers (PM and FB). If there were conflicting results between these
two observers, then a final evaluation was made with the lower score
chosen every time. Nonparametric data were analyzed by using the
Kruskal-Wallis test and the Mann-Whitney rank sum test for pairwise
comparisons. The significance level for all statistical analyses was set
JOE — Volume -, Number -, - 2010
Basic Research—Technology
at a = 0.05. All statistical analyses were performed with the SPSS for
Windows 12.0 software package (SPSS Inc, Chicago, IL).
Results
After consensus was reached for each group, mean scores for
smear layer removal in the apical third and the middle third were listed
(Table 1). The full set of negative control samples scored a 5 with
a complete covering of a thick smear layer. All the positive control
samples scored a 1 with no visible smear layer. In the middle third,
comparisons between each group showed a statistically significant
difference (p < 0.005). When comparing each test group, only the
‘‘no-activation group’’ scored a 3 with a thin smear layer and showed
Final Irrigant Activation Protocols for Smear Layer Removal in Curved Canals 3
 ARTICLE IN PRESS
Basic Research—Technology

Figure 2. A new fine-tuned scale used to evaluate sample cleanliness. Magnification: 1,000.

a statistical difference with the three other activation groups (p < 0.05) group, the ‘‘sonic group’’ (final irrigation + Endoactivator) showed
in which smear layer scores were always inferior to 3. a statistical difference compared with all the test groups (p < 0.05).
Comparisons between each group showed a statistically significant The exception was the ‘‘manual-dynamic activation group’’ (final irriga-
difference (p < 0.005) in the apical third. When comparing each test tion + gutta-percha agitation) in which no statistical diffence was

4 Caron et al. JOE — Volume -, Number -, - 2010

 ARTICLE IN PRESS
TABLE 1. Mean Score  Standard Deviation Comparing the Smear Layer
among the Four Final Irrigation Regimens in the Apical and Middle Thirds
Group N Apical third Middle third
Final irrigation without 10 3.16 0.958 3.470.874
activation
Final irrigation + 10 2.21 1.032 2.05 1.05
Master cone
Final irrigation + 10 3 1.414 2.5 1
Rinsendo
Final irrigation + 10 1.75 0.55 1.88 0.857
Endoactivator
detected. However, only the Endoactivator group showed smear layer
removal lower than a score 2, which equates to a high level of cleanli-
ness in all apical one-third samples.
Discussion
The endodontic community is now unanimous concerning the
positive benefit of irrigation during the root canal preparation phase
(22). The chemomechanical preparation should ideally result in a fully
cleansed and disinfected root canal system. Literature has shown that
apical enlargement and deeper positioning of the irrigation needle
are required to clean the apical third (5, 23, 24). However, very little
data exist regarding smear layer removal, especially in molar teeth
exhibiting curved canals where emphasis was placed on preparing
a fully tapered and well-shaped canal with narrow apical diameters.
Only one recent SEM study by Khademi et al (25) has shown the
importance of the canal taper in curved canals. When the root canal
taper was 0.06 mm/mm, there was comparable smear layer removal
when the apical diameters were between 0.30 mm and 0.40 mm. It
has been shown that for more narrow apical diameters the taper needs
to be increased to 0.10 mm/mm in order to eliminate a maximum
amount of debris (26, 27).
A recent study on curved roots has shown a correlation between
creating sufficient taper and propagation improvement of irrigants in
root canal during the shaping process (28). In the present study, all
the shaping procedures complied with the criteria of tapered canals
and maintaining apical foramen as small as practical. In funnel-
shaped canals, both the tapered gutta-percha master cones and the
tapered EndoActivator tips, when activated, provided cleaner results
than syringe delivery systems (final irrigation with no activation and Rin-
sEndo).
In this study, the four-wall access cavity provided a strategic reser-
voir to hold a more effective volume of irrigant for exchange during acti-
vation. This is in direct contrast with many studies in which the crown
had been removed from the samples. Desirably, the irrigating solutions
are apically exchanged each time the activator system is inserted into the
canal. When the activator tip moves toward length, the reagent is dis-
placed. When the activator is partially withdrawn, there is an effective
exchange of solution into the apical one third of the canal. The efficiency
of this hydrodynamic circuit is further enhanced when combined with
sonic oscillating movements. A pumping action synergistically
combined with mechanical agitation explains the better results achieved
with the EndoActivator. Recently, Uroz-Torres et al (29) found no differ-
ence in smear layer removal between the Endoactivator and conven-
tional Max-I-Probe (Dentsply Rinn, Elgin, IL) irrigation using NaOCl
and EDTA. The difference in results is attributed to differences in the
activation protocols used. In our present study, a second activation
was performed after the final flush with NaOCl, and all apical one-
third samples were shaped to 10% to enhance irrigation exchange
and efficiency (30).
JOE — Volume -, Number -, - 2010
Basic Research—Technology
So far, activation of irrigants without concomitant instrumentation
of the root canal walls has been defined as passive ultrasonic irrigation
(PUI) (9). PUI has been shown to be effective in removing debris (10)
and smear layer in straight canals (31). Nevertheless, there are conflict-
ing results about the performance of PUI in terms of smear layer elim-
ination (9, 32). Even when ultrasonically driven metal canula or
instruments are precurved, there are obvious considerations and
limitations using these devices in curved canals and to length (9,
33). There is always a risk of touching the walls, which would
automatically trigger the formation of a new undesirable smear layer.
Of greater concern, contacting a dentinal wall with an activated
ultrasonic instrument invites iatrogenic events. This should be
contrasted with the nonmetal surfaces of the activation systems used
in this study (gutta-percha or polymer), which cannot generate
a smear layer, internal ledge, or external transportation of the foramen.
It should be noted that all of the samples tested by manual-dynamic
irrigation or by sonic activation yielded very little smear layer. This level
of cleanliness is an important finding because it was achieved on curved
canals using activation systems other than metal ultrasonic files.
Although these systems generate lower frequencies compared with
the ultrasonically driven files (25-30 kHz), the vertical-stroke pumping
motion used as part of the protocol promotes dynamic coronoapical
circulation of the irrigating solutions. The benefit of irrigant renewal
and activation needs to be researched in greater detail, comparing
this irrigation dynamic with the streaming pattern observed with PUI.
Our experimental model used final irrigation times (34) and final
irrigation volumes that proved effective and efficient (35) while at the
same time avoiding peritubular and intertubular erosion. However,
the timeframe given in the protocol may not be long enough for a system
such as RinsEndo, which may require more time to achieve the same
scores as the other activation systems. During the shaping procedures,
the volume of 1 mL of irrigant dispensed after the use of each file was
sufficient to get a clear solution inside the pulp chamber without visible
debris.
The data gathered through this experiment are transposable to
clinical practice because the experimental model proposed closely
mirrors the actual conditions encountered in routine molar treatment,
but results should be interpreted with precaution because of the large
standard deviation observed. One possible explanation could be the
challenge of standardizing activation procedures in complex anatomy
of mandibular molars where the two mesial canals commonly commu-
nicate along their lengths.
Conclusion
The experimental design implemented in this study prompted the
following observations: the activation of irrigating solutions yielded
cleaner canals compared with no activation, and a tapered activator
that closely adapts to the dimensions of a shaped canal is the most effec-
tive (ie, the master gutta-percha cone and Endoactivator). Further
investigations will be required to confirm this preliminary data, partic-
ularly in terms of biofilm removal and apical disinfection results.
Acknowledgments
The authors are grateful to Du¨rr Dental for loaning the Rin-
sEndo device used in this experiment. The authors thank Dr C.
Ruddle and Advanced Endodontics for loaning the Endoactivator
device used in this experiment. The authors also thank Septodont
for providing the irrigating solutions Parcan and Largal Ultra
used in this experiment.
Final Irrigant Activation Protocols for Smear Layer Removal in Curved Canals 5
 ARTICLE IN PRESS
Basic Research—Technology
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