Basic Research—Technology
Effects of Endodontic Sealers and Irrigation
Systems on Smear Layer Removal after Post
Space Preparation
Xuan Chen,* Haixia Liu, MA,* Yuanli He,* Tao Luo,* and Ling Zou, PhD, MD*†
Abstract
Introduction: The aim of this study was to investigate
the effects of endodontic sealer types and ultrasound on
smear layer removal after post space preparation.
Methods: Thirty-six bovine incisors were chemome-
chanically instrumented and randomly divided into
3 groups (n = 12) according to the endodontic sealer
(AH Plus [Dentsply DeTrey, Konstanz, Germany],
Apexit Plus [Ivoclar Vivadent AG, Schaan, F€urstentum
Liechtenstein], or iRoot SP [Innovative Bioceramix, Van-
couver, BC, Canada]) used during root canal obturation,
and the groups were further subdivided randomly into 3
subgroups (n = 4) based on the post dowel irrigation
systems (ultrasound, regular rinse, or control) used.
The samples were examined under a scanning electron
microscope and were scored for debris and tubule open-
ings using a 3-scale grading system. The Friedman test,
Wilcoxon signed rank test, Kruskal-Wallis analysis, and
Mann-Whitney U test were used to statistically analyze
the results (a = 0.05). Results: Samples in the AH Plus
group were more easily debrided than those in the iRoot
SP group (P < .05). The best tubule opening condition
was presented in samples in the AH Plus group, whereas
those in the iRoot SP group presented the worst
(P < .05). The regular rinse and ultrasonic groups
were similarly good at smear layer removal and tubule
opening (P > .05) compared with the control group
(P < .05). The samples using AH Plus in combination
with ultrasound or syringe rinsing showed the best
cleaning result among all of the subgroups (P < .05).
Conclusions: AH Plus presented the easiest removal
from the post space, whereas iRoot SP presented the
most difficult removal. Ultrasound improved the clean-
ing efficacy of post dowels as did the regular rinse. (J En-
dod 2018;44:1293–1297)
Key Words
AH Plus, Apexit Plus, iRoot SP, post space preparation,
smear layer removal, ultrasonic irrigation
From the *State Key Laboratory of Oral Diseases, Sichuan University, Chengdu, China; †National Clinical Research Center for Oral Diseases, Department of Endodon-
tics, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
Address requests for reprints to Dr Ling Zou, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Endodontics,
West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China. E-mail address: zouling@scu.edu.cn
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.05.014
JOE — Volume 44, Number 8, August 2018
I ntraradicular posts are
generally required to
improve the retention of
Significance
Our study focused on observing whether the type
of endodontic sealers and post irrigation systems
an additional restoration
would affect the post space smear layer removal,
in endodontically treated
providing novel insights into the appraisal of
teeth having an extensive
different endodontic sealers and post space irriga-
loss of tooth structure
tion systems.
(1). Adhesively luted
fiber-reinforced compos-
ite posts exhibit good physiochemical properties and biocompatibility and are widely
used (1–5). Failure of adhesive luting fiber post restoration usually occurs because
of bond deficiencies (4, 5). The binding mechanism of the luting systems to the post
dowel dentinal walls is based on hybridization of the demineralized surface and on
resin tags and adhesive lateral branches formation (2). Many factors can affect this mi-
cromechanical procedure (5); among these, removing or modifying the smear layer
containing sealer and gutta-percha remnants (6) has been presumed to enhance the
micromechanical retention of resin cements (5).
It is well-known that endodontic sealers are used to obturate canal wall irreg-
ularities and seal the voids between gutta-percha and canal dentin (7). Different
types of root canal sealers have been introduced into the endodontic field (8).
AH Plus (Dentsply DeTrey, Konstanz, Germany) is an epoxy resin–based sealer
and presents high bond strengths to dentin (9). Calcium hydroxide–based sealer
exhibits alkalinity and sterilization ability (10). iRoot SP (Innovative Bioceramix,
Vancouver, BC, Canada) is a novel bioceramic-based sealer with favorable physio-
biological properties (9). Few parallel comparisons have been performed on the
effects of these types of sealer on post space smear layer removal. On the other
hand, ultrasound irrigation might enhance the dispersal of the irrigant and activate
it (11) and was presumed to be effective in smear layer removal (1, 12). The aim
of this study was to investigate the effects of endodontic sealer types and ultrasound
on smear layer removal after post space preparation.
Materials and Methods
Specimen Preparation
Thirty-six freshly extracted, anatomically similar bovine incisors with fully devel-
oped apical foramens were selected and stored in 0.02% buffered thymol solution. The
teeth were decoronated to standardize the root length at 15 mm. All the root canals were
manually enlarged up to #40 file size (Dentsply Maillefer, Ballaigues, Switzerland)
and were then instrumented up to F5 using ProTaper Universal rotary instruments
Smear Layer Removal after Post Space Preparation 1293
Basic Research—Technology
(F3-F4-F5, Dentsply Maillefer) according to the manufacturers’ instruc-
tions. All experimental operations were performed by the same practi-
tioner.
Root Canal Obturation
After instrumentation, the teeth were randomly divided into 3
experimental groups (n = 12) according to the sealer type used:
1. The AH Plus group (G-AH); obturate root canals with gutta-percha
and AH Plus
2. The Apexit Plus (Ivoclar Vivadent AG, Schaan, F€urstentum
Liechtenstein), calcium hydroxide–based sealer group (G-AP);
obturate root canals with F5 gutta-percha and Apexit Plus
3. The iRoot SP group (G-SP); obturate root canals with gutta-percha
and iRoot SP
All root canal sealers were mixed according to the manufacturers’
recommendations and were delivered into the canal using a spiral
spreader (#40 21 mm; MANI, INC, Tochigi, Japan). A main gutta-
percha point (Dentsply Maillefer) with a tip diameter of 0.5 mm
(#50) and a taper of .06 was inserted into the canal to the working
length. Additional gutta-percha points (#25.02 tapered, Dentsply Mail-
lefer) were introduced into the apical 5 mm of the canal using a #25
lateral condensation plugger (21 mm, MANI, INC) to reach an adequate
apical sealing for warm vertical compaction. After sealing of the apical
5 mm, the standard warm vertical compaction procedure was followed
to fill all the canals.
Post Space Preparation
After obturation, a Pesso reamer (#5 28 mm, MANI, INC) was
immediately applied to remove the coronal 10 mm of gutta-percha,
leaving 5 mm of the apical sealing untouched. Post space preparations
were completed with a #3 drill (3M ESPE; 3M Deutschland GmbH,
Neuss, Germany), resulting in a post space with a 1.9-mm diameter
at the coronal level.
Post Space Irrigation
After post dowel preparation, the specimens within each group
were then randomly subdivided into 3 subgroups (n = 4) according
to the irrigation system used:
1. The regular rinse subgroup (RR): the post space was rinsed with 5
mL 2% chlorhexidine (CHX) for 1 minute followed by rinsing with 5
mL 17% EDTA for 1 minute and a final rinse with 5 mL distilled water
for 1 minute. All rinse procedures were performed using 5-mL sy-
ringes and 23-G needles.
2. The ultrasonically irrigated (UI) subgroup: the post space was ultra-
sonically irrigated with 5 mL 2% CHX for 1 minute followed by ul-
trasonic irrigation with 5 mL 17% EDTA for 1 minute and a final
rinse with 5 mL distilled water for 1 minute using ultrasonic agita-
tion. All solutions were delivered by a 5-mL syringe and a 23-G nee-
dle and were activated by a size 25 ultrasonic K-file (Satelec Acteon,
Merignac France), which was driven by an ultrasonic device (P5-
Suprasson, Satelec Acteon) at a power setting of 6 according to
the manufacturer’s instructions.
3. The control subgroup (CT): the irrigants (CHX, EDTA, and distilled
water) were successively flushed into each canal and left in place for
1 minute. During irrigant replacement, paper points were used to
absorb the former irrigant from the canal.
1294 Chen et al.
Evaluation by Scanning Electron Microscopy
Longitudinal grooves along the buccolingual direction were
prepared in each specimen without penetrating the post space. The roots
were split into 2 halves with a chisel and a surgical hammer to expose the
dowel walls. The superior bisection of each pair was coded. The coded
halves were then dried in a desiccator for 24 hours, mounted on metallic
stubs, sputter coated with gold, and evaluated at the middle third
(9–10 mm coronal from the apex) under a scanning electron
microscope (Inspect F, FEI, Netherlands). Five serial microphotographs
of the dowel walls were recorded continuously at 1000 magnification
at 0.2-mm intervals and were rated by 3 blinded endodontic
practitioners separately according to the criteria modified from the
protocols of Guo et al (12) and Serafino et al (13). The amount of debris
was scored from 0 to 2 as follows: 0, no debris particles or the remnant
particles covered <25% of the canal walls; 1, few debris particles
(the covered area was evident in 25%–50% of the canal surface) and
a maximum particle diameter <20 mm; and 2, large amounts of debris
particles (the covered area was evident in >50% of the canal surface) or
a particle diameter $20 mm in any direction. The number of dentinal
tubule openings was scored from 0 to 2 as follows: 0, the open dentinal
tubules occupied >75% of the dentinal walls; 1, the open dentinal
tubules occupied 50%–75% of the dentinal walls; and 2, the open
dentinal tubules occupied <50% of the dentinal walls.
Before scoring, 50 photographs were randomly selected, and the 3
examiners were asked to assess the photographs together for calibra-
tion purposes; then, the 3 examiners worked individually to rank all
of the specimens, and for some specimens with less agreement levels,
the final scores were determined by consensus. For each photograph,
the mean debris and dentinal tubules opening scores were calculated.
Statistical Analysis
The Cohen kappa test was applied for the assessment of interexa-
miner agreement. The effects of sealer type and cleaning procedure on
post wall cleanliness were statistically compared using the Friedman
test, with a post hoc Wilcoxon signed rank test. For subgroup compar-
isons, Kruskal-Wallis analysis was used, with a post hoc Mann-Whitney
U test. All tests were 2 tailed at a significance level of 0.05. The data were
analyzed using SPSS software (Version 20.0; IBM Corp, Armonk, NY).
Results
The Cohen kappa test showed that good agreement was obtained
between examiners 1 and 3 (k = 0.742) and examiners 2 and 3
(k = 0.693). Excellent agreement was obtained between examiners 1
and 2 (k = 0.813).
Complete removal of the smear layer and debris was found in the
G-AH-UI group. Small areas of debris and moderate amounts of open
tubules were discovered in the G-AH-RR, G-AP-RR, and G-AP-UI groups.
All control groups and all samples in the G-SP group were covered by
large areas of smear layers, and open dentinal tubules could hardly be
found (Fig. 1). Distributions of the scores of debris and open tubules in
all the tested subgroups are presented in Figures 2 and 3, and
comparisons between groups are tabulated in Tables 1 and 2.
Generally, samples in the G-AH group were more easily debrided
than those in the G-SP and the G-AP groups (P < .01); the best tubule
opening condition was presented in samples in the G-AH group
(P < .05) followed by samples in the G-AP group (P < .05), whereas
those in the G-SP group presented the worst condition (P < .05). Samples
in the regular rinse and the ultrasonically irrigated groups exhibited
similarly (P > .05) good smear layer removal and tubule opening results,
which were better than that presented in the G-CT group (P < .01).
JOE — Volume 44, Number 8, August 2018
 Basic Research—Technology

Figure 1. Representative scanning electron microscopic photomicrographs showing the debridement and dentinal tubules opening results of all the tested groups
(1000). (A, D, and E) Small areas of debris and moderate amounts of open tubules. (B) Complete removal of the smear layer and debris. (C and F–I) Large areas
of smear layers and open dentinal tubules could hardly be found.
Statistical comparisons among the specific subgroups showed that lowed the order ultrasonic irrigation = regular rinse > control. Loss of
the samples using AH Plus in combination with ultrasound or regular retention is considered 1 of the most frequent failure types in post resto-
syringe rinsing showed the best cleaning result among all of the sub- ration (4, 14). The adhesive bond of the post to the dentinal walls
groups (P < .05) (Figs. 2 and 3). is based on the micromechanical retention created by the
demineralized surface and resin tag formation (15). However, drilling
a post space always creates a smear layer consisting of gutta-percha and
Discussion sealer remnants that cover the dentin surface (16); this makes it difficult
According to our current results, iRoot SP was the most difficult to
remove, whereas AH Plus was the easiest, and the cleaning efficacy fol-

Figure 3. Distribution of open tubules scores. Lines with * marks connect

Figure 2. Distribution of debris scores. Lines with * marks connect values that values that are statistically different. (*.01 < P < .05, **P < .01,
are statistically different. (*.01 < P < .05, **P < .01; Mann-Whitney U test). ***P < .001; Mann-Whitney U test).

JOE — Volume 44, Number 8, August 2018 Smear Layer Removal after Post Space Preparation 1295
Basic Research—Technology
TABLE 1. Comparisons Between Groups According to Debris Removal iRoot SP was the most difficult material to remove when compared
with the other materials appraised in this study. iRoot SP is a newly intro-
Mean ± SD
duced calcium phosphate silicate–based bioceramic sealer and is
Comparison First group Second group P value* known for its outstanding biocompatibility and bioactivity (9, 22).
G-AH  G-AP 1.38  0.89 1.73  0.67 <.01 This sealer type strongly adheres to the intracanal dentin, and its
G-AH  G-SP 1.38  0.89 1.88  0.42 <.001 bonding strength has been reported to be stronger than those of
G-AP  G-SP 1.73  0.67 1.88  0.42 >.1† some popular sealers (9, 22). The bonding strategy of this sealer is
G-RR  G-UI 1.62  0.72 1.38  0.90 >.06†
G-RR  G-CT 1.62  0.72 2.00 <.0001 to first interact with dentinal fluids and then create intrafibrillar
G-UI  G-CT 1.38  0.90 2.00 <.001 apatite deposits and form taglike structures within the dentin, which
lays a foundation for further bonding between the sealer and the
G-AH, AH Plus group; G-AP, Apexit Plus, calcium hydroxide–based sealer group; G-CT, control group; G-SP,
dentin surface (17). This strategy is even applied in the so-called mono-
iRoot SP group; G-RR, regular rinse group; G-UI, ultrasonically irrigated group; SD, standard deviation.
*The Wilcoxon signed rank test.
block concept in root canal obturation to completely eliminate interfa-
†
P > .05, no statistically significant difference.
cial gaps and produce perfect coronal and apical seals (23). We
supposed that this unique bonding strategy made it difficult to remove
iRoot SP from the post space in the current study. Although the single-
to etch the canal dentin, leading to deficient micromechanical retention
cone filling method in combined use with iRoot SP has newly raised
and eventually hindering fiber post adhesive bonding (13, 15, 16).
attention for its convenience (24), we chose warm vertical compaction
Hence, the dentin surface of the root canal needs to be effectively
to avoid unnecessary variables in this experiment.
cleaned before fiber post cementation (15).
Regarding irrigation techniques, ultrasound has been used as an
Endodontic sealers are known components of the smear layer and
auxiliary technique to enhance smear layer removal (12). Ultrasonic
can compromise fiber-post cementation (16). Because physicochem-
irrigation uses acoustic streaming effects, and the small ultrasonic oscil-
ical properties vary with sealer type, it remains controversial whether
lating file used in this system has been proven able to deliver irrigants
the type of endodontic sealer used affects the efficacy of smear layer
into the apical portion of the root canal; thus, ultrasonic activation is
removal during post space irrigation. AH Plus is an epoxy resin–
believed to be more beneficial to smear layer removal (11, 13).
based sealer that has been widely accepted as the gold standard sealing
However, some studies contradict the notion that ultrasonic irrigation
material (8, 17). Resinous sealers can form covalent bonds with the
has similar efficacy to that of conventional syringe rinsing (12, 15),
dentin collagen (17) and can easily penetrate to collateral canals and
and this was confirmed by the present study. The discrepancies might
dentinal tubules; thus, they are suspected to exert adverse effects on
be because of the different experimental designs used and the
post space cleaning and post retention (9). However, our experimental
nonuniform sizes of the irrigated spaces.
results showed that AH Plus was the easiest to remove after post space
CHX was chosen as the endodontic irrigant used in this study for its
preparation, confirming its excellence as a canal sealer.
credible antimicrobial effects, substantivity, and cytocompatibility (3, 16,
Calcium hydroxide–based sealers are widely used. Their alkalin-
25). Unlike sodium hypochlorite, CHX does not trigger the release of
ization property has been shown to be bactericidal, and the released cal-
oxygen, which can negatively affect resin polymerization; furthermore,
cium ions from the sealer components can trigger calcium carbonate
CHX does not interfere with the dentin constituents to induce collagen
crystal generation, which can consequentially stimulate mineralized tis-
denaturation, thus preserving the quality and integrity of the dentin
sue formation and may have potential clinical benefits (18, 19). Some
substrate (1, 2). Moreover, CHX is a broad-spectrum inhibitor of matrix
researchers have found that this type of sealer exhibits stronger
metalloproteinases and cysteine cathepsins in the hybrid layer (26) and
adhesion to dentin and speculated that it would be difficult to remove
can prevent endogenous proteolytic initiation and improve composite-
them from the dentinal walls (20); several other studies directly
dentin adhesive bonding durability (1, 3).
compared the effects of sealer type on the fiber post bond strength
According to Perdigao et al (27), the cervical portion of the root ca-
(10, 21), but these conjectures and results could not explicitly
nal is wider and always affords more access than the medium and apical
measure the performance of calcium hydroxide–based sealers when
thirds, making it easier for this portion to receive the treatment; this finding
it comes to post space cleaning. Furthermore, because the methodolo-
was corroborated by the study of Guo et al (12). On the other hand, the
gies used in these experiments differed, it was difficult to achieve a uni-
irregular structures and smaller number of dentinal tubules in the apical
fied and clinical beneficial result. Our study focused on observing
part of the root canal may hamper the cleaning and bonding process (4,
whether the calcium hydroxide sealer could be easily removed from
28). For these reasons, we chose the middle portion (9–10 mm from the
the dentinal walls, thus providing a new perspective from which to
apex) of the root canal to detect differences among the treated groups.
analyze the possible influences of sealers on the bond strength of posts.
We evaluated only cleanliness in this work, providing novel in-
sights into the appraisal of different endodontic sealers and post space
TABLE 2. Comparisons Between Groups According to Open Tubule Condition irrigation systems. However, further studies of the effects that these ma-
Mean ± SD nipulations may have on the direct bonding strength, longevity, and
thermal and mechanical fatigue of fiber-post adhesion are warranted.
Comparison First group Second group P value*
G-AH  G-AP 1.07  0.89 1.48  0.81 <.05
G-AH  G-SP 1.07  0.89 1.75  0.60 <.001 Conclusions
G-AP  G-SP 1.48  0.81 1.75  0.60 <.05 Within the limitations of this in vitro study, the following conclu-
G-RR  G-UI 1.32  0.79 1.13  0.95 >.2† sions can be drawn:
G-RR  G-CT 1.32  0.79 1.85  0.48 <.01
G-UI  G-CT 1.13  0.95 1.85  0.48 <.0001 1. AH Plus was the easiest material to remove from the post space.
G-AH, AH Plus group; G-AP, Apexit Plus, calcium hydroxide–based sealer group; G-CT, control group; G-SP, 2. Neither ultrasonic agitation nor regular rinse effectively removed iR-
iRoot SP group; G-RR, regular rinse group; G-UI, ultrasonically irrigated group; SD, standard deviation. oot SP from the dentinal walls of the post dowel.
*The Wilcoxon signed rank test. 3. Ultrasonic oscillation improved the smear layer removal after post
†
P > .05, no statistically significant difference. space preparation and was as effective as regular syringe rinsing.

1296 Chen et al. JOE — Volume 44, Number 8, August 2018


Acknowledgments
Supported by grants from the National Natural Science Foun-
dation of China (grant no. 81570974) and The Key Project of the
Science and Technology Department of Sichuan Province (grant
no. 2015JY0260). The authors deny any conflicts of interest related
to this study.
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