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www.eda-egypt.org • Codex : 82/1801
I.S.S.N 0070-9484
Fixed Prosthodontics, Dental materials, Conservative Dentistry and Endodontics
EGYPTIAN
DENTAL JOURNAL
Vol. 64, 457:465, January, 2018
* Assistant Professor of Endodontics, Faculty of Dentistry, Suez Canal University, Ismailia, Egypt
** Assistant Professor of Endodontics, Faculty of Dentistry, Ahram Canadian University, Giza, Egypt.
INTRODUCTION
Root canal therapy includes the use of
instruments in combination with irrigating
solutions in order to eliminate bacteria from lumen
of the pulp. Although instrumentation reduces the
number of microorganisms (1), it generates a layer
of organic and inorganic residues covering the root
canal known as smear layer. The smear layer is a
rough coating containing pulp tissue, odontoblastic
process, necrotic debris, microorganisms (2). Despite
the controversy over keeping or maintaining the
smear layer, it has been revealed that the smear
layer might be infected and keep the bacteria inside
the dentinal tubules. This layer has also been shown
to prevent the diffusion of intracanal medications
and irrigants into dentinal tubules (3).
A COMPARATIVE STUDY TO EVALUATE THE EFFECT OF
DIFFERENT IRRIGATING SOLUTIONS ON THE SMEAR LAYER
Hayam Y. Hassan * and Ahmed M. Negm**
ABSTRACT
Aim: This study compared the capability of Biopuer MTAD, QMixTM2in1, 17% EDTA, 6.25%
Morinda Citrifolia juice, 2% Nano-Chitosan, 2% Chitosan, 2% Chlorhexidine and distilled water
in smear layer removal.
Methods: eighty extracted premolars having single root canals were distributed into eight
groups allocated to the nal irrigant used. Roots were separated in bacco-lingual direction into two
equal halves then analyzed using Scanning Electron Microscope (SEM) at the coronal, middle, and
apical parts.
Results: In the coronal and middle parts of the roots the Biopure MTAD showed the highest
mean values of smear layer elimination, followed by 17% EDTA, QMixTM2in1, and then 6.25%
MCJ. While 2% nano-chitosan, 2% chitosan, 2% CHX and distilled water showed the least mean
values of smear layer elimination. The capability of smear layer elimination decreased in the apical
third for Biopuer MTAD, 17% EDTA, QMixTM2in1and 6.25 % MCJ. It was only inhibited with 2%
nano-chitosan, 2%chitosan, 2% CHX and distilled water.
Conclusion: the study concluded that Biopuer MTAD had the highest mean value for smear
layer removal in middle, coronal and to a lesser degree in apical thirds.
KEYWORDS: Smear layer, Biopuer MTAD, QMixTM2in1, EDTA, Chitosan.
(458) Hayam Y. Hassan and Ahmed M. NegmE.D.J. Vol. 64, No. 1
Sodium hypochlorite (NaOCl) followed by
EDTA has an effect in eliminating pulpal tissue
remnants and components of smear layer (4). Biopure
MTAD shown promise action in smear layer
elimination (5). However, the antimicrobial efcacy
and substantivity of this irrigant combination has
been challenged (6). Biopure MTAD is also relatively
ineffective against E. faecalis biolms (7) which are
more resistant to antimicrobial medications. It is
effective in eliminating canal wall smear layers but
demineralizes intraradicular dentin (8). QMixTM2in1
irrigating solution is also a mixture of endodontic
irrigant containing EDTA, chlorhexidine gluconate,
and a non-specied detergent that might give the
action of 17% EDTA (9).
The main drawbacks, safety property, and
ineffectiveness of most of the synthetic irrigating
solutions to mainly clean root canals advise that
neith ofer of these irrigating solutions are perfect.
At this time, few natural fruit juices that might be
used complementary to NaOCl or Chlorhexidine
(CHX) as applicable irrigants. Morinda Citrifolia
juice (MCJ) has therapeutic and antimicrobial
properties (10), suggesting that it is effective to be
used as an endodontic irrigant.
The limitations of current disinfectants have
prompted researchers to look for new alternatives.
Chitosan, is a nontoxic cationic natural biopolymer
that is obtained through the alkaline deacetylation
process of chitin. This biopolymer possesses activity
against many fungi and bacteria (11). Antibacterial
nanoparticles, like nano-chitosan, have a signicant
antibacterial activity when compared with other
antibacterial powders. This is due to a wide surface
area and charge density that enables it to react with
the negative charge surface of bacterial cell walls,
lead to bacterial cell death (12).
This study compared the capability of Biopuer
MTAD, QMixTM2in1, 17% EDTA, 6.25% Morinda
Citrifolia juice, 2% nano-chitosan, 2% Chitosan,
2% Chlorhexidine and distilled water for smear
layer removal.
MATERIALS AND METHODS
Ethical clearance was taken before starting the
study. Eighty extracted human premolars with
single root canal were collected. Teeth with cracks
or fracture lines were eliminated after examining
using loops. The teeth were cleansed and kept in
saline solution.
The working length was adjusted to 17 mm
using a diamond disk (D&Z, Darmstadt, Germany).
The root canals were accessed and the initial
standardized crown down technique for coronal
preparation was done with Gates-Glidden drills
(Dentsply Maillefer, Ballaigues, Switzerland) up
to size 4. Sequentially K les (Dentsply-Maillefer,
Ballaigues, Switzerland) were used up to size 40
for apical preparation with 2.5% NaOCl irrigation
(Oxford Laboratory, Mumbai, India), followed by
washing with 5 ml of saline. The samples were
distributed into eight groups (n= 10) matching to the
nal irrigation used.
• Group 1: Biopure MTAD (Dentsply Tulsa
Dental Specialties, Tulsa, OK).
• Group 2: QMixTM2in1 (Dentsply Tulsa Dental
Specialties, Oklahoma, USA).
• Group 3: 17% EDTA (ethylene diamine
tetracetic acid) (Prevest Denpro Limited
Company Jammu, India).
• Group 4: 6.25% Morinda Citrifolia (NONI)
Juice (MCJ) (Dynamic Health Laboratories,
Inc. Brooklyn, USA).
• Group 5: 2% Nano-Chitosan (Nano Tech,
Dream Land, Egypt).
• Group 6: 2% Chitosan (Nano Tech, Dream
Land, Egypt).
• Group 7: 2% Chlorhexidine gluconate (CHX)
(El Nasr Pharmaceutical Chemicals Company,
Egypt).
• Group 8: Distilled water (control).
THE EFFECT OF DIFFERENT IRRIGATING SOLUTIONS ON THE SMEAR LAYER (459)
Chitosan was prepared by deacetylation of the
chitin, which forms the exoskeleton of crustaceans.
Dissolving the high molecular weight chitosan
powder in 1% acetic acid solution to form a 2%
chitosan solution. For preparation of 2% nano-
chitosan, add 2% chitosan solution to thirty percent
of H2O2 (hydrogen peroxide) aqueous solution in
the ratio of 1:100. The reaction was done at 60oC,
regulating the solution to pH 8. Formed solution
was centrifuged at pH 7 using deionized water. The
formed paste was freezed, thawed at 60oC. Then,
milled the chitosan in TJH-2-4L multidimensional
swipe nano-ball-mill with a driving motor of 7 kW.
1% acetic acid was added to nano-chitosan, then
stirred for 2 h using a magnetic stirrer till crystalline
homogeneous solutions with 3.2 pH formed(13, 14).
For group 1: each root canal was irrigated with
freshly prepared Biopure MTAD according to
manufacturer instructions, 1 ml as an initial rinse
and soaked for 5 minutes. A nal wash was done
using 4 ml for each canal. Finally, each root canal
was washed by 5 ml of distilled water and dried
with sterile paper points.
For the other groups from 2 to 8, root canals were
irrigated with 5 ml for 2 minutes of each freshly
prepared and standardized irrigant corresponding to
each group according to manufactures instructions.
Irrigants were delivered into the root canals with
Max-I-Probe, a side vented endodontic irrigating
needle (Dentsply-Rinn, Elgin,IL) until the working
length using manual technique. Finally, each root
canal was washed with 5 ml of distilled water and
dried with sterile paper points.
All the root canals were sectioned in the bucco-
lingual direction using diamond discs to make deep
grooves on the external root surfaces. Then the
grooves were split using chisel and mallet.
The specimens were dehydrated by ethyl alcohol
then mounted on coded stubs, air dried, placed in a
vacuum and coated with a 300 A gold coat for one
half of each root. The specimens were then examined
and photographed using Scanning Electron
Microscope (SEM) (JEOL JXA-810, Technics Co.,
Tokyo, Japan). The dentine surfaces were observed
and photographed at the coronal, middle, and
apical parts at X 1000 magnication. The presence
or absence of smear layer and visualization of the
dentinal tubules. The scores were directed to the
rating system established by Madison and Hokett
1997 (15)
:
0- No, no removal of smear layer, no dentinal tu-
bules visible.
1- Partial, partial removal of smear layer, some
dentinal tubules visible.
2. Complete, complete removal of smear layer, all
dentinal tubules visible.
The data obtained were statistically analyzed.
RESULTS
Kruskal Wallis analysis of variance was used
for intragroup comparison. The mean rank values
recorded that there was a signicant difference
among the tested irrigants in smear layer elimination
in the coronal, middle and apical thirds (P< 0.05). For
the coronal and middle thirds of the roots, Biopure
MTAD showed the highest mean value of smear
layer elimination, followed by 17% EDTA then
QMixTM2in1, (they were almost equal) followed by,
6.25% MCJ. While 2% nano-chitosan, 2% chitosan,
2% CHX and distilled water showed the least mean
values of smear layer elimination. The capability of
smear layer elimination decreased in the apical third
with Biopure MTAD, 17% EDTA, QMixTM2in1 and
6.25% MCJ. It was inhibited for 2% nano-chitosan,
2% chitosan, 2% CHX and distilled water, as shown
in (Table 1) and Figs. (1-8)
(460) Hayam Y. Hassan and Ahmed M. NegmE.D.J. Vol. 64, No. 1
TABLE (1) Mean Rank values of smear layer removal at the coronal, middle and apical thirds of all the
tested solutions.
Tested solutions
Mean Rank1
Coronal Middle Apical
Biopure MTAD 65.00 66.15 66.35
QMixTM2in1 59.80 64.30 64.80
17% EDTA 62.40 64.30 64.80
6.25% MCJ 36.85 30.25 28.05
2% Nano-Chitosan 31.80 24.75 25.00
2% Chitosan 31.80 24.75 25.00
2% Chlorohexidine Gluconate (CHX) 21.85 27.50 25.00
Distilled Water (Control) 14.50 22.00 25.00
Chi-Square value 55.512 66.297 72.869
P value 0.0001 0.0001 0.0001
1The Kruskal Wallis test (one-way analysis of variance by ranks), (P< 0.05).
a) Coronal b) Middle c) Apical
Fig. (1) Scanning electron microscope (SEM) images of Biopure MTAD (Group 1) at the (a) coronal, (b) middle and (c) apical
thirds (original magnication 1000×).
THE EFFECT OF DIFFERENT IRRIGATING SOLUTIONS ON THE SMEAR LAYER (461)
a) Coronal b) Middle c) Apical
Fig. (2) Scanning electron microscope (SEM) images of QMixTM2in1 (Group 2) at the (a) coronal, (b) middle and (c) apical
thirds (original magnication 1000×).
a) Coronal b) Middle c) Apical
Fig. (3) Scanning electron microscope (SEM) images of 17% EDTA (Group 3) at the (a) coronal, (b) middle and (c) apical thirds
(original magnication 1000×).
a) Coronal b) Middle c) Apical
Fig. (4) Scanning electron microscope (SEM) images of 6.25% Morinda citrifolia Juice (MCJ) (Group 4) at the (a) coronal, (b)
middle and (c) apical thirds (original magnication 1000×).
(462) Hayam Y. Hassan and Ahmed M. NegmE.D.J. Vol. 64, No. 1
a) Coronal b) Middle c) Apical
Fig. (5) Scanning electron microscope (SEM) images of 2% Nano-Chitosan (Group 5) at the (a) coronal, (b) middle and (c)
apical thirds (original magnication 1000×).
a) Coronal b) Middle c) Apical
Fig. (6) Scanning electron microscope (SEM) images of 2% Chitosan (Group 6) at the (a) coronal, (b) middle and (c) apical
thirds (original magnication 1000×).
a) Coronal b) Middle c) Apical
Fig. (7) Scanning electron microscope (SEM) images of 2% Chlorohexidine gluconate (CHX) (Group 7) at the (a) coronal, (b)
middle and (c) apical thirds (original magnication 1000×).
THE EFFECT OF DIFFERENT IRRIGATING SOLUTIONS ON THE SMEAR LAYER (463)
DISCUSSION
The efciency of any irrigating solution to
eliminate smear layers at different zones of the
root canal depends on the type of the irrigant
and the delivery method (16). Method of delivery
was not examined at this study that evaluated
the effectiveness of irrigant solutions rather than
irrigation.
The current study presented efcient elimination
of smear layer in coronal and middle parts rather
than apical parts of the root canals. This came in
agreement with several studies that showed efcient
cleaning of coronal and middle parts of the canals
even when using different irrigation volumes and
several times (17-20). Coronal and middle thirds
have wider canal diameter that exposes dentin to
a greater volume of irrigants, giving better ow of
the solution, and hence increasing the smear layer
elimination capacity (18, 20)
.
Biopuer MTAD showed the highest mean value of
smear layer elimination due to the active ingredient
of 4.25% citric acid and detergent polysorbate
80 that decreased the surface tension leading to
increased permeability allowing Biopuer MTAD to
permeate better enhancing the decalcication effect
(21)
. These came in an agreement with De-Deus et
al (8) Torabinejad et al (22) and Ghoddusi et al (23)
who concluded that Biopuer MTAD demineralizes
dentin faster than 17% EDTA without affecting the
structural integrity of dentinal tubules.
EDTA and QMixTM2in1 showed almost equal
values for smear layer elimination due to the fact
that the active ingredient in both irrigants is EDTA.
This came in agreement with Dai et al (24) who found
that EDTA has the same effect as two versions of
QMixTM 2in1. EDTA possess high surface tension
than Biopuer MTAD which reduce its ability to
wet root canal surface, also the hydrogen exchange
of calcium from dentin resulting in a subsequent
lowering in pH. Therefore the capability of EDTA
reduced by time (25).
Findings showed that MCJ had signicantly
reduced ability to remove smear layer which came
in agreement with Murray et al (26) who found that
although MCJ had strong antibacterial action and
did not have an effect on smear layer elimination.
To enhance its effect, a nal rinse with EDTA 17%
was done.
Among the premises of the study Chitosan and
Nano-Chitosan have shown reduction in smear
layer but with less mean value than the previously
mentioned irrigants as mentioned by Geethapriya
a) Coronal b) Middle c) Apical
Fig. (8) Scanning electron microscope (SEM) images of Distilled Water (Control) (Group 8) at the (a) coronal, (b) middle and (c)
apical thirds (original magnication 1000×).
(464) Hayam Y. Hassan and Ahmed M. NegmE.D.J. Vol. 64, No. 1
et al(27) who tested the effect of Chitosan accompa-
nied by EDTA as an efcient smear layer removal
with less erosion in dentinal tubules.
Based on the results of this investigation, CHX
had no effect on smear layer completely and left
most of dentinal tubules occluded. This was in
harmony with studies which showed that CHX
has strong antibacterial effect with no effect on the
dentine components of root canal (28-30).
Nearly, all the groups revealed less or no effect
on smear layer at the apical part of the root canal.
This is due to the ow and backow capability of
the uid which are less at this part due to the narrow
diameter and the increase in depth of the root
canal, together with the lesser amount of dentinal
tubules than coronally and abundance of sclerotic
dentine (31).
CONCLUSION
The present study concluded that Biopuer MTAD
had the highest mean value for smear layer removal
in middle, coronal and to a minimal effect in apical
parts while the rest of irrigants performed well in
coronal and middle parts with no effect apically.
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