Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0040-1715985
Effect of a Modified Irrigation Protocol on the Cleanliness of Moderately Curved Canals
![](https://www.thieme-connect.de/media/10.1055-s-00042133/202101/lookinside/thumbnails/10-1055-s-0040-1715985_00466-1.jpg)
Abstract
Objectives This study tested the hypothesis that modifying the sequence of sodium hypochlorite (NaOCl)/ethylene diamine tetra-acetic acid (EDTA) irrigation during root canal shaping would improve apical cleanliness in moderately curved canals.
Materials and Methods Forty-five root canals were prepared using Protaper Gold with three irrigation protocols. Standard irrigation (SI) used 0.5 mL 3% NaOCl between each instrument, followed by 5 mL 17% EDTA manually agitated for 30 seconds. Reverse irrigation (RI) used 0.5 mL of 17% EDTA between each instrument, then 5 mL of 3% NaOCl, manually agitated for 30 seconds. Reverse irrigation plus (RI+) was similar to RI, except NaOCl (5 mL), used as a final rinse, was allowed to interact for 3 minutes with dentin before manual agitation (30 seconds).
Root canal cleanliness was evaluated under the scanning electron microscope (SEM) (Hulsmann score); the chemical composition of dentin after irrigation was analyzed by energy dispersive X-ray (EDX).
Statistical Analysis Results were compared using Kruskal–Wallis ANOVA by ranks and Wilcoxon matched paired posthoc tests. A Chi-square test assessed whether the best cleanliness would demonstrate a significant association with one irrigation protocol; odds ratio calculation was performed using score “1” versus score “2 or more” (2+) (p < 0.05).
Results In the apical region, cleanliness was better in RI+ than SI and both significantly better than RI. Odd ratios indicate that the cleanliness in RI+ was significantly better than RI and SI groups (p < 0.000 and 0.003, respectively). Independently of the irrigation protocol, EDX analyses showed no chemical alteration of root dentin.
Conclusions Using 17% EDTA during shaping, followed by 3% NaOCl rinse for 3 minutes, improved apical cleanliness without inducing erosion of dentin.
Publication History
Article published online:
01 October 2020
© 2020. European Journal of Dentistry. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
-
References
- 1 Sen BH, Piskin B, Demirci T. Observation of bacteria and fungi in infected root canals and dentinal tubules by SEM. Endod Dent Traumatol 1995; 11 (01) 6-9
- 2 Siqueira Jr JF, Rôças IN, Favieri A, Lima KC. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1%, 2.5%, and 5.25% sodium hypochlorite. J Endod 2000; 26 (06) 331-334
- 3 Cullen JK, Wealleans JA, Kirkpatrick TC, Yaccino JM. The effect of 8.25% sodium hypochlorite on dental pulp dissolution and dentin flexural strength and modulus. J Endod 2015; 41 (06) 920-924
- 4 Yamada RS, Armas A, Goldman M, Lin PS. A scanning electron microscopic comparison of a high volume final flush with several irrigating solutions: Part 3. J Endod 1983; 9 (04) 137-142
- 5 Paqué F, Boessler C, Zehnder M. Accumulated hard tissue debris levels in mesial roots of mandibular molars after sequential irrigation steps. Int Endod J 2011; 44 (02) 148-153
- 6 Violich DR, Chandler NP. The smear layer in endodontics - a review. Int Endod J 2010; 43 (01) 2-15
- 7 Von der Fehr F, Nygaard Ostby B. Effect of EDTAC and sulfuric acid on root canal dentine. Oral Surg Oral Med Oral Pathol 1963; 16: 199-205
- 8 Zehnder M, Schmidlin P, Sener B, Waltimo T. Chelation in root canal therapy reconsidered. J Endod 2005; 31 (11) 817-820
- 9 Holleman AF, Wiberg E. Inorganic Chemistry. San Diego: Academic Press; Berlin: W De Gruyter. 2001
- 10 Byström A, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endod J 1985; 18 (01) 35-40
- 11 Zehnder M. Root canal irrigants. J Endod 2006; 32 (05) 389-398
- 12 Hülsmann M, Heckendorff M, Lennon A. Chelating agents in root canal treatment: mode of action and indications for their use. Int Endod J 2003; 36 (12) 810-830
- 13 Hülsmann M, Rümmelin C, Schäfers F. Root canal cleanliness after preparation with different endodontic handpieces and hand instruments: A comparative SEM investigation. J Endod 1997; 23 (05) 301-306
- 14 Gambarini G, Laszkiewicz J. A scanning electron microscopic study of debris and smear layer remaining following use of GT rotary instruments. Int Endod J 2002; 35 (05) 422-427
- 15 Haupt F, Meinel M, Gunawardana A, Hülsmann M. Effectiveness of different activated irrigation techniques on debris and smear layer removal from curved root canals: A SEM evaluation. Aust Endod J 2020; 46 (01) 40-46
- 16 Schneider SW. A comparison of canal preparations in straight and curved root canals. Oral Surg Oral Med Oral Pathol 1971; 32 (02) 271-275
- 17 Faraj S, Boutsioukis C. Observer variation in the assessment of root canal curvature. Int Endod J 2017; 50 (02) 167-176
- 18 Parente JM, Loushine RJ, Susin L. et al. Root canal debridement using manual dynamic agitation or the EndoVac for final irrigation in a closed system and an open system. Int Endod J 2010; 43 (11) 1001-1012
- 19 Boutsioukis C, Van der Sluis LWM. Syringe irrigation: blending endodontics and fluid dynamics. In: Endodontic Irrigation, Chemical Disinfection of the Root Canal System. Springer International Publishing; 2015: 45-6
- 20 Bronnec F, Bouillaguet S, Machtou P. Ex vivo assessment of irrigant penetration and renewal during the cleaning and shaping of root canals: a digital subtraction radiographic study. Int Endod J 2010; 43 (04) 275-282
- 21 Caron G, Nham K, Bronnec F, Machtou P. Effectiveness of different final irrigant activation protocols on smear layer removal in curved canals. J Endod 2010; 36 (08) 1361-1366
- 22 Saito K, Webb TD, Imamura GM, Goodell GG. Effect of shortened irrigation times with 17% ethylene diamine tetra-acetic acid on smear layer removal after rotary canal instrumentation. J Endod 2008; 34 (08) 1011-1014
- 23 Virdee SS, Seymour DW, Farnell D, Bhamra G, Bhakta S. Efficacy of irrigant activation techniques in removing intracanal smear layer and debris from mature permanent teeth: a systematic review and meta-analysis. Int Endod J 2018; 51 (06) 605-621
- 24 Senia ES, Marshall FJ, Rosen S. The solvent action of sodium hypochlorite on pulp tissue of extracted teeth. Oral Surg Oral Med Oral Pathol 1971; 31 (01) 96-103
- 25 Khademi A, Yazdizadeh M, Feizianfard M. Determination of the minimum instrumentation size for penetration of irrigants to the apical third of root canal systems. J Endod 2006; 32 (05) 417-420
- 26 Sedgley CM, Nagel AC, Hall D, Applegate B. Influence of irrigant needle depth in removing bioluminescent bacteria inoculated into instrumented root canals using real-time imaging in vitro. Int Endod J 2005; 38 (02) 97-104
- 27 Boutsioukis C, Gogos C, Verhaagen B, Versluis M, Kastrinakis E, Van der Sluis LW. The effect of root canal taper on the irrigant flow: Evaluation using an unsteady Computational Fluid Dynamics model. Int Endod J 2010; 43 (10) 909-916
- 28 Saber Sel-D, Hashem AA. Efficacy of different final irrigation activation techniques on smear layer removal. J Endod 2011; 37 (09) 1272-1275
- 29 Al-Ali M, Sathorn C, Parashos P. Root canal debridement efficacy of different final irrigation protocols. Int Endod J 2012; 45 (10) 898-906
- 30 De-Deus G, Reis C, Paciornik S. Critical appraisal of published smear layer-removal studies: methodological issues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112 (04) 531-543
- 31 Rossi-Fedele G, Doğramaci EJ, Guastalli AR, Steier L, de Figueiredo JA. Antagonistic interactions between sodium hypochlorite, chlorhexidine, EDTA, and citric acid. J Endod 2012; 38 (04) 426-431
- 32 Qian W, Shen Y, Haapasalo M. Quantitative analysis of the effect of irrigant solution sequences on dentin erosion. J Endod 2011; 37 (10) 1437-1441
- 33 Wang Z, Maezono H, Shen Y, Haapasalo M. Evaluation of root canal dentin erosion after different irrigation methods using energy dispersive X-ray spectroscopy. J Endod 2016; 42 (12) 1834-1839
- 34 Niu W, Yoshioka T, Kobayashi C, Suda H. A scanning electron microscopic study of dentinal erosion by final irrigation with EDTA and NaOCl solutions. Int Endod J 2002; 35 (11) 934-939
- 35 Gu LS, Huang XQ, Griffin B. et al. Primum non nocere - The effects of sodium hypochlorite on dentin as used in endodontics. Acta Biomater 2017; 61: 144-156
- 36 Calt S, Serper A. Time-dependent effects of EDTA on dentin structures. J Endod 2002; 28 (01) 17-19
- 37 Haapasalo M, Qian W, Shen Y. Irrigation: beyond the smear layer. Endod Topics 2012; 27: 35-53
- 38 Wang Z, Shen Y, Haapasalo M. Effect of smear layer against disinfection protocols on Enterococcus faecalis-infected dentin. J Endod 2013; 39 (11) 1395-1400
- 39 Morago A, Ordinola-Zapata R, Ferrer-Luque CM, Baca P, Ruiz-Linares M, Arias-Moliz MT. Influence of smear layer on the antimicrobial activity of a sodium hypochlorite/etidronic acid irrigating solution in infected dentin. J Endod 2016; 42 (11) 1647-1650
- 40 Clark-Holke D, Drake D, Walton R, Rivera E, Guthmiller JM. Bacterial penetration through canals of endodontically treated teeth in the presence or absence of the smear layer. J Dent 2003; 31 (04) 275-281