The Effect of EDTA with and without Ultrasonics on Removal

of the Smear Layer

Hong-Guan Kuah, BDS, MDS, MRD,*

Jeen-Nee Lui, BDS, MDS, MRD,*

Patrick S.K. Tseng, BDS, MSc,

and Nah-Nah Chen, BDS, MDS, MS*

Abstract
This study evaluated in vitro effectiveness of 17%
EDTA with and without ultrasonics on smear layer
removal. One hundred and ve extracted premolars
randomly divided into seven groups were instrumented
with different nal irrigating protocols: group A
(Sal3US), saline for 3 minutes with ultrasonics; groups
B (Na3) and C (Na3US), 1% sodium hypochlorite for 3
minutes without and with ultrasonics, respectively;
groups D (ED3) and E (ED3US), 17% EDTA for 3 minutes
without and with ultrasonics, respectively; and groups F
(ED1) and G (ED1US), 17% EDTA for 1 minute without
and with ultrasonics, respectively. Specimens were
examined under scanning electron microscope and
scored for smear layer and debris removal. Statistical
analysis showed that groups with EDTA and ultrasonic
irrigation, groups E (ED3US) and G (ED1US), had signif-
icantly more specimens with complete smear layer and
debris removal. There was no signicant difference
between groups E (ED3US) and G (ED1US). A 1-minute
application of combined use of EDTA and ultrasonics is
efcient for smear layer and debris removal in the apical
region of the root canal. (J Endod 2009;35:393396)
Key Words
EDTA, irrigation, smear layer, ultrasonics
T
he smear layer produced during root canal instrumentation consists of organic and
inorganic substances derived from ground dentin and predentin; pulpal remnants;
odontoblast processes; and, in cases of infected root canals, bacteria (1, 2). The pres-
ence of microorganisms within the smear layer and dentinal tubules is well documented
(35). The smear layer hinders effective penetration of antimicrobial agents and root
canal sealers into dentinal tubules (6, 7) and has the potential of compromising the seal
between root lling material and the root canal wall (2, 811). Although not substan-
tiated in clinical trials, the removal of the smear layer before root lling would appear to
be prudent.
Sodium hypochlorite (NaOCl), in concentrations of 0.5% to 5.25%, is the irrigant
of choice for root canal disinfection (12) but, when used alone, is ineffective in smear
layer removal (1, 2). The addition of a chelating agent, such as 17% EDTA, to the irri-
gation regimen has been shown to be effective in achieving smear-free walls in the
middle and coronal thirds of the root canal (4, 7, 13). However, smear layer removal
in the apical region remains unpredictable (1, 3, 4, 7, 14, 15).
The apical third of the root canal is the most difcult portion to clean possibly
because of its narrower dimensions, which can prevent effective penetration of irri-
gants, resulting in limited contact of solutions with root canal surfaces (16, 17). The
use of ultrasonics has been suggested to improve irrigation in the root canal. Less debris
and smear layer have been observed in the apical region of the canal than its coronal
aspects with the use of ultrasonics; this effect is thought to be generated by acoustic
streaming (18).
Various studies on the use of ultrasonics for root canal irrigation have been pub-
lished (1921), but the literature suggests a lack of data on the effectiveness of the
combined use of EDTA with ultrasonics for smear layer removal at the apical region
of the root canal. The time of EDTA application required for smear layer removal is
also unclear.
The purpose of this in vitro study was to evaluate various regimens for the removal
of the smear layer at the apical third of the instrumented root canal. The effectiveness of
EDTA irrigation with and without the use of ultrasonics and the efcacy between a
1-minute and 3-minute application of ultrasonics was examined.
Materials and Methods
Sample Selection and Preparation
One hundred and ve extracted fully developed human premolars with single
canals and curvatures less than 30

according to Schneiders classication were stored

in saline after collection (22). Teeth were selected based on uniformroot canal width as
determined by buccolingual and mesiodistal radiographs and decoronated to obtain
a standardized root length of 12 mm. Specimens were randomly assigned to 7 treatment
groups of 15 roots. This sample size was calculated based on a desired power of 80%
for the study.
Preparation of Root Canals
Working lengths of specimens were determined by deducting 1 mm from the
length recorded when the tip of a #10 K-le was just visible at the apical foramen. Teeth
were shaped with .04 ProFile rotary les (Dentsply Maillefer, Ballaigues, Switzerland)
using a crown down technique with apical preparation prepared by Flex-O hand les
From the *Department of Restorative Dentistry, National
Dental Centre of Singapore, Singapore;

private practice,
Singapore; and

the Faculty of Dentistry, National University
of Singapore, Singapore.
Address requests for reprints to Dr Hong-Guan Kuah, The
Endodontic Ofce, Orchard Medical Specialists Centre, Lucky
Plaza, 304 Orchard Road, #05-31, Singapore 238863. E-mail
address: hgkuah@endoofces.com.
0099-2399/$0 - see front matter
Copyright 2009 American Association of Endodontists.
doi:10.1016/j.joen.2008.12.007
Basic ResearchTechnology
JOE Volume 35, Number 3, March 2009 The Effect of EDTA 393
(Dentsply Maillefer) to ISO size #40. Between instrument changes, irri-
gation with 1 mL of 1% NaOCl (Procter & Gamble, NSW, Australia) was
performed by using a disposable syringe with a 27-G needle.
After instrumentation, teeth in different groups underwent
different nal irrigating sequences. Ultrasonics (Satelec P-Max; Satelac,
Merignac, France), when used in the nal irrigating sequence, was used
with a #15 K-le at a distance of 1 mm from the working length, with
a power setting of 2.
The nal irrigation sequences were as follows: (1) group A
(Sal3US) (control): 5 mL of saline (Baxter) for 3 minutes with ultra-
sonics followed by 5 mL of saline, (2) group B (Na3): 5 mL of 1%NaOCl
for 3 minutes followed by 5 mL of 1%NaOCl (3) group C (Na3US): 5 mL
of 1% NaOCl for 3 minutes with ultrasonics followed by 5 mL of 1%
NaOCl, (4) group D (ED3): 5 mL of 17% EDTA (Pulpdent, Watertown
MA, USA) for 3 minutes followed by 5 ml of 1% NaOCl, (5) group E
(ED3US): 5 mL of 17% EDTA for 3 minutes with ultrasonics followed
by 5 mL of 1% NaOCl; (6) group F (ED1): 5 mL of 17% EDTA for 1
minute followed by 5 mL of 1% NaOCl; and (7) group G (ED1US): 5
mL of 17% EDTA for 1 minute with ultrasonics followed by 5 mL of
1% NaOCl.
Scanning Electron Microscopic Evaluation
Teeth were split open in a buccolingual direction to expose root
interiors. A longitudinal groove was made along the root surface with
a diamond disc at low-speed and a wedge used to split the roots into
two halves. The specimens were dried, mounted on metallic stubs,
gold sputtered, and evaluated under scanning electron microscope
(SEM) (JEOL Ltd, Tokyo, Japan) at the apical and middle levels of
the center of the canal. Serial SEM photomicrographs at magnications
of 1,000 and 3,000 were taken of canal walls at 2 and 6 mm from
the apical foramen.
The amount of debris and smear layer present was scored as
follows (23): debris score: 0, no debris present; 1, few debris particles
present; and 2, a large amount of debris particles present and smear
layer score: 0, all dentinal tubules are open and no smear layer present;
1, some dentinal tubules are open with smear layer covering some of the
openings of the dentinal tubules; and 3, all dentinal tubules are covered
by the smear layer.
Two examiners performed the blinded evaluations independently
after the examination of 20 specimens jointly for calibration purposes.
Interexaminer reliability for the SEM assessment was veried by the
Kappa test.
Statistical Analysis
The mean debris and smear layer scores were calculated and eval-
uated between groups using the chi-square test/Fisher exact test. The
level of signicance was set at p < 0.05.
Results
Kappa test results showed good interexaminer agreement with
values of 0.9 or above for the different categories. Representative
SEMphotomicrographs are shown in Figure 1. Smear and debris scores
for the specimens are presented in Figures 2 and 3.
At the 2-mm level, groups with EDTA, D (ED3), E (ED3US), F
(ED1), and G (ED1US), performed signicantly better than groups
with saline or sodium hypochlorite, A (Sal3US), B (Na3), and C
(Na3US), in smear and debris removal. Groups with both ultrasonics
and EDTA, E (ED3US) and G (ED1US), had signicantly more speci-
mens with smear layer and complete debris removal as compared to
groups with EDTA alone, D(ED3) and F (ED1). There was no signicant
difference between group E (ED3US) and G (ED1US).
At the 6-mm level, groups D (ED3), E (ED3US), F (ED1), and G
(ED1US) produced more specimens with the smear layer removed.
Only specimens from groups E (ED3US) and G (ED1US) had a signi-
cantly higher number of specimens with complete debris removal.
Discussion
In this study, we attempted a systematic evaluation on various
irrigation regimens to improve smear layer removal at the apical third
of the instrumented root canal. The results indicate that instrumented
root canals exposed to EDTA, D (ED3), E (ED3US), F (ED1), and G
(ED1US), in the nal irrigating sequence had more effective smear
layer removal, which was further enhanced with the use of ultrasonics
in groups E (ED3US) and G (ED1US). There was no signicant differ-
ence between a 1-minute and 3-minute application of EDTA with ultra-
sonics.
The relative inefcacy of NaOCl or ultrasonics and their combina-
tion in groups A (Sal3US), B (Na3), and C (Na3US) for smear layer
removal in this study corroborates with results in other studies (4,
19, 23, 24). Use of a higher concentration of NaOCl in our study can
be speculated to reduce debris and smear scores. However, it has
been noted that 0.5%, 1.0%, 2.5%, and 5.25% NaOCl were ineffective
in removing the smear layer (19). The addition of ultrasonic irrigation
to NaOCl has various reported effects on smear layer removal, ranging
from little effect (19, 24), moderate effect (16), and very effective (20,
21). The wide range of results in these studies can be attributed to the
different stages of instrumentation at which ultrasonics was used and
different levels of the root canal examined. It has been shown that ultra-
sonic irrigation requires both NaOCl and EDTA for smear layer removal
(24) because neither EDTA nor NaOCl is capable of removing both
organic and inorganic components of the smear layer when used alone
(4).
The addition of ultrasonics to EDTA in groups E (ED3US) and G
(ED1US) was very effective for smear layer and debris removal in the
apical region of the root canal. This is likely to be due to the use of
a small le with ultrasonics for introduction of solutions into the apical
region to promote the interaction of the chelating agent with the dentinal
wall (25). Ultrasonic irrigation was more effective than syringe irriga-
tion in removing articially created dentine debris (26). For irrigants
to work effectively, solutions must readily contact the region or surfaces
concerned. With the use of a syringe, it has been shown that the solution
does not penetrate more than 1 mm beyond the tip of the needle (27).
Therefore, syringe irrigation seems predictable only if the needle tip can
be introduced to within 1 mm of the working length.
Currently, there are no clinical recommendations as to the optimal
period of time EDTA should be left in the canal for smear layer removal.
In our study, we looked at the time required for smear layer removal
and noted that a 1-minute application of EDTA was as effective as
a 3-minute application. Previous in vitro studies on dentine blocks
(28) and root canals of extracted teeth (29) also found that a 1-minute
application was sufcient for smear layer removal. Future research
should examine the effectiveness of shorter time periods using EDTA
and ultrasonics.
The samples in this study were single-rooted premolars with rela-
tively straight canals. Thus, our results may be limited only to such clin-
ical instances. In this study, ultrasonics was used only after the
completion of instrumentation to fully use the principle of acoustic
streaming (18). A low-power setting was used to avoid planing of the
canal walls. Clinically, in canals with a greater degree of curvature, dif-
culties might exist in the introduction of the le into the apical part of the
canal without contacting the canal walls. In a curved canal, the volume
of irrigant available may be reduced and the depth of penetration of
Basic ResearchTechnology
394 Kuah et al. JOE Volume 35, Number 3, March 2009
EDTA solution may decrease. The actions of ultrasonics are best
achieved with a free oscillating le (30). A study comparing the use
of a smooth wire and a K-le for ultrasonic irrigation of simulated
straight root canals in resin blocks noted that the smooth wire was as
effective as the K-le in the removal of debris and had the potential of
causing less cutting damage to the canal wall (31).
Within the limitations of this study, it is shown that a 1-minute
application of EDTA with ultrasonics followed by a nal ush of NaOCl
Figure 1. Representative SEM photomicrographs of specimens with smear score: 0 and debris score: 0 (A1) 1,000 (A2) 3,000; smear score: 1 and debris
score: 1 (B1) 1,000 (B2) 3,000; and smear score: 2 and debris score: 2 (C1) 1,000 (C2) 3000.
Distribution of Specimens at 2mm and 6mm Levels
(Smear Score)
0
2
4
6
8
10
12
14
16
A
2mm
A
6mm
B
2mm
B
6mm
C
2mm
C
6mm
D
2mm
D
6mm
E
2mm
E
6mm
F
2mm
F
6mm
G
2mm
G
6mm
Groups
N
u
m
b
e
r

o
f

s
p
e
c
i
m
e
n
s
Smear score = 0
Smear score = 1
Smear score = 2
Figure 2. Smear score distribution at 2-mm and 6-mm levels from the apex.
Distribution of Specimens at 2mm and 6mm Levels
(Debris Score)
0
2
4
6
8
10
12
14
16
A
2mm
A
6mm
B
2mm
B
6mm
C
2mm
C
6mm
D
2mm
D
6mm
E
2mm
E
6mm
F
2mm
F
6mm
G
2mm
G
6mm
Groups
N
u
m
b
e
r

o
f

s
p
e
c
i
m
e
n
s
Debris score = 0
Debris score = 1
Debris score = 2
Figure 3. Debris score distribution at 2-mm and 6-mm levels from the apex.
Basic ResearchTechnology
JOE Volume 35, Number 3, March 2009 The Effect of EDTA 395
is efcient for smear and debris removal at the apical region of the in-
strumented root canal.
Acknowledgments
The authors thank Dr Chan Yiong Huak from the Biostatistics
Unit, Yong Loo Lin School of Medicine, National University of
Singapore, for assistance in statistical analysis.
References
1. McComb D, Smith DC. A preliminary scanning electron microscopic study of root
canals after endodontic procedures. J Endod 1975;1:23842.
2. Mader CL, Baumgartner JC, Peters DD. Scanning electron microscope investigation
of the smeared layer on root canal walls. J Endod 1984;10:47783.
3. Baker N, Eleazer P, Averbach R, et al. Scanning electron microscopic study of the
efcacy of various irrigating solutions. J Endod 1975;1:2735.
4. Yamada RS, Armas A, Goldman M, et al. A scanning electron microscopic compar-
ison of a high volume nal ush with several irrigating solutions: part 3. J Endod
1983;9:13742.
5. Meryon S, Tobias R, Jakeman K. Smear removal agents: a quantitative study in vivo
and in vitro. J Prosthet Dent 1987;57:1749.
6. Goldberg DB, Abramovich A. Analysis of the effects of EDTAC on the dentinal walls of
the root canal. J Endod 1977;3:1015.
7. Baumgartner JC, Mader CL. A scanning electron microscopic evaluation of four root
canal irrigating regimens. J Endod 1987;13:14757.
8. White R, Goldman M, Lin PS. The inuence of the smeared layer upon dentinal
tubule penetration by plastic lling materials. J Endod 1984;10:55862.
9. Kennedy WA, Walker WA, Gough RW. Smear layer removal effects on apical leakage.
J Endod 1986;12:217.
10. Cergneux M, Ciucchi B, Dietschi JM, et al. The inuence of smear layer on the seal-
ing ability of canal obturation. Int Endod J 1987;20:22832.
11. Saunders WP, Saunders EM. The effect of smear layer upon the coronal leakage of
gutta-percha root llings and a glass ionomer sealer. Int Endod J 1992;25:2459.
12. Zehnder M. Root canal irrigants. J Endod 2006;32:38998.
13. Goldman M, Goldman LB, Cavaleri R, et al. The efcacy of several endodontic irrigating
solutions: a scanning electron microscopic study: part 2. J Endod 1982;8:48792.
14. Abbott PV, Heijkoop PS, Cardaci SC, et al. An SEM study of the effects of different
irrigation sequences and ultrasonics. Int Endod J 1991;24:30816.
15. OConnell MS, Morgan LA, Beeler WJ, et al. A comparative study of smear layer
removal using different salts of EDTA. J Endod 2000;26:73943.
16. Ciucchi B, Khettabi M, Holz J. The effectiveness of different endodontic irrigation
procedures on the removal of smear layer: a scanning electron microscope study.
Int Endod J 1989;22:218.
17. Takeda FH, Harashima T, Kimura Y, et al. A comparative study of the removal of
smear layer by three endodontic irrigants and two types of laser. Int Endod J
1999;32:329.
18. Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic debridement of root canals: acoustic
streaming and its possible role. J Endod 1987;13:4909.
19. Baumgartner JC, Cuenin PR. Efcacy of several concentrations of sodium hypochlo-
rite for root canal irrigation. J Endod 1992;18:60512.
20. Cameron JA. The use of ultrasonics in the removal of smear layer: a scanning elec-
tron microscope study. J Endod 1983;9:28992.
21. Cameron JA. The use of ultrasound for the removal of the smear layer. The effect of
sodium hypochlorite concentration: SEM study. Aus Dent J 1988;33:193200.
22. Schneider SW. A comparison of canal preparations in straight and curved root
canals. Oral Surg Oral Med Oral Pathol 1971;32:2715.
23. Lui JN, Kuah HG, Chen NN. Effect of EDTA with and without surfactants or ultrasonics
on removal of smear layer. J Endod 2007;33:4725.
24. Guerisoli DMZ, Marchesan MA, Walmsley AD, et al. Evaluation of smear layer
removal by EDTAC and sodium hypochloride with ultrasonic agitation. Int Endod
J 2002;35:41821.
25. Krell KV, Johnson RJ, Madison S. Irrigation patterns during ultrasonic canal instru-
mentation. Part I. K-type les. J Endod 1988;14:658.
26. Lee SJ, Wu MK, Wesselink PR. The effectiveness of syringe irrigation and ultrasonics
to remove debris from simulated irregularities within prepared root canal walls. Int
Endod J 2004;37:6728.
27. Abou-Rass M, Piccinini MV. The effectiveness of four clinical irrigation methods on
the removal of root canal debris. Oral Surg Oral Med Oral Pathol 1982;5:3238.
28. Calt S, Serper A. Time dependent effects of EDTA on dentine structures. J Endod
2002;28:179.
29. Teixeira CS, Felippe MCS, Felippe WT. The effect of application time of EDTA and
NaOCl on intracanal smear layer removal: an SEM analysis. Int Endod J 2005;38:
28590.
30. Lumley PJ, Walmsley AD, Laird WR. Streaming patterns produced around endosonic
les. Int Endod J 1991;24:2907.
31. van der Sluis LW, Wu MK, Wesselink PR. A comparison between a smooth wire and
a K-le in removing articially placed dentine debris from root canals in resin
blocks during ultrasonic irrigation. Int Endod J 2005;38:5936.
Basic ResearchTechnology
396 Kuah et al. JOE Volume 35, Number 3, March 2009