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Endodontic Topics 2005, 10, 103122 Copyright r Blackwell Munksgaard

All rights reserved ENDODONTIC TOPICS 2005


1601-1538

Effects of mechanical and chemical


procedures on root canal surfaces
KISHOR GULABIVALA, BINA PATEL, GLYNIS EVANS & YUAN-LING NG

Root canal treatment may be performed on teeth with presenting surfaces must be appreciated. Since root
irreversibly inflamed dental pulps to prevent apical canal treatment may be carried out on teeth with or
periodontitis or on teeth with apical periodontitis to without apical periodontitis and with vital or necrotic
treat it. The presenting condition of the root canal pulp tissue, a diverse range of conditions may present,
surface may therefore vary from that of an intact pulp especially considering the age of the patient at
dentine complex, through partially degraded pulp presentation.
tissue with infection, to a dentine surface coated with
a mature bacterial biofilm (1). Subsequent treatment
procedures will alter the surface in ways that depend Influence of canal anatomy
upon the root canal anatomy, the instruments used, the The complexity of the root canal system and the
strategy and mode of their use, and the chemicals used patterns of prevalence of types of systems in different
to facilitate debridement. The effects range from teeth and roots are well documented in different racial
displacement and/or deformation of soft and/or hard groups (25) and are reviewed elsewhere in this volume.
tissue components, to changes in the biological, These have a dominant effect on the outcomes of
mechanical, and chemical properties of the root canal mechanical (6) and therefore chemical preparation (7).
dentine surface. These changes may have a profound
effect on the survival of the tooth, both in terms of
progression of apical periodontitis and the long-term Surface characteristics of the uninfected root
integrity of the tooth. An evidence-based synthesis of canal surface
the literature on the chain of events associated with the During elective pulpectomy on a tooth with healthy
effects of root canal treatment, on the internal dentine pulp tissue, a normal pulpdentine complex would be
surfaces, has required subjective assimilation. The mass encountered. Extirpation of the pulp tissue may leave
of published, largely laboratory data, relevant to the odontoblasts either remaining in the dentinal tubules
topic is heterogenous and contradictory, leaving room (8) or torn out. Depending upon the condition of the
for conjecture, differences of opinion, and further pulp tissue, it may fragment or be removed largely in
questions. The original questions posed in laboratory one piece (Fig. 1). It is likely that the apical parts of the
studies were not guided by clinical outcome data and pulp, which are more fibrous, and those in accessory
therefore lacked relevant focus. The synthesized view anatomies may remain (7, 9, 1012), particularly in
presented below is based on the authors interpretation curved canals (9, 13, 14). A dying pulp, deprived of a
of the literature findings, sought systematically by hand blood supply, may shrink and pull away from the
and electronic search methods. dentine surface (Fig. 2). Otherwise, an uninfected,
necrotic pulp may remain behind as a dried vestige of
Presenting condition of root canal the vital organ.
In contrast, an inflamed pulp would lose its
surfaces before treatment
organization and break down, leaving variable frag-
Before the effects of treatment procedures on root ments of necrotic tissue over the dentine surface. If the
canal surfaces can be evaluated, the condition of the pulp had been invaded by bacteria, the fragmentation

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Gulabivala et al.

Fig. 1. Extirpated pulp and SEM view of pulp separating from dentine surface with odontoblastic processes drawing out
of their tubules.

Fig. 2. SEM views showing dried pulp tissue and remnants of necrotic pulp tissue on the canal wall, in one case forming a
sludge-like layer.

may be more complete, to the point where little tissue irregular, disorganized sludge-like material covering
residue is evident, clinically or at light microscopic level. and masking the openings of dentinal tubules and any
At an ultrastructural level, debris will be evident as depressions in the canal wall (15) (Fig. 2). A regular

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Effects of mechanical and chemical procedures

dentine surface with patent dentinal tubules is there- (Fig. 4) (24). There may be a difference in the
fore often taken to mean a clean dentine surface. Teeth proportions of morphotypes present in coronal and
subjected to various microbial insults (through caries, apical parts of root canals (27) but this has yet to be
tooth surface loss, periodontal disease) or restorative confirmed by cultural and molecular studies (28, 29).
stimuli may demonstrate various degrees of dystrophic TEM observation of carious teeth (Fig. 5) suggests
calcification. Depending upon the size, shape, and that most of the flora in the apical 5 mm of the root
position of these relative to the canal walls, they may canal is suspended in an apparently moist canal lumen
obstruct access to the apical anatomy to varying (1). Less frequently, dense aggregates of morphologi-
degrees. Unless formed close to the pulpdentine cally uniform bacterial cells embedded in extra-cellular
complex, such calcifications in a necrotic pulp are likely matrix are observed sticking to the dentinal wall.
to be loose and potentially capable of apical or coronal Sometimes, there are clusters of multi-layered bacterial
translocation during treatment. From this account, it is condensations containing various morphotypes. The
obvious that studies using debris scores as the outcome filamentous forms were often adherent perpendicular
measure for evaluating the effects of treatment to the canal wall, with coccoid forms either arranged in
procedures should standardize the pre-clinical condi- strings in the same direction or adherent to the
tion of the teeth used, a requirement not always filaments giving a corn-cob appearance (1, 24). This
observed. was the first true depiction of biofilms in root canals; yet
The root canal dentine surface presents with an its full significance for root canal treatment was not
unmineralized front with a hardness value that is lowest
for dentine (30 kg/mm2). Elsewhere and in some areas
of the root canal dentine, particularly in older teeth, the
higher mineralization may raise hardness to 6070 kg/
mm2 (16). Furthermore, the dentine surface is porous
owing to the patency of dentinal tubules, although they
may sometimes be sclerosed. The presence, density, and
diameter of the dentinal tubules vary with the corono-
apical site in the tooth as well as with age and insult
(1719).
Where present, the dentinal tubules are irregular in
density and direction in the apical region of roots; while
another complication found is the embedded pulp
stone (19), other descriptions include the so-called
denticle, posing yet another surface complexity on the
root canal wall (20).

Surface characteristics of the infected root


canal surface
When teeth have infected root canals, the pattern of
bacterial invasion and associated pulp necrosis has been
revealed by microscopic surveys (light, dark-field,
transmission electron microscopy (TEM) and scanning
electron microscope (SEM)) of such sample teeth (1,
2126). Bacteria appear to be concentrated in the
coronal part of root canals and appear in smaller
numbers as the apical foramen is reached, particularly in
Fig. 3. Lower and higher magnification light microcopic
teeth with closed pulp chambers and residual vital pulp views (methylene blue stain) showing dying pulp with a
tissue apically (Fig. 3) (21). In contrast, cariously bacterial front colonizing the dentine surface and
exposed canals are evenly coated with a bacterial plaque beginning to penetrate the dentinal tubules.

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Gulabivala et al.

Fig. 5. TEM views showing the relationship between the


bacterial biofilm and dentine surface, as well as that
between the bacterial cells in the root canal. Note the
Fig. 4. SEM views showing a bacterial biofilm overlying
fimbrae extending from cell to cell and the characteristic
the root canal surface from which bacterial cells appear to
orientation of the bacterial cells to the canal wall.
be penetrating the dentinal tubules.

concentrations of lipopolysaccharide in the inner layers,


realized until later (30). The physiology of biofilm up to 300 mm in depth (37).
development and its relevance for human disease and its The overall picture, therefore, is one of a variable
treatment have been reviewed in detail before (31, 32). distribution of bacteria within the root canal system and
Bacteria in biofilms are regarded as more difficult to kill dentine. The state at any given time may represent a
than those that grow in fluid suspension as planktonic stage of a changing microflora, with bacteria extend-
phenotypes. ing up to and sometimes beyond the apical foramina.
Bacterial penetration into dentine is only evident in The depth of penetration into dentine is variable but
the presence of pulp necrosis. The predentine is easily generally appears to be confined within the area close to
and commonly infected but the calcified dentine less so the root canal and is probably dominated by Gram-
(1, 21). Bacterial penetration into dentine around the positive bacteria. The distribution of morphotypes also
root canal is confined to the close proximity of the appears to be variable.
canal, where the tubules end in a vital periodontal
ligament (22, 3335). Bacteria are observed along the
entire length of the dentinal tubules only when the
Mechanical properties of dentine in teeth
tubules end in necrotic periodontal tissue (22). Bacteria
with vital and non-vital pulps
penetrating dentine appear to be dominated by Gram- It is possible that the mechanical properties of the
positive rods (68%) and cocci (27%). The predominant pulpless tooth are different from those of a matching
types are Lactobacillus (30%), Streptococcus (13%), and vital tooth but definitive proof has been elusive.
Propionibacterium (9%) species (35, 36). The presence Nevertheless, there is convincing circumstantial evi-
of Gram-negative bacteria in root canal dentine has dence for the putative causes of fracture of non-vital
been indirectly confirmed by the detection of high and root-treated teeth (38). The main causes may be

106
Effects of mechanical and chemical procedures

loss of tooth tissue, altered physical properties of (6365), the conceptual importance of this was not
dentine, and altered response to occlusal loading. It is fully realized.
likely that these factors interact cumulatively to The proportion of root canal dentine surface planed
influence tooth loading and distribution of stresses, by instruments has been quantified recently using high-
ultimately increasing the possibility of catastrophic resolution computed tomography; it was found that
failure. 3553% of the root canal surface remained uninstru-
Loss of tooth tissue reduces the force required to mented (6669). Using a cruder approach, it has also
strain and ultimately fracture teeth, with the pattern of been demonstrated that anterior maxillary teeth have
loss influencing the magnitudes of the induced strains significant proportions of their root canal surfaces left
as observed in vitro (3942). Evidence from clinical uninstrumented, regardless of access cavity design (70).
studies confirms these observations (43, 44). The In addition to its flushing action, the chief role of the
relative importance of disruption of the marginal ridge irrigant is debridement of the uninstrumented canal
and the width and depth of occluso-proximal cavities walls. This would seem to require two conditions:
continues to be debated, but tooth anatomy is also firstly that an irrigant capable of dissolving organic
likely to play an important part (45). The presence of an tissue is used, and secondly that a method suitable for
endodontic access cavity may weaken teeth further, its delivery to the uninstrumented surfaces is used.
although the extent of effect is unresolved (42, 46, 47). Following on from the descriptions above, it is possible
Wide coronal flaring of canals has been implicated as an to envisage that as mechanical preparation is com-
additional factor in fracture of root-treated teeth (48). menced, in the absence of a chemically active irrigant
It has been proposed that loss of pulp vitality alters (one capable of dissolving organic tissue), several
the properties of dentine; the properties assessed outcomes may be apparent in a tooth with a vital pulp.
include: changes in moisture content (4953), nature The instruments (depending upon their design) may
of collagen (54, 55), and other standard laboratory remove some of the residual tissue by engaging it, some
physical properties (50, 5658). The findings have will be pushed and compacted apically, and some will be
been contradictory or equivocal and as yet no definitive compacted and burnished against the root canal wall.
proof of mechanical weakening of dentine exists. Two Such organic tissue will also be forced into depressions
fundamental problems are that: firstly, since all tests are or accessory anatomies (71, 72).
carried out in the laboratory, the dentine tested is by The irrigant will serve to flush out debris from the
definition non-vital; secondly, the science of measure- root canal system, but to a certain extent, tags of tissue
ment is still improving and there is evidence that the may remain bound and merely be displaced apico-
methods used have significantly influenced findings on coronally. The final shape of the prepared canal will be
the properties of dentine (59). determined by the shape and mode of use of the root
It has also been hypothesized that pulpless teeth may canal instruments. In the absence of an active irrigant,
have a reduced capacity to detect occlusal loading and compaction and burnishing of tissue into the non-
therefore be more susceptible to fractures (60, 61). instrumented parts of the root canal system will leave a
space, the boundaries of which are determined by
instrumentation alone. The root-filling material will
therefore trace out a radiographic shape projected by
Effect of mechanical instrumentation the instrumentation. In contrast, the use of active
irrigants, such as sodium hypochlorite (NaOCl) and
on root canal surfaces
ethylene-diamine-tetra-acetic acid (EDTA), will help
The role of canal preparation (shaping) has undergone remove such compacted debris from the non-instru-
a paradigm shift from one fulfilling a prime debriding mented anatomy and facilitate its display by virtue of
function, to one regarded more as a radicular access to extension of the root-filling material into it. The
the complex root canal systems, for the irrigant and classically complex root-filling shapes seen in radio-
root-filling material (62) (Fig. 6). Although evidence graphs used by endodontists to display their technical
had been gathering for some time that mechanical root prowess is because of the extension of root-filling
canal preparation techniques failed to instrument material into non-instrumented anatomy such as fins
a large proportion of the internal dentine surface and lateral canals. In the case of an infected root canal,

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Gulabivala et al.

Fig. 6. A cleared extracted tooth showing the complexity of the root canal system, accompanied by a diagram of the same
tooth with the superimposed canal preparation, depicting the discrepancy between the uninstrumented and
instrumented anatomy. It also shows the radicular access role of the canal preparation.

any bacterial biofilm on the instrumented canal surfaces resistance to occlusal loading as well as the ability, in
is likely to be disturbed or removed, although some of dentine, to deform and cover patent dentinal tubules
the bacterial cells may become embedded within the during functional abrasion. Equally, such a smear layer
smear of tissue and deformed dentine (73). The may be formed as a result of instrumentation of the root
bacterial biofilm on the uninstrumented surface should canal system (71, 74). The latter group gave a more
in theory remain mechanically undisturbed, except by detailed description of the layer as a 12 mm thick,
the displacement of any pulpal tissue or dentinal debris amorphous, irregular, and granular layer with a deeper
from the prepared part of the canal. It is probably part that penetrated up to 40 mm into the dentinal
fortuitous that changes in the ecology of the root canal tubules. The penetration into tubules is hypothesized
system may influence the demise rather than survival of to be a result of capillary action and adhesive forces
bacteria on the uninstrumented surface. Yet, the between the dentinal tubules and the smear layer (75,
uninstrumented surface should be regarded as essen- 76). Others have estimated the layer to be up to 5 mm
tially still contaminated. thick, with inorganic particles of 0.050.15 mm dia-
meter (7779). Essentially, the structure is a complex
mixture of inorganic and organic particles, coagulated
Effect on instrumented surface and smear
proteins, pulp tissue, saliva, blood cells and in infected
layer
canals, bacteria and fungi (24, 80).
Hydroxyappatite has the unique property of smearing The influence of various pre-operative and intra-
when abraded by another hard surface. Presumably, operative variables on the extent of the smear layer is
evolutionary processes have selected this material for its difficult to gauge because studies show considerable

108
Effects of mechanical and chemical procedures

variation in experimental design, making comparison of about its impact on treatment outcome and the merits of
results futile. The experimental teeth vary from those removing it (24, 79, 80, 99). One view is that it is
with single, straight roots to molars with various canal undesirable because it may: (1) harbor microorganisms
curvatures. In some studies, the root canals were (24, 71); (2) prevent or delay diffusion of irrigants and
instrumented and irrigated prior to extraction (9, 10) medicaments into dentinal tubules (100, 101); and (3)
but the pre-operative pulpal status was not always known, reduce the sealing ability of obturation materials (102,
especially in laboratory studies. Furthermore, extracted 103). In truth, although, the clinical significance of the
teeth may be stored in a variety of media or be frozen, residual debris and smear layer is unknown. A recent
introducing another factor that may confound findings study reported that root canal isolates grew only when
(8183). The delivery and type of irrigants vary exposed to tissue fluids, such as blood, serum, and saliva;
considerably, with crucial details often omitted from they failed to thrive in pulp tissue or tooth components
the published papers. The quality of standardization and (104). The inference is that although residual debris
reporting is only occasionally better (84). It should be has become a marker for canal cleanliness in laboratory
noted that the use of EDTA as an irrigant is likely to studies, it is a poor outcome measure because a standard
influence the residual smear layer (85, 86). The position amount cannot be guaranteed pre-operatively and it has
of the working length relative to the root canal terminus no obvious clinical relevance.
is indicated in some studies, when it is frequently 1 mm
short of the apical foramen (8789). Less often, it was
Residual bacterial infection in the root canal
0.5 mm short (90) or at the apical foramen (63). Patency
system after mechanical debridement
filing was used by several groups (89, 91, 92) but was not
always reported. The number of uses of the files before Numerous studies have evaluated the effect of different
discarding, a factor that may influence the amount of stages of root canal treatment on the bacterial flora, in
smear layer, is quite variable. Depending upon the study, qualitative and sometimes also quantitative terms. They
file re-usage is not always reported; where reported, files represent a multitude of methodologies as well as
have been re-used in 10 canals (91, 92), three canals (93), treatment protocols. Some studies have merely re-
two canals (94), or not re-used at all (11, 95). ported positive culture tests, whereas others have
The vast majority of studies comparing various speciated and quantified the bacterial flora before and
mechanical methods of debridement attempt to after various stages of treatment. Accepting the
quantify the retained debris and smear layer. Prepared differences in methodologies as limitations for direct
sections may be examined under a microscope with a comparison, it was still possible to discern trends that
calibrated eyepiece micrometer (11) or the image may may be potentially helpful in framing new hypotheses.
be captured by a grid system (85), photomicrograph A number of studies have evaluated the effect of
(86), or digitized (94). The image is then quantified by mechanical preparation on the bacterial flora, using
a scoring system that is invariably subjective. Such water or saline as the irrigant (105110). They all noted
systems vary from simple criteria, such as debris a reduction in the bacterial flora with the achievement
present or absent (12, 96) to arbitrary three-, four-, of negative cultures in a proportion (mean 25%, range
five-, or seven-point scoring systems (11, 72, 88, 97). 4.653%). Data on individual bacterial species and their
Scores may be expressed in terms of amount of debris respective reduction rates were not available but one
or smear layer per root level or canal, or alternatively, as study made the broad observation that none of the pre-
percentage area of root surface occupied (90, 94, 98). treatment species was especially persistent after treat-
Given the subjective nature of the scoring, some form ment (108).
of reproducibility tests should be performed (11) but
are rarely reported. The latter studies also took the
Effect on mechanical properties of dentine
additional step of blinding the examiners to the
treatment groups. Standardization of the experimental Irrigation of the root canal system with water or saline is
protocol may aid comparison of studies. unlikely to induce changes in the mechanical properties
More crucially, the important question centers on the of root canal dentine (111, 112).
clinical relevance of the quantity of residual canal debris The mechanical properties of root dentine may be
and smear layer. There has been considerable debate affected by the extent of dentine removal; it is therefore

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Gulabivala et al.

prudent to be cautious about overinstrumentation. exposure to canal surfaces (instrumented and unin-
Interfacial forces are generated during pushpull filing strumented). It is self-evident that penetration of the
and can vary considerably by operator and instrument irrigant or medicament will be dependent upon
size (113, 114). The actual forces acting along the adequate apical enlargement (121, 122) and likely
length of the instrument are likely to be dictated by its canal taper (12, 123), as well as the delivery system and
relative flexibility and displaceability on the one hand fluid properties of the irrigant. It is surprising to note
and the cushioning effect of the periodontal ligament that the issue of irrigation dynamics has been so poorly
and alveolar bone, on the other. That is, dentine will be researched (124).
cut in those places where the interfacial and transla-
tional forces exceed the fracture strength of the dentine
Effect on canal contents
engaged by the sharp edges of the instrument. In
contrast, rotational instrumentation techniques, such Vital healthy pulps will be extirpated as previously
as balanced force, rely on actively engaging dentine described. However, the added benefit of a chemically
across opposing parts of the canal, in order to effect the active agent will be to promote organic tissue dissolu-
fracture of microchips of dentine. This allows stress to tion (10). The tissue-dissolving ability of NaOCl has
develop both within the dentine and the instruments been found to be related to the duration of exposure
(115, 116). (125) and its concentration and temperature (126). It is
The use of rotary nickeltitanium instruments has also dependent on the amount of organic tissue present,
introduced numerous other variables as potential the frequency and intensity of the irrigant fluid flow, and
contributors to induction of stress within the dentine, the available surface area for interaction (127).
including type of instrument, motor, tooth, canal Partially or completely necrotic pulps are dissolved
anatomy, and experience of operator (115, 117119). more easily (65, 82, 127129) but the efficacy of
So far, most of the research has focused on the effect of dissolving solution on the uninstrumented surfaces is
stress on the instrument, little effort has been put into dependent on an effective irrigation regime.
the effect of the same stress on the root dentine (116).
It is possible that such stress could also induce cracks or
Effect on instrumented surface and smear
fractures in the roots, although the sole study on this
layer
concluded that this was not a danger.
The smear layer is amenable to removal by chemical,
ultrasonic, and laser treatments (99). The present
Effect on chemical properties of dentine review focuses on the current evidence in relation to the
Irrigation of the root canal system with water or saline is efficacy of various chemical preparations that have been
unlikely to induce significant chemical changes in the used to remove the smear layer, either as a sole agent, in
root canal dentine (120). conjunction with other solutions, or with ultrasonic
energization.
Assuming that removal of the smear layer is a
Effect of chemical agents on root canal desirable outcome, an ideal root canal irrigant should
be biologically compatible, chemically able to remove
surfaces
both organic and inorganic substrates, be antibacterial,
As inferred earlier, the use of an active irrigant would demonstrate good surface wetting, have no adverse
seem desirable, given that a large proportion of the root effects on remaining tooth structure, and be easy to use
canal surface remains uninstrumented. The goal is to and effective within clinical parameters. No single agent
deliver the irrigant into the prepared radicular access appears to meet these criteria; those agents used and
and from there to disperse it into the uninstrumented tested are shown in Table 1. Their chemistry of action is
parts of the root canal system (62). In considering the covered elsewhere (127, 130133).
effects of the chemical or active agents used on the The vast research efforts on smear layer removal are
root canal contents and surfaces, it is necessary to take naturally predominantly laboratory studies, but un-
account of canal preparation dimensions, canal con- fortunately are difficult to compare because of lack of
tents, irrigation dynamics, chemical properties, and standardization of methodology. Most researchers have

110
Effects of mechanical and chemical procedures

Table 1. A classification of types of chemicals used for root canal irrigation

Type of chemical Generic and brand examples

Chelating agents EDTA, EDTAC, REDTA, Salvizol, Tublicid, RCPrep; Glyde; EGTA
(EDTA containing)

Halide complexes Sodium hypochlorite, tincture of iodine, povidoneiodine, iodine potassium iodide, oxidative potential
water (electrochemically activated water)

Acids Phosphoric acid, citric acid, lactic acid, polyacrylic acid, tannic acid, DMSA (dimercaptosuccinic acid)
(organic and inorganic)

Antibiotics Tetracycline hydrochloride, doxycycline hydrochloride

Oxidizing agents Hydrogen peroxide

Others Cetrimide, bardac-22 (quaternary ammonium compound), tergensol (0.2% lauryl sodium sulfate),
chlorhexidine, MTAD (tetracycline isomer, an acid, detergent), ethylenediamine, methylene blue dye,
titanium tetrafluoride, trientine hydrochloride (Syprine), Succimer (Chemet)

Organic solvents Chloroform, halothane, xylene, eucalyptus oil, orange oil

used decoronated teeth with unlimited access, perhaps rotary techniques may vary considerably from
giving false insight into effectiveness. Other experi- that formed using stainless-steel instrumentation be-
mental variables include the age, type, and sample size cause of the different mechanical and chemical forces
of teeth used, instrumentation techniques, irrigant in play. Furthermore, the chelating gels routinely
delivery systems, depth of penetration, volume, con- recommended for use with nickeltitanium instruments
centration and pH of agent, and duration of its use. As to avoid instrument breakage (139, 147, 151)
before, the outcome measures vary and include may significantly alter the nature of the smear layer
subjective scoring systems for debris and smear layer, formed (147). In the latter study, use of Glyde prep
as well as erosive effects on dentine. Reproducibility of in conjunction with 2.5% NaOCl resulted in a residual
scores by examiners and blinding of observations are smear layer. The differences in flow properties of
often overlooked, to add to the bias created by non- the agents (fluid vs. gel) may be a contributory factor.
randomized, selective examination of roots at different The plethora of liquid and paste-type chelators curr-
levels. Most images have been captured from the SEM ently available, their mode of action, advantages,
but a diverse range of sample preparation methods and and disadvantages have been well reviewed elsewhere
varying magnification has been used. (133).
The most common solutions used for smear layer EDTA was introduced to endodontics as a tool for
removal include: varying concentrations of NaOCl (15, negotiating narrow or sclerosed canals, where demi-
74, 65) and EDTA preparations (134139). These are neralization of root dentine on application of 15%
used either as sole irrigants or in conjunction with each EDTA was proportional to the observation time (152).
other (75, 140149). However, the demineralizing effect of the chelating
The quality and quantity of the smear layer produced agent is self-limiting, because it is exhausted (134).
may vary as chemo-mechanical instrumentation pro- Furthermore, organic material inhibits the action of
ceeds, depending on the mechanical approach, irrigant EDTA when used on its own; but when combined with
properties, and mode of delivery. During the early stages NaOCl, the quantity of inorganic material becomes the
of instrumentation, the smear layer may have a higher limiting factor (141). The combination of NaOCl and
organic content because of the presence of pulp tissue in EDTA produces a synergistic effect, resulting in
the canal. With the progressive dissolution of organic effective removal of the entire smear layer (142, 149).
substrate, the inorganic component may increase and be On the other hand, the latter study demonstrated a
more amenable to removal by EDTA (150). The nature reduced antibacterial effect of NaOCl when used in the
of the smear layer created with current nickeltitanium presence of EDTA.

111
Gulabivala et al.

Several agents have been combined with EDTA Various agents with surface wetting and antibacterial
in an attempt to improve surface wettability and properties have been added to EDTA or new agents
penetration into dentine. Earlier studies explored the have been tested in an attempt to improve the efficacy
use of NaOCl in conjunction with hydrogen peroxide of smear layer removal without deleterious effects on
but the combined cleaning effect was found to be dentine. Experimental evidence suggests that various
weakened (71, 142, 153, 154). A comparison of the EDTA-based solutions are not more successful at
cleaning effects of 2% chlorhexidine and NaOCl gave removal of the smear layer than those with EDTA
similar residual debris scores in the cervical third of roots alone (138, 158, 171, 172). Other agents introduced
with both agents, although smear layer removal was include oxidative potential water (OPW) (electroche-
poor (155). mically activated water) and tetracycline-based agents.
Numerous studies have evaluated the effectiveness of Electrochemically activated water has been used as a
inorganic and organic acids (Table 1) for smear layer commercial disinfectant, sterilizing agent and for
removal and found them to be highly effective, but too agricultural and industrial processes, without adverse
aggressive; their use has therefore not been universally effects on biological tissues (173, 174). It has proper-
adopted (136, 140, 154, 156161). ties similar to OPW developed by Japanese researchers
The effects of ultrasonic agitation of irrigants have (175, 169). Collective experimental findings from
been evaluated with contradictory results (85, 150, endodontic investigations indicate that these agents
162167). The reasons for this may include: lack of are ineffective in removing the smear layer efficiently,
attention to variation in power outputs of the ultrasonic unless combined with NaOCl or EDTA.
generators; frequencies of output; dimensions of files Tetracyline-based solutions may be potentially suc-
or tips used; and their mode of use. cessful irrigants because of their chelating and sustained
Despite the experimental variables inherent in the antibacterial actions. The efficacy of doxycycline
studies mentioned, it may be concluded that NaOCl is hydrochloride in removing the smear layer in the
efficient at debris removal in the coronal and middle middle and apical thirds of root canals has been noted
thirds of root canals but fails to disperse the smear layer (176); it was attributed to its acid pH of 2. There is no
and plugs from dentinal tubules (15). In addition, the information on its potential interaction with NaOCl
challenge of debridement of the apical anatomy has not regarding smear layer removal.
been fully resolved (71, 139, 155). Nevertheless, the A new solution for root canal irrigation, which
combination of agents, and the sequence in which they combines a tetracycline isomer, an acid, and a detergent
are used, clearly can enable better apical cleaning (140). (Biopure, Dentsply Tulsa, Tulsa, OK, USA) has
A final flush of NaOCl has been advocated, as EDTA recently been proposed (177, 178). The agent appears
may leave the organic part of the smear layer behind to be partially effective at removing the smear layer on
(168) and it also neutralizes the acidic effects of any its own but exhibits superior cleaning when used in
residual EDTA (147). conjunction with NaOCl. The erosive effects of this
The counter-side of the picture is that these alternat- combination are less than those of NaOCl and EDTA,
ing regimes of NaOCl and EDTA have adverse effects and it has been proposed for use with NaOCl (2.65%)
too (145, 146, 148, 169, 170). Two groups have as a final rinse. Added benefits apparently include
independently observed significant intertubular and broad-spectrum antibacterial effects sustained over
peritubular dental erosion in the middle third of roots time. The irrigant remains to be tested clinically.
treated with both 17% EDTA and 5.0% NaOCl.
Shorter application times and/or reduced volumes of
Effect on uninstrumented surface and
irrigants were proposed to minimize such damage,
biofilm layer
particularly in young patients. An irrigation regime
incorporating 4% titanium tetrafluoride (TTF), follow- Where there is an absence of a bacterial infection on the
ing irrigation with NaOCl and EDTA, has been uninstrumented surface, 2.5% and 5% NaOCl may
advocated to help re-mineralize the dentine (143). dissolve most of the predentine, exposing the globular
TTF supposedly forms a tenacious coating over the mineralizing front, the calcospherites (Fig. 7) (179).
enamel and cementum. This proposal remains to be Based on work evaluating the instrumented and
confirmed by other researchers. uninstrumented root canal surfaces, it may be reason-

112
Effects of mechanical and chemical procedures

debridement shows the benefit of the procedure (range


2598%, mean 73%) (181, 186). The majority of
studies have reported culture reversals during the inter-
appointment period without the aid of further active
antibacterial dressing between appointments. The
reversals were attributed to re-growth of residual
bacteria or re-contamination by bacterial leakage
around the access cavity restoration (105, 186189).
Other antibacterial irrigation and dressing agents
have also been used experimentally, including Biosept
(a quaternary ammonium compound) giving 32%
(107) and 40% (190) negative cultures, respectively;
Nebacin antibiotic giving 60% negative cultures (107);
and Cresatin/CMCP/polyantibiotic paste giving 76%
negative cultures (189).
The most significant series of studies (100, 108, 180,
182, 183) evaluated the effect of various root canal
treatment procedures on the bacterial flora both
qualitatively and quantitatively using standardized
methodology. The effects of mechanical preparation,
NaOCl irrigation (0.5%, 5.0%, 5.0% with EDTA), the
addition of ultrasonic activation, and calcium hydroxide
dressing were evaluated in series and each showed a
better antibacterial effect than the last. They collectively
also observed that the antibacterial action reduced the
Fig. 7. SEM views across the dentine surface showing the
mineralized dentine, and the irregular surface formed by number of bacteria from an initial range of 102108 cells
the mineralizing front of overlapping calcospherites. to 102103 fewer cells after initial debridement, further
reducing down to no recoverable cells after inter-
able to assume that the combination NaOCl and EDTA appointment dressing with calcium hydroxide.
would help to remove the biofilm layer (141). However, The benefit of dressing the root canal system with
there is no specific research investigating the degrada- calcium hydroxide directly after irrigation with water
tion of the residual biofilm on the uninstrumented (following mechanical preparation) has been confirmed
surface. Indirect evidence, if it may be called that, (109, 184), in addition to its use after irrigation with
suggests that the combined use of NaOCl and EDTA NaOCl (100, 191, 192). Only Peters et al. (193) found
facilitates better reduction of the bacterial load in root no obvious benefit of dressing with calcium hydroxide
canals of single-rooted teeth (180). The precise between visits.
mechanism is unknown but it may be hypothesized that Most importantly, Sundqvists group noted that the
it is because of a combination of EDTA: (1) helping to collective antibacterial action during root canal treat-
remove debris obstructing access to the uninstrumented ment in their material did not give rise to the
surfaces; and (2) chelating heavy metal ions that help to persistence of any particular species in the later visits.
bind bacterial cells together in the biofilm. They therefore concluded that there was an absence of
evidence that specific bacteria were implicated in
persistent infections (108). This view has been con-
Residual bacterial infection in the root canal
firmed for primary root canal treatment by several
system after chemomechanical debridement
groups (181, 185, 194). Gomes et al. (185) did,
Numerous studies (108, 180185) have used NaOCl however, reach the overall conclusion (based on both
irrigation (concentration range 0.55.25%) to supple- primary and secondary root canal treatments) that
ment mechanical preparation and the increased fre- certain species were more resistant to biomechanical
quency of negative cultures immediately after procedures than others.

113
Gulabivala et al.

The residual species in previously root-filled teeth Effect on chemical properties of dentine
with apical periodontitis appear to have root canal
The changes in mechanical properties of dentine as a
infections that are dominated by Gram-positive bacter-
result of root canal irrigants and dressings are almost
ia (195, 196), suggesting that incomplete root canal
certainly because of the altered chemical composition
debridement may allow these less fastidious bacteria to
of dentine. It has been conclusively shown that the
dominate the infection. These types of bacteria are
organic element of dentine (collagenous component) is
found infecting the dentine (35) and therefore may be a
depleted by soaking in NaOCl (120, 201), while the
source for recontamination of the root canal system.
mineral component is left relatively intact. If irrigation
Numerous in vitro studies have evaluated dentinal
with NaOCl is alternated with EDTA, the hydroxyap-
tubule infection and its treatment (33, 35, 197, 198).
patite is also degraded and consequently leads to
While such studies are important for understanding the
greater dentine strain and a change in visco-elastic
nature of tubule infection, the clinical relevance of
properties (201). The combined chemical effect of
studies evaluating the efficacy of eliminating single
NaOCl and EDTA explains both the changes in
species from radicular dentine remains questionable.
mechanical properties as well as the surface erosions
noticed in dentine as a result of aggressive irrigation.
Effect on mechanical properties of dentine
Medicaments and root-filling materials may influence Priorities for improvement in success
the physical and mechanical properties of dentine.
rates of root canal treatment
Eugenol-containing root canal sealers, for example, can
harden intra-canal dentine (199), while chloroform, The average success rate of root canal treatment has
xylene, and halothane soften dentine (200). NaOCl is been reported to be 74% with a range of 31100%
known to reduce the modulus of elasticity of dentine (205), while, using meta-regression in a framework of
(111, 112), as well as its flexural strength (111, 112). multi-level modelling, the mean probability of success
Dynamic mechanical analysis has revealed that while was estimated at 84% (206). The pre-operative pulpal
the visco-elastic properties of dentine are not altered by and periapical status of teeth are the most significant
NaOCl alone, when used in combination with EDTA, a factors affecting the success rate of root canal treatment
significant change is elicited (201). and therefore imply the predisposition of some teeth to
Irrigation with a 5.25% solution of NaOCl signifi- failure, regardless of treatment protocol (207209).
cantly increased the tooth surface strain of teeth using The single most important treatment factor influen-
cyclic non-destructive loading in a whole-tooth model. cing success is the apical extent of root filling, although
Furthermore, sequential repeated 30 min irrigation this probably implies both apical extents of canal
steps with 5.25% NaOCl did not result in a linear preparation as well as filling (207, 208, 210). The
increase in tooth surface strain, but one that plateaued probability of success is reduced if the root filling is
after the first two steps (111, 202). In contrast, extruded beyond the radiographic apex, regardless of
alternate irrigation with NaOCl and EDTA eliminated the presence or absence of pre-existing periapical
the plateau effect, with a continuously increasing tooth disease. The effect of root fillings flush with or short
surface strain (202), suggesting a more severe effect. of the radiographic apex depends upon the pre-
The dressing of root canals with calcium hydroxide existence of periapical disease. In the presence of
may also reduce the flexural strength of dentine but not periapical disease, flush root fillings result in a higher
the modulus of elasticity (112). If the dressing is left probability of success, while short root fillings would
long term, it could render teeth more susceptible to result in the reverse. In the absence of periapical disease,
fracture (203). A similar in vitro test protocol applied to short and flush root fillings result in an approximately
MTAD (Biopure) suggested that if used according to equal probability of success. The influence of the
clinical protocol, there was no change in the flexural mechanical preparation technique on success rate has
strength and modulus of elasticity of dentine. If, rarely been investigated (209, 211213). An important
however, a longer duration of contact was used, then clinical guideline in root canal treatment is the size to
changes in both properties were evident with MTAD which the canal is prepared apically; yet, its effect on
and EDTA (204). outcome has never been properly investigated and

114
Effects of mechanical and chemical procedures

where it is assessed, it gives contradictory results (209, however, their effectiveness in the apical anatomy
211, 212). Similarly, the effect of canal taper on depends upon a careful regimen and adequate mechan-
outcome has also not been specifically analyzed, but ical preparation. Overenthusiastic mechanical or che-
one study (208) suggested increased success rates with mical root canal preparation has severe consequences
greater canal flare. Instrumentation with nickeltita- on the mechanical properties of dentine and may
nium files may result in higher success rates compared render teeth more susceptible to fracture. Therefore, a
with stainless-steel files because of better maintenance balance has to be achieved in delivering antibacterial
of canal shape and access to apical anatomy (214). agents effectively to the apical anatomy while main-
Although numerous irrigants and medicaments have taining tooth strength and integrity.
been used during root canal treatment, their effects on The quantity of literature on smear layer removal
success rate have never been properly compared in seems in exaggerated proportion to that on the
randomized clinical trials. A number of studies (215 biological and clinical factors that are likely to influence
220) have reported a significantly higher chance of success rates of root canal treatment. It may be that this
success after obtaining a negative culture prior to obsession, partly driven by the desire for observing the
obturation, compared with a positive culture; the filling of root canal anatomy, radiographically, has
success rates were between 10% and 26% higher with coincidentally helped bacterial biofilm degradation in
a mean of 12%. However, others (210, 221224) have the uninstrumented parts of the root canal system. The
found no significant difference in success rates between precise dynamics and biological mechanisms leading to
pre-obturation positive and negative culture tests. successful root canal treatment still remain to be
Despite being researched extensively ex vivo, the determined. Upon achievement of such an under-
influence of canal cleanliness (presence of debris and standing, modifications to root canal treatment should
smear layer) prior to obturation, on success rate, has lead to an evidence-based improvement in success rates,
never been studied. There is a great need for properly including apical healing and tooth survival.
designed randomized-controlled trials to compare the
effect of different mechanical and chemical root canal
debridement protocols on the outcome of root canal Acknowledgments
treatment.
The authors would like to thank Nicky Mordan, Naomi
Richardson, and Shailesh Rojekar for producing the micro-
scopic views of the root canal surface.
Conclusions
Root canal treatment procedures bring about a multi-
References
tude of changes to the root canal surface, which can be
described in mechanical, chemical, and biological 1. Nair PNR. Light and electron microscope studies of
terms. The changes may be considered to be beneficial root canal flora and periapical lesions. J Endod 1987:
and/or damaging. Much of the above research has 13: 2933.
been driven by contemporary concepts upon which 2. Gulabivala K, Aung TH, Ng YL. Root canal morphol-
ogy of Burmese mandibular molars. Int Endod J 2001:
root canal treatment procedures are based. Unfortu-
34: 359370.
nately, these in turn are not always founded upon 3. Gulabivala K, Opasanon A, Alavi A. Root canal
clinical outcomes research. The latter suggests that the morphology of Thai mandibular molars. Int Endod J
presence or absence of residual infection in the apical 2002: 35: 5662.
4. Ng YL, Aung TH, Gulabivala K. Root canal morphol-
anatomy and length of root canal treatment are the
ogy of Burmese maxillary molars. Int Endod J 2001: 34:
prime determinants of success. 620630.
The principal aim of root canal preparation is 5. Alavi A, Opasanon A, Gulabivala K. Root canal
therefore to obtain and maintain access to the apical morphology of Thai maxillary molars. Int Endod J
anatomy, for the purpose of delivering antimicrobial 2002: 35: 478485.
6. Jardine S, Gulabivala K. An in-vitro comparison of canal
agents to the infection in this site. A combination of preparation using two automated rotary nickeltita-
NaOCl and EDTA remains the irrigant of choice for nium instrumentation techniques. Int Endod J 2000:
both smear layer removal and bacterial debridement; 33: 381391.

115
Gulabivala et al.

7. Biffi JCG, Rodrigues HH. Ultrasound in endodontics: a 24. Sen BH, Wesselink PR, Turkun M. The smear layer: a
quantitative and histological assessment using human phenomenon in root canal therapy. Int Endod J 1995:
teeth. Endod Dent Traumatol 1989: 5: 5562. 28: 141148.
8. Tjaderhane L, Salo T, Larjava H, Larmas M, Overall 25. Lomcali G, Sen BH, Cankaya H. Scanning electron
CM. A novel organ culture method to study the microscopic observations of apical root surfaces of teeth
function of human odontoblasts in vitro: gelatinase with apical periodontitis. Endod Dent Traumatol 1996:
expression by odontoblasts is differentially regulated by 12: 7076.
TGF-b1. J Dent Res 1998: 77: 14881498. 26. Siqueira JF, Lopes HP. Bacteria on the apical root
9. Walton RE. Histologic evaluation of different methods surfaces of untreated teeth with periradicular lesions: a
of enlarging the pulp canal space. J Endod 1976: 2: scanning electron microscopy study. Int Endod J 2001:
304311. 34: 216220.
10. Rosenfield EF, James GA, Burch BS. Vital pulp tissue 27. Thilo BE, Baelini P, Holtz J. Dark-field observation of
response to sodium hypochlorite. J Endod 1978: 4: the bacterial distribution in root canals followed pulp
140146. necrosis. J Endod 1986: 12: 202205.
11. Wu MK, Wesselink PR. Efficacy of three techniques in 28. Baumgartner JC, Falker WA Jr. Bacteria in the apical
cleaning the apical portion of curved root canals. Oral 5 mm of infected root canals. J Endod 1991: 17: 380
Surg Oral Med Oral Pathol Oral Radiol Endod 1995: 383.
79: 492496. 29. Dougherty WJ, Bae KA, Watkins BJ, Baumgartner JC.
12. Evans GE, Speight PM, Gulabivala K. The influence of Black-pigmented bacteria in coronal and apical seg-
preparation technique and sodium hypochlorite on ments of infected root canals. J Endod 1998: 24:
removal of pulp and predentine from root canals of 356358.
posterior teeth. Int Endod J 2001: 34: 322330. 30. Spratt DA, Pratten J, Wilson M, Gulabivala K. The
13. Haga CS. Microscopic measurements of root canal in vitro effect of antiseptic agents on bacterial biofilms
preparations following instrumentation. J Br Endod Soc generated from selected root canal isolates. Int Endod J
1968: 2: 4145. 2001: 34: 300307.
14. Gutierrrez JH, Garcia J. Microscopic and macroscopic 31. OToole G, Kaplan HB, Kolter R. Biofilm formation as
investigation on results of mechanical preparation of microbial development. Ann Rev Microbiol 2000: 54:
root canals. Oral Surg Oral Med Oral Pathol 1968: 25: 4979.
108116. 32. Wilson M. Bacterial biofilms and human disease. Sci
15. Moodnik RM, Dorn SO, Feldman MJ, Meadow E, Prog 2001: 84: 235254.
Levely M, Brook S, Borden BG. Efficacy of biomecha- 33. Oguntebi BR. Dentine tubule infection and endo-
nical instrumentation: a scanning electron microscopic dontic therapy implications. Int Endod J 1994: 27:
study. J Endod 1976: 2: 261267. 218222.
16. Kinney JH, Marshall SJ, Marshall GW. The mechanical 34. Peters LB, Wesselink PR, Moorer WK. The fate and role
properties of human dentin: a critical review and re- of bacteria left in root canal dentinal tubules. Int Endod
evaluation of the dental literature. Crit Rev Oral Biol J 1995: 28: 9599.
Med 2003: 14: 1329. 35. Love RM, Jenkinson HF. Invasion of dentinal tubules
17. Marshall GW. Dentin: microstructure and characterisa- by oral bacteria. Crit Rev Oral Biol Med 2002: 13: 171
tion. Quintessence Int 1993: 24: 606617. 183.
18. Torneck CD. Dentinepulp complex. In: Ten Cate AR, 36. Ando A, Hoshino E. Predominant obligate anaerobes
ed. Oral Histology, Development, Structure and Func- invading the deep layers of root canal dentine. Int
tion, 5th edn. St. Louis: Mosby Inc, 1998: 150196. Endod J 1990: 23: 2027.
19. Mjor IA, Smith MR, Ferrari M, Mannocci F. The 37. Horiba N, Maekawa Y, Matsumoto T, Nakamura H. A
structure of dentine in the apical region of human teeth. study of the distribution of endotoxin of infected root
Int Endod J 2001: 34: 346353. canals. J Endod 1990: 16: 331334.
20. Moss-Salentijn L, Klyvert MH. Epithelially induced 38. Burke FJT. Tooth fracture in vivo and in vitro. J Dent
denticles in the pulps of recent, erupted noncarious 1992: 20: 131139.
human premolars. J Endod 1983: 9: 554560. 39. Vale WA. Cavity preparation. Irish Dent Rev 1956: 2:
21. Shovelton DS. The presence and distribution of 3341.
microorganisms within non-vital teeth. Br Dent J 40. Mondelli J, Steagall I, Ishikiriama A, Navarro MF,
1964: 117: 101107. Soares FB. Fracture strength of human teeth with cavity
22. Andreasen JO, Rud J. A histo-bacteriologic study of preparations. J Prosth Dent 1980: 43: 419422.
dental and periapical structures after endodontic 41. Larson TD, Douglas WH, Geistfeld Effect of prepared
surgery. Oral Surg Oral Med Oral Pathol 1972: 1: cavities on the strength of teeth. Operat Dent 1981: 6:
272281. 25.
23. Molven O, Olsen I, Kerekes K. Scanning electron 42. Panitvisai P, Messer HH. Cuspal deflection in molars in
microscopy of bacteria in the apical part of root canals in relation to endodontic and restorative procedures.
permanent teeth with periapical lesions. Endod Dent 1995: 21: 5761.
Traumatol 1991: 7: 226229.

116
Effects of mechanical and chemical procedures

43. Cavel WT, Kelsey WP, Blankenhall RJ. An in vivo study 61. Randow K, Glantz PO. On cantilever loading of vital
of cuspal fracture. J Prosth Dent 1985: 53: 3841. and non-vital teeth an experimental clinical study.
44. Hansen EK, Asmussen E, Christiansen NC. In vivo Acta Odontol Scand 1986: 44: 271277.
fractures of endodontically treated posterior teeth 62. Gulabivala K. Preparation of the root canal. In: Stock
restored with amalgam. Endod Dent Traumatol, 6: CJR, Gulabivala K, Walker RT, Goodman J, eds. Color
4955. Atlas and Text of Endodontics, 2nd edn. London:
45. Khera SC, Carpenter CW, Vetter JD, Staley RN. Mosby-Wolfe, 1995: 97144.
Anatomy of cusps of posterior teeth and their fracture 63. Coffae KD, Brilliant JD. The effect of serial preparation
potential. J Prosth Dent 1990: 64: 139147. versus non-serial preparation on tissue removal in the
46. Reeh ES, Messer HH, Douglas WH. Reduction in root canals of extracted mandibular molars. J Endod
tooth stiffness as a result of endodontic & restorative 1975: 1: 211214.
procedures. J Endod 1989: 15: 512516. 64. Baker NA, Eleazor PD, Averbach RE, Seltzer S.
47. Howe CA, McKendry DJ. Effect of endodontic access Scanning electron microscope study of the efficacy
preparation on resistance to crown-root fracture. J Am of various irrigating solutions. J Endod 1975: 1:
Dent Assoc 1990: 121: 712715. 127135.
48. Hansen EK, Asmussen E. Cusp fracture of endodonti- 65. Baumgartner C, Cuenin PR. Efficacy of several con-
cally treated posterior teeth restored with amalgam centrations of sodium hypochlorite for root canal
teeth restored in Denmark before 1975 versus after irrigation. J Endod 1992: 18: 605612.
1979. Acta Odontol Scand 1993: 51: 7377. 66. Peters OA, Laib A, Gohring TN, Barbakow F. Changes
49. Helfer AR, Melnick S, Schilder H. Determination of the in root canal geometry after preparation assessed by
moisture content of vital and pulpless teeth. Oral Surg high-resolution computed tomography. J Endod
Oral Med Oral Pathol 1972: 34: 661670. 2001a: 27: 16.
50. Huang TG, Schilder H, Nathanson D. Effects of 67. Peters OA, Schonenberger K, Laib A. Effects of four
moisture content and endodontic treatment on some NiTi preparation techniques on root canal geometry
mechanical properties of human dentine. J Endod assessed by micro-computed tomography. Int Endod J
1992: 18: 209215. 2001b: 34: 221230.
51. Jameson MW, Hood JAA, Tidmarsh BG. The effects of 68. Peters OA, Peters CI, Schonenberger K, Barbakow F.
dehydration and rehydration on some mechanical ProTaper rotary root canal preparation: effects of canal
properties of human dentine. J Biomech 1993: 26: anatomy on final shape analysed by microCT. Int Endod
10551065. J 2003: 36: 8692.
52. Jameson MW, Tidmarsh BG, Hood JAA. Effect of 69. Hubscher W, Barbakow F, Peters OA. Root canal
storage media on subsequent water loss and regain by preparation with FlexMaster: canal shapes analysed by
human and bovine dentine and on mechanical proper- micro-computed tomography. Int Endod J 2003: 36:
ties of human dentine in vitro. Arch Oral Biol 1994: 39: 740747.
759767. 70. Mannan G, Smallwood E, Gulabivala K. The influence
53. Papa J, Cain C, Messer HH. Moisture content of vital vs of access cavity design on filing of canals in anterior
endodontically treated teeth. Endod Dent Traumatol teeth. Int Endod J 2001: 34: 176183.
1994: 10: 9193. 71. McComb D, Smith DC. A preliminary scanning
54. Rivera E, Yamaguchi G, Chandler G, Bergenholtz G. electron microscopic study of root canals after endo-
Dentine collagen cross-links of root filled and normal dontic procedure. J Endod 1975: 1: 238243.
teeth. J Endod 1988: 14: 195. 72. Hulsmann M, Rummelin C, Schafers F. Root canal
55. Rivera E, Yamauchi M. Dentin collagen cross-links of cleanliness after preparation with different endodontic
root-filled teeth and normal teeth. J Endod 1990: 16: handpieces and hand instruments: a comparative SEM
190. investigation. J Endod 1997: 23: 301306.
56. Lewinstein I, Grajower R. Root dentine hardness of 73. McComb D, Smith DC, Beagrie GS. The results of in
endodontically treated teeth. J Endod 1981: 7: 421422. vivo endodontic chemomechanical instrumentation a
57. Carter JM, Sorensen SE, Johnson RR, Teitelbaum RL, scanning electron microscope study. J Br Endod Soc
Levine MS. Punch shear testing of extracted vital and 1976: 9: 1117.
endodontically treated teeth. J Biomech 1983: 16: 841 74. Mader C, Baumgartner J, Peters D. Scanning electron
848. microscopic investigation of the smeared layer on root
58. Sedgley CM, Messer HH. Are endodontically treated canal walls. J Endod 1984: 10: 477483.
teeth more brittle? J Endod 1992: 18: 332335. 75. Cengiz T, Aktener B, Piskin B. The effect of dentinal
59. Kinney JH, Marshall SJ, Marshall GW. The mechanical tubule orientation on the removal of smear layer by root
properties of human dentine: a critical review and re- canal irrigants. A scanning electron microscopic study.
evaluation of the dental literature. Crit Rev Oral Biol Int Endod J 1990: 23: 163171.
Med 2003: 14: 1329. 76. Aktener BO, Cengiz T, Piskin B. The penetration of
60. Lowenstein NR, Rathkamp R. A study on the presso- smear material into dentinal tubules during instrumen-
receptive sensibility of the tooth. J Dent Res 1955: 34: tation with surface active reagents: a scanning electron
287294. microscopic study. J Endod 1989: 15: 588590.

117
Gulabivala et al.

77. Eick JD, Wilko RA, Anderson CH, Sorenson SE. tec SC rotary NiTi instruments. Int Endod J 2003b: 36:
Scanning electron microscopy of cut tooth surfaces 748756.
and identification of debris by use of the electron 93. Bechelli C, Zecchi Orlandini S, Colafranceschi M.
microprobe. J Dent Res 1970: 49: 13591368. Scanning electron microscope study on the efficacy of
78. Pashley D, Tao L, Boyd L. Scanning electron micro- root canal wall debridement of hand versus Lightspeed
scopy of the substructure of smear layers in human instrumentation. Int Endod J 1999: 32: 484493.
dentine. Arch Oral Biol 1988: 33: 265270. 94. Usman N, Baumgartner JC, Marshall JG. Influence of
79. Pashley D. Smear Layer: overview of structure and instrument size on root canal debridement. J Endod
function. Proc Finn Dent Soc 1992: 88(Suppl 1): 215 2004: 30: 110112.
224. 95. Schafer E, Zapke K. A comparative scanning electron
80. Czonstkowsky M, Wilson EG, Holstein FA. The smear microscopic investigation of the efficacy of manual and
layer in endodontics. Dent Clin North Am 1990: 34: automated instrumentation of root canals. J Endod
1325. 2000: 26: 660664.
81. Svec TA, Harrison JW. Chemomechanical removal of 96. Suffridge CB, Hartwell GR, Walker TL. Cleaning
pulpal and dentinal debris with sodium hypochlorite efficiency of nickel-titanium GT and .04 rotary files
and hydrogen peroxide vs normal saline solution. when used in a torque-controlled rotary handpiece. J
J Endod 1977: 3: 4953. Endod 2003: 29: 346348.
82. The SD. The solvent action of sodium hypochlorite on 97. Cameron JA. The choice of irrigant during hand
fixed and unfixed necrotic tissue. Oral Surg Oral Med instrumentation and ultrasonic agitation of the root
Oral Pathol 1979: 47: 558561. canal: a scanning electron microscope study. Aust Dent
83. Yang SF, Rivera EM, Walton RE, Baumgartner KR. J 1995b: 40: 8590.
Canal debridement: effectiveness of sodium hypochlor- 98. Fariniuk LF, Baratto-Filho F, da Cruz-Filho AM, de
ite and calcium hydroxide as medicaments. J Endod Sousa-Neto MD. Histologic analysis of the cleaning
1996: 22: 521525. capacity of mechanical endodontic instruments acti-
84. Huulsmann M, Gressmann G, Schafers F. A compara- vated by the ENDOflash system. J Endod 2003: 29:
tive study of root canal preparation using FlexMaster 651653.
and HERO 642 rotary NiTi instruments. Int Endod J 99. Torabinejad M, Handysides R, Khademi AA, Bakland
2003a: 36: 358366. LK. Clinical implications of the smear layer in
85. Mayer BE, Peters OA, Barbakow F. Effects of rotary endodontics: a review. Oral Surg Oral Med Oral Pathol
instruments and ultrasonic irrigation on debris and Oral Radiol Endod 2002: 94: 658666.
smear layer scores: a scanning electron microscopic 100. Bystrom A, Claesson R, Sundqvist G. The antibacterial
study. Int Endod J 2002: 35: 582589. effect of camphorated paramonochlorophenol, cam-
86. Gambarini G, Laszkiewicz J. A scanning electron phorated phenol and calcium hydroxide in the treat-
microscopic study of debris and smear layer remaining ment of infected root canals. Endod Dent Traumatol
following use of GT rotary instruments. Int Endod J 1985: 1: 170175.
2002: 35: 422427. 101. rstavik D, Haapasalo M. Disinfection by endodontic
87. Lumley PJ. Cleaning efficacy of two apical preparation irrigants and dressings of experimentally infected
regimens following shaping with hand files of greater dentinal tubules. Endod Dent Traumatol 1990: 6:
taper. Int Endod J 2000: 33: 262265. 142149.
88. Jeon IS, Spangberg LS, Yoon TC, Kazemi RB, Kum KY. 102. Saunders WP, Saunders EM. The effect of smear layer
Smear layer production by 3 rotary reamers with different upon the coronal leakage of gutta-percha fillings and a
cutting blade designs in straight root canals: a scanning glass ionomer sealer. Int Endod J 1992: 25: 245249.
electron microscopic study. Oral Surg Oral Med Oral 103. Oksan T, Aktener BO, Sen BH, Tezel H. The
Pathol Oral Radiol Endod 2003: 96: 601607. penetration of root canal sealers into dentinal tubules.
89. Schafer E, Vlassis M. Comparative investigation of two A scanning electron microscopic study. Int Endod J
rotary nickel-titanium instruments: protaper versus 1993: 26: 301305.
RaCe. Part 2. Cleaning effectiveness and shaping ability 104. Khot A, Spratt DA, NG Y-L, Gulabivala K. Utilisation
in severely curved root canals of extracted teeth. Int of nutritional resources by root canal isolates. Int Endod
Endod J 2004: 37: 239248. J 2004: 37: 345346.
90. Barbizam JV, Fariniuk LF, Marchesan MA, Pecora JD, 105. Ingle JI, Zeldow BJ. An evaluation of mechanical
Sousa-Neto MD. Effectiveness of manual and rotary instrumentation and the negative culture in endodontic
instrumentation techniques for cleaning flattened root therapy. J Am Dent Assoc 1958: 57: 471476.
canals. J Endod 2002: 28: 365366. 106. Nicholls E. The efficacy of cleansing of the root canal.
91. Rodig T, Hulsmann M, Muhge M, Schafers F. Quality Br Dent J 1962: 112: 167170.
of preparation of oval distal root canals in mandibular 107. Grahnen H, Krasse B. The effect of instrumentation
molars using nickeltitanium instruments. Int Endod J and flushing of non-vital teeth in endodontic therapy.
2002: 35: 919928. Odontol Rev 1963: 14: 167177.
92. Hulsmann M, Herbst U, Schafers F. Comparative study 108. Bystrom A, Sundqvist G. Bacteriologic evaluation of
of root-canal preparation using Lightspeed and Quan- the efficacy of mechanical root canal instrumentation

118
Effects of mechanical and chemical procedures

in endodontic therapy. Scand J Dent Res 1981: 89: endodontic irrigant. Oral Surg Oral Med Oral Pathol
321328. 1980: 49: 175176.
109. rstavik D, Kerekes K, Molven O. Effects of extensive 127. Moorer WR, Wesselink PR. Factors promoting the
apical reaming and calcium hydroxide dressing on tissue dissolving capability of sodium hypochlorite. Int
bacterial infection during treatment of apical period- J Endod 1982: 15: 187196.
ontitis: a pilot study. Int Endod J 1991: 24: 17. 128. Hand RE, Smith ML, Harrison JW. Analysis of the
110. Dalton CB, rstavik D, Phillips C, Pettiette M, Trope effect of dilution on the necrotic tissue dissolution
M. Bacterial reduction with nickeltitanium rotary property of sodium hypochlorite. J Endod 1978: 4: 60
instrumentation. J Endod 1999: 24: 763767. 64.
111. Sim TP, Knowles J, Ng YL, Shelton J, Gulabivala K. 129. Gordon TM, Damato D, Christner P. Solvent effect of
Effect of sodium hypochlorite irrigant concentration on various dilutions of sodium hypochlorite on vital and
strain in teeth. Int Endod J 2001: 34: 120132. necrotic tissue. J Endod 1981: 7: 466469.
112. Grigoratos D, Knowles J, Ng Y-L, Gulabivala K. Effect 130. Fraser JG. Chelating agents: their softening effect on
of exposing dentine to sodium hypochlorite and root canal dentin. Oral Surg Oral Med Oral Pathol
calcium hydroxide on its flexural strength and elastic 1974: 37: 803811.
modulus. Int Endod J 2001: 34: 113119. 131. Seidberg BH, Schilder H. An evaluation of EDTA in
113. Regan JD, Sherrif M, Meredith N, Gulabivala K. A endodontics. Oral Surg Oral Med Oral Pathol 1974:
survey of interfacial forces used during filing of 37: 609620.
root canals. Endod Dent Traumatol 2000: 16: 101 132. Dow PR. EDTA-time for re-evaluation? Int Endod J
106. 1984: 17: 25.
114. Gulabivala K, Abdo S, Sherrif M, Regan JD. The 133. Hulsmann M, Heckendorff M, Lennon A. Review.
influence of interfacial forces and duration of filing on Chelating agents in root canal treatment: mode of
root canal shaping. Endod Dent Traumatol 2000: 16: action and indications for their use. Int Endod J 2003c:
166174. 36: 810830.
115. Blum JY, Machtou P, Esber S, Micallef JP. Analysis of 134. Von der Fehr FR, Nygaard stby B. Effect of EDTAC
forces developed during root canal preparation with the and sulfuric acid on root canal dentine. Oral Surg Oral
balanced force technique. Int Endod J 1997: 30: 386 Med Oral Pathol 1963: 16: 199205.
396. 135. Goldberg F, Abramovich A. Analysis of the effect of
116. Mayhew JT, Eleazer PD, Hnat WP. Stress analysis of EDTAC on the dentinal walls of the root canal. J Endod
human tooth root using various root canal instruments. 1977: 3: 101105.
J Endod 2000: 26: 523524. 136. Garberoglio R, Beece C. Smear layer removal by root
117. Sattapan B, Palamara JE, Messer HH. Torque during canal irrigants. Oral Surg Oral Med Oral Pathol 1994:
canal instrumentation using rotary nickeltitanium 78: 359367.
files. J Endod 2000: 26: 156160. 137. Hottel TL, El-Refai N, Jones JJ. A comparison of the
118. Peters OA, Barbakow F. Dynamic torque and apical effects of three chelating agents of the root canal of
forces of ProFile .04 rotary instruments during extracted human teeth. J Endod 1999: 25: 716717.
preparation of curved canals. Int Endod J 2002: 35: 138. Verdelis K, Eliades G, Oviir T, Margelos J. Effect of
379389. chelating agents on the molecular composition and
119. Peters OA, Peters CI, Schonenberger K, Barbakow F. extent of decalcification at cervical, middle and apical
ProTaper rotary root canal preparation: assessment of root dentin locations. Endod Dent Traumatol 1999:
torque and force in relation to canal anatomy. Int Endod 15: 164170.
J 2003: 36: 9399. 139. OConnell MS, Morgan LA, Beeler WJ, Baumgartner
120. ODriscoll Dowker S, Anderson P, Wilson R, Gulabi- JC. A comparative study of smear layer removal using
vala K. Effects of sodium hypochlorite solution on root different salts of EDTA. J Endod 2000: 26: 739744.
dentine composition. J Mater Sci Mat Med 2002: 13: 140. Yamada RS, Armas A, Goldman M, Sun Lin P. A
219223. scanning electron microscopic comparison of high
121. Ram Z. Effectiveness of root canal irrigation. Oral Surg volume final flush with several irrigating solutions: part
Oral Med Oral Pathol 1977: 44: 306312. 3. J Endod 1983: 9: 137142.
122. Chow TW. Mechanical effectiveness of root canal 141. Baumgartner C, Mader CL. A scanning electron
irrigation. J Endod 1983: 9: 475479. microscopic evaluation of four root canal irrigation
123. Machtou P. Personal communication based on unpub- regimens. J Endod 1987: 13: 147156.
lished research, 2003. 142. Baumgartner JC, Ibay AC. The chemical reactions of
124. Harrison JW. Irrigation of the root canal system. Dent irrigants used for root canal debridement. J Endod
Clin North Am 1984: 28: 797808. 1987: 13: 4751.
125. Senia ES, Marshall FJ, Rosen S. The solvent action of 143. Hakan B, Buyukyilmaz T. The effect of 4% titanium
sodium hypochlorite on pulp tissue of extracted teeth. tetrafluoride solution on root canal walls a preliminary
Oral Surg Oral Med Oral Pathol 1971: 31: 6103. investigation. J Endod 1998: 24: 239243.
126. Cunningham WT, Balekjian AY. Effect of temperature 144. Tatutsa CT, Morgan LA, Baumgartner JC, Adey JD.
on collagen-dissolving ability of sodium hypochlorite Effect of CaOH and 4 irrigation regimens on instru-

119
Gulabivala et al.

mented and uninstrumented canal wall topography. cavity walls. Bull Group Int Rech Sci Stomatol Odontol
J Endod 1999: 25: 9398. 2001: 43: 4652.
145. Calt S, Serper A. Smear layer removal by EGTA. 162. Cameron JA. The use of ultrasonics in the removal of
J Endod 2000: 26: 459461. the smear layer: a scanning electron microscope study.
146. Calt S, Serper A. Time dependent effects of EDTA on J Endod 1983: 9: 289292.
dentine structures. J Endod 2002: 28: 1719. 163. Cameron JA. Factors affecting the clinical efficiency of
147. Grandini S, Balleri P, Ferrari M. Evaluation of Glyde ultrasonic endodontics: a scanning electron microscopy
File Prep in combination with sodium hypochlorite as a study. Int Endod J 1995a: 28: 4753.
root canal irrigant. J Endod 2002: 28: 300303. 164. Abbott PV, Heijkoop PS, Cardaci SC, Hume WR.
148. Niu W, Yoshiaka T, Kobayashi C, Suda H. A scanning Heithersay. An SEM study of the effects of different
electron microscopic study of dentinal erosion by final irrigation sequences and ultrasonics. Int Endod J 1991:
irrigation with EDTA and NaOCL solution. Int Endod 24: 308316.
J 2002: 35: 934939. 165. Panghini M, Jacquot B. Scanning electron microscopic
149. Grawehr M, Sener B, Waltimo T, Zehnder M. Interac- evaluation of ultrasonic debridement comparing so-
tions of ethylenediamine tetracetic acid with sodium dium hypochlorite and Bardac-22. J Endod 1995: 21:
hypochlorite in aqueous solutions. Int Endod J 2003: 272276.
36: 411415. 166. Yoshida T, Shibata T, Shinohara T, Gomyo S, Sekine I.
150. Cameron JA. The use of ultrasound in removal of the Clinical evaluation of the efficacy of EDTA solu-
smear layer. The effect of sodium hypochlorite con- tion as an endodontic irrigant. J Endod 1995: 21:
centration; SEM study. Aust Dent J 1988: 33: 193 592593.
200. 167. Guerisoli DMZ, Marchesan MA, Walmsley AD, Lumley
151. Lim TS, Wee TY, Choi MY, Koh WC, Sae-Lim V. Light PJ, Pecora JD. Evaluation of smear layer removal by
and scanning electron microscopic evaluation of Glyde EDTAC and sodium hypochlorite with ultrasonic
File Prep in smear layer removal. Int Endod J 2003: 36: agitation. Int Endod J 2002: 35: 418421.
336343. 168. Goldman M, Goldman LK B, Cavaleri R, Bogis J, Sun
152. Nygaard-stby B. Chelation in root canal therapy: Lin P. The efficacy of several endodontic irrigating
ethylenediaminetetracetic acid for cleansing and widen- solutions:: part 2. J Endod 1982: 8: 487492.
ing root canals. Odontol Tidskr 1957: 65: 311. 169. Serper A, Calt S, Dogan AL, Guc D, Ozcelikk Kuraner
153. Tidmarsh B G. Acid-cleansed and resin-sealed Root T. Comparision of the cytotoxic effects of smear layer
canals. J Endod 1978: 4: 117121. removing capacity of oxidative potential water, NaOCl
154. Berry EA, Von der Lehr WN, Herrin HK. Dentine and EDTA. J Oral Sci 2001: 43: 233238.
surface treatments for removal of the smear layer: an 170. Yoshioka WN, Kobayashi C, Suda H. A scanning
SEM study. J Am Dent Assoc 1987: 115: 6567. electron microscopic study of dentinal erosion by final
155. Yamashita JC, Tanomaru M, Leonardo MR, Rossi MA, irrigation with EDTA and NaOCl solutions. Int J
Silva LAB. Scanning electron microscopic study of the Endod 2002: 35: 934939.
cleaning ability of chlorhexidine as a root-canal irrigant. 171. Goldberg F, Spielberg C. The effect of EDTAC and the
Int Endod J 2003: 36: 391394. variation of its working time analysed with scanning
156. Baumgartner C, Brown CM, Mader CL, Peters DD, electron microscopy. Oral Surg Oral Med Oral Pathol
Shulman JD. A scanning electron microscopic evalua- 1982: 53: 7477.
tion of root canal debridement using saline, sodium 172. Berg MS, Jacobsen EA, BeGole EA, Remeikis NA. A
hypochlorite, and citric acid. J Endod 1984: 10: 525 comparison of five irrigating solutions: a scanning
530. electron microscope study. J Endod 1986: 12: 192
157. Bitter NC. A 25% tannic acid solution as a root 197.
canal irrigant cleanser: a scanning electron microscope 173. Marais JT. Cleaning efficacy of a new root canal
study. Oral Surg Oral Med Oral Pathol 1989: 67: 333 irrigation solution: a preliminary evaluation. Int Endod
337. J 2000: 33: 320325.
158. Liolios E, Economides N, Parissis-Messimeris B. The 174. Solovyeva AM, Dummer PMH. Cleaning effectiveness
effectiveness of three irrigating solutions on root canal of root canal irrigation with electrochemically activated
cleaning after hand and mechanical preparation. Int anolyte and catholyt solutions: a pilot study. Int J Endod
Endod J 1997: 30: 5157. 2000: 33: 494504.
159. Morgan LA, Baumgartner C. Demineralization of 175. Hata G, Hayami S, Weine FS, Toda T. Effectiveness of
resected root-ends with methylene blue dye. Oral Surg oxidative potential water as a root canal irrigant. Int
Oral Med Oral Pathol Oral Radiol Endod 1997: 84: Endod J 2001: 34: 308317.
7478. 176. Barkhordar RA, Watanabe LG, Marshall GW, Hussain
160. Sabbak SA, Hassanin M B. A scanning electron MZ. Removal of intracanal smear by doxycycline in
microscopic study of tooth surface changes induced vitro. Oral Surg Oral Med Oral Pathol Oral Radiol
by tanninc acid. J Prosth Dent 1998: 79: 169174. Endod 1997: 84: 420423.
161. Luz M, Garone Netto N, Arana-Chavez VE. SEM study 177. Torabinejad M, Khademi AA, Babagoli J, Cho Y,
of different treatments of the smear layer on different Johnson WB, Bozhilov K, Kim J, Shabahang S. A new

120
Effects of mechanical and chemical procedures

solution for the removal of the smear layer. J Endod 194. Olgart LG. Bacteriological sampling from root canals
2003a: 29: 170175. directly after chemo-mechanical treatment: a clinical
178. Torabinejad M, Yongbum C, Khademi AA, Bakland and bacteriological study. Acta Odontol Scand 1969:
LK, Shabahang S. The effect of various concentrations 27: 91103.
of sodium hypochlorite on the ability of MTAD to 195. Sundqvist G, Figdor D, Persson S. Microbiological
remove the smear layer. J Endod 2003b: 29: 233239. analysis of teeth with failed endodontic treatment and
179. Koskinen KP, Meurman JH, Stenvell H. Appearance of outcome of conservative re-treatment. Oral Surg Oral
chemically treated root canal walls in the scanning Med Oral Pathol 1988: 85: 8693.
electron microscope. Scand J Dent Res 1980: 88: 397 196. Molander A, Reit C, Dahlen G, Kvist T. Microbiolo-
405. gical status of root-filled teeth with apical periodontitis.
180. Bystrom A, Sundqvist G. The antibacterial action of Int Endod J 1998: 31: 17.
sodium hypochlorite and EDTA in 60 cases of 197. Haapasalo M, rstavik D. In vitro infection and
endodontic therapy. Int Endod J 1985: 18: 3540. disinfection of dentinal tubules. J Dent Res 1987: 66:
181. Cvek M, Nord C-E, Hollender L. Antimicrobial effect 13751379.
of root canal debridement in teeth with immature roots. 198. Taniverdi F, Esener T, Erganis O, Belli S. An in vitro
A clinical and microbiological study. Odontol Rev 1976: test model for investigation of disinfection of dentinal
27: 110. tubules infected with Enterococcus faecalis. Braz Dental
182. Bystrom A, Sundqvist G. Bacteriologic evaluation of J 1997: 8: 6772.
the effect of 0.5% sodium hypochlorite in endodontic 199. Biven GM, Bapna MS, Heuer MA. Effect of eugenol
therapy. Oral Surg Oral Med Oral Pathol 1983: 55: and eugenol-containing root canal sealers on the
307312. microhardness of human dentine. J Dent Res 1972:
183. Sjogren U, Sundqvist G. Bacteriologic evaluation of 51: 16021609.
ultrasonic root canal instrumentation. Oral Surg Oral 200. Rotstein I, Cohenca N, Teperovich E, Moshonov J,
Med Oral Pathol 1987: 63: 366370. Mor C, Roman I, Gedalia I. Effect of chloroform,
184. Yared GM, Bou Dagher FE. Influence of apical xylene, halothane on enamel and dentine microhard-
enlargement on bacterial infection during treatment ness of human teeth. Oral Surg Oral Med Oral Pathol
of apical periodontitis. J Endod 1994: 20: 535537. 1999: 87: 366368.
185. Gomes BPFA, Lilley JD, Drucker DB. Variations in the 201. Reddington LP, Knowles JC, Nazhat SN, Young A,
susceptibility of components of the endodontic micro- Gulabivala K. An in vitro evaluation of the visco-elastic
flora to bio-mechanical procedures. Int Endod J 1996: behaviour and composition of dentine matrix soaked in
29: 235241. EDTA and NaOCl independently and in combination.
186. Stewart GG, Cobe HM, Rappaport H. A study of a new Int Endod J 2003: 36: 939.
medicament in the chemomechanical preparation of 202. Rajasingham R, Knowles JC, Ng Y-L, Sobhani O,
infected root canals. J Am Dent Assoc 1961: 63: 33. Rahbaran S, Gulabivala K. The effect of root canal
187. Myers JW, Marshall FJ, Rosen S. The incidence and irrigation with sodium hypochlorite and EDTA on
identity of microorganisms present in root canals at tooth surface strain. Int Endod J 2003: 36: 932.
filling following culture reversals. Oral Surg Oral Med 203. Andreasen JO, Farik B, Munksgaard EC. Long-term
Oral Pathol 1969: 28: 889896. calcium hydroxide as a root canal dressing may increase
188. Bence R, Madonia JV, Weine FS, Smulson MH. A risk of root fracture. Dent Traumatol 2002: 18: 134
microbiologic evaluation of endodontic instrumenta- 137.
tion in pulpless teeth. Oral Surg Oral Med Oral Pathol 204. Machnick TK, Torabinejad M, Munoz CA, Shabahang
1973: 35: 676683. S. Effect of MTAD on flexural strength and modulus of
189. Tsatsas B, Tzamouranis Mitsis F. A bacteriological elasticity of dentin. J Endod 2003: 29: 747750.
examination of root canals before filling. J Br Endod Soc 205. Ng Y-L, Rahbaran S, Lewsey J, Gilthrope M, Gulabivala
1974: 7: 7880. K. Primary root canal treatment outcome systema-
190. Engstrom B. The significance of Enterococci in root tic review and meta-analyses. Int Endod J 2003: 36:
canal treatment. Odontol Rev 1964: 15: 87106. 926.
191. Reit C, Dahlen G. Decision-making analysis of en- 206. Lewsey JD, Gilthorpe MS, Gulabivala K. An introduc-
dodontic treatment strategies in teeth with apical tion to meta-analysis within the framework of multi-
periodontitis. Int Endod J 1988: 21: 291299. level modelling using the probability of success of root
192. Sjogren U, Figdor D, Spangberg L, Sundqvist G. The canal treatment as an illustration. Comm Dent Health
antimicrobial effect of calcium hydroxide as a short- 2001: 18: 131137.
term intracanal dressing. Int Endod J 1991: 24: 119 207. Sjogren U, Hagglund G, Sundqvist G, Wing K. Factors
125. affecting the long-term results of endodontic treat-
193. Peters LB, van Winklehoff AJ, Buijs JF, Wesselink PR. ment. J Endod 1990: 16: 498504.
Effects of instrumentation, irrigation and dressing 208. Smith CS, Setchell DJ, Harty FJ. Factors influencing
with calcium hydroxide on infection in pulpless teeth the success of conventional root canal therapy a five
with periapical bone lesions. Int Endod J 2002a: 35: year retrospective study. Int Endod J 1993: 26: 321
1321. 333.

121
Gulabivala et al.

209. Hoskinson SE, Ng YL, Hoskinson AE, Moles DR, apy after pulpectomy. Odontol Revy 1965: 16: 193
Gulabivala K. A retrospective comparison of outcome 203.
of root canal treatment using two different protocols. 218. Oliet S, Sorin SM. Evaluation of clinical results based
Oral Surg Oral Med Oral Pathol Oral Radiol Endod upon culturing root canals. J Br Endod Soc 1969: 3:
2002: 6: 705715. 36.
210. Storms JL. Factors that influence the success of 219. Heling B, Shapira J. Roentogenologic and clinical
endodontic treatment. J Canad Dent Assoc 1969: 35: evaluation of endodontically treated teeth, with or
8397. without negative culture. Quintessence Int 1978: 11:
211. Strindberg LZ. The dependence of the results of pulp 7984.
therapy on certain factors an analytical study based on 220. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence
radiographic and clinical follow-up examinations. Acta of infection at the time of root filling on the outcome of
Odontol Scand 1956: 14(Suppl): 1175. endodontic treatment of teeth with apical periodontitis.
212. Kerekes K, Tronstad L. Long-term results of endodon- Int Endod J 1997: 30: 297306.
tic treatment performed with a standardised technique. 221. Seltzer S, Bender BI, Turkenkopf S. Factors affecting
J Endod 1979: 5: 8390. successful repair after root canal therapy. J Am Dent Ass
213. Peters OA, Barbakow F, Peters CI. An analysis of 1963: 67: 651662.
endodontic treatment with three nickel-titanium rotary 222. Bender BI, Seltzer S, Turkenkopf S. To culture or not to
root canal preparation techniques. Int Endod J 2004: culture? Oral Surg Oral Med Oral Pathol 1964: 18:
37: 849859. 527540.
214. Pettiette MT, Delano O, Trope M. Evaluation of 223. Matsumoto T, Nagai T, Ida K, Ito M, Kawai Y, Horiba
success rate of endodontic treatment performed by N, Sato R, Nakamura H. Factors affecting successful
students with stainless-steel K-files and nickeltitanium prognosis of root canal treatment. J Endod 1987: 13:
hand files. J Endod 2001: 27: 124127. 239242.
215. Buchbinder M. A statistical comparison of cultured and 224. Peters LB, Wesselink PR. Periapical healing of endo-
non-cultured root canal cases. J Dent Res 1941: 20: 93 dontically treated teeth in one and two visits obturated
96. in the presence or absence of detectable microorgan-
216. Filgueiras J. Importance of bacteriologic tests in root isms. Int Endod J 2002: 35: 660667.
canal therapy. J Am Dent Assoc 1942: 29: 22112215.
217. Engstrom B, Lundberg M. The correlation between
positive culture and the prognosis of root canal ther-

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