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Endodontic Topics 2005, 10, 103122 Copyright r Blackwell Munksgaard

All rights reserved ENDODONTIC TOPICS 2005


Effects of mechanical and chemical

procedures on root canal surfaces

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

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

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
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.

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

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,

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
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

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

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
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
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
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

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.

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-

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.

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

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
The authors would like to thank Nicky Mordan, Naomi
Richardson, and Shailesh Rojekar for producing the micro-
scopic views of the root canal surface.
Root canal treatment procedures bring about a multi-
tude of changes to the root canal surface, which can be
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