Endodontology, Vol.

15, 2003

Comparison of removal of endodontic smear layer

using NaOCl, EDTA, and different concentrations
of maleic acid A SEM study
*Prabhu SG **Rahim N ***Bhat KS ***Mathew J

ABSTRACT

The purpose of this in vitro study on extracted teeth was to evaluate and
compare the ability of maleic acid in different concentrations, NaOCl and
EDTA in the removal of smear layer formed along the root canal walls after
chemomechanical preparation.
Sixty freshly extracted teeth human maxillary incisors were divided into six
groups and root canals were prepared with step back technique, using
different solutions; namely, 5%,7%, 10% and 15% maleic acid,5.25% NaOCl
and 17%EDTA.The teeth were then split and the canal surfaces were viewed
under SEM for removal of smear layer. The results showed that NaOCl failed
to remove the smear layer. Smear removing ability of maleic acid was
significantly better than EDTA.

Key wordsGutta percha removal, Xylene, Gates Glidden, Profiles, Hedstrom files.

Introduction regarding the desirability of retaining the smear

The complete obliteration of root canal
space with an inert filling material and creation
of a fluid tight seal are the goals for successful
endodontic therapy1. In order to create a fluid
tight seal, it is imperative that the endodontic
filling material closely adapts or bonds to the
tooth structure. This however is impaired by
the presence of endodontic smear layer, which
invariably forms after instrumentation2,3.
The smear layer contains organic material,
odontoblastic processes, bacteria and blood
cells. Although there is some controversy
* Assistant Professor
** Former PG student
*** Professor Emeritus
**** Associate Professor,
Dept of Conservative Dentistry & Endodontics,
College of Dental Surgery,
Manipal Academy of Higher Education, Karnataka
20
layer in adhesive dentistry, in endodontics, its
removal is considered to be advantageous and
highly desirable.
Various materials and techniques have
been reported with wide variations in their
efficacy regarding removal of the intra canal
smear layer2, 4. The most widely used chemical
for the purpose is EDTA in different
formulations5. They have been reported to
consistently produce canals with patent
dentinal tubules6. However, it has been found
to be less efficient in narrow portions of the
canal7, requires a long application time for
optimum results8 and can seriously damage
the dentin, if used in excess9.
Modern adhesive techniques utilize
suitable treatment of smear layer by the
application of a conditioner, which either
Prabhu SG et al.
removes it or modifies it, depending upon the
adhesive systems used. Some of the adhesive
system use 10% maleic acid as a dentin
conditioner to remove the smear layer10,11
while others reported that it modifies the smear
layer12.
The review of literature shows that maleic
acid has not been tested against the
endodontic smear layer. The aim of this in vitro
study was to use different concentration of
maleic acid to remove the endodontic smear
layer and to evaluate the outcome, using
scanning electron microscopy and compare its
ability with sodium hypochlorite and EDTA
solutions.
Materials and Methods
Sixty freshly extracted human maxillary
anterior teeth were selected. After access
opening, a no 10 K-file was placed in the canal
until it was just visible at the apical foramen.
The working length was established by
reducing 1 mm from this point. The apical
portion of the root tip was then covered with
sticky wax.
Chemomechanical preparation was done
according to the conventional step back
preparation using K flex files. The apical portion
was enlarged to a no 40 file and irrigated with
NaOCl solution after each file. Following this,
the samples were divided randomly into 6
groups as follows:
Group I : 5.25% NaOCl
Group II : 17% EDTA solution
Group III : 5% Maleic acid
Group IV : 7% Maleic acid
Group V : 10% Maleic acid
Group VI : 15% Maleic acid
The root canals were then step backed to
no 60 file and the coronal third was enlarged
using gates glidden drills from sizes 2 to 5.
Irrigation was done after each instrument with
1ml of the test solution using a syringe, the
needle was placed as far as possible into the
21
Removal of endodontic smear layer...
canal without binding. The root canals were
finally irrigated with 3ml of distilled water to
remove any precipitate that may have formed
from the test irrigants.
After the root canal preparation, the canals
were dried with paper points. A cotton pellet
was placed in the access cavity and the tooth
was stored in a plastic bag placed in a humidor.
A longitudinal groove was cut on the buccal
and lingual surface without penetrating the
canal using a fine diamond bur. Each tooth was
then split into two with cutting pliers and stored
until analysis with SEM. The specimens were
dehydrated and coated with gold using an ion
sputter and immediately examined for SEM
evaluation. Several photomicrographs were
made at X1000 and X3000 magnifications, at
the middle and apical third to observe the
surface morphology.
The representative areas were evaluated
under the following criteria by two independent
evaluators who did not know the groups to
which the samples belonged. The scoring was
made, as described by Rome13.
Score Findings
0 No smear layer, all dentinal tubules
open
1 Minimum smear layer > 50% dentinal
tubules visible
2 Moderate smear layer; < 50% of
dentinal tubules open
3 Heavy smear layer; outline of dentinal
tubules obliterated.
The acquired data was then subjected to
statistical analysis using SPSS/PC+4.0, the
statistical package from IBM PC (Chicago,
USA)
Results
The Wilcoxon matched-pairs signed rank
test was used to compare the scores between
two raters. Results showed that there was no

significant difference between the two
evaluators in all the groups, except in the
middle third of group VI. Therefore, any
difference in smear layer removal efficacy
would be due to procedural variable and not
due to inter examiner disagreement except
probably in Group VI.
The mean scores for the different groups
in both the middle and apical third are given in
Table 1.
Statistical analysis revealed a very highly
significant difference in the smear layer
removing ability between sodium hypochlorite
and all the other groups in both the middle &
apical third (p=0)
A very highly significant difference was
found between EDTA and the different
concentration of maleic acid in the middle third
(p=0). In the apical third, there was a significant
difference between EDTA and 5%maleic acid
(p=0.0271) and 7%maleic acid (p=0.0244)
whereas it was highly significant with 10%
maleic acid (p=0.0001) and 15% maleic acid
(P= 0.0001)
No significant difference was found
between 5% and 7% maleic acid (p=0.5533)
and between 5% and 10%maleic acid in the
middle third (p=0.7684). However, a highly
significant difference was found between 5%
and 15%maleic acid in the middle third
(p=0.006), with 5%maleic acid showing better
removing ability.
In the apical third, no significant difference
was seen between 5% and 7%maleic acid
Table 1. Mean score for smear layer at middle and apical third
NaOCl EDTA Maleic acid Maleic acid
5%
Middle 3.00 0.90
third
Apical 3.00 1.60
third
Endodontology, Vol. 15, 2003
(p=0.3940) whereas compared to 5% maleic
acid, highly significant difference with 10%
(p=0.0083) and a significant difference with
15%maleic acid was seen (p=0.0230)
Statistical analysis showed highly
significant difference between 10% and
15%maleic acid in the middle third (p=0.0034)
and no significant difference in the apical third
(p=0.0771).
Discussion
The endodontic smear layer has been
described as one that is formed during
instrumentation, consisting of not only dentin
but also necrotic and viable tissue, including
remnants of odontoblastic processes, pulp
tissue and bacteria3. The smear layer plays an
important role in the lateral sealing of the root
canal, by acting as an intermediate physical
barrier that may interfere with adhesion and
penetration of the root canal sealer into the
dentinal tubules3. Pashley et al14 had described
the smear layer as a porous structure which
was permeable to even large molecules like
albumin. Mader et al15 had stated that the
smear layer was a non homogenous and
weakly adherent structure and may slowly
disintegrate and dissolve around leaking filling
margins, thus creating voids between root
canal walls and filling material / sealer.
Kennedy et al16 found that with the smear
layer intact, apical leakage was significantly
increased. The smear layer's presence plays
a significant role in an increase or decrease in
apical leakage. Its absence makes the dentin
Maleic acid Maleic acid
7% 10% 15%
0.33 0.05 0.05 2.16
1.25 1.05 0.65 1.00
22
Prabhu SG et al. Removal of endodontic smear layer...

more conducive to a better and closer controlled conditions.

adaptation of the gutta-percha to the canal
The results of this study indicate that
wall17.
sodium hypochlorite did not remove the smear
Maleic acid has been in use as acid layer in the middle and apical third of the root
conditioner in some of the adhesive systems. canal (Fig 1 & Fig 2). This is in agreement with
It has been reported to remove the smear layer studies done by earlier researchers3,15.
present in cavities prepared for adhesive
The other findings of the study indicates
dentistry 10,11. The smear layer present in
that EDTA is efficient in removing the smear
adhesive dentistry can be quite different from
layer mainly from the middle third (Fig 3), its
the endodontic smear layer. In the former, the
action in apical third is however, very much
tooth may be vital and the dentinal tubules
impaired (Fig 4). This is in agreement with
contain odontoblastic processes and dentinal
Ciucchi et al18 who stated that there was a
fluid, whereas in the case of the endodontic
definite decline in the efficiency of irrigating
smear layer, the tooth is nonvital and devoid of
solution along the apical part of the canals. This
dentinal fluid or odontoblastic processes.
can probably be explained to the fact that dentin
Hence it was decided to subject different
in the apical third is much more sclerosed and
concentrations of maleic acid and compare it
the number of dentinal tubules present there
with EDTA and sodium hypochlorite in the
is less. Also EDTA requires an application time
middle and apical third of the root canal under

Fig. 1. Effects of 5.25% NaOCl on
middle third of the root canal. Note the
typical appearance of amorphous
smear layer. The dentinal tubule
openings are obscured by the
adherent smear layer.
Fig. 2. Effects of 5.25% NaOCl on
apicle third of the root canal: The canal
wall appears covered by a heavy
smear layer. Cracks can be seen on
the smear layer. Pieces of inorganic
debris are scattered on the surface.
Fig. 3. Effects of 17% EDTA on middle
third of the root canal: The smear layer
has been removed. Little debris can
be seen. Smooth and flat intertubular
dentin. The tubules are open and
widened.

Fig. 4. Effects of 17% EDTA on apical
third of the root canal: Smear layer not
completely removed. Some debris can
be seen. Dentinal tubules are partially
open and can be seen to have smear
plugs in them.
Fig. 5. Effects of 5% Maleic acid on
middle third of the root canal: smear
layer and smear plugs are completely
removed. Little or no debris can be
seen on the surface. Intertubular
dentin smooth and flat.
Fig. 6. Effects of 5% Maleic acid on
apicle third of the root canal: Partially
opened dentinal tubules can be seen.
Little or no debris on the canal wall.

23
 Endodontology, Vol. 15, 2003

of not less than 15 minutes for optimum results8
and it may also not have such a pronounced
action at the narrow apical portion as in the
middle third.
In the present study, 5% maleic acid
showed a very highly significant result
(p<0.001) compared to EDTA in the middle
third (Fig 5) and a significant result (p<0.05) in
the apical part of the canal (Fig 6). There was
no smear layer nor plugs in the middle third
although many of the tubules were plugged in
the apical third. There was little or no debris
observed. The results show that 5% maleic acid
is a good replacement for EDTA, as it shows
better removal of the smear layer.
There was no significant difference in the
smear layer removing ability between 5% and
7% maleic acid, both in the middle and in the
apical third of the root canal. There was little or
no debris and the intertubular dentin was not
demineratized nor damaged (Fig 7 & Fig 8).
However, use of 10%maleic acid resulted
in damage and demineralization to the
intertubular dentin, although the smear layer
was completely removed (Fig 9 & Fig10). A
similar result was also seen with 15% maleic
acid. In these groups the dentinal tubules were
widened and fully open especially in the middle
third (Fig11). In the apical third, the tubules
were open and widened. Some of these tubules
had smear plugs in them (Fig12). Thus a
concentration below 10% can be
recommended for removal of intracanal smear
layer.
The smear layer removing ability of maleic
acid in the present study is in agreement with
Erickson10 and Van Meerbeek et al11 who
reported that the smear layer was removed in

Fig. 7. Effects of 7% Maleic acid on
middle third of the root canal: Smear
layer has been removed. Dentinal
tubules are widened and little or no
debris can be seen.
Fig. 8. Effects of 7% Maleic acid on
apicle third of the root canal: Smear
layer has been removed. Dentinal
tubules are widened and little or no
debris can be seen.
Fig. 9. Effects of 10% Maleic acid on
middle third of the root canal:
Demineralization of the intertubular
dentin can be seen.

Fig. 10. Effects of 10% Maleic acid on
apical third of the root canal: Dentin
tubules are open and widened.
Fig. 11. Effects of 15% Maleic acid on
middle third of the root canal: Smear
layer completely removed.
Demineralization has taken place and
dentin chips can be seen on the
surface.
Fig. 12. Effects of 15% Maleic acid on
apicle third of the root canal: Partially
opened dentinal tubules can be seen
alongwith demineralization of
intertubular dentin.

24
Prabhu SG et al.
adhesive dentistry using a self-etching primer
(Scotch bond 2 - 3M) and disagrees with
Jordon12 who reported that it only modifies the
smear layer. One possible explanation why the
smear layer removing ability of maleic acid was
less in vital teeth, could be due to the presence
of the dentinal fluid which can exert pressure
and so affect its complete removal.
However, in the present study, irrigants
were used during step back preparation of the
canal. But earlier investigators' studies
mentioned above, had exposed the
instrumented canal surface to the test irrigants,
maintained for different time intervals8. Hence
a fair comparison of the results is difficult.
Conclusions
Following conclusions were made from this
study;
1. Maleic acid removed the smear layer
effectively at all concentration.
2. 5% and 7% maleic acid can be an
alternative to routine use of 17% EDTA.
3. An increase in concentration of maleic acid
to 10% or more can result in
demineralization and damage to root canal
wall.
4. Sodium hypochlorite did not remove the
smear layer.
5. EDTA, which is conventionally used to
remove the smear layer, was less efficient
than the all concentrations of maleic acid.
6. The technique of use and biologic effects
of maleic acid on periapical tissues needs
evaluation, before it is routinely employed
for clinical use.
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