Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
ABSTRACT : Aims and Objectives: To compare the efficacy on the removal of Smear layer by using four different
irrigants as a final rinse: Qmix 2 in 1, MTAD, 17% EDTA and Normal Saline using scanning electron microscope.
Materials and Method: Forty freshly extracted human single rooted teeth were decoronated at 17 mm from the
anatomic apex using double sided diamond disk attached to micro-motor and straight hand piece. The specimens were
randomly divided into 4 groups of 10 samples each, working length was determined by reducing 1mm from the
anatomic apex using 10 No. K file. Biomechanical preparation was done using crown down technique with Protaper
rotary files at the speed of 250 RPM. Teeth were prepared till F3 size.
Initial post instrumentation irrigation after using each file was done using 30 gauge side vented needles with 5 ml of 5%
Sodium Hypochlorite for three groups i.e., Qmix 2 in 1, 17% EDTA, normal saline (control group), the fourth group for
MTAD was irrigated using 5 ml of 1.3% Sodium Hypochlorite as per the manufacturer's recommendation. Specimens
were subjected to SEM analysis for evaluation according to the criteria described by Mahmoud Torabinejad [15].
Results: Specimens were fixed using 2% Glutaraldehyde and dehydrated using ascending percentage of Ethanol.
Thereafter, a thin layer of gold sputter coating was done (BAL-TEC SCD 005, Leica Microsystems, Germany).
Photomicrographs were taken using Field Emission Scanning Electron Microscope (Quanta 200F, FEI USA). Three
images per sample at the level of apical (0 to 5 mm), middle (6 to 10 mm), coronal (11 to 15mm) from the apex were
taken at 2000X. As scores were on ordinal scale, non-parametric test Kruskal Wallis Test was used for data analysis.
Conclusion: For coronal 1/3rd 17% EDTA, Qmix and MTAD removed smear layer better than normal saline. For
middle 1/3rd and apical 1/3rd Qmix and MTAD removed better smear layer than 17% EDTA followed by normal
saline. Also, Qmix and BioPure MTAD removed smear layer equally well in all the three segments of the samples. On
the other hand, 17% EDTA removed more of smear layer in coronal 1/3rd followed by Middle 1/3rd and Apical 1/3rd.
INTRODUCTION : The main goal of root canal therapy is to
clean, shape and then obturate the root canal system in three
dimensions so as to prevent reinfection. Over the years less
attention is given to techniques that completely clean and
disinfect the root canal system.
Microscopically root canal systems are complex and are
irregularly shaped with many fins, cul-de-sacs, lateral canals
and dentinal tubules opening onto the root canal surface.
The microorganisms present in the root canal system invade
the anatomic irregularities of the root canal, the dentinal
A COMPARISON OF EFFICACY OF FOUR
DIFFERENT IRRIGANTS USED AS A FINAL RINSE
ON THE REMOVAL OF SMEAR LAYER:
A SCANNING ELECTRON MICROSCOPIC STUDY.
Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 82
University J Dent Scie 2018; Vol. 4, Issue 2
Research Article
Keywords :
Conflict of interest: Nil
No conflicts of interest : Nil
1Dr. Kunwar Suhrab Singh, 1Assistant Professor, Department of Conservative Dentistry and Endodontics Santosh Dental College, Ghaziabad 2Professor and Head, Department of Conservative Dentistry and Endodontics,PCDS & RC, Bhopal3Professor, Department of Conservative Dentistry and Endodontics, KD Dental College & Hospital, Mathura4Professor and Head, Department of Conservative Dentistry and Endodontics, Santosh Dental College, Ghaziabad 5Assistant Professor, Department of Conservative Dentistry and Endodontics, PCDS & RC, Bhopal) 6Assistant Professor, Department of Conservative Dentistry and Endodontics Santosh Dental College, Ghaziabad
2 3 4 5 6Dr. M.P Singh, Dr. Amit Garg, Dr. Dildeep Bali, Dr. Nishant Khurana Dr. Era Arora
tubules and can re-infect the root canals if they remain viable
after inadequate root canal treatment. [1].
Studies show that currently employed methods of cleaning
and shaping, especially rotary instrumentation techniques,
produce a smear layer that covers the root canal walls and the
openings of the dentinal tubules [2, 3].
The smear layer is made up of organic and inorganic
substances, including odontoblast ic processes,
microorganisms, necrotic materials, which prevent intra-
canal medicaments and irrigants from penetrating into the
irregularities of the root canal system and also prevent
complete adaptation of obturating materials to the prepared
canal walls [4].Smear layer is usually 1 to 2 µm thick, but may
be deeply packed into the dentinal tubules as far as 40 µm [5].
Bacteria are the main cause of periapical disease [6] and are
found abundantly in smear layer. [18,19]
While instruments play an important role in removal of the
infected and necrotic dentine from the main root canal,
irrigants play a vital role in areas which are inaccessible to
instruments, such as lateral canals, accessory canals,fins and
webs. [8]
One of the most important requirements of an ideal
endodontic irrigant is to have antibacterial effect. Other
desirable characteristics would be the ability to dissolve
organic and inorganic tissue and to have lubricating and
flushing effect. In addition, it should nontoxic to the
surrounding and periapical tissues, and not weaken the tooth
structure [9]
For effective removal of the smear layer, combined
application of sodium hypochlorite (NaOCl) and a chelating
agent, such as ethylenediaminetetraacetic acid (EDTA), is
recommended [10].
This irrigant BioPure MTAD is a solution containing a
mixture of an antibiotic (doxycycline), citric acid, and a
detergent (Tween-80). Citric acid works as a chelating agent
in association with the lower chelating action of the antibiotic,
while surfactant is able to facilitate the penetration of the
solution into the root canal system.
QMiX is an endodontic irrigant introduced by Dentsply for
smear layer removal with added antimicrobial agents. It
contains EDTA, CHX and a detergent.
The aim of this study was to assess the smear layer removal
ability of three Endodontic root canal irrigants, QMIX 2 in 1,
17% EDTA and BioPure MTAD used as final rinse.
MATERIALS AND METHODS : Forty freshly extracted
human single rooted teeth were decoronated at 17 mm from
the anatomic apex using double sided diamond disk attached
to micro-motor and straight hand piece. The specimens were
randomly divided into 4 groups of 10 samples each.
Working length was determined by reducing 1mm from the
anatomic apex using 10 No. K file. Biomechanical
preparation was done using crown down technique with
Protaper rotary files at the speed of 250 RPM. Teeth were
prepared till F3 size.
Because the objective of the study was to evaluate the
effectiveness of the irrigants instead of the efficacy of root
canal irrigation, an open system design with an unsealed root
apex that permits air and vapour communication between the
external environment and the canal space was adopted for the
study.
Initial post instrumentation irrigation after using each file was
done using 30 gauge side vented needles with 5 ml of 5%
Sodium Hypochlorite for three groups i.e., Qmix 2 in 1, 17%
EDTA, normal saline (control group), the fourth group for
MTAD was irrigated using 5 ml of 1.3% Sodium
Hypochlorite as per the manufacturer's recommendation. The
irrigants were expressed within 2 minutes for each group.
Specimens were dried using paper points and final irrigation
was done using 30 gauge side vented needles with 5 ml of the
following irrigants which was delivered within 2 mins per
sample -
Group-1 (Control): normal saline
Group-2: 17% EDTA
Group-3: Qmix 2 in 1
Group-4: MTAD
Specimens were split using chisel (API) and mallet (GDC)
after two longitudinal grooves made using double sided
diamond disk on both buccal and lingual aspects without
perforating the canal space.
Specimens were fixed using 2% Glutaraldehyde and
dehydrated using ascending percentage of Ethanol.
Thereafter, a thin layer of gold sputter coating was done.
Photomicrographs were taken using Field Emission Scanning
Electron Microscope (Quanta 200F)
Three images per sample at the level of apical (0 to 5 mm),
middle (6 to 10 mm), coronal (11 to 15mm) from the apex
were taken at 2000X.
The specimen images were then coded based on the presence
or absence of smear layer on the surface of the root canal or in
the dentinal tubules at the coronal, middle, and apical portion
of each canal according to the following criteria described by
Mahmoud Torabinejad [15].
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 83
University J Dent Scie 2018; Vol. 4, Issue 2
1) No smear layer. No smear layer on the surface of the
root canals; all tubules were clean and open.
2) Moderate smear layer. No smear layer on the surface
of root canal, but tubules contained debris.
3) Heavy smear layer. Smear layer covered the root
canal surface and the tubules.
Frequency (number), percentage, mean, standard deviation
(SD), median, minimum and maximum values of smear layer
scores at coronal 1/3, middle 1/3 and apical /3 were
calculated. As scores were on ordinal scale, non-parametric
test Kruskal Wallis Test was used for data analysis. When
Kruskal Wallis Test showed significant difference between
groups, Mann-Whitney U test was used for pairwise
comparison. The Weighted kappa (Kw) statistics was used to
measure intra-observer reproducibility. P value <0.05 was
considered statistically significant.
RESULTS : Intra-observer reproducibility: The Weighted
Kappa values were between 0.89 to 0.93 for coronal, middle
and apical third, which was “almost perfect agreement”
according to Landis and Koch.
Figure 1: SEM photomicrograph of Normal Saline (Control)
group showing Coronal 1/3rd, Middle 1/3rd and Apical 1/3rd
respectively at 2000X magnification.
Table 1: Comparison of Smear layer scores for Coronal 1/3,
Middle 1/3 and Apical 1/3 in Normal Saline group.
Figure 2: SEM photomicrograph of ETDA group showing
Coronal 1/3rd, Middle 1/3rd and Apical 1/3rd respectively at
2000X magnification.
Table 2: Comparison of Smear layer scores for Coronal 1/3,
Middle 1/3 and Apical 1/3 in EDTA group.
Figure 3: SEM photomicrograph of Qmix group showing
Coronal 1/3rd, Middle 1/3rd and Apical 1/3rd respectively at
2000X magnification.
Table 3: Comparison of Smear layer scores for Coronal 1/3,
Middle 1/3 and Apical 1/3 in Qmix group.
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 84
University J Dent Scie 2018; Vol. 4, Issue 2
Figure 4: SEM photomicrograph of MTAD group showing
Coronal 1/3rd, Middle 1/3rd and Apical 1/3rd respectively at
2000X magnification.
Table 4: Comparison of Smear layer scores for Coronal 1/3,
Middle 1/3 and Apical 1/3 in MTAD group.
Thus the results showed that;
For coronal 1/3rd 17% EDTA, Qmix and MTAD removed
smear layer better than normal saline. For middle 1/3rd and
apical 1/3rd Qmix and MTAD removed better smear layer
than 17% EDTA followed by normal saline.
Also, Qmix and BioPure MTAD removed smear layer equally
well in all the three segments of the samples. On the other
hand, 17% EDTA removed more of smear layer in coronal
1/3rd followed by Middle 1/3rd and Apical 1/3rd.
DISCUSSION : McComb and Smith first identified the
smear layer 30 years ago on the walls of instrumented root
canals and reported it to be irregular, amorphous, and granular
in shape under scanning electron microscope [14].
But the question of keeping it or removing it during canal
treatment is still a matter of debate. Some investigators argue
that the presence of the smear layer increases the success rate
of endodontic treatment by blocking the dentinal tubules and
preventing bacterial exchange from the tubules into the canal
space or vice versa by reducing dentine permeability [20, 21].
In contrast to this, some investigators believe that the smear
layer should be completely eliminated from the surface of the
root canal walls because it can harbor bacteria.
Brännstr? m along with P´erez-Heredia et al. believes that the
smear layer serves as a ground for feeding of micro-organisms
and also helps them colonize [22] and affect sterilization of
dentinal tubules by blocking sodium hypochlorite, calcium
hydroxide, and other intracanal medicaments and irrigants
from penetrating and reaching into the dentinal tubules. It also
acts as a barrier between the obturating material.
[23,24,25,26].
Investigators showed root canal sealers to have a better
adhesion to the root canal walls after the smear layer was
removed [26].
Because of the aforementioned reasons, the purpose of this in
vitro study was to evaluate the efficacy of four different
irrigants Used as a Final Rinse on the Removal of Smear
Layer using scanning Electron Microscope.
Irrigants selected for final irrigation in this study included
Qmix 2 in 1, BioPure MTAD, 17% EDTA liquid and 5%
Sodium Hypochlorite as the post instrumentation initial
irrigant.
None of the present irrigants meet all the requirements of an
ideal endodontic irrigant. Hence for best results combined,
concomitant use of two or more irrigating solutions is
required.
Currently, NaOCl (0.5–6.15 %) and EDTA (15–17 %) are the
two most commonly used intracanal irrigants [10, 11]
NaOCl acts as a solvent of organic material and is a potent
antimicrobial agent, whereas, EDTA serves as an inorganic
solvent or a chelating agent.
However, when these agents are combined together before
application or in situ mixing, it results in complete loss of
freely available chlorine, thus adversely affecting the
antimicrobial properties of NaOCl [11, 27]
Furthermore, it has been shown that if NaOCl is used as a final
irrigating solution after using EDTA, the structural integrity
of the dentin is compromised [28,29,30]
After smear layer removal with EDTA elimination of an
additional rinsing with NaOCl has been shown to preserve the
integrity of dentin [31].
However, disinfection of the dentin surface and dentinal
tubules after smear layer removal may still be necessary and
therefore, rinsing the root canal with chlorhexidine (2 %) can
be done.
But on contact between residual NaOCl and chorhexidine,
there may be formation of a precipitate of para-chloroaniline,
which is potentially toxic.
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 85
University J Dent Scie 2018; Vol. 4, Issue 2
Therefore, it is necessary to eliminate and neutralize any
remaining amount of NaOCl prior to using chlorhexidine.
Bio Pure MTAD was introduced in Endodontics in 2003 by
Torabinejad. MTAD must be prepared chair side by mixing
two components and therefore is required to be prepared
freshly. MTAD is an acidic solution with a pH of 2.15.
Another study reported that MTAD was less cytotoxic than
calcium hydroxide, eugenol, 5.25% NaOCl and EDTA [16].
Tay et al. (2006) [12,32] demonstrated red purple staining of
the root canal dentine when MTAD was used as a final rinse
after using 1.3% of NaOCl as the initial irrigant. The reason
for the staining was probably because of oxidation of
doxycycline caused by sodium hypochlorite.
QMiX is an endodontic irrigant developed for smear layer.
Due to its proprietary nature exact composition of QMiX is
not yet known [33]. Mixing EDTA and CHX is known to
produce a white precipitate, [13] But in QMiX, this is avoided
because of its chemical design.
Another study done by Chandrasekhar. V et al, on the issue of
biocompatibility of Qmix TM 2 in 1 in comparison to saline,
3% NaOCl , 2% CHX and 17% EDTA, found that Qmix TM
2 in 1 was less toxic to the subcutaneous tissue.
For BioPure MTAD, it contains a mixture of a tetracycline
other has antimicrobial effect, low pH and thus can act as a
calcium chelator and cause enamel and root surface
demineralization [34]. Its surface demineralization of dentin
is comparable to that seen using citric acid [35].
A detergent Tween-80 added to the solution lowers the
surface tension and increase the penetrating ability of the
irrigating solution.
Vapor lock in a closed canal system may affect the efficacy of
smear layer removal from the apical third of the canal wall, the
presence of a film of irrigant between the air bubble and the
canal wall still permits some form of smear layer removal
although in a less efficient manner [17].
In the future the smear layer removal efficiency of different
irrigants including Qmix and MTAD should be evaluated in a
closed canal system by sealing the apex and embedding the
roots in a polyvinylsiloxane impression material before the
delivery of the irrigant [18] in conjugation with agitation
devices such as sonic and ultra-sonic agitation systems as well
as devices that incorporate negative pressure approach.
CONCLUSION : From the results of this study it can be
concluded that:
1) For coronal 1/3rd smear layer removal was better with
17% EDTA, Qmix and MTAD followed by normal
saline.
2) For middle 1/3rd smear layer removal was better with
Qmix and MTAD followed by 17% EDTA and then
followed by normal saline.
3) For apical 1/3rd smear layer removal was better with
Qmix and MTAD followed by 17% EDTA and then
followed by normal saline.
4) There was no significant difference for smear layer
scores for Coronal 1/3, Middle 1/3 and Apical 1/3 in
Qmix group.
5) There was significant difference for smear layer scores
for Coronal 1/3, Middle 1/3 and Apical 1/3 in EDTA
group. Mann Whitney U test showed that Middle 1/3 and
Apical 1/3 scores were significantly higher than Coronal
1/3. There was no significant difference between Middle
1/3 and Apical 1/3 scores.
6) There was no significant difference for smear layer
scores for Coronal 1/3, Middle 1/3 and Apical 1/3 in
MTAD group.
REFERENCES :
1. Orstavik D, Haapasalo M. Disinfection by endodontic irrigants
and dressings of experimentally infected dentinal tubules.
Endod Dent Traumatol. 1990;6(4):142-9.
2. Peters OA, Barbakow F. Effects of irrigation on debris and
smear layer on canal walls prepared by two rotary techniques: a
scanning electron microscopic study. J Endod. 2000;26(1):6-
10.
3. Heard F, Walton RE. Scanning electron microscope study
comparing four root canal preparation techniques in small
curved canals. Int Endod J. 1997;30(5):323-31.
4. Torabinejad M, Handysides R, Khademi AA, Bakland LK.
Clinical implications of the smear layer in endodontics: a
review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2002;94(6):658-66.
5. O'Connell MS, Morgan LA, Beeler WJ, Baumgartner JC. A
comparative study of smear layer removal using different salts
of EDTA. J Endod. 2000;26(12):739-43.
6. Kakehashi s, stanley hr, fitzgerald rj. The effects of surgical
exposures of dental pulps in germ-free and conventional
laboratory rats. Oral surg oral med Oral pathol. 1965;20:340-9.
7. Bystrom A, Happonen RP, Sjogren U, Sundqvist G. Healing of
periapical lesions of pulpless teeth after endodontic treatment
with controlled asepsis. Endod Dent Traumatol. 1987;3(2):58-
63.
8. Hasselgren G, Olsson B, Cvek M. Effects of calcium hydroxide
and sodium hypochlorite on the dissolution of necrotic porcine
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 86
University J Dent Scie 2018; Vol. 4, Issue 2
muscle tissue. J Endod. 1988;14(3):125-7.
9. Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in
endodontics. Br Dent J. 2014;216(6):299-303.
10. Torabinejad M, Khademi AA, Babagoli J, Cho Y, Johnson WB,
Bozhilov K, Kim J, Shabahang S. A new solution for the
removal of the smear layer. J Endod. 2003;29(3):170-5.
11. Zehnder M, Schmidlin P, Sener B, Waltimo T. Chelation in
Root Canal Therapy Reconsidered. J Endod 2005; 31: 817-820.
12. Tay F, Pashley DH, Loushine RJ, Doyle MD, Gillespie WT,
Weller RN. Ultrastructure of smear layer – covered
intraradicular dentin after irrigation with BioPure MTAD. J
Endod 2006;32(3):218-21
13. Rasimick BJ, Nekich M, Hladek MM, Musikant BL, Deutsch
AS. Interaction between chlorhexidine digluconate and EDTA.
J Endod. 2008;34:1521–3.
14. McComb D, Smith DC. A preliminary scanning electron
microscopic study of root
15. Haznedaroðlu F. Efficacy of various concentrations of citric
acid at different pH values for smear layer removal. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2003;96(3):340-4.
16. Torabinejad M, Cho Y, Khademi AA, Bakland LK, Shabahang
S. The effect of various concentrations of sodium hypochlorite
on the ability of MTAD to remove the smear layer. J Endod.
2003 Apr;29(4):233-9. Erratum in: J Endod. 2003;29(6):424.
17. Singla MG, Garg A, Gupta S. MTAD in endodontics: an update
review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2011;112(3):e70-6.
18. Eliot C, Hatton JF, Stewart GP, Hildebolt CF, Jane Gillespie M,
Gutmann JL. The effect of the irrigant QMix on removal of
canal wall smear layer: an ex vivo study. Odontology.
2014;102(2):232-40.
19. Mader CL, Baumgartner JC, Peters DD. Scanning electron
microscopic investigation of the smeared layer on root canal
walls. J Endod. 1984;10:477–83.
20. Pashley D. Clinical considerations of microleakage. J Endod.
1990;16:70–7.
21. Michelich VJ, Schuster GS, Pashley DH. Bacterial penetration
of human dentin in vitro. J Dent Res. 1980;59:1398–403.
22. Safavi KE, Spangberg LS, Langeland K. Root canal dentinal
tubule disinfection. J Endod. 1990;16:207–10.
23. M. Brännstr?m, “Smear layer: pathological and treatment
considerations,” Operative Dentistry—Supplement, vol. 3,
pp.35–42, 1984.
24. Yang SE, Bae KS. Scanning electron microscopy study of the
adhesion of Prevotella nigrescens to the dentin of prepared root
canals. J Endod 2002;28:433–7.
25. Czonstkowsky M, Wilson EG, Holstein FA. The smear layer in
endodontics. Dent Clin North Am 1990;34:13–25.
26. Cergneux M, Ciucchi B, Dietschi JM, Holz J. The influence of
the smear layer on the sealing ability of canal obturation. Int
Endod J 1987;20:228 –32.
27. Baumgartner JC, Ibay AC. The chemical reactions of irrigants
used for root canal debridement. J Endod. 1987;13(2):47-51.
28. Marending M, Paqué F, Fischer J, Zehnder M. Impact of
irrigant sequence on mechanical properties of human root
dentin. J Endod. 2007;33(11):1325-8.
29. Sim TP, Knowles JC, Ng YL, Shelton J, Gulabivala K. Effect of
sodium hypochlorite on mechanical properties of dentine and
tooth surface strain. Int Endod J. 2001;34(2):120-32.
30. Qian W, Shen Y, Haapasalo M. Quantitative analysis of the
effect of irrigant solution sequences on dentin erosion. J Endod.
2011;37(10):1437-41.
31. Niu W, Yoshioka T, Kobayashi C, Suda H. A scanning electron
microscopic study of dentinal erosion by final irrigation with
EDTA and NaOCl solutions. Int Endod J. 2002;35(11):934-9.
32. Tay FR, Mazzoni A, Pashley DH, Day TE, Ngoh EC, Breschi L.
Potential iatrogenic tetracycline staining of endodontically
treated teeth via NaOCl/MTAD irrigation: a preliminary report.
J Endod. 2006;32(4):354-8.
33. Pai S, Thomas MS. The effect of QMix, an experimental
antibacterial root canal irrigant, on removal of canal wall smear
layer and debris. J Endod. 2011 Jun;37(6):741; author reply
741-3.
34. Björvatn K, Skaug N, Selvig KA. Tetracycline-impregnated
enamel and dentin: duration of antimicrobial capacity. Scand J
Dent Res 1985;93:192–7.
35. Wikesjö UM, Baker PJ, Christersson LA, et al. A biochemical
approach to periodontal regeneration: tetracycline treatment
conditions dentin surfaces. J Periodontal Res 1986;21:322–9.
CORRESPONDING AUTHOR
Dr. Kunwar Suhrab Singh
B.S.- 22, Sector 70, Noida-201301, U.P.
Mobile No. - 9755712732
Email id- [email protected]
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 87
University J Dent Scie 2018; Vol. 4, Issue 2