15 A COMPARISON OF EFFICACY - Aligarh Muslim University COMPARISON OF EFFICACY.pdf · Biomechanical...

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].



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.


Middle 1/3 and Apical 1/3 in EDTA group.

Figure 3: SEM photomicrograph of Qmix group showing




Middle 1/3 and Apical 1/3 in Qmix group.



Figure 4: SEM photomicrograph of MTAD group showing




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.



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.

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CORRESPONDING AUTHOR

Dr. Kunwar Suhrab Singh

B.S.- 22, Sector 70, Noida-201301, U.P.

Mobile No. - 9755712732

Email id- [email protected]



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