Journal of Dental Sciences (2011) 6, 41e47

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Original Article

Effects of liquid- and paste-type EDTA on

smear-layer removal during rotary root-canal
instrumentation
Gin Chen 1,2,3, Yu-Chao Chang 1*

1
School of Dentistry, College of Oral Medicine, Chung Shan Medical University, Taichung, Taiwan
2
Division of Endodontics and Periodontics, Department of Dentistry, Taichung Veterans General Hospital, Taichung, Taiwan
3
College of Dentistry, National Yang-Ming Medical University, Taipei, Taiwan

Received 8 November 2010; accepted 11 February 2011

Available online 21 March 2011

KEYWORDS Abstract Background/purpose: EDTA is routinely recommended as a chemical irrigant during

chemo-mechanical root-canal treatment, but few studies have compared the effectiveness in smear-layer
instrumentation; removal during rotary root-canal instrumentation. The purpose of this study was to evaluate,
EDTA; in vitro, the effect of liquid- and paste-type EDTA in root-canal debris removal during rotary
rotary root-canal root-canal instrumentation using an incremental crown-down technique.
instrumentation; Materials and methods: One hundred human single-root teeth were used in this study. Speci-
smear layer mens were accessed and instrumented with K3 rotary nickeletitanium files using an incre-
mental crown-down technique. The teeth were then randomly divided into 5 groups and
alternately irrigated with 5 mL of 2.6% NaOCl and treated with one of the following chelators:
Endo-cleanse, RC-Prep, Glyde-File, or File-Eze. The teeth were then dried, split into 2 halves
and examined under scanning electron microscopy. The micrographs were analyzed using
a 4-point evaluation index at the coronal, middle, and apical third of the root-canal wall.
Results: We found that root-canal cleanliness gradually increased from the apical to the
coronal part. Rates of complete cleansing were up to 48.3%. No complete root-canal cleanli-
ness was obtained even when liquid EDTA (Endo-Cleanse) was used as the positive control.
In the coronal and middle parts of the root canals, the cleaning abilities of File-Eze and
Glyde-File were statistically significant better than that of RC-Prep. No differences were found
in the cleansing effects in the apical part of the root canal. However, statistically significant
differences were found between File-Eze and Endo-Cleanse in the coronal and apical parts
of the root canals.

* Corresponding author. Department of Dentistry, Chun Shan Medical University Hospital, 110 Jianguo North Road, Section 1, Taichung 402,
Taiwan. Tel.: þ886 4 24718668x55161; fax: þ886 4 24759065.
E-mail address: [email protected] (G. Chen).

1991-7902/$36 Copyright ª 2011, Association for Dental Sciences of the Republic of China. Published by Elsevier Taiwan LLC. All rights reserved.
doi:10.1016/j.jds.2011.02.007
42 G. Chen, Y.-C. Chang

Conclusions: The use of paste/gel-type chelators during rotary nickeletitanium instrumenta-

tion resulted in improved cleanliness in the coronal and middle parts of the root canal. We
recommend using liquid EDTA as a final flushing solution during root-canal preparation because
it provides a better smear layer-free condition before 3-dimensional root-canal obturation.
Copyright ª 2011, Association for Dental Sciences of the Republic of China. Published
by Elsevier Taiwan LLC. All rights reserved.

Introduction canal disinfection by facilitating removal of the smear layer.

Therefore, removal of the smear layer in clinical endodon-
Successful endodontic procedures depend on complete tics allows better disinfection of the contaminated root-
root-canal cleansing and shaping, 3-dimensional hermetic canal dentine and increases adhesion of root-canal filling
root-canal system obturation, and good fittings with no materials to the root-canal wall.6,16,17
leakage of coronal restorations. Some previous studies The current literature predominantly reports on the
demonstrated that mechanical instrumentation of a root actions of EDTA and recommends it for routine use as
canal might create a bacterium-free environment and a lubricant during rotary root-canal preparation to reduce
maintain disinfection results.1,2 Therefore, various types of stress on the instruments and improve hard-tissue debride-
hand- and engine-driven rotary instruments and irrigation ment.18 However, few studies have compared the effec-
solutions were developed for root-canal preparation. tiveness of chelating agent with paste or gel consistency in
However, current cleansing techniques are not able to clean smear-layer removal during rotary root-canal instrumenta-
the entire root-canal system, especially the contaminated tion. During the past few years, nickeletitanium rotary
root canals. Numerous investigations using scanning elec- instruments were developed and have become popular in
tronic microscopy (SEM) proved that in addition to the root-canal preparation as they improve the cleansing effi-
superficial debris left on the canal wall, root-canal instru- ciency. Moreover, rotary nickeletitanium instrumentation
mentation leaves organic and inorganic substances that with an incremental crown-down technique completely
accumulate in the smear layer on the root-canal wall.1e4 differs from traditional root-canal instruments in both the
The smear layer was shown to contain remnants of determined distance of the shaping procedures and instru-
necrotic pulp tissues, dentinal cutting debris, and microor- ment designs.19,20 Most clinicians believe that smear-layer
ganisms.5 The presence of a smear layer inside the root- formation during rotary root-canal preparation differs from
canal system is controversial, but many studies indicated that previously reported because the rake angle of the
that removal of the smear layer is desirable because it cutting blade, helix angles, and pitch may allow the cutting
prevents penetration of the irrigation solutions and intra- debris to accumulate and make it difficult to remove.21,22 A
canal medications into the dentinal tubules and irregulari- study by Pashley in 1984 emphasized that the depth and
ties of the root-canal system and also hinders the complete packing density of the smear layer varies widely depending
adaptation of obturation materials to the prepared root- on whether the dentin is cut dry or wet, the amount and
canal wall.6 The smear layer, therefore, impedes root-canal composition of the irrigating solution used, and the type and
disinfection and allows microleakage that can cause root- speed of the instrument used.5,23,24 The purpose of this
canal treatment failure. Furthermore, the discussion study was to evaluate, in vitro, the effect of liquid- and
regarding whether the smear layer should be removed, paste-type EDTA in root-canal debris and smear-layer
there is still a debate about the volume of irrigant and removal during rotary root-canal instrumentation using an
contact interval. incremental crown-down technique.
In order to obtain a clean environment and enhance
hermetic sealing during root-canal obturation, some inves- Materials and methods
tigators recommended the use of various irrigants and
techniques such as sodium hypochlorite (NaOCl), organic One hundred human single-root teeth, with completely
citric acid, chelating agents like ethylenediaminetetra- formed apices, were collected from teeth freshly extracted
acetic acid (EDTA), ultrasonics, and lasers for adjunct from patients at the Department of Dentistry, Taichung
chemical and mechanical debridement during root-canal Veterans General Hospital because of orthodontic or severe
treatment to remove the smear layer.7e10 Recently, the periodontal disease. Written informed consent was
cleansing action of EDTA in association with a sodium hypo- obtained from each patient before tooth extraction. All
chlorite solution was extensively used during chemo- specimens were immersed in a physiological saline solution
mechanical preparation of root canals especially with rotary before root-canal treatment.
nickeletitanium instrumentation.6,10e12 EDTA was first Before root-canal preparation, the crowns of the teeth
introduced in root-canal treatment procedures by Nygaard- were sectioned at the cementoenamel junction (CEJ) and
Ostby in 1957.13 Sodium hypochlorite has been in use for then discarded. The working length was determined using
more than 70 years.10,12,14 Chelating agents such as EDTA act a 10-k-type file to reach 1.0 mm short of the apical foramen.
on calcified tissues by substituting sodium ions, which All root canals were instrumented with a K3 rotary nickele
combine with dentine to produce soluble salts, for the titanium file for a determined distance, using the incre-
calcium ions that are then bound in less-soluble combina- mental crown-down technique, a reduction handpiece
tions.15 This may help prevent canal blockage and aid root- (16:1; W&H Dentalwerk Burmoos, Burmoos, Austria), and an
Smear-layer removal during rotary instrumentation 43

electric motor (TCM 3000; Nouvag, Goldach, Switzerland). Total:100 teeth

Canal preparation combined with irrigation was sequentially Experimental:80/control:20
performed with K3 rotary files of 0.12/25 (12% taper and
0.25 mm apical size, with the root canal prepared to
a distance of 10 mm from the apex), 0.10/25 (with the root GP 1:20 teeth GP 2:20 teeth GP 3:20 teeth GP 4:20 teeth
Endo-Cleanse Rc-Prep Glyde File File-Eze
canal prepared to a distance of 8 mm from the apex), 0.08/
25 (with the root canal prepared to a distance of 6 mm from
the apex), 0.06/25 (with the root canal prepared to Figure 1 Specimens and paste/gel-type chelators used
a distance of 4 mm from the apex), 0.04/25 (with the root during and after rotary root-canal instrumentation with the
canal prepared to a distance of 2 mm from the apex), and incremental crown-down technique.
0.02/25 (with the root canal prepared to the apex), and then
recapitulated up to 0.04/25 and 0.06/25. During root-canal
instrumentation, a disposable 5-mL syringe with a 27-guage
After the chemo-mechanical preparation was complete,
blunt hypodermic needle that was placed 3 mm from the
all teeth were irrigated with distilled water. The canals
apical foramen was used to introduce a 2.6% NaOCl solution.
were then aspirated and left to dry in their respective
Furthermore, 1.0 mL of EDTA chelating paste (including RC-
covered containers to prevent dust contamination. The
prep, Glyde-File, and File-Eze) was used in accordance with
teeth were cut along the buccolingual direction using a no.
the manufacturer’s instructions and introduced into the
2 diamond round bur and then split with a chisel. The most
apical 3 mm of the root canal using a disposable 5-mL syringe
regular and integrated hemi-section of each tooth was
during every step of root-canal instrumentation (Table 1).
chosen for SEM analysis. The micrographs (500 and 1000)
The amount used was always sufficient to fill the canal
of the complete areas were numbered and analyzed by
entrance.
3 endodontists using a 4-point evaluation index at the
During root-canal instrumentation, the teeth were
coronal, middle, and apical third of the root canal
randomly divided into 4 groups and treated with different
according to the method described by Hulsmann in 2002.25
EDTA chelating agents as follows (Fig. 1).
The four points are defined as follows (Fig. 2): I, indicated
In Group 1, 40 specimens were irrigated with 5 mL of
that dentinal tubules were completely open and no smear
2.6% NaOCl during canal preparation, and 5 mL of the
layer was found; II, indicated that >50% of the dentinal
solution was used to irrigate the canal at every step of the
tubules were open; III, indicated that <50% of the dentinal
root-canal instrumentation. In this group (which served as
tubules were open; and IV, indicated that >75% of the
a positive control), 20 canals were rinsed with 1.0 mL of
dentinal tubules were covered by the smear layer.
Endo-Cleanse which was introduced into the apical 3 mm of
Data were statistically analyzed using the Manne
the root canal using a disposable 5-mL syringe with a 27-
Whitney test and KruskaleWallis test. The level of signifi-
gauge needle (Roydent, Rochester Hills, MI, USA) during the
cance for all statistical tests was accepted at P < 0.05.
cleaning and shaping procedures. The other 20 canals
(negative control) were rinsed with 2.6% of NaOCl only. In
group 2, 20 specimens were irrigated with 5 mL of 2.6% Results
NaOCl during canal preparation, and 1.0 mL of RC-Prep
(Premier-Dental, Plymouth, PA, USA) paste was used with The results of the SEM observations of the removal of the
the same procedures as described for Group 1, and the smear layer (root-canal cleanliness) are shown in Table 2. In
canal was filled until the end of instrumentation. In group general, the root-canal wall of Group 1 (the positive
3, 20 specimens were irrigated with 5 mL of 2.6% NaOCl control) showed remarkable cleanliness, and up to 66.7%
during canal preparation, and 1.0 mL of Glyde-File (Dents- (40 of 60) of the examined pictures were free of a smear
ply/Maillefer, Tulsa, OK, USA) paste was used with the same layer (score I) in the 3 different areas. For Groups 2, 3, and
procedures as described for Group 1, and the canal was 4, in which paste/gel-type EDTA was used, we found root-
filled until the end of instrumentation. In group 4, 20 canal cleanliness gradually increased from the apical to the
specimens were irrigated with 5 mL of 2.6% NaOCl during coronal part. However, higher rates of smear layer-free
canal preparation, and 1.0 mL of File-Eze (Ultradent, Salt areas (48.3% with score I and 22.0% with score II) were
Lake City, UT, USA) gel was used with the same procedures observed in the coronal part. Scores III and IV were found in
as described for Group 1, and the canal was filled until the the apical area. Overall, the results showed that no
end of instrumentation. complete cleanliness of root canal was obtained even when

Table 1 Composition and form of the 3 chelators.

Endo-Cleanse RC-Prep Glyde-File File-Eze
Composition 17% EDTA in a 15% EDTA and 15% EDTA, 19% EDTA in a water-soluble mixture
neutral pH 10% Urea peroxide 10% Urea peroxide,
Polyethylene glycol and
Cetylalcohol 20% Propylene
Propylene glycol glycol
Form Liquid Paste Paste Gel
Manufacturer Roydent Premier Dentsply/Maillefer Ultradent
44 G. Chen, Y.-C. Chang

Figure 2 The 4-score evaluation index described by Hulsmann in 2002.25

liquid EDTA (Endo-Cleanse) was used in the positive-control prevent tissue breakdown that could interfere with the
specimens in Group 1. In the coronal and middle parts of normal defense and repair mechanisms on which the
the root canals, the cleansing ability rates (scores I and II, > restoration of the tooth to health and function depends.1,7
50% areas of cleanliness) of File-Eze and Glyde-File were as Many investigations reported that mechanical instrumen-
high as 76.7% and 69.4%, respectively, and both were tation of a root-canal leaves organic and inorganic
statistically significant (P < 0.05) and higher than RC-Prep substances that accumulate in the smear layer on the
in the same areas. No differences were found in the dentinal wall.1e3 In order to obtain a clean environment
cleansing effects in the apical part of the root canal among and enhance hermetic sealing during root-canal obturation,
these paste/gel-type chelators (Fig. 3). The statistical some authors proposed copious irrigation of the canal with
analyses showed that there were a significant difference in a wide variety of irrigants, including chelating agents.6,7
cleansing between the coronal and apical parts of the root Because the introduction of EDTA into endodontics by
canals treated with File-Eze (EDTA gel) and Endo-Cleanse Nygaard-Ostby in 1957, chelators have been used to soften
(liquid EDTA) (P < 0.05) (Fig. 4). the dentin and facilitate enlargement of calcified and
narrow root canals.13 Although the benefits of chelators
were widely discussed, liquid EDTA at different concen-
Discussion trations and with the addition of various detergents and
surfactants was proposed to serve as a lubricating agent for
Successful endodontic procedures depend on complete root-canal preparation, particularly during rotary nickele
root-canal cleansing and removal of inflamed and necrotic titanium instrumentation, which is currently the most
tissue from the root-canal system. Thorough cleansing popular shaping technique in clinical endodontics.18,10,12
reduces or eliminates microorganisms and endotoxins which Therefore, the purpose of this study was to evaluate the

Table 2 Results of root-canal cleanliness after using different EDTA agents.

Score Group 1: Endo-cleanse Group 2: RC-Prep Group 3: Glyde-File Group 4: File-Eze
Coronal Middle Apical Coronal Middle Apical Coronal Middle Apical Coronal Middle Apical
I 16 14 10 7 4 4 11 10 7 16 10 7
II 2 4 4 5 7 5 4 3 6 3 6 4
III 2 2 4 5 6 7 3 5 5 1 3 6
IV 0 0 2 3 3 4 2 2 2 0 1 3
Statistical significance set at P < 0.05.
Smear-layer removal during rotary instrumentation 45

Figure 3 Box-plot diagrams of the cleanliness of different chelators in the same area of root-canal walls. Significant differences
(P < 0.05) are indicated by horizontal bars.

Figure 4 Box-plot diagrams of the cleanliness of chelators in 3 different areas of root-canal walls. Significant differences
(P < 0.05) are indicated by horizontal bars.
46 G. Chen, Y.-C. Chang

cleansing ability (root-canal cleanliness) of 3 paste/gel- canal. The degree of root-canal cleanliness gradually
type chelators used during rotary nickeletitanium root- decreased from the coronal to the apical part of the root
canal preparation. canal. In conclusion, the use of paste/gel-type chelators
Although, there is no consensus on the best method for during rotary nickeletitanium instrumentation in the
removing the smear layer and cleansing the root-canal wall, present study resulted in improved cleanliness in the
the results of the present study, similar to those of several coronal and middle parts of the root canal. We recommend
previous investigations,1,9,10,26e32 showed that the thick- using liquid EDTA (such as REDTA or Endo-Cleanse) as
ness and penetration of the smear layer in the dentinal a final flushing solution during root-canal preparation
tubules varied in the 3 selected areas: coronal, middle, and because it provides better smear layer-free conditions
apical portions. Although the design of the rotary nickele before 3-dimensional obturation.
titanium instrument, a pre-flaring 0.06 tapered canal
shape, may have affected the extent of smear-layer
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