International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17%
EDTA Solution - A Short Study
Datta Prasad S1, Anusha S2, Sunil Kumar C3, Hemadhri M4, Sasidhar Reddy3, Sunil Kumar5
1
Principal and Head of the Department, 2Post Graduate, 3Professor, 4Assistant Professor, 5Senior Lecture,
Department of Conservative Dentistry and Endodontics, C.K.S Theja Dental College, Tirupati.
Corresponding Author: Anusha S

Received: 04/05/2016 Revised: 05/06/2016 Accepted: 08/06/2016

ABSTRACT

Aim and objective: To evaluate the efficacy of canal brush, diode laser, 17% EDTA solution with
NaoCl as irrigant during instrumentation on smear layer removal.
Materials and Methods: 36 freshly extracted single rooted mandibular premolars were collected,
stored in distilled water, decoronated to 14mm length and instrumented up to F3 protaper. Irrigation
was done with 1ml 3% NaoCl in all experimental groups while irrigated only with distilled water in
control group & were assigned into groups: control, Laser, Canal brush, 17% EDTA groups, finally
irrigated with distilled water, stored separately in labeled bottles. Now roots were split longitudinally
in B-L plane, grooved at 4, 8,12mm length from root apices, dehydrated in series of ethanol, gold
sputtered & photographed using SEM. Smear layer removal was evaluated.
Results: At apical third LASER, at middle third EDTA, at coronal third EDTA is best in smear layer
removal. Canal brush good at apical third in smear layer removal next to laser
Conclusion: Based on this study, combined use of physical method & irrigant improves the efficacy
of smear layer removal especially at apical third. Hence it is suggested to use 17% EDTA along with
LASER.

Keywords: Canal brush, 17% EDTA, Laser, NaoCl, Smear layer, SEM.

INTRODUCTION observed this layer on the walls of

The success of the root canal therapy instrumented root canals and reported that it
depends on the method and quality of was similar in appearance to smear layer,
instrumentation, method of irrigation, type formed on cut enamel. Instrumentation
of irrigant used, disinfection and 3-D produces1-5µm thick smear layer on
obturation in root canal system. The aim of dentinal surface, (1) consisting of organic
instrumentation and irrigation is for and inorganic components, such as vital or
disinfection of root canal system, prior to necrotic pulp tissue, microorganisms, saliva,
obturation. It has been shown under SEM, blood cells and dentinal debris. (2) Bacteria
that a layer of sludge material is always harbor themselves deep into dentinal tubules
formed over the surface of dentinal walls; and may survive for longer period and may
whenever dentine is cut (BOYDE and cause reinfection later. For this reason, it
KNIGHT in the year 1970).This layer of becomes mandatory to remove smear layer
debris has been called the “smear layer”. from root canal for optimum success of
(3)
Boyde et al. (1963) first described the treatment. Sodium hypochlorite
presence of smear layer on the surface of cut considered one of the most efficient
enamel while Mc Comb and smith (1975) endodontic irrigants, merely removes the

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Vol.6; Issue: 7; July 2016
Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

organic part of the smear layer. Therefore, premolars, with a single root canal and
Sodium hypochlorite has been used in complete root formation, extracted for
association with 17% EDTA (Ethylene orthodontic or periodontal reasons were
Diamine Tetra Acetic acid) solution, which used. All the teeth were non carious teeth.
acts on inorganic portion formed in After extraction, intact apical root tips,
instrumented root canal. To achieve the presence of single root canal, were verified
optimum results in clinical conditions, it is with the periapical radiographs. Inclusion
recommended to leave 17 % EDTA inside criteria were permanent teeth with intact
the root canal for 15 minutes (4) however; apices, no previous endodontic treatment
this longer exposure of EDTA can cause and no restorations. Exclusion criteria were
excessive removal of both peritubular and root length shorter than 15mm, extensive
intratubular dentine. Most of the studies restorations, root caries, cracks and
have demonstrated incomplete smear layer fractures. The teeth were cleaned from
removal with these agents, especially in the attachment debris and calculus and then
apical third of the root canal. Researchers stored in deionised water until used in the
have proposed that improved irrigant study. Standardized the length of roots to
activation methods to address this issue. (5) 14mm, by decoronation of all those selected
In the past, various activation techniques teeth with diamond disc under water
have claimed to be successful in smear layer coolant. Working length was established by
removal such as manual, sonic and reducing 1mm from anatomical length.10K
ultrasonic devices and all of them with file was inserted into canal orifice until its
conflicting results. Recently, activation of tip became just visible through apical
irrigating solutions with laser devices foramen. All root canals were instrumented
becomes popular. Diode laser have gained with protaper Ni-Ti rotary instruments upto
increasing importance in dentistry owing to F3 size (0.3mm) to facilitate better
their compactness and affordable cost .A irrigation, penetration and to allow tips of
combination of smear layer removal, devices to reach appropriate working length.
bacterial reduction and reduced apical During the instrumentation, irrigation was
leakage are advantages of using this laser (5) done with of 3% NaoCl between each file in
and make it viable for endodontic treatment. all experimental groups while irrigated only
Canal brush (coltene / Whaledent) is an with distilled water in control group.
endodontic microbrush recently introduced. Finally, after root canal preparation the
This highly flexible micro brush is molded canals were flushed with sterile distilled
entirely from polypropylene and can be used water to terminate any solvent action of the
with rotary action in a contra angle hand irrigants. All the root canals were dried with
piece. It is considered that use of small and sterile paper points. After preparation, all
flexible canal brush with irrigation solutions specimens were enclosed with sticky wax to
remove debris from root canal extensions create closed end canal model and divided
and irregularities. (6) But still there are very as following groups: 1.Control 2.Laser
few studies about this. Therefore, present 3.Canal brush 4.17% EDTA solution.
study is planned to evaluate the efficacy of Laser Group:
Diode laser and Canal brush on removal of 980nm wavelength GaAlAs diode
smear layer in coronal, middle and apical laser device was used in this experiment.
third of root canal. Power -3W, frequency -10 Hz is used,
Diode laser used in pulsed mode, for 10
MATERIALS AND METHODS cycles of 10 sec/cycle. The delivery system
Selection and Preparation of Teeth consists of flexible fiber that had 200 µm
Specimens: diameter. 3%NaoCl was placed in the canals
A total of thirty six freshly extracted of specimens and then lased for 10secs. It
single rooted permanent human mandibular must be stressed that the laser tip should be

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Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

in constant motion while in root canal of fresh irrigant was flushed through the
during irradiation to avoid rise in canal to attenuate any thermal stress on
temperature on root surface. Fiber tip was external root surface. A final rinse of
moving in clockwise direction combined distilled water following the 10th cycle was
with inward and outward movement (spiral used to remove residual irrigant (fig 1).
motion). Between the each lasing cycle, 1ml

Fig (1): Laser Group

Canal Brush Group: 17%EDTA Group:

Recently, Canal brush (Coltene, Here 17%EDTA solution was left in the
Germany) specifically fabricated for root canal for 50secs followed by flushing of
canal cleaning and it has been introduced 3%NaoCl solution and again 17%EDTA
which are available in three sizes (small, solution is left in the canal for 50 secs and
medium and large) to correspond for apical finally rinsed with distilled water to remove
diameter of 25, 30, 40 respectively, residual irrigants if any.
according to ISO classification. This is used Control Group:
in conjunction with contra angle handpiece Here no any specific irrigation
at speed of 450 rpm for 20s for 5times. protocol is followed to remove smear layer.
3%NaoCl was delivered into root canal with Only instrumentation done under distilled
a 30 gauge needle, application of canal water, to assess the maximum smear layer
brush. Between each time of application of that can be formed after instrumentation.
canal brush, 3ml of the same solution was Specimen Preparation for Sem Analysis
flushed through the canal. At the end all All The root canals were dried with
specimens received, final rinse with distilled paper points. A longitudinal groove in the
water to remove any remaining irrigants (fig buccolingual direction was made using a
2). diamond disk. Colored gutta-percha cones
were used to prevent the intrusion of the
cutting disk into the canals. (7,8) Specimens
were split by applying slight pressure to an
enamel chisel into the longitudinal groove
(fig 3), and one half of the specimen was
randomly chosen for scanning electron
microscope (SEM) evaluation.
Each specimen was dehydrated in
ascending graded series of aqueous ethanol
solutions (80%, 90%, 100% for 15mts per
step) mounted on stubs, gold-sputtered and
examined under Scanning electron
Fig (2): Canal Brush group
microscope. SEM photomicrographs were

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Vol.6; Issue: 7; July 2016
Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

taken at apical third (4mm from apex), (next 4mm) of all the specimens for
middle third (next 4mm) and coronal third analysis.

Fig (3): Splitting tooth specimen with enamel chisel

The amount of smear layer was Score 3- <50% dentinal tubules open.
assessed and recorded in accordance with Score 4- Nearly all of the dentinal tubules
the criteria proposed by Sadr- Lahijani et al. covered with smear layer.
(7,9)
SEM figures representing the scores
Score 1- Dentinal tubules completely open. according to Sadr-Lahijani et al criteria:
Score 2- >50% dentinal tubules open.

Fig (4): Score 1 Dentinal tubules completely open Fig (5): Score2 >50% dentinal tubules open

Fig (6): Score3 <50% dentinal tubules open Fig (7): Score4 nearly all of the dentinal tubules
covered with smear layer.

Note: The less the score, more will be the RESULTS

efficacy of smear layer removal SEM figures at canal thirds of all
Statistical Analysis groups are given below:
Data was analyzed using SPSS
software version by non-parametric
Kruskal-Wallis test.

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Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

Fig (8)
Apical third Middle third Coronal third
Control group

Laser group

Canal brush group

17% EDTA group

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Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

Comparison of Canal Thirds

Comparison between canal thirds

with in laser group apical third shows
highest smear layer removal efficacy, there
was no statistically significant difference
between coronal and middle thirds. Within
canal brush group, apical third showed
highest smear layer removal. However the
efficacies of coronal and middle third were
not significantly different from each other.
While 17% EDTA shows best at coronal
third followed by middle and was least at
apical third.

DISCUSSION
Intergroup comparison shows that
The removal of any vital and
diode laser is the best at apical third in
necrotic pulp tissue, microbes and their
smear layer removal followed by canal
toxins along with smear layer is essential for
brush and then by 17% EDTA solution. At
endodontic success. Studies have shown that
middle third 17% EDTA is the best in smear
currently used method of especially rotary
layer removal followed by laser and canal
instrumentation technique produces a smear
brush. At coronal third 17% EDTA is the
layer that covers root canal walls and block
best followed by laser and canal brush.
opening of dentinal tubules. Therefore, this

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Vol.6; Issue: 7; July 2016
Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

study evaluated the efficacy of diode laser apical third, canal brush presented the best
and canal brush on removal of smear layer results. (10)
and EDTA as it is one of the acceptable The use of compact near infra-red
method that removes the smear layer.SEM diode laser of 980nm wavelength may offer
is one of the most commonly used benefits such as photo thermal disinfection
techniques to assess the removal of smear and bio stimulation. Such effects rely on
layer. (7) penetration of near infra-red laser energy
To the authors knowledge this is the through dentine, means that the
first study to compare the effectiveness of microorganisms distant from root canal
diode laser irradiation and canal brush as a space could be inactivated which would add
means for activation or/ and agitating the to antimicrobial effects from irrigants.
irrigants to enhance the smear layer removal Diode laser parameters used in this present
in apical third of the root canal system. study were based on the known threshold
Given the challenge of effective cleaning of laser settings required to induce agitation in
root canal system, a technique which cavitation and shock waves using 980nm
augments the effects of existing irrigants is diode laser. (11)
of the potential clinical interest. Mohamed Helmy et.al, by his
In present study, minimum scores electron microscopic study, determined the
were observed in group I (980nm Diode effect of 980nmdiode laser and some
laser) at apical third. It showed the efficacy irrigants (H2O2 and NaoCl) on surface
of laser is more followed by canal brush and morphology of root canal wall and
17% EDTA at apical third. 17% EDTA concluded that SEM showed a smoother
showed minimum scores at middle third and dentine surface with the removal of smear
at coronal third followed by diode laser and layer and debris when treated with laser
canal brush. This can be attributed to the irradiation compared to irrigation with
narrower canal in the apical third. If the root NaoCl and H2 O2. This improves adaptability
canal is narrower, then the laser tip will be of sealer to root canal wall. Thus, diode
closer to canal wall, it is easy for melting laser will be future therapy in endodontic
and evaporating the smear layer. (5) treatment for cleaning the root canal of
Canal brush is rotated at 450 rpm for tooth. (12)
20 secs to agitate the irrigant solution inside The results observed by Xiaogu
the canal to remove debris and is more Wang et al., in his study, Effect of diode
efficient at apical third next to laser than laser on smear layer removal from root
middle and coronal third. The probable canal walls and apical leakage after
reason could be because of canal brush obturation is in support with the results of
disrupts vapor lock and hence enables more this study as the diode laser 980nm removes
volume of irrigants to reach apical third of the smear layer the best at apical third.
the root canal. A recent report by Weise et Diode laser removes smear layer and debris
al showed that the use of the small and as best at apical third and reducing apical
flexible canal brush with an irrigant leakage after obturation and would be useful
removed the debris effectively from for root canal treatment in clinic. (5)
simulated canal extensions and Xiangjun Guo et. al, compared
irregularities. (6) different irrigant activation techniques
Nishi Singh et al. compared the combined with 3% NaoCl and 17% EDTA
smear layer removal efficacy of three in smear layer removal. The results showed
different irrigant activation systems (canal that without any activation, combination of
brush, endo-activator and F-file) showed NaoCl used as irrigant during root canal
significant differences among the three preparation and 17% EDTA as final irrigant
groups. Concerning smear layer removal at was effective for smear layer removal, but
complete removal of smear layer was not

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Datta Prasad S et al. Comparison of Smear Layer Removal with Diode Laser, Canal Brush, 17% Edta Solution -
A Short Study

achieved particularly in apical third, suggested to use the combination of 17%

probably because of the following reasons: EDTA solution and Diode laser to remove
(1) As the diameter of the root canal smear layer. With the laser use, surface
gradually decreased from the coronal to tension of EDTA can be reduced. Increasing
apical third, the volume of the irrigant the temperature results in increased wetting
decreased, which decreased the liquid of the root canal surface. Thus, resulting in
backflow. Thus, less irrigant was flushed better way for removal of smear layer on
into the apical third than the middle and root canal system.
coronal thirds; (2) fewer dentinal tubules
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How to cite this article: Prasad DS, Anusha S, Kumar SC et al. Comparison of smear layer
removal with diode laser, canal brush, 17% EDTA solution - a short study. Int J Health Sci Res.
2016; 6(7):168-176.

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