|Year : 2020 | Volume
| Issue : 2 | Page : 106-110
Effect of Irritrol™ endodontic irrigant and ethylenediaminetetraacetic acid in smear layer removal from instrumented human root canal dentine: A scanning electron microscopic analysis
Swastika Bhattacharya1, Tina Puthen Purayil1, Nidambur Vasudev Ballal1, Kalyana Chakravarthy Pentapati2
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
|Date of Submission||06-Jun-2019|
|Date of Decision||28-Jun-2019|
|Date of Acceptance||14-Aug-2019|
|Date of Web Publication||23-Apr-2020|
Dr. Tina Puthen Purayil
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Ethylenediaminetetraacetic acid (EDTA) is a chelating agent that is most widely used for smear layer removal. Irritrol™ is a novel endodontic irrigating solution that contains EDTA and chlorhexidine that can be used as a final irrigating agent which claims of being more efficient but less aggressive. The aim of the study was to evaluate and compare the effects of Irritrol and EDTA in smear layer removal from instrumented human root canal dentine.
Materials and Methods: Thirty-nine extracted human single-rooted maxillary incisors were decoronated at the cementoenamel junction. Chemomechanical preparation was done using ProTaper Gold rotary instruments and intermittent irrigation of 2.5% sodium hypochlorite. Random division of the samples into three groups (n = 13) was done with Group A: Irritrol; Group B: 17% EDTA; and Group C: 0.9% saline solution. The samples were dehydrated, gold sputtered, and evaluated under scanning electron microscope.
Statistical Analysis: Statistical analysis was performed using Kruskal–Wallis ANOVA with post hoc Conover test with a significance level of P = 0.05%.
Results: It was demonstrated that 17% EDTA was significantly more effective in removal of smear layer than Irritrol in coronal, middle, and apical third of the root canal.
Conclusions: 17% EDTA had better smear layer removal effect than Irritrol when used as a final irrigant.
Keywords: Ethylenediaminetetraacetic acid, Irritrol, scanning electron microscopy, smear layer
|How to cite this article:|
Bhattacharya S, Purayil TP, Ballal NV, Pentapati KC. Effect of Irritrol™ endodontic irrigant and ethylenediaminetetraacetic acid in smear layer removal from instrumented human root canal dentine: A scanning electron microscopic analysis. Saudi Endod J 2020;10:106-10
|How to cite this URL:|
Bhattacharya S, Purayil TP, Ballal NV, Pentapati KC. Effect of Irritrol™ endodontic irrigant and ethylenediaminetetraacetic acid in smear layer removal from instrumented human root canal dentine: A scanning electron microscopic analysis. Saudi Endod J [serial online] 2020 [cited 2020 Aug 5];10:106-10. Available from: http://www.saudiendodj.com/text.asp?2020/10/2/106/283145
| Introduction|| |
Mechanical instrumentation of dentine during cavity preparation or root canal therapy produces microcrystalline debris that coats the dentine and clogs the orifices of the dentinal tubules. This layer of debris is termed as smear layer. The smear layer contains bacteria and prevents antimicrobial agents from gaining access to underlying contaminated dentinal tubules. The removal of the smear layer holds paramount importance in disinfection of the root canal system. Irrigation is hence an essential part of endodontic therapy.,
Sodium hypochlorite (NaOCl) is the gold standard irrigating solution in root canal treatment due to its antimicrobial activity and tissue-dissolving capability. However, the inorganic portion of smear layer cannot be removed by NaOCl., For this reason, it is advised to use the combination of NaOCl with a chelating agent. Chelating agents such as ethylenediaminetetraacetic acid (EDTA), tetracycline hydrochloride, citric acid, maleic acid, MTAD (an acid, a tetracycline isomer mixture, and a detergent), and Decal (ammonium oxyl acetate, oxyl acetate, and cetrimide) are available in the market for the removal of the smear layer.
Disodium salt of EDTA is widely used chelating agent in endodontic therapy. It is used to enlarge root canals and to prepare the dentinal walls for better adhesion of filling materials. Wu et al. showed that the smear layer removal ability of 17% EDTA was significantly better than 20% of citric acid and MTAD. However, EDTA has certain drawbacks like decreased efficiency in removal of smear layer from apical third of the root canal system. Also, it is cytotoxic.
Irritrol™ is a two-in-one endodontic irrigating solution (Essential Dental Systems, S. Hackensack, New Jersey, USA) that contains EDTA and chlorhexidine and is used as a final rinse after NaOCl. Manufacturers claim that Irritrol efficiently removes the smear layer less aggressively than conventional irrigants, thereby causing less demineralization of dentine. Previous study on Irritrol have shown better apical seal after obturation when compared to maleic acid and EDTA and speculated that Irritrol allowed better smear layer removal. However, to date, comparative studies on the effect of Irritrol and EDTA in smear layer removal from instrumented human root canal dentine is lacking. The aim of this study was to evaluate and compare the effects of Irritrol and EDTA in smear layer removal from instrumented human root canal dentine.
| Materials And Methods|| |
Ethical clearance was obtained from Institutional Review Board 858/2016. Thirty-nine extracted human single-rooted maxillary incisors were selected, and after surface debridement with scaling instruments, the samples were stored at 4°C in 0.2% sodium azide (Merck KGaA, Darmstadt, Germany) until experiment.
- Thirty-nine noncarious human permanent maxillary incisors with straight root and single canal
- Teeth with completely formed apex.
- Teeth with calcified canals
- Fractured/restored or cracked teeth
- Teeth with developmental defects
- Endodontically treated teeth.
The teeth were decoronated using a diamond disc (Kerr Endodontics and Kerr Rotary, Orange, California, USA) at the cementoenamel junction to standardize root length to 15 mm. Determination of working length was done by placing a 10K file (Mani Inc., Utsunomiya, Tochigi, Japan) into the canal until the file tip was just visible at the apical foramen and subtracting 1 mm from this measurement. Mechanical preparation of the teeth was done till the working length using ProTaper Gold rotary instruments (Densply, Maillefer, Ballaigues, Switzerland) and each canal was enlarged to F3 size. Each set of ProTaper Gold instruments were replaced after preparation of five canals. Irrigation of the canals was done after each instrument change for 1 min using 2 mL of 2.5% NaOCl (KMC Pharmacy, Manipal, Karnataka, India). Samples were then randomly divided into three groups (n = 13) according to the final irrigation regimen:
- Group A: 5 mL of Irritrol (Essential Dental Systems, S. Hackensack, New Jersey, USA) for 1 min
- Group B: 5 mL of 17% EDTA (Merck, Darmstadt, Germany) for 1 min
- Group C: 5 mL of 0.9% Saline (KMC Pharmacy, Manipal, Karnataka, India) for 1 min.
A 30-gauge Side Vent needle (Orikam, Gurgaon, Haryana, India) was used to introduce the irrigating solutions into the canal by placing it 1 mm short of the working length. To remove any precipitates that might have formed, 5 mL of distilled water was used to irrigate the canals. After irrigating with the respective irrigants, canals were dried using sterile paper points (Dentsply Sirona, Woodbridge, ON, Canada). A diamond disc attached to a slow speed handpiece was used to place the longitudinal grooves on buccal and lingual surfaces of the root of the tooth. This was accomplished without penetrating the disc into the canal. Finally, a chisel (Acharya Instruments, Manipal, Karnataka, India) was used to split the teeth into two halves. The better half, showing the anatomy of the root canal from the cervical to the apical third, was chosen for further evaluation under scanning electron microscope (EVO MA18, Carl Zeiss AG, Oberkochen, Germany). The samples were stored in 100% humidity at 37°C until the scanning electron microscopic study could be performed. Dehydration of the specimens was done using increasing concentrations of 25%, 50%, 75%, and 100% ethyl alcohol. An ion sputter was used for the gold sputtering of the samples after mounting them on the metallic stubs. The teeth were then examined under microscope. The scoring criteria followed for the presence and absence of smear layer was given by Torabinejad et al. [Table 1].
|Table 1: The scoring criteria given by Torabinejad et al. (2002) for the presence and absence of smear layer|
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Multiple photomicrographs were taken to observe the morphology of the three-thirds of each specimen at ×1500 magnification at 10 kV [Figure 1]. Two independent investigators, unaware of the experimental groups, evaluated the samples.
|Figure 1: Representative scanning electron microscopic images of the three experimental groups in coronal, middle, and apical third|
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All the analyses were done using MedCalc Version 14.8.1 (MedCalc Software bvba, Ostend, Belgium). Interexaminer reliability was evaluated using Cohen's Kappa coefficient. Both inter- and intra-group comparisons of mean smear layer scores were done using Kruskal–Wallis ANOVA with post hoc Conover test. P < 0.05 was considered as statistically significant.
| Results|| |
A good agreement between the two investigators was observed in the results of Cohen's Kappa coefficient, when scoring the presence of smear layer in the three-thirds of the root canal system for Irritrol, 17% EDTA, and 0.9% saline. The percentage agreement between the two investigators was 76.92%. [Table 2] shows distribution of smear layer scores among the three test groups at all the three-thirds of the root canal system.
|Table 2: Distribution of smear layer scores of the three test groups at all the three thirds of the root canal system|
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On intragroup analysis in Group A (Irritrol), smear layer was removed more efficiently in coronal third when compared to middle and apical third of the root canal (P < 0.001). However, there was no significant difference between middle and apical third. In Group B (17% EDTA), there was no significant difference in coronal and middle third. However, in apical third, smear layer was not completely removed (P < 0.001). In Group C (0.9% saline), all the three-thirds were heavily smeared (P = 0.515) [Table 3].
|Table 3: Intragroup comparison showing mean and standard deviation in coronal (C), middle (M), and apical third (A)|
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On intergroup comparison, there was significant difference in smear layer removal among all the three irrigants (P < 0.001). Post hoc test showed that EDTA was significantly better than Irritrol and saline in all the thirds of the root canal system. On comparison between Irritrol and saline, there was no significant difference in middle third and apical third (P < 0.001 and 0.004). However, in coronal third, Irritrol removed smear layer significantly better than saline [Table 4].
|Table 4: Intergroup comparison showing mean and standard deviation among experimental groups; Irritrol (A), 17% ethylenediaminetetraacetic acid (B), and 0.9% saline (C)|
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| Discussion|| |
Formation of smear layer is inevitable on mechanical instrumentation making irrigation an indispensable step in root canal therapy. The removal of smear layer using chelating agents for irrigation is the common norm which subsequently has shown to have better clinical and roentgenographic outcomes in teeth with initial signs and symptoms or in necrotic pulpal conditions.
In this study, we have evaluated the efficacy of Irritrol and 17% EDTA as a final irrigating agent to observe the smear layer removal from the coronal, middle, and apical thirds of the human root canal dentine. The results showed that 17% EDTA showed better smear layer removal in all the thirds of the root canal system compared to Irritrol.
Irritrol, in the present study, showed poor chelating properties compared to EDTA. This may be attributed to the combination of chlorhexidine with EDTA leading to the formation of a salt with a white precipitate that adheres to the root canal, thereby diminishing the efficacy of removal of smear layer.,
The results of this study demonstrated that EDTA removed smear layer efficiently in coronal and middle third compared to apical third. This is in agreement with previous studies., This may be due to the sclerosed dentin present in this region. The decreased content of noncollagenous proteins and the less number of dentinal tubules in the apical region of root canal have been correlated to this reduction in chelating effect of EDTA and the resulting prominent removal of smear layer from the coronal third.
The use of 5 mL of test solutions as final rinse was based on the study by Mello et al. who found that there is no difference between 5 mL, 10 mL, and 15 mL of EDTA solution. De-Deus et al. reported earlier that the microhardness of root dentin decreased after the use of 17% EDTA. 0.9% saline was used as a negative control in this study, and it did not have any effect on the removal of smear layer. This is in compliance with the study done by Ballal et al.
As chemomechanical preparation of human root canal dentin requires removal of organic content of smear layer, 2.5% NaOCl was used. Demonstration of lower concentrations of NaOCl being equally effective in removal of organic component as its higher concentrations has been done previously, and hence, a concentration of 2.5% was used in this study.
30-gauge Side Vent irrigating needles were utilized for the experiment which were positioned 1 mm short of the working length. This is in compliance with the study by Boutsioukis et al. The volume (5 ml) and duration of irrigation (1 min) in this study were standardized.
There are other methods to evaluate efficacy of smear layer removal. Some of them are atomic force microscopy, microcomputed tomography, digital image analysis, and environmental scanning electron microscopy. However, in this case, we have used scanning electron microscopy as this is a tool that is most commonly accessible for the evaluation of the presence of smear layer.
The scoring method employed was a qualitative form of analysis, but the multiple examiners presented concordance in their calibrations, as evaluated by Cohen's Kappa coefficient test, making the results reliable. Other elaborate scoring systems are also available,, but quantitative analysis could have been compromised on using more convoluted criteria.
The main benefit of Irritrol is that it can be used as a final irrigating solution that contains antibacterial as well as chelating properties which can be well harnessed in clinical practice. As this study is anin vitro analysis of the smear layer removal in straight canals, further analysis in curved and narrow canals along within vivo experiments should be conducted to evaluate the smear layer removal efficacy of Irritrol to gain further knowledge.
| Conclusions|| |
The results of this study demonstrated that 17% EDTA removed smear layer efficiently than Irritrol in all the thirds of the root canal system.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McComb D, Smith DC, Beagrie GS. The results ofin vivo
endodontic chemomechanical instrumentation – A scanning electron microscopic study. J Br Endod Soc 1976;9:11-8.
Violich DR, Chandler NP. The smear layer in endodontics – A review. Int Endod J 2010;43:2-15.
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;94:658-66.
Zehnder M. Root canal irrigants. J Endod 2006;32:389-98.
Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation. J Endod 1992;18:605-12.
Goldman LB, Goldman M, Kronman JH, Lin PS. The efficacy of several irrigating solutions for endodontics: A scanning electron microscopic study. Oral Surg Oral Med Oral Pathol 1981;52:197-204.
Baumgartner JC, Mader CL. A scanning electron microscopic evaluation of four root canal irrigation regimens. J Endod 1987;13:147-57.
Torabinejad M, Khademi AA, Babagoli J, Cho Y, Johnson WB, Bozhilov K, et al.
A new solution for the removal of the smear layer. J Endod 2003;29:170-5.
Bystrom A, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endod J 1985;18:35-40.
Eldeniz AU, Erdemir A, Belli S. Shear bond strength of three resin based sealers to dentin with and without the smear layer. J Endod 2005;31:293-6.
Wu L, Mu Y, Deng X, Zhang S, Zhou D. Comparison of the effect of four decalcifying agents combined with 60°C 3% sodium hypochlorite on smear layer removal. J Endod 2012;38:381-4.
Ballal NV, Kandian S, Mala K, Bhat KS, Acharya S. Comparison of the efficacy of maleic acid and ethylenediaminetetraacetic acid in smear layer removal from instrumented human root canal: A scanning electron microscopic study. J Endod 2009;35:1573-6.
Ballal NV, Kundabala M, Bhat S, Rao N, Rao BS. A comparativein vitro
evaluation of cytotoxic effects of EDTA and maleic acid: Root canal irrigants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:633-8.
Agrawal R, Purayil TP, Ballal NV, Belle VS. Comparative evaluation of postobturation apical seal following intracanal irrigation with maleic acid or a combination of chlorhexidine and ethylenediaminetetraacetic acid: Anin vitro
study. Saudi Endod J 2018;8:34-8. [Full text]
Pintor AV, Dos Santos MR, Ferreira DM, Barcelos R, Primo LG, Maia LC. Does smear layer removal influence root canal therapy outcome? A Systematic review. J Clin Pediatr Dent 2016;40:1-7.
Rasimick BJ, Nekich M, Hladek MM, Musikant BL, Deutsch AS. Interaction between chlorhexidine digluconate and EDTA. J Endod 2008;34:1521–3.
González-López S, Camejo-Aguilar D, Sanchez-Sanchez P, Bolaños-Carmona V. Effect of CHX on the decalcifying effect of 10% citric acid, 20% citric acid, or 17% EDTA. J Endod 2006;32:781-4.
Ballal NV, Ferrer-Luque CM, Sona M, Prabhu KN, Arias-Moliz T, Baca P. Evaluation of final irrigation regimens with maleic acid for smear layer removal and wettability of root canal sealer. Acta Odontol Scand 2018;76:199-203.
Paqué F, Luder HU, Sener B, Zehnder M. Tubular sclerosis rather than the smear layer impedes dye penetration into the dentine of endodontically instrumented root canals. Int Endod J 2006;39:18-25.
Mello I, Robazza CR, Antoniazzi JH, Coil J. Influence of different volumes of EDTA for final rinse on smear layer removal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e40-3.
De-Deus G, Paciornik S, Mauricio MH. Evaluation of the effect of EDTA, EDTAC and citric acid on the microhardness of root dentine. Int Endod J 2006;39:401-7.
Boutsioukis C, Lambrianidis T, Verhaagen B, Versluis M, Kastrinakis E, Wesselink PR, et al.
The effect of needle-insertion depth on the irrigant flow in the root canal: Evaluation using an unsteady computational fluid dynamics model. J Endod 2010;36:1664-8.
Butala R, Kabbinale P, Ballal V. Comparative evaluation of ethylenediaminetetraacetic acid, maleic acid, and peracetic acid in smear layer removal from instrumented root canal system: A scanning electron microscopic analysis study. Saudi Endod J 2017;7:170-5. [Full text]
Rome WJ, Doran JE, Walker WA 3rd
. The effectiveness of gly-oxide and sodium hypochlorite in preventing smear layer formation. J Endod 1985;11:281-8.
Hülsmann M, Heckendorff M, Lennon A. Chelating agents in root canal treatment: Mode of action and indications for their use. Int Endod J 2003;36:810-30.
Dua A, Dua D, Uppin VM. Evaluation of the effect of duration of application of Smear Clear in removing intracanal smear layer: SEM study. Saudi Endod J 2015;5:26-32. [Full text]
[Table 1], [Table 2], [Table 3], [Table 4]