?The effect of using EDTA with Sodium Hypochlorite in removing the smear layer in comparison to Sodium Hypochlorite alone

Does the use of NaOCL with EDTA have better effectiveness in removing the smear layer over the use of NaOCL alone in extracted teeth?

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Introduction:
One of our main objectives in our root canal treatments is to eliminate the microbial infection in the root canal system. This can be achieved by using instruments and solutions that aid in this mechanical process. Multiple solutions were introduced to the root canal system as irrigants. The most used irrigant in our clinics and daily practice is the Sodium Hypochlorite (NaOCL), it has an upper hand in anti-microbial effect and the ability to dissolve most organic tissues in comparing to other solutions.ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.1016/S0099-2399(06)81109-X”,”ISSN”:”00992399″,”PMID”:”8596078″,”abstract”:”The effect of eliminating the smear layer by means of 15% EDTA solution as a root canal irrigant was studied in 189 single-rooted infected teeth. Each tooth was treated at two appointments, and the root canal bacteriological examination was studied on the first (pretreatment, and after enlargement and irrigation) and second (pretreatment) visits. The root canals were irrigated with 15% EDTA solution with ultrasonics agitation. No antibacterial intracanal medications was used between the appointment. When 15% EDTA solution was used, no bacteria could recovered from 93 of 129 root canals at the sampling stage on second visit. No bacteria were found in 21 of 60 root canals when saline solution was used as an irrigant. These results suggest that 15% EDTA solution is more effective than saline solution as a root canal irrigant. © 1995 The American Association of Endodontists.”,”author”:{“dropping-particle”:””,”family”:”Yoshida”,”given”:”Takakazu”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Shibata”,”given”:”Taiji”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Shinohara”,”given”:”Tomomi”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Gomyo”,”given”:”Shunji”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Sekine”,”given”:”Ichiro”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”Journal of Endodontics”,”id”:”ITEM-1″,”issue”:”12″,”issued”:{“date-parts”:”1995″},”page”:”592-593″,”title”:”Clinical evaluation of the efficacy of EDTA solution as an endodontic irrigant”,”type”:”article-journal”,”volume”:”21″},”uris”:”http://www.mendeley.com/documents/?uuid=81111e7c-24e5-4a70-bb64-7c69ac50828b”},”mendeley”:{“formattedCitation”:”(Yoshida <i>et al.</i>, 1995)”,”plainTextFormattedCitation”:”(Yoshida et al., 1995)”,”previouslyFormattedCitation”:”(Yoshida <i>et al.</i>, 1995)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”} (Yoshida et al., 1995) ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“ISSN”:”0099-2399″,”author”:{“dropping-particle”:””,”family”:”Baumgartner”,”given”:”J Craig”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Cuenin”,”given”:”Paul R”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issue”:”12″,”issued”:{“date-parts”:”1992″},”page”:”605-612″,”title”:”54311-SNC-100-AR-DD-018_0.pdf”,”type”:”article-journal”,”volume”:”18″},”uris”:”http://www.mendeley.com/documents/?uuid=914f505b-c812-49a6-9bcf-c6df8c0891b4″},”mendeley”:{“formattedCitation”:”(Baumgartner and Cuenin, 1992)”,”plainTextFormattedCitation”:”(Baumgartner and Cuenin, 1992)”,”previouslyFormattedCitation”:”(Baumgartner and Cuenin, 1992)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Baumgartner and Cuenin, 1992). But there is still a debate about whether it can remove the smear layer or not. Smear layer is a layer of organic and inorganic material that may contain bacteria and their by-products. It can prevent the penetration of intracanal medicaments into dentinal tubules and influence the adaptation of filling materials to canal walls.ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.1111/j.1365-2591.2009.01627.x”,”ISBN”:”1365-2591″,”ISSN”:”01432885″,”PMID”:”20002799″,”abstract”:”Root canal instrumentation produces a layer of organic and inorganic material called the smear layer that may also contain bacteria and their by-products. It can prevent the penetration of intracanal medicaments into dentinal tubules and influence the adaptation of filling materials to canal walls. This article provides an overview of the smear layer, focusing on its relevance to endodontics. The PubMed database was used initially; the reference list for smear layer featured 1277 articles, and for both smear layer dentine and smear layer root canal revealed 1455 publications. Smear layer endodontics disclosed 408 papers. A forward search was undertaken on selected articles and using some author names. Potentially relevant material was also sought in contemporary endodontic texts, whilst older books revealed historic information and primary research not found electronically, such that this paper does not represent a ‘classical’ review. Data obtained suggests that smear layer removal should enhance canal disinfection. Current methods of smear removal include chemical, ultrasonic and laser techniques – none of which are totally effective throughout the length of all canals or are universally accepted. If smear is to be removed, the method of choice seems to be the alternate use of ethylenediaminetetraacetic acid and sodium hypochlorite solutions. Conflict remains regarding the removal of the smear layer before filling root canals, with investigations required to determine the role of the smear layer in the outcomes of root canal treatment.”,”author”:{“dropping-particle”:””,”family”:”Violich”,”given”:”D. R.”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Chandler”,”given”:”N. P.”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”International Endodontic Journal”,”id”:”ITEM-1″,”issue”:”1″,”issued”:{“date-parts”:”2010″},”page”:”2-15″,”title”:”The smear layer in endodontics – A review”,”type”:”article-journal”,”volume”:”43″},”uris”:”http://www.mendeley.com/documents/?uuid=16fec3dd-badd-4d6a-91c2-f84df108d0f0″},”mendeley”:{“formattedCitation”:”(Violich and Chandler, 2010)”,”plainTextFormattedCitation”:”(Violich and Chandler, 2010)”,”previouslyFormattedCitation”:”(Violich and Chandler, 2010)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”} (Violich and Chandler, 2010).
Ethylenediaminetetraacetic acid shortcut (EDTA) is a chelating agent that is used to lubricate the root canal system to assist the insertion of the instrument inside the canal it can also dissolve organic materials such as smear layer. Previous studies were conducted on the dissolving effects of NaOCL and other irrigants. In 1992 Baumgartner studied different concentrations of NaOCL and used different approaches in inserting the irrigant inside the root canal system in an ex vivo study, he used two pair of teeth as a control group which didn’t receive any irrigation and four experimental groups which received different irrigation concentration of NaOC1 (5.25%, 2.5%, 1.0%, and 0.5%). He found that there wasn’t a significant difference not in the concentration nor in the delivery technique. Part of the smear layer got removed but it remained partially intact.ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“ISSN”:”0099-2399″,”author”:{“dropping-particle”:””,”family”:”Baumgartner”,”given”:”J Craig”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Cuenin”,”given”:”Paul R”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issue”:”12″,”issued”:{“date-parts”:”1992″},”page”:”605-612″,”title”:”54311-SNC-100-AR-DD-018_0.pdf”,”type”:”article-journal”,”volume”:”18″},”uris”:”http://www.mendeley.com/documents/?uuid=914f505b-c812-49a6-9bcf-c6df8c0891b4″},”mendeley”:{“formattedCitation”:”(Baumgartner and Cuenin, 1992)”,”plainTextFormattedCitation”:”(Baumgartner and Cuenin, 1992)”,”previouslyFormattedCitation”:”(Baumgartner and Cuenin, 1992)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”} (Baumgartner and Cuenin, 1992). Later on, in 1995, Yoshida decided to take a clinical approach in investigating the relation between the results of the culturing test and the presence of the smear layer. He studied 189 infected teeth all with single roots from 126 patients in the University of Asahi School of dentistry in the Endodontic clinic. Three samples were taken and two irrigation solutions were used in this study 15% EDTA solution for 129 teeth and saline solution for 60 teeth. First sample was taken directly from the hand file that was used in the canal having attached debris and dentine, the second sample taken from an absorbing paper point that dried the fluid between each irrigation and the third sample was taken in a second visit after 1 week a paper point was inserted inside a canal for 1 min then removed and inserted in the medium. No significance between the first two samples, however, the third sample showed a significantly lower percentage of negative culture when using saline solution than 15% EDTA.ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.1016/S0099-2399(06)81109-X”,”ISSN”:”00992399″,”PMID”:”8596078″,”abstract”:”The effect of eliminating the smear layer by means of 15% EDTA solution as a root canal irrigant was studied in 189 single-rooted infected teeth. Each tooth was treated at two appointments, and the root canal bacteriological examination was studied on the first (pretreatment, and after enlargement and irrigation) and second (pretreatment) visits. The root canals were irrigated with 15% EDTA solution with ultrasonics agitation. No antibacterial intracanal medications was used between the appointment. When 15% EDTA solution was used, no bacteria could recovered from 93 of 129 root canals at the sampling stage on second visit. No bacteria were found in 21 of 60 root canals when saline solution was used as an irrigant. These results suggest that 15% EDTA solution is more effective than saline solution as a root canal irrigant. © 1995 The American Association of Endodontists.”,”author”:{“dropping-particle”:””,”family”:”Yoshida”,”given”:”Takakazu”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Shibata”,”given”:”Taiji”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Shinohara”,”given”:”Tomomi”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Gomyo”,”given”:”Shunji”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Sekine”,”given”:”Ichiro”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”Journal of Endodontics”,”id”:”ITEM-1″,”issue”:”12″,”issued”:{“date-parts”:”1995″},”page”:”592-593″,”title”:”Clinical evaluation of the efficacy of EDTA solution as an endodontic irrigant”,”type”:”article-journal”,”volume”:”21″},”uris”:”http://www.mendeley.com/documents/?uuid=81111e7c-24e5-4a70-bb64-7c69ac50828b”},”mendeley”:{“formattedCitation”:”(Yoshida <i>et al.</i>, 1995)”,”plainTextFormattedCitation”:”(Yoshida et al., 1995)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”} (Yoshida et al., 1995).

In the late 1990’s Takeda did a comparison study between 3 different irrigants and two types of a laser having 60 mandibular premolars all single root with closed apexes. They were distributed randomly in 5 groups, G1 was the controlled group irrigated by 17% EDTA, G2 irrigated by 6 % phosphoric acid, G3 citric acid 6% concentration as well, G4 Carbon dioxide (CO2) laser G5 Er: YAG laser. There were no statistically significant differences between the irrigation solutions however the difference was significant when comparing G1 to G4 and G5, the lasers showed better cleanliness in middle and apical one-third of the root canal. (Takeda et al., 1999)

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