Smear Layer In Endodontics

The presence or absence of the smear layer is of interest not only to restorative dentists, but to endodontists as well. Whenever dentin is filed, a smear is produced on its surface. This has been demonstrated in many studies with SEM (Baker & others, 1975; McComb, Smith &Beagrie, 1976; Lester & Boyde, 1977; Goldma & others, 19!"). #ig$ %"

Dentin of a root canal treated with ! "a#$l and %&! EDT' to remove pulpal tissue and the smear layer. ' no. ( file was drawn over the clean surface in the middle of the scannin) electron micro)raph, creatin) a smear layer. Scannin) electron micro)raph *+,,,.

The morpholo)y of the canal wall is of interest in this conte-t. .n adult teeth the walls may be partly covered with atubular, irre)ular dentin and thus the tubules are bloc/ed in the same way as under erosion and abrasion. .nfection may not be seen in the tubules in such an area. 0owever, in many adult teeth and especially in youn) teeth we may have lar)e areas with primary dentin facin) the root canal. 1rom a necrotic and infected canal, bacteria enter the dentin and can be found rather deep in the tubules. .nfected tubules with fluid communication to the e-terior may cause patholo)ical complications such as e-ternal resorption of roots and periapical pathosis. .n the treatment of infected roots there is a )ood reason to remove smear plu)s from the apertures of the tubules by usin), for instance, EDT'. .n this same way, the bacteria within the tubules at some distance can be more easily destroyed
&%

Smear Layer In Endodontics

by an intracanal dressin). #n the other hand, if the asepsis or the sealin) is poor, we may run the ris/ of reinfectin) dentinal tubules opened and widened by treatment with EDT'. The situation is similar to that for cavities. 'nother important consideration is that the smear layer is a separate structure from the underlyin) dentin. 1i). 2%3 fi) 4,p) %(,op dent %5(4 is a fortuitous scannin) electron micro)raph of the smear layer linin) a root canal that pulled away from the underlyin) dentin durin) processin). The absence of superficial smear layer may facilitate )ood contact between the sealin) material and the wall of cut dentin. #ig %%

SEM of a re)ion in the root canal where the smear layer (S6) crac/ed open and pulled away from the underlyin) dentinal tubules (DT). * %&,,

The removal of the smear layer from the dentin linin) the pulp chamber and root canals has been the sub7ect of numerous investi)ations $ Lester & Boyde &1977' found that treatment for 2 days with ! sodium hypochlorite did not remove smear plu)s from apertures of tubules and may not diffuse into the dentinal tubules sufficiently to ta/e care of microbes that have penetrated deeper into the dentinal tubules. 0owever, Camero &19!%', usin) an ultrasonic techni8ue, found that 2! sodium hypochlorite combined with ultrasound for 2 to minutes removed not only the superficial smear layer but also the smear plu)s9
&+

Smear Layer In Endodontics

but one minute of ultrasound removed only the superficial smear layer. .n this method we may have a selective techni8ue that can modify the effect of an irri)atin) solution. 's su))ested by (amada & others &19!%', an alternative would be a combination of irri)ants. They found the combined use of %, ml of %&! EDT', followed by %, ml of sodium hypochlorite effective. Goldma & others &19!"' recommend alternate use of sodium hypochlorite and EDT' to remove smeared dentin. The sodium hypochlorite removes the or)anic material, includin) the colla)enous matri- of dentin, and EDT' removes the minerali:ed dentin, thereby e-posin) more colla)en. There are no reasons to believe that a short application of these solutions would have any deleterious effects on the periapical tissues already replaced by )ranulation tissue. Such preparative treatment of root canals presumably permits a better adaptation of obturatin) materials and sealers to the dentin. To reduce the ris/ of reinfection, but also to avoid the development of secondary caries, in permanent coronal restorations of root;filled teeth the cavity should be treated in the same way as cavities in vital teeth, that is, a proper cleansin) and linin) of all cavity walls. Smear layer in Endodontics can be discussed under the followin) headin)s3 (.) (..) (...) (.<) (<) Effect of instrumentation on endodontic smear layer .ntracanal medicaments and smear layer #bturation and smear layer =ost cementation and smear layer >oot;end filin) and smear layer

&2

Smear Layer In Endodontics

&)'

*##*C+ ,# )-S+./M*-+0+),- ,- *-1,1,-+)C SM*0. L0(*.

Thorou)h biomechanical preparation of the root canal is unanimously

considered to be one of the ma7or re8uirements for successful endodontic treatment. The prime ob7ectives of this phase are to remove completely the or)anic substance that may be infected, or become so, and to shape the root canal in conformity with the principles of obturation. #ver the years a variety of instruments and techni8ues have been proposed to reach this )oal. Manual preparation techni8ues vary both in the type of instruments used and in the se8uence of usin) them. 0and preparation techni8ues are time consumin), technically demandin) and may lead to iatro)enic errors (led)in), :ippin), canal transportation and apical bloc/a)e). Since optimal shapin) and cleanin) of root canals with manual files is one of the most difficult aspects of root canal treatment, many alternative techni8ues have been su))ested. Since the %5 ,s a number of different endodontic handpieces have been developed for root canal preparation with the aim to mainly decrease instrumentation time and to simplify root canal preparation. 'utomated techni8ues utili:e devices ($anal 1inder, E-calibur, ?iromatic, Endolift, $avi;Endo etc.) that rotate files, displace them vertically, or that do both movements. "umerous investi)ations have demonstrated the limitation of manual and automated root canal instrumentation re)ardin) the overall 8uality of preparation ( 2ei e et al, 1976; Lehma Girstei , 19!"; +3rek & La gela d, 19!"; Bola os et al, 19!!; 43lsma & &

Stryga, 199%, Bertra d et al, 1999 ). These problems have resulted in a wide search for innovative materials, instruments and techni8ues to obtain a clean, disinfected debris;free canal for obturation ((a g et al, 1996). Durin) the last decade several new nic/el;titanium instruments for manual root canal preparation as well as for use in rotary endodontic handpiece, have been developed in order to facilitate the difficult and time;consumin) process of cleanin) and shapin) the root canal system and to improve the final 8uality of root canal preparation. "umerous studies have reported they could efficiently create a
&4

Smear Layer In Endodontics

smooth, predetermined funnel;form shape, with minimal ris/ of led)in) and transportin) the canals (*s5osito & C3 i gham, 1995; Glosso et al, 1995, Short et al, 1997; +hom5so & 13mmer, 1997b ). Shapin) procedures can be completed more easily, 8uic/ly and predictably. $leansin) efficiency has been one of the issues discussed with re)ard to preparation techni8ues. .t has been studied e-tensively, mainly by means of observation of the root canal walls and contents after preparation. The pulpal debris and smear layer produced by instrumentation of the canal walls must be removed (Cerg e36, 19!7; Gettlema et al, 1991). Durin) preparation, insufficient removal of debris and smear layer material can induce stresses on the cuttin) se)ment of endodontic instruments. Their removal depends not only on the irri)ation method but also on the endodontic instrument, i.e., the way the instrument is used and the method of preparation. "umerous studies have been reported on the relative effectiveness of different instrumentation techni8ues, based on a variety of ways of evaluatin) canal debridement. #utcomes of instrumentation differ accordin) to the method of canal preparation and evaluation, each method showin) advanta)es and disadvanta)es (4eard & 2alto , 1997). .ntroduction of the scannin) electron microscope (SEM) has proved to be a valuable method for assessment of the ability of the endodontic procedures to remove debris from the root canals, thus enablin) comparison of instruments and techni8ues. "umerous authors ( Bola os & 7e se , 19!8; 4aikel & 0llema , 19!!, 43lsma et al, 1997 ) have indicated that scannin) electron microscopes are indeed useful in e-aminin) instrumented root canal walls within the conte-t of evaluatin) the efficiency of different instrumentation systems. SEM studies focus on observin) the smear layer, the patency of dentinal tubules, instrumentation striations and calcospherites. These studies have conflictin) results. .n most investi)ations manual preparation was found to be more effective and superior to automated preparation and ultrasonic preparation. .n other studies ultrasonic preparation resulted in cleaner canals. Several researchers did not find si)nificant differences
&

Smear Layer In Endodontics

between preparation techni8ues. Similarly, the cleanin) effectiveness of the rotary nic/el;titanium systems is controversial. 's both manual and mechanical shapin) produce smear layer and debris (43lsma & Stryga, 199%; 4eard & 2alto , 1997), it is important to develop an instrumentation technique for endodontic treatment that produces a minimal amount of smear layer and debris in order to obtain the optimal seal of the root canals. Studies evaluatin) the cleansin) efficiency of preparation techni8ues are as follows3 &0' +4,S* +40+ )-1)C0+* B*++*. CL*0-S)-G *##)C)*-C( 2)+4 M0-/0L )-S+./M*-+0+),-9 :el;art &19!7' found hand instrumentation to be superior to ultrasonic cleanin) in the apical third of the canal. $omplete cleanliness could be achieved by none of the techni8ues and devices investi)ated. Baker et al &19!!' compared the canal cleanliness followin) ultrasonic preparation and manual preparation. They found significantly cleaner root canal walls in the middle part of the root canal following hand instrumentation 9 in the apical and coronal parts no si)nificant differences were detected. 0hl<3ist et al &"881' compared the cleanliness of the root canal walls followin) either a manual techni8ue usin) stainless steel S;files (S7odin)s, Sendoline, Sweden) or a rotary techni8ue (=ro1ile@ >otary nic/el;titanium files in a handpiece) of canal instrumentation. .t was found that the manual technique employed produced cleaner canal walls than the rotary technique.

&A

Smear Layer In Endodontics

&B' +4,S* +40+ )-1)C0+* B*++*. CL*0-S)-G *##)C)*-C( 2)+4 /L+.0S,-)C 0-1 S,-)C 1*:)C*S9 Bola os et al &19!!' compared sonic instrumentation with hand instrumentation and the ?iromatic system. The sonic preparation resulted in the best cleanliness in all parts of the root canal in strai)ht or curved canals. Hand instrumentation was slightly superior to Giromatic preparation. Schadle et al &1998' compared the efficacy of various root canal cleanin) instruments, i.e. hand;instruments, sonic instruments (Sonic 'ir 2,,, and Endostar ), mechanical instruments ($analfinder System), and ultrasonic instruments ($avi;Endo with or without inte)rated rinsin)). The smear layer was somewhat reduced by the Cavi-Endo without the inte)rated spray. =rati et al &199>' evaluated the morpholo)y of the smear layer and the amount of debris and pulpal residues in the apical third of human teeth by comparin) four manual endodontic instruments, an ultrasonicBendosonic system and an automated system (E-calibur). The scorin) system was as described by 0hmed et al &19!!', i.e. a three point scorin) system3 ,3 smear layer was absent and more than ,! of tubules were visible and partially open. %3 less than ,! of dentinal tubules were visible9 smear layer was present in some areas. +3 smear layer covered the canal wall9 dentinal tubules were partially visible in limited area. 23 smear layer covered the dentinal tubules. Ultrasonic technique showed the complete removal of the smear layer (scores , to +), leavin) small amounts of pulp debris at the apical third. Camero &1995' reported a superior cleaning ability of the ultrasonic

systems. Even most of the smear layer could be removed.

&&

Smear Layer In Endodontics

43lsma

et al &1997' evaluated the root canal cleanliness after preparation

with ei)ht different automated devices and hand instruments. The teeth were investi)ated under the SEM usin) the five cate)ory scorin) system which is as follows (1i). 24) 3 Score %3 "o smear layer, dentinal tubuli open. Score +3 Small amount of smear layer, some dentinal tubuli open. Score 23 0omo)enous smear layer coverin) the root canal wall, only few dentinal tubuli open. Score 43 $omplete root canal wall covered by a homo)enous smear layer, no open dentinal tubuli. Score 3 0eavy, nonhomo)enous smear layer coverin) the complete root canal wall. "o preparation system or techni8ue resulted in complete removal of smear layer and debris. The ultrasonic unit performed best followed by the Canal eader !""" and hand instrumentation.

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Smear Layer In Endodontics

#ig %>

Score 1

Score "

Score %

Score >

Score 5

&5

Smear Layer In Endodontics

&C' +4,S* +40+ )-1)C0+* B*++*. CL*0-S)-G *##)C0C( 2)+4 0/+,M0+*1 40-1=)*C*S9 Bartha & .occa &199%' assessed the cleansin);effect of two endodontic handpieces (E-calibur, W C 09 MM %4,, Micro Me)a). .t was found that E#calibur was superior in eliminating the $ . Scha?er et al &"888' investi)ated the cleanin) effectiveness of automated (Da<o;Endo 1lash device and =ro1ile system) and manual root canal instrumentation with the aid of SEM. Evaluation for smear layer was done usin) the ;step scale as )iven by 43lsma et al &1997'. $omparison of manual instrumentation with the automated %a&o-Endo 'lash resulted in an equivalent degree of canal cleaning. 1urthermore, in comparison with the canals that were instrumented with the (ro'ile instruments) the %a&o-Endo 'lash resulted in significantly better root canal cleanliness in curved canals . These results corroborate the reports from other authors, in that most cases of manual instrumentation proved to be superior to mechanical instrumentation as far as cleanin) efficiency is concerned (43lsma et al, 1997; Mi@rahi et al, 1975; SchAar@e & Ge3rtse , 1996) and that automated devices in most cases create a thic/er smear layer than manual instrumentation (SchAar@e & Ge3rtse , 1996). &1' +4,S* +40+ )-1)C0+* B*++*. CL*0-S)-G *##)C)*-C( 2)+4 .,+0.( +*C4-)B/*S9 :alli et al &1996' compared the debridement ability of $anal Master and D; 1iles usin) scannin) electron microscope. The results showed that the Canal *aster produced cleaner showin) lesser debris than that produced by D;1iles. Bertra d et al &1999' determined the ability of the Euantec Series +,,, rotary nic/el;titanium endodontic system to remove the dentinal debris and smear layer produced durin) canal preparation. The absence or presence of a smear layer

(,

Smear Layer In Endodontics

was rated and scored on three appearances usin) the scale described by Ci3cchi et al &19!9' as follows3 Score ,3 "o visible tubule orifices;surface is totally smeared. Score 3 Scattered open tubules orifices;surface is partially free of smear layer. Score %,3 >e)ularly distributed open tubule orifices;surface is free of smear layer. The conclusion was that +uantec rotary system produced cleaner canal walls than conventional manual instrumentation , particularly in the middle and apical third. Bechelli et al &1999' compared the efficacy of root canal wall debridement followin) hand versus 6i)htspeed F instrumentation. present in the apical region following ess smear layer was ightspeed, instrumentation than

stainless steel hand files, but this difference was statistically not si)nificant. .ogge dor? et al &1999' found (ro'ile superior to instrumentation. Medio i et al &1999' reported the superior cleaning ability of +uantec $eries !""" when compared to 0E># A4+, =ro1ile, and hand instrumentation. =eters & BarbakoA &"888' studied the effect of irri)ation on debris and smear layer on the canal walls prepared by two rotary techni8ues, i.e.3 6i)htspeed (6S) and =rofiles (=S) systems. The lar)er canal preparations obtained in this study with ightspeed instruments enabled a more effective removal of the smear layer than the =1 )roup. 43lsma , Schade & Scha?ers &"881' compared cleanin) ability usin) two ightspeed and

+uantec instruments (no specification on the type of Euantec files) or hand

different rotary nic/el;titanium instruments3 0E># A4+ (MicroMe)a, 1rance) and Euantec S$ (Tycom, $', GS'). >esults indicated that cleaner root canal walls were found after preparation with HE-. /0! 1234 scores 5 and !6) followed by +uantec $C 10546.
(%

Smear Layer In Endodontics

Gambari i & Las@kieAic@ &"88"' assessed the debris and smear layer remainin) followin) canal preparation with ?T rotary instruments. .t was concluded that the GT, rotary instruments removed debris effectively, but left root canal walls covered with smear layer particularly n the apical third. Ba3ma et al &"88%' found that -CT with -aCe, had better smear layer

removal than hand instrumentation. 0lma ai et al &"88%' compared 4 different rotary nic/el;titanium

instruments (=ro1ile@, =roTaper@, >a$e@, and "iTee@) with re)ards to canal cleanliness. Si)nificantly less smear layer was observed in the apical third of the (roTaper group when compared with the (ro'ile group. ) CSoo 7eo et al &"88%' compared the 8uality and amount of smear layer )enerated in the apical third of strai)ht root canals by + rotary nic/el;titanium reamers and . rotary steel reamer with different cuttin) blade desi)ns. 'utomated preparation was performed with =ro1ile and 0E># A4+ reamers usin) the crown; down techni8ue and with a stainless steel en)ine reamer (Mani) by usin) a reamin) motion. ' 4 H cate)ory scorin) system for smear layer was used which is as follows3 ,3 no smear layerBall tubules clean and open. %3 no superficial smear layerBtubule openin)s visible, but some contain debris plu) or soft tissue remnants. +3 moderate smear layerBsome tubules open and others closed. 23 heavy smear layer and mostBall tubule openin)s obscured. The results indicated that the least smear layer remained in the HE-. /0! group. .n the =ro1ile )roup, the smear layer had a shiny and burnished appearance with few openin)s of dentinal tubules. The depth of the pac/ed smear layer into the tubules was deeper than in the 0ero )roup. The smear layer )enerated by the steel reamers appeared thinner and less compressed than in the =ro1ile )roup.
(+

Smear Layer In Endodontics

#ig %5 ' I

' scannin) electron micro)raph of a canal wall prepared with 0ero A4+ rotary reamers has a snowy appearance with many open dentinal tubules (Score %3 #ri)inal ma)nification *% ,,).

' scannin) electron micro)raph of a canal wall prepared with =ro1ile rotary reamers. The canal wall was to be covered by a thic/, nonhomo)enous layer, with a shiny burnished appearance and almost no open dentinal tubule (Score 29 ori)inal ma)nification -% ,,).

$ut;view of a canal wall prepared with =ro; 1ile rotary reamers at the apical +mm level. The smear layer had a muddy appearance (* ,,,).

$ut;view of a canal wall prepared with the 0ero rotary reamers at the apical +mm level. ?enerally, the tubular pac/in) is less fre8uent than that obtained in the =ro1ile )roup. Thin smear layer with many open dentinal tubules covered on the root canal wall (*2,,,).

(2

Smear Layer In Endodontics

&*' +4,S* +40+ 40:* S4,2- )-C,-CL/S):* .*S/L+S ,. S)M)L0. .*S/L+S 2)+4 1)##*.*-+ +*C4-)B/*S9 Dlimm et al &1998' evaluated the efficacy of irrigated) hand root canal preparation by SEM. 7n all groups a homogeneous or inhomogeneous smear layer of different thic/ness and e-tent dominated. Ma del et al &1998' evaluated the cleansin) efficiency of manual serial preparation, endosonic ($avi;Endo) preparation and automated preparation with the $anal 1inder System. 8o preparation technique was found to result in any characteristic microscopic features that distinguished it from the other techniques. L3mley et al &199"' investi)ated the effect of precurvin) Endosonic files on the amount of debris and smear layer remainin) in curved root canals. The result of this study indicated that precurving of files decreased the amount of debris but did not affect smear layer removal. Syd ey et al &1996' analy:ed the smear layer removal after root canal preparation by a manual techni8ue and by an automated handpiece, the $anal 1inder System ($1S).9oth the techniques showed root canal walls with dense smear layer. 4eard & 2alto &1997' compared four root canal preparation techni8ues in small curved canals. The four methods were3 (%) step;bac/ without initial coronal flarin), (+) step;bac/ with coronal flarin), (2) step;bac/ with initial coronal flarin) and finished by ultrasonic irri)ation and, (4) ultrasonics only. The results indicated that there were no statistically significant differences between the techniques. Dochi et al &199!' could find no difference between +uantec ("o information on type of file) and manual preparation using %-files.
(4

Smear Layer In Endodontics

Mayer et al &"88"' evaluated smear layer scores after two types of instruments to ultrasonically activate irri)ants durin) + types of canal preparation (=ro1ile .,4 and 6i)htspeed). .t was found that ultrasonically activated irri)ants did not reduce smear layer scores and this findin) was not influenced by the material or by the desi)n of the instrument used to transmit ultrasonic activation. There were no differences in amount of smear layer on canal wall prepared with (' or $ instruments. Lichota et al &"88%' assessed the cleanliness of root canal walls followin) =ro1ile rotary techni8ue of instrumentation. Thus thou)h they removed debris effectively, (ro'iles left the root canal walls covered with smear layer in the apical and middle thirds. Thus, from the above studies we can conclude that there is still no consensus on the best instrumentation techni8ue which may result in cleanest possible canal without the presence of a smear layer. 1urther research is re8uired to resolve the current controversy on the best instrumentation techni8ue.

Smear Layer In Endodontics

&))'

)-+.0C0-0L M*1)C0M*-+S 0-1 SM*0. L0(*.

The )oal of clinical treatment is to completely disrupt and destroy the

bacteria involved in the endodontic infection. Endodontic infection will persist until the source of irritation is removed. =revious studies have shown that bacteria in infected root canals and periradicular tissues are capable of invadin) and residin) deeply within dentin and in cementum around the periape-. ( 0 do & 4oshi o, 1998; Diry3 et al, 199>; =eters et al, "881). 1urther more, it has been demonstrated that althou)h bacteria in artificial smear layers and prepared reservoir channels in deeper layers of root dentin could be eliminated by procedures such as ultrasonic irri)ation with "a#$l (43<3e et al, 199!), microor)anisms within fins and isthmuses could still remain viable ( Sato et al, 1996). Even after chemomechanical instrumentation of the canal, some bacteria still remain in the canal and dentinal tubules ( Bystrom & S3 d<;ist, 19!1, 19!%, 19!5). Total debridement is impeded because of accessory canals, fins, cul;de; sacs and communications between the main canals. Such microor)anisms may cause root canal treatment to fail. The rationale behind intracanal medication is to destroy residual microor)anisms and their to-ins and to remove or)anic tissue. The medicament should inhibit microbial recoloni:ation of the cleaned parts of root canal system by preventin) residual microor)anisms from )rowin) and new or)anisms invadin) throu)h lateral communications and coronal access. 1or this reason, chemomechanical cleansin) is often supported by the use of disinfectants. <arious medicaments have been proposed for disinfection of root canals. The traditional phenolic or fi-ative a)ents include camphorated monochlorophenol ($M$=), formocresol, and cresatin. .odine potassium iodide and calcium hydro-ide are the main nonphenolic intracanal medications. These medicaments are potent antibacterial a)ents under laboratory test conditions9 however their effectiveness in clinical use is unpredictable (Messer & Che , 19!>). 'ccordin) to some researchers, they also neutrali:e and render canal tissue
(A

Smear Layer In Endodontics

remnants inert. Some medications contain aldehyde derivatives that can be used to fi- fresh tissues for histolo)ical e-amination9 however, they may not effectively fi- necrotic or decomposed tissues (2alto & .i;era, "88"). 'ccordin) to 2esseli k et al &1977', fi-ed tissues are not inert and may become more to-ic and anti)enic after fi-ation. .ntracanal medications have also been used clinically to prevent posttreatment pain. Studies have shown, however, that routine use of these materials as intracanal medication has no si)nificant effect on the prevention of pain. 'ccordin) to ,g3 tebi &199>', most currently used intracanal medicaments have a limited antibacterial spectrum and anti)enic potential. .n addition, some of them have a limited ability to diffuse into dentinal tubules. *??ect o? i traca al medicatio s o bacteria i de ti al t3b3les9 'fter removal of the smear layer, 4aa5asalo & ,rsta;ik &19!7' inoculated the bovine incisors with E. faecalis and found penetration of these bacteria into the dentinal tubules upto % mm. They demonstrate that li8uid $M$= completely disinfected the dentinal tubules but that $a(#0) + was ineffective. Beh e et al &"881' had better success /illin) E. faecalis with either =ulpdent or a %,! solution of $a(#0)+ than with the traditional thic/ mi-es. The difference mi)ht have been attributable to the different viscosity of various types of $a(#0) + used in this e-periment. 4eli g & Cha dler &199!' also inoculated dentinal tubules of bovine teeth with E. faecalis and then e-amined the disinfectin) effect of various irri)ants. They found that none of the test irri)ants (chlorhe-idine, hydro)en pero-ide, sodium hypochlorite, EDT' or their combinations) were totally effective. Si<3eira & 1e /@eda &1996' inoculated bovine dentinal cylinders with % facultative and + obli)ate anaerobic bacteria and e-amined the disinfectin) effect of $a(#0)+ mi-ed with saline solution or $M$= for % hour, % day, and % wee/. Their results showed that $a(#0) + and saline solution were ineffective in disinfectin) the dentinal tubules after % wee/ of application. .n contrast, a mi-ture of $a(#0)+ and $M$= resulted in complete disinfection of the dentinal tubules in % day. 7ea so e & 2hite &199>' and D3r3;illa & Damath &199!' e-amined the antibacterial effect of chlorhe-idine )luconate and sodium hypochlorite on

(&

Smear Layer In Endodontics

inoculated human teeth in vitro. They reported a reduction in bacterial counts but not total disinfection of the root canals. .n an in vivo e-periment, Dateb@adeh et al &1999' showed that infected do) teeth that were filled e-perienced treatment failure more fre8uently than those medicated with $a(#0)+ before obturation. SEogre et al &1997' e-amined the presence and the influence of bacteria on the lon);term success of root canal therapy. Their results show that 4,! of root canals remain infected after instrumentation. .n addition, they reported that teeth filled in % visit without the use of $a(#0)+ e-perienced treatment failure si)nificantly more fre8uently than those that were medicated for % wee/ with $a(#0) + (A(! vs. 54!). The results of this study corroborate the findin)s of Bystrom et al &19!7', who showed improved clinical success rates after effective disinfection of root canals. G3tierre@ et al &1991' evaluated the diffusion of medicaments within the root canal dentin after mechanical preparation and flushin) with alternate "a#$l and hydro)en pero-ide followed by placement of the medicaments ($M$=, $M$= with formocresol and methylcresylacetate) by paper points. .t was found that all 2 medicaments crystalli:ed both on dentin walls and inside the dentinal tubules. Iacteria remainin) in dentinal tubules in close relationship with $M$= crystals appeared shrun/en. Smear layerC a 5hysical barrier ?or disi ?ecta ts9 'ccordin) to some authors (Goldberg & 0bramo;ich, 1977; 2ayma et al, 1979; (amada et al, 19!%; Berg et al, 19!6; Ba3mgart er & Mader, 19!7 ) the presence of the smear layer may bloc: the antimicrobial effect of intracanal disinfectants into the tubules by preventin) their penetration into the tubules. .n an in vitro study, ,rsta;ik & 4aa5asalo &1998' showed the importance of removal of the smear layer and the presence of patent dentinal tubules for decreasin) the time necessary to achieve the disinfectin) effect of intracanal medications. They found that camphorated p;monochlorophenol was )enerally more efficient than $alasept, and of the irri)ants tested, iodine potassium iodide
((

Smear Layer In Endodontics

appeared more potent than sodium hypochlorite or chlorhe-idine. They also concluded that the smear layer did delay) but not abolish the action of disinfectants. 0owever, followin) the removal of the smear layer, bacteria in dentinal tubules can be easily destroyed ( Bra strom, 19!>) and in this way, it may be beneficial to use lower concentrations andBor amounts of antibacterial a)ents since all of these a)ents show some de)ree of to-icity to viable host cells. Bystrom & S3 d<;ist &19!5' have also shown that the presence of a smear layer can inhibit or significantly delay the penetration of antimicrobial agents such as intracanal irri)ants and medications into the dentinal tubules. Diffusion throu)h dentin is directly proportional to the surface area of dentinal tubules and inversely proportional to the dentin thic/ness. 'lso the presence of the smear layer acts as a diffusion barrier that can reduce diffusion by + ;2,! (=ashley, 19!!). The presence of a smear layer has previously been demonstrated to decrease the diffusion of triamcinolone and demethylchlortetracycline, two active components of the root canal medicament, edermi#, throu)h radicular dentin (0bbott et al, 19!9). #oster et al &199%' evaluated the effect of smear layer removal on the diffusion of calcium hydro-ide throu)h radicular dentin. =ulp e-tirpation and the placement of $a(#0)+ into the root canal & to %4 days after a traumatic episode are recommended to decrease the incidence of inflammatory root resorption. +ro stad &19!1' su))ested that $a(#0)+ placed in the root canal elevates the p0 in areas of resorption on the surface of the root by diffusion of #0 ; throu)h the dentin, thereby decreasin) osteoclastic activity and activatin) al/aline phosphatases. The result of this study demonstrated that Ca1.H6! diffuses from the root canal to the e#terior surface of the root and that the removal of the smear layer may facilitate this diffusion. Thus the root canal space may be considered a route for medication delivery to the dentinal tubules themselves, if disinfection is re8uired, andBor to the e-ternal root surface.

(5

Smear Layer In Endodontics

Cr3@ et al &"88"' evaluated the penetration of propylene )lycol into root dentin. =ropylene )lycol is a vehicle that has the potential for use in root canal medicaments. .t has been reported to be a widely used vehicle for various pharmaceutical and commercial products such as dru)s, cosmetics and foods (Morshed et al, 19!!) and it is also used as a constituent of $aries Detector (#3sayama, 19!!). .n endodontics, it has been used as a vehicle for calcium hydro-ide (SaiiEo, 1957; LaAs, 196"; LaAs, 1971; Simo et al, 1995). .n this study, Safranin # in propylene )lycol and in distilled water was introduced into root canals with and without smear layer. .t was found that the area and depth of penetration with propylene )lycol was si)nificantly )reater than with distilled water. $mear layer significantly delayed the penetration of dye . Thus it is seen that propylene )lycol delivered dye throu)h root canal system rapidly and more effectively indicatin) its potential use in deliverin) intracanal medicaments. 'lso, propylene )lycol is less cytoto-ic than other vehicles, possesses antibacterial properties and is hy)roscopic, thus allowin) absorption of water which results in sustained release of intracanal medicaments for prolon)ed periods ( #a;a & Sa3 ders, 1999). Thus, it is seen that )enerally, removal of smear layer helps in diffusion of the intracanal medicaments and thereby improves their efficacy.

5,

Smear Layer In Endodontics

&)))' ,B+/.0+),- 0-1 SM*0. L0(*.

$omplete obturation of the root canal with an inert fillin) material and creation of a hermetic, apical seal have been proposed as )oals for successful endodontic treatment (-g3ye , 19!>). To achieve this, the root canal fillin) must seal the canal space both apically and coronally to prevent the in)ress of microor)anisms or tissue fluids into the canal space. 'pical lea/a)e is considered a common reason for the clinical failure of endodontic therapy. 6i/ewise, coronal lea/a)e is also reported to be an important reason for failure ( Madiso et al, 19!7; Sa3 ders & Sa3 ders, 199>). ?utta;percha is considered an impermeable core material9 therefore, lea/a)e throu)h an obturated canal is e-pected to ta/e place at the interface between sealer and dentin or sealer and )utta;percha, or throu)h voids within the sealer. 0ence, the sealin) 8uality of a root canal fillin) depends much on the sealin) ability of the sealer. ' review of a lar)e number of published lea/a)e studies points to )eneral a)reement that lea/a)e occurs between the root fillin) and the root canal wall. Therefore, anythin) that may influence the adaptation of the root fillin) to the canal wall is of )reat si)nificance in determinin) the de)ree and the e-tent of lea/a)e, and ultimately the pro)nosis of the endodontic therapy. Iecause the smear layer remainin) on the root canal wall has been characteri:ed, there has been much interest in the possible effect of the smear layer on the lea/a)e of the root canal sealer. There is a controversy over whether or not to remove this layer before obturation and there is still no consensus on the influence of the smear layer on the development of an effective seal of the root canal system. Some consider that it is desirable to remove this layer as it covers prepared areas and prevents medicaments and fillin) material from penetratin) the dentinal tubules or even contactin) the canal wall. 's of today, almost no material has been shown to enter dentinal tubules with the smear layer present. >emoval of the smear layer is also considered to be desirable by others because, in addition to inor)anic particles, it may contain some or)anic material, as well as viable
5%

Smear Layer In Endodontics

bacteria. Iiolo)ically, the presence of the smear layer has been postulated to be an avenue for lea/a)e and a source of substrate for bacterial )rowth and in)ress (=ashley, 19!>). The fre8uency of bacterial penetration in the presence of a smear layer, when canals were obturated with thermoplastici:ed )utta;percha and sealer, has been shown to be si)nificantly hi)her than with smear layer removal and obturation (Behre d et al, 1996). ' further concern is the presence of viable bacteria that may remain in the dentinal tubules and use the smear layer for sustained )rowth and activity (Bra strom, 19!>; ,lgart et al, 197>).

Iecause of the bacterial content of the smear layer, any apical e-trusion of the smear layer durin) instrumentation or obturation can defeat one of the )oals of endodontic therapy3 the return to and maintenance of an inflammation;free state in the periapical area. To be considered an ideal sealer, a material should not itself cause or further irritate the periapical tissue. Some root canal fillin) materials, especially "+ paste and silver points, are not biocompatible. To ris/ further tissue trauma with a techni8ue that may induce or potentiate periapical inflammation is unthin/able. Smear layer induced inflammation of the periapical area can be caused by over instrumentation or by the careless measurement and fillin) of a master cone. .t has been recommended that master cones be foreshortened to fit %mm short of the ape- as an effective countermeasure to creatin) pre; and post obturation periapical inflammation. Some doubt e-ists if the formation of apical plu)s from a combination of dentin chips, soft;tissue fra)ments and fibers from instrumentation may enhance the seal of a root canal fillin). Dentin filin)s occur durin) instrumentation, but the formation of an apical plu), from them is often an inadvertent or accidental occurrence. Well;formed apical plu)s can often reduce the inflammatory reactions followin) fillin) by limitin) the apical e-tension of fillin) materials thereby encoura)in) healin). .f more cementum is )oin) to form to create a better apical seal, dentin chips at the ape- of a root can act as a nidus for formation of hard tissue. Iacterial contamination by the presence of the smear layer can prevent this.
5+

Smear Layer In Endodontics

Endodontic sealers act as a )lue to ensure a )ood adaptation of )utta percha to the canal walls. .f the smear layer is not removed, the )utta percha may occasionally be )lued to the dentin in the smear layer as well as to e-posed parts of the canal wall. The smear layer may interfere with the penetration of the )utta; percha into the tubules and the adhesion and penetration of the sealers into the dentinal tubules. "ot bein) firmly attached to the dentin, the smear layer may laminate off the canal wall and create a false seal, voids in the fill and an e-pected environment for microlea/a)e. Thus the retention or removal of the smear layer before obturation may influence the 8uality of the obturation. .n contrast, other investi)ators (=ashley et al, 19!1) consider that the smear layer should be left intact, as it may actually form a protective barrier. The smear layer may be responsible for e-cludin) bacteria from dentinal tubules as well as restrictin) the surface area available for the diffusion of many molecules. #ne study (Michelich et al, 19!8) has shown that the smear layer will prevent bacterial penetration (Streptococcus mutans), but will permit fluid filtration. 'nother study (2illiams & Goldma , 19!5) has revealed that the smear layer simply delays the penetration of some bacteria (Proteus vulgaris) rather than preventin) it. Many articles have been written on the physical properties of root canal sealers, includin) the their adhesive stren)th to dentin ( ,rsta;ik et al, 19!%; McComb & Smith, 1976) and to )utta;percha (,rsta;ik et al, 19!%). 'dhesive stren)th measurements may be important to clinical usa)e, because hi)her adhesive stren)ths may reduce lea/a)e in clinical situations. #penin) of the tubuli by removal of the smear layer prior to fillin) the root canal system ma/es )reat sense. .f chemical adhesion between the dentin and sealers, pastes, cements or plastics cannot be easily achieved, then why not a mechanical loc/J The material will flow or be forced bac/ into the empty dentinal tubules, )rippin) li/e tentacles and forever resistin) displacementK This may actually increase the adhesive stren)th of sealers to dentin and improve the sealin) ability of the fillin).

52

Smear Layer In Endodontics

The type of sealer used has different implications once the smear layer is removed. ' powder;li8uid combination, the most common of which is ?rossmanLs sealer, contains small particles in the powder that could enter the orifices of the dentinal tubules and help create a secure interface between sealer and canal wall. Iut studies have shown that the adhesion of ?rossman type root canal sealers to dentin is established by electrostatic bondin) and not by its penetration into the tubules. So the action of EDT' to remove the smear layer and open the dentinal tubule orifices does not si)nificantly increase the adhesion value of ?rossman type root canal sealers. $alcium hydro-ide based sealers have the advanta)e of promotin) the apposition of cementum and sealin) it off a)ainst microlea/a)e. 'lthou)h calcium hydro-ide has dentin re)eneratin) properties, the formation of secondary dentin alon) the canal wall is prevented by the absence of vital pulp tissue. The calcium ion is used in the formation of osteoid or dentoid type material. $irculation of blood (which is absent in filled canals) is needed for the calcium ion to promote new tissue9 thus the calcium hydro-ide sealers are effective for sealin) only at the root ape-. .t is also seen that the adhesion values of Sealape-, a calcium hydro-ide based sealer is 8uite low even with the removal of the smear layer, which allows )reater penetration into the tubules. This can be e-plained by the hi)h settin) time, solubility and disinte)ration of the sealer. 'lso the sealer is easily displaced from the tubules due to low cohesive structure. Epo-y based resin sealers showed increased adhesion values with dentin treated with EDT' when compared to the dentin without any treatment. This is due to the fact that EDT' removes the smear layer and opens the tubule orifices, which are then partially filled with the sealer with the resultant formation of resin ta)s, causin) a hi)her mechanical bondin) between the sealer and the root canal wall. Since the epo-y resin based sealers are stron)ly cross; and end to end lin/ed with ether bonds and had improved physical inte)rity, they appeared more li/ely

54

Smear Layer In Endodontics

to remain intact in the tubules after penetration ( 2hite, Goldma & =eck S3 Li , 19!7). ' )lass;ionomer based sealer Detac;Endo has been shown to bond chemically with the hydro-yapatite of the root dentin. Several studies have shown that that the removal of the smear layer from the root canals decreased microlea/a)e. $onditionin) of the tooth surfaces with acids can remove the smear layer from the instrumented root canals and alter the surface ener)y, allowin) the )lass ionomer to flow and adapt more easily, enhancin) its adhesion. .n addition, acid conditionin) removes surface contaminants before )lass ionomer sealer placement, possibly permittin) )reater ionic e-chan)e and better bondin) between the cement and tooth structure. There is no practical advanta)e to the use of an autocure unfilled resin as a seal over the tubules before )utta percha obturation. The resin would be susceptible to moisture throu)h the lateral canals and throu)h the ape-. Gpon polymeri:ation, the resin would shrin/ creatin) a )ap between the fill and the canal wall. The use of some dentin;bondin) a)ents to harden the smear layer to the canal wall and to harden the apical plu) is a sub7ect of research. .t is doubtful that the bondin) a)ent would be antimicrobial to the bacteria in the smear layer. .t is probable that the insertion of a ti)ht;fittin) post into the canal wall would help to prevent lamination of the smear layer off of the canal wall if the layer wad retained and treated with a dentin;bondin) a)ent. =ossibly, it would be better to remove the smear layer. #nce pac/ed down, the apical debris is hard9 whether further hardenin) with a dentin;bondin) a)ent would improve the seal permanently and enhance retention is problematical.

'nother important factor to be considered is the obturation techni8ue which is used. Since the most common cause of endodontic failure has been attributed to incomplete obturation () gle showed A,! of endodontic failures to be caused by
5

Smear Layer In Endodontics

incomplete obturation), many different obturation techni8ues have been developed in order to increase the success of root canal treatment. ?utta;percha has been the material of choice for obturation since %(A& and many different )utta;percha techni8ues have been introduced in order to increase the 8uality of the apical seal of the root canal. 6ateral condensation has proven to be a very popular )utta;percha techni8ue. 0owever, Schilder &1C-0, 1967' and Brayto et al &197%' noted that with lateral condensation of )utta;percha at no time did a homo)enous mass form nor did the )utta;percha adapt to the root canal walls. The voids in this nonhomo)enous mass may remain empty or be filled with sealer which may resorb in time, decreasin) the effectiveness of root canal obturation (=eters, 19!6). The concept of root canal obturation with thermoplastici:ed )utta;percha was introduced by (ee et al &1977'. ' ma7or impetus for this development was the need to ensure better adaptation of the root canal fillin) material to the prepared canal walls. They reported in7ected )utta;percha to be superior to lateral condensation and capable of fillin) multiple foramina and other ramification. 1urther studies by +orabi eEad et al &197!', Marli et al &19!1' a d B3dd et al &1991' have supported this achievement in that the thermoplastici:ed )utta;percha was shown to replicate the intricacies of the root canal system and achieve a seal e8ual to, if not superior to, that produced by other obturation methods (Micha oAic@ & C@o stkoAsky, 19!>; C@o stkoAsky et al, 19!5; *l1eeb, 19!5; *;a s &Simo , 19!6; Ma & Mc2alter, 19!7). 1avourable results for the sealin) ability of the low;temperature thermoplastici:ed )utta;percha techni8ue (Gltrafil) and close adaptation to the canal walls have been reported (Micha oAic@ & C@o stkoAsky, 19!>; Micha oAic@ et al, 19!6 ). 'nother thermoplastici:ed )utta;percha techni8ue, Thermafil which consists of a metal carried with ;phase )utta;percha was introduced by 7oh so condensation. &197!, 19!!'.

Beatty et al &19!9) found that Thermafil produced a better apical seal than lateral

5A

Smear Layer In Endodontics

$urrent methods of canal obturation usin) thermoplastici:ed )utta;percha all e-tol the virtues of the adaptation of the softened materials to the canal irre)ularities. #ne techni8ue has been shown to have dentinal tubule penetration with the softened )utta;percha even without the use of sealer ( Micha oAic@ et al, 19!6). When sealer was used no penetration was evident. 0owever, they still advised usin) sealer to produce better apical seal. #ther plastic;type fillin) materials (p0EM' and silicone) have also been shown to penetrate the dentinal tubules in the absence of root canal sealer ( 2hite et al, 19!>). 0owever, this situation poses a dilemma, as the use of root canal sealer has been advocated as essential with thermoplastici:ed )utta;percha to achieve the best possible seal (*l1eeb, 19!5; *;a s & Simo , 19!6; Ski al, 19!9). 'n additional dilemma in this issue is the ability of the )utta;percha to be adapted intimately to the root canal wall when the smear layer is present (Mood ik et al, 1976; 2hite et al, 19!>). The effect of removal of smear layer on the overall success rate of endodontic therapy is unclear. 'lthou)h Biester?eld & +ai tor &19!8', Madiso & Drell &19!>', Goldberg et al &19!5' and *;a s & Simo &19!6' did not find any improvement in sealin) of smear;free canals, e-periments by De edy et al &19!6', 0bramo;ich & Goldberg &1976', +idmarsh &197!' and 2hite et al &19!>' showed better adhesionBsealin) of smear;free canals. >emovin) of the smear layer prior to fillin) may actually increase the adhesive stren)th of the fillin) to dentin and improve the sealin) ability of the fillin). 0owever, most of the studies carried out with a variety of sealers and by different obturatin) techni8ues do indicate that removal of smear layer does indeed improve the adaptation and the seal of the fillin) material. ?iven below are some of the several studies that support this, thou)h different sealers and obturatin) techni8ues do vary in their sealin) abilityBpenetrationBadhesion when smear layer has been removed. er & 4imel, 19!7; BradshaA et

5&

Smear Layer In Endodontics

(') Sealers a d smear layer9 (amada et al &19!%' stated that a case could be made for the removal of smear layer3 M1or instance, it may interfere with the adaptation of filling materials to the canal wall by imposin) an additional interfaceN. They also went on to state, Min addition, openin) all the tubules can perhaps provide a better seal by allowin) sealer or fillin) material to penetrate the dentinN. Cerg e36 et al &19!7' compared the sealin) ability of obturated root canals which had previously been cleaned chemically by EDT' or mechanically by ultrasound. The results indicated that when the smear layer is not eliminated 1control group6) there is a tendency for greater dye infiltration . 'lso that the EDT';treated canals showed the least infiltration, while those treated with ultrasound showed less sealin) ability that the EDT' treated )roup but si)nificantly less lea/a)e than the control )roup. 2hite, Goldma & =eck S3 Li &19!7) evaluated the influence of the smeared layer upon dentinal tubule penetration by different endodontic fillin) materials, i.e., p0EM' (0ydron), silicone (Endo;fill) and laterally condensed )utta;percha with + different sealers (>oth (,% and '0 +A). .t was found that pHE*;) silicone and both sealers consistently entered the dentinal tubules when the smear layer was removed with EDT' prior to fillin). When the smeared layer was present durin) fillin), tubular penetration was unpredictable and infre8uent. Gettlema et al &1991' assessed the influence of smear layer on the

adhesion of sealer cements to dentin. The results showed si)nificant differences amon) '0+A, Sultan, and Sealape-, with ;H!/ being the strongest and $ealape# being the wea:est and that ;H!/ had a stronger bond when smear layer was removed.

5(

Smear Layer In Endodontics

,ska et al &199%' evaluated the effect of smear layer on the penetration of 4 root canal sealers into dentinal tubules. .t was observed that the smear layer obstructed the penetration of the tubules by the sealers . 0owever, the penetration into the tubules was better with <ia:et) 8! and $(;< , than with 1orfenan when the smear layer was removed. Do3;as et al &199!' e-amined the effect of the smear layer on the penetration depth of Sealape-, >oth (%%, and $>$S root canal sealers into the dentinal tubules. The removal of the smear layer allowed penetration of all 2 sealers into the dentinal tubules to a depth of between 2 m and (, m, with penetration depth of >oth (%% sealer bein) %,;A, m, that of Sealape- bein) 2,; (, m and that of $>$S bein) %;2 m. The $ealape# and -oth =55 sealers penetrated deeper than the C-C$ sealer since their particle si:e was smaller than that of $>$S. The de)ree of obstruction of the dentinal tubules differed dependin) on the sealer, with C-C$ providing a better) tighter seal . This su))ested that the microstructure of the sealer paste in the dentinal tubules and the de)ree of their closure, rather than their depth of penetration, mi)ht be an important factor for a ti)ht obturation of a smear;free root canal. The presence of smear layer at the root canal walls obstructed the penetration of all sealers into the dentinal tubules. #ig %6

=icture of $>$S in smear layer;free dentinal tubule the stratified appearance of the sealer.

The presence of smear layer inhibited Sealapefrom striatin) the dentinal tubules

55

Smear Layer In Endodontics

*co omides et al &1999' evaluated the influence of the smear layer removal on the apical sealin) ability of different sealers (>oth (%% and '0+A) The results indicated that the smear layer removal resulted in statistically significant reduction of microlea:age values in the groups obturated with ;H!/. Ste;e s &"88%' investi)ated the sealer penetration of >othOs (,% sealer into smear;free dentinal tubules followin) a final rinse of 5 ! ethyl alcohol and also ascertained the whether this final rinse affects lea/a)e. .t was found that followin) smear layer removal with %&! EDT'B .+ ! "a#$l, flushing the canal with >24 ethyl alcohol prior to obturation will significantly improve sealer penetration and significantly decrease lea:age as compared to the )roup in which the final rinse was carried out with "a#$l after smear layer removal. Coba kara et al &"88>' determined the effect of the smear layer on apical and coronal lea/a)e in root canals obturated with '0+A or >oe/oSeal (a polydimethylsilo-ane based sealer) sealers. 'ccordin) to the results of this study, the smear 1?6 groups displayed higher apical and coronal lea:age than those smear 1-6 groups for both root canal sealers. There was no statistical significant difference in either apical or coronal lea/a)e between -oe:o$eal and ;H!/, regardless of the presence or absence of the smear layer . *co omides et al &"88>' compared the microlea/a)e of + root canal sealers with and without the smear layer bein) present. .n this study, a resin;based sealer Fibrefill and the $alcibiotic root canal sealer ($>$S), which is a calcium hydro-ide;based sealer, were assessed. The results indicated that the canals treated with 'ibrefill lea:ed less than those treated with C-C$ , re)ardless of whether the smear layer had been removed. ess microlea:age was found with both sealers when the smear layer was removed , but the value did not differ statistically from the results with an intact smear layer. Dokkas et al &"88>' e-amined the influence of the smear layer on dentinal tubule penetration depth by three different root canal sealers ('0 =lus, 'pe-it,
%,,

Smear Layer In Endodontics

and >oth (%%). E-amination in SEM revealed that the smear layer obstructed all the sealers from penetratin) dentinal tubules. .n contrast, smear layer removal allowed the penetration of all sealers to occur to a varying depth. These findin)s su))est that smear layer plays an important role in sealer penetration into the dentinal tubules, as well as in the potential clinical implications. (I) ,bt3ratio tech i<3es a d smear layer9 G3tma &199%' e-amined with SEM the adaptation of thermoplastici@ed)

inAected gutta-percha 1.btura)6 to prepared dentin devoid of smear layer. .t was found in this study that the gutta-percha penetrated into the patent dentinal tubules with or without the root canal sealer . This was in direct contrast to the findin)s of Micha oAic@ et al &19!6', in which )utta;percha did not penetrate the dentinal tubules in the presence of sealer. 0owever, here a different thermoplastici:ed in7ection system (Gltrafil) was used and condensation was not performed (1i). 2&).

%,%

Smear Layer In Endodontics

#ig %7

Discrete penetration of softened )utta;percha into the patern tubules in the form of plu)s. "ote that seperation of the plu)s su))estin) a decreased number of dentinal tubules in the apical position of the canal. "o sealer used *% ,,

?uttapercha matted to)ether with sealer, SEM *54,.

?uttapercha plu)s showin) discrete penetration into the tubules without the use of sealer, SEM ori)inal ma)nification *54,.

Entan)lement of )utta;percha plu)s and sealer, SEM *&+,

%,+

Smear Layer In Endodontics

Ge cogl3 et al &199%' evaluated the dentinal adaptation of in7ected thermoplastici:ed )utta;percha and thermoplastici:ed )utta;percha resultin) from Gltrafil and Thermafil systems respectively, by SEM, and compared it with adaptation obtained with lateral condensation techni8ue. Each method was evaluated with and without the smear layer removed. The results showed that thermoplastici@ed gutta-percha resulting from either system had better dentinal wall adaptation than lateral condensation in either the absence or presence of the smear layer. 7n the absence of smear layer) the adaptation of gutta-percha was improved in all groups. .n another study by Ge cogl3 et al &199%' these + thermoplastici:ed )utta; percha techni8ues showed si)nificantly less apical lea/a)e than the lateral condensation techni8ue with and without the smear layer. -emoving the smear layer reduced the lea:age significantly in all groups. .t has been postulated that heated )utta;percha forced into the patent tubules may establish a mechanical loc/ or bond between the fillin) material and the canal wall in the absence of the smear layer (*;a s & Simo , 19!6). Lloyd et al &1995' assessed the sealability of another thermoplastici:ed )utta;percha techni8ue, i.e. is the Trifecta technique, in the presence or absence of smear layer. The results also showed that the prevalence of sealer and guttapercha penetration into the dentinal tubules was significantly more common in the absence of smear layer. -emoval of the smear layer did not enhance the sealability despite increasing the proportion of specimens with dentinal penetration of sealer and gutta-percha. =allares et al &1995' compared the adaptation of mechanically softened )utta;percha (P.S. Euic/;fill and '0;+A sealer) to the root canal in the presence and absence of smear layer. .t was found that the sealer penetrated into the dentinal tubules along with proAections of gutta-percha only in those teeth without the smear layer.

%,2

Smear Layer In Endodontics

Dytrido3 et al &1999' evaluated the adaptation and the short; and lon);term sealability of two different thermoplastic techni8ues (Thermafil and System I), in the absence of smear layer. .t was found that both obturation techni8ues were not si)nificantly different in the apical third adaptation. 9ut it was seen that Thermafil demonstrated significantly more long-term apical lea:age than $ystem 9. 1ollowin) are the few studies which indicated that the smear layer removal did not help to improve the adhesion BpenetrationBsealin) ability of sealers and various obturation techni8ues3 Saleh et al &"88"' studied the effects of dentine pretreatment on the adhesion of root;canal sealers (?rossmanLs sealer, 'pe-it, Detac;Endo, '0 =lus, >oe/oSeal 'utomi- or >oe/oSeal 'utomi- with an e-perimental primer). 7t was concluded that removal of the smear layer might impair sealer adhesion to dentine. Different sealer types re8uire different dentine pretreatments for optimal adhesion. .n another study, Saleh et al &"88%' found that penetration of the endodontic sealers into the dentinal tubules when the smear layer was removed was not associated with higher bond strength. Coba kara et al &"88"' tested the effect of two different root canal sealers (i.e. Detac;Endo and '0+A) on resistance to root fracture and also evaluated the effect of smear layer. The use of adhesive sealers in the root canal system may offer an opportunity to reinforce the endodontically treated tooth. The results of this study indicated that the canals obturated with either sealer were significantly stronger than roots whose canals were instruments but not obturated. The presence of absence of the smear layer did not cause any significant effect on the root fracture resistance of the teeth. Daradag et al &"88>' evaluated the influence of passive ultrasonic activation of the irri)ants on the penetration depth of different sealers. Gnder the conditions of this study, it can be said that ultrasonically activated irrigation did not reduce
%,4

Smear Layer In Endodontics

the smear layer effectively at 5 min and ".2 min time intervals. ;ccording to this result) no difference was observed between the penetrations of sealers. Even thou)h most of these in vitro findin)s showed that removin) the smear layer reduced the apical lea/a)e and improved the adhesion and penetration of the sealers, the effects of the smear layer on in vivo lea/a)e cannot be easily determined. 1urther wor/ should therefore include more clinical studies correlatin) with these in vitro studies. .n addition, studies are needed which further evaluates which sealers seal better in the presence and as well as the absence of the smear layer. 'lso, evaluation on which sealers wor/ best utili:in) specific obturatin) techni8ues should be completed. $learly, further research is necessary into the properties of different sealer cements, in order to establish the factors that affect and determine their clinical usefulness.

%,

Smear Layer In Endodontics

&):' =,S+ C*M*-+0+),- 0-1 SM*0. L0(*.

Endodontically treated teeth with loss of coronal tooth structure )enerally re8uire a radicular post for restoration of the tooth function. .n the last %, years, several e-perimental and clinical studies established that pre;fabricated posts offer a better pro)nosis than cast post and cores for endodontically treated teeth ( )sidor & Bro d3m, 199" and Ma occi et al, 199!).

>etention of all types of posts is affected by the cement selected for lutin) it to the post space. >emoval of smear layer increases the cementation bond and the tensile stren)th of the cementin) medium by allowin) penetration of these lutin) cements into the dentinal tubules. ?lass ionomer cements are effective in post cementation after smear layer removal because the )lass ionomer has a better union with tooth structure. The need for removal of smear layer is controversial while usin) )lass ionomer lutin) cements. 1ew reports su))est that the smear layer could assist adhesion because its hi)h calcium and phosphate content provide potential sites for stron) adhesive bondin). 0owever, in clinical situations, contamination of the smear layer is unavoidable and therefore removal of the whole contaminated layer may become necessary. 0eretofore, there has been no si)nificant difference between cements when the final rinse was +cc of .+ ! "a#$l ( Goldma , 1e :itre & +e ca, 19!>). When an unfilled Iis;?M' resin was used after "a#$l rinse, the stren)th of the resin bond was better than that of polycarbo-ylate cement. Bhen the smear layer was removed by flushing with E<T; and 8a.Cl rinse) the 9is-G*; resin followed into the e#posed dentinal tubules and into the serrations on the post) vastly improving retention. =ost len)th only made minimal difference when the canals were flushed with either rinse and the post was cemented with one of the conventional cements. Iut with removal of smear layer and an unfilled resin bondin) a)ent, shorter posts can be used ( Goldma , 1e :itre & +e ca, 19!>). Scannin) electron microscopic studies have shown that with the unfilled resins,
%,A

Smear Layer In Endodontics

serrated posts are recommended over smooth posts, and parallel posts show more retentive ability than tapered posts (Goldma , 1e :itre & +e ca, 19!>). The use of a dentin bondin) a)ent prior to cementin) a post with a composite cement or a )lass ionomer cement may or may not dictate removal of the smear layer, dependin) upon which bondin) a)ent is used or whether a )lass ionomer is used. Goldma , 1e :itre & =ier &19!>a' and Goldma , 1e :itre, 2hite & -atha so &19!>b' demonstrated that removing the smear layer with E<T; from the root canal permits increased tensile strength of plastic posts . The increased retention was associated with penetration of the resin into the open dentinal tubules. #ig %!

Gnfilled resin was applied to cleaned dentin inside root canal 7ust prior to insertion of a plastic post covered with more unfilled resin. 'fter polymeri:ation, the tooth substance was deminerali:ed and the or)anic matri- di)ested away to leave a plastic cast of the thousands of resin ta)s e-tendin) into open dentinal tubules. >oot canals covered with a smear layer did not permit resin to penetrate the tubules. *(5.

Since %55,, the use of resin cement has increased in order to reduce the stress created by post cementation. 'dhesive resin cements are also more desirable than other lutin) cements as they are insoluble in oral fluids and produce much hi)her enamel and dentin bond stren)ths. Several factors, includin) post retention and apical and mar)inal seal, are influenced by the methods of )utta; percha removal and by post space preparation. When a fiber post is used to restore endodontically treated teeth, the bondin) mechanism of adhesive systems to root
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Smear Layer In Endodontics

dental walls is essentially micromechanical in nature, based on hybridi:ation of the deminerali:ed surface and on resin ta)s and adhesive lateral branch formation. .t has been assumed that to achieve the hybrid layer it is necessary to remove the smear layer and debris from the dentin canal walls and the initial part of dentinal tubules to increase retention when resin cement is used ( Morris et al, "881). =ost space preparation is commonly performed usin) rotary instruments, and the mechanical removal of the sealer impre)nated dentin from the canal walls durin) post space preparations the critical step in achievin) optimum retention ( Boo e et al, "881). 23 et al &"888' su))ested that the percenta)e of sealer;coated perimeter was influenced by different condensation procedures3 hi)her after lateral condensation than after vertical condensation. 'nother factor influencin) the characteristics of the canal dentin surface and the percenta)e of sealers and )utta;percha into dentinal tubules is the irri)ation re)imen. $ommonly used a)ents are "a#$l and EDT' that are used alternately with a final flush of "a#$l to stop the chelatin) effect (1oga & Calt, "881). Thus, Sera?i o et al &"88>' evaluated the surface cleanliness of root canal walls alon) post space after endodontic treatment usin) + different irri)ant re)imens ( .+ ! "a#$l or alternate use of .+ ! "a#$l and %,! EDT'), obturation techni8ues (cold lateral condensation and warm vertical condensation) and post space preparation for adhesive bondin) (use of drills followed by 2 ! phosphoric acid )el). The amount of openin)s of the dentinal tubules compared to smear layer, debris, and sealerB)utta;percha remnants were )raded between , and + (1i). 25)3 Score of , was assi)ned when all dentinal tubules were open and no smear layer, debris, or sealerB)utta;percha was present or no instrumented calcospherites were noted9 Score of % was recorded when some dentinal tubules were open and a thin smear layer, debris, or sealerB)utta;percha remnants covered the openin)s of the cut dentinal tubules9 Score of + was recorded when all dentinal tubules were covered by smear layer, debris, or sealerB)utta;percha remnants.
%,(

Smear Layer In Endodontics

.t was found that canal walls along post space shows large areas 1covered by smear layer) debris) or sealerCgutta-percha remnants6 not available for adhesive bonding and resin cementation of fiber posts . Thus, the results of this study underscore the difficulty in obtainin) a dentin surface cleaned and suitable for resin adhesion in endodontically treated tooth after a routine post space preparation, despite acid etchin) and irri)ation. .t is therefore su))ested that a pretreatment with chelatin) a)ent and sodium hypochlorite be carried out before post cementation (Sta dlee & Ca53to, 199"). #ig %9
Score;, Score;%

Score;+

Li & Liao &1999' evaluated the effect of EDT' with different density on adhesive power of castin) post and its scannin) electromicroscopy (SEM) observation. 1our different densities of EDT' ( !, %,!, % !, %&!) were used to rinse the smear layer of root canal before they were cemented with Q=. .t was found that EDT' with different densities has different effect in the rinse of smear
%,5

Smear Layer In Endodontics

layer of root canal9 it was proved by both SEM observation and the records of tensile stren)th of castin) post. E<T; with density 5"4 is more effective in both the rinse of smear layer of root canal and the enhancement of adhesive power of casting post. #n the other hand, B3r s et al &199%' found that E<T; did not significantly affect retention) when they compared the retention of endodontic posts after preparation with ET<;. This study indicated that EDT' treatment for the removal of smear layer within a root canal space before endodontic post cementation can be harmful. EDT' removed the inor)anic smear layer, but the ad7acent dentin of the canal wall may also be appreciably wea/ened by it because of the deterioration to the inor)anic matri- of dentin. Thus, thou)h the resin did form mechanical interloc/s with the dentin, the diminished dentinal stren)th due to EDT', caused a de)radation of the interface, resultin) in less retention. Therefore, use of a milder dentinal smear layer solvent may be less detrimental to the ad7acent dentinal wall.

%%,

Smear Layer In Endodontics

&:' .,,+C*-1 #)LL)-G 0-1 SM*0. L0(*.

.nstrumentation of dentin results in accumulation of a smear layer coverin) the dentinal surface and occludin) the dentinal tubules. .t has been shown that bacteria may coloni:e in the smear layer and penetrate the dentinal tubules (Michelich et al, 19!8). >emoval of this smear layer seems desirable in the situation of root;end fillin)s that are placed in bacterially contaminated root ape-. .rri)ation with tetracycline has been shown to remove the smear layer (Barkhordar et al, 1997). Smear layer removal from resected root ends and dentin deminerali:ation by citric acid has been shown to be associated with more rapid healin) and deposition of cementum o the resected root ends ( Craig & 4arriso , 199%). Tetracyclines have a number of properties of interest to the endodontists9 they are antimicrobial a)ents, effective a)ainst periodontal patho)ens9 they bind stron)ly to dentin9 and when released they are still biolo)ically active ( .i?ki et al, 199%). >oot surfaces e-posed to anaerobic bacteria accumulate endoto-in and e-hibit colla)en loss, which may suppress fibroblast mi)ration and proliferation, thus interferin) with healin) (0leo et al, 1975). >oot surface conditionin) with acidic a)ents such as tetracycline, not only removes the smear layer, it also removes endoto-in from contaminated root surfaces (Mi abe et al, 199>). Barkhordar & .3ssel &199!' reported on an in vitro studied that e-amined the effect of irri)ation with do-ycycline hydrochloride, a hydro-y derivative of tetracycline, on the sealin) ability of .>M and amal)am when used as root end fillin)s. Their results indicated si)nificantly less microlea/a)e followin) irri)ation with do-ycycline involvin) both .>M and amal)am, compared with the control irri)ation with saline. They also su))ested that because of the lon) lastin) sustentative of do-ycycline on root surfaces and its slow release in a biolo)ically active state, their results support its use for dentin conditionin) before placement of a root;end fillin) in a periradicular sur)ery.

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Smear Layer In Endodontics

.t has also been su))ested by =itt #ord & .oberts &1998' that the failure of )lass;ionomer retro)rade fillin)s after apical sur)ery may result from the de)radation of the smear layer. .n a latest study done by Go3ACSoares S et al &"88>' it was shown that the Er3R'? +.54 micro m and the 5.A micro m $#(+) laser used for root canal resection and dentine surface treatment, prior to retrofillin) durin) apicoectomy resulted in a reduction of permeability to methylene blue dye.

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