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

Evaluasi Perbandingan Asam Ethylenediaminetetraacetic, asam maleat, dan asam perasetat

dalam membersihkan smear layer dari saluran akar yang diinstrumentasi: Studi analisis
mikroskop pemindai elektron

Abstrak

Pendahuluan: Tujuan dari penelitian ini adalah untuk menilai kemampuan 7% asam maleat,
0,5% asam perasetat (PAA), dan 17% asam etilenadiaminetetraasetat (EDTA) dalam
membersihkan smear layer pada saluran akar gigi menggunakan mikroskop pemindai elektron
(SEM).

Bahan dan Metode: Tiga puluh lima gigi anterior yang tidak memiliki karies dengan akar
tunggal dipilih sebagai sampel untuk penelitian ini. Preparasi chemo-mechanical dilakukan
dengan menggunakan teknik crown down dengan irigasi 2,5% NaOCl setelah setiap penggunaan
instrumen. Sampel akan dibagi secara acak menjadi tiga kelompok eksperimen dan satu
kelompok kontrol: (1) Kelompok asam maleat: 07% (n = 10), (2) kelompok PAA: 0,5% (n =
10 ), (3) kelompok EDTA: 17% (n = 10), dan (4) kelompok kontrol: saline 0,9% (n = 5)
tergantung pada bahan irigasi akhir yang digunakan. Sampel gigi kemudian dievaluasi dengan
menggunakan analisis SEM untuk melihat ada atau tidak adanya smear layer, sehingga dapat
menganalisis efektivitas pembersihan bahan irigasi pada sepertiga koronal, tengah, dan apikal
pada saluran akar. Reliabilitas pemeriksa diverifikasi dengan menggunakan uji Kappa. Data skor
untuk perbandingan dalam kelompok dan perbandingan antar kelompok untuk evaluasi ada atau
tidaknya smear layer dianalisis secara statistik dengan uji Pearson Chi-square, dengan tingkat
signifikansi statistik adalah P <0,05.

Results: In the coronal thirds of the root canal, there was no statistically significant difference
between the EDTA and the maleic acid groups when evaluated for their efficacy at smear layer
removal. Whereas, maleic acid performed significantly better than PAA and EDTA in removing
smear layer from middle and apical thirds of the root canal system.
Hasil: Pada sepertiga koronal saluran akar, tidak ada perbedaan yang signifikan secara statistik
antara EDTA dan kelompok asam maleat ketika dievaluasi untuk keefektifan pada pengangkatan
smear layer. Sedangkan, asam maleat memiliki kinerja yang jauh lebih baik daripada PAA dan
EDTA dalam menghilangkan smear layer dari sepertiga bagian tengah dan apikal saluran akar.

Kesimpulan: Irigasi menggunakan asam maleat 7% lebih efektif daripada 17% EDTA dan 0,5%
PAA bila digunakan sebagai bahan pembersih smear layer di sepertiga apikal saluran akar.

PENDAHULUAN
Mikroorganisme dalam saluran akar memiliki peran penting dalam patogenesis periodontitis
apikal. Pembersihan saluran akar, pengisian dengan bahan inert dan seal yang baik adalah tujuan
untuk perawatan endodontik yang sukses. Bahan pengisi endodontik harus dapat melekat pada
struktur gigi untuk pembuatan seal yang baik. Namun, hal ini dapat terganggu oleh pembentukan
smear layer setelah instrumentasi mekanis pada saluran akar. Smear layer yang amorf dan
memiliki struktur yang tidak beraturan mengandung komponen organik seperti mikroorganisme
dan produk metaboliknya, debris nekrotik, jaringan pulpa, dan proses odontoblastik serta
komponen anorganik seperti debris dentin.

There have been controversial reports over the maintenance or removal of this endodontic smear
layer. While some suggest that its persistence will alter dentinal permeability by blocking the
dentinal tubules thus limiting bacterial or toxin penetration,[5-7] others believe that it can harbor
bacteria and cause leakage thus necessitating its entire removal from the root canal walls.[8-10]
This loosely adherent structure is also known to prevent adaptation of endodontic sealers to
canal walls as well as interfere with penetration of irrigants and intracanal medicaments into the
dentinal tubules.[11-14]

Pemeliharaan atau pembersihan smear layer endodontik memiliki beberapa laporan

kontroversial. Beberapa menyatakan bahwa akan mengubah permeabilitas gigi dengan
menghalangi tubulus dentin sehingga membatasi penetrasi bakteri atau toksin, [5-7] yang lain
percaya bahwa itu dapat melindungi bakteri dan menyebabkan kebocoran sehingga memerlukan
seluruh pengangkatannya dari dinding saluran akar. [8 [10] Struktur yang melekat secara longgar
ini juga dikenal untuk mencegah adaptasi sealer endodontik ke dinding saluran serta
mengganggu penetrasi obat-obatan yang irrigant dan intracanal ke dalam tubuli dentin. [11-14]
Several techniques have been employed for the removal of smear layer ranging from the use of
chelating agents and ultrasonics to lasers during root canal therapy.[15] Current methods to
remove the smear layer might involve the use of a chelating agent during irrigation or as a final
rinse in combination with other irrigants having tissue dissolving properties.[16]

Ethylenediaminetetraacetic acid (EDTA), a calcium chelating agent is used routinely in

endodontics for the removal of smear layer.[17] The combination of sodium hypochlorite
(2.5%–5%) and EDTA (10%–17%) has been proven to be successful in the removal of organic
and inorganic debris.[18,19] Studies have stated that a final irrigation of the root canal with
EDTA can open up the dentinal tubules thereby increasing the number of lateral canals to be
filled eventually by the sealer.[20]

Maleic acid is used as an acid conditioner in adhesive dentistry.[21] This mild organic acid is
found to remove smear layer from the surface of teeth.[22] Ballal et al. have shown that smear
layer removal from the apical third of the root canal was performed better using 7% maleic acid
than EDTA.[23]

Peracetic acid (PAA) is one of the most potent disinfectants. It has been used as a single
endodontic irrigant in the former German democratic republic.[24] It has antibacterial,
sporicidal, antifungal, and antiviral effects.[24] It has been used for the elimination of biofilm
formation in various areas.[25,26] The acetic acid content seems to cause inorganic material
dissolution while also forming water soluble complexes with calcium. It has been shown that
2.25% PAA solution is comparable with 17% EDTA at removing the smear layer.[19] The
caustic effect of 2.25% PAA on oral mucosa has led to its use in lower concentrations such as
0.5%.[26] In vitro studies done by Lottanti et al. and De-Deus et al. have proven that 0.5% PAA
is effective in removal of smear layer.[19,27]

The aim of the present study is to evaluate and compare the efficiency of 7% maleic acid, 0.5%
PAA, and 17% EDTA to remove smear layer following instrumentation of root canal system.

MATERIALS AND METHODS

Ethical clearance was attained for the use of human extracted teeth (IEC 342/2016). Thirty-five
non-carious anterior teeth with type I canal anatomy and straight roots were selected for the
study. Radiographs were taken to ascertain the presence of single, non-calcified canal with
mature apex. Teeth showing the presence of resorption or obturation of root canal system were
excluded from this study. The teeth were cleaned with a brush to remove the superficial soft
tissues following which they were stored in 0.2% sodium azide (Sigma Chemical Co., St. Louis,
MO, USA) at 4°C.

A standardized root length of 14 mm was achieved by decoronation of the samples at the

cementoenamel junction. Following this, the samples were randomly divided into three
experimental groups (n = 10) and one control group (n = 5). A no. 10 K file (Mani Inc., Tochigi
Ken, Japan) was used to assess the working length. It was inserted into each canal until it was
just visible at the apical foramen (observed under magnifying loupes) and 1 mm was subtracted
from this point. Thereafter, the apices were sealed using sticky wax.The canals were prepared
using ProTaper nickel titanium rotary instruments (Dentsply/ Tulsa Dental, Tulsa, OK, USA) to
size F4 in a crown-down technique. Throughout the preparation, canals were irrigated with 2.5%
NaOCl (KMC Pharmacy, Manipal, Karnataka, India) solution for 1 min using 29-gauge Navi
Tip side vented needle (Ultradent products Inc., South Jordan, UT, USA) after every instrument
change.The needle was introduced 1 mm short of the working length for all samples by adjusting
the rubber stopper on the needle to the desired length.

The final irrigation sequence in each group was as follows:

• Group 1: 5 ml of 7% maleic acid was used for 1 min (KMC Pharmacy, Karnataka, India)

• Group 2: 5 ml of 0.5% PAA was used for 1 min (National Peroxide Ltd., India)

• Group 3: 5 ml of 17% EDTA was used for 1 min (Presvest Denpro, India)

• Group 4: 5 ml of 0.9% saline was used for 1 min (Fresenius Kabi Pvt. Ltd., India).

Thereafter, drying of canals was carried out using sterile paper points (Dentsply-Maillefer,
Ballaigues, China). Longitudinal grooves were prepared on the buccal and lingual surfaces of
each root by using a diamond disc (Horico, Germany) at a slow speed. Care was taken not to
penetrate the root canal. A chisel was used to split the root into two halves. The specimens were
dehydrated using 100% ethyl alcohol and placed in furnace at 60°C for 24 h. The samples were
manually marked at the coronal (10–12 mm from apex), middle (6–7 mm from apex), and apical
(1–2 mm from apex) thirds of each specimen before the scanning electron microscopic analysis
(SEM) analysis. The samples were mounted on metallic stubs followed by gold sputtering using
an ion sputter. These samples were then examined under scanning electron microscope (JEOL
Ltd., USA) for the presence or absence of smear layer. Several photomicrographs were taken at
×1500, 20 kV magnification to observe the surface morphology of the canal walls. These were
evaluated by two independent examiners unaware of the experimental groups to which the
samples belonged.

The images were scored according to the criteria given by Torabinejad et al.:[28]

• 1 = No smear layer (no smear layer on the surface of the root canal; all tubules were
clean and open)

• 2 = Moderate smear layer (no smear layer on the surface of the root canal, but tubules
contained debris)

• 3 = Heavy smear layer (smear layer covered the root canal surface and the tubules).

The inter examiner’s reliability was verified using the Kappa test. The data of the score for
intragroup comparison and intergroup comparison to evaluate the presence or absence of smear
layer were statistically analyzed by Pearson Chi-square test. The level of statistical significance
was set at P < 0.05.