Serbian Dental Journal, vol.

63, No 2, 2016 57

ORIGINAL ARTICLE  DOI: 10.1515/sdj-2016-0006

ORIGINALNI RAD UDC: 616.314.16-08

Ultrastructural analysis of uninstrumented root canal

areas following various irrigation regimens
Radomir Barac1, Jelena Popović1, Slavoljub Živković2, Aleksandar Mitić1, Marija Nikolić1,
Jovanka Gašić1
1
Department of Dental Diseases and Endodontics, Dental Clinic, School of Medicine, University of Niš, Niš, Serbia;
2
Department of Restorative Odontology and Endodontics, School of Dental Medicine, University of Belgrade, Belgrade,
Serbia

SUMMARY
Introduction During endodontic treatment smaller or larger areas of root canal wall remain non-instrumented. This
can affect prognosis of endodontic treatment as some bacteria may be left behind. The purpose of this study was to
evaluate the morphology of non-instrumented areas of the root canal wall using scanning-electron-microscopy (SEM)
after completed instrumentation and various irrigation regiments.
Materials and Methods Eighteen single-rooted extracted teeth were divided into the six groups. One tooth in each
group represented a control sample. In all samples only one half of the canal was instrumented using ISO 40 hand files.
Control samples were subjected to an irrigation protocols without instrumentation. Irrigants used were physiological
saline, 3% sodium hypochlorite and 15% of ethylene-diamine-tetra-acetate. Irrigation protocol included using each
of these irrigants alone, or a combination of NaOCl and EDTA, as well as their combination with final irrigation using
NaOCl or chlorhexidine. Then after, roots were sectioned longitudinally and prepared for SEM.
Results Saline irrigation left pulpal debris on uninstrumented areas of the canal wall. Irrigation with 3% NaOCl left
behind canal wall with different forms of calcospherites. However, after EDTA irrigation dentin appeared as an undu-
lating surface with open tubules without a smear layer. The combination of NaOCl and EDTA showed remnants of
calcospherites and open slightly widened dentinal tubules. Final irrigation with NaOCl on the uninstrumented areas
showed enlarged dentinal tubules along with dentinal erosion, while after final irrigation with CHX clean dentin and
open dentinal tubules without smear layer were noted.
Conclusion From the morphological point of view, the most favorable effect of irrigation on both uninstrumented and
uninstrumented canal walls was achieved after irrigation with NaOCl and EDTA or NaOCl, EDTA and chlorhexidine
as the final irrigant.
Keywords: root canal instrumentation; uninstrumented root canal areas; root canal irigation; SEM

INTRODUCTION Due to limited effectiveness of endodontic instruments

in root canal cleaning, it is necessary to use appropriate
One of the basic preconditions for successful endodontic chemical agents during and after instrumentation. Their
treatment is adequate instrumentation of the root canal. role is to eliminate and reduce any remaining microorgan-
However, satisfactory instrumentation and irrigation is dif- isms as well as remove smear layer [8-10]. Even though
ficult to achieve due to the very specific and complex root there is no general consensus about removing smear layer
canal morphology, as well as limited effect of instruments immediately before obturation, most endodontists agree
[1]. Morphological variations of the root canal system and that if it is not removed, it could disintegrate and lead to
inability of endodontic instruments to reach all parts of microleakage due to the low quality of the bond strength
root canal wall make cleaning of complete root canal prac- between the sealer and root canal walls [9, 10].
tically impossible [1, 2]. Micro-computerized tomography The aim of this study was to use a SEM analysis to
has confirmed that some areas of root canal walls remain evaluate the morphology of uninstrumented areas of the
untouched after instrumentation [3-6]. These areas may root canal walls following mechanical instrumentation
contain bacteria and compromise endodontic treatment and application of various irrigation regimens.
[7]. In addition, the presence of smear layer and debris as a
result of instrumentation is significant clinical problem [2,
8]. This layer often contains bacteria and blocks dentinal MATERIALS AND METHODS
tubules, which significantly decrease the effect of used ir-
rigant affecting the quality of obturation and the outcome The material used in this research included 18 freshly ex-
of endodontic treatment [8, 9]. tracted intact human maxillary single-rooted teeth without

Address for correspondence: Radomir BARAC, Department of Restorative Dentistry and Endodontics, Clinic of Dentistry,
Medical Faculty, University of Niš, Bulevard dr Zorana Djindjića 81, 18000 Niš, Serbia; [email protected]
Unauthenticated
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58 Barac R. et al. Ultrastructural analysis of uninstrumented root canal areas following various irrigation regimens

any visible damage (root caries, cracks, internal or external tion, care was taken that endodontic instruments did not
resorption, etc.). According to the irrigation regimens, all come in contact with the oposing side of the canal wall
teeth were divided into six groups, with one tooth in each that represented the “uninstrumented” half. The control
group representing a control specimen. The teeth samples sample from each group was used for comparison of un-
were kept for eight hours in 0.5% NaOCl solution to facili- instrumented areas of the canal with the uninstrumented
tate removal of organic debris. After rinsing teeth under main root canal following identical irrigation regimens.
running water, they were immersed in saline solution and The amount of the irrigant used for each irrigation regi-
refrigerated until the beginning of the experiment. men was identical and carefully controlled, and the total
Prior to canal instrumentation, using a diamond disc, time of chemomechanical preparation was 10 min.
longitudinal grooves were created on the facial and lingual The following irrigation regimens were used: (I) saline;
surfaces of the root, without penetrating it, in order to (II) 3% sodium hypochlorite (NaOCl-Parcan,Septodont);
facilitate the fracture. The crowns were amputated and (III) 15% Ethylene diaminetetraacetic acid (EDTA - Largal
discarded, while the remaining debris was removed using Ultra, Septodont); (IV) combination of 3% NaOCl+15%
running water. Following pulp extirpation, one tooth from EDTA; (V) combination of 3% NaOCl+15% EDTA and
each group (two control samples) underwent different ir- 3% NaOCl as the final irrigant; (VI) combination of 3%
rigation regimens only without previous instrumentation. NaOCl+15% EDTA and 2% chlorhexidine (R4, Septodont)
All root canals were checked for patency and working as the final irrigant (Table 1).
length was determined by shortening the distance to the Applying mild pressure and using a spatula, the sam-
anatomical foramen by 1 mm. The apex was sealed with ples were fractured in half (so that a total of 36 samples
a pink wax piece. were obtained) and placed in open Petri dishes to dry at
The root canals of experimental teeth were instrument- the room temperature. After 24 hours, they were attached
ed using the step back technique to the instrument size 40 to cylindrical tooth carriers using a fixing agent (Dotite
(NiTi files I-FLEX, IMD, USA). Only one half of each root paint xc 12 Carbon JEOL, Tokyo, Japan), gold sputtered
canal, either the facial or the lingual half, was particularly (using a JFC 1100E Ion Sputter JEOL) and analyzed using
marked and instrumented [11]. During the instrumenta- scanning electron microscopy (SEM, JEOL-JSM-5300).

Table 1. Irrigants and irrigation regimens of the experimental and control samples
Tabela 1. Irigacioni rastvori i protokol irigacije eksperimentalnih i kontrolnih uzoraka
Groups Irrigants Irrigation regimen of the experimental samples Irrigation regimen of the control samples
Grupe Irigacioni rastvori (uninstrumented areas in uninstrumented canals)* (uninstrumented canals)*
Irigacioni protocol eksperimentalnih uzoraka Irigacioni protocol kontrolnih uzoraka
(neinstrumentisane površine u instrumentisanim kanalima)* (neinstrumentisani kanali)*
I Saline solution Irrigation using 3 ml saline solution after pulp extirpation and Irrigation using 3 ml saline solution following pulp
after each endodontic instrument extirpation
Irigacija sa 3 ml fiziološkog rastvora posle ekstirpacije pulpe i Irigacija sa 3 ml fiziološkog rastvora posle ekstirpacije
posle svakog endodontskog instrumenta pulpe
II 3% NaOCl Irrigation using 3 ml NaOCl following pulp extirpation and after Irrigation using 3 ml NaOCl following pulp
(Parcan, Septodont) each endodontic instrument extirpation
Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe i posle svakog Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe
endodontskog instrumenta
III 15% EDTA Irrigation using 3 ml saline solution following pulp extirpation Irrigation using 3 ml saline solution following pulp
(Largal Ultra, and after each endodontic instrument, final irrigation with 3 ml extirpation, final irrigation using 3 ml EDTA for 60
Septodont) EDTA for 60 seconds seconds
Irigacija sa 3 ml fiziološkog rastvora posle ekstirpacije pulpe i Irigacija sa 3 ml fiziološki rastvora posle ekstirpacije
posle svakog endodontskog instrumenta; završno ispiranje sa 3 pulpe; završno ispiranje sa 3 ml EDTA u trajanju od
ml EDTA u trajanju od 60 sekundi 60 sekundi
IV 3% NaOCl Irrigation using 3 ml NaOCl following pulp extirpation and after Irrigation using 3 ml NaOCl following pulp
(Parcan, Septodont) each endodontic instrument; final irrigation using 3 ml EDTA for extirpation; final irrigation using 3 ml EDTA
+ 15% EDTA 60 seconds for 60 seconds
(Largal Ultra, Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe i posle svakog Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe;
Septodont) endodontskog instrumenta; završno ispiranje sa 3 ml EDTA u završno ispiranje sa 3 ml EDTA u trajanju
trajanju od 60 sekundi od 60 sekundi
V 3% NaOCl+15% Irrigation using 3 ml NaOCl following pulp extirpation and after Irrigation using 3 ml NaOCl following pulp
EDTA and 3% each endodontic instrument; flushing using 3 ml EDTA for 60 extirpation; flushing using 3 ml EDTA for 60 seconds,
NaOCl as the seconds, final irrigation using 3 ml NaOCl for 3 min. final irrigation using 3 ml NaOCl for 3 min.
final irrigant / kao Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe i posle svakog Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe;
završni irigans endodontskog instrumenta; ispiranje sa 3 ml EDTA u trajanju od ispiranje sa 3 ml EDTA u trajanju od 60 sekundi,
60 sekundi, završno ispiranje sa 3 ml NaOCl u trajanju od 3 min. završno ispiranje sa 3 ml NaOCl u trajanju od 3 min.
VI 3% NaOCl+15% Irrigation using 3 ml NaOCl following pulp extirpation and each Irrigation using 3 ml NaOCl following pulp
EDTA and 2% endodontic instrument; flushing using 3 ml EDTA for a period of extirpation; flushing using 3 ml EDTA for 60 seconds,
chlorhexidine 60 seconds, final irrigation using 3 ml CHX for 3 min. final irrigation using 3 ml CHX for 3 min.
(R4, Septodont) as Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe i posle svakog Irigacija sa 3 ml NaOCl posle ekstirpacije pulpe;
the final irrigant / endodontskog instrumenta; ispiranje sa 3 ml EDTA u trajanju od ispiranje sa 3 ml EDTA u trajanju od 60 sekundi,
kao završni irigans 60 sekundi, završno ispiranje sa 3 ml CHX u trajanju od 3 min. završno ispiranje sa 3 ml CHX u trajanju od 3 min.
*At the end of all the irrigation regimens, as well as after irrigation with each tested irrigant, sterile water was used [11] in the amount of 3 ml, and canal was dried with sterile
paper points prior to the use of the following instrument/irrigant.
* Kod svih irigacionih protokola je na kraju, kao i posle irigacije sa svakim testiranim irigansom, korišćena sterilna voda [11] u količini od 3 ml, a kanal je sušen papirnatim
poenima pre korišćenja sledećeg instrumenta/irigansa.
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 Stomatološki glasnik Srbije. 2016;63(2):57-65 59

Table 2. SEM analysis of uninstrumented and instrumented areas in the root canal after different irrigation protocols
Tabela 2. SEM opis neinstrumentisanih i instrumentisanih površina u kanalu korena posle različitih irigacionih protokola
Groups Irrigants Uninstrumented areas in uninstrumented canals Instrumented canals
Grupe Irigacioni rastvori Neinstrumentisane površine u instrumentisanim kanalima Instrumentisani kanali
I Saline solution Amorphous layer of residual pulpal components found, along Smear layer and dentin debris, tubules not visible at all.
Fiziološki rastvor with predentin and pulpal debris, tubules barely visible
Prisutan amorfni sloj zaostalih komponenata pulpe, Razmazni sloj i dentinski debris, kanalići se uopšte ne
predentin i pulpni debris, kanalići se jedva uočavaju uočavaju
II NaOCl Absence of predentin and pulpal debris (pulpal Flat surface of dentin wall, smear layer and dentin debris
remnants), presence of dome-shaped and ridge-shaped present, some orifices of dentinal tubules visible
calcospherites, noted orifices of the tubules, rough surface
of calcospherites.
Odsutan predentin i pulpni debris (pulpni ostaci), prisutni Ravna površina dentinskog zida, prisutan razmazni sloj
kupolasti i grebenasti kalcisferiti, uočavaju se otvori kanalića, i dentinski debris, nazire se po neki otvor dentinskih kanalića
površina kalcisferita gruba
III EDTA There are no calcospherites, pulpal debris was found, dentin Flat surface of the dentin wall, removed smear layer, debris
present as an undulating surface, open tubules present
Ne uočavaju se kalcisferiti, nađeni delovi pulpnog debrisa, Ravna površina dentinskog zida, uklonjen razmazni sloj,
talasasta površina dentinskog zida, otvoreni tubuli prisutan debris
IV NaOCl + EDTA Reduced calcospherites with smooth surface. No predentin Flat surface of dentin, removed smear layer and dentin
and pulpal debris, open tubules, slightly wider, clearly visible. debris, tubules wide open
Smanjeni kalcisferiti sa glatkom površinom. Odsutan Ravna površina dentinskog zida, uklonjen razmazni sloj i
predentin i pulpni ostaci, kanalići otvoreni, blago prošireni, dentinski debris, kanalići široko otvoreni
jasno uočljivi
V NaOCl + EDTA + Greater reduction of calcospherites in comparison to Flat surface of dentin wall, removed smear layer and dentin
NaOCl previous irrigation regimen (V). No predentin and pulpal debris, tubular orifices, openings enlarged, excessive erosion
debris. Tubules wide open, significantly enlarged, excessive of intertubular and peritubular dentin
erosion of intertubular dentin
Veća redukcija kalcisferita u odnosu na prethodni Ravna površina dentinskog zida, uklonjen razmazni sloj i
irigacioni protokol (V). Odsutni predentin i pulpni ostaci. dentinski debris, otvori kanalića uvećani, izrazita erozija
Kanalići široko otvoreni, znatno uvećani, izrazita erozija intertubularnog i peritubularnog dentina
intertubularnog dentina
VI NaOCl +EDTA + Calcospherites reduction. Absence of predentin and pulpal Flat surface of dentin wall, removed smear layer and dentin
CHX remnants, open tubules clearly visible, intertubular dentin debris, open dentinal tubules, intertubular dentin preserved
preserved. No difference compared to irrigation regimen IV
Redukcija kalcisferita. Odsutni predentin i ostaci pulpe, Ravna površina dentinskog zida sa uklonjenim razmaznim
kanalići otvoreni, jasno uočljivi intertubularni dentin očuvan. slojem i dentinskim debrisom, otvoreni dentinski kanalići,
Nije uočena razlika u odnosu na irigacioni protokol IV intertubularni dentin očuvan

RESULTS instrumentation using SEM. Several studies used micro-

computerized tomography to determine the presence of
After irrigation with saline pulpal debris covering dentin uninstrumented surfaces in the main root canal by calcu-
of uninstrumented areas of the canal was noticed. Irri- lating the area that remains intact after instrumentation
gation with 3% NaOCl left behind dentin with different (canal volume before and after instrumentation, distance
forms of calcospherites. When EDTA was used alone for between canal surface before and after instrumentation
irrigation dentin was present as an undulating surface and in μm, the size of a specific area, the width of the canal,
open tubules without a smear layer were visible. Combina- taper, etc.) [3-6]. On the other hand, SEM analysis allows
tion of NaOCl and EDTA for irrigation left remnants of visualization of root canal walls, their cleanliness, dentinal
calcospherites and open and slightly widened dentinal tu- tubules covered with smear layer, as well as complete den-
bules. If NaOCl was used as the final irrigant (after NaOCl tin morphology at ultrastructural level [13-15].
and EDTA) enlarged dentinal tubules were noted along In the current study the control samples included un-
with dentinal erosion, while if the final irrigant was CHX, instrumented canals after performed irrigation regimens.
clean dentin and open dentinal tubules without smear That way it was possible to compare the morphology of
layer were noted. uninstrumented canals with uninstrumented surfaces
SEM findings on uninstrumented and instrumented of instrumented canals. According to Peters et al. after
areas are shown in Table 2 and Figures 1-7. Wall morphol- biomechanical instrumentation, both hand or rotary, ap-
ogy of uninstrumented areas in instrumented root canals proximately 35% of the canal wall remains untouched
did not show any differences compared to the morphology by the instruments [16]. In addition, other studies have
of uninstrumented canals (control samples) following all also confirmed the presence of uninstrumented surfaces,
irrigation regimens. especially in the apical third of the root canal, where any
irregularities on canal walls (grooves and depressions)
prevent contact between the wall and instrument [17, 18].
DISCUSSION Endodonic instruments are mostly designed to fit into the
conical root configuration, which leaves untreated regions
The aim of this study was to analyze the morphology of in oval and flat canals [16]. Beside complex canal mor-
uninstrumented areas of the root canal walls after canal phology [19], limitation of instrumentation techniques
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60 Barac R. et al. Ultrastructural analysis of uninstrumented root canal areas following various irrigation regimens

Figure 1. Saline solution. a) uninstrumented area – remnants of Figure 5. NaOCl + EDTA + NaOCl. a) uninstrumented area – apro-
pulpal components, parts of odontoblasts, noticeable elongated nounced reduction in calcospherites with a funnel-like widening
dentinal tubules; b) instrumented area with a tree-bark model of on dentinal tubules, no organic debris; b) instrumented area – root
smear layer which appears in both hand and rotary root canal in- canal wall with removed debris and smear layer, but with intratu-
strumentation [9]. bular dentin which has worn away. Dentin erosion in some areas
Slika 1. Fiziološki rastvor. a) neinstrumentisana površina – zaostale connects two or more orifices of the dentin tubules.
komponente pulpe, delovi odontoblasta, uočljivi uzdužno presečeni Slika 5. NaOCl + EDTA + NaOCl. a) neinstrumentisana površina
dentinski kanalići; b) instrumentisana površina sa tree-bark mod- – izrazita redukcija kalcisferita sa levkasto proširenim dentinskim
elom razmaznog sloja koji se pojavljuje i kod ručne i kod mašinske kanalićima, odsutan organski debris; b) instrumentisana površina
obrade kanala korena [12]. – zid kanala korena sa uklonjenim debrisom i razmaznim slojem,
ali i sa istanjenim intratubularnim dentinom. Dentinska erozija na
nekim mestima spaja dva ili više otvora dentinskih kanalića.

Figure 2. NaOCl. a) uninstrumented area – dome-shaped calco-

spherites with a grainy, uneven surface; b) instrumented area –
smear layer covers dentin, with barely visible tubular orifices Figure 6. NaOCl + EDTA + CHX. a) uninstrumented area-mod-
Slika 2. NaOCl. a) neinstrumentisana površina – kupolasti kalcis- erately reduced calcospherites, some of which have retained their
feriti sa sitno zrnastom, neravnom površinom; b) instrumentisana dome-shaped form; b) instrumented area – root canal wall with
površina – razmazni sloj pokriva dentinsku površinu, jedva uočljivi removed debris and smear layer, no erosion of intratubular and
otvori dentinskih kanalića peritubular dentin.
Slika 6. NaOCl + EDTA + CHX. a) neinstrumentisana površina –
umereno redukovni kalcisferiti, pojedini su zadržali kupolasti oblik;
b) instrumentisana površina – zid kanala korena sa uklonjenim de-
brisom i razmaznim slojem, nema erozije intratubularnog i peritu-
bularnog dentina.

Figure 3. EDTA. a) uninstrumented area – groovy surface of dentin

with no calcospherites; b) instrumented area – removed smear layer,
but with presence of debris
Slika 3. EDTA. a) neinstrumentisana površina – talasasta površina
dentina bez kalcisferita; b) instrumentisana površina – uklonjen
razmazni sloj, ali prisutan debris Figure 7. a) The darker areas on the micrography represent instru-
mented surfaces; b) An ultrastructural appearance of the unin-
strumented root canal following irrigation using NaOCl solution,
magnified at 350×. On dentin walls dome-shaped and ridge-shaped
calcospherites are noted.
Slika 7. a) tamna polja na mikrografiji predstavljaju instrumenti-
sane površine; b) ultrastrukturni izgled neinstrumentisanog kanala
korena posle irigacije sa NaOCl na uvećanju 350×. Na dentinskim
zidovima se uočavaju kupolasti i grebenasti kalcisferiti.

[20], instrument taper [21] or file alloy properties [22]

Figure 4. NaOCl + EDTA. a) uninstrumented area – a reduction in
calcospherites, no organic debris; b) instrumented area – root canal add to impossibility to instrument all canal walls.
wall with removed debris and smear layer In the current study we assumed that uninstrumented
Slika 4. NaOCl + EDTA. a) neinstrumentisana površina – redukcija surfaces in the main root canal actually exist, which is why
kalcisferita, nema organskog debrisa; b) instrumentisana površina biomechanical instrumentation was performed with the
– zid kanala korena sa uklonjenim debrisom i razmaznim slojem intention of leaving half of the root canal uninstrumented.
On the other hand, instrumented areas of the root canal
showed surfaces with expected morphology and more-less
Unauthenticated
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 Stomatološki glasnik Srbije. 2016;63(2):57-65 61

clean wall surfaces following certain irrigation regimens as CONCLUSION

reported in other studies [13-15]. In our study we analyzed
only the coronal and middle third of the canal, while the Taking into consideration limitations of all in vitro stud-
apical third was excluded due to its complexity and pos- ies, the following can be concluded:
sible presence of a smear layer even after irrigation that The morphology of uninstrumented areas of main root
could influence the interpretation of obtained results. canal is similar to the morphology of those parts of the
Uninstrumented areas of the canal were difficult to no- canal endodontic instruments cannot reach (narrowings,
tice prior to irrigation with NaOCl that removed organic lateral canals, anastomosis, invagination of the root canal,
debris and exposed conical and wedge-shaped calcosphe- etc.).
rites. Structures that were found on uninstrumented areas The presence of uninstrumented areas in the root canal
included pulpal tissue remnants, odontoblastic extensions, during endodontic instrumentation is inevitable due to
but no smear layer was found. In the current study 3% the complex morphology of the canals and indicates the
NaOCl solution was used and completely removed organic importance of irrigants use during instrumentation.
debris. In studies where canals were irrigated with 0.5% Even though this was not the primary aim of this study,
NaOCl solution, dentin of uninstrumented areas was not the most favorable effect of irrigation (including instru-
completely cleaned of organic debris [23]. mented and uninstrumented areas of the canal) was noted
According to the findings of many studies, NaOCl ir- following the irrigation regimen: NaOCl+EDTA, or even
rigation is exceptionally important because it dissolves better using NaOCl+EDTA+CHX as the final irrigant.
organic tissue very efficiently. Even though it has an in-
adequate surface tension and cannot reach narrow canals,
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instrumentation. Int Endod J. 2013; 46:332-8. [DOI: 10.1111/j.1365-
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prevent any unwanted interactions between the irrigants 10. Peters OA. Current challenges and concepts in the preparation
and obtain desired result [11]. of root canal systems: a review. J Endod. 2004; 30:559-67. [DOI:
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no dentinal erosion was noted. According to the literature, 11. Braumgartner JC, Mader CL. A scanning electron microscopic evalu-
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when EDTA and CHX come into contact EDTA anion is [DOI: 10.1016/S0099-2399(87)80132-2] [PMID: 3106553]
neutralized with CHX cation and there is no further re- 12. Prati C, Foschi F, Nucci C, Lucio, Montebugnoli L, Marchionni S. Ap-
duction in dentin [30]. In addition, antimicrobial effect of pearance of the root canal walls after preparation with NiTi rotary
CHX against Enterococcus faecalis and Candida albicans as instruments: A comparative SEM Investigation. Clinic Oral Invest.
well as its substantivity (prolonged effect) support its use 2004; 8:102-10. [DOI: 10.1007/s00784-004-0253-8] [PMID: 14760541]
as the final irrigant in endodontic treatment [24].
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62 Barac R. et al. Ultrastructural analysis of uninstrumented root canal areas following various irrigation regimens

13. Rodig T, Dollmann S, Konietschke F, Drebenstedt S, Hulsmann M. 22. Grande NM, Plotino G, Butti A, Messina F, Pameijer CH, Somma
Effectiveness of different irrigant agitation techniques on debris F. Cross-sectional analysis of root canals prepared with NiTi rotary
and smear layer removal in curved root canals: a scanning elec- instruments and stainless steel reciprocating files. Oral Surg Oral Med
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14. Akyuz Ekim SN, Erdemir A. Comparison of different irrigation 23. Baumgartner JC, Cuenin PR. Efficacy of several concentrations of
activation techniques on smear layer removal: An in vitro study. sodium hypochlorite for root canal irrigation. J Endod. 1992; 18:605-
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25582378] 24. Zehnder M. Root canal irrigants. J Endod. 2006; 32:389-98. [DOI:
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YT, Silva SR. Effects of various irrigation/aspiration protocols on 25. Grande NM, Plotino G, Falanga A, Pomponi M, Somma F. Inter-
cleaning of flattened root canals. Braz Oral Res. 2015; 29:1-9. [DOI: action between EDTA and sodium hypochlorite: a nuclear mag-
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techniques on root canal geometry assessed by micro computed 26. Clarkson RM, Podlich HM, Moule AJ. Influence of ethylene diamine
tomography. Int Endod J. 2001; 34:221-30. [DOI: 10.1046/j.1365- tetra acetic acid on the active chlorine content of sodium hypo-
2591.2001.00373.x] [PMID: 12193268] chlorite solutions when mixed in various proportions. J Endod. 2011;
17. Schafer E, Schlingemann R. Efficiency of rotary nickel titanium K3 37:538-543. [DOI: 10.1016/j.joen.2011.01.018] [PMID: 21419305]
instruments compared with stainless steel hand K-Flexofile. Part 27. Qian W, Shen Y, Haapasalo M. Quantitative analysis of the effect of
2. Cleaning effectiveness and shaping ability in severely curved irrigant solution sequences on dentin erosion. J Endod. 2011; 37:1437-
root canals of extracted teeth. Int Endod J. 2003; 36:208-17. [DOI: 41. [DOI: 10.1016/j.joen.2011.06.005] [PMID: 21924198]
10.1046/j.1365-2591.2003.00644.x] [PMID: 12657147] 28. Gasic J, Popovic J, Zivkovic S, Petrovic A, Barac R, Nikolić M. Ultra-
18. Foschi F, Nucci C, Montebugnoli L, Marchionni S, Breschi L, structural analysis of the root canal walls after simultaneous irrigation
Malagnino VA., Pratti C. SEM evaluation of canal wall dentine follow- of different sodium hypochlorite concentration and 0.2% chlorhexi-
ing use of Mtwo and ProTaper NiTi rotary instruments. Int Endod dine gluconate. Microsc Res Tech. 2012; 75:1099-103. [DOI: 10.1002/
J. 2004; 37:832-9. [DOI: 10.1111/j.1365-2591.2004.00887.x] [PMID: jemt.22036] [PMID: 22419366]
15548274] 29. Rossi-Fedele G, Dogramaci EJ, Guastalli AR, Steier L, de Figueiredo JA.
19. de Oliveira MA, Venancio JF, Pereira AG, Raposo LH, Biffi JC. Critical Antagonistic interactions between sodium hypochlorite, chlorhexi-
instrumentation area: influence of root canal anatomy on the endo- dine, EDTA, and citric acid. J Endod. 2012; 38:426-31. [DOI: 10.1016/j.
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6440201300013] [PMID: 25252259] 30. Rasimick BJ, Nekich M, Hladek M, Musikant BL, Deutsch AS. Inter-
20. Wu MK, Wesselink PR. A primary observation on the preparation action between hlorhexidine digluconate and EDTA. J Endod. 2008;
and obturation of oval canals. Int Endod J. 2001; 34:137-41. [DOI: 34:1521-23. [DOI: 10.1016/j.joen.2008.08.039] [PMID: 19026886]
10.1046/j.1365-2591.2001.00361.x] [PMID: 11307262]
21. Elayouti A, Chu AL, Kimionis I, Klein C, Weiger R, Lost C. Efficacy of ro-
tary instruments with greater taper in preparing oval root canals. Int
Endod J. 2008; 41:1088-1092. [DOI: 10.1111/j.1365-2591.2008.01475.x] Received: 03.02.2016 • Accepted: 20.04.2016
[PMID: 19133098]

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 Stomatološki glasnik Srbije. 2016;63(2):57-65 63

Ultrastrukturna analiza neinstrumentisanih površina u kanalu

korena posle različitih irigacionih protokola
Radomir Barac1, Jelena Popović1, Slavoljub Živković2, Aleksandar Mitić1, Marija Nikolić1, Jovanka Gašić1
Odeljenje za bolesti zuba i endodonciju, Klinika za stomatologiju, Medicinski fakultet, Univerzitet u Nišu, Niš, Srbija;
1

Klinika za bolesti zuba i endodonciju, Stomatološki fakultet, Univerzitet u Beogradu, Beograd, Srbija
2

KRATAK SADRŽAJ
Uvod Tokom endodontske terapije manje ili veće površine kanala korena zuba ostaju neinstrumentisane i mogu sadržavati bakterije,
što može dovesti do neuspešnog ishoda. Cilj rada je bio da se skening-elekron-mikroskopskom (SEM) analizom proceni morfologija
neistrumentisanih delova zidova kanala posle instrumentacije i primene različitih irigacionih protokola.
Materijal i metode rada Osamnaest jednokorenih ekstrahovanih zuba je podeljeno u šest grupa. Jedan zub iz svake grupe je pred-
stavljao kontrolni uzorak. Eksperimentalni uzorci su preparisani do instrumenta veličine ISO40. Kod svakog zuba je instrumentisana
samo jedna polovina kanala. Kontrolni uzorci su podvrgnuti samo irigacionim protokolima bez preparacije. Osim fiziološkog rastvora,
3% natrijum-hipohlorita i 15% etilen-diamin-tetra-acetata, koji su primenjeni samostalno, eksperimentalni uzorci su irigirani i sa
kombinacijom NaOCl i EDTA, kao i sa kombinacijom istih iriganasa, pri čemu je kao završni irigans korišćen ili NaOCl ili hlorheksidin.
Korenovi su uzdužno presečeni i pripremljeni za SEM.
Rezultati Posle irigacije sa fiziološkim rastvorom u neinstrumentisanim delovima kanala uočen je dentin pokriven debrisom, posle
irigacije sa NaOCl dentin sa različitim oblicima kalcisferita. Posle irigacije sa EDTA uočena je talasasta površina dentinskog zida sa
otvorenim tubulima bez razmaznog sloja. Irigacija kombinacijom NaOCl i EDTA je pokazala ostatke kalcisferita i otvorene, blago
proširene dentinske tubule. Završno ispiranje sa NaOCl na neinstrumentisanim delovima dentina pokazuje proširene dentinske
tubule i eroziju dentina, a završno ispiranje sa CHX čist dentin i otvorene dentinske tubule bez razmaznog sloja.
Zaključak Sa morfološkog aspekta, najpovoljniji efekat irigacije (i kod instrumentisanih i kod neinstrumentisanih delova kanala)
ustanovljen je posle irigacionih protokola sa: NaOCl i EDTA i NaOCl, EDTA i hlorheksidinom kao završnim irigansom.
Ključne reči: preparacija kanala; neinstrumentisane površine kanala; irigacija kanala; SEM

UVOD Cilj ovog rada je bio da se SEM analizom proceni morfologija

neinstrumentisanih delova zidova kanala korena posle meha-
Jedan od osnovnih preduslova za uspeh endodontskog lečenja je ničke instrumentacije i primene različitih protokola za irigaciju.
adekvatna preparacija kanala korena zuba. Međutim, instrumen-
taciju i irigaciju je uglavnom teško realizovati zbog vrlo speci-
fične i kompleksne kanalne morfologije, ali i ograničenog efekta MATERIJAL I METODE RADA
instrumenata u nepristupačnom i ograničenom prostoru [1].
Morfološke varijacije kanalnog sistema i nemogućnost en- Kao materijal u ovom istaživanju korišćeno je 18 sveže ekstra-
dodontskog instrumenta da dopre do svih delova zidova kana- hovanih intaktnih jednokorenih humanih zuba bez vidljivih
la korena potpuno čišćenje kanala čine praktično nemogućim oštećenja (karijes korena, pukotine, unutrašnje ili spoljašnje
[1, 2]. Nekoliko studija je primenom mikrokompjuterizovane resorpcije itd.). U odnosu na irigacioni protokol, svi zubi su
tomografije potvrdilo da tokom preparacije kanala deo zido- podeljeni u šest grupa, pri čemu je po jedan zub iz svake pred-
va ostaje potpuno neobrađen [3-6]. Na ovim nepristupačnim stavljao kontrolu. Uzorci zuba su čuvani osam časova u 0,5%
površinama zidova kanala mogu se zadržavati bakterije i time NaOCl da bi se lakše uklonili ostaci organskog tkiva. Potom su
ugroziti i kompromitovati endodontsko lečenje [7]. čišćeni, ispirani tekućom vodom, potopljeni u fiziološki rastvor
Osim toga, i prisustvo razmaznog sloja i debrisa kao po- i čuvani u frižideru do početka eksperimenta.
sledica instrumentacije i sečenja dentina predstavlja značajan Pre instrumentacije kanala pažljivo su dijamantskim diskom
klinički problem [2, 8]. Ovaj sloj često sadrži bakterije i blokira napravljeni žlebovi po uzdužnoj osovini korena (vestibularno
dentinske tubule, čime značajno umanjuje efekat sredstava za i oralno), ali bez kontakta sa kanalom, kako bi se kasnije olak-
irigaciju, odnosno značajno utiče na kvalitet opturacije i ishod šalo razdvajanje polovina. Krunice zuba su uklonjene, a debris
endodontskog lečenja [8, 9]. nastao prilikom presecanja je ispran u tekućoj vodi.
Zbog ograničene efikasnosti endodontskih instrumenata u Posle uklanjanja sadržaja kanala pulp ekstirpatorima, po
čišćenju kanala neophodno je tokom i posle instrumentacije jedan zub (dva kontrolna uzorka) iz svake grupe je podvrgnut
obavezno koristiti i odgovarajuća hemijska sredstva. Njihova samo irigacionim protokolima bez prethodne preparacije.
uloga je u eliminaciji i redukciji zaostalih mikroorganizama, Na korenovima ostalih zuba izvršena je provera prohodno-
odnosno u efikasnom čišćenju kanalnog sistema, kao i rastva- sti, a radna dužina preparacije je određivana skraćivanjem za 1
ranju i uklanjanju razmaznog sloja [8-10]. mm od dužine endodontske igle kada vrh igle dosegne apeksni
Iako ne postoji opšta saglasnost oko uklanjanja razmaznog otvor. Apeks svakog uzorka zuba je potom zapečaćen kuglicom
sloja neposredno pre opturacije, najveći broj endodonata je sa- roze voska.
glasan da, ukoliko se on ne ukloni, vremenom može doći do nje- Korenovi eksprimentalnih zuba su preparisani step back
gove dezintegracije i povećanog kruničnog mikropropuštanja, tehnikom instrumentima do dijametra ISO40 (NiTi I-FLEX,
usled slabijeg kvaliteta veze materijala za opturaciju sa zidovima IMD, USA). Posebno je obeležena i instrumentisana samo jedna
kanala korena [9, 10]. polovina kanala korena (vestibularna ili oralna) [11]. Pri pre-
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64 Barac R. et al. Ultrastructural analysis of uninstrumented root canal areas following various irrigation regimens

paraciji se vodilo računa da endodontski instrumenti ne dođu gućena bolja vizuelizacija kvaliteta čišćenja zidova kanala korena,
u kontakt sa drugim delom kanala koji je predstavljao „nein- pokrivenost dentinskih tubula razmaznim slojem, kao i komplet-
strumentisanu“ polovinu kanala korena. Kontroloni uzorak iz na morfologija dentina na ultrastrukturnom nivou [13-15].
svake grupe je služio za poređenje neinstrumentisanih delova Ovo istraživanje je koristilo kao kontrolne uzorke neinstru-
kanala sa neinstrumentisanim kanalom korena posle identičnih mentisane zidove kanala koji su predstavljali model ultrastruk-
irigacionih protokola. ture dentinskog zida posle određenih irigacionih protokola. Na
Količina irigansa koja je korišćena sa svaki irigacioni proto- ovaj način je bilo moguće porediti morfologiju neinstrumenti-
kol bila je identična i pažljivo kontrolisana, kao i ukupno vreme sanih kanala sa neinstrumentisanim površinama preparisanih
hemomehaničke obrade svakog kanala (10 min). kanala. Prema Petersu i sar., u toku procesa širenja i oblikovanja,
U eksperimentu je korišćeno šest protokola ispiranja: (I) bilo mašinskim ili ručnim instrumentima, oko 35% površine
samo fiziološki rastvor; (II) samo 3% natrijum-hipohlorit (Na- kanala ostaje neinstrumentisano [16]. Takođe, i druge studije
OCl-Parcan, Septodont); (III) samo 15% etilen-diamin-tetra- potvrđuju prisustvo neinstrumentisanih polja, naročito u apek-
acetat (EDTA – Largal Ultra, Septodont); (IV) kombinacija 3% snoj trećini u kojoj nepravilnosti na zidovima kanala (žlebovi i
NaOCl+15% EDTA; (V) kombinacija 3% NaOCl+15% EDTA udubljenja) sprečavaju kontakt između zida i instrumenata [17,
i 3% NaOCl kao završni irigans; (VI) kombinacija 3% Na- 18]. Endodontski instrumenti su uglavnom dizajnirani tako da
OCl+15% EDTA i 2% hlorheksidin (R4, Septodont) kao završni se uklope u konusnu konfiguraciju korena, što ovalne ili spljo-
irigans. (Tabela 1). štene kanale ostavlja sa nepreparisanim poljima [16]. Drugi
Uz blagi pritisak, uzorci su pomoću špatule podeljeni na autori postojanje neinstrumentisanih regija opravdavaju pre
polovine (tako je dobijeno 36 uzoraka) i stavljeni u otvorene svega kompleksnom kanalnom morfologijom [19], ograničeno-
Petrijeve šolje da bi se sušili na sobnoj temperaturi. Posle 24 šću instrumentacionih tehnika [20], koničnošću instrumenata
časa uzorci su pričvršćeni za cilindrične nosače sredstvom za [21] ili osobinama legure od koje su izrađeni instrumenti [22].
fiksiranje (Dotite paint xc 12 Carbon JEOL, Tokyo, Japan), napa- U ovom istraživanju se pošlo od pretpostavke da neinstru-
ravani tankim slojem zlata po površini (u uređaju JFC 1100E Ion mentisane površine u glavnom korenskom kanalu zaista posto-
Sputter JEOL) i analizirani skening elektronskim mikroskopom je, zbog čega je mehanička instrumentacija urađena sa name-
(SEM, JEOL-JSM-5300). rom da se polovina zida korenskog kanala ostavi bez mehaničke
obrade. S druge strane, instrumentisani delovi u kanalu korena
su pokazali površinu sa očekivanom morfologijom manje ili
REZULTATI više čistih zidova posle određenih irigacionih protokola, kako
je objavljeno i u drugim studijama [13-15]. U ovom istraživanju
Dobijeni rezultati SEM analize su pokazali da je u neinstrumen- su analizirane samo cervikalna i srednja trećina kanala, dok je
tisanim delovima kanala posle irigacije sa fiziološkim rastvo- izostavljena apeksna trećina, koja bi zbog svoje kompleksnosti
rom uočen dentin pokriven pulpnim debrisom, posle irigacije i mogućeg prisustva razmaznog sloja i posle irigacionih proto-
sa 3% rastvorom NaOCl uočen dentin sa različitim oblicima kola mogla uticati na tumačenje dobijenih rezultata.
kalcisferita, a posle irigacije sa EDTA uočena je talasasta po- Neinstrumentisane oblasti zidova kanala je bilo teško uočiti
vršina dentinskog zida i otvoreni tubuli bez razmaznog sloja. pre irigacije sa NaOCl, koji je uklonio organske ostatke i prika-
Kada je korišćena kombinacija NaOCl i EDTA, uočeni su ostaci zao kupolaste ili grebenaste kalcisferite. Na neinstrumentisanim
kalcisferita i otvoreni i blago prošireni dentinski tubuli. Kada površinama su nađene strukture koje su zbog svoje pozicije uka-
je kao završni irigans korišćen NaOCl na neinstrumentisanim zivale na ostatke pulpnog tkiva, ili čak delove odontoblastičnih
delovima dentina, uočeni su uvećani dentinski tubuli i erozija produžetaka, ali na njima nije bilo razmaznog sloja. U ovom
dentina, a kada je kao završni irigans korišćen CHX – čist dentin istraživanju je korišćen 3% NaOCl, koji je kompletno uklonio
i otvoreni dentinski tubuli bez razmaznog sloja. organske ostatke. U studijama gde je kanal korena irigiran sa
Rezultati SEM neinstrumentisanih i instrumentisanih po- 0,5% NaOCl, površine dentinskog zida neinstrumentisanih obla-
vršina su prikazani u tabeli 2 i na mikrografijama od 1 do 10. sti nisu bile u potpunosti očišćene od organskih ostataka [23].
Morfologija zidova neinstrumentisanih delova preparisanog Prema nalazima većine studija, korišćenje NaOCl tokom in-
kanala korena nije pokazivala razlike u odnosu na morfologiju strumentacije je izuzetno važno jer ovaj irigans dobro rastvara
neinstrumentisanih kanala (kontrolne uzorke) posle svih iri- organsko tkivo u kanalnom sistemu korena. Iako ima neadekva-
gacionih protokola. tan površinski napon i ne može da prodre do uskih i akcesornih
kanala, NaOCl efikasno „čisti“ neistrumentisane delove glavnog
kanala, koji se sastoje od predentina, nekrotičnog pulpnog tkiva
DISKUSIJA i bakterijskog biofilma [7, 24].
Posle irigacionih protokola IV (NaOCl i EDTA), V (NaOCl
U ovom istraživanju je bio cilj da se SEM-om ispita morfologija + EDTA i NaOCl kao završni irigans) i VI (NaOCl + EDTA i
neinstrumentisanih delova zidova kanala korena tokom obrade CHX kao završni irigans), na neinstrumentisanim površinama
kanala. Nekoliko studija je metodom mikrokompjuterizovane nađeni su manje ili više redukovani kalcisferiti, što je u skladu sa
tomografije ustanovilo prisustvo neinstrumentisanih polja u drugim istraživanjima, iako u nekim studijama posle identičnih
glavnom korenskom kanalu izračunavanjem površine koja osta- protokola irigacije kalcisferiti nisu ni uočeni [11, 18].
je netaknuta tokom tretmana (meren je volumen kanala pre i U ovom istraživanju, posle irigacionog protokola V, gde je
posle instrumentacije, rastojanje između površine kanala pre i kao završni irigans korišćen NaOCl, došlo je do erozije inter-
posle preparacije u μm, površina određenog polja, debljina kanala, tubularnog i peritubularnog dentina i kod neinstrumentisanih
koničnost itd.) [3-6]. Za razliku od toga, SEM analizom je omo- i kod instrumentisanih polja. Ovo se može objasniti time što
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 Stomatološki glasnik Srbije. 2016;63(2):57-65 65

NaOCl nije mogao da spreči demineralizujuće dejstvo EDTA na CHX (enteroccocus faecalis i Candida albicans), kao i osobina
peritubularni i intertubularni dentin jer dovodi do veoma spore supstantivnosti ovog irigansa (protrahirani efekat), opravda-
degradacije ovog helatora [25]. Pored toga, postoji interakcija vaju njegovu upotrebu kao završnog irigansa u endodontskom
između EDTA i NaOCl, koja se ogleda u naglom smanjenju ko- tretmanu [24].
ličine slobodnog hlora odmah pri kontaktu ovih iriganasa, što
može da ima za posledicu gubitak aktivnosti NaOCl i nemoguć-
nost rastvaranja mekog tkiva unutar kanala [26]. U ovom istra- ZAKLJUČAK
živanju nije primećen ni organski debris posle primene ovog
protokola, ali mnogi autori ne preporučuju NaOCl kao finalni Uprkos ograničenjima karakteristišnim za sva in vitro istraži-
irigans (posle EDTA) zbog moguće erozije dentina [25, 27]. vanja, na osnovu dobijenih rezultata može se zaključiti sledeće:
Literaturni podaci ukazuju i na postojanje interakcije izme- • Morfologija neinstrumentisanih delova glavnog korenskog
đu iriganasa, koje se mogu ispoljiti međusobnom inaktivacijom, kanala je slična morfologiji onih delova kanala do kojih
prebojavanjem dentina ili stvaranjem štetnih precipitata [28- endodontski instrumenti ne mogu dopreti (suženja, bočni
30], zbog čega se preporučuje ispiranje kanala sa destilovanom kanali, anastomoze, invaginacije zidova korena itd.).
(sterilnom) vodom između svakog irigansa i sušenje kanala pre • Prisustvo neinstrumentisanih površina kanala korena
uvođenja novog rastvora za irigaciju [26, 29, 30]. U protokolu tokom endodontske instrumentacije je neizbežno zbog
ovog istraživanja su uvažene ove preporuke, kako bi se sprečile kompleksne morfologije kanala i ukazuje na važnost ade-
neželjene interakcije između iriganasa i pritom dobio adekvatan kvatne primene hemijskih sredstava i dezinfekcije svih
rezultat [11]. oblasti kanalnog sistema.
Posle irigacionog protokola VI (NaOCl + EDTA i CHX kao • Iako to nije bio primarni cilj istraživanja, najpovoljniji efe-
završni irigans) nije uočena erozija dentina. Prema podacima kat irigacije (i kod instrumentisanih i kod neinstrumen-
iz literature, pri kontaktu EDTA i CHX dolazi do neutralizacije tisanih delova kanala) uočen je posle primene irigacionih
anjonskog EDTA pomoću katjonskog CHX, zbog čega nema protokola sa: NaOCl i EDTA, odnosno NaOCl, EDTA i CHX
dalje redukcije dentina [30]. Pored toga, antimikrobni efekat kao završnim irigansom.

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Download Date | 9/17/18 9:29 PM