Abstract
Background
The smear layer formed during root canal instrumentation negatively affects root canal irrigation activity, which in turn can affect the treatment prognosis of endodontic treatment.
Aim
The aim of this study is to compare the efficiency of smear layer and debris removal in root canals using different irrigation protocols using scanning electron microscopy (SEM).
Materials and methods
The quality of smear layer removal throughout the root canal was assessed in 30 intact extracted teeth divided into 3 groups according to the irrigation protocol: Group 1: 3% sodium hypochlorite (NaOCL) alternately with 17% ethylenediaminetetraacetic acetate (EDTA) was used. Group 2: 3% NaOCL alternately with 9% etidronate solution diluted with distilled water and Group 3: 9% etidronate solution diluted in 3% NaOCL. The quality of smear layer removal was assessed using scanning electron microscopy (SEM). The nonparametric Mann-Whitney test was used to compare the protocols of irrigations.
Results
The study showed significant differences in the quality of smear layer removal in the apical part of the root canal. The best results were obtained in the groups using 9% etidronate and 9% etidronate solution diluted in 3% sodium hypochlorite. Conducting a comparative evaluation of the effectiveness of removing the smear layer using 3% NaOCL + 17% EDTA, 3% NaOCL + 9% etidronic acid diluted with distilled water, 3% NaOCL + 9% etidronic acid diluted with 3% hypochlorite showed greater effectiveness of protocols using etidronate. When comparing statistical data, protocols using etidronate were 4 times more effective than EDTA.
Conclusion
The smear layer formed during mechanical treatment of the root canal was better removed during irrigation with etidronate solution.
Keywords: EDTA, Etidronate, Irrigation, Root canal treatment, Smear layer
Introduction
The rapid development in dentistry allows for effective tooth-preserving manipulations. The number of successful cases of endodontic treatment has increased significantly due to improved mechanical treatment of root canal (RC), which makes it possible to excise infected dentin and obtain optimal RC geometry, accumulation of knowledge of root canal treatment (RCT) and improvement of obturation techniques, which reduce the risk of insufficient and excessive filling of root canal [1]. During the preparation (instrumentation) of root canals (RC) with manual or rotary instruments, a smear layer (SL) is formed, which may remain in the root canal sealing the dentinal tubules, which decrease the success of endodontic treatment. During the treatment of necrotic forms of pulpitis and periodontitis, the endodontist must not only widen the root canal for adequate obturation and disinfection, but also ensure maximum treatment of the dentinal tubules adjacent to the RC wall with temporary and permanent filling materials [1, 2]. The SL formed during the treatment must be removed, so great importance should be related to the irrigation protocol used in endodontic treatment [3].
The use of modern irrigants allows for effective control of the endodontic microbiota and allows for the removal of up to 92% of microorganisms from the RC system during irrigation with sodium hypochlorite (NaOCL) [4, 5]. One of the most frequently used irrigants is NaOCL (1–5%). It effectively combats the RC microbiota and dissolves soft tissue residues [6]. Its antiseptic activity has a wide spectrum of action against E. Faecalis, P. Endodontalis, St. Intermedius. However, the smear layer (SL) reduces its antiseptic activity [7]. The duration of the process causes a formation of biofilms on the walls of the root canal and a penetration of microflora into the dentinal tubules up to 200 μm [8, 9]. Therefore, an important aspect in endodontic treatment is the removal of smear layer after mechanical treatment. This allows NaOCL (surface tension 75 dyne/cm) to better penetrate the dentinal tubules [10]. The smear layer can be removed by physical and chemical methods. For physical action, laser action is used, which effectively removes SL and microorganisms. However, it requires equipment and specialized skills of the doctor [11, 12]. For the chemical method of removing the smear layer in the root canal, ethylenediaminetetraacetic acetate (EDTA) 17–20% is most often used [13]. EDTA has low antiseptic activity, so it is used in combination with NaOCL 1–5% [14]. This combination of irrigants affects the microbiota (NaOCL 1–5%) and root canal debris (EDTA 17–20%). This widely used protocol has proven its effectiveness and has good long-term clinical results. However, it has disadvantages, as according to existing studies, the use of EDTA 17–20% is ineffective for removing the smear layer in the apical third of the root canal, which can cause the development of a relapse of chronic apical periodontitis [15, 16]. To improve the quality of root canal treatment with EDTA solution, additional activation is necessary, for this purpose ultrasonic or laser activation is used [17]. Combinations of these irrigants have several disadvantages, such as the need to use several syringes with different solutions and intermediate rinsing with water, since no precipitates are formed upon contact of irrigants, but gaseous chlorine is released [18]. Also, EDTA 17–20% damages peritubular dentin upon prolonged contact with dentin [19].
All the above disadvantages of EDTA are the reason for further search for irrigants for SL removal. Recently, solutions based on etidronic acid have become very popular. Etidronic acid is a soft and biocompatible chelating agent, a distinctive feature of which is the ability to dilute etidronate directly in NaOCL [20]. An additional advantage is the release of root dentin growth factors after treatment with etidronate [21]. The most common concentration is 9%; due to the instability of the solution, it must be prepared immediately before use. To prepare the irrigant, 0.9 g of etidronate is dissolved in 10 ml of NaOCL or distilled water and used within an hour [10]. The etidronate solution in hypochlorite has a mild chelating effect on the root canal walls, removes debris at all stages of treatment, does not damage the structure of dentin and does not affect its hardness [22]. Ultrasonic activation of the solution also improves the quality of SL removal [23]. The aim of the study was to compare the efficiency of removing smear layer and debris in root canals using different irrigation protocols in vitro.
Materials and methods
The ethics committee at medical institute of peoples’ Friendship University of Russia approved this study (Protocol 21 at 19.10.2023). This in vitro study was conducted to evaluate three irrigation protocols on removing smear layer and debris from the root canal walls. For the study, 30 intact teeth with straight root canals, extracted for periodontal indications (18 incisors, 3 canines, 9 premolars) were selected. Depending on the protocol used, the teeth were divided into 3 groups, 10 in each. Informed consent was obtained from all subjects, whose teeth were used after extraction.
Group 1 (protocol 1)
10 teeth (6 incisors, 1 canine and 3 premolars) were mechanically processed with S-flexi instruments (Geosoft Endoline, Russia) till apical master file 35 and irrigated according to the protocol with 3% NaOCL (2 ml of solution) alternately with 17% EDTA (2 ml of solution) for 30 s. Each solution was activated by an EQ-S sonic endoactivator (Meta Biomed, South Korea) for 30 s after each instrument, the final irrigation was carried out with distilled water.
Group 2 (protocol 2)
10 teeth (6 incisors, 1 canine and 3 premolars) were mechanically processed with S-flexi instruments till apical master file 35 and the root canal was irrigated according to protocol 2 using 3% NaOCL (2 ml of solution) alternately with 9% etidronate solution diluted with distilled water (2 ml of solution) for 30 s. Each solution was activated by the EQ-S sonic endoactivator for 30 s after each instrument, the final irrigation was performed with distilled water.
Group 3 (protocol 3)
10 teeth (6 incisors, 1 canine and 3 premolars) were mechanically processed with S-flexi instruments till master file 35 and canals were irrigated according to Protocol 3 using a 9% solution of etidronate diluted in 3% NaOCL (2 ml of solution) after each instrument for 30 s, with activation by an EQ-S endoactivator for 30 s, final irrigation was performed with distilled water.
Upon completion of sample preparation, the root canal was dried with absorbent paper points and the root was cut longitudinally with a diamond disk and divided into three parts (apical, middle and coronal). The dried samples were prepared for electron scanning microscopy and covered with a layer of platinum.
The prepared samples were examined on a LEO-1430 VP scanning electron microscope (Carl Zeiss, Germany). In the experiment, the resolution was about 40 nm. The quality of smear layer removal was assessed by two independent experts using photographs obtained after scanning electron microscopy (SEM) using a scoring system from 1 to 5 proposed by Hulsmann et al. [24]. The following values served as criteria:
Score 1:
No smear layer, dentinal tubules visualized.
Score 2:
Small amount of smear layer covering the root canal, many dentinal tubules are visualized.
Score 3:
Smear layer and debris covering the root canal walls and a few dentinal tubules are visualized.
Score 4:
The surface of root canal covered completely with smear layer; no dentinal tubules visualized.
Score 5:
Heavy smear layer and debris covered the root canal surface.
Statistical analysis was performed using IBM SPSS Statistics Version 22 for Windows (IBM®, NY, USA). The nonparametric Mann-Whitney and Kruskal Wallis tests were used for the comparison between the irrigation protocols. Statistical significance was set at 0.05.
Results
The SEM results showed that in the first group, when using protocol 1 (3% NaOCL and 17% EDTA), the smallest number of open dentinal tubules was determined. The results are presented in Table 1. When using a combination of 3% NaOCL and 17% EDTA, SL removal in the coronal part was more pronounced than in the middle and apical parts (Fig. 1, 1-A, 1-B and 1-C).
Table 1.
Results of SEM scoring of samples
| Score | NaOCL 3%+EDTA 17% | Etidronate 0,9 g distilled water 10 ml | Etidronate 0,9 g + NaOCL 3% 10 ml | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Coronal | Middle | Apical | Coronal | Middle | Apical | Coronal | Middle | Apical | |
| 1 | 0% | 0% | 0% | 80% | 60% | 20% | 60% | 20% | 40% |
| 2 | 40% | 40% | 0% | 20% | 40% | 40% | 20% | 0% | 20% |
| 3 | 40% | 40% | 0% | 0% | 0% | 20% | 0% | 60% | 20% |
| 4 | 20% | 20% | 80% | 0% | 0% | 10% | 20% | 0% | 20% |
| 5 | 0% | 0% | 20% | 0% | 0% | 10% | 0% | 20% | 0% |
Fig. 1.
SEM of the root canal after treatment with 17% EDTA, A) apical third, B) middle third, C) coronal third, scale bar 2 and 20 μm
When analyzing the second group, it was revealed that the wall of the root canal in the coronal and middle parts was characterized by an almost complete absence of smear layer, well-open dentinal tubules, and clean peritubular dentin, with the absence of chemical erosions. The apical third of the root canal was covered with a thinner smear layer compared to the first irrigation protocol. Data on the preservation of the smear layer in the apical part of the canal were shown in Fig. 2 (2-A, 2-B, 2-C).
Fig. 2.
SEM of root canal wall after treatment with 9% aqueous etidronate solution, A) apical part, B) middle third, C) coronal part, scale bar 2 and 20 μm
Samples of the third group Fig. 3 (3-A, 3-B, 3-C) showed results like the samples of the second group. Treatment with etidronate in hypochlorite quite effectively removed the SL in all thirds of the root canal, open dentinal tubules with clean peritubular dentin were visualized in SEM photographs.
Fig. 3.
Root canal walls after treatment with 9% etidronate solution in 3% Sodium hypochlorite magnification A) apical part, B) middle third, C) coronal part, scale bar 2 μm
Comparison of the results of scanning electron microscopy at the apical part in all three protocols revealed a lesser effect of 17% EDTA solution on the smear layer. At the same time, no significant difference was found between treatment with 9% etidronate solution and treatment with 9% etidronate solution in 3% Sodium hypochlorite. According to the results of scanning electron microscopy of 10 samples in each group (30 samples in total), it was revealed that the maximum number of open dentinal tubules was observed in the second and third groups.
When compared the smear layer removal among protocols in coronal, middle and apical thirds of the root canal, Kruskal Wallis test showed statistical differences P = 0.01, 0.00 and 0.03, respectively. And when analyzing the smear layer removal differences between the protocols in the coronal, middle and apical third of the root canal, Mann-Whitney criterion demonstrated that Protocols 2 and 3 outperformed the first protocol in different parts (P ≤ 0.05) (Table 2).
Table 2.
Comparison the smear layer removal between the irrigation protocols in coronal, middle and apical thirds of the root canal
| Protocols comparison (smear layer removal) | Root canal part | P Value |
|---|---|---|
| Protocols 1 and 2 | Coronal parts | 0.001 |
| Middle parts | 0.001 | |
| Apical parts | 0.004 | |
| Protocols 1 and 3 | Coronal parts | 0.03 |
| Middle parts | 0.68 | |
| Apical parts | 0.001 | |
| Protocols 2 and 3 | Coronal parts | 0.39 |
| Middle parts | 0.005 | |
| Apical parts | 0.63 |
As a result of the statistical analysis, it can be concluded that protocols 2 and 3 have statistically significant differences from the control protocol 1. The use of irrigation protocol 3 (Etidronate 9% in 3% NaOCL) shows high efficiency in the apical part in 40% of cases (assigned a score of 1 point). When using the other protocols (9% etidronate in physiological solution + 3% NaOCL), a result of 1 score was obtained in 20% of cases and 2 score in 40% of cases (insignificant smear layer, single dentinal tubules are visualized). And in protocol 1 (EDTA 17% + 3% NaOCL), the distribution of points was only within 4–5 (abundant smear layer, dentinal tubules are not visualized). The data was presented in Fig. 4.
Fig. 4.
Percentage distribution of the amount of smear layer in the apical part
Discussion
Elimination of microorganisms in the root canal system during treatment is an important task in endodontic treatment [25]. This is why removing the smear layer from the root canal walls is so important since microbiota may remain in the thickness of the debris. The use of etidronate is a promising direction for further research. A distinctive feature is the lack of hypochlorite neutralization [26].
Based on the results of this study, it can be assumed that treatment with a 17% EDTA solution is less effective in removing the smear layer. According to Yang. G. et al. 2008, the apical part of the root canal most often remains untreated when irrigated with 17% EDTA [16]. Also, 17% EDTA neutralizes the alkaline environment of 3% NaOCL, reducing its antiseptic activity. Additionally, the literature indicates the erosive effect of 17% EDTA on peritubular dentin [27].
In combination with an obviously better removal of the smear layer in the apical part, etidronate becomes preferable in the endodontic treatment [28]. Similar results were obtained in a study conducted by Aoun. C. et al., 2023, when comparing the efficiency of SL removal in groups using 17% EDTA and groups using etidronate, the best result was obtained after etidronate irrigation [23].
The protocol used etidronate diluted in 3% NaOCL is the most convenient for clinical use. The use of a solution that simultaneously has the properties of an antiseptic and a chelating agent optimizes the workflow. Additionally, the risk of losing the working length due to obturation of part of the canal with sawdust is reduced [28].
Many authors obtained data similar to ours when studying etidronate in endodontic treatment. However, in their studies, they used etidronate as a finishing irrigant and investigated the effect of sound and ultrasound activation on the effectiveness of the irrigant [16, 27–31]. However, many studies evaluated the etidronate as finial irrigation solution, but not constant or sequential, after each endodontic instrument, as proposed in our study, specifically for the prevention of debris accumulation in the isthmuses and dentinal tubes [28]. An important factor is patients’ safety during treatment. That is why, in addition to efficiency, it is necessary to consider the safety of irrigants. Given the high activity of 5.25% NaOCL, we propose using etidronate dilution in 3% NaOCL to prevent complications and maintain high bactericidal activity [29].
Thus, the use of etidronate can be an alternative to irrigation with EDTA due to the high efficiency of SL removal and optimization of the irrigation process. The use of etidronate as a chelating solution allows for almost complete removal of the smear layer along the entire length of the root canal, which increases the efficiency of irrigation.
Conclusions
The smear layer formed during mechanical treatment of the root canal was removed during irrigation with solutions from all the stated protocols. Using etidronate solution protocol increases the efficiency of smear layer removal during root canal treatment by 4 times compared to EDTA.
Acknowledgements
The authors declare no acknowledgments. This paper has been supported by the RUDN University Strategic Academic Leadership Program.
Abbreviations
- SEM
Scanning Electron Microscopy
- NaOCL
Sodium Hypochlorite
- EDTA
Ethylenediaminetetraacetic Acetate
- SL
Smear Layer
- RC
Root Canal
Author contributions
Conceptualization, S.N. and A.B.; methodology, A.B., H.B. and A.K; software, V.T. and R.B; validation, S.R. and V.T; formal analysis, H.B and A.K.; investigation, A.K. and R.B.; resources, A.B. and H.B.; data curation, S.R and V.T.; writing—original draft preparation, H.B. and A.K.; writing—review and editing, S.R. and A.B.; visualization, R.B.; supervision, S.R.; project administration, S.R and A.B. All authors read and approved the final manuscript.
Funding
No funds were received for this study.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethical approval
The study was reviewed and approved by the research ethics committee at the medical institute, Peoples’ Friendship University of Russia under protocol number 21 at 19.10.2023. Informed consent was obtained from all subjects, whose teeth were used after extraction. Teeth samples experiments were performed in accordance with relevant guidelines and regulations.
Consent for application
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Alhat MB, Mattigatti SB, Mahaparale RR, Wahane KD, Jadhav A. Comparative evaluation of different methods of activation of chelating solution for Smear Layer removal in the apical portion of the Root Canal using a scanning Electron Microscopy: an in Vitro Study. Cureus. 2024;16(8):e66622. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Zancan RF, Di Maio A, Tomson PL, Duarte MAH, Camilleri J. The presence of smear layer affects the antimicrobial action of root canal sealers. Int Endod J. 2021;54(8):1369–82. [DOI] [PubMed] [Google Scholar]
- 3.Razumova SN, Brago AS, Enina YI, Agarkova PD, Guryeva ZA, Kozlova YS. Treatment efficacy of reversible and initial forms of pulpitis (retrospective analysis). Clin Dentistry (Russia). 2022;25(4):20–5. [Google Scholar]
- 4.Chubb DWR. A review of the prognostic value of irrigation on root canal treatment success. Aust Endod J. 2019;45(1):5–11. [DOI] [PubMed] [Google Scholar]
- 5.Wenzler JS, Falk W, Frankenberger R, Braun A. Impact of adjunctive laser irradiation on the bacterial load of Dental Root canals: a Randomized Controlled Clinical Trial. Antibiot (Basel). 2021;10(12):1557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Zehnder M. Root canal irrigants. J Endod. 2006;32(5):389–98. 10.1016/j.joen.2005.09.014. [DOI] [PubMed] [Google Scholar]
- 7.Morago A, Ordinola-Zapata R, Ferrer-Luque CM, Baca P, Ruiz-Linares M, Arias-Moliz MT. Influence of Smear Layer on the antimicrobial activity of a Sodium Hypochlorite/Etidronic Acid Irrigating Solution in infected dentin. J Endod. 2016;42(11):1647–50. [DOI] [PubMed] [Google Scholar]
- 8.Kukushkin VL, Barkhatova MS, Smirnitskaya MV. Microbial landscape of the endodontist in the dynamics of treatment of chronic apical periodontitis. Russian Dentistry. 2019;12(2):50. [Google Scholar]
- 9.Peters OA, Boessler C, Paqué F. Root canal preparation with a novel nickel-titanium instrument evaluated with micro-computed tomography: canal surface preparation over time. J Endod. 2010;36(6):1068–72. [DOI] [PubMed] [Google Scholar]
- 10.Giardino L, Del Fabbro M, Morra M, et al. Dual Rinse® HEDP increases the surface tension of NaOCl but may increase its dentin disinfection efficacy. Odontology. 2019;107(4):521–29. [DOI] [PubMed] [Google Scholar]
- 11.Razumova SN, Brago AS, Barakat HB, Kozlova YS, Velichko EV, Vasiliev YL. Microbiological study of the efficiency of root canal treatment with Er:yYAG laser. Biomedical Photonics. 2019;8(4):11–6. [Google Scholar]
- 12.Razumova S, Brago A, Kozlova Y, Barakat H, Howijieh A. Evaluation the efficacy of Er:YAG Laser in removing the Smear Layer during Endodontic Treatment. J int dent med Res. 2021;14(3):333–37. [Google Scholar]
- 13.Demirel A, Önder NS, Alkış M, Sarı Ş. Smear layer removal efficacy of irrigating solutions applied distinct needle designs: a scanning electron microscopy study. J Clin Pediatr Dent. 2023;47(1):58–66. [DOI] [PubMed] [Google Scholar]
- 14.Wu Z, Guo XJ, Qiao F, Wu LG. Antibacterial and residual antimicrobial activities of five final irrigants in infected root canal: an in vitro comparative study. Zhonghua Kou Qiang Yi Xue Za Zhi. 2016;51(9):532–7. [DOI] [PubMed] [Google Scholar]
- 15.Gambarini G, Laszkiewicz J. A scanning electron microscopic study of debris and smear layer remaining following use of GT rotary instruments. Int Endod J. 2002;35(5):422–7. 10.1046/j.1365-2591.2002.00495.x. [DOI] [PubMed] [Google Scholar]
- 16.Yang G, Wu H, Zheng Y, Zhang H, Li H, Zhou X. Scanning electron microscopic evaluation of debris and smear layer remaining following use of ProTaper and Hero Shaper instruments in combination with NaOCl and EDTA irrigation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):e63–71. [DOI] [PubMed] [Google Scholar]
- 17.Katunarić A, Grgac SF, Gabrić D, Pavelić B, Bago I. Effect of sodium hypochlorite and ethylenediaminotetraacetic acid activated by laser and ultrasonic energy on surface morphology and chemical composition of intracanal dentin. Microsc Res Tech. 2024;87(4):818–31. [DOI] [PubMed] [Google Scholar]
- 18.Prado M, Santos Júnior HM, Rezende CM, Pinto AC, Faria RB, Simão RA, et al. Interactions between irrigants commonly used in Endodontic Practice: a Chemical Analysis. J Endod. 2013;39(4):505–10. [DOI] [PubMed] [Google Scholar]
- 19.Calt S, Serper A. Time-dependent effects of EDTA on dentin structures. J Endod. 2002;28(1):17–9. [DOI] [PubMed] [Google Scholar]
- 20.Mousa M, Elbanna A, Rahman M, Elmesellawy M. Comparative evaluation of the Antibacterial Effect of different combinations of Etidronate, Nanochitosan and NaOCl on E. Faecalis Biofilm. J Int Dent Med Res. 2022;15:1429–33. [Google Scholar]
- 21.Deniz Sungur D, Aksel H, Ozturk S, Yılmaz Z, Ulubayram K. Effect of dentine conditioning with phytic acid or etidronic acid on growth factor release, dental pulp stem cell migration and viability. Int Endod J. 2019;52(6):838–46. [DOI] [PubMed] [Google Scholar]
- 22.El-Banna A, Elmesellawy MY, Elsayed MA. Flexural strength and microhardness of human radicular dentin sticks after conditioning with different endodontic chelating agents. J Conserv Dent. 2023;26(3):344–48. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Aoun C, Rechenberg DK, Karam M, Mhanna R, Plotino G, Zogheib C. Effect of continuous chelation irrigation using DualRinse HEDP + 3% NaOCl with or without high-power Sonic activation on debris and smear layer removal. Eur Endod J. 2023;8(2):162–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Hülsmann M, Rümmelin C, Schäfers F. Root canal cleanliness after preparation with different endodontic handpieces and hand instruments: a comparative SEM investigation. J Endod. 1997;23(5):301–6. [DOI] [PubMed] [Google Scholar]
- 25.Tsarev AV, Dikopova NZh, Ippolitov EV, Volkov AG, Razumova SN, Podporin MS, et al. The effect of anodic dissolution of various types of electrodes on the antibacterial effect during transcanal endodontic direct current exposure. Med Alphabet. 2023;1(1):28–32. [Google Scholar]
- 26.Murugesan K, Vishwanath S, Kadandale S, Thanikachalam Y, Parthasarathy R, Ilango S. Comparative evaluation of Smear Layer removal in apical third using four different irrigants with Ultrasonic agitation: an in Vitro Scanning Electron Microscopy (SEM) analysis. Cureus. 2022;14(3):e23142. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Ballal NV, Das S, Rao BSS, Zehnder M, Mohn D. Chemical, cytotoxic and genotoxic analysis of etidronate in sodium hypochlorite solution. Int Endod J. 2019;52(8):1228–34. [DOI] [PubMed] [Google Scholar]
- 28.Zehnder M. Etidronate (DualRinse HEDP) for root canal irrigation in clinical use. Quintessenz Zahnmed. 2019;70(8):896–905. [Google Scholar]
- 29.De-Deus G, Namen F, Galan J Jr, Zehnder M. Soft chelating irrigation protocol optimizes bonding quality of Resilon/Epiphany root fillings. J Endod. 2008;34(6):703–5. [DOI] [PubMed] [Google Scholar]
- 30.Tartari T, Wilchenski BS, de Souza Lima LA, Vivan RR, Ballal V, Duarte MAH. The use of sodium hypochlorite mixed with etidronic acid during canal preparation increases debris extrusion. Aust Endod J. 2023;49(3):584–91. 10.1111/aej.12788. [DOI] [PubMed] [Google Scholar]
- 31.Mankeliya S, Singhal RK, Gupta A, Jaiswal N, Pathak VK, Kushwah A. A comparative evaluation of Smear Layer removal by using four different irrigation solutions like Root Canal irrigants: an in Vitro SEM study. J Contemp Dent Pract. 2021;22(5):527–31. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.