The Endodontic Smear Layer - A Literature Review Smitha R *, Abstract: Root canal instrumentation produces a layer of organic and

inorganic material called the smear layer which contains bacteria and their by-products. This can prevent the penetration of intracanal medicaments into dentinal tubules and influence the adaptation of filling materials to canal walls. Currently, methods of smear removal include chemical, ultrasonic and laser techniques which are not totally effective throughout the length of all canals or are universally accepted. For smear layer removal, the alternate use of Ethylene Diamine Tetra acetic Acid and sodium hypochlorite solutions are routinely suggested. This article provides an overview of enigmatic smear layer, enlightening its relevance to endodontics. Key words: Root canal instrumentation, EDTA, smear layer, dentinal tubules. Introduction: During hand or rotary instrumentation, significant amount of energy is expended at the interface of a substrate and a tool. The generation of frictional heat, plastic and elastic deformation can contribute potentially to alteration and deterioration of the substrate. Such smeared contaminants lower the surface energy and therefore have a profound effect upon the reactivity of the substrate surface. Identification of the smear layer was made possible using the electron microprobe with scanning electron microscope (SEM) attachment. In 1970 Eick et al reported, that the particles of smear layer were ranging in size from less than 0.51.5m. Brannstrom & Johnson in 1974 through their Scanning electron microscope studies demonstrated a thin layer of debris 25m thick, extending a few micrometres into the dentinal tubules. The smear layer in root canal cannot be directly compared to smear layer in Bhuvan Shome Venigalla **

cavity since the number of dentinal tubules in root canal shows a greater variation and there are likely to be more soft tissue remnants. Lester & Boyde in 1977 described the smear layer as organic matter trapped within translocated inorganic dentine. Senior lecturer *, Professor **, Department of Conservative Dentistry & Endodontics, Sri Sai College of Dental Surgery and Hospitals, Vikarabad, Andhra Pradesh. In 1981 Goldman et al estimated the smear thickness as 1m and reported to be largely inorganic in composition. Cameron and Mader et al discussed the smear material in two parts: first superficial smear layer and second the material packed into the dentinal tubules. Cengiz et al in 1990 proposed that penetration of smear material into dentinal tubules could also be caused by capillary action due to adhesive forces between the dentinal tubules and the material. The amount of smear layer produced during motorized preparation as with Gates-Glidden or post drills, has been reported as greater in volume than that produced by hand filing (Czonstkowsky et al 1990). However, Mc Comb & Smith in 1975 observed under SEM that instrumentation with K-reamers, K-files and Giromatic reciprocating files created similar surfaces. Additional work by Pashley in 1992 has shown that the smear layer contains organic and inorganic substances that include fragments of odontoblastic processes, micro organisms and necrotic materials. Considerable effort has been made to understand the effect of the smear layer on the apical and coronal seal (Madison & Krell 1984, Evans & Simon 1986, Kennedy et al 1986, Saunders & Saunders 1992, 1994) who concluded differently, with current knowledge of interactions between the smear layer and factors such as filling technique and sealer type. Some authors suggest that maintaining the smear layer may block the dentinal tubules and limit bacterial or toxin penetration by altering dentinal permeability (Michelich et al 1980, Pashley et al 1981)whereas others believe that the smear layer, being a loosely adherent structure, should be completely removed

from the surface of the root canal wall because it can harbor bacteria and provide an avenue for leakage (Mader et al 1984, Meryon & Brook 1990). It may also limit the effective disinfection of dentinal tubules by preventing sodium hypochlorite, calcium hydroxide and other intra canal medicaments from penetrating the dentinal tubules. Controversies exist regarding removal or retaining the smear layer. Some investigations have focused on its removal, whilst others have considered its effects on apical and coronal micro leakage, bacterial penetration of the tubules and the adaptation of root canal materials. Points that support its removal are : its unpredictable thickness and volume; the presence of bacteria, their by-products and necrotic tissue, which may act as a substrate for bacteria, allowing their deeper penetration in the dentinal tubules; it may limit the optimum penetration of disinfecting agents; can act as a barrier between filling materials and the canal wall and therefore compromise the formation of a satisfactory seal; is a loosely adherent structure and a potential avenue for leakage and bacterial contaminant passage between the root canal filling and the dentinal walls. Conversely, some investigators believe in retaining the smear layer during canal preparation, because it can block the dentinal tubules, preventing the exchange of bacteria and other irritants by altering permeability as suggested by Michelich et al in 1980 and Pashley et al in 1981. Smear layer Removal: A number of chemicals have been investigated as irrigants to remove the smear layer. Chlorhexidine, which is popular as an irrigant and having a long lasting antibacterial effect through adherence to dentine, does not dissolve organic material or remove the smear layer whereas NaOCl is well known for its ability to dissolve organic tissues. NaOCl during or after instrumentation produces superficially clean canal walls. Chelating agents are another group of chemical irrigants used in root canal treatment. The most common chelating solutions are based on EDTA which reacts with the calcium ions in dentine and forms soluble calcium chelate. It has been reported that EDTA decalcified dentine to a depth of

20-30m in 5 min however, Fraser in 1974 stated that the chelating effect was almost negligible in the apical 3rdof root canals. Various formulations of EDTA have been used as root canal irrigants. Urea peroxide added to EDTA encourage debris to float out of the root canal. In 1963 a quaternary ammonium bromide (Cetrimide) has been added to EDTA solutions to reduce surface tension and increase penetrability of the solution. In an effort to produce an irrigant capable of both removing the smear layer and disinfecting the root canal system, Torabinejad et al in 2003 developed a new irrigating solution, MTAD containing a mixture of tetracycline isomer, an acid, and a detergent. MTAD was reported to be an effective solution for the removal of the smear layer. One other method of removing smear layer is by Ultrasonic activation using continuous flow of NaOCl which showed smear-free canal surfaces. However, Ahmad et al in 1987 claimed that direct physical contact of the file with the canal walls throughout instrumentation reduced acoustic streaming. Acoustic streaming is maximized when the tips of the smaller instruments vibrate freely in a solution. Researchers suggested that the ultrasonic technique is useful only for the final irrigation of root canal after completion of hand instrumentation. Lasers are nowadays tried for removal of smear layer in root canal walls. Lasers can be used to vaporize tissues in the main canal, remove the smear layer and eliminate residual tissue in the apical portion of root canals. Takeda et al in 1998 and 1999 used the erbium-yttrium-aluminium-garnet (Er :YAG) laser and demonstrated an optimal removal of the smear layer without melting, charring or recrystallization associated with other laser types. The main difficulty with laser removal of the smear layer is its inaccessibility to the small canal spaces with the relatively large probes that are available. Conclusion : Current methods of smear layer removal include chemical, ultrasonic and laser techniques - neither of them are totally effective throughout the length of all canals nor they are used universally. However, if the smear layer is

to be removed the method of choice seems to be the alternate use of EDTA and NaOCl solutions. As several new sealers and core materials have recently been introduced, further investigations are required to determine the role of the enigmatic smear layer in the outcome of Root canal treatment. References: 1. Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic debridement of root canals: acoustic streaming and its possible role. J Endod 1987a; 13: 4909. 2. Ahmad M, Pitt Ford TR, Crum LA .Ultrasonic debridement of root canals: an insight into the mechanisms involved. J Endod 1987b;13: 93101. 3. Brannstrom M, Johnson G. Effects of various conditioners and cleaning agents on prepared dentin surfaces: a Scanning electron microscopic investigation. J Prosthet Dent 1974; 31: 42230. 4. Cameron JA. The use of ultrasonics in the removal of the smear layer: a Scanning electron microscope study. J Endod 1983; 9: 28992. 5. Cengiz T, Aktener BO, Piskin B. Effect of dentinal tubule orientation on the removal of smear layer by root canal irrigants. A scanning electron microscopic study. Int Endod J 1990; 23: 16371. 6. Cergneux M, Ciucchi B, Dietschi JM, Holz J. The influence of the smear layer on the sealing ability of canal obturation. Int Endod J 1987; 20: 22832. 7. Chailertvanitkul P, Saunders WP, MacKenzie D. The effect of smear layer on microbial coronal leakage of gutta percha root fillings. Int Endod J 1996; 29 : 2428. 8. Czonstkowsky M, Wilson EG, Holstein FA. The smear layer in endodontics. Dent Clin North Am 1990; 34: 1325. 9. Eick JD, Wilko RA, Anderson CH, Sorensen SE . Scanning electron microscopy of cut tooth surfaces and identification of debris by use of the electron microprobe. J Dent Res 1970; 49(Suppl): 135968.

10. Evans JT, Simon JHS. Evaluation of the apical seal produced by injected thermoplasticized gutta-percha in the absence of smear layer and root canal sealer. J Endod 1986; 12: 1007. 11. Fraser JG. Chelating agents: their softening effect on root canal dentin. Oral Surg Oral Med Oral Pathol 1974; 37: 803 11. 12. Garberoglio R, Brannstrom M. Scanning electron microscopic investigation of human dentinal tubules. Arch Oral Biol 1976; 21: 35562. 13. Goldberg F, Artaza LP, De Silvio A. Apical sealing ability of a new glass ionomer root canal sealer. J Endod 1995; 21: 498500. 14. Goldman LB, Goldman M, Kronman JH, Lin PS. The efficacy of several irrigating solutions for endodontics: scanning electron microscopic study. Oral Surg Oral Med Oral Pathol 1981; 52: 197204. 15. Gutmann JL. Adaptation of injected thermoplasticized gutta-percha in the absence of the dentinal smear layer. Int Endod J 1993; 26: 8792. 16. Kennedy WA, Walker WA III, Gough RW. Smear layer removal effects on apical leakage. J Endodontics 1986; 12: 217. 17. Lester KS, Boyde A. Scanning electron microscopy of instrumented, irrigated and filled root canals. Br Dent J 1977; 143: 35967. 18. Mader CL, Baumgartner JC, Peters DD. Scanning electron microscopic investigation of the smear layer on root canal walls. J Endod 1984; 10: 47783. 19. Madison S, Krell KV. Comparison of ethylene diamine tetra acetic acid and sodium hypochlorite on the apical seal of endodontically treated teeth. J Endod 1984; 10: 499503. 20. McComb D, Smith DC. A preliminary scanning electron microscopic study of root canals after endodontic procedures. J Endod 1975; 1: 23842. 21. Meryon SD, Brook AM. Penetration of dentine by three oral bacteria in vitro and their associated cytotoxicity. Int Endod J 1990; 23: 196202.

22. Michelich VJ, Schuster GS, Pashley DH. Bacterial penetration of human dentin in vitro. J Dent Res 1980; 59: 1398403. 23. Moorer WR, Wesselink PR. Factors promoting the tissue dissolving capability of sodium hypochlorite. Int Endod J 1982; 15: 18796. 24. Outhwaite WC, Livingston MJ, Pashley DH. Effects of changes in surface area, thickness, temperature and postextraction time on human dentine permeability. Arch Oral Biol 1976; 21: 599603. 25. Pashley DH. Michelich V, Kehl T. Dentin permeability: effects of smear layer removal. J Prosthet Dent 1981; 46: 5317. 26. Pashley DH. Dentin-predentin complex and its permeability: physiologic overview. J Dent Res 1985; 64 Spec Iss: 61320. 27. Pashley DH. Smear layer: overview of structure and function. Proceedings of the Fin Dent Soc 1992; 88 Suppl 1: 21524. 28. Saunders WP, Saunders EM. The effect of smear layer upon the coronal leakage of gutta-percha root fillings and a glass- ionomer sealer. Int Endod J 1992; 25: 2459. 29. Saunders WP, Saunders EM. Influence of smear layer on the coronal leakage of Thermafil and laterally condensed gutta-percha root fillings with a glass ionomer sealer. J Endod 1994; 20: 1558. 30. Takeda FH, Harashima T, Kimura Y, Matsumoto K. Comparative study about the removal of smear layer by three types of laser devices. J Clin Laser Med Surg 1998a; 16 : 117-22. 31. Takeda FH, Harashima T, Kimura Y, Matsumoto K. A comparative study of the removal of smear layer by three endodontic irrigants and two types of laser. Int Endod J 1999; 32: 329. 32. Torabinejad M, Khademi AA, Babagoli J et al. A new solution for the removal of the smear layer. J Endod 2003; 29: 1705.

33. Vonder Fehr FR, Nygaard Ostby B. Effect of EDTAC and sulfuric acid on root canal dentin. Oral Surg, Oral Med Oral Pathol 1963; 16: 199205. 34. White RR, Goldman M, Lin PS. The influence of the smeared layer upon dentinal tubule penetration by endodontic filling materials. Part II. J Endod 1987; 13: 36974.

1. Eick JD, Wilko RA, Anderson CH, Sorensen SE . Scanning electron microscopy of cut tooth surfaces and identification of debris by use of the electron microprobe. J Dent Res 1970; 49(Suppl): 135968. 2. Brannstrom M, Johnson G. Effects of various conditioners and cleaning agents on prepared dentin surfaces: a Scanning electron microscopic investigation. J Prosthet Dent 1974; 31: 42230. 3. Lester KS, Boyde A. Scanning electron microscopy of instrumented, irrigated and filled root canals. Br Dent J 1977; 143: 35967. 4. Goldman LB, Goldman M, Kronman JH, Lin PS. The efficacy of several irrigating solutions for endodontics: scanning electron microscopic study. Oral Surg Oral Med Oral Pathol 1981; 52: 197 204. 5. Cameron JA. The use of ultrasonics in the removal of the smear layer: a Scanning electron microscope study. J Endod 1983; 9: 28992 ( 6 Mader CL, Baumgartner JC, Peters DD. Scanning electron microscopic investigation of the smear layer on root canal walls. J Endod 1984; 10: 47783.

7 Cengiz T, Aktener BO, Piskin B. Effect of dentinal tubule orientation on the removal of smear layer by root canal irrigants. A scanning electron microscopic study. Int Endod J 1990; 23: 16371. 8 Czonstkowsky M, Wilson EG, Holstein FA. The smear layer in endodontics. Dent Clin North Am 1990; 34: 1325.

9 McComb D, Smith DC. A preliminary scanning electron microscopic study of root canals after endodontic procedures. J Endod 1975; 1: 23842. 10 Pashley DH. Smear layer: overview of structure and function. Proceedings of the Fin Dent Soc 1992; 88 Suppl 1: 21524. 11 Madison S, Krell KV. Comparison of ethylene diamine tetra acetic acid and sodium hypochlorite on the apical seal of endodontically treated teeth. J Endod 1984; 10: 499503. 12 Evans JT, Simon JHS. Evaluation of the apical seal produced by injected thermoplasticized gutta-percha in the absence of smear layer and root canal sealer. J Endod 1986; 12: 1007. 13 Kennedy WA, Walker WA III, Gough RW. Smear layer removal effects on apical leakage. J Endodontics 1986; 12: 217. 14 Saunders WP, Saunders EM. The effect of smear layer upon the coronal leakage of gutta-percha root fillings and a glass- ionomer sealer. Int Endod J 1992; 25: 2459. 15 Saunders WP, Saunders EM. Influence of smear layer on the coronal leakage of Thermafil and laterally condensed gutta-percha root fillings with a glass ionomer sealer. J Endod 1994; 20: 1558. 16 Michelich VJ, Schuster GS, Pashley DH. Bacterial penetration of human dentin in vitro. J Dent Res 1980; 59: 1398403. 17 Pashley DH. Michelich V, Kehl T. Dentin permeability: effects of smear layer removal. J Prosthet Dent 1981; 46: 5317 18 Meryon SD, Brook AM. Penetration of dentine by three oral bacteria in vitro and their associated cytotoxicity. Int Endod J 1990; 23: 196 202. 19 Torabinejad M, Khademi AA, Babagoli J et al. A new solution for the removal of the smear layer. J Endod 2003; 29: 1705.

20 Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic debridement of root canals: acoustic streaming and its possible role. J Endod 1987a; 13: 4909. 21 Ahmad M, Pitt Ford TR, Crum LA .Ultrasonic debridement of root canals:an insight into the mechanisms involved. J Endod 1987b;13: 93101. 22 Takeda FH, Harashima T, Kimura Y, Matsumoto K. Comparative study about the removal of smear layer by three types of laser devices. J Clin Laser Med Surg 1998a; 16 : 117-22. 23 Takeda FH, Harashima T, Kimura Y, Matsumoto K. A comparative study of the removal of smear layer by three endodontic irrigants and two types of laser. Int Endod J 1999; 32: 329.