Basic Research—Technology
A Comparative Scanning Electron Microscopic Investigation
of the Smear Layer after the Use of Sodium Hypochlorite Gel
and Solution Forms as Root Canal Irrigants
Vahid Zand, DDS, MSc,* Mehrdad Lotfi, DDS, MSc,* Saeed Rahimi, DDS, MSc,*
Hadi Mokhtari, DDS, MSc,* Ali Kazemi, DDS,* and Vahideh Sakhamanesh, DDS†
Abstract
Introduction: The effect of sodium hypochlorite
(NaOCl) gel along with EDTA on the removal of the smear
layer has not been studied; therefore, the aim of the
present study was to compare the efficacy of gel and
solution forms of NaOCl in removal of the smear layer
from root canal walls. Methods: A total of 40 single-
rooted teeth with minimum curvature (<5 ) were
selected and divided into two experimental groups,
each containing 15 teeth and one positive control group
containing 10 teeth. The canals of all the teeth were
prepared with rotary RaCe instruments up to #35. In
the NaOCl solution group, the root canals were flushed
with 2.5% NaOCl solution during instrumentation and in
NaOCl gel group, the instruments were coated with gel
form of NaOCl and used inside the root canals; then
saline was used for root canal irrigation. Finally, 1 mL
of 17% EDTA was used to rinse inside the root canals
and remained in the root canals for 2 minutes in the
both experimental groups; in the saline group, only
saline was used for irrigation. The amount of the smear
layer was quantified according to the Torabinejad
method using a scanning electron microscope. Data
were analyzed by the Kruskal-Wallis and Mann-
Whitney tests. All the statistical analyses were set with
a significance level of a = 0.05. Results: There were
no significant differences between NaOCl gel and solu-
tion forms in the coronal, middle, and apical thirds of
root canals. There were significant differences between
NaOCl solution and saline groups in the three parts of
root canal walls and between NaOCl gel and saline in
the coronal, middle, and apical thirds. Conclusion:
The use of NaOCl gel can be as effective as NaOCl solu-
tion along with EDTA in smear layer removal in the three
parts of root canal walls. (J Endod 2010;36:1234–1237)
Key Words
EDTA, NaOCl, scanning electron microscope, smear
layer
From the *The Department of Endodontics,Tabriz Dental School,Tabriz University of Medical Sciences, Tabriz, Iran; and †Private Practice, Tabriz, Iran.
Address requests for reprints to Dr Mehrdad Lotfi, Department of Endodontics, Tabriz Dental School, Tabriz University of Medical Sciences, Tabriz, Iran. E-mail
address: mehrlotfi@yahoo.com.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.02.033
1234 Zand et al.
S uccessful endodontic therapy requires shaping and cleaning of root canal systems
(1). During canal preparation of infected teeth, special attention must be given to
the elimination of bacteria and their toxins from the root canal system (2). The smear
layer is produced during root canal preparation by the manipulation of the surface
elements of the dentinal walls of canals. It is believed, from a biologic point of view,
that the presence of a smear layer contributes to leakage, and it is a source of nutrients
for microorganisms (3).
One of the most popular root canal irrigants is sodium hypochlorite (NaOCl)
because of its physicochemical and antibacterial properties (2). NaOCl has the unique
capacity to dissolve necrotic tissue and the organic components of the smear layer (4).
However, there are some disadvantages for NaOCl. It is toxic to tissues, causing hemo-
lysis, ulceration, and inhibition of neutrophil migration; it results in damage to endo-
thelial and fibroblast cells, facial nerve weakness, allergic reaction, and necrosis after
extrusion during root canal treatment (5). NaOCl is an alkaline solution with a pH of
approximately 11 to 12. It causes injury primarily by oxidation of proteins. Heggers
et al studied the toxic effects of NaOCl and found that at a concentration of 0.025%,
the solution was both bactericidal and nontoxic. However, at a concentration of
0.25%, the solution became significantly toxic to tissues. They found severe inflamma-
tion and cellular destruction in all tissues except for heavily keratinized epithelium (6).
Inadvertent injection of sodium hypochlorite beyond the apical foramen may
occur in teeth with wide apical foramina or when the apical construction has been de-
stroyed during root canal preparation or by resorption. In addition, extreme pressure
during irrigation or binding of the irrigation needle tip in the root canal may result in
contact of large volumes of the irrigant with the apical tissues (7). If this occurs, excel-
lent tissue-dissolving capacity of NaOCl will lead to tissue necrosis (7). The use of the gel
form of NaOCl can reduce the risk of extrusion of NaOCl into periapical tissues. The
effect of NaOCl gel along with EDTA on the removal of the smear layer has not been
studied; therefore, the present study tested the hypothesis that a gel formulation of
2.5% NaOCl as a lubricant accompanied with saline is as effective as 2.5% NaOCl solu-
tion in removing the smear layer when 17% EDTA is used as a final rinse.
Materials and Methods
A total of 40 extracted human anterior single-rooted teeth with mature apices and
minimum curvature (<5 ) were selected for the purpose of this study. The degree of
canal curvature was determined using the Schneider method (8). After access cavity
preparation, the pulp tissues were removed with a barbed broach (Dentsply, Maillefer,
Switzerland), and the size of the apical foramen was gauged with a #15 K-file (Dentsply,
JOE — Volume 36, Number 7, July 2010
 Basic Research—Technology
Maillefer, Switzerland). The teeth were then randomly divided into two
experimental groups, each containing 15 teeth and one positive control
group containing 10 teeth.
The working length was determined by measuring the length of the
initial file (#10) at the apical foramen minus 1 mm in all the groups. The
apical part of the roots was put inside green stick compound during
instrumentation. The canals of all the teeth were prepared up to file
#35. Each instrument was used only in three canals and then was re-
placed by a new one.
Instrumentation was performed by using RaCe rotary instruments
(FKG; Dentaire, La-Chaux-de-Fonds, Switzerland). These instruments
were set into rotational speed (500 rpm) with an eight:one reduction
handpiece powered by a torque limited electric motor (TCM Motor
3000; Novage, Konstanz, Germany). Instrumentation was completed using
the crown-down technique according to the manufacturer’s instructions.
The preparation sequence was as follows: (1) 0.1 tapered #40
instruments were used to one third of the working length, (2) 0.08
tapered #35 instruments were used to one half of the working length,
(3) 0.06 tapered #25 instruments were used to two thirds of the
working length, (4) 0.04 tapered #30 instruments were used to the
full working length, and (5) 0.04 tapered #35 instruments were used
to the full working length. During instrumentation, root canals in the
three groups were flushed with different irrigation protocols as follows:
In the NaOCl solution group, the root canals were flushed with 5
mL of 2.5% NaOCl (Pakshoma, Tehran, Iran) during instrumentation,
and at the end of preparation 1 mL of 17% EDTA (Merck, Darmeshtadt,
Germany) was used as the irrigation solution, which was left in the
canals for 2 minutes. At the end of instrumentation, 5 mL of distilled
water was used as final rinse.
In the NaOCl gel group, gel form of 2.5% NaOCl was used. Instru-
ments were coated with the gel form of NaOCl during instrumentation
and used inside the root canals. During instrumentation, canals were irri-
gated with saline after introducing each instrument. One milliliter of 17%
EDTA was used as a final irrigant, which remained in the canal for 2
minutes. Finally, 5 mL of distilled water was used for the final irrigation.
In the saline group, saline was used for root canal irrigation in the
positive control group during instrumentation, and 1 mL of distilled
water was used as a final irrigant and 5 mL of distilled water was
used as final rinse.

Evaluation
All root canal preparations were completed by one operator,
whereas the scanning electron microscope (SEM) evaluations were
performed by two other examiners who were blind to the experimental
groups.

Canal Cleanliness
After preparation, two longitudinal grooves were prepared on the
buccal and lingual aspects of the teeth using a #1 diamond disk (D&Z,
Diamant, Germany). The grooves were not deep enough to enter the
canals. A plastic instrument was then used to separate the teeth into
two halves, and both halves were prepared for SEM evaluation under
an LEO 360 SEM (Leo Electron Microscopy, Cambridge, UK) at
1,000 magnifications. Photomicrographs from the approximate
center of the coronal, middle, and apical thirds were exposed at
1,000 for each specimen. Two endodontists scored the presence Figure 1. (A) Comparison of the smear layer in the coronal third of the root
or absence of the smear layer in a blind manner. The images were canals between the three groups. (B) Comparison of the smear layer in the
scored according to the following criteria reported by Torabinejad et middle third of the root canals between the three groups. (C) Comparison
al (9): (1) no smear layer: no smear layer on the surface of the root of the smear layer in the apical third of the root canals between the three
groups. (This figure is available in color online at www.aae.org/joe/.)
canal and all the tubules clean and open; (2) moderate smear layer:
no smear layer on the surface of the root canal, but tubules containing

JOE — Volume 36, Number 7, July 2010 SEM Investigation of the Smear Layer after Use of NaOCl as Root Canal Irrigants 1235
Basic Research—Technology
Figure 2. (A) The canal wall after using NaOCl solution, the clean canal wall in the coronal third of the prepared canal (score 1). (B) The canal wall after using
NaOCl gel, the clean canal wall in the middle third of the prepared canal (score 1). (C) The canal wall after using saline, complete coverage of the canal wall with the
smear layer in the apical third of the canal (score 3).
debris; and (3) heavy smear layer: smear layer covering the root canal
surface and the tubules.
Data were analyzed by the Kruskal-Wallis test and the Mann-
Whitney rank sum test for pair-wise comparisons. All the statistical anal-
yses were set with a significance level of a = 0.05.
Results
The results for smear layer removal are presented in Figure 1A
through C. These figures show the mean ranks for the smear layer re-
maining in the coronal, middle, and apical thirds of the root canals with
three different irrigation regimens. The Kruskal-Wallis test showed
significant differences among irrigation solutions in the coronal,
middle, and apical thirds (p = 0.004, p < 0.001, and p = 0.012, respec-
tively). The Mann-Whitney rank sum test for pair-wise comparisons did
not reveal any significant differences between NaOCl solution and gel
groups in the coronal (Figs. 1A and 2A), middle (Figs. 1B and 2B),
and apical (Figs. 1C and 2C) thirds of the root canal walls (p = 0.68,
p = 0.87, and p = 0.51, respectively); however, there were significant
differences between NaOCl solution and saline groups in the coronal,
middle, and apical thirds of the root canals (p = 0.016, p < 0.001,
and p = 0.012, respectively) and between NaOCl gel and saline groups
in the coronal, middle, and apical thirds (p < 0.001, p < 0.001,
p = 0.045, respectively). More smear layer was observed in the saline
group in comparison with NaOCl gel and solution groups.
Discussion
The choice of an irrigant is of great importance because there are
differences in their efficacy to act as lubricants during instrumentation
to flush debris, smear layer, and bacteria out of the canal. Different
chemical formulations of irrigants might have different reactions on
the pulp and periapical tissues, leading to tissue necrosis (10).
NaOCl is an effective endodontic irrigation solution in a variety of
concentrations, ranging from 0.5% to 6% (7, 11). However, it may
cause serious complications because of incorrect use or mistakes.
The most common complication is accidental injection into the
periapical tissues in teeth with immature apical foramina or when the
apical constriction has been destroyed during root canal preparation
or by resorption (11–13). In addition, extreme pressure during
irrigation or binding of the irrigation needle tip in the root canal with
no escape route for the irrigant to leave the root canal in a coronal
1236 Zand et al.
direction may result in contact of large volumes of the irrigant with
the apical tissues (7). This study was conducted to test the hypothesis
that a gel form of 2.5% NaOCl as a lubricant accompanied with saline
is as effective as 2.5% NaOCl solution in removing the smear layer
from instrumented root canal walls.
The gel form of NaOCl was prepared by adding 2.5% NaOCl to
a water-soluble vehicle (polypropylene and polyethylene glycol). There-
fore, the gel is completely soluble in water. Each instrument used in the
canal was coated with this gel as a lubricant, and then the root canals
were irrigated with saline for flushing the remaining NaOCl gel and
debris out of the root canal. Figure 2A through C shows the photomi-
crographs of coronal, middle, and apical thirds of root canal walls.
As stated previously, none of the irrigation regimens used
completely removed the smear layer from the root canal. This finding
is consistent with the results of other studies (14, 15). However, we
did not find any significant differences between NaOCl solution and
gel in the three parts of the root canal walls, which shows that the
use of NaOCl gel can be effective in smear layer removal and we can
eliminate the side effects of NaOCl solution with the use of NaOCl gel.
Other investigators such as Antonio et al (16) and Rahmann et al
(17) used Carisolve (Med Team, Goteborg, Sweden) as a root canal ir-
rigant without any significant effectiveness in smear layer removal. Car-
isolve is a gel form of 0.05% NaOCl that is advocated for
chemomechanical removal of infected carious dentin (18). Rahman
et al used Carisolve for 30 minutes in the immature root canal and
concluded that it is as effective as 1% NaOCl. We used 2.5% NaOCl
gel during root canal instrumentation without spending any extra
time for its effect, which is very close to clinical situations. Unsuccessful
results of using Carisolve in the Antonio et al study might be attributed to
the low concentration of NaOCl in Carisolve.
The results of this study show that using NaOCl gel in combination
with the flushing effect of saline when EDTA 17% is used as a final rinse
can be effective in removing the smear layer. Studies on the antibacterial
effect of NaOCl gel can be helpful if NaOCl gel is to be suggested in root
canal instrumentation.
Conclusion
On the basis of the results of the present study, it can be concluded
that NaOCl gel can be effective in removing the smear layer, and the side
effects of NaOCl solution can be avoided with the use of NaOCl gel.
JOE — Volume 36, Number 7, July 2010

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