RESEARCH AND EDUCATION

Effect of irrigation protocol during post space preparation on

the dentin adhesive interface: An in vitro study
Anna Thereza Peroba Rezende Ramos, DDS, MSc, PhD,a
Keren Cristina Fagundes Jordão-Basso, DDS, MSc, PhD,b Thiago Soares Porto, DDS, MSc, PhD,c and
Milton Carlos Kuga, DDS, MSc, PhDd

Retention of a fiber post is ABSTRACT

essential to successfully restore
Statement of problem. The post space must be prepared with techniques that do not interfere
endodontically treated teeth with the bond strength. These techniques are related to the availability of opened dentinal
with extensive loss of coronal tubules and incidence of residue among the dentin, the adhesive, and the cement. Nevertheless,
,
structure.1 2 However, several the effect of different irrigants during endodontic instrumentation is unclear.
factors may affect the post
Purpose. The purpose of this in vitro study was to assess the incidence of residue, the number of
stability, including the end- opened dentinal tubules, and the bond strength of the cementation system to root dentin of post
odontic technique, post space space after 3 different irrigation protocols.
preparation, and the materials
Material and methods. The roots of bovine incisors were obturated, prepared to receive a fiber
used for cementation.2-6
post, and divided into 3 groups as per the irrigation protocol: without irrigation, with alternating
Adequate bonding be- irrigation, and with continuous irrigation. Thirty roots (n=10) were evaluated by using scanning
tween cement and dentin is electron microscopy to assess the incidence of residue (×100 magnification) and the number of
important for post retention, opened dentinal tubules (×2000 magnification). The fiber posts were cemented, and the
especially in the middle and remaining specimens (n=10) were subjected to pushout testing and failure mode evaluation.
apical thirds, where dentin Results. All protocols presented a similar incidence of residue, regardless of the post space third
bonding is challenging.2,4,6-8 (P>.05). The irrigation protocol without irrigation had the lowest number of opened dentinal
Improved luting materials and tubules in the cervical and middle thirds (P<.05). The number of opened dentinal tubules was
adhesive systems, such as self- similar in all protocols in the apical third of the post space (P>.05). The irrigation protocol
etching and self-adhesive without irrigation had the lowest bond strength values in the cervical and middle thirds (P<.05).
cementation systems, have The irrigation protocol with continuous irrigation had the highest bond strength values in the
apical third (P<.05).
been developed to optimize
1,9,10 Conclusions. Post space preparation without irrigation negatively affected the bond strength of the
adhesion. Moreover, the
quality of the dentin substrate resin cementation system to root dentin. (J Prosthet Dent 2020;-:---)
affects bonding, and the inci-
dence of residue on or within the dentinal tubules may negatively interfere with the hybridization of the etch-
negatively affect the cement-to-dentin adhesive inter- and-rinse or self-etching adhesive systems.5,13,14
5,11,12
face. Furthermore, the type of adhesive system may The preparation of the post space results in residue in
affect the incidence of residue on the dentin surface, the root canal,11,12 especially when irrigation is not used,
reducing the exposure of the collagen matrix, which can or only performed after the post space has been

a
Professor, Department of Endodontics, UniRedentor, São José do Rio Preto, SP, Brazil.
b
Researcher, Department of Restorative Dentistry, São Paulo State University (UNESP), Araraquara, Brazil.
c
Assistant professor, Division of Restorative and Prosthetic Dentistry, College of Dentistry, The Ohio State University, Columbus, Ohio.
d
Professor, Department of Restorative Dentistry, São Paulo State University (UNESP), Araraquara, Brazil.

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Table 1. Median, maximum, and minimum values, first and third

quartiles of scores attributed to incidence of residue on dentin surface of
Clinical Implications post space
The type of irrigation during post space preparation WI AI CI
affects the formation of residue on the root dentin Third Median (Vmax-Vmin) Median (Vmax-Vmin) Median (Vmax-Vmin)
and the bond strength of the cementation system. Cervical 2* (2-2) 2* (2-1) 2* (2-1)
Continuous irrigation appears to be a good option, Middle 2* (2-2) 2* (2-1) 2* (2-1)
but clinical trials are still needed. Apical 2* (2-2) 2* (2-2) 2* (2-2)

AI, alternate irrigation; CI, continuous irrigation; WI, no irrigation; Vmax, maximum value,
Vmin, minimum value. *No difference found among post space preparation protocols.

prepared.2,5,12-16 Furthermore, the absence of continuous

irrigation during the intraradicular preparation and the
dentinal tubules (n=30), and the bond strength of the
removal of obturation material can cause a temperature
cementation system to root dentin (n=30). The root ca-
rise in the dentin.17-19 Therefore, a continuous or alter-
nals were prepared to receive a fiber post (White Post
nating irrigation protocol during the intraradicular prep-
DC1; FGM Dental Products) by following the manufac-
aration has been recommended on each rotary
turer’s recommendations. Bovine conoid lateral incisors
instrument change, minimizing root heating and pre-
with a smaller canal size than central incisors were also
cipitation of residue on the dentin surface.20 The irriga-
selected.
tion method used in the root canal retreatment directly
The crowns were removed with a diamond disk
affects the persistence of residue on the root dentin.21
(KG Sorensen), leaving a 16-mm root canal length. A
However, few studies have evaluated the effects of
#15 K file (Dentsply Sirona) was used to obtain the
different irrigation protocols during post space prepara-
working length, and the root canals were prepared by
tion.20-23
using the ProTaper Rotary System up to the F5 in-
The clinical procedure for fiber post cementation has
strument (Dentsply Sirona) according to Aranda-
been simplified by the development of resin cements
Garcia et al.23
with a 1-step self-etching adhesive system.3,24-28 Self-
The working length was established as 15 mm, and
etching adhesive systems partially incorporate the
the root apex was sealed with composite resin (Filtek
smear layer and increase adhesion by a chemical inter-
Z350; 3M ESPE). Subsequently, the root canals were
action between dentin and acidic monomers.27,28
irrigated with 5.0 mL of 2.5% sodium hypochlorite
The effects of different irrigation methods during the
(Asfer Chemical Industry Ltd) whenever the in-
preparation of the prosthetic space requires investigation.
struments were changed. Ethylenediaminetetraacetic
Therefore, assessing the incidence of remaining residue
acid (EDTA) (17%) (Biodynamic Chemicals & Pharma-
and its interference in the adhesive interface of the self-
ceuticals) was used as an irrigant for 3 minutes, fol-
etching adhesive system associated with resin cement
lowed by irrigation with 5 mL of 2.5% NaOCl. The root
to root dentin is essential to improving the cementation
canals were dried with an absorbent paper point and
procedure.29-35
filled with an epoxy sealer (AH Plus; Dentsply Sirona)
The purpose of this in vitro study was to evaluate
and F5 gutta percha with the single-cone technique,
the incidence of residue and the number of opened
followed by the vertical condensation technique.5 The
dentinal tubules on the bond strength of a dual
cervical access was sealed with a glass ionomer cement
resin cementation system (Single Bond Universal and
(Maxxion R; FGM Dental Products). The teeth were
RelyX Ultimate) after the post space irrigation and
maintained in distilled water for 7 days at 37  C, and
preparation protocols: without irrigation (WI), with
then, 30 roots were selected for evaluation of the inci-
alternating irrigation (AI), and with continuous irriga-
dence of residue analysis and the number of opened
tion (CI). The null hypotheses were that no difference
dentinal tubules on the dentin surface. The remaining
would be observed among post space preparations
roots were subjected to pushout testing to assess the
with different irrigation protocols, regardless of the
bond strength to dentin.
dentin third.
The remaining 30 roots were obturated and divided
into 3 groups based on the following intraradicular
MATERIAL AND METHODS
irrigation and preparation protocols. For the
This study was approved by the Research Ethics Com- WI protocol, 12-mm long #1 and #2 Largo Drills
mittee of FOAr-UNESP (1.603.859). Sixty roots of bovine (Dentsply Sirona) in an endodontic handpiece (X-Smart
incisors with similar anatomy and root canal dimensions Plus; Dentsply Sirona) at 800 rpm and a torque of 0.5
were standardized from radiographs made in the buc- Ncm were used to remove the obturation material.
colingual and mesiodistal directions. The teeth were used Then, a White Post DC1 (FGM Dental Products) drill
to evaluate the incidence of residue, the number of was used for the finishing. No irrigant was used during

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Figure 1. Representative image (original magnification ×100) of residue on dentin surface as per irrigation protocols in post space. A, without irrigation,
cervical third. B, alternate irrigation, cervical third. C, continuous irrigation, cervical third. D, Without irrigation, middle third. E, Alternate irrigation, middle
third. F, Continuous irrigation, middle third. G, Without irrigation, apical third. H, Alternate irrigation, apical third. I, Continuous irrigation, apical third.

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Table 2. Mean ±standard deviation values of number of opened dentinal tubules in dentin thirds of post space, after different irrigation protocols
WI AI CI
Third Mean ±Standard Deviation Mean ±Standard Deviation Mean ±Standard Deviation
Cervical 3.40b ±1.17 69.0a ±8.85 73.4a ±13.60
b a
Middle 1.60 ±0.96 59.20 ±6.59 64.40a ±6.05
a a
Apical 1.70 ±0.67 2.20 ±1.54 2.70a ±1.25
ab
AI, alternate irrigation; CI, continuous irrigation; WI, no irrigation. Different letters indicate significant difference (P<.05).

this space preparation. The AI protocol was similar to applied on the dentin surface as per the manufacturers
WI. However, the intraradicular space was irrigated with recommendations, a conventional dual resin cement
20 mL of distilled water at each rotary instrument (RelyX Ultimate; 3M ESPE) was inserted, and the post
change. An irrigation cannula (NaviTip 30G; Ultradent was placed inside the root canal; then, the assembly was
Products, Inc) was inserted 10 mm in length, and irri- light polymerized (Valo; Ultradent Products Inc.) for 20
gation was carried out with 2-mm cervical-apical seconds at 1200 mW/cm2.
movements. For the CI protocol, the space was pre- The specimens were vertically centralized inside a
pared similarly to the WI group; however, continuous polyvinyl chloride (PVC) matrix (Ø16.5×15.0 mm) with
irrigation was performed with 50 mL of distilled water, a surveyor and filled with polyester resin (Maxi Rub-
with each rotary instrument, in the cervical access using ber). The assembly was left undisturbed for 24 hours.
the connected irrigation cannula. Subsequently, the specimens were removed from the
After the post preparation, all root canals were irri- matrices and sectioned perpendicular to their long axis
gated with 5 mL of distilled water and dried with with a diamond disk in a low-speed cutting machine
absorbent paper points. The 30 roots submitted to the (Isomet 1000; Buehler Ltd) under running water cool-
post space preparation protocol received 2 longitudinal ing. Three sections with a 2.0 ±0.1-mm thickness were
grooves in the buccal and lingual faces next to the root cut from the apical, middle, and cervical thirds of the
canal with a double-sided diamond disk (KG Sorensen). post space. Cervical, middle, and apical sections were
After that, the roots were sectioned with a straight chisel submitted from 1.0 mm, 5.0 mm, and 8.0 mm,
(Wedelstaedt 5/6; Quinelato Surgical Instruments). respectively, from the root cervical face according to
The distal face of the root was used to evaluate the Ramos et al.4
incidence of residue. The cervical, middle, and apical Irregularities in the sections were removed with #1200
thirds were demarcated with a groove in the buccal and abrasive paper (Norton Saint-Gobain) under running
lingual surface 3, 6, and 9 mm in length from the root water cooling. Specimens of each root third were sub-
cervical, respectively. mitted to pushout testing using a universal testing ma-
The specimens were dehydrated inside a sealed chine (InstroneEMIC; Instron Brasil Equipamentos
chamber containing silica gel for 7 days. Mounted on Cientificos Ltda)36-38 with a crosshead speed of 0.5 mm/
metal stubs and examined with a scanning electron mi- min with 5-kN load cell until the complete displacement
croscope (SEM) (JSM-7900F; JEOL USA, Inc) operating of the post. The force required for the displacement was
at 20 kV. A representative image of the marked region in obtained in N and transformed into bond strength values
the root canal was made and enlarged (×100 magnifi- (MPa) in accordance with the study by Guiotti et al.29 A
cation). The incidence of residue was classified according specific notched crosshead for axial displacement was
to Serafino et al.11 used for each third: cervical 1.2 mm, middle 0.9 mm, and
Additional SEM images were obtained in the same apical 0.5 mm.
region to assess the number of dentinal tubules opened Each specimen was assessed with a stereomicroscope
(×2000 magnification) by following the same methodol- at ×20 magnification to analyze the failure mode, which
ogy. The number of dentinal tubules was counted by using was classified according to Elnaghy16 as Type 1 (adhe-
an imaging software program (ImageJ; U.S. National sive) between the post and cement; Type 2 (adhesive)
Institute of Health) according to Escalante-Otárola et al.13 between the cement and dentin; Type 3 (cohesive) within
The 30 roots selected for the pushout testing received the cement; and Type 4 (mixed) when 2 or more types of
the irrigation protocols, as previously described (n=10). failure mode were combined.
The adaptation of the fiber post (White Post DC1; FGM The data for the incidence of residue were submitted
Dental Products) was evaluated inside the root space. to the Kruskal-Wallis and Dunn tests (a=.05). The
The post surface was cleaned with isopropyl alcohol, and number of opened dentinal tubules and bond strength
2 layers of silane (Prosil; FGM Dental Products) were data were subjected to the Shapiro-Wilk test. Normality
applied throughout its length. A universal self-etching data were analyzed by using 1-way ANOVA and the
adhesive system (Scotchbond Universal; 3M ESPE) was Tukey honestly significant difference test (a=.05).

THE JOURNAL OF PROSTHETIC DENTISTRY Peroba Rezende Ramos et al

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Figure 2. Representative image of number of opened dentinal tubules (original magnification ×2000) as per irrigation protocols in post space. A, without
irrigation, cervical third. B, alternate irrigation, cervical third. C, continuous irrigation, cervical third. D, without irrigation, middle third. E, alternate irrigation,
middle third. F, continuous irrigation, middle third. G, without irrigation, apical third. H, alternate irrigation, apical third. I, continuous irrigation, apical third.

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1.e6 Volume - Issue -

Table 3. Mean and standard deviation values of bond strength (MPa) of cementation system as per dentin thirds of post space after different irrigation
protocols
WI AI CI
Third Mean ±Standard Deviation Mean ±Standard Deviation Mean ±Standard Deviation
Cervical 33.51b ±4.67 43.20a ±6.05 45.13a ±5.91
b a
Middle 33.17 ±7.68 43.46 ±6.36 44.25a ±4.05
Apical 27.56a ±4.48 30.40a ±10.44 39.42a ±7.70
ab
AI, alternate irrigation; CI, continuous irrigation; WI, no irrigation. Different letters indicate significant difference (P<.05). WI, no irrigation; AI, alternate irrigation; CI, continuous irrigation.

RESULTS Residue on the root canal dentin may negatively affect

the adhesive interface and bonding to dentin.5,29,32 The
In relation to the incidence of residue on the dentin
bond to the post is directly related to the bonding quality;
surface, all protocols presented similar outcomes, with
therefore, residual debris from the post space preparation
the SEM evaluation revealing considerable residue
should be avoided, either residue from dentin prepara-
regardless of the post space third (P>.05). SEM images of
tion or from removal of the obturation material.1,11,12
the cervical and middle thirds of the post space showed
Regardless of the dentin root third or irrigation
amorphous material, presumably residue from the
protocol, the present study found a similar incidence of
obturation material, regardless of the irrigation protocol
residue on the root dentin with SEM analysis at ×100
used. Some images displayed grooves on the residue,
magnification. The residue may have been affected by
suggesting the mechanical and thermal action of rotary
the rotary instrument (Largo or DC1) used to remove
instruments on the smear layer.
the endodontic material from the post space or the
Table 1 shows the median, maximum, and minimum
adequacy of irrigation during the post space
values, first and third quartiles of the scores attributed to
preparation.17,19,20,22
the incidence of residue in all dentin thirds. Figure 1
A temperature rise between 2.3  C and 15.6  C has
shows the incidence of residue on the dentin surface,
been reported during post space preparation by using
as per the irrigation protocols and root thirds.
rotary instruments, with the highest temperatures
From the SEM images, WI had the lowest number of
recorded during the use of Peeso drills.18,19 In addition,
opened dentinal tubules in the cervical and the middle
the molecular structure of the beta-phase of gutta percha
thirds (P<.05). AI and CI were similar (P>.05). However,
can be altered when the temperature is close to 65  C or
all protocols had a similar number of opened dentinal
after several heating and cooling cycles.33,34
tubules in the apical third (P>.05). Table 2 shows the
The present study used Largo and DC1 drills for the
mean and standard deviation values for the numbers of
post space preparation, with similar morphology to the
opened dentinal tubules in all dentin thirds. Figure 2
Peeso drill.3-5 The endodontic obturation was performed
displays the number of opened dentinal tubules as per
with the beta-phase of gutta percha, and consequently,
the post preparation protocols and dentin thirds.
the heating generated by the rotary instruments may
The bond strength values of the cementation system
have deformed and plasticized the gutta percha, causing
to dentin were different as per the root third. WI
its precipitation on the dentin surface, as shown in
showed the lowest bond strength values in the cervical
Figures 1.20,22
and middle thirds (P<.05). The AI and CI protocols
The irrigation protocol may also have influenced the
were similar (P>.05). In contrast, the CI protocol
incidence of residue on the root dentin surface.11,12
showed the highest bond strength values in the apical
Although AI and CI protocols were performed under
third (P<.05). The WI and AI protocols had similar
irrigation with distilled water, it was not sufficient to
values (P>.05).
reduce the dentin heating, causing residue, mainly gutta
Table 3 shows the mean and standard deviation
percha.22
values of the bond strength of the cementation system to
The AI protocol generated heat during preparation
different dentin thirds. Figure 3 shows the failure mode
because the irrigation was only carried out at each rotary
as per the post space preparation protocols and dentin
instrument change. The CI protocol may not have pro-
thirds.
vided sufficient irrigant to prevent heating because of the
adaptation of the rotary instrument to the root canal
DISCUSSION
anatomy.
All protocols showed incidence of residue on the dentin When the dentin was analyzed with a higher
surface, affecting the bond strength of dual resin cement magnification (×2000), the number of opened
and self-etching adhesive to the root dentin. Therefore, dentinal tubules (unobstructed by residue) could be
the null hypothesis was rejected. counted. The WI showed the lowest number of

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WI 10.0% 10.0% 60.0% 20.0%

AI 12.5% 75.0% 12.5%

CI 87.5% 12.5%

0% 20% 40% 60% 80% 100%

Type 1 Type 2 Type 3 Type 4

A

WI 30.0% 10.0% 60.0%

AI 55.6% 44.4%

CI 40.0% 40.0% 20.0%

0% 20% 40% 60% 80% 100%

Type 1 Type 2 Type 3 Type 4

B

WI 90.0% 10.0%

AI 10.0% 90.0%

CI 40.0% 10.0% 10.0% 40.0%

0% 20% 40% 60% 80% 100%

Type 1 Type 2 Type 3 Type 4

C
Figure 3. Failure mode frequency as per irrigation protocols in post space and dentin thirds. Type 1 (adhesive), fiber post/cement; Type 2 (adhesive),
dentin/cement; Type 3 (cohesive), within cement, and type 4 (mixed), 2 or more types of failure mode combined. A, Cervical third. B, Middle third. C,
Apical third.

opened dentinal tubules in the cervical and middle So et al22 reported that when using the same end-
thirds. Probably, the irrigation cleaned the dentin with odontic resin sealer used in this present study, the
less residue precipitated on the opened dentinal tu- apical third presented an average of 9% more residue
bules, as observed with root canals retreatments.21,22 than the cervical and middle third. In comparison with

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1.e8
the present study, fewer open dentinal tubules were
observed.
The incidence of residue and open dentinal tubules
was similar in the apical third for all protocols, probably
because the irrigation solution did not reach the apical
third.21 In addition, little mechanical cleaning of the
dentin surface may have occurred.21,23 Figure 2 shows
opened dentinal tubules and that the residue was
constantly present in the apical third for all different
protocols by using a rotary instrument. This suggests that
either alternate or continuous irrigation has discretely
reached the cervical and middle thirds, confirming the
hypothesis that the irrigation solution did not effectively
reach the apical third.
The present study used a universal adhesive system
through the self-etching method and conventional dual
resin cement owing to their good performance on the
adhesive interface of the root canal.1,7,26-28 Adhesion
mechanism from self-etching adhesive occurs with the
chemical interactions of acidic monomers with metal
ions, mainly the calcium from the dentin substrate. Thus,
a dentin surface free of residue is important for
bonding.27,31 This finding is consistent with that of
Guiotti et al,29 who reported that residue on the dentin
surface reduced the bond strength, presenting data
similar to the WI group in the present study. Guiotti
et al29 did not used irrigation in the preparation of the
root canal and reported a similar decrease in the bond
strength.
Although residue was similar among the irrigation
protocols, dentin exposure was greater in the cervical and
middle thirds, with more opened dentinal tubules.
Moreover, these thirds showed better bonding of the
cement to dentin. However, the CI protocol showed the
highest bond values because the apical irrigation is poor
in the AI protocols, as previously described. These find-
ings were consistent with those of Magro et al,32 who
reported that even after several endodontic irrigation
protocols, the incidence of residue in the apical third was
persistent.
Although a chemical interaction is the main mech-
anism of action, bonding with a universal adhesive
system requires incorporating the smear layer and
forming mechanical microretentions at the adhesive
interface.28 The AI and CI protocols showed a great
number of opened dentinal tubules in the cervical and
middle thirds of the post space. It is possible that the
dentinal penetrability of adhesive systems increased the
bonding surface area, resulting in higher bond strength
values.
The irrigation solution can affect the bonding between
the adhesive system and the root dentin. Distilled water
was selected as an irrigant, as sodium hypochlorite affects
the collagen matrix and EDTA affects the dentin mineral
component, which would reduce bond strength.9,10,15
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume - Issue -
In the present study, the bond strength was assessed
by using the pushout test, as the fracture pattern occurs
parallel to the adhesive interface and transverse to the
orientation of the root canal dentinal tubules.7 Limita-
tions of the test include misalignment of the specimens
during the test, differences in the diameters of the
notched crosshead used in the axial displacement, and
different diameters of the post space.35-38 However, this
methodology has been routinely used to evaluate adhe-
sion between fiber post cementation systems and the
dentin substrate.35-38
To minimize misalignment of the specimens and to
avoid differences in the adhesive interface from the
angulations of the dentinal tubules in relation to the
cementation system during the axial displacement of
the notched crosshead, the specimens were oriented
with a dental surveyor, and the slices were carefully
obtained across the root axis.4 In addition, to prevent
contact in a restricted area of the fiber post and
cementation system, the notched crosshead used in
the present study were of 3 diameters (1.2 mm, 0.9
mm and 0.5 mm for the cervical, middle and apical
thirds, respectively), selected as per the third of the
post space.3 The limitations of the results obtained in
the pushout test were complemented by the evaluation
of the adhesive interface through the classification of
the failure mode.3,8,38
Other limitations of the present study included the
lack of thermocycling or mechanical stress,7 requiring
future studies to evaluate the effects of these parameters
on the adhesion interface.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusion was drawn:
1. The post space preparation without irrigation had
the highest incidence of residue on the dentin sur-
face and the fewest opened dentinal tubules, which
negatively affected the bond strength of the resin
cementation system to root dentin.
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Corresponding author:
Dr Anna Thereza Peroba Rezende Ramos
Department of Restorative Dentistry
Araraquara Dental School
São Paulo State University
Humaitá St, 1680, Araraquara, SP 14801-903
BRAZIL
Email: annatherezaramos@hotmail.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.09.024
THE JOURNAL OF PROSTHETIC DENTISTRY