oo ORAL SURGERY

Vol. 94 No. 6 December 2002

o ORAL MEDICINE
ORAL PATHOLOGY

REVIEW ARTICLE

Clinical implications of the smear layer in endodontics:

A review
Mahmoud Torabinejad, DMD, MSD, PhD,a Robert Handysides, DDS,b
Abbas Ali Khademi, DMD, MS,c and Leif K. Bakland, DDS,d Loma Linda, Calif
LOMA LINDA UNIVERSITY

It has been recognized for many years that root canal instrumentation produces a smear layer that covers the
surfaces of prepared canal walls. This layer contains inorganic and organic substances such as fragments of
odontoblastic processes and necrotic debris. There is a lack of agreement regarding the effect of the smear layer on the
quality of instrumentation and obturation, but the smear layer itself may be infected and may protect the bacteria
within the dentinal tubules. Various methods have been used to remove the smear layer. Conflicting results have been
obtained from numerous in vitro studies regarding the significance of the presence or the removal of the smear layer.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:658-66)

Studies have shown that current methods of cleaning
and shaping root canals produce a smear layer that
covers the instrumented walls.1-5 This layer contains
inorganic and organic substances that include frag-
ments of odontoblastic processes, microorganisms, and
necrotic materials (Fig 1).5 According to Mader et al,3
the smear layer consists of a superficial layer on the
surface of the canal wall approximately 1 to 2 ␮m in
thickness and a deeper layer packed into the dentinal
tubules to a depth of up to 40 ␮m. The components of
the smear layer can be forced into the dentinal tubules
to varying distances.2,4 This can occur as a result of the
linear movement and rotation of instruments and be-
cause of capillary action generated between the dentinal
tubules and the smear material.4
The purpose of this article was to review current
a
Professor and Program Director, Department of Endodontics, School
of Dentistry, Loma Linda University.
b
Assistant Professor, Department of Endodontics, School of Den-
tistry, Loma Linda University.
c
Professor of Endodontics and Vice President of Academic Affairs,
School of Dentistry, University of Isfehan, Iran.
d
Professor and Chair, Department of Endodontics, School of Den-
tistry, Loma Linda University.
Received for publication Mar 22, 2002; returned for revision May 13,
2002; accepted for publication Jul 9, 2002.
© 2002, Mosby, Inc.
1079-2104/2002/$35.00 ⫹ 0 7/15/128962
doi:10.1067/moe.2002.128962
evidence regarding clinical implications of the smear
layer in endodontics.
BACTERIAL PRESENCE
When pathologic changes occur in the dental pulp,
the root canal system can harbor several species of
bacteria, their toxins, and byproducts. A number of
investigations have shown that pulpal and periradicular
pathoses do not develop without the presence of bac-
teria.6-9 Depending on the stage of pulpal pathosis,
various species of bacteria can be cultured from in-
fected root canals. These bacteria are predominantly
gram-negative anaerobes8,10,11 that can infect the root
canals by direct pulp exposures (caries or traumatic
injuries) or by coronal microleakage.12-16 Davis et al17
have shown that the morphology of root canals is very
complex and that mechanically prepared canals contain
areas not accessible by currently used endodontic in-
struments. Bacteria can be found in all areas of the root
canal system and in the dentinal tubules (Fig 2).18-20
DENTINAL TUBULES
In the root, dentinal tubules extend from the pulp-
predentin junction to the intermediate dentin just inside
the cementum-dentin junction. Dentinal tubules in the
root run a relatively straight course between the pulp
and the periphery in contrast to the typical S-shaped
contours of the tubules in the tooth crown. They range
in size from approximately 1 to 3 ␮m in diameter.21,22

658
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 94, Number 6
Fig 1. The presence of smear layer on the surface of an
instrumented root canal. Original magnification ⫻5000.
The density or number of dentinal tubules per square
millimeter varies from 4900 to 90,000.21 This density
increases in an apical-coronal direction to the root
surface and similarly in an external to internal direction
from the root surface. At the cementoenamel junction,
the number of dentinal tubules has been estimated to be
approximately 15,000 per square millimeter.
Available evidence shows that bacteria and its by-
products present in infected root canals may invade the
dentinal tubules.18-20,23-29 Investigators18,19 have re-
ported the presence of bacteria in the dentinal tubules of
infected teeth at approximately half the distance be-
tween the root canal walls and the cementodentinal
junction. Sen et al20 examined 10 extracted human teeth
with necrotic pulps under a scanning electron micro-
scope and reported bacterial penetration into the den-
tinal tubules up to 150 ␮m in the apical two thirds of
the roots. Horiba et al23 found endotoxin within the
dentinal walls of infected root canals. In addition, in
vitro studies have shown bacterial penetration into the
dentinal tubules in experimentally inoculated root ca-
nals.24-26
Siqueira et al27 removed the smear layer in bovine
teeth and inoculated them with 5 species of bacteria and
Enterococcus faecalis as a control. Their scanning elec-
tron microscope examination showed that all of the test
bacteria were able to penetrate into the dentinal tubules
to varying depths. Perez et al28 found a mean penetra-
tion depth of 479 ␮m for Streptococcus sanguis after 28
days of incubation, with a maximum penetration of 737
␮m. Peters et al29 evaluated the presence, depth of
penetration, morphotypes, and the number of colony-
forming units of bacteria in the root dentin of teeth with
periapical lesions. They reported the presence of bac-
teria in more than half of their samples close to the
cementum. Drake et al30 showed that removal of the
Torabinejad et al 659
Fig 2. The presence of several bacteria in a dentinal tubule of
a tooth with necrotic pulp. Original magnification ⫻5000.
smear layer opened the tubules, allowing bacteria to
colonize in the tubules to a much higher degree
(10-fold) compared with roots with an intact smear
layer.
Factors such as the number and the type of bacteria,
in addition to the length of exposure and the presence or
absence of smear layer, could influence the depth of
penetration of bacteria into the dentinal tubules. Be-
cause of the difficulties involved in sampling the den-
tinal tubules, the exact microflora of infected dentinal
tubules is unknown. Ørstavik and Haapasalo26 have
expressed concern regarding the effect of bacteria in the
dentinal tubules after inadequate root canal therapy.
INTRACANAL MEDICATIONS
The removal of diseased tissue, elimination of bac-
teria present in the canals and dentinal tubules, and
prevention of recontamination after treatment are the
objectives of endodontic therapy. These objectives are
achieved by thoroughly cleaning, shaping, and disin-
fecting the root canal system; by sealing the root canals
with a 3-dimensional obturation; and by placing a coro-
nal seal.
Because of the complexity of root canal systems and
the current inability to instrument all aspects of canal
wall surfaces, it is impossible to achieve complete
removal or destruction of all bacteria.31,32 Byström and
Sundqvist31 have shown that residual bacteria in an
instrumented but unfilled canal can multiply to their
original numbers within 2 to 4 days. To prevent recolo-
nization of the root canals with residual bacteria, some
authors recommend the use of intracanal medication
and, therefore, the completion of treatment of infected
root canals in more than 1 visit.32-34
660 Torabinejad et al
Various medicaments have been proposed for disin-
fection of root canals.26,35-37 The traditional phenolic or
fixative agents include camphorated monochlorophenol
(CMCP), formocresol, and cresatin. Iodine potassium
iodide and calcium hydroxide are the main nonphenolic
intracanal medications. These medicaments are potent
antibacterial agents under laboratory test conditions;
however, their effectiveness in clinical use is unpredict-
able.38 According to some researchers, they also neu-
tralize and render canal tissue remnants inert. Some
medications contain aldehyde derivatives that can be
used to fix fresh tissues for histologic examination;
however, they may not effectively fix necrotic or de-
composed tissues.35 According to Wesselink et al,39
fixed tissues are not inert and may become more toxic
and antigenic after fixation. Intracanal medications
have also been used clinically to prevent posttreatment
pain. Studies have shown, however, that routine use of
these materials as intracanal medication has no signif-
icant effect on the prevention of pain.40-43
According to Oguntebi,44 most currently used intra-
canal medicaments have a limited antibacterial spec-
trum and antigenic potential. In addition, some of them
have a limited ability to diffuse into the dentinal tu-
bules.
Effects of intracanal medications on bacteria in
dentinal tubules
After removal of the smear layer, Haapasalo and
Ørstavik25 inoculated the bovine incisors with E faeca-
lis and found penetration of these bacteria into the
dentinal tubules up to 1 mm. They demonstrated that
liquid CMCP completely disinfected the dentinal tu-
bules but that Ca(OH)2 was ineffective. Behnen et al45
had better success killing E faecalis with either Pulp-
dent or a 10% solution of Ca(OH)2 than with the
traditional thick mixes. The difference might have been
attributable to the different viscosity of various types of
Ca(OH)2 used in this experiment. Heling and Chand-
ler46 also inoculated dentinal tubules of bovine teeth
with E faecalis and then examined the disinfecting
effect of various irrigants. They found that none of the
test irrigants (chlorhexidine, hydrogen peroxide, so-
dium hypochlorite, EDTA, or their combinations) were
totally effective. Siqueira and de Uzeda47 inoculated
bovine dentin cylinders with 1 facultative and 2 obli-
gate anaerobic bacteria and examined the disinfecting
effect of Ca(OH)2 mixed with saline solution or CMCP
for 1 hour, 1 day, and 1 week. Their results showed that
Ca(OH)2 and saline solution were ineffective in disin-
fecting the dentinal tubules after 1 week of application.
In contrast, a mixture of Ca(OH)2 and CMCP resulted
in complete disinfection of the dentinal tubules in 1
day. Jeansonne and White48 and Kuruvilla and Ka-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
December 2002
math49 examined the antibacterial effect of chlorhexi-
dine gluconate and sodium hypochlorite on inoculated
human teeth in vitro. They reported a reduction in
bacterial counts but not total disinfection of the root
canals.
In an in vivo experiment, Katebzadeh et al50 showed
that infected dog teeth that were filled experienced
treatment failure more frequently than those medicated
with Ca(OH)2 before obturation. Sjögren et al51 exam-
ined the presence and influence of bacteria on the
long-term success of root canal therapy. Their results
show that 40% of root canals remain infected after
instrumentation. In addition, they reported that teeth
filled in 1 visit without the use of Ca(OH)2 experienced
treatment failure significantly more frequently than
those that were medicated for 1 week with Ca(OH)2
(68% vs 94%). The results of this study corroborate the
findings of Byström et al,52 who showed improved
clinical success rates after effective disinfection of root
canals.
Effects of smear layer on penetration of root
canal medicaments and sealers into the dentinal
tubules
In an in vitro study, Ørstavik and Haapasalo26
showed the importance of removal of the smear layer
and the presence of patent dental tubules for decreasing
the time necessary to achieve the disinfecting effect of
intracanal medications. Byström and Sundqvist53 have
also shown that the presence of a smear layer can
inhibit or significantly delay the penetration of antimi-
crobial agents such as intracanal irrigants and medica-
tions into the dentinal tubules.
Studies54-56 have shown better adhesion of obturation
materials to the canal walls after removal of the smear
layer. Pitt Ford and Roberts57 have suggested that the
failures of glass-ionomer retrograde fillings after apical
surgery may result from degradation of the smear layer.
Other investigators58-62 assessed the penetration depth
of different sealers, including Tubliseal, AH26, Seala-
pex, Rosin, Roth’s 811, and CRCS, into the dentinal
tubules. They found the penetration to be 10 to 80 ␮m
after removal of the smear layer, whereas no penetra-
tion was observed with the smear layer intact.
MICROLEAKAGE OF ROOT CANAL FILLINGS
WITH AND WITHOUT A SMEAR LAYER
The presence or absence of a smear layer may play
an important role in the adhesiveness of some sealers to
the root canal walls. Studies have shown a significant
increase in adhesive strength and resistance to mic-
roleakage of AH26 sealer when the smear layer was
removed.63,64 Gettleman et al63 did not find any changes
in adhesive strengths when Sultan and Sealapex sealers
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 94, Number 6
were evaluated with or without the smear layer intact.
Several investigators64-70 have shown less dye leakage
after removal of the smear layer with various obturation
techniques and root canal sealers. Other investigators
have reported that the removal of the smear layer did
not have any significant effect on the microleakage of
root canals when various sealers and obturation tech-
niques were used.71-75 In contrast to these findings,
Timpawat et al76 have reported that removal of the
smear layer has adverse effects on the microleakage of
filled root canals. These conflicting results might be
attributable to differences in the types of sealer and
obturation techniques, the means of producing a smear
layer, and the diversity of bacteria used under various
laboratory conditions.
REMOVAL OF THE SMEAR LAYER
Despite the controversy regarding the effect of the
smear layer on the quality of instrumentation and ob-
turation, several investigators1,77,78 have found that the
smear layer itself may be infected and may protect the
bacteria already present in the dentinal tubules. Be-
cause of these concerns, one may deem it prudent to
remove the initially created smear layer in infected root
canals and to allow penetration of intracanal medica-
tions into the dentinal tubules of these teeth. Efforts to
remove the smear layer have included chemical, me-
chanical, and laser means. After disinfection of the root
canal system, one can recreate a new smear layer by
mechanical filing of the root canal walls.
Chemical removal
The components of the smear layer are very small
particles with a large surface-mass ratio, which makes
them very soluble in acids.5 Because of this character-
istic, acids have been used to remove the smear layer.
McComb and Smith1 were the first investigators to
show that REDTA (a commercial brand of EDTA) can
remove the smear layer. Goldman et al79 showed that
when used alone, REDTA removed the inorganic por-
tion and left an organic layer intact in the tubules. To
remove this organic layer, another solvent is needed.
Sodium hypochlorite (NaOCl) has been shown to be
very effective for this purpose. When used alone,
NaOCl can dissolve pulpal remnants and predentin.
However, many studies have shown its ineffectiveness
in removing the entire smear layer when used alone.
Goldman et al,79 Yamada et al,80 and Baumgartner and
Mader81 showed that alternating the use of EDTA and
NaOCl is an effective method for smear layer removal.
O’Connell et al82 compared the ability of various salts
of EDTA to remove the smear layer. They showed that
all salts of EDTA were capable of removing the smear
layer from the coronal two thirds of root canals. In
Torabinejad et al 661
addition, they reported that tetrasodium salt pH-ad-
justed with HCl is less expensive and just as effective
as the more commonly used disodium EDTA.
Aktener and Bilkay83 developed a solution of EDTA
and ethylenediamine to work in dual action. Their goal
was to see whether a single irrigating solution could be
developed to remove the inorganic and the organic
components of the smear. They found many patent
tubules but concluded that more research was needed to
determine the efficacy of this combination. Goldberg
and Abramovich84 added a quaternary ammonium bro-
mide (Cetavlon) to EDTA to reduce its surface tension;
this solution is called EDTAC. This addition increased
the wetting effect on the canal wall and permitted
deeper penetration of the solution into irregularities.
This combination was shown by Goldberg and Spiel-
berg85 to be very effective in smear layer removal,
reaching its peak effect at 15 minutes and increasing the
diameter of the opened dentinal tubules. Recently, Çalt
and Serper86 reported that ethylene glycol-bis (b-ami-
noethyl ether)-N,N,N’, N’-tetraacetic acid was some-
what effective in removing the smear layer without
inducing dentinal erosion commonly caused by EDTA
(Fig 3).
Morgan and Baumgartner87 showed that the quantity
of smear layer removed by a material is directly related
to its pH and the time of exposure. Loel58 used a 50%
citric acid solution to treat canal walls after instrumen-
tation and found better penetration of rosin sealer into
the tubules and improved adaptation of gutta-percha
than in untreated canals. Tidmarsh55 and Baumgartner
et al88 also showed that 50% citric acid is an effective
irrigant to remove the smear layer from the surface of
prepared root canal walls. Wayman et al89 found lactic
acid at 50% concentration was less effective than 50%
citric acid for removal of the smear layer. This might be
attributed to the viscosity of lactic acid. They also
determined that alternating use of 10% citric acid and
2.5% NaOCl was a very effective method for removing
the smear layer.
Bitter90 reported that 25% tannic acid was effective
in removing the smear layer. Sabbak and Hasanin91
refuted these findings and explained that tannic acid
increased the cross-linking of exposed collagen within
the smear layer and within the matrix of the underlying
dentin, thus increasing organic cohesion to the tubules.
Polyacrylic acid (Durelon liquid and Fuji II liquid) at
40% was reported by Berry et al92 to be very effective
for removal of the smear layer. Because of its potency,
the application of polyacrylic acid should not exceed 30
seconds according to the authors’ recommendations.
Derivatives of oxine (8-hydroxy-quinoline) were
known to possess antiseptic qualities as early as 1895.93
662 Torabinejad et al
Fig 3. Erosion of the dentinal tubule after placement of EDTA in the root canal for 5 minutes. Original magnification ⫻5000.
Dequalinium compounds, which belong to this
group, have been widely used in medicine against
infections of bacteria, molds, and fungi.94 Bis-de-
qualinium-acetate (BDA) has been shown by Kauf-
man et al94 and Kaufman95 to remove the smear layer
throughout the canal, even in the apical third. BDA is
well tolerated by the tissues within the periodontium
and has a low surface tension that allows penetration
into spaces that instruments cannot reach.94 BDA is
also considered less toxic than NaOCl and can be
used as a root canal dressing. Kaufman and Green-
berg96 compared Salvizol (a commercial brand of
0.5% BDA) with 5.25% NaOCl and found both com-
parable in their ability to remove organic debris, but
only Salvizol was able to open dentinal tubules. Berg
et al97 reported Salvizol to be less effective at open-
ing dentinal tubules than was REDTA.
Tetracyclines (including tetracycline-HCl, mino-
cycline, and doxycycline) are broad-spectrum antibi-
otics that are effective against a wide range of mi-
croorganisms. Genco et al98 have suggested that
tetracyclines significantly enhance healing after sur-
gical periodontal therapy. Tetracyclines have many
unique properties in addition to their antimicrobial
effect. They have a low pH in concentrated solution
and thus can act as a calcium chelator, and they can
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
December 2002
cause enamel and root surface demineralization.99
The surface demineralization of dentin is comparable
with that of citric acid.100 The substantivity of these
antibiotics allows them to be absorbed and released
gradually from tooth structures such as dentin and
cementum.100-102
The ability of the tetracycline family of antibiotics to
remove smear layers has also been studied. They have
been used to demineralize dentin surfaces, uncover and
widen the orifices of dentinal tubules, and expose the
dentin collagen matrix. These effects provide a matrix
that stimulates fibroblast attachment and growth. Bark-
hordar et al103 showed that doxycycline HCl (100 mg/
mL) is effective in removing the smear layer from the
surfaces of instrumented canals and root-end cavity
preparations. They speculated that a reservoir of active
antibacterial agents might be created because doxycy-
cline readily attaches to dentin and can be subsequently
released. Haznedaroglu and Ersev104 showed that 1%
tetracycline hydrochloride or 50% citric acid can be
used to remove the smear layer from the surfaces of
instrumented root canals. Although they reported no
difference between these 2 groups, it appears that the
tetracycline demineralized less peritubular dentin than
did the 50% citric acid.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 94, Number 6
Ultrasonic removal
Cameron105 produced a debris-free canal with the use
of a 3% NaOCl solution combined with ultrasonic
instrumentation for 5 minutes after conventional canal
instrumentation. The mechanism of action for debris
removal was described as acoustic streaming by Ahmad
et al.106 Acoustic streaming is maximized when the tips
of the smaller instruments operate at high power and
vibrate freely in a solution. Lumley et al107 recom-
mended that only size 15 files be used to maximize the
microstreaming for removal of debris.
Cameron108 showed complete smear removal with
4% NaOCl and ultrasonic instrumentation for 2 min-
utes. Prati et al109 also achieved smear layer removal
with ultrasonics. Walker and del Rio110,111 in 2 separate
reports showed no significant difference between tap
water and NaOCl when used with ultrasonics, but they
reported that neither solution used with ultrasonics was
effective at any level in the canal to remove the smear
layer. Baumgartner and Cuenin112 also observed that
ultrasonically energized NaOCl, even at full strength,
did not remove the smear layer from the root canal
walls. Guerisoli et al113 evaluated the use of ultrasonics
to remove the smear layer and found it necessary to use
15% EDTAC with either distilled water or 1% NaOCl
to achieve the desired result.
Laser removal
Takeda et al114,115 found that lasers can be used to
vaporize tissues in the main canal, remove the smear
layer, and eliminate the residual tissue in the apical
portion of the root canals. Several investigators116-118
have reported that the effectiveness of lasers depends
on many factors, including the power level, the duration
of exposure, the absorption of light in the tissue, the
geometry of the root canal, and the tip-to-target dis-
tance.
Dederich et al116 and Tewfik et al119 used variants of
the neodymium-yttrium-aluminum-garnet laser and re-
ported a range of findings from no change or disruption
of the smear layer to actual melting and recrystalliza-
tion of the dentin. This pattern of dentin disruption was
observed in other studies with various lasers, including
the carbon dioxide laser,117 the argon fluoride excimer
laser,120 and the argon laser.118,121 Takeda et
al,114,115,122 using the erbium-yttrium-aluminum-garnet
(Er:YAG) laser, demonstrated optimal removal of the
smear layer without the melting, charring, and recrys-
tallization associated with other laser types. Kimura et
al123 demonstrated the removal of the smear layer with
an Er:YAG laser as well. Although they showed re-
moval of the smear layer, the photomicrograph showed
destruction of the peritubular dentin. The main diffi-
culty with laser removal of the smear layer continues to
Torabinejad et al 663
be the access to small canal spaces with the relatively
large probes that are available for delivery of the laser
beam.
CONCLUSION
On the basis of the available evidence, it can be
concluded that current methods of root canal instru-
mentation produce a layer of organic and inorganic
material (smear layer) that may also contain bacteria
and their byproducts. This layer covers the instru-
mented walls and may prevent the penetration of int-
racanal medications into the dentinal tubules and may
affect close adaptation between root canal filling mate-
rials and the root canal walls.
Considering the aforementioned observations, it
seems reasonable to suggest that removal of the smear
layer can result in a more thorough disinfection of the
root canal system and the dentinal tubules, which
would ensure a better adaptation between the obturation
materials and the root canal walls. Current methods of
smear layer removal include chemical, ultrasonic, and
laser techniques—none of which is totally effective or
has received universal acceptance. Conflicting reports
exist regarding the removal of the smear layer before
the obturation of root canals. One may deem it prudent,
because of its potential contamination, to remove the
smear layer in teeth with infected root canals and allow
penetration of intracanal medications into the dentinal
tubules. After disinfection of the root canal system, if
advised, one may recreate a new smear layer by cir-
cumferential hand-filing or the use of rotary instru-
ments. To effectively disinfect the root canal system, an
irrigant or an intracanal medication with the following
characteristics should be used:
1. It should be able to completely remove the smear
layer.
2. It should be able to disinfect the dentin and its
tubules.
3. It should have sustained antibacterial effect after
use.
4. It should allow the penetration of antimicrobial
agents present in the solution into the dentinal
tubules.
5. It should be nonantigenic, nontoxic, and noncarci-
nogenic to tissue cells surrounding the tooth.
6. It should have no adverse effects on the physical
properties of exposed dentin.
7. It should have no adverse effect on the sealing
ability of filling materials.
8. It should not discolor the tooth.
9. It should have convenient application.
10. It should be relatively inexpensive.
Clinical investigations are needed to determine the
664 Torabinejad et al
role of smear layer in the outcome of root canal ther-
apy.
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Reprint requests:
Mahmoud Torabinejad, DMD, MSD, PhD
Department of Endodontics
School of Dentistry
Loma Linda University
Loma Linda, CA 92350