Vol. 107 No.

4 April 2009

ENDODONTOLOGY Editor: Larz S.W. Spångberg

Comparison of different irrigants on calcium hydroxide

medication removal: microscopic cleanliness evaluation
Ricardo Julio Cabrales Salgado, DDS,a Cacio Moura-Netto, DDS, MSc,b
Andrea Kanako Yamazaki, DDS, MSc,b Luciano Natividade Cardoso, DDS, MSc,b
Abílio Albuquerque Maranhão de Moura, DMD, MSc, PhD,c and
Igor Prokopowitsch, DDS, MSc, PhD,d São Paulo, Brazil
UNIVERSITY OF SÃO PAULO-USP

Calcium hydroxide dressing residuals can compromise endodontic sealing. This study evaluated the cleaning
efficacy of different endodontic irrigants in removing calcium hydroxide by SEM image analysis. Fifty-four single-
rooted mandibular premolars were instrumented to a master apical file #60 and dressed with calcium hydroxide. After
36 hours, the teeth were reopened and Ca(OH)2 medication was removed by 5 different experimental groups: 0.5%
NaOCl (G1), EDTA-C (G2), citric acid (G3), EDTA-T (G4), and re-instrumentation with MAF using NaOCl and
lubrificant, followed by EDTA-T (G5). The roots were split in the buccal-lingual direction and prepared for SEM
analysis in cervical, middle, and apical thirds (9, 6, and 3mm from the apex). Five blinded examiners evaluated the
wall cleanliness using a scale from 1 to 5. Statistical analysis was performed using Kruskal-Wallis at 5% level of
significance. Group G5 had the best results in all thirds, with significant statistical differences compared to all other
groups in the middle and coronal third, and to G1 in the apical third. On the other hand, G1, only flushed with
NaOCl, had the worst results, with statistical differences in all thirds compared to the other groups. The best
cleanliness was achieved by G4 and G5 groups. The recapitulation of MAF in combination with irrigants improved the
removal of calcium hydroxide medication better than an irrigant flush alone. (Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009;107:580-584)

To achieve the best adaptation of filling material, it is
necessary to clean the dentin wall of smear layer and
debris as well as intracanal medication. Calcium hy-
droxide medication is frequently used between ses-
sions, because of its antibacterial property1-4 and to
promote apexification.5,6
If this medication is not completely removed, its
a
MSc student, Department of Endodontics, University of São Paulo-
USP, São Paulo, Brazil.
b
PhD student, Department of Endodontics, University of São Paulo-
USP, São Paulo, Brazil.
c
Professor, Department of Endodontics, University of São Paulo-
USP, São Paulo, Brazil.
d
Professor, Department of Endodontics, University of São Paulo-
USP, São Paulo, Brazil.
Received for publication Sep 14, 2008; returned for revision Dec 1,
2008; accepted for publication Dec 5, 2008.
1079-2104/$ - see front matter
© 2009 Published by Mosby, Inc.
doi:10.1016/j.tripleo.2008.12.008
presence on the dentin wall could compromise the
cleanliness and permeability achieved by the final flush
after root canal instrumentation.7,8 Several studies have
shown that the presence of calcium hydroxide on dentin
walls can affect the penetration of sealers into the
dentinal tubules.9-12 The removal of calcium hydroxide
has been investigated using various products and tech-
niques such as chelants to dissolve inorganic particles
of the smear layer and intracanal medication.13,14
EDTA-T is widely used as the best irrigant to clean the
smear layer, mainly when it is associated with a cat-
ionic detergent, allowing a better diffusion and effec-
tiveness.15,16 Another efficient irrigant used for the
same purpose is citric acid, used in different concen-
trations.17-19 To dissolve organic tissues, sodium hypo-
chlorite is recommended in various concentrations
(0.5% to 5.25%) associated or not with a lubrificant,
such as RC-Prep, Glyde File Prep, or Endo-PTC.20-23
Assuming the importance of the complete removal of

580
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Volume 107, Number 4
Table I. Experimental groups
Group n Irrigant solution
G1 10 15 mL of 0.5% sodium hypochlorite
G2 10 15 mL of EDTA-C
G3 10 15 mLof 15% citric acid
G4 10 15 mL of 17% EDTA-T
G5 10 15 mL of 17% EDTA-T ⫹ instrumentation
with MAF and 0.5% sodium
hypochlorite ⫹ Endo-PTC; 15 mL of
0.5% sodium hypochlorite and 15 mL of
17% EDTA-T.
calcium hydroxide medication before root canal filling,
this study evaluated the cleaning efficacy of various
endodontic irrigants, through scanning electron micro-
scope (SEM) image analysis.
MATERIAL AND METHODS
After the approval of the Ethics Committee of the
Dental College of the University of São Paulo, 54
single-rooted mandibular premolars, stored in 1% thy-
mol solution, were selected from a tooth bank for this
study. To minimize variables, only teeth within the 19
to 21 mm length range were selected. After coronal
access with diamond burs, the orifice openings were
flared using Largo and Gates Glidden burs #2-3
(Maillefer, Ballaigues Switzerland). The working
length was determined at 1 mm from the apical foramen
with radiographic confirmation. Root canal preparation
was performed using K-files (Maillefer) and 0.5% so-
dium hypochlorite with Endo-PTC lubrificant (associ-
ation of urea peroxide, Tween 80 and Carbowax -
Formula e Ação, Brazil) in conventional technique. All
teeth were prepared with a master apical file #60
(MAF), followed by a final irrigation with 15 mL of
0.5% sodium hypochlorite and 15 mL of 17% EDTA-T
(EDTA and 0.2% lauril sodium sulfate biologic deter-
gent - Formula e Ação, Brazil). The teeth were dried
and filled with calcium hydroxide mixed with 1% lido-
caine anesthetic solution, with exception of 2 teeth used
as positive control. Mesio-distal and bucco-lingual ra-
diographs were taken to confirm complete filling. All
roots were then stored in a sealed box at room temper-
ature for 36 hours. Two roots without calcium hydrox-
ide were used as negative controls.
The remaining 50 roots were randomly divided into
5 groups, according to the solution used for calcium
hydroxide removal (Table I). All substances were
placed in 20-mL sterilized syringes with a 30-gauge
needle, calibrated at the working length with a rubber
stop. For each irrigation, 15 mL of the substances were
used, divided in 3 rinses of 5 mL. After each rinse, a
K-file #15 was inserted inside the canal and oscillated
Salgado et al. 581
Table II. Criteria for degree of cleanliness and removal
of calcium hydroxide
Score Criteria
1 80%-100% of removal of calcium hydroxide – total
cleanliness
2 60%-80% of removal of calcium hydroxide – great
cleanliness
3 40%-60% of removal of calcium hydroxide – partial
cleanliness
4 20%-40% of removal of calcium hydroxide – light
cleanliness
5 0%-20% of removal of calcium hydroxide – no
cleanliness
for 5 seconds. Particularly for group G5, the final
irrigation procedure consisted of 15 mL of irrigation of
17% EDTA-T, as in other groups. Afterward, a new
instrumentation using the MAF and 0.5% sodium hy-
pochlorite ⫹ Endo-PTC was made. To complete this
procedure, another 15 mL of 17% EDTA-T was used
also with the same method of the other groups.
All roots were split in the bucco-lingual direction and
the sections were dehydrated by a series of graded
ethanol solutions and then coated with a gold layer after
drying. The selected dentinal surfaces of cervical, mid-
dle, and apical thirds (9, 6, and 3 mm from the apex,
respectively), equidistant from lateral walls, were ob-
served by SEM (XL30, Philips, the Netherlands) at
⫻1000 magnification. Five calibrated examiners ana-
lyzed, independently and in a blind manner, the re-
moval of calcium hydroxide and cleanliness of dentinal
walls using a 5-grade scale (Table II). The standards for
best and worst results of cleanliness were positive and
negative groups, respectively. Statistical analysis was
performed using Kruskal-Wallis at 5% level of signif-
icance.
RESULTS
The scores and medians of calcium hydroxide re-
moval are shown in Table III, as well as statistical
comparisons between thirds of the same group and
between groups. Group G5 had the best results, with
statistically significant differences compared to all
other groups in middle and coronal thirds, and to G1
also in the apical third according to the Kruskal-Wallis
test (P ⬍ .05). On the other hand, G1, flushed only with
NaOCl, had the worst results, with statistical differ-
ences in all thirds compared to the other groups. Fig. 1
presents the image comparison of all groups in the
different thirds. Comparing the thirds of the same
groups, statistical differences were present only in G5,
between the coronal third and the other thirds.
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582 Salgado et al. April 2009

Table III. Removal of Ca(OH)2 medication scores and median

Kruskal-Wallis statistical analysis (P ⬍ .05)*
Scores 1 2 3 4 5 Median vs thirds Apical Middle Coronal
Group 1
Apical — — — 8 17 5.0 n.s. a a a
Middle — 1 4 9 11 4.0
Coronal — 2 5 8 10 4.0
Group 2
Apical 1 10 11 3 — 3.0 n.s. b b b
Middle 2 7 10 5 1 3.0
Coronal 7 11 5 2 — 2.0
Group 3
Apical 4 11 8 2 — 2.0 n.s. b b b
Middle 2 9 12 2 — 2.0
Coronal 3 13 8 1 — 2.0
Group 4
Apical 5 13 6 1 — 2.0 n.s. b b b
Middle 4 12 9 — — 2.0
Coronal 7 13 5 — — 2.0
Group 5
Apical 12 8 4 1 — 2.0 a b c c
Middle 17 8 — — — 1.0 a
Coronal 21 4 — — — 1.0 b
n.s., not significant.
*Statistical comparison between thirds of the same group and between groups. Different letters denote significant differences.

Fig. 1. SEM images comparing all groups in different thirds (a ⫽ apical, m ⫽ middle, c ⫽ coronal).

DISCUSSION promoting formation of calcium carbonate particles and

In endodontics, the use of chemical substances and
files in root canal treatment is extremely important to
promote disinfection and cleanliness of dentine walls,
removing the smear layer attached to them.24
The use of calcium hydroxide paste as an intracanal
medication between sessions, due to its excellent anti-
microbial efficacy, can reduce canal permeability by
interfering with the sealing ability of endodontic ce-
ment.10 Consequently, several studies tried to achieve
the best protocol to remove all calcium hydroxide med-
ication before root canal filling.
Sodium hypochlorite is primarily used as an end-
odontic irrigant, in different concentrations, with great
results in disinfecting root canals.24-33 However, the
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Volume 107, Number 4
efficacy of this irrigant could be improved by associat-
ing it with a peroxide-based lubricant, such as Gly-
Oxide, RC-PREP, and Endo-PTC, causing less friction,
suspending debris for an easier removal and improving
wall permeability.25 This study showed the worst re-
sults of calcium hydroxide removal in the NaOCl
group, with significant differences compared to all
other groups in all thirds. Similar results were found by
Kenee et al.34 Citric acid and EDTA, with or without
detergent associated, are also used for cleaning root
canal walls and removing the smear layer, due to its
efficacy over calcium ions.33 The present study showed
the best results on G4 and G5, the groups who used
EDTA-T, a combination of a chelant agent and a 0.2%
lauryl sodium sulfate biologic detergent, which appar-
ently improved its efficacy eliminating calcium ions
and wall debris. However, it is also essential to clean
the canal walls using the last apical file from instru-
mentation, with NaOCl and lubricants, before the final
flush, to improve the removal of Ca(OH)2 medication.
Group 5, which used this protocol, achieved better
results than the other groups, which flushed only the
irrigant, with significant differences in almost all com-
parisons. Ultrasonic devices as shown by Nandini et
al.35 and van der Sluis et al.36 can improve cleanliness.
Comparing the thirds in each group, the results on the
apical third were typically worse than the other thirds,
proving the difficulty of cleaning this region. However,
G5 achieved satisfactory results in this region. Conse-
quently, cleaning the apical third can be augmented by
using a file.
Based on the results, the best cleanliness was
achieved in the G4 and G5 groups. The recapitulation
of MAF in combination with irrigants removed more
calcium hydroxide medication, than an irrigant flush
alone.
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Reprint requests:
Cacio Moura-Netto, DDS, MSc
R. Apeninos, 930, cj 141
São Paulo/SP – Brazil 04104-903
caciomn@usp.br