doi:10.1111/j.1365-2591.2009.01655.
The effect of irrigation time, root morphology and
dentine thickness on tooth surface strain when
using 5% sodium hypochlorite and 17% EDTA
O. E. Sobhani1, K. Gulabivala1, J. C. Knowles2 & Y.-L. Ng
1
Unit of Endodontology, Divisions of Restorative Dental Sciences; and 2Biomaterials and Tissue-Engineering, UCL Eastman Dental
Institute, University College London, London, UK
Abstract
Sobhani OE, Gulabivala K, Knowles JC, Ng Y-L. The
effect of irrigation time, root morphology and dentine thickness
on tooth surface strain when using 5% sodium hypochlorite
and 17% EDTA. International Endodontic Journal, 43, 190–199,
2010.
Aim To evaluate the effect of irrigation with 5%
sodium hypochlorite (NaOCl) alone and in conjunction
with 17% ethylenediaminetetraacetic acid (EDTA) on
tooth surface strain (TSS) and to analyse the influence
of irrigation time, root morphology and dentine
thickness.
Methodology Thirty-six single-rooted pre-molars
with single canals had their crown and enamel reduced
and root canals prepared using a standardized protocol.
Teeth were grouped according to anatomical criteria
and randomly distributed to experimental irrigation
groups: (A) saline (negative control); (B) 5% NaOCl
(positive control); (C) 5% NaOCl alternated with 17%
EDTA. TSS was measured using electrical strain gauges
bonded to the cervico-proximal part of the tooth. Teeth,
mounted in clear acrylic resin placed in a universal
testing machine, were subjected to nine consecutive
10-min irrigation periods followed by non-destructive
occlusal loading to record TSS. Statistical analysis was
Introduction
Sodium hypochlorite (NaOCl) and ethylenediaminetet-
raacetic acid (EDTA) are widely used during root canal
Correspondence: Kishor Gulabivala, Professor and Head of
Endodontology, UCL Eastman Dental Institute, 256 Gray’s Inn
Road, London WC1X 8LD, UK (Tel.: +020 7915 1033; fax:
+020 7915 2371; e-mail: k.gulabivala@eastman.ucl.ac.uk).
190 International Endodontic Journal, 43, 190–199, 2010
carried out using two-way hierarchical anova and
post hoc multiple comparisons.
Results Two groups showed an increase in TSS from
the baseline (initial 10-min irrigation with saline).
Group A showed a negligible reduction of 1.2%
(343–339 le), which was not statistically significant
(P = 0.7). Group B showed a highly significant
(P = 0.001) increase in TSS by 53.7% (178–253 le),
and group C showed a significant (P = 0.02) increase
in TSS by 17.4% (163–192 le). The rate of change in
TSS was significantly different between test groups.
The length of the tooth (P = 0.04) as well as the
mesio-distal (P = 0.05) width had significant effects on
TSS.
Conclusions Irrigation with 5% with or without
17% EDTA increased TSS. The increase was signifi-
cantly greater with 5% NaOCl alone than with 5%
NaOCl alternated with 17% EDTA in contrast to
previous findings with longer duration of irrigant
exposure. Tooth length and mesio-distal root width
significantly contributed to the increase in TSS.
Keywords: EDTA, irrigation, NaOCl, tooth surface
strain.
Received 30 June 2009; accepted 27 October 2009
treatment for established and good biological reasons
(Byström & Sundqvist 1985). However, their potential
influence on the mechanical properties of teeth and
dentine has become apparent (Yamada et al. 1983,
Dogan & Calt 2001, Grigoratos et al. 2001, Sim et al.
2001, Calt & Serper 2002, Rajasingham et al. 2010).
The effect of such chemical agents has been inves-
tigated on a range of mechanical properties of dentine.
One of the outcome measures adopted in some studies
ª 2010 International Endodontic Journal

is tooth surface strain (TSS) measured at the cervical
level of the tooth, using electrical strain gauges, during
cyclic loading of the irrigated teeth (Sim et al. 2001,
Goldsmith et al. 2002, Rajasingham et al. 2010).
Irrigation with 5% NaOCl had yielded contrasting
results in two previous reports (Sim et al. 2001,
Goldsmith et al. 2002), the latter of which had consid-
erable variation in their data. Rajasingham et al.
(2010) confirmed the findings of Sim et al. (2001) that
consistent strain patterns may only be revealed with
precise attention to detail in the experimental set-up.
The key steps included aligning of the strain gauges to
the long axis of the tooth, flattening of the occlusal
surface of the tooth to allow true and consistent
perpendicular loading and mounting of the tooth in a
resin with minimal dimensional change. Rajasingham
et al. (2010) also found that all the teeth irrigated with
5% NaOCl had an increase in peak strain values
followed in the majority by a plateauing of strain
increase. Furthermore, alternate irrigation with 5%
NaOCl and 17% EDTA resulted in a significant increase
in TSS compared to the saline control as well as the 5%
NaOCl group (after the fourth 30-min irrigation cycle).
In addition, as hypothesized, the plateauing of strain
increase evident with the sole use of NaOCl, was
eliminated, supporting the view that alternate irriga-
tion (5% NaOCl and 17% EDTA) probably allowed
cyclic depletion of organic (O’Driscoll et al. 2002) and
inorganic material (Sayin et al. 2007), with a greater
cumulative effect on TSS.
The clinical inference was that root-treated teeth,
already compromised by loss of tooth structure,
particularly with breaks in the continuity of the band
of circumferential enamel, could be further weakened
by 5% NaOCl irrigation acting alone but particularly
when alternated with 17% EDTA. The increase in
strain, although significant, does not directly infer
increased risk of tooth fracture. It could however be
hypothesized that since such irrigation patterns might
produce surface flaws in dentine (Calt & Serper 2002),
cyclic loading under normal stresses of mastication
may allow crack growth through fatigue to cata-
strophic proportions (Kinney et al. 2003, Kishen
2006).
The negligible changes in strain from baseline values
for all teeth irrigated with 17% EDTA alone might
imply that its effect on the inorganic component of
dentine is restricted. Alternate irrigation with 3%
NaOCl and 17% EDTA produced small, statistically
insignificant but noticeable increases in strain values,
which were similar in trend to those found for the
ª 2010 International Endodontic Journal
Sobhani et al. Effect of irrigants on tooth strain
5% NaOCl regimen (Rajasingham et al. 2010). The
duration, concentration and irrigant combination
appear to be critical as shown in other in vitro work
(Marending et al. 2007).
All of the TSS studies (Sim et al. 2001, Goldsmith
et al. 2002, Rajasingham et al. 2010) have found wide
variations in TSS within and between control and test
groups, which seemed to be attributable to anatomical
variations in teeth. However, the crude radiographic
measures of ‘dentine thickness’ at the cemento-enamel
junction and ‘canal morphology type’ proved not to
have any significant associations with changes in TSS
after exposure to NaOCl or EDTA solutions (Rajasing-
ham et al. 2010). The effect of other parameters of
tooth anatomy should therefore be explored further.
The present study aimed to measure TSS using an
established experimental model to investigate the effect
of irrigation using 5% NaOCl alone and in conjunction
with 17% EDTA for specified short periods of time
(10 min), whilst accounting for root anatomy and
thickness of residual dentine in a more comprehensive
manner than previously determined.
Materials and methods
Preparation of teeth and allocation to experimental
groups and anatomical subgroups
Human extracted teeth were obtained with consent
from patients undergoing routine extractions for
orthodontic or restorative reasons. One hundred and
ten extracted, single-rooted pre-molars were collected
and stored separately in numbered glass jars contain-
ing 10 mL of 4% formal saline (BDH Laboratory
Supplies, Poole, UK) immediately following extraction.
The teeth were radiographed in a standard manner
from mesio-distal and bucco-lingual directions and
used to select 36 non-carious intact teeth with one
main root canal. The surfaces of the teeth were
cleaned with a sharp scalpel and a line drawn 4 mm
coronal to the cemento-enamel junction to guide
reduction of the crown using a rotary grinder (Struers
Knuth Rotor-3, Solihull, UK), leaving a flattened
surface perpendicular to the long axis of the tooth.
The remaining enamel was removed in its entirety
with a diamond bur.
The root canals were prepared to an apical size 30
with a 0.06-taper in a standard manner using Profile
nickel-titanium endodontic instruments (Dentsply Ma-
illefer, Ballaigues, Switzerland) and saline irrigation to
the apical foramen. Canals larger than this dimension
International Endodontic Journal, 43, 190–199, 2010 191
 Effect of irrigants on tooth strain Sobhani et al.

before preparation were not enlarged further. Follow-
ing preparation, each tooth was radiographed again, in
two planes perpendicular to each other comparable to
the previous views.
Digital calipers (Mitutoyo Ltd, Andover, UK) were
used to measure the thickness of dentine, from the rim
of the access cavity to the periphery of the crown
(buccal, lingual, mesial, distal). The dimensions quan-
tified included the tooth length (from flattened surface
to root tip – L1), the average thickness of dentine in
bucco-lingual (L2) and mesio-distal (L3) dimensions at
the flattened coronal surface, and the bucco-lingual
(L4) and mesio-distal (L5) width of the root at the acrylic
level (Fig. 1). The cross-section of the root was also
assessed and designated either ‘Circular I’ (oval shape)
or ‘Circular II’ (circular shape). Another line was
drawn around the tooth, 6 mm apical to the flattened
occlusal surface, equivalent to 2 mm below the cemen-
to-enamel junction, the level to which the roots were
embedded in acrylic resin. The teeth were kept
hydrated at all times and after preparation returned
to their storage jar.

M
Access cavity

L3

B L2 L

Prepared
D

Acrylic level

L1
Acrylic
L4
L5

L1. Length of the tooth from the

flattened surface to the apex

L2. Average distance from rim of

the access cavity to the periphery in
the bucco-lingual direction.

L3. Average distance from the rim

of the access cavity to the periphery
in mesio-distal direction.

L4. The diameter of root

in bucco-lingual direction at the
B. Buccal acrylic level.
M. Mesial
L. Lingual L5. The diameter of root
D. Distal in mesio-distal direction

Figure 1 A diagrammatic representation of a tooth set in acrylic and its measurements.

192 International Endodontic Journal, 43, 190–199, 2010 ª 2010 International Endodontic Journal
 Sobhani et al. Effect of irrigants on tooth strain

Table 1 Distribution of canal anatomical groups, cross-sectional shape of access openings and measurements of various
anatomical features of teeth by experimental groups
Group A Group B Group C

5% NaOCl 5% NaOCl &

Saline alone alone 17% EDTA

Irrigation regime Number Number Number

Canal anatomical groups

Closed mature apex (n = 12) 4 4 4
Open apexa with 2 canal exits (n = 9) 3 3 3
Open apexa with non-parallel root canal walls (n = 6) 2 2 2
Open apexa with parallel root canal walls (n = 9) 3 3 3
Cross-sectional shape of access opening
Circular 6 4 6
Oval 6 8 6
Mean (95% confidence interval)

Dimensions of teeth measured

Length of the tooth (mm) 18.3 (17.9, 18.7) 18.7 (18.3, 19.2) 17.7 (17.4, 18.1)
Dentine thickness in bucco-lingual direction at the 2.9 (2.8, 3.0) 3.1 (2.9, 3.3) 3.0 (2.9, 3.2)
flattened coronal surface (mm)
Dentine thickness in mesio-distal direction at the 1.8 (1.7, 1.9) 2.0 (1.9, 2.1) 1.7 (1.6, 1.8)
flattened coronal surface (mm)
Root width in bucco-lingual direction at the acrylic level (mm) 7.1 (6.9, 7.3) 7.4 (7.3, 7.5) 7.1 (7.0, 7.2)
Root width in mesio-distal direction at the acrylic level (mm) 4.5 (4.4, 4.6) 5.2 (5.0, 5.4) 4.3 (4.2, 4.4)
a
Teeth with canal terminus wider than 1 mm in diameter were classified as those with open apex.
NaOCl, sodium hypochlorite.

The teeth were divided into four anatomical groups

(Table 1), based on radiographic appearance, develop-
mental stage of root apex and morphology of root canal
at the cervical and apical regions. Teeth from each
anatomical group were randomly allocated to three
experimental irrigation groups (A, B or C; each with 12
teeth) to achieve a degree of anatomical resemblance
between the groups. The irrigation groups were as
follows: A – physiologic saline (Baxter Healthcare Ltd.,
Thetford, UK); B – 5% NaOCl – verified by iodometric
Figure 2 Tooth mounted in clear resin with central position
titration (BDH Laboratory Supplies); and C – 5%
and vertical alignment.
NaOCl/17% EDTA (BDH Laboratory Supplies).

Mounting of teeth Bonding of strain gauges

The teeth were mounted in clear acrylic resin (Specifix-
20, Struers Epoxy resins; Struers A/S, Solihull, UK) in
moulds of 2.5 cm high, ensuring that each tooth was
centrally positioned with the long axis of the tooth
aligned parallel to the sides of the mould (Fig. 2). The
resin was allowed to set for 24 h at room temperature
and humidity, when the mould was dismantled and the
acrylic trimmed so that its base was perpendicular to
the long axis and parallel to the flattened occlusal
surface of the tooth. The mounted teeth were main-
tained hydrated throughout.
Constantan strain gauges (Measurements Group UK
Ltd, Basingstoke, UK) with short attached copper leads,
a resistance of 120 X (type EA-06-062AP-120, option
LE) and gauge factor of 2.05, were used. The polyimide
backing of the gauge was trimmed to a 1-mm border
around the gauge to enable positioning on the tooth.
The gauges were carefully bonded to the cervico-
proximal surface of the tooth so that the top edge of the
backing was approximately 1 mm below the flattened
occlusal surface and vertically aligned along the long
axis of the tooth, using a thin layer of cyanoacrylate

ª 2010 International Endodontic Journal International Endodontic Journal, 43, 190–199, 2010 193
 Effect of irrigants on tooth strain Sobhani et al.

adhesive (M-Bond 200 Adhesive; Measurements Group
UK Ltd). A dummy gauge was bonded to another tooth
and subjected to identical environmental conditions but
without loading, to account for heat generation during
the experiment (Dally & Riley 1991). The teeth were
wrapped in damp gauze within a sealed polythene bag
until testing. Shortly before testing, a length of shielded
twin cable (RS Components Ltd, Corby, UK) was
soldered to the copper leads on a vero board, and
absence of component burnt-out was verified.
Preparation of teeth for loading
The acrylic block containing the test tooth was secured
in a brass receptacle within a Universal loading
machine (Instron Ltd, High Wycombe, UK) with a
1.0-kN load cell in the upper member. A 5.0-mm ball-
bearing fixed to the end of the loading arm and
attached to the load cell was used to deliver the load.
The position of the brass receptacle was adjusted to
locate the loading arm over the centre of the access
preparation and remained in this position during the
entire test procedure. The cross-head was lowered to
create operative room for irrigation procedures.
Irrigation procedures
Teeth in each group received standardized irrigation
regimes (Table 2). The coronal portion of the tooth was
isolated with rubber dam to protect the strain gauges
and wires from the irrigant. The irrigation cycle began
with 0.60 mL of irrigant delivered to within 4.0 mm of
the working length over 20 s, followed by agitation
with a size 25 Flexo-file (Dentsply Maillefer), extend-
ing to the working length for 100 s. This was repeated
five times to give a total of 3.0 mL of irrigant delivered
over 10 min, followed by 1.2 mL of saline to wash-out
the test solution. The canal irrigant was removed using
a portable suction unit and paper points. The rubber
dam was then removed, and the tooth was subjected to
the loading cycle described later. The above irrigation
cycle was repeated nine times in both the experimental
and control groups.
Calibration of the strain gauge circuit
On completion of the irrigation procedure, the bridge
circuit was balanced to a baseline value and output
logging commenced; after 15–20 s, the calibration
resistor was switched into the circuit for a further
period of 20 s, and the transducer adjusted to record a
second baseline value. After a further 20 s, the loading
procedure was commenced. The time periods were
chosen to enable adequate sampling.
Testing of teeth
Each loading period consisted of three stages: (1)
loading from 0 N to 20 N (the pre-load); (2) five cycles
of loading from 20 N up to 110 N and unloading down
to 20 N at a cross-head speed of 0.1 mm s)1; (3)
unloading from 20 N to 0 N. The preload was set at the
start of each loading period by programming the test
machine; the remainder of the loading regime was
controlled by the Instron Series XII software (Instron
Ltd) programmed with the appropriate parameters.
Stage 2 of the load testing was completed within
2–3 min. At the end of the loading period, the recorded
data were saved to a data file. The irrigation and
loading procedures were repeated nine times and
completed in one sitting for each tooth.

Strain value analysis

Table 2 The experimental groups and the irrigation sequence
The data files were converted to Microsoft Excel files
Group A Group B Group C (Microsoft Corporation, Redmond, WA, USA); a typical
Irrigation
periods Irrigation Irrigation Irrigation graphical output is shown in Fig. 3. Shunting the
(min) regime regime regime calibration resistor into the circuit produced a simu-
10 Saline Saline Saline lated strain, which could be calculated from the
20 Saline 5% NaOCl 5% NaOCl resistances of the calibration resistor and the bridge
30 Saline 5% NaOCl 17% EDTA completion resistors in the circuit. The subsequent peak
40 Saline 5% NaOCl 5% NaOCl
output voltage from the strain gauge on loading the
50 Saline 5% NaOCl 17% EDTA
60 Saline 5% NaOCl 5% NaOCl tooth could be directly compared to the calibration
70 Saline 5% NaOCl 17% EDTA output voltage; knowing the value of strain corre-
80 Saline 5% NaOCl 5% NaOCl sponding to the calibration output, the value of the
90 Saline Saline Saline peak strain could be deduced from a simple ratio. The
NaOCl, sodium hypochlorite. peak strain corresponding to each peak output voltage

194 International Endodontic Journal, 43, 190–199, 2010 ª 2010 International Endodontic Journal

Period of
calibration,
(Vc)
5
4 Series1
3
2
1
Output
0
voltage
–1
–2
–3
–4
–5
Period when circuit was balanced,
Figure 3 A typical graph obtained
(Vb)
from the data.
(and loading cycle) was deciphered and a mean of the
five peak strain values obtained.
Statistical analysis
The effects of irrigant, duration of irrigation and
various anatomical parameters on TSS were analysed
using linear regression with cluster sandwich estima-
tion for robust standard error to account for the
clustering effect of repeated measurement obtained
from the same tooth (STATA 9 2005; STATA Corpo-
ration: College Station, TX, USA). The five anatomical
parameters investigated in the regression model in-
cluded the tooth length (from flattened surface to root
tip – L1), the average thickness of dentine in the bucco-
lingual (L2) and mesio-distal (L3) dimensions at the
flattened coronal surface, and the bucco-lingual (L4)
and mesio-distal (L5) width of the root at the acrylic
level.
Results
Observational analysis
Control group A (saline)
There was a wide variation in the baseline TSS values
(range 102–691 le) with a mean value of 342.93
(95% CI: 227.84, 458.02) le. There was little change
in these values following each irrigation period (IP). At
IP 90, the mean TSS was 338.88 (95% CI: 222.36,
455.39) le, reflecting a percentage reduction of 1.2%.
Two teeth behaved differently compared to others;
tooth 3 showed a slight decrease in TSS between the
ª 2010 International Endodontic Journal
Sobhani et al. Effect of irrigants on tooth strain
Peak voltages corresponding to
each loading cycle, (Pv1-5)
0 500 1000 1500 2000 2500 3000
Time
Pre-load peak
first and second IP; tooth 5 showed an increase in TSS
after the second IP followed by a decrease from third to
fourth IPs.
Experimental group B (5% NaOCl)
Teeth in this group were irrigated with saline at the IP
10 and 90, and with 5% NaOCl at IP 20–80. Consistent
with other groups, there were variations in baseline
TSS values, which ranged from 12 to 485 le, with a
mean value of 165.00 (95% CI: 86.14, 243.87) le. All
teeth showed an increase in TSS from their baseline
values after irrigation. At IP 90 [with the mean TSS of
253.61 (95% CI: 144.91, 362.31) le], there was a
53.7% increase compared to IP 10. Teeth 26, 27, 29,
31, 33, 34 and 36 all exhibited notable increases in
TSS between sixth and the seventh periods of irrigation.
The increase in TSS from IP 10 to IP 60 was 24.4%
[165.00 (95% CI: 86.14, 243.87) le to 205.34 (95%
CI: 110.66, 300.02) le], which increased to 46.6% at
IP 70 [241.86 (95% CI: 135.45, 348.26) le].
Experimental group C (5% NaOCl & 17% EDTA)
Teeth in this group were irrigated with saline at IP 10
and 90, with alternate irrigation of 5% NaOCl and 17%
EDTA from IP 20 to 70. As in the saline (control)
group, there was wide variation in the baseline TSS
values (range 35–631 le) with a mean value of
163.47 (95% CI: 58.94, 268.01) le. The TSS value
at IP 90 was 191.84 (89.01, 294.67) le, an increase of
17.4% from the baseline. However, substantial changes
had already taken place after the second IP with an
increase of 16.6% in TSS between the first and the
second IP [163.47 (95% CI: 58.94, 268.01] le to
International Endodontic Journal, 43, 190–199, 2010 195
 Effect of irrigants on tooth strain Sobhani et al.

Table 3 Mean and 95% confidence intervals of peak surface was significantly higher than those in group B (NaOCl
strain (le) over time by irrigation group alone) (P = 0.01) and group C (NaOCl, EDTA)
95% 95% (P = 0.04). The significant interaction between IP
Mean confidence confidence and test group suggests that the rate of change in
peak interval interval TSS between test groups was significantly different. For
Period surface (upper (lower
the saline group (group A), there was a 0.02 ()0.09,
Group (min) strain (le) bound) bound)
0.13) le min)1 reduction in TSS, but the reduction
A 10 342.93 227.84 458.02
was not statistically significant (P = 0.7). Whereas, for
A 20 334.07 220.71 447.42
A 30 340.13 228.94 451.33
the teeth in group B (NaOCl alone) and group C
A 40 337.48 222.70 452.26 (NaOCl/EDTA), TSS increased significantly over time at
A 50 339.55 223.96 455.35 a rate of 1.12 (95% CI: 0.58, 1.66) le min)1
A 60 336.10 221.47 450.74 (P = 0.001) and 0.24 (95% CI: 0.05, 0.43) le min)1
A 70 336.68 221.81 451.55
(P = 0.02), respectively. The rates of change in both
A 80 338.71 221.85 455.58
A 90 338.88 222.36 455.39
group B (P < 0.001) and group C (P = 0.01) were
B 10 165.00 86.14 243.87 significantly higher than that in group A. The rate of
B 20 178.86 96.67 261.05 change in group B was in turn significantly
B 30 186.37 95.30 277.43 (P = 0.001) higher than in group C.
B 40 202.27 104.44 300.11
Adding the parameters that characterized anatomi-
B 50 198.12 103.44 292.80
B 60 205.34 110.66 300.02
cal variation as covariates in the model, the length of
B 70 241.86 135.45 348.26 the tooth (L1) (P = 0.04) was found to have a
B 80 246.51 139.76 353.26 significant influence on the TSS which reduced by
B 90 253.61 144.91 362.31 14.79 (95% CI: 0.58, 29.00) le with every 1-mm
C 10 163.47 58.94 268.01
increase in tooth length. In addition, the TSS was also
C 20 190.65 83.60 297.72
C 30 168.74 55.07 282.41
significantly (P = 0.05) reduced by 60.40 (95% CI:
C 40 182.95 80.59 285.31 )0.99, 121.79) le with every 1-mm increase in the
C 50 179.18 68.15 290.22 width of the root in the mesio-distal dimension at the
C 60 185.14 79.54 290.94 acrylic level (L5). There was no significant influence
C 70 185.78 80.88 290.68
from any other anatomical parameter: cross-sectional
C 80 188.61 84.72 292.49
C 90 191.84 89.01 294.67
shape of access cavity (P = 0.6); canal morphology
(P = 0.4), thickness of dentine in the bucco-lingual
(L2) (P = 0.5) and mesio-distal (L3) (P = 1.0) dimen-
190.65 (95% CI: 83.60, 297.72) le], after which the sions at coronal surface level and the width of the root
values tended to shift up or down in some teeth, but in the bucco-lingual dimension at the acrylic level (L4)
this pattern was not regular for a particular irrigant. (P = 0.8).
The means of all TSS values for each IP are presented
in Table 3, and the mean changes in TSS are plotted for
Discussion
each group in Fig. 4.
This was the fourth in a series of studies investigating
TSS associated with root canal irrigation, and as such
Statistical analysis
the methodology was well established, and the selected
Linear regression analysis was performed using TSS as research questions were designed to build on previous
the dependent variable (Table 4). To check the assump- data. The key questions under investigation were the
tion of the linear regression, a graph of the residuals influence of irrigation time, dentine thickness and root
revealed an approximately normal distribution of TSS. morphology on TSS. The findings provided further
Furthermore, the residuals plotted against the predicted insights into the nature of influence of NaOCl and
strain values of the model showed a random scatter of EDTA on the strain characteristics of dentine and teeth,
points suggesting that there was homogeneity the enamel having been removed.
of variance. The analysis showed a significant A single gauge was precisely aligned to measure the
(P = 0.03) difference between the test groups as well principal compressive component as per previous
as a significant (P < 0.001) interaction between IP and studies (Goldsmith et al. 2002, Rajasingham et al.
test group (Table 4). TSS for teeth in group A (saline) 2010) by ensuring that the proximal wall was

196 International Endodontic Journal, 43, 190–199, 2010 ª 2010 International Endodontic Journal
 Sobhani et al. Effect of irrigants on tooth strain

120

100

)
Changes in peak surface strain (
NaOCl
80

60

40
NaOCl / EDTA

20

Saline
0
20 30 40 50 60 70 80 90

–20

–40
Duration of irrigation (min)

Figure 4 Mean and 95% confidence interval of changes in peak surface strain [microstrains (le)] over time by irrigation group.

Table 4 Final linear regression model presenting the effects of test group, duration of irrigation and their interaction as well as the
two significant anatomical factors on the average tooth surface strain
Factor Coefficient 95% CI for coefficient P-value

Test group 0.02*

Group A (saline) 0 – –
Group B (NaOCl alone) )169.31 )327.42, )11.19 0.04
Group C (NaOCl/EDTA) )186.45 )324.92, )47.99 0.01
Irrigation period 0.45 0.27, 0.62 <0.001
Test group & irrigation period <0.001*
Group A (saline) 0 – –
Group B (NaOCl alone) 0.26 0.06, 0.45 0.01
Group C (NaOCl/EDTA) 1.14 0.64, 1.63 <0.001
Group C versus Group B 0.88 0.37, 1.39 0.001
Tooth length (L1) )14.79 )29.00, )0.58 0.04
Mesio-distal width of root at acrylic level (L5) )60.40 )121.79, 0.99 0.05

NaOCl, sodium hypochlorite.

*P-value of test for heterogeneity for categorical factor.

appropriately flattened to accommodate the strain
gauge during enamel removal. The intimacy of
bonding of the strain gauges together with variations
in the remaining dentine structure may potentially
affect baseline values.
The alternate irrigation regimen with 5% NaOCl
and 17% EDTA, which had shown a significant effect
when used in 30-min cycles for 150 min (Rajasing-
ham et al. 2010), was selected for test again but this
time at the greater frequency of 10-min alternation
for a total duration of 90 min. As 3% NaOCl was
found to have no significant effect on the TSS in
previous studies (Sim et al. 2001, Rajasingham et al.
2010), only the 5% NaOCl solution was tested in the
present study. Whilst previous studies (Sim et al.
2001, Rajasingham et al. 2010) had found the TSS
values to reach a plateau after 60 min of irrigation
with 5% NaOCl, the shorter irrigation cycles only
allowed the plateau to be reached after 90 min in a
pilot study (Sobhani 2002).
Heat generation is a confounding factor in strain
measurement, so Sim et al. (2001) used intermittent
excitation voltage to limit heat generation, whilst this
study used a constant excitation voltage but accounted
for heat generation using a ‘dummy’ gauge (Dally &
Riley 1991), as in previous studies (Goldsmith et al.
2002, Rajasingham et al. 2010). The loading and
unloading cycles were previously validated (Sim et al.
2001, Goldsmith et al. 2002, Rajasingham et al.
2010), with the mean of five peak strain gauge outputs
taken to represent the test condition. The TSS values in
this study were similar in magnitude to those found by
Sim et al. (2001), but lower than those found by others
(Meredith 1992, Goldsmith et al. 2002, Rajasingham

ª 2010 International Endodontic Journal International Endodontic Journal, 43, 190–199, 2010 197
 Effect of irrigants on tooth strain Sobhani et al.
et al. 2010). This difference could be because of any
one or a combination of minor differences in method-
ology. The wide variation in baseline TSS values across
all experimental groups could be accounted for by the
position of the loading arm on the occlusal surface of
the tooth. Small changes in the position of the loading
arm on the occlusal surface could influence the
magnitude of the baseline strain dramatically. The
adopted practice of fixing the tooth position precisely
and firmly in the Universal testing machine throughout
the test period was therefore crucial in allowing
comparison between stages and for each tooth to act
as its own control.
The wide variation in TSS baseline values (Sim et al.
2001, Goldsmith et al. 2002, Rajasingham et al. 2010)
might have been caused by anatomical variations;
moreover, dentine thickness could interact with the
influence of irrigant on TSS. The latter study, utilizing
the average of bucco-lingual and mesio-distal dentine
thicknesses at the cervical level and canal morphology
(judged radiographically) as outcome measures, could
not detect any effect of anatomy on TSS. However, this
absence of effect could conceivably have been as a
result of the relative crudeness of anatomical represen-
tation. Hence, the present study sought to investigate
the influence of more accurately defined and measured
parameters.
Quantification of dentine thickness at the coronal
and cervical levels revealed that coronal dentine
thickness might contribute to this initial variation, as
higher TSS values were exhibited by teeth with the
thinnest dentine walls. Overall however, it was found
that of all the anatomical parameters, tooth length and
mesio-distal dimension had the most significant impact
on TSS. Given the rigidity of tooth fixation, it is unlikely
that mechanical tooth deformation along the entire
length of the root could account for these observations.
Further studies have been designed to investigate
whether the presence of simulated periodontal ligament
in the test model would have a significant impact on
the TSS. The significant finding of 60 le reduction in
TSS with every 1-mm increase in the mesio-distal width
of the root at the acrylic level is expected given that the
strain gauges were attached to the mesial proximal
surfaces.
Teeth in the saline group showed minimal change in
TSS throughout the experimental period as found in
other studies (Sim et al. 2001, Rajasingham et al.
2010).
All 12 teeth in the NaOCl group showed a significant
(P < 0.001) increase in peak strain values of 54% from
198 International Endodontic Journal, 43, 190–199, 2010
the baseline, supporting earlier findings (Sim et al.
2001, Rajasingham et al. 2010) but contradicting the
findings of Goldsmith et al. (2002). The former two
investigators in agreement found that the strain
increase reduced after 60-min of irrigation. During
the 90-min IP used in this study, teeth were exposed to
5% NaOCl for 70 min (the first and last irrigation cycles
used saline) with sampling at every 10 min. It was
found that after 60 min there was 24% increase in TSS,
increasing to 47% at 70 min.
Ethylenediaminetetraacetic acid alone has been
found to have a negligible effect on TSS (Rajasingham
et al. 2010). Alternate irrigation with EDTA and NaOCl
has been recommended as the most effective way to
adequately clean the root canal system (Yamada et al.
1983, Baumgartner & Mader 1987). The current
investigation found alternate irrigation with 5% NaOCl
and 17% EDTA to increase TSS by an average of
17.4%, confirming the trend found by Rajasingham
et al. (2010), although the magnitude of increase in
TSS was substantially higher (48%) in the latter study.
In contrast to their study, however, alternate irrigation
with these agents had a lesser effect than NaOCl alone.
The inference is that alternation of irrigant agents
with greater frequency reduces the overall effect of the
agents on TSS. It is speculated that this is the result of
reduced overall contact with unreacted active ions,
based on three observations. The first is that the
increased frequency of alternation extended the time
required to reach a plateau when using NaOCl alone. In
the present study, there was no evidence of a plateau
being reached even after extending the irrigation time
from 60 to 90 min. The second is that the length of
root, which was the most important anatomical factor
influencing TSS, might be a surrogate measure of canal
surface area, which in turn might represent the
buffering capacity of the root canal system and dentine
(Haapasalo et al. 2007). Therefore, the longer the root,
the more rapidly is the reservoir of unreacted ions likely
to become depleted. It may be thought that the
increased frequency of replenishment might have
countered this effect, except for the fact that irrigant
replacement is a significant challenge in a viscously
dominated system such as the root canal and mixing
requires an active effort (Huang et al. 2008, Gulabivala
et al. 2009, unpublished data). Although 1.2 mL of
saline wash was used after each cycle of irrigation,
unless performed with active vigour rather than static
injection, it is unlikely to have replaced the resident
spent irrigant completely. Therefore, the process of
alternation between NaOCl and EDTA is likely to bring
ª 2010 International Endodontic Journal

about the third phenomenon, which is of chemical
neutralization as the two solutions react with each
other (Grawehr et al. 2003, Grande et al. 2006). It is
likely that EDTA would retain its potency, whilst the
activity of NaOCl might be reduced. It has been
speculated that the depletion of mineral content would
progressively expose the organic matrix, which may
confer protection on the dentine, whilst the presence of
unreacted ionic components of NaOCl would enable
further dentinal erosion to take place (Niu et al. 2002,
Grande et al. 2006).
In the clinical situation, more frequent alternation
between NaOCl and EDTA might have the effect of
reducing the structural damage to the dentine; whether
it reduces the potency of NaOCl in its effect on the
bacterial biofilm remains to be determined.
Conclusions
Within the limitations of this study, the increase in TSS
after irrigation with 5% NaOCl was highly significant
(P = 0.001) at a rate of 1.12 (0.58, 1.66) le min)1.
Root canal irrigation with 5% NaOCl alternated with
17% EDTA increased TSS significantly (P = 0.02) but
to a lesser extent and at a slower rate [0.24 (0.05,
0.43) le min)1]. Tooth length (P = 0.04) and the
mesio-distal width of the root at the acrylic level
(P = 0.05), amongst all the anatomical parameters
recorded, were found to influence TSS significantly.
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