MICROSCOPY RESEARCH AND TECHNIQUE 75:781–790 (2012)

Debris and Smear Removal in Flattened Root Canals After

Use of Different Irrigant Agitation Protocols
EDUARDO MILANI RIBEIRO,1 YARA T.C. SILVA-SOUSA,1* ALINE EVANGELISTA SOUZA-GABRIEL,1
MANOEL DAMIÃO SOUSA-NETO,2 KARINA TORALES LORENCETTI,1 AND SILVIO ROCHA CORREA SILVA1
1
School of Dentistry, University of Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
2
Department of Restorative Dentistry, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto, São Paulo, Brazil

KEY WORDS endodontics; irrigant agitation protocols; smear layer; scanning electron
microscopy
ABSTRACT Scanning electron microscopy (SEM) can be used to analyze the presence of debris
and smear layer on the internal walls of root canal. This study evaluated the debris and smear re-
moval in flattened root canals using SEM after use of different irrigant agitation protocols. Fifty
mandibular incisors were distributed into five groups (n 5 10) according to the irrigant agitation
protocol used during chemomechanical preparation: conventional syringe irrigation with NaviTip
needle (no activation), active scrubbing of irrigant with brush-covered NaviTip FX needle, manual
dynamic irrigation, continuous passive ultrasonic irrigation, and apical negative pressure irriga-
tion (EndoVac system). Canals were irrigated with 5 mL of 2.5% NaOCl at each change of instru-
ment and received a final flush with 17% EDTA for 1 min. After instrumentation, the roots were
split longitudinally and SEM micrographs at 3100 and 31,000 were taken to evaluate the amount
of debris and smear layer, respectively, in each third. Data were analyzed by Kruskal–Wallis and
Dunn’s post-hoc tests (a 5 5%). Manual dynamic activation left significantly (p < 0.05) more debris
inside the canals than the other protocols, while ultrasonic irrigation and EndoVac were the most
effective (p < 0.05) for debris removal. Regarding the removal of smear layer, there was no statisti-
cally significant difference (p > 0.05) either among the irrigant agitation protocols or between the
protocol–canal third interactions. Although none of the irrigant agitation protocols completely
removed debris and smear layer from flattened root canals, the machine-assisted agitation systems
(ultrasound and EndoVac) removed more debris than the manual techniques. Microsc. Res. Tech.
75:781–790, 2012. V 2011 Wiley Periodicals, Inc.
C

INTRODUCTION and creates a wider apical stop and minimal apical

The efficacy of root canal cleaning can be evaluated
by the presence of residual debris and smear layer af-
ter chemomechanical preparation. Hülsmann et al.
(1997) defined debris as dentine chips and residual
vital and necrotic pulp tissue that remain loosely
attached to the root canal walls after chemomechanical
preparation. The smear layer is a 1- to 2-lm-thick sur-
face film composed of dentine particles, pulp tissue
remnants, bacterial components, and retained chemi-
cal irrigants, which is formed during instrumentation
and remains adherent to the root canal walls, possibly
occluding the tubule openings (Mader et al., 1984).
Smear layer is formed only in the areas of the canal
that were touched by the endodontic instruments
(Moodnik et al., 1976). The presence of smear layer is
considered a negative factor in root canal adhesion
because it is weakly adhered to dentine surface and
acts as a physical barrier between the filling material
and canal walls (Kennedy et al., 1986; White et al.,
1984), affecting sealer penetration to form intratubular
tags (Alfredo et al., 2008; Sousa-Neto et al., 2005), and
favoring the occurrence of marginal leakage (Rached-
Junior et al., 2009; Shahravan et al., 2007).
The use of NiTi instruments during chemomechani-
cal preparation produces smoother root canal walls
(Fornari et al., 2010; Pasternak-Junior et al., 2009)
transportation when compared with stainless steel
instruments (Pasternak-Junior et al., 2009), while
removing a larger amount of pulp tissue, contaminated
dentine, and microorganisms. Despite the research-
based evidence of their advantages, NiTi instruments
are not effective for cleaning flattened root canals or
those in which the canal shape does not permit instru-
mentation of all dentine walls (Fariniuk et al., 2003;
Fornari et al., 2010; Siqueira Junior et al., 1997). In
these cases, irrigating solutions may have fundamental
importance in chemomechanical preparation of the
root canal system.
In addition to the physicochemical properties inher-
ent to each endodontic irrigant, constant renewal of
the solution during canal preparation by various irri-
gation/agitation cycles avoids saturation, precipitation
of particles, and favors the removal of debris in suspen-
sion inside the root canal (Nadalin et al., 2009). A num-
ber of methods have been used for delivery and activa-
tion of irrigants in the root canals namely conventional
*Correspondence to: Prof. Yara Teresinha Corrêa Silva-Sousa, Rua Célia de
Oliveira Meirelles, 350, 14024-070, Ribeirão Preto, São Paulo, Brazil. Tel.:/Fax:
155-16-3603-6763. E-mail: ysousa@unaerp.br
Received 12 September 2011; accepted in revised form 18 October 2011
DOI 10.1002/jemt.21125
Published online 1 December 2011 in Wiley Online Library (wileyonlinelibrary.com).

V
C 2011 WILEY PERIODICALS, INC.

782 E.M. RIBEIRO ET AL.
Luer-Lock syringe irrigation with needles of different
calibers (Cameron, 1995), active scrubbing of irrigant
with brush-covered needles (Goel and Tewari, 2009; Gu
et al., 2009), ultrasonic irrigation (Ferreira et al., 2004;
Passarinho-Neto et al., 2006; Vander Sluis et al., 2007),
dynamic manual activation (Gu et al., 2009; Susin
et al., 2010), and hydrodynamic irrigation systems,
such as the EndoVac system (Nielsen and Baumgart-
ner, 2007; Shin et al., 2010; Susin et al., 2010).
The NavitTip FX needles (Ultradent Products, South
Jordan, UT) are 30-gauge irrigation needle covered
with a brush in their tip, which have been designed to
increase the mechanical debridement with active
scrubbing of the canal walls during up and down
motion and aid agitating the irrigating solution in
order to enhance its chemical action (Gu et al., 2009).
Continuous passive ultrasonic irrigation consists in the
activation of an endodontic file with an ultrasonic de-
vice inside the root canal for mechanical agitation of
the irrigant without contacting of the canal walls
(Vander Sluis et al., 2007). Manual dynamic activation
is a simple and inexpensive irrigation protocol in which
a well-fitting gutta-percha master cone is moved inside
the canal in an corono-apical direction using back-and-
forth strokes of 1 mm and frequency of 100 movements/
min (Gu et al., 2009; Susin et al., 2010). The recom-
mended protocol for the use of apical negative pressure
irrigation includes two main phases: macro-irrigation
and micro-irrigation. Systems that use hydrodynamic
irrigation, such as the EndoVac system, are composed
by a macro-cannula and a micro-cannula that make
the irrigating solution circulate due to difference of
pressure caused by the vacuum inside the root canal
system (Nielsen and Baumgartner, 2007; Shin et al.,
2010; Susin et al., 2010).
The aim of the present study was to evaluate debris
and smear removal in flattened root canals using scan-
ning electron microscopy (SEM) after use of the follow-
ing irrigant agitation protocols: conventional syringe
irrigation with NaviTip needle (no activation), active
scrubbing of irrigant with brush-covered NaviTip FX
needle, manual dynamic irrigation, continuous passive
ultrasonic irrigation, and apical negative pressure irri-
gation (EndoVac system).
MATERIAL AND METHODS
The study protocol was reviewed and approved by
the Ethics’ Committee of University of Ribeirão Preto.
Fifty human mandibular incisors from a local human
teeth bank with completely formed apices and roots
with curvature angles equal or less than 108 (mild cur-
vature) according to Schneider’s method (Schneider,
1971) were used. A set of mesiodistal radiographs was
taken to confirm that all teeth had a single flattened
root canal and no internal calcifications or resorptions.
The crowns were removed at the cementoenamel
junction with a water-cooled diamond disc (KG Soren-
sen, Barueri, SP, Brazil) at low speed to obtain a stand-
ardized root length of 13 mm. A size 15 K-file (Dentsply
Maillefer, Ballaigues, Switzerland) was passively intro-
duced into each canal until its tip was just visible at
the apical foramen as observed with a 34 magnifier.
The working length (WL) was established by subtract-
ing 1 mm from this length. The roots were fixed by
their apices in a condensation silicone base (Perfil;
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Vigodent S.A., Rio de Janeiro, RJ, Brazil) to provide
stabilization during the chemomechanical preparation
phase as well as to avoid that the irrigants passed
freely through the apical foramen during the irrigating
procedures.
The canals were prepared by a single, experienced
operator according to a crown-down technique using
the K3 NiTi rotary system (SybronEndo, Orange, CA)
activated with an electric motor (Anthogyr; Injecta,
Steinach, Germany) in the sequence recommended by
manufacturer and according to the tooth type: enlarge-
ment of the coronal third with #30.06 and #40.06
instruments followed by #20.02, #20.04, #25.02, #25.04,
#30.02, #30.04, and #35.02 instruments to the WL. The
roots were randomly assigned to five groups of 10 speci-
mens each according to the following irrigant agitation
protocols: conventional syringe irrigation with NaviTip
needle (no activation); active scrubbing of irrigant with
brush-covered NaviTip FX needle (Ultradent Prod-
ucts); manual activation with gutta-percha cone (man-
ual dynamic irrigation); continuous passive ultrasonic
irrigation; EndoVac apical negative pressure irrigation
system (Discus Dental, Culver city, CA).
The irrigating solutions used in all groups were
5.25% sodium hypochlorite (NaOCl) and 17% ethylene-
diaminetetraacetic acid (EDTA). Except for the Endo-
Vac system group, the canals were irrigated at each
change of instrument with 5 mL of 5.25% NaOCl in a
disposable 20-mL syringe coupled to a brushless 30-
guage NaviTip 30 3 4 G needle (Ultradent Products).
The needle was advanced into the canal until it
adjusted to the canal walls and was then retracted 1
mm from the WL to allow easy back flow of the irrigat-
ing solution during aspiration of the solution with flexi-
ble Capillary Tips (Ultradent Products). After the last
instrument, the canals of these groups were irrigated
with 5 mL of 2.5% NaOCl followed by 5 mL of 17%
EDTA for 1 min, varying the irrigant agitation proto-
cols as described below.
Conventional syringe irrigation (no activation—
control): NaOCl and EDTA were delivered to the canal
with the NaviTip needle and were aspirated with Cap-
illary Tips; NaviTip FX: NaOCl and sequentially EDTA
were delivered and agitated using the brush-covered
30-guage NaviTip FX needle with 458 clockwise and
counter clockwise movements combined with back-
and-forth strokes of 2 mm during 1 min in order to pro-
mote a brushing action on dentine walls. Aspiration of
the solutions was performed as described in the control
group; Manual Dynamic Irrigation: NaOCl and
sequentially EDTA were delivered to the canal with the
NaviTip needle and agitated with a size 35 main gutta-
percha cone introduced to the WL and moved during 1
min in a corono-apical direction using back-and-forth
strokes of approximately 1 mm and frequency of 100
movements/min. Aspiration of the solutions was per-
formed as described in control group; Continuous Pas-
sive Ultrasonic Irrigation: NaOCl and sequentially
EDTA were delivered to the canal with the NaviTip
needle and agitated with a size 20 K-file (Dentsply-
Maillefer) coupled to the file-holding adapter of the
handpiece of a conventional dental ultrasonic scaler
(Profi II US-AS; Dabi-Atlante, Ribeirão Preto, Brazil).
The file was placed into the canal 1 mm short of WL
without touching the walls, so that it could vibrate
Microscopy Research and Technique

IRRIGATION PROTOCOLS ON CANAL CLEANING
Fig. 1. Percent distribution of scores attributed for removal of debris and smear layer according to the
irrigant agitation protocols. Different letters indicate statistically significant difference (Dunn’s test, a 5 5%).
freely. The file was activated for 1 min. Aspiration of
the solutions was performed as described in control
group. In the group irrigated with the Apical Negative
Pressure Irrigation (EndoVac system), at each change
of instrument, 5 mL of 2.5% NaOCl was delivered via
the master delivery tip of the macro-cannula for 30 s
(macro irrigation) and the solution was aspirated with
the macro-cannula placed 2 mm from the WL. After
the last instrument, a new macro-irrigation cycle was
performed with 2.5% NaOCl, followed by a micro-irri-
gation cycle. The micro-cannula alternated corono-api-
cal movements remaining 6 s at the WL and 6 s 2 mm
short of the WL until completing 30 s. Macro-irrigation
and micro-irrigation cycles were performed with 5 mL
of 17% EDTA, until completing 1 min, as in the other
groups.
In all groups, after irrigation with EDTA, the canals
received a final rinse with 5 mL of 2.5% NaOCl fol-
lowed by aspiration with Capillary Tips, irrigation
with 10 mL of distilled and deionized water, aspiration
with Capillary Tips, and drying with size 30 absorbent
paper points.
Sequentially, longitudinal sulcus along buccal and
palatal surfaces of all the specimens were done using
diamond disks (KG Sorensen, Barueri, SP, Brazil), at
low speed (Dabi Atlante, Ribeirão Preto, SP, Brazil),
careful not to reach the root canal. The teeth were then
fractured longitudinally with a bi-tapered chisel and a
surgical hammer exposing the entire root canal. Bur
demarcations were done in the external portion of den-
tin (not in root canal) with a diamond bur at 5 and 9
mm from the root apices to define coronal, middle, and
apical thirds of 4 mm each.
SEM Analysis
The mesial and distal halves were dehydrated in
ascending ethanol concentrations up to 100% and
mounted on aluminum stubs. Gold-palladium sputter
coating of approximately 300 Å was carried out using a
fine-coat ion sputter (Denton Desk II, Denton Vacuum
LLC, Moorestown, NJ) and the specimens were exam-
ined with a scanning electron microscope (JSM-5410,
Microscopy Research and Technique
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783
JEOL Ltd., Tokyo, Japan) operated at 15 kV. The areas
of interest in each canal third of each specimen were
selected and magnifications of 3100 and 31,000 were
used to evaluate the removal of debris and smear layer,
respectively. Three calibrated and blinded independent
evaluators examined the SEM micrographs. Debris
and smear layer remaining on the canal walls after
chemomechanical preparation using the different irri-
gant agitation protocols were evaluated according to
scoring systems adapted from Hülsmann et al. (1997):
analysis of debris removal—score 1: clean root canal,
only few small debris particles; score 2: debris covering
less than 50% of the root canal walls; score 3: debris
covering more than 50% of the root canal walls; score 4:
root canal walls completely covered by debris; analysis
of smear layer removal—score 1: absence of smear
layer and several open dentinal tubules; score 2: little
smear layer and several open dentinal tubules; score 3:
homogenous smear layer covering the root canal walls
and few open dentinal tubules; score 4: root canal walls
completely covered by smear layer and absence of open
dentinal tubules.
Cohen’s kappa coefficient was used to calculate inter-
and intraexaminer reproducibility using the criteria
proposed by Landis and Koch (1977). Statistical analy-
sis was performed with the Kruskal–Wallis and post
hoc Dunn’s tests (a 5 5%) using the GraphPad soft-
ware (GraphPad Inc., San Diego, CA).
RESULTS
Inter-examiner agreement was 91% with a kappa of
0.9057 (95% CI, 0.8530–0.9791). Intra-examiner agree-
ment was 96% with a kappa of 0.9632 (95% CI, 0.9276–
1). The inter-examiner and intra-examiner reproduci-
bility was excellent (0.81–1.0) (Landis and Koch, 1977).
Figure 1 presents the distribution of scores attrib-
uted to removal of debris and smear layer according to
the irrigant agitation protocols.
Comparing the irrigant agitation protocols with
respect to debris removal, manual dynamic irrigation
presented significantly (p < 0.05) higher scores (me-
dian 5 3) than the other irrigant agitation protocols,

784 E.M. RIBEIRO ET AL.
Fig. 2. Panel of SEM micrographs representative of the conven-
tional syringe irrigation with NaviTip needle (no activation) group. A:
Coronal third with debris (1003); (B) coronal third with smear layer
and partially occluded tubules (1,0003); (C) middle third with debris
in the flattened area of the canal (*) (1003); (D) middle third with
which means that this technique left more debris in
the canal than the others. Conventional syringe needle
irrigation, in turn, differed significantly (p < 0.05) from
manual dynamic irrigation and both machine-assisted
agitation systems (ultrasound and EndoVac).
Comparing debris removal at each root canal third,
manual dynamic irrigation presented the highest
scores (median 5 3) and differed significantly (p <
0.05) from ultrasonic irrigation and EndoVac at the cor-
onal third (median 5 2). No statistically significant dif-
ference (p > 0.05) was found among the irrigant agita-
tion protocols at the middle third. At the apical third,
ultrasonic irrigation differed significantly (p < 0.05)
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smear-covered dentin surface and partially occluded tubules (10003);
(E) apical third with debris agglomeration in the canal lumen and in
the flattened area (*) (1003); (F) apical third with dentinal tubules
partially occluded by smear layer (1,0003).
from conventional syringe needle irrigation and man-
ual dynamic irrigation.
Regarding smear layer removal, no statistically sig-
nificant difference (p > 0.05) was found among the five
irrigant agitation protocols either considering the
entire root canal or each individual root third.
SEM Analysis of the Photomicrographs
The specimens that received conventional syringe
needle irrigation (no activation) presented debris at all
root canal thirds, with agglomerations in the flattened
areas (Figs. 2A, 2C, and 2E). A higher magnification
Microscopy Research and Technique

IRRIGATION PROTOCOLS ON CANAL CLEANING
Fig. 3. Panel of SEM micrographs representative of brush-covered
NaviTip FX group. A: Coronal third with scattered debris in the canal
lumen and less amount of debris in the flattened area of the canal (*)
(1003); (B) coronal third with smear layer and few occluded tubules
revealed smear-covered canal walls with partially
occluded tubules (Figs. 2B, 2D, and 2F).
The specimens irrigated with NaviTip FX exhibited
scattered debris on root dentine surface, and the flat-
tened areas presented less debris than the specimens
of Group 1 (Figs. 3A, 3C, and 3E). It was also possible
to observe smear layer partially obliterating the denti-
nal tubules (Figs. 3B, 3D, and 3F).
At 3100 magnification, the SEM micrographs of the
specimens subjected to manual activation revealed
great amount of debris, covering more than 50% of the
dentine walls along the root canal and in the flattened
areas (Figs. 4A, 4C, and 4E). At 31,000 magnification,
Microscopy Research and Technique
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785
(1,0003); (C) middle third with debris (1003); (D) middle third with
smear layer and partially occluded tubules (1,0003); (E) apical third
with debris agglomerations (1003); (F) apical third with smear layer
and few open tubules (1,0003).
smear layer was observed in areas with open tubules
and areas with no open tubules (Figs. 4B, 4D, and 4F).
The specimens subjected to continuous passive ultra-
sonic irrigation presented less than 50% of the dentine
walls covered by debris along the canal as well as in
the flattened areas (Figs. 5A, 5C, and 5E). However,
the tubules were partially occluded by smear layer
(Figs. 5B, 5D, and 5F).
The specimens irrigated with the EndoVac system
presented a cleaning pattern similar to that of ultra-
sonic activation. Relatively clean canals and flattened
areas, with less than 50% of the surface covered by de-
bris (Figs. 6A, 6C, and 6E) and smear layer partially

786 E.M. RIBEIRO ET AL.
Fig. 4. Panel of SEM micrographs representative of the manual
dynamic irrigation group. A: Coronal third with the flattened area of
the canal covered by debris (*) (1003); (B) Coronal third with smear
layer and partially occluded tubules (1,0003); (C) middle third with
obliterating the dentinal tubules (Figs. 6B, 6D, and
6F).
There were no significant differences among the
canal thirds as for the removal of debris and smear
layer, regardless of the irrigation/activation protocol.
DISCUSSION
A recent article has presented an overview of the
irrigant agitation methods currently available and
their debridement efficacy. According to those authors,
agitation devices might be divided into the manual and
machine-assisted systems (Gu et al., 2009). Manual
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agglomerations of debris (1003); (D) middle third with smear layer
and partially occluded tubules (1,0003); (E) apical third with debris
agglomerations in the canal (1003); (F) apical third with several
tubules occluded by smear layer (1,0003).
techniques include conventional syringe irrigation with
needles/cannulas of different diameters, brush-covered
needles and manual-dynamic irrigation by hand agita-
tion of the instrumented canals with well-fitting gutta-
percha points. The mechanical systems include rotary
brushes, continuous irrigation during rotary instrumen-
tation, sonic and ultrasonic mechanisms, and pressure
alternation devices. In the present study, the cleanliness
of flattened root canals in relation to the removal of de-
bris and smear layer was investigated after use of differ-
ent irrigation/agitation protocols.
Scanning electron (Goel and Tewari, 2009) and opti-
cal (Fariniuk et al., 2003, Fornari et al., 2010; Siqueira
Microscopy Research and Technique

IRRIGATION PROTOCOLS ON CANAL CLEANING
Fig. 5. Panel of SEM micrographs representative of the continu-
ous passive ultrasonic irrigation group. A: Coronal third with no de-
bris in the canal or in the flattened area (*) (1003); (B) coronal third
with partially occluded tubules (1,0003); (C) middle third without de-
Junior et al., 1997) microscopy can be used to evaluate
the cleaning of root canal walls. However, while SEM
reveals the presence of debris and smear layer, optical
microscopy permits evaluating only the presence of de-
bris. In the present SEM study, a 3100 magnification
was used to evaluate the efficacy of the irrigation/agita-
tion protocols for removing debris and then the magni-
fication was increased to 31,000 for analysis of smear
layer removal from the canal walls. This methodology
optimizes the number of teeth used in the study and
has been used in previous studies (Hülsmann et al.,
1997; Salman et al., 2010). Another important factor to
be considered is that three calibrated and double-
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787
bris. The asterisk indicate the flattened area (*) (1003); (D) middle
third with smear layer and partially occluded tubules (1,0003); (E)
apical third free of debris (1003); (F) apical third with tubules
occluded by smear layer (1,0003).
blinded evaluators independently scored the specimens
on the qualitative SEM analysis, increasing the reli-
ability and accuracy of obtained results.
It should also be mentioned that all groups used the
same irrigating solutions, 2.5% NaOCl and 17% EDTA,
varying the irrigant agitation protocol. NaOCl have a
strong organic tissue solving capacity, which favors
root canal cleaning by transformation of insoluble sub-
stances (pulp tissues and necrotic rests) into soluble
substances, such as soaps, chloramines, and amino
acids salts. The action of soaps produced in the reaction
maintains fatty bodies in suspension (micelles), facili-
tating their subsequent aspiration (Spanó et al., 2002).

788 E.M. RIBEIRO ET AL.
Fig. 6. Panel of SEM micrographs representative of the EndoVac
system group. A: Coronal third with small amount of debris (1003);
(B) coronal third with partially occluded tubules (1,0003); (C) middle
third free of debris (1003); (D) apical third with tubules occluded by
EDTA is a weak organic acid with a chelating effect,
which acts on the inorganic components of the smear
layer and root dentin, causing decalcification of the
peri and intertubular dentine matrix (Hülsmann et al.,
2003; Mello et al., 2010).
Regarding the removal of debris, none of the irriga-
tion/activation protocols could completely clean the
root canal system. This result is in agreement with
those of studies that used similar SEM analysis (Hüls-
mann et al., 1997; Salman et al., 2010; Vivan et al.,
2010) or optical microscopy (Ferreira et al., 2004; For-
nari et al., 2010; Nadalin et al., 2009; Passarinho-Neto
et al., 2006), and found debris in flattened areas of the
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smear layer (1,0003); (E) Apical third free of debris. The asterisk
indicate the flattened area of the canal (*) (1003); (F) apical third
with few open tubules (1,0003).
canals that were not reached by the endodontic instru-
ments. However, among the irrigation/activation proto-
cols evaluated in the present study, those using ultra-
sonic and apical negative pressure irrigation (EndoVac
system) were more effective for removal of debris.
Regarding the ultrasonically driven agitation of the
irrigant, it is important to mention that the file
remained loose inside the canal during irrigation, with
no pressure on the canal walls or intentional removal
of dentin, characterizing the passive ultrasonic irriga-
tion technique (Sabins et al., 2003). This allows the
irrigant to reflux and causes more debris to be dis-
placed coronally, while avoiding the inadvertent extru-
Microscopy Research and Technique

IRRIGATION PROTOCOLS ON CANAL CLEANING
sion of the irrigant into periapical tissues. The energy
is transmitted from an oscillating file to the irrigant in
the root canal by means of ultrasonic waves. This
action induces hydrodynamic turbulence, producing
cavitation of the irrigant and bubble implosion, which
increase the temperature and hydrostatic pressure,
producing impact waves that will ultimately cause
removal of debris by continuous flow of irrigating
solution. In addition, it has been demonstrated that
activation of the irrigant with ultrasonic devices may
potentialize the action of NaOCl (Ferreira et al., 2004;
Passarinho-Neto et al., 2006) by heating the solution.
In the same way as ultrasound, the EndoVac system
promotes rapid circulation and continuous renewal of
the irrigating solution inside the root canal. This sys-
tem combines the use of macro- and micro-cannulas
that promote great difference of pressure producing
vacuum inside the root canal system (Nielsen and
Baumgartner, 2007; Shin et al., 2010; Susin et al.,
2010). The action of the machine-assisted irrigation
systems used in the present study probably allowed the
removal of debris from the flattened areas of the canal
that were not touched by the instruments during che-
momechanical preparation. Although none of the pro-
tocols was capable of producing completely clean root
canals, there was a predominance of score 2, which
means the presence of debris covering less than 50% of
the root canal walls. The SEM analysis revealed re-
moval of debris from the flattened areas by agitation of
the solution promoted by these systems.
Described as a simples and low-cost technique, man-
ual dynamic activation produces an effective hydrody-
namic effect inside the root canal when the gutta-per-
cha cone is hand-activated using pull–push movement,
and this technique improves the displacement and
exchange of the irrigating solution and eliminates the
air entrapped in the apical region (Susin et al., 2010).
However, in the present study, manual dynamic activa-
tion was the least effective of the evaluated irrigant
agitation protocols for removal of debris, while the
brush-covered NaviTip FX needles presented interme-
diate results, sometimes similar to the conventional sy-
ringe needle irrigation without activation, sometimes
similar to the machine-assisted protocols. One of the
possible explications for the lower removal of debris by
manual dynamic activation is that pulp rests were
impregnated on the surface of the gutta-percha cone
during the repeated back-and-forth movements into
the root canal. The repeated friction of the debris-cov-
ered cone against the canal walls produces more parti-
cle agglomeration (Shahravan et al., 2007). Susin et al.
(2010) found that manual dynamic irrigation was less
efficient than the EndoVac apical negative pressure
irrigation system, as observed in the present study.
SEM analysis of the specimens irrigated with Navi-
Tip FX revealed the presence of scattered debris inside
the root canal, probably resulting from the action of the
brush on the flattened areas that were not reached by
the instruments. While the push–pull motion of the
brush acts by physically displacing tissue remains, the
friction created between the brush bristles and the
canal walls hinders the flow of the solution inside the
canals. In the group treated with conventional syringe
needle irrigation without activation, debris was
observed in the untouched canal surfaces.
Microscopy Research and Technique
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789
In the present study, no significant difference was
found among canal the thirds as for smear layer re-
moval, regardless of the irrigant activation protocol,
which is in agreement with Vivan et al. (2010). Accord-
ing to Khademi et al. (2006), if coronal preparation is
adequate, it is not necessary to enlarge the final diame-
ter to files larger than #30, which is the minimum
instrumentation size needed for penetration of irri-
gants to the apical third of the root canal. In the pres-
ent study, cervical flaring and preparation of canals to
the WL were performed up to instrument #35.02, pro-
ducing divergent walls that permitted an adequate
flow of the irrigating solution in all canal thirds.
The irrigant activation protocols evaluated in this
study had similar efficacy on smear layer removal,
with specimens having predominantly partially cov-
ered canal walls and open dentinal tubules. It is worth
mentioning that, in the same way as done in previous
investigations (Goel and Tewari, 2009; Uroz-Torres
et al., 2010), in all groups of the present study EDTA
was left in the canal during 1 min and activated using
one of the evaluated activation protocols. EDTA has
been reported to remove smear layer within 1–5 min
(Hülsmann et al., 2003). As a chelating agent, EDTA
needs to be in contact with the dentine surface during
some time for the chelating reaction to occur. According
to Cruz-Filho et al. (2001), 3 min are necessary for
EDTA to promote alteration on dentine microhardness.
In the present study, neither manual nor mechanical
activation of EDTA influenced the removal of smear
layer, although Abbott (1991) have reported that ultra-
sound-activation of EDTA decreases its demineralizing
effect for reducing its contact time and action. There-
fore, the partial removal of smear layer observed in the
present study may be related to the short action time of
EDTA.
The EndoVac system is based on apical negative
pressure to the take the irrigating solution to this
region in order to optimize the removal of smear layer
and minimize the extrusion of solution through the api-
cal foramen. Although greater volume of irrigating so-
lution is needed compared with conventional irrigation
in the same period of time (Nielsen and Baumgartner,
2007), the solution has a shorter action time due to the
rapid and efficient vacuum aspiration, and this power
can be one of the factors that explain the results
obtained in the present study.
Chemomechanical preparation with NiTi instru-
ments energized by electric and pneumatic engines has
been a reality in endodontics for many years. The asso-
ciation of NiTi instrumentation with irrigating solu-
tions and efficient irrigant agitation protocols should
be investigated with the goal of obtaining cleaner
canals prior to filling, which is particularly challenging
in root canal systems with complex anatomy. In these
canals, the use of chemical irrigants delivered by
adequate irrigation methods is mandatory for dissolv-
ing organic and inorganic matter in the areas that
were not touched by the endodontic instrument during
chemomechanical preparation.
In conclusion, although none of the irrigant agitation
protocols was capable to remove completely debris and
smear layer from flattened root canals, the machine-
assisted agitation systems (ultrasound and EndoVac)
removed more debris than the manual techniques.

790 E.M. RIBEIRO ET AL.
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Microscopy Research and Technique