Photomedicine and Laser Surgery

Volume XX, Number XX, 2017 Original Research

ª Mary Ann Liebert, Inc.
Pp. 1–10
DOI: 10.1089/pho.2016.4234

Comparison of Three Final Irrigation Activation Techniques:

Effects on Canal Cleanness, Smear Layer Removal,
and Dentinal Tubule Penetration of Two Root Canal Sealers

Elmas Turkel, DDS,1 Emel Olga Onay, DDS, PhD,2 and Mete Ungor, DDS, PhD3

Abstract

Objective: The aim of this study was to compare three final irrigation activation techniques with respect to their
effects on debridement efficacy, smear layer removal, and dentinal tubule penetration of two different root canal
sealers. Background data: Different applications to improve the delivery of irrigating solutions within the root
canal system are currently being investigated, as not all of the mechanisms and effects of these techniques have
been clearly identified. Materials and methods: One hundred forty-two single-rooted teeth were randomly
divided into a control group and three experimental groups based on the irrigant activation technique used:
EndoVac (EV) system, photon-induced photoacoustic streaming (PIPS), and conventional syringe irrigation
(CSI). Thirteen specimens from each experimental group were evaluated for debris and smear layer removal
using scanning electron microscopy. The remaining 30 specimens per group were divided into two subgroups
according to the root canal sealer used: AH Plus and TotalFill BC. The maximum depth and total percentage of
sealer penetration were measured using confocal laser scanning microscopy. Results: PIPS resulted in sig-
nificantly less debris in the middle third of the root canal compared with CSI ( p < 0.01). There were no
significant differences among CSI, EV, and PIPS concerning debris removal at coronal and apical levels or
smear layer removal at all levels ( p > 0.05). TotalFill BC use after final irrigation with EV and CSI at 2 mm or
PIPS at 5 mm exhibited a significantly higher percentage of sealer penetration than that with AH Plus ( p < 0.05).
When AH Plus was used, PIPS allowed deeper sealer penetration than CSI at 2 mm ( p < 0.05). Conclusions:
The effects of EV, PIPS, and CSI on debridement efficacy, smear layer removal, and dentinal tubule penetration
were almost comparable. TotalFill BC showed superior tubular penetration than AH Plus.

Keywords: dentin, dentistry, endodontics, laser confocal microscopy, lasers, Er-YAG

Introduction croleakage between root canal walls and filling materials.5

For these reasons, it is desirable to completely remove debris

D uring endodontic instrumentation, debris and smear

layer form on the root canal wall.1 Debris is defined as
dentinal particles and vital and necrotic pulp tissue remnants
that adhere weakly to the root canal walls after chemo-
mechanical preparation.2 The smear layer is an amorphous,
irregular, tenacious structure consisting of dentin, pulp tissue
remnants, and microbial elements that occlude dentinal tu-
bule openings.3 Both can harbor microorganisms and their
by-products.2,4 Also, the smear layer can act as a barrier to the
penetration of intracanal disinfectants and root canal sealers
into dentinal tubules, and this can lead to a subsequent mi-
and the smear layer by alternate use of sodium hypochlorite
(NaOCl), a deproteinizing agent,6 and the calcium-chelating
agent ethylenediaminetetraacetic acid (EDTA).7
Different equipment and concepts have been introduced in
effort to achieve sufficient delivery of irrigating solutions
within the root canal system.8–10 The EndoVac system (EV)
(SybronEndo, Orange, CA), based on method of apical neg-
ative pressure irrigation system, was designed to distribute
irrigating solutions to working length and evacuate the root
canal of debris.11 Recently, a new laser activation technique,
referred to as photon-induced photoacoustic streaming (PIPS),

1
Turkish Ministry of Health, Edirne Dental Hospital, Edirne, Turkey.
2
Department of Endodontics, School of Dentistry, Baskent University, Bahcelievler-Ankara, Turkey.
3
Department of Endodontics, School of Dentistry, Baskent University, Bahcelievler-Ankara, Turkey.

1
2 TURKEL ET AL.

has become commercially available. In this concept, by using
subablative energy and restricting tip placement to within
the coronal part of the tooth, impulses interact with water
molecules within the irrigation solution, generating photon-
induced shock waves that lead to rapid fluid streaming and
enhance the action of the irrigation solutions.12
In addition, preparing the root canal chemomechanically,
hermetic three-dimensional filling of the root canal is also
considered a key factor in successful endodontic therapy.13
During root canal filling, penetration of root canal sealer into
the dentinal tubule is necessary because it increases the con-
nection between the core material and dentin, thereby helping
to optimize the adaptability and sealing capability of the root
canal filling.7 Further, sealer penetration can promote an an-
timicrobial effect in dentinal tubules, which increases when
the sealer comes in close contact with microorganisms.14
Different physical properties and compositions of root
canal sealers can also influence penetration depth.15 Total-
Fill BC sealer (FKG Dentaire SA, La Chaux-de-Fonds,
Switzerland) is a new calcium silicate-based bioceramic root
canal sealer containing zirconium oxide, tricalcium silicate,
calcium hydroxide, dicalcium silicate, calcium phosphate
monobasic, thickening agents, and filler.16 AH Plus sealer
(Dentsply DeTrey, Konstanz, Germany) is a widely used
epoxy resin-based sealer demonstrated to have excellent
tubular penetration and adaptation.17
Both the diameter and density of dentinal tubules vary
among root regions. Dentinal tubule orifices are larger and
denser in the coronal and middle thirds compared with the
apical third.18 Therefore, it is important to compare debris
and smear layer removal and tubular penetration of sealers
among canal thirds.
The aim of this study was to compare EV, PIPS, and
conventional syringe irrigation (CSI) with respect to their
effects on debridement efficacy; smear layer removal in the
coronal, middle, and apical thirds of the root canal; and
dentinal tubule penetration of root canal sealers AH Plus and
TotalFill BC at three separate root regions.
Materials and Methods
This study was approved by the Baskent University In-
stitutional Review Board (Project No. D-KA15/04). One
hundred forty-two straight and mature roots from extracted
human maxillary central incisor and mandibular canine teeth
with single canals were selected for the study. The teeth
were decoronated with a 0.3-mm diamond disc to stan-
dardize the root length to 17 mm from the anatomic apex.
The roots were prepared with ProTaper rotary instruments
(Dentsply Maillefer, Ballaigues, Switzerland) up to F4
(#40). The root canals were irrigated with 2 mL of 5%
NaOCl between instruments. The root apices were covered
with sticky wax to simulate clinical conditions and create a
closed root canal system to obtain a vapor lock effect.9 A
size 40 gutta-percha point was placed into the root canal to
prevent melted wax from entering it.
One hundred forty-two specimens were randomly assigned
into a control group (n = 13) and three experimental groups
(n = 43) based on the irrigation activation technique used
(Table 1). In the PIPS group, an erbium:yttrium–aluminum–

Table 1. Experimental Groups and Protocols

Group name n Activation Protocol
Control 13 CSI Root canals were irrigated with 15 mL distilled water using a 27-gauge notched-tip
needle (Ultradent, South Jordan, UT) for 90 sec. During irrigation, the needle was
inserted deeply at 1 mm from the WL and moved *1–2 mm in a coronoapical
direction.
CSI 43 CSI Final rinse with 5 mL 5% NaOCl followed by 5 mL 17% EDTA using a 27-gauge
notched-tip needle (Ultradent) for 30 sec each. During irrigation, the needle was
inserted deeply at 1 mm from the WL and moved *1–2 mm in a coronoapical
direction.
EV 43 EV The master delivery tip was located in the coronal part of the root canal to deliver
solutions into the root canal and then two cycles of microirrigation were performed.
Each cycle of microcannular irrigation involved placing the tip at the full WL for
6 sec, withdrawing 2 mm from the full WL for 6 sec and then returning back to the
full WL for the next 6 sec. This up and down motion continued for 30 sec. The first
microirrigation cycle was completed using 5 mL 5% NaOCl, and the second cycle
was completed using 5 mL 17% EDTA. At the end of the second cycle, the
microcannula was left at the WL to remove excess irrigant.
PIPS 43 PIPS The air and water spray in the laser system were switched off. Then, 0.5 mL 5% NaOCl
was applied into the root canal and activated with the laser fiber tip for 30 sec. The
laser fiber tip remained stationary in the coronal part of the root canal (no further than
4 mm in the root canal) during the irrigation activation protocol. When the irrigating
solution in the root canal decreased, a fresh NaOCl solution was added.
Subsequently, 0.5 mL 17% EDTA was placed in the root canal and activation was
performed as before for 30 sec. When the irrigating solution in the root canal
decreased, a fresh EDTA solution was added. The total activation time was 60 sec,
and irrigation resulted in 5 mL total irrigant volume for NaOCl and 5 mL total
irrigant volume for EDTA.
CSI, conventional syringe irrigation; EDTA, ethylenediaminetetraacetic acid; EV, EndoVac system; NaOCl, sodium hypochlorite; PIPS,
photon-induced photoacoustic streaming; WL, working length.
EFFICACY OF IRRIGATION ACTIVATION TECHNIQUES 3

Table 2. Laser Parameters walls. For each specimen, the half containing the most visible
part of the endodontic wall was selected and labeled. Labeled
Manufacturer Fotona, Ljubljana, Slovenia specimens were then dehydrated through graded ethanol
Model Fidelis AT baths up to 100%. Each specimen was mounted on an alu-
Laser system Er:YAG minum stub, sputter-coated with *10 nm gold, and then
Probe PIPS tip (300 lm diameter, examined under SEM (Quanta 200 FEG, Hillsboro, OR) at
14-mm long fiber tip design) 5 kV. For each specimen, the coronal, middle, and apical
Wavelength 2940 nm thirds of the root canal were examined under 1000 · magni-
Power 0.3 W fication. Three representative areas were identified randomly
Energy per pulse 20 mJ and a mean score was calculated. Two researchers performed
Repetition rate 15 Hz a blind evaluation separately. The intraclass correlation co-
Pulse duration SSP, 50 lsec efficients method was used to confirm the intraobserver and
Placement of the tip Coronal part of the root canal
interobserver agreement for SEM evaluation. The efficacy of
Application type Stationary
Duration of each 30 sec debris2 and smear layer19 removal was assessed using criteria
activation protocol proposed by Hulsmann et al.

Confocal laser scanning microscopic analysis

garnet (Er:YAG) laser with a wavelength of 2940 nm was
used. A 14-mm long, 300 lm laser fiber tip was operated
at 0.3 W, 15 Hz, and 20 mJ/pulse. The pulse duration was
50 lsec (Table 2). In all the experimental groups, root canals
were subsequently irrigated with 5 mL distilled water using
a 27-gauge notched-tip needle for 30 sec to avoid prolonged
effects of EDTA solution, and were dried with sterile paper
points. For all groups tested, the irrigation and activation
methods involved 15 mL total irrigation solution volume and
90 sec total irrigation solution delivery time.
Scanning electron microscopy evaluation
Thirteen specimens from each experimental group were
evaluated for debris and smear layer removal using scanning
electron microscopy (SEM; Fig. 1). To facilitate fracturing,
shallow longitudinal grooves were created on the buccal and
lingual root surfaces with a diamond disc. Roots were then
split in half using a chisel with a ProTaper F4 gutta-percha
cone in the root canal to limit tooth fragments covering canal
of sealer penetration in dentinal tubules
The remaining 30 specimens from each experimental
group were assigned into two subgroups (each n = 15) ac-
cording to the root canal sealer used: AH Plus or TotalFill BC
(Fig. 1). The fluorescent rhodamine B isothiocyanate dye
(Merck Chemistry, Dannstadt, Germany) was incorporated to
each sealer at an approximate concentration of 0.1 wt% to be
able to visualize the specimens under confocal laser scanning
microscopy (CLSM). The sealer was delivered to the canal
using a #40 paper point (SureDent Corporation, Seongnam,
Korea). Root canals were then filled using the cold lateral
compaction technique. Excess gutta-percha was removed
using a heated instrument and vertical compaction was ap-
plied with a plugger at the coronal level for 10 sec. Access
cavities were sealed with Cavit G (3M; ESPE, St. Paul, MN)
and specimens were stored in 100% humidity at room tem-
perature for 1 week to allow the sealers to set completely.
The roots were embedded in self-cure acrylic repair ma-
terial (Meliodent; Heraeus Kulzer, Hanau, Germany). Each

FIG. 1. Experimental design. CLSM,

confocal laser scanning microscopy; CSI,
conventional syringe irrigation; EV, En-
doVac system; PIPS, photon-induced
photoacoustic streaming; SEM, scanning
electron microscopy.
4 TURKEL ET AL.
root was sliced 90 to its long axis in 1-mm-thick sections
using a 0.3-mm microtome saw (Metkon, Bursa, Turkey)
under water cooling. The cuts were made at 2, 5, and 8 mm
from the root apex. All specimens were mounted onto glass
slides and examined under CLSM (Carl Zeiss LSM 510;
Carl Zeiss Microscopy, Jena, Germany) at a wavelength of
575 nm and 4 · magnification with a zoom oil lens. Each
section was evaluated using Zeiss LSM Image Browser
Version 4.2.0.121 (Carl Zeiss MicroImaging GmbH 1997–
2006) with a calibrated measuring tool. The maximum depth
and total percentage of sealer penetration were measured as
previously described.20
Statistical analysis
All values are presented as mean – standard deviation and
mean (maximum - minimum) percentage and frequencies.
Normally distributed groups with homogeneous variances
were compared by Student’s t-test or analysis of variance as
appropriate. Regarding variables for which parametric test
assumptions were not available, comparisons were made
using the Mann–Whitney U test or Kruskal–Wallis test. For
comparisons of means of repeated measures, repeated
measures analysis of variance was used. If preconditions
were not met for parametric tests, the Friedman test was
used. Multiple comparisons were adjusted for using Bon-
ferroni’s correction. Categorical data were analyzed using
Fisher’s exact test or the chi-square test. p Values <0.05
were considered statistically significant.
Results
Evaluation of debris and smear layer removal
Intergroup comparison (irrigation activation technique
comparison). In the middle third of the root, PIPS removed
debris more effectively than CSI ( p < 0.01), whereas there was
no significant difference between EV and PIPS ( p > 0.05). In
the coronal and apical thirds (Fig. 2A), there were no signif-
icant differences among CSI, EV, and PIPS regarding debris
removal. There were no significant differences among the
FIG. 2. Intergroup and intragroup analysis
for debris (A) and smear layer (B) removal in
apical, middle, and coronal thirds. *Significance
at p < 0.01.
EFFICACY OF IRRIGATION ACTIVATION TECHNIQUES 5

FIG. 3. Representative scanning electron microscopic images showing coronal, middle, and apical thirds of the root canal
after irrigation activation with CSI, EV, and PIPS. The most intense debris and amorphous smear layer with no open
dentinal tubules were observed in the control group. Experimental groups demonstrated minimal debris with a few occluded
tubules in the coronal third, fewer open dentinal tubules with more smear plugs in the middle third, and a thick smear layer
and more debris with few patent tubules in the apical third.

FIG. 4. Representative confocal laser scanning microscopic images from each group at 2, 5, and 8 mm.
6 TURKEL ET AL.

methods with respect to smear layer removal at any of the
three levels ( p > 0.05; Fig. 2B).
All experimental groups except CSI had better debris and
smear layer removal than the control group at all levels of
the radicular dentin ( p < 0.01). There were no significant
differences between the CSI and control groups regarding
debris removal at the middle and apical thirds ( p > 0.05).
Intragroup comparison (comparison of canal thirds).
CSI, EV, and PIPS removed debris and smear layer more
effectively in the coronal and middle thirds than at the apical
third ( p < 0.01). CSI and EV removed debris more effec-
tively (Fig. 2A) and CSI, EV, and PIPS removed smear layer
more effectively (Fig. 2B) at the coronal third compared
with the middle third ( p < 0.01). The PIPS group had a
significantly lower mean debris score in the middle third
than in the coronal third ( p < 0.01; Fig. 2A). In the control
group, there were no significant differences regarding debris
or smear layer removal among the three levels of radicular
dentin ( p > 0.05).
None of the irrigation activation systems was capable of
removing debris and smear layer completely. Characteristic
SEM images in the coronal, middle, and apical thirds of all
groups are presented in Fig. 3.
Evaluation of sealer penetration
One specimen from the CSI + AH Plus group and one
from the EV + TotalFill BC group were excluded from the
study because of technical issues during preparation for

FIG. 5. Comparison of different irrigation activation techniques and sealers relative to maximum depth (A) and per-
centage (B) of sealer penetration at 2, 5, and 8 mm. *Significance at p < 0.05. A, AH Plus; T, TotalFill BC.
EFFICACY OF IRRIGATION ACTIVATION TECHNIQUES 7

Percentage, mean (–SD)

confocal laser scanning microscopic analysis. Characteristic

(29.6)–93.1 (11.3){
(32.6)–78.9 (19.2)

(23.9)–84.9 (16.2)
(23.9)–84.9 (16.2)
(16.2)–84.9 (16.2)
(32.6)–86.5 (92){

(29.6)–89.8 (8.1)

(8.1)–93.1 (11.3)
CLSM images from all groups at 2, 5, and 8 mm are shown

(19.2)–86.5 (92)
in Fig. 4.

Irrigation activation technique comparison

Maximum depth of sealer penetration. Among the
groups in which AH Plus was used, there was a significant
difference between CSI + AH Plus and PIPS + AH Plus

78.9
72.8
72.8
84.9
54.6
54.6
89.8
58
58
regarding the maximum depth of sealer penetration at 2 mm

TotalFill BC
( p < 0.05; Fig. 5A). There were no other significant differ-
ences at 2, 5, or 8 mm ( p > 0.05). Among the groups in

Table 3. Comparisons of Maximum Depth and Total Percentage of Sealer Penetration by Section

(370.9)–1470.4 (491.9){
(370.9)–1947.1 (585.7){

(532.9)–1713.8 (361.5){
(105.7–2034.6 (445.4){
(105.7)–1558.2 (470.4)

(470.4)–2034.6 (445.4)

(491.9)–1947.1 (585.7)

(430.8)–1713.8 (361.5)
Max. depth, mean (–SD), (l)
which TotalFill BC was used, there were no significant

(532.9)–1458 (430.8){
differences in the maximum depth of sealer penetration at
any of the levels ( p > 0.05).

Percentage of sealer penetration. For both sealer types,

no significant differences in the percentage of penetration
were observed among the irrigation activation techniques at
any of the levels ( p > 0.05; Fig. 5B).

1458
834.1
834.1

932.3
932.3

813.5
1558.2

1470.4
813.5
Sealer comparison
Maximum depth of sealer penetration. TotalFill BC
showed a significantly greater maximum depth of penetra-
tion than AH Plus for CSI at 2 mm ( p < 0.05), however, no

Percentage, mean (–SD)

(28.7)*

(16.8)*

(13.6)*
(18.3){

(17.2){
(18.3)

(17.2)
significant differences were observed for EV or PIPS

(9.4){
(9.4)
( p > 0.05). In addition, no significant differences were ob-
served between AH Plus and TotalFill BC at 5 and 8 mm

(25.1)–60.6
(25.1)–83.1
(28.7)–83.1
(26.8)–81.9
(26.8)–87.3
(16.8)–87.3
(33.9)–78.9
(33.9)–91.6
(13.6)–91.6
( p > 0.05; Fig. 5A).

Percentage of sealer penetration. TotalFill BC had

greater percentage of penetration than AH Plus in CSI and 29.3
29.3
60.6
51.9
51.9
81.9

78.9
42
42

Significant differences are indicated by asterisks (*p < 0.05) and number sign ({p < 0.01).
EV at 2 mm and in PIPS at 5 mm ( p < 0.05). However, no
other significant differences were observed between the
sealers at 2, 5, and 8 mm ( p > 0.05; Fig. 5B).
AH Plus

(570.7)–1212.7 (626.3)*

(626.3)–1915.3 (213.7)*
(570.7)–1915.3 (213.7){

(472.4)–1368.5 (286.1){
(472.4)–1586.8 (385.3){

(636.7)–1547.5 (509.1){
(286.1)–1586.8 (385.3)
Max. depth, mean (–SD), (l)

Sectional comparisons

(636.7)–1930 (496.9){
(509.1)–1930 (496.9)
For each experimental group, the maximum depth and
highest total percentage of sealer penetration were observed
at 8 mm, followed by 5 and 2 mm. Statistically significant
differences among sections are shown in Table 3.

Discussion
Smear layer removal from root canal walls during in-
391.9
391.9

616.1
1212.7
616.1

1368.5
805.2
805.2
1547.5

strumentation allows endodontic irrigants and filling ma-

terials to enter the dentinal tubules. In previous studies,
activation of NaOCl and EDTA using the EndoVac (EV)
Max., maximum; SD, standard deviation.

system and PIPS appeared to improve smear layer removal

comparison (mm)

and the cleaning capability of irrigants compared with

CSI.21–23 However, in this study, no significant differences
Sectional

among these groups were noted regarding smear layer re-

2–5
2–8
5–8
2–5
2–8
5–8
2–5
2–8
5–8

moval; the most important step in removing the smear

layer appeared to be introduction of EDTA into the ca-
nal.24 In addition, no significant differences among ex-
perimental groups were observed in debris removal at
apical and coronal levels. These findings are similar to
the study by Howard et al.,25 who presented no signifi-
Group name

cant differences in canal and isthmus cleanliness between

EV and side-ported needle irrigation. They reported that
PIPS

irrigation volume was a greater factor in debris and bac-

CSI

EV

teria removal than the irrigation method. In this study,

8 TURKEL ET AL.
standardized irrigation/activation procedures (15 mL total
irrigation solution volume and 90 sec total irrigation solu-
tion delivery time) were tested for all groups. The similar
debridement efficacy of CSI observed may be attributed
to the high volume and long action time of the irrigation
solutions. On the other hand, a study by Versiani et al.26
using the micro-computed tomography has shown signifi-
cantly greater percentage of aggregated debris in the mesial
canals (mainly in the isthmus area) of mandibular molars
with CSI than EV. The methodology of this study might
have some limitations, making it difficult to compare the
results with the clinical environment. Therefore, further
studies on molar teeth with different assessment techniques
are needed.
In this study, none of the irrigation activation systems was
able to remove debris and smear layer completely in the
apical third of the canal, even for single-canal teeth. The
placement of the PIPS endodontic fiber tip in the coronal
part of the root may be too far away to activate fluid flow
toward the apical part of the canal, affecting its debridement
efficacy.27,28 In a previous study,12 PIPS was activated for
20 sec, whereas in this study, the activation time was ex-
tended to 60 sec. Despite the longer activation time used in
our study, compared with CSI, significant improvement of
debridement efficacy was observed only in the middle third
of the canal using PIPS.
Penetration of root canal sealers into chemomechanically
exposed dentinal tubules is considered advantageous with
respect to filling materials’ sealing and bonding capability,7
as well as microbial activity.14 Although recent studies
demonstrated no relationship between sealer penetration and
sealability29 or bonding ability30 of root filling materials,
presence of sealer within the dentinal tubules can be con-
sidered an indicator of efficient smear layer removal.31
Therefore, we evaluated the maximum depth of sealer
penetration along with the percentage of penetration in this
study.
When subgroups with the same sealer were compared,
PIPS allowed greater sealer penetration of AH Plus than CSI
at 2 mm. This finding is in accord with the result of a pre-
vious study in which PIPS demonstrated greater dentinal
penetration than CSI.32 Our findings for EV and CSI were
partially supported by the findings of Kara Tuncer and
Unal.33 They reported that the maximum depth and per-
centage of sealer penetration using EV were significantly
greater than those for CSI at 1 and 3 mm. In contrast, they
reported that there was no difference between EV and CSI at
5 mm. Given that the percentage of sealer penetration is
considered to be more clinically related than the maximum
depth of sealer penetration,31 it is reasonable to consider that
the smear layer removal efficacy and dentinal tubule pene-
tration were consistent among all three irrigation activation
methods tested in this study.
When subgroups using the same irrigation activation
technique were compared, TotalFill BC use after final ir-
rigation procedures with EV and CSI at 2 mm and with
PIPS at 5 mm showed a significantly greater percentage of
penetration than AH Plus use. In addition, TotalFill BC use
after final irrigation procedures with CSI at 2 mm exhibited
a significantly greater maximum depth of penetration than
AH Plus use. To date, no studies have yet analyzed the
effectiveness of TotalFill BC for dentinal tubule penetra-
tion. iRoot SP sealer (Innovative BioCeramix, Inc., Van-
couver, Canada), which has a similar composition to
TotalFill BC, was shown to have a greater penetration area
than AH Plus.32 The greater dentinal tubule penetration area
of iRoot SP was found to be related to sealer’s small par-
ticle content and high viscosity.32 Further, after drying the
root canals with paper points, the amount of remaining ir-
rigation solution in the root canal system is unpredictable
because canal anatomy varies.34 As shown previously, re-
sidual moisture in the root canal is critical for AH Plus,
which may decrease dentinal tubule penetration of the
sealer.34 Recently, an epoxy-amine resin-based sealer has
been advocated for use with an ultrasonic activation method
that allowed an enhanced sealer penetration into lateral
canals.35
Regarding the overall comparison of canal thirds, previ-
ous reports indicated that debris and smear layer remov-
al22,23 and tubular penetration of the sealers17,32,36 were
greater in the coronal and middle thirds of root canals than
in the apical third. This may be caused by a decreased flow
and irrigant distribution,37 a decrease in the diameter and
number of the dentinal tubules, and greater formation of
tubular sclerosis in the apical third compared with those in
the coronal and middle thirds.18,38
The literature contains some controversy regarding the
relationship between the smear layer and dentinal tubule
penetration of sealers. Some studies have demonstrated no
sealer penetration when a smear layer was present,15,39
while others have shown that the presence of this layer
does not completely block the dentinal tubule; a trace of
sealer penetration can be observed.40 One potential limi-
tation of our study’s methodology might be that no in-
vestigation of dentinal tubule penetration in the presence of
the smear layer was performed. Therefore, further studies
are needed to investigate the effect of the smear layer on
sealer penetration.
Conclusions
EV, PIPS, and CSI produced almost similar debridement
efficacy, smear layer removal, and dentinal tubule penetra-
tion. TotalFill BC sealer achieved superior tubular pene-
tration compared with AH Plus.
Acknowledgments
This study was supported by the Baskent University Re-
search Fund (Project No. D-KA15/04).
Author Disclosure Statement
No competing financial interests exist.
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Emel Olga Onay
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layer removal: an SEM analysis. Int Endod J 2005;38:285– Department of Endodontics
290. Faculty of Dentistry
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rather than the smear layer impedes dye penetration into the 82. Sok. No. 26, Bahcelievler
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Endod J 2006;39:18–25. Turkey
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CK. The influence of the smear layer on dentinal tubule E-mail: eonay@baskent.edu.tr
penetration depth by three different root canal sealers: an
in vitro study. J Endod 2004;30:100–102. Received: September 30, 2016.
40. Kuçi A, Alaçam T, Yavas x O, Ergul-Ulker Z, Kayaoglu G. Accepted after revision: December 5, 2016.
Sealer penetration into dentinal tubules in the presence or Published online: February 22, 2017.