0099-2399/83/0907-0289/$02.
00/0
JOURNAL OF ENDODONTICS
Copyright 9 1983 by the American Association of Endodontists
The Use of Ultrasonics in the Removal of the Smear
Layer: A Scanning Electron Microscope Study
J. A. Cameron, BDS
The root canals of 35 extracted human teeth were
chemomechanically prepared to clinical standards
and then subjected to ultrasound for either 1, 3, or
5 min. A Cavitron dental unit generated the ultra-
sonic energy and delivered it to the 3 % NAOCI
irrigation solution within the root canal. The scan-
ning electron microscope (SEM) study indicated
this to be an efficient way to remove part or all of
the smear layer from the root canal wall.
The chemomechanical phase of endodontic treatment
is designed to remove debris and infected material
from the root canal and to shape the canal, making it
easier to place the root canal filling. Scanning electron
.microscope (SEM) studies (1-3) have shown that
debris is retained in root canals prepared to clinical
standards. This debris can contain bacteria, pulp rem-
nants, necrotic tissue, and dentin chips. This debris
collects and is most evident in the apical third of the
canal. Where the canal wall has been instrumented,
the presence of dentinal tubules is obscured by a
"smear layer," which has been described as
"translocated dentine" (1) or dentin plus necrotic and
viable tissue (2). Similar smear layers have been de-
scribed for coronal cavity preparations (4) and for root
surfaces after scaling with hand instruments (5). The
smear layer is described as loosely attached to the
underlying surface and shows shrinkage cracks as a
result of drying the specimens for SEM investigation.
The presence of a smear layer could adversely effect
attempts to obtain and maintain a satisfactory apical
seal.
Removal of the smear layer under clinical conditions
has presented some problems. Although Tidmarsh (6)
flooded the canal with 50% citric acid during instru-
mentation and the acid prevented the formation of a
smear layer, 60 ml of distilled water was required as
a final irrigation to remove the crystals of calcium
citrate from the canal wall. McComb and Smith (2)
found that even after 15 min of exposure to REDTA
(Roth and Co.), the smear layer remained intact, but
sealing the REDTA into the canal for 24 h and then
289
Printed in U.S.A.
VOL. 9, NO. 7, JULY 1983
irrigating with water removed the smear layer com-
pletely.
Ram (7), in his study of chelating agents, found that
the use of RC Prep (Premier) during instrumentation
did not prevent the formation of a smear layer. Gold-
man et al. (3) used 20 ml of 5% NaOCI delivered
through a perforated needle, and they were still unable
to remove the smear layer in instrumented sections of
the root canal. Immersing an extracted, instrumented
tooth in 5% NaOCI for 3 days removed the superficial
smear layer but left plugs of debris in the openings to
the dentinal tubules (1).
A SEM study was designed to investigate the effi-
ciency of ultrasound, used with a 3% NaOCI solution,
as a means of removing the smear layer. Every effort
was to be made to duplicate clinical conditions so that
any conclusions would have chair-side significance.
MATERIALS AND METHODS
For this experiment, the 39 teeth that were used
had been extracted the same day from mature adults
for prosthetic purposes were used. The sample in-
cluded maxillary and mandibular incisors, canines,
and premolars. The canals were instrumented through
a conventional access cavity, using Hedstrom files
with stoppers set to a length 1 mm short of the visual
apex. The apical funnel was enlarged by a minimum
of two instrument sizes; the remaining canal was
shaped with the appropriate size Gates-Glidden in-
strument. To irrigate, 1 ml of 3% NaOCI was used
between each instrument size; the final irrigation was
accomplished with 5 ml of 3% NaOCI and 5 ml of 3%
H202, and 1 ml of each irrigant was used alternately.
Any further protein solvent action of the NaOCI was
minimized by irrigating the canals with a 2-ml cartridge
of anesthetic solution. The ultrasonic unit (Cavitron
model 70011) had a smooth broach in the endodontic
insert (no. PR30) (Fig. 5). The length of the broach
was adjusted so that its tip would reach the middle
third of the root canal; the power knob of the unit was
set to no. 3.
The teeth were apportioned into groups 1 through
4 randomly as follows:
 290 Cameron Journal of Endodontics

RESULTS

The smear layer was thought to consist of two

separate layers: one was superficial and loosely ad-
herent to the underlying dentine and the other con-
sisted of debris plugs in the openings of the dentinal
tubules. When the four groups were assessed for the
absence of either of these two layers, the specimens
within each group were consistent, and the differ-
ences between groups 1, 2, and 3 were distinctive.
The cleaner areas of specimens in group 3 were
similar to the overall appearance of specimens in
group 4. All groups had dentin chips on the canal wall.
Figures 1 through 4 represent areas typical of each
group.
Group 1 r a T h e specimens in this control group had
a typical smear layer appearance (Fig. 1). The pres-
FtG 1. Control group showed complete smear layer, which obliter-
ence of the dentinal tubules was obscured and dentin
ated presence of dentinal tubules (original magnification x4,500).
chips were present in all samples.
Group 2 - - A f t e r 1 min of ultrasound, the superficial
Group 1 (four t e e t h ) E T h i s group received no fur-
smear layer had been removed; dentinal tubules were
ther treatment and served as a control.
now seen (Fig. 2). The debris plug in the mouth of
Group 2 (1 5 t e e t h ) E T h e root canal and pulp cham-
these tubules was still present but showed signs of
ber were filled with 3% NaOCI, the tip of the ultrasonic
shrinkage during preparation of the specimen. An
probe (ultratip) was placed in the solution in the middle
elevated ring of peritubular dentin was just evident.
third of the root canal, and the ultrasonic unit was
Dentin chips were present in all specimens.
activated for I min. The probe was then removed from
Group 3 - - A f t e r 3 min of ultrasound, most of the
the tooth, and the canal was irrigated with a 2-ml
smear layer had been removed (Fig. 3). The dentinal
cartridge of anesthetic solution.
tubules were now clearly seen and most had patent
Group 3 (1 5 t e e t h ) - - T h e root canal and pulp cham-
openings. Dentin chips were present in all samples.
ber were filled with 3% NaOCI, the ultratip was placed
Group 4 m A f t e r 5 min of ultrasound, removal of the
in the middle third of the canal, and the unit was smear layer was virtually complete (Fig. 4A); little
activated for 1 min. The probe was then removed, the evidence of any debris in or around the dentinal tu-
canal was given an intermediate irrigation of approxi- bules existed. The mouths of the dentinal tubules were
mately 1 ml of 3% NaOCI, and the ultratip was re- now rounded over instead of square, and, overall, the
placed in the middle of the canal. This process was surface appeared to be less smooth. One specimen
repeated until the canal had received a total of 3 min disclosed an uninstrumented hollow (Fig. 4B), with no
of ultrasound. The canal was then given a final irriga-
tion of 2 ml of anesthetic solution.
Group 4 (five t e e t h ) - - T h e teeth in this group were
given treatment similar to that given the teeth in group
3 except that the teeth in group 4 received a total of
5 min of ultrasound in five increments of 1 min each.
The final irrigation was a 2-ml cartridge of anesthetic
solution.
In eady experiments, the roots of the teeth were
grooved and split to expose the root canal surface,
but the samples obtained were not always suitable for
use on the electron m i c r o s c o p e - - t h e apical area had
a tendency to split independent of the external
grooves. The final specimens were prepared-from the
apical third of the root and a diamond wheel and a
fine water-air mist. The specimens were then dried,
given a minimum thickness gold co~ting, and viewed
with a Joel JXA50A electron microscope. The speci-
men was photographed with a Mamiya camera on F~G2. One minute of ultrasound removed superficial smear layer
Ilford HP5 film. (original magnification x4,500).
Vol. 9, No. 7, July 1983
FIG 3. Three minutes of ultrasound removed superficial smear layer
and most of plugs from the dentinal tubules (original magnification
x4,500).
FIG 4. A, Removal of smear layer is complete after 5 min of
ultrasound. Surface now appears to be eroded (original magnifica-
tion x4,500). B, Uninstrumented area in apical third of root canal
after 5 rain of ultrasound. Note absence of predentin, smear layer,
and gross debris (original magnification x4,500).
Ultrasonics in Smear Layer 291
FtG 5. Smooth broach in Cavitron endodontic insert no. PR30.
evidence of debris, predentin, or smear layer in this
hollow. Dentin chips were still present.
DISCUSSION
This study was based on observations made during
the recovery of root canal filling models. When a tooth
that had been prepared to meet clinical standards was
root filled and then split, the root canal sealer adhered
to the gutta-percha. If an instrumented tooth was
subjected to 3% NaOCI in an ultrasonic bath before
root filling and splitting, then the root canal sealer
showed equal adhesion to gutta-percha or the root
canal wall. The smear layer appeared to be serving as
a "release layer," as is used in fiberglass moulding,
and to be preventing the sealer from adhering to the
canal wall. This effect could have clinical significance
because the setting shrinkage of the sealer could pull
the sealer away from the canal wall, whereas a space
between the gutta-percha and sealer would be pref-
erable. A smear-free wall would be more receptive to
adhesive or chemically bonded sealers.
This study would indicate that the smear layer con-
sists of two separate layers: one superficial layer
loosely attached to the underlying dentine and the
other layer consisting of debris plugs in the openings
of the dentinal tubules. This concept is supported by
the results of previous workers who used NaOCI (1)
or REDTA (2) to remove the smear layer. The appear-
ance of the specimens in groups 2 and 3, i.e. those
receiving 1 or 3 min of ultrasound, respectively, was
consistent enough to suggest that the operator could
remove the superficial smear layer and leave the tu-
bules closed with a dentin plug, or increase the ex-
posure to ultrasound and remove both components of
the smear layer. This ability to selectively remove the
superficial debris would satisfy clinicians who think
that a dentin/debris plug is the most effective way of
sealing dentinal tubules. Perhaps, in the future, a
sealer with a microfine grain size will be designed to
enter the tubules.
The presence of dentin chips on the canal wall in all
specimens might be the result of deviation from clinical
practice or in the preparation of the specimens. The
final irrigation of a root canal is usually 5 ml of NaOCI
292 Cameron Journal of Endodontics

solution, but not 2 ml of anestheic solution. The extra
volume could reduce the number of dentin chips pres-
ent. For this experiment, the canals were not dried by
clinical methods after the final irrigation. Paper points
could absorb those chips suspended in the irrigation
solution. Some of the chips might have appeared
during the preparation of the specimens using a dia-
mond wheel. Whatever the reason for the presence of
these chips, their numbers could not be regarded as
significant.
In 5 min, ultrasound used in conjunction with 3%
NaOCI will have cleaned the uninstrumented canal
wall as effectively as 3 days of exposure to 5% NaOCI.
Currently, this clean uninstrumented area is merely an
interesting observation and has little clinical signifi-
ance with the root canal filling materials that are being
used at present. However, some thought to the future
in terms of materials used to obturate root canals
could improve endodontics without sacrificing the
quality.
SUMMARY AND CONCLUSIONS
The use of a Cavitron dental ultrasonic unit to re-
move the smear layer was investigated using a SEM.
The irrigation solution was 3% NaOCI. The results
would indicate that the smear layer consists of two
separate layers: one layer, superficial and loosely
attached to the underlying dentin, and the other layer,
dentin/debris plugs in the mouths of the dentinal
tubules. One minute of ultrasound removed the su-
perficial smear layer but left the dentinal tubules
sealed off. Three minutes of ultrasound removed all of
the superficial smear layer and most of the dentinal
tubule plug layer. Five minutes of ultrasound removed
all debris in instrumented and uninstrumented areas
except for a few dentin chips.
This method would seem to be the most effective
method of cleaning root canals and could stimulate
new areas of research in material technology.
References
1. Lester KS, Boyde A. Scanning electron microscopy of instrumented,
irrigated and filled root canals. Br Dent J 1977;143:359-67.
2. McComb D, Smith D. A preliminary scanning electron microscopic
study of root canals after endodontic procedures. J Endodon 1975;1:238-
42.
3. Goldman L, et al. Scanning electron microscope study of a new
irrigation method in endodontic treatment. Oral Surg 1979;48:79-83.
4. Boyle A. Finishing techniques for the exit margin of the approximal
portion of Class II cavities. Br Dent J 1973;134:326-7.
5. Jones S, et al. Tooth surfaces treated in situ with periodontal instru-
ments. Br Dent J 1972;132:60-1.
6. Tidmarsh B. Acid-cleansed and resin sealed root canals. J Endodon
1978;4:117-121.
7. Ram Z. Chelation in root canal therapy. Oral Surg 1980;49:64-7.

AAE ENDOWMENT AND MEMORIAL

FOUNDATION

Grants-in-Aid Program fund research

The Grants-in-Aid Program awards
qualified investigators grants from
$100 to $1,000. For applications, write
AAE's Endowment and Memorial
Foundation at the central office.
Awards from the Grants-in-Aid Pro-
gram (May 1982 through February
1983) have been presented to these
investigators:
Dr. Bjorn Ragnar Ragnarsson, "Col-
lagenase inhibition in hard dental
structures." University of Illinois Col-
lege of Dentistry. Awarded $300.
Dr. Paul Fabian Bery, "Influence of a
dentinal plug in the efficacy of the
seal in endodontically treated teeth."
University of Illinois College of Den-
tistry. Awarded $200.
Dr. Mark Steven Berg, "Comparative
study of Salvisol, sodium hypochlo-
rite, and EDTA-C as adjuncts to che-
momechanical preparation of the
root canal." University of Illinois Col-
lege of Dentistry. Awarded $500.
Dr. Thomas Joseph Rysz, "An evalua-
tion of experimental sampling tech-
niques and anaerobic media adapted
for routine endodontic culturing."
University of Illinois College of Den-
tistry. Awarded $450.
Dr. Laurence Douglas John, "A com-
parison of the effect of bioinstrumen-
tation and root canal filling on the
periapical tissues in monkeys." In-
diana University School of Dentistry.
Awarded $580.
Dr. Steven Mark Patterson, "A com-
parison of the effect of bioinstrumen-
tation and root canal filling on the
periapical tissues in monkeys." In-
diana University School of Dentistry.
Awarded $580.
Dr. Ling Huey Chiueh, "Dose response
characteristics of macrophage to
metallic ion." Northwestern Univer-
sity Dental School. Awarded $350.
Dr. Gary W. Moss, "A microprobe anal-
ysis of cellular cementum in normal
and diseased teeth." Loma Linda
University School of Dentistry.
Awarded $450.
Dr. Greg Arthur Burk, "Pulpal re-
sponse to operative trauma following
ligamental injections." Tufts Univer-
sity School of Dental Medicine.
Awarded $490.
Dr. Bayardo Martell, "Comparative tis-
sue toxicity evaluations of gutta-per-
cha root canal sealers: 8- and 24-
hour assays from rat connective tis-
sue." Temple University School of
Dentistry. Awarded $400.
Dr. James Sanfilippo, "The effect of
the removal of the smeared layer on
marginal seal adaptation using un-
filled resin-lined restorative mate-
rials." Tufts University School of
Dental Medicine. Awarded $400.