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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 1  |  Page : 2-8

Comparative evaluation of oxytetracycline versus QMix, MTAD, and ethylenediaminetetraacetic acid as smear layer removal agents: An in vitro study


1 Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
2 Conservative Dentistry and Endodontics, Previous Post Graduate Student in Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Date of Web Publication4-Jun-2018

Correspondence Address:
Meenu Garg Singla
Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_72_17

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  Abstract 

Aim: The aim is to evaluate the smear layer removal efficacy of Oxytetracycline and compare it with different endodontic irrigating solutions (QMix, mixture of tetracycline, citric acid, and detergent [MTAD] and ethylenediaminetetraacetic acid [EDTA]) under scanning electron microscope (SEM).
Materials and Methods: Fifty single-rooted teeth were decoronated. All the root canals were shaped with K3XF rotary Ni-Ti instruments (#30.,06) and irrigation was done with 2 ml of 5.25% sodium hypochlorite (NaOCl) solution between each file change. The samples were divided randomly into the 5 groups (n = 10) depending on the final irrigant used as follows: 5.25% NaOCl as control (Group 1), 17% EDTA (Group 2), QMix (Group 3), BioPure MTAD (Group 4), and Oxytetracycline (Group 5). The final irrigation was done using 5 ml of the respective irrigating solutions, each for 60 s. Specimens were fractured longitudinally. For each root, the half containing most visible part of apex was selected for the SEM analysis. The presence/absence of smear layer was evaluated at the coronal, middle, and apical third of the root canal using three score criteria. Data were analyzed using Mann–Whitney U-test and Kruskal–Wallis test.
Results: QMix showed the least smear layer scores followed by MTAD, EDTA, NaOCl, and Oxytetracycline.
Conclusion: Within the limitation of this study, it can be concluded that the test irrigant Oxytetracycline failed to remove the smear layer throughout the entire length of the root canal.

Keywords: Ethylenediaminetetraacetic acid, mixture of tetracycline, citric acid, and detergent, oxytetracycline, QMix, scanning electron microscope, smear layer removal


How to cite this article:
Singla MG, Relhan N, Aggarwal H. Comparative evaluation of oxytetracycline versus QMix, MTAD, and ethylenediaminetetraacetic acid as smear layer removal agents: An in vitro study. Endodontology 2018;30:2-8

How to cite this URL:
Singla MG, Relhan N, Aggarwal H. Comparative evaluation of oxytetracycline versus QMix, MTAD, and ethylenediaminetetraacetic acid as smear layer removal agents: An in vitro study. Endodontology [serial online] 2018 [cited 2018 Oct 21];30:2-8. Available from: http://www.endodontologyonweb.org/text.asp?2018/30/1/2/233750


  Introduction Top


The elimination of microorganisms from the root canal is an important step in the success of endodontic therapy.[1] Such outcome can be achieved by the cleaning and shaping phase of root canal therapy, where the zone of infection in the root canals is removed and subsequently sealed in all three dimensions.[2] During cleaning and shaping process, organic pulpal material and inorganic dentinal debris accumulate on the canal wall, producing an amorphous irregular smear layer, first described by McComb and Smith in 1975.[3]

The smear layer may harbor bacteria and has the potential to protect bacteria within the dentinal tubules, thereby preventing the canal from being disinfected.[4] It also negatively affects the penetration and adhesion of obturation materials on root canal walls.[5]

The removal of smear layer is necessary to achieve disinfection of the root canal system by deeper penetration of the root canal medicaments and irrigants. It also allows greater penetration of the root canal sealers into the dentinal tubule openings, aiding an intimate adaptation of the obturating materials with the prepared canal walls.[6]

To maximize removal of microorganisms, the shaping and mechanical enlargement of root canal must be accompanied by copious irrigation.[7] The ideal requirements of endodontic irrigating solutions should be systemically nontoxic, nonacoustic to periodontal tissues, little potential to cause anaphylactic reaction, broad antimicrobial spectrum, ability to dissolve necrotic pulp tissue remnants, ability to inactivate endotoxin, as well as ability to prevent formation of the smear layer during instrumentation or to dissolve the latter once it has formed.[8]

Currently, no conventionally used irrigating solution meets all these characteristics. Sodium hypochlorite (NaOCl) being the most commonly used irrigant, has advantages of its antimicrobial action, the ability to dissolve vital and necrotic tissue, its lubricating action, and the mechanical flushing of debris from the canal. In addition, it is inexpensive and readily available. However, its capacity to remove smear layer from the instrumented root canal walls has been found to be lacking, as it dissolves only organic material.[9] while ethylenediaminetetracetic acid (EDTA) is most widely used as chelating agent for the removal of smear layer, lacks antibacterial activity.[10]

Recently another irrigant, QMix (DENTSPLY Tulsa dental, OK, USA), has been introduced which contains EDTA, chlorhexidine, and a detergent.[11] Dai et al.[12] and Stojicic et al.[13] found that QMix was effective in killing Enterococcus faecalis and plaque bacteria. It was also found to be effective in removal of smear layer.

Tetracyclines are a group of broad-spectrum antibiotics which are effective against wide variety of microorganisms. They readily attach to dentine and are subsequently released without losing their antibacterial activity.[14] Torabinejad et al. and associates introduced a tetracycline-based endodontic irrigant containing 3% doxycycline Hyclate, 4.25% citric acid and detergent (Tween-80) being commercialized as Biopure mixture of tetracycline, citric acid, and detergent (MTAD) (DENTSPLY Tulsa dental, OK, USA).[15] It is effective against E. faecalis, and it can also eliminate other microorganisms in root canals.[16] MTAD has also been found to be effective in the removal of smear layer when used alone or combination with NaOCl.[15]

Although both these irrigants have shown good efficiency as antibacterial agent and in smear layer removal, their high cost and limited feasibility still preclude their use in day-to-day practice.

Tetracycline and its derivatives in pure form have been recommended as a chelating agent during periodontal and endodontic treatment.[15] Doxycycline has been used during the periodontal treatment because of its antibacterial and chelating ability as well as its substantiveness.[15] Chai et al.[17] and Mittal et al.[18] proved the antibacterial efficacy of Oxytetracycline against E. faecalis when used as endodontic irrigant. However, there is not much evidence in the literature regarding smear layer removal ability of Oxytetracycline, when used as an endodontic irrigant.

Thus, an in vitro study was designed to evaluate the smear layer removal efficacy of Oxytetracycline, a tetracycline derivative and compare it with well-established smear layer removing agents (EDTA, MTAD, and QMix) when used as endodontic irrigating solutions, by scanning electron microscope (SEM) of the root canal walls at the coronal, middle, and apical third of each canal.


  Materials and Methods Top


Fifty single-rooted human teeth extracted for periodontal reasons were selected for this study. They were stored in normal saline at room temperature immediately after extraction until use. Inclusion criteria were morphological similarity; single-canal roots; straight roots; absence of root decay; absence of previous endodontic treatment; cracks; root length of at least 13 mm; apical diameter of at least #20. Teeth were sterilized by autoclaving for 15 min at 15 psi pressure and 121°C temperature immediately before use. The crown of each tooth was removed to obtain root segments of similar length of 13 mm. Two longitudinal grooves were prepared on the palatal/lingual and buccal surfaces of each root with a diamond bur in a high-speed water-cooled handpiece to facilitate vertical splitting with chisel after canal instrumentation.

The root canals were instrumented using stainless steel files #08–10–15 k-files (Mani, Prime Dental Product Pvt. Ltd., India) to create a glide path then shaped with K3XF (SybronEndo, USA) rotary Ni-Ti instruments. Each canal was prepared till ISO size #30 with a. 06 apical taper according to K3XF protocol. Root canals were irrigated during instrumentation between each file change with 2 mL of 5.25% NaOCl (Chemident, India). The roots were randomly assigned in 5 groups of 10 specimens each depending on the type of the final irrigant used, as follows: Group 1 (n = 10): Each root canal was flooded with 5.25% NaOCl (control) irrigating solution for 60 s as a final rinse. Group 2 (n = 10): Each root canal was flooded with 17% EDTA (Prevest Dentpro, India) irrigating solution for 60 s as a final rinse. Group 3 (n = 10): Each root canal was flooded with QMix (Dentsply Tulsa, OK, USA) irrigating solution for 60 s as a final rinse. Group 4 (n = 10): Each root canal was flooded with BioPure MTAD (Dentsply Tulsa, OK, USA) irrigating solution for 60 s as a final rinse. Group 5 (n = 10): Each root canal was flooded with Oxytetracycline (Oxytetracycline injection I. P. 50 mg/ml, Dueful Healthcare Pvt Limited, India) irrigating solution for 60 s as a final rinse.

Irrigation in each sample was done using NaviTip (29G, Ultradent Dental Products, South Jordan, USA) so as to reach within the apical third of the canal. The root canals were irrigated using 5 ml of the respective irrigating solution, each for 60 s. Each canal was finally flushed with 5 ml of distilled water and dried with absorbent paper points (Aishwarya healthcare, Himachal Pradesh, India). The teeth were split longitudinally, with the aid of chisel and a surgical mallet, through the previously placed grooves. For each root, the half containing the most visible part of apex was selected for SEM evaluation, and the remaining half was discarded.

Scanning electron microscope evaluation

Coded samples were mounted on metallic stubs, gold sputtered and viewed under SEM (ZEISS EVO 40). Photographs at magnifications of ×4000 were taken for each specimen. All the samples were evaluated at different levels of root canal that is coronal, middle, and apical to evaluate the presence and absence of smear layer. The amount of smear layer remaining on the surface of the root canal and dentinal tubules was scored according to a three-score system developed by Torabinejad et al.[15]

  • Score 1: No smear layer – no smear layer was detected on the surface of the root canal, and all tubules were open
  • Score 2: Moderate smear layer – no smear layer was detected on the surface of the root canal walls but tubules contained debris
  • Score 3: Heavy smear layer– smear layer covered the root canal wall surface and the tubules.



  Results and Observation Top


The results of the smear layer scores for each group with their mean and standard deviation values were obtained. Intragroup comparison of mean smear layer scores of coronal, middle, and apical third in each group was done using Friedman test along with post hoc pair-wise comparison using Wilcoxon test, which showed irrigating solutions (QMix, MTAD, and EDTA) were more effective in coronal third area followed by middle third and apical third area, and their intergroup comparison was done using Kruskal–Wallis test in the coronal, middle, and apical third area [Table 1]. The results showed that QMix had the least smear layer scores when compared to others. This was followed by MTAD, EDTA, 5.25% NaOCl, and Oxytetracycline.
Table 1: Intragroup and intergroup comparison of smear layer scores

Click here to view



  Discussion Top


Irrigation is an important step during and after instrumentation for effective removal of smear layer and lubrication of root canal system during instrumentation.[19]

The purpose of this study was to evaluate the smear layer removal ability of a pure tetracycline derivative, that is, Oxytetracycline and compare it with endodontic irrigants (EDTA, MTAD, and QMix) from the root canal walls at the coronal, middle, and apical third area.

Smear layer removal from canal walls was evaluated with SEM as it is one of the effective qualitative tools to study the surface morphology. The dentinal tubules are very well appreciated at ×4000.[20] The smear layer removal evaluation was done using criteria given by Torabinejad et al.[15] as it is the most commonly used criteria to evaluate smear layer in other studies.

In Group 1, NaOCl was used in the concentration of 5.25% as a control group. The results showed the presence of heavy smear layer on coronal, middle, and apical third area [Figure 1]. This proved that NaOCl failed to remove the smear layer in tested specimens. The finding of the present study is similar to the studies done by O'Connell et al.,[21] Torabinejad et al.,[22] Mancini et al.,[23] and Wu et al.[24]
Figure 1: Scanning electron microscope images of 5.25% sodium hypochlorite group: (a) Coronal third showing the smear layer covering the root canal surface and tubules (score = 3). (b) Middle third showing the smear layer covering the root canal surface and tubules (score = 3). (c) Apical third showing the smear layer covering the root canal surface and tubules (score = 3)

Click here to view


In Group 2, 17% EDTA was found to be effective in removal of smear layer from coronal and middle third area and was less effective in the apical third of root canal [Figure 2], which is in accordance with a study done by Torabinejad et al.[15] and Mancini et al.[23] The less efficacy in removal of smear layer in apical third area may be due to the presence of sclerotic dentine in the apical third of the root canal system, where 17% EDTA may not have pronounced action as described by Vasiliadis et al.[25] and Paqué et al.[26]
Figure 2: Scanning electron microscope images of 17% ethylenediaminetetraacetic acid group: (a) Coronal third showing absence smear layer on the root canal surface, but tubules contain debris (score = 2). (b) Middle third showing absence smear layer on the root canal surface, but tubules contain debris (score = 2). (c) Apical third showing absence smear layer on the root canal surface, but tubules contain debris (score = 2)

Click here to view


In Group 3, QMix 2 in 1 solution showed promising results in smear layer removal from the coronal, middle, and apical thirds of the root canal [Figure 3]. The same results were also shown by Dai et al.,[12] Stojicic et al.,[13] Eliot et al.,[27] and Vemuri et al.[19] The possible reason for effective smear layer removal could be attributed to combined effect of its constituent chelating agent, that is, EDTA, that dissolves the inorganic content of the root canal by reacting with calcium ions which forms soluble chelates [8] and a surface active agent, that is, cetrimide, which enables better penetration of an irrigant in the root canal.[13]
Figure 3: Scanning electron microscope images of QMix group: (a) Coronal third showing absence of smear layer on the surface of root canal and all the tubules are clean and open (score = 1). (b) Middle third showing absence of smear layer on the surface of root canal and all the tubules are clean and open (score = 1). (c) Apical third showing absence of smear layer on the surface of root canal and all the tubules are clean and open (score = 1)

Click here to view


In Group 4, MTAD also showed good results in removing smear layer from coronal, middle, and apical thirds of the root canal [Figure 4]. These results were similar to the results of studies conducted by Adigüzel et al.[28] and Paul et al.[29] which showed that MTAD is a good irrigating solution for removing smear layer in apical third. The possible reason for smear layer removal could be attributed to the detergent polysorbate 80, which decreases the surface tension and increases the permeability of 4.25% citric acid in MTAD to permeate better.[24]
Figure 4: Scanning electron microscope images of mixture of tetracycline, citric acid, and detergent group: (a) Coronal third showing absence of smear layer on the surface of root canal and all the tubules are clean and open (score = 1). (b) Middle third showing absence smear layer on the root canal surface, but tubules contain debris (score = 2). (c) Apical third showing absence smear layer on the root canal surface, but tubules contain debris (score = 2)

Click here to view


In Group 5, smear layer removal efficacy of test irrigant (Oxytetracycline) was evaluated. In this investigation, commercially available injectable form of Oxytetracycline was used to avoid the problem of insolubility of antibiotics in water.[30] Results showed that Oxytetracycline failed to remove smear layer in any of the tested specimens at all the level, that is, coronal, middle, and apical third [Figure 5].
Figure 5: Scanning electron microscope images of Oxytetracycline group: (a) Coronal third showing the smear layer covering the root canal surface and tubules (score = 3). (b) Middle third showing the smear layer covering the root canal surface and tubules (score = 3). (c) Apical third showing the smear layer covering the root canal surface and tubules (score = 3)

Click here to view


On intergroup comparison of smear layer removal efficacy, QMix showed the best results in coronal, middle, and apical third area of the root canal, but these results were not significantly different from MTAD. Vemuri et al.[19] reported that QMix showed significantly better results than MTAD in smear layer removal. This difference in the results might be due to difference in the period for which irrigant was used, that is, 3 min in their study, while it was used for 1 min in the present study.

QMix showed significantly better results than 17% EDTA in middle third, but the results were not statistically different in coronal and apical third area. A study done by Dai et al.[12] reported that QMix was as effective as 17% EDTA in removal of smear layer from the root canal system. Eliot et al.[27] demonstrated that QMix was superior to 17% EDTA in removal of canal wall smear layer. These findings support the result obtained in the present study. Venghat et al.[31] did a study to evaluate smear layer removal efficacy and reported that EDTA performed better than QMix, though the results were not significantly different. This difference in the results obtained from that of our study could be attributed to the different scoring system used in their study.

On comparison between MTAD and 17% EDTA, MTAD showed better removal of smear layer. An earlier studies done by Torabinejad et al.,[15] Jindal et al.,[10] and Paul et al.[29] reported that MTAD was more effective as compared to 17% EDTA in removal of smear layer. In contrast, Wu et al.[24] concluded that the use of EDTA solution was significantly more effective than MTAD at the coronal and middle third, which contradict the results obtained in the present study. This could be explained by the difference in volume of the irrigant used as we used 5 ml of MTAD in the present study, while only 1 ml of the irrigant was used in the study done by Wu et al.

Further, it was seen in the present study that QMix and MTAD showed significantly better removal of smear layer than 5.25% NaOCl and Oxytetracycline in coronal, middle, and apical third area of root canal.

Similarly, 17% EDTA showed significantly better removal of smear layer than 5.25% NaOCl and Oxytetracycline in coronal and middle third area, but the results of 17% EDTA were not significantly different from any of the test group in apical third of the root canal. Previous studies done by Torabinejad et al.[15] and Mancini et al.[23] also showed that EDTA was less effective in smear layer removal from the apical third of root canal. In contrast Kuah et al.[32] found that 1 min application of EDTA is efficient for smear layer and debris removal in the apical region of the root canal. The possible reason for better smear layer removal in the apical region could be the use of ultrasonic with EDTA in their study. However, in the present study, no ultrasonics were used.

In the present study, Oxytetracycline group was unable to remove the smear layer at all the levels in the canal. While in the studies done by Barkhordar et al.[33] and Haznedaroğlu and Ersev [34] which used tetracycline hydrochloride and doxycycline, respectively, effective removal of smear layer was noted. This difference in the results may be due to the difference in chemical structure and behavior of Oxytetracycline from other salts of tetracycline.


  Conclusion Top


Within the limitation of this study, it can be concluded that

  • Qmix showed the maximum smear layer removal efficacy compared to all other tested irrigants, followed by MTAD and 17% EDTA
  • None of the irrigants could remove smear layer in the apical third area completely
  • Oxytetracycline failed to remove the smear layer at all the levels of root canal.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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