Effectiveness of Nd:YAG Laser on the elimination of debris and Smear Layer. A comparative study with two different irrigation solution: EDTA and QMix® in addition to NaOCl

J Clin Exp Den . 2018;10(1):e70-4. E ec i eness o Nd:YAG Lase e70 Jou nal sec ion: Ope a i e Den is y and Endodon ics Publica ion Types: Resea ch E ec i eness o Nd:YAG Lase on he elimina ion o deb is and Smea Laye . A compa a i e s udy wi h wo di e en i iga ion solu ion: EDTA and QMix® in addi ion o NaOCl Paloma Mon e o-Mi alles, Robe o Es é ez-Luaña, Césa DeG ego io-González, Oli e Valencia-dePablo, Da- id E. Ja amillo, Ra ael Cisne os-Cabello 1 Uni e sidad de Se illa. School o Den is y. Se illa Co espondence: Uni e sidad de Se illa School o Den is y A icena S/N. 41009 Se illa mon e [email p o ec ed] Recei ed: 10/09/2017 Accep ed: 06/12/2017 Abs ac Backg ound: The aim o his s udy was o e alua e he e ec i eness in den in deb is and smea laye emo al om oo canal walls using EDTA and QMix® alone and also ac i a ed wi h Nd:YAG lase . Ma e ial and Me hods: 50 single- oo ed ee h we e ins umen ed and di ided in 5 g oups acco ding o i iga ion p o ocol: 17% EDTA, QMix®, Nd:YAG lase alone, and combina ion o 17% EDTA - Nd:YAG lase and QMix® - Nd:YAG lase . Samples we e e alua ed using SEM. S a is ical analysis was done using Chi-Squa e Fishe exac es and McNema es . Resul s: Den inal deb is analysis showed s a is ically signi ican di e ences when compa ing 17% EDTA s Lase and Lase s QMix® in combina ion wi h Lase a he apical hi d. The Smea Laye analysis also showed s a- is ically signi ican di e ences a he apical hi d when compa ing 17% EDTA s Lase , QMix® s QMix® in combina ion wi h Lase and Lase s QMix® in combina ion wi h Lase . Conclusions: 17% EDTA was he mos e icien i igan showing he bes esul s. Lase alone was no e ec i e emo ing ei he den inal deb is o smea laye . Key wo ds: Lase , endodon ics, Smea Laye . doi:10.4317/jced.54395 h p://dx.doi.o g/10.4317/jced.54395 In oduc ion The smea laye is a mic oscopic laye o med a e oo canal ins umen a ion and loca ed along he oo canal walls. I blocks den inal ubule o i ices and c ea es an in e ace be ween illing ma e ial and oo canal wall, a ec ing sealing abili y o he oo canal sys em. The wid h o his laye is be ween 1 o 2 mic ons (1) and i educes pene a ion o i igan s and seale s in o den inal ubules (2,3). Some s udies ha e shown ha mechanical ins umen a- ion and chemical ac ion o NaOCl a e no enough o emo e he smea laye o ally om he oo canal wall (4,5). Chela ing agen s a e used o i s emo al. QMix® (Dens ply-Maille e , Tulsa, USA) has been ecen ly launched, composed o an an imic obial agen , Chlo - hexidine, mixed wi h a chela ing agen , EDTA, and a su ac an (6). Lase echnology has been de eloping o se e al yea s A icle Numbe : 54395 h p://www.medicinao al.com/odo/indice.h m © Medicina O al S. L. C.I.F. B 96689336 - eISSN: 1989-5488 eMail: [email p o ec ed] Indexed in: Pubmed Pubmed Cen al® (PMC) Scopus DOI® Sys em Mon e o-Mi alles P, Es é ez-Luaña R, DeG ego io-González C, Va- lencia-dePablo O, Ja amillo DE, Cisne os-Cabello R. E ec i eness o Nd:YAG Lase on he elimina ion o deb is and Smea Laye . A com- pa a i e s udy wi h wo di e en i iga ion solu ion: EDTA and QMix® in addi ion o NaOCl. J Clin Exp Den . 2018;10(1):e70-4. h p://www.medicinao al.com/odo/ olumenes/ 10i1/jced 10i1p70.pd J Clin Exp Den . 2018;10(1):e70-4. E ec i eness o Nd:YAG Lase e71 and has become mo e widely used in he medical and den al ield. I s e ec i eness will depend upon such ac o s as: ene gy le el, du a ion o exposi ion, abso p- ion in issues, oo canal geome y and he dis ance be ween he ip o he lase and he issue being ea ed (7-9). The mos s udied lase in den al li e a u e is he Neodymium:Y ium-Aluminium-Ga ne (Nd:YAG), wi h a wa eleng h o 1064 nm and possessing pa ial wa e abso p ion. In endodon ics, i s e ec on he oo canal wall p oduce emo al o smea laye and pulp is- sue emnan s, oo canal decon amina ion, o ganic is- sue apo iza ion inside den inal ubules and usion and c ys alliza ion o he ino ganic componen o he den in (mel ing). I also p oduces physical-chemical changes on hyd oxyapa i e c ys als, which modi ies den in solu- bili y, hus becoming less suscep ible o acids ac ion. The objec i e o he p esen s udy was o e alua e he cle- aning capabili y o QMix®, 17% EDTA in combina ion wi h sodium hypochlo i e, plus he ac ion o Nd:YAG lase alone and wi h he p e ious chela ing solu ions. Ma e ial and Me hods This s udy was app o ed by he E hical Commi ee o he Eu opean uni e si y o Mad id. 50 eshly ex ac ed single- oo ed human ee h we e kep in 10% o malin un il used. Inclusion c i e ia we e: p esence o only one oo canal, comple e apical closu e and no p e ious oo canal ea men done p io o i s use. The c owns o all ee h we e cu o wi h he use o a diamond disk (Buehle , Düsseldo , Ge many) and oo h leng h s anda dized o 16 mm. A glide pa h was pe o - med wi h a #20 hand K-Flexo ile (Dens ply-Maille e , Tulsa, USA) and he cleaning and shaping o he oo canal was comple ed using he M wo® o a y sys em (VDW, Munich, Ge many) up o 40.04 o 15mm. Ca e was aken o keep oo canal pa ency a all imes. Du ing ins umen a ion, he oo canal was i iga ed in be ween iles wi h 1 ml o 4.2% NaOCl using a 5 ml Monojec i iga ion sy inge and a 27g i iga ion needle (Tyco Heal hCa e G oup, No walk, CT, USA) ha was kep 1 mm sho o he wo king leng h. A e his s ep, ee h we e kep in saline solu ion un il p ocessed o SEM. Samples we e andomly di ided using he so wa e www. andom.o g in o 5 g oups o 10 ee h each. Fo he inal i iga ion cycle, all oo s we e sealed apically wi h modeling wax (Ce a Reus, Reus, Spain) and a ese oi was c ea ed co onally. S udy g oups: G oup 1: 1 minu e o i iga ion wi h 5 ml o 17% EDTA (Pulpden , Oakland, MA, USA), ollowed by 5 ml o 4.2% NaOCl o 2 minu es and a inal inse wi h 2.5 ml dis illed wa e . G oup 2: 1 minu e o i iga ion wi h 5 ml o QMix® (Dens ply-Maille e , Tulsa, OK, USA) and a inal inse wi h 2.5 ml dis illed wa e . G oup 3: Nd:YAG lase (DEKA, Fi enze, I aly), o- llowed by desc ibed p o ocol by Gu knech and Be- h ens: powe se a 1.5 W, 15Hz and 100 mJ o ene gy [10]. Wa eleng h o 1.064 nm. A 320 mic ons op ic ibe was used wi h an apical o co onal helicoidal mo ion. Wo king leng h was es ablished a 15 mm. A ubbe s op was placed on he ibe op ic ip a 14 mm o se his as a wo king ield o he lase . The lase was ac i a ed on a 5 seconds cycle i e imes aking a es o 20 seconds in be ween each cycle. 2.5 ml o dis illed wa e was used as a inal inse (Fig. 1). Fig. 1: Nd:YAG lase applica ion. G oup 4: 1 minu e o i iga ion wi h 5ml o 17% EDTA plus lase . The lase ip used as p e iously desc ibed; hen, a inse wi h 5 ml o 4.2% NaOCl o 2 minu es and a inal inse wi h 2.5 ml o dis illed wa e . G oup 5: 1 minu e o i iga ion wi h 5 ml o QMix® in combina ion wi h lase , used as p e iously desc ibed and a inal inse wi h 2.5 ml o dis illed wa e . Roo s we e longi udinally spli using a 20x0.25 mm ine diamond disk (Buehle , Düsseldo , Deu schland) in a low speed mo o (NSK, Japan), a oiding passing he disk h ough he oo canal lumen o p e en he accu- mula ion o sec ioning deb is. Wi h he help o a ine chisel and wi h a e y ine pounding, bo h hal es o he oo we e ob ained. Roo s we e ea ed wi h a se ial dilu ion o di e en con- cen a ions o alcohol (30% o 100%) o he dehyd a ion p ocess. Samples we e moun ed on a special s ainless s eel base and aken inside he spu e ing machine o be coa ed wi h a ine laye o g aphi e (Blaze Union Med 010). Immedia ely a e , he samples ecei ed a 25 nm laye o gold (Emi ech K550X). A o al o 60 samples we e obse ed unde SEM. A SEM (JEOL JSM-6400) mic oscope was used wi h a 20kV, 100 mA. The wo - king dis ance was se a 39 mm. A speci ic a ea o he J Clin Exp Den . 2018;10(1):e70-4. E ec i eness o Nd:YAG Lase e72 apical and middle hi d o he oo canal was chosen o be he obse a ion spo s. Pic u es we e andomly aken i s a 20X magni ica ion o he co ec localiza ion o he obse a ion spo . Ima- ges we e cen e ed a he apical zone in o de o obse e he ma k le behind by he apical calib a ion ins umen . A 0.5 mm om his spo a 100X image was aken. Two images we e ob ained a 500X and 1000X magni ica ion. Magni ica ion was es ablished a 100x again o each ou he middle hi d, and wo images we e aken a 5 mm om he wo king leng h, a 500X y 1000X. The same p ocedu e was done a he middle a ea o he oo canal. All images we e analyzed by a p e iously calib a ed expe iewe . A modi ied Hülsmann classi ica ion (11) was used o measu e a he 500X le el o he p esen- ce o den inal deb is and a 1000X o he p esence o Smea Laye (Fig. 2). Fig. 2: Hülsmann modi ied classi ica ion. The sco es alues was assigned in his way: Sco e 0: specimens showing a clean su ace and mos o he den inal ubules open Sco e 1: specimens showing mos o he den inal ubules open bu emaining deb is co e ing less han a 25% o he analyzed a ea Sco e 2: specimens showing majo i y o den inal ubules plugged wi h smea laye and emaining deb is co e ing less han a 50% o he analyzed a ea Sco e 3: specimens showing no den inal ubules open and emaining deb is co e ing less han a 75% o he analyzed a ea Associa ion be ween all g oups and he deg ee o clean- liness, we e e alua ed using he chi-squa e and Fishe exac es o hose cases whe e mo e han 25% o he samples we e less han 5. Fo all he es s, a signi ica ion alue o 5% will be accep ed. The equency dis ibu ion was e alua ed wi hin he a iable esul s wi h 2 mag- ni ica ions (500X and 1000X) using he McNema es . Da a was analyzed wi h he SPSS 15.0 so wa e (SPSS Inc, Chicago, IL, USA). Resul s On den in deb is analysis, in he apical hi d, he bes cleanliness was achie ed by 17% EDTA in combina ion wi h lase and he esul s showed a s a is ically signi i- can di e ence (p= .015) when compa ed wi h he 17% EDTA g oup. Lase in combina ion wi h QMix® was ound be e (p= .028) han QMix® alone. In he middle hi d, no s a is ically signi ican di e ences we e ound a any s udied g oup. The smea laye analysis, in he apical hi d, when com- pa ing 17% EDTA in combina ion wi h lase (p= .031) wi h 17% EDTA, he combina ion o EDTA and lase showed be e esul s and a s a is ically signi ican di- e ence. Also, a s a is ically signi ican di e ence was ound when compa ing QMix® and QMix® in combi- na ion wi h lase (p=.029) whe e QMix® in combina ion wi h lase showed be e esul s when compa ing Lase in combina ion wi h QMix® s Lase , (p= .03) a s a is- ically signi ican di e ence was also ound p esen ing QMix® in combina ion wi h lase be e esul s. In he middle hi d, no s a is ically signi ican di e ences we e ound in any s udied g oup, (Tables 1-3). Discussion The smea laye emo al has been ho oughly in es iga- ed by many au ho s, du ing he las decades. The p e- sence o his mic oscopic laye , could a ec he adequa- e sealing o he oo canal sys em. The emo al o his ino ganic ma e , which con ains some o ganic emnan s as well, is pa icula ly di icul in he apical hi d. The objec i e o he p esen s udy was o e alua e he cle- aning abili y o QMix® in combina ion wi h Nd:YAG lase compa ed o 17% EDTA, o he den in deb is and smea laye emo al. Roo canals we e p epa ed o 40.04 allowing he 320 mi- c ons Nd:YAG ibe lase ip o each 1 mm sho o he es ablished wo king leng h and a he same ime allow o a be e lowabili y o he selec ed i igan (12). By doing his, a size 44 diame e was made a he le el whe- e he lase ip was placed, which allowed enough space be ween he canal walls and his ip. In o de o simula e a clinical condi ion, we used mo- deling wax in he apex o keep he oo canal sys em closed a oiding he ex usion o he i igan used du ing he inal inse s ep. Dai e al. used an open sys em in hei compa a i e s udy o smea laye emo al using 17% EDTA and QMix® (6). They concluded ha i was no possible o comple ely emo e he smea laye . Thei esul s showed no di e ence. In he p esen s udy, 17% EDTA and QMix® we e no e ec i e a apical and J Clin Exp Den . 2018;10(1):e70-4. E ec i eness o Nd:YAG Lase e73 middle hi ds. 17% EDTA was supe io o QMix® a all le els. The e was a s a is ically signi ican di e ence in den in deb is emo al a middle hi d. A his le el, QMix® was be e han 17% EDTA whe e den inal u- bules we e clean 8.3% o he ime, wi h no s a is ically signi ican di e ence. Time and concen a ion o he applica ion o chela ing agen s is an impo an ac o (13). Dai e al. applied QMix® o 2 minu es while S ojicic e al., used i o 5 minu es (14). In ou s udy, i iga ion iming was s anda - dized a 1 minu e (15-18). By doing his, i was possible o ob ain be e esul s wi h QMix® s 17% EDTA o he smea laye emo al, wi hou a s a is ically signi i- can di e ence. Mo e s udies a e needed o s anda dize he co ec applica ion iming o QMix. GROUP 1 (EDTA 17%) GROUP 3 (Lase ) Apical x500 0 0 % 0 0 % 1 25 % 1 0 % 2 66,7 % 2 50 % 3 8,3 % 3 50 % p=0.015 Apical x1000 0 0 % 0 0 % 1 25 % 1 0 % 2 50 % 2 33,3 % 3 25 % 3 66,7 % p=0.031 Table 1: Compa a i e deb is and Smea Laye analysis in apical hi d (17% EDTA and Lase ). GROUP 1 (Lase ) GROUP 3 (QMix® + Lase ) Apical x500 0 0 % 0 16,7 % 1 0 % 1 25 % 2 50 % 2 16,7 % 3 50 % 3 41,7 % p=0.028 Apical x1000 0 0 % 0 16,7 % 1 0 % 1 33,3 % 2 33,3 % 2 0 % 3 66,7 % 3 50 % p=0.003 Table 2: Compa a i e deb is and Smea Laye analysis in apical hi d (Lase and QMix® + Lase ). GROUP 2 (QMix®) GROUP 5 (QMix® + Lase ) Apical x1000 0 0 % 0 16,7 % 1 16,7 % 1 33,3 % 2 33,3 % 2 0 % 3 50 % 3 50 % p=0.029 Table 3: Compa a i e Smea Laye analysis in apical hi d (QMix® and QMix® + Lase ). Fo he smea laye emo al, he ecommended olume o 17% EDTA is in be ween 3 o 20 ml pe oo canal (11,17). Mello e al. showed ha a inal inse wi h 5ml o 17% EDTA was as e ec i e as 10-15 ml o EDTA o smea laye emo al (19). In ou s udy, 5 ml o 17% EDTA was used in acco dance wi h Mello´s s udy. In his s udy he specimens unde ea men wi h lase , showed a minimal amoun o open den inal ubules. The pa ame e s used we e 1.5 w o powe , a equency o 15Hz and 100 mJ o ene gy (10). 100% o QMix® in combina ion wi h lase samples, p esen ed a sco e o 2-3. QMix® in combina ion wi h lase samples and la- se samples showed he same esul s a he middle po - ion o he oo canal. Ou esul s a e in acco dance wi h hose om Hasheminia e al., Zhang e al., Ba bakow e J Clin Exp Den . 2018;10(1):e70-4. E ec i eness o Nd:YAG Lase e74 al., and Ki anc e al. Thei esul s showed ha Nd:YAG Lase is no as e ec i e as EDTA o he smea laye emo al (20-23). The aim o ou s udy was o show no only i he lase was e ec i e in he emo al o he smea laye , bu also, i adding a chela ing agen could imp o e i s e icacy. When he apical hi d was s udied, he g oup ea ed wi h QMix® in combina ion wi h lase , showed a be e cle- aning abili y han using QMix® alone. When he middle hi d was s udied, den in deb is emo al showed simila esul s in bo h g oups, and he smea laye emo al was be e in he g oup i iga ed wi h QMix®. This could be explained because QMix® was used only o one minu e and i migh need mo e con ac ime o achie e be e esul s as p oposed by S ojicic e al. (14). In all g oups whe e he lase was used, a be e smea laye emo al was shown. No g oups ea ed wi h EDTA ob ained a alue o 0 (comple e clean su ace), bu he e was always a supe io cleanliness a he apical hi d (on bo h smea laye and den in deb is emo al) al hough he di e ence was no de ini i e in he middle hi d. Mou a-Ne o e al. (24) ound in hei s udy ha Nd:YAG lase uses and solidi ies he den inal su ace wi h a pa - ial emo al o den inal deb is. In ag eemen wi h his s udy and based on he esul s ob ained in he p esen s udy, we can conclude ha we canno compa e he use o lase wi h he use o chela ing agen s, because he- se solu ions possess he abili y o dissol e smea laye , while lase s p oduce mel ing, apo iza ion and c ys alli- za ion o his ma e . Re e ences 1. Made CL, Baumga ne JC, Pe e s DD. Scanning elec on mi- c oscopic in es iga ion o he smea ed laye on oo canal walls. J Endod 1984;10:477-483. 2. Goldbe g DB, Ab amo ich A. Analysis o he e ec s o EDTAC on he den inal walls o he oo canal. J Endod 1977;3:101-105. 3. Baumga ne JC, Made CL. A scanning elec on mic oscopic e a- lua ion o ou oo canal i iga ing egimens. J Endod 1987;13:147- 157. 4. Moodnik RM, Do n SO, Feldman MJ, Le ey M, Bo den BG. E i- cacy o biomechanical ins umen a ion: a scanning elec on mic os- copic s udy. J Endod 1976;2:261-266. 5. Sulewski JG. His o ical su ey o lase den is y. Den Clin No h Am 2000;44:717-752. 6. Dai L, Khechen K, Khan S, Gillen B, Loushine BA, Wimme BS, Gu mann JL, Pashley D, Tay FR. The e ec o QMix, an expe imen- al an ibac e ial oo canal i igan , on emo al o canal wall smea laye and deb is. J Endod 2011;37:80-84. 7. Dede ich DN, Zaka iasen KL, Tulip J. Scanning elec on mic os- copic analysis o canal wall den in ollowing neodymium-y ium- aluminum-ga ne lase i adia ion. J Endod 1984;10:428-431. 8. Tew ik HM, Pashley DH, Ho ne JA, Sha awy MM. S uc u al and unc ional changes in oo den in ollowing exposu e o KTP/532 lase . J Endod 1993;19:492-497. 9. Moshono J, Sion A, Kasi e J, Ro s ein I, S abholz A. E icacy o a gon lase i adia ion in emo ing in acanal deb is. O al Su g O al Med O al Pa hol O al Radiol Endod 1995;79:221-225. 10. Gu knech N, Beh ens V. Ins umen a ion o oo canal walls wi h Nd:YAG lase . ZWR 1991;100:748-755. 11. Hülsmann M, Rümmelin C, Schä e s F. Roo canal cleanliness a e p epa a ion wi h di e end endodon ic handpieces and hand ins umen s. A compa a i e SEM. J Endod 1997;23:301-306. 12. Usman N, Baumga ne JC, Ma shall JG. In luence o ins umen size on oo canal deb idemen . J Endod 2004;30:110 –112. 13. Qian W, Shen Y, Haasapalo M. Quan i a i e analysis o he e ec o i igan solu ion sequences on den in e osion. J Endod 2011;37:1437-1441. 14. S ojicic S, Shen Y, Qian W, Johnson B, Haasapalo M. An ibac- e ial and smea laye emo al abili y o a no el i igan , QMix. In Endod J 2012;45:363-371. 15. Wu MK, Wesselink PR. E icacy o h ee echniques in cleaning he apical po ion o cu ed oo canals. O al Su g O al Med O al Pa h 1995;79:492-49. 16. Çal S, Se pe A. Smea Remo al by EGTA. J Endod 2000;26:459- 461. 17. Teixei a CS, Felippe MCS, Felippe WT. The e ec o applica- ion ime o EDTA and NaOCl on in acanal smea laye emo al: an SEM analysis. In Endod J 2005;38:285–290. 18. Kuah H-G, Lui J-N, Tseng PSK, e al. The e ec o EDTA wi h and wi hou ul asonics on emo al o he smea laye . J Endod 2009;35:393–396. 19. Mello I, Robazza CRC, An oniazzi JH, e al. In luence o di e- en olumes o EDTA o inal inse on smea laye emo al. O al Su g O al Med O al Pa hol O al Radiol Endod 2008;106:40–43. 20. Hasheminia SM, Bi ang R, Feizian a d M, Nasou i M. A compa- a i e s udy o he emo al o Smea Laye by wo endodon ic i i- gan s and Nd:YAG lase : A scanning Elec on Mic oscopic S udy. ISRN Den 2012:1-7. 21. Zhang C, Kimu a Y, Ma sumo o K, Ha ashima T, Zhou H. E ec s o pulsed Nd:YAG lase i adia ion in oo canal wall den in wi h di- e en lase ini ia o s. J Endod 1998;24:352-335. 22. Ba bakow F, Pe e s O, Ha anek. E ec s o Nd:YAG lase s on oo canal walls: a ligh and scanning elec on mic oscopic s udy. Quin essence In 1999;30:837-845. 23. Ki anç BH, Ulusoy OIA, Gö gül G. E ec s o E :YAG lase and Nd:YAG lase ea men on he oo canal den in o human ee h: a SEM s udy. Lase s Med Sci 2008;23:247-252. 24. Mou a-Ne o C, de Mou a AAM, Da idowicz H, Aun CE, An- onio MPS. Mo phologic changes and emo al o deb is on apical den in su aces a e Nd:YAG lase and diode lase i adia ion. Pho- omed Lase Su g 2008;26:263-266. Con lic s o In e es The au ho s decla e ha hey ha e no con lic o in e es .