doi:10.1111/iej.

12118

Effects of sodium hypochlorite associated with

EDTA and etidronate on apical root transportation

P. A. R. Silva e Souza1, R. S. E. das Dores1, T. Tartari1, T. P. S. Pinheiro2,

F. M. Tuji2 & M. H. Silva e Souza Jr3
1

Department of Endodontics, Dental School, Federal University of Par

a, Bel
em; 2Department of Radiology, Dental School,
3
Federal University of Par

a, Bel
em; and Department of Restorative Dentistry and Biomaterials, Dental School, Federal
University of Par
a, Bel
em, Brazil

Abstract
Silva e Souza PAR, das Dores RSE, Tartari T, Pinheiro
TPS, Tuji FM, Silva e Souza MH Jr. Effects of sodium
hypochlorite associated with EDTA and etidronate on apical
root transportation. International Endodontic Journal, 47, 20
25, 2014.

Aim To evaluate the influence of sodium hypochlorite associated with EDTA and etidronate on apical
root transportation.
Methodology Forty-five roots of human mandibular
molars with curvatures of 1525 were embedded in
acrylic resin to allow standardized angulation of the
initial and final radiographs. The pre-instrumentation
radiographs of the mesiobuccal canal of each root were
taken using a radiograph digital sensor with a size
15 K-file in the canal. The canals were prepared with
the ProTaper Universal system (Dentsply Maillefer, Ballaigues, Switzerland), using one of the following irrigation regimens during the instrumentation (n = 15): G1
irrigation with 20 mL of saline solution (control); G2
alternating irrigation with 2.5% hypochlorite solution (NaOCl) (15 mL); and 17% ethylenediaminetetraacetic acid (EDTA) (5 mL). During instrumentation, the
canal was filled with NaOCl and then between each

Introduction
The achievement of adequate balance between apical
disinfection and preservation of the root canal

Correspondence: Mario H. Silva e Souza, Jr., Department of

Restorative Dentistry and Biomaterials, Dental School,
Federal University of Par

a, Travessa Dom Romualdo de
Seixas, 156, Ap. 501, CEP: 66050-110 - Bel
em, PA, Brazil
(e-mail: mario-honorato@hotmail.com).

20

International Endodontic Journal, 47, 2025, 2014

exchange of instrument filled with EDTA for 1 min,

and G3 irrigation with 20 mL of 5% NaOCl and 18%
etidronate solution (HEBP) mixed in equal parts. The
postinstrumentation radiographs were made with a F3
instrument in the canal. The images were magnified
and superposed with Adobe Photoshop software
(Adobe Systems, Mountain View, CA, USA). Apical
transportation was determined with AutoCAD 2012
software (Autodesk Inc., San Rafael, CA, USA) by measuring the distance in millimetres between the tips of
the instruments. The results were subjected to the nonparametric statistical KruskalWallis test (a < 0.05).
Results The median transportation and interquartile
range values were 0.00  0.05 for G1, 0.08  0.23
for G2 and 0.13  0.14 for G3. Comparison between
groups showed that apical transportation in G3 was
significantly greater than in G1 (P < 0.05).
Conclusion The use of NaOCl associated with etidronate increased apical transportation in the canals of
extracted teeth.
Keywords: chelating agents, edetic acid, etidronic
acid, sodium hypochlorite root canal irrigants, therapeutic irrigation.
Received 28 September 2012; accepted 3 April 2013

anatomy remains a challenge, particularly in curved

root canals (Kunert et al. 2010).
Regardless of the instrumentation techniques utilized,
cleaning and shaping procedures invariably lead to the
removal of dentine from the canal walls (Schilder
1974). However, in curved root canals, the action of the
instruments may lead to an excessive removal of dentine
in one direction instead of symmetrically, a phenomenon known as canal transportation (Hartmann et al.
2007). In this phenomenon, portions of the root canal

2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

Silva e Souza et al. Irrigation and apical deviation

walls are not instrumented, which allows for the retention of contaminated dentine and remnants of debris,
necrotic or decayed tissue, whilst other areas may suffer
excessive dentine removal that weakens the root (Paqu
e
et al. 2005).
The use of nickel-titanium instruments in root
canal preparation has become increasingly common,
particularly in curved root canals. These instruments
have greater flexibility and a greater capacity to
maintain the original canal configuration, thereby
reducing the possibility of iatrogenic events such as
transportation, ledge or perforation (Di Fiore et al.
2006, Hartmann et al. 2007).
In addition to shaping procedures, irrigating solutions
play an important role by cleaning areas of the root
canal system that are not directly affected by the action
of manual or rotary instruments (Qing et al. 2006).
The use of a chelating agent associated with
sodium hypochlorite (NaOCl) has been advocated to
remove the smear layer, which consists of dentine
particles embedded in an amorphous mass of organic
material that forms during instrumentation (Torabinejad et al. 2002).
An irrigation regimen based on the alternating use
of NaOCl and ethylenediaminetetraacetic acid (EDTA)
appears to be promising tool due to the efficiency with
which it eliminates Enterococcus faecalis from within
the root canal biofilm (Soares et al. 2010). Recently,
etidronate solution (HEBP) was suggested as a substitute for EDTA, as it reportedly results in less damage
to dentine (De-Deus et al. 2008). Indeed, in contrast to
EDTA or citric acid, HEBP can be mixed with NaOCl
solution without interfering with its antimicrobial
properties (Zehnder et al. 2005).
Several studies advise caution with regard to the
application of irrigants to remove the smear layer,
because these solutions can cause changes in
the chemical structure of dentine, thus changing the
calcium/phosphorus (Ca/P) ratio (Hennequin et al.
1994, Do
gan & Qalt 2001). Changes in the mineral
content modify the original properties of dentine,
thereby increasing its permeability and solubility and
reducing its microhardness (Rotstein et al. 1996).
Studies have indicated that regardless of the concentrations, NaOCl reduces the microhardness of dentine
(Ari et al. 2004, Slutzky-Goldberg et al. 2004). Decalcification by chelating agents depends on the duration
of application, pH and concentration of the solutions
(P
erez-Heredia et al. 2008).
Different methodologies have been used to assess
apical transportation in curved root canals, including

2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

the analysis of root cross sections (Aguiar et al. 2009),

the use of digital radiographs (Sch
afer & Schlingemann
2003, Guelzow et al. 2005, Kunert et al. 2010) and
computed tomography (Hartmann et al. 2007, Oliveira
et al. 2009). These studies have demonstrated the
occurrence of apical deviation, regardless of the types
of instruments or techniques used to prepare canals.
Numerous studies have evaluated the effectiveness of
different preparation techniques and instruments in
maintaining the original path of the root canal
(Di Fiore et al. 2006, Hartmann et al. 2007, Aguiar
et al. 2009, Oliveira et al. 2009, Kunert et al. 2010).
However, further research is necessary to evaluate the
effects of irrigants on apical transportation, considering
that these solutions not only act as cleaning agents but
also decrease the microhardness of dentine, which
could compromise the maintenance of the original
path of the root canal. Thus, this study used pre- and
postoperative radiographic images to evaluate the
influence of NaOCl associations with EDTA and HEBP
on apical root transportation. The null hypothesis was
that the irrigation solutions do not influence root canal
transportation.

Materials and methods

Solutions
The 17% EDTA used in the current study was prepared
by dissolving disodium EDTA (Sigma Aldrich, St. Louis,
MO, USA) in distilled water with the aid of sodium
hydroxide (NaOH) (Sigma Aldrich); the pH was adjusted
to 7.0 by adding hydrochloric acid (HCl) (Sigma
Aldrich). The 2.5 and 5% NaOCl (Sigma Aldrich) and
18% HEBP (Zschimmer & Schwarz Mohsdorf GmbH &
Co KG, Burgst
adt, Germany) solutions were prepared by
mixing pure chemicals with distilled water. Using a
calibrated pH meter, the following pH values were
determined for these solutions: 2.5% NaOCl: 12.0;
5% NaOCl: 12.0; 17% EDTA: 7.0; 18% HEBP: 10.6;
and a 1:1 mixture of 18% HEBP with 5% NaOCl: 10.5.
All of the solutions were stored in air-tight, dark
containers at 5 C between experiments. On the day
of the experiment, the solutions were removed from
refrigeration and stored for 60 min at room temperature prior to use.

Tooth selection and preparation of samples

Human mandibular first and second molars with fully
formed roots, normal root morphology, similar length

International Endodontic Journal, 47, 2025, 2014

21

Irrigation and apical deviation Silva e Souza et al.

and two mesial canals with independent foramina were

selected. The experimental protocol had previously
been approved by the ethics committee on human
research. Tissue and debris were removed from the root
surfaces with hand curettes. The teeth were stored in
saline at 5 C prior to use.
After preparing access cavities, the distal roots of
all samples were separated at the furcation level with
a diamond disc (KG Sorensen Ind. e Com., Barueri,
SP, Brazil) under coolant. The mesiobuccal canals
were localized and explored with a size 10 K-file
(Dentsply Maillefer, Ballaigues, Switzerland) that was
passively advanced into the canals until the tip of the
instrument had reached the apical foramen. The real
canal length was recorded, and the working length
(WL) was calculated by subtracting 1 mm from this
measurement.
Acrylic resin (Dent Bras, Pirassununga, SP, Brazil)
was mixed according to the manufacturers instructions and poured into a four-sided metal mould
(length, 10 mm; width, 10 mm; height, 15 mm).
Each root was inserted in the acrylic resin with its
long axis parallel to the long axis of the mould. To
prevent foramen blockage by the acrylic resin, wax
balls were placed on the apex of each specimen before
inclusion.
To maintain a standard position of the sensortoothX-ray combination in all of the radiographs, an
apparatus was prepared with a radiographic positioner
used for the parallel technique. Using this positioner,
the X-ray was directed perpendicular to the digital
radiography sensor with a focal length of 40 cm.
Preoperative radiographs were taken with a size
15 K-file inserted to WL using a Digora Optime digital
radiography sensor (Soredex, Tuusula, Finland). The
angle of the root curvature was determined using the
RadioImp software (Radiomemory, Belo Horizonte,
MG, Brazil), in accordance with a method proposed
by Schneider (1971). On the basis of this analysis, 45
canals with curvatures ranging from 15 to 25 were
chosen.
After the first radiograph, the specimens were
randomly assigned to three groups (n = 15) according
to the irrigation regimen used:
Group 1 (G1): Irrigation with 20 mL of saline
(control).
Group 2 (G2): Alternating irrigation with 2.5% NaOCl
(15 mL) and 17% EDTA (5 mL). During instrumentation, the canal was filled with NaOCl. In between
each instrument change, the canal was filled with
EDTA for 1 min.

22

International Endodontic Journal, 47, 2025, 2014

Group 3 (G3): Irrigation with 20 mL of a 5% NaOCl

solution and 18% HEBP mixed in equal parts immediately before the experiments, resulting in a solution
that contained 2.5% NaOCl and 9% HEBP.
All samples were instrumented with a ProTaper
Universal rotary system (Dentsply Maillefer), using
the X-Smart electric motor (Dentsply Maillefer), at
300 rpm and a torque of 3N. The final instrument for
all of the specimens was F3, and canal patency was
maintained with a size 10 K-file.
The irrigants were delivered into the root canal
using a disposable plastic syringe attached to a 30gauge ProRinse needle (Dentsply Tulsa Dental, Johnson City, TN, USA). Irrigation was achieved with the
needle placed as close as possible to the working
length (12 mm). A small (12 mm), constant apicalcoronal movement of the needle was maintained
during expression of irrigant. The irrigants were aspirated from the canal using another irrigation needle
12 mm from working length.
After instrumentation, a new radiograph was
obtained with the final F3 instrument positioned at
WL.

Evaluation of root canal deviation

The initial and final images were superimposed using
Photoshop CS5 (Adobe Systems, Mountain View, CA,
USA). The software AutoCAD 2012 (Autodesk Inc., San
Rafael, CA, USA) was used to assess apical transportation by measuring the distance in millimetres between
the tips of the instruments in the initial and final overlay
images (Fig. 1).

Statistical analysis
The sample size was determined after a pilot study by
one-way analysis of variance (ANOVA), considering the
difference in means to be at least 0.12 and the standard deviation of the error to be 0.014. To detect a
difference of 15%, using a test power of 80% and a
bilateral a of 5%, the minimum sample size required
was determined to be 13 specimens per group.
The sample was not normally distributed as determined by the preliminary ShapiroWilk test for
normality. The data were presented as the medians
and interquartile deviation, and the nonparametric
KruskalWallis statistical test was used to analyse the
differences between the groups. In all statistical tests,
P < 0.05 was deemed to indicate statistical significance.

2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

Silva e Souza et al. Irrigation and apical deviation

Figure 1 Initial and final images superimposed to determine the apical deviation.

Table 1 Sample size, number of canals with no deviation,

median and interquartile range of apical transportation
Groups

No deviation

Median (mm)

IQR

G1
G2
G3

15
15
15

8
5
2

0.00
0.08
0.13

0.05
0.23
0.14

G1 saline; G2 NaOCl associated with EDTA; G3 NaOCl

associated with HEBP.

Table 2 Rank difference and P-value (KruskalWallis) to

compare apical transportation between groups
Groups
G1 X G2
G1 X G3
G2 X G3

Rank difference
8.36
13.93
5.56

P-value
ns
< 0.05
ns

G1 saline; G2 NaOCl associated with EDTA; G3 NaOCl

associated with HEBP; P < 0.05.

Results
The number of canals with no deviation, median
values and interquartile ranges for apical root transportation after instrumentation are shown in Table 1.
G3 exhibited significantly higher apical deviation than
G1 (P < 0.05, Table 2). None of the other comparisons between groups were significant.

Discussion
Maintenance of original root canal direction and the
integrity of the apical foramen are of fundamental importance during root canal treatment. Canal transportation

2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

can be defined as any undesired deviation of the original

root canal lumen (Peters 2004) and can result in inadequate cleaning and persistence of periapical lesions (Pettiette et al. 2001, Paqu
e et al. 2005) that may adversely
influence the prognosis of endodontic treatment (L

opez
et al. 2009, Oliveira et al. 2009).
According to Peters (2004), canal transportation of
up to 0.10 mm is acceptable. In the present study,
G1 and G2 yielded median values below 0.10 mm, but
in G3, the median was 0.13 mm (Table 1). Conversely,
canal transportation above 0.30 mm may have a
negative impact on the root filling, affecting the results
of treatment (Wu et al. 2000). In G2, there were two
specimens with apical deviations exceeding 0.30 mm.
Irrigation conducted by alternating 2.5% NaOCl and
17% EDTA solutions prevents smear layer compaction
resulting from the action of instruments in contact
with the root canal walls (Peters et al. 2001, Hartmann et al. 2007). However, these irrigation solutions
change the chemical structure of dentine (Hennequin
et al. 1994, Do
gan & Qalt 2001), which may also
adversely affect the maintenance of the root canal path
during instrumentation. Bramante & Betti (2000)
reported that the use of EDTA increased the transport
of root canals in teeth prepared with Ni-Ti hand files.
This effect was observed in the results, although statistical analysis did not detect any significant differences
between G1 (control) and G2 (NaOCl + EDTA), possibly because of the high coefficient of variation in
G2 (0.23). This coefficient of variation may indicate a
distinct behaviour, which could be revealed in highly
curved canals.

International Endodontic Journal, 47, 2025, 2014

23

Irrigation and apical deviation Silva e Souza et al.

The only statistically significant difference in apical

root transportation in this study was between G1 and
G3. Considering that HEBP is a weak chelating agent
that does not affect the dentine structure as much as
EDTA (De-Deus et al. 2008), these results may be due
to this irrigant having the longest time in contact with
the dentine walls during canal preparation. Another
reason may be related to the creation of deproteination canals by NaOCl (Di Renzo et al. 2001), which
remains active even when mixed with HEBP (Zehnder
et al. 2005). These canals may have increased the
surface area available to HEBP action, leading to a
greater decrease in surface microhardness, facilitating
the cutting of dentine by instruments.
Digital radiography was used to quantify apical
transportation in this study due to its low cost and
absence of sample damage, and because the images
generated can be processed and analysed by computer
software (Shearer et al. 2001), this may reduce the
probability of human error and facilitate the detection
of small deviations caused by biomechanical preparation (L
opez et al. 2009).
Root canal transportation in the apical region may
occur in different directions (Peters et al. 2001). Comparison of the pre- and postoperative images of the
root canal showed that apical deviation occurred
mainly towards the outside of the curvature. This
finding was consistent with several studies that have
reported that there is a greater tendency for transportation to the external side of the curvature (mesial
direction), as a result of the increased pressure
exerted on this area when instruments are inserted
into the apical third of a curved canal (Wu et al.
2000, Tasdemir et al. 2005, Hartmann et al. 2007,
Oliveira et al. 2009).

Conclusions
On the basis of the methodology used and the results
of this study, it could be concluded that the irrigation
regimens used in G2 and G3 were associated with
apical deviation, but with no differences between
them. However, the use of NaOCl associated with
HEBP during canal preparation caused a greater
increase in apical root transportation than that in the
control group.

Acknowledgements
This study was in part supported by CNPq (National
Counsel of Technological and Scientific Development).

24

International Endodontic Journal, 47, 2025, 2014

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