doi:10.1111/j.1365-2591.2006.01181.

Leakage along apical root fillings with and without

smear layer using two different leakage models: a
two-month longitudinal ex vivo study

H. Shemesh, M.-K. Wu & P. R. Wesselink

Department of Cariology Endodontology Pedodontology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The
Netherlands

Abstract between the groups in glucose concentrations and fluid

transport were statistically analysed with the Kruskal–
Shemesh H, Wu M-K, Wesselink PR. Leakage along apical
Wallis and the Mann–Whitney tests. The level of
root fillings with and without smear layer using two different
significance was set at a ¼ 0.05.
leakage models: a two-month longitudinal ex vivo study.
Results Glucose penetration was significantly differ-
International Endodontic Journal, 39, 968–976, 2006.
ent between the three groups after the first 8 days
Aim To compare two different experimental models (P < 0.05). Resilon leaked the most throughout the
when measuring leakage along root fillings with or experiment period. No significant difference (P > 0.05)
without smear layer. existed between the two gutta-percha groups at all time
Methodology One hundred and twenty single- intervals (Mann–Whitney test). In the fluid transpor-
rooted teeth were prepared to size 50 and allocated to tation model, no statistically significant differences
two groups: fluid transport model (n ¼ 60) and glucose were observed between all three experimental groups
penetration model (n ¼ 60). The roots in each group (P > 0.05) at either 1 or 8 weeks after filling (Kruskal–
were divided into three subgroups of 20 teeth each. Wallis test).
Smear layer was left in place in group 1 but removed in Conclusions Under the conditions of this study, the
groups 2 and 3. In groups 1 and 2 canals were filled glucose penetration model was more sensitive in
with laterally compacted gutta-percha cones and AH detecting leakage along root fillings. Removing the
26. Group 3 was laterally compacted with Resilon smear layer before filling did not improve the sealing of
cones and Epiphany sealer. The coronal portion of the the apical 4 mm of filling. Resilon allowed more glucose
filling was removed to assure only 4 mm of filling penetration but the same amount of fluid transport as
remained in the canal. Leakage of glucose was evalu- the gutta-percha root fillings.
ated by measuring its concentration once a week for a
Keywords: gutta-percha, leakage, Resilon, root
total period of 56 days using a glucose penetration
canal filling, smear layer.
model. Fluid transport was evaluated by measuring the
movement of an air-bubble using a fluid transport Received 20 March 2006; accepted 13 June 2006
model, 1 and 8 weeks after canal filling. Differences

between the canal and periapical tissues (Sundqvist

Introduction
et al. 1998).
The purpose of a root filling is to prevent bacterial A variety of laboratory-based experimental models
growth and penetration of fluid and antigenic agents are used to detect and measure leakage along root
fillings. Dye leakage, fluid transport and bacterial
penetration are currently the methods used most often.
Correspondence: H. Shemesh, Department of Cariology Endo-
dontology Pedodontology, ACTA, Louwesweg 1, 1066 EA
Recently Xu et al. (2005) discussed a new model that
Amsterdam, The Netherlands (Tel.: 3120 518 8549; fax measures the leakage of glucose molecules. The model
3120 669 2881; e-mail: [email protected]). consists of a tube containing concentrated glucose

968 International Endodontic Journal, 39, 968–976, 2006 ª 2006 International Endodontic Journal
 Shemesh et al. Leakage of apical root fillings

solution that is connected to the coronal aspect of the Pentron Clinical Technologies, Wallingford, CT, USA).
tooth, whilst the apical region is dipped in water. This material resembles gutta-percha in appearance,
Glucose that accumulates in the apical chamber is has similar handling properties and is available both in
measured with a spectrophotometer following an cone format and in pellets for warm injection. The
enzymatic reaction. Glucose has a low molecule weight corresponding sealer (Pentron Clinical Technologies) is
of 180 Da, and may be used as an indication for toxins a dual curable dental resin composite. This so-called
that might penetrate the canal (Xu et al. 2005). ‘Epiphany’ system (Resilon and sealer combined with
Leakage studies consistently show bacterial penetra- self-etching of the canal wall) is claimed to form a
tion through root fillings. Torabinejad et al. (1990) ‘monoblock’ which adheres to the dentine walls,
reported that 50% of filled single-rooted teeth were prevents leakage and increases resistance to fracture
contaminated along the whole length of the canal after (Shipper et al. 2004, Teixeira et al. 2004).
19 and 42 days of exposure depending on the infecting The purpose of this study was to compare two
microorganism. Khayat et al. (1993) reported that all different experimental models in measuring leakage
root canals filled with laterally or vertically condensed along apical root fillings with and without the smear
gutta-percha were contaminated in less than 30 days layer.
after exposure to human saliva.
One of the methods previously described for improv-
Materials and methods
ing the seal and for minimizing leakage is the removal
of the smear layer before filling (Clark-Holke et al.
Selection and preparation of teeth
2003). This has been claimed to improve sealer
penetration inside the dentinal tubules, achieving a One hundred and sixty recently extracted single-rooted
potentially greater adherence to the canal wall (Kokkas human teeth were selected and stored in 0.2% sodium
et al. 2004). Indeed, some studies that investigated the azide, NaN3 (E. Merck, Darmstadt, Germany) at +4 C
removal of the smear layer concluded that a better seal until use. Mandibular incisors were excluded because of
was achieved when the smear layer was removed their morphological diversity (Kaffe et al. 1985). Pre-
(Kennedy et al. 1986, Cergneux et al. 1987, Taylor molars were used only when a radiograph indicated a
et al. 1997, Clark-Holke et al. 2003, Çobankara et al. single canal. Teeth with open apices or large carious
2004). Other studies have suggested that removing the lesions were excluded.
smear layer increases dentine permeability and might The coronal portions of all teeth were removed so that
impair the sealing ability, and even allow bacteria to each root specimen was 15 mm long. A diamond bur
grow inside the dentinal tubules (Pashley et al. 1981, (FG 173 Horico, Berlin, Germany) was used to
Drake et al. 1994, Galvan et al. 1994, Love 1996). Two gain straight-line entry to the root canal. A size 20
review articles on the clinical implications of the smear K-Flexofile (Dentsply Maillefer, Ballaigues, Switzerland)
layer in endodontics (Şen et al. 1995, Torabinejad et al. was inserted into the canal to verify patency (Kuttler
2002) confirmed the uncertainty and debate relating to 1955). All samples were examined under a microscope
the removal of smear layer before filling. More recently (Zeiss Stemi SV6, Jena, Germany) to exclude cracks. The
Gulabivala et al. (2005) discussed the effects of coronal 4 mm of the root specimens were then embed-
mechanical and chemical procedures including the ded in acryl (Vertex; Dentimex BV, Zeist, the Nether-
removal of the smear layer on the seal and stated that lands) to form an acrylic cylinder around the root and
the mechanisms leading to successful root canal enable intimate contact between the rubber tube used to
treatment remained to be determined. connect the specimen during the leakage phase of the
Current filling materials and techniques fail to study and the root specimen. All procedures and
provide a leak-free seal (Wu & Wesselink 1993, Wu treatments were preformed by one individual.
et al. 1993). Gutta-percha is the most popular filling
material and has been used for this purpose for many
Instrumentation and obturation of root canals
years. Systems like warm injection and carrier-coated
root fillings have been developed but have been shown The working length was determined by subtracting
to leak to a certain extent (Mannocci et al. 1999, 1 mm from the total length of the root. The apical
Abarca et al. 2001, Wu et al. 2003, Chu et al. 2005). portion of the canal was instrumented to a size 50
Recently, a new thermoplastic synthetic polymer- master file using the balanced force technique (Roane &
based root filling material was introduced (Resilon; Sabala 1985) with K-Flexofiles (Dentsply Maillefer). A

ª 2006 International Endodontic Journal International Endodontic Journal, 39, 968–976, 2006 969
 Leakage of apical root fillings Shemesh et al.

step-back flaring technique was then performed at root. Three paper points size 50 were used to remove
1 mm increments with Gates Glidden burs number 2–6 excess primer after 1 min from each root. Roots were
(Dentsply Maillefer) making the taper 0.2 mm mm)1 then filled with lateral compaction of Resilon cones and
(Wu et al. 2002). The purpose of this preparation Epiphany sealer (Pentron Clinical Technologies) in the
regimen was to create a uniform size of canal and to same way as in group 1. The filling was removed from
overcome the variation in natural morphology. Each the coronal portion of the canal in the same manner as
canal was irrigated with freshly prepared 2% NaOCl group 1, leaving 4 mm of the apical filling intact.
with a 27-gauge needle after every instrument and
ensuring patency by extrusion of the solution beyond Positive control group
the apical foramen. A minimum of 10 mL NaOCl Canals were filled using lateral compaction of gutta-
solution was used for each root. The prepared roots percha cones without any sealer. No warm vertical
were randomly divided into three experimental groups forces were used and the whole length of the filling
of 40 roots, and two control groups of 20 roots each. remained.

Group 1 Negative control group

After preparation was completed, canals were rinsed All roots were sealed with laterally compacted gutta-
with an additional 5 mL 2% NaOCl solution and then percha and AH 26 for the whole length of the canal
with 5 mL deionized water. Each canal was dried using and completely covered with nail varnish.
paper point size 50. After filling all specimens were maintained for
A size 50 gutta-percha master cone coated with AH 1 week at 37 C and 100% humidity to allow the
26 sealer (Dentsply Maillefer) was inserted into the materials to set. Specimens in each group were then
canal. Light pumping motions were used to fill the divided equally between the two different models,
canal with sealer and bring the cone to full working glucose penetration and fluid transport.
length. Lateral compaction was achieved using a size C
finger spreader (Dentsply Maillefer) and size 25 acces-
Glucose penetration model – preparation and
sory gutta-percha cones that initially reached to within
measurements
1 mm of the working length. The tip of each accessory
cone was lightly coated with sealer, placed and The difference between the current version of the
compacted laterally. The process was repeated until glucose penetration model and the original model
cones could not be inserted more than 10 mm into the introduced by Xu et al. (2005) lies mainly in the
canal. An estimation of the total amount of sealer used environment in which the equipment was stored: in
was achieved by using a 0.5 cm · 0.5 cm square of order to overcome evaporation of fluids, specimens
mixed sealer for each tooth. were placed in a closed jar with 100% humidity. From
The coronal gutta-percha was removed with a hot a pilot study it was concluded that this method would
plugger (0.5 mm diameter, Dentsply Maillefer) and eliminate the effect of fluid evaporation on glucose
vertically packed, leaving the apical 4 mm of root filling concentration measurements.
subjected to the leakage test (Fan et al. 1999). The resin block around the coronal part of each root
was connected to a rubber tube with stainless steel
Group 2 wires, which was in itself connected to a 16 cm long
After completion of preparation canals were rinsed with pipette (Pyrex, Acton, MA, USA). The assembly was
5 mL 17% EDTA for 3 min to remove the smear layer then placed in a sterile glass bottle with a screw cap
(Hülsmann et al. 2003) and then rinsed with 5 mL and sealed with sticky wax. A uniform hole was drilled
deionized water. The filling was completed in the same in the screw cap with a diamond bur (No.173 Horico,
way as group 1. Berlin, Germany) to assure an open system at all times
(Fig. 1). Two millilitres of 0.2% NaN3 solution were
Group 3 inserted into the glass bottle, such that the root samples
All canals were rinsed with 5 mL 17% EDTA for 3 min were immersed in the solution. NaN3 was used to
and then with 5 mL deionized water. After drying, a inhibit the growth of microorganisms that might
self-etching primer (Epiphany primer; Pentron Clinical influence the glucose readings. The tracer used in the
Technologies) was placed into the canal with a 26- present study was 1 mol L)1 glucose solution (pH 7.0).
gauge needle. Two drops of primer were used for each Glucose has a low molecular weight and is hydrophilic

970 International Endodontic Journal, 39, 968–976, 2006 ª 2006 International Endodontic Journal
 Shemesh et al. Leakage of apical root fillings

Glucose solution 33, 40, 48 and 56 days. The same amount of fresh
0.2% NaN3 was added to the glass bottle reservoir to
maintain a constant volume of 2 mL. The sample was
then analysed with a Glucose kit (Megazyme, Wicklow,
Ireland) in a spectrophotometer (Molecular Devices,
Glass tube
Spectra max 384 plus) at a wavelength of 340 nm.
Concentrations of glucose in the lower chamber were
presented in mmol L)1 at each time interval following
filling. The lowest glucose level for which the current
Open system procedure is believed to be accurate is 0.003 mmol L)1
which derives from an absorbance difference of 0.02
14 cm
(d-Glucose-HK assay procedure; Megazyme, 2004).
Below this level, the absorbance readings become
relatively small, and results are subject to greater error
Rubber tube from technique variables. Concentrations smaller than
this were thus ignored. Similarly, once leakage excee-
Acrylic cylinder ded 21 mmol L)1 samples were no longer observed as
the glucose concentration in the lower chamber
Metal wire suggested substantial leakage had occurred.
Root specimen
Fluid transport model – preparation and
0.2% NaN3 solution measurements
Roots were mounted in the fluid transport device
Figure 1 Glucose penetration model. (Fig. 2) previously described by Wu et al. (1993). The
pipettes used were 22 mm long 1 mL glass pipettes
(Witeg, Wertheim, Germany). All connections were
and chemically stable. About 4.5 mL of the glucose tightly closed by twisting pieces of stainless steel wire in
solution, containing 0.2% NaN3, was injected into the a water bath at 20 C. Fluid transport along the root
pipette until the top of the solution was 14 cm higher filling was measured under a headspace pressure of
than the top of gutta-percha in the canal, which 30 kPa (0.3 atm) and after 3 h the volume of fluid
created a hydrostatic pressure of 1.5 kPa or 15 cm H2O transport was recorded. The results were expressed as
(Xu et al. 2005). All specimens were then returned to lL min)1. After measurements teeth were carefully
the incubator at 37 C for the duration of the obser- disconnected from the assembly, placed in 0.2% NaN3
vation period. A total of 25 lL of solution was drawn solution and returned to the incubator for a period of
from the glass bottle using a micropipette at 8, 13, 20, 8 weeks. The medium was changed with a fresh NaN3

Headspace pressure
Silicon tube Water bath (20°)
Filled root Standard capillary
Air bubble

Silicon tube

Figure 2 Fluid transport model. Wire connections

ª 2006 International Endodontic Journal International Endodontic Journal, 39, 968–976, 2006 971
 Leakage of apical root fillings Shemesh et al.

solution every week. After 8 weeks the roots were GP+AH26, GP+AH26, SL Resilon-Epiphany
SL present removed

Glucose concentration mmol L–1

mounted again and checked for fluid transport in the Negative control Positive control

same way. 26
22
18
Statistical analysis
14
The differences between the groups with regard to 10
glucose concentrations and fluid transport were statis- 6
tically analysed with the Kruskal–Wallis and the 2
Mann–Whitney tests (version 12.0.1, SPSS, Chicago,
IL, USA). The level of significance was set at a ¼ 0.05. 0 10 20 30 40 50 60
Days after obturation

Figure 3 Median glucose penetration in mmol L)1 after

Results
2 months.
The results for the glucose model are shown in Table 1
and Figs 3 and 4. The positive control group had
substantial leakage of glucose from the first day which
GP+AH26, GP+AH26, SL Resilon-
increased over time. After 2 weeks all samples had SL present
Negative control
removed
Positive control
Epiphany

maximum leakage (21 mmol L)1). In the negative

Percent leakaing samples

control group no glucose was detected in the apical 100
90
reservoirs throughout the experiment. Glucose concen- 80
70
trations in the experimental groups revealed that after 60
the first 8 days the difference between the three groups 50
40
was significant (Kruskal–Wallis test, P < 0.05). 30
Resilon laterally compacted had the most leakage at 20
10
all time intervals. However, no significant difference 0
existed between the two gutta-percha groups (Mann– –10 0 10 20 30 40 50 60
Whitney test, P > 0.05) at all time intervals. The Day after obturation
statistical significance of the differences between all
Figure 4 Percentage of leaking samples in the glucose penet-
three groups is summarized in Table 2. ration model – after 2 months.
The results of the fluid transport model are shown in
Table 3. The positive control group had bubble move-
ment that exceeded the pipette length after 3 h and was (P > 0.05) existed between the three experimental
impossible to measure. The negative control group had groups at both time intervals, 1 and 8 weeks, after
no movement of the bubble. No significant difference filling (Kruskal–Wallis test).

Table 1 Mean and median of glucose leakage in mmol L)1 at different times after obturation

Day

Group 8 13 20 33 40 48 56

GP AH 26 (smear layer present)

Mean (SD) 3.1 (6.0) 4.1 (7.3) 4.6 (7.9) 5.1 (7.9) 5.5 (8.0) 6.0 (8.4) 7.3 (8.7)
Median (range) 0 (0–21) 0 (0–21) 0 (0–21) 0 (0–21) 0.2 (0–21) 0.8 (0–21) 2.2 (0–21)
Percentage leaking 30 40 40 45 50 50 70
GP AH 26 (smear layer removed)
Mean (SD) 3.2 (6.6) 3.6 (6.8) 4.5 (7.3) 4.8 (7.5) 6.3 (8.7) 6.8 (9.0) 7.0 (9.0)
Median (range) 0 (0–21) 0 (0–21) 0 (0–21) 0 (0–21) 1.5 (0–21) 2.0 (0–21) 2.5 (0–21)
Percentage leaking 30 35 40 40 55 55 55
Resilon–Epiphany (smear layer removed)
Mean (SD) 3.5 (5.6) 6.2 (7.0) 6.6 (7.0) 8.0 (7.2) 9.6 (7.4) 12.0 (8.0) 12.8 (7.9)
Median (range) 1.4 (0–13.5) 2.4 (0–21) 2.9 (0–21) 4.4 (0–21) 7.2 (0–21) 12.3 (0–21) 12.9 (0–21)
Percentage leaking 55 90 90 90 90 90 90

972 International Endodontic Journal, 39, 968–976, 2006 ª 2006 International Endodontic Journal
 Shemesh et al. Leakage of apical root fillings

Table 2 P values – statistical signifi-

Kruskal–Wallis test Mann–Whitney test
cance of the difference in glucose con-
centrations between the groups at Time after P (groups P (groups 1 P (groups 1 P (groups 2
specific time intervals filling (days) 1–3) and 2) and 3) and 3)

8 0.415 – – –
13 0.012 0.799 0.015 0.013
20 0.026 0.989 0.020 0.033
33 0.034 0.799 0.038 0.026
40 0.031 0.799 0.023 0.030
48 0.020 0.820 0.013 0.026
56 0.035 0.738 0.035 0.024

Table 3 Average fluid transportation and percentage of leak- filling, making the glucose test more sensitive. Fur-
ing samples 1 and 8 weeks after obturation thermore, summated glucose leakage during 2 months
Average fluid transport was measured whereas fluid transportation was meas-
in lL (percentage ured for 3 h and observed at two different time
leaking samples) intervals, 1 and 8 weeks after filling.
Group 1 week 8 weeks Evaporation of fluids during the 56 days experiment
GP/AH26 (smear layer 0.5 (20) 0.2 (10) duration could alter the glucose concentrations both in
present; n ¼ 20) the apical and the coronal chambers. Evaporation will
GP/AH26 (smear layer 0.1 (15) 0.05 (5) inevitably occur as these two compartments have to
removed; n ¼ 20)
have an opening to release pressure build-up and
Resilon/Epiphany (smear 0.0 (0) 0.0 (0)
layer removed; n ¼ 20)
cannot be closed hermetically in order to allow leakage
to occur. Xu et al. (2005) refers only to evaporation
from the apical chamber, compensating it with water
according to a representative sample. The method used
Discussion
here, storing the models in a closed humid jar,
Several test methods have been described to evaluate addresses the evaporation factor from both chambers
the sealing quality of filled root canals. In the present and proved to be effective in initial pilot studies.
study, two different models were used: the fluid The effect of the removal of smear layer before
transport model (Wu et al. 1993) and the glucose obturation has been the subject of extensive debate.
penetration model (Xu et al. 2005). The latter can be According to the current findings, the smear layer did
seen as a further development of the fluid transporta- not affect the seal with gutta-percha and AH 26 in the
tion concept: both measure passage of fluid along root apical 4 mm, when checked with the fluid transport or
filled teeth after subjecting them to constant pressure. the glucose penetration models. These results are in
However, the glucose model allows measurements of agreement with those of Saunders & Saunders (1994a)
diffusion of the marker molecules as well. The glucose who found no significant difference in dye leakage after
test might be more sensitive than the measurement of 4 months between root fillings when the smear layer
air-bubble movement, not only because the detected was removed or present. Saunders & Saunders (1994b)
threshold measurement by eye is higher than that of assessed dye leakage of Thermafil fillings and laterally
the spectrophotometer, but also because the convective condensed gutta-percha with glass–ionomer sealer no
fluid transport was combined with glucose molecule significant difference was observed after 4 months
diffusion. between any of the groups. Madison & Krell (1984)
Time difference is an important factor when com- and Evans & Simon (1986) also found no difference in
paring the results from the two different models. In the leakage when the smear layer was removed or not.
glucose penetration model the tooth is continuously Although dye-leakage results have debatable relevancy
subjected to the pressure of the glucose solution in the (Wu & Wesslink 1993) they were the most frequently
coronal chamber for a period of 2 months. The fluid used to assess the influence of smear layer. In contrast
penetration model detects leakage after subjecting the to these findings, Clark-Holke et al. (2003) checked a
filling to pressure for 3 h. This enormous time differ- mixed culture of bacteria penetrating through root
ence might result in detection of smaller voids in the fillings. A total of 30 teeth were used, amongst which

ª 2006 International Endodontic Journal International Endodontic Journal, 39, 968–976, 2006 973
 Leakage of apical root fillings Shemesh et al.

10 served as controls. During the 2-month observation canal during polymerization might exceed the bond
period, leakage was not observed in the group where strength, and a high volumetric shrinkage of the sealer
smear layer was removed, whilst 60% of the specimen might occur when it polymerizes. In cross-sections of
having a smear layer leaked. In spite of the small filled roots, gaps were observed between the dentine
number of specimen and the authors’ own claim that and the Epiphany layer (Tay et al. 2005a). These
leakage could occur after the 2-month observation imperfections in the bonding to the walls of the canal
period, it was suggested that removing the smear layer might be too small to be detected by bacterial penet-
decreased bacterial leakage. Similarly, Kennedy et al. ration models.
(1986) and Cergneux et al. (1987) observed that smear The dimensional stability of Resilon should also be
layer removal reduced dye leakage. These conflicting addressed. Preliminary unpublished studies have
reports might be attributed to difference in the type of shown that Resilon cones discharged a coloured
sealer and filling technique, the method of producing substance to the surrounding medium it, that may
and removing the smear layer and different laboratory affect the measurements of optical density. As this
procedures to check the leakage (Şen et al. 1995). More colour (pink) is not absorbed at the same wavelength
recently, Paqué et al. (2006) found no effect of the that is assessed by the glucose kit, the results were not
smear layer on dye penetration through root dentine, compromised. However, every new material that is
and suggested that tubular sclerosis rather than the about to be checked with this method, should be
smear layer that influences penetrability. assessed for its colour properties when it is immersed in
Resilon is a new root filling material that consists of a fluid for an extended period. Gutta-percha and AH 26
composite that may be bonded to the wall of the canal. on the other hand, did not show any colour discharge
Results from the current experiment indicate that the when soaked in water.
apical 4 mm of Resilon–Epiphany root canal fillings Tay et al. (2005b,c) discussed the susceptibility of
allowed more glucose penetration than gutta-percha. Resilon to degradation in two different studies: in the
Shipper et al. (2004) detected more rapid bacterial first, 15 mm diameter Resilon and gutta-percha discs
leakage in gutta-percha and AH 26 fillings when were immersed in sodium etoxide for 20 and 60 min.
compared with Resilon–Epiphany during a period of The treated discs were then examined with a
31 days when the whole length of the root canal was scanning electronic microscope and dispersive X-ray
filled with laterally or vertically compacted material. In analysis. The surface of the Resilon discs was
the current experiment only the 4 apical mm of filling hydrolysed after 20 min exposing the filler, whilst
were checked. The dentinal tubules configuration gutta-percha discs were unaffected. The second
which is less dense in the apical part than the coronal experiment examined 15 mm diameter discs of Resi-
part (Fogel et al. 1988) might lead to compromised lon, gutta-percha and polycaprolactone that were
bonding apically. Tay et al. (2005a) observed in a incubated with phosphate-buffered saline, Lipase PS
transmission electron micrograph gaps of about 2 lm or cholesterol esterase. Resilon and polycaprolactone
between the root dentine and the Resilon primer. These discs had significant weight loss and surface thinning
imperfections in the bonding might be too small to be when compared with the gutta-percha discs. The
detected by bacterial penetration models, as the aver- influence of this phenomenon on glucose penetration
age length of bacteria varies from 0.2 to more than may be greater in the current setting than in that of
10 lm, the width from 0.2 to 1.5 lm (Hobot 2002). Shipper et al. (2004) because of the longer observa-
The influence of the geometric variables involved in tion period. These results challenge the claims of the
the use of adhesive sealers was previously discussed by manufacturer (‘Epiphany Newsletter’, July 2005,
Feilzer et al. (1993) and more recently by Tay et al. Pentron Clinical Technologies) that the colour dis-
(2005a). The latter study simulated different scenarios charge from Resilon cones is only food grade dye
and appraised the C-factors that arise from thin resin ‘leaching out into the tooth’. However, it may
films. In a Class I cavity, the bonded surface area is five provide an explanation for the increased leakage in
times more than the unbonded surface area (C-factor is the Resilon group.
5). As the unbonded surface area becomes smaller, as
in a root canal, the C-factor becomes much higher,
Conclusions
there is insufficient stress relief by flow and a high
probability that one or more bonded areas will debond. • The glucose penetration model is a sensitive method
The probability of imperfect dentine bonding in a root to detect leakage along root fillings.

974 International Endodontic Journal, 39, 968–976, 2006 ª 2006 International Endodontic Journal
 Shemesh et al. Leakage of apical root fillings

• Under the conditions of this study, no statistically Gulabivala K, Patel B, Evans G, Ng YL (2005) Effects of
significant difference in glucose penetration or fluid mechanical and chemical procedures on root canal surfaces.
transportation was observed along the 4 mm apical Endodontic Topics 10, 103–22.
root filling with gutta-percha and AH 26 whether or Hobot JA (2002) Molecular Medical Microbiology. London, UK:
Academic Press, p. 7.
not the smear layer was removed prior to filling.
Hülsmann M, Heckendorff M, Lennon A (2003) Chelating
• Canals filled with Resilon had more glucose penetra-
agents in root canal treatment: mode of action and
tion than gutta-percha and AH 26 during a period of indications for their use. International Endodontic Journal
56 days, whilst no statistically significant difference 36, 810–30.
was observed between the Resilon and gutta-percha Kaffe L, Kaufman A, Littner MM, Lazarson A (1985) Radio-
filled teeth in the fluid transportation model either at 1 graphic study of the root canal system of mandibular
or 8 weeks. anterior teeth. International Endodontic Journal 18, 253–9.
Kennedy WA, Walker WA Jr, Gough RW (1986) Smear layer
removal effects on apical leakage. Journal of Endodontics 12,
References 21–7.
Abarca AM, Bustos A, Navia M (2001) A comparison of Khayat A, Lee SJ, Torabinejad M (1993) Human saliva
apical sealing and extrusion between Thermafil and penetration of coronally unsealed obturated root canals.
lateral condensation techniques. Journal of Endodontics Journal of Endodontics 19, 458–61.
27, 670–2. Kokkas AB, Boutsioukis Ach, Vassiliadis LP, Stavrianos CK
Cergneux M, Ciucchi B, Dietschi JM, Holz J (1987) The (2004) The influence of the smear layer on dentinal tubule
influence of the smear layer on the sealing ability of canal penetration depth by three different root canal sealers: an in
obturation. International Endodontic Journal 20, 228–32. vitro study. Journal of Endodontics 30, 100–2.
Chu CH, Lo EC, Cheung GS (2005) Outcome of root canal Kuttler Y (1955) Microscopic investigation of root apexes.
treatment using Thermafil and cold lateral condensation Journal of the American Dental Association 50, 544–52.
filling techniques. International Endodontic Journal 38, 179– Love RM (1996) Adherence of Streptococcus gordonii to
85. smeared and nonsmeared dentine. International Endodontic
Clark-Holke D, Drake D, Walton R, Rivera E, Guthmiller JM Journal 29, 108–12.
(2003) Bacterial penetration through canals of endodonti- Madison S, Krell KV (1984) Comparison of ethylenediamine
cally treated teeth in the presence or absence of the smear tetraacetic acid and sodium hypochlorite on the apical seal
layer. Journal of Dentistry 31, 275–81. of endodontically treated teeth. Journal of Endodontics 10,
Çobankara FK, Adanr N, Belli S (2004) Evaluation of the 499–503.
influence of smear layer on the apical and coronal sealing Mannocci F, Innocenti M, Bertelli E, Ferrari M (1999) Dye
ability of two sealers. Journal of Endodontics 30, 406–9. leakage and SEM study of roots obturated with Thermafill
Drake DR, Wiemann AH, Rivera EM, Walton RE (1994) and dentin bonding agent. Endodontics and Dental Trauma-
Bacterial retention in canal walls in vitro: effect of smear tology 15, 60–4.
layer. Journal of Endodontics 20, 78–82. Paqué F, Luder HU, Sener B, Zehnder M (2006) Tubular
Evans JT, Simon JH (1986) Evaluation of the apical seal sclerosis rather than the smear layer impedes dye penetra-
produced by injected thermoplasticized Gutta-percha in the tion into the dentine of endodontically instrumented root
absence of smear layer and root canal sealer. Journal of canals. International Endodontic Journal 39, 18–25.
Endodontics 12, 100–7. Pashley DH, Michelich V, Kehl T (1981) Dentin permeability:
Fan B, Wu MK, Wesselink PR (1999) Coronal leakage along effects of smear layer removal. Journal of Prosthetic Dentistry
apical root fillings after immediate and delayed post 46, 531–7.
space preparation. Endodontics and Dental Traumatology Roane JB, Sabala CL (1985) The balanced force concept for
15, 124–6. instrumentation of curved canals. Journal of Endodontics 11,
Feilzer AJ, de Gee AJ, Davidson CL (1993) Setting stresses in 203–11.
composites for two different curing modes. Dental Materials Saunders WP, Saunders EM (1994a) Coronal leakage as a
9, 2–5. cause of failure in root-canal therapy: a review. Endodontics
Fogel HM, Marshall FJ, Pashley DH (1988) Effects of distance and Dental Traumatology 10, 105–8.
from the pulp and thickness on the hydraulic conductance Saunders WP, Saunders EM (1994b) Influence of smear layer
of human radicular dentin. Journal of Dental Research 67, on the coronal leakage of Thermafil and laterally condensed
1381–5. GP root fillings with a glass ionomer sealer. Journal of
Galvan DA, Ciarlone AE, Pashley DH, Kulild JC, Primack PD, Endodontics 20, 155–8.
Simpson MD (1994) Effect of smear layer removal on the Şen BH, Wesselink PR, Türkün M (1995) The smear layer: a
diffusion permeability of human roots. Journal of Endodontics phenomenon in root canal therapy. International Endodontic
20, 83–6. Journal 28, 141–8.

ª 2006 International Endodontic Journal International Endodontic Journal, 39, 968–976, 2006 975
 Leakage of apical root fillings Shemesh et al.

Shipper G, Ørstavik D, Teixeira FB, Trope M (2004) An Torabinejad M, Ung B, Kettering JD (1990) In vitro bacterial
evaluation of microbial leakage in roots filled with a penetration of coronally unsealed endodontically treated
thermoplastic synthetic polymer-based root canal filling teeth. Journal of Endodontics 16, 566–9.
material (Resilon). Journal of Endodontics 30, 342–7. Torabinejad M, Handysides R, Khademi AA, Bakland LK
Sundqvist G, Figdor D, Persson S, Sjögren U (1998) Microbi- (2002) Clinical implications of the smear layer in endod-
ologic analysis of teeth with failed endodontic treatment and ontics: a review. Oral surgery, Oral Medicine, Oral Pathology,
the outcome of conservative re-treatment. Oral surgery, Oral Oral Radiology and Endodontics 94, 658–66.
Medicine, Oral Pathology, Oral Radiology and Endodontics 85, Wu MK & Wesselink PR (1993) Endodontic leakage studies
86–93. reconsidered. Part I. Methodology, application and rele-
Tay FR, Loushine RJ, Lambrechts P, Weller RN, Pashley DH vance. International Endodontic Journal 26, 37–43.
(2005a) Geometric factors affecting dentin bonding in root Wu MK, De Gee AJ, Wesselink PR, Moorer WR (1993) Fluid
canals: a theoretical modeling approach. Journal of Endo- transport and bacterial penetration along root canal fillings.
dontics 31, 584–9. International Endodontic Journal 26, 203–8.
Tay FR, Pashley DH, Williams MC et al. (2005b) Susceptibility Wu MK, Tigos E, Wesselink PR (2002) An 18-month
of a polycaprolactone-based root canal filling material to longitudinal study on a new silicon-based sealer, RSA
degradation. I. Alkaline hydrolysis. Journal of Endodontics RoekoSeal: a leakage study in vitro. Oral surgery, Oral
31, 593–98. Medicine, Oral Pathology, Oral Radiology and Endodontics 4,
Tay FR, Pashley DH, Yiu CK et al. (2005c) Susceptibility of a 499–502.
polycaprolactone-based root canal filling material to degra- Wu MK, van der Sluis LW, Ardila CN, Wesselink PR (2003)
dation. II. Gravimetric evaluation of enzymatic hydrolysis. Fluid movement along the coronal two-thirds of root fillings
Journal of Endodontics 31, 737–41. placed by three different GP techniques. International Endo-
Taylor JK, Jeansonne BG, Lemon RR (1997) Coronal leakage: dontic Journal 36, 533–40.
effects of smear layer, obturation technique, and sealer. Xu Q, Fan MW, Fan B, Cheung GS, Hu HL (2005) A new
Journal of Endodontics 23, 508–12. quantitative method using glucose for analysis of endodon-
Teixeira FB, Teixeira EC, Thompson JY, Trope M (2004) tic leakage. Oral surgery, Oral Medicine, Oral Pathology, Oral
Fracture resistance of roots endodontically treated with a Radiology, and Endodontics 99, 107–11.
new resin filling material. Journal of the American Dental
Association 135, 646–52.

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