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ORIGINAL RESEARCH

The Effect of Silver, Zinc Oxide, and Titanium Dioxide

Nanoparticles Used as Final Irrigation Solutions on
the Fracture Resistance of Root-Filled Teeth
This article was published in the following Dove Press journal:
Clinical, Cosmetic and Investigational Dentistry

Zahra Jowkar 1 Aim: This study was conducted to evaluate the effect of three nanoparticle solutions used as
Seyed Ahmadreza Hamidi 2 final root canal irrigants on the fracture resistance of endodontically treated roots.
Fereshteh Shafiei1 Materials and Methods: Sixty intact single-rooted premolar teeth were used after remov-
Yasamin Ghahramani3 ing the crowns below the cementum–enamel junction to standardize the length of the
remaining roots to 13 mm. After instrumenting the roots using ProTaper Universal rotary
1
Oral and Dental Disease Research
instruments up to size F4, the roots were randomly divided into six groups (n=10) according
Center, Department of Operative
Dentistry, School of Dentistry, Shiraz to the final irrigating solutions: Group 1: normal saline; Group 2: 2% chlorhexidine (CHX);
University of Medical Sciences, Shiraz, Group 3: 17% EDTA+2.5% NaOCl; Group 4: 17% EDTA+0.1% silver nanoparticle (SNP)
Iran; 2Department of Operative
Dentistry, School of Dentistry, Shiraz solution; Group 5: 17% EDTA+0.1% titanium dioxide nanoparticle (TNP) solution; Group 6:
University of Medical Sciences, Shiraz, 17% EDTA+0.1% zinc oxide nanoparticle (ZNP) solution. After filling the root canals with
Iran; 3Department of Endodontics, gutta-percha and AH Plus sealer, the fracture resistance (FR) values were measured. The data
School of Dentistry, Shiraz University of
Medical Sciences, Shiraz, Iran were subjected to the one-way analysis of variance and the Tamhane post hoc test (p=0.05).
Results: EDTA + NaOCl had the lowest FR value, followed by normal saline and CHX (p
values < 0.05). No significant difference was found between the FR of roots irrigated with CHX
and normal saline (p > 0.05). The application of nanoparticles (SNP, TNP, and ZNP) was
associated with a significantly greater FR than that of other irrigation solutions (p values < 0.05).
Conclusion: The final irrigation of root canals with nanoparticles enhanced the fracture
resistance of the endodontically treated roots. The lowest FR value was observed for NaOCl.
Keywords: fracture resistance, nanoparticles, root canal irrigants

Introduction
Chemomechanical preparation during endodontic treatment weakens the tooth
structure and decreases its fracture strength.1 The quality of adhesion and the
mechanical interlocking between the root canal dentin and the filling material can
positively affect the fracture strength of endodontically treated teeth.1,2 Gutta-
percha used with an insoluble root canal sealer has been universally regarded as
the gold standard for root canal filling materials. However, the ability of gutta-
percha used with a sealer to reinforce the fracture resistance of an endodontically
treated root is still controversial.2,3 It has been suggested that using adhesive sealers
in the root canal system enhances the fracture resistance of root-filled teeth.2
Root canal irrigation solutions have been employed along with mechanical instru-
mentations to eliminate the pulp remnants and the smear layer formed after preparing
Correspondence: Fereshteh Shafiei the root canal. Irrigation solutions can also open the dentinal tubules to clean the root
Tel +98 71-36263193
Email shafief@[Link] canal space adequately and therefore resulting in better conditions for subsequent canal

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obturation and adhesion. Moreover, smear layer removal inhibitory effect on matrix metalloproteinase, low cytotoxi-
from the root canal may improve the contact of root canal city, and substantivity.14 Furthermore, when used as a final
filling materials and root canal sealers with the canal walls irrigant after EDTA/NaOCl irrigation, CHX was able to
and thus may improve the penetration of sealers into the enhance the fracture resistance of root-filled teeth with
dentinal tubules.4 However, some irrigation solutions might AH Plus in a previous study.15 CHX can also decrease the
negatively affect the bond strength of resinous materials to contact angle of root canal sealers and thus increase
root dentin.5 It has been reported that the chemical properties wettability.16
and concentration of irrigants may affect some physical Recently, metal nanoparticles (NPs) have gained more
properties of root canal dentin such as microhardness and attention in dentistry especially because of their antibacterial
flexural strength.5–7 After the application of the irrigation properties. NPs have been shown to have a high degree of
solution, the chemically altered dentin may has such pro- interaction with the bacterial cell wall because of their high
blems as dentinal cracks and vertical root fracture.1 Final surface area and small size.17 Even in a remarkably lower
irrigation solutions can alter the wetting of root canal dentin concentration, silver nanoparticles (SNPs) have demon-
by sealers which may possibly influence the bond strength of strated the same bactericidal effect as 5.25% NaOCl against
root canal filling materials to root canal dentin.4 It has Enterococcus faecalis.18 Therefore, SNPs have been pro-
recently been reported that final irrigation regimens have an posed as a novel non-toxic endodontic irrigant.19 The sig-
impact on the fracture resistance of the teeth.1 The chemical nificant antibacterial efficacy of zinc oxide nanoparticles
interactions between different irrigants during root canal (ZNPs) against planktonic Enterococcus faecalis has been
treatment and the subsequent cumulative effects on the root previously demonstrated.17 Recently, titanium dioxide nano-
dentin have also been assumed.8 particles (TNPs) have also been used in dentistry as an
The bacteria might still be present within the dentinal antibacterial agent. TNPs have higher antibacterial properties
tubules even after root canal cleaning and shaping and might than chlorhexidine, possess a pleasing color, and have a high
be inaccessible to the currently used irrigants or medicaments biocompatibility.20,21
due to their limited penetrability into the dentinal tubules.9 No previous study has been conducted on the efficacy
Besides, bacterial biofilm has demonstrated some degree of of SNPs, TNPs, and ZNPs used as novel root canal irri-
resistance to common root canal irrigation solutions such as gants on the fracture resistance of endodontically treated
sodium-hypochlorite and chlorhexidine.9 Therefore, some teeth. Therefore, the aim of the present study was to assess
attempts have been made to introduce novel antimicrobial the effect of three nanoparticle solutions used as final root
solutions as root canal irrigants. canal irrigants on the fracture resistance of roots filled with
Various irrigation solutions have been used for final irriga- gutta-percha and AH Plus sealer (Dentsply De Trey Gmbh,
tion purposes in endodontic practice such as sodium hypo- Konstanz, Germany).
chlorite (NaOCl), chlorhexidine (CHX), and ethylenediamine
tetraacetic acid (EDTA).1 One of the most common irrigation Materials and Methods
solutions used by endodontists is sodium hypochlorite The study protocol was approved by the Research and Ethics
(NaOCl) because of its ability to solubilize tissues, its anti- Committee of Shiraz University of Medical Sciences
microbial effect, and its ability to dissolve biofilms.10 (Protocol # [Link].1398.75). The patients
However, some important drawbacks of NaOCl are its unplea- whose extracted teeth were used for this research provided
sant smell and negative effect on the penetration of the resin written informed consent. All of the procedures of this
sealer into dentin and its polymerization.10,11 Additionally, experimental study were performed by a blinded calibrated
NaOCl is a deproteinizing agent that dissolves collagen and operator. Sixty intact single-rooted human mandibular pre-
degenerates dentin.11 In a previous study, the mechanical molar teeth (with the buccolingual dimension at the cemen-
properties of root dentin such as flexural strength, ultimate toenamel junction (CEJ) of 5.1±0.5 mm and the mesiodistal
tensile strength, and fracture resistance were significantly dimension of 4.4 ± 0.5 mm) which were extracted for ortho-
reduced after NaOCl application.12 It has been previously dontic or periodontal reasons were collected for this study
reported that NaOCl solutions could reduce the fracture resis- and were stored in a 0.5% chloramine solution at 4°C for
tance of root canal-treated bovine teeth by about 30%.13 a period of no longer than one month after extraction until
CHX has been recommended as a final irrigation solu- use. The teeth were sectioned below the CEJ perpendicular to
tion because of its wide range of antimicrobial activity, the long axis of the roots so that the crowns were removed

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and the remaining length of the roots was 13 ± 1 mm. The to the lower plate of a universal testing machine (Instron
root canals of all the specimens were instrumented with the Z020, Zwick Roell, Ulm, Germany), a steel ball with
ProTaper NiTi rotary system (Dentsply Maillefer, Ballaigues, a spherical tip (5 mm in diameter) was mounted on the
Switzerland) up to size F4. The working length of each upper plate and was placed over the center of the root canal
sectioned root was considered to be 1 mm shorter than the orifice to apply a compressive load at a speed of 1 mm/min to
root length. After using each file, 1 mL 2.5% NaOCl (Sigma- the root parallel to its long axis until fracture. The force
Aldrich, St. Louis, MO, USA) via a 27-G irrigating tip required to fracture each root was recorded in Newtons (N).
(Endo-Eze; Ultradent, South Jordan, UT) was used for root The fracture pattern of the roots was examined using a 4 ×
canal irrigation. The outward flow of irrigant from the apices magnifying glass. The schematic representation of the speci-
was prevented by sealing the apices of the roots with wax. men preparation procedures has been shown in Figure 1.
Following the completion of root canal instrumentation, all The normality of the data was checked using the
the samples were irrigated with 5 mL 2.5% NaOCl and 2 mL Kolmogorov–Smirnov test. The one-way analysis of var-
saline. The sectioned roots were randomly divided into six iance (one-way ANOVA), followed by the Tamhane
experimental groups (n=10) based on the final sequence of post hoc test, was used for data analysis. All the analyses
irrigation: were conducted using SPSS software version 17 (SPSS
Group 1: normal saline (5 mL, 1 minute) Inc, Chicago, USA). The statistical comparisons were
Group2: 17% EDTA (5 mL, 1 min) and 2% chlorhex- considered significant at p values less than 0.05.
idine (Consepsis, Ultradent Inc., South Jordan, UT, USA)
(5 mL, 1 minute) Results
Group 3: 17% EDTA (5 mL, 1 min) and 2.5% NaOCl The mean fracture resistance (FR) values and standard
(5 mL, 1 min) deviations (SD) in N are shown in Table 1. The one-way
Group 4: 17% EDTA (5 mL, 1 min) and 0.1% SNP ANOVA test showed a significant difference among all
solution (5 mL, 1 min) groups (P<0.05). The Tamhane post hoc test was per-
Group 5: 17% EDTA (5 mL, 1 min) and 0.1% TNP formed for pair-wise comparisons. Group 3 (EDTA +
solution (5 mL, 1 min) NaOCl) had the lowest FR value (636.90 N), followed
Group 6: 17% EDTA (5 mL, 1 min) and 0.1% ZNP by group 1 (normal saline, 871.60 N), and group 2
solution (5 mL, 1 min) (CHX, 861.20) (p values < 0.05). No significant difference
The particle sizes of the SNPs, ZNPs, and TNPs (pur- was found between the FR of roots irrigated with CHX
chased from ASEPE Company, Tabriz, Iran) were 20 nm, and normal saline (p > 0.05). The applications of nano-
<50 nm, and 20 nm, respectively. EDTA was applied in all particles (SNP, TNP, and ZNP) were associated with sig-
experimental groups except group 1 (normal saline). nificantly greater FR of roots compared to that of other
Each root canal was rinsed with 5 mL of distilled water to irrigation solutions (p values < 0.05). No significant differ-
remove any residual irrigation solution after the application of ences in FR values were noted among groups 4 (EDTA +
the final irrigant solution. After drying the root canals with SNP), 5 (EDTA + TNP), and 6 (EDTA + ZNP) (p values >
paper points, the roots were filled with ProTaper F4 gutta- 0.05). Regardless of the final irrigant, the examination of
percha (Dentsply Maillefer, Ballaigues, Switzerland) and AH the fracture pattern of the roots revealed that the majority
Plus root canal sealer (Dentsply DeTrey, Konstanz, Germany) of the samples fractured in a labiolingual direction.
using a single-cone technique. The obturation quality of the
root canals was checked using periapical radiographs. After Discussion
being wrapped in moist gauze, the specimens were stored in This study was conducted to evaluate the effect of differ-
separate jars in a 37 º C incubator for 1 week to allow the ent final irrigation solutions on the FR of endodontically
proper setting of the sealer. To simulate the periodontal liga- treated roots filled with gutta-percha and AH Plus.
ment, the surfaces of the roots were coated with a silicone According to the results of the present study, the three
material with a uniform thickness (2 mm) (C-silicone, groups finally irrigated with nanoparticles (SNPs, TNPs,
Zetalabor, Zhermack SpA, Badia Polesine, Italy) up to 2 mm and ZNPs) demonstrated greater FR compared to those
apical to the CEJ. The roots were embedded in self-curing irrigated with normal saline, CHX, or NaOCl. The lowest
acrylic resin (Acropars, Marlik Co., Tehran, Iran) covering the mean of FR value was observed in the group treated with
apical 10 mm of each root. After attaching the acrylic blocks NaOCl.

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Figure 1 The schematic representation of the specimen preparation procedures. (A) The crown of a premolar tooth was sectioned and removed. (B) The instrumentation
of the root was performed using the ProTaper NiTi rotary system. (C) The final irrigation protocol was performed according to the experimental group. (D) The root was
obturated. (E) The roots were embedded in the self-curing acrylic resin block. (F) The fracture resistance was measured.

NaOCl, CHX, and EDTA are the most common endo- NaOCl for the effective disinfection of difficult-to-reach
dontic irrigants.22 Therefore, the effects of the nanoparti- areas is also questionable.23 In this study, the lowest frac-
cles on the FR of endodontically treated roots were ture value was observed for the roots finally irrigated with
compared to those of normal saline, CHX, and NaOCl in NaOCl. This result is in line with a previous study which
this study. One of the root canal irrigants used in this study showed that NaOCl could reduce the FR of root canal-
was NaOCl. It is an antimicrobial agent with the ability to treated bovine teeth by about 30%.13 This undesired root
dissolve biofilms. However, NaOCl is incapable of remov- weakening effect can be attributed to the effects of NaOCl
ing the smear layer and inorganic residues.10,12 Therefore, on dentin. The depletion of the dentin components of the
the application of a chelating agent such as EDTA is organic framework (about 22 wt%) can result from the
recommended.10 Moreover, the organic substances in the proteolytic action of NaOCl which has negative impacts
root canal might easily inactivate NaOCl. The ability of on dentin such as weakening the dentin framework and
reducing the dry weight by 14%.12,24 Therefore, after the
application of NaOCl, physical and mechanical changes in
Table 1 The Mean Fracture Resistance Values ± Standard
the dentin may occur such as microcrack formation and
Deviations (N) of the Experimental Groups
the reduction of flexural strength, microhardness, and
Group Final Irrigation Procedures Fracture Resistance modulus of elasticity.12 The reduction of flexural strength
1 Normal saline (control) 871.60 ± 52a and elastic modulus may potentially make dentin more
2 CHX 861.20 ± 91a brittle.12 An increase in stress concentration, dentin con-
3 EDTA + NaOCl 636.90 ± 89b traction, and crack propagation following the deleterious
4 EDTA + SNP 1146.50 ± 81c
effects of NaOCl solutions on the organic framework of
5 EDTA + TNP 1276.70 ± 193c
6 EDTA + ZNP 1055.90 ± 112c
dentin might ultimately result in a significant decrease in
FR.24
Note: Different superscripted letters indicate statistically significant differences
(p < 0.05). In spite of being incapable of removing the smear
Abbreviations: CHX, chlorhexidine; EDTA, ethylenediamine tetraacetic acid;
layer, CHX has been suggested as a final irrigant.25 CHX
NaOCl, sodium hypochlorite; SNP, silver nanoparticle; TNP, titanium dioxide nano-
particle; ZNP, zinc oxide nanoparticle. did not affect the FR of the root-filled teeth in this study

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which is in line with a previous study.1 Moreover, the FR properties against Streptococcus mutans and have antibacter-
of roots which were finally irrigated with NaOCl was ial properties by causing the production of free radicals.37
lower than that of those irrigated with CHX. This finding One of the main problems of common root canal irri-
might be related to the negative effect of NaOCl on the gants is their inability to reach the apical third and the
bond strength of resin-based sealers to root dentin and the most complex anatomical structures (isthmi and anastomo-
positive influence of CHX on the bonding stability of sis). Nanoparticles have small-sized molecules and might
resin-based sealers to root dentin.25 Besides, less smear have better penetration into these areas.36,38
layer is formed after using CHX as a root canal irrigant in In the present study, EDTA was employed before the
comparison with using NaOCl.26 It was found in application of the nanoparticles. The presence of the smear
a previous research that the final irrigation with CHX did layer on the root canal walls negatively affected the adap-
not influence the bond strength of gutta-percha/AH Plus to tation, penetration, and bond strength of the sealers.15,39
root canal dentin.5 Although CHX did not affect the FR of The application of a chelating agent such as EDTA for the
endodontically treated roots in the present study, it could removal of the smear layer resulted in improved penetra-
prevent the subsequent possible coronal microleakage due tion, retention, and bond strength of the AH Plus sealer.39
to its substantivity.14 Therefore, in the present study, EDTA was applied for
Recently, metal NPs have received more attention in 1 minute before irrigation with the nanoparticles.
dentistry especially due to their antibacterial properties. Although EDTA has been proposed for final irrigation, it
SNPs, TNPs, and ZNPs have recently been suggested to be has some limitations such as low antimicrobial activity and
used as dentin or enamel surface pretreatments so that their changing the mechanical properties of dentin.40,41 For
antimicrobial properties can be exploited.27 Additionally, no these reasons, the application of the nanoparticles used in
interference with the push-out bond strength of the fiber posts this study after EDTA can compensate for its limitations.
was observed after intraradicular dentin pretreatment with Moreover, demineralized microporous collagen matrices
SNPs, TNPs, and ZNPs.28 Nanoparticles can also be used as were identified from instrumented canal walls after using
root canal irrigants.19 Three nanoparticles (SNPs, TNPs, and 17% EDTA.41 Therefore, the simultaneous removal of
ZNPs) were used as final irrigation solutions in this study and smear layers and making dentinal tubules patent without
the groups treated with them had the highest FR values. No demineralizing dentin is difficult to obtain using common
significant differences were found among the fracture resis- smear layer–removing endodontic irrigants.41 The thin
tances of the three nanoparticles used in this study. Compared layer of demineralized collagen fibrils which may remain
to CHX, metal nanoparticles can penetrate into the deeper on the root canal dentin surface after using EDTA as the
layers of the biofilm due to their small size and can be final canal irrigant can lead to the poor wettability of root
mechanically trapped in plaques.29 SNPs have exhibited canal sealers after EDTA irrigation.41 The reduced surface
long-term broad-spectrum antibacterial properties via sus- tension of root canal irrigants by the application of
tained silver ion release.30 Additionally, the biocompatibility a surfactant has improved their dentin wetting ability.42
of SNPs has been previously shown.31 The bacteriostatic and One possible explanation for the improved FR of the roots
bactericidal effects of SNPs on five different oral pathogenic irrigated with the nanoparticles may be the probable
bacteria were significantly higher than those of chlorhexidine improved wettability and the increased dentin surface
in a previous study.32 When used as intracanal irrigants, energy possibly due to irrigating the canals with them.
silver nanoparticles can eliminate bacteria and bacterial bio- However, the effects of nanoparticles on wettability and
films more efficiently than chlorhexidine.33 Another nano- dentin surface energy were not assessed in this study and
particle that was used in this study was ZNP. The selective should be evaluated in future. On the other hand, nanos-
antibacterial effects of ZNPs against several types of gram- cale molecules such as nanofillers from dentin adhesives
negative and gram-positive bacteria with minimal effects on cannot penetrate into a fully expanded demineralized col-
human cells have been previously confirmed.34 Additionally, lagen matrix.43 Most endodontic sealers contain macro/
an MMP inhibitory effect has been reported for ZNPs.35 microfillers by classification. Besides, a dried, collapsed,
Moreover, ZNPs were able to retain their antibacterial prop- demineralized collagen matrix which remains after
erties against Enterococcus faecalis even after aging for 90 the application of EDTA is not appropriate for the infiltra-
days.36 The last nanoparticle which was used in this study tion of resin sealer molecules.41 The application of nano-
was TNP. TNPs have demonstrated good antiadhesive particles after EDTA in this study might have led to

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a better contact of the nanoparticles with a higher surface nanoparticle size.46 Moreover, nanoparticles can inhibit bac-
area of dentin and subsequently the better penetration of terial adherence to the root canal system.17
the nanoparticle molecules into the demineralized micro- This in vitro study has some limitations. This study was
porous collagen fibers. These explanations might justify only a preliminary study to assess the effect of nanoparticles
the higher FR values obtained for the nanoparticles used as used as final irrigants on the fracture resistance of the endo-
final irrigants compared to the other agents. dontically treated teeth. EDTA was applied before nanopar-
In the current study, it was observed that the roots ticles in this study and further studies are required to assess
treated with nanoparticles had higher FR than those treated the effect of the nanoparticles used as final irrigants without
with CHX groups. This effect might be related to the fact applying EDTA to exactly clarify the effect of nanoparticles
that nanoparticles have smaller sizes than the molecules of on the fracture resistance of the endodontically treated roots.
CHX. Besides, nanoparticle molecules have a large pro- The vertical root fracture is a multifactorial problem.
portion of surface atoms, a high surface energy, and a large Different factors affecting the FR of endodontically treated
surface area.44 These properties might affect the penetra- teeth such as occlusion, residual tooth structure, parafunc-
tion of the nanoparticles into the dentinal collagen. This tional habits, and coronal restoration should also be consid-
issue should be assessed in future studies. ered in future studies.47 The effects of nanoparticles on the
The bonding of the root canal sealer to the radicular wetting ability of radicular dentin and surface free energy
dentin is one of the necessary requirements for increasing were not assessed in this study. Only one type of sealer was
the root strength.45 It has been demonstrated that root used in the present study. Therefore, further in vitro and
canal irrigants can affect the bond strength of resin sealers in vivo studies are needed to investigate the effects of
such as AH Plus (which was used in this study) to dentin SNPs, TNPs and ZNPs used as final irrigants on the early
by modifying the surface properties of the root canal and long-term bond strength of the sealer to root canal dentin
dentin or removing the smear layer.5,39 Moreover, irrigants and the resultant effect on the FR of the roots using various
may alter the wettability of root canal sealers and possess types of resin sealers. Besides, the possible long-term anti-
the ability to clean and demineralize dentin surfaces.39,42 It bacterial properties of nanoparticles in root canals, the pos-
has been previously found that SNP pretreatment before sible release of nanoparticles into saliva and oral cavity, and
fiber post cementation with resin cements can improve the their accumulation in vital organs should be evaluated.
push-out bond strength of fiber post to root canal dentin.28
The effect of the nanoparticles used as root canal irrigants Conclusion
on the bond strength of the resin sealer to radicular dentin The final irrigation protocol influenced the FR of endo-
was not assessed directly in the present study. However, dontically treated roots. The final irrigation of root canals
the high fracture resistance values observed for the groups with nanoparticles enhanced the fracture resistance of the
irrigated with the nanoparticles might be related to the endodontically treated roots. The lowest value of FR was
positive effects of the nanoparticles on the sealer bond observed for NaOCl.
strength to root dentin. The probable better contact of the
sealer to the root canal walls treated with the nanoparticles
and its subsequent altered penetration into the dentinal Acknowledgments
The authors thank the Vice-Chancellery of Research,
tubules could justify this finding. Besides, nanoparticles
Shiraz University of Medical Sciences for supporting this
might alter the wettability of radicular dentin which should
research and Biomaterial Research Center of Shiraz
be assessed in future studies.
University of Medical Sciences for testing the specimens
Generally, the use of nanoparticles as root canal irrigants
may have some advantages over common root canal irri- (Number: 98-01-99-20035). The authors thank Dr. Mehrab
gants. The average diameter of dentinal tubules (1 µm) is Sayadi from the Dental Research Development Center for
ten times greater than the average diameter of nanoparticles the statistical analyses. The authors also thank Dr. Arash
(0.1 µm) which leads to the easier penetration of nanoparti- Moradi for editorial assistance.
cles into the tubules and their probable subsequent sustained
release and longer antibacterial effects.38 Nanoparticles have Disclosure
a bactericidal activity which is inversely related to the The authors report no conflicts of interest in this work.

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19. Chan EL, Zhang C, Cheung GS. Cytotoxicity of a novel nano-silver

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