INDIAN DENTAL JOURNAL

Offical Publication of Society of Medical Dental & Public Health

ENDODONTIC IRRIGATION: AN UPDATE

Hena Rahman1 Anil Chandra2 K K Wadhwani 3

1
Senior Resident 2Professor 3Professor and Head, Department of Conservative Dentistry and Endodontics, King George Medical
University, Lucknow, UP, India.
Address for Correspondence: Dr. Hena Rahman, Department of Conservative Dentistry and Endodontics, King George
Medical University, Lucknow, UP, India.
E-mail: ahanachandra@yahoo.com

ABSTRACT
Irrigation has a key role in successful endodontic treatment. The identification and elimination of bacteria, removal
of other necrotic products from the canal with appropriate irrigating solutions with proper technique ensures definite
fulfillment of one of the objectives of root canal therapy.

KEYWORDS Endodontic Irrigation, Disinfection, Root Canal Treatment, Sodium Hypochlorite

I
1
NTRODUCTION - Debridement of the root
canal system is essential for endodontic success.
Irrigation is a vital part of root canal debridement
. Unfortunately, many studies have shown that
currently used chemomechanical methods of root
canal preparation do not effectively debride the entire
root canal system 2– 6. Irrigation has a central role in
endodontic treatment. During and after
instrumentation, the irrigants facilitate removal of
microorganisms, tissue remnants, and dentin chips
from the root canal through a flushing mechanism.
Purpose of irrigation
Desired functions of irrigating solutions are: Washing
action (helps remove debris), Reduce instrument
friction during preparation (lubricant), Facilitate
dentin removal (lubricant), Dissolve inorganic tissue
(dentin), Penetrate to canal periphery, Dissolve
organic matter (dentin collagen, pulp tissue, biofilm),
Kill bacteria and yeasts (also in biofilm), Do not
irritate or damage vital periapical tissue, no caustic or
cytotoxic effects, Do not weaken tooth structure.
None of the available irrigating solutions can be
regarded as optimal. Using a combination of products
in the correct irrigation sequence contributes to a
successful treatment outcome.

CLASSIFICATION

17

Sodium Hypochlorite
Sodium hypochlorite appears to be most ideal
irrigant, as it covers more of the requirements for
endodontic irrigant than any other compound known.
NaOCl is commonly used in concentrations between
0.5% and 6%. Effective against bacteria,
bacteriophages, spores, yeast and viruses. It kills
sessile endodontic pathogens organized in biofilms
and in dentinal tubules as efficiently as CHX or
iodine at comparable concentration.19-20 It dissolves
necrotic and vital tissue. It dissolves organic
component of smear layer.21 Inactivates endotoxin.22
Chlorine, is responsible for the tissue dissolving and
antibacterial capacity of NaOCl, is unstable and is
consumed rapidly during the first phase of tissue
dissolution, probably within 2 min; therefore
continuous replenishment is essential.
EDTA and CA
Complete cleaning of the root-canal system requires
the use of irrigants that dissolve organic and
inorganic material. As hypochlorite is active only
against the former, other substances must be used to
complete the removal of the smear layer and dentin
debris. EDTA and CA effectively dissolve inorganic
material, including hydroxyapatite.23-26 They have
little or no effect on organic tissue and alone they do
not have antibacterial activity, despite some
conflicting reports on EDTA. EDTA is most
commonly used as a 17% neutralized solution
(disodium EDTA, pH 7), but a few reports have
indicated that solutions with lower concentrations
(eg, 10%, 5%, and even 1%) remove the smear layer
equally well after NaOCl irrigation. Considering the
high cost of EDTA, it may be worthwhile to consider
using diluted EDTA. CA is also marketed and used in
various concentrations, ranging from 1% to 50%,
with a 10% solution being the most common. EDTA
and CA are used for 2 to 3 minutes at the end of
instrumentation and after NaOCl irrigation. Removal
of the smear layer by EDTA or CA improves the
antibacterial effect of locally used disinfecting agents
in deeper layers of dentin.27, 28
Chlorhexidine Digluconate
Chlorhexidine digluconate (CHX) is widely used in
disinfection in dentistry because of its good
antimicrobial activity.29–31 it has gained considerable
popularity in endodontics as an irrigating solution
and as an intracanal medicament. CHX does not
possess some of the undesired characteristics of
sodium hypochlorite (ie, bad smell and strong
irritation to periapical tissues). However, CHX has no
tissue-dissolving capability and therefore it cannot
replace sodium hypochlorite. CHX permeates the
INDIAN DENTAL JOURNAL
Offical Publication of Society of Medical Dental & Public Health
microbial cell wall or outer membrane and attacks the
bacterial cytoplasmic or inner membrane or the yeast
plasma membrane. In high concentrations, CHX
causes coagulation of intracellular components.3 One
of the reasons for the popularity of CHX is its
substantivity (ie, continued antimicrobial effect),
because CHX binds to hard tissue and remains
antimicrobial. However, similar to other endodontic
disinfecting agents, the activity of CHX depends on
the pH and is also greatly reduced in the presence of
organic matter. 31 Several studies have compared the
antibacterial effect of NaOCl and 2% CHX against
intracanal infection and have shown little or no
difference between their antimicrobial effectiveness.
32–35
although bacteria may be killed by CHX, the
biofilm and other organic debris are not removed by
it. Residual organic tissue may have a negative effect
on the quality of the seal by the permanent root
filling, necessitating the use of NaOCl during
instrumentation.
Other Irrigating Solutions
Other irrigating solutions used in endodontics have
included sterile water, physiologic saline, hydrogen
peroxide, urea peroxide, and iodine compounds. All
of these except iodine compounds lack antibacterial
activity when used alone, and they do not dissolve
tissue either. Therefore there is no good reason for
their use in canal irrigation in routine cases. In
addition, water and saline solutions bear the risk of
contamination if used from containers that have been
opened more than once. Iodine potassium iodide (eg,
2% and 4%, respectively) has considerable
antimicrobial activity but no tissue dissolving
capability 36, 37 and it could be used at the end of the
chemomechanical preparation like CHX. However,
some patients are allergic to iodine, which must be
taken into consideration.
Combination Products
Although some of the main irrigating solutions
cannot be mixed without loss of activity or
development of potentially toxic by-products, several
combination products are on the market, many with
some evidence of improved activity and function.
Surface active agents have been added to several
different types of irrigants to lower their surface
tension and to improve their penetration in the root
canal. In the hope of better smear-layer removal,
detergents have been added to some EDTA
preparations (eg, SmearClear 38) and hypoclorite (eg,
Chlor-XTRA). Detergent addition has been shown to
increase the speed of tissue dissolution by
hypochlorite.39 recently, a few studies have been
published in which the antibacterial activity of a
18

chlorhexidine product with surface-active agents
(CHX-Plus) has been compared with regular CHX,
both with 2% chlorhexidine concentrations. The
studies 40, 41 have shown superior killing of planktonic
and biofilm bacteria by the combination product.
MTAD (a mixture of tetracycline isomer, acid, and
detergent, Biopure, Tulsa Dentsply, Tulsa, OK, USA)
and Tetraclean are new combination products for
root-canal irrigation that contain an antibiotic,
doxycycline.42-44 MTAD and Tetraclean are MTAD
(a mixture of tetracycline isomer, acid, and detergent,
Biopure, Tulsa Dentsply, Tulsa, OK, USA) and
Tetraclean are new combination products for root-
canal irrigation that contain an antibiotic,
doxycycline.42-44 MTAD and Tetraclean are designed
primarily for smear-layer removal with added
antimicrobial activity. Both contain CA, doxycycline,
and a detergent. They differ from each other in CA
concentration and type of detergent included. They
do not dissolve organic tissue and are intended for
use at the end of chemomechanical preparation after
sodium hypochlorite. Although earlier studies
showed promising antibacterial effects by
MTAD,45,46 recent studies have indicated that an
NaOCl/EDTA combination is equally or more
effective than NaOCl/MTAD.47,48 Comparative
studies on MATD and Tetraclean have indicated
better antibacterial effects by the latter.49 Although a
mixture containing an antibiotic may have good
short-term and long-term effects, concerns have been
expressed regarding the use of tetracycline
(doxycycline) because of possible resistance to the
antibiotic and staining of the tooth hard tissue, which
has been demonstrated by exposure to light in an in
vitro expreriment.50 However, no report of in vivo
staining has been published.
Suggested regimen
In summary, sodium hypochlorite is the most
important irrigating solution and the only one capable
of dissolving organic tissue, including biofilm and
the organic part of the smear layer. It should be used
throughout the instrumentation phase. However, use
of hypochlorite as the final rinse following EDTA or
CA rapidly produces severe erosion of the canal-wall
dentin and should probably be avoided.51 CHX does
not cause erosion of dentin like NaOCl does as the
final rinse after EDTA, and therefore 2% CHX may
be a good choice for maximized antibacterial effect at
the end of the chemomechanical preparation.52
MTAD can be used as a final rinse for 5 min along
with 1.3% NaOCl as main irrigant to provide better
disinfection of the root canal.53 To accomplish
objectives of irrigation, there must be an effective
delivery system to working length. Working length
INDIAN DENTAL JOURNAL
Offical Publication of Society of Medical Dental & Public Health
may be defined as the distance from a coronal
reference point to where the canal system is cleaned,
shaped, and obturated to prevent recurrent infection.
An improved delivery system for root canal irrigation
is highly desirable. Such a delivery system must have
adequate flow and volume of irrigant to working
length to be effective in debriding the canal system
without forcing the solution into periradicular tissues
3, 7
.
Needles
Although 25-gauge needles were common place for
endodontic irrigation a few years ago, they were first
replaced by 27-G needles, now 30-G and even 31-G
needles are taking over for routine use in irrigation.
As 27 G corresponds to International Standards
Organization size 0.42 and 30 G to size 0.31, smaller
needle sizes are preferred.
EndoActivator
EndoActivator (Advanced Endodontics, Santa
Barbara, CA, USA) is a new type of irrigation
facilitator. It is based on sonic vibration (up to 10,000
cpm) of a plastic tip in the root canal. The system has
3 different sizes of tips that are easily attached (snap-
on) to the handpiece that creates the sonic vibrations
(Fig. 1). EndoActivator does not deliver new irrigant
to the canal but it facilitates the penetration and
renewal of the irrigant in the canal. Two recent
studies have indicated that the use of EndoActivator
facilitates irrigant penetration and mechanical
cleansing compared with needle irrigation, with no
increase in the risk of irrigant extrusion through the
apex.8-9
Vibringe
Vibringe (Vibringe BV, Amsterdam, The
Netherlands) is a new sonic irrigation system that
combines battery-driven vibrations (9000 cpm) with
manually operated irrigation of the root canal .
Vibringe uses the traditional type of syringe/needle
delivery but adds sonic vibration.
RinsEndo
The RinsEndo system (Durr Dental Co) is based on a
pressure-suction mechanism with approximately 100
cycles per minute.6-8 A study of the safety of several
irrigation systems reported that the risk of
overirrigation was comparable with manual and
RinsEndo irrigation, but higher than with
EndoActivator or the EndoVac system.9
EndoVac system
The EndoVac system (Discus Dental, Culver City,
CA) is a novel new irrigation system. A
19

delivery/evacuation tip is attached to a syringe of
irrigant and the high speed suction of the dental chair
(Fig. 2A). A small tube attaches either a macro- or
microcannula to the suction (Fig. 2B, C). The
delivery/evacuation tip places irrigant in the chamber
and siphons off the excess to prevent overflow (Fig.
2D). The macrocannula is plastic with an open end
that measures International Standards Organization
(ISO) size 55 with a .02 taper. The microcannula is
stainless steel and has 12 small, laterally positioned,
offset holes in 4 rows of 3, with a closed end
measuring ISO size 32. As these cannulas are placed
in the canal, negative pressure pulls irrigant from a
fresh supply in the chamber, down the canal to the tip
of the cannula, into the cannula, and out through the
suction hose. The microcannula can be used at
working length in a canal enlarged to ISO size 35 or
larger. There is evidence that, compared with
traditional needle irrigation and some other systems,
the EndoVac system lowers the risks associated with
irrigation close to the apical foramen considerably.9
Another advantage of the reversed flow of irrigants
may be good apical cleaning at the 1-mm level and a
strong antibacterial effect when hypochlorite is used,
as shown by recent studies.10,11
Ultrasound
The comparative effectiveness of ultrasonics and
hand-instrumentation techniques has been evaluated
Fig.1. (A) EndoActivator with the large Fig.1. (B) Same tip in sonic
(blue) plastic tip.
Fig.2. .(B) The macrocannula attached Fig.2. (C) The microcannula
to its handle used for initial flushing of attached to its handle.
the coronal portion of the canal.
INDIAN DENTAL JOURNAL
Offical Publication of Society of Medical Dental & Public Health
in several earlier studies.11–14 Most of these studies
concluded that ultrasonics, together with an irrigant,
contributed to a better cleaning of the root-canal
system than irrigation and hand-instrumentation
alone. Cavitation and acoustic streaming of the
irrigant contribute to the biologicchemical activity for
maximum effectiveness.15 Analysis of the physical
mechanisms of the hydrodynamic response of an
oscillating ultrasonic file suggested that stable and
transient cavitation of a file, steady streaming, and
cavitation microstreaming all contribute to the
cleaning of the root canal.16 Ultrasonic files must
have free movement in the canal without making
contact with the canal wall to work effectively.17 Van
der Sluis and colleagues 18 suggested that a smooth
wire during ultrasonic irrigation is as effective as a
size 15 K-file in the removal of artificially placed
dentin debris in grooves in simulated root canals in
resin blocks.
CONCLUSION
Irrigation has a key role in successful endodontic
treatment. The identification and elimination of
bacteria, removal of other necrotic products from the
canal with appropriate irrigating solutions with
proper technique ensures definite fulfillment of one
of the objectives of root canal therapy.
Fig 2. (A) The complete EndoVac
motion system including all tubing and
vacuum attachment.
Fig.2. (D) The delivery/
evacuation tip attached to a
syringe.
20

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