Current Oral Health Reports

https://doi.org/10.1007/s40496-019-00241-6

MODERN APPROACHES TO ENDODONTICS (S KIM AND B KARABUCAK, SECTION EDITORS)

Irrigation in Endodontics: a Review

Sarah Bukhari 1 & Alaa Babaeer 2

# Springer Nature Switzerland AG 2019

Abstract
Purpose of Review The purpose of this chapter was to review progress in the endodontic irrigation and advances in disinfection
process and their clinical implication.
Recent Findings This review shed the light on the culturing techniques shortcomings and the complexity of the root canal
infection both anatomically and microbiologically. It also discusses in depth the most widely used endodontic irrigants, their
antimicrobial efficacy, safety, advantages, and disadvantages. Irrigation issues to discuss are not merely centered on which
antimicrobial solution to use, but also its method of delivery, preferably to all parts of the complex anatomy of root canals,
bearing in mind the complex features of the offending microbial biofilm. The new direction has been toward developing a reliable
delivery system to ensure thorough disinfection to the inaccessible areas of the root canal system such as passive ultrasonic
irrigation, XP Endo finisher, Endo Vac, and Gentlewave.
Summary To date, sodium hypochlorite (NaOCl) remains the gold standard of endodontic irrigants, due to its tissue dissolving
capacity exhibited by no other. However, it still falls short of completely rendering root canal bacteria free. Moreover, its toxicity
is detrimental when extruded beyond the apex. In this review, potential complementary irrigation solutions are discussed along
with adjunctive irrigation techniques for safer and more effective delivery of the irrigation aiming to perfect disinfection of root
canal.

Keywords Endodontic irrigation . Microbial elimination . Sodium hypochlorite solution . Root canal disinfection . Gentlewave .
Antimicrobial nanoparticles

Introduction pulpal and peri-radicular infections [3]. Since complete erad-

Microbes have been long implicated as the primary cause in
the pathological process of apical periodontist [1]. Bacterial
biofilms were recently recognized as the dominant form of
endodontic infections rather than planktonic bacteria [2].
The goal of endodontic treatment is to prevent and/or treat
This article is part of the Topical Collection on Modern Approaches to
Endodontics
* Sarah Bukhari
bukharisa1@ngha.med.sa
Alaa Babaeer
babeer@upenn.edu
1
Department of Dental Services, King Abdulaziz Medical City –
Jeddah, Ministry of National Guard Health Affairs, P.O. Box: 9515,
Jeddah 21423, Saudi Arabia
2
Department of Endodontics, School of Dental Medicine, University
of Pennsylvania, 240 S. 40th Street, Philadelphia, PA 19104, USA
ication of microbes is not attainable, this goal relies on reduc-
ing the microbiological load below a certain threshold to allow
for healing of periapical lesion [4]. Disinfection process in-
volves mechanical preparation of root canal, chemical irriga-
tion, and if needed, intracanal medicaments. Mechanical prep-
aration aims to enlarge the canal for more efficient irrigation
and in preparation for obturation. It also reduces the microbi-
ological load possibly by scarping biofilm attached to the
dentinal wall [5]. However, due to the complexity of root
canal system and since root canals are mostly oval in shape,
they do not correspond well with files shape resulting in large
areas of un-instrumented canal potentially harboring microbes
[6]. Therefore, mechanical preparation is complemented with
chemical irrigation for adequate disinfection and for flushing
instrumentation-related dentinal debris. The ideal endodontic
irrigant should be strong enough to dissolve intracanal
necrotic/vital tissue and to eliminate bacteria and gentle
enough on the extraradicular tissues, i.e., non-toxic, non-anti-
genic, and non-carcinogenic. Furthermore, it should be effec-
tive in the presence of body fluid, exhibits long-lasting effect,

does not negatively impact dentin physical properties, does
not affect bonding of sealer/post to dentin, able to inactivate
bacterial endotoxins, does not stain tooth structure, act as lu-
bricant, remove smear layer, cost-effective, and easy to use/
store, Unfortunately, there is no irrigant that currently com-
bines all these desirable characteristics. This review will be
discussing the three most widely used endodontic irrigants
along with commercially available irrigant combinations and
advanced technologies in root canal disinfection.
1. Sodium hypochlorite (NaOCl)
Mechanism of action:
When NaOCl contacts the water, it breaks into sodium
hydroxide (NaOH) and hypochlorous acid (HOCl) in a dy-
namic reaction. NaOH degrades the fatty acid through sapon-
ification reaction resulting in fatty salts and glycerol, which is
the first NaOCl organic tissue dissolution mechanism. NaOH
also neutralizes the amino acids releasing hydroxyl ion (OH
−). OH− are oxidative free radicals that attack bacteria by
damaging phospholipids, an integral part of bacterial cell
membrane via lipid peroxidation. The alkalinity resulting
from the OH− action interferes with the bacterial enzymatic
activity.
HOCl is involved in the chloramination reaction, in which
amino acid is degraded (the second tissue dissolving mecha-
nism) by replacing the hydrogen group in the amino acid with
chlorine. The resultant byproduct is chloramine, which irre-
versibly oxidizes the bacterial enzymes sulfhydryl group (SH)
consequently inhibiting bacterial enzymatic activity and there-
by cell metabolism [7] (Table 1).
Anti-microbial efficacy:
Planktonic cells:
Several in vitro studies have demonstrated the high and
instant antimicrobial potency of NaOCl against planktonic
bacteria even in very low concentration (0.0001%) [8, 9].
However, this superior performance is not matched clinically.
This discrepancy can be explained with the inhibitory effect of
dentin and serum albumin in the inflammatory exudate on
NaOCl antimicrobial activity [10, 11].
Table 1 Advantages and disadvantages of NaOCl
Advantages • Its well-established antimicrobial activity.
• The most important advantage that makes sodium
hypochlorite stands out amongst all irrigants is the
tissue solvent capacity.
• It acts as a lubricant.
• Quick onset.
Disadvantages • Toxic
• Not substantive
• Bad odor and corrosion
• Does not dissolve the inorganic part of smear layer
Curr Oral Health Rep
A recent systematic review comparing the antimicrobial
efficacy of NaOCl and chlorhexidine (CHX) reported variable
results [12]. One study showed NaOCl to be more effective
than CHX [13]. Another demonstrated opposite findings [14].
Two studies reported both irrigants are equally effective [15,
16], and one showed both are ineffective in eliminating endo-
toxins [17]. The literature is filled with similar studies with
conflicting conclusions.
This might be due to limitations of the clinical sampling
technique (whether culture or molecular) taken with a sterile
paper points immersed within the main canal. This would
underestimate the number of bacteria by omitting information
about bacteria within inaccessible areas such as isthmus, lat-
eral canals, and apical ramifications [18]. Furthermore, the
culture method has low sensitivity, and as-yet-uncultivated
bacteria cannot be detected. With regard to the molecular tech-
niques, the majority of the studies used DNA-based quantita-
tive polymerase chain reaction (qPCR). This has been shown
to potentially underestimate the number of remaining bacteria
as it only detects the presence of bacteria, not their viability in
comparison to RNA-based qPCR, which is more sensitive to
microbial metabolic activity. Therefore, careful interpretation
of the efficacy of specific disinfection protocols using DNA-
based methods should be considered [19].
Biofilms:
After recent technological advances in the imaging and
histological fields, multiple observations of biofilm structure
attached to the canal walls were documented. Hence, apical
periodontitis was classified as a biofilm-induced disease.
Biofilm is a community of microorganism coexisting together
in the self-produced extracellular matrix. Bacteria in biofilms
are 100–1000-fold more resistant to the antimicrobial agents
than their freely swimming correspondents. Thereby, the need
for updated research that investigates the disinfectant capacity
of currently used irrigants under biofilm concept has emerged.
Chávez de Paz et al. showed that 1% NaOCl damaged the
membrane integrity and removed most biofilm cells (24 h
old) after 5 min contact with four different strains isolated
from persisted cases of apical periodontitis [20]. However,
mature biofilms are more resistant than their young counter-
parts. Wang et al. demonstrated that NaOCl was more success-
ful in killing 1-day-old Enterococcus faecalis biofilm than 3-
week-old biofilm. This effect was directionally proportional to
exposure time and NaOCl concentration [21]. Liu et al.
showed that the resistance of E. faecalis biofilms is affected
by the maturity of biofilms and was also dependent on the
physiological phase of biofilms [22].
Moreover, it has been shown that 2% NaOCl and 2% CHX
performed poorly on multispecies biofilm in comparison to
single species-based model [21]. It is fair to assume that
biofilms within the root canal system would be mostly multi-
species in nature and at least a few weeks old by the time the
Curr Oral Health Rep
treatment is initiated. Thereby, the results of some in vitro
studies in which young single species biofilm is used should
be carefully interpreted, as the efficacy of the tested irrigants is
potentially overestimated. Du et al. have found that irrigation
with 5% NaOCl followed by placement of sealer exhibits a
synergistic antimicrobial effect on dentin infection [23].
Furthermore, mechanical instrumentation in large root canals
was shown to enhances the effect of NaOCl irrigation on
E. faecalis biofilms when compared to irrigation alone [24]
and that increasing apical preparation size significantly rein-
force disinfection with NaOCl [25]. E. faecalis is one of the
most studied microbial species in endodontic research. Mostly
because of its repeated isolation from persistent apical peri-
odontitis cases and due to its relatively easy of handling in
laboratory conditions and thus detection. Interestingly, it has
been established that NaOCl inactivates E. faecalis
lipoteichoic acid (EfLTA), which is responsible for inflamma-
tory mediators induction [26].
Tissue solvent capacity:
NaOCl tissue dissolution capacity was shown to be depen-
dent on several factors such as concentration, temperature,
agitation, volume, contact time, type of tissue, refreshment
of the solution, and adding surfactant.
Hand et al. have long shown that the dissolution capacity of
NaOCl is a function of concentration [27]. Unfortunately, con-
centration and toxicity have a linear relation as well [28]. As a
result, other methods were explored to maximize tissue disso-
lution capacity independent of the concentration.
Cunningham et al. have shown that the tissue dissolving effect
of 2.5% of NaOCl when heated to body temperature (37 °C) is
equal to that of 5% at room (21 °C) or body temperature [29].
However, another study demonstrated that while increasing
the temperature increases the tissue dissolution capacity of
NaOCl, but 5.25% NaOCl was still more effective than
2.6% regardless of the temperature [30].
Moreover, the clinical relevance of preheating NaOCl was
questioned in an in vivo study, since NaOCl temperature was
quickly buffered to equilibrium once injected inside the root
canal [31]. NaOCl was also found to be most effective in
dissolving fresh tissues and progressively less effective on
necrotic and fixed tissues, respectively. Moorer et al. have
analyzed other parameters. They demonstrated the importance
of continuous NaOCl flow, as the organic material quickly
buffer its activity [32]. Moreover, they were the first to state
that mechanical agitation and its frequency had a significant
influence on enhancing the solvent action of NaOCl. These
findings were confirmed by Stojicic et al. who reported that
agitation had more impact on improving dissolution than in-
creasing temperature [33]. Furthermore, NaOCl products with
added surfactant were found to be more efficient in dissolving
tissues at all concentrations and temperatures than products
without those agents. This superior surfactant-dependent
performance could be due to better contact of NaOCl to the
surface of tissues.
Ideal concentration:
Various concentrations of NaOCl ranging between 0.5 and
5.25% are used clinically. The optimum concertation of
NaOCl is debatable due to conflicting results in the literature.
Concentration influences dissolution and toxicity and possibly
antimicrobial capacity, smear layer removal, hard tissue debris
extrusion, and dentin physical properties. A recent clinical
study found higher healing rate at 1-year follow-up after pri-
mary root canal treatment associated with high NaOCl con-
centration (5%) compared to a lower one (1%), although this
difference was not statistically significant [34]. The healing of
apical periodontitis might reflect a better microbial control.
The contradiction in the literature regarding the concentration
effect on the NaOCl antimicrobial capacity is related to plank-
tonic bacteria. However, there seems to be some consensus
regarding the efficacy of higher concentration of NaOCl in
eliminating mature biofilms. Frough-Reyhani et al. have
shown that 1% NaOCl was incapable of eliminating
E. faecalis biofilms at three stages of development (4, 6, and
10 weeks), in contrast to medium (2.5%) and higher (5%)
concentrations [35]. This finding is corroborated by others
[36–38]. The concentration-dependent antibiofilm activity of
NaOCl might be explained by the associated linear increase in
dissolution capacity that may disrupt the extracellular matrix
of the biofilm exposing the bacterial cells to NaOCl.
Effect on dentine:
Tissue-dissolving capacity of NaOCl is a desirable charac-
teristic. Unfortunately, it is nonselective. While it dissolves
pulp remnants and the organic part of the smear layer and
biofilm matrix, it also alters the dentin structure by dissolving
the organic part of the dentinal matrix, mainly the collagen
[39]. This negatively affects the mechanical properties of the
dentin and the bonding strength of resin-based post cementa-
tion or root canal sealer, which is dependent on dentin quality
and collagen integrity [40]. The negative impact of NaOCl on
dentin physical properties was found to be concentration and
time-dependent.
NaOCl accidents:
Extrusion of NaOCl beyond the apex results in severe im-
mediate pain, profuse intracanal bleeding, progressive swell-
ing, and sometimes ecchymosis [41, 42]. This is usually self-
limiting, but occasionally severe complications arise, includ-
ing chemical burns and necrosis, neurological deficit, and air-
way obstruction [43]. NaOCl accidents are unpredictable, as
several case reports recorded different concentrations and vol-
umes of extruded NaOCL with similar presentation [41].
Thus, prevention is of utmost importance. Table 2 summarizes
prevention and management of NaOCl accidents [44–46]
 Curr Oral Health Rep

Table 2 NaOCl accidents:

prevention and management
Prevention • Maintenance of the irrigation needle 1 mm shy of the working length.
• Using side vented closed ended needle or negative pressure system.
• Applying low flow pressure.
• Checking for irrigant backflow.
• Avoid wedging the needle within the canal.
• Verification of perforation when suspected via apex locater or radiograph.
Management
1. Psychological • Dentist should recognize the signs and symptoms of the accident
• Remain calm
• Immediately stop the treatment
• Reassure the patient and clearly explain what happened and what to expect.
2. Pain control • Profuse irrigation with saline to dilute the extruded NaOCl.
• Nerve block in the affected area with long lasting anesthetic solution.
• Acetaminophen-based analgesics can be prescribed. NSAIDs might promote
more bleeding into interstitial tissues and thereby more ecchymosis.
• Cold compressors in first 24 h after the accident might help in reducing the
pain by numbing the affected area.
3. Inflammatory • Cold compressors in first 24 h helps in reducing the swelling by
contraction of blood vessels.
• Warm compressor can be prescribed after the first two days to control the
inflammatory part.
• Antibiotics are prescribed for 7–10 days in anticipation of any secondary
infections. Some authors recommend using steroids for 2–3 days to reduce
the inflammation.
4. Follow-up Following up with the patient is an important aspect of the management, since
aforementioned complications might occur hours or days after the incidents.

Adjunctive irrigation techniques:
Passive Ultrasonic Irrigation PUI:
PUI works according to the two phenomena, the shear
stress created by the acoustic streaming and the vacuum effect
resulting from gas bubbles collapse caused by cavitation. This
potentially can disrupt bacterial cells and/or remaining pulp
and hard tissues. Also, the increased NaOCl temperature as-
sociated with PUI might increases NaOCl antibacterial and
dissolution effect
A recent systematic review reported that PUI was superior
to conventional needle irrigation (CNI) in removing pulpal
remaining tissues and hard tissue debris, but not in an adding
antimicrobial benefit [47]. Over half of the included studies
reported PUI to be more effective than CNI microbiologically,
while the remaining studies found no difference except one
that favored CNI. Since smear layer and hard tissue debris
were found to attenuate the antimicrobial efficacy of NaOCl,
possibly by depleting the existing chlorine [48], even if their
removal is the only benefit PUI can offer, it is worth incorpo-
rating into irrigation protocol as it is easy and cost-effective
compared to other adjunctive methods.
EndoVac:
EndoVac (Discus Dental, Culver City,EUA) is a negative
pressure system, that is aimed to thoroughly clean the canal
safely without extrusion of NaOCl. However, there are con-
flicting results in the literature regarding its superior microbial
control over CNI [49–51]. This might be due to significant
methodological variations between studies. Several investiga-
tions showed comparable hard tissue debris removal capacity
of the EndoVac with CNI, PUI, and XPF [52–54].
XP-Endo finisher (XPF):
XP-Endo finisher (FKG Dentaire, La Chaux-de-Fonds,
Switzerland) is a nickel-titanium (NiTi) rotary instrument
manufactured from MaxWire alloy. It is straight at room tem-
perature and transitions into austinite phase at body tempera-
ture, resulting in a spoon shape to theoretically contact more
canal surface with an agitation effect on irrigant while rotat-
ing. Several studies have shown that XPF was superior in
bacterial reduction and biofilm removal than other adjunctive
techniques such as PUI and CNI [55–58]. However, its hard
tissue debris and/or smear layer removal capacity was compa-
rable to that of the PUI [59–61].
Gentlewave GWS (Sonendo Inc, Laguna Hills, CA) is a non-
instrumentation endodontic disinfection system that relies on
multisonic activation of the irrigant and generation of a broad
spectrum of waves with subsequent cavitation and microbubble
generation. The cavitation leads to acoustic wave formation
within the irrigant to clean the root canal system [62].
Curr Oral Health Rep
In in vitro studies, GWS performed significantly better than
CNI in removing residual debris from middle and apical por-
tions of narrow canals when evaluated histologically [63].
GWS was also found to be comparable to endoVac with re-
gard to irrigant extrusion beyond the apex [64]. GWS was
reported to be over eight times more effective in tissue disso-
lution compared to the ultrasonic method.
Regarding bacterial reduction, the efficacy of GWS and
ultrasonic systems was compared using qPCR. Both had com-
parable bacterial DNA reduction. However, GWS resulted in a
higher reduction in total bacterial counts
GWS has also been tested clinically for evaluation of apical
healing and showed a high success rate at 12 months [65].
However, the sample size was limited, the follow-up period
was short, and there was no control group of any other irriga-
tion activation method to compare the outcome with. Given
that this technology is recent, only a few studies have been
conducted to investigate its overall effectiveness. Thereby the
conclusion needs to be drawn with caution with consideration
to more strong research in the future. Otherwise, its superiority
would only be arguably related to expediting the endodontic
procedure.
2. Chlorhexidine
Advantages:
Substantive antimicrobial activity
Low key toxicity [66]
Disadvantage:
Lack of tissue dissolving capacity [67]
Mechanism of action:
CHX is either bacteriostatic or bacteriostatic depending on
its concentration. CHX cationic molecules bind to negatively
charged bacterial components on cell wall [68].
Antimicrobial activity:
As previously mentioned, CHX antimicrobial efficacy was
found to be clinically equal, less effective or more effective
than that of NaOCl [12]. In vitro, CHX was found to be sig-
nificantly less effective in eliminating biofilms than NaOCl
[69]. This might be due to cationic bisbiguanides deactivation
by biofilm’s organic matter and the lack of the tissue dissolv-
ing capacity exhibited by NaOCl [70]. On the other hand,
NaOCl lacks the antimicrobial substantivity offered by
CHX. When used separately, both irrigants failed to disinfect
the root canal thoroughly. For this reason, some authors inves-
tigated the combined effect of both irrigants to take advantage
of their unique characteristics complementing each other.
Zamany et al. explored this potential. The results showed there
was a significant reduction in the number of teeth that yielded
positive culture when CHX was added to the irrigation proto-
col [71].
Chlorhexidine substantivity:
Obturation with viable bacteria surviving the disinfection
process has a significant influence on the success of root canal
treatment [72]. Therefore, it is beneficial to have an irrigant
with long-standing antimicrobial impact even after obturation.
The lingering antimicrobial effect of CHX might be its most
appealing characteristic. It is what makes it stand out from
NaOCl along with its low cytotoxicity. This is due to its high
affinity to hydroxyapatite [73]. The CHX adsorbs to the acidic
proteins in the hydroxyapatite and get released over time. The
retention of CHX to dentin canal wall in a sufficient antimi-
crobial amount was shown to last for at least 12 weeks after
obturation [74]. These findings were confirmed by Souza
et al., who showed that 2% CHX in either solution or gel form
could be retained within root canal dentin for up to 90 days
[75].
CHX effect on dentin:
CHX was found to inhibit intrinsic dentinal proteolytic
enzymes that can negatively affect bonding interface with
resin-based cement. CHX was reported to promote bonding
strength of glass fiber post after 6 months [76]. Thereby, it is
beneficial to consider it as a final flush, especially when a post
is planned to be placed.
Interaction between NaOCl and CHX:
Interaction between NaOCl and CHX induces the forma-
tion of thick reddish-brown precipitate as a result of proton
exchange between the two products in an acid-base reaction
[77]. It is controversial whether this precipitate contains para-
chloroaniline (PCA) or not [78–80]. PCA is an industrial
chemical. It is also a precursor for chlorhexidine. The interna-
tional agency for research on cancer has classified it as Group
2B, with limited and less than sufficient evidence of carcino-
genicity on human and animals, respectively [81].
Moreover, it has been reported to cause methemoglobine-
mia [82]. Using five sensitive methods, a recent study con-
firmed that the participate resulting from NaOCl/CHX reac-
tion contains PCA [83]. Regardless of the nature of this pre-
cipitate, its formation during the irrigation of root canal is
problematic. This chemical smear layer can significantly re-
duce the dentin permeability throughout the canal [78, 84].
Furthermore, coronal microleakage was shown to increase
substantially after obturation due to precipitate occluding the
opening of dentinal tubules and preventing adequate seal of
the root filling [85]. Therefore, prevention of this by-product
formation is crucial. Absolute alcohol (96% ethyl alcohol)
after NaOCl was shown to completely prevent its formation
[78]. Nevertheless, alcohol and its effect as endodontic irrigant
are not thoroughly studied. Intermediate irrigation with either
Saline or distilled water was shown to minimize the formation
of the precipitate [78, 86].
3. Ethylene diamine tetraacetic acid (EDTA)

Is a chelator that is often used in endodontics in a concen-
tration of 17% or 15%. It demineralizes the dentin by physi-
cally removing the calcium from the dentin and makes it water
soluble. This characteristic is desirable as it makes it an effi-
cient in terms of removing the inorganic part of smear layer
(the organic component is dissolved by preceding EDTA with
NaOCl), thereby exposing the dentinal tubule openings for the
action of the next irrigant, intracanal medicament or sealer.
Two minutes was found to be the effective contact time for
smear layer removal [87]. Although the antimicrobial benefit
of this solution was found to be limited, as the biofilm concept
was introduced to endodontics, chelator agents were found to
play a role in detaching biofilms possibly through sequester-
ing calcium which is essential for the biofilm extracellular
matrix stability [88]. Herrera et al. have shown that EDTA
activated by PUI resulted in a great reduction of bacterial
endotoxins lipopolysaccharides (LPS) potentially due to its
binding to the calcium in the lipids [89]. Citric acid is a more
aggressive chelator agent that can be used instead of EDTA.
4. Combination irrigants
MTAD: a mixture of doxycycline, citric acid, and a
surfactant
Was found to be efficient in removing smear layer with
contradictory antimicrobial efficacy, causes less dentin ero-
sion and promote bonding [90].
EDTAC and Smearclear:
Mainly EDTA with surfactant for enhanced contact with
the substrate as a result of decreased surface tension for better
penetrability.
Qmix: a mixture of EDTA, CHX, and a surfactant
Conflicting smear layer removal efficacy compared to
EDTA. Moreover, its antimicrobial capacity was found to be
comparable to 1% NaOCl but less than that of 6% NaOCl. Its
substantivity reported to be up to 120 days [91].
5. Antimicrobial nanoparticles
Nanoparticles have captured the interest of many re-
searchers in the field of endodontics with high hopes to over-
come the limitations and challenges of the current disinfection
protocols. For nanoparticles fulfill this expectation, they have
to meet specific criteria:
1. Should be biocompatible with equal or better
antimicrobial/antibiofilm effect than the currently used
irrigants/medicaments.
2. Their antimicrobial effect should not be affected by the
buffering effect of the tissues, dentine or LPS.
3. Be able to reach the inaccessible anatomical complexities
potentially harboring microbes. It is worth noting that
there is a misconception that nanoparticles molecules are
Curr Oral Health Rep
smaller than the active molecules of currently used
irrigants such as NaOCl. NaOCl active components
HOCl and ClO- are also very small and even smaller than
some of these nanoparticles.
Several nanoparticles were investigated at the laboratory
level. However, each is associated with certain concerns that
warrant more investigations before reaching the level of clin-
ical recommendations.
For example, while chitosan nanoparticle was found to
eliminate E. faecalis biofilm in a dose-time-dependent man-
ner, chitosan antimicrobial capacity was significantly affected
by tissue inhibitors such as pulp tissue and serum albumin, but
not by dentine or LPS [92]. Therefore, investigations about
this nanoparticle were directed towards improving the efficacy
of CHX [93] or conditioning dentine surface to improve its
mechanical properties for better sealer penetration [94, 95].
Silver diamine fluoride is another nanoparticle that was
investigated. It was reported that its antimicrobial efficacy is
either lower than that of CHX and NaOCl or comparable to
NaOCl [96]. However, it required prolonged contact time and
was recommended as a medicament rather than irrigant [97].
Moreover, there are concerns about tissue toxicity and dentine
discoloration [98, 99].
Iron oxide nanoparticles (IONPs) have also been intro-
duced to the field of endodontics as a potential novel antimi-
crobial agent. IONP is a catalytic nanoparticle with
peroxidase-like activity (Nanozyme) that catalyze the reaction
of H2O2 to produce free radicals and ultimately potentiates the
antimicrobial effect of H2O2. In an in vitro study investigating
the antimicrobial effect of IONP-H2O2 compared to NaOCl
and CHX, Bukhari et al. observed a significantly higher effi-
cacy of IONP-H2O2 than both solutions in 5-min treatment
time. However, the study involved the use of CLSM as the
only assessment method, and confirmatory investigations are
needed [100]. A potential advantage that IONP has over other
nanoparticles is their ability to be magnetically manipulated
and directed to the site of interest [101].
In summary, nanoparticles were introduced into the field of
endodontics to potentially solve the difficulties currently en-
countered in endodontic disinfection. However, the current
level of evidence indicates that none of the nanoparticles
available seem to predictably change the status quo of root
canal disinfection, especially regarding superior delivery to
anatomical complexities. Hence, further investigations are
warranted.
6. Photodynamic therapy
Photodynamic therapy (PDT) involves the application of a
photosensitizer at the site of interest first, followed by laser or
light emitting diode (LED) activation of the photosensitizer to
generate free radicals [102]. The light source must be inserted
Curr Oral Health Rep
into the canal. However, a study by Rödig et al. showed that
the depth of the light fiber inside the canal had a negligible
effect on the antimicrobial effect of PDT [103]. Moreover, it
was reported that the LED lamp light of 630 nm had a better
antimicrobial effect than diode laser with 810 nm when used
as activators for toluidine blue [104]. Garzes et al. showed that
adding PDT as an adjunct to root canal therapy can increase
the total microbial reduction to more than 98% [105]. In a
preliminary report, they also showed that PDT could render
the canal bacteria free when used after conventional root canal
retreatment procedure [106]. However, when compared to
2.5% NaOCl, it showed inferior antimicrobial effect.
Moreover, the lower antimicrobial effect of PDT when com-
pared with PUI with NaOCl and EDTA was reported [107].
Conclusions
Based on the currently available evidence reviewed here,
NaOCl is recommended as the main irrigant throughout the
mechanical instrumentation due to its wide spectrum bacteri-
cidal effect and dissolution capacity on organic pulp remnants
and biofilm matrix. Since with lower concentration the disso-
lution capacity and antibiofilm effect are compromised (bio-
film disruption and removal) and with higher concentration
toxicity and negative impact on dentin structure is increased,
there is no consensus in the literature defining the optimum
concentration. Thereby, we recommend a medium concentra-
tion (2.5–3%) aided by continuous replenishment and agita-
tion with PUI for the temperature-based increased dissolution
effect and increased antimicrobial effect. After completing the
instrumentation, NaOCl activation with one of the adjunctive
irrigant-activation methods reviewed here (PUI, XP-Finisher
or EndoVac) should be conducted. It should be followed by
activation of EDTA for smear layer removal. Alternating
NaOCl with EDTA or other chelating agents should be
avoided as it reduces the available chlorine and thereby de-
creases NaOCl efficacy [108]. Using NaOCl as final flush
following EDTA can cause dentin erosion [109]. Finally, to
complement the NaOCl antibacterial effect, CHX is consid-
ered as a final rinse [15, 71]. EDTA, when mixed with CHX,
has been shown to form a white precipitate (90% of which is
either EDTA or CHX salt). However, the clinical implication
of this precipitate is not fully understood. The research regard-
ing how much of it adhered to root canal walls and its effect on
the apical seal is scarce. To avoid it, paper points could be used
to dry the EDTA before using CHX, or an intermediate rinse
with sterile water or saline, or an alternative chelator to EDTA
such as acetic acid could be used [87, 110].
The most recent advances in the root canal disinfection
(i.e., Gentlewave and lasers) are showing promising results.
However, more clinical investigations to discern their superi-
ority over the current protocols are warranted.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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