Endodontics

Lec. ‫ عالء مهدي الحداد‬.‫د‬

Irrigation in Endodontics
The anatomical complexity of the root canal system, invasion of dentinal tubules
by microorganisms, and formation of smear layer during mechanical preparation of
the canals are the main difficulties that necessitate the use of root canal irrigation.
The benefits of using irrigants in root canal treatment are:
1. Removal of dentinal shavings by physical flushing.
2. Wetness & lubricating of canal which makes the instrumentation easier, smoother
& decrease the possibility of instrument breakage inside the canal.
3. Dissolving the organic debris & pulp remnant.
4. Opening of dentinal tubules by removal of the smear layer.
5. Disinfection areas inaccessible to endodontic instruments.
6. Irrigants also have bleaching action to lighten teeth discoloration.
Properties of an ideal irrigation solution.
1. Bactericide and fungicide.
2. Remain stable in solution and have a prolonged antimicrobial effect.
3. Nonirritant to the periapical tissues.
4. Not interfere with repair of periapical tissues.
5. Have low surface tension.
6. Not stain tooth structure.
7. Nonantigenic and not induce a cell-mediated immune response.
8. Be able to remove the smear layer.
9. Have no adverse effects on the physical properties of dentin.
10. Have no adverse effects on the sealing ability of filling materials.
11. Have a convenient application.
12. Be relatively inexpensive.

COMMONLY USED IRRIGANTS

-Chemically non active solution
• Normal Saline
-Chemically active materials
• Sodium hypochlorite (NaOCl) 0.5–5.25%.
• Chlorhexidine (2%).
• Chelating agents: Ethylene diamine tetraacetic (EDTA) acid, citric acid.
• Oxidizing agents: Hydrogen peroxide, carbamide peroxide.
-Combination of active materials
• MTAD, Tetraclean and QMiX.
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Normal saline
0.9% W/V used as adjunct with other irrigant.
Biocompatible if it extruded apically.
Ineffective as antimicrobial agents and will not dissolve organic material.
Sodium hypochlorite (NaOCl)
Used in concentrations: 0.5-5.25%
Advantages:
1. Dissolve the necrotic & vital pulp tissue.
2. It has antimicrobial & bleaching effect.
3. Economical & easily available.
Disadvantages:
1. Irritant to tissues, if extruded periapically.
2. Inability to remove smear layer.

-Factors affecting the efficacy of sodium hypochlorite

Both low and high concentrations are equally effective regarding antimicrobial
activity. But, it is believed that the
tissue dissolution by NaOCl is directly
related to the concentration, the
higher the concentration, the better
dissolution ability. It is very
important to take in consideration
that the active components of NaOCl
will be exhausted rapidly, so
constant replenishment of the
irrigating solution inside the canals is
mandatory.

Toxicity of NaOCl
Despite the advantages of NaOCl, it can be very irritant if extruded to the periradicular
tissues and can cause acute inflammatory responses including hemolysis, epithelial
ulceration, edema, necrosis, and paresthesia. The high alkalinity of NaOCl make it
cytotoxic to all cells except heavily keratinized epithelia and can cause chemical burn
to the tissues. The symptoms are rapid and painful, with intensities proportional to
the concentration and volume of the NaOCl extruded.

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Chlorhexidine (CHX)
2% solution is used as root canal irrigant. 0.2% solution is the concentration for
mouth wash.
Advantage:
1. Potent antimicrobial property.
2. Less irritant than NaOCl.
3. Substantivity
Disadvantages:
1. It has no tissue-dissolving capability and therefore it cannot replace sodium
hypochlorite.
2. Cannot remove smear layer.
3. Bitter taste.
Substantivity of Chlorhexidine
The cationic nature chlorhexidine molecule gave it
the ability to absorb to the negatively charged
intraoral surfaces (e.g. teeth, oral mucosa and
restorations), and then it is gradually released from
these sites to give a prolonged antimicrobial action
lasts for hours. This phenomenon is called
Substantivity and it depends on the concentration,
which means as the concentration increases, more
layers of CHX will adsorb on the surfaces and the
antimicrobial action will last for longer time.
What will occur if NaOCl irrigant used in combination with Chlorhexidine irrigant?
5%NaCl and 2% CHX when come in contact produce orange discoloration and a
precipitate of 4-chloroaniline crystals which will block the dentinal tubules& interfere
the sealing of root obturation.
This discoloration is increase by increasing the percentage of NaOCl.
-To prevent this discoloration, rinse the canal by distilled water or saline then irrigate
by Chlorhexidine.

EDTA (Ethylene Diamine Tetra Acetic Acid)

Available as either gel or solution. EDTA in a concentration of 17% is commonly used
for removing smear layer, where it is left in contact with the canal walls for 1-3
minutes. Even though, EDTA alone cannot remove the smear efficiently without the
aid of a proteolytic agent, like NaOCl, to remove the organic portions of the smear
layer. Also EDTA is valuable in negotiating narrow calcified canals.

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Mechanism of Action
It forms a stable bond with calcium, dissolving dentin & removes the smear layer.
When all chelators are used up an equilibrium is reached and no further
decalcification takes place; therefore, the EDTA is considered self-limiting.
Advantages:
1. Efficient in removal of the inorganic portion of smear layer.
2. It helps in dentin dissolving & enlarging narrow canals.
3. Good lubricant makes easier manipulation of instruments.
4. Reduces time needed for debridement.

HYDROGEN PEROXIDE
Hydrogen peroxide (H2O2), 3-5% concentration, was a common endodontic irrigant
because of its antimicrobial activity.
It decomposes to produce free radicals (•OH) that can destroy proteins and DNA of
the bacteria, but this effect is transient and diminishes in the presence of organic
debris.
It also has tissue-dissolving capacity but it is undoubtedly lower than that of NaOCl.
H2O2 is unstable solution and should be stored in special conditions, besides it offers
no advantage over other modern irrigants, therefore it is no longer recommended as
a routine irrigant.
It has bleaching action especially when used in conjunction with NaOCl.
Clinical note: when using H2O2, always rinse the canal with NaOCl and normal saline
after H2O2 because H2O2 reacts with blood or pulp tissue to produce nascent gas
causing gaseous pressure & severe post-operative pain (apical tenderness).

MTAD and Tetraclean

These irrigants are a Mixture of Tetracycline (antibiotics), citric Acid, and a Detergent
(MTAD). MTAD is usually recommended as a final rinse after completion of
chemomechanical preparation.
Tetraclean is another product that is similar to MTAD. They differ in the concentration
of the antibiotics (doxycycline 150 mg/ 5 ml for MTAD and 50 mg/5 ml for Tetraclean)
and the type of the detergent used (Tween 80 for MTAD, polypropylene glycol for
Tetraclean)
Advantages:
1. Remove smear layer
2. Disinfecting the canals.
Disadvantages:
1. It comes as a powder and a liquid have to be mixed prior to use.
2. Its shelf life is short (short expire date).
3. Its cost is high.
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Mode of action of MTAD and Tetraclean
Antimicrobial effect. The antimicrobial effect is attributed to the tetracyclines
(tetracycline, minocycline, and doxycycline) which are broad-spectrum antibiotics. A
combination of doxycycline, citric acid, and Tween 80 together may have a synergistic
effect on the disruption of the bacterial cell wall and on the cytoplasmic membrane.
Smear layer removal. Most studies are attributing the action of smear layer removal
to the presence of doxycycline and citric acid. Both of these components are able to
remove the smear layer.
Tween 80, the detergent, has been added to decrease the surface tension to facilitate
penetration into dentin. It may increase the antibacterial effect of other substances.
On the contrary, Tween 80 may inactivate the antibacterial action of other irrigants
like CHX.

QMiX
It is a newer combination product introduced in 2011; that contains a CHX-analog,
Triclosan, and EDTA. It is intended to disinfect the RCS and remove the smear layer,
and recommended to be used as a final rinse after NaOCl.

Sequence of irrigation
Each time a file is working inside the canal, irrigating solution must be present.
It is recommended to begin the treatment by:
1. An application of sodium hypochlorite in order to:
a) To destroy the biggest amount of pulp tissue (The warm NaOCl is more
efficient in destroying the collagen and this will reduce the time needed for
the elimination of the organic part)
b) Control bleeding.
c) Disinfect the canal
2. When the preparation of the canal is complete EDTA 17% must be used to
remove smear layer and open dentinal tubules
3. Chlorhexidine can be used for a total elimination of the bacteria inside the canal
4. Distilled water or normal saline is used between each irrigating solution in order
to prevent interaction between the irrigant.
5. A final copious irrigation with distilled water or normal saline to neutralize all the
chemical agents before the fitting of the master gutta-percha cone so that the
master cone does not push any of the chemicals outside the canal that might cause
an inflammation of the surrounding tissues.

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Advantages of smear layer removal
1) Allow penetration of irrigants into dentinal tubules
2) Enhance penetration and adhesion of sealer to dentin
3) Reduce leakage

METHODS OF IRRIGATION
1.manually:
Traditionally, irrigation has been performed with a plastic disposable syringe
(3, 5, 10 mL) attached to closed, safe-ended needle releasing irrigant from lateral
opening to pass side away & prevent apical extrusion of the irrigant. Different gauges
needles are available: 25, 27, 30, 31 or 32.

Preventive measures to avoid extrusion of irrigant outside the canal:

1- Use safe ended needles with side vent.
2- The solution must be
introduced slowly and
passively into the canal,
never use excessive force.
3- Needle should remain
loose in the canal and
never be wedged into the
canal.
4- The irrigation needle
should be introduced 2
mm short of working
length.

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blunt bend of 30° in the center of needle can be given to reach the
optimum length to the canal.

Placing a rubber stop on the needle will prevent extrusion of irrigant beyond
the apex of the tooth

Manual-Dynamic Irrigation
Manual dynamic irrigation involves gently moving a well-fitting gutta-percha
master cone up and down in short 2 mm to 3 mm strokes within an instrumented
canal, thereby producing a hydrodynamic effect and significant irrigant exchange.
Additionally, there are a number of automated devices designed for agitation of root
canal irrigants.
2. Machined:
1. EndoActivator:
Endo Activator is a battery operated handpiece based on sonic vibration of a plastic
tip inside the canal. The system has 3 different sizes of tips that are easily attached
to the handpiece. These tips are disposable.
EndoActivator does not deliver new irrigant to the canal but it facilitates the
penetration and renewal of the irrigant in the canal.

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2. The Vibringe system
It allows delivery and sonic activation of the irrigating solution in one step. It employs
a 2-piece syringe with a rechargeable battery. The irrigant is sonically activated, as is
the needle that attaches to the syringe.

3. Rotary Brushes
A microbrush attached to a rotary handpiece to facilitate debris and smear layer
removal from root canals. The brush is highly flexible and rotates at slow speed
causing the bristles to deform into the irregularities of the preparation. This helps to
displace residual debris out of the canal in a coronal direction. It might be used
manually with a rotary action, however, it is more effective when attached to a
contra-angle handpiece.

4. Endovac System
The Endovac system is based on a negative pressure approach, where the irrigant
placed in the pulp chamber & down to the root canal, it will be sucked back again
through a special design tube.

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Advantages of Endovac system:

1.Safe because less apical extrusion& post-operative pain risk compared with needle
irrigant.
2.Effecient: better debridement 1mm from the WL.