ROOT CANAL DISINFECTION

• Successful root canal treatment is based on establishing an accurate diagnosis and developing an
appropriate treatment plan; applying knowledge of tooth anatomy and morphology; and
performing the debridement, disinfection, and obturation of the entire root canal system.

• Canal medication with antibacterial activities plays only a secondary role in successful
endodontic therapy.

• Sterilization of the root canal may be accomplished by:

1-Chemical means. 2-Physical means. 3-Combination of both.

A) Chemical means or root canal medicaments:

- It is the sterilization of the root canal by certain medicaments or irrigants.
- Requirement for ideal root canal medicaments:
1. Should be germicidal and fungicidal.
2. Should be non-irritating to the soft tissues and periapical tissues.
3. Should remain stable in solution.
4. Should have prolonged antibacterial effect.
5. Should be effective in the presence of blood, serum, and protein derivatives of tissues.
6. Should be capable of penetrating the tissue deeply.
7. Should be easily introduced into the root canal.
8. Should be capable of being inactivated or neutralized in culture media.
9. Shouldn't interfere with periapical tissue repair.
10. Should not stain tooth structure.

ROOT CANAL MEDICAMENTS

1)Camphorated monochlorophenol (CMCP).

2) Formocresol:
• It is a drug that is highly irritating to periapical tissue.
• Can be used in cases where the coronal pulp is vital and bleeds excessively during access
procedure making it difficult to complete access.
• The formocresol tend to "embalm" the surface pulp so that it does not bleed so freely at the
next appointment.

Procedure for medication

1. Place three or four drops of the medicament in the shallow end of the dappen dish.
2. Make certain that the canals and chamber are as dry as you can get them with cotton
pellets and paper points.
3. Place a small cotton pellet in the medicament. Touch the pellet to the sterile towel to
remove excess .
4. Place the pellet in the pulp chamber over the opening to the root canal, allowing sufficient
space for an adequate bulk of temporary filling material.
5. If an excess of the medicament is on the pellet, the pressure of packing in the temporary
filling may force the CMCP into the periapical area where it may cause a severe post
treatment flareup.
3) Poly-antibiotic paste:
• Considered as one of the most common and effective combination of the antimicrobial drug
against a wide range of microorganisms commonly isolated from infected root canals.
• The poly-antibiotic paste consists of:
i) Penicillin: to eliminate gram-positive organisms.
ii) Bacitracin: against penicillin-resistant organisms.
iii) Streptomycin: against gram-negative organisms.
iv) Caprylate sodium or Nystatin: against yeasts.
v) Vehicle.

• Triple antibiotic paste (TAP) :

a) Ciprofloxacin: aerobic ( +ve / -ve ) -- is a 3rd generation cephalosporin used against
resistant bacteria (to penicillin or other antibiotics)
b) Metronidazole: anaerobic ( +ve / -ve )
c) Minocycline: Discoloration in tooth

• Double antibiotic paste (DAP)

a) Ciprofloxacin (500 mg): aerobic ( +ve / -ve )
b) Metronidazole (500 mg): anaerobic ( +ve / -ve )
grind them into powder and mix them with saline to form thick paste.

• The poly-antibiotic paste is applied to the wall of the canal by means of root canal file or
lentulo spiral.

4- Corticosteroid - Antibiotic combination:

• Uses:
1) It reduces pain and inflammation by having anti inflammatory effect on periapical tissues
of over instrumented teeth. (It gives the greatest impact in the first 24-hrs. post operative).
2) Most effect in case of root external resorption.

• Disadvantage
Corticosteroid decrease effect of antibiotic ( effect immunity )
• Contraindication:
In case of pain of inflammation and injury not for pain associated with infection and swelling.
• Forms:
Is found in the form of paste or drops.

5-Calcium hydroxide:
• Uses:
1. Reduce bacterial colonies and their byproducts
(best results achieved when left in the canal for at least a week - due to time of
neutralization of bacteria - in addition to removing the smear layer and maintaining apical
patency).

2. Have the possibility to reduce postoperative pain (Bactericidal / Bacteriostatic)

(by having ability of killing and neutralizing their by-products).

3. At least 1 Week no more than 5 Weeks. Why? -Due to effect microcollagen of dentin so
decrease hardness of tooth and may lead to fracture of tooth.
 • Methods of application:
1. Vertical compaction.
2. Injectable formula. ( Meta Paste )
3. Lentulo spiral. Which is the most consistent method to deliver Ca(OH)2 to the working
length.
4. Hand file (in anti clockwise direction).
5. Calcium hydroxide points.

• Indications:
1. Necrotic pulp.
2. In case of over-instrumentation
3. If there is a strong possibility of post operative flareup.

• Disadvantage:
1. Inability to effectively kill Enterococcus species (E.faecalis) .
2. N.B. The antibacterial action of calcium hydroxide is related to its high PH;
It minimizes the occurrence of flare-up as it has the ability of killing anaerobic bacteria.

Root canal irrigants

Functions of Root Canal Irrigants:
1. Gross debridement.
2. Tissue debris dissolvent.
3. Antimicrobial action.
4. Lubrication.
5. Bleaching effect.
6. Removal of the smear layer.

- N.B: Smear layer is a microcrystalline layer of cutting debris covering the canal walls after
the preparation
- Smear layer consists of ; organic layer which is removed by irrigants and inorganic layer
which is removed by chelating agents.
- Removal of smear layer aids in better adaptation of obturating materials to the canal walls.
- In addition to the previous criteria,an ideal irrigant should have low toxicity, low surface
tension and of reasonable prices.

Types of irrigants:
1) Sodium hypochlorite (NaOCl):

- The most popular irrigants.

- Used in concentrations between 0.5% and 5.25%.
- Has an organic tissue dissolution effect.
- Has high antibacterial effect specially against E.feacalis
( Mechanical activation + NaOCL will kill E.feacalis that responsible for failure endodontic
treatment almost 90% )
- The efficiency of the solution is affected by its concentration and temperature,
(warming the solution increases its tissue dissolving action).
- It act as a canal lubricant.
2) Hydrogen peroxide :
- It has an effervescence effect which is capable of removing loose debris from inside the
canal.
- Release of nascent oxygen works against Anaerobic bacteria.
- Combination of 5.25% NaOCl + Hydrogen peroxide gives proper antibacterial effect.
- NaOCl should be the last irrigant to wash the nascent oxygen which may cause:
tissue emphysema if it passes to periapical tissues and post operative pain.

3) Chlorhexidine :
- It has an antibacterial effect. Except E.feacalis.
- Doesn’t cause tissue dissolution.
- Less toxic than the NaOCl.
- Has NO bleaching effect.

4)Morinda Citrifolia:
- Recently introduced irrigant.
- Natural Polynesian plant.
- It has antibacterial, antiviral, antifungal properties.

5)Ozone Gas :
- Recently used technique for the cleaning of root canal through the irrigation using saline
followed by the application of ozone gas for fixed duration
- Destroy E.feacalis.

6)MTAD :
- It is a mixture of doxycycline, citric acid, and detergent (tween 80)
- It has antimicrobial activity
- It has a smear layer and pulp tissue dissolving capabilities.
- It is relatively biocompatible

B) Physical means
- The most suitable physical means of root canal disinfection nowadays is by laser.
- The antimicrobial effect of laser depends on several factors such as:
i) Type of laser.
ii) Power and energy.
iii) Irradiation exposure time.
iv) Type of bacteria present in the root canal(s).

C) Combination of both chemical and physical means:

# Ultrasonic disinfection:
- It is performed when using Sodium hypochlorite with ultrasonic preparation files or tips.
- The most effective methods to debride the root canals.
- Ultrasonic waves
▪ will slightly rise the sodium hypochlorite solution temperature, which will result in,
increased antimicrobial effect of the solution.
▪ will force the solution into the inaccessible portions and minute areas of the root canal
system, which will also result in increasing its antimicrobial efficiency.