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RECENT ADVANCEMENT

IN IRRIGATING
SOLUTIONS AND
IRRIGATING DEVICES

INTRODUCTION
The pulp chamber and root canals of
untreated nonvital teeth are filled with
a gelatinous mass of necrotic pulp
remnants and tissue fluid.

Essential to endodontic success is the


careful removal of these remnants,
microbes, and dentinal filings from the
root canal system.

Forcing this noxious infected material


through the apical foramen might
lead to an acute apical abscess.

The apical portion of the


root canal is especially
important because of its
relationship to the
periradicular tissue

Although instrumentation of the


root canal is the primary method
of canal dbridement, irrigation is
a critical adjunct.

Irregularities in canal systems such


as narrow isthmi and apical deltas
prevent complete dbridement by
mechanical instrumentation alone.

HISTORY
Prior to 1940s Water was the most
commonly used irrigant as it was:

Readily available.

Inexpensive.

Provided a lubricating
during instrumentation.

effect

During 1940s proteolytic enzymes like


streptokinase, streptodomase, papain,
enzyme etc. were used

They had tissue dissolving property.

In 1943, Grossman introduced the concept of


using oxidizing agents as irrigants.

He recommended that solution of 3%


hydrogen peroxide be alternated with a
solution of 5.25% sodium hypochlorite.

so that effervescence action results in


removal of debris from the canal system.

Recently another oxidizing agent, glyoxide


has been recommended, particularly for
narrow, curved canals.

Contains carbamide peroxide in an


anhydrous glycerol base which is highly
viscous, provides good lubrication, has little
antibacterial activity & not a tissue solvent.

In 1945, Daniel formulated an irrigating


solution comprising of a aminoacridine.
In 1970s chelating agents were used
increasingly because of their biologically
acceptable properties.

IMPORTANCE OF
IRRIGATION
Irrigation serves as a
Physical flush to remove debris
As well as serving as a bactericidal
agent,
Tissue solvent, and
Lubricant.
Furthermore, some irrigants are
effective in eliminating the smear
layer.

Goals of irrigation;
According to INGLE-

1. Lavage of debris.

2. Tissue dissolution.

3. Antibacterial action.

4. Lubrication.

Ideal requirements of irrigating solutions


(DCNA;

1. Antimicrobial property.
2. Dissolve necrotic tissue debris.

3. Aid in debridement of the root


canal system.

4. Non-toxic
tissues

to

the

periapical

Role of intracanal irrigants (Weine):

Irrigants perform important physical


and biologic function during endodontic
therapy

1. Loosens tissue debris Dentinal


shavings and microorganisms from the
irregular radicular dentine walls.

2. Flushes The above into the pulp


chamber space where it is easily
removed by aspiration or paper points.

3. Dissolves Organic tissues that are


entrapped in accessory or lateral canals
and
that
is
inaccessible
to
hand
instruments.

4. Antibacterial action Certain irrigants


posses germicidal action, other reduce the
number of microorganisms by eliminating
the source or substrate for survival of
these organisms.

5. Lubricating
effect
:
instrumentation of the canals.

6. Irrigants possess a bleaching action

Facilitates

REMOVAL OF SMEAR
LAYER

During root canal preparation, cut


debris is smeared over the dentinal
surface, forming a smear layer.

The smear layer has been defined


as any debris composed of organic
and inorganic particles of calcified
tissue, necrotic tissue, and
microorganisms.

It
has
been
described
by
scanning electron microscopy
(SEM)as
an
amorphous
substance with an irregular
surface.

SEM studies have demonstrated that the


smear layer covers the anatomical
structures of the root canal. The smear
layer thickness is not constant but
ranges from 1 to 5 m.

There are two layers ,The surface


layer,i.e.,smear debris (SD), covers the
orifices of dentinal tubules and is 2 to 5
m thick.

The inner layer penetrates into dentinal


tubules, occludes them and provides a
natural barrier against fluid movement
within the tubules.

The smear layer thickness can be


influenced by the type of a root
instrument used and by the amount and
composition of irrigants employed.

It has become apparent that only agents


combining both organic and inorganic
solvents can effectively and totally
remove smear layers.

However, not only the combinations of


agents but also the way of application
and their quantity have been found to
be important .

The
syringe
application
of
irrigants, which is used most
frequently, can be replaced by
treatment of the root canal by
ultrasound.

In endodontics,the ultrasound
technique utilizes the mechanical
and
cavitation
effect
and
acoustic streaming of ultrasound
to
remove
the
surface
component of the smear layer.

CLASSIFICATION OF
IRRIGATING SOLUTIONS

I.

ACIDS

ORGANIC

Citric acid

Maleic acid

Tannic acid

Phosphoric acid

Tublicid

Lactic acid

INORGANIC

H2SO4 50%

HCl 30%

CHELATING AGENTS

EDTA

EDTAC

RC-Prep

II. PROTEOLYTIC ENZYMES

- Streptokinase.

- Enzymol.

- Streptodornase.

- Purified trypsin.

- Papain

III.

- 3% hydrogen peroxide.

- Urea peroxide.

- Glyoxide.

IV.

OXIDIZING AGENTS

ALKALINE SOLUTIONS

Sodium dioxide.

Urea.

Sodium hydroxide.

Sodium hypochlorite 0.5%,


1%, 2.6%, 5.25%.

Potassium hydroxide.

Chloramine-T.

V. OTHERS

Chlorhexidine gluconate 0.2%

Glutaraldehyde.

Oxidative potential water.

2% potentiated acid.

Calcium hydroxide solution.

COMMONLY USED
IRRIGATING SOLUTIONS

SODIUM HYPOCHLORITE

Most popular irrigating solutions. Used as


an irrigant for over 4 decades.
It was first recommended by HENRY
DAKIN in 1915 and was called as DAKINs
SOLUTION. During the time of World WarII
(NaOCl
buffered
with
sodium
bicarbonate) it was used for the
treatment of infected wounds.

Manufactured:

It is made by bubbling chlorine gas


through NaOH to form equal amounts of
sodium hypochlorite and sodium chloride.

(NaOH gas NaOCl + NaCl2)

NaOCl has been used in various


concentrations ranging from 0.5-5.25%.

Most commonly used concentration 2.5%

Antibacterial:

Direct contact with microorganisms.

Vapor action.

Destruction of the bacteria takes place in


two phases:

1. Penetration into the bacterial cell.

2.
Chemical
protoplasm of
destroys it.

combination
with
the bacterial cell

the
that

Sodium hypochlorite is a strong base


(pH>11). At 1% concentration,sodium
hypochlorite presents ;
A surface tension equal to 75 dynes/cm,
65.5 ms of conductivity,
1.04 g/cm 3 of density and
Moistening capacity equal to 1 h and 27
min.
The antimicrobial effectiveness of sodium
hypochlorite, based in its high pH
(hydroxyl ions action), is similar to the
mechanism of action of calcium hydroxide

The high pH of sodium hypochlorite


interferes in the cytoplasmic
membrane integrity with an: Irreversible enzymatic inhibition,
Biosynthetic alterations in cellular
metabolism and
Phospholipid degradation observed
in lipidic peroxidation.

TISSUE SOLVENT PROPERTY


NaOCl possesses strong tissue
dissolution property .

This equals to that of H2SO4 and HCl.

The solvent action of NaOCl has


been attributed to its high alkalinity.

Grossman and Meiman reported that


5% sodium hypochlorite dissolves
pulp tissue in 20 min to 2 h.

5.25% of NaOCl is capable of


penetrating into the dentinal tubules
& dissolving the contents of tubules
adjacent to the main canal.

This is an extremely important


property for an endodontic irrigant
because of the irregularities in the
surface of the canal walls which
prevents contact by instruments.

Other Properties of NaOCl


1.
Lubricant

for
effective
instrumentation.
2. Bleaching action on discolored
teeth.
3.
Increased
permeability
of
dentinal
tubules
for
easier
penetration
of
an
intra-canal
medicaments.

Sodium Hypochlorite Used in Combination with


Other Medicaments;
Whether sodium hypochlorite should be used
alone or in combination with other agents is
also a source of controversy.
There is increasing evidence that the efficacy of
sodium hypochlorite,as an antibacterial agent,
is increased when it is used in combination with
other solutions, such as calciumhydroxide,
EDTAC, or chlorhexidine.
Hasselgren et al.found that pretreatment of
tissue with calcium hydroxide can enhance the
tissue-dissolving effect of sodium hypochlorite.

Wadachi et al found that the combination of


calcium hydroxide and sodium hypochlorite
was more effective than using either
medicament alone.

Other variables to be considered include


temperature as well as shelf life of the
solution.

The antimicrobial property may be achieved


in a significantly lesser time by pre-warming
the solution (room temperature 22C-body
temperature 37C).

NaOCl and Smear layers


NaOCl alone is not very effective in
removal of the smear layer, but when used
in conjunction with other solutions or with
ultrasonics it has shown to remove the
smear layer effectively.
Yamada and associates (1983) reported
that a final flushing of 17% EDTA, followed
by 10ml of 5.25% NaOCl, was more
effective in removing both inorganic and
organic debris.
These authors concluded, that flushing with
a chelating agent removed the final calcific
sludge that remained on the canal walls.

Flushing with 10ml NaOCl removed


any remaining organic tissue, thus
leaving patent dentinal tubules on
the surface of the canal walls.

NaOCl has been to deplete dentin of


organic compounds & increase the
permeability

HYDROGEN PEROXIDE

For
years
3%
H 2O 2
was
recommended as a canal irrigant
because

Its effervescent action


presence of blood products.

Disinfecting properties.

in

Actions:

1) Effervesent action:

This action was specially indicated in


mandibular teeth where the bubbling of the
peroxide was thought to lift debris from the
canal system almost defying gravity.

However, H2O2 does not possess tissue


dissolution properties and is not effective as
a lubricant.

Hence, alternate use of H2O2 + NaOCl


irrigating solutions was recommended by
Grossman

This alternate irrigation regimen during


chemicomechanical preparation
produces.

1. Transient but energetic effervescence


that mechanically forces out debris and
microorganisms out of the canal.

2. At the same time the O2 that is


liberated in an active state assists in
destroying anaerobic microorganisms.

3. In combination with NaOCl


effectively removes the soft tissue
debris.

4. The permeability of dentinal


tubules is increased allowing
deeper penetration of intracanal
medicament.

5. Increases the bleaching action


on discolored teeth.

CHELATING AGENTS

Chelating agents were introduced by


Nygaard-Ostby in1957,as an aid for
preparation narrow and calcified root canals .
A liquid solution of
ethylenediaminetetraacetic acid (EDTA) was
thought to chemically soften dentin.
CHELATOR PREPARATIONS:
Liquid chelators:
Calcinase: Contains 17% Sodium acetate,
sodium hydroxide as a stabilizer and purified
water.

REDTA ( Roth International ) has 17% EDTA


solution with addition of 0.84g Cetyl-trimethyl-ammonium bromide ( Cetrimide )to
reduce the surface tension with 9.25 ml 5
M sodium hydroxide and 100ml distill
water.
EDTA-T: Contains 17% EDTA+Sodium
lauryl ether sulfate (Tergentol) as a
detergent.
EGTA: (Sigma) is a chelator whose main
component is ethylene glycol bis ( bamino-ethyl-ether) N,N,N,N-tetra acetic
acid. It is reported to bind Ca+ more
specifically than EDTA

Largal ultra (septodent) contains 15% EDTA,


0.75% Cetyl-tri-methyl-ammonium bromide
( Certimide ) & sodium hydroxide to adjust the
pH value to 7.4
SALVIZOL (Ravens,Germany) is based on 5%
amino-quinal-di-numdiacetate in propylene
glycol with pH 6.6
Calcinase slide : it contains 15% sodium EDTA
&58 to 60% water. Has alkaline pH value of 8-9.
ADVANTAGES
water soluble hence easily rinsed from root
canal system . The gel is firm at room
temperature and develops a creamy
consistency when agitated .

RC-Prep : It contains 15% EDTA, 10% Urea


peroxide and glycol in aqueous ointment
base .
Oxygen is set free by reaction of NaOCl with
RC-Prep resulting in effervescence, so that
pulpal remnants and blood coagulates can
be easily removed from the root canal wall
(Stewart et al).
Urea peroxide retains its antimicrobial action
in presence of blood .The manufacturers
claim that tooth can be bleached in this way
Glycol acts as a lubricant, it also inhibits the
oxidation of EDTA by urea peroxide.

GLYDE FILE :

Is composed of 15% EDTA & 10%


Urea peroxide in aqueous solution.
It has got properties similar to RCPrep

FILECARE EDTA & FILE EZE are the


other EDTA available in the market .

Clinical recommendation;
1)Root canal preparation can be carried out
with the aid of chelator paste.This may be
introduced into the root canal with the
preparation instrument. The canals first
should have been flooded with NaOCl to
dissolve vital or necrotic tissue.
2)A chelator in paste form serves as a
lubricant for files and may reduce the risk
of instrument fracture in the canal.
3) Preferably NaOCl solution should be used
during preparation because of its
antibacterial and tissue dissolving
property

4) A final intensive rinse with 17% EDTA reduces


the extent of the smear layer remaining which in
turn results in a cleaner canal wall and better
adaptation of the root fillings to the canal walls.
5) EDTA containing agents should be used
between
1-5 minutes .
6) Liquid EDTA solution may be introduced into the
pulp chamber to identify the entrance of
calcified canals.
7) The differences in certain properties and modes
of action of individual chelators found in the few
comparative studies do not allow the
recommendation of any particular chelator
preparation,

8)EDTA pretreatment may reduce


bond strength of adhesive materials
and obturative materials
9) There is no evidence for
bleaching effect when using EDTA
preparations containing urea
peroxide.
10) Apical extrusion of the chelator
solution should be avoided.

ADVANCEMENT IN
IRRIGATING SOLUTIONS

Chlorhexidine gluconate
It is a cationic chlorophenyl
bisguanide with bacteriostatic and
bacteriocidal action.
The cation of the chlorhexidine as
antiplaque agent was suggested by
schroeder in 1969.
The most common preparation is
with digluconate salt ,because of
higher water solubility.

Antibacterial action

At physiologic pH CHX is a large dicationic


molecule, with the positive charge
distributed over the nitrogen atoms on
either side of the heamatoxylin bridge.
The bacterial cell is characteristically
negatively charged. The cationic
chlorhexidine molecule is rapidly attracted
to the negatively charged bacterial cell
surface with specific and strong adsorption
to phosphate containing compounds.
This alters the integrity of the bacterial cell
membrane and CHX is attracted towards the
inner cell membrane.

CHX binds to the phospholipids in


the inner membrane and cause
leakage of low molecular weight
components such as potassium
ions.
At this sub lethal stage the effects
of CHX are reversible. Removal of
excess of CHX by neutralizers
allow the bacterial cell to recover

Increasing the conc. Of CHX cause


progressively greater damage to the
membrane, this is reflected in the size of
permeable species lost from the cell.
As the conc.of CHX increases, leakage of
low molecular cytoplasmic components fall
reflecting the coagulation and precipitation
of the cytoplasm by the formation of
phosphated complexes such as ATP and
nucleic acid.
This stage is irreversible.

Properties of CHX;
It possesses a broad-spectrum
antimicrobial action, substantivity,
and a relative absence of toxicity.
However, chlorhexidine gluconate is
not known to possess a tissuedissolving property.
The results from the individual trial of
chlorhexidine gluconate and sodium
hypochlorite indicate that they are
equally effective antibacterial agents.

However, when Kuruvilla and Kamath


combined the solutions within the root
canal, the results showed that the
alternate use of sodium hypochlorite and
chlorhexidine gluconate irrigants resulted
in a greater reduction of microbial flora
(84.6%) when compared with the
individual use of sodium hypochlorite
(59.4%) or chlorhexidine gluconate (70%)
alone.
White et al. found that chlorhexidine
instills effective antimicrobial activity for
many hours after instrumentation.

Although sodium hypochlorite is equally


effective on initial exposure, it is not a
substantive antimicrobial agent.

Dametto et al found that on initial


exposure to chlorhexidine, antimicrobial
activity is at least as effective as with
NaOCl. Its substantive antimicrobial
activity offers potential protection of
the canal tissues for as many as 7 days
after instrumentation.

Microbial activity of 2% chlorhexidine, gel and


liquid, are more effective than 5.25% NaOCl
in keeping a low Enterococcus faecalis CFU
count 7 days after bio-mechanical
instrumentation.
It was concluded that chlorhexidine
gluconate, in gel and liquid forms, has
potential for use as an auxiliary antimicrobial
agent during the biomechanical procedures.
Chlorhexidine substantivity in root canal
dentin was also studied by Sidney et al. The
results of this study indicated that CHX is
retained in root canal dentin in antimicrobially
effective amounts for up to 12 weeks.

An Effective Method of
Inactivating
Chlorhexidine;
An effective inactivating agent is required
for chlorhexidine that would facilitate
removal of all residual antimicrobial effect,
which may cause false negative results
during microbiologic culturing.
The combination of 3% Tween 80 and 0.3%
L-a- lecithin was found to be the most
effective inactivating agent, allowing full
recovery of the test organisms in the
presence of chlorhexidine

OXIDATIVE POTENTIAL
WATER

OPW has been used extensively in Japan for


household and agricultural disinfection
because of its safety and bactericidal
effectiveness.

According to the manufacturers claims, the


antimicrobial and antiviral activities of OPW
are sufficiently powerful to kill a wide variety
of pathogens, including Methicillin resistant
Staphylococcus Aureus (MRSA) and HIV.

The scientific basis for the


development of the OPW is
that microorganisms cannot
survive in an aqueous
environment with both low pH
(less than 3) and high
oxidation-reduction potential
(greater than 0.9 V) (Becking
et al. 1960).

OPW has strong anti-microbial


activity, killing viruses as well as
bacteria, an unusually low pH of 2.7
or less, and oxidation-reduction
potentials of 1050 mV or greater
(Okuda et al. 1994).

This is considerably greater than tap


water, which, in Japan, averages
300 mV to 400 mV, and greater than
several activated oxygen-containing
antimicrobial constituents, such as
HOCl and O 3 .

It has been confirmed that OPW


can condition both enamel and
dentine for bonding with
composite resin because of its
low pH (Inoue et al. 1994).

Oxidative potential water is well


suited for dental treatment
because of its low toxicity and
lack of irritation to soft tissues,

It quickly loses its high oxidationreduction potential and low pH when it


reacts with light-sensitive and/or organic
substances.

For these reasons it is completely safe


as a root canal irrigant. A previous study
(Hata et al. 1996) showed that OPW
effectively removed the smear layer
from instrumented canal walls when
used as an irrigant

NISIN
Nisin is a naturally occurring antimicrobial
peptide
Produced
by
strains
of
Lactococcus lactis, nisin is an antibiotic
peptide, and is a class I bacteriocin
(Klaenhammer 1993). Nisin is safe to
humans and is used extensively as a
food preservative in over 40 countries
(Delves-Broughton 1990), mainly in
preservation of meat and dairy products

The mode of action of nisin, while


not completely under-stood, is due
to interaction with the phospholipid
membrane of the target bacterial
cell (Driessen et al. 1995).
Nisin disrupts the cellular membrane
inducing
leakage
of
small
intracellular contents from the cell
(Montville & Chen 1998).

Nisin is comparable with calcium


hydroxide in its ability to eliminate the
species tested, both within the root canal
and associated canal wall radicular
dentine in vitro.

The ability of nisin to effectively kill E.


faecalis -- to which E. faecalis has no
defense mechanism.

Nisin is reported to be active against a


broad range of Gram-positive bacteria
(Kuipers et al. 1992).

ELECTRO-CHEMICALLY ACTIVATING
WATER

Over the course of the past 28


years Russian scientists have
developed and refined the
process of electro-chemically
activating water. (Leonov 1997,
Bakhir 1997).

ECA is produced from water and


saline solution by a special unit that
houses a unique flow-through
electrolytic module (FEM).

The FEM contains the anode, made


from titanium and coated with
rutheniumoxide, iridium and
platinum, and the cathode, made
from titanium coated with
pyrocarbon and glass-carbon.

The physical and chemical nature of


ECA is not yet fully understood. Two
types of ECA solution are produced.

Anolyte has a high oxidation


potential (plus 400 to plus 1200
millivolts). The manufacturers claim
that it is possible to produce acidic,
neutral or alkaline anolyte (pH 29),
and that anolyte is antimicrobial

Catholyte is an alkaline solution (pH 7


12) with a high reduction potential
(minus 80 to minus 900 millivolts).
Catholyte is reputed to have a strong
cleaning or detergent effect.

Both these solutions remain in the


metastable state for approximately 48
h before the solution returns to the
stable state, becoming inactive once
more.

BIS-DEQUALINIUM ACETATE
(BDA)
Kaufman reported the success of several
cases using BDA as a disinfectant and
chemotherapeutic agent
He cited its low toxicity, lubrication
action, disinfecting ability, and low
surface tension, as well as its chelating
properties and low incidence of posttreatment pain

Others have pointed out the efficacy of


BDA. In one report, it was rated
superior to sodium hypochlorite in
dbriding the apical third.

Marketed
as
Solvidont
(Dentsply/DeTrey, Switzerland), the
University of Malaysia reported a
remarkable decrease in postoperative
pain and swelling when BDA was used.

They attributed these results to the


chelation properties of BDA in removing
the smear layer coated with bacteria and
contaminants as well as the surfactant
properties that allow BDA to penetrate
into areas inaccessible to instruments.

Bis-dequalinium acetate is recommended


as an excellent substitute for sodium
hypochlorite in those patients who are
allergic to the latter.

Metranidazole

Antibiotic spectrum confined solely to


obligate anaerobes.

Active
against
bacteroides,
porphyromonas
fusibacterium,
clostridium
and
peptococci
and
peptostreptococci.

Comes as an injection: Metranidazole


500mg, NaCl2 0.8, Water.

Barnett and Tronstad reported the


successful use of metranidazole in
controlling
infections
by
bacterioides spp and pseudomonas
spp colonized at root ends of
endodontically treated teeth that
had failed to heal and remained
refractory to all other treatment.

DOXYCYCLINE
HYDROCHLORIDE

More recently DH, a hydroxy derivative


of tetracycline is under study as an
irrigant. It is the most potent
anticollagenase
antibiotic
among
commercially available tetracyclines.

The tetracyclines are broad spectrum


antibiotics demonstrated to be effective
in control of periodontal pathogens.

Advantages:

1. The dentin surface is capable of


acting as a reservoir by adsorbing and
slowly releasing antibacterial levels of
doxycycline
into
the
adjacent
environment
for
several
days
following topical applications of this
antibiotic solutions.

2. Inhibit extracellular collagenase


activity and bone resorption.

Ruddle solution

This
contains
5%
NaOCl,
hypaque, and 17% EDTA.

Hypaque
is
an
aqueous
solution of 2 iodine salts
diatrizoate
meglumine
and
sodium iodine. It is water
soluble with pH of 6.7-7.7.

This composition simultaneously


provides
the solvent action of full-strength
NaOCl,
Visualization ( radiodensity),
Penetration

( tensioactive agent )

MTAD

It is a mixture of a tetracycline
isomer (doxycycline), an acid
[citric acid)], and a detergent
(Tween 80 )

Tetracycline is bacteriostatic in nature.


This property may be advantageous
because in the absence of bacterial cell
lysis, antigenic by-products (i.e.
endotoxin) are not released.

Tetracycline has many unique properties


other than its antimicrobial effect. It has a
low pH and thus can act as a calcium
chelator and cause enamel and root
surface demineralization .
Its surface demineralization of dentin is
comparable to that seen using citric acid .

In addition, it has been shown that it


is a substantive medication
(becomes absorbed and gradually
released from tooth structures such
as dentin and cementum

Finally, studies have shown that


tetracycline significantly enhances
healing after surgical periodontal
therapy.

Studies have shown that MTAD as a


final rinse is capable of removing the
smear layer with minimal erosive
changes on the surface of dentin.

Experimentation with various


concentrations of
these materials showed that a mixture of
doxycycline, citric acid, and Tween-80 was
capable of removing the smear layer from
the surface of instrumented root canals
better than a combination of only
doxycycline and citric acid.

In another study, Beltz et al.


investigated the amount of tissue
loss after exposing bovine pulp
and
dentin
to
various
concentrations of NaOCl, EDTA, or
MTAD. Their results showed that
various concentrations of NaOCl
removed organic components of
pulp and dentin effectively.

The soluble effects of EDTA on pulp and


dentin were somewhat similar to those
of MTAD. The major difference between
the actions of these solutions is a high
binding affinity of doxycycline present in
MTAD for the dentin.

It is also found that MTAD maintains its


bactericidal properties significantly more
than NaOCl or EDTA.

Cytotoxicity is less when


compared to sodium
hypochlorite. There was no
effect on flexural strength
and modulus of elasticity of
dentin when MTAD was used

OZONE
Ozone is a pale blue gas which is made up of
three atoms of oxygen with a cyclic structure

The medical generator of ozone


produces it from pure oxygen
passing through a high voltage
gradient of 5-13 Mega volts
according to the reaction,

3O2 + 68,400cal--------2O3

Ozone is 1.6 fold denser and 10 fold


more soluble in water than oxygen.
It is the third most potent oxidant
after fluorine and persulphate.
It is an unstable gas that cannot be
stored and should be used at once.
It has a half life of 40 mins. But
when mixed into pyrogen free
water , the half life is 9-10 hrs at
ph-7 and at 20 C

OZONE THERAPY IN ENDODONTICS ;

It is difficult to achieve the objective of


complete sterilization of the root canal
system by means of conventional
Endodontics

Being able to sterilize the root canal


system completely would significantly
improve the prognosis for all teeth to
be treated Endodontically.

The application of ozone makes the


complete sterilization of the root
canal system a real possibility in the
near future.
Tooth that is to be treated
Endodontically needs to be built up
so that the clinical crown is restored.
The Ozone is applied from the access
opening , making the technical
realization quite a simple process.

There are five differently sized


silicone cups available to enable
perfect tooth sealing

Inserting the ozone cannula into


the prepared root canal

Endodontic treatment using


ozone with complete seal

The ability of Ozone as a root canal


disinfectant depends upon;
The ability of ozone to penetrate the root
canal system to the apex
The effect of any proceeding preparation
for certain instrument sizes.
To ensure the exact canal size for the
placement of cannula and proper
application of ozone towards apex ,further
develepments in the ozone equipment are
in progress.

Waterlase Laser

For years, lasers have been used in


dentistry to improve the comfort,
precision, efficiency and effectiveness of
many procedures.

Waterlase uses the Hydrokinetic


process which gently washes away decay
with YSGG laser-energized water droplets.
Hydrokinetic energy is produced by
combining a spray of atomized water with
laser energy.

The resulting Waterlase (Hydrokinetic)


energy gently and precisely removes a wide
range of human tissue including tooth enamel
(the hardest substance in the body), and soft
tissue (gum tissue) with no heat or discomfort
in most cases.

What can the Waterlase be


used for?
Root Canals
Decay Removal
Cavity Preparation
Smile Design
General soft tissue procedures

Benefits of Waterlase Endodontics:


Superior intra-operative and postoperative patient comfort.
Reduced post-operative complications
such as inflammation, swelling and pain.
Versatile and effective for root canal
preparation.
No vibration and pressure as found with
conventional instruments.
Little or no anesthesia.
More healthy tooth structure is preserved.

IRRIGATING DEVICES

Although the technique for irrigation is simple,


the potential for serious complications exists.

Regardless of the delivery system, the


solution must be introduced slowly and the
needle never wedged in the canal.The
greatest danger exists from forcing the
irrigant and canal debris into the periradicular
tissue owing to a piston-like effect.

Several types of plastic disposable syringes


are available. Usually, the irrigating solution is
kept in a dappen dish that is kept filled. The
syringe is filled by immersing the hub into the
solution while withdrawing the plunger.

ProRinse.

In case of prorinse system the needle,


or probe is attached. Care must be
taken with irrigants like sodium
hypochlorite to prevent accidents.

The irrigating needle may be one of


several types. It should be bent to allow
easier delivery of the solution and to
prevent deep penetration of the needle
or probe.

A commonly used needle is the


27-gauge needle with a notched
tip, allowing for solution flowback
or the blunt-end ProRinse.

Monoject endodontic
needles

Moser
and
Heuer
reported
Monoject
endodontic needles to
be the most efficient
delivery system in
which longer needles
of a blunted,open-end
system were inserted
to the full length of
the canal.

Stropko Ni-Ti Irrigation


Needles
Stropko Ni-Ti Irrigation Needles
available from Vista Dental. They are
available in short (17 mm) and (25
mm) long sizes and can be sterilized
and reused.
Needle size is 27 guage, side vented
,flexibility and their resistance to
clogging helps in effective irrigation.

Closed-end
needle
eliminates
possibilities of puncture of the apical
foramen or a water cannon effect
from open-end needles. [Courtesy of
Dentsply/Tulsa Dental.]

Endo Irrigator II

The Endo
Irrigator II has 3
reservoirs. The
gun on the right
has four buttons.
Three activate
the solutions and
one is for suction.
The device has a
built in heater.

Walton and Torabinejad stated that


Perhaps the most important factor is
the delivery system and not the
irrigating solution per se.

Furthermore, it was found that the


volume of the irrigant is more
important than the concentration or
type of irrigant.

Wedging a needle in a canal


is dangerous and can
cause serious sequelae.

Canal size and shape are crucial to the


penetration of the irrigant. The apical 5 mm
are not flushed until they have been enlarged
to size 30 and more often size 40 file.
It is reported that In order to be effective,
the needle delivering the solution must come
in close proximity to the material to be
removed.
Small-diameter needles were found to be
more effective in reaching adequate depth
but were more prone to problems of possible
breakage and difficulty in expressing the
irrigant from the narrow needles.

Kahn, Rosenberg et al. at New York


University, in an in vitro study, tested
various methods of irrigating the canal.
ProRinse probes were highly effective in all
gauges and in all sizes of canals tested.
The Micromega 1500 and CaviEndo
systems were highly effective at the size
20, 25, and 30 K-file levels.
The effectiveness of the ProRinse seemed
related to its design. It has a blunt tip, with
the lumen 2 mm from the tip. Expression of
fluid through the lumen creates turbulence
around and beyond the end of the probe.

The effectiveness of the ProRinse


seemed related to its design. It has a
blunt tip, with the lumen 2 mm from
the tip. Expression of fluid through
the lumen creates turbulence around
and beyond the end of the probe.

Max-i-Probe
These are designed to produces
upward flushing motion for
complete canal irrigation .
Side port dispersal prevents
solution and debris from being
expressed through the apex
Closed, rounded end reduces risk
of apex damage.

Ultrasonic irrigation

Ultrasonics devices were first introduced


in endodontics by Richman[ 1957]
Two types of ultrasonics irrigation have
been described in the literature;
One where irrigation is combined with
simultaneous ultrasonic instrumentation
Another without simultaneous
instrumentation called passive
ultrasonic irrigation.

Cavitation - Oscillation of gas / vapour


filled
bubbles in an acoustic
field
Acoustic microstreaming- Rapid
movement of fluid around an
oscillating instrument

Ultrasonic energy passes through the


irrigating solution and exerts its
acoustic streaming or scrubbing
effect on the canal wall.

According to studies [Weber et al] there


may be an advantage of interappointment
medication with
calcium hydroxide combined with passive
ultrasonic activation with chlorhexidine.
This may provide patients with reduced
interappointment flare-ups and decrease
multiple visits to single appointments.

JOURNAL REVIEW

Effect of EDTA with and without


surfactants or ultrasonics on
removal of smear layer.
Lui JN, Kuah HG, Chen NN
JOE 2007
This study compared the in vitro efficacy
of Smear Clear (Sybron Endo, CA), a 17%
ethylenediaminetetraacetic acid (EDTA)
solution with surfactants, to 17% EDTA,
with and without the use of ultrasonics, in
removal of the smear layer.

Addition of surfactants to EDTA in


Smear Clear did not result in
better smear layer removal. The
use of ultrasonics with 17% EDTA
improved smear layer removal.

Killing of Enterococcus faecalis by MTAD and


chlorhexidine digluconate with or without
cetrimide in the presence or absence of
dentine powder or BSA.
Portenier I, Waltimo T, rstavik D, Haapasalo M.
JOE 2006.
The antibacterial efficacy of irrigating solutions and
local disinfectants used in endodontics appears
poorer in vivo than in vitro. One explanation may be
inactivation by compounds present in the root canal.
MTAD (a mixture of tetracycline isomer, acid, and
detergent) is a new root canal irrigation solution with
antibacterial activity.
The aim of this study was to investigate the
antibacterial activity of MTAD and chlorhexidine
towards two strains of Enterococcus faecalis and the
inhibitory effects of dentine and bovine serum
albumin on the antibacterial activity.

Full concentration (100%) MTAD and


0.2% chlorhexidine rapidly killed both
strains. Combining chlorhexidine with
cetrimide further reduced the time
required for killing.
The presence of dentine caused a
marked delay in killing by both
medicaments. The two E. faecalis
strains tested showed minor
differences in their susceptibility to
the disinfectants.

Effects of Er:YAG and Nd:YAG laser


irradiation on radicular dentine
permeability using different
irrigating solutions.
Brugnera A, Zanin F, Barbin EL,
Span JC, Santana R , Pcora JD.
LAS SUR MED 2003
To evaluate the effect of Er:YAG and
Nd:YAG laser on radicular dentine
permeability when using distilled and
deionized water and 1% NaClO as
irrigating solutions.

CONCLUSIONS:
The use of distilled and deionized water
and Er:YAG laser showed the greater
increase of dentine permeability.
The use of 1% NaClO with Nd:YAG laser,
distilled, and deionized water with
Nd:YAG laser and the use of water
increased dentine permeability less
than the other groups.
The use of 1% NaClO with and without
Er:YAG laser application were positioned
intermediately among the treatments.

Influence of irrigating needle-tip designs in


removing bacteria inoculated into
instrumented root canals measured using
single-tube luminometer.
Vinothkumar TS, Kavitha S,
Lakshminarayanan L, Gomathi NS, Kumar V.
JOE 2007
This study tested the mechanical efficacy of
various irrigating needle tip designs on bacteria
inoculated into instrumented root canals.
Root canals of 30 extracted permanent canines
were prepared to size 60 at working length (WL)
using ProFile 0.04 taper rotary nickel-titanium
files. Root canals were autoclaved and inoculated
with a 20-microl suspension (1.4 x 10(7) cells) of
genetically engineered Escherichia coli pYUB556.

Safety-ended needles with single (group


1) and double (group 2) side-port and
hypodermic needles (group 3) were used
upto 1 mm short of WL. The percentage
of bacteria remaining after irrigation was
67.9 +/- 9.5, 75.3 +/- 12.9 and 77.7 +/11.8 respectively (p < 0.05; KruskalWallis) with no difference between group
II and group III (p > 0.05; Mann-Whitney).

Irrigation using safety needles with single


side port was significantly effective.

An in vitro evaluation of the irrigating


characteristics of ultrasonic and subsonic
handpieces and irrigating needles and
probes.
Kahn FH, Rosenberg PA, Gliksberg J.
JOE 1995
The objective of this in vitro study was to
evaluate the efficacy of a variety of endodontic
irrigating devices. This study utilized plastic
blocks with artificial canals to simulate the
clinical setting. The canals were instrumented,
and red food dye was introduced into each
canal. The blocks were placed in a jig to simulate
maxillary and mandibular arch orientation.

Irrigation was performed with: (a) B-D


22-gauge needle; (b) Monoject
Endodontic Needle 23 and 27 gauge;
(c) Max-i-Probe 25-, 28-, and 30-gauge
probes; (d) Cavi-Endo ultrasonic
handpiece; and (e) Micromega 1500
subsonic handpiece.
The Max-i-Probe probes were the most
effective instrument used to clear dye
from the simulated canals in both the
mandibular and maxillary positions.

The Effect of Passive Ultrasonic


Activation of 2%Chlorhexidine or 5.25%
Sodium Hypochlorite Irrigant on
Residual Antimicrobial Activity in Root
Canals
Carol Diener Weber, DDS, MS, Scott B.
McClanahan
JOE 2003
The purpose of this study was to evaluate
the
effect of passive ultrasonic activation of 2%
chlorhexidine and 5.25% NaOCl irrigant on
residual antimicrobial activity in root canals.

By using passive ultrasonic


activation with chlorhexidine,
perhaps the clinician would not need
to spend additional time with an
interappointment medication such
as calcium hydroxide.

There may be an advantage of


interappointment medication with
calcium hydroxide combined with
passive ultrasonic activation with
chlorhexidine.

CONCLUSION

Many
new
materials
and
methods have recently been
introduced to improve root
canal debridement and to
achieve root canal sterilization.
Some of the new treatment
modalities have been marketed
to dentists, with the claim that
it is possible to sterilize an
infected root canal system,

However, bearing in mind the complex


anatomy of the root canal system and the
ability of microorganisms to survive
under adverse conditions, it might be
premature to believe that the total
sterilization of the root canal system
could be readily achieved.
In the age of evidence-based dentistry, it is
advisable
to
wait
until
quality
independent data are available to support
the use of such new technologies.