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IRRIGATION IN ENDODONTICS

CONTENTS

CONTENTS  Introduction  Interactions  History  Recent developments  Objective and functions . 
  • Introduction

  • Interactions

  • History

  • Recent developments

  • Objective and functions .

  • Irrigation protocol in different

  • Mode of action

clinical situations

  • Conclusion

  • Classification of irrigants

 
  • Introduction of each irrigants

  • History

  • Mechanism of action

  • Advantage of irrigation

  • Disadvantages of irrigation

  • Irrigation is a key part of successful root canal treatment as it fulfils several important mechanical, chemical and (micro) biological functions. Irrigation is also the only way to impact those

areas of the root canal wall that are not touched by mechanical

instrumentation.

  • Hence it is said to be a part of cleaning and shaping of root canals.

 Irrigation is a key part of successful root canal treatment as it fulfils several important
  • A bigger challenge for irrigation may be the areas untouched by the

files, such as fins, isthmuses and large lateral canals. Also, large areas in the oval and flat canals may remain untouched despite careful instrumentation.

  • These areas contain tissue remnants and biofilms that only can be removed by chemical means using irrigation.

  • The apical root canal poses a special challenge to irrigation as the

balance between safety and effectiveness is particularly important

in this area.

  • One of the key factors for failure of endodontic treatment is persistence of bacteria in the endodontic space, or the contamination during the endodontic treatment or later, because of an incomplete seal of the coronal restoration.

  • First of all, such contamination should be prevented, by the use of an aseptic technique, including the rubber dam; this improves the outcome of endodontic treatment. More over , failure to use rubber dam can negatively influence the choice of endodontic irrigants.

  • Substances that have been used to rinse and chemically clean root canals have different purposes, such as dissolution of soft and hard tissues, antimicrobial effect against bacteria or other microorganisms in the root canal, and inactivation of bacterial lipopolysaccharides.

  • These substances also should be as nontoxic as possible to protect

the periradicular tissues.

  • Unfortunately, solutions that are toxic for bacterial cells frequently are toxic for human cells as well, so care must be taken to avoid extrusion of irrigants into periapical regions.

  • Several factors are important for efficient root canal irrigation. One critical factor is the volume of irrigant. In a study evaluating the effect of different amounts of fluids, the volume of irrigant was found to affect the cleanliness of the root canal. NaOCl and EDTA administered in larger volumes produced significantly cleaner root canal surfaces than smaller volumes.

  • Primary endodontic treatment goal- optimize root canal disinfection and to prevent re-infection by cleaning the root canal system thoroughly and making it free of microbiota and debris, as they have definite role in the initiation and perpetuation of pulpal and periapical diseases

(Kandaswamy and Venkateshbabu, 2010).

2.HISTORY

 


Potassium hypochlorite was the first chemically

produced aqueous chlorine solution, invented in France by Berthollet (1748-1822).

The first listed literature about the need for

frequent irrigation of the root canal was advocated by Taft ( 1859)

He recommended the use of a ‘deodorizing agent’

like chloride of sodium.

  • Schreir (1893) introduced potassium and sodium metals into canals for removal of necrotic pulp.

  • 20-25% aqueous solution of sulphuric acid applied on a cotton pledget and sealed into the root canal for 24-48 hours was introduced by Callahan (1894) .

  • A saturated solution of bicarbonate soda was then introduced into the root canals thereby producing an effervescent action and forcing debris to the surface.

  • In the late 20th century, studies conducted by Grossman and

Meiman in 1941 led to introduction of the combined use of double

strength sodium hypochlorite and hydrogen peroxide to wash out

fragments of pulp tissue and dentinal shavings after mechanical

instrumentation. This was published later in 1943 by Grossman.

Histrory of NaOCl

Histrory of NaOCl  sodium hypochlorite was recommended by Labarraque(1777- 1850) to prevent childbed fever and
  • sodium hypochlorite was recommended by

Labarraque(1777- 1850) to prevent childbed fever and other infectious diseases.

  • Based on the controlled laboratory studies by Koch and Pasteur, hypochlorite then gained wide acceptance as a disinfectant by the end of the 19th century.

  • In World War I, the chemist Henry Drysdale Dakin and the surgeon Alexis Carrel extended the use of a buffered 0.5% sodium hypochlorite solution to the irrigation of infected wounds, based on Dakin’s meticulous studies on the efficacy of different solutions on infected necrotic tissue.

  • Walker (1936) stated that beside their wide- spectrum, nonspecific killing efficacy on all microbes, hypochlorite preparations are sporicidal, virucidal, and show far greater tissue dissolving effects on necrotic than on vital tissues.

3. OBJECTIVE AND FUNCTIONS

3. OBJECTIVE AND FUNCTIONS
3. OBJECTIVE AND FUNCTIONS
Irrigation reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves

Irrigation reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves tissue, and cools the file and tooth especially during the use of ultrasonic energy.

Irrigation reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves
Irrigation reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves
Irrigation reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves
Irrigation reduces friction between the instrument and dentine, improves the cutting effectiveness of the files, dissolves
IT SHOULD ALSO HAVE BLEACHING ACTION OF PULP CHAMBER.

IT SHOULD ALSO HAVE BLEACHING ACTION OF PULP CHAMBER.

IT SHOULD ALSO HAVE BLEACHING ACTION OF PULP CHAMBER.
  • The ideal root canal irrigant has been described by Zehnder

  • as being systemically nontoxic, noncaustic to

periodontal tissues, having little potential to cause

ananaphylactic reaction,

  • possessing a broad antimicrobial spectrum, capable

of dissolving necrotic pulp tissue, inactivating

endotoxins, and either preventing the formation of a smear layer or dissolving it once it has formed.

FACTORS THAT MODIFY ACTIVITY OF

INTRACANAL IRRIGATING SOLUTIONS

FACTORS THAT MODIFY ACTIVITY OF INTRACANAL IRRIGATING SOLUTIONS  CONCENTRATION: higher the concentration better the results.Baumgartner JC " id="pdf-obj-18-6" src="pdf-obj-18-6.jpg">
  • CONCENTRATION: higher the concentration better the results.

NaOCl in concentrations of 5.25%, 2.5%, and 1% completely removed

pulpal remnants and predentin from the uninstrumented surfaces.

Although 0.5% NaOCl removed the majority of pulpal remnants and

predentin from the uninstrumented surfaces, it left some fibrils on the

surface.

Efficacy of several concentrations of sodium hypochlorite for root canal irrigation.Baumgartner JC

  • CONTACT time: more the contact time better the removal of biofilm, smear layer

The most effective irrigation regimen is reported to be 5.25% at 40 min

(Kandaswamy and Venkateshbabu, 2010).

  • Quantity of irrigants: more the quanty used more the effectyiveness

  • Needle Gauge: bigger the gauge ,more volume which will flow in the canal with less pressure , smaller the gauge less irrigant will flow but more will be with pressure.

  • Surface tension : less surface tension of the irrigant more the flow, more contact with the canal wall

    • Temperature: NaOCl, at a concentration of 1% heated to 20°C, is less effective than that at 45°C, which in turn is less effective than that at 60°C, as more chlorine is released at higher temperatures.

(Antimicrobial Irrigants in the Endodontic Therapy, Azhar Iqbal, IJHS,2012)

  • Frequency: more times the irrigants used, better the removal of debris.

  • Canal diameter : . Bigger the canal diameter better debribment. MAF=35.06) showed 100% acceptable debridement. This rate was 92.9% for MAF=35.04.

Effect of Master Apical File Size and Taper on Irrigation and Cleaning of the Apical Third of Curved Canals Nahid Mohammadzadeh Akhlaghi, J Dent (Tehran). 2014

  • Age of irrigan

  • Many irrigating solutions have been studied

extensively to determine which best exhibit these ideal properties, but the ideal irrigant has not yet been realized.

CLASSIFICATION OF IRRIGANTS (1)

CLASSIFICATION OF IRRIGANTS (1)
  • Many different irrigants and combinations of irrigants have been used in RCT to achieve these goals. These include: (2)

    • 1. Sodium hypochlorite;

  • 2. Chlorhexidine;

  • 3. Sterilox (Hypochlorous acid (HClO)

  • 4. EDTA

  • 5. Iodine potassium iodide

  • 6. Hydrogen peroxide

  • 7. Local anaesthetic, saline and/or water;

CATEGORIES OF IRRIGANTS: (3)

CATEGORIES OF IRRIGANTS: (3)  lubricants,  disinfectants,  and chelating agents.
  • lubricants,

  • disinfectants,

  • and chelating agents.

LUBRICANTS

LUBRICANTS  used to make instrumentation easier.  They reduce the friction between the endodontic instrument

used to make instrumentation easier.

They reduce the friction between the endodontic

instrument and the canal wall.

Removing dentin by either hand instrumentation

or mechanical instrumentation becomes much

easier if the canal is wet or lubricated.

Instrument lubrication can be achieved easily by

using either sterile water, saline, or sodium

hypochlorite (NaOCl) for most routine cases.

  • Eg. 17% ethylenediaminetetraacetic acid (EDTA) in liquid, gel, or paste formulations.

  • 17% EDTA Plus (Essential Dental Systems) in

water for use as a lubricant when instrumenting

tight canals because it contains a surfactant which

enables the EDTA to wet the canal walls more easily

DISINFECTANTS

DISINFECTANTS  The disinfectant category of irrigants comprises several products. The most frequently used irrigant is
  • The disinfectant category of irrigants comprises several products. The most frequently used irrigant is NaOCl.

  • This irrigant has 2 great advantages: (1) it dissolves necrotic tissue, and (2) it kills bacteria quite effectively

CHELATING AGENTS

CHELATING AGENTS  The last category of root canal irrigants is chelating agents. Chelants are chemicals
  • The last category of root canal irrigants is chelating agents. Chelants are chemicals that form soluble complex molecules with certain metal ions, inactivating the ions so that they cannot normally react with other elements or ions to produce precipitates or scale.

  • In dentistry, chelating agents bind with calcium and

carry it out of the canal. The chelating agent most

used in endodontics is EDTA.

CLASSIFICATION (4) KANDASWAMY D, VENKATESHBABU

CLASSIFICATION (4) KANDASWAMY D, VENKATESHBABU

ENDODONTIC IRRIGANTS

ENDODONTIC IRRIGANTS <a href=BANDU NAPTE , SURYA RAGHAVENDRA SRINIDHI , JOURNAL ODDENTAL AND ALLIED SCIENCE,2015  Based on their mechanism of action, they are classified into nonbactericidal and bactericidal irrigants. Nonbactericidal irrigants Saline, local anesthetics and distilled water. Bactericidal irrigants: Sodium hypochlorite (0.5%, 1%, 1.5%, 2.5%, 5.25%, and 6% concentrations) Chlorhexidine (CHX) (2%) Iodine Hydrogen peroxide (H O ) (3%). " id="pdf-obj-31-4" src="pdf-obj-31-4.jpg">

BANDU NAPTE, SURYA RAGHAVENDRA SRINIDHI, JOURNAL ODDENTAL AND ALLIED SCIENCE,2015

  • Based on their mechanism of action, they are classified into nonbactericidal and bactericidal irrigants.

Nonbactericidal irrigants

Saline, local anesthetics and distilled water. [6]

Bactericidal irrigants:

Sodium hypochlorite (0.5%, 1%, 1.5%, 2.5%, 5.25%, and 6%

concentrations) Chlorhexidine (CHX) (2%) Iodine Hydrogen peroxide (H 2 O 2 ) (3%).

Chelator solutions

diamine tetra acetic acid (EDTA, 17%)

  • Citric acid (10-50%)

  • Mixture of tetracycline, acid and detergent (MTAD, Tween 80)

  • Tetraclean

  • Maleic acid.

Herbal irrigants

Others:

activated water (EAW)

  • Bis-dequalinium acetate (BDA)

  • Photo-activated disinfection (PAD)

  • Ozone

  • Laser.

Sodium hypochlorite

INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS

Sodium hypochlorite INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS
Sodium hypochlorite INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS
Sodium hypochlorite INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS
Sodium hypochlorite INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS
Sodium hypochlorite INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS
Sodium hypochlorite INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS

1. SODIUM

HYDROCHLORITE

1. SODIUM HYDROCHLORITE  comprising a <a href=sodium cation (Na ) and a hypochlorite anion (ClO or OCl ). It may also be viewed as the sodium salt of hypochlorous acid.  The solution is commonly known as liquid bleach or simply bleach , a household chemical widely used (since the 18th century) as a disinfectant or a bleaching agent .  The solution is alkaline in nature with a ph of 11 " id="pdf-obj-34-6" src="pdf-obj-34-6.jpg">

anion (ClO or OCl ). It may also be viewed as the sodium salt of hypochlorous acid.

Update on endodonticirrigating solutions

BETTINA BASRANI & MARKUS HAAPASALO ,2012

HISTORY



NaOCl was first produced in 1789 in Javelle,

France, by passing chlorine gas through a solution

of sodium carbonate.

The resulting liquid, known as “Eau de Javelle” or Javelle water” was a weak solution of sodium hypochlorite. However, this process was not very

efficient and alternate production methods were

sought.

  • One such method involved the extraction of chlorinated lime (known as bleaching powder) with sodium carbonate to yield low levels of available chlorine.

  • This method was commonly used to produce NaOCl

solutions for use as a hospital antiseptic that was

sold under the trade names “Eusol” and “Dakin’s

solution.” Sodium hypochlorite as a buffered 0.5%

solution was recommended for the irrigation of wounds during World War I by Dakin.

MODE OF ACTION

MODE OF ACTION  P ι cora et al . reported that NaOCl exhibits a dynamicDeivanayagam Kandaswamy , Nagendrababu Venkateshbabu ,jcd,2010 " id="pdf-obj-38-4" src="pdf-obj-38-4.jpg">
  • Pιcora et al. reported that NaOCl exhibits a dynamic balance as is shown by the reaction: NaOCl + H 2 O ↔ NaOH + HOCl ↔ Na + + OH + H + + OCl

sodium hydroxide

Hypochlorous acid

hydroxide ions

hypochlirite ion

  • Three types of chemical reaction occur between organic tissue and hypochlorite

    • 1. Saponification reaction

    • 2. Amino acid neutralization reaction

      • 3. Chloramination reaction

Root canal irrigants, Deivanayagam Kandaswamy, Nagendrababu Venkateshbabu,jcd,2010

In simple terms, saponification is the name for a chemical reaction between an acid and a base to form a salt.

When hypochlorous acid, a substance present in NaOCl solution, comes in contact with organic tissue it

When hypochlorous acid, a substance present in NaOCl solution,

comes in contact with organic tissue it acts as a solvent and releases

chlorine, which combines with the protein amino group to form chloramines

Hypochlorous acid (HOCl ) and hypochlorite ions (OCl ) lead to amino acid degradation and hydrolysis.

The chloramination reaction between chlorine and the amino group (NH) forms chloramines that interfere in cell

The chloramination reaction between chlorine and the amino

group (NH) forms chloramines that interfere in cell

metabolism. Chlorine (a strong oxidant) has an antimicrobial action, inhibiting bacterial enzymes and leading to an irreversible oxidation of SH groups (sulphydryl group) of

essential bacterial enzymes.

  • Thus, the saponification, amino acid neutralization, and chloramination reactions that occur in the presence of microorganisms and organic tissue lead to the antimicrobial effect and tissue dissolution process.

CONCENTRATIONS

CONCENTRATIONS  NaOCl is used in concentrations between 0.5 and 6%.  Some in vitro studies
  • NaOCl is used in concentrations between 0.5 and 6%.

  • Some in vitro studies have shown that NaOCl in higher concentrations is more effective against Enterococcus faecalis and Candida albicans. In contrast other studies have indicated both low and high concentration of NaOCl is effective.

  • NaOCl in higher concentrations has a better tissue-dissolving ability, but even in lower concentrations when used in high volumes it can be equally effective .

  • Higher concentrations of NaOCl are more toxic than lower concentrations ; however, due to the confined anatomy of the root canal system, higher concentrations have successfully been used during root canal treatment with a low incidence of mishaps.

  • Grossman , observing pulp tissue dissolution capacity, reported that 5% sodium hypochlorite dissolves this tissue in between 20 min and 2 h.

  • Other studies done concluded that:

    • 1. Higher the concentration faster is the dissolution of pulp tissue

  • 2. Higher the temperature faster was the dissolution.

  • 3. the greater the initial concentration of the

sodium hypochlorite solutions, the smaller the

reduction in pH

TEMPERATURE EFFECTS

TEMPERATURE EFFECTS  Cunningham reported that the collagen dissolving ability of 2.6% sodium hypochlorite was comparable

Cunningham reported that the collagen dissolving ability of 2.6% sodium hypochlorite was comparable to that of 5.25% at both 21°C and 37°C.

They also compared the ability of the solutions to kill bacteria at different temperatures. They tested 2.6% and 5.25% sodium hypochlorite in reducing a planktonic culture of E. coli results concluded that that it took less time to kill E. coli in both concentrations at 37°C.

Interestingly, it was also reported that sodium hypochlorite at 50°C did not help in making the root canal cleaner. However, at (50°C),

Berutti et al. observed a thin, less organized, and less adherent smear

layer on the root canal wall. This thinner layer was not evident on root canals irrigated with sodium hypochlorite at 21°C.

  • raising the temperature of the sodium hypochlorite to 37°C does not help dissolve tissues more effectively. Although raising the temperature of irrigants is a way to kill bacteria more effectively, the temperature should not be raised more than a few degrees above body temperature as this may have harmful effects on the cells of the periodontal ligament

  • Different devices for warming the NaOCl syringes have come onto the market, but these devices are not capable of maintaining any increase of temperature. The best way of heating NaOCl is to use an ultrasonic device in situ.

ADVANTAGES

ADVANTAGES
  • The three parameters potentially affecting NaOCl penetration that were evaluated in a study was

1.

concentration,

  • 2. time, and

3.

temperature.

  • Perhaps the most surprising observation was that increasing the concentration from 1% to 6% did not result in more than a 30%50% increase in penetration.

  • A longer exposure time in their study resulted in deeper penetration of NaOCl, although the speed of penetration declined sharply over time ..

Zoe et al

  • For example, at 20°C, the penetration depth of 1% NaOCl in 2 min was about 77 mm; after another 18 min at the same temperature, the depth reached about 185 mm

DISADVANTAGE:

DISADVANTAGE:  The weaknesses of NaOCl include the unpleasant taste, toxicity, and its inability to remove
  • The weaknesses of NaOCl include the unpleasant taste, toxicity, and its inability to remove the smear layer by itself, as it dissolves only organic material.

  • The limited antimicrobial effectiveness of NaOCl in vivo is also disappointing.

  • The poorer in vivo performance compared with in vitro is probably caused by problems in penetration to the most peripheral parts of the root- canal system such as fins, anastomoses, apical canal, lateral canals, and dentin canals.

  • Also, the presence of inactivating substances such as exudate from the periapical area, pulp tissue, dentin collagen, and microbial biomass counteract the effectiveness of NaOCl..

  • Recently, it has been shown by in vitro studies that long-term exposure of dentin to a high concentration sodium hypochlorite can have a detrimental effect on dentin elasticity and flexural

strength.

  • Although there are no clinical data on this phenomenon, it raises the question of whether hypochlorite in some situations may increase the risk of vertical root fracture

  • however it is said that only solutions containing

more than 40% sodium hypochlorite by weight are

considered hazardous oxidizers. Solutions less

than 40% are classified as a moderate oxidizing hazard.

  • The toxic effects of NaOCl on vital tissues include hemolysis, epithelial ulceration, and necrosis .

  • Several mishaps during root canal irrigation have

been described in the dental literature.

  • These range from damage to the patient’s clothing, splashing the irrigant into the patient’s or operator’s eye, injection through the apical foramen, and allergic reactions to the irrigant, to inadvertent use of an irrigant as an anesthetic solution.

 These range from damage to the patient’s clothing, splashing the irrigant into the patient’s or
  • The main symptoms when NaOCl is injected into the periapical and periradicular tissues are

  • immediate severe pain;

  • immediate edema of neighboring soft tissues; possible extension

of edema over the injured side of the face, upper lip, or infra-

orbital region;

  • profuse bleeding from the root canal;

  • profuse interstitial bleeding with hemorrhage of the skin and

mucosa (ecchymosis);

  • chlorine taste or irritation of the throat after injection into the maxillary sinus;

    • secondary infection;

    • reversible anesthesia; and paresthesia.

 The main symptoms when NaOCl is injected into the periapical and periradicular tissues are 
  • Current treatment protocol for sodium hypochlorite accident are suggest:

  • early recognition of extrusion,

  • immediate canal irrigation with normal saline, encouragement of bleeding,

  • Pain control with local anesthetics and analgesics and

warm compresses and frequent warm mouth rinses

  • for stimulation of the local systemic circulation,

  • reassurance of the patient, and monitoring of improvement.

  • Cancellous bone( soft bone) is significantly affected by NaOCl, whereas cortical bone is minimally affected.

  • harm to the cells occur as they have a specific environment to thrive , NaOCl changes that environment and damages them.

Chlorhexidine

INTRODUCTION

HISTORY

MODE OF ACTION

ADVANTAGES

DISADVANTAGES

INTERACTIONS

Chlorhexidine INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS

INTRODUCTION.

INTRODUCTION.  Chlorhexidine is a potent antiseptic, which is widely used for chemical plaque control in
  • Chlorhexidine is a potent antiseptic, which is widely used for chemical plaque control in the oral cavity.

  • Aqueous solutions of 0.1 to 0.2% are recommended for that purpose, while 2% is the concentration of root canal irrigating solutions usually found in the endodontic literature (Zehnder, 2006). It is commonly held that chlorhexidine would be less caustic than sodium hypochlorite.

  • Another advantage of CHX is on increasing the temperature even of lesser concentration it would increase its local efficacy in the root canal system while keeping the systemic toxicity low.

  • Despite its advabtages CHX can still not be considered a gold standard irrigant because:

    • 1. chlorhexidine is unable to dissolve necrotic tissue remnants, and

  • 2. chlorhexidine is less effective on Gram-negative than on Gram- positive bacteria

  • Due to the cationic nature of the CHX molecule, it can be absorbed by anionic substrates such as the oral mucosa. It has the binding ability to albumin present in saliva , pellicle of tooth surface etc. but this is reversible, this reversible reaction of uptake and release of CHX leads to substantive antimicrobial activity and is referred to as “substantivity”.

  • Higher the concentration of CHX more will be its substantivity.

  • Another application of CHX is in the treatment and management of periodontal diseases, a well as in the reduction of the incidence, severity, and duration of aphthous ulceration. In addition, it has been advocated as a denture disinfectant in patients susceptible to oral candidiasis. CHX can be prepared in the form of mouth rinses, gels, varnishes, and controlled-release devices

HISTORY

HISTORY  CHX was developed more than 50 years ago at Imperial Chemical Industries in England,
  • CHX was developed more than 50 years ago at

Imperial Chemical Industries in England, and was first marketed in the United Kingdom in 1953 as an antiseptic cream . Since 1957 it has been used

for general disinfection purposes and also for the treatment of skin, eye, and throat infections in both humans and animals

MODE OF ACTION.

MODE OF ACTION.
  • Due to its cationic nature, CHX is capable of electrostatically binding to the negatively charged surfaces of bacteria, damaging the outer layers of the cell wall and rendering it permeable . Depending on its concentration, CHX can have both bacteriostatic and bactericidal effects.

ADVANTAGES



Notably, 2% CHX was very effective in eliminating a biofilm of E. faecalis.

In infected root canals, it reduces bacteria as effectively as Ca(OH)2 when applied for 1 week.

CHX is an effective antifungal agent especially against Candida albicans.

CHX has antibacterial substantivity in dentin for up to 12 weeks

Medication and/or irrigation with CHX may delay the contamination of

root-filled teeth by bacteria entering through the coronal restoration/tooth interface & will not increase leakage through the root-filled apical foramen

  • CHX can significantly improve the integrity of the hybrid layer and resindentin bond stability

  • The biocompatibility of CHX is acceptable

DISADVANTAGE.

DISADVANTAGE.  No tissue [organic or Inorganic] dissolving property.  Interacts with NaOCl .  The
  • No tissue [organic or Inorganic] dissolving property.

  • Interacts with NaOCl .

  • The effect of CHX on microbial biofilms is

significantly less than that of NaOCl

INTERACTION,.

INTERACTION,.  A suggested clinical protocol by Zehnder for treating the dentin before root canal filling

A suggested clinical protocol by Zehnder for treating the dentin

before root canal filling consists of irrigation with NaOCl to

dissolve the organic components, irrigation with EDTA to eliminate the smear layer, and irrigation with CHX to increase the antimicrobial spectrum of activity and impart substantivity.

Although such a combination of irrigants may enhance the overall antimicrobial effectiveness , the possible chemical interactions amongst the irrigants need to be considered. Some studies have reported the occurrence of a color change and precipitation when NaOCl and CHX are combined

  • The formation of a precipitate could be explained by the acid-base reaction that occurs when NaOCl and CHX are mixed together. CHX, a dicationic acid, has the ability to donate protons while NaOCl is alkaline and can accept protons from the dicationic acid.

  • This proton exchange results in the formation of a neutral and insoluble substance referred to as the “precipitate” called as para- chloroaniline (PCA).

 The formation of a precipitate could be explained by the acid-base reaction that occurs when
  • A recent study aimed to determine if the formation of para- chloroaniline (PCA) can be avoided by using an alternative irrigant following sodium hypochlorite but before chlorhexidine; however, none of the tested solutions used for intermittent irrigation prevented the formation of PCA. The investigators concluded that citric acid used as the intermediate irrigant resulted in the least amount of PCA formation in the canal system

DECALCIFYING SOLUTIONS

DECALCIFYING SOLUTIONS  Until recently, decalcifying solutions in endodontics were only comprised of chelators and acids,
  • Until recently, decalcifying solutions in endodontics were only comprised of chelators and acids, most commonly EDTA and citric acid. In the last few years, however, several combination products have appeared where their main functionthat is, their decalcifying effecthas been combined with other characteristics thought to be helpful for treatment.

  • The added characteristics are reduced surface tension and, perhaps more importantly, antibacterial activity.

  • The new combination products are based either on EDTA or citric acid.

  • Smear layer consit of both organic and inorganic composnents. Both NaOCl and a decalcifying agent are required for complete removalof the smear layer.

EDTA

INTRODUCTION

HISTORY

MODE OF ACTION

ADVANTAGES

DISADVANTAGES

INTERACTIONS

EDTA INTRODUCTION HISTORY MODE OF ACTION ADVANTAGES DISADVANTAGES INTERACTIONS

EDTA( ETHYLENE DIAMINE TETRAACITIC ACID)

EDTA( ETHYLENE DIAMINE TETRAACITIC ACID)  EDTA is often suggested as an irrigation solution because it
EDTA( ETHYLENE DIAMINE TETRAACITIC ACID)  EDTA is often suggested as an irrigation solution because it
  • EDTA is often suggested as an irrigation solution because it can chelate and remove the mineralized portion of smear layers.

  • This colorless, watersoluble solid is produced on a large scale for many applications. Its prominence as a chelating agent arises from its ability to “sequester” di- and tri-cationic metal ions such as Ca2+ and Fe3+. After being bound by EDTA, metal ions remain in solution but exhibit diminished reactivity.

  • It is available in concentrations of 17% as a root canal irrigant with a pH of 7.

HISTORY



The compound was first described in 1935 by Ferdinand Munz, who prepared the compound from ethylenediamine and chloroacetic acid.

Chelating agents were introduced into endodontics as an aid for the preparation of narrow and calcified root canals in 1957 by Nygaard-Ostby. • A liquid solution of ethylene-diamine-tetra-acetic acid (EDTA) was thought

to chemically soften the root canal dentine and dissolve the smear layer, as well as to increase dentine permeability

Today, EDTA is mainly synthesized from ethylenediamine (1,2- diaminoethane), formaldehyde (methanal), and sodium cyanide.

  • Chelating agents can be applied in liquid or pastetype form.

  • The origin of paste-type preparations dates back to 1961, when Stewart devised a combination of urea peroxide with glycerol. Later, based on the results of that first preliminary study and the successful introduction of EDTA to endodontic practice, urea peroxide and EDTA were combined in a water-soluble carbowax (polyethylene glycol) vehicle.

  • Similar pastetype chelators containing EDTA and peroxide have later been marketed by other manufacturers. However, none of these pastes should be used, as they are inefficient in preventing the formation of a smear layer.

  • Furthermore, instead of lowering physical stress on rotary instruments as advocated, carbowax-based lubricants, depending on instrument geometry, have either no effect or are even counterproductive

MODE OF ACTION

MODE OF ACTION  It kills microbes by chelating with metallic ions needed for growth of
  • It kills microbes by chelating with metallic ions needed for growth of bacteria.

  • The concentrations of 15-17% eliminates calcium from dentine leaving an organic matrix and removes the smear layer.

  • Application of EDTA in the root canal system is done for 1- 5 min to get the optimum effect. The use of EDTA at a concentration of 17% for ≥10 min has been lead to cause erosion of peritubular and intertubular dentine.

  • According to Saito et al. greater smear layer removal was found in the 1- min EDTA irrigation group than the 30-sec or 15-sec groups

  • The addition of a quaternary ammonium bromide (Cetavlon) increases the action of EDTA by decreasing its surface tension.

  • This combination is called as EDTAC, and it is effective in smear layer removal and increasing the diameter of opened dentin tubules.

  • EDTA performed significantly better than NaCl and NaOCl in smear layer removal and dentinal tubule opening when used with ultrasonic aggitation.

ADVANTAGES

ADVANTAGES

DISADVANTAGE

DISADVANTAGE  Alone cannot remove smear layer.  For root canal preparation, EDTA has limited value
  • Alone cannot remove smear layer.

  • For root canal preparation, EDTA has limited value as an irrigation fluid. It may open up a very narrow canal if given the time to soften the 50 micron m it is capable of decalcifying.

INTERACTIONS BETWEEN EDTA, NAOCL, AND CHX

INTERACTIONS BETWEEN EDTA, NAOCL, AND CHX  Grawehr concluded that ethylenediamine tetraacetic acid retained its calcium-complexing
INTERACTIONS BETWEEN EDTA, NAOCL, AND CHX  Grawehr concluded that ethylenediamine tetraacetic acid retained its calcium-complexing
  • Grawehr concluded that ethylenediamine tetraacetic acid retained its calcium-complexing ability when mixed with NaOCl.

  • However, EDTA caused NaOCl to lose its tissuedissolving capacity, and virtually no free chlorine was detected in the combinations. Clinically, this suggests that EDTA and NaOCl should be used separately. In an alternating irrigating regimen, copious amounts of NaOCl should be administered to wash out remnants of EDTA.

  • The combination of chlorhexidine and EDTA produces a white precipitate. Rasimick et al. determined if the precipitate involves the chemical degradation of chlorhexidine.

  • The precipitate was produced and re-dissolved in a known amount of dilute trifluoroacetic acid. Based on the results, chlorhexidine forms a salt with EDTA rather than undergoing a chemical reaction.

  • Scelza et al evaluated the inflammatory response of 17% EDTA, 17% EDTA-T, and 10% citric acid in bony defect created in rat jaws and they concluded that 10% citric acid showed less aggressive in inflammatory response.[86] The use of 25% citric acid was found to be ineffective in eradication of biofilms of E faecalis after 1, 5, and 10 min of exposure.

DIFFERENT FORMS OF EDTA

1.
1.

EDTAC and DTPAC are produced when 100 mL of EDTA (15%) and diethyl-triamine-penta acetic acid (DTPA) at pH 8 are added to

0.75g of the detergent Cetyl-tri-methyl ammonium bromide

(Cetrimide).(Pawlicka eXal 1981.1982).

2.

EDTA-T (Formula & Acao Parmacia. Sao Paulo, Brazil) consists of

17% EDTA + sodium lauryl ether sulfate (Tergentol) as a detergent

(Scelza et al 2000).

3.

EGTA (Sigma. St Louis. MO. USA) main component is ethylene glycol bis (β-amino-ethylether)-N.N.N’.N'-tetra acetic acid. It is reported to bind Ca ions more specifically than EDTA (calt & Serper 2000)

  • 1. CDTA (experimental solution) is a 1% solution of cyclohexane-], 2-diaminetetraacetic acid (Cruz-Filho 2011) Largal Ultra (Septodont, Paris, France) contains a 15% EDTA solution as a disodium salt.O.75'!{i Cetyl-tri-methyl ammonium bromide (Cetrhnide) and sodium hydroxide to adjust the pH value to 7.4.

  • 2. Salvizol (Ravens, Konstanz. Germany) is based on a 5% aminoquinaldinumdiacetate in propylcne glycol and has a pH of 6.6 (Kaufman ct at. 1978).

MALEIC ACID

MALEIC ACID  Maleic acid is a mild organic acid used as an acid conditioner in
  • Maleic acid is a mild organic acid used as an acid conditioner in adhesive dentistry.

  • Ballal et al. reported that final irrigation with 7% maleic acid for 1 min was more efficient than

17% EDTA in the removal of smear layer from the apical third of the root canal system

CITRIC ACID



Citric acid is a chelating agent that reacts with metals to form a

nonionic soluble chelate. Goldman et al. reported that the effects

on the removal of the smear layer obtained with citric acid were

similar to those by EDTA. Ando reported that citric acid is less

cytotoxically irritable to tissue than EDTA.

Also, Garrett et al. studied the effect of citric acid on diseased root

surfaces.

  • EDTA (ethylenediamine tetra-acetic acid), 10% citric acid, EDTA-T (EDTA plus 1.25% sodium lauryl ether sulfate), EGTA (ethylene glycol-bis-(b-amino-ethyl ether) N,N,N9,N9-tetra-acetic acid) and MTDA (mixture of a tetracycline isomer, a detergent, and an acid) are considered effective decalcifying agents used for endodontic treatment for smear layer removal.

  • Several studies have shown the biocompatibility of 10% citric acid,

17% EDTA, and EDTA-T, indicating that citric acid was the most

biocompatible solution of these.

  • Both 10% citric acid and EDTA-T provide a large number of open dentinal tubules after a 4-min irrigation, with no statistical difference between them. It has also been reported that irrigation with 10% citric acid for 3 min showed a similar pattern of Ca++ extraction compared to EDTA-T used for a much longer time interval (15 min).

  • Both 10% citric acid and EDTA-T provide a large number of open dentinal tubules after a 4-min irrigation, with no statistical difference between them. It has also been reported that irrigation with 10% citric acid for 3 min showed a similar pattern of Ca++ extraction compared to EDTA-T used for a much longer time interval (15 min).

NEWER IRRIGATING SOLUTION

1.

MTAD

  • 2. Tetraclean

  • 3. Q MIX

  • 4. HEBP

  • 5. Green tea and Triphala

  • 6. Silver diamine fluoride

Other irrigating solutions:

1. Hydrogen peroxide.

2. Iodine potassium iodide

  • 7. Electrochemically activated solutions

  • 8. Photon-activated disinfection

MTAD

MTAD  Torabinejad et al. developed a irrigant with combined chelating and antibacterial properties.  MTAD
  • Torabinejad et al. developed a irrigant with combined chelating and antibacterial properties.

  • MTAD (151) was the first irrigating solution capable of removing the smear layer and disinfecting the root canal system at the same time. MTAD is a mixture of 3% doxycycline hyclate, 4.25% citric acid, and 0.5% polysorbate (Tween) 80 detergent.

  • It has been commercialized as BioPure MTAD and is available as a two-part set, liquid in a syringe and powder in a bottle, which should be mixed before application.

  • MTAD has been recommended for use in clinical practice as a final rinse after completion of a conventional chemomechanical preparation

MODE OF ACTION.



MTAD is composed of three constituents that are expected to act synergistically against bacteria.

The bactericidal effect of MTAD was inferior to 1%-6% NaOCl against E faecalis biofilms.

The antibacterial activity of MTAD might also be inhibited by the buffering effect of dentin and the serum albumin present in the root canal.

MTAD has been reported to be effective in removing smear layer.

  • In the MTAD preparation, the citric acid may

serve to remove the smear layer, allowing

doxycycline to enter the dentinal tubules and exert an antibacterial effect.

  • The recently revised protocol for clinical use of MTAD advises an initial irrigation for 20 min with 1.3% NaOCl, followed by a 5-min final rinse with MTAD.

BOND STRENGTH

BOND STRENGTH  The use of MTAD as a final rinse with gutta- percha/AH Plus resulted
  • The use of MTAD as a final rinse with gutta- percha/AH Plus resulted in a significant reduction in bond strength (1.76±1.67 Mpa) when compared with EDTA.[81] A final rinse with MTAD might have a negative effect on the bonding ability of both resin-based and calcium hydroxidebased sealers due to the precipitate formation

PROTOCOL FOR USE

PROTOCOL FOR USE  The MTAD protocol was developed on the basis of a pilot project
  • The MTAD protocol was developed on the basis of a pilot project .

  • The results of this project showed that the consistent

disinfection of the infected root canals could occur after

chemomechanical preparation using 1.3% NaOCl as a root

canal irrigant and a 5-min exposure to MTAD as a final rinse.

TETRACLEAN



Tetraclean (Ogna Laboratori Farmaceutici, Muggio,

Italy) is another combination product similar to

MTAD.

The two irrigants differ in the concentration of

antibiotics (doxycycline 150 mg/5 mL for MTAD and 50 mg/5 mL for Tetraclean) and the kind of

detergent (Tween 80 for MTAD, polypropylene

glycol for Tetraclean).

  • Comparison of antimicrobial efficacy of 5.25% NaOCl, MTAD, and Tetraclean against E faecalis biofilm showed that only 5.25% NaOCl could consistently disgregate and remove the biofilm at every time interval.

  • However, treatment with Tetraclean caused a high degree of biofilm disgregation in every considered time interval (5, 30, and 60 min at 20°C) as compared with MTAD.

Q MIX

Q MIX  QMiX was introduced in 2011.  QMiX is one of the new combination

QMiX was introduced in 2011.

QMiX is one of the new combination products introduced for root canal irrigation .

Its manufacturer recommends that it be used at the

end of instrumentation after NaOCl irrigation.

QMiX contains EDTA, CHX, and a detergent and comes as a ready-to-use clear solution.

PROTOCOL

PROTOCOL  QMiX should be used as a final rinse. If sodium hypochlorite was used throughout
  • QMiX should be used as a final rinse. If sodium hypochlorite was used throughout the cleaning and shaping, saline should be used to rinse out the

  • NaOCl to prevent the formation of PCA, although no precipitate has been described when mixing QMiX and

PROTOCOL  QMiX should be used as a final rinse. If sodium hypochlorite was used throughout

NaOCl (see interaction between NaOCl and CHX).

SMEAR LAYER REMOVAL

SMEAR LAYER REMOVAL  Stojicic et al. investigated the effectiveness of smear layer removal by QMiX
  • Stojicic et al. investigated the effectiveness of smear layer removal by QMiX using scanning electron microscopy.

  • QMiX removed the smear layer equally as well as

EDTA (P = 0.18).

  • They concluded that the ability to remove the smear layer by QMiX wascomparable to that of EDTA.

  • Six percent NaOCl and QMiX were the most

effective disinfecting solutions against the young biofilm, whereas against the 3-week-old biofilm, 6% NaOCl was the most effective followed by QMiX.

HEBP ETIDRONIC ACID

HEBP ETIDRONIC ACID  HEBP (1-hydroxyethylidene-1,1-bisphosphonate; also called etidronic acid) is a chelator that can be
  • HEBP (1-hydroxyethylidene-1,1-bisphosphonate; also called etidronic acid) is a chelator that can be used in combination with sodium hypochlorite (NaOCl) without affecting its proteolytic or antimicrobial properties .

However, in contrast to EDTA, HEBP is a weak decalcifying agent and hence cannot be used as a mere final rinse. Therefore, it is recommended that HEBP be

mixed with NaOCl to be used as a more complete root

canal irrigant.

.

  • This combination is advantageous in that the solution keeps the sodium hypochloritehypochlorous acid equilibrium toward NaOCl, which has better tissue dissolution capacity than hypochlorous acid and is also less cytotoxic

  • Furthermore, an irrigating protocol using the NaOCl + HEBP combination has been shown as able to optimize the bonding by Resilon/Epiphany root fillings. It also reduces dentin debris accumulation in the root canal during rotary instrumentation

GREEN TEA AND TRIPHALA



Natural products, especially food extracts, have been used in medicine and have been shown to be good alternatives to synthetic chemicals.

The polyphenols of green tea (i.e. EGCg) were found to be cost

effective. They have inhibitory activity against the MMPs (-2, -

9) found in saliva and dentin.

Moreover, EGCg is also a broad spectrum antibacterial, and

studies have reported its effectiveness in inhibiting acid

production in dental plaque bacteria as well as antimicrobial activity against S. mutans. These findings open a new avenue for the prevention of caries and debonding.

Triphala (IMPCOPS Ltd., Chennai,

India) is an Indian ayurvedic herbal formulatio consisting of

dried and powdered fruits of three medicinal plants, Terminalia

bellerica, Terminalia chebula, and Emblica officinalis (GTPs;

Essence and Flavours, Mysore, India). Polyphenols found in

green tea , the traditional drink of Japan and China, is

prepared from the young shoots of tea plant Camellia

sinensis. Japanese green teas were found not have an

  • irritating potential and some results suggest that extracts of Japanese green tea may be useful as a medicament for treatment of infected root canals. Herbal alternatives showed promising antibacterial efficacy on 3- and 6-week biofilm . However, presently there is not enough evidence to support the use of antibacterial components of green tea or other herbs as endodontic disinfecting agents

SILVER DIAMINE FLUORIDE

SILVER DIAMINE FLUORIDE  A 3.8% w/v silver diamine fluoride (Ag[NH ] F) solution has been
  • A 3.8% w/v silver diamine fluoride (Ag[NH ] F) solution has been developed for intracanal irrigation.

  • This represents a 1:10 dilution of the original 38% Ag(NH ) F solution used for root canal infection.

  • The study on the antibacterial effect of 3.8% Ag(NH ) F against a E faecalis biofilm model concluded that Ag(NH ) F has potential for use as an antimicrobial root canal irrigant or interappointment medicament to reduce bacterial loads

  • . E faecalis was completely killed by Ag(NH ) F after exposure to these agents for 60 min. The silver deposits were found to occlude tubular orifices after removal of the smear layer.

TRICLOSAN AND GANTREZ

TRICLOSAN AND GANTREZ  Triclosan is a broad spectrum antimicrobial agent, active against gram-positive and gram-negative
  • Triclosan is a broad spectrum antimicrobial agent, active against gram-positive and gram-negative bacteria as well as some fungi and viruses.

  • Nudera et al. evaluated the minimum inhibitory concentrations (MIC) and minimum bactericidal concentrations (MBC) of triclosan and

  • triclosan with Gantrez against P intermedia, F nucleatum, A naeslundii, P gingivalis, and E faecalis. The MBC of triclosan ranged from 12-94 μg/ml. The MBC of triclosan with Gantrez ranged from <0.3-10.4 μg/ml. The addition of Gantrez enhanced the bactericidal activity of triclosan.

  • Both triclosan and triclosan with Gantrez demonstrated bactericidal activity against the five specific endodontic pathogens

MORINDA CITRIFOLIA (MCJ)

 Cheese fruit
Cheese fruit
  • has a broad range of therapeutic effects, including antibacterial, antiviral, antifungal, antitumor, antihelmintic, analgesic, hypotensive, anti- inflammatory, and immune-enhancing effects. MCJ contains the antibacterial compounds L- asperuloside and alizarin.

  • Murray et al. proved that, as an intracanal irrigant to remove the smearlayer, the efficacy of 6% MJC was similar to that of 6% NaOCl in conjunction with EDTA. The use of MCJ as an irrigant might be advantageous because it is a biocompatible antioxidant[113] and not likely to cause severe injuries to patients as might occur through NaOCl accidents.

HYDROGEN PEROXIDE

HYDROGEN PEROXIDE  Hydrogen peroxide has been used as an endodonticirrigant for a long period of
  • Hydrogen peroxide has been used as an endodonticirrigant for a long period of time, mainly in concentrations ranging between 3% and 5%. It is active against bacteria, viruses, and yeasts. Hydroxy-free radicals (•OH) destroy proteins and DNA. The tissuedissolving capacity of hydrogen peroxide is clearly lower than that of

sodium hypochlorite; also its

  • antibacterial effect is considered weak. When

used in combination with sodium hypochlorite, bubbling will occur as a result of evaporating oxygen. Although no longer recommended as a routine irrigant, its use is still not uncommon in some countries.

IODINE POTASSIUM IODIDE

IODINE POTASSIUM IODIDE  Iodine potassium iodide (IPI) has been proposed  and used as an
  • Iodine potassium iodide (IPI) has been proposed

  • and used as an endodontic disinfectant due to its

  • excellent antibacterial properties and low cytotoxicity

  • (169,170). It is used as a solution of 2% iodine in 4%

  • potassium iodide (171). Allergic reactions to iodine

  • and the staining of dentin are often mentioned as

  • potential risks with the use of IPI; however, reports of

  • such harmful side effects when IPI is used in

  • endodontics seem to be extremely rare

ELECTROCHEMICALLY ACTIVATED

SOLUTIONS
SOLUTIONS
ELECTROCHEMICALLY ACTIVATED SOLUTIONS  Electrochemically Activated (ECA) solutions are produced from tap water and low-concentrated salt
  • Electrochemically Activated (ECA) solutions are produced from tap water and low-concentrated salt solutions (Solovyeva and Dummer, 2000; Bakhir et al., 1986; Bakhir et al., 1989).

  • The ECA technology represents a new scientific paradigm developed by Russian scientists at the All-Russian Institute for Medical Engineering (Moscow, Russia, CIS). Principle of ECA is transferring liquids into a metastable state via an electrochemical unipolar (anode or cathode) action through the use of an element/reactor (―Flow-through Electrolytic Module‖ or FEM).

  • The FEM consists of an anode, a solid titanium cylinder with a special coating that fits coaxially inside the cathode, a hollow cylinder also made from titanium with another special coating. A ceramic membrane separates the electrodes.

  • The FEM is capable of producing types of solutions that have bactericidal and sporicidal activity; yet they are odourless, safe to human tissue and essentially noncorrosive for most metal surfaces (Solovyeva and Dummer, 2000).

  • Electrochemical treatment in the anode and cathode chambers results in the synthesis of two types of solutions: that produced in the anode chamber is termed an Anolyte, and that produced in the cathode chamber is Catholyte. Anolyte solutions containing a mixture of oxidizing substances demonstrate pronounced microbiocidal effectiveness against bacteria, viruses, fungi, and protozoa

  • Anolyte solution has been termed Superoxidized Water or Oxidative Potential.

  • Depending on the type ECA device that incorporated the FEM elements the pH of anolyte varies; it may be acidic (anolyte), neutral (anolyte neutral), or alkaline (anolyte neutral cathodic); acidic anolyte was used initially but in recent years the neutral and alkaline solutions have been recommended for clinical application

  • . Under clean conditions, freshly generated

superoxidized solution was found to be highly active against all these microorganisms giving a 99.999% or greater reduction in two minutes or

less.

  • That allowed investigators to treat it as a potent microbiocidal agent (Selkon et al., 1999; Shetty et al., 1999). It is nontoxic when being in contact with vital biological tissues .

  • Clinical applications of anolyte and catholyte were reported to be effective (Legchilo et al., 1996).

  • ECA solutions demonstrated more pronounced clinical effect and were associated with fewer incidences of allergic reactions compared to other antibacterial irrigants tested (Legchilo et al.,

1996).

  • Cleaning efficiency and safety for surfaces of dental instruments and equipment has been demonstrated in a number of studies. ECA is showing promising results due to ease of removal of debris and smear layer, nontoxic and efficient in apical one third of canal. It has a potential to be an efficient root canal irrigant.

PHOTON-ACTIVATED DISINFECTION

PHOTON-ACTIVATED DISINFECTION  Oscar Raab introduced the photo-activated therapy for the inactivation of microorganisms in the
  • Oscar Raab introduced the photo-activated therapy for the inactivation of microorganisms in the endodontic management.

  • PAD is the placement of a dye (toluidine blue or methylene blue) into the root canals which is then activated by the laser radiation emitted from a low power (100 mW) laser device, causing interference with the microbial cell walls and bacterial death.

  • After normal irrigation, the canals are washed with sterile water, and they are dried by sterilized paper points before the application of the PAD solution into the canals.

  • The photosensitizer molecules will attach to the membrane of the microorganisms and the irradiation with a precise wavelength coordinated to the absorption of the photosensitizer will form singlet oxygen which causes cell wall rupture and death of the microbes. The benefit of PAD is that the dye is only poisonous to bacteria, and there are no side effects to adjacent tissues.

OZONE TOP

OZONE TOP  It occurs in the environment either in gaseous form or as ozonated water.
  • It occurs in the environment either in gaseous form or as ozonated water. [32] It is an antiseptic, powerful oxidant, and antibacterial agent.

  • It is a strong oxidizer of cell walls and the cytoplasmic membranes of microorganisms, making it a bactericidal, antiviral, and antifungal agen

VITAL PULP

 Philippe Sleiman
Philippe Sleiman
  • 1)after access opening first irrgation with sodium hypochlorite.(concentration, temp, time). This "elevator effect" will evacuate the organic debris outside the access cavity, disorganize the coronal pulp tissue and help to better detect the canal orifices.

  • second application and its activation is obtained by using a K file (08-10). This will disorganize the pulpal tissue in both the cervical and middle thirds of the endodontic system. This step has to be preceded by an abundant irrigation with distilled water in order to eliminate the first mixture present in the access cavity.

  • Once the preparation of the canal has begun, Smear Clear (Sybron Endo,Orange, CA) (17 percent EDTA cetrimide, and surfactants) must be used. The EDTA is an organic acid which eliminates the mineral part of pulp tissue, the surface tension inhibitor will allow a better contact with the dentin for a higher efficiency of the product.

  • It is advised to alternate the use of EDTA from the beginning of the preparation in order to eliminate the mineral layer before its thickening and condensing it inside the canal systems which will close the entrances of lateral and accessory canals and dentinal tubules.

  • Each time a rotary file is working inside the canal, irrigating solution must be present. Ultrasonic activation of the irrigating solution, using a small diameter file, is advised for a more efficient chemical preparation.

  • The early use of EDTA facilitates the flow of the different irrigants in the lateral canals permitting a chemical preparation of all the endodontic system. Chlorehexidine can be used for a total elimination of the bacteria inside the canal.

  • Distilled water is used between each irrigating solution in order to prevent an acid/ base reaction, between sodium hypochlorite and EDTA, for a more efficient action of the chemicals on the tissues.

  • A copious neutralization of all the chemical agents must be done by the end of the preparation and before the fitting of the gutta percha cones so that the master cone does not push any of the chemicals outside the canal that might cause an inflammation of the surrounding tissues.

NECROTIC TEETH

NECROTIC TEETH  The main difference between vital teeth and necrotic ones is the absence, not
  • The main difference between vital teeth and necrotic ones is the absence, not in total, of the pulpal parenchyme and the abundance of bacteria present in the latter. For this reason, the irrigation sequence will be different. Irrigation will be initiated with either sodium hypochlorite (5.25%, 60%C) for its bacterial effect or with chlorohexidine (0.2%) (10 minutes)for the elimination of various bacterial types present in the root canals and dentinal tubuli. Followed by irrigation with normal saline to neutralize the irrigant.

  • The irrigation protocol changes if there is pus discharge actively present. Once there is no pus discharge present in the canal the irrgation protocol can be followed like the previous way.

  • The EDTA, by eliminating the smear layer and opening the dentinal tubuli will permit an easy flow of NaOCl or chlorhexidine for a better disinfection of the endodontic system. In both clinical situations (vital and necrotic teeth) it is necessary2,11,13 to end our sequence by using distilled water in order to eliminate the chemical agents or to neutralize their effects. This will inhibit:

Their flow towards the periodontal tissues - The alteration of the filling material

- The formation of a precipitating layer due to the crystallization of

sodium hypochlorite after drying the canal walls.

PRESENCE OF RESORPTIONS

PRESENCE OF RESORPTIONS  When we suspect an internal resorption, the irrigation sequence is the same
PRESENCE OF RESORPTIONS  When we suspect an internal resorption, the irrigation sequence is the same
  • When we suspect an internal resorption, the irrigation sequence is the same that was described for vital teeth. But this sequence will be followed by the use of citric acid 50 percent (10 minutes) in order to eliminate the granulation tissue and to obtain smooth dentinal walls. This will ameliorate the adaptation of the filling material. The citric acid is eliminated by NaOCl and distilled water.

  • The same sequence is adopted for external apical resorption but with an activation of the patency

CONCLUSION



Irrigation has a key role in successful endodontic treatment.

The main goal of root canal treatment is to completely eliminate the different components of pulpal tissue, bacteria, and biofilm and produce a hermetic seal to prevent infection or reinfection and promote healing of the surrounding tissues.

The extratime we gain by using rotary NiTi instruments should be used for abundant irrigation to achieve better cleaning of the root

canal system, thereby contributing to improved success of the

treatment.

  • The most commonly used irrigating solution is sodium hypochlorite. While sodium hypochlorite has many desirable qualities and properties, by itself it is not sufficient to totally clean the root canal system oforganic and inorganic debris and biofilm.

  • For optimal irrigation, a combination of different irrigating solutions must be used. The dentist should be aware of the interactions between the various chemicals found in irrigants as they may weaken each others’ activity and result in the development of products that ar harmful to the host. Developing a rational irrigation sequence so that the chemicals are administered ina proper manner to release their full potential is imperative for successful endodontic treatment.