IRRIGATION IN ROOT CANAL

TREATMENT
 CONTENTS
• Introduction
• Historical Perspective
• Goals Of Irrigation
• Ideal Properties Of An Irrigating Solution
• Functions Of Irrigants
• Factors Modifying The Action Of Irrigants
 CONTENTS
• Challenges Of Irrigation
• Various Types Of Irrigating Solutions
• Properties And Actions Of Individual Irrigant
• Irrigation Regimen/Protocol
• Mishaps Of Irrigating Solutions
• Methods Of Irrigation
• Conclusion
• References
 INTRODUCTION
• During the past 20-25 years, endodontics has begun to appreciate critically the
important role of irrigation in successful endodontic treatment.

• The use of irrigating solutions is a critical part of the cleaning process of a root
canal space and is the synergistic counterpart to shaping.

• Irrigation physically enhances bacterial removal from the system and facilitates
the dissolution of organic and inorganic tissue.

• When this bioburden within the root canal is turned into a fluid mass and
eliminated, the progress of cleaning the space and maintaining uninterrupted
instrument working length is greatly improved.
 INTRODUCTION
• Over the years, research and clinical practices have concentrated on
instrumentation, irrigation and medication of root canal system followed by
obturation & placement of coronal seal.

• But every root canal system has spaces that cannot be cleaned mechanically.
The only way one can clean the webs, fins and anastomoses is through the
effective use of an irrigating solution.

• Thus its truly said, ‘INSTRUMENTS SHAPE, IRRIGANTS CLEAN.’

(GROSSMAN 12TH EDITION)

ACCORDING TO COHEN,

Irrigation is defined as to wash out a body cavity or wound with water or a

medicated fluid.

OBJECTIVES:

1. MECHANICAL

2. BIOLOGICAL

3. CHEMICAL
HISTORICAL PERSPECTIVE
• World War I- NaOCl was first introduced by chemist Henry Drysdale Dakin for
treating infected wounds. Also known as Dakin’s solution. (Original conc. 0.5%)
• 1916- NaOCl was first introduced into endodontics by Coolidge.
• 1936- Walker and Grossman advocated the irrigation of root canals with a
double strength chlorinated soda solution. Thus NaOCl was introduced as a root
canal irrigant.
• 1961- Stewart compared antibacterial property of 10% urea peroxide in
anhydrous peroxide with an aqueous 3% solution of H2O2.
• 1961- Stewart & others also proposed anhydrous glycerol base Glyoxide as an
irrigating agent.
 HISTORICAL PERSPECTIVE
• 1960’s - 15% solution of EDTA at a neutral pH had been recommended by
Nygaard-Ostby for cleaning and widening canals.
• 1963- Nygaard and Ostby introduced EDTAC – EDTA with centrimide.
• 1970’s- Davis G.E. studied the broad antibacterial spectrum of Chlorhexidine.
They concluded that it is a potent antibacterial agent.
• The use of ultrasonics in endodontics was first suggested in 1957 (Richman
1957). The concept was revised in 1971 (Nossek 1971) and suitable equipment
became available to the clinician in 1982
• 2000- MTAD irrigant was introduced by Torabinejad et al at the Loma Linda
Dental School.
 GOALS OF IRRIGATION
• Lavage of Debris: Debridement is accomplished with instrumentation.
This alone is not able to remove all the tissue remnants in the pulp
chamber and canals. One must therefore, rely on lavage and and some
means of chemical debridement of remaining tissue.

• Tissue Dissolution: Instrumentation alone is not able to remove all pulp

tissue from canal, so remaining vital, necrotic or chemically fixed tissue
should be removed by irrigation.
 GOALS OF
IRRIGATION
• Antimicrobial Action: Bacteria are present in canal. Instruments may
force such bacteria and debris beyond apical foramen, resulting in
periapical inflammation and infection. Irrigant, having antibacterial
property to eliminate bacteria should be used to sterilize canal.

• Lubrication: To facilitate instrumentation in canal and for ease of

debris removal canal should be lubricated by irrigants. Files and
reamers are much less likely to break when canal walls are lubricated
by irrigants.
 GOALS OF
IRRIGATION
• Bleaching: Irrigant should also have a bleaching action to lighten teeth
discolouration by trauma or extensive silver amalgam restorations and
decrease the chance of postoperative darkening.

• To Remove Smear Layer: A smear layer is an amorphous, relatively

smooth layer of microcrystalline debris whose featureless layer cannot
be seen by naked eye. Irrigants should remove smear layer and
facilitate better apical seal.
 IDEAL PROPERTIES
• Broad spectrum antimicrobial properties.
• Aid in debridement of the root canal system.
• Ability to dissolve necrotic tissue or debris.
• Low toxicity level.
• Good lubricant.
• Ability to sterilise the canal.
• Prevent/remove smear layer.
• Inactivate bacterial endotoxins.
 IDEAL PROPERTIES
• Be an effective germicide and fungicide
• Be non-irritating to the periapical tissues.
• Remain stable in the solution
• Be active in presence of blood, serum, and protein
derivatives of tissue.
• Not induce cell-mediated response
• Low surface tension to flow into inaccessible areas.
• Not interfere with repair of periapical tissues
• Not stain tooth structure
 IDEAL PROPERTIES

•Be able to completely remove the smear layer, and be able to

disinfect the underlying dentin and its tubules.
•Have no adverse effects on the physical properties of exposed
dentin
•Have no adverse effects on the sealing ability of filling
materials .
•Have a convinient application.
•Be relatively inexpensive.
(COHEN, PATHWAYS OF
PULP,11TH EDITION)
 FUNCTIONS
• Perform physiologic and biologic functions- remove
dentinal shavings by irrigation.
• Increase the efficiency of instruments.
• Dissolve necrotic tissue.
• Remove debris from lateral & accessory canals.
• Germicidal and antibacterial properties.
• Bleaching action.
• Opening of dentinal tubules by removing smear layer.
• Disinfection and cleaning of areas inaccessible to
endodontic instruments.
 FACTORS MODIFYING THE
ACTION OF IRRIGANTS
• Volume of the irrigant used
• Concentration of the irrigant
• Frequency of irrigation
• Temperature of the irrigant
• Length & time of intracanal contact
• Gauge of the irrigating needle
• Depth of penetration
• Diameter of the prepared canals
• Age of the irrigating solution
• Irrigation pressure
• Type and orientation of the bevel of the needle
Challenges of
irrigation
 SMEAR LAYER
• The smear layer is an amorphous, relatively smooth
layer of microcrystalline debris whose featureless
surface cannot be seen with the naked eye.
• The presence of smear layer was first reported by
Eick et al. (1970)
• McComb & Smith (1975) first described the smear
layer on the surface of instrumented root canals.
• Canal surface after shaping with mechanical
instruments is characterised by an irregularly Cross section of root dentin covered by
distributed layer of soft & hard tissue debris that is the smear layer created by
smeared onto the dentin surface. It contains instrumentation.
dentinal debris, remnants of odontoblastic process,
pulp tissue & bacteria.
• This 1-5 um thin superficial structure consists of 2
layers- a loose superficial layer & an attached
layer that also extends into the dentinal tubuli.
 SMEAR LAYER
• The smear layer is primarily calcific & it requires the action of mild acids & chelators
for its removal.

• Baumgartner & Mader demonstrated that all canal walls that are planed with cutting
instruments develop a smear layer which block the tubule openings.
(J Endod 13:147,1987)

• Canal walls not touched by files did not develop a smear layer, therefore needed only
NaOCl to be cleaned.

• Removal of smear layer has been a matter of debate for more than 50 years now.

• Orstavik,Haapasalo reported that presence of smear layer delays but doesnt eliminate
disinfection. (Endod Dent Traumatol 1990;6:142)
 SMEAR LAYER
• Drake DR, Wiemann AH reported that a smear layer might act as a beneficial barrier
preventing micro organisms from entering tubules when root canal is contaminated between
appointments. It plugs the tubules, microbes & tissues. This plugging may help prevent
bacterial egress from tubules after treatment. Their microbiological analyses showed that
early removal of smear layer may lead to higher bacterial counts. ( J Endod
1994;20:2-78)

• Williams & Goldman have shown that smear layer slows bacterial movement but doesnt
prevent eventual egress. (J Endod 1985;11:385.)
• Kennedy, Wades in their study have shown that teeth obturated with gutta percha are more
completely sealed when smear layer is removed. J Endod 1986;12:21

• The presence of smear layer may increase microleakage after obturation as shown by Sen
B,Wesselink. ( Int Endod J 1995;28:141)

• Also the smear layer while acting as a barrier might block irrigating solutions from entering
the dentinal tubules thus hampering effective disinfection as reported by Torabinejad M,
 SMEAR LAYER
• According to D.R. Violich & N.P.Chandler (Int End J 2010;43:2-15), the factors in
favour of smear layer removal are:

• It has an unpredictable thickness & volume since a great portion of it consists of water.
• It contains bacteria, their by-products & necrotic tissue. Bacteria may survive & multiply
& can proliferate into the dentinal tubules which may serve as a reservoir of microbial
irritants.
• It may act as a substrate for bacteria, allowing their deeper penetration in the tubules.
• It may limit the optimum penetration of disinfectants in the tubules. Bacteria maybe
found deep within the tubules & smear layer may block the effects of disinfectants.
• It can act as a barrier between filling materials & canal wall & compromise the
formation of a satisfactory seal thus causing microleakage.

• Thus it appears prudent to create the cleanest dentinal surface possible by using
chelating agents.
 Dentin Erosion
• One of the goals of endodontic treatment is to protect the tooth structure so
that the physical procedures & chemical treatments do not cause weakening of
the dentin/root.

• Erosion of dentin hasnt been studied much; but there is a general consensus
that dentin erosion may be harmful & should be avoided.

• Marending M, Luder HU in their study have shown that long term exposure
to high concentrations of NaOCl can lead to considerable reduction in the
flexural strength & elastic modulus of dentin. Int Endod J 2007;40:786-93
 Dentin Erosion
• Even short term irrigation with NaOCl after EDTA or Citric acid at the end of
chemomechanical preparation causes strong erosion of the canal wall surface dentin as
reported by Niu W, Yoshioko T. Int Endod J 2002;35:934-9.

• Markus Haapasalo, Ya Shen et al have suggested to avoid the use of NaOCl after
demineralising agents. Instead CHX irrigation has been recommended for additional
disinfection at the end of treatment. DCNA 54(2010) 291-312.

Considerable erosion of canal-wall dentin

occurs when hypochlorite is used after
EDTA or CA.
CLEANING OF UNINSTRUMENTED
PARTS OF ROOT CANAL
• Cleaning & removing of necrotic tissue,
debris & biofilms from untouched areas
rely completely on chemical means.
Sufficient use of NaOCl is the key factor.

• The untouched areas especially

anastomoses between canals are packed
with debris during instrumentation.

• Although at present it is not known how

these debris can best be removed (if at
all), it is likely that physical agitation (eg.
Ultrasound) & the use of demineralising
agents are needed in addition to NaOCl.
An anastomosis between 2 joining canals has been packed
with debris during rotary
instrumentation.
 Biofilm
• Biofilm can be removed or eliminated through the following methods:
• mechanical removal by instruments (effective only in some areas of the
root canal);
• dissolution by hypochlorite; and
• detachment by ultrasonic energy.

Bacteria growing on dentin surface;

early stages of biofilm formation.
 Biofilm
• Other chemical means, such as chlorhexidine, can kill biofilm
bacteria if allowed a long enough contact time. However, as
they lack tissue-dissolving ability, the dead microbial biomass
stays in the canal if not removed mechanically or dissolved by
hypochlorite.

• Any remaining organic matter, microbes, or vital or necrotic

tissue jeopardizes the integrity of the seal of the root filling.
Therefore the goal of the treatment is not only to kill the
microbes in the root canal but also to remove them as
completely as possible.
TYPES OF IRRIGATING
SOLUTIONS
• Antibacterial- Sodium hypochlorite, Hydrogen peroxide,
Chlorhexidene, Iodine potassium iodide

• Chelating agents- EDTA, Citric acid, Tannic acid, Phosphoric acid

• Antibiotic containing- MTAD, Tetraclean

• Others- Urea, Urea peroxide, Salvizol, Physiologic saline

• Newer developments- Ruddle’s Solution, Electrochemically activated water,

Oxidative potential water, Ozonated water,
Photoactivated disinfection, Lasers

• Herbal Alternatives- Morinda citrifolia, Propolis, Neem, Tea tree oil,

Triphala & Green tea polyphenols
 SODIUM
HYPOCHLORITE
 NaOCl
• It is one of the most popular irrigating solutions. It is used in different
concentrations like 0.5%, 1%, 2.6% and 5.25%. It can be easily prepared by
dissolving sodium carbonate and chlorinated lime.

PROPERTIES-
• NaOCl is green to yellow in colour.
• NaOCl acts as organic & fat solvent degrading fatty acids, transforming them
into fatty acid salts and glycerol (alcohol) that reduces the surface tension of the
remaining solution.
• NaOCl is a strong base, pH >11.
• At 1% concentration NaOCl presents following properties-
• Surface tension - 75 dynes/cm,
• Conductivity - 65.5%
• Density - 1.04 g/cm3
 MOA of NaOCl
• Pecora et al . reported that NaOCl exhibits a dynamic balance as shown by
reaction:
NaOCl + H2O<< NaOH + HOCl << Na+ + OH- + H+ + OCl-

a) Saponification reaction:
NaOCl acts as an organic & fat solvent degrading fatty acids, transforming them into
fatty acid salts (soap) & glycerol (alcohol) that reduces the surface tension of the
remaining solution.

Reaction 1
 MOA of NaOCl
b) Neutralisation reaction:
NaOCl neutralises amino acids forming water & salt.

Reaction 2

c) Chloramination reaction:
With the exit of hydroxyl ions, there is a reduction in pH. Hypochlorous acid, a
substance present in sodium hypochlorite solution, when in contact with organic
tissues acts as a solvent, releases chlorine that, combined with the protein amino
group, forms chloramines.
Hypochlorus acid (HOCl) and Hypochlorite ions (OCl) lead to amino acid
degradation and hydrolysis.
 MOA of NaOCl
The chloramination reaction between chlorine and amino group (NH) forms chloramine
that interferes in cell metabolism. Chlorine presents antimicrobial action inhibiting
bacterial enzymes leading to an irreversible oxidation of sulphydryl group of essential
bacterial enzymes.

Reaction 3
A possible sequence of events during chloramination would be-
• Disruption of cell wall barrier by the reactions of chlorine with the target sites on the
cell surface
• Release of vital cellular constituents from the cell.
• Termination of membrane-associated functions.
• Termination of cellular functions within the cell.
• Antimicrobial effectiveness of NaOCl is based in its high pH (hydroxyl
ions action).
• The high pH of NaOCl interferes in the cytoplasmic membrane integrity
with an irreversible enzymatic inhibition, biosynthesis alteration in cellular
metabolism and phospholipid degradation observed in lipidic per oxidation.

(COHEN, PATHWAYS OF PULP,11TH EDITION)

The dissolution of the pulp tissue by NaOCl (0.5, 1.0, 2.5, 5.0%) was studied under different
conditions and concluded that:

• The velocity of the dissolution of the pulp fragments was directly proportional to the
concentration of NaOCl solution and was greater without surfactant.

• With the elevation of the temperature of the NaOCl solution, dissolution of pulp tissue
was very rapid.

• The percent variation of the NaOCl solution, after dissolution, was inversely proportional
to the initial concentration of the solution. The greater the initial concentration of the
NaOCl solutions, the smaller was the reduction of its pH.
CONCENTRATION OF NaOCl???

• Determining the right concentration of NaOCl for endodontic usage has been a
controversial subject for many years. Various concentrations from 0.5% to 5.25% have
been tried out.

• It has been suggested that higher the concentration, the better the antibacterial and
tissue dissolution properties. It is also true that the higher the concentration the more the
chances of tissue reaction.

• Harrison & Hand showed that dilution of 5.25% NaOCl resulted in a significant decrease
in its ability to dissolve necrotic tissue. A 2.5% concentration was approximately a third as
effective as the 5.25% concentration, and 1% & 0.5% concentration were completely
ineffective as necrotic tissue solvents. OOOOE 1971; 32:90-9

• Baker and others reported that a 1% concentration of NaOCl, with or without 3% hydrogen
peroxide was no more effective than normal saline solution as an aid in debriding canals
during chemomechanical preparation. JDR 1979 May-June;48:35-51
• Spangberg recommended diluting NaOCl to reduce the potential for periapical
tissue irritation. As a result of a cytotoxicity study, he concluded that 5.25% NaOCl
was too toxic for clinical use as an endodontic irrigant. OOOOE 1973;36:856-71

• Contradicting earlier findings, Zehnder reported that buffering had little effect on
tissue dissolution. NaOCl was equally effective on necrotic & fresh tissues. No
differences were recorded in the antibacterial properties at different concentrations.
OOOOE 2002;94:756-62
• The most desirable concentration would be one that
combines maximum antibacterial effect with minimum
toxicity. Effectiveness of low concentration of NaOCl may be
improved by using large volumes of irrigant, frequent
exchange of irrigant, or by the presence of replenished
irrigant in the canals for the longer periods of time.
 Antibacterial effect of NaOCl

• Gomes et al. studied effect of various concentrations of NaOCl against

E.faecalis & reported that E.faecalis was killed within 30 seconds by
5.25% solution while 10 & 30 mins was required to kill all bacteria by
2.5% & 0.5% solution. Int End J 2001;34:424-8

• Haapasalo et al. demonstrated rapid killing of E. Faecalis by 0.3%

solution. Int End J 2000;33:126-31

• Portenier et al. showed rapid killing of E.faecalis strains in logarithmic &

stationary growth phase by even 0.001% NaOCl. J Endod 2005;31:380-6
 Antibacterial effect of NaOCl

• Waltimo et al. showed that C.albicans was killed in 30 seconds by both 5%

& 0.5% NaOCl solutions. Int End J 1999; 32:421-9

• Vianna et al. showed that 0.5% NaOCl required 30 mins to kill C.albicans
whereas 5.25% solution killed all yeast cells in 15 seconds. OOOOE
2004;97:79-84

• Also gram negative organisms like P.gingivalis, P.endodontalis & Pr.

Intermedia often isolated from apical periodontitis showed high
susceptibility to NaOCl & all species were killed in 15 seconds with 0.5%
to 5% NaOCL. OOOOE 2004;97:79-84
 EFFCT OF TEMPERATURE ON
BACTERICIDAL ACTION OF NaOCl

• Cunningham et al demonstrated that in-vitro bactericidal action of NaOCl

solution was comparable at room temperature(22ºc) and the body
temperature(37ºC), sterility was achieved in significantly less time at 37ºC. In
addition this study concluded that a 2.6% solution at 37ºC was as effective for
tissue dissolution as a 5.2% solution at either 37ºC or 22ºC.

• Berutti et al compared the effect of 5% NaOCl solution at 21ºC and 50ºC. The
finding demonstrated that in middle third of the root canal space, where NaOCl
had been used at 50ºC,the smear layer was thinner and made of finer, less
organized particles than where it had been used at 21ºC. In the apical third, the
smear layer was of almost the same thickness in two groups of specimen, although
the particles were finer where the NaOCl had been used at 50ºC.
• Ellerbruch & Murphy demonstrated that even the vapours of
NaOCl exert a strong antimicrobial activity that is primarily
bactericidal. It was hypothesized that warming 2.6% NaOCl to
body temperature should enhance its bactericidal action, as
well as its tissue dissolving properties.
• Irrigation syringe warmers are now commercially available. Thermo
acceleration of an irrigation solution would logically speed up the
dissolution of organic debris.

• Alternatively, solution can be micro waved before the procedure and coffee
cup warmers can be used to hold the solution container during procedure.

• One must be careful not to overheat the solution because this can cause
breakdown of NaOCl constituents and ruin the solution.
EFFECT OF TISSUE TYPE ON THE
SOLVENT ACTION OF NaOCl

• The question of whether NaOCl is equally effective in dissolving vital, nonvital or fixed
tissue is important since all three types of tissue may be encountered in the root canal
system.

• Pulp tissue consists of 15% of collagen, containing approximately 13% hydroxyapatite.

• Necrotic pulp canals most likely contain material resulting from necrotizing agents and
body’s response to them.

• Dilution to 2.5% does not affect NaOCl as it is a powerful solvent whose action starts
immediately and continues for atleast an hour.
• Rosenfield et al demonstrated that 5.25% NaOCl dissolves vital tissue. In addition, as a
necrotic tissue solvent, 5.25% NaOCl was found to be significantly better than 2.6%, 1%,
or 0.5% NaOCl

• Grey concluded that the vascularity resisted the action of NaOCl on vital pulp.

• However Rosenfield showed that there was a nonspecific non coagulating effect on vital,
young healthy human pulp tissue and the solvent effect was merely restricted by the size of
the lumen and not by the viability or the vascularity of tissue.

• Hand showed that 5.25% NaOCl solution was superior to the diluted strengths in dissolved
necrotic connective tissue.

• Thus, by increasing the concentration, contact time & volume of NaOCl solution, there can
be increased amount of dissolution in necrotic tissue.
HYDROGEN PEROXIDE
• H2O2 is a clear & colourless liquid. Concentrations from 1-30% have been
used in endodontics.

• H2O2 produces hydroxyl-free radicals (HO-) that attack microbial components

such as proteins & DNA.

• It has antimicrobial properties against various micro organisms including

viruses, bacteria, yeasts & even bacterial spores. More effective against Gram
positive than Gram negative organisms.
H2O2 has two modes of action:
1) Bubbling out of solution in contact with tissue and certain chemicals. Physically foams
debris from the canal.

2) Liberation of oxygen destroys strictly anaerobic microorganisms. H2O2 liberates nascent

oxygen, which oxidizes necrotic matter and bacteria. Catalase present in tissues speeds
decomposition resulting in foaming, which helps in loosening and removing debris.

• Hydrogen peroxide is less damaging to periapical tissues.

• Also it is non problematic from an environmental point of view since it degrades into water
& oxygen.
NaOCl AND H2O2 COMBINATION

• Their interaction in canal produces a transient, but energetic effervescence,

that mechanically forces debris and microorganisms out of canal. At the
same time, oxygen liberated in an active state assists in destroying
anaerobic microorganisms.

Advantages of combinations:
1) Effervescent reaction, in which it mechanically bubbles and pushes debris
out of canal through least resistant orifice into chamber.
2) Solvent action of NaOCl on organic debris of pulp tissue.
3) Disinfecting action of both solutions.
4) Bleaching action of both solutions.
Disadvantages of combination :
1) Reduction in tissue dissolving property of NaOCl.
2) According to Harrison (1978), using equal amount of 3% H2O2 and 5.25% NaOCl inhibits
antibacterial action of irrigants.
3) H2O2 generates O2 with a catalase reaction, that might cause periapical discomfort. It
should not be the last irrigant, since nascent O2 may remain after cavity preparation closure
and cause build up of pressure.

• Always use NaOCl last because hydrogen peroxide can react with pulp debris and pulp to
form gas. Any gas trapped within the tooth will cause continuous pain.
 CONTENTS
• Introduction
• Historical Perspective
• Goals Of Irrigation
• Ideal Properties Of An Irrigating Solution
• Functions Of Irrigants
• Factors Modifying The Action Of Irrigants
 CONTENTS
• Challenges Of Irrigation
• Various Types Of Irrigating Solutions
• Properties And Actions Of Individual Irrigant
• Irrigation Regimen/Protocol
• Mishaps Of Irrigating Solutions
• Methods Of Irrigation
• Conclusion
• References
CHLORHEXIDENE
 CHLORHEXIDENE
• CHX in the form of a salt (i.e. gluconate, acetate or hypo chlorate) has been used
since 1950’s at different concentration as an oral antiseptic in the form of a
mouthwash, subgingival irrigant, gel toothpaste and chewing gums.

PROPERTIES-
• CHX is a cationic bis biguanide, with optimum antimicrobial action ranging from
pH 5.5 to 7.0.

• It is active against a wide range of microorganisms such as Gram positive, Gram

negative bacteria, lipophilic virus, yeasts and dermatophytes. Mycobacteria &
bacterial spores however are resistant to CHX.

• It is bacteriostatic at lower concentration and bactericidal at higher concentration.

• CHX is a biocompatible substance. Its relatively lack of toxicity, makes it a

substance of choice as an Endodontic irrigant in patient allergic to NaOCl.
 MOA Of CHX
2- Fold (Hennessey 1973):
a) High concentrations: Bactericidal
• CHX penetrates the cell wall & causes precipitation or coagulation of
cytoplasm probably caused by cross-linking.

b) Low concentrations: Bacteriostatic

• Positively charged molecules of CHX bind readily to the negatively
charged cell wall, mainly to phosphate groups in liposaccharide & carboxyl
groups in proteins.
• It therefore interferes with membrane transport initiating a leakage of low
molecular weight intracellular components.
• Bacteriostatic effects of CHX are considered to be more important because
the bound CHX molecule is slowly released for up to 24 hours.

• CHX binds electrostatically to negatively charged sites on bacteria. By

attaching to the bacterial cytoplasmic membrane, CHX causes the osmotic
balance to be lost, resulting in leakage in intracellular material.

• It also binds to hydroxyapatite and soft tissues, changing their electrical

field to compete with bacterial binding.

• CHX can displace the calcium that are bound to sulfated glycoprotein of
dental plaque. This explains the property of substantivity of CHX.
• 2% CHX concentration instilled greater & longer lasting antimicrobial
activity than the 0.12% CHX concentration.

• Vianna et al found that CHX in a gel form required a longer time to kill
E.faecalis than the corresponding solution in liquid form.
(OOOOE;2004;97:79-84)

• Its broad spectrum action against gram positive & gram negative bacteria
and its ability to adsorb to dental tissues and mucous membrane with
prolonged gradual release at therapeutic level (substantivity), as well as its
biocompatibility, are some of the properties that justify its clinical use as an
irrigating solution in the root canal system.
• Synergism between CHX & H2O2 was
reported by Steinberg et al. They showed
complete eradication of E.faecalis in
concentrations clearly lower than required
when the compounds were used alone.

• CHX a membrane active agent makes the

bacterial membranes more permeable to
H2O2 that can more easily penetrate the cells
& cause damage to intracellular organelles.
J Oral Rehabil 1999;26:151-6

• However CHX & NaOCl are not soluble in

each other & a brownish-orange precipitate
is formed. This precipitate prevents clinical
use of the mixture.
• Mixing CHX and EDTA
immediately produces a white
precipitate.

• Although the properties of the

mixture and the cleared
supernatant have not been
thoroughly studied, it seems that
the ability of EDTA to remove the
smear layer is reduced.
• Chlorhexidine does not have any tissue dissolution properties and therefore cannot be used as
a primary irrigant in Endodontics. It is however used as an adjuvant to NaOCl.

• Chlorhexidine is more effective against gram positive bacteria than gram negative bacteria.
However, in primary endodontic infections, which are usually polymicrobial, Gram-negative
anaerobes predominate.

• Chlorhexidine is particularly effective against E.Faecalis, a bacterium commonly found in

failed root canals.

• Therefore the use of Chlorhexidine as an adjuvant is suggested especially in non vital and
retreatment cases.

• Chlorhexidine has an affinity to dental hard tissues, and once bound to a surface, has
prolonged antimicrobial activity, a phenomenon called “Substantivity”. Therefore it is often
used as the final irrigant.
Iodine potassium iodide
IODINE POTASSIUM IODIDE
• Iodine compounds are best known for their use on surfaces, skin & operation fields.

• Molecular form I2 is the active antimicrobial component. Iodine pentrates rapidly into the
micro organisms & causes cell death by attacking the proteins, nucleotides & other key
molecules of the cell.

• In the root canal, iodine compounds come in contact with dentin & various proteins. Studies
have shown that the interaction of IPI with the chemical environment of necrotic root canal
have shown that dentin can reduce or even abolish the effect of 0.2-0.4% IPI against
E.faecalis.

• Portenier et al have shown that dentin matrix & heat killed cells of E.faecalis & C.albicans
inhibit the antibacterial activity of IPI.

• These studies indicate that inactivation of iodine compounds is one factor explaining the
difficulty in obtaining sterile root canals.
• In practice, a solution of 5% iodine in potassium iodide or Churchill’s solution can be
used.

• Churchill’s solution consists of iodine (16.5 g), potassium iodide (3.5 g), distilled water
(20 g) and 90% ethanol (60 g). The presence of smear may decrease the effectiveness of
the irrigant and it should therefore be used after smear removal.

• Although the action of irrigant was considered to be affected by the anatomy and material
properties of the dentine walls of a root canal, iodine solutions were considered to be a
potentially useful adjunct to sodium hypochlorite, certainly for the killing of E. faecalis.

(IEJ 2003;36:810-830)
Chelating agents
• The term ‘chelate’ originates from the Greek word ‘chele’ (crab claw).
• Chelators were first introduced in endodontics by Nygaard-Ostby (1957) who
recommended the use of a 15% EDTA solution (pH 7.3) with the following
composition:
• Disodium salt of EDTA – 17g

• 5 M sodium hydroxide – 9.25 ml

• They function by forming calcium chelate solution with calcium ions of dentine.
The dentine thereby becomes more friable and easier to instrument. Their action is
to substitute sodium ions which combine with the dentine to give soluble salts.
The walls of canal are thus softer and canal enlargement is facilitated.
(IEJ 2003;36:810-830)
EDTA
PROPERTIES:
• EDTA has demineralization action on dentin. A normal concentration of EDTA can
remove 10.5 g from 100 g calcium. Demineralizing effects are self limiting due to
pH changes during demineralization of dentin.

• Root canal dentin showed severe peritubular and intratubular erosions after 10 min
irrigation with 17% EDTA.

• EDTA produces higher degree of decalcification in coronal & middle third of roots
than the apical part of root dentin.

• EDTA increase dentin permeability and reduce micro leakage between root canal
filling & canal wall. Tubular orifices are enlarged because of dissolution of
peritubular dentin.
• Because EDTA removes inorganic components of smear layer, use in
combination with NaOCl, in order to remove organic remnants is
recommended.

• According to Goldberg & Spielberg (1982), the optimal cleaning effects

are only achieved after 15 min.

• EDTA provokes more cytotoxic effects than oxidative potential water or

NaOCl. So extrusion of EDTA into the periapical tissue during chemo
chemical root canal preparation should be avoided.
Formulations of EDTA:
Liquid chelators:
• EDTAC- 15% EDTA with + 0.84 g centrimide, a quarternary ammonium bromide
(Cetavlon) is used to reduce surface tension, increase penetration and for greater germicidal
activity. It is having greater inflammatory potential. EDTAC increases permeability of
dentinal tubules, accessory canals and apical foramina.

• R- EDTA is a mixture of 17% EDTA and 0.84g cetyl-trimethylammonium bromide

(Cetrimide), NaOCl and distilled water. It is the most effective agent for chemically
cleaning the walls of root canal. It is less caustic than NaOCl. It is similar to NaOCI, except
tissue solvent and antibacterial property. R-EDTA sealed in canal for 24 hours produces
cleanest dentinal walls.

• EDTA- T - 17% EDTA + Sodium lauryl ether sulfate (Tergentol) as a detergent.

• EGTA - Having main ingredient ethylene glycol, which binds calcium more specifically
than EDTA.
Paste type chelators:
• RC Prep- 10% urea peroxide, 15% EDTA & glycol in an ointment base.
Oxygen is set free by the reaction of RC-PREP with a NaOCl irrigant so that
pulpal remnants and blood coagulates can be easily removed from the root canal
wall. Urea peroxide retains its antibacterial action in the presence of blood. The
glycol component of RC-Prep serves as a lubricant for instrument for
instruments and is thought to inhibit the oxidation of EDTA by urea peroxide.

• Glyde file (Dentsply, Germany) – 17% EDTA + 10% urea peroxide

• File Care EDTA (Ultradent)- 17% EDTA + 10% urea peroxide
• File EZE (VDW)- contains 19% EDTA in aqueous water based solution.
• EDTA removes smear layer more effectively when used in conjunction with NaOCl
by acting on the inorganic component of dentin.
• It thus improves the antibacterial effect of locally used disinfectants in deeper
layers of dentin, facilitating cleaning & elimination of bacteria.
Citric Acid
• CITRIC ACID
• In Endodontics ,10-50% solutions are effective for calcium removal.

• 10% citric acid is the commonly used concentration.

• Citric acid is a chelating agent that reacts with metals to form nonionic
soluble chelates.
• EDTA and citric acid strongly interact with sodium hypochlorite . Both citric acid
and EDTA immediately reduce the available chlorine in solution, rendering the
sodium hypochlorite irrigant ineffective on bacteria and necrotic tissue. Hence,
citric acid or EDTA should never be mixed with sodium hypochlorite.

• The same goes for paste-type EDTA preparations: at a 1:10 ratio, they immediately
rid a 1% sodium hypochlorite solution of all hypochlorite.

• The “bubbling effect” or effervescence used to advocate for such products is only
proof of the chemical reaction that takes place between hypochlorite on the one
hand and EDTA and hydrogen peroxide (if contained in the paste-type chelating
product) on the other hand, resulting in evaporating gas.

• Oxygen evaporates from aqueous peroxide-hypochlorite mixtures, and chlorine and

oxygen gas from corresponding mixtures of NaOCl with EDTA or citric acid.
• Hydroxyethylidene bisphosphonate (HEBP), also called etidronate, is a
decalcifying agent that shows only little short-term interference with sodium
hypochlorite. It has recently been suggested by Zehnder et al. as a possible
alternative to citric acid or EDTA .

• However, whether this agent will improve or abbreviate endodontic irrigation will
have to be shown in future studies.

(JOE—Volume 32, Number 5, May

2006)
 CONTENTS
• Introduction
• Historical Perspective
• Goals Of Irrigation
• Ideal Properties Of An Irrigating Solution
• Functions Of Irrigants
• Factors Modifying The Action Of Irrigants
 CONTENTS
• Challenges Of Irrigation
• Various Types Of Irrigating Solutions
• Properties And Actions Of Individual Irrigant
• Irrigation Regimen/Protocol
• Mishaps Of Irrigating Solutions
• Methods Of Irrigation
• Conclusion
• References
MTAD
 MTAD
• Introduced by Torabinejad & Johnson in 2003.

• It is a mixture of tetracycline isomer, an acid and a detergent. It is used as a

final rinse on the surface of instrumented root canal.

• Various antibiotics such as penicillin, bacitracin and streptomycin have

been used in the past to disinfect the root canals. However because of
ineffectiveness of these antibiotics against the flora of infected root canals
and their potential antigenicity, their use has been very limited.

• Tetracycline including tetracycline HCl, minocycline & doxycycline are

broad spectrum antibiotics that are effective against a wide range of
microorganisms.
Composition:
1. Mixture of Tetracycline isomer (Doxycycline 3%)
2. Acid (citric acid) -4.25%
3. Detergent (Tween 80)

• Doxycycline assists in killing bacteria found in canal anatomy.

• Tween 80 and citric acid act in unison as a surfactant to increase the

wetting effect of solution to help breakdown the smear layer.
PROPERTIES-
• Tetracycline is bacteriostatic in nature. This property may be advantageous because
in absence of cell lysis, antigenic by products (endotoxin) is not released.
• It has a lower pH, thus can acts as a calcium chelator and cause enamel & root
surface demineralization.
• It is a substantive medication.
• Tetracycline significantly enhances healing of periradicular tissues.
• MTAD removes the smear layer efficiently from the instrumented root canals, and
allow the penetration of doxycycline into root canal irregularities and dentinal
tubules.
• MTAD is less destructive to tooth structure compared with EDTA when used as a
final irrigant. EDTA causes erosion of coronal & middle third of root dentin,
MTAD does not significantly change the structure of dentinal tubules when used in
conjunction with NaOCl as a root canal irrigant.
• For the best results use of 1.3% NaOCl for irrigation while instrumentation is
recommended as suggested by Torabinejad et al. Placement of MTAD with a cotton
wrapped barbed broach allows intimate contact of the solution, even in the apical region
of the canals and improves debridement of root canal walls.

• Beltz et al found that MTAD solubilizes dentin, whereas organic pulp tissue is
unaffected. J Endod 2003;29:334-7

• Shabahang & Torabinejad investigated the effect of MTAD on root canals

contaminated with E.faecalis & reported good antibacterial activity. J Endod
2003;29:576-9

• Portenier showed that MTAD killed E.faecalis in less than 5 mins. J Endod
2006;32:138-41

• The antibacterial effect of MTAD maybe based on antibiotic component & the combined
effect of other ingredients (Tween 80,citric acid) on the integrity & stability of the
microbial cell wall.
TETRACLEAN
• Tetraclean (Ogna Laboratori Farmaceutici, Muggiò (Mi), Italy), like
MTAD, is a mixture of an antibiotic, an acid and a detergent.

• However, the concentration of the antibiotic, doxycycline (50 mg/5ml), and

the type of detergent (polypropylene glycol) differ from those of MTAD.

• In a study by Giardano et.al , the antimicrobial efficacy of 5.25% NaOCl,

MTAD, and Tetraclean against an E. faecalis biofilm generated on cellulose
nitrate membrane filters.

• Only the NaOCl could disaggregate and remove the biofilm at every time
interval tested although treatment with Tetraclean caused a high degree of
biofilm disaggregation at each time interval when compared with MTAD.
J Endod 2007; 33:852-5.
• The action of smear layer removal of chelating agents is enhanced if used in
conjunction with NaOCl.

• NaOCl acts on the organic content & chelators act on the inorganic component of
smear layer.

• Niu et al. studied ultrastructure of canal walls after EDTA & EDTA plus NaOCl
irrigation by SEM & concluded that more debris was removed by irrigation with
EDTA followed by NaOCl than by EDTA alone. Int End J 2002;35:934-9

• Takeda et al. reported that irrigation with 17 % EDTA, 6 % phosphoric acid & 6 %
citric acid didnt remove entire smear layer from canal walls thus concluding that
NaOCl is required for effective removal of smear layer. Int Endod J 1999; 32:32-9
Ruddle’s solution
 Ruddle’s solution
• This solution is based on the use of HYPAQUE – M, a radio- opaque, high contrast
injectible dye. This dye has previously been used in several applications such as
arteriography, venography and ureterography in the medical field. This particular solution
was introduced by an American researcher, Dr. Clifford J. Ruddle.

COMPOSITION:
• 5% Sodium Hypochlorite
• Hypaque M
• 17% EDTA
• Hypaque M is a high viscous aqueous solution of
two iodine salts-
Diatrizoate Meglumine and Sodium
• It has a pH between 6.5 - 7.7
• It is stable at room temperature
• Crystals may form when cooled but dissolve when heated to body temperature
Mechanism of action:

• The solvent action of NaOCl, improved penetration due to EDTA & radiopacity
because of hypaque helps to visualise the shape & microanatomy of canals & dentin
thickness during endodontic therapy.

• The Ruddle Solution is passively injected into the root canal system once sufficient
access has been made. The sodium hypochlorite portion of the composition will digest
the pulp and eliminate the bacteria and related irritants which are harbored within the
root canal system. The solvent action of this solution progressively clears out the
contents of the root canal system thus enabling the iodine portion of the composition to
flow into the vacated space.
Applications:

• Useful for "visualizing pathological events" such as decay, certain fractures, missed
canals and leaking restorations.
• Assists the diagnostician in managing internal resorption because the solution will map
its location, size and extent.
• Shows promise in endodontic nonsurgical retreatment for improving diagnostics,
treatment planning, and management of "iatrogenic events“.
• Following disassembly procedures, helps clinicians visualize canals that may have
been previously blocked, ledged, transported or perforated.
• Visualization assists dentists in determining the best course of action and in deciding
whether to salvage or extract a tooth.
Elctrochemically activated water
 ELECTROCHEMICALLY
ACTIVATED WATER
• Russian scientists have developed a process whereby electrochemically activated
water is produced with a new and unique anode-cathode system (Leonov 1997).

• Technology is based on the process of transferring liquid into a metastable state via
an electrochemical unipolar anode or cathode action through the use of an element
or reactor.

• Two types of ECA solutions are produced.

1) Anolyte, with high oxidation potential (400-1200 millivolts). It is possible to
produce acidic, neutral or alkaline anolyte (pH 2- 8) Anolyte is claimed to be highly
antimicrobial.

2) Catholyte is an alkaline solution (pH 7 – 12), with high reduction potential.

Catholyte is reputed to have a strong cleaning or detergent effect.
• Sterilox (Optident, Peterborough, UK), is a commercially available unit that produces
anolyte (Sterilox solution) and catholyte (sodium hydroxide pH 12.5) from a quality
controlled pre packaged solution.

• The main active ingredient that is produced by the Sterilox generator is 85–95%
hypochlorous acid.

• This agent is a very effective biocide but is also non-toxic, non-sensitizing, non-
irritating and non-mutagenic.

• The electrolyte is effective at removing the biofilm from dental water lines and can be
used as a surface disinfectant or for disinfecting impressions.

• It may be useful as an endodontic irrigant.

Int Endod J 2000;33:494 –504.

Oxidative potential water
 Oxidative potential water

• OPW has been used extensively in Japan for household & agriculture disinfection.

• Antimicrobial & antiviral activities of OPW are sufficiently powerful to kill a wide
variety of pathogens including Methicillin resistant staphylococcus aureus & HIV.

• Scientific basis for development of OPW is that microorganisms cannot survive in

an aqueous environment with low pH (<3) and high oxidation reduction potential (>
0.9 V).

• OPW is electrochemically created; highly acidic water that accumulates in the

anode compartment after sodium chloride is added to water.
PHYSICAL PROPERTIES –
• pH - 2.3 to 2.7,
• Oxidative reduction potential- 1000 to 1100 mV,
• Dissolved chlorine - 30 to 40 ppm,
• Dissolved oxygen - 10 to 30 ppm,
• OPW is known to suppress the growth of bacteria and viruses without having lining
systems.
• OPW has low toxicity, lack of irritation to soft tissues because it quickly loses its
high oxidative reduction potential and low pH when it reacts with light sensitive
and / or organic substances.
Photoactivated
disinfection
 PAD
• The technique of photosensitization has been used in medicine for some time.
• PAD utilizes the photoactive agent tolonium chloride (toluidine chloride).
• The root canal is irrigated with the solution, which selectively binds to the cellular
membrane of bacteria in the biofilm.
• The labelled bacterial cells rupture when exposed to laser light of the appropriate
wavelength.
• The PAD system (Safedent: Denfotex Light Systems Ltd,
Scotland, UK) uses a red laser-emitting radiation of
wavelength 635 nm.
• The light is directed to the tip of a small flexible optical
fibre that is inserted into the root canal.
• The maximum power setting of 100 mW ensures
that the unit does not generate sufficient heat to
harm the adjacent tissue.
• Tolonium chloride dye is biocompatible and
will not stain dental tissue.
• Seal et al reported that the PAD system was effective against Streptococcus intermedius
biofilms in the root canal but was not as effective as 3% sodium hypochlorite, which
eliminated the entire bacterial population.

• Initial difficulties with the system arose because the laser light had not been transmitted
correctly through the endodontic probe. The author commented that in infected root
canals there may be complex anatomical features colonized by polymicrobial biofilms
and, although sodium hypochlorite should still remain the primary irrigant of choice,
PAD may be a useful adjunct.

• Tolonium chloride, the labelling solution, is rendered ineffective by sodium hypochlorite

and 3% EDTA. The manufacturers therefore recommend that the canal system is
thoroughly washed out with sterile water, saline or citric acid before using it.
Ozonated water
 Ozonated water
• Ozone is a powerful oxidizing agent and has high
bactericidal properties.
• An ozone delivery unit has been manufactured for use
in dentistry (HealOzone: CurOzone USA Inc, Farora,
Canada). Initially, this device was used to reduce the
microbial colonies associated with root caries.
• Attempts to sterilize the entire root canal system have
proved complex, as perfusion of the gas is not reliable.
In-vitro experiments have shown that ozone may be
effective in killing planktonic E. faecalis but has little
effect on E. faecalis embedded in biofilms.
• Ozone destroys cell walls & cytoplasmic membranes of bacteria & fungi.
• Increased permeability leads to ingress of ozone which causes microbial death.
However there is a fundamental need for more evidence of appropriate rigour and quality
before the use of ozone can be accepted into mainstream primary dental care or can be
considered a viable alternative to current methods for the management and treatment of
dental caries.
lasers
• The potential of different endodontic lasers in eradicating root canal microbes has been a
focus of interest for many years.

• Excellent antibacterial efficiency against E.faecalis was reported by Gutknecht et al

using holmium:yttrium-aluminium-garnet (Ho:YAG) laser. 99.98% of bacteria were
eliminated.

• Le Goff used CO2 laser with an efficiency of only 85% of bacteria being eliminated.

• But Kesler et al showed that complete sterility of root canal can be obtained with a CO2
laser microprobe coupled onto a special handpiece attached to the delivery fiber.

• However disinfection & complete sterility still remains to be a challenge with laser
treatment and further research is needed on this front.
• The potential of different endodontic lasers in eradicating root canal microbes has been a
focus of interest for many years.

• Excellent antibacterial efficiency against E.faecalis was reported by Gutknecht et al

using holmium:yttrium-aluminium-garnet (Ho:YAG) laser. 99.98% of bacteria were
eliminated.

• Le Goff used CO2 laser with an efficiency of only 85% of bacteria being eliminated.

• But Kesler et al showed that complete sterility of root canal can be obtained with a CO2
laser microprobe coupled onto a special handpiece attached to the delivery fiber.

• However disinfection & complete sterility still remains to be a challenge with laser
treatment and further research is needed on this front.
• The potential of different endodontic lasers in eradicating root canal microbes has been a
focus of interest for many years.

• Excellent antibacterial efficiency against E.faecalis was reported by Gutknecht et al

using holmium:yttrium-aluminium-garnet (Ho:YAG) laser. 99.98% of bacteria were
eliminated.

• Le Goff used CO2 laser with an efficiency of only 85% of bacteria being eliminated.

• But Kesler et al showed that complete sterility of root canal can be obtained with a CO2
laser microprobe coupled onto a special handpiece attached to the delivery fiber.

• However disinfection & complete sterility still remains to be a challenge with laser
treatment and further research is needed on this front.
Herbal alternatives
 propolis
• Propolis is a resinous mixture that honey bees collect from
tree buds, sap flows, or other botanical sources. It is used as
a sealant for unwanted open spaces in the hive.

• The most important pharmacologically active constituents in

propolis are flavonoids, phenolics and aromatics.

• Propolis being a good antimicrobial and anti-inflammatory

agent, can serve as a better intracanal irrigant and intracanal Raw propolis
medicament.

OOOOE 2007; 104:709-16

Int.J Med. Med .Sci 2010; 2:210-15.
• A comparative evaluation on microbial efficacy of propolis, NaOCl and
saline when used as intracanal irrigants indicated that the propolis has
antimicrobial activity equal to that of NaOCl. The antibacterial efficacy of
three commonly used intracanal medicaments with propolis against
Enterococcus faecalis has been compared. They concluded that propolis had
good invitro antibacterial activity against Enterococcus faecalis in the root
canals, suggesting that it could be used as an alternative intracanal
medicament. IJCD 2011 (1): 34-37

• The antimicrobial activity of propolis with Ca(OH)2 as intracanal,

medicament against Enterococcus faecalis found that propolis was effective
in eliminating the microorganisms. IE J 2010;43:419-23.
 Morinda citrifolia

• Morinda Citrifolia commercially known as Noni, is

indigenous to tropical countries and is considered as
an important folkmedicine.

• It is also called as Indian Mulberry, Ba ti tian, Nono

or Nonu, Cheese fruit and Nhan in various cultures
throughout the world.

• The use of Morinda Citrifolia juice as an endodontic

irrigant might be of interest because it is a
biocompatible antioxidant and not likely to cause the
severe injuries to patients that might occur through
NaOCl accidents.
• An invitro study compared the effectiveness of Morinda citrifolia juice with
NaOCl and CHX to remove the smear layer from the root canal walls of
instrumented teeth.

• It was concluded that the efficacy of Morinda Citrifolia was similar to

NaOCl in conjunction with EDTA as an intracanal irrigant.

• The antimicrobial activity of 2% CHX gel propolis, Morinda Citrifolia juice

and Ca(OH)2 has been compared on E.faecalis infected root canal dentin at
two different depths and three intervals. It was concluded that Propolis and
Morinda Citrifolia were effective against E. faecalis in dentin on extracted
teeth.
OOOOE 2007; 104:709-16
IJCD 2011 (1): 34-37
 Neem extract
• Azadirachta indica A. Juss is a commonly seen
medicinal tree in India, which is popularly known
as “Indian neem/ Margosa tree” or “Indian lilac”.

• The authors compared the antimicrobial activity of

2% sodium hypochlorite and Neem leaf extract
against E. faecalis, C. albicans and mixed culture
and to assess the antimicrobial property of neem
leaf extract against endodontic pathogens, using
the agar diffusion method.

• The study showed that the neem leaf extract has a

significant antimicrobial effect against E. faecalis
and C. albicans and mixed state.
Endodontology June 2010;10-14
 Triphala & green tea
polyphenols
• Triphala is one of the well known Indian Ayurvedic herbal
formulation consisting of dried and powdered fruits of three
medicinal plants namely Terminalia Bellerica, Terminalia
Chebula and Emblica Officinalis.

• It can be used as an effective antiplaque agent because of its

antioxidant properties and it can effectively inhibit the biofilm
formation.

• Green tea is a traditional drink of Japan and China and is

prepared from the young shoots of tea plant Camellia
Sinensis. The leaves from the tea plant contain polyphenolic
components with activity against a wide spectrum of
microbes.
• An in vitro study conducted to evaluate the antimicrobial efficacy of
Triphala, GTPs, MTAD, and 5% Sodium Hypochlorite against E-faecalis
biofilm formed on tooth substrate showed maximum antibacterial activity
with NaOCl and statistically significant antibacterial activity with Triphala,
GTPs and MTAD.

J Endod 2010;36:83-86.
• The major advantages of using herbal alternatives are easy availability,
cost effectiveness, increased shelf life, low toxicity and lack of microbial
resistance reported so far.

• The in vitro observations of herbal products appear promising but

preclinical and clinical trials are needed to evaluate the biocompatibility
and safety factor before they can conclusively be recommended as
intracanal irrigating solutions and medicaments.
Irrigation regimen
According to Mathhias Zehnder (2006),

• The chemicals used to clean infected canals should be administered in such manner
that they can unleash their full potential on their targets in the root canal rather than act
on each other.

• Hence, a hypochlorite solution should be employed throughout instrumentation,

without altering it with EDTA or citric acid.

• Canals should always be filled with sodium hypochlorite. This will increase the
working time of the irrigant.

• Between instruments, canals should be irrigated using copious amounts of the

hypochlorite solution.
• Once the shaping procedure is completed, canals can be thoroughly rinsed using aqueous
EDTA or citric acid. No clear-cut recommendations exist as to the time this procedure
should be exercised.

• Generally each canal is rinsed for at least 1 min using 5 to 10ml of the chelator irrigant.

• After the smear removing procedure a final rinse with an antiseptic solution appears
beneficial. The choice of the final irrigant depends on the next treatment step, i.e. whether an
intervisit dressing is planned or not.

• If calcium hydroxide is used for the interim, the final rinse should be sodium hypochlorite,
as these two chemicals are perfectly complementary.
• If the canal walls are perceived to be clean of debris and the plan is to fill the root
canal or to place a chlorhexidine gel as an intervisit dressing, chemicals other than
sodium hypochlorite may be employed. Chlorhexidine appears to be the most
promising agent to be used as a final irrigant in this situation.

• A final irrigation using a chlorhexidine solution appears advantageous, especially in

re-treatment cases, where high proportions of Gram-positive bacteria are to be
expected in the root canal system.

• If hypochlorite is still present in the canal, subsequently added chlorhexidine will

precipitate in the form of a brownish-reddish mass. Copious amounts of
chlorhexidine irrigant should thus be administered to secure proper action of the
chlorhexidine and to prevent discoloring of the tooth by these precipitates.
Alternatively, the canal can be dried using paper points before the final chlorhexidine
rinse.

JOE—Volume 32, Number 5, May 2006

According to Philippe Sleiman & Khaled (2005), in :

1. VITAL TEETH
• Begin the treatment by:
1) An application of sodium hypochlorite and/or an application of urea peroxide.
The purpose of this mixture:
a) The collagenic anti-aggregation effect due to the proteolytic and lipidic affinity
of urea peroxide.
b) To destroy the biggest amount of pulp tissue inside the access cavity and
provide a better view of the canal orifices by controlling bleeding and
preventing any collagenic plugs from forming.
c) At this stage the effect of EDTA is only important for its antibacterial effect in
combination with other antibacterial agents.
• The second step consists of irrigating with 2ml of sodium hypochlorite 5.25 percent
(60°C). The warm NaOCl is more efficient in destroying the collagen and this will
reduce the time needed for the elimination of the organic part. This irrigation will
create an effervescent effect between the sodium hypochlorite and urea peroxide.
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.

• A 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. 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.

• 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.
2) NECROTIC TEETH
• 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.

• Use distilled water to neutralize the effect of these irrigants. Then one can repeat
the same irrigation sequence described previously for vital teeth.
• 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 necessary to end the 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.

Oral Health, May 2005

Methods of
irrigation
• Throughout the history of endodontics, endeavors have continuously been
made to develop more effective irrigant delivery and agitation systems for
root canal irrigation.

• These systems might be divided into 2 broad categories, manual agitation

techniques and machine-assisted agitation devices
 MANUAL
SYRINGE IRRIGATION MANUAL-DYNAMIC
WITH NEEDLES & AGITATION
CANNULA Hand activated well
End venting; side venting fitted gutta percha

BRUSHES
Endobrush; NaviTip FX
 Syringes with
needle/cannula
• The most common method of delivering irrigant into the root canal is with the aid
of a syringe to which is affixed a needle.
• Syringe can be made up of either glass or plastic. Earlier glass-metal syringes were
used for irrigation of root canal. Now, plastic syringes are used. Glass syringes
with metal needles are also satisfactory but are much more expensive and more
easily broken.
• Gauge of the needle- the gauge used varies from 25-31. 27 gauge needles are
most commonly used.
• The needle should be bent at an obtuse angle to allow for easier access & entry
into the orifice. The bend should be closer to the hub of the syringe.
• Fitting of needle with syringe is of two types
1) Friction lock fit
2) Luer lock fit- Luer lock syringes include a screw-in lock to keep the needle
securely attached. This fit should be used to prevent accidental separation of
needles from syringes.
Designs of needles:

• Open ended blunt needles

• Bevelled needles
• Perforated needles
• Notched tip- Monoject

• Stropko irrigator (Sybron endo)

• ProRinse (Dentsply)
• Maxi – Probe (Dentsply)
• Endo irrigator
 Monoject needles
• Flow Control notched tip permits
greater irrigation of tooth canal.
Fluid pressure at apex is
significantly reduced by notched
tip design.

• Color-coded translucent,
polypropylene hub fits tightly on
luer lock syringe.

• In endodontics, 27 gauge needle

is generally used.
 Stropko irrigator

• Invented by John Stropko.

• The Stropko Irrigator places the perfect amount of air and water pressure
into the field.
• Its small, luer-lock tips do not impede visibility during irrigation or drying
and are excellent for use under the microscope.
• Fits most Triplex air/water syringes.
• The needles are 30-gauge, slotted & side vented.
• Autoclavable & coated on inside & outside to protect against corrosive
action of NaOCl.
• Available in 17mm & 25 mm working length.
 ProRinse

• Vents solution laterally to

ensure maximum irrigation and complete cleansing.
• Delivers solution to optimal depth with 25mm length and 30-gauge tip
• Increases canal maneuverability through flexible design
• Offers excellent results with the highest degree of safety
• Features a Luer-connector for secure attachment and easy removal
 Endo irrigator
• 3 reservoirs for irrigating solutions

• Gun on right has 4 buttons- 3 for activating

irrigants & 4th for suction

• On left is stropko irrigator.

• The device has a built in heater for warming up

the solutions.

• Disadvantage is that the unit is bulky &

sometimes the gun is inaccessible in posterior
teeth
THE TECHNIQUES:
• Secure rubber dam isolation
• Fill syringe via hub irrigant stored in a dappen dish by the chairside.

SOMMER’S TECHNIQUE:
• Place a few drops of irrigant in the pulp chamber, then “Whirlpool” the
solution into the canal with a small file.

GROSSMAN’S TECHNIQUE:
• Advocated flooding the pulp chamber with the irrigant once it was placed into
the canal. This served as a reservoir of irrigant to replenish the one present in
the root canal as it was being instrumented.
• When the needle is introduced into the canal & meets resistance, it is withdrawn a
few mm to prevent it from wedging & forcing the irrigant into periapical tissues.
Once irrigant delivery starts, look for the backflow of the irrigant from the canal
orifice
• The hand holding the irrigating syringe is always kept in motion when dispensing
irrigant.
• Files potentially carry irrigant progressively deeper into the canal by surface
tension.In small canals, the files displace the irrigant. When the instrument is
withdrawn, the irrigant usually flows into the space the file occupied.
• Clinicians should irrigate copiously, recapitulate & re-irrigate after each instrument
size.
• Besides using an aspirator, Grossman suggested the use of a gauze sponge held
against the tooth to absorb the backflow of the irrigant.
• Once the shaping & cleaning is accomplished, the irrigant is aspirated from the
canal with syringes & subsequently dried with paper points.
• The mechanical flushing action created by conventional hand-held syringe
needle irrigation is relatively weak.
• A previous study has shown that when conventional syringe needle
irrigation was used, the irrigating solution was delivered only 1 mm deeper
than the tip of the needle. This is a disturbing issue because the needle tip is
often located in the coronal third of a narrow canal or, at best, the middle
third of a wide canal .
• The penetration depth of the irrigating solution and its ability to disinfect
dentinal tubules are therefore limited.
• Factors that have been shown to improve the efficacy of syringe needle
irrigation include:
• closer proximity of the irrigation needle to the apex
• larger irrigation volume
• smaller-gauge irrigation needles. Smaller-gauge needles/cannulas might be
chosen to achieve deeper and more efficient irrigant replacement and
debridement . However, the closer the needle tip is positioned to the apical
tissue, the greater is the chance of apical extrusion of the irrigant.
• Slow irrigant delivery in combination with continuous hand movement will
minimize NaOCl accidents.
 Brushes
• brushes are not directly used for delivering an irrigant into the canal spaces.
They are adjuncts that have been designed for debridement of the canal
walls or agitation of root canal irrigant.
• a 30-gauge irrigation needle covered with a brush (NaviTip FX; Ultradent
Products Inc, South Jordan, UT) was introduced commercially
• A recent study reported improved cleanliness of the coronal third of
instrumented root canal walls irrigated and agitated with the NaviTip FX
needle over the brushless type of NaviTip needle.
• Also friction created between the brush bristles and the canal irregularities
might result in the dislodgement of the radiolucent bristles in the canals that
are not easily recognized by clinicians, even with the use of a surgical
microscope.
• The Endobrush (C&S Microinstruments Ltd, Markham, Ontario, Canada)
is a spiral brush designed for endodontic use that consists of nylon bristles
set in twisted wires with an attached handle and has a relatively constant
diameter along the entire length.
• Keir used it in his study & concluded that During debridement, the bristles
of the brush were extended to the noninstrumented canal walls and into the
fins, cul-de-sacs, and isthmi of the canal system to remove trapped tissue
and debris. Indeed, the results in that study indicated that instrumentation
with the Endobrush was significantly better than instrumentation alone in
debriding the root canal.
• However, the Endobrush could not be used to full working length because
of its size, which might lead to packing of debris into the apical section of
the canal after brushing .
Vapour lock effect
• The mechanical debridement efficacy of
an irrigation delivery/agitation system is
dependent on its ability to deliver the
irrigant to the apical and noninstrumented
regions of the canal space and to create a
strong enough current to carry the debris
away from the canal walls .
• Because the root is enclosed by the bone
socket during in vivo cleaning and
shaping , the canal behaves as a closed-
end channel, which results in gas
entrainment at its closed end , producing a
vapor lock effect during irrigant delivery .
 Vapour lock effect
• This vapour lock effect has practical implications where irrigants are delivered by
syringe needles from the coronal or middle third of a root canal.
• The time-frame of endodontic irrigation means that air entrapment in the apical
portion of the canal might preclude this region from contact or disinfection by an
irrigant.

• In a classic study Senia et al (1971) showed that NaOCl demonstrated this effect by
not engaging the apical 3mm of the canal even when the root apex was enlarged to a
size 30.
• NaOCl will react with organic material in the root canal to form micro gas bubbles at
the apical termination that commingle into an apical vapour lock with subsequent
instrumentation.
• It can’t be displaced within a clinically relevant time through simple mechanical
action and prevents further irrigants from flowing into the apical region.
• The apical vapour lock will prevent acoustic microstreaming and cavitation, as these
can only occur in a liquid phase.
For positive-pressure irrigation with a needle delivery system:
 irrigant replacement is limited to 1–1.5 mm beyond the needle tip,
 a high flow rate is required to generate turbulent fluid flow for effective
agitation.
 The apical seat also has to be enlarged to at least size 35–40 for needle
placement to within 1-2mm of the apical seat.

• The irrigant extrusion beyond 1–1.5 mm of a side-venting needle may

generate a liquid film along the air bubble–canal wall interface.
• Fluid stagnation in this ‘‘deadwater zone’’ fails to provide adequate irrigant
replacement, resulting in gross debris retention in this region.
• This is esp. applicable for side vented needle delivery & cannot be
extrapolated to other systems like sonic,ultrasonic or negative suction devices
that can create more forceful currents.
J Endod
• It appears that dynamic mechanical agitation (the use of a well-fitting
gutta-percha cone for manual agitation of an irrigant-filled canal) has the
potential to displace the apical gas entrapment from a closed system.

• Because the material cone is closely adapted to the canal, this manual
agitation technique can effectively displace debris away from the collagen
matrix created by acidic/chelating irrigants in a closed canal system that is
totally sealed from apex to the cementoenamel junction.

Int End J 2008;41:602-8

Manual-Dynamic Irrigation

• An irrigant must be in direct contact with the canal walls for effective action.
However, it is often difficult for the irrigant to reach the apical portion of the
canal because of the so-called vapor lock effect.

• Gently moving a well-fitting gutta-percha master cone up and down in short

2- to 3-mm strokes (manualdynamic irrigation) within an instrumented canal
can produce an effective hydrodynamic effect and significantly improve the
displacement and exchange of any given reagent.

• McGill et al and Huang et al demonstrated that manual-dynamic irrigation

was significantly more effective than an automated-dynamic irrigation system
(RinsEndo; Durr Dental Co, Bietigheim-Bissingen, Germany) and static
irrigation.

Int End J 2008;41:60-71

• Several factors could have contributed to the positive results of manual-dynamic
irrigation:
(1) the push-pull motion of a well fitting gutta-percha point in the canal might generate
higher intracanal pressure changes during pushing movements, leading to more
effective delivery of irrigant to the ’’untouched’’ canal surfaces.

(2) the frequency of push-pull motion of the gutta-percha point (3.3 Hz, 100 strokes per
30 seconds) is higher than the frequency (1.6 Hz) of positive-negative hydrodynamic
pressure generated by RinsEndo, possibly generating more turbulence in the canal.

(3) the push-pull motion of the gutta-percha point probably acts by physically displacing,
folding, and cutting of fluid under ‘‘viscously-dominated flow’’ in the root canal
system. The latter probably allows better mixing of the fresh unreacted solution with
the spent, reacted irrigant.
• Although manual-dynamic irrigation has been advocated as a method of
canal irrigation as a result of its simplicity and cost-effectiveness, the
laborious nature of this hand-activated procedure still hinders its
application in routine clinical practice.

• Therefore, there are a number of automated devices designed for agitation

of root canal irrigants that are either commercially available or under
production by manufacturers.
• The Endox Endodontic System
• (Lysis Srl, Nova Milanese, Italy) may also be considered for root canal
disinfection.
• The Endox Endodontic System exploits high-frequency electrical pulses (high-
frequency electric waves) to eliminate organic tissue within the root canal. All
tissues possess a molecular structure that is sensitive to the action produced by
electromagnetic fields generated by a high-frequency current.

Different tips, suitable for different clinical

utilization, can be mounted on the handpiece of
the system.
• The flow of electrons generates a packet of electromagnetic waves that releases a
considerable quantity of energy in the field involved by the electrical discharge and in
immediately surrounding areas.

• There are three main effects:

 increase of local temperature (between 300 and500°C),
 increased percentage of ozone (O3) due to ionization of the medium,
 production of UV rays .

• The latter are a by-product of the spark generated by the flow of electrons in the
medium. These effects are assumed to act synergistically, eliminating the content of
the root canal by vaporizing all organic and inorganic components.
• The EndoActivator System (Dentsply Tulsa
Dental Specialties, Tulsa, OK)
• is a more recently introduced sonically driven canal irrigation system (95).
• It consists of a portable handpiece and 3 types of disposable polymer tips of different
sizes. These tips are claimed to be strong and flexible and do not break easily.
Because they are smooth, they do not cut dentin.
• The EndoActivator System was reported to be able to effectively clean debris from
lateral canals, remove the smear layer, and dislodge clumps of simulated biofilm
within the curved canals of molar teeth
• During use, the action of the EndoActivator tip frequently produces a cloud of debris
that can be observed within a fluid-filled pulp chamber. Vibrating the tip, in
combination with moving the tip up and down in short vertical strokes, synergistically
produces a powerful hydrodynamic phenomenon.
• In general, 10,000 cycles per minute (cpm) has been shown to optimize
debridement and promote disruption of the smear layer and biofilm.
• A possible disadvantage of the polymer tips used in the EndoActivator
system is that they are radiolucent. Although these tips are designed to be
disposable and do not break easily during use, it would be difficult to
identify them if part of a tip separates inside a canal.
• Presumably, these tips might be improved by incorporating a
radiopacifier in the polymer.
GENTLE WAVE SYSTEM
PUI
• Passive ultrasonic irrigation was first described by Weller et al. (1980). The term
‘passive’ does not adequately describe the process, as it is in fact active; however, when it
was first introduced the term ‘passive’ related to the ‘noncutting’ action of the
ultrasonically activated file.

• PUI relies on the transmission of acoustic energy from an oscillating file or smooth wire
to an irrigant in the root canal. The energy is transmitted by means of ultrasonic waves
and can induce acoustic streaming and cavitation of the irrigant.

• Two flushing methods might be used during PUI, namely

i. a continuous flush of irrigant from the ultrasonic handpiece or

ii. an intermittent flush technique by using syringe delivery

A) Continuous Ultrasonic Irrigation

• Chlorine, which is responsible for the dissolution of organic tissues and the
antibacterial property of NaOCl , is unstable and is consumed rapidly during the first
phase of tissue dissolution, probably within 2 minutes.

• Therefore, an improved delivery system that is capable of continuous replenishment of

root canal irrigants is highly desirable.

• Recently, a needle-holding adapter to an ultrasonic handpiece has been developed by

Nusstein.

• During ultrasonic activation, a 25-gauge irrigation needle is used instead of an

endosonic file. This enables ultrasonic activation to be performed at the maximum
power setting without causing needle breakage
• The unique feature of this needle-holding adapter is that the needle is
simultaneously activated by the ultrasonic handpiece, while an irrigant is
delivered from an intravenous tubing connected via a Luer-lok to an irrigation-
delivering syringe
• The irrigant can thus be delivered apically through the needle under a
continuous flow instead of being intermittently replenished from the coronal
access opening.
• This technology has been studied in vivo & it was demonstrated that:
a) 1 minute of continuous ultrasonic irrigation produced significantly cleaner
canals and isthmi in both vital and necrotic teeth.
b) It also resulted in a significantly greater reduction of colony-forming unit
(CFU) counts in infected necrotic human molars.
c) Reduction of time required for irrigation.
Aust Endod J
2006;32:123–8.
B) Intermittent Flush Ultrasonic Irrigation

• The irrigant is delivered to the root canal by a syringe needle. The irrigant is then
activated with the use of an ultrasonically oscillating instrument.

• The irrigant is replenished several times after each ultrasonic activation cycle.

• The amount of irrigant flowing through the apical region of the canal can be
controlled because both the depth of syringe penetration and the volume of irrigant
administered are known.
• This is not possible with the use of the continuous flush regime.

• Both flushing methods have been shown to be equally effective in removing dentin
debris from the root canal in an ex vivo model when the irrigation time was set at 3
minutes.
Int End J 2006;39:472-6
 Pressure alternation
devices
• Traditionally, irrigation involved placement of an end-port or side-port
needle into the canal and expressing solution out of the needle to be
suctioned coronally.
• This creates a positive pressure system with force created at the end of the
needle, which may lead to solution being forced into the periapical tissues.
• Chow (1983) showed that positive pressure irrigation has little or no effect
apical to the needles orifice. He said that for the solution to be
mechanically effective in removing all the particles, it has to:
(a) reach the apex,
(b) create a current force and
(c) carry the particles away.’
• In an apical negative pressure irrigation system, the irrigation solution is expressed
coronally and suction at the tip of the irrigation needle at the apex creates a current flow
down the canal towards the apex and is drawn up the needle.

• But true apical negative pressure only occurs when the needle (cannula) is utilized to
aspirate irrigants from the apical termination of the root canal.

• The apical suction pulls irrigating solution down the canal walls towards the apex,
creating a rapid turbulent current force towards the terminus of the needle.

• Haas and Edson (2007) found ‘the teeth irrigated with negative apical pressure had no
apical leakage. While the teeth irrigated with positive pressure leaked an average of
2.41ml out of 3ml’.

• Fukumoto found using [apical] negative pressure less extrusion of irrigant than needle
irrigation (positive pressure) when both were placed 2mm from working length.
 ANTIBACTERIAL
NANOPARTICLES
• 1-100nm
• Antibacterial nanoparticles have antimicrobial
activity
• Have been mixed with irrigants, sealers etc

(COHEN 11TH EDITION)

 CONCLUSION
• A Better understanding of the fluid dynamics
of different mode of irrigation will contribute
to achieving predictable disinfection of the
root canal system.
• Hence, in endodontic disinfection, the process
of delivery is as important as the antibacterial
characteristics of the irrigant.
THANKYOU