ROOT CANAL IRRIGATION

•Recent Advances

Presented by-
• Dr. Sayak Gupta
• MDS 1st Year
 IRRIGATION

• According to Webster’s dictionary: “The term irrigation is

defined as the therapeutic flushing of a body part with a
stream of liquid.”

• Disinfectant, meanwhile, is defined as “an agent that

destroys or inhibits the activity of microorganisms that
cause disease.”
Why do we need to do Irrigation?
• Chemical debridement
is especially needed
for teeth with complex
internal anatomy such
as fins or other
irregularities that might
be missed by
instrumentation.

*(Ref.-Baker NA, Eleazer PD, Averbach RE, Seltzer S.

Scanning electron microscopic study of the efficacy of
various irrigation solutions. J Endod 1975;4:127-35.)
• Irrigants can augment
mechanical
debridement by
flushing out debris,
dissolving tissue, and
disinfecting the root
canal system.

*(Ref.-Kandaswami D. Root Canal Irrigants.

Journal of Conservative Dentistry,Oct-Dec
2010,Vol 13,Issue 4,256-264)
Desired functions of Irrigants
1.Washing action (helps remove debris)
2. Reduce instrument friction during preparation (lubricant)
3. Facilitate dentin removal (lubricant)
4. Dissolve inorganic tissue (dentin)
5. Penetrate to canal periphery
6. Dissolve organic matter (dentin collagen, pulp tissue, biofilm)
7. Kill bacteria and yeasts (also in biofilm)
8. Do not irritate or damage vital periapical tissue, no caustic or
cytotoxic effects
9. Do not weaken tooth structure

*(Ref.-Haapasalo et al. Irrigation in Endodontics. Dent Clin N Am 54 (2010) 291–312)

 CLASSIFICATION
(Kandaswamy and Venkateshbabu)
CHEMICAL AGENTS NATURAL AGENTS

1. Tissue dissolving Antibacterial agents :

agents : NaOCl • Green Tea
• Triphala

2. Antibacterial agents
a) Bacteriocidal : CHX
b) Bacteriostatic : MTAD

3. Chelating agents
a) Mild pH : HEBP *(Ref.-Kandaswami D. & Venkateshbabu N. Root Canal
Irrigants. Journal of Conservative Dentistry,Oct-Dec
b) Strong pH : EDTA 2010,Vol 13,Issue 4,256-264)
Most Commonly used Irrigants
1. Sodium Hypochlorite (NaOCl) 0.5-5.25%
2. Chlorhexidine
3. Ethylenediaminetetraacetic Acid (EDTA)
4. Hydrogen Peroxide
5. Hydrochloric Acid
6. Sodium Lauryl Sulfate
7. Local Anesthetic
8. Saline
9. Water
 • Most Commonly used irrigating
Sodium Solution
Hypochlorite • Studies have generally shown that
NaOCl has a broad spectrum
antimicrobial activity -

It can rapidly kill vegetative bacteria, spore

forming bacteria, fungi, viruses, and
bacterial spores.

• Some investigations show the ability

of even 0.5% NaOCl to kill bacteria to
a greater extent than other irrigants .
Mechanism of Action
• Destruction of the bacteria takes place in two phases:
1. penetration into the bacterial cell.
2. chemical combination with the protoplasm of the
bacterial cell
• NaOCL posses strong tissue dissolution property.

• The solvent action of NaOCI has been attributed to its

high alkalinity.

• Grossman and Meiman reported that 5% sodium

hypochlorite dissolves pulp tissue in 20 min to 2 h.
 After 5
minutes
After 10
min

Extirpated
pulp

Immediately
after
Placement
into
10
NaOCL
Concentrations
• NaOCL has been used in various concentrations ranging from
0.5-5.25%.

• More recently upto 10% also.

• the ADA (American Dental Association) accepted concentration

for clinical use of NaOCl as an irrigant is 5.25% (Cunningham et
al. 1980).

• Most commonly used concentration - 2.5%

• The antibacterial effectiveness and tissue dissolving capacity of

NaOCl is a function of its concentration but so is its toxicity.
Adverse Effects
• Sodium hypochlorite is a cytotoxic agent (Gatot et al. 1991,
Gernhardt et al. 2004).

• When it comes into contact with vital tissue, it causes

• haemolysis,
• ulceration,
• inhibits neutrophil migration
• and damages endothelial and fibroblast cells (Gatot et al.1991).

• It has a pH of approximately 11–12 and causes injury

primarily by oxidation of proteins. (Kaufman & Keila 1989,
Gatot et al. 1991, Serper et al. 2004).
Sodium Hypochlorite Accidents
NaOCl can go beyond the apical foramen:
• when the apical constriction has been destroyed during root canal
preparation or by resorption.
• may occur in teeth with wide apical foramina

• Additionally,
• extreme pressure during irrigation
• or binding of the irrigation needle tip in the root canal

which results in contact of large volumes of the irrigant to the apical

tissues.

• If this occurs, the excellent tissue-dissolving capability of sodium

hypochlorite will lead to tissue necrosis.
SYMPTOMS
• Pain-
• Immediate severe pain ( 2-6 minutes)

• Oedema
• Immediate oedema of neighbouring
soft tissues
• Possible extension of oedema over the
injured half side of the face, upper lip,
infraorbital region

• Bleeding
• Profuse bleeding from the root canal
• Profuse interstitial bleeding with
haemorrhage of the skin and mucosa
(ecchymosis)
INTERACTION BETWEEN IRRIGATING
SOLUTION
1. NaOCl+EDTA/CA 1. ↓ Loss of NaOCl activity

2. NaOCl+CHX 2. ↓ Loss of NaOCl activity,

with brown-orange
precipitate
3. CHX+EDTA 3. ↓ Loss of activity of
EDTA, with White
precipitate
4. NaOCl+H2O2
4. ↑ Better effect than
NaOCl alone.
5. H2O2+CHX 5. ↑ Better antibacterial
activity

*(Ref.-Haapasalo et al. Irrigation in Endodontics.

Dent Clin N Am 54 (2010) 291–312)
RECENT ADVANCES IN ROOT
CANAL IRRIGATING SOLUTIONS
 NEWER ENDODONTIC IRRIGATION DEVICE

(REF.-Gu L et al. Review of Contemporary Irrigant Agitation Techniques and Devices - Journal of Endodontics..
2009;35(6): 791–804 )
Manual Agitation Techniques
• The simplest of all mechanical activation techniques is the
manual irrigant agitation, which can be performed with different
systems.
• The easiest way to achieve this effect is moving vertically and
passively the endodontic file within the root canal.
• The file promotes the irrigant penetration and reduces the
presence of air bubbles in the canal space, but does not improve
the final cleaning.
• Endodontic brushes and specific needles for endodontic irrigation
with bristles on their surface is another technique.
• These systems have shown to be valid in the removal of smear
layer from root canal walls, thus they can be indicated during
irrigation with EDTA to improve their efficacy at the end of the
preparation.
Max-i-probe
• Max-i-probe is a modified design of regular
manual irrigation needles with a well-
rounded, close tip and side-port dispersal.
• Range: 21-30 gauge
• The rounded tip prevents the risk of
perforating the apex and allows for safe
irrigation of the entire length of the root
canal.
• The dispersal of the irrigating solution
through the side-port in the cannula creates
a unique upward turbulent motion, which
thoroughly irrigates the root canal
preparation but prevents solution and REF.-Elumalai DD, Kumar DA, Tewari
debris from being expressed through the DR, Mishra SK, Iftekhar H, Alam S,
Andrabi M. Newer Endodontic irrigation
periapical foramen. devices: An update. IOSR Journal of
Dental and Medical Sciences (IOSR
JDMS) 2014;13(6):04–8.
NaviTip Fx
• NaviTip Fx is a 30-gauge irrigation needle covered with a
brush.
• Brush is an adjunct that has been designed for
debridement of the canal walls or agitation of root canal
irrigant.
• NaviTip FX needle gave improved cleanliness in coronal
third when compared to brushless NaviTip needle.
• Disadv.-NaviTip FX brush bristles may dislodge inside the
canal irregularities due to the friction, because of its
radiolucent nature it is very difficult to identify
radiographically and even with the use of a surgical
microscope.
Machine-Assisted Agitation Systems-Rotary
Brushes
• The evolution of the manual systems led to the
introduction of instruments that may be rotated by
handpieces at low speed inside the canal fill with irrigant.
Instruments such as plastic files can show a smooth
surface and increased taper (25-27), or even a surface
with lateral plastic extensions (28-30). Studies on these
systems have shown conflicting results. There are better
results for the machine-assisted agitation systems than
for the conventional irrigation technique with syringe, but
worse than other more effective systems
The Quantec-E irrigation system
• The Quantec-E irrigation system is a selfcontained fluid
delivery unit that is attached to the Quantec-E Endo
System.
• It uses a pump console, 2 irrigation reservoirs, and tubing
to provide continuous irrigation during rotary
instrumentation.
• It has been proposed that continuous irrigant agitation
during active rotary instrumentation would
I. generate an increased volume of irrigant,
II. increase irrigant contact time, and
III. facilitate greater depth of irrigant penetration inside the
root canal.
• This should result in more effective canal debridement
compared with syringe needle irrigation.
• However studies conducted by Setlock et al10 and
Walters et al11 proved that Quantec-E irrigation did result
in cleaner canal walls and more complete debris and
smear layer removal in the coronal third of the canal walls
and there was no significant difference between standard
syringe needle irrigation and irrigation with the Quantec-E
pump.
The Vibringe System
• The Vibringe System an irrigation device that combines
manual delivery and sonic activation of the solution.
• The Vibringe is a cordless handpiece that fits in a special
disposable 10-mL Luer-Lock syringe that is compatible
with every irrigation needle.
• The Vibringe allows delivery and sonic activation of the
irrigating solution in one step.
• It employs a 2-piece syringe with a rechargeable battery.
• The irrigant is sonically activated, as is the needle that
attaches to the syringe.
• Rödig et al evaluated the efficacy of vibringe system they
concluded that vibringe demonstrated significantly better
results than syringe irrigation in the apical root canal third
in removing debris.
• However it was not as effective as the passive ultra sonic
irrigation.
EndoActivator System
• Sonically driven canal irrigation system
• Consist of :
I. Portable handpiece
II. 3 types of disposable polymer non-cutting/smooth tips
(strong & flexible) of different sizes
• Vibrating tip in combination with up and down short
vertical strokes, has shown to optimize debridement and
promote disruption of smear layer and biofilm.
• Reported to be able to clean debris from Lateral Canals &
remove smear layer effectively.
Sonic Activation
• Sonic activation systems have smooth plastic tips of
different sizes activated at sonic frequency by a hand piece.
• This system seems to be able to effectively clean the main
canal, to remove the smear layer and to promote the filling
of a greater number of lateral canals.
• Another recently introduced technique uses a syringe with
sonic vibration that allows the delivery and activation of the
irrigant in the root canal at the same time.
• Sonic activation differs from the ultrasonic because it
operates at a lower frequency (1-6 kHz), and for this reason
it is generally found to be less effective in removing debris
than the ultrasonic systems.
Ultrasonic Irrigation
• Ultrasonic irrigation can be used as an intermittent
irrigation or a continuous ultrasonic irrigation.
• In intermittent flushed 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.
• 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
• In this continuous ultra sonic irrigation system the needle
is simultaneously activated by the ultrasonic handpiece,
while an irrigant is delivered from 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.
• Various studies demonstrated that 1 minute of continuous
ultrasonic irrigation produced significantly cleaner canals
in both vital and necrotic teeth.
The EndoVac System
• The EndoVac apical negative pressure irrigation system has been introduced by Discus
Dental Company.
• It has three components: The Master Delivery Tip, MacroCannula and MicroCannula.
• The Master Delivery Tip simultaneously delivers and evacuates the irrigant.
• The MacroCannula is used to suction irrigant from the chamber to the coronal and middle
segments of the canal.
• The MacroCannula or MicroCannula is connected via tubing to the high-speed suction of
a dental unit.
• The Master Delivery Tip is connected to a syringe of irrigant and the evacuation hood is
connected via tubing to the high-speed suction of a dental unit.
• The plastic macrocannula has a size 55 open end with a .02 taper and is attached to a
titanium handle for gross, initial flushing of the coronal part of the root canal.
• The size 32 stainless steel microcannula has 4 sets of 3 laser-cut, laterally positioned,
offset holes adjacent to its closed end.
• This is attached to a titanium finger-piece for irrigation of the apical part of the canal by
positioning it at the working length. The microcannula can be used in canals that are
enlarged to size 35 or larger. During irrigation, the delivery/evacuation tip delivers irrigant
to the pulp chamber and siphons off the excess irrigant to prevent overflow.
• The cannula in the canal simultaneously exerts negative pressure that
pulls irrigant from its fresh supply in the chamber, down the canal to the
tip of the cannula, into the cannula, and out through the suction hose.
• Thus, a constant flow of fresh irrigant is being delivered by negative
pressure to working length. Apical negative pressure has been shown
to enable irrigants to reach the apical third and help overcome the
issue of apical vapor lock.
• Apart from being able to avoid air entrapment, the EndoVac system is
also advantageous in its ability to safely deliver irrigants to working
length without causing their undue extrusion into the periapex, thereby
avoiding sodium hypochlorite incidents.
• It is important to note that it is possible to create positive pressure in
the pulp canal if the Master Delivery Tip is misused, which would create
the risk of a sodium hypochlorite incident. The manufacturer’s
instructions must be followed for correct use of the Master Delivery Tip.
Photo-Activated Disinfection (PAD)
• This technique is based on the principle that the photosensitizing
molecules (photosensitizer - PS) are able to bind to the
membrane of the bacteria.
• PS is activated at specific wavelength and produces free
oxygen, which causes the rupture of the bacterial cell wall on
which the PS is associated with, determining a bactericidal
action.
• An endodontic system called Light-Activated Disinfection (LAD)
was developed. It is based on a combination of a PS and a
special light source.
• The PS attacks the membranes of microorganisms and binds to
their surface, absorbs energy from light and then releases this
energy in the form of oxygen (O2), which is transformed into
highly reactive forms that effectively destroy microorganisms.
• The LAD is not only effective against bacteria, but also against other
microorganisms including viruses, fungi and protozoa .
• The PSs have far less affinity for the cells of the body; therefore toxicity
tests carried out did not report adverse effects of this treatment .
• Clinically, after the root canal preparation, PS is introduced into the canal
until working length with an endodontic needle and is left in situ for 60 s.
• The specific endodontic tip is then inserted into the root canal up to the
depth that can be reached and the light irradiation is performed for 30 s in
each canal.
• Care should be taken to ensure maximum penetration of the PS, since it is
important that it comes in direct contact with the bacteria, otherwise the
process of photosensitivity does not occur.
• In addition, LAD seems to be effective not only against the bacteria in
suspension, but also against biofilm.
• Currently LAD is not considered as an alternative, but rather as a possible
supplement to standard protocols of root canal disinfection already in use.
Ozone
• Ozone is a triatomic molecule consisting of three oxygen atoms.
• It is applied to oral tissues in the forms of ozonated water, ozonated olive oil
and oxygen/ozone gas.
• It is unstable and dissociates readily back into oxygen (O2), thus liberating
so-called singlet oxygen (O1), which is a strong oxidizing agent which
further impose the deleterious effect on microorganisms.
• Various delivery systems available for endodontic irrigation like Neo Ozone
Water-S unit, HealOzone (Kavo) unit, the OzoTop unit.
• Notably, when the specimen was irrigated with sonication, ozonated water
had nearly the same antimicrobial activity as 2.5% NaOCl.
• Ozone works best when there is less organic debris remaining. Therefore,
the recommendation is to use either ozonated water or ozone gas at the
end of the cleaning and shaping process. Ozone is effective when it is used
in sufficient concentration, for an adequate time. Ozone will not be effective
if too little dose of ozone is delivered or it is not delivered appropriately.
The VATEA system
• The VATEA system is an irrigation device which is an
integral part of Self Adjusting file rotary system (SAF).
• The VATEA system is a self-contained, fluid delivery unit
intended to be attached to dental handpieces to deliver
irrigation during endodontic procedures.
• During the endodontic treatment, irrigation solution is
pumped from the VATEA's 400 ml reservoir. The irrigant is
delivered via a disposable silicone tube to the endodontic
file. The flow of irrigant is toggled using a foot pedal. The
operator can adjust the flow rate from 1- 10 ml/min by
using the -/+ push buttons located on the control panel.
Laser In the Endodontics
• several types of laser have been used to improve root canal disinfection:
diode laser, gas laser (CO2), erbium: YAG laser, neodymium:
• YAG laser. Bactericidal action of the laser depends on the wavelength and
energy, and in many cases it is due to thermal effects that produce
alteration of the cell wall of the bacteria, leading to changes in osmotic
gradients up to cell death.
• Some studies have concluded that the laser irradiation is not an
alternative, but rather a possible integration to existing protocols to
disinfect root canal.
• The laser energy emitted from the tip of the optical fiber is directed along
the canal and not necessarily lateral to the walls. To overcome this
limitation, a delivery system that allows lateral emission of the radiation
aimed to improve the antimicrobial effect , but a complete elimination of
the biofilm and bacteria was not yet possible. In conclusion, there is still
no strong evidence to support the application of high-power lasers for
direct disinfection of root canals.
Nanoparticles
• Nanoparticles of magnesium oxide, calcium oxide or zinc
oxide are microscopic particles that have antibacterial
properties.
• Nanoparticles synthesized from powders of silver, copper
oxide and zinc oxide are currently used and may generate
active oxygen species.
• They are responsible for the anti-bacterial effect by the
electrostatic interaction between positively charged
nanoparticles and negatively charged bacterial cells.
• In addition, nanoparticles may change the chemical and
physical properties of dentin and reduce the bacterial
strength of adhesion to the dentin itself
Bioactive Glass
• Recently, the bioactive glass or bioactive glass-ceramics
have been the object of considerable interest for
endodontic disinfection due to their antibacterial
properties, but with conflicting results
Natural Plant Extracts
• A current trend directed to the use of natural plant extracts
takes advantage of the antibacterial activity of
polyphenolic molecules generally used for storing food.
• These compounds have a poor antibacterial efficacy, but
a little significant ability to reduce the formation of biofilms,
although the mechanism by which this occurs is not clear.
Thank You