ROOT CANAL IRRIGANTS

PRESENTED BY:
DR. SALONI
PG ,IInd YEAR
Dept. of conservative dentistry and endodontics
 CONTENTS:
• Introduction
• History
• Ideal properties of irrigants
• Functions
• Factors affecting the efficacy of root canal irrigants
• Classification
• Irrigant solutions
• Herbal plants as an irrigants
• Irrigation devices & techniques
• Conclusion
• References
 INTRODUCTION:
• The success of any endodontic treatment depends on the satisfactory completion of the
endodontic triad of biomechanical preparation, disinfection and obturation in three
dimensions to create a fluid tight seal.

• biomechanical preparation  formation of a smear layer  primarily of fine inorganic

particles, along with some organic material from necrotic and/or viable pulp tissue,
odontoblastic processes, bacteria and blood cells.

• Root canal irrigants  remove the organic/inorganic debris, lubricate endodontic instruments
and minimize the number of micro-organisms.

• Failure of root canal treatment is likely caused by the inability to eliminate bacteria from the
root canal system.
• it has long been established that a root with “a tapering canal and a single foremen” is
the exception rather than the rule.
• Investigators have shown multiple foramina, additional canals, deltas, intercanal
connections, ‘Cshaped’ canals and accessory canals which makes a root canal a far
deviation from ‘a tapared canal with a single foramen’
• Thus a root canal irrigant is needed to aid in the disinfection of the canals
completely.
• Mechanical instrumentation cannot sufficiently disinfect root canals regardless of the
instrumentation technique or system used.
• Despite technological advances in the ability to shape root canals, at least 35% of root
canal surfaces still remain uninstrumented
• and Cleaning of the canal in terms of soft tissue removal and elimination of bacteria
Relies heavily on the adjunctive action of chemically active irrigating solutions.
 HISTOR
Y
• Until the advent of the 20th century, water was perhaps the most commonly used endodontic irrigant

• It was
• readily available
• Inexpensive
• Provided some amount of lubricating effect

• 1st world war – Dakin’s solution

• 1936 – walker – sodium hypochlorite (Crane 1920)

• 1940 – Grossman & Grossman & Meiman – 3% hydrogen peroxide & 5.25% sodium hypochlorite
• 1930 – 1940 : Proteolytic enzymes – Streptodonnase, Papain, Enzymol & purified Trypsin

• 1920 – 1940 : Strong acids – 20 – 50% Sulfuric acid, Hydrochloric & Nitric acid, 50% Aqua
Regia.

• 1957 : Nygard Ostby – EDTA

• 1960s : RCprep & Glyoxide

• 1970s & early 80s : Chlorhexidine

• Recent advances : Ruddle’s solution & MTAD

 IDEAL PROPERTIES OF IRRIGANTS:
• Effective germicide and fungicide
• Non irritating to the periapical tissues.
• Remain stable in solution
• Prolonged antimicrobial effect.
• Active in the presence of blood serum and protein derivative of tissues.
• Have low surface tension
• Should not interfere with repair of periapical tissues
• Capable of inactivation in culture medium
• Should not induce a cell mediated immune response.
• Be able to completely remove the smear layer and disinfect underlying dentin.
• Non antigenic non carcinogenic and non toxic to surrounding tissues.
• No adverse effects on physical properties of dentin
• No adverse effects on sealing ability of filling materials
• Inexpensive and convenient application.
 FUNCTIONS:
• lubrication of the canal system which facilitates instrumentation

• dissolution of remaining organic matter

• antibacterial properties

• Chelating action

• Certain irrigants can cause a bleaching action.

• softening and removing the smear layer

• penetrating into areas inaccessible to instruments thereby extending the cleaning processes
Volume of the irrigant Temperature of the Diameter of the prepared
used irrigant canals

Concentration of the Frequency of irrigation

irrigant FACTORS
AFFECTING THE
EFFICACY OF Age of the
ROOT CANAL irrigating
Length and time IRRIGANTS
of intra-canal solution
contact

Surface tension of the

irrigant
diameter of the Depth of penetration
irrigating needle
 CLASSIFICATION:
CHLORIN
E OXIDIZIN
RELEASIN G AGENTS CHELATIN ORGANIC Inorganic DETERGE
OTHERS
G AGENTS G AGENTS ACIDS acids NTS

Chlorhexidine
POTASSIUM
HYPOCHLORITE HYDROGEN
EDTA Citric acid HCL 30% Bis- dequalinium
PEROXIDE
ZEPHIRAN acetate Antibiotics
CHLORIDE
MTAD
SODIUM
HYPOCHLORITE
Electrochemically
activated water
UREA PEROXIDE RC-PREP Maleic acid NITRIC ACID
Propolis
SODIUM DICHLORO
ISOCYARUNATE
Ozone

ENDOQUIL
Photodynamic therapy
GLYOXIDE EDTAC Tannic acid H2SO4 50%
CHLORAMINE –T
Lasers
 SALINE :

• From a biologic view point it is the safest irrigant.

• In isotonic concentration (0.9w/v) it produces no recognizable tissue damage and it can flush
debris from the canals.

• It can be used as an alternative in patients sensitive to other powerful irrigants and as final
flushing at the end of biomechanical preparation.

• Normal saline accomplishes gross debridement but do not possess antimicrobial property.
 DISADVANTAGES:

• - Absent antimicrobial property

• - Incapable of removing smear layer
• - Incapable of dissolution of necrotic tissue
• [ Hassel Gren, Olsson & Crek JOE, 1988 ]

• A study done by Morgan et al showed that isotonic solution dissolved a mean 10.48% of tissue, not
statistically different from calcium hydroxide 11.94%.

• Belltz el al showed that isotonic solution pH 5.0 solubalized higher percentage of pulpal mass than MTAD
pH 2.2 or EDTA pH 8.
 SODIUM HYPOCHLORITE

• Most popular irrigating solution used as an irrigant for well over many decades.
• It was first recommended by Henry Dakin in 1915 and was called as DAKIN‘s solution
during the time of World War-ll
• NaOCI 0.5% buffered with sodium biocarbonate was used for treatment of infected
wounds.
• Commercially available household bleach (Chlorox – 5.25% available chlorine) was first
recommended by Lewis (1954), and has since gained wide acceptance.
• ANTIMICROBIAL ACTION-
• NaOCl has a broad spectrum antimicrobial activity -
• It can rapidly kill vegetative bacteria, spore forming bacteria, fungi, viruses, and bacterial
spores.

• Tissue solvent property-

• 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.
 VARIOUS
CONCENTRATIONS

• NaOCL has been used in various concentrations ranging from 0.5- 5.25%.
• the ADA (American Dental Association) accepted concentration for clinical use of NaOCl
as an irrigant is 5.25% (Cunningham et al. 1980).
• The antibacterial effectiveness and tissue dissolving capacity of NaOCl is a function of its
concentration but so is its toxicity
• Thelower and higher concentrations are equally efficient in reducing the number of
bacteria in infected root canal
• But the tissue dissolvingeffect is directly related to the concentration
• Baumgartner and Cuenin commented that- The effectiveness of low concentrations of
NaOCl may be improved by using larger volumes of irrigant and replenishing fresh
solutions into the canal more frequently
Effect of temperature
• On pulp dissolution capacity
• According to Waltimo, the capacity of a 0.5% NaOCl at 45°C to dissolve human dental
pulps was found to be equal to that of a 5-25% solution at 20°C .
• While at 60°C 0.5% solution was significantly more effective.

Clinically warming NaOCl in a water bath at 60ºC

Effect of temperature:
• On antimicrobial efficacy
• A 100- fold increase in killing efficacy of E.feacalis was observed between the
corresponding NaOCl solutions at 20°C and 45°C in a study conducted by George et
al( 2005)
 MECHANISM OF ACTION

• Pecora et al. reported that NaOCl exhibits a dynamic balance as is shown by the reaction:
• NaOCl + H2O ↔ NaOH + HOCl ↔ Na+ + OH− + H+ + OCl−

• The chemical reactions between organic tissue and NaOCl are shown in Schemes-
 • O= R – C – O – R +NaOH ↔ R – C – O – Na + R –
Saponificati
OH Fatty acid sodium hydroxide Soap
on reaction Glycerol

Amino acid
neutralizatio
n reaction
Amino acid sodium hydroxide salt water

Chloraminati
on reaction
• When hypochlorous acid, comes in contact with organic tissue it acts as a solvent and
releases chlorine, which combines with the protein amino group to form chloramines
• Hypochlorous acid (HOCl−) and hypochlorite ions (OCl−)lead to amino acid
degradation and hydrolysis.
• The chloramination reaction between chlorine and the amino group (NH) forms
chloramines that interfere in cell metabolism.
• Chlorine (a strong oxidant) has an antimicrobial action, inhibiting bacterial enzymes
and leading to an irreversible oxidation of SH groups (sulphydryl group) of essential
bacterial enzymes.
Antimicrobial efficiency:

• 1% NaOCl has found to kill both bacterial spores and HIV over a period of 30 minutes.

• 1% NaOCl requires 1 hour to kill Candida albicans.

• Ruff et al found that 1 min application of 6% NaOCl & 2% CHX were equally effective in
eliminating microorganisms and superior to MTAD and 17% EDTA in eliminating Candida albicans
infections .

• Williamson et al (JOE 2009) – 1 min of 6% solution reduced enterococci in biofilm by 7-8 orders
of magnitude.

Williamson AE, Sandor AJ, Justman BC: A comparison of three nickel-titanium rotary systems, endosequence , protaper universal and profile GT for canal- cleaning ability. J Endod
2009;35;217.
• Zehnder et al (JOE- 2002) – 15 min at .25% in contaminated dentin blocks deactivates
enterococci.
Zehnder M, Kosicki D,Luder H, Sener B, Waltimo T. Tissue dissolving capacity and antibacterial effect of buffered and
unbuffered hypochlorite solution. OOOe 94: 756,2002.

• Radcliffe et al (IEJ) – 10 sec at .5% in direct contact with bacteria, inhibits the growth of
the actinomyces organisms.
Radcliffe CE, quershi R, Worthington H. An antimicrobial activity of vaying concentration of sodium hypochlorite on the
endodontic microoganisms actinomyces israelli, a. naeslundii. IEJ 37;438:2004.

• Ruff et al (JOE-2006) – 1 min of 6% solution: no growth of Candida.

Ruff ML, McClanahan SB, Babel BS. In vitro antifungal efficacy of four irrigants as a final rinse. J ENDOD 32;331,2006
 EFFECTS OF NAOCI ON:
• Smear layer removal- minimally removes dentin debris or smear layers.Therefore,
concurrent use of dimineralizing agents is recommended.

• Bond Strength- decreased bond strength between dentin and resin cements and may require
a reversal agent because of its ability to affect the polymerization of the resin sealer. Agents
such as ascorbic acid or sodium ascorbate have been shown to completely reverse this
reduction in bond strength.
• Corossion of NiTI instruments-
It is supposed that these microstructural defects can lead to areas of stress collection and
crack formation, weakening the structure of the instrument (Oshida et al. 1992)
and decreases the cutting effieciency of endodontic files (Stokes et al. 1999)
 INTERACTION BETWEEN NAOCL AND CHX
• The reaction between NaOCl and CHX produces a carcinogenic product, parachloroanaline .
• The precipitate is an insoluble neutral salt formed by the acid-base reaction between NaOCl
and CHX.
• When mixed with NaOCl, CHX molecules become hydrolyzed into smaller fragments, each
forming a byproduct.
• Leaching of PCA from the insoluble precipitate formed is of concern because it has been
shown to be cytotoxic in rats and possibly carcinogenic in humans.
• This reaction coats the canal surface and significantly occludes the dentinal tubules and
affects the seal of the root canal.
Orange precipitate formed by mixing CHX & NaOCl
 ADVERSE EFECTS OF SODIUM HYPOCHLORITE:

SODIUM HYPOCHLORITE ACCIDENT:

• The inadvertent injection of NaOCI into the soft tissues can elicit a violent and frightening response.

• When the apical constriction has been destroyed during root canal preparation or by resorption.
• may occur in teeth with wide apical foramina
• Additionally, can occur
-extreme pressure during irrigation
• -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.
• Symptomatology:
• Pain- Immediate severe pain ( 2-6 minutes)
• Oedema- Immediate oedema of neighbouring soft tissues
Possible extension of oedema
• Bleeding- Profuse bleeding from the root canal
Profuse interstitial bleeding with haemorrhage of the skin and mucosa (ecchymosis)
• Reversible anaesthesia or paraesthesia possible
 MANAGEMENT-

• Stop treatment and give an explanation to the patient- Remain Calm Reassure patient.

• Immediately irrigate with copious amounts of saline

• Evaluate airway

• Pain control
• Immediately with a nerve block
• Prescribe analgesics

• Corticosteroids for 3 days.

• Triamcinolone
• 8mg Doxona I.M
• Consider incision and trephination if deemed necessary

• Antibiotics for 1 week

• Prophylactic: Penicillin & Metronidazole

• Cold compresses for first 6 hours followed by warm compresses and mouth rinses – 1 week.

• PREVENTION -
• Prevention of inadvertent extrusion of irrigant past apex. Measures include:
• Express intra canal irrigant slowly
• Passive needle placement in canal (especially if beveled)
• Watch for flow back of irrigant
• Procedure to be performed under Rubber Dam
 HYDROGEN PEROXIDE
• In 1943, Grossman introduced 3% Hydrogen peroxide as an Endodontic irrigant which was
recommended to be used alternately with Sodium Hypochlorite to have disinfecting and
bleaching effects of both solutions

• Ohara, Torabinejad & Kettring comparatively evaluated 3% H2O2 to other contemporary

irrigants with respect to it’s anti-microbial efficiency and found it to be moderate to the
anaerobic pathogens.

• Their interaction in the canal produced a transient but energetic effervescence because of the
production of nascent oxygen.

• This was responsible for forcing debris and microorganism out of the canal.
• H2O2 does not possess tissue dissolving properties, nor is it a lubricant. It has a limited
antimicrobial action only.

• In contrast, Harrison et al have shown that using equal amounts of 3% Hydrogen peroxide
and 5.25% NaOCl inhibited the antibacterial action of the irrigant

• When irrigating with Hydrogen peroxide the last irrigant used should be NaOCl to prevent
any nascent oxygen from being trapped in the canal.

• MECHANISM OF ACTION-
• It involves the reaction of superoxide ion to produce hydroxyl radicals which are the
strongest oxidants known .
• These radicals can attack to membrane lipids, DNA and other essential components.
• According to OHALA et al :It took 15 mins for hydrogen peroxide to kill bacteria at concentration of 0.3% .

• It has been used as an endodontic irrigant for many years mainly in concentration ranging between 3% to 5%.

• It is active against bacteria, viruses, and yeasts. Hydroxyl free radicals ( ͘OH) destroy protiens and DNA.

• The tissue dissolving capacity of H2O2 is clearly lower than that NaOCl .

• When used in combination with NaOCl bubbling will occur as a result of nascent oxygen being released
through the chemical reaction between these two liquids.

• Generally this is no longer recommended as a routine irrigant.

• It has synergistic action with CHX.

 CHLORHEXIDINE
-
• Chlorhexidine digluconate is widely used in disinfection because of its excellent antimicrobial
activity. However, it completely lacks tissue dissolving capability.

• Chlorhexidine in the form of a salt, has been used since the 1950’s at different concentrations as an
oral antiseptic in the form of a Mouthwash, sub gingival irrigant, gel, toothpaste & chewing gum.

• CHX has a wide range of activity against both Gram positive and Gram negative bacteria.

• CHX is an effective antifungal agent especially against C. albicans.

• The effect of CHX on microbial biofilms is significantly less than that of NaOCl.

• CHX has antibacterial substantivity in dentine for up to 12 weeks.

 STRUCTURE AND MECHANISM OF ACTION-

• CHX is a synthetic cationic bis-guanide that consists of two symmetric 4-chlorophenyl

rings and two biguanide groups connected by central hexam-ethylene chains.

• CHX is a positively charged hydrophobic and lipophilic molecule that interacts with
phospholipids and lipopolysaccharides on the cell membrane of bacteria and enters the
cell through some type of active or passive transport mechanism
• This alters the cells’ osmotic equilibrium. This increases the permeability of the cell wall,
allowing the CHX molecule to penetrate into the bacteria.

• Damage to this delicate membrane is followed by leakage of intracellular constituents,

particularly phosphate entities such as adenosine triphosphate and nucleic acids.

• As a consequence, the cytoplasm becomes congealed, with resultant reduction in leakage;

thus, there is a biphasic effect on membrane permeability.

• CHX antimicrobial activity is pH dependant, with the optimal range being 5.5–7
 ANTIBACTERIAL
ACTIVITY-
• Basson and Tait compared the ex vivo effectiveness of calcium hydroxide, iodine potassium
iodide (IKI), and CHX solution in disinfecting root canal systems that were infected with
Actinomyces israelii.
• CHX was the only disinfectant that was able to eliminate A israelii.
• Oncag et.al evaluated the antibacterial properties against Enterococcus faecalis of 5.25%
NaOCl, 2% CHX, and 0.2% CHX plus 0.2% cetrimide after 5 min and 48 h.
• The 2% CHX and Cetrexidin were significantly more effective against E faecalis.

• Both the 2% gel and 2% liquid formulations of CHX eliminated Staphylococcus aureus and
Candida albicans within 15 sec, whereas the gel formulation killed E faecalis within 1 min.
 EFFECT OF CHX ON DENTIN-

• CHX has the ability to bind anionic molecules such as phosphate present in the structure of
hydroxyapatite.

• Phosphate exists in calcium carbonate complexes in dentin.

• CHX can bind phosphate, which leads to release of small amounts of calcium from the root
canal dentin.
 INTERACTION OF CHX AND EDTA-
• When CHX and EDTA interact, a precipitate is formed that is over 90% CHX and EDTA,
with less than 1% of the potential decomposition product, p-chloroaniline.

• The high recovery indicates that CHX is not degraded by EDTA under normal conditions.
The precipitate is most likely a salt formed by electrostatic neutralization of cationic CHX
by anionic EDTA.

• The suspected net ionic equation is:

• 2HEDTA-2(aq)+ 3H2CHX+2(aq) = (HEDTA)2 (H2CHX)3(s).

• The clinical significance of this precipitate is largely unknown

 SUBSTANTIVITY:
• White et al. evaluated the antimicrobial substantivity of a 2% CHX solution as an
endodontic irrigant and reported that the substantivity lasted 72 h.

• Khademi et al. found that 5-min application of 2% CHX solution induced substantivity for
up to 4 weeks.

• Rosenthal et al. evaluated the substantivity of 2% CHX solution within the root canal
system after 10 min of application and they reported that the CHX was retained in the root
canal dentine in antimicrobially effective amounts for up to 12 weeks.

• Antimicrobial substantivity depends on the number of CHX molecules available to interact

with the dentine.
 CHX AND DENTINE BONDING
(ANTICOLLAGENOLYTIC ACTIVITY)
• Human dentin contains collagenase (MMP-8), gelatinases MMP-2 and MMP-9, and enamelysin
MMP-20 .

• Dentine collagenolytic and gelatinolytic activities can be suppressed by protease inhibitors,

indicating that MMP inhibition could be beneficial in the preservation of hybrid layers.

• CHX, known to have a broad-spectrum MMP inhibitory effect significantly improved the
integrity of the hybrid layer in a 6-month clinical trial.

• Auto-degradation of collagen matrices can occur in resin-infiltrated dentine but may be prevented
by the application of a synthetic protease inhibitor such as CHX On the whole, because of its
broadspectrum MMP-inhibitory effect, CHX can significantly improve the resin–dentine bond
stability
 CYTOTOXICITY OF
CXH:
• Ribeiro et al. evaluated the genotoxicity (potential damagetoDNA) of formocresol,
paramonochlorophenol,calcium hydroxide, and CHX against Chinese hamster ovary cells.

• Results showed that none of the mentioned agents contributed to DNA damage. Thus,in the
clinically used concentrations, the biocompatibility of CHX is acceptable.
 ALLERGIC REACTIONS:

• to CHX Contant dermatitis is a common adverse reaction.

• CHX may have a number of rare side effects, such as desquamative gingivitis, discoloration
of the teeth and tongue.
 IODINE-
• Iodine compounds are the oldest disinfectants still actively used.

• They are best known for their use on skin surfaces and operation field.

• Two iodine preparations are used as endodontic irrigants

• Povidone iodine – 10%

• Iodine Potassium Iodide 2%

• I2 is the active antimicrobial component. Iodine penetrates rapidly into the microorganisms and cause cell death by attacking
protiens, nucloetides, and other key molecules of the cell.

• Low toxicity

• E.faecalis is often associated with therapy resistant periapical infections and combinations of IKI and CHX may be able to
kill calcium hydroxide resistant bacteria more efficiently.
 CHELATING AGENTS -

• Although NaOCl appears to be the most desirable single endodontic irrigant, it cannot dissolve
inorganic dentin particles and thus remove the smear layer formed during instrumentation.

• In addition calcifications hindering mechanical preparation are frequently encountered in the canal
system which cannot be negotiated without use of chelating agents.

• Demineralizing agents such as EDTA and citric acid have therefore been recommended as adjuvant
in root canal therapy
• The term chelate originates from Greek word "chele" (crab claw)

• Chelates are particularly stable complexes of metal ions with organic substances .
 EDTA-
• Nygaard - Ostby in 1957 introduced EDTA .

• EDTA is an insoluble, odorless, crystalline white powder; it is relatively non toxic & only slightly irritating
in weak solutions.

• Has a pH of 7

• The disodium salt of EDTA is the usual form employed in dentistry, adequately buffered to 10-15%

• Self Limiting Action Cohen & Burns: Functions of EDTA

• -Lubrication
• -Emulsification
• -Smear Layer removal
• EDTA has been dispensed in two forms – Viscous and Aqueous.
• Of the above three functions listed, a viscous product is used for the first two during canal
preparation whereas the aqueous solution is used as a final flush after shaping and cleaning
for smear layer removal
• Ethylenediaminetetraacetic acid (EDTA) is a chelating agent can bind to metals via four
carboxylate and two amine groups. It is a polyamino carboxylic acid and a colorless, water-
soluble solid, which is widely used to dissolve lime scale.
• It is produced as several salts, notably disodium EDTA and calcium disodium EDTA.
• EDTA reacts with the calcium ions in dentine and forms soluble calcium chelates.
• EDTA & SMEAR LAYER-

• It is reported that though EDTA was effective in removing smear layer from the coronal
aspect of the canal, it failed to do so from the apical third.

• Barnett showed that the tubular structure of the root canal was more completely cleaned
when EDTA & urea peroxide were used alternately.

• Based upon these studies, it was said that the use of a high volume flush with 17% EDTA
followed by NaOCl would effectively remove the smear layer. Whilst EDTA would remove
the inorganic substance, NaOCl would be capable of dissolving pulpal remanants &
predentin.
• Isabel et al conducted a study to verify the impact of the final rinse technique on smear layer
removal ability of 17% ethylenediaminetetraacetic acid (EDTA) and it was concluded that a
continuous rinse with 5 mL of EDTA for 3 minutes can more efficiently remove the smear
layer from root canal walls.

• Maria et al conducted a study to analyze, in vitro, by scanning electron microscopy (SEM),

the effect of EDTA at concentrations of 3%, 5%, 10% and 17% for 1 and 3 minutes, on the
removal of the smear layer and opening of dentinal tubules and concluded that regarding the
smear layer removal and dentinal tubule opening, the efficacy of EDTA is not altered with the
increase of the application time from 1 to 3 minutes.

• (Maria de Fáti ma MALVA Gesteira, Silvio José ALBERGARIA da Silva. Action of 1- and 3-Minute EDTA Applications on the
Smear Layer Pesq Bras Odontoped Clin Integr, João Pessoa, 9(3):367-372, 2009)
 HEBP :
• HEBP (1-hydroxyethylidene- 1, 1-bisphosphonate), also known as etidronic acid or
etidronate, has been proposed as a potential alternative to EDTA or citric acid because this
agent shows no short-term reactivity with NaOCl.

• HEBP is nontoxic and has been systematically applied to treat bone diseases. The
demineralization kinetics promoted by both 9% HEBP and 18% HEBP were significantly
slower than those of 17% EDTA.

• De-Deus et al. reported that the soft chelating irrigation protocol (18% HEBP) optimized
the bonding quality (3.1–6.1 MPa) of Resilon/Epiphany.
 CITRIC ACID
• The use of 10% citric acid as final irrigation has shown good results in smear layer removal.
• In vitro studies have shown their cytotoxicity, and 10% citric acid has proven to be more
biocompatible than 17% EDTA-T and 17% EDTA.

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

Moliz MT, Luque CM, García ME, Baca P. Enterococcus faecalis Biofilms eradication by root canal irrigants. J Endod
2009
 Q MIX :
• QMix 2 in 1 solution contains a mixture of a bisbiguanide antimicrobial agent, a
polyaminocarboxylic acid calcium-chelating agent, and a surfactant, and has been found to
be effective against bacterial biofilms.

• To evaluate the biocompatibility of a new root canal irrigant Q mix™ 2 in 1 in comparison

to 0.9% sterile saline, 3% sodium hypochlorite (NaOCl), 2% chlorhexidine (CHX), and 17%
ethylenediaminetetraacetic acid.

•  The results of this study indicate that QMix™ 2 in 1 solution is less toxic to the rat
subcutaneous tissue than 3% NaOCl, 2% CHX, and 17% EDTA. QMix™ 2 in 1 may
therefore be considered safe for use as a final irrigant after NaOCl.

Chandrasekhar V, Amulya V, Rani VS, Prakash TJ, Ranjani AS, Gayathri C. Evaluation of biocompatibility of a new root canal
irrigant Q MixTM 2 in 1- An in vivo study. Journal of Conservative Dentistry : JCD. 2013;16(1)
 MALEIC ACID:
• Maleic acid is a mild organic acid used as an acid conditioner in adhesive dentistry.

• Ballal et al. reported that final irrigation with 7% maleic acid for 1 min was more efficient
than 17% EDTA in the removal of smear layer from the apical third of the root canal system.

Ballal NV, Kandian S, Mala K, Bhat KS. Comparison of the efficacy of maleic acid and ethylenediaminetetraacetic acid in
smear layer removal from instrumented human root canal: A Scanning Electron Microscopic Study. J Endod 2009
 NEWER ROOT CANAL IRRIGANTS:
• (1) MTAD,
• (2)Tetraclean,
• (3) Electrochemically activated solutions,
• (4) Ozonated water,
• (5) Photon-activated disinfection,
• (6) Herbal irrigants
 MTAD AND TETRACLEAN:
• Recently MTAD and tetraclean , two new irrigants based on a mixture of antibiotics, citric acid
and a detergent, have been developed.

• MTAD is the first irrigating solution created which is capable of removing the both the smear layer
and disinfecting root canal system.

• It is a mixture of 3% doxycycline , 4.25% citric acid and 0.5% polysorbate-80 (Tween 80) detergent.

• Commercially available as Biopure MTAD (DENTSPLY TULSA DENTAL, TULSA, OK), it is

mixed as a liquid and powder prior to use.

• MTAD has been recommended as final rinse after completion of conventional chemomechanical
preparation
• Tetraclean (Ogna Laboratori Farmaceutici, Muggio, Italy) is another combination product similar to MTAD.

• The two irrigants differ in concentration of antibiotics (doxycycline 150mg/5ml for MTAD and 50mg/5ml of
Tetraclean) and kind of detergent (Tween 80 for MTAD and polypropylene glycol for Tetraclean).

• MTAD and smear layer

• Although MTAD removes most of the smear layer some remnants of the organic component are left scattered on root
canal wall surface.

• Effectiveness is enhanced when low concentrations of NaOCl are used as intra canal irrigant before the use of MTAD
as final rinse.

• Antimicrobial effect
• MTAD appears to be more effective than 5.25% NaOCl in disinfecting root canals after the removal of the smear
layer.

• Has the capability to kill E. faecalis. Tetraclean caused a high degree of biofilm disaggregation at each time interval
when compared with MTAD.
• Mancini et al conducted a study to compare the efficacy of Bio-Pure MTAD (Dentsply Tulsa,
Tulsa, OK), 17% EDTA, and 42% citric acid in endodontic smear layer removal and degree of erosion
in the apical third of endodontic canals and the results showed that efficacy of BioPure MTAD and
17% EDTA in removing the smear layer was significantly greater than 5.25% NaOCl (control).

• (Manuele Mancini, Emiliano Armellin, A comparative study of smear layer removal and erosion in apical intraradicular dentine with three
irrigating solutions: a scanning electron microscopy evaluation. JOE 2009,35,6 Pages: 900-903).

• Gevik et al conducted a study to evaluate the antibacterial efficacy of a final rinse with BioPure
MTAD (MTAD) and intracanal medication with 2% chlorhexidine gel (CHX) in teeth with apical
periodontitis and it was concluded that the final rinse with MTAD and medication with CHX did not
reduce bacterial counts beyond levels achieved by canal preparation with NaOCl.

• Gevik Malkhassian, Aldo J. Manzur . Antibacterial Efficacy of MTAD Final Rinse and Two Percent Chlorhexidine Gel Medication in Teeth with
Apical Periodontitis: A Randomized Double-blinded Clinical Trial. Journal of Endodontics November 2009(Vol. 35, Issue 11,Pages 1483-1490)
• MTAD is less cytotoxic than eugenol, 3%hydrogen peroxide,calciumhydroxide
paste,5.25%NaOCl,Peridex,and EDTA and more cytotoxic than 2.63%, 1.31%, and 0.66%
NaOCl.

• MTAD can be a useful irrigant due to its antimicrobial property, less cytotoxic,but its
effectiveness against fungi and value in the apical one third need to be assessed further.
 ELECTROCHEMICALLY ACTIVATED
SOLUTION
• It is produced from tap water and salt solutions.

• The ECA technology represents a new scientific paradigm developed by Russian scientists at
the All-Russian Institute for Medical Engineering.

• Principle of ECA is transferring liquids into a metastable state via an electrochemical

unipolar (anode or cathode) action through the use of an element/reactor (“Flow-through
Electrolytic Module” or FEM). The FEM consists of an anode, a solid titanium cylinder with
a special coating that fits coaxially inside the cathode.
• A ceramic membrane separates the electrodes. The FEM is capable of producing types of
solutions that have bactericidal and sporicidal activity; yet they are odourless, safe to human
tissue, and essentially noncorrosive for most metal surfaces

• Anolyte solutions containing a mixture of oxidizing substances demonstrate pronounced

microbiocidal effectiveness against bacteria, viruses, fungi, and protozoa .
• Anolyte solution has been termed Superoxidized Water or Oxidative Potential Water.

• The anolyte neutral cathodic solution (ANC) provides an increased antiseptic effect and an
enhanced cleaning ability at lower concentrations of active chlorine compared to the acidic
anolyte and anolyte neutral solutions because of its higher concentration of peroxides.
 OZONATED WATER:
Ozone is a chemical compound consisting of three oxygen atoms (O3–triatomic oxygen),
a higher energetic form than normal atmospheric oxygen (O2). Thus, the molecules of
these two forms are different in structure. Ozone is produced naturally by the following
natural methods.

(i) The first is from electrical discharges following thunderstorms. Ozone is created when
an oxygen molecule receives an electrical discharge breaking it into two oxygen atoms. The
individual atoms combine with another oxygen molecule to form an O3 molecule.

(ii) The second from ultraviolet rays emitted from the sun which plays the role of electrical
discharge over oxygen present in the stratosphere, thus, creating the ozone layer which
absorbs most of the ultraviolet radiation emitted by the sun.
• It was reported that ozone at low concentration, 0.1 ppm, is sufficient to inactivate bacterial
cells including their spores

• Although ozonated water is a powerful antimicrobial agent against bacteria, fungi, protozoa,
and viruses, less attention has been paid to the antibacterial activity of ozonated water in
bacterial biofilm and hence in root canal infection.

• Nagayoshi et al. found that killing ability of ozonated water and 2.5% of sodium
hypochlorite was almost comparable when the specimen was irrigated with sonication .

• Study by Hems et al. however found that NaOCI was superior to ozonated water in killing E.
faecalis in broth culture and in biofilm.
 GLY-OXIDE

• Another oxidizing agent, which is used, is gly-oxide. It is a combination of carbamide

peroxide and glycerol. Its germicidal action is greater than H2O2 and it is an excellent
lubricant .
• There are decreased chances of strip formation /perforation while instrumenting in curved
canals.

• It is better tolerated by periapical tissue than NaOCl yet has greater solvent action.
 PHOTON-ACTIVATED DISINFECTION
• The use of photodynamic therapy (PDT) for the inactivation of microorganisms was first
shown by Oscar Raab who reported the lethal effect of acridine hydrochloride on Paramecia
caudatum.

• PDT is based on the concept that nontoxic photo sensitizers can be preferentially localized in
certain tissues and subsequently activated by light of the appropriate wavelength to generate
singlet oxygen and free radicals that are cytotoxic to cells of the target tissue.

• Methylene blue (MB) is a well established photosensitizer that has been used in PDT for
targeting various gram-positive and gram-negative oral bacteria
• Soukos et al. used the combined effect of MB and red light (665nm) exhibited up to 97%
reduction of bacterial viability.
• Along with methylene blue, tolonium chloride has been also used as a photosensitizing
agent.
• The agent binds to the cellular membrane of bacteria, which will then rupture when activated
by a laser source emitting radiation at an appropriate wavelength.
• The light is transmitted into the root to a disposable handpiece. The laser emits a
maximum of only 100mW and does not generate sufficient heat to harm adjacent tissues.
• Furthermore, tolonium chloride dye is biocompatible and does not stain dental tissue. Lethal
photosensitization of Streptococcus intermedius biofilms in root canals is unable to achieve a
total kill rate when a combination of a helium-neon laser and tolonium chloride is used.
 HERBAL AGENTS:
• The search for more biocompatible and dentin friendly irrigants that can overcome the
limitations of these chemical antimicrobial irrigants is on the rise. Herbal products are
gaining popularity in every field of medicine, mainly due to their biocompatibility.

• The herbal extracts also possess high medicinal properties such as anti-oxidant,
antimicrobial, and anti-inflammatory properties which have favoured their use in
Endodontics for canal disinfection.
• ALOE VERA
• Bazvand et al. evaluated aloe vera as an intracanal medicament against Enterococcus
faecalis in comparison with the triantibiotic paste, CHX gel and propolis.
• He observed that though aloe vera was effective against E. faecalis, it was not as effective as
the triantibiotic paste and CHX gel .
• Bazvand L, Aminozarbian MG, Farhad A, Noormohammadi H, Hasheminia SM, Mobasherizadeh S. Antibacterial effect of triantibiotic mixture,
chlorhexidine gel, and two natural materials Propolis and Aloe vera against Enterococcus faecalis: An ex vivo study. Dent Res J (Isfahan) 2014

• Cinnamon (Cinnamomum zeylanicum)

• Cinnamon has been shown to have antibacterial efficacy against both E. faecalis and S.
mutans
• The antimicrobial effect has been attributed to the presence of essential oils like eugenol in
the cinnamon extract
 BEE GLUE (PROPOLIS)

• It is a natural antibiotic extracted from the honey bees. Propolis has been used in dentistry
owing to its antioxidant , antimicrobial and anti-inflammatory properties. It has been tried
for dentin disinfection in root canal treatment.
• Carbajal, study proved that in comparison with 2% CHX and calcium hydroxide (Ca(OH)2),
propolis possessed equally good antibacterial efficacy against E. faecalis; however, its
antifungal efficacy was less.
• The antimicrobial properties might be attributed to the presence of flavonoids.
 Green Tea (Camellia Sinesis)
• Epigallocatechin-3-gallate (EGCG) is the most abundant polyphenol in green tea. Lee and
Tan evaluated the effects of EGCG against E. faecalis biofilm and its virulence.
• They concluded that EGCG is an effective antimicrobial agent against E. faecalis and its
antimicrobial action might be due to the production of hydroxyl radicals .

Triphala
• In dentistry, it has been used because of their antimicrobial antiplaque, antigingivitis,
anticariogenic and anti-collagenase properties.
• Shakouie et al. compared the antimicrobial efficacy of triphala with various concentrations
of NaOCl against E. faecalis and reported that triphala exhibited better antimicrobial activity
against E. faecalis when compared to 0.5 and 1% NaOCl.
 TURMERIC (CURCUMA LONGA)

It has antimicrobial , antiinflammatory and antioxidant and antitumour activity.

• The main bioactive ingredient is Curcumin (diferuloylmethane) in turmeric.
• Curcumin also has been found to be a better disinfectant against E.faecalis both in its
planktonic and biofilm forms when used as a blue light photosensitizers.
• However, curcumin did not show any toxicity against odontoblast-like cells,
undifferentiated pulp cells and human embryonic stem cells .
 IRRIGATION DEVICES AND TECHNIQUES
• The effectiveness and safety of irrigation depends on the means of delivery. Traditionally,
irrigation has been performed with a plastic syringe and an open-ended needle into the canal
space. An increasing number of novel needle-tip designs and equipment are emerging in an
effort to better address the challenges of irrigation.
 SYRINGE DELIVERY:
• Plastic syringes of different sizes (1–20 mL) are most commonly used for irrigation. large-
volume syringes- allow some time-savings, but are more difficult to control for pressure and
accidents may happen. so, to maximize safety and control, use of 1- to 5-mL syringes is
recommended instead of the larger ones.
• All syringes for endodontic irrigation must have a Luer-Lok design.
• Because of the chemical reactions between many irrigants, separate syringes should be
used for each solution.
 NEEDLES-

Gauges ranging from standard 22 to finer 30 have been used in endodontic irrigation.

Since irrigation of the apical third requires the needle to be in close proximity for adequate effect the canals
should be flushed with a 27-30 gauge preferably.

It should be bent approximately 30degrees in the center of the needle to allow easier delivery of the
solution and to prevent deep penetration of the needle or probe.
Monoject type- Bevelled needle Irrigant Safe ended tip
irrigant passes sideways and passes apically Irrigant passes sideways
apically
 MANUALLY ACTIVATED IRRIGATION:

• Coronal-apical movement of irrigating needles, stirring movements with small endodontic

instruments and Apically fitting gutta-percha cones used in an up-and-down motion have
been recommended.
• Although this facilitates the exchange of the apical solution, the overall volume of fresh
solution in the apical canal is likely to remain small.
ENDOACTIVATOR
• Vibringe
• Vibringe is a new sonic irrigation system that combines battery-driven vibrations (9000
cpm) with manually operated irrigation of the root canal.

• RinsEndo
• The RinsEndo system is based on a pressure-suction mechanism with approximately 100
cycles per minute.
• A study of the safety of several irrigation systems reported that the risk of overirrigation
was comparable with manual and RinsEndo irrigation, but higher than with EndoActivator
or the EndoVac system.
 ENDOVAC

• EndoVac system is based on a negative-pressure approach whereby the irrigant placed in the
pulp chamber is sucked down the root canal and back up again through a thin needle with a
special design
• There is evidence that, compared with traditional needle irrigation and some other systems,
the EndoVac system lowers the risks associated with irrigation close to the apical foramen
considerably.
• Another advantage of the reversed flow of irrigants may be good apical cleaning at the 1-
mm level and a strong antibacterial effect when hypochlorite is used, as shown by recent
studies.
 ULTRASONIC
IRRIGATION:
• Ultrasonic devices were first introduced in Endodontics by Richman (1957).
• Ultrasonically activated files have the potential to prepare and debride root canals mechanically.
• The files are driven to oscillate at ultrasonic frequencies of 25–30 kHz
• The files operate in a transverse vibration, setting up a characteristic pattern of nodes and anti-
nodes along their length (Walmsley 1987, Walmsley & Williams 1989).
• Ultrasonic irrigation has been shown not very effective for shaping the root canal.
• On the other hand it has been shown that ultrasonically driven files are effective for the ‘irrigation’ of
root canals.
 MECHANISMS INVOLVED
• 1. CAVITATION:
• When a vibrating object is immersed in a fluid, oscillations are set up in the liquid.
• During the rarefaction phase, the liquid can fail under stress & form bubbles. (This is termed
PSEUDOCAVITATION by Cameron)
• During the next positive pressure phase, these vapor filed cavities collapse implosively
producing a high temperature and pressure of the gas still contained within the cavity.
• These high temperatures & pressures in turn result in free radical generation & radiate shock
waves from the collapse which leads to it’s WATER HAMMER ACTION on solid surfaces.
• 2. ACOUSTIC STREAMING

• Definition: Rapid movement of particles of fluid in a vortex like motion

about a vibrating object but may also be associated with small gas bubbles
set into oscillation by the fluctuating pressure field generated by the file.
• Ahmad et al (JOE 1987) found a streaming pattern where liquid was
transported from the apical end to the coronal end of the file in a region
very close to the file.
• An irregular array of rapid eddying motions was observed concentrated at
the apical end of the file. This would be capable of dislodging debris &
microorganisms.
 ULTRASONICS & MICROBRUSHES:
• Advances in small wire technology, injection moulding processes, bristle materials & bristle attaching techniques
have led to the creation of an endodontic microbrush.
• Bristles can be attached to either-
- Braided wires or
- Flexible, plastic cores
• Fabricated as either rotary or ultrasonic endobrushes
• Contain 16mm of bristles with D0 bristle diameters of 0.40, 0.50, 0.60,
0.80mm.
• Have Non standardized Gutta Percha master cone tapers:
-Fine
-Medium
-Large
• Used in conjunction with NaOCI & EDTA to produce clean canals
 GENTLE WAVE SYSTEM:
• Gentlewave (GW) system aims to clean the root canal through generation of different
physiochemical mechanisms including a broad spectrum of sound waves.
• Non – instrumentational
• Multisonic waves are initiated at the tip of GentleWave handpiece, which is positioned
inside the pulp chamber .
• It delivers a stream of treatment solution from the handpiece tip into the pulp chamber while
excess fluid is simultaneously removed by the built-in vented suction through the handpiece.
• Upon initiation of flow through the treatment tip of the handpiece, the stream of the
treatment fluid interacts with the stationary fluid inside the chamber creating a force which
causes hydrodynamic cavitation. The continuous formation of microbubbles inside
cavitation cloud generates acoustic field with broadband frequency spectrum that travels
through the fluid into the entire canal
Photon-induced photoacoustic streaming (PIPS)

• PIPS is based on the radial firing stripped tip with laser impulses of subablative energies of
20 mJ at 15 Hz for an average power of 0.3W at 50 μs impulses.
• These impulses induce interaction of water molecules with peak powers of 400W. This
creates successive shock waves leading to formation of a powerful streaming of the
antibacterial fluid located inside the canal, with no temperature rising .

• the unique tapered PIPS tip is not mandatory to be placed inside the canal itself but rather
in the pulp chamber only.
• This procedure can effectively remove both vital and nonvital tissues, kill bacteria, and
disinfect dentin tubules
 CONCLUSION:

• The success of endodontic treatment is directly influenced by elimination of microorganisms

in infected root canals. The irrigant solutions are very important during root canal
preparation because they aid in the cleaning of the root canal, lubricate the files, flush out
debris, and have an antimicrobial effect and tissue dissolution, without damage to periapical
tissues. The selection of an ideal irrigant depends on its action on microorganisms and
periapical tissues.
 REFERENCES
:
• Endodontics by Ingle & Balkland , 6th edition
• Cohen & Burns , 10th edn
• Grossman & Oliet, 12th edn
• Baumgartner JC, Cuenin PR. Efficacy of several concentration of sodium
hypochlorite for root canal irrigation. J Endod 1987;18:605.
• Trepagnier CM,Madden RM, Lazzari EP. Quantitative study of sodium hypochlorite
as an in vitro endodontic irrigant. JOE 1977;3:194.
• Spångberg L, Engstrom B, Langeland K. Biological effects of dental materials: III.
Toxicity and antimicrobial effects of endodontic antiseptics in vitro. Oral Surg
1974;55:856.
• Bystrom A, Sundquist G. Bacteriological evaluation of the effect of 0.5 percent sodium hypochlorite
in endodontic therapy. Oral Surg 1983;55:307.
• Xiaolia Hu, Yanwena P, Chee-penga S. Effects of Concentrations and Exposure Times of Sodium
Hypochlorite on Dentin Deproteination: Attenuated Total Reflection Fourier Transform Infrared
Spectroscopy Study. J Endod 2010, 12: 2008-2011.
• Sen BH, Safavi KE, Spangberg LSW. Antifungal effects of sodium hypochlorite and chlorhexidine in
root canals. J Endodon 1999;25:235–8.
• Williamson AE, Sandor AJ, Justman BC: A comparison of three nickel-titanium rotary systems,
endosequence , protaper universal and profile GT for canal- cleaning ability. J Endod 2009;35;217.
• Zehnder M, Kosicki D,Luder H, Sener B, Waltimo T. Tissue dissolving capacity and antibacterial
effect of buffered and unbuffered hypochlorite solution. OOOe 94: 756,2002.