Introduction to Endodontics Forth Year

1. IRRIGANTS
AND
INTRACORONAL MEDICAMENTS

2. Primary
therapy
goals of
ELIMINATE INFECTION
endodontic
PREVENT REINFECTION
 CLEANING
 OBTURATION
 SHAPING
 CORONAL RESTORATION

3. CLEANING AND SHAPING
CHEMO MECHANICAL PREPARATION
CHEMICAL
 IRRIGANTS
 INTRACANAL MEDICAMENTS
MECHANICAL
 INSTRUMENTS

4. Objectives
 Removal of organic debris
 Elimination of bacteria

5. IRRIGANTS
Properties of an ideal irriganting solution
1.Organic tissue solvent
2.Inorganic tissue solvent
3.Antimicrobial action
4.Non – toxic
5.Low surface tension
6.Lubricant

6. 
Should be non irritating to periapical tissue

Should be an effective germicide and fungicide

Should be stable in solution

Should have prolonged antimicrobial effect

Should be active in presences of blood, serum proteins
derivatives of Tissue.

7. 
Should have low surface tension

Should not interfere with repair of periapical tissues

Should not stain tooth structure .

Should not induce a cell mediated immune response

8.  Irrigation solutions
 Lubricants
 Decalcifying / chelating agents

9. SODIUM HYPOCHLORITE
[ NaOCl ]
Commonly used household bleach [ Clorox ]
Most common and popular irrigant in endodontics
Advantages:
 Mechanical flushing of debris from the canal
 Tissue dissolving capacity → Vital + Non vital [necrotic]
 Antimicrobial action
 Lubrication
 Inexpensive
 Easily available

10. Cl
NaOCl
TISSUE
PROTEOLYTIC AGENT
PROTEINS
AMINO ACIDS

11.  Recommended concentration 0.2% → 5.25%
 Commonly used 2.5% - less toxic and retains the
tissue dissolving capacity and antimicrobial property.
 Decrease in concentration ↔ increase in volume
 Effectiveness can be improved by heating the solution
 NaOCl can act only when in contact with tissues
hence shaping with instruments is necessary

13. Sodium hypochlorite accident
Extrusion of the irrigant beyond the apical foramen causes
extensive tissue damage.
Preventive measures:
 The needle of the irrigating syringe should be placed loosely
within the canal
 The irrigant should not be pushed with force.
 The needle should not be introduced to the apex
 Side vented irrigating needle is used.
 The needle is agitated or moved up and down loosely to
agitate the liquid

14. NaOCl beyond root apex causes
•
Pain
•
Hematoma
•
Swelling
•
Hemorrhage
•
Inflammation of gingival tissue

15. Limitations

Toxic

Not active against E. faecalis

Ineffective at low concentrations.

Not substantive

Corrodes


Unpleasant odor.
Ineffective in smear layer removal.

16. CHLORHEXIDINE
 It is a Bisguanide
 It has a broad spectrum of anti microbial action
 Effective on a wide range of bacterial strains
E. faecalis
 Less toxicity
 NaOCl + CHX → increased effectiveness

17. Anti microbial action :
Adsorption to the surface of bacteria [due to cationic-anionic
electrostatic attraction]
Increase the membrane permeablility
Results in micro leakage of intracellular components leading
to cell death
CHX

18. SUBSTANTIVITY:
The chlorhexidine molecule gets attached to the dentin
of the root canal and release chlorhexidine slowly as the
concentration of
environment
D
e
n
t
i
n
CHX decreases in the surrounding

19. 
Normally used in concentrations between 0.12 and 2.0%

Extremely low level of tissue toxicity

Allergic reaction to CHX are rare

20. Disadvantages:
 Lack of tissue dissolving capacity
 Inability to remove the smear layer

21. SODIUM HYPOCHLORITE +CHLORHEXIDINE
It is seen that when a combination 2.5% NaOCl & 0.2 % CHX is
used in root canal could gain
1) an additive antimicrobial action
2) a tissue dissolving property that is better than that
obtained with
use of CHX alone
3) a solution less toxic then NaOCl

22. OTHER IRRIGATING SOLUTIONS
HYDROGEN PER OXIDE
[ H2O2 ]
It is an oxidizing agent .
It is almost used in conjunction with NaOCl
It acts by two mechanisms
1. The reaction with NaOCl produces effervescence
which mechanically pushes the debris out of the
canal
2. The nascent oxygen released acts as a powerful
antimicrobial agent especially for the anaerobic
organisms

23. Advantages:
 It produces less damage to the periapical tissues
 It is a good anti anaerobic agent
 The nascent oxygen produced tends to penetrate deeper into the tubules. Hence
very effective on bacteria residing deeper in the dentinal tubules.
 When used along with CHX, hydrogen peroxide dislodges the smear layer
allowing the CHX to be more effective
 A side effect which is beneficial is that it causes bleaching

24. Other agents:
•
SAVLON : Combination of 0.3% cetrimide and
0.03% CHx
•
OXIDATIVE POTENTIAL WATER
• SALVIZOL : root canal chelating irrigant
•
BDA (bis-dequalinium acetate): recommended as an
excellent substitute for sodium hypochlorite in those patients who
are allergic to the latter.
•
ELECTRO CHEMICALLY ACTIVATED WATER

26. PRO RINSE
MONOJECT

27. Ultrasonics [passive ultrasonic irrigation]
 Most of the dentine debris is inorganic
matter that cannot be dissolved by
NaOCl. Therefore, removal of dentine
debris relies mostly on the flushing
action of irrigant.
 The ultrasound device allow the
endodontic irrigant to pass along the
ultrasonic files. The irrigant is activated
by the ultrasonic energy imparted from
the energized instruments producing
acoustic streaming and cavitation

28. LUBRICANTS:

Facilitate the file movement during the cleaning and shaping
 Help in the initial canal negotiation especially in narrow
canals
 They reduce the torsional force on the instruments – reduce
the fracture potential

29. Commonly used lubricants;
 Glycerin
 Glycol + urea peroxide + EDTA
 EDTA 19% + 10 %
GEL]
[ RC PREP]
carbamide peroxide [DOLO ENDO

30. Disadvantages:
 EDTA compounds may cause deactivation of
NaOCl by reducing the available chlorine
 Toxic by product

31. SMEAR LAYER:
Cleaning and shaping → layer of
organic pulpal material
+
inorganic dentin debris
The layer may contain microorganisms
The smear layer may be 1 to 5 μ
Smear layer removal ?????????

32. Removal of the smear layer is the better option
 Enhance the irrigants to penetrate the dentinal tubules
 Enhance the penetration and adhesion of sealers

33. DECALCIFYING / CHELATING AGENTS
Agents that dissolve or dissolute the inorganic portions of the
root dentine [ calcified portions]
Ethylene di-amine tetra acetic acid [ EDTA]
Helps in the removal of the smear layer
Irrigation with 17% EDTA followed by the final rinse with
NaOCl is recommended

34. Chelators remove the inorganic portion of the debris leaving
behind the organic portions which can be dissolved or
removed with NaOCl
 Effect of EDTA is dependant on the time of contact with the
debris and the concentration
 Recommended time for the removal of the smear layer is 1 min
 EDTA supplied as a
•
liquid
•
paste

35. MTAD [ BIOPURE MTAD]
MTAD was developed by Mohmand Torabinajed et al
MTAD contains mixture of :
•
tetracycline isomer doxy cycline
•
acid- citric acid
•
a detergent - Tween 80
Antimicrobial activity of MTAD
MTAD has superior antimicrobial activity than 5.25% sodium
hypochlorite. The efficiency of MTAD in disinfecting surface of
the roots is a result of the presence of doxycycline.

36.  Generally used as a final rinse to remove the smear layer
 Effectiveness is enhanced when the canal is irrigated with
low concentration of NaOCl before the use of MTAD.
 1.3% recommended concentration
 Superior than NaOCl in antimicrobial action
 Doxycycline has the ability to bind the tubules and
gradually released over time
 Effective in killing E.faecalis
 Biocompatible
 Does not alter the properties of dentin
 Enhances the bond strength

37. INTRA CANAL MEDICAMENTS

38. PHENOLICS
ALDEHYDES

Eugenol

Formocresol

Camphorated monoparachloro phenol

Glutaraldehyde
[CMCP]

Parachlorophenol [PCP]
HALIDES

Camphorated parachloro phenol [CPC]

Sodium hypochlorite

Metacresylacetate

Iodine – potassium iodide

Cresol

Creosote [ beechwood]

Thymol
STERIODS
CALCIUM HYDROXIDE
ANTIBIOTICS
COMBINATION

39. MAIN PURPOSE FOR INTRACANAL MEDICAMENT
 To reduce interappointment pain
 To decrease the bacterial count and regrowth
 To render the canal contents inert

40. Physico-chemical properties

pH

Viscosity [Viscosity changes over time ]

Adhesion

Solubility

Radio-opacity

Working time

Sealing ability

41. Phenols and Aldehydes :
 Non specific in action
Destroy both
HOST TISSUES + MICRO-ORGANISMS
 Toxic
 Aldehydes fix the tissues
 May reach the periapical tissues → systemic circulation
EUGENOL:
 Part of root canal sealers, temporary filling
 Antiseptic & anodyne effect
 Effect is dose related
•
Low dose (anti-inflammatory activity): inhibits-Pg synthesis, nerve activity,WBC
chemotaxis
•
High dose (cytotoxic effect)- induces cell death, inhibits cell respiration

42. Calcium hydroxide

Ca(OH)2 widely used as an IM

pH 12 to 13

Antimicrobial activity is due to the high alkalinity

May aid in dissolving the tissue remnants, bacteria
and their by-products.

Recommended as an IM in root canals with necrotic
tissue and infected tissue

Little benefit with vital pulp

43. Can be placed in the canals as
 Dry powder
 Paste
: calcium hydroxide mixed with
→ water
→ local anesthetic solution
→ glycerin
→ chlorhexidine
 Proprietary paste supplied in syringes

44. The material is carried into the canal with the help of

lentulo spiral

using a file

injecting

45. Corticosteroids
 Anti-inflammatory agents
 Proposed to decrease Post operative pain and suppress
inflammation
 Can be used in patients with acute apical periodontitis
 Hydrocortisone + antibiotics
Chlorhexidine
 2% chlorhexidine gel
 When mixed with calcium hydroxide the antimicrobial
effect is greater
 Disadvantage :
does not remove the smear layer

46. COMBINATION
Corticosteroid + antibiotic
 Use of corticosteroid: reduces pain in inflamed tissue
and gives instant
relief
 Use of antibiotic: prevents overgrowth of bacteria
when the inflammation
subsides
Eg. Corti-sporin,Tetra-Cortil

47. Ledermix paste :
 Combination of a corticosteroid and
antibiotic
 Corticosteroid → Triamcinolone
acetonide
 Antibiotic →
Demeclocycline calcium

48. 
Frequency of placement:

Disinfectant dressing should be preferably
renewed in a week and not longer than 2 weeks

Medicaments used for apexification are used for
3-6 months