Irrigation in endodontics

Irrigation in Endodontics
Irrigation in Endodontics
Dr. Mohamed S. Zeglam
BDS, MFDS RCPS(Glasg), MSc (Rest Dent)
BDS, MFDS RCPS(Glasg), MSc (Rest Dent)

Introduction
• Success or failure in root canal therapy is
depending on the removal of all or most of
infective agents and necrotic material from
the entire root canal system.
• The purpose of root canal instruments is to
create sufficient space for the ingress of
effective irrigant solutions.

• Large areas of canal wall are
untouched
• Debris is pushed deeper
• Smear layer is generated
• Lateral canals are not entered
We therefore rely
on irrigants to help
overcome some
challenges

The objectives of irrigation are to:
Rinsing of debris
Penetrating into areas inaccessible
to instruments, thereby extending
the cleaning process.
Lubrication of the canal system
which facilitates instrumentation
Dissolution of remaining organic
matter
Antibacterial properties
Softening and removing the smear
layer
European Society of Endodontology, Int Endo J, 2006

Penetrating into areas
inaccessible to instruments,
thereby extending the cleaning
process.
matter
layer European Society of Endodontology, Int Endo J, 2006

The actions of an irrigant include:
matter
layer

matter
Softening and removing the
smear layer

HOWEVER…..
No single irrigant fulfills all of
these desired properties, more
than one solution are required
each with an adequate
concentration, formulation,
volume and time to act.
McDonnell G, Russell AD, Clin Microbiol Rev, 1999

Concentration
Volume
Canaldiameter
Theviscosityorsurface tensionof the solution
Thediameteranddepthof penetrationof theirrigating
needle
Anatomyofthe canal
Themethodof deliveringthe irrigant
Contacttimewiththe tissue
Temperature of theirrigant
Ultrasonic activation
Theeffect ofcombining different typesof solutions
Variables affecting the irrigation

• British Endodontic Society (BES)
• European Society of Endodontology (ESE)
• American Endodontic Society (AES)
currentlyhavenodetailedguidelines.
• On the use of endodontic ‘solutions’, it was
decided to undertake a literature review to
help inform in clinical practice

1. Sodium Hypochlorite (NaOCl)
2. Chlorhexidine (CHX)
3. EDTA
4. Iodine
5. Hydrogen peroxide
6. Sterile saline, water or LA
7. Other products and concepts
I. Antibiotics
II. Photo-activated disinfection (PAD)
III. Electronically Activated Water
IV. Laser
Irrigating solutions

Sodium hypochlorite (NaOCl)
Antibacterial agent
Dissolves vital and non-vital tissue.
Lubricant during instrumentation
NaOCl has been criticized for:
 Unpleasant taste
 Relative toxicity
 Inability to remove smear layer

2
 Sodium hypochlorite (NaOCl) is the solution most
commonly used to irrigate the canal.
Leonardo MR, et al J Endod 1999
Kuruvilla JR, et al J Endod 1998
 Various concentrations of sodium hypochlorite varying
from 0.5% to 5.25% have been recommended.
 NaOCl solutions and demonstrated greater cytotoxicity
on healthy tissue with 5.25% NaOCl than with 0.5%
and 1% solutions.
Pashley et al. 1985
 Therefore, due to its cytotoxisity at higher conc.,
0.5% to 1% is recommended.
Haapasalo et al Endo Top 2005
Concentration

 Higher temperatures potentiate the antimicrobial and
tissue-dissolving effects of NaOCl.
 Increasing the temperature of hypochlorite irrigant to
370C, significantly increased its tissue dissolving ability
Temperature
Cunningham &Balekjian 1980

 The volume of the irrigant has a greater potential to
significantly reduce bacteria colonies in root canal.
Volume
Baker et al. 1975, Brown and Doran 1975,
Cunningham 1982, Cunningham et al.1982,
Siqueira at al.2000, Sedgley et al.2005.

2% solution
20% solution
1% gel
0.2 % solution
0.12% solution
0.06% solution
Chlorhexidine

Chlorhexidine
• Broad-spectrum antimicrobial
• Substantive (more than 12 hours)
• No tissue solvent activity
Do not mix with NaOCl: generates a rust colour
precipitation called Para-chloroaniline
Chlorhexidine
This insoluble salt as a precipitate can be
prevented using absolute alcohol and
minimized using saline and distilled water
as intermediate flushes
Krishnamurthy S, et al. J Endod 2010

• The +ve charged ions released by CHX can absorb into
dentine and prevent microbial colonization on dentine
surface for more than 12 hours. ( Athanassiadis et al. 2007)
• CHX solution at 1% and 2% concentrations was shown to
be as fast as 5.2% NaOCl in killing E faecalis.
• The 2% concentration is best for endodontic use.
( Zamany et al. 2003)
• CHX is more effective against gram positive bacteria and
therefore may have a role as an endodontic irrigant in
retreatment cases. ( Good M et al. 2012)
• In vitro studies have shown it to be effective against
E faecalis. ( Sen BH et al. 1999) (Gomes BP et al. 2001)
Chlorhexidine

• CHX has an effective anti-bacterial activity (Gram +ve & Gram
-ve)
• CHX has an effective anti-fungal activity (C. albicans)
• Less effective on biofilm than NaOCl
• Substantivity in dentine for up to 12 weeks.
• No ability to dissolve organic tissues
• Biocompatibility is acceptable (allergic in rare cases)
• Mixing CHX with Ca(OH)2 enhance its antimicrobial activity
• Mixing CHX with NaOCl should be avoided
Chlorhexidine
Mohammadi Z, Abbott P, Int Endo J 2009

 EDTA (15 - 17%, pH 7)
 EDTA is available in a liquid form for irrigation and a
gel form for lubrication
 It effectively removes smear layer by chelating the
inorganic component of the dentine.
 Aid in mechanical canal shaping.
EDTA

 EDTA has little if any antibacterial activity.
 It also emulsifies soft tissue and removes the smear
layer with no deleterious effect to periapical tissues.
Eliyas S et al. 2010
 EDTA has been shown to be a faster chelating agent
than cetric acid. Gonzalez-Lopez S, et al 2006
EDTA

1. Sodium Hypochlorite (NaOCl)
2. Chlorhexidine (CHX)
3. EDTA
4. Iodine
5. Hydrogen peroxide
6. Sterile saline, water or LA
7. Other products and concepts
I. Antibiotics
II. Photo-activated disinfection (PAD)
III. Electronically Activated Water
IV. Laser
Irrigating solutions
 Iodine was introduced into endodontics in 1979.
 antiseptic against a broad range of micro-organisms,
bactericidal, fungicidal, tuberculocidal, virucidal and
sporicidal. Eliyas S et al. 2010
 Has low toxicity
 It has ability to diffuse through dentinal
tubules and kill bacteria in vivo.
Fuss Z,et al. 2002
 However, the duration of its antimicrobial
effect is short. Good M et al. 2012
Iodine

Hydrogen peroxide (H2O2)
It is a clear, colorless liquid.
Used in a variety of concentrations, 1% - 30%.
H2O2 is active against viruses, bacteria, and yeasts.
It produces free radicals (•OH), which attack several
cell components such as proteins and DNA.
In endodontics, H2O2 has long been used because of
its antimicrobial and cleansing properties.
It is used in canal irrigation as well as cleaning the
pulp chamber from blood and tissue remnants,

 A combination of NaOCl and H2O2 was no more
effective against E. faecalis in contaminated root
canals than NaOCl alone.
Siqueira et al. (1997)
 Although H2O2 has long been used in disinfection
and canal irrigation in endodontics, the available
literature does not support its use over that of other
irrigating solutions.

 A combination of NaOCl and H2O2 was no more
effective against E. faecalis in contaminated root
canals than NaOCl alone.
Siqueira et al. 1997
 Although H2O2 has long been used in disinfection
and canal irrigation in endodontics, the available
literature does not support its use over that of other
irrigating solutions.

Flushes debris, lubricant,
non-irritant
BUT
no antimicrobial or solvent
action, LA not cheap.
Sterile saline, water or local anaesthetic

MTAD
• “Mixture of Tetracycline, Acid and Detergent”
• MTAD has been seen to remove the smear
layer without significantly changing the
structure of the dentinal tubules, and the
canals were seen to be cleaner when
compared with EDTA.
Torabinejad M et al. 2003
• As this irrigant is based on a tetracycline
isomer, there may be problems with staining,
resistance and sensitivity.
• Limited evidence is available for the use of
these compared with conventional irrigants,
such as NaOCl.

MTAD
 Application of a dye (Toluidine blue) into the root canal system,
followed by a laser radiation which activates the dye.
 Photosensitizer molecules will attach to the membrane of the
bacteria, and then the irradiation with a specific wavelength
matched to the absorption of the photosensitizer will lead to
the production of free radicals, causing rupture of the cell wall
and death of the bacteria.
Bergmans L et al. 2006
 Depends on the power, length of exposure, absorption of light
into the tissues, and tip-to-target tissue distance.
 There is no robust evidence for this technique.
 Laser expensive items to purchase.
Photo-activated Disinfection (PAD)

MTAD
Also known as Oxidative Potential
Water.
It is essentially electrolysing saline
solution.
The thought is that EAW is able to
disrupt biofilms as well as removing the
adhering ability of microbes to canal
walls by creating a negative isotonic
pressure.
However, it was not as effective as 3%
NaOCl. Gulabivala K, et al 2004
Electronically Activated Water

To sum…
• There is no evidence to suggest that using
numerous irrigants is any better than using
NaOCl alone.
• NaOCl remains the irrigant of choice in
endodontics. It is recommended that NaOCl
should only be used where RD isolation is in
place.
Eliyas S et al. 2010

Recommended protocol
according to the
literature
1. After access:
NaOCl for heamostasis
2. For negotiation/glide path:
EDTA gel lubricant
3. During instrumentation:
NaOCl
4. After shaping:
EDTA
Chlorhexidine final flush

Recommended protocol
1. After access:
NaOCl for heamostasis
2. For negotiation/glide path:
EDTA gel lubricant
3. During instrumentation:
NaOCl
4. After shaping:
EDTA
Chlorhexidine final flush
Thank you

Irrigation in endodontics

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