2. Introduction
Why we need Irrigation during Endodontic Preparation
Ideal Properties of Endodontic Irrigant
The most common Irrigant used
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
3. Origin of the Endodontic Infections
Bacterial in origin…….. Kakehashi et al 1965
Sundqvist 1976
Biofilm ………. Nair 2010
The Aims of the Endodontic Treatment
1. Treatment ……
Remove and kill all microorganisms
2. Prevention
By bacteria- tight seal obturation & coronal restoration
guarantee healing of
periapical lesions
prevent reinfection
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
4. How to achieve the aims of endodontic treatment ??
By root canal instrumentation
Two primary goals for root canal instrumentation :
1. To provide a biological environment that is conducive to healing
2. To provide a canal shape that is conformable to sealing.
John T. McSpadden
Can mechanical canal preparation alone provides a biological
environment that is conduce to healing ?
No
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
5. mechanical canal preparation can’t provides a biological
environment that is conduce to healing…
Challenges
Complexities of root canal anatomy
Metallurgy of Endodontic Files
Until now no endodontic files can prepare
all the pulp canal system configuration
without a fear of file separation ,
Canal transportation or perforation
Why???
Roland Ordinola -Zapata
“Of all the phases of anatomic study in the
human system, one of the most complex is that of
the pulp cavity morphology “ Barret 1925
Apical deltas….
which endodontic file will reach??
Dr. Jojo..India
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
6. mechanical canal preparation can’t provides a biological
environment that is conduce to healing…Why???
conclusions
Inability of shaping tools in acting within the anatomical
complexity of the root canal.
Preparation of oval, flattened, or irregular shaped
cross-sectional root canals using different instruments has
shown to leave unprepared extensions or recesses which
can harbor remnants of necrotic pulp tissue and biofilm.
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
7. mechanical canal preparation can’t provides a biological
environment that is conduce to healing…Why???
Roland Ordinola -Zapata
Using high-resolution computed tomography; it was found that
35–53% of the root canal surface remained uninstrumented
Gulabivala et al.
Effects of mechanical and chemical procedures on root canal surfaces
Endodontic Topics 2005, 10, 103–122 • Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
8. mechanical canal preparation can’t provides a biological
environment that is conduce to healing…Why???
Endodontic files(hand or rotary)
Create round-shaped canal
Middle third
cross-sections
Apical third
cross-sections
What endodontic files do?
Spreading and flushing the irrigant throughout the canal space acts mechanically and
chemically on remnants of necrotic pulp tissue and bacterial
communities colonizing the canal.
M.A. Versiani et al. Endodontic Irrigation
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
10. Most Common Irrigation Solutions
Dutner J, Mines P, Anderson A. Irrigation trends
among American Association of Endodontists members:
a web-based survey. J Endod. 2012;38(1):37–40
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
11. Aims of Root Canal Irrigation
The Chemical Effect
Simultaneous but
Distinct effect
The Mechanical Effect
Destroy / Kill / Remove
Biofilm
Microorganisms
Endotoxin
Pulp Tissues Remnants
NaOCI
&
CHX
Concentration
Time
Area of contact
Detachment / Remove
The destroyed
microorganisms, biofilm &
pulp tissues remnants
Dentin Debris( smear layer )
Normal Saline
&
EDTA
Pressure
Objectives Factors affective
12. An effective antimicrobial and proteolytic agent , excellent organic
tissue solvent , and lubricant with fairly quick effect
Concentration
0.5 to 6 %. It was proven that the lower and
higher concentrations are equally efficient in
reducing the number of bacteria in infected
root canal system but the tissue-dissolving
effect is directly related to the concentration.
Volume More critical for disinfection than concentration
NaOCI will inactivate its components very fast, so
fresh irrigating solution should be added to the canal
system constantly.
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
13. )
Time
Misinterpreted
….. show bacterial killed in 30 min /0.5 % NaOCI
….. higher concentrations need only 30 s
Some articles
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• SudaneseDentalCenter
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April. 2020
It is important to remember
organic matter, inflammatory exudates, tissue
remnants, and microbial biomass consumes
NaOCI and weakens its effect.
The chlorine ion, which is responsible for the
dissolving and antibacterial capacity of NaOCI,
is unstable and consumed rapidly during the
first phase of tissue dissolution, probably
within 2 min, ….. Refreshment
The greater the initial concentration of the NaOCI,
the smaller the reduction of its pH
14. Most Common Irrigation Solutions
)
Effect on Dentin 22 % organic material by weight
NaOCI solutions may affect mechanical dentin properties
via the degradation of organic dentin component
Depth of Penetration 77 and 300 μm
depends on
concentration
time
temperature
Zou et al. Penetration of sodium hypochlorite
into dentin. J Endod. 2010;36(5):793–6.
1 % NaOCI
for 2 min
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• SudaneseDentalCenter
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April. 2020
15. Most Common Irrigation Solutions
)
Effect on Biofilms
3-6 % NaOCI
was the only agent capable of both physically
removing biofilm and killing bacteria
Clegg et al
The effect of exposure to irrigant solutions on
apical dentin biofilms in vitro.
J Endod. 2006;32:434–7.
control specimen positive control dentin section treated
with 6 % NaOCI
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16. Most Common Irrigation Solutions
)
Efficiency improvement
Temperature elevations….Warning NaOCI 10℃ temperature
rise….45℃
Activation ……. Ultrasonic or Sonic activation efficiency & also by indirectly
temperature
Refreshment ……. Keeping the % at high level to compensate the buffering effect of
remnant tissues, microorganisms, pus ,blood & dentin structures
Exposure (Retention) Time ……. Contact time with the canal wall efficiency
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
17. Most Common Irrigation Solutions
)
Efficiency improvement
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• SudaneseDentalCenter
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Important clinical points
Pulp Chamber – Reservoir of fresh irrigant Retention time of irrigant
18. )
Efficiency improvement
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• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
Important clinical points
NaOCI should remain the primary irrigant.
EDTA effective against cell-rich/EPS-poor biofilms.
CHX did not remove biofilm.
the concert effects of multiple instruments,
high volume of irrigation,
and long retention time of NaOCI irrigant had a
positive influence on intracanal disinfection during
chemomechanical preparation
conclusion
19. Most Common Irrigation Solutions
)
Limitations
Toxicity
Nonsubstantive
Ineffective in smear layer removal
Corrosion & Discoloration
Unpleasant odor.
Negative effect on sealer / dentine bonding
when used as a final rinse
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• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
20. )
2.5-6% NaOCI in concentrations must be used during the whole
cleaning and shaping procedure.
Pulp chamber must used as a reservoir of fresh irrigant
Activation is very important to improve the efficiency of NaOCI
Clinical Recommendation
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• SudaneseDentalCenter
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Summary
The most important Clinical Factors
Concentration
Volume
Retention Time
The most important irrigant in endodontic treatment
The only irrigant capable in dissolving and removing
- Organic tissues( pulp tissues)
- Biofilm ( destroy Microorganisms)
- Organic substances of the smear layers
21. Chlorhexidine Gluconate
CHX 2%
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• SudaneseDentalCenter
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April. 2020
Depending on its concentration, %CHX …. Bactericidal … damaging the cell membrane
% CHX…. Bacteriostatic … causing low - molecular -
weight substances ( eg.potassium) to leak
out from the cell membrane without the
cell being permanently damaged
.
0.2 % … mouthwash
2% ..irrigate
22. • Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
Chlorhexidine Gluconate
CHX 2%
Substantivity
Reversible reaction ( uptake and release) of CHX by oral mucosa and teeth substances
( hydroxyapatite )leads to substantive antimicrobial activity (week – month),
…. Depends on
Concentration………………. % substantive antibacterial effects.
Exposure (retention) time….. ET substantive antibacterial effects
Inhibitions of Matrix Metalloproteinases ( MMPs)
CHX is potent inhibitor of MMPs ,this improves the dentin- sealer bonding
Two important factors as far as CHX2% irrigant are concerned
23. • Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
Chlorhexidine Gluconate
CHX 2%
Disinfection ability
NaOCI is more active than. 2% CHX. ,,
because;-
- CHX can’t destroy and dissolve biofilm
, bacteria & organic tissues.
- NaOCI reduce endotoxins levels better
than CHX
Using CHX as a final irrigant ( if pusher in periapical area)
may delay healing of apical periodontitis
24. • Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020
Chlorhexidine Gluconate
CHX 2%
1. In teeth with open apices or perforation where
there is a risk to extrude NaOCI.
2. When maximal antimicrobial effect is desirable
as a final rinse after EDTA to further facilitate
disinfection( Heavy infected & Retreatment Cases ..potent action
against E faecalis)
and to improve dentin bonding
Clinical Recommendations
2% CHX is an alternative irrigant but it certainly can’t replace NaOCI
25. Combination of NaOCI / CHX
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• SudaneseDentalCenter
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April. 2020
Update of Endodontic Irrigating Solutions
Endodontic Irrigation
Bettina Basrani
The combination of NaOCI and CHX produces
a toxic precipitate.
The reaction is dependent of the concentration of NaOCI.
The higher the concentration of NaOCI the larger
the precipitate
26. Saline
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• SudaneseDentalCenter
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Saline with Pressure
Objectives
Mechanical effect in
removing debris / smear layers
Neutralizes the effects
of other irrigants
Help Sealer adhesion
27. Chelating Agents
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• SudaneseDentalCenter
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Strong Agents Weak Agents
EDTA Etidronate (HEDP)
Citric acid
Maleic acid
Classified according to chelation ability
Characteristics Factors as far as endodontic irrigation is concerned:-
- Disinfection &Cleaning ability by dissolving inorganic Substances
and detach biofilms adhering to root canal walls.
- Help dentin / sealer adhesion
28. Chelating Agents
Dr.Abdalazim Badraldin
SudaneseDentalCenter
Khartoum-Sudan
April. 2020
Ethylenediaminetetraacetic Acid
EDTA
EDTA alone normally cannot remove the smear layer
effectively; a proteolytic component, such as NaOCI,
must be added to remove the organic
components of the smear layer.
EDTA is normally used in a concentration of 17 %
and can remove the smear layer when in direct
contact with the root canal wall for 1 -2 mins .
EDTA is helpful when used in negotiating narrow, tortuous ,
calcified canals to establish patency
30. Combination of EDTA /NaOCI/CHX
Dr.Abdalazim Badraldin
SudaneseDentalCenter
Khartoum-Sudan
April. 2020
CHX was found to form a salt ( white precipitate with
EDTA rather than undergoing a chemical reaction
EDTA retained its calcium-complex ability when mixed with NaOCI
EDTA caused NaOCI to lose its tissue-dissolving capacity, with virtually
no free chlorine detected in the combinations.
White cloud precipitation
Update of Endodontic Irrigating Solutions
Endodontic Irrigation
Bettina Basrani
31. Chelating Agents
Dr.Abdalazim Badraldin
SudaneseDentalCenter
Khartoum-Sudan
April. 2020
HEDP
Hydroxyethylidene diphosonate
Is there a biocompatible decalcified ( chelating ) agent can mix with NaOCI
without interfering their benefit effects as a root canal irrigation solution ???
Etidronate (HEDP) didn’t interfere with NaOCI
when mixed together
39. Chelating Agents
Dr.Abdalazim Badraldin
SudaneseDentalCenter
Khartoum-Sudan
April. 2020
Dual Rinse HEDP
1-Preparation
One capsule / 10ml 2.5% NaOCI
Mixing time ….1-2 min using cement. Spatula
for stirring( until clear solution prepared
Concentration of 5% NaOCI or more must be used
The mixture must not be heated even for short
time ( become unstable & active chlorine quickly lost.
40. Chelating Agents
Dr.Abdalazim Badraldin
SudaneseDentalCenter
Khartoum-Sudan
April. 2020
Dual Rinse HEDP
2- Clinical Procedures
during canal preparation, the pulp chamber & canal must be
flooded with the mixture ( continuous irrigation with
continuous chelating action
Activate the solution with sonic / ultrasonic .
The mixture has a good hemostatic effect in bleeding canal
and maintenance beaching effect of NaOCI in blood-stained dentin.
If bubbles rise from the canal ( reaction of chlorine ion & organic substances) ,renew
the irrigant and activate it or leaved to act passively until bubble disappeared.
Revascularization treatment (incomplete root development) it recommended to used ,17%
EDTA, 10% Citric acid or 18% HEDP ( diluted in sterile saline
…one capsule / 5 ml saline) as a final irrigant
The duration and amount of the irrigant depend on the
degree of infection and complexity of the root canal anatomy
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SudaneseDentalCenter
Khartoum-Sudan
April. 2020
Three essential Components
Leur Lock
Rubber stopper.. WL
Close ended with side
vented
Which syringe size ???
5 ml
P --- pressure developed inside syringe barrel
F --- tactile force applied to syringe plunger
A --- cross-section area of the syringe plunger
52. • Dr.Abdalazim Badraldin
• SudaneseDentalCenter
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April. 2020
Activation of irrigant with sonic or
ultrasonic energy creates acoustic streaming. This
Manual agitation/dynamic pumping:
a GP cone is inserted into the irrigant-filled canal
and pumped vertically to agitate the irrigant
54. Two Content Layout with Table
• First bullet point here
• Second bullet point here
• Third bullet point here
Class Group A Group B
Class 1 82 95
Class 2 76 88
Class 3 84 90
matrix metalloproteinases MMPs are a group o mammalian enzymes capable of degrading all extracellular matrix components .
Human dentin matrix contains at least MMP-2---MMP-9 MMP-8 & MMP-20 t
MMP-2 may be the prevalent MMP in dentin .. The incomplete infiltration of collagen fibers by the dental adhesive leads to the exposure of the fibers and to collagenolytic activity of MMPs, which may be. Activated by low pH values during the etching of dentin. As a result , hybrid layer degenerates, the bond strength gradually deteriorates and the restoration ends in failure.