Various Irrigation Solution in Endodontic

10/9/200610/9/2006

The use of irrigating solutions is an important part of effective chemomechanical preparation.

Antibacterial agent.

Tissue solvent.

Flush debris.

Lubricant.

Eliminate the smear layer.

Various Irrigation Solution in Endodontic

NaOClNaOCl

NaOClNaOCl 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

Bactericidal of NaOClNaOCl

HOCl exerts its effects by oxidizing sulphydryl groups within bacterial enzyme systems, thereby disrupting the metabolism of the microorganism, resulting in the killing of the bacterial cells.

Unbuffered solution at pH 11 in concentration 0.5–5.25% , and buffered with bicarbonate buffer (pH 9.0) usually as a 0.5% solution (Dakin's solution).

NaOClNaOCl Buffering had little effect on tissue dissolution.

Dakin's solution was equally effective on necrotic and fresh tissues.

No differences were recorded for the antibacterial properties of Dakin's solution and an equivalent unbuffered hypochlorite solution

Zehnder et al. (2002)

In Vitro Antibacterial Studies

High resistance of E. faecalis and the high susceptibility of C. albicans to NaOCl. .

C. albicans was killed in vitro in 30 s by both 5% and 0.5% NaOCl.

E. faecalis was killed in less than 30 s by the 5.25% solution, while it took 10 and 30 min for complete killing of the bacteria by 2.5% and 0.5% solutions.

Radcliffe et al (2004) , Gomes et al. (2001)

Peciuliene et al. (2001) ,Waltimo et al.

(1999)

Although 0.5% NaOCl, with or without (EDTA), improved the antibacterial efficiency of preparation compared with saline irrigation, all canals could not be rendered bacteria free even after several appointments.

No significant difference in antibacterial efficiency in vivo between 0.5% and 5% NaOCl solutions.

Byström & Sundqvist (1983,1985)

In Vivo Antibacterial Studies

The in vitro studies performed in A test tube. Root canals of extracted teeth. Prepared dentine blocks infected with a pure culture of

one organism at a time.

The in vivo studies, on the other hand, have focused on

the elimination of microorganisms from the root canal

system in teeth with primary apical periodontitis..

Antibacterial Studies

Explanation to poorer in vivo performance

Root canal anatomy, in particular, the difficulty in reaching the most apical region of the canal with large volumes of fresh irrigant.

Chemical milieu in the canal is quite different from a simplified test tube environment

Antibacterial Studies

Concentration

Compared the biological effects of mild and strong NaOCl solutions and demonstrated greater cytotoxicity and caustic effects on healthy tissue with 5.25% NaOCl than with 0.5% and 1% solutions.

Either 5.25% or 2.5% sodium hypochlorite has the same effect when used in the root canal space for a period of 5 minutes.

Trepagnier et al. (1977)

Pashley et al. (1985)

Concentration

5% NaOCl may be too toxic for routine use. They found that 0.5% NaOCl solution dissolves necrotic but not vital tissue and has considerably less toxicity than a 5% solution.

They suggested that 0.5% NaOCl be used in endodontic therapy.

Spångberg et al.(1974)

Commented that “It seemed probable that there would be a greater amount of organic residue present following irrigation of longer, narrower, more convoluted root canals that impede the delivery of the irrigant.”

Concentration of NaOCl

Baumgartner &Cuenin (1992)

The ability of an irrigant to be distributed to the apical portion of a canal is dependent on:

Canal anatomy

Size of instrumentation

Delivery system

Commented that “The effectiveness of low concentrations of NaOCl may be improved by using larger volumes of irrigant or by the presence of replenished irrigant in the canals for longer periods of time.”

Concentration of NaOCl

Baumgartner & Cuenin (1992)

The efficacy of 0.5%, 2.5% and 5.25% sodium hypochlorite (NaOCl) as intracanal irrigants associated with hand and rotary instrumentation techniques against E. faecalis within root canals and dentinal tubules.

5.25% NaOCl has a greater antibacterial activity inside the dentinal tubules infected with E. faecalis than the other concentrations tested.

.Berber et al. (2006)

Concentration of NaOCl

Is NaOClNaOCl equally effective in dissolving vital, non-vital, or fixed tissue???

Demonstrated that 5.25% sodium hypochlorite dissolves vital tissue. (Rosenfeld et al. 1978 )

As a necrotic tissue solvent, 5.25% sodium hypochlorite was found to be significantly better than 2.6%, 1%, or 0.5%. (Hand et al.1978)

3% sodium hypochlorite was found to be optimal for

dissolving tissue fixed with parachlorophenol or formaldehyde (Thé SD.1979)

NaOClNaOCl & Other Medicaments

NaOCl & Ca(OH)2

Pretreatment of tissue with calcium hydroxide can enhance the tissue-dissolving effect of sodium hypochlorite. .

Hasselgren et al.(1988)

Combination of calcium hydroxide and sodium hypochlorite was more effective on the dissolution of soft tissue on the root canal wall than using either medicament alone.

Wadachi et al.(1998)

Complete chemomechanical instrumentation combined with 2.5% sodium hypochlorite irrigation alone accounted for the removal of most tissue remnants in the main canal. Prolonged contact with calcium hydroxide after complete instrumentation was ineffective.

Tissues in inaccessible areas of root canals were not contacted by calcium hydroxide or sodium hypochlorite and were poorly débrided.

NaOCl & Ca(OH)2

Yang et al. 1998

NaOCl & EDTA

Combining 5.0% sodium hypochlorite with EDTA enhance considerably the bactericidal effect.

Byström & Sundqvist (1985)

NaOCl & CHX

The alternate use of sodium hypochlorite and

chlorhexidine gluconate irrigants resulted in a greater

reduction of microbial flora (84.6%) when compared

with the individual use of sodium hypochlorite

(59.4%) or chlorhexidine gluconate (70%) alone.

Kuruvilla and Kamath (1998)

NaOCl & CHX The time required to eliminate E. faecalis depended on the

concentration and type of irrigant used.

Chlorhexidine in the liquid form at all concentrations tested

(0.2%, 1% and 2%) and NaOCl (5.25%) were the most

effective irrigants. However, the time required by 0.2%

chlorhexidine liquid and 2% chlorhexidine gel to promote

negative cultures was only 30 s and 1 min, respectively.

Gomes et al.(2001)

Temperature

Higher temperatures potentiate the antimicrobial and tissue-dissolving effects of NaOCl.

Increasing the temperature of hypochlorite irrigant to Increasing the temperature of hypochlorite irrigant to 373700C, significantly increased its tissue dissolving C, significantly increased its tissue dissolving abilityability

Cunningham &Balekjian (1980)

Volume

The volume of the irrigant has a greater potential to significantly reduce bacteria colonies in root canal.

Baker et al. 1975, Brown and Doran 1975, Cunningham 1982, Cunningham et al.1982,siqueira

at al.2000, Sedgley et al.2005.

Chlorhexidine (CHX)

Chlorhexidine (CHX)

It possesses a broad-spectrum antimicrobial action and a relative absence of toxicity.

CHX lacks the tissue-dissolving ability.

It penetrates the cell wall and attacks the bacterial cytoplasmic or inner membrane or the yeast plasma membrane.

Concentrations between 0.2% and 2%.

Its activity is pH dependent and is greatly reduced in the presence of organic matter.

Chlorhexidine (CHX)

In direct contact with human cells, CHX is cytotoxic; a comparative study using fluorescence assay on human PDL cells showed corresponding cytotoxicity with 0.4% NaOCl and 0.1% CHX.

Chang et al.(2001)

In Vitro-the antibacterial effect of CHX

In vitro, CHX is superior to NaOCl in killing of E. faecalis and Staphylococcus aureus.

Gomes et al. (2001)

Oncag et al. (2003) Vianna et al. (2004)

CHX effectively killed C. albicans

Barkvoll P & Attramadal A (1989)

Hiom e al. (1992) Hamers et al. (1996)

Waltimo et al. (1999)

In vivo-the antibacterial effect of CHX

There are no in vivo studies yet available that would confirm the better activity of CHX against E. faecalis in the infected root canal.

CHX & H2O2

In Vitro, 3% H2O2 and CHX was superior in its

antibacterial activity (E. faecalis ) compared with other regimens such as CHX alone and NaOCl.

Heling & Chandler (1998)

The combination of the two substances totally killed E. faecalis in concentrations much lower than each component alone.

Steinberg et al. (1999)

CHX & H2O2

There are No reports of clinical studies where the combinations of CHX and H2O2 have been used to disinfect the root canal system.

Cytotoxicity of the medicament combinations should first be investigated. Interestingly, combinations of CHX and carbamide peroxide have been shown to be additive in their cytotoxicity (Babich et al.1995).

A potential weakness of CHX in the root canal may be its susceptibility to the presence of organic matter.

(Russell AD & Day MJ 1993)

In an in vitro study, the effect of CHX is showed to be reduced, although not prevented, by the presence of dentine. Haapasalo et al. (2000)

CHX was strongly inhibited by dentine matrix (the organic component of dentine).

Portenier et al. (2002)

CHX

H2O2

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 hydroxyl 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 has been particularly popular in cleaning the pulp chamber from blood and tissue remnants, but it has also been used in canal irrigation.

In Vivo-the antibacterial effect of H2O2

Bacteria counts were greatly reduced when 10% H2O2 was used as part of the irrigating protocol., but the protocol used could not predictably produce sterile root canals in monkey teeth.

Möller et al. (2004)

The antibacterial effect of H2O2

A combination of NaOCl and H2O2 was no more effective against E. faecalis in contaminated root canals than NaOCl alone.

Siqueira et al. (1997)

H2O2

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.

MTAD

MTAD

A mixture of tetracycline isomer, acid, and detergent. (doxycycline, citric acid, and the detergent Tween-80))

It has antibacterial activity. It has low pH 2.15 low pH 2.15

MTAD The tissue-solubilizing action of MTAD, NaOCl, and

EDTA was compared.

MTAD solubilized dentine well, whereas organic pulp tissue was clearly more unaffected by it.

Beltz et al. (2003)

MTAD & NaOCl The effect of various concentrations of NaOCl as an

irrigant before irrigation with MTAD as a final rinse on the smear layer was evaluated.

The results showed that MTAD removed most of the smear layer when used alone; however, remnants of the organic component of the smear layer could be detected on the root canal walls.

There were no significant differences between the ability of 1.3%, 2.6%, and 5.25% NaOCl as root canal irrigants and MTAD as a final rinse to remove the smear layer. All combinations removed both the smear layer as well as the organic remnants. (Torabinejad etal.2003)

The antibacterial effect of MTAD

In vitro study, the antibacterial effects of MTAD, NaOCl, and EDTA were compared using a disk-diffusion test on agar plates.

The results showed that even highly diluted MTAD produced clear zones of inhibition of the test bacterium, E. faecalis

Torabinejad et al. 2003

The antibacterial effect of MTAD

In vitro study, the effect of MTAD on root canals contaminated with either saliva or E. faecalis was evaluated, and reported good antibacterial activity.

Shabahang et al. (2003)

Shabahang & Torabinejad (2003)

Cytotoxicity of MTAD

Cytotoxicity of MTAD was evaluated on fibroblasts.

MTAD is less cytotoxic than eugenol, 3% H2O2,

Ca(OH)2 paste, 5.25% NaOCl, Peridex (a CHX mouth rinse with additives), and EDTA, but more cytotoxic than 2.63%, 1.31%, and 0.66% NaOCl.

Zhang et al. (2003)

BDA

BDA Bis-dequalinium acetate (BDA)

Low toxicity Lubrication action Disinfecting ability Low surface tension Chelating properties. Low incidence of post-treatment pain.

Bis-dequalinium acetate is recommended as an Bis-dequalinium acetate is recommended as an excellent substitute for sodium hypochlorite in those excellent substitute for sodium hypochlorite in those patients who are allergic to the latter. patients who are allergic to the latter.

Kaufman 1981

Smear Layer Removal

Smear Layer Removal Removal of the smear layer is an

important step to facilitate disinfection of the root canal

Organic Acid Irrigants: Citric acid (Citric acid (1% - 50% ). Polyacrylic acid (e.g. Durelon and Fuju II liquids).Polyacrylic acid (e.g. Durelon and Fuju II liquids).

Solutions Carbamide peroxide. Aminoquinaldinium diacetate (i.e., Salvizol).

Chelating Agents EDTAEDTA

Removal of the smear layer by EDTA (or citric acid) improves the antibacterial effect of locally used disinfecting agents in deeper layers of dentine.

Ørstavik & Haapasalo (1990)

Effect of Citric acidEffect of Citric acid

10% citric acid was more effective in removing the smear layer from apical root-end cavities than ultrasound.

Gutmann et al. (1994)

10% citric acid was more effective in dentin demineralization than 1% citric acid, which was more effective than EDTA.

Machado-Silveiro et al (2004)

Chelating AgentsChelating Agents

Chelating Agents

EDTA (ethylene-diaminetetra-aceticacid) EDTAC (ethylene-diaminetetra-aceticacid &centrimide) File-Eze RC Prep

EDTA

EDTA

EDTA (17%, disodium salt, pH 7)

EDTA has little if any antibacterial activity.

It effectively removes smear layer by chelating the inorganic component of the dentine.

Aid in mechanical canal shaping.

EDTA The ultrastructure on canal walls after EDTA and

combined EDTA & NaOCl irrigation was evaluated by scanning electron microscopy.

More debris was removed by irrigation with EDTA followed by NaOCl than with EDTA alone.

Niu et al. (2002)

The optimal working time of EDTA is 15 minutes, after which time no more chelating action can be expected.

EDTA solutions should replaces in the canal each 15 minutes.

Goldberg and Spielberg (1982)

RC-Prep

RC-Prep

RC-Prep is composed of EDTA and urea peroxide in a base of Carbowax.

It is not water soluble.

NaOCl & RC-Prep

Interaction of the urea peroxide in RC-Prep with sodium hypochlorite, producing a bubbling action thought to loosen and help float out dentinal debris.

RC-Prep

A residue of RC-Prep remains in the canals in spite of further irrigation and cleansing.

RC-Prep allowed maximum leakage into filled canals over 2.6 times the leakage of the controls.

Zubriggen et al.(1975)

Cooke et al. (1976)

Ultrasonic IrrigationUltrasonic Irrigation

Ultrasonic IrrigationUltrasonic Irrigation

The flushing action of the irrigant solution may be more important than the ability of the irrigant solution to dissolve tissue.

(Baker et al. 1975)

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.

Ultrasonic IrrigationUltrasonic Irrigation

The enhancement of the flushing action of an irrigant solution by using ultrasound is well documented.

(Cunningham & Martin 1982, Cunningham et al. 1982, Stock 1991,

Lumley et al. 1993, Lee et al. 2004)

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 eddies.

(Ahmad et al. 1987, Krell & Johnson 1988, Stock 1991)

Ultrasonic Irrigation

More bacterial spores and dentine debris were removed during ultrasonic irrigation than hand irrigation.

Cunningham & Martin (1982) Cunningham et al. (1982)

Types of endodntic needles

Beveled needle Monoject endodontic needle. ProRinse probes.

Monoject endodontic needles to be the most efficient delivery system in which longer needles of a blunted, open-end system were inserted to the full length of the canal.

The point is that a larger volume of solution can be delivered by this method. However, the closer the needle tip is placed to the apex, the greater the potential for damage to the periradicular tissues.

Moser and Heuer (1982)

The most important factor is the delivery system and not the irrigating solution per se.

The volume of the irrigant is more important than the concentration or type of irrigant.

Walton and Torabinejad

In order to be effective, the needle delivering the solution must come in close proximity to the material to be removed.”

Small diameter needles were found to be more effective in reaching adequate depth but were more prone to problems of possible breakage and difficulty in expressing the irrigant from the narrow needles.

Abou-Rass M (1982)

Method of Use

Method of Use

It is strongly recommended that the needle lie passively in the canal and not engage the walls.

The solution must be introduced slowly.

The irrigating needle should be bent to allow easier delivery of the solution and to prevent deep penetration of the needle.

Care must be taken with irrigants like sodium hypochlorite to prevent accidents.