endodontic irrigating solutions

ENDODONTIC IRRIGATING SOLUTIONS

DONE BY DR.MARWA AHMED

The use of irrigating solutions in combination with canal instrumentation, loosen debris, pulp tissue and micro-organisms from the irregular dentin walls so that they can be removed from the canal.

Irrigation is defined as “to wash out a body cavity or wound with water or a medicated fluid”

Objectives of irrigationMechanical & Chemical functions

Flushing Lubrication DissolutionSmear layer removal

Introduction

Biological functionsAntimicrobial

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Requirements of Ideal Irrigants

1. It must have broad spectrum antimicrobial effect.

2. It must aid in the root canal debridement.

3. Ability to dissolve necrotic tissue or debris.

4. Low toxicity level.

5. Act as a good lubricant.

6. Low surface tension to flow

easily into the inaccessible areas.

7. Remove the smear layer.

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Factors Effecting The Irrigants action

1.Concentration(%).

2. Contact.

3. Presence of organic tissue.

4. Quantity.

5. Temperature.

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The smear layerThe smear layer is a micro – crystalline layer of cutting debris covering

the canal walls after the preparation and its removal may aid in better adaptation of the obturating materials to the canal walls.

It consist of:

A. Organic layer ----- removed by irrigants.

B. Inorganic layer --- removed by chealating agent.

Cross section of root dentin covered by the smear layer created by instrumentation.Notice smear plugs in dentin canals

Commonly used irrigating agents used in endodontics

CHEMICALLY INACTIVE SOLUTIONS

1.Normal saline .

2.Local anaesthetic solution . CHEMICALLY ACTIVE SOLUTIONS

1.Main solutions: A. Sodium hypochlorite (NAOCL)

B. Chlorhexidine (CHX) 2. Decalcifying solutions: A. Ethylene diamine tetra acetic acid(EDTA). B. Citric acid. C. Hydroxy ethylidene-bisphosphonate(HEBP) D. Qmix (químico MECÁNICA MIX) E. Mixture of tetracycline Acid detergent(MTAD). F. Tetraclean. 3.Other irrigating agents : A. Hydrogen peroxide. B. Iodine based compounds. 4. Recent advances in irrigation: A. Carisolv. B. Ruddles solution. C. Bioactive materials like bio(active) glass D. Chitosan.. E. Cetrexidine

1.main solutions

A. Sodium hypochlorite (NaOCl) 0.5-5.25% the ideal concentration 2.5%

Current irrigant of choice Effective antimicrobial agent Excellent organic tissue solvent Lubricates Effective fairly quickly

Toxic (hypochlorite accident) Not substantive Corrodes, unpleasant odor Removes only the organic part of the smear layer

Advantages Disadvantages

Safety (Sodium hypochlorite accidents)

Toxic effects of NaOCl on vital tissues include hemolysis, epithelial ulceration, and necrosis Several mishaps during root canal irrigation can range from damage to the patient’s clothing, splashing the irrigant into the patient’s or operator’s eye, injection through the apical foramen.

Treatment protocol for sodium hypochlorite accident…

Early recognition of extrusion,

Immediate canal irrigation with normal saline,

Encouragement of bleeding,

Pain control with local anesthetics and analgesics

and warm compresses and frequent warm mouth

rinses for stimulation of the local systemic circulation,

Reassurance of the patient, and

Monitoring of improvement.

Preventive measures

Plastic bib to protect patient’s clothing

Rubber dam isolation

side-exit Luer-Lock needles

Irrigation needle a minimum of 2 mm short of the working length Avoidance of binding of the needle into the root canal Avoidance of excessive pressure during irrigation

Protective eye-wear

b.CHLORHEXIDINE (CHX) (0.2% - 2%)

1. It has antibacterial effect (long standing effect by binding to hydroxyapatite and in combination with Ca(OH)2 effective against anaerobes).2. Low toxicity compared to NaOCL.

1. main solutions

Advantages

Disadvantages

1.Does not have tissue solvent action.2.Discolaration .3.Bitter taste.4.Toxic (in case of swallowing).So to over come these disadvantages it shouldn’t use alone but in combination with other irrigation solutions.

NaOCl + CHX

2.5% NaOCL + 0.2 % CHX

an additive antimicrobial action

Tissue dissolving property that is better than that obtained with use of CHX alone

less toxic then NaOcl

Immediate formation of an orange-brown precipitate (para-chloroaniline)

NaOCl+CHX precipitate tends to occlude the dentinal tubules

Precipitate could be prevented by using absolute alcohol or minimized by using saline and distilled water as intermediate flushes

2.DECALCIFYING SOLUTIONSA. Ethylene Diamine Tetra Acetic Acid ( EDTA)

Remove the inorganic part of the smear layer

Contribute to the elimination of bacteria in the root canal

Combination products have wide-spectrum antimicrobial

activity.

EDTA may have antifungal activity

Low toxicity

. It used for cleaning and widening the canal.

. Used in concentration of 17%.

. Optimal working time 15 minutes.

Advantages

Disadvantages

1.Demineralize dentin (20–50 um).2. Does not have tissue solvent action.

So to over come these disadvantages it shouldn’t use alone but in combination with other irrigation solutions.

EDTA 17% + NaOCl 2.5%

EDTA causes NaOCl to lose its tissue dissolving capacity, and virtually no free chlorine is available

EDTA 17% + CHX 0.2%

Immediate formation of a white, foggy precipitate

Precipitate involves the chemical degradation of chlorhexidine

Variations

REDTA EDTA + Sodium hydroxide + cetyl trimethylammonium bromide + water

RC prep EDTA + urea peroxide

EDTAC EDTA + Cetavlon

EGTA ethylene glycol bis (β aminoethyl ether)-N,N,N,N- tetra acetic acid

B. CITRIC ACID 10%

can also be used for irrigation of the root canal and for removal of smear layer

used in various concentrations, ranging from 1% to 50%, with a 10% solution being the most common

10% citric acid has been shown to remove the smear layer more effectively from apical root end cavities than ultrasound

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

2.DECALCIFYING SOLUTIONS

C. Hydroxy ethylidene-bisphosphonat(HEBP) 9%-18%also called etidronic acid Chelator that can be used in combination with sodium hypochlorite (NaOCl) without affecting its proteolytic or antimicrobial properties

HEBP is a weak decalcifying agent and hence cannot be used as a mere final rinse.. Does not have tissue solvent action.So to over come these disadvantages it shouldn’t use alone but in combination with other irrigation solutions.

NaOCl 5% + HEBP 18% : better tissue dissolution capacity less cytotoxic reduces dentin debris accumulation

Disadvantages

NaOCl 5% + HEBP 18%


D. QMiX(QUÍMICO MECÁNICA MIX)

Q mix is an irrigation solution used as a final rinse. It is a combination of CHX with EDTA and a surfactant solution to improve penetration in dentinal tubules.

Low surface tension is one of the ideal characteristics of an irrigant Superior Antibacterial efficacy.Superior smear layer removalReady to use, fast workingLess demineralization OF DENTEN compare to EDTA

advantages

6% NaOCl and QMiX were the most effective disinfecting solutions against the young biofilm, whereas against the 3-week-old biofilm, 6% NaOCl was the most effective followed by QMiX


E. MTAD ( mixture of tetracyclin , acid and detergent).

MTAD is a mixture of doxycycline (150MG/5ML), citric acid, and a detergent

F.TETRACLEAN

IS A MIXTURE OF CITRIC ACID DOXYCYCLINE 50MG/5ML AND POLYPROPYLENE GLYCOL AS DETERGENT

Smear layer removal

BOTH MTAD & TETRACLEAN performed better than EDTA in cleaning dentinal tubules of debris and removing the smear layer in the apical third of root canals AND ALSO BOTH created less erosion than EDTA in the coronal and middle thirds of the root canals.

Antibacterial efficacy

1.3% NaOCl followed by 5 min MTAD was more effective in the disinfection of canals than a protocol of 5.25% NaOCl followed by 1 min 17% EDTA and then 5 min 5.25% NaOCl as a final rinse


A . HYDROGEN PEROXIDE

an oxidizing agent used in conc. of 3-5% .It is odorless, clear liquid.

.Its effervescence action capable for removing loose debris from inside the canal.

.Release of nascent oxygen (O2) works against anaerobic

bacteria.

3.Other irrigating agents

Disadvantage: 1. Tissue emphysema if it passes to the periapical tissue. 2. Post – Operative Pain

Note:it should not use alone or as final irrigant

1. NaOCl 5.25% + H2O2 3%

produce foaming action flush the debris out of root canal significantly increase dentinal permeability deactivationof bacterial endotoxins In combination antibacterial effect of both solutions was less than that of individual solutions and it used to decrease tissue dissolving action of NaOCl

Combination with other irrigant

NaOCl 5.25% + H2O2 3%

2. CHX 2% + H2O2 3%

CHX +H2O2 when combined do not counter act one another at specific concentration

H2O2 Smear layer removal

greater antibacterial effect at deeper layers kills most of the bacteria in the area adjacent to the lumen

CHXallow penetration of CHX into the dentinal tubules

CHX 2% + H2O2 3%

B. IODINE BASED COMPOUNDSAqueous iodine solutions are rather unstable

development of iodophors (‘iodine carriers’)

Povidone–iodine Poloxamer– iodine

Antimicrobial action of iodine is rapid, even at low concentrations, Iodine penetrates into microorganisms and attacks key groups of cell molecules, such as proteins, nucleotides, and fatty acids, resulting in cell death

Allergic reactions to iodine and the staining of dentin.Expensive. Toxic in case of swallowing .

In endodontics, iodine potassium iodide (IPI) in 10% concentration is used

Advantages

Disadvantages


C. GLY-OXIDE

10% solution of carbamide peroxide in glycerol

provides lubrication without softening dentin. antimicrobial activity more than 3% H2O2.

produces transient energetic effervescence with NaOCl .

useful in narrow and curved canals.

does not remove smear layer.

Disadvantages

Advantages


4.RECENT ADVANCES IN IRRIGATION

A. Cetrexidine 0.2% CHX and 0.2% citrimide better penetration of CHX into the dentinal tubules and better antimicrobial efficacy

B. Carisolv

potential as on irrigant as it is antibacterial and has collagen dissolving potential

C. Ruddles solution

Radiopaque agent Hypaque + NaOCl + EDTA

used to detect the presence of lateral / accessory canals

D. Bioactive materials like bio(active) glass Antimicrobial activity against a range of microbesE. Chitosan

naturally occurring polysaccharide chitosan at 0.2% concentration as chelating agent without the negative effects of high concentration EDTA

easily and locally available, cheap, biocompatible, biodegradable, has the property of bioadhesion and has antimicrobial activity

Advantages:

endodontic irrigating solutions

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