Various Irrigation Solution in Endodontic

10/9/2006

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

NaOCl

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

Bactericidal of NaOCl

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).

NaOCl

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 NaOCl 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)

NaOCl & 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

370C, significantly increased its tissue dissolving

ability

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 moreeffective 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

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

BDABis-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 excellent

substitute for sodium hypochlorite in those 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 (1% - 50% ).

Polyacrylic acid (e.g. Durelon and Fuju II liquids).

Solutions

Carbamide peroxide.

Aminoquinaldinium diacetate (i.e., Salvizol).

Chelating Agents

EDTA

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 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 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 Irrigation

Ultrasonic 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 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.