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Intracanal irrigants for pulpectomy in primary teeth: a systematic review and meta-analysis.Pozos-Guillen A, Garcia-Flores , Esparza-Villalpando , Garrocho-Rangel

Int J Paediatr Dent. 2016 Nov;26(6):412-425

contentsIntroductionObjectivesBenefitsPropertiesClassificationFactors affectingIrrigants used in permanent teethIrrigants used in primary teeth conclusion

Irrigation is defined as to wash out a body cavity or wound with water or a medicated fluid Disinfectant is defined as an agent that destroys or inhibits the activity of microorganisms that cause disease.

Successful root canal treatment is dependent on the removal of microorganisms from the pulp and other anatomical irregularities of the root canal system through chemo-mechanical instrumentation with the use of instruments and irrigating solutions. Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue, and disinfecting the root canal system. Chemical debridement is especially needed for primary teeth with complex internal anatomy and zones inaccessible to debridement, such as accessory canals, ramifications, and dentinal tubules that might be missed by instrumentation. The choice of a cleanser in the pulpal therapy of primary teeth should take into account the differences among the dentin substrata, and not be irritating to the periapical tissues.4

The objectives of irrigation in endodontics are mechanical, chemical, and biologic. The mechanical and chemical objectives are as follows: (1) flush out debris, (2) lubricate the canal, (3) dissolve organic and inorganic tissue, and (4) prevent the formation of a smear layer during instrumentation or dissolve it once it has formed.42 The mechanical effectiveness will depend on the ability of irrigation to generate optimum streaming forces within the entire root-canal system. The chemical effectiveness will depend on the concentration of the antimicrobial irrigant, the area of contact, and the duration of interaction between irrigant and infected material.65 The final efficiency of endodontic disinfection will depend on its chemical and mechanical effectiveness.The biologic function of irrigants is related to their antimicrobial effects. In principle, irrigants should (1) have a high efficacy against anaerobic and facultative microor ganisms in their planktonic state and in biofilms, (2) inac tivaendotoxin, and (3) be nontoxic when they come in contact with vital tissues, and (4)b not cause an anaphylactic reaction.te 5

Removal of particulate debris and wetting of the canal walls Destruction of microorganisms Dissolution of organic debris Opening of dentinal tubules by removal of the smear layer Disinfection and cleaning of areas inaccessible to endodontic instruments

BENEFITS OF USING IRRIGANTS

Be an effective germicide and fungicide Be nonirritating to the periapical tissues Remain stable in solution Have a prolonged antimicrobial effect Be active in the presence of blood, serum, and protein derivatives of tissue Have low surface tension Not interfere with repair of periapical tissues Not stain tooth structure Be capable of inactivation in a culture medium Not induce a cell-mediated immune response Be able to completely remove the smear layer, and be able to disinfect the underlying dentin and its tubules Be nonantigenic, nontoxic, and noncarcinogenic to tissue cells surrounding the tooth Have no adverse effects on the physical properties of exposed dentin Have no adverse effects on the sealing ability of filling materials Have a convenient application Be relatively inexpensive

Properties Of An Ideal Irrigant For Root Canal Treatment

CHEMICAL AGENTS : Kandaswamy and Venkateshbabua) tissue dissolving agents : Naocl

b)antibacterial agents :Bacteriostatic : CHX , MTADBactericidal : NaOCL

c) chelating agents :Weak : HEBPStrong : EDTA

d) combination products ( tissue dissolution & antibacterial effect):MTAD, QMIX, SMEARCLEAR, TETRACLEAN

B) NATURAL AGENTS :Green teaTriphalaCLASSIFICATION OF IRRIGATING SOLUTIONS :J Conserv Dent. 2010 Oct-Dec; 13(4): 256264.

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Permanent teethSodium hypochlorite(0.5-6%)Normal salineHydrogen peroxide 3%Urea 30% solutionUrea peroxide (GLYOXIDE) (10%)Chlorhexidine (2%)EDTA (17%)Citric acidIodine Potassium iodide (IPI)HEBP(Hydroxyethylidene Bisphosphonate)SalvizolUltrasonic irrigation

MTADElectrochemically activated solutionOPWRuddle solutionPhoto activated disinfectionTetracleanQmixHerbal:Triphala and Green tea polyphenols (GTP) Morinda Citrifolia (NONI) German chamomile and tea tree oil

Recent

Primary teeth

Sodium hypochlorite (0.5-6%)Normal salineHydrogen peroxideChlorhexidine gluconate (0.2%-2%)EDTA (17%)Citric acidMTADHydrogen peroxideMaleic acidChlorine dioxideTetracleanSmearclear

Electrochemically activated solutionsOzonated waterCarisolv

Herbal: PropolisMiswakGerman chamomile and tea tree oilTriphala and Green tea polyphenols (GTP) Morinda Citrifolia (NONI)

Penetration depth of needleDiameter of root canalInner & outer dia of needleOrientation of needle bevelType of needle bevelVelocity of irrigant at needle tipViscosity of irrigantIrrigation pressureFactors affecting efficiency of root canal irrigation :

Efficiency of root canal irrigation in terms of debris removal and eradication of bacteria depends on several factors: penetration depth of the needle, diameter of the root canal, inner and outer diameter of the needle, irrigation pressure, viscosity of the irrigant, velocity of the irrigant at the needle tip, and type and orientation of the needle bevel (Fig. 6-52). Penetration Depth of the Needle The size and length of the irrigation needlein relation to root canal dimensionsis of utmost importance for the effectiveness of irrigation. Diameter of the Root Canal The apical diameter of the canal has an impact on needle penetration depth (see earlier in this chapter for details regarding apical preparation size (see Fig. 6-7, Table 6-2).72,578Inner and Outer Diameter of the Needle (Fig. 6-53, A and B) The external needle diameter is of relevance for the depth of introduction into the root canal and for rigidity of the tip, an important consideration for irrigation of curved canals. Common 27 gauge injection needles have an external diameter of 0.42 mm, but smaller irrigation tips with external diameters of 0.32 mm (30 gauge) are available.235 The Stropko Flexi-Tip (30 gauge) needle is fabricated from nickel-titanium to improve penetration into curved root canals.205 Irrigation Pressure The internal diameter determines the pressure necessary for moving the syringe plunger. The speed of the plunger determines the velocity with which the irrigant is extruded. Narrow needles require more pressure onto the plunger and extrude the irrigant with higher velocity than large needle sizes, which extrude greater amounts of irrigants but cannot be introduced as deep. Type and Orientation of the Bevel of the Needle To improve safety of irrigation and prevent extrusion of the irrigant through the apical foramen, some needles release the solution via lateral openings and have a closed, safe-ended tip The orientation of the bevel is crucial to produce a turbulence effect on the dentinal wall of the canal. Side-vented and double side-vented needles lead to maximum shear stress concentrated on the wall facing the outlet (the proximal outlet for the double side-vented).13

most commonly used irrigating solution.antibacterial capacity ability to dissolve necrotic tissue, vital pulp tissue, and the organic components of dentin and biofilms in a fast mannerSodium hypochlorite

Effective against : Enterococcus faecalis Candida albicansPorphyromonas gingivalis Porphyromonas endodontalisPrevotella intermedia

Milton soltn is 3% naocl stabilised with 16% nacl14

In 2002 Estrela reported that sodium hypochlorite exhibits a dynamic balance (Fig. 6-54)142: 1. Saponification reaction: Sodium hypochlorite acts as an organic and fat solvent that degrades fatty acids and transforms them into fatty acid salts (soap) and glycerol (alcohol), reducing the surface tension of the remaining solution. 2. Neutralization reaction: Sodium hypochlorite neutralizes amino acids by forming water and salt. With the exit of hydroxyl ions, the pH is reduced. 3. Hypochlorous acid formation: When chlorine dissolves in water and it is in contact with organic matter, it forms hypochlorous acid. It is a weak acid with the chemical formula HClO that acts as an oxidizer. Hypochlorous acid (HOCl) and hypochlorite ions (OCl) lead to amino acid degradation and hydrolysis. 4. Solvent action: Sodium hypochlorite also acts as a solvent, releasing chlorine that combines with protein amino groups (NH) to form chloramines (chloramination reaction). Chloramines impede cell metabolism; chlorine is a strong oxidant and inhibits essential bacterial enzymes by irreversible oxidation of SH groups (sulfydryl group).142 5. High pH: Sodium hypochlorite is a strong base (pH > 11). The antimicrobial effectiveness of sodium hypochlorite, based on its high pH (hydroxyl ions action), is similar to the mechanism of action of calcium hydroxide. The high pH interferes in cytoplasmic membrane integrity due to irreversible enzymatic inhibition, biosynthetic alterations in cellular metabolism, and phospholipid degradation observed in lipidic peroxidation.15

TemperatureConcentrations

Higher concentrations of NaOCl are more toxic than lower concentrations

Grossman : pulp tissue dissolution capacity 5% sodium hypochlorite dissolve tissue in between 20 minutes and 2 hours

TimeAllergic reactionsToxicity

DRAWBACKSCytotoxicDo not remove inorganic component of smear layerUnpleasant taste

Saline0.9% solution

Gross debridement

Lubrication of root canals

Flushing action

Can be used as final rinse

No adrNo disinfecting and dissolution properties

Cannot clear microbial flora from inacessible areas

Do not remove smear layerDisadvantages:

Chlorhexidine

Excellent antimicrobial activity

Effective against both Gram-positive and Gram-negative bacteria as well as yeast

2% in concentrationVery effective against Ent. faecalis

Mode of action

SubstantivityEndodontic irrigantInteraction between CHX, NaOCl, and EDTA Allergic Reactions to Chlorhexidine DRAWBACKSNot considered as main irrigant in standard endo therapyUnable to dissolve necrotic tissue remnentsLess effective on gram negative bacteria

Chelating agent

LubricationEmulsificationHolding debris in suspensionSmear layer removal

On direct exposure for extended time, EDTA extracts bacterial surface proteins by combining with metal ions from the cell envelope, which can eventually lead to bacterial death

Dentin disolving propertiesEnlarge narrow canalsEasy manipulation of instrumentsReduces time needed for debridementEthylenediamine Tetra-Acetic Acid FunctionsMode of actionUses

Irrigation with 17% EDTA for one minute followed by a final rinsewith NaOCl is the most commonly recommended method to remove thesmear layerEDTA decalcified dentin to a depth of 2030 m in 5 min

Interaction of EDTA and NaOCl Different forms of EDTAR-EDTAEDTATEDTA-CRC Prep = EDTA + UREA PEROXIDE + POLYETHYLENE GLYCOL

A) Instrumented root canal wall after irrigation with 5% sodium hypochlorite (NaOCl) and 17% ethylenediamine-tetra-acetic acid (EDTA), each for 5 minutes. Smear layer has been completely removed.

B) Close-up scanning electron micrograph of the root canal wall after removal of smear layer with NaOCl and EDTA.

Hydrogen Peroxide H2O2 has antimicrobial activity against various microorganisms including viruses, bacteria, yeasts, and even bacterial spores.

It is more effective against Gram-positive than Gram-negative bacteria30% H2O2 (Superoxol) has been recommended as the first step in tooth surface disinfection after mechanical cleaning3% SOLUTION : IRRIGANT

H2O2 = H2O + [O]

[O] : bactericidal effect

Causes oxidation of bacterial sulfhydryl group of enzymesInterfere with bacterial metabolismMechanism of actionUse

It is highly unstable and easilly decomposed by heat and light. It rapidly dissociates into H2O + [O].On coming contact with tisssue enzymes catalase and peroxidase, liberated [o] produces bactericidal effect but this is transient and dimnish in presence of organic debris.It causes oxidation of.The rapid relese of [O] on contact with organic tissue results in effervescence or bubbling action which is thought to aid in mechanical debridement by dislodging particles of necrotic tissue and dentinal debris and floating them to surface.

USE :As irrigating solution either alone or alternatively with naocl.Adv of using alternately 3% h2o2 and 5.2% naocl are :Effervescence reactn by h2o2 bubbles push debris mechanically out of canalSolvent action of naoclon organic debrisDisinfecting and bleaching action by both solutionsWhile using in combo with naocl always use naocl in last because h2o2can react wid pulp debris and blood to produce gas which builds up pressure on closing tooth, can result in severe pain.26

Chelating agentConcentrations : 1% to 50%

The use of 10% citric acid as final irrigation has shown good results in smear layer removal and proven to be more biocompatible than 17% EDTA-T and 17% EDTACitric acidShould NEVER be mixed with NaOCl

Citric acid can also be used for irrigationof the root canal to remove the smearlayer.35,43,44 Concentrations ranging from1% to 50% have been used.43 The use of10% citric acid as final irrigation hasshown good results in smear layerremoval45 and proven to be morebiocompatible than 17% EDTA-T and17% EDTA.46,Hariharan et al40 conductedan in vitro study to determine the efficacyof 5.25% NaOCl, 5.25 NaOCl + 10%EDTA, 6% citric acid and 2%chlorhexidine and saline (control) inremoving the smear layer in primary teethroot canals after hand instrumentation.They showed the superior efficacy of 6%citric acid than the other tested irrigants onremoving the smear layer in primary teeth. Never be mixed with naocl as it strongly interacts with naocl and reduce available chlorine in solution and thus making it ineffective against bacteria.

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final irrigant for smear layer removal.MTAD

Effective in eliminating resistant microorganisms Providing sustained antimicrobial activity

mixture of tetracycline isomer, citric acid, and detergent(tween 80)

pH : 2.15

an initial irrigation for 20 min with 1.3% NaOCl, followed by a 5-min final rinse with MTAD.

Cohen & nisha garg28

AdvantagesRemove smear layerKills E faecelisBiocompatibleHigh binding affinity of doxycycline present allows prolonged antibacterial effect

Tetraclean Mixture of doxycycline hyclate (at a lower concentration than in MTAD), an acid, and a detergent

Recommended to be used as a final rinse after root canal preparation

Remove both the smear layer and organic tissue from the infected the root canal systemFinal 5min rinse

(50mg/5ml instead of 150mg/5ml)

Smear clear 17% EDTA solution along with centrimide and additional proprietary surfactantsgreat efficacy

Effective against gram +ve & -ve

Journal of Advanced Medical and Dental Sciences Research |Vol. 2|Issue 2| April-June 2014

Smear clear Designed to remove the smear layer, SmearClear contains 17% EDTA solution along with centrimide and additional proprietary surfactants. These components aid in the removal of inorganic matter left in the canal during instrumentation. By removing the smearlayer and leaving the dentinal tubules clear of inorganic matter, a more effective seal may be facilitated. SmearClear has been recently launched as a 17% EDTA-based endodontic irrigant containing cetrimide and additional proprietary surfactants. This product is known to have been evaluated in only one in vitro study with permanent teeth,69 which compared the efficacy of different root canal irrigants against Enterococcus faecalis biofilms. These authors found that SmearClear had greater efficacy than almost of them. These results may be attributed to the fact that SmearClear contains cetrimide, which is a quaternary ammonium compound and a cationic detergent that is effective against grampositive and gram-negative microorganisms31

Maleic acid

Chlorine dioxide tuberculocidal, bactericidal, virucidal, and fungicidal

exists as gas in water

less cytotoxic as compared to Sodium hypochloriteSingh et al : compared the dissolution efficacy of chlorine dioxide and sodium hypochlorite on human pulp tissue.

Conclusion : 5% Chlorine dioxide is capable of dissolving human pulp tissue but sodium hypochlorite was more effective

Ozonated Water 3 oxygen atoms (O3triatomic oxygen), a higher energetic form than normal atmospheric oxygen (O2)

powerful bactericide

0.1 ppm is sucient to inactivate bacterial cells including their spores

carisolv0.5% Naocl with aminoacidsMode of action : Degrade denatured collagen

Indian J Dent Res 2012;23:120-1

Study by singhal and das in 2012 "The purpose of this study was to evaluate the efficacy of Carisolv TM , 1% sodium hypochlorite (NaOCl) gel, and 1% NaOCl solution as root canal irrigants in deciduous anterior teeth."Materials and Methods: Thirty-six extracted deciduous anterior teeth were used. Root canals were flooded with NaOCl solution in Group A, NaOCl gel in Group B and Carisolv TM in Group C and incubated for 30 min. Scanning electron microscope photomicrographs of canal wall debris in the apical, middle and coronal thirds were scored.Results: The results showed that regardless of irrigation regime, canals were consistently cleaner in the coronal and middle thirds than in the apical thirds. NaOCl solution, NaOCl gel, and Carisolv TM had comparable activity at coronal third and middle third of root canals. At the apical third, NaOCl solution cleaned canals better than NaOCl gel and Carisolv TM . Carisolv TM cleaned debris better than NaOCl gel at the apical third. Conclusion: Carisolv TM can be used as an adjunct to root canal preparation.35

Electrochemically activated solutionsTap water + low conc salt solution

Ease of debris and smear layer removal

Nontoxic

Effective with wide range of microbial spectraSuper oxised water (OPW)

anolytecatholyteCatholyte solutionAnolyte solutionSuper oxidised waterAlkaline or neutral ph

Triphala and Green tea polyphenols (GTP) Terminalia Bellerica, Terminalia Chebula and Emblica Officinalis

Triphala achieved 100% killing of E faecalis at 6 min

citric acid : removal of the smear layer.

GTPantioxidant anticariogenic anti-inflammatory thermogenicprobiotic antimicrobial properties

Prabhakar et al. 5% of sodium hypochlorite exhibited excellent antibacterial activity in both 3-week and 6-week biolm, whereas Triphala and MTAD showed complete eradication only in 3-week biolm .37

Morinda Citrifolia (NONI) antibacterialanti-inflammatoryantiviralantitumorantihelmenthic analgesic hypotensiveanti-inflammatory immune enhancing effects first juice to be identified as a possible alternative to the use of NaOCl as an intracanal irrigant.

An invitro study compared the effectiveness of MCJ with NaOCl and CHX to remove the smear layer from the root canal walls of instrumented teeth. It was concluded that the efficacy of Morinda Citrifolia was similar to NaOCl in conjunction with EDTA as an intracanal irrigant.38

German chamomile and tea tree oilantiinflamatoryAnalgesic anti-microbial antispasmic sedative properties

antiseptic, an antifungal agent and a mild solvent

terpinen-4-ol(typically 30-40%) : antibacterial & antifungal properties

SEM study : efficacy of chamomile to remove smear layer was superior to NaOCl alone but less than NaOCl combined with EDTA

PropolisPotent antimicrobialAnti-inflammatoryAnti-oxidant25-30% concEradicate E.faecalis and Candida albicans

MiswakDerived from plant Salvadora persica

Limonoid has great antimicrobial activity

Inhibit gram +ve and gram ve Interfere with extrapolysachh and glycosidase enzymes

10-20%

An invitro study showed 10-20% miswak was effectve antifungal n anti bact against candida n e fecalis.A study on pri teeth showed it could be good natural substitute to naocl41

studyageIrrigant usedsampleEvalution periodcharacteristicsresultsconclusionRuiz-Esparza et al

J Clin Pediatr Dent. 2011 Spring;35(3):265-70.

3-9Saline 2% chlorhexidine gluconate20202020Pre irrgPost-irrigPre-irrigPost-irrigNecrotic pulp, abscess,fistula

Presence of Radiolucent area in furcal or periapical regionStatistically significant difference observedCHX showed greater reduction of intracanal bact loading

studyagecharacteristicssampleIrrigant usedEvaluation periodresultsconclusionLouwak & Prucksatha-mrongkul

Pediatr Dent. 2012 Nov-Dec;34(7):e192-6.

3-964 mandi pri teeth

Presence of deep carious lesion with pulp exposure

h/o spontaneous pain

Presence of abscess , fistula32

32Saline solution

2% chx6 mo12 mo18 mo

6mo12mo18 moAt 6 mo in favour of experimental group

No difference at 12 0r 18 moChx could improve resultsn6mo after intervention

studyagecharacteristicssampleIrrigant usedEvaluation periodresultsconclusionValdez-Gonzalez et al

J Clin Pediatr Dent. 2012 Fall;37(1):31-5.

3-8Pri teeth with necrotic pulp canal, abscess, fistula

Presence of Radiolucent area in furcal or periapical region

Carious lesion without direct exposure to oral environment

2020

2020NaOCl 1%

Oxidative potential water(OPW)Pre-irrigPost-irrig

Pre-irrigPost-irrig

Significant difference in favour of experimental grp when evaluated pre and post irrigationOPW was as effective as NaOCl

studyagecharacteristicssampleirrigantEvaluation periodresultsconclusionJolly et al

J Clin Pediatr Dent. 2013 Spring;37(3):243-9.

6-1260 children with pulpally involve max molars pimary

Acute apical abscess

No antibiotics in past 3-6mo15

15

15

15Saline

2% CHX

Calcium hydroxide 4%

Propolis 4%Pre-irrigPostPre-irrigPost

Pre-irrigPost

Pre-irrigpostIn all grps, significant dec in mean aerobic CFU seen

Maximal change in anaerobic CFU was seen with 2% CHXCHX proved to be superior antimicrobial agent against both aerobes and anaerobes.

studyagecharacteristicssampleirrigantEvaluation periodresultsconclusionTulsani et al

J Clin Pediatr Dent. 2014 Fall;39(1):30-4.

4-8Pts without systemic condtion

Pri teeth with necrotic pulp, asymptomatic

Without pdl lesions

Without surgical intervention10

15

15Isotonic saline 0.9%

2.5% NaOCL

MTADPost irrigationStatisticaly significant diff btw Naocl & MTAD against control

No diff btwn experimental grpsBoth irrigants Naocl and MTAD were effective against E.faecalis

studyagecharacteristicssampleIrrigant usedEvaluation periodresultsconclusionVerma et al

J Indian Soc Pedod Prev Dent. 2014 Apr-Jun;32(2):120-4

4-770 pri teeth

Good gen health

No antibiotic coverage h/o

r/f evidence of carious pulp exposure35

35Isotonic saline 0.9%

Water soluble propolis 25%Pre-irrigPost-irrig

Pre-irrigPost-irrigGreater reduction in bact colony counts in propolisWater solulble propolis extract 25% can be used as irrigant

studyagecharacteristicssampleIrrigant usedEvaluation periodresultsconclusionFarhin et al

J Clin Pediatr Dent. 2015 Winter;39(2):100-43-760 pri molars with atleast 1 canal with necrotic pupl, abscess, fistula

Presence of Radiolucent area in furcal or periapical region

30

30

30

30Naocl 1%

MTADPre-irrig

Post-irrig

Pre-irrig

Post-irrigNaocl grp showed significant dec in bact load

Same in MTAD grp

MTAD superior among both grps in post irrigationPromising results

studysampleIrrigant usedresultconclusionIrfan et al48 extracted single rooted tooth5.25%NaOCL(negative control)

2. 10% Citric acid

3. 7%Maleic acid

4. MTAD ( canal walls in Citric acid,Maleic acid and MTAD groups were significantly clearer than the control group (p < 0.001 ) in the apical,middle and coronal levels

Dentinal tubules treated with MTAD significantly clear than citric and maelic acidMTAD is an effective solution for the removal of smear layer when used as a final rinse.

2.sodium hypochlorite did not remove smear layer.

3.10% Citric acid and 7% Maleic acid was able to remove smear layer.

The success of pulpectomy therapy in primary teeth depends on achieving an adequate level of disinfection within the root canals. It is challenging for paediatric dentists to choose the most appropriate irrigant agent when performing pulpectomy treatments. More high-quality clinical studies are denitely needed, with proper monitoring, 51

Hypophosphatasia: diagnosis and clinical signs - a dental surgeon perspective.Bloch-Zupan A

Int J Paediatr Dent. 2016 Nov;26(6):426-438

INTRODUCTION

rare genetic disorder with autosomal dominant and autosomal recessive inheritance. It is characterised by a mineralisation decit affecting the bones and teeth, which is associated with decient and reduced enzymatic activity of tissue-nonspecic alkaline phosphatase (TNSALP)14. Mutations of the ALPL gene (1p36.1-p34), which encodes TNSALP, are responsible for the reduction in enzymatic activity. TNSALP is expressed in the liver, bones, and kidneys, and also found in the enamel, dentine, cementum, and alveolar bone5. In the event of reduced enzymatic activity of TNSALP, substrates that are not broken down (pyridoxal 50-phosphate, inorganic pyrophosphate, and phosphoethanolamine) build up and produce toxic effects; for example, inorganic pyrophosphate is a powerful mineralisation inhibitor6. These substrates may be detected in blood and urine.

54

EPIDEMIOLOGYSEVERE HPP (EUROPE) : 1 PER 300,000 INDIVIDUALSMODERATE FORMS > SEVERE FORMS : 1 IN 6370JAPAN (SEVERE PERINATAL LETHAL HPP) : 2-3 CASES PER 100,000 BIRTHSCANADA : 1 IN 1OO,OOOCLINICAL SIGNS & SYMPTOMSBone symptomsDental symptoms

0

Differential diagnosis

Laboratory testsManagementTreatmentenzyme replacement therapy asfotase alfa Asfotase alfa is a recombinant human TNSALP onto which an anchor has been grafted to allow it to afx to the bone Normal serum ALP levels (male or female adults): a) 24.5 units (Bondansky)b) 413 units (King Armstrongc) 40120 IU/L14,45

Q MIXPDTLASERSTUDIESCONCLUSIONCONTENTS

Q MIX QMix contains a CHX-analog, Triclosan (N-cetyl-N,N,N-trimethylammonium bromide), and EDTA as a decalcifying agent. QMiX and 1% NaOCl killed all planktonic E. faecalis and plaque bacteria in 5 seconds. QMiX and 2% NaOCl killed up to 12 times more biofilm bacteria than 1% NaOCl (P < .01) or 2% CHX (P < .05; P < .001).

QMiX was introduced in 2011; it is one of the new combination products introduced for root canal irrigation (Fig. 6-64). It is recommended to be used at the end of instrumentation, after NaOCl irrigation. According to the patent194 QMix contains a CHX-analog, Triclosan (N-cetyl-N,N,N-trimethylammonium bromide), and EDTA as a decalcifying agent; it is intended as antimicrobial irrigant as well as an agent to remove canal wall smear layers and debris. QMiX is suggested as a final rinse. Smear Layer Removal Stojic and colleagues investigated the effectiveness of smear layer removal by QMiX using scanning electron microscopy.500 QMiX removed smear layer equally well as EDTA. Dai and colleagues examined the ability of two pH versions of QMiX to remove canal wall smear layers and debris using an open canal design.113 Within the limitations of an open-canal design, the two experimental QMiX versions are as effective as 17% EDTA in removing canal wall smear layers after the use of 5.25% NaOCl as the initial rinse.

64

Photon-ActivatedDisinfection

Photodynamic therapy (PDT) or light-activated therapy (LAT) may have endodontic applications because of its antimicrobial effectiveness.203 In principle, antimicrobial photodynamic therapy (APDT) is a two-step procedure that involves the introduction of a photosensitizer (step 1: photosensitization of the infected tissue) followed by light illumination (step 2: irradiation of the photosensitized tissue) of the sensitized tissue, which would generate a toxic photochemistry on the target cell, leading to cell lysis. Each of these elements used independently will not have any action, but together they have a synergism effect to produce antibacterial action. (COHEN) PDT is based on the concept that nontoxic photosensitizers can be preferentially localized in certain tissues and subsequently activated by light of the appropriate wavelength to generate singlet oxygen and free radicals that are cytotoxic to cells of the target tissue [77]. Methylene blue (MB) is a wellestablished photosensitizer that has been used in PDT for targeting various gram-positive and gram-negative oral bacteria and was previously used to study the eect of PDT on endodontic disinfection. Soukos et al. used the combined eect of MB and red light (665nm) exhibited up to 97% reduction of bacterial viability . Along with methylene blue, tolonium chloride has been also used as a photosensitizing agent. It is applied to the infected area and left in situ for a short period. The agent binds to the cellular membrane of bacteria, which will then rupture when activated by a laser source emitting radiation at an appropriate wavelength (e.g., 635nm radiation emitted by SaveDent; Denfotex Light Systems Ltd., Inverkeithing, United Kingdom). The light is transmitted into the root canalsatthetipofasmallexibleopticalberthatisattached to a disposable handpiece. The laser emits a maximum of only 100mW and does not generate sucient heat to harm adjacent tissues. irrigation with sodium hypochlorite (3%) eliminated the entire bacterial population. The dierence could be because the optical ber was not properly introduced into the root canals, and so the light could not transmit through the tooth structure. Thus, PAD might not be able to achieve a 100% kill rate in infected root canalsthathavecomplexanatomicfeaturesandcolonizedby polymicrobial biolms of varying properties.

Pagonis et al. studied the in vitro eects of poly(lacticcoglycolic acid) (PLGA) nanoparticles loaded with the photosensitizermethyleneblue(MB)andlightagainstEnterococcus faecalis (ATCC 29212) [93]. The study showed that utilization of PLGA nanoparticles encapsulated with photoactive drugsmaybeapromisingadjunctinantimicrobialendodontic treatment65

LASER Er:YAG laser wavelength (2940 nm) has the highest absorption in water and a high affinity to hydroxyapatite

Laser devices have been proposed to improve the efficacy of irrigants.186 Lasers have been studied for their ability to clean and effectively disinfect root canals. The Er:YAG laser wavelength (2940 nm) has the highest absorption in water and a high affinity to hydroxyapatite, which makes it suitable for use in root canal treatment.107 Laser energy may be used to activate irrigant solutions in different waysfor example, at a molecular level, as in photoactivated disinfection (PAD), or at a bulk flow level, as in laser-activated irrigation (LAI). Several studies in vivo and ex vivo have indicated that laser activated irrigation is promising for removing smear layer168 and dentin debris121,122 in less time than PUI. The mechanism of action56 is based on the generation of a secondary cavitation effect with expansion and successive implosion of fluids.

erbium laser technique that used a photon-induced photoacoustic streaming (PIPS) of irrigants. In that technique, the laser tip is placed into the coronal access opening of the pulp chamber only and is kept stationary without advancing into the orifice of the canal.132 The use of a newly designed tapered and stripped tip with specific minimally ablative laser settings is required, resulting in low energy (20 mJ), a pulse repetition rate of 15 Hz, and a very short pulse duration (50 s). The difference in laser penetration and bacterial killing is attributed to the difference in the degree of absorption of different wavelengths of light within the dentin. Endodontic pathogens that grow as biofilms, however, are difficult to eradicate even upon direct laser exposure.65 66

StudyagecharacteristicsirrigantsEvaluation periodresultconclusionVerma et al

J Indian Soc Pedod Prev Dent. 2014 Apr-Jun;32(2):120-4.4-7 yrsradiographic evidence of carious pulp exposure Group A: 0.9% isotonic saline

GroupB :25% extract water-soluble propolisPre-irrig

Post -irrigreduction in the mean bacterial colony counts of all the isolated bacteria in grp Blow toxicity concerns and antibacterial effectiveness

PROPOLIS

studyagecharacteristicsirrigantsEvaluation periodresultconclusionJolly et al

J Clin Pediatr Dent. 2013 Spring;37(3):243-9.60 children

6-12yacute apical abscess of the maxillary primary molars. 2% Chlorhexidine 4% Calcium hydroxide

4% Dimethyl Sulfoxide (DMSO) extract of propolis

Normal saline as the control Maximum change in anaerobic cfu count was seen with 2% chlorhexidine.Chlorhexidine : superior antimicrobial agent against both endodontic aerobes and anaerobes.

Calcium hydroxide was found to be least effective.

An in vivo randomized controlled trial was conducted in a group of 60 children aged 6-12 years presenting with an acute apical abscess of the maxillary primary molars. Fifteen children each were divided randomly into four groups where irrigation during pulpectomy was performed using either 2% chlorhexidine, 4% calcium hydroxide or 4% Dimethyl Sulfoxide (DMSO) extract of propolis with normal saline as the control irrigant. Microbiological samples were taken from the disto-buccal root canal before initiating the pulpectomy as well as after 3 days later and for mixed aerobic and anaerobic bacterial cultures.68

studysampleirrigantsresultconclusionShingare et al

Germs. 2011 Dec 24;1(1):12-21.40 infected primary molarsGroup 1 :3% Naocl

Group 2: 12.5% alcoholic extract of miswak,

Group 3: 11% alcoholic extract of propolis

Group 4: 0.9% saline. greatest difference being seen in group 1 (95.549%)

group 2 (89.794%),

group 3 (34.735%)

group 4 (28.087%)miswak could be a good natural substitute to sodium hypochlorite

propolis showed results comparable to those of the negative control.

studysampleirrigantsresultconclusionBalto et al

J Contemp Dent Pract. 2015 Mar 1;16(3):187-91.40 extracted pri ant teeth3minutes with 5 ml of 17% (EDTA) or saline respectively.

experimental groups :

3 minutes with 5 ml of 1 mg/ml ethanolic extract of S. persica (n = 15) or

BioPure MTAD (n = 15) and then flushed with 2 ml of saline. MTAD solution was as effective as 17% EDTA in removing the smear layer.MTAD >> S.persica (miswak) at middle third of canal

AIM:To evaluate the efficacy of ethanolic extract of Salvadora persica (S. persica) and BioPure MTAD (a mixture of a tetracycline isomer, an acid, and a detergent) in removing the intracanal smear layer of primary teeth.MATERIALS AND METHODS:The root canal of 40 extracted human primary anterior teeth were cleaned, shaped and grouped into experimental (n = 30) and control (n = 10). The root canals of the positive (n = 5) and the negative control (n = 5) were irrigated for 3 minutes with 5 ml of 17% ethylenediaminetetraacetic acid (EDTA) or saline respectively. The canals in the experimental groups were irrigated for 3 minutes with 5 ml of 1 mg/ml ethanolic extract of S. persica (n = 15) or BioPure MTAD (n = 15) and then flushed with 2 ml of saline. The presence or absence of smear layer at the coronal and middle portion of each canal were examined under a scanning electron microscope (SEM).RESULTS:A significant difference (p = 0.004) in smear layer removal between S. persica and MTAD at the middle third of the canal was observed. MTAD solution was as effective as 17% EDTA in removing the smear layer.CONCLUSION:MTAD was significantly more effective in smear layer removal than S. persica solution at the middle third of the canal wall.CLINICAL SIGNIFICANCE:Both tested irrigant solutions have the ability to remove the intracanal smear from primary root dentin following cleaning and shaping of the root canal and could be an alternative to EDTA.70

studyirrigantsresultPrabhakar et al

J Endod. 2010 Jan;36(1):83-6.Extracted teethTriphala

green tea polyphenols (GTP)

MTAD

5% sodium hypochlorite against E. faecalis biofilm5% sodium hypochlorite showed maximum antibacterial activity against E. Faecalis biofilm formed

studysampleirrigantsresultconclusionVenkataram, Gokhale, Kenchappa et al

Eur Arch Paediatr Dent. 2013 Aug;14(4):247-5230 extracted primary anteriorschamomile hydroalcoholic extract,

Biopure (MTAD)

2.5% (NaOCl) Smear removal MTAD >> chamomile extractefficacy of chamomile to remove the smear layer was superior to 2.5 % NaOCl alone, but less effective than MTAD mixture.Lotfi et al

J Endod. 2012 Oct;38(10):1391-4. In the MTAD group, the root canals were flushed with 1.3% NaOCl solution during 10-minute instrumentation, and MTAD was used as the final rinse. In other experimental group, 5.25% NaOCl was used during instrumentation, and 17% ethylenediaminetetraacetic acid (EDTA) was used as the final rinse. In the positive control group, sterile distilled water was used for irrigationIn 10-minute instrumentation period, the use of 5.25% NaOCl during instrumentation and 17% EDTA as the final rinse is more effective than using 1.3% NaOCl as primary irrigation and MTAD as final rinse on removal of the smear layer.

METHODS:Thirty extracted single-rooted, primary human teeth were allocated at random into three experimental groups of 10 teeth each. For each tooth, the canal was prepared using the step-back technique. During instrumentation, 2 ml of the irrigant was used for at least 10 s after each file and 10 ml as a final flush for 2 min for chamomile and NaOCL irrigants. Whereas for MTAD, an initial rinse with 1.3 % NaOCl for a cumulated period of 20 min, and use of MTAD as the final rinse for a period of 5 min was followed. Longitudinal grooves were made on root segments, then split into two halves with a chisel, stored in 2.5 % glutaraldehyde solution and fixed in ethanol series. Specimens were examined for the smear layer according to Hulsmann et al. (Int Endod J 35:668-679, 2002) criteria using a scanning electron microscope.STATISTICS:Kruskal-Wallis and Mann-Whitney U tests were used.RESULTS:The most effective result in removal of smear layer occurred with the use of MTAD, followed by chamomile extract. The chamomile extract was found to be significantly more effective than 2.5 % NaOCl solution which had only minor effects.CONCLUSIONS:The efficacy of chamomile to remove the smear layer was superior to 2.5 % NaOCl alone, but less effective than MTAD mixture.72

studysampleirrigantsresultconclusionAshofteh , Sohrabi et al

Iran J Microbiol. 2014 Feb;6(1):26-30.135 extracted single rooted 5.25% Naocl

2% CHX

MTAD

830 nm diode laser BACTERIAL REDUCTION

99.970.14 : Naocl

99.651.13 for CHX

97.566.36 : LASER

96.915.60 : MTADNaocl was the most effective agent against Enterococcus faecalis

INTRODUCTION:Bacteria are the primary etiology of pulpal and periradicular pathosis. In endodontically treated teeth with persistent infections only one or a few bacterial species are present of which the most important is Enterococcus faecalis. The aim of this study was to compare antibacterial efficacy of canal disinfectants including 5.25% sodium hypochlorite, 2% chlorhexidine, MTAD (a mixture of doxycycline, citric acid and a detergent (Tween 80) and 830 nm diode laser.METHODS AND MATERIALS:The canals of 135 extracted single rooted human teeth were prepared using rotary instruments. The canals were contaminated with Enterococcus faecalis for 4 weeks and then were divided into 4 groups of 30 teeth in each, a positive control group containing 10 teeth and a negative control group of 5 teeth. After using the disinfectants, samples obtained from canals by paper points and also shaving the canal walls were cultured. The Kruskal-Wallis test was used to analyze the results.RESULTS:The results showed the bacterial reduction as follows: 99.970.14 for sodium hypochlorite, 99.651.13 for chlorhexidine, 97.566.36 for laser and 96.915.60 for MTAD. The count of CFU obtained from dentin shavings was: 16/9691/23 for sodium hypochlorite, 82/73186/63 .for chlorhexidine, 47/26112/21 for laser and 341/341139/83 for MTAD.CONCLUSION:According to the results, sodium hypochlorite was the most effective agent against Enterococ73

studyirrigantsconclusionDagna et al

Int J Artif Organs. 2011 Sep;34(9):914-9.Niclor 5 (5% NaOCl solution)

Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution)

3% hydrogen peroxide

17% EDTA with 5%NaoclE.Faecalis

S.mutans5%Naocl with 17% EDTA showed greatest antimicrobial efficacy

The objective of this study was to compare in vitro, by MTT assay, the antimicrobial efficacy of Niclor 5 (5% NaOCl solution), Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution), 3% hydrogen peroxide and 17% EDTA against two microorganisms associated with primary endodontic infections.METHODS:Enterococcus faecalis and Streptococcus mutans strains were selected for this test. Freshly extracted single-rooted human teeth were endodontically treated, inoculated with bacterial strains and then divided into different groups, each of them rinsed with Niclor 5 (5% NaOCl solution), Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution), 3% hydrogen peroxide,17% EDTA and with 5% NaOCl solution (positive control).RESULTS:Even though all the tested irrigating solutions demonstrated antibacterial effects against E. faecalis and S. mutans, the results were significantly different between the various groups. The greatest antimicrobial effects were observed in groups treated with 5% NaOCl and 17% EDTA. Interestingly, the effectiveness of EDTA could be ascribed to its capability of detaching biofilm from canal walls.74

studysampleirrigantsHegde et al

Contemp Clin Dent. 2016 Apr-Jun;7(2):216-2030 pri ant teeth10 ml 17% EGTA (ethylene glycol bis (beta-amino ethyl ether)-N, N, N', N'-tetraacetic acid)followed by 5% Naocl

10 ml 6% CITIC ACID

10 ml 0.9% SALINE : controlsequential irrigation of the pulp canal walls with 17% EGTA followed by 5% NaOCl produced efficacious and smear-free root canal walls.Hariharan et al

J Indian Soc Pedod Prev Dent. 2010 Oct-Dec;28(4):271-730 pri incisors 5.25% NaOCl,

5.25% NaOCl + 10% EDTA,

6% citric acid,

2% chlorhexidine,

saline superior efficacy of 6% citric acid

Thirty primary anterior teeth were chosen for the study. The teeth were distributed into three groups having ten teeth each. Following instrumentation, root canals of the first group were treated with 17% EGTA and the second group with 6% citric acid. Only saline was used as an irrigant for the control group. Then, the teeth were subjected to scanning electron microscopy (SEM) study. The scale given by Rome et al. for the smear layer removal was used in the present study.RESULTS:The pictures from the SEM showed that among the tested irrigants, 17% EGTA + 5% sodium hypochlorite (NaOCl) group showed the best results when compared to other groups.CONCLUSION:The results advocate that the sequential irrigation of the pulp canal walls with 17% EGTA followed by 5% NaOCl produced efficacious and smear-free root canal walls.The pictures from the scanning electron microscopy showed that among the tested irrigants, citric acid has the best efficacy to remove the smear layer without altering the normal dentinal structures, which was supported by the lowest mean smear scores. The pictures from the 10%EDTA + 5.25% sodium hypochlorite group showed that even though it removed the smear layer, it adversely affected the dentine structure. SEM pictures of the other groups like sodium hypochlorite, chlorhexidine revealed that these irrigants does not have the capacity to remove the smear layer in primary teeth.CONCLUSIONS:The results of the present study clearly indicate the superior efficacy of 6% citric acid than the other tested irrigants on removing the smear layer in primary teeth root canals.75

studyirrigantsconclusionBotton et al

Int Endod J. 2016 Aug;49(8):746-54sodium hypochlorite (1% and 2.5%)

2% chlorhexidine

6% citric acid

17% EDTAToxicity test All groups showed some level of toxicity.

Amongst the main solutions, chlorhexidine presented less cytotoxic potential.

EDTA was the least cytotoxic of the auxiliary irrigant solutions, and the association of these two solutions showed the lowest toxicity potential amongst all groups.

studysamplegroupsresultconclusionKapdan et al

Niger J Clin Pract. 2015 Jul-Aug;18(4):538-43The KTP laser (1,5 W); gaseous ozone (150 s); sodium hypochlorite (NaOCl); saline groupComplete sterilization was achieved in the 2.5% NaOCl group KTP laser and ozone application provided a significant antibacterial effect in primary root canals; however, 2.5% NaOCl was superiorGoztas et al

Eur J Dent. 2014 Oct;8(4):469-7458 extracted pri molarGroup I: 25 mg/L of Ozonated water (O3aq),

Group II: 25 mg/L of O3aq with ultrasonication,

Group III: 2.5% Sodium hypochloride (NaOCl),

Group IV: 2% CHX and Group V: Positive control. NaOCI irrigation was found significantly most effective.

The aim of the study was to evaluate the antimicrobial activity of the-potassium-titanyl-phosphate--the KTP laser and ozone in of primary root canals.MATERIALS AND METHODS:Sixty primary incisor teeth were selected. The specimens were inoculated with 10 mL Enterococcus faecalis (E. faecalis). Groups: The KTP laser (1,5 W); gaseous ozone (150 s); sodium hypochlorite (NaOCl); saline group. Sterile paper points used to sample bacteria from the canals to tubes containing 5 mL of brain heart infusion broth. Then, 10 mL suspension was incubated in culture media for 24 h. Data were analyzed statistically using Kruskal-Wallis and Mann-Whitney U-test.RESULTS:There were statistically significant differences between all groups (P