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Journal List J Conserv Dent v.13(4); Oct-Dec 2010 PMC3010032

J Conserv Dent. 2010 Oct-Dec; 13(4): 256264.

doi: 10.4103/0972-0707.73378

PMCID: PMC3010032

Root canal irrigants

Deivanayagam Kandaswamy and Nagendrababu Venkateshbabu

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Abstract

Successful root canal therapy relies on the combination of properinstrumentation, irrigation, and obturation of the root canal. Ofthese three essential steps of root canal therapy, irrigation of theroot canal is the most important determinant in the healing of theperiapical tissues. The primary endodontic treatment goal must

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Irrigation in endodontic treatment.

[Alpha Omegan. 2011]

Comparison of the antimicrobial efficacy of

1.3% NaOCl/BioPure MTAD to 5.25%

[J Endod. 2007]

Irrigants for non-surgical root canal

treatment in mature permanent teeth.

[Cochrane Database Syst Rev. 2012]

The properties and applications ofchlorhexidine in endodontics .

[Int Endod J. 2009]

Application of biologically-oriented dentin

bonding principles to the use of endodontic

[Am J Dent. 2005]

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thus be to optimize root canal disinfection and to preventreinfection. In this review of the literature, various irrigants andthe interactions between irrigants are discussed. We performed aMedline search for English-language papers published untill July2010. The keywords used were root canal irrigants andendodontic irrigants. The reference lists of each article were

manually checked for additional articles of relevance.

Keywords: Root canal irrigants, endodotic irrigants, NaOCl,EDTA, MTAD, CHX,E faecalis

INTRODUCTION

Bacteria have long been recognized as the primary etiologic factors

in the development of pulp and periapical lesions.[13] Successfulroot canal therapy depends on thorough chemomechanicaldebridement of pulpal tissue, dentin debris, and infectivemicroorganisms. Irrigants can augment mechanical debridement

by flushing out debris, dissolving tissue, and disinfecting the rootcanal system. Chemical debridement is especially needed for teeth

with complex internal anatomy such as fins or other irregularities

that might be missed by instrumentation.[4] For this review articlewe performed a Medline search for all English-language articlespublished till July 2010. We used the keywords root canal irrigantsand endodontic irrigants.

IDEAL REQUIREMENTS OF ROOT CANALIRRIGANTS[5]

Cited by other articles in PMC

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The effects of various irrigating solutions on

intra-radicular dentinal surface: An SEM

[Journal of Pharmacy & Bioallie...]

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1. Broad antimicrobial spectrum2. High efficacy against anaerobic and facultative

microorganisms organized in biofilms3. Ability to dissolve necrotic pulp tissue remnants4. Ability to inactivate endotoxin

5. Ability to prevent the formation of a smear layer duringinstrumentation or to dissolve the latter once it has formed.6. Systemically nontoxic when they come in contact with

vital tissues, noncaustic to periodontal tissues, and withlittle potential to cause an anaphylactic reaction.

CLASSIFICATION
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Go to:SODIUM HYPOCHLORITE

History

Sodium Hypochlorite (NaOCl) has an extensive history in medicineand dentistry and continues to be popular even today. During

World War I, the chemist Henry Drysdale Dakin and the surgeon

Alexis Carrel extended the use of buffered 0.5% NaOCl solution tothe irrigation of infected wounds.[6]

Me chanism of action

Pcora et al.[7] reported that NaOCl exhibits a dynamic balance asis shown by the reaction:

NaOCl + H O NaOH +HOCl Na + OH + H +

OCl

NaOCl + H O NaOH + HOClNa + OH + H + OCl

The chemical reactions between organic tissue[78] and NaOClare shown in Schemes 13:

NaOCl acts as an organic and fat solvent, degrading fatty acids andtransforming them into fatty acid salts (soap) and glycerol(alcohol), which reduces the surface tension of the solution [Scheme 1].[9]

2+ +

2+ - + -

ON THE USE OF CERTAIN ANTISEPTIC

SUBSTANCES IN THE TREATMENT OF

[Br Med J. 1915]

Solvent action of sodium hypochlorite on

bovine pulp and physico-chemical

[Braz Dent J. 2001]

Mechanism of action of sodium

hypochlorite. [Braz Dent J. 2002]
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Scheme 1Saponification reaction

NaOCl neutralizes amino acids forming water and salt [Scheme 2].With the exit of hydroxyl ions, there is a reduction of pH.

Scheme 2Amino acid neutralization reaction

When hypochlorous acid, a substance present in NaOCl solution,comes in contact with organic tissue it acts as a solvent andreleases chlorine, which combines with the protein amino group toform chloramines [Scheme 3]. Hypochlorous acid (HOCl ) andhypochlorite ions (OCl ) lead to amino acid degradation andhydrolysis.[9] The chloramination reaction between chlorine andthe amino group (NH) forms chloramines that interfere in cellmetabolism. Chlorine (a strong oxidant) has an antimicrobialaction, inhibiting bacterial enzymes and leading to an irreversibleoxidation of SH groups (sulphydryl group) of essential bacterialenzymes.[9]

Scheme 3Chloramination reaction

Thus, the saponification, amino acid neutralization, andchloramination reactions that occur in the presence of

-

-



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1. Altering the pH:

microorganisms and organic tissue lead to the antimicrobial effectand tissue dissolution process.[9]

Antimicrobial property Concentration and time

The most effective irrigation regimen is reported to be 5.25% at 40min;[10] irrigation with 1.3% and 2.5% NaOCl for this same time

interval is ineffective in removing E faecalis from infected dentincylinders.[11] NaOCl was moderately effective against bacteria butless effective against endotoxins in root canal infection.[12]

Effect on biofilm[13]

1. Complete dissolution of cells with absence of visualevidence

2. Bacterial cells are disrupted and separated from the biofilmand are nonviable

3. Bacterial cells remain adherent within the biofilm but arenonviable

4. Bacterial cells are disrupted and separated from the biofilmbut are viable

5. Bacterial cells remain adherent within the biofilm and are

still viable.[14]

Increasing the efficacy of NaOCl

a. The antibacterial properties and tissue-dissolving properties of 5.25% NaOCl decrease when it isdiluted.[1416] When NaOCl is added to water, the following


See more ...

Chemomechanical reduction of the

bacterial population in the root canal after

[J Endod. 2000]

Minimum contact time and concentration

of sodium hypochlorite required to

[J Endod. 2010]

The effect of dilution and organic matter on

the anti-bacterial property of 5.25%

[J Endod. 1981]
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reaction takes place:

NaOCl + H O NaOH +HOCl (hypocholorous acid) (1)

In aqueous solution, hypochlorous acid partially dissociates into theanion hypochlorite (OCl ):

HOCl H OCl (2)The available chlorine is the sum of the HOCl and OClconcentrations in the solution.[17] Available chlorine might be

defined as a measurement of oxidizing capacity and is expressed interms of the amount of elemental chlorine. HOCl is considered to

be a stronger oxidant than the hypochlorite ion. The HOClmolecule is responsible for the strong chlorinating and oxidizingaction on tissue and microorganisms. HOCl dissociation [Equation2] depends on pH, with the clinical equilibrium between HOCl andOCl being maintained as HOCl is consumed through its germicidal

function.[18] Baker[19] gave the relationship between HOCl, OCl ,and pH. At pH 10, basically all chlorine is in the OCl form; thereverse occurs at a pH of 4.5, w hen all chlorine is in the form ofHOCl. The disinfecting properties decrease with higher pH,paralleling the concentration of dissociated HOCl. Bloomfield andMiles[17] confirmed that hypochlorites at a lower pH possessgreater antimicrobial activity. Andrews and Orton[19] reported

2

-

+

-

-

--

The effects of temperature, concentration,

and tissue type on the solvent ability of

[J Endod. 1981]
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2. Temperature

that HOCl was responsible for the destruction of microorganisms.Morris[20] found that OCl ion possesses approximately 1/80 ofthe germicidal potency of HOCl in killing Escherechia coli.

Reactive chlorine in aqueous solution at body temperature can taketwo forms: hypochlorite (OCl ) or hypochlorous acid (HOCl). Theconcentration of these can be expressed as available chlorine bydetermining the electrochemical equivalent amount of elementalchlorine,[21] according to the following equations:

Cl + 2e = 2Cl (1)OCl + 2e + 2H = Cl

+ H O (2)

Therefore, 1 mol of hypochlorite contains 1 mol of availablechlorine. The state of available chlorine is dependant on the pH ofthe solution. Above a pH of 7.6, the predominant form ishypochlorite and below this value it is hypochlorous acid.[22] Bothforms are extremely reactive oxidizing agents. Pure hypochloritesolutions, as are used in endodontics, have a pH of 12,[23] and thusthe entire available chlorine is in the form of OCl . However, atidentical levels of available chlorine, HOCl is more bactericidal thanhypochlorite.[24]

A rise in temperature by 25C increased NaOClefficacy by a factor of 100 (25). The capacity of a 1% NaOCl at

- th

-

2

- +

2

-

Some factors affecting the concentration

of available chlorine in commercial

[Int Endod J. 2001]

The antibacterial properties of sodium

dichloroisocyanurate and sodium

[J Appl Bacteriol. 1979]

Final rinse optimization: influence of
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3. Ultrasonic

45C to dissolve human dental pulps was found to be equal to thatof a 5.25% solution at 20C.[26]

The use of ultrasonic agitation increased theeffectiveness of 5% NaOCl in the apical third of the canal wall.[26]Passive ultrasonic irrigation with a nickel-titanium tip producedsuperior tissue-dissolving effects as compared to sonic irrigantactivation.[27]

Influence on mechanical properties

NaOCl is an efficient organic solvent that causes dentindegeneration because of the dissolution of collagen by the

breakdown of the bonds between carbon atoms and disorganization

of the proteic primary structure.[28] The reduction of the bondstrength seen between adhesive systems and dentin walls may bebecause of the removal of collagen fibrils from the dentin surfaceby NaOCl, impeding the formation of a consistent hybrid layer.[29]

Influence of NaOCl on NiTi

Busslinger and Barbakow[30] evaluated corrosion of endodontic

files caused by NaOCl solutions of different concentrations from0.5% to 5.5%. These authors concluded that the quantities of ionsreleased by the corrosion process into the NaOCl solutions wereinsignificant. Consequently, no significant corrosion of NiTi files inthese solutions was detected. Fabiola et al.[31] suggests thatexposure to 5.25% NaOCl solution affects neither resistance toflexural fatigue nor torsional resistance of NiTi K3 endodontic files.

different agitation protocols.[J Endod. 2010]

Final rinse optimization: influence of

different agitation protocols.[J Endod. 2010]

Acoustic hypochlorite activation in

simulated curved canals. [J Endod. 2009]

Effect of NaClO treatment on bonding to

root canal dentin using a new evaluation[Dent Mater J. 2001]

Bond strengths to endodontically-treated

teeth. [Am J Dent. 1999]

Effects of sodium hypochlorite on nickel-

titanium Lightspeed instruments.[Int Endod J. 1998]

Influence of sodium hypochlorite on

mechanical properties of K3 nickel-

[J Endod. 2007]
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Influence of NaOCl on bond strength

NaOCl irrigation leads to decreased bond strength between dentinand resin cements and may require a reversal agent because of itsability to affect the polymerization of the resin sealer.[32,33]

Agents such as ascorbic acid or sodium ascorbate have been shown

to completely reverse this reduction in bond strength.[34]

Interaction of NaOCl and chlorhexidine

Kuruvilla et al.[35] suggested that the antimicrobial effect of 2.5%NaOCl and 0.2% chlorhexidine (CHX) used in combination wasgreater than that of either agent used separately. The reaction

between NaOCl and CHX produces a carcinogenic product,

parachloroanaline (PCA), the potential leakage of which into thesurrounding tissues is a concern. The precipitate is an insolubleneutral salt formed by the acid-base reaction between NaOCl andCHX. PCA is the main product of the interaction of NaOCl andCHX, and has the molecular formula NaC H Cl.[36] When mixed

with NaOCl, CHX molecules become hydrolyzed into smallerfragments, each forming a byproduct. The first bonds to be broken

in this reaction are those between carbon and nitrogen because ofthe low-bond dissociation energy between these two atoms. Thepresence of PCA was confirmed by the Beilstein test for thepresence of chlorine and the HCl solubility test for the presence ofaniline. Leaching of PCA from the insoluble precipitate formed is ofconcern because it has been shown to be cytotoxic in rats[37] andpossibly carcinogenic in humans.[3840] This reaction coats the

6 4

See more ...

Effects of sodium hypochlorite and RC-

prep on bond strengths of resin cement to

[J Endod. 2001]

Effects of NaOCl on bond strengths ofresin cements to root canal dentin.[J Endod. 2003]

Antimicrobial activity of 2.5% sodium

hypochlorite and 0.2% chlorhexidine

[J Endod. 1998]

Interaction between sodium hypochloriteand chlorhexidine gluconate.[J Endod. 2007]

Carcinogenicity of p-chloroaniline in rats

and mice. [Food Chem Toxicol. 1991]

Evaluation and prevention of the

precipitate formed on interaction between

[J Endod. 2010]

Evaluation of the interaction between

sodium hypochlorite and chlorhexidine

[J Endod. 2008]
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canal surface and significantly occludes the dentinal tubules andaffects the seal of the root canal.[41]

EDTA

EDTA reacts with the calcium ions in dentine and forms solublecalcium chelates. It has been reported that EDTA decalcified dentin

to a depth of 2030m in 5 min.[42]

Time duration for smear layer removal

A continuous rinse with 5 ml of 17% EDTA, as a final rinse for 3min efficiently removes the smear layer from root canal walls.[43]

According to Saito et al. greater smear layer removal was found inthe 1-min EDTA irrigation group than the 30-sec or 15-sec

groups.[44,45]

Effect on tooth surface strain

Irrigation with 5% NaOCl alone or alternated with 17% EDTA(used in 30-min cycles) significantly increased tooth surface strain.The alternated regimen showed significantly greater changes intooth surface strain than NaOCl alone. Irrigation with 3% NaOCl

and 17% EDTA individually or in combination did not significantlyalter the tooth surface strain.[46]

EDTA with ultrasonics

A 1-min application of 17% EDTA combined with ultrasonics isefficient for smear layer and debris removal in the apical region of

Influence of final rinse technique on ability

of ethylenediaminetetraacetic acid of

[J Endod. 2010]

Effect of shortened irrigation times with

17% ethylene diamine tetra-acetic acid on

[J Endod. 2008]

The effect of sodium hypochlorite and

ethylenediaminetetraacetic acid irrigation,

[Int Endod J. 2010]
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the root canal.[47] EDTA performed significantly better than NaCland NaOCl in smear layer removal and dentinal tubuleopening.[48]

Chlorhexidine

Chlorhexidine digluconate is widely used in disinfection because of

its excellent antimicrobial activity. However, it completely lackstissue dissolving capability.[49]

Structure and mechanism of action

CHX is a synthetic cationic bis-guanide that consists of twosymmetric 4-chlorophenyl rings and two biguanide groupsconnected by central hexam-ethylene chains.[50] CHX is a

positively charged hydrophobic and lipophilic molecule thatinteracts with phospholipids and lipopolysaccharides on the cellmembrane of bacteria and enters the cell through some type ofactive or passive transport mechanism.[51] Its efficacy is becauseof the interaction of the positive charge of the molecule with thenegatively charged phosphate groups on microbial cell

walls,[52,53] which alters the cells osmotic equilibrium. This

increases the permeability of the cell wall, allowing the CHXmolecule to penetrate into the bacteria.[49] Damage to this delicatemembrane is followed by leakage of intracellular constituents,particularly phosphate entities such as adenosine triphosphate andnucleic acids. As a consequence, the cytoplasm becomes congealed,

with resultant reduction in leakage; thus, there is a biphasic effecton membrane permeability. CHX antimicrobial activity is pH

The effect of EDTA with and without

ultrasonics on removal of the smear layer.[J Endod. 2009]

Effect of different irrigation on smear layer

removal after post space preparation.[J Endod. 2009]

Review The properties and applications of

chlorhexidine in endodontics.[Int Endod J. 2009]

Review Chlorhexidine. An adjunct to

periodontal therapy. [J Periodontol. 1986]

Review The use of calcium hydroxide,

antibiotics and biocides as antimicrobial

[Aust Dent J. 2007]

Effectiveness of 2% chlorhexidine gel and

calcium hydroxide against Enterococcus

[Int Endod J. 2003]

Evaluation of time required for

recontamination of coronally sealed

[Int Endod J. 2003]

Review The properties and applications ofchlorhexidine in endodontics.[Int Endod J. 2009]

Reduction in the cultivable bacterial

populations in infected root canals by a

[J Endod. 2007]
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dependant, with the optimal range being 5.50.7 [Figure 1].[54]

Figure 1Mechanism of action of CHX.

Antibacterial activity

Basson and Tait[55] compared the ex vivo effectiveness of calciumhydroxide, iodine potassium iodide (IKI), and CHX solution indisinfecting root canal systems that were infected with

Actinomyces israelii. The root canals were exposed to either IKI,calcium hydroxide, or 2% CHX for periods of 3, 7, and 60 days.

CHX was the only disinfectant that was able to eliminateA israelii.Oncag et al.[56] evaluated the antibacterial properties against

Enterococcus faecalis of 5.25% NaOCl, 2% CHX, and 0.2% CHXplus 0.2% cetrimide after 5 min and 48 h. The 2% CHX andCetrexidin were significantly more effective against E faecalis.Two studies[57,58] have investigated the antimicrobial activityagainst endodontic pathogens of three concentrations (0.2%, 1%,

and 2%) of two forms of CHX (gel and liquid) and compared themwith five concentrations of NaOCl (0.5%, 1%, 2.5%, 4%, and5.25%). Both the 2% gel and 2% liquid formulations of CHXeliminatedStaphylococcus aureus and Candida albicans within 15sec, whereas the gel formulation killedE faecalis within 1 min. Allof the tested irrigants eliminatedPorphyromonas endodontalis,

Porphyromonas gingivalis, andPrevotella intermedia within 15

Effectiveness of three root canal

medicaments to eliminate Actinomyces

[SADJ. 2001]

Comparison of antibacterial and toxic

effects of various root canal irrigants.[Int Endod J. 2003]In vitro antimicrobial activity of several

concentrations of sodium hypochlorite and

[Int Endod J. 2001]

In vitro evaluation of the antimicrobial

activity of chlorhexidine and sodium Med Oral Pathol Oral Radiol Endod. 2004]
http://pdfcrowd.com/http://pdfcrowd.com/redirect/?url=http%3a%2f%2fwww.ncbi.nlm.nih.gov%2fpmc%2farticles%2fPMC3010032%2f&id=ma-130616004630-07b7a9b7http://pdfcrowd.com/customize/http://pdfcrowd.com/html-to-pdf-api/?ref=pdfhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010032/figure/F0004/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010032/figure/F0004/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010032/figure/F0004/http://www.ncbi.nlm.nih.gov/pubmed/11885423/http://www.ncbi.nlm.nih.gov/pubmed/12801290/http://www.ncbi.nlm.nih.gov/pubmed/11556507/http://www.ncbi.nlm.nih.gov/pubmed/14716261/


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sec.[57,58]

Effect of CHX on dentin

CHX has the ability to bind anionic molecules such as phosphatepresent in the structure of hydroxyapatite. Phosphate exists incalcium carbonate complexes in dentin. CHX can bind phosphate,

which leads to release of small amounts of calcium from the rootcanal dentin.[60]

Interaction of CHX and EDTA

When CHX and EDTA interact, a precipitate is formed that is over90% CHX and EDTA, with less than 1% of the potentialdecomposition product, p-chloroaniline. The high recovery

indicates that CHX is not degraded by EDTA under normalconditions. The precipitate is most likely a salt formed byelectrostatic neutralization of cationic CHX by anionic EDTA. Thesuspected net ionic equation is:

The clinical significance of this precipitate is largely unknown.[60]

CHX and bioflim

Spratt et al. have evaluated the effectiveness of 2.25% NaOCl, 0.2%CHX, 10% povidone iodine against monoculture biofilms ofPintermedia, P miros, S intermedius, F nucleatum , andE faecalis.

Interaction between chlorhexidine

digluconate and EDTA. [J Endod. 2008]

See links ...

An in vitro evaluation of the antimicrobial

Th t d th t N OCl th t ff ti ti i bi l efficacy of irrigants on biofilms of root

[Int Endod J 2001]
http://pdfcrowd.com/http://pdfcrowd.com/redirect/?url=http%3a%2f%2fwww.ncbi.nlm.nih.gov%2fpmc%2farticles%2fPMC3010032%2f&id=ma-130616004630-07b7a9b7http://pdfcrowd.com/customize/http://pdfcrowd.com/html-to-pdf-api/?ref=pdfhttp://www.ncbi.nlm.nih.gov/pubmed/19026886/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010032/http://www.ncbi.nlm.nih.gov/pubmed/11482142/http://www.ncbi.nlm.nih.gov/pubmed/11482142/


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They reported that NaOCl was the most effective antimicrobialagent, followed by the iodine solution.[61] Clegg et al. evaluated theex vivo effectiveness against apical dentine biofilms of threeconcentrations of NaOCl (6%, 3%, and 1%), 2% CHX, and Mixtureof Tetracycline acid and detergents (MTAD). They reported that the6% NaOCl and 3% NaOCl were capable of disrupting and removing

the biofilm, the 1% NaOCl and the MTAD were capable ofdisrupting the biofilm but did not eliminate the bacteria, and the2% CHX was not capable of disrupting the biofilm.[62]

Substantivity

White et al. evaluated the antimicrobial substantivity of a 2% CHXsolution as an endodontic irrigant and reported that the

substantivity lasted 72 h.[63] Khademi et al.[64] found that 5-minapplication of 2% CHX solution induced substantivity for up to 4

weeks. Rosenthal et al.[65] evaluated the substantivity of 2% CHXsolution within the root canal system after 10 min of applicationand they reported that the CHX was retained in the root canaldentine in antimicrobially effective amounts for up to 12 weeks.

Antimicrobial substantivity depends on the number of CHX

molecules available to interact with the dentine.[49]

CHX and dentine bonding (anticollagenolytic activity)

Human dentin contains at least collagenase (MMP-8), gelatinasesMMP-2 and MMP-9, and enamelysin MMP-20.[66,67] Dentinecollagenolytic[68] and gelatinolytic activities[68] can be suppressed

by protease inhibitors, indicating that MMP inhibition could be

efficacy of irrigants on biofilms of root

[Int Endod J. 2001]

The effect of exposure to irrigant solutions

on apical dentin biofilms in vitro.[J Endod. 2006]

Residual antimicrobial activity after canalirrigation with chlorhexidine.[J Endod. 1997]

Evaluation of the antibacterial substantivity

of several intra-canal agents.[Aust Endod J. 2006]

Chlorhexidine substantivity in root canal

dentin. Med Oral Pathol Oral Radiol Endod. 2004]

Review The properties and applications of

chlorhexidine in endodontics.[Int Endod J. 2009]

The matrix metalloproteinase gelatinase A

in human dentine. [Arch Oral Biol. 2000]

b fi i l i h i f h b id l hi
http://www.ncbi.nlm.nih.gov/pubmed/11482142/http://pdfcrowd.com/http://pdfcrowd.com/redirect/?url=http%3a%2f%2fwww.ncbi.nlm.nih.gov%2fpmc%2farticles%2fPMC3010032%2f&id=ma-130616004630-07b7a9b7http://pdfcrowd.com/customize/http://pdfcrowd.com/html-to-pdf-api/?ref=pdfhttp://www.ncbi.nlm.nih.gov/pubmed/11482142/http://www.ncbi.nlm.nih.gov/pubmed/16631843/http://www.ncbi.nlm.nih.gov/pubmed/9594771/http://www.ncbi.nlm.nih.gov/pubmed/17201752/http://www.ncbi.nlm.nih.gov/pubmed/15472666/http://www.ncbi.nlm.nih.gov/pubmed/19220510/http://www.ncbi.nlm.nih.gov/pubmed/10869489/http://www.ncbi.nlm.nih.gov/pubmed/17045563/


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beneficial in the preservation of hybrid layers. This wasdemonstrated in anIn vivo study in which the application of CHX,known to have a broad-spectrum MMP-inhibitory effect,[69]significantly improved the integrity of the hybrid layer in a 6-month clinical trial.[70] Auto-degradation of collagen matrices canoccur in resin-infiltrated dentine but may be prevented by the

application of a synthetic protease inhibitor such as CHX.[71] Onthe whole, because of its broad-spectrum MMP-inhibitory effect,CHX can significantly improve the resindentine bond stability.

Cytotoxicity of CHX

Cytotoxic effects of CHX on canine embryonic fibroblast andStaphylococcus aureus showed that bactericidal concentrations

were lethal to canine embryonic fibroblasts while non-cytotoxicconcentrations allowed survival of bacteria.[72] Ribeiro et al.[73]evaluated the genotoxicity (potential damage to DNA) offormocresol, paramonochlorophenol, calcium hydroxide, and CHXagainst Chinese hamster ovary cells. Results showed that none ofthe mentioned agents contributed to DNA damage. Thus, in theclinically used concentrations, the biocompatibility of CHX is

acceptable.

Allergic reactions to CHX

Contant dermatitis is a common adverse reaction.[74] CHX mayhave a number of rare side effects, such as desquamative gingivitis,discoloration of the teeth and tongue, or dysgeusia.[49]

Matrix metalloproteinase-8 (MMP-8) is the

major collagenase in human dentin.[Arch Oral Biol. 2007]

Collagen degradation by host-derived

enzymes during aging. [J Dent Res. 2004]

Inhibition of the activities of matrix

metalloproteinases 2, 8, and 9 by[Clin Diagn Lab Immunol. 1999]

Chlorhexidine arrests subclinicaldegradation of dentin hybrid layers in vivo.[J Dent Res. 2005]

In vivo preservation of the hybrid layer by

chlorhexidine. [J Dent Res. 2007]

Chlorhexidine diacetate and povidone-iodine cytotoxicity to canine embryonic

[Vet Surg. 1988]

Genotoxicity of antimicrobial endodontic

compounds by single cell gel (comet)

Med Oral Pathol Oral Radiol Endod. 2005]

See links ...

MTAD
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Go to:MTAD

Torabinejad et al. developed a irrigant with combined chelating andantibacterial properties.[75] MTAD is a mixture of 3% doxycycline,4.25% citric acid, and detergent (Tween-80).[75,76]

Antibacterial activity and smear layer removal

MTAD is composed of three constituents that are expected to actsynergistically against bacteria.[75] The bactericidal effect ofMTAD was inferior to 1%-6% NaOCl againstE faecalis

biofilms.[77] The antibacterial activity of MTAD might also beinhibited by the buffering effect of dentin and the serum albuminpresent in the root canal.[78] MTAD has been reported to beeffective in removing smear layer.[79] I n the MTAD preparation,the citric acid may serve to remove the smear layer, allowingdoxycycline to enter the dentinal tubules and exert an antibacterialeffect.[80] The recently revised protocol for clinical use of MTADadvises an initial irrigation for 20 min with 1.3% NaOCl, followed

by a 5-min final rinse with MTAD.[80]

Bond strength

The use of MTAD as a final rinse with gutta-percha/AH Plusresulted in a significant reduction in bond strength (1.761.67 Mpa)

when compared with EDTA.[81] A final rinse with MTAD mighthave a negative effect on the bonding ability of both resin-basedand calcium hydroxidebased sealers due to the precipitate

A new solution for the removal of the

smear layer. [J Endod. 2003]

A new solution for the removal of the

smear layer. [J Endod. 2003]

Review Effects of dentin on the

antimicrobial properties of endodontic[J Endod. 2007]

Comparative evaluation of endodontic

irrigants against Enterococcus faecalis[J Endod. 2006]

Effect of MTAD on Enterococcus faecalis-

contaminated root canals of extracted

[J Endod. 2003]

The effect of various concentrations of

sodium hypochlorite on the ability of

[J Endod. 2003]

The effect of different irrigating solutions

on bond strength of two root canal-filling[J Endod. 2009]

Evaluation of the effect of MTAD in

comparison with EDTA when employed as[Aust Endod J. 2011]

.
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OTHER IRRIGANTS

Citric acid and EDTA-T

The use of 10% citric acid as final irrigation has shown good resultsin smear layer removal.[83]In vitro studies have shown their

cytotoxicity, and 10% citric acid has proven to be morebiocompatible than 17% EDTA-T and 17% EDTA.[84,85].

Scelza et alevaluated the inflammatory response of 17% EDTA,17% EDTA-T, and 10% citric acid in bony defect created in rat jawsand they concluded that 10% citric acid showed less aggressive ininflammatory response.[86] The use of 25% citric acid was found to

be ineffective in eradication of biofilms ofE faecalis after 1, 5, and10 min of exposure.[87]

Maleic acid

Maleic acid is a mild organic acid used as an acid conditioner inadhesive dentistry.[89] Ballal et al. reported that final irrigation

with 7% maleic acid for 1 min was more efficient than 17% EDTA

in the removal of smear layer from the apical third of the rootcanal system.[89]

HEBP

HEBP (1-hydroxyethylidene- 1, 1-bisphosphonate), also known asetidronic acid or etidronate, has been proposed as a potentialalternative to EDTA or citric acid because this agent shows no

See more ...

An evaluation of the antimicrobial

effectiveness of citric acid as a root canal[J Endod. 1986]

Evaluation of inflammatory response of

EDTA, EDTA-T, and citric acid in animal[J Endod. 2010]

Enterococcus faecalis biofilms eradication

by root canal irrigants. [J Endod. 2009]

Comparison of the efficacy of maleic acid

and ethylenediaminetetraacetic acid in

[J Endod. 2009]

Chelation in root canal therapy

short term reactivity with NaOCl [90] HEBP is nontoxic and has

reconsidered [J Endod 2005]
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short-term reactivity with NaOCl.[90] HEBP is nontoxic and hasbeen systematically applied to treat bone diseases.[91] Thedemineralization kinetics promoted by both 9% HEBP and 18%HEBP were significantly slower than those of 17% EDTA.[92] De-Deus et al. reported that the soft chelating irrigation protocol (18%HEBP) optimized the bonding quality (3.16.1 MPa) of

Resilon/Epiphany .[93]

Chlorine dioxide

Chlorine dioxide (ClO ) is chemically similar to chlorine orhypochlorite, the familiar household bleach. An In vitro studycompared organic tissue dissolution capacity of NaOCl and ClO .It was concluded that ClO and NaOCl are equally efficient for

dissolving organic tissue.[94] ClO produces little or notrihalomethanes.[95] A study showed that trihalomethane is ananimal carcinogen and a suspected human carcinogen.[96] ClOmight therefore be a better dental irrigant than NaOCl.[97]

Silve r diamine fluoride

A 3.8% w/v silver diamine fluoride (Ag[NH ] F) solution has been

developed for intracanal irrigation. This represents a 1:10 dilutionof the original 38% Ag(NH ) F solution used for root canalinfection.[98] The study on the antibacterial effect of 3.8%

Ag(NH ) F against aE faecalis biofilm model concluded thatAg(NH ) F has potential for use as an antimicrobial root canalirrigant or interappointment medicament to reduce bacterial

2

2

2

2

2

3 2

3 2

3 2

3 2

reconsidered. [J Endod. 2005]

Review Bisphosphonates: from the

laboratory to the clinic and back again.[Bone. 1999]

Longitudinal co-site optical microscopy

study on the chelating ability of etidronate

[J Endod. 2008]

Soft chelating irrigation protocol optimizes

bonding quality of Resilon/Epiphany root[J Endod. 2008]

Comparison of organic tissue dissolution

capacities of sodium hypochlorite and

[J Endod. 2010]

Comparison of disinfection byproductformation from chlorine and alternative[Water Res. 2007]

Cancer risk associated with household

exposure to chloroform.[J Toxicol Environ Health A. 2002]

Influence of chlorine dioxide on cell death

and cell cycle of human gingival[J Dent. 2008]

Morphological and atomic analytical

changes of root canal wall dentin after

[J Clin Laser Med Surg. 1999]

Antimicrobial efficacy of 3.8% silver

diamine fluoride and its effect on root[J Endod. 2010]

loads.[99] E faecalis was completely killed by Ag(NH ) F after3 2
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loads.[99]E faecalis was completely killed by Ag(NH ) F afterexposure to these agents for 60 min. The silver deposits were foundto occlude tubular orifices after removal of the smear layer.

Tetraclean

Tetraclean is a mixture of doxycycline hyclate (at a lower

concentration than in MTAD), an acid, and a detergent.[100,101]It is able to eliminate microorganisms and smear layer in dentinaltubules of infected root canals with a final 5-min rinse. Comparisonof antimicrobial efficacy of 5.25% NaOCl, MTAD, and TetracleanagainstE faecalis biofilm showed that only 5.25% NaOCl couldconsistently disgregate and remove the biofilm at every timeinterval. However, treatment with Tetraclean caused a high

degree of biofilm disgregation in every considered time interval (5,30, and 60 min at 20C) as compared with MTAD.[102]

Triclosan and Gantrez

Triclosan is a broad spectrum antimicrobial agent, active againstgram-positive and gram-negative bacteria as well as some fungiand viruses.[103,104] Nudera et al.[105] evaluated the minimum

inhibitory concentrations (MIC) and minimum bactericidalconcentrations (MBC) of triclosan and triclosan with GantrezagainstP intermedia, F nucleatum, A naeslundii, P gingivalis, and

E faecalis. The MBC of triclosan ranged from 12-94 g/ml. TheMBC of triclosan with Gantrez ranged from


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Triphala

Green tea

Morinda citrifolia

bactericidal activity against the five specific endodontic pathogens.

Herbal

Triphala consists of dried and powdered fruits of threemedicinal plants Terminalia bellerica, Terminalia chebula, and

Emblica officinalis.[106] Triphala achieved 100% killing ofEfaecalis at 6 min. This may be attributed to its formulation, whichcontains three different medicinal plants in equal proportions; insuch formulations, different compounds may help enhance thepotency of the active compounds, producing an additive orsynergistic effect.[107] Triphala contains fruits that are rich incitric acid, which may aid in removal of the smear layer. The major

advantages of using herbal alternatives are easy availability, cost-effectiveness, longer shelf life, low toxicity, and lack of microbialresistance.[108]

Green tea polyphenols, the traditional drink of Japan andChina is prepared from the young shoots of the tea plant Camelliasinensis.[109] Green tea polyphenols showed statistically significantantibacterial activity againstE faecalis biofilm formed on tooth

substrate. It takes 6 min to achieve 100% killing ofE faecalis.[107]

Morinda citrifolia (MCJ) has a broad range oftherapeutic effects, including antibacterial, antiviral, antifungal,antitumor, antihelmintic, analgesic, hypotensive, anti-inflammatory, and immune-enhancing effects.[110113] MCJcontains the antibacterial compounds L-asperuloside and

The evaluation of the radioprotective effect

of Triphala (an ayurvedic rejuvenating drug)

[Phytomedicine. 2002]

Evaluation of antimicrobial efficacy of

herbal alternatives (Triphala and green tea

[J Endod. 2010]

Review Anti-cariogenic properties of tea

(Camellia s inensis).[J Med Microbiol. 2001]

Analgesic and behavioural effects of

Morinda citrifolia. [Planta Med. 1990]

Evaluation of antimicrobial efficacy of

herbal alternatives (Triphala and green tea

[J Endod. 2010]

Cancer preventive effect of Morinda

alizarin[113]. Murray et al.[113] proved that, as an intracanal citrifolia (Noni). [Ann N Y Acad Sci. 2001]
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alizarin[113]. Murrayet al.[113] proved that, as an intracanalirrigant to remove the smearlayer, the efficacy of 6% MJC wassimilar to that of 6% NaOCl in conjunction with EDTA. The use ofMCJ as an irrigant might be advantageous because it is a

biocompatible antioxidant[113] and not likely to cause severeinjuries to patients as might occur through NaOCl accidents.

CONCLUSION

During instrumentation canals should be irrigated using copiousamounts of the NaOCl solution. Once the shaping procedure iscompleted, canals can be thoroughly rinsed using aqueous EDTA orcitric acid. Generally each canal is rinsed for at least 1 min using 5to 10 ml of the chelator irrigant. After the smear layer removal

procedure, a final rinse with an antiseptic solution appearsbeneficial. Chlorhexidine appears to be the most promising agentfor use as a final irrigant in this situation. It has an affinity fordental hard tissues and, once bound to a surface, it has prolongedantimicrobial activity, a phenomenon called substantivity. After theintroduction of MTAD irrigant, newer irrigating regimen followed

was initial rinse with 1.3 % NaOCl for 20 min and followed by final

rinse with MTAD for 5 min. Future research on irrigants needs tofocus on finding a single irrigant that has tissue dissolving capacity,smear layer removal property, and antibacterial efficacy.

Footnotes

Source of Support: Nil

Evaluation of Morinda citrifolia as an

endodontic irrigant. [J Endod. 2008]

Conflict of Interest: None declared.
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Go to:REFERENCES

1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgicalexposures of dental pulps in germ-free and conventional laboratoryrats. Oral Surg Oral Med Oral Pathol. 1965;20:3409. [PubMed]

2. Baumgartner JC, Falkler WA. Bacteria in the apical 5 mm ofinfected root canals. J Endod. 1991;17:3803. [PubMed]

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