Various Irrigation Solution in Endodontics

Various Irrigation Solution in Endodontic

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

 Antibacterial agent.
 Tissue solvent.  Flush debris.  Lubricant.  Eliminate the

smear layer.

Variables affecting the irrigation

          

Concentration of irrigant. The volume of the solution used. Canal diameter. The viscosity or surface tension of the solution. The diameter and depth of penetration of the irrigating needle. The anatomy of the canal. The method of delivering the irrigant. Contact time with the tissue. Temperature of the irrigant. Ultrasonic activation. The effect of combining different types of solutions.

NaOCl

NaOCl
 

Antibacterial agent Dissolves vital and non-vital tissue. However vital tissue takes longer to dissolve 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)

Questions concerning the use of sodium hypochlorite Appropriate concentration Method of delivery Cellular damage caused by extrusion into the periradicular tissues.

  

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)

In Vivo Antibacterial Studies



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.
Bystrm & Sundqvist (1983,1985)

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

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.
Pashley et al. (1985)

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)

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.
Spngberg et al.(1974)

Concentration of NaOCl

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.
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

Concentration of NaOCl

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.
Baumgartner & Cuenin (1992)

Concentration of NaOCl

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)

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



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

hypochlorite

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 (Th SD.1979)

NaOCl & Other Medicaments



The antibacterial efficacy of sodium hypochlorite, is increased when it is used in combination with other solutions, such as calcium hydroxide, EDTAC, or chlorhexidine. sodium hypochlorite with other chemicals comes from the release of chlorine gas.

 Possibly,the bactericidal effect gained by combining

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)

NaOCl & Ca(OH)2

 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 dbrided.

Yang et al. 1998

NaOCl & EDTA

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

Temperature


Both the debriding and disinfection properties of 2.6% NaOCl are enhanced in vitro by elevating the temperature of the solution to 370C.
Cunningham et al. (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)

Chlorhexidine (CHX)


It has a wide antimicrobial spectrum and is effective against both Gram-positive and Gram-negative bacteria as well as yeasts, while mycobacteria and bacterial spores are resistant to CHX (Shaker et al 1988, Russell AD. 1996). CHX is not considered to be an effective antiviral agent, , and its activity is limited to lipid-enveloped viruses (Park JB & Park NH. 1989). 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.

MOLECULAR STRUCTURE AND MECHANISM OF ACTION

Chlorhexidine is a cationic molecule and consists of two symmetric 4-chlorophenly rings, and two bisguanide groups connected by a central hexamethylene chain. Chlorhexidine has a pH of 5.50-7.00 (American Society 50of Health-System harmacists, 2003). The most common preparation is with the digluconate salt because of its Health2003). stability and high water solubility

Being dicationic it electrostatically binds to negatively charged surfaces of bacteria damaging the outer layers of the bacterial cell wall and rendering it permeable. The resulting penetration of into the cell causes precipitation of the cytoplasm, preventing repair of cell chlorhexidine membrane and leading to the destruction of the bacterial cell. At low concentrations, chlorhexidine is only bacteriostatic, causing low molecular weight substances such as potassium and phsphorous to leak out without the cell being irreversibly damaged.
At higher concentrations it causes irreversible cell damage by precipitation of cytoplasm. At neutral pH its action is unimpeded but at acidic pH its action is reduced.

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



It can be postulated that the exposure of bacteria to CHX leads to a more permeable cell wall that H2O2 can penetrate easily and hence damage the intracellular organelles.

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).

CHX


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)

H2O2

H 2O2
 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.
Mller et al. (2004)

The antibacterial effect of H2O2

 A combination of NaOCl and H2O2 was no more

effective against E. faecalis in contaminated root canals than NaOCl alone. Siqueira et al. (1997)

H2O2
Although H2O2 has long been used in disinfection and canal irrigation in endodontics, the available literature does not support its use over that of other irrigating solutions.

MTAD

MTAD
 A mixture of tetracycline isomer, acid, and detergent.

(doxycycline, citric acid, and the detergent Tween-80) )

 It has antibacterial activity.  It has low pH 2.15

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 (Torabinejad etal.2003) as the organic remnants.

The antibacterial effect of MTAD



In vitro study, the antibacterial effects of MTAD, NaOCl, and EDTA were compared using a diskdiffusion test on agar plates. The results showed that even highly diluted MTAD produced clear zones of inhibition of the test bacterium, E. faecalis
Torabinejad et al. 2003

The antibacterial effect of MTAD

In vitro study, the effect of MTAD on root canals contaminated with either saliva or E. faecalis was evaluated, and reported good antibacterial activity.
Shabahang et al. (2003) Shabahang & Torabinejad (2003)

Cytotoxicity of MTAD
 

Cytotoxicity of MTAD was evaluated on fibroblasts. MTAD is less cytotoxic than eugenol, 3% H2O2, Ca(OH)2 paste, 5.25% NaOCl, Peridex (a CHX mouth rinse with additives), and EDTA, but more cytotoxic than 2.63%, 1.31%, and 0.66% NaOCl.
Zhang et al. (2003)

BDA

BDA
Bis-dequalinium acetate (BDA)  Low toxicity  Lubrication action  Disinfecting ability  Low surface tension  Chelating properties.  Low incidence of post-treatment pain.


BisBis-dequalinium acetate is recommended as an excellent substitute for sodium hypochlorite in those patients who are allergic to the latter.
Kaufman 1981

BDA


Goldberg et al (1986), rated BDA as superior to sodium hypochlorite in dbriding the apical third. When marketed as Solvidont, the University of Malaysia reported a remarkable decrease in postoperative pain and swelling when BDA was used. They attributed these results to the chelation properties of BDA in removing the smear layer coated with bacteria and contaminants as well as the surfactant properties that allow BDA to penetrate into areas inaccessible to instruments

Various Irrigation Solution in Endodontic

Removal of root canal debris seems to be related to:
 Canal diameter (the

canal must be enlarged at least

size 40 at the apex

 Viscosity or surface tension of the solution.  Diameter of the irrigating needle.  Depth of penetration of the irrigating needle.  Volume of the solution used.  Anatomy of the canal.

Ram (1977)

Previous studies showed that both mechanical and chemical action of the irrigant were dependent upon:
 

 

The efficiency of the delivery system (Abou-Rass M, (AbouOglesby SW 1981) 1981) The tissue surface area in contact with the irrigant solution ( Baker et al. 1975, Moored WR, Wesselink 1975, PR 1982,Gomes et al. 2001, Radcliffe et al. 2004, Vianna 1982,Gomes 2001, 2004, et al. 2004,). 2004,). The frequency of changing the solution (Moorer WR, Wesselink PR 1982) 1982) The total volume of the irrigant (Cunningham et al.1982,siqueira at al.2000, Sedgley et al.2005). al.1982,siqueira al.2000, al.2005).

The depth of irrigant needle in removing bacteria

The mechanical efficacy of 6 mL of irrigant in reducing intracanal bacteria was significantly greater when delivered 1 mm compared with 5 mm from WL.
Sedgley et al. (2005)

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.
rstavik & 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)

Effect of Citric acid



Irrigation with 17% EDTA, 6% phosphoric acid and 6% citric acid did not remove the entire smear layer from the root canal system. In addition, these acidic solutions demineralized the intertubular dentine around tubular openings, which became enlarged. The CO2 laser was useful in removing and melting the smear layer on the instrumented root canal walls, and the Er : YAG laser was the most effective in removing the smear layer from the root canal wall.
Takeda et al. (1999)

Tidmarsh (1978), who felt that 50% citric acid gave the cleanest dentin walls without a smear layer.

Canal wall untreated by acid

Midroot canal (citric acid)

Midroot canal (phosphoric acid)

Apical area (phosphoric acid)

Effect of Citric acid

Excellent filling results after preparation with citric acid (20%), followed by 2.6% sodium hypochlorite and a final flushing with 10% citric acid.
Wayman et al. (1979)

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)

The optimal pH for the demineralizing efficacy of EDTA on dentin was shown by Valdrighi (1981) to be between 5.0 and 6.0.276 Goldberg and Abramovich (1977)have shown that EDTAC increases permeability into dentinal tubules, accessory canals, and apical foramina.

Coronal portion of canal of in vivo endodontically treated tooth with EDTAC. The tubules are open, and the canal is clean and free of smear. B, Filed canal treated with EDTAC.Longitudinal section of dentinal tubules shows thin intertubular matrix.

McComb and Smith(1975) found that EDTA (in its commer- cial form, REDTA), when sealed in the canal for 24 hours, produced the cleanest dentinal walls Goldman et al. (1981) have shown that the smear layer is not removed by sodium hypochlorite irrigation alone but is removed with the combined use of REDTA.

Removal of the smear layer is an important step to facilitate disinfection of the root canal. Both EDTA and citric acid can effectively remove the smear layer created during canal instrumentation. Although citric acid may also have an antibacterial effect, this has not been compared with other root canal disinfecting agents in in vitro or in vivo studies.

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.
Zubriggen et al.(1975)

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

Ultrasonic Irrigation


Ultrasonic proved superior to syringe irrigation alone when the canal narrowed to 0.3 mm (size 30 instrument) or less. (Teplitsky et al. 1987) less.

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)

ProRinse

- It has closed-end and side vent.

- It eliminates possibilities of puncture of the apical foramen. - Expression of fluid through the lumen creates turbulence around and beyond the end of the probe

Evaluated were Becton-Dickinson 22-gauge needles;Monoject endodontic needles, 23 and 27 gauge; ProRinse 25-, 28-, and 30-gauge probes ; CaviEndo ultra- sonic handpiece; and the MicroMega.

ProRinse probes were highly effective in all gauges and in all sizes of canals tested. In canals instrumented to size 30 K file and size 35 K file, the smaller-lumen 27gauge notch-tip needle was found to be highly effective. The larger 23-gauge notch-tip needle was found to be relatively ineffective, as was the standard 22-gauge beveled needle
Kahn, Rosenberg et al

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.

 

There are inherent differences in the in vitro test model from the in vivo situation. In vivo variables that affect delivery of the irrigant are canal length and quality of instrumentation. In vitro results, although potentially valuable, cannot be directly extrapolated to the in vivo situation. .