Various Irrigation

Solution in Endodontic

10/9/2006
 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.

NaOCl
 NaOCl
Antibacterial agent
Dissolves vital and non-vital tissue.
Lubricant during instrumentation

NaOCl has been criticized for

Unpleasant taste
Relative toxicity
Inability to remove smear layer
 Bactericidal of NaOCl
HOCl exerts its effects by oxidizing sulphydryl
groups within bacterial enzyme systems, thereby
disrupting the metabolism of the microorganism,
resulting in the killing of the bacterial cells.
Unbuffered solution at pH 11 in concentration 0.5
5.25% , and buffered with bicarbonate buffer (pH 9.0)
usually as a 0.5% solution (Dakin's solution).
 NaOCl
Buffering had little effect on tissue dissolution.
Dakin's solution was equally effective on necrotic and
fresh tissues.
No differences were recorded for the antibacterial
properties of Dakin's solution and an equivalent
unbuffered hypochlorite solution
Zehnder et al. (2002)
 In Vitro Antibacterial Studies

High resistance of E. faecalis and the high susceptibility

of C. albicans to NaOCl.
C. albicans was killed in vitro in 30 s by both 5% and
0.5% NaOCl.
E. faecalis was killed in less than 30 s by the 5.25%
solution, while it took 10 and 30 min for complete
killing of the bacteria by 2.5% and 0.5% solutions.
Radcliffe et al (2004) ,
Gomes et al. (2001)
Peciuliene et al. (2001)
,Waltimo et al. (1999)
 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 hypochlorite

dissolves vital tissue. (Rosenfeld et al. 1978 )
As a necrotic tissue solvent, 5.25% sodium
hypochlorite was found to be significantly better than
2.6%, 1%, or 0.5%. (Hand et al.1978)

3% sodium hypochlorite was found to be optimal for

dissolving tissue fixed with parachlorophenol or
formaldehyde (Th SD.1979)
NaOCl & Other Medicaments
 NaOCl & Ca(OH)2
Pretreatment of tissue with calcium hydroxide can enhance
the tissue-dissolving effect of sodium hypochlorite.

Hasselgren et al.
(1988)

Combination of calcium hydroxide and sodium hypochlorite

was more effective on the dissolution of soft tissue on the
root canal wall than using either medicament alone.
Wadachi et al.
(1998)
 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)
 Volume
The volume of the irrigant has a greater potential to
significantly reduce bacteria colonies in root canal.

Baker et al. 1975, Brown and Doran 1975,

Cunningham 1982, Cunningham et al.1982,siqueira
at al.2000, Sedgley et al.2005.
Chlorhexidine (CHX)
 Chlorhexidine (CHX)
It possesses a broad-spectrum antimicrobial action and
a relative absence of toxicity.
CHX lacks the tissue-dissolving ability.

It penetrates the cell wall and attacks the bacterial

cytoplasmic or inner membrane or the yeast plasma
membrane.
Concentrations between 0.2% and 2%.

Its activity is pH dependent and is greatly reduced in

the presence of organic matter.
 Chlorhexidine (CHX)
In direct contact with human cells, CHX is cytotoxic; a
comparative study using fluorescence assay on human
PDL cells showed corresponding cytotoxicity with
0.4% NaOCl and 0.1% CHX.

Chang et al.(2001)
 In Vitro-the antibacterial effect of CHX

In vitro, CHX is superior to NaOCl in killing of E. faecalis

and Staphylococcus aureus.
Gomes et al. (2001)

Oncag et al. (2003)

Vianna et al. (2004)

CHX effectively killed C. albicans

Barkvoll P & Attramadal A (1989)

Hiom e al. (1992)
Hamers et al. (1996)
Waltimo et al. (1999)
 In vivo-the antibacterial effect of CHX

There are no in vivo studies yet available that would

confirm the better activity of CHX against E. faecalis
in the infected root canal.
 CHX & H2O2
In Vitro, 3% H2O2 and CHX was superior in its
antibacterial activity (E. faecalis ) compared with
other regimens such as CHX alone and NaOCl.
Heling & Chandler
(1998)
The combination of the two substances totally killed
E. faecalis in concentrations much lower than each
component alone.
Steinberg et
al. (1999)
 CHX & H2O2

There are No reports of clinical studies where the

combinations of CHX and H2O2 have been used to
disinfect the root canal system.
Cytotoxicity of the medicament combinations should
first be investigated. Interestingly, combinations of
CHX and carbamide peroxide have been shown to be
additive in their cytotoxicity (Babich et al.1995).
 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
 H2O2
It is a clear, colorless liquid.

Used in a variety of concentrations, 1% - 30%.

H2O2 is active against viruses, bacteria, and yeasts.

It produces hydroxyl free radicals (OH), which attack

several cell components such as proteins and DNA.
In endodontics, H2O2 has long been used because of its
antimicrobial and cleansing properties.
It has been particularly popular in cleaning the pulp
chamber from blood and tissue remnants, but it has
also been used in canal irrigation.
 In Vivo-the antibacterial effect of H2O2

Bacteria counts were greatly reduced when 10% H2O2

was used as part of the irrigating protocol., but the
protocol used could not predictably produce sterile root
canals in monkey teeth.
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
as the organic remnants. (Torabinejad etal.2003)
 The antibacterial effect of MTAD

In vitro study, the antibacterial effects of MTAD,

NaOCl, and EDTA were compared using a disk-
diffusion test on agar plates.
The results showed that even highly diluted MTAD
produced clear zones of inhibition of the test
bacterium, E. faecalis
Torabinejad et al. 2003
 The antibacterial effect of MTAD

In vitro study, the effect of MTAD on root canals

contaminated with either saliva or E. faecalis was
evaluated, and reported good antibacterial activity.

Shabahang et al. (2003)

Shabahang & Torabinejad (2003)
 Cytotoxicity of MTAD

Cytotoxicity of MTAD was evaluated on fibroblasts.

MTAD is less cytotoxic than eugenol, 3% H2O2,
Ca(OH)2 paste, 5.25% NaOCl, Peridex (a CHX mouth
rinse with additives), and EDTA, but more cytotoxic
than 2.63%, 1.31%, and 0.66% NaOCl.
Zhang et al. (2003)
BDA
 BDA
Bis-dequalinium acetate (BDA)
Low toxicity
Lubrication action
Disinfecting ability
Low surface tension
Chelating properties.
Low incidence of post-treatment pain.

Bis-dequalinium acetate is recommended as an excellent

substitute for sodium hypochlorite in those patients who
are allergic to the latter.
Kaufman 1981
Smear Layer Removal
 Smear Layer Removal
Removal of the smear layer is an
important step to facilitate disinfection
of the root canal
Organic Acid Irrigants:
Citric acid (1%
( - 50% ).
Polyacrylic acid (e.g. Durelon and Fuju II liquids).
Solutions
Carbamide peroxide.
Aminoquinaldinium diacetate (i.e., Salvizol).
Chelating Agents
EDTA
 Removal of the smear layer by EDTA (or citric acid)
improves the antibacterial effect of locally used
disinfecting agents in deeper layers of dentine.

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)
Chelating Agents
 Chelating Agents
EDTA (ethylene-diaminetetra-aceticacid)
EDTAC (ethylene-diaminetetra-aceticacid &centrimide)
File-Eze
RC Prep
EDTA
 EDTA
EDTA (17%, disodium salt, pH 7)
EDTA has little if any antibacterial activity.
It effectively removes smear layer by chelating the
inorganic component of the dentine.
Aid in mechanical canal shaping.
 EDTA
The ultrastructure on canal walls after EDTA and
combined EDTA & NaOCl irrigation was evaluated by
scanning electron microscopy.
More debris was removed by irrigation with EDTA
followed by NaOCl than with EDTA alone.

Niu et al. (2002)

 The optimal working time of EDTA is 15 minutes,
after which time no more chelating action can be
expected.
EDTA solutions should replaces in the canal each 15
minutes.

Goldberg and Spielberg (1982)

RC-Prep
 RC-Prep
RC-Prep is composed of EDTA and urea peroxide in a
base of Carbowax.
It is not water soluble.
NaOCl & RC-Prep
Interaction of the urea peroxide in RC-Prep with sodium
hypochlorite, producing a bubbling action thought to
loosen and help float out dentinal debris.
 RC-Prep
A residue of RC-Prep remains in the canals in spite of
further irrigation and cleansing.
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
etal. 1982, Stock 1991,
Lumley etal. 1993, Lee etal. 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 etal. 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 etal. (1982)
 Types of endodntic needles

Beveled needle
Monoject endodontic needle.
ProRinse probes.
 Monoject endodontic needles to be the most efficient
delivery system in which longer needles of a blunted,
open-end system were inserted to the full length of
the canal.
The point is that a larger volume of solution can be
delivered by this method. However, the closer the
needle tip is placed to the apex, the greater the
potential for damage to the periradicular tissues.

Moser and Heuer (1982)

 The most important factor is the delivery system and
not the irrigating solution per se.
The volume of the irrigant is more important than the
concentration or type of irrigant.
Walton and
Torabinejad
 In order to be effective, the needle delivering the
solution must come in close proximity to the material
to be removed.
Small diameter needles were found to be more
effective in reaching adequate depth but were more
prone to problems of possible breakage and difficulty
in expressing the irrigant from the narrow needles.
Abou-Rass M
(1982)
Method of Use
 Method of Use
It is strongly recommended that the needle lie
passively in the canal and not engage the walls.
The solution must be introduced slowly.
The irrigating needle should be bent to allow easier
delivery of the solution and to prevent deep
penetration of the needle.
Care must be taken with irrigants like sodium
hypochlorite to prevent accidents.