Various Irrigation

Solution in Endodontic
10/9/2006
The use of irrigating solutions is an important
part of effective chemomechanical preparation.
Antibacterial agent.
Tissue solvent.
Flush debris.
Lubricant.
Eliminate the smear layer.

Various Irrigation Solution in Endodontic
NaOCl
NaOCl
Antibacterial agent
Dissolves vital and non-vital tissue.
Lubricant during instrumentation

NaOCl has been criticized for
Unpleasant taste
Relative toxicity
Inability to remove smear layer
Bactericidal of NaOCl
HOCl exerts its effects by oxidizing sulphydryl
groups within bacterial enzyme systems, thereby
disrupting the metabolism of the microorganism,
resulting in the killing of the bacterial cells.
Unbuffered solution at pH 11 in concentration 0.5
5.25% , and buffered with bicarbonate buffer (pH 9.0)
usually as a 0.5% solution (Dakin's solution).

NaOCl
Buffering had little effect on tissue dissolution.
Dakin's solution was equally effective on necrotic and
fresh tissues.
No differences were recorded for the antibacterial
properties of Dakin's solution and an equivalent
unbuffered hypochlorite solution
Zehnder et al. (2002)
In Vitro Antibacterial Studies
High resistance of E. faecalis and the high susceptibility
of C. albicans to NaOCl.
C. albicans was killed in vitro in 30 s by both 5% and
0.5% NaOCl.
E. faecalis was killed in less than 30 s by the 5.25%
solution, while it took 10 and 30 min for complete
killing of the bacteria by 2.5% and 0.5% solutions.


Radcliffe et al (2004) , Gomes et al.
(2001) Peciuliene et al. (2001)
,Waltimo et al. (1999)
Although 0.5% NaOCl, with or without (EDTA),
improved the antibacterial efficiency of preparation
compared with saline irrigation, all canals could not
be rendered bacteria free even after several
appointments.
No significant difference in antibacterial efficiency in
vivo between 0.5% and 5% NaOCl solutions.

Bystrm & Sundqvist (1983,1985)
In Vivo Antibacterial Studies
The in vitro studies performed in
A test tube.
Root canals of extracted teeth.
Prepared dentine blocks infected with a pure culture of
one organism at a time.
The in vivo studies, on the other hand, have focused on
the elimination of microorganisms from the root canal
system in teeth with primary apical periodontitis.
Antibacterial Studies
Explanation to poorer in vivo performance
Root canal anatomy, in particular, the difficulty in
reaching the most apical region of the canal with large
volumes of fresh irrigant.
Chemical milieu in the canal is quite different from a
simplified test tube environment

Antibacterial Studies
Concentration
Compared the biological effects of mild and strong
NaOCl solutions and demonstrated greater cytotoxicity
and caustic effects on healthy tissue with 5.25% NaOCl
than with 0.5% and 1% solutions.

Either 5.25% or 2.5% sodium hypochlorite has the
same effect when used in the root canal space for a
period of 5 minutes.
Trepagnier et al. (1977)

Pashley et al. (1985)
Concentration
5% NaOCl may be too toxic for routine use. They
found that 0.5% NaOCl solution dissolves necrotic
but not vital tissue and has considerably less toxicity
than a 5% solution.
They suggested that 0.5% NaOCl be used in
endodontic therapy.
Spngberg et al.(1974)
Commented that It seemed probable that there would
be a greater amount of organic residue present
following irrigation of longer, narrower, more
convoluted root canals that impede the delivery of the
irrigant.
Concentration of NaOCl
Baumgartner &Cuenin (1992)

The ability of an irrigant to be distributed to the apical
portion of a canal is dependent on:
Canal anatomy
Size of instrumentation
Delivery system

Commented that The effectiveness of low
concentrations of NaOCl may be improved by using
larger volumes of irrigant or by the presence of
replenished irrigant in the canals for longer periods of
time.
Concentration of NaOCl
Baumgartner & Cuenin (1992)

The efficacy of 0.5%, 2.5% and 5.25% sodium
hypochlorite (NaOCl) as intracanal irrigants
associated with hand and rotary instrumentation
techniques against E. faecalis within root canals and
dentinal tubules.
5.25% NaOCl has a greater antibacterial activity
inside the dentinal tubules infected with E. faecalis
than the other concentrations tested.
. Berber et al. (2006)
Concentration of NaOCl
Is NaOCl equally effective in dissolving vital,
non-vital, or fixed tissue ???
Demonstrated that 5.25% sodium hypochlorite
dissolves vital tissue. (Rosenfeld et al. 1978 )
As a necrotic tissue solvent, 5.25% sodium
hypochlorite was found to be significantly better than
2.6%, 1%, or 0.5%. (Hand et al.1978)

3% sodium hypochlorite was found to be optimal for
dissolving tissue fixed with parachlorophenol or
formaldehyde (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)


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.

NaOCl & Ca(OH)2
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
37
0
C, 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
I n 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)



I n 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 & H
2
O
2
In Vitro, 3% H
2
O
2
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 & H
2
O
2
There are No reports of clinical studies where the
combinations of CHX and H
2
O
2
have been used to
disinfect the root canal system.
Cytotoxicity of the medicament combinations should
first be investigated. Interestingly, combinations of
CHX and carbamide peroxide have been shown to be
additive in their cytotoxicity (Babich et al.1995).

A potential weakness of CHX in the root canal may be
its susceptibility to the presence of organic matter.
(Russell AD & Day MJ 1993)
In an in vitro study, the effect of CHX is showed to be
reduced, although not prevented, by the presence of
dentine. Haapasalo et al. (2000)
CHX was strongly inhibited by dentine matrix (the
organic component of dentine).
Portenier et al. (2002)
CHX
H
2
O
2
H
2
O
2
It is a clear, colorless liquid.
Used in a variety of concentrations, 1% - 30%.
H
2
O
2
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, H
2
O
2
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 H
2
O
2
Bacteria counts were greatly reduced when 10% H
2
O
2

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 H
2
O
2
A combination of NaOCl and H
2
O
2
was no more
effective against E. faecalis in contaminated root canals
than NaOCl alone.
Siqueira et al. (1997)
H
2
O
2
Although H
2
O
2
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% H
2
O
2
,
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.


RC-Prep allowed maximum leakage into filled canals
over 2.6 times the leakage of the controls.
Zubriggen et al.(1975)
Cooke et al. (1976)
Ultrasonic Irrigation
Ultrasonic Irrigation
The flushing action of the irrigant solution may be
more important than the ability of the irrigant solution
to dissolve tissue.
(Baker et al. 1975)
Most of the dentine debris is inorganic matter that
cannot be dissolved by NaOCl. Therefore, removal of
dentine debris relies mostly on the flushing action of
irrigant.

Ultrasonic Irrigation
The enhancement of the flushing action of an irrigant
solution by using ultrasound is well documented.
(Cunningham & Martin 1982, Cunningham et al. 1982,
Stock 1991, Lumley et al. 1993, Lee et al. 2004)
The ultrasound device allow the endodontic irrigant to
pass along the ultrasonic files. The irrigant is activated
by the ultrasonic energy imparted from the energized
instruments producing acoustic streaming and eddies.
(Ahmad et al. 1987, Krell & Johnson 1988, Stock 1991)
Ultrasonic Irrigation
More bacterial spores and dentine debris were
removed during ultrasonic irrigation than hand
irrigation.
Cunningham & Martin (1982)
Cunningham et al. (1982)
Types of endodntic needles
Beveled needle
Monoject endodontic needle.
ProRinse probes.

Monoject endodontic needles to be the most efficient
delivery system in which longer needles of a blunted,
open-end system were inserted to the full length of
the canal.
The point is that a larger volume of solution can be
delivered by this method. However, the closer the
needle tip is placed to the apex, the greater the
potential for damage to the periradicular tissues.
Moser and Heuer (1982)
The most important factor is the delivery system and
not the irrigating solution per se.
The volume of the irrigant is more important than the
concentration or type of irrigant.
Walton and Torabinejad

In order to be effective, the needle delivering the
solution must come in close proximity to the material
to be removed.
Small diameter needles were found to be more
effective in reaching adequate depth but were more
prone to problems of possible breakage and difficulty
in expressing the irrigant from the narrow needles.
Abou-Rass M (1982)

Method of Use
Method of Use
It is strongly recommended that the needle lie
passively in the canal and not engage the walls.
The solution must be introduced slowly.
The irrigating needle should be bent to allow easier
delivery of the solution and to prevent deep
penetration of the needle.
Care must be taken with irrigants like sodium
hypochlorite to prevent accidents.