IRRIGATION IN ENDODONTICS

CONTENTS
 Introduction  Interactions
 History  Recent developments
 Objective and functions .  Irrigation protocol in different
 Mode of action clinical situations
 Conclusion

 Classification of irrigants
 Introduction of each irrigants
 History
 Mechanism of action
 Advantage of irrigation
 Disadvantages of irrigation
 Irrigation is a key part of successful root canal treatment as it
fulfils several important mechanical, chemical and (micro)
biological functions. Irrigation is also the only way to impact those
areas of the root canal wall that are not touched by mechanical
instrumentation.

 Hence it is said to be a part of cleaning

and shaping of root canals.

 A bigger challenge for irrigation may be the areas untouched by the

files, such as fins, isthmuses and large lateral canals. Also, large
areas in the oval and flat canals may remain untouched despite
careful instrumentation.
 These areas contain tissue remnants and biofilms that only can be
removed by chemical means using irrigation.

 The apical root canal poses a special challenge to irrigation as the

balance between safety and effectiveness is particularly important
in this area.

 One of the key factors for failure of endodontic treatment is

persistence of bacteria in the endodontic space, or the
contamination during the endodontic treatment or later, because of
an incomplete seal of the coronal restoration.
 First of all, such contamination should be prevented, by the use of
an aseptic technique, including the rubber dam; this improves the
outcome of endodontic treatment. More over , failure to use rubber
dam can negatively influence the choice of endodontic irrigants.

 Substances that have been used to rinse and chemically clean root
canals have different purposes, such as dissolution of soft and hard
tissues, antimicrobial effect against bacteria or other
microorganisms in the root canal, and inactivation of bacterial
lipopolysaccharides.

 These substances also should be as nontoxic as possible to protect

the periradicular tissues.
 Unfortunately, solutions that are toxic for bacterial cells frequently
are toxic for human cells as well, so care must be taken to avoid
extrusion of irrigants into periapical regions.

 Several factors are important for efficient root canal irrigation. One
critical factor is the volume of irrigant. In a study evaluating the
effect of different amounts of fluids, the volume of irrigant was
found to affect the cleanliness of the root canal. NaOCl and EDTA
administered in larger volumes produced significantly cleaner root
canal surfaces than smaller volumes.
 Primary endodontic treatment goal- optimize root
canal disinfection and to prevent re-infection by
cleaning the root canal system thoroughly and
making it free of microbiota and debris, as they
have definite role in the initiation and
perpetuation of pulpal and periapical diseases
(Kandaswamy and Venkateshbabu, 2010).
2.HISTORY
 Potassium hypochlorite was the first chemically
produced aqueous chlorine solution, invented in
France by Berthollet (1748-1822).

 The first listed literature about the need for

frequent irrigation of the root canal was advocated
by Taft ( 1859)

 He recommended the use of a ‘deodorizing agent’

like chloride of sodium.
 Schreir (1893) introduced potassium and sodium
metals into canals for removal of necrotic pulp.

 20-25% aqueous solution of sulphuric acid

applied on a cotton pledget and sealed into the
root canal for 24-48 hours was introduced by
Callahan (1894) .
 A saturated solution of bicarbonate soda was then introduced into
the root canals thereby producing an effervescent action and forcing
debris to the surface.

 In the late 20th century, studies conducted by Grossman and

Meiman in 1941 led to introduction of the combined use of double
strength sodium hypochlorite and hydrogen peroxide to wash out
fragments of pulp tissue and dentinal shavings after mechanical
instrumentation. This was published later in 1943 by Grossman.
Histrory of NaOCl

 sodium hypochlorite was recommended by

Labarraque(1777- 1850) to prevent childbed fever
and other infectious diseases.
 Based on the controlled laboratory studies by
Koch and Pasteur, hypochlorite then gained wide
acceptance as a disinfectant by the end of the
19th century.
 In World War I, the chemist Henry Drysdale Dakin and
the surgeon Alexis Carrel extended the use of a buffered
0.5% sodium hypochlorite solution to the irrigation of
infected wounds, based on Dakin’s meticulous studies on
the efficacy of different solutions on infected necrotic
tissue.
 Walker (1936) stated that beside their wide-
spectrum, nonspecific killing efficacy on all
microbes, hypochlorite preparations are
sporicidal, virucidal, and show far greater tissue
dissolving effects on necrotic than on vital
tissues.
3. OBJECTIVE AND FUNCTIONS
Irrigation reduces friction
between the instrument and
dentine, improves the cutting
effectiveness of the files,
dissolves tissue, and cools the
file and tooth especially during
the use of ultrasonic energy.
IT SHOULD ALSO HAVE BLEACHING
ACTION OF PULP CHAMBER.
 The ideal root canal irrigant has been described by
Zehnder
 as being systemically nontoxic, noncaustic to
periodontal tissues, having little potential to cause
ananaphylactic reaction,
 possessing a broad antimicrobial spectrum, capable
of dissolving necrotic pulp tissue, inactivating
endotoxins, and either preventing the formation of
a smear layer or dissolving it once it has formed.
FACTORS THAT MODIFY ACTIVITY OF
INTRACANAL IRRIGATING SOLUTIONS

 CONCENTRATION: higher the concentration better the results.

NaOCl in concentrations of 5.25%, 2.5%, and 1% completely removed
pulpal remnants and predentin from the uninstrumented surfaces.
Although 0.5% NaOCl removed the majority of pulpal remnants and
predentin from the uninstrumented surfaces, it left some fibrils on the
surface.
Efficacy of several concentrations of sodium hypochlorite for root canal
irrigation.Baumgartner JC
 CONTACT time: more the contact time better the removal of
biofilm, smear layer

The most effective irrigation regimen is reported to be 5.25% at 40 min

(Kandaswamy and Venkateshbabu, 2010).

 Quantity of irrigants: more the quanty used more the effectyiveness

 Needle Gauge: bigger the gauge ,more volume which will flow in the canal
with less pressure , smaller the gauge less irrigant will flow but more will be
with pressure.

 Surface tension : less surface tension of the irrigant more the

flow, more contact with the canal wall

 Temperature: NaOCl, at a concentration of 1% heated to 20°C, is

less effective than that at 45°C, which in turn is less effective than
that at 60°C, as more chlorine is released at higher temperatures.
(Antimicrobial Irrigants in the Endodontic Therapy, Azhar Iqbal, IJHS,2012)
 Frequency: more times the irrigants used, better
the removal of debris.

 Canal diameter : . Bigger the canal diameter better

debribment. MAF=35.06) showed 100% acceptable debridement.
This rate was 92.9% for MAF=35.04.
Effect of Master Apical File Size and Taper on Irrigation and Cleaning of the Apical Third of Curved
Canals Nahid Mohammadzadeh Akhlaghi, J Dent (Tehran). 2014

 Age of irrigan
 Many irrigating solutions have been studied
extensively to determine which best exhibit these
ideal properties, but the ideal irrigant has not yet
been realized.
CLASSIFICATION OF IRRIGANTS (1)
 Many different irrigants and combinations of
irrigants have been used in RCT to achieve these
goals. These include: (2)
1. Sodium hypochlorite;
2. Chlorhexidine;
3. Sterilox (Hypochlorous acid (HClO)
4. EDTA
5. Iodine potassium iodide
6. Hydrogen peroxide
7. Local anaesthetic, saline and/or water;
8. Mixtures of irrigants (QMIXR).
CATEGORIES OF IRRIGANTS: (3)

 lubricants,
 disinfectants,

 and chelating agents.

LUBRICANTS
 used to make instrumentation easier.
 They reduce the friction between the endodontic
instrument and the canal wall.
 Removing dentin by either hand instrumentation
or mechanical instrumentation becomes much
easier if the canal is wet or lubricated.
 Instrument lubrication can be achieved easily by
using either sterile water, saline, or sodium
hypochlorite (NaOCl) for most routine cases.
 Eg. 17% ethylenediaminetetraacetic acid (EDTA)
in liquid, gel, or paste formulations.

 17% EDTA Plus (Essential Dental Systems) in

water for use as a lubricant when instrumenting
tight canals because it contains a surfactant which
enables the EDTA to wet the canal walls more
easily
DISINFECTANTS

 The disinfectant category of irrigants comprises

several products. The most frequently used
irrigant is NaOCl.
 This irrigant has 2 great advantages: (1) it
dissolves necrotic tissue, and (2) it kills bacteria
quite effectively
CHELATING AGENTS

 The last category of root canal irrigants is chelating

agents. Chelants are chemicals that form soluble
complex molecules with certain metal ions,
inactivating the ions so that they cannot normally
react with other elements or ions to produce
precipitates or scale.

 In dentistry, chelating agents bind with calcium and

carry it out of the canal. The chelating agent most
used in endodontics is EDTA.
CLASSIFICATION (4) KANDASWAMY D,
VENKATESHBABU
 ENDODONTIC IRRIGANTS
BANDU NAPTE, SURYA RAGHAVENDRA SRINIDHI, JOURNAL ODDENTAL AND
ALLIED SCIENCE,2015

 Based on their mechanism of action, they are classified into

nonbactericidal and bactericidal irrigants.
Nonbactericidal irrigants
Saline, local anesthetics and distilled water. [6]

Bactericidal irrigants:
Sodium hypochlorite (0.5%, 1%, 1.5%, 2.5%, 5.25%, and 6%
concentrations)
Chlorhexidine (CHX) (2%)
Iodine
Hydrogen peroxide (H 2 O 2 ) (3%).
Chelator solutions
diamine tetra acetic acid (EDTA, 17%)
 Citric acid (10-50%)
 Mixture of tetracycline, acid and detergent (MTAD, Tween 80)
 Tetraclean
 Maleic acid.

Herbal irrigants

Others:
activated water (EAW)
 Bis-dequalinium acetate (BDA)
 Photo-activated disinfection (PAD)
 Ozone
 Laser.
Sodium hypochlorite
INTRODUCTION
HISTORY
MODE OF ACTION
ADVANTAGES
DISADVANTAGES
INTERACTIONS
1. SODIUM HYDROCHLORITE

 comprising a sodium cation (Na +) and a hypochlorite

anion (ClO− or OCl−). It may also be viewed as the sodium salt of
hypochlorous acid.

 The solution is commonly known as liquid bleach or

simply bleach, a household chemical widely used (since the 18th
century) as a disinfectant or a bleaching agent.

 The solution is alkaline in nature with a ph of 11

Update on endodonticirrigating solutions
BETTINA BASRANI & MARKUS HAAPASALO ,2012
HISTORY
 NaOCl was first produced in 1789 in Javelle,
France, by passing chlorine gas through a solution
of sodium carbonate.

 The resulting liquid, known as “Eau de Javelle” or

“Javelle water” was a weak solution of sodium
hypochlorite. However, this process was not very
efficient and alternate production methods were
sought.
 One such method involved the extraction of
chlorinated lime (known as bleaching powder) with
sodium carbonate to yield low levels of available
chlorine.

 This method was commonly used to produce NaOCl

solutions for use as a hospital antiseptic that was
sold under the trade names “Eusol” and “Dakin’s
solution.” Sodium hypochlorite as a buffered 0.5%
solution was recommended for the irrigation of
wounds during World War I by Dakin.
 MODE OF ACTION
 Pιcora et al. reported that NaOCl exhibits a dynamic balance as is
shown by the reaction:

NaOCl + H2O ↔ NaOH + HOCl ↔ Na + + OH− + H + + OCl−

sodium hydroxide Hypochlorous acid hydroxide ions hypochlirite ion

 Three types of chemical reaction occur between organic tissue and

hypochlorite
1. Saponification reaction

2. Amino acid neutralization reaction

3. Chloramination reaction

Root canal irrigants, Deivanayagam Kandaswamy, Nagendrababu Venkateshbabu,jcd,2010



In simple terms, saponification is the name for a chemical reaction

between an acid and a base to form a salt.
When hypochlorous acid, a substance present in NaOCl solution,
comes in contact with organic tissue it acts as a solvent and releases
chlorine, which combines with the protein amino group to form
chloramines
 Hypochlorous acid (HOCl− ) and hypochlorite ions
(OCl− ) lead to amino acid degradation and
hydrolysis.


The chloramination reaction between chlorine and the amino
group (NH) forms chloramines that interfere in cell
metabolism. Chlorine (a strong oxidant) has an antimicrobial
action, inhibiting bacterial enzymes and leading to an
irreversible oxidation of SH groups (sulphydryl group) of
essential bacterial enzymes.
 Thus, the saponification, amino acid
neutralization, and chloramination reactions that
occur in the presence of microorganisms and
organic tissue lead to the antimicrobial effect and
tissue dissolution process.
 CONCENTRATIONS
 NaOCl is used in concentrations between 0.5 and 6%.

 Some in vitro studies have shown that NaOCl in higher

concentrations is more effective against Enterococcus faecalis and
Candida albicans. In contrast other studies have indicated both low
and high concentration of NaOCl is effective.

 NaOCl in higher concentrations has a better tissue-dissolving ability,

but even in lower concentrations when used in high volumes it can
be equally effective .
 Higher concentrations of NaOCl are more toxic than
lower concentrations ; however, due to the confined
anatomy of the root canal system, higher concentrations
have successfully been used during root canal treatment
with a low incidence of mishaps.

 Grossman , observing pulp tissue dissolution capacity,

reported that 5% sodium hypochlorite dissolves this tissue
in between 20 min and 2 h.
 Other studies done concluded that:
1. Higher the concentration faster is the dissolution
of pulp tissue
2. Higher the temperature faster was the
dissolution.
3. the greater the initial concentration of the
sodium hypochlorite solutions, the smaller the
reduction in pH
 TEMPERATURE EFFECTS
 Cunningham reported that the collagen dissolving ability of 2.6%
sodium hypochlorite was comparable to that of 5.25% at both 21°C
and 37°C.

 They also compared the ability of the solutions to kill bacteria at

different temperatures. They tested 2.6% and 5.25% sodium
hypochlorite in reducing a planktonic culture of E. coli results
concluded that that it took less time to kill E. coli in both
concentrations at 37°C.

 Interestingly, it was also reported that sodium hypochlorite at 50°C

did not help in making the root canal cleaner. However, at (50°C),
Berutti et al. observed a thin, less organized, and less adherent smear
layer on the root canal wall. This thinner layer was not evident on root
canals irrigated with sodium hypochlorite at 21°C.
 raising the temperature of the sodium hypochlorite to 37°C
does not help dissolve tissues more effectively. Although
raising the temperature of irrigants is a way to kill bacteria
more effectively, the temperature should not be raised more
than a few degrees above body temperature as this may have
harmful effects on the cells of the periodontal ligament
 Different devices for warming the NaOCl
syringes have come onto the market, but these
devices are not capable of maintaining any
increase of temperature. The best way of heating
NaOCl is to use an ultrasonic device in situ.
ADVANTAGES
 The three parameters potentially affecting NaOCl
penetration that were evaluated in a study was
1. concentration,
2. time, and
3. temperature.
 Perhaps the most surprising observation was that
increasing the concentration from 1% to 6% did not
result in more than a 30%–50% increase in
penetration.

 A longer exposure time in their study resulted in

deeper penetration of NaOCl, although the speed of
penetration declined sharply over time..
Zoe et al
 For example, at 20°C, the penetration depth of
1% NaOCl in 2 min was about 77 mm; after
another 18 min at the same temperature, the depth
reached about 185 mm
DISADVANTAGE:

 The weaknesses of NaOCl include the unpleasant

taste, toxicity, and its inability to remove the smear
layer by itself, as it dissolves only organic
material.

 The limited antimicrobial effectiveness of NaOCl

in vivo is also disappointing.
 The poorer in vivo performance compared with in
vitro is probably caused by problems in
penetration to the most peripheral parts of the root-
canal system such as fins, anastomoses, apical
canal, lateral canals, and dentin canals.

 Also, the presence of inactivating substances such

as exudate from the periapical area, pulp tissue,
dentin collagen, and microbial biomass counteract
the effectiveness of NaOCl..
 Recently, it has been shown by in vitro studies
that long-term exposure of dentin to a high
concentration sodium hypochlorite can have a
detrimental effect on dentin elasticity and flexural
strength.
 Although there are no clinical data on this
phenomenon, it raises the question of whether
hypochlorite in some situations may increase the
risk of vertical root fracture
 however it is said that only solutions containing
more than 40% sodium hypochlorite by weight are
considered hazardous oxidizers. Solutions less
than 40% are classified as a moderate oxidizing
hazard.
 The toxic effects of NaOCl on vital tissues include
hemolysis, epithelial ulceration, and necrosis .

 Several mishaps during root canal irrigation have

been described in the dental literature.
 These range from damage to the patient’s clothing, splashing the
irrigant into the patient’s or operator’s eye, injection through the
apical foramen, and allergic reactions to the irrigant, to inadvertent
use of an irrigant as an anesthetic solution.
 The main symptoms when NaOCl is injected into the periapical
and periradicular tissues are
 immediate severe pain;
 immediate edema of neighboring soft tissues; possible extension
of edema over the injured side of the face, upper lip, or infra-
orbital region;
 profuse bleeding from the root canal;
 profuse interstitial bleeding with hemorrhage of the skin and
mucosa (ecchymosis);

 chlorine taste or irritation of the throat

after injection into the maxillary sinus;

 secondary infection;
 reversible anesthesia; and paresthesia.
 Current treatment protocol for sodium hypochlorite
accident are suggest:
 early recognition of extrusion,

 immediate canal irrigation with normal saline,

encouragement of bleeding,
 Pain control with local anesthetics and analgesics and

warm compresses and

frequent warm mouth rinses
 for stimulation of the local systemic circulation,

 reassurance of the patient, and monitoring of

improvement.
 Cancellous bone( soft bone) is significantly
affected by NaOCl, whereas cortical bone is
minimally affected.

 harm to the cells occur as they have a specific

environment to thrive , NaOCl changes that
environment and damages them.
Chlorhexidine
INTRODUCTION
HISTORY
MODE OF ACTION
ADVANTAGES
DISADVANTAGES
INTERACTIONS
INTRODUCTION.

 Chlorhexidine is a potent antiseptic, which is widely used for

chemical plaque control in the oral cavity.

 Aqueous solutions of 0.1 to 0.2% are recommended for that

purpose, while 2% is the concentration of root canal irrigating
solutions usually found in the endodontic literature (Zehnder,
2006). It is commonly held that chlorhexidine would be less caustic
than sodium hypochlorite.
 Another advantage of CHX is on increasing the temperature even
of lesser concentration it would increase its local efficacy in the
root canal system while keeping the systemic toxicity low.

 Despite its advabtages CHX can still not be considered a gold

standard irrigant because:

1. chlorhexidine is unable to dissolve necrotic tissue remnants, and

2. chlorhexidine is less effective on Gram-negative than on Gram-

positive bacteria
 Due to the cationic nature of the CHX molecule, it can be absorbed
by anionic substrates such as the oral mucosa. It has the binding
ability to albumin present in saliva , pellicle of tooth surface etc.
but this is reversible, this reversible reaction of uptake and release
of CHX leads to substantive antimicrobial activity and is referred
to as “substantivity”.

 Higher the concentration of CHX more will be its substantivity.

 Another application of CHX is in the treatment and
management of periodontal diseases, a well as in the
reduction of the incidence, severity, and duration of
aphthous ulceration. In addition, it has been
advocated as a denture disinfectant in patients
susceptible to oral candidiasis. CHX can be prepared
in the form of mouth rinses, gels, varnishes, and
controlled-release devices
HISTORY

 CHX was developed more than 50 years ago at

Imperial Chemical Industries in England, and was
first marketed in the United Kingdom in 1953 as
an antiseptic cream . Since 1957 it has been used
for general disinfection purposes and also for the
treatment of skin, eye, and throat infections in
both humans and animals
MODE OF ACTION.
 Due to its cationic nature, CHX is capable of

electrostatically binding to the negatively charged surfaces

of bacteria, damaging the outer layers of the cell wall and

rendering it permeable . Depending on its concentration,

CHX can have both bacteriostatic and bactericidal effects.

ADVANTAGES
 Notably, 2% CHX was very effective in eliminating a biofilm of E.
faecalis.

 In infected root canals, it reduces bacteria as effectively as Ca(OH)2 when

applied for 1 week.

 CHX is an effective antifungal agent especially against Candida albicans.

 CHX has antibacterial substantivity in dentin for up to 12 weeks

 Medication and/or irrigation with CHX may delay the contamination of

root-filled teeth by bacteria entering through the coronal restoration/tooth
interface & will not increase leakage through the root-filled apical
foramen
 CHX can significantly improve the integrity of
the hybrid layer and resin–dentin bond stability

 The biocompatibility of CHX is acceptable

DISADVANTAGE.

 No tissue [organic or Inorganic] dissolving

property.
 Interacts with NaOCl .

 The effect of CHX on microbial biofilms is

significantly less than that of NaOCl
INTERACTION,.
 A suggested clinical protocol by Zehnder for treating the dentin
before root canal filling consists of irrigation with NaOCl to
dissolve the organic components, irrigation with EDTA to eliminate
the smear layer, and irrigation with CHX to increase the
antimicrobial spectrum of activity and impart substantivity.

 Although such a combination of irrigants may enhance the overall

antimicrobial effectiveness , the possible chemical interactions
amongst the irrigants need to be considered. Some studies have
reported the occurrence of a color change and precipitation when
NaOCl and CHX are combined
 The formation of a precipitate could be explained by the acid-base
reaction that occurs when NaOCl and CHX are mixed together.
CHX, a dicationic acid, has the ability to donate protons while
NaOCl is alkaline and can accept protons from the dicationic acid.

 This proton exchange results in the formation of a neutral and

insoluble substance referred to as the “precipitate” called as para-
chloroaniline (PCA).
 A recent study aimed to determine if the formation of para-
chloroaniline (PCA) can be avoided by using an alternative
irrigant following sodium hypochlorite but before chlorhexidine;
however, none of the tested solutions used for intermittent
irrigation prevented the formation of PCA. The investigators
concluded that citric acid used as the intermediate irrigant resulted
in the least amount of PCA formation in the canal system
DECALCIFYING SOLUTIONS
 Until recently, decalcifying solutions in endodontics were only
comprised of chelators and acids, most commonly EDTA and
citric acid. In the last few years, however, several combination
products have appeared where their main function—that is, their
decalcifying effect—has been combined with other
characteristics thought to be helpful for treatment.

 The added characteristics are reduced surface tension and,

perhaps more importantly, antibacterial activity.

 The new combination products are based either on EDTA or

citric acid.
 Smear layer consit of both organic and inorganic
composnents. Both NaOCl and a decalcifying
agent are required for complete removalof the
smear layer.
EDTA
INTRODUCTION
HISTORY
MODE OF ACTION
ADVANTAGES
DISADVANTAGES
INTERACTIONS
EDTA( ETHYLENE DIAMINE TETRAACITIC
ACID)

 EDTA is often suggested as an irrigation solution because it can

chelate and remove the mineralized portion of smear layers.

 This colorless, watersoluble solid is produced on a large scale

for many applications. Its prominence as a chelating agent arises
from its ability to “sequester” di- and tri-cationic metal ions
such as Ca2+ and Fe3+. After being bound by EDTA, metal ions
remain in solution but exhibit diminished reactivity.
 It is available in concentrations of 17% as a root
canal irrigant with a pH of 7.
 HISTORY
 The compound was first described in 1935 by Ferdinand Munz, who
prepared the compound from ethylenediamine and chloroacetic acid.

 Chelating agents were introduced into endodontics as an aid for the

preparation of narrow and calcified root canals in 1957 by Nygaard-Ostby. •
A liquid solution of ethylene-diamine-tetra-acetic acid (EDTA) was thought
to chemically soften the root canal dentine and dissolve the smear layer, as
well as to increase dentine permeability

 Today, EDTA is mainly synthesized from ethylenediamine (1,2-

diaminoethane), formaldehyde (methanal), and sodium cyanide.
 Chelating agents can be applied in liquid or pastetype form.

 The origin of paste-type preparations dates back to 1961, when

Stewart devised a combination of urea peroxide with glycerol.
Later, based on the results of that first preliminary study and the
successful introduction of EDTA to endodontic practice, urea
peroxide and EDTA were combined in a water-soluble carbowax
(polyethylene glycol) vehicle.
 Similar pastetype chelators containing EDTA and peroxide have
later been marketed by other manufacturers. However, none of
these pastes should be used, as they are inefficient in preventing
the formation of a smear layer.

 Furthermore, instead of lowering physical stress on rotary

instruments as advocated, carbowax-based lubricants, depending
on instrument geometry, have either no effect or are even
counterproductive
MODE OF ACTION
 It kills microbes by chelating with metallic ions needed for
growth of bacteria.

 The concentrations of 15-17% eliminates calcium from

dentine leaving an organic matrix and removes the smear
layer.

 Application of EDTA in the root canal system is done for 1-

5 min to get the optimum effect. The use of EDTA at a
concentration of 17% for ≥10 min has been lead to cause
erosion of peritubular and intertubular dentine.
 According to Saito et al. greater smear layer removal was found in the 1-
min EDTA irrigation group than the 30-sec or 15-sec groups
 The addition of a quaternary ammonium bromide (Cetavlon)
increases the action of EDTA by decreasing its surface tension.

 This combination is called as EDTAC, and it is effective in

smear layer removal and increasing the diameter of opened
dentin tubules.

 EDTA performed significantly better than NaCl and NaOCl in

smear layer removal and dentinal tubule opening when used
with ultrasonic aggitation.
ADVANTAGES
DISADVANTAGE

 Alone cannot remove smear layer.

 For root canal preparation, EDTA has limited
value as an irrigation fluid. It may open up a very
narrow canal if given the time to soften the 50
micron m it is capable of decalcifying.
INTERACTIONS BETWEEN EDTA, NAOCL,
AND CHX
 Grawehr concluded that ethylenediamine tetraacetic acid
retained its calcium-complexing ability when mixed with
NaOCl.

 However, EDTA caused NaOCl to lose its tissuedissolving

capacity, and virtually no free chlorine was detected in the
combinations. Clinically, this suggests that EDTA and
NaOCl should be used separately. In an alternating
irrigating regimen, copious amounts of NaOCl should be
administered to wash out remnants of EDTA.
 The combination of chlorhexidine
and EDTA produces a white
precipitate. Rasimick et al.
determined if the precipitate
involves the chemical degradation
of chlorhexidine.
 The precipitate was produced and
re-dissolved in a known amount of
dilute trifluoroacetic acid. Based on
the results, chlorhexidine forms a
salt with EDTA rather than
undergoing a chemical reaction.
 Scelza et al evaluated the inflammatory response
of 17% EDTA, 17% EDTA-T, and 10% citric acid
in bony defect created in rat jaws and they
concluded that 10% citric acid showed less
aggressive in inflammatory response.[86] The use
of 25% citric acid was found to be ineffective in
eradication of biofilms of E faecalis after 1, 5,
and 10 min of exposure.
 DIFFERENT FORMS OF EDTA
1. EDTAC and DTPAC are produced when 100 mL of EDTA (15%)
and diethyl-triamine-penta acetic acid (DTPA) at pH 8 are added to
0.75g of the detergent Cetyl-tri-methyl ammonium bromide
(Cetrimide).(Pawlicka eXal 1981.1982).

2. EDTA-T (Formula & Acao Parmacia. Sao Paulo, Brazil) consists of

17% EDTA + sodium lauryl ether sulfate (Tergentol) as a detergent
(Scelza et al 2000).

3. EGTA (Sigma. St Louis. MO. USA) main component is ethylene

glycol bis (β-amino-ethylether)-N.N.N’.N'-tetra acetic acid. It is
reported to bind Ca ions more specifically than EDTA (calt &
Serper 2000)
1. CDTA (experimental solution) is a 1% solution of
cyclohexane-], 2-diaminetetraacetic acid (Cruz-Filho
2011) Largal Ultra (Septodont, Paris, France)
contains a 15% EDTA solution as a disodium
salt.O.75'!{i Cetyl-tri-methyl ammonium bromide
(Cetrhnide) and sodium hydroxide to adjust the pH
value to 7.4.

2. Salvizol (Ravens, Konstanz. Germany) is based on a

5% aminoquinaldinumdiacetate in propylcne glycol
and has a pH of 6.6 (Kaufman ct at. 1978).
MALEIC ACID

Maleic acid is a mild organic acid used as an acid

conditioner in adhesive dentistry.
 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 root canal system
CITRIC ACID
 Citric acid is a chelating agent that reacts with metals to form a
nonionic soluble chelate. Goldman et al. reported that the effects
on the removal of the smear layer obtained with citric acid were
similar to those by EDTA. Ando reported that citric acid is less
cytotoxically irritable to tissue than EDTA.

 Also, Garrett et al. studied the effect of citric acid on diseased root
surfaces.
 EDTA (ethylenediamine tetra-acetic acid), 10% citric acid, EDTA-T
(EDTA plus 1.25% sodium lauryl ether sulfate), EGTA (ethylene
glycol-bis-(b-amino-ethyl ether) N,N,N9,N9-tetra-acetic acid) and
MTDA (mixture of a tetracycline isomer, a detergent, and an acid)
are considered effective decalcifying agents used for endodontic
treatment for smear layer removal.

 Several studies have shown the biocompatibility of 10% citric acid,

17% EDTA, and EDTA-T, indicating that citric acid was the most
biocompatible solution of these.

 Both 10% citric acid and EDTA-T provide a large number of open
dentinal tubules after a 4-min irrigation, with no statistical
difference between them. It has also been reported that irrigation
with 10% citric acid for 3 min showed a similar pattern of Ca++
extraction compared to EDTA-T used for a much longer time
interval (15 min).
 Both 10% citric acid and EDTA-T provide a large
number of open dentinal tubules after a 4-min
irrigation, with no statistical difference between
them. It has also been reported that irrigation with
10% citric acid for 3 min showed a similar
pattern of Ca++ extraction compared to EDTA-T
used for a much longer time interval (15 min).
 NEWER IRRIGATING SOLUTION
1. MTAD
2. Tetraclean
3. Q MIX Other irrigating solutions:
4. HEBP 1. Hydrogen peroxide.
5. Green tea and Triphala
6. Silver diamine fluoride
2. Iodine potassium iodide
7. Electrochemically activated solutions
8. Photon-activated disinfection
MTAD
 Torabinejad et al. developed a irrigant with combined
chelating and antibacterial properties.

 MTAD (151) was the first irrigating solution capable of

removing the smear layer and disinfecting the root canal
system at the same time. MTAD is a mixture of 3%
doxycycline hyclate, 4.25% citric acid, and 0.5%
polysorbate (Tween) 80 detergent.
 It has been commercialized as BioPure MTAD
and is available as a two-part set, liquid in a
syringe and powder in a bottle, which should be
mixed before application.
 MTAD has been recommended for use in clinical
practice as a final rinse after completion of a
conventional chemomechanical preparation
MODE OF ACTION.
 MTAD is composed of three constituents that are expected to
act synergistically against bacteria.

 The bactericidal effect of MTAD was inferior to 1%-6%

NaOCl against E faecalis biofilms.

 The antibacterial activity of MTAD might also be inhibited by

the buffering effect of dentin and the serum albumin present
in the root canal.

 MTAD has been reported to be effective in removing smear

layer.
 In the MTAD preparation, the citric acid may
serve to remove the smear layer, allowing
doxycycline to enter the dentinal tubules and
exert an antibacterial effect.

 The recently revised protocol for clinical use of

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

 The use of MTAD as a final rinse with gutta-

percha/AH Plus resulted in a significant reduction
in bond strength (1.76±1.67 Mpa) when
compared with EDTA.[81] A final rinse with
MTAD might have a negative effect on the
bonding ability of both resin-based and calcium
hydroxide–based sealers due to the precipitate
formation
PROTOCOL FOR USE

 The MTAD protocol was developed on the basis of a pilot

project .

 The results of this project showed that the consistent

disinfection of the infected root canals could occur after
chemomechanical preparation using 1.3% NaOCl as a root
canal irrigant and a 5-min exposure to MTAD as a final rinse.
TETRACLEAN
 Tetraclean (Ogna Laboratori Farmaceutici, Muggio,
Italy) is another combination product similar to
MTAD.

 The two irrigants differ in the concentration of

antibiotics (doxycycline 150 mg/5 mL for MTAD
and 50 mg/5 mL for Tetraclean) and the kind of
detergent (Tween 80 for MTAD, polypropylene
glycol for Tetraclean).
 Comparison of antimicrobial efficacy of 5.25%
NaOCl, MTAD, and Tetraclean against E faecalis
biofilm showed that only 5.25% NaOCl could
consistently disgregate and remove the biofilm at
every time interval.

 However, treatment with Tetraclean caused a high

degree of biofilm disgregation in every considered
time interval (5, 30, and 60 min at 20°C) as
compared with MTAD.
Q MIX
 QMiX was introduced in 2011.

 QMiX is one of the new combination products

introduced for root canal irrigation .

 Its manufacturer recommends that it be used at the

end of instrumentation after NaOCl irrigation.
QMiX contains EDTA, CHX, and a detergent and
comes as a ready-to-use clear solution.
PROTOCOL
 QMiX should be used as a final rinse.
If sodium hypochlorite was used
throughout the cleaning and shaping,
saline should be used to rinse out the

 NaOCl to prevent the formation of

PCA, although no precipitate has been
described when mixing QMiX and
NaOCl (see interaction between
NaOCl and CHX).
SMEAR LAYER REMOVAL

 Stojicic et al. investigated the effectiveness of

smear layer removal by QMiX using scanning
electron microscopy.

 QMiX removed the smear layer equally as well as

EDTA (P = 0.18).

 They concluded that the ability to remove the

smear layer by QMiX wascomparable to that of
EDTA.
 Six percent NaOCl and QMiX were the most
effective disinfecting solutions against the young
biofilm, whereas against the 3-week-old biofilm,
6% NaOCl was the most effective followed by
QMiX.
 HEBP ETIDRONIC ACID

 HEBP (1-hydroxyethylidene-1,1-bisphosphonate; also

called etidronic acid) is a chelator that can be used in
combination with sodium hypochlorite (NaOCl) without
affecting its proteolytic or antimicrobial properties .

However, in contrast to EDTA, HEBP is a weak

decalcifying agent and hence cannot be used as a mere
final rinse. Therefore, it is recommended that HEBP be
mixed with NaOCl to be used as a more complete root
canal irrigant.

.
 This combination is advantageous in that the solution
keeps the sodium hypochlorite–hypochlorous acid
equilibrium toward NaOCl, which has better tissue
dissolution capacity than hypochlorous acid and is
also less cytotoxic

 Furthermore, an irrigating protocol using the NaOCl

+ HEBP combination has been shown as able to
optimize the bonding by Resilon/Epiphany root
fillings. It also reduces dentin debris accumulation in
the root canal during rotary instrumentation
GREEN TEA AND TRIPHALA
 Natural products, especially food extracts, have been used in
medicine and have been shown to be good alternatives to
synthetic chemicals.

 The polyphenols of green tea (i.e. EGCg) were found to be cost

effective. They have inhibitory activity against the MMPs (-2, -
9) found in saliva and dentin.

 Moreover, EGCg is also a broad spectrum antibacterial, and

studies have reported its effectiveness in inhibiting acid
production in dental plaque bacteria as well as antimicrobial
activity against S. mutans. These findings open a new avenue for
the prevention of caries and debonding.
Triphala (IMPCOPS Ltd., Chennai,
India) is an Indian ayurvedic herbal formulatio consisting of
dried and powdered fruits of three medicinal plants, Terminalia
bellerica, Terminalia chebula, and Emblica officinalis (GTPs;
Essence and Flavours, Mysore, India). Polyphenols found in
green tea , the traditional drink of Japan and China, is
prepared from the young shoots of tea plant Camellia
sinensis. Japanese green teas were found not have an
 irritating potential and some results suggest that
extracts of Japanese green tea may be useful as a
medicament for treatment of infected root canals.
Herbal alternatives showed promising antibacterial
efficacy on 3- and 6-week biofilm .
However, presently there is not enough evidence to
support the use of antibacterial components of green
tea or other herbs as endodontic disinfecting agents
SILVER 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 dilution of the original 38% Ag(NH ) F

solution used for root canal infection.

 The study on the antibacterial effect of 3.8% Ag(NH ) F

against a E faecalis biofilm model concluded that Ag(NH ) F
has potential for use as an antimicrobial root canal irrigant or
interappointment medicament to reduce bacterial loads
 . E faecalis was completely killed by Ag(NH ) F
after exposure to these agents for 60 min. The
silver deposits were found to occlude tubular
orifices after removal of the smear layer.
 TRICLOSAN AND GANTREZ
 Triclosan is a broad spectrum antimicrobial agent, active against
gram-positive and gram-negative bacteria as well as some fungi and
viruses.

 Nudera et al. evaluated the minimum inhibitory concentrations

(MIC) and minimum bactericidal concentrations (MBC) of triclosan
and

 triclosan with Gantrez against P intermedia, F nucleatum, A

naeslundii, P gingivalis, and E faecalis. The MBC of triclosan
ranged from 12-94 μg/ml. The MBC of triclosan with Gantrez
ranged from <0.3-10.4 μg/ml. The addition of Gantrez enhanced the
bactericidal activity of triclosan.
 Both triclosan and triclosan with Gantrez
demonstrated bactericidal activity against the five
specific endodontic pathogens
MORINDA CITRIFOLIA (MCJ)
 Cheese fruit

 has a broad range of therapeutic effects, including

antibacterial, antiviral, antifungal, antitumor,
antihelmintic, analgesic, hypotensive, anti-
inflammatory, and immune-enhancing effects.
MCJ contains the antibacterial compounds L-
asperuloside and alizarin.
 Murray et al. proved that, as an intracanal
irrigant to remove the smearlayer, the efficacy of
6% MJC was similar to that of 6% NaOCl in
conjunction with EDTA. The use of MCJ as an
irrigant might be advantageous because it is a
biocompatible antioxidant[113] and not likely to
cause severe injuries to patients as might occur
through NaOCl accidents.
HYDROGEN PEROXIDE

 Hydrogen peroxide has been used as an

endodonticirrigant for a long period of time,
mainly in concentrations ranging between 3% and
5%. It is active against bacteria, viruses, and
yeasts. Hydroxy-free radicals (•OH) destroy
proteins and DNA. The tissuedissolving capacity
of hydrogen peroxide is clearly lower than that of
sodium hypochlorite; also its
 antibacterial effect is considered weak. When
used in combination with sodium hypochlorite,
bubbling will occur as a result of evaporating
oxygen. Although no longer recommended as a
routine irrigant, its use is still not uncommon in
some countries.
IODINE POTASSIUM IODIDE

 Iodine potassium iodide (IPI) has been proposed

 and used as an endodontic disinfectant due to its
 excellent antibacterial properties and low cytotoxicity
 (169,170). It is used as a solution of 2% iodine in 4%
 potassium iodide (171). Allergic reactions to iodine
 and the staining of dentin are often mentioned as
 potential risks with the use of IPI; however, reports of
 such harmful side effects when IPI is used in
 endodontics seem to be extremely rare
ELECTROCHEMICALLY ACTIVATED
SOLUTIONS

 Electrochemically Activated (ECA) solutions are produced

from tap water and low-concentrated salt solutions
(Solovyeva and Dummer, 2000; Bakhir et al., 1986; Bakhir
et al., 1989).
 The ECA technology represents a new scientific paradigm
developed by Russian scientists at the All-Russian Institute
for Medical Engineering (Moscow, Russia, CIS). Principle
of ECA is transferring liquids into a metastable state via an
electrochemical unipolar (anode or cathode) action through
the use of an element/reactor (―Flow-through Electrolytic
Module‖ or FEM).
 The FEM consists of an anode, a solid titanium
cylinder with a special coating that fits coaxially
inside the cathode, a hollow cylinder also made
from titanium with another special coating. A
ceramic membrane separates the electrodes.
 The FEM is capable of producing types of
solutions that have bactericidal and sporicidal
activity; yet they are odourless, safe to human
tissue and essentially noncorrosive for most metal
surfaces (Solovyeva and Dummer, 2000).
 Electrochemical treatment in the anode and cathode chambers results in
the synthesis of two types of solutions: that produced in the anode
chamber is termed an Anolyte, and that produced in the cathode chamber
is Catholyte. Anolyte solutions containing a mixture of oxidizing
substances demonstrate pronounced microbiocidal effectiveness against
bacteria, viruses, fungi, and protozoa

 Anolyte solution has been termed Superoxidized Water or Oxidative

Potential.

 Depending on the type ECA device that incorporated the FEM elements
the pH of anolyte varies; it may be acidic (anolyte), neutral (anolyte
neutral), or alkaline (anolyte neutral cathodic); acidic anolyte was used
initially but in recent years the neutral and alkaline solutions have been
recommended for clinical application
 . Under clean conditions, freshly generated
superoxidized solution was found to be highly
active against all these microorganisms giving a
99.999% or greater reduction in two minutes or
less.
 That allowed investigators to treat it as a potent
microbiocidal agent (Selkon et al., 1999; Shetty et
al., 1999). It is nontoxic when being in contact
with vital biological tissues .
 Clinical applications of anolyte and catholyte were reported to be
effective (Legchilo et al., 1996).

 ECA solutions demonstrated more pronounced clinical effect and

were associated with fewer incidences of allergic reactions
compared to other antibacterial irrigants tested (Legchilo et al.,
1996).

 Cleaning efficiency and safety for surfaces of dental instruments

and equipment has been demonstrated in a number of studies. ECA
is showing promising results due to ease of removal of debris and
smear layer, nontoxic and efficient in apical one third of canal. It
has a potential to be an efficient root canal irrigant.
PHOTON-ACTIVATED DISINFECTION
 Oscar Raab introduced the photo-activated therapy for the
inactivation of microorganisms in the endodontic
management.

 PAD is the placement of a dye (toluidine blue or methylene

blue) into the root canals which is then activated by the
laser radiation emitted from a low power (100 mW) laser
device, causing interference with the microbial cell walls
and bacterial death.

 After normal irrigation, the canals are washed with sterile

water, and they are dried by sterilized paper points before
the application of the PAD solution into the canals.
 The photosensitizer molecules will attach to the
membrane of the microorganisms and the
irradiation with a precise wavelength coordinated
to the absorption of the photosensitizer will form
singlet oxygen which causes cell wall rupture and
death of the microbes. The benefit of PAD is that
the dye is only poisonous to bacteria, and there
are no side effects to adjacent tissues.
OZONE TOP

 It occurs in the environment either in gaseous form or as

ozonated water. [32] It is an antiseptic, powerful oxidant,
and antibacterial agent.

 It is a strong oxidizer of cell walls and the cytoplasmic

membranes of microorganisms, making it a bactericidal,
antiviral, and antifungal agen
VITAL PULP
 Philippe Sleiman

 1)after access opening first irrgation with sodium

hypochlorite.(concentration, temp, time). This "elevator effect" will
evacuate the organic debris outside the access cavity, disorganize the
coronal pulp tissue and help to better detect the canal orifices.

 second application and its activation is obtained by using a K file (08-10).

This will disorganize the pulpal tissue in both the cervical and middle
thirds of the endodontic system. This step has to be preceded by an
abundant irrigation with distilled water in order to eliminate the first
mixture present in the access cavity.
 Once the preparation of the canal has begun, Smear Clear (Sybron
Endo,Orange, CA) (17 percent EDTA cetrimide, and surfactants)
must be used. The EDTA is an organic acid which eliminates the
mineral part of pulp tissue, the surface tension inhibitor will allow
a better contact with the dentin for a higher efficiency of the
product.

 It is advised to alternate the use of EDTA from the beginning of the

preparation in order to eliminate the mineral layer before its
thickening and condensing it inside the canal systems which will
close the entrances of lateral and accessory canals and dentinal
tubules.
 Each time a rotary file is working inside the canal, irrigating
solution must be present. Ultrasonic activation of the irrigating
solution, using a small diameter file, is advised for a more efficient
chemical preparation.

 The early use of EDTA facilitates the flow of the different irrigants
in the lateral canals permitting a chemical preparation of all the
endodontic system. Chlorehexidine can be used for a total
elimination of the bacteria inside the canal.

 Distilled water is used between each irrigating solution in order to

prevent an acid/ base reaction, between sodium hypochlorite and
EDTA, for a more efficient action of the chemicals on the tissues.
 A copious neutralization of all the chemical
agents must be done by the end of the preparation
and before the fitting of the gutta percha cones so
that the master cone does not push any of the
chemicals outside the canal that might cause an
inflammation of the surrounding tissues.
NECROTIC TEETH
 The main difference between vital teeth and necrotic ones is the
absence, not in total, of the pulpal parenchyme and the abundance
of bacteria present in the latter. For this reason, the irrigation
sequence will be different. Irrigation will be initiated with either
sodium hypochlorite (5.25%, 60%C) for its bacterial effect or with
chlorohexidine (0.2%) (10 minutes)for the elimination of various
bacterial types present in the root canals and dentinal tubuli.
Followed by irrigation with normal saline to neutralize the irrigant.
 The irrigation protocol changes if there is pus discharge actively
present. Once there is no pus discharge present in the canal the
irrgation protocol can be followed like the previous way.

 The EDTA, by eliminating the smear layer and opening the

dentinal tubuli will permit an easy flow of NaOCl or
chlorhexidine for a better disinfection of the endodontic system.
In both clinical situations (vital and necrotic teeth) it is
necessary2,11,13 to end our sequence by using distilled water in
order to eliminate the chemical agents or to neutralize their
effects. This will inhibit:

Their flow towards the periodontal tissues

- The alteration of the filling material
- The formation of a precipitating layer due to the crystallization of
sodium hypochlorite after drying the canal walls.
PRESENCE OF RESORPTIONS

 When we suspect an internal resorption, the irrigation sequence is the

same that was described for vital teeth. But this sequence will be
followed by the use of citric acid 50 percent (10 minutes) in order to
eliminate the granulation tissue and to obtain smooth dentinal walls.
This will ameliorate the adaptation of the filling material. The citric
acid is eliminated by NaOCl and distilled water.

 The same sequence is adopted for external apical resorption but with
an activation of the patency
CONCLUSION
 Irrigation has a key role in successful endodontic treatment.

 The main goal of root canal treatment is to completely eliminate the

different components of pulpal tissue, bacteria, and biofilm and
produce a hermetic seal to prevent infection or reinfection and
promote healing of the surrounding tissues.

 The extratime we gain by using rotary NiTi instruments should be

used for abundant irrigation to achieve better cleaning of the root
canal system, thereby contributing to improved success of the
treatment.
 The most commonly used irrigating solution is sodium
hypochlorite. While sodium hypochlorite has many
desirable qualities and properties, by itself it is not
sufficient to totally clean the root canal system oforganic
and inorganic debris and biofilm.

 For optimal irrigation, a combination of different irrigating

solutions must be used. The dentist should be aware of the
interactions between the various chemicals found in
irrigants as they may weaken each others’ activity and
result in the development of products that ar harmful to the
host. Developing a rational irrigation sequence so that the
chemicals are administered ina proper manner to release
their full potential is imperative for successful endodontic
treatment.