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Irrigation in endodontics

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    Irrigation in endodontics Irrigation in endodontics Presentation Transcript

    • IRRIGATION IN ENDODONTICS CONTENTS • • • • • • • • Introduction Irrigation solutions in endodontics Irrigation devices & techniques Challenges of irrigation Recent advances in irrigation Sequence of irrigation Conclusion References
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References INTRODUCTION Barret in 1925… "of all the phases anatomic study` in human system, one of most complex is that of pulp cavity morphology" of the the the
    • The sequence of events & procedures in the control of endodontic infections are:  host defence system, Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References systemic antibiotic therapy,  instrumentation & irrigation (“cleaning & shaping”),  intracanal medicaments used between appointments,  permanent root filling & coronal restoration.
    • The use of irrigating solutions in combination with canal instrumentation, loosen debris, pulp tissue and micro-organisms from the irregular dentin walls so that they can be removed from the canal. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Irrigation is defined as “to wash out a body cavity or wound with water or a medicated fluid”
    • Objectives of irrigation: Mechanical & Chemical functions  Flushing  Lubrication  Dissolution  Smear layer removal Biological functions  Antimicrobial Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References
    • Characteristics of an ideal endodontic irrigant : Endodontic Topics 2012,27,74-102 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References 1. Effective germicide and fungicide. 2. Non-irritating to the periapical tissues. 3. Stable in solution. 4. Prolonged & sustained antibacterial 5. Active in the presence of blood, serum, a protein derivatives of tissue. 6. Able to completely remove the smear layer. 7. Low surface tension. 8. Able to disinfect the dentin/dentinal tubules. 9. Does not interfere with repair of periapi tissues.
    • Characteristics of an ideal endodontic irrigant : Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References 10. Does notEndodontic Topics 2012,27,74-102 stain tooth structure. 11. Inactivation in a culture medium. 12. Does not induce a cell-mediated immune response. Is non-antigenic, non-toxic, and non-carcinogenic to tissue cells surrounding the tooth. 13. Has no adverse effects on the physical properties of exposed dentin. 14. Has no adverse effect on the sealing ability of filling materials. 15. Easy to use/apply. 16. Inexpensive.
    • Classification of Irrigating solutions: By Kandaswamy D, Venkateshbabu N. A) Chemical agents: a. Tissue dissolving agents: NaOCl Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References b. Antibacterial agents  Bacteriostatic (CHX, MTAD)  Bactericidal (NaOCl) c. Chelating agents:  Weak (HEBP)  Strong (EDTA) d. Combination products (tissue dissolution & antibacterial effect): MTAD, QMiX, SmearClear, Tetraclean B) Natural agents: a. Antibacterial agents: e.g. Green tea, Triphala Conserv Dent 2010: 13: 256–264
    • Classification of Irrigating solutions: By STOCK .  CHEMICALLY INACTIVE SOLUTIONS ( normal saline or local anaesthetic solution) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  CHEMICALLY ACTIVE SOLUTIONS Alkaline solutions  Sodium dioxide  Urea  Sodium hydroxide  Sodium hypochlorite  Potassium hydroxide  Chloramine-T Acidic solutions  Organic acids (Citric acid, maleic acid, tannic acid, phosphoric acid, lactic acid)  Inorganic acids (H2SO4, HCl) Oxidizing agents  3% H2SO4  Urea peroxide  Glyoxide
    • Classification of Irrigating solutions: By STOCK .  CHEMICALLY ACTIVE SOLUTIONS Chelating agents  EDTA  EDTAC  RC-Prep Proteolytic enzymes  Streptokinase  Enzymol  Streptodornase  Purified trypsin  Papain Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References OTHERS  Chlorhexidine gluconate (CHX)  Glutraldehyde  Oxidative potential water  2% potentiated acid  1% pentanedial  Calcium hydroxide solution  Bardac-2
    • Commonly used irrigating agents used in endodontics Sodium hypochlorite (NaOCl) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Toxic (hypochlorite  Current irrigant of accident) choice   Effective antimicrobial Not substantive  agent Corrodes, unpleasa  Excellent organic nt odor tissue solvent  Removes only the  Lubricates of the  Effective fairly quicklyorganic part 2012,27,74-102 Endodontic Topics smear layer
    • Mode of action… 1. Saponification reaction NaOCl + fatty acids  Soap + glycerol 2. Neutralization reaction Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References NaOCl + aminoacids  Salt + water (H2O) 3. Chloramination reaction Amino acids + HOCl  Chloramine + water (H2O)  High pH of NaOCl interferes in the cytoplasmic membrane integrity with an irreversible enzymatic inhibition, biosynthetic alterations in cellular Braz Dent metabolism, and phospholipid degradation J 2002: 13: 113–117
    • Concentrations..  used in concentrations between 0.5 and 7%  NaOCl in higher concentrations is more effective against E. faecalis and Candida albicans Int Endod J 2001: 34: 424–428 Int Endod J 2004: 37: 438–446 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Int Endod J 1999: 32: 421–429  Both low and high concentrations to be equally effective in reducing bacteria from the root canal system Scand J Dent Res 1981: 89: 321–328 Odontol Revy 1976: 27: 1–10  higher concentrations has a better tissue-dissolving ability J Endod 1978: 4: 60–64  higher concentrations of NaOCl are more toxic than lower concentrations Oral Surg Oral Med Oral Pathol 1973: 36: 856–864.  Solution to be used in higher volume and in more frequent intervals, if in lower concentration J Endod 2000: 26: 331–334
    • Time of exposure for optimal effect  when the confounding factors are eliminated, it has been shown that NaOCl kills the target microorganisms rapidly even at low concentrations of less than 0.1%. Dent Clin North Am 2010: 5: 291–312 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  continuous irrigation and time are important factors for the effectiveness of NaOCl in invivo conditions  The optimal time that a sodium hypochlorite irrigant at a given concentration needs to remain in the canal system is an issue yet to be resolved Storage & handling J Endod 2006: 32: 389–398 Austral Dent J 1998: 43: 250–256  Stability of NaOCl solutions is reduced by lower pH, presence of metallic ions, exposure to light, open containers and higher temperatures  If diluted, they should be diluted as soon as possible after purchase
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  NO metallic containers  corrosive nature of sodium hypochlorite must be considered before disposal Safety (Sodium hypochlorite accidents) Endod Topics 2007: 16: 27–63  Solutions containing more than 40% : hazardous oxidizers  Solutions less than 40% : moderate oxidizing hazard (NFPA 430, 2000)  Toxic effects of NaOCl on vital tissues include hemolysis, epithelial ulceration, and necrosis  Several mishaps during root canal irrigation can 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
    • Preventive measures BDJ 2007: 202: 555–559  Plastic bib to protect patient’s clothing  Protective eye-wear  Rubber dam isolation  side-exit Luer-Lock needles  Irrigation needle a minimum of 2 mm short of the working length  Avoidance of binding of the needle into the root canal  Avoidance of excessive pressure during irrigation Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References
    • Treatment protocol for sodium hypochlorite accident… Compend Contin Educ Dent 2007: 28: 544–546.  Early recognition of extrusion, Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  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.
    • Effect of NaOCl on dentin  Degradation of organic dentin  Clear concentration dependent effect of NaOCl solutions on mechanical dentin properties Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Int Endod J 2007: 40: 786– 793 Sodium hypochlorite penetration of dentinal tubules  Increasing the concentration from 1% to 6% did not result in more than a 30%–50% increase the first to report Zou et al. is in penetration in which NaOCl penetration into  At 20 C, the penetration depth of 1% NaOCl in 2 min was about 77 mm; after dentin has been measured with another 18 min at the same temperature, the depth reached about 185 mm micrometer accuracy.  The highest values, 291 and 300 mm, were found in the groups treated with 6% NaOCl at 37 C and 45 C for 20 min. J Endod 2010: 36: 793–796
    • Allergic reactions to NaOCl  unlikely to occur  hypersensitivity and contact dermatitis may occur  greater cytotoxicity and caustic effects on healthy tissue with 5.25% NaOCl than with 1.0 & 0.5 % solutions J Endod 1985: 11: 525-8 Effect on biofilm Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Oral Surg Oral Med Oral Pathol 2001; 92:446-50 Clegg et al. : 6% NaOCl was the only agent capable of both physically removing artificial biofilm and killing bacteria  dosedependent effect of NaOCl against bacteria  Antibiofilm effects of NaOCl may be a result of removal of organic tissue, thus eliminating the bacterial attachment to dentin and other organisms J Endod 2006: 32: 434–437
    • Influence of NaOCl on bond strength  decreased bond strength between dentin and resin cements  require a reversal agent Influence of NaOCl on NiTi Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Busslinger and Barbakow: quantities of ions released by the corrosion process into the NaOCl solution were insignificant Int Endod J 1998;31:2904 Increasing the efficacy of NaOCl  Altering the pH  Increasing the temperature  Agitation Endodontic Topics 2012, 27, 74–102
    • 1. Altering the pH  NaOCl + H20  NaOH + HOCl  HOCl  H+ OCl HOCl molecule : stronger chlorinating and oxidizing action on tissue & microorganisms Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Baker gave the relationship between HOCl, OCl-, and pH. At pH 10, basically all chlorine is in the OCl- form; the reverse occurs at a pH of 4.5, when all chlorine is in the form of HOCl. Bloomfield and Miles: hypochlorites at a lower ph possess greater antimicrobial activity Andrews and Orton: HOCl was responsible for the destruction of microorganisms Morris: OCl- ion possesses approximately 1/80th of the germicidal potency of HOCl in killing Escherechia coli JOCD; Oct-Dec 2010; Volume 13; Issue 4
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References 2. Increasing the temperature Cunningham : collagen dissolving ability of 2.6% NaOCl was comparable to that of 5.25% at both 21 C and 37 C Oral Surg Oral Med Oral Pathol 1980: 50: 569–571 Raising the temperature killS bacteria more quickly. However, raising the temperature of the NaOCl to 37 C does not help dissolve tissues more effectively. However, raising the temperature till 60⁰C is also advocated J Endod 2006 32: 389-398 Fig. Heating devices for NaOCl syringes Best way is to use an ultrasonic device in situ
    • 3. Agitation Moorer & Wesselin : impact of mechanical agitation of NaOCl solutions on tissue dissolution was very important (violent fluid flow and shearing forces caused by ultrasound) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Int Endod J 1982: 15: 187–196 Stojicic et al. refreshing the NaOCl solution by agitation, preferably continuous, results in increase in the NaOCl effect J Endod 2010: 36: 1558–1562 Fabiani : use of ultrasonic agitation increased the effectiveness of 5% NaOCl in the apical third of the canal wall. Endod 2010: 36: 282–285 The effect of agitation on tissue dissolution was greater than that of temperature; continuous agitation resulted in the fastest tissue dissolution J Endod 2010: 36: 1558–1562
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References CHLORHEXIDINE (CHX)  excellent antimicrobial activity  effective antifungal agent  less effective on microbial biofilms  antibacterial substantivity in dentin for up to 12 weeks  Organic matter may reduce or inhibit the antibacterial activity  no ability to dissolve organic or inorganic tissue  Less contamination & apical leakage  Combinations of NaOCl and CHX cause color changes and formation of a precipitate, which may interfere with the seal of the root filling  improve the integrity of the hybrid layer and resin–dentin bond stability  Biocompatibile Aust Endod J 2009: 35: 131–139
    • 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 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  At high concentration exerts a bactericidal activity  At low sub-lethal concentrations, chlorhexidine is bacteriostatic Substantivity  Concentration dependent effect  Lin et al : only after the saturation point is reached after the first hour that the antimicrobial capability of CHX increases with time. Residual antimicrobial activity from CHX remains in the root canal system for up to 12 weeks Aust Endod J 2009: 35: 131–139
    • Cytotoxicity  normally used at concentrations between 0.12% and 2.0%  At these concentrations, CHX has a low level of tissue toxicity, both locally and systemically (Loe) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  when CHX is in contact with NaOCl, there is formation of parachloroaniline (PCA), which may have a negative impact on tissues J Endod 2007: 33: 966– 969 Chlorhexidine application in endodontics  as an irrigant and intracanal medication  In infected root canals, it reduces bacteria as effectively as Ca(OH)2 when applied for 1 week Endodontic Topics 2012,27,74-102
    • Chlorhexidine as an endodontic irrigant  2% CHX as an irrigant has a better antibacterial efficacy than 0.12% CHX in vitro Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003: 96: 618–624 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Canals treated with 2% CHX gel were cleaner than those treated with 2% CHX liquid or 5.25% NaOCl  2% CHX liquid was inferior to 2.5% NaOCl in cleaning the canals Int Endod J 2003: 36: 391–394 Clinical studies Ringel et al : 2.5% sodium hypochlorite was significantly more effective than 0.2% chlorhexidine when the infected root canals were irrigated for 30 min by either of the solutions Endod 1982: 8: 200–204  However, in a recent study, no significant difference between the antibacterial efficacy of 2.5% NaOCl and 0.12% CHX liquid J Endod 2007: 33: 541–547
    • CHX and dentin bonding  Carrilho et al: auto-degradation of collagen matrices can occur in resin infiltrated dentin, but may be prevented by the application of a synthetic protease inhibitor such as CHX. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Overall, because of its broad-spectrum MMP-inhibitory effect, CHX can significantly improve resin–dentin bond stability Am J Dent 2005: 18: 315–317 Effect on biofilm  2% CHX and 2% NaOCl killed only 13% to 15% of the 3-weekold biofilm bacteria in dentin after 1 min of exposure where as 6% NaOCl being the most effective J Endod 2012: 38: 1376–1379 Allergic reactions to CHX  No publications of allergic reactions following root canal irrigation with CHX
    • Irrigant solutions with added detergent reduce surface tension& improve their wettability. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Fig. SmearClear, Chlor-XTRA and CHX-Plus.  6% NaOCl and Chlor-XTRA were superior against E. faecalis biofilms compared to 2% CHX and CHX-Plus J Endod 2009: 35: 95–97
    • NaOCl + CHX  an additive antimicrobial action Reason for this augmented microbial action  Tissue dissolving property that is better than that obtained with use of CHX alone  less toxic then NaOcl NaOCl is an oxidizing agent Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References oxidize the gluconate part of CHX to gluconic acid chloro group might get added onto the guanidine component CHLOROHEXIDINE CHLORIDE 2.5% NaOCL + 0.2 % CHX
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Interaction between NaOCl and CHX Fig. Immediate formation of an orangebrown precipitate (para-chloroaniline) Int Endod J 2002: 35: 791–795 Basrani et al: Amount of PCA directly increased with the increasing conc. of NaOCl J Endod 2007: 33: 966– 969 Bui et al. NaOCl/CHX precipitate tends to occlude the dentinal tubules J Endod 2008: 34: 181–185 Precipitate could be prevented by using absolute alcohol or minimized by using saline and distilled water as intermediate flushes J Endod 2010: 36: 1154–1157
    • DECALCIFYING SOLUTIONS EDTA Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  polyamino carboxylic acid  Remove the inorganic part of the smear layer  Contribute to the elimination of bacteria in the root canal  Combination products have wide-spectrum antimicrobial activity.  EDTA may have antifungal activity EDTA extracts bacterial surface  Demineralize dentin (20–50 mm) proteins by combining with metal ions from the cell envelope  Low toxicity
    • Applications in endodontics Haapsalo M, Qrstavik: removal of the smear layer by EDTA (or citric acid) improves the antibacterial effect of locally used disinfecting agents in deeper layers of dentin J Dent Res 1987;66:1375-9 Endod Dent Traumatol 1990;6:142-9 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Antiseptics such as quaternary ammonium compounds (EDTAC) or tetracycline antibiotics (MTAD) have been added to EDTA and citric acid irrigants, respectively, to increase their antimicrobial capacity Variations EDTAC EDTA + Cetavlon REDTA EDTA + Sodium hydroxide + cetyl trimethylammonium bromide + water RC prep EGTA EDTA + urea peroxide ethylene glycol bis (β aminoethyl ether)-N,N,N,N- tetra acetic acid
    • Interactions between EDTA, NaOCl, and CHX EDTA + NaOCl EDTA causes NaOCl to lose its tissuedissolving capacity, and virtually no free chlorine is available (Grawehr) Int Endod J 2003: 36: 411–417 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References EDTA + CHX Immediate formation of a white, foggy precipitate Precipitate involves the chemical degradation of chlorhexidine (Rasimick et al) J Endod 2008: 34: 1521– 1523
    • CITRIC ACID  can also be used for irrigation of the root canal and for removal of smear layer Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  used in various concentrations, ranging from 1% to 50%, with a 10% solution being the most common 10% citric acid has been shown to remove the smear layer more effectively from apical root end cavities than ultrasound Int Endod J 1994;27:318-24 10% citric acid was more effective than 1% citric acid, which was more effective than EDTA in demineralizing dentin Int Endod J2004;37:365-9
    • HEBP  HEBP (1-hydroxyethylidene-1,1-bisphosphonate; also called etidronic acid) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Chelator that can be used in combination with sodium hypochlorite (NaOCl) without affecting its proteolytic or antimicrobial properties  HEBP is a weak decalcifying agent and hence cannot be used as a mere final rinse NaOCl + HEBP :  better tissue dissolution capacity  less cytotoxic  reduces dentin debris accumulation
    • QMiX  QMiX contains EDTA, CHX, and a detergent and comes as a ready-to-use clear solution  CHX and EDTA do not cause a white precipitate; the solution is clear Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Surface tension  Low surface tension is one of the ideal characteristics of an irrigant (Grossman) Smear layer removal  QMiX removed the smear layer equally as well as EDTA (Stojicic et al. ) Antibacterial efficacy and effect on biofilms Int Endod J 2012: 45: 363–371  6% 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 & both were more effective than 2% NaOCl and 2% CHX (Wang et al) J Endod 2012: 38: 1376–1379
    • MTAD & TETRACLEAN MTAD is a mixture of 3% doxycycline hyclate, 4.25% citric acid, and 0.5% polysorbate (Tween) 80 detergent Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Tetraclean is a mixture of citric acid doxycycline 50 mg/5 Ml (whereas 150 mg/5 mL for MTAD) and polypropylene glycol as detergent
    • Mode of action  Tetracycline is a bacteriostatic antibiotic which exerts its effect through the inhibition of protein synthesis  In the absence of bacterial cell lysis, antigenic by products (i.e. endotoxin) are not released (Torabinejad) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Doxycycline, citric acid, and Tween 80 combined might have a synergistic effect on the bacterial cell wall and on the cytoplasmic membrane Cytotoxicity of MTAD MTAD appeared to be less cytotoxic than eugenol, 3% H2O2, Ca(OH)2 paste, 5.25% NaOCl, Peridex, and EDTA and more cytotoxic than 2.63%, 1.31%, and 0.66% NaOCl solutions (Zhang et al ) Surface tension J Endod 2003: 29: 654–657 MTAD has a lower surface tension than 5.25% NaOCl, 17% EDTA, or water
    • Smear layer removal MTAD performed better than EDTA in cleaning dentinal tubules of debris and removing the smear layer in the apical third of root canals (Torabinazad et al.) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References MTAD created less erosion than EDTA in the coronal and middle thirds of the root canals. J Endod 2003: 29: 400–403 Antibacterial efficacy 1.3% NaOCl followed by 5 min MTAD was more effective in the disinfection of canals than a protocol of 5.25% NaOCl followed by 1 min 17% EDTA and then 5 min 5.25% NaOCl as a final rinse J Endod 2003: 450–452
    • Other irrigating agents HYDROGEN PEROXIDE an oxidizing agent used in conc. of 3-5% Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Tissue dissolving capacity less than NaOCl  Weak antibacterial effect  3% H2O2 is effective against anaerobic bacteria  less effective as a solvent , produce less damage to periapical tissue  Bleaching effect  WIEN strongly recommend its use bcoz of low toxicity  used in conjunction with NaOCL Mechanism of axn: reaction of superoxide ions to produce hydroxyl radicals Oxidation of sulphydryl groups and double bonds in proteins, lipids, and surface membranes. Antimicrobial action
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References NaOCl + H2O2  combination was introduced by Grossman  produce foaming action flush the debris out of root canal  significantly increase dentinal permeability (Marshall et al 1980)  deactivationof bacterial endotoxins (De .Rensin 1981)  In combination antibacterial effect of both solutions was less than that of individual solutions and it used to decrease tissue dissolving action of NaOCl  release nascent O2 which can lead to pain and swelling, if used as last rinse  but at the same time this [O] toxic to the anaerobes  Tissue emphysema may occur
    • CHX + H2O2  combination was introduced by Helling et al Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  CHX +H2O2 when combined do not counter act one another at specific conc (synergistic axn) H2O2 Smear layer removal greater antibacterial effect at deeper layers CHX allow penetration of CHX into the dentinal tubules kills most of the bacteria in the area adjacent to the lumen
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References IODINE BASED COMPOUNDS Aqueous iodine solutions are rather unstable development of iodophors (‘iodine carriers’)  Povidone–iodine  Poloxamer– iodine In endodontics, iodine potassium iodide (IPI) in 10% concentration is used Mo ller (1966) Antimicrobial action of iodine is rapid, even at low concentrations, Iodine penetrates into microorganisms and attacks key groups of cell molecules, such as proteins, nucleotides, and fatty acids, resulting in cell death  Dentine powder, organic dentine matrix and heat-killed cells of E. faecalis and C. albicans effectively abolished the effect of 0.2/0.4% IPI against E. faecalis  Allergic reactions to iodine and the staining of dentin
    • GLY-OXIDE  10% solution of carbamide peroxide in anhydrous glycerol  provides lubrication without softening dentin  antimicrobial activity more than 3% H2O2  produces transient energetic effervescence with NaOCl  useful in narrow and curved canals  does not remove smear layer Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References MALEIC ACID Ballal et al. reported that final irrigation with 7% maleic acid for 1min was more efficient than 17% EDTA in the removal of smearlayer from the apical third of the root canal system J Endod 2009;35:1573-6
    • IRRIGATION DEVICES AND TECHNIQUES MANUAL Syringe irrigation with needles/ cannulas (end/side vent) Brushes (Endobrush, Navi tip FX) Mnual Dynamic Agitation (hand activated well fitting gutta percha Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References MACHINE ASSISTED Rotary brushes (Ruddlebrush, C analbrush) Continuous irrigation during rotary instrumentation (Quantec-E) JOE — Volume 35, Number 6, June 2009 Sonic (Rispisonic file, Endoactivat or) Ultrasonic Pressure alternating devices (EndoVac, Rinse Endo)
    • Plastic syringes for irrigation  Different sizes (1-20 ml)  Luer-Lok design Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Modifications of needles A)Bivelled B) Monoject C) Safe ended (A) (B) (C )
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Modifications of needles Bending the tip Flexiglide needle  27-31 gauge recommended  should not bind in the canal  easily controlled  not enough flushing action Oral Surg Oral Med Oral Pathol 1977; 44:306–12
    • Brushes Endobrush  used only as an adjuncts  Nylon bristles set in twisted wire  Can’t be used till NaviTip FX working length  recently introduced  Dislodgement of  30-gaugebristles radiolucent needle covered with brush Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References
    • MANUAL DYNAMIC AGITATION  Effect of “apical vapor lock” Dent Today 2008;27:82,84,86–87 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Technique: Gently moving a wellfitting gutta-percha master cone up and down in short 2- to 3mm strokes within an instrumented canal  Principles: 1. changes in intracanal pressure 2. frequency of 3.3Hz, 100 strokes per 30 seconds
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References ROTARY BRUSHES Ruddle brush Canal brush Continuous Irrigation During Rotary Instrumentation (Quantec-E)  Selfcontained fluid delivery unit  uses a pump console, 2 irrigation reservoirs & tubing  but no significant results in middle & apical in cleaning efficiency (Walters et al) J Endod 2002;28:837–9
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References SONIC IRRIGATION Rispisonic file  combines battery-driven vibrations (9000 cpm) with manually operated irrigation of the root canal Vibringe
    • ENDOACTIVATOR Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  consists of a portable handpiece and 3 types of disposable polymer tips of different sizes  10,000 cycles per minute (cpm) Stamos et al reported that the more powerful ultrasonic systems removed more dentin debris from the root canal than the less powerful sonic irrigation systems. J Endod 1987;13:434–40
    • ULTRASONICS  Ultrasonically activated files have the potential to prepare and debride root canals mechanically. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Files are driven to oscillate at ultrasonic frequencies of 25–30 kHz in a transverse vibration Two types of ultrasonic irrigation :  Active ultrasonic irrigation (UI)  Passive ultrasonic irrigation (PUI)  Endodontic literature supports that it is more advantageous to apply ultrasonics after completion of canal preparation J Endod 2006;32:389–98
    • PASSIVE ULTRASONIC IRRIGATION (PUI) (Weller et al )  During PUI, the energy is transmitted from an oscillating file or a smooth wire to the irrigant in the root canal by means of ultrasonic waves. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References The latter induces acoustic streaming and cavitation Application Methods During PUI:  Irrigant of the irrigant. a) Continuous Ultrasonic Irrigation b) Intermittent Flush Ultrasonic Irrigation Acoustic streaming cavitation
    • a) Continuous Ultrasonic Irrigation  Nusstein’s needle holding devices  25-gauge irrigation needle is used instead of an endosonic file Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  needle is simultaneously activated by the ultrasonic handpiece, while an irrigant is delivered from an intravenous tubing connected via a Luerlok to an irrigation-delivering syringe. b) Intermittent Flush Ultrasonic Irrigation
    • PUI is more effective than syringe needle irrigation in removing pulpal tissue remnants and dentin debris. J Endod 2003;29:674–8 Guerisoli et al reported that smear layers were effectively removed from the apical, middle, and cervical thirds of the canal walls by EDTA plus Cetavlon (EDTAC) and NaOCl by using a size 15 file energized by ultrasonic agitation. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Int Endod J 2002;35:418–21 Removal of Bacteria:  High-power ultrasound causes de-agglomeration of bacterial biofilms via the action of acoustic streaming  Cavitation may produce temporary weakening of the cell membrane
    • PRESSURE ALTERNATION DEVICES The EndoVac System…. Multi-Port Adapter (MPA) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References
    • The EndoVac System…. (A) (B) (C) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References (D) (A) Macrocannula with handpiece (B) Microcannula with fingerpiece (C) Master delivery tip (D) Tip of microcannula
    • The EndoVac System…. Clinical use: (A) (B) (C) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References (D) Negative pressure Positive pressure
    • Safety: Less apical extrusion risk using the EndoVac system compared with needle irrigation J Endod. 2010 Feb;36(2):338-41 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Efficacy: Better debridement 1 mm from working length using the EndoVac system compared with needle irrigation J Endod 2007;33:611-615 SUCCESS: Negative apical pressure irrigation system EndoVac results in significantly less postoperative pain & necessity for analgesic medication than a conventional needle irrigation protocol using the Max-i-Probe J Endod 2010;36:1295-1301
    • The RinsEndo System Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  65 mL of a rinsing solution oscillating at a frequency of 1.6 Hz is drawn from an attached syringe and transported to the root canal via an adapted cannula.  Suction phase (100 times per minute)  higher risk of apical extrusion of the irrigant
    • CHALLENGES OF IRRIGATION DCNA 2010;54: 291-312 1. Smear Layer  Remove organic & inorganic parts Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Fig. Instrumented canal wall after removal of the smear layer by NaOCl and EDTA.
    • 2. Dentin Erosion  reduction in the flexural strength and elastic modus of dentin Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Fig. Considerable erosion of canal-wall dentin occurs when hypochlorite is used after EDTA or CA. 3. Cleaning of Uninstrumented Parts of the Root-canal System Fig. An anastomosis between 2 joining canals has been packed with debris during rotary instrumentation
    • 4. Biofilm  How to remove it?  can CHX be an alternative to NaOCl here? Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Fig. Bacteria growing on dentin surface; eradication of the microbes in the apical canal should be the key early stages of biofilm formation to success…. 5. Safety versus Effectiveness in the Apical Root Canal But what about safety concerns???
    • RECENT ADVANCES IN IRRIGATION 1. LASERS Moshonov et al. assessed that Nd: YAG laser irradiation significantly reduced the number of bacteria (E. faecalis), but its inferior to NaOCl irrigation, which effectively disinfected the canals. Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Endod Dent Traumatol 1995: 11: 220–224. Ho : YAG shows excellent antibacterial efficiency against E. faecalis while CO2 laser shows a mixed response (Gutknecht et al) J Clin Laser Med Surg 1997: 15: 75–78 Takeda et al., concluded that CO2 laser removed and melted the smear layer on the instrumented canal walls, while the Er: YAG laser was the most effective in removing the smear layer Int Endod J 1999: 32: 32–39
    • 2. Light-activated Disinfection (LAD)  Photodynamic antimicrobial chemotherapy  Photosensitizer (toluidine blue dye, methylene blue dye, etc) Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  The canal is then filled with a photosensitizer and then illuminated with a light source (laser, white light, red light, or a light-emitting diode). Dent Clin N Am 55 (2011) 461–480 Fig. FotoSan: comercially available LAD
    • Application of photosensitizer Light Activated Disinfection
    • 3. Electrochemically (ECA) activated water  produced with a new and unique anode–cathode system (Leonov 1997)  extremely biocompatibility Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  ECA produced much clearer dentinal walls compared to NaOCl (J.T Marais) 4. Oxidative potential water (OPW)  electrolyzed NaCl in a special machine called aquacida 5. Cetrexidine  0.2% CHX and 0.2% citrimide  better penetration of CHX into the dentinal tubules and better antimicrobial efficacy
    • 6. Carisolv  potential as on irrigant as it is antibacterial and has collagen dissolving potential (M.G Al Kilani and Dummer) 7. Ruddles solution Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  Radiopaque agent Hypaque + NaOCl + EDTA  used to detect the presence of lateral / accessory canals 8. Bioactive materials like bio(active) glass  Antimicrobial activity against a range of microbes J Endod 2004;30:220-4 9. Chitosan  naturally occurring polysaccharide chitosan at 0.2% concentration has been proposed by Silva et al as an efficient chelating agent without the negative effects of high concentration EDTA Int Endod J 2012  easily and locally available, cheap, biocompatible, bio degradable, has the property of bioadhesion and has antimicrobial activity
    • SEQUENCE OF IRRIGATION Oral Health, May 2005 VITAL TEETH urea peroxide (collagen anti-aggregation effect) sodium hypochlorite Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References ("elevator effect" ) NaOCl + K file activation EDTA ( removes the inorganic part & reduction of inflammatory reaction by CHX NaOCl inhibiting the affinity of macrophages to the vaso-active peptides of the pulpal tissue) + + CAUTION: USE DISTILLED WATER IN BETWEEN EVERY IRRIGATING AGENTS
    • SEQUENCE OF IRRIGATION Oral Health, May 2005 NON VITAL TEETH NaOCl CHX PRESENCE OF RESORPTIONS VitalEDTA teeth + + NaOCl Citric acid + CHX CAUTION: USE DISTILLED WATER AS THE END IRRIGANT Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References
    • SEQUENCE OF IRRIGATION CONDITION IRRIGANTS Necrotic pulp NaOCI+CHX/H2O2 Vital pulp exposure NaOCl+H2O2 Calcified/sclerotic canal EDTA + NaOCl Infected canal-exudate present NaOCl + H2O2 Periapical abscess-to establish Hot water/saline......Later NaOCl drainage Open apex/apical perforation H2O2 + CHX Curved canals Glyoxide + NaOCl Canals left open for drainage H2O2 + NaOCl Retreatment cases CHX + NaOCl Final rinse-to remove the smear EDTA + NaOCl LAYER
    • CONCLUSION  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 Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References  The extra time 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.  For optimal irrigation, a combination of different irrigating solutions must be used.  Developing a rational irrigation sequence so that the chemicals are administered in a proper manner to release their full potential is imperative for successful endodontic treatment. Endodontic Topics 2012, 27, 74–102
    • Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References Endodontic Topics 2012, 27, 74–102
    • 1. Ingle’s Endodontics; 6 edition. Introduction 2. Cohen’s Pathways of pulp;Irrigationth 10 solutions Irrigation devices REFERENCES Challenges edition. Recent advances Irrigation sequence 3. Weine’s Endodontic Therapy; Conclusion References 6th edition. 4. Principles and Practice of Endodontics by Walton & Torabinajad; 3rd edition. 5. Grossman’s Endodontic Practice; 12th edition. 6. Textbook of Endodontics; Nisha Garg; 2nd edition. 7. Update on endodontic irrigating
    • REFERENCES Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References 8. Irrigation in Endodontics; Markus Haapasalo; Wei Qian; Dent Clin N Am 54 (2010) 291-irrigants; D Kandaswamy; 312. 9. Root canal N.Venkateshbabu; Journal of conservative dentistry; Oct-Dec 2010; volume 13; issue 4. 10. Eradication of endodontic infection by instrumentation and irrigation solutions; Markus Haapasalo, Unni Endal, Homan Zandi & Jeffrey M. Coil; Endodontic Topics 2005, 10, 77–102. 11. Root Canal Irrigants; Matthias Zehnder; JOE — Volume 32, Number 5, May 2006. 12. Sequence of Irrigation in Endodontics
    • REFERENCES Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References 13. Sodium hypochlorite in endodontics: an update review Zahed Mohammadi Yazd, Iran; International 14. Technologic Dental Advances Journal in Endodontics; (2008)58, 329-341. Rory E. Mortman; Dent Clin N Am 55 (2011) 461–480. 15. Review of Contemporary Irrigant Agitation Techniques and Devices Li-sha Gu, Jong Ryul Kim, Junqi Ling,Kyung Kyu Choi,David H. Pashley, and Franklin R. Tay ; JOE — Volume 35, Number 6, June 2009. 16. Passive ultrasonic irrigation of the root canal: review of the literature; L. W. M. van
    • REFERENCES Introduction Irrigation solutions Irrigation devices Challenges Recent advances Irrigation sequence Conclusion References 17. Complications during root canal Irrigation; Michael Hu¨ Lsmann, Tina Ro¨ Dig & Sabine Nordmeyer; Endodontic Topics 2009, 16, 27–63. 18. Advances in root canal disinfection; Baiju Gopalan Nair, K Amarendhar Reddy, Naga Lakshmi Reddy, Upendranath Reddy; JPBMS, Vol.05, Issue 05. 19. Comparison of apical extrusion of NaOCl using the EndoVac or Needle Irrigation of Root canals. Mitchell, Yang, Baumgartner; JOE-Vol 33, 2007.