Irrigation

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Introduction to Endodontics
Forth Year

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Irrigation

  1. 1. IRRIGANTS AND INTRACORONAL MEDICAMENTS
  2. 2. Primary therapy goals of ELIMINATE INFECTION endodontic PREVENT REINFECTION  CLEANING  OBTURATION  SHAPING  CORONAL RESTORATION
  3. 3. CLEANING AND SHAPING CHEMO MECHANICAL PREPARATION CHEMICAL  IRRIGANTS  INTRACANAL MEDICAMENTS MECHANICAL  INSTRUMENTS
  4. 4. Objectives  Removal of organic debris  Elimination of bacteria
  5. 5. IRRIGANTS Properties of an ideal irriganting solution 1.Organic tissue solvent 2.Inorganic tissue solvent 3.Antimicrobial action 4.Non – toxic 5.Low surface tension 6.Lubricant
  6. 6.  Should be non irritating to periapical tissue  Should be an effective germicide and fungicide  Should be stable in solution  Should have prolonged antimicrobial effect  Should be active in presences of blood, serum proteins derivatives of Tissue.
  7. 7.  Should have low surface tension  Should not interfere with repair of periapical tissues  Should not stain tooth structure .  Should not induce a cell mediated immune response
  8. 8.  Irrigation solutions  Lubricants  Decalcifying / chelating agents
  9. 9. SODIUM HYPOCHLORITE [ NaOCl ] Commonly used household bleach [ Clorox ] Most common and popular irrigant in endodontics Advantages:  Mechanical flushing of debris from the canal  Tissue dissolving capacity → Vital + Non vital [necrotic]  Antimicrobial action  Lubrication  Inexpensive  Easily available
  10. 10. Cl NaOCl TISSUE PROTEOLYTIC AGENT PROTEINS AMINO ACIDS
  11. 11.  Recommended concentration 0.2% → 5.25%  Commonly used 2.5% - less toxic and retains the tissue dissolving capacity and antimicrobial property.  Decrease in concentration ↔ increase in volume  Effectiveness can be improved by heating the solution  NaOCl can act only when in contact with tissues hence shaping with instruments is necessary
  12. 12. Sodium hypochlorite accident Extrusion of the irrigant beyond the apical foramen causes extensive tissue damage. Preventive measures:  The needle of the irrigating syringe should be placed loosely within the canal  The irrigant should not be pushed with force.  The needle should not be introduced to the apex  Side vented irrigating needle is used.  The needle is agitated or moved up and down loosely to agitate the liquid
  13. 13. NaOCl beyond root apex causes • Pain • Hematoma • Swelling • Hemorrhage • Inflammation of gingival tissue
  14. 14. Limitations  Toxic  Not active against E. faecalis  Ineffective at low concentrations.  Not substantive  Corrodes   Unpleasant odor. Ineffective in smear layer removal.
  15. 15. CHLORHEXIDINE  It is a Bisguanide  It has a broad spectrum of anti microbial action  Effective on a wide range of bacterial strains E. faecalis  Less toxicity  NaOCl + CHX → increased effectiveness
  16. 16. Anti microbial action : Adsorption to the surface of bacteria [due to cationic-anionic electrostatic attraction] Increase the membrane permeablility Results in micro leakage of intracellular components leading to cell death CHX
  17. 17. SUBSTANTIVITY: The chlorhexidine molecule gets attached to the dentin of the root canal and release chlorhexidine slowly as the concentration of environment D e n t i n CHX decreases in the surrounding
  18. 18.  Normally used in concentrations between 0.12 and 2.0%  Extremely low level of tissue toxicity  Allergic reaction to CHX are rare
  19. 19. Disadvantages:  Lack of tissue dissolving capacity  Inability to remove the smear layer
  20. 20. SODIUM HYPOCHLORITE +CHLORHEXIDINE It is seen that when a combination 2.5% NaOCl & 0.2 % CHX is used in root canal could gain 1) an additive antimicrobial action 2) a tissue dissolving property that is better than that obtained with use of CHX alone 3) a solution less toxic then NaOCl
  21. 21. OTHER IRRIGATING SOLUTIONS HYDROGEN PER OXIDE [ H2O2 ] It is an oxidizing agent . It is almost used in conjunction with NaOCl It acts by two mechanisms 1. The reaction with NaOCl produces effervescence which mechanically pushes the debris out of the canal 2. The nascent oxygen released acts as a powerful antimicrobial agent especially for the anaerobic organisms
  22. 22. Advantages:  It produces less damage to the periapical tissues  It is a good anti anaerobic agent  The nascent oxygen produced tends to penetrate deeper into the tubules. Hence very effective on bacteria residing deeper in the dentinal tubules.  When used along with CHX, hydrogen peroxide dislodges the smear layer allowing the CHX to be more effective  A side effect which is beneficial is that it causes bleaching
  23. 23. Other agents: • SAVLON : Combination of 0.3% cetrimide and 0.03% CHx • OXIDATIVE POTENTIAL WATER • SALVIZOL : root canal chelating irrigant • BDA (bis-dequalinium acetate): recommended as an excellent substitute for sodium hypochlorite in those patients who are allergic to the latter. • ELECTRO CHEMICALLY ACTIVATED WATER
  24. 24. PRO RINSE MONOJECT
  25. 25. Ultrasonics [passive ultrasonic irrigation]  Most of the dentine debris is inorganic matter that cannot be dissolved by NaOCl. Therefore, removal of dentine debris relies mostly on the flushing action of irrigant.  The ultrasound device allow the endodontic irrigant to pass along the ultrasonic files. The irrigant is activated by the ultrasonic energy imparted from the energized instruments producing acoustic streaming and cavitation
  26. 26. LUBRICANTS:  Facilitate the file movement during the cleaning and shaping  Help in the initial canal negotiation especially in narrow canals  They reduce the torsional force on the instruments – reduce the fracture potential
  27. 27. Commonly used lubricants;  Glycerin  Glycol + urea peroxide + EDTA  EDTA 19% + 10 % GEL] [ RC PREP] carbamide peroxide [DOLO ENDO
  28. 28. Disadvantages:  EDTA compounds may cause deactivation of NaOCl by reducing the available chlorine  Toxic by product
  29. 29. SMEAR LAYER: Cleaning and shaping → layer of organic pulpal material + inorganic dentin debris The layer may contain microorganisms The smear layer may be 1 to 5 μ Smear layer removal ?????????
  30. 30. Removal of the smear layer is the better option  Enhance the irrigants to penetrate the dentinal tubules  Enhance the penetration and adhesion of sealers
  31. 31. DECALCIFYING / CHELATING AGENTS Agents that dissolve or dissolute the inorganic portions of the root dentine [ calcified portions] Ethylene di-amine tetra acetic acid [ EDTA] Helps in the removal of the smear layer Irrigation with 17% EDTA followed by the final rinse with NaOCl is recommended
  32. 32. Chelators remove the inorganic portion of the debris leaving behind the organic portions which can be dissolved or removed with NaOCl  Effect of EDTA is dependant on the time of contact with the debris and the concentration  Recommended time for the removal of the smear layer is 1 min  EDTA supplied as a • liquid • paste
  33. 33. MTAD [ BIOPURE MTAD] MTAD was developed by Mohmand Torabinajed et al MTAD contains mixture of : • tetracycline isomer doxy cycline • acid- citric acid • a detergent - Tween 80 Antimicrobial activity of MTAD MTAD has superior antimicrobial activity than 5.25% sodium hypochlorite. The efficiency of MTAD in disinfecting surface of the roots is a result of the presence of doxycycline.
  34. 34.  Generally used as a final rinse to remove the smear layer  Effectiveness is enhanced when the canal is irrigated with low concentration of NaOCl before the use of MTAD.  1.3% recommended concentration  Superior than NaOCl in antimicrobial action  Doxycycline has the ability to bind the tubules and gradually released over time  Effective in killing E.faecalis  Biocompatible  Does not alter the properties of dentin  Enhances the bond strength
  35. 35. INTRA CANAL MEDICAMENTS
  36. 36. PHENOLICS ALDEHYDES  Eugenol  Formocresol  Camphorated monoparachloro phenol  Glutaraldehyde [CMCP]  Parachlorophenol [PCP] HALIDES  Camphorated parachloro phenol [CPC]  Sodium hypochlorite  Metacresylacetate  Iodine – potassium iodide  Cresol  Creosote [ beechwood]  Thymol STERIODS CALCIUM HYDROXIDE ANTIBIOTICS COMBINATION
  37. 37. MAIN PURPOSE FOR INTRACANAL MEDICAMENT  To reduce interappointment pain  To decrease the bacterial count and regrowth  To render the canal contents inert
  38. 38. Physico-chemical properties  pH  Viscosity [Viscosity changes over time ]  Adhesion  Solubility  Radio-opacity  Working time  Sealing ability
  39. 39. Phenols and Aldehydes :  Non specific in action Destroy both HOST TISSUES + MICRO-ORGANISMS  Toxic  Aldehydes fix the tissues  May reach the periapical tissues → systemic circulation EUGENOL:  Part of root canal sealers, temporary filling  Antiseptic & anodyne effect  Effect is dose related • Low dose (anti-inflammatory activity): inhibits-Pg synthesis, nerve activity,WBC chemotaxis • High dose (cytotoxic effect)- induces cell death, inhibits cell respiration
  40. 40. Calcium hydroxide  Ca(OH)2 widely used as an IM  pH 12 to 13  Antimicrobial activity is due to the high alkalinity  May aid in dissolving the tissue remnants, bacteria and their by-products.  Recommended as an IM in root canals with necrotic tissue and infected tissue  Little benefit with vital pulp
  41. 41. Can be placed in the canals as  Dry powder  Paste : calcium hydroxide mixed with → water → local anesthetic solution → glycerin → chlorhexidine  Proprietary paste supplied in syringes
  42. 42. The material is carried into the canal with the help of  lentulo spiral  using a file  injecting
  43. 43. Corticosteroids  Anti-inflammatory agents  Proposed to decrease Post operative pain and suppress inflammation  Can be used in patients with acute apical periodontitis  Hydrocortisone + antibiotics Chlorhexidine  2% chlorhexidine gel  When mixed with calcium hydroxide the antimicrobial effect is greater  Disadvantage : does not remove the smear layer
  44. 44. COMBINATION Corticosteroid + antibiotic  Use of corticosteroid: reduces pain in inflamed tissue and gives instant relief  Use of antibiotic: prevents overgrowth of bacteria when the inflammation subsides Eg. Corti-sporin,Tetra-Cortil
  45. 45. Ledermix paste :  Combination of a corticosteroid and antibiotic  Corticosteroid → Triamcinolone acetonide  Antibiotic → Demeclocycline calcium
  46. 46.  Frequency of placement:  Disinfectant dressing should be preferably renewed in a week and not longer than 2 weeks  Medicaments used for apexification are used for 3-6 months

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