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  • 1. IRRIGATING SOLUTIONS INTRODUCTION An important objective of endodontic therapy is the removal of necrotic infected pulp and dentinal debris from the root canal system of infected or non-vital teeth. In order to accomplish this objective, it is essential to use an irrigating solution or a combination of irrigating solutions during BMP of the root canals. Failure to use an irrigating solution during BMP results in considerable amount of debris to be left behind in the root canal system ultimately leading to endodontic failure. Hence for obtaining an optimum level of disinfection of the root canal system chemicomechanical preparation is a must. 1
  • 2. HISTORY Prior to 1940’s Water was the most commonly used irrigant as it was: - Readily available. - Inexpensive. - Provided a lubricating effect during instrumentation. During 1940’s proteolytic enzymes like streptokinase, streptodomase, papain, enzymal etc. were being used as irrigating solutions because of their tissue dissolving property. In 1943, Grossman introduced the concept of using oxidizing agents as irrigants. In 1945, Daniel formulated an irrigating solution comprising of a aminoacridine. In 1970’s chelating agents were used increasingly because of their biologically acceptable properties. Goals of irrigation (Ingle): 1. Lavage of debris. 2. Tissue dissolution. 2
  • 3. 3. Antibacterial action. 4. Lubrication. Ideal requirements of irrigating solutions (DCNA): 1. Antimicrobial property. 2. Dissolve necrotic tissue debris. 3. Aid in debridement of the root canal system. 4. Non-toxic to the periapical tissues. Role of intracanal irrigants (Weine): Irrigants perform important physical and biologic function during endodontic therapy. 1. Loosens tissue debris – Dentinal shavings and microorganisms from the irregular radicular dentine walls. 2. Flushes – The above into the pulp chamber space where it is easily removed by aspiration or paper points. 3. Dissolves – Organic tissues that are entrapped in accessory or lateral canals and that is inaccessible to hand instruments. 4. Antibacterial action – Certain irrigants possess germicidal action, other reduce the number of microorganisms by 3
  • 4. eliminating the source or substrate for survival of these organisms. 5. Lubricating effect : Facilitates instrumentation of the canals. 6. Irrigants possess a bleaching action. CLASSIFICATION: I. ACIDS and CHELATING AGENTS ORGANIC EDTA Citric acid EDTAC Maleic acid RC-Prep Tannic acid Phosphoric acid Tublicid Lactic acid INORGANIC H2SO4 50% HCl 30% II. PROTEOLYTIC ENZYMES - Streptokinase. 4
  • 5. - Enzymol. - Streptodornase. - Purified trypsin. - Papain III. OXIDIZING AGENTS - 3% hydrogen peroxide. - Urea peroxide. - Glyoxide. IV. ALKALINE SOLUTIONS - Sodium dioxide. - Urea. - Sodium hydroxide. - Sodium hypochlorite 0.5%, 1%, 2.6%, 5.25%. - Potassium hydroxide. - Chloramine-T. V. OTHERS - Chlorhexidine gluconate 0.2% - Glutaraldehyde. - Oxidative potential water. - 2% potentiated acid. 5
  • 6. - 1% pentanedial. - Calcium hydroxide solution. - Bardac-22 INDIVIDUAL IRRIGANTS TAP WATER One of the early irrigating solutions used for flushing of the root canals showed good clinical success. Studies performed in 1955 by Lorixzy et al showed periapical bone regeneration of after mechanical instrumentation using tap water as an irrigating solution. HOT WATER A stream of hot water, 140-178°F discharged from an insulated syringe was the first irrigant used. Physiologic Saline: From a biological stand point, sterile normal saline is the best irrigant to use because it causes. • Least apical tissue irritation or damage. • Biocompatible. • Least amount of cell lysis. 6
  • 7. Disadvantages: 1. However saline solution does not remove the smear layer but merely flushes out some of the superficial debri from the root canal system. 2. Has poor antibacterial properties, however irrigation followed by ultrasonic and sonic instrumentation have been reported to be almost as effective as 0.5 to 2.5% NaOCl irrigation in reducing the number of bacteria in infected root canals. SODIUM HYPOCHLORITE Is one of the most popular irrigating solutions. It has been used as an irrigant for well over 4 decades. - It was first recommended as an antiseptic solution by HENRY DAKIN in 1915 and was called as DAKIN’s SOLUTION during the time of World War-I (NaOCl buffered with sodium bicarbonate). - 0.5% NaOCl solution was then used as a treatment for infected wounds. 7
  • 8. Manufactured: It is made by bubbling chlorine gas through NaOH to form equal amounts of sodium hypochlorite and sodium chloride (NaOH  gas NaOCl + NaCl2) Properties of NaOCl: 1. Antibacterial action 2. Strong dissolution property: Fresh tissue Necrotic tissue Fixed tissue 3. Lubricant – for effective instrumentation. 4. Bleaching action on discolored teeth. 5. Increased permeability of dentinal tubules for easier penetration of an intra-canal medicaments. NaOCl has been used in various concentrations ranging from 0.5-5.25%. Most commonly used concentration – 2.5% 8
  • 9. ACTIONS: Antibacterial: NaOCl exerts its antibacterial action either by: - Direct contact with microorganisms. - Vapour action. Destruction of the bacteria takes place in two phases: 1. Penetration into the bacterial cell. 2. Chemical combination with the protoplasm of the bacterial cell that destroys it. - Sodium hypochlorite at 5.25% is an extremely effective antimicrobial agent. - Studies have shown that this solution will destroy most of the microorganisms found in the root-canal system after exposure of 1 minute or less. 9
  • 10. FACTORS AFFECTING THE ANTIMICROBIAL PROPERTIES OF NaOCl: 1. Diluting 5.25% NaOCl inhibits its antimicrobial property significantly. 2. Bactericidal effectiveness of 5.25% NaOCl decreases over time. Martin suggested a storage shelf-life of 3 months for undiluted preparations. 3. The antimicrobial property may be achieved in a significantly lesser time by prewarming the solution (room temperature 22°C-body temperature 37°C). 4. It maintains a remarkable degree of antimicrobial activity in the presence of organic matter such as blood and serum albumin. ** Briseno (1992) and coworkers demonstrated that the irrigation of the root canal with 1% NaOCl (manual) was more effective against the test organisms (E-edi + S.mutans) than irrigation of the root canal with 2% NaOCl + ultrasound. 10
  • 11. TISSUE SOLVENT PROPERTY NaOCl possesses strong tissue dissolution property for fresh vital tissue, necrotic tissue and fixed tissues. This tissue dissolving capacity equals to that shown by H2SO4 and HCl. The solvent action of NaOCl has been attributed to its high alkalinity. The removal of organic tissue by NaOCl is by the release of hypochlorous acid which reacts with insoluble proteins to form soluble polypeptides, aminoacids and other by products. NaOCl – hypochlorus acid + insoluble proteins – soluble polypeptides, aminoacids and byproducts. Grossman has shown that it can dissolve an entire pulp in 20 minutes to 2 hours. 5.25% of NaOCl is capable of penetrating into the dentinal tubules and dissolving the contents of the tubules adjacent to the main canal. 11
  • 12. This is an extremely important property for an endodontic irrigant because of the irregularities in the surface of the canal walls which prevents contact by instruments regardless of the BMP techniques utilized. NaOCl and Smear layers NaOCl alone is not very effective in removal of the smear layer, but when used in conjunction with other solutions or with ultrasonics it has shown to remove the smear layer effectively. Yamada and associates (1983) reported that a final flushing of 17% EDTA, followed by 10ml of 5.25% NaOCl, was more effective in removing both inorganic and organic debris. These authors concluded, that flushing with a chelating agent removed the final calcific sludge that remained on the canal walls. Flushing with 10ml NaOCl removed any remaining organic tissue, thus leaving patent dentinal tubules on the surface of the canal walls. 12
  • 13. A recent study (Lengiz in 97) showed that the use of 0.5% NaOCl in combination with Ca(OH)2 preparation and ultrasonics in the root canal can effectively remove the smear layer. Also this is considered to be more safer than the use of NaOCl solution is 5% concentration which is proved to be highly toxic. TOXICITY OF NaOCl TO PERIAPICAL TISSUE: NaOCl is an effective solvent of both necrotic and vital tissues, which makes it toxic to the surrounding tissues. There have been numerous reports of soft tissue complications as a result of its inadvertent infection beyond the root canal system. - Severe pain. - Edema. - Profuse haemorrhage both interstitially and through the tooth. This may be followed by (for several days) - Increasing edema. - Ecchymosis. - Tissue necrosis. 13
  • 14. - Parasthesia. - Secondary infection (rarely). Majority of cases, have shown complete resolution within a couple of weeks. In some cases they may be long-term parasthesia or scarring. Treatment for this type of emergency: 1. Remain calm and assist the patient in remaining calm. 2. Evaluate the reclined dental chair to decrease pressure from the head. a. For immediate relief of pain – nerve block and L.A. b. Wet, cold, compress – continually applied to the face – for relief of pain and burning sensation and minimize swelling (for upto 6 hours). c. Analgesics – after emergency treatment. d. To control inflammation – corticosteroids immediately i.v. for 3 days. e. To prevent infection – antibiotics (1wk). 14
  • 15. f. Heat packs and warm mouth rinse (after initial treatment). To improve circulation to the area. 3. Advise the patient concerning the anticipated swelling and ecchymosis. 4. Give the patient both verbal and written instructions. 5. Reassure the patient that he will regain his normal appearance within a short period. HYDROGEN PEROXIDE For years 3% H2O2 was recommended as a canal irrigant because of: • Its effervescent action. • Disinfecting properties. 15
  • 16. Actions: 1) Effervesent action: This action was specially indicated in mandibular teeth where the bubbling of the peroxide was thought to lift debris from the canal system almost defying gravity. However, H2O2 does not possess tissue dissolution properties and is not effective as a lubricant. Hence, alternate use of H2O2 + NaOCl irrigating solutions was recommended by Grossman. This alternate irrigation regimen during chemicomechanical preparation produces. 1. Transient but energetic effervescence that mechanically forces out debris and microorganisms out of the canal. 2. At the same time the O2 that is liberated in an active state assists in destroying the anaerobic microorganisms. 3. NaOCl effectively removes the soft tissue debris. 16
  • 17. 4. The permeability of dentinal tubules is increased allowing deeper penetration of intracanal medicament. 5. Increases the bleaching action on discolored teeth. Toxicity. CHELATING AGENTS Chelating agents have come to be used in endodontic repeatedly to aid in the mechanical enlargement of difficult root canals by softening the root canal dentin walls. EDTA – The most common chelating solutions used in endodontics are based on ethylene diamine tetra-acetic acid composed by Disodium salt of EDTA distilled water 100ml, 5N NaOH 4.25ml. This was 1st described for use in endodontics by Ostby. He found the following with EDTA. Functions: - It has certain dentin dissolving effects desirable in all kinds of root canal therapy – ease in instrumentation. 17
  • 18. - It reduced the time necessary for debridement and disinfection. - It aided in enlarging narrow / obstructed canals. - It helped make possible the bypassing of broken instruments in the canals. - Removed the inorganic component of smear layer. - Had no corrosive effects on the instruments. Action: The sodium salts of EDTA are capable of forming soluble non- ionic chelates with large number of metallic ions viz. calcium ions. Because EDTA would seek the calcium metal ion in the hydroxyapatite crystals of dentin in a chelate and thereby act to demineralize dentin and enamel. Ostby and associates found that EDTA decalcified dentin to a depth of 20-30µm in 5 minutes. Precautions to be taken with EDTA. 18
  • 19. Researchers have reported that it is possible to overchelate a canal which can lead to perforation. EDTA is known to remain active within the canal for 5 days. - If not inactivated the solution may seep into the periapical tissues and damage the bone. - Therefore at the completion of appt, the canal must be irrigated with NaOCl. RC Preparation: It’s a combination of 17% EDTA + ureperoxide 10%, developed by Stewart and colleagues. Effective lubricating and cleaning agent. - It allows deeper penetration of the medicament into the dentin. - It is not water-soluble. - It is popularly used in combination with NaOCl. 19
  • 20. - Because it is thought to produce a bubbling action helps loosen and float out dentinal debris. Studies have shown RC preparation might affect the apical seal. - Cook and associates reported twice as much leakage in canals obturated with GP or silver cones following cleaning and shaping with RC preparation NaOCl than with NaOCl alone. EDTAC (commercial name) There is addition of quaternary ammonium compound to EDTA – Cetavlon which has lead to a solution called EDTA-C, has greater germicidal acitivity and disinfecting properties. REDTA – A quaternary ammonium bromide has been added to EDTA solution to reduce the surface tension + increase the permeability of the solution. This combination has been shown to remove the smear layer in the RC during instrumentation. 20
  • 21. SALVIZOL Another chelating agent is salvizol based on aminoquinaldinum diacetate. Properties: 1. It has surface acting property similar to quaternary ammonium groups. 2. Chelating action. 3. Organic debridement. 4. Bactericidal activity. ORGANIC ACIDS The use of organic acid irrigants to irrigate and debride root canals is as old as root canal therapy itself. CITRIC ACID: Has been recommended as a canal irrigant because of its ability to demineralize and remove the smear layer effectively. 21
  • 22. 2 observations were made: 1. It acts as a chelating agent on dentine. 2. Therefore, it occurs naturally in the body, it is more acceptable biologically than other acids ((Jenkin and Dawer 1963). The chelating action of citric acid softens the dentin and facilitates easy removal of the smear layer. CA has been used effectively in concentration of 10, 25 and 50% as RC irrigant. Disadvantages: C.A. may leave precipitated crystals (calcium and phosphate containing crystals) in the canal wall. Which may be a disadvantage. - Citric acid has been used in combination with NaOCl to effectively clean the R.C. - C.A. removes smear layer better than many acids like poly acrylic acid, lactic acid and phosphoric acid. 22
  • 23. TANNIC ACID Tannic acid is another cleansing agent for root canal preparation was suggested by Graham Mount. It has been extensively used in the treatment of burns (more than 100 years old). Action: It acts as a surface coagulant by precipitating proteins. *Studies have shown that the use of tannic acid in the root canal as an irrigant cleansed the canal more effectively than the conventional combination of NaOCl + H2O2. CHLORHEXIDINE GLUCONATE Chlorhexidine has become recognized as an effective antimicrobial agent and its use as a potential endodontic irrigant has been demonstrated in the last decade. Recently, it has been accepted as a root canal irrigant in endodontics. 23
  • 24. Advantages: 1. Has a broad spectrum antimicrobial action. 2. Relative absence of toxicity. Disadvantage – it is not known to possess a tissue dissolving property. Structure is a symmetrical cationic molecule consisting of: 4-chlorophenyl rings and 2 biguanide groups Connected by a central hexamethylene chain Specturm of activity Chlorhexidine is bactericidal and effective against gram +ve, gram-ve, yeast, Candida albicans. Action: C.G. acts by adsorbing into the cell wall of the microorganisms and causing leakage of the intracellular components. At low concentration of chlorhexidine, small molecule wt substances will leach out, resulting in bacteriostatic effect. 24
  • 25. At higher concentration, chlorhexidine is bactericidal because of precipitation or coagulation of the cytoplasm caused by protein cross linking. The bacteriostatic effect of chlorhexidine is considered to be more effective. The bound chlorhexidine molecule is slowly released for upto 24 hours, as the concentration decrease. According to Klimn et al When used as an intra canal irrigant in the endodontic treatment for periapical lesions C.G. showed: 1. Clinical relief of symptoms. 2. Sterility. 3. Reduction in the size of periapical lesions. All at a mean follow up of 24 months. In another study (O hara et al) showed that CG was the most efficient antibacterial agent when compared to 3% H2O2, 5.25% NaOCl, saline REDTA 17%. 25
  • 26. GLUTARALDEHYDE Lately glutaraldehyde has been suggested as an endodontic irrigant. Weine suggested that the use of 2% aqueous solution of glutaraldehyde as a canal irrigant. Glutaraldehyde is known to cause irreversible fixation without any adverse tissue reactions. Weine observed that apart from the normal mechanical and chemical techniques for preparing and disinfecting root canals, a different concept is that: detoxification can be obtained by using fixatives. These are able to block off certain end groups in the aminoacids of the organic component of debris formed during instrumentation. This renders them metabolically inert (remaining organic debris). 26
  • 27. Since it is impossible to remove all the organic material from the lateral canals, ramifications and dentinal tubules, complete fixation of the root canal contents remaining after mechanical cleansing might therefore be considered to be the ideal treatment. 5 year clinical results of root canal treatment with 2% glutaraldehyde showed a success rate of 96% for chronic and 89% for acute periapical conditions. Glutaraldehyde was preferred to formaldehyde. Therefore it has 4 additional properties: 1. Irreversible bonding with proteins. 2. Limited diffusion into tooth structure. 3. No periapical irritation. 4. Appears to cause a softening of dentin for limited duration, facilitating the mechanical preparation of the root canal. Thus the greater reduction in microorganisms with glutaraldehyde 2% can be attributed to the fixative property rendering the microorganisms inert and non-toxic. 27
  • 28. 9-AMINOACRIDINE The efficacy of 9-aminoacridine has been reviewed by Schmitz. Properties: - Antibacterial action. - Low toxicity. - Osteogenic potential. Disadvantage: 1. Not a chelator. 2. Not a tissue solvent. It use is not widespread. Mechanism of action: Disruption of cellular metabolic pathways of microorganisms: i. Inhibition of cells, protein synthesis. ii. Inhibition of DNA synthesis. 28
  • 29. Use: 1. The most promising use of 9-aminoacridine appears to be in the management of endodontically involved teeth with large periapical absecesses. It is one of the few endodontic medicaments recommended for pressure irrigation of the periapical tissues via the canals. 2. Since it possesses a low inflammatory potential consistent with its ability to maintain asepsis the drug may be sealed in the canal as an interim medication. Glyoxide: Glyoxide is an irrigation solution i.e. comprised of 10% urea peroxide (Carbamide peroxide) in a vehicle of anhydrous glycerol in 1961 Stewart proposed glyoxide to be an effective adjunct to instrumentation for cleaning of the root canal. Action: 1. Antibacterial activity that is more potent than 3% H2O2. 29
  • 30. 2. Enhances root canal lubrication without softening the dentin. Hence, unlike other chelating agents that react with dentine (and may cause root perforation or ledging in softened walls). With glyoxide this does not occur, here only lubrication is enhanced. 3. It is less toxic to periapical tissues than NaOCl. 4. It also has greater solvent action than 3% H2O2. Use: 1. the best use of glyoxide is in narrow and curved canals where slippery effect of glycerol is maximized for instrumentation. OXIDATIVE POTENTIAL WATER This was developed in Japan and is an electrolytically obtained highly acidic water that has an outstanding antimicrobial activity killing bacteria and viruses. BARDAC-22 (0.5%). New quaternary ammonium compound. 30
  • 31. IMPORTANT FACTORS ASSOCIATED WITH IRRIGATION 1. The most important factor in irrigation is the delivery system and not the irrigating solution per se. 2. Volume of the irrigation used is more important than the concentration or the type of the irrigant. 3. Depth of irrigating device within the canal. 4. Irrigant penetration is influenced by factors like: - Canal. - Type and size of the irrigant needle. - Canal size and shape. Technique of Endodontic Irrigation: 1. After rubber dam elevation, access is gained to the root canal system. The pulp chamber is thoroughly debrided and flushed with the irrigating solution. 2. The orifice of the canal especially of posterior teeth is very narrow hence care must be exercised to properly enlarge the orifice and to flare the canals so that the needle of the 31
  • 32. irrigating syringe passes easily into the canal. The needle is best at an angle so as to allow easy access into the root canals. 3. The needle is inserted into the canal and slowly advanced apically without bendens with the canal walls and when resistance is felt the needle should be withdrawn by few months. 4. The irrigating solution is deposited slowly without any pressure. If the needle is forced apical until it binds against the canal walls injection of any solution even water will cause discomfort to the patient. A perforated irrigating needle (Goldstein) has been developed to deliver irrigant at 360° to the root canal. The disadvantage with this needle is that it is delicate and bends out of shape easily. Ultrasonic hand pieces may be used for irrigate. They pass sound waves to the endodontic file and cause it to librate at 25,000 vibrations. 32
  • 33. They cut dentin and result in acoustic streaming of the irrigant. Martin and Cunningham stated that cavitation occurs within the irrigating solution and this leads to increased debris dislodgment from the canal walls. A sonic handpiece may also be used to irrigate canals. This handpiece has endodontic files with sound waves causing the file to liberate at 8,000 vibration and dislodge the debris within the canals. DOXYCYCLINE HYDROCHLORIDE More recently DH, a hydroxy derivative of tetracycline is under study as an irrigant. It is the most potent anticollagenase antibiotic among commercially available tetracyclines. The tetracyclines are broad spectrum antibiotics demonstrated to be effective in control of periodontal pathogens. Advantages: 1. The dentin surface is capable of acting as a reservoir by adsorbing and slowly releasing antibacterial levels of doxycycline into the adjacent environment for several days following topical applications of this antibiotic solutions. 33
  • 34. 2. Inhibit extracellular collagenase activity and bone resorption. Metranidazole Antibiotic spectrum confined solely to obligate anaerobes. Active against bacteroides, porphyromonas fusibacterium, clostridium and peptococci and peptostreptococci. Comes as an injection: Metranidazole 500mg, NaCl2 0.8, Water. Barnett and Tronstad reported the successful use of metranidazole in controlling infections by bacterioides spp and pseudomonas spp colonized at root ends of endodontically treated teeth that had failed to heal and remained refractory to all other treatment. Adverse reactions include: - Nausea. - Headache. - Metallic taste. - Xerostomia. 34
  • 35. Conclusion: Debridement of the root canal systems is essential for a predictably successful endodontic treatment. The identification and elimination of bacteria, removed of other necrotic products from the canal with appropriate irrigating solutions with proper technique ensures definite fulfillment of one of the objectives of root canal therapy. 35