Materials for disinfecting the pulp space


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Materials for disinfecting the pulp space

  2. 2. Introduction <ul><li>The complexity of root canal morphology presents a challenging objective to the endodontic community. </li></ul><ul><li>These complexities hampers the ability to thoroughly achieve pulp cavity disinfection </li></ul><ul><li>The objective therefore is to remove all of the pulpal and dentinal debris from the root canal system. </li></ul>
  3. 3. <ul><li>Biomechanical preparation & chemical preparation are used concomitantly in order to debride the root canal system. </li></ul><ul><li>Biomechanical preparation attains free access to the apical foramen through the access opening and through the root canal system by mechanical means, which exposes, enlarges & shapes the root canal. </li></ul><ul><li>At the time of biomechanical preparation suitable irrigants are used which help in achieving debridement and disinfection of the root canal system </li></ul>
  4. 4. Functions of irrigation <ul><li>Antimicrobial activity </li></ul><ul><li>Flushing action - debridement of the canal system </li></ul><ul><li>Dissolution of necrotic and vital tissues </li></ul><ul><li>Lubrication </li></ul><ul><li>Removal of smear layer </li></ul><ul><li>Bleaching action </li></ul>
  5. 5. The Irrigants <ul><li>Physiologic saline </li></ul><ul><li>Sodium hypochlorite </li></ul><ul><li>Hydrogen peroxide </li></ul><ul><li>Chelating agents </li></ul><ul><li>The acids : tannic acids, citric acids & the others </li></ul><ul><li>Tetracyclines </li></ul><ul><li>Chlorhexidine </li></ul><ul><li>Calcium hydroxide </li></ul><ul><li>Iodine </li></ul><ul><li>Oxidised potential water </li></ul><ul><li>Ozonated water </li></ul><ul><li>Glutaraldehyde </li></ul><ul><li>MTAD </li></ul>
  6. 6. Physiologic saline <ul><li>0.9% w/v commonly used irrigant in endodontics </li></ul><ul><li>Primary flushing action </li></ul><ul><li>Very biofriendly </li></ul><ul><li>Disadvantages : </li></ul><ul><ul><li>Absent antimicrobial property </li></ul></ul><ul><ul><li>Incapable of removing smear layer </li></ul></ul><ul><ul><li>Incapable of dissolution of necrotic tissue. </li></ul></ul>
  7. 7. Sodium hypochlorite <ul><li>Strong oxidizing agent </li></ul><ul><li>Clear straw colored </li></ul><ul><li>5% of available chlorine (Grossman) </li></ul><ul><li>Commercially available chlorox pH 10.83 – 10.98 </li></ul>
  8. 8. <ul><li>STORAGE & HANDLING </li></ul><ul><ul><li>Store in light proof (opaque glass / polyethylene) </li></ul></ul><ul><ul><li>Stability of NaOCl is reduced by </li></ul></ul><ul><ul><ul><li>lower pH </li></ul></ul></ul><ul><ul><ul><li>Presence of metallic ions </li></ul></ul></ul><ul><ul><li>Exposure to light </li></ul></ul><ul><ul><ul><li>Open containers </li></ul></ul></ul><ul><ul><ul><li>High temperatures </li></ul></ul></ul>
  9. 9. <ul><ul><li>0.5% - 5.25% </li></ul></ul><ul><ul><li>Effectiveness of low concentrations of NaOCl can be improved by </li></ul></ul><ul><ul><ul><li>Larger volumes </li></ul></ul></ul><ul><ul><ul><li>Frequent change </li></ul></ul></ul><ul><ul><ul><li>Longer period of exposure </li></ul></ul></ul>EFFICACY OF SEVERAL CONCENTRATIONS
  10. 10. VOLUME OF IRRIGANTS <ul><ul><li>The general report for the volume of irrigants used per tooth amounts to 5ml. </li></ul></ul><ul><ul><li>It has been shown that usage of 3ml of NaOCl at 5.25% is sufficient to cause effective debridement with antimicrobial effect. </li></ul></ul>
  11. 11. ANTIMICROBIAL EFFICIENCY <ul><ul><li>1% NaOCl has found to kill both bacterial spores and HIV over a period of 30minutes. </li></ul></ul>
  12. 12. TIME REQUIRED FOR TISSUE CLEARANCE <ul><ul><li>At 15 & 30 Min Intervals NaOCl found to clear the coronal & middle third of the canal better than saline. However in apical 3mm no difference was seen. </li></ul></ul><ul><ul><li>NaOCl more effective in large diameter canals. </li></ul></ul><ul><ul><li>More effective in cleaning an isthmus. </li></ul></ul>
  13. 13. SODIUM HYPOCHLORITE:MECHANISM OF ACTION <ul><li>Germicidal activity of sodium hypochlorite is because of formation of Hypochlorus acid. </li></ul><ul><li>Permeates cell wall and combines with the protoplasm. </li></ul><ul><li>Dissolves necrotic tissue because of high alkalinity. </li></ul><ul><li>Biopolymers like proteins are hydrolyzed into amino acids. </li></ul><ul><li>NaOCl reacts rapidly with Glycine in a phosphate buffer (pH & 7.0) at 20 0 C </li></ul>
  14. 14. ADVERSE EFECTS OF SODIUM HYPOCHLORITE: <ul><li>1. SODIUM HYPOCHLORITE ACCIDENT: </li></ul><ul><li>The inadvertent injection of NaOCI into the soft tissues can elicit a violent and frightening response. </li></ul><ul><li>The cause of this emergency can be related to both the irrigant and the irrigant technique (Wedged needle with forceful irrigation). </li></ul><ul><li>Mechanism from injury is primary oxidation of proteins followed by inflammatory reaction from the body. </li></ul>
  15. 15. HYDROGEN PEROXIDE <ul><li>In 1943, Grossman introduced 3% Hydrogen peroxide as an Endodontic irrigant which was recommended to be used alternately with Sodium Hypochlorite. Disinfecting and bleaching effects of both solutions. </li></ul><ul><li>- Moderate to the anaerobic pathogens. </li></ul>
  16. 16. <ul><ul><li>Interaction of NAOCL and HYDROGEN PEROXIDE . In the canal produced a transient but energetic effervescence because of the production of nascent oxygen. </li></ul></ul><ul><ul><li>This was responsible for forcing debris and microorganism out of the canal. </li></ul></ul><ul><ul><li>Action to be especially useful in lifting debris from the canal system, almost defying gravity in mandibular teeth. </li></ul></ul>
  17. 17. <ul><ul><li>H2O2 does not posses tissue dissolving properties, nor is it a lubricant. Limited antimicrobial action only. </li></ul></ul><ul><ul><li>-This was the coupled with the solvent action of NaOCI on the organic debris. </li></ul></ul><ul><li>When irrigating with H 2 O 2 the last irrigant used should be NaOCI to prevent any nascent oxygen from being trapped in the canal. </li></ul>
  18. 18. CHELATING AGENTS <ul><li>Ethylene diamine tetracetic acid (disodium salt)-17.0gm </li></ul><ul><li>Distilled water- 100 cc </li></ul><ul><li>5/N NaOH- 9.25 cc </li></ul><ul><li>EDTA is an insoluble, odorless, crystalline while powder; it is relatively non toxic & only slightly </li></ul><ul><li>irritating in weak solutions. </li></ul><ul><li>Has a pH of 8.3 </li></ul>
  19. 19. <ul><li>Has dentin dissolving effects desirable in all kinds of Root Canal therapy. </li></ul><ul><li>2. Reduced the time necessary for debridement. </li></ul><ul><li>3. Aided in enlarging narrow/ obstructed canals. </li></ul><ul><li>4. Helped bypass fragmented instruments. </li></ul>
  20. 20. <ul><li>5. Not corrosive on instruments </li></ul><ul><li>6. Antimicrobial – neither bactericidal nor bacteriostatic </li></ul><ul><li>7. Self Limiting Action </li></ul><ul><ul><li>When all chelating ions have reacted, an equilibrium will be reached; then no further dissolution will takes place. </li></ul></ul>
  21. 21. DEMINERALIZING EFFICIENCY OF EDTA <ul><li>Ca 10 (PO 4 ) 6 (OH) 2 = 10Ca 2 + 6PO 4 3 - + 2(OH) </li></ul><ul><li>+ </li></ul><ul><li>EDTA </li></ul><ul><li>EDTA-Ca </li></ul>
  22. 22. METHODS & TECHNIQUES OF IRRIGATION <ul><li>The most common method of delivering irrigant into the canal is with the aid of a syringe to which is affixed a needle. </li></ul><ul><li>A 5ml syringe of the disposable Leur Lok twist mechanism is the preferred one. In this case the needle will not to be dislodged when the plunger of the syringe is displaced. </li></ul>
  23. 23. THE NEEDLE <ul><li>1. Gauge of the needle: </li></ul><ul><ul><li>Since irrigation of apical third requires the needle to be in it’s proximity for adequate effect, the canals contents should be flushed with a 27-30 gauge needle placed in apical third. </li></ul></ul>2. The needle should be bent to an obtuse angle to allow for easier access & entry to the orifice. This bend is to be placed closer to the hub of the syringe.
  24. 24. THE TECHNIQUES: <ul><li>1. Secure rubber dam isolation </li></ul><ul><li>2. Fill syringe via hub irrigant stored in a dappen dish by the chairside. </li></ul><ul><li>3. SOMMER’S TECHNIQUE </li></ul><ul><ul><li>Place a few drops of irrigant in the pulp chamber , then “Whirlpool” the solution into the canal with a small file. </li></ul></ul>
  26. 26. <ul><ul><li>Advocated flooding the pulp chamber with the irrigant once it was placed into the canal. This served as a reservoir of irrigant to replenish the one present in the root canal as it was being instrumented. </li></ul></ul><ul><ul><li>When the needle is introduced into the canal & meets resistance , it is withdrawn a few mms to prevent it from wedging & forcing the irrigant into periapical tissues. </li></ul></ul>
  27. 27. <ul><li>6. Once irrigant delivery starts, look for the backflow of the irrigant from the canal orifice. </li></ul><ul><li>7. The hand holding the irrigating syringe is always kept in motion when dispensing irrigant. </li></ul><ul><li>8. Files potentially carry irrigant progressively deeper into the canal by surface tension. </li></ul><ul><li>In small canals, the files displace the irrigant. When the instrument is withdrawn, the irrigant usually flows into the space the file occupied. </li></ul><ul><li>9. Clinicians should irrigate copiously, recapitulate & re-irrigate after each instrument size. </li></ul>
  28. 28. 10. Besides using an aspirator, Grossman suggested the use of a gauze sponge held against the tooth to absorb the backflow of the irrigant. 11. Once the shaping & cleaning is accomplished, the irrigant is aspirated from the canal with syringes & subsequently dried with paper points.