SlideShare a Scribd company logo
1 of 235
Download to read offline
In Endodontics
1
CONTENTS
2
introduction
history
ideal requirements
classification
chlorine releasing agents
oxidizing agents
chelating agents
organic acids
inorganic acids
other irrigating solutions
• chx
• mtad
• carisolv
• electrochemically activated water
• oxidative potential water
• ozone
• photodynamic therapy
• lasers
irrigating devices
conclusion
3
According to Webster’s dictionary
The term irrigation is defined as
- the therapeutic flushing of a body part with a stream of liquid
4
Why do we need irrigants???
 Goals of root canal therapy
 Eliminate infection
 Which is done through
 cleaning of organic remnants
 shaping to receive a three dimensional filling of the
entire root canal space
 Prevent re-infection
 Obturation
 Coronal restoration
5
The canal is
 Cleansed primarily by irrigation
 Shaped primarily by instrumentation
HENCE
CLEANING AND SHAPING
6
 Failure of root canal treatment is likely caused by the
inability to eliminate bacteria from the root canal
system.
 cleaning and shaping of the root canal system is able
to reduce the number of bacteria, however complete
disinfection of the canal is difficult
 because of internal complexity of the root canal
system.
7
 it has long been established that a root with “a
tapering canal and a single foremen” is the exception
rather than the rule.
 Investigators have shown
 multiple foramina,
 additional canals,
 fins, deltas, intercanal connections,
 ‘Cshaped’ canals and
 accessory canals
 which makes a root canal a far deviation from ‘a
tapared canal with a single foramen’
8
9
Isthmus connections
10
 Thus a root canal irrigant is needed to aid in the
disinfection of the canals completely.
 Studies have demonstrated that mechanical
instrumentation cannot sufficiently disinfect root
canals regardless of the instrumentation technique
or system used.
11
 Despite technological advances in the ability to shape root canals,
at least 35% of root canal surfaces still remain uninstrumented
 and Cleaning of the canal in terms of soft tissue removal and
elimination of bacteria Relies heavily on the adjunctive action of
chemically active irrigating solutions.
12
 The choice of an irrigating solution for use in infected root
canals requires previous knowledge of the microorganism
responsible for the infectious process
 as well as the properties of different irrigating solutions.
13
14
 Potassium hypochlorite was the first chemically produced
aqueous chlorine Solution, invented in France by Bertholiet (1748-
1822).
 First use of hypochlorite solutions was as bleaching agents.
 Subsequently, sodium hypochlorite was recommended by
Labarraque(1777-1850) to be used for infectious diseases.
 Based on the studies by Koch and Pasteur, hypochlorite then
gained wide acceptance as a disinfectant by the end of the 19th
century.
15
 In world war II(1915),the chemist Henry Dakin and the surgeon
Alexis Carrel extended the use of a buffered 0.5% sodium
hypochlorite solution to the irrigation of infected wounds
 It was observed that hypochlorite preparations are sporocidal,
virucidal , and show far greater tissue dissolving effects on
necrotic than on vital tissues
 These features prompted the use of aqueous sod hypochlorite in
endodontics as the main irrigant as early as 1920
16
 Prior to 1940’s Water(140-167 degree C) 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, papain, etc
were used and they had tissue dissolving property.
17
 Grossman and Meiman in 1941 introduced sodium
hypochlorite.
 He recommended that solution of 3% hydrogen peroxide be
alternated with a solution of 5 .25% sodium hypochlorite, so
that effervescence action results in removal in debris from the
canal system.
 In 1954, commercially available household bleach
(Chlorox,5.25% available chlorine) was first recommended by
Lewis.
18
 In 1957 Nygaard Ostby introduced chelating agents(EDTA) as an
aid for preparation of narrow and calcified root canals.
 Towards 1970's chelating agents were used increasingly because
of their biologically acceptable properties.
 ln 1978 quarternary ammonium solutions was introduced as
irrigants by Spangberg.
19
 ln 1979 Phosphoric acid, Citric acid and Lactic acid was used by
Wayman to remove smear layer from the root canals.
 In 1980, Electrochemically activated water was used by
Russians as root canals irrigants.
 In 1980 Martin and colleagues claimed that ultrasonics and
NaOCL act synergistically when used together for root canal
debridement.
20
 In 1982 chlorhexidine was introduced by Delany for its use as an
irrigant emphasizing on its antibacterial properties.
 Gly- oxide was used by Rome et al in 1985
 The last few decades has seen the introduction of Ozone
Photodynamic therapy, Lasers as efficient tools for
intra canal disinfection.
21
22
Role of intracanal irrigants ( Weine)
 loosens dentinal shavings and microorganisms from irregular
radicular dentine walls.
 flushes - the above into the pulp chamber space where it is easily
removed by aspiration or paper points.
 dissolves - Organic tissues that are entrapped in accessory or
lateral canals and that is inaccessible to hand instruments.
23
Role of intracanal irrigants ( Weine)
 antimicrobial action - Certain irrigants posses germicidal
action, others reduce the number of microorganisms by
eliminating the source or substrate for survival of these
organisms.
 lubricating effect-Facilitates instrumentation of the canals.
 Some of the irrigants also possess a bleaching action.
24
goals of irrigation( Ingle)
 Lavage of debris.
 Tissue dissolution.
 Antibacterial action.
 Lubrication
25
 Irrigants should possess low surface tension.
 Low surface tension promotes flow of fluid into in accessible area.
 high surface tension inhibit the spread of liquid over a surface to
limit its ability to penetrate a capillary tube.
26
 The efficiency of an irrigant could be improved by reducing its
surface tension, thereby increasing its wettability hence-
penetration into the dentinal tubules of the main and lateral
canals.
 Alcohol added to an irrigant decreases surface tension.
27
28
I. Chlorine releasing agents
potassium hypochlorite
sodium hypochlorite
sodium dichloro isocyarunate
chloramine –T
II. Oxidizing agents
Hydrogen peroxide
Urea peroxide
Glyoxide
III. CHELATING AGENTS
EDTA
EDTAC
RC-Prep
IV. ORGANIC ACIDS
Citric acid
Maleic acid
Tannic acid
lactic acid
V. Inorganic acids
H2SO4 50%
HCL 30%
NITRIC ACID
29
VI. Detergents
Zephiran chloride
Endoquil
VII. Others
Chlorhexidine
Glutaraldehyde
Bis- dequalinium acetate
Antibiotics
NISIN
MTAD
Carisolv
Electrochemically activated water
Oxidative potential water
Propolis
Ozone
Photodynamic therapy
Lasers
Electronic sterilization 30
31
sodium hypochlorite
1. manufacture
2. mechanism of action
3. various actions- antimicrobial
-tissue dissolving property
-action on smear layer
-other actions
4. various concentrations
5. toxicity and complications
32
SODIUM HYPOCHLORITE
 Most popular irrigating solution used as an irrigant for well over
many decades.
 It was first recommended by Henry Dakin in 1915 and was called
as DAKIN‘s solution during the time of World War-ll
 NaOCI 0.5% buffered with sodium biocarbonate was used for
treatment of infected wounds.
33
 Commercially available household bleach (Chlorox – 5.25%
available chlorine) was first recommended by Lewis (1954), and
has since gained wide acceptance.
 Other suggested brands include
 Hypo (5% available chlorine),
 Sainsbury’s household bleach (3% available chlorine)
34
35
ANTIMICROBIAL ACTION
 NaOCl is best known for its antibacterial activity.
 Studies have generally shown that NaOCl has a broad spectrum
antimicrobial activity -
It can rapidly kill vegetative bacteria, spore forming
bacteria, fungi, viruses, and bacterial spores.
 Some investigations show the ability of even 0.5% NaOCl to kill
bacteria to a greater extent than other irrigants .
36
Mechanism of 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
37
 In water NaOCl disassociates into-
Na + OCl ions
HOCl
 Between pH 4-7 chlorine exists predominantly as HCLO, whereas
above it as OCl
 It is the hpyochlorous acid that is resposible for bacteria
inactivation.
38
 The bactericidal ability of NaOCl results from the formation of
hypochlorous acid (HOCl), when in contact with organic debris.
 which exerts its germicidal effect by oxidative action on
sulphydryl (-SH) groups of bacterial enzymes.
 It disrupts oxidative phosphorylation and other membrane
associated activities as well as DNA synthesis.
 As essential enzymes are inhibited, important metabolic reactions
are disrupted, resulting in the death of the bacterial cells.
39
protiens
hydrolyzed by HOCl
Amino acids
Cl
Chloramines
Interfere with cell metabolism
causes cell death
40
 Gomes et al. (2001) gave almost similar results regarding the time
taken to kill cultures of this species- E. faecalis
They have shown that
 Percentages contact time
 5.25% o.5 min
 2.5 % 10 min
 1.0 % 20 min
 0.5% 30 min
41
Tissue solvent property
 NaOCL posses strong tissue dissolution property.
 The solvent action of NaOCI has been attributed to its high
alkalinity.
 Grossman and Meiman reported that 5% sodium hypochlorite
dissolves pulp tissue in 20 min to 2 h.
42
43
Extirpated pulp
Immediately after
Placement into
NaOCL
After 5 minutes
After 10 min
Various concentrations
 there has been much controversy over the appropriate
concentration of hypochlorite solutions to be used in
endodontics.
 As Dakin's original 0.5% sodium hypochlorite solution was
designed to treat open (burnt) wounds,
 it was surmised that in the confined area of a root canal system,
higher concentrations should be used , as they would be more
efficient than Dakin's solution .
44
Various concentrations
 NaOCL has been used in various concentrations ranging from 0.5-
5.25%.
 More recently upto 10% also.
 the ADA (American Dental Association) accepted concentration
for clinical use of NaOCl as an irrigant is 5.25% (Cunningham et al.
1980).
 Most commonly used concentration - 2.5%
 The antibacterial effectiveness and tissue dissolving capacity of
NaOCl is a function of its concentration but so is its toxicity
45
 The lower and higher concentrations are equally efficient in
reducing the number of bacteria in infected root canal
 But the tissue dissolving effect is directly related to the
concentration
46
 Baumgartner and Cuenin commented that-
The effectiveness of low concentrations of NaOCl may be improved
by using larger volumes of irrigant and replenishing fresh
solutions into the canal more frequently.
47
Effect of temperature
 On pulp dissolution capacity
 According to Waltimo, the capacity of a 1% NaOCl at 45°C to dissolve
human dental pulps was found to be equal to that of a 5-25% solution
at 20°C .
 While at 60°C 1% solution was significantly more effective.
48
Clinically warming
NaOCl in a water bath
at 60ºC
49
Effect of heating 0.5% NaOCl on pulp dissolution capacity
Effect of temperature
 On antimicrobial efficacy
 The effects of temperature on sodium hypo short term stability,
pulp dissolution capacity and antimicrobial efficacy.
 George Sirtes, Waltimo,Marc Schaetzle
 Journal of endodontics sept 2005
 A 100- fold increase in killing efficacy of E.feacalis was observed
between the corresponding NaOCl solutions at 20°C and 45°C in a
study conducted by George et al( 2005)
50
51
Effect of NaOCL on physical properties of dentin
 Grigoratos et al. 2001, Sim et al.
International Endodontic Journal 2001.
 A 2-h exposure of dentine to NaOCl solutions of more than 3%
significantly decreases the elastic modulus and flexural strength
of dentine compared to physiological saline
52
Corrosion of instruments
Corrosion adversely affects the metallic surfaces by causing pitting and porosity,
It is supposed that these microstructural defects can lead to areas of stress collection and crack
formation, weakening the structure of the instrument (Oshida et al. 1992).
and decreases the cutting effieciency of endodontic files (Stokes et al. 1999)
53
54
in17% EDTA
solution,
demonstrating
locally
corroded area
5.25% NaOCl
solution, showing severe corrosion
0.2%
chlorhexidine gluconate solution,
showing pitting with the corrosion
SEMof stainless-steel control
file revealed no evidence of corrosion
Corrosion of instruments
The corrosion rates of stainless-steel files in the tested solutions from
the highest to the lowest were:
0.2% chlorhexidine gluconate
> 5.25% NaOCl
>17% EDTA
55
56
 A 1% concentration of NaOCl provides sufficient tissue
dissolution and antimicrobial effect,
 but the concentration used has been as high as 5.25%
because of enhanced anti-microbial activity (Yesilsoy et
al. 1995).
 As the concentration used rises so does its toxicity.
 numerous reports have described clinical complications
because of the improper use of NaOCl
57
NaOCL toxicity
 Sodium hypochlorite is a cytotoxic agent (Gatot et al. 1991,
Gernhardt et al. 2004).
 When it comes into contact with vital tissue, it causes
 haemolysis,
 ulceration,
 inhibits neutrophil migration
 and damages endothelial and fibroblast cells (Gatot et
al.1991).
 It has a pH of approximately 11–12 and causes injury primarily by
oxidation of proteins. (Kaufman & Keila 1989, Gatot et al. 1991,
Serper et al. 2004).
58
Damage to clothing
 Probably the most common incidents during root canal
irrigation concern damage of the patients’ clothing.
 Prevention
 by proper protection of the patients’ clothing.
 When using hand irrigation, one should assure that the
irrigation needle and syringe are securely attached.
59
Damage to the eye
 Irrigant in contact with the patient’s or operator’s eyes
results in immediate pain, profuse watering, intense
burning, and erythema.
 Management
 Immediate ocular irrigation with large amounts of tap
water or sterile saline should be performed by the dentist
 the patient should be referred to an ophthalmologist for
further examination and treatment (Ingram 1990).
60
Injection of sodium hypochlorite beyond the apical
foramen- NaOCL Accidents
 when the apical constriction has been destroyed during
root canal preparation or by resorption.
 may occur in teeth with wide apical foramina
 Additionally,
 extreme pressure during irrigation
 or binding of the irrigation needle tip in the root canal
which results in contact of large volumes of the irrigant to
the apical tissues.
 If this occurs, the excellent tissue-dissolving capability of
sodium hypochlorite will lead to tissue necrosis.
61
Symptomatology
 Pain-
 Immediate severe pain ( 2-6 minutes)
 Oedema
 Immediate oedema of neighbouring soft tissues
 Possible extension of oedema over the injured half
side of the face, upper lip, infraorbital region
 Bleeding
 Profuse bleeding from the root canal
 Profuse interstitial bleeding with haemorrhage of
the skin and mucosa (ecchymosis)
62
Symptomatology
 Chlorine taste and irritation of the throat after
injection into the maxillary sinus may be experienced
by patient.
 Secondary infection possible
 Reversible anaesthesia or paraesthesia possible
63
64
65
66
Swelling and extraoral ecchymosis
following inadvertent extrusion of
sodium hypochlorite (3%) through
the apical foramen of a maxillary
left cuspid.
Management
 For the dentist-
 remain calm
 to inform patient on cause and severity of complication
 Immediate irrigation with normal saline to dilute the NaOCl
inorder to reduce the soft tissue irritation.
 Pain control
 Immediate relief of acute pain- local anaesthesia nerve
block
 analgesics- acetominophen.
 In severe cases:
 referral to a hospital
67
 Antibiotics:
 not obligatory. Only in cases of high risk or evidence of
secondary infection – amoxicillin 500mg
 Antihistamine:
 not obligatory
 Corticosteroids:
 Controversial- dexamethasone, methylprednisolone
 For reduction of swelling
 Extra oral cold compresses for the first 6 hrs
 warm compresses and frequent warm mouthrinses to be
done after that.
68
 Most patients recover within 1-2 weeks although some cases
of long term paresthesia and scarring have been reported.
 Further endodontic therapy
 with sterile saline or chlorhexidine as root canal
irrigants
69
Prevention of NaOCl accidents
 The following steps can help clinicians avoid NaOCl accidents:
 Adequate access preparation to facilitate better access.
 Good working length control
 Irrigation needle placed 1 mm to 3 mm short of working
length
 The needle can be bent so as to confine the tip of it to higher
levels in the root canal.
 Needle to be placed passively and not locked in the canal .
70
 Irrigant to be expressed into the root canal slowly and
gently
 "Flowback" of solution as it is expressed into the canal
should be observed
 Constant in and out movements of the irrigating
needle into the canal space to be done to ensure that
the tip is free to express irrigant without resistance.
 In case of any resistance felt irrigation to be
immediately stopped
71
 Use of side delivery needles that are specifically de-
signed for endodontic purposes is advocated.
 The hub of the needle should be checked for a tight fit
to prevent inadvertent separation and accidental
exposure of the irrigant to the patient’s eye.
72
Allergic reactions to NaOCl
 The patient immediately will report of
 severe pain and a burning sensation,
 within a few s the upper lip and cheek up to the infraorbital
area may be swollen,
 accompanied by ecchymosis and profuse haemmorhage from
the root canal.
 Management
 Systemic corticosteroid and antihistamine administered
intravenously and antibiotics are recommended.
73
NaOCL accidents
 Palatal mucosa necrosis because of accidental sodium
hypochlorite injection instead of anaesthetic solution.
 Gursoy UK, Bostancı V, Kosger HH.
 International Endodontic Journal,2006.
74
Advantages
 The ability of NaOCl to dissolve organic soft tissue of the
pulp
 It is well recognized to be effective against a broad range of
pathogens: gram-positive and gram-negative bacteria, fungi,
spores, and viruses including the human immunodeficiency
virus.
 Gross debridement and flushing out of debris.
 Removes smear layer when used with EDTA.
75
Disadvantages
 Acute inflammation followed by necrosis results when
NaOCl comes into contact with vital tissue- when extrude
out of the apical foramen.
 Hypersensitivity, irritation to eyes
 Corrosive nature on carbon steel instruments- if left within a
syringe may crystallize jamming the plunger.
 May crystallize on the root canal walls
 Effect on physical properties
 Degraded by light, air, and contaminants- hence to use fresh
solution always.
76
 Severe irritations have been reported when concentrated
solutions were inadvertently forced into the periapical region or
leakage through rubber dam
 Furthermore a 5.25% solution significantly decreases the elastic
modulus and flexural strength of dentin
 The reduction of intracanal microbiota is not any greater when
5% NaOCl is used as compared to 0.5%.
 1% solution has shown to dissolve the entire pulp tissue during the
course of treatment when replenished frequently.
 Hence based on the current evidences there is no rationale for
using hypochlorite solutions at concentrations above 1%.
77
- Hydrogen peroxide
- Urea peroxide
78
79
 H2O2 is a widely used biocide for disinfection and sterilization.
 It is a clear, colorless liquid that is used in a variety of
concentrations in dentistry, ranging from 1% to 30%.
 it degrades into water and oxygen.
 H2O2 solutions are quite stable.
80
 H2O2 is active against viruses, bacteria, yeasts, and even
bacterial spores .
 The mechanism of action of this oxidizing solution involves the
reaction of superoxide ions to produce hydroxyl radicals, which
are the strongest oxidants known.
 This radical can attack membrane lipids, DNA and other
essential cell components.
81
 Moller recommended 30% H2O2 as the first step in tooth surface
disinfection.
 It has been particularly popular in cleaning the pulp chamber
from blood and tissue remnants, it has also been used in canal
irrigation.
82
 For years 3% H2O2 has been recommended as a canal irrigant
because of its effervescent action in presence of blood products.
 effervescent action:
 This action was specially indicated in mandibular teeth where the
bubbling of the peroxide was thought to lift debris from the canal
system.
 However, H2O2 does not possess tissue dissolution properties
and is not effective as a lubricant.
83
 Hence, alternate use of H202 + 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 02 that is liberated in an active state assists
in destroying anaerobic microorganisms.
84
3. ln combination with NaOCl it effectively removes the soft tissue
debris.
4. Increases the bleaching action on discolored teeth.
85
 Certain disadvantages associated with it are-
 It does not possess tissue dissolving property
 Not a lubricant
 Has limited antimicrobial action.
86
Complications
 When peroxide is used it must eliminated from the pulp cavity
before the crown is sealed otherwise oxygen may be evolved
afterwards as a result of contact with blood or tissue fluids.
 Besides causing pressure within the periapical region, this could
force debris and microorganisms into the tissues.
87
Complications
 Injection of hydrogen peroxide beyond the apex:
 Bhat (1974) reported a case in which hydrogen peroxide of
unknown concentration was injected into the soft tissues.
 As treatment was performed under local anesthesia, the
patient experienced no pain but complained about a rapidly
developing swelling on the upper lip and some difficulty in
breathing.
 The canal was left open, the patient was prescribed antibiotics
and instructed to apply cold packs.
 The emphysema, caused by oxygen liberated from the hydrogen
peroxide, subsided in 1 week and root canal treatment was
completed. 88
89
 Urea peroxide
 (Endo-PTC or Gly-Oxide)
 is another widely used solution to aid instrumenation
 The peroxides are oxidizing agents that react chemically,
liberating great amounts of nascent oxygen that explains their
 bactericidal action,
 the effervescence, due to the liberation of oxygen,
 contributes to the removal of pulp tissue remains and dentin
particles during the chemico-mechanical preparation.
90
Antimicrobial action-
 Mechanism of action
 Produces hydroxyl radicals that oxidixes sulphydryl groups, double
bonds in protiens, lipid and outer membranes- cause cell death.
 It retains its antibacterial activity in the presence of blood whereas
aqueous 3% hydrogen peroxide does not.
91
 The Urea Peroxide has several desirable characteristics for the
Irrigation of root canals
 It presents detergent properties
 not irritating to the periapical tissues and
 non allergenic.
92
Glyoxide
 is an irrigant comprising of 10% urea peroxide (carbamide
peroxide) in a vehicle of anhydrous glycerol .
93
94
Although NaOCl appears to be the most desirable single endodontic irrigant, it cannot dissolve
inorganic dentin particles and thus remove the smear layer formed during instrumentation.
In addition calcifications hindering mechanical preparation are frequently encountered in the canal
system which cannot be negotiated without use of chelating agents.
Demineralizing agents such as EDTA and citric acid have therefore been recommended as adjuvant in
root canal therapy
95
 The term chelate originates from Greek word "chele" (crab claw)
 Chelates are particularly stable complexes of metal ions with
organic substances .
 The ability of chelator to bind and inactivate metallic ions is
widely exploited in medicine to bring about excretion of
dangerous ions in case of metal poisoning
 or in treatment of copper metabolism disturbances.
96
Historical development of chelators
 1957- Chelators were first introduced to Endodontics by Nygaard-
Ostby who recommended the use of 15% EDTA solution (pH 7.3)
 Original Nygaard Ostby formula for 15% EDTA was:
-diSodium salt of EDTA - 17.0 g
-distilled water - 100.00 ml
-5N sodium hydroxide - 9.25 ml
97
Historical development of chelators
 1963- A detergent was added to increase the cleaning and
bactericidal potential of EDTA.
 The new composition being known as EDTAC which has 0.84g of
quaternary ammonium compound - Cetavlon
 EDTAC reduced surface tension of the irrigant facilitating
wetting of the entire root canal wall thereby increasing the
ability of chelators to penetrate dentine.
 It also had a greater anti-microbial effect than EDTA.
98
 1969- Strewart et al. introduced RC-Prep (Premier Dental) paste
type chelating agent.
 Recently paste type chelators have regained popularity as
almost all manufacturers of Ni-Ti instruments recommend the use
of EDTA as a lubricant during rotary root canal preparation to
reduce the risk of instrument separation.
99
-Dimeralization action- dentin permeability
- working time
-Antibacterial action
-Biocompatibility
-Combined use of EDTA and NaOCl
-Other effects
-Various preparations
100
EDTA
 ethylenediamine Tetra Acetic Acid (EDTA) is a chelating
substance that has been used as an irrigant.
 It is capable of removing calcium ions of the dentin giving rise to
demineralization
 and as a consequence, increasing the dentin permeability of the
root canals.
 EDTA is used in concentrations from 10 to 17%
101
Demineralization
 When EDTA solution comes in contact with dentine the calcium
ions are removed from dentine by the chelating action, causing
decalcification of dentine
 EDTAH + Ca = EDTACa + H
 as this reaction proceeds, acid accumulates and protonation
of EDTA prevails thus decreasing the rate of demineralization
 EDTAH + H = EDTAH2
102
 The extent of dimineralization zone is dependant on duration of
action( 20 min- 96 hrs)
 A 20- 30 micron demineralized zone was apperent after 5 min.
 This increased to 30- 40 µm after 30 min
 And 50 µm after 24-48 hrs.
 This layer was separated from the deeper unchanged dentin by a
clearly defined smooth demarcation line.
103
Self limiting action
 This effect is found to be rapid during first 1 hr and reaches
equilibrium by the end of 7 hrs.
104
 This demineralizing action
 Removes inorganic component of smear layer
 Reduces the time necessary for debridement
 Aides in enlarging narrow/ obstructed canals
 Helps bypass fragmented instruments
105
Smear layer
106
Smear layer on dentin surface after
instrumentation
Smear plugs into dentinal
tubules
Smear layer
107
Surface after removal of smear
layer with 17% EDTA solution.
CHANGES IN DENTINE PERMEABILITY
 after removal of smear layer with the aid of EDTA, dentin
permeability increased and reduction in micro leakage between
the definitive root canal filling and canal wall was achieved.
 The ability of the sealer to penetrate the dentinal tubules and
thereby the adaptation of the root canal filling to the root canal
wall is much improved.
 Further more this increase in root dentin permeability results in
an increase in the activity of endodontic medicament.
108
Working time of the chelator
 Several studies have reported a good cleaning efficiency of EDTA
between working time of 1-5min.
 Yamada et al. 1983,
 Cergneux et al. 1987,
 gait & Serper 2000,
 Hulsmann & Heckendorff 2002,
 Scelza et al. 2003.
109
Clinical recommendations
 Hulsmann M, Heckendroff M, Lennon A.
 chelating agents in root canal treatment: mode of action and
indications for use- a review
 IEJ 2003
1) root canal preparation can be carried out with the aid of chelator
paste.
This may be introduced into the root canal with the preparation
instrument.
The canals first should have been flooded with NaOCl to dissolve
vital or necrotic tissue.
2) A chelator in paste form serves as a lubricant for files and
reduces the risk of instrument fracture in the canal.
110
3. A final intensive rinse with 17% EDTA reduces the extent of the
smear layer remaining which in turn results in a cleaner canal
wall and better adaptation of the root fillings to the canal walls.
4. EDTA containing agents should be used between 1-5 minutes .
5. liquid EDTA solution may be introduced into the pulp chamber
to identify the entrance of calcified canals.
6. Apical extrusion of the chelator solution should be avoided.
111
Various preparations
 liquid chelators:
 Calcinase
 Contains 17% Sodium edetate, sodium hydroxide as a stabilizer and
purified water.
 REDTA (Roth International )
 has 17% EDTA solution
 with addition of 0.84g Cetrimide to reduce the surface tension.
112
 EDTA-t
 Contains 17% EDTA+ Sodium lauryl ether sulfate (Tergentol) as a
detergent.
 EGTA (sigma)
 main component is ethylene glycol bis ( amino ethyl ether)
N,N,N,N-tetra acetic acid.
 It is reported to bind Ca+ more specifically than EDTA
 Largal ultra (septodent)
 contains 15% EDTA,
 0.75% certimide
 pH value to 7.4
113
 Salvizol (Ravens,Germany)
 N1-decamethylene-bis-4-aminoquinaldinium diacetate in
propylene glycol.
 pH 6.6.
 Kaufman et al. have suggested that salvizol with a neutral pH,
has a broad spectrum of bactericidal activity and the ability to
chelate calcium.
 This gives the product a cleansing potency while being
biologically compatible.
114
 Paste chelators
 these paste chelators are the one most commonly recommended
with rotary instrumentation.
 Calcinase slide:
 it contains 15% sodium EDTA
 58 to 60% water.
 Has alkaline pH value of 8.9
 it is water soluble hence easily rinsed from root canal system
 The gel is firm at room temperature and develops a creamy
consistency when agitated .
115
 RC-PREP-
 It contains 15% EDTA,
 10% Urea peroxide and
 glycol in aqueous ointment base .
 Oxygen is set free by reaction of NaOCI with RC-Prep resulting In
effervessence, so that pulpal remnants and blood coagulates can
be easily removed from the root canal wall (Stewart et al).
 Glycol acts as a lubricant
116
 Glyde file :
 Is composed of 15% EDTA
 10% Urea peroxide in aqueous solution.
 It has got properties similar to RC-Prep .
 FileCare EDTA
 Also composed of 15% EDTA and
 10% urea peroxide
 file EZE
 Contains 19% EDTA
117
Ruddle solution
 contains:- 5% NaOCl,
Hypaque
17%EDTA
 Hypaque is a high contrast radiopaque & injectable dye.
 lt is water soluble with pH of 6.7- 7.7.
 This composition simultaneously provides the solvent action of
full-strength NaOCl, visualization, & improved penetration.
 Used to visualize the microanatomy, verify the shape, monitor
the remaining root wall thickness.
118
- Citric acid
- Maleic acid
- Tannic acid
119
CITRIC ACID
 One of its advantages is its non-cytotoxicity, it is more
acceptable biologically than other acids (Jenkin and Dawer 1963).
 Many different concentrations of citric acid have been used, with
varying degrees of success.
 10% , 20%, 25%, 50% solutions are used successfully for these
purposes .
 A SEM study showed that 20% citric acid was slightly more
effective than 10% Citric acid; however, these differences did not
appear to be significant.
120
121
122
-Antibacterial action
-Substantivity
-Combination with NaOCl
-Biocompatibility- cytotoxicity
-Limitations
CHLORHEXIDINE
 CHX in the form of a salt( gluconate, acetate or hydrochlorate)
has been widely used since 1950’s at different concentrations as
an oral antiseptic because of its excellent antimicrobial activity.
 The most common preparation is with digluconate salt because
of higher water solubility.
 pH of 5.5 – 7
 of 5.5
123
CHLORHEXIDINE
 Unlike NaOCl ,
 CHX does not have a bad odor
 Is not equally irritating to periapical tissues
 Does not cause spot bleaching of patient and doctor’s clothes.
 Has no deleterious effects on the physical properties of dentin
 of 5.5
124
Structure
 It is a cationic chlorophenyl bisguanide with bacteriostatic and
bacteriocidal action.
125
NH C NH C NH (CH2)6 NH C NH C
NH
NH NH NH NH
Cl Cl
Concentration
 Include
 0.12%,
 0.2%,
 and 2%
 Commercially available oral rinse typically contains 0.12% CHX
gluconate.
 0.12% CHX has been found to be ineffective for endodontic use
whereas concentrations above it have been successfully used
 Sassone (2003)
 Luciana M( Aust Endo J 2008)
 Available in both gel and liquid formulations
126
Antibacterial action
 It has a wide antimicrobial spectrum and is effective against both
Gram-positive and Gram-negative bacteria as well as yeasts,
while bacterial spores are resistant to CHX.
 It shows comparatively greater efficacy towards gm positive
bacteria
 It has been reported that CHX does not inactivate
lipopolysaccharide (LPS), which is a structural component of the
Gram-negative bacteria’s outer cell envelope
127
 at physiologic pH CHX is a large dicationic molecule, with the
positive charge distrubuted over the nitrogen atoms on either
side of the heamatoxylin bridge.
 The bacterial cell is characteristically negatively charged.
128
 Low concentrations- bacteriostatic
 High concentrations- bactericidal
 CHX penetrates the cell wall and causes precipitation or
coagulation of cytoplasm probably caused by cross linking.
129
cationic-anionic electrostatic attraction…
-
-
-
-
-
Adsorption to the surface of bacteria due to the
cationic-anionic electrostatic attraction…
… making the membrane permeable
this results in micro leakage of intracellular
components leading to cell death
133
Substantivity
 clinically CHX’s substantivity seems to be another advantage
over NaOCl, sustaining the antimicrobial activity over a period of
48 hours or 72 hrs after treatment
 Their cationic properties also allow them to bind electrostatically
to surfaces
 They are gradually released from the surface, as the
concentration of chlorhexidine in the environment decreases
TOOTH
134
The reversible reaction of uptake and release of CHX
results in a substantive antibacterial activity
Parsons et al 1980
Fardal and Turnbull 1986
Greesntein et al 1986
Jeansonne and White 1994
Biocompatibility
 Extremely low level of tissue toxicity as compared to NaOCl ( as
low as 0.5%)
 Loe 1973
 Tanomaru Filho M IEJ 2002
 Oncag O et al IEJ 2003
 Allergic reaction to CHX are rare
 Okano et al. 1989
 Garvey et al 2001
136
limitation
 The inability of CHX to dissolve organic matter
 Jeansonne and White 1994
 D’Arcangelo et al 1999
 Marley et al 2001
 Okino and Siqueira et al 2004
 No action on smear layer
137
138
139
 Bio pure MTAD ( Dentsply Tulsa Dental) is an irrigating solution
containing
 An antibiotic- 3% doxycycline hydrate
 An acid- 4.25% citric acid
 A detergent- 0.5% polysorbate 80 (Tween 80)
140
 Based on extensive well conducted studies MTAD has been shown
to be clinically effective,
 Biocompatible
 Removes smear layer while being less erosive
 With potential sustained antibacterial activity.
141
dentinal erosion
142
Irrigating solution during root
canal preparation: 5.25% NaOCl.
Final solution for removal of smear
layer (5 min.): MTAD
Irrigating solution during root
canal preparation: 5.25% NaOCl.
Final solution for removal of smear
layer (5 min.): 17% EDTA
Tetraclean
 Tetraclean is another combination product similar to MTAD
 Similar to MTAD Tetraclean, is also capable of removing the
smear layer.
their low surface tension, increases the intimate contact of
irrigant solutions with the dentinal walls, they may permit
deeper penetration.
143
144
ECA
 Russian scientists have developed a process whereby so-called
electro-chemically activated water (ECA) is produced with a new
and unique anode–cathode system (Leonov 1997).
 ECA is produced from tap water and saline solution by a special
unit that houses a unique flow-through electrolytic module
(FEM).
 to obtain the best end solutions with the ECA,
NaCI water solutions with no more than 5.0 g/L concentration
or fresh water of less than 1.0 g/L mineralization is needed.
145
 The FEM contains the
 Anode
 -made from titanium and coated with
ruthenium-oxide, iridium and Platinum,
 cathode
 made from titanium coated with
pyrocarbon and glass carbon.
 the anode being a solid cylinder fits
coaxially inside the cathode which is a
hollow cylinder
 Membrane
 Made up of ceramic in between them.
146
 Electrolysis of water is known as a redox reaction.
 At the anode,
 electrons are removed from the water and it is oxidized, as in
2H202 = O2 + 4H+ 4e-
 we get oxygen gas and hydrogen ions
 At the cathode
 electrons are added to the water as it is reduced,
 2H2O + 4e = 2H2 + 4 OH
 we get hydrogen gas and hydroxide ions.
147
 The physical and chemical nature of ECA is not yet fully
understood.
 The solution supposedly exists in a metastable or disequilibrious
state for 48 h after production and contains many free radicals
and a variety of molecules.
 After 48 h the solution returns to the stable state, becoming
inactive again.
 In the metastable state the solutions have a very high oxidation-
reduction potential.
 Two types of ECA solutions are produced.
148
Oxidative potential water
 Oxidative potential water (OPW) has been used extensively in
Japan for household and agricultural disinfection because of its
safety and bactericidal effectiveness.
 According to the manufacturers’ claims, the antimicrobial and
antiviral activities of OPW are sufficiently powerful to kill a wide
variety of pathogens, including HIV.
 The basis for the development of the OPW is that
microorganisms cannot survive in an aqueous environment with
both low pH (less than 3) and high oxidation-reduction potential
(greater than 0.9 V) (Becking et al . 1960).
149
 Oxidative potential water is an electrochemically created, highly
acidic water that accumulates in the anode Compartment
 OPW has strong antimicrobial activity, killing viruses as well as
bacteria, an unusually low pH of 2.7 or less, and oxidation-
reduction potentials of 1050 mV or greater
150
 Oxidative potential water is well suited for dental treatment
because
 of its low toxicity and lack of irritation to soft tissues,
 and because it quickly loses its high oxidation-reduction
potential and low pH when it reacts with light-sensitive and/or
organic substances.
 For these reasons it is completely safe as a root canal irrigant.
 A study by Hata et al .( 1996) showed that OPW effectively
removed the smear layer from instrumented canal walls when
used as an irrigant.
151
152
Middle third of a root canal irrigated with 10 mL.
(b) Apical third of a root canal irrigated
with 20 mL. Dentinal tubules were open,
although occasionally blocked by smear
plugs.
Middle and apical thirds of a root canal
irrigated with 30 mL.
Syringe irrigation with OPW removed
the superficial smear layer and debris
from the canal wall.
153
 Ozone (O3) is an unstable gas, which breaks down into oxygen
very quickly
 hence, it cannot be bottled, but must be generated fresh when it
is needed.
 half-lifehalf-life - 40 minutes

154
MODE OF ACTION OF OZONE
 when ozone dissolves in water, it becomes highly unstable and
rapidly decomposes through a complex series of chain reactions
(Hoigne & Bader 1976, Shin et al. 1999).
 in two different and coexisting modes
 one involving direct reactions of molecular ozone
 the other a free radical-mediated reaction (Staehelin &
Hoigne´ 1985).
 As a result, hydroxyl (OH) radicals are generated, which are
amongst the most reactive oxidizing species.
155
MODE OF ACTION OF OZONE
 Both these mechanisms may be involved in the destruction of
bacteria by ozone.
 Destroys microorganisms by oxidizing bacterial cell walls and
membranes and finally rupturing their membranes
156
OZONE THERAPY IN ENDODONTICS
 The application of ozone makes the complete sterilization of the
root canal a real possibility in the near future.
 Tooth that is to be treated ozonically needs to be built up so
that the clinical crown is restored.
 Ozone is applied from the access opening, making the technical
realization a simple process.
 There are five differently sized silicone cups
available to enable perfect tooth sealing
157
158
Inserting the ozone cannula into the prepared
Root canal
Treatment with ozone with a complete seal
 Ozone has limitations as it is irritating to the respiratory system
(Hazucha et al. 1989).
 Very low concentrations (0.2–0.5 ppm) may cause headache, and
irritation or dryness of the nose, throat and eyes (McDonnell et
al. 1983).
 Higher concentrations (1–10 ppm over a few hours) may cause
lung congestion, oedema, haemorrhage, changes to the blood
and loss of vital lung capacity.
 It is irritating to the eyes and can cause redness, pain and blurred
vision
159
CONTENTS
160
introduction
history
ideal requirements
classification
chlorine releasing agents
oxidizing agents
chelating agents
organic acids
inorganic acids
other irrigating solutions
• CHX
• MTAD
• Electrochemically activated water
• Oxidative potential water
• Ozone
•
• lasers
• photodynamic therapy
• irrigating devices
 Ultrasonic irrigation
 conclusion
161
Lasers
 The potential use of different endodontic lasers in eradicating
the root canal microbes has been the focus of interest for many
years.
 dental lasers provide greater accessibility of formerly
unreachable parts of the tubular network due to their better
penetration into dentinal tissues
162
Lasers
 Scientific research was first conducted with the Nd: YAG and the
diode lasers which gained widespread acceptance in the fields of
laser assisted endodontics,
 For both wavelengths, a high disinfecting capability was
reported.
 At the same time lasers suitable for the preparation of dental
hard substances like the Er:YAG and the Er.Cr :YSGG underwent
further development resulting in delivery systems also usable for
root canal application.
163
 In various laser systems used in dentistry, the emitted energy can
be delivered into the root canal system by
 a thin optical fiber
 Nd:YAG
 Er,Cr:YSGG
 argon
 diode.
 or by a hollow tube –
 C02
 Er:YAG
 Recent Investigations Indicate that these laser systems exhibit
satisfying bactericidal abilities thus constituting relatively new
additions to the spectrum of lasers used in endodontics .
164
 It has been documented that
 C02 ,
 Nd:YAG,
 argon,
 Er,Cr:YSGG
 and Er:YAG laser irradiation
 has the ability to remove debris and smear layer from the root
canal walls following biomechanical instrumentation.
165
Limitations
 There are several limitations that may be associated with the
intracanal use of lasers that cannot be overlooked.
 The emission of laser energy from the tip of the optical fiber or
the laser guide is directed along the root canal and not necessary
laterally to the root canal wall.
 Thus it is almost impossible to obtain uniform coverage of the
canal surface using a laser making complete removal of smear
layer and debris difficult
 Investigators strongly recommended improving the endodontic
tip to enable irradiation of all areas of the root canal walls.
166
Limitation
 Another limitation is the safety of such a procedure because
thermal damage to the periapical tissues potentially is possible.
 Direct emission of laser irradiation form the tip of the optical
fiber In the vicinity of the apical foramen of a tooth may result In
transmission of the irradiation beyond the foramen.
 Which in turn, may effect the supporting tissue of the tooth
adversely and can be hazardous in teeth with close proximity to
the mental foramen or to the mandibular nerve.
167
168
 During the early 1990’s Prof. M. Wilson and Prof. G. Pearson first
proved PAD killed strep mutans in significant numbers and
reasoned that PAD could kill all bacteria involved in oral
infections in caries, root canals, and periodontics
 Prof. Wilson and Prof. Pearson worked with Denfotex to convert
PAD into a routine clinical procedure, patented by both E.D.I.
and Denfotex.
169
 Also known as photodynamic therapy(PDT)
 is based on the concept that a nontoxic,photosensitizing agent
known as photosensitizer(PS) can be preferentially localized in
certain tissues and
 subsequently activated by light of the appropriate wavelength to
generate
 singlet oxygen and free radicals that are cytotoxic to cells of the
target tissues
170
Components
 PAD solution
 A dilute solution containing tolonium chloride which was
established as the most effective photosensitiser, packaged either
in syringes (for delivery to root canals) or dropper bottles.
 SaveDent laser
 A low power 635 nm laser light source which optimally activates
the solution.
171
APPLICATION
 Canal is washed out thoroughly with sterile saline solution and
dried
 P.A.D solution is introduced into canal from syringe via a
suitable needle and canal and pulp chamber filled with P.A.D
solution.
 the solution is agitated in the canal for 60 s using an endodontic
file one size smaller than that to which the canal has been
prepared.
172
Root canal prepared  PAD solution applied and agitated
 
 The flexible emitter tip is introduced into
the canal until resistance
 P.A.D laser is activated according to
manufacturer’s instructions for 150 s at 100 mW.
 when the distance from the entrance in the pulp chamber to the
point of resistance in the canal exceeds 10 mm,
 the canal is treated in sections by withdrawing the emitter in 5
mm steps and then irradiate each section for 150 s.
 After canal has been completely treated, canal washed with
sterile solution and dried by aspiration followed by sterile paper
points.
173
How Does PAD Work ?
 PAD solution is activated by 635nm light and acts as a
photosensitiser, releasing reactive oxygen species which disrupt
the membrane of the micro organism.
 Independently, the laser and solution have no effect, but in
combination produce a powerful anti-bacterial action.
174
Bacteria before photo activated disinfection
Same bacteria sample after photo
activated disinfection process
showing disruption of membrane.
175
Mixed lactobacilli and streptococci bacteria in
an infection
PAD solution (in blue) attached to
bacteria
PAD solution activated by
red laser light
Bacteria destroyed by PAD
176
Efficacy
 Extensive laboratory and in-vitro studies at the Eastman Dental
Institute, London, together with clinical assessment in Germany
and UK in root canals and carious lesions have clearly proved the
efficacy of PAD.
 PAD has been shown to kill all types of bacteria commonly found
in caries and root canals including-
 Streptococcus mutans, S. sobrinus, S. intermedius
 Actinomyces
 Lactobacillus
 Veilonella
 Prevotella intermedia
 Peptostreptococcus micros
 Fusobacterium nucleatum
 E. faecalis
177
178
 An alternative regimen for root canal disinfection
 Bonsor, R. Nichol, T. M. S. Reid and G. J. Pearson
 Br Dent J 2006
 Results of this study indicate that the use of a chelating agent
and photo-activated disinfection to kill bacteria is an effective
alternative to the use of hypochlorite as a root canal cleaning
system.
 Soukes et al JOE 2006 showed the combination of methylene blue
with red light were able to eliminate 97% of E.feacalis biofilm
bacteria in root canals .
179
PAD
 Seal GJ, Gulabivala K.IEJ 2002
 The combined use of a photosensitizing agent and a low power
laser directed at the access cavity was bactericidal to S.
intermedius biofilms in root canals but was unable to achieve
total kill, unlike 3% NaOCl.
180
ADVANTAGES
 PAD can be applied effectively for killing gram-positive, gram-
negative, aerobic and anaerobic bacteria - in fact, all commonly
encountered bacteria associated with dental disease.
 PAD can kill bacteria in complex biofilms, which are typically
resistant to the action of antimicrobial agents.
 Photo activated disinfection overcomes the problems of
antibiotic resistance.
 PAD does not pose any thermal risks due to the low power of the
PAD laser.
181
Disadvantages
 At the concentration provided, PAD solution produces no side
effect other than
 a transient color change in the dentine on the surface of the
canal wall.
 This is removed by the washing process with sterile saline
performed after disinfection of the canal
182
QMiX (QUÍMICO MECÁNICA MIX)
 Q mix is an irrigation solution used as a final rinse. It is
a combination of CHX with EDTA and a surfactant
solution to improve penetration in dentinal tubules.
Advantages:
 Low surface tension is one of the ideal characteristics of an irrigant
Superior Antibacterial efficacy.
Superior smear layer removal
Ready to use, fast working
Less demineralization OF DENTIN compared to EDTA
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
184
185
Herbal
• Murray et al. evaluated Morinda citrifolia juice in conjunction with
EDTA as a possible alternative to NaOCl.
• Triphala (IMPCOPS Ltd, Chennai, India) is an Indian ayurvedic herbal
formulation consisting of dried and powdered fruits of three
medicinal plants, Terminalia bellerica, Terminalia chebula, and
Emblica officinalis, and green tea polyphenols (GTPs; Essence and
Flavours, Mysore, India); the traditional drink of Japan and China is
prepared from the young shoots of tea plant Camellia sinensis.
• Dimethyl sulfoxide (DMSO) is used as a solvent for Triphala and GTP,
although they are readily soluble in water. DMSO is a clean, safe,
highly polar, aprotic solvent that helps in bringing out the pure
properties of all the components of the herb being dissolved
186
• Herbal alternatives showed promising antibacterial efficacy on 3- and
6-week biofilm along with MTAD and 5% sodium hypochlorite.
• Although Triphala and green tea polyphenols (GTPs) exhibited similar
antibacterial sensitivity on E. faecalis planktonic cells, Triphala
showed more potency on E. faecalis biofilm. This may be attributed
to its formulation, which contains three different medicinal plants in
equal proportions. In such formulations, different compounds may
be of help in enhancing the potency of the active compounds
resulting in an additive or synergistic positive effect.
• According to Prabhakar et al. 5% of sodium hypochlorite exhibited
excellent antibacterial activity in both 3-week and 6-week biofilm,
whereas Triphala and MTAD showed complete eradication only in 3-
week biofilm
187
• Triphala and GTPs are proven to be safe, containing active
constituents that have beneficial physiologic effect apart from its
curative property such as antioxidant, anti-inflammatory, and radical
scavenging activity and may have an added advantage over the
traditional root canal irrigants.
188
189
 Although the technique for irrigation is simple, the potential for
serious complications exists.
 Regardless of the delivery system,
-the solution must be introduced slowly
- the needle never wedged in the canal
 As a rule, the clinician should irrigate copiously, recapitulate and
continue.
190
 The most common method of delivering irrigant into the canal is
with the aid of a syringe and needle
 A 5 ml syringe with a Leur Lok mechanism is the preferred one.
 Gauge of the needle
 Gauges ranging from standard 22 to finer 30 have been used in
endodontic irrigation.
 Since irrigation of the apical third requires the needle to be in
close proximity for adequate effect the canals should be flushed
with a 27-30 gauge preferably.
191
 For relatively large canals the tip of the syringe is placed until
resistance from the canal wall is felt, the tip is withdrawn a few
millimeters, the solution is expressed very slowly until the
chamber is full.
 In treatment of posterior teeth and or small canals the solution
is deposited in the chamber .
 The file will carry the irrigants into the canals and the capillary
action of narrow canal diameter will retain much of the solution.
192
 Excess irrigant is carried away by aspiration with a small tip of
approximately 16 gauge otherwise a folded gauze pad is held near
the tooth to absorb the excess.
 Several types of plastic disposable syringes are available.
193
 It should be bent approximately 30degrees in the center of the
needle to allow easier delivery of the solution and to prevent deep
penetration of the needle or probe.
194
195
Squeezing the plunger with the thumb
may result in more rapid delivery
Of irrigant and possible extrusion
Using a forefinger to depress the plunger
gives greater control of irrigant delivery
Designs of needle
 1. open ended blunt needles
 2. beveled needles
 3. blunt ended side venting needle
 4.notched tip
 5. perforated needle
196
197
Bevelled needle
Irrigant passes apically
Monoject type-
irrigant passes sideways
and apically
Safe ended tip
Irrigant passes sideways
Designs of needle
 ProRinse probes
 The effectiveness of the ProRinse seemed related to its design.
 It has a blunt tip, with the lumen 2 mm from the tip.
 Expression of fluid through the lumen creates turbulence around
and beyond the end of the probe.
 Also prevents forceful periapical injection of irrigant.
198
199
 Moser and Heuer reported monoject endodontic needles to be the
most efficient delivery system in which longer needles of a
blunted, open-end system were inserted to the full length of the
canal.
200
 Stropko NI-TI irrigation needles
 They are available in short (17 mm) and (25 mm) long sizes and
can be sterilized and reused.
 Needle size is 27 gauge, side vented.
 Advantages are its good flexibility and their resistance to
clogging.
201
 MAX-l-PROBE
 These are designed to produces upward flushing motion for
complete canal irrigation.
 Side port dispersal prevents solution and debris from being
expressed through the apex closed,
 rounded end reduces risk of apex damage.
 Closed-end needle eliminates possibilities of puncture of the
apical foramen
202
203
THE ENDO VAC SYSTEM
 The EndoVac system (Discus Dental) consists of a
delivery/evacuation tip attached to a syringe of irrigant and the
highspeed suction of the dental unit.
 A small tube attaches either a macro or micro-cannula to the
suction.
 The delivery/evacuation tip places irrigant in the chamber and
siphons off the excess to prevent overflow.
204
THE ENDO VAC SYSTEM
 The macro-cannula is plastic with an open end that measures
size 55 with a 0.02 taper.
 The micro-cannula is stainless steel and has 12 small, laterally
positioned, offset holes in 4 rows of 3, with a closed end
measuring ISO size 30.
 The micro-cannula can be used at working length in a canal
enlarged to ISO size 35 or larger.
205
206
Scanning electron microscope photograph of
the microcannula
Comparison picture of
the closed-ended
microcannula
(ISO size 30)
open-ended macrocannula
(ISO size 55).
207
The macrocannula attached to its handle used for
initial flushing of the coronal portion of the canal.
The microcannula attached to its handle.
and is used for irrigation at the apical portion
of the canal to working length.
208
The delivery/evacuation tip attached to a syringe.
Irrigant is delivered to the pulp chamber by the metal needle.
Any excess is immediately suctioned off through the plastic tubing
surrounding the metal that is attached to the suction.
209
A) The complete EndoVac system including all tubing and vacuum
attachment.
The free end of the large tubing plugs into the high speed
suction of the dental chair.
 MICRO BRUSHUS
 Advancement in small wire technology, bristle materials and
bristle attaching techniques have enabled the creation of an
endodontic microbrush of clinical field testing.
 A micro-brush is provided to remove the smear layer that
remains in the root canal after the pulp, bacteria, and related
irritants have been mechanically and chemically removed from
the root canal using files and irrigants like sodium hypochlorite.
210
 The brush includes a shaft or shank and a tapered brush section
extending from the distal end of the shank.
 The brush section includes bristles extending radially from a
central wire base.
 The shank can be provided with a handle for manual use or the
shank can be adapted to be received in a rotary, sonic, or
ultrasonic handpiece to impart rotational or vibratory motion to
the micro-brush.
211
 The brush section has a diameter of between about 0.2 mm and
about 0.7 mm at a tip end and a diameter of between about 1 mm
and 2 mm at a coronal-most end.
 The brush section is about 16 mm long, and thus has a taper of
about 0.06 mm/mm and about 0.12 mm/mm.
212
 Rotary and ultrasonic endo brushes are fabricated in ISO
lengths, containing 16mm of bristles, have the bristle diameter of
0.40,0.50,0.60 and 0.80mm
 Rotary activated microbrushes run at about 300 rpm and the
helical bristle pattern effectively augers residual debris out of the
canal in coronal direction
 Microbrushes designed for ultrasonic use effectively brush the
walls of the preparation and activate solution of NaOCl and 17%
EDTA to produce cleaned canal.
213
Microbrushes
214
215
Ultrasonic irrigation
 Ultrasonic devices were first introduced in Endodontics by
Richman (1957).
 Martin and Cunningham have coined the term endosonics.
 In 1976 Martin had designed the first commercial system which
used ultrasonics for preparing root canal.
216
Ultrasonic irrigation
 Ultrasonically activated files have the potential to prepare and
debride root canals mechanically.
 The files are driven to oscillate at ultrasonic frequencies of 25–30
kHz
 The files operate in a transverse vibration, setting up a
characteristic pattern of nodes and anti-nodes along their length
(Walmsley 1987, Walmsley & Williams 1989).
 Ultrasonic irrigation has been shown not very effective for
shaping the root canal.
217
 On the other hand it has been shown that ultrasonically driven
files are effective for the ‘irrigation’ of root canals.
 Two types of ultrasonic irrigation have been described in the
literature:
 1. where irrigation is combined with simultaneous ultrasonic
instrumentation (UI)
 2. without simultaneous instrumentation, so called passive
ultrasonic irrigation (PUI).
218
 Acoustic streaming
 Acoustic streaming is the rapid movement of fluid in a circular or
vortex-like motion around a vibrating object. ( file)
 The acoustic streaming that occurs in the root canal during
ultrasonic irrigation has been described as acoustic micro-
streaming.
 The shear flow caused by acoustic microstreaming produces
shear stresses along the root canal wall, which can remove debris
and bacteria from the wall.
219
220
Acoustic streaming around a file in free water and a schematic
drawing.
 Cavitation
 Acoustic cavitation can be defined as the creation of new bubbles
or the expansion, contraction and/or distortion of pre-existing
bubbles (so-called nuclei) in a liquid, the process being coupled to
acoustic energy (Leighton 1994).
 These bubbles expand and then rapidly collapse producing a
focus of energy.
221
222
Piezon unit
The ultrasonically energized file
creates current of streaming of
irrigant within the root canal
223
Dentine debris packed in oval shaped
root canal after syringe irrigation
and clean oval canal after 3 min
of PUI
224
SEM micrograph of a size 15 stainless
steel K-file used for ultrasonic
activation of the irrigation
SEM micrograph of a blunt
Ni–Ti-wire used for
ultrasonic activation of the
irrigation
 Application of irrigant during PUI
 Two flushing methods can be used during PUI, namely
 a continuous flush of irrigant from the ultrasonic handpiece
 or an intermittent flush method using syringe delivery
(Cameron 1988).
 In the intermittent flush method, the irrigant is injected into the
root canal by a syringe, and replenished several times after each
ultrasonic activation.
 Both flushing methods were equally effective in removing dentine
debris from the root canal in an ex vivo model when the
irrigation time was set at 3 min (van der Sluis et al. 2006).
225
Heat generation
 Cameron (1988) reported a rise of the intracanal temperature
from 37 to 45 C close to the tip of the instrument
and 37 C away from the tip when the irrigant was ultrasonically
activated for 30 s without replenishment.
 The external root surface temperature recorded was 40 C
 A cooling effect from 37 to 29 C was recorded when the irrigant
was replenished with a continuous flow of irrigant.
 Ahmad (1990) reported a mean rise of temperature of 0.6 C during
a continuous flow of irrigant.
 A rise of temperature within these ranges will not cause
pathological temperature rises in the periodontal ligament.
226
 Based on this literature review it is concluded that PUI appears to
be an adjunctive treatment for cleaning the root canal system
 and that PUI is more effective than syringe irrigation.
227
 THE MICROMEGA 1500
 is a sonic hand pieces that can be used with endodontic files and
irrigation solutions to debride canals.
 Sonic handpieces allows for simultaneous canal flaring,
debridement and irrigation with cavitation effect.
228
 Endo Irrigator Plus (K Dent Dental System)
 It is based on ACWIS concept, i.e. activated continuous warm
irrigation and evacuation system.
 Strong vacuum evacuation system insures that Sodium Hypochlorite
doesn’t reach the periapical region so it does not harm or damage the
peri-apical tissues.
 This device creates positive and negative pressure inside the canal.
 This gives a perfect cleaning and disinfection of root canal assisted by
negative and positive pressure with warm Sodium hypochlorite.
 In this unit the Sodium hypochlorite is warmed upto 45°. Positive
pressure irrigation with warm hypochlorite cleans and disinfect upto
middle 1/3rd, removes all macro debris and negative pressure
irrigation with warm hypochlorite cleans and disinfect upto apical
1/3rd, removes all micro and nano debris.
 According to the manufacturers due to its powerful suction ability not
even a single drop of Sodium Hypochlorite solution comes out of the
canal (even if working in maxillary molars or if there is wide/ open
apex) 229
230
231
Conclusion
 Instrumentation of the root canal system must always be
supported by an irrigation system capable of removing pulp
tissue remnants and dentin debris.
 Liberal amounts of irrigation are essential for the effective
function of the files.
 A variety of chemical agents in fluid form and sometimes in
viscous preparation has been used to aid canal preparation and
irrigation.
232
Conclusion
 The most popular and advocated irrigation is sodium
hypochlorite in various concentration.
 Ongoing researchers are directed towards comparing the
different irrigating solutions and different methods of irrigation
to enhance the cleanliness of the root canal preparation
 Clinician must always be alert to fundamental concept of
cleaning and shaping that provide success of root canal
treatment.
233
 Many new materials and methods have recently been introduced
to improve root canal debridement and to achieve root canal
sterilization.
 However, bearing in mind the complex anatomy of the root canal
system and the ability of microorganisms to survive under
adverse conditions, it might be premature to believe that the
total sterilization of the root canal system could be readily
achieved by any of the systems.
 In the age of evidence-based dentistry, it is advisable to wait until
quality independent data are available to support the use of such
new technologies.
234
235

More Related Content

What's hot

INTRACANAL MEDICAMENTS IN ENDODONTICS
INTRACANAL MEDICAMENTS IN ENDODONTICSINTRACANAL MEDICAMENTS IN ENDODONTICS
INTRACANAL MEDICAMENTS IN ENDODONTICSSk Aziz Ikbal
 
Irrigation in endodontics
Irrigation in endodonticsIrrigation in endodontics
Irrigation in endodonticsMettinaAngela
 
1. Intracanal medicaments
1. Intracanal medicaments 1. Intracanal medicaments
1. Intracanal medicaments Ishani Sharma
 
Recent advances in endodontic irrigation devices
Recent advances in endodontic irrigation devicesRecent advances in endodontic irrigation devices
Recent advances in endodontic irrigation devicesDrAnuprabha Shrivastav
 
Working length determination
Working length determinationWorking length determination
Working length determinationSaeed Bajafar
 
Restoration of endodontically treated teeth
Restoration of endodontically treated teethRestoration of endodontically treated teeth
Restoration of endodontically treated teethNivedha Tina
 
Endodontic Irrigants
Endodontic IrrigantsEndodontic Irrigants
Endodontic IrrigantsSNEHA RATNANI
 
Management of hot tooth
Management of hot toothManagement of hot tooth
Management of hot toothHrudi Sahoo
 
INTRACANAL medicaments
INTRACANAL medicamentsINTRACANAL medicaments
INTRACANAL medicamentssurabhisoumya1
 
Root Canal Irrigation in RCT
Root Canal Irrigation in RCTRoot Canal Irrigation in RCT
Root Canal Irrigation in RCTCing Sian Dal
 
Rotary in endodontic
Rotary in endodonticRotary in endodontic
Rotary in endodonticms khatib
 
Endodontic irrigating solutions
Endodontic irrigating solutionsEndodontic irrigating solutions
Endodontic irrigating solutionsMarwa Ahmed
 
Irrigation agitation techniques
Irrigation agitation techniquesIrrigation agitation techniques
Irrigation agitation techniquesHIMANI THAWALE
 
Interim and Temporary restorations
Interim and Temporary restorationsInterim and Temporary restorations
Interim and Temporary restorationsParikshit Harnoor
 
Rationale of endodontics
Rationale of endodonticsRationale of endodontics
Rationale of endodonticsalka shukla
 

What's hot (20)

INTRACANAL MEDICAMENTS IN ENDODONTICS
INTRACANAL MEDICAMENTS IN ENDODONTICSINTRACANAL MEDICAMENTS IN ENDODONTICS
INTRACANAL MEDICAMENTS IN ENDODONTICS
 
Irrigation in endodontics
Irrigation in endodonticsIrrigation in endodontics
Irrigation in endodontics
 
1. Intracanal medicaments
1. Intracanal medicaments 1. Intracanal medicaments
1. Intracanal medicaments
 
Endodontic irrigation
Endodontic irrigationEndodontic irrigation
Endodontic irrigation
 
Recent advances in endodontic irrigation devices
Recent advances in endodontic irrigation devicesRecent advances in endodontic irrigation devices
Recent advances in endodontic irrigation devices
 
Endodontic emergencies
Endodontic emergenciesEndodontic emergencies
Endodontic emergencies
 
Working length determination
Working length determinationWorking length determination
Working length determination
 
Obturation
ObturationObturation
Obturation
 
Irrigants in endodontics
Irrigants in endodontics Irrigants in endodontics
Irrigants in endodontics
 
Restoration of endodontically treated teeth
Restoration of endodontically treated teethRestoration of endodontically treated teeth
Restoration of endodontically treated teeth
 
Endodontic Irrigants
Endodontic IrrigantsEndodontic Irrigants
Endodontic Irrigants
 
Management of hot tooth
Management of hot toothManagement of hot tooth
Management of hot tooth
 
INTRACANAL medicaments
INTRACANAL medicamentsINTRACANAL medicaments
INTRACANAL medicaments
 
Root Canal Irrigation in RCT
Root Canal Irrigation in RCTRoot Canal Irrigation in RCT
Root Canal Irrigation in RCT
 
Rotary in endodontic
Rotary in endodonticRotary in endodontic
Rotary in endodontic
 
Endodontic irrigating solutions
Endodontic irrigating solutionsEndodontic irrigating solutions
Endodontic irrigating solutions
 
Pin retained restorations
Pin retained restorationsPin retained restorations
Pin retained restorations
 
Irrigation agitation techniques
Irrigation agitation techniquesIrrigation agitation techniques
Irrigation agitation techniques
 
Interim and Temporary restorations
Interim and Temporary restorationsInterim and Temporary restorations
Interim and Temporary restorations
 
Rationale of endodontics
Rationale of endodonticsRationale of endodontics
Rationale of endodontics
 

Viewers also liked

Sodium hypochlorite
Sodium hypochloriteSodium hypochlorite
Sodium hypochloriteAnoop Nair
 
Irrigation in endodontics
Irrigation in endodonticsIrrigation in endodontics
Irrigation in endodonticsMohamed Zeglam
 
Irrigation in endo ppt
 Irrigation in endo ppt Irrigation in endo ppt
Irrigation in endo pptDaniel Baiyee
 
Root canal irrigants /endodontic courses
Root canal irrigants /endodontic coursesRoot canal irrigants /endodontic courses
Root canal irrigants /endodontic coursesIndian dental academy
 
Endodontic irrigants pres
Endodontic irrigants presEndodontic irrigants pres
Endodontic irrigants presDrhind 88
 
Current concept of endodontic irrigation
Current concept of endodontic irrigationCurrent concept of endodontic irrigation
Current concept of endodontic irrigationDenny Rinto Alam DDS
 

Viewers also liked (6)

Sodium hypochlorite
Sodium hypochloriteSodium hypochlorite
Sodium hypochlorite
 
Irrigation in endodontics
Irrigation in endodonticsIrrigation in endodontics
Irrigation in endodontics
 
Irrigation in endo ppt
 Irrigation in endo ppt Irrigation in endo ppt
Irrigation in endo ppt
 
Root canal irrigants /endodontic courses
Root canal irrigants /endodontic coursesRoot canal irrigants /endodontic courses
Root canal irrigants /endodontic courses
 
Endodontic irrigants pres
Endodontic irrigants presEndodontic irrigants pres
Endodontic irrigants pres
 
Current concept of endodontic irrigation
Current concept of endodontic irrigationCurrent concept of endodontic irrigation
Current concept of endodontic irrigation
 

Similar to Root canal irrigants and devices

Intracanal irrigants and medicaments.pptx
Intracanal irrigants and medicaments.pptxIntracanal irrigants and medicaments.pptx
Intracanal irrigants and medicaments.pptxDrRiyaGupta1
 
Irrigation of root canals/ orthodontic course by indian dental academy
Irrigation of root canals/ orthodontic course by indian dental academyIrrigation of root canals/ orthodontic course by indian dental academy
Irrigation of root canals/ orthodontic course by indian dental academyIndian dental academy
 
Efficiency of different concentration of sodium hypochlorite during
Efficiency of different concentration of sodium hypochlorite duringEfficiency of different concentration of sodium hypochlorite during
Efficiency of different concentration of sodium hypochlorite duringDrshruti Sood
 
IRRIGATION IN ENDODONTICS.pptx
IRRIGATION IN ENDODONTICS.pptxIRRIGATION IN ENDODONTICS.pptx
IRRIGATION IN ENDODONTICS.pptxDrRutikaNaik
 
Irrigation in Endodontics.pdf
Irrigation in Endodontics.pdfIrrigation in Endodontics.pdf
Irrigation in Endodontics.pdfAltilbaniHadil
 
Microbiological fingerprinting of Anolyte - Prof. Cloete
Microbiological fingerprinting of Anolyte - Prof. CloeteMicrobiological fingerprinting of Anolyte - Prof. Cloete
Microbiological fingerprinting of Anolyte - Prof. CloeteTrevor William Sievert
 
Calcium hydroxide final /prosthodontic courses
Calcium hydroxide final /prosthodontic coursesCalcium hydroxide final /prosthodontic courses
Calcium hydroxide final /prosthodontic coursesIndian dental academy
 
CALCIUM HYDROXIDE in Dentistry
 CALCIUM HYDROXIDE in Dentistry CALCIUM HYDROXIDE in Dentistry
CALCIUM HYDROXIDE in DentistrySindhuVemula1
 
Safe Tap Water Research Paper
Safe Tap Water Research PaperSafe Tap Water Research Paper
Safe Tap Water Research PaperKrista Clark
 
Can The Effective Treatment Of Wastewater In Developing
Can The Effective Treatment Of Wastewater In DevelopingCan The Effective Treatment Of Wastewater In Developing
Can The Effective Treatment Of Wastewater In DevelopingJennifer Perry
 
Root canal irrigants
Root canal irrigantsRoot canal irrigants
Root canal irrigantsSaeed Bajafar
 
(THPS BIOCIDE BASE ) moniotoring in sea water
(THPS BIOCIDE BASE ) moniotoring in sea water(THPS BIOCIDE BASE ) moniotoring in sea water
(THPS BIOCIDE BASE ) moniotoring in sea waterAlsayed Yakoot
 
Treatment of industrial effluent
Treatment of industrial effluentTreatment of industrial effluent
Treatment of industrial effluentShehla Jabeen
 

Similar to Root canal irrigants and devices (20)

Intracanal irrigants and medicaments.pptx
Intracanal irrigants and medicaments.pptxIntracanal irrigants and medicaments.pptx
Intracanal irrigants and medicaments.pptx
 
Irrigation of root canals/ orthodontic course by indian dental academy
Irrigation of root canals/ orthodontic course by indian dental academyIrrigation of root canals/ orthodontic course by indian dental academy
Irrigation of root canals/ orthodontic course by indian dental academy
 
Irrigation manju.pptx
Irrigation manju.pptxIrrigation manju.pptx
Irrigation manju.pptx
 
Env
EnvEnv
Env
 
Efficiency of different concentration of sodium hypochlorite during
Efficiency of different concentration of sodium hypochlorite duringEfficiency of different concentration of sodium hypochlorite during
Efficiency of different concentration of sodium hypochlorite during
 
Irrigation
IrrigationIrrigation
Irrigation
 
Irrigating solutions
Irrigating solutionsIrrigating solutions
Irrigating solutions
 
ENDODONTIC IRRIGANTS
ENDODONTIC IRRIGANTSENDODONTIC IRRIGANTS
ENDODONTIC IRRIGANTS
 
IRRIGATION IN ENDODONTICS.pptx
IRRIGATION IN ENDODONTICS.pptxIRRIGATION IN ENDODONTICS.pptx
IRRIGATION IN ENDODONTICS.pptx
 
Disinfection
DisinfectionDisinfection
Disinfection
 
Irrigation in Endodontics.pdf
Irrigation in Endodontics.pdfIrrigation in Endodontics.pdf
Irrigation in Endodontics.pdf
 
Microbiological fingerprinting of Anolyte - Prof. Cloete
Microbiological fingerprinting of Anolyte - Prof. CloeteMicrobiological fingerprinting of Anolyte - Prof. Cloete
Microbiological fingerprinting of Anolyte - Prof. Cloete
 
Calcium hydroxide final /prosthodontic courses
Calcium hydroxide final /prosthodontic coursesCalcium hydroxide final /prosthodontic courses
Calcium hydroxide final /prosthodontic courses
 
chapter4.pptx
chapter4.pptxchapter4.pptx
chapter4.pptx
 
CALCIUM HYDROXIDE in Dentistry
 CALCIUM HYDROXIDE in Dentistry CALCIUM HYDROXIDE in Dentistry
CALCIUM HYDROXIDE in Dentistry
 
Safe Tap Water Research Paper
Safe Tap Water Research PaperSafe Tap Water Research Paper
Safe Tap Water Research Paper
 
Can The Effective Treatment Of Wastewater In Developing
Can The Effective Treatment Of Wastewater In DevelopingCan The Effective Treatment Of Wastewater In Developing
Can The Effective Treatment Of Wastewater In Developing
 
Root canal irrigants
Root canal irrigantsRoot canal irrigants
Root canal irrigants
 
(THPS BIOCIDE BASE ) moniotoring in sea water
(THPS BIOCIDE BASE ) moniotoring in sea water(THPS BIOCIDE BASE ) moniotoring in sea water
(THPS BIOCIDE BASE ) moniotoring in sea water
 
Treatment of industrial effluent
Treatment of industrial effluentTreatment of industrial effluent
Treatment of industrial effluent
 

More from Ankit Patel

endodontic Mishaps
endodontic Mishapsendodontic Mishaps
endodontic MishapsAnkit Patel
 
Corticosteroid in dentistry
Corticosteroid in dentistryCorticosteroid in dentistry
Corticosteroid in dentistryAnkit Patel
 
Antibiotics in endodontics
Antibiotics in endodonticsAntibiotics in endodontics
Antibiotics in endodonticsAnkit Patel
 
Antibiotics in endodontics
Antibiotics in endodonticsAntibiotics in endodontics
Antibiotics in endodonticsAnkit Patel
 
Gingival tissue management
Gingival tissue managementGingival tissue management
Gingival tissue managementAnkit Patel
 
Laser in dentistry
Laser in dentistryLaser in dentistry
Laser in dentistryAnkit Patel
 
Root apex and working length determination
Root apex and working length determinationRoot apex and working length determination
Root apex and working length determinationAnkit Patel
 
Flare up in endodontics
Flare up in endodonticsFlare up in endodontics
Flare up in endodonticsAnkit Patel
 
Glass ionomer cement
Glass ionomer cementGlass ionomer cement
Glass ionomer cementAnkit Patel
 

More from Ankit Patel (10)

endodontic Mishaps
endodontic Mishapsendodontic Mishaps
endodontic Mishaps
 
Corticosteroid in dentistry
Corticosteroid in dentistryCorticosteroid in dentistry
Corticosteroid in dentistry
 
Antibiotics in endodontics
Antibiotics in endodonticsAntibiotics in endodontics
Antibiotics in endodontics
 
Antibiotics in endodontics
Antibiotics in endodonticsAntibiotics in endodontics
Antibiotics in endodontics
 
Gingival tissue management
Gingival tissue managementGingival tissue management
Gingival tissue management
 
Bonding agents
Bonding agents Bonding agents
Bonding agents
 
Laser in dentistry
Laser in dentistryLaser in dentistry
Laser in dentistry
 
Root apex and working length determination
Root apex and working length determinationRoot apex and working length determination
Root apex and working length determination
 
Flare up in endodontics
Flare up in endodonticsFlare up in endodontics
Flare up in endodontics
 
Glass ionomer cement
Glass ionomer cementGlass ionomer cement
Glass ionomer cement
 

Recently uploaded

CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 

Recently uploaded (20)

Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 

Root canal irrigants and devices

  • 2. CONTENTS 2 introduction history ideal requirements classification chlorine releasing agents oxidizing agents chelating agents organic acids inorganic acids other irrigating solutions • chx • mtad • carisolv • electrochemically activated water • oxidative potential water • ozone • photodynamic therapy • lasers irrigating devices conclusion
  • 3. 3
  • 4. According to Webster’s dictionary The term irrigation is defined as - the therapeutic flushing of a body part with a stream of liquid 4
  • 5. Why do we need irrigants???  Goals of root canal therapy  Eliminate infection  Which is done through  cleaning of organic remnants  shaping to receive a three dimensional filling of the entire root canal space  Prevent re-infection  Obturation  Coronal restoration 5
  • 6. The canal is  Cleansed primarily by irrigation  Shaped primarily by instrumentation HENCE CLEANING AND SHAPING 6
  • 7.  Failure of root canal treatment is likely caused by the inability to eliminate bacteria from the root canal system.  cleaning and shaping of the root canal system is able to reduce the number of bacteria, however complete disinfection of the canal is difficult  because of internal complexity of the root canal system. 7
  • 8.  it has long been established that a root with “a tapering canal and a single foremen” is the exception rather than the rule.  Investigators have shown  multiple foramina,  additional canals,  fins, deltas, intercanal connections,  ‘Cshaped’ canals and  accessory canals  which makes a root canal a far deviation from ‘a tapared canal with a single foramen’ 8
  • 9. 9
  • 11.  Thus a root canal irrigant is needed to aid in the disinfection of the canals completely.  Studies have demonstrated that mechanical instrumentation cannot sufficiently disinfect root canals regardless of the instrumentation technique or system used. 11
  • 12.  Despite technological advances in the ability to shape root canals, at least 35% of root canal surfaces still remain uninstrumented  and Cleaning of the canal in terms of soft tissue removal and elimination of bacteria Relies heavily on the adjunctive action of chemically active irrigating solutions. 12
  • 13.  The choice of an irrigating solution for use in infected root canals requires previous knowledge of the microorganism responsible for the infectious process  as well as the properties of different irrigating solutions. 13
  • 14. 14
  • 15.  Potassium hypochlorite was the first chemically produced aqueous chlorine Solution, invented in France by Bertholiet (1748- 1822).  First use of hypochlorite solutions was as bleaching agents.  Subsequently, sodium hypochlorite was recommended by Labarraque(1777-1850) to be used for infectious diseases.  Based on the studies by Koch and Pasteur, hypochlorite then gained wide acceptance as a disinfectant by the end of the 19th century. 15
  • 16.  In world war II(1915),the chemist Henry Dakin and the surgeon Alexis Carrel extended the use of a buffered 0.5% sodium hypochlorite solution to the irrigation of infected wounds  It was observed that hypochlorite preparations are sporocidal, virucidal , and show far greater tissue dissolving effects on necrotic than on vital tissues  These features prompted the use of aqueous sod hypochlorite in endodontics as the main irrigant as early as 1920 16
  • 17.  Prior to 1940’s Water(140-167 degree C) 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, papain, etc were used and they had tissue dissolving property. 17
  • 18.  Grossman and Meiman in 1941 introduced sodium hypochlorite.  He recommended that solution of 3% hydrogen peroxide be alternated with a solution of 5 .25% sodium hypochlorite, so that effervescence action results in removal in debris from the canal system.  In 1954, commercially available household bleach (Chlorox,5.25% available chlorine) was first recommended by Lewis. 18
  • 19.  In 1957 Nygaard Ostby introduced chelating agents(EDTA) as an aid for preparation of narrow and calcified root canals.  Towards 1970's chelating agents were used increasingly because of their biologically acceptable properties.  ln 1978 quarternary ammonium solutions was introduced as irrigants by Spangberg. 19
  • 20.  ln 1979 Phosphoric acid, Citric acid and Lactic acid was used by Wayman to remove smear layer from the root canals.  In 1980, Electrochemically activated water was used by Russians as root canals irrigants.  In 1980 Martin and colleagues claimed that ultrasonics and NaOCL act synergistically when used together for root canal debridement. 20
  • 21.  In 1982 chlorhexidine was introduced by Delany for its use as an irrigant emphasizing on its antibacterial properties.  Gly- oxide was used by Rome et al in 1985  The last few decades has seen the introduction of Ozone Photodynamic therapy, Lasers as efficient tools for intra canal disinfection. 21
  • 22. 22
  • 23. Role of intracanal irrigants ( Weine)  loosens dentinal shavings and microorganisms from irregular radicular dentine walls.  flushes - the above into the pulp chamber space where it is easily removed by aspiration or paper points.  dissolves - Organic tissues that are entrapped in accessory or lateral canals and that is inaccessible to hand instruments. 23
  • 24. Role of intracanal irrigants ( Weine)  antimicrobial action - Certain irrigants posses germicidal action, others reduce the number of microorganisms by eliminating the source or substrate for survival of these organisms.  lubricating effect-Facilitates instrumentation of the canals.  Some of the irrigants also possess a bleaching action. 24
  • 25. goals of irrigation( Ingle)  Lavage of debris.  Tissue dissolution.  Antibacterial action.  Lubrication 25
  • 26.  Irrigants should possess low surface tension.  Low surface tension promotes flow of fluid into in accessible area.  high surface tension inhibit the spread of liquid over a surface to limit its ability to penetrate a capillary tube. 26
  • 27.  The efficiency of an irrigant could be improved by reducing its surface tension, thereby increasing its wettability hence- penetration into the dentinal tubules of the main and lateral canals.  Alcohol added to an irrigant decreases surface tension. 27
  • 28. 28
  • 29. I. Chlorine releasing agents potassium hypochlorite sodium hypochlorite sodium dichloro isocyarunate chloramine –T II. Oxidizing agents Hydrogen peroxide Urea peroxide Glyoxide III. CHELATING AGENTS EDTA EDTAC RC-Prep IV. ORGANIC ACIDS Citric acid Maleic acid Tannic acid lactic acid V. Inorganic acids H2SO4 50% HCL 30% NITRIC ACID 29
  • 30. VI. Detergents Zephiran chloride Endoquil VII. Others Chlorhexidine Glutaraldehyde Bis- dequalinium acetate Antibiotics NISIN MTAD Carisolv Electrochemically activated water Oxidative potential water Propolis Ozone Photodynamic therapy Lasers Electronic sterilization 30
  • 31. 31
  • 32. sodium hypochlorite 1. manufacture 2. mechanism of action 3. various actions- antimicrobial -tissue dissolving property -action on smear layer -other actions 4. various concentrations 5. toxicity and complications 32
  • 33. SODIUM HYPOCHLORITE  Most popular irrigating solution used as an irrigant for well over many decades.  It was first recommended by Henry Dakin in 1915 and was called as DAKIN‘s solution during the time of World War-ll  NaOCI 0.5% buffered with sodium biocarbonate was used for treatment of infected wounds. 33
  • 34.  Commercially available household bleach (Chlorox – 5.25% available chlorine) was first recommended by Lewis (1954), and has since gained wide acceptance.  Other suggested brands include  Hypo (5% available chlorine),  Sainsbury’s household bleach (3% available chlorine) 34
  • 35. 35
  • 36. ANTIMICROBIAL ACTION  NaOCl is best known for its antibacterial activity.  Studies have generally shown that NaOCl has a broad spectrum antimicrobial activity - It can rapidly kill vegetative bacteria, spore forming bacteria, fungi, viruses, and bacterial spores.  Some investigations show the ability of even 0.5% NaOCl to kill bacteria to a greater extent than other irrigants . 36
  • 37. Mechanism of 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 37
  • 38.  In water NaOCl disassociates into- Na + OCl ions HOCl  Between pH 4-7 chlorine exists predominantly as HCLO, whereas above it as OCl  It is the hpyochlorous acid that is resposible for bacteria inactivation. 38
  • 39.  The bactericidal ability of NaOCl results from the formation of hypochlorous acid (HOCl), when in contact with organic debris.  which exerts its germicidal effect by oxidative action on sulphydryl (-SH) groups of bacterial enzymes.  It disrupts oxidative phosphorylation and other membrane associated activities as well as DNA synthesis.  As essential enzymes are inhibited, important metabolic reactions are disrupted, resulting in the death of the bacterial cells. 39
  • 40. protiens hydrolyzed by HOCl Amino acids Cl Chloramines Interfere with cell metabolism causes cell death 40
  • 41.  Gomes et al. (2001) gave almost similar results regarding the time taken to kill cultures of this species- E. faecalis They have shown that  Percentages contact time  5.25% o.5 min  2.5 % 10 min  1.0 % 20 min  0.5% 30 min 41
  • 42. Tissue solvent property  NaOCL posses strong tissue dissolution property.  The solvent action of NaOCI has been attributed to its high alkalinity.  Grossman and Meiman reported that 5% sodium hypochlorite dissolves pulp tissue in 20 min to 2 h. 42
  • 43. 43 Extirpated pulp Immediately after Placement into NaOCL After 5 minutes After 10 min
  • 44. Various concentrations  there has been much controversy over the appropriate concentration of hypochlorite solutions to be used in endodontics.  As Dakin's original 0.5% sodium hypochlorite solution was designed to treat open (burnt) wounds,  it was surmised that in the confined area of a root canal system, higher concentrations should be used , as they would be more efficient than Dakin's solution . 44
  • 45. Various concentrations  NaOCL has been used in various concentrations ranging from 0.5- 5.25%.  More recently upto 10% also.  the ADA (American Dental Association) accepted concentration for clinical use of NaOCl as an irrigant is 5.25% (Cunningham et al. 1980).  Most commonly used concentration - 2.5%  The antibacterial effectiveness and tissue dissolving capacity of NaOCl is a function of its concentration but so is its toxicity 45
  • 46.  The lower and higher concentrations are equally efficient in reducing the number of bacteria in infected root canal  But the tissue dissolving effect is directly related to the concentration 46
  • 47.  Baumgartner and Cuenin commented that- The effectiveness of low concentrations of NaOCl may be improved by using larger volumes of irrigant and replenishing fresh solutions into the canal more frequently. 47
  • 48. Effect of temperature  On pulp dissolution capacity  According to Waltimo, the capacity of a 1% NaOCl at 45°C to dissolve human dental pulps was found to be equal to that of a 5-25% solution at 20°C .  While at 60°C 1% solution was significantly more effective. 48 Clinically warming NaOCl in a water bath at 60ºC
  • 49. 49 Effect of heating 0.5% NaOCl on pulp dissolution capacity
  • 50. Effect of temperature  On antimicrobial efficacy  The effects of temperature on sodium hypo short term stability, pulp dissolution capacity and antimicrobial efficacy.  George Sirtes, Waltimo,Marc Schaetzle  Journal of endodontics sept 2005  A 100- fold increase in killing efficacy of E.feacalis was observed between the corresponding NaOCl solutions at 20°C and 45°C in a study conducted by George et al( 2005) 50
  • 51. 51
  • 52. Effect of NaOCL on physical properties of dentin  Grigoratos et al. 2001, Sim et al. International Endodontic Journal 2001.  A 2-h exposure of dentine to NaOCl solutions of more than 3% significantly decreases the elastic modulus and flexural strength of dentine compared to physiological saline 52
  • 53. Corrosion of instruments Corrosion adversely affects the metallic surfaces by causing pitting and porosity, It is supposed that these microstructural defects can lead to areas of stress collection and crack formation, weakening the structure of the instrument (Oshida et al. 1992). and decreases the cutting effieciency of endodontic files (Stokes et al. 1999) 53
  • 54. 54 in17% EDTA solution, demonstrating locally corroded area 5.25% NaOCl solution, showing severe corrosion 0.2% chlorhexidine gluconate solution, showing pitting with the corrosion SEMof stainless-steel control file revealed no evidence of corrosion
  • 55. Corrosion of instruments The corrosion rates of stainless-steel files in the tested solutions from the highest to the lowest were: 0.2% chlorhexidine gluconate > 5.25% NaOCl >17% EDTA 55
  • 56. 56
  • 57.  A 1% concentration of NaOCl provides sufficient tissue dissolution and antimicrobial effect,  but the concentration used has been as high as 5.25% because of enhanced anti-microbial activity (Yesilsoy et al. 1995).  As the concentration used rises so does its toxicity.  numerous reports have described clinical complications because of the improper use of NaOCl 57
  • 58. NaOCL toxicity  Sodium hypochlorite is a cytotoxic agent (Gatot et al. 1991, Gernhardt et al. 2004).  When it comes into contact with vital tissue, it causes  haemolysis,  ulceration,  inhibits neutrophil migration  and damages endothelial and fibroblast cells (Gatot et al.1991).  It has a pH of approximately 11–12 and causes injury primarily by oxidation of proteins. (Kaufman & Keila 1989, Gatot et al. 1991, Serper et al. 2004). 58
  • 59. Damage to clothing  Probably the most common incidents during root canal irrigation concern damage of the patients’ clothing.  Prevention  by proper protection of the patients’ clothing.  When using hand irrigation, one should assure that the irrigation needle and syringe are securely attached. 59
  • 60. Damage to the eye  Irrigant in contact with the patient’s or operator’s eyes results in immediate pain, profuse watering, intense burning, and erythema.  Management  Immediate ocular irrigation with large amounts of tap water or sterile saline should be performed by the dentist  the patient should be referred to an ophthalmologist for further examination and treatment (Ingram 1990). 60
  • 61. Injection of sodium hypochlorite beyond the apical foramen- NaOCL Accidents  when the apical constriction has been destroyed during root canal preparation or by resorption.  may occur in teeth with wide apical foramina  Additionally,  extreme pressure during irrigation  or binding of the irrigation needle tip in the root canal which results in contact of large volumes of the irrigant to the apical tissues.  If this occurs, the excellent tissue-dissolving capability of sodium hypochlorite will lead to tissue necrosis. 61
  • 62. Symptomatology  Pain-  Immediate severe pain ( 2-6 minutes)  Oedema  Immediate oedema of neighbouring soft tissues  Possible extension of oedema over the injured half side of the face, upper lip, infraorbital region  Bleeding  Profuse bleeding from the root canal  Profuse interstitial bleeding with haemorrhage of the skin and mucosa (ecchymosis) 62
  • 63. Symptomatology  Chlorine taste and irritation of the throat after injection into the maxillary sinus may be experienced by patient.  Secondary infection possible  Reversible anaesthesia or paraesthesia possible 63
  • 64. 64
  • 65. 65
  • 66. 66 Swelling and extraoral ecchymosis following inadvertent extrusion of sodium hypochlorite (3%) through the apical foramen of a maxillary left cuspid.
  • 67. Management  For the dentist-  remain calm  to inform patient on cause and severity of complication  Immediate irrigation with normal saline to dilute the NaOCl inorder to reduce the soft tissue irritation.  Pain control  Immediate relief of acute pain- local anaesthesia nerve block  analgesics- acetominophen.  In severe cases:  referral to a hospital 67
  • 68.  Antibiotics:  not obligatory. Only in cases of high risk or evidence of secondary infection – amoxicillin 500mg  Antihistamine:  not obligatory  Corticosteroids:  Controversial- dexamethasone, methylprednisolone  For reduction of swelling  Extra oral cold compresses for the first 6 hrs  warm compresses and frequent warm mouthrinses to be done after that. 68
  • 69.  Most patients recover within 1-2 weeks although some cases of long term paresthesia and scarring have been reported.  Further endodontic therapy  with sterile saline or chlorhexidine as root canal irrigants 69
  • 70. Prevention of NaOCl accidents  The following steps can help clinicians avoid NaOCl accidents:  Adequate access preparation to facilitate better access.  Good working length control  Irrigation needle placed 1 mm to 3 mm short of working length  The needle can be bent so as to confine the tip of it to higher levels in the root canal.  Needle to be placed passively and not locked in the canal . 70
  • 71.  Irrigant to be expressed into the root canal slowly and gently  "Flowback" of solution as it is expressed into the canal should be observed  Constant in and out movements of the irrigating needle into the canal space to be done to ensure that the tip is free to express irrigant without resistance.  In case of any resistance felt irrigation to be immediately stopped 71
  • 72.  Use of side delivery needles that are specifically de- signed for endodontic purposes is advocated.  The hub of the needle should be checked for a tight fit to prevent inadvertent separation and accidental exposure of the irrigant to the patient’s eye. 72
  • 73. Allergic reactions to NaOCl  The patient immediately will report of  severe pain and a burning sensation,  within a few s the upper lip and cheek up to the infraorbital area may be swollen,  accompanied by ecchymosis and profuse haemmorhage from the root canal.  Management  Systemic corticosteroid and antihistamine administered intravenously and antibiotics are recommended. 73
  • 74. NaOCL accidents  Palatal mucosa necrosis because of accidental sodium hypochlorite injection instead of anaesthetic solution.  Gursoy UK, Bostancı V, Kosger HH.  International Endodontic Journal,2006. 74
  • 75. Advantages  The ability of NaOCl to dissolve organic soft tissue of the pulp  It is well recognized to be effective against a broad range of pathogens: gram-positive and gram-negative bacteria, fungi, spores, and viruses including the human immunodeficiency virus.  Gross debridement and flushing out of debris.  Removes smear layer when used with EDTA. 75
  • 76. Disadvantages  Acute inflammation followed by necrosis results when NaOCl comes into contact with vital tissue- when extrude out of the apical foramen.  Hypersensitivity, irritation to eyes  Corrosive nature on carbon steel instruments- if left within a syringe may crystallize jamming the plunger.  May crystallize on the root canal walls  Effect on physical properties  Degraded by light, air, and contaminants- hence to use fresh solution always. 76
  • 77.  Severe irritations have been reported when concentrated solutions were inadvertently forced into the periapical region or leakage through rubber dam  Furthermore a 5.25% solution significantly decreases the elastic modulus and flexural strength of dentin  The reduction of intracanal microbiota is not any greater when 5% NaOCl is used as compared to 0.5%.  1% solution has shown to dissolve the entire pulp tissue during the course of treatment when replenished frequently.  Hence based on the current evidences there is no rationale for using hypochlorite solutions at concentrations above 1%. 77
  • 78. - Hydrogen peroxide - Urea peroxide 78
  • 79. 79
  • 80.  H2O2 is a widely used biocide for disinfection and sterilization.  It is a clear, colorless liquid that is used in a variety of concentrations in dentistry, ranging from 1% to 30%.  it degrades into water and oxygen.  H2O2 solutions are quite stable. 80
  • 81.  H2O2 is active against viruses, bacteria, yeasts, and even bacterial spores .  The mechanism of action of this oxidizing solution involves the reaction of superoxide ions to produce hydroxyl radicals, which are the strongest oxidants known.  This radical can attack membrane lipids, DNA and other essential cell components. 81
  • 82.  Moller recommended 30% H2O2 as the first step in tooth surface disinfection.  It has been particularly popular in cleaning the pulp chamber from blood and tissue remnants, it has also been used in canal irrigation. 82
  • 83.  For years 3% H2O2 has been recommended as a canal irrigant because of its effervescent action in presence of blood products.  effervescent action:  This action was specially indicated in mandibular teeth where the bubbling of the peroxide was thought to lift debris from the canal system.  However, H2O2 does not possess tissue dissolution properties and is not effective as a lubricant. 83
  • 84.  Hence, alternate use of H202 + 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 02 that is liberated in an active state assists in destroying anaerobic microorganisms. 84
  • 85. 3. ln combination with NaOCl it effectively removes the soft tissue debris. 4. Increases the bleaching action on discolored teeth. 85
  • 86.  Certain disadvantages associated with it are-  It does not possess tissue dissolving property  Not a lubricant  Has limited antimicrobial action. 86
  • 87. Complications  When peroxide is used it must eliminated from the pulp cavity before the crown is sealed otherwise oxygen may be evolved afterwards as a result of contact with blood or tissue fluids.  Besides causing pressure within the periapical region, this could force debris and microorganisms into the tissues. 87
  • 88. Complications  Injection of hydrogen peroxide beyond the apex:  Bhat (1974) reported a case in which hydrogen peroxide of unknown concentration was injected into the soft tissues.  As treatment was performed under local anesthesia, the patient experienced no pain but complained about a rapidly developing swelling on the upper lip and some difficulty in breathing.  The canal was left open, the patient was prescribed antibiotics and instructed to apply cold packs.  The emphysema, caused by oxygen liberated from the hydrogen peroxide, subsided in 1 week and root canal treatment was completed. 88
  • 89. 89
  • 90.  Urea peroxide  (Endo-PTC or Gly-Oxide)  is another widely used solution to aid instrumenation  The peroxides are oxidizing agents that react chemically, liberating great amounts of nascent oxygen that explains their  bactericidal action,  the effervescence, due to the liberation of oxygen,  contributes to the removal of pulp tissue remains and dentin particles during the chemico-mechanical preparation. 90
  • 91. Antimicrobial action-  Mechanism of action  Produces hydroxyl radicals that oxidixes sulphydryl groups, double bonds in protiens, lipid and outer membranes- cause cell death.  It retains its antibacterial activity in the presence of blood whereas aqueous 3% hydrogen peroxide does not. 91
  • 92.  The Urea Peroxide has several desirable characteristics for the Irrigation of root canals  It presents detergent properties  not irritating to the periapical tissues and  non allergenic. 92
  • 93. Glyoxide  is an irrigant comprising of 10% urea peroxide (carbamide peroxide) in a vehicle of anhydrous glycerol . 93
  • 94. 94
  • 95. Although NaOCl appears to be the most desirable single endodontic irrigant, it cannot dissolve inorganic dentin particles and thus remove the smear layer formed during instrumentation. In addition calcifications hindering mechanical preparation are frequently encountered in the canal system which cannot be negotiated without use of chelating agents. Demineralizing agents such as EDTA and citric acid have therefore been recommended as adjuvant in root canal therapy 95
  • 96.  The term chelate originates from Greek word "chele" (crab claw)  Chelates are particularly stable complexes of metal ions with organic substances .  The ability of chelator to bind and inactivate metallic ions is widely exploited in medicine to bring about excretion of dangerous ions in case of metal poisoning  or in treatment of copper metabolism disturbances. 96
  • 97. Historical development of chelators  1957- Chelators were first introduced to Endodontics by Nygaard- Ostby who recommended the use of 15% EDTA solution (pH 7.3)  Original Nygaard Ostby formula for 15% EDTA was: -diSodium salt of EDTA - 17.0 g -distilled water - 100.00 ml -5N sodium hydroxide - 9.25 ml 97
  • 98. Historical development of chelators  1963- A detergent was added to increase the cleaning and bactericidal potential of EDTA.  The new composition being known as EDTAC which has 0.84g of quaternary ammonium compound - Cetavlon  EDTAC reduced surface tension of the irrigant facilitating wetting of the entire root canal wall thereby increasing the ability of chelators to penetrate dentine.  It also had a greater anti-microbial effect than EDTA. 98
  • 99.  1969- Strewart et al. introduced RC-Prep (Premier Dental) paste type chelating agent.  Recently paste type chelators have regained popularity as almost all manufacturers of Ni-Ti instruments recommend the use of EDTA as a lubricant during rotary root canal preparation to reduce the risk of instrument separation. 99
  • 100. -Dimeralization action- dentin permeability - working time -Antibacterial action -Biocompatibility -Combined use of EDTA and NaOCl -Other effects -Various preparations 100
  • 101. EDTA  ethylenediamine Tetra Acetic Acid (EDTA) is a chelating substance that has been used as an irrigant.  It is capable of removing calcium ions of the dentin giving rise to demineralization  and as a consequence, increasing the dentin permeability of the root canals.  EDTA is used in concentrations from 10 to 17% 101
  • 102. Demineralization  When EDTA solution comes in contact with dentine the calcium ions are removed from dentine by the chelating action, causing decalcification of dentine  EDTAH + Ca = EDTACa + H  as this reaction proceeds, acid accumulates and protonation of EDTA prevails thus decreasing the rate of demineralization  EDTAH + H = EDTAH2 102
  • 103.  The extent of dimineralization zone is dependant on duration of action( 20 min- 96 hrs)  A 20- 30 micron demineralized zone was apperent after 5 min.  This increased to 30- 40 µm after 30 min  And 50 µm after 24-48 hrs.  This layer was separated from the deeper unchanged dentin by a clearly defined smooth demarcation line. 103
  • 104. Self limiting action  This effect is found to be rapid during first 1 hr and reaches equilibrium by the end of 7 hrs. 104
  • 105.  This demineralizing action  Removes inorganic component of smear layer  Reduces the time necessary for debridement  Aides in enlarging narrow/ obstructed canals  Helps bypass fragmented instruments 105
  • 106. Smear layer 106 Smear layer on dentin surface after instrumentation Smear plugs into dentinal tubules
  • 107. Smear layer 107 Surface after removal of smear layer with 17% EDTA solution.
  • 108. CHANGES IN DENTINE PERMEABILITY  after removal of smear layer with the aid of EDTA, dentin permeability increased and reduction in micro leakage between the definitive root canal filling and canal wall was achieved.  The ability of the sealer to penetrate the dentinal tubules and thereby the adaptation of the root canal filling to the root canal wall is much improved.  Further more this increase in root dentin permeability results in an increase in the activity of endodontic medicament. 108
  • 109. Working time of the chelator  Several studies have reported a good cleaning efficiency of EDTA between working time of 1-5min.  Yamada et al. 1983,  Cergneux et al. 1987,  gait & Serper 2000,  Hulsmann & Heckendorff 2002,  Scelza et al. 2003. 109
  • 110. Clinical recommendations  Hulsmann M, Heckendroff M, Lennon A.  chelating agents in root canal treatment: mode of action and indications for use- a review  IEJ 2003 1) root canal preparation can be carried out with the aid of chelator paste. This may be introduced into the root canal with the preparation instrument. The canals first should have been flooded with NaOCl to dissolve vital or necrotic tissue. 2) A chelator in paste form serves as a lubricant for files and reduces the risk of instrument fracture in the canal. 110
  • 111. 3. A final intensive rinse with 17% EDTA reduces the extent of the smear layer remaining which in turn results in a cleaner canal wall and better adaptation of the root fillings to the canal walls. 4. EDTA containing agents should be used between 1-5 minutes . 5. liquid EDTA solution may be introduced into the pulp chamber to identify the entrance of calcified canals. 6. Apical extrusion of the chelator solution should be avoided. 111
  • 112. Various preparations  liquid chelators:  Calcinase  Contains 17% Sodium edetate, sodium hydroxide as a stabilizer and purified water.  REDTA (Roth International )  has 17% EDTA solution  with addition of 0.84g Cetrimide to reduce the surface tension. 112
  • 113.  EDTA-t  Contains 17% EDTA+ Sodium lauryl ether sulfate (Tergentol) as a detergent.  EGTA (sigma)  main component is ethylene glycol bis ( amino ethyl ether) N,N,N,N-tetra acetic acid.  It is reported to bind Ca+ more specifically than EDTA  Largal ultra (septodent)  contains 15% EDTA,  0.75% certimide  pH value to 7.4 113
  • 114.  Salvizol (Ravens,Germany)  N1-decamethylene-bis-4-aminoquinaldinium diacetate in propylene glycol.  pH 6.6.  Kaufman et al. have suggested that salvizol with a neutral pH, has a broad spectrum of bactericidal activity and the ability to chelate calcium.  This gives the product a cleansing potency while being biologically compatible. 114
  • 115.  Paste chelators  these paste chelators are the one most commonly recommended with rotary instrumentation.  Calcinase slide:  it contains 15% sodium EDTA  58 to 60% water.  Has alkaline pH value of 8.9  it is water soluble hence easily rinsed from root canal system  The gel is firm at room temperature and develops a creamy consistency when agitated . 115
  • 116.  RC-PREP-  It contains 15% EDTA,  10% Urea peroxide and  glycol in aqueous ointment base .  Oxygen is set free by reaction of NaOCI with RC-Prep resulting In effervessence, so that pulpal remnants and blood coagulates can be easily removed from the root canal wall (Stewart et al).  Glycol acts as a lubricant 116
  • 117.  Glyde file :  Is composed of 15% EDTA  10% Urea peroxide in aqueous solution.  It has got properties similar to RC-Prep .  FileCare EDTA  Also composed of 15% EDTA and  10% urea peroxide  file EZE  Contains 19% EDTA 117
  • 118. Ruddle solution  contains:- 5% NaOCl, Hypaque 17%EDTA  Hypaque is a high contrast radiopaque & injectable dye.  lt is water soluble with pH of 6.7- 7.7.  This composition simultaneously provides the solvent action of full-strength NaOCl, visualization, & improved penetration.  Used to visualize the microanatomy, verify the shape, monitor the remaining root wall thickness. 118
  • 119. - Citric acid - Maleic acid - Tannic acid 119
  • 120. CITRIC ACID  One of its advantages is its non-cytotoxicity, it is more acceptable biologically than other acids (Jenkin and Dawer 1963).  Many different concentrations of citric acid have been used, with varying degrees of success.  10% , 20%, 25%, 50% solutions are used successfully for these purposes .  A SEM study showed that 20% citric acid was slightly more effective than 10% Citric acid; however, these differences did not appear to be significant. 120
  • 121. 121
  • 122. 122 -Antibacterial action -Substantivity -Combination with NaOCl -Biocompatibility- cytotoxicity -Limitations
  • 123. CHLORHEXIDINE  CHX in the form of a salt( gluconate, acetate or hydrochlorate) has been widely used since 1950’s at different concentrations as an oral antiseptic because of its excellent antimicrobial activity.  The most common preparation is with digluconate salt because of higher water solubility.  pH of 5.5 – 7  of 5.5 123
  • 124. CHLORHEXIDINE  Unlike NaOCl ,  CHX does not have a bad odor  Is not equally irritating to periapical tissues  Does not cause spot bleaching of patient and doctor’s clothes.  Has no deleterious effects on the physical properties of dentin  of 5.5 124
  • 125. Structure  It is a cationic chlorophenyl bisguanide with bacteriostatic and bacteriocidal action. 125 NH C NH C NH (CH2)6 NH C NH C NH NH NH NH NH Cl Cl
  • 126. Concentration  Include  0.12%,  0.2%,  and 2%  Commercially available oral rinse typically contains 0.12% CHX gluconate.  0.12% CHX has been found to be ineffective for endodontic use whereas concentrations above it have been successfully used  Sassone (2003)  Luciana M( Aust Endo J 2008)  Available in both gel and liquid formulations 126
  • 127. Antibacterial action  It has a wide antimicrobial spectrum and is effective against both Gram-positive and Gram-negative bacteria as well as yeasts, while bacterial spores are resistant to CHX.  It shows comparatively greater efficacy towards gm positive bacteria  It has been reported that CHX does not inactivate lipopolysaccharide (LPS), which is a structural component of the Gram-negative bacteria’s outer cell envelope 127
  • 128.  at physiologic pH CHX is a large dicationic molecule, with the positive charge distrubuted over the nitrogen atoms on either side of the heamatoxylin bridge.  The bacterial cell is characteristically negatively charged. 128
  • 129.  Low concentrations- bacteriostatic  High concentrations- bactericidal  CHX penetrates the cell wall and causes precipitation or coagulation of cytoplasm probably caused by cross linking. 129
  • 131. - Adsorption to the surface of bacteria due to the cationic-anionic electrostatic attraction…
  • 132. … making the membrane permeable
  • 133. this results in micro leakage of intracellular components leading to cell death 133
  • 134. Substantivity  clinically CHX’s substantivity seems to be another advantage over NaOCl, sustaining the antimicrobial activity over a period of 48 hours or 72 hrs after treatment  Their cationic properties also allow them to bind electrostatically to surfaces  They are gradually released from the surface, as the concentration of chlorhexidine in the environment decreases TOOTH 134
  • 135. The reversible reaction of uptake and release of CHX results in a substantive antibacterial activity Parsons et al 1980 Fardal and Turnbull 1986 Greesntein et al 1986 Jeansonne and White 1994
  • 136. Biocompatibility  Extremely low level of tissue toxicity as compared to NaOCl ( as low as 0.5%)  Loe 1973  Tanomaru Filho M IEJ 2002  Oncag O et al IEJ 2003  Allergic reaction to CHX are rare  Okano et al. 1989  Garvey et al 2001 136
  • 137. limitation  The inability of CHX to dissolve organic matter  Jeansonne and White 1994  D’Arcangelo et al 1999  Marley et al 2001  Okino and Siqueira et al 2004  No action on smear layer 137
  • 138. 138
  • 139. 139
  • 140.  Bio pure MTAD ( Dentsply Tulsa Dental) is an irrigating solution containing  An antibiotic- 3% doxycycline hydrate  An acid- 4.25% citric acid  A detergent- 0.5% polysorbate 80 (Tween 80) 140
  • 141.  Based on extensive well conducted studies MTAD has been shown to be clinically effective,  Biocompatible  Removes smear layer while being less erosive  With potential sustained antibacterial activity. 141
  • 142. dentinal erosion 142 Irrigating solution during root canal preparation: 5.25% NaOCl. Final solution for removal of smear layer (5 min.): MTAD Irrigating solution during root canal preparation: 5.25% NaOCl. Final solution for removal of smear layer (5 min.): 17% EDTA
  • 143. Tetraclean  Tetraclean is another combination product similar to MTAD  Similar to MTAD Tetraclean, is also capable of removing the smear layer. their low surface tension, increases the intimate contact of irrigant solutions with the dentinal walls, they may permit deeper penetration. 143
  • 144. 144
  • 145. ECA  Russian scientists have developed a process whereby so-called electro-chemically activated water (ECA) is produced with a new and unique anode–cathode system (Leonov 1997).  ECA is produced from tap water and saline solution by a special unit that houses a unique flow-through electrolytic module (FEM).  to obtain the best end solutions with the ECA, NaCI water solutions with no more than 5.0 g/L concentration or fresh water of less than 1.0 g/L mineralization is needed. 145
  • 146.  The FEM contains the  Anode  -made from titanium and coated with ruthenium-oxide, iridium and Platinum,  cathode  made from titanium coated with pyrocarbon and glass carbon.  the anode being a solid cylinder fits coaxially inside the cathode which is a hollow cylinder  Membrane  Made up of ceramic in between them. 146
  • 147.  Electrolysis of water is known as a redox reaction.  At the anode,  electrons are removed from the water and it is oxidized, as in 2H202 = O2 + 4H+ 4e-  we get oxygen gas and hydrogen ions  At the cathode  electrons are added to the water as it is reduced,  2H2O + 4e = 2H2 + 4 OH  we get hydrogen gas and hydroxide ions. 147
  • 148.  The physical and chemical nature of ECA is not yet fully understood.  The solution supposedly exists in a metastable or disequilibrious state for 48 h after production and contains many free radicals and a variety of molecules.  After 48 h the solution returns to the stable state, becoming inactive again.  In the metastable state the solutions have a very high oxidation- reduction potential.  Two types of ECA solutions are produced. 148
  • 149. Oxidative potential water  Oxidative potential water (OPW) has been used extensively in Japan for household and agricultural disinfection because of its safety and bactericidal effectiveness.  According to the manufacturers’ claims, the antimicrobial and antiviral activities of OPW are sufficiently powerful to kill a wide variety of pathogens, including HIV.  The basis for the development of the OPW is that microorganisms cannot survive in an aqueous environment with both low pH (less than 3) and high oxidation-reduction potential (greater than 0.9 V) (Becking et al . 1960). 149
  • 150.  Oxidative potential water is an electrochemically created, highly acidic water that accumulates in the anode Compartment  OPW has strong antimicrobial activity, killing viruses as well as bacteria, an unusually low pH of 2.7 or less, and oxidation- reduction potentials of 1050 mV or greater 150
  • 151.  Oxidative potential water is well suited for dental treatment because  of its low toxicity and lack of irritation to soft tissues,  and because it quickly loses its high oxidation-reduction potential and low pH when it reacts with light-sensitive and/or organic substances.  For these reasons it is completely safe as a root canal irrigant.  A study by Hata et al .( 1996) showed that OPW effectively removed the smear layer from instrumented canal walls when used as an irrigant. 151
  • 152. 152 Middle third of a root canal irrigated with 10 mL. (b) Apical third of a root canal irrigated with 20 mL. Dentinal tubules were open, although occasionally blocked by smear plugs. Middle and apical thirds of a root canal irrigated with 30 mL. Syringe irrigation with OPW removed the superficial smear layer and debris from the canal wall.
  • 153. 153
  • 154.  Ozone (O3) is an unstable gas, which breaks down into oxygen very quickly  hence, it cannot be bottled, but must be generated fresh when it is needed.  half-lifehalf-life - 40 minutes  154
  • 155. MODE OF ACTION OF OZONE  when ozone dissolves in water, it becomes highly unstable and rapidly decomposes through a complex series of chain reactions (Hoigne & Bader 1976, Shin et al. 1999).  in two different and coexisting modes  one involving direct reactions of molecular ozone  the other a free radical-mediated reaction (Staehelin & Hoigne´ 1985).  As a result, hydroxyl (OH) radicals are generated, which are amongst the most reactive oxidizing species. 155
  • 156. MODE OF ACTION OF OZONE  Both these mechanisms may be involved in the destruction of bacteria by ozone.  Destroys microorganisms by oxidizing bacterial cell walls and membranes and finally rupturing their membranes 156
  • 157. OZONE THERAPY IN ENDODONTICS  The application of ozone makes the complete sterilization of the root canal a real possibility in the near future.  Tooth that is to be treated ozonically needs to be built up so that the clinical crown is restored.  Ozone is applied from the access opening, making the technical realization a simple process.  There are five differently sized silicone cups available to enable perfect tooth sealing 157
  • 158. 158 Inserting the ozone cannula into the prepared Root canal Treatment with ozone with a complete seal
  • 159.  Ozone has limitations as it is irritating to the respiratory system (Hazucha et al. 1989).  Very low concentrations (0.2–0.5 ppm) may cause headache, and irritation or dryness of the nose, throat and eyes (McDonnell et al. 1983).  Higher concentrations (1–10 ppm over a few hours) may cause lung congestion, oedema, haemorrhage, changes to the blood and loss of vital lung capacity.  It is irritating to the eyes and can cause redness, pain and blurred vision 159
  • 160. CONTENTS 160 introduction history ideal requirements classification chlorine releasing agents oxidizing agents chelating agents organic acids inorganic acids other irrigating solutions • CHX • MTAD • Electrochemically activated water • Oxidative potential water • Ozone • • lasers • photodynamic therapy • irrigating devices  Ultrasonic irrigation  conclusion
  • 161. 161
  • 162. Lasers  The potential use of different endodontic lasers in eradicating the root canal microbes has been the focus of interest for many years.  dental lasers provide greater accessibility of formerly unreachable parts of the tubular network due to their better penetration into dentinal tissues 162
  • 163. Lasers  Scientific research was first conducted with the Nd: YAG and the diode lasers which gained widespread acceptance in the fields of laser assisted endodontics,  For both wavelengths, a high disinfecting capability was reported.  At the same time lasers suitable for the preparation of dental hard substances like the Er:YAG and the Er.Cr :YSGG underwent further development resulting in delivery systems also usable for root canal application. 163
  • 164.  In various laser systems used in dentistry, the emitted energy can be delivered into the root canal system by  a thin optical fiber  Nd:YAG  Er,Cr:YSGG  argon  diode.  or by a hollow tube –  C02  Er:YAG  Recent Investigations Indicate that these laser systems exhibit satisfying bactericidal abilities thus constituting relatively new additions to the spectrum of lasers used in endodontics . 164
  • 165.  It has been documented that  C02 ,  Nd:YAG,  argon,  Er,Cr:YSGG  and Er:YAG laser irradiation  has the ability to remove debris and smear layer from the root canal walls following biomechanical instrumentation. 165
  • 166. Limitations  There are several limitations that may be associated with the intracanal use of lasers that cannot be overlooked.  The emission of laser energy from the tip of the optical fiber or the laser guide is directed along the root canal and not necessary laterally to the root canal wall.  Thus it is almost impossible to obtain uniform coverage of the canal surface using a laser making complete removal of smear layer and debris difficult  Investigators strongly recommended improving the endodontic tip to enable irradiation of all areas of the root canal walls. 166
  • 167. Limitation  Another limitation is the safety of such a procedure because thermal damage to the periapical tissues potentially is possible.  Direct emission of laser irradiation form the tip of the optical fiber In the vicinity of the apical foramen of a tooth may result In transmission of the irradiation beyond the foramen.  Which in turn, may effect the supporting tissue of the tooth adversely and can be hazardous in teeth with close proximity to the mental foramen or to the mandibular nerve. 167
  • 168. 168
  • 169.  During the early 1990’s Prof. M. Wilson and Prof. G. Pearson first proved PAD killed strep mutans in significant numbers and reasoned that PAD could kill all bacteria involved in oral infections in caries, root canals, and periodontics  Prof. Wilson and Prof. Pearson worked with Denfotex to convert PAD into a routine clinical procedure, patented by both E.D.I. and Denfotex. 169
  • 170.  Also known as photodynamic therapy(PDT)  is based on the concept that a nontoxic,photosensitizing agent known as photosensitizer(PS) can be preferentially localized in certain tissues and  subsequently activated by light of the appropriate wavelength to generate  singlet oxygen and free radicals that are cytotoxic to cells of the target tissues 170
  • 171. Components  PAD solution  A dilute solution containing tolonium chloride which was established as the most effective photosensitiser, packaged either in syringes (for delivery to root canals) or dropper bottles.  SaveDent laser  A low power 635 nm laser light source which optimally activates the solution. 171
  • 172. APPLICATION  Canal is washed out thoroughly with sterile saline solution and dried  P.A.D solution is introduced into canal from syringe via a suitable needle and canal and pulp chamber filled with P.A.D solution.  the solution is agitated in the canal for 60 s using an endodontic file one size smaller than that to which the canal has been prepared. 172 Root canal prepared  PAD solution applied and agitated  
  • 173.  The flexible emitter tip is introduced into the canal until resistance  P.A.D laser is activated according to manufacturer’s instructions for 150 s at 100 mW.  when the distance from the entrance in the pulp chamber to the point of resistance in the canal exceeds 10 mm,  the canal is treated in sections by withdrawing the emitter in 5 mm steps and then irradiate each section for 150 s.  After canal has been completely treated, canal washed with sterile solution and dried by aspiration followed by sterile paper points. 173
  • 174. How Does PAD Work ?  PAD solution is activated by 635nm light and acts as a photosensitiser, releasing reactive oxygen species which disrupt the membrane of the micro organism.  Independently, the laser and solution have no effect, but in combination produce a powerful anti-bacterial action. 174
  • 175. Bacteria before photo activated disinfection Same bacteria sample after photo activated disinfection process showing disruption of membrane. 175
  • 176. Mixed lactobacilli and streptococci bacteria in an infection PAD solution (in blue) attached to bacteria PAD solution activated by red laser light Bacteria destroyed by PAD 176
  • 177. Efficacy  Extensive laboratory and in-vitro studies at the Eastman Dental Institute, London, together with clinical assessment in Germany and UK in root canals and carious lesions have clearly proved the efficacy of PAD.  PAD has been shown to kill all types of bacteria commonly found in caries and root canals including-  Streptococcus mutans, S. sobrinus, S. intermedius  Actinomyces  Lactobacillus  Veilonella  Prevotella intermedia  Peptostreptococcus micros  Fusobacterium nucleatum  E. faecalis 177
  • 178. 178
  • 179.  An alternative regimen for root canal disinfection  Bonsor, R. Nichol, T. M. S. Reid and G. J. Pearson  Br Dent J 2006  Results of this study indicate that the use of a chelating agent and photo-activated disinfection to kill bacteria is an effective alternative to the use of hypochlorite as a root canal cleaning system.  Soukes et al JOE 2006 showed the combination of methylene blue with red light were able to eliminate 97% of E.feacalis biofilm bacteria in root canals . 179
  • 180. PAD  Seal GJ, Gulabivala K.IEJ 2002  The combined use of a photosensitizing agent and a low power laser directed at the access cavity was bactericidal to S. intermedius biofilms in root canals but was unable to achieve total kill, unlike 3% NaOCl. 180
  • 181. ADVANTAGES  PAD can be applied effectively for killing gram-positive, gram- negative, aerobic and anaerobic bacteria - in fact, all commonly encountered bacteria associated with dental disease.  PAD can kill bacteria in complex biofilms, which are typically resistant to the action of antimicrobial agents.  Photo activated disinfection overcomes the problems of antibiotic resistance.  PAD does not pose any thermal risks due to the low power of the PAD laser. 181
  • 182. Disadvantages  At the concentration provided, PAD solution produces no side effect other than  a transient color change in the dentine on the surface of the canal wall.  This is removed by the washing process with sterile saline performed after disinfection of the canal 182
  • 183. QMiX (QUÍMICO MECÁNICA MIX)  Q mix is an irrigation solution used as a final rinse. It is a combination of CHX with EDTA and a surfactant solution to improve penetration in dentinal tubules. Advantages:  Low surface tension is one of the ideal characteristics of an irrigant Superior Antibacterial efficacy. Superior smear layer removal Ready to use, fast working Less demineralization OF DENTIN compared to EDTA 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
  • 184. 184
  • 185. 185
  • 186. Herbal • Murray et al. evaluated Morinda citrifolia juice in conjunction with EDTA as a possible alternative to NaOCl. • Triphala (IMPCOPS Ltd, Chennai, India) is an Indian ayurvedic herbal formulation consisting of dried and powdered fruits of three medicinal plants, Terminalia bellerica, Terminalia chebula, and Emblica officinalis, and green tea polyphenols (GTPs; Essence and Flavours, Mysore, India); the traditional drink of Japan and China is prepared from the young shoots of tea plant Camellia sinensis. • Dimethyl sulfoxide (DMSO) is used as a solvent for Triphala and GTP, although they are readily soluble in water. DMSO is a clean, safe, highly polar, aprotic solvent that helps in bringing out the pure properties of all the components of the herb being dissolved 186
  • 187. • Herbal alternatives showed promising antibacterial efficacy on 3- and 6-week biofilm along with MTAD and 5% sodium hypochlorite. • Although Triphala and green tea polyphenols (GTPs) exhibited similar antibacterial sensitivity on E. faecalis planktonic cells, Triphala showed more potency on E. faecalis biofilm. This may be attributed to its formulation, which contains three different medicinal plants in equal proportions. In such formulations, different compounds may be of help in enhancing the potency of the active compounds resulting in an additive or synergistic positive effect. • According to Prabhakar et al. 5% of sodium hypochlorite exhibited excellent antibacterial activity in both 3-week and 6-week biofilm, whereas Triphala and MTAD showed complete eradication only in 3- week biofilm 187
  • 188. • Triphala and GTPs are proven to be safe, containing active constituents that have beneficial physiologic effect apart from its curative property such as antioxidant, anti-inflammatory, and radical scavenging activity and may have an added advantage over the traditional root canal irrigants. 188
  • 189. 189
  • 190.  Although the technique for irrigation is simple, the potential for serious complications exists.  Regardless of the delivery system, -the solution must be introduced slowly - the needle never wedged in the canal  As a rule, the clinician should irrigate copiously, recapitulate and continue. 190
  • 191.  The most common method of delivering irrigant into the canal is with the aid of a syringe and needle  A 5 ml syringe with a Leur Lok mechanism is the preferred one.  Gauge of the needle  Gauges ranging from standard 22 to finer 30 have been used in endodontic irrigation.  Since irrigation of the apical third requires the needle to be in close proximity for adequate effect the canals should be flushed with a 27-30 gauge preferably. 191
  • 192.  For relatively large canals the tip of the syringe is placed until resistance from the canal wall is felt, the tip is withdrawn a few millimeters, the solution is expressed very slowly until the chamber is full.  In treatment of posterior teeth and or small canals the solution is deposited in the chamber .  The file will carry the irrigants into the canals and the capillary action of narrow canal diameter will retain much of the solution. 192
  • 193.  Excess irrigant is carried away by aspiration with a small tip of approximately 16 gauge otherwise a folded gauze pad is held near the tooth to absorb the excess.  Several types of plastic disposable syringes are available. 193
  • 194.  It should be bent approximately 30degrees in the center of the needle to allow easier delivery of the solution and to prevent deep penetration of the needle or probe. 194
  • 195. 195 Squeezing the plunger with the thumb may result in more rapid delivery Of irrigant and possible extrusion Using a forefinger to depress the plunger gives greater control of irrigant delivery
  • 196. Designs of needle  1. open ended blunt needles  2. beveled needles  3. blunt ended side venting needle  4.notched tip  5. perforated needle 196
  • 197. 197 Bevelled needle Irrigant passes apically Monoject type- irrigant passes sideways and apically Safe ended tip Irrigant passes sideways
  • 198. Designs of needle  ProRinse probes  The effectiveness of the ProRinse seemed related to its design.  It has a blunt tip, with the lumen 2 mm from the tip.  Expression of fluid through the lumen creates turbulence around and beyond the end of the probe.  Also prevents forceful periapical injection of irrigant. 198
  • 199. 199
  • 200.  Moser and Heuer reported monoject endodontic needles to be the most efficient delivery system in which longer needles of a blunted, open-end system were inserted to the full length of the canal. 200
  • 201.  Stropko NI-TI irrigation needles  They are available in short (17 mm) and (25 mm) long sizes and can be sterilized and reused.  Needle size is 27 gauge, side vented.  Advantages are its good flexibility and their resistance to clogging. 201
  • 202.  MAX-l-PROBE  These are designed to produces upward flushing motion for complete canal irrigation.  Side port dispersal prevents solution and debris from being expressed through the apex closed,  rounded end reduces risk of apex damage.  Closed-end needle eliminates possibilities of puncture of the apical foramen 202
  • 203. 203
  • 204. THE ENDO VAC SYSTEM  The EndoVac system (Discus Dental) consists of a delivery/evacuation tip attached to a syringe of irrigant and the highspeed suction of the dental unit.  A small tube attaches either a macro or micro-cannula to the suction.  The delivery/evacuation tip places irrigant in the chamber and siphons off the excess to prevent overflow. 204
  • 205. THE ENDO VAC SYSTEM  The macro-cannula is plastic with an open end that measures size 55 with a 0.02 taper.  The micro-cannula is stainless steel and has 12 small, laterally positioned, offset holes in 4 rows of 3, with a closed end measuring ISO size 30.  The micro-cannula can be used at working length in a canal enlarged to ISO size 35 or larger. 205
  • 206. 206 Scanning electron microscope photograph of the microcannula Comparison picture of the closed-ended microcannula (ISO size 30) open-ended macrocannula (ISO size 55).
  • 207. 207 The macrocannula attached to its handle used for initial flushing of the coronal portion of the canal. The microcannula attached to its handle. and is used for irrigation at the apical portion of the canal to working length.
  • 208. 208 The delivery/evacuation tip attached to a syringe. Irrigant is delivered to the pulp chamber by the metal needle. Any excess is immediately suctioned off through the plastic tubing surrounding the metal that is attached to the suction.
  • 209. 209 A) The complete EndoVac system including all tubing and vacuum attachment. The free end of the large tubing plugs into the high speed suction of the dental chair.
  • 210.  MICRO BRUSHUS  Advancement in small wire technology, bristle materials and bristle attaching techniques have enabled the creation of an endodontic microbrush of clinical field testing.  A micro-brush is provided to remove the smear layer that remains in the root canal after the pulp, bacteria, and related irritants have been mechanically and chemically removed from the root canal using files and irrigants like sodium hypochlorite. 210
  • 211.  The brush includes a shaft or shank and a tapered brush section extending from the distal end of the shank.  The brush section includes bristles extending radially from a central wire base.  The shank can be provided with a handle for manual use or the shank can be adapted to be received in a rotary, sonic, or ultrasonic handpiece to impart rotational or vibratory motion to the micro-brush. 211
  • 212.  The brush section has a diameter of between about 0.2 mm and about 0.7 mm at a tip end and a diameter of between about 1 mm and 2 mm at a coronal-most end.  The brush section is about 16 mm long, and thus has a taper of about 0.06 mm/mm and about 0.12 mm/mm. 212
  • 213.  Rotary and ultrasonic endo brushes are fabricated in ISO lengths, containing 16mm of bristles, have the bristle diameter of 0.40,0.50,0.60 and 0.80mm  Rotary activated microbrushes run at about 300 rpm and the helical bristle pattern effectively augers residual debris out of the canal in coronal direction  Microbrushes designed for ultrasonic use effectively brush the walls of the preparation and activate solution of NaOCl and 17% EDTA to produce cleaned canal. 213
  • 215. 215
  • 216. Ultrasonic irrigation  Ultrasonic devices were first introduced in Endodontics by Richman (1957).  Martin and Cunningham have coined the term endosonics.  In 1976 Martin had designed the first commercial system which used ultrasonics for preparing root canal. 216
  • 217. Ultrasonic irrigation  Ultrasonically activated files have the potential to prepare and debride root canals mechanically.  The files are driven to oscillate at ultrasonic frequencies of 25–30 kHz  The files operate in a transverse vibration, setting up a characteristic pattern of nodes and anti-nodes along their length (Walmsley 1987, Walmsley & Williams 1989).  Ultrasonic irrigation has been shown not very effective for shaping the root canal. 217
  • 218.  On the other hand it has been shown that ultrasonically driven files are effective for the ‘irrigation’ of root canals.  Two types of ultrasonic irrigation have been described in the literature:  1. where irrigation is combined with simultaneous ultrasonic instrumentation (UI)  2. without simultaneous instrumentation, so called passive ultrasonic irrigation (PUI). 218
  • 219.  Acoustic streaming  Acoustic streaming is the rapid movement of fluid in a circular or vortex-like motion around a vibrating object. ( file)  The acoustic streaming that occurs in the root canal during ultrasonic irrigation has been described as acoustic micro- streaming.  The shear flow caused by acoustic microstreaming produces shear stresses along the root canal wall, which can remove debris and bacteria from the wall. 219
  • 220. 220 Acoustic streaming around a file in free water and a schematic drawing.
  • 221.  Cavitation  Acoustic cavitation can be defined as the creation of new bubbles or the expansion, contraction and/or distortion of pre-existing bubbles (so-called nuclei) in a liquid, the process being coupled to acoustic energy (Leighton 1994).  These bubbles expand and then rapidly collapse producing a focus of energy. 221
  • 222. 222 Piezon unit The ultrasonically energized file creates current of streaming of irrigant within the root canal
  • 223. 223 Dentine debris packed in oval shaped root canal after syringe irrigation and clean oval canal after 3 min of PUI
  • 224. 224 SEM micrograph of a size 15 stainless steel K-file used for ultrasonic activation of the irrigation SEM micrograph of a blunt Ni–Ti-wire used for ultrasonic activation of the irrigation
  • 225.  Application of irrigant during PUI  Two flushing methods can be used during PUI, namely  a continuous flush of irrigant from the ultrasonic handpiece  or an intermittent flush method using syringe delivery (Cameron 1988).  In the intermittent flush method, the irrigant is injected into the root canal by a syringe, and replenished several times after each ultrasonic activation.  Both flushing methods were equally effective in removing dentine debris from the root canal in an ex vivo model when the irrigation time was set at 3 min (van der Sluis et al. 2006). 225
  • 226. Heat generation  Cameron (1988) reported a rise of the intracanal temperature from 37 to 45 C close to the tip of the instrument and 37 C away from the tip when the irrigant was ultrasonically activated for 30 s without replenishment.  The external root surface temperature recorded was 40 C  A cooling effect from 37 to 29 C was recorded when the irrigant was replenished with a continuous flow of irrigant.  Ahmad (1990) reported a mean rise of temperature of 0.6 C during a continuous flow of irrigant.  A rise of temperature within these ranges will not cause pathological temperature rises in the periodontal ligament. 226
  • 227.  Based on this literature review it is concluded that PUI appears to be an adjunctive treatment for cleaning the root canal system  and that PUI is more effective than syringe irrigation. 227
  • 228.  THE MICROMEGA 1500  is a sonic hand pieces that can be used with endodontic files and irrigation solutions to debride canals.  Sonic handpieces allows for simultaneous canal flaring, debridement and irrigation with cavitation effect. 228
  • 229.  Endo Irrigator Plus (K Dent Dental System)  It is based on ACWIS concept, i.e. activated continuous warm irrigation and evacuation system.  Strong vacuum evacuation system insures that Sodium Hypochlorite doesn’t reach the periapical region so it does not harm or damage the peri-apical tissues.  This device creates positive and negative pressure inside the canal.  This gives a perfect cleaning and disinfection of root canal assisted by negative and positive pressure with warm Sodium hypochlorite.  In this unit the Sodium hypochlorite is warmed upto 45°. Positive pressure irrigation with warm hypochlorite cleans and disinfect upto middle 1/3rd, removes all macro debris and negative pressure irrigation with warm hypochlorite cleans and disinfect upto apical 1/3rd, removes all micro and nano debris.  According to the manufacturers due to its powerful suction ability not even a single drop of Sodium Hypochlorite solution comes out of the canal (even if working in maxillary molars or if there is wide/ open apex) 229
  • 230. 230
  • 231. 231
  • 232. Conclusion  Instrumentation of the root canal system must always be supported by an irrigation system capable of removing pulp tissue remnants and dentin debris.  Liberal amounts of irrigation are essential for the effective function of the files.  A variety of chemical agents in fluid form and sometimes in viscous preparation has been used to aid canal preparation and irrigation. 232
  • 233. Conclusion  The most popular and advocated irrigation is sodium hypochlorite in various concentration.  Ongoing researchers are directed towards comparing the different irrigating solutions and different methods of irrigation to enhance the cleanliness of the root canal preparation  Clinician must always be alert to fundamental concept of cleaning and shaping that provide success of root canal treatment. 233
  • 234.  Many new materials and methods have recently been introduced to improve root canal debridement and to achieve root canal sterilization.  However, bearing in mind the complex anatomy of the root canal system and the ability of microorganisms to survive under adverse conditions, it might be premature to believe that the total sterilization of the root canal system could be readily achieved by any of the systems.  In the age of evidence-based dentistry, it is advisable to wait until quality independent data are available to support the use of such new technologies. 234
  • 235. 235

Editor's Notes

  1. is an oxidizing agent, particularly used for narrow, curved canals containing carbamide peroxide
  2. Buffering renders solution unstable dec shelf life to less than a week.
  3. Buffering renders solution unstable dec shelf life to less than a week.
  4. Blunderbuss canal which irrigant? with no release for the irrigant to leave the root canal coronally)
  5. Cold- to minimize swelling and pain warm to encourage a healthy healing response. inglefor stimulation of local systemic circulation
  6. Cold- to minimize swelling and pain warm to encourage a healthy healing response. ingle
  7. (after mechanical cleaning)
  8. it also inhibits the oxidation of EDTA by urea peroxide it also inhibits the oxidation of EDTA by urea peroxide
  9. That means that electrons are being moved from one molecule to another,
  10. which means that in 40 minutes half the ozone will have dissipated.
  11. eg Sherwood Monoject endodontic syringe needle.
  12. or a "water cannon" effect from open-end needles
  13. that are beyond the limit of human hearing.
  14. that are beyond the limit of human hearing.