Endodontic irrigation 1

Dr.Abdalazim Badraldin
SudaneseDentalCenter
Khartoum-Sudan
April. 2020

Introduction
Why we need Irrigation during Endodontic Preparation
Ideal Properties of Endodontic Irrigant
The most common Irrigant used
• Dr.Abdalazim Badraldin
• SudaneseDentalCenter
• Khartoum-Sudan
April. 2020

 Origin of the Endodontic Infections
Bacterial in origin…….. Kakehashi et al 1965
Sundqvist 1976
Biofilm ………. Nair 2010
 The Aims of the Endodontic Treatment
1. Treatment ……
Remove and kill all microorganisms
2. Prevention
By bacteria- tight seal obturation & coronal restoration
guarantee healing of
periapical lesions
prevent reinfection
• Khartoum-Sudan
April. 2020

How to achieve the aims of endodontic treatment ??
By root canal instrumentation
Two primary goals for root canal instrumentation :
1. To provide a biological environment that is conducive to healing
2. To provide a canal shape that is conformable to sealing.
John T. McSpadden
Can mechanical canal preparation alone provides a biological
environment that is conduce to healing ?
No
• Khartoum-Sudan
April. 2020

mechanical canal preparation can’t provides a biological
environment that is conduce to healing…
Challenges
 Complexities of root canal anatomy
 Metallurgy of Endodontic Files
Until now no endodontic files can prepare
all the pulp canal system configuration
without a fear of file separation ,
Canal transportation or perforation
Why???
Roland Ordinola -Zapata
“Of all the phases of anatomic study in the
human system, one of the most complex is that of
the pulp cavity morphology “ Barret 1925
Apical deltas….
which endodontic file will reach??
Dr. Jojo..India
• Khartoum-Sudan
April. 2020

environment that is conduce to healing…Why???
conclusions
 Inability of shaping tools in acting within the anatomical
complexity of the root canal.
 Preparation of oval, flattened, or irregular shaped
cross-sectional root canals using different instruments has
shown to leave unprepared extensions or recesses which
can harbor remnants of necrotic pulp tissue and biofilm.
• Khartoum-Sudan
April. 2020

Roland Ordinola -Zapata
 Using high-resolution computed tomography; it was found that
35–53% of the root canal surface remained uninstrumented
Gulabivala et al.
Effects of mechanical and chemical procedures on root canal surfaces
Endodontic Topics 2005, 10, 103–122 • Dr.Abdalazim Badraldin
• Khartoum-Sudan
April. 2020

Endodontic files(hand or rotary)
Create round-shaped canal
Middle third
cross-sections
Apical third
cross-sections
What endodontic files do?
Spreading and flushing the irrigant throughout the canal space acts mechanically and
chemically on remnants of necrotic pulp tissue and bacterial
communities colonizing the canal.
M.A. Versiani et al. Endodontic Irrigation
• Khartoum-Sudan
April. 2020

Classifications of Endodontic Irrigants
Chemical
Irrigants
Natural
Irrigants
1- Organic tissues Dissolving Agents
NaOCI
2- Inorganic tissues Dissolving Agents
(Chelating Agents)
- strong pH… EDTA
- mild pH …… HEBP
3- Antimicrobial Agents
- bactericidal……NaOCI
- bacteriostatic …CHX
4- combination Products
MTAD….SmearClear….Tetraclean
Antibacterial Agent
Green Tea
• Khartoum-Sudan
April. 2020

Most Common Irrigation Solutions
Dutner J, Mines P, Anderson A. Irrigation trends
among American Association of Endodontists members:
a web-based survey. J Endod. 2012;38(1):37–40
• Khartoum-Sudan
April. 2020

Aims of Root Canal Irrigation
The Chemical Effect
Simultaneous but
Distinct effect
The Mechanical Effect
Destroy / Kill / Remove
 Biofilm
 Microorganisms
 Endotoxin
 Pulp Tissues Remnants
NaOCI
&
CHX
Concentration
Time
Area of contact
Detachment / Remove
 The destroyed
microorganisms, biofilm &
pulp tissues remnants
 Dentin Debris( smear layer )
Normal Saline
&
EDTA
Pressure
Objectives Factors affective

An effective antimicrobial and proteolytic agent , excellent organic
tissue solvent , and lubricant with fairly quick effect
 Concentration
0.5 to 6 %. It was proven that the lower and
higher concentrations are equally efficient in
reducing the number of bacteria in infected
root canal system but the tissue-dissolving
effect is directly related to the concentration.
 Volume More critical for disinfection than concentration
NaOCI will inactivate its components very fast, so
fresh irrigating solution should be added to the canal
system constantly.
• Khartoum-Sudan
April. 2020

)
 Time
Misinterpreted
….. show bacterial killed in 30 min /0.5 % NaOCI
….. higher concentrations need only 30 s
Some articles
• Khartoum-Sudan
April. 2020
It is important to remember
 organic matter, inflammatory exudates, tissue
remnants, and microbial biomass consumes
NaOCI and weakens its effect.
 The chlorine ion, which is responsible for the
dissolving and antibacterial capacity of NaOCI,
is unstable and consumed rapidly during the
first phase of tissue dissolution, probably
within 2 min, ….. Refreshment
 The greater the initial concentration of the NaOCI,
the smaller the reduction of its pH

)
 Effect on Dentin 22 % organic material by weight
NaOCI solutions may affect mechanical dentin properties
via the degradation of organic dentin component
 Depth of Penetration 77 and 300 μm
depends on
concentration
time
temperature
Zou et al. Penetration of sodium hypochlorite
into dentin. J Endod. 2010;36(5):793–6.
1 % NaOCI
for 2 min
• Khartoum-Sudan
April. 2020

)
 Effect on Biofilms
3-6 % NaOCI
was the only agent capable of both physically
removing biofilm and killing bacteria
Clegg et al
The effect of exposure to irrigant solutions on
apical dentin biofilms in vitro.
J Endod. 2006;32:434–7.
control specimen positive control dentin section treated
with 6 % NaOCI
• Khartoum-Sudan
April. 2020

)
Efficiency improvement
 Temperature elevations….Warning NaOCI 10℃ temperature
rise….45℃
 Activation ……. Ultrasonic or Sonic activation efficiency & also by indirectly
temperature
 Refreshment ……. Keeping the % at high level to compensate the buffering effect of
remnant tissues, microorganisms, pus ,blood & dentin structures
 Exposure (Retention) Time ……. Contact time with the canal wall efficiency
• Khartoum-Sudan
April. 2020

)
• Khartoum-Sudan
April. 2020
Important clinical points
Pulp Chamber – Reservoir of fresh irrigant Retention time of irrigant

)
• Khartoum-Sudan
April. 2020
Important clinical points
NaOCI should remain the primary irrigant.
EDTA effective against cell-rich/EPS-poor biofilms.
CHX did not remove biofilm.
the concert effects of multiple instruments,
high volume of irrigation,
and long retention time of NaOCI irrigant had a
positive influence on intracanal disinfection during
chemomechanical preparation
conclusion

)
 Limitations
 Toxicity
 Nonsubstantive
 Ineffective in smear layer removal
 Corrosion & Discoloration
 Unpleasant odor.
 Negative effect on sealer / dentine bonding
when used as a final rinse
• Khartoum-Sudan
April. 2020

)
 2.5-6% NaOCI in concentrations must be used during the whole
cleaning and shaping procedure.
 Pulp chamber must used as a reservoir of fresh irrigant
 Activation is very important to improve the efficiency of NaOCI
Clinical Recommendation
• Khartoum-Sudan
April. 2020
Summary
The most important Clinical Factors
 Concentration
 Volume
 Retention Time
 The most important irrigant in endodontic treatment
 The only irrigant capable in dissolving and removing
- Organic tissues( pulp tissues)
- Biofilm ( destroy Microorganisms)
- Organic substances of the smear layers

Chlorhexidine Gluconate
CHX 2%
• Khartoum-Sudan
April. 2020
 Depending on its concentration, %CHX …. Bactericidal … damaging the cell membrane
% CHX…. Bacteriostatic … causing low - molecular -
weight substances ( eg.potassium) to leak
out from the cell membrane without the
cell being permanently damaged
.
0.2 % … mouthwash
2% ..irrigate

• Khartoum-Sudan
April. 2020
CHX 2%
Substantivity
Reversible reaction ( uptake and release) of CHX by oral mucosa and teeth substances
( hydroxyapatite )leads to substantive antimicrobial activity (week – month),
…. Depends on
 Concentration………………. % substantive antibacterial effects.
 Exposure (retention) time….. ET substantive antibacterial effects
Inhibitions of Matrix Metalloproteinases ( MMPs)
CHX is potent inhibitor of MMPs ,this improves the dentin- sealer bonding
Two important factors as far as CHX2% irrigant are concerned

• Khartoum-Sudan
April. 2020
CHX 2%
Disinfection ability
NaOCI is more active than. 2% CHX. ,,
because;-
- CHX can’t destroy and dissolve biofilm
, bacteria & organic tissues.
- NaOCI reduce endotoxins levels better
than CHX
Using CHX as a final irrigant ( if pusher in periapical area)
may delay healing of apical periodontitis

• Khartoum-Sudan
April. 2020
CHX 2%
1. In teeth with open apices or perforation where
there is a risk to extrude NaOCI.
2. When maximal antimicrobial effect is desirable
as a final rinse after EDTA to further facilitate
disinfection( Heavy infected & Retreatment Cases ..potent action
against E faecalis)
and to improve dentin bonding
Clinical Recommendations
2% CHX is an alternative irrigant but it certainly can’t replace NaOCI

Combination of NaOCI / CHX
• Khartoum-Sudan
April. 2020
Update of Endodontic Irrigating Solutions
Endodontic Irrigation
Bettina Basrani
 The combination of NaOCI and CHX produces
a toxic precipitate.
 The reaction is dependent of the concentration of NaOCI.
 The higher the concentration of NaOCI the larger
the precipitate

Saline
• Khartoum-Sudan
April. 2020
Saline with Pressure
Objectives
Mechanical effect in
removing debris / smear layers
Neutralizes the effects
of other irrigants
Help Sealer adhesion

Chelating Agents
• Khartoum-Sudan
April. 2020
Strong Agents Weak Agents
EDTA Etidronate (HEDP)
Citric acid
Maleic acid
Classified according to chelation ability
Characteristics Factors as far as endodontic irrigation is concerned:-
- Disinfection &Cleaning ability by dissolving inorganic Substances
and detach biofilms adhering to root canal walls.
- Help dentin / sealer adhesion

Chelating Agents
Khartoum-Sudan
April. 2020
Ethylenediaminetetraacetic Acid
EDTA
 EDTA alone normally cannot remove the smear layer
effectively; a proteolytic component, such as NaOCI,
must be added to remove the organic
components of the smear layer.
 EDTA is normally used in a concentration of 17 %
and can remove the smear layer when in direct
contact with the root canal wall for 1 -2 mins .
 EDTA is helpful when used in negotiating narrow, tortuous ,
calcified canals to establish patency

Khartoum-Sudan
April. 2020
Ethylenediaminetetraacetic Acid
EDTA
 EDTA must not be used as primary, first or last irrigant
due to it’s corrosive ability to dentin--
 EDTA …increased success rate for Retreatment
 EDTA ….Is markedly superior in dissolving root canal sealers
than NaOCI

Combination of EDTA /NaOCI/CHX
Khartoum-Sudan
April. 2020
CHX was found to form a salt ( white precipitate with
EDTA rather than undergoing a chemical reaction
 EDTA retained its calcium-complex ability when mixed with NaOCI
 EDTA caused NaOCI to lose its tissue-dissolving capacity, with virtually
no free chlorine detected in the combinations.
White cloud precipitation
Update of Endodontic Irrigating Solutions
Endodontic Irrigation
Bettina Basrani

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
Hydroxyethylidene diphosonate
Is there a biocompatible decalcified ( chelating ) agent can mix with NaOCI
without interfering their benefit effects as a root canal irrigation solution ???
Etidronate (HEDP) didn’t interfere with NaOCI
when mixed together

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
Your text here
Smear layer not formed

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
The mixture decreased the accumulation of the hard tissues debris in isthmus

Chelating Agents
Khartoum-Sudan
April. 2020
Hydroxyethylidene diphosonate(HEDP)
The mixture is as good as
NaOCI

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
 Increase dentin / sealer bond strength
 The torsional load on rotary instrument is decreased.

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
 EDTA solutions resulted in the highest bond strength values and dentinal penetration
 HEBP/NaOCI combinations were as effective as EDTA at the middle and apical thirds

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
 The ability of Etidronate to chelate calcium is not affected by NaOCI
 Etidronate has a very low cytotoxicity and doesn’t increase that of NaOCI

Chelating Agents
Khartoum-Sudan
April. 2020
Hydroxyethylidene diphosonate(HEDP)
 Antimicrobial Efficacity
 Postoperative Pain
 The Host Response
HEDP didn’t affect the NaOCI activities as a root
canal irrigant

Chelating Agents
Khartoum-Sudan
April. 2020
Dual Rinse HEDP
1-Preparation
 One capsule / 10ml 2.5% NaOCI
 Mixing time ….1-2 min using cement. Spatula
for stirring( until clear solution prepared
 Concentration of 5% NaOCI or more must be used
 The mixture must not be heated even for short
time ( become unstable & active chlorine quickly lost.

Chelating Agents
Khartoum-Sudan
April. 2020
Dual Rinse HEDP
2- Clinical Procedures
 during canal preparation, the pulp chamber & canal must be
flooded with the mixture ( continuous irrigation with
continuous chelating action
 Activate the solution with sonic / ultrasonic .
 The mixture has a good hemostatic effect in bleeding canal
and maintenance beaching effect of NaOCI in blood-stained dentin.
 If bubbles rise from the canal ( reaction of chlorine ion & organic substances) ,renew
the irrigant and activate it or leaved to act passively until bubble disappeared.
 Revascularization treatment (incomplete root development) it recommended to used ,17%
EDTA, 10% Citric acid or 18% HEDP ( diluted in sterile saline
…one capsule / 5 ml saline) as a final irrigant
 The duration and amount of the irrigant depend on the
degree of infection and complexity of the root canal anatomy

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
 HEDP used in :-
- Water and waste-water treatment
- In detergents and cleaning agents
- In cosmetic
- As a drug
- Inhibition of corrosion

Khartoum-Sudan
April. 2020
Three essential Components
Leur Lock
Rubber stopper.. WL
Close ended with side
vented
Which syringe size ???
5 ml
P --- pressure developed inside syringe barrel
F --- tactile force applied to syringe plunger
A --- cross-section area of the syringe plunger

Chelating Agents
Khartoum-Sudan
April. 2020
HEDP
Is there a biocompatible decalcified ( chelating ) agent can mix with NaOCI
without interactive negatively with each other ???

• Khartoum-Sudan
April. 2020

• Khartoum-Sudan
April. 2020
Canal taper
Stagnation area (dead space)
35/4%
o.39
0.57
0.61
0.65
0.69
0.53

• Khartoum-Sudan
April. 2020

• Khartoum-Sudan
April. 2020
Activation of irrigant with sonic or
ultrasonic energy creates acoustic streaming. This
Manual agitation/dynamic pumping:
a GP cone is inserted into the irrigant-filled canal
and pumped vertically to agitate the irrigant

Two Content Layout with Table
• First bullet point here
• Second bullet point here
• Third bullet point here
Class Group A Group B
Class 1 82 95
Class 2 76 88
Class 3 84 90

Endodontic irrigation 1

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