This document provides an outline and overview of various irrigants used in endodontics (root canal treatment). It discusses the components of the dental pulp that need to be removed during root canal treatment and the ideal characteristics of an irrigant. Several commonly used irrigants are described in detail, including sodium hypochlorite, chlorine dioxide, EDTA, citric acid, and chlorhexidine. The document outlines the advantages and disadvantages of each irrigant and notes important interactions between irrigants. The goal of irrigation is to fully cleanse the root canal of both organic and inorganic tissues and microbes.

1. IRRIGATION
ENDODONTICS
CEZAR EDWARD LAHHAM “BDS”
AL-QUDS UNIVERSITY

2. LECTURE OUTLINE
• 1-DENTAL PULP COMPONENTS
• 2-IDEAL IRRIGANT CHARACTERISTICS
• 3-IRRIGANTS THAT USED IN ENDODONTICS & THEIR CHARACTERISTICS
• 4- HERBAL ALTERNATIVES : 2ND PART
• 5-REFERENCES
1st Part

3. INTRODUCTION
• THE DENTAL PULP CONTAINS ORGANIC MATTER “ LARGE PART” & INORGANIC MATTER “SMALL
PART”
• WHEN THE PULP BECOMES INFECTED ; IT CONTAINS : ORGANIC + INORGANIC + MICROBES!
• ORGANIC PART IS THE PULPAL TISSUE & MICRO-ORGANISIMS “MO”
• INORGANIC PART : MENIALS … WHICH CAN COVER THE MO AND COLLAGEN FIBERS BY
BLOCKING THE LATERAL AND ACCESSORY CANALS
• SO WHEN WE DECIDE TO DO RCT : I SHOULD REMOVE ALL OF THEM

4. HOW TO DO THAT ?
• STUDIES SHOW THAT 35% AND MORE OF THE DENTINAL WALLS REMAIN UNTOUCHED
AFTER INSTRUMENTATION  SO IRRIGATION IS MUST !!

5. MICROBIOLOGY
• E. faecalis and yeast, mainly C. albicans, has been repeatedly identified as the species most commonly recovered from
root canals undergoing retreatment, in cases of failed endodontic therapy and canals with persistent infections
• E. faecalis are gram positive cocci and facultative anaerobes. They are normal intestinal organisms and may inhabit the
oral cavity and gingival sulcus. When this bacterium is present in small numbers, it is easily eliminated; but if it is in
large numbers, it is difficult to eradicate. E. faecalis has many distinct features which make it an exceptional survivor in
the root canal. These microorganisms can perform the following:-
•Live and persist in poor nutrient environment
•Survive in the presence of several medications (e.g., calcium hydroxide) and irrigants (e.g., sodium hypochlorite)
•Form biofilms in medicated canals
•Invade and metabolize fluids within the dentinal tubules and adhere to collagen
•Convert into a viable but non-cultivable state
•Acquire antibiotic resistance
•Survive in extreme environments with low pH, high salinity and high temperatures
•Endure prolonged periods of starvation and utilize tissue fluid that flows from the periodontal ligament

6. PROPERTIES OF AN IDEAL IRRIGANT
• • BACTERICIDAL, GERMICIDAL, AND FUNGICIDAL EFFECTS
• • ABILITY TO SERVE AS A LUBRICANT DURING INSTRUMENTATION
• • ABILITY TO DISSOLVE ORGANIC DENTINAL TISSUES (PULP TISSUE, COLLAGEN, AND BIOFILM)
• • ABILITY TO DISSOLVE INORGANIC DENTINAL TISSUES
• • NO IRRITATION OF PERIAPICAL TISSUES
• • SOLUTION STABILITY
• • PROLONGED AND SUSTAINABLE ANTIBACTERIAL ACTIVITY AFTER USE
• • ACTIVITY IN AN ENVIRONMENT IN WHICH BLOOD, SERUM, AND TISSUE PROTEIN PRODUCTS ARE
PRESENT

7. • • ABILITY TO REMOVE THE SMEAR LAYER COMPLETELY
• • LOW SURFACE TENSION
• • DISINFECTION OF DENTIN AND DENTINAL TUBULES
• • NO INTERFERENCE WITH PERIAPICAL TISSUE HEALING
• • NO STAINING OF TOOTH TISSUES
• • NO WEAKENING OF TOOTH TISSUES
• • NO TRIGGERING OF A CELL-MEDIATED IMMUNE RESPONSE
• • NO ANTIGENIC, TOXIC, OR CARCINOGENIC EFFECT ON THE PERIPHERAL TISSUE CELLS OF THE TOOTH
• • NO NEGATIVE EFFECT ON THE PHYSICAL PROPERTIES OF THE EXPOSED DENTIN
• • NO NEGATIVE EFFECT ON THE SEALING ABILITIES OF SEALERS
• • EASE OF APPLICATION AND LOW COST
• • LONG SHELF LIFE.

8. Endodontic irrigation needles have a diameter of 0.42 mm – 27G or 0.31 mm – 30G.

10. • THE MOST WIDELY USED
• BECAME EXTREMELY WIDESPREAD IN THE LATE 19TH CENTURY
• DURING WORLD WAR I, USED BUFFERED 0.5% NAOCL TO WASH AND DISINFECT INFECTED
WOUNDS.
• FIRST USE IN DENTISTRY WAS IN 1920

11. ADVANTAGES
• BROAD ANTIBACTERIAL SPECTRUM AND IS SPORICIDAL AND VIRICIDAL.
• TISSUE-DISSOLVING ACTIVITY IS GREATER FOR NECROTIC TISSUE THAN FOR VITAL TISSUE.
“DISSOLVES ORGANIC MATERIALS “
DISSOLVES NECROTIC @ 0.5% CONCENTRATION
WHILE VITAL TISSUES NEED MORE !
• NAOCL IS USED AT CONCENTRATIONS RANGING BETWEEN 0.5% AND 5.25%
• CHEAP
• LUBRICANT
• AVAILABLE

12. DISADVANTAGES
• 1- THE USE OF NAOCL FOR IRRIGATION WAS FOUND TO
REDUCE THE BOND STRENGTH BETWEEN THE ADHESIVE
SYSTEM AND THE DENTINAL WALL. NAOCL IS THOUGHT TO
REMOVE COLLAGEN FIBRILS FROM THE DENTIN SURFACE,
THEREBY INHIBITING THE FORMATION OF THE HYBRID LAYER,
AS REQUIRED TO ACHIEVE A DENTIN–ADHESIVE LINK.
2- TOXIC : INCREASE WITH CONC. “ SODIUM ACCIDENT “ #
3- BAD SMELL
4- UNABLE TO REMOVE INORGANIC MATTER
5- BAD TASTE,
6- ABILITY TO BLEACH CLOTHES
7-ABILITY TO CAUSE CORROSION OF METAL OBJECTS.
• # TREATMENT OF NAOCL ACCIDENTS IS PALLIATIVE AND CONSISTS OF OBSERVATION OF THE PATIENT AS WELL AS PRESCRIBING ANTIBIOTICS AND
ANALGESICS.

13. DISADVANTAGES
• 8- HIGH SURFACE TENSION  LOW WETTING & CAN DO A VAPOR LOCK “ FIGURE”
• 9- IRRITANT VAPORS TO THE EYES

14. SODIUM HYPOCHLORITE “NOTES”
• ORGANIC MATTERS REDUCE THE SODIUM HYPOCHLORITE EFFECTIVENESS.
• EFFECTIVENESS : 1% NAOCL “AT 45 C” = 5.25% NAOCL “ AT 20 C”
• EFFECTIVENESS : LARGE VOLUME WITH LOW CONC. = SMALL VOLUME WITH HIGH CONC.
• TOXICITY : 1% NAOCL “AT 45 C” < 5.25% NAOCL “ AT 20 C”
• TOXICITY : LARGE VOLUME WITH LOW CONC. < SMALL VOLUME WITH HIGH CONC.
• DURATION OF APPLICATION IS THE MOST IMPORTANT FACTOR AFFECTS THE EFFECTIVENESS
OF CLEANING AND DISINFECTION.

15. • APPLAY ! NAOCL AFTER CHELATING AGENT “EXAMPLE: EDTA” IS ADVISABLE : BECAUSE
CHELATING AGENT REMOVE INORAGANIC MATTERS WHICH COVER THE COLLAGEN FIBERS!
SEE THE NEXT SLIDE PLEASE .
• FACTORS AFFECT THE EFFECTIVENESS OF CLEANING ARE : 1- TIME 2-CONC. 3-VOLUME 4-
ACTIVATION
• CONC. IS THE CRITICAL FACTOR THAT CAN INCREASE THE TOXICITY IF REACH PERIAPICAL
REGION
• WHEN NAOCL IS ACTIVATED WITH AN ULTRASONIC DEVICE, IT MUST BE USED AFTER THE
COMPLETION OF ROOT CANAL PREPARATION.
• THE DISINFECTING PROPERTIES OF HYPOCHLORITE SOLUTIONS DECREASE WITH INCREASING
PH, WHEREAS THEIR ANTIMICROBIAL EFFICACY INCREASES WITH DECREASING PH.
• WHEN POURED IN WATER, IT DISSOCIATES IN NA+ AND OCL− IONS. AT NEUTRAL OR ACID PH,
THE PREDOMINANT FORM IS HOCL, WHICH IS RESPONSIBLE FOR THE ANTIMICROBIAL ACTIVITY.

16. Blocked laterally

17. • THE MOST EFFECTIVE IRRIGATION REGIMEN IS 5.25% AT 40 MINUTES, WHEREAS IRRIGATION
WITH 1.3% AND 2.5% NAOCL FOR THIS SAME TIME INTERVAL IS INEFFECTIVE IN REMOVING E.
FAECALIS FROM INFECTED DENTIN CYLINDERS. SO YOU HAVE TO USE A COMBINATION OF
IRRIGANT ! & ACTIVATION DEVICES.

18. INTERACTIONS OF NAOCL
• THE REACTION BETWEEN NAOCL AND CHLORHEXIDINE (CHX) PRODUCES PARA-
CHLOROANILINE (PCA), WHICH IS CARCINOGENIC. THIS REACTION PRODUCT COVERS THE
SURFACES OF ROOT CANALS, BLOCKING THE DENTINAL TUBULES AND COMPROMISING THE
ROOT CANAL SEAL
• SO USE THEN IN SEQUENCE “ NO COMBINATION”
• EDTA MIXED WITH NAOCL SHOWED A SUDDEN AND RAPID DECREASE IN THE AMOUNT OF
CHLORINE IN NAOCL, SIGNIFICANTLY REDUCING THE ABILITY OF NAOCL TO DEGRADE TISSUE
& DECREASE THE ANTIMICROBIAL ACTIVITY.

19. 2-CHLORINE DIOXIDE (CLO2)
• LIKE NAOCL
• AN ALTERNATIVE TO NAOCL

20. 3-ETHYLENEDIAMINETETRAACETIC ACID (EDTA)
• DISSOLVING INORGANIC PART OF SMEAR LAYER .
• IN 1957, NYGAART-OSTBY PROPOSED THE USE OF CHELATING AGENTS TO AID IN THE
PREPARATION OF NARROW AND CALCIFIED ROOT CANALS.
• THE SOLUTION REACTS WITH THE CALCIUM IONS IN THE DENTIN AND FORMS SOLUBLE
CALCIUM CHELATES.
• 1 MIN IRRIGATION WITH 10 ML OF 17% EDTA SOLUTION EFFECTIVELY REMOVED THE SMEAR
LAYER FROM THE CANAL WALL.
• THE EDTA CONCENTRATION (FROM 10% TO 17%), AND THE PH (FROM 7.5 TO 9)

21. EDTA ADVANTAGES
• REMOVE INORGANIC MATTER
• THERE ARE 2 FORMS OF EDTA : LIQUID ( MORE EFFECTIVE) & PASTE(LESS EFFECTIVE)

22. EDTA DISADVANTAGES
• NO ANTIMICROBIAL ACTIVITY
• DO NOT REMOVE ORGANIC MATTER

23. • SOME AUTHORS RECOMMEND USING A 95% CONCENTRATED ETHANOL SOLUTION AT THE
END OF THE CANAL DISINFECTION PHASE TO CREATE A MORE DRY ENVIRONMENT ALLOWING
A DEEPER PENETRATION OF ENDODONTIC SEALERS INSIDE DENTINAL TUBULES.
• IT IS ADVISABLE TO RINSE WITH EDTA & FINAL RINSE WITH NAOCL

24. EDTA INTERACTIONS
• CHX SOLUTIONS ARE INSOLUBLE IN EDTA. THE RESULTING PRECIPITATE IS A SALT FORMED BY
ELECTROSTATIC NEUTRALIZATION OF THE CATIONIC CHX BY THE ANIONIC EDTA. THE CLINICAL
IMPLICATIONS OF THIS PRECIPITATE ARE NOT KNOWN WIDELY. IT IS KNOWN TO REDUCE THE
ABILITY OF EDTA TO REMOVE THE SMEAR LAYER
• EDTA MIXED WITH NAOCL SHOWED A SUDDEN AND RAPID DECREASE IN THE AMOUNT OF
CHLORINE IN NAOCL, SIGNIFICANTLY REDUCING THE ABILITY OF NAOCL TO DEGRADE TISSUE
& DECREASE THE ANTIMICROBIAL ACTIVITY.

25. 4-CITRIC ACID (CA)
• USED AT CONCENTRATIONS RANGING FROM 1% TO 50%
• THE USE OF 10% CA AS A FINAL IRRIGATION SOLUTION YIELDED VERY GOOD RESULTS IN TERMS OF SMEAR
LAYER REMOVAL (INORGANIC PART)
• CA HAS SHOWN SLIGHTLY BETTER PERFORMANCE THAN EDTA AT SIMILAR CONCENTRATIONS,
ALTHOUGH BOTH SOLUTIONS ARE HIGHLY EFFECTIVE IN REMOVING THE SMEAR LAYER FROM ROOT CANAL
WALLS
• A 10% CA SOLUTION WAS PROVEN TO BE MORE BIOCOMPATIBLE THAN A 17% EDTA SOLUTION
• IN ONE STUDY, A 25% CA SOLUTION FAILED TO DESTROY ENTEROCOCCUS FAECALIS BIOFILMS IN 10-MIN
APPLICATIONS !!
• SO NOT GOOD ANTIMICROBIAL ACTIVITY

26. 5-HYDROXYETHYLIDENE BISPHOSPHONATE
(HEBP)
• KNOWN AS ETIDRONIC ACID OR ETIDRONATE
• DISSOLVES INORGANIC MATTER , ALTERNATIVE TO EDTA , CA
• HEBP PREVENTS BONE RESORPTION, AND THUS IS USED AS A SYSTEMIC DRUG IN
THE TREATMENT OF OSTEOPOROSIS AND PAGET'S DISEASE !!!
• DEMINERALIZATION WITH 9% OR 18% HEBP IS SLOWER THAN THAT WITH 17% EDTA

27. 6-CHLORHEXIDINE (CHX)
• 0.1%–0.2% AQUEOUS SOLUTIONS ARE USED AS MOUTHWASH, A 2% CONCENTRATION IS
USED FOR ROOT CANAL IRRIGATION IN ENDODONTIC TREATMENT.
• THE ANTIMICROBIAL ACTIVITY OF CHX DEPENDS ON THE ACHIEVEMENT OF AN OPTIMAL PH
(5.5–7) . CHX IS BACTERIOSTATIC AT LOWER CONCENTRATIONS AND BACTERICIDAL AT HIGHER
CONCENTRATIONS

28. CHX ADVANTAGES
• CHX IS POWERFUL ANTISEPTIC ,ACTIVE AGAINST GRAM-POSITIVE AND GRAM-NEGATIVE BACTERIA,
BACTERIAL SPORES, LIPOPHILIC VIRUSES, YEAST, FUNGI, AND DERMATOPHYTES
• THIS SOLUTION IS USED COMMONLY AS AN INTRACANAL MEDICAMENT WITH CALCIUM
HYDROXIDE (CA(OH)2)
• ONE REASON FOR THE WIDESPREAD USE OF CHX IS ITS PROLONGED ANTIBACTERIAL EFFECT; CHX
BINDS TO HARD TISSUES AND MAINTAINS ITS ANTIMICROBIAL ACTION. THIS EFFECT IS DUE TO THE
NUMBER OF CHX MOLECULES INTERACTING WITH DENTIN .WHITE ET AL. REPORTED THAT THE
EFFECT OF 2% CHX PERSISTED FOR 72 H TO 12 WEEKS
• EVERY (5-6) MINUTES GIVE EFFECT. FOR 1 WEEK !

29. • VERY IMPORTANT ADVANTAGE : CHX IS A BROAD-SPECTRUM MATRIX
METALLOPROTEINASE (MMP) INHIBITOR (ANTICOLLAGENOLYTIC
EFFECT). ATTACHMENT OF CHX TO THE DENTIN SURFACE
INCREASES RESIN INFILTRATION INTO THE DENTINAL TUBULES,
THEREBY INCREASING THE BOND STRENGTH
• CHX CAN BE USED IN THE DISINFECTION OF GUTTA PERCHA.

30. CHX DISADVANTAGES
• CANNOT DISSOLVES ORGANIC & INORGANIC !!!!!!
• DESQUAMATIVE GINGIVITIS,
• DENTAL AND ORAL PIGMENTATION,
• DISGUSTING (BAD-METALLIC TASTE IN THE MOUTH)

31. • THE HEATING OF A LOW-CONCENTRATION CHX SOLUTION INCREASES TOTAL ANTIMICROBIAL
EFFICACY WHILE MAINTAINING LOW SYSTEMIC TOXICITY
• QMIX IS AN IRRIGATION SOLUTION DEVELOPED FOR USE IN THE FINAL ROOT CANAL
CLEANING. A COMBINATION OF CHX WITH AN ADDED SURFACTANT AND EDTA IS USED TO
INCREASE PENETRATION TO THE DENTINAL TUBULES

32. CHX INTERACTIONS
• THE REACTION BETWEEN NAOCL AND CHLORHEXIDINE (CHX) PRODUCES PARA-
CHLOROANILINE (PCA), WHICH IS CARCINOGENIC. THIS REACTION PRODUCT COVERS THE
SURFACES OF ROOT CANALS, BLOCKING THE DENTINAL TUBULES AND COMPROMISING THE
ROOT CANAL SEAL
• SO USE THEN IN SEQUENCE “ NO COMBINATION”

33. 7-IODINE POTASSIUM IODIDE (IPI)
• CONC. : 2-5%
• PH 7-9
• LOW TOXICITY
• BROAD SPECTRUM ANTIMICROBIAL ACTIVITY
• DO NOT REMOVE ORGANIC & INORGANIC MATTER
• USED AS ANTISEPTIC LIKE CHX
• THE ADVANTAGE OF IODINE OVER THE OTHER IRRIGANTS IS THAT 2% PREPARATIONS OF
IODINE POTASSIUM IODIDE (IPI) USED IN ENDODONTICS ARE SHOWN TO BE LESS IRRITATING
AND TOXIC THAN FORMOCRESOL, CAMPHORATED MONOCHLOROPHENOL (FMCP), AND
CRESATIN

34. • HYPOALLERGENIC, WITH LOW TOXICITY
• HAS A DECREASED TENDENCY TO STAIN DENTINE
• BACTERICIDAL, FUNGICIDAL, TUBERCULOCIDAL, VIRUCIDAL AND SPORICIDAL.
• THE COLLAGEN MATRIX IN DENTINE CAN INHIBIT IODINE
• IODINE ATTACKS KEY GROUP PROTEINS, NUCLEOTIDES AND FATTY ACIDS, LEADING
TO CELL DEATH.
• CONCENTRATION OF 2% IS FASTER AT REDUCING THE BACTERIAL LOAD THAN A
CALCIUM HYDROXIDE INTER-APPOINTMENT DRESSING; 2%IPI NEEDS 1–2 HOURS TO
PREVENT GROWTH OF E. FAECALIS.
• IPI & CHX KILL BACTERIA THAT HAVE RESISTANCE TO CAOH

35. 8-MIXTURE OF TETRACYCLINE ISOMER, ACID, AND
DETERGENT (MTAD)
• TORABINEJAD ET AL. INTRODUCED A COMBINATION OF 3% DOXYCYCLINE, 4.25% CA,
AND DETERGENT (TWEEN-80) AS AN ALTERNATIVE TO EDTA WITH THE AIM OF IMPROVING
SMEAR LAYER REMOVAL.
• MIXTURE ACTS AS A CHELATOR AND HAS ANTIMICROBIAL ACTIVITY.
• NO ORGANIC TISSUE DISSOLVING CAPACITY
• SO USED AS FINAL RINSE AFTER NAOCL TO REMOVE INORGANIC MATTER “SMEAR LAYER”
AND IMPROVE BONDING PROPERTIES
• ITS BACTERICIDAL EFFECT ON E. FAECALIS BIOFILM IS LESS THAN THAT OF NAOCL
SOLUTION AT CONCENTRATIONS OF 1%–6%

36. RECOMMENDED IRRIGATION METHOD
• GENERALLY, EACH CANAL SHOULD BE IRRIGATED FOR AT LEAST 1 MIN WITH 5–10 ML OF
CHELATING SOLUTION. AFTER SMEAR LAYER REMOVAL, IRRIGATION WITH AN ANTISEPTIC
SOLUTION IS HELPFUL. CHX IS ONE OF THE MOST PROMISING SOLUTIONS FOR FINAL
IRRIGATION IN THIS CONTEXT.
• CHX HAS HIGH AFFINITY FOR DENTAL HARD TISSUES AND ITS ANTIMICROBIAL ACTIVITY
PERSISTS FOR A LONG TIME ONCE IT IS BOUND TO THE SURFACE. AFTER THE
INTRODUCTION OF MTAD IRRIGANTS TO THE MARKET, A NEW IRRIGATION METHOD WAS
RECOMMENDED: INITIAL IRRIGATION WITH 1.3% NAOCL FOR 20 MIN, FOLLOWED BY
FINAL IRRIGATION WITH MTAD”5ML” FOR 5 MIN.

37. 9-TETRACLEAN
• SAME AS MTAD COMPONENTS
• AN ALTERNATIVE TO MTAD
• SLIGHTLY MORE EFFECTIVE “MORE ANTIMICROBIAL POTENCY”

38. HERBAL ALTERNATIVES

39. TRIPHALA
• A PLANT BLEND CREATED BY DRYING AND PULVERIZING THE FRUIT OF THREE PLANTS
(TERMINA BELLERICA, TERMINA CHEBULA, AND EMBLICA OFFICINALIS)
• KILLS 100% OF E. FAECALIS WITHIN 6 MIN.!!!!!!!!!
• TRIPHALA CONTAINS FRUIT RICH IN CA, WHICH CAN AID SMEAR LAYER REMOVAL

40. GREEN TEA POLYPHENOLS (GTP)
• THEY HAVE SHOWN SIGNIFICANT ANTIBACTERIAL ACTIVITY IN E. FAECALIS BIOFILMS
GROWN ON DENTAL CULTURE, KILLING E. FAECALIS COMPLETELY WITHIN 6 MIN

41. REFERENCES
• DIOGUARDI M, DI GIOIA G, ILLUZZI G, LANEVE E, COCCO A, TROIANO G.
ENDODONTIC IRRIGANTS: DIFFERENT METHODS TO IMPROVE EFFICACY AND
RELATED PROBLEMS. EUR J DENT [SERIAL ONLINE] 2018 [CITED 2018 DEC
13];12:459-66.
• WWW.EURJDENT.COM/TEXT.ASP?2018/12/3/459/237873
• TOPBAS C, ADIGUZEL O. ENDODONTIC IRRIGATION SOLUTIONS: A REVIEW. INT
DENT RES 2017;7:54-61.
• PATHWAY OF THE PULP “ COHENS” 11TH EDITION CH6
• TEXTBOOK OF ENDODONTICS NISHA GARG 2ND ED CH17
• SIQUEIRA JR JF, MACHADO AG, SILVEIRA RM, LOPES HP, DE UZEDA M. EVALUATION
OF THE EFFECTIVENESS OF SODIUM HYPOCHLORITE USED WITH THREE IRRIGATION
METHODS IN THE ELIMINATION OF
• ENTEROCOCCUS FAECALIS FROM THE ROOT CANAL, IN VITRO. INT ENDOD J
1997;30:279-82.
REVIEW ARTICLE
Year : 2018 | Volume :
12 | Issue : 3 | Page : 459-466