1. IRRIGATION IN ENDODONTICS
CONTENTS
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•
•
•
•
•
•
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Introduction
Irrigation solutions in endodontics
Irrigation devices & techniques
Challenges of irrigation
Recent advances in irrigation
Sequence of irrigation
Conclusion
References

2. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
INTRODUCTION
Barret in 1925…
"of all the phases
anatomic study` in
human system, one of
most complex is that of
pulp cavity morphology"
of
the
the
the

3. The sequence of events & procedures in the
control of endodontic infections are:
 host defence system,
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
systemic antibiotic therapy,
 instrumentation & irrigation (“cleaning & shaping”),
 intracanal medicaments used between appointments,
 permanent root filling & coronal restoration.

4. The use of irrigating solutions in combination
with canal instrumentation, loosen debris, pulp
tissue and micro-organisms from the irregular
dentin walls so that they can be removed from
the canal.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Irrigation is defined as “to wash out a body cavity or
wound with water or a medicated fluid”

5. Objectives of irrigation:
Mechanical & Chemical functions
 Flushing
 Lubrication
 Dissolution
 Smear layer removal
Biological functions
 Antimicrobial
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References

6. Characteristics of an ideal endodontic
irrigant :
Endodontic Topics 2012,27,74-102
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
1. Effective germicide and fungicide.
2. Non-irritating to the periapical tissues.
3. Stable in solution.
4. Prolonged & sustained antibacterial
5. Active in the presence of blood, serum, a
protein derivatives of tissue.
6. Able to completely remove the smear layer.
7. Low surface tension.
8. Able to disinfect the dentin/dentinal tubules.
9. Does not interfere with repair of periapi
tissues.

7. Characteristics of an ideal endodontic
irrigant :
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
10. Does notEndodontic Topics 2012,27,74-102
stain tooth structure.
11. Inactivation in a culture medium.
12. Does not induce a cell-mediated immune
response. Is non-antigenic, non-toxic, and
non-carcinogenic to tissue cells surrounding
the tooth.
13. Has no adverse effects on the physical
properties of exposed dentin.
14. Has no adverse effect on the sealing
ability of filling materials.
15. Easy to use/apply.
16. Inexpensive.

8. Classification of Irrigating solutions:
By Kandaswamy D, Venkateshbabu N.
A) Chemical agents:
a. Tissue dissolving agents: NaOCl
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
b. Antibacterial agents
 Bacteriostatic (CHX, MTAD)
 Bactericidal (NaOCl)
c. Chelating agents:
 Weak (HEBP)
 Strong (EDTA)
d. Combination products (tissue dissolution & antibacterial effect):
MTAD, QMiX, SmearClear, Tetraclean
B) Natural agents:
a. Antibacterial agents: e.g. Green tea, Triphala
Conserv Dent 2010: 13: 256–264

9. Classification of Irrigating solutions:
By STOCK .
 CHEMICALLY INACTIVE SOLUTIONS
( normal saline or local anaesthetic solution)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 CHEMICALLY ACTIVE SOLUTIONS
Alkaline solutions
 Sodium dioxide
 Urea
 Sodium hydroxide
 Sodium hypochlorite
 Potassium hydroxide
 Chloramine-T
Acidic solutions
 Organic acids (Citric
acid, maleic acid, tannic
acid, phosphoric
acid, lactic acid)
 Inorganic acids
(H2SO4, HCl)
Oxidizing agents
 3% H2SO4
 Urea peroxide
 Glyoxide

10. Classification of Irrigating solutions:
By STOCK .
 CHEMICALLY ACTIVE SOLUTIONS
Chelating agents
 EDTA
 EDTAC
 RC-Prep
Proteolytic enzymes
 Streptokinase
 Enzymol
 Streptodornase
 Purified trypsin
 Papain
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
OTHERS
 Chlorhexidine
gluconate (CHX)
 Glutraldehyde
 Oxidative potential
water
 2% potentiated acid
 1% pentanedial
 Calcium hydroxide
solution
 Bardac-2

11. Commonly used irrigating agents
used in endodontics
Sodium hypochlorite
(NaOCl)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Toxic
(hypochlorite
 Current irrigant of
accident)
choice

 Effective antimicrobial Not substantive

agent
Corrodes, unpleasa
 Excellent
organic
nt odor
tissue solvent
 Removes only the
 Lubricates
of the
 Effective fairly quicklyorganic part 2012,27,74-102
Endodontic Topics
smear layer

12. Mode of action…
1. Saponification reaction
NaOCl + fatty acids  Soap + glycerol
2. Neutralization reaction
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
NaOCl + aminoacids  Salt + water (H2O)
3. Chloramination reaction
Amino acids + HOCl  Chloramine + water (H2O)
 High pH of NaOCl interferes in the cytoplasmic
membrane integrity with an irreversible enzymatic
inhibition, biosynthetic alterations in cellular
Braz Dent
metabolism, and phospholipid degradation J 2002: 13: 113–117

13. Concentrations..
 used in concentrations between 0.5 and 7%
 NaOCl in higher concentrations is more effective against E.
faecalis and Candida albicans
Int Endod J 2001: 34: 424–428
Int Endod J 2004: 37: 438–446
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Int Endod J 1999: 32: 421–429
 Both low and high concentrations to be equally effective in reducing bacteria
from the root canal system
Scand J Dent Res 1981: 89: 321–328
Odontol Revy 1976: 27: 1–10
 higher concentrations has a better tissue-dissolving ability
J Endod 1978: 4: 60–64
 higher concentrations of NaOCl are more toxic than lower concentrations
Oral Surg Oral Med Oral Pathol 1973: 36: 856–864.
 Solution to be used in higher volume and in more frequent intervals, if in
lower concentration
J Endod 2000: 26: 331–334

14. Time of exposure for optimal effect
 when the confounding factors are eliminated, it has been
shown that NaOCl kills the target microorganisms rapidly
even at low concentrations of less than 0.1%.
Dent Clin North Am 2010: 5: 291–312
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 continuous irrigation and time are important factors for
the effectiveness of NaOCl in invivo conditions
 The optimal time that a sodium hypochlorite irrigant at a given concentration
needs to remain in the canal system is an issue yet to be resolved
Storage & handling
J Endod 2006: 32: 389–398
Austral Dent J 1998: 43: 250–256
 Stability of NaOCl solutions is reduced by lower pH, presence of metallic
ions, exposure to light, open containers and higher temperatures
 If diluted, they should be diluted as soon as possible after purchase

15. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 NO metallic containers
 corrosive nature of sodium hypochlorite must be
considered before disposal
Safety (Sodium hypochlorite accidents)
Endod Topics 2007: 16: 27–63
 Solutions containing more than 40% : hazardous oxidizers
 Solutions less than 40% : moderate oxidizing hazard
(NFPA 430, 2000)
 Toxic effects of NaOCl on vital tissues include hemolysis, epithelial
ulceration, and necrosis
 Several mishaps during root canal irrigation can range from damage to the
patient’s clothing, splashing the irrigant into the patient’s or operator’s
eye, injection through the apical foramen, and allergic reactions to the
irrigant, to inadvertent use of an irrigant as an anesthetic solution

16. Preventive measures
BDJ 2007: 202: 555–559
 Plastic bib to protect patient’s clothing
 Protective eye-wear
 Rubber dam isolation
 side-exit Luer-Lock needles
 Irrigation needle a minimum of 2
mm short of the working length
 Avoidance of binding of the needle
into the root canal
 Avoidance of excessive pressure during irrigation
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References

17. Treatment protocol for sodium
hypochlorite accident…
Compend Contin Educ Dent 2007: 28: 544–546.
 Early recognition of extrusion,
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Immediate canal irrigation with normal saline,
 Encouragement of bleeding,
 Pain control with local anesthetics and analgesics and warm
compresses and frequent warm mouth rinses for stimulation of
the local systemic circulation,
 Reassurance of the patient, and
 Monitoring of improvement.

18. Effect of NaOCl on dentin
 Degradation of organic dentin
 Clear concentration dependent effect of NaOCl
solutions on mechanical dentin properties
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Int Endod J 2007: 40: 786– 793
Sodium hypochlorite penetration of dentinal tubules
 Increasing the concentration from 1% to 6% did not result in more than a
30%–50% increase the first to report
Zou et al. is in penetration
in which NaOCl penetration into
 At 20 C, the penetration depth of 1% NaOCl in 2 min was about 77 mm; after
dentin has been measured with
another 18 min at the same temperature, the depth reached about 185 mm
micrometer accuracy.
 The highest values, 291 and 300 mm, were found in the groups treated
with 6% NaOCl at 37 C and 45 C for 20 min.
J Endod 2010: 36: 793–796

19. Allergic reactions to NaOCl
 unlikely to occur
 hypersensitivity and contact dermatitis may occur
 greater cytotoxicity and caustic effects on healthy tissue
with 5.25% NaOCl than with 1.0 & 0.5 % solutions
J Endod 1985: 11: 525-8
Effect on biofilm
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Oral Surg Oral Med Oral Pathol
2001; 92:446-50
Clegg et al. : 6% NaOCl was the only agent capable of both physically
removing artificial biofilm and killing bacteria
 dosedependent effect of NaOCl against bacteria
 Antibiofilm effects of NaOCl may be a result of removal of organic tissue,
thus eliminating the bacterial attachment to dentin and other organisms
J Endod 2006: 32: 434–437

20. Influence of NaOCl on bond strength
 decreased bond strength between dentin and resin
cements
 require a reversal agent
Influence of NaOCl on NiTi
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Busslinger and Barbakow: quantities of ions released by the corrosion
process into the NaOCl solution were insignificant
Int Endod J 1998;31:2904
Increasing the efficacy of NaOCl
 Altering the pH
 Increasing the temperature
 Agitation
Endodontic Topics 2012, 27, 74–102

21. 1. Altering the pH
 NaOCl + H20  NaOH + HOCl
 HOCl  H+ OCl HOCl molecule : stronger chlorinating and oxidizing action
on tissue & microorganisms
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Baker gave the relationship between HOCl, OCl-, and pH. At pH
10, basically all chlorine is in the OCl- form; the reverse occurs at a pH of
4.5, when all chlorine is in the form of HOCl.
Bloomfield and Miles: hypochlorites at a lower ph possess greater
antimicrobial activity
Andrews and Orton: HOCl was responsible for the destruction of
microorganisms
Morris: OCl- ion possesses approximately 1/80th of the germicidal potency
of HOCl in killing Escherechia coli
JOCD; Oct-Dec 2010; Volume 13; Issue 4

22. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
2. Increasing the temperature
Cunningham : collagen dissolving ability of 2.6% NaOCl
was comparable to that of 5.25% at both 21 C and 37 C
Oral Surg Oral Med Oral Pathol 1980: 50: 569–571
Raising the temperature killS bacteria more quickly. However, raising the
temperature of the NaOCl to 37 C does not help dissolve tissues more
effectively.
However, raising the
temperature till 60⁰C
is also advocated
J Endod 2006 32: 389-398
Fig. Heating devices for NaOCl syringes
Best way is to use an
ultrasonic device in situ

23. 3. Agitation
Moorer & Wesselin : impact of mechanical agitation of
NaOCl solutions on tissue dissolution was very important
(violent fluid flow and shearing forces caused by ultrasound)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Int Endod J 1982: 15: 187–196
Stojicic et al. refreshing the NaOCl solution by agitation, preferably
continuous, results in increase in the NaOCl effect
J Endod 2010: 36: 1558–1562
Fabiani : use of ultrasonic agitation increased the effectiveness of 5%
NaOCl in the apical third of the canal wall.
Endod 2010: 36: 282–285
The effect of agitation on tissue
dissolution was greater than that of
temperature;
continuous
agitation
resulted in the fastest tissue dissolution
J Endod 2010: 36: 1558–1562

24. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
CHLORHEXIDINE (CHX)
 excellent antimicrobial activity
 effective antifungal agent
 less effective on microbial biofilms
 antibacterial substantivity in dentin for up to 12 weeks
 Organic matter may reduce or inhibit the antibacterial activity
 no ability to dissolve organic or inorganic tissue
 Less contamination & apical leakage
 Combinations of NaOCl and CHX cause color changes and formation of a
precipitate, which may interfere with the seal of the root filling
 improve the integrity of the hybrid layer and resin–dentin bond stability
 Biocompatibile
Aust Endod J 2009: 35: 131–139

25. Mode of action
 Due to its cationic nature, CHX is capable of
electrostatically binding to the negatively charged
surfaces of bacteria, damaging the outer layers of the cell
wall and rendering it permeable
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 At high concentration exerts a bactericidal activity
 At low sub-lethal concentrations, chlorhexidine is bacteriostatic
Substantivity
 Concentration dependent effect
 Lin et al : only after the saturation point is reached after the first hour
that the antimicrobial capability of CHX increases with time.
Residual antimicrobial activity from CHX remains in the root canal system for
up to 12 weeks
Aust Endod J 2009: 35: 131–139

26. Cytotoxicity
 normally used at concentrations between 0.12% and
2.0%
 At these concentrations, CHX has a low level of tissue
toxicity, both locally and systemically (Loe)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 when CHX is in contact with NaOCl, there is formation of parachloroaniline
(PCA), which may have a negative impact on tissues
J Endod 2007: 33: 966– 969
Chlorhexidine application in endodontics
 as an irrigant and intracanal medication
 In infected root canals, it reduces bacteria as effectively as Ca(OH)2
when applied for 1 week
Endodontic Topics 2012,27,74-102

27. Chlorhexidine as an endodontic irrigant
 2% CHX as an irrigant has a better antibacterial efficacy
than 0.12% CHX in vitro
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003: 96: 618–624
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Canals treated with 2% CHX gel were cleaner than those treated with 2%
CHX liquid or 5.25% NaOCl
 2% CHX liquid was inferior to 2.5% NaOCl in cleaning the canals
Int Endod J 2003: 36: 391–394
Clinical studies
Ringel et al : 2.5% sodium hypochlorite was significantly more effective
than 0.2% chlorhexidine when the infected root canals were irrigated for 30
min by either of the solutions
Endod 1982: 8: 200–204
 However, in a recent study, no significant difference between the
antibacterial efficacy of 2.5% NaOCl and 0.12% CHX liquid
J Endod 2007: 33: 541–547

28. CHX and dentin bonding
 Carrilho et al: auto-degradation of collagen matrices
can occur in resin infiltrated dentin, but may be prevented
by the application of a synthetic protease inhibitor such as
CHX.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Overall, because of its broad-spectrum MMP-inhibitory effect, CHX can significantly
improve resin–dentin bond stability
Am J Dent 2005: 18: 315–317
Effect on biofilm
 2% CHX and 2% NaOCl killed only 13% to 15% of the 3-weekold
biofilm bacteria in dentin after 1 min of exposure where as 6% NaOCl being
the most effective
J Endod 2012: 38: 1376–1379
Allergic reactions to CHX
 No publications of allergic reactions following root canal irrigation with
CHX

29. Irrigant solutions with added detergent
reduce surface tension&
improve their wettability.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Fig. SmearClear, Chlor-XTRA and CHX-Plus.
 6% NaOCl and Chlor-XTRA were superior against E. faecalis biofilms
compared to 2% CHX and CHX-Plus
J Endod 2009: 35: 95–97

30. NaOCl + CHX
 an additive
antimicrobial action
Reason for this augmented
microbial action
 Tissue dissolving
property that is better
than that obtained with
use of CHX alone
 less toxic then NaOcl
NaOCl is an oxidizing agent
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
oxidize the gluconate part of CHX
to gluconic acid
chloro group might get added onto
the guanidine component
CHLOROHEXIDINE
CHLORIDE
2.5% NaOCL + 0.2 % CHX

31. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Interaction between NaOCl and CHX
Fig. Immediate formation of an orangebrown precipitate (para-chloroaniline)
Int Endod J 2002: 35: 791–795
Basrani et al: Amount of
PCA directly increased with
the increasing conc. of NaOCl
J Endod 2007: 33: 966– 969
Bui et al. NaOCl/CHX precipitate
tends to occlude the dentinal
tubules
J Endod 2008: 34: 181–185
Precipitate could be prevented by using absolute alcohol or minimized
by using saline and distilled water as intermediate flushes
J Endod 2010: 36: 1154–1157

32. DECALCIFYING SOLUTIONS
EDTA
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 polyamino carboxylic acid
 Remove the inorganic part of the smear layer
 Contribute to the elimination of bacteria in the root
canal
 Combination products have wide-spectrum antimicrobial
activity.
 EDTA may have antifungal activity
EDTA extracts bacterial surface
 Demineralize dentin (20–50 mm) proteins by combining with metal
ions from the cell envelope
 Low toxicity

33. Applications in endodontics
Haapsalo M, Qrstavik: removal of the smear layer by EDTA
(or citric acid) improves the antibacterial effect of locally
used disinfecting agents in deeper layers of dentin
J Dent Res 1987;66:1375-9
Endod Dent Traumatol 1990;6:142-9
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Antiseptics such as quaternary ammonium compounds (EDTAC) or
tetracycline antibiotics (MTAD) have been added to EDTA and citric acid
irrigants, respectively, to increase their antimicrobial capacity
Variations
EDTAC
EDTA + Cetavlon
REDTA
EDTA + Sodium hydroxide + cetyl trimethylammonium bromide + water
RC prep
EGTA
EDTA + urea peroxide
ethylene glycol bis (β aminoethyl ether)-N,N,N,N- tetra acetic acid

34. Interactions between EDTA, NaOCl, and CHX
EDTA + NaOCl
EDTA causes NaOCl to lose its tissuedissolving
capacity, and virtually no free chlorine is available
(Grawehr)
Int Endod J 2003: 36: 411–417
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
EDTA + CHX
Immediate formation of a white, foggy
precipitate
Precipitate involves the chemical degradation
of chlorhexidine (Rasimick et al)
J Endod 2008: 34: 1521– 1523

35. CITRIC ACID
 can also be used for irrigation of the root canal and for
removal of smear layer
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 used in various concentrations, ranging from 1% to 50%,
with a 10% solution being the most common
10% citric acid has been shown to remove the smear layer more effectively
from apical root end cavities than ultrasound
Int Endod J 1994;27:318-24
10% citric acid was more effective than 1% citric acid, which was more
effective than EDTA in demineralizing dentin
Int Endod J2004;37:365-9

36. HEBP
 HEBP (1-hydroxyethylidene-1,1-bisphosphonate; also
called etidronic acid)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Chelator that can be used in combination with sodium
hypochlorite (NaOCl) without affecting its proteolytic or
antimicrobial properties
 HEBP is a weak decalcifying agent and hence cannot be used as a mere
final rinse
NaOCl + HEBP :
 better tissue dissolution capacity
 less cytotoxic
 reduces dentin debris accumulation

37. QMiX
 QMiX contains EDTA, CHX, and a
detergent and comes as a ready-to-use clear
solution
 CHX and EDTA do not cause a white
precipitate; the solution is clear
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Surface tension
 Low surface tension is one of the ideal characteristics of an irrigant (Grossman)
Smear layer removal
 QMiX removed the smear layer equally as well as EDTA (Stojicic et al. )
Antibacterial efficacy and effect on biofilms
Int Endod J 2012: 45: 363–371
 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 & both were more effective than 2% NaOCl and 2%
CHX (Wang et al)
J Endod 2012: 38: 1376–1379

38. MTAD & TETRACLEAN
MTAD is a mixture of 3%
doxycycline
hyclate,
4.25%
citric
acid, and 0.5% polysorbate
(Tween) 80 detergent
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Tetraclean is a mixture of citric acid doxycycline 50 mg/5 Ml
(whereas 150 mg/5 mL for MTAD) and polypropylene glycol as
detergent

39. Mode of action
 Tetracycline is a bacteriostatic antibiotic which exerts
its effect through the inhibition of protein synthesis
 In the absence of bacterial cell lysis, antigenic by products
(i.e. endotoxin) are not released (Torabinejad)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Doxycycline, citric acid, and Tween 80 combined might have a synergistic
effect on the bacterial cell wall and on the cytoplasmic membrane
Cytotoxicity of MTAD
MTAD appeared to be less cytotoxic than eugenol, 3% H2O2, Ca(OH)2
paste, 5.25% NaOCl, Peridex, and EDTA and more cytotoxic than
2.63%, 1.31%, and 0.66% NaOCl solutions (Zhang et al )
Surface tension
J Endod 2003: 29: 654–657
MTAD has a lower surface tension than 5.25% NaOCl, 17% EDTA, or
water

40. Smear layer removal
MTAD performed better than EDTA in cleaning dentinal
tubules of debris and removing the smear layer in the
apical third of root canals (Torabinazad et al.)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
MTAD created less erosion than EDTA in the coronal and
middle thirds of the root canals.
J Endod 2003: 29: 400–403
Antibacterial efficacy
1.3% NaOCl followed by 5 min MTAD was more effective in the
disinfection of canals than a protocol of 5.25% NaOCl followed by 1 min
17% EDTA and then 5 min 5.25% NaOCl as a final rinse
J Endod 2003: 450–452

41. Other irrigating agents
HYDROGEN PEROXIDE
an oxidizing agent used in conc. of 3-5%
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Tissue dissolving capacity less than NaOCl
 Weak antibacterial effect
 3% H2O2 is effective against anaerobic bacteria
 less effective as a solvent , produce less damage to periapical tissue
 Bleaching effect
 WIEN strongly recommend its use bcoz of low toxicity
 used in conjunction with NaOCL
Mechanism of axn:
reaction of superoxide
ions
to
produce
hydroxyl radicals
Oxidation of sulphydryl
groups and double bonds
in proteins, lipids, and
surface membranes.
Antimicrobial
action

42. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
NaOCl + H2O2
 combination was
introduced by
Grossman
 produce foaming action flush the debris out of root canal
 significantly increase dentinal permeability (Marshall et al 1980)
 deactivationof bacterial endotoxins
(De .Rensin 1981)
 In combination antibacterial effect of both solutions was less than that of
individual solutions and it used to decrease tissue dissolving action of NaOCl
 release nascent O2 which can lead to pain and swelling, if used as last rinse
 but at the same time this [O] toxic to the anaerobes
 Tissue emphysema may occur

43. CHX + H2O2
 combination was
introduced by
Helling et al
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 CHX +H2O2 when combined do not counter act one another at specific
conc (synergistic axn)
H2O2
Smear layer removal
greater antibacterial
effect at deeper layers
CHX
allow penetration of
CHX into the dentinal
tubules
kills most of the
bacteria in the area
adjacent to the lumen

44. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
IODINE BASED COMPOUNDS
Aqueous iodine solutions are rather
unstable
development of iodophors (‘iodine
carriers’)
 Povidone–iodine
 Poloxamer– iodine
In endodontics, iodine potassium
iodide (IPI) in 10% concentration is
used
Mo ller (1966)
Antimicrobial action of iodine is rapid, even at low concentrations, Iodine penetrates
into microorganisms and attacks key groups of cell molecules, such as
proteins, nucleotides, and fatty acids, resulting in cell death
 Dentine powder, organic dentine matrix and heat-killed cells of E. faecalis and
C. albicans effectively abolished the effect of 0.2/0.4% IPI against E. faecalis
 Allergic reactions to iodine and the staining of dentin

45. GLY-OXIDE
 10% solution of carbamide peroxide in anhydrous glycerol
 provides lubrication without softening dentin
 antimicrobial activity more than 3% H2O2
 produces transient energetic effervescence with NaOCl
 useful in narrow and curved canals
 does not remove smear layer
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
MALEIC ACID
Ballal et al. reported that final irrigation with 7% maleic acid for 1min was
more efficient than 17% EDTA in the removal of smearlayer from the apical
third of the root canal system
J Endod 2009;35:1573-6

46. IRRIGATION DEVICES AND TECHNIQUES
MANUAL
Syringe irrigation
with needles/
cannulas
(end/side vent)
Brushes
(Endobrush, Navi
tip FX)
Mnual Dynamic
Agitation
(hand activated
well fitting gutta
percha
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
MACHINE ASSISTED
Rotary brushes
(Ruddlebrush, C
analbrush)
Continuous irrigation
during rotary
instrumentation
(Quantec-E)
JOE — Volume 35, Number 6, June 2009
Sonic
(Rispisonic
file, Endoactivat
or)
Ultrasonic
Pressure
alternating
devices
(EndoVac, Rinse
Endo)

47. Plastic syringes for irrigation
 Different sizes
(1-20 ml)
 Luer-Lok design
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Modifications
of needles
A)Bivelled
B) Monoject
C) Safe ended
(A)
(B)
(C )

48. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Modifications of needles
Bending the tip
Flexiglide
needle
 27-31 gauge
recommended
 should not bind in
the canal
 easily controlled
 not enough flushing
action Oral Surg Oral Med Oral Pathol 1977; 44:306–12

49. Brushes
Endobrush
 used only as an
adjuncts
 Nylon bristles set in
twisted wire
 Can’t be used till
NaviTip FX
working length
 recently introduced
 Dislodgement of
 30-gaugebristles
radiolucent needle
covered with brush
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References

50. MANUAL DYNAMIC AGITATION
 Effect of “apical vapor lock”
Dent Today 2008;27:82,84,86–87
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Technique: Gently moving a wellfitting gutta-percha
master cone up and down in short 2- to 3mm strokes within an instrumented canal
 Principles:
1. changes in intracanal pressure
2. frequency of 3.3Hz, 100 strokes per
30 seconds

51. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
ROTARY BRUSHES
Ruddle brush
Canal brush
Continuous Irrigation During Rotary
Instrumentation (Quantec-E)
 Selfcontained fluid delivery unit
 uses a pump console, 2 irrigation
reservoirs & tubing
 but no significant results in middle &
apical in cleaning efficiency (Walters et al)
J Endod 2002;28:837–9

52. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
SONIC IRRIGATION
Rispisonic file
 combines battery-driven
vibrations (9000 cpm) with
manually operated
irrigation of the root canal
Vibringe

53. ENDOACTIVATOR
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 consists of a portable handpiece and 3 types of disposable
polymer tips of different sizes
 10,000 cycles per minute (cpm)
Stamos et al reported that the more powerful ultrasonic
systems removed more dentin debris from the root canal than
the less powerful sonic irrigation systems.
J Endod 1987;13:434–40

54. ULTRASONICS
 Ultrasonically activated files have the potential
to prepare and debride root canals mechanically.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Files are driven to oscillate at ultrasonic
frequencies of 25–30 kHz in a transverse vibration
Two types of ultrasonic irrigation :
 Active ultrasonic irrigation (UI)
 Passive ultrasonic irrigation (PUI)
 Endodontic literature supports that it is more
advantageous to apply ultrasonics after completion of
canal preparation
J Endod 2006;32:389–98

55. PASSIVE ULTRASONIC IRRIGATION
(PUI)
(Weller et al )
 During PUI, the energy is transmitted
from an oscillating file or a smooth wire to
the irrigant in the root canal by means of
ultrasonic waves.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
The latter induces acoustic streaming and
cavitation Application Methods During PUI:
 Irrigant of the irrigant.
a) Continuous Ultrasonic Irrigation
b)
Intermittent
Flush
Ultrasonic
Irrigation
Acoustic
streaming
cavitation

56. a) Continuous Ultrasonic Irrigation
 Nusstein’s needle holding devices
 25-gauge irrigation needle is used instead of an
endosonic file
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 needle is simultaneously activated by the ultrasonic handpiece, while
an irrigant is delivered from an intravenous tubing connected via a Luerlok to an irrigation-delivering syringe.
b) Intermittent Flush Ultrasonic
Irrigation

57. PUI is more effective than syringe needle irrigation in
removing pulpal tissue remnants and dentin debris.
J Endod 2003;29:674–8
Guerisoli et al reported that smear layers were effectively
removed from the apical, middle, and cervical thirds of the
canal walls by EDTA plus Cetavlon (EDTAC) and NaOCl by
using a size 15 file energized by ultrasonic agitation.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Int Endod J 2002;35:418–21
Removal of Bacteria:
 High-power ultrasound causes de-agglomeration of bacterial biofilms via
the action of acoustic streaming
 Cavitation may produce temporary weakening of the cell membrane

58. PRESSURE ALTERNATION DEVICES
The EndoVac System….
Multi-Port Adapter (MPA)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References

59. The EndoVac System….
(A)
(B)
(C)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
(D)
(A) Macrocannula with handpiece (B) Microcannula with fingerpiece
(C) Master delivery tip (D) Tip of microcannula

60. The EndoVac System….
Clinical use:
(A)
(B)
(C)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
(D)
Negative
pressure
Positive
pressure

61. Safety:
Less apical extrusion risk using the EndoVac system
compared with needle irrigation
J Endod. 2010 Feb;36(2):338-41
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Efficacy:
Better debridement 1 mm from working length using the EndoVac system
compared with needle irrigation
J Endod 2007;33:611-615
SUCCESS:
Negative apical pressure irrigation system EndoVac results in
significantly less postoperative pain & necessity for analgesic medication
than a conventional needle irrigation protocol using the Max-i-Probe
J Endod 2010;36:1295-1301

62. The RinsEndo System
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 65 mL of a rinsing solution oscillating at a frequency of 1.6 Hz is
drawn from an attached syringe and transported to the root canal via
an adapted cannula.
 Suction phase (100 times per minute)
 higher risk of apical extrusion of the irrigant

63. CHALLENGES OF IRRIGATION
DCNA 2010;54: 291-312
1. Smear Layer
 Remove organic &
inorganic parts
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Fig. Instrumented canal
wall after removal of the
smear layer by NaOCl and
EDTA.

64. 2. Dentin Erosion
 reduction in the flexural strength and elastic
modus of dentin
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Fig. Considerable erosion of canal-wall dentin
occurs when hypochlorite is used after EDTA
or CA.
3. Cleaning of Uninstrumented Parts of the Root-canal System
Fig. An anastomosis between 2 joining canals
has been packed with debris during rotary
instrumentation

65. 4. Biofilm
 How to remove it?
 can CHX be an alternative to NaOCl here?
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Fig. Bacteria growing on dentin surface;
eradication of the microbes in the apical canal should be the key
early stages of biofilm formation
to success….
5. Safety versus Effectiveness in the Apical Root Canal
But what about safety concerns???

66. RECENT ADVANCES IN IRRIGATION
1. LASERS
Moshonov et al. assessed that Nd: YAG laser irradiation
significantly reduced the number of bacteria (E. faecalis), but its
inferior to NaOCl irrigation, which effectively disinfected the
canals.
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Endod Dent Traumatol 1995: 11: 220–224.
Ho : YAG shows excellent antibacterial efficiency against E. faecalis while CO2
laser shows a mixed response (Gutknecht et al)
J Clin Laser Med Surg 1997: 15: 75–78
Takeda et al., concluded that CO2 laser removed and melted the smear layer on
the instrumented canal walls, while the Er: YAG laser was the most effective in
removing the smear layer
Int Endod J 1999: 32: 32–39

67. 2. Light-activated Disinfection
(LAD)
 Photodynamic antimicrobial chemotherapy
 Photosensitizer (toluidine blue dye, methylene
blue dye, etc)
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 The canal is then filled with a photosensitizer and then illuminated with a
light source (laser, white light, red light, or a light-emitting diode).
Dent Clin N Am 55 (2011) 461–480
Fig. FotoSan: comercially available
LAD

68. Application of
photosensitizer
Light Activated
Disinfection

69. 3. Electrochemically
(ECA)
activated
water
 produced with a new and unique anode–cathode system
(Leonov 1997)
 extremely biocompatibility
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 ECA produced much clearer dentinal walls compared to NaOCl (J.T Marais)
4. Oxidative potential water (OPW)
 electrolyzed NaCl in a special machine called aquacida
5. Cetrexidine
 0.2% CHX and 0.2% citrimide
 better penetration of CHX into the dentinal tubules and better antimicrobial
efficacy

70. 6. Carisolv
 potential as on irrigant as it is antibacterial and has
collagen dissolving potential (M.G Al Kilani and Dummer)
7. Ruddles solution
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 Radiopaque agent Hypaque + NaOCl + EDTA
 used to detect the presence of lateral / accessory canals
8. Bioactive materials like bio(active) glass
 Antimicrobial activity against a range of microbes
J Endod 2004;30:220-4
9. Chitosan
 naturally occurring polysaccharide
chitosan at 0.2% concentration has been
proposed by Silva et al as an efficient
chelating agent without the negative
effects of high concentration EDTA
Int Endod J 2012
 easily
and
locally
available, cheap, biocompatible, bio
degradable, has the property of
bioadhesion and has antimicrobial
activity

71. SEQUENCE OF IRRIGATION
Oral Health, May 2005
VITAL TEETH
urea peroxide
(collagen anti-aggregation effect)
sodium hypochlorite
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
("elevator effect" )
NaOCl + K file activation
EDTA
( removes the inorganic part & reduction of inflammatory reaction by
CHX
NaOCl
inhibiting the affinity of macrophages to the vaso-active peptides of
the pulpal tissue)
+
+
CAUTION: USE DISTILLED WATER IN BETWEEN EVERY IRRIGATING AGENTS

72. SEQUENCE OF IRRIGATION
Oral Health, May 2005
NON VITAL TEETH
NaOCl
CHX
PRESENCE OF RESORPTIONS
VitalEDTA
teeth
+
+
NaOCl
Citric acid
+
CHX
CAUTION: USE DISTILLED WATER AS THE END IRRIGANT
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References

73. SEQUENCE OF IRRIGATION
CONDITION
IRRIGANTS
Necrotic pulp
NaOCI+CHX/H2O2
Vital pulp exposure
NaOCl+H2O2
Calcified/sclerotic canal
EDTA + NaOCl
Infected canal-exudate present
NaOCl + H2O2
Periapical abscess-to
establish Hot water/saline......Later NaOCl
drainage
Open apex/apical perforation
H2O2 + CHX
Curved canals
Glyoxide + NaOCl
Canals left open for drainage
H2O2 + NaOCl
Retreatment cases
CHX + NaOCl
Final rinse-to remove the smear EDTA + NaOCl LAYER

74. CONCLUSION
 The main goal of root canal treatment is to completely
eliminate the different components of pulpal
tissue, bacteria, and biofilm and produce a hermetic seal to
prevent infection or reinfection and promote healing of the
surrounding tissues
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
 The extra time we gain by using rotary NiTi instruments should be used
for abundant irrigation to achieve better cleaning of the root canal
system, thereby contributing to improved success of the treatment.
 For optimal irrigation, a combination of different irrigating solutions
must be used.
 Developing a rational irrigation sequence so that the chemicals are
administered in a proper manner to release their full potential is
imperative for successful endodontic treatment.
Endodontic Topics 2012, 27, 74–102

75. Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
Endodontic Topics
2012, 27, 74–102

76. 1. Ingle’s Endodontics; 6 edition.
Introduction
2. Cohen’s Pathways of pulp;Irrigationth
10 solutions
Irrigation devices
REFERENCES
Challenges
edition.
Recent advances
Irrigation sequence
3. Weine’s Endodontic Therapy;
Conclusion
References
6th edition.
4. Principles and Practice of
Endodontics
by
Walton
&
Torabinajad; 3rd edition.
5.
Grossman’s
Endodontic
Practice; 12th edition.
6. Textbook of Endodontics; Nisha
Garg; 2nd edition.
7. Update on endodontic irrigating

77. REFERENCES
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
8. Irrigation in Endodontics; Markus
Haapasalo; Wei Qian; Dent Clin N
Am 54 (2010) 291-irrigants; D Kandaswamy;
312.
9. Root canal
N.Venkateshbabu; Journal of conservative
dentistry; Oct-Dec 2010; volume 13; issue 4.
10. Eradication of endodontic infection by
instrumentation and irrigation solutions;
Markus Haapasalo, Unni Endal, Homan Zandi &
Jeffrey M. Coil; Endodontic Topics 2005, 10,
77–102.
11. Root Canal Irrigants; Matthias Zehnder;
JOE — Volume 32, Number 5, May 2006.
12. Sequence of Irrigation in Endodontics

78. REFERENCES
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
13.
Sodium
hypochlorite
in
endodontics: an update review
Zahed Mohammadi Yazd, Iran;
International
14. Technologic Dental
Advances Journal
in Endodontics;
(2008)58, 329-341.
Rory E. Mortman; Dent Clin N Am 55 (2011)
461–480.
15. Review of Contemporary Irrigant
Agitation Techniques and Devices Li-sha Gu,
Jong Ryul Kim, Junqi Ling,Kyung Kyu
Choi,David H. Pashley, and Franklin R. Tay ;
JOE — Volume 35, Number 6, June 2009.
16. Passive ultrasonic irrigation of the root
canal: review of the literature; L. W. M. van

79. REFERENCES
Introduction
Irrigation solutions
Irrigation devices
Challenges
Recent advances
Irrigation sequence
Conclusion
References
17. Complications during root canal
Irrigation; Michael Hu¨ Lsmann,
Tina Ro¨ Dig & Sabine Nordmeyer;
Endodontic Topics 2009, 16, 27–63.
18. Advances in root canal disinfection; Baiju
Gopalan Nair, K Amarendhar Reddy, Naga
Lakshmi Reddy, Upendranath Reddy; JPBMS,
Vol.05, Issue 05.
19. Comparison of apical extrusion of NaOCl
using the EndoVac or Needle Irrigation of Root
canals. Mitchell, Yang, Baumgartner; JOE-Vol
33, 2007.