Irrigation manju.pptx

ENDODONTIC IRRIGANTS
DR MANJUSHA GOVIND
IIIrd YEAR POST GRADUATE
DEPARTMENT OF CONSERVATIVE DENTISTRY &
ENDODONTICS

contents
INTRODUCTION
HISTORY
OBJECTIVES OF IRRIGATION
IDEAL CHARACTERISTICS OF
ENDODONTIC IRRIGANT
CLASSIFICATIONS
CHALLENGES OF IRRIGATION
SALINE
SODIUM HYPOCHLORITE
HYDROGEN PEROXIDE
 CHLORHEXIDINE GLUCONATE
 CHELATING AGENTS: EDTA, ORGANIC
ACIDS, HEBP
 TETRACYCLINE
 CHITOSAN

 ELECTROCHEMICALLY ACTIVATED SOLUTIONS
 OZONATED WATER TETRACYCLINE BASED: TETRACLEAN,
MTAD
 COMBINATION: Q MIX,
 NANOPARTICLES: SILVER NANOPARTICLES
 HERBAL IRRIGANTS
 DISINFECTION PROTOCOL
 REFERENCES
 CONCLUSION

 The goal of endodontic treatment is to remove all vital and necrotic tissues, microorganisms, and
microbial byproducts from the root canal system.
 The root canal is shaped with hand and rotary instruments under constant irrigation to remove the inflamed
and necrotic tissue, microbes/biofilms, and other debris from the root-canal space.
 Several studies using advanced techniques such as microcomputed tomography (CT) scanning have
demonstrated that proportionally large areas of the main root-canal wall remain untouched by the
instruments(30–50% of the root canal wall) emphasizing the importance of chemical means of cleaning
and disinfecting all areas of the root canal
(Peters et al. 2001, Gulabivala et al. 2005)
INTRODUCTION
micro-computed tomographic scans taken before (green) and after (red) root canal
preparation, showing areas not touched by instruments in the apical third
Therefore, irrigants are required to be used as an
important addition in the disinfection process

Potassium
hypochlorite was
the first
chemically
produced
aqueous chlorine
Solution
sodium
hypochlorite
was
recommended
to be used for
infectious
diseases
Introduced
chelating
agents(EDTA)
recommended
solution of 3%
H2O2
use of a
buffered 0.5%
sodium
hypochlorite
solution to
the irrigation
of infected
wounds.
Bertholiet (1748- 1822).
Labarraque(1777-1850)
Henry Dakin in 1915
Grossman and Meiman in 1941
In 1957 Nygaard Ostby
HISTORY

Quarternary
ammonium
solutions was
introduced as
irrigants
Phosphoric
acid, Citric
acid and Lactic
acid was used
to remove
smear layer
from the root
canals.
chlorhexidine
was
introduced for
its use as an
irrigant
claimed that
ultrasonics and NaOCL
act synergistically
when used together
for root canal
debridement
Electrochemic
ally activated
water was
used as root
canals
irrigants.
Spangberg ln 1978 .
Wayman ln 1979
Russians In 1980
In 1980 Martin
In 1982 Delany
The last few decades has seen the
introduction of Ozone Photodynamic therapy,
Lasers as efficient tools for intra canal
disinfection.
HISTORY

Objectives of irrigation in endodontics
MECHANICAL CHEMICAL BIOLOGIC

The mechanical objectives are as follows:
 flush out debris
 lubricate the canal
Chemical objectives
 dissolve organic and inorganic tissue
 prevent the formation of a smear layer during instrumentation or dissolve it once it
has formed.
biological objec-tives
related to their antiseptic and nontoxic effects such as
efficacy against anaerobic facultative microorganisms (planktonic and biofilms),
ability to inactivate endotoxin, nontoxic and noncaustic,
and little potential to cause anaphylaxis

 Ability to serve as a lubricant
during instrumentation
 Ability to dissolve organic
dentinal tissues (pulp tissue,
collagen, and biofilm)
 Ability to remove the smear
layer completely
 Low surface tension
 Disinfection of dentin and
dentinal tubules
 No interference with
periapical tissue healing
 Ease of application and low
cost
 Long shelf life
PROPERTIES
OF AN
IDEAL
IRRIGANT
TORABINEJAD-1989

Stock classified irrigating solutions based on their chemical activity as
Chemically inactive solutions
water saline or LA
Chemically active solutions which includes
a) Alkalis
b)Acids
c)Chelators
d)Oxidisers
e)Antibacterials
f)Detergents
g)Enzymes
CLASSIFICATION
Walton classified chemical adjuncts based on their functions
a) Irrigants
b) Dentin softeners - Chelators - De-calcifiers
c) Lubricants
d) Dessicants

ENDODONTIC
IRrIGANTS
CHEMICAL
AGENTS
Tissue Dissolving Agents
(e.g., NaOCl, ClO2)
Antibacterial Agents
1) Bactericidal (e.g., CHX)
2) Bacteriostatic (e.g., MTAD)
Chelating Agents
1) Mild pH (e.g., HEBP)
2) Strong pH (e.g., EDTA)
NATURAL
AGENTS
Antibacterial Agents
(e.g., Green tea, Triphala)
Kandaswamy et al.,
JCD 2010

CHALLENGES OF IRRIGATION
 Removal of the smear layer is straightforward and predictable when the correct irrigants are used.
 The smear layer is created only on areas touched by the instruments.
 Delivery of irrigants to these areas is usually unproblematic, with the possible exception of the most
apical canal, depending on canal morphology and the techniques/equipment used for irrigation.
 However, careless irrigation, with needles introduced only to the coronal and middle parts of the root
canal, is likely to result in incomplete removal of the smear layer in the apical root canal
1. Smear Layer

 A few studies have shown that long-term exposure to high concentrations of hypochlorite can lead to
considerable reduction in the flexural strength and elastic modus of dentin
 Several authors’ suggest that hypochlorite irrigation after demineralization agents should be avoided.
 Instead, chlorhexidine irrigation could be used for additional disinfection at the end of the treatment.
Considerable erosion of canal-wall
dentin occurs when hypochlorite
is used after EDTA or CA.
2.Dentin Erosion
 There is a general consensus that dentin erosion may be harmful and
should be avoided.

3. Cleaning of Uninstrumented Parts of the Root-canal System
 Irrigation is most feasible in the instrumented areas because the
irrigation needle can follow the smooth path created by the
instruments.
 Cleaning and removing of necrotic tissue, debris, and biofilms from
untouched areas rely completely on chemical means, and sufficent use of
sodium hypochlorite is the key factor in obtaining the desired results in
these areas
 A recent study showed that untouched areas, in particular anastomoses between canals, are
frequently packed with debris during instrumentation.
Canal-wall dentin in an
uninstrumented area after
hypochlorite irrigation revealing the
large calcospherites

Biofilm can be removed or eliminated through the following
methods:
 Mechanical removal by instruments (effective only in some areas of
the root canal)
 Dissolution by hypochlorite
 Detachment by ultrasonic energy.
4. Biofilm
Bacteria growing on dentin surface;
early stages of biofilm formation.
Any remaining organic matter, microbes, or vital or necrotic tissue jeopardizes the integrity of the
seal of the root filling.
Therefore the goal of the treatment is not only to kill the microbes in the root canal but also to
remove them as completely as possible.

 Irrigation must maintain a balance between 2 important goals: SAFETY AND EFFECTIVENESS.
 Irrigants can cause pain and other problems if they gain access to the periapical tissues.
5. Safety versus Effectiveness in the Apical Root Canal
 Effectiveness is often jeopardized in the apical root canal by restricting anatomy and valid safety
concerns.
 Sufficient exchange of hypochlorite and other irrigants in this area while keeping the apical pressure of the
solutions minimal is the obvious goal of irrigation of the apical root canal.
 A better understanding of fluid dynamics and the development of new needle designs and equipment for irrigant
delivery are the 2 important areas to deal with in the challenges of irrigating the most apical part of the canal

From a biological stand point, sterile normal saline is the best irrigant to
use because it causes.
Least apical tissue irritation or damage.
Biocompatible.
Least amount of cell lysis.
DISADVANTAGES:
 Does not remove the smear layer but merely flushes out some of the superficial debris
from the root canal system.
 Has poor antibacterial properties, however irrigation followed by ultrasonic and sonic
instrumentation have been reported to be almost as effective as 0.5 to 2.5% NaOCl
irrigation in reducing the number of bacteria in infected root canals.

Sodium hypochlorite (naocl) is the most widely used in endodontic treatment because
of its effective antimicrobial activity and ability to dissolve organic tissues
Commonly used in concentrations between 0.5% and 6%.
It is used as an unbuffered solution at ph 11 in the various concentrations or buffered
with bicarbonate buffer (ph 9.0), usually as a 0.5% (dakin solution) or 1% solution.
SODIUMHYPOCHLORITE

SODIUM HYPOCHLORITE:MECHANISM OF ACTION
1.SAPONIFICATION REACTION: NAOCL + FATTY ACID => SOAP (FATTY ACID SALTS) + GLYCEROL
2. NEUTRALIZATION REACTION: NAOCL + AMINO ACID => SALT+ WATER
3. CHLORAMINATION REACTION: HOCL + AMINO ACID => CHLORAMINES+ WATER

There is conflcting evidence regarding the time course of the antibacterial effect of NaOCl.
Such differences are likely a result of several factors like the presence of organic matter that
has a detrimental effect on the antibacterial activity of NaOCl.
When such factors are eliminated, it has been shown that NaOCl kills the target
microorganisms rapidly even at low concentrations of less than 0.1%.
However, in vivo the presence of organic matter (inflmmatory exudate, tissue remnants, and
microbial biomass) weakens its effect.
The penetration ability to the uninstrumented area of root canal systems can be increased by
lowering the surface tension of NaOCl
Haapasalo et al -2000 calcium hydroxide solution, 1% sodium
hypochlorite, 0.5% and 0.05% chlorhexidine
acetate, and 2/4% and 0.2/0.4% iodine
potassium iodide.
showed that in the absence of
dentin powder, 1% NaOCl kills E.
faecalis in less than 5 minutes

 Effectiveness of low concentrations of NaOCl can be improved by
 Larger volumes
 Frequent change
 Longer period of exposure
 In contrast, clinical studies have indicated both low and high concentrations to be
equally effective in reducing bacteria from the root canal system.
 However, in lower concentrations when used in high volumes it can be equally
effective.
 the amount of freely available chlorine increases when the NaOCl concentration is
raised or when the solution is repeatedly replenished over a longer period of time
(Siqueira et al. 2000)
Virdee SS, Farnell DJ, Silva MA, Camilleri J, Cooper PR, Tomson PL. The influence of irrigant activation, concentration and contact time
on sodium hypochlorite penetration into root dentine: an ex vivo experiment. International endodontic journal. 2020 Jul;53(7):986-97.
The chlorine ion, which is responsible for the dissolving and antibacterial capacity of NaOCl, is
unstable and consumed rapidly during the fist phase of tissue dissolution, probably within 2
minutes, which provides another reason for continuous replenishment.

AUTHOR METHOD CONCLUSION
Torabinejad M et al -2010 An invitro study done using 1.3%, 2.5%, or
5.25% concentration of NaOCl was applied in
5-, 10-, 15-, 20-, 25-, 30-, 35-, and 40-minute
most effective irrigation regimen was
5.25% at 40 minutes, whereas
irrigation with 1.3% and 2.5% NaOCl
for this same time interval was
ineffective in removing E. faecalis
Farnell et Al-2020 NaOCl concentration
(2%; 5.25%) and irrigant contact time (10 min;
20 min)
Longer durations of sodium
hypochlorite exposure
at lower concentrations result in
similar depths of tubular penetration
as those achieved at higher
concentrations

Siquiera et al.,Joe,2000 1.3% and 2.5% 5.25% NaOCl at 40 min most effective irrigation regimen is reported
to be
5.25% at 40 min
SOARES et al-2006 1, 2.5 and 5% sodium hypochlorite NEGATIVE CULTURE IN G III WAS 93.4%-
5% NaOCl offered the best antiseptic potential
N. Verma & J. Duhan-2019 high‐concentration (HC) 5% sodium
hypochlorite and low‐concentration (LC) 1%
sodium hypochlorite
Greater healing was observed in the HC (81.4%)
group compared with the LC group (72.1%)
Patrícia de almeida n 1%, 2.5%, or 5.25% NaOCl for 30 minutes NaOCl at low concentrations is capable of
promoting changes in dentin permeability.
NaOCl modifies the permeability of root dentin
directly proportional to its concentration.

Increasing the temperature of NaOCl solutions to 37degree celcius or even 60 degree celcius
improves their immediate tissue-dissolution capacity, but if over heated NaOCl solution
breaksdown.
Furthermore, heated hypochlorite solutions remove organic debris from dentin shavings more
efficiently.
The systemic toxicity of preheated NaOCl irrigants is lower than
the one of more concentrated nonheated counterparts
Temperature
Device for heating syringes filled with
irrigation solution (e.g., sodium
hypochlorite) before use.

• However, it was demonstrated that as soon as the irrigant touches the root canal system, the
temperature reaches the body temperature.
.
• Therefore, some authors recommend in situ heating of NaOCl. This can be done by activating
ultrasonic or sonic tips to the NaOCl inside the root canal for a couple of minutes.
• 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.
Zeltner et al.: Temperature changes during ultrasonic irrigation with different inserts and modes of activation, J
Endod 35:573, 2009
.

Sirtes, et al. (2005) Stability of 5.25, 2.62, and 1% NaOCl
solutions for 60 min at 20, 45, and 60
degrees C was assessed
NaOCl at 45˚C has better antibacterial
efficacy than at 20˚C.
Carpio-perochena, et al. (2015) concentration of 1% at different
temperatures (22°C and 37°C)
The temperature variation of the NaOCl
is not relevant in killing or dissolving
bacterial biofilms
Giardino, et al.10 (2016) compare the antimicrobial activity of
5.25% NaOCl, Hypoclean
and Chlor-Xtra at 20 °C and 45 °C in
bovine root dentin.
The antibacterial activity of Hypoclean
and Chlor-Xtra at 45 °C were
significantly greater than other tested
solutions.
N ayez et al (2021) NaOCl 2ºC, NaOCl 25ºC and NaOCl 45ºC Preheating NaOCl does not provide any
extra antibacterial effect and results in a
higher postoperative pain value than the
cold NaOCl when used for final irrigation

Spratt et al. - NaOCl (2.25%), 0.2% CHX, 10% povidone iodine against monoculture biofilms of five root canal
isolates including P. intermedia, Peptostreptococcus miros, Streptococcus intermedius, F. nucleatum, E. faecalis.
CONCLUSION NaOCl was the most effective anti-microbial followed by the iodine solution
Clegg et al. -3 concentrations of NaOCl (6%, 3%, and 1%), 2% CHX and BioPure MTAD on apical dentine
biofilms in vitro. CONCLUSION : 6% NaOCl was the only irrigant capable of both rendering bacteria nonviable
and physically removing the biofilm.
Ng et al. - 2.5% NaOCl and 10% iodine for decontamination . CONCLUSION Bacterial DNA
could be detected significantly more frequently from the tooth surfaces after iodine (45%) compared with NaOCl
(13%)
Giardino et al. - 5.25% NaOCl and MTAD against against E. faecalis biofilm and . CONCLUSION only 5.25%
NaOCl can disgregate and remove the biofilm at every time.
NAOCL AND BIOFILMS
Mohammadi Z. Sodium hypochlorite in endodontics: an update review. International dental journal. 2008 Dec;58(6):329-41.

Antifungal activity
Sen et al.-- 1% NaOCl, and 5% NaOCl and 0.12% CHX against Candida albicans using cylindrical
dentine tubes.
C. albicans to be more resistant in the presence of smear layer than in the absence of smear layer.
When smear layer was absent, NaOCl started to display antifungal activity after 30 minutes.
Waltimo et al. evaluated the susceptibility of seven strains of C. albicans to four disinfectants: NaOCl,
IKI, CHX acetate and calcium hydroxide.
C. albicans cells were highly resistant to calcium hydroxide. NaOCl (5% and 0.5%) and iodine (2%)
potassium iodide (4%) killed all yeast cells within 30s, whilst CHX acetate (0.5%) showed complete killing
after 5min.
THE ANTIFUNGAL ACTIVITY OF NAOCL IS SUPERIOR TO OR AT LEAST EQUAL TO OTHER COMMON IRRIGATION SOLUTIONS

 NaOCl is corrosive to metals involving selective removal of nickel from the surface creating
micropitting
 It is supposed that these microstructural defects can lead to areas of stress concentration and crack
formation, weakening the structure of the instrument
O’Hoy et al. detected significant corrosive phenomena of NiTi instruments
exposed to 1% NaOCl for up to 10 cleaning cycles.
Berutti and Marini evaluated the influence of immersion in NaOCl on resistance to cyclic fatigue
fracture and corrosion of ProTaper NiTi rotary instruments.
if NiTi rotary instruments operate immersed in a NaOCl solution contained in the pulp chambers of
teeth restored with metals or alloys having different electrochemical nobility values, galvanic corrosion
may occur.
Haikel et al. reported that the mechanical properties of Ni-Ti instruments were not affected by NaOCl, nor
was the cutting efficiency.
Influence of NaOCl on NiTi

NaOCl and
chlorhexidine
produces a carcinogenic product, parachloroanaline (PCA), CHX and NaOCl are not soluble in
each other; a brownish-orange precipitate is formed
NaOCl+ EDTA(CA)
instantaneously reduces the amount of chlorine when mixed
with sodium hypochlorite, resulting in the loss of NaOCl
activity. Thus, these solutions should not be mixed.
CHX and EDTA
immediately produces a white precipitate. t the ability of EDTA to remove the
smear layer is reduced
NaOCl with
H2O2
more vigorous bubbling, the effectiveness of the mixture has
not been shown to be better than that of NaOCl alone
Haapasalo M, Shen Y, Qian W, Gao Y. Irrigation in endodontics. Dental Clinics. 2010 Apr 1;54(2):291-312.

Influence of NaOCl on bond strength
Dentine is degenerated by NaOCl treatment because of the dissolution of dentinal collagen .
Residual NaOCl may interfere with polymerisation of bonding resin due to oxygen
generation
NaOCl irrigation leads to decreased bond strength between dentin and resin
cements and may require a reversal agent because of its ability to affect the
polymerization of the resin sealer.
Agents such as Ascorbic Acid or Sodium Ascorbate have been shown to completely
reverse this reduction in bond strength.
Vongphan et al.

TOXICITY OF NaOCl TO PERIAPICAL TISSUE:
SOFT TISSUE COMPLICATIONS ARE
Severe pain.
-Edema.
-Profuse haemorrhage both interstitially and through the tooth.
-Increasing edema.
-Ecchymosis.
-Tissue necrosis.
-Parasthesia.
-Secondary infection (rarely).
Majority of cases, have shown complete resolution within a couple of
weeks. In some cases they may be long-term parasthesia or scarring.
•SODIUM HYPOCHLORITE ACCIDENT:

SEQUENCE OF EVENTS: (SABALA & POWELL,JOE 1989)
• Excruciating pain within 2-5 min
• Burning sensation in affected area
• Immediate swelling (ballooning) of the tissue in the area with spread to surrounding
loose connective tissue.
• Profuse bleeding episode either interstitially or through the root canal system.
• Over the next few days, the pain subsides to a constant discomfort, swelling persists
over a week and progressively subsides.
• The interstitial hemorrhage may result in echymosis over the skin because of which
the affected skin is discolored.

Remain calm and assist the patient in remaining calm.
Evaluate the reclined dental chair to decrease pressure from the head.
For immediate relief of pain –
onerve block and L.A.
oWet, cold, compress – continually applied to the face – for relief of pain and burning
sensation and minimize swelling (for upto 6 hours).
oAnalgesics – after emergency treatment.
To control inflammation – corticosteroids immediately i.v. for 3 days.
To prevent infection – antibiotics (1wk).
Heat packs and warm mouth rinse (after initial treatment).-To improve circulation to the
area.
Advise the patient concerning the anticipated swelling and ecchymosis.
Give the patient both verbal and written instructions.
Reassure the patient that he will regain his normal appearance within a short period.
Treatment for this type of emergency:

PREVENTION
• Prevention of inadvertent extrusion of irrigant past apex. Measures include:
• Express intra canal irrigant slowely
• Passive needle placement in canal (especially if beveled)
• Watch for flow back of irrigant
• Procedure to be performed under Rubber Dam
HYPERSENSITIVITY TO NaOCI
• Described in a case report by Kaufman & Keila (JOE 1999).
• History taking is important, can be followed up with a patch test for confirmation
• Adverse effects cannot only be related to Clinical Toxicity (Harrison) but also to
Allerginicity.
• In such patients, use alternative solutions like Solvidont

CHLORHEXIDINE GLUCONATE
It is a cationic bisbiguanide with optimal antimicrobial action between pH 5.5-7
(Leonardo et al)
•CONCENTRATIONS OF USE OF CHLORHEXIDENE :
 Include 0.12%, 0.2% & 2% (Hays, Janer & White)
 A commercially available oral rinse typically contains 0.12% Chlorhexidene
gluconate, 11.6% alcohol, glycerin, flavoring agents, saccharin.

ACCORDING TO KLIMN ET AL
When used as an intra canal irrigant in the endodontic treatment for periapical lesions C.G.
showed:
1.Clinical relief of symptoms.
2.Sterility.
3.Reduction in the size of periapical lesions.
All at a mean follow up of 24 months.
In another study (O hara et al) showed that CG was the most efficient antibacterial agent when
compared to 3% H2O2, 5.25% NaOCl, Saline,REDTA 17%.

Gomes ET AL 2009 compare the efficacy of chemomechanical
preparation with 2.5% sodium hypochlorite
(NaOCl) and 2% chlorhexidine (CHX) gel on
eliminating oral bacterial lipopolysaccharide
(LPS) in teeth with pulp necrosis and apical
periodontitis
The 2.5% NaOCl and 2% CHX gel were not effective
in eliminating endotoxin from the primarily
infected root canals.
Siqueira Jr ET AL 2010 Compared the antimicrobial effects2.5% sodium
hypochlorite (NaOCl) and 0.12% chlorhexidine
digluconate (CHX)
NaOCl or CHX significantly reduced the number of
bacterial taxa with no significant difference
between these substances.
Kusum ET AL 2010 compare the levels of postoperative pain after
cleaning and shaping of root canals 2%
chlorhexidine solution in group I and 5.25%
sodium hypochlorite solution in group II
More pain was present using 5.25% NaOCl.
Significant difference in pain level was present only
at 6th hour postoperatively, and at all other periods
(24 th hour, 4 th and 7 th days) there was no
significant difference in pain level between the two
groups.
Zandi ET AL 2016 antibacterial effects of 1% sodium hypochlorite
(NaOCl) and 2% chlorhexidine digluconate
(CHX)
NaOCl and CHX both reduced bacterial counts and
the number of infected canals.

Heating of CHX to 460C enhanced the antimicrobial action of 0.12% Chlorhexidene and
produced a reduction of E. faecalis.
CHX & Biofilm
CLEGG ET AL. reported that 1% NaOCl and MTAD were capable of disrupting
the biofilm but did not eliminate the bacteria and the 2% CHX was not capable
of disrupting the biofilm
Substantivity
Root dentin treated with Chlorhexidene has shown to acquire substantivity, which extends to at
least a period of 7 days.
Antimicrobial
substantivity depends
on the number of CHX
molecules available to
interact with dentine.

Effect of chx on
dentin
CHX binds to phosphate of HA-leads to release of
small amounts of calcium from the root canal dentin
CHX and dentine
bonding
CHX is able to inhibit the MMPs’ collagenolytic activity, improving the longevity
of the bond between adhesives and dentin.
Gendron et al. found that the minimum concentrations that are adequate for this
inhibition are 0.001% for MMP-2, 0.02% for MMP-8, and 0.002% for MMP-9.
Allergic reactions to CHX
Side effects are:-
Contact dermatitis
Desquamative gingivitis
Discolouration of the teeth and tongue,or dysgeusia
Carrilho et al: Chlorhexidine preserves dentin bond in vitro, J Dent Res 86:90, 2007

In 1943, Grossman introduced 3% Hydrogen peroxide as an
Endodontic irrigant because of:
•Its effervescent action.
•Disinfecting properties.
1)Effervescent action:
the bubbling of the peroxide was thought to lift debris
from the canal system almost defying gravity.
H2O2 does not possess tissue dissolution properties and is
not effective as a lubricant.
Hydrogen peroxide

 The combination has been shown to inhibit individual antibacterial properties
 No chlorine is actually available at the end of these reactions therefore the
bactericidal activity of this combination is questionable.
NaOCI and H2O2
 Another drawback with H2O2 is not neutralized it can produce gas bubbles, which can
cause continuous pain.
 It is especially useful in canals, which have been left open for drainage as the effervescence can help
dislodge food particles / debris which could have got accumulated within the canal.
 In spite of all these drawbacks Wein strongly recommends its usage because of
its low toxicity.

There is a rare but potential danger of effervescence with H2O2 and seepage into the
tissues may lead to air emphysema.
The main symptom of this is crepitus of the swelling.
In most cases emphysema during root canal treatment does not require antibiotics or
any other therapy;
The emphysema in most cases resolves after few days.

Glyoxide is an irrigation solution i.e. comprised of 10% urea peroxide (Carbamide
peroxide) in a vehicle of anhydrous glycerol.
1.Antibacterial activity that is more potent than 3% H2O2.
2.Enhances root canal lubrication without softening the dentin.
Hence, unlike other chelating agents that react with dentine,With glyoxide, only lubrication is
enhanced.
3.It is less toxic to periapical tissues than NaOCl.
4.It also has greater solvent action than 3% H2O2.
Glyoxide
Use:
The best use of glyoxide is in narrow and curved canals where slippery
effect of glycerol is maximized for instrumentation.
According to Walton, there is decreased chances of strip formation
/perforation while instrumenting curved canals

 Nygaard - Ostby in 1957 introduced EDTA with the following
formulation as an adjuvant in root canal therapy:
 Ethylene diamine tetracetic acid is an insoluble, odorless, crystalline
while powder; it is relatively non toxic & only slightly irritating in
weak solutions.
 Has a pH of 8.3
 The effects of EDTA have been reviewed by Seidberg & Sehilder
CHELATING AGENTS

PROPERTIES
 Has dentin dissolving effects and Reduced the time necessary for debridement
 Aided in enlarging narrow/ obstructed canals , Not corrosive on instruments
 Helped bypass fragmented instruments
 Antimicrobial – neither bactericidal nor bacteriostatic
Inhabited the growth of & eventually destroyed bacteria by the process of starvation. The metallic ions in the
medium which were necessary for growth were chelated 7 rendered inassimilable by the micro-organisms
 Self Limiting Action:
Chelators such as EDTA form a stable complex with calcium. When all available ions have been bound,
equilibrium is formed and no further dissolution takes place.
Doumani M, Habib A, Doumani A, Kinan M. A review: the applications of EDTA in endodontics (Part I). IOSR
Journal of Dental and Medical Sciences. 2017;16(9):83-5.

The sodium salts of EDTA are capable of forming
soluble non-ionic chelates with large number of
metallic ions viz. calcium ions.
Because EDTA would seek the calcium metal ion in the
hydroxyapatite crystals of dentin in a chelate and
thereby act to demineralize dentin and enamel.
Ostby and associates found that EDTA decalcified
dentin to a depth of 20-30µm in 5 minutes.
Action:

ANTIFUNGAL ACTIVITY
Koulaouzidou, alkaline EDTA solution & found them to be moderately to severely cytotoxic.
It has been reported that 5-50 mM of EDTA may be found in periapical tissues with the extrusion of
EDTA. A 1% concentration of EDTA= 26.3mM. this when extruded may lead to
• Decalicificant action on periapical bone
• Neuroimmune regulation in even very low concentrations.
• Because EDTA chelates to Ca2+ it prevents binding of C.albicans to proteins in a dose
dependent manner.
• It removes Ca2+ from the cell walls & thereby causes the cell walls to collapse.
• Also inhibits enzymatic reactions
CYTOTOXIC EFFECTS: (JOE 1999)

SMEAR LAYER REMOVAL
Wu et al. showed that the smear layer removal ability of 17% EDTA
was significantly better than 20% of citric acid and MTAD
Caron et al.revealed that although 17% EDTA 3% NaOCl in removing the
smear layer, sonic and ultrasonic activation improved the efficacy of the
mentioned combination in removing the smear layer.
Mello et al.demonstrated that a continuous rinse with 5 ml of EDTA for
3 min could remove the smear layer from root canal walls efficiently.
Gu et al.showed that EDTA performed significantly better than NaCl and
NaOCl in smear layer removal and dentinal tubule opening

EFFECTS ON DENTINE MICROHARDNESS
Pawlicka reported that chelators can reduce the root dentine
microhardness, whereby the greatest differences are to be found
in dentine immediately adjacent to the root canal lumen.
Cruz-Filho et al revealed that EDTA and citric acid had the
greatest overall effect, causing a sharp decrease in dentin
microhardness without a significant difference from each other
Ballal et al. found that there was no significant difference
between EDTA and maleic acid in the reduction of
microhardness of dentine
De-Deus et al assessed the effect of EDTA, EDTAC and citric acid on dentine
microhardness and found that microhardness decreased with increasing time of
application of chelating solutions
The effect of the chelator is
already apparent after 5 min and
cannot be significantly increased
by extending the working time
to 24 h

TIME & DEMINERALIZATION
• EDTA has been reported to remove smear layer in < 1 minute if it is
able to reach the root canal surface
• Since EDTA has a strong demineralizing effect, it caused
• Enlargement of the dentinal tubules
• Softening of the dentin
• Denaturation of collagen fibers.
• This may affect the adaptation of the root canal filling materials to
the canal wall

 Yamada et al reported a few seconds of EDTA to be sufficient whereas
Goldberg & Spielberg reported an optimum time of fifteen minutes.
 Calt & Serper (JOE 2002) showed that a ten
minute application caused severe peritubular &
intertubular erosion. Because of more erosion,
the diameter of the openings are greater than
the tubules themselves – known as
WORMHOLE APPERANCE
Time-Dependent Effects of EDTA on Dentin Structures : Semra Çalt, DDS, PhD, and Ahmet Serper,
DDS, PhD, AAE VOL. 28, NO. 1, JANUARY 2002

It has been recommended as a canal irrigant because of its ability to
demineralize and remove the smear layer effectively.
It acts as a chelating agent on dentine.
it is more acceptable biologically than other acids (Jenkin and Dawer 1963).
ORGANIC ACIDS
The use of organic acid to irrigate and debride root
canals is as old as root canal therapy itself.
CITRICACID:
C.A. may leave precipitated crystals (calcium and phosphate containing crystals)
in the canal wall.
DISADVANTAGES:

 Citric acid + NaOCl has been used in combination to effectively clean
the Root canal.
 C.A. removes smear layer better than many acids like poly acrylic acid,
lactic acid and phosphoric acid.
 Used effectively in concentration of 10, 25 and 50% as RC irrigant.

TANNICACID
 suggested by Graham Mount
 Action: It acts as a surface coagulant by precipitating proteins.
 Tanizaki & Inoue reported that it caused an increase in dentin hardness because of it’s
inhibiting effect on calcium dissolution while the organic matter in dentin was reinforced.
 Studies have shown that the use of tannic acid in the root canal as an irrigant
cleansed the canal more effectively than the conventional combination of NaOCl +
H2O2.
Moliz et al. Enterococcus faecalis Biofilms eradication by root canal irrigants. J Endod 2009;

Maleic acid is a mild organic acid used as an acid conditioner in adhesive dentistry
(Wieczkowski et al. 1992).
Maleic acid
 Ballal et al. reported that final irrigation with 7% maleic acid for 1 min was more efficient than
17% edta in the removal of smear layer from the apical third of the root canal system
Surface roughness
Maleic acid produced maximum rough surface of the root canal dentin compared with that of
EDTA.
This could be because of the better smear layer removal capacity and the demineralizing
ability of maleic acid compared with EDTA.

1-Hydroxyethylidene-1, 1-Bisphosphonate is a weak biocompatible chelator.
It can be used in combination with NaOCl without interfering with its antimicrobial or
dissolution activity and needs 300 seconds to completely remove the smear layer
NaOCl + HEBP combination has been shown to optimize the bonding by Resilon/Epiphany
root fillings.
It also reduces dentin debris accumulation in the root canal during rotary instrumentation
•De-Deus G, Zehnder M, Reis C, Fidel S, Fidel RA. Longitudinal co-site optical microscopy study on the chelating ability of etidronate and edta using a comparative
single-tooth model. J Endod 2008;34:71-5.
HEBP

 Clodronate, like etidronate, is a non-nitrogenous chelator containing phosphorous instead.
 In NaOCl, the chlorine essentially carries a positive charge and will attack electrophilic centres such as
nitrogen atoms (Fukuzaki 2006). Phosphorous is less electronegative than nitrogen so is less likely to react
with NaOCl.
 Indeed, NaOCl is used in the synthesis of clodronate, with the end-point of the reaction being the formation
of clodronate (Veps€al€ainen et al. 1991), and this fact helps explain its lack of reaction with NaOCl.
 Two concentrations of clodronate were tested and compared with corresponding etidronate solutions and
standard endodontic sequences. Smear layer was removed in the clodronate mixtures; however, the % was
found to be lower when compared to etidronate
Wright PP, Cooper C, Kahler B, Walsh LJ. From an assessment of multiple chelators, clodronate has potential for use in
continuous chelation. International endodontic journal. 2020 Jan;53(1):122-34.

AUTHOR METHOD RESULTS
De–Deus G et al.,
(2008)
study on the chelating ability of
etidronate and EDTA using a
comparative single–tooth model.
9% HEBP and 18% HEBP had significantly slower
demineralisation kinetics than 17% EDTA.
No difference was observed between the chelating abilities of
HEBP and EDTA
Cobankara FK et al.,
(2011)
Effects of chelating agents on the
mineral content of root canal dentin.
Peracetic acid & CA has the greatest decrease in P, K, Mg,
Na, S.
Highest Ca2+ ions decrease was with peracitic acid, CA and
EDTA. HEBP showed the least decrease in Ca2+ ions
Dineshkumar MK et
al., (2012)
Effect of EDTA, MTAD™, and HEBP as
a final rinse on the microhardness of root
dentin.
The highest microhardness was observed in HEBP-treated
root dentin.
Karale R et al., (2016) Effect of dentin on the antimicrobial
efficacy of 3% sodium hypochlorite, 2%
chlorhexidine, 17% EDTA, and 18%
etidronic acid on Candida albicans.
NaOCl and EDTA reduced number of C. albicans during root
canal therapy.
HEBP showed good antimicrobial efficacy .It showed less
effect on dentin structure.

Weine suggested the use of 2% aqueous solution of glutaraldehyde as an endodontic
irrigant.
Glutaraldehyde is known to cause irreversible fixation without any adverse tissue
reactions.
Weine observed that apart from the normal mechanical and chemical techniques for
preparing and disinfecting root canals, a different concept is that: detoxification can be
obtained by using fixatives.
5 year clinical results of root canal treatment with 2% glutaraldehyde showed a success rate
of 96% for chronic and 89% for acute periapical conditions.
Glutaraldehyde

Glutaraldehyde has following additional properties:
1.Irreversible bonding with proteins.
2.Limited diffusion into tooth structure.
3.No periapical irritation.
4.Appears to cause a softening of dentin for limited duration, facilitating the
mechanical preparation of the root canal.
Thus the greater reduction in microorganisms with
glutaraldehyde 2% can be attributed to the fixative
property rendering the microorganisms inert and non-toxic.

TETRACYCLINES
• Include
• Tetracycline HCI
• Minocycline
• Doxycycline
• Are broad spectrum antibiotics effective against a wide range of micro-organisms.
• Low pH in concentrated solutions & thus can act as calcium chelators. This may cause root
surface demineralization comparable to citric acid.
• Substantivity of these antibiotics allows them to be absorbed & released gradually from
tooth structures.
• Ability to remove smear layer also studied.

• Barkhodar et al- Doxycycline HCI (100mg/ml) effective in removing smear
layer of instrumented canals.
• Haznedaroglu & Ersev (JOE 2001) reported that 1% Tetracycline HCI could
remove the smear as efficiently as 50% citric but was found to retain the
peritubular architecture of dentin.

ENDODONTIC IRRIGANTS
MANJUSHA GOVIND
IIIrd YEAR POST GRADUATE
DEPARTMENT OF CONSERVATIVE DENTISTRY &
ENDODONTICS

contents
INTRODUCTION
HISTORY
OBJECTIVES OF IRRIGATION
IDEAL CHARACTERISTICS OF ENDODONTIC IRRIGANT
CLASSIFICATIONS
CHALLENGES OF IRRIGATION
SALINE
SODIUM HYPOCHLORITE
HYDROGEN PEROXIDE
 CHLORHEXIDINE GLUCONATE
 GLUTERALDEHYDE
 CHELATING AGENTS: EDTA, ORGANIC ACIDS, HEBP

 CHITOSAN
 OXIDISED POTENTIAL WATER
 OZONATED WATER
 TETRACYCLINE BASED: TETRACLEAN, MTAD
 COMBINATION: Q MIX,
 NANOPARTICLES: SILVER NANOPARTICLES
 HERBAL IRRIGANTS
 IRRIGATION PROTOCOL
 REFERENCES
 CONCLUSION

Chitosan is a natural polysaccharide has a high chelating ability for various metal ions in acidic
conditions
Chitosan is obtained by the deacetylation of chitin.
(Kurita 1998)
5% EDTA, 0.2% chitosan and 10% citric acid have been shown to effectively remove smear layer from
the middle and apical thirds of root canals.
P. V. Silva et al.2012
It has been reported that chitosan enhanced the sustained release of chlorhexidine gluconate when
tested against Enterococcus faecalis.
Ballal et al AEJ 2009
chitosan

 An electrolytically obtained, highly acid water having accumulated in the anode
compartment after sodium chloride is added to water.
 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
 Opw is safe for patients to hold in oral cavity
 Volume for use –10ml . time -> 1 min
 Does not effectively remove smear layer (serper & colleagues)
OXIDISED POTENTIAL WATER
Hata G, Hayami S, Weine FS, Toda T. Effectiveness of oxidative potential water as a root canal irrigant.
International endodontic journal. 2001 Jun;34(4):308-17.

OZONATED WATER
• Ozonated water is powerful antimicrobial agent against bacteria, fungi protoza and
viruses.
• Ozone in aqueous or gaseous phases has a strong oxidizing power with reliable
microbial effects
a) Ozone destroys cell walls & cytoplasmic membranes of bacteria & fungi
b) Increased permeability leads to ingress of ozone which cause microbial death.

• Disadvantages:
• Requires continuous flow for it’s
action.
• Rapid ozone degradation in contacting
organic compounds.
• Advantages:
• Ease of handing
• Lack of mutagenicity
• Rapid microbial effects
• Showed lesser toxicity to L929 mouse
fibroblasts than NaOCI.
(Nagayoshi & associates)

MTAD , introduced by Torabinejad and Johnson at Loma Linda University in 2003, is an
aqueous solution of
3% doxycycline, a broad-spectrum antibiotic;
Calcium chelator
Surface demineralization similar to citric acid
Substantive property
Promotes healing
Removes smear layer
4.25% citric acid, a demineralizing agent; and
0.5% polysorbate 80 detergent (Tween 80).
It is mixed as a liquid and powder prior to use. MTAD has been recommended in clinical
practice as a final rinse after completion of conventional chemomechanical preparation.
BioPure MTAD and Tetraclean

• Tetracyclines inhibit protein synthesis by reversibly binding to the 30S subunit of
bacterial ribosome in susceptible bacteria.
• Tetracycline is bacteriostatic ; but in high conc, they have bactericidal effect.
• Doxycycline, citric acid, and Tween 80 together have a synergistic effect on the
disruption of the bacterial cell wall and cytoplasmic membrane.
•Tetraclean (Ogna Laboratory, Italy) is a combination product similar to MTAD.
• The two irrigants differ in the concentration of antibiotics (doxycycline 150 mg/ 5 ml
for MTAD and 50 mg/5 ml for Tetraclean) and the kind of detergent (Tween 80 for
MTAD, polypropylene glycol for Tetraclean).
Mode of Action

Torabinejad showed that the combination of NaOCl as a root canal irrigant and
MTAD as a final rinse was significantly more effective against E. faecalis than the
other regimens.
Effectiveness is enhanced when low concentrations of 1.3%NaOCI are used as intra canal
irrigant before the use of MTAD as final rinse.
Torabinejad et al. A new solution for the removal of the smear layer. J Endod 2003;
Antibacterial Efficacy

• introduced in 2011. It is recommended to be used as final rinse
• QMiX contains a CHX analog TRICLOSAN, (N –cetyl N ,N ,N -trimethylammonium
bromide), and EDTA as a decalcifying agent and a detergent
• antimicrobial irrigant as well as to be used in the removal of canal wall smear layers and
debris.
• If sodium hypochlorite is used throughout the cleaning and shaping, saline can rinse out
NaOCl to prevent the formation of PCA (parachloranaline).
• QMiX is incorporated a detergent in its formula to decrease the surface tension
QMiX

Stojicic et al.
QMiX removed the smear layer equally as well as EDTA
Dai et al
examined the ability of two versions of QMiX to remove canal wall smear layers and debris
QMiX versions are as effective as 17% EDTA in removing canal wall smear layers after the
use of 5.25% NaOCl as the initial rinse
SMEAR LAYER REMOVAL

• Wang et al. compared the antibacterial effects of different disinfecting solutions on young
and old E. faecalis biofilms in dentin canals
• concluded that 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.
• Stojicic et al. assessed the efficacy of QMiX against E. faecalis and mixed plaque bacteria in
planktonic phases and biofilms.
• QMiX and 1% NaOCl killed all planktonic E. faecalis and plaque bacteria in 5 s.
• QMiX and 2% NaOCl killed up to 12 times more biofilm bacteria than 1% NaOCl (P < 0.01) or 2%
CHX
Antibacterial Efficacy and Effect on Biofilms

RUDDLE’S SOLUTION
• containing 5% sodium hypochlorite (NaOCl), Hypaque and 17% EDTA
• Hypaque is a water soluble, radiopaque, contrast solution which can
be utilized to visualize root canal system anatomy, monitor the
remaining wall thickness during preparation procedures, detect
pathological defects and manage iatrogenic mishaps
• This particular solution was introduced by an American researcher, Dr. Clifford J.
Ruddle.

• It has a pH between 6.5 - 7.7
• It is stable at room temperature
ADVANTAGE
• Solvent action and ( radio-opacity similar to Gutta Percha) because of
Hypaque
• Penetration because the tensioactive agent decreases the surface tension
besides removing the smear layer

Triphala contains Terminalia Bellerica, Terminalia Chebula and Emblica
Officinalis.
The polyphenols are found in Green tea
Triphala and GTPs are proven to be safe,have anti-oxidant, anti-inflammatory
and radical scavenging activity and may have an added advantage over the
traditional root canal irrigants.
H
e
r
b
a
l
I
R
R
I
G
A
N
T
S
Triphala and Green tea polyphenols(GTP)

A comparative evaluation on microbial efficacy of propolis, NaOCl and saline
when used as intracanal irrigants indicated that the propolis has
antimicrobial activity equal to that of NaOCl.
The antimicrobial activity of propolis with Ca(OH)2 as intracanal,
medicament against E. faecalis found that propolis was effective in
eliminating the microorganisms.
(D.Kandaswamy et al 2010)
Propolis

Morinda Citrifolia is biocompatible antioxidant and not likely to cause the severe
injuries.
It was concluded that the efficacy of Morinda Citrifolia was similar to NaOCl in
conjunction with EDTA as an intracanal irrigant
It was concluded that Propolis and Morinda Citrifolia were effective against E. faecalis
in dentin on extracted teeth.
Morinda Citrifolia appears to be the first juice to be identified as a possible alternative
to the use of NaOCl as an intracanal irrigant.
(Flaviana Bombarda de Andrade Ferreira, ey al 2010)
Morinda citrifolia

It is an invasive weed of high- nitrogen soils
An in vitro evaluation of antimicrobial activity showed a great
microbial inhibition by arctium lappa against the tested
endodontic pathogens.
Act against e.Faecalis
(julaina vianna et al ..2005)
Arctium Lappa

An SEM study was conducted using two medicinal plants
german chamomile extract and tea tree oil which might disinfect the
root canal system with less toxicity when used as irrigants.
It was concluded that the efficacy of chamomile to remove smear layer
was superior to NaOCl alone but less than NaOCl combined with
EDTA.
[M.S. Sadr Lahijani et al.2006)
German chamomile and tea tree oil

J.Prabhakar et al. 2010 Antimicrobial efficacy of triphala, gtps,
MTAD, and 5% sodium hypochlorite against
e-faecalis biofilm
Maximum antibacterial activity with naocl and
statistically significant antibacterial activity with
triphala, gtps and MTAD
Podar et al, 2015 In vivo antimicrobial efficacy of
6% Morinda citrifolia, neem, and 3%
sodium hypochlorite as root canal
irrigants
6% percentage MCJ, A. indica, and 3% NaOCl
showed a significant reduction in the mean
colony forming units counts for aerobic and
anaerobic bacteria between baseline and 3
days.
Mutha et al 2020 Comparative evaluation of smear layer
removal efficacy of
three herbal irrigants in the apical third of the
root canal:Neem extract , Orange peel extract
, Tulasi extract ,5.25% sodium hypochlorite
Neem extract showed statistically significant
less smear layer scores in comparison to Orange
peel extract and Tulasi .Neem showed no
statistically significant
difference with sodium hypochlorite
Varma et al 2021 Comparison of cytotoxicity and smear layer
removal efficacy of triphala and 5.25% sodium
hypochlorite as root
canal irrigants
Triphala can be considered as a superior irrigant
with good antibacterial efficacy and least
cytotoxicity potential
compared to conventional hypochlorite

CURRENT RESEARCH ON IRRIGATION
• Antibacterial Nanoparticles show a broad spectrum of antimicrobial
activity.
• Metallic NPs of titanium, gold, zinc, and copper have different physical
properties and spectra of antimicrobial effect.( Vier and Figueiredo)
• A study by Anil Kishen and annie shreshta concluded nanoparticles
derived from bioactive materials have the ability to mediate targeted
antibacterial efficacy while sparing the mammalian cells.
• (Clinical Dentistry Reviewed 2018 Springer)

SILVER NANO PARTICLES
• Nanomaterials are a field that takes a materials science-based approach on nanotechnology.
• Recently, silver nanoparticles have been introduced in root canal therapy.
• It has been studied Based on the findings of an in vitro study, adding silver nanoparticles to
Angelus white MTA enhanced its antimicrobial activity against E. faecalis, C. albicans, and P.
aeruginosa.

• Rodrigues et al,2018 IEJ
• Antibacterial properties of silver nanoparticles in aqueous vehicle, sodium
hypochlorite, chlorhexidine against E.faecalis
• AgNp solution eliminated fewer bacteria, but was able to dissolve more biofilm
compared to chlorhexidine
• Less antibacterial action compared to NaOCl

Antimicrobial effect of three new and two established root canal irrigation solutions, Zahed Mohammadi, General
dentistry, Nov 2012

sequence of irrigation
Irrigation sequence during root canal treatment of a vital tooth
Access cavity prepared
30-second irrigation with naocl to destroy the majority of the pulp tissue and to provide a better view of the
canal orifices by controlling bleeding and preventing any collagen plugs from forming.
A second application of naocl and its activation is performed with a k-file (size 8 or 10).
Once the preparation of the canal has begun, with the use of any rotary file, EDTA must be used.
Ultrasonic activation of the irrigating solution with a small-diameter file is recommended for more efficient
chemical preparation.
Ensure that the tip stays at least 5mm away from the working length to avoid pushing any chemical outside
the root canal

Each time a rotary file is used, an irrigating solution must be present inside the canal, and this should be EDTA.
Saline or distilled water can be used to wash out the previous chemical prior to the use of a different one
Then, chlorhexidine is introduced into each canal for 10 seconds
The use of EDTA facilitates the flow of the other irrigants, especially NaOCl or chlorhexidine, into the lateral canals,
isthmuses, allowing for proper chemical preparation of the root canal system.
17% EDTA plays an important role in the reduction of inflammatory reaction by inhibiting the affinity of
macrophages to the vasoactive peptides in the pulpal tissue.
The total exposure time of 4 to 5 minutes for EDTA inside the canal must not be exceeded
McDaniel J. Lebanon. Simon and Schuster; 2014 Nov 17.

The main difference between vital and necrotic teeth is the absence, though partial, of the
pulpal parenchyma with the abundance of bacteria present in the latter.
Irrigation sequence during root canal treatment of a necrotic tooth
For this reason, the irrigation sequence is different.
Irrigation should be initiated with either NaOCl (5.25%) for its antibacterial effect or
with chlorhexidine (0.02%) for 30 to 40 seconds to eliminate the various bacterial types
present in the root canals and dentinal tubules.
Distilled water is used to neutralise the effect of each of these irrigants. Then, the same
irrigation sequence as described previously for vital teeth is repeated.
McDaniel J. Lebanon. Simon and Schuster; 2014 Nov 17.

RESORPTIONS
 When we suspect an internal resorption, the irrigation sequence is the same that was described for
vital teeth.
 But this sequence will be followed by the use of citric acid 50 percent (10 minutes) in order to
eliminate the granulation tissue and to obtain smooth dentinal walls.
 The citric acid is eliminated by NaOCl and distilled water.
 The same sequence is adopted for external apical resorptions but with an activation of the patency.
WEEPING CANAL
 Irrigation done with normal saline
 Then canal is irrigated with chlorhexidine
 Calcium hydroxide placed as intracanal medicament
ABSCESS
 Irrigation done by using 2.5% sodi.hypochlorite with open 30- gauge needle at 2mm from
working length(Jesus Alejandro Quinones Pedraza et al 2017)
 Then canal is irrigated with normal saline
Parakh, P., Bhondwe, S., Mahajan, V., Dhoot, R. and Muthiyan,
S., 2019. Sequence of Irrigation in Endodontics.

PULP POLYP
 Irrigation done with 5ml of 5% sodi.hypochlorite
solution (KanakamedalaAnilkumar et al.2016)
 Then irrigation done with normal saline
OPEN APEX
 After coronal access ,root canal filled with 3% sodi.hypochlorite
 Then irrigation performed with 10 ml of saline
 root canal was flushed with 5 ml of 17% EDTA And finished with 10 ml of 3% sodium
hypochlorite gel and 10 ml of saline
 Care should be taken to prevent apical extrusion of irrigation solution (Miriam
GrazieleMagro et al 2017)
Parakh, P., Bhondwe, S., Mahajan, V., Dhoot, R. and Muthiyan, S., 2019. Sequence of Irrigation in
Endodontics.

IRRIGATION REGIMEN
NaOCl: throughout instrumentation – frequent replenishment
EDTA/ Citric acid : after shaping procedure completed : 5-10 ml for 1min
Antiseptic rinse
Ca(OH)2 intracanal medicament
placed
Final rinse: NaOCl
retreatment cases
Final rinse: 2% CHX
(Matthias Zehnder ; JOE 2006 Vol 32)
SALINE

Recommended irrigation protocol for root canal treatment:. The following steps are the most
commonly used:
1. 2.5–5 % NaOCl throughout the instrumentation procedure until fi nal shape of the canal is
achieved (adequate size and taper).
2. Activation and heating of the fresh NaOCl (such as ultrasonic, sonic or laser activation) for
approx. 30 sec with fresh solution per canal.
3. Apical negative pressure devices are optional to enhance apical irrigation without extrusion
(ex. Endovac).
4. Smear layer removal (EDTA, Citric acid, etc.) for approx. 1min (activation and/or apical
negative pressure optional).
5. Final rinse options:
a. Fresh NaOCl for approx. 1 min or
b. CHX, QMiX, or
c. Alcohol
5. Dry with paper points and obturate
Disinfection Protocol Suggested
B. Basrani (ed.), Endodontic Irrigation: Chemical Disinfection of the Root Canal
System

IRRIGANTS PROPERTIES EFFECT ON DENTIN
NAOCL Tissue dissolving
Antimicrobial activity
Elastic modulus & flexural strength reduced
CHX Antimicrobial substantivity CHX is able to inhibit the MMPs’ collagenolytic activity,
improving the longevity of the bond between adhesives and
dentin.
EDTA Smear layer removal Can reduce the root dentine microhardness
HEBP Smear layer removal
Continous chelation
It showed less effect on dentin structure.
slower demineralisation kinetics than 17% EDTA
MTAD Bacteriostatic
Substantivity
Removes the smear layer (CITRIC
ACID)
more aggressive in demineralizing intact intraradicular dentin
exposing collagen matrices
QMIX antimicrobial irrigant removal of
smear layers
reduction in dentine microhardness

CONCLUSION
• Looking at the various root canal irrigants to be used in the dental field, reformation is needed.
• The use of an endodontic irrigant during canal preparation is necessary to adequately debride the
canal system.
• Even though further investigations are required for some irrigants like plant extracts; improved
irrigants like maleic acid, Tetraclean and the modifications of sodium hypochlorite have proven be
less toxic and compatible for the root canal.
• By the use of the advancements in irrigants, root canal therapy can be a great success reducing
the number of microorganisms in the canal for a successful obturation.

• Endodontic practice:-14th edition-by grossmann
• Endodontic therapy:-6th edition-by weine
• Pathways of pulp:-11th edition- by cohen
• Endodontics:-7th edition-by ingle
• Advanced endodontics for clinicians-by jacob Daniel
• Endodontic Irrigation-Chemical Disinfection of the Root Canal
System- Bettina Basrani
References

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J.T.MARALS,..VOL.33,2000,IEJ.
 A COMPARATIVE STUDY OF SMEAR LAYER REMOVAL USING DIFFERENT SALTS OF
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 COMPLICATIONS DURING ROOT CANAL IRRIGATION-LITERATURE REVIEW..BY:-
M.HULSMANN & W.HAHN..VOL,33,2000,IEJ.
 TETRACYCLINE HCL SOLUTION AS A ROOT CANAL IRRIGANT.BY:-FARUK & HANDAN
ERSEV.. VOL,27,DECEMBER 2001,JOE
 EFFECT OF SODIUM HYPOCHLORITE ON MECHANICAL PROPERTIES OF DENTIN AND
TOOTH SURFACE STRAIN..BY:-TPC.SIM & JC.KNOWLES..VOL,34,,2001,IEJ.

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