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Intracanal irrigants for primary teeth: a systematic review
- 2. Intracanal irrigants for pulpectomy in primary teeth: a systematic review and meta-analysis. Pozos-Guillen A, Garcia-Flores , Esparza-Villalpando , Garrocho-Rangel Int J Paediatr Dent. 2016 Nov;26(6):412-425
- 3. contents Introduction Objectives Benefits Properties Classification Factors affecting Irrigants used in permanent teeth Irrigants used in primary teeth conclusion
- 4. Irrigation is defined as “to wash out a body cavity or wound with water or a medicated fluid” Disinfectant is defined as “an agent that destroys or inhibits the activity of microorganisms that cause disease.
- 6. ◆ Removal of particulate debris and wetting of the canal walls ◆ Destruction of microorganisms ◆ Dissolution of organic debris ◆ Opening of dentinal tubules by removal of the smear layer ◆ Disinfection and cleaning of areas inaccessible to endodontic instruments BENEFITS OF USING IRRIGANTS
- 7. ◆ Be an effective germicide and fungicide ◆ Be nonirritating to the periapical tissues ◆ Remain stable in solution ◆ Have a prolonged antimicrobial effect ◆ Be active in the presence of blood, serum, and protein derivatives of tissue ◆ Have low surface tension ◆ Not interfere with repair of periapical tissues ◆ Not stain tooth structure ◆ Be capable of inactivation in a culture medium ◆ Not induce a cell-mediated immune response ◆ Be able to completely remove the smear layer, and be able to disinfect the underlying dentin and its tubules ◆ Be nonantigenic, nontoxic, and noncarcinogenic to tissue cells surrounding the tooth ◆ Have no adverse effects on the physical properties of exposed dentin ◆ Have no adverse effects on the sealing ability of filling materials ◆ Have a convenient application ◆ Be relatively inexpensive Properties Of An Ideal Irrigant For Root Canal Treatment
- 8. A) CHEMICAL AGENTS : Kandaswamy and Venkateshbabu • a) tissue dissolving agents : Naocl • 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 : Green tea Triphala CLASSIFICATION OF IRRIGATING SOLUTIONS : J Conserv Dent. 2010 Oct-Dec; 13(4): 256–264.
- 11. Permanent teeth • Sodium hypochlorite (0.5-6%) • Normal saline • Hydrogen peroxide 3% • Urea 30% solution Urea peroxide (GLYOXIDE) (10%) • Chlorhexidine (2%) • EDTA (17%) • Citric acid • Iodine Potassium iodide (IPI) • HEBP(Hydroxyethylidene Bisphosphonate) Salvizol • Ultrasonic irrigation • MTAD • Electrochemically activated solution • OPW • Ruddle solution • Photo activated disinfection • Tetraclean • Qmix • Herbal: • Triphala and Green tea polyphenols (GTP) • Morinda Citrifolia (NONI) • German chamomile and tea tree oil Recent
- 12. Primary teeth • Sodium hypochlorite (0.5-6%) • Normal saline • Hydrogen peroxide • Chlorhexidine gluconate (0.2%- 2%) • EDTA (17%) • Citric acid • MTAD • Hydrogen peroxide • Maleic acid • Chlorine dioxide • Tetraclean • Smearclear • Electrochemically activated solutions • Ozonated water • Carisolv Herbal: • Propolis • Miswak • German chamomile and tea tree oil • Triphala and Green tea polyphenols (GTP) • Morinda Citrifolia (NONI)
- 13. Penetration depth of needle Diameter of root canal Inner & outer dia of needle Orientation of needle bevel Type of needle bevel Velocity of irrigant at needle tip Viscosity of irrigant Irrigation pressure Factors affecting efficiency of root canal irrigation :
- 14. • most commonly used irrigating solution. • antibacterial capacity • ability to dissolve necrotic tissue, vital pulp tissue, and the organic components of dentin and biofilms in a fast manner Sodium hypochlorite Effective against : Enterococcus faecalis Candida albicans Porphyromonas gingivalis Porphyromonas endodontalis Prevotella intermedia
- 16. Temperature Concentrations Higher concentrations of NaOCl are more toxic than lower concentrations Grossman : pulp tissue dissolution capacity 5% sodium hypochlorite dissolve tissue in between 20 minutes and 2 hours
- 17. Time Allergic reactions Toxicity DRAWBACKS Cytotoxic Do not remove inorganic component of smear layer Unpleasant taste
- 18. Saline 0.9% solution Gross debridement Lubrication of root canals Flushing action Can be used as final rinse No adr No disinfecting and dissolution properties Cannot clear microbial flora from inacessible areas Do not remove smear layer Disadvantages:
- 19. Chlorhexidine Excellent antimicrobial activity Effective against both Gram-positive and Gram-negative bacteria as well as yeast 2% in concentration Very effective against Ent. faecalis
- 20. Mode of action
- 21. Substantivity Endodontic irrigant Interaction between CHX, NaOCl, and EDTA Allergic Reactions to Chlorhexidine DRAWBACKS • Not considered as main irrigant in standard endo therapy • Unable to dissolve necrotic tissue remnents • Less effective on gram negative bacteria
- 22. Chelating agent • Lubrication • Emulsification • Holding debris in suspension • Smear layer removal • On direct exposure for extended time, EDTA extracts bacterial surface proteins by combining with metal ions from the cell envelope, which can eventually lead to bacterial death • Dentin disolving properties • Enlarge narrow canals • Easy manipulation of instruments • Reduces time needed for debridement Ethylenediamine Tetra-Acetic Acid Functions Mode of action Uses
- 23. Irrigation with 17% EDTA for one minute followed by a final rinse with NaOCl is the most commonly recommended method to remove the smear layer EDTA decalcified dentin to a depth of 20–30 µm in 5 min Interaction of EDTA and NaOCl Different forms of EDTA R-EDTA EDTAT EDTA-C RC Prep = EDTA + UREA PEROXIDE + POLYETHYLENE GLYCOL
- 24. A) Instrumented root canal wall after irrigation with 5% sodium hypochlorite (NaOCl) and 17% ethylenediamine-tetra-acetic acid (EDTA), each for 5 minutes. Smear layer has been completely removed. B) Close-up scanning electron micrograph of the root canal wall after removal of smear layer with NaOCl and EDTA.
- 25. Hydrogen Peroxide H2O2 has antimicrobial activity against various microorganisms including viruses, bacteria, yeasts, and even bacterial spores. It is more effective against Gram-positive than Gram- negative bacteria 30% H2O2 (Superoxol) has been recommended as the first step in tooth surface disinfection after mechanical cleaning 3% SOLUTION : IRRIGANT
- 26. H2O2 = H2O + [O] [O] : bactericidal effect • Causes oxidation of bacterial sulfhydryl group of enzymes • Interfere with bacterial metabolism Mechanism of action Use
- 27. • Chelating agent • Concentrations : 1% to 50% • The use of 10% citric acid as final irrigation has shown good results in smear layer removal and proven to be more biocompatible than 17% EDTA-T and 17% EDTA Citric acid Should NEVER be mixed with NaOCl
- 28. final irrigant for smear layer removal. MTAD • Effective in eliminating resistant microorganisms • Providing sustained antimicrobial activity mixture of tetracycline isomer, citric acid, and detergent(tween 80) pH : 2.15 an initial irrigation for 20 min with 1.3% NaOCl, followed by a 5-min final rinse with MTAD.
- 29. Advantages Remove smear layer Kills E faecelis Biocompatible High binding affinity of doxycycline present allows prolonged antibacterial effect
- 30. Tetraclean Mixture of doxycycline hyclate (at a lower concentration than in MTAD), an acid, and a detergent Recommended to be used as a final rinse after root canal preparation Remove both the smear layer and organic tissue from the infected the root canal system Final 5min rinse (50 mg/5ml instead of 150mg/5ml)
- 31. Smear clear 17% EDTA solution along with centrimide and additional proprietary surfactants Journal of Advanced Medical and Dental Sciences Research |Vol. 2|Issue 2| April-June 2014
- 32. Maleic acid mild organic acid used acid conditioner in adhesive dentistry •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.
- 33. Chlorine dioxide tuberculocidal, bactericidal, virucidal, and fungicidal exists as gas in water less cytotoxic as compared to Sodium hypochlorite Singh et al : compared the dissolution efficacy of chlorine dioxide and sodium hypochlorite on human pulp tissue. Conclusion : 5% Chlorine dioxide is capable of dissolving human pulp tissue but sodium hypochlorite was more effective
- 34. Ozonated Water 3 oxygen atoms (O3–triatomic oxygen), a higher energetic form than normal atmospheric oxygen (O2) powerful bactericide 0.1 ppm is sufficient to inactivate bacterial cells including their spores
- 35. carisolv 1. 0.5% Naocl with aminoacids 2. Mode of action : Degrade denatured collagen Indian J Dent Res 2012;23:120-1
- 36. Electrochemically activated solutions Tap water + low conc salt solution Ease of debris and smear layer removal Nontoxic Effective with wide range of microbial spectra Super oxised water (OPW) anolyte catholyte Catholyte solution Anolyte solution Super oxidised water Alkaline or neutral ph
- 37. Triphala and Green tea polyphenols (GTP) Terminalia Bellerica, Terminalia Chebula and Emblica Officinalis Triphala achieved 100% killing of E faecalis at 6 min citric acid : removal of the smear layer. GTP antioxidant anticariogenic anti-inflammatory thermogenic probiotic antimicrobial properties
- 38. Morinda Citrifolia (NONI) antibacterial anti-inflammatory antiviral antitumor antihelmenthic analgesic hypotensive anti-inflammatory immune enhancing effects first juice to be identified as a possible alternative to the use of NaOCl as an intracanal irrigant.
- 39. German chamomile and tea tree oil antiinflamatory Analgesic anti-microbial antispasmic sedative properties antiseptic, an antifungal agent and a mild solvent terpinen-4-ol(typically 30-40%) : antibacterial & antifungal properties SEM study : efficacy of chamomile to remove smear layer was superior to NaOCl alone but less than NaOCl combined with EDTA
- 40. Propolis • Potent antimicrobial • Anti-inflammatory • Anti-oxidant • 25-30% conc Eradicate E.faecalis and Candida albicans
- 41. Miswak Derived from plant Salvadora persica Limonoid has great antimicrobial activity Inhibit gram +ve and gram –ve Interfere with extrapolysachh and glycosidase enzymes 10-20%
- 43. study age Irrigant used sampl e Evalution period characte ristics results conclusion Ruiz- Esparza et al J Clin Pediatr Dent. 2011 Spring;3 5(3):265 -70. 3-9 Saline 2% chlorhexidi ne gluconate 20 20 20 20 Pre –irrg Post-irrig Pre-irrig Post-irrig Necrotic pulp, abscess, fistula Presenc e of Radioluc ent area in furcal or periapic al region Statistically significant difference observed CHX showed greater reduction of intracanal bact loading
- 44. study age characteristics sample Irrigant used Evaluatio n period results conclusio n Louwak & Prucksath a- mrongkul Pediatr Dent. 2012 Nov- Dec;34(7) :e192-6. 3-9 64 mandi pri teeth Presence of deep carious lesion with pulp exposure h/o spontaneous pain Presence of abscess , fistula 32 32 Saline solution 2% chx 6 mo 12 mo 18 mo 6mo 12mo 18 mo At 6 mo in favour of experime ntal group No difference at 12 0r 18 mo Chx could improve resultsn6 mo after interventi on
- 45. study age characteristics sample Irrigant used Evaluatio n period results conclusio n Valdez- Gonzalez et al J Clin Pediatr Dent. 2012 Fall;37(1): 31-5. 3-8 Pri teeth with necrotic pulp canal, abscess, fistula Presence of Radiolucent area in furcal or periapical region Carious lesion without direct exposure to oral environment 20 20 20 20 NaOCl 1% Oxidative potential water (OPW) Pre-irrig Post-irrig Pre-irrig Post-irrig Significant difference in favour of experimen tal grp when evaluated pre and post irrigation OPW was as effective as NaOCl
- 46. study age characteristics sample irrigant Evaluatio n period results conclusion Jolly et al J Clin Pediatr Dent. 2013 Spring;37( 3):243-9. 6-12 60 children with pulpally involve max molars pimary Acute apical abscess No antibiotics in past 3-6mo 15 15 15 15 Saline 2% CHX Calcium hydroxide 4% Propolis 4% Pre-irrig Post Pre-irrig Post Pre-irrig Post Pre-irrig post In all grps, significant dec in mean aerobic CFU seen Maximal change in anaerobic CFU was seen with 2% CHX CHX proved to be superior antimicrobi al agent against both aerobes and anaerobes.
- 47. study age characteristics sample irrigant Evaluatio n period results conclusion Tulsani et al J Clin Pediatr Dent. 2014 Fall;39(1): 30-4. 4-8 Pts without systemic condtion Pri teeth with necrotic pulp, asymptomatic Without pdl lesions Without surgical intervention 10 15 15 Isotonic saline 0.9% 2.5% NaOCL MTAD Post irrigation Statisticaly significant diff btw Naocl & MTAD against control No diff btwn experimen tal grps Both irrigants Naocl and MTAD were effective against E.faecalis
- 48. study age characteristics sample Irrigant used Evaluatio n period results conclusion Verma et al J Indian Soc Pedod Prev Dent. 2014 Apr- Jun;32( 2):120- 4 4-7 70 pri teeth Good gen health No antibiotic coverage h/o r/f evidence of carious pulp exposure 35 35 Isotonic saline 0.9% Water soluble propolis 25% Pre-irrig Post-irrig Pre-irrig Post-irrig Greater reduction in bact colony counts in propolis Water solulble propolis extract 25% can be used as irrigant
- 49. study age characteristics sampl e Irrigant used Evaluatio n period results conclusion Farhin et al J Clin Pediat r Dent. 2015 Winter ;39(2): 100-4 3-7 60 pri molars with atleast 1 canal with necrotic pupl, abscess, fistula Presence of Radiolucent area in furcal or periapical region 30 30 30 30 Naocl 1% MTAD Pre-irrig Post-irrig Pre-irrig Post-irrig Naocl grp showed significant dec in bact load Same in MTAD grp MTAD superior among both grps in post irrigation Promising results
- 50. study sample Irrigant used result conclusion Irfan et al 48 extracted single rooted tooth 5.25%Na OCL(nega tive control) 2. 10% Citric acid 3. 7%Maleic acid 4. MTAD ( canal walls in Citric acid,Maleic acid and MTAD groups were significantly clearer than the control group (p < 0.001 ) in the apical,middle and coronal levels Dentinal tubules treated with MTAD significantly clear than citric and maelic acid MTAD is an effective solution for the removal of smear layer when used as a final rinse. 2.sodium hypochlorite did not remove smear layer. 3.10% Citric acid and 7% Maleic acid was able to remove smear layer.
- 53. Hypophosphatasia: diagnosis and clinical signs - a dental surgeon perspective. Bloch-Zupan A Int J Paediatr Dent. 2016 Nov;26(6):426-438
- 54. INTRODUCTION
- 56. EPIDEMIOLOGY SEVERE HPP (EUROPE) : 1 PER 300,000 INDIVIDUALS MODERATE FORMS > SEVERE FORMS : 1 IN 6370 JAPAN (SEVERE PERINATAL LETHAL HPP) : 2-3 CASES PER 100,000 BIRTHS CANADA : 1 IN 1OO,OOO Bone symptoms Dental symptoms
- 58. 0
- 60. Laboratory tests Management Treatment enzyme replacement therapy asfotase alfa Asfotase alfa is a recombinant human TNSALP onto which an anchor has been grafted to allow it to affix to the bone Normal serum ALP levels (male or female adults): a) 2–4.5 units (Bondansky) b) 4–13 units (King Armstrong c) 40–120 IU/L14,45
- 63. • Q MIX • PDT • LASER • STUDIES • CONCLUSION CONTENTS
- 64. Q MIX QMix contains a CHX-analog, Triclosan (N-cetyl-N,N,N- trimethylammonium bromide), and EDTA as a decalcifying agent . QMiX and 1% NaOCl killed all planktonic E. faecalis and plaque bacteria in 5 seconds. QMiX and 2% NaOCl killed up to 12 times more biofilm bacteria than 1% NaOCl (P < .01) or 2% CHX (P < .05; P < .001).
- 66. LASER Er:YAG laser wavelength (2940 nm) has the highest absorption in water and a high affinity to hydroxyapatite
- 67. Study age characteristics irrigants Evaluation period result conclusion Verma et al J Indian Soc Pedod Prev Dent. 2014 Apr- Jun;32(2): 120-4. 4-7 yrs radiographic evidence of carious pulp exposure Group A: 0.9% isotonic saline Group B :25% extract water- soluble propolis Pre-irrig Post -irrig reduction in the mean bacterial colony counts of all the isolated bacteria in grp B low toxicity concerns and antibacterial effectiveness PROPOLIS
- 68. study age characteristics irrigants Evaluati on period result conclusion Jolly et al J Clin Pediatr Dent. 2013 Spring;37(3 ):243-9. 60 childr en 6-12y acute apical abscess of the maxillary primary molars. 2% Chlorhexidine 4% Calcium hydroxide 4% Dimethyl Sulfoxide (DMSO) extract of propolis Normal saline as the control Maximum change in anaerobic cfu count was seen with 2% chlorhexidin e. Chlorhexidine : superior antimicrobial agent against both endodontic aerobes and anaerobes. Calcium hydroxide was found to be least effective.
- 69. study sampl e irrigants result conclusion Shingare et al Germs. 2011 Dec 24;1(1):12- 21. 40 infect ed prima ry molar s Group 1 :3% Naocl Group 2: 12.5% alcoholic extract of miswak, Group 3: 11% alcoholic extract of propolis Group 4: 0.9% saline. greatest difference being seen in group 1 (95.549%) group 2 (89.794%), group 3 (34.735%) group 4 (28.087%) miswak could be a good natural substitute to sodium hypochlorite propolis showed results comparable to those of the negative control.
- 70. study sample irrigants result conclusion Balto et al J Contemp Dent Pract. 2015 Mar 1;16(3):187 -91. 40 extracted pri ant teeth 3minutes with 5 ml of 17% (EDTA) or saline respectively. experimental groups : 3 minutes with 5 ml of 1 mg/ml ethanolic extract of S. persica (n = 15) or BioPure MTAD (n = 15) and then flushed with 2 ml of saline. MTAD solution was as effective as 17% EDTA in removing the smear layer. MTAD >> S.persica (miswak) at middle third of canal
- 71. study irrigants result Prabhakar et al J Endod. 2010 Jan;36(1):8 3-6. Extracted teeth Triphala green tea polyphenols (GTP) MTAD 5% sodium hypochlorite against E. faecalis biofilm 5% sodium hypochlorite showed maximum antibacterial activity against E. Faecalis biofilm formed
- 72. study sample irrigants result conclusion Venkataram , Gokhale, Kenchappa et al Eur Arch Paediatr Dent. 2013 Aug;14(4):2 47-52 30 extracted primary anteriors chamomile hydroalcoholic extract, Biopure™ (MTAD) 2.5% (NaOCl) Smear remo val MTAD >> cham omile extrac t efficacy of chamomile to remove the smear layer was superior to 2.5 % NaOCl alone, but less effective than MTAD mixture. Lotfi et al J Endod. 2012 Oct;38(10): 1391-4. In the MTAD group, the root canals were flushed with 1.3% NaOCl solution during 10-minute instrumentation, and MTAD was used as the final rinse. In other experimental group, 5.25% NaOCl was used during instrumentation, and 17% ethylenediaminet etraacetic acid (EDTA) was used as the final rinse. In 10-minute instrumentation period, the use of 5.25% NaOCl during instrumentation and 17% EDTA as the final rinse is more effective than using 1.3% NaOCl as primary irrigation and MTAD as final rinse on removal of the smear layer.
- 73. study sample irrigants result conclusion Ashofteh , Sohrabi et al Iran J Microbiol. 2014 Feb;6(1):26 -30. 135 extracted single rooted 5.25% Naocl 2% CHX MTAD 830 nm diode laser BACTERIAL REDUCTION 99.97±0.14 : Naocl 99.65±1.13 for CHX 97.56±6.36 : LASER 96.91±5.60 : MTAD Naocl was the most effective agent against Enterococcus faecalis
- 74. study irrigants conclusion Dagna et al Int J Artif Organs. 2011 Sep;34(9):9 14-9. Niclor 5 (5% NaOCl solution) Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution) 3% hydrogen peroxide 17% EDTA with 5%Naocl E.Faecalis S.mutans 5%Naocl with 17% EDTA showed greatest antimicrobial efficacy
- 75. study sample irrigants Hegde et al Contemp Clin Dent. 2016 Apr- Jun;7(2):21 6-20 30 pri ant teeth 10 ml 17% EGTA (ethylene glycol bis (beta-amino ethyl ether)-N, N, N', N'- tetraacetic acid)followed by 5% Naocl 10 ml 6% CITIC ACID 10 ml 0.9% SALINE : control sequential irrigation of the pulp canal walls with 17% EGTA followed by 5% NaOCl produced efficacious and smear-free root canal walls. Hariharan et al J Indian Soc Pedod Prev Dent. 2010 Oct- Dec;28(4):2 71-7 30 pri incisors 5.25% NaOCl, 5.25% NaOCl + 10% EDTA, 6% citric acid, 2% chlorhexidine, saline superior efficacy of 6% citric acid
- 76. study irrigants conclusion Botton et al Int Endod J. 2016 Aug;49(8):7 46-54 sodium hypochlorit e (1% and 2.5%) 2% chlorhexidi ne 6% citric acid 17% EDTA Toxicity test All groups showed some level of toxicity. Amongst the main solutions, chlorhexidine presented less cytotoxic potential. EDTA was the least cytotoxic of the auxiliary irrigant solutions, and the association of these two solutions showed the lowest toxicity potential amongst all groups.
- 77. study sampl e groups result conclusion Kapdan et al Niger J Clin Pract. 2015 Jul- Aug;18(4):538-43 The KTP laser (1,5 W); gaseous ozone (150 s); sodium hypochlorite (NaOCl); saline group Complete sterilization was achieved in the 2.5% NaOCl group KTP laser and ozone application provided a significant antibacterial effect in primary root canals; however, 2.5% NaOCl was superior Goztas et al Eur J Dent. 2014 Oct;8(4):469-74 58 extract ed pri molar Group I: 25 mg/L of Ozonated water (O3aq), Group II: 25 mg/L of O3aq with ultrasonication, Group III: 2.5% Sodium hypochloride (NaOCl), Group IV: 2% CHX and Group V: Positive control. NaOCI irrigation was found significantly most effective.
- 78. study No of canal groups Naocl conc Duration min conclusion Meire et al. 2009 60/60 1- Nd:YAG laser 2- KTP laser 3- PDT 4- NaOCl 5- Positive/negative control 2.5% 15 Laser systems and PDT were less efficacious than NaOCl in reducing EF, either in aqueous solution or in an infected-tooth model. Rios et al. 2011 - 1- 6% NaOCl 2- TB 3- PDT with no TB 4- PDT + TB 5- PDT + TB + NaOCl Positive and negative controls 6% 0.5 PDT with TB might be useful as auxiliary therapy for conventional endodontic treatment in reducing the amount of bacteria Poggio et al. 2011 100/1 00 1- PDT 2- PDT + NaOCl 3- TB 4- Prolonged PDT 5- 5% NaOCl (positive control) 6- Negative control 5% 3 antimicrobial efficacy of 5% NaOCl is greater than that of PDT. NaOCl can be used as an auxiliary procedure for endodontic treatment. A longer irradiation time may be necessary to improve effectiveness. Nunes et al. 2011 60/60 1- Control group 2- NaOCl 3- PDT with OF + 90-s ET 4- PDT with no OF + 180-s ET 5- PDT with no OF + 90-s ET 1% 15 PDT was effective against EF regardless of use of optical fiber
Editor's Notes
- Successful root canal treatment is dependent on the removal of microorganisms from the pulp and other anatomical irregularities of the root canal system through chemo-mechanical instrumentation with the use of instruments and irrigating solutions. Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue, and disinfecting the root canal system. Chemical debridement is especially needed for primary teeth with complex internal anatomy and zones inaccessible to debridement, such as accessory canals, ramifications, and dentinal tubules that might be missed by instrumentation. The choice of a cleanser in the pulpal therapy of primary teeth should take into account the differences among the dentin substrata, and not be irritating to the periapical tissues.
- The objectives of irrigation in endodontics are mechanical, chemical, and biologic. The mechanical and chemical objectives are as follows: (1) flush out debris, (2) lubricate the canal, (3) dissolve organic and inorganic tissue, and (4) prevent the formation of a smear layer during instrumentation or dissolve it once it has formed.42 The mechanical effectiveness will depend on the ability of irrigation to generate optimum streaming forces within the entire root-canal system. The chemical effectiveness will depend on the concentration of the antimicrobial irrigant, the area of contact, and the duration of interaction between irrigant and infected material.65 The final efficiency of endodontic disinfection will depend on its chemical and mechanical effectiveness. The biologic function of irrigants is related to their antimicrobial effects. In principle, irrigants should (1) have a high efficacy against anaerobic and facultative microor ganisms in their planktonic state and in biofilms, (2) inac tivaendotoxin, and (3) be nontoxic when they come in contact with vital tissues, and (4)b not cause an anaphylactic reaction.te
- Efficiency of root canal irrigation in terms of debris removal and eradication of bacteria depends on several factors: penetration depth of the needle, diameter of the root canal, inner and outer diameter of the needle, irrigation pressure, viscosity of the irrigant, velocity of the irrigant at the needle tip, and type and orientation of the needle bevel (Fig. 6-52). Penetration Depth of the Needle The size and length of the irrigation needle—in relation to root canal dimensions—is of utmost importance for the effectiveness of irrigation. Diameter of the Root Canal The apical diameter of the canal has an impact on needle penetration depth (see earlier in this chapter for details regarding apical preparation size (see Fig. 6-7, Table 6-2).72,578 Inner and Outer Diameter of the Needle (Fig. 6-53, A and B) The external needle diameter is of relevance for the depth of introduction into the root canal and for rigidity of the tip, an important consideration for irrigation of curved canals. Common 27 gauge injection needles have an external diameter of 0.42 mm, but smaller irrigation tips with external diameters of 0.32 mm (30 gauge) are available.235 The Stropko Flexi-Tip (30 gauge) needle is fabricated from nickel-titanium to improve penetration into curved root canals.205 Irrigation Pressure The internal diameter determines the pressure necessary for moving the syringe plunger. The speed of the plunger determines the velocity with which the irrigant is extruded. Narrow needles require more pressure onto the plunger and extrude the irrigant with higher velocity than large needle sizes, which extrude greater amounts of irrigants but cannot be introduced as deep. Type and Orientation of the Bevel of the Needle To improve safety of irrigation and prevent extrusion of the irrigant through the apical foramen, some needles release the solution via lateral openings and have a closed, safe-ended tip The orientation of the bevel is crucial to produce a turbulence effect on the dentinal wall of the canal. Side-vented and double side-vented needles lead to maximum shear stress concentrated on the wall facing the outlet (the proximal outlet for the double side-vented).
- Milton soltn is 3% naocl stabilised with 16% nacl
- In 2002 Estrela reported that sodium hypochlorite exhibits a dynamic balance (Fig. 6-54)142: 1. Saponification reaction: Sodium hypochlorite acts as an organic and fat solvent that degrades fatty acids and transforms them into fatty acid salts (soap) and glycerol (alcohol), reducing the surface tension of the remaining solution. 2. Neutralization reaction: Sodium hypochlorite neutralizes amino acids by forming water and salt. With the exit of hydroxyl ions, the pH is reduced. 3. Hypochlorous acid formation: When chlorine dissolves in water and it is in contact with organic matter, it forms hypochlorous acid. It is a weak acid with the chemical formula HClO that acts as an oxidizer. Hypochlorous acid (HOCl−) and hypochlorite ions (OCl−) lead to amino acid degradation and hydrolysis. 4. Solvent action: Sodium hypochlorite also acts as a solvent, releasing chlorine that combines with protein amino groups (NH) to form chloramines (chloramination reaction). Chloramines impede cell metabolism; chlorine is a strong oxidant and inhibits essential bacterial enzymes by irreversible oxidation of SH groups (sulfydryl group).142 5. High pH: Sodium hypochlorite is a strong base (pH > 11). The antimicrobial effectiveness of sodium hypochlorite, based on its high pH (hydroxyl ions action), is similar to the mechanism of action of calcium hydroxide. The high pH interferes in cytoplasmic membrane integrity due to irreversible enzymatic inhibition, biosynthetic alterations in cellular metabolism, and phospholipid degradation observed in lipidic peroxidation.
- It is highly unstable and easilly decomposed by heat and light. It rapidly dissociates into H2O + [O].On coming contact with tisssue enzymes catalase and peroxidase, liberated [o] produces bactericidal effect but this is transient and dimnish in presence of organic debris. It causes oxidation of…. The rapid relese of [O] on contact with organic tissue results in effervescence or bubbling action which is thought to aid in mechanical debridement by dislodging particles of necrotic tissue and dentinal debris and floating them to surface. USE : As irrigating solution either alone or alternatively with naocl. Adv of using alternately 3% h2o2 and 5.2% naocl are : Effervescence reactn by h2o2 bubbles push debris mechanically out of canal Solvent action of naoclon organic debris Disinfecting and bleaching action by both solutions While using in combo with naocl always use naocl in last because h2o2can react wid pulp debris and blood to produce gas which builds up pressure on closing tooth, can result in severe pain.
- Citric acid can also be used for irrigation of the root canal to remove the smear layer.35,43,44 Concentrations ranging from 1% to 50% have been used.43 The use of 10% citric acid as final irrigation has shown good results in smear layer removal45 and proven to be more biocompatible than 17% EDTA-T and 17% EDTA.46, Hariharan et al40 conducted an in vitro study to determine the efficacy of 5.25% NaOCl, 5.25 NaOCl + 10% EDTA, 6% citric acid and 2% chlorhexidine and saline (control) in removing the smear layer in primary teeth root canals after hand instrumentation. They showed the superior efficacy of 6% citric acid than the other tested irrigants on removing the smear layer in primary teeth. Never be mixed with naocl as it strongly interacts with naocl and reduce available chlorine in solution and thus making it ineffective against bacteria.
- Cohen & nisha garg
- Smear clear Designed to remove the smear layer, SmearClear contains 17% EDTA solution along with centrimide and additional proprietary surfactants. These components aid in the removal of inorganic matter left in the canal during instrumentation. By removing the smearlayer and leaving the dentinal tubules clear of inorganic matter, a more effective seal may be facilitated. SmearClear has been recently launched as a 17% EDTA-based endodontic irrigant containing cetrimide and additional proprietary surfactants. This product is known to have been evaluated in only one in vitro study with permanent teeth,69 which compared the efficacy of different root canal irrigants against Enterococcus faecalis biofilms. These authors found that SmearClear had greater efficacy than almost of them. These results may be attributed to the fact that SmearClear contains cetrimide, which is a quaternary ammonium compound and a cationic detergent that is effective against grampositive and gram-negative microorganisms
- Study by singhal and das in 2012 "The purpose of this study was to evaluate the efficacy of Carisolv TM , 1% sodium hypochlorite (NaOCl) gel, and 1% NaOCl solution as root canal irrigants in deciduous anterior teeth." Materials and Methods: Thirty-six extracted deciduous anterior teeth were used. Root canals were flooded with NaOCl solution in Group A, NaOCl gel in Group B and Carisolv TM in Group C and incubated for 30 min. Scanning electron microscope photomicrographs of canal wall debris in the apical, middle and coronal thirds were scored. Results: The results showed that regardless of irrigation regime, canals were consistently cleaner in the coronal and middle thirds than in the apical thirds. NaOCl solution, NaOCl gel, and Carisolv TM had comparable activity at coronal third and middle third of root canals. At the apical third, NaOCl solution cleaned canals better than NaOCl gel and Carisolv TM . Carisolv TM cleaned debris better than NaOCl gel at the apical third. Conclusion: Carisolv TM can be used as an adjunct to root canal preparation.
- Prabhakar et al. 5% of sodium hypochlorite exhibited excellent antibacterial activity in both 3-week and 6-week biofilm, whereas Triphala and MTAD showed complete eradication only in 3-week biofilm .
- An invitro study compared the effectiveness of MCJ with NaOCl and CHX to remove the smear layer from the root canal walls of instrumented teeth. It was concluded that the efficacy of Morinda Citrifolia was similar to NaOCl in conjunction with EDTA as an intracanal irrigant.
- An invitro study showed 10-20% miswak was effectve antifungal n anti bact against candida n e fecalis. A study on pri teeth showed it could be good natural substitute to naocl
- • The success of pulpectomy therapy in primary teeth depends on achieving an adequate level of disinfection within the root canals. It is challenging for paediatric dentists to choose the most appropriate irrigant agent when performing pulpectomy treatments. More high-quality clinical studies are definitely needed, with proper monitoring,
- rare genetic disorder with autosomal dominant and autosomal recessive inheritance. It is characterised by a mineralisation deficit affecting the bones and teeth, which is associated with deficient and reduced enzymatic activity of tissue-nonspecific alkaline phosphatase (TNSALP)1–4. Mutations of the ALPL gene (1p36.1-p34), which encodes TNSALP, are responsible for the reduction in enzymatic activity. TNSALP is expressed in the liver, bones, and kidneys, and also found in the enamel, dentine, cementum, and alveolar bone5. In the event of reduced enzymatic activity of TNSALP, substrates that are not broken down (pyridoxal 50-phosphate, inorganic pyrophosphate, and phosphoethanolamine) build up and produce toxic effects; for example, inorganic pyrophosphate is a powerful mineralisation inhibitor6. These substrates may be detected in blood and urine.
- QMiX was introduced in 2011; it is one of the new combination products introduced for root canal irrigation (Fig. 6-64). It is recommended to be used at the end of instrumentation, after NaOCl irrigation. According to the patent194 QMix contains a CHX-analog, Triclosan (N-cetyl-N,N,N-trimethylammonium bromide), and EDTA as a decalcifying agent; it is intended as antimicrobial irrigant as well as an agent to remove canal wall smear layers and debris. QMiX is suggested as a final rinse. Smear Layer Removal Stojic and colleagues investigated the effectiveness of smear layer removal by QMiX using scanning electron microscopy.500 QMiX removed smear layer equally well as EDTA. Dai and colleagues examined the ability of two pH versions of QMiX to remove canal wall smear layers and debris using an open canal design.113 Within the limitations of an open-canal design, the two experimental 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.
- Photodynamic therapy (PDT) or light-activated therapy (LAT) may have endodontic applications because of its antimicrobial effectiveness.203 In principle, antimicrobial photodynamic therapy (APDT) is a two-step procedure that involves the introduction of a photosensitizer (step 1: photosensitization of the infected tissue) followed by light illumination (step 2: irradiation of the photosensitized tissue) of the sensitized tissue, which would generate a toxic photochemistry on the target cell, leading to cell lysis. Each of these elements used independently will not have any action, but together they have a synergism effect to produce antibacterial action. (COHEN) PDT is based on the concept that nontoxic photosensitizers can be preferentially localized in certain tissues and subsequently activated by light of the appropriate wavelength to generate singlet oxygen and free radicals that are cytotoxic to cells of the target tissue [77]. Methylene blue (MB) is a wellestablished photosensitizer that has been used in PDT for targeting various gram-positive and gram-negative oral bacteria and was previously used to study the effect of PDT on endodontic disinfection. Soukos et al. used the combined effect of MB and red light (665nm) exhibited up to 97% reduction of bacterial viability . Along with methylene blue, tolonium chloride has been also used as a photosensitizing agent. It is applied to the infected area and left in situ for a short period. The agent binds to the cellular membrane of bacteria, which will then rupture when activated by a laser source emitting radiation at an appropriate wavelength (e.g., 635nm radiation emitted by SaveDent; Denfotex Light Systems Ltd., Inverkeithing, United Kingdom). The light is transmitted into the root canalsatthetipofasmallflexibleopticalfiberthatisattached to a disposable handpiece. The laser emits a maximum of only 100mW and does not generate sufficient heat to harm adjacent tissues. irrigation with sodium hypochlorite (3%) eliminated the entire bacterial population. The difference could be because the optical fiber was not properly introduced into the root canals, and so the light could not transmit through the tooth structure. Thus, PAD might not be able to achieve a 100% kill rate in infected root canalsthathavecomplexanatomicfeaturesandcolonizedby polymicrobial biofilms of varying properties. Pagonis et al. studied the in vitro effects of poly(lacticcoglycolic acid) (PLGA) nanoparticles loaded with the photosensitizermethyleneblue(MB)andlightagainstEnterococcus faecalis (ATCC 29212) [93]. The study showed that utilization of PLGA nanoparticles encapsulated with photoactive drugsmaybeapromisingadjunctinantimicrobialendodontic treatment
- Laser devices have been proposed to improve the efficacy of irrigants.186 Lasers have been studied for their ability to clean and effectively disinfect root canals. The Er:YAG laser wavelength (2940 nm) has the highest absorption in water and a high affinity to hydroxyapatite, which makes it suitable for use in root canal treatment.107 Laser energy may be used to activate irrigant solutions in different ways—for example, at a molecular level, as in photoactivated disinfection (PAD), or at a bulk flow level, as in laser-activated irrigation (LAI). Several studies in vivo and ex vivo have indicated that laser activated irrigation is promising for removing smear layer168 and dentin debris121,122 in less time than PUI. The mechanism of action56 is based on the generation of a secondary cavitation effect with expansion and successive implosion of fluids. erbium laser technique that used a photon-induced photoacoustic streaming (PIPS) of irrigants. In that technique, the laser tip is placed into the coronal access opening of the pulp chamber only and is kept stationary without advancing into the orifice of the canal.132 The use of a newly designed tapered and stripped tip with specific minimally ablative laser settings is required, resulting in low energy (20 mJ), a pulse repetition rate of 15 Hz, and a very short pulse duration (50 µs). The difference in laser penetration and bacterial killing is attributed to the difference in the degree of absorption of different wavelengths of light within the dentin. Endodontic pathogens that grow as biofilms, however, are difficult to eradicate even upon direct laser exposure.65
- An in vivo randomized controlled trial was conducted in a group of 60 children aged 6-12 years presenting with an acute apical abscess of the maxillary primary molars. Fifteen children each were divided randomly into four groups where irrigation during pulpectomy was performed using either 2% chlorhexidine, 4% calcium hydroxide or 4% Dimethyl Sulfoxide (DMSO) extract of propolis with normal saline as the control irrigant. Microbiological samples were taken from the disto-buccal root canal before initiating the pulpectomy as well as after 3 days later and for mixed aerobic and anaerobic bacterial cultures.
- AIM: To evaluate the efficacy of ethanolic extract of Salvadora persica (S. persica) and BioPure MTAD (a mixture of a tetracycline isomer, an acid, and a detergent) in removing the intracanal smear layer of primary teeth. MATERIALS AND METHODS: The root canal of 40 extracted human primary anterior teeth were cleaned, shaped and grouped into experimental (n = 30) and control (n = 10). The root canals of the positive (n = 5) and the negative control (n = 5) were irrigated for 3 minutes with 5 ml of 17% ethylenediaminetetraacetic acid (EDTA) or saline respectively. The canals in the experimental groups were irrigated for 3 minutes with 5 ml of 1 mg/ml ethanolic extract of S. persica (n = 15) or BioPure MTAD (n = 15) and then flushed with 2 ml of saline. The presence or absence of smear layer at the coronal and middle portion of each canal were examined under a scanning electron microscope (SEM). RESULTS: A significant difference (p = 0.004) in smear layer removal between S. persica and MTAD at the middle third of the canal was observed. MTAD solution was as effective as 17% EDTA in removing the smear layer. CONCLUSION: MTAD was significantly more effective in smear layer removal than S. persica solution at the middle third of the canal wall. CLINICAL SIGNIFICANCE: Both tested irrigant solutions have the ability to remove the intracanal smear from primary root dentin following cleaning and shaping of the root canal and could be an alternative to EDTA.
- METHODS: Thirty extracted single-rooted, primary human teeth were allocated at random into three experimental groups of 10 teeth each. For each tooth, the canal was prepared using the step-back technique. During instrumentation, 2 ml of the irrigant was used for at least 10 s after each file and 10 ml as a final flush for 2 min for chamomile and NaOCL irrigants. Whereas for MTAD, an initial rinse with 1.3 % NaOCl for a cumulated period of 20 min, and use of MTAD as the final rinse for a period of 5 min was followed. Longitudinal grooves were made on root segments, then split into two halves with a chisel, stored in 2.5 % glutaraldehyde solution and fixed in ethanol series. Specimens were examined for the smear layer according to Hulsmann et al. (Int Endod J 35:668-679, 2002) criteria using a scanning electron microscope. STATISTICS: Kruskal-Wallis and Mann-Whitney U tests were used. RESULTS: The most effective result in removal of smear layer occurred with the use of MTAD, followed by chamomile extract. The chamomile extract was found to be significantly more effective than 2.5 % NaOCl solution which had only minor effects. CONCLUSIONS: The efficacy of chamomile to remove the smear layer was superior to 2.5 % NaOCl alone, but less effective than MTAD mixture.
- INTRODUCTION: Bacteria are the primary etiology of pulpal and periradicular pathosis. In endodontically treated teeth with persistent infections only one or a few bacterial species are present of which the most important is Enterococcus faecalis. The aim of this study was to compare antibacterial efficacy of canal disinfectants including 5.25% sodium hypochlorite, 2% chlorhexidine, MTAD (a mixture of doxycycline, citric acid and a detergent (Tween 80) and 830 nm diode laser. METHODS AND MATERIALS: The canals of 135 extracted single rooted human teeth were prepared using rotary instruments. The canals were contaminated with Enterococcus faecalis for 4 weeks and then were divided into 4 groups of 30 teeth in each, a positive control group containing 10 teeth and a negative control group of 5 teeth. After using the disinfectants, samples obtained from canals by paper points and also shaving the canal walls were cultured. The Kruskal-Wallis test was used to analyze the results. RESULTS: The results showed the bacterial reduction as follows: 99.97±0.14 for sodium hypochlorite, 99.65±1.13 for chlorhexidine, 97.56±6.36 for laser and 96.91±5.60 for MTAD. The count of CFU obtained from dentin shavings was: 16/96±91/23 for sodium hypochlorite, 82/73±186/63 .for chlorhexidine, 47/26±112/21 for laser and 341/34±1139/83 for MTAD. CONCLUSION: According to the results, sodium hypochlorite was the most effective agent against Enterococ
- The objective of this study was to compare in vitro, by MTT assay, the antimicrobial efficacy of Niclor 5 (5% NaOCl solution), Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution), 3% hydrogen peroxide and 17% EDTA against two microorganisms associated with primary endodontic infections. METHODS: Enterococcus faecalis and Streptococcus mutans strains were selected for this test. Freshly extracted single-rooted human teeth were endodontically treated, inoculated with bacterial strains and then divided into different groups, each of them rinsed with Niclor 5 (5% NaOCl solution), Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution), 3% hydrogen peroxide,17% EDTA and with 5% NaOCl solution (positive control). RESULTS: Even though all the tested irrigating solutions demonstrated antibacterial effects against E. faecalis and S. mutans, the results were significantly different between the various groups. The greatest antimicrobial effects were observed in groups treated with 5% NaOCl and 17% EDTA. Interestingly, the effectiveness of EDTA could be ascribed to its capability of detaching biofilm from canal walls.
- Thirty primary anterior teeth were chosen for the study. The teeth were distributed into three groups having ten teeth each. Following instrumentation, root canals of the first group were treated with 17% EGTA and the second group with 6% citric acid. Only saline was used as an irrigant for the control group. Then, the teeth were subjected to scanning electron microscopy (SEM) study. The scale given by Rome et al. for the smear layer removal was used in the present study. RESULTS: The pictures from the SEM showed that among the tested irrigants, 17% EGTA + 5% sodium hypochlorite (NaOCl) group showed the best results when compared to other groups. CONCLUSION: The results advocate that the sequential irrigation of the pulp canal walls with 17% EGTA followed by 5% NaOCl produced efficacious and smear-free root canal walls. The pictures from the scanning electron microscopy showed that among the tested irrigants, citric acid has the best efficacy to remove the smear layer without altering the normal dentinal structures, which was supported by the lowest mean smear scores. The pictures from the 10%EDTA + 5.25% sodium hypochlorite group showed that even though it removed the smear layer, it adversely affected the dentine structure. SEM pictures of the other groups like sodium hypochlorite, chlorhexidine revealed that these irrigants does not have the capacity to remove the smear layer in primary teeth. CONCLUSIONS: The results of the present study clearly indicate the superior efficacy of 6% citric acid than the other tested irrigants on removing the smear layer in primary teeth root canals.
- The aim of the study was to evaluate the antimicrobial activity of the-potassium-titanyl-phosphate--the KTP laser and ozone in of primary root canals. MATERIALS AND METHODS: Sixty primary incisor teeth were selected. The specimens were inoculated with 10 mL Enterococcus faecalis (E. faecalis). Groups: The KTP laser (1,5 W); gaseous ozone (150 s); sodium hypochlorite (NaOCl); saline group. Sterile paper points used to sample bacteria from the canals to tubes containing 5 mL of brain heart infusion broth. Then, 10 mL suspension was incubated in culture media for 24 h. Data were analyzed statistically using Kruskal-Wallis and Mann-Whitney U-test. RESULTS: There were statistically significant differences between all groups (P<0.05). Complete sterilization was achieved in the 2.5% NaOCl group. The number of bacteria were significantly reduced in experimental groups in comparison to the saline group. CONCLUSION: The KTP laser and ozone application provided a significant antibacterial effect in primary root canals; however, 2.5% NaOCl was superior.