This presentation is all about the various irrigants and the irrigation systems used currently in dental practice ( in cleaning and shaping of Root canal systems)

1. “What you remove from the root canals, is more important
than what you place back………”

2. Dr. SURABHI SOUMYA

3. CONTENTS
• Introduction & history
• Goals of irrigation
• Ideal requirements
• Classification
• Individual irrigants
ØSaline
ØNaOCl
ØHydrogen peroxide

4. § Chelating agents
§ Organic acids
§ Factors associated with irrigation
§ Newer methods of irrigation
§ TECHNIQUES OF IRRIGATION
§ Complications during root canal irrigation
§ Conclusion

5. INTRODUCTION
• Irrigation is defined as “to wash out a body cavity or wound
with water or a medicated fluid” and,
• Disinfectant, meanwhile, is defined as “an agent that destroys
or inhibits the activity of microorganisms that cause disease.”
-Cohen 11th Ed

6. HISTORY
• 1st world war – Dakin’s solution(1915)
• 1920 – 1940 : Strong acids – 20 – 50% Sulfuric acid,
Hydrochloric & Nitric acid, 50% Aqua Regia
• 1936 – walker – sodium hypochlorite (Crane 1920)
• 1943 – Grossman introduced the concept of using
oxidizing agents as irrigants
• 1945 - Daniel formulated an irrigating solution
comprising of a aminoacridine.

7. • 1957 - Nygard Ostby – EDTA
• 1960s - RC prep & Glyoxide
• 1970’s chelating agents were used
increasingly because of their biologically
acceptable properties.
• 1970s & early 80s - Chlorhexidine
• Recent advances - Ruddle’s solution &
MTAD

8. Acc to Stock
Classific
ation

9. OBJECTIVES
• The objectives of irrigation in endodontics are mechanical,
chemical, and biologic.
• The mechanical and chemical objectives are as follows:
Øflush out debris,
Ølubricate the canal,
Ødissolve organic and inorganic tissue, and
Øprevent the formation of a smear layer during
instrumentation or dissolve it once it has formed.

10. • Biologic function of irrigants is related to their antimicrobial
effects.
• The biological objective are-
Øhave a high efficacy against anaerobic and facultative
microorganisms in their planktonic state and in biofilms
Øinactivate the endodotoxins
Ønontoxic when they come in contact with vital tissues
Ønot cause an anaphylactic reaction

11. FACTORS DETERMINING EFFICIENCY
OF ROOT CANAL IRRIGATION
• 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

12. • Inner and Outer Diameter of the Needle –
• The external needle diameter determines the depth of
introduction into the root canal and for rigidity of the tip, especially
for irrigation of curved canals.
• Commonly 27 gauge injection needles are used which have an
external diameter of 0.42 mm, but smaller irrigation tips with
external diameters of 0.32 mm (30 gauge) are available.
• The Stropko Flexi-Tip (30 gauge) needle is fabricated from nickel-
titanium to improve penetration into curved root canals.

13. • Irrigation Pressure –
ØThe internal diameter determines the
pressure necessary for moving the syringe
plunger.
ØThe speed of the plunger determines the
velocity with which the irrigant is extruded.
ØNarrow 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.

14. q Type and Orientation of the Bevel of the Needle –
ØThe orientation of the bevel is crucial to produce a
turbulence effect on the dentinal wall of the canal
ØTo 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
ØSide-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)

15. Fitting of needle with syringe should be Luer lock :
Include a screw-in for:
• Easy removal
• Secure attachment
• Prevent accidental separation of needles
from syringes

16. IRRIGANTS

17. no solution can
be regarded as
optimal but
combined use
of selected
irrigants can
contribute to
successful
treatment
outcome

18. FACTORSTHAT MODIFY ACTIVITY OF
INTRACANAL IRRIGATING SOLUTIONS
1. Concentration- Higher conc more cytotoxic.
2. Contact – for better debridement
3. Presence of organic tissue- decrease the effect of
medicament.
4. Quantity- Barber et al – ability to debride related
directly to quantity of irrigating solution
5. Temperature – some irrigants when warmed before
irrigation are more effective. ( eg. Hypo at 60-70 )℃

19. OTHER FACTORS:
• Gauge of the irrigating needle- 27 or 28 gauge
preferred as they can go deeper into the canal
• Surface Tension – lower surface tension = better
wettability
• Frequency of irrigation – more irrigation causes more
debridement and each time a fresh solution is introduced
• Age of irrigant – freshly prepared solutions are more
efficient

20. COMMONLY USED
IRRIGANTS

21. NORMAL SALINE
• Normal saline as 0.9% W/V is commonly used as
irrigant in endodontics
• Gross debridement and lubrication of root
canals.
• Since it is very mild in action, it can be used as an
adjunct to any chemical irrigant.
• Mode of action: flushing
• Also used as a final rinse to remove any irrigant

22. SODIUM HYPOCHLORITE
• Clear, pale, green-yellow liquid with
strong odor of chlorine.
• Easily miscible with water and gets
decomposed by light
• It is the irrigant of choice in
endodontics, owing to its efficacy
against pathogenic organisms and pulp
dissolution

23. First produced in 1789 in France.
Introduced in 1st World War by Dakin.
Walker - 1936 - First suggested its use in
root canal therapy
Grossman - 1941 - Used it as an
intracanal medicament
Spangberg - 1973 – 0.5% NaOCl has good
germicidal activity
Madden - 1977 - Compared the different
concentrations of hypo
Foley et al – 1983 - Compared
effectiveness of 0.5 percent NaOCl and
Glyoxide.
History

24. MANUFACTURING
Two methods
1. Cl2 + 2NaOH NaOCl+ NaCl+
H2O
2. Electrolysis of saturated brine
solution to produce Na+ & Cl
ions
STORAGE & HANDLING
Store in light proof (opaque
glass /polyethylene)
Stability of NaOCl is
reduced by
Ølower pH
ØPresence of metallic ions
ØExposure to light
ØHigh temperatures

25. • At body temperature, reactive chlorine in aqueous solution exists in
two forms-
Hypochlorite (OCl– )- pH> 7.6
hypochlorous acid (HOCl)- pH< 7.6
• Hypo has 5% of free chlorine - for breakdown of proteins into amino
groups
• Sodium hypochlorite commonly has a pH of 12, at which the OCl form
exits; dissolves necrotic tissue
• To increase the efficacy of NaOCl solution, 1% sodium bicarbonate
is added as buffering agent which makes the solution unstable, thus
decreases its shelf life to even less than one week.

26. • In 2002 Estrela reported that sodium hypochlorite
exhibits a dynamic balance – ( Cohen 11th Edition)
i. Saponification
reaction
ii. Neutralization
reaction
iii. Hypochlorous acid
formation
iv. Solvent action
v. High pH value

27. 5.25% NaOCI
remains
relatively stable
for 1 week and
decreases at 2
weeks and
above
warmed hypo 2.6%
bactericidal against
E.Coli,S.Sanguis,B.Subtilis
spores,P.Vulgaris,S.Aureus
organisms as early as 45
seconds.(Cunningham &
Joseph OOO,1990)

28. FEW STUDIES ON SODIUM
HYPOCHLORITE
Regardingitsconcentration
• Baumgartner et al (JOE, 1992, vol.
12) – no difference in efficacy of 5.25,
2.5 & 1% NaOCl
• Harrison & Hand – dilution of
5.25% NaOCl resulted in decrease in
its ability to dissolve necrotic tissue
• Yesiloy et al– 5.25% NaOCl effective
against all microorganisms tested but
less effective when diluted

29. Regardingitsvolume
• 5ml per tooth - optimal
• 3ml of NaOCl at 5.25% is
sufficient to cause effective
debridement with antimicrobial
effect
• Baker and associates however
advocate the use of 20cc flush of
5% NaOCl Cohen 11th
Ed

30. SOLVENT ACTION ANTIMICROBIAL EFFECT
• Morgan et al – 80% tissue
solvency – 2.6% solution
• Grossman & Meiman –
more effective pulp solvent
than KOH, H2SO4, NaOH,
HCl and Papain
• Sen et al – 1 & 5% NaOCl
effective against C.albicans
• Kuruvilla & Kamath – 50%
reduction in microbial count –
2.5% NaOCl, synergistic
response with CHX (0.2%)
lead to 80% reduction in
microbial load.

31. Time required for
antimicrobial effect
• In presence of smear layer – 1
hour (samples at 1minute,
5minutes & 30 minutes were
positive)
• If smear layer was removed, 5%
NaOCl complete antimicrobial
activity (Sen et al JOE 1999)

32. Time required for
tissue clearance
Grossman observed pulp tissue
dissolution capacity and
reported that 5% sodium
hypochlorite dissolved this
tissue in between 20 minutes
and 2 hours
Cohen 11th Edition

33. REVIEW:THE USE OF SODIUM HYPOCHLORITE IN
ENDODONTICS — POTENTIAL COMPLICATIONS AND
THEIR MANAGEMENT H. R. SPENCER,1V. IKE2 AND P.A. BRENNAN3
BDJ VOLUME 202 NO. 9 MAY 12 2007
• Plastic bib to protect patient’s clothing
• Provision of protective eye-wear for both patient and operator
• The use of a sealed rubber dam for isolation of the tooth under
treatment
• The use of side exit Luer-Lock needles for root canal irrigation
• Irrigation needle a minimum of 2 mm short of the working length
• Avoidance of wedging the needle into the root canal
• Avoidance of excessive pressure during irrigation
Preventive measures that should be taken to minimise potential
complications with sodium hypochlorite

34. • Sodium hypochlorite is nontoxic but 5.25%
NaOCl can cause serious damage if injected
periapically (forceful irrigation, wedged
needle) it causes excruciating pain,
periapical bleeding and swelling and
ecchymosis
• Mechanism from injury is primary oxidation
of proteins followed by inflammatory
reaction from the body
HypochloriteAccident
• Stop treatment and give an explanation to the patient- Remain Calm Reassure
patient.
• There is no antidote per se for NaOCI, therefore resort to palliative care
• Immediately irrigate with copious amounts of saline
• Pain control
Ø Immediately with a nerve block
Ø Prescribe analgesics
Ø (Becking found Naproxen in a dosage of 500-1000mg/day sufficient)

35. • Corticosteroids for 3 days.
Ø Ist dose I.V. Reeh & Messer HH recommend 4-48
mg/day Triamcinolone
Ø 8mg Doxona I.M. would also suffice
• Consider incision and trephination if deemed necessary
• Antibiotics for 1 week (Becker, Cohen, Borer)
Ø Prophylactic: Becking – Penicillin & Metronidazole
• Cold compresses for first 6 hours followed by warm
compresses and mouth rinses – 1 week.
• Provide verbal and written home care
• Set up regular recall visits

36. FIGS 1-3 BRUISING AND OEDEMA OFTHREE
PATIENTS WHO PRESENTED WITH
HYPOCHLORITE
EXTRUSION INTOTHE SOFTTISSUES

37. • Causes tissue dissolution
• Antibacterial and bleaching
action
• Causes lubrication of canals.
• Economical
• Easily available
• High surface tension, its
ability to wet dentin is less
• Severe cellular damage if
extruded
• inflammation of gingiva
because of its caustic nature
• bleach the clothes if spilt.
• bad odor and taste
Advantages Disadvantages
Fresh Scent Clorox

38. SODIUMHYPOCHLORITEIN
COMBINATIONWITHOTHER
MEDICAMENTS
• Tissue dissolving capacity of NaOCl or CHX is found to be
increased when tissue is pretreated with calcium hydroxide
(Hasselgren, et al)
• Wadachi et al. in their study have shown that combination of
calcium hydroxide and sodium hypochlorite was better than either
of medicament alone
• Various studies have shown that combination of sodium
hypochlorite and EDTA has more bactericidal effect which is
probably due to removal of contaminated smear layer by EDTA
• The alternate use of sodium hypochlorite and chlorhexidine
results in greater reduction of microflora than the use of either
alone as shown by Kuruvilla and Kamath.

39. HYDROGEN PEROXIDE
• It is clear, odorless liquid, used at a conc of 3%
• It is highly unstable, easily decomposed by heat and
light rapidly into H2 O + [O] (water and nascent
oxygent).
• On coming in contact with tissue enzymes catalase
and peroxidase, the liberated [O] produces
bactericidal effect by oxidation of bacterial sulfhydryl
group of enzymes and thus interferes with bacterial
metabolism.

40. • [O] nascent oxygen in contact with necrotic tissues causes
effervescence or bubbling action which aids in mechanical
debridement by dislodging particles of necrotic tissue and
dentinal debris and floating them to the surface.
Uses:
• as an irrigating solution especially in cases of root or floor
perforations or when apical constrictions have been destroyed
• Used either alone or alternatively with sodium hypochlorite
5.25% with the advantages being:
1. Effervescent reaction by H2O2 pushes debris
mechanically out of root canal
2. Solvent action of sodium hypochlorite on organic debris
3. Disinfecting and bleaching action by both solutions
Hypo should be used
at the end because
H2O2 reacts with
pulp debris & blood
to produce a gas
which builds up
pressure resulting in
severe pain.

41. Ohara,Torabinejab & Kettring comparatively evaluated 3% H2O2
to other contemporary irrigants w.r.t. it’s anti-microbial efficiency
and found it to be moderate to the anaerobic pathogens.
Disadvantages:
• Lacks tissue dissolving
property
• Non lubricant
• Limited antimicrobial action
only.action against gram +ve
bacteria than gram –ve
bacteria.
Nahlieli & Neder in Israel
reported a case of Iatrogenic
Penumo-Mediastinum after
irrigation with H2O2
Such a patient may present with
pain, dyspnoea, fever,
leukocytosis and swelling.
Prophylactic antibiotics – 10days
Monitoring of patient’s vitals

42. CHLORHEXIDINE
• Developed in the late 1940’s
• Most potent of the tested bisbiguanides
• Most stable in the form of its salts, i.e. chlorhexidine
gluconate
• Potent antiseptic which is widely used for chemical
plaque control in the oral cavity in concentrations of
0.2%
• Optimal antimicrobial action between pH 5.5-7.0

43. For using it as an irrigant, it
should be used as 2% in
concentration.
Ø CHX lacks a tissue-
dissolving property hence
NaOCl is still
considered the primary
irrigating solution in
endodontics.
Ø Hence, CHX can be used
in combination with hypo
for better cleaning
efficiency
• Broad spectrum antimicrobial agent
• The antibacterial mechanism is related to
its cationic bisbiguanide molecular
structure
• The cationic molecule is absorbed to the
negatively charged inner cell membrane
and causes leakage of intracellular
components.
• At low concentration- bacteriostatic
• At higher concentrations- coagulation and
precipitation of cytoplasm (bactericidal)
• Both 2 and 0.2% CHX can cause residual
antimicrobial activity for 72 hours, if used
as an endodontic irrigant- Substantivity
(residual effect)
MOA

44. Ø CHX is a base, capable of forming salts of a number of organic
acids.
Ø NaOCI – oxidizing agent, which oxidizes gluconate part of
Chlorhexidene gluconate to gluconic acid.
Ø The CI- groups may get added into the guanidine component of
the chlorhexidene molecule forming Chlorhexidene –CI Hence,
resulting in increasing ionizing capacity of Chlorhexidene
(i.e. makes solution more alkaline)
Ø CHX – 6.5pH
Ø NaOCI-9 pH
Ø combination- 10
Ø Has effective action against E. facealis
CHX+HYPO

45. Bacteriostatic effect is considered to be more
important since the bound CHX molecule is
released slowly over 24 hours.
When 2% & 0.2% each of NaOCI &
Chlorhexidene were compared, it was found
that both showed equivalent antimicrobial
effect (Vahdaty et al)
Note:

46. Interactionb/wNaOCl,CHX&EDTA
NaOCl and CHX when in contact produce a change of color and a
precipitate. Basrani & colleagues evaluated the chemical nature of this
precipitate and reported the formation of Para chloroaniline (PCA)
which is known to be toxic in humans with short-term exposure,
resulting in cyanosis, which is a manifestation of methemoglobin
formation.
This insoluble ppt that may interfere with the seal of the root
obturation, hence the canal should be dried using paper points before
the final CHX rinse
The combination of CHX and EDTA produces a white precipitate,
so a group of investigators did a study to find out that CHX formed a
salt with EDTA rather than undergoing a chemical reaction.
Cohen 11th Ed

47. • 2% solution is used as root
canal irrigant
• 0.2% solution can be used in
controlling plaque activity
• effective on gram-positive
bacteria than gram negative
bacteria
• It is not considered as the
main irrigant in standard
endodontic therapy
• It is unable to dissolve
necrotic tissue remnants
Advantages Disadvantages

48. CHELATING AGENTS
• Chelating agent is defined as a chemical which combines
with a metal to form chelate.
• Egs: EDTA, citric acid, polyacrylic acids
• EDTA is most commonly used chelating agent,
introduced in dentistry by Nygaard Ostby for cleaning
and shaping of the canals.
• contains four acetic acid groups attached to
ethylenediamine
• relatively nontoxic and slightly irritating in weak solution
Structural configuration
of EDTA

49. Cohen 11th Ed
• EDTA extracts bacterial surface proteins by
combining with metal ions from the cell
envelope, which eventually leads to
bacterial cell death.
• It forms a stable complex with calcium.
• When all available ions have been bound,
equilibrium is formed and no further
dissolution takes place; therefore, EDTA is
self-limiting
Even though EDTA has self-limited action, if it is
left in the canal for longer or NaOCl is used
after EDTA, erosion of dentin has been
demonstrated
MOA
SEM 2 mins of EDTA placement

50. Uses:
• Lubrication
Emulsification
• Smear Layer removal
• Dispensed in 2 forms–
viscous product is used
for the first two during
canal preparation
followed by aqueous
solution for final flush
after shaping and
cleaning for smear layer
removal.
Cohen 11th Ed
Sen,Akdeniz & Denizci (OOO, 2000) have
shown that this product may posses
ANTIFUNGAL ACTIVITY
CYTOTOXIC EFFECTS
•It removes Ca2+
from the cell
walls leading to
its collapse.
•Also inhibits
enzymatic
reactions
Koulaouzidou, et al
reported
5-50 mm of EDTA if
extruded may lead to
decalcification of peri
apical bone &
Neuroimmune
regulation even at very
low concentrations

51. • Chelating agent can be applied in
liquid or paste form
• Paste type preparation- Stewart who
polyethylene glycol as vehicle (
soluble carbowax)
• Presence of glycol- lubrication, hence
easy instrumentation
• Combined use of sodium
hypochlorite and RC Prep causes an
efficient cleaning of canals.Their
combination causes release of
nascent oxygen which kills anaerobic
bacteria and effervescence action
which mechanically pushes the debris
out of canal.
• EDTA - 15%.
• Urea peroxide - 10%
• in a water soluble
polyethylene base or
a base of carbowax.

52. Different Forms of EDTA
• R-EDTA: EDTA is combined with cetrimide, i.e.cetyllrimethy 1 ammonium
bromide. It helps in better cleaning of canals
• EDTAT: (EDTA +Texapon) EDTA is combined with sodium lauryl sulfate
which results in decreasing the surface tension
• EDTA-C: commercially available as 15% solution and pH of 7.3 under the
name EDTAC because it contains cetavelon, a quaternary ammonium
compound which has been added to it for its disinfecting properties
• Introduction of surfactant reduces the contact angle of EDTA when placed on
dentin surface and thus enhances its cleaning efficacy.

53. interactionsofEDTAwithNaOCl
• Investigators have suggested that EDTA
retained its calcium-complex ability when
mixed with NaOCl, but EDTA caused
NaOCl to lose its tissue-dissolving capacity
• Hence, EDTA and NaOCl should be used
separately in an alternating irrigating regimen
• It can be activated with ultrasonic activation
for better penetration in dentinal tubules
• When EDTA is heated from 20° to 90°, the
calcium binding capacity decreases
Others
• Largal ultra
(15%EDTA+ 0.75
gms cetrimide)
• Tubilicid plus (3%)
• File-Eze (19%)

54. It is a weak chelator and a potential
alternative to EDTA because it has no
short-term reactivity with NaOCl
Can be used in combination with NaOCl
without affecting its proteolytic or
antimicrobial properties
It is nontoxic and is used in medicine to
treat bone diseases.
HydroxyethylideneBisphosphonate
(HEBP)

55. BondStrengthtoDentine(MorrisJoe,JOE
2001
v A treatment with 5% NaOCI & R C Prep produces a
significantly large reduction in bond strengths in dentin
Ø NaOCI:
• Oxidizing action of this agent leads to the oxidation of the dentin
matrix that is critical during composite polymerization. Bond
strength was as low as 8.5 Mpa (JOE,Vol 31,No.3,March 2005)
Ø RC-prep
• Residual peroxide breaks down to produce oxygen & water which
forms bubbles or voids which interfere with resin infiltration into
etched dentin
Ø No loss of bond strength is reported from CHX irrigation
before resin bonding.

56. SUMMARY

57. THE ACIDS
• 30% HCl
• 50% sulphuric acid
• phenol sulfonic acid,
• 50% reverse aqua regia
• citric acid
• tannic acid

58. • 50% Citric Acid solution has
antimicrobial efficacy
equivalent to 5.25% NaOCI
against several anaerobic
bacteria.
• Use 10ml for a duration of
5min-15min (Nekolaus,
Wayman, Encinas JOE 1988)
• Tannic Acid 25% is used
• First suggested by Graham
Mount
• Has ASTRINGENT
PROPERTIES - coagulation
by precipitation of proteins.
• ANTIMICROBIAL
PROPERTY
CITRIC ACID TANNIC ACID

59. Fewstudiesoncitricacid
• It removed smear layer from both
middle & apical thirds of the canal
• Was equally effective for smear
layer removal as was 17% EDTA-
(KhedmatS, et al JOE 2008)
• 10% citric acid removes the
smear layer more effectively in
the apical root end cavities (IEJ
1994)

60. MISCELLANEOUS
ANTIBIOTICS:
• Tetracycline HCI
• Minocycline
• Doxycycline
• Broad spectrum
antibiotics
• Act as calcium
chelators, Ability
to remove smear
layer also studied.
• Substantivity
• Barkhodar et al- Doxycycline HCI (100mg/ml)
effective in removing smear layer of instrumented
canals
• Haznedaroglu & Ersev (JOE 2001) reported that
1% Tetracycline HCI removed smear layer as efficiently
as 50% citric but was found to retain the peritubular
architecture of dentin.

61. TAP WATER:
Ø Flushing agent for superficial
loose debris
Ø Studies performed in 1955
by Lorixzy et al showed
periapical bone regeneration
after mechanical
instrumentation using tap
water as an irrigating
solution.
HOT WATER:
Ø 140-178°F discharged
from an insulated
syringe was the first
irrigant used

62. RECENT ADVANCES

63. • A new irrigant solution produced from the tap
water and low concentration salt solution.
• Electrochemical treatment results in synthesis
of two type of solutions, i.e. anolyte (produced
in anode chamber) and catholyte (produced in
cathode chamber)
• Anolyte solution is known as super oxidized
water or oxidative potential water but now a
days neutral and alkaline solutions has been
recommended for clinical application
• Advantages:
Ø Non-toxic to biological tissues
Ø Effective with wide range of microbial spectra
Electrochemically activated water

64. OZONATED WATER
• shown to be powerful antimicrobial
agent against bacteria, fungi, protozoa
and viruses
• Ozone is an unstable gas, capable of
oxidizing any biological entity
• At a low concentration of 0.1 ppm,
sufficient to inactivate the bacterial
cells and even their spores
• Advantages-
Ø Its potency
Ø Ease of handling
Ø Lack of mutagenicity
Ø Rapid microbial effects
Newer root canal irrigants – a review ; Sushma Jaju (IJD
2011)

65. RUDDLE’S SOLUTION
Ø experimental irrigating solution,
introduced in an attempt to
visualize the microanatomy of
the root canal system
Ø Composition:
§ 70% EDTA
§ 5%percent NaOCl
§ Hypaque which is an aqueous
solution of iodide salts viz;
Ditrizoate and sodium iodine

66. MOA
Ø Sodium hypochlorite- solvent action
Ø EDTA- improved penetration
Ø Hypaque- radiopacity
Ø The solvent action of sodium hypochlorite
clears the contents of root canal system and
thus enables hypaque component to flow
into every nook and corner of the canal
system such as fracture, missed canals and
defective restoration.

67. PHOTOACTIVATEDDISINFECTION Ø PAD is a breakthrough in the fight
against pathogenic bacteria.
Ø It is a fast, effective and minimally invasive
disinfection system which is considered
to kill more than 99.99 percent of
bacteria in the endodontic biofilm.
PAD solution is activated by 635nm
light and acts as a photosensitiser,
releasing reactive oxygen species
which disrupt the membrane of the
micro organism. Independently, the
laser and solution have no effect,
but in combination produce a
powerful anti-bacterial action.
MOA
Advantages:
• Effectively kills gram-
negative, gram-positive,
aerobic and anaerobic
bacterias
• Overcomes the problems of
antibiotic resistance
• No thermal risk
• Non toxic to patients

68. MTAD-MixtureofaTetracyclineIsomer,
anAcidandaDetergent
Ø Introduced in 2000 by Torabinejad
et al as a final rinse
Ø MTAD is able to safely remove the
smear layer and is effective against
E. faecalis
Purpose
• Dentin disinfection
• Remove the smear layer
• Open the dentinal
tubules and allow the
antimicrobial agents to
penetrate the entire RCS
Composition
Tetracycline: bacteriostatic
broad spectrum antibiotic, low
pH, acts as calcium chelator, has
property of substantivity &
promotes healing
Citric acid: Bactericidal,
removes smear layer
Detergent (Tween 80):
decreases surface tension
Cohen 11th Ed

69. ADVANTAGES
Ø Effective solution for removal of most of the smear layer
Ø Kills most significant bacterial stains, i.e. E faecalis which has been
shown resistance to many intracanal medicaments and irrigants
Ø Biocompatible
Ø Minimal effect on properties of teeth
Ø similar solubilizing effects on pulp and dentin to those of EDTA
Ø The high binding affinity of doxycycline present in MTAD for dentin
allows prolonged antibacterial effect (it’s the main difference
between MTAD and EDTA)
The effectiveness of MTAD to completely remove the smear layer is
enhanced when a low concentration of NaOCl (1.3%) is used as an irrigant
before placing 1 ml of MTAD in a canal for 5 minutes and rinsing it with an
additional 4 ml of MTAD as the final rinse

70. TETRACLEAN

71. Q-MIX
Ø Introduced in 2011
Ø Recommended to be used at the
end of instrumentation, after
NaOCl irrigation.
Ø According to the patent, QMix
contains
• a CHX analog
• Triclosan (N-cetyl-N,N,N-
trimethylammonium bromide)
• EDTA as a decalcifying agent
Ø Intended as an antimicrobial irrigant
as well as an agent to remove
smear layer and debris.
Dai and colleagues examined the
ability of two pH versions of QMiX
to remove canal wall smear layers
and debris.
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
Cohen 11th Ed

72. • A 3.8% SDF (Ag[NH3]2F)
solution was developed for
use as an irrigant
• This solution is the 1:10
diluted form of the original
38% solution of Ag[NH3]2F,
which was developed for the
treatment of root canal
infections
SilverDiamineFluoride

73. • Triclosan is a Gram-positive and Gram-negative bactericide, as well as
a broad spectrum agent effective against fungi and viruses
• Nudera et al. investigated the minimum inhibitory and bacterial
concentrations of triclosan with Gantrez against Prevotella
intermedia, Fusobacterium nucleatum,Actinomyces naeslundii,
gingivalis, and E. faecalis.
• The addition of Gantrez to triclosan increased bactericidal activity
against the five major endodontic pathogens
Triclosan and Gantrez

74. • Nanoparticles of magnesium oxide, calcium oxide or zinc oxide
are microscopic particles that have antibacterial properties
• Nanoparticles synthesized from powders of silver, copper oxide
and zinc oxide are currently used and may generate active oxygen
species.
• They are responsible for the anti-bacterial effect by the
electrostatic interaction between positively charged nanoparticles
and negatively charged bacterial cells
• In addition, nanoparticles may change the chemical and physical
properties of dentin and reduce the bacterial strength of adhesion
to the dentin
NANOPARTICLES

75. Ø TRIPHALA:
Ø Plant blend created by drying &
pulverizing the fruit of three
plants (termina bellerica, termina
chebula, and emblica officinalis)
used for medicinal purposes
Ø Triphala kills 100% of E. faecalis
within 6 mins
Ø Triphala contains fruit rich in CA,
which helps in smear layer
removal
HERBAL ALTERNATIVES

76. Ø GTP are derived from fresh leaves of
tea (Camellia sinensis), an important
component of traditional Japanese
and Chinese culture
Ø Have shown significant antibacterial
activity in E. faecalis biofilms grown on
dental culture, killing E. faecalis
completely within 6 minutes
GreenTea Polyphenols
(GTP)
Prabhakar J, et al. Evaluation of
antimicrobial efficacy of herbal
alternatives (Triphala and Green Tea
Polyphenols), MTAD, and 5% sodium
hypochlorite against enterococcus
faecalis biofilm formed on tooth
substrate: An in vitro study. J Endod
2010;36:83-6.

77. Ø MC (noni fruit) has a wide range of
therapeutic effects, such as antibacterial,
antiviral, antifungal, antitumor,
antihelminthic, analgesic, hypotensive,
anti- inflammatory, and immune-
developmental effects
Ø It contains L-asperuloside and alizarin,
which have antibacterial properties
Ø it is a more biocompatible antioxidant
& has no harmful effect on the patient
or the environment, which is relevant in
the context of NaOCl accidents
MORINDA CITRIFOLIA
(Indian Mulberry)
Murray et al. compared the
abilities of 6% MC and 6%
NaOCl irrigation solutions to
remove the smear layer.As a
final irrigating agent, 17% EDTA
was used after both solutions.
The two solutions were found
to have equivalent smear layer
removal capabilities

78. PROPOLIS
Jolly M. et al conducted a study
(Comparative evaluation of anti
microbial potential; 2013)
To evaluate the anti microbial & anti
inflammatory potential of Propolis
against mixed endodontists, aerobic
and anaerobic bacteria
ü Eradicates E. Faecalis &
C.Albicans

79. LATEST

80. IRRIGANT AGITATION
TECHNIQUES & DEVICES

81. AGITATION
TECHNIQUES
Gu et al (JOE —
Volume 35, Number 6,
June 2009)

82. • Stropko irrigator:
• In this system
combination of
delivery and recovery
of irrigant is present in
one probe.
• Here the needle
delivers the solution
and an aspirator held in
same sheath retrieves
the irrigant.
Needle with notched
tip- prevents the flow in
peri apical area
Needle with bevel; if it
gets wedged in canals-
extrusion of debis
Monojet needles:
considered
efficient- inserted
to the full length
Can cause damage,
if placed in the peri
apical area
• Prorinse/ Max I probe
• Effective in all gauges but
27gauge notch tip needle
is highly effective as it
cleans the periapical area
without placing near the
apical foramen.
• It has a blunt tip, with
lumen 2 mm away from
the tip
• Fluid from the lumen
creates turbulence in all
directions.

83. • Bristles are attached to braided wires or
flexible plastic cores
• These micro brushes can be used as rotary or
ultrasonic endo brushes
• Tapers like non standardized GP cones
• Used in conjunction with sodium hypochlorite
and EDTA to produce clean canals.
Micro brushes • Used in 2-3 mm push-pull motion for 1 min
• Adv: Bristles of the brush extended to the
noninstrumented areas of the canal like the fins,
cul-de-sacs, and isthmi; better cleaning
• Dis adv: Endo- brush could not be used to full
working length because of its size, which might
lead to packing of debris into the apical section
of the canal after brushing
Gu et al (JOE — Volume
35, Number 6, June 2009)

84. • Effect of apical vapor lock
• Gently moving a well-fitting GP cone up and down in short 2- to
3-mm strokes
• Frequency of 3.3 Hz, 100 strokes per 30 sec
• Effective hydrodynamic effect and significantly improves the
displacement and exchange of any given reagent
• McGill et al and Huang et al demonstrated that manual-dynamic
irrigation was significantly more effective than an automated-
dynamic irrigation system (RinsEndo)
MANUAL DYNAMIC
AGITATION

85. • This system uses a particular instrument with abrasive
surface ( low cutting efficiency) that enlarges the canal by
friction and in a vibrating motion allows the irrigant to flow
through the file itself
• This system has shown excellent results in terms of
anatomy preservation and cleaning ability. It can reach
anatomical areas of difficult access as isthmuses, oval canals
or C-shaped canals
CONTINUOUSIRRIGATION
SYSYTEMS

86. SELF ADJUSTING
FILE (SAF)

87. Ø Manufactured by Redent- Nova
Ø The file is really a cylinderical,
hollow device designed as a thin
walled Ni-Ti lattice with a light
abrasive surface
Ø Initial glide path is established
with 20 K file to allow the
insertion of SAF files
Ø The file is compressed from its
1.5 mm diameter into dimensions
equivalent to those of #25 K-file
Ø Operated with a handpiece that
generates in and out vibrations
(4000/min) and 0.4 mm amplitude
Ø The file is hollow which
allows for continuos
irrigation through the file
while its operation.
Ø In vitro studies show that
these files make more wall
contact as compared to the
other rotary files, resulting
is better debridement and
antimicrobial efficacy.
Ø Shaping quality is also on
par with the rotary
instruments

89. Cavitation and acoustic streaming

90. SONIC
Rispisonic files
Vibringe
Combines battery-driven vibrations
(9000 cpm) with manually operated
irrigation of the root canal
Ø Most aggressive file
Ø Barbed files, might cause damage
to the canal preparation
Ø Made up of stainless steel
Ø Autoclavable
Ø Available in lengths of 19 & 22 mm
• Operate at 1500-6500 cycles /min.
• Prepare the canal by push & pull
and circumferential strokes.
• Uses water as an irrigant
• Rispi file (coronal 2/3rd of canal)
• Heli-sonic file, Shapers

91. ENDOACTIVATOR
Operates at 10,000 cycles per minute
• Polymer tips: strong and flexible
and do not break easily.
• Smooth - they do not cut dentin
Disadvantage - Tips used are
radiolucent, it would be difficult to
identify them if part of a tip separates
inside a canal

92. ULTRASONICAGITATION
Ø Frequency of 25–30 kHz, which
are beyond the limit of human
auditory perception (>20 kHz)
Ø They operate in a transverse
vibration, setting up a
characteristic pattern of nodes
and antinodes along their length
• Two types:
• The first type is combination of
simultaneous ultrasonic
instrumentation and irrigation
(UI)
• The second type, often referred
to as passive ultrasonic irrigation
(PUI), operates without
simultaneous instrumentation

93. • The term PUI was first used byWeller
et al to describe an irrigation scenario
where there was no instrumentation,
planing, or contact of the canal walls with
an endodontic file or instrument
• With this noncutting technology, the
potential to create aberrant shapes
within the root canal was reduced
• During PUI, the energy is transmitted
from an oscillating file or a smooth wire
to the irrigant in the root canal by means
of ultrasonic waves.
• The latter induces acoustic streaming and
cavitation of the irrigant
Ø During PUI two
flushing methods:
Ø continuous flush of
irrigant from the
ultrasonic handpiece
Ø intermittent flush
INTERMITTENT FLUSH
Ø The irrigant is delivered to the
root canal by a syringe needle
Ø It is then activated with the use
of an ultrasonically oscillating
instrument.The root canal is then
flushed with fresh irrigant to
remove the dislodged or
dissolved remnants from the
canal walls.

94. CONTINUOUS FLUSH
Ø Chlorine (dissolution of organic tissues) and NaOCl (antibacterial property) is
unstable and is consumed rapidly during the first phase of tissue dissolution
(within 2 minutes)
Ø Hence, an improved delivery system that is capable of continuous replenishment
of root canal irrigants is highly desirable
Ø Recently, a needle-holding adapter to an ultrasonic handpiece has been
developed by Nusstein
Ø It uses a 25-gauge irrigation needle which enables ultrasonic activation to be
performed at the maximum power without causing needle breakage
Ø The unique feature of this needle-holding adapter is that the needle is
simultaneously activated by the ultrasonic handpiece, while an irrigant
is delivered from an intra-venous tubing connected via a Luer-lock to
an irrigation-delivering syringe.
Advantages:
Greater reduction in bacterial load, Less time required

95. ENDOVAC SYSTEM

100. RINSENDOSYSYTEM Ø RinsEndo irrigates the canal
by using pressure suction
technology
Ø Components:
§ Handpiece
§ Disposable Cannula
§ Syringe carrying irrigant
Ø The handpiece is powered by
dental air compressor and
has an irrigation speed of 6.2
ml/min ( 1.6 Hz amplitude)
Ø Periapical extrusion of
irrigant has been reported
with this device

101. GENTLEWAVESYSTEM

102. • It’s a modification of LGS (Laser Guided
Shock wave ) concept which uses more
rigid, short conical tips, as opposed to the
flexible tips with long conical ends
• Developed by Dr. Enrico DiVito
• A novel, non ablative, 9 mm long, quartz
tapered tips of 600 micro meters diameter
with a polyamide sheath stripped 3 mm
from its end is used with an Er: YAG laser
to deliver shock waves throughout the
RCS
PIPS ( Photon-induced
photoacoustic streaming)

103. Uses low energy levels (<20 mJ) and short
micro second pulse rates (50 micro seconds) at
a wavelength of 2940 nm to create power spikes
that generate a profound shock wave which
travels three dimensionally throughput the RCS
The use of low level energy generates a minimal
thermal effect
Each impulse absorbed by the water molecules,
creates a strong “shock waves” that leads to the
formation of an effective streaming of fluids
inside the canals.

104. • The profound and distant effect of PIPS eliminates the need to
introduce the tips into the RCS unlike traditional laser.
• The tips in PIPS is placed only in the coronal portion, however
traditional laser techniques requires placement of the tips 1mm
from the apex, or even 5 mm from the apex.

106. SUMMARY
IRRIGATION
PROTOCOLS
Philippe Sleiman, DDS, DESE, Fadl
Khaled, DDS, DESE Oral Health, May
2005

108. ØEndodontics by Ingle & Balkland , 7th edn
ØEndodontics by Ingle & Balkland, 6th edn
ØCohen & Burns , 10th edn
ØCohen & Burns, 11th edn
ØHarty’s Practical Manual of Endodontics, Pitt Ford
ØGrossman & Oliet, 11th edn
ØJOE,Vol 31,No.3,March 2005.(151-165)
ØInternational Endodontic Journal,34, 237–243, 2001
ØBRITISH DENTAL JOURNALVOLUME 202 NO. 9 MAY
12 2007
REFERENCES