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Endodontic Irrigants

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a very beautifully compiled seminar on endodontic irrigants, do comment if any suggestions regarding anything more to be added, as it is a very huge topic and everyday expanding

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Endodontic Irrigants

  1. 1. “Today it’s our turn” GOOD MORNING
  2. 2. Endodontic Irrigants PRESENTED BY DR SNEHA RATNANI
  3. 3. The ideal requirements of irrigation solution 1. It should have broad spectrum of antimicrobial activity. 2. It must aid in debridement of the canal system. 3. It should have the ability to dissolve necrotic tissue. 4. It should have low toxicity level. 5. It should be a good lubricant. 6. It should have low surface tension so that it can easily flow into inaccessible areas. 7. It should be able to effectively sterilize the root canal. 8. It should be able to prevent formation of smear layer during instrumentation or remove the latter once it has formed. 9. It should inactivate microbial toxins. 10.It should not corrode instruments. 11. Dissolve inorganic tissue. 12.Penetrate to canal periphery. 13.Do not weaken tooth structure.
  4. 4. goals Tissue Dissolution Lavage Of Debris Lubrication Antibacterial Action
  5. 5. VARIABLES  Quantity and temperature  Time of contact  Type and gauge of irrigating needle  Surface tension  Age
  6. 6. Gulabivala k et al 2005 Endodontic topics Classification
  7. 7. COMMONLY USED IRRIGATING SOLUTIONS
  8. 8. TAP WATER One of the early irrigating solutions used for flushing of the root canals showed good clinical success. Studies performed in 1955 by Lorixzy et al showed periapical bone regeneration of after mechanical instrumentation using tap water as an irrigating solution. HOT WATER A stream of hot water, 140-178°F discharged from an insulated syringe was the first irrigant used.
  9. 9. Physiologic Saline: 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: • However saline solution does not remove the smear layer but merely flushes out some of the superficial debris from the root canal system. • Has poor antibacterial properties,
  10. 10. • It should not be used alone as root canal irrigant, it should be used as an adjunct to the chemical disinfectant where the chemical irrigant provides disinfection and the dissolution properties and saline helps in mechanical debridement. • It can also be used as a final flush of the root canal to remove any chemical irrigant left inside the root canal.
  11. 11. UREA • White, odorless, crystalline powder. • In 1951, Blechman and Cohen suggested 30% urea solution can be used as an irrigant. • Mild solvent for necrotic tissue, pus and an antiseptic too. Mechanism of action • Denaturation of proteins by destroying bonds of secondary structure resulting in loss of functional activity of proteins. • Chemically debrides the wound by softening underlying substrate of fibrin.
  12. 12. Urea peroxide • White crystalline powder with slight odor, soluble in water, alcohol and glycerine. • Dissociates into urea and hydrogen peroxide • 10% urea peroxide solution with anhydrous glycerol available as glyoxide • Glycerol increases stability of urea peroxide solution, increases its shelf life, acts as a good lubricant facilitates negotiation of fine tortuous canals. Disadvantages • It dissociates very slowly. • Its effervescence effect is prolonged but not pronounced. • This can be overcome by alternating irrigation with hypochlorite.
  13. 13. Sodium Hypochlorite The use of sodium hypochlorite for treating wounds was introduced during World War I by a physician named Dakin The solution used is called Dakin’s solution and is used for lavaging large flesh wounds. • Sodium hypochlorite is a reducing agent. • It is a clear, straw coloured solution containing about 5% of available chlorine. • The solution should be kept in a cool place away from sunlight. • Popular household bleaching agents such as Clorox or purex are usually 5.2% solution of sodium hypochlorite and are satisfactory.
  14. 14. • Solution ranging in strength from 0.5 to 5.25% have been recommended for use in endodontics. • NaOCl should be used clinically in concentration of 2.6 – 5.25% to take advantage of its ability to dissolve pulp tissue from all aspects of the root canal system. • Increasing concentration will increase the rate at which organic material is dissolved and may improve its effectiveness as an antibacterial agent. • 50% dilution of commercial preparation (clorox) with distilled water gives a solution of 2.6% NaOCl.
  15. 15. • Sodium hypochlorite (Naocl) has a broad-spectrum antimicrobial activity. It can rapidly kill vegetative bacteria, spore-forming bacteria, fungi, protozoa, and viruses (including HIV, rotavirus, HSV-l and -2, and hepatitis A and B. • Heating the solution elevating the temperature causes an increase in the tissue solvent action of the NaOCl. Too high a temperature can cause breakdown of the solution. • Clinically a 60o C warm water bath is prepared by placing a beaker of water on a hot plate. Preloaded syringes of NaOCl maybe warmed by placing them into this warm water bath.
  16. 16. Endo Irrigator • The Endo Irrigator II has 3 reservoirs for irrigating solutions NaOCl 5.25 %, EDTA 17% and alcohol 95%. The gun on the right has four buttons. Three to activate the solutions and one is for suction. The gun on the right is a Stropko irrigator and is an option. The device has a built in heater that also heats the lines so the irrigating solutions come out warm. There are two settings that allow for "push-intermittent" and push-on, push-off" dispensing of the solutions.
  17. 17. • Solutions of NaOCl should be prepared fresh daily to obtain optimal clinical results. • Stable shelf life of 5.25% NaOCl – 10 weeks. • Whereas 2.6 and 1.0% NaOCl - 1 week after mixing with water. • Disinfection by means of NaOCl is initially slow, but increases progressively. • In fact one of the most advantages of pretreatment is to build teeth up so they have pulp chambers that can retain irrigants. • The potential for an irrigant is maximized when it is heated, flooded into shaped canals and given ample time to work.
  18. 18. • Mechanism of Action of Sodium Hypochlorite • Antibacterial: • - Direct contact with microorganisms. • - Vapor action. • Destruction of the bacteria takes place in two phases: • 1. Penetration into the bacterial cell. • 2. Chemical combination with the protoplasm of the bacterial cell that destroys it.
  19. 19. • Mechanism of Action of Sodium Hypochlorite
  20. 20. Chemical combination Sodium hypochlorite acts as an organic and fat solvent degrading fatty acids, transforming them into fatty acid salts (soap) and glycerol (alcohol), -> reduces the surface tension.
  21. 21. • Sodium hypochlorite neutralizes amino acids forming water and salt (neutralization reaction).
  22. 22. • With the exit of hydroxyl ions, there is reduction of pH. • Results in formation of Hypochlorous acid, when in contact with organic tissue acts as a solvent. • It also releases chlorine that, combined with the protein amino group, forms chloramines. • Hypochlorous acid and hypochlorite ions (OCl - ) lead to amino acid degradation and hydrolysis.
  23. 23. • The chloramination reaction between chlorine and the amino group (NH) forms chloramines that interfere in cell metabolism. • Chlorine (strong oxidant) presents antimicrobial action inhibiting bacterial enzymes leading to an irreversible oxidation of SH groups (sulphydryl group) of essential bacterial enzymes. • Sodium hypochlorite is a strong base (pH>11). At 1% concentration, sodium hypochlorite presents :- ) • A surface tension equal to 75 dynes/cm, 65.5 ms of conductivity, 1.04 g/cm 3 of density and moistening capacity equal to 1 h and 27 min.
  24. 24. • 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 of sodium hypochlorite interferes in the cytoplasmic membrane integrity with an:- • Irreversible enzymatic inhibition, • Biosynthetic alterations in cellular metabolism and • Phospholipid degradation observed in lipidic peroxidation.
  25. 25. L I N E O F C O N T R O L INTRA CANAL irrigants BACTERIA
  26. 26. • The amino acid chloramination reaction (reaction3) forming chloramines interferes with cellular metabolism. • Oxidation promotes irreversible bacterial enzymatic inhibition replacing hydrogen with chlorine. • This enzyme inactivation can be observed in the reaction of chlorine with amino groups and an irreversible oxidation of sulphydryl groups of bacterial enzymes (cystein). • Thus, sodium hypochlorite presents antimicrobial activity with action on bacterial essential enzymatic sites promoting irreversible inactivation originated by hydroxyl ions and chloramination action.
  27. 27. TISSUE SOLVENT PROPERTY • NaOCl possesses strong tissue dissolution property . • This equals to that of H2SO4 and HCl. • The solvent action of NaOCl has been attributed to its high alkalinity. • Grossman and Meiman reported that 5% sodium hypochlorite dissolves pulp tissue in 20 min to 2 h.
  28. 28. • 5.25% of NaOCl is capable of penetrating into the dentinal tubules & dissolving the contents of tubules adjacent to the main canal. • This is an extremely important property for an endodontic irrigant because of the irregularities in the surface of the canal walls which prevents contact by instruments. Other Properties of NaOCl • 1. Lubricant – for effective instrumentation. • 2. Bleaching action on discolored teeth. • 3. Increased permeability of dentinal tubules for easier penetration of an intra- canal medicaments.
  29. 29. • Baumgartner and Cuenin, in an in vitro study, found that 5.25%, 2.5%, and 1.0% solutions of sodium hypochlorite completely removed pulpal remnants and predentin from uninstrumented surfaces of single-canal premolars. • Although 0.5% sodium hypochlorite removed most of the pulpal remnants and predentin from uninstrumented surfaces, it left some fibrils on the surface.
  30. 30. • The ability of an irrigant to be distributed to the apical portion of a canal is dependent on canal anatomy, size of instrumentation, and delivery system. • Trepagnier et al. reported that either 5.25% or 2.5% sodium hypochlorite has the same effect when used in the root canal space for a period of 5 minutes.
  31. 31. • Spångberg et al. noted that 5% sodium hypochlorite may be too toxic for routine use. They found that 0.5% sodium hypochlorite solution dissolves necrotic but not vital tissue and has considerably less toxicity for HeLa cells than a 5% solution. • They suggested that 0.5% sodium hypochlorite be used in endodontic therapy.
  32. 32. • Bystrom and Sundquist examined the bacteriologic effect of 0.5% sodium hypochlorite solution in endodontic therapy. In that in vivo study, using 0.5% sodium hypochlorite, no bacteria could be recovered from 12 of 15 root canals at the fifth appointment. • This was compared with 8 of 15 root canals when saline solution was used as the irrigant.
  33. 33. • Baumgartner and Cuenin also commented that “The effectiveness of low concentrations of NaOCl may be improved by using larger volumes of irrigant or by the presence of replenished irrigant in the canals for longer periods of time.” • On the other hand, a higher concentration of sodium hypochlorite might be equally effective in shorter periods of time.
  34. 34. Disadvantage : • Unpleasant taste • Relative toxicity • Inability to to move smear layer • Corrosion of instruments • Damages clothes
  35. 35. Toxicity • On contact with Vital tissue: – Heamolysis – Ulceration – Inhibits neutrophil migration – Damages Endothelial and Fibroblast cells • Pashley et al (1985) and chang et al (2001) – 0.5-1% NaOCl
  36. 36. Causes of complications • Increased pressure application • Wedging of the syringe • Periapical bone destruction • Lateral perforation • Incorrect Working Length determination
  37. 37. Possible Complications • Inadvertant injection in to periapical tissue • In to Maxillary sinus • Hypersensitivity or allergic reactions • Mixing of syringes (LA) • Swallowing : pharyngeal oedema or oesophagal burns • Paediatric : damage to Permanent tooth follicles
  38. 38. Immediately following endodontic procedure One month later Neurological complications Infra orbital Nerve parasthesia
  39. 39. Accidental injection of NaOCl
  40. 40. Cannot be considered non-toxic!!!
  41. 41. • There have been numerous reports of soft tissue complications as a result of its inadvertent infection beyond the root canal system. • Severe pain, Edema, Profuse hemorrhage both interstitially and through the tooth. This may be followed by (for several days) • 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.
  42. 42. Treatment for this type of emergency: • 1. Remain calm and assist the patient in remaining calm. • 2. Evaluate the reclined dental chair to decrease pressure from the head. • a. For immediate relief of pain – nerve block and L.A. • b. Wet, cold, compress – continually applied to the face – for relief of pain and burning sensation and minimize swelling (for upto 6 hours). Analgesics – after emergency treatment. To control inflammation – corticosteroids immediately- i.v. for 3 days. To prevent infection – antibiotics (1wk).
  43. 43. 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.
  44. 44. Chlorhexidine Digluconate • is a cationic bis-biguanide that is usually marketed as a gluconate salt. • pH of 5.5-7. • The most common preparation is with the digluconate salt because of its stability and high water solubility. wide spectrum antibacterial agent, and is active against Gram-positive and Gram-negative bacteria, facultative anaerobic and aerobic bacteria, spores, viruses and yeast. • Being a cationic agent, chlorhexidine electrostatically binds to negatively-charged surfaces of bacteria, damaging the outer layers of the bacterial cell wall and rendering it permeable. • The resulting penetration of chlorhexidine into the cell causes precipitation of the cytoplasm, preventing repair of the cell membrane and leading to the destruction of the bacterial cell.
  45. 45. Hydrogen Peroxide H2O2  It is a clear, colorless,odorless liquid.  H2O2 is active against viruses, bacteria, and yeasts.  It has been particularly popular in cleaning the pulp chamber from blood and tissue remnants, but it has also been used in canal irrigation.  Suggested for irrigating canals of teeth that have been left open for drainage, since the effervescence is effective in dislodging food particles as well as other debris that may have packed the canal. Being less effective as a solvent, H202 is also less damaging to periapical tissues. Therefore, when procedural accidents have caused either root or floor of chamber perforation or when the apical constriction has been destroyed, it is the preferred irrigant.
  46. 46. Hydrogen Peroxide H2O2 • 1. Effervescence of the solution when in contact with tissue and certain chemicals physically foams debris from the canal. • 2. Liberation of oxygen destroys strictly anaerobic microorganisms.
  47. 47. Mechanism of action  It is highly unstable and easily decomposed by heat and light.  it rapidly dissociate into H2O+O (water+nascent oxygen) . the liberated O has bactericidal effect but this effect is transient and diminishes in presence of organic debris .  The rapid release of O nascent oxygen on contact with organic tissue results in effervescence (bubbling) action which aid in mechanical debridement by dislodging dentin debris and necrotic tissue particles and floating them to the surface.
  48. 48. Advantages of using alternating 3% H2O2 with Naocl solution are : 1.Effervescent reaction (bubbles pushes debris mechanichally out of root canal) 2.Solvent action of sodium hypochrorite on organic debris. 3.Disinfection and bleaching effect by both solutions.
  49. 49. Limitation  Unable to remove smear layer.  Always use Naocl last because Hydrogen peroxide release of nascent oxygen on contact with organic tissue which may build up pressure on closing tooth and causes pain . • Soft tissue emphysema may occur when hydrogen peroxide irrigant enforced beyond the apical foramen.
  50. 50. Chelating agents
  51. 51. • Chelating agent is a chemical which combines with a metal to form a chelate. • The purpose of a chelator is Lubrication Emulsification and Holding debris in suspension smear layer removal Chelators are formulated as viscous suspension or an aqueous suspension.
  52. 52. A viscous suspension of a chelator advantageously • promotes the emulsification of organic tissue • facilitates the negotiation of the canal and • is best used for holding debris in liquid suspension. An aqueous solution of chelator • best reserved for finishing the preparation, • it removes the smear layer in an organic or inorganic film or both formed on the walls of the canal by the cutting action of instruments.
  53. 53. Ethylenediamine Tetra Acetic Acid (EDTA) • EDTA is a non specific divalent cation chelator, chelating with calcium ions as well as with magnesium ions. • Nygard Ostby was the first who suggested the use of EDTA for cleaning and widening canals. Advantages • Facilitate canal identification, • to clean and disinfect the dentinal wall • to enhance chemomechanical enlargement of the canals. • EDTA results in increased dentin permeability which augments the action of drugs. • It can decalcify up to a 50-mm thin layer of the root canal.
  54. 54. EDTA • If functions by forming a calcium chelate solution with the calcium ion of dentin, the dentin thereby becomes more friable and easier to instrument. • EDTA is used during cleaning and shaping of the root canal and is effective for achieving canal patency, enlargement, debridement and disinfection. • EDTA contains four acetic acid groups attached to ethylenediamine. C2H3O2 C2H3O2 N-CH2 –CH2-N C2H3O2 C2H3O2 • The formula is as follows : Disodium salt of EDTA : 17.0 g Distilled water : 100.0ml 5N Sodium hydroxide : 9.25 ml
  55. 55. Effects of EDTA : • EDTA is effective in softening dentin • EDTA has distinct antimicrobial properties. • EDTA is capable of causing a moderate degree of irritation. • EDTA has no deleterious effect when used clinically as an irrigating solution. • Irrigation with EDTA removes the smear layer. • The extent of demineralization of EDTA is proportional to the exposure time. • EDTA effects partial demineralization of dentin to a depth of 20 to 30 m in 5 minutes. • The most common chelating solution used for irrigation include Tublicid, EDTA, EDTAC, File Eze and RC-Prep in all of which EDTA is the active ingredient.
  56. 56. CHX and EDTA • Mixing CHX and EDTA immediately produces a white precipitate * it seems that the ability of EDTA to remove the smear layer is reduced.
  57. 57. RC Prep • RC prep is a viscous chelator. introduced by Stewart et al in 1969. • Its principle ingredients are 15% EDTA, 10% Urea Peroxide and Propylene Glycol in a base of Carbo Wax. • 10% urea peroxide produces hydroxyl radicals that oxidize sulfhydryl groups, double bonds in proteins, lipids, and outer membranes, and cause cell death. • According to Stewart et al, urea peroxide retains its antibacterial activity in the presence of blood whereas aqueous 3% hydrogen peroxide does not.
  58. 58. • Glycol is the lubricant that coats instruments and facilitates their movements in canals, coating calcific material or in restricted canals that exhibits various degree of calcification. • It also protects the EDTA from oxidation by urea peroxide • It is not water soluble. • Irrigation with NaOCl following the use of RC prep removes smear layer and produces significant effervescence, creating an elevator action to evacuate debris that was dislodged from the root canal system. • Since it is foamy, RC prep is placed on flutes of a file and carried directly to walls of canal being prepared.
  59. 59. EDTAC • Fehr and Nygaard-Ostby introduced EDTAC (N-O Therapeutics Hd, Sweden), quaternary ammonium bromide, used to reduce surface tension and increase penetration. • The addition of Cetavlon (0.84 gm), a quaternary ammonium compound to EDTA produce a solution called EDTAC, which has greater germicidal activity. • It has greater inflammatory potential to tissue as well. • The inactivator for EDTAC is NaOCl.
  60. 60. EDTAT • EDTA + texapon • Edta is combined with sodium lauryl sulphate which results in decreasing surface tension. REDTA EDTA is combined with cetrimide ,cetyltrimethyl 1 ammonium bromide.it helps in better cleaning of canals.
  61. 61. Hydroxyethylidene bisphosphonate (HEBP) • Also called etidronic acid. • Has chelating properties. • The advantageous property of HEBP as chelating agent is that it shows only short term interference with sodium hypochlorite.
  62. 62. Salvizol • It contains a quaternary ammonium salt. • It is a root canal chelating irrigant, N1- decamethylene-bis-4–aminoquinoldinium diacetate. • Has a broad spectrum of bactericidal activity and the ability to chelate calcium, biologically compatible. • Its low-surface tension and chelating effect aids in biomechanical cleansing. • Salvizol induces irritation of tissue at levels similar to those of iodophores but less than those of sodium hypochlorite or quaternary ammonium compounds (Zephiran).
  63. 63. Recent advances
  64. 64. Bis-Dequalinium Acetate (BDA) / Solvidont • It is used as a disinfectant and chemotherapeutic agent. • It has – Low toxicity – Lubrication action – Disinfecting ability – Low surface tension – Chelating properties – Low incidence of post operative pain. • It was marketed as Solvidont. • BDA is recommended as an excellent substitute for NaOCl in those patients who are allergic to NaOCl. • The University of Malaysia reported a remarkable decrease in postoperative pain and swelling when BDA was used.
  65. 65. MTAD : • A new solution for the removal of the smear layer. • Mixture of Tetracycline isomer (Doxycycline) + Acid (citric acid) + Detergent (Tween 80). • MTAD is an effective solution for the removal of the smear layer and does not change the structure of dentinal tubules when canals are irrigated with NaOCl and followed with a final rinse of MTAD.
  66. 66. • Tetracycline including Tetracycline HCl, Minocycline and Doxycycline are Broad Spectrum Antibiotics that are effective against a wide range of microorganisms. • Mechanism of action : Tetracycline has the following properties : • It is bacteriostatic in nature. This property may be advantageous because in the absence of bacterial cell lysis, antigenic byproducts (i.e. Endotoxins) are not released. • Low pH : Thus it can act as a calcium chelator and cause enamel and root surface demineralization. • Substantive medication : Becomes absorbed and is gradually released from tooth structures such as dentin and cementum have prolonged effect. • It significantly enhances healing after surgical periodontal therapy.
  67. 67. • Acid : Citric acid were effective in removal of smear layer when used for 1 to 5 minutes. • Detergent : The role of the detergent in this mixture is to lower the surface tension and increase the generating ability of the irrigating solution. • Experimentation with various concentrations of these material showed that a mixture of Doxycycline, Citric acid and Tween-80 was capable of removing the smear layer from the surface of instrumented root canals better than a combination of Doxycycline and citric acid alone.
  68. 68. • When EDTA is alternately used with 5.25% NaOCl, the smear layer is completely removed in the middle and coronal thirds of canal preparations, but this combination is less effective in the apical third. • This is probably because of inadequate volume and/or penetration of the solution into the apical portion of the canal during irrigation. • The placement of MTAD with a cotton wrapped barbed broach allows intimate contact of the solution even in the apical region of the canals and improves debridement and less abrasive. • MTAD also is less destructive to the tooth structure compared with EDTA when used as a final irrigant. Close examination of the appearance of the dentinal tubules showed higher amounts of erosion with EDTA.
  69. 69. Ruddle’s Solution : • It contains 5% NaOCl Hypaque 17% EDTA • Hypaque is a high contrast and injectable dye • Used in medicine for - Angiography Arteriography Urography & Nephrotomography • Hypaque is an aqueous solution of 2 iodine salts, diatrizoate meglumine and sodium iodine. • This is a radiopaque contrast solution to radiographically visualize root canal system preparation procedure.
  70. 70. • The solution has the same specific gravity as NaOCl, is water soluble, has a pH of 6.7 to 7.7, and is stable at room temperature. • This composition simultaneously provides the solvent action of full strength NaOCl, visualization (because its radiodensity is similar to gutta percha), and improved penetration (because the tensioactive agent lowers surface tension). • Clinician can use endogram to visualize the microanatomy, verify the shape and monitor the remaining root wall thickness during preparation procedure.
  71. 71. • Clinically, the solution is flushed into the root canal system of a tooth once sufficient access to the pulp chamber has been made. • The sodium hypochlorite portion of the composition will dissolve the pulp and eliminate the bacteria, along with endotoxins that are harbored within the root canal system. • The solvent action of this solution progressively clears out the contents of the root canal system, thus enabling the iodine portion of the composition to flow into this vacated space.
  72. 72. • Endograms are useful in visualizing pathologic events, such as caries, certain fractures, missed canals, and leaking restorations. • Additionally, endograms can assist the clinician in managing internal resorption, because the solution will map its location, size, and extent. In endodontic nonsurgical retreatment, the endogram has shown promise for improving diagnostics, treatment planning, and management of iatrogenic mishaps. • This method of visualization assists dentists in determining the best course of action and in deciding whether to salvage or extract a particular tooth.
  73. 73. Superoxidized water • Super oxidized water is saline that has been electrolyzed to form super- oxidized water (hypocholorus acid and free chorine radicals) • Supplied as Sterilox (sterilox Technologies,Radnor,PA) . • This solution is nontoxic to biological tissues yet able to kill microorganisms. • It was shown that it has potential irrigating solution.
  74. 74. ECA • ECA was produced from tap water and saline solution by a special unit that houses a unique floe through electrolytic module . • The fluid electrolytic module contains anode , made from titanium coated with ruethenium-oxide ,iridium and platinum and the cathode made from titanium coated with pyro carbon and glass carbon. • A diaphragm consist ultra filtration , electro catalytic ceramics on the bed of zirconium, yttrium, aluminium and nobium oxides separates the anode and cathode.
  75. 75. • The solution exist in a metastable or equilibrious state after the production and contains many free radicals and variety of molecules and ions in the metastable state the solution has a very high oxidation potential . • Two types of ECA was produced. One is anolyte which has a high oxidation potential and catholyte is an alkaline solution with a high reduction potential • It has strong chelating effect and detergent effect. • These solutions remain in the metastable condition for about 48 hours before coming to stable state. • These solutions were active against Mycoba-cterium tuberculosi, M avium – intercellular, M chelonae, E coli. E feacalis. pseudomionas aeruginosa. Bacillus subtilis, Methicillin resistant staphylococcus aureus. candida albicans.
  76. 76. • Compared to NaOCl, the ECA solutions left a thinner smear layer with a smoother and more even surface. • NaOCl enhanced the opening of tubules predominantly in the coronal and middle thirds of canals, whereas combination of ANOLYTE and CATHOLYTE resulted in more numerous open dentine tubules throughout the whole length of canals.
  77. 77. Chlorhexidine Gluconate gel • Natrosol, a biocompatible carbon polymer, should be used as a gel base for chlorhexidine gluconate. • It is a water soluble substance and therefore can be completely removed from the root canal with a final flush of distilled water. • Studies have confirmed the antimicrobial activity of chlorhexidine and sodium hypochlorite demonstrated that the gel form may overcome the inability of chlorhexidine to dissolve organic tissues by its mechanical action. • So chlorhexidine gel has potential as a routine endodontic irrigant, (if Natrosol is used as a gel base) because it has proved to be of low toxicity and possess a wide antimicrobial spectrum.
  78. 78. Ozonated Water • Powerful antimicrobial agent against bacteria, fungi, protozoa, and viruses. • The advantages of ozone in the aqueous phase are its Potency, Ease of handling, Lack of mutagenicity, Rapid microbicidal effects, and suitability for use as a soaking solution for medical and dental instruments. Oxidation mediated by ozone destroys the cell walls and cytoplasmic membranes of bacteria and fungi. After the membrane is damaged by oxidation, its permeability increases and ozone molecules can readily enter the cells, causing the microorganism to die.
  79. 79. Endoquil (castor oil dete-rgent) • Natural product derived from a tropical plant, Ricinus communis. • Endoquil was developed in the Chemistry Institute of Sao Carlos (Sao Carlos, Brazil). • Ferreira et al using Endoquil and 0.5% NaOCl in vivo as irrigating solutions, observed a signi-ficant reduction in the number of colony forming units for anaerobic microorganisms S. mutans and streptococci, with no statistical difference betwe-en these two solutions.
  80. 80. Ultrasonics : • Richman in 1957 was the first to use ultrasonic scaler for apicoectomies. • He was followed by Martin who designed a commercial system harnessing the ultrasonic energy for the preparation and cleaning the root canal in 1976. This technique was termed endosonics. Endosonics : Martin and Cunningham have coined the term endosonics, to refer to endodontic treatment by supersonic, sonic or subsonic systems. There are principally two different types of devices. • The ultrasonic device which oscillates at a frequency of 20-30 KHz. Eg. Caviendo, Piezo Ultrasonic. • The sonic device which oscillates at a frequency of 1-6 KHz. Eg. Endosonic air.
  81. 81. Method for Action • Ultrasonic cleaning was described initially as Implosion or Cavitation. • Cavitation occurs when ultrasonic file vibrates in a liquid to produce alternating compression and rarefaction of pressure in the form of growth and subsequent violent collapse of bubbles in fluid. • A negative pressure develops within the exposed cells of the intracanal materials (pulp tissue, bacteria, debris, metabolites, substrates etc). • This causes an implosion or inward explosion that breaks these cells apart inwardly and leads to their destruction. • Since an irrigation / aspiration system is employed in the endodontic equipment for ultrasonics, the broken cell part are washed out and then removed from the canal system. The atomic bomb also works by the Implosion principle.
  82. 82. Ultrasonics
  83. 83. • In 1975 Ahmad and group described another mechanism for ultrasonic cleaning – Acoustical Streaming. • Ahmad stated that cavitation cannot occur in closed environment as in root canals for 2 reasons. • For cavitation to occur in root canal the file must vibrate at a displacement amplitude of atleast 135 micrometers and power setting in endosonic unit was too low to produce this amplitude. • Cavitation also depends on the free displacement amplitude of the file. • This would be impossible to achieve during instrumentation because when the file contacts the canal walls there will be reduction in amplitude.
  84. 84. Acoustic Streaming • Acoustic streaming is produced around an object oscillating in a liquid, that is it creates small, intense circular fluid movement (i.e. eddy; flow) around the instrument. • It is characterized by the production of large shear forces that are capable of dislodging or disassociating lumps of material. However the forces of acoustic streaming are not sufficient to break up the bacterial cell wall.
  85. 85. • The eddying occurs closer to the tip than in the coronal end of the file, with an apically directed flow at the tip. • Streaming forces occurring around the file disassociate clumps of bacteria without disrupting them. • The acoustic streaming generated by the file help reduce the number of bacteria in the canal by removing the smear layer and debris harboring bacteria, thereby facilitating their mechanical removal. • The main advantage of ultrasonic files is that they move irrigant around the canal and penetrate to the most apical extent of the instrument. • The general conclusion is that acoustic micro streaming does occur around the oscillating file. To be effective in this action, the file must be kept moving at all times so that free oscillation can be maintained. Instruments are generally moved circumferentially within the canal space.
  86. 86. Photo-activated disinfection • Two components – PAD solution: Tolonium Chloride – Save Dent Laser -635 nm • Mechanism of action: • Photosensitiser • Reactive Oxygen sp • Disrupts membrane
  87. 87. • It includes PDT/LAT i.e photo dynamic therapy or light activated therapy. Light of Photosensitizer Oxygen based free specific wavelength Activation radical formed (tolonium chloride) Multiple Target Membrane damage Genetic damage Enzyme inactivation • Optic fibre may be used to direct the irradiation to the intended side of application.
  88. 88. Advantages • Ease or use • Disinfection • Duration -1-2 min • Toxicity • Spectrum • Does not affect fibroblasts or Keratinocytes • Laser is safe
  89. 89. IRRIGATION DEVICES IN ENDODONTIC І- MANUAL 1.Syringe irrigation with needles/ cannulas (end/side vent) 2.Brushes A. Endobrush B.Navitip FX 3.Manual Dynamic Agitation (hand activated well fitting gutta percha) ІІ- MACHINE ASSISTED 1.Rotary brushes A.Ruddle brush B.Canal brush 2.Continuous irrigation during rotary instrumentatin (Quantec-E) 3.Sonic A.Rispisonic file B.Endoactivator 4.Ultrasonic 5. Pressure alternating devices A.EndoVac B.Rinse Endo 6. Recent advance system A. Lasers b. Light activated disinfection (LAD) C. Electrochemically activated water (ECA) D.Oxidative potential water (OPW)
  90. 90.  Different sizes (1-20 ml)  Luer-Lok design Modifications of tip of the needles A) Bivelled B) Monoject C) Safe ended (A) (B) (C ) І- MANUAL 1.Syringe irrigation with needles/ cannulas(end/side vent)
  91. 91. Monoject endodontic needles
  92. 92.  27-31 gauge recommended  should not bind in the canal  easily controlled Advantages not enough flushing action  deliver solution only 1 mm deeper than the tip of the needle Disadvantages
  93. 93. 2.Brushes B. NaviTip FX A. Endobrush  used only as an adjuncts  Nylon bristles set in twisted wire  Can’t be used till working length  Dislodgement of radiolucent bristles  recently introduced  30-gauge needle covered with brush І- MANUAL Disadvantages
  94. 94. 3.MANUAL DYNAMIC AGITATION  Effect of “apical vapor lock”  Technique: Gently moving a well-fitting gutta-percha master cone up and down in short 2- to 3-mm strokes within an instrumented canal  Principles: 1. changes in intracanal pressure 2. frequency of 3.3Hz, 100 strokes per 30 seconds 3. viscously dominated flow (mixing of fresh spent solution with the reacted irrigant) І- MANUAL
  95. 95. 1. ROTARY BRUSHES A.Ruddle brush B.Canal brush 2. Continuous Irrigation During Rotary Instrumentation (Quantec-E)  Self contained fluid delivery unit  uses a pump console, 2 irrigation reservoirs & tubing - no significant results in middle & apical in cleaning efficiency ІІ- MACHINE ASSISTED A.Ruddle brush B.Canal brush (Quantec-E) Disadvantages
  96. 96. 3.SONIC IRRIGATION A. Rispisonic file Vibringe  combines battery-driven vibrations (9000 Cycle per Minute) with manually operated irrigation of the root canal ІІ- MACHINE ASSISTED A.Rispisonic file B. Endoactivator  consists of a portable handpiece and 3 types of disposable polymer tips of different sizes 10,000 cycles per minute .
  97. 97. IT is the simultaneous combination of ultrasonic irrigation and instrumentation. it has been almost discarded in the clinical  Ultrasonically activated files have the potential to prepare and debride root canals mechanically.  Files are driven to oscillate at ultrasonic frequencies of 25–30 kHz in a transverse vibration Two types of ultrasonic irrigation : A. Active ultrasonic irrigation (AUI) B. Passive ultrasonic irrigation (PUI) ІІ- MACHINE ASSISTED A. Active ultrasonic irrigation (AUI) 4.Ultrasonic
  98. 98. PASSIVE ULTRASONIC IRRIGATION (PUI)  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. Irrigant Application Methods During PUI: a) Continuous Ultrasonic Irrigation  Nusstein’s needle holding devices  needle is simultaneously activated by the ultrasonic handpiece, while an irrigant is delivered from an intravenous tubing connected via a Luer-lok to an irrigation-delivering syringe. b) Intermittent Flush Ultrasonic Irrigation Acoustic streaming cavitation
  99. 99. 1-PUI is more effective than syringe needle irrigation in removing pulpal tissue remnants and dentin debris. 2-smear layers were effectively removed from the apical, middle, and cervical thirds of the canal walls by EDTA plus Cetavlon (EDTAC) and NaOCl by using a size 15 file energized by ultrasonic agitation.  High-power ultrasound causes de-agglomeration of bacterial biofilms via the action of acoustic streaming  Cavitation may produce temporary weakening of the cell membrane Removal of Bacteria: B.PASSIVE ULTRASONIC IRRIGATION (PUI) Removal of smear layer:
  100. 100. 5. PRESSURE ALTERNATION DEVICES A. The EndoVac System…. Multi-Port Adapter (MPA) ІІ- MACHINE ASSISTED (B) (C) (D) (A) (A) Macrocannula with handpiec (B) Microcannula with fingerpiece (C) Master delivery tip (D) Tip of microcannula
  101. 101. The EndoVac System…. APPLICATION OF MICROCANNULE IN THE CANAL : Negative pressure Positive pressure Advantages OF ENDOVAC SYSTEM 1.Safety:Less apical extrusion risk using the EndoVac system compared with needle irrigation 2.Efficacy:Better debridement 1 mm from working length using the EndoVac system compared with needle irrigation 3.SUCCESS:Negative apical pressure irrigation system EndoVac results in significantly less postoperative pain & necessity for analgesic medication than a conventional needle irrigation protocol
  102. 102. B. The RinsEndo System  65 mL of a rinsing solution oscillating at a frequency of 1.6 Hz is drawn from an attached syringe and transported to the root canal via an adapted cannula.  Suction phase (100 times per minute)  higher risk of apical extrusion of the irrigant ІІ- MACHINE ASSISTED Disadvantage 5. PRESSURE ALTERNATION DEVICES
  103. 103. CONCLUSION • Regardless of which type or combinations of irrigants are used, it is important to remember several points. The type of irrigant is only part of the cleaning and shaping process. Gross removal of tissue is very important to the dissolution of the remaining tissue, if the majority of the tissue can be removed with files and initial irrigation, this leaves less material to be dissolved. • It is also important to remember that without proper access preparation and canal enlargement, it is nearly impossible to get deep enough needle penetration to allow the irrigant to provide the maximum benefit at the apical portion of the tooth. These two are very important, since even if we discover an ideal irrigant, it will be ineffective without proper access and canal preparation. • Since there is no ideal irrigant and since many different types and combinations of irrigants have been used successfully in root canal therapy, it is important for the practitioner to choose an
  104. 104. References • Pathways of the pulp ,cohen, 6th & 9th edition • Endodontics, ingle,6th edition. • Endodontic practice, Grossman , 11th edi. & 12th edi. • Lisha G, Kim JR. review of contemporary irrigant agitation techniques and devices. J Endod 2009:35(6):791-804. • Safety and Efficacy Considerations in Endodonti Irrigation :A Peer-Reviewed Publication Written by Gary Glassman, 2011

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