PROTOCOL FOR ROOT CANAL IRRIGANTS

Presented byDr. Neha Gulati

Introduction

Challenge: The complexity of root canal morphology hampers the ability to thoroughly achieve pulp cavity disinfection

Objective : To remove all of the pulpal and dentinal debris from the root canal system.

Chemo-mechanical preparation attains free access to the apical foramen through the access opening and through the root canal system by mechanical means, which exposes, enlarges & shapes the root canal.

At the time of chemo-mechanical preparation suitable irrigants are used which help in achieving debridement and disinfection of the root canal system

PROPERTIES OF IDEAL IRRIGATING SOLUTIONS

Tissue Dissolution Lubrication Chelation Antibacterial Action Bleaching Action Some are Radio-

Opaque Low Toxicity Biocompatible

Low Surface Tension Low Neutralizability Easy Avalibility Cost Effective Convenient for Usage Good Shelf Life Easy Storage

Various Irrigating Solutions

SODIUM HYPOCHLORITE EDTA MTAD RUDDLE’S SOLUTION

SODIUM HYPOCHLORITE

Clear straw colour liquid containing 5% chlorine

Strong oxidizing agent Used in concentrations between 0.5-7% Exists as HOCl

DISRUPTS OXIDATIVE PHOSPHORYLATION

DISRUPTS DNA SYNTHESIS

Properties

Potent antimicrobial agent Effectively dissolves pulpal remnants &

organic components of dentin Does not remove Smear layer

Increase in temperature Increases tissue dissolving property

EFFICACY OF SEVERAL CONCENTRATIONS

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

Effectiveness of low concentrations of NaOCl can be improved by

Larger volumes Frequent change Longer period of exposure

Yesiloy et al– 5.25% NaOCl effective against all microorganisms tested but less effective when diluted

ANTIMICROBIAL EFFICIENCY

1% NaOCl has found to kill both bacterial spores and HIV over a period of 30minutes.

Sen et al (JOE, 1999) – 1 & 5% NaOCl effective against C.albicans.

Ohara et al (Dent Traumatol, 1993) – 1/10 concentrations of NaOCl effective against several anaerobic bacteria. However dilution below 1/10 was completely ineffective.

Kuruvilla & Kamath (JOE, 1998) – 50% reduction in microbial count – 2.5% NaOCl, synergistic response with CHX (0.2%) lead to 80% reduction in microbial count.

TIME REQUIRED FOR TISSUE CLEARANCE

At 15 & 30 Min Intervals NaOCl found to clear the coronal & middle third of the canal better than saline. However in apical 3mm no difference was seen.

NaOCl more effective in large diameter canals. More effective in cleaning an isthmus.

SODIUM HYPOCHLORITE:MECHANISM OF ACTION

• Germicidal activity of sodium hypochlorite is because of formation of Hypochlorus acid.(Jawetz,Melnick & Adelberg)

• Permeates cell wall and combines with the protoplasm.

• Dissolves necrotic tissue because of high alkalinity.

• Biopolymers like proteins are hydrolyzed into amino acids.

• NaOCl reacts rapidly with Glycine in a phosphate buffer (pH & 7.0) at 200C

ADVERSE EFFECTS

Excruciating pain within 2-5 min

Burning sensation in affected area

Immediate swelling (ballooning) of the tissue in the area with spread to

surrounding loose connective tissue.

Profuse bleeding episode either interstitially or through the root canal

system.

The interstitial hemorrhage may result in echymosis over the skin

because of which the affected skin is discolored.

EDTA

Effective chelating agent (Ph-8.3) Removes smear layer when used with NaOCl Odourless, Crstalline white powder,relatively

non-toxic Dentin dissolving effect Enlarges narrow/ obstructed canals Bypass fragmented instruments

Properties

Antimicrobial – neither bactericidal nor bacteriostatic Inhabited the growth of & eventually destroyed bacteria by the process

of starvation. The metallic ions in the medium which were necessary for growth were chelated 7 rendered inassimilable by the micro-organisms.

Self Limiting Action: EDTA forms a stable bond with calcium & the deposited solution can

dissolve only a certain amount of dentin EDTA + 2Ca2+ Ca EDTA Ca When all chelating ions have reacted, an equilibrium will be reached;

then no further dissolution will takes place. This effect was found to be rapid during first one hour and reached

equilibrium by the end of seven hours.

Cohen & Burns: Functions of EDTA Lubrication Emulsification Smear Layer removal

The authors also cite references and report that EDTA has been dispensed in two forms – Viscous and Aqueous.

a viscous product is used for the first two functions during canal preparation

the aqueous solution is used as a final flush after shaping and cleaning for smear layer removal.

MTAD

It is composed of a mixture of

A) Tetracycline:

i) Broad spectrum antibiotic

Bacteriostatic in nature.

ii) Low pH

iii) Calcium chelator

Surface demineralization similar to citric acid

iv) Substantive property

v) Promotes healing

vi) Removes smear layer

B) Citric Acid – also removes smear layer, Bactericidal

C) Detergent – Tween 80, decreases surface tension.

MTAD AND SMEAR LAYER (2min application, 5ml volume)

Although MTAD removes most of the smear layer some

remnants of the organic component are scattered on root canal

wall surface.

Effectiveness is enhanced when low concentrations of NaOCI

are used as intra canal irrigant before the use of MTAD as final

rinse.

The regimen doesn’t change the structure of the dentinal tubules.

Properties

ANTIMICROBIAL EFFECT

MTAD appears to be more effective than 5.25% NaOCI in

disinfecting root canals after the removal of he smear layer.

Has the capability kill E. faecalis even at dilutions of 200 X

whereas for NaOCI, this was restricted to a dilution of 32X

SOLUBILIZING ACTION:

Lesser than NaOCI but similar to EDTA

RUDDLE’S SOLUTION

This solution is based on the use of HYPAQUE – M,

a radio- opaque, high contrast injectible dye.

This dye has previously been used in several

application such as arteriography, venography and

ureterography in the medical field.

COMPOSITION 5% Sodium Hypochlorite Hypaque M 17% EDTA Hypaque M is a high viscous aqueous solution of two iodine salts- Diatrizoate

Meglumine and Sodium It has a pH between 6.5 - 7.7 It is stable at room temperature Crystals may form when cooled but dissolve when heated to body temperature

ADVANTAGE Solvent action and ( radio-opacity similar to Gutta Percha) because of Hypaque Penetration because the tensioactive agent decreases the surface tension

besides removing the smear layer

IMPORTANT FACTORS ASSOCIATED WITH IRRIGATION

DELIVERY SYSTEM

VOLUME OF IRRIGATION

DEPTH OF IRRIGATING DEVICE

IRRIGANT EVACCUATION

IRRIGANT DELIVERY

After rubber dam elevation, access is gained to the root canal system. The pulp chamber is thoroughly debrided and flushed with the irrigating solution

The needle is inserted into the canal and slowly advanced apically in the canal walls and when resistance is felt the needle should be withdrawn .

The irrigating solution is deposited slowly without any pressure.

If the needle is forced apical until it binds against the canal walls injection of any solution even water will cause discomfort to the patient.

THE NEEDLE

1. Gauge of the needle:

Gauges ranging from standard 22 gauge to the finer 30 gauge needles were effective for

endodontic irrigation.

2. The needle should be bent to an obtuse angle to allow for easier access & entry to the

orifice. This bend is to be placed closer to the hub of the syringe.

3. Designs of Needles:

Open ended blunt needles

Beveled needles

Blunt ended side venting needle (ProRinse)

Notched tip (Monojet – 27 gauge)

Perforated needle –Endovage (Goldman & others)

NEWER DELIVERY SYSTEMS

TRIPLEX SYRINGE The Triplex Syringe is optimal for air and water

delivery. Its locking buttons are perfect for adapting to the Stropko Irrigator.

The Stropko Irrigator places the perfect amount of air and water pressure into the field. Its small, luer-lock tips do not impede visibility during irrigation or drying and are excellent for use under the microscope..

TRIPLEX SYRINGE

RINSE ENDO Contains a titanium hand piece and a supply

of disposable special cannulas and splash protectors

Results in thorough cleaning right till the apex

IRRIGANT ACTIVATION

EFFECT OF TEMPERATURECollagen dissolving effectCunningham & Balekijan showed that increasing the temperature from

220C-370C of a 2.6% NaOCl solution increased its tissue dissolving properties which were equivalent to those of 5.25% solution at room temperature.

Bactericidal effect:Was shown that for warmed 2.6% solution against

E.Coli,S.Sanguis,B.Subtilis spores,P.Vulgaris,S.Aureus organisms as early as 45 seconds.(Cunningham & Joseph OOO,1990).The spores took the longest time- 180 secs.(compared to 600 secs for solution at 22 0C)

-Ellerburch & Murphy demonstrated that even vapors of NaOCl exert strong bactericidal action.

ULTRASONICS Sound energy with frequency more than 25khz During passive ultrasonic irrigation,a small ulrasonically vibrating

file is placed in the centre of the root canal Energy is transferred to the irrigant Acoustic microstreaming and/or cavitation occurs The irrigant can flow through the canal and file can vibrate freely PUI with NaOCl removes more dentin debris,planktonic bacteria

& dental pulp tissue than manual syringe irrigation

ENDOACTIVATOR EndoActivator System uses safe, non-cutting polymer tips in an

easy-to-use hand piece to quickly and vigorously agitate irrigant solutions during endodontic therapy.

Evidence-based endodontics has shown that cavitation and acoustic streaming improve debridement and the disruption of the smear layer and biofilm.

Activated fluids promote deep cleaning and disinfection into lateral canals, fins, webs and anastomoses.

VIBRINGE First endodontic sonic irrigation system that enables

activation of the irrigation solution, acoustic streaming, in the root canal, in only one step

Clinically proven that it removes organic and inorganic debris from hard-to-reach areas faster than the conventional syringe.

Completely safe for all endodontic irrigation procedures and is compatible with all irrigation solutions like sodium hypochlorite and EDTA

VIBRINGE -next level endodontic hand irrigation

TIME SAVING

SAFE

SUPERCLEAN

IRRIGANT EVACCUATION

ENDOVAC / IRRIVAC Developed as a means to irrigate and remove debris to the apical

constricture without forcing solution out the apex into the periapical tissue.

The system utilizes apical negative pressure through the offices high volume evacuation system permitting thorough irrigation with

high volumes of irrigation solution.

Master Delivery tip being used to provideconstant irrigation as the canal isinstrumented

Use of the EndoVacMacroCannula

Use of the MicroCannula of the EndoVac system showing placement of the tip in theapical root end

USE OF LASERS

Ho:YAG /CO2 laser Effect of laser is dependent on the applied

output power and is specific for different bacteria

Also helps in removal of smear layer

To summarize irrigation of the root canal can be done by THE FIRE CONCEPT

F- FILL THE CANAL WITH IRRIGANT

I- INITIATE THE IRRIGANT

R- REFILL THE CANAL

E- EVACCUATION OF THE IRRIGANT

THANK YOU