7. Desired function of Irrigating Solutions
► Washing action → prevent apical blocking
► Reduce friction → (Lubricant)
► Ability to remove/eliminate smear layer
► Dissolve organic and inorganic tissue
8. Desired function of Irrigating Solutions
► Antimicrobial effect (biofilm, bacteria, etc)
► Ability to penetrate canal periphery
► Non-toxic and non-irritant
► Do not weaken tooth structure
11. Sodium Hypochlorite (NaOCl)
Most popular irrigating solution
0,5% - 6%, pH at 11
Disrupts vital function of bacteria cell
Dissolves necrotic and vital organic tissue
Inexpensive and easy to purchase
12. Temperature ↑ to 600C → increased its
antimicrobial and tissue-dissolving effects.
Effective time of use : 40 minutes
13. DISADVANTAGE
Unpleasant taste
Inability to completely remove smear layer
Toxicity
Pain and periapical injury
Decrease dentin elasticity and strength → risk of fracture
Do not use as final rinse → severe erosion of canal-wall
15. Management to overcome toxicity
• Immediately irrigate with normal saline
• Let the bleeding response continue
• Ice bag compression for 24 hours
16. Management to overcome toxicity
• Warm compression after 24 hours
• Pain control with strong analgesics
• Prophylactic antibiotic for 7 to 10 days
• Monitoring & Inform the patient
17. 2. EDTA and CITRIC ACID (CA)
• Lubricant, chelating agent and
decalcifying agent
• Dissolve some organic and inorganic
material
• Removal of dentin debris and smear
layer
• 17-18 % , pH 7
18. EDTA/CA…
• Used for 2-3 minutes after NaOCl irrigation and
rinsing solution in between
• No comparative study about the effectiveness of gel
and liquid in demineralize dentin
• Do not have anti bacterial activity
19. Cross section of root dentin covered by the smear
layer created by instrumentation.
20. Advantages of smear layer removal
(Walton & Weine)
1. Allows penetration of irrigants into dentinal tubules.
2. Enhances penetration and adhesion of sealer to dentin.
3. Filling materials adapt better to the canal wall.
4. Reduces coronal and apical leakage.
22. 3. CHLORHEXIDINE DIGLUCONATE (CHX)
• Good antimicrobial activity
• Can be used as irrigating solution and intracanal
medicament
• Speciality : binds to hard tissue and remain
antimicrobial
23. CHX…
• Concentration 2% , 2-3 minutes
• Low toxic irrigant
• Does not cause dentin erosion
• A good choice for final rinse
24. CHX weaknesses
• Cannot remove biofilm, smear layer and organic matter
• Effectiveness greatly reduce by the presence of organic
matter
• No tissue dissolving ability (necrotic tissue, etc)
25. Other irrigating solutions
• Sterile water
• Physiologic saline
• Hydrogen peroxide
• Urea peroxide
• Iodine compounds
• Lack antibacterial activity
• Do not dissolve tissue
28. CHX + NaOCl
• Not soluble with each other
• A brownish-orange precipitate is formed when mixed
• Charactheristic :
– Contain iron → orange colour
– parachloroalanine → mutatogenik
29. CHX + EDTA/CA
• Immediately produce white precipitate
• Ability of EDTA to remove smear layer
greatly reduced
30. SUPPORTIVE PRODUCT
• Surface-active agents have been added to
several types of irrigants
Better penetration to root canal
Better smear-layer removal
Increase of antibacterial activity
increase the speed of tissue dissolution
32. MTAD
(Mixture of Tetracycline isomer, Acid, and Detergent)
• Citric Acid
• Doxycycline
• Detergent
Study : promising antibacterial
effect (esp. E.Faecalis)
Smear layer removal effect
Do not dissolve organic tissue
Intended to use as final irrigant
Study : NaOCL + EDTA = NaOCl + MTAD
34. CHALLENGE OF IRRIGATION
• Smear layer removal
• Dentin erosion
• Cleaning of uninstrumented parts of root canal system
• Biofilm
• Safely versus effectiveness
38. 2. Needle
– Size 25G, 27G, 30G and 31G
– Types of needle-end design (single vent, double vent)
39. 3. EndoActivator
• Facilitate penetration of irrigant to canal
• Study : more irrigant penetration and
mechanical cleansing
• No risk of irrigant extrusion through apex
• Up to 10.000 cpm (sonic vibration)
41. 4. Ultrasound
• Contribute better cleaning system ran
irrigation and hand instrumentation alone
• Effective to cases with complex
anastomoses canal system
• Less preparation complication with
ultrasonic files
47. CONCLUSION
• IDEAL OR PERFECT IRRIGATION SOLUTION DOES NOT EXIST
• COMBINE WITH 2 OR MORE KIND TO INCREASE EFFECTIVENESS
• USE IRRIGANTS IN THE RIGHT SEQUENCE TO MAXIMIZE THE
RESULT OF IRRIGATION
48. REFERENCE
• 1. Torabinejad M, Walton RE. Endodontics principles and practice. 4th ed.
Saunders; 2009. p. 391-404.
• 2. Cohen S, Hargreaves KM. Pathways of the pulp. 9th ed. St. Louis: Mosby;
2006. p. 318-323.
• 3. Ingle JI,Bakland LK. Endodontics. 5th ed. BC Decker;2002. p. 498-505.
• 4. Weine FS. Endodontic therapy. 6th ed. St. Louis:Mosby; 2004. p. 221-226
• 5. Haapasalo M, Shen Y, Qian W, Gao Y. Irrigation in endodontics. Dent Clin
N Am. 2010; 54: 291-312.
Editor's Notes
“The key to achieve successful endodontic treatment are to ensure the eradication of present infection and prevention of reinfection in the future.”
Why we need irrigation?
Why we need irrigation?
1. During the treatment of a root canal, the increase in pH likely creates a microenvironment that is not particularly hospitable to bacteria in the root canal system.
2. According to several studies The lower and higher concentrations are equally efficient in reducing the number of bacteria in infected root canals
3. A common concentration of NaOCl is 2.5% which decreases toxicity and still maintains some tissue dissolving and antimicrobial activity.
4. Disrupts vital function of bacteria cell → cell death/instant killing
5. The only root-canal irrigant that dissolves necrotic and vital organic tissue
6. pH at 11 (unbuffered), range 9,0 – 11
First rinse, soaked canal for 5 minutes
Inform about the cause and nature of complication
Irrigate to decrease soft tissue irritation by diluting the NaOCl
Let the bleeding response continue as it helps to flush the irritant out of the tissues.
Recommend ice bag compresses for 24 hours (15-minute intervals)to minimize swelling.
Recommend warm, moist compresses after 24 hours (15-minute intervals).
pain control with strong analgesics for 3 to 7 days
Prophylactic antibiotic coverage for 7 to 10 days to prevent secondary infection or spreading of the present infection.
The optimal working time of EDTA is 15 minutes, after which time no more chelating action can be expected.
Should be used after fine instrument reached apex, except calcifying canal
If leave in canal, will remain active for 5 days, If the apical constriction has been opened, the chelate may seep out & damage the periapical bone.
1 minute already working to remove inorganic components
Notice smear plugs in dentin canals
Smear layer :
1-2 micrometer
Disturb antibacterial activity
Disrupt sealer attachment in canal
Increase potential of microorganism leakage
N.B: The small particles of the smear layer are primarily inorganic. (Walton)
SEPERTI DIFOTO PAKAI CAMERA 360 YA….
1. Cannot replace NaOCl
2. Study : no difference of antimicrobial effectiveness between NaOCl and 2% CHX
3. Study : CHX gel slightly better antimicrobial performance than CHX liquid
0.2% is concentration commonly used for chemically plaque control in oral cavity .
2% is concentration used as root canal irrigation.
Sterile water and saline can act as rinse between irrigant solutions
Water and saline bear the risk of contamination if used from container that have been opened more than once
Hydrogen peroxide → bubble effect (cannot be proven)
Iodine potassium has considerable microbial activity but no tissue dissolving capability and some patients are allergic to iodine
EDTA/CA instantaneously reduces the amount of chlorine when mixed with NaOCl
Many clinician mixed NaOCl with H2O2 but despite of vigorous bubbling, the effectiveness has not been shown to be better than NaOCl alone
Hydrogen peroxide + CHX → increase considerably antibacterial activity in dentin block, but no data regarding clinical use
No data available about dentin penetration also improved
CHX vs CHX-Plus → superior killing of platonic and biofilm bacteria for CHX-Plus
No study about surface-active agents increases the risk of irrigants escaping to periapical area in clinical use.
4. Better smear-layer removal (EDTA/SmearClear & Chlor-Xtra)
Smear Layer
Cannot rely on EDTA alone
Smear layer created only on area touched by instruments
Dentin erosion
To protect tooth structure from weakening caused by physical and chemical
Short term and Long term exposure to NaOCl and EDTA
Cleaning
Include necrotic tissue etc
Biofilm
Procedure : mechanical by instrument + dissolving by NaOCl + detached by ultrasonic energy
Chx → can kill bacteria if long enough contact
Safely
Low toxic, low effectiveness
Can cause pain
Luer lock = male and female design for leaked free
The irrigant doesn't move apically more than 1 mm beyond the irrigation tip
The volume of irrigant is more important than the concentration or type of irrigant
The apical 5 mm are not flushed until they have been enlarged to size 30 and more often size 40 file.
Size 27G is international standard
Single vent is better according to dr. Bernard
Guttap percha agitation point inside canal
ENDOVAC
ENDO BRUSH – CANNOT USE IN WORKING LENGTH
ULTRASOUND : ACTIVE & PASSIVE
The best way to remove smear layer
Great anti bacterial activity
The canal is then filled with a photosensitizer and then illuminated with a light source (laser, white light, red light, or a light-emitting diode).