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CURRENT CONCEPT OF
ENDODONTIC IRRIGATION
MICROBIAL/
PRESENT
INFECTION
RE-INFECTION
IN THE
FUTURE
SUCCESSFUL ENDODONTIC
“The key to achieve successful endodontic treatment
are to ensure the eradication of present infection and
prevention of reinfection in the future.”
INTRODUCTION
INTRODUCTION
COMPLEX root canal system
Mechanically → IMPOSSIBLE
The only way → IRRIGATION
Current concept of endodontic irrigation
Bacteria growing in dentin surface
Desired function of Irrigating Solutions
► Washing action → prevent apical blocking
► Reduce friction → (Lubricant)
► Ability to remove/eliminate smear layer
► Dissolve organic and inorganic tissue
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
IDEAL OR PERFECT
IRRIGATION SOLUTION
IRRIGATION SOLUTIONS
1. SODIUM HYPOCHLORITE (NaOCl)
?
=
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
 Temperature ↑ to 600C → increased its
antimicrobial and tissue-dissolving effects.
 Effective time of use : 40 minutes
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
NaOCl Toxicity
Management to overcome toxicity
• Immediately irrigate with normal saline
• Let the bleeding response continue
• Ice bag compression for 24 hours
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
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
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
Cross section of root dentin covered by the smear
layer created by instrumentation.
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.
Current concept of endodontic irrigation
3. CHLORHEXIDINE DIGLUCONATE (CHX)
• Good antimicrobial activity
• Can be used as irrigating solution and intracanal
medicament
• Speciality : binds to hard tissue and remain
antimicrobial
CHX…
• Concentration 2% , 2-3 minutes
• Low toxic irrigant
• Does not cause dentin erosion
• A good choice for final rinse
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)
Other irrigating solutions
• Sterile water
• Physiologic saline
• Hydrogen peroxide
• Urea peroxide
• Iodine compounds
• Lack antibacterial activity
• Do not dissolve tissue
INTERACTION BETWEEN
IRRIGATION SOLUTIONS
NaOCl + EDTA
LOSS OF NaOCl ACTIVITY
CHX + NaOCl
• Not soluble with each other
• A brownish-orange precipitate is formed when mixed
• Charactheristic :
– Contain iron → orange colour
– parachloroalanine → mutatogenik
CHX + EDTA/CA
• Immediately produce white precipitate
• Ability of EDTA to remove smear layer
greatly reduced
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
Current concept of endodontic irrigation
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
MTAD
CHALLENGE OF IRRIGATION
• Smear layer removal
• Dentin erosion
• Cleaning of uninstrumented parts of root canal system
• Biofilm
• Safely versus effectiveness
erosion of canal wall dentin
when NaOCl used after EDTA/CA
ENDO IRRIGATION TIMELINE
NaOCl
(rinse)
Sterile water
(rinse)
2% CHX
(1-3 min)
Dry & Obturate
NaOCl
(min. 5 min)
EDTA 17%
(2-3 min)
Irrigation device and technique
1. Syringe (common 1-5 mL size), Luer-Lock design
2. Needle
– Size 25G, 27G, 30G and 31G
– Types of needle-end design (single vent, double vent)
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)
Current concept of endodontic irrigation
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
5. ENDOVAC SYSTEM
5. LASER IRRIGATION
6. Light-activated Disinfection (LAD)
 Photodynamic antimicrobial chemotherapy
 Photosensitizer (toluidine blue dye,methylene
blue dye, etc)
Application of photosensitizer Light Activated Disinfection
7. GUTTA PERCHA CONE ACTIVATION
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
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.
Current concept of endodontic irrigation

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Current concept of endodontic irrigation

  • 2. MICROBIAL/ PRESENT INFECTION RE-INFECTION IN THE FUTURE SUCCESSFUL ENDODONTIC “The key to achieve successful endodontic treatment are to ensure the eradication of present infection and prevention of reinfection in the future.”
  • 4. INTRODUCTION COMPLEX root canal system Mechanically → IMPOSSIBLE The only way → IRRIGATION
  • 6. Bacteria growing in dentin surface
  • 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
  • 10. IRRIGATION SOLUTIONS 1. SODIUM HYPOCHLORITE (NaOCl) ? =
  • 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
  • 27. NaOCl + EDTA LOSS OF NaOCl ACTIVITY
  • 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
  • 33. MTAD
  • 34. CHALLENGE OF IRRIGATION • Smear layer removal • Dentin erosion • Cleaning of uninstrumented parts of root canal system • Biofilm • Safely versus effectiveness
  • 35. erosion of canal wall dentin when NaOCl used after EDTA/CA
  • 36. ENDO IRRIGATION TIMELINE NaOCl (rinse) Sterile water (rinse) 2% CHX (1-3 min) Dry & Obturate NaOCl (min. 5 min) EDTA 17% (2-3 min)
  • 37. Irrigation device and technique 1. Syringe (common 1-5 mL size), Luer-Lock design
  • 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
  • 44. 6. Light-activated Disinfection (LAD)  Photodynamic antimicrobial chemotherapy  Photosensitizer (toluidine blue dye,methylene blue dye, etc)
  • 45. Application of photosensitizer Light Activated Disinfection
  • 46. 7. GUTTA PERCHA CONE ACTIVATION
  • 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

  1. “The key to achieve successful endodontic treatment are to ensure the eradication of present infection and prevention of reinfection in the future.”
  2. Why we need irrigation?
  3. Why we need irrigation?
  4. 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
  5. First rinse, soaked canal for 5 minutes
  6. 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.
  7. 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.
  8. 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
  9. Notice smear plugs in dentin canals
  10. 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)
  11. SEPERTI DIFOTO PAKAI CAMERA 360 YA….
  12. 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
  13. 0.2% is concentration commonly used for chemically plaque control in oral cavity . 2% is concentration used as root canal irrigation.
  14. 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
  15. EDTA/CA instantaneously reduces the amount of chlorine when mixed with NaOCl
  16. 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
  17. 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)
  18. Ga bermaksud buat promosi loh ya
  19. MTAD : Low toxic Biocompatible Prolonged bacterial effect
  20. 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
  21. 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.
  22. Size 27G is international standard Single vent is better according to dr. Bernard
  23. Guttap percha agitation point inside canal ENDOVAC ENDO BRUSH – CANNOT USE IN WORKING LENGTH ULTRASOUND : ACTIVE & PASSIVE
  24. The best way to remove smear layer Great anti bacterial activity
  25. 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).