Endodontic irrigation

Dentistry

1. IRRIGATION
IN
ENDODONTICS
Dr.Mohamed Ali Alazrak
BDS.MSc
Tripoli Medical Center –Libya
[email protected]

2. Introduction
•Everyrootcanalsystemhasspacesthat
cannotbecleanedmechanichally.
•Theonlywaytocleanwebs,finsand
anastomosesisthrougheffectiveuseof
irrigationsolution.
•inordertogetthemaximumefficiency
fromirrigant,irrigantmustreachthe
apicalportionofthecanal.

3. Antimicrobialproperties
Tissuesolvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level
Properties of ideal irrigantsolution

4. COMMONLY
USED
IRRIGATING
SOLUTIONS

5. I.Chemicallynon active solution:
Water.
Saline.
Anesthesia.

6. I.Chemically non active solution:
Antimicrobialproperties
Tissuesolvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level

7. II.Chemicallyactive materials :
•Alkalis : sodium hypochlorite
•Antibacterial agents : chlorhexidin
•Oxidizing agents: hydrogen prioxide
•Chelating agents: EDTA ( ethylene diaminetetra acetic acid)

8. Sodium hypochlorite (NaOcl)
Clear,palegreen-yellowliquidwith
strongodorofchlorine.
Itisapotentantimicrobialagent,
killingmostbacteriainstantlyon
directcontact.Italsoeffectively
dissolvesnecroticandvitalpulp
tissue.
The most advocated irrigant,inexpensiveand readily available.

9. Sodium hypochlorite (NaOcl)
Antimicrobialproperties
Tissuesolvent.
( dissolve vital and non vital tissue)
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.

10. Mechanism of action
Sodium hypochlorite (NaOCl) ionizes in water into Na and
the hypochlorite ion, OCl, establishing an equilibrium with
hypochlorousacid (HOCl).
Hypochlorousacid is responsible for the antibacterial
activity; the OClion is less effective than the undissolved
HOCl.
Hypochloricacid disrupts several vital functions of the
microbial cell, resulting in cell death.

11. Mechanism of action
AtacidicandneutralpH,chlorineexistspredominantlyas
HOCl,whereasathighpHof9andabove,OClpredominates.

12. Concentration
NaOCliscommonlyusedinconcentrationsbetween0.5%
and5%.
AccordingtoseveralstudiesThelowerandhigher
concentrationsareequallyefficientinreducingthenumber
ofbacteriaininfectedrootcanals.
Thetimeneededtoinhibitbacterialgrowthandtissue
dissolvingeffectofNaOclirrigantarerelatedtoitis
concentration,butsoisitistoxicity.

13. Increasingthetemperatureofhypochloriteirrigant
to60
0
C,significantlyincreaseditsantimicrobialand
tissue-dissolvingeffects.
Temperature

14. Limitation :
Unpleasant taste
Relative toxicity
Inability to remove smear layer

15. Sodium hypochloride accident
Immediateseverepainfor 2-
6minutes.
immediateedemainadjacentsoft
tissuebecauseofperfusiontothe
looseconnectivetissue.
Extensionofedematoalargesiteof
thefacesuchascheeks,peri-orbital
region,orlips.
Ecchymosisonskinormucosaasa
resultofprofuseinterstitialbleeding.

16. Sodium hypochloride accident
Management
inform the patient about the cause and
nature of the complication.
Immediately irrigate with normal saline
to decrease the soft-tissue irritation by
diluting the NaOCl.
Let the bleeding response continue as
it helps to flush the irritant out of the
tissues.

17. Sodium hypochloride accident
Recommendicebagcompressesfor24
hours(15-minuteintervals)tominimize
swelling.
Recommendwarm,moistcompresses
after24hours(15-minuteintervals).
paincontrolwithstronganalgesicsfor
3to7days

18. Sodium hypochloride accident
Prophylacticantibioticcoveragefor7
to10daystopreventsecondary
infectionorspreadingofthepresent
infection.

19. Chlorhexidine(CHX)
Strongbase,moststableinformof
itssalt…Chlorohexdingluconate.
Itpossessesabroad-spectrum
antimicrobialactionandarelative
absenceoftoxicity.
CHXlacksthetissue-dissolving
ability.

20. Anti microbial properties
(broadspctrumantimicrobialagent)
Tissuesolvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.
Chlorhexidine (CHX)

21. Mechanism of action
Itpenetratesthecellwallandattacksthebacterial
cytoplasmicorinnermembraneortheyeastplasma
membrane.
Inaddtionchlorhexidinhaspropertyofsubstantivity
(residualeffect).

22. Concentration
0.2%isconcentrationcommonlyusedforchemicallyplaque
controlinoralcavity.
2%isconcentrationusedasrootcanalirrigation.

23. Limitation
Unable to dissolve remaining necrotic tissue.
Less effective on gram negative than on gram positive.
Unable to remove smear layer.

24. Hydrogen Peroxide H
2O
2
Itisaclear,colorless,odorlessliquid.
H
2O
2isactiveagainstviruses,bacteria,
andyeasts.
Ithasbeenparticularlypopularin
cleaningthepulpchamberfrom
bloodandtissueremnants,butithas
alsobeenusedincanalirrigation.

25. Hydrogen Peroxide H
2O
2
Anti microbial properties
(broadspctrumantimicrobialagent)
Tissuesolvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.

26. Mechanism of action
Itishighlyunstableandeasilydecomposedbyheatand
light.
itrapidlydissociateintoH2O+O(water+nascentoxygen).
theliberatedOhasbacteriocidaleffectbutthiseffectis
transientanddiminishesinpresenceoforganicdebris.
TherapidreleaseofOnascentoxygenoncontactwith
organictissueresultsineffervesce(bubbling)actionwhich
aidinmechanicaldebridementbydislodgingdentindebris
andnecrotictissueparticlesandfloatingthemtothe
surface.

27. Concentration
Itisrecommendedtousein3%
conentrationforendodontic
irrigation.

28. Advantagesofusingalternating3%H2O2withNaoclsolution
are:
1.Effervescentreaction(bubblespushesdebrismechanichally
outofrootcanal)
2.Solventactionofsodiumhypochroriteonorganicdebris.
3.Disinfectionandbleachingeffectbybothsolutions.

29. Limitation
Unabletoremovesmearlayer.
AlwaysuseNaocllastbecauseHydrogenperoxidereleaseof
nascentoxygenoncontactwithorganictissuewhichmay
builduppressureonclosingtoothandcausespain.
•Softtissueemphysemamayoccurwhenhydrogenperoxide
irrigantenforcedbeyondtheapicalforamen.

30. MTAD
Amixtureoftetracyclineisomer,acid,anddetergent.
(doxycycline,citricacid,andthedetergentTween-80)

31. Anti microbial properties
(broadspctrumantimicrobialagent)
Tissuesolvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.

32. Advantges
1)it is an effective solution for removal of most of smear
layer.
2)Antibactrialeffect ( kill most significant bacterial strains i.e.
E faecaliswhich has been shown to resist to many
intracanalmedicament and irrigants.).
3)It is biocompatible .
4)The high binding affinity of doxycycline present in MTAD for
dentin allows prolonged antibacterial effect. (substantivity)

33. Chelating Agents
EDTA (ethylene-diaminetetra-aceticacid)
Thebasicpurposeofchelating
agentislubrication,emulsification
andholdingdebrisinsuspension.

34. Mechanism of action
•EDTAfunctionsbyformingcalcium
chelatesolutionwithcalciumionsof
dentinwhichmakeitmorefriableand
thusdentinbecomeeasilyto
manipulatebyinstrumentation.

35. EDTA
17%EDTA(pH7)
EDTAhasnoantibacterialactivity.
Iteffectivelyremovessmearlayer
bychelatingtheinorganic
componentofthedentine.
Aidinmechanicalcanalshaping.

36. TheoptimalworkingtimeofEDTAis15minutes,after
whichtimenomorechelatingactioncanbeexpected.

37. Smear Layer
Thesmearlayerisalayerofdebris,compromisingboth
organicandinorganiccomponents,foundoncanalwallsafter
endodonticinstrumentation,itistypically1-2uminthick.
Itismadeuplargelyofparticularlydentindebrisremovedby
endodonticinstrumentduringcanalpreparationbutmayalso
containsremnantsofpulptissueandmicroorganisms.

38. Smear Layer
Presenceofsmearlayeronthecanalwallspotentially
interferewiththeadaptationofsealeragainstcanalwalland
maycreateavenueofleakageofmicroorganismsbyactas
substrateformicrobialproliferation.

39. Smear layer removal
Canbeaccomplishedbyoneofthefollowingways:
1)Useofchelatingagents(17%EDTA)duringthecleaning
andshaping.Uponcompletetherootcanalshapingsoak
thecanalfor1minutewithliquidEDTA,thenrinsethe
canalthoroughlywithNaOcl.
2)AfterirrigationwithNaOclSoakthecanalfora5minutes
withMTADasfinalirrigant.
Drycanalwithpaperpoints,sotheitisnowreadyfor
obturation.

41. Irrigation technique
and devices

42. ①Plastic syringe with needles
•Plasticsyringesofdifferentsizes
(1–20mL)aremostcommonlyused
forirrigation.
•Allsyringesforendodonticirrigation
musthaveaLuer-Lockdesign.

43. Types of endodnticneedles
1)Beveled needle:
Needlewithbevelifgetlodgedinto
canalthereisariskofforcing
irrigantbeyondtheapex.

44. Types of endodntic needles :
2)Monojectirrigating needle:
Monojectendodonticneedlestobe
themostefficientdeliverysystemin
whichlongerneedlesofablunted,
open-endsystemwereinsertedto
thefulllengthofthecanaltoensure
optimumcleaning.
Alargervolumeofsolutioncanbe
deliveredbythismethod.

45. 3)Max-i-Probeirrigatingneedle:
Ithasclosed-endandsidewindow.
Thisdesignallowforupward
flushingactionforbettercanal
irrigationandalsoeliminates
possibilitiesofirriganttobepushed
beyondtheapicalforamen.

46. Irrigation method:
Itisstronglyrecommendedthattheneedlelie
passivelyinthecanalandnotengagethewalls.
A27-or30-gaugeneedleispreferred
Thesolutionmustbeintroducedslowly.
Theirrigatingneedleshouldbebenttoalloweasier
deliveryofthesolutionandtopreventdeep
penetrationoftheneedle.
Caremustbetakenwithirrigantslikesodium
hypochloritetopreventaccidents.

47. ②Gutta-percha Points
agitation
•useofapicallyfittinggutta-percha
coneinanup-and-downmotionat
theworkinglength.Althoughthis
facilitatestheexchangeofthe
apicalsolution,buttheoverall
volumeoffreshsolutioninthe
apicalcanalislikelytoremain
small.

48. ③EndoActivator
•Itisbasedonsonicvibration
(upto10,000rpm)ofaplastictip
intherootcanal.Thesystemhas3
differentsizesoftipsthatare
easilyattachedtothebattery
operatedhandpiecethatcreates
thesonicvibrations.

49. ③EndoActivator
•itallowmoreirrigantpenetration
and mechanical cleansing
comparedwithneedleirrigation,
withnoincreaseintheriskof
irrigantextrusionthroughthe
apex.

50. ④Ultrasound
•Ultrasound is sound energy with frequency
above 25 KHZ.
•Passiveultrasonicirrigationhaveshownto
cleanrootcanalsoreliminatebacteriafrom
thewallsbetterthanconventional
methods.

51. Mechanism of action
•Whenasmallfile(size10-20)is
placedfreelyinthecenterofthe
canalfollowingpreparationand
ultrsonicactivationisgiven.The
ulrtasonicenergypassagethrough
irrigatingsolutionandexertsits
(acousticstreamingeffect).

52. Mechanism of action
•Thismechanichalenergywarmsthe
irrigantsolution(NaOcl)anddislodge
debrisfromcanals.
•Thecombinationofactivationand
heatingtheirrigationsolutionis
adjunctincleaningtherootcanal
system.

54. ⑤EndoVac
•TheEndoVacsystemisbasedon
anegative-pressureapproachwherebythe
irrigantplacedinthepulpchamberis
suckeddowntherootcanalandbackup
againthroughathinneedlewithaspecial
design.

55. Advantges :
1)theEndoVacsystemlowerstherisks
associatedwithirrigationclosetothe
apicalforamen.
2)goodapicalcleaningatthe1-mmlevel
canbeachievedbyreversedflowof
irrigantsandastrongantibacterial
effectwhenhypochloriteisused.

56. Thank you
Photo for Sabratha ancient city -Libya