Root Canal Irrigation in RCT

Root Canal Irrigation in RCT
Copyright by Conservative Department, UDM

1. Root canal Irrigation

2. objectives To remove debris created during instrumentation To dissolve and/or flush out inorganic and organic remnants of the pulp system, bacteria and bacteria by products that are not removed by mechanical instrumentation With the introduction of obturation materials designed to bond with dentine, irrigation solution must be used with consideration to create the dentine surface that is most suitable for bonding.

3. Modern root canal treatment requires the use of both mechanical and chemical preparation and disinfection of the canal system.

4. Characteristics of an ideal irrigation system Physical flushing of debris Biocompatible Bactericidal agent Sustained effect Disinfect and detoxify dentine and tubules of all microbial substances Tissue solvent lubricant

5. Smear layer removal Low surface tension Non-mutagenic, non-carcinogenic or non- cytotoxic effect Remain active following storage Ease of storage Adequate shelf-life Inexpensive

6. User friendliness Not be easily neutralized in the canal to retain effectiveness

7. Smear layer During cleaning and shaping procedures, a superficial amorphous layer of tissue remnants, organic and inorganic materials, and bacteria and their by products accumulate on the canal walls. This smear layer may interfere adhesion of sealers to the canal wall and serve as a substrate for bacteria growth. Evidence tends to support removing the smear layer prior to obturation.

8. Advantages of removal of smear layer Reduction of potential irritants. Permits better adaption of sealer to the canal walls.

9. Irrigation solution for removal of smear layer 17% EDTA(ethylene diaminetetraacetate ) ( chelator ) Flushing of the canal with EDTA, followed by a final rinse of sodium hypochloride 2.5-5.2% Chelators remove the inorganic components, dentine chips, calcified organic materials and sodium hypochlorite is necessary for removal of the remaining organic components.

10. Citric acid (10-50%)-chelator Alternative to EDTA for removing smear layer Adequate irrigation of root canals requires an effective irrigant as well as an efficient delivery system

11. Other irrigating solutions Chlorhexidine gluconate Hydrogen peroxide 3% Urea peroxide10% Sodium hypochlorite1-6% Iodine solutions-10% iodine Urea 30% Quantanary ammonium compounds

12. 8.MTAD-mixture of tetracycline, citric acid and detergent 9.EAW-electrochemically-activated water, oxidative potential power 10.PAD-photoactivated disinfection 11.ozone-powerful oxidizing agent and has high bactericidal properties, but perfusion of gas is not reliable.

13. Physiologic solution Distilled water saline

14. Iodine potassium iodideIKI Used as an irrigant in retreatment cases Some strains of bacteria associated with retreatment cases, due to their survival in calcium hydroxide eg.,enterococcus faecalis are sensitive to IKI. 2% solution of iodine in 4%aqueous Potassium Iodide.

15. Sodium hypochlorite( NaOCl ) Used as an irrigant of choice globally. Used as an irrigant in endodontic treatment for many years. Inexpensive, readily available, highly antimicrobial. Has valuable tissue dissolving action. 0.5-5.25% concentration has been recommended in endodontics .

16. 0.5%NaOCl kills bacteria in root canal. NaOCl solution >1% will effectively dissolve organic tissue. Increasing the concentration will increase the rate of tissue dissolution and antimicrobial action. Increasing the temperature (60’C) has similar effect.

17. Volume is more important than concentration. Frequent replenishment during C&S will improve the flushing action to remove debris, killing bacteria and dissolution of organic debris. Tissue dissolution ability of NaOCl depend upon amount of organic tissue present in the root canal, fluid flow, and the surface area available.

18. Active ingredient of NaOCl is free chlorine. dissolves pulp tissue and clean both large and extremely fine canals, is able to penetrate, dissolve and flush out organic debris from inaccessible aspects of the root canal system where files cannot reach.

19. NaOCl cleans the root canal after shaping and can penetrate deep into dentinal tubules when used in the correct procedure, concentration and appropriate amount of time. Ph(approximately 12-13) Store in a cool and dark place for better clinical results.

20. Hypochlorite accident A hypochlorite accident refers to any event where NaOCl is expressed beyond the apex of a tooth and the patient immediately manifests some combination of the following symptoms Severe pain Swelling Profuse bleeding

21. Chlorhexidine gluconate Broad spectrum antimicrobial activity, low toxicity Used in concentrations between 0.2-2% biocompatible Poor tissue digesting properties Action is best when used along with sodium hypochloride

22. Hydrogen peroxide Release nascent oxygen Bubbling oxygen rising to the access opening, tend to carry loose debris Bacterial destruction Hydrogen peroxide is alternately with NaOCl Due to release of nascent oxygen, the last irrigation solution should be NaOCl

23. Quaternary ammonium compound Detergents Has low surface tension and low antimicrobial action Can remove tissue from pulp tissue breakdown They are no longer used due to their toxicity

24. Delivery of irrigants Can be delivered with endodontic irrigating syringe or ultrasonic devices Disposable hypodermic syringe and needle. Closed end and perforated side needle (side delivery design) to irrigate the apical area more effectively than conventional needle.

25. Method of use needle placed 3mm short of working length Frequently and appropriate amount of volume 1-2ml

26. Factors influencing efficacy of irrigation Diameter of the irrigating needle Depth of the irrigating needle engaged in root canal Size of enlarged root canal Viscosity of the irrigating solution Velocity of the irrigating solution at the tip of the canal

27. Ultrasonics , sonics Orientation of the bevel of the needle temperature

28. Early recognition of symptoms of a sodium hypochlorite ( NaOCl ) accident Immediate severe pain (for 2-6 minutes) despite effective local anesthesia immediate edema in adjacent soft tissue because of perfusion to the loose connective tissue

29. • Extensive edema. Possible extension of oedema over the injured half side of the face, upper lip, and infraorbital region Profuse bleeding from the root canal • Profuse interstitial bleeding with hemorrhage of the skin and mucosa ( ecchymosis )

30. Emphysema --- crepitus of swelling Epithelial necrosis

31. • Chlorine taste and irritation of the throat after injection into the maxillary sinus Eye pain, blurring of vision • Severe initial pain replaced with a constant throbbing and numbness

32. Possibility of secondary infection or spread of pre-existing infection • Reversible or irreversible anesthesia or paresthesia possible • Facial paralysis

33. Massive swelling of the lower lip and right cheek region after injection of sodium hypochlorite and hydrogen peroxide through a perforation in a mandibular right cuspid .

34. Treatment of a sodium hypochlorite ( NaOCl ) accident Remain calm and inform the patient about the cause and nature of the complication • Immediately irrigate with normal saline; dilute the NaOCl • Let the bleeding response continues as it helps to flush the irritant out of the tissues

35. Use cold compresses to minimize swelling • Use a warm, moist pack after 24 hours (15-minute intervals) • Advice rinsing with normal saline for 1 week to improve circulation to the affected area

36. Provide pain control o Initial control of acute pain can be achieved with anesthetic nerve block o analgesics

37. Provide prophylactic antibiotic coverage for 7 to 10 days to prevent secondary infection or spread of the present infection • Consider steroid therapy with methylprednisolone for 2 to 3 days to control inflammatory reaction Daily recall to monitor recovery

38. In severe cases, such as respiratory distress, hospitalize the patient Consider surgical debridement -meticulous debridement of grossly necrotic tissue

39. Steps that can help clinicians to avoid sodium hypochlorite ( NaOCl ) extrusion Use a rubber dam—it is the most effective barrier to protect the intraoral tissue from the damaging effects of NaOCl Care in use of NaOCl

40. Use a side-venting needle to minimize the risk of accidental extrusion through the apical foramen • Adequate access preparation • Good working length control • Irrigation needle placed 1 to 3 mm short of working length

41. The needle should not reach the apical extent of the prepared canal. The irrigant is delivered slowly with minimal pressure index finger should be used rather than thumb to depress the plunger

42. Needle placed passively and not locked in the canal • Observe ‘ flowback ’ of solution out of the canal

43. in immature teeth, both Sodium hypochlorite and saline are recommended for irrigation if hypochlorite is used it has been suggested the final irrigation should be with saline to remove any hypochlorite from the canal.

44. Root canal medication & intracanal medicaments Primary function To reduce microflora and counteract coronal microleakage Antisepsis Disinfections

45. Secondary functions Hard tissue formation – to increase apical closure To reduce periapical inflammation Pain control Exudation control Resorption control

46. Neutralization of canal remnants To dissolve the remaining organic material

47. Categorization of medicaments Phenolics –- eugenol , phenol, parachlorophenol , camphorated monoparachlorophenol (CMCP), Cresol, Cresote compound, cresatin , thymol . 2.Aldehydes – formocresol , glutaraldehyde 1&2 are potential cell killer, kill bacteria, have allergic to tissues

48. 3.Halides – NaOCl , iodine in Potassium Iodide( Vitapex ) 4. Halogen compounds(chlorine, iodine, Chlorhexidine) are oxidizing agents and have rapid bactericidal effect

49. Steroids – prednisolone , triamcinolone , hydrocortisone anti inflammatory and pain relief 6.Ca(OH)2- very popular as an intracanal medicament. Paste form- hypocal , calform , pulpent Powder form-mix with sterile water, saline or anesthetic solution to get thick slurry paste

50. Advantages: most effective against root canal pathogens Has broad spectrum antibacterial activity Denature bacterial endotoxin and organic tissue Duration is long – lasting in canal

51. 7. antibiotics-Grossman’s polyantibiotic paste PBSN Penicillin, bacitracin , streptomycin, nystacin Advantages- non toxic to periapical tissues -do not stain tooth Disadvantages-resistance strains -allergic response

52. 8. C ombinations- Calcium hydroxide + antimicrobials Steroids + phenolics Antibiotics + steroids ( ledermix ) Antibiotic +anti- inflammatory Ca(OH)2 + iodoform ( calplus ) More effective than single use.

53. Method of placement Non- vapour forming intracanal medicaments eg calcium hydroxide are placed in the canal using paper points, spreader, lentulospiral or injection syringe system Vapour –releasing eg formocresol is placed with a cotton pellet.