Types of irigation & activation in endodontic .pptx

Irrigants are chemical solutions used to dissolve organic tissue, disinfect the root canal system, and flush out debris. No single solution can do it all, so a combination is often used.

1. Types of Irrigation & Activation Supervised by : Dr.Soliman Kamha Presented by : Abdelrahman badway Mohamed nabil Moaz Maher

2. THE GOAL OF Shaping and Cleaning Elimination of a microbial infection in the root canal system There is a widely accepted view that instrumentation and irrigation CLEANING AND SHAPING of the root canal system is the most important step toward a canal free from microbes

3. Goals of Irrigation Disinfection: Eliminates bacteria and contaminants from the canal. Debridement: Removes pulp tissue remnants, debris, and organic material from the canal walls. Smear Layer Removal: Irrigants like EDTA help dissolve the smear layer, a byproduct of the mechanical cleaning process that can hinder proper sealing. Lubrication: Facilitates the smooth operation of instruments, reducing the risk of procedural errors like instrument binding

4. Method of irrigation Rubber dam isolation Use 30-gauge needles Side vented needles 2-3 mm from the working length. Always keep needle in motion. The solution must be introducedslowly . Never bind the needle into the canal

5. GOAL OF INSTRUMENTATION AND IRRIGATION The goal of instrumentation and irrigation is to remove all necrotic and vital organic tissue, as well as some hard tissue, from the root canal system

6. INSTRUMENTATION SHAPESTHECANALSYSTEMTOFACILITATE: 1) Irrigation. 2) Placement of a permanent root filling (obturation).

7. the root canal morphology the root canal morphology presents distinct complexities, which include lateral and accessory canals, isthmuses, apical deltas, and dentinal tubules. These complexities render root canal cleaning an extremely challenging procedure, resulting in substantial unprepared areas with residual bacterial biofilms in the root canal

8. Even in small and/or rounded canals, micro-tomographic studies report that different instrumentation systems leave approximately 10% to 50% of the total surface area unprepared. These numbers can be even higher when only the apical surface of the canal is evaluated. In more complex canals such as oval/flat canals, the amount of intact surface area after preparation can vary from 10 % to 80

9. Merged micro-CT images depicting the root canals Green : pretreatment Red : post treatment

10. Instrumentation alone is not capable of touching all of the root canal walls.

11. The key objective of instrumentation and irrigation is to remove and eradicate the microorganisms residing in the necrotic root canal system 1. As independent free-floating cells (planktonic state). 2. As members of organized surface-attached microbial communities called biofilms.

12. Schematic representation of the microbial biofilm development stages. The first stage in biofilm formation includes initial attachment of the cells to a surface, followed by cells aggregation and formation of a monolayer along the surface and microcolonies in the second stage. The third step includes the formation of a mature community with mushroom-shaped macro-colonies . During the third stage, the biofilm structure can be disrupted, and microbial cells can be liberated and transferred into another location/surface, causing expansion of the infection

13. Why Bacteria Form Biofilms? Biofilms are composed of microorganisms that are embedded in extracellular matrix. Biofilms provide bacteria with protective environments against: a. Immune responses. b. Antibacterial agents. c. Antibiotics.

14. Free-floating microorganisms can be easily eliminated from the root canal. There is a major challenge to combat bacteria firmly attached to the root canal walls. This is especially so when microorganisms are in all areas of the canal space as well as in the dentinal tubules (lateral canals, apical delta, ramifications).

15. Planktonic bacteria are generally more sensitive to antimicrobial agents as they are in direct contact with the irrigant . The heterogeneous nature of bacterial biofilms makes the biofilm more resistant to antimicrobial agents

16. Although the terms CLEANING AND SHAPING are often used to describe root canal treatment procedures, reversing the order to SHAPING AND CLEANING more correctly reflects the fact that enlarged canals facilitate the cleaning action of irrigants and the removal of infected dentin.

17. PROPERTIES OF AN IDEAL IRRIGANT FOR ROOT CANAL TREATMENT Have aprolonged antimicrobial effect. Be non-irritating to the periapical tissues. Have low surface tension. Not stain tooth structure. Be able to completely remove the smear layer. Be able to disinfect the underlying dentin and dentinal tubules. Be non-antigenic, nontoxic, and non-carcinogenic to tissues surrounding the tooth. Have no adverse effects on the physical properties of exposed dentin. Have no adverse effects on the sealing ability of filling materials. Be relatively inexpensive.

18. BENEFITS OF USING IRRIGANTS IN ROOT CANAL TREATMENT Removal of debris. Prevent packing infected hard and soft tissue apically in the root canal and into the periapical area. Lubricate the canal walls. Destruction of microorganisms. Dissolution of organic debris. Opening of dentinal tubules by removal of the smear layer. Disinfection and cleaning of areas inaccessible to endodontic instruments

19. Chemically active solution Alkalis: sodium hypochlorite Antibacterial agents : chlorhexidin Oxidizing agents : hydrogen prioxide Chelating agents : EDTA

20. Sodium Hypochlorite Antimicrobial Properties Sodium hypochlorite is highly effective against a wide range of microorganisms, including bacteria , fungi , and viruses . It kills pathogens by disrupting their cell walls and inhibiting their metabolic functions. This makes it an excellent irrigating solution for cleaning and disinfecting the root canal system, which may harbor harmful microbes that can lead to infection or re-infection of the treated tooth.

21. 2. Tissue Dissolution One of the most important properties of NaOCl in endodontics is its ability to dissolve organic tissue , including necrotic pulp tissue , which may be present inside the root canal. This is crucial because it helps remove debris that can interfere with proper cleaning and filling of the canal. NaOCl helps break down and flush out tissue remnants, reducing the risk of infection and improving the success of root canal treatment. 3. Cleaning and Shaping During the root canal procedure, NaOCl is used as an irrigant to wash away debris from the root canal after mechanical instrumentation. The instrumenting and cleaning process leaves a variety of materials that need to be removed to ensure effective disinfection and to create space for filling. NaOCl also assists in the lubrication of the canal, making the cleaning and shaping process easier and more effective. 4. Concentration and Application Concentration : Sodium hypochlorite is typically used in concentrations ranging from 0.5% to 5.25% in endodontics. The concentration used depends on the specific needs of the procedure and the type of infection. Higher concentrations may provide more potent antimicrobial effects but can also be more irritating to the surrounding tissues. Application : NaOCl is delivered into the root canal system using syringes or irrigation needles . It is usually applied throughout the cleaning process to ensure continuous disinfection.

22. Temperature Increasing the temperature of low-concentration NaOCl solutionsimproves their immediate tissue-dissolution capacity Heated hypochlorite solutions remove organic debris from dentinshavings more efficiently. There are various devices to preheat NaOCl syringes; however, it wasdemonstrated that as soon as the irrigant touches the root canal system, thetemperature reaches the body temperature Therefore, in situ heating of NaOCl can be done by activating ultrasonic orsonic tips to the NaOCl inside the root canal for a couple of minutes

23. 6. Side Effects and Precautions While sodium hypochlorite is highly effective, it is important to use it carefully to avoid irritation or damage to the surrounding tissues. If it extrudes beyond the root apex (the tip of the root), it can cause tissue damage and significant discomfort, known as NaOCl extrusion injury . In rare cases, patients may experience a strong, unpleasant odor due to the chemical’s interaction with organic material in the canal.

24. Facial appearance of the patient after accidental NaOCl leakage from the rubber dam during endodontic treatment. Toxic effect of sodium hypochlorite on periradicular tissues. Osteonecrosis was evident after 3 weeks.

25. sodium hypochlorite accident

26. How to avoid problems that may be caused by NAOCL irrigation? 1) Precise evaluation of the working length is essential. 2) Placing the irrigation needle 1–3 mm short of working length. 3) A rubber dam should be used to prevent any leakage or contact of the solution to the soft tissue. 4) Permitting free movement of the needle within the canal (needle is not wedged in the canal)

27. Side vented needle is recommended over the open ended needles 1) To prevent extrusion of the irrigant through the apical foramen. 2) Side-vented and double sidevented needles lead to maximum shear stress concentrated on the wall facing the outlet.

28. The TruNatomy Irrigation Needle The back to back 2-sided vent design. Its soft polypropylene allows the needle to curve and flex easily to follow the root canal anatomy.

29. CHLORHEXIDINE (CHX) CHX is a wide-spectrum antimicrobial agent, active against gram-positive, gram-negative bacteria and yeasts. CHX belongs to the polybiguanide group with a pH between 5.5 and 7. CHX digluconate salt is easily soluble in water and very stable.

30. Mode of Action of Chlorhexidine Chlorhexidine, because of its cationic charges, is capable of electrostatically binding to the negatively charged surfaces of bacteria, damaging the outer layers of the cell wall and rendering it permeable.

31. Interaction between CHX and NaOCl When CHX is mixed with NaOCl , PARACHLOROANILINE precipitate is formed which may lead to tooth discoloration and might interfere with the seal of the root obturation The higher the concentration of NaOCl , the more precipitate is generated in the presence of 2% CHX.

32. Smear Layer Smear layer was defined by the American Association of Endodontists as: surface film of debris retained on dentin of canal walls after instrumentation either with rotary or hand instruments . It consist of dentin particles, remnant of necrotic or vital pulp tissue, bacterial component and retained irrigants . The importance of smear layer in endodontic treatment is still controversial, some researchers suggest removing it, others suggest retaining it as protection to bacterial invasion into dentinal tubules. To remove smear layer, we use Chelating agents

33. Common Chelating agent EDTA Citric Acid MTAD QMix

34. Ethylenediamine Tetra-Acetic Acid ( EDTA) Colorless soluble product. Common Chelating agent Effective on removal of smear layer and pose no effect on organic tissue. So irrigation with EDTA alone is not ideal. Also pose little or no antimicrobial activity. Concentration in endodontics is 17% Recommended irrigation time is 1 minutes or so. Irrigation for longer period cause erosion and softening of dentin

35. Mode of Action On direct exposure for extended time, EDTA extracts bacterial surface proteins by combining with metal ions from the cell envelope, which makes the cell envelope leaky, eventually leading to bacterial death. Also it inhibits the growth of microbes by chelating with the metallic ions needed for its growth Chelators such as EDTA form a stable complex with calcium. When all available ions have been bound, equilibrium is formed and no further dissolution takes place; Therefore, EDTA is self-limiting.

36. Citric Acid Used in 10% concentration in Endodontics Slightly more potent at similar concentration than EDTA More biocompatible than EDTA Less aggressive inflammatory response when it pass beyond the foramen

37. MTAD ( commercially known as BioPure ® and TetraClean ® Combination of antibiotic, citric acid and detergent. Used to gain both smear layer removal and antimicrobial action Antibiotic Enhance antimicrobial activity Citric acid Chelating agent detergent Decreasing surface tension to increase efficiency Clinical studies: As chelating agent proved equally effective as EDTA. As antimicrobial agent is less than optimal. As compared to 5.25% NaOCl , the latter proved superior antimicrobial action.

38. QMix New product introduced in 2011. Proved equally effective as EDTA in smear layer removal. As for antimicrobial activity, it proved effective. Further clinical studies from independent researchers needed in this matter. Lack tissue dissolution capacity, NaOCl irrigation is still required. Qmix contains: CHX-analog. Triclosan. EDTA.

39. Concentration Range of Irrigants Sodium hypochlorite ( 0.25% - 5.25% ) Chlorhixidine ( 0.2% - 2% ) EDTA ( 17% ) Citric acid (10%)

40. Interaction between irrigants Chx + NaOCl produce change in color and formation of a precipitate ( Parachloroanline ) may lead to tooth discoloration and might interfere with the seal of obturation and . So mixing of both irrigant should be avoided. And drying the canal with paper point before final irrigation with Chx .

41. Interaction between irrigants Chx + EDTA produce white precipitate and cancel the chemical action of Chx . Mixing is avoided.

42. Interaction between irrigants NaOCl + EDTA mixing take away the tissue dissolving capacity of NaOCl . As no free Chlorine ( the active agent in sodium hypochlorite) was found in the mixture. Mixing is to be avoided.

43. Penetration Depth of the Needle : The size and length of the irrigation needle—in relation to root canal dimensions is of the most importance for the effectiveness of irrigation. Diameter of the Root Canal: The apical diameter of the canal has an impact on needle penetration depth

44. Inner and Outer Diameter of the Needle The external needle diameter is of relevance for the depth of introduction into the root canal and for rigidity of the tip, an important consideration for irrigation of curved canals . the Common 27 gauge injection needles have an external diameter of 0.42 mm, but smaller irrigation tips with external diameters of 0.32 mm (30 gauge) are available.

45. Types of Irrigation Needles Figure 1: irrigation needles commercially available Open-ended Flat Open-ended Beveled Open-ended notched Close-ended Side vented Close-ended Double vented Close-ended Multiple vented Generally, open-ended needles generate more velocity of irrigation than close-ended. But close-ended are safer. Avoiding irrigation extrusion beyond the apex is more important than irrigation velocity.

46. Types of Irrigation Needles

47. Types of Irrigation Needles Side vented needles are used to prevent extrusion of the irrigant through the apical foramen. These needles lead to maximum shear stresses on the wall.

48. Types of Irrigation Needles 27 gauge injection needles barely reach the middle third. 30 gauge side vent needle reach the apical third as it’s of a smaller diameter .

49. IrriFlex Single use 30G flexible root canal irrigation needle with 2 back to back side vents

50. TruNatomy Soft Polypropylene tip allows the needle to curve and flex easily to follow the root canal anatomy. The back to back sided vent design

51. Technical tips for irrigation The needle should placed loosely in the canal and not bent. Deliver the irrigant drop-by-drop and not continuous flushing, especially NaOCl . Use index finger to press the needle head, instead of thumb, as less force will be delivered and always keep the needle in motion The irrigant technically will not go more than 1 mm away from the needle tip. Placing the irrigation needle 1-3 mm short of the working length Do not mix irrigants .

52. How much time for each irrigant ? NaOCl , still controversial, 30 minutes seems reasonable. Plus use files and irrigation synergistically EDTA , 1 minute is enough. Chlorhexidine , not reported. Use your own clinical judgment.

53. Does Temperature Affect Irrigant Efficiency? Heating sodium hypochlorite increase its efficiency by improving it’s immediate tissue-dissolution capacity, but once delivered into the canal it reaches body temperature. So activation with Ultrasonic or Sonic is still superior.

54. Irrigation Activation / Agitation Root canal poses several irregularities such as isthmuses and ramifications that can not be cleaned with regular irrigation . Moreover, studies have shown that 30% of root canal system is not irrigated with regular irrigation. For the above reasons, activation of irrigation is a necessity.

55. Apical vapor lock When sodium hypochlorite interaction with organic substances in the canal . It produces some gases which trapped in the last apical third of the canal preventing the irrigation To reach this area and cleaning it

56. Activation depends on 1- Oscillation 2-Aquastic streaming 3-Cavitation

57. Oscillation The oscillations produce acoustic streaming and microcavitation in the liquid.

58. The file oscillations are primarily responsible for the production of acoustic streaming, which is the movement of fluid in a vortex-like motion around the tip when pressure waves are projected through it. Acoustic streaming may also be associated with the occurrence of cavitation . Acoustic streaming

59. Cavitation Cavitation in irrigation refers to the formation , growth , and collapse of bubbles in a liquid due to rapid changes in pressure or energy . In endodontic irrigation Types of Cavitation 1-Stable Cavitation 2- Transient (Inertial)

60. Different techniques of activation Manual agitation Sonic and Ultrasonic activation Negative apical pressure Safety irrigator Laser activation system

61. 1- Manual Dynamic Activation ) agitation ( Cheapest method. Use master cone gutta percha , cut 2 mm from its tip. Place it in the canal and use vertical up and down strokes Recommended No. of strokes, 100 stroke per minute.

62. 2-Sonic activation Commercially know as EndoActivator ® Use vibrating movement 1500Hz-6000Hz / Second Place the tip into the canal and switched on. Simple as that. Less risk of perforation as compared with Ultrasonic system.

63. EDDY is a sonic powered endodontic irrigation tip made of polyamide & can be applied on air scaler

64. Vibringe system uses a syringe with sonic vibration that allows the delivery and activation of the irrigant in the root canal at the same time.

65. Ultrasound is sound energy with a frequency above the range of human hearing, which is 20 kHz. The range of frequencies employed in the original ultrasonic units was between 25 and 40 kHz. There are two basic methods of producing ultrasound is magnetostriction , piezoelectric 68 Ultrasound

66. 3-Passive Ultrasonic activation (PUI) Vibtation movement reach 20,000 Hz / second and more. Activate irrigation by concept of acoustic streaming . Sonic or Ultrasonic? Studies contradict each other, but majority of the studies prefer Ultrasonic one.

67. The physical effects created by the production of ultrasound are Acoustic Microstreaming cavitation Heat Biophysical effects of Ultrasonics

68. Ultrasonic activation is also able to increase the temperature of the surrounding irrigant in a root canal up to 10 degrees Celsius. It has been shown that heating sodium hypochlorite greatly increases tissue dissolution. 71 Heat

69. The current evidence on the effect of ultrasonic dental equipment on cardiovascular implantable electronic devices (pacemakers) is inconclusive . Current guidelines recommend the avoidance of magnetostrictive devices on those patients with pacemakers, whereas the use of piezoelectric devices does not appear to affect pacemakers. 72 Pacemakers

70. Benefits 1. Enhanced Debris Removal 2. Improved Smear Layer Removal 3. Better Apical Cleaning 4. Enhanced Penetration of Irrigants 5. Reduced Treatment Time 6. increases removal of organic and inorganic debris from the root canal

71. PUI ACOUSTIC STRE A MING : is phenomenon that occurs when high-frequency sound waves (such as those from ultrasonic devices) cause the movement of fluid in a steady, unidirectional flow. In endodontics, this effect is harnessed during ultrasonic activation of irrigants to improve cleaning and disinfection within root canals.

72. ENDO U L TRA Cordless Ultrasonic Endo Activation Device

73. 4-Negative apical pressure Commercially known as EndoVac ® The main advantage of this technique is safety . M i n imi z es the risk of ap i cal e x trus i o n a n d po t en tial for sodium hypochlorite accident

74. ( En d o V a c )

75. ENDOSAFE PLUS

76. Safety irrigator Similar in functionality to EndoVac ® system

77. RinsEndo

78. 5-Gentle wave system ( noninstrumentational ) G W system delivers e n ergized i r r i g a tion soluti o n, and t he buil t - in suction r e m o ves the outflowing fluid creating negative pressure within the root canal system. Muli sonic ultracleaning Fluid dynamics Negative pressure

79. 6-Laser activation system (LAI) New Modern technique Several studies indicated that laser is promising for removing smear layer and dentin debris in less time than Ultrasonic

80. Laser activation system LAI The mechanism of this interaction has been attributed to the effective absorption of laser light by sodium hypochlorite making micro-explosions This leads to the vaporization of the irrigant and to formation of vapor bubbles , which expand and implode with secondary cavitation effects

81. Photon-induced photoacoustic streaming (PIPS) The PIPS technique is based on the power of Erbium: YAG laser to create photoacoustic shock waves within the irrigant introduced in the canal

82. Xp -finisher

83. Abstract study evaluates the efficiency of laser and ultrasonic irrigation activation methods in removing smear and debris from root canals in two types of endodontic access cavity designs: Traditional Endodontic Cavity (TEC) and Conservative Endodontic Cavity (CEC) . The research used 60 human mandibular molar teeth, comparing three irrigation protocols: conventional needle irrigation , passive ultrasonic activation , and laser activation .

84. Findings Access Cavity Design : There was no statistically significant difference in smear and debris removal between TEC and CEC designs Irrigation Activation Methods : Laser activation was significantly more effective than ultrasonic activation and conventional needle irrigation in removing smear and debris. Smear and debris removal was most challenging in the apical region, regardless of the access cavity design.

85. Conclusion Laser activation demonstrated superior efficiency in cleaning root canals compared to ultrasonic and conventional needle methods. However, access cavity design (TEC or CEC) did not significantly affect the cleaning efficacy, suggesting that both cavity types are similarly effective when paired with advanced irrigation activation techniques .

86. References Cohen Pathways of Pulp, Chapter 6, Cleaning and Shaping of Root Canal System. Endodotnics : Principle and Practice. 5 th edition, Chapter 16, Cleaning and Shaping. Matthias Zehnder , JOE, Volume 32, Number 5, 2006. Root Canal Irrigants JOE, Irrigation Trends among American Association of Endodontists Members: A Web-based Survey