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The use of irrigating solutions is an important


part of effective chemomechanical preparation.
˜ Antibacterial agent.

˜ Tissue solvent.

˜ Flush debris.

˜ Lubricant.

˜ Eliminate the smear layer.


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a xoncentration of irrigant.
a The volume of the solution used.
a xanal diameter.
a The viscosity or surface tension of the solution.
a The diameter and depth of penetration of the irrigating
needle.
a The anatomy of the canal.
a The method of delivering the irrigant.
a xontact time with the tissue.
a Temperature of the irrigant.
a Ultrasonic activation.
a The effect of combining different types of solutions.
Ô 
Ô 
˜ Antibacterial agent
˜ Dissolves vital and non-vital tissue. However
vital tissue takes longer to dissolve
˜ Lubricant during instrumentation
NaOxl has been criticized for

˜ Unpleasant taste
˜ Relative toxicity
˜ Inability to remove smear layer
]   Ô
Ô 
a HOxl exerts its effects by oxidizing sulphydryl
groups within bacterial enzyme systems, thereby
disrupting the metabolism of the microorganism,
resulting in the killing of the bacterial cellsO
a Unbuffered solution at pH 11 in concentration 0.5±
5.25% , and buffered with bicarbonate buffer (pH 9.0)
usually as a 0.5% solution (Dakin's solution).
Ô 
a ]uffering had little effect on tissue dissolution.
a Dakin's solution was equally effective on necrotic and
fresh tissues.
a No differences were recorded for the antibacterial
properties of Dakin's solution and an equivalent
unbuffered hypochlorite solution
Ñ    

è 



 
  

˜ Appropriate concentration
˜ Method of delivery
˜ xellular damage caused by extrusion into the
periradicular tissues.

| 
    

a High resistance of u  and the high susceptibility


of   
 to NaOxl..
a   
 was killed in vitro in 30 s by both 5% and
0.5% NaOxl.
a u   killed in less than 30 s by the 5.25%
solution, while it took 10 and 30 min for complete
killing of the bacteria by 2.5% and 0.5% solutions.
u  
    
 
     
   


|
    

a Although 0.5% NaOxl, with or without (EDTA),


improved the antibacterial efficiency of preparation
compared with saline irrigation, all canals could not
be rendered bacteria free even after several
appointments.
a No significant difference in antibacterial efficiency 

 between 0.5% and 5% NaOxl solutions.

]  
!"!#
ë$  

The 
  studies performed in
a A test tube.
a Root canals of extracted teeth.
a Prepared dentine blocks infected with a pure culture of
one organism at a time.

The 
  studies, on the other hand, have focused on
the elimination of microorganisms from the root canal
system in teeth with primary apical periodontitis..
ë 
 

Explanation to poorer in  performance

˜ Root canal anatomy, in particular, the difficulty in


reaching the most apical region of the canal with large
volumes of fresh irrigant.
˜ xhemical milieu in the canal is quite different from a
simplified test tube environment
x 
xompared the biological effects of mild and strong
NaOxl solutions and demonstrated greater cytotoxicity
and caustic effects on healthy tissue with 5.25% NaOxl
than with 0.5% and 1% solutions.
   
!#

Either 5.25% or 2.5% sodium hypochlorite has the


same effect when used in the root canal space for a
period of 5 minutes.
% &'   
((
x 
a 5% NaOxl may be too toxic for routine use. They
found that 0.5% NaOxl solution dissolves necrotic
but not vital tissue and has considerably less toxicity
than a 5% solution.
a They suggested that 0.5% NaOxl be used in
endodontic therapy.
&)'$ ' 
(
x  *+x

xommented that ³It seemed probable that there would


be a greater amount of organic residue present
following irrigation of longer, narrower, more
convoluted root canals that impede the delivery of the
irrigant.´
]' x 

The ability of an irrigant to be distributed to the apical
portion of a canal is dependent on:

˜ xanal anatomy

˜ Size of instrumentation
˜ Delivery system
x  *+x

xommented that ³The effectiveness of low


concentrations of NaOxl may be improved by using
larger volumes of irrigant or by the presence of
replenished irrigant in the canals for longer periods of
time.´
]' x 

x  *+x

a The efficacy of 0.5%, 2.5% and 5.25% sodium


hypochlorite (NaOxl) as intracanal irrigants
associated with hand and rotary instrumentation
techniques against u  within root canals and
dentinal tubules.
a 5.25% NaOxl has a greater antibacterial activity
inside the dentinal tubules infected with u 
than the other concentrations tested.

O ] $   
, 
Ô
Ô    
 
 


  

a Demonstrated that 5.25% sodium hypochlorite


dissolves vital tissue.
u     (!
a As a necrotic tissue solvent, 5.25% sodium
hypochlorite was found to be significantly better than
2.6%, 1%, or 0.5%.
-   (!

a 3% sodium hypochlorite was found to be optimal for


dissolving tissue fixed with parachlorophenol or
formaldehyde
%. / (
Ô   ! 


˜ The antibacterial efficacy of sodium hypochlorite, is


increased when it is used in combination with other
solutions, such as calcium hydroxide, EDTAx, or
chlorhexidine.
˜r he bactericidal effect gained by combining
sodium hypochlorite with other chemicals comes from
the release of chlorine gas.
Ô   ! 

*+xx
+-

a Pretreatment of tissue with calcium hydroxide can


enhance the tissue-dissolving effect of sodium
hypochlorite..
- '   
!!

a xombination of calcium hydroxide and sodium


hypochlorite was more effective on the dissolution of
soft tissue on the root canal wall than using either
medicament alone.
  
!
*+xx
+-

a xomplete chemomechanical instrumentation combined


with 2.5% sodium hypochlorite irrigation alone
accounted for the removal of most tissue remnants in
the main canal. Prolonged contact with calcium
hydroxide after complete instrumentation was
ineffective.
a Tissues in inaccessible areas of root canals were not
contacted by calcium hydroxide or sodium hypochlorite
and were poorly débrided.
0'  !
*+x1/%ë

xombining 5.0% sodium hypochlorite with EDTA


enhance considerably the bactericidal effect.

]  
!#
*+xx-2

The alternate use of sodium hypochlorite and


chlorhexidine gluconate irrigants resulted in a greater
reduction of microbial flora (84.6%) when compared
with the individual use of sodium hypochlorite
(59.4%) or chlorhexidine gluconate (70%) alone.

3 3
!
*+xx-2
a The time required to eliminate u  depended on
the concentration and type of irrigant used.

a xhlorhexidine in the liquid form at all concentrations


tested (0.2%, 1% and 2%) and NaOxl (5.25%) were the
most effective irrigants. However, the time required by
0.2% chlorhexidine liquid and 2% chlorhexidine gel to
promote negative cultures was only 30 s and 1 min,
respectively.
   

% & 

a Higher temperatures potentiate the antimicrobial and


tissue-dissolving effects of NaOxl.
a Increasing the temperature of hypochlorite irrigant to
370x, significantly increased its tissue dissolving
ability
x'] 45
!
% & 

a ]oth the debriding and disinfection properties of 2.6%


NaOxl are enhanced in vitro by elevating the
temperature of the solution to 370x.

x'  
!
|
The volume of the irrigant has a greater potential to
significantly reduce bacteria colonies in root canal.

]4   (#]6/(#x'! x' 


 !    '   #
x 
"x 
 
"#$%

˜ It possesses a broad-spectrum antimicrobial action and


a relative absence of toxicity.
˜ xHX lacks the tissue-dissolving ability.

˜ It penetrates the cell wall and attacks the bacterial


cytoplasmic or inner membrane or the yeast plasma
membrane.
˜ xoncentrations between 0.2% and 2%.

˜ Its activity is pH dependent and is greatly reduced in


the presence of organic matter.
 
"#$%
a In direct contact with human cells, xHX is cytotoxic; a
comparative study using fluorescence assay on human
PDL cells showed corresponding cytotoxicity with
0.4% NaOxl and 0.1% xHX.
x    O
 
"#$%
m It has a wide antimicrobial spectrum and is effective against
both Gram-positive and Gram-negative bacteria as well as
yeasts, while mycobacteria and bacterial spores are resistant to
xHX 
      ëO O

m xHX is not considered to be an effective antiviral agent, , and


its activity is limited to lipid-enveloped viruses (Park J] & Park
NH. 1989).

m In direct contact with human cells, xHX is cytotoxic; a


comparative study using fluorescence assay on human PDL cells
showed corresponding cytotoxicity with 0.4% NaOxl and 0.1%
xHX ( xhang et al. 2001).

|  
    #$

a à  xHX is superior to NaOxl in killing of u 


 and   .
   
 
+'  
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|  
 

a xHX effectively killed   



]4 ëë
!
-  

-   
,
  

à 
    #$

There are no 
 studies yet available that would
confirm the better activity of xHX against u 
in the infected root canal.
ÿ   

ÿ 
ÿ 

x    
   
   

      
 
 
 
 
   

   
  
  
O x    
    O  O


     O      
 
    
   
O
 
   

 
    
 
      
   
      


  O   
 



      
    

    ››    


 
 
    
   O   



    
 
   
      
   

           
   O
   


        
 O

   
 
         
   O
#$ ›#&&

a à
 , 3% H2O2 and xHX was superior in its
antibacterial activity (u  ) compared with
other regimens such as xHX alone and NaOxl.
- 'x 
!

a The combination of the two substances totally killed


u  in concentrations much lower than each
component alone.
 $ '  

#$ #&&

˜ It can be postulated that the exposure of bacteria to


xHX leads to a more permeable cell wall that H2O2
can penetrate easily and hence damage the intracellular
organelles.
#$ #&&

˜ There are No reports of clinical studies where the


combinations of xHX and H2O2 have been used to
disinfect the root canal system.
˜ xytotoxicity of the medicament combinations should
first be investigated. Interestingly, combinations of
xHX and carbamide peroxide have been shown to be
additive in their cytotoxicity (]  O).
x-2
a A potential weakness of xHX in the root canal may be
its susceptibility to the presence of organic matter.

u  ë/  /  "

a In an 
 study, the effect of xHX is showed to be
reduced, although not prevented, by the presence of
dentine. -&  

a xHX was strongly inhibited by dentine matrix (the


organic component of dentine).
    

- +
# &&
˜ It is a clear, colorless liquid.

˜ Used in a variety of concentrations, 1% - 30%.

˜ 0  is active against viruses, bacteria, and yeasts.

˜ It produces hydroxyl free radicals (‡OH), which attack


several cell components such as proteins and DNA.
˜ In endodontics, 0  has long been used because of its
antimicrobial and cleansing properties.
˜ It has been particularly popular in cleaning the pulp
chamber from blood and tissue remnants, but it has
also been used in canal irrigation.

| 
    #&&

a ]acteria counts were greatly reduced when 10% 0 


was used as part of the irrigating protocol., but the
protocol used could not predictably produce sterile root
canals in monkey teeth.
   

@
    #&&

a A combination of NaOxl and 0  was no more


effective against u  in contaminated root canals
than NaOxl alone.
   
(
#&&

Although 0  has long been used in disinfection and


canal irrigation in endodontics, the available literature
does not support its use over that of other irrigating
solutions.
!@'
%ë/
a A —ixture of etracycline isomer, cid, and etergent.
(doxycycline, citric acid, and the detergent Tween-80))
a It has antibacterial activity.
a It has low pH 2.15
%ë/
a The tissue-solubilizing action of MTAD, NaOxl, and
EDTA was compared.
a MTAD solubilized dentine well, whereas organic pulp
tissue was clearly more unaffected by it.
] 7  
"
%ë/*+x
a The effect of various concentrations of NaOxl as an
irrigant before irrigation with MTAD as a final rinse on
the smear layer was evaluated.
a The results showed that MTAD removed most of the
smear layer when used alone; however, remnants of the
organic component of the smear layer could be detected
on the root canal walls.
a There were no significant differences between the ability
of 1.3%, 2.6%, and 5.25% NaOxl as root canal irrigants
and MTAD as a final rinse to remove the smear layer.
All combinations removed both the smear layer as well
as the organic remnants.
%$ 5  "
@
    %ë/

a I
 study, the antibacterial effects of MTAD,
NaOxl, and EDTA were compared using a disk-
diffusion test on agar plates.
a The results showed that even highly diluted MTAD
produced clear zones of inhibition of the test
bacterium, u 
%$ 5   "
@
    %ë/

I
 study, the effect of MTAD on root canals
contaminated with either saliva or u  was
evaluated, and reported good antibacterial activity.

$'  
"
$'%$ 5
"
x 8 %ë/

a xytotoxicity of MTAD was evaluated on fibroblasts.


a MTAD is less cytotoxic than eugenol, 3% 0  ,
xa(OH)2 paste, 5.25% NaOxl, Peridex (a xHX mouth
rinse with additives), and EDTA, but more cytotoxic
than 2.63%, 1.31%, and 0.66% NaOxl.
Ñ'  
"
]/ë
]/ë
]
—(]DA)
˜ Low toxicity
˜ Lubrication action
˜ Disinfecting ability
˜ Low surface tension
˜ xhelating properties.
˜ Low incidence of post-treatment pain.

a ]is-dequalinium acetate is recommended as an excellent


]is-
substitute for sodium hypochlorite in those patients who
are allergic to the latter.
3!
]/ë
a Goldberg et al (1986), rated ]DA as superior to sodium
hypochlorite in débriding the apical third.
a When marketed as Ô  , the University of
Malaysia reported a remarkable decrease in
postoperative pain and swelling when ]DA was used.
a They attributed these results to the chelation properties
of ]DA in removing the smear layer coated with
bacteria and contaminants as well as the surfactant
properties that allow ]DA ³to penetrate into areas
inaccessible to instruments
|  
   





Removal of root canal debris seems to be related to:

˜ xanal diameter (  
   
  
      
˜ |iscosity or surface tension of the solution.
˜ Diameter of the irrigating needle.
˜ Depth of penetration of the irrigating needle.
˜ |olume of the solution used.
˜ Anatomy of the canal. u
((
Previous studies showed that both mechanical and
chemical action of the irrigant were dependent upon:

˜    
    
   
   
˜       

    

 

  O  
     

r  
           
 


   O
O
˜   
  

    

  

 r   
˜         

x


  
O
O   O 
  O     O 
O O
O
@ 

 


  

The mechanical efficacy of 6 mL of   in


reducing intracanal bacteria was significantly greater
when delivered 1 mm compared with 5 mm from
WL.

 '  
#
 ( )
 ( )
       
 
 
  

    

+'ë9':
˜ xitric acid (1%
( - 50% ).
˜ Polyacrylic acid (e.g. Durelon and Fuju II liquids).

 
˜ xarbamide peroxide.
˜ Aminoquinaldinium diacetate (i.e., Salvizol).
x   ë 
˜ EDTA
Removal of the smear layer by EDTA (or citric acid)
improves the antibacterial effect of locally used
disinfecting agents in deeper layers of dentine.

U 4-&

1 x

a 10% citric acid was more effective in removing the


smear layer from apical root-end cavities than
ultrasound.
  


a 10% citric acid was more effective in dentin


demineralization than 1% citric acid, which was more
effective than EDTA.
;  

1 x

a Irrigation with 17% EDTA, 6% phosphoric acid and


6% citric acid did not remove the entire smear layer
from the root canal system. In addition, these acidic
solutions demineralized the intertubular dentine around
tubular openings, which became enlarged.
a The xO2 laser was useful in removing and melting the
smear layer on the instrumented root canal walls, and
the Er : YAG laser was the most effective in removing
the smear layer from the root canal wall.
%4   

m  
       
   
 

    
O
xanal wall m

 by acid Midroot canal (citric acid)

Midroot canal (phosphoric acid) Apical area (phosphoric acid


1 x

Excellent filling results after preparation with citric


acid (20%), followed by 2.6% sodium hypochlorite
and a final flushing with 10% citric acid.
   
(
 


 



˜ EDTA (ethylene-diaminetetra-aceticacid)
˜ EDTAx (ethylene-diaminetetra-aceticacid &centrimide)
˜ File-Eze
˜ Rx Prep
1/%ë
1/%ë

˜ EDTA (17%, disodium salt, pH 7)


˜ EDTA has little if any antibacterial activity.
˜ It effectively removes smear layer by chelating the
inorganic component of the dentine.
˜ Aid in mechanical canal shaping.
1/%ë
a The ultrastructure on canal walls after EDTA and
combined EDTA & NaOxl irrigation was evaluated by
scanning electron microscopy.
a More debris was removed by irrigation with EDTA
followed by NaOxl than with EDTA alone.

*  

a The optimal working time of EDTA is 15 minutes,
after which time no more chelating action can be
expected.
a EDTA solutions should replaces in the canal each 15
minutes.

$ '& $ '


!
m The optimal pH for the demineralizing efficacy of
EDTA on dentin was shown by |aldrighi (1981) to
be between 5.0 and 6.0.276
m Goldberg and Abramovich (1977)have shown that
EDTAx increases permeability into dentinal tubules,
accessory canals, and apical foramina.
xoronal portion of canal of 
  endodontically treated
tooth with u  The tubules are open, and the canal is
clean and free of smear. , Filed canal treated with
EDTAx.Longitudinal section of dentinal tubules shows thin
intertubular matrix.
m Mcxomb and Smith(1975) found that EDTA (in its
commer- cial form, REDTA), when sealed in the
canal for 24 hours, produced the cleanest dentinal
walls
m Goldman et al. (1981) have shown that the smear
layer is not removed by sodium hypochlorite
irrigation alone but is removed with the combined use
of REDTA.
m        
 
 
  

    
O  
 
  
     
   
 




O      
 

     
 

        
 



 
       O
ux; &
ux; &
a Rx-Prep is composed of EDTA and urea peroxide in a
base of xarbowax.
a It is not water soluble.
a NaOxl & Rx-Prep
Interaction of the urea peroxide in Rx-Prep with sodium
hypochlorite, producing a bubbling action thought to
loosen and help float out dentinal debris.
ux; &
a A residue of Rx-Prep remains in the canals in spite of
further irrigation and cleansing.
Ñ$''  
(#

a Rx-Prep allowed maximum leakage into filled canals


over 2.6 times the leakage of the controls.
x4   
(,
¦  
 

¦  
 

a The flushing action of the irrigant solution may be


more important than the ability of the irrigant solution
to dissolve tissue.
]  O 

a Most of the dentine debris is inorganic matter that


cannot be dissolved by NaOxl. Therefore, removal of
dentine debris relies mostly on the flushing action of
irrigant.
¦  
 

a The enhancement of the flushing action of an irrigant


solution by using ultrasound is well documented.


x'! x'   ! 
4<    "<      

a The ultrasound device allow the endodontic irrigant to


pass along the ultrasonic files. The irrigant is activated
by the ultrasonic energy imparted from the energized
instruments producing acoustic streaming and eddies.

ë   !( 3    !! 4 
¦  
 

     


  
  
 
 
 



O

x'
! 
x'   
!
¦  
 

a Ultrasonic proved superior to syringe irrigation


alone when the canal narrowed to 0.3 mm (size
30 instrument) or less.
less.
% &4   !(
@


 

˜ ]eveled needle
˜ Monoject endodontic needle.
˜ ProRinse probes.
a Monoject endodontic needles to be the most efficient
delivery system in which longer needles of a blunted,
open-end system were inserted to the full length of
the canal.
a The point is that a larger volume of solution can be
delivered by this method. However, the closer the
needle tip is placed to the apex, the greater the
potential for damage to the periradicular tissues.

 -  
!
ProRinse

- It has closed-end and side vent.


- It eliminates possibilities of puncture of the apical foramen.
- Expression of fluid through the lumen creates turbulence around
and beyond the end of the probeί
a Evaluated were ]ecton-Dickinson 22-gauge needles;Monoject
endodontic needles, 23 and 27 gauge; ProRinse 25-, 28-, and
30-gauge probes ; xaviEndo ultra- sonic handpiece; and the
MicroMega.

a r         


  


  
  O 

 

 
    
      


 
   
     O
   
 
   
 
 
      
 

 

3u $ ' 


a The most important factor is the delivery system and
not the irrigating solution per se.
a The volume of the irrigant is more important than the
concentration or type of irrigant.
%$ 5
a In order to be effective, the needle delivering the
solution must come in close proximity to the material
to be removed.´
a Small diameter needles were found to be more
effective in reaching adequate depth but were more
prone to problems of possible breakage and difficulty
in expressing the irrigant from the narrow needles.
ë$;u
!
 =
! ¦

a It is   !!  that the   


"  in the canal and not engage the walls.
a The solution must be introduced slowly.
a The irrigating needle should be bent to allow easier
delivery of the solution and to prevent deep
penetration of the needle.
a xare must be taken with irrigants like sodium
hypochlorite to prevent accidents.
a There are inherent differences in the 
 test
model from the 
 situation.
a à
 variables that affect delivery of the irrigant are
canal length and quality of instrumentation. à

results, although potentially valuable, cannot be
directly extrapolated to the 
 situation..