12 Trends
Edition
1-2-3 steps in endodontic irrigation
By Philippe Sleiman, DDS, DUA, MSc, PhD, FICD
Irrigation has an important
role during endodontic treat-
ment. To achieve the best chem-
ical preparation possible, we
propose an optimal sequence
for the use of various irrigating
agents.
During the last several years,
endodontics has progressed to the
point that treatment is less trau-
matic for the patient and less
stressful for the dentist. However,
if the use of nickel titanium rotary
instruments has allowed us to
gain time during endodontic
treatment, it has also tempted us
to neglect one of the main objec-
tives of endodontics: the "clean-
ing" that Dr. Herbert Schilder em-
phasized when he insisted on
"cleaning and shaping" the root
canal. It may be more appropriate
to say, "shaping for cleaning."
The main goal of the root canal
treatment is to completely elimi-
nate the different components of
the pulpal tissue, calcification,
and bacteria, and to place a her-
metic seal to prevent infection or
reinfection and to promote heal-
ing of the surrounding tissues if
needed.
There are many techniques
available to accomplish the root
canal preparation. There are also
many techniques for filling the
root canal system (i.e., vertical
compaction of warm gutta-per-
cha, System B, lateral condensa-
tion, etc.).
We must ask ourselves the
question: "Why do we irrigate and
what irrigation protocol will pro-
vide the cleanest canal?" In this
context, remember that shaping is
Fig. 1a
the result of endodontic instru-
ments, while cleaning results
from irrigation. Therefore, we
have two types of preparation:
chemical and mechanical. This
article addresses chemical prepa-
ration.
The close correlation between
these two types of preparation has
been proven. In fact, with greater
tapered preparations, the quantity
and the concentration of the irri-
gating solution will be greater and
will therefore better eliminate the
smear layer.1 Files can clean only
parts of the root canal system.
They create a reservoir that can
hold the different irrigating solu-
tions, which will access and clean
portions of the root canal system
that the instruments cannot
reach.
In endodontics, the most com-
monly used irrigating solution is
sodium hypochlorite (NaOCl). It
has many desirable qualities and
properties. It performs bacterici-
dal cytotoxicity, dissolution of or-
ganic material, and minor lubrifi-
cation.2 But sodium hypochlorite
by itself is not sufficient for total
cleaning of the endodontic sys-
tem.3 It has no effect on the smear
layer and its high surface tension
does not allow for cleaning and
disinfection of the root canal sys-
tem's totality. For this reason, and
according to individual clinical
situations, we must use other irri-
gants in combination with sodium
hypochlorite.
This article does not address
retreatments and dissolving obtu-
ration material. Our discussions
here are limited to vital and
necrotic teeth, as well as those
Fig. 1b
ENDO TRIBUNE
teeth with internal resorptions.
The various irrigants that will be
used according to the clinical sit-
uations are:
• EDTA (Ethylene diaminetetra-
acetic acid) (17%) (Smear Clear,
SybronEndo, Orange, Calif.)
• Chlorhexidine 0.2%
• Sodium hypochlorite 5.25%
• Citric acid 50%
• Distilled water
In general, the most common
step after accomplishing the access
cavity is the introduction of an en-
dodontic file in the root canal. But
this step should not be considered
automatic, for many reasons.
These include:
• The spread of bacterial toxins in
all of the endodontic system and in
the periapical area will affect a
successful prognosis for the en-
dodontic treatment due to the
post-operative "flare-up" that may
occur.
• The breakdown and accumulation
of pulp tissue with its collagenic
may create an organic plug within
the root canal.
Remember that the access cavity,
having four walls, will create a
"reservoir" for the irrigation solu-
tions to be frequently and continu-
ously refreshed.
Vital teeth
In clinical cases such as the one
shown in Figs. 1a and b, we are
Figs. 1a-b:
Several anterior
teeth treated in a
single session using
K3 rotary files.
U.S.
challenged with treating the com-
plexities of the different compo-
nents of the pulp, and eventually
the presence of bacteria. For these
cases we suggest the following irri-
gation sequence.
Step 1:
Apply sodium hypochlorite
and/or urea peroxide
The purpose of this mixture is to:
• Create a collagenic anti-aggre-
gation effect due to the prote-
olytic and lipidic affinity of urea
peroxide.4
• Destroy the biggest amount of
pulp tissue inside the access cav-
ity and provide a better view of
the canal orifices by controlling
bleeding and preventing any col-
lagenic plugs from forming.
At this stage the EDTA is only
important for its antibacterial ef-
fect in combination with other an-
tibacterial agents.4
Step 2:
Irrigate with 2ml of sodium
hypochlorite 5.25 percent (60°C)
The warm NaOCl is more effi-
cient in destroying the collagen
and this will reduce the time
needed for the elimination of the
organic portion of the tissue. This
irrigation will create an efferves-
cent effect between the sodium
hypochlorite and urea peroxide.
This "elevator effect" will evacu-
ate the organic debris outside the
access cavity, disorganize the
coronal pulp tissue, and help to
better detect the canal orifices.5,6
Step 3:
Apply sodium hypochlorite
again and activate using a
K file (08-10).
This will disorganize the pulpal
tissue in both the cervical and
middle thirds of the endodontic
system. This step has to be pre-
ceded by an abundant irrigation
with distilled water in order to
eliminate the first mixture pres-
ent in the access cavity.
Step 4:
Once the preparation of
the canal has begun, apply
Smear Clear (SybronEndo,
Orange, Calif.) (17 percent
EDTA cetrimide, and
surfactants)
The EDTA is an organic acid
that eliminates the mineral part of
pulp tissue;7,8 the surface tension
inhibiter will allow better contact
with the dentin for higher effi-
ciency.
ENDO TRIBUNE U.S. Edition
We advise alternating the use of
EDTA from the beginning of the
preparation in order to eliminate
the mineral layer before it thick-
ens and condenses inside the
canal systems, closing the en-
trances of lateral and accessory
canals and dentinal tubules.
Trends 13
tion, using a small-diameter file,
is advised for a more efficient
chemical preparation.
The early use of EDTA facili-
tates the flow of the different irri-
gants in the lateral canals, permit-
ting a chemical preparation of the
endodontic system. 9 EDTA also
plays an important role in the re-
duction of inflammatory reaction
by inhibiting the affinity of
macrophages to the vaso-active
peptides of the pulpal tissue.10 The
EDTA should not be inside the
canal for longer than 4 or 5 min-
utes.
Chlorehexidine can be used for
a total elimination of the bacteria
inside the canal. Distilled water is
used between each irrigating so-
lution to prevent an acid/base re-
action between sodium hypochlo-
rite and EDTA and for a more effi-
cient action of the chemicals on
the tissues. Copious irrigation is
Fig. 2: necessary to neutralize all the
A central incisor chemical agents by the end of the
treated in two sessions.
The pulp was necrotic preparation and before the fitting
and some swelling of the gutta percha cones so that
was noticed.
the master cone does not push
any of the chemicals outside the
canal, potentially causing an in-
flammation of the surrounding
Each time a rotary file is work- tissues.11
ing inside the canal, irrigating so-
lution must be present. Ultrasonic
activation of the irrigating solu- ET page 14
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14 Trends ENDO TRIBUNE U.S. Edition

ET page 13
Necrotic teeth
The main difference between
vital teeth and necrotic ones is the
absence, not in total, of the pulpal
parenchyme and the abundance
of bacteria present in the latter.
Figs. 2 and 3 illustrate necrotic
cases.
Irrigation should be initiated
with either sodium hypochlorite
(5.25%, 60ºC) for its bacterial ef-
fect or with chlorohexidine
(0.2%) (10 minutes)12 for the elim-
ination of various bacterial types
present in the root canals and
dentinal tubuli.13 Distilled water
should be used to neutralize the
effect of these irrigants. Then the
same irrigation sequence de-
scribed previously for vital teeth
should be repeated.
By eliminating the smear layer
and opening the dentinal tubuli,
the EDTA will permit an easy flow
of NaOCl or chlorhexidine for a
better disinfection of the en-
dodontic system. In both clinical
situations (vital and necrotic
teeth) it is necessary4,14,15 to end
our sequence by using distilled
water to eliminate the chemical
agents or to neutralize their ef-
Fig. 3
fects. This will inhibit their flow
toward the periodontal tissues,
the alteration of the filling materi-
al, and the formation of a precipi-
tating layer due to the crystalliza-
tion of sodium hypochlorite after
drying the canal walls.
Presence of resorptions
When we suspect an internal
resorption, the irrigation se-
quence is the same as was de-
scribed for vital teeth. But this se-
quence should be followed by the
use of citric acid 50 percent (10
minutes) to eliminate the granu-
lation tissue and to obtain smooth
dentinal walls. This will amelio-
rate the adaptation of the filling
Fig. 3:
An upper canine
treated in one
session, after a
crown fracture of
the composite
filling.
Fig. 4:
A retreatment
of two lower
premolars. Fig. 4
material. The citric acid is elimi- chlorhexidine, citric acid, distilled
nated by NaOCl and distilled water, and EDTA is essential for
water. The same sequence is the cleaning of the endodontic
adopted for external apical re- system.3,16,17
sorptions but with an activation of
the patency. The time we gain by using ro-
tary NiTi instruments should be
offset by abundant irrigation for a
better cleaning of the endodontic
Discussion system. This will contribute to the
Many types of irrigants can be increased success rate of en-
used in endodontic treatment, dodontic treatment.
such as H2O216, anesthetic solu-
tions, physiological serum, and Chemical preparation is a dou-
de-ionized water. Our proposed ble-edged sword: it will help us
sequence of irrigation can become achieve adequate cleaning of the
more complex to address different main canal and its systems, but it
clinical situations (Fig. 4). must be followed by a 3-dimen-
sional obturation to fill all the
The alternate use of urea per- spaces that have been cleansed
oxide, sodium hypochlorite, and prepared.

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ENDO TRIBUNE U.S. Edition Trends 15

Perfect absorption of the fluid is root canal systems and accomplish- tray—has to be systematically eval- (Editor’s note: This article originally ap-
essential in the main canal and all of ing a 3-dimensional obturation. uated in order to become an en- peared in Oral Health and Dental Practice
its systems. If this is not accom- dodontic entity having a precise Management, and appears here in revised
plished, adherence between the With the introduction of new chronology and codification. ET form by permission of the author.)
sealer and the dentin will be com- materials for root canal obtura-
promised. In addition, the presence tion and progress toward adhesive
of the fluid inside the systems can endodontics, the root canal irriga- ET About the author
create negative hydraulic pressure, tion/chemical preparation is com-
preventing the obturation material parable (with some small modifi- Philippe Sleiman, DDS, DUA, MSc,
from entering the complexity of the cations) to dentine and enamel PhD, FICD, is an endodontist and in-
conditioning prior to the use of structor at the Lebanese University
adhesive restorative materials. Dental School. He lectures and con-
References ducts hands-on endodontics courses
worldwide and has contributed to sev-
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techniques: a scanning electron mi- Irrigation is often dismissed uted by Hu-Friedy.
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and calcium hydroxide. Int End J usually reduced to a needle on the
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