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
1. Chlorhexidine gluconate
2. Hydrogen peroxide 3%
3. Urea peroxide10%
4. Sodium hypochlorite1-6%
5. Iodine solutions-10% iodine
6. Urea 30%
7. 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.

16. Physiologic solution
1. Distilled water
2. saline

17. 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.

18. 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.

19. • 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.

20. • 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.

21. • 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.

22. • 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.

23. 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
1. Severe pain
2. Swelling
3. Profuse bleeding

24. 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

25. 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

26. 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

27. 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.

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

29. 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

30. • Ultrasonics, sonics
• Orientation of the bevel of the needle
• temperature

31. 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

32. • 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)

33. • Emphysema ---crepitus of swelling
• Epithelial necrosis

34. • 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

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

37. 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.

38. 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

39. • 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

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

41. • 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

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

43. 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

44. • 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

45. • 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

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

47. • 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.

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

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

50. • Neutralization of canal remnants
• To dissolve the remaining organic material

51. Categorization of medicaments
1. 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

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

53. 5. 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

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

55. 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

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

60. 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.