1) The document reviews various irrigants used for pulpectomy in primary teeth, including sodium hypochlorite, chlorhexidine, EDTA, citric acid, MTAD, tetraclean and herbal agents.
2) A meta-analysis found that chlorhexidine showed greater reduction of intracanal bacterial loading compared to saline in primary teeth.
3) Studies evaluated the antimicrobial efficacy of irrigants like chlorhexidine, oxidative water, propolis and found them to be as effective or more effective than sodium hypochlorite in reducing bacteria in primary teeth.
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Root cana Irrigants
1.
2. Intracanal irrigants for pulpectomy in primary
teeth: a systematic review and meta-analysis.
Pozos-Guillen A, Garcia-Flores , Esparza-Villalpando , Garrocho-Rangel
Int J Paediatr Dent. 2016 Nov;26(6):412-425
4. Irrigation is defined as “to wash out a body cavity or wound with water or a
medicated fluid”
Disinfectant is defined as “an agent that destroys or inhibits the activity of
microorganisms that cause disease.
6. ◆ Removal of particulate debris and wetting of 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
BENEFITS OF USING IRRIGANTS
7. ◆ Be an effective germicide and fungicide
◆ Be nonirritating to the periapical tissues
◆ Remain stable in solution
◆ Have a prolonged antimicrobial effect
◆ Be active in the presence of blood, serum, and protein derivatives of tissue
◆ Have low surface tension
◆ Not interfere with repair of periapical tissues
◆ Not stain tooth structure
◆ Be capable of inactivation in a culture medium
◆ Not induce a cell-mediated immune response
◆ Be able to completely remove the smear layer, and be able to disinfect the underlying dentin and its tubules
◆ Be nonantigenic, nontoxic, and noncarcinogenic to tissue cells 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
◆ Have a convenient application
◆ Be relatively inexpensive
Properties Of An Ideal Irrigant For Root Canal
Treatment
8. A) CHEMICAL AGENTS : Kandaswamy and Venkateshbabu
• a) tissue dissolving agents : Naocl
• b)antibacterial agents :
Bacteriostatic : CHX , MTAD
Bactericidal : NaOCL
• c) chelating agents :
Weak : HEBP
Strong : EDTA
• d) combination products ( tissue dissolution & antibacterial effect):
MTAD, QMIX, SMEARCLEAR, TETRACLEAN
B) NATURAL AGENTS :
Green tea
Triphala
CLASSIFICATION OF IRRIGATING SOLUTIONS :
J Conserv Dent. 2010 Oct-Dec; 13(4): 256–264.
13. Penetration
depth of needle
Diameter of root
canal
Inner & outer
dia of needle
Orientation of
needle bevel
Type of needle
bevel
Velocity of irrigant
at needle tip
Viscosity of
irrigant
Irrigation
pressure
Factors affecting efficiency of root canal irrigation :
14. • most commonly used irrigating
solution.
• antibacterial capacity
• ability to dissolve necrotic tissue,
vital pulp tissue, and the organic
components of dentin and biofilms
in a fast manner
Sodium hypochlorite
Effective against :
Enterococcus faecalis
Candida albicans
Porphyromonas gingivalis
Porphyromonas endodontalis
Prevotella intermedia
15.
16. Temperature
Concentrations
Higher concentrations of NaOCl are more
toxic than lower concentrations
Grossman : pulp tissue dissolution capacity
5% sodium hypochlorite dissolve tissue in
between 20 minutes and 2 hours
18. Saline
0.9% solution
Gross debridement
Lubrication of root
canals
Flushing action
Can be used as final
rinse
No adr
No disinfecting and
dissolution properties
Cannot clear microbial flora
from inacessible areas
Do not remove smear layer
Disadvantages:
19. Chlorhexidine
Excellent antimicrobial activity
Effective against both Gram-positive
and Gram-negative bacteria as well as
yeast
2% in concentration
Very effective against Ent. faecalis
21. Substantivity
Endodontic irrigant
Interaction between CHX, NaOCl, and
EDTA
Allergic Reactions to Chlorhexidine
DRAWBACKS • Not considered as main irrigant in standard
endo therapy
• Unable to dissolve necrotic tissue remnents
• Less effective on gram negative bacteria
22. Chelating agent
• Lubrication
• Emulsification
• Holding debris in suspension
• Smear layer removal
• On direct exposure for extended time, EDTA extracts bacterial surface proteins by
combining with metal ions from the cell envelope, which can eventually lead to
bacterial death
• Dentin disolving properties
• Enlarge narrow canals
• Easy manipulation of instruments
• Reduces time needed for debridement
Ethylenediamine Tetra-Acetic Acid
Functions
Mode of action
Uses
23. Irrigation with 17% EDTA for one minute followed by a final rinse
with NaOCl is the most commonly recommended method to remove the
smear layer
EDTA decalcified dentin to a depth of 20–30 µm in 5 min
Interaction of EDTA and NaOCl
Different forms of EDTA
R-EDTA
EDTAT
EDTA-C
RC Prep = EDTA + UREA PEROXIDE +
POLYETHYLENE GLYCOL
24. A) Instrumented root canal wall after irrigation with 5% sodium hypochlorite (NaOCl)
and 17% ethylenediamine-tetra-acetic acid (EDTA), each for 5 minutes. Smear layer has
been completely removed.
B) Close-up scanning electron micrograph of the root canal wall after removal of smear
layer with NaOCl and EDTA.
25. Hydrogen Peroxide
H2O2 has antimicrobial activity against various
microorganisms including viruses, bacteria, yeasts, and
even bacterial spores.
It is more effective against Gram-positive than Gram-
negative bacteria
30% H2O2 (Superoxol) has been recommended as the
first step in tooth surface disinfection after mechanical
cleaning
3%
SOLUTION :
IRRIGANT
26. H2O2 = H2O + [O]
[O] : bactericidal effect
• Causes oxidation of bacterial sulfhydryl group of enzymes
• Interfere with bacterial metabolism
Mechanism of action
Use
27. • Chelating agent
• Concentrations : 1% to 50%
• The use of 10% citric acid as final irrigation has shown good results in
smear layer removal and proven to be more biocompatible than 17%
EDTA-T and 17% EDTA
Citric acid
Should NEVER be mixed with NaOCl
28. final irrigant for smear layer removal.
MTAD
• Effective in eliminating resistant
microorganisms
• Providing sustained antimicrobial activity
mixture of tetracycline isomer,
citric acid, and
detergent(tween 80)
pH : 2.15
an initial irrigation
for 20 min with
1.3% NaOCl,
followed by a 5-min
final rinse with
MTAD.
29. Advantages
Remove smear layer
Kills E faecelis
Biocompatible
High binding affinity of doxycycline present
allows prolonged antibacterial effect
30. Tetraclean
Mixture of doxycycline
hyclate (at a lower
concentration than in MTAD),
an acid, and a detergent
Recommended to be used as
a final rinse after root canal
preparation
Remove both the smear layer
and organic tissue from the
infected the root canal
system
Final 5min rinse
(50
mg/5ml instead of 150mg/5ml)
31. Smear clear
17% EDTA solution
along with
centrimide and
additional
proprietary
surfactants
Journal of Advanced Medical and Dental Sciences Research |Vol. 2|Issue 2| April-June
2014
32. Maleic acid
mild organic acid used
acid conditioner in adhesive dentistry
•Ballal et al. reported that final irrigation with 7% maleic acid for 1 min was more
efficient than 17% EDTA in the removal of smear layer from the apical third of
the root canal system.
33. Chlorine dioxide
tuberculocidal,
bactericidal,
virucidal, and
fungicidal
exists as gas in water
less cytotoxic as
compared to Sodium
hypochlorite
Singh et al : compared the dissolution
efficacy of chlorine dioxide and sodium
hypochlorite on human pulp tissue.
Conclusion : 5% Chlorine dioxide is
capable of dissolving human pulp tissue
but sodium hypochlorite was more
effective
34. Ozonated Water
3 oxygen atoms (O3–triatomic
oxygen), a higher energetic form than
normal atmospheric oxygen (O2)
powerful bactericide
0.1 ppm is sufficient to inactivate
bacterial cells including their spores
35. carisolv
1. 0.5% Naocl with aminoacids
2. Mode of action : Degrade denatured
collagen
Indian J Dent Res 2012;23:120-1
36. Electrochemically activated solutions
Tap water + low conc salt
solution
Ease of debris and smear layer
removal
Nontoxic
Effective with wide range of
microbial spectra
Super oxised water (OPW)
anolyte
catholyte
Catholyte
solution
Anolyte
solution
Super oxidised
water
Alkaline or
neutral ph
37. Triphala and Green tea polyphenols (GTP)
Terminalia Bellerica,
Terminalia Chebula
and Emblica
Officinalis
Triphala achieved
100% killing of E
faecalis at 6 min
citric acid : removal
of the smear layer.
GTP
antioxidant
anticariogenic
anti-inflammatory
thermogenic
probiotic
antimicrobial
properties
39. German chamomile and tea tree oil
antiinflamatory
Analgesic
anti-microbial
antispasmic
sedative
properties
antiseptic, an antifungal agent
and a mild solvent
terpinen-4-ol(typically 30-40%)
: antibacterial & antifungal
properties
SEM study : efficacy of chamomile to remove smear layer was
superior to NaOCl alone but less than NaOCl combined with EDTA
41. Miswak
Derived from plant Salvadora
persica
Limonoid has great antimicrobial
activity
Inhibit gram +ve and gram –ve
Interfere with extrapolysachh and
glycosidase enzymes
10-20%
42.
43. study age Irrigant
used
sampl
e
Evalution
period
characte
ristics
results conclusion
Ruiz-
Esparza
et al
J Clin
Pediatr
Dent.
2011
Spring;3
5(3):265
-70.
3-9 Saline
2%
chlorhexidi
ne
gluconate
20
20
20
20
Pre –irrg
Post-irrig
Pre-irrig
Post-irrig
Necrotic
pulp,
abscess,
fistula
Presenc
e of
Radioluc
ent area
in furcal
or
periapic
al region
Statistically
significant
difference
observed
CHX
showed
greater
reduction
of
intracanal
bact
loading
44. study age characteristics sample Irrigant
used
Evaluatio
n period
results conclusio
n
Louwak &
Prucksath
a-
mrongkul
Pediatr
Dent.
2012 Nov-
Dec;34(7)
:e192-6.
3-9 64 mandi pri
teeth
Presence of
deep carious
lesion with pulp
exposure
h/o
spontaneous
pain
Presence of
abscess , fistula
32
32
Saline
solution
2% chx
6 mo
12 mo
18 mo
6mo
12mo
18 mo
At 6 mo in
favour of
experime
ntal group
No
difference
at 12 0r
18 mo
Chx could
improve
resultsn6
mo after
interventi
on
45. study age characteristics sample Irrigant
used
Evaluatio
n period
results conclusio
n
Valdez-
Gonzalez
et al
J Clin
Pediatr
Dent.
2012
Fall;37(1):
31-5.
3-8 Pri teeth with
necrotic pulp
canal, abscess,
fistula
Presence of
Radiolucent
area in furcal or
periapical
region
Carious lesion
without direct
exposure to
oral
environment
20
20
20
20
NaOCl 1%
Oxidative
potential
water
(OPW)
Pre-irrig
Post-irrig
Pre-irrig
Post-irrig
Significant
difference
in favour
of
experimen
tal grp
when
evaluated
pre and
post
irrigation
OPW was
as
effective
as NaOCl
46. study age characteristics sample irrigant Evaluatio
n period
results conclusion
Jolly et al
J Clin
Pediatr
Dent.
2013
Spring;37(
3):243-9.
6-12 60 children
with pulpally
involve max
molars pimary
Acute apical
abscess
No antibiotics
in past 3-6mo
15
15
15
15
Saline
2% CHX
Calcium
hydroxide
4%
Propolis
4%
Pre-irrig
Post
Pre-irrig
Post
Pre-irrig
Post
Pre-irrig
post
In all grps,
significant
dec in
mean
aerobic
CFU seen
Maximal
change in
anaerobic
CFU was
seen with
2% CHX
CHX proved
to be
superior
antimicrobi
al agent
against
both
aerobes
and
anaerobes.
47. study age characteristics sample irrigant Evaluatio
n period
results conclusion
Tulsani et
al
J Clin
Pediatr
Dent.
2014
Fall;39(1):
30-4.
4-8 Pts without
systemic
condtion
Pri teeth with
necrotic pulp,
asymptomatic
Without pdl
lesions
Without
surgical
intervention
10
15
15
Isotonic
saline 0.9%
2.5%
NaOCL
MTAD
Post
irrigation
Statisticaly
significant
diff btw
Naocl &
MTAD
against
control
No diff
btwn
experimen
tal grps
Both
irrigants
Naocl and
MTAD
were
effective
against
E.faecalis
48. study age characteristics sample Irrigant
used
Evaluatio
n period
results conclusion
Verma
et al
J Indian
Soc
Pedod
Prev
Dent.
2014
Apr-
Jun;32(
2):120-
4
4-7 70 pri teeth
Good gen
health
No antibiotic
coverage h/o
r/f evidence of
carious pulp
exposure
35
35
Isotonic
saline
0.9%
Water
soluble
propolis
25%
Pre-irrig
Post-irrig
Pre-irrig
Post-irrig
Greater
reduction in
bact colony
counts in
propolis
Water
solulble
propolis
extract
25% can
be used as
irrigant
49. study age characteristics sampl
e
Irrigant
used
Evaluatio
n period
results conclusion
Farhin
et al
J Clin
Pediat
r Dent.
2015
Winter
;39(2):
100-4
3-7 60 pri molars with
atleast 1 canal with
necrotic pupl,
abscess, fistula
Presence of
Radiolucent area in
furcal or periapical
region
30
30
30
30
Naocl 1%
MTAD
Pre-irrig
Post-irrig
Pre-irrig
Post-irrig
Naocl grp
showed
significant
dec in bact
load
Same in
MTAD grp
MTAD
superior
among both
grps in post
irrigation
Promising
results
50. study sample Irrigant
used
result conclusion
Irfan et al 48
extracted
single
rooted
tooth
5.25%Na
OCL(nega
tive
control)
2. 10%
Citric acid
3.
7%Maleic
acid
4. MTAD
(
canal walls in Citric
acid,Maleic acid
and MTAD groups
were significantly
clearer than the
control group (p <
0.001 ) in the
apical,middle and
coronal levels
Dentinal tubules
treated with MTAD
significantly clear
than citric and
maelic acid
MTAD is an
effective solution
for the removal of
smear layer when
used as a final
rinse.
2.sodium
hypochlorite did
not remove smear
layer.
3.10% Citric acid
and 7% Maleic acid
was able to remove
smear layer.
51.
52.
53. Hypophosphatasia: diagnosis and clinical
signs - a dental surgeon perspective.
Bloch-Zupan A
Int J Paediatr Dent. 2016 Nov;26(6):426-438
56. EPIDEMIOLOGY
SEVERE HPP (EUROPE) : 1 PER 300,000
INDIVIDUALS
MODERATE FORMS > SEVERE FORMS :
1 IN 6370
JAPAN (SEVERE PERINATAL LETHAL
HPP) : 2-3 CASES PER 100,000 BIRTHS
CANADA : 1 IN 1OO,OOO
Bone
symptoms
Dental
symptoms
64. Q MIX
QMix contains a CHX-analog,
Triclosan (N-cetyl-N,N,N-
trimethylammonium
bromide), and EDTA as a
decalcifying agent
. QMiX and 1% NaOCl killed all planktonic E. faecalis and plaque bacteria in 5 seconds.
QMiX and 2% NaOCl killed up to 12 times more biofilm bacteria than 1% NaOCl (P <
.01) or 2% CHX (P < .05; P < .001).
67. Study age characteristics irrigants Evaluation
period
result conclusion
Verma et
al
J Indian
Soc
Pedod
Prev
Dent.
2014 Apr-
Jun;32(2):
120-4.
4-7
yrs
radiographic
evidence of
carious pulp
exposure
Group A:
0.9%
isotonic
saline
Group
B :25%
extract
water-
soluble
propolis
Pre-irrig
Post -irrig
reduction in
the mean
bacterial
colony
counts of all
the isolated
bacteria in
grp B
low toxicity
concerns and
antibacterial
effectiveness
PROPOLIS
68. study age characteristics irrigants Evaluati
on
period
result conclusion
Jolly et al
J Clin
Pediatr
Dent. 2013
Spring;37(3
):243-9.
60
childr
en
6-12y
acute apical
abscess of the
maxillary
primary molars.
2%
Chlorhexidine
4% Calcium
hydroxide
4% Dimethyl
Sulfoxide
(DMSO)
extract of
propolis
Normal
saline as the
control
Maximum
change in
anaerobic
cfu count
was seen
with 2%
chlorhexidin
e.
Chlorhexidine :
superior
antimicrobial
agent against
both
endodontic
aerobes and
anaerobes.
Calcium
hydroxide was
found to be
least effective.
69. study sampl
e
irrigants result conclusion
Shingare et
al
Germs.
2011 Dec
24;1(1):12-
21.
40
infect
ed
prima
ry
molar
s
Group 1 :3% Naocl
Group 2: 12.5% alcoholic
extract of miswak,
Group 3: 11% alcoholic
extract of propolis
Group 4: 0.9% saline.
greatest difference
being seen in group 1
(95.549%)
group 2 (89.794%),
group 3 (34.735%)
group 4 (28.087%)
miswak could be
a good natural
substitute to
sodium
hypochlorite
propolis showed
results
comparable to
those of the
negative control.
70. study sample irrigants result conclusion
Balto et al
J Contemp
Dent Pract.
2015 Mar
1;16(3):187
-91.
40
extracted
pri ant
teeth
3minutes with 5 ml of
17% (EDTA) or saline
respectively.
experimental groups :
3 minutes with 5 ml of
1 mg/ml ethanolic
extract of S. persica (n =
15) or
BioPure MTAD (n = 15)
and then flushed with 2
ml of saline.
MTAD solution
was as effective as
17% EDTA in
removing the
smear layer.
MTAD >>
S.persica
(miswak) at
middle third of
canal
71. study irrigants result
Prabhakar
et al
J Endod.
2010
Jan;36(1):8
3-6.
Extracted
teeth
Triphala
green tea polyphenols
(GTP)
MTAD
5% sodium
hypochlorite
against E. faecalis
biofilm
5% sodium
hypochlorite showed
maximum antibacterial
activity against E.
Faecalis biofilm formed
72. study sample irrigants result conclusion
Venkataram
, Gokhale,
Kenchappa
et al
Eur Arch
Paediatr
Dent. 2013
Aug;14(4):2
47-52
30 extracted
primary anteriors
chamomile
hydroalcoholic
extract,
Biopure™ (MTAD)
2.5% (NaOCl)
Smear
remo
val
MTAD
>>
cham
omile
extrac
t
efficacy of chamomile to
remove the smear layer was
superior to 2.5 % NaOCl
alone, but less effective than
MTAD mixture.
Lotfi et al
J Endod.
2012
Oct;38(10):
1391-4.
In the MTAD
group, the root
canals were
flushed with
1.3% NaOCl
solution during
10-minute
instrumentation,
and MTAD was
used as the final
rinse.
In other
experimental
group, 5.25%
NaOCl was used
during
instrumentation,
and 17%
ethylenediaminet
etraacetic acid
(EDTA) was used
as the final rinse.
In 10-minute
instrumentation period, the
use of 5.25% NaOCl during
instrumentation and 17%
EDTA as the final rinse is
more effective than using
1.3% NaOCl as primary
irrigation and MTAD as final
rinse on removal of the
smear layer.
73. study sample irrigants result conclusion
Ashofteh ,
Sohrabi et
al
Iran J
Microbiol.
2014
Feb;6(1):26
-30.
135
extracted
single
rooted
5.25% Naocl
2% CHX
MTAD
830 nm diode laser
BACTERIAL
REDUCTION
99.97±0.14 :
Naocl
99.65±1.13 for
CHX
97.56±6.36 :
LASER
96.91±5.60 :
MTAD
Naocl was the most
effective agent against
Enterococcus faecalis
74. study irrigants conclusion
Dagna et al
Int J Artif
Organs.
2011
Sep;34(9):9
14-9.
Niclor 5 (5% NaOCl
solution)
Cloreximid (0.2%
chlorhexidine and 0.2%
cetrimide solution)
3% hydrogen peroxide
17% EDTA with 5%Naocl
E.Faecalis
S.mutans
5%Naocl with 17% EDTA
showed greatest
antimicrobial efficacy
75. study sample irrigants
Hegde et al
Contemp
Clin Dent.
2016 Apr-
Jun;7(2):21
6-20
30 pri ant
teeth
10 ml 17% EGTA
(ethylene glycol bis
(beta-amino ethyl
ether)-N, N, N', N'-
tetraacetic
acid)followed by 5%
Naocl
10 ml 6% CITIC ACID
10 ml 0.9% SALINE :
control
sequential irrigation of the pulp
canal walls with 17% EGTA
followed by 5% NaOCl produced
efficacious and smear-free root
canal walls.
Hariharan
et al
J Indian Soc
Pedod Prev
Dent. 2010
Oct-
Dec;28(4):2
71-7
30 pri
incisors
5.25% NaOCl,
5.25% NaOCl + 10%
EDTA,
6% citric acid,
2% chlorhexidine,
saline
superior efficacy of 6% citric acid
76. study irrigants conclusion
Botton et al
Int Endod J.
2016
Aug;49(8):7
46-54
sodium
hypochlorit
e (1% and
2.5%)
2%
chlorhexidi
ne
6% citric
acid
17% EDTA
Toxicity test All groups showed some level of toxicity.
Amongst the main solutions, chlorhexidine
presented less cytotoxic potential.
EDTA was the least cytotoxic of the auxiliary
irrigant solutions, and the association of
these two solutions showed the lowest
toxicity potential amongst all groups.
77. study sampl
e
groups result conclusion
Kapdan et al
Niger J Clin Pract.
2015 Jul-
Aug;18(4):538-43
The KTP laser (1,5 W);
gaseous ozone (150 s);
sodium hypochlorite
(NaOCl); saline group
Complete
sterilization was
achieved in the
2.5% NaOCl
group
KTP laser and
ozone application
provided a
significant
antibacterial
effect in primary
root canals;
however, 2.5%
NaOCl was
superior
Goztas et al
Eur J Dent. 2014
Oct;8(4):469-74
58
extract
ed pri
molar
Group I: 25 mg/L of
Ozonated water (O3aq),
Group II: 25 mg/L of O3aq
with ultrasonication,
Group III: 2.5% Sodium
hypochloride (NaOCl),
Group IV: 2% CHX and
Group V: Positive control.
NaOCI irrigation
was found
significantly most
effective.
78. study No of
canal
groups Naocl conc Duration
min
conclusion
Meire et al.
2009 60/60
1- Nd:YAG laser
2- KTP laser
3- PDT
4- NaOCl
5- Positive/negative
control
2.5% 15 Laser systems and PDT were less
efficacious than NaOCl in reducing
EF, either in aqueous solution or
in an infected-tooth model.
Rios et al.
2011
- 1- 6% NaOCl
2- TB
3- PDT with no TB
4- PDT + TB
5- PDT + TB + NaOCl
Positive and negative
controls
6% 0.5 PDT with TB might be useful as
auxiliary therapy for conventional
endodontic treatment in reducing
the amount of bacteria
Poggio et
al. 2011
100/1
00
1- PDT
2- PDT + NaOCl
3- TB
4- Prolonged PDT
5- 5% NaOCl (positive
control)
6- Negative control
5% 3 antimicrobial efficacy of 5%
NaOCl is greater than that of PDT.
NaOCl can be used as an auxiliary
procedure for endodontic
treatment. A longer irradiation
time may be necessary to
improve effectiveness.
Nunes et al.
2011 60/60
1- Control group
2- NaOCl
3- PDT with OF + 90-s ET
4- PDT with no OF + 180-s
ET
5- PDT with no OF + 90-s
ET
1% 15 PDT was effective against EF
regardless of use of optical fiber
Editor's Notes
Successful root canal treatment is dependent on the removal of microorganisms from the pulp and other anatomical irregularities of the root canal system through chemo-mechanical instrumentation with the use of instruments and irrigating solutions. Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue, and disinfecting the root canal system. Chemical debridement is especially needed for primary teeth with complex internal anatomy and zones inaccessible to debridement, such as accessory canals, ramifications, and dentinal tubules that might be missed by instrumentation. The choice of a cleanser in the pulpal therapy of primary teeth should take into account the differences among the dentin substrata, and not be irritating to the periapical tissues.
The objectives of irrigation in endodontics are mechanical, chemical, and biologic. The mechanical and chemical objectives are as follows: (1) flush out debris, (2) lubricate the canal, (3) dissolve organic and inorganic tissue, and (4) prevent the formation of a smear layer during instrumentation or dissolve it once it has formed.42 The mechanical effectiveness will depend on the ability of irrigation to generate optimum streaming forces within the entire root-canal system. The chemical effectiveness will depend on the concentration of the antimicrobial irrigant, the area of contact, and the duration of interaction between irrigant and infected material.65 The final efficiency of endodontic disinfection will depend on its chemical and mechanical effectiveness.
The biologic function of irrigants is related to their antimicrobial effects. In principle, irrigants should (1) have a high efficacy against anaerobic and facultative microor ganisms
in their planktonic state and in biofilms, (2) inac tivaendotoxin, and (3) be nontoxic when they come in contact with vital tissues, and (4)b not cause an anaphylactic reaction.te
Efficiency of root canal irrigation in terms of debris removal and eradication of bacteria depends on several factors: penetration depth of the needle, diameter of the root canal, inner and outer diameter of the needle, irrigation pressure, viscosity of the irrigant, velocity of the irrigant at the needle tip, and type and orientation of the needle bevel (Fig. 6-52). Penetration Depth of the Needle The size and length of the irrigation needle—in relation to root canal dimensions—is of utmost importance for the effectiveness of irrigation. Diameter of the Root Canal The apical diameter of the canal has an impact on needle penetration depth (see earlier in this chapter for details regarding apical preparation size (see Fig. 6-7, Table 6-2).72,578
Inner and Outer Diameter of the Needle (Fig. 6-53, A and B) 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. 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.235 The Stropko Flexi-Tip (30 gauge) needle is fabricated from nickel-titanium to improve penetration into curved root canals.205 Irrigation Pressure The internal diameter determines the pressure necessary
for moving the syringe plunger. The speed of the plunger determines the velocity with which the irrigant is extruded. Narrow needles require more pressure onto the plunger and extrude the irrigant with higher velocity than large needle sizes, which extrude greater amounts of irrigants but cannot be introduced as deep. Type and Orientation of the Bevel of the Needle To improve safety of irrigation and prevent extrusion of the irrigant through the apical foramen, some needles release the solution via lateral openings and have a closed, safe-ended tip The orientation of the bevel is crucial to produce a turbulence effect on the dentinal wall of the canal. Side-vented and double side-vented needles lead to maximum shear stress concentrated on the wall facing the outlet (the proximal outlet for the double side-vented).
Milton soltn is 3% naocl stabilised with 16% nacl
In 2002 Estrela reported that sodium hypochlorite exhibits a dynamic balance (Fig. 6-54)142: 1. Saponification reaction: Sodium hypochlorite acts as an organic and fat solvent that degrades fatty acids and transforms them into fatty acid salts (soap) and glycerol (alcohol), reducing the surface tension of the remaining solution. 2. Neutralization reaction: Sodium hypochlorite neutralizes amino acids by forming water and salt. With the exit of hydroxyl ions, the pH is reduced. 3. Hypochlorous acid formation: When chlorine dissolves in water and it is in contact with organic matter, it forms hypochlorous acid. It is a weak acid with the chemical formula HClO that acts as an oxidizer. Hypochlorous acid (HOCl−) and hypochlorite ions (OCl−) lead to amino acid degradation and hydrolysis. 4. Solvent action: Sodium hypochlorite also acts as a solvent, releasing chlorine that combines with protein amino groups (NH) to form chloramines (chloramination reaction).
Chloramines impede cell metabolism; chlorine is a strong oxidant and inhibits essential bacterial enzymes by irreversible oxidation of SH groups (sulfydryl group).142 5. High pH: Sodium hypochlorite is a strong base (pH > 11). The antimicrobial effectiveness of sodium hypochlorite, based on its high pH (hydroxyl ions action), is similar to the mechanism of action of calcium hydroxide. The high pH interferes in cytoplasmic membrane integrity due to irreversible enzymatic inhibition, biosynthetic alterations in cellular metabolism, and phospholipid degradation observed in lipidic peroxidation.
It is highly unstable and easilly decomposed by heat and light. It rapidly dissociates into H2O + [O].On coming contact with tisssue enzymes catalase and peroxidase, liberated [o] produces bactericidal effect but this is transient and dimnish in presence of organic debris.
It causes oxidation of….
The rapid relese of [O] on contact with organic tissue results in effervescence or bubbling action which is thought to aid in mechanical debridement by dislodging particles of necrotic tissue and dentinal debris and floating them to surface.
USE :
As irrigating solution either alone or alternatively with naocl.
Adv of using alternately 3% h2o2 and 5.2% naocl are :
Effervescence reactn by h2o2 bubbles push debris mechanically out of canal
Solvent action of naoclon organic debris
Disinfecting and bleaching action by both solutions
While using in combo with naocl always use naocl in last because h2o2can react wid pulp debris and blood to produce gas which builds up pressure on closing tooth, can result in severe pain.
Citric acid can also be used for irrigation
of the root canal to remove the smear
layer.35,43,44 Concentrations ranging from
1% to 50% have been used.43 The use of
10% citric acid as final irrigation has
shown good results in smear layer
removal45 and proven to be more
biocompatible than 17% EDTA-T and
17% EDTA.46,
Hariharan et al40 conducted
an in vitro study to determine the efficacy
of 5.25% NaOCl, 5.25 NaOCl + 10%
EDTA, 6% citric acid and 2%
chlorhexidine and saline (control) in
removing the smear layer in primary teeth
root canals after hand instrumentation.
They showed the superior efficacy of 6%
citric acid than the other tested irrigants on
removing the smear layer in primary teeth.
Never be mixed with naocl as it strongly interacts with naocl and reduce available chlorine in solution and thus making it ineffective against bacteria.
Cohen & nisha garg
Smear clear Designed to remove the smear layer, SmearClear contains 17% EDTA solution along with centrimide and additional proprietary surfactants. These components aid in the removal of inorganic matter left in the canal during instrumentation. By removing the smearlayer and leaving the dentinal tubules clear of inorganic matter, a more effective seal may be facilitated. SmearClear has been recently launched as a 17% EDTA-based endodontic irrigant containing cetrimide and additional proprietary surfactants. This product is known to have been evaluated in only one in vitro study with permanent teeth,69 which compared the efficacy of different root canal irrigants against Enterococcus faecalis biofilms. These authors found that SmearClear had greater efficacy than almost of them. These results may be attributed to the fact that SmearClear contains cetrimide, which is a quaternary ammonium compound and a cationic detergent that is effective against grampositive and gram-negative microorganisms
Study by singhal and das in 2012 "The purpose of this study was to evaluate the efficacy of Carisolv TM , 1% sodium hypochlorite (NaOCl) gel, and 1% NaOCl solution as root canal irrigants in deciduous anterior teeth."
Materials and Methods: Thirty-six extracted deciduous anterior teeth were used. Root canals were flooded with NaOCl solution in Group A, NaOCl gel in Group B and Carisolv TM in Group C and incubated for 30 min. Scanning electron microscope photomicrographs of canal wall debris in the apical, middle and coronal thirds were scored.
Results: The results showed that regardless of irrigation regime, canals were consistently cleaner in the coronal and middle thirds than in the apical thirds. NaOCl solution, NaOCl gel, and Carisolv TM had comparable activity at coronal third and middle third of root canals. At the apical third, NaOCl solution cleaned canals better than NaOCl gel and Carisolv TM . Carisolv TM cleaned debris better than NaOCl gel at the apical third.
Conclusion: Carisolv TM can be used as an adjunct to root canal preparation.
Prabhakar et al. 5% of sodium hypochlorite exhibited excellent antibacterial activity in both 3-week and 6-week biofilm, whereas Triphala and MTAD showed complete eradication only in 3-week biofilm .
An invitro study compared the effectiveness of MCJ with NaOCl and CHX to remove the smear layer from the root canal walls of instrumented teeth. It was concluded that the efficacy of Morinda Citrifolia was similar to NaOCl in conjunction with EDTA as an intracanal irrigant.
An invitro study showed 10-20% miswak was effectve antifungal n anti bact against candida n e fecalis.
A study on pri teeth showed it could be good natural substitute to naocl
• The success of pulpectomy therapy in primary teeth depends on achieving an adequate level of disinfection within the root canals. It is challenging for paediatric dentists to choose the most appropriate irrigant agent when performing pulpectomy treatments. More high-quality clinical studies are definitely needed, with proper monitoring,
rare genetic disorder with autosomal dominant and autosomal recessive inheritance. It is characterised by a mineralisation deficit affecting the bones and teeth, which is associated with deficient and reduced enzymatic activity of tissue-nonspecific alkaline phosphatase (TNSALP)1–4. Mutations of the ALPL gene (1p36.1-p34), which encodes TNSALP, are responsible for the reduction in enzymatic activity. TNSALP is expressed in the liver, bones, and kidneys, and also found in the enamel, dentine, cementum, and alveolar bone5. In the event of reduced enzymatic activity of TNSALP, substrates that are not broken down (pyridoxal 50-phosphate, inorganic pyrophosphate, and phosphoethanolamine) build up and produce toxic effects; for example, inorganic pyrophosphate is a powerful mineralisation inhibitor6. These substrates may be detected in blood and urine.
QMiX was introduced in 2011; it is one of the new combination products introduced for root canal irrigation (Fig. 6-64). It is recommended to be used at the end of instrumentation, after NaOCl irrigation. According to the patent194 QMix contains a CHX-analog, Triclosan (N-cetyl-N,N,N-trimethylammonium bromide), and EDTA as a decalcifying agent; it is intended as antimicrobial irrigant as well as an agent to remove canal wall smear layers and debris. QMiX is suggested as a final rinse. Smear Layer Removal Stojic and colleagues investigated the effectiveness of smear layer removal by QMiX using scanning electron microscopy.500 QMiX removed smear layer equally well as EDTA. Dai and colleagues examined the ability of two pH versions of QMiX to remove canal wall smear layers and debris using an open canal design.113 Within the limitations of an open-canal design, the two experimental QMiX versions are as effective as 17% EDTA in removing canal wall smear layers after the use of 5.25% NaOCl as the initial rinse.
Photodynamic therapy (PDT) or light-activated therapy (LAT) may have endodontic applications because of its antimicrobial effectiveness.203 In principle, antimicrobial photodynamic therapy (APDT) is a two-step procedure that involves the introduction of a photosensitizer (step 1: photosensitization of the infected tissue) followed by light illumination (step 2: irradiation of the photosensitized tissue) of the sensitized tissue, which would generate a toxic photochemistry on the target cell, leading to cell lysis. Each of these elements used independently will not have any action, but together they have a synergism effect to produce antibacterial action. (COHEN)
PDT is based on the concept that nontoxic photosensitizers can be preferentially localized in certain tissues and subsequently activated by light of the appropriate wavelength to generate singlet oxygen and free radicals that are cytotoxic to cells of the target tissue [77]. Methylene blue (MB) is a wellestablished photosensitizer that has been used in PDT for targeting various gram-positive and gram-negative oral bacteria and was previously used to study the effect of PDT on endodontic disinfection.
Soukos et al. used the combined effect of MB and red light (665nm) exhibited up to 97% reduction of bacterial viability .
Along with methylene blue, tolonium chloride has been also used as a photosensitizing agent. It is applied to the infected area and left in situ for a short period. The agent binds to the cellular membrane of bacteria, which will then rupture when activated by a laser source emitting radiation at an appropriate wavelength (e.g., 635nm radiation emitted by SaveDent; Denfotex Light Systems Ltd., Inverkeithing, United Kingdom). The light is transmitted into the root canalsatthetipofasmallflexibleopticalfiberthatisattached to a disposable handpiece. The laser emits a maximum of only 100mW and does not generate sufficient heat to harm adjacent tissues.
irrigation with sodium hypochlorite (3%) eliminated the entire bacterial population. The difference could be because the optical fiber was not properly introduced into the root canals, and so the light could not transmit through the tooth structure. Thus, PAD might not be able to achieve a 100% kill rate in infected root canalsthathavecomplexanatomicfeaturesandcolonizedby polymicrobial biofilms of varying properties.
Pagonis et al. studied the in vitro effects of poly(lacticcoglycolic acid) (PLGA) nanoparticles loaded with the photosensitizermethyleneblue(MB)andlightagainstEnterococcus faecalis (ATCC 29212) [93]. The study showed that utilization of PLGA nanoparticles encapsulated with photoactive drugsmaybeapromisingadjunctinantimicrobialendodontic treatment
Laser devices have been proposed to improve the efficacy of irrigants.186 Lasers have been studied for their ability to clean and effectively disinfect root canals. The Er:YAG laser wavelength (2940 nm) has the highest absorption in water and a high affinity to hydroxyapatite, which makes it suitable for use in root canal treatment.107 Laser energy may be used to activate irrigant solutions in different ways—for example, at a molecular level, as in photoactivated disinfection (PAD), or at a bulk flow level, as in laser-activated irrigation (LAI). Several studies in vivo and ex vivo have indicated that laser activated irrigation is promising for removing smear layer168 and dentin debris121,122 in less time than PUI. The mechanism of action56 is based on the generation of a secondary cavitation effect with expansion and successive implosion of fluids.
erbium laser technique that used a photon-induced photoacoustic streaming (PIPS) of irrigants. In that technique, the laser tip is placed into the coronal access opening of the pulp chamber only and is kept stationary without advancing into the orifice of the canal.132 The use of a newly designed tapered and stripped tip with specific minimally ablative laser settings is required, resulting in low energy (20 mJ), a pulse repetition rate of 15 Hz, and a very short pulse duration (50 µs). The difference in laser penetration and bacterial killing is attributed to the difference in the degree of absorption of different wavelengths of light within the dentin.
Endodontic pathogens that grow as biofilms, however, are difficult to eradicate even upon direct laser exposure.65
An in vivo randomized controlled trial was conducted in a group of 60 children aged 6-12 years presenting with an acute apical abscess of the maxillary primary molars. Fifteen children each were divided randomly into four groups where irrigation during pulpectomy was performed using either 2% chlorhexidine, 4% calcium hydroxide or 4% Dimethyl Sulfoxide (DMSO) extract of propolis with normal saline as the control irrigant. Microbiological samples were taken from the disto-buccal root canal before initiating the pulpectomy as well as after 3 days later and for mixed aerobic and anaerobic bacterial cultures.
AIM:
To evaluate the efficacy of ethanolic extract of Salvadora persica (S. persica) and BioPure MTAD (a mixture of a tetracycline isomer, an acid, and a detergent) in removing the intracanal smear layer of primary teeth.
MATERIALS AND METHODS:
The root canal of 40 extracted human primary anterior teeth were cleaned, shaped and grouped into experimental (n = 30) and control (n = 10). The root canals of the positive (n = 5) and the negative control (n = 5) were irrigated for 3 minutes with 5 ml of 17% ethylenediaminetetraacetic acid (EDTA) or saline respectively. The canals in the experimental groups were irrigated for 3 minutes with 5 ml of 1 mg/ml ethanolic extract of S. persica (n = 15) or BioPure MTAD (n = 15) and then flushed with 2 ml of saline. The presence or absence of smear layer at the coronal and middle portion of each canal were examined under a scanning electron microscope (SEM).
RESULTS:
A significant difference (p = 0.004) in smear layer removal between S. persica and MTAD at the middle third of the canal was observed. MTAD solution was as effective as 17% EDTA in removing the smear layer.
CONCLUSION:
MTAD was significantly more effective in smear layer removal than S. persica solution at the middle third of the canal wall.
CLINICAL SIGNIFICANCE:
Both tested irrigant solutions have the ability to remove the intracanal smear from primary root dentin following cleaning and shaping of the root canal and could be an alternative to EDTA.
METHODS:
Thirty extracted single-rooted, primary human teeth were allocated at random into three experimental groups of 10 teeth each. For each tooth, the canal was prepared using the step-back technique. During instrumentation, 2 ml of the irrigant was used for at least 10 s after each file and 10 ml as a final flush for 2 min for chamomile and NaOCL irrigants. Whereas for MTAD, an initial rinse with 1.3 % NaOCl for a cumulated period of 20 min, and use of MTAD as the final rinse for a period of 5 min was followed. Longitudinal grooves were made on root segments, then split into two halves with a chisel, stored in 2.5 % glutaraldehyde solution and fixed in ethanol series. Specimens were examined for the smear layer according to Hulsmann et al. (Int Endod J 35:668-679, 2002) criteria using a scanning electron microscope.
STATISTICS:
Kruskal-Wallis and Mann-Whitney U tests were used.
RESULTS:
The most effective result in removal of smear layer occurred with the use of MTAD, followed by chamomile extract. The chamomile extract was found to be significantly more effective than 2.5 % NaOCl solution which had only minor effects.
CONCLUSIONS:
The efficacy of chamomile to remove the smear layer was superior to 2.5 % NaOCl alone, but less effective than MTAD mixture.
INTRODUCTION:
Bacteria are the primary etiology of pulpal and periradicular pathosis. In endodontically treated teeth with persistent infections only one or a few bacterial species are present of which the most important is Enterococcus faecalis. The aim of this study was to compare antibacterial efficacy of canal disinfectants including 5.25% sodium hypochlorite, 2% chlorhexidine, MTAD (a mixture of doxycycline, citric acid and a detergent (Tween 80) and 830 nm diode laser.
METHODS AND MATERIALS:
The canals of 135 extracted single rooted human teeth were prepared using rotary instruments. The canals were contaminated with Enterococcus faecalis for 4 weeks and then were divided into 4 groups of 30 teeth in each, a positive control group containing 10 teeth and a negative control group of 5 teeth. After using the disinfectants, samples obtained from canals by paper points and also shaving the canal walls were cultured. The Kruskal-Wallis test was used to analyze the results.
RESULTS:
The results showed the bacterial reduction as follows: 99.97±0.14 for sodium hypochlorite, 99.65±1.13 for chlorhexidine, 97.56±6.36 for laser and 96.91±5.60 for MTAD. The count of CFU obtained from dentin shavings was: 16/96±91/23 for sodium hypochlorite, 82/73±186/63 .for chlorhexidine, 47/26±112/21 for laser and 341/34±1139/83 for MTAD.
CONCLUSION:
According to the results, sodium hypochlorite was the most effective agent against Enterococ
The objective of this study was to compare in vitro, by MTT assay, the antimicrobial efficacy of Niclor 5 (5% NaOCl solution), Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution), 3% hydrogen peroxide and 17% EDTA against two microorganisms associated with primary endodontic infections.
METHODS:
Enterococcus faecalis and Streptococcus mutans strains were selected for this test. Freshly extracted single-rooted human teeth were endodontically treated, inoculated with bacterial strains and then divided into different groups, each of them rinsed with Niclor 5 (5% NaOCl solution), Cloreximid (0.2% chlorhexidine and 0.2% cetrimide solution), 3% hydrogen peroxide,17% EDTA and with 5% NaOCl solution (positive control).
RESULTS:
Even though all the tested irrigating solutions demonstrated antibacterial effects against E. faecalis and S. mutans, the results were significantly different between the various groups. The greatest antimicrobial effects were observed in groups treated with 5% NaOCl and 17% EDTA. Interestingly, the effectiveness of EDTA could be ascribed to its capability of detaching biofilm from canal walls.
Thirty primary anterior teeth were chosen for the study. The teeth were distributed into three groups having ten teeth each. Following instrumentation, root canals of the first group were treated with 17% EGTA and the second group with 6% citric acid. Only saline was used as an irrigant for the control group. Then, the teeth were subjected to scanning electron microscopy (SEM) study. The scale given by Rome et al. for the smear layer removal was used in the present study.
RESULTS:
The pictures from the SEM showed that among the tested irrigants, 17% EGTA + 5% sodium hypochlorite (NaOCl) group showed the best results when compared to other groups.
CONCLUSION:
The results advocate that the sequential irrigation of the pulp canal walls with 17% EGTA followed by 5% NaOCl produced efficacious and smear-free root canal walls.
The pictures from the scanning electron microscopy showed that among the tested irrigants, citric acid has the best efficacy to remove the smear layer without altering the normal dentinal structures, which was supported by the lowest mean smear scores. The pictures from the 10%EDTA + 5.25% sodium hypochlorite group showed that even though it removed the smear layer, it adversely affected the dentine structure. SEM pictures of the other groups like sodium hypochlorite, chlorhexidine revealed that these irrigants does not have the capacity to remove the smear layer in primary teeth.
CONCLUSIONS:
The results of the present study clearly indicate the superior efficacy of 6% citric acid than the other tested irrigants on removing the smear layer in primary teeth root canals.
The aim of the study was to evaluate the antimicrobial activity of the-potassium-titanyl-phosphate--the KTP laser and ozone in of primary root canals.
MATERIALS AND METHODS:
Sixty primary incisor teeth were selected. The specimens were inoculated with 10 mL Enterococcus faecalis (E. faecalis). Groups: The KTP laser (1,5 W); gaseous ozone (150 s); sodium hypochlorite (NaOCl); saline group. Sterile paper points used to sample bacteria from the canals to tubes containing 5 mL of brain heart infusion broth. Then, 10 mL suspension was incubated in culture media for 24 h. Data were analyzed statistically using Kruskal-Wallis and Mann-Whitney U-test.
RESULTS:
There were statistically significant differences between all groups (P<0.05). Complete sterilization was achieved in the 2.5% NaOCl group. The number of bacteria were significantly reduced in experimental groups in comparison to the saline group.
CONCLUSION:
The KTP laser and ozone application provided a significant antibacterial effect in primary root canals; however, 2.5% NaOCl was superior.