protocol for root canal irrigants
TRANSCRIPT
PROTOCOL FOR ROOT CANAL IRRIGANTS
Presented byDr. Neha Gulati
Introduction
Challenge: The complexity of root canal morphology hampers the ability to thoroughly achieve pulp cavity disinfection
Objective : To remove all of the pulpal and dentinal debris from the root canal system.
Chemo-mechanical preparation attains free access to the apical foramen through the access opening and through the root canal system by mechanical means, which exposes, enlarges & shapes the root canal.
At the time of chemo-mechanical preparation suitable irrigants are used which help in achieving debridement and disinfection of the root canal system
PROPERTIES OF IDEAL IRRIGATING SOLUTIONS
Tissue Dissolution Lubrication Chelation Antibacterial Action Bleaching Action Some are Radio-
Opaque Low Toxicity Biocompatible
Low Surface Tension Low Neutralizability Easy Avalibility Cost Effective Convenient for Usage Good Shelf Life Easy Storage
Various Irrigating Solutions
SODIUM HYPOCHLORITE EDTA MTAD RUDDLE’S SOLUTION
SODIUM HYPOCHLORITE
Clear straw colour liquid containing 5% chlorine
Strong oxidizing agent Used in concentrations between 0.5-7% Exists as HOCl
DISRUPTS OXIDATIVE PHOSPHORYLATION
DISRUPTS DNA SYNTHESIS
Properties
Potent antimicrobial agent Effectively dissolves pulpal remnants &
organic components of dentin Does not remove Smear layer
Increase in temperature Increases tissue dissolving property
EFFICACY OF SEVERAL CONCENTRATIONS
Baumgartner et al (JOE, 1992, vol. 12) – no difference in efficacy of 5.25, 2.5 & 1% NaOCl
Harrison & Hand – dilution of 5.25% NaOCl resulted in decrease in its ability to dissolve necrotic tissue
Effectiveness of low concentrations of NaOCl can be improved by
Larger volumes Frequent change Longer period of exposure
Yesiloy et al– 5.25% NaOCl effective against all microorganisms tested but less effective when diluted
ANTIMICROBIAL EFFICIENCY
1% NaOCl has found to kill both bacterial spores and HIV over a period of 30minutes.
Sen et al (JOE, 1999) – 1 & 5% NaOCl effective against C.albicans.
Ohara et al (Dent Traumatol, 1993) – 1/10 concentrations of NaOCl effective against several anaerobic bacteria. However dilution below 1/10 was completely ineffective.
Kuruvilla & Kamath (JOE, 1998) – 50% reduction in microbial count – 2.5% NaOCl, synergistic response with CHX (0.2%) lead to 80% reduction in microbial count.
TIME REQUIRED FOR TISSUE CLEARANCE
At 15 & 30 Min Intervals NaOCl found to clear the coronal & middle third of the canal better than saline. However in apical 3mm no difference was seen.
NaOCl more effective in large diameter canals. More effective in cleaning an isthmus.
SODIUM HYPOCHLORITE:MECHANISM OF ACTION
• Germicidal activity of sodium hypochlorite is because of formation of Hypochlorus acid.(Jawetz,Melnick & Adelberg)
• Permeates cell wall and combines with the protoplasm.
• Dissolves necrotic tissue because of high alkalinity.
• Biopolymers like proteins are hydrolyzed into amino acids.
• NaOCl reacts rapidly with Glycine in a phosphate buffer (pH & 7.0) at 200C
ADVERSE EFFECTS
Excruciating pain within 2-5 min
Burning sensation in affected area
Immediate swelling (ballooning) of the tissue in the area with spread to
surrounding loose connective tissue.
Profuse bleeding episode either interstitially or through the root canal
system.
The interstitial hemorrhage may result in echymosis over the skin
because of which the affected skin is discolored.
EDTA
Effective chelating agent (Ph-8.3) Removes smear layer when used with NaOCl Odourless, Crstalline white powder,relatively
non-toxic Dentin dissolving effect Enlarges narrow/ obstructed canals Bypass fragmented instruments
Properties
Antimicrobial – neither bactericidal nor bacteriostatic Inhabited the growth of & eventually destroyed bacteria by the process
of starvation. The metallic ions in the medium which were necessary for growth were chelated 7 rendered inassimilable by the micro-organisms.
Self Limiting Action: EDTA forms a stable bond with calcium & the deposited solution can
dissolve only a certain amount of dentin EDTA + 2Ca2+ Ca EDTA Ca When all chelating ions have reacted, an equilibrium will be reached;
then no further dissolution will takes place. This effect was found to be rapid during first one hour and reached
equilibrium by the end of seven hours.
Cohen & Burns: Functions of EDTA Lubrication Emulsification Smear Layer removal
The authors also cite references and report that EDTA has been dispensed in two forms – Viscous and Aqueous.
a viscous product is used for the first two functions during canal preparation
the aqueous solution is used as a final flush after shaping and cleaning for smear layer removal.
MTAD
It is composed of a mixture of
A) Tetracycline:
i) Broad spectrum antibiotic
Bacteriostatic in nature.
ii) Low pH
iii) Calcium chelator
Surface demineralization similar to citric acid
iv) Substantive property
v) Promotes healing
vi) Removes smear layer
B) Citric Acid – also removes smear layer, Bactericidal
C) Detergent – Tween 80, decreases surface tension.
MTAD AND SMEAR LAYER (2min application, 5ml volume)
Although MTAD removes most of the smear layer some
remnants of the organic component are scattered on root canal
wall surface.
Effectiveness is enhanced when low concentrations of NaOCI
are used as intra canal irrigant before the use of MTAD as final
rinse.
The regimen doesn’t change the structure of the dentinal tubules.
Properties
ANTIMICROBIAL EFFECT
MTAD appears to be more effective than 5.25% NaOCI in
disinfecting root canals after the removal of he smear layer.
Has the capability kill E. faecalis even at dilutions of 200 X
whereas for NaOCI, this was restricted to a dilution of 32X
SOLUBILIZING ACTION:
Lesser than NaOCI but similar to EDTA
RUDDLE’S SOLUTION
This solution is based on the use of HYPAQUE – M,
a radio- opaque, high contrast injectible dye.
This dye has previously been used in several
application such as arteriography, venography and
ureterography in the medical field.
COMPOSITION 5% Sodium Hypochlorite Hypaque M 17% EDTA Hypaque M is a high viscous aqueous solution of two iodine salts- Diatrizoate
Meglumine and Sodium It has a pH between 6.5 - 7.7 It is stable at room temperature Crystals may form when cooled but dissolve when heated to body temperature
ADVANTAGE Solvent action and ( radio-opacity similar to Gutta Percha) because of Hypaque Penetration because the tensioactive agent decreases the surface tension
besides removing the smear layer
IMPORTANT FACTORS ASSOCIATED WITH IRRIGATION
DELIVERY SYSTEM
VOLUME OF IRRIGATION
DEPTH OF IRRIGATING DEVICE
IRRIGANT EVACCUATION
IRRIGANT DELIVERY
After rubber dam elevation, access is gained to the root canal system. The pulp chamber is thoroughly debrided and flushed with the irrigating solution
The needle is inserted into the canal and slowly advanced apically in the canal walls and when resistance is felt the needle should be withdrawn .
The irrigating solution is deposited slowly without any pressure.
If the needle is forced apical until it binds against the canal walls injection of any solution even water will cause discomfort to the patient.
THE NEEDLE
1. Gauge of the needle:
Gauges ranging from standard 22 gauge to the finer 30 gauge needles were effective for
endodontic irrigation.
2. The needle should be bent to an obtuse angle to allow for easier access & entry to the
orifice. This bend is to be placed closer to the hub of the syringe.
3. Designs of Needles:
Open ended blunt needles
Beveled needles
Blunt ended side venting needle (ProRinse)
Notched tip (Monojet – 27 gauge)
Perforated needle –Endovage (Goldman & others)
NEWER DELIVERY SYSTEMS
TRIPLEX SYRINGE The Triplex Syringe is optimal for air and water
delivery. Its locking buttons are perfect for adapting to the Stropko Irrigator.
The Stropko Irrigator places the perfect amount of air and water pressure into the field. Its small, luer-lock tips do not impede visibility during irrigation or drying and are excellent for use under the microscope..
TRIPLEX SYRINGE
RINSE ENDO Contains a titanium hand piece and a supply
of disposable special cannulas and splash protectors
Results in thorough cleaning right till the apex
IRRIGANT ACTIVATION
EFFECT OF TEMPERATURECollagen dissolving effectCunningham & Balekijan showed that increasing the temperature from
220C-370C of a 2.6% NaOCl solution increased its tissue dissolving properties which were equivalent to those of 5.25% solution at room temperature.
Bactericidal effect:Was shown that for warmed 2.6% solution against
E.Coli,S.Sanguis,B.Subtilis spores,P.Vulgaris,S.Aureus organisms as early as 45 seconds.(Cunningham & Joseph OOO,1990).The spores took the longest time- 180 secs.(compared to 600 secs for solution at 22 0C)
-Ellerburch & Murphy demonstrated that even vapors of NaOCl exert strong bactericidal action.
ULTRASONICS Sound energy with frequency more than 25khz During passive ultrasonic irrigation,a small ulrasonically vibrating
file is placed in the centre of the root canal Energy is transferred to the irrigant Acoustic microstreaming and/or cavitation occurs The irrigant can flow through the canal and file can vibrate freely PUI with NaOCl removes more dentin debris,planktonic bacteria
& dental pulp tissue than manual syringe irrigation
ENDOACTIVATOR EndoActivator System uses safe, non-cutting polymer tips in an
easy-to-use hand piece to quickly and vigorously agitate irrigant solutions during endodontic therapy.
Evidence-based endodontics has shown that cavitation and acoustic streaming improve debridement and the disruption of the smear layer and biofilm.
Activated fluids promote deep cleaning and disinfection into lateral canals, fins, webs and anastomoses.
VIBRINGE First endodontic sonic irrigation system that enables
activation of the irrigation solution, acoustic streaming, in the root canal, in only one step
Clinically proven that it removes organic and inorganic debris from hard-to-reach areas faster than the conventional syringe.
Completely safe for all endodontic irrigation procedures and is compatible with all irrigation solutions like sodium hypochlorite and EDTA
VIBRINGE -next level endodontic hand irrigation
TIME SAVING
SAFE
SUPERCLEAN
IRRIGANT EVACCUATION
ENDOVAC / IRRIVAC Developed as a means to irrigate and remove debris to the apical
constricture without forcing solution out the apex into the periapical tissue.
The system utilizes apical negative pressure through the offices high volume evacuation system permitting thorough irrigation with
high volumes of irrigation solution.
Master Delivery tip being used to provideconstant irrigation as the canal isinstrumented
Use of the EndoVacMacroCannula
Use of the MicroCannula of the EndoVac system showing placement of the tip in theapical root end
USE OF LASERS
Ho:YAG /CO2 laser Effect of laser is dependent on the applied
output power and is specific for different bacteria
Also helps in removal of smear layer
To summarize irrigation of the root canal can be done by THE FIRE CONCEPT
F- FILL THE CANAL WITH IRRIGANT
I- INITIATE THE IRRIGANT
R- REFILL THE CANAL
E- EVACCUATION OF THE IRRIGANT
THANK YOU