Download - Endodontic irrigation
Irrigation in Endodontics
Dr.Mohamed Ali Alazrak BDS.MScTripoli Medical Center – [email protected]
Introduction
•Every root canal system has spaces that can not be cleaned mechanichally .
•The only way to clean webs, fins and anastomoses is through effective use of irrigation solution.
•in order to get the maximum efficiency from irrigant , irrigant must reach the apical portion of the canal .
Anti microbial properties
Tissue solvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level
Properties of ideal irrigant solution
COMMONLY USED
IRRIGATING SOLUTIONS
I.Chemically non active solution:
Water.
Saline.
Anesthesia.
I.Chemically non active solution: Anti microbial properties
Tissue solvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level
II.Chemically active materials :
•Alkalis : sodium hypochlorite
•Antibacterial agents : chlorhexidin
•Oxidizing agents: hydrogen prioxide
•Chelating agents: EDTA ( ethylene diamine tetra acetic acid)
Sodium hypochlorite (NaOcl)Clear ,pale green-yellow liquid
with strong odor of chlorine.
It is a potent antimicrobial
agent, killing most bacteria
instantly on direct contact. It
also effectively dissolves
necrotic and vital pulp tissue.The most advocated irrigant,inexpensive and readily available.
Sodium hypochlorite (NaOcl)
Anti microbial properties
Tissue solvent. ( dissolve vital and non vital tissue)
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.
Mechanism of action Sodium hypochlorite (NaOCl) ionizes in water into
Na and the hypochlorite ion, OCl, establishing an
equilibrium with hypochlorous acid (HOCl).
Hypochlorous acid is responsible for the
antibacterial activity; the OCl ion is less effective
than the undissolved HOCl.
Hypochloric acid disrupts several vital functions of
the microbial cell, resulting in cell death.
Mechanism of action
At acidic and neutral pH, chlorine exists
predominantly as HOCl, whereas at high pH of 9 and
above, OCl predominates.
Concentration NaOCl is commonly used in concentrations
between 0.5% and 5%.
According to several studies The lower and higher
concentrations are equally efficient in reducing the
number of bacteria in infected root canals.
The time needed to inhibit bacterial growth and
tissue dissolving effect of NaOcl irrigant are related
to it is concentration ,but so is it is toxicity.
Increasing the temperature of hypochlorite irrigant to 600C, significantly increased its antimicrobial and tissue-dissolving effects.
Temperature
Limitation : Unpleasant taste
Relative toxicity
Inability to remove smear layer
Sodium hypochloride accident
Immediate severe pain for
2-6 minutes .immediate edema in adjacent
soft tissue because of perfusion
to the loose connective tissue.Extension of edema to a large
site of the face such as cheeks,
peri- orbital region, or lips.Ecchymosis on skin or mucosa
as a result of profuse interstitial
bleeding.
Sodium hypochloride accident
Managementinform the patient about the
cause and nature of the
complication.Immediately irrigate with normal
saline to decrease the soft-tissue
irritation by diluting the NaOCl.Let the bleeding response
continue as it helps to flush the
irritant out of the tissues.
Sodium hypochloride accident
Recommend ice bag compresses
for 24 hours (15-minute
intervals)to minimize swelling.Recommend warm, moist
compresses after 24 hours (15-
minute intervals).pain control with strong
analgesics for 3 to 7 days
Sodium hypochloride accident
Prophylactic antibiotic coverage
for 7 to 10 days to prevent
secondary infection or spreading of
the present infection.
Chlorhexidine (CHX)
Strong base, most stable in form of its salt …Chlorohexdin gluconate.
It possesses a broad-spectrum antimicrobial action and a relative absence of toxicity.
CHX lacks the tissue-dissolving ability.
Anti microbial properties
(broad spctrum antimicrobial
agent )
Tissue solvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.
Chlorhexidine (CHX)
Mechanism of action It penetrates the cell wall and attacks the bacterial
cytoplasmic or inner membrane or the yeast plasma
membrane.
In addtion chlorhexidin has property of substantivity
(residual effect).
Concentration 0.2% is concentration commonly used for chemically plaque
control in oral cavity .
2% is concentration used as root canal irrigation.
Limitation Unable to dissolve remaining necrotic tissue.
Less effective on gram negative than on gram positive.
Unable to remove smear layer.
Hydrogen Peroxide H2O2
It is a clear, colorless,odorless
liquid.
H2O2 is active against viruses,
bacteria, and yeasts.
It has been particularly popular
in cleaning the pulp chamber
from blood and tissue remnants,
but it has also been used in
canal irrigation.
Hydrogen Peroxide H2O2
Anti microbial properties
(broad spctrum antimicrobial
agent )
Tissue solvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.
Mechanism of action It is highly unstable and easily decomposed by heat and
light.
it rapidly dissociate into H2O+O (water+nascent oxygen)
. the liberated O has bacteriocidal effect but this effect is
transient and diminishes in presence of organic debris .
The rapid release of O nascent oxygen on contact with
organic tissue results in effervesce (bubbling) action
which aid in mechanical debridement by dislodging
dentin debris and necrotic tissue particles and floating
them to the surface.
Concentration
It is recommended to use in
3% conentration for
endodontic irrigation.
Advantages of using alternating 3% H2O2 with Naocl
solution are :
1.Effervescent reaction (bubbles pushes debris
mechanichally out of root canal)
2.Solvent action of sodium hypochrorite on organic
debris.
3.Disinfection and bleaching effect by both solutions.
Limitation Unable to remove smear layer.
Always use Naocl last because Hydrogen peroxide
release of nascent oxygen on contact with organic
tissue which may build up pressure on closing tooth
and causes pain .
• Soft tissue emphysema may occur when hydrogen
peroxide irrigant enforced beyond the apical
foramen.
MTAD
A mixture of tetracycline isomer, acid, and detergent.
(doxycycline, citric acid, and the detergent Tween-80)
Anti microbial properties
(broad spctrum antimicrobial agent )
Tissue solvent.
Flush debris.
Lubricant.
Eliminate the smear layer.
Low toxicity level.
Advantges1) it is an effective solution for removal of most of smear
layer.
2) Antibactrial effect ( kill most significant bacterial
strains i.e. E faecalis which has been shown to resist to
many intracanal medicament and irrigants.).
3) It is biocompatible .
4) The high binding affinity of doxycycline present in
MTAD for dentin allows prolonged antibacterial effect.
(substantivity)
Chelating Agents
EDTA (ethylene-diaminetetra-aceticacid)
The basic purpose of
chelating agent is lubrication
,emulsification and holding
debris in suspension .
Mechanism of action
•E
DTA functions by forming
calcium chelate solution with
calcium ions of dentin which
make it more friable and thus
dentin become easily to
manipulate by instrumentation.
EDTA
17% EDTA ( pH 7 )
EDTA has no antibacterial activity.
It effectively removes smear layer by
chelating the inorganic component of
the dentine.
Aid in mechanical canal shaping.
T
he optimal working time of EDTA is 15 minutes, after which
time no more chelating action can be expected.
Smear Layer T
he smear layer is a layer of debris ,compromising both
organic and inorganic components, found on canal walls
after endodontic instrumentation, it is typically 1-2 um in
thick .
I
t is made up largely of particularly dentin debris removed
by endodontic instrument during canal preparation but may
also contains remnants of pulp tissue and microorganisms.
Smear Layer P
resence of smear layer on the canal walls potentially
interfere with the adaptation of sealer against canal
wall and may create avenue of leakage of
microorganisms by act as substrate for microbial
proliferation .
Smear layer removal Can be accomplished by one of the following ways :
1)Use of chelating agents (17% EDTA) during the
cleaning and shaping . Upon complete the root canal
shaping soak the canal for 1 minute with liquid
EDTA , then rinse the canal thoroughly with NaOcl .
2)After irrigation with NaOcl Soak the canal for a 5
minutes with MTAD as final irrigant.
Dry canal with paper points, so the it is now ready
for obturation .
Irrigation
technique and devices
① Plastic syringe with needles
•Plastic syringes of different sizes (1–20 mL) are most commonly used for irrigation .
•All syringes for endodontic irrigation must have a Luer-Lock design.
Types of endodntic needles
1) Beveled needle:
Needle with bevel if get lodged
into canal there is a risk of
forcing irrigant beyond the
apex.
Types of endodntic needles :
2) Monoject irrigating needle:
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 to
ensure optimum cleaning.
A larger volume of solution can
be delivered by this method.
3) Max-i-Probe irrigating needle :
It has closed-end and side window.
This design allow for upward
flushing action for better canal
irrigation and also eliminates
possibilities of irrigant to be pushed
beyond the apical foramen.
Irrigation method: I
t is strongly recommended that the needle lie passively in the canal and not engage the walls.
A 27- or 30-gauge needle is preferred
The solution must be introduced slowly.
The irrigating needle should be bent to allow easier delivery of the solution and to prevent deep penetration of the needle.
Care must be taken with irrigants like sodium hypochlorite to prevent accidents.
② Gutta-percha Points agitation
• u
se of apically fitting gutta-
percha cone in an up-and-down
motion at the working length.
Although this facilitates the
exchange of the apical solution,
but the overall volume of fresh
solution in the apical canal is
likely to remain small.
③ EndoActivator
•I
t is based on sonic vibration
(up to 10,000 rpm) of a
plastic tip in the root canal.
The system has 3 different
sizes of tips that are easily
attached to the battery
operated handpiece that
creates the sonic vibrations.
③ EndoActivator
•i
t allow more irrigant
penetration and mechanical
cleansing compared with
needle irrigation, with no
increase in the risk of irrigant
extrusion through the apex.
④ Ultrasound
•U
ltrasound is sound energy with frequency
above 25 KHZ.
• P
assive ultrasonic irrigation have shown to clean
root canals or eliminate bacteria from the walls
better than conventional methods.
Mechanism of action
•W
hen a small file (size 10-20) is
placed freely in the center of the
canal following preparation and
ultrsonic activation is given .
The ulrtasonic energy passage
through irrigating solution and
exerts its (acoustic streaming
effect ).
Mechanism of action
•T
his mechanichal energy warms
the irrigant solution (NaOcl) and
dislodge debris from canals.
•T
he combination of activation
and heating the irrigation
solution is adjunct in cleaning
the root canal system .
⑤ EndoVac•T
he EndoVac system is based on
a negative-pressure
approach whereby the irrigant
placed in the pulp chamber is sucked
down the root canal and back up
again through a thin needle with a
special design.
Advantges :1) the EndoVac system lowers the
risks associated with irrigation
close to the apical foramen .
2) good apical cleaning at the 1-mm
level can be achieved by
reversed flow of irrigants and a
strong antibacterial effect when
hypochlorite is used.
Thank you
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