irigare endodontie
TRANSCRIPT
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Edgar Schäfer
Irrigation of the root canal
Key words
apical
periodontitis,
chlorhexidine,
disinfection,
smear layer,
sodium
hypochlorite
The root canal
system is
colonised with
microorganisms
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in cases of apical periodontitis. Currently, it is impossible to totally eliminate these microbes
purely with mechanical instrumentation. Therefore, irrigants are required to eradicate
intraradicular infection. In this article, the different actions and in-teractions of the most commonly
used irrigants are discussed and a clinical protocol suggested. t least two different irrigants
should be used to achie!e the most effecti!e reduction of intraradicular microorganisms. Edgar ch!fer
"epartment of #perati!e
"entistry,
$ni!ersity of %&nster,
'aldeyerstr. (), "-*+*
%&nster, ermany
Tel/ 0* 12 +(*3)*)
Email/ eschaef4uni-
muen-ster.de
Introduction "ulpitis versus apical periodontitis
In recent years, there ha!e been ma5or ad!ances in impro!ing
the properties of root canal instruments. Since the introduction
of nic6el-titanium alloy 78iTi9 into endodontics, nearly e!ery
month a new rotary 8iTi-system comes onto the dental mar6et.
%ore-o!er, there are se!eral new products and root canal filling
materials. $nfortunately, all these ad!ances are focused on the
technical aspects of the root canal treatment. more biologically
based approach has recei!ed less attention. There is a renewed
interest in the relationship between mechanical root canal in-
strumentation and intraradicular disinfection. Infec-tion controlduring root canal treatment is important for successful outcome
in nonsurgical root canal treatment.
Therefore, the aim of this re!iew is to analyse the rele!ant
literature on root canal irrigation. n irrigation protocol for
the e!eryday clinical practice is also proposed, including
other rele!ant recom-mendations.
The healthy pulp can be affected by se!eral irritants such as dental
caries 7bacteria and their products9, traumatic in5uries, iatrogenic
factors 7dehydration of dentine, to:ic influences from filling
materials, and lea6age of the restoration9 and, !ery seldom, sys-
temic influences 7nutritional deficiencies9. ;i6e all other connecti!e
tissues in the body, the pulp reacts to these irritants with
inflammation. %ost frequent-ly, an inflammatory reaction in the pulp
is caused by bacteria from a profound carious lesion, since denti-nal
tubules are portals of entry for these bacteria, bacterial antigens and
tissue brea6down products to reach the pulp tissue but e!en at this stage,
the remaining !ital pulp tissue will defend itself against the in!ad-ing
microbes2 and thus the infection will remain rel-
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1# Schäfer Root canal irrigation
ati!ely superficial. In the more apical part of the root canal, most of the pulp tissue will be !ital and free of bacteria at this
point of the disease?.
"ue to this microbial aetiology of pulpitis, it is clear that the treatment of irre!ersible pulpitis, in other words the treatment of !ital
cases, should focus on pre!ention of infection rather than an elimination of intraradicular infection *. s the apical part of the root
canal system is bacteria free, the aim is asepsis3. $nder clinical conditions, the easiest and by far the most efficient methods to
guarantee asepsis during endodontic treatment are coronal disinfection of the tooth and mandatory use of rubber dam. %oreo!er,
sterilised burs and root canal instruments must be used, glo!es must be worn, and the root canal obturation should if possible be
performed at the first !isit?
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ment with another report in as far
ias no difference
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in healing between teeth filled after epositi!ezor
ssen
negati!e root canal cultures was obser!ed3.
Endodontic infection$ localisation of %icroorganis%s
In general, endodontic infection can be di!ided into primary 7primary apical periodontitis9 or secondary root canal infection
7pre!iously root-filled teeth with apical periodontitis9. In general, primary root canal infection is characterised by strictly anaerobic
bacteria and is typically polymicrobial1,+ less than )
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action of the cellular 7phagocytes9 and molecular
7antibodies, complement system9 host defences1,1.
The microbes sur!i!e on pulp tissue remnants and
e:udate from the periodontium1), the reason why in
most cases intraradicular microbes are mostly locat-ed
in the apical part of the root canal system1(. These
microorganisms at the apical part of the root canal are
usually delineated from the inflamed periapical tissues
either by a dense accumulation of polymor-phonuclear
neutrophils or by an epithelial plug near the apical
foramen1,1(. s a result, these microbes are protected
from the host defences. 'ithin the root canal these
microorganisms are organised on the surface of the
canal walls as an aggregation in an e:-tracellular
polysaccharide matri:, the so-called Dbiofilm(),(.
$nfortunately, microbes organised in a biofilm are
about )))-fold more resistant to antimi-crobial agents
than their plan6tonic counterparts that e:ist in the root
canal(1.
'hen intraradicular infection is not adequately treated,
microorganisms will penetrate from the main root canal
into dentinal tubules, lateral canals, and other canal
irregularities. The in!asion of dentine is es-timated to
occur in appro:imately 2)
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tissue damage are caused by bacteria enHymes 7e.g.
i
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collagenase, hyaluronidase9, e:oto:ins and metabo-
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lites 7e.g. butyrate, ammonium, sulphur compounds9, and other bacterial
components, such as peptidogly-cans, teichoic acid and lipopolysaccharides1,(+.
The lipopolysaccharide, in particular, seems to be capable of causing se!ere
tissue destruction by stimulating the de!elopment of host immune reaction1. The
endo-to:in is located in the outer membrane of ram-neg-ati!e bacteria and is
able, as mentioned abo!e, to cause tissue damage e!en in the absence of !iable
bacteria?. It has been shown in an animal model that placing lipopolysaccharide
in empty sterile root canals led to the de!elopment of periapical lesions(. In pulp
tissue of teeth associated with apical periodontitis, high le!els of
lipopolysaccharides were found*), and there was a strong association between
lipopolysac-charide le!els and the pre!alence of ram-negati!e bacteria*.
These obser!ations that bacterial metabo-lites and brea6down products play a
significant role in the pathogenesis of apical periodontitis? confirmed the need for
a root canal irrigant capable of neutralis-ing lipopolysaccharides.
%icrobes can also reside in the root canal system within the smear layer. This is
a thin surface film formed on the root canal wall after instrumentation. smear
layer is produced on areas touched by root canal instruments. The smear layer
consists of den-tine particles, bacterial components, and remnants of !ital or
necrotic pulp tissue*1,*(. "ue to these organ-ic remnants, the microbes ha!e easy
access to nutri-ents inside the smear layer. Therefore, it is clear that in infected
cases the smear layer should be re-
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'ig 1 ram-positi!e bacteria that ha!e penetrated into the dentinal tubules 7ram> original magnifica-tion *)):9.
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1( Schäfer Root canal irrigation
mo!ed to achie!e the greatest possible reduction of intraradicularmicroorganisms.
E:traradicular infections may occur, but they are rare?,1. $sually, they may occur in
the form of an acute periradicular abscess or in cases of actinomycosis 1. The
problem with e:traradicular infection is that microbes are established in the
periradicular tissues, inaccessible to nonsurgical endodontic treatment procedures.
s a result, e:traradicular infection may cause endodontic failure. There is
o!erwhelming e!idence in the litera-ture that microorganisms left in the root canal
system after root canal preparation or re-infection of the root filled tooth 7secondary
infection9, are the main causes of endodontic failure*,3,*,12.
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'ig & Scanning electron micrograph of multiple accessory
foramina on the pulp chamber floor of a mandibular molar
7original magnification +):9.
Root canal instru%entation and bacterial
reduction
"ue to its comple: anatomy, with the multiple fins, isthmuses,
ramifications and accessory canals** 7Big 19, it is !irtually impossible
for mechanical root canal instrumentation to shape and clean the
entire root canal system*2. Intraradicular microbes may be lodged in
these areas, which are inaccessible to in-strumentation?. In addition,
this comple: en!iron-ment pre!ents irrigants from e:erting their full
an-timicrobial potential*. ppro:imately 3 of all per-manent
molars ha!e accessory canals in the furcation area*? 7Big (9. These
canals may ha!e diameters of up
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'ig # Aost-operati!e radiograph showing a lateral root canal that is
partially filled with sealer and associated with a lateral lesion 7see circled
area9.
to 1)) Gm, so microbes can easily penetrate from the root canal
system into the periodontal tissues or !ice !ersa. Therefore,
nowadays an adhesi!e seal of the pulp chamber floor, after the
obturation of the root canal space, is recommended to a!oid re-
infection of the root canal system !ia the periodontium*?.
Classic Scandina!ian studies by Fystrm and Sundq!ist clearly
indicated that mechanical instru-mentation is able to reduce
significantly the number of microbes in the root canal system*3
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Clinical studies performed in Scandina!ia showed
that copious irrigation with an antimicrobial solution
during mechanical root canal preparation has an
essential effect on the reduction of intraradicular
microorganisms*3,*+,22. %echanical root canal
preparation using saline as an irrigant lea!es only
about 1) of canals bacteria-free. The percentage
of bacteria-free canals was increased to up to 2)when 8a#Cl was used for irrigation. $ltrasonic
acti!ation of sodium hypochlorite achie!ed a further
reduction of intraradicular microbes, with
appro:imately 3) of all canals bacteria-free.
These studies confirmed the paramount importance
of antibacterial irrigation solutions. The employment
of one or more antimicrobial irrigation solutions
during root canal treatment is good clinical practice.
odiu% hypochlorite
Sodium hypochlorite 78a#Cl9 is the most widely
used irrigation solution in endodontics. Currently
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a!ailable e!idence strongly indicates that 8a#Cl is
i
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n
. In water, 8a#Cl dissociates in-
t
z
the irrigant of choice
e
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to 8a0 and #Cl-, the hypochlorite ion. Fetween p= * and p= 3, chlorine from
8a#Cl e:ists predomi-nantly as =Cl# 7hypochlorous acid9, whereas abo!e
p= , #Cl- predominates*,2. lthough the antimi-crobial effecti!eness of
hypochlorous acid is greater than that of hypochlorite2, in the clinically used
8a#Cl solutions, the entire a!ailable chlorine is in the form of #Cl-
, as thep= of the solution is normally about 13,?). $nfortunately, due to se!eral
technical problems 7e.g. stability of the solution9, 8a#Cl solu-tions with a
lower p=, which would increase the amount of a!ailable hypochlorous acid,
are not com-mercially a!ailable at present3.
In endodontic therapy, 8a#Cl solutions are used in concentrations !arying
from ).2 to 2.12*. lso a!ailable are unbuffered solutions at p=
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äfer
t canal irrigation
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hte
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behalten
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Canal wall
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paration
rotary nic6el-
um instru-
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ts/ a9 using
l as an irrigant,
sing 8a#Cl for
ation. 8otice
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when using
Cl nearly no
nants of pulpal
e or debris
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found on the
l wall 7original
nification *):9.
y root-filled teeth with apical periodontitis1?, E. faecalis is much
e resistant to 8a#Cl than the aforementioned microbes.
we!er, despite the re-duced effecti!eness of 8a#Cl against E.
alis, 8a#Cl has the unique ability to disrupt or to remo!e
biofilms3
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tissue-dissolution capability and the antimi-crobial efficiency as well
he to:icity of 8a#Cl is dependent on the concentration of the
tion. The higher the concentration of the solution the greater the
to:icity+1
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'ig , Ecchymosis due to accidentally in5ection of 8a#Cl be-yond the ape:. Clinical situation
two wee6s after this com-plication.
tor and in dar6 bottles to a!oid degradation caused by light.
8a#Cl is caustic if accidentally e:truded into pe-riapical tissues or ad5acent anatomical
structures such as the ma:illary sinus?. In the case of accidental in-5ection of 8a#Cl
into periapical tissues, emphysema may de!elop within )
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d all
ed, as the two irrigants in combinationi
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thanzfor
E. faecalis in concentrations much lower e
ssen
each component alone3. lthough this synergistic
mechanism of C=M and hydrogen pero:ide has not been
elucidated in detail, it may be speculated that C=M denatures
the bacterial cell walls and creates pores in the membrane,
resulting in a more perme-able cell wall3, which then allows
hydrogen pero:-ide to penetrate the microbes and damage
intracel-lular organelles such as "83. similar synergistic
effect has also been shown for C=M and hydrogen pero:ide
when used as an antiplaque mouth rinse+. =owe!er, there
are no clinical studies at present that ha!e in!estigated the
potential synergistic effect of these irrigants against
intraradicular microbes*. Since a combination of C=M and
carbamide pero:ide was found to be additi!e in their
cytoto:icity, an as-sessment of the biocompatibility of this
combination is urgently required before any clinical
recommenda-tions are made*.
$nli6e 8a#Cl, C=M does not possess any tissue-
dissol!ing ability*,1), and is unable to remo!e the smear
layer or neutralise lipopolysaccharides, which are ob!iousbenefits of 8a#Cl. It is only because of these differences
that C=M cannot be a substitute for 8a#Cl as the gold
standard of root canal irrig-ants. lso, C=M seems to be
less effecti!e against ram-negati!e bacteria 7which
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dominate in pri-mary endodontic infection91. Burther wea6nesses of C=M
ude its susceptibility to the presence of organic material> the antimicrobial
ct of C=M is strongly reduced by the presence of dentine, in-flammatory
dates, serum albumin, dentine ma-tri:, and heat-6illed cells of E. faecalis
C. albi-cans2+,11
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alone. In other words, the combination of the solu-
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n
tions 6illed E. faecalis in concentrations much lower
t
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than each irrigant could alone?,3. Certainly this topic warrants further in!estigation as the mecha-nism has yet to be fully
understood*.
In conclusion, there is no scientific e!idence indi-cating that =1#1 may be superior to other irrigants*.
'ig - Arecipitation of chlorhe:idine when mi:ed with 8a#Cl.
3ydrogen pero0ide
=ydrogen pero:ide 7=1#19 is used in dentistry in !arious
concentrations ranging from to ()*. Bor endodontic treatment, a
concentration between ( and 2 is preferred. Solutions of =1#1 are
chemically stable and =1#1 is acti!e against bacte-ria, yeasts, and
!iruses* due to the production of hy-dro:y free radicals 7N#=9. Theseradicals attac6 se!-eral cell components such as proteins and "8*,2.
The antimicrobial efficiency and the tissue-dis-sol!ing capacity of
=1#1 are poor in comparison with 8a#Cl. It was pre!iously
thought that an irri-gation protocol employing 8a#Cl and =1#1
alter-nately could ha!e beneficial effects on canal clean-liness and
reduce intraradicular microorganisms, but this has not been
substantiated scientifically. Se!er-al studies showed that a
combination of 8a#Cl and =1#1 resulted in a mar6ed reduction in
both the tis-sue dissolution capacity and the antibacterial effi-
ciency of 8a#Cl?,12. In fact, a combination of these two solutions
resulted in a bubbling effect as a result of the chemical reaction.
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of teeth*). nother concern is the high concentration of tetracycline in %T"> re-
sistance to tetracycline is not uncommon among bac-teria isolated from root
canals*. In fact, a higher in-cidence of tetracycline-resistant bacteria must be
e:-
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of antibi-
pected in future years. The local applicationi
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otics must be !iewed !ery critically, as theespectrumsz
ssen
of some antibiotics are narrower than commonly used antimicrobial
irrigating solutions3,2. ccording to Qehnder, the Duse of antibiotics
instead of biocides such as hypochlorite or chlorhe:idine appears un-
warranted3.
"henolic co%pounds
These irrigants are relati!ely ineffecti!e under clinical
conditions*1, and from reports of numerous studies there
is clear scientific e!idence that solutions con-taining
camphorated paramonochlorophenol are ir-ritating anddisplay to:ic effects on healthy tis-sues+1,*(,**. The
application of these irrigants in the root canal results in
systemic distribution*2. In gen-eral, phenolic compounds
are assessed as Dincompat-ible with a biologic approach
to endodontic treat-ment*?.
Therefore, phenolic compounds must be seen as
obsolete*3 and will not be discussed further in this
re!iew.
Irrigation solutions to re%ove the
s%ear layer
E65A
Ethylenediaminetetraacetic acid 7E"T9 as a 3
solution 7p= 39 effecti!ely remo!es the smear layer by
chelating the inorganic components of the den-tine*,*+.
E"T has almost no antibacterial acti!ity*, is highly
biocompatible, can demineralise intertubu-lar dentine
and reduces the surface hardness of root canal wall
dentine3,*. Some caution should be e:-ercised when
using E"T inside root canals because prolongede:posure to E"T may wea6en root den-tine2) and
thereby increase the ris6 of creating a per-foration during
mechanical root canal instrumenta-tion.
ccording to the results of preliminary studies, irrigation
of the root canal using alternately 8a#Cl and E"T
appears to be !ery promising2. This combination seems
to enhance the tissue-dissolution capability of
8a#Cl2,21 and is more
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efficient in reducing intraradicular microbes than
8a#Cl alone*
. E"T retains its calcium-comple:ingability when mi:ed with 8a#Cl, but E"T causes
8a#Cl to lose its tissue-dissol!ing capacity22.
Therefore E"T and 8a#Cl should be used
separately and E"T should ne!er be mi:ed with
8a#Cl3,2(. Burthermore, chelating agents li6e E"T
can disrupt the biofilm adhering to the root canal
wall3,2*. fter irrigation of the canals with E"T, 1 ml
of 8a#Cl should be finally used to neutralise the
acidic effects of E"T and to allow 8a#Cl to
penetrate into the dentinal tubules, which are opened
after the use of E"T.
/itric acid
Concentrations ranging from
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tion of the root canal system. Birstly, microorganisms
i
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embedded in the smear layer are eliminated and
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canal cleanliness is impro!ed. Secondly, it has been shown that the remo!al of
the smear layer impro!es the antimicrobial effect of intraradicular medica-ments
in the deeper layer of dentine(*,?). Therefore, either E"T or citric acid should
be included in the ir-rigation regimen 7Table 9.
Irrigants for drying the root canal
Jinsing the root canal with alcohol before obturation has been anecdotally
practised?. The basic premise is that alcohol reduces the surface tension of
irrigants and root canal sealers?1. ;owering the surface ten-sion of a fluid or a
sealer will increase the fluid flow into the dentinal tubules. Thus alcohol will spread
into the dentinal tubules and dry the root canal as it e!aporates. Therefore alcohol
might affect sealer penetration and lea6age of the root canal filling. In a recently
published study it was shown that a final rinse with 2 alcohol before root canal
obturation resulted in increased sealer penetration and conse-quently decreasedlea6age?. This is in agreement with another study demonstrating that a final rinse
with alcohol allowed better sealer co!erage than dry-ing with paper points?(.
Therefore a final rinse of appro:imately ( ml of 2 ethyl alcohol per
canal can be recommended in order to impro!e the sealing ability of the
root canal filling 7Table 9.
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'ig . #pened dentinal tubules of root canal dentine/ the smear layer was remo!ed with citric acid.
E8"# 1))3>79/-13
## Schäfer Root canal irrigation
'ig Ble:ible ()-gauge irrigation nee-dles with safety tips
78a!iTips, $ltradent, %unich, ermany9.
'ig 2 Cur!ed root canal enlarged with rotary nic6el-titanium
Ble:%aster 7P"', %unich, ermany9 to an apical siHe of )1@(2.
E!en in this cur!ed canal a pre-bent ()-gauge needle can be
inserted
to about
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/linical and technical aspects of irrigation
The most important technical aspect of root canal irri-gation is thecorrelation between the diameter of the irrigating needle and the apical
preparation siHe. Inside the root canal the effect of irrigation is limited
to (
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R Fetween instruments/ 1
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Chugal 8%, Cli!e %, Spngberg ;S. prognostic modeli
for assessment of the outcome of endodontic treatment/n
8a#Cl should always be employed throughout
effect of biologic and diagnostic !ariables. #ral Surg #ral
t
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canal. 'hen the shaping procedure is complet-
dodontic treatment of teeth with apical periodontitis. Int
ed, flush with a high !olume of 8a#Cl3(.
Endod 3>()/13-()?.
2.
OatebHadeh 8, Sigurdsson , Trope %. Jadiographic e!al-
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R fter shaping/ irrigation with 2 ml of E"T per
uation of periapical healing after obturation of infected root
canal for minute 7or with citric acid9. fter a fi-
canals/ an in-vivo study. Int Endod 1)))>((/?)-??.
?.
O!ist T, %olander , "ahlen , Jeit C. %icrobiological e!al-
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nal rinse of 8a#Cl, the canals should be irrigat-
uation of one- and two-!isit endodontic treatment of teeth
ed with either E"T or citric acid to remo!e the
with apical periodontitis/ a randomiHed, clinical trial.
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Endod 1))*>()/231-23?.
smear layer.
3.
Aeters ;F, !an 'in6elhoff , Fui5s B, 'esselin6 AJ. Effects
R Binal rinse/ irrigation with 1 ml of 8a#Cl per canal
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of instrumentation, irrigation and dressing with calcium hy-
dro:ide on infection in pulpless teeth with periapical bone
to neutralise the acidic effect of E"T and to al-
lesions. Int Endod 1))1>(2/(-1.
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ment cases/ chlorhe:idine. Jinse with water to re-
.
Babricius ;, "ahlen, , #hman E, %ller . Aredominant
mo!e 8a#Cl and then with a 1 chlorhe:idine
indigenous oral bacteria isolated from infected root canals
after !aried times of closure. Scand "ent Jes
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solution.
1).
+1>)/(*-**.
R #ptional, before root canal filling/ rinse with ( ml
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u
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$ltrasonic root-end preparation. Aart . SE% analysis.
ndod *>13/(+-(1*.
hado-Sil!eiro ;B, onHales-;opes S, onHales-
rigueH %A. "ecalcification of root canal dentine by cit-
cid, E"T and sodium citrate. Int Endod 1))*>(3/(?2-
23.
Lamaguchi %, Loshida O, SuHu6i J, 8a6amura =. Joot
canal irrigation with citric acid solution. Endod
?>11/13-1.
2+.
"i ;enarda J, Cadenaro %, SbaiHero #. Effecti!eness of
mol ;- citric acid and 2 E"T irrigation on smear layer
remo!al. Int Endod 1)))>((/*?-21.
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Ha %B, Tei:eira %, ScelHa A. "ecalcifying effect of
-T, ) citric acid, and 3 E"T on root canal
n. #ral Surg #ral %ed #ral Aathol #ral Jadiol Endod
1))(>2/1(*-1(?.
# 1))3>79/-13
pasalo %, Vrsta!i6 ". n vitro infection and disinfec-tion of
nal tubules. "ent Jes +3>??/(32-(3.
ens J', Strother %, %cClanaban SF. ;ea6age and sealer
tration in smear-free dentin after a final rinse with 2nol. Endod 1))?>(1/3+2-3++.
ningham 'T, Cole S, Fale65ian L. Effect of alcohol on the
ading ability of 8a#Cl endodontic irrigant. #ral Surg #ral %ed
Aathol +1>2*/(((-((2.
o: ;J, 'iemann =. Effect of a final alcohol rinse on
er co!erage of obturated root canals. Endod
2>1/12?-12+.
Sedgley C%, 8agel C, =all ", pplegate F. Influence of irrigant needle depth in remo!ing
bioluminescent bacteria inoculated into instrumented root canals using real-time im-aging in vitro.
Int Endod 1))2>(+/3-)*.
py
o
r
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fer
canal irrigation
hte
b
y
Q
vorbehalten
?2. %cur6in-Smith J, Trope %,
u
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", Sigurdsson .
uction of intracanal bacteria using T rotary instrumen-
n, 2.12 8a#Cl, E"T,
#=91. Endod
2>(/(2-(?(.
ssen
??. =&lsmann %, Aeters #, "ummer
A%=. %echanical
preparation of root canals/ shaping goals, techniques and
means. Endodontic Topics 1))2>)/()-3?.
?3. Schäfer E, Plassis, %. Comparati!e in!estigation of two ro-tary nic6el-titanium
instruments/ AroTaper !ersus JaCe. Aart 1. Cleaning effecti!eness and shaping ability in
se!ere-ly cur!ed root canals of e:tracted teeth. Int Endod 1))*>(3/1(-1*+.
?+. Tepel , Schäfer E, =oppe '. Ounststoffe als %odellmaterial in der Endodontie. "tsch
QahnärHtl Q (>*+/3(?-3(+.
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109/110
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110/110