Various Irrigation Solution in Endodontic

,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Various Irrigation Solution in Endodontic,10/9/2006,The use of irrigating solutions is an important part of effective chemomechanical preparation.,Antibacterial agent.,Tissue,solvent.,Flush debris.,Lubricant.,Eliminate the smear layer.,Various Irrigation Solution in Endodontic,Variables affecting the irrigation,Concentration of,irrigant,.,The volume of the solution used.,Canal diameter.,The viscosity or surface tension of the solution.,The diameter and depth of penetration of the irrigating needle.,The anatomy of the canal.,The method of delivering the,irrigant,.,Contact time with the tissue.,Temperature of the,irrigant,.,Ultrasonic activation.,The effect of combining different types of solutions.,NaOCl,NaOCl,Antibacterial agent,Dissolves vital and non-vital tissue.,Lubricant during instrumentation,NaOCl,has been criticized for,Unpleasant taste,Relative toxicity,Inability to remove smear layer,Bactericidal of,NaOCl,HOCl,exerts its effects by oxidizing,sulphydryl,groups within bacterial enzyme systems, thereby disrupting the metabolism of the microorganism,resulting in the killing of the bacterial cells,.,Unbuffered,solution at pH 11 in concentration 0.55.25% , and buffered with bicarbonate buffer (pH 9.0) usually as a 0.5% solution (,Dakins,solution).,NaOCl,Buffering had little effect on tissue dissolution.,Dakins,solution was equally effective on necrotic and fresh tissues.,No differences were recorded for the antibacterial properties of,Dakins,solution and an equivalent,unbuffered,hypochlorite solution,Zehnder et al. (2002),Questions concerning the use of sodium hypochlorite,Appropriate concentration,Method of delivery,Cellular damage caused by extrusion into the,periradicular,tissues,.,In Vitro Antibacterial Studies,High resistance of,E.,faecalis,and the high susceptibility of,C.,albicans,to,NaOCl,.,C.,albicans,was killed in vitro in 30s by both 5% and 0.5%,NaOCl,.,E.,faecalis,was,killed in less than 30s by the 5.25% solution, while it took 10 and 30min for complete killing of the bacteria by 2.5% and 0.5% solutions.,Radcliffe et al (2004) , Gomes et al. (2001) Peciuliene et al. (2001) ,Waltimo et al. (1999),Although 0.5%,NaOCl, with or without (EDTA), improved the antibacterial efficiency of preparation compared with saline irrigation, all canals could not be rendered bacteria free even after several appointments.,No significant difference in antibacterial efficiency,in vivo,between 0.5% and 5%,NaOCl,solutions.,Bystrm & Sundqvist (1983,1985),In Vivo Antibacterial Studies,The,in vitro,studies performed in,A test tube.,Root canals of extracted teeth.,Prepared dentine blocks infected with a pure culture of one organism at a time.,The,in vivo,studies, on the other hand, have focused on the elimination of microorganisms from the root canal system in teeth with primary apical periodontitis.,Antibacterial Studies,Explanation to poorer in,vivo,performance,Root canal anatomy, in particular, the difficulty in reaching the most apical region of the canal with large volumes of fresh irrigant.,Chemical milieu in the canal is quite different from a simplified test tube environment,Antibacterial Studies,Concentration,Compared the biological effects of mild and strong NaOCl solutions and demonstrated greater cytotoxicity and caustic effects on healthy tissue with 5.25% NaOCl than with 0.5% and 1% solutions.,Either 5.25% or 2.5% sodium hypochlorite has the same effect when used in the root canal space for a period of 5 minutes.,Trepagnier et al. (1977),Pashley et al. (1985),Concentration,5%,NaOCl,may be too toxic for routine use. They found that 0.5%,NaOCl,solution dissolves necrotic but not vital tissue and has considerably less toxicity than a 5% solution.,They suggested that 0.5%,NaOCl,be used in,endodontic,therapy.,Spngberg et al.(1974),Commented that “It seemed probable that there would be a greater amount of organic residue present following irrigation of longer, narrower, more convoluted root canals that impede the delivery of the irrigant.,Concentration of NaOCl,Baumgartner &Cuenin (1992),The ability of an irrigant to be distributed to the apical portion of a canal is dependent on:,Canal anatomy,Size of instrumentation,Delivery system,Commented that “The effectiveness of low concentrations of NaOCl may be improved by using larger volumes of irrigant or by the presence of replenished irrigant in the canals for longer periods of time.,Concentration of NaOCl,Baumgartner & Cuenin (1992),The efficacy of 0.5%, 2.5% and 5.25% sodium hypochlorite (,NaOCl,) as,intracanal,irrigants,associated with hand and rotary instrumentation techniques against,E.,faecalis,within root canals and dentinal tubules.,5.25%,NaOCl,has a greater antibacterial activity inside the dentinal tubules infected with,E.,faecalis,than the other concentrations tested.,.,Berber et al. (2006),Concentration of NaOCl,Is,NaOCl,equally effective in dissolving vital, non-vital, or fixed tissue ?,Demonstrated that 5.25% sodium hypochlorite dissolves vital tissue.,(,Rosenfeld et al. 1978 ),As a necrotic tissue solvent, 5.25% sodium hypochlorite was found to be significantly better than 2.6%, 1%, or 0.5%.,(Hand et al.1978),3% sodium hypochlorite was found to be optimal for dissolving tissue fixed with,parachlorophenol,or formaldehyde,(,Th,SD.1979),NaOCl,& Other Medicaments,The antibacterial efficacy of sodium hypochlorite, is increased when it is used in combination with other solutions, such as calcium hydroxide, EDTAC, or,chlorhexidine,.,Possibly,t,he,bactericidal effect gained by combining sodium hypochlorite with other chemicals comes from the release of chlorine gas.,NaOCl,& Other Medicaments,NaOCl & Ca(OH)2,Pretreatment of tissue with calcium hydroxide can enhance the tissue-dissolving effect of sodium hypochlorite,.,Hasselgren,et al.(1988),Combination of calcium hydroxide and sodium hypochlorite was more effective on the dissolution of soft tissue on the root canal wall than using either medicament alone.,Wadachi,et al.(1998),Complete,chemomechanical,instrumentation combined with 2.5% sodium hypochlorite irrigation alone accounted for the removal of most tissue remnants in the main canal. Prolonged contact with calcium hydroxide after complete instrumentation was ineffective.,Tissues in inaccessible areas of root canals were not contacted by calcium hydroxide or sodium hypochlorite and were poorly,dbrided,.,NaOCl & Ca(OH)2,Yang et al. 1998,NaOCl & EDTA,Combining 5.0% sodium hypochlorite with EDTA enhance considerably the bactericidal effect.,Bystrm & Sundqvist (1985),NaOCl & CHX,The alternate use of sodium hypochlorite and chlorhexidine gluconate irrigants resulted in a greater reduction of microbial flora (84.6%) when compared with the individual use of sodium hypochlorite (59.4%) or chlorhexidine gluconate (70%) alone.,Kuruvilla and Kamath (1998),NaOCl & CHX,The time required to eliminate,E.,faecalis,depended on the concentration and type of,irrigant,used.,Chlorhexidine,in the liquid form at all concentrations tested (0.2%, 1% and 2%) and,NaOCl,(5.25%) were the most effective,irrigants,. However, the time required by 0.2%,chlorhexidine,liquid and 2%,chlorhexidine,gel to promote negative cultures was only 30s and 1min, respectively.,Gomes et al.(2001),Temperature,Higher temperatures,potentiate,the antimicrobial and tissue-dissolving effects of,NaOCl,.,Increasing the temperature of hypochlorite,irrigant,to 37,0,C, significantly increased its tissue dissolving ability,Cunningham &Balekjian (1980),Temperature,Both the,debriding,and disinfection properties of 2.6%,NaOCl,are enhanced in vitro by elevating the temperature of the solution to 37,0,C.,Cunningham et al. (1980),Temperature,Tested 5.25% sodium hypochlorite on,Streptococcus,faecalis, Staphylococcus,aureus,and,Pseudomonas,aeruginosa,at 21C and 37C.,Found that increasing the temperature made no difference on antimicrobial efficacy and may even have decreased it.,Raphael et al (1981),Volume,The volume of the irrigant has a greater potential to significantly reduce bacteria colonies in root canal.,Baker et al. 1975, Brown and Doran 1975, Cunningham 1982, Cunningham et al.1982,siqueira at al.2000, Sedgley et al.2005.,Chlorhexidine (CHX),Chlorhexidine (CHX),It possesses a broad-spectrum antimicrobial action and a relative absence of toxicity.,CHX lacks the tissue-dissolving ability.,It penetrates the cell wall and attacks the bacterial,cytoplasmic,or inner membrane or the yeast plasma membrane.,Concentrations between 0.2% and 2%.,Its activity is pH dependent and is greatly reduced in the presence of organic matter.,Chlorhexidine (CHX),In direct contact with human cells, CHX is,cytotoxic,; a comparative study using fluorescence assay on human PDL cells showed corresponding,cytotoxicity,with 0.4%,NaOCl,and 0.1% CHX.,Chang et al.(2001,),Chlorhexidine (CHX),It has a wide antimicrobial spectrum and is effective against both Gram-positive and Gram-negative bacteria as well as yeasts, while mycobacteria and bacterial spores are resistant to CHX,(Shaker et al 1988, Russell AD. 1996).,CHX is not considered to be an effective antiviral agent, , and its activity is limited to lipid-enveloped viruses (Park JB & Park NH. 1989).,In direct contact with human cells, CHX is cytotoxic; a comparative study using fluorescence assay on human PDL cells showed corresponding cytotoxicity with 0.4% NaOCl and 0.1% CHX ( Chang et al. 2001).,In Vitro-the antibacterial effect of CHX,In vitro,CHX is superior to,NaOCl,in killing of,E.,faecalis,and,Staphylococcus,aureus,.,Gomes et al. (2001),Oncag,et al. (2003),Vianna,et al. (2004),CHX effectively killed,C.,albicans,Barkvoll,P &,Attramadal,A (1989),Hiom,e al. (1992),Hamers,et al. (1996),Waltimo,et al. (1999),In vivo-t,he antibacterial effect of CHX,There are,no,in vivo,studies,yet available that would confirm the better activity of CHX against,E. faecalis,in the infected root canal.,CHX & H,2,O,2,In Vitro, 3%,H,2,O,2,and CHX was superior in its antibacterial activity (,E.,faecalis,) compared with other regimens such as CHX alone and,NaOCl,.,Heling,& Chandler (1998),The combination of the two substances totally killed,E.,faecalis,in concentrations much lower than each component alone.,Steinberg et al. (1999),CHX & H,2,O,2,It can be postulated that the exposure of bacteria to CHX leads to a more permeable cell wall that H,2,O,2,can penetrate easily and hence damage the intracellular organelles.,CHX & H,2,O,2,There are,No reports of clinical studies,where the combinations of CHX and H,2,O,2,have been used to disinfect the root canal system.,Cytotoxicity,of the medicament combinations should first be investigated. Interestingly, combinations of CHX and,carbamide,peroxide have been shown to be additive in their,cytotoxicity,(,Babich,).,A potential weakness of CHX in the root canal may be its susceptibility to the presence of organic matter.,(Russell AD & Day MJ 1993),In an,in vitro,study, the effect of CHX is showed to be reduced, although not prevented, by the presence of dentine.,Haapasalo,et al. (2000),CHX was strongly inhibited by dentine matrix (the organic component of dentine).,Portenier,et al. (2002),CHX,H,2,O,2,H,2,O,2,It is a clear, colorless liquid.,Used in a variety of concentrations, 1% - 30%.,H,2,O,2,is active against viruses, bacteria, and yeasts.,It produces hydroxyl free radicals (OH), which attack several cell components such as proteins and DNA.,In,endodontics,H,2,O,2,has long been used because of its antimicrobial and cleansing properties.,It has been particularly popular in cleaning the pulp chamber from blood and tissue remnants, but it has also been used in canal irrigation.,In Vivo-the antibacterial effect of,H,2,O,2,Bacteria counts were greatly reduced when 10%,H,2,O,2,was used as part of the irrigating protocol., but the protocol used could not predictably produce sterile root canals in monkey teeth.,Mller et al. (2004),The antibacterial effect of,H,2,O,2,A combination of,NaOCl,and,H,2,O,2,was no more effective against,E.,faecalis,in contaminated root canals than,NaOCl,alone.,Siqueira,et al. (1997),H,2,O,2,Although,H,2,O,2,has long been used in disinfection and canal irrigation in endodontics, the available literature does not support its use over that of other irrigating solutions.,MTAD,MTAD,A,m,ixture of,t,etracycline isomer,a,cid, and,d,etergent.,(,doxycycline, citric acid, and the detergent Tween-80,),It has antibacterial activity.,It has,low pH 2.15,MTAD,The tissue-,solubilizing,action of MTAD,NaOCl, and EDTA was compared.,MTAD,solubilized,dentine well, whereas organic pulp tissue was clearly more unaffected by it.,Beltz,et al. (,2,003),MTAD & NaOCl,The effect of various concentrations of,NaOCl,as an,irrigant,before irrigation with MTAD as a final rinse on the smear layer was evaluated.,The results showed that MTAD removed most of the smear layer when used alone; however, remnants of the organic component of the smear layer could be detected on the root canal walls.,There were no significant differences between the ability of 1.3%, 2.6%, and 5.25%,NaOCl,as root canal,irrigants,and MTAD as a final rinse to remove the smear layer. All combinations removed both the smear layer as well as the organic remnants.,(Torabinejad etal.2003),The antibacterial effect of,MTAD,I,n vitro,study, the antibacterial effects of MTAD,NaOCl, and EDTA were compared using a disk-diffusion test on agar plates.,The results showed that even highly diluted MTAD produced clear zones of inhibition of the test bacterium,E.,faecalis,Torabinejad et al. 2003,The antibacterial effect of,MTAD,I,n vitro,study, the effect of MTAD on root canals contaminated with either saliva or,E. faecalis,was evaluated, and reported good antibacterial activity.,Shabahang et al. (2003),Shabahang & Torabinejad (2003),Cytotoxicity of MTAD,Cytotoxicity of MTAD was evaluated on fibroblasts.,MTAD is less cytotoxic than eugenol, 3%,H,2,O,2, Ca(OH)2 paste, 5.25% NaOCl, Peridex (a CHX mouth rinse with additives), and EDTA, but more cytotoxic than 2.63%, 1.31%, and 0.66% NaOCl.,Zhang et al. (2003),BDA,BDA,Bis-dequalinium acetate,(BDA),Low toxicity,Lubrication action,Disinfecting ability,Low surface tension,Chelating properties.,Low incidence of post-treatment pain.,Bis-dequalinium,acetate is recommended as an excellent substitute for sodium hypochlorite in those patients who are allergic to the latter.,Kaufman 1981,BDA,Goldberg et al (1986), rated BDA as superior to sodium hypochlorite in,dbriding,the apical third.,When marketed as,Solvidont, the University of Malaysia reported a remarkable decrease in postoperative pain and swelling when BDA was used.,They attributed these results to the,chelation,properties of BDA in removing the smear layer coated with bacteria and contaminants as well as the surfactant properties that allow BDA “to penetrate into areas inaccessible to instruments,Various Irrigation Solution in Endodontic,Removal of root canal debris seems to be related to:,Canal diameter (,the canal must be enlarged at least size 40 at the apex,Viscosity or surface tension of the solution.,Diameter of the irrigating needle.,Depth of penetration of the irrigating needle.,Volume of the solution used.,Anatomy of the canal.,Ram (1977),Previous studies showed that both mechanical and chemical action of the irrigant were dependent upon:,The efficiency of the delivery system (,Abou-Rass,M, Oglesby SW 1981),The tissue surface area in contact with the,irrigant,solution ( Baker et al. 1975, Moored WR,Wesselink,PR 1982,Gomes,etal.,2001,Radcliffe,et al.,2004,Vianna,etal.,2004,).,The frequency of changing the solution (,Moorer,WR,Wesselink,PR 1982),The total volume of the,irrigant,(Cunningham et al.1982,siqueira at al.2000,Sedgley,et al.2005).,The depth of irrigant needle in removing bacteria,The mechanical efficacy of 6mL of,irrigant,in reducing intracanal bacteria was significantly greater when delivered 1mm compared with 5mm from WL.,Sedgley et al. (2005),Smear Layer Removal,Smear Layer Removal,Removal of the smear layer is an important step to facilitate disinfection of the root canal,Organic Acid Irrigants:,Citric acid (,1% - 50% ).,Polyacrylic,acid (e.g.,Durelon,and,Fuju,II liquids).,Solutions,Carbamide,peroxide.,Aminoquinaldinium,diacetate,(i.e.,Salvizol,).,Chelating Agents,EDTA,Removal of the smear layer by EDTA (or citric acid) improves the antibacterial effect of locally used disinfecting agents in deeper layers of dentine.,rstavik & Haapasalo (1990),Effect of Citric acid,10% citric acid was more effective in removing the smear layer from apical root-end cavities than ultrasound,.,Gutmann,et al. (1994),10% citric acid was more effective in dentin demineralization than 1% citric acid, which was more effective than EDTA.,Machado-,Silveiro,et al (2004),Effect of Citric acid,Irrigation with 17% EDTA, 6% phosphoric acid and 6% citric acid did not remove the entire smear layer from the root canal system. In addition, these acidic solutions,demineralized,the,intertubular,dentine around tubular openings, which became enlarged.,The CO2 laser was useful in removing and melting the smear layer on the instrumented root canal walls, and the,Er,:YAG laser was the most effective in removing the smear layer from the root canal wall.,Takeda et al. (1999),Tidmarsh (1978), who felt that 50% citric acid gave the cleanest dentin walls without a smear layer.,Canal wall,untreated,by acid,Midroot canal (citric acid),Midroot canal (phosphoric acid),Apical area (phosphoric acid,),Effect of Citric acid,Excellent filling results after preparation with citric acid (20%), followed by 2.6% sodium hypochlorite and a final flushing with 10% citric acid.,Wayman et al. (1979),Chelating Agents,Chelating Agents,EDTA (,e,thylene-,d,iamine,t,etra-,a,ceticacid,),EDTAC (,e,thylene-,d,iamine,t,etra-,a,ceticacid,&,centrimide,),File-,Eze,RC Prep,EDTA,EDTA,EDTA (17%,disodium,salt, pH 7),EDTA has little if any antibacterial activity.,It effectively removes smear layer by chelating the inorganic component of the dentine.,Aid in mechanical canal shaping.,EDTA,The,ultrastructure,on canal walls after EDTA and combined EDTA &,NaOCl,irrigation was evaluated by scanning electron microscopy.,More debris was removed by irrigation with EDTA followed by,NaOCl,than with EDTA alone.,Niu et al. (2002),The optimal working time of EDTA is 15 minutes, after which time no more chelating action can be expected.,EDTA solutions should replaces in the canal each 15 minutes.,Goldberg and Spielberg (1982),The optimal pH for the demineralizing efficacy of EDTA on dentin was shown by Valdrighi,Goldberg and Abramovich (1977)have shown that EDTAC increases permeability into dentinal tubules, accessory canals, and apical foramina.,Coronal portion of canal of,in vivo,endodontically treated tooth with,EDTAC.,The tubules are open, and the canal is clean and free of smear.,B, Filed canal treated with section of dentinal tubules shows thin intertubular matrix.,McComb and Smith(1975) found that EDTA (in its commer- cial form, REDTA), when sealed in the canal for 24 hours, produced the cleanest dentinal walls,Goldman et al. (1981) have shown that the smear layer is not removed by sodium hypochlorite irrigation alone but is removed with the combined use of REDTA.,Removal of the smear layer is an important step to facilitate disinfection of the root canal. Both EDTA and citric acid can effectively remove the smear layer created during canal instrumentation. Although citric acid may also ha