In an old root canal treated case filled with silver point,

lateral retention of silver point in the canal might have

been reduced due to chronic leakage and corrosion of silver
points and if the butt end of silver point is easily accessible in
the pulp chamber, then silver point removal is accomplished
quite easily.
• But most of the times, the butt end of silver point is
embedded in the cement, composite or amalgam core.
So, the initial access is made with round burs with
extended shanks to carefully remove the core material
without inadvertently shortening the silver points.
• Then ultrasonic instruments can be used to carefully
“brush-cut” the core material to expose the silver point
which can be then grasped using a suitable grasping
instrument such as Steiglitz pliers.
• Ultrasonic energy can also be used when silver point lies
below the orifice to disintegrate the interface within the
canal and enhance the removal of silver point.
Removal of Obstructions from Root Canal
such as Separated Instruments
Various microtube removal techniques have been currently
introduced to aid in the removal of the obstruction from
the root canal.
The Masserann kit, instrument removal system (IRS),
endoextractor system (EES) are few commercially available
kits that can be used for removal of obstructions such as
separated instruments from the root canal.
WHAT ARE THE MATERIALS USED AS
TEMPORARY RESTORATIONS?
In case of multivisit Endodontic therapy, temporary
restorations or cements have to be placed in the access
cavity or pulp chamber to achieve a satisfactory coronal
seal in order to prevent contamination from the bacteria
and fluids from the oral cavity.
It is recommended that these cements be placed in the
thickness of 4–5 mm for an effective coronal seal and that the
cement has sufficient strength to withstand the masticatory
forces.
Temporary cements include:
Cavit
• It is a premixed material for use as temporary cement.
• Composition: Zinc oxide, calcium sulfate, glycol,
polyvinyl acetate, polyvinyl chloride, triethanolamine.
• Cavit cement sets as it absorbs fluid.
• For adequate seal, it should have depth of at least
3.5 mm.
Intermediate Restorative Material (IRM)
• It is a polymer resin-reinforced zinc oxide cement
• Available as powder and liquid in mixing capsules
• Its compressive strength is double that of Cavit.
It has been found to cause extensive marginal leakage.
TERM
• It is light cured filled composite resin which can be used
as temporary restoration.
• Composition: Urethane Dimethacrylate (UDMA) polymers,
inorganic radiopaque filler, pigments, initiators.
• Adequate seal can be achieved with it even at the
thickness of 1 to 3 mm.
Figure 11.45 shows photograph of a commercially
available temporary restorative cement.
Fig. 11.45 Commercially available ready mixed temporary filling
material which sets when it comes in contact with patient’s saliva
(Courtesy of Ammdent)
190 Short Textbook of Endodontics
WHAT IS THE ARMAMENTARIUM FOR
PERIRADICULAR SURGERY?
For details refer to Chapter 26 Surgical Endodontics.
• BP blade no. 15 or microsurgical scalpel
• Periosteal elevator
• Microexplorer, endoexplorer
• Microtissue forceps
• Miniature handpieces
• Straight handpiece with different burs
• Sterile saline
• Sterile cotton, cotton pliers
• Surgical forceps
• Curettes
• Root-end filling materials:
– Amalgam
– Mineral trioxide aggregate (MTA)
– Composite resin system (Retroplast)
– Intermediate restorative material (IRM)
– Super-EBA
– Glass ionomer cements
– Resin cements such as Diaket
• Micromirrors
• Microcondensers or microburnishers and pluggers of
different sizes
• Needle holder, suturing needle, suturing material
• Hemostatic agents:
↓↓
Collagen-based Noncollagen based
– Collacote – Bone wax
– Collastat – Ferric sulfate
– Gelfoam
– Thrombin
WHAT ARE THE MATERIALS USED FOR POSTENDODONTIC
RESTORATION?
Instruments for Postspace Preparation
• Peeso drills can be used for postspace preparation
• Various postspace preparation drills are available with
the preformed post systems.
Flow charts 11.1 and 11.2 list the materials used for post-
Endodontic restoration. They have been discussed in detail
in Chapter 21 Restoration of Endodontically Treated Teeth.
WHAT IS THE ROLE OF LASER
DEVICE IN ENDODONTICS?
Different types of lasers used in dentistry:
• Er:YAG laser
– Effective for drilling and cutting enamel and dentin.
• CO2 laser
– Quite effective in soft tissues of oral cavity. But not
suitable for drilling and cutting enamel and dentin.
Flow chart 11.1 Classification of post systems for restoration of Endodontically treated teeth
Flow chart 11.2 Classification of core materials for restoration of
Endodontically treated teeth
Endodontic Armamentarium: Instruments, Materials and Devices 191
• Nd:YAG laser
– Effective on dark pigmented tissue.
• Argon laser
– Effective on pigmented or highly vascular tissues.
Applications of lasers in Endodontics:
– Laser Doppler flowmetry developed to assess pulpal
blood flow to determine vitality of pulp.
– Lasers may be used for pulp capping and pulpotomy
procedures.
– Lasers have been tried in the cleaning and shaping
procedures and also in obturation.
– Nd:YAG and Er:YAG lasers may be used for removal
of old root canal filling materials during Endodontic
retreatment.
– Lasers may be used for root-end preparation during
periradicular surgery.
Lasers have been explained in detail in Chapter 32
Lasers in Endodontics.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.233-81.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication; 1991.pp.190-6, 210-6.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.800-76.
4. Ingle, Bakland Endodontics, 5th edn. BC Decker-Elsevier; 2002.
pp.473-98.
5. “Rotary Instrumentation: An Endodontic Perspective,”
Colleagues for Excellence, Winter 2008, American Association
of Endodontists.

Asepsis and Sterilization of

Endodontic Instruments
This chapter explains the importance of infection control and the various methods to achieve effective
infection control in dental practice. It describes the ways to take proper care and about sterilization of
various Endodontic instruments.
 You must know
• Why is Effective Infection Control Important in Endodontics?
• How to Achieve Effective Infection Control in Dental Practice?
• What is Sterilization and Disinfection?
• How to Take Proper Care of Endodontic Instruments?
• What are the Commonly Employed Methods of Sterilization/Disinfection of Various
Endodontic Instruments?
12
CHAPTER
WHY IS EFFECTIVE INFECTION CONTROL
IMPORTANT IN ENDODONTICS? (FIG. 12.1)
Asepsis is the state of being free from disease-causing microorganisms
or preventing contact with microorganisms. It
is necessary to avoid contamination by microorganisms
during Endodontic therapy as postoperative infection can
be caused by break in sterile technique. Aseptic techniques
in Endodontics such as use of sterilized instruments,
disinfecting solutions, use of procedural barriers such as
rubber dam, etc. is very important to prevent infection.
Protection of Dental Health Care Personnel
All dental health care personnel (including both those that
are directly involved and those that are indirectly involved
in patient care) are at risk for exposure to a wide variety of
infectious microorganisms from the blood and saliva of
patients.
For example, influenza, hepatitis B, C, D, upper
respiratory disease, herpes, AIDS, etc.
So, effective infection control procedures must be used
to protect the dental team from contracting infections while
delivering dental procedures.
Protection of Patients
Infection should not get transmitted from one patient to
other patient due to use of same infected instruments
without sterilizing them.
The dental team should never be responsible for
introducing infection in patients due to lack of adopting
appropriate infection control methods.
Fig. 12.1 Goal of infection control
Asepsis and Sterilization of Endodontic Instruments 193
Sterile instruments and proper techniques should be
used to avoid contamination by microorganisms during
Endodontic therapy in order to prevent postoperative
infection.
Transmission of infection can occur in 2 ways: (Crossinfection)
HOW TO ACHIEVE EFFECTIVE INFECTION
CONTROL IN DENTAL PRACTICE?
Occupational Safety and Health Administration (OSHA),
American Dental Association (ADA), Center for Disease
Control (CDC) and other Governmental and Non-
Governmental agencies give recommendations for infection
control.
These guidelines must be followed by the dental team.
Considerations for Dental Operatory
• Operatory surfaces such as over-head light handles,
X-ray unit heads, dental chair switches and any other
surface likely to become contaminated with potentially
infectious material should be covered or disinfected.
Protective coverings can be in the form of clear plastic
wrap, special plastic sleeves, etc. These covers should
be changed between patients.
• Endodontic microscopes: Handles and controls
of microscope should be covered with barriers.
Microscope manufacturer’s guidelines should be used
for disinfection of microscope.
• Sensors of digital radiography are covered with singleuse
plastic sleeves for each patient.
• Dental unit water lines should be periodically flushed.
This can be done with water or a 1:10 dilution of 5.25%
sodium hypochlorite to reduce biofilm formation.
Biofilm is sticky water line with bacteria, that can
travel upstream in dental unit water lines due to slow
movement of water.
Flushing water lines for 20–30 seconds between
patients is recommended to avoid transmission of
microbes from one patient to the next.
• Waste management: Sharps are included in regulated
medical waste category and should be discarded in a
rigid container with ‘biohazard’ label. Sharps include
needles, scalpel blades, Endodontic instruments and
other items that can cause injury to skin. Gauze or cotton
rolls soaked in blood or saliva are also regulated medical
waste and should be appropriately disposed.
• It is recommended that there should be separate areas
in the operatory for the cleaning/sorting/packaging of
contaminated instruments for sterilization.
• Aerosols generated during dental procedures can
spread throughout the room, so all surfaces need to be
disinfected. Doors, drawer pulls should also be covered
with barriers or disinfected routinely.
• High-volume evacuation can greatly reduce the number
of bacteria in dental aerosols and should be used when
using high-speed handpiece or ultrasonics.
Considerations for Dental Personnel
• Vaccination: All dental health care personnel should be
vaccinated against infectious diseases such as hepatitis
B, influenza, etc.
• Protective attire and barrier techniques:
– Protective clothing such as gowns, aprons, lab coats,
clinic jackets, either disposable or reusable must be
worn. Endodontic surgery will require long sleeved
uniforms.
Contaminated laundry should not be taken home
for wash to avoid transmission of infection to family
members.
– Protective eyeglasses with solid side shields are
required when splashes or sprays of infectious
materials are anticipated.
– Use of disposable latex or vinyl gloves and masks.
Gloves should be replaced after each patient
contact.
Commonly available masks protect the wearer
only partially. Small droplets containing bacteria
can pass through them. If the mask becomes wet, it
should be changed immediately.
Sterile gloves to be worn for surgical procedures.
Examination gloves may be contaminated and may
harbor microbes. Since gloves do not give total
protection, chlorhexidine disinfectant hand wash
can be used due to its property of substantivity, it
bonds to skin and maintains antibacterial action for
longer time as compared to other scrubs.
Polyethylene gloves can be worn over treatment
gloves to prevent contamination of objects, such as
drawers, light handles or patient charts.
Figure 12.2 shows photograph of disposable
examination gloves, mask and protective eye glasses.
194 Short Textbook of Endodontics
Considerations Related to the Patient
• Patient’s clothing should be protected from splatter and
caustic materials with plastic coverings.
• Reducing bacteria within oral cavity before treatment
by use of appropriate mouthwash such as 0.12%
chlorhexidine gluconate.
• Use of rubber dam as a protective barrier is mandatory
for nonsurgical root canal treatment.
• Patient screening: A thorough medical history must
be taken and updated at each visit to include specific
questions regarding hepatitis, AIDS, current illnesses,
weight loss, etc.
Figure 12.3 shows mind-map to remember all points of
infection control in dental practice.
Fig. 12.2 Disposable examination gloves, mask and protective eye
glasses (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
Fig. 12.3 A mind-map to remember all points of infection control in dental practice
Asepsis and Sterilization of Endodontic Instruments 195
WHAT IS STERILIZATION AND DISINFECTION?
Sterilization is the process of destroying all life forms,
including spores, from an article or surface.
Disinfection is the process of destroying most life forms,
especially pathogens, but does not include killing spores.
1. Autoclave: (Moist heat/Pressurized steam)
– Commonly used method
– Cycle: 250oF temperature (121oC)
15 psi pressure
15–20 minutes
– Flash sterilization 273oF (134oC)
at higher 30 psi pressure
temperatures: 10 minutes
Autoclaves are available as:
– Top loading
– Front loading
Figures 12.4A and B show photograph showing
commercially available front loading autoclave.
2. Chemiclave:
– It utilizes a solution of 72% ethanol and 0.23%
formaldehyde in place of water in its autoclave.
– It is not suitable for liquids
– Temperature of 270oF (132oC) at 20 psi pressure for
20 minutes.
– It avoids instrument corrosion.
3. Dry heat:
– It utilizes still air in an oven or forced air.
– It avoids instrument corrosion.
Based on this principle, there are two sterilizers:
i. Hot salt sterilizer
ii. Glass bead sterilizer.
Hot salt sterilizer: It is an efficient and compact apparatus
for sterilization of Endodontic instruments.
• Components: It consists essentially of a metal cup in
which table salt is kept at the temperature of between
425oF and 475oF (218.3oC–246.1oC)
Table salt contains:
– Sodium silicoaluminate 1% and
– Magnesium carbonate/sodium carbonate
A thermometer is kept inserted in the salt at all times.
• Uses:
– Broaches, files and reamers are sterilized by
immersion for 5 seconds.
– Absorbent points and cotton pellets can be sterilized
by immersion for 10 seconds.
• Advantages:
– Table salt is readily available
– Eliminates the risk of clogging the root canal. Thus,
the hot salt sterilizer has superseded the moltenmetal
sterilizer and glass bead sterilizer.
• Disadvantages:
– Ineffective in killing spores
– Dry heat has poor penetration capability.
Figs 12.4A and B Photograph showing commercially available front loading autoclave (Courtesy of Mr Amar, Dr Mukul Dabholkar’s
clinic)
AB
196 Short Textbook of Endodontics
Glass bead sterilizer: It is an efficient and compact apparatus
for sterilization of Endodontic instruments.
• Components: It consists of glass beads of less than 1 mm
diameter in a metal cup.
Large beads cannot transfer heat effectively to
Endodontic instruments due to large air spaces
between the beads that reduce the efficiency of
sterilizer.
Figures 12.5A and B show photograph of commercially
available glass bead sterilizer.
• Temperature: 425–475oF (218–246oC)
• Uses:
– Broaches, files and reamers are sterilized by
immersion for 5 seconds.
– Absorbent points and cotton pellets for 10 seconds.
4. Cold chemicals:
• Recommended only for those items that cannot be heat
sterilized.
• They usually require extended soak times.
HOW TO TAKE PROPER CARE OF
ENDODONTIC INSTRUMENTS?
Effective care for Endodontic instruments involves:
• Preparation of instruments for sterilization
• Sterilization proper
• Effective storage of instruments.
Figs 12.5A and B Glass bead sterilizers. (A) As seen from front; (B) As
seen from above. Note the different timings required for sterilization
of various instruments are mentioned on the lid (Courtesy of Dr
Nishant Singh)
Preparation of Instruments for Sterilization
Handling, cleaning and packaging of contaminated
instruments are frequent sources of injury and possible
infection.
Reusable instruments that become contaminated after
use are immediately taken to a dedicated area for removal
of gross debris by scrubbing or by use of ultrasonic
cleaner. Clean, dry instruments can then be subjected to
sterilization process.
A
B