GOOD

AFTERNOON

Dr.SHAIK MOHD SAJID

 INTRA CANAL IRRIGANTS

• The complexity of root canal morphology presents a

challenging objective to the endodontic community.
• These complexities hamper the ability to thoroughly
achieve pulp cavity disinfection.
• The objective therefore is to remove all of the pulpal and
dentinal debris from the root canal system.
• Biomechanical preparation & chemical preparation are
used concomitantly in order to debride the root canal
system.
• Biomechanical 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.
 FUNCTIONS OF IRRIGANTS

• Antimicrobial activity
• Flushing action - debridement of the canal
system
• Dissolution of necrotic and vital tissues
• Lubrication
• Removal of smear layer
• Bleaching action
TYPES OF IRRIGATING AGENTS
• Sodium hypochlorite
• Chelating agents
• Chlorhexidine
• Hydrogen peroxide
• The acids : tannic acids, citric acids & the others
• Tetracyclines
• Physiologic saline
• Iodines
• BDA & Salvizol
• Johnston - Callahan method
• 9 – amino acridine
• Endoquil
• Glutaraldehyde
• Oxidised potential water
• Ozonated water
• MTAD
• Ruddle solution
• others
 1- SODIUM HYPOCHLORITE

• Strong oxidizing agent

• Clear straw colored
• 5% of available chlorine
• Commercially available chlorox pH 10.83 – 10.98
• Composition : NaOCl - 5.25%
Na2CO3 -0.20 %
NaCl- 4.0 %
NaOH 0.005 – 0.015%
H2O - 90%
 MECHANISM OF ACTION

• Germicidal activity of sodium hypochlorite is

because of formation of Hypochlorus acid
• 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
 SEVERAL CONCENTRATIONS

• 0.5% - 5.25%
– no difference in efficacy of 5.25, 2.5 & 1%
NaOCl Effectiveness of low
concentrations of NaOCl can be improved by
• Larger volumes
• Frequent change
• Longer period of exposure
• Volume of irrigants used per tooth amounts to 5ml.
• 2.5% solution – powerful solubaliser
ANTIMICROBIAL EFFICIENCY
– 1% NaOCl has found to kill both bacterial spores and HIV over a period
of 30minutes.
– effective against C.albicans
– 1/10 concentrations of NaOCl effective against several anaerobic
bacteria.
– 50% reduction in microbial count –and 2.5% NaOCl, synergistic
response with CHX (0.2%) lead to 80% reduction in microbial count.
– In presence of smear layer – 1 hour (samples at 1minute, 5minutes &
30 minutes were positive)
– 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.
– increasing the temperature from 220C-370C of a 2.6% NaOCl solution
increased its tissue dissolving properties
 ADVERSE EFECTS OF SODIUM
HYPOCHLORITE:
SODIUM HYPOCHLORITE ACCIDENT:
• The inadvertent injection of NaOCI into the soft tissues can elicit a
violent and frightening response.

• The cause of this emergency can be related to both the irrigant and
the irrigant technique (Wedged needle with forceful irrigation).

• Mechanism from injury is primary oxidation of proteins followed by

inflammatory reaction from the body.

• This response is similar to that proposed in Angioneurotic edema

with release of Histamine or histamine like substance, a
vasodilatation with subsequent transudation of plasma accompanied
by hemorrhage
• The amount of tissue destruction depends
on:
– Host response
– Volume of irrigation
– Concentration of irrigant
– Temperature of irrigant
– Spread of solution
 Sequence of Events:
• 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.
• Over the next few days, the pain subsides to a constant
discomfort, swelling persists over a week and
progressively subsides.
• The interstitial hemorrhage may result in echymosis over
the skin because of which the affected skin is discolored.
 Treatment Modality

• Stop treatment and give an explanation to the

patient- Remain Calm Reassure patient.
• There is no antidote per se for NaOCI, therefore
resort to palliative care
• Immediately irrigate with copious amounts of
saline
• Evaluate airway
• Pain control
– Immediately with a nerve block
– Prescribe analgesics
– (Naproxen in a dosage of 500-1000mg/day sufficient)
• Corticosteroids for 3 days.
• Consider incision and trephination if
deemed necessary
• Antibiotics for 1 week
• Prophylactic:– Penicillin & Metronidazole
– Cold compresses for first 6 hours followed by
warm compresses and mouth rinses Provide
verbal and written home care
• Set up regular recall visits
 CHELATING AGENT (Ethylene
Diamine Tetracetic Acid)
• Nygaard - Ostby in 1957 introduced EDTA with
the following formulation as an adjuvant in root
canal therapy:
• Ethylene diamine tetracetic acid (disodium salt)-
17.0gm
• Distilled water- 100 cc
• 5/N NaOH- 9.25 cc
• EDTA is an insoluble, odorless, crystalline white
powder; it is relatively non toxic & slightly
irritating in weak solutions.
• pH of 8.3
 Functions of EDTA

– Lubrication
– Emulsification
– Smear Layer removal
– Dispensed in two forms –
Viscous and Aqueous. A
viscous product is used for the first two
functions during canal preparation whereas
the aqueous solution is used as a final flush
after shaping and cleaning for smear layer
removal.
 The effects of EDTA

1. Has dentin dissolving effects

2. Reduces the time necessary for debridement
3. Aids in enlarging narrow/ obstructed canals
4. Helped bypass fragmented instruments
5. Not corrosive on instruments
6. Antimicrobial – neither bactericidal nor
bacteriostatic
– Inhibits the growth of & eventually destroyed bacteria
by the process of starvation. The metallic ions in the
medium which were necessary for growth were
chelated and rendered inassimiable by the micro-
organisms.
7. Self Limiting Action:
– EDTA forms a stable bond with calcium & the
deposited solution can dissolve only a certain
amount of dentin
– When all chelating ions have reacted, an
equilibrium will be reached; then no further
dissolution will takes place.
– This effect was rapid during first one hour and
reached equilibrium by the end of seven
hours.
• R-EDTA (EDTA + cetrimide – cety1 trimethhy1
ammonium bromide) cleaned the canals effectively of
inorganic portions with organic material being left behind.
• A quaternary ammonium bromide- Cetavlon was
added to EDTA to reduce its surface tension & was
called walls EDTAC. This addition increased the wetting
effect on the canal walls & permitted deeper penetration
into the tubular irregularities.
• EDTA-T (with sodium lauryl sulfate)
• Solution of EDTA & Ethylenediamine (a strong organic
solvent).
• R-EDTA (EDTA + cetrimide – cety1 trimethhy1
ammonium bromide) cleaned the canals effectively of
inorganic portions with organic material being left behind.
• A quaternary ammonium bromide- Cetavlon was
added to EDTA to reduce its surface tension & was
called walls EDTAC. This addition increased the wetting
effect on the canal walls & permitted deeper penetration
into the tubular irregularities.
• EDTA-T (with sodium lauryl sulfate)
• Solution of EDTA & Ethylenediamine (a strong organic
solvent).
 Solution of EDTA & HYDROGEN
PEROXIDE
• (a strong organic solvent). HYDROGEN PEROXIDE

• In 1943, Grossman introduced 3% Hydrogen peroxide as an

Endodontic irrigant which was recommended to be used alternately
with Sodium Hypochlorite. Disinfecting and bleaching effects of both
solutions

• be moderate to the anaerobic pathogens.

– Their interaction In the canal produced a transient but energetic

effervescence because of the production of nascent oxygen.

– This was responsible for forcing debris and microorganism out of

the canal. .
– H2O2 does not posses tissue dissolving
properties, nor is it a lubricant. Limited
antimicrobial action only.

– This was the coupled with the solvent action

of NaOCI on the organic debris.
 stoichiometric basis
For the interaction between NaOCI and H2O2 which is
summarized as follows:
• 2NaOCI + H2O2 - O2 + CI2 + 2NaOH
• 2NaOH + CI2 - NaCI + NaOCI + H2O2
• No chlorine is actually available at the end of these
reactions therefore the bactericidal activity of this
combination is questionable.
• The combination has been shown to inhibit individual
antibacterial properties
• When irrigating with H2O2 the last irrigant used should
be NaOCI to prevent any nascent oxygen from being
trapped in the canal.
• Adverse Sequelae:
– reported case of Iatrogenic Penumo-
Mediastinum after irrigation with hydrogen
peroxide.
– Such a patient may present with pain,
dyspnoea, fever, leukocytosis and swelling
CXR is advised.
• Prophylactic antibiotics – 10days
• Monitoring of patient’s vitals
 CHLORHEXIDENE

• Chlorhexidene in the form of a salt (i.e.guconate ,

acetate or hydrochlorate) has been used since the
1950’s as an oral antiseptic in the form of a Mouthwash,
sub gingival irrigant, gel, toothpaste & chewing gum.

• It is a cationic bisbiguanide with optimal antimicrobial

action between pH 5.5-7.0

• Concentrations of use of Chlorhexidene :

– Include 0.12%, 0.2% & 2%
– A commercially available oral rinse typically contains 0.12%
Chlorhexidene gluconate, 11.6% alcohol, glycerin, flavoring
agents, saccharin.
 ANTIMICROBIAL ACTIVITY:
• Posesses a broad spectrum against gram positive & gram negative
bacteria, fungi, bacteria spores, lipophyllic virus, dermatophytes

• Mechanism of Action – 2 fold (Hennessey 1973)

• High Concentrations: Bactericidal

– Chlorhexidene penetrates the cell wall & causes precipitation or
coagulation of cytoplasm probably caused by cross- linking.

– Low Concentrations: Bacteriostatic

• Positively charged molecules of chlorhexidene bind readily to the
negatively charged cell wall, mainly to phosphate groups in LPS, &
carboxyl groups in proteins.
• It therefore interferes with membrane transport initiating a leakage
of low molecular weight substances.
• Acts by adsorbing into the cell walls of the micro-
organisms & causing leakage of intracellular
components.
• Bacteriostatic effect is considered to be more important
since the bound chlorhexidene molecule is released
slowly over 24 hours.
• When 2% & 0.2% each of NaOCI &Chlorhexidene were
used
-Chlorhexidene is a base, capable of forming salts of a
number of organic acids.
-NaOCI – oxidizing agent: Oxidizes gluconate part of
Chlorhexidene gluconate to gluconic acid.
• The CI- groups may get added into the guanidine component of the
chlorhexidene molecule forming Chlorhexidene -CI
• Results in increasing ionizing capacity of Chlorhexidene
• Makes solution more alkaline
– CHX – 6.5pH
– NaOCI-9 pH
– combination- 10
• effective action against E. facealis
• Buck & others have reported on the ability of a combination of
Chlorhexidene , NaOCI & alcohol to detoxify LPS molecules by
hydrolysis within the canal.
• Heating of Chlorhexidene solution to 460 C enhanced the
antimicrobial action of 0.12% Chlorhexidene.
• antifungal properties
 MTAD(Mixture Of Tetracycline
Acid And Detergent )
• Introduced to scientific literature in 2000, this irrigant was introduced by
Torabinejad et al at the Loma Linda Dental School.
• 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
 RUDDLE’S SOLUTION

• Introduced by an American researcher, Dr. Clifford J.

Ruddle. This solution is based on the use of HYPAQUE
– M, a radio- opaque, high contrast injectible dye.

• COMPOSITION
• 5% Sodium Hypochlorite
• Hypaque M
• 17% EDTA
• It has a pH between 6.5 - 7.7
• 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
 OXIDISED POTENTIAL WATER

• was developed in Japan

• Defined as an electrolytically obtained highly acidic
water having accumulated in the anode
compartment after sodium chloride added water
has consumed OH ions
• Oxidative potiential
• strongly acidic with a pH of 2.5
• Possesses several oxygen containing antimicrobial
constituents like HOCI and O3-
• Shimizu reported killing of viruses which
include HSV, HIV and Mouse CMV..
– for patients to hold in oral cavity
– Volume for use –10ml . Time -> 1 min
– Does not effectively remove smear layer
 OZONATED WATER

• Ozonated water is powerful antimicrobial

agent against bacteria, fungi protoza and
viruses.
• Ozone in aqueous or gaseous phases has
a strong oxidizing power with reliable
microbial effects
– Ozone destroys cell walls & cytoplasmic
membranes of bacteria & fungi
– Increased permeability leads to ingress of
ozone which cause microbial death.
 Johnston - Callahan method

• Dr. H.B.Johnston – (Atlanta)

• 20% sulfuric acid & saturated solution of
bicarbonate of soda
• Frequent complications
• Potential for necrosis
 THE ACIDS

TANNIC ACID
• Tannic Acid 25% as a cleansing agent in endodontics
was first suggested by Graham Mount.

• It has ASTRINGENT PROPERTIES.

• It is also known to possess antimicrobial properties

• increase in dentin hardness because of it’s inhibiting

effect on calcium dissolution Constriction & obliteration
of dentinal tubules has been observed & dissolution of
organic matter was inhibited.
 CITRIC ACID

• A 50% Citric Acid solution possesses antimicrobial

efficacy equivalent of 5.25% NaOCI against several
anaerobic bacteria.
• Use 10ml for a duration of 5min-15min
• A combination of citric acid & NaOCI has also been
demonstrated for it’s antimicrobial properties
• As Citric Acid is very acidic (pH=1.28), the initial reaction
readily occurs to yield a large amount of Hypochlorus
acid which decomposes to form chlorine gas.
• It removed smear layer from both middle & apical thirds
of the canal
• Was equally effective for smear layer removal as was
17% EDTA.
 TETRACYCLINES

• Include
– Tetracycline HCI
– Minocycline
– Doxycycline

• Are broad spectrum antibiotics effective against a wide range of micro-

organisms.

• Low pH in concentrated solutions & thus can act as calcium chelators. This
may cause root surface demineralization comparable to citric acid.

• Substantivity of these antibiotics allows them to be absorbed & released

gradually from tooth structures.

• Ability to remove smear layer also studied.

• Doxycycline HCI (100mg/ml) effective in removing smear layer of

instrumented canals.
 IODINES

• Two iodine preparations are in use as endodontic irrigants

• Povidone iodine ( Betadine) – 10%

• Iodine Potassium Iodide - 2%

• use of Povidone – Iodine solution has Rapid antiseptic action

against a wide range of micro – organisms

– IKI achieved 100% sterility is 15 min time frame

– Low toxicity
– Hypoallerginicity
– Decreased tendency to stain dentin as compared to other iodine
containing antiseptics
 SALVIZOL
• Derivatives of oxine (8 hydroxy quinolone) are known antiseptics
.Salvizol belongs to the surface acting materials similar to the
quaternary Ammonium group. It differs from the latter by its anti
bacterial activity even in the presence of organic materials.

Antimicrobial Efficacy

• Most active on gram +ve & gram -ve micro-organisms as well as

fungi.

• A related compound Bis-Dequalinium Acetate (BDA) marked as

SOLVIDONT

• slightly enhanced action in apical 1/3 rd of root canal.

• Dispensing forms: -
– Irrigation solution – 0.125 %
– Working solution – 0.5%
 AMINO ACRIDINE

• Is a cationic antiseptic agent.

• Requires 25 – 50mg of Amimoacridine /
endodontic visit.
• Entirely non – irritating in dilution 1:500 &
1:1000.
• All organisms except Pseudomonas
aeruginosa were susceptible to high
dilutions of 9- Aminoacridine.
 ENDOQUIL – CASTOR OIL
BASED IRRIGANT

• Endoquil is a natural product derived from a

tropical plant Ricinus communis, a castor oil
detergent.
• Fereira et al used endoquil & 0.5% NaOCI as
irrigants & found the former to reduce CFU’s for
anaerobic organisms better in teeth with
necroses & periapical lesions.
• Effective against gram +ve organisms only .
• Acts on the biofilm of adherence between canal
wall & bacteria.
 GLUTARALDEHYDE

• Investigated as an irrigant because of

germicidal activity.
• However, is also capable of producing
inflammation
• 2% glutaraldehyde to produce extensive
necrosis
• never become popular as an irrigant
 OTHER IRRIGANTS

1. Quartenary Ammonium compound

2. Chloramine-T

3. 1% Dodecyl aminoethyl Glycine

4. 5% Dichloro iso cyanourate (NaDCC)

5. 10% Paracetic acid

6. Nitroimidazoles – Metronidazole & Tinidazole

7. Carisolv

8. Therasol
 • 10% PARACETIC ACID THERASOL
•CHLORAMINE-T
• DENTSPLY MPL's Max-i-Probe®
irrigating probes fully irrigate root canals,
including the apical third. In addition, the
Max-i-Probe® irrigating probes cleanse
the full gingival sulci for effective reduction
of bacteria, without tissue laceration.
• MAXI-PROBE
 METHODS & TECHNIQUES OF
IRRIGATION
• Walton & Torabinejad stated that “Perhaps the most
important factor is the delivery system & not the irrigation
solution per se”.

• The most common method of delivering irrigant into the

canal is with the aid of a syringe to which is affixed a
needle.

• A 5ml syringe of the disposable Leur Lok twist

mechanism is the preferred one. In this case the needle
will not to be dislodged when the plunger of the syringe
is displaced.
• 1. Gauge of the needle: from 21 to 30 gauge needles are
used.
– Since irrigation of apical third requires the needle to be in it’s
proximity for adequate effect, the canals contents should be
flushed with a 27-30 gauge needle placed in apical third.
• 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:
– a) Open ended blunt needles
– b) Beveled needles
– c)Blunt ended side venting needle (ProRinse)
• The ProRinse endodontic irrigating
• probe (Dentsply,
Tulsa Dental, Johnson City,
• Tenn.) is among the
smallest-bore irrigating
• needles, with features
of flexibility, sideventing
• and a
closed blunt end.
d)Maxi-probe

Notched tip (Monojet – 27 gauge)

e) Perforated needle –Endovage (Goldman &
others)
• MAXI-PROBE
• The effective canal clearance seen in the
Pro- rinse system is attributed to its tip
design with the lumen being 2mm from the
tip. This creates turbulence along &
beyond the probe. This also prevents
forceful periapical injection of irrigant
• Recent Innovation: Stropko Irrigator this
irrigation system combines the delivery &
recovery of irrigant in one probe. The
needle delivers the solution and an
aspirator held in the same sheath retrieves
the delivered irrigant.
 OTHER METHODS OF
DELIVERY:

ENDO –IRRIGATOR

• A system that delivers various kinds of on-

line irrigants from one in –office air
pressurized bottles at the push of a button
 .
• . ENDO IRRIGATOR
I

ENDO IRRIGATOR I
QUANTEC IRRIGATION SYSTEM:

– The peristaltic pump delivers irrigant via the

handpiece as the root canal is being prepared
by rotary files.
 THE TECHNIQUES:

1. Secure rubber dam isolation

2. Fill syringe via hub irrigant stored in a dappen dish by

the chairside.

3. SOMMER’S TECHNIQUE
– Place a few drops of irrigant in the pulp chamber , then
“Whirlpool” the solution into the canal with a small file.

4. GROSSMAN’S TECHNIQUE
– flood the pulp chamber with the irrigant. This served as a
reservoir of irrigant to replenish the one present in the root canal
as it was being instrumented.
5. When the needle meets resistance inside canal , it is
withdrawn a few mms to prevent it from wedging &
forcing the irrigant into periapical tissues.
6. Once irrigant delivery starts, look for the backflow of the
irrigant from the canal orifice.
7. The hand holding the irrigating syringe is always kept in
motion when dispensing irrigant.
8. Files potentially carry irrigant progressively deeper into
the canal by surface tension. In small canals, the files
displace the irrigant. When the instrument is withdrawn,
the irrigant usually flows into the space the file occupied.
9. Clinicians should irrigate copiously, recapitulate
& re-irrigate after each instrument size.
10. Besides using an aspirator, Grossman
suggested the use of a gauze sponge held
against the tooth to absorb the backflow of the
irrigant.
11. Once the shaping & cleaning is accomplished,
the irrigant is aspirated from the canal with
syringes & subsequently dried with paper points.
 ENDOSONICS& IRRIGATION:

• At the US Navy Dental Center, Martin & Cunningham

developed a system which used ultrasonics for preparing
the root canal.
• The power source they employed was a magnetostrictive
unit. Recently piezoelectric units have also been used.
• This technique was termed a “SYNERGISTIC SYSTEM”
because the instrument abrades dentin delivers a
copious flow of irrigant to the tip of the instrument
• The instrument tip is moved 0.001-0.004 of an inch
through a push pull motion of the handpiece at a
frequency of 20-25 thousand Hz
• A continuous irrigant flow is provided at 45ml/minute.
 MECHANISMS INVOLVED
CAVITATION
CAVITATION:
• When a vibrating object is immersed in a fluid, oscillations are set up
in the liquid.

• During the rarefaction phase, the liquid can fail under stress & form
bubbles. (This is termed PSEUDOCAVITATION by Cameron)

• During the next positive pressure phase, these vapor filed cavities
collapse implosively producing a high temperature and pressure of
the gas still contained within the cavity.

• These high temperatures & pressures in turn result in free radical

generation & radiate shock waves from the collapse which leads to
it’s WATER HAMMER ACTION on solid surfaces.
 ACOUSTIC STREAMING

• Is the more prominent method by which the action has been

explained.

• Definition: Rapid movement of particles of fluid in a vortex like

motion about a vibrating object but may also be associated with
small gas bubbles set into oscillation by the fluctuating pressure field
generated by the file.

• streaming pattern where liquid was transported from the apical end
to the coronal end of the file in a region very close to the file.

• The authors found no difference between hand instrumentation &

ultrasonic. They postulated that canal surfaces seem to be the
function of the type of irrigant rather than the technique used.
 ULTRASONICS &
MICROBRUSHES:
• Bristle materials & bristle attaching techniques have led
to the creation of an endodontic microbrush.
• Bristles can be attached to either
– Braided wires or
– Flexible, plastic cores
• Fabricated as either rotary or ultrasonic endobrushes.
• Have Non standardized Gutta Percha master cone
tapers:Fine .Medium.Large
• Used in conjunction with NaOCI & EDTA to produce
clean canals