Irrigation in

Endodontics
Dr.Mohamed Ali Alazrak
BDS.MSc
Tripoli Medical Center Libya
Azrakdent@gmail.com

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 .

Properties of ideal irrigant solution

Anti microbial properties
Tissue
Flush

solvent.

debris.

Lubricant.
Eliminate
Low

the smear layer.

toxicity level

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 :

lkalis : sodium hypochlorite

ntibacterial agents : chlorhexidin

xidizing agents: hydrogen prioxide

helating agents: EDTA ( ethylene diamine tetra acetic

acid)

Sodium hypochlorite (NaOcl)

Clear ,pale green-yellow liquid
.with strong odor of chlorine
It

is

agent,

potent
killing

antimicrobial

most

bacteria

instantly on direct contact. It

also

effectively

dissolves

.necrotic and vital pulp tissue

st advocated irrigant,inexpensive and readily available

Sodium hypochlorite (NaOcl)

Anti microbial properties
Tissue

solvent.
( dissolve vital and non vital
tissue)

Flush

debris.

Lubricant.
Eliminate
Low

the smear layer.

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

Temperature

Increasing the temperature of hypochlorite irrigant to

600C, significantly increased its antimicrobial and
tissue-dissolving effects.

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

Management
inform 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

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

ability.

lacks

the

tissue-dissolving

Chlorhexidine (CHX)
Anti

microbial

properties

(broad spctrum antimicrobial

agent )
Tissue
Flush

solvent.

debris.

Lubricant.
Eliminate
Low

the smear layer.

toxicity level.

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
Flush

solvent.

debris.

Lubricant.
Eliminate
Low

the smear layer.

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

endodontic irrigation.

for

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
foramen.

enforced beyond the apical

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
Flush

solvent.

debris.

Lubricant.
Eliminate
Low

the smear layer.

toxicity level.

Advantges
1) 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
DTA

functions

calcium

chelate

by

forming

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.

he optimal working time of EDTA is 15 minutes, after which

time no more chelating action can be expected.

Smear Layer

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 .

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
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 .

rrigation
technique and
devices

 Plastic syringe with needles

lastic syringes of different sizes
(120 mL) are most
commonly used for irrigation .

ll
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, openend 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.

27- or 30-gauge needle is preferred

The solution must be introduced slowly.

T
he irrigating needle should be bent to allow easier delivery of the
solution and to prevent deep penetration of the needle.

C
are must be taken with irrigants like sodium hypochlorite to prevent
accidents.

 Gutta-percha Points
agitation

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.

 EndoActivator

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
operated

to

the

handpiece

battery
that

creates the sonic vibrations.

 EndoActivator

allow

more

irrigant

penetration and mechanical

cleansing
needle

compared

irrigation,

with

with

no

increase in the risk of irrigant

extrusion through the apex.

 Ultrasound
U
ltrasound is sound energy with frequency
above 25 KHZ.

assive ultrasonic irrigation have shown to

clean root canals or eliminate bacteria from
the walls better than conventional methods.

Mechanism of action
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
his mechanichal energy warms
the irrigant solution (NaOcl) and
dislodge debris from canals.

he combination of activation and

heating the irrigation solution is
adjunct

in

cleaning

canal system .

the

root

 EndoVac
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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