INTRACANAL IRRIGANTS

INTRA CANAL
IRRIGANTS
Dr. Aadil Thimwala
Part II , G.R.I.D.S, Gandhinagar

Seminar Outline
– Introduction
– History
– Functions of irrigation
– Irrigantion
– Saline
– Sodium
hypochlorite
– Chlorhexidine

– Hydrogen peroxide
– The acids : tannic acids, citric acids
– Tetracyclines
– Iodines
– Ozonated water
– Glutaraldehyde
– MTAD
– Ruddle solution
– Methods of Irrigation.

Introduction
– The complexity of root canal morphology presents a
challenging objective to the endodontic community.
– Body infection is eliminated by systemic antibiotics.
– Endodontic infection follows a different pathway for
elimination.
Ingle’s Endodontics, 6th Edn.

– The sequence of events and procedures in the control of
endodontic infections are
– Host defense system,
– Systemic antibiotic therapy ,
– Instrumentation and Irrigation
– Intracanal medicament

– Root canal system is complicated with fins,
webs and anastomoses
– These complexities hampers 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.
Disinfection of root canal system, Cohencha 1st Edn.
Textbook of Endo. Nisha Garg, 3rd Edn.

– The body is unable to destroy the microbes well
entrenched in the sanctuary of the necrotic root canal,
which is beyond the body’s immune system.
– The major goal of the root canal debridement is to
eliminate the biofilm and bacteria-harboring debris.

– It is important to appreciate that while hand and rotary
instrumentation produce shape, it is the irrigants that clean
the root canal system.
– Irigants not only are important for the removal of debris
and dentinal chips produced during shaping and cleaning,
but also are of critical importance in eradicating the
intraradicular microbial infection.
Endodontic Practice, Grossman 13th Edn.

History
– Until the advent of the 20th century, water was perhaps the
most commonly used endodontic irrigant
– It was readily available Inexpensive Provided some amount
of lubricating effect
– 1st world war – Dakin’s solution
– 1936 – walker – sodium hypochlorite (Crane 1920)
– 1940 – Grossman & Grossman & Meiman – 3% hydrogen
peroxide & 5.25% sodium hypochlorite
Sedgley, Christine M.. “Root canal irrigation--a historical
perspective.” Journal of the history of dentistry 52 2 (2004): 61-5.

– 1930 – 1940 : Proteolytic enzymes – Streptodonnase, Papain,
Enzymol & purified Trypsin
– 1920 – 1940 : Strong acids – 20 – 50% Sulfuric acid,
Hydrochloric & Nitric acid, 50% Aqua Regia.
– 1957 : Nygard Ostby – EDTA
– 1970s & early 80s : Chlorhexidine
Sedgley, Christine M.. “Root canal irrigation--a historical
perspective.” Journal of the history of dentistry 52 2 (2004): 61-5.

Ideal Requirements of an Endodontic
Irrigant
– Should have good antimicrobial activity
– Mechanically flush out the debris from the canal.
– Nontoxic and biocompatible.
– Removes the smear layer.
– Non staining
– Cost effective
– Dissolves the necrotic and vital pulp tissues.
– Serves as the lubricant
Endodontic Practice, Grossman 13th Edn.

– Have low surface tension so that it can easily flow into
inaccessible areas.
– Be able to penetrate root canal periphery.
– Be able to dissolve pulp tissue, smear layer and biofilm.
– Be fungicidal.
– Not weaken the tooth structure.
– Be easily available.
– Be cost effective.
– Be easy to use.
– Have adequate shelf life.

FUNCTIONS OF IRRIGANTS
– Remove dentinal shavings by physical flushing

– Increase the efficiency of instruments
– Dissolve necrotic tissue
– Remove debris from lateral and accessory canals
– Germicidal as well as antibacterial properties
– Irrigants with lubricating agent further increase the
efficiency
– Opening of dentinal tubules by removal of smear layer

Goals of Irrigation
– Eradication of root canal microbes.
– Killing and removal of microorganisms
– Removal of necrotic and inflamed tissue and dentine debris
– To reduce friction between the instrument and dentine,
improves the cutting effectiveness.

– To dissolves tissue, and cools the file and tooth especially
during the use of ultrasonic energy.
– Prevent packing of the hard and soft tissue into the apical
root canal and extrusion of bacteria out into the periapical
tissues.
- Hapasalo et al. BDJ:216 /6 /2014

Classification
(A) Antibacterial agents:
- Sodium hypochlorite (NaOCl), chlorhexidine (CHX).
(B) Decalcifying agents:
1. Weak: Hydroxyethylidene bisphosphonate or etidrona
acid (HEBP).
2. Strong: Ethylenediaminetetraacetic acid (EDTA).
Disinfection of root canal system: Cohencha 1st Edn.

(C) Combinations (antibacterial agents and/or chelating
agents+detergent):
1. MTAD (Dentsply Tulsa Dental Specialties, Tulsa, OK) and
Tetraclean (Ogna Laboratori Farmaceutici, Muggiò, Italy):
tetracycline+acid+detergent.
2. QMiX (Dentsply Tulsa Dental, Tulsa, OK): CHX,
EDTA+detergent.
3. Smear Clear (SybronEndo, Orange, CA): EDTA+detergent.
4. Chlor-Xtra (Vista Dental, Racine, WI): NaOCl+detergent.
5. CHX plus (Vista Dental, Racine, WI): CHX+detergent.
(D) Natural agents: Green tea, Triphala.

Factors That Modify Activity of Irrigating Solutions
Concentration
– Tissue dissolving ability of sodium hypochlorite is greater at
a concentration of 5.2 percent than at 2.5 percent and 0.5
percent.
– But higher concentrations are more cytotoxic than lower
concentrations.

Contact
– To be effective, the intracanal agent must contact the
substrate.
– When the canals are sufficiently enlarged, the solution can
be deposited directly in the apical area of the preparation
with a fine irrigating needle.

Quantity of the Irrigant Used
– Baber et al proved that ability of solution to debride is
directly related to the quantity of irrigating solution.
Gauge of Irrigating Needle
– Usually, a 27-or 28-gauze needle is preferred as it can go
– deeper in canal for better delivery and debridement action.

Surface Tension of Irrigant
– Lower the surface tension, better is wettability,
Temperature of the Irrigant
– It has been shown in studies that if sodium hypochlorite is
warmed before irrigation, it is much (60–70°C) more
effective as a tissue solvent.

Frequency of Irrigation
– A canal should be copiously irrigated during instrumentation.
– Increased frequency of irrigation has two advantages:
1. More irrigation causes better debridement of tissues.
2. Each time a fresh potent irrigants plays an action.
Canal Diameter
– Wider the canal, better is debridement action of irrigant.
Age of Irrigant
– Freshly prepared solutions are more efficient, than older ones.

CHOICE OF AN IRRIGANT SOLUTION
– There is no single irrigant that can fulfill all the criteria and
so we have to rely on different irrigating solutions.
– Sometimes their combination.
– The main irrigants include sodium hypochlorite,
chlorhexidine and ethylene diamine tetra-acetic acid.
– Unfortunately, this does not seem to be one clear regimen
that should be followed to maximize the benefits of each of
these materials.

NORMAL SALINE
– Gross debridement and lubrication of root
canals.
– Very mild in action, it can be used as an
adjunct to chemical irrigant.
– Normal saline as 0.9%W/V is commonly
used as irrigant in endodontics.
– Acts by flushing action.
– Also be used as final rinse for root canals to
remove any chemical irrigant left after root
canal preparation.

Advantages
– It is biocompatible in nature.
– No adverse reaction even if extruded periapically because
osmotic pressure of normal saline is same as that of the
blood.

Disadvantages
– Does not possess dissolution and disinfecting properties.
– Too mild to thoroughly clean the canals
– Cannot clear microbial flora from inaccessible areas like
accessory canal.
– Does not possess antimicrobial activity
– Does not remove smear layer.

Sodium hypochlorite
– Hypochlorite was first produced in 1789 in Javelle, France, by
passing chlorine gas through a solution of sodium carbonate.
– The resulting liquid, known as Eau de Javelle or Javelle water
– Strong oxidizing agent
– Clear straw colored
– pH is 12
– Composition : NaOCl 5.25%
Na2CO3 0.20 %
NaCl 4.0 %
NaOH 0.005 – 0.015%
H2O 90%

MANUFACTURING
Two methods Cl2 + 2NaOH NaOCl + H2O
Electrolysis of saturated brine solution to produce Na+ & Cl- ions

STORAGE & HANDLING
Store in light proof (opaque glass / polyethylene)
Stability of NaOCl is reduced by -
lower pH
Presence of metallic ions
Exposure to light
Open containers
High temperatures

– Frequent opening of a container or failure to close it
securely would have an effect similar to leaving a container
open, and the shelf life would be reduced accordingly.
– Metallic containers should never be used for sodium
hypochlorite, as the hypochlorite will react with the metal
in the containers.

EFFICACY OF SEVERAL CONCENTRATIONS
– Baumgartner et al (JOE, 1992, vol. 12) – no difference in efficacy
of 5.25, 2.5 & 1% NaOCl
– Harrison & hand – dilution of 5.25% NaOCl resulted in decrease in
its ability to dissolve necrotic tissue
– Effectiveness of low concentrations of NaOCl can be improved by
– Larger volumes
– Frequent change
– Longer period of exposure

VOLUME OF IRRIGANTS
– The general report for the volume of irrigants used per tooth
amounts to 5ml.
– It has been shown that usage of 3ml of NaOCl at 5.25% is
sufficient to cause effective debridement with antimicrobial
effect
– Baker and associates however advocate the use of 20cc flush
of 5% NaOCl.

SOLVENT ACTION OF NaOCl
– Grossman & Meiman – more effective pulp solvent than KOH, H2SO4,
NaOH, HCl.
– 2.5% solution – powerful solubaliser – Koskinen et al
– Morgan et al – 80% tissue solvency – 2.6% solution

ANTIMICROBIAL EFFICIENCY
– 1% NaOCl has found to kill both bacterial spores and HIV over a
period of 30minutes.
– Sen et al reported 1 & 5% NaOCl effective against C.albicans.
Ingles Endodontics, 6th Edn.

– Ohara et al stated thst 1/10 concentrations of NaOCl
effective against several anaerobic bacteria.
– However dilution below 1/10 was completely ineffective.
– Kuruvilla & Kamath suggested 50% reduction in microbial
count – 2.5% NaOCl, synergistic response with CHX
(0.2%) lead to 80% reduction in microbial count.
Ingles Endodontics, 6th Edn.

TIME REQUIRED FOR TISSUE CLEARANCE
– 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.
– NaOCl more effective in large diameter canals.
– More effective in cleaning an isthmus.
– Marvan Abon – Rass reported high success with at least
the shaping should be done till .diameter no.25

EFFECT OF TEMPERATURE
Collagen dissolving effect
– Cunningham & Balekijan showed that increasing the
temperature from 220C-370C of a 2.6% NaOCl solution
increased its tissue dissolving properties which were
equivalent to those of 5.25% solution at room temperature.

Bactericidal effect:
– Was shown that for warmed 2.6% solution against
E.Coli,S.Sanguis,B.Subtilis spores,P.Vulgaris,S.Aureus
organisms as early as 45 seconds.
– The spores took the longest time- 180 secs.(compared to
600 secs for solution at 22 0C)
– Ellerburch & Murphy demonstrated that even vapors of
NaOCl exert strong bactericidal action

SMEAR LAYER REMOVAL
– The smear layer produced by instrumentation was not
removed by NaOCl.
– This is of significance since retention of smear layer can
i. Increase time required for disinfecting
ii. Inhibit or delay penetration of intracanal
irrigants/medicaments to dentinal tubules
iii. Prevent adhesion of obturating materials to root canal
walls.

SODIUM HYPOCHLORITE:MECHANISM OF
ACTION
1. Germicidal activity of sodium hypochlorite is because of formation of
Hypochlorus acid.(Jawetz,Melnick & Adelberg)
2. Permeates cell wall and combines with the protoplasm.
3. Dissolves necrotic tissue because of high alkalinity.
4. Biopolymers like proteins are hydrolyzed into amino acids.
5. NaOCl reacts rapidly with Glycine in a phosphate buffer at 200C

Chloramination
– When hypochlorite contacts tissue proteins, within a short
time, nitrogen, formaldehyde the peptide links are broken
up to dissolve the proteins.
– Hydrogen in the imino groups (–NH–) is replaced by
chlorine (–N⋅Cl–), forming chloramines, which plays an
important role in antimicrobial effectiveness.

Saponification
– Sodium hypochlorite acts as an organic and fat solvent that
degrades fatty acids and transforms them into fatty acid
salts (soap) and glycerol.

Neutralization
– Sodium hypochlorite neutralizes amino acids, forming
water and salt.
– When chlorine dissolves in water and gets in contact with
organic matter, it forms hypochlorous acid.
– This acid acts as a solvent, releasing chlorine that combined
with the protein amino group forms chloramines.

SODIUM HYPOCHILORITE &
SURFACTANTS
– Studies of Senia, Marshall & Rosen, Salzgeber & Brilliant,
and Ram have demonstrated that little or no spreading of
the irrigant occurs in canals that are smaller than file size
No.40.
– A reduction in surface tension would allow for a more
intimate contact between the irrigant and the root canal
system.

– Traditionally Amine oxides have been used as surfactants in
household bleaches, but Moule reports that there is no
clinical data available on their performance.
– Abou – Rass & Patonai reported a lowered surface tension
(79.6 to 69.8 mN/M for 5.25% NaOCI) when Polysorbate 80
was used.

– Cunningham & Associates used Ethyl alcohol and found that
greater the concentration used (till 50%) the more the
hypochlorite’s surface tension decreased.
– However the available chlorine with a 50% solution was rapidly
lost.
– A 30% solution was found to be more stable but working time
was only 15 minutes.

– Cameron et al reported the use of a fluorocarbon surfactant.
– Fluorad FC 99 (25% active solution of amine perfluoroulkyl
sulfonates in water)
– The ranges pH 6-7
– Added as 1ml/litre of 4 percent NaOCI solution
– Reduced surface tension from 70MN/m to 27MN/m

ADVERSE EFECTS OF SODIUM
HYPOCHLORITE:
1. 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 irrigant
– Temperature of irrigant
– Spread of solution

Sequence of Events: (Sabala & Powell)
– 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.

– Stop treatment and give an explanation to the patient.
– Remain Calm and reassure patient.
– There is no antidote 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
– Becking found Naproxen in a dosage of 500-1000mg/day sufficient
TREATMENT MODALITY

– Corticosteroids for 3 days.
– Ist dose I.V. Reeh & Messer HH recommend 4-48 mg/ day
Triamcinolone
– 8mg Doxona I.M. would also suffice.
– Consider incision and trephination if deemed necessary
– Antibiotics for 1 week (Becker, Cohen, Borer)
– Prophylactic: Becking – Penicillin & Metronidazole

– Cold compresses for first 6 hours followed by warm
compresses and mouth rinses – 1 week.
– Provide verbal and written home care
– Set up regular recall visits

PREVENTION
– Prevention of inadvertent extrusion of irrigant past
apex.
Measures include:
– Express intra canal irrigant slowely
– Passive needle placement in canal (especially if
beveled)
– Watch for flow back of irrigant
– Procedure to be performed under Rubber Dam

– Set a rubber stopper on the needle.

HYPERSENSITIVITY TO NaOCI
– Described in a case report by Kaufman & Keila (JOE 1999).
– History in important, can be followed up with a patch test
for confirmation
– Adverse effects cannot only be related to Clinical Toxicity
(Harrison) but also to Allerginicity.

SKIN INJURY
– Reported by Serper & Others from Turkey
– Occurred along corner of mouth down to the chin because
of leakage of Rubber Dam.
– Disappeared in 3 months

– Treatment :
– With Hamamelis virginiana extract which resolved the
burn in 2 weeks.
– It is a Plant derived extract
Mechanism of Action:
– Anti-inflammatory
– Promotes healing by modulating cytokine function,
keratinocyte/ endothelial cell proliferation
– Good scavenging properties against free radicals such
as superoxide anion.

Chlorhexidine (CHX)
– Developed more than 50 years ago at
Imperial Chemical Industries in
England.
– First marketed in the United Kingdom
in 1953 as an antiseptic cream.
Disinfection of root canal system : Cohencha 1st Edn.

Molecular structure
– Belongs to the polybiguanide antibacterial family.
– Consisting of two symmetric 4-chlorophenyl rings and two
biguanide groups connected by a central hexamethylene
chain

Mode of action
– CHX is a wide-spectrum antimicrobial agent.
– Active against
1. Gram-positive
2. Gram-negative bacteria
3. Yeasts.
– Cationic nature, CHX is capable of electrostatically binding
to the negatively charged surfaces of bacteria.
– Makes outer layers of the cell wall and rendering it
permeable

– Depending on its concentration, CHX can have both
bacteriostatic and bactericidal effects.
At high concentration
– CHX acts as a detergent, and by damaging the cell
membrane it causes precipitation of the cytoplasm and
thereby exerts a bactericidal effect.

At low sublethal concentrations
– CHX is bacteriostatic, causing low molecular weight
substances, that is, potassium and phosphorus, to leak out
without the cell being irreversibly damaged.
– Abolishing the activity of the phosphotransferase system
(PTS) sugar transport system and inhibiting acid production
in some bacteria

Substantivity
– Owing to the cationic nature, CHX can be absorbed by
anionic substrates such as the oral mucosa.
– CHX has the ability to bind to proteins such as albumin,
which is present in serum or saliva, pellicle found on the
tooth surface, salivary glycoproteins, and mucous
membranes.
– CHX can also be adsorbed onto hydroxyapatite and teeth.
– It is reversible.

– This reversible reaction of uptake and release of CHX leads
to substantive antimicrobial activity and is referred to as
substantivity.
– The antibacterial substantivity of three concentrations of
CHX solution (4%, 2%, and 0.2%) after 5min of application
has been evaluated.

– Lin et al. attributed the substantivity of CHX to its ability to
adsorb on to the dentin during the first hour.
– They stated that it is only after the saturation point is
reached after the first hour that the antimicrobial capability
of CHX increases with time.
– Komorowski et al. revealed that 5min application of CHX
did not induce substantivity and that the dentin should be
treated with CHX for 7 days.

Cytotoxicity
– CHX is normally used at concentrations between 0.12% and
2.0%.
– Loe et al. suggested it has low tissue toxicity at this level.
– When 2% CHX was used as a subgingival irrigant, no
apparent toxicity was noted on gingival tissues.

– Hidalgo et al demonstrated that CHX is cytotoxic to some
lines of cultured human skin fibroblasts.
– When CHX is in contact with other agents such as NaOCl.
– By-product of the reaction of CHX with NaOCl is the
formation of toxic breakdown products such as para-
chloroaniline (PCA)
– This compound has negative effect on tissues.

Chlorhexidine as an endodontic irrigant
– Many investigations have been conducted to study the
antibacterial effectiveness of CHX in different
concentrations.
– It has been demonstrated that 2% CHX as an irrigant has a
better antibacterial efficacy than 0.12% CHX in-vitro.
– Unlike NaOCl, CHX lacks the tissue-dissolving property.
– Therefore, NaOCl is still considered to be the primary
irrigation solution used in endodontics.

Effect on biofilm
– A dentin infection model was used to compare the
antibacterial effect of different disinfecting solutions on
young and old E. faecalis biofilm.
– High-concentration NaOCl (6%) showed the strongest
antibacterial effect among the solutions tested for both
young and old E. faecalis biofilms.

– 1 min exposure: 2% CHX and 2% NaOCl killed only 13–15%
of the 3-week-old biofilm bacteria in dentin.
– This result suggests that a quick final rinse with these two
agents at the given concentration is not effective in
reducing the number of viable bacteria in the tubules

Irrigant solutions with added detergent
– Added to reduce surface tension and improve their
wettability.
– Smear Clear ,Chlor-Xtra and CH plus MTAD, and QMiX are
examples of the EDTA, NaOCl, and CHX based irrigants that
contain surface-active detergents.

Interaction NaOCl and CHX
– A suggested clinical protocol by Zehnder et al.
1. NaOCl to dissolve the organic components.
2. Irrigation with EDTA to eliminate the smear layer.
3. Irrigation with CHX to increase the antimicrobial
spectrum of activity and impart substantivity.
– Possible chemical interactions among the irrigants have to
be considered.

– Some studies have reported the occurrence of color change
and precipitation when NaOCl and CHX are combined.
– The color change may have some clinical relevance because
of staining
– The precipitate might interfere with the seal of the root
filling.

– The formation of a precipitate, which consisted mainly of
PCA.
– PCA has been shown to be toxic with short-term exposure
of humans to PCA resulting in cyanosis, which is a
manifestation of methemoglobin formation.

Hydrogen peroxide
– Clear, odorless liquid.
– Produces hydroixyl-free
radicals (HO).
– Attack microbial components
such as proteins and DNA.
Ingle’s Endodontics. 6th Edn.

– It causes oxidation of bacterial sulfhydryl group of enzymes
and thus interferes with bacterial metabolism.
– The rapid release of nascent oxygen on contact with
organic tissuee results in effervescence or bubbling action.
– Aid in mechanical debridement by dislodging particles of
necrotic tissue.

EDTA
– Chelate and remove the mineralized
portion of smear layers.
– Nygaard - Ostby in 1957 introduced EDTA.
– EDTA is an insoluble, odorless, crystalline
while powder; it is relatively non toxic

Mode of action
– Extracts bacterial surface proteins by combining with metal
ions from the cell envelope.
– This leads to bacterial death.

– EDTA forms a stable bond with calcium & the deposited solution
can dissolve only as certain amount of dentin
– When all chelating ions have reacted, an equilibrium will be
reached; then no further dissolution will takes place

Functions of EDTA
– Lubrication Emulsification
– Smear Layer removal
Antifungal Activity
– Because EDTA chelates to Ca2+ it prevents binding of
C.albicans to proteins in a dose dependent manner.
– It removes Ca2+ from the cell walls & thereby causes the
cell walls to collapse.
– Also inhibits enzymatic reactions
Pathways of Pulp : Cohen 9th Edn.

– Chelating agents can be applied in liquid or paste-type
form.
– The origin of paste-type preparations dates back to 1961
– Stewart devised a combination of urea peroxide with
glycerol.
– Later,urea peroxide and EDTA were combined in a water-
soluble carbowax vehicle.
– These pastes should be used, as they are inefficient in
preventing the formation of a smear layer.

Interactions between EDTA, NaOCl, and CHX
– Grawehr et al. studied the interactions of EDTA with NaOCl.
– EDTA retained its calcium-complexing ability when mixed
with NaOCl.
– EDTA caused NaOCl to lose its tissue-dissolving capacity.
– The combination of CHX and EDTA produces a white
precipitate
– The precipitate involves the chemical degradation of CHX

Different Forms of EDTA
R-EDTA:
– In this EDTA is combined with cetrimide, i.e
cetyltrimethylammonium bromide.
– It helps in better cleaning of canals.
EDTAT (EDTA + Texapon):
– Here EDTA is combined with sodiumlauryl sulfate which
results in decreasing the surface tension.
Textbook of endodontics: Nisha garg 3ed Edn.

EDTA-C:
– It is commercially available as 15% solution and pH of 7.3
under the name EDTAC because it contains cetavelon,
– Quaternary ammonium compound which is added due to
its disinfecting properties.
– Also the addition of surfactant reduces the contact angle of
EDTA when placed on dentin surface and thus enhances its
cleaning efficacy.

1.TANNIC ACID
– Tannic Acid 25% as a cleansing agent in endodontics was first
suggested by Graham Mount to Norman C. Bitter.
– It has been safely used in the body for more than 100 years
– It has Astringent properties for coagulation by precipitation of
proteins.
– It is also known to possess antimicrobial properties.

– Bitter et al. evaluated a 25% tannic acid solution as
root canal irrigant cleanser.
– They found the walls of the canal to be cleaner &
smoother & it was shown to be effective in removing
the smear layer.

2. CITRIC ACID
– A 50% CA solution possesses antimicrobial efficacy
– Use 10ml for a min of 5min-15min is recommended.
– A combination of circle acid & NaOCI has also been demonstrated
for it’s antimicrobial.
– Loel described the foaming action which occurred on the addition
of 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.
– As Citric Acid to dissolve the inorganic calcified material in
the root canal & it’s potential effect on the smear layer has
also been investigated .
– It was found to be more effective in removing the smear layer
than 50% lactic acid which was more viscous provd by
Wayman et al.

TETRACYCLINES
– Include
– Tetracycline HCI
– Minocycline
– Doxycycline
– Are broad spectrum antibiotics effective against a wide
range of micro-organisms.
– Enhance healing after surgical periodontal therapy
Ingle’s Endodontics: 6 th Edn.

– 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.

– Barkhodar et al- Doxycycline HCI (100mg/ml) effective in
removing smear layer of instrumented canals.
– Haznedaroglu & reported that 1% Tetracycline HCI could remove
the smear as efficiency as 50% citric acid.
– Since tetracyclines chelate, they, as a side effect, are capable of
causing staining of teeth.

IODINES
– Two iodine preparations are in use as endodontic
irrigants
1. Povidone iodine ( Betadine) – 10%
2. Iodine Potassium Iodide 2%
– Betadine scrub is also available which incorporates a
surfactant.
Ingle’s Endodontics: 6th Edn.

– Rapid antiseptic action against a wide range of micro –
organisms
– Low toxicity
– Hypoallerginicity
– Decreased tendency to stain dentin as compared to other
iodine containing antiseptics

Mechanism of Action
– Iodine is strong oxidizing agent.
– It reacts with free sulfhydryl groups of bacterial enzymes resulting in
disulfide linkages.
– Therefore effective against several root canal microbes

SALVIZOL
– Derivatives of oxine (8 hydroxy quinolone) are known antiseptics
since 1895 & have action against bacteria, fungi & molds.
– Used in dentistry in 1956 first by Trotter for post extraction
infections.
– Salvizol belongs to the surface acting materials similar to the
quaternary Ammonium group.
– Differs from the latter by it’s anti bacterial activity even in the
presence of organic materials.
Textbook of Enddontics: Nisha garg 3rd edn.

Toxicity
– Lower than NaOCI, I, KI, EDTA
– Material is well tolerated by PDL tissues.
Disinfection of root canal systems: Cohencha 1st Edn.

Smear layer
– Root canals treated with 0.5% Dequalinium solution were
cleaner than those treated with 14% EDTA (Kaufman)
– Because of it’s detergent properties, it can penetrate into
places that cannot be reached by instruments.
– It removes organic material from dentin material & to a
lesser extent inorganic portions
– Effective even in apical 1/3rd of canal.
Disinfection of root canal systems: Cohencha 1st Edn.

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
a) Ozone destroys cell walls & cytoplasmic membranes of bacteria &
fungi
b) Increased permeability leads to ingress of ozone which cause
microbial death.
Textbook of Nisha Garg : 3rd Edn.

Advantages:
– Potency
– Ease of handing
– Lack of mutagenicity
– Rapid microbial effects
– Showed lesser toxicity to L929 mouse fibroblasts than
NaOCI.

Disadvantages:
– Requires continuous flow for it’s action.
– Rapid ozone degradation in contacting organic compounds

GLUTARALDEHYDE
– Investigated as an irrigant because of germicidal activity.
– However, is also capable of producing inflammation
– Martin et al found 2% glutaraldehyde to produce extensive pan-
necrosis with only mild necrosis for 5% NaOCI
– Therefore it has never become popular as an irrigant.
Disinfection of root canal system: 1st Edn.

MTAD
– Introduced to scientific literature in 2000, this irrigant was
introduced by Torabinejad & others at the Loma Linda Dental
School.
– It is composed of a mixture of
1. Tetracyclne
2. Citric acid
3. Detergent

A) Tetracycline:
i) Broad spectrum antibiotic
ii) Low pH
iii) Calcium chelator
iv) Substantive property
v) Promotes healing
vi) Removes smear layer
– 3% doxycycline hyclate is used instead of tetracycline.

B) Citric Acid – also removes smear layer, Bactericidal
C) Detergent – Tween 80, decreases surface tension.

MTAD AND SMEAR LAYER (2min application, 5ml volume)
– Although MTAD removes most of the smear layer some remnants of
the organic component are scattered on root canal wall surface.
– Effectiveness is enhanced when low concentrations of NaOCI are
used as intra canal irrigant before the use of MTAD as final rinse.
– The regimen doesn’t change the structure of the dentinal tubules.

RUDDLE’S SOLUTION
– This solution is based on the use of HYPAQUE – M, a radio- opaque, high
contrast injectable dye.
– This dye has previously been used in several application such as
arteriography, venography, ureterography and the like in the medical by
Senia, Marshal and Rosen in the ‘70’s and of late in 1995 by Scarfe , Fana
and Farman
– This particular solution was introduced by an American researcher, Dr.
Clifford J. Ruddle.
Textbook of Endodontics: Nisha garg 3rd Edn.

COMPOSITION
– 5% Sodium Hypochlorite
– Hypaque M
– 17% EDTA
– Hypaque M is a high viscous aqueous solution of two iodine salts-
Diatrizoate Meglumine and Sodium
– It has a pH between 6.5 - 7.7
– It is stable at room temperature
– Crystals may for when cooled but dissolve when heated to body
temperature

ADVANTAGE
– 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

HEBP
– 1-hydroxyethylidene-1,1-bisphosphonate.
– Also called etidronic acid.
– Chelator that can be used in combination with NaOCl.
– Weak decalcifying agent ,hence cannot be used as a final
rinse.
– Recommanded – to be mixed with NaOCl.

– Advantage:- the solution keeps the hypochlorite
hypochlorous acid equilibrium toward hypochlorite.
– Hypochlorite has better tissue dissolution capacity than
hypochlorous acid

Green tea & Triphala
– Food extracts, have been used in medicine and have been
shown to be good alternatives to synthetic chemicals.
– The green tea contains polyphenols ( EGCg,
epigallocatechin gallate)
– EGCg is also a broad-spectrum antibacterial agent.
– Inhibits acid production in dental plaque bacteria as well as
antimicrobial activity against Streptococcus mutans.
Disinfection of root canal system, Coencha 1st Edn.

– Triphala (IMPCOPS Ltd., Chennai, India) is an Indian
ayurvedic herbal formulation consisting of dried and
powdered fruits of three medicinal plants
1. Terminalia bellerica,
2. Terminalia chebula, and
3. Emblica officinalis

– Polyphenols found in green tea is the traditional drink of
Japan and China.
– Prepared from the young shoots of the tea plant Camellia
sinensis.
– Japanese green teas do not have an irritating potential.

– Extracts of Japanese green tea may be useful as a
medicament for treatment of infected root canals.
– Herbal alternatives showed promising antibacterial efficacy
on 3- and 6-week biofilm .
– No enough evidence to support the use of antibacterial
components of green tea orother herbs as endodontic
disinfecting agents.

Allium sativum ( Garlic)
– Garlic has major component as Alicin which is like
penicillin.
– Acts as bacteriostatic as well as bactericidal.
– Contains vitamins, amino acids, nutrients, and organic
sulphur compounds.
– Organosulfur compounds are anticarcinogenic.
Alharbi et al. IJPCDR : 2017; 4(4) : 311-314

1. Inhibition of tumour growth
2. Stimulating immune response
3. Initiation of apoptosis
– Garlic extract showed similar antimicrobial properties as
5.25% sodium hypochlorite against the E Faecalis when in
used in concentration of 70%

Propolis (Bee Glue)
– Propolis means defender in the city of Greek.
– Derived from honey bees’ hives.
– Composition
Resin ( 50%)
Essential oils
Waxes (30%)
Bee Glue
Pollen (5%)
Amino acids
Highly active bioflavonoids (10%)
Ethanol

– Ethanol extract of propolis helps in hard tissue formation
and bone regeneration.
– As effective as NaOCl against E Faecalis

Aloe Vera
– Aloe vera means ‘ true shiny bitter substance
’.
– The word derived from Arabic and Greek.
– Consist of 0.001% Proteins and 99.5% Water
– It has minerals, vitamins, amino acids,
organic and in organic compunds.
– The main ingredients are alloins and
barbadoins.

Miswak
– It is chewing stick called by different
names in different cultures.
– Main components are alkaloids like
trimethylamine and salvadorine.
– Chlorides and flourides are also present
in high ratio.
– In 1994 Almes et al concluded that E
Feacalis is sensitive to Miswak.

Turmeric
– Indian spice and a traditional medicine
being used for wound healing,
gastrointestinal symptoms and rhinitis.
– It has wide pharmacological activities like
anti-inflammatory, antimicrobial,
antioxidant, and antimalarial.
– Active component is diferuloymethane.
– Insoluble in water but soluble in solvants.

– Inhibits the protein filamenting mutant Z.
– Mutant Z is responsible for cell wall division of bacteria.
– Thus, it inhibits the bacterial multiplication.
– Turmeric is weak agent against E Feacalis.

Disinfection of root canal system, Coencha 1st Edn.

Methods of Irrigation
– Following points should be in mind while
irrigating the canal-
– The solution must be introduced slowly
and passively into the canal.
– Needle should never be wedged into the
canal and should allow an adequate
backflow.
– Blunted needle of 25 gauge or 27 gauge
are preferred
Textbook of Endodontics, Nisha /garg 3rd Edn.

– In case of small canals, deposit the
solution in pulp chamber.
– Then file will carry the solution into the
canal.
– To remove the excess fluid, either the
aspirating syringe or 2 × 2 inches folded
gauge pad is placed near the chamber
Textbook of Endodontics, Nisha /garg 3rd Edn.

– Canal size and shape are crucial for irrigation of the canal.
– For effective cleaning of apical area, the canals must be
enlarged to size 30 or larger size.
– For effective cleaning, the needle delivering the solution
should be in close proximity to the material to be removed.
– In case of large canals, the tip of needle should be
introduced until resistance is felt, then withdraw the
needle 2 to 3 mm away from that point and irrigate the
canal passively

– A blunt bend of 30° in the center of needle can be given
to reach the optimum length to the canal.

Various delivery systems for
irrigation
– Stropko irrigator
– 27-gauge needle with notched tip
– Needle with bevel
– Monojet endodontic needle
– 23-gauge
– 27-gauge
– ProRinse—25, 28, 30 gauge probes
– Ultrasonic handpiece.

Ideal properties of irrigating
needle
– Be blunt
– Allow back-flow
– Be flexible
– Be longer in length
– Be easily available
– Be cost-effective.

Stropko Irrigator
– Combination of delivery and
recovery of irrigant are present in
one probe.
– Here the needle delivers the
solution and an aspirator held in
same sheath retrieves the irrigant.

27-Gauge Needle with
Notched Tip
– Notched tip allows backflow of the solution and does not
create pressure in the periapical area.

– It ensures optimum cleaning without damage to periapical
area.

Monojet Endodontic Needle
– Considered to be efficient one as
the long blunt needles can be
inserted to the full length of the
canal.
– The only drawback observed is that
if needles are placed near to the
periapical area, it can cause
damage.

ProRinse probes
– This probe is proved to be highly effective in all gauges but
27 gauge notch tip needle is proved to be highly effective.
– Its efficiency lie in its design as it has a blunt tip, with
lumen 2 mm from the tip.

The Apical Vapour Lock
– The root canal is similar to a closed system.
– A column of gas bubbles is entrapped in the apical part of
the canal and restricts or blocks irrigant penetration.
– Caused by one of the principal properties of sodium
hypochlorite, the dissolution capacity of the organic
component

– This process leads to the formation of carbon dioxide and
ammonia in the root canals
– Producing small bubbles that prevent the penetration of
irrigants.

IRRIGANT ACTIVATION /
AGITATION
Process of activating and irrigant through
introducing an instrument inside the canal and
moving it within the canal with a reciprocating ,
oscillating, or rotating action.
Grossmen’s endodontic practice, 13th Edn.

Grossmen’s Endodontic practice, 13th Edn.

Manual Dynamic Agitaiton
– A well fitted greater taper gutta-percha master cone is
moved up and down the instrumented canal containing
the irrigant in short 2-3 mm strokes.
– The frequency of the push-pull motion is 100 strokes per 30
secs.
– Results in hydrodynamic effect improving irrigant exchange
and replacement.

Brushes
– Adjunctive aids in canal debridement
or agitation of irrigants.
– The bristles help in cleaning the
uninstrumented recesses of the
radicular pulp space.
– Eg. – Endobrush, NaviTip FX

Machine assisted agitation
A. Rotary Brushes - Consist of microbrushes attached to
rotary handpieces. E.g, Canalbrush
B. Continuous irrigation during instrumentation- Contains
an irrigant delivery system which provides increased
irrigation depth and duration.

Sonic Irrigation
– This technique involves sonic waves
operating at a frequency of 1–6 kHz
which help in irrigant activation, e.g.,
EndoActivator System (Dentsply Tulsa
Dental Specialties, Tulsa, OK).
– It consists of a portable handpiece
with three different sizes of polymer
tips operating at 10,000 cycles per
minute.

ULTRASONIC IRRIGATION
– Clean the root canals or eliminates bacteria from the walls
better than conventional methods.
– Operates on the frequency of 25-30 kHz.
– Two types
1. Continuous ultrasonic irrigation
– In CUI, an irrigant is simultaneously activated while it is
being delivered continuously via an irrigation delivering
syringe

– The results of this study show that ultrasonic agitation was
not significantly different from the control.
– There was no significant between the ultrasonic agitation
and the use of EndoActivator, F-File, and sonic agitation.
Ultrasonic agitation was significantly more effective at
removing bacteria than needle irrigation and EndoVac
irrigation
Cameron townsend, James Maki : JOE — Volume 35, Number 7, July 2009

- Concerning debris removal, no significant differences
among groups were detected.
- In the coronal region, agitation of the irrigants resulted in
significantly more smear layer removal than the control.
EndoActivator was significantly more effective than
ultrasonic agitation and CanalBrush.
Rodig et al : JOE — Volume 36, Number 12, December 2010

2. Passive ultrasonic irrigation (PUI):
– It relies on the transmission of
acoustic energy from an oscillating file
or a smooth wire to an irrigant in the
root canal.
– The energy is transmitted by means of
ultrasonic waves and can induce
acoustic streaming and cavitation of
the irrigant.

EndoVac
– The device consists of a macrocannula and a microcannula
connected via a tubing to an irrigating syringe and the high-
speed suction of a dental unit.
– The macrocannula aids in the gross, initial flushing of the
coronal part of the root canal while the microcannula can
be positioned at the working length to facilitate irrigation.

– The EndoVac functions on negative pressure irrigation
technology.
Advantages:
– Irrigation at the working length with minimal irrigant
extrusion
– More debris removal at 1 mm from the working length
– Avoids air entrapment

RinsEndo
– It is based on pressure-suction technology with 65 μL of a
rinsing solution oscillating at a frequency of 1.6 Hz.
– Better cleaning than the other pressure devices.

Recent Advances
Antibacterial nanoparticles (NPs)
– Containing unbound particles in the size range of 1-100 nm.
– These materials present 3 properties.
1. Large surface area
2. Mass ratio, and
3. Increased chemical reactivity
Zahed et al. Iranian Endodontic Journal 2017;12(4): 402-406

Mechanism:
– Electrostatic interaction between negatively charged bacterial
cells and positively charged NPs.
– Accumulation of increased number of NPs on the cell membrane
– Results in loss of membrane permeability and destruction of cell
wall.
– Metallic NPs of titanium, gold, zinc, and copper have broad
spectrum of antimicrobial effect

– Zhang et al. assessed the efficacy of calcium hyderoxide
with a silver NPs to eliminate the biofilm of Enterococcus
faecalis .
– Concluded that silver NPs with CH has a significant
inhibitory effect on the biofilm of Enterococcus faecalis.

Antimicrobial photodynamic
therapy (APDT)
– Two-step procedure
– Involves the application of a photosensitizer, followed by
light illumination of the sensitized tissues.
– This generates a toxic photochemistry on target cells,
leading to killing of microorganisms.
– APDT may be combined with the usual mechanical
instrumentation and chemical antimicrobials

– APDT is considered as a supplement to traditional protocols
for canal disinfection.
– Garcez et al. compared the effectiveness of APDT, standard
root canal therapy and the combined treatment to
eliminate bacteria present in infected canals.
– Concluded that root canal therapy alone reduced bacteria
by 90% while APDT alone reduced it by 95%
– J Endod. 2010;36: 1463–6

Photon-induced photoacoustic
streaming (PIPS)
– Based on the radial firing stripped tip with laser impulses of
subablative energies of 20 mJ at 15 Hz for an average
power of 0.3W at 50 μs impulses.
– Impulses induce interaction of water molecules with peak
powers of 400W.
– This creates successive shock waves leading to formation of
a powerful streaming of the antibacterial fluid.

– the unique tapered PIPS tip is not mandatory to be placed
inside the canal.
– But only in the pulp chamber.
– This can reduce the need for using larger instruments to
create larger canals.
– Effectively remove both vital and non vital tissues, kill
bacteria, and disinfect dentin tubules.
– Int Endod J 2014; 47:1072-7

Gentlewave irrigation
– Aims to clean the root canal through
generation of different physiochemical
mechanisms including a broad spectrum
of sound waves.
– Multisonic waves are initiated at the tip
of GentleWave handpiece, which is
positioned inside the pulp chamber.
GentleWave™ (Sonendo)

– Delivers a stream of treatment solution from the handpiece tip
into the pulp chamber while excess fluid is simultaneously
removed by the built-in vented suction through the handpiece.
– Upon initiation of flow through the treatment tip of the
handpiece, the stream of the treatment fluid interacts with the
stationary fluid inside the chamber creating a force which causes
hydrodynamic cavitation.
– Continuous formation of microbubbles inside cavitation cloud
generates acoustic field with broadband frequency to reach the
entire canal.

– Haapasalo et al. Concluded that the GW System provides tissue
dissolution of eight and ten times faster than ultrasonic devices
and needle irrigation.
– showed that GW system Gentle removed CH within 90 sec using
water irrigation alone
– Clin Oral Investig 2015
– Molina et al. the GW system showed greater cleaning and
reduction in residual debris within the canals than those cleaned
conventionally.
– J Endod 2015;41: 1701-1705

References
1. Grossmen’s Endodontic Practice
2. Ingle’s Textbook of Endoodntics
3. Disinfection of root canal system, Cohencha 1st Edn.
4. Cohen Pathways if pulp, 9th Edn.
5. Sedgley, Christine M.. “Root canal irrigation--a historical perspective.” Journal of
the history of dentistry 52 2 (2004): 61-5.
6. Abdulazizlafi et al, Herbal endodontic irrigants : IJPCDR: 2017;4(4):311-314
7. Zahed et al , Recent Advances in Root Canal Disinfection: A Review : Iranian
Endodontic Journal 2017;12(4): 402-406
8. Rodig et al : Effectiveness of Different Irrigant Agitation Techniques on Debris and
Smear Layer Removal in Curved Root Canals: A Scanning Electron Microscopy
Study : JOE —36,:12, 2010
9. Cameron townstand : An In Vitro Comparison of New Irrigation and Agitation
Techniques to Ultrasonic Agitation in Removing Bacteria From a Simulated Root
Canal : JOE — 35;7, 2009

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