Endodontic irrigation
A webinar by Dr Benali Oussama
04/02/2024
CONTENTS
01 The objectives
02 The means
03 The procedures
04 The protocols
01
The objectives
Why do we need irrigation in endodontics?
The root canal system contains vital and/or necrotic pulp substrates and
microorganisms and their toxins in case of disease
The aims of endodontic therapy are:
• The removal of all the contents of the canal system
• Enlargement of the canal so that the irrigants can reach apical
area.
• Obturation and sealing of the canal space to prevent re-entry of
microorganisms
Primary infections of the endodontic
space
Mainly caused by obligate anaerobic species, while
the most responsible one for endodontic failure is
Enterococcus faecalis.
This bacterium is able to withstand many
intracanal medications and also represents an
important microorganism in the biofilm
development
Effect of Ultrasonics on Enterococcus faecalis Biofilm in a Bovine Tooth Model
Grasiela Longhi Gründling et al 2011
The“Smear layer”
Mechanical Instrumentation, in addition to the removal of necrotic or vital pulp
tissue, leads to the formation of a thin layer of debris, known as“smear layer”.
This layer is made up of potentially infective organic and inorganic substances
that must be removed from the canal walls, dentin tubules, and root canal
branches with the aid of root canal irrigants.
Untouched terittory
The presence of isthmuses, anastomosis
and lateral canals can make the
chemical cleansing of the root canal
system very difficult since they can be
filled withbiofilm and smear layer
What is needed ?
The ideal features of a root canal irrigant include
• Cleansing effect
• Lubrication of endodontic instruments and root canal system,
• Dissolution of inorganic and organic substances
• Antimicrobial action
• Absence of cytotoxicity
• Inefficacy in the alteration of dental microstructure
02
The means What are the main irrigants used in
endodontic therapy and their means of
delivery?
The main irrigants used as of now:
• Sodium hypochlorite (NaOCl)
• Ethylene-Diamine-Tetra-Acetic acid (EDTA)
• Chlorhexidine
• Citric acid
• Normal saline
• Water
Sodium hypochlorite (NaOCl)
• The most widely used irrigant
• Used at concentrations ranging between 0.5% and 5.25% (C.E Radcliffe et Al 2004)
• NaOCl is the only irrigant that can dissolve the necrotic and the less vital pulp
• It fails to dissolve innorganic material (smear layer)
• Preheating it increases its dissolving and desinfection effects (George Sirtes et al
2005)
• Tissue dissolving ability depends on concentration. Antibacterial effect
depends on continuous fresh reservoir change
• Beware of sodium hypochlorite extrusion aka hypochlorite accident !!
Recognize and react to the first signs
Chlorhexidine digluconate
• Irrigant with an efficient antibacterial activity
• Used at a concentration of 2% (lower concentrations are
inefficient)
• It cannot remove necrotic residues
• Not to be mixed simultaneously with sodium hypochlorite as
this creates rusty residue
EDTA
• Used as pH 7 solution to remove the inorganic layer caused by instrumentation
• Has no antibacterial properties
• Not to be used simultaneously with sodium hypochlorite as it decreases its
efficacy
• Chelator effect, Has decalcifying effect, causes dentine softening and erosion
• Increases risk of iatroginec damage by files (End-cutting an stiff files)
Citric acid
• Used as pH 7 solution to remove the inorganic layer caused by instrumentation
• Used at both 10% and 1% concentrations
• Has no antibacterial properties
• Not to be used simultaneously with sodium hypochlorite as it decreases the
efficacy of the later.
• Chelator effect, It softens dentin and opens dentinal tubules
• Citric acid is beneficial in regenerative endodontic procedures due to higher TGF-
β1 release (Y Chae et Al 2018)
• Effective at dissolving/cleaning calcium hydroxide from canals
Isopropyl alcohol / Ethanol
• Irrigant as final rinse
• Used to dry the canal walls and remove any solutions from dentinal tubules
• Used at 70% concentration
• Summary
03
The procedures What are the diffrent methods of irrigation?
What tools are used ?
The needle
• 30G are suitable for endodontic irrigation
• Side or double side vented are safer
• Blunt end
• Preferably with rubber stopper
• Modern flexible Irrigation systems for curved
canals and challenging anatomy (IrriFlex)
The syringe
• Syringes with a capacity of <5 ml are used to avoid exerting too much
pressure on canal walls
• Good quality syringes with good quality, leak-proof piston
Other equipements
Endovac (Negative
Pressure)
04
the protocols What is the protocol during endodontic
irrigation for an efficient disinfection?
Principles
Removal of pulp tissue (Vital and Sodium hypochlorite
necrotic) (NaOCl)
Removal of smear layer / Calcification EDTA, Citric acid
Disinfection of the root canal system NaOCl, Chlorhexidine
Activation of irrigant Ultrasonics, sonic, agitation
Drying of root canals Alcohol / Ethanol
The
• protocol
Irrigation is a must before instrumention is innitiated as well as after each
instrument is used
• Sodium hypochlorite is injected in the canal making sure the needle is loose
and not binding with dentin with down/up movements
• Activation/Agitation or recapitulation
• Sodium hypochlorite to flush out debris
Finishing protocol of irrigation
• Suction / Paper point drying
• EDTA is injected, needle loose with down up movements
• Activation/Agitation or recapitulation
• suction/drying
• Sodium hypochlorite final disinfection
The protocol
For an ideal irrigation protocol, it is essential
to use a 5.25% concentrated NaOCl solution
for a suitable time during both the shaping
the final irrigation phases, alternating the
use of NaOCl with EDTA.
The
activation
Why do we need activation ?
Vapor lock
The disolving reaction of sodium hypochlorite creates gas bubbles that can
get trapped in the apical portion of the canal. Therefore any form of
aggitation will remove the trapped gas making sure there is a constant
contact between canal walls and the irrigants
Vapor lock
CBCT-Based Assessment of Vapor Lock Effects on Endodontic Disinfection.
Francesco Puleio et al, 2023
The
activation
hypochlorite/etidronate mixture in vitro. Ming Cai et al 2022
Impact of agitation/activation strategies on the antibiofilm potential of sodium
The influence of irrigant activation, concentration and contact time on sodium hypochlorite
penetration into root dentine: an ex vivo experiment. S. S. Virdee et Al 2020
Nil: Negative control
CNI: Conventional needle irrigation XPF: XP finisher
MDA: Manual dynamic activation UAI: Ultrasonic activated irrigation
PUI: Passive ultrasonic irrigation SNI: Simple needle irrigation
SI: Sonic irrigation
Conventional needle irrigation
• When blunt ended needle is used,
needle should reach 1mm short from
the apex
• Flat or beveled needles create extreme
pressure in apical direction, therefore
they should not be used near the 2-3
mm from apex
Evaluation of irrigant flow in the root canal using different needle types by an unsteady
computational fluid dynamics model. C. Boutsioukis et al 2009
Manual dynamic activation
• Master gutta percha cone is held using
forceps 1ml short of WL
• Canal is filled with irrigant
• The cone is inserted in the canal and the
irrigant is agitated with up and down
movements for 10sec
Passive ultrasonic
irrigation
• Creates vortex effect and cavitations
• Use of flexible ultrasonic tips
• Causes destruction of bacterial biofilm
and smear layer in all canal spaces
(lateral canals, isthmi). Moreover it
delivers irrigants to these challenging
areas
• Ultrasonic tip held inside the canal
1-2 mm from apex for 10 sec
• Causes heating of irrigant
Remarks
• The pulp chamber should always be filled with irrigant (except during WL
measurment), this shows the importance of pre-endodontic buildup.
• Extreme pressure during irrigant injection may result in contact of large
volumes of the irrigant with the apical tissues especialy if needle
stuck/binding dentin
• The needle should be loose in the canal
• Needle penetration depth should be 1-2mm from apical constriction when
using blunt end needles
THANK YOU
