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Irrigation in Endodontics

Irrigation in Endodontics - Nature paper

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309 views5 pages

Irrigation in Endodontics

Irrigation in Endodontics - Nature paper

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hunarsandhu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Irrigation in endodontics IN BRIEF

• Highlights the importance of irrigation in


endodontics.

PRACTICE
M. Haapasalo,* Y. Shen, Z. Wang and Y. Gao
1 1 1,2 3 • Provides an overview of solutions used in
the irrigation of the root canal.
• Outlines old and new equipment for
irrigation.

Irrigation is a key part of successful root canal treatment. It has several important functions, which may vary according to
the irrigant used: it reduces friction between the instrument and dentine, improves the cutting effectiveness of the files,
dissolves tissue, cools the file and tooth, and furthermore, it has a washing effect and an antimicrobial/antibiofilm effect.
Irrigation is also the only way to impact those areas of the root canal wall not touched by mechanical instrumentation.
Sodium hypochlorite is the main irrigating solution used to dissolve organic matter and kill microbes effectively. High
concentration sodium hypochlorite (NaOCl) has a better effect than 1 and 2% solutions. Ethylenediaminetetraacetic acid
(EDTA) is needed as a final rinse to remove the smear layer. Sterile water or saline may be used between these two main
irrigants, however, they must not be the only solutions used. The apical root canal imposes a special challenge to irrigation
as the balance between safety and effectiveness is particularly important in this area. Different means of delivery are used
for root canal irrigation, from traditional syringe-needle delivery to various machine-driven systems, including automatic
pumps and sonic or ultrasonic energy.

Fig. 1 Particle
INTRODUCTION tracking during
irrigation simulated
Irrigation is a key part of successful root by a computational
canal treatment as it fulfils several important fluid dynamics model
mechanical, chemical and (micro) biological (left), with the high
functions. Irrigation is also the only way magnification of the
root canal (right). The
to impact those areas of the root canal
simulation illustrates the
wall that are not touched by mechanical weak effect irrigation
instrumentation. Much of the research on has on the apical canal.
endodontic irrigation has focused on the Yellow arrow shows the
effect of irrigation on the smear layer.1–4 position of the tip of the
However, smear layer removal can be irrigation needle, the
accomplished relatively easily when correct white arrow shows the
place of the side vent
protocols are followed. A bigger challenge
for irrigation may be the areas untouched by
the files, such as fins, isthmuses and large removed by chemical means using irrigation. is to secure optimal spreading of the irrigants
lateral canals.5 Also, large areas in the oval The apical root canal poses a special challenge throughout the root canal system for more
and flat canals may remain untouched despite to irrigation as the balance between safety and predictable cleaning of the difficult-to-reach
careful instrumentation. These areas contain effectiveness is particularly important in this areas. Ultrasonic irrigation using ultrasonic
tissue remnants and biofilms that only can be area (Fig. 1).6 Negative pressure irrigation was tips to deliver the solutions directly into the
introduced to endodontic treatment several canal space have shown promising results
1
Division of Endodontics, Department of Oral Biological years ago as a safe method to effectively for cleaning even the most difficult areas
and Medical Sciences, UBC Faculty of Dentistry, The irrigate the most apical canals.7,8 Comparative such as long and narrow isthmuses between
University of British Columbia, 2199 Wesbrook Mall,
Vancouver, BC, Canada, V6T 1Z3; 2The State Key Labora- studies on negative pressure and positive two canals.14–16
tory Breeding Base of Basic Science of Stomatology pressure irrigation have indicated that the This review is a summary of the present
(Hubei-MOST) and Key Laboratory of Oral Biomedicine negative pressure method can improve the knowledge of effective and safe endodontic
Ministry of Education, School and Hospital of Stomatol-
ogy, Wuhan University, Wuhan, China; 3State Key Labo- quality of cleaning of the apical root canal irrigation and will include recommendations
ratory of Oral Diseases, West China College & Hospital without the risk of extrusion of the solution.7,9 for optimal irrigation with regard to different
of Stomatology, Sichuan University, Chengdu, China Different means of delivery are used for solutions, concentration, irrigant sequence
*Correspondence to: Professor Markus Haapasalo
Email: [email protected] root canal irrigation, from traditional syringe- and methods of delivery.
needle delivery to various machine-driven
Refereed Paper systems, including automatic pumps, vibrating GOALS OF IRRIGATION
Accepted 23 January 2014
DOI: 10.1038/sj.bdj.2014.204 tips and sonic or ultrasonic energy.10–13 The Irrigation is often regarded as the most
© British Dental Journal 2014; 216: 299-303
goal of the various ways to improve irrigation important part of endodontic treatment,

BRITISH DENTAL JOURNAL VOLUME 216 NO. 6 MAR 21 2014 299

© 2014 Macmillan Publishers Limited. All rights reserved


PRACTICE

in particular for the eradication of root Table 1 Characteristics of an optimal


canal microbes. During and following irrigating solution in root canal treatment
instrumentation, irrigating solutions Characteristics
facilitate the killing and removal of
Low cost
microorganisms, necrotic and inflamed
tissue and dentine debris.5 Irrigation reduces Washing action
friction between the instrument and dentine,
Reduction of friction
improves the cutting effectiveness of the
files, dissolves tissue, and cools the file and Improving cutting of dentine by the instruments
tooth especially during the use of ultrasonic
Temperature control Fig. 2 The smear layer on the wall of the
energy. Irrigation may prevent packing of the
main root canal after instrumentation
hard and soft tissue into the apical root canal Dissolution of organic and inorganic matter
and extrusion of planktonic and biofilm
Good penetration within the root canal system
bacteria out into the periapical tissues.17
The most important irrigating solutions have Killing of planktonic microbes
tissue-dissolving activity either on organic
Killing of biofilm microbes
or inorganic tissue. In addition, several
irrigating solutions have antimicrobial Detachment of biofilm
activity and actively kill bacteria and yeasts
Non-toxic to periapical tissue
in direct contact with them.18 However,
irrigating solutions show varying degrees of Non-allergenic
cytotoxicity and sodium hypochlorite may Does not react with negative consequences with
cause severe, immediate and long lasting other dental materials
pain if it is expressed under pressure and Fig. 3 Instrumented canal wall after removal
Does not weaken dentin of the smear layer by NaOCl and a final rinse
then escapes through the apical foramen. In
by EDTA
theory, an optimal irrigating solution has the
positive characteristics listed in Table 1, but have reported conflicting results of the
none of the negative or harmful properties comparative effectiveness of hypochlorite
mentioned above. Clearly, none of the at different concentrations, recent studies
presently available irrigating solutions can have confirmed the superiority of high
be regarded as optimal, or even close to that. concentration hypochlorite over 1  and
In clinical practice, use of a combination of 2% solutions.32,33 Hypochlorite should be
solutions in a specific sequence is necessary used throughout the instrumentation, as
in order to maximally contribute to the the only solution at this stage, and for
success of root canal treatment.5 one  to two  minutes after completing the
instrumentation. Alternating use of NaOCl
SOLUTIONS USED IN THE and for example, ethylenediaminetetraacetic
IRRIGATION OF THE ROOT CANAL acid (EDTA) will abolish the antibacterial
Sodium hypochlorite (NaOCl) is the most activity of the NaOCl and should be avoided.
important irrigant in root canal treatment.19–21 According to one  recent study, tissue that
It is the only presently used solution that has been exposed to EDTA is thereafter
can dissolve organic matter in the canal.22–24 not effectively dissolved by NaOCl.34 When
Therefore the use of hypochlorite is of utmost smear layer removal is completed by EDTA,
importance in removing necrotic tissue hypochlorite should not be used again as
remnants as well as biofilm. NaOCl ionises in it causes erosion on dentine after EDTA
water into sodium (Na+) and the hypochlorite or citric acid.35 If hypochlorite comes into
ions, OCl–, and establishes an equilibrium contact with chlorhexidine, an orange- Fig. 4 The clear zone between the open ended
with hypochlorous acid (HOCl). At acidic and brown precipitate that contains potentially needle tip and the apical blue liquid shows the
neutral pH, most of the chlorine exists as carcinogenic para-chloroaniline (PCA) is effect of active irrigation beyond the needle
HOCl, whereas at pH of nine and above, OCl– formed.36–38 Therefore, the canal should be tip during a flow rate of ca. 6 ml/min
is most abundant.25 Hypochlorous acid has the rinsed, for example, with water or saline,
strongest antibacterial effect while the OCl– between use of these two solutions. EDTA is a chelator, which is used after
ion is less effective. Hypochloric acid affects Sterile water and saline can be used NaOCl as the final irrigant.1–4 EDTA solution
directly on the vital functions of the microbial between two  irrigating solutions, for is neutral or slightly alkaline; at an acidic
cell, rapidly resulting in cell death.26,27 example, NaOCl and chlorhexidine, to pH EDTA precipitates. EDTA is usually
Hypochlorite is used in concentrations prevent chemical reactions between them. used as a 17% or 15% solution, although
between 0.5‑6%. 28–31 To maximise the However, water and saline must not be some studies have suggested that 5% and
effectiveness of hypochlorite irrigation, the used as the main irrigants as they have even 1% EDTA solution is strong enough
solution should be frequently refreshed and neither tissue-dissolving nor antimicrobial for smear layer removal. The recommended
kept in motion by agitation or continuous activity.39,40 The root canal space will be left time for smear layer removal is around
irrigation. The speed of tissue dissolution with more tissue remnants and bacteria after two  minutes, but thick layers may require
can be increased with effective agitation and treatment is completed if NaOCl and EDTA longer times of exposure.30,41 The smear layer
refreshment.15,16 While several earlier studies (see below) are not used. should be removed as it contains microbes

300 BRITISH DENTAL JOURNAL VOLUME 216 NO. 6 MAR 21 2014

© 2014 Macmillan Publishers Limited. All rights reserved


PRACTICE

and microbial antigens baked into it during biofilm models including a dentine biofilm effective and sufficient. 10,11 Small size
instrumentation of the necrotic, infected model have shown that 6% NaOCl has a 27-gauge or preferably 30-gauge needles
root canal (Figs  2 and 3).3,42 EDTA only much stronger antibiofilm effect than 2% should be used to gain access to the apical
affects the inorganic part of dentine and CHX, which is comparable or weaker than canal.6 Irrigant exchange beyond the needle
smear layer (hydroxyapatite) and complete 1 and 2% NaOCl.32,33 tip reaches only one to three mm, depending
removal of the smear layer can only be Although many bacteria may be killed by on the needle type and irrigant flow (Fig. 4).
achieved when NaOCl has been used before CHX, it cannot dissolve the biofilm or other Side-vented needles (tip) may offer safer
the final rinse with EDTA.43,44 EDTA has little organic debris. Residual organic tissue is irrigation than open-ended needles in
or no antimicrobial activity, although some likely to weaken the quality of the seal by positive pressure irrigation. 6,65 Agitation
studies have indicated antifungal activity the permanent root filling, necessitating the of the irrigant and constant refreshment
for EDTA.45,46 However, EDTA weakens the use of NaOCl as the main irrigant during greatly increases the effectiveness of the
bacterial cell membrane without killing instrumentation. On the positive side, CHX solutions.24 If the apical canal cannot be
the cell, but it may work in a synergistic as the final rinse after EDTA does not cause easily reached by the irrigation needle, a
manner with other chemicals, for example, erosion of dentine as NaOCl does; therefore gutta-percha point in a size corresponding
chlorhexidine, which more vigorously 2% CHX may be considered for irrigation to the dimensions of the apical canal can
attack the bacterial cell wall.47 EDTA greatly after the smear layer is removed.58 be used to facilitate irrigant exchange in
weakens the effect of NaOCl and should not Much of the research in endodontics this region.66–68 A recent study24 showed that
be used (mixed or alternating) with it. When on the use of CHX has been done with agitation of the irrigant by active needle
mixed with chlorhexidine, EDTA forms a Enterococcus faecalis; it is therefore possible irrigation, sonic and ultrasonic activation
white, cloudy precipitate.36–38,48 that the studies have given too optimistic were equally effective in increasing the
Citric acid has a long history of use in a picture of the usefulness of CHX as an speed of tissue dissolution by NaOCl, up
root canal irrigation. It can be used instead antimicrobial agent in endodontics. A recent to over ten-fold as compared to passive
of EDTA as the final rinse to remove the study suggested that use of CHX as the final irrigation (no activation or refreshment).
smear layer after use of NaOCl. One  to rinse may in fact have a negative impact on This result suggests that movement of the
ten percent solutions have been used. Citric the healing of apical periodontitis.59 More irrigant and refreshment are the key factors
acid is somewhat more aggressive than research is needed to identify the optimal in its effectiveness.
EDTA, and if NaOCl is used after citric acid irrigation regimen for various types of New equipment introduced to root canal
(not recommended), the root canal wall endodontic treatments. irrigation includes the EndoActivator 69,
erosion is more pronounced than in the Vibringe,70 and various ultrasonic devices
EDTA–NaOCl sequence.35 Citric acid is used Combination products where the irrigant is directed into the canal
as a component in MTAD and Tetraclean, for root canal irrigation through the vibrating tip.15,16 Several reports
the combination products for smear In recent years several combination products have indicated that the various devices
layer removal.49,50 have been introduced for the irrigation of may facilitate irrigation, particularly in the
Chlorhexidine digluconate (CHX) is the root canals. These include sodium difficult-to-reach areas of the canals, such
used in dentistry for plaque prevention hypochlorite mixed with a surfactant (Chlor- as fins and isthmuses and in large lateral
and disinfection because of its good Xtra, White King) and EDTA or citric acid canals.15 The EndoVac 71,72 uses negative
antimicrobial activity.51–53 It has also been products mixed with surfactants and/or pressure to achieve safe irrigation of the
much used in endodontics as a final irrigant antibacterial agents (MTAD, SmearClear, apical canal. In the EndoVac system the
after EDTA. CHX is cytotoxic to human Tetraclean, QMiX).5,20,47,49,50,60,61 The role of irrigant is applied to the pulp chamber or
cells but it does not cause pain comparable surfactants in improving the antibacterial or coronal root canal (teeth with one single root
to NaOCl if accidentally extruded to the tissue dissolving effect of hypochlorite has canal) from where it is sucked down the canal
periapical area. CHX does not dissolve been debated in recent years,24,62–64 the partly and back via the needle. In other words,
organic or inorganic matter and therefore contradictory results may be due to the the direction of the irrigant flow has been
it cannot be used as the only irrigating different types of tissue used for the studies reversed, which creates the negative pressure
solution. CHX attacks the microbial cell wall as well as different dilutions of solutions for at the apical foramen and thereby prevents
or outer membrane resulting in killing of the experiments.24,62 Several studies have the possibility of irrigant extrusion. Some
the microbe.25 However, it kills planktonic shown that the addition of surfactants, which studies have shown improved cleanliness or
bacteria much more slowly than NaOCl; may also have a direct antimicrobial effect, antimicrobial effect in the most apical canal
against biofilm bacteria its effect is equal and other antimicrobial agents to EDTA or with the EndoVac as compared to positive
to or lower than 1 and 2% NaOCl and much citric acid adds considerable antimicrobial pressure irrigation.71–73
weaker than 5 or 6% NaOCl.32,33 CHX binds activity to these solutions.32,33 The use of
to hard tissue and remains antimicrobial combination products should simplify CONCLUSION
(substantivity), which has been one reason irrigation and also eliminate the need the Instrumentation and irrigation are the most
for its use. However, the potential impact use of final NaOCl rinse after EDTA (erosion important parts of root canal treatment.
of the continued antimicrobial effect risk), as the new the smear layer removing Irrigation has several key functions, the
of CHX in the root canal has not been ‘cocktail’ solutions now have a pronounced most important of which are to dissolve
well examined. antimicrobial effect.24,32,61 tissue and to have an antimicrobial effect.
Several earlier studies that compared the Apical irrigation poses a special challenge
antibacterial effect of NaOCl and 2% CHX OLD AND NEW EQUIPMENT with regard to effectiveness and safety.
against intracanal infection have shown little FOR IRRIGATION Small, 30-gauge side-vented needles and/or
or no difference between their antimicrobial The classical way of irrigating the root negative pressure irrigation with NaOCl and
effectiveness.54–57 However, recent studies canal is with a syringe and needle. When EDTA in the apical canal will secure the best
using viability staining and more advanced carefully used, needle irrigation can be results in this important area.

BRITISH DENTAL JOURNAL VOLUME 216 NO. 6 MAR 21 2014 301

© 2014 Macmillan Publishers Limited. All rights reserved


PRACTICE

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