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 4- IRRIGATION (clinical handouts) l Endodontics series


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Irrigation techniques

Clinical criteria for termination of the root canal preparation :

  • Adequate debridement.
  • Good apical stop.
  • Adequate taper.
  • Spreader reaches 1-2mm shorter than the full working length

 

Irrigation :

Irrigant :

  • a solution capable of disinfection of root canal system and dissolving organic tissues.
  • Requirements:

  1. Tissue and debris solvent.
  2. Broad spectrum antibacterial action.
  3. Lubricant.
  4. Remove smear layer.
  5. Available and of low cost.
  6. Low or minimal toxicity.

Types :

  1. Sodium hypochlorite (NaOCl).
  2. Chlorohexidine.
  3. EDTA.
  4.  Qmix.
  5. Tetraclean.
  6. MTAD.
  7. Hydrogen peroxide (H2O2).

Methods of activation of irrigation :

  • Manual dynamic irrigation
  • Endoactivator system “sonic”
  • Ultrasonic activated irrigation.
  • Laser.
  • Photoactivated disinfection.
  • Antibacterial nanoparticles.
  • Herbal.
  • Calcium hydroxide.
  • Triple antibiotic paste “TAP”.
  • irrigant reaches 2-3mm from the end of the needle tip without activation.
  • to remove smear layer use NaOCl to remove its inorganic part and EDTA to remove the organic part.

 

Protocols of irrigation :

  • During cleaning and shaping : between files, use file #10 to make sure of apical patency and to loosen the debris.

Final rinsing :

  • NaOCl + chleating agent after MAf and before obturation.
  • total removal of smear layer.

 

NaOCl :

Disadvantages:

  • Doesn’t totally remove smear layer à only its organic part, so should be used with chleating agent
  • Allergy
  • Very irritant if pushed beyond the apex
  • Affect flexural strength of dentin and cause collagen to collapse if left for long time

Efficacy increases by:

  • Concentration
  • Time of contact
  • Activation

CHX 2%:

  • Antibacterial used with persistent infection
  • Disadvantages:

  1. Not tissue solvent
  2. Doesn’t remove smear layer

 

NaOCl + CHX ?

  • NaOCl à Saline à CHX
  • Don’t mix them together, as if they combine together they form “parachloroaniline” which ppt on dentin wall occluding dental tubules, prevent sealer from forming adequate sealing

 

H2O2:

  1. Release nacent O2 à ancerobic
  2. Flushing out of debris
  3. NaOCl + H2O2 ?

  • Increase foaming action, but then combination inhibit antibacterial action of both solutions

 

EDTA 17%:

  • Chleating agent
  • Gel or sol.
  • Gel à lubricant, calcified canals
  • Sol à final irrigation rinsing

QMix:

  • EDTA + CHX + Surfactant à increase penetration force
  • Used as final rinse

 

MTAD:

  • Tetracyclin “Doxycyclin” + Acid “Citric Acid” + Detergent “Tween 80”
  •  Detergent decreases surface tension, and increase penetration

 

Photodynamic Therapy:

  • Dye “Methelyne blue” + Diode laser à excitation  à Free radical, Singlet O2 à Antibacterial

 

CaOH, Antibiotics:

  • Intracanal med , left for 1 week

 

Triple Antibiotic Paste:

  • Doxycycline + Metronidazole + Ciprofloxacin
  • Crush mix with saline, apply into canal
  • Doxycyclin à discoloration
  • Leave 7-10 days

Active Irrigation:

  • Complete disinfection of the canal requires active irrigation
  • Don’t use NaOCl after EDTA, use Saline or Alcohol as NaOCl causes erosion and collision of collagen and affects the mechanical properties of dentin.

Methods of activation:

  • manually activated
  • sonically activated
  • ultrasonically activated
  • Endovac ( negative apical pressure).
  • continuous irrigation.
  • self-adjusting file
  • XP endo finisher / fanta max blue file (cleaning file).

 

Manual dynamic :

  • by moving the needle up and down
  • or by cutting 1-2mm of the master cone and move it up and down with the irrigant in the canal for 1 min.
  • it helps the irrigant to reach inaccessible areas in the final rinse.

Sonic :

  • Endo-activator by dentsply.
  • sonic vibration of a non cutting tip.
  • tips come with 3 different sizes ( yellow, red and blue) + sonic handpiece.
  • its able to remove debris from the lateral anatomy and also remove smear
  • layer and eradicates biofilm within curved canals.
  • Vibrating sonic syringe
  • battery connected to irrigation syringe.  

Passive ultrasonic :

  • non-cutting tip.
  • acoustic streaming.


 

Negative pressure irrigation “Endovac” :

  • Macro canula to deliver the irrigant through the access cavity.
  • Micro canula to reach the full working length and remove the irrigant from the canal.
    the delivery and suctioning activate the irrigant and prevents sodium hypochlorite accident.
  • the delivery and suctioning activate the irrigant and prevents sodium hypochlorite accident.

 

Self-adjusting file :

  • able to be compressed.
  • connected to vita unit which releases 5ml/min.
  • cleaning and shaping are done at the same time.
  • easily retrieved if broken in the canal.



XP endo finisher :

  • cleaning file only “non-cutting” tip size #25 , taper 0% .
  • scrubbing canal walls removing  debris or gutta-percha remnants.
  • cool the file before working using ethyl chloride.
  • time in the canal = 1 min.
  • single use.


Non instrumentation tech. :

  • “Gentle wave”  open the access then place the suctioning tip in it.
  • it suctions all the contents of the canal ( pulp tissues, bacteria, smear layer,….   ) without any cutting in dentin.
  • obturation with thermoplactisized gutta-percha or biosealer.

 

 

Mishaps during cleaning and shaping :

Canal blockage :

  • detection à master cone or MAF doesn’t reach full working length.
  • cause à ignoring irrigation between files leading to debris aggregation and canal blockage.
  • avoid à check the patency by file #10 between files,  copious irrigation.


Over and under-instrumentation :

  •   cause à inaccurate working length determination.
  •   under instr. à failure due to inadequate cleaning , management: adjust WL & complete cleaning and shaping.

over instr.

  • over instr. à violation of the apical constriction , traumatization of the periapical tissues and inter-appointment flare-up ,  management: increase size of MAF.

Ledge: 

  • detectionà file hits a hard object or step and doesn’t reach full WL.
    cause
  • cause à no straight line access or using large instrument in curved canal.
  • management à bypassing

Perforation :

  • artificial communication between root canal and periodontium.
  • causes àpathologic due to caries or iatrogenic.
    types
  • types à cervical , mid-root “strip” and apical.
  • prognosis à depends on site, size and time (recent or old).