Root Canal Irrigants & Intracanal Medications PDF

Root Canal Irrigants Intracanal Medications BDS8131 Date : xx / xx / xxxx And Aims: The educational aims of this lecture are to explain the properties of different root canal irrigants and medications Objectives: On completion of this lecture, the student should have an understanding of the ben...

Root Canal Irrigants Intracanal Medications BDS8131 Date : xx / xx / xxxx And Aims: The educational aims of this lecture are to explain the properties of different root canal irrigants and medications Objectives: On completion of this lecture, the student should have an understanding of the benefits of root canal irrigation and medications, their indications and how to use them efficiently Desired Functions of Irrigating Solutions: • • • • • • • • • Gross debridement. Tissue and debris solvent (either vital or necrotic). Antibacterial action. Lubricant. Opening of the dentinal tubules by the removal of the smear layer. Disinfection and cleaning of areas inaccessible to endodontic Instruments. Low toxicity & low surface tension (wetting characteristics ). Stable, inexpensive and easy to use. Bleaching action. Types Of Root Canal Irrigants: 1-Sodium hypochlorite. 2-Chlorohexedine gluconate 2-Hydrogen peroxide. 4- BioPure MTAD. 5- Saline. 6- Herbal irrigants. 7-Chelating agents. 1-Sodium Hypochlorite (NaOCl): It is the most popular irrigating solution. • Advantages: 1- Organic Solvent (dissolve organic component of dentine and biofilms). 2- Antimicrobial action. 3- Gross Debridement . 4- Lubricant. 5- Inexpensive. • Disadvantages: 1- Toxicity when injected into periradicular tissues. 2- Foul smell and taste. 3- Bleaches clothes. 4- Corrosion of metal objects. 5- Doesn’t remove the inorganic part of smear layer. Household Bleach 0.5 – 5.25 % Higher concentrations of sodium hypochlorite. Greater tissue-dissolving properties. Severe toxicity and adverse reaction if it is accidentally forced into the tissues. Increasing the temperature of NaOCl solutions improves their immediate tissue-dissolution capacity but it affects its stability. Sodium Hypochlorite Accident: 1-Severe pain. 2-Edema of neighboring soft tissues. 3-Possible extension of edema over the injured half of face and upper lip. 4-Profuse bleeding from root canal. 5-Profuse interstitial hemorrhage of skin bleeding and with mucosa (ecchymosis). 6-Chlorine taste and irritation of throat. Management: 1- Dentist: remain calm and explain what happened to the patient to provide some reassurance . 2- Immediate irrigation with saline to dilute the effect of NaOCl to decrease tissue irritation. 3- Pain relief: by administration of local anesthesia and prescription of analgesics. 4- Reduce the swelling: by application of extraoral cold compresses , then after 1 day, warm compresses and frequent warm mouth rinses for stimulation of local systemic circulation. 5- The use of antibiotics, antihistaminic and corticosteroids is not obligatory (according to severity of the case). 6- Patient should be recalled daily to monitor recovery. 2-Chlorohexidine Gluconate(2%): • Advantages: 1- Uptake and release of CHX leads to substantive antimicrobial activity and is referred to as substantivity. 2- Wide spectrum antimicrobial. 3- Low toxicity. 4- No foul smell and taste. • Disadvantages: 1- Does not have any tissue solvent action. 2- No action on smear layer. 3-Hydrogen Peroxide( H2O2) 3%: Release of nascent oxygen which works against anaerobic bacteria. Effervescence action is capable of removing loose debris from inside the canal. If H2O2 is used, final irrigation should be with NaOCl because H2O2 liberates nascent oxygen which may cause : •Tissue emphysema if it passes to the apical tissue. •Postoperative pain. 4-BioPure MTAD: •A mixture of: • Doxycyline, •Citric acid, •Detergent ( Tween 80). 1-Antimicrobial action. 2-Lubricant 3-Flush debris 4-Eliminate smear layer. 5-Doesn’t dissolve organic tissue. It is used as a final rinse 5-SALINE: • • • • • Antimicrobial X Mechanical Debridement √ Organic Solvent X Lubricant √ Doesn’t remove smear layer. X • Non irritant. √ 6- Herbal Irrigants: Morinda citrifolia Morinda citrifolia juice (MCJ) has a broad range of therapeutic effects, including antibacterial, antiviral, antifungal, antitumor, analgesic, hypotensive, anti-inflammatory, and immune-enhancing effects. 7-Chelating Agents: Smear layer: Smear layer was defined by the American Association of Endodontists in 2003 as a surface film of debris retained on dentin after instrumentation with either rotary instruments or endodontic files; it consists of 1- Dentin particles 2- Remnants of vital or necrotic pulp tissue 3- Bacterial components. • It consists of : A- Organic layer--------- removed by irrigant. B- Inorganic layer--------- removed by chelating agent.  Its removal will aid in better adaptation of obturating materials to the canal walls & allows better penetration of root canal irrigants. Chelate: React with calcium forming complexes causing demineralization of dentine . Functions of chelating agent: 1- Used to enlarge narrow calcified canal. 2- Aid in the removal of smear layer (inorganic part) Chelators such as EDTA form a stable complex with calcium. When all available ions have been bound, equilibrium is formed and no further dissolution takes place; therefore, EDTA is selflimiting 1-Ethylene Diamine Tetra Acetic Acid (EDTA) • • • • • Mechanical Debridment. Organic Solvent X In-organic Solvent . Lubricant. Used in concentration of 17 %. 2-RC –Prep (EDTA+ Urea peroxide)+ glycol: • Increase chelation & irrigation. • When used with NaOCl : remove smear layer & produce bubbling action to lose debris. • Glycol: acts as a lubricant Irrigant Combinations Interaction between CHX +NaOCl: • NaOCl and CHX when in contact produce a change of color and a precipitate. • Color change may have some clinical relevance because of staining, and the resulting precipitate might interfere with the seal of the root obturation. • Alternatively, the canal can be dried using paper points before the final CHX rinse. Interaction between CHX +EDTA: • The combination of CHX and EDTA produces a white precipitate. Interaction between NaOCl +EDTA: • They concluded that EDTA retained its calcium-complex ability when mixed with NaOCl, but EDTA caused NaOCl to lose its tissue-dissolving capacity, with virtually no free chlorine. • EDTA and NaOCl should be used separately. In an alternating irrigating regimen, copious amounts of NaOCl should be administered to wash out remnants of the EDTA. Method of Irrigation Syringe And Needle Irrigation: 1- The solution must be discarded slowly and gently. 2- The needle should never be wedged in the canal. 3- A syringe with leur lok mechanism is the preferred one. 4- Syringe with gauges from 27-30 is preferred to be able to reach the apical portion of the canal. 5- Irrigation needle placed 1-3 mm short of the working length. 6- The needle should be bent  accessibility 7-Constant in and out movement of the irrigating needle into the canal space to ensure that the needle is not locked. 8- Flow back of the solution coronally should always be observed . Irrigant Activation Devices • Manual agitation: Using hand-files (MAF) or a well fitted gutta-percha cone (MC) in a push–pull motion. • Ultrasonic Irrigation: • Sonic agitation: -EndoActivator. -Vibringe. (vibrating needle attached to a syringe). • Negative Apical Pressure agitation: EndoVac EndoVac® is a simple but ingenious device, which delivers the irrigant into the coronal chamber but sucks the irrigant down into the canal through an attachment that passes to the apical end of the radicular preparation. Intra Canal Medicaments They are medicaments used in root canal between appointments 1- Anti- microbial activity in the pulp & peri-apex. 2-Neutralization of canal remnants to render them inert. 3- Control or prevention of post-treatment pain. 4- Used to control exudates in weeping canals. 5-Control root resorption. The use of traditional medicaments is decreased due to: 1- Intra-canal population can be eliminated by careful instrumentation & irrigation. 2- Lack of evidence of medicament usefulness. 3- Toxicity. Limitations & contraindications: 1- Intra-canal environment. Their effect is limited to surface action & does not reach the area where the bacteria is hidden. 2-Duration. Some medicaments loose their activity within 24 hours (phenolics) 3-Toxicity. Any chemical that kills bacteria, will also kill host cells e.g: phenol, aldehyde. 4-Distribution. Pulp is not isolated from rest of body, it is connected to the periapical tissue & even to systemic circulation. 5-Taste & smell. Commonly used intra-canal medicaments: 1- Phenolics. They are considered irritant & carcinogenic. 2-Aldehydes. ( Formcresol) 3- Halogens.( Iodine potassium iodide) 4- Calcium hydroxide. 5-Antibiotics. 5- Steroids. 6- Combination steroids + antibiotics 7-Chlorhexidine. 1-Phenol-based Agents: Phenol, parachlorophenol, camphorated parachlorophenol, metacresyl acetate, cresol and thymol. Pure phenol was not widely used because of its toxicity but its chemical modification monochlorophenol was adopted because of its lower toxicity and improved bactericidal effect. 1-Their antibacterial effect is not long Lasting. 2-They are able to diffuse through the temporary filling material cause an unpleasant taste in the mouth. 3-Soften the filling material. 2-Aldehydes:  They include: formaldehyde containing preparations as formocresol, gluteraldehyde. Have mainly been used in pediatric dentistry.  Formaldehyde-containing materials have been used for their antimicrobial and fixative properties, but they are very toxic to the periradicular tissues. 3- Halogens:  Iodine, in the form of iodine potassium iodide (IKI), is a very effective antiseptic solution.  It has low tissue toxicity.  IKI releases vapors with a strong antimicrobial effect. HOWEVER! An obvious disadvantage of Iodine is possible allergic reaction in some patients + tooth staining 4-Calcium Hydroxide: • Most popular intracanal medicament. • Antimicrobial, neutralize the acidity of inflammation. ( due to its alkaline pH) • Degrade organic remnants. • Used in weeping canals. • Induce hard tissue barrier. • In case of internal and external resorption. Forms: Paste form /Powder mixed with water. Placement: Paper point/ files/ lentulo spirals/ injectable forms. 5-Antibiotics: • It was tried as intra-canal medication , but fear from developing bacterial resistance leads to decrease of its use. • Since no single antibiotic is active against all the bacteria found in the root canal system, a combination of antibiotics with different ranges of activity is used, usually in the form of a paste. • Example: triple-antibiotics paste: composed of metronidazole, ciprofloxacin, and minocycline. They appear to combine the best effects of iodoform and calcium hydroxide . 6-Steroids: • Steroids: (prednisolone, triamcinalone, hydrocortisone, dexamethasone). • Used in root canals mainly for pain relief and antiinflammatory action to avoid postoperative pain, however there is fear of lowering immunity. • They may be mixed with other antibacterial agents, such as calcium hydroxide or antibiotics. 7-Chlorohexidine: • What is the most commonly used root canal irrigant? • Tissue dissolving ability • Substantivity • Nascent oxygen • List the different methods of irrigant activation. • Give an example of a final rinse. • Give an example of an irrigating system that uses negative pressure. • Define the smear layer and how can you remove it? • What is the most commonly used intracanal medicament? • Ledermix A- side vented needle gauge 30 B- End vented needle gauge 23 A B Aims: The educational aims of this lecture are to explain the properties of different root canal irrigants and medications Objectives: On completion of this lecture, the student should have an understanding of the benefits of root canal irrigation and medications, their indications and how to use them efficiently Reading material: -The dental reference manual, Geraldine M. Weinstein, springer 2017 (Chapter 12) -Essential skills for dentists, Peter A.Mossey et al, Oxford, 2006 (Chapter 2.6) -Endodontics, Kishor Gulabivala and Yuan-Ling NG, Mosby Elsevier 2014 -Harty`s endodontics in clinical practice, Bun San Chong, Elsevier 2017 -Clinical endodontics, Lief Tronstad, Thieme 2009 (main reference) Thank you Date : xx / xx / xxxx