Endodontic irrigants: Different methods to improve efficacy and related problems

 

 Permissions and Reprints

ABSTRACT

Shaping and cleaning a root canal system along with the preservation of the surrounding periodontal tissues are the principal goals of an endodontic treatment. While most of the attention is paid to the mechanical aspects of a root canal treatment, an essential feature of it is the irrigation. All over the years, many materials have been used to clean the root canal of a tooth, and certainly, the sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic acid solutions are the most used and most reliable ones. Putting them inside of a canal is mostly done using a normal syringe, but many techniques have been involved in this process, including the use of sonic/ultrasonic instruments, the use of shaping files, and even laser, to increase the efficacy of irrigant solutions, especially of NaOCl one. Each one of this technique faces some disadvantages, just as the vapor lock effect and the apical extrusion, and has a different action on features such as the reaction rate and the shear stress of an endodontic irrigant solution. In this narrative review, we describe the different features of many irrigant solutions and the different ways of upgrading their efficacy in the cleaning of a root canal system, with the use of tables to summarize the entire description, and drawing the readers' attention to a photographic illustration for a better understanding of the topic.

• REFERENCES

• 1 Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997; 30: 297-306
  CrossrefPubMedGoogle Scholar
• 2 Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965; 20: 340-9
  CrossrefPubMedGoogle Scholar
• 3 Sakko M, Tjäderhane L, Rautemaa-Richardson R. Microbiology of root canal infections. Prim Dent J 2016; 5: 84-9
  CrossrefPubMedGoogle Scholar
• 4 Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: Its role in root canal treatment failure and current concepts in retreatment. J Endod 2006; 32: 93-8
  CrossrefPubMedGoogle Scholar
• 5 Estrela C, Silva JA, de Alencar AH, Leles CR, Decurcio DA. Efficacy of sodium hypochlorite and chlorhexidine against Enterococcus faecalis – A systematic review. J Appl Oral Sci 2008; 16: 364-8
  CrossrefPubMedGoogle Scholar
• 6 Saatchi M, Shokraneh A, Navaei H, Maracy MR, Shojaei H. Antibacterial effect of calcium hydroxide combined with chlorhexidine on Enterococcus faecalis: A systematic review and meta-analysis. J Appl Oral Sci 2014; 22: 356-65
  CrossrefPubMedGoogle Scholar
• 7 van der Waal SV, Connert T, Crielaard W, de Soet JJ. In mixed biofilms Enterococcus faecalis benefits from a calcium hydroxide challenge and culturing. Int Endod J 2016; 49: 865-73
  CrossrefPubMedGoogle Scholar
• 8 Sangalli J, Júnior EG, Bueno CR, Jacinto RC, Sivieri-Araújo G, Filho JE. et al Antimicrobial activity of psidium cattleianum associated with calcium hydroxide against Enterococcus faecalis and Candida albicans: An in vitro study. Clin Oral Investig 2018; 22: 2273-9
  CrossrefPubMedGoogle Scholar
• 9 Del Carpio-Perochena A, Kishen A, Felitti R, Bhagirath AY, Medapati MR, Lai C. et al Antibacterial properties of chitosan nanoparticles and propolis associated with calcium hydroxide against single- and multispecies biofilms: An in vitro and in situ study. J Endod 2017; 43: 1332-6
  CrossrefPubMedGoogle Scholar
• 10 Mehta S, Verma P, Tikku AP, Chandra A, Bains R, Banerjee G. et al Comparative evaluation of antimicrobial efficacy of triple antibiotic paste, calcium hydroxide, and a proton pump inhibitor against resistant root canal pathogens. Eur J Dent 2017; 11: 53-7
  Article in Thieme ConnectPubMedGoogle Scholar
• 11 Silveira CF, Cunha RS, Fontana CE, de Martin AS, Gomes BP, Motta RH. et al Assessment of the antibacterial activity of calcium hydroxide combined with chlorhexidine paste and other intracanal medications against bacterial pathogens. Eur J Dent 2011; 5: 1-7
  Article in Thieme ConnectPubMedGoogle Scholar
• 12 Tomson PL, Simon SR. Contemporary cleaning and shaping of the root canal system. Prim Dent J 2016; 5: 46-53
  CrossrefPubMedGoogle Scholar
• 13 Dioguardi M, Troiano G, Laino L, Lo Russo L, Giannatempo G, Lauritano F. et al ProTaper and WaveOne systems three-dimensional comparison of device parameters after the shaping technique. A micro-CT study on simulated root canals. Int J Clin Exp Med 2015; 8: 17830-4
  PubMedGoogle Scholar
• 14 Pintor AV, Dos Santos MR, Ferreira DM, Barcelos R, Primo LG, Maia LC. et al Does smear layer removal influence root canal therapy outcome? A systematic review. J Clin Pediatr Dent 2016; 40: 1-7
  PubMedGoogle Scholar
• 15 Troiano G, Dioguardi M, Cocco A, Giuliani M, Fabiani C, D'Alessandro A. et al Centering ability of ProTaper next and WaveOne classic in J-shape simulated root canals. ScientificWorldJournal 2016; 2016: 1606013
  PubMedGoogle Scholar
• 16 Troiano G, Dioguardi M, Cocco A, Giannatempo G, Laino L, Ciavarella D. et al Influence of operator's experience on the shaping ability of protaper universal and WaveOne systems: A comparative study on simulated root canals. Open Dent J 2016; 10: 546-52
  CrossrefPubMedGoogle Scholar
• 17 Torabinejad M, Handysides R, Khademi AA, Bakland LK. Clinical implications of the smear layer in endodontics: A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94: 658-66
  CrossrefPubMedGoogle Scholar
• 18 Jena A, Sahoo SK, Govind S. Root canal irrigants: A review of their interactions, benefits, and limitations. Compend Contin Educ Dent 2015; 36: 256-61
  PubMedGoogle Scholar
• 19 Zehnder M. Root canal irrigants. J Endod 2006; 32: 389-98
  CrossrefPubMedGoogle Scholar
• 20 Kandaswamy D, Venkateshbabu N. Root canal irrigants. J Conserv Dent 2010; 13: 256-64
  CrossrefPubMedGoogle Scholar
• 21 Bryce G, O'Donnell D, Ready D, Ng YL, Pratten J, Gulabivala K. et al Contemporary root canal irrigants are able to disrupt and eradicate single- and dual-species biofilms. J Endod 2009; 35: 1243-8
  CrossrefPubMedGoogle Scholar
• 22 Tosić G, Miladinović M, Kovaević M, Stojanović M. Choice of root canal irrigants by serbian dental practitioners. Vojnosanit Pregl 2016; 73: 47-52
  CrossrefPubMedGoogle Scholar
• 23 Radcliffe CE, Potouridou L, Qureshi R, Habahbeh N, Qualtrough A, Worthington H. et al Antimicrobial activity of varying concentrations of sodium hypochlorite on the endodontic microorganisms Actinomyces israelii, Anaeslundii, Candida albicans and Enterococcus faecalis . Int Endod J 2004; 37: 438-46
  CrossrefPubMedGoogle Scholar
• 24 Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. The effect of exposure to irrigant solutions on apical dentin biofilms in vitro . J Endod 2006; 32: 434-7
  CrossrefPubMedGoogle Scholar
• 25 Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in endodontics. Br Dent J 2014; 216: 299-303
  CrossrefPubMedGoogle Scholar
• 26 Bosch-Aranda ML, Canalda-Sahli C, Figueiredo R, Gay-Escoda C. Complications following an accidental sodium hypochlorite extrusion: A report of two cases. J Clin Exp Dent 2012; 4: e194-8
  PubMedGoogle Scholar
• 27 de Sermeño RF, da Silva LA, Herrera H, Herrera H, Silva RA, Leonardo MR. et al Tissue damage after sodium hypochlorite extrusion during root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: e46-9
  PubMedGoogle Scholar
• 28 Gomes BP, Vianna ME, Zaia AA, Almeida JF, Souza-Filho FJ, Ferraz CC. et al Chlorhexidine in endodontics. Braz Dent J 2013; 24: 89-102
  CrossrefPubMedGoogle Scholar
• 29 Bernardi A, Teixeira CS. The properties of chlorhexidine and undesired effects of its use in endodontics. Quintessence Int 2015; 46: 575-82
  PubMedGoogle Scholar
• 30 Ballal NV, Jain I, Tay FR. Evaluation of the smear layer removal and decalcification effect of QMix, maleic acid and EDTA on root canal dentine. J Dent 2016; 51: 62-8
  CrossrefPubMedGoogle Scholar
• 31 Ram Z. Chelation in root canal therapy. Oral Surg Oral Med Oral Pathol 1980; 49: 64-74
  CrossrefPubMedGoogle Scholar
• 32 Zehnder M, Schmidlin P, Sener B, Waltimo T. Chelation in root canal therapy reconsidered. J Endod 2005; 31: 817-20
  CrossrefPubMedGoogle Scholar
• 33 Rossi-Fedele G, Doǧramaci EJ, Guastalli AR, Steier L, de Figueiredo JA. Antagonistic interactions between sodium hypochlorite, chlorhexidine, EDTA, and citric acid. J Endod 2012; 38: 426-31
  CrossrefPubMedGoogle Scholar
• 34 Thiruvenkadam G, Asokan S, John B, Priya PG. Effect of 95% ethanol as a final irrigant before root canal obturation in primary teeth: An in vitro study. Int J Clin Pediatr Dent 2016; 9: 21-4
  PubMedGoogle Scholar
• 35 Kara Tuncer A, Tuncer S. Effect of different final irrigation solutions on dentinal tubule penetration depth and percentage of root canal sealer. J Endod 2012; 38: 860-3
  CrossrefPubMedGoogle Scholar
• 36 Torabinejad M, Khademi AA, Babagoli J, Cho Y, Johnson WB, Bozhilov K. et al A new solution for the removal of the smear layer. J Endod 2003; 29: 170-5
  CrossrefPubMedGoogle Scholar
• 37 Giardino L, Ambu E, Becce C, Rimondini L, Morra M. Surface tension comparison of four common root canal irrigants and two new irrigants containing antibiotic. J Endod 2006; 32: 1091-3
  CrossrefPubMedGoogle Scholar
• 38 Yadav HK, Tikku AP, Chandra A, Yadav RK, Patel DK. Efficacy of etidronic acid, bioPure MTAD and smearClear in removing calcium ions from the root canal: An in vitro study. Eur J Dent 2015; 9: 523-8
  Article in Thieme ConnectPubMedGoogle Scholar
• 39 Haapasalo M, Shen Y, Qian W, Gao Y. Irrigation in endodontics. Dent Clin North Am 2010; 54: 291-312
  CrossrefPubMedGoogle Scholar
• 40 Ma J, Wang Z, Shen Y, Haapasalo M. A new noninvasive model to study the effectiveness of dentin disinfection by using confocal laser scanning microscopy. J Endod 2011; 37: 1380-5
  CrossrefPubMedGoogle Scholar
• 41 Troiano G, Laino L, Dioguardi M, Giannatempo G, Lo Muzio L, Lo Russo L. et al Mandibular class II furcation defect treatment: Effects of the addition of platelet concentrates to open flap: A systematic review and meta-analysis of randomized clinical trials. J Periodontol 2016; 87: 1030-8
  CrossrefPubMedGoogle Scholar
• 42 Ahmed HM, Neelakantan P, Dummer PM. A new system for classifying accessory canal morphology. Int Endod J 2018; 51: 164-76
  CrossrefPubMedGoogle Scholar
• 43 Arias-Moliz MT, Morago A, Ordinola-Zapata R, Ferrer-Luque CM, Ruiz-Linares M, Baca P. et al Effects of dentin debris on the antimicrobial properties of sodium hypochlorite and etidronic acid. J Endod 2016; 42: 771-5
  CrossrefPubMedGoogle Scholar
• 44 van der Sluis LW. Endodontics in motion: New concepts, materials and techniques 3. The role of irrigants during root canal treatment. Ned Tijdschr Tandheelkd 2015; 122: 533-8
  CrossrefPubMedGoogle Scholar
• 45 Mehra P, Clancy C, Wu J. Formation of a facial hematoma during endodontic therapy. J Am Dent Assoc 2000; 131: 67-71
  CrossrefPubMedGoogle Scholar
• 46 Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents. Compend Contin Educ Dent 2007; 28: 544-6 548, 550
  PubMedGoogle Scholar
• 47 Zhu WC, Gyamfi J, Niu LN, Schoeffel GJ, Liu SY, Santarcangelo F. et al Anatomy of sodium hypochlorite accidents involving facial ecchymosis – A review. J Dent 2013; 41: 935-48
  CrossrefPubMedGoogle Scholar
• 48 Kavanagh CP, Taylor J. Inadvertent injection of sodium hypochlorite into the maxillary sinus. Br Dent J 1998; 185: 336-7
  CrossrefPubMedGoogle Scholar
• 49 Ehrich DG, Brian Jr JD, Walker WA. Sodium hypochlorite accident: Inadvertent injection into the maxillary sinus. J Endod 1993; 19: 180-2
  CrossrefPubMedGoogle Scholar
• 50 Motta MV, Chaves-Mendonca MA, Stirton CG, Cardozo HF. Accidental injection with sodium hypochlorite: Report of a case. Int Endod J 2009; 42: 175-82
  CrossrefPubMedGoogle Scholar
• 51 Hülsmann M, Hahn W. Complications during root canal irrigation – Literature review and case reports. Int Endod J 2000; 33: 186-93
  CrossrefPubMedGoogle Scholar
• 52 Tasdemir T, Er K, Celik D, Yildirim T. Effect of passive ultrasonic irrigation on apical extrusion of irrigating solution. Eur J Dent 2008; 2: 198-203
  Article in Thieme ConnectPubMedGoogle Scholar
• 53 Boutsioukis C, Lambrianidis T, Kastrinakis E. Irrigant flow within a prepared root canal using various flow rates: A computational fluid dynamics study. Int Endod J 2009; 42: 144-55
  CrossrefPubMedGoogle Scholar
• 54 Sirtes G, Waltimo T, Schaetzle M, Zehnder M. The effects of temperature on sodium hypochlorite short-term stability, pulp dissolution capacity, and antimicrobial efficacy. J Endod 2005; 31: 669-71
  CrossrefPubMedGoogle Scholar
• 55 Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR. et al Review of contemporary irrigant agitation techniques and devices. J Endod 2009; 35: 791-804
  CrossrefPubMedGoogle Scholar
• 56 Salzgeber RM, Brilliant JD. An in vivo evaluation of the penetration of an irrigating solution in root canals. J Endod 1977; 3: 394-8
  CrossrefPubMedGoogle Scholar
• 57 Agarwal A, Deore RB, Rudagi K, Nanda Z, Baig MO, Fareez MA. et al Evaluation of apical vapor lock formation and comparative evaluation of its elimination using three different techniques: An in vitro study. J Contemp Dent Pract 2017; 18: 790-4
  CrossrefPubMedGoogle Scholar
• 58 Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod 2005; 31: 166-70
  CrossrefPubMedGoogle Scholar
• 59 van der Sluis LW, Versluis M, Wu MK, Wesselink PR. Passive ultrasonic irrigation of the root canal: A review of the literature. Int Endod J 2007; 40: 415-26
  CrossrefPubMedGoogle Scholar
• 60 Mohammadi Z, Shalavi S, Giardino L, Palazzi F, Asgary S. Impact of ultrasonic activation on the effectiveness of sodium hypochlorite: A review. Iran Endod J 2015; 10: 216-20
  PubMedGoogle Scholar
• 61 Ferreira RB, Marchesan MA, Silva-Sousa YT, Sousa-Neto M. Effectiveness of root canal debris removal using passive ultrasound irrigation with chlorhexidine digluconate or sodium hypochlorite individually or in combination as irrigants. J Contemp Dent Pract 2008; 9: 68-75
  CrossrefPubMedGoogle Scholar
• 62 Barnett F, Godick B, Tronstad L. Clinical suitability of a sonic vibratory endodontic instrument. Endod Dent Traumatol 1985; 1: 77-81
  CrossrefPubMedGoogle Scholar
• 63 Velvart P. Efficiency of root canal preparation with ultrasound using various irrigants. Schweiz Monatsschr Zahnmed 1987; 97: 756-65
  PubMedGoogle Scholar
• 64 Schoeffel GJ. The endoVac method of endodontic irrigation: Safety first. Dent Today 2007; 26: 92, 94, 96
  PubMedGoogle Scholar
• 65 Konstantinidi E, Psimma Z, Chávez de Paz LE, Boutsioukis C. Apical negative pressure irrigation versus syringe irrigation: A systematic review of cleaning and disinfection of the root canal system. Int Endod J 2017; 50: 1034-54
  CrossrefPubMedGoogle Scholar
• 66 Wang X, Cheng X, Liu B, Liu X, Yu Q, He W. et al Effect of laser-activated irrigations on smear layer removal from the root canal wall. Photomed Laser Surg 2017; 35: 688-94
  CrossrefPubMedGoogle Scholar
• 67 Hasheminia SM, Birang R, Feizianfard M, Nasouri M. A comparative study of the removal of smear layer by two endodontic irrigants and Nd: YAG laser: A scanning electron microscopic study. ISRN Dent 2012; 2012: 620951
  PubMedGoogle Scholar
• 68 George R, Meyers IA, Walsh LJ. Laser activation of endodontic irrigants with improved conical laser fiber tips for removing smear layer in the apical third of the root canal. J Endod 2008; 34: 1524-7
  CrossrefPubMedGoogle Scholar
• 69 Arslan D, Kustarci A. Efficacy of photon-initiated photoacoustic streaming on apically extruded debris with different preparation systems in curved canals. Int Endod J 2018; 51 (Suppl. 01) e65-72
  CrossrefPubMedGoogle Scholar
• 70 Azim AA, Aksel H, Margaret Jefferson M, Huang GT. Comparison of sodium hypochlorite extrusion by five irrigation systems using an artificial root socket model and a quantitative chemical method. Clin Oral Investig 2018; 22: 1055-61
  CrossrefPubMedGoogle Scholar
• 71 Virdee SS, Seymour DW, Farnell D, Bhamra G, Bhakta S. Efficacy of irrigant activation techniques in removing intracanal smear layer and debris from mature permanent teeth: A systematic review and meta-analysis. Int Endod J 2018; 51: 605-21
  CrossrefPubMedGoogle Scholar
• 72 Muhammad OH, Chevalier M, Rocca JP, Brulat-Bouchard N, Medioni E. Photodynamic therapy versus ultrasonic irrigation: Interaction with endodontic microbial biofilm, an ex vivo study. Photodiagnosis Photodyn Ther 2014; 11: 171-81
  CrossrefPubMedGoogle Scholar
• 73 Mancini M, Cerroni L, Iorio L, Armellin E, Conte G, Cianconi L. et al Smear layer removal and canal cleanliness using different irrigation systems (EndoActivator, endoVac, and passive ultrasonic irrigation): Field emission scanning electron microscopic evaluation in an in vitro study. J Endod 2013; 39: 1456-60
  CrossrefPubMedGoogle Scholar
• 74 Kungwani ML, Prasad KP, Khiyani TS. Comparison of the cleaning efficacy of EndoVac with conventional irrigation needles in debris removal from root canal An. in vivo study. J Conserv Dent 2014; 17: 374-8
  CrossrefPubMedGoogle Scholar
• 75 Karade P, Chopade R, Patil S, Hoshing U, Rao M, Rane N. et al Efficiency of different endodontic irrigation and activation systems in removal of the smear layer: A scanning electron microscopy study. Iran Endod J 2017; 12: 414-8
  PubMedGoogle Scholar
• 76 Tay FR, Gu LS, Schoeffel GJ, Wimmer C, Susin L, Zhang K. et al Effect of vapor lock on root canal debridement by using a side-vented needle for positive-pressure irrigant delivery. J Endod 2010; 36: 745-50
  CrossrefPubMedGoogle Scholar