Endodontic Irrigation

Endodontic Irrigation
There is a famous saying with regard to endodontic treatment "It does not matter what you put in, it is more important what you take out" (from root canals). And irrigation protocols can play a key role in disinfecting and debriding root canal system. Another important aspect is that chemo-mechanical action is needed to optimally clean the canal system. Mechanical part is done by instruments and chemical prep is done by using irrigation.

Irrigation in Endodontic treatment serves the following purposes:


Lubricate canal, which is very important to avoid un necessary instrument separation
Dissolve the pulp remnants
Washing out debris created by canal instrumentation
Kill/remove the bacteria/micro-organisms in root canal (Planktonic or biofilm)
Clean the smear layer

Some of the commonly used irrigants are:

Sodium hypochlorite 5.25% By far one of the best, it has bactericidal cytotoxicity, dissolution of organic material, and minor lubrification
EDTA (17%) (Ethylene diaminetetraacetic acid) smear layer removal
Chlorhexidine 0.2% bacteria removal
Citric acid 50%
MTAD (doxycycline, citric acid, Polysorbate 80)
distilled water clean canal of all remnants of any solutions
There are so many systems which help you deliver the irrigants safely to the canals, but the safest and best in recent times is Endovac, it absolutely ensures safely of your patient (See this apical extrusion study) and avoids nasty hypochlorite accidents despite cleaning apex to full working length in addition to giving you the cleanest possible apical portion ensuring success in single visit endo. 5.25% hypochlorite is easily used with Endovac which has proved to be most effective but can also cause more tissue damage if goes beyond canal orifice, and hence not adviced to be used with manual syringe methods. High cost of Endovac may be a deterrent where input costs are crucial, but better than paying huge costs after litigation.

One important aspect to note is that irrigant can clean only if it comes in contact with the canal walls, and this can happen only if you have canal size prepared to at aleast a size 30. Other important thing is volume exchange, many sonic/ultrasonic methods fail on this count they can agitate the solution but do not work completely as there is inadequate exchange of solution. Many believe that using patency file or matercone will puch the irrigant to apical third, it does not happen because of airlock. Watch This Video to see airpocket

It is often asked if one should use ETDA paste or liquid ? It is common sense that paste will mix with debris and is harder to get in and out of canal. Liquid EDTA is always easy to use and much more efficient. One can easily prepare 17% ETDA by following the method given below:
Put 50 gms of EDTA salt in 300 ml distilled water, stir it ( it will not fully dissolve), then put 5-10 gm NaOH in this liquid and you will see the liquid quickly becomes totally transparent. Store in a dark bottle.

Some recommend use of warm hypochlorite, but it does not have any merits and literature does not support it. To read on hypochorite accident and its management CLICK HERE

Available Systems:


Endovac Safest and the best
Ultrasonic Irrigation- flood the canal and use a small tip to stirr for one minute (better than just hand irrigation) or use Vibringe
Sonic Irrigation-Endo activator by Ruddle
SonicMax from DentalMaximum
Rinsendo from Airtechniques
IRRISAFE Passive Ultrasonic Irrigation (PUI)-Satelec
Micro irrigators from ASI

Passive ultrasonic irrigation (PUI) is after the root canal has been shaped to MAF. Small file (10-20) is placed (without touching the canal walls) and activated by ultrasonic unit. Proponents of this technique claim that this leads to acoustic streaming around the file leading to efficient action.

Recommended protocol for manual irrigation
After gaining access to pulp chamber, fill hypochlorite and vigorously scrape with excavator. Henceforth use EDTA until WL determination with EAL is over. Hypochorite is known to interfere with Apex Locator readings. During canal instrumentation pulp chamber is flooded with EDTA. Between change of instruments flush out the canal with NAOCL.
After instrumentation is complete irrigate the canal with HypoCl, EDTA (removes smear layer and open tubules), and final irrigation with Chlorhexidine (disinfects opened up tubules)