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INTRODUCTION An important objective in endodontic therapy is the removal of pulpal and dentinal debris from the root canal

system, to accomplish this it is essential to use an irrigant or combination of irrigants during and after biomechanical preparation of the canal system. Refers to as chemical preparation, when accomplished simultaneously are often reported as chemomechanical preparation. GOALS OF IRRIGATION Four goals of irrigation : . !avage of debris ". #issue dissolution. $. Antibacterial action and %. !ubrication. &ebridement with hand instruments alone are not possible able to remove all the tissue remnants in the pulp chamber and canals. 't is necessary to rely on some means of chemical dissolution of the remaining tissue, and this depend upon the type of remaining tissue whether it is vital, necrotics, or chemically fi(ed tissue, unfortunately, irrigants are not e)ually effective on all three tissue types. *ome tissue all three tissues may be encountered clinically in the same tooth. +ther variables are the method and e(tent of canal instrumentation , whether coronal apical or apico coronal -step bac./, preparation.

!aboratory studies have shown, for e(ample, that the step0bac. preparation leaves less tissue debris. #he e(tent of instrumentation and the si1e of the last instrument used at wor.ing length influence the penetration of irrigants. 2uantity and temperature of the irrigating solutions the length of time of contact, the level of observations -apical, middle, or coronal/, the presence of serum proteins, the depth of penetration of the irrigating needle, the type and gauge of the irrigating needle, the surface tension of the irrigating solution -with alcohol or detergent/, and the age of the solution are all influences the effects of the irrigating solutions.

DESIRABLE PROPERTIES FOR AN ENDODONTIC IRRIGANT


#he chemical agent selected for endodontic irrigation should poses from major properties : . *hould have antimicrobial activity. ". &issolve necrotis tissue. $. Aid in debridement of the canal system. %. 3e nonto(ic to the periradicular tissues. #he first three of these properties are interrelated, tissue dissolution property aids in the debridement by dissolving organic debris, these assist in reducing the microbial flora by removing necrotic debris and thereby reducing the substrate that promotes the growth of microorganisms.

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HISTORY OF IRRIGATING SOLUTIONS


4rior to 5%6, water was the most commonly used endodontic irrigant, it provided lubricating effect ma.ing instrumentation of the canal wall easier. #he number and types of irrigants that have been recommended later on include acid, chelating agents, proteolytic en1ymes, al.aline solutions and other clinical agents such as o(idi1ing agents and normal saline solutions. ACIDS AND CHELATING AGENTS Acids and chelating agents were used because of their ability to soften dentin, ma.ing enlargement of the canal system easier. Acids such as $67 hydrochloric acid and 867 phosphoric acid were used as late as 5%6s with little or no understanding of effects on periradicular tissues. #hese caustic acids dissolved inorganic structure of dentin with the remaining organic matri( offering less resistance to instrumentation. Chelating agents 0 came into increasing use in the 596s. #hey softened the dentin better then acids and also far more biologically acceptable to the soft tissues. #hey combine with and inactivate calcium ions. #his decalcification effect results in less resistance to instrumentation. CHELATING AGENTS ARE: :&#A, R:&#A -:&#A buffered with sodium hydro(ide in an a)ueous vehicle/. R;04reparation -:&#A and urea pero(ide/ and citric acid.

Pr te l!ti" En#!$es
<ere utili1ed in 5$6s and 5%6s for their tissue solvency effect. #hey possessed very little tissue solvency property within root canal systems. :n1ymes used in the therapy are : *trepto.inase, streptodornase, papain, en1ymol and purified trypsin.

Al%aline S l&ti ns
=sed solutions are, sodium dio(ide, sodium hypochlorite, potassium hydro(ide, urea and sodium hypochlorite. *odium hypochlorite has been proved clinically acceptable and is the most commonly used irrigant in endodontics. O'i(i#ing Agents 'n 5%$, >rossman introduced the concept of using an o(idi1ing agent as an irrigant in conjunction with sodium hypochlorite. ?e recommended that solution of $7 hydrogen pero(ide be alternated with a solution of 8."87 sodium hypochlorite, so that the foaming action resulting from the chemical reaction would help to remove debris from the canal system. Recently another o(idi1ing agent, gly0o(ide has been recommended, particularly for narrow, curved canals contains carbamide pero(ide in an anhydrous glyceral base is highly viscous, glyceral base provides very good lubrication, has little antibacterial activity not a tissue solvent.

S (i&$ H!) "hl rite


=sed as an endodontic irrigant for well over four decades. 't is reducing agent, is a clean straw colored solution containing about 87 of available chlorine. #his irrigant when used during cleaning and shaping act as a lubricant, solvent of the pulp tissue, antiseptic and bleach. #he amount of dilution and its use in combination with other irrigants such as glyo(ide, R;04rep, or hydrogen pero(ide still remain controversial. #repagnier has reported either 8."87 or ".@7 sodium hypochlorite has the same effects for a period of 8 minutes when used in root canal system. ;unningham has shown 8."@7 and ".@7 Aa+cl were e)ually effective at $9B; -body temperature/ warming the solution increase its antibacterial effect. Rosefield demonstrated 8."87 sodium hypochlorite dissolves vital tissue and dissolves necrotic tissue better than in any other concentration. Antimicrobial property is due to the destruction of bacterial by penetration into the bacterial cell and chemical combination with the protoplasm of the bacterial cell.

?and and associates have shown that sodium hypochlorite retain its antimicrobial activity in the presence of organic matter such as blood and serum albumin. Alternate irrigation with sodium hypochlorite and hydrogen pero(ide -$7/ produces energetic effervescence that mechanically forces debris and microorganisms out of the canal. Release of nascent o(ygen causes the forming effect. ;ombination seems to reduce the tissue solving property advantage is mechanically bubbles and pushes the debris. #he solvent action of the sodium hypochlorite. #he disinfectant and, bleaching action by both solution. *odium hypochlorite should be used last because hydrogen pero(ide can react with pulp debris and blood to form gas, trapped gas in the tooth causes continuous pain. Fischer and ?uerta believe it is the al.aline property -p? .6 , .8/ of

sodium hypochlorite that ma.es it effective against anaerobic microbes. 3actericidal effect gained by combining sodium hypochlorite with other chemicals come from the release of chlorine gas. 't is true with citric acid, some e(tent with :&#A and not with hydrogen pero(ide. *odium hypochlorite is a tissue irritant and this discourages its use to its full strength.

CHELATING AGENTS
Cost common chelating solutions used for irrigation #ublicid, :&#A, :&#A;, File0:1e and R;04rep. 'n all of these :&#A0:thyline diamine tetra0 acetic acid is the active ingradient. 'ntroduced into the endodontic practice by Aygaard +stby. !ater he introduced :&#A;, :&#A with cetrimide, )uaternary ammonium compound to reduce surface tension and increase penetration, cetrimide acts as disinfectant. :&#A functions by forming a calcium chelate solution with the calcium ion of dentin : -the dentin becomes more fliable and easier to instrument/. <hen all of the available inorganic matter of dentin is chelated by the :&#A0 &entin reaction, a chemical e)uilibrium is established. :&#A D "caDD ;a :&#A ;a

#his e)uilibrium reaches within 9 hours, regardless of surface area involved indicating that :&#A is chemically self limiting in the chelation of irorganic material from dentin. #he optimal p? for the deminerali1ing efficiency of :&#A as shown by Ealdrighi is between 8.6 and @.6.

>oldberg has shown :&#A; increases permeability into dentinal tubules accessory canals and apical foramina. Cc;omb found :&#A sealed in the canal for "% hrs produced the cleanest dentinal walls. >oldman and colleagues in 5F were shown combined use of sodium hypochlorite and :&#A removed smear layer, chelating agents remove only calcified tissues whereas sodium hypochlorite removes organic material confirming the composition of smear layer. +riginal Aygaard +stby formula for 87 :&#A was &isodium salt of :&#A 9.6g &istilled water 66.66ml 8ml sodium hydro(ide 5."8 ml

*ummari1ing the effects of :&#A studied by both in vitro and invivo. . :ffective in softening the dentin. ". ?as distinct antimicrobial properties. $. 's capable of causing moderate degree of irritation. %. ?as no deliterious effect when used clinically. 8. 'rrigation with :&#A removes smear layer. @. &eminerali1ation is proportional to the e(posure time. 9. #o a depth of "60$6 in 8 minutes. 'n 5@5 *tewart and others developed R;0prep. is composed of :&#A and urea pero(ide in a base of carbowa(. An effectiev lubricating and cleaning agent for root canals and allowed deeper penetration of the medicament into the dentin.

According to ;oo. and associates R;0preparation allowed ma(imum lea.age into filled canals over "0@ times the lea.age of the canals. Another root canal irrigant is solvi1ol which is A 0A 0&ecamethylene , A%, A%0decamethylenebis , % , amino )uinaldinium,diacetate Gaufman suggested that with a neutral p? has a broad spectrum of bactericidal activity as well as the ability to chelate calcium, ma.es it a cleansing potency and biologically compatible. #his applies to tublicid -green, red and blue/ as well. :&#A is inserted by depositing a few drops in the pulp chamber with a syringe and then carefully pumping the solution into the root canal with a fine root canal instrument, and is continued with the solution bathing the canal at all times until cleaning and shaping are completed.

ORGANIC ACIDS
#idmarch, felt 867 citric acid gave the cleanest dentin walls without a smear layer. <ayman reported e(cellent filling results after preparation with citric acid -"67/, followed by ".@7 sodium hypochlorite and a final flushing with 67 citric acid =* Air Force tested effective as a bactericidal in 80 6min. other organic acid used to remove smear layer are polyacrylic acid for one as &urelon and Fuji '' li)uids, both %67 polyacrylic acids.

OTHER IRRIGANTS
50amine acridine reviewed by *chmit1 enjoys regional popularity because of its low to(icity and antimicrobial action and has a purported osteogenic potential, has no wide spread use because its not a tissue solvent or chelator. ;hloriamine , # has little ability to dissolve necrotic tissue. ;hlorhe(idine gluconate -6."7/. Recently, !oma !inda group reported it to be more effective as an antimicrobial agent. Gaufman reported bis0de)ualinium acetate -3&A/ as disinfectant and chemotherapeutic agent. ?e cites its low to(icity, lubrication action, disinfecting ability, and low surface tension, as well as its chelating properties and low incidence of post0treatment pain. 't is mar.ed as solvidont. 3&A is recommended as an e(cellent substitute for sodium hypochlorite in those who are allergic to sodium hypochlorite. A"ti n * "hl rhe'i(ine : action is the result of absorption of chlorhe(idine onto the cell wall of the microbes thereby altering the cells osmotic e)uilibriumH resulting in lea.age of intracellular components. 3road spectrum, antimicrobial, substantivity and relative absence of to(icity.

+, gl&taral(eh!(e 0 <emes and co0wor.ers 5F" used "7 glutaraldehyde as an endodontic irrigant. 't causes irreversible fi(ation of tissues, they observed smooth layer of dentin material resulted in closure of apical and lateral canals and the dentinal tubules and showed considerable antibacterial effect.

ULTRASONIC IRRIGATION
#he use of ultrasonic irrigation to better cleanse root canals, of their fillings debris and bacteria has been well reported by Cartin and ;unningham. #he oscillating movement of the file creates ultrasonic wave of sodium hypochlorite irrigant solution which is delivered along the side of the file and the vibration produces heat that increases the chemical effectiveness. 't also produces cavitation, that is the growth and collapse of bubbles, with a resulting increase in the mechanical cleansing activity of the solution, this increases in thermal and mechanical activity of the solution, helps in removal of debris and tissue from the isthmus and removal of smear layer are more efficient bactericidal action also increases. *onic system uses water as an irrigant and doesnIt usually re)uire diamond files for the flare of the preparation.

Te"hni-&e
#he instrument re)uired is a disposable plastic or glass syringe with an endodontic notched needle. #he needle should be bent to an angle to reach the canals of posterior as well as anterior teeth. #he needle is inserted into the

canal part way and should not bind the canal sufficient room between the needle and canal allows for the return flow and avoids forcing of solution into the periapical time. <hen it is not binding, the solution should be ejected with little or no pressure, on the plunger during the shaping and cleaning of the canal care should be ta.en that canals are always full of fresh solution. A perforated irrigating needle deliver irrigant $@6B in the canal, and large volumes of the irrigant solution physically remove more material it has been claimed. &isadvantage is that it is delicate and bends out of shape easily. .ICROBIAL FLORA #he basis of pulpal disease and the ultimate death of the dental pulp is found in the science of microbiology, clinician must recogni1e the cause and effect of bacterial invasion of the pulp tissue, what occurs to the bacteria when treatment ensures and final conse)uences when treatment is completed.

BRIEF HISTORICAL PERSPECTI/E


'n F5% Ciller became the first researcher to identify bacteria in the diseased pulp.

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'n 5 6 <illiam ?unter described dissemination of microorganisms, which became formally .nown as focal infection theory, which caused concern with oral focal infection. 'n 5$5 F. <ilfred Fish investigated 1ones in tissue that formed in response to infection, recogni1ing four 1ones of reaction. Appleton suggested that without bacteria no need would e(ist for endodontic treatment supported by the study of ;abechashi and colleagues. Appleton maintained that the function of root canal therapy is to render the canal and periapical tissue sterile and a bacteriologic e(amination has therefore necessary. *ince 56 the )uestion of the validity of culturing remains and the controversy continues. :arlier studies described a flora consisting predominantly of aerobic and facultative anaerobic microorganisms. #he differences in flora, as reported by different investigations over the past 8 years, are the result of improved technology in sampling such as new anaerobic culturing techni)ues, new and improved culturing media, and more sophisticated methods of isolation and identification of microorganisms and also the interest of the investigator. 'n 5 5, ?enric and ?art1ell -began indentifying bacteria from the

dental pulp/ found that @87 of the organisms were streptococci, "67 were staphylococci, and the remaining bacteria were corynebacteria and yeasts. $

'n

58", >rossman and ;ristrian found that infected pulpal tissue

occupied 997 gram positive cocci, @7 yeast and 87 gram negative rods. 'n 59$ 3erg and Cord and in 59% Gant1 and ?enry used anaerobic isolation and obliggate anaerobes in "97 of their samples. Actinomyces, ;amrlobaction, :ubacteria, Fusobacteria, streptococcus and veilonells. 3ystorm and *und)uist found F97 of their isolation anaerobes. *and)uist concluded that accute inflammation of the periradicular area is induced by combinations of bacterial strains and predominately that of bacteriocids. 3lac. pigmented bacteriocidal, 3.gingivalis and 3. endodontalis were present only in acute infections. >lic. and associates were able to identify ?'E -?uman 'mmuno &eficiency Eirus/ in noninflammed dental pulps of patients with A'&* through the use of polyacrylase chain reaction -4;R/ test, which present in fibroblasts of pulp. Caidorf compiled a list of generali1ation regarding organisms isolated from root canal are : . Ci(ed infections are more common than single organism isolates. ". #he wide variety of organisms found are partially related to the periapical inserts and culture techni)ues of these investigations. %

$. #he invasion of dentin from the pulp has been described but the type of organisms, growth rate and variability are poorly understood. %. 4ulpal isolates are similar to oral flora with gram positive cocci predominating. 8. +rganisms associated with flare ups do not differ from asymptomatic canal isolates. @. ;ultured organism elaborate a variety of invasive en1ymes. 9. #he present practice of treating the source of the infection of the root canal and not the periapical tissue confirms to the findings of ?edman.

BACTERIAL PATH0AYS INTO THE PULP


Ba"teria enter the )&l) thr &gh : . #he crown or root following traumatic e(posure of the pulp, through the dentinal tubules following carious invasion, restorative procedures including crown preparation and lea.ing restorations. ". From the periodontal tissue through e(posed dentinal tubules, lateral and accessory canals or apical and lateral foramina. $. 3y lymphatic or hematogenous route, anachoresis is defined as the locali1ation of transient bacteria in the blood into an inflamed area, such as a traumati1ed or inflamed pulp.

BACTERIOLOGIC E1A.INATION
*terility of a canal or a reduction in the number of microorganisms in a root canal canIt be determined by sight and smell. *ome organisms are chromogenic and not all bacteria give if no(ious odour, culture is a valuable and important tool. 3uchbinder showed that 67 more teeth had treated successfully on postoperative chec. up if they had a negative culture before obturation. +liet and *o(in, Jolcow and 'ngle have shown higher success rate under similar circumstances. :ggin. found difference in healing for upto $ years when obturated in the presence of positive or negative cultures, from the time of healing. Cor)u contended that the success rate is the same whether the root canal yields a positive or negative culture at the time of obturation. #he difference of 67 in result obtained by most investigators does not appear great. 3ut in 67 of all teeth treated in presence of a positive culture is the success is unli.ely. :ndodontic treatment without the benefit of bacteriologic control is justified neither elonofically or ethically.

CULTURE .EDIA
;ulture techni)ues is to determine the type of organisms to be found whether it is in the canal proper or the periradicular area of the teeth. Aot all microorganisms present in a root canal grow in readily available media especially obligate anaerobes, e(posure to air during endodontic treatment or to the chemical agents such as sodium hypochlorite will destroy obligate anaerobes. :ven though single organism of certain species is enough to initiate growth in culture media, according to >rossman ma(imum number of organisms needed is ten. C $$ n en( ( nti" "&lt&re $e(ia are: 3rain heart infusion broth with 6. 7 agar. #rypticase soy broth with 6. 7 Agar -#*A/ 6. Agar facilitates growth of anaerobes. #hioglycolate and glucose ascites broth. Addition of 87 Ascitic fluid or 67 horse serum will enable fastidious organism to grow. #est tubes filled to a high level, should be used for culturing to provide different degrees of o(ygen tension at different levels of the culture medium. 'n viability media for growth -EC>/ and stuart transport medium must strains survive for longer period.

Coller 0 base culture medium containing veal, veal heart, peptone prodintia an agar gel, and certain supplements will give slow grower time to produce a positive result continue about " wee.s.

*and)uist 0 used pre0reduced media anaerobic bo( to grow anaerobes, >riffee found prereduced thioglycollate medium twice effective.

-<hen samples are ta.en/ proper use of nitrogen gas over the canal orifice before samples were ta.en ensure canal orifice free from atmosphere o(ygen. 3lood agar, trypticase soy, or greenKheart infusions media base may be

fortified with defibrineted blood the presence of catalase present in the hemolysed blood destroys the to(ic effects of hydrogen pero(ide, which is lethal to anaerobic organisms. ?emin, sodium lactate and vitamin G are added to any of the above base media and illustrated in chambers with flowing gas mi(tures of almost pure carbon dio(ide with less than 87 hydrogen or mi(tures of o(ygen free gases, such as F67 nitrogen, 67 hydrogen and 67 carbon dio(ide allow anaerobic growth.

TA2ING THE CULTURE


#he dressing from the previous visit is removed from the root canal and is discarded. A sterile charcoal impregnated absorbant point is inserted into the canal, with a spring motion to cleanse the canal surface of any trace of F

medicament, the point is removed and discarded which will prevent carrying any of the medicament into the culture medium could inhibit bacterial growth and possible false negative culture. A fresh sterile absorbant point is now inserted into the apical foramen and is allowed to remain for at least min to absorb as much periapical e(udate and microorganisms from the root canal as possible. #he absorbent point is removed with sterili1ed cotton pliers held with thumb, inde( and middle finger, while the plug or cap of the test tube is removed with little finger and palm of the same hand, the test tube held in the other hand is tilted slightly to prevent air contamination, the lip of the tube is flamed the absorbent point is dropped and the plug or cap is replaced and the culture tube is incubated properly.

ANAEROBIC CULTURING
Fastidious process that re)uires special e)uipment and media used in a temperature controlled o(ygen free environment. For clinicians wish to culture anaerobic microorganisms from samples obtained from periradicular tissue and root canal.

PERIRADICULAR SA.PLE
=sing an aseptic techni)ue, insert the sterile needle into the periradicular space -i.e., swelling/ aspirate fluid, eject air inside the syringe band immediately, insert the needle through the rubber septum stopper of an Anaport

vial from which the gas has been removed and eject the fluid, transport the sample within % hour after ta.ing the sample to culturing department.

ROOT CANAL SA.PLE


Aseptically prepare an access cavity into the pulp chamber, inject few drops of prereduced anaerobically sterili1ed medium -chopped meat glucose broth sand)uist/ into chamber, pump the medium into the root canal with a sterile endodontic file, aspirate the fluid, eject any air from the syringe immediately, insert the needle through the rubber stopper of an anaport vial and eject the fluid. 'f an e(udate is present inside the root canal, the injection of additional medium is unaccessory for sampling.

SU..ARY AND CONCLUSION


'rrigants in endodontic therapy is a must and are many, it is for the clinician to select particular irrigant, depending on the clinical observation, sterility canal configuration, the .nowledge of the microbial flora, and their isolations and maintaining negative field in the canal improves the success of root canal.

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C ntents
'ntroduction >oals of 'rrigation &esirable 4roperties 'rrigating *olutions =ltrasonic 'rrigation Cicrobial Flora 3acterial 4athways into the 4ulp 3acteriologic :(amination ;ulture Cedia #a.ing the ;ulture *ummary L ;onclusion

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