GUIDED BY: Presented by:

DR.P.KARUNAKAR R.DEEPIKA
DR.RAJI VIOLA SOLOMON Pg 2nd year
DR.SRAVAN KUMAR
Contents part 1:

• Introduction
• Historical perspective
• Endodontic Irrigants
4.CHELATING AGENTS
1.SODIUM HYPOCHLORITE
Classification
Properties EDTA
Complications and management Properties
2.HYDROGEN PEROXIDE Combinations
Mode of its action Organic acids-citric acid and maleic
3.CHLOREXIDINE acid
properties Ethylene glycol tetraacetic acid
Combinations
Part 2 contents

 Glutaraldehyde
 Iodines  BioPure MTAD
 Electro-chemically activating water  Tetraclean
 Oxidative potential water  Metronidazole
 Ozone:  Qmix
 Photoactivated disinfection  Various herbal irrigants
 Nisin  Nanoparticle based irrigants
 BIS-DEQUALINIUM ACETATE (BDA)  Conclusion
 HEBP  references
GLUTARALDEHYDE

 Lately glutaraldehyde has been suggested as an endodontic irrigant.

 Weine suggested that the use of 2% aqueous solution of glutaraldehyde as
a canal irrigant.
 Glutaraldehyde is known to cause irreversible fixation without any adverse
tissue reactions.
 Weine observed that apart from the normal mechanical and chemical techniques
for preparing and disinfecting root canals, a different concept is that:
detoxification can be obtained by using fixatives.

 These are able to block off certain end groups in the amino acids of the organic
component of debris formed during instrumentation.

 This renders them metabolically inert (remaining organic debris).

Glutaraldehyde was preferred to formaldehyde.
As it has 4 additional properties:
1. Irreversible bonding with proteins.
2.Limited diffusion into tooth structure.
3.No periapical irritation.
4.Appears to cause a softening of dentin for limited duration, facilitating the mechanical
preparation of the root canal.
 Thus the greater reduction in microorganisms with 2% glutaraldehyde can be
attributed to the fixative property rendering the microorganisms inert and non-toxic.
IODINES

Povidone iodine ( Betadine) – 10%

Iodine Potassium Iodide 2%

Torneck advocated the use of Povidone –

 Iodine solution because of rapid antiseptic action against a wide range of micro
organisms.
 Performs better in antibacterial efficiency as compared to CA(OH) 2.
 IKI achieved 100% sterility is 15 min time frame
Mechanism of Action
 Iodine is strong oxidizing agent. It reacts with free sulfhydryl groups of bacterial
enzymes resulting in disulfide linkages.
 Therefore effective against several root canal microbes
 Also found to have lower toxicity to tissue culture cells at 2% concentration

compared to other intracanal medicaments except Ca(OH) 2.

 ELECTRO-CHEMICALLY ACTIVATING WATER

 Over the course of the past 28 years Russian scientists have

developed and refined the process of electro-chemically activating
water. (Leonov 1997, Bakhir 1997).

 ECA is produced from tap water and saline solution by a special

unit that houses a unique flow-through electrolytic module (FEM).

 The FEM contains the anode, made from titanium and coated with
ruthenium–oxide, iridium and platinum,
 and the cathode, made from titanium coated with pyrocarbon and
glass-carbon.
 Anolyte has a high oxidation
potential (plus 400 to plus 1200
millivolts).
 The manufacturers claim that it is
possible to produce acidic, neutral or
alkaline anolyte
. (pH 2–9), and that
anolyte is antimicrobial.

 Catholyte is an alkaline solution (pH 7–12) with

a high reduction potential (minus 80 to minus
900 millivolts).
 Catholyte is reputed to have a strong cleaning
or detergent effect.
 Both these solutions remain in the metastable
state for approximately 48 h before the solution
returns to the stable state, becoming inactive
once more.
 OXIDATIVE POTENTIAL WATER

 OPW has been used extensively in Japan for household and agricultural
disinfection because of its safety and bactericidal effectiveness.

 According to the manufacturers’ claims, the antimicrobial and antiviral

activities of OPW are sufficiently powerful to kill a wide variety of
pathogens, including Methicillin Resistant Staphylococcus Aureus (MRSA)
and HIV.
Mechanism of Action:

Acc to Becking et al. 1960.

 Microorganisms cannot survive in an aqueous environment with both low
pH (less than 3)
 High oxidation-reduction potential (greater than 0.9 V) .
 This is considerably greater than tap water, which, in Japan, averages 300
mV to 400 mV, and greater than several activated oxygen-containing
antimicrobial constituents, such as HOCl and O 3 .
 It has been confirmed that OPW can condition both enamel and dentine for
bonding with composite resin because of its low pH (Inoue et al. 1994).

 Oxidative potential water is well suited for dental treatment because of its
low toxicity and lack of irritation to soft tissues,

 It quickly loses its high oxidation-reduction potential and low pH when it

reacts with light-sensitive and/or organic substances.
 Removal of Smear Layer in the Root Canal Using Oxidative Potential Water, J Endod
1996;22:212-6”
“The Effectiveness of Oxidative Potential Water as a Root Canal Irrigant, Int Endod J
2002;34:308-17 ”

Conclusion
Hata et al., found that OPW used as an irrigant was as effective as 5% NaOCl or 17%
EDTA for opening and keeping the dentinal tubules patent.”
Ozone:

 Ozone is a very powerful bactericide that can kill micro organisms effectively.
 It is an unstable gas, capable of oxidizing any biological entity.
 It was reported that ozone at low concentration, 0.1 ppm, is sufficient to
inactivate bacterial cells including their spores.
 It is present naturally in air and can be easily produced by ozone generator
 When introduced in water, ozone dissolves rapidly and dissociates rather quickly.

 The concentration of ozone in ozonated water can be measured using a dissolved

ozone meter.

 Although ozonated water is a powerful antimicrobial agent against bacteria, fungi,

protozoa, and viruses, less attention has been paid to the antibacterial activity of
ozonated water in bacterial biofilm and hence in root canal infection.
 Cavitation is the formation of vapor-containing bubbles inside a fluid causing
formation of pressure waves/ shockwaves characterized by rapid changes in pressure
and high amplitude.

 A forced collapse of bubbles causes implosions that impact on surfaces, causing shear
forces, surface deformation, and removal of surface material.

 In the root canal environment, such shockwaves could potentially disrupt bacterial
biofilms, rupture bacterial cell walls, and remove smear layer and debris.
 Shockwave generation can also enhance the breakdown of agents such as
hydrogen peroxide and ozone dissolved in water and thereby enhance their
disinfecting and debriding actions.

 Nagayoshi et al. found that killing ability of ozonated water and 2.5% of sodium
hypochlorite was almost comparable when the specimen was irrigated with
sonication

OZONE SYSTEMS AVAILABLE FOR USE IN ROOT CANAL THERAPY KaVo produces the HealOzone, which
delivers 2,100 ppm ozone at a flow rate of 615 cc per minute and has been proven to be safe
 OZONATED WATER

Ozonated water is powerful antimicrobial agent against bacteria, fungi

protoza and viruses.
Ozone in aqueous or gaseous phases has a strong oxidizing power with
reliable microbial effects
a) Ozone destroys cell walls & cytoplasmic membranes of bacteria & fungi
b) Increased permeability leads to ingress of ozone which cause microbial death.

evidence-based efficacy of ozone for root canal irrigation. edward lynch etal
volume 2 0 , number 5 , 2 0 0 8 287
Advantages:
Potency
Ease of handing
Lack of mutagenicity
Rapid microbial effects
Showed lesser toxicity to L929 mouse fibroblasts than NaOCI. (Nagayoshi &
associates)

Disadvantages:
Requires continuous flow for it’s action.
Rapid ozone degradation in contacting organic compounds.
 Photoactivated disinfection

• Photoactivated disinfection is new technology that may be a less toxic alternative

to chemical disinfectants and uses a combination of photosensitizing dye and a
light of specific wavelength.
• This combination had been shown to kill a high population of bacteria in
planktonic suspension, collagen, and carious dentine.

Oscar Raab.

Photo-activated disinfection of the root canal: a new role for lasers in endodontics. Lee MT, Bird PS, Walsh LJ. School of
Dentistry, The Univesity of Queensland.
 antimicrobial photodynamic therapy (APD), photodynamic antimicrobial
chemotherapy (PACT) and photodynamic disinfection (PD) (Wainwright 1998,
Takasaki et al. 2009, Rossoni et al. 2010).

 Currently, light sources of a specific wavelength (between 630 and 800

nanometres) mostly applied in PDT are helium–neon lasers (633 nm), gallium–
aluminium–arsenide diode lasers (630–690, 830 or 906 nm) and argon lasers
(488–514 nm).

Tolonium chloride has been also used as a photosensitizing

agent. It is biocompatible and does not stain dental tissue
 Tooth staining and discoloration may be an adverse effect that follows the use of PDT
in root canal treatment when methylene blue (MB) is used as the photosensitizer (PS)
(Carvalho Edos et al. 2011,Ramalho et al. 2017).

 It has been concluded that 2.5% NaOCl used during cleaning and shaping of the
root canals was effective in preventing tooth staining related to the application of MB
during PDT (Carvalho Edos et al. 2011).
 Souza et al. (2017) reported that the use of ultrasonics improved the ability of 17%
EDTA and QMix to remove the PS from the cervical, middle and apical regions of
the root canal walls after PDT

 Other studies reported that PDT cytotoxicity was significantly less compared with
NaOCl when used for root canal disinfection (George & Kishen 2007a, Gomes-
Filho et al. 2016).
 NISIN :

 Nisin is a naturally occurring antimicrobial

peptide and was discovered in 1928.

 Produced by strains of Lactococcus lactis, nisin is

an antibiotic peptide, and is a class I bacteriocin.

 Nisin is safe to humans and is used extensively as

a food preservative in over 40 countries mainly in
preservation of meat and dairy products
 The mode of action of nisin, while not completely under-stood, is due to
interaction with the phospholipid membrane of the target bacterial cell
(Driessen et al. 1995).

 Nisin disrupts the cellular membrane inducing leakage of small intracellular

contents from the cell (Montville & Chen 1998).
 Nisin is comparable with calcium hydroxide in its ability to eliminate the species
tested, both within the root canal and associated canal wall radicular dentine in
vitro.

 The ability of nisin to effectively kill E. faecalis -- to which E. faecalis has no defence
mechanism.

 Nisin is reported to be active against a broad range of Gram-positive bacteria

(Kuipers et al. 1992).
BIS-DEQUALINIUM ACETATE
(BDA)

 It is used as a disinfectant and chemotherapeutic

agent .
 low toxicity, lubrication action, disinfecting ability, and
low surface tension, as well as its chelating properties
and low incidence of post-treatment pain.
 Marketed as Solvidont ,reported a remarkable
decrease in postoperative pain and swelling when BDA
was used.
 They attributed these results to the chelation properties of BDA in removing
the smear layer coated with bacteria and contaminants as well as the
surfactant properties that allow BDA “to penetrate into areas inaccessible to
instruments.”

 Bis-dequalinium acetate is recommended as an excellent substitute for

sodium hypochlorite in those patients who are allergic to the latter.
Metranidazole:

• Antibiotic spectrum confined solely

to obligate anaerobes.
• Active against bacteroides,
porphyromonas fusibacterium,
clostridium and peptococci and
peptostreptococci.
• Comes as an injection:
Metranidazole 500mg, NaCl2 0.8,
Water.
Barnett and Tronstad reported the successful use of metranidazole in controlling
infections by bacterioides spp and pseudomonas spp colonized at root ends of
endodontically treated teeth that had failed to heal and remained refractory to all
other treatment.
DOXYCYCLINE
HYDROCHLORIDE

o More recently DH, a hydroxy derivative of tetracycline is

under study as an irrigant.
o It is the most potent anticollagenase antibiotic among
commercially available tetracyclines.
o The tetracyclines are broad spectrum antibiotics
demonstrated to be effective in control of periodontal
pathogens.
Advantages:
1.   The dentin surface is capable of acting as a reservoir by adsorbing and slowly
releasing antibacterial levels of doxycycline into the adjacent environment for several
days following topical applications of this antibiotic solutions.

2.   Inhibit extracellular collagenase activity and bone resorption.

Triclosan and Gantrez
 Triclosan and Gantrez Triclosan is a broad spectrum antimicrobial agent.

 Nudera et al. evaluated the minimum inhibitory concentrations (MIC the

MBC of triclosan ranged from 12–94 μg/ml.

 The MBC of triclosan with Gantrez® ranged from <0.3–10.4 μg/ml.

 bactericidal activity against the five specific endodontic pathogens.

 Chlorine dioxide (ClO2)

 An In vitro study compared organic tissue dissolution capacity of NaOCl and

ClO2.
 It was concluded that ClO2 and NaOCl are equally efficient for dissolving organic
tissue .
 A study showed that trihalomethane is an animal carcinogen and a suspected
human carcinogen .
 ClO2 might therefore be a better dental irrigant than NaOCl.
Silver Diamine Fluoride

 A 3.8% w/v silver diamine fluoride (Ag [NH3]2F) solution has been
developed for intracanal irrigation.
 This represents a 1:10 dilution of the original 38% Ag [NH3]2F solution used
for root canal infection .
 Ag[NH3]2F for 60 min has potential for use as an antimicrobial root canal
irrigant or interappointment medicament to reduce bacterial loads .

The silver deposits were found to occlude tubular orifices after

removal of the smear layer.
 HEBP :

 Known as 1-hydroxyethylidene-1, 1-
bisphosphonate (HEBP) or etidronate.

 It is considered the unique chelator that

can be mixed with NaOCl without
interfering with its antimicrobial
property.
 This irrigant has the ability to remove the smear layer similar to that of EDTA or
citric acid, and it can be mixed with NaOCl without any loss of the NaOCl
antimicrobial activity.

 Consequently, the NaOCl/HEBP solution could be used as a single irrigant during

and after instrumentation, replacing the final rinse with a chelating agent.
RECENT ADVANCES
Combinations and Solutions with
Detergents

 The irrigant flow can be affected by density, viscosity, contact angle, and wetting
behavior of the irrigant.

 Even though density and viscosity always affect the flow, surface tension only affects
the flow when 2 immiscible (incapable of mixing) fluids are present.
Some added detergents in the market are:
• Smear Clear: EDTA + detergents
• Chlor-XTRA: NaOCl+ detergents
• CHX-Plus: CHX+ detergents
• Tetraclean: 50 mg/mL doxycycline + polypropylene glycol + citric acid
• MTAD: 3 % doxycycline hyclate + 4.25 % citric acid + Tween 80
• QMiX: CHX + EDTA + detergent
 BioPure MTAD

 Two new irrigants based on a mixture of antibiotics, citric acid, and a detergent have
been developed.
 MTAD, introduced by Torabinejad and Johnson at Loma Linda University in 2003.
 It is an aqueous solution of

 3 % DOXYCYCLINE,
 A BROAD-SPECTRUM ANTIBIOTIC;
 4.25 % CITRIC ACID, A DEMINERALIZING
AGENT; AND
 0.5 % POLYSORBATE TWEEN 80
DETERGENT.
• It is mixed as a liquid and powder prior to use.
• MTAD has been recommended in clinical practice as a final rinse after completion
of conventional chemomechanical preparation.
• It is effective against A.capnocytophaga, P.gingivalis, and P.
intermedia and affects both gram-positive and gram-negative (more
gram-negative effect).
• Tetracycline is a bacteriostatic antibiotic, but in high concentrations,
tetracycline may also have a bactericidal effect.
• Doxycycline, citric acid, and Tween 80 together may have a synergistic
effect on the disruption of the bacterial cell wall and on the
cytoplasmic membrane.
Antibacterial Efficacy :

• Torabinejad et al. found that MTAD was effective in killing E. faecalis

up to 200× dilution.

Shabahang and Torabinejad showed that the combination of 1.3 % NaOCl as a

root canal irrigant and MTAD as a final rinse was significantly more effective
against E. faecalis than other regimens.
Protocol for Use :

• MTAD was developed as a final rinse to disinfect the root canal

system and remove the smear layer.
• The effectiveness of MTAD to completely remove the smear layer is
enhanced when a low concentration of NaOCl (1.3 %) is used as an
intracanal irrigant before placing 1 ml of MTAD in a canal for 5 min
and rinsing it with an additional 4 ml of MTAD as the final rinse .
 Tetraclean:

o Tetraclean is a combination product similar to MTAD.

o These irrigants are capable of removing both the smear layer and organic tissue
from the infected root canal system.
o Tetraclean®, a mixture of doxycycline hyclate, lower con than MTAD an acid, and a
detergent.
o It is able to eliminate microorganisms and smear layer in dentinal tubules of
infected root canals with a final 5 min rinse;
Difference between MTAD and
tertaclean

MTAD TETRACLEAN
Conc of Antibiotic 150mg doxyxline 50mg doxycycline
Kind of detergent tween 80 propylene glycol
Mode of Action :

• These derivatives exhibit different characteristic such as

• absorption,
• protein binding,
• metabolism, excretion,
• degree of activity against susceptible organism.
• Tetracyclines inhibit protein synthesis by reversibly binding to the 30S subunit of
bacterial ribosome in susceptible bacteria.
QMiX :

QMiX was introduced in 2011;

It is one of the new combination products introduced for root canal
irrigation.
it is intended as a antimicrobial irrigant as well as to be used in the
removal of canal wall smear layers and debris.
• QMiX contains a ANTI
MICROBIAL SMEAR LAYER
• CHX analog, REMOVAL
• Triclosan (N-cetyl-N,N,N-trimethylammonium bromide
• EDTA as a decalcifying agent

Mixing EDTA and CHX is known to produce a white precipitate (Rasimick et al.
2008). In QMiX, this is avoided because of its chemical design.
Protocol :

• QMiX is suggested as a final rinse.

• If sodium hypochlorite was used throughout the cleaning and
shaping, saline can rinse out NaOCl to prevent the formation of PCA.
Smear Layer Removal :

• Stojicic et al.investigated the effectiveness of smear layer removal by

QMiX using scanning electron microscopy.
• QMiX removed smear layer equally well as EDTA.
• QMiX is as effective as 17 % EDTA in removing canal wall smear
layers after the use of 5.25 % NaOCl as the main rinse.
Antibacterial Efficacy and Biofilms:

• QMiX and 1 % NaOCl killed all planktonic E. faecalis and plaque

bacteria in 5 s.

• QMiX and 2 % NaOCl killed up to 12 times more biofilm bacteria

than 1 % NaOCl (P < 0.01) or 2 % CHX (P < 0.05; P < 0.001).
Alexidine (ALX) 1%

 Alexidine (ALX), a bisbiguanide-like CHX, is a disinfectant which

has recently gained much attention for its longer substantivity and
potency against E. faecalis.

 This is through its greater affinity for the major virulence factors
such as bacterial lipopolysaccharide (LPS) and lipoteichoic acid
(LTA),making it a potentially ideal final irrigating solution.
 Carisolv:

• Dummer investigated the RC irrigant potential of Carisolv as it

has antibacterial and collagen dissolving potential.
• They showed that Carisolv was better than PBS and worse than
4.5% NaOCl in canal cleaning ability.
• Carisolv cleans pulp debris from the walls of immature root
canals as effectively as NaOCl (1%) during static, unrefreshed
wall contact between 20 and 30 min.
HERBAL IRRIGANTS:
Introduction:

Though chemical irrigants are helpful in chemomechanical preparation none as served

all the requirement of an ideal irrigant, even the biocompatibility of the solution
during periapical extrusion is possing a problem.
Herbal irrigants Properties as irrigants

1. AZADIRACHTA INDICA  Nimbidin a major crude -antibacterial activity and anti fungal anti viral.
 Bohora and co-workers have concluded that neem leaf extract has a significant
antimicrobial effect against E. fecalis.

2. TULSI (OCIMUM  leaves contains eugenol, a phenolic compound-antimicrobial, antidiabetic, and

SANCTUM): anticancer properties.
 Gupta et al.compared the antimicrobial efficacy .

3. ALOE VERA (ALOE  Sahebi et al. evaluated the antibacterial efficacy of aloe vera as an irrigant in
BARBADENSIS MILLER) comparison with 2.5% NaOCl.
 They also reported that aloe vera was not effective against E. faecalis and hence
did not recommend it as an irrigant.

4. CINNAMON  Gupta et al. compared the antimicrobial efficacy of Cinnamomum zeylanicum

(CINNAMOMUM with Ocimum sanctum, Syzygium aromaticum and NaOCl against both the
ZEYLANICUM) forms (Planktonic form and biofilm) of E. faecalis.
 antimicrobial effect due to essential oils eugenol
Garlic (Allium  Eswar et al. investigated the efficacy of Garlic against E. faecalis.
Sativum) Garlic showed better antibacterial efficacy compared to Ca(OH)2 and
performed less when compared to 2 % CHX.
 Tissue dissolution of ASE is attributed to its characteristic
organosulfur compounds such as allicin .
Green Tea  The antimicrobial activity is due to inhibition of bacterial enzyme
(Camellia gyrase by binding to ATP B sub-unit.
Sinensis)  Lee and Tan evaluated the effects of EGCG Epigallocatechin-3-gallate
(EGCG), against E. faecalis biofilm and its virulence. They concluded
that EGCG is an effective antimicrobial agent against E. faecalis and
its antimicrobial action might be due to the production of hydroxyl
radical.
triphala  Prabhakar et al79.evaluated the antimicrobial efficacy of Triphala,
Green tea polyphenols and NaOCl on E. faecalis biofilms. They
observed that NaOCl had the maximum antibacterial activity
followed by Triphala and green tea.
 is rich in citric acid, shows the property of chelation and helps in the
removal of the smear layer from the walls of the root canal
Nutmeg  It exerts an antimicrobial effect against E. faecalis and C albicans. antimicrobial
(MyristicaFragrans efficacy -presence of myristic acid

Turmeric (Curcuma longa)  Curcumin in surfactant preparations showed its potential as a photosensitizer
[PS] in antibacterial photodynamic therapy [aPDT] in vitro-Haukvik et al.
(2010) ,
 Neelakantan (Neelakantan, Subbarao, & Subbarao, 2011), it has been shown that
curcumin has significant antibacterial activity against E. faecalis

Grapefruit (Citrus  Rees et al. observed that Grapefruit seed extract was able to remove the smear
Paradisi) layer.

Morinda citrifolia
Noni(L-asperuloside and
alizarin, and acetone extracts
from MCJ have also shown
antimicrobial effects)
 The minimum inhibitory concentration of MCJ on E. faecalis growth in test
tubes was found to be a 6% solution.
 According to Murray et al76 when EDTA was used with, 6% MCJ was as effective
as 6% NaOCl and more effective than 2% CHX to remove the smear layer from
E. faecalis infected instrumented root canal walls.
Liquorice (Glycyrrhiza Ca(OH)2 alone. The reason for its antibacterial efficacy is due to
Glabra) the presence of glycyrrhizin

Mango (Mangifera Indica) Subbiya et al. compared the antibacterial efficacy of Mangifera
indica L. kernel and Ocimum sanctum L. leaves (tulsi) extracts
with NaOCl and CHX against E.faecalis biofilm. Mango kernel
showed a higher zone of inhibition when compared to the
other herbs.
tannins -antimicrobial

Emblica Officinalis antimicrobial activity -tannins, flavonoids, and saponins

present in its fruits.

Salvadora Persica The 10% water extract SalvodoraPersica -effective antibacterial

 propolis

The antimicrobial properties of propolis are attributed

to its high flavonoid content and in particular with the
presence of galanin and pinocembrin.

Carbajal, the study proved that in comparison

with 2% CHX and calcium hydroxide
(Ca(OH)2), propolis possessed equally good
antibacterial efficacy against E. faecalis;
however, its antifungal efficacy was less.
According to Saxena et al(2015) Propolis showed
the highest zone of inhibition among all the herbal
extracts next to sodium Hypochlorite followed by
AI > Triphala > C. longa = MC > ethanol.
Papacarie- Papain gel:

• Papain is a cysteine protease enzyme present in papaya.

• Papain is the main ingredient of Papacarie, a gel used for
chemomechanical dental caries removal.
• Because of its protein-dissolving properties, papain has been
investigated as a potential endodontic irrigant.
• Antibacterial efficacy of papain gel was found to be lower than that of
3.3% castor oil and 0.5% NaOCl
Endoquil

• Endoquil: A castor oil based irrigant

• Endoquil, a 3.3% Ricinus communis detergent has
produced good results as an endodontic irrigant.
• Its antimicrobial activity was found to be similar to that
of a 0.5% solution of sodium hypochlorite when used
in the treatment of root canals with pulpal necrosis.
• Endoquil was effective against many Gram-positive
microorganisms when a 0.5% solution of NaOCl was
effective only against S. aureus.
Nanoparticles:

• Various nanoparticles have gained popularity as antimicrobial agents as a result of

their broad spectrum of activity and biocompatibility .
Nanoparticulates exhibit higher antibacterial activity as a result of their
polycationic/polyanionic nature with higher surface area and
 charge density,
 greater degree of interaction with the bacterial cell .
It has been observed that the size
of nanoparticulates plays an
important role in their
antibacterial activity, with smaller
particles showing higher
antibacterial activity than the
macroscaledones .
 chitosan
Chitosan (poly (1, 4), b-d glucopyranosamine) is obtained from deacetylation of the second most
abundant polymer, chitin.

 The antibacterial mechanism of chitosan has been

attributed to its polycationic nature that interacts
with the negatively charged surface of bacteria,
altering cell permeability and resulting in the
leakage of intracellular components.

 This biopolymer is also capable of improving the

mechanical properties of the root dentin.
 Two theories have been used to explain the chelating mechanism of
chitosan.

 First, the bridge model states that two or more amino groups of chitosan bind to the same
metal ion.
 Second, the pendant model suggests that one amino group is utilized in the binding, and
the metal ion is linked to the amino group like a pendant.
 Either of the two mechanisms could be responsible for the chelation of calcium ions in
dentin resulting in the depletion of inorganic matter from the smear layer.
 Studies has shown that dentin surfaces coated with chitosan have the potential to
remineralize the demineralized dentin.
 Chitosan with minimal chelation produced cleaner dentinal walls with minimal erosion of
intraradicular dentin and so removed smear layer efficiently.
 0.2% chitosan removes the smear layer with greater efficiency than 17% EDTA at apical third
of the root canals.

Scanning Electron Microscopic Evaluation of Efficacy of 17% Ethylenediaminetetraacetic Acid and Chitosan for Smear Layer
Removal with Ultrasonics: An In vitro Study.Aradhana Babu Kamble, Sathish Abraham, Deepak Dadarao Kakde,1 C
Shashidhar, and Disha Lalit Mehta. Contemp Clin Dent. 2017 Oct-Dec; 8(4): 621–626.
Iron oxide nano particles

 IO-NPs/H2O2 displayed a strong antimicrobial activity against E. faecalis

infection of dentinal tubules, which was significantly superior to CHX and
NaOCl.

 IO-NP activation of H2O2 through its intrinsic ‘peroxidaselike activity’’

catalyzing free radical generation on site, which rapidly kills bacteria.

Novel Endodontic Disinfection Approach Using Catalytic Nanoparticles

Sarah Bukhari, BDS, MS,* Dongyeop Kim, PhD,† Yuan Liu, DDS, PhD,†
Bekir Karabucak, DMD, MS,* and Hyun Koo, DDS, MS, PhD‡JOE — Volume 44, Number 5, May 2018
 The mechanism of action is based on iron oxide–mediated nano catalysis
Wherein H2O2 binds to the iron oxide nanostructure with subsequent
activation of H2O2 by ferric and ferrous ions in situ, generating free radicals
$OH (hydroxyl radical) and O2_/HO_2 (superoxide anion radical/perhydroxyl
radical) pH dependent so that the catalysis is activated at an acidic pH value
(between 4.5 and 5.5).
Zinc oxide nano particles

 Binding of ZnO Np to the bacterial cell might have altered the cell wall
permeability, which leads to leakage of proteins and other components,
and consequently, to cell death.
 5 to 20 nm
 Silver nano particles

Ag Np with size ranges from 5 to 20 nm provided capacity to significantly

decrease the number of viable CFUs present in the biofilm

 Silver nanoparticles bind to the cell membrane leading to Another mode is free radical formation by the silver NPs
altered cell permeability, thus affecting the transport when in contact with bacteria, and these radicals have
system through the plasmatic membrane. the ability to damage the cell membrane and make it
 Hence, silver ions, released due to the oxidation of porous which can ultimately lead to cell death.
nanoparticles after binding to the cell membrane, are able
to penetrate inside the bacteria and react with specific
proteins.
 toxic effects of AgNPs are proportional to the activity of free
Ag + ions released by the NPs.
 Corrosive products and discolorations of dental materials in
contact with silver NPs are also drawbacks.
Effects of a peganum harmala (zygophyllaceae) preparation for root canal
disinfection. Phytother Res. 2018 Apr;32(4):672-677.
Tabrizizadeh m1, kazemipoor m2, hakimian m3, maleksabet m3, kazemipoor m
1
, zandi h4, pourrajab f5, che ct6, cordell ga7,8.

 The aim of this study was to determine the antimicrobial capacity, minimum inhibitory
concentration (MIC), and cytotoxic effects of a Peganum harmala seed extract in
comparison to 5.25% sodium hypochlorite (NaOCl).
 The results show that 5.25% NaOCl and P. harmala seed extract have similar
antimicrobial activity against Enterococcus faecalis; but P. harmala, which shows
reduced cytotoxicity, should be considered for further investigation as a safe,
phytotherapeutic, intracanal irrigant.
Comparative evaluation of smear layer removal by chitosan and
ethylenediaminetetraacetic acid when used as irrigant and its effect on root
dentine: An in vitro atomic force microscopic and energy-dispersive X-ray
analysis. Mathew SP, Pai VS, Usha G, Nadig RR.J Conserv Dent 2017;20:245-50.

That 0.2% and 0.5% chitosan group cause significantly

less alteration in ca/P ratio on root dentine than 17%
EDTA when used as a final irrigant for 1 min.

Chitosan polymer is hydrophilic and adsorbed to canal wall which favors intimate contact. In
addition, it has a large number of free hydroxyl and amino groups that make it cationic in
nature that is responsible for the ionic interaction between the dentin calcium ions and the
chelating agent.
Irrigation protocol in vital teeth
zender et al
Irrigation protocol in necrotic teeth
Philippe Sleiman et al
Irrigation protocol in resorption cases
Philippe Sleiman et al
Irrigation in regenerative endodontics
Irrigation in retreatment cases
5.25% Sodium hypochlorite
rinsed using aqueous EDTA or
citric acid.(1 min 5 to 10 ml
The choice of the final irrigant
2 %Chlorhexidine -final irrigant -Substantivity
Irrigation will be initiated with either sodium hypochlorite (5.25%,
60%C) for its bacterial effect or with chlorohexidine (0.2%) (10
minutes)15 for the elimination of various bacterial types
Same as vital tooth
citric acid 50 percent (10 minutes) in order to eliminate the granulation
tissue and to
AAE recommend the use of lower concentrations of NaOCl in REPs
EDTA was often included in the final irrigation protocol
Chx not used
2%chx
CONCLUSION:

• The success of endodontic treatment depends on the eradication of

microbes from the root-canal system and prevention of reinfection. 

• Irrigation is one of the most important step in root canal treatment

which ultimately dictates the success of root canal
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