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Journal List J Conserv Dent v.13(4); Oct-Dec 2010 PMC3010032
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J Conserv Dent. 2010 Oct-Dec; 13(4): 256264. doi: 10.4103/0972-0707.73378 PMCID: PMC3010032
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Root canal irrigants

Deivanayagam Kandaswamy and Nagendrababu Venkateshbabu
Author information Article notes Copyright and License information This article has been cited by other articles in PMC.
Irrigation in endodontic treatment. [Alpha Omegan. 2011] Comparison of the antimicrobial efficacy of 1.3% NaOCl/BioPure MTAD to [J Endod. 5.25% 2007] NaOCl/15% EDTA for root canal irrigation. Irrigants for non-surgical root canal treatment [Cochrane in mature Database permanent Syst teeth. Rev. 2012] Go to: The properties and applications of chlorhexidine in endodontics. [Int Endod J. 2009] Application of biologically-oriented dentin bonding principles to the use [Am ofJendodontic Dent. 2005] irrigants.
Abstract
Successful root canal therapy relies on the combination of proper instrumentation, irrigation, and obturation of the root canal. Of these three essential steps of root canal therapy, irrigation of the root canal is the most important determinant in the healing of the periapical tissues. The primary endodontic treatment goal must
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thus be to optimize root canal disinfection and to prevent reinfection. In this review of the literature, various irrigants and the interactions between irrigants are discussed. We performed a Medline search for English-language papers published untill July 2010. The keywords used were root canal irrigants and endodontic irrigants. The reference lists of each article were manually checked for additional articles of relevance. Keywords: Root canal irrigants, endodotic irrigants, NaOCl, EDTA, MTAD, CHX, E faecalis
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The effects of various irrigating solutions on intra-radicular [Journal dentinal of Pharmacy surface: An & Bioallie...] SEM analysis
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INTRODUCTION
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Bacteria have long been recognized as the primary etiologic factors in the development of pulp and periapical lesions.[13] Successful root canal therapy depends on thorough chemomechanical debridement of pulpal tissue, dentin debris, and infective microorganisms. Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue, and disinfecting the root canal system. Chemical debridement is especially needed for teeth with complex internal anatomy such as fins or other irregularities that might be missed by instrumentation.[4] For this review article we performed a Medline search for all English-language articles published till July 2010. We used the keywords root canal irrigants and endodontic irrigants.
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Root canal irrigants

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IDEAL REQUIREMENTS OF ROOT CANAL IRRIGANTS[5]

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IRRIGANTS[5]
1. Broad antimicrobial spectrum 2. High efficacy against anaerobic and facultative microorganisms organized in biofilms 3. Ability to dissolve necrotic pulp tissue remnants 4. Ability to inactivate endotoxin 5. Ability to prevent the formation of a smear layer during instrumentation or to dissolve the latter once it has formed. 6. Systemically nontoxic when they come in contact with vital tissues, noncaustic to periodontal tissues, and with little potential to cause an anaphylactic reaction.
CLASSIFICATION
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SODIUM HYPOCHLORITE
History
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Sodium Hypochlorite (NaOCl) has an extensive history in medicine and dentistry and continues to be popular even today. During World War I, the chemist Henry Drysdale Dakin and the surgeon Alexis Carrel extended the use of buffered 0.5% NaOCl solution to the irrigation of infected wounds.[6]
Mechanism of action
ON THE USE OF CERTAIN ANTISEPTIC SUBSTANCES IN THE TREATMENT [Br Med J. 1915] OF INFECTED WOUNDS.
Pcora et al.[7] reported that NaOCl exhibits a dynamic balance as is shown by the reaction:
NaOCl + H2O NaOH + HOCl Na+ + OH + H+ + OCl

NaOCl + H2 O NaOH + HOCl Na+ + OH- + H+ + OClThe chemical reactions between organic tissue[78] and NaOCl are shown in Schemes 13: NaOCl acts as an organic and fat solvent, degrading fatty acids and transforming them into fatty acid salts (soap) and glycerol (alcohol), which reduces the surface tension of the solution [ Scheme 1].[9]
Solvent action of sodium hypochlorite on bovine pulp and physico-chemical [Braz Dent J. 2001] properties of resulting liquid. Mechanism of action of sodium hypochlorite. [Braz Dent J. 2002]
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Scheme 1 Saponification reaction NaOCl neutralizes amino acids forming water and salt [Scheme 2]. With the exit of hydroxyl ions, there is a reduction of pH. Scheme 2 Amino acid neutralization reaction When hypochlorous acid, a substance present in NaOCl solution, comes in contact with organic tissue it acts as a solvent and releases chlorine, which combines with the protein amino group to form chloramines [Scheme 3]. Hypochlorous acid (HOCl-) and hypochlorite ions (OCl-) lead to amino acid degradation and hydrolysis.[9] The chloramination reaction between chlorine and the amino group (NH) forms chloramines that interfere in cell metabolism. Chlorine (a strong oxidant) has an antimicrobial action, inhibiting bacterial enzymes and leading to an irreversible oxidation of SH groups (sulphydryl group) of essential bacterial enzymes.[9] Scheme 3 Chloramination reaction Thus, the saponification, amino acid neutralization, and chloramination reactions that occur in the presence of
Mechanism of action of sodium hypochlorite. [Braz Dent J. 2002]
Mechanism of action of sodium hypochlorite. [Braz Dent J. 2002]
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microorganisms and organic tissue lead to the antimicrobial effect and tissue dissolution process.[9]
Antimicrobial property Concentration and time
hypochlorite.
[Braz Dent J. 2002]
The most effective irrigation regimen is reported to be 5.25% at 40 min;[10] irrigation with 1.3% and 2.5% NaOCl for this same time interval is ineffective in removing E faecalis from infected dentin cylinders.[11] NaOCl was moderately effective against bacteria but less effective against endotoxins in root canal infection.[12]
Effect on biofilm[13]
Chemomechanical reduction of the bacterial population in the root [J Endod. canal after 2000] instrumentation and irrigation with 1%, Minimum contact time and concentration of sodium hypochlorite required [J Endod. to 2010] eliminate Enterococcus faecalis.
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1. Complete dissolution of cells with absence of visual evidence 2. Bacterial cells are disrupted and separated from the biofilm and are nonviable 3. Bacterial cells remain adherent within the biofilm but are nonviable 4. Bacterial cells are disrupted and separated from the biofilm but are viable 5. Bacterial cells remain adherent within the biofilm and are still viable.[14]
Increasing the efficacy of NaOCl
1. Altering the pH: a. The antibacterial properties and tissue-
dissolving properties of 5.25% NaOCl decrease when it is diluted.[1416] When NaOCl is added to water, the following
The effect of dilution and organic matter on the anti-bacterial property of [J 5.25% Endod. 1981] sodium hypochlorite.
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reaction takes place:
NaOCl + H2O NaOH + HOCl(hypocholorousacid)
The effects of temperature, concentration, and tissue type on the solvent [J Endod. ability 1981] of sodium hypochlorite.
(1)
In aqueous solution, hypochlorous acid partially dissociates into the anion hypochlorite (OCl-):
HOCl H+OCl
(2)
The available chlorine is the sum of the HOCl and OClconcentrations in the solution.[17] Available chlorine might be defined as a measurement of oxidizing capacity and is expressed in terms of the amount of elemental chlorine. HOCl is considered to be a stronger oxidant than the hypochlorite ion. The HOCl molecule is responsible for the strong chlorinating and oxidizing action on tissue and microorganisms. HOCl dissociation [Equation 2] depends on pH, with the clinical equilibrium between HOCl and OCl- being maintained as HOCl is consumed through its germicidal function.[18] Baker[19] gave the relationship between HOCl, OCl-, and pH. At pH 10, basically all chlorine is in the OCl- form; the reverse occurs at a pH of 4.5, when all chlorine is in the form of HOCl. The disinfecting properties decrease with higher pH, paralleling the concentration of dissociated HOCl. Bloomfield and Miles[17] confirmed that hypochlorites at a lower pH possess greater antimicrobial activity. Andrews and Orton[19] reported
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that HOCl was responsible for the destruction of microorganisms. Morris[20] found that OCl- ion possesses approximately 1/80th of the germicidal potency of HOCl in killing Escherechia coli. Reactive chlorine in aqueous solution at body temperature can take two forms: hypochlorite (OCl-) or hypochlorous acid (HOCl). The concentration of these can be expressed as available chlorine by determining the electrochemical equivalent amount of elemental chlorine,[21] according to the following equations:
Cl2 + 2e = 2Cl OCl- + 2e + 2H+ = Cl + H2O
(1)
(2)
Therefore, 1 mol of hypochlorite contains 1 mol of available chlorine. The state of available chlorine is dependant on the pH of the solution. Above a pH of 7.6, the predominant form is hypochlorite and below this value it is hypochlorous acid.[22] Both forms are extremely reactive oxidizing agents. Pure hypochlorite solutions, as are used in endodontics, have a pH of 12,[23] and thus the entire available chlorine is in the form of OCl-. However, at identical levels of available chlorine, HOCl is more bactericidal than hypochlorite.[24]
2. Temperature A rise in temperature by 25C increased NaOCl
Some factors affecting the concentration of available chlorine in commercial [Int Endod J. 2001] sources of sodium hypochlorite. The antibacterial properties of sodium dichloroisocyanurate [J and Applsodium Bacteriol. 1979] hypochlorite formulations.
efficacy by a factor of 100 (25). The capacity of a 1% NaOCl at

Final rinse optimization: influence of

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45C to dissolve human dental pulps was found to be equal to that of a 5.25% solution at 20C.[26]
3. Ultrasonic The use of ultrasonic agitation increased the
different agitation protocols. [J Endod. 2010]
effectiveness of 5% NaOCl in the apical third of the canal wall.[26] Passive ultrasonic irrigation with a nickel-titanium tip produced superior tissue-dissolving effects as compared to sonic irrigant activation.[27]
Influence on mechanical properties
Final rinse optimization: influence of different agitation protocols. [J Endod. 2010] Acoustic hypochlorite activation in simulated curved canals. [J Endod. 2009]
NaOCl is an efficient organic solvent that causes dentin degeneration because of the dissolution of collagen by the breakdown of the bonds between carbon atoms and disorganization of the proteic primary structure.[28] The reduction of the bond strength seen between adhesive systems and dentin walls may be because of the removal of collagen fibrils from the dentin surface by NaOCl, impeding the formation of a consistent hybrid layer.[29]
Influence of NaOCl on NiTi
Effect of NaClO treatment on bonding to root canal dentin using [Dent a new Mater evaluation J. 2001] method. Bond strengths to endodontically-treated teeth. [Am J Dent. 1999]
Busslinger and Barbakow[30] evaluated corrosion of endodontic files caused by NaOCl solutions of different concentrations from 0.5% to 5.5%. These authors concluded that the quantities of ions released by the corrosion process into the NaOCl solutions were insignificant. Consequently, no significant corrosion of NiTi files in these solutions was detected. Fabiola et al.[31] suggests that exposure to 5.25% NaOCl solution affects neither resistance to flexural fatigue nor torsional resistance of NiTi K3 endodontic files.
Effects of sodium hypochlorite on nickeltitanium Lightspeed instruments. [Int Endod J. 1998] Influence of sodium hypochlorite on mechanical properties of K3 [J nickelEndod. 2007] titanium rotary instruments.
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Influence of NaOCl on bond strength
NaOCl irrigation leads to decreased bond strength between dentin and resin cements and may require a reversal agent because of its ability to affect the polymerization of the resin sealer.[32,33] Agents such as ascorbic acid or sodium ascorbate have been shown to completely reverse this reduction in bond strength.[34]
Interaction of NaOCl and chlorhexidine
Effects of sodium hypochlorite and RCprep on bond strengths of resin [J Endod. cement 2001] to endodontic surfaces. Effects of NaOCl on bond strengths of resin cements to root canal [Jdentin. Endod. 2003]
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Kuruvilla et al.[35] suggested that the antimicrobial effect of 2.5% NaOCl and 0.2% chlorhexidine (CHX) used in combination was greater than that of either agent used separately. The reaction between NaOCl and CHX produces a carcinogenic product, parachloroanaline (PCA), the potential leakage of which into the surrounding tissues is a concern. The precipitate is an insoluble neutral salt formed by the acid-base reaction between NaOCl and CHX. PCA is the main product of the interaction of NaOCl and CHX, and has the molecular formula NaC6 H4 Cl.[36] When mixed with NaOCl, CHX molecules become hydrolyzed into smaller fragments, each forming a byproduct. The first bonds to be broken in this reaction are those between carbon and nitrogen because of the low-bond dissociation energy between these two atoms. The presence of PCA was confirmed by the Beilstein test for the presence of chlorine and the HCl solubility test for the presence of aniline. Leaching of PCA from the insoluble precipitate formed is of concern because it has been shown to be cytotoxic in rats[37] and possibly carcinogenic in humans.[3840] This reaction coats the
Antimicrobial activity of 2.5% sodium hypochlorite and 0.2% chlorhexidine [J Endod. 1998] gluconate separately and combined, as Interaction between sodium hypochlorite and chlorhexidine gluconate. [J Endod. 2007] Carcinogenicity of p-chloroaniline in rats and mice. [Food Chem Toxicol. 1991] Evaluation and prevention of the precipitate formed on interaction [J Endod. between 2010] sodium hypochlorite and chlorhexidine. Evaluation of the interaction between sodium hypochlorite and chlorhexidine [J Endod. 2008] gluconate and its effect on root dentin.
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canal surface and significantly occludes the dentinal tubules and affects the seal of the root canal.[41]
EDTA
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EDTA reacts with the calcium ions in dentine and forms soluble calcium chelates. It has been reported that EDTA decalcified dentin to a depth of 2030 m in 5 min.[42]
Time duration for smear layer removal
A continuous rinse with 5 ml of 17% EDTA, as a final rinse for 3 min efficiently removes the smear layer from root canal walls.[43] According to Saito et al. greater smear layer removal was found in the 1-min EDTA irrigation group than the 30-sec or 15-sec groups.[44,45]
Effect on tooth surface strain
Influence of final rinse technique on ability of ethylenediaminetetraacetic [J Endod. acid of 2010] removing smear layer. Effect of shortened irrigation times with 17% ethylene diamine tetra-acetic [J Endod. acid 2008] on smear layer removal after rotary canal
Irrigation with 5% NaOCl alone or alternated with 17% EDTA (used in 30-min cycles) significantly increased tooth surface strain. The alternated regimen showed significantly greater changes in tooth surface strain than NaOCl alone. Irrigation with 3% NaOCl and 17% EDTA individually or in combination did not significantly alter the tooth surface strain.[46]
EDTA with ultrasonics
The effect of sodium hypochlorite and ethylenediaminetetraacetic [Int Endod acid irrigation, J. 2010] individually and in alternation, on tooth
A 1-min application of 17% EDTA combined with ultrasonics is efficient for smear layer and debris removal in the apical region of
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the root canal.[47] EDTA performed significantly better than NaCl and NaOCl in smear layer removal and dentinal tubule opening.[48]
Chlorhexidine
The effect of EDTA with and without ultrasonics on removal of the [J Endod. smear layer. 2009] Effect of different irrigation on smear layer removal after post space preparation. [J Endod. 2009]
Chlorhexidine digluconate is widely used in disinfection because of its excellent antimicrobial activity. However, it completely lacks tissue dissolving capability.[49]
Structure and mechanism of action
Review The properties and applications of chlorhexidine in endodontics. [Int Endod J. 2009]
CHX is a synthetic cationic bis-guanide that consists of two symmetric 4-chlorophenyl rings and two biguanide groups connected by central hexam-ethylene chains.[50] CHX is a positively charged hydrophobic and lipophilic molecule that interacts with phospholipids and lipopolysaccharides on the cell membrane of bacteria and enters the cell through some type of active or passive transport mechanism.[51] Its efficacy is because of the interaction of the positive charge of the molecule with the negatively charged phosphate groups on microbial cell walls,[52,53] which alters the cells osmotic equilibrium. This increases the permeability of the cell wall, allowing the CHX molecule to penetrate into the bacteria.[49] Damage to this delicate membrane is followed by leakage of intracellular constituents, particularly phosphate entities such as adenosine triphosphate and nucleic acids. As a consequence, the cytoplasm becomes congealed, with resultant reduction in leakage; thus, there is a biphasic effect on membrane permeability. CHX antimicrobial activity is pH
Review Chlorhexidine. An adjunct to periodontal therapy. [J Periodontol. 1986] Review The use of calcium hydroxide, antibiotics and biocides[Aust as antimicrobial Dent J. 2007] medicaments in endodontics. Effectiveness of 2% chlorhexidine gel and calcium hydroxide against [Int Enterococcus Endod J. 2003] faecalis in bovine root dentine in vitro. Evaluation of time required for recontamination of coronally [Int Endod sealed J. 2003] canals medicated with calcium hydroxide Review The properties and applications of chlorhexidine in endodontics. [Int Endod J. 2009] Reduction in the cultivable bacterial populations in infected root[J canals Endod. by2007] a chlorhexidine-based antimicrobial
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on membrane permeability. CHX antimicrobial activity is pH dependant, with the optimal range being 5.50.7 [Figure 1].[54] Figure 1 Mechanism of action of CHX.
Antibacterial activity
Basson and Tait[55] compared the ex vivo effectiveness of calcium hydroxide, iodine potassium iodide (IKI), and CHX solution in disinfecting root canal systems that were infected with Effectiveness of three root canal medicaments to eliminate Actinomyces [SADJ. 2001] Actinomyces israelii. The root canals were exposed to either IKI, israelii from infected dentinal tubules in Comparison of antibacterial and toxic calcium hydroxide, or 2% CHX for periods of 3, 7, and 60 days. effects of various root canal [Int Endod irrigants. J. 2003] CHX was the only disinfectant that was able to eliminate A israelii. In vitro antimicrobial activity of several Oncag et al.[56] evaluated the antibacterial properties against concentrations of sodium [Int hypochlorite Endod J. 2001] and Enterococcus faecalis of 5.25% NaOCl, 2% CHX, and 0.2% CHX chlorhexidine gluconate in the elimination In vitro evaluation of the antimicrobial plus 0.2% cetrimide after 5 min and 48 h. The 2% CHX and [Oral Surg Oral activity Med Oral of chlorhexidine Pathol Oral Radiol and sodium Endod. 2004] Cetrexidin were significantly more effective against E faecalis. hypochlorite. Two studies[57,58] have investigated the antimicrobial activity against endodontic pathogens of three concentrations (0.2%, 1%, and 2%) of two forms of CHX (gel and liquid) and compared them with five concentrations of NaOCl (0.5%, 1%, 2.5%, 4%, and 5.25%). Both the 2% gel and 2% liquid formulations of CHX eliminated Staphylococcus aureus and Candida albicans within 15 sec, whereas the gel formulation killed E faecalis within 1 min. All of the tested irrigants eliminated Porphyromonas endodontalis, Porphyromonas gingivalis, and Prevotella intermedia within 15
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sec.[57,58]
Effect of CHX on dentin
CHX has the ability to bind anionic molecules such as phosphate present in the structure of hydroxyapatite. Phosphate exists in calcium carbonate complexes in dentin. CHX can bind phosphate, which leads to release of small amounts of calcium from the root canal dentin.[60]
Interaction of CHX and EDTA
Interaction between chlorhexidine digluconate and EDTA. [J Endod. 2008]
When CHX and EDTA interact, a precipitate is formed that is over 90% CHX and EDTA, with less than 1% of the potential decomposition product, p-chloroaniline. The high recovery indicates that CHX is not degraded by EDTA under normal conditions. The precipitate is most likely a salt formed by electrostatic neutralization of cationic CHX by anionic EDTA. The suspected net ionic equation is:
The clinical significance of this precipitate is largely unknown.[60]

CHX and bioflim
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Spratt et al. have evaluated the effectiveness of 2.25% NaOCl, 0.2% CHX, 10% povidone iodine against monoculture biofilms of P intermedia, P miros, S intermedius, F nucleatum , and E faecalis.
An in vitro evaluation of the antimicrobial efficacy of irrigants on biofilms [Int Endod of root J.pdfcrowd.com 2001]
They reported that NaOCl was the most effective antimicrobial agent, followed by the iodine solution.[61] Clegg et al. evaluated the ex vivo effectiveness against apical dentine biofilms of three concentrations of NaOCl (6%, 3%, and 1%), 2% CHX, and Mixture of Tetracycline acid and detergents (MTAD). They reported that the 6% NaOCl and 3% NaOCl were capable of disrupting and removing the biofilm, the 1% NaOCl and the MTAD were capable of disrupting the biofilm but did not eliminate the bacteria, and the 2% CHX was not capable of disrupting the biofilm.[62]
Substantivity
efficacy of irrigants on biofilms [Int Endod of root J. 2001] canal isolates. The effect of exposure to irrigant solutions on apical dentin biofilms in [J vitro. Endod. 2006]
White et al. evaluated the antimicrobial substantivity of a 2% CHX solution as an endodontic irrigant and reported that the substantivity lasted 72 h.[63] Khademi et al.[64] found that 5-min Residual antimicrobial activity after canal irrigation with chlorhexidine. [J Endod. 1997] application of 2% CHX solution induced substantivity for up to 4 Evaluation of the antibacterial substantivity weeks. Rosenthal et al.[65] evaluated the substantivity of 2% CHX of several intra-canal agents. [Aust Endod J. 2006] solution within the root canal system after 10 min of application Chlorhexidine substantivity in root canal and they reported that the CHX was retained in the root canal [Oral Surg Oral dentin. Med Oral Pathol Oral Radiol Endod. 2004] dentine in antimicrobially effective amounts for up to 12 weeks. Review The properties and applications of Antimicrobial substantivity depends on the number of CHX chlorhexidine in endodontics. [Int Endod J. 2009] molecules available to interact with the dentine.[49]
CHX and dentine bonding (anticollagenolytic activity)
Human dentin contains at least collagenase (MMP-8), gelatinases MMP-2 and MMP-9, and enamelysin MMP-20.[66,67] Dentine collagenolytic[68] and gelatinolytic activities[68] can be suppressed by protease inhibitors, indicating that MMP inhibition could be
The matrix metalloproteinase gelatinase A in human dentine. [Arch Oral Biol. 2000]
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by protease inhibitors, indicating that MMP inhibition could be beneficial in the preservation of hybrid layers. This was demonstrated in an In vivo study in which the application of CHX, known to have a broad-spectrum MMP-inhibitory effect,[69] significantly improved the integrity of the hybrid layer in a 6month clinical trial.[70] Auto-degradation of collagen matrices can occur in resin-infiltrated dentine but may be prevented by the application of a synthetic protease inhibitor such as CHX.[71] On the whole, because of its broad-spectrum MMP-inhibitory effect, CHX can significantly improve the resindentine bond stability.
Cytotoxicity of CHX
Matrix metalloproteinase-8 (MMP-8) is the major collagenase in [Arch human Oral dentin. Biol. 2007] Collagen degradation by host-derived enzymes during aging. [J Dent Res. 2004] Inhibition of the activities of matrix metalloproteinases [Clin Diagn 2, 8, Lab and Immunol. 9 by 1999] chlorhexidine. Chlorhexidine arrests subclinical degradation of dentin hybrid [J Dent layers Res. in 2005] vivo. In vivo preservation of the hybrid layer by chlorhexidine. [J Dent Res. 2007]
Cytotoxic effects of CHX on canine embryonic fibroblast and Staphylococcus aureus showed that bactericidal concentrations were lethal to canine embryonic fibroblasts while non-cytotoxic Chlorhexidine diacetate and povidoneiodine cytotoxicity to canine [Vet embryonic Surg. 1988] concentrations allowed survival of bacteria.[72] Ribeiro et al.[73] fibroblasts and Staphylococcus aureus. Genotoxicity of antimicrobial endodontic evaluated the genotoxicity (potential damage to DNA) of [Oral Surg Oral compounds Med Oral Pathol by single Oral cell Radiol gelEndod. (comet) 2005] formocresol, paramonochlorophenol, calcium hydroxide, and CHX assay in Chinese hamster ovary (CHO) against Chinese hamster ovary cells. Results showed that none of the mentioned agents contributed to DNA damage. Thus, in the clinically used concentrations, the biocompatibility of CHX is acceptable.
Allergic reactions to CHX
Contant dermatitis is a common adverse reaction.[74] CHX may have a number of rare side effects, such as desquamative gingivitis, discoloration of the teeth and tongue, or dysgeusia.[49]
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MTAD
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Torabinejad et al. developed a irrigant with combined chelating and antibacterial properties.[75] MTAD is a mixture of 3% doxycycline, 4.25% citric acid, and detergent (Tween-80).[75,76]
Antibacterial activity and smear layer removal
A new solution for the removal of the smear layer. [J Endod. 2003]
MTAD is composed of three constituents that are expected to act synergistically against bacteria.[75] The bactericidal effect of MTAD was inferior to 1%-6% NaOCl against E faecalis biofilms.[77] The antibacterial activity of MTAD might also be inhibited by the buffering effect of dentin and the serum albumin present in the root canal.[78] MTAD has been reported to be effective in removing smear layer.[79] In the MTAD preparation, the citric acid may serve to remove the smear layer, allowing doxycycline to enter the dentinal tubules and exert an antibacterial effect.[80] The recently revised protocol for clinical use of MTAD advises an initial irrigation for 20 min with 1.3% NaOCl, followed by a 5-min final rinse with MTAD.[80]
Bond strength
A new solution for the removal of the smear layer. [J Endod. 2003] Review Effects of dentin on the antimicrobial properties of endodontic [J Endod. 2007] medicaments. Comparative evaluation of endodontic irrigants against Enterococcus [J Endod. faecalis 2006] biofilms. Effect of MTAD on Enterococcus faecaliscontaminated root canals of [Jextracted Endod. 2003] human teeth. The effect of various concentrations of sodium hypochlorite on the[J ability Endod. of 2003] MTAD to remove the smear layer.
The use of MTAD as a final rinse with gutta-percha/AH Plus resulted in a significant reduction in bond strength (1.761.67 Mpa) when compared with EDTA.[81] A final rinse with MTAD might have a negative effect on the bonding ability of both resin-based and calcium hydroxidebased sealers due to the precipitate formation.[82]
The effect of different irrigating solutions on bond strength of two root [J canal-filling Endod. 2009] systems. Evaluation of the effect of MTAD in comparison with EDTA [Aust when Endod employed J. 2011] as
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formation.[82]
OTHER IRRIGANTS
Citric acid and EDTA-T
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The use of 10% citric acid as final irrigation has shown good results in smear layer removal.[83] In vitro studies have shown their cytotoxicity, and 10% citric acid has proven to be more biocompatible than 17% EDTA-T and 17% EDTA.[84,85]. Scelza et al evaluated the inflammatory response of 17% EDTA, 17% EDTA-T, and 10% citric acid in bony defect created in rat jaws and they concluded that 10% citric acid showed less aggressive in inflammatory response.[86] The use of 25% citric acid was found to be ineffective in eradication of biofilms of E faecalis after 1, 5, and 10 min of exposure.[87]
Maleic acid
An evaluation of the antimicrobial effectiveness of citric acid as [J Endod. a root canal 1986] irrigant.
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Evaluation of inflammatory response of EDTA, EDTA-T, and citric acid [J Endod. in animal 2010] model. Enterococcus faecalis biofilms eradication by root canal irrigants. [J Endod. 2009]
Maleic acid is a mild organic acid used as an acid conditioner in adhesive dentistry.[89] Ballal et al. reported that final irrigation with 7% maleic acid for 1 min was more efficient than 17% EDTA in the removal of smear layer from the apical third of the root canal system.[89]
Comparison of the efficacy of maleic acid and ethylenediaminetetraacetic [J Endod. acid in 2009] smear layer removal from instrumented
HEBP
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HEBP (1-hydroxyethylidene- 1, 1-bisphosphonate), also known as etidronic acid or etidronate, has been proposed as a potential alternative to EDTA or citric acid because this agent shows no
Chelation in root canal therapy

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alternative to EDTA or citric acid because this agent shows no short-term reactivity with NaOCl.[90] HEBP is nontoxic and has been systematically applied to treat bone diseases.[91] The demineralization kinetics promoted by both 9% HEBP and 18% HEBP were significantly slower than those of 17% EDTA.[92] DeDeus et al. reported that the soft chelating irrigation protocol (18% HEBP) optimized the bonding quality (3.16.1 MPa) of Resilon/Epiphany .[93]
Chlorine dioxide
Chelation in root canal therapy reconsidered. [J Endod. 2005] Review Bisphosphonates: from the laboratory to the clinic and back [Bone. again. 1999] Longitudinal co-site optical microscopy study on the chelating ability [J Endod. of etidronate 2008] and EDTA using a comparative singleSoft chelating irrigation protocol optimizes bonding quality of Resilon/Epiphany [J Endod. root 2008] fillings.
Chlorine dioxide (ClO 2 ) is chemically similar to chlorine or hypochlorite, the familiar household bleach. An In vitro study compared organic tissue dissolution capacity of NaOCl and ClO 2 . It was concluded that ClO 2 and NaOCl are equally efficient for dissolving organic tissue.[94] ClO 2 produces little or no trihalomethanes.[95] A study showed that trihalomethane is an animal carcinogen and a suspected human carcinogen.[96] ClO 2 might therefore be a better dental irrigant than NaOCl.[97]
Silver diamine fluoride
Comparison of organic tissue dissolution capacities of sodium hypochlorite [J Endod. and 2010] chlorine dioxide. Comparison of disinfection byproduct formation from chlorine and [Water alternative Res. 2007] disinfectants. Cancer risk associated with household exposure [J to Toxicol chloroform. Environ Health A. 2002] Influence of chlorine dioxide on cell death and cell cycle of human gingival [J Dent. 2008] fibroblasts.
A 3.8% w/v silver diamine fluoride (Ag[NH3 ]2 F) solution has been developed for intracanal irrigation. This represents a 1:10 dilution of the original 38% Ag(NH3 )2 F solution used for root canal infection.[98] The study on the antibacterial effect of 3.8% Ag(NH3 )2 F against a E faecalis biofilm model concluded that Ag(NH3 )2 F has potential for use as an antimicrobial root canal irrigant or interappointment medicament to reduce bacterial
3 2
Morphological and atomic analytical changes of root [J Clin canal Laser wallMed dentin Surg. after 1999] treatment with thirty-eight percent Antimicrobial efficacy of 3.8% silver diamine fluoride and its effect [J Endod. on root 2010] dentin.
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loads.[99] E faecalis was completely killed by Ag(NH3 )2 F after exposure to these agents for 60 min. The silver deposits were found to occlude tubular orifices after removal of the smear layer.
Tetraclean
Tetraclean is a mixture of doxycycline hyclate (at a lower concentration than in MTAD), an acid, and a detergent.[100,101] It is able to eliminate microorganisms and smear layer in dentinal tubules of infected root canals with a final 5-min rinse. Comparison of antimicrobial efficacy of 5.25% NaOCl, MTAD, and Tetraclean against E faecalis biofilm showed that only 5.25% NaOCl could consistently disgregate and remove the biofilm at every time interval. However, treatment with Tetracleancaused a high degree of biofilm disgregation in every considered time interval (5, 30, and 60 min at 20C) as compared with MTAD.[102]
Triclosan and Gantrez
A new solution for the removal of the smear layer. [J Endod. 2003] Surface tension comparison of four common root canal irrigants [J and Endod. two 2006] new irrigants containing antibiotic. Comparative evaluation of antimicrobial efficacy of sodium hypochlorite, [J Endod. MTAD, 2007] and Tetraclean against Enterococcus
Triclosan is a broad spectrum antimicrobial agent, active against gram-positive and gram-negative bacteria as well as some fungi and viruses.[103,104] Nudera et al.[105] evaluated the minimum inhibitory concentrations (MIC) and minimum bactericidal concentrations (MBC) of triclosan and triclosan with Gantrez against P intermedia, F nucleatum, A naeslundii, P gingivalis, and E faecalis. The MBC of triclosan ranged from 12-94 g/ml. The MBC of triclosan with Gantrez ranged from <0.3-10.4 g/ml. The addition of Gantrez enhanced the bactericidal activity of

Review Antiseptics and disinfectants: activity, action, and [Clin resistance. Microbiol Rev. 1999] Effect of a triclosan/copolymer/fluoride dentifrice on the oral microflora. [Am J Dent. 1990] Antimicrobial effect of triclosan and triclosan with Gantrez on five [J Endod. common 2007] endodontic pathogens.
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triclosan. Both triclosan and triclosan with Gantrez demonstrated bactericidal activity against the five specific endodontic pathogens.
Herbal
Triphala Triphala consists of dried and powdered fruits of three
medicinal plants Terminalia bellerica, Terminalia chebula, and Emblica officinalis.[106] Triphala achieved 100% killing of E faecalis at 6 min. This may be attributed to its formulation, which contains three different medicinal plants in equal proportions; in such formulations, different compounds may help enhance the potency of the active compounds, producing an additive or synergistic effect.[107] Triphala contains fruits that are rich in citric acid, which may aid in removal of the smear layer. The major advantages of using herbal alternatives are easy availability, costeffectiveness, longer shelf life, low toxicity, and lack of microbial resistance.[108]
Green tea Green tea polyphenols, the traditional drink of Japan and
The evaluation of the radioprotective effect of Triphala (an ayurvedic [Phytomedicine. rejuvenating 2002] drug) in the mice exposed to gamma-radiation. Evaluation of antimicrobial efficacy of herbal alternatives (Triphala [J and Endod. green 2010] tea polyphenols), MTAD, and 5% sodium Review Anti-cariogenic properties of tea (Camellia sinensis). [J Med Microbiol. 2001]
China is prepared from the young shoots of the tea plant Camellia sinensis.[109] Green tea polyphenols showed statistically significant antibacterial activity against E faecalis biofilm formed on tooth substrate. It takes 6 min to achieve 100% killing of E faecalis.[107]
Morinda citrifolia Morinda citrifolia (MCJ) has a broad range of
Analgesic and behavioural effects of Morinda citrifolia. [Planta Med. 1990] Evaluation of antimicrobial efficacy of herbal alternatives (Triphala [J and Endod. green 2010] tea polyphenols), MTAD, and 5% sodium
therapeutic effects, including antibacterial, antiviral, antifungal, antitumor, antihelmintic, analgesic, hypotensive, antiinflammatory, and immune-enhancing effects.[110113] MCJ contains the antibacterial compounds L-asperuloside and
Cancer preventive effect of Morinda

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alizarin[113]. Murray et al.[113] proved that, as an intracanal irrigant to remove the smearlayer, the efficacy of 6% MJC was similar to that of 6% NaOCl in conjunction with EDTA. The use of MCJ as an irrigant might be advantageous because it is a biocompatible antioxidant[113] and not likely to cause severe injuries to patients as might occur through NaOCl accidents.
citrifolia (Noni). [Ann N Y Acad Sci. 2001] Evaluation of Morinda citrifolia as an endodontic irrigant. [J Endod. 2008]
CONCLUSION
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During instrumentation canals should be irrigated using copious amounts of the NaOCl solution. Once the shaping procedure is completed, canals can be thoroughly rinsed using aqueous EDTA or citric acid. Generally each canal is rinsed for at least 1 min using 5 to 10 ml of the chelator irrigant. After the smear layer removal procedure, a final rinse with an antiseptic solution appears beneficial. Chlorhexidine appears to be the most promising agent for use as a final irrigant in this situation. It has an affinity for dental hard tissues and, once bound to a surface, it has prolonged antimicrobial activity, a phenomenon called substantivity. After the introduction of MTAD irrigant, newer irrigating regimen followed was initial rinse with 1.3 % NaOCl for 20 min and followed by final rinse with MTAD for 5 min. Future research on irrigants needs to focus on finding a single irrigant that has tissue dissolving capacity, smear layer removal property, and antibacterial efficacy.
Footnotes
Source of Support: Nil
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Conflict of Interest: None declared.
REFERENCES
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NaOCl + H2O NaOH + HOCl Na+ + OH + H+ + OCl

Mechanism of action of sodium hypochlorite. [Braz Dent J. 2002]

Mechanism of action of sodium hypochlorite. [Braz Dent J. 2002]

[Braz Dent J. 2002]

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reaction takes place:

NaOCl + H2O NaOH + HOCl(hypocholorousacid)

Cl2 + 2e = 2Cl OCl- + 2e + 2H+ = Cl + H2O

efficacy by a factor of 100 (25). The capacity of a 1% NaOCl at

Final rinse optimization: influence of

different agitation protocols. [J Endod. 2010]

Influence of NaOCl on bond strength

Interaction between chlorhexidine digluconate and EDTA. [J Endod. 2008]

The clinical significance of this precipitate is largely unknown.[60]

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Chelation in root canal therapy

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Cancer preventive effect of Morinda

Conflict of Interest: None declared.

Endod. 2008;34:6670. [PubMed]

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