Disinfectants, Dentin Surface Modifiers, and Lubricants Studies have demonstrated conclusively that mechanical instrumentation cannot sufficiently

disinfect root canals, regardless of whether stainless steel[80] or NiTi[112] instruments are used (Fig. 9-40). Irrigation solutions are required to eradicate microbiota, and over time, a variety of chemicals have been promoted for this purpose. The ideal irrigant or combination of irrigants kills bacteria, dissolves necrotic tissue, lubricates the canal, removes the smear layer, and does not irritate healthy tissues.[153],[191] Some formaldehyde-containing materials are no longer recommended for clinical use, but many irrigating solutions and varying concentrations of commonly used materials are described in the literature. Some solutions used in the past were sterile saline, alcohol, hydrogen peroxide, NaOCl, and detergents (e.g., quaternary ammonium compounds, chlorhexidine, citric acids, and EDTA).[399] The following section describes current irrigation solutions and gives some recommendations for their clinical use. FIG. 9-40 Remaining potentially infected tissue in fins and isthmus configuration after preparation with rotary instruments. A, Cross section through a mesial root of a mandibular molar, middle to coronal third of the root. Both canals have been shaped; the left one is transported mesially (10). B, Magnified view of rectangle in A. Note the presence of soft tissue in the isthmus area (63). (Courtesy Professor H. Messer.)

Sodium Hypochlorite NaOCl encompasses many desirable properties of a main root canal irrigant and has therefore been described as the most ideal of all available rinsing agents.[268],[481] NaOCl has been in use for almost a century.[111],[446] A 0.5% solution of NaOCl was used effectively during World War I to clean contaminated wounds.[111] In the endodontic field, NaOCl possesses a broad-spectrum antimicrobial activity against endodontic microorganisms and biofilms (Table 9-1), including microbiota difficult to eradicate from root canals, such as Enterococcus, Actinomyces, and Candida organisms.[175,320,338,481]

TABLE 9-1 -- Efficacy of Various Irrigants in Deactivating Microorganisms* NaOCl CHX IPI MTAD Ca(OH)2 1 min of 6% solution reduced biofilm by 7-8 orders of magnitude[4
59]

ENTEROCOC CI

15 min at 0.25% in

7 days of 0.5% dressing resulted in complete killing in dentin blocks up to full depth of 950 m[330]

24 hours for iodine (2%) in potassium iodide (4%) resulted in complete killing in

5 min applicatio n resulted in no growth on infected dentin[373] MTAD as efficient

24 hours to reduce cultured bacteria below detection limit, but inhibited by dentin powder,

NaOCl contaminate d dentin blocks[482] 30 min at 0.5% and 2 min at 5.25% in direct contact with bacteria[322]

CHX 24 hours to reduce cultured bacteria below detection limit[318] and 5 min when in direct contact with bacteria[122]

IPI dentin blocks up to a depth of 700 m[38

4]

MTAD as 5.25% NaOCl in cultures[42

3]

Ca(OH)2 hydroxyapatit e, and serum albumin[318] Showed little effect on Enterococcus faecalis[50] Complete killing in dentin blocks up to full depth of 950 m[385] 7 days of Ca(OH)2 in 0.5% chlorhexidine acetate dressing resulted in complete killing in dentin blocks up to full depth of 950 m[385]

1 hour to reduce bacteria under 0.1% and 24 hours below detection limit; however, loss of activity through dentin powder[31
7]

ACTINOMYC ES ORGANISMS

1 min at 1% solution[37] 10 sec at 0.5% in direct contact with bacteria[322]

No growth directly after rinsing with 2% CHX in patients with necrotic pulps and/or apical granuloma[1

After 60 days, 25% of Actinomyces israelii infected root canal walls and dentinal ND tubules in vitro treated 27] with IKI still showed 3 days for 2% CHX to bacterial growth[41] eliminate Actinomyces israelii from

After 60 days, 50% of Actinomyces israeliiinfected root canal walls and dentinal tubules in vitro treated with calcium hydroxide still showed bacterial growth[41]

NaOCl

CHX all samples of infected dentin[41] 1 hour at 0.12% on root dentin with smear layer[368] 10 sec at 0.5% solution in direct contact with bacteria[322] 5 min at 0.5% solution to kill all yeast cells and 1 hour at 0.05% solution; less effective than IKI and NaOCl[449]

IPI

MTAD

Ca(OH)2

CANDIDA ORGANISMS

1 hour at 1% or 5% solution on root dentin with smear layer[368] 30 sec for both the 0.5% solutions to kill all cells in culture[449] 1 min of 6% solution: no growth[338]

30 sec for both 2% and 4% solution to kill all cells in culture; 0.2% and 0.4% as effective as 0.5% CHX[449] 1 min of 2% solution: no growth[33
8]

Not effective against C. albicans after 5 min exposure[338]

After 1 hour and 24 hours, only a small reduction of CFU observed[449] Not effective against C. albicans after 5 min exposure[338]

Ca(OH)2, Calcium hydroxide; CHX, chlorhexidine acetate; IKI, iodine potassium iodide; MTAD, BioPure MTAD (mixture of tetracycline, acid, and detergent); NaOCl, sodium hypochlorite; ND, not determined.
*

Effects achieved by killing through antimicrobial action.

NaOCl dissolves organic material such as pulp tissue and collagen. If the organic portion of a smear layer is dissolved in NaOCl, and bacteria inside the main root canal, lateral canals, and dentinal tubulesif in direct contact with the irrigantare destroyed, then to a minor degree, endotoxins may be eliminated.[256],[444] During endodontic therapy, NaOCl solutions are used at concentrations ranging from 0.5% to 6%. In infected dentin blocks, a 0.25% solution of NaOCl was sufficient to kill Enterococcus faecalis in 15 minutes; a concentration of 1% NaOCl required 1 hour to kill Candida albicans.[368] In infected extracted teeth, Ruff et al.[338] found that a 1-minute application of 6%

NaOCl and 2% chlorhexidine were equally effective in eliminating microorganisms and statistically significantly superior to MTAD and 17% EDTA in eliminating Candida albicans infections. Lower concentrations (e.g., 0.5% or 1%) dissolve mainly necrotic tissue.[482] Higher concentrations allow better tissue dissolution but dissolve both necrotic and vital tissue, which is not always a desirable effect. In some cases, full-strength NaOCl (6%) may be indicated, but although higher concentrations may increase antibacterial effects in vitro,[477] enhanced clinical effectiveness has not been demonstrated conclusively for concentrations stronger than 1%.[399] Commercially available household bleach (Clorox, The Clorox Company, Oakland, CA) contains 6.15% NaOCl, has an alkaline pH of 11.4, and is hypertonic.[399],[482] Some authors recommend dilution of commercially available NaOCl with 1% bicarbonate instead of water to adjust the pH to a lower level.[111],[399] Others do not see any reduction of the aggressiveness on fresh tissue by buffering NaOCl and recommend diluting solutions of NaOCl with water to obtain less concentrated irrigation solutions.[383],[482] NaOCl only minimally removes dentin debris or smear layers (Fig. 9-41). Therefore, some authors recommend concurrent use of demineralizing agents to rid the root canal surface of a postinstrumentation smear layer and thus enhance cleaning of difficult-to-reach areas, such as dentinal tubules and lateral canals.[81],[283] When using NaOCl over extended periods of time during treatment, it should be mentioned that NaOCl seems to have an undesired side effect on the flexural strength of dentin. One study[252] investigated the influence of irrigants on flexural strength of dentin bars and concluded that a 24-minute exposure time to a 2.5% hypochlorite solution caused a significant drop in flexural strength, while the modulus of elasticity was not altered during this time. Other authors discovered a lowering of both flexural and elastic strength after 2-hour submersion of dentin bars in NaOCl.[11],[164] The loss of calcium ions appears to be both dependent on NaOCl concentration (5% showing the greatest amount of decalcification) and time of exposure.[351] FIG. 9-41 Surface textures of an unprepared root canal at various levels. A, Ground section of a mandibular premolar. Areas viewed by scanning electron microscopy (SEM) are indicated by black lines. B, Canal surface at middle section, showing open dentinal tubules and typical calcospherites (500). C-E, Coronal, middle, and apical areas as compound scanning electron micrographs. Note the numerous open tubules in C-D, whereas fewer tubules are visible in E (200).

Chlorhexidine Chlorhexidine (CHX) is a broad-spectrum antimicrobial agent effective against gram-negative and gram-positive bacteria (see Table 9-1). It has a cationic molecular component that attaches to negatively charged cell membrane areas, causing cell lysis.[26],[156] CHX as a mouth rinse and periodontal irrigant has been used in periodontal therapy, implantology, and cariology for many years to control dental plaque.[130],[232] Its use as an endodontic irrigant[40,96,131,181,454] is based on its substantivity and long-lasting antimicrobial effect, which arises from binding to

hydroxyapatite. However, it has not been shown to have more superior clinical properties than NaOCl. In fact, an in situ disinfection study suggests no additive effect on typical endodontic flora.[259] When compared to CHX as an irrigant, it was found that hypochlorite significantly more often achieved negative cultures than CHX.[333] When used as combination, NaOCl and CHX did not improve the antimicrobial activity of CHX against tested microorganisms.[443] Some researchers found that CHX had significantly better antibacterial effects than Ca(OH)2 when tested on cultures.[230] Combinations of CHX and Ca(OH)2 are available and show antimicrobial activity against obligate anaerobes, the combination in some studies augmenting the antibacterial effect of either medicament on certain species.[315],[385] However, 2% CHX gel alone was more effective than its combination with Ca(OH)2 against several tested microorganisms in other investigations.[155],[248] Medicaments containing 2% CHX have the ability to diffuse through dentin and display antimicrobial action on the outer root surface. The addition of CHX or iodine potassium iodide to an intracanal dressing of Ca(OH)2 in vitro did not affect the alkalinity (and hence the efficacy) of the Ca(OH)2 suspensions.[385] Chlorhexidine (2%) has been advocated as a final rinse irrigant owing to its substantivity, which allows binding to dentin and sustained antimicrobial activity, especially in endodontic retreatment.[480] Iodine Potassium Iodide Iodine potassium iodide (IKI) is a traditional root canal disinfectant and is used in concentrations ranging from 2% to 5%. IKI kills a wide spectrum of microorganisms found in root canals (see Table 9-1) but shows relatively low toxicity in experiments using tissue cultures.[398] Iodine acts as an oxidizing agent by reacting with free sulfhydryl groups of bacterial enzymes, cleaving disulfide bonds. E. faecalis often is associated with therapy-resistant periapical infections (see Chapter 15), and combinations of IKI and CHX may be able to kill Ca(OH)2-resistant bacteria more efficiently. One study[385] evaluated the antibacterial activity of a combination of Ca(OH)2 with IKI or CHX in infected bovine dentin blocks. Although Ca(OH)2 alone was unable to destroy E. faecalis inside dentinal tubules, Ca(OH)2 mixed with either IKI or CHX effectively disinfected dentin. Others[31] demonstrated that IKI was able to eliminate E. faecalis from bovine root dentin when used with a 15-minute contact time. An obvious disadvantage of iodine is a possible allergic reaction in some patients. MTAD BioPure (DENTSPLY Tulsa Dental), also known as MTAD (mixture of tetracycline, acid, and detergent), is an irrigation solution that contains doxycycline, citric acid, and a surface-active detergent (Tween 80).[423] Chemicals and their combinations as root canal irrigants are developed constantly, including solutions based on antibiotics. However, doxycycline and other locally applied antibiotics have been unable to destroy microbiota organized in biofilms. One research group[282] investigated the effect of five antibiotics on a mature biofilm after 8 days of growth on dentin; in their experiment, none of the topically applied substances could eradicate the biofilm. Use of these irrigants is also controversial because of the emergence of increasingly resistant strains of bacteria (e.g., therapy-resistant enterococci), which may be due to overprescription of

antibiotics in general. The increased risk of host sensitization by local antibiotics can be circumvented to some degree by using the antibiotic as a dressing. Because exposure to vital tissues is limited, higher microbicidal concentrations may be used.[269] A number of antibiotics, including erythromycin, chloramphenicol, tetracycline, and vancomycin, have been tested successfully against enterococci. In one study, investigators evaluated microbial susceptibility to different antibiotics in vitro and found that enterococcal isolates were resistant to benzylpenicillin, ampicillin, clindamycin, metronidazole, and tetracycline but sensitive to erythromycin and vancomycin.[110] Another investigation[202] used extracted teeth infected with E. faecalis and compared the efficacy of NaOCl and EDTA versus NaOCl and MTAD. They concluded that although the NaOCl/EDTA combination consistently disinfected the test specimens, almost half of the teeth rinsed with NaOCl/BioPure MTAD remained contaminated.[202] In a recent study,[371] doxycycline was replaced with CHX in one of the test groups of E. faecalisinfected teeth. Whereas no specimens that were cleaned with MTAD or MTAD + CHX showed the presence of residual bacteria, 70% of the samples rinsed with CHX as a substitute for doxycycline demonstrated growth of E. faecalis. The citric acid component in MTAD effectively removed a smear layer.[44,372,421] Under these conditions, BioPure MTAD was more aggressive in eroding dentin than EDTA. In another investigation,[410] however, the addition of NaOCl was necessary to achieve dissolution of organic matter. Ethylenediamine Tetra-Acetic Acid EDTA came into use in endodontics in 1957[283]; chelators such as EDTA create a stable calcium complex with dentin mud, smear layers, or calcific deposits along the canal walls. This may help prevent apical blockage (Fig. 9-42) and aid disinfection by improving access of solutions through removal of the smear layer. FIG. 9-42 Presence of dentin dust as a possible source of microbial irritation. Tooth #18 underwent root canal therapy. The clinician noted an apical blockage but was unable to bypass it. Unfortunately, intense pain persisted and at the patient's request, the tooth was extracted a week later. A, Mesial root of tooth #18; mesial dentin has been removed. B, Magnified view (125) of rectangle in A shows an apical block (gradation of ruler is 0.5 mm).

Neutral EDTA (17% concentration) showed a higher degree of decalcification of dentin surfaces than RC-Prep (a gel-type preparation of EDTA), although its effect was reduced in apical regions.[441] Similar to MTAD, RC-Prep did not erode the surface dentin layer.[421] The effect of chelators in negotiating narrow, tortuous, calcified canals to establish patency depends on both canal width and the amount of active substance available, since the demineralization process continues until all chelators have formed complexes with calcium.[191],[485] Calcium binding results in the release of protons, and EDTA loses its efficiency in an acidic environment. Thus the action of EDTA is thought to be self-limiting.[367] In one

study, demineralization up to a depth of 50 m into dentin was demonstrated for EDTA solutions[191]; however, other reports demonstrated significant erosion after irrigation with EDTA.[421] A comparison of bacterial growth inhibition showed that the antibacterial effects of EDTA were stronger than citric acid and 0.5% NaOCl but weaker than 2.5% NaOCl and 0.2% CHX.[379] EDTA had a significantly better antimicrobial effect than saline solution. It exerts it strongest effect when used synergistically with NaOCl, although no disinfecting effect on colonized dentin could be demonstrated.[181] Recent reports have indicated that several disinfecting agents such as Ca(OH)2, IKI, and CHX are inhibited in the presence of dentin.[169,317,318] Moreover, chemical analyses indicated that chlorine, the active agent in NaOCl, is inactivated by EDTA.[161],[483] In light of these facts, in addition to the unproven effect of lubricants containing EDTA on rotary-instrument torque, use of these solutions probably should be limited to hand instrumentation early in a procedure. Moreover, an EDTA solution preferably is used at the end of a procedure to remove the smear layer but does not prevent future bacterial penetration between root canal fillings and canal walls.[343,470,483] Clean, smear layerfree canal walls, tubulus openings, and entrances into lateral canals and isthmus areas, taken together with sufficient volume of NaOCl, ensures high disinfecting efficacy by enabling NaOCl to penetrate even into deeper dentin layers (Fig. 9-43). FIG. 9-43 Penetration of irrigants into dentinal tubules after root canal preparation with different dentin pretreatments. Left column, Irrigation with tap water and then with blue dye. Right column, Smear layer is removed with 17% EDTA, applied in high volume and with a 30-gauge needle, followed by irrigation with blue dye. Note the comparable diffusion of dye in the apical sections, whereas dye penetrated deeper into the dentin in the two coronal sections.

Calcium Hydroxide Ca(OH)2 via its alkaline pH is generally very effective at eradicating intraradicular bacteria, with the exception of E. faecalis.[133] Increased effectiveness was observed when Ca(OH)2 was mixed with some common irrigating solutions. Although additive effects could not be confirmed, and a reduction in the antimicrobial action of CHX was detected,[176] it appears that Ca(OH)2 mixed with IKI or CHX may be able to kill Ca(OH)2-resistant bacteria[385] (Box 9-4). BOX 9-4 Benefits of Using Irrigants in Root Canal Treatment Removal of particulate debris and wetting of the canal walls Destruction of microorganisms Dissolution of organic debris Opening of dentinal tubules by removal of the smear layer Disinfection and cleaning of areas inaccessible to endodontic instruments

Unfortunately, it is not as effective when used short term and is not recommended as an irrigant but rather as an interappointment dressing.[388] To achieve optimal antimicrobial activity, therefore, it requires prolonged exposure[36] or higher temperatures for use as an endodontic irrigant.[131] Other Irrigants Electrochemically activated water (also known as oxidative potential water) recently was tested as a potential irrigant.[166,250,391] Although this solution is active against bacteria[166] and removes the smear layer,[249] no assessment of its clinical potential is available, and in vitro research indicates that NaOCl is a superior disinfectant.[166] Hydrogen peroxide traditionally has been used as an irrigant in conjunction with NaOCl; however, no additional benefit beyond NaOCl was registered.[181] Some authors have advocated the use of 0.2% or 0.5% CHX in addition to NaOCl,[169],[181] either as an irrigant or mixed with Ca(OH)2 as an interappointment medicament. These combinations can overcome the inhibiting effect of dentin dust on conventional medicaments[169],[318] and can optimize their antimicrobial properties against certain resistant bacteria and yeasts.[449],[451] Recently, one group[233] compared NaOCl with a final 17% EDTA rinse with an equal mixture of 2% NaOCl and 18% etidronic acid during and after instrumentation and a protocol involving 1% NaOCl during preparation and 2.25% peracetic acid after instrumentation. The results indicated that both acids had a similar effect on a smear layer as EDTA but with less demineralization of intratubular dentin. Strong demineralization has been shown to have a negative influence on canal sealability.[115] Lubricants