CLINICAL TIPS

Irrigants in endodontics
Which are the best irrigants in endodontics and how are they used?

Background
In endodontics, the root canal system requires both mechanical and chemical
preparation to achieve the goal of resolving or preventing apical periodontitis.
Endodontic instrumentation alone may not access all pulp space surfaces and
irregularities. Thus, root canal irrigants should possess ideal characteristics, including
broad-spectrum antimicrobial properties, pulp tissue dissolution ability, periradicular
tissue biocompatibility, lubricating action, chelating action to remove smear layer,
and minimal allergic potential.1 Although no substance yet combines all of these
FIGURE 1: Evolution of tissue dissolution observed in pulp after a 40-minute
characteristics, clinicians must choose from the current available irrigation methods exposure to 2.5% sodium hypochlorite.
and materials. This article aims to review the irrigants that are most frequently used
in endodontics and provide clinicians with tips on how to use them appropriately. Table 1: Main advantages and disadvantages of using NaOCl solution
in endodontic treatment.
Sodium hypochlorite Advantages Disadvantages
The literature widely supports the use of sodium hypochlorite (NaOCl) solution as Antimicrobial activity Cytotoxicity
a root canal irrigant, as do the European Society of Endodontology and the Ability to dissolve pulp tissue Delicate storage
American Association of Endodontics. Bleaching action Strong smell
NaOCl is considered the gold standard irrigant mainly due to its antimicrobial and Stains clothes
tissue-dissolving actions (Figure 1), and it can be found in concentrations of 0.5-
6%. The most widely used, for safety reasons, are concentrations ranging from Chlorhexidine
0.5-2.5%. To maximise the effectiveness of NaOCl irrigation, the solution should The literature also supports the use of chlorhexidine (CHX), which is available in 2%
be frequently refreshed and kept in motion by agitation or continuous irrigation. aqueous solution and gel forms. Some of its desirable properties include antimicrobial
The speed of tissue dissolution can be increased with effective agitation and activity and substantivity (residual action). However, unlike NaOCl, CHX does not
refreshment.1 Table 1 summarises the key pros and cons of NaOCl usage. dissolve pulp tissue, and this is one of its main disadvantages. CHX can be used as an
alternative to NaOCl, especially in cases of necrotic teeth with an open apex, or when
Complications and accidents the patient reports an allergy to NaOCl. 2% CHX may also be considered for the final
Despite its great advantages, NaOCl can be cytotoxic, and this can be a concern. rinse after smear layer removal by ethylenediaminetetraacetic acid (EDTA). Care must
NaOCl may extrude beyond the apical foramen, causing reactions ranging from mild also be taken with extrusion accidents, especially when using liquid CHX.2
discomfort to serious tissue damage.
Clinical tip
Clinical tip How to use 2% CHX gel:
To help prevent these complications: n fill the canal with 2% CHX gel;
n use needles with lateral exit, at a depth short of the patency length of the n start instrumentation;
root canal; n flush the canal with inert solution (saline solution or distilled water) to
n control the force exerted on the syringe plunger during irrigation; remove ‘dirty’ CHX gel;
n do not let the needle stick to the root canal walls; and, n refill with ‘fresh’ 2% CHX gel;
n opt for regular replacement of a weaker NaOCl solution (1-2.5%) with n proceed with instrumentation; and,
larger volumes, rather than using a higher concentration. n repeat until instrumentation is finished.

1
Isabella Figueiredo Assis Macedo DDS MSc1 Restorative Dentistry Department,
Larissa Fassarela Marquiore DDS1 School of Dentistry,
Isabella Faria da Cunha Peixoto DDS MSc PhD1 Universidade Federal de Minas Gerais,
Warley Luciano Fonseca Tavares DDS MSc PhD1 Belo Horizonte, MG, Brazil
Ana Cecília Diniz Viana DDS MSc PhD1
Corresponding author: Ana Cecília Diniz Viana
Restorative Dentistry Department, School of Dentistry, Universidade Federal de Minas Gerais (UFMG)
E: [email protected]

2 Journal of the Irish Dental Association | September 2024

 CLINICAL TIPS

Table 2: Main effects of irrigant mixtures and how to prevent by- Clinical tip
product formation. Activation
Combination Reaction product Clinical effect How to prevent Traditional needle and syringe irrigation may fail to reach the full canal length.
by-product
formation Enhance irrigant action with an agitation method, especially as a final step. This
NaOCl + CHX Orange-brown Potential Washing the root is known as dynamic/active irrigation.
precipitate (Figure discolouration and canal with a 5%
2) leaching of sodium thiosulphate
unidentified solution neutralises Manual dynamic activation
chemicals into the NaOCl. n Flood the root canals with irrigant and place a well-fitting gutta percha cone
peri-radicular
tissues. 2-3mm short of the canal length; and,
NaOCl + EDTA Chlorine gas bubbles Low or null effect on Intermediate flushes n perform a repeated ‘in and out’ movement at a rate of around 100 strokes
calcium-chelating with distilled water.
ability of EDTA. per minute, for one minute.5
CHX + EDTA Milky white Unclear Intermediate flushes
precipitate with distilled water.
Sonic irrigation
FIGURE 2: Brown precipitate n Operate a sonic system such as EndoActivator System (Dentsply Sirona,
(parachloroaniline) formation when 2% CHX
USA), positioned 2-3mm within the root canal, at 10,000 cycles per minute
was mixed with 2.5% NaOCl.
for one minute.5

Passive ultrasonic irrigation (Figure 3)

n Set the ultrasonic device to 10% power;
n position a thin insert, like Irrisonic E1 (Helse Technology, Brazil), 2-3mm
short of the canal length or until the curvature;
n activate for three 20-second cycles; and,
n refresh irrigating solution at the start of each cycle.

XP-endo finisher (FKG, Switzerland) (Figure 3)

n Calibrate the instrument to a position 2-3mm short of the canal length;
n cool the file with a coolant spray just before inserting it into the canal to
maintain the straight shape; and,
n activate it with a rotary motion at 800-1,000rpm and 1N·cm of torque, for
one minute.

Conclusion
Irrigation is an important step in endodontic treatment and must not be
neglected. Appropriate chemicals and agitation optimise the effects of the
FIGURE 3: A and C: Xp-endo Finisher (FKG), and ultrasonic tip Irrisonic irrigant, enabling more predictable patient care outcomes to be achieved.
(Helse). B and D: Same instruments inserted into a root canal, 3mm short of
canal length (arrows). Funding
Ethylenediaminetetraacetic acid This article was financed in part by the Fundação de Amparo à Pesquisa do
EDTA (15-17%) is usually used after instrumentation, as a chelating agent to Estado de Minas Gerais – FAPEMIG – #340.
remove the inorganic component of the smear layer produced during root canal
instrumentation, followed by an irrigation with NaOCl to remove the smear References
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Irrigants are typically delivered into the root canal using a disposable syringe and J Endod. 2013;39(4):511-515.
a fine needle (27-30 gauges) capable of reaching 2-3mm short of the canal 5. Yilmaz A, Yalcin TY, Helvacioglu-Yigit D. Effectiveness of various final irrigation tech-
length. Gentle pressure with a flow rate of around 4mL/min ensures effective niques on sealer penetration in curved roots: a confocal laser scanning microscopy
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