Root Canal Irrigation Protocol and Medicaments

root canal x ray

Root Canal Irrigation Protocol and Medicaments

root canal irrigation
Sure it looks pretty BUT is it really clean? The chemicals and techniques we use decide that.

Vista protocol (which I currently use) VPro Canal clean kit

  1. NaOCl
  2. EDTA (Maybe switch to 7% MA and .2%CTR?)
  3. NaOCl
  4. EDTA or 7% MA and .2% CTR or Citric Acid or Alcohol (use cheapest cause just rinsing really)
  5. CHX at least 1 minute 10 minutes is even more potent .2%CTR added even better? Aug 11

CTR=cetrimide and SLS are both surfactants added to any of the solutions to increase the effects

Another reason finish with CHX. “From a clinical point of view, leaving the collagen exposed by the use of a chelating agent before root canal obturation results in other benefits. One of them is avoiding the use of NaOCl as the final irrigating solution because it affects the polymerization of methacrylate resin sealers to radicular dentin (31). On the other hand, the use of EDTA improves the bond strength of an adhesive sealer to the human dentin surface (32), which is not affected (33) or may even improve (34) with the posterior use of 2% CHX.”

Nanobubbles look promising as all solutions can consist of nanobubbles and possibly be more effective. Shawli JOE 2020

PUI = passive ultrasonic irrigation = ESI, Irri-safe, ss #15 k file in ultrasonic for 1 minute 1 mm short length
CUI = continuous ultrasonic irrigation = irrigant continually replenished = VPro StreamClean System 30g = ProUltra PiezoFlow .5mm I=injection mode and A=aspiration mode=off-label
Negative apical pressure NAP= Endovac and VPro Endosafe
*Modified negative apical pressure = Used for canals with isthmus solution in one endovac in other
SAI = Sonic irrigation = Endoactivator or EDDY system
SNI = standard needle irrigation
LAI = laser activated irrigation
PIPS=photon-induced photoacoustic streaming
Gentlewave = hydrodynamic cavitation

My thoughts reading the studies is CUI is best but NAP modified tech is great for teeth with isthmus so mesial canals of lower molars, C shaped lower molars, 2 canal premolars maybe, and mesial buccal root uppers.  Test see if any fluid flow one canal to other, if yes then use modified NAP (solution into one canal and removed from other canal=this flushed out isthmus areas)


Studies on Root Canal Irrigation Techniques

NAP=PUI Freire JOE 2015

PIPS>Endoactivator>SNI Removal DAP and TAP ER:YAG laser Hakan 2014 JOE

LAI>PUI>endoactivator=SNI  Removal of biofilm in cow tooth Ordinola-Zapata 2014 IEJ
LAI>SNI  Using PIPS Removal of biofilm Er:YAG  Olivi 2014 JADA

CUI>PUI=SNI in biofilm removal Layton JOE June 2015

Efficacy  clean lateral canal CUI Injection > CUI aspiration>PUI>Endovac=nothing        AND——->
Safety Endovac>CUIA>PUI>CUII  for extrusion.   If the 30 gauge from VPro can get within ~1 mm apex then CUIA if not then CUII technique.  #20.04 will lock around D3 and #20.06 around D2


Endovac>PUI – Mancini 2013

Ultrasonics the best – control = K-file = gutta-percha < EndoActivator = Plastic Endo < Satelec = EMS. At 1 mm from the apex, the highest score was found for the EMS group compared with the control, K-file, gutta-percha, EndoActivator, and Plastic Endo groups, whereas no difference was found with the Satelec group.  (Measured irrigant penetration)

CUI>>Manual dynamic activation with tapered cone>ANP=Safety Irrigator=MDA non-tapered>syringe June 12

Endovac = standard needle irrigation when looking at antimicrobial effect (not sure this is a good test for what you are trying to accomplish with technique.  Should look at amount material left in tooth probably being more important.  They only used .5% NaOCl in this test)

VPro Endosafe=SNI debridement

CUI > traditional in debris removal.  I should hope so! But no control group so not sure how much more effective really is

Sonic = SNI Vibringe in particular same at removal in MB root apical area (Not sure about this test)

CUI beats PUI May 12 1 minute CUI at 1mm from WL but mostly just in straight canals (sonic irrigation may be better in curved??)

hand/rotary/PUI 1 minute vs. hand/rotary  Isthmuses, 33% versus 83%, 31% versus 86%, 45% versus 91%.  Would love to see this exact experiment with CUI and sonic and manual activation with tapered GP

PUI=Sonic>Endovac>needle July 09 at removing bacteria from plastic

PUI not significant improvement disinfection

PUI irrigation with 12% NaOCl appeared to eliminate bacteria efficiently from surface, shallow and deep layers of root dentin.

PUI beats sonic EndoUltra>Endoactivator>>SNI for removing smear layer Karade 2018

Endovac=SNI=Endoactivator E. faecalis

SNI=PUI=Endoactivator at apex E. faecalis

PUI>SNI entire canal disinfection

Rinsendo NOPE


Studies on Root Canal Irrigation Techniques for Isthmus

UAI > SAI > SNI Linden JOE 2020

NAP>>Manual dynamic >PUI>SNI Neelakantan JOE 2016

Modified negative apical pressure>>NAP=PUI>SNI Thomas 2014 JOE

Isthmus between 2 lower molar mesial canals.


Root canal irrigation and Apical size and taper

35.06 to 40.04 big increase, 40.04 to 40.06 big increase, greater than 40.06 in size = no difference. amount curvature significant effect on amount at solution at apical Endovac only study so not sure would translate to other techniques

Apical preparation of 2 sizes larger than the initial apically binding file with a 4% taper leads to a lower success rate in comparison to larger files. Teh majority of canals need a #25 6% taper or a #30 4% taper. Fatima JOE 2021


Root canal irrigation Solutions for disinfecting

1% Chitosan is effective antimicrobial Shenoi Gen Dent 2016

6% NaOCl + 17% EDTA + 2% CHX best combo against biofilm Wang 2013

NaOCl is used up fast! Moorer 1982

CHX beats laser

Dextranase and DNase I both help CHX by breaking up biofilm

CHX wins again

BAK disrupts cell adhesion Could be anti-biofilm June 12 in Bisco etch maybe use TE with that for bonding

Cetrimide .1% CTR is slightly helpful to CHX and NAOCl 

.2% CTR added to 7%MA, 17%EDTA, or 10% LA June 12all have equal in reduction bacterial growth and better than any of them without CTR

NaOCl needs to follow EDTA April 83 oldie but goodie

1% NaOCl beats ozone April 12

triantibiotic paste>CHX>CaOH 

Chlor-XTRA that reduces surface tension is NOT better De-Deus 2013 Clarkson 2012 Jungbluth 2012

Root canal irrigation Solutions for de-mineralizing

Tetraclean beat EDTA – Tetraclean is citric acid, tetracycline, cetrimide, and polypropylene glycol (a detergent) similar to MTAD which is citric acid, tetracycline, and Tween 80=propylene glycol and cetrimide??pg 534 (a detergent)  They said significant

7%MA with .2%CTR appears better than EDTA in many ways, smear layer, less toxic, more anitmicrobial, no effects with CHX Oct 12. may be time to switch

7% MA effects NaOCl but not CHX, EDTA does form precipitate with CHX Oct 11

Why 7% was found to be used for MA

EDTA stops NaOCl but NaOCl does not stop EDTA or CA   Good article lots of interaction studies Rossi 2012 JOE April

Root canal obturation technique studies

CPoint is a nylon core cone with polymer exterior that expands.

Using calcium silicate based sealer.  CPoint=warm vertical=single cone in terms of sealer penetration.  Jeong 2017 JOE

Continous wave = singel cone in terms voids JOE Iglecias 2017

Root canal medicament interactions 1

CHX and NaOCl make something (debate on exactly what) but not PCA Orhan 2016 JOE
EDTA and CHX make salt
CHX OK with CA
EDTA and NaOCl makes NaOCl useless

Purity of irrigation solutions

27% of NaOCl used in dental offices is less than what the dentist thinks it is.  NaOCl should be replaced every 5 months.  Store bought bleach were less reliable (probably because in bigger bottle thus has more time to sit on shelf and degrade).  Diluted samples were less reliable (adding in the human factor of mistakes possibly being made).  van der Waal Dec 2014 JOE


Ca(OH)2 removal is another blog.