Root Canal Irrigation Protocol and Medicaments
Root Canal Irrigation Protocol and Medicaments
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
- NaOCl
- EDTA (Maybe switch to 7% MA and .2%CTR?)
- NaOCl
- EDTA or 7% MA and .2% CTR or Citric Acid or Alcohol (use cheapest cause just rinsing really)
- 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)
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
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
Dextranase and DNase I both help CHX by breaking up biofilm
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
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.
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