Over the past few weeks we have seen an increased number of calls from dental teams concerned about which solutions should be used for the irrigation of root canals.
There are 4 main steps to success with root canal treatments and new technology is helping with each of them.
CT scans, digital x-rays, loupes and microscopes all make this step much easier than before.
Modern heated treated alloys mean that our files either rotary or reciprocation shape canals more predictably and quicker than ever.
Bioceramic sealers have made achieving a 3-dimensional seal very simple.
These hi-tech solutions can be relatively expensive, the easiest, arguably most important and most overlooked area of root canal success is cheap and low tech - Irrigation.
When to irrigate?
You should start irrigating the canal the moment you open the pulp chamber.
This gets rid of debris that can block the fine, unprepared canals and will improve your ability to locate canal orifices and starts the disinfection process.
Then, you simply can’t irrigate enough. At every opportunity flush out the canal system. Make sure that your hand files and especially rotary files are working in a pulp chamber and canals filled with irrigant.
Sodium hypochlorite (aka Bleach or NaOCl) is widely accepted as the gold standard endodontic
Typically a 3% or 5% solution is recommended. The key though is turnover - keep refreshing the fluid
as much as you can.
Bleach is available from many sources such as supermarkets however its concentration varies from supplier to supplier.
Using hypochlorite is not without risks and bleach accidents are very common with claims ranging from damage to clothing through to chemical burns and tissue damage caused by bleach escaping into tissue surrounding teeth.
The DDU Journal have highlighted a very good questioned raised by their members with concerns to the Dento-Legal implication of using domestic bleach rather than medical quality sodium hypochlorite and stated
"We are not aware of any national guidance on this or on the best concentration of sodium hypochlorite to use for irrigation. However, from a practical viewpoint, its worth considering the potential difficulties of justifying the use of household bleach bought from a supermarket to a non- dentist, such as a judge or a lay member of a GDC fitness-to-practise panel, especially if it has caused harm to the patient."
The use of bleach in Endodontics click here >
Consequently practices using Sodium hypochlorite would be sensible to consider using a product which is licensed for use as an endodontic irrigant.
Examples include products such as Parcan, CanalPro and Chlor Xtra.
These products come with the appropriate COSHH sheets and are supplied by Dental wholesalers which gives practices a level of reassurance should an accident occur.
Should you have any issues that result in a patient complaint, it’s much easier to defend the use of a licensed medicinal product than a bottle of 49p household detergent.
The BDJ has published a very useful guide to the potential complications and management with the use of sodium hypochlorite in endodontics,to read more click here >
Other Commonly Used Irrigants
Saliva: (if not using rubber dam) Not recommended
Local anaesthetic: Expensive and ineffective
Chlorhexidine: Doesn’t break down pulp or smear layer and is also relatively expensive
Milton: At 2% this is already very dilute so definitely don’t dilute it further. At this concentration, the contact time to achieve disinfection is too long for it to be effective as a root canal irrigant.
Saline: Possibly sensible if there is a wide open apex or a perforation but otherwise hopeless.
When using any solution for irrigation, the use of Rubber Dam is an absolute must and should be applied at all times to reduce the risk of solutions escaping into the surrounding tissue or worse the ingestion by the patient of a hand file or reamer.
Use dedicated endodontic irrigation needles such as the monoject needles.
The final step is to use EDTA - this comes in 2 forms:
Gel - which is great for lubricating instruments but not irrigating
Liquid - this is usually a 17.5% solution such as Smear Clear and we use it after all the shaping is done to “etch” the root canal, so removing any smear layer.
Give the canals a 30 second rinse with EDTA and leave it in the canal while you take an X-ray to check the position of the GP points.
Then give the canal a final rinse with hypochlorite.
The search for the perfect irrigant, i.e. as effective as bleach but far safer to use has led to the development of an interesting product called OraWize.
This is based on Hypochlorous acid, which is proven to be highly effective against all organisms found in root canals but also completely harmless to the surrounding tissue.
It is on the market and available from dental suppliers; it is also going through clinical trials at a leading dental school.
There are several ways of enhancing the activity of bleach inside the root canal. Passive agitation with a GP point works well, ultrasonic tips, endosonic tips, lasers and sonic disruption devices are all available - these will be covered in the “Root Canal Irrigation” CPD course coming soon.
Key points - effective irrigation is the key to successful Endodontics - remember the old adage - its not what you put in but what you take out of the canal that counts.
Isopharm will be introducing a “Root Canal Irrigation” CPD course in due course which will include a more detailed look into Root Canal Irrigation and how simple techniques can enhance the procedure.