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Industry Insights: Simplifying Endodontic Irrigation Dr. Allen Ali Nasseh

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Categories: Endodontics;
Industry Insights: Simplifying Endodontic Irrigation 

A new single-bottle solution from Brasseler could eliminate the need to juggle bottles and syringes

by Dr. Allen Ali Nasseh

It’s been drilled into our heads by most of our mentors that the cleaning component of the endodontic triad of cleaning, shaping and obturation is the most important determinant of clinical success in root canal therapy. However, we tend to spend more time and effort evaluating the latest instrumentation method or finding ways to enhance the final look of our radiographs by incorporating more radio-opaque cements into our clinical armamentarium instead of focusing on improving our irrigation protocol and, by proxy, our outcomes.

To make things worse, when we finally decide to focus on irrigation, we find that we either are facing a complicated irrigation protocol shared by many experts on the field or are told that we need expensive laser-based or sound-based devices to facilitate the irrigation process, forcing us to either increase our fees or face a greater overhead. How can we simplify our irrigation protocol without expensive gadgets and complicated initial and final irrigation protocols?

Before we set out to simplify our irrigation protocol, it would be worthwhile to review the important concepts that apply to effective irrigation, which chemicals are commonly used and the objective for their use. I’ll briefly discuss some of the physical and chemical parameters in irrigation process and irrigation solutions and potential interactions between the reagents commonly used.

Physical parameters and limitations

The root canal anatomy can be intricate, with many curves, fins and anastomoses. And while the coronal pulp chamber and the coronal root have many dentinal tubules that can act as potential sites of microbial penetration, these spaces constitute a very small volume. The root canal has a volume of 20–40 microliters,1 with an average of about 0.025 cubic centimeters (cc), equal to the volume of about half a drop of water. Therefore, each cc of irrigation solution will displace 20–40 root canal volumes. This is important considering the fact that volume is a key component of effective irrigation. However, we don’t know exactly how much volume replacement is enough for effectively cleaning and whether the chemistry of chemicals used can catalyze this event. We do know that heat increases the kinetic energy of the solution and will therefore catalyze the rate of reaction.2,3

Beyond the volume, the delivery of the solutions into the root canal is also important. Positive-pressure irrigation is when the solution is pushed through the syringe with the use of a needle deep in the root canal. Needles with different tip designs distribute the irrigants differently. Closed-ended, side-vented needles are currently the safest needles for use because they reduce the risk of irrigation extrusion from inside the canal. However, while these needles must be placed deep in the canal to be effective, it’s important to use the thinnest needle available and make sure it’s not binding in the canal during irrigation. To help reduce the odds of accidental extrusion, negative-pressure systems were recently developed where the vacuum force is moved to the apex with the aid of a thin needle/cannula and the irrigation solution is deposited coronally in the access opening. This method helps reduce the odds of solution extrusion. The downside of negative pressure, however, is the ergonomics of the system and the chance of the small suction needle getting blocked prematurely
Industry Insights: Simplifying Endodontic Irrigation
Fig. 1:Positive pressure using thick needles does not allow the needle to go deep in the canal. Furthermore, it can lock the needle in the thinner portions of the canal, causing a hypochlorite extrusion.
Industry Insights: Simplifying Endodontic Irrigation
Fig. 2:This is why the thinnest available needles (Size 31 gauge) should be used to allow deeper insertion without needle binding, allowing the solution to fl ow back up coronally instead of apically.


Chemical parameters and limitations

Simply put, most irrigation solutions are solutions based on acids, bases, disinfectants or lubricants. The main goal of irrigation is the removal of the macrodebris generated during instrumentation and use the aforementioned chemicals to achieve the three main objectives of irrigation:
  • Dissolve organic tissue—pulp, organic portion of dentinal chips, collagen, smear layer, etc.— from inside the root canal.
  • Gently dissolve inorganic tissue—smear layer, dentinal chips and calcifications— inside the root canal space.
  • Disinfect surfaces left behind by destroying all forms of established biofilms inside the root canal.
To date, this has been achieved with a concentration of 1%–6% sodium hypochlorite solution (NaClO), with lower concentrations used for disinfection only and higher concentrations for additional tissue dissolution. In addition, we’ve used a 17% solution of ethylenediamide tetraacetic acid (EDTA) to remove loose inorganic components inside the root canal. Additional lubricants such as RC Prep (Premier Dental) and surfactants to reduce surface tension and aid in solution penetration inside dentinal tubules have also been used for additional benefits, but aren’t essential to the irrigation process.

One challenge: NaClO and EDTA can’t be mixed because they neutralize and hydrolyze each other within a few minutes after mixing.4 This is why operators have to use two separate syringes for each solution. If chlorhexidine (CHX) is also used, an additional water rinse is required between NaClO and CHX to avoid a toxic precipitate.

Generally, the NaClO and EDTA solutions are used intermittently throughout the process, with additional protocols of EDTA at the end to remove the smear layer. This is because of an additional chemical limitation when using NaClO in teeth: It is not only buffered by EDTA but also buffered and neutralized very quickly upon contact with dentin and dentinal chips. Therefore, the use of EDTA interchangeably throughout the process has been theorized to help dissolve the dentinal chips and help reduce the rate of NaClO deactivation. But because they cannot be mixed together, they are used in different syringes interchangeably. Lubricants enter the scene as well as per operator’s discretion.

These chemical interactions and buffering limitations have created a long, laborsome process of using multiple syringes with multiple needles throughout the process. Are we forced to work through this multiple syringe system and accept this complexity?
Industry Insights: Simplifying Endodontic Irrigation


A better solution?

While the use of these three basic solutions in alternate syringes has become second nature to most of us, chemists from a few companies over the past decade have been working to develop a series of chelating chemicals that can withstand the harsh and corrosive reaction between NaClO and EDTA by focusing on replacing the EDTA component of irrigation with a series of substitute chelating agents that are less neutralizing to NaClO.

It’s important to note that this scientific effort was made to replace EDTA rather than NaClO in this process because NaClO is considered the gold standard irrigant in the endodontic therapy, primarily because of its simultaneous action on organic tissue dissolution while being an effective disinfectant. As a result, instead of reinventing the wheel by developing a new disinfectant and a new organic solvent, which would have required prospective long-term studies to validate their efficacy, NaClO was used as the base for a new solution that contains a mix of 11 different gentle chelators that exhibit resistance to NaClO and do not buffer NaClO as quickly as EDTA.

Furthermore, a number of saponification agents and lubricants were added to the mix, so the final cocktail of solutions can address all three requirements of irrigation and potentially more all in one solution. The resulting irrigation solution is Triton (Brasseler). The delivery of the irrigants in one bottle is possible through its unique dual-barrel delivery system, in which 8% NaClO is mixed 1:1 with a solution of chelating agents, lubricants, surfactants and detergents. As a result, the final solution drawn into the syringe is a 4% solution of NaClO with all the additional ingredients in it.

The solution is stable for three to five hours after mixing/drawing from the bottle, beyond which the NaClO concentration is considered too low for its intended use, so it is drawn/mixed to use per patient. Each bottle yields a total 480ml of solution, which at 6ml/cc per case (average use) would allow for about 80 cases. The unmixed solution in the bottle has a shelf life of one year on the bench top and two years in the refrigerator.

Independent scientific studies have been performed by universities around the world and the studies are on the publication path at the time this article was written. The results of these studies show excellent disinfection qualities, as expected from a NaClO-based solution. Further synergistic effect is possible, because simultaneous application of chelation during disinfection can potentially have a catalytic effect on both processes. This and other results have to be seen. Being a hypochlorite solution, Triton should be kept inside the tooth and the same care with any NaClO irrigation should be applied here.

While the future of this particular product is bright and it may be shown to improve the irrigation/ disinfection process, one thing is certain: The move from multiple syringes and a complicated irrigation protocol to a simpler irrigation protocol where a single syringe can be used from the beginning to the end of the procedure without any sequencing needs allows for a more efficient irrigation protocol for most clinicians.

Also, by maintaining 4% sodium hypochlorite as the main active ingredient in Triton, we can apply through precedent the existing body of literature and long-term clinical experience about the efficacy of this solution for disinfection. All the additional benefits and its potential synergy will be a bonus to the clinician.

Reference
1. Cardoso, F.G. da R., Martinho, F.C., Ferreira, N de S., do Prado, R.F., Manhães-Júnior, L.R.C., Rocco, M.A., and Valera, M.C. “Correlation Between Volume of Root Canal, Cultivable Bacteria, Bacterial Complexes and Endotoxins in Primary Infection.” Braz Dent J 30 (2); March-April 2019. https://doi. org/10.1590/0103-6440201902239
2. Basrani, B. and Haapasalo, M. “Update on Endodontic Irrigating Solutions.” Endod Topics, 27: 74–102 (2012). https://doi.org/10.1111/etp.12031
3. Haapasalo, M., Shen, Y., Wang, Z., et al. “Irrigation in Endodontics.” Br Dent J 216, 299–303 (2014). https://doi.org/10.1038/sj.bdj.2014.204
4. Zehnder, M. “Root Canal Irrigants,” Journal of Endodontics, Vol. 32, Issue 5, 389–398 (2016), https://doi.org/10.1016/j.joen.2005.09.014.

Author Bio
Dr. Allen Ali Nasseh
Dr. Allen Ali Nasseh received his dental degree from Northwestern University Dental School and completed his postdoctoral endodontic training at Harvard School of Dental Medicine, where he also earned a master’s degree in the area of bone physiology. He has been a clinical instructor in the postdoctoral endo department at Harvard School of Dental Medicine since 1994. Nasseh is the current president and CEO of Real World Endo and the editor of the Harvard Dental Bulletin and several other dental journals and periodicals. He has a solo private endodontic practice and an endodontic educational institute in downtown Boston.

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