INTRODUCTION:

The main goals of a root canal treatment are three-dimensional cleaning, shaping, and a proper obturation with adequate seal of the root canal. Complete debridement, with smear layer removal is also an important step in the treatment. (1)

Removal of microorganisms from infected root canals is a complicated task. The outcome of the treatment is higher if infection is eradicated effectively before the root canal system is obturated. However, there is a high risk of treatment failure if microorganisms persist at the time of obturation, or if they penetrate into the canal after obturation. (2,3)

The success of the root canal therapy depends on thorough chemomechanical debridement of dentin debris pulpal tissue, and infective microorganisms. Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue, and disinfecting the root canal system. Chemical debridement is needed for teeth with complex internal anatomy such as fins or other irregularities that might be missed by instrumentation.(4)

Ideal requirements of a root canal irrigant: (5)

1. High efficacy against anaerobic and facultative microorganisms organized in biofilms

2. Ability to dissolve necrotic pulp tissue remnants and inactivate endotoxin

3. Prevent the formation of a smear layer during instrumentation or to dissolve the latter once it has formed.

4. Broad antimicrobial spectrum

5. As endodontic irrignats come in contact with vital tissues they should be systematically nontoxic, noncaustic to periodontal tissues, and with little potential to cause an anaphylactic reaction.

This article mainly reviews the properties and uses of the new root canal irrigants found in the recent times.

Root canal irrigants:

MTAD

MTAD was introduced as an alternative to EDTA to remove the smear layer by Torabinejad et al. Its composition consists of 3% doxycycline, 4.25% citric acid and detergent-Tween 80. It has a combined chelating effect and antibacterial activity.(6)

The pH of BioPure MTAD is 2.15(7) so it can act as a calcium chelator, thereby causing enamel and root surface demineralization. The extent of dentin surface demineralization can be compared to that of citric acid, and it mainly removes the inorganic substances.(8,9)

BioPure MTAD contains citric acid and Tween 80. Citric acid is a crystalline organic acid, antibacterial and helps in removal of smear layer in concentration of 10% and 25%, and helps in deeper penetration of doxycycline into the dentinal tubules and exhibits its antibacterial action.(10) Tween 80 (polyoxyethylene sorbitan monooleate) is a detergent present in MTAD and is a non-ionic surfactant. enhances the flow and penetration of irrigating solutions deeper into the dentinal tubules by reducing the surface tension of distilled water, NaOCl, EDTA, and thus completely disinfects the canal spaces. It has a pH of 7.0 and is a biologically acceptable material.(11-13)BioPure MTAD also contains doxycycline hyclate in powder form and is a broad spectrum antibiotic effective against wide range of microorganisms. (14)

Tay and Hiraishi demonstrated use of 1.3% NaOCl as an initial rinse followed by MTAD as final rinse, resulting in 30% reduction of the antimicrobial substantivity of MTAD. However, erosion of dentinal tubules was less when compared to that when MTAD was used as an initial rinse.(15)

Torabinejad et al studied the antimicrobial efficiency of MTAD by in vitro investigation to test its ability to kill E. faecalis and compare its efficacy to that of 2.5% NaOCl and ethylene diamine tetra acetic acid (EDTA). The zones of inhibition and minimum inhibitory concentrations were measured for these root canal irrigants. EDTA demonstrated no antibacterial effects against E. faecalis, NaOCl and MTAD proved to be antibacterial to varying degrees. NaOCl continued to exert its efficacy up to 32_ dilutions. On the other hand, MTAD was effective in killing E. faecalis up to 200 dilutions.(16)

Torabinejad and Cho studied the effect of various concentrations of sodium hypochlorite on the ability of MTAD to remove the smear layer, to investigate the effectiveness as an intracanal irrigant before final rinse with BioPure MTAD. The results showed that MTAD removed most of the smear layer when used as an intracanal irrigant, however, some remnants of the organic component of the smear layer remained scattered on the surface of the root canal walls. They noticed that effectiveness of MTAD to completely remove the endodontic smear layer was enhanced when low concentrations of sodium hypochlorite were used as an intracanal irrigant before final rinse with MTAD. Also, the regimen did not seem to significantly change the structure of dentinal tubules. They concluded that MTAD could remove smear layer much more effectively than various concentrations of sodium hypochlorite.(7)

MTAD a tetracycline derivative has the ability to intrinsically stain teeth during odontogenesis, can chelate calcium ions and can get incorporated into teeth, resulting in discolouration of both primary and permanent dentitions.(13)

Giardino et al. showed that MTAD was not able to remove bacterial biofilms [17]. Stojicic et al. demonstrated that MTAD was unable to kill all plaque bacteria in 30 seconds, and some E. faecalis cells were able to survive even after 3 minutes exposure [18].

Hypoclean

Hypoclean which is a new NaOCl – based endodontic irrigant is composed of 5.25% sodium hypochlorite and two detergents. There are only limited published studies which describes about its antibacterial activity, however it is found that Hypoclean offers substantivity up to four weeks as demonstrated by Mohammadi et al. He also found out that Hypoclean offered considerably lower residual antibacterial activity compared to Tetraclean.(19) From the experiment conducted by Zahed Mohammadi et al, it was found out that Hypoclean was the most effective irrigant against C. albicans, P. aeroginosa, and L. casei. (20)

Citric acid

Citric acid is a demineralizing solution available in a concentration of 10-50% and it is used in the endodontic therapy to remove the smear layer from the prepared root canal. The biocompatibility of citric acid is 10% more and it is also effective in removing the smear layer than 17% of EDTA. Citric acid interferes with the mechanism of action of NaOCl. (21) The use of 10% citric acid has shown good results in smear layer removal when it is used as a final irrigation solution. (22) 10% citric acid has proven to be more biocompatible than 17% EDTA-T and 17% EDTA in the in vitro studies which have showed their cytotoxicity.(23,24) The use of 25% citric acid was ineffective in the eradication of biofilms of E faecalis after 1, 5, and 10 min of exposure. (25)

Cetrimide

According to the previous studies, researchers have proved that 0.2% cetrimide (CTR), 17% EDTA, 2% chlorhexidine (CHX), can eliminate E.faecalis to some extent. (26,27) CTR exhibits excellent antibacterial activity and it can also act as a cationic surfactant. (28) Previous studies indicated that the sterilisation outcome of 0.1% of CTR and 2% of CHX on E.feacalis in the dentinal tubules was found to be same. (29,30) The antibacterial effect of 0.2% CTR was found to be weaker than that of 2% CHX, the reason may be due to the stronger ability of CTR in reducing the bacterial adhesion which enables the counting of more viable bacteria. It was also proved that cetrimide possess residual antimicrobial activities that last for 24 hours.(31)

Propolis

Honey bees produce a natural resinous hive substance from plants called propolis. (32) The composition of propolis includes organic compounds such as esters and phenolic compounds, flavonoids (flavonols, flavones, flavonones, dihydroflavonols, and Ann chalcones), terpenes, aromatic aldehydes and alcohols, beta-steroids, sesquiterpenes, and stilbene terpenes. (33) Propolis also has antibacterial, antiviral, antifungal, anti-inflammatory, antioxidant, anti tumour, hepatoprotective and immunomodulatory effects. (33) Studies have also shown that propolis has a positive effect on bond strength to dentin. (34) Ethanolic extract of propolis inhibits hyaluronidase activity and has agreat potential as an anti -inflammatory agent. (35). Propolis can be used as an alternative intracanal medicament since it has a good invitro antibacterial activity against E.faecalis in the root canals. (36)

HEBP (Etidronic acid)

Hydroxyethylidene bisphosphonate (HEBP) (1-hydroxyethylidene- 1, 1-bisphosphonate), also known as etidronic acid or etidronate, is a decalcifying agent that shows only little short-term interference with sodium hypochlorite and has been proposed as a potential alternative to citric acid or EDTA. (37,38) HEBP is non toxic, prevents bone resorption and is used systemically in patients suffering from osteoporosis or Paget’s disease. (39) The demineralization kinetics promoted by both 9% HEBP and 18% HEBP were significantly slower than those of 17% EDTA. (40)

Chlorine dioxide

Chlorine dioxide (ClO2) is chemically similar to chlorine or hypochlorite, the familiar household bleach. An in vitro study compared organic tissue dissolution capacity of NaOCl and ClO2 and it was concluded that ClO2 and NaOCl are equally efficient for dissolving organic tissue.[41] ClO2 produces little or no trihalomethanes. (42) A study showed that trihalomethane is an animal carcinogen and a suspected human carcinogen. (43)

Maleic acid

Maleic acid is a mild organic acid used as an acid conditioner in adhesive dentistry. (44) Ballal et al., have suggested that final irrigation with 7% maleic acid for 1 min was more efficient than 17% EDTA in the removal of smear layer from the apical third of the root canal system. (45) Also 7% Maleic acid produces maximum surface roughness on root canal walls as compared to 17% EDTA. This surface roughness produces an important role in micromechanical bonding of resin sealers. (46)

Silver diamine fluoride

A 3.8% of w/v silver diamine fluoride (Ag(NH3)2F) solution has been developed for intracanal irrigation. This represents a 1:10 dilution of the original 38% of Ag(NH3)2F solution used for root canal infection.[47] The study conducted on the antibacterial effect of 3.8% of Ag(NH3)2F against a E. faecalis biofilm model concluded that Ag(NH3)2F has potential for use as an antimicrobial root canal irrigant or interappointment medicament to reduce bacterial loads.[48]

Ozonated water

Ozone is a chemical compound containing three oxygen atoms. It is a powerful antimicrobial agent against bacteria, fungi, protozoa, and virus but rarely used as irrigant. (49) Huth et al. suggested that the efficacy of ozonated water and 2.5% NaOCl were about the same when the specimen was irrigated with sonication [50]. However, another study by Hems et al. demonstrated that NaOCl was superior to ozonated water in killing E. faecalis in biofilm and broth culture. (51)

Tetraclean

Tetraclean is a mixture of antibiotic, an acid and a detergent-like MTAD, but the concentration of antibiotic, doxycline (50 mg/ml), and type of detergent is different. (52) Comparison of antimicrobial efficacy of 5.25% NaOCl, MTAD, and Tetraclean against E faecalis biofilm showed that only 5.25% NaOCl could consistently disgregate and remove the biofilm at every time interval. However, treatment with Tetraclean caused a high degree of biofilm disgregation in every considered time interval (5,30, and 60 min at 20°C) as compared with MTAD.( 53)

Qmix

Qmix is composed of EDTA, CHX, and a detergent.(54) QMix has also been proven to have effective antimicrobial activity for the disinfection of hydroxyapatite discs infected with E. faecalis. (55)

Herbal irrigants

Green tea

Green tea polyphenols, the traditional drink of Japan and China is prepared from the young shoots of the tea plant Camellia sinensis. [56] Green tea polyphenols showed statistically significant antibacterial activity against E faecalis biofilm formed on tooth substrate. It takes 6 min to achieve 100% killing of E faecalis. (57)

Triphala

Triphala consists of dried and powdered fruits of three medicinal plants Terminalia bellerica, Terminalia chebula, and Emblica officinalis [58]. Triphala achieved 100% killing of E faecalis at 6 min and this may be attributed to its formulation, which contains three different medicinal plants in equal proportions; in such formulations, different compounds may help enhance the potency of the active compounds, producing an additive or synergistic effect [57]. Triphala contains fruits that are rich in citric acid, which may aid in removal of the smear layer. The major advantages of using herbal alternatives are easy availability, low toxicity, cost-effectiveness longer shelf life, and lack of microbial resistance [59].

Morinda citrifolia

Morinda citrifolia (MCJ) has a broad range of therapeutic effects, including antibacterial, antiviral, antifungal, antitumor, antihelmintic, analgesic, hypotensive, antiinflammatory, and immune-enhancing effects.[60-63] MCJ contains the antibacterial compounds L-asperuloside and alizarin(63]. Murray et al. proved that, as an intracanal irrigant to remove the smearlayer, the efficacy of 6% MJC was similar to that of 6% NaOCl in conjunction with EDTA. The use of MCJ as an irrigant might be advantageous because it is a biocompatible antioxidant[63]

CONCLUSION:

This article reveiwed the new potential irrigants which could substitute the traditional irrigants and also demonstrates the important properties of each irrigant. Selection and use of the appropriate root canal irrigant heklps in achieving endodontic success. Further research and studies has to be done on the newer root canal irrigants.

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Received on 07.09.2016 Modified on 28.09.2016

Research J. Pharm. and Tech 2016; 9(12):1451-1456.

DOI: 10.5958/0974-360X.2016.00473.X