Jemds.

com Review Article

Removal Techniques for Intracanal Medicament- A Review

Samrudhi Sunil Khatod1, Anuja Dhananjay Ikhar2, Pradnya Prashant Nikhade3, Manoj Chandak4,
Nidhi Manohar Motwani5, Madhulika Shyamsundarji Chandak6, Chanchal Kishor Rathi7, Arpan Sanjay Jaiswal8

1Department of Conservative Dentistry and Endodontics, Datta Meghe Institute of Medical Sciences, Sharad Pawar
Dental College, Sawangi, Wardha, Maharashtra, India. 2Department of Conservative Dentistry and Endodontics, Datta
Meghe Institute of Medical Sciences, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India. 3Department
of Conservative Dentistry and Endodontics, Datta Meghe Institute of Medical Sciences, Sharad Pawar Dental College,
Sawangi, Wardha, Maharashtra, India. 4Department of Conservative Dentistry and Endodontics, Datta Meghe Institute
of Medical Sciences Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India. 5Department of Conservative
Dentistry and Endodontics, Datta Meghe Institute of Medical Sciences, Sharad Pawar Dental College, Sawangi, Wardha,
Maharashtra, India. 6Department of Conservative Dentistry and Endodontics, Datta Meghe Institute of Medical
Sciences, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India. 7Department of Conservative Dentistry
and Endodontics, Datta Meghe Institute of Medical Sciences, Sharad Pawar Dental College, Sawangi, Wardha,
Maharashtra, India. 8Department of Conservative Dentistry and Endodontics, Datta Meghe Institute of Medical
Sciences Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India.

ABSTRACT

BACKGROUND
This article reviews irrigation techniques for removal of intracanal medicament in Corresponding Author:
endodontic practice. Microorganisms are the primary etiological factors for pulpal Samrudhi Khatod,
and periradicular diseases. So primary purpose is to completely eradicate Datta Meghe Institute of Medical Sciences,
Radhikabai, F-6,
microorganism from the root canal. It is done through chemo-mechanical
Sawangi-442001,
preparation of the canal. Complete disinfection of the pulp space cannot be achieved Maharashtra, India.
with most sophisticated instrumentation techniques. Therefore use of inter E-mail: [email protected]
appointment intracanal medicaments is mandatory. Removal of the medicament is
mandatory, as its remnants may mechanically block the apical area of the root canal DOI: 10.14260/jemds/2020/236
system. Also affects viscosity, working time, tubule penetration and adhesion of root
canal sealers. Remnants of Ca(OH)2 in the canal react with unreacted eugenol Financial or Other Competing Interests:
present in ZOE based sealer to form calcium eugenolate. Today’s irrigation None.
armamentarium presents a diverse variety of tools and techniques , that can assist
How to Cite This Article:
the practitioner in reducing bacteria, debris, intracanal medicament within the Khatod SS, Ikhar AD, Nikhade PP, et al.
canal system. Conventional syringe irrigation is a routinely practiced method for Removal techniques for intracanal
removal of medicament. It consists of delivering the irrigant in the canal passively medicament- a review. J. Evolution Med.
or by agitation. Rotary brush does not actually render irrigating solution for Dent. Sci. 2020;9(13):1097-1101, DOI:
removal of medicament. This acts like auxiliaries during removal of medicament 10.14260/jemds/2020/236
from canal or for increased movement of irrigating solution. Ultrasonic irrigation is
done with or without simultaneous ultrasonic instrumentation. EndoVac is negative Submission 28-02-2020,
Peer Review 07-03-2020,
pressure irrigation, which can be used as an alternative method that helps in safe Acceptance 12-03-2020,
removal of medicament in apical thirds. RinsEndo is also based on pressure Published 30-03-2020.
alteration technology like EndoVac. Sonically driven system safely activates various
intracanal reagents and vigorously produces the hydrodynamic phenomenon as it
includes EndoActivator and Vibringe. Laser activated irrigation is more effective for
cleaning of root canal. Er:YAG is most commonly used laser in endodontics.
Therefore, the aim of this article is to highlight the irrigation techniques used for
removal of the intracanal medicament in endodontic practice.

KEY WORDS
Calcium Hydroxide, Ultrasonic, Sonic, Manual

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BACKGROUND (i) Conventional Syringe Irrigation

Routinely practiced method for removal of medicament.
Consist of delivering the irrigant in canal passively or by
Microorganisms are primary etiological factors for pulpal and agitation i.e. back and forth motion in canal (2-3 mm strokes).
periradicular diseases. So primary purpose is to completely Efficacy depends on gauge of needle and its design, which in
eradicate microorganism from the root canal. It is done turn effect flow, length of infiltration of irrigant, pressure
through chemo-mechanical preparation of the canal. This over wall of canal and apical terminus. Penetration depth of
include proper cleaning and shaping by instrumentation and needle is inversely proportional to its gauge. 27-gauge needle
irrigation.(1,2,3) Because of complexity of root canal, is favourable for routine root canal treatment.(11)
biomechanical preparation fails to completely eradicate
microorganism. This left over bacteria might multiply in Needle Gauge Apex of Size to Which Needle Can Reach
between appointments and might reach to same previous 21 ISO size 80 canal
23 Size 50
degree of concentration, so intracanal medicament has been 25 Size 35
used for complete canal disinfection. Rationale for intracanal 30 Size 25
medicament use is to totally eradicate microorganism from Needle Gauge Selection
the root canal and forbid reinfection.(2,4,5)
Antimicrobial activity of intracanal medicaments varies, As per studies it says irrigating solution flow just 1-2 mm
they belong to various groups, mostly different away from needle end. Different type of needle tip are
chemicals/drugs are combined to achieve increased invented to enhance efficiency and minimize peril. Open-
efficiency with a single application. Thus, to deactivate ended tips release irrigant from end towards apical region
microbial activity intracanal medicament with prolonged and lead to increase in apical pressure in canal. Closed-ended
antimicrobial activity has to be used in between tips are side-vented therefore to greater extent pressure is on
appointments.(6,7) Medicament should be efficient during its walls of canal and enhance hydrodynamic energizing of
entire time of application and should penetrate the tubule irrigant and decrease the chance of apical leakage. Close
and eradicate the microbes. Intracanal medicament shows ended tip causes irrigant to reflux and efficiently displace
comparatively prolonged antimicrobial action when debris coronally. Advantages of syringe irrigation is control
compared to irrigants.(6) Calcium hydroxide was invented by on extent of needle placement in canal and quantity of
Herman in 1920 is routinely used intracanal medicament irrigant to be irrigated in canal. Different sizes of syringe are
because of its antimicrobial, alkalinity, tissue repair and available from 1 - 20 mL. Low volume syringe are time
inhibiting osteoclastic properties. It is used in cases like consuming compared to large volume but problem with
weeping canal, in blunderbuss canal for apexogenesis and large-volume is it is hard to take power on pressure and
apexification, root resorption cases.(8,9) unfavourable incidence might occur. Thus, to enhance safety
However prolonged placement of intracanal Ca(OH)2 has and control low volume syringe (1 to 5 mL) should be
adverse effect on dentin, making it prone to root fracture. In used.(11)
many in vitro studies it has been stated that more than 5
weeks of placement of intracanal Ca(OH)2 causes decrease in
root fracture resistance. Remnants of Ca(OH)2 in canal react (ii) Instrumentation Using Master Apical File or Gutta
with unreacted eugenol present in ZOE based sealer to form Percha
calcium eugenolate. Calcium eugenolate has been observed as This are used for agitation while irrigation to improve its
disorganized layer which inhibit sealer infiltration in dentin efficacy.(11)In straight root canal, filing with last file used
and affects proper seal. Leftover calcium hydroxide get during biomechanical preparation along with irrigating
dissolve by tissue fluid and affect apical seal. Also it affect the solution might enhance medicament withdrawal when
efficacy of apex locator, bond strength decreases between checked with irrigating solution itself. While in curved roots
resin based sealer and dentin when calcium hydroxide was rotary nickel titanium file found to be effective without
used as intracanal medicament, this might be because of altering root canal anatomy.(12,13)
alkalinity of calcium hydroxide which neutralizes acidic
monomer present in resin based sealer. Remnants of According to Mridusmita Mukherjee et al in coronal third
antibiotic paste is detrimental to stem cells.(6,10) PUI method and that of master apical file performed better
Therefore for thorough removal of medicament especially than the other group. In middle third efficacy was better for
in apical third use of various irrigation delivery system is PUI, followed by NaviTip FX, master apical file, canal brush, in
essential. Various method employed for removal of smear apical third PUI outperformed other groups.
layer, debris, intracanal medicament are 1) Manual 2)
Machine assisted 3) Chemical (irrigants). (11)
MA C H I N E A S S I S T E D

MANUAL IRRIGATION It comprises of

(i) Rotary Brush- canal brush, endo brush, NaviTip FX.
It comprises of mainly (i) Conventional syringe irrigation (ii) (ii) Pressure Alternation Device- EndoVac, RinsEndo
Instrumentation by master apical file or gutta percha. (iii) Sonic irrigation- EndoActivator, Vibringe (iv) Passive
ultrasonic irrigation (v) Laser.

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(i) Rotary Brush made of medical-grade polymer, elastic enough and are 22
Brushes do not actually render irrigating solution for removal mm in length with marking rings at XVIII, XIX, XX mm.(17)
of medicament. This act like auxiliaries during removal of Criteria for tip selection is select a tip which do not adhere to
medicament from canal or for increase movement of canal wall at apical 2-3 mm so that it enable easy up and
irrigating solution. 30-gauge needle encircled by brush down motion of tip.(18) Tips cannot be reused. Autoclaving the
(NaviTip FX) is commercially available in 17- and 25-mm tip decreases its flexibility, thus reduces its back-and-forth
length. It has shown positive result in coronal cleaning of action. Sonic system has been engineered for risk free
canal over the brushless needle. Although friction between triggering of irrigating solution safely and vigorously create
brushes and canal irregularities may cause breakage of non- hydrodynamic phenomenon. It is more competent to clean
radio opaque bristles in canal which clinicians fail to identify, and remove medicament and efficiently enables cleaning of
even by use of magnification. In early 1990s, same findings accessory canals.(19) Sonic activation system differ from
showing enhanced canal debridement by utilization of canal ultrasonic as sonic system function at a low frequency (1-6
brushes by Keir et al.(14) The Endo brush is a spiral brush that kHz). Vibrating tip cause irrigant activation, produces
comprises of nylon bristles set in twisted wires with handle. intracanal waves. waves breakdown, which causes
Used in active brushing and rotary motion but endo brush production of bubbles that oscillates in irrigant. Bubbles
cannot be used till apex of canal due to its structure, that may spread out, gets unsteady because of heat and pressure, then
cause clogging of debris in bottom region in the canal post breakdown and explode. Each explosion produces thirty
use of it. Canal Brush is also an endodontic micro brush. It is thousand shockwaves that infiltrate strongly, breakdown
highly flexible and is formed completely by polypropylene, biofilms, and clean the surface.(20)Procedure - 10 mL of 3%
works manually by rotary motion. Weise et al., said debris NaOCl is irrigated using syringe and activated via handpiece
was efficiently withdrawn from canal extensions, with suitable tip short of 2 mm of apex, moving tip back and
irregularities by usage of Canal Brush with an irrigant.(14,15) forth, that is II - III mm up down strokes at least up to sixty
seconds.(14)
Vibringe- Is other type of sonic activation system
(ii) EndoVac discovered by Dutch company Vibringe B, which tie-up
Is based on apical negative pressure irrigation to carry out battery-driven vibrations (9000 rpm) that adds sonic
efficient flow of irrigant and simultaneous removal vibration to manual irrigation of canal. It consists of cordless
respectively. Thus, improved penetration of irrigant in root handpiece which engages X mL leur lock syringe to which any
complexity. Comprises of various sizes of cannula. Cannula is needle can be attached and conventional syringe irrigation
attached with high speed suction which produce negative like delivery occurs, studies yet to found on MedLine.(14)
pressure which draws irrigating solution towards end of
cannula and removes irrigation solution along with debris
from little openings.(16) Negative pressure produced causes (iv) Passive Ultrasonic Irrigation
risk free delivery of irrigating fluids till apex of root. Unit Introduced by Richman in 1957 in endodontics.
consist of master delivery tip. Macrocannula for removal of Ultrasonically activated file has ability to prepare and
debris, intracanal medicament from upper and middle one simultaneously remove debris and medicament present in
third of root and microcannula for removal from apical one the canal.(19) Oscillating frequency of file is 25- 30 KHz.
third. Advantages of EndoVac over other system is mainly Ultrasonically activated file have a typical form of node,
safe delivery of irrigant without risk of apical extrusion, antinode throughout its entire length. Drawback of ultrasonic
enhanced canal cleaning ability especially in apical one third irrigation is uncontrolled cutting of dentin.(21) Basically
because it inhibit vapor lock effect.(16)Procedure- Irrigate ultrasonic irrigation is of 2 types-
canal firstly by 5 mL 3% NaOCl for half minute by a) Irrigation associated with cutting instrumentation
macrocannula keeping it 3-4 mm short of working length, b) One without cutting instrumentation so called PUI
then microcannula positioned to entire WL, followed by
irrigation like macrocannula.(14) PUI was 1st explained by Weller et al (1980). "Passive"
RinsEndo- Introduced by Durr Dental Co. This irrigation denote no cut down activity by ultrasonically triggered
system is also based on pressure alteration technology like instrument.(22, 23)
EndoVac. Consist of handpiece, cannula which have seven-
millimeter-long exit aperture, and a syringe to deliver Principal - Transmission of acoustic energy from
irrigating solution. 65 ul of irrigating solution moves at oscillating file to irrigating solution.(22)
frequency of 1.6 Hertz, with speed of 6.2 mL/min.(14) Mechanism of action - Acoustic streaming and
According to Melek akman et.al Needle irrigation was cavitation.(22)
least efficient, at apical and middle part. PUI, SAF, EndoVac,
EndoActivator group withdraw significantly more than Acoustic streaming means fast motion of irrigant in
needle irrigation.(14) circular motion surrounding an oscillating file. Acoustic
streaming occurs in root canal during PUI is called as
microstreaming. Displacement amplitude is at peak at tip of
(iii) Endo Activator file, causing directional flow to coronal part of root canal.
Sonic instruments in endodontics first described by Tronstad When file is not able to vibrate easily in canal microstreaming
et al 1985. This sonically driven system compromised of will decrease in intensity, but it will not stop totally. When file
cordless handpiece and plastic tips of various colour contacts canal at antinode there will be more decrease for
corresponding to file size yellow, red, blue. Tip is noncutting, displacement amplitude rather than when node touch the

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canal. Microstreaming is not directly proportional to surface Another study shows 20% citric acid better then 17% EDTA
area of file coming in contact to canal.(22) Cavitation is solution for removal of Metapex. This might be due to citric
minimal and is restricted upto tip of file, whereas effect of acid penetrability in silicone oil is better than EDTA.(7)Apart
acoustic streaming is significant.(22) to it 0.2% chitosan proved to be effective from XVII %
Ethylene Diamine Tetra-Acetic Acid and 20% citric acid
Procedure - U file no 15 or 20 is placed in center of root solution for withdrawal of water‑based and oil‑based
canal as apical as possible then 10 mL of NaOCl will be Ca(OH)2. This is in accordance to Nandini et al and Ballal et
agitated for 1 minute at power setting of 6 and scaler set on al.(25) Thus Combine use of ultrasonic agitation and chelator
endomode.(14) leads to comparatively cleaner canal irrespective of vehicle
According to Michael Hulsmann et al PUI performed used. Calcium hydroxide mixed with distilled water are
better than RinsEndo, EndoActivator, canal brush, and comparatively easy to remove than Oil-based.(29,30,31)
manual syringe irrigation in apical third.(19)

CONCLUSIONS
(v) Laser
Laser Activated Irrigation is more effective for Cleaning of
Root Canal. Er: YAG is most commonly used laser in Use of irrigants and agitation by different mechanical devices
endodontics. Because of photoacoustic streaming effect leads to increase removal of intracanal medicaments and
which occur when light energy pulse in irrigant. Laser emit adequate cleaning of canal.
photons to create photoacoustic shockwave in canals,
shockwave is targeted 3- dimensionally into irrigant and thus
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