Speaker 1: Welcome to a look at the podcast Where and the
Speaker 1: Danteks Miss Clarity, hosted by Ahmed Shauki I Ahmed.
Speaker 2: Hi Francisca and of course by Francesca Surety. Today we
Speaker 2: are diving into a deceptively simple question, how do we
Speaker 2: actually deliver irrigation into the root canal system? Because if
Speaker 2: there's one thing we have learned over the years, that's
Speaker 2: it shaping alone is not enough. Even with the latest
Speaker 2: nakel titanium systems, even with the perfect instrumentation technique, we
Speaker 2: simply cannot eliminate all the micro organisms. That's a fact
Speaker 2: that we have to agree upon. And the anatomy is
Speaker 2: two complex letter canalristhmases, irregularities and by film persists inside
Speaker 2: those difficult areas. That's why irrigation is not just an adjunct,
Speaker 2: it's a central and it is important really for the
Speaker 2: prognosis of our treatments.
Speaker 1: Yeah, and it's found that despite technological advancement, we still
Speaker 1: are using a syringe and needle to deliver the irregant
Speaker 1: to the rootcnalcism. And then we can discuss about the
Speaker 1: shape of the needles and materials and stuff. But that's
Speaker 1: what we use and The main difference between general practitioners
Speaker 1: and specialists is in the fact that general practitioners in
Speaker 1: general only use sodia hypochorrite with a syringe, and specialists
Speaker 1: use more than one irregant and they tend to activate
Speaker 1: the irregants that they use.
Speaker 2: Yes, inside the root canel, fluid dynamics are extremely limited
Speaker 2: and problematic. There is a consistent background that the literature
Speaker 2: gives us studying how can we clinically applicate critical concepts?
Speaker 2: We are dealing with a narrow, confined space where discuss
Speaker 2: theory stricts the flow. On top of that, we often
Speaker 2: face closed ended systems where vapor loucks prevent the arrogant
Speaker 2: from the reaching the epical area, not to mention the
Speaker 2: fluid exchange, and there is debris, dent and chips, organic tissues, biofilms,
Speaker 2: all of the accumulates and things inside the canal that
Speaker 2: creates barriers. So even when we think we irrigate properly,
Speaker 2: in reality, large portions of the canal are not flooded
Speaker 2: with our arrogant, which we need really important in our treatment.
Speaker 1: So basically they tell us that we have to find
Speaker 1: the balance between the taper of the instruments that we
Speaker 1: are using, the diameter of our epical preparation, the irregent
Speaker 1: that we choose at the time that we spend while
Speaker 1: doing this clinical step. For example, in this case it's
Speaker 1: it's valentize it. Of course, you see that I opened
Speaker 1: the access cavity and then I use files from the
Speaker 1: ataperchase this step. I'm not using any irrigant because the
Speaker 1: file can just navigate inside the GUTA. Person's kind of soft,
Speaker 1: so I don't really need to labricate them. But between
Speaker 1: every file I will irrigate to remove or the debris
Speaker 1: that I'm creating with my shaping. As we saw in
Speaker 1: the last episode, what you see here is that my
Speaker 1: typical diameter is sixty So I did an epical plug
Speaker 1: with MTA, and you see that all the case leads
Speaker 1: to the resolution of the epical patology.
Speaker 2: Nowadays, we are moving towards conservative shaping protocol, or we
Speaker 2: can call it minimally invasive heated antics to preserve the
Speaker 2: two structure, and that creates a paradox. The more conservative
Speaker 2: we are, the harder it becomes to deliver the arrogant
Speaker 2: effectively into the canal. Because of the shapes and tapers,
Speaker 2: and that's where technique becomes critical. Let's consider needed literation.
Speaker 2: In ideal conditions, a twenty seven gauge needle can reach
Speaker 2: about three milimeters from the apex in straight canals. A
Speaker 2: thirty gauge needle can perform slightly better in curved canals,
Speaker 2: but in conservative shaping, the needle offense go beyond four
Speaker 2: milimeters from the apex. That means that the most critical area,
Speaker 2: the epical third, is precisely where irrigation becomes the least effective.
Speaker 1: Yeah, and we know that increasing the epical preparation size
Speaker 1: can improve our penetration of the irrogant because a larger
Speaker 1: canal allows for a better flow, better exchange of irrogant,
Speaker 1: and more effective clinic. But clinically speaking, this is not
Speaker 1: always feasible. We cannot achieve this all the time. And
Speaker 1: also there are some studies that tell us that we
Speaker 1: have to go over the size of twenty five if
Speaker 1: we want to make sure that our irrogant can arrive
Speaker 1: to the epical third and be effective. But some odd
Speaker 1: studies tell us that there is no really significant difference
Speaker 1: between a preparation of twenty five or six and thirty
Speaker 1: zero four if we use a performing polypropylenk for example.
Speaker 2: So it's controversial, I agree, and so we need to
Speaker 2: follow strict clinical guidelines. You would sind needles ideally thirty
Speaker 2: gauge needles. Prefer side vented designs, of course, because we
Speaker 2: need to have lateral cheer stresses on the latter walls.
Speaker 2: Stay two to three eleven short of the working lens.
Speaker 2: Never bind the needle inside the canal because we might
Speaker 2: have an accident by doing that, And never force the
Speaker 2: arrogant because that also leads an accident. There are simple rules,
Speaker 2: but they make a huge difference. If you want to
Speaker 2: improve the effectiveness of our irrigation, we can act on
Speaker 2: several parameters. Time, concentration of the solution volume, temperature is
Speaker 2: very important. Combination of arrogance because we need to remove
Speaker 2: all the organic and inorganic words, activation, shaping, type of
Speaker 2: the needle, and irrigation depth.
Speaker 1: Yeah, but let's move to chemistry, because not all irrigation
Speaker 1: is created equal. I mean, so the hypochlorrite remains the
Speaker 1: gold standard and its effectiveness depends mainly on concentration time
Speaker 1: and renewal and higher concentration. Yes, they provide a faster
Speaker 1: tissue dissolution, stronger antibacterial action, and deeper penetration into the
Speaker 1: dentinal tubules. But there's note ones here. Increasing concentration does
Speaker 1: not necessarily improve the biofilm removal and complex anatomis like
Speaker 1: isthmus tis or lateral canals, and it doesn't significantly affect
Speaker 1: the post operative pain either. So again it's not just
Speaker 1: about more is better, It's about how we manage the
Speaker 1: irregan dynamically.
Speaker 2: That's very important and I agree with that. And one
Speaker 2: of the most important underestimated factors in irrigation is the
Speaker 2: refreshment keeping flowing. A refreshed solution, fresh solution and arrogant
Speaker 2: loses effectiveness quickly once it reacts with organic tissue, so
Speaker 2: frequent replacement is essential. In fact, a lower concentration that
Speaker 2: is consequently and continuously refreshed can perform at a high
Speaker 2: concentration left stagnant. And we have additional variables temperature, as
Speaker 2: I said before, volume irrigation depths, combination with other solutions
Speaker 2: like edita or surfactants to improve the pendeftation into the
Speaker 2: inaccessible areas. All of these influenced the final outcome.
Speaker 1: Yeah, and as we you were saying temperature is also
Speaker 1: important because heating sodium hypochlorte could enhance the chemical properties
Speaker 1: of the solution by increasing its reaction rate. And we
Speaker 1: can warm sodium hypocrite either outside or inside the canal,
Speaker 1: but it seems like intercanala heating is more effective then
Speaker 1: preheating sodium hyperchorrite and then put it into the syringe
Speaker 1: and deliver it into the roocanal system. And how can
Speaker 1: we clinically achieve this Well, we can do it by
Speaker 1: activating the solution, for example with ultrasonics or with laser devices.
Speaker 2: A very interesting article by but UKs traces some guidelines
Speaker 2: to irrigate effectively. At this point, we can summarize everything
Speaker 2: into five key principles of irrigation delivery. First, deliver the
Speaker 2: arrogant to the entire root canal system. That's logic, of course. Second,
Speaker 2: refresh it frequently because we need fresh We need fresh
Speaker 2: reactions to perform its action. Third, generate sheer stresses where
Speaker 2: it matters, we need side vented needles because it generates
Speaker 2: a lot of lateral stresses which can clear the root
Speaker 2: canals well. Laterally, Fourth, allow reverse flow for proper exchange.
Speaker 2: We need to eliminate anything that prevents any potential lack
Speaker 2: of exchange. Fifth, always prevent extrusion, avoid accidents. And these
Speaker 2: are not optional, These are not extravaganza. These are essential.
Speaker 1: Yeah, And preventing excusion is particularly important and we will
Speaker 1: discuss maybe in another episode about this. But we need
Speaker 1: to be aware of the risk factors such as large
Speaker 1: for amina or root resoortion or an incorrect positioning of
Speaker 1: the needle, because improper irrigation is not just ineffective, it
Speaker 1: can be dangerous. And if there's one concept that really
Speaker 1: changes the game, it's activation. Yes, because irrigation without movement
Speaker 1: is passive and so it's limited. It cannot go where
Speaker 1: we really need it. So when we activate the irregant,
Speaker 1: we increase share stress, we improve the penetration, and we
Speaker 1: disrupt the biofilm more than just leaving the irregant inside
Speaker 1: of the rock canal and waiting for it to be effective.
Speaker 2: And the numbers are really impressive because tissue dissolution can
Speaker 2: be up to twelve times faster with continuous agitation. We
Speaker 2: have several options manual dynamic activation by vibrating the master cone.
Speaker 2: We have some ext systems. We have ultrasonic devices, pressure
Speaker 2: alternating systems, laser activation, other message multisonic activation, or specific
Speaker 2: devices like the pulp soccer. Each method has its own advantage,
Speaker 2: but they all share the same goal. We have to
Speaker 2: move and keep the arrogant moving inside the root canal effectively.
Speaker 1: Yeah, and one aspect that maybe is interesting more for
Speaker 1: the patient than for our cell is post operative pain.
Speaker 1: Because every technique can lead to some postoperative pain, some
Speaker 1: extrusion of the hypochloride. But it seems that the application
Speaker 1: of agitation technique like laser activation, ultrasonic variation, gentle wave
Speaker 1: or end of that can result in less or similar
Speaker 1: post operative pain compared to serinjurrigation with no significant difference
Speaker 1: among these activation. So maybe it's better to activate our
Speaker 1: irrigant even to try to reduce the post operatunity pay
Speaker 1: for the patient.
Speaker 2: You know what, Francisca, The problem is that we are
Speaker 2: missing a protocol. This is our problem. They say that volumes, application, time, activation, etc.
Speaker 2: Should be standardized, but no one has done it yet.
Speaker 2: In our retreatment book to Stylitaro retreatment books, in the
Speaker 2: chapter by Ricardotonini and Francisca Shruti, we try to clarify
Speaker 2: these steps. First of all, the arrogant used during the
Speaker 2: shaping phase only has the function to lubricate the files
Speaker 2: and remove the debris. This is the main function during
Speaker 2: the shaping.
Speaker 1: Exactly, so the proper irrigation starts when we are ready
Speaker 1: to alternate. Exactly when we are done with our shaping them.
Speaker 1: We irrigate and we start counting how many millimeters of
Speaker 1: irrigant we are using, So in that phrase we pothesize
Speaker 1: like the minimum that we can do. It's like using
Speaker 1: almost ten millimeters of sodium hyprocyte perucnal delivered slowly drop
Speaker 1: by drop, and each couple of milliliters we activate and
Speaker 1: then we were fresh, and then we activate again. And
Speaker 1: so after this we are taking care of the organic part.
Speaker 1: We can just wash out all the sodium hyperchorrite with
Speaker 1: distal water and use a couple of milliliters of edita
Speaker 1: pero canal delivered in the same way, activated in the
Speaker 1: same way. And then we know that since dita opens
Speaker 1: the tubules, if we do one more passage of sodium
Speaker 1: hyper right after this is going to go deeper. It's
Speaker 1: going to be more effective. So why not we can
Speaker 1: do this again and last, since we don't want and
Speaker 1: it can make an interaction between our sailor and our irrigant,
Speaker 1: we wash everything away with some distill water.
Speaker 2: I think this is the real takeaway. So what you
Speaker 2: have just said is a real protocol that we follow
Speaker 2: day to day in our practice and it is really
Speaker 2: important and guys, please listen to that many times because
Speaker 2: it's really important. So the real takeaway again is that
Speaker 2: irrigation is not a simple rink just flow some liquid
Speaker 2: inside the real canal. It is a controlled, dynamic and
Speaker 2: highly technical process. It requires understanding of the fluid dynamics, chemistry,
Speaker 2: anatomy and the technique that you are using, all working together.
Speaker 2: So you have to think think about that thoroughly because
Speaker 2: in the end, irrigation is not a waste of time.
Speaker 2: It really is the most important part of our treatment.
Speaker 1: Yeah, it's because it's the core of disinfection, and disinfection
Speaker 1: is the core of the end around its success. And
Speaker 1: so thank you everyone for listening. We hope you liked
Speaker 1: these indications about irrigation and stay tuned for the next
Speaker 1: EPIDO of Indocast. Bye bye bye,