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<v Speaker 1>Welcome to a look at the podcast Where and the

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<v Speaker 1>Danteks Miss Clarity, hosted by Ahmed Shauki I Ahmed.

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<v Speaker 2>Hi Francisca and of course by Francesca Surety. Today we

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<v Speaker 2>are diving into a deceptively simple question, how do we

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<v Speaker 2>actually deliver irrigation into the root canal system? Because if

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<v Speaker 2>there's one thing we have learned over the years, that's

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<v Speaker 2>it shaping alone is not enough. Even with the latest

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<v Speaker 2>nakel titanium systems, even with the perfect instrumentation technique, we

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<v Speaker 2>simply cannot eliminate all the micro organisms. That's a fact

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<v Speaker 2>that we have to agree upon. And the anatomy is

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<v Speaker 2>two complex letter canalristhmases, irregularities and by film persists inside

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<v Speaker 2>those difficult areas. That's why irrigation is not just an adjunct,

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<v Speaker 2>it's a central and it is important really for the

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<v Speaker 2>prognosis of our treatments.

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<v Speaker 1>Yeah, and it's found that despite technological advancement, we still

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<v Speaker 1>are using a syringe and needle to deliver the irregant

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<v Speaker 1>to the rootcnalcism. And then we can discuss about the

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<v Speaker 1>shape of the needles and materials and stuff. But that's

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<v Speaker 1>what we use and The main difference between general practitioners

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<v Speaker 1>and specialists is in the fact that general practitioners in

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<v Speaker 1>general only use sodia hypochorrite with a syringe, and specialists

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<v Speaker 1>use more than one irregant and they tend to activate

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<v Speaker 1>the irregants that they use.

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<v Speaker 2>Yes, inside the root canel, fluid dynamics are extremely limited

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<v Speaker 2>and problematic. There is a consistent background that the literature

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<v Speaker 2>gives us studying how can we clinically applicate critical concepts?

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<v Speaker 2>We are dealing with a narrow, confined space where discuss

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<v Speaker 2>theory stricts the flow. On top of that, we often

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<v Speaker 2>face closed ended systems where vapor loucks prevent the arrogant

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<v Speaker 2>from the reaching the epical area, not to mention the

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<v Speaker 2>fluid exchange, and there is debris, dent and chips, organic tissues, biofilms,

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<v Speaker 2>all of the accumulates and things inside the canal that

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<v Speaker 2>creates barriers. So even when we think we irrigate properly,

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<v Speaker 2>in reality, large portions of the canal are not flooded

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<v Speaker 2>with our arrogant, which we need really important in our treatment.

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<v Speaker 1>So basically they tell us that we have to find

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<v Speaker 1>the balance between the taper of the instruments that we

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<v Speaker 1>are using, the diameter of our epical preparation, the irregent

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<v Speaker 1>that we choose at the time that we spend while

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<v Speaker 1>doing this clinical step. For example, in this case it's

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<v Speaker 1>it's valentize it. Of course, you see that I opened

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<v Speaker 1>the access cavity and then I use files from the

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<v Speaker 1>ataperchase this step. I'm not using any irrigant because the

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<v Speaker 1>file can just navigate inside the GUTA. Person's kind of soft,

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<v Speaker 1>so I don't really need to labricate them. But between

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<v Speaker 1>every file I will irrigate to remove or the debris

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<v Speaker 1>that I'm creating with my shaping. As we saw in

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<v Speaker 1>the last episode, what you see here is that my

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<v Speaker 1>typical diameter is sixty So I did an epical plug

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<v Speaker 1>with MTA, and you see that all the case leads

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<v Speaker 1>to the resolution of the epical patology.

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<v Speaker 2>Nowadays, we are moving towards conservative shaping protocol, or we

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<v Speaker 2>can call it minimally invasive heated antics to preserve the

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<v Speaker 2>two structure, and that creates a paradox. The more conservative

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<v Speaker 2>we are, the harder it becomes to deliver the arrogant

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<v Speaker 2>effectively into the canal. Because of the shapes and tapers,

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<v Speaker 2>and that's where technique becomes critical. Let's consider needed literation.

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<v Speaker 2>In ideal conditions, a twenty seven gauge needle can reach

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<v Speaker 2>about three milimeters from the apex in straight canals. A

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<v Speaker 2>thirty gauge needle can perform slightly better in curved canals,

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<v Speaker 2>but in conservative shaping, the needle offense go beyond four

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<v Speaker 2>milimeters from the apex. That means that the most critical area,

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<v Speaker 2>the epical third, is precisely where irrigation becomes the least effective.

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<v Speaker 1>Yeah, and we know that increasing the epical preparation size

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<v Speaker 1>can improve our penetration of the irrogant because a larger

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<v Speaker 1>canal allows for a better flow, better exchange of irrogant,

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<v Speaker 1>and more effective clinic. But clinically speaking, this is not

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<v Speaker 1>always feasible. We cannot achieve this all the time. And

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<v Speaker 1>also there are some studies that tell us that we

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<v Speaker 1>have to go over the size of twenty five if

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<v Speaker 1>we want to make sure that our irrogant can arrive

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<v Speaker 1>to the epical third and be effective. But some odd

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<v Speaker 1>studies tell us that there is no really significant difference

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<v Speaker 1>between a preparation of twenty five or six and thirty

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<v Speaker 1>zero four if we use a performing polypropylenk for example.

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<v Speaker 2>So it's controversial, I agree, and so we need to

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<v Speaker 2>follow strict clinical guidelines. You would sind needles ideally thirty

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<v Speaker 2>gauge needles. Prefer side vented designs, of course, because we

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<v Speaker 2>need to have lateral cheer stresses on the latter walls.

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<v Speaker 2>Stay two to three eleven short of the working lens.

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<v Speaker 2>Never bind the needle inside the canal because we might

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<v Speaker 2>have an accident by doing that, And never force the

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<v Speaker 2>arrogant because that also leads an accident. There are simple rules,

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<v Speaker 2>but they make a huge difference. If you want to

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<v Speaker 2>improve the effectiveness of our irrigation, we can act on

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<v Speaker 2>several parameters. Time, concentration of the solution volume, temperature is

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<v Speaker 2>very important. Combination of arrogance because we need to remove

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<v Speaker 2>all the organic and inorganic words, activation, shaping, type of

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<v Speaker 2>the needle, and irrigation depth.

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<v Speaker 1>Yeah, but let's move to chemistry, because not all irrigation

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<v Speaker 1>is created equal. I mean, so the hypochlorrite remains the

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<v Speaker 1>gold standard and its effectiveness depends mainly on concentration time

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<v Speaker 1>and renewal and higher concentration. Yes, they provide a faster

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<v Speaker 1>tissue dissolution, stronger antibacterial action, and deeper penetration into the

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<v Speaker 1>dentinal tubules. But there's note ones here. Increasing concentration does

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<v Speaker 1>not necessarily improve the biofilm removal and complex anatomis like

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<v Speaker 1>isthmus tis or lateral canals, and it doesn't significantly affect

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<v Speaker 1>the post operative pain either. So again it's not just

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<v Speaker 1>about more is better, It's about how we manage the

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<v Speaker 1>irregan dynamically.

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<v Speaker 2>That's very important and I agree with that. And one

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<v Speaker 2>of the most important underestimated factors in irrigation is the

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<v Speaker 2>refreshment keeping flowing. A refreshed solution, fresh solution and arrogant

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<v Speaker 2>loses effectiveness quickly once it reacts with organic tissue, so

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<v Speaker 2>frequent replacement is essential. In fact, a lower concentration that

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<v Speaker 2>is consequently and continuously refreshed can perform at a high

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<v Speaker 2>concentration left stagnant. And we have additional variables temperature, as

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<v Speaker 2>I said before, volume irrigation depths, combination with other solutions

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<v Speaker 2>like edita or surfactants to improve the pendeftation into the

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<v Speaker 2>inaccessible areas. All of these influenced the final outcome.

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<v Speaker 1>Yeah, and as we you were saying temperature is also

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<v Speaker 1>important because heating sodium hypochlorte could enhance the chemical properties

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<v Speaker 1>of the solution by increasing its reaction rate. And we

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<v Speaker 1>can warm sodium hypocrite either outside or inside the canal,

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<v Speaker 1>but it seems like intercanala heating is more effective then

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<v Speaker 1>preheating sodium hyperchorrite and then put it into the syringe

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<v Speaker 1>and deliver it into the roocanal system. And how can

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<v Speaker 1>we clinically achieve this Well, we can do it by

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<v Speaker 1>activating the solution, for example with ultrasonics or with laser devices.

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<v Speaker 2>A very interesting article by but UKs traces some guidelines

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<v Speaker 2>to irrigate effectively. At this point, we can summarize everything

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<v Speaker 2>into five key principles of irrigation delivery. First, deliver the

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<v Speaker 2>arrogant to the entire root canal system. That's logic, of course. Second,

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<v Speaker 2>refresh it frequently because we need fresh We need fresh

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<v Speaker 2>reactions to perform its action. Third, generate sheer stresses where

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<v Speaker 2>it matters, we need side vented needles because it generates

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<v Speaker 2>a lot of lateral stresses which can clear the root

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<v Speaker 2>canals well. Laterally, Fourth, allow reverse flow for proper exchange.

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<v Speaker 2>We need to eliminate anything that prevents any potential lack

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<v Speaker 2>of exchange. Fifth, always prevent extrusion, avoid accidents. And these

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<v Speaker 2>are not optional, These are not extravaganza. These are essential.

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<v Speaker 1>Yeah, And preventing excusion is particularly important and we will

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<v Speaker 1>discuss maybe in another episode about this. But we need

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<v Speaker 1>to be aware of the risk factors such as large

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<v Speaker 1>for amina or root resoortion or an incorrect positioning of

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<v Speaker 1>the needle, because improper irrigation is not just ineffective, it

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<v Speaker 1>can be dangerous. And if there's one concept that really

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<v Speaker 1>changes the game, it's activation. Yes, because irrigation without movement

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<v Speaker 1>is passive and so it's limited. It cannot go where

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<v Speaker 1>we really need it. So when we activate the irregant,

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<v Speaker 1>we increase share stress, we improve the penetration, and we

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<v Speaker 1>disrupt the biofilm more than just leaving the irregant inside

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<v Speaker 1>of the rock canal and waiting for it to be effective.

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<v Speaker 2>And the numbers are really impressive because tissue dissolution can

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<v Speaker 2>be up to twelve times faster with continuous agitation. We

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<v Speaker 2>have several options manual dynamic activation by vibrating the master cone.

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<v Speaker 2>We have some ext systems. We have ultrasonic devices, pressure

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<v Speaker 2>alternating systems, laser activation, other message multisonic activation, or specific

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<v Speaker 2>devices like the pulp soccer. Each method has its own advantage,

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<v Speaker 2>but they all share the same goal. We have to

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<v Speaker 2>move and keep the arrogant moving inside the root canal effectively.

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<v Speaker 1>Yeah, and one aspect that maybe is interesting more for

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<v Speaker 1>the patient than for our cell is post operative pain.

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<v Speaker 1>Because every technique can lead to some postoperative pain, some

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<v Speaker 1>extrusion of the hypochloride. But it seems that the application

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<v Speaker 1>of agitation technique like laser activation, ultrasonic variation, gentle wave

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<v Speaker 1>or end of that can result in less or similar

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<v Speaker 1>post operative pain compared to serinjurrigation with no significant difference

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<v Speaker 1>among these activation. So maybe it's better to activate our

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<v Speaker 1>irrigant even to try to reduce the post operatunity pay

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<v Speaker 1>for the patient.

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<v Speaker 2>You know what, Francisca, The problem is that we are

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<v Speaker 2>missing a protocol. This is our problem. They say that volumes, application, time, activation, etc.

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<v Speaker 2>Should be standardized, but no one has done it yet.

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<v Speaker 2>In our retreatment book to Stylitaro retreatment books, in the

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<v Speaker 2>chapter by Ricardotonini and Francisca Shruti, we try to clarify

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<v Speaker 2>these steps. First of all, the arrogant used during the

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<v Speaker 2>shaping phase only has the function to lubricate the files

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<v Speaker 2>and remove the debris. This is the main function during

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<v Speaker 2>the shaping.

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<v Speaker 1>Exactly, so the proper irrigation starts when we are ready

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<v Speaker 1>to alternate. Exactly when we are done with our shaping them.

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<v Speaker 1>We irrigate and we start counting how many millimeters of

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<v Speaker 1>irrigant we are using, So in that phrase we pothesize

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<v Speaker 1>like the minimum that we can do. It's like using

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<v Speaker 1>almost ten millimeters of sodium hyprocyte perucnal delivered slowly drop

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<v Speaker 1>by drop, and each couple of milliliters we activate and

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<v Speaker 1>then we were fresh, and then we activate again. And

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<v Speaker 1>so after this we are taking care of the organic part.

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<v Speaker 1>We can just wash out all the sodium hyperchorrite with

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<v Speaker 1>distal water and use a couple of milliliters of edita

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<v Speaker 1>pero canal delivered in the same way, activated in the

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<v Speaker 1>same way. And then we know that since dita opens

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<v Speaker 1>the tubules, if we do one more passage of sodium

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<v Speaker 1>hyper right after this is going to go deeper. It's

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<v Speaker 1>going to be more effective. So why not we can

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<v Speaker 1>do this again and last, since we don't want and

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<v Speaker 1>it can make an interaction between our sailor and our irrigant,

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<v Speaker 1>we wash everything away with some distill water.

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<v Speaker 2>I think this is the real takeaway. So what you

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<v Speaker 2>have just said is a real protocol that we follow

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<v Speaker 2>day to day in our practice and it is really

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<v Speaker 2>important and guys, please listen to that many times because

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<v Speaker 2>it's really important. So the real takeaway again is that

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<v Speaker 2>irrigation is not a simple rink just flow some liquid

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<v Speaker 2>inside the real canal. It is a controlled, dynamic and

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<v Speaker 2>highly technical process. It requires understanding of the fluid dynamics, chemistry,

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<v Speaker 2>anatomy and the technique that you are using, all working together.

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<v Speaker 2>So you have to think think about that thoroughly because

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<v Speaker 2>in the end, irrigation is not a waste of time.

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<v Speaker 2>It really is the most important part of our treatment.

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<v Speaker 1>Yeah, it's because it's the core of disinfection, and disinfection

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<v Speaker 1>is the core of the end around its success. And

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<v Speaker 1>so thank you everyone for listening. We hope you liked

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<v Speaker 1>these indications about irrigation and stay tuned for the next

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<v Speaker 1>EPIDO of Indocast. Bye bye bye,