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The main purpose of endodontic treatment is the successful disinfection of the entire root canal system, which can be achieved by the complete removal of microorganisms and their components and thereby prevent further reinfection during or after the therapy (Plotino et al, 2016). The main goal of the therapy is achieved by the use of chemo-mechanical debridement, in which the mechanical systems are allied with irrigating solutions (Kishen, 2010). The Aim of this essay is to summarise the recent research and protocols of chemomechanical endodontic treatments. 

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Main Body

Bacteria have been associated with the development of pulpal and periapical pathologies. Good prognosis after root canal treatment is dependent on the conscientious chemo-mechanical debridement of the tooth pulp tissue, infected dentin, and the pathological micro-organisms 
(Kandaswamy, 2010). With the complex internal anatomy of teeth, chemical debridement is an important step along side mechanical instrumentation for the proper cleaning of the canal. 

Ideal requirements of the root canal irrigation solution  (Zehnder, 2006)

Broad antimicrobial spectrum 
Ability to dissolve necrotic pulp
Ability to inactivate endotoxins 
Prevention of the formation of a “smear layer” during the mechanical cleaning procedure or dissolving ability after it has formed.
High efficacy against anaerobic micro-organisms organised in biofilms 

Standard Endodontic Irrigation Protocols

Sodium Hypochlorite (NaOCl) has been the main irrigation solution used in endodontic treatment due to its antibacterial properties and its ability to dissolve organic solvents (Zehnder, 2006). The effectiveness of solution is altered by its concentration, temperature and pH (Beus, 2012). Research has indicated that heated solutions between 45-60°C and concentration of 5 – 6% have a higher tendency to dissolve tissue (Zehnder 2006). However, with a higher concentration of sodium hypochlorite solution, there is an increased risk of adverse reaction to the body if the irrigant passes through into the periapical tissue by means or improper instrumentation  (Mehdipur, 2007). Therefore special endodontic needles and injection techniques without pressure are advised to reduced the risk of infection. 

Ultrasonic activation of sodium hypochlorite

Ultrasound can be used between 25 and 40 kHz during the root canal preparation to improve  the disinfection of the root canal. This is done by creating bubbles of positive and negative pressure in the molecules of the liquid that it interacts with. A study by Plotino et al 2007, indicated that ultrasonic activation of sodium hypochlorite significantly enhances its effectiveness in cleaning the root canal by improving the flow of the fluid, antibacterial effect, and the effective removal of the organic and inorganic debris from the root canal walls. 

2. Activation Systems

Mechanical instrumentations alone can reduce microorganisms found in the root canal, however, it cannot ensure the effective and complete disinfection.  Similarly, chemical irrigation themselves without mechanical therapy are unable to significantly reduce intracanal bacterial infections. There are multiple techniques and irrigation solutions that have been used over time which show positive results (Paragliola, 2010).

Manual Agitation Techniques

The simplest mechanical activation technique is with the use of manual irrigation agitation and the simplest method involves the vertical movement of files along the root canal. Endodontic brushes and special needles for irrigation with bristles on the surfaces is another technique which allows the irrigant to move effectively within the canal. Studies have indicated that these methods are promising for the removal of the smear layer, and therefore are indicated to be used along side EDTA (Zmener 2009).

With the successful result of the manual systems, the evolution of modern techniques have led to the introduction of mechanical instruments that are rotated by hand pieces at a low speed within the canal. Studies have shown good results for such machine assisted agitation systems (Gu et al, 2009)

Recent challenges in improving the efficacy in disinfection has led to the development of new systems introduced to the market. These systems use instruments with abrasive surfaces which help to enlarge the canal by friction and with a vibration motion allows the irrigation solution to flow into the canal through the file. This new system has shown positive results in the preservation of the anatomy of the root canal along side the effective cleaning ability, however it has a limited cutting efficiency, and so indicated to be used as an additional technique to improve the cleaning ability of the root canal system (Dietrich et al. 2012).

Other methods include sonic activation, which has shown to clean the canal, remove the smear layer and fill lateral canal. It differs from ultrasonic as it uses a lower frequency 1 – 6 kHz, therefore, it is less effective than ultrasonic systems (Bronnec et al, 2010)

Laser Activation
A new era of endodontic therapy combines the use of laser and irrigation. This method uses  laser activated irrigation and Photon initiated photo-acoustic streaming. The method assigns the effective absorption of the laser light by sodium hypochlorite, leading to the vaporisation of the irrigant and formation of bubbles that lead to secondary cavitation effects by expanding and imploding.  However, a study carried out by Pedulla et al (2012), found no significant difference between laser activated sodium hypochlorite and the use of sodium hypochlorite on its own in its effects in the reduction of bacteria within the canal.

Endodontic research has also identified alternative solutions and techniques that may further assist in the positive disinfection and complete destruction of biofilms thereby eliminating microorganisms.  Such methods include, Photo-Activated Disinfection (PAD), lasers such as diode lasers, gas lasers, YAG lasers, however, these methods are not considered as alternatives but a potential supplement to the standard protocol due to unfavourable results on their own (Bonsor 2006). 

Some alternative antibacterial systems include the use of nanoparticles of magnesium oxide, calcium oxide or zinc oxide that have antibacterial affect. these particles have the ability to change the properties of dentin and reduce the strength of bacterial adhesion to dentin (Kishen, 2008)

Conclusion

It has been evident of the important of different irrigation systems in the affective removal of micro-organisms, which provide a range of benefits in the clinical outcome of root canal treatments. However it is also clear the upcoming technologies that have been combined with new and old methods and materials may enhance everyday clinical practice. 

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