irigare endodontie

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Edgar Schäfer

Irrigation of the root canal

Key words

apical

periodontitis,

chlorhexidine,

disinfection,

smear layer,

sodium

hypochlorite

The root canal

system is

colonised with

microorganisms


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in cases of apical periodontitis. Currently, it is impossible to totally eliminate these microbes

purely with mechanical instrumentation. Therefore, irrigants are required to eradicate

intraradicular infection. In this article, the different actions and in-teractions of the most commonly

used irrigants are discussed and a clinical protocol suggested. t least two different irrigants

should be used to achie!e the most effecti!e reduction of intraradicular microorganisms. Edgar ch!fer

"epartment of #perati!e

"entistry,

$ni!ersity of %&nster,

'aldeyerstr. (), "-*+*

%&nster, ermany

Tel/ 0* 12 +(*3)*)

Email/ eschaef4uni-

muen-ster.de

Introduction "ulpitis versus apical periodontitis

In recent years, there ha!e been ma5or ad!ances in impro!ing

the properties of root canal instruments. Since the introduction

of nic6el-titanium alloy 78iTi9 into endodontics, nearly e!ery

month a new rotary 8iTi-system comes onto the dental mar6et.

%ore-o!er, there are se!eral new products and root canal filling

materials. $nfortunately, all these ad!ances are focused on the

technical aspects of the root canal treatment. more biologically

based approach has recei!ed less attention. There is a renewed

interest in the relationship between mechanical root canal in-

strumentation and intraradicular disinfection. Infec-tion controlduring root canal treatment is important for successful outcome

in nonsurgical root canal treatment.

Therefore, the aim of this re!iew is to analyse the rele!ant

literature on root canal irrigation. n irrigation protocol for

the e!eryday clinical practice is also proposed, including

other rele!ant recom-mendations.

The healthy pulp can be affected by se!eral irritants such as dental

caries 7bacteria and their products9, traumatic in5uries, iatrogenic

factors 7dehydration of dentine, to:ic influences from filling

materials, and lea6age of the restoration9 and, !ery seldom, sys-

temic influences 7nutritional deficiencies9. ;i6e all other connecti!e

tissues in the body, the pulp reacts to these irritants with

inflammation. %ost frequent-ly, an inflammatory reaction in the pulp

is caused by bacteria from a profound carious lesion, since denti-nal

tubules are portals of entry for these bacteria, bacterial antigens and

tissue brea6down products to reach the pulp tissue but e!en at this stage,

the remaining !ital pulp tissue will defend itself against the in!ad-ing

microbes2 and thus the infection will remain rel-

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1# Schäfer Root canal irrigation

ati!ely superficial. In the more apical part of the root canal, most of the pulp tissue will be !ital and free of bacteria at this

point of the disease?.

"ue to this microbial aetiology of pulpitis, it is clear that the treatment of irre!ersible pulpitis, in other words the treatment of !ital

cases, should focus on pre!ention of infection rather than an elimination of intraradicular infection *. s the apical part of the root

canal system is bacteria free, the aim is asepsis3. $nder clinical conditions, the easiest and by far the most efficient methods to

guarantee asepsis during endodontic treatment are coronal disinfection of the tooth and mandatory use of rubber dam. %oreo!er,

sterilised burs and root canal instruments must be used, glo!es must be worn, and the root canal obturation should if possible be

performed at the first !isit?


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ment with another report in as far

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in healing between teeth filled after epositi!ezor

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negati!e root canal cultures was obser!ed3.

Endodontic infection$ localisation of %icroorganis%s

In general, endodontic infection can be di!ided into primary 7primary apical periodontitis9 or secondary root canal infection

7pre!iously root-filled teeth with apical periodontitis9. In general, primary root canal infection is characterised by strictly anaerobic

bacteria and is typically polymicrobial1,+ less than )


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action of the cellular 7phagocytes9 and molecular

7antibodies, complement system9 host defences1,1.

The microbes sur!i!e on pulp tissue remnants and

e:udate from the periodontium1), the reason why in

most cases intraradicular microbes are mostly locat-ed

in the apical part of the root canal system1(. These

microorganisms at the apical part of the root canal are

usually delineated from the inflamed periapical tissues

either by a dense accumulation of polymor-phonuclear

neutrophils or by an epithelial plug near the apical

foramen1,1(. s a result, these microbes are protected

from the host defences. 'ithin the root canal these

microorganisms are organised on the surface of the

canal walls as an aggregation in an e:-tracellular

polysaccharide matri:, the so-called Dbiofilm(),(.

$nfortunately, microbes organised in a biofilm are

about )))-fold more resistant to antimi-crobial agents

than their plan6tonic counterparts that e:ist in the root

canal(1.

'hen intraradicular infection is not adequately treated,

microorganisms will penetrate from the main root canal

into dentinal tubules, lateral canals, and other canal

irregularities. The in!asion of dentine is es-timated to

occur in appro:imately 2)


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tissue damage are caused by bacteria enHymes 7e.g.

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collagenase, hyaluronidase9, e:oto:ins and metabo-

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lites 7e.g. butyrate, ammonium, sulphur compounds9, and other bacterial

components, such as peptidogly-cans, teichoic acid and lipopolysaccharides1,(+.

The lipopolysaccharide, in particular, seems to be capable of causing se!ere

tissue destruction by stimulating the de!elopment of host immune reaction1. The

endo-to:in is located in the outer membrane of ram-neg-ati!e bacteria and is

able, as mentioned abo!e, to cause tissue damage e!en in the absence of !iable

bacteria?. It has been shown in an animal model that placing lipopolysaccharide

in empty sterile root canals led to the de!elopment of periapical lesions(. In pulp

tissue of teeth associated with apical periodontitis, high le!els of

lipopolysaccharides were found*), and there was a strong association between

lipopolysac-charide le!els and the pre!alence of ram-negati!e bacteria*.

These obser!ations that bacterial metabo-lites and brea6down products play a

significant role in the pathogenesis of apical periodontitis? confirmed the need for

a root canal irrigant capable of neutralis-ing lipopolysaccharides.

%icrobes can also reside in the root canal system within the smear layer. This is

a thin surface film formed on the root canal wall after instrumentation. smear

layer is produced on areas touched by root canal instruments. The smear layer

consists of den-tine particles, bacterial components, and remnants of !ital or

necrotic pulp tissue*1,*(. "ue to these organ-ic remnants, the microbes ha!e easy

access to nutri-ents inside the smear layer. Therefore, it is clear that in infected

cases the smear layer should be re-


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'ig 1 ram-positi!e bacteria that ha!e penetrated into the dentinal tubules 7ram> original magnifica-tion *)):9.

E8"# 1))3>79/-13

1( Schäfer Root canal irrigation

mo!ed to achie!e the greatest possible reduction of intraradicularmicroorganisms.

E:traradicular infections may occur, but they are rare?,1. $sually, they may occur in

the form of an acute periradicular abscess or in cases of actinomycosis 1. The

problem with e:traradicular infection is that microbes are established in the

periradicular tissues, inaccessible to nonsurgical endodontic treatment procedures.

s a result, e:traradicular infection may cause endodontic failure. There is

o!erwhelming e!idence in the litera-ture that microorganisms left in the root canal

system after root canal preparation or re-infection of the root filled tooth 7secondary

infection9, are the main causes of endodontic failure*,3,*,12.

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'ig & Scanning electron micrograph of multiple accessory

foramina on the pulp chamber floor of a mandibular molar

7original magnification +):9.

Root canal instru%entation and bacterial

reduction

"ue to its comple: anatomy, with the multiple fins, isthmuses,

ramifications and accessory canals** 7Big 19, it is !irtually impossible

for mechanical root canal instrumentation to shape and clean the

entire root canal system*2. Intraradicular microbes may be lodged in

these areas, which are inaccessible to in-strumentation?. In addition,

this comple: en!iron-ment pre!ents irrigants from e:erting their full

an-timicrobial potential*. ppro:imately 3 of all per-manent

molars ha!e accessory canals in the furcation area*? 7Big (9. These

canals may ha!e diameters of up


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'ig # Aost-operati!e radiograph showing a lateral root canal that is

partially filled with sealer and associated with a lateral lesion 7see circled

area9.

to 1)) Gm, so microbes can easily penetrate from the root canal

system into the periodontal tissues or !ice !ersa. Therefore,

nowadays an adhesi!e seal of the pulp chamber floor, after the

obturation of the root canal space, is recommended to a!oid re-

infection of the root canal system !ia the periodontium*?.

Classic Scandina!ian studies by Fystrm and Sundq!ist clearly

indicated that mechanical instru-mentation is able to reduce

significantly the number of microbes in the root canal system*3


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Clinical studies performed in Scandina!ia showed

that copious irrigation with an antimicrobial solution

during mechanical root canal preparation has an

essential effect on the reduction of intraradicular

microorganisms*3,*+,22. %echanical root canal

preparation using saline as an irrigant lea!es only

about 1) of canals bacteria-free. The percentage

of bacteria-free canals was increased to up to 2)when 8a#Cl was used for irrigation. $ltrasonic

acti!ation of sodium hypochlorite achie!ed a further

reduction of intraradicular microbes, with

appro:imately 3) of all canals bacteria-free.

These studies confirmed the paramount importance

of antibacterial irrigation solutions. The employment

of one or more antimicrobial irrigation solutions

during root canal treatment is good clinical practice.

odiu% hypochlorite

Sodium hypochlorite 78a#Cl9 is the most widely

used irrigation solution in endodontics. Currently

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a!ailable e!idence strongly indicates that 8a#Cl is

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. In water, 8a#Cl dissociates in-

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to 8a0 and #Cl-, the hypochlorite ion. Fetween p= * and p= 3, chlorine from

8a#Cl e:ists predomi-nantly as =Cl# 7hypochlorous acid9, whereas abo!e

p= , #Cl- predominates*,2. lthough the antimi-crobial effecti!eness of

hypochlorous acid is greater than that of hypochlorite2, in the clinically used

8a#Cl solutions, the entire a!ailable chlorine is in the form of #Cl-

, as thep= of the solution is normally about 13,?). $nfortunately, due to se!eral

technical problems 7e.g. stability of the solution9, 8a#Cl solu-tions with a

lower p=, which would increase the amount of a!ailable hypochlorous acid,

are not com-mercially a!ailable at present3.

In endodontic therapy, 8a#Cl solutions are used in concentrations !arying

from ).2 to 2.12*. lso a!ailable are unbuffered solutions at p=


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äfer

t canal irrigation


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Canal wall


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paration

rotary nic6el-

um instru-


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ts/ a9 using

l as an irrigant,

sing 8a#Cl for

ation. 8otice


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when using

Cl nearly no

nants of pulpal

e or debris


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found on the

l wall 7original

nification *):9.

y root-filled teeth with apical periodontitis1?, E. faecalis is much

e resistant to 8a#Cl than the aforementioned microbes.

we!er, despite the re-duced effecti!eness of 8a#Cl against E.

alis, 8a#Cl has the unique ability to disrupt or to remo!e

biofilms3


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tissue-dissolution capability and the antimi-crobial efficiency as well

he to:icity of 8a#Cl is dependent on the concentration of the

tion. The higher the concentration of the solution the greater the

to:icity+1


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'ig , Ecchymosis due to accidentally in5ection of 8a#Cl be-yond the ape:. Clinical situation

two wee6s after this com-plication.

tor and in dar6 bottles to a!oid degradation caused by light.

8a#Cl is caustic if accidentally e:truded into pe-riapical tissues or ad5acent anatomical

structures such as the ma:illary sinus?. In the case of accidental in-5ection of 8a#Cl

into periapical tissues, emphysema may de!elop within )


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d all

ed, as the two irrigants in combinationi

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thanzfor

E. faecalis in concentrations much lower e

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each component alone3. lthough this synergistic

mechanism of C=M and hydrogen pero:ide has not been

elucidated in detail, it may be speculated that C=M denatures

the bacterial cell walls and creates pores in the membrane,

resulting in a more perme-able cell wall3, which then allows

hydrogen pero:-ide to penetrate the microbes and damage

intracel-lular organelles such as "83. similar synergistic

effect has also been shown for C=M and hydrogen pero:ide

when used as an antiplaque mouth rinse+. =owe!er, there

are no clinical studies at present that ha!e in!estigated the

potential synergistic effect of these irrigants against

intraradicular microbes*. Since a combination of C=M and

carbamide pero:ide was found to be additi!e in their

cytoto:icity, an as-sessment of the biocompatibility of this

combination is urgently required before any clinical

recommenda-tions are made*.

$nli6e 8a#Cl, C=M does not possess any tissue-

dissol!ing ability*,1), and is unable to remo!e the smear

layer or neutralise lipopolysaccharides, which are ob!iousbenefits of 8a#Cl. It is only because of these differences

that C=M cannot be a substitute for 8a#Cl as the gold

standard of root canal irrig-ants. lso, C=M seems to be

less effecti!e against ram-negati!e bacteria 7which


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dominate in pri-mary endodontic infection91. Burther wea6nesses of C=M

ude its susceptibility to the presence of organic material> the antimicrobial

ct of C=M is strongly reduced by the presence of dentine, in-flammatory

dates, serum albumin, dentine ma-tri:, and heat-6illed cells of E. faecalis

C. albi-cans2+,11


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alone. In other words, the combination of the solu-

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tions 6illed E. faecalis in concentrations much lower

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than each irrigant could alone?,3. Certainly this topic warrants further in!estigation as the mecha-nism has yet to be fully

understood*.

In conclusion, there is no scientific e!idence indi-cating that =1#1 may be superior to other irrigants*.

'ig - Arecipitation of chlorhe:idine when mi:ed with 8a#Cl.

3ydrogen pero0ide

=ydrogen pero:ide 7=1#19 is used in dentistry in !arious

concentrations ranging from to ()*. Bor endodontic treatment, a

concentration between ( and 2 is preferred. Solutions of =1#1 are

chemically stable and =1#1 is acti!e against bacte-ria, yeasts, and

!iruses* due to the production of hy-dro:y free radicals 7N#=9. Theseradicals attac6 se!-eral cell components such as proteins and "8*,2.

The antimicrobial efficiency and the tissue-dis-sol!ing capacity of

=1#1 are poor in comparison with 8a#Cl. It was pre!iously

thought that an irri-gation protocol employing 8a#Cl and =1#1

alter-nately could ha!e beneficial effects on canal clean-liness and

reduce intraradicular microorganisms, but this has not been

substantiated scientifically. Se!er-al studies showed that a

combination of 8a#Cl and =1#1 resulted in a mar6ed reduction in

both the tis-sue dissolution capacity and the antibacterial effi-

ciency of 8a#Cl?,12. In fact, a combination of these two solutions

resulted in a bubbling effect as a result of the chemical reaction.


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of teeth*). nother concern is the high concentration of tetracycline in %T"> re-

sistance to tetracycline is not uncommon among bac-teria isolated from root

canals*. In fact, a higher in-cidence of tetracycline-resistant bacteria must be

e:-

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of antibi-

pected in future years. The local applicationi

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otics must be !iewed !ery critically, as theespectrumsz

ssen

of some antibiotics are narrower than commonly used antimicrobial

irrigating solutions3,2. ccording to Qehnder, the Duse of antibiotics

instead of biocides such as hypochlorite or chlorhe:idine appears un-

warranted3.

"henolic co%pounds

These irrigants are relati!ely ineffecti!e under clinical

conditions*1, and from reports of numerous studies there

is clear scientific e!idence that solutions con-taining

camphorated paramonochlorophenol are ir-ritating anddisplay to:ic effects on healthy tis-sues+1,*(,**. The

application of these irrigants in the root canal results in

systemic distribution*2. In gen-eral, phenolic compounds

are assessed as Dincompat-ible with a biologic approach

to endodontic treat-ment*?.

Therefore, phenolic compounds must be seen as

obsolete*3 and will not be discussed further in this

re!iew.

Irrigation solutions to re%ove the

s%ear layer

E65A

Ethylenediaminetetraacetic acid 7E"T9 as a 3

solution 7p= 39 effecti!ely remo!es the smear layer by

chelating the inorganic components of the den-tine*,*+.

E"T has almost no antibacterial acti!ity*, is highly

biocompatible, can demineralise intertubu-lar dentine

and reduces the surface hardness of root canal wall

dentine3,*. Some caution should be e:-ercised when

using E"T inside root canals because prolongede:posure to E"T may wea6en root den-tine2) and

thereby increase the ris6 of creating a per-foration during

mechanical root canal instrumenta-tion.

ccording to the results of preliminary studies, irrigation

of the root canal using alternately 8a#Cl and E"T

appears to be !ery promising2. This combination seems

to enhance the tissue-dissolution capability of

8a#Cl2,21 and is more

E8"# 1))3>79/-13


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efficient in reducing intraradicular microbes than

8a#Cl alone*

. E"T retains its calcium-comple:ingability when mi:ed with 8a#Cl, but E"T causes

8a#Cl to lose its tissue-dissol!ing capacity22.

Therefore E"T and 8a#Cl should be used

separately and E"T should ne!er be mi:ed with

8a#Cl3,2(. Burthermore, chelating agents li6e E"T

can disrupt the biofilm adhering to the root canal

wall3,2*. fter irrigation of the canals with E"T, 1 ml

of 8a#Cl should be finally used to neutralise the

acidic effects of E"T and to allow 8a#Cl to

penetrate into the dentinal tubules, which are opened

after the use of E"T.

/itric acid

Concentrations ranging from


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tion of the root canal system. Birstly, microorganisms

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embedded in the smear layer are eliminated and

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canal cleanliness is impro!ed. Secondly, it has been shown that the remo!al of

the smear layer impro!es the antimicrobial effect of intraradicular medica-ments

in the deeper layer of dentine(*,?). Therefore, either E"T or citric acid should

be included in the ir-rigation regimen 7Table 9.

Irrigants for drying the root canal

Jinsing the root canal with alcohol before obturation has been anecdotally

practised?. The basic premise is that alcohol reduces the surface tension of

irrigants and root canal sealers?1. ;owering the surface ten-sion of a fluid or a

sealer will increase the fluid flow into the dentinal tubules. Thus alcohol will spread

into the dentinal tubules and dry the root canal as it e!aporates. Therefore alcohol

might affect sealer penetration and lea6age of the root canal filling. In a recently

published study it was shown that a final rinse with 2 alcohol before root canal

obturation resulted in increased sealer penetration and conse-quently decreasedlea6age?. This is in agreement with another study demonstrating that a final rinse

with alcohol allowed better sealer co!erage than dry-ing with paper points?(.

Therefore a final rinse of appro:imately ( ml of 2 ethyl alcohol per

canal can be recommended in order to impro!e the sealing ability of the

root canal filling 7Table 9.


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'ig . #pened dentinal tubules of root canal dentine/ the smear layer was remo!ed with citric acid.

E8"# 1))3>79/-13

## Schäfer Root canal irrigation

'ig Ble:ible ()-gauge irrigation nee-dles with safety tips

78a!iTips, $ltradent, %unich, ermany9.

'ig 2 Cur!ed root canal enlarged with rotary nic6el-titanium

Ble:%aster 7P"', %unich, ermany9 to an apical siHe of )1@(2.

E!en in this cur!ed canal a pre-bent ()-gauge needle can be

inserted

to about


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/linical and technical aspects of irrigation

The most important technical aspect of root canal irri-gation is thecorrelation between the diameter of the irrigating needle and the apical

preparation siHe. Inside the root canal the effect of irrigation is limited

to (


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R Fetween instruments/ 1


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Chugal 8%, Cli!e %, Spngberg ;S. prognostic modeli

for assessment of the outcome of endodontic treatment/n

8a#Cl should always be employed throughout

effect of biologic and diagnostic !ariables. #ral Surg #ral

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canal. 'hen the shaping procedure is complet-

dodontic treatment of teeth with apical periodontitis. Int

ed, flush with a high !olume of 8a#Cl3(.

Endod 3>()/13-()?.

2.

OatebHadeh 8, Sigurdsson , Trope %. Jadiographic e!al-


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R fter shaping/ irrigation with 2 ml of E"T per

uation of periapical healing after obturation of infected root

canal for minute 7or with citric acid9. fter a fi-

canals/ an in-vivo study. Int Endod 1)))>((/?)-??.

?.

O!ist T, %olander , "ahlen , Jeit C. %icrobiological e!al-


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nal rinse of 8a#Cl, the canals should be irrigat-

uation of one- and two-!isit endodontic treatment of teeth

ed with either E"T or citric acid to remo!e the

with apical periodontitis/ a randomiHed, clinical trial.


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Endod 1))*>()/231-23?.

smear layer.

3.

Aeters ;F, !an 'in6elhoff , Fui5s B, 'esselin6 AJ. Effects

R Binal rinse/ irrigation with 1 ml of 8a#Cl per canal


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of instrumentation, irrigation and dressing with calcium hy-

dro:ide on infection in pulpless teeth with periapical bone

to neutralise the acidic effect of E"T and to al-

lesions. Int Endod 1))1>(2/(-1.


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ment cases/ chlorhe:idine. Jinse with water to re-

.

Babricius ;, "ahlen, , #hman E, %ller . Aredominant

mo!e 8a#Cl and then with a 1 chlorhe:idine

indigenous oral bacteria isolated from infected root canals

after !aried times of closure. Scand "ent Jes


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solution.

1).

+1>)/(*-**.

R #ptional, before root canal filling/ rinse with ( ml

Sundq!ist . Ta:onomy, ecology, and pathogenicity of the

root canal flora. #ral Surg #ral %ed #ral Aathol


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of alcohol per canal to dry the root canal.

*>3+/211-2().

1.

Faumgartner C, Bal6ler '. Facteria in the apical 2 mm of

infected root canals. Endod >3/(+)-(+(.

11.


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omes FAB, ;illey ", "ruc6er "F. Clinical significance of

dental root canal microflora. "ent ?>1*/*3-22.

1(.

8air A8. Aathogenesis of apical periodontitis and the cause

of endodontic failures. Crit Je! #ral Fiol %ed


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1))*>2/(*+-(+.

1*.

'altimo T%, Siren EO, Tor66o =;, #lsen I, =aapasalo %A.

References

Bungi in therapy-resistant apical periodontitis. Int Endod


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Siqueira B. Endodontic infections/ concepts, paradigms, and perspecti!es.

#ral Surg #ral %ed #ral Aathol #ral Jadiol Endod 1))1>*/1+-1(.

Isolation of Enterococcus faecalis in pre!iously root-filled canals in a

;ithuanian population. Endod 1)))/ 1?/ 2(-22.

Siqueira B r. Jocas I8. Aolymerase chain reaction-based analysis of

microorganisms associated with failed endodon-tic treatment. #ral Surg

#ral %ed #ral Aathol #ral Jadiol Endod 1))*>3/+2-*.

=aapasalo %, $dnaes T, Endal $. Aersistent, recurrent and acquired infection of

the root canal system posttreatment. Endodontic Topics 1))(>?/1-2?.

8air A8. ;ight and electron microscopic studies of root canal flora and

periapical lesions. Endod +3>(/ 1-(.

Costerton ', ;ewandows6i Q, "eFeer ", Caldwell ", Oorber ", ames .

Fiofilms, the customiHed microniche. Facteriol *>3?/1(3-1*1.

'ilson %. Susceptibility of oral bacterial biofilms to antimi-crobial agents.

%ed %icrobiol ?>**/3-+3.

Sho!elton "=. The presence and distribution of microorgan-isms within non-!ital

teeth. Fr "ent ?*>3/)-)3.

Vrsta!i6 ", =aapasalo %. "isinfection by endodontic irrig-ants and dressings of

e:perimentally infected dentinal tubules. Endod "ent Traumatol )>?/*1-*.

E8"# 1))3>79/-13


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äfer Root canal irrigation


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hte


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s ;F, 'esselin6 AJ, %oorer 'J. Aenetration of bacteria

Farnett B, Ste!ens J=. Efficacy of bacterial re-

!ine root dentine in !itro. Int Endod 1)))>((/1+-(?.


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from instrumented root canals innvitro relatedvorbehalten to in-

rs ;F, 'esselin6 AJ, Fui5s B, Pan 'in6elhoff . Piable

ation technique and siHe. #ral Surge#ral %edz#ral

eria in root dentinal tubules of teeth with apical peri-

ol #ral Jadiol Endod 1))1>*/(??-(3.

en


71/110

ntitis. Endod 1))>13/3?-+.

eira B r, Jocas I8, Santos SJ, ;ima OC, %agalhaes B,

J%, en6inson =B. In!asion of dentinal tubules by oral

Heda %. Efficacy of instrumentation techniques and ir-

eria. Crit Je! #ral Fiol %ed 1))1>(/3-+(.

on regiments in reducing the bacterial population

SA, %egh5i S, 'ilson %, Jeddi O, 'hite A, =enderson

n root canal. Endod 1))1>1+/+-+*.


72/110

acterially induced bone destruction/ mechanisms and

onnell , Jussell ". ntiseptics and disinfectants/ ac-

onceptions. Infect Immun ?>?*/1(3-1(+).

, action, and resistance. Clin %icrobial Je!

er T, Torabine5ad %. Jadiographic and histologic

>1/*3-3.

uation of the effect of endoto:in on the periapical tis-?). Brais S, 8g L;, ulabi!ala O. Some factors affecting the


73/110

of the cat. Endod +>3/(-(2.

entration of a!ailable chlorine in commercial sources of

in F, Schilder =. Endoto:in content in endodontically

m hypochlorite. Int Endod 1))>(*/1)?-12.

!ed teeth. Endod 32>/-1.

der %, Oosic6i ", ;uder =, Sener F, 'altimo T. Tissue-

Wn , FergenholtH . Endoto:in acti!ity in teeth with

ol!ing capacity and antibacterial effect of buffered and

otic pulp. "ent Jes +)>2/)((-)*).

uffered hypochlorite solutions. #ral Surg #ral %ed


74/110

dini S, Falleri A, Berrari %. E!aluation of lyde Bile Arep

Aathol #ral Jadiol Endod 1))1>*/32?-3?1.

mbination with sodium hypochlorite as a root canal ir-?1. Oaufman L, Oeila S. =ypersensiti!ity to sodium hypochlo-

t. Endod 1))1>1+/())-()(.

Endod +>2/11*-11?.

t ", Joane F, oerig C. Cleaning and shaping the


75/110

s6an %O, Tur6un %, lper S. llergy to sodium

canal system. In/ Cohen S, Furns JC 7eds9. Aathways

chlorite during root canal therapy/ a case report. Int

e Aulp. ?th ed. St. ;ouis, $S/ %osby Lear Foo6,

od *>13/?(-?3.

*.

da6is C, ;ambrianidis T, Foura A. Immunologic e!alua-

'. Qur natomie der 'urHel6anäle des menschlichen

of dental patient with history of hypersensiti!ity reac-


76/110

sses mit Fer&c6sichtigung der feinen PerHweigungen

to sodium hypochlorite. Endod "ent Traumatol

oramen api6ale. SchweiH Piertel5ahresschr Qahnheil6

)>?/+*-+3.

3>/-2(.

nni 8, Thoma O, Qehnder %. Soft tissue dissolution ca-

s #. Current challenges and concepts in the preparation

y of currently used and potential endodontic irrigants.

ot canal systems/ a re!iew. Endod 1))*>()/22-2?3.


77/110

dod 1))*>()/3+2-3+3.

masch6e T, 'itt %, #tt O, Schäfer E. Scanning elec-

mgartner C, %ader C;. scanning electron microscop-

microscopic in!estigation of incidence, location, and

aluation of four root canal irrigation regimens. Endod

of accessory foramina in primary and permanent mo-

3>(/*3-23.


78/110

Xuintessence Int 1))*>(2/?-3)2.

erreH =, ofre , Pillena B. Scanning electron micro-

rm , Sundq!ist . Facteriologic e!aluation of the ef-

e study on the action of endodontic irrigants on bacte-

of ).2 percent sodium hypochlorite in endodontic ther-

!ading the dentinal tubules. #ral Surg #ral %ed #ral

#ral Surg #ral %ed #ral Aathol +(>22/()3-(1.

ol )>?/*-2).


79/110


80/110

bility of human pulp tissue in calcium hydro:ide and sodi-

ndod +2>+/(2-*).

ypochlorite. Endod "ent Traumatol 1>+/)*-)+.

A', =enry S, Cano P, Pera . %icrobial status of apical

I, ;eonardo %J, ssed S, Tanomaru Bilho %.

canal system of human mandibular first molars with

ological study of the effect of some irrigating solutions

ary apical periodontitis after Yone-!isitZ endodontic

acterial endoto:in in dogs. FraH "ent 1))*>2/)-

ment. #ral Surg #ral %ed #ral Aathol #ral Jadiol


81/110

od 1))2>/1(-121.

inoff , #;eary T, %iller C=. The comparati!e effec-

on FC, Vrsta!i6 ", Ahillips C, Aettiette %, Trope %.

ess of !arious agents in deto:ifying diseased root sur-

erial reduction with nic6el-titanium rotary instrumenta-

s. Aeriodontol +(>2*/33-+).

Endod +>1*/3?(-3?3.


82/110

er TO, Crwawford . The deto:ifying effect of !arying

a!i6 ", Oere6es O, %ol!en #. Effects of e:tensi!e api-

entrations of sodium hypochlorite on endoto:ins.

eaming and calcium hydro:ide dressing on bacterial in-

od +1>+/2-??.

on during treatment of apical periodontitis/ a pilot

ada JS, rmas , oldman %, ;in AS. scanning elec-

y. Int Endod >1*/-3.

microscopic comparison of a high !olume final flush


83/110

te-uillot %A, Fadet C, Aeli B, AereH B. Effect of nic6-

se!eral irrigating solutions/ Aart (. Endod

anium rotary file techniques on infected root dentin re-

(>/(3-*1.

on. #ral Surg #ral %ed #ral Aathol #ral Jadiol Endod

omb ", Smith "C, Feagrie S. The results of in vivo

?>)1/12*-12+.

odontic chemomechanical instrumentation/ a scan-

eira B r, ;ima OC, %agalhaes B, ;opes =A, de $Heda


84/110

electron microscopy study. Fr Endod Soc

echanical reduction of the bacterial population in the

>/-+.

canal by three instrumentation techniques, Endod

mo T%, Vrsta!i6 ", Siren EO, =aapasalo %A. n vitro

>12/((1-((2.

eptibility of Candida albicans to four disinfectants and

6y ;, I!anyi I, rigar , BaHe6as . ntimicrobial effica-

combinations. Int Endod >(1/*1-*1.


85/110

!arious root canal preparation techniques/ an in vitro

cliffe CE, Aotouridou ;, Xuereshi J, =abahdeh 8,

parati!e study. Endod 1))1/1+/?)(-?)2.

through , 'orthington =, "ruc6er "F. ntimicrobial

ping F, Vrsta!i6 ", Sirgurdsson , Trope %.

ity of !arying concentrations of sodium hypochlorite

uction of intracanal bacteria using nic6el-titanium ro-

e endodontic microorganisms !ctinomyces israelii, !.

instrumentation and !arious medications. Endod

slundii, Candida albicans and Enterococcus faecalis.


86/110

)>1?/32-322.

ndod 1))*>(3/*(+-**?.

# 1))3>79/-13

na %E, omes FA, Ferber PF, Qaia , BerraH CC, de

Ha-Bilho B;. n vitro e!aluation of the antimicrobial acti!ity

lorhe:idine and sodium hypochlorite. #ral Surg #ral %ed

Aathol #ral Jadiol Endod 1))*>3/3-+*.

es FA, BerraH CC, Pianna %E, Ferber PF, Tei:eira BF, de

a-Bilho B. n vitro antimicrobial acti!ity of se!eral

entrations of sodium hypochlorite and chlorhe:idine gluconate

e elimination of Enterococcus faecalis. Int Endod

>(*/*1*-*1+.

tt ", Aratten , 'ilson %, ulabi!ala O. n in vitro

uation of the antimicrobial efficacy of irrigants on biofilms of

canal isolates. Int Endod 1))>(*/())-()3.

"una!ant TJ, Jegan ", lic6man 8, Solomon ES, =oneyman ;. Comparati!e

e!aluation of endodontic irri-gants against Enterococcus faecalis biofilms. Endod

1))?>(1/213-2(.

Clegg %S, Pertucci B, 'al6er C, Felanger %, Fritto ;J. The effect of e:posure to irrigant solutions

on apical dentin biofilms in !itro. Endod 1))?>(1/*(*-*(3.

Spngberg ;, Engstrm F, ;angeland O. Fiologic effects of dental materials. (. To:icity and

antimicrobial effect of en-dodontic antiseptics in vitro. #ral Surg #ral %ed #ral Aathol

3(>(?/+2?-+3.

Aashley E;, Firdsong, 8;, Fowman O, Aashley "=. Cytoto:ic effects of 8a#Cl on !ital

tissue. Endod +2>/212-21+.

Chang LC, =uang B%, Tai O', Chou %L. The effect of sodium hypochlorite and

chlorhe:idine on cultured human periodontal ligament cells. #ral Surg #ral %ed #ral Aathol

#ral Jadiol Endod 1))>1/**?-*2).

C!e6 %, 8ord CE, =ollender ;. ntimicrobial effect of root canal debridement in teeth with

immature root/ a clinical and microbiologic study. #dontol Je!y 3?>13/-).


87/110

s , 'altimo T, SchaetHle %, Qehnder %. The effects of

perature on sodium hypochlorite short-term stability, pulp

olution capacity, and antimicrobial efficacy. Endod

2>(/??-?3.

rer 'J, 'esselin6 AJ. Bactors promoting the tissue

ol!ing capability of sodium hypochlorite. Int Endod

1>2/+3-?.

ningham 'T, Fale65ian L. Effect of temperature on

gen-dissol!ing ability of sodium hypochlorite en-dodontic

ant. #ral Surg #ral %ed #ral Aathol +)>*/32-33.

buris , Far6er T=, Farfield J", EleaHer A". Jemo!al of

nic debris from bo!ine dentin sha!ings. Endod

(>1/22-2?.

nigham 'T, oseph S'. Effect of temperature on the

ericidal action of sodium hypochlorite endodontic ir-rigant.

Surg #ral %ed #ral Aathol +)>2)/2?-23.

-Jass %, #glesby S'. The effects of temperature,

entration, and tissue type on the sol!ent ability of sodi-um

chlorite. Endod +>3/(3?-(33.

F=, Safa!i OE, Spngberg ;S. ntifungal effects of sodi-

ypochlorite and chlorhe:idine in root canals. Endod

>12/1(2-1(+.

r 8S, EleaHer A", #!erbach J", SeltHer S. Scanning electron

oscopic study on the efficacy of !arious irriga-tion solutions.

od 32>/13-(2.

ley C%, pplegate F, 8agel C, =all ". Jeal-time im-aging

quantification of bioluminescent bacteria in root canals in vitro.

dod 1))*>()/+(-++.

n F, Tur6un %. Stability of !arious sodium hypochlorite

ions. Endod 2>1/12(-122.

mann %, =ahn '. Complications during root canal ir-

on/ literature re!iew and case reports. Int Endod

)>((/+?-(.

py

o

r

i

g



88/110

hte

Q

vorbehalten

3.

u

Schäfer E, Fssmann O. ntimicrobial efficacy of chloro:-

i

ylenol and chlorhe:idine in the treatment of infected root


89/110

ls. m "ent 1))>*/1((-1(3.

heim F, ermann T=, Fircher . Chlorhe:idine ana-

en

phyla:is/ case report and re!iew of the literature. Contact

"ermatitis 1))*>2)/(-?.

.

Lesilsoy C, 'hita6er E, Cle!eland ", Ahillips E, Trope %.

ntimicrobial and to:ic effects of established and potential


90/110

canal irrigants. Endod 2>1/2(-22.

Southard SJ, "ris6o C;, Oilloy ', Cobb C%, Tira "E. The

t of 1.) chlorhe:idine digluconate irrigation on clin-

parameters and the le!el of Bacteroides "in"ivales in

periodontal pic6ets. Aeriodontol +>?)/()1-().

).

Schäfer E, Fssmann O. ntimicrobial efficacy of chlorhe:i-

dine and two calcium hydro:ide formulations against

Enterococcus faecalis. Endod 1))2>(/2(-2?.


91/110

masch6e T, Schneider $, Stratmann $, %o6rys O, Loo

Schäfer E. Effect of root canal dressings on the repair of

med periapical tissue. cta #dontol

nd

2>?(/*(-21.

)(.

Tanomaru Bilho %, ;eonardo %J, Sil!a ;F, nibal BB,

Bacciolo ;=. Inflammatory response to different endodon-

tic irrigation solutions. Int Endod 1))1>(2/3(2-3(.

)*.

Qamany , Safa!i O, Spngberg ;S. The effect of chlorhe:-


92/110

as an endodontic disinfectant. #ral Surg #ral %ed

Aathol #ral Jadiol Endod 1))(>?/23+-2+.

ey ;=, Joed-Aetersen , =usum F. naphylactic reac-

in anaesthetised patients/ four cases of chlorhe:idine

allergy. cta naesthesiol Scand 1))>*2/1)-1*.

)?.

Fasrani F, Santos %, T5aederhane ;, rad =, orduysus #,

=uang et al. Substanti!e antimicrobial acti!ity in chlorhe:-

idine-treated human root dentin. #ral Surg #ral %ed #ral


93/110

ol #ral Jadiol Endod 1))1>*/1*)-1*2.

ag #, =osgor %, =ilmioglu S, Qe6ioglu #, Eronat C,

anoglu ". Comparison of antibacterial and to:ic effects

rious root canal irrigants. Int Endod 1))(>(?/*1(-*(1.

)+.

Tanomaru Bilho %, ;eonardo %J, da Sil!a ;F. Effect of ir-

rigation solution and calcium hydro:ide root canal dressing

on the repair of apical and periapical tissues of teeth with

periapical lesion. Endod 1))1>1+/12-1.


94/110


95/110

EO, =aapasalo %A, Janta O, Salmi A, Oerosuo E8.

obiological findings and clinical treatment procedures

dodontic cases selected for microbiological in!estiga-

. Int Endod 3>()/-2.

1.

Jlla , ;oe =, Schiott CJ. Jetention of chlorhe:idine in

the human oral ca!ity. rch #ral Fiol 3>?/)-?.

(.

Jlla , ;oe =, Schiott CJ. The affinity of chlorhe:idine for

hydro:yapatite and sali!ary mucins. Aeriodontal Jes


96/110

)>2/)-2.

e JJ, aner ;J, =ays ;. Jesidual antimicrobial acti!i-

sociated with a chlorhe:idine endodontic irrigant used

sodium hypochlorite. m "ent >1/*+-2).

"ona F;, rundemann ;, Steinfort , Timmerman %B, !an

der 'ei5den . The inhibitory effect of combining

chlorhe:idine and hydrogen pero:ide on (-day plaque ac-

cumulation. Clin Aeriodontol +>12/+3-++(.


97/110

g I, Chandler %A. ntimicrobial effect of irrigant combi-

ns within dentinal tubules. Int Endod +>(/+-*.

nberg ", =eling I, "aniel I, insburg I. ntibacterial

rgistic effect of chlorhe:idine and hydrogen pero:ide

against Streptococcus sobrinus, Streptococcus faecalis

and Staphylococcusaureus. #ral

Jehabil

>1?/2-2?.

# 1))3>79/-13


98/110


ch =, 'urHburger F, Jubin L;, Sinens6y %C, Flau ;. n in vitro study on the

o:icity of chlorhe:idine diglu-conate to human gingi!al cells. Cell Fiol To:icol

2>/3-++.

A8, S5gren $, Orey , Oahnberg OE, Sundq!ist . Intraradicular bacteria and fungi in

filled, asympto-matic human teeth with therapy-resistant periapical lesions/ a long-term

and electron microscopic follow-up study. Endod )>?/2+)-2++.

son C. Susceptibility of !arious microorganisms to chlorhe:idine. Scand "ent Jes

3>+2/122-1?2.

el %, Aatterson SS, 8ewton C', %iller %. n vivo e!aluation of chlorhe:idine

onate solution and sodium hypochlorite solution as root canal irrigants. Endod

1>+/1))-1)*.

enier I, =aapasalo =, Vrsta!i6 ", Lamauchi %, =aapasalo %. Inacti!ation of the

acterial acti!ity of io-dine potassium iodide and chlorhe:idine digluconate against

rococcus faecalis by dentin, dentin matri:, type-I collagen, and heat-6illed microbial

e cells. Endod 1))1>1+/?(*-?(3.

enier I, =aapasalo =, Jye , 'altimo T, Vrsta!i6 ", =aapasalo %. Inacti!ation of root

l medicaments by dentine, hydro:ylapatite and bo!ine serum albumin. Int Endod

>(*/+*-++.

nell S. The use of antimicrobial in the mouth. Int %ed Jes +>/133-1+1.

eira B r, %achado , Sil!eira J%, ;opes =A, de $Heda %. E!aluation of the

ti!eness of sodium hypochlorite used with three irrigation methods in the elim-ination of

rococcus faecalis from the root canal, in vitro. Int Endod 3>()/13-1+1.

mgartner C, Ibay C. The chemical reactions of irrigants used for root canal debridement.

d +3>(/*3-2.

nder , Jeit C, "ahlen . The antimicrobial effect of calcium hydro:ide in root

ls pretreated with 2 iodine potassium iodide. Endod "ent Traumatol >2/1)2-

gberg ;, Jutberg %, Jydinge E. Fiologic effects of en-dodontic antimicrobial agents. Endod

2/??-32.

pasalo =O, Siren EO, 'altimo T%, Vrsta!i6 ", =aapasalo %A. Inacti!ation of local

canal medicaments by dentine/ an in vitro study. Int Endod 1)))>((/1?-(.

FeltH JE, Torabine5ad %, Aouresmail %. Xuantitati!e analy-sis of

the solubiliHing action of %T", sodium hypochlorite, and E"TS

on bo!ine pulp and dentin. Endod 1))(>1/((*-((3.

Torabine5ad %, Cho L, Ohademi , Fa6land ;O, Shabahang S.

The effect of !arious concentrations of sodi-um hypochlorite on the

ability of %T" to remo!e the smear layer. Endod 1))(>1/1((-

1(.

Qhang ', Torabine5ad %, ;i L. E!aluation of cytoto:icity of %T"

using the %TT-tetraHolium method. Endod 1))(>1/?2*-?23.

%achni6 TO, Torabine5ad %, %unoH C, Shabahang . Effect of

%T" on the bond strength to enamel and dentin. Endod

1))(>1/++-+13.

%achni6 TO, Torabine5ad %, %unoH C, Shabahang . Effect of%T" on fle:ural strength and modulus of elas-ticity of dentin.

Endod 1))(>1/3*3-32).

Shabahang S, Aouresmail %, Torabine5ad %. n vitro an-timicrobial

efficacy of %T" and sodium. Endod 1))(>1/*2)-*21.

Shabahang S, Torabine5ad %. Effect of %T" on Enterococcus

faecalis-contaminated root canals of e:tract-ed human teeth.

Endod 1))(>1/23?-23.

Torabine5ad %, Shabahang S, precio J%, Oettering ". The

antimicrobial effect of %T"/ an in vitro in!estigation. Endod

1))(/1/*))-*)(.

py


99/110

h

Rechte

t

b


100/110

(+. Oho A,F aumgartner C. comparison of the antimicro-

bial efficiency of

i

8a#Cl@Fiopuren%T"vorbehalten!ersus

8a#Cl@E"T against

t

.

Endodz

Enterococcus faecalise


101/110

?>(1/?21-?22.

en

%;, %cClanahan SF, Fabel FS. n vitro antifungal ef-

y of four irrigants as a final rinse. Endod

?>(1/((-(((.

*).

Tay BJ, %aHHoni , Aashley "=, "ay TE, 8goh EC, Freschi

;. Aotential iatrogenic tetracycline staining of endodontical-

ly treated teeth !ia 8a#Cl@%T" irrigation/ a preliminary

report. Endod 1))?>(1/(2*-(2+.

*.

"ahlen , Samuelsson ', %olander , Jeit C.

Identification and antimicrobial susceptibility of Enterococci

isolated from the root canal. #ral %icrobiol Immunol

1)))>2/()-(1.


102/110


103/110


104/110

tures. Endod 1))1>1+/3-.

ashita C, Tanomaru Bilho %, ;eonardo %J, Jossi %,

;. Scanning electron microscopic study of the clean-

ability of chlorhe:idine as a root-canal irrigant. Int

od 1))(>(?/(-(*.

', Loshio6a T, Oobayashi C, Suda =. scanning elec-

microscopic study of dentinal erosion by final irrigation

with E"T and 8a#Cl solutions. Int Endod 1))1>(2/(*-

(.

2(.

rawehr %, Sener F, 'altimo T, Qehnder %. Interaction of

ethylenediamine tetraacetic acid with sodium hypochlorite

in aqueous solutions. Int Endod 1))(>(?/*-*3.

2*.

Fonsor S, 8ichol J, Jeid T%, Aearson . n alternati!e reg-

imen for root canal disinfection. Fr "ent 1))?>11/)-)2.


105/110

mann ;, Saunders 'A, 8guyen ;, ou IL, Saunders

$ltrasonic root-end preparation. Aart . SE% analysis.

ndod *>13/(+-(1*.

hado-Sil!eiro ;B, onHales-;opes S, onHales-

rigueH %A. "ecalcification of root canal dentine by cit-

cid, E"T and sodium citrate. Int Endod 1))*>(3/(?2-

23.

Lamaguchi %, Loshida O, SuHu6i J, 8a6amura =. Joot

canal irrigation with citric acid solution. Endod

?>11/13-1.

2+.

"i ;enarda J, Cadenaro %, SbaiHero #. Effecti!eness of

mol ;- citric acid and 2 E"T irrigation on smear layer

remo!al. Int Endod 1)))>((/*?-21.


106/110

Ha %B, Tei:eira %, ScelHa A. "ecalcifying effect of

-T, ) citric acid, and 3 E"T on root canal

n. #ral Surg #ral %ed #ral Aathol #ral Jadiol Endod

1))(>2/1(*-1(?.

# 1))3>79/-13

pasalo %, Vrsta!i6 ". n vitro infection and disinfec-tion of

nal tubules. "ent Jes +3>??/(32-(3.

ens J', Strother %, %cClanaban SF. ;ea6age and sealer

tration in smear-free dentin after a final rinse with 2nol. Endod 1))?>(1/3+2-3++.

ningham 'T, Cole S, Fale65ian L. Effect of alcohol on the

ading ability of 8a#Cl endodontic irrigant. #ral Surg #ral %ed

Aathol +1>2*/(((-((2.

o: ;J, 'iemann =. Effect of a final alcohol rinse on

er co!erage of obturated root canals. Endod

2>1/12?-12+.

Sedgley C%, 8agel C, =all ", pplegate F. Influence of irrigant needle depth in remo!ing

bioluminescent bacteria inoculated into instrumented root canals using real-time im-aging in vitro.

Int Endod 1))2>(+/3-)*.

py

o

r


107/110

fer

canal irrigation

hte

b

y

Q

vorbehalten

?2. %cur6in-Smith J, Trope %,

u


108/110

", Sigurdsson .

uction of intracanal bacteria using T rotary instrumen-

n, 2.12 8a#Cl, E"T,

#=91. Endod

2>(/(2-(?(.

ssen

??. =&lsmann %, Aeters #, "ummer

A%=. %echanical

preparation of root canals/ shaping goals, techniques and

means. Endodontic Topics 1))2>)/()-3?.

?3. Schäfer E, Plassis, %. Comparati!e in!estigation of two ro-tary nic6el-titanium

instruments/ AroTaper !ersus JaCe. Aart 1. Cleaning effecti!eness and shaping ability in

se!ere-ly cur!ed root canals of e:tracted teeth. Int Endod 1))*>(3/1(-1*+.

?+. Tepel , Schäfer E, =oppe '. Ounststoffe als %odellmaterial in der Endodontie. "tsch

QahnärHtl Q (>*+/3(?-3(+.


109/110


110/110

irigare endodontie

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