Chlorhexidine in Endodontics

Chemical auxiliary substances (CAS) are essential for a successful disinfection and cleanness of the root canals, being used during the instrumentation and if necessary, as antimicrobial intracanal medicaments. Different CAS have been proposed and used, among which sodium hypochlorite (NaOCl), chlorhexidine (CHX), 17% EDTA, citric acid, MTAD and 37% phosphoric acid solution. CHX has been used in Endodontics as an irrigating substance or intracanal medicament, as it possesses a wide range of antimicrobial activity, substantivity (residual antimicrobial activity), lower cytotoxicity than NaOCl whilst demonstrating efficient clinical performance, lubricating properties, rheological action (present in the gel presentation, keeping the debris in suspension); it inhibits metalloproteinase, is chemically stable, does not stain cloths, it is odorless, water soluble, among other properties. CHX has been recommended as an alternative to NaOCl, especially in cases of open apex, root resorption, foramen enlargement and root perforation, due to its biocompatibility, or in cases of allergy related to bleaching solutions. The aim of this paper is to review CHX's general use in the medical field and in dentistry; its chemical structure, presentation form and storage; mechanism of action; antimicrobial activity including substantivity, effects on biofilms and endotoxins, effects on coronal and apical microbial microleakage; tissue dissolution ability; interaction with endodontic irrigants; effects on dentin bonding, metalloproteinases and collagen fibrils; its use as intracanal medicament and diffusion into the dentinal tubules; its use as disinfectant agent of obturation cones; other uses in the endodontic therapy; and possible adverse effects, cytotoxicity and genotoxicity.

Resumo Substâncias químicas auxiliares (SQA) são essenciais para o processo de limpeza e desinfecção dos canais radiculares, sendo utilizadas durante a instrumentação dos canais radiculares e, se necessário, como medicamentos intracanais. Diferentes SQA têm sido propostas e utilizadas, entre elas: hipoclorito de sódio (NaOCl), clorexidina (CHX), EDTA 17%, ácido cítrico, MTAD e solução de ácido fosfórico a 37%. CHX tem sido usada na endodontia como SQA ou medicação intracanal. CHX possui uma ampla gama de atividade antimicrobiana; substantividade (atividade antimicrobiana residual); menor citotoxicidade que NaOCl, demonstrando desempenho clínico eficiente; propriedades de lubrificação; ação reológica (presente na apresentação gel, mantendo os detritos em suspensão); inibe metaloproteinases; é quimicamente estável; não mancha tecidos; é inodora; solúvel em água; entre outras propriedades. CHX tem sido recomendada como uma alternativa ao NaOCl, especialmente em casos de ápice aberto, reabsorção radicular, perfuração radicular e durante a ampliação foraminal, devido à sua biocompatibilidade, ou em casos de alergia ao NaOCl. O objetivo deste trabalho é fazer uma revisão do uso da clorexidina na medicina e na odontologia; sua estrutura química; forma de apresentação e armazenamento; mecanismo de ação, atividade antimicrobiana, incluindo, substantividade, efeitos sobre biofilmes e endotoxinas; efeito sobre infiltração microbiana coronal e apical; capacidade de dissolução do tecido; interação com os irrigantes; efeitos sobre a união à dentina, metaloproteinases e fibrilas de colágeno; a sua utilização como medicamento intracanal e difusão ...

In vitro evaluation of fluoride and calcium sodium phosphosilicate toothpastes, on root dentine caries lesions.

OBJECTIVES: The aim of this in vitro study was to assess the effect of toothpastes containing three different sodium fluoride concentrations and a calcium sodium phosphosilicate system, on root dentine demineralization and remineralization. METHODS: During a fourteen-day pH-cycling protocol, pre-softened bovine root dentine specimens were immersed twice daily, before and after the demineralization periods, for 2 min, in the following toothpaste slurries: (a) non-fluoridated (control), (b) 7.5% calcium sodium phosphosilicate, (c) 1450 ppm F, (d) 2800 ppm F, and (e) 5000 ppm F. Subsequently, the slabs were subjected to a fifty-hour acid resistance test. Knoop microhardness at different lesion depths was assessed in specimen cross-sections and KHN values were converted to vol.% mineral. Comparisons between the groups were performed at each lesion depth through ANOVA-based tests and furthermore, regression analysis of the derived statistic of "integrated vol.% mineral loss" was carried out. Also, lesions were evaluated qualitatively using transmission and polarized light microscopy. RESULTS: The 5000 ppm F toothpaste group, during pH-cycling, presented significantly less total vol.% mineral loss and subsequently exhibited considerably increased surface acid resistance, compared to all the other tested groups. The calcium sodium phosphosilicate toothpaste, during pH-cycling, inhibited demineralization and/or promoted remineralization of the surface layers significantly more effectively than the control group nevertheless, subsequently, the acid resistance of the calcium sodium phosphosilicate dentifrice group was similar to that of the control group. These observations were confirmed by microscopic examination of the lesions. CONCLUSIONS: Under the present experimental conditions, the 5000ppm F toothpaste, promoted remineralization and inhibited demineralization more effectively, than the other tested toothpastes.

A study of the relation between erosion and microhardness of root canal dentin.

OBJECTIVE: The aim of this study was to find a relation between erosion and microhardness of root canal dentin after irrigation with different canal irrigants. STUDY DESIGN: Seventy-two single-canal human premolar teeth were selected and enlarged by rotary Protaper files. The middle part of each root was transversely sectioned to a 4-mm slice. The initial microhardness values of intact specimens were measured at depths of 100 microm and 500 microm from the pulp-dentin interface using a Vickers microhardness tester. the specimens were divided into 6 groups of 12 specimens and were treated as follows: 1: 2.6% NaOCl, 2: 17% EDTA (5 minutes) then 2.6% NaOCl (5 minutes), 3: 17% EDTA (1 minute) then 2.6% NaOCl (1 minute), 4: MTAD (5 minutes), 5: 2% Chlorhexidine (5 minutes), and 6: saline (control), respectively. Posttreatment microhardness values were obtained in the same manner as the initial ones. Afterwards, the specimens were prepared for scanning electron microscopy analysis. The amount of dentin erosion was examined. RESULTS: Group 2 showed the most erosive effect on dentin (P < .0001) along with the least decrease of dentin microhardness at depth of 100 microm, whereas MTAD showed the most reduction of dentin microhardness and less erosive effect on dentin. CONCLUSION: It can be concluded that erosion is not the main factor in decreasing the dentin microhardness, whereas the amount of irrigant penetration might be the main cause.

Tissue-dissolution capacity and dentin-disinfecting potential of calcium hydroxide mixed with irrigating solutions.

OBJECTIVE: The goal of this study was to compare the tissue-dissolution potential and antibacterial effectiveness of a conventional Ca(OH)(2)/saline paste with equivalent Ca(OH)(2)/NaOCl and Ca(OH)(2)/chlorhexidine digluconate medications. STUDY DESIGN: Tissue specimens were obtained from freshly dissected pig palates. Tissue pieces of similar form and weight were incubated in air-tight containers with Ca(OH)(2) pastes or solutions proper for up to 7 days. Antimicrobial testing was performed in dentin blocks infected with Enterococcus faecalis. Medicated, sealed dentin specimens were incubated for 1 and 5 days, and bacterial growth was tested at different dentin depths. RESULTS: Up to day 4, the Ca(OH)(2)/irrigating solution mixtures dissolved tissue more effectively than the conventional Ca(OH)(2)/saline paste. After 7 days, however, no statistically significant differences were found between the saline and hypochlorite mixtures, but the Ca(OH)(2)/chlorhexidine medication was significantly less effective. Dentin block disinfection was quicker and more thorough with the Ca(OH)(2)/chlorhexidine or the Ca(OH)(2)/NaOCl than with the Ca(OH)(2)/saline paste. CONCLUSION: Ca(OH)(2)/irrigant mixtures under investigation appear more advantageous than the conventional Ca(OH)(2)/saline mixture, and merit further investigation in a clinical study.

Permeability of the root canal wall and occlusion of dentinal tubules by Ag(NH3)2F: a comparison of combined use with pulsed Nd:YAG laser or iontophoresis.

OBJECTIVE: We used SEM-EDX and the Vickers hardness test to compare the penetration and hardness of silver resulting from use of either (i) pulsed Nd:YAG laser or (ii) iontophoresis, after root canal wall shaping using the standard method of coating with 38% Ag(NH3)2F solution. SUMMARY BACKGROUND DATA: There have not been any reports of penetration and hardness following the application of Ag(NH3)2F solution together with laser or iontophoresis. METHODS: We used 21 extracted human single-rooted teeth randomly divided into three groups. Group 1 was coated with Ag(NH3)2F, Group 2 was irradiated with a Nd:YAG laser after coating with Ag(NH3)2F solution, and Group 3 was iontophoresised after coating. Then we observed the permeability of silver through the root canal wall using SEM-EDX. RESULTS: The results show that iontophoresis after coating with Ag(NH3)2F solution (Group 3) resulted in the greatest and deepest penetration of silver into the root canal wall. There was no significant difference between teeth in Groups 1 and 2. For the hardness test, the 21 teeth were tested using SEM-EDX test, 7 untreated teeth were used as a control. The results show that Group 2 (laser treatment) teeth were the hardest. CONCLUSION: We therefore propose that root canals should be treated using irradiation with an Nd:YAG laser that has been coated with Ag(NH3)2F solution and that this method provides better results than either iontophoresis after coating, or coating alone.

An in vitro model for studying the efficacy of fluoride dentifrices in preventing root caries.

This investigation tested and validated an in vitro model for studying the effects of fluoride on human dentin mineral content and fluoride uptake. Four studies examined the effects of different concentrations of fluoride, established dose-response profiles with NaF and Na2PO3F, and tested commercial dentifrices. A 7- or 14-day cyclic treatment regimen involved four 1-min exposures of sound human dentin specimens to the treatment agents, a 4-hour acid challenge period, and 20 h in human saliva daily. Mineral content was analyzed by image analysis microradiography and fluoride assays were performed using a microdrill biopsy technique. Data from these studies established the ability of the in vitro model to provide reproducible results, to demonstrate significant dose-related differences in the effects of both NaF- and Na2PO3F-containing treatments on dentin fluoride uptake and demineralization, and to detect a fluoride-induced reduction in dentin caries, relative to a nonfluoride control, similar to results established in a clinical trial.

The possible role of pH changes during EDTA demineralization of teeth.

Demineralization of dentin is a dynamic process. The pH of EDTA solutions inside pulp cavities decreases as demineralization occurs. Increasing EDTA concentration from 0.1 mol/L to 0.5 mol/L causes a faster acid accumulation and a higher demineralization rate. The efficiency of EDTA solutions decreases as time goes on, probably because of the acid released from EDTAHNa3 (the predominating species under the neutral conditions). Not all the available EDTA reacts after a few hours. The so-called autolimitation might be due to this acidification of the EDTA solution.