Dear Vinisha,

Traditionally is commun to use Sodium hypochlorite, but... there are individual situations for each treatment in patients, so you can use others to reach susccess purpose. e.g. EDTA to lubricate and enlarge canals in wide.....

Good luck ;-)

Hi,

Sodium hypochlorite is essential, tissue dissolution and disinfection. 

Other important is EDTA For smear layer removal

2% Chlorheksidine to widen antimicrobial 

Sodium hypoclorite (3 to 6%) is the best for dissolution of organic matherial an to kill bacterias, folowed by EDTA to remove the smear layer. Clorhexidine is a good irrigation solution, but dont dissolve the organic matherials and is not active against some bacterias. H2O2 is good after access cavity, in cases of biopulpectomy, to remove the blood.

Hi! Sodium hypochlorite(0.5-6%) is commonly used irrigant to remove organic debris whereas 15-17% EDTA is used to remove inorganic portion of the smear layer.. Also it is used as a lubricant especially with rotary instrumentation. Now -a-days 0.12-2% chlorhexidine is being used as endodontic irrigant because of its wide antimicrobial spectrum..other irrigant that are used are MTAD, Etidronate, herbal irrigant like Azadirachta indica, Curcuma longa, Propolis, Aloe Barbadrnsis Miller, morinda etc 

Provodone iodine diluted with hydrogen peroxide and EDTA.

NaOCl is the standard irrigation solution (1 - 5 %). For removal of the smear layer you can also use (unbuffered) citric acid (we do as a standard within our clinic) in concentrations from 10 - 40 %. It is cheaper and works quicker than EDTA. Citric acid is also good as an intermediate irrigation to separate Chlorhexidine from NaOCl (which is important to avoid the build- up of cloraniline that is toxic (Interaction of ChX and NaOCl)). Ethanol 70% as a final irrigant helps to dry the root canal system and enables a deeper penetration of sealers into the dentinal tubules.

Dear Vanisha,

sodium hypochlorite is the best irrigant to remove the organic  material and to kill the bacteria.2% chlorhexidine can also be used 

The question is does hypochlorite actually fill the canal at the apical 1/3rd and how long does it need to sit before it is effective.

Disrespecting clinical needs in a clinical specialty is a basic  mistake.

Don't just refer to some experimental data, even if they are repeated in thousands of thousands studies - they don't get more valid.

http://www.ncbi.nlm.nih.gov/pubmed/22972129

Cochrane Database Syst Rev. 2012 Sep 12;9:CD008948. doi: 10.1002/14651858.CD008948.pub2.

Irrigants for non-surgical root canal treatment in mature permanent teeth.

Fedorowicz Z1, Nasser M, Sequeira-Byron P, de Souza RF, Carter B, Heft M.

AUTHORS' CONCLUSIONS:

Although root canal irrigants such as sodium hypochlorite and chlorhexidine appear to be effective at reducing bacterial cultures when compared to saline, most of the studies included in this review failed to adequately report these clinically important and potentially patient-relevant outcomes. There is currently insufficient reliable evidence showing the superiority of any one individual irrigant. The strength and reliability of the supporting evidence was variable and clinicians should be aware that changes in bacterial counts or pain in the early postoperative period may not be accurate indicators of long-term success. Future trials should report both clinician-relevant and patient-preferred outcomes at clearly defined perioperative, as well as long-term, time points.

My opinion: Based on some logic thoughts, I consider it nearly impossible to get better results with NaOCl than with NaCl...

Brilliant: expert opinion and logic thoughts trounces  evidence...Not wishing to decry expert opinion but much like evidence it has known to be 'flawed' at best and potentially dangerous at worst. The Cochrane review assess the evidence for effect (based on RCTs) and its strength and direction it does NOT make recommendations.. thats where 'expert' opinion can be helpful.

If you disagree with the evidence and you have high level evidence, other than a study N of 1, then you should present it making sure that the methodological approach to collating synthesising and reporting of that evidence is robust and follows current best practice.

Dear Dr Fedorowicz,

I was torn back and forth whether to answer with the same ironic attitude. But... no. That is not really compatible with a serious discussion.    

You seem to have the conviction I would trounce evidence? But there is no evidence that NaOCl would be superior compared to saline in a clinical setting concerning outcome. Thus, I could never do for what you blame me. It is not nice to be reproached with some constructed reasons. Or did I misunderstand your post?

Without evidence, as you confirm, logical thinking/expert opinions gain importance. And that is what I wanted to do: explain, why - in my opinion! - it is unlikely that there could be established evidence in this regard.

Besides that: Yes, I can imagine that there is evidence for a superiority of a certain matarial, but this might be of academic interest, since the field on which that evidence was established may simply be irrelevant for the final outcome...

Could you please name exactly what you mean, where I should have trounced evidence? This would be quite important for me personally, because I do have the same conviction like you concerning evidence and experts, I even use the same words like you ("... dangerous at worst").

Yours Yango Pohl

The distinction between evidence and eminence based medicine/dentistry has been a counter point for discussion since the advent of the EBM 'movement'. I'm sure you will find numerous references to this in the literature. Most systematic reviews as indeed this one had pre-specified outcomes which were not designed to be of 'academic interest' and in fact had clinical relevance and included patient preferred outcomes. 

Absence of evidence is not evidence of absence and in many instances its just because the research hasnt been conducted so in these instances expert opinion even if its N of 1 trounces evidence. If evidence is available and it has been quality assessed using for example the GRADE approach it should be used to guide clinical decision making by integrating 'expert' experience ( not opinion) and patient preferences.  

Dear Dr Fedorowicz,

thank you for your hints.

I have a question: in your review you express your findings exclusively in 'negative' phrases, like: "Based on these data there was no evidence that the inter-appointment pain was different between any of the intervention groups." (p13)

Is it allowed to use 'positive' phrases: "Based on these data there was evidence that the inter-appointment pain was not different between any of the intervention groups." or "There is evidence that in all intervention groups interappointment pain was equal". When to use which, are there rules?

Kind regards

Yango Pohl

Positive or negative Im not sure about that but using the phraseology you suggest could be confusing/ send the wrong message for people who dont have a good command of the English language.

It would be most interesting to see how this was dealt with in the translated versions of the review. I think its available in spanish/ portuguese..?

I dont think Cochrane proscribes but if there was none ie NO then that would be linguistically/semantically appropriate

Perhaps I will translate into Arabic and see what we get

Yes, linguistics / semantics are extremely important for interpreting any text.

If there are just two options/values (difference "yes" and difference "no") , then "not no" is the same like "yes", and "not yes" is identical to "no".

However, the recognition by the reader is totally different, because in most situations in our daily life there are more than just two options, there is not just black or white, or at least we hope for that: We know that life ends on earth, but we don't like to be just dead, therefore we hope for or believe in a third way. Therefore a "not no" may be very different, nearly the opposite, to a "yes". At least in societies/languages I know this is true.

This means that phraseology can be used to hide or to expose certain results or aspects. Or, as you said: Changing the phraseology from "not no" to "yes" '... could be confusing/ send the wrong message...'. However, this introduces significant bias into the reviews which are considered as highest level amongst all levels of evidence. That means that the results may be eminence based yet everybody considers them highest level evidence based. This is definitely dangerous, and I wonder whether this can be overcome or what has to be done to minimize the bias.

In the actual case concerning root canal irrigants:

The phrase: "No evidence for differences" is recognized as "there is no evidence concerning irrigants at all", rather than "there is evidence that irrigants are equally effective". At least that was my impression (and therefore I wrote that post where I complained that I was blamed for trouncing evidence, while there would be no evidence at all).

From the used phraseology it seems that the authors of the review expected results showing differences between the irrigants. And that they think it is a matter of the studies which only need to be redone reporting more comprehensively the results, and evidence should be established easily, favoring actually used irrigants (NaOCl, ChX). However, this can only be assumed by the reader (as it is not clearly expressed), but indeed: that is what is happening. And if one study could have shown a significant difference between irrigants I'm quite sure that we would have read something like: there is (weak) evidence that irrigant 1 is better than irrigant 2.

However, with the same certainty it could have been concluded that "there is evidence that it is irrelevant which irrigant is used", or "there is evidence that rinsing with NaCl gives no worse / the same results like NaOCl".

Which conclusion is the correct one, taken into account that the recognition by the reader is depending on phraseology? Why did the authors decide to use the 'negative' "no evidence" phrase, but not the 'positive' "there is evidence" phrase?

I am not just a little irritated that - even with the best intention of the authors - we are facing biased eminence rather than expected evidence.

Some confusing thoughts which prevent me from falling asleep....

Regardless of type of irritant, the efficacy of irrigation affected by the followings:

1. Depth of needle penetration.

2. Storage and freshly prepared use of irrigant solution.

3. Temperature of irrigant ( warming solution better effect).

4. Concentration of solution.

5. Type of irrigant.

I might add to Mr Talabani's post-

6.refreshing the solution within the canal

7. synergistic effects of alternate use of differing solutions eg EDTA and Na Hypochlorite

However, I am not aware of an exact answer to the second half of the question "what is the most commonly used?" 

One good way is to irrigate using NaOCl solution during instrumentation of the canal and once the procedure is completed, rinsing with EDTA is recommended. There are different thoughts about the subject and one must choose the best according the the available evidence and clinical experience.

Best of luck !

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010032/

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0048513/