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Maiola EC, Boppré LM, Savaris JM, Dias Junior LCDL, Garcia LDFR, Teixeira CDS, Bortoluzzi EA. Did in-between rinsing and agitating with distilled water prevents precipitate formation by the interaction between sodium hypochlorite and chlorhexidine canal irrigants? Microsc Res Tech 2024; 87:315-325. [PMID: 37811954 DOI: 10.1002/jemt.24435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/16/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
The interaction of sodium hypochlorite (NaOCl) and chlorhexidine gluconate (CHX) produces an orange-brown precipitate. The present study evaluated the influence of distilled water (H2 O) in different irrigation protocols designed to prevent the formation of precipitate with NaOCl and CHX. Fifty canine teeth were instrumented and split longitudinally. The canal was examined with a stereomicroscope and photographed by canal-thirds. The tooth halves were repositioned and distributed randomly into five groups, according to the final irrigation protocol (n = 10): G1 (control)-Ethylenediaminetetraacetic acid (EDTA) + NaOCl + CHX, conventional irrigation (CI); G2-EDTA + NaOCl + CHX, activated with passive ultrasonic irrigation (PUI); G3-EDTA (PUI) + NaOCl (PUI) + H2 O (CI) + CHX (PUI); G4-EDTA + NaOCl + H2 O + CHX (PUI); G5-EDTA (PUI) + NaOCl (PUI) + H2 O (continuous ultrasonic irrigation [CUI]) + CHX (PUI). The specimens were evaluated with a stereomicroscope and scanning electron microscope (SEM). Energy dispersive x-ray spectroscopy analysis was performed to identify the elemental profile of the irrigated canal walls. The images were scored according to the extensiveness of precipitate. Data were analyzed (Kruskal-Wallis test, α = 5%). Under the stereomicroscope, G1 had significantly higher scores than all the other groups in all canal-thirds (p < .05). All four experimental groups showed similar scores (p > .05). There were no significant differences in precipitate formation among root-thirds in intragroup analysis (p > .05). Upon SEM examination, overall, only G5 had lower scores than G1 (p < .05). Analysis by canal-thirds showed no significant difference among groups and among canal-thirds in the intragroup analysis (p > .05). G1 showed high Cl peaks. In-between irrigation with H2 O activated by CUI is effective in preventing precipitate formation during canal debridement with NaOCl and CHX. RESEARCH HIGHLIGHTS: Continuous ultrasonic irrigation with distilled water was capable to prevent the precipitate formation. The precipitate can be classified as a chemical smear layer.
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Affiliation(s)
- Emanuelle Catherine Maiola
- Postgraduate Program in Dentistry, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Letícia Mendes Boppré
- Postgraduate Program in Dentistry, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Julia Menezes Savaris
- Postgraduate Program in Dentistry, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | | | | | | | - Eduardo Antunes Bortoluzzi
- Department of Diagnosis & Oral Health, Division of Endodontics, University of Louisville, Louisville, Kentucky, USA
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Drews DJ, Nguyen AD, Diederich A, Gernhardt CR. The Interaction of Two Widely Used Endodontic Irrigants, Chlorhexidine and Sodium Hypochlorite, and Its Impact on the Disinfection Protocol during Root Canal Treatment. Antibiotics (Basel) 2023; 12:antibiotics12030589. [PMID: 36978457 PMCID: PMC10044599 DOI: 10.3390/antibiotics12030589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
In recent years, sodium hypochlorite and chlorhexidine digluconate have been the gold standard of irrigation solutions utilized within the disinfection protocol during root canal treatments. Nowadays, it is known that, during chemical disinfection of the root canal, consecutive application of sodium hypochlorite and chlorhexidine digluconate leads to the formation of an orange-brown precipitate. This precipitate is described as being chemically similar to para-chloroaniline, which is suspected to have cytotoxic and carcinogenic effects. Concerns also exist regarding its influence on the leakage of root canal fillings, coronal restorations, and tooth discoloration. The purpose of this article is to review the literature on the interaction of sodium hypochlorite and chlorhexidine digluconate on the tooth and its surrounding tissues, and to discuss the effect of the precipitate formed during root canal treatment. We further address options to avoid the formation of the precipitate and describe alternative irrigation solutions that should not interact with sodium hypochlorite or chlorhexidine digluconate.
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Affiliation(s)
- Dirk-Joachim Drews
- Private Dental Practice, 69469 Weinheim, Germany
- University Outpatient Clinic for Conservative Dentistry and Periodontology, Martin-Luther-University Halle-Wittenberg, 06112 Halle, Germany
| | - Anh Duc Nguyen
- University Outpatient Clinic for Conservative Dentistry and Periodontology, Martin-Luther-University Halle-Wittenberg, 06112 Halle, Germany
| | - Antje Diederich
- University Outpatient Clinic for Conservative Dentistry and Periodontology, Martin-Luther-University Halle-Wittenberg, 06112 Halle, Germany
| | - Christian Ralf Gernhardt
- University Outpatient Clinic for Conservative Dentistry and Periodontology, Martin-Luther-University Halle-Wittenberg, 06112 Halle, Germany
- Correspondence: ; Tel.: +49-345-557-3741
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Bueso V, Parikh N, Terlier T, Holland JN, Sarmast ND, Jeong JW. Comparative evaluation of intermediate solutions in prevention of brown precipitate formed from sodium hypochlorite and chlorhexidine gluconate. Clin Exp Dent Res 2022; 8:1591-1597. [PMID: 36102230 PMCID: PMC9760148 DOI: 10.1002/cre2.654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To evaluate intermediate treatments between sodium hypochlorite and chlorhexidine gluconate irrigations for the prevention of a toxic brown precipitate in root canal therapy. MATERIALS AND METHODS Thirty-nine premolars were irrigated with 6% sodium hypochlorite and divided into either: No intermediate treatment; Dry paper points; three different irrigations with 17% ethylenediaminetetraacetic acid, deionized water, or 5% sodium thiosulfate. 2% chlorhexidine gluconate was the final irrigant in all groups. Sectioned teeth were analyzed for brown precipitate intensity and area using stereomicroscopy and components related to para-chloroaniline using Time-of-Flight Secondary Ion Mass Spectrometry (ToF-SIMS). RESULTS Stereomicroscopy showed that 5% STS significantly reduced brown precipitate intensity and area as compared with no intermediate irrigation (p < .05, Chi-square, generalized linear model, and Tukey's multiple comparison tests). Utilizing ToF-SIMS, 5% sodium thiosulfate was most effective in reducing the components representing para-chloroaniline and chlorhexidine gluconate. CONCLUSION The 5% sodium thiosulfate was most effective among other intermediate treatments, assessed by stereomicroscopy and ToF-SIMS.
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Affiliation(s)
- Vashti Bueso
- School of DentistryThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Neha Parikh
- Department of Diagnostic and Biomedical Sciences, The University of Texas Health Science Center at HoustonSchool of DentistryHoustonTexasUSA
| | - Tanguy Terlier
- SIMS Laboratory, Shared Equipment AuthorityRice UniversityHoustonTexasUSA
| | - Julian N. Holland
- Office of Research, The University of Texas Health Science Center at HoustonSchool of DentistryHoustonTexasUSA
| | - Nima D. Sarmast
- Department of Endodontics, The University of Texas Health Science Center at HoustonSchool of DentistryHoustonTexasUSA
| | - Ji Wook Jeong
- Department of Endodontics, The University of Texas Health Science Center at HoustonSchool of DentistryHoustonTexasUSA
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Orhan EO, Irmak Ö, Hür D. What does not form after accidental sodium hypochlorite contact with chlorhexidine? Int Endod J 2022; 55:685-688. [PMID: 35511028 DOI: 10.1111/iej.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/23/2022] [Accepted: 03/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Ekim Onur Orhan
- Translational Medicine Research and Clinical Center, Eskisehir Osmangazi University, Eskisehir, Turkey.,Department of Endodontics, Faculty of Dentistry, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Özgür Irmak
- Department of Restorative Dentistry, Faculty of Dentistry, Near East University, Nicosia, Cyprus
| | - Deniz Hür
- Department of Chemistry, Faculty of Science, Eskişehir Technical University, Eskisehir, Turkey
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Terlier T, Jeong JW, Sarmast ND, Parikh N. Response to letter by Orhan et al. 2021, regarding Jeong et al. (2021) 'Assessment of the cytotoxic effects and chemical composition of the insoluble precipitate formed from sodium hypochlorite and chlorhexidine gluconate'. Int Endod J 2022; 55:689-691. [PMID: 35511029 DOI: 10.1111/iej.13730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tanguy Terlier
- SIMS Laboratory, Shared Equipment Authority, Rice University, Houston, Texas, USA
| | - Ji Wook Jeong
- Department of Endodontics, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Nima D Sarmast
- Department of Endodontics, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Neha Parikh
- Department of Diagnostic and Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Jeong JW, Sarmast ND, Terlier T, van der Hoeven R, Holland JN, Parikh N. Assessment of the cytotoxic effects and chemical composition of the insoluble precipitate formed from sodium hypochlorite and chlorhexidine gluconate. Int Endod J 2021; 54:1892-1901. [PMID: 34081782 DOI: 10.1111/iej.13583] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022]
Abstract
AIM To investigate (1) the cytotoxic potential of the brown precipitate (BP) formed with sodium hypochlorite (NaOCl) and chlorhexidine gluconate (CHX), using both a small animal model of Caenorhabditis elegans (C. elegans) and cultured human gingival fibroblasts; and (2) the chemical composition of BP using Time-of-Flight Secondary Ion Mass Spectrometry (ToF-SIMS). METHODOLOGY Brown precipitate was obtained by mixing equal volumes of 6% NaOCl and 2% CHX and separating the BP from clear supernatant by centrifugation. The brown precipitate was weighed and solubilized in dimethyl sulfoxide for cytotoxicity experiments. The cytotoxic effect of BP was assessed using C. elegans larvae and primary immortalized human gingival fibroblasts-hTERT (hTERT-hNOF) cells. Various dilutions of BP (25 ng/µL-150 ng/µL), supernatant (0.15% v/v), NaOCl (1:100-1:1000 dilutions of 6% NaOCl) or CHX (1:500-1:1000 dilutions of 2% CHX) along with vehicle control (0.5% v/v ethanol and 0.15% v/v DMSO) or untreated control (growth medium) were tested on C. elegans larvae and hTERT-hNOF cells. Viability was assessed in C. elegans larvae using stereomicroscopy and in hTERT-hNOF cells using dehydrogenase-based colorimetric assay. ToF-SIMS was used to assess the chemical composition of BP in comparison with CHX and para-chloroaniline (PCA). The C. elegans and cell line data were analysed using Log-Rank test and Student's t-test, respectively (p < .05). RESULTS BP-75 ng/µL and BP-150 ng/µL were significantly more toxic to C. elegans larvae than the untreated, vehicle, supernatant or CHX treatment groups (p < .0001). Similarly, in hTERT-hNOF cells, BP-50 ng/µL, BP-75 ng/µL and BP-150 ng/µL induced significant cytotoxicity within 2 h compared with untreated, vehicle, supernatant and CHX treatments (p < .05). ToF-SIMS analysis of BP revealed ion composition characteristic of both CHX and the carcinogen PCA. CONCLUSIONS Brown precipitate was toxic in both C. elegans larvae and hTERT-hNOF cells. The ToF-SIMS analysis of BP revealed ions characteristic of CHX and PCA that could account for the toxicities observed in C. elegans larvae and human gingival fibroblasts. Because of the insoluble and toxic nature of BP, consecutive use of CHX and NaOCl irrigants should be avoided in root canal treatment.
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Affiliation(s)
- Ji Wook Jeong
- Department of Endodontics, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nima D Sarmast
- Department of Periodontics, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tanguy Terlier
- SIMS Laboratory, Shared Equipment Authority, Rice University, Houston, TX, USA
| | - Ransome van der Hoeven
- Department of Diagnostic and Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julian N Holland
- Office of Research, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Neha Parikh
- Department of Diagnostic and Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Khatib MS, Ameer B, Ajit Mannur N, Ramalingaiahsetty AM, Peerzade SM, Bambawale A. Decoding the Perplexing Mystery of Para-Chloroaniline Formation: A Systematic Review. J Int Soc Prev Community Dent 2020; 10:142-147. [PMID: 32670901 PMCID: PMC7340001 DOI: 10.4103/jispcd.jispcd_488_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/26/2019] [Accepted: 12/30/2019] [Indexed: 11/04/2022] Open
Abstract
Objective The objective of this article was to understand and decode the mystery of the formation of para-chloroaniline (PCA). The ingredient of the brown precipitate after mixing sodium hypochlorite (NaOCl) and chlorhexidine gluconate (CHX) is still in debate. Materials and Methods Various studies adopt a different methodology to substantiate that it may contain PCA, which is a carcinogenic agent. The purpose of this systematic review is to evaluate the relationship between PCA and brown precipitate. Two reviewers independently conducted a comprehensive literature search. The MEDLINE, Embase, Cochrane, and PubMed databases were searched. In addition, the bibliographies were manually searched. There was no disagreement between the two reviewers. This review was reported and conducted in step with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Of 233 articles, only 13 articles met the inclusion criteria. Available scientific evidence was more supportive that the brown precipitate form after mixing NaOCl and CHX may form para-chloroamide moiety rather than free PCA, and PCA may be the by-product of CHX degradation. Conclusion On the basis of the current evidence and data extracted from the various databases, it can be concluded that the mixture of sodium hypochlorite and chlorhexidine does not form PCA, and PCA may be the by-product of high concentrated chlorhexidine. Further studies are required to substantiate the evidence.
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Affiliation(s)
- Mohd Sibghatullah Khatib
- Department of Conservative Dentistry and Endodontics, Dr. Syamala Reddy Dental College Hospital and Research Centre, Bangalore, India
| | - Bilal Ameer
- SJM Dental College and Hospital, Chitradurga, India
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Mohammadi Z, Shalavi S, Moeintaghavi A, Jafarzadeh H. A Review Over Benefits and Drawbacks of Combining Sodium Hypochlorite with Other Endodontic Materials. Open Dent J 2017; 11:661-669. [PMID: 29387282 PMCID: PMC5750725 DOI: 10.2174/1874210601711010661] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/03/2017] [Accepted: 11/11/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION As the root canal system considered to be complex and unpredictable, using root canal irrigants and medicaments are essential in order to enhance the disinfection of the canal. Sodium hypochlorite is the most common irrigant in endodontics. Despite its excellent antimicrobial activity and tissue solubility, sodium hypochlorite lacks some important properties such as substantivity and smear layer removing ability. OBJECTIVE The aim of this review was to address benefits and drawbacks of combining sodium hypochlorite with other root canal irrigants and medicaments. DISCUSSION According to the reviewed articles, NaOCl is the most common irrigation solution in endodontics. However, it has some drawbacks such as inability to remove smear layer. One of the drawbacks of NaOCl is its inability to remove the smear layer and lack of substantivity. CONCLUSION The adjunctive use of other materials has been suggested to improve NaOCl efficacy. Nevertheless, further studies are required in this field.
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Affiliation(s)
- Zahed Mohammadi
- Iranian Center for Endodontic Research (ICER), Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Amir Moeintaghavi
- Department of Periodontics, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Jafarzadeh
- Department of Endodontics, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
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