TETRACLEAN: A contribution to root canal cleaning

Dr. Luciano Giardino

The aim of endodontic therapy is to remove the infection and root out the bacteria from the root canal system (Sjogren U, Fidgor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with periapical periodontitits Int. End. J 1997; 30(5): 297-306). The instrumentation is unable to root out the bacterial load by itself (Bystrom A, Sundqvist G. Bacteriologic evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scan J Dent Res 1981; 89(4): 321-8). These findings have been confirmed by subsequent works, as well, such as Dalton et Al.s (Dalton BC et Al. bacterial reduction with nickel-titanium rotary instrumentation. J Endod 1998; 24(11): 763-7), which pointed out that there is no noticeable difference in root canal cleaning when rotary or manual instruments are used. During the instrumentation phase the main function of the irrigants is to remove the debris from the root canal: thanks to the synergy between instrumentation and irrigation the number of bacteria inside the root canal is significantly reduced (Siqueira JF, et al. Mechanical reduction of the bacterial population in the root canal by three instrumentation techniques. J Endod 1999; 25(5): 332-5). As Radcliffe pointed out (Radcliffe CE et Al: Antimicrobial activity of varying concentrations of sodium hypochlorite on the endodontic microrganisms Actinomices Israelii, A. naeslundii Candida Albicans and Enterococcus Faecalis Int. Endod. J 2004; 37: 438-46) the action of sodium hypochlorite is made difficult by the anatomical complexity of the endodontium (pic 1), by the polymicrobial nature of the bacterial flora (pic 2), by the presence of the biofilm (pic 3) and by the presence of the smear layer (pic 4) produced by our instruments. Moreover the endodontic environment proves to be very hostile to the irrigants. Haapasalo and colleagues (Haapasalo M, Qian W, Portenier I, Waltimo T. Effects of Dentin on the antimicrobial properties of endodontic medicaments. J Endodon 2007; 33(8): 917-925) indicated the interactions between irrigants and intermediate medications used in vivo.

Collagen, hydroxyapatite, serum proteins and dentin can strongly inhibit the action of various substances used in the cleaning of the root canal system. Dentin, for example, acts as a buffer both with acid and basic substances. Sodium hypochlorite is unable to remove any bacterial load, after a one-hour incubation, if the irrigant has been preincubated with dentin powder 24 hours before use. Other substances, such as the organic ones, can interfere with the action of the irrigants. 20% of the dentin biomass is made up of Type I Collagen; remaining necrotic pulp tissue and inflammatory secretion, which can accumulate in the root canal from the various foramina, are to be added. Another aspect, connected to the decrease in the action of the disinfectants, is linked to their very mechanism of action. In order to remove the bacterial load there must be contact between the bacterial wall and the irrigant. The dynamics of the action contemplates on the one hand a reduction of the bacterial load but, at the same time, a progressive inactivation of the used substances. Moreover, a decrease in the results is always observed when switching from in vitro to in vivo experimentations. There are several possible reasons that may explain this (Haapasalo M. et Al. 2007): in addition to the already mentioned inactivation mechanisms of the drugs inside the canals, the irrigants have a short exposition time and a reduced total volume: this means that only a very limited amount of irrigant comes into contact with the bacteria and for a time that is always too limited. Inside our canals most of the bacteria are linked together in a highly organized structure, the biofilm (pics 5,6), able to resist the removal action in various ways. The bacteria in the biofilm are immersed in a matrix, called glycocalyx, that acts as a mechanical barrier against antibacterial agents. During its evolution, the biofilm releases bacteria that infect, in planktonic form, the surrounding space. The biofilm is more resistant to the action of antibiotics like doxycycline, amoxycycline and metronidazole. The final result of all these actions is that the biofilm turns out to be 1000 times more resistant than the bacteria in planktonic form (Svensater G, Bergenholtz G. Biofilms in endodontics infections. Endodontic Topics 2004; 9: 27-36). In 2003 Torabinejad suggested to use a universal irrigant which, used with 1.3% Sodium Hypochlorite, would be able to remove the smear layer from the root canal

walls (Torabinejad M et Al A new solution for the removal of smear layer. J Endod 2003; 29: 170-5) and make it easier to get rid of the Enterococcus Faecalis from the infected dentin (Shabahang S, Torabinejad M. Effects of MTAD on Enterococcus Faecalis contaminated root canals of extracted human teeth. J Endod 2003; 29: 5769). This irrigant is a mixture of Doxycycline (an antibiotic of the tetracycline group), Citric Acid and a surfactant (Tweed 80). Citric acid acts as a chelating agent, assisted by a weak action of the antibiotic, while the surfactant should make its penetration in the root canal system easier. Despite a long series of articles promoted by Torabinejads team stressed its efficiency, other articles showed important limitations. Tay and colleagues (Tay et Al Ultrastructure of smear layer covered intraradicular dentin after irrigation with BioPure MTAD J. Endod 2006; 32(3): 218-21) showed that the composite is too aggressive on the intertubular dentin, resulting in a marked reduction of the exposed collagen matrix . Ruff and colleagues underlined its complete inefficiency against fungi (Ruff ML, McClanahan SB, Babel BS. In vitro antifungal efficacy of four irrigants as a final rinse. J Endod 2006; 32(4): 331-3) while Dunavant (Dunavant TR et Al. Comparative evaluation of endodontic irrigants against Enterococcus Faecalis biofilms. J Endodon 2006; 32(6): 527-31) noticed that Sodium Hypochlorite was more efficient in eliminating the biofilm while Clegg and colleagues (Clegg MS et Al. The effects of exposure to irrigants solution on apical dentin biofilm in vitro. J Endodon 2006; 32(5): 434-7) underlined the inability of this product to remove the biofilm from the third apical. A study carried out on a biofilm model published by Giardino and colleagues (Giardino L, Ambu E, Rimondini R, Savoldi E, Cassanelli C, Debbia EA Comparative evaluation of antimicrobial efficacy of Sodium Hypochlorite, MTAD and Tetraclean against Enterococcus faecalis biofilm. J Endodon 2007; 33(7): 852-5) confirmed the very poor aIn 2004 Luciano Giardino patented an irrigant prototype, always antibiotic-based, called Tetraclean. It is similar to MTAD, although showing important differences: the amount of doxycycline is reduced to a third (50mg/5ml vs. 150mg/5ml of MTAD) Polypropylene glycol Citric acid and cetrimide

The researches to validate the effectiveness of the product were conducted in cooperation with the University of Genoa, with the team from the University of Modena-Reggio Emilia, with Dr. Emanuele Ambu, holding the Chair of Endodontics at the same University and his team, with Professors Mario and Renato Leonardo and Dr. Fernanda Pappen from Araraquara University of Sao Paulo, Brazil , Prof. M. Haapasalo Dean of British Columbia University, Professors Sandro Rengo, P. Ausiello, A. Valletta, F. Riccitiello, M. Amato, M. Simeone, Dr. F.A. DApolito, Dr. G. Spagnuolo, Dr. V. DAnt, Dr. C. DAmbrosio, Dr. P. Carrat of the Department of Odontostomatologic and Maxillofacial Sciences, Department of Endodontics, University of Naples Federico II. The base research made it possible to verify that Tetraclean is active, in agar, on the bacteria responsible of primary endodontic infections, such as Prevotella Intermedia and the Porphyiromonas Gingivalis (pics 8,9) (L. Giardino, E. Ambu, R. Rimondini, E.A. Debbia Antimicrobial effect of MTAD, Tetraclean, Cloreximid and Sodium Hypochlorite on three common endodontic pathogens. IJDR 2009 in press) and on the Enterococcus Faecalis causing an inhibition area larger than the one determined by Sodium Hypochlorite (Giardino L, Ambu E, Generali L, Savoldi E. Effetto antimicrobico di due nuovi irriganti nei confronti dellEnterococcus faecalis: studio comparativo in vitro. G It Endo 2006; 20(2); 91-94). ction of MTAD on this structure (pic 7) .
The trials were also performed in dirty conditions (Tab 1) and also in these cases Tetraclean passed the European validation tests (Test for the Evaluation of Bactericidal Activity Dilution-Neutralization Method EN 1276 1997) (Neglia R, et Al. Comparative in vitro and ex vivo studies on the bactericidal activity of Tetraclean, a new generation endodontic irrigant, and sodium hypochlorite. New Microbiologica: 2008; 31, 57-65).

Tetraclean, vice versa, seems to have no action at all after the irrigation (its behaviour being similar to the nutrient broth), but exerts its action progressively during the subsequent 72 hours until it completely eradicates the bacterial loads in all the examined samples. The hypotheses on this behaviour are partially linked to the bacteriostatic action of the doxycycline and partially to its substantivity, i.e. it quickly binds to the dentin and is subsequently released without losing its antibacterial activity; this property creates a reserve of active antibacterial agent which is slowly and steadily released from the dentinal surface.

However the problem seems to be more complex. During the speculative phase, the authors have conjectured that the behaviour of Sodium Hypochlorite is quite linear: its antibacterial action is very strong because it completely eliminates the bacterial load from the root canal surface. However, due to the difficulties to penetrate into dentinal tubules, as showed by Elio Berutti and colleagues (Berutti E, Marini R, Angeretti A. Penetration ability of different irrigants into dentinal tubules. J Endodon 1997, 23(12), 725-7), Sodium Hypochlorite is not able to reach the deepest areas of the root canal system: for this reason these areas represent reservoirs of infection for the recontamination of the root canal system. Tetraclean is probably able to penetrate these structures and exert its action over the time, thus eliminating the bacterial strains under development. In order to confirm this hypothesis another study was carried out its preliminary findings were presented by Ambu and Giardino at the 2007 SIE Congress held in Naples while the final results, in publishing, were presented for the first time at the SIE National Congress held in Turin in November 2008. In this research the authors investigated the tubular penetration of 5.25% Sodium Hypochlorite and Tetraclean, marking the irrigants and observing the samples with a polarized optical microscope and a confocal laser microscope. The findings of this experience confirm that Tetraclean is able to penetrate deep into dentinal tubules (6-700) (pics 14,15)while the action of Sodium Hypochlorite is usually confined to the root canal surface(pic 16).