This article explains why hydrogen peroxide is no longer recommended in endodontic treatments, supported by contemporary scientific evidence. The discussion includes biochemical limitations, risks, and the superiority of modern irrigants such as sodium hypochlorite and EDTA.
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Hydrogen peroxide (H₂O₂) was widely used for decades in root canal therapy due to its effervescence and perceived cleaning capability. However, current endodontic literature strongly discourages its use.
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Modern research demonstrates that H₂O₂ lacks essential chemical properties needed for root canal disinfection and introduces several clinical risks. Today, evidence-based endodontics prioritizes irrigants that dissolve tissue, eradicate biofilms, and maintain biocompatibility, criteria that hydrogen peroxide fails to meet.
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➤ Lack of Organic Tissue Dissolution
A primary goal of irrigation is the dissolution of necrotic and vital pulp tissue. Unlike sodium hypochlorite, hydrogen peroxide cannot break down organic matter, significantly limiting its cleaning and disinfecting effects. Haapasalo et al. (2010) emphasize that irrigants must chemically degrade tissue to support mechanical instrumentation, a function H₂O₂ does not provide.
➤ Insufficient Antimicrobial Effect
Modern studies confirm that hydrogen peroxide has weak antibacterial action and is ineffective against biofilms, particularly Enterococcus faecalis, a key pathogen in persistent endodontic infections (Zehnder, 2006). This makes it inadequate as a primary or adjunctive irrigant.
➤ Risk of Oxygen Release and Subcutaneous Emphysema
Hydrogen peroxide decomposes into water and oxygen gas upon contact with catalase in tissues. This reaction may cause:
▪️ Apical extrusion of gas
▪️ Pain and pressure
▪️ Subcutaneous emphysema, a documented complication (McDonnell et al., 1982)
Because of these risks, contemporary guidelines reject its intracanal use.
➤ No Effect on Smear Layer Removal
EDTA is the gold standard for eliminating smear layer. Hydrogen peroxide cannot chelate or remove inorganic debris, leaving dentinal tubules obstructed and preventing adequate seal and penetration of medicaments or sealers (Torabinejad & Walton, 2015).
➤ Incompatibility with Sodium Hypochlorite
Studies show that mixing or alternating H₂O₂ and NaOCl results in foam production and reduced hypochlorite efficacy, compromising the cleaning process (Zehnder, 2006). This makes hydrogen peroxide incompatible with the irrigant that forms the foundation of modern endodontics.
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Based on current evidence, clinicians should adhere to the following irrigant sequence for predictable outcomes:
1. Sodium hypochlorite (NaOCl) as the primary irrigant
2. EDTA for smear layer removal
3. Final NaOCl rinse or CHX (never mixed with NaOCl)
4. Optional activation (ultrasonic or sonic)
Hydrogen peroxide should not be included under any circumstance.
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Hydrogen peroxide was historically used for its effervescence, but modern endodontics no longer supports its use. Scientific literature consistently demonstrates that it lacks the biochemical properties required for effective canal disinfection, poses clinical risks due to oxygen release, and is inferior to contemporary irrigants. For safe, predictable, and evidence-based treatment, clinicians should rely on NaOCl, EDTA, and irrigant activation protocols, fully abandoning H₂O₂.
📚 References
✔ Haapasalo, M., Shen, Y., Wang, Z., & Gao, Y. (2010). Irrigation in endodontics. Dental Clinics of North America, 54(2), 291–312. https://doi.org/10.1016/j.cden.2009.12.001
✔ McDonnell, G., Russell, A. D., & Hugo, W. B. (1982). The mechanism of hydrogen peroxide action. Journal of Antimicrobial Chemotherapy, 10(5), 389–393.
✔ Torabinejad, M., & Walton, R. E. (2015). Principles and Practice of Endodontics (5th ed.). Saunders.
✔ Zehnder, M. (2006). Root canal irrigants. Journal of Endodontics, 32(5), 389–398. https://doi.org/10.1016/j.joen.2005.09.014
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