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intracanal medicament

Rationale and review of applications
Time of use of medicaments
Various medicament regimens
Properties of ideal medicament
Classification of intracanal medicaments
Individual agents
Mode of application
Limitations and contraindications
Complication and side effects
 Scribonius
(in 1045 A.D.) wrote of using oils and wine in the mouth
of a patient with pain.
 Other
references came in middle age; these were usually of the oil
of cloves (eugenol)
 Beechwood
creosote was mentioned in the 1840 article “Creosote
and cotton in Fang Filling”.
 Richmond,
 The
in 1884, advocated “Knocking out the pulp” .
“focus of infection” era followed on the heels of the
discoveries of intracanal medicaments.
 Allow
hard tissue formation.
 Alleviating
clinical pain from both infectious and aseptic pulpo-
periodontal inflammation.
 Treatment
is aimed at dealing with potential infection as well
as drying or coagulating the exudating surface.
 The
minimum inter-appointment time interval should be 10
days, unless symptoms not subsiding.
 The
length of time a medicament will remain effective within
the root canal will depend on the following factors:
 Size
of the apical foramen
 Size
of dentinal tubules
 Presence
 Absence
of smear layer
of cementum
 Presence
of pulpal tissue
 Temporary
 The
sealing of the access cavity
medicament being used
Ability to stimulate hard tissue repair
Ability to prevent or reduce pain
Non-irritant to the periapical and periodontal tissues
Ability to diffuse through dentine
Quick acting initially
Long lasting antimicrobial effect
Effective in the presence of blood, pus and organic debris
Water soluble
Practical to use (easy to place and remove)
Non-staining to the tooth and soft tissues
A long shelf life
Should remain stable in solution
Should have low surface tension
According to Harty:
A. Aldehydes:
Formocresol dressing
19% formaldehyde, 35% cresol, 46% water and glycerine
B. Halogens:
Irrigating solution: sodium hypochlorite 0.5% in 1%
Sodium bicarbonate as Dakin’s solution, or 0.5-5.25% in aqueous solution
Irrigating solution and short term dressing: 2% - 5%
KI aqueous solution
Field disinfection: 5% - in tincture of alcohol
C. Phenols
Camphorated phenol
Dressing: 30% phenol, 60% camphor, 10% ethanol
• Para-mono-chlorophenol (PMCP)
Irrigating solution: 2% aqueous solution
Dressing: Camphorated PMCP (CMCP); 65% camphor, 35%
• Eugenol
• Dressing: full strength
D. Chlorhexidine
 Chlorhexidine
Field disinfection and irrigating solution: 0.12 – 2%
Aqueous solution
E. Calcium hydroxide
 Dressing:
aqueous suspension/paste with varying amounts of salts
According to Walton and Torabinejad:
Camphorated monoparachlorophenol (CMCP)
Parachlorophenol (PCP)
Camphorated parachlorophenol (CPC)
Metacresylacetate (Cresatin)
Creosote (Beechwood)
B. Aldehydes
 Formocresol
 Glutaraldehyde
C. Halides
 Sodium
 Iodine-potassium
D. Steroids
E. Heavy metal salts
F. Calcium hydroxide
G. Antibiotics
H. Combinations
Sulpha preparations
 In
1956, Nygaard-Ostby presented a technique that uses a
suspension of sulphathiazole.
 Sulphathiazole
can be used with certain variations which appear
to increase its effectiveness.
 Instead
of water, the sulphathiazole has been mixed with
prednisolone, camphorated monochlorophenol (CMCP) or
 Moreover,
although effective against many gram-negative
and gram-positive microorganisms , Sulpha drugs are
ineffective against Enterococci and Pseudomonas
 Also,
sulphonamides tend to cause yellowish discoloration of
the tooth.
Actions of tetracycline
 shows
affinity for hard tissues
 may be retained on tooth surfaces.
 substantive due to their hard tissue binding capability
 have an innate antiresorptive action.
 ability to bind to the tooth surface and then be slowly
released in active form.
 Its
derivative doxycycline forms the antibiotic ingredient in
 However,
its antimicrobial spectrum is quite narrow, and it
may be ineffective against several oral and endodontic
 Reports
on the treatment of pulpitis by means of a
corticosteroid have been published since 1958.
 The use of steroids in endodontics was initially criticized .
 Might interfere with the body’s reactions to microbial invasion.
 Local application could interfere with natural synthesis of
When the pulp contains only necrotic tissue, intracanal
steroid application is not recommended.
There are three possible explanations for this finding:
not great enough to prevent all prostagladin synthesis.
The remaining necrotic pulp tissue and bacteria may
continue to act as strong irritants.
May suppress the inflammatory and immune responses
without inhibiting the growth of bacteria.
 Schroeder
(1962) formulated a drug for the specific purpose of
inhibiting pulpitis and infection.
Composition of ledermix
The ledermix was supplied in two forms:
Ledermix A (paste):
 Triamcinolone
(corticosteroid) 1% and
 Dimethylchlortetracycline
calcium 3% in a water soluble cream.
Ledermix B (Cement):
 Powder
→ triamcinolone 0.67%, dimethylchlortetracycline 2%,
zinc oxide, Canada balsam, rosin, and calcium hydroxide;
 Liquid
→ eugenol and rectified turpentine oil
 These
are non specific agents which act by denaturing cell
 “Nonspecifics” are effective in the treatment of septic canals.
 It includes formaldehyde, paraformaldehyde and
glutaraldehyde. They are water soluble, protein-denaturing
agents and are among the most potent disinfectants.
Glutaraldehyde is:
Colorless oil, slightly soluble in water
Slightly acidic reaction
Strong disinfectant and fixative
Its bacteriostatic in action
Dankert et al have recommended 2% glutaraldehyde as an intracanal medicament.
Van Valzen have said that glutaraldehyde did not produce any immunologic reaction unlike
 Halogens
 They
include chlorine and iodine.
are potent oxidizing agents with rapid bactericidal
 NaOCl
used as iodine potassium iodide, and
in iodophors
 is
a very potent antibacterial agent
 low
 low
tissue irritating qualities
 As
a short-term dressing, in a 2% solution of iodine in 4%
aqueous potassium iodide.
 The
most effective and safest intracanal antiseptic, regardless of
mode, is the iodine potassium iodide solution.
 Phenol
or carbolic acid and its derivatives were introduced by Lord
Lister in 1867.
 A protoplasm
 Is
highly effective in as low a concentration as 1 to 2%.
 It
is often liquefied in camphor and used in endodontics as a
solution of camphorated phenol (Phenol 30%; camphor 60%; ethyl
alcohol, 10%).
Camphorated phenol
least toxic of the phenolic compounds
has excellent antimicrobial effect paired with good anodyne activity.
the preferred preparation when relief from pain is part of the treatment objective.
derivative of phenol
derivative para-mono-chlorophenol has been very popular
used as a dressing : in aqueous solution
 Monochlorphenol
and CMCP are often recommended as vapor-
forming intracanal medicaments.
Camphorated Mono parachlorophenol (CMCP)
 Developed
 He
by Walkoff in 1891 .
mixed PCP with camphor in the mistaken notion that this would
increase the effectiveness of the drug.
 Camphor
serves as a vehicle and a diluent, reduces irritating
effect of pure PCP.
 It
is a substitute product of phenol.
 1%
aqueous solution of paramonochlorophenol has been
shown in vitro to be effective against a variety of microorganisms encountered in infected root canals, and to be
appreciably less toxic in experimental animals than CMCP.
 Dilute
aqueous solutions of paramonochlorophenol are
undoubtedly effective clinically and are therefore preferred to
Has three isomers of which metacresol is the most effective as
an antiseptic.
• The most frequently used formula in endodontics is formocresol
(formaldehyde, 19%; cresol, 35%; water and glycerine, 46%).
Buckley(1906) mixed 19% formaldehyde with 35% cresol.
He supposed that the formaldehyde would be the active
ingredient and that cresol (for some unknown reason) would
decrease its toxicity.
Metacresyl acetate (Cresatin)
 Was
reported by Schilder and Amsterdam.
 Has
both antiseptic and obtundent properties
 Coolidge
recommended the use of Cresatin, the acetic acid of
metacresol, in combination with benzene as an endodontic
intracanal medicament.
Heavy Metal Salts
 Salts
of silver, copper and mercury has been used as ICM.
 They
are generally toxic with exception of mercury salts.
Mercury salts used are Mercurophen, Metaphen,
Mercurochrome and Merthiolate. Mercury salts are good
 But they are very less effective in tissue fluid and proteins in
the root canal. They are impractical alternatives for ICM.
Chlorhexidine appear to have great potential as an intracanal
Its substantivity (persistence in the area of interest), its relatively
broad spectrum of activity and, its low toxicity makes it well-suited
for irrigation and dressing applications in endodontics.
Heling et al. found that, when used as an intracanal medication, it
was more effective than calcium hydroxide in eliminating E.faecalis.
Calcium Hydroxide
Calcium hydroxide cannot be categorized as a conventional antiseptic.
Introduced by Hermann in 1930.
Various properties of calcium hydroxide
It is a formless, thin, granular powder with strong basic properties and a density of 2.1.
It can dissolve only slightly in water and is insoluble in alcohol.
It can be mixed with various vehicles such as glycerin, Ringer’s solution, anesthetic
solution and saline.
Calcium hydroxide can be purchased as a paste in several commercial
preparations (for example Pulpdent paste, Calxyl, Calasept, Hypo-cal)
or in powder form.
In a nonaqueous medium does not hydrolyze unless an aqueous
medium is added.
When dissolved in water, calcium hydroxide dissociates into hydroxide
ions and calcium ions.
High concentrations of glycerin or propylene glycol reduces the
conductivity of calcium hydroxide solutions and thus its dissociation.
Mechanism of action of calcium hydroxide
Related to release of hydroxyl ions in an aquoeus environment, producing a pH
of approx 12.5, even in very dilute mixtures.
Damage to the bacterial cytoplasmic membrane by inducing lipid peroxidation
Protein denaturation
Damage to bacterial DNA
Serving as a physical barrier that withholds nutrients for bacterial growth and
limits space for bacterial multiplication.
It is believed that calcium hydroxide stimulates calcification by causing limited
cell death adjacent to the material. This resultant sterile necrotic layer then
undergoes passive calcification.
 When
inhibition of inflammation or active inflammatory root
resorption is necessary or when there is pain, calcium hydroxide
should not be used as the initial dressing since it has been reported
to be an irritant. This can cause exacerbation of the symptoms or of
already existing inflammation.
 Sjogren
et al. and Bystrom et al reported that 7-day and 30-days
applications of calcium hydroxide, respectively, eliminated bacteria
that survived instrumented root canals.
 However,
Haapsalo and Østravik found it to be ineffective
against tubular infection with E. faecalis.
 It
has been demonstrated that the ability of Enterococcus
faecalis to use a proton pump to control intracellular pH, when
exposed to calcium hydroxide, may be responsible for the
resistance of this bacteria.
 Recently,
the ability of calcium hydroxide medication to eradicate
completely bacterial species from the root canal has been questioned.
 For
example, ex vivo studies have shown that dentine can inactivate the
antibacterial activity of calcium hydroxide (Haapasalo et al. 2000, Portenier
et al. 2001)
 One
clinical study (Peters et al. 2002) has shown that the number of
bacterial positive canals increased after calcium hydroxide medication.
 In
1988, a very disturbing observation presented by StØrmer et al
claiming that 60% of all endodontically treated teeth with immature
root formation have had cervical fractures due to minor impacts.
 Calcium
hydroxide may, due to its alkaline nature, neutralize,
dissolve, or denature some of the acidic components of the organic
portion of dentin acting as bonding agents and thereby weaken the
Combination of ledermix and calcium hydroxide dressings
Rationale for use is
that it is anti-inflammatory and antibacterial in action and
also capable of inducing hard tissue formation.
Demeclocycline (in Ledermix) release was significantly slower if a
combination was used.
 Studies
have (Taylor MA, 1987; Abbott et al 1989) shown that
mixing these two pastes potentiates the antibacterial efficacy of
ledermix in vitro.
2. Iodoform and Calcium hydroxide
Commercially available preparations of iodoform and calcium hydroxide, such as Metapex, are
The material is highly radio-opaque and is useful to confirm that the entire root canal system
has been obliterated with medicament prior to sealing the access cavity.
3. Combination of calcium hydroxide and chlorhexidine
Recent studies have suggested that CHX could be used in combination with calcium hydroxide
to improve antimicrobial efficacy against calcium hydroxide resistant microbes.
Calcium hydroxide combined with 0.5% CHX has been shown to eliminate C.albicans
In another study combination with 1% CHX was found to be effective against E.faecalis. (JOE
Podbielski et al (JOE 2003) concluded that an antibacterial
synergism exists between the calcium hydroxide suspension and
chlorhexidine when used against E.faecalis.
The average pH of an aqueous solute of chlorhexidine as a mixing
vehicle for calcium hydroxide was 12.7.
Another study concluded that 10% Ca(OH)2 may be more effective
than 0.12% chlorhexidine gluconate (0.12%) [Peridex] or 10%
Ca(OH)2 in Peridex for the elimination of E.faecalis from dentin
precipitates when mixed with calcium hydroxide. The reduced
efficacy of the CHX and Ca(OH)2 mixtures, in addition to
precipitation, may be due to the deprotonation of the biguanide at
pH > 8.0.
Therefore, a mixture of CHX and Ca(OH)2 may not provide a
sufficient reservoir of free CHX molecules.
 Despite
the potential loss of chlorhexidine when mixed with calcium
hydroxide, the antimicrobial efficiency of this mixture was as
effective as CHX alone on E.faecalis.
Effect of CHX on the various physicochemical properties of
1. Effect on pH
Did not alter the pH of Ca(OH)2
2. Effect on contact angle
Addition of CHX lowers the contact angle of Ca(OH)2 and improves the wettability of the
medication on the root canal.
3. Working time
Presence of CHX did not affect the working time of the calcium hydroxide paste.
4. Radiopacity
40% calcium hydroxide medication with or without chlorhexidine would be approximately 5.9 to
6.0 times more radio-opaque than the dentin.
4. Polyantibiotic pastes
They can be used instead of chemicals in case of wide apical foramen, overinstrumented canal
Also chemical antiseptics lose potency within a short duration compared to antibiotics.
Hence in case of larger period of appointments antibiotics are preferred than chemicals as
intracanal medicaments.
5. Calcium hydroxide combination with camphorated
 This
association has a broader antimicrobial spectrum, a high
radius of antibacterial action, and kills bacteria faster than
mixtures of calcium hydroxide with inert vehicles (water, saline,
 It
has been shown to be effective in eradicating E.faecalis from
the infected dentinal tubules
6. Chlorhexidine mixed with zinc oxide
This combination has been shown to be highly effective in killing C.albicans within dentin.
7. Triple antibiotic paste
Consisting of metronidazole, ciprofloxacin and minocycline
Is considered very effective in removing endodontic pathogens and well tolerated by vital
pulp tissue.
Recently introduced in Germany.
It’s a liquid medicament.
It is claimed to be as effective as a temporary root canal dressing
for a duration of 2 days.
It is said to be non toxic to the tissues.
It contains: chloroxyleno (10%)-4 chloro-3,5 dimethyl phenol, camphor
 Japanese
green tea is frequently drunk and it has been recently
reported that they have antibacterial action against various
bacteria inhabiting the intestines.
 Nakagawa (1970) reported that japanese green tea contained
about 15% of various kinds of polyphenols of which a great
portion is catechin. These polyphenols have been responsible
for the anti-bacterial and bactericidal actions. Also they do not
have an irritating potential.
A study was done using the PICO stratergy (P- Problem, Iintervention, C-comparison, O-outcome) to identify studies dealing
with various intracanal medicaments. (JOE, 2004)
 These
studies have shown that it is impossible to achieve a sterile
root canal system in all cases by cleaning and shaping alone (62%
remaining positive).
 Also
that calcium hydroxide remains the best medicament available
and should be used as interappointment dressing for a minimum of
7 days.
Spiral root filler
Spiral root fillers are favoured if the canal has been enlarged and shaped.
• The spiral should be advanced vertically into the canal but it should not reach any further
than 3mm short of the canal working length.
• To completely coat the canal walls and fill the canal lumen, the spiral should be moved
vertically up and down the canal several times and on the final withdrawal the motor should
be kept running.
2. Hand reamer
Hand reamers are used in fine, unprepared canals or in canals with sharp curves.
3. Paper point
applying medications to a blunted paper point that has been placed into a dried canal.
use of a paper point saturated with medicament. “The point should fit the canal fairly closely,
so as to allow the maximum volume of drug to be applied and to provide close contact
between it and the root dentin”.
4. Grossman(1965) advocates “pumping” the medicament into
the root canal to allow it to come into contact with the tissue
to be sterilized.
5. Schilder(1965) recommends the use of smaller amounts of
drugs and also suggests that medication is secondary to a
thorough debridement of the canal. He recommends that the
medication be placed only on a small pledget of cotton
confined to the pulp chamber.
6. Steward and colleagues(1969) seem to advocate the use of
larger amount of medication when they state that “by increasing
the volume of the root canal, greater quantities of medication can
be sealed in to destroy the remaining microorganisms”.
7. Use of cotton pellet
Application using a cotton pellet requires vaporization of the medicament so that it can reach
microbes in the pulp space.
 Germicidal
vapors must dissolve in the tissue and cells to be
effective, therefore, the concentration of medicament applied on a
cotton pellet must be 100 to 1000 times higher than that of a
medicament applied directly.
 Only
medicaments containing chlorine, iodine and formaldehyde
are reasonably effective.
8. Lentulo spiral
Gutmann stated that the lentulo spiral offers perhaps the most
convenient method of introducing commercially available
pastes into the canal system.
Calcium hydroxide is best introduced with a lentulo spiral, dried
with coarse absorbent points, and packed with appropriately
sized root canal pluggers. Often this procedure has to be
repeated to give a dense fill.
9. Placement techniques for calcium hydroxide
A study by Sigurdsson et. al. (JOE 1992) evaluated 3
placement techniques for calcium hydroxide:
Lentulo spiral
Injection with a syringe followed by compaction with plugger,
Counterclockwise rotation of a K-file.
The authors concluded that canal curvature was the limiting factor for proper paste placement.
Calcium hydroxide placement techniques in straight
canals have concluded the following techniques to be
most effective:
Use of the messing gun
The messing gun kit comes with three nozzles and plungers measuring 1, 1.25, and 1.5
mm in diameter and can be autoclaved.
The suggested form of calcium hydroxide for this technique is a dry powder mixture.
The appropriate nozzle and plunger is selected for messing gun according to the
following criteria:
The largest diameter nozzle that will fit to within 3mm of
the working length is used, and
The smallest nozzle can be used to the same depth as
the Gates Glidden #4 bur.
The Pastinject (specifically designed paste carrier)
Lentulo spiral (lesser degree)
MacSpadden compactor
The Lentulo Spirals
 Recently
Ultradent (South Jordan,UT) designed a 0.014-inch-
diameter tip for ease of calcium hydroxide paste placement. It is
made up of polypropylene plastic and is not easily separated in
the root canal system.
10. Calcium hydroxide containing points
 In
the course of a prospective clinical study, the calcium
containing gutta-percha points (CHP) were found to be as
clinically successful as CHS when used as short-term
 The
highly water-soluble components of the tenside and
sodium chloride incorporated in CHPP are likely to be
responsible for the surface corrosion and consequent
improved calcium release.
 After
superficial particle dissolution in CHPP, a larger
surface accounts for further dissolution. This mechanism
might be responsible for the increasing calcium release
over time observed for CHPP.
10. Chlorhexidine containing guttapercha points
Various properties of Activ Points (GP points containing CHX) :
ISO sized and are radiopaque
Is accurately applied to W.L. after completion of root canal preparation
Not necessary to dry the canals because the GP points release the
CHX in presence of solution.
Removal is easy
Intracanal environment
Taste and smell
These agents causes marked destruction of the tissues
Delays healing (e.g. Phenolica and aldehyde derivatives)
Allergic reactions (e.g. antibiotics)
They may act as hapten and alter the tissue to the extent that
they may become foreign substance to the body.
They may induce immune response.
It may be cytotoxic
It may by carcinogenic and mutagenic.
Intracanal medicament in endodontics have been used for a
number of reasons in the past and currently.
• Often, different chemicals or drugs are combined in a
“cocktail” in an attempt to elicit a variety of effects with a
single application.
• There is still a controversy whether or not to use a intracanal
medicament. But the practice still continues….