INTRACANAL MEDICAMENTS IN DENTISTRY

1. INTRACANAL
MEDICAMENTs
in endodontics
:
NORTH BENGAL DENTAL
COLLEGE & HOSPITAL
UNDER THE GUIDANCE
OF:-
Prof.(Dr.) Soumen
Chakrobarty,
Dr. Anuradha mukharjee,
Dr. Dwaipyan Bhattacharya
Dr. Partha Mondal
(Department of Conservative
dentistry)

2. INTRODUCTION
 An agent used as an adjunt to
cleaning and shaping for prevention
or treatment of apical periodontitis.
 Intracanal medicaments have a long
history of
use as interim appointment dressings.
They have
been employed for the following three
purposes:
(1) to reduce interappointment
pain.
(2) to decrease the bacterial count
and prevent regrowth.
(3) to render the canal contents
inert.

3.  If root canal treatment is not
completed in a single appointment,
antimicrobial agents are
recommended for intracanal
antisepsis to prevent the growth of
microorganisms between
appointments
. In the past, numerous
antimicrobial agents have been
used , provided relatively short-
term antisepsis.
These included traditional phenolic
and
fixative agents such as:
camphorated
monochlorophenol, formocresol

4.  The current intracanal dressing of
choice is calcium hydroxide .
studies have shown calcium hydroxide
to be an effective antimicrobial agent .
Other studies have shown it to be an
effective interappointment dressing
over several weeks .
 Several different techniques for
placing
calcium hydroxide into root canals
have been proposed, such as amalgam
carriers, vertical pluggers, McSpadden
compactors, Lentulo drills, files and
special syringes

5. A .According to Grossman
1. Essential oils
- Eugenol
2. Phenolic compound
- Phenol
- Para chlorophenol
- CPC
- Formocresol
- Glutaraldehyde
- Cresatin
3. Halogens
-sodium hypochlorite
- Iodides
4. Quaternary Ammonium
compounds
- 9-amino acridine
CLASSIFICATIONS

6. B.According to DCNA
1. Phenolics
- Eugenol
- CMCP
-PCP
- CPC
-Metacresylacetate
(Cresatin)
- Cresol
- Creosote (Beechwood)
- Thymol
2. Aldehydes
- Formocresol
- Glutaraldehyde
3. Halides
- Sodium hypochlorite
- Iodine
- Potassium iodide
4. Steroids
5. Calcium hydroxide
6. Antibiotics
7. Combinations

7. INDIVIDUAL INTRACANAL
MEDICAMENTS

8. From a biological stand point, sterile
normal saline is the best irrigant to use
because it causes.
I.Least apical tissue irritation or
damage.
II.Biocompatible.
III.Least amount of cell lysis
Disadvantages:
Does not remove the smear layer.
Flushes out some of the superficial
debris from the root canal system.
Has poor antibacterial properties.
.
Physiologic Saline

9. Phenol
•It is the oldest compound for controlling
microorganisms.
• It was introduced by Lord Lister in 1867.
•It is white crystalline substance, and has a
characteristic odor derived from coal tar.
•Phenol is a protoplasmic poison and produces
necrosis of soft tissues by its ability to
penetrate and disrupt the cell wall of bacteria
and subsequently the protoplasm.
•Liquefied phenol consists of 9 parts of phenol
and 1 part water.
•Highly effective in 1 to 2% concentration.

10. Camphorated Phenol
• This contains 30% phenol, 60% camphor,
10% ethyl alcohol.
• It is the least toxic of the phenolic
compounds.
• It has excellent antimicrobial effect and
also relieves pain.
• Camphorating process aims at developing
a less caustic
medicament as a result of the slow
release of phenol.
• Camphor serves as a vehicle and diluent.

11. Camphorated Paramonochlorophenol
(CMPCP) (Developed by Walkhoff 1891)
- Contains :
35% monochlorophenol
65% camphor
- Its antimicrobial effect is good.
- Highly toxic to the tissues.
- It is used in the form of vapor forming
intracanal medicament. The vapors can
pass through the apical foramen.

12. Formocresol
Developed by BUCKLEY in 1906
Contents : 19% formaldehyde
35% cresol
46% water
Glycerine.
or is a combination of formalin and cresol in the
proportion of 1:2
Formocresol combines the protein -
coagulating effect of phenolic compounds with
the alkylating effect of formaldehyde.
The bactericidal effect of formocresol is good at
levels as low as 2%.
It is a strong poison and causes widespread
destruction of living tissue followed by a
persistent inflammatory reaction.
Studies have reported that formocresol treated
tissue produced a cell mediated immune
response.

13. Polyantibiotic paste(pbsc & pbscn by
grossman)
Grossman mentioned about the
utilization of polyantibiotic paste as an
intracanal medicament in a weeping
canal or where there was a continous
seepage from the pulp space.
He had mentioned about PBSC
containing :PENICILIN, BACITRACIN
and STREPTOMYCIN with
CRYOLITE as a vehicle.
PBSCN combination was also
advocated with N standing for
NEOMYCIN as an antifungal agent

14.  Ca(OH)2 is effective in inhibiting
microbial growth in canals, although it
remains controversial.
(see limitations of Ca(OH)2)
 No pain reduction effects.
 Recommended for use in teeth with
necrotic pulp tissue and bacterial
contamination.
 Has little benefit with vital pulps.
CALCIUM HYDROXIDE
CA(OH)2

15. Base :
i. L –methyl trimethylene
disalicylate
ii. Calcium sulphate
iii. Titanium dioxide
 Catalyst :
i. Calcium hydroxide
ii. Zinc oxide
iii. Sulphonamide
COMPOSITION:

16. FORM AND APPLICATION:
 Can be placed as a dry powder, a
powder mixed with a liquid such as local
anesthetic solution, saline, water or
glycerine to form a thick paste or a paste
supplied in a syringe.
 A lentulo spiral is effective and efficient
for placement.
 Removal after placement is difficult. This
is especially true in the apical portion of
the root.

17.  Note: Long term use of Ca(OH)2
may be necessary. However, the
use of intracanal medicament
for long periods does not seem
to be acceptable in modern
endodontics
LENTULO SPIRAL

18.  Ca(OH)2 is useful for weeping cases
 Weeping cases: the tooth with
 1. Constant clear or reddish
exudation
 2. A large apical radiolucency
 3. Often asymptomatic, but it may be
tender to percussion or sensitive to
digital pressure over the apex.
 4. If cultured, the drainage generally
will not support bacterial growth.

19.  Canals with exudates were not
considered to be ready for filling.
 Prescribing antibiotics for the patient
seems foolish, because of the
frequency of negative cultures

20.  Treatment: the treatment of this
problem is to dry the canal with
sterile absorbent paper points
and place Ca(OH)2 paste in the
canal.
 It is interesting to see a
perfectly dry clean canal at the
next appointment that is simple
to fill after minimal further
preparation

21. LIMITATIONS OF CA(OH)2
 Residual Ca(OH)2 can shorten
the setting time of zinc oxide
eugenol-based endodontic
sealers.
 Ca(OH)2 is not totally effective
against E. faecalis and candida
albicans.
 Dentin can inactivate the
antibacterial activity of Ca(OH)2.

22.  A clinical study has shown that the
number of bacteria-positive canals
actually increased after Ca(OH)2
medication.
 Other studies have also indicated
that cultures changed from negative
to positive after Ca(OH)2 placement.
 Therefore, based on the current
best available evidence, Ca(OH)2
has limited effectiveness in
eliminating bacteria from human
root canals

23. CHLORHEXIDINE (CHX)
 Chlorhexidine (CHX) has been recently used as
an intra-canal medicament.
 A 2% gel is recommended.
 It can be used alone in gel form or mixed with
Ca(OH)2. When used with Ca(OH)2, the
antimicrobial activity is greater than when
Ca(OH)2 is mixed with saline, although it remains
controversial.
 2% CHX gel was significantly more effective than
Ca(OH)2 combined with 2% CHX or Ca(OH)2
alone, against root dentin infected with E. faecalis
and candida albicans after 7, 15 and 30 days of
incubation

24. IODINE POTASSIUM IODIDE
(IKI)
 Iodine potassium iodide (IKI) is
very effective antiseptic solution
with low tissue toxicity.
 IKI releases vapours with a strong
antimicrobial effect.
 IKI can kill bacteria in infected
dentin in 5 minutes in vitro.

25. ANTIBIOTICS
 Sulphonamides are used as
medicaments by mixing distalled
water or moistened paper point into
jar containing the powder.
 It is indicated in case of acute peri-
apical abcess.
 Disadvatage, yellowish tooth
discoloration.

26. CORTICOSTEROID-ANTIBIOTIC
COMBINATION
Corticosteroids are anti-inflammatory agents
that may decrease postoperative pain in
certain situations e.g. irreversible pulpitis and
acute apical periodontitis.
 Corticosteroids may be ineffective, particularly
with greater pain levels.
 Corticosteroid-antibiotic combinations are
useful in treating apical periodontitis,
occurring either as a pretreatment symptom
or as a result of overi-nstrumentation.

27.  Ledermix is a corticosteroid-
antibiotic paste, made in
Germany.
 Ledermix is a nonsetting, water-
soluble paste, used as root canal
medicament or as direct or
indirect pulp capping agent.
 At the first 24 hours, 30% of the
corticosteroid was released. By
the end of 14 weeks, the
remaining 70% has been
released.

28.  In case of replanted teeth,
immediate intracanal
placement of Ledermix may
inhibit root resorption.
 Note: Intracanal antibiotic
paste may cause bacterial
resistance.
 Mixing erythromycin with
Ca(OH)2 improved the
effectiveness against E.
faecalis as compared to
Ca(OH)2 alone.

29. REFERENCE
 Grossman’s ENDODONTIC
PRACTICE (13TH edition)
 Ingle j.i and bakland (5th edition )
 Akapta e.s: j.endod 2nd edition 1976
 Harty’s Chapter 7
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