1- Intracanal Medicaments

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1- Intracanal Medicaments

Transcript of 1- Intracanal Medicaments


INTRACANAL MEDICAMENTS Definition: Antiseptic agents in the chemical form applied to the walls of the root canals with the objective of eliminating microorganisms present before or even after cleaning & irrigating the root canal system Functions:1. Reduction of the number of microorganisms2. Prevention of the growth/re-growth of any new/old microorganisms (antibacterial action is the most important function) 3. Disinfection of root canal system4. Suppression of inter-appointment pain by reducing inflammation (some have anti-inflammatory action)5. Render the canal contents inert6. Facilitation of periapical healing

** Sometimes it is hard to finish the whole treatment in only one visit, and in order not to leave the canals empty until the next visit, canals are filled by intracanal medicaments to prevent bacterial invasion

Ideal requirements of any true intracanal medicament with true anti-bacterial action:1. Should be an effective germicide & fungicide2. Should NOT irritate periapical tissues3. Should remain stable in solution4. Should have prolonged antimicrobial effect5. Should have low surface tension (this leads to high penetration inside the root canal system)6. Should be active in the presence of serum, blood & protein derivatives of tissues7. Should NOT interfere with periapical healing8. Should be easily placed & removed9. Should NOT stain the tooth structure10. Should NOT induce a cell mediated immune response11. Should be economical with a long shelf life

** NO single intracanal medicament fulfills all these requirements and thus there's nothing called ideal intracanal medicament


PHENOLICS Phenol is a protoplasm poison (TOXIC) They have access to systemic circulation They have a strong inflammatory potential They have unpleasant odor & foul taste They are ineffective Their clinical use is NOT justified PHENOLIC COMPOUNDS: Eugenol Parachlorophenol (PCP) Camphorated monoparachlorophenol (CMCP) Camphorated parachlorophenol (CPC) Metacresylacetate (Cresatin) Cresol Creosote (beechwood) Thymol

EUGENOL This is the chemical essence of oil of clove ( ) It is both antiseptic and an anodyne (pain relieving agent) It is slightly irritant to periapical tissues It is a constituent of most root canal sealers & used as a temporary sealing (luting) material, post cement and temporary filling

PARACHLOROPHENOL (PCP) It is a substitution product of phenol It penetrates deep into dentinal tubules 1% solution has shown destruction of microorganisms It produces mild inflammation

CAMPHORATED MONOPARACHLOROPHENOL (CMCP) It consists of 2 parts of Parachlorophenol & 3 parts of gum Camphor Camphor serves as a vehicle & diluents Camphor reduces the irritating effect of PCP Camphor prolongs the antimicrobial effect (this is the best property)

METACRESYLACETATE (CRESATIN) It is a clear, stable, oily liquid of low volatility It is both antiseptic & obtunding (alters level of consciousness) It is less irritating among other Phenolics (but NOT used anymore)

ALDEHYDES Formocresol This is a combination of Formalin & Cresol in a ratio 1:2 or 1:1 It is a non-specific bactericidal agent most effective against aerobes & anaerobes It is used as a pulpotomy agent

** Pulpotomy is the removal of the superficial infected layer of dental pulp, then applying a fixative agent (such as Formocresol for 5 minutes) then putting the final filling material

It is mutagenic & carcinogenic It is effective for 5-7 days


It is a colorless oil & slightly soluble in water. It is a strong disinfectant & fixative agent (but NOT used anymore) 2% preparation is used as an intracanal medicament. It is a Bacteriostatic agent It has the potential to cause hypersensitivity

HALIDES SODIUM HYPOCHLORITE (NaOCl) Chlorine is the active ingredient NaOCl vapor is bactericidal It reacts rapidly with organic matter (good tissue dissolving ability) It is Unstable It is activity is intense BUT of short duration It is TOXIC to periapical tissues** It is one of the most famous agents that is used as irrigant and intracanal medicament ** Used in a concentration of 0.5-5.25% ** In hypochlorite accidents, sodium hypochlorite is forced outside the apex, which will cause the patient an immediate severe pain, numbness, necrosis, bleeding, and immediate swelling

IODINE POTASSIUM IODIDE (IKI) It is very effective antibacterial agent It kills bacteria in infected dentin in 5 minutes It is antibacterial action of short duration It causes allergic reactions It stains teeth It has a relatively low toxicity** Can be used in combination with calcium hydroxide

STEROIDS Have been advocated for decreasing postoperative pain by suppressing inflammation (anti-inflammatory action) Evidence suggests that they may be ineffective, particularly with greater pain levels Might be used in cases of irreversible pulpitis & acute apical periodontitis (but NOT used anymore)

CALCIUM HYDROXIDE Introduced by Hermann in 1920 It is one of the most commonly used intracanal medicaments Used for short & long term durations** Short period of time for one or two weeks to inhibit the bacterial growth and make the canal free of bacteria between visits of RCT** Long period of time for 3-6 months to promote the formation of hard tissue barrier at the apical foramen in the apexification process done for immature teeth in children seeking RCT** Long period of time to promote the formation of hard tissue barrier at pulp exposure sites, which preserve the vital pulp tissue and enable root development to continue in the apexogenesis process done for immature teeth in children not seeking RCT

It is a broad spectrum antimicrobial agent Its antibacterial action is related to its high pH It may aid in dissolving necrotic tissue remnants and bacteria and their by-products It demonstrates no pain-reduction effects It has been recommended for use in teeth with necrotic pulp tissue It probably has little benefit with vital pulps Limitations: The handling and proper placement presents a challenge to the average clinician The removal is frequently incomplete** Total removal of non-setting calcium hydroxide from the root canal system is very difficult and thus, residual Ca(OH)2 particles are always left behind

Residual Ca(OH)2 can shorten the setting time of ZOEbased endodontic sealers (and this can put the whole RCT in danger) It is NOT effective against Entercoccus Faecalis & Candida albicans** Entercoccus Faecalis is the bacteria encountered in retreatment cases when original RCT fails

Dentin can inactivate the antibacterial activity of non-setting Ca(OH)2

Application: Powder is mixed with water or saline or glycerin until mixture gets a creamy texture Lentulo spiral (also called a root canal filler) is coated with Ca(OH)2 mixture and applied inside the root canals while being rotated Hand spreader and syringes can be also used to place Ca(OH)2 Finger spreaders and files can be also used to place Ca(OH)2 in anticlockwise motion to prevent forcing it outside the apex It is very important to apply the Ca(OH)2 to all canal walls from inside and reach all the areas** Unfortunately it is very difficult to any chemical agent to reach each area inside a canal because of the complicated internal anatomy

It is very important for Ca(OH)2 to reach the apical area of the canal There are two types of Ca(OH)2: Setting( Dycal, used for lining and capping) & Non-setting (used as intracanal medicament)

CHLORHEXIDINE It is a broad spectrum antimicrobial agent 2% gel is recommended Can be mixed with calcium hydroxide to increase its antibacterial activity & enhance the periradicular healing It doesnt remove smear layer** Smear layer is the layer formed after mechanical instrumentation of the root canal system and that should be eliminated before any farther procedure is done

It is a fixative** Usually used as a mouth wash in a concentration of 0.2%

ANTIBIOTICS PBSC Penicillin Effective against Gram positive microorganisms Bacitracin Effective against Penicillin-resistant bacteria Streptomycin Effective against Gram negative microorganisms Caprylate Effective against Fungi** Nystatin now replaces Caprylate i.e. PBSN

Sulfonamides Mixed with sterile distilled water Used in acute periapical abscess Causes yellowish tooth discoloration

Grossmans paste Potassium Penicillin 1000,000 units Bacitracin 10,000 units. Streptomycin sulphate 1.0 g Sodium Caprylate 1.0 g Silicone fluid 3ml Vehicle** Was the most famous formula in the 50s and 60s** All antibiotics aren't used anymore these days!!

Limitations for all intracanal medicaments: Their therapeutic action depends on direct contact with tissues Do NOT reach all areas of root canal system Limited to surface action only Chemically NOT active for a long duration Development of resistant strains of bacteria Might cause tooth discoloration TEMPORIZATION: Objectives:1. Coronal seal (prevent microleakage) 2. Enhance isolation3. Protection of tooth structure4. Allow of ease of placement & removal 5. Satisfy esthetics

Determining factors:A. Intended duration of useB. Occlusal load & wearC. Complexity of accessD. Loss of tooth structure

Types: Cavit IRM GIC TERM

CAVIT Based on zinc oxide & calcium sulfate (NO EUGENOL is used) Premixed cement that sets in the presence of moisture Low strength & rapid occlusal wear Used in short-term sealing of simple access cavities Clinically, 4 mm of Cavit provides an effective seal against bacterial p