Intracanal Medicaments and irrigants.pptx

85
Intracanal Medicaments And Irrigating Agents

description

endodobtic medicaments and irrigants

Transcript of Intracanal Medicaments and irrigants.pptx

Page 1: Intracanal Medicaments and irrigants.pptx

Intracanal Medicaments

And

Irrigating Agents

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Despite the fact that sterilization is a cardinal

principle of surgery…

It is an established fact that…

In case of root canal

therapy what can be best achieved is…

Thorough debridement and disinfection.

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This goal is adequately achieved by…

Biomechanical preparation in combination with irrigation and…

Placement of an intracanal medicament.

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The aim of instrumentation and irrigation is…

To remove all necrotic debris, micro-organisms and vital organic tissue as well as some hard tissue from

the root canal system, and …

To give the canal system a shape that allows easy debridement and predictable placement of locally

used medicaments and a permanent root filling material.

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Mechanical instrumentation is the core method for achieving

debridement through cleaning and shaping

The use of irrigating solutions in combination with canal

instrumentation, loosen debris, pulp tissue and micro-organisms from the irregular dentin walls so that they can be removed from

the canal.

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It has long been established that a root with a tapering canal and a single foramen is an exception

rather than a rule.

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It is the irrigating agent in combination with

biomechanical instrumentation that…

Reaches the nooks and crannies of the canal system

to…

Achieve optimum debridement and disinfection.

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Role of Irrigants

• Removal of particulate debris and wetting of the canal walls.

• Dissolution of organic debris.• Disinfection and cleaning of

areas inaccessible to endodontic instruments.

• Destruction of micro-organisms.• Opening of dentinal tubules by

removal of smear layer.

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Various irrigants used in endodontics:

• Sodium hypochlorite• Hydrogen peroxide• Gly-oxide• Iodine potassium iodide• Chlorhexidine• MTAD

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Sodium Hypochlorite

• Hypochlorite was first used by Semmelweis in 1847 as a hand disinfectant.

• This initial use of potassium hypochlorite was later followed by sodium hypochlorite (NaOCl), as Carrel and Dakin introduced its use for wound disinfection.

• Now a days commonly used intra canal irrigant.

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Mechanism of action:• When hypochlorite contacts tissue proteins;

nitrogen, formaldehyde and acetaldehyde are formed within a short time. The peptide links are broken up to dissolve the proteins.

• It has a rapid action but for a short duration.

• During the process, hydrogen in the imino groups (-HN-) is replaced by chlorine (-N.Cl-) forming chloriamine, which plays an important role for the antimicrobial effectiveness.

• Thus, necrotic tissue and pus are dissolved, and the antimicrobial agent can better reach and clean the infected areas.

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• Temperature increase will significantly improve the antimicrobial effect of sodium hypochlorite.

• Dakin suggested a 0.5% solution (Dakin's solution), a concentration with low toxicity affecting only necrotic tissue.

• Recommended concentration is 5.25%

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• To prepare fresh hypochlorite solutions, mix one part of a 5% solution of NaOCl such as "household bleach," with four (1 %) or nine (0.5%) parts of sterile 1 % sodium bicarbonate solution. This preparation will have a pH of 10, far less than the pH of commercial solutions, which is about 13 to 14.

• It should be stored in a cold place and protected from light. This provides a stable solution for several weeks.

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Hydrogen peroxide

• Recommended concentration is 3%.

• Produces transient effervescence that mechanically forces debris & microbes out of canal.

• Anti-microbial action: When it comes in contact with organic matter, it releases nascent oxygen which destroys anaerobic microorganisms.

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Recommended manner of use:

• Alternate use of 3% H2O2 and 5.2% NaOCl.

• NaOCl should be used last because H2O2 forms gas. Any gas trapped in canal will create pressure & will result in continuous pain.

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Iodine Potassium Iodide

• It is a traditional root canal disinfectant.

• It kills wide spectrum of micro-organisms found in root canals.

• Acts as an oxidizing agent by reacting with free sulfhydryl groups of bacterial enzymes, cleaving disulfide bonds

• It is able to kill calcium hydroxide resistant bacteria (E-faecalis).

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Chlorhexidine

• It is a broad spectrum antimicrobial agent effective against gram-negative and gram-positive bacteria.

• It has a cationic molecular component that attaches to negatively charged cell membrane areas, denatures the membrane and creates pores further resulting in cell lysis.

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• Its use as an endodontic irrigant is based on its substantivity and long lasting antimicrobial effect, which arises from binding to hydroxyapatite.

• Concentration: 0.2 – 2%• It lacks the tissue dissolving

activity of NaOCl.• Its potential weakness in the root

canal is its reduced antimicrobial activity in the presence of organic matter.

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Role of chelating agents• A smear layer is formed after

instrumentation of root canals.

• Smear layer is a microcrystalline layer of organic and inorganic debris which forms as a result of instrumentation of the tooth surface.

• Chelating agents effectively removes smear layer by chelating the the inorganic component of the dentin.

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• Smear layer consists of both an organic and an inorganic component. Chelating agent alone cannot remove the entire smear layer effectively.

• A proteolytic component ( NaOCl ) must also be used to remove the organic component of the smear layer.

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• Therefore by facilitating cleaning and removal of infected tissue, chelating agents contribute to the elimination of bacteria in the root canal.

• It has also been shown that removal of smear layer improves the antibacterial effect of locally used disinfecting agents in deeper layers of dentin.

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Chelating Agents

• Sulfuric acid (1894, Callhan)• Hydrochloric acid (1946,

Grossman)• Carbamide peroxide• EDTA (1957, Ostby)• EDTAC• RC Prep• Citric acid• MTAD

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EDTA (Ethylenediamine tetra-acetic

acid.)

• Introduced in endodontic practice by Nygaard-Ostby in 1957

• Chemically contains 4 acetic acid groups attached to ethylenediamine.

Actions:• Removal of smear layer• Forms Ca-chelate when comes in contact

with dentin. So BMP can be done effectively

• Lubrication of canal• Anti-microbial properties

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• It can decalcify upto 50 microns of the root canal wall in less than a minute.

• The decalcifying process is self-limiting, because the chelator is used up.

• It is used in concentration of 15% and 17% and has a pH of 7.3

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• Cetavlon a quaternary ammonium compound is added for additional antibacterial action. It is commercially available as EDTAC.

• RC-Prep is composed of EDTA and urea peroxide. When used in combination with sodium hypochlorite produces a bubbling action which is thought to loosen and remove the debris.

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Citric acid

• Citric acid can also be used for irrigation of the root canal to remove smear layer.

• Concentration used – 10%

• It also has an antibacterial effect.

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MTAD(Mixture of Tetracycline

isomer, Acid and detergent)

• It is a new product in the quest for a better root canal irrigant, with a pH as low as 2.15.

• It consists of:– Doxycycline– Citric acid– Detergent-tween 80.

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• It has good antibacterial activity since it contains tetracycline, acid and detergent.

• MTAD results in satisfactory

removal of smear layer, when canals are first irrigated with NaOCl, followed by a final rinse of MTAD.

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Photoactivated Disinfection

• The technique of photosensitization has been used in medicine for some time. PAD utilizes the photoactive agent tolonium chloride (toluidine chloride).

• The root canal is irrigated with the solution, which selectively binds to the cellular membrane of bacteria in the biofilm. The labelled bacterial cells rupture when exposed to laser light of the appropriate wavelength.

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Photoactivated disinfection system

The PAD endotip

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Lasers• Lasers can be used effectively for

additional disinfection of root canal system

• Lasers used : Carbon dioxide, Nd:YAG, Er:YAG, argon lasers.

• Limitations:– Difficulty in cleaning all the walls,

accessory canals of root canal. Thus no uniformity in the cleaning action.

– Can be potentially hazardous to periapical tissues.

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Ozone• Ozone is a powerful oxidizing

agent and has high bactericidal properties.

• Initially, this device was used to reduce the microbial colonies associated with root caries.

• Attempts to sterilize the entire root canal system have proved complex, as perfusion of the gas is not reliable.

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Endox

• The Endox Endodontic System (Lysis srl,Nova Milanese, Italy) has been reported to sterilize the root canal by emitting highfrequency electrical impulses.

• Sterilization occurs as a result of fulguration and the manufacturer claims it is able to eliminate both pulp and bacteria from the entire root canal system

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Note that…

Photoactivated disinfection and disinfection by means of ozone, endox and lasers

serve only as an adjunct to the primary irrigation by

sodium hypochlorite

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Method of root canal irrigation

• The technique of irrigation is simple. A leur lock plastic syringe with an endodontic notched needle of 25 gauge is used.

• The needle should be bent to an obtuse angle, to reach the canals of posterior as well as anterior teeth.

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• The needle is inserted partway into the root canal. It should not be inserted so it binds. Sufficient space between needle and canal wall allows for return flow of the solution and avoids forcing of solution into the periapical tissue.

• The solution is ejected from the syringe with little or no pressure on the plunger.

• A perforated needle has been developed to deliver irrigant 3600

in the root canal.

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Design of irrigating needles

Bevelled needle: irrigantforced apically; there isa risk of extrusion if theneedle becomes lodged

in the canal.

Monoject tip: irrigant can pass

sideways.

Safe-ended tip: irrigant passespass sideways.

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The return flow of solution is caught on a gauze piece or

aspirated. Final drying is effected by absorbent points.

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It is proved beyond doubt that…

Biomechanical instrumentation in

combination with copious irrigation is the primary means of achieving…

Adequate disinfection of root canal system.

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Some suggest that these techniques may not

completely eradicate micro organisms in a necrotic pulp

space and that further disinfection with an effective intracanal medicament may

be necessary

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Intracanal medicaments have always gone hand in

glove with endodontics

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The rationale for the use of intracanal

medicaments …

• The medicament may reduce the microbial flora below the levels already achieved during canal preparation.

• The presence of intracanal medicament restricts bacterial growth in between appointments by creating an environment which is not conducive for bacterial growth.

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• In special cases use of an intracanal medicament like calcium hydroxide can bring about periapical repair.

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Before considering root canal medication, one

question that arises is…

Which organisms are we trying to destroy?

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Root canal flora

• Most commonly found microorganisms.are the gram +ve In some cases it may be gram -ve and few of the cases yeasts.

• These organisms are found in various combinations and not as a single species.

• In teeth with periapical lesion obligate anaerobes are often found.

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• The endodontic problem is primarily one of eliminating gram +ve organisms because they are the most abundant, consisting chiefly of streptococci and staphylococci.

• Among the streptococci is a small resistant group of enterococci. In addition a small percentage of gram -ve organisms and yeasts can be isolated from saliva and from root canals.

• Recent reports on bacterial flora describe the presence of obligate and facultative anaerobes.

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Disinfection of root canal system by means of intracanal medicaments is accomplished

by:• Chemical means

• Physical means/ electrosterilization/ electrolytic medication

• Combination of physical and chemical means

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Ideal Requirements of ICM

The intra canal medicament should be –

1. Potent antibacterial & antifungal agent

2. Potent pulp tissue solvent3. Non irritant to periapical tissue4. Long duration of action5. Have low surface tension6. No hypersensitivity or allergic

reaction

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7. No interference with repair of periapical tissues

8. Active in presence of blood, abscess or protein derivatives of the tissue

9. Should be stable & should have longer shelf life

10.Capable of inactivation in culture medium

11.Economic, easily available

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Classification(Based on chemical nature)

I. Essential oil- Eugenol

II. Phenolic compoundsex: Phenol, camphorated phenol, camphorated mono chlorophenol, cresol, cresatin, thymol

III. Aldehydes ex: Formocresol, Glutaraldehyde

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IV. Halides Sodium hypochlorite, Iodine - Potassium iodide.

V . Steroids

VI. Calcium hydroxide

VII. Antibiotics

VIII. Combinations

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Eugenol• It is the chemical essential of oil of clove

but chemically related to phenol

• It has a weak antiseptic and anodyne effectThe ability of eugenol to inhibit nerve activity reportedly accounts for its anodyne property.

• Masillamoni and others reported that eugenol is a potent antimicrobial action at a dilution of 1:640 and is not as effective as formocresol and CMCP in its undiluted form.

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Phenolic Compounds

• Phenol/ carbolic acid introduced by Lord Lister in 1867 is one of the oldest antimicrobial agent used in medicine.

• It is used as a standard for comparing the relative effectiveness of other disinfectants.It serves as the basis for a number of derivatives extensively used in dentistry

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• Mechanism of action: Phenol is a protoplasm 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.

• This substance is highly effective in as low concentration as 1 to 2%

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Camphorated parachlorophenol

• It contains 35% parachlorophenol in 65% camphor vehicle.

• It is the least toxic of the phenolic compounds

• It has an excellent antimicrobial effect.

• Addition of camphor aims at developing a less caustic medicament as a result of the slow release of phenol.

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Camphor serves as:

• A vehicle and diluent.

• Results in less toxic phenolic compound as it slows the release of toxins to the surrounding tissues.

• Prolongs the antimicrobial effect.

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Camphorated Mono Chloro Phenol

( CMCP)• Developed by Walkhoff 1891

• Composition: 35% Monochlorophenol 65% camphor

• It has a wide antibacterial and antifungal spectrum.

• It is used in the form of vapor forming intracanal medicament. The vapors can pass through the apical foramen.

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• It is much less irritating to the periapical tissues than either phenol or eugenol .

• It is inexpensive and has a long shelf life.

• Least toxic of all phenolic compounds.

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Cresol• Cresol is about three times more

powerful as a disinfectant than phenol and is slightly less toxic

• It is used as a root canal disinfectant specifically in combination with solutions of formaldehyde.

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Formocresol

• It is a combination of cresol and formalin in proportion of 1:2, 1:1 which was popularized in United States by Buckley in 1905.

• Contents: 19% formaldehyde, 35% cresol, 6% glycerine and water.

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• Formalin is a strong disinfectant and a fixative which combines with albumin to form an insoluble and indecomposable substance .

• 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%.

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• It causes widespread destruction of living tissue followed by a persistent inflammatory reaction.

• Its vapor forming effect is also good.

• Studies have reported that formo cresol treated tissue produced a cell mediated immune response. It has mutagenic and carcinogenic potential.

• It is used in pulpotomy to fix the retained pulp tissue.

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Cresatin• Metacresylacetate or cresatin is

the acetic acid ester of metacresol.

• It is an antiseptic, analgesic and fungicidal agent

• It is a clear, somewhat oily liquid of low volatility and is stable.

• Its antibacterial effect is enhanced because of its low surface tension and its effect is prolonged by its low volatility.

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Creosote• It is a mixture of phenol and phenol

derivative a better disinfectant than phenol and is less toxic and irritating.

• It is less commonly used than phenol because of its pungent, highly penetrating odor which, in the past, gave many dental offices their characteristic odour.

• In dentistry only beechwood variety of creosote is used.

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Gluteraldehyde • It is a colorless oil slightly soluble in H2O .

• Like formalin it is strong disinfectant and a fixative.its antimicrobil action is concentration and time dependent.

• Used in concentration of 2% as ICM.

• Extent of toxicity is less compared to formaldehyde. Its molecular weight is high compared to formaldehyde hence does not penetrate into the periapical tissues.

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Halogens

• Chlorine and iodine are the bases of a number of oxidizing antiseptics commonly used in endodontic practice.

• The disinfectant action of halogens is inversely proportional to their atomic weight.

• Chlorine having the lowest atomic weight, has the greatest disinfectant action of members of this group.

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• Chlorine disinfectants have a solvent action on necrotic tissue but as a class they are not stable. Hence they are used in the form of sodium hypochlorite or camphorated monochlorophenol.

• Sodium hypochlorite although used primarily as an irrigant, has been suggested for use as an intracanal medicament because it is less irritating than other intracanal medications.

• Ellerbruch and Murphy reported that NaOCl vapours were bactericidal.

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• NaOCl reacts rapidly with organic matter; therefore, the longevity of its antimicrobial effectiveness is questionable.

• As an intracanal medicament iodine is used in the form of iodine potassium iodide ( 2% iodine, 4% potassium iodide & 94% distilled water.

• Iodine has a staining potential and may cause allergic reactions.

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• Iodine potassium iodide has an excellent antimicrobial activity and has only minimal toxicity and tissue-irritating qualities, so it continues to provide an active antimicrobial effect at a concentration with no cytotoxicity.

• The vapor-forming effect is good as well, providing an antimicrobial effect.

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Quaternary ammonium compounds

• The quaternary ammonium compounds are cationic detergents or wetting agents, are mild disinfectants.

• They are positively charged and micro-organisms are negatively charged a surface active effect results such that the compound clings to the micro-organisms and reverses the charge.

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• 9 aminoacridine a mild disinfectant has been suggested as an endodontic irrigant and intracanal medication.

• A 1:500 dilution of 9-aminoacridine was found to exhibit more effective antimicrobial activity than eugenol or cresatin but less than camphorated monochlorophenol.

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Calcium Hydroxide

• Introduced by Herman in 1930

• One of the most popular ICM

• The pH of calcium hydroxide is highly alkaline about 12.5, several bacterial species commonly found in infected root canals are eliminated after a short period when in direct contact with this substance.

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• Antimicrobial activity of calcium hydroxide is related to the release of hydroxyl ions in an aqueous environment.

• Hydroxyl ions are highly oxidant free radicals that show extreme reactivity.

• Their lethal effects on bacterial cells are probably due to the following mechanisms:

1. Damage to the bacterial cytoplasmic membrane

2. Protein denaturation3. Damage to the DNA

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Damage to the bacterial cytoplasmic membrane

• Hydroxyl ions induce destruction of

phospholipids, which are the structural

components of the cellular membrane of

the bacteria.

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Protein Denaturation

• The alkalinization provided by calcium hydroxide induces the breakdown of ionic bonds that maintain the tertiary structure of proteins.

• This results in the loss of biological activity of the enzyme and disruption of the cellular metabolism

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Damage to the DNA

• Hydroxyl ions react with the bacterial DNA and induce the splitting of the strands.

• DNA replication is inhibited and the cellular activity is disarranged.

• Free radicals may also induce lethal mutations.

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Vehicles used for Ca(OH)2

1. Distilled water :• Rapid hydrolysis of compound into its

active parts

2. Camphorated mono chlorophenol :• Dual effect of a vehicle as well as an

additional antibacterial action

3. Propylene glycol :• Resultant paste has better handling

characteristics because glycerin is humectant.

• Ca(OH)2 readily dissolves in glycerin

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Antibiotics

Few antibiotics are used as an intracanal medicaments, may be alone or in combination or with corticosteroids:

• PBSC & PBSN• Sulfonamides• Tetracycline• Metronidazole• Chloramphenicol• Bacitracin • Neosporin

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PBSC

It is available in paste form which contains,

1. Penicillin : effective against Gm +ve microorganisms

2. Bacitracin : effective against penicillin resistant microorganisms

3. Streptomycin : effective against Gm -ve microorganisms

4. Caprylate : effective against fungi

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PBSN

Penicillin : effective against Gm +ve microorganismsBacitracin : effective against penicillin resistant microorganismsStreptomycin : effective against Gm -ve microorganisms Nystatin : effective against fungi

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• Disadvantages:

Both the preparations have shown severe hypersensitivity or allergic reaction to any of the constituent, so its use is largely declined

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Sulfonamides• Sulfanilamide & sulfathiazole Used

as medicament by mixing with sterile distilled water or by placing the moistened paper point into a jar containing this powder & then putting it into canal.

Disadvantages:• Hypersensitivity reaction• Yellowish discoloration of tooth.

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Chloramphenicol

• Broad spectrum antibiotic, active against aerobic as well as anaerobic micro-organisms.

• Method of use:Crystals in a few drops of normal saline is mixed well to form paste. Use of paper point or reamer to introduce the paste into canal.

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Corticosteroids

• Used in combination with antibiotics in a paste form.

• Primary function of corticosteroid is to prevent or reduce periapical inflammation .

• Highly effective in the treatment of over instrumentation.

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Thank You