INTRACANAL MEDICAMENTs in endodontics

: NORTH BENGAL DENTAL COLLEGE & HOSPITAL

UNDER THE GUIDANCE OF:-Prof.(Dr.) Soumen Chakrobarty,Dr. Anuradha mukharjee,Dr. Dwaipyan BhattacharyaDr. Partha Mondal (Department of Conservative dentistry)

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.

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

The current intracanal dressing ofchoice is calcium hydroxide .studies have shown calcium

hydroxideto be an effective antimicrobial

agent .Other studies have shown it to be

aneffective interappointment dressingover several weeks . Several different techniques for

placingcalcium hydroxide into root canalshave been proposed, such as

amalgamcarriers, vertical pluggers,

McSpaddencompactors, Lentulo drills, files andspecial syringes

A .According to Grossman1. Essential oils

- Eugenol2. Phenolic compound

- Phenol- Para chlorophenol- CPC- Formocresol- Glutaraldehyde- Cresatin

3. Halogens-sodium

hypochlorite- Iodides

4. Quaternary Ammonium compounds

- 9-amino acridine

CLASSIFICATIONS

B.According to DCNA1.Phenolics

- Eugenol- CMCP -PCP- CPC-Metacresylacetate

(Cresatin)- Cresol- Creosote (Beechwood)- Thymol

2.Aldehydes- Formocresol- Glutaraldehyde

3.Halides - Sodium hypochlorite- Iodine - Potassium iodide

4.Steroids5.Calcium hydroxide6.Antibiotics7.Combinations

INDIVIDUAL INTRACANAL

MEDICAMENTS

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

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.

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.

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.

Formocresol Developed by BUCKLEY in 1906Contents : 19% formaldehyde

35% cresol46% 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.

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

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

Base :i. L –methyl

trimethylene disalicylate

ii. Calcium sulphate iii. Titanium dioxide

Catalyst :i. Calcium hydroxideii. Zinc oxide iii. Sulphonamide

COMPOSITION:

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.

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

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.

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

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

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.

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

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

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.

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.

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.

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.

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.

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 -------------