Dr.

Tahani Abualteen

INTRACANAL MEDICAMENTS & TEMPORIZATION

 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 microorganisms
2. Prevention of the growth/re-growth of any new/old microorganisms (antibacterial
action is the most important function)
3. Disinfection of root canal system
4. Suppression of inter-appointment pain by reducing inflammation (some have anti-
inflammatory action)
5. Render the canal contents inert
6. 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 & fungicide
2. Should NOT irritate periapical tissues
3. Should remain stable in solution
4. Should have prolonged antimicrobial effect
5. 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 tissues
7. Should NOT interfere with periapical healing
8. Should be easily placed & removed
9. Should NOT stain the tooth structure
10. Should NOT induce a cell mediated immune response
11. 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
 Types:
o PHENOLICS
o ALDEHYDES
o HALIDES

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o STEROIDS
o CALCIUM HYDROXIDE
o ANTIBIOTICS
o COMBINATIONS
 PHENOLICS
o Phenol is a protoplasm poison (TOXIC)
o They have access to systemic circulation
o They have a strong inflammatory potential
o They have unpleasant odor & foul taste
o They are ineffective
o Their clinical use is NOT justified
o PHENOLIC COMPOUNDS:
 Eugenol
 Parachlorophenol (PCP)
 Camphorated monoparachlorophenol (CMCP)
 Camphorated parachlorophenol (CPC)
 Metacresylacetate (Cresatin)
 Cresol
 Creosote (beechwood)
 Thymol
o EUGENOL
 This is the chemical essence of oil of clove (‫)زيت القرنفل‬
 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

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o 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

o 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)
o 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)
o 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
 Glutaraldehyde
 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

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 HALIDES
o 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
o 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
o Have been advocated for decreasing postoperative
pain by suppressing inflammation (anti-inflammatory
action)
o Evidence suggests that they may be ineffective,
particularly with greater pain levels
o Might be used in cases of irreversible pulpitis & acute
apical periodontitis (but NOT used anymore)
 CALCIUM HYDROXIDE
o Introduced by Hermann in 1920
o It is one of the most commonly used intracanal medicaments
o Used for short & long term durations

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** 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
o It is a broad spectrum antimicrobial agent
o Its antibacterial action is related to its high pH
o It may aid in dissolving necrotic tissue remnants and bacteria and their
by-products
o It demonstrates no pain-reduction effects
o It has been recommended for use in teeth with necrotic pulp tissue
o It probably has little benefit with vital pulps
o 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 ZOE–based
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

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o 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)

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 CHLORHEXIDINE
o It is a broad spectrum antimicrobial
agent
o 2% gel is recommended
o Can be mixed with calcium hydroxide to
increase its antibacterial activity & enhance
the periradicular healing
o It doesn’t 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
o It is a fixative
** Usually used as a mouth wash in a concentration of 0.2%

 ANTIBIOTICS
o 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
o Sulfonamides
 Mixed with sterile distilled water
 Used in acute periapical abscess
 Causes yellowish tooth discoloration
o Grossman’s 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:
o Their therapeutic action depends on direct contact with tissues
o Do NOT reach all areas of root canal system
o Limited to surface action only

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o Chemically NOT active for a long duration

o Development of resistant strains of bacteria
o Might cause tooth discoloration
 TEMPORIZATION:
 Objectives:
1. Coronal seal (prevent microleakage)
2. Enhance isolation
3. Protection of tooth structure
4. Allow of ease of placement & removal
5. Satisfy esthetics
 Determining factors:
A. Intended duration of use
B. Occlusal load & wear
C. Complexity of access
D. Loss of tooth structure
 Types:
o Cavit
o IRM
o GIC
o TERM
 CAVIT
o Based on zinc oxide & calcium sulfate (NO EUGENOL is
used)
o Premixed cement that sets in the presence of
moisture
o Low strength & rapid occlusal wear
o Used in short-term sealing of simple access cavities
o Clinically, 4 mm of Cavit provides an effective seal
against bacterial penetration for 3 weeks
 IRM
o IRM = Intermediate Restorative Material
o Reinforced zinc oxide-eugenol cement
(EUGENOL is used)
o Improved strength & wear resistance
o Leaks more than Cavit
 GIC
o GIC = Glass Ionomer Cement

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o Durable & effective barrier against microbial leakage.

o Adhesion to moist tooth structure
o Anti-cariogenic properties due to
release of fluoride
o Biocompatibility and low toxicity
o Poor mechanical properties (poor
strength and wear resistance)
o Present in 2 forms: liquid & powder
or capsules
 TERM
o TERM = Temporary Endodontic
Restorative Material
o Specially formulated light-polymerized
composite materials (no fillers are used)
o Improved strength & wear resistance
o Provides a moisture-free seal

 Points to remember:
o Pulp chamber and cavity walls should be dry
o A minimum depth of 3 to 4 mm of temporary
filling material is required
o At least 3 mm thick in the cingulum area
o Small piece of cotton pellet is used under the
temporary filling (sometimes cotton pellet isn’t
used at all)
o Care must be taken not to incorporate cotton
fibers into the restorative material
o Packing into the access opening with a
plastic instrument in increments from the bottom up and pressing
against the cavity walls and into undercuts
o Excess is removed, and the surface smoothed with moist cotton pellet
o Occlusion of patient is checked

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o The patient should avoid chewing on the tooth for at least an hour

** Sometimes, no cotton pellet is used, which is right, but it will make it very
difficult for the temporary filling material to be removed from the orifices of root
canals
** Putting a very big cotton pellet is wrong because it will compromise the
space available for the temporary filling material and eneases its breakage
under occlusal loads
** Don’t place the temporary filling material in one shot, but place it in
increments and condense it against walls and smoothen it
 Extensive Coronal Breakdown
o A strong filling material (high-strength GIC) is
required
o Take care to ensure an adequate thickness and
good marginal adaptation proximally
o Should extend well into the pulp chamber deep
to the proximal margin to ensure a marginal
seal
o Reducing the height of undermined cusps well
out of occlusion reduces the risk of fracture.
o For severely broken-down teeth, a cusp-onlay amalgam or a well-fitting
orthodontic band cemented onto the tooth is needed

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 Provisional Post Crowns

o Used when a cast post and core is being fabricated
o The post could be (preformed
aluminum post, safety pin wire, paper
clip, or a sectioned large endodontic
file)
o The coronal seal is generally
inadequate
o The post should fit the canal snugly
(not binding)
o The post should extend apically 4 to
5 mm short of working length and
coronally to within 2 to 3 mm of
the incisal edge
o A polycarbonate crown is trimmed to a good fit
o Good contouring and occlusal adjustment
o Provisional luting cement (Temp Bond or similar
cement) is placed on the coronal 3 to 4 mm of the
post and root face
o A provisional removable partial over-denture is a
useful alternative
 Long-Term Temporary Restorations
o A durable material, such as amalgam, GIC, or acid-
etch composite, should be used.
o The pulp chamber is filled with Cavit to provide a good coronal seal and
covered with a sufficient thickness of the restorative material to ensure
strength and wear resistance
o The layer of Cavit can be easily removed in the next visit

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