DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS

ROOT CANAL MEDICAMENTS

 INTRODUCTION

Bacteria have been implicated in the

pathogenesis and progression of pulp and
periapical diseases. The primary aim of
endodontic treatment is to remove as many
bacteria as possible from the root canal system.
Disinfection of the pulp space is an important
step during and after cleaning and shaping. It
primarily involves cleaning and shaping the root
canal space with endodontic instruments along
with irrigants.
However, in certain clinical conditions, the
polymicrobial nature of the endodontic infection
demands the use of an intra-canal medicament
in addition to the irrigants
 Vital Teeth with Inflamed Pulp
• In the treatment of teeth with a vital pulp that
is inflamed but not necrotic, there is no need
for intra-canal medication
• However, if time does not allow completion of
the treatment in one appointment, it is
generally recommended that the root canal
should be filled between appointments with
an antimicrobial dressing, for example,
Ca(OH)2, to maintain sterility in the canal
space until a permanent root filling is placed.
 Teeth with Pulpal Necrosis and Apical
Periodontitis
Most root canals contain viable microorganisms
after the completion of the chemo-mechanical
preparation at the end of the first appointment.
Therefore, a variety of intra-canal medicaments
have been used between appointments to
complete disinfection of the root canal.
 Indications
• To dry persistently wet or so called weeping
canals
• To eliminate any remaining microbes in the
pulp space
 OBJECTIVE OF INTRACANAL
MEDICAMENTS
 They disinfect the root canal system

 Eliminate or destroy any remaining viable bacteria in the root canal

system that have not been destroyed by the chemo-mechanical
preparation processes

 Reduce peri-radicular inflammation and hence reduce pain,

 Control of persistent peri-apical abscess.

 Prevent re-infection of the root canal system by acting as both a chemical

and a physical barrier if the temporary or interim restoration breaks down
 IDEAL PROPERTIES
• It should be effective germicide and fungicide.
• It should be non irritating to pulpal tissue.
• It should remain stable in the solution.
• It should have prolonged antimicrobial action.
• It should remain active in presence of blood and pus etc.
• It should have low surface tension.
• It should not interfere with the repair of periapical
tissue.
• It should not stain tooth.
• It should have no deleterious effect on vital tissues.
• It should not alter the physiologic activities of the host tissues.
• It should reduce pain.
• It should induce healing and hard tissue formation
• It should eliminate apical exudates.
• It should control inflammatory root resorption.
• It should have reasonable shelf life.
• It should be readily available
• It should be inexpensive.
• It should be easy to handle (mix & place and remove)

No single agent fulfills all these criteria.

 
 INDICATIONS OF INTRACANAL MEDICATION IN ROOT CANAL TREATMENT

o As an anti inflammatory agent to reduce inflammation of the pulp

remnants or periapical tissues.
 

o As an antibacterial agent to eliminate any remaining bacteria in the

root canal after canal instrumentation.

o As a barrier against leakage or breakdown of the temporary filling:

o To control persistent abscesses and persistent “weeping /wet

canal”
CLASSIFICATION
 According to Franklin S. Weine(1995) According to D.Orstavik(1990)(Harty’s
Endodontics in Clinical Practice)

1.Phenol and related compounds 1. Aldehydes

• Eugenol • Formocresol (dressing: 19 %
• Camphorated paramonochlorophenol formaldehyde, 35%cresol, 46% water and
• Metacresyacetate glycerine)
• Cresol
• Thymol 2. Halogens
• Chlorine
2.PBSC
• Iodine
• Penicillin
• Bacitracin
•  
• Streptomycin 3. Phenols
• Caprylate • Camphorated phenol
• Paramonochlorophenol (PMCP)
3.Sulphonamides • Eugenol

4.Corticosteroid – antibiotic combinations 4. Chlorhexidine

5.Calcium hydroxide.
5.Calcium hydroxide
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 According to Ingle
3. Heavy metal salts - Salts of silver,
1. Alcohols mercury, copper.
- Ethylalcohol
- Isopropyl alcohol 4. Cationic detergents - Quaternary
ammonium compounds.
2. Phenolic compounds
- Phenol 5. Halogens
-Camphorated phenol - Na hypochlorite
-Monochlorophenol - Potassium iodide, iodine
-Paramonochlorophenol
-Thymol
-Eugenol
-Creosote

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 According to Grossman (1990), intracanal medicaments can be classified as

 1.Essential oils
5. Halogens
• Eugenol
 Sodium hypochlorite
2.Phenolic compounds  Iodides
• Phenol  Chlorhexidine
• Parachlorophenol
• Camphorated para chlorophenol
• Cresol 6.Quaternary ammonium compounds
• Formocresol
•
9-aminoacridine
Creosote
• Cresatin
• Cresanol 7.Fatty acids
Propionic acid
3. N2
Caproic acid
4. Salts of heavy metals Caprylic acid
• Metaphen
• Merthiolate
8. Sulphonamides
• Mercurophen
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 METHODS OF APPLICATION

. There are basically three methods:

• The medicament can be placed on a cotton pellet and placed

in the pulp chamber or
• The root canal can be flooded with the preparation.
• Paper points medicinally impregnated.
• Syringe system
• lentulospirals

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INDIVIDUAL MEDICAMENTS
 CHLORHEXIDINE
• It is a cationic bibisguanide.

• Used as an intracanal medicament in the form of:

2% gel or
with calcium hydroxide

Mechanism of action:

• It seems to act by adsorbing onto the cell wall of microorganisms and causes
leakage of intracellular components.

• low concentrations : small molecular weight compounds leak out, resulting

in a bacteriostatic effect.

• higher concentrations : it has a bactericidal effect due to precipitation or

coagulation of cytoplasm, probably caused by protein
cross linking.
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 Calcium hydroxide

• Hermann introduced Ca(OH)2 paste as an Intracanal medicament in 1920

• The high pH of calcium hydroxide is responsible for the destructive effect on

bacterial cell membranes and protein structures.

• It is a white odorless powder with the formula Ca(OH)2

• a molecular weight of 74.08.

• It has a high pH of 12 – 12.8 and

• insoluble in alcohol

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 MECHANISM OF ACTION(Haliwell 1987,Imlay &
Linn1988,Cortal et al 1999)

• Damage to bacterial cell wall: hydroxyl ions induce lipid peroxidation resulting in
destruction of phospholipids present on cell wall.
 
• Protein denaturation: Alkaline pH induces a breakdown of ionic bond that
maintain the structure of protein.

• Damage to DNA: OH ion react with bacterial DNA and induce spliting of the
strands.

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 Various vehicles used for calcium hydroxide:

There are three types of vehicles used:

• Aqueous vehicles
• Viscous vehicles
• Oily vehicles.

Aqueous vehicles
• The various aqueous vehicles used are sterile water, distilled water,
sterile saline, anesthetic solutions, ringer’s solution, methylcellulose,
carboxy methylcellulose.

Viscous vehicles
• These are glycerine, polyethylene glycol, propylene glycol.
• (calen, calen+CMCP, )

Oily vehicles:
• Olive oil, fatty acids, camphorated parachlorophenol, eugenol.(endoapex,
vitapex)
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 METHODS OF APPLICATION

Number of instruments can be used depending on the handling,

convenience, size and location

 syringe systems
lentulo spirals
messing gun
mcspadden compactor
amalgam carrier
 K type ultrasonic files
prefitted pluggers
ultrasonics
 paper points can be used
 
• The minimum interappointment time interval should be no less
than 14 days since inflammation takes 10-14 days to subside. But
longer time may be required as Calcium Hydroxide takes 3-4 weeks
to reach its maximum concentration within apical dentin.
 
• Role of calcium in calcium hydroxide

• Calcium acts, clearing the carbon dioxide used by bacteria for

anaerobic respiration.

• However, the calcium ion plays an essential role on tissue

mineralization.
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 Ca (OH)2 Points
• Because of poor handling property and challenge for its complete
removal ,Ca(OH)2 points were introduced which contain calcium hydroxide
instead of zinc oxide at a concentration of 50-54% (wt %).

• The points are 28mm in length and a distinctive brown color.

• available in ISO sizes of 15 to140.

• An improved version of calcium hydroxide points is the calcium hydroxide

plus points (CHPP) which additionally contain
sodium chloride and tensides which reduces
the surface tension of liquid

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Advantages of Calcium hydroxide points

 Minimal or no residue left

 No smearing around the access cavity during insertion
 Firm for easy insertion and flexible enough to follow the
natural canal curvature
 Time saving
 Uniform calcium hydroxide release.

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In addition the Calcium hydroxide plus points have
shown to have
i)three fold high calcium release
ii) Superior pH values
iii)Increased wettability of canal
iv)Increased release of zinc oxide compared to normal gutta percha points thus
increasing its antibacterial effects
v) Sustained alkaline pH for 7 days as against 3 days which was seen with
calcium hydroxide points.

Disadvantages
• 1. Action is short lived
• 2. Lack of sustained release
• 3. Radiolucent

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 Retrieval of CH

Vehicles used to carry CH may affect its retrieval

• 17% EDTA as irrigant along with hand instrument is more

effective in removing powder form of CH than metapex.

• 10% citric acid was better in removing metapex.

(JOE 2006)

• The powdered form in distilled water was removed by 96 to 99%

compared to 73-89% silicon oil containing metapex.

• Ultrasonic have been found to be effective in removing calcium

hydroxide from the canal.
 
(Int. Endo. Journal Jan 2007)
 Difficulties associated with calcium hydroxide as an
intracanal medicament

• May not penetrate anatomical areas.

• Resistance of bacterial strains to calcium hydroxide.

• May not penetrate the tubules because of bacterial biofilm.

• May release ions slowly.

• Ability of E. faecalis to colonize in the tubule & thus evade the

OH-ions

• Difficulty in removing calcium hydroxide from the canal

 CALCIUM HYDROXIDE AS A MEDICAMENT FOR
“WEEPING CANALS”

• One of the most perplexing situation is to treat the tooth with

constant clear or reddish exudate associated with the large
apical radiolucency.

• The tooth is often asymptomatic, but it may be tender to

percussion or sensitive to digital pressure over the apex.

• The canal has already been enlarged to more than an

acceptable size. This is referred to as “weeping canal”.
(Weine 2004)
 Treatment

According to Weine (2004), the best way to stop the

exudate in such cases is to dry the canal with sterile
paper points and to place Ca(OH)2 paste in the canal.
The possible mechanism of action of Ca(OH)2 in
these cases is related to

• Three theories have also been proposed:

(i) its basic pH, which converts the acidic pH of periapical tissues
to a more basic environment.
(ii)the calcifying potential of CH may start to build up bone in
the lesion
(iii) its caustic action cauterizes residual chronically inflamed tissues
 Antibiotics

• Antibiotics were first discovered in 1928 but were not routinely used clinically
until the early 1940s during the World War II.

• In endodontics and dental traumatology, antibiotics may be applied systemically

(orally and parenterally) and locally.

• The first reported local use of an antibiotic in endodontic treatment was in 1951
when Grossman used a polyantibiotic paste.

• Penicillin: - effective against gram positive microorganisms (10,00,000 units)

• Bacitracin: - effective against penicillin resistant microorganisms (10,000 units)

• Streptomycin- effective against gram negative microorganisms (1gm)

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• Caprylate- as the sodium salt, effective against fungi (1gm)

• Nystatin replaces sodium caprylate as the antifungal agent in

a similar medicament, PBSN.
• These compounds were all suspended in a silicone vehicle.

• Both are available in a paste form that may be injected into

the root canal or impregnated on paper points.

• But with the decline in popularity of intracanal medicament in

general, and because of the potential for sensitivity due to
topical use of antibiotics, PBSC, largely has fallen into disuse.

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 Rationale for Local Applications of Antibiotics

• systemic antibiotics : potential risk of adverse systemic effects,

allergic reactions, toxicity, side effects, and development
of resistant strains of microbes.

• Therefore, local application of antibiotics may be a more effective mode

for delivering antibiotics

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Ledermix paste

• Ledermix, a glucocorticosteroid antibiotic compound.

• developed by Schroeder and Triadan in 1960

• Ledermix paste remains a combination of :

3.2 %demeclocycline HCl (tetracycline antibiotic)
1% triamcinolone acetonide corticosteroid(4 times more potent
than cortisone thus low conc.) in a polyethylene glycol base.

• The two therapeutic components of the Ledermix are capable of diffusing

through dentinal tubules and cementum to reach the periodontal and
periapical tissues.

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• corticosteroid : to control pain and inflammation.
• antibiotic component : to compensate for corticoid-induced reduction
in the host immune response.

• Ledermix paste had no damaging effects upon the periodontal membrane

and that this paste was an effective medication for the treatment of
progressive root resorption in traumatically injured teeth.

• Ledermix paste treated roots had statistically significantly more healing

and less resorption than the roots treated with Ca(OH)2

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 Combination of Ledermix and Calcium
Hydroxide

• advocated by Schroeder

• A 50-50 mixture of Ledermix paste and calcium hydroxide has also been
advocated as an intracanal dressing in cases of

infected root canals,

pulp necrosis ,
infection with incomplete root formation, perforations,
inflammatory root resorption,
inflammatory periapical bone resorption, and
large periapical radiolucent lesions.

• slower release and diffusion of the active components (last longer)

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 Triple Antibiotic Paste

• The infection of the root canal system is considered to be a polymicrobial

infection, consisting of both aerobic and anaerobic bacterial.

• A combination of antibiotics would also decrease the likelihood of the

development of resistant bacterial strains.

• The combination that appears to be most promising consists of metronidazole,

ciprofloxacin, and minocycline.

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 TECHNIQUE OF USING ANTIBIOTIC PASTES:

• To avoid dilution of the paste, or inactivation of one or more of its

constituents, an absorbent point is first inserted into the canal to check
that the irrigant has been completely removed.

• The instrument used to handle the paste should be sterile and dry, and
it should not be hot as heat destroys the antibiotic.

• Since pastes are less diffusible than chemical antiseptics, it is necessary

to ensure that they touch the entire canal wall.

• This is done by transferring the paste to the pulp chamber with a plastic
instrument as ‘spiral root filler’ or “ rotary paste filler and then
propelling it apically along the root canal with a paste carrier.

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 Limitations of Intra Canal Medicaments

• Intra canal environment- The therapeutic action of these

medicaments depends on the direct contact with the tissues. But
these substances probably do not reach all the areas where bacteria
or tissues are present and are limited to the surface action only.

• Duration To be effective these agents should remain chemically

active during the time of inter appointments.

• Phenols lose their activity very quickly with in 24 hrs. Calcium

hydroxide retains the antimicrobial action for a prolonged period.

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 CONCLUSION

• Intra canal medicaments in endodontics have been used for a number of

reasons in the past and currently. Often, different chemicals or drugs are

combined in a “cock tail” in an attempt to elicit a variety of effects with a

single application. After reviewing in vivo and in vitro research, there is a

decided evidence of lack of clinical effectiveness of Intra canal medicaments .

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 SUMMERY
• Antimicrobial agents used as inter-appointment
medicaments must be able to penetrate through the
dental tissues in the presence of microbes to reach a
sufficiently high concentration in order to eliminate
the disease causing bacteria in a predictable manner

• In Intra canal environment, the therapeutic action of

these medicaments depends on the direct contact
with the tissues.
• But these substances probably do not reach all the
areas where bacteria or tissues are present and are
limited to the surface action only.
THANK YOU