Intracanal

Medicaments

Dr. Hadil Abdallah Altilbani

BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine .
“What Is Removed From The
Canal Has A Greater
Significance In Endodontic
Success Than What Is Placed In
The Canal.”

CRITERIA FOR OBTURATION

• The canal should be reasonably Dry with
no weeping of fluids in the form of
bleeding or serous discharge
• When patient is without Sensitivity To
Percussion
• Teeth with No Periradicular Radiolucency
After optimal cleaning and shaping is
achieved
AIM :
• Disinfection of the root canal , that is
destruction of pathogenic microorganisms is
accomplished by intracanal medication.

• Evidence is sufficient to indicate that

disinfection of the root canal is an Important
Phase of endodontic treatment.

• Microorganisms present in the canal can

invade the Periapical Tissue And May Not
Only Give Rise To Pain, But Also Destroy The
Periodontium Including Bone.

• Endodontics may be considered the

treatment or prevention of apical
periodontitis, which translates into the
elimination or control of root canal infection
 ROOT CANAL FLORA :
• Before considering intracanal medication –
• we might ask the question:
• What Microorganisms Are We Trying To Destroy?

• In most cases, gram-positive organisms are present;

• in some cases, gram-negative organisms;
• in a few cases, yeasts.
• These organisms are found most often in various Combinations rather than as a single
species.
• Obligate anaerobes are often associated with teeth that have a Periapical Lesion.
• The microbial flora of the root canals is likely to comprise organisms that can survive on dead pulp
tissue, that is, saprophytes, as they can grow in an environment of low oxygen tension

• The endodontic problem is primarily one of eliminating Gram-positive

organisms because they are the most abundant, consisting chiefly of
Streptococci And Staphylococci.
• Among the streptococci is a small but resistant group of Enterococci.
When?
• Vital Cases
In vital cases where root canal treatment is carried out under aseptic conditions an intracanal
medicaments is Not required.

• Infected Teeth
o Approximately 50% of infected root canals were Not Disinfected using an antibacterial irrigant
alone during root canal treatment.
o Residual bacteria remaining in the root canal following preparation are able to multiply rapidly
between appointments if the canal remains empty.

The Use Of Intracanal Medicament Is Generally Indicated In Case

Of:

• Teeth with Necrotic Pulp that are been treated in multi-visits.

• Teeth that have Failed root canal treatment and undergoing Retreatment
• Teeth with Periapical Pathology
How?
• The Antibacterial Activity Should Be Greater Than
The Cytotoxic Effect.

• The Agent Should Be In Contact With The Residual

Bacteria.

• The Agent Must Be Present In Sufficient

Concentration.

• Antibacterial Intracanal Medicaments Must Have A

Wide Spectrum Of Activity.

• The Agent Must Have A Sufficient Duration Of

Action.

Intracanal medication is recommended as part of routine endodontic treatment for a

variety Pittford of reasons.

However, it must Not Be Used As A Substitute for efficient chemomechanical

preparation of the root canal system, which forms the basis of sound and successful
endodontic treatment.
After proper instrumentation and irragation of root canal, some dentists may place
antibacterial agent inside the canal and seal the cavity with temporary filling for the
next appointment.
Intracanal medicaments
Functions
Primary
Antisepsis
Disinfection

Secondary
Hard tissue formation
Pain control exudation
Resorption control
Secondary Function Of
Medicaments

• To aid in the elimination of micro- organisms

• To reduce pain
The most important aspect of any dental treatment is the comfort of the patient
In both acute apical periodontitis and the acute exacerbation of the chronic
condition , the use of anti inflammatory medicaments will add to the effectiveness of
debridement and drainage and help in overcoming pain.

• To eliminate apical exudates

Before a root canal filling can be placed it is essential for two reasons that no apical exudate is present.
1. Exudate indicates that there is a continuing active inflammatory process in the periapical
tissues.
2. The physical presence of moisture prevents the creation of an apical seal with the filling materials now
available.

• To induce healing and hard tissue formation

• To control inflammatory root resorption

INTRACANAL MEDICAMENTS : REQUIREMENTS

The requirements of a root canal disinfectant are as follows:

1. Should be an effective germicide and Fungicide

2. Should be Nonirritating to the periapical tissues
3. Should remain Stable In Solution
4. Should have a Prolonged Antimicrobial Effect
5. Should be Active In The Presence of blood, serum and protein
derivatives of tissue
6. Should have low surface tension
7. Should Not Interfere with repair of periapical tissues
8. Should Not Stain tooth structure
9. Should Not Induce A Cell-mediated Immune Response.
 INTRACANAL MEDICAMENTS CLASSIFICATION

Till Now There Is No Ideal Material That Server All Theses

Functions Completely, Several Materials Has Been Proposed
Throughout History, Including:

1. Phenols
PHENOLS AND ALDEHYDES
2. Aldehydes
3. Calcium Hydroxide • They were common intracanal
4. Chlorhexidine medicaments.
• However, their use is no longer
5. Iodine-potassium Iodide recommended.
6. Corticosteroids • Their components are cytotoxic,
carcinogenic and mutagenic.
7. Triple Antibiotic Past • They are banned in several countries
8. Bioactive Glass including USA.
• Eugenol
This substance is the chemical essence of oil of clove and is related to phenol. It
is slightly more irritating than oil of clove and is both an antiseptic and an
anodyne.
• Phenol
This white crystalline substance has a characteristic odour derived from coaltar.
Phenol is a protoplasm poison and produces necrosis of soft tissue.
Has inflammatory potential so less used.
• Formocresol
Formalin is a Strong Disinfectant that combines with albumin to form an insoluble,
indecomposable substance.

Formaldehyde : 19%
Cresol : 35 %
Water and glycerine : 46%

Necrosis Was Followed By A Persistent Inflammatory Reaction.

Formaldehyde produced an immunologic reaction through the T cells
• Glutaraldehyde
This colorless oil is slightly soluble in water and thereby has a slightly Acidic
Disinfectant And Fixative.
Glutaraldehyde replaced formocresol in endodontics because of its fixative
properties and bactericidal effectiveness and results in less destruction of tissues
Calcium Hydroxide

• One of the Most Commonly Used intracanal medicaments. And it’s the first
choice as intracanal dressing material by most dentists.
• Non setting (pH : 11 – 13) – intracanal medicament
• Its Antiseptic action probably relates to its High Ph and its leaching action
on necrotic pulp tissue.
• Calcium hydroxide paste is best used as an intracanal medicament when one
anticipates an Excessive Delay Between Appointments because it is
efficacious as long as it remains within the root canal.
Calcium Hydroxide As A Medicament For
“Weeping” Cases

• One of the most perplexing conditions to treat is the tooth with constant Clear Or
Reddish Exudation Associated With A Large Apical Radiolucency.

• The tooth often is Asymptomatic, but it may be Tender To Percussion Or Sensitive

To Digital Pressure Over The Apex.

• If cultured, the drainage generally will not support bacterial growth.

• When opened at the start of the endodontic appointment, a reddish discharge may
well up, whereas at a succeeding appointment the exudates will be clear.

• Some pressure is present, but not nearly as much as with an acute periapical abscess.
• If the tooth is left open under a rubber dam for 15 to 30 minutes, it may be closed
up by absorbing the exudate with an aspirator and paper points; But a similar
condition wil be seen in next appointment.

• This is referred to as a Weeping Canal.

• The answer to this problem is to Dry the canal with sterile absorbent paper points
and Place calcium hydroxide paste in the canal.

• Mechanism for the action of calcium hydroxide is closely related to the pH of the
periapical tissues which must be acidic in weeping stage.
• Others believe that the Calcifying Potential of the medicament starts to
buildup bone in the lesion.
• Still others suggest that the Caustic Action of the calcium hydroxide burns
residual chronic inflamed tissue.
• Because of its pH, few microorganisms can survive in calcium hydroxide’s
presence.

• The material has an excellent record of helping to Heal Radiolucencies.

• Unlike the phenolic derivatives, calcium hydroxide leads, at worst, to a minimal

number of immunologic reactions.
How to prepare and place?
Calcium hydroxide paste is prepared by mixing powder with sterile water or saline or
local anesthetic solution.
The mixture should be thick to carry as many Ca(OH)2 particles as possible, however,
do not overdried the mix to maintain solubility and high PH.
Lentulo Spiral are effective for placing the paste inside the canal.
Calcium hydroxide must placed to fill the entire canal to the full working length. Care
should be taken not to extrude it beyond the apex. Rotary instruments has been
suggested for placing the material into the prepared root canal. Nevertheless, paper
points can do the job.
Limitations of Calcium
Hydroxide

Despite its wide clinical use, it has been presented

with some limitations:
•The handling and proper placement of material
may be difficult.
•Removal of the paste also incomplete, even with
saline, NaOCl or EDTA, resulting in residual
Ca(OH)2 which shorten the setting time of zinc
oxide eugenol based endodontic sealers, if used.
•It’s ineffective againts E. Faecalis, a common
endodontic pathogen, and also ineffective against
Candida Albican.
CHLORHEXIDINE GEL
• Chlorhexidine (CHX) 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, Causing Cell Lysis.

• CHX has been used in Periodontal Therapy for many years.

• Its use as an endodontic Irrigant Is Based On Its Substantivity
and long-lasting antimicrobial effect, which arises from binding to
hydroxyapatite.
IODINE-POTASSIUM IODIDE

• It’s very effective intracanal medicament with

low toxicity but it’s not available in the market.
• If you want to use it, you should prepare it
manually.
• It’s prepared by mixing 2 g of iodine in 4 g of
potassium iodide, this mixture is then dissolved in
94 ml of distilled water.
LEDERMIX ( STEROID )

• Is Anti-inflammatory Agent that reduce pain and inflammation in the

periapical tissue.
• Ledermix has been advocated as intracanal dressing if the patient
reported symptoms of pain and inflammation.

• However, Ledermix substances can reach the systemic circulation via

diffusion through dentinal tubules, lateral canals and apical foramen.

• Its use has been restricted in the United State.

• In addition to that, Ledermixed, which is a Steroid, act as antiinfmmatory

and reduce the symptoms of pain, but the infection is still there.

• This could mask the infection and deceive the clinician. Therefore, they
are not popular now despite their common use in the past.
TRIPLE ANTIBIOTIC PASTE

It’s composed of Metronidazole, Ciprofloxacin

an Minocycline.
It is very effective at eradicate baterial
colonies in root canals.
But it has some disadvantages:
1. Minocyline cause tooth discoloration.
2. Fear of bacterial resistance
3. high toxicity to stem cells

For tooth discoloration reason, dual paste can

be used in place of triple paste.
Or use of Ca(OH)2 should be considered.
APPLICATION OF INTRACANAL MEDICAMENT

• After completion of mechanical instrumentation

and irrigation the following procedures are
recommended :
 Drying the canal
 Placement of medicament
 Covering the canal
 Sealing the medication
 Double seal
 Checking the occlusion
 DRYING THE CANAL
• The root canal must be Dried before
placing the medicaments.

• This can be achieved by first Aspirating

the bulk of remaining liquid from the
canal with the irrigating syringe.

• Then, sterile absorbent Paper Points of

an appropriate size are placed in the
canal to absorb the remaining fluid.

• Wide canals can also be dried by

wrapping some cotton wool around
a hand file and placing it in the canal
to the predetermined root length.
MEDICAMENTS IN ROOT CANAL MAY ACT

1. Within the canal itself

2. Within dentinal tubules
3. Within apical foramina
4. Periodontal, and
5. Periapical tissues
PLACEMENT OF MEDICAMENTS

SYRINGE DELIVERY
• Probably the Easiest way of applying a medicament

• Calcium hydroxide preparations come in different concentrations and in different

formats.

• Disposable plastic tips are excellent, as there is no risk of cross-infection

• Metal syringe tips must be autoclaved between patients.

• It is important to place a fine file along the bore of the needle to ensure that the tip
does not become blocked

• The syringe tips on most commercial systems Can Be Premeasured to prevent extrusion.
HAND FILE

• A file can be used to place the medicament in the canal

• The agent should be smeared on the walls of the root canals, and
can be carried to the working length by gently rotating the file in
an anti-clockwise direction.

• If it is mixed to a Thick Paste consistency a Plugger can be

used to ensure that the material is carried completely to all parts
of the prepared root canal system.
SPIRAL ROOT FILLERS

• These devices are used in a low speed handpiece and can be obtained in Different
Sizes.

• Once the spiral is in the canal, the motor is started and should be run at A Low

Speed And In The Forward Direction.

• It should not be advanced any further than 3 mm short of the working length.

• The spiral should be kept short of the apical foramen so that the material is not
forced beyond the foramen.

• Spiral should not be used in fine or sharply curved canals if they have not been
instrumented and enlarged.

• In these cases, a hand reamer should be used.

CLEARING THE PULP
CHAMBER
Care should be taken to avoid placing any of the
medicament within the crown of the tooth in
order to allow sufficient space for the insertion of
a temporary seal and also to prevent
discoloration.

COVERING THE CANAL ORIFICES

The canal orifices should be covered with dry
cotton-wool.
This done to prevent any particles from falling into
the canal during placement or removal of the
temporary filling material.
The cotton wool also provides a barrier to separate
the temporary filling material and the medicament
and aids easy access at subsequent appointments.
 Reinforced ZOE cements
Single cotton fibres must not penetrate the temporary filling as they
represent a path for the penetration of microorganisms.
• SEALING THE MEDICATION
• The root canal system must be sealed between all appointments in order to
Prevent Contamination from oral microflora and leakage of the medicament into
the mouth.

• Of the materials available for sealing access cavities, cavit or IRM are
recommended providing there is a thickness of at least 3.5 mm of material
placed in the access cavity.
• CHECKING THE OCCLUSION
Once the temporary restoration has been placed and the rubber dam removed, the
occlusion should be rechecked with thin articulating paper to ensure the temporary
restoration is not in occlusal contact.

• FREQUENCY OF MEDICATION
• In accordance with general principles of root canal management, disinfectant
dressing should preferably be renewed in A Week And Not Longer Than 2 Weeks
because dressing become diluted by periapical fluid and are decomposed by
interaction with the microorganisms.
LIMITATIONS AND CONTRAINDICATIONS

1. INTRACANAL ENVIRONMENT.
The chemical or therapeutic action of medicaments depends on direct contact of
the agent with microbes or tissue.
This is a drawback to chemicals used in the pulp space; these substances probably
do not reach all areas where bacteria or tissues are hidden and are limited to
surface action only.

2. DURATION
To be effective, most agents should remain chemically
active during the time between appointments.

3.TOXICITY
Any chemical that kills bacteria will also kill host cells.
Another potential adverse side effect is allergenicity.
Some medicaments act as haptens and alter tissues to become forein
substances, which then elict an immune response
4. DISTRIBUTION
A popular misconception is that the pulp space is isolated from the body.

This is not true.

There is ample evidence that substances placed in the pulp, with or without
tissue, have ready access to periradicular tissues and even to the systemic
circulation are unknown, the use of potent chemicals that have no
demonstrated beneficial effects is questionable.

5. TASTE AND SMELL

• The phenolics in particular posses a pungent odor and foul taste.
• These medicaments soak into and through the temporary into the oral
cavity.
• Patients report a disagreeable medicinal taste; many find this most
objectionable.
• Some dentists believe that if a patient report a bad taste, the temporary is
defective and will leak saliva into the canal; there is no evidence to support
this presumption.