INTRACANAL MEDICAMENTS IN DENTISTRY

1. Intracanal
Medicaments
PRESENTED BY – DR ISHANI
SHARMA
MDS 2ND
YEAR PG PAEDO

2. Defination
The general definition of intracanal
medicaments is “temporary placement
of medicaments with good
biocompatibility into root canals for the
purpose of inhibiting coronal invasion
of bacteria from the oral cavity”.
(kawashima et al, 2009)

3. HISTORY
Seribonius in 1045 AD wrote of using oils
and wine in the mouth of a patient in pain.
This was a crude attempt to achieve a
topical anesthetic effect on a tooth to be
extracted.
Dental writings through the Middle Ages
indicate the use of oil of cloves, a plant
extract containing a high percentage of
eugenol.

4. In 1800 specific medicaments were recommended
for endodontic treatment.
Beechwood creosate was mentioned in 1840
article ‘Creosate and cotton in Fang filling.’
1884 Richmond advocated “Knocking out the
pulp” by whittling down orangewood to a small
size, soaking the stick in phenol and tapping this
into exposed pulp canal.
Phenol was added to preserve and sterilize the
contents of canal and to alleviate pain.

5. IDEAL
REQUIREMENTS
It should be an effective germicide and
fungicide.
It should be non-irritating to the periapical
tissues.
It should remain stable in solution.
It should have prolonged antimicrobial effect
It should be active in the presence of blood,
serum and protein derivatives of tissues.

6. It should have low surface tension.
It should not interfere with repair of
periapical tissues.
It should not induce cell mediated immune
response.

7. FUNCTIONS
Eliminate microorganisms: The objective is to
sterilize (destroy all viable microorganisms) or
to disinfect (destroy all pathogens) in the canal
space.
Rendering contents of canal inert: This
represents the attempt usually by chemical
means to “mummify”, fix or neutralize tissue or
debris left intentionally or unintentionally in the
pulp space.
Prevention or control of post treatment pain

8. Enhancing Anesthesia: By reducing the
sensitivity of the inflamed tissue which can
be difficult to anesthetize pulp.
Control of persistent periapical abscess : In
cases of continually “weeping” canal or
significant pain or swelling medicaments
have been suggested as a means of
controlling this difficult situation.

9. Root canal flora

10. Predominantly consists of-
aerobic and facultative anaerobic microflora.
• Intact non-vital teeth – bacteroides,
peptococcus, peptostreptococcus, fusiform,
bacilli and corynebacterium.

11. Mazarella and colleagues 1955,
Mcdonalds and associates 1957, Brown
and Rudolph 1957
Gram +ve organisms Gram –ve organisms
Streptococci
Staphylococci
Corynebacterium
Yeasts
Spirochetes
Neisseria
Bacteroides
Fusobacterium
Pseudomonas
Coliform bacteria

12. Microflora in decidous root
canal
 Anaerobes:
Gram positive cocci -
Peptostreptococcus
 Gram positive bacilli -
Lactobacilli, Propionibac
terium , Actinomyces &
Eubacterium
Gram negative cocci -
Veillonella parvula
Gram negative bacilli
-Bacteroides &
Fusobacterium
Aerobes:
Streptococci,
Staphylococcus
Diptheroids.

13. The commonest organisms of the mouth,
streptococci are also the most frequently found
in root canals.
Among the streptococci is a small resistant
group of enterococci.

14. E. Faecalis
E.Faecalis is a gram +ve cocci present in
root canals.
It has the ability to survive the harsh
environment including alkaline pH, salt
concentrations.
It resists bile salts, detergents, heavy metals,
ethanol.
It can survive temp upto 60 UC.

15. Mechanism of action
Bind the dentin and invades the dentinal tubules.
Alters the host response and suppresses the action of
lymphocytes.
It can colonize the root canal without competing with
any other microorganism.
It forms a biofilm and renders it resistant to
phagocytosis , antibodies and antimicrobial agents
such as calcium hydroxide by maintaing the pH
haemostasis.

16. Factors disposing tooth infection

17. Trauma: The tooth under treatment should be
disoccluded if necessary.
Devitalized tissue: If present in the root canal
or periapical tissue will interfere with repair or
disinfection.

18. Dead spaces : for maximum effect the
medicament should be in contact with the
microorganisms in the root canal.
Accumulation of exudate : Exudate should be
allowed to drain or be removed as it accumulates.

19. Cell wall

20. Individual Intracanal Medicaments

21. Various root canal medicaments
Chlorhexidine
Formocresol
Calcium hydroxide
Antibiotics
Corticosteroids
Herbal medicaments

22. Chlorhexidine
Chlorhexidine (CHX) is a broad spectrum
antimicrobial agent. The property is due to its
cationic bisbiguanide molecular structure.
It is bacteriostatic at lower concentrations and
bactericidal at higher concentrations.
Chlorhexidine gluconate gel is widely used in
dentistry as an intracanal medicament.

23. Mechanism of action

24. Chlorhexidine can be applied in varies forms.
1. Mouthwash (0.12% and 0.2%),
2. Gels (1%)- medicament
3. Varnishes (1%, 10%, 20%, and 35%)
0.12% and 0.2% Chlorhexidine solutions showed a
significant decrease in streptococcus mutans after 24
hours.
Kulkarni VV et al 2003

25. Acc to Grossman
Gel 2% as medicament.
Mixture of CHX and calcium hydroxide

26. Studies show that Chlorhexidine is more effective
in elimination of E. faecalis inside dentinal tubules.
Chlorhexidine both alone and along with calcium
hydroxide showed more antibacterial efficacy
against E faecalis than calcium hydroxide alone.
Nidhi sinha et al, 2013

27. Formocresol
Developed by BUCKLEY in
1906.
Contents : 19% formaldehyde
35% cresol
46% H2O and glycerine.
Combination- formalin and cresol in the
proportion of 1:2.

28. 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%.

29. Formocresol is a non- specific bacterial
medicament most effective against aerobic and
anaerobic organisms found in root canals.
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.

30. Mechanism of action
ZONE OF FIXATION
Causes the coagulation necrosis of the tissue at the
amputation site because of protein denaturation by the
poisons.
Inactivates the oxidative enzymes.
Causing tissue fixation and renders the root canal inert
and resistant to enzymatic breakdown.
ZONE OF POOR CELLULAR NECROSIS
Farther away where the concentration of formocresol
is less.

31. ZONE OF CHRONIC INFLAMMATION
Apical to zone of cellular necrosis.
It blends into normal tissue.

32. Calcium hydroxide
Hermann introduced Ca(OH)2 paste as an ICM in
1920 .
Calcium hydroxide paste for intracanal use is a thick
suspension of Ca(OH)2 powder in sterile water or
saline or glycerine.

33. Used to obtain;
1. Microbial control,
2. Dissolve organic remnants,
3. Heal periapical inflammation,
4. Inhibit inflammatory root resorption,
5. Stimulate hard tissue formation and
6. Serve as a temporary obturating material between
appointments.

34. Mechanism

37. Three histologic zones under calcium hydroxide in 4-9
days:
1. Coagulation necrosis.
2. Deep staining areas with varied osteodentin.
3. Relatively normal pulp tissue, slightly hyperemic,
underlying an odontoblastic layer.
 Fuks AB et al. Vital pulp therapy with new materials for primary teeth: new
directions and treatment perspectives. Pediatr Dent. 2008 May-Jun; 30(3):
211-9.
 Witherspoon DE. Vital pulp therapy with new materials: new directions and
treatment perspectives- permanent teeth.

38. Its antimicrobial action is related to its high pH,
which results in the inactivation of bacterial
membrane enzymes.
Mahmoud Reza Hamidi et al. 2012

39. Studies done to test the antibacterial efficacy of
calcium hydroxide show that calcium hydroxide is
ineffective against E. Faecalis. It resists calcium
hydroxide for about 10 days. Calcium hydroxide
shows limited action against facultative anaerobes
and Candida species but is effective against
obligate anaerobes.
Hemanshi kumar. An in vitro evaluation of the antimicrobial efficacy of Curcuma longa,
Tachyspermum ammi, chlorhexidine gluconate, and calcium hydroxide on Enterococcus
faecalis. Journal of conservative dentistry. Year : 2013 Volume : 16 Issue : 2 Page : 144-
147

40. Antibiotics
Used Alone and in combination with other drugs.
Antibiotics are indicated in a small minority of
cases when root canal infection persists despite
other antiseptics.
Example; Ledermix paste or polyantibiotic paste
(PBSC) are used.

41. PBSC paste/ grossmans paste (1951)
Contains :
Potassium penicillin G (10,00,000 units)
Bacitracin (10,000 units)
Streptomycin paste (1gm)
Sodium caprylate / Nystatin (1gm)
PBSC contained penicillin to target gram-positive organisms,
bacitracin for penicillin-resistant strains, streptomycin for
gram-negative organisms, and caprylate sodium to target
yeasts.

42. Ineffective against anaerobes.
In 1975 – banned due to allergic reactions due to
penicillin.
Now Nystatin replaces sodium caprylate as the
antifungal agent .i.e. PBSN.

43. CORTICOSTERIODS- ANTIBIOTICS
COMBINATIONS
Highly effective in the treatment of over instrumentation.
Placed in the inflamed tissue by a paper point or reamer.
The steroid constituent reduces the periapical
inflammation and gives instant relief of pain.
The antibiotic constituents are present so that no over
growth of micro organisms occurs.

44. Ledermix paste
Ledermix is a glucocorticosteroid antibiotic
compound. Ledermix paste was developed by
Schroeder and Triadan in 1960 and was released
for sale in Europe by Lederle Pharmaceuticals in
1962.
The primary interest of Schroeder and Triadan in
the development of Ledermix paste was based on
the use of corticosteroid to control pain and
inflammation.

45. Constituents
Tetracycline antibiotic
Demeclocycline HCL-3.2%
Triamcinolone acetonide – 1%
Polyethylene glycol

47. A 50:50 mixture of Ledermix paste and calcium
hydroxide has been advocated as an intracanal
dressing in cases of -
1. Pulpless infected root canals,
2. Pulp necrosis and infection with incomplete root
formation (apexification),
3. Perforations,
4. Inflammatory root resorption,
5. Inflammatory periapical bone resorption
6. Large periapical radiolucent lesions.

48. Corticosteroid based preparations have shown to cause
an increased degree of inflammatory response,
maximum being at 28 days.
After 7 days of experiment, all tested substance had
low levels of inflammatory cells.
Therefore, corticosteroid-based medications can be
used for periods no longer than 7 days.
Ramos E et al 2012

49. Septomixine Forte
Septomixine Forte (Septodont, Saint- Maur, France)
contains two antibiotics: —
Neomycin and Polymixin B sulphate.
Neither of these can be considered as suitable for use
against the commonly reported endodontic bacteria
because of their inappropriate spectra of activity.
Abbott PV, Hume WR, Pearman JM, Antibiotics and endodontics. Aust Dent J 35:50-60,
1990.

50. Neomycin is bactericidal against gram-negative bacilli
but it is ineffective against bacteroides and related
species, as well as against fungi.
Polymyxin B sulphate is ineffective against gram
positive bacteria, as shown by Tang et al., who
demonstrated that a routine one-week application of
Septomixine Forte was not effective in inhibiting
residual intracanal bacterial growth between
appointments.

51. TRIPLE ANTIBIOTIC PASTE
Triple antibiotic paste is a combination of three
antibiotics namely minocycline (100mg),
ciprofloxacin (200mg) , metronidazole (500mg) and
propyelene glycol, saline as carrier. (Sato et al 1996)
Triple antibiotic powder, either mixed with normal
saline or 2% chlorhexidine, produced the largest zone
of inhibition against E. faecalis.

52. The triple antibiotic paste is very effective against E.
faecalis.

53. Concentrations used
1:1:1 - Hoshino et al ,1996
1:3:3- Takushige T et al, 2004
 Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In
vitro antibacterial susceptibility of bacteria from infected root dentin to a
mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J.
1996;29:125–30
 Takushige T, Cruz EV, Moral AA, Hoshino E. Endodontic treatment of
primary teeth using a combination of antibacterial drugs. Int Endod J.
2004;37:132–8

54. Takushige et al. (2004) evaluated the efficacy of
poly-antibiotic paste consisted of ciprofloxacin,
metronidazole, and minocycline, on the clinical
outcome of so-called “Lesion Sterilization and
Tissue Repair,” LSTR, therapy in primary teeth
with periradicular lesions.

55. Results showed that in all cases, clinical symptoms
such as gingival swelling, sinus tracts, induced dull
pain, spontaneous dull pain, and pain on biting
disappeared after treatment, although in four cases
clinical signs and symptoms were finally resolved
only after retreatment using the same procedures.
Thus, gingival abscesses and fistulae, if present,
disappeared after a few days.

56. Herbal medicaments

57. Natural and herbal products have been used in
medicine and dentistry since time unknown. Use of
plant products in medicine is known as phytomedicine
or phytotherapy.
Since chemical and synthetic products are expensive
and cause cytotoxic reactions and are not very efficient
in elimination of bacteria, herbal products are used.
Sharad Kamat et al

58. Propolis
Propolis is prepared from resin collected by bees from
trees of poplars, conifers and flowers of genera clusia .
The pharmacologically active constituents in propolis
are flavonoids, phenolics and aromatics.
 Propolis is a good antimicrobial and anti-
inflammatory agent, which can serve as a better
intracanal irrigant and intracanal medicament.

59. Propolis can be used as short-term intracanal
medication in cases of pulp and periapical
inflammatory processes.
Fabiane Bortoluci da Silva et al.

60. Curcumin
Turmeric (Curcuma longa) is extensively used as a
spice, food preservative and coloring material in India,
China and South East Asia.
It has been used in traditional medicine for the
treatment of numerous diseases.

61. Curcumin which is the main yellow bioactive
component of turmeric has been shown to have a wide
spectrum of biological actions, including
antimicrobial, anti-inflammatory and anti- oxidant
activities.

62. Method of preparation
The dried rhizomes of turmeric were grounded to fine
powder under hygienic conditions to form a turmeric
powder.
This turmeric powder, distilled water, and radiolucent
material were mixed on a glass slab with the help of
stainless steel spatula, and mixing ratio of turmeric
powder, distilled water, and radiolucent material was
1:3:3.
Rajiv N Purohit et al 2017.

63. A study showed that curcumin was able to demonstrate
complete eradication of E. faecalis.
Another study showed that there was a gradual
decrease in the anti bacterial activity of curcumin at 3
and 7 days which may be due to the buffering ability
of dentin. Curcumin does not affect the micro hardness
of root dentin and is a potential intracanal medicament.
AR Prabhakar et al. 2013

64. Pulpotomy treatment using turmeric powder in
primary teeth has shown good clinical and
radiographic success.
Purohit R et al, 2017

65. Arctium Lappa
This plant is popular all over the world for its
therapeutic applications. It is found to have
antimicrobial action against microorganisms causing
endodontic infections.
 It is a potential intracanal medicament.

66. Nissin
Nissin is a naturally occurring antimicrobial peptide,
produced by Streptococcus lactis sub species lactis.
It has antimicrobial activity against a wide range of
bacteria and their spores.
Studies show that it is effective in elimination of E
faecalis from root canal and is more effective than
calcium hydroxide.
Hemadri M et al.2011

67. Conclusion
Endodontic treatment are essentially debridement
procedures to disrupt and remove the microbial
ecosystem that is associated with the disease process.
It is important that clinicians understand the close
relationship between the presence of microorganisms
and endodontic disease processes to develop an
effective rationale for treatment.

68. References
 Endodontic therapy- Weine
 Endodontic Practice- Gross man
 Endodontics – Ingle
 Cohen & Burns , 8th edn

69. THANK YOU