Intracanal Medication

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 of choice is calcium hydroxide . studies have shown calcium hydroxide to be an effective antimicrobial agent . Other studies have shown it to be an effective interappointment dressing over several weeks .

Several different techniques for placing calcium hydroxide into root canals have been proposed, such as amalgam carriers, vertical pluggers, McSpadden compactors, Lentulo drills, files and special syringes.

The Weeping Canal

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.

When opened at the start of the endodontic appointment, a reddish discharge may will up, whereas at a succeeding appointment the exudates will be clear. Some pressure is present, If the tooth is left open under a rubber dam for 15 to 30minutes, it may be closed up by absorbing the exudates with an aspirator and paper points, however, a similar condition will still be present at the next appointment.

The canal has already been enlarged to a more than acceptable size. This is referred to as WEEPING CANAL . classically those with exudates were not considered to be ready for filling.

One is always in a quandary as to the correct method for treating such canal .

The answer to this problem is to dry the canal with sterile absorbent paper points . and place calcium hydroxide paste in the canal . It is absolutely to see a perfectly dry clean canal at the next appointment that is simple to fill after minimal further preparation .

Root-end closure (apexification)

Principles & Practice of

It means creation of an artificial barrier across an open apex. Success depends on the debridement of the pulp space & complete coronal seal.

Endodontics

Placing Ca(0H)2 provides a suitable medium to permit apical closure

Root-end closure (apexification)

Principles & Practice of Endodontics

Technique:
- The technique is divided into 3 phases: 1. Access. 2. Instrumentation. 3. Placement of Ca(OH)2 or MTA.

Root-end closure (apexification)

Principles & Practice of Endodontics

Technique:
1. Preparing large access after isolation. 1. Removing the necrotic pulp with large Hedstrom file. 2. Determining the working length (slightly short of the radiographic apex). 3. Instrumentation is performed with copious irrigation.

Root-end closure (apexification)

Principles & Practice of Endodontics

5. Drying the canal with sterile paper points. 6. Applying Ca(OH)2 paste containing Barium Sulfate in the canal with caution not to push it too much periapically. 7. Making a radiograph before temporization to assure that the canal space is filled without voids.

Principles & Practice of Endodontics

Root-end closure (apexification)

Root-end closure (apexification)

Principles & Practice of Endodontics

Root-end closure (apexification)

Principles & Practice of Endodontics

Recall Schedule:
- The patient is recalled in 4-6 weeks. - In each recall a radiograph is made, so if the material does not appear dense, it must be washed out & repacked. - If it was dense, with no clinical symptoms or signs, there is no need to be replaced. - Recall is then scheduled for 3 & 6 months.

Root-end closure (apexification)

Principles & Practice of Endodontics

- If healing has progressed well after 1 year, Ca(OH)2 is removed. - The hard tissue is often not visible radiographically but detected tactically. - If the apex is still open, Ca(OH)2 is replaced & patient is recalled in 3 months.

Root-end closure (apexification)

Principles & Practice of Endodontics

Obturation:
- The canal is cleaned & irrigated copiously & then dried. - Modified lateral condensation technique is used. - After obturation , recall appointments scheduled up to 4 years.

Root-end closure (apexification)

The paste must reach the apical portion of the canal to stimulate the tissues to form a calcific barrier . therefore a syringe may by used to ensure proper depth of placement . a stopper is placed on the needle portion at the proper working length, and a uniform paste is easily delivered to the correct position in the canal .

Root-end closure (apexification)

Root-end closure (apexification)

Recently, interest has centered on the use of MTA for apexification.This material has demonstrated good biocompatibility and ability to seal, and its high pH may impart some antimicrobial properties.

Root-end closure (apexification) Root-End Closure (Apexification) with MTA:

1. Anesthesia & preparing a large access to allow debridement. 2. Disinfection of the canal by applying Ca(OH)2 paste for 1 week. 3. Removing of Ca(OH)2 in the subsequent appointment & applying MTA. 4. Radiographic evaluation of the MTA placement.

Principles & Practice of Endodontics

Root-end closure (apexification)

Principles & Practice of Endodontics

5. Placing of moist cotton pellet over the material to ensure setting. 6. Obturating of the remainder of the canal with gutta-percha, & performing the final restoration.

Root-end closure (apexification)

Principles & Practice of Endodontics