INTRACANAL MEDICAMENTS & TEMPORIZATION

NIDAL HABAHBEH BDS,MSc Endodontics RMS

INTRACANAL MEDICAMENTS
Definition : Antiseptic agents in the chemical form applied to the walls of the root canals with the objective of eliminating microorganisms present even after cleaning & irrigating the root canal system.

INTRACANAL MEDICAMENTS
Functions :
1. Reduction of the number of microorganisms. 2. Prevention the growth of any new microorganisms. 3. Disinfection of root canal system. 4. Suppression of interappointment pain by reducing inflammation. 5. Render the canal contents inert. 6. Facilitation of periapical healing.

INTRACANAL MEDICAMENTS
Ideal requirements : 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. 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.

INTRACANAL MEDICAMENTS
NO single agent fulfills these requirements.

INTRACANAL MEDICAMENTS
Types :
PHENOLICS ALDEHYDES HALIDES STEROIDS CALCIUM HYDROXIDE ANTIBIOTICS COMBINATIONS

PHENOLICS
 Eugenol  Parachlorophenol (PCP)  Camphorated monoparachlorophenol (CMCP)  Camphorated parachlorophenol (CPC)  Metacresylacetate (Cresatin)  Cresol  Creosote (beechwood)  Thymol

PHENOLIC COMPOUNDS
 Phenol is a protoplasm poison (TOXIC).  They have access to systemic circulation.  They have a strong inflammatory potential.  They have unpleasant odor & foul taste.  They are ineffective.  Their clinical use is NOT justified.

EUGENOL
 This is the chemical essence of oil of clove.  It is both antiseptic and an anodyne( pain relieving).  It is slightly irritant to periapical tissues.  It is a constituent of most root canal sealers & used as a temporary sealing material.

PARACHLOROPHENOL (PCP)
o It is a substitution product of phenol. o It penetrates deep into dentinal tubules. o 1% solution has shown destruction of microorganisms. o It produces mild inflammation.

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.

METACRESYLACETATE (CRESATIN)
 Its clear, stable, oily liquid of low volatility.  It has both antiseptic & obtundent effect.  It is less irritating among other phenolics.

ALDEHYDES
Formocresol Glutaraldehyde

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.  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. 2% used as an intracanal medicament. It is a Bacteriostatic agent. It has the potential to cause hypersensitivity.

HALIDES
NaOCl IKI

SODIUM HYPOCHLORITE(NaOCl)
 Chlorine is the active ingredient.  NaOCl vapor is bactericidal.  It reacts rapidly with organic matter.  It is Unstable.  Its activity is intense BUT of short duration.  Its TOXIC to periapical tissues.

IODINE POTASSIUM IODIDE
 It is very effective antibacterial agent.  It kills bacteria in infected dentin in 5min.  Its antibacterial action of short duration.  It causes allergic reactions.  It stains teeth.  It has a relatively low toxicity.

STEROIDS
 Have been advocated for decreasing postoperative pain by suppressing inflammation.  Evidence suggests that they may be ineffective, particularly with greater pain levels.  Might be used in cases of irreversible pulpitis & acute apical periodontitis.

CALCIUM HYDROXIDE
• • • • • Introduced by Hermann in 1920. Used for short & long term durations. It is a broad spectrum antimicrobial agent. Its antibacterial action is related to its high pH It may aid in dissolving necrotic tissue remnants and bacteria and their by-products. • It demonstrates no pain-reduction effects. • It has been recommended for use in teeth with necrotic pulp tissue. • It probably has little benefit with vital pulps.

CALCIUM HYDROXIDE
Limitations: • The handling and proper placement presents a challenge to the average clinician. • The removal is frequently incomplete. • Residual Ca(OH)2 can shorten the setting time of ZOE–based endodontic sealers. • It is NOT effective against E. faecalis & C. albicans. • Dentin can inactivate the antibacterial activity of Ca(OH)2 .

CHLORHEXIDINE
 It is a broad spectrum antimicrobial agent.  2% gel is recommended.  Can be mixed with calcium hydroxide to increase its antibacterial activity & enhance the periradicular healing.  It doesn’t remove smear layer.  It is a fixative.

ANTIBIOTICS
 PBSC  Sulfonamides  Grossman’s paste

PBSC
 Penicillin: Effective against Gram + MO’s.  Bacitracin : Effective against Penicillinresistant bacteria.  Streptomycin : Effective against Gram – MO’s.  Caprylate : Effective against Fungi.  Nystatin now replaces Caprylate : i.e. PBSN

SULFONAMIDES
 Mixed with sterile distilled water.  Used in acute periapical abscess.  Causes yellowish tooth discoloration.

GROSSMAN’S PASTE
 Potassium Penicillin G 1000,000 units.  Bacitracin 10,000 units.  Streptomycin sulphate 1.0 g.  Sodium caprylate 1.0 g.  Silicone fluid 3ml Vehicle.

INTRACANAL MEDICAMENTS
Limitations :  Their therapeutic action depends on direct contact with tissues.  Do NOT reach all areas of root canal system.  Limited to surface action only.  Chemically NOT active for a long duration.  Development of resistant strains of bacteria.  Might cause tooth discoloration.

TEMPORIZATION
Objectives : 1. Coronal seal. 2. Enhance isolation. 3. Protection of tooth structure. 4. Allow of ease of placement & removal. 5. Satisfy esthetics.

TEMPORIZATION
Determining factors : A. Intended duration of use. B. Occlusal load & wear. C. Complexity of access. D. Loss of tooth structure.

TEMPORIZATION
Types : i. Cavit. ii. IRM. iii. GIC. iv. TERM.

CAVIT
 Based on zinc oxide & calcium sulfate.  A premixed cement that sets in the presence of moisture.  Low strength & rapid occlusal wear.  Used in short-term sealing of simple access cavities.  Clinically, 4 mm of Cavit provided an effective seal against bacterial penetration for 3 weeks.

IRM
 Intermediate Restorative Material.  A reinforced zinc oxide-eugenol cement.  Improved wear resistance.

GIC
 Glass Ionomer Cement.  Durable & effective barrier against microbial leakage.  Adhesion to moist tooth structure.  Anticariogenic properties due to release of fluoride.  Biocompatibility and low toxicity.  Poor mechanical properties.

TERM
o Temporary Endodontic Restorative Material. o A specially formulated light-polymerized composite materials. o Improved wear resistance. o Provides a moisture-free seal.

TEMPORIZATION
Points to remember :  Pulp chamber and cavity walls should be dry.  A minimum depth of 3 to 4 mm is required.  At least 3 mm thick in the cingulum area.  Care must be taken not to incorporate cotton fibers into the restorative material.  Packing into the access opening with a plastic instrument in increments from the bottom up and pressing against the cavity walls and into undercuts.  Excess is removed, and the surface smoothed with moist cotton pellet.  The patient should avoid chewing on the tooth for at least an hour.

Extensive Coronal Breakdown
 A strong filling material (high-strength GIC) is required.  Take care to ensure an adequate thickness and good marginal adaptation proximally.  Should extend well into the pulp chamber deep to the proximal margin to ensure a marginal seal.  Reducing the height of undermined cusps well out of occlusion reduces the risk of fracture. For severely broken-down teeth, a cusp-onlay amalgam or a well-fitting orthodontic band cemented onto the tooth is needed.

Provisional Post Crowns
 Used when a cast post and core is being fabricated.  The post could be (preformed aluminum post, safety pin wire, paper clip, or a sectioned large endodontic file).  The coronal seal is generally inadequate.  The post should fit the canal snugly (not binding).  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.  A polycarbonate crown is trimmed to a good fit; autopolymerizing material then is added to the inside.  Good contouring and occlusal adjustment.  A provisional luting cement (Temp Bond or similar cement) is placed on the coronal 3 to 4 mm of the post and root face.  A provisional removable partial overdenture is a useful alternative.

Long-Term Temporary Restorations
• A durable material, such as amalgam, GIC, or acid-etch composite, should be used. • 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. • The layer of Cavit can be easily removed in the next visit.

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