International Dental Journal (2009) 59, 5-11

Root canal medicaments*

Nobuyuki Kawashima, Reiko Wadachi and Hideaki Suda
Tokyo, Japan
Thai Yeng and Peter Parashos
Melbourne, Australia
* FDI Science Committee Project 4-00

The ultimate goals of endodontic treatment are complete removal of bacteria, their by-
products and pulpal remnants from infected root canals and the complete seal of disin-
fected root canals. Intracanal medicaments have been thought an essential step in killing
the bacteria in root canals; however, in modern endodontics, shaping and cleaning may
be assuming greater importance than intracanal medicaments as a means of disinfecting
root canals. Until recently, formocresol and its relatives were frequently used as intracanal
medicaments, but it was pointed out that such bactericidal chemicals dressed in the canal
distributed to the whole body from the root apex and so might induce various harmful
effects including allergies. Furthermore, as these medicaments are potent carcinogenic
agents, there is no indication for these chemicals in modern endodontic treatment. Today,
biocompatibility and stability are essential properties for intracanal medicaments. The more
modern meaning of intracanal dressing is for a blockade against coronal leakage from the
gap between filling materials and cavity wall. Calcium hydroxide has been determined as
suitable for use as an intracanal medicament as it is stable for long periods, harmless to
the body, and bactericidal in a limited area. It also induces hard tissue formation and is
effective for stopping inflammatory exudates. Single-visit endodontics, where intracanal
medicaments are not used, is generally not now contraindicated and various reports
have shown that the clinical outcomes between single- and multiple- visit endodontics
are similar. There is no reason to counsel against single-visit endodontics: however, if
multiple-visit endodontics is chosen, calcium hydroxide is recommended to be used as
an intracanal medicament.

Key words: Endodontics, intra-canal medicaments, single-visit, multiple visits

The popular aetiology of periapical pathosis involves
bacterial invasion via infected root canals resulting
from the progression of pulpal inflammation that is
also caused by bacterial infection1. Pulpal and periapical
inflammation is an immunological self defence reaction
against sustained bacterial stimuli; therefore, strate-
gies for endodontic treatment are directed toward the
removal of these bacteria and their by-products from
the root canal system. This also involves the permanent
sealing of the root canal system after disinfection to
ensure that bacterial re-invasion is not introduced from
the oral cavity. Each step of root canal treatment fol-
lows such strategies. For effective removal of bacteria,
intracanal medicaments serving as disinfection materials
were thought to be an essential step until quite recently.
Walton2 wrote that “Intracanal medicaments have tradi-
tionally gone hand-in-glove with endodontics. They are
© 2009 FDI/World Dental Press
0020-6539/09/01005-07
generally considered to be an integral part of treatment
and important to the success of root canal therapy”.
Strong disinfection medical agents have commonly
been used as intracanal medicaments in an attempt to
‘sterilise’ the intracanal space until recently. These days,
‘shaping and cleaning’ is regarded as the most essential
step for removing microbial challenges to the root canal
system in modern endodontics3. Mechanical removal of
infectious debris using hand or rotary instruments and
chemical cleansing with a bactericidal solution (sodium
hypochlorite is popularly used) destroy microbes to a
harmless level and disinfect the pulp space4-9. Presently,
a single-visit treatment is regarded as one of the ac-
cepted approaches for root canal treatment10-27, in which
intracanal medicaments are not included. Nonetheless,
intracanal medicaments remain commonly used in
multiple-visit treatments. However, intracanal medica-
doi:10.1922/IDJ_2060Kawashima07
6
ments in modern endodontics have a somewhat differ-
ent rationale. They are expected to act as a physical and
chemical blockage against coronal leakage from tempo-
rary filling materials. The most important property of
intracanal medicaments is regarded as their biocompat-
ibility. Therefore, intracanal medicaments, which were
the early ‘shining stars’ of endodontic treatments, seem
to have been retired from the front line, but still retain
some significance. Here, the contemporary meaning of
intracanal medicaments is evaluated.
History of intracanal medicaments
The historical origins of intracanal medicaments date
back to very early times. Beechwood creosote was
mentioned in the 1840 article Creosote and Cotton in Fang
Filling28. In 1884, Richmond recommended applying a
small-sized piece of orangewood with phenol in order
to devitalise the pulp29. Thus, phenolics, which include
eugenol (this may be differentially classified as an essen-
tial oil), parachlorophenol, camphorated parachloroph-
enol, camphorated monoparachlorophenol, cresatin
(metacresylacetate), cresol, thymol and creosote, are
drugs with a long history in the dental field that begins
in the 1800s. Many combinations of these drugs were
prepared and played major roles in root canal treatment
from the 19th to the 20th century. Formocresol, which is
categorised into the aldehydes, was often used as a root
canal medicament and played a major role in root canal
treatment since Buckley30 referred to it as an effective
intracanal medicament in 1904. Phenolics, aldehydes
and their combinations show strong bactericidal effects.
Although halides including sodium hypochlorite and
iodine, chlorhexidine gluconate, antibiotics, steroids and
non-steroidal anti-inflammatory drugs (NSAIDS) have
been reported as intracanal medicaments, none of them
holds a premier position at present.
Furthermore, many reports have pointed out the
risks of using intracanal medicaments that involve drugs
with strong actions. Phenol and formocresol have been
shown to exhibit marked cytotoxicity31-33, and formoc-
resol has also been reported to show teratogenicity and
tumorigenicity34,35 and induce immune reactions36-38.
Formaldehyde in contact with pulpal and periapical
tissues is transported to all parts of the body. Antibiot-
ics may be transported from the apical opening to the
entire body and induce the development of resistant
strains, microbial substitution and allergy39. The effects
of steroids and NSAIDs on periapical pathosis are
still uncertain, and they are suggested for routine use.
However, aqueous solutions of sodium hypochlorite,
a typical halogen disinfectant, are still in wide use for
root canal irrigation; as well, chlorhexidine gluconate is
also reported to be effective for root canal irrigation in
certain circumstances40.
Calcium hydroxide has been used as a component
of pulp-dressing preparations, vital pulp amputation
International Dental Journal (2009) Vol. 59/No.1
preparations and as a sealant for root canal fillings since
Hermann applied it to dentistry in 192041. It came to be
widely used for root canal treatment in the 1970s and
is now regarded as one of the first choices as a multi-
ple-visit root canal medication. It is mixed with various
vehicles and is available in many commercial products42.
Clinically satisfactory results have been reported in many
pulpectomised and root canal infection cases40.
Elimination of bacteria from the root canal
system
Successful treatment of primary endodontic infections,
with or without apical lesions, is strongly dependent on
the elimination of microbial infection from the root
canal. Therefore, information about the absence or pres-
ence of bacteria in the root canals is critical to evaluate
possible treatment modalities.
Identification of bacteria
Möller43 developed and validated a protocol to accu-
rately sample the root canal without contamination. An
advantage of culturing is the ability to provide a broad
range of quantitative data and to detect viable cells;
particularly important when the effects of antimicrobial
treatment are being evaluated44. However, many bacterial
species are difficult or impossible to culture in vitro45,
and the methodology for accurate root canal sampling
is very technique sensitive46. For example, a negative
culture does not imply sterility because other regions in
the root canal system can harbour bacteria that cannot
be reached by sampling fluids, or the bacterial level in
the canal is below the sensitivity of the culture method
used, or they are unable to grow under laboratory condi-
tions44. A false positive result is usually related to a lack
of sterility in the clinical working area around the root
canal of the tooth.
The limitations imposed by the inability to culture
many bacteria47 can be overcome by molecular identifi-
cation methods48-50. Using broad range PCR (polymerase
chain reaction), a wider range of endodontic infection-
related bacteria, including the presence of previously
unidentified or uncultivable bacteria, can be identified51.
A major drawback of the PCR method is that this tech-
nique is based on recognition of gene sequences and it
cannot distinguish between living and dead bacteria45.
Because of the higher sensitivity of molecular methods,
detection of a given bacteria does not always indicate
a causal relationship with disease49. DNA that persists
after bacterial cell death will be detected by PCR and
may just reflect an historical record of bacteria that have
entered the root canal system and collected over time45.
On the other hand, the bacterial species and strains
identified may be pathogenic and induce direct or indi-
rect damage to the host, support other bacteria, provide

other species with growth factors or create favourable
conditions for co-existence52.
Efficacy of root canal irrigation
Sodium hypochlorite, the most commonly used endo-
dontic irrigant7, 53-57, has a potent antibacterial effect and
the ability to dissolve vital and necrotic organic matter6,
7, 58-66
. The action of sodium hypochlorite is exerted in
combination with mechanical enlargement of root ca-
nals8. It is not clear whether increasing the strength and/
or the exposure time of sodium hypochlorite are effec-
tive in removing bacteria from the canal. It is thought
that the use of sodium hypochlorite is not enough to
achieve predictably bacteria-free canals by conventional
culturing techniques; however, its use makes it possible
to reduce the bacterial load in the canal to levels that
will allow the root canal to be filled immediately with
optimal outcomes7, 67, 68.
Contemporary definition of intracanal
medicaments
Walton2 wrote that intracanal medicaments were useful
for elimination of micro-organisms, rendering canal
contents inert, controlling persistent periapical ab-
scesses, preventing or controlling post-treatment pain
and enhancing anaesthesia. Today, shaping and cleaning
is expected to accomplish the first four items. Careful
instrumentation in the presence of an adequate irriga-
tion solution is effective for preventing or controlling
post-treatment pain40. Several anaesthesia techniques
allow for the performance of pulpectomy without the
assistance of ‘paralysing’ medicaments. Therefore, there
is no reason to use intracanal medicaments for these
purposes.
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”. Coronal leakage has been demonstrated to
contribute to treatment failure69,70. Maintaining a coronal
seal and the placement of a definitive restoration should
be considered essential components of successful en-
dodontic treatment71.
Induction of apex growth is expected in cases of
root canal treatments on incompletely developed roots72.
Therefore, the most important properties of root canal
medicaments are their biocompatibility and stability.
Bactericidal effects without host damage are prefer-
able. The capacity to induce hard tissue formation is
effective for endodontic treatment of immature teeth.
The only material that satisfies all these conditions is
calcium hydroxide.
7
Calcium hydroxide as an intracanal
medicament
Calcium hydroxide has been widely utilised in endo-
dontic therapy as an intracanal dressing7,41,73-80 and its
history of use over a long period of time in the endo-
dontic field has established its safety. The absence of
harmful actions may be related to its properties. It is a
crystal that is poorly soluble in water and only induces
localised effects. The bactericidal effects are caused by
its high pH (12.5-12.8), which prevents the growth and
survival of bacteria, most of which cannot survive pH
11 or above7,54. Calcium hydroxide also denatures and
detoxifies bacterial products, such as lipopolysaccha-
ride77. Calcium hydroxide is reported to be effective in
controlling the inflammatory exudates from the periapi-
cal region, and the mechanism behind this action may
be related to its antimicrobial properties81,82, contraction
of capillaries83, and formation of an apical plug81. Cal-
cium hydroxide is used as a paste or a powder84, unlike
most of the other root canal preparations; however, this
property is both advantageous and disadvantageous. An
advantage of a pasty preparation is that it can obturate
the root canal. Örstavik et al.85 considered that calcium
hydroxide minimises the entry of effusion and nutri-
tional substances by obturating the root canal system.
A disadvantage is that it is inconvenient to place and
remove from the root canal. Because calcium hydroxide
does not vaporise, it must be placed in tight contact with
the root canal walls because its effectiveness depends
on the degree of contact with the walls as well as its
antibacterial activity per se. Also, because of its pasty
nature, experimental comparisons with other liquid
preparations are difficult.
Another noteworthy property of calcium hydroxide
is its capacity to induce hard tissue formation, even in
those that have not been programmed to mineralise86,87.
Various hypotheses have been proposed to explain this
mechanism. Its high pH is believed to elevate local
tissue pH, inactivate osteoclasts by neutralising acidi-
fied inflammatory lesions, and activate alkaline phos-
phatase80,88. Calcium hydroxide has also been reported
to affect the enzyme activities of cells involved in bone
formation or resorption89. Freeman et al.89 created a
combination of calcium hydroxide, barium hydroxide,
and tetracycline with glycerol, implanted the mixture
into bone defects in the rat femur, and compared the
state of healing. They observed the greatest bone for-
mation in the calcium hydroxide group and considered
that calcium hydroxide induced hard tissue formation
because of its pH or antibacterial activities as well as
other possible effects. It is possible that the future ap-
plication of molecular biological techniques will clarify
factors, apart from those controlling infection, that are
involved in hard tissue formation and resorption.
FDI project: Root canal medicaments
8

Role of root canal medicaments in approximately 55% of dentists frequently medicated

management of dental trauma the root canal with calcium hydroxide paste as the initial
intracanal medicament of choice for necrotic teeth.
Dental injuries often involve damage to both supporting
If an immature tooth with an open apex is trauma-
tissues and the tooth. Should the pulp become necrotic
tised, there are various different apical configurations
and infected, treatment is required. Trauma-induced
that can result103. Calcium hydroxide has the widest
resorption is a common clinical sequel and can be classi-
acceptance as the medicament of choice for induction
fied90 as; 1) Surface, 2) Transient apical internal, 3) Pres-
of apical barrier formation104. Domingeuz-Reyes et al.92
sure, 4) Orthodontic, and 5) Replacement resorptions.
reported 100% success with apical closure following cal-
As well, infection-induced root resorptions (internal,
cium hydroxide dressing, and classified the shape of the
external, and combined internal-external lesions) may be
apex after apexification as: a physiological shape, round
superimposed on a traumatic injury3. Intracanal medica-
apices, or straight apices. Sheehy et al.105 reviewed ten
ments are used to control inflammatory root resorption
calcium hydroxide studies on humans and reported the
(IRR) resulting from a necrotic and infected pulp91, as
overall success rate was 74-100%, and the mean length
well as in procedures to promote apical hard tissue bar-
of time for induction of apical healing was 5-20 months.
rier formation in traumatised permanent teeth with an
Monthly replacement of calcium hydroxide paste is not
immature apex92. The IADT (International Association
necessary for apexification to occur106. Indeed, with
of Dental Traumatology) guidelines for the management
recent advances in the use of MTA (Mineral Trioxide
of dental injuries93,94, recommend that any luxation in-
Aggregate), induction of apical barrier formation can
juries associated with a necrotic pulp should be dressed
be achieved in a one-visit regimen. Felippe et al.107 dem-
with calcium hydroxide as an intracanal medicament
onstrated that the initial use of calcium hydroxide paste
until the root canal is filled; for avulsion injuries, the
was not necessary for apexification to occur, and that the
use of calcium hydroxide medicament is recommended
use of MTA alone could achieve successful apical bar-
for up to one month. Currently, these guidelines do not
rier formation with good periapical healing. El-Meligy
recommend any other intracanal medicaments.
et al.108 compared MTA following one week of calcium
Calcium hydroxide paste has been recommended for
hydroxide dressing and the use of MTA alone. Clinically
use as an intracanal medicament based on its antibac-
and radiographically, MTA alone performed better and
terial4,79 and anti-resorptive80,95 properties. IRR occurs
apexification occurred regardless of whether calcium
when the normally protective cementum/cementoid is
hydroxide was placed or not prior to the use of MTA.
damaged and so surface resorption occurs exposing the
However, placement of calcium hydroxide for one week
underlying dentine allowing bacteria to penetrate to the
could be justified from the standpoint of achieving a
external root surface96. If the exposed dentine surfaces
predictable bacterial reduction109,110, rather than for its
are also associated with an infected root canal system,
use to promote hard tissue barrier formation.
then a significantly larger area of resorption is seen
LedermixTM paste (Lederle Pharmaceuticals, Wolfrat-
compared to that with a non-infected root canal97. This
shausen, Germany), a combination antibiotic (demeth-
suggests that bacteria and their by-products can invade
ylchlortetracycline)/corticosteroid (triamcinolone)
through the dentinal tubules towards the root surface
paste111, is reported to be effective for the treatment of
void of cementum to cause external destruction. The
progressive root resorption and accompanying PDL in-
ability of calcium hydroxide to diffuse through exposed
flammation in teeth following dental trauma112. Though
dentinal tubules and to raise the pH at the root surface
many clinicians have accepted Ledermix paste as an
has been demonstrated in vitro80,98. However, some au-
intracanal medicament based on anecdotal evidence90, a
thors believe that calcium hydroxide should be delayed
more rigorous clinical trial involving intentional bacterial
for at least two weeks to avoid cellular necrosis and
contamination of canals and evidence of established
ankylosis if used as an initial intracanal medicament99,100;
inflammatory resorption before intervention would be
or if possible, to avoid placing calcium hydroxide in the
needed to determine whether Ledermix paste is better
first three months after dental injury101.
than calcium hydroxide for routine clinical use113.
Hammarström et al.95 reported that the application of
calcium hydroxide resulted in limited necrosis of cells
forming reparative cementum but induced necrosis of Single visit endodontics
resorbing cells at the denuded dentine surface. They also
noted that reparative cementum began forming within Single and multiple visit endodontic treatments have the
a few days after the medicament was placed, suggesting same underlying philosophy114 that bacteria are the cause
that calcium hydroxide had only a transient inflamma- of root canal infection43,115,116 and their eradication will
tory effect on the periodontal ligament (PDL). This result in healing117. Their basic difference relates to the
finding agreed with Tronstad et al.80 who found that al- reliability of shaping and cleaning. One-visit treatment
kaline pH inhibited the osteoclastic action of cells along holds that shaping and cleaning remove bacteria to a suf-
the external root surface and created an environment for ficient level, and if there is some remaining bacteria, they
hard tissue formation. A recent survey102 revealed that are not so much of a problem because root canal filling
International Dental Journal (2009) Vol. 59/No.1

will entomb them26. As chemo-mechanical debridement
and intracanal medicaments cannot predictably remove
bacteria completely26,68,110, entombing them effectively
within the root canal system should result in the remain-
ing bacteria being sealed by the root filling within denti-
nal tubules, lateral canals, apical ramifications, recesses
of oval canals and isthmuses118. There are conflicting
opinions about the need for complete disinfection of
the root canal space before obturation and it is presently
unknown if the amount or types of bacteria remaining
prior to root filling affect the treatment outcome119.
Another issue is that a temporal seal needs to be placed
between appointments in multiple visit treatments. This
means the root canals are exposed to the risk of coronal
leakage, which has been demonstrated to contribute to
treatment failure69,70. Single visit endodontic treatments
avoid the risk of coronal leakage if adhesive materials
are placed on the root canal filling materials.
While multi-visit treatment advocates claim that the
decrease of bacteria by chemo-mechanical cleaning is not
sufficient, calcium hydroxide dressings between appoint-
ments have not shown the expected effects in disinfection
of the root canal system and treatment outcomes26,120.
It is apparent that the rationale behind immediate
root filling to prevent bacterial growth, as employed
in single-visit endodontic treatment, works in most
infected cases114. Thus, placement of an intracanal
medicament may not be required. However, in a recent
study, Fabricius et al.121 demonstrated the importance
of obtaining a bacteria-free root canal system before
permanent root filling to achieve optimal healing of
periapical tissues. When bacteria remained after an
endodontic treatment, 79% of the root canals showed
non-healed periapical lesions, compared with 28%
where no bacteria were found.
Based on the current best available evidence, a sys-
tematic review of the literature of randomised control
clinical trials conducted in humans found a single-visit
root canal treatment appears to be no less effective than
a multiple visit treatment22.
Conclusions
When pharmacological agents are administered to humans,
safety is of critical importance. From this point of view,
calcium hydroxide is the most acceptable medicament for
placement in root canals. While no intracanal medicament
used in multiple-visit treatment induces regrowth of bac-
teria26, complete removal of calcium hydroxide from root
canal systems is achieved with some difficulty.
In terms of radiological success, there is no differ-
ence between the effectiveness of root canal treatments
in single- or multiple-visit endodontic treatments. As
well, most short- and long-term complications resulting
from the treatments are similar in terms of frequency15.
Thus, there is no reason to avoid choosing single-visit
endodontic treatment when applicable.
9
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Correspondence to: Dr. N. Kawashima, Pulp Biology and Endodon-
tics, Department of Restorative Sciences, Graduate School, Tokyo
Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo
113-8549, Japan. Email: kawashima.n.endo@tmd.ac.jp
FDI project: Root canal medicaments