Endodontics

An in vitro study of the diffusibility of intracanal medicaments

'*' Zuhal Kirzioglu*

In this study, the diffusion properties of the vapors offour canal antiseptics were ex-
amined. Tricresol, camphore-chlorophenol, Cre.sophene. andpovidone-iodine in clinical
doses were te.%ted against Staphylococcus aureus and Streptococcus faeealis. Forty-five
extracted human maxillary centred ineisor teeth were used, and their root canals were
prepared. A small amount of antiseptic was placed on a cotton pellet in the pulp cham-
ber of each tooth, and the chamber was sealed with Cavit. Vapors from each of the test
medicaments produced zones of inhibition on Staphylococcus aureus and Streptococ-
cus faeealis. The study showed that vapors of the test medicaments do pa.is through ihe
apex of a tooth and thus have a potential efject at the periapical area. The largest zone
of inhibition resulted from the vapor of tricresol. (Quintessence Int 199Ú-21-
649-653.)

Introduction possible to lessen the undesirable inflammatory re-

In endodontics, intracanal medications are used be-
tween visits to enhance disinfection of the root canal
space. Most medicaments are effective, nonspecific,
antimicrobial agents applied in various ways and
quantities. Use of medicaments is controversial, and
some authors recommend large quantities,' while oth-
ers favor smaller amounts,-' Some researchers admin-
ister the medication to the coronal portion of the caii-
ai,-"' whereas others rely on a vehicle, such as a paper
point, to carry the liquid drug apically^ '
Clinical experiences and experimental results sug-
gest that minimal amounts of intracanal medications
effectively disinfect the entire root canal system,'' This
is because the bactericidal efficiency of the drugs de-
pends on their vaporization into the canals of the
teeth. In addition, the drugs themselves have some
harmful, such as toxic, effects,'-'*"'" With use ofa min-
imal effective dose ofa nonspecific drug, it would seem
' Department of Pedodontics, Atatürk University, School of Den-
tistry, 25170 Erzurum, Turkey,
actions, including pain and associated tissue damage,'
All the phenolics and similar compounds are highly
volatile, with low surface tension, and should be used
with a cotton pellet in the pulp chamber." If medi-
caments are placed on a cotton pellet, which is then
blotted and placed in the chamber of a tooth, the
vapors will permeate the entire space. Thus, plaeement
on a paper point is unnecessary.
The purpose of this study was to examine the dif-
fusibility of intracana! medicaments: tricresol, cam-
phore-chlorophenol, Cresophene, and povidone-io-
dine in extracted teeth placed in blood agar.
{Method and materials
Staphylococcus aureus and Streptococcus faeealis were
the bacterial organisms utilized in this study The test
medicaments were (1) tricresol {Krezoform, Bayer
Chemical); (2) camphore-chlorophenol (Phenic aeid,
Bayer Chemical); (3) Cresophene (Septodont-St
Maun); and (4) povidone-iodine (Betadine, Purdue
Frederick),
The quantity of medication to be used was deter-
mined by weighing several dry No, 3 cotton pellets,
moistening them in the medicament, blotting them
dry, and then reweighing them. The average weight of
the remaining drug was considered to be the clinical

Quintessöfice Internattotrá) Volume 51 ^^utnber 8/1990 649

Endodontics

Compound
Streaked
agar
Pellet
Cavit

Peilet
Streaked Cavit
agar
Compound

Fig 1 Apparatus tor examination ot the apex of extracted Fig 2 Apparatus for examination of the apex of extracted
maxiilary teeth (apex down). maxillary teeth (apex up).

Table Í Mean inhibitory effect of intracanal medi-
caments placed in Petri dish
Zone of inhibition (mm)
Medicament S attreus S faecal is
Tricresol 35.0 25.0
Phenic acid 28.0 19,0
Creso ph ene 15.0 18,0
Povidone-iodine 6,0 4,0
dose. Controls for the inhibitory capacity of the clin-
ical dose consisted of stock inocula of S aureus and
S faecalis that were streaked on a blood agar Pctri
dish. The chnical dose of each drug was then placed
on a pellet on the plate and incubated at 37 °C for 24
hours. In this pilot experiment, ten controls were
made.
Forty-five maxillary anterior teeth were cleaned and
shaped. The apex was kept open with a No, 15 file,
the body of the canal was enlarged to create a tapering
funnel shape, a No, 30 file was penetrated to the full
working length, and a No. 50 file was penetraled to
the full working length, within 1 or 2 mm of the apex.
Irrigation with sodium hypochlorite was employed to
fiush the debris from the canal. The teeth were dried
with sterile dental sponges, and the root canals were
dried with sterile paper points.
Each tooth was immersed into each medicament,
ethyl alcohol, and 100 mL of distilled water. In this
way the possibihty of microbial inhibition was elimi-
nated. The teeth were placed on a streaked plate to
determine if any residual inhibitory activity remained.
The teeth were found to he noninhibitory.
The teeth were divided into tour groups often each.
The teeth in group 1 received tricresol, group 2 Phenic
acid, group 3 Cresophene, and group 4 povidone-
iodine on a cotton pellet in the pulp chamber. Five
teeth, used as controls, received a dry, sterile cotton
pellet. All points of access were sealed with Cavit
(Kcrr/Sybron Corp),
Half of the teeth in each group were fixed to the lid
from their crowns with carding wax (Fig 1), In the
other half of each group, the procedure was repeated,
and the whole system was inverted (Fig 2), By ex-
amination of the inhibition with the apex of the ex-
tracted teeth up or down, the effect of gravity on the
diffusion of the drugs could be determined. The dishes
were incnbated aerobically at 37 °C and observed at
8-, 24-, and 36-hour intervals. All zones of inhibition
at the apex were recorded.
Results
In the pilot (control) experiment, vapors from all the
test medicaments produced zones of inhibition on S
aureus and 5 faecalis. The largest average zone of in-
hibition resulted from vapors of tricresol, while pov-
idone-iodine produced the smallest average zone. The
vapors of the test medicaments showed the same in-
hibitory effect on bolh organisms (Table 1).
The differences in medicine, the bacterial groups,
and the interaction between medicine and bacterial
groups were found to be statistically significant (P <

650 .Number 6/1990

 Endodontics

Table 2 Analysis of variance

Source of variation DF SS MS
Medicaments 3 3432.5 1144-16 91.10**
Bacteria 1 202.5 202.50 16.08'"
Interaction of medicaments and bacteria 3 282.5 94,16 7.50**
Error 32 402,0 12.56
Total 39 4319.5
" P <.O1 (significance of F).

Table 3 Mean inhibitory effects of the medicaments placed ¡n pulp chamber

Zone of inhibition (mm)

Position
Medicament of apex S aureus S faecalis
Tricresol Up 12.5 17.0
Down 4.3 5.5
Phenic acid Up 3.5 25.0
Down 6.0 9.0
Cresophene Up 5.0
Down 3.5
Povidone-iodine Up 4.5
Down 2.5
' No dilTusion,
Mean
(mm)
s taecalis
S au/eus
.01) by the analysis of variance test (Table 2). The
bacteria did not react to each medication equally
(Fig 3).
When the medicaments were placed in the pulp
chambers, the mean zone of inhibition in the inverted
teeth (apex up) was greater than the mean zone in
teeth whose apices were placed down. This demon-
strated the quick diffusion and vaporization of med-
icaments used in maxillary teeth {Table 3).
As shown in Table 3, use of Cresophene and Be-
tadine in the pulp chambers did not result in an in-
hibition zone against S aureus. Other medicaments
formed small inhibition zones against S aureus. No
inhibition zone was formed by any of the teeth in the
control group. 1 2 3 4
There was little evidence of microbial growth at 8 Drugs
hours. On the other hand, no detennination of effec- Fig 3 The mean area of inhibition (mm) ol two bacteria
tive drug diffusion was possible. No apparent differ- resulting from the application of four medicaments: (1) tri-
ences in the growth of inhibition zones were observed cresol; (2) Phenic acid; (3) Cresophene; and (4) povidone-
at 24 or 36 hours. iodine.

IntPrnationai Volume 21,'^iimber 8/1990 651

Endodontics
Discussion
Several factors must he considered before the results
of this study can be related to clinical situations. These
factors include the diameter ofthe apical constriction,
drug diffusion barriers, periapical pressures, and the
presence of canal debris.
This investigation did not reveal apical constriction
diameter to be a determining faclor in the results. The
second factor, however, was important, because dif-
fusion of the vapors from intracanal medications
Ihrotigh periapical tissues may be quite different from
diffusion through agar. Of equal importance is the
effect on vapors of positive and negative periapical
pressures, as reported by Muhorn and coworkers.'"
These pressures, if present, alter the movement of in-
tracanal medication vapors through the root canal
space and periapical tissues. In addition, protein-
aceous debris, blood, and serum thai are present in
vivo have been found to have inhibitory effects on the
efficacy of intracanal medication.-" Therefore, the in-
hibitory effects of blood and serum on intracanal med-
ications were not determined in this in vitro investi-
gation.
In endodontic research, which is frequently isolated
from the canal, and as fonnd in similar studies in the
literature, S faecalis and S aureus are the organisms
usually chosen for testing. Because of the frequent
presence of these microorganisms their use for anti-
biotic sensitivity testing before the prescription of an
antimicrobial agent is also recommended by several
authors.'-'''"-'^''' Blood agar was used for these micro-
organisms, as it has been in similar studies in the lit-
erature.'-'"'''
Pear'^ tested the vapors of several drugs in Petri
dishes but not under simulated clinical conditions.
Different inhibition zones were observed with use
of the same drug, and this may be due to several fac-
tors. First, although teeth with roots of similar di-
mensions were chosen, even the smallest differences in
length might change the diameter of the inhibition
zone on the agar.
In addition, Wantulok et al"' reported that the pres-
ence of lateral canals would allow the drug to escape
before it reached the apex, accounting for a lack of
inhibition on the agar surface. In addition, apical for-
amina that exit short of the actual tooth length may
prevent the intraeanal medication vapors from direct
access to the Petri dish, thus preventing inhibition on
the agar surface.
The zone of inhibition was greater in teeth whose
652
apex was up than in teeth whose apex was down. This p
may be due to the evaporation of the drugs that were K
put in the pulp chamber. '
The medicaments were applied with a cotton that ^
was moistened with a chnical dose. This reliance on j
vaporization may be the reason that povi do ne-iodine s
formed a much smaller inhibition zone; it might be •
more effective when used on paper points within a
eanal.
In preliminary experiments, vapors of several com-
monly used nonspecific endodontic medicaments
(such as formocresol. eugenol, phenol, cresatin, beech-
wood creosate, and camphorated monochlorophenol
and parachlorophenol) were found to be effective in
inhibiting the growth of S aureus and ineffective
against the growth of S faecalis after a 24-hour in-
cubation period. These findings are in agreement with
the findings of Wesley and coworkers,' Harrison and
Madonia," and Cwikla."
In the present study, Betadine and Cresophene did
not have an effect on 5 aureus. This may be explained
by the study by Treaner and Goldman.'" Their re-
search showed that intracanal medicaments do va-
porize, although not to the degree at which they can
penetrate through the apex of the tooth. The vapors
remain within the canal.
Future studies to evaluate the effectiveness of en-
dodontic medicaments should simulate in vivo con-
ditions more effectively.
Summary
Forty-five extracted hnman maxillary central incisors
were uniformly cleaned and prepared to compare the
diffusion properties of four endodontic intraeanal
medicaments. The intracanal medicaments were
sealed in the pulp chambers, and the apices were
placed adjacent to freshly streaked Petri dishes that
had been surface-inoculated with Staphylococcus au-
reus or Streptococcus faecalis.
Effective drug diffusion was considered to have oc-
curred with the presence of bacterial inhibition. The
present study showed that vapors of the test medica-
ments do pass through the apex of a tooth.
References
1. Schilder H, Amsterdam M: Inflammatory potential of root can-
al medicaments. Onil Swg Oral Med Oytil Palho! 1959 t2211-
221.
8/t990
 Endodontics

2. White E, Pallasch TJ: Intracanal medication, in lngie JI led]:
Endodomics. Philadelphia, Lea & Febiger, 1976, p 581.
3. Wesley DJ, Marshall FJ, Rosen S: The quantitation of formo-
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Falltol I97O;25:6O3-612.
4. Wantulok JC. Wash S, Brown Jt: An in vitro aludy of the
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1972;34:653-66Û.
5. Grossman LI: Endodottiii Practice, ed 7. Philadelphia, Lea &
Fehiger. 1965, pp 2.1Q-253.
6. Nichois E: Endodomies. Bristol, England, John Wright and Sons
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7. Sommer RF. Ostrander FD, Crowley MC: Clinical Endodontics.
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8. Torneck CD. Reaction of hamster tissue to drugs used in ster-
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1961:14:73t)-741.
9. Wall GLV, Dowson S. Shipm.in C: Antibacterial efficacy and
cytotosicity of Ihree endodontic drugs. Oral Surg Oral Med Oral
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KI. Treanor HF. Goldman M: Bactericidal efficiency of intracanal
medications. Oral Surg Oral Med Oral Pathol 1972;33:791-796.
11. Weine FS: Endodontic Therapy, ed 3. Si Louis. CV Moshy Co
1982, p 324.
12. Muhorn HW, Dowson J, Bliinkenship JR: Odontic periapical
pressure following vitnl pulp extirpation. Oral Surg Oral Med
Oral Pathol 1571 ;31:536-544.
13. Harrison JW, Madonia JV: Antimicrobial effectiveness of par-
achlorophenol. Oral Surg Ond Med Ond Patho! t970-30-'65-
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14. Cwikia JR: The vaporization and capillary effect of endodontic
medicaments. Oral Surg Oral Med Oral Pathol i972:34:n7-12L
15. Pear JR: Bacleiicidal effects of some drugs used in puip canal
therapy. .1 Am Dem Assoc 1942;29:244-248. D

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