Intracanal Medicaments

And

Irrigating Agents

Despite the fact that sterilization is a cardinal principle of surgery…
It is an established fact that… In case of root canal therapy what can be best achieved is… Thorough debridement and disinfection.

This goal is adequately achieved by…

Biomechanical preparation in combination with irrigation and…

Placement of an intracanal medicament.

The aim of instrumentation and irrigation is… To remove all necrotic debris, micro-organisms and vital organic tissue as well as some hard tissue from the root canal system, and …
To give the canal system a shape that allows easy debridement and predictable placement of locally used medicaments and a permanent root filling material.

loosen debris.Mechanical instrumentation is the core method for achieving debridement through cleaning and shaping The use of irrigating solutions in combination with canal instrumentation. . pulp tissue and micro-organisms from the irregular dentin walls so that they can be removed from the canal.

.It has long been established that a root with a tapering canal and a single foramen is an exception rather than a rule.

It is the irrigating agent in combination with biomechanical instrumentation that… Reaches the nooks and crannies of the canal system to… Achieve optimum debridement and disinfection. .

• Disinfection and cleaning of areas inaccessible to endodontic instruments. • Dissolution of organic debris. • Destruction of micro-organisms. .Role of Irrigants • Removal of particulate debris and wetting of the canal walls. • Opening of dentinal tubules by removal of smear layer.

Various irrigants used in endodontics: • • • • • • Sodium hypochlorite Hydrogen peroxide Gly-oxide Iodine potassium iodide Chlorhexidine MTAD .

. • This initial use of potassium hypochlorite was later followed by sodium hypochlorite (NaOCl). • Now a days commonly used intra canal irrigant. as Carrel and Dakin introduced its use for wound disinfection.Sodium Hypochlorite • Hypochlorite was first used by Semmelweis in 1847 as a hand disinfectant.

and the antimicrobial agent can better reach and clean the infected areas. hydrogen in the imino groups (-HN-) is replaced by chlorine (-N. • During the process.Cl-) forming chloriamine. formaldehyde and acetaldehyde are formed within a short time. The peptide links are broken up to dissolve the proteins. nitrogen. • It has a rapid action but for a short duration. . necrotic tissue and pus are dissolved.Mechanism of action: • When hypochlorite contacts tissue proteins. • Thus. which plays an important role for the antimicrobial effectiveness.

25% . • Dakin suggested a 0. a concentration with low toxicity affecting only necrotic tissue.5% solution (Dakin's solution).• Temperature increase will significantly improve the antimicrobial effect of sodium hypochlorite. • Recommended concentration is 5.

This preparation will have a pH of 10." with four (1 %) or nine (0. far less than the pH of commercial solutions. • It should be stored in a cold place and protected from light. which is about 13 to 14.• To prepare fresh hypochlorite solutions. .5%) parts of sterile 1 % sodium bicarbonate solution. This provides a stable solution for several weeks. mix one part of a 5% solution of NaOCl such as "household bleach.

it releases nascent oxygen which destroys anaerobic microorganisms. • Produces transient effervescence that mechanically forces debris & microbes out of canal. • Anti-microbial action: When it comes in contact with organic matter.Hydrogen peroxide • Recommended concentration is 3%. .

Recommended manner of use: • Alternate use of 3% H2O2 and 5. • NaOCl should be used last because H2O2 forms gas. . Any gas trapped in canal will create pressure & will result in continuous pain.2% NaOCl.

• It kills wide spectrum of micro-organisms found in root canals. .Iodine Potassium Iodide • It is a traditional root canal disinfectant. • Acts as an oxidizing agent by reacting with free sulfhydryl groups of bacterial enzymes. cleaving disulfide bonds • It is able to kill calcium hydroxide resistant bacteria (E-faecalis).

Chlorhexidine • It is a broad spectrum antimicrobial agent effective against gram-negative and grampositive bacteria. • It has a cationic molecular component that attaches to negatively charged cell membrane areas. denatures the membrane and creates pores further resulting in cell lysis. .

2 – 2% • It lacks the tissue dissolving activity of NaOCl. which arises from binding to hydroxyapatite.• Its use as an endodontic irrigant is based on its substantivity and long lasting antimicrobial effect. • Concentration: 0. • Its potential weakness in the root canal is its reduced antimicrobial activity in the presence of organic matter. .

• Chelating agents effectively removes smear layer by chelating the the inorganic component of the dentin. • Smear layer is a microcrystalline layer of organic and inorganic debris which forms as a result of instrumentation of the tooth surface. .Role of chelating agents • A smear layer is formed after instrumentation of root canals.

Chelating agent alone cannot remove the entire smear layer effectively. • A proteolytic component ( NaOCl ) must also be used to remove the organic component of the smear layer.• Smear layer consists of both an organic and an inorganic component. .

• It has also been shown that removal of smear layer improves the antibacterial effect of locally used disinfecting agents in deeper layers of dentin. chelating agents contribute to the elimination of bacteria in the root canal. .• Therefore by facilitating cleaning and removal of infected tissue.

Callhan) Hydrochloric acid (1946. Grossman) Carbamide peroxide EDTA (1957.Chelating Agents • • • • • • • • Sulfuric acid (1894. Ostby) EDTAC RC Prep Citric acid MTAD .

EDTA (Ethylenediamine tetra-acetic acid. Actions: • Removal of smear layer • Forms Ca-chelate when comes in contact with dentin.) • Introduced in endodontic practice by Nygaard-Ostby in 1957 • Chemically contains 4 acetic acid groups attached to ethylenediamine. So BMP can be done effectively • Lubrication of canal • Anti-microbial properties .

3 .• It can decalcify upto 50 microns of the root canal wall in less than a minute. • The decalcifying process is self-limiting. • It is used in concentration of 15% and 17% and has a pH of 7. because the chelator is used up.

• Cetavlon a quaternary ammonium compound is added for additional antibacterial action. It is commercially available as EDTAC. • RC-Prep is composed of EDTA and urea peroxide. When used in combination with sodium hypochlorite produces a bubbling action which is thought to loosen and remove the debris. .

• Concentration used – 10% • It also has an antibacterial effect. .Citric acid • Citric acid can also be used for irrigation of the root canal to remove smear layer.

• It consists of: – Doxycycline – Citric acid – Detergent-tween 80.MTAD (Mixture of Tetracycline isomer. . Acid and detergent) • It is a new product in the quest for a better root canal irrigant.15. with a pH as low as 2.

acid and detergent. followed by a final rinse of MTAD. when canals are first irrigated with NaOCl. • MTAD results in satisfactory removal of smear layer. .• It has good antibacterial activity since it contains tetracycline.

The labelled bacterial cells rupture when exposed to laser light of the appropriate wavelength. PAD utilizes the photoactive agent tolonium chloride (toluidine chloride). • The root canal is irrigated with the solution. which selectively binds to the cellular membrane of bacteria in the biofilm. .Photoactivated Disinfection • The technique of photosensitization has been used in medicine for some time.

Photoactivated disinfection system The PAD endotip .

argon lasers. accessory canals of root canal. Thus no uniformity in the cleaning action. Er:YAG. . – Can be potentially hazardous to periapical tissues. • Limitations: – Difficulty in cleaning all the walls. Nd:YAG.Lasers • Lasers can be used effectively for additional disinfection of root canal system • Lasers used : Carbon dioxide.

this device was used to reduce the microbial colonies associated with root caries. • Initially.Ozone • Ozone is a powerful oxidizing agent and has high bactericidal properties. • Attempts to sterilize the entire root canal system have proved complex. as perfusion of the gas is not reliable. .

Endox • The Endox Endodontic System (Lysis srl. Italy) has been reported to sterilize the root canal by emitting highfrequency electrical impulses. • Sterilization occurs as a result of fulguration and the manufacturer claims it is able to eliminate both pulp and bacteria from the entire root canal system .Nova Milanese.

endox and lasers serve only as an adjunct to the primary irrigation by sodium hypochlorite .Note that… Photoactivated disinfection and disinfection by means of ozone.

to reach the canals of posterior as well as anterior teeth.Method of root canal irrigation • The technique of irrigation is simple. . A leur lock plastic syringe with an endodontic notched needle of 25 gauge is used. • The needle should be bent to an obtuse angle.

• A perforated needle has been developed to deliver irrigant 3600 in the root canal.• The needle is inserted partway into the root canal. • The solution is ejected from the syringe with little or no pressure on the plunger. . Sufficient space between needle and canal wall allows for return flow of the solution and avoids forcing of solution into the periapical tissue. It should not be inserted so it binds.

Design of irrigating needles

Bevelled needle: irrigant forced apically; there is a risk of extrusion if the needle becomes lodged in the canal.

Monoject tip: irrigant can pass sideways.

Safe-ended tip: irrigant passes pass sideways.

The return flow of solution is caught on a gauze piece or aspirated. Final drying is effected by absorbent points.

It is proved beyond doubt that… Biomechanical instrumentation in combination with copious irrigation is the primary means of achieving…

Adequate disinfection of root canal system.

Some suggest that these techniques may not completely eradicate micro organisms in a necrotic pulp space and that further disinfection with an effective intracanal medicament may be necessary

Intracanal medicaments have always gone hand in glove with endodontics .

. • The presence of intracanal medicament restricts bacterial growth in between appointments by creating an environment which is not conducive for bacterial growth.The rationale for the use of intracanal medicaments … • The medicament may reduce the microbial flora below the levels already achieved during canal preparation.

.• In special cases use of an intracanal medicament like calcium hydroxide can bring about periapical repair.

Before considering root canal medication. one question that arises is… Which organisms are we trying to destroy? .

• These organisms are found in various combinations and not as a single species. .are the gram +ve In some cases it may be gram -ve and few of the cases yeasts.Root canal flora • Most commonly found microorganisms. • In teeth with periapical lesion obligate anaerobes are often found.

• Among the streptococci is a small resistant group of enterococci. .• The endodontic problem is primarily one of eliminating gram +ve organisms because they are the most abundant. • Recent reports on bacterial flora describe the presence of obligate and facultative anaerobes. consisting chiefly of streptococci and staphylococci. In addition a small percentage of gram -ve organisms and yeasts can be isolated from saliva and from root canals.

Disinfection of root canal system by means of intracanal medicaments is accomplished by: • Chemical means • Physical means/ electrosterilization/ electrolytic medication • Combination of physical and chemical means .

6.Ideal Requirements of ICM The intra canal medicament should be – 1. 4. 2. 5. 3. Potent antibacterial & antifungal agent Potent pulp tissue solvent Non irritant to periapical tissue Long duration of action Have low surface tension No hypersensitivity or allergic reaction .

Capable of inactivation in culture medium 11. Economic. abscess or protein derivatives of the tissue 9. Should be stable & should have longer shelf life 10. Active in presence of blood.7. easily available . No interference with repair of periapical tissues 8.

cresatin.Classification (Based on chemical nature) I. thymol III. Aldehydes ex: Formocresol. Essential oil. camphorated mono chlorophenol. cresol. Glutaraldehyde . camphorated phenol.Eugenol II. Phenolic compounds ex: Phenol.

Antibiotics VIII.Potassium iodide. Calcium hydroxide VII.IV. Steroids VI. V . Iodine . Halides Sodium hypochlorite. Combinations .

.Eugenol • It is the chemical essential of oil of clove but chemically related to phenol • It has a weak antiseptic and anodyne effectThe ability of eugenol to inhibit nerve activity reportedly accounts for its anodyne property. • Masillamoni and others reported that eugenol is a potent antimicrobial action at a dilution of 1:640 and is not as effective as formocresol and CMCP in its undiluted form.

Phenolic Compounds • Phenol/ carbolic acid introduced by Lord Lister in 1867 is one of the oldest antimicrobial agent used in medicine.It serves as the basis for a number of derivatives extensively used in dentistry . • It is used as a standard for comparing the relative effectiveness of other disinfectants.

• Liquefied phenol consists of 9 parts of phenol and 1 part water.• Mechanism of action: Phenol is a protoplasm poison and produces necrosis of soft tissues by its ability to penetrate and disrupt the cell wall of bacteria and subsequently the protoplasm. • This substance is highly effective in as low concentration as 1 to 2% .

Camphorated parachlorophenol • It contains 35% parachlorophenol in 65% camphor vehicle. • Addition of camphor aims at developing a less caustic medicament as a result of the slow release of phenol. . • It is the least toxic of the phenolic compounds • It has an excellent antimicrobial effect.

• Prolongs the antimicrobial effect. • Results in less toxic phenolic compound as it slows the release of toxins to the surrounding tissues.Camphor serves as: • A vehicle and diluent. .

The vapors can pass through the apical foramen.Camphorated Mono Chloro Phenol ( CMCP) • Developed by Walkhoff 1891 • Composition: 35% Monochlorophenol 65% camphor • It has a wide antibacterial and antifungal spectrum. • It is used in the form of vapor forming intracanal medicament. .

• It is much less irritating to the periapical tissues than either phenol or eugenol . • Least toxic of all phenolic compounds. . • It is inexpensive and has a long shelf life.

Cresol • Cresol is about three times more powerful as a disinfectant than phenol and is slightly less toxic • It is used as a root canal disinfectant specifically in combination with solutions of formaldehyde. .

Formocresol • It is a combination of cresol and formalin in proportion of 1:2. 6% glycerine and water. . 1:1 which was popularized in United States by Buckley in 1905. • Contents: 19% formaldehyde. 35% cresol.

• Formocresol combines the protein .• Formalin is a strong disinfectant and a fixative which combines with albumin to form an insoluble and indecomposable substance .coagulating effect of phenolic compounds with the alkylating effect of formaldehyde. . • The bactericidal effect of formocresol is good at levels as low as 2%.

• It causes widespread destruction of living tissue followed by a persistent inflammatory reaction. It has mutagenic and carcinogenic potential. . • Studies have reported that formo cresol treated tissue produced a cell mediated immune response. • Its vapor forming effect is also good. • It is used in pulpotomy to fix the retained pulp tissue.

Cresatin • Metacresylacetate or cresatin is the acetic acid ester of metacresol. somewhat oily liquid of low volatility and is stable. . • It is an antiseptic. analgesic and fungicidal agent • It is a clear. • Its antibacterial effect is enhanced because of its low surface tension and its effect is prolonged by its low volatility.

• It is less commonly used than phenol because of its pungent. in the past. . • In dentistry only beechwood variety of creosote is used. highly penetrating odor which.Creosote • It is a mixture of phenol and phenol derivative a better disinfectant than phenol and is less toxic and irritating. gave many dental offices their characteristic odour.

• Extent of toxicity is less compared to formaldehyde.Gluteraldehyde • It is a colorless oil slightly soluble in H2O . . • Used in concentration of 2% as ICM.its antimicrobil action is concentration and time dependent. • Like formalin it is strong disinfectant and a fixative. Its molecular weight is high compared to formaldehyde hence does not penetrate into the periapical tissues.

has the greatest disinfectant action of members of this group.Halogens • Chlorine and iodine are the bases of a number of oxidizing antiseptics commonly used in endodontic practice. . • The disinfectant action of halogens is inversely proportional to their atomic weight. • Chlorine having the lowest atomic weight.

• Sodium hypochlorite although used primarily as an irrigant.• Chlorine disinfectants have a solvent action on necrotic tissue but as a class they are not stable. Hence they are used in the form of sodium hypochlorite or camphorated monochlorophenol. . • Ellerbruch and Murphy reported that NaOCl vapours were bactericidal. has been suggested for use as an intracanal medicament because it is less irritating than other intracanal medications.

therefore. . the longevity of its antimicrobial effectiveness is questionable. • Iodine has a staining potential and may cause allergic reactions. 4% potassium iodide & 94% distilled water.• NaOCl reacts rapidly with organic matter. • As an intracanal medicament iodine is used in the form of iodine potassium iodide ( 2% iodine.

providing an antimicrobial effect. • The vapor-forming effect is good as well. so it continues to provide an active antimicrobial effect at a concentration with no cytotoxicity. .• Iodine potassium iodide has an excellent antimicrobial activity and has only minimal toxicity and tissueirritating qualities.

Quaternary ammonium compounds • The quaternary ammonium compounds are cationic detergents or wetting agents. are mild disinfectants. • They are positively charged and microorganisms are negatively charged a surface active effect results such that the compound clings to the micro-organisms and reverses the charge. .

• 9 aminoacridine a mild disinfectant has been suggested as an endodontic irrigant and intracanal medication. . • A 1:500 dilution of 9-aminoacridine was found to exhibit more effective antimicrobial activity than eugenol or cresatin but less than camphorated monochlorophenol.

.5.Calcium Hydroxide • • • Introduced by Herman in 1930 One of the most popular ICM The pH of calcium hydroxide is highly alkaline about 12. several bacterial species commonly found in infected root canals are eliminated after a short period when in direct contact with this substance.

• Antimicrobial activity of calcium hydroxide is related to the release of hydroxyl ions in an aqueous environment. Protein denaturation 3. • • Their lethal effects on bacterial cells are probably due to the following mechanisms: 1. Damage to the DNA . Damage to the bacterial cytoplasmic membrane 2. Hydroxyl ions are highly oxidant free radicals that show extreme reactivity.

which are the structural components of the cellular membrane of the bacteria.Damage to the bacterial cytoplasmic membrane • Hydroxyl ions induce destruction of phospholipids. .

• This results in the loss of biological activity of the enzyme and disruption of the cellular metabolism .Protein Denaturation • The alkalinization provided by calcium hydroxide induces the breakdown of ionic bonds that maintain the tertiary structure of proteins.

• Free radicals may also induce lethal mutations.Damage to the DNA • Hydroxyl ions react with the bacterial DNA and induce the splitting of the strands. • DNA replication is inhibited and the cellular activity is disarranged. .

Propylene glycol : • Resultant paste has better handling characteristics because glycerin is humectant. • Ca(OH)2 readily dissolves in glycerin . Distilled water : • Rapid hydrolysis of compound into its active parts 2.Vehicles used for Ca(OH)2 1. Camphorated mono chlorophenol : • Dual effect of a vehicle as well as an additional antibacterial action 3.

Antibiotics Few antibiotics are used as an intracanal medicaments. may be alone or in combination or with corticosteroids: • • • • • • • PBSC & PBSN Sulfonamides Tetracycline Metronidazole Chloramphenicol Bacitracin Neosporin .

Penicillin : effective against Gm +ve microorganisms 2. Bacitracin : effective against penicillin resistant microorganisms 3.PBSC It is available in paste form which contains. 1. Caprylate : effective against fungi . Streptomycin : effective against Gm -ve microorganisms 4.

PBSN Penicillin : effective against Gm +ve microorganisms Bacitracin : effective against penicillin resistant microorganisms Streptomycin : effective against Gm -ve microorganisms Nystatin : effective against fungi .

• Disadvantages: Both the preparations have shown severe hypersensitivity or allergic reaction to any of the constituent. so its use is largely declined .

. Disadvantages: • Hypersensitivity reaction • Yellowish discoloration of tooth.Sulfonamides • Sulfanilamide & sulfathiazole Used as medicament by mixing with sterile distilled water or by placing the moistened paper point into a jar containing this powder & then putting it into canal.

.Chloramphenicol • Broad spectrum antibiotic. active against aerobic as well as anaerobic micro-organisms. Use of paper point or reamer to introduce the paste into canal. • Method of use: Crystals in a few drops of normal saline is mixed well to form paste.

• Highly effective in the treatment of over instrumentation.Corticosteroids • Used in combination with antibiotics in a paste form. . • Primary function of corticosteroid is to prevent or reduce periapical inflammation .

Thank You .