Intracanal medicaments in Endodontics

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2.  INTRODUCTION
 OBJECTIVES
 IDEAL PROPERTIES
 CLASSIFICATION
 CALCIUM HYDROXIDE
 ANTIBIOTICS
 NON PHENOLIC COMPOUNDS
 PHENOLIC COMPOUNDS
 IODINE
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3.  BIOACTIVE GLASS
 BIOCOMPATIBILITY
 CONCLUSION
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4.  Bacteria have been implicated in the pathogenesis and
progression of pulpal and periapical diseases. The
primary aim of endodontic treatment is to remove as many
bacteria as possible from the root canal system.
 Therefore an effective antimicrobial agent in the root canal
is required for a predetermined time period to predictably
eradicate or destroy any remaining bacteria.
 Antimicrobial agents used as inter-appointment
medicaments must be able to penetrate through the dental
tissues in the presence of microbes to reach a sufficiently
high concentration in order to eliminate the disease-
causing bacteria in a predictable manner.
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5.  Eliminate or destroy any remaining viable bacteria in the root
canal system that have not been destroyed by the
chemomechanical preparation processes (i.e., Instrumentation and
irrigation)
 Reduce periradicular inflammation and hence reduce pain.
 Help eliminate apical exudate if it is present.
 Prevent or arrest inflammatory root resorption if it is present.
 Prevent re-infection of the root canal system by acting as both a
chemical and a physical barrier if the temporary or interim
restoration breaks down.
 Induce healing
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6.  It should be effective germicide and fungicide.
 It should be non irritating to periapical tissue.
 It should remain stable in the solution.
 It should have prolonged antimicrobial action.
 It should remain active in presence of blood and
pus etc.
 It should have low surface tension.
 It should not interfere with the repair of
periapical tissue.
 It should not stain tooth.
 It should not induce immune response
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7.  PHENOLS
Eugenol
Camphorated monochlorophenol
Parachlorophenol
Camphorated parachlorophenol
Metacresylacetate
Cresol
Cresolate
Thymol
 ALDEHYDES
Formaldehydes
Glutaraldehydes
 HALIDES
Sodium hypochlorite
Iodine potassium iodide
 STEROIDS
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8.  CALCIUM HYDROXIDE
 ANTIBIOTICS
 COMBINATIONS
Dental clinics of north america 28,783,1984
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9. According to Grossman
1. Essential oils - Eugenol
2. Phenolic compound - Phenol
- Para chlorophenol
- Camphorated para chlorophenol
- Formocresol
- Glutaraldehyde
- Cresatin
- N2
3.Halogens - Na hypochlorite
- Iodides
4. Quaternary Ammonium compounds
9 - amino acridine
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10. According to Ingle
He classified antimicrobial agents broadly into 2 groups
Conventional antiseptics / Locally used antiseptics
Chemotherapeutics
Locally used antiseptics: Examples
1. Alcohols - Ethyl alcohol
- Isopropyl alcohol
2. Phenolic compounds - Phenol
- Camphorated phenol
- Monochlorophenol
- Paramonochlorophenol
- Thymol
- Eugenol
- Creosole
3. Heavy metal salts- Salts of silver, mercury, copper.
4. Cationic detergents - Quaternary ammonium compounds.
5. Halogens - Na hypochlorite
- Potassium iodide, iodine
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11.  It was introduced by B.W. Hermann in 1920.
 It is a strong alkaline substance, which has a pH
of approximately 12.5.
 Calcium hydroxide has low solubility in water,
and is insoluble in alcohol (about 1.2 g /l at
25oC)
 A molecular weight of 74.08.
 It is one of the most biocompatible material in
dentistry.
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12.  Antimicrobial activity
 Tissue-dissolving ability
 Inhibition of tooth resorption
 Induction of repair by hard tissue formation.
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13.  The antimicrobial activity of calcium hydroxide is
due to the release and diffusion of hydroxyl ions
(OH-) leading to a highly alkaline environment
which is not conducive to the survival of micro-
organisms.
 The rate of diffusion of hydroxyl ions is slow due
to the inherent buffering capacity of the dentine.
 Availability of calcium ions at the site of action
appears to be useful for exerting therapeutic
effects which are mediated through ion channels.
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14. The lethal effects of calcium hydroxide are due to
several mechanisms, namely:
(a) A chemical action through:
• Damage to the microbial cytoplasmic membrane by
the direct action of hydroxyl ions.
• Suppression of enzyme activity and disruption of
cellular metabolism.
• Inhibition of DNA replication by splitting DNA.
(b) Physically by:
• Acting as a physical barrier that fills the space
within the canal and prevents the ingress of bacteria
into the root canal system.
 Killing the remaining micro-organisms by
withholding substrates for growth and limiting
space for multiplication.
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15. The biological properties of calcium
hydroxide include:
• Biocompatibility (due to its low solubility in
water and limited diffusion).
• The ability to encourage periapical hard
tissue healing around teeth with infected
canals.
• Inhibition of root resorption and stimulation
of periapical healing after trauma.
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16. The limited effectiveness of the short-term use of
calcium hydroxide in disinfecting dentinal tubules is
due to several factors, :
 Inhibition by dentinal protein buffering, particularly
in terms of the ability of hydroxyl ions to reach the
apical third and have an antibacterial effect.
 The low solubility and diffusibility of calcium
hydroxide may make it difficult to gain a rapid
increase in pH to reach the level necessary to
eliminate or kill bacteria within the dentinal tubules
and anatomical variations.
 The varying alkaline potential of different
formulations.
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17.  A lentulo spiral,
 Injection with a syringe system
 Counterclockwise rotation of a K file
 Specifically designed paste carrier (the
pastinject )
 Ca(OH)2 Points
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18.  Because of poor handling property and challenge
for its complete removal, Ca(OH)2 points were
introduced which contain calcium hydroxide at a
concentration of 50-54% (wt %).
 The points are 28mm in length and a distinctive
brown color.
 available in ISO sizes of 15 to140.
 An improved version of calcium hydroxide points
is the calcium hydroxide plus points (CHPP)
which additionally contain sodium chloride and
tensides.
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20.  Minimal or no residue left
 No smearing around the access cavity during
insertion
 Firm for easy insertion and flexible enough to
follow the natural canal curvature
 Time saving
 Uniform calcium hydroxide release.
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21.  The first reported local use of an antibiotic in endodontic
treatment was in 1951 when Grossman used a
polyantibiotic paste known as PBSC (penicillin, bacitracin,
streptomycin, and caprylate sodium).
Penicillin - gram-positive organisms,
Bacitracin - penicillin-resistant strains,
Streptomycin - gram-negative organisms,
Caprylate sodium - target yeasts.
 These compounds were all suspended in a silicone vehicle.
 Later, nystatin replaced caprylate sodium as an antifungal
agent in a similar medicament, PBSN.
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22.  While systemic antibiotics appear to be clinically
effective as an adjunct in certain surgical and
nonsurgical endodontic cases, their administration is
not without the potential risk of adverse systemic
effects, particularly possibilities of allergic reactions,
toxicity, side effects, and development of resistant
strains of microbes.
 Also, systemic administration of antibiotics relies on
the circulation to bring an active drug to an infected
site that may no longer possess a normal vasculature,
including the necrotic pulpless tooth and the
periradicular tissues. Therefore, local application of
antibiotics may be a more effective mode for
delivering antibiotics
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23.  Ledermix is a glucocorticosteroid antibiotic
compound.
 Ledermix paste was developed by Schroeder and
Triadan in 1960 and was released for sale in
Europe by Lederle Pharmaceuticals in 1962.
 Schroeder and Triadan initially incorporated
chloramphenicol in their first trials but when
Lederle Pharmaceuticals became the
manufacturer, the antibiotic was changed to
demeclocycline HCl.
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24. COMPOSITION:
 Demeclocycline HCl (3.2 percent),
 Triamcinolone acetonide ( 1 percent),
 in a polyethylene glycol base.
 It possesses the therapeutic effect of both
tetracycline and corticosteroid.
 While steroid is known to suppress
inflammation and is considered to have
inhibitory effect on the osteoclastic activity;
 Tetracycline has been demonstrated to
possess antimicrobial effect and
antiresorptive property.
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25.  In a study by Kim et al demonstrated that
Ledermix paste may cause discolouration of
teeth. Such effects can be minimized if
placement of the paste is restricted to below
the gingival margin.
 And also it was seen that Sunlight caused
Ledermix-filled teeth to become even darker.
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26.  Septomixine Forte contains two antibiotics: —
Neomycin and Polymixin B sulphate.
 Neither of these can be considered as suitable for use
against the commonly reported endodontic bacteria
because of their inappropriate spectra of activity.
 Neomycin is bactericidal against gram-negative
bacilli but it is ineffective against bacteroides and
related species, as well as against fungi.
 Polymyxin B sulphate is ineffective against gram
positive bacteria.
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27.  Hoshino et al. determined that a combination
of ciprofloxacin, metronidazole and
minocycline, each at a concentration of 25μg
per ml (0.0025 per cent) of paste, was able to
disinfect infected root dentine in vitro.
 Sato et al. evaluated the potential of a
mixture of ciprofloxacin, metronidazole and
minocycline to kill bacteria in the deep layers
of root canal dentine in situ.
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28.  3 MIX-MP composition:
Antibiotics (3Mix)
• Ciprofloxacin 200 mg
• Metronidazole 500 mg
• Minocycline 100 mg
Carrier (MP)
• Macrogol ointment
• Propylene glycol
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29. Protocol for preparation
Antibiotics (3Mix) – Be sure not to cross-contaminate.
• Remove sugar coating from tablets with surgical blade, crush
individually in separate mortars
• Open capsules, crush individually in separate mortars
• Grind each antibiotic to a fine powder
• Combine equal amounts of antibiotics (1:1:1) on mixing pad
Carrier (MP)
• Equal amounts of macrogol ointment and propylene glycol
(1:1)
• Using clean spatula, mix together on pad
• Result should be opaque
• Separate out small portions of 3Mix and incorporate into MP
using the following:
• 1:5 (MP:3Mix)→creamy consistency
• 1:7 (standard mix)→smears easily but does not crumble
• If result is flaky or crumbly, then too much 3Mix has been
incorporated
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30. Storage
• Antibiotics must be kept separately in
moisture-tight porcelain containers.
• Macrogol ointment and propylene glycol
must be stored separately.
• Discard if mixture is transparent (evidence of
moisture contamination
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31.  Metronidazole is a nitroimidazole compound that
exhibits a broad spectrum of activity against
protozoa and anaerobic bacteria.
 It is a strong antibacterial agent against
anaerobic cocci, as well as gram negative and
gram-positive bacilli.
 It has been used both systemically and topically
in the treatment of periodontal disease.
 Metronidazole readily permeates bacterial cell
membranes. It then binds to the DNA, disrupting
its helical structure, and leads to very rapid cell
death.
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32.  Tetracyclines, which include doxycycline and
minocycline, are a group of bacteriostatic
antimicrobials.
 They have a broad spectrum of activity against
both gram-positive and gram-negative
microorganisms and are effective against most
spirochaetes, and many anaerobic and facultative
bacteria.
 The tetracyclines gain access to bacterial cells by
passive diffusion through the outer membrane
followed by active transport through the inner
membrane. They then act by inhibiting protein
synthesis on the surfaces of ribosomes.
 Minocycline is a semisynthetic derivative of
tetracycline with a similar spectrum of activity.
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33.  Ciprofloxacin, a synthetic floroquinolone, has a
bactericidal mode of action.
 Ciprofloxacin has very potent activity against
gram-negative pathogens but very limited activity
against gram-positive bacteria.
 Most anaerobic bacteria are resistant to
ciprofloxacin, therefore, it is often combined with
metronidazole in the treatment of mixed
infections.
 It acts through the inhibition of DNA gyrase,
resulting in degradation of the DNA by
exonucleases.
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34.  Biocides comprise a large group of diverse chemical
agents that are capable of inactivating a variety of
micro-organisms.
 Biocides have a long history of safety and therefore
are used in a large variety of applications.
 Some of the commonly used biocides include
alcohols (e.g., ethanol), aldehydes (e.g.,
formaldehyde, glutaraldehyde), biguanides (e.g.,
chlorhexidine), quaternary ammonium compounds
(QACs), zinc, and phenolic compounds including
essential oils and phenylethers (e.g., triclosan).
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35.  While antibiotics affect a specific target site in
microorganisms resulting in bacteriostatic and
bactericidal effects at therapeutic
concentrations.
 Biocides have a broader spectrum of activity as
they work on multiple target sites. Hence,
bacterial resistance to biocides is unlikely to
develop.
 In general, biocides bind to target molecules
within the cell wall, which becomes disrupted
and this allows the agent to then penetrate into
the cell and interact with the cytoplasmic
constituents.
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36.  Membrane damage and leakage
 Protein denaturation
 Binding of thiol groups
 Initiation of autolysis
Sreenivasan P, Gaffar SP.
J Clin Periodontol 2002.
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37.  Biocide susceptibility is a function of the
permeability of the biocide through the cell wall
.
 Gram-positive bacteria are more permeable and
susceptible to biocides, whereas mycobacteria
and gram-negative bacteria, which have a more
complex cell wall, are less permeable and
susceptible.
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38. FACTORS AFFECTING BIOCIDE
ACTIVITY
Biocide activity is affected by several factors :
 concentration,
 period of contact,
 pH,
 temperature, and
 The presence of organic matter.
 Concentration is a factor of prime importance –
QACs, chlorhexidine (CHX) and glutaraldehyde
retain much of their activity when diluted but
alcohols rapidly lose activity readily on dilution.
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39.  Glutaraldehyde and cationic biocides (CHX,
QACs) are most active at alkaline pH, whereas
hypochlorites and phenolics are most potent
at acid pH.
 Interaction with organic matter (such as
blood, serum, pus) and non-ionic surfactants
can adversely affect the efficacy of some
biocides.
 The activity of biocides can be enhanced by
the use of chemical agents (e.g., EDTA,
polylysine) which increase the permeability of
bacterial cell membranes. 11/3/2021 39

40.  Chlorhexidine has a reasonably wide range of
activity against aerobic and anaerobic
organisms as well as Candida species.
 It is more effective at alkaline than at acid
pH, and its action is inhibited by the presence
of soaps and organic matter.
 CHX is sporostatic (prevents the outgrowth
but not the germination of bacterial spores)
but not sporicidal towards bacterial Spores.
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41.  CHX is a positively charged hydrophobic and
lipophilic molecule that interacts with phospholipids
and lipopolysaccharides on the cell membrane of
bacteria and then enters the cell through some type
of active or passive transport mechanism.
 Its efficacy is based on the interaction between the
positive charge of the molecule and negatively
charged phosphate groups on the bacterial cell wall.
 This increases the permeability of the cell wall which
allows the chlorhexidine molecule to penetrate into
the bacteria with intracellular toxic effects.
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42.  CHX at low concentrations will result in a
bacteriostatic effect but at higher concentrations, it is
bactericidal due to precipitation and/or coagulation of
the cytoplasm which is probably caused by protein
cross-linking.
 Attachment of bacteria to oral surfaces represents a
critical step in the pathogenic process, CHX has been
shown to inhibit adherence of key pathogens (e.g.,
that of P. gingivalis to host cells).
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43.  CHX has a unique feature in that dentine
medicated with it acquires antimicrobial
substantivity.
 The positively-charged molecules of CHX can
adsorb onto dentine and prevent microbial
colonization on the dentine surface for some
time beyond the actual medication period this
may inhibit re-infection of the canal
subsequent to treatment during that time
period.
 CHX is retained in root canal dentine in levels
sufficient to exert antimicrobial effects for at
least 12 weeks. 11/3/2021 43

44.  These medicaments have been applied either
on a cotton wool pellet placed in the pulp
chamber or on a paper point placed in the
root canal, with the rationale being that the
antimicrobial effect is delivered through
vaporization of the medicament.
 The antimicrobial action in the apical portion
of the root and within the dentinal tubules is
therefore dependent on the volatility of the
medicament.
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45.  Depending on the volatility of the agent used, the
amount which can be loaded onto a cotton pellet
or paper point is small and some of the
medicament will be lost through evaporation into
the atmosphere before the access cavity is closed.
 If this loss were great, the duration of
effectiveness of the remaining material within the
canal will be limited.
 In studies by Messer and Chen, there was 73 per
cent loss of the CMCP from cotton pellets,
inserted into pulp chambers within 1day of
insertion.
JOE; Vol. 12, No. 6, June 1986
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46.  Camphorated parachlorophenol, or camphorated
paramonochlorophenol (CMCP), was introduced by
Walkhoff in 1891.
Parachlorophenol- 33-37% and
Camphor- 63-67%
 Parachlorophenol (C6H5OCl, molecular weight
128.56) has a characteristic phenolic odour and is
presented in crystal form.
 Camphor (C10H16O, molecular weight 152.54) is a
ketone obtained from Cinnamomum camphora or
synthetically in the laboratory.
 It has a characteristic and penetrating odour, a
bitter taste and low solubility in water.
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47.  The combination of calcium hydroxide and
camphorated parachlorophenol was proposed in the
1960s by Kaiser (1964) and Frank (1964, 1966).
 The combination has been advocated to extend the
antibacterial spectrum of calcium hydroxide mainly
against some facultative or aerobic bacteria
 Apart from extending the antibacterial spectrum,
the combination was also effective in eliminating
strict and facultative anaerobic bacteria located in
dentinal tubules
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48. INDICATIONS
 Apexification
 Perforation defects after internal resorption.
 Reversal of external root resorption.
 As an intracanal dressing in nonvital teeth.
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49.  It was first introduced to dentistry by Coolidge
in 1912 for the treatment of necrotic pulps.
 Chemically, metacresylacetate is an acetic
ester of metacresol in combination with
benzene.
 It is an oily liquid with antibacterial, analgesic
and sedative properties.
 Vander Wall et al. (1972) showed less
cytotoxic activity compared with camphorated
parachlorophenol.
 Its proprietary brand name is Cresatin.
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50. INDICATIONS
 Pulp capping
 Pulpotomy
 Root end induction in immature non-vital
teeth
 Retreatment after endodontic and surgical
failures
 Root resorption
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51. EUGENOL
 Eugenol (C10H12O2, molecular weight 164.20)
 It is obtained from oil of cloves and other
sources.
 It has been employed as an intracanal dressing
for vital and non-vital deciduous teeth (Murata
1959).
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52. Buckley’s solution:
 19% formaldehyde
 35% cresol
 15% glycerine and water
 Used in 1:5 concentrated solution.
 First thoroughly mix 3 parts of glycerine with
1 part of distilled water then add 4 parts of
this preparation to 1 part of buckley’s
formocresol and thoroghly mix again.
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53. Mechanism of action:
Aldehyde groups of formaldehyde form bonds
with side groups of amino acids of both
bacterial protein and remaining pulp tissue
thus acts as a bactericidal and fixative to pulp
tissue.
Dose:
 The estimated formaldehyde dose associated
with 1 pulpotomy procedure, assuming a 1:5
dilution of formocresol placed on a cotton
pellet that has been squeezed dry, is
approximately 0.02– 0.10 mg.
 Daily uptake- 10.55 mg per day.
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54. POTENTIAL RISKS
Mutagenicity,
Genotoxicity,
Cytotoxicity.
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55.  Iodine is rapidly bactericidal, fungicidal,
tuberculocidal, virucidal, and sporicidal.
 Aqueous iodine solutions are unstable,
Iodophors (iodine carriers) and are complexes
of iodine and a solubilizing agent or carrier,
which acts as a reservoir of the active free
iodine.
 In 1976, Torneck advocated the use of
povidone-iodine solution as an endodontic
irrigant.
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56. MECHANISM OF ACTION:
 The antimicrobial action of iodine is rapid, even at
low concentrations, but the exact mode of action
is not fully known. It is thought that iodine attacks
key groups such as proteins, nucleotides, and
fatty acids, resulting in cell death.
Iodoform containing pastes:
 Endoapex ( Ca (OH)2 + Iodoform + liquid silicon)
 Vitapex calcium hydroxide (30.3%),
iodoform (40.4%),
silicone oil (22.4%) and
other (6.9%).
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57.  Recently iodoform has been included in gutta
percha cones (long star technologies, USA)
 It contains 10% iodoform.
 Iodoform in the cone remains inert until it
comes in contact with tissue fluids and releases
the free iodine.
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58.  Bioactive glass (BAG) contains oxides of calcium,
sodium, phosphorus, and silicon in a proportion
that provides the material with surface activity
and with a property to form a bond with
mineralized hard tissues such as bone or
dentin.
 In an aqueous environment, BAG liberates Ca2+,
Na+, PO4
3–, Si+4, causing an increase in pH and
osmotic pressure. Therefore, BAG is mildly toxic
and shows antimicrobial activity.
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59. Leaching of Na+ ions
Dissolution of calcium, phosphate, and silica
from the glass in an aqueous environment,
Si-rich layer on the material
Template for calcium phosphate
precipitations
Can connect to mineralized hard tissue
surfaces
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60.  Since 1970s, Bags have been mainly used for
augmentation of closed bony defects that are
not exposed to the external environment after
the clinical procedure.
 In dentistry, Bag is used to augment alveolar
ridges and to treat periodontal pockets.
 Dentin hypersensitivity
 Pulp capping
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61.  Because of the inhibition of antimicrobial
agents commonly used in endodontics by the
presence of dentin, inhibition of the
antimicrobial activity of BAG was expected.
 However, contrary to expectations, preliminary
experiments by Salonen J et al demonstrated
an additive antimicrobial effect of BAG S53P4
in the presence of dentin.
 BAG S53P4 incubated with dentin or bone
powder caused a marked decrease in bacterial
viability as compared with the effect by BAG
alone. 11/3/2021 61

62.  An alternative to calcium hydroxide as an
inter appointment dressing.
 Because of their ability to bind to dentin and
bone, BAGs might also be considered as
root-filling materials.
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63.  Calcium hydroxide introduced into the periapical
region appears to be well tolerated and is
subsequently resorbed (Martin & Crabb1977).
 It was found to be one of the least irritating root
filling materials and was replaced by new bone
within 12 weeks after placement (SpHngberg 1969).
 Calcium hydroxide has been reported to have a
detrimental effect on periodontal tissues, Blomlof et
al. (1988) observed that calcium hydroxide could
negatively influence marginal soft tissue healing
and suggested the completion of endodontic
therapy prior to the removal of cementum as might
occur during periodontal therapy.
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64.  Ledermix has been found to be safe to
periapical tissues by Barker & Lockett (1972),
who observed a normal histological
appearance of the periapical tissues 3 months
after the application of Ledermix in dog root
canals.
 Contrary to their findings Tepel et al. (1994)
found an infiltrate of inflammatory cells in the
periapical tissue after the use of Ledermix.
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65.  Seltzer (1988) expressed concern that the
intracanal use of corticosteroids, which have
an effect on inflammatory cells and protein
synthesis, may interfere with phagocytosis
with resultant impaired and delayed tissue
repair.
 Abott et al in 1992 suggested that the
intradental use of Ledermix paste and
Ledermix cement is unlikely to result in any
systemic side-effects.
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66.  All of these compounds coagulate cell contents
indiscriminately and will cause tissue necrosis on
contact.
 These compounds have been proven to be tissue
irritating and highly toxic ( SpHngberg et al.1979)
and to have limited antimicrobial effectiveness
(Bystrom et al. 1985).
 The combination of high toxicity and limited clinical
effectiveness exclude the phenol-based compounds
from the recommended list of contemporary
intracanal antibacterial medicaments.
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67.  When the antimicrobial activity of similar
concentrations of chlorhexidine and sodium
hypochlorite was compared in vitro, both
compounds were found to be equally effective
as antibacterial agents (Vahdaty et al.
1993).but cytotoxic potential of CHX was
much less than hypochlorite.
 It is important to note that various symptoms
of immediate hypersensitivity, including
anaphylactic reactions, have been reported
after topical treatment with chlorhexidine
(Bergqvist-Karlsson 1988, Lauerma 2001).
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68.  In an in vitro study on the toxicity of
chlorhexidine to human gingival cells showed that
the toxic potency of chlorhexidine is dependent
on the length of exposure and the composition of
the exposure medium(Babich et al.1995).
 Addition of foetal bovine serum, albumin, lecithin
and heat-killed Escherichia coli reduced the
cytotoxicity of chlorhexidine, These findings
suggest that similar reactions within a root canal
may reduce the potential of a cytotoxic reaction in
the periapical tissues.
Journal of Endodontics 20,6-8.
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69.  Complete removal of the microorganism from root
canal can only be achieved through the use of a
combination of aseptic treatment techniques,
chemomechanical preparation of the root canal,
antimicrobial irrigating solutions and intracanal
medicaments.
 Many medicaments have been used in an attempt to
achieve the above aims but no single preparation has
been found to be completely predictable or effective.
 Each has its own advantages and disadvantages, and
further research is required to determine which is best
suited for a particular condition.
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70.  The use of calcium hydroxide, antibiotics and biocides
as antimicrobial medicaments in endodontics. B
Athanassiadis et al. Australian Dental Journal
Supplement 2007;52:(1 Suppl):S64-S82.
 Rationale and efficacy of root canal medicaments and
root filling materials with emphasis on treatment
outcome. LARZ S. W. SPÅNGBERG & MARKUS
HAAPASALO. Endodontic Topics 2002, 2, 35–58.
 Inactivation of local root canal medicaments by dentine:
an in vitro study. H. K. Haapasalo et al. International
Endodontic Journal, 33, 126±131, 2000.
 Inactivation of root canal medicaments by dentine,
hydroxylapatite and bovine serum albumin. I. Portenier
1, H. Haapasalo. International Endodontic Journal, 34
184 , 184–188, 2001
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71.  Antibacterial Efficacy of Chlorhexidine Gluconate
Intracanal Medication In Vivo. Lisane Paquette et al. JOE—
Volume 33, Number 7, July 2007.
 The Susceptibility of Starved, Stationary Phase, and
Growing Cells of Enterococcus faecalis to Endodontic
Medicaments. Isabelle Portenier et al. JOE—Volume 31,
Number 5, May 2005.
 On the local applications of antibiotics andantibiotic-
based agents in endodontics and dental traumatology. Z.
Mohammadi& P. V. Abbott. International Endodontic
Journal, 42, 555–567, 2009.
 Case reports on the clinical use of calcium hydroxide
points as an intracanal medicament. Mithra n. Hegde
farah niaz .
 Regeneration Potential of the Young Permanent Tooth:
What Does the Future Hold? Kenneth M. Hargreaves et al.
JOE — Volume 34, Number 7S, July 2008.
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72. Thank you
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