PRESENTED BY – DR ISHANI
YEAR PG PAEDO
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”.
(kawashima et al, 2009)
Seribonius in 1045 AD wrote of using oils
and wine in the mouth of a patient in pain.
This was a crude attempt to achieve a
topical anesthetic effect on a tooth to be
Dental writings through the Middle Ages
indicate the use of oil of cloves, a plant
extract containing a high percentage of
In 1800 specific medicaments were recommended
for endodontic treatment.
Beechwood creosate was mentioned in 1840
article ‘Creosate and cotton in Fang filling.’
1884 Richmond advocated “Knocking out the
pulp” by whittling down orangewood to a small
size, soaking the stick in phenol and tapping this
into exposed pulp canal.
Phenol was added to preserve and sterilize the
contents of canal and to alleviate pain.
It should be an effective germicide and
It should be non-irritating to the periapical
It should remain stable in solution.
It should have prolonged antimicrobial effect
It should be active in the presence of blood,
serum and protein derivatives of tissues.
It should have low surface tension.
It should not interfere with repair of
It should not induce cell mediated immune
Eliminate microorganisms: The objective is to
sterilize (destroy all viable microorganisms) or
to disinfect (destroy all pathogens) in the canal
Rendering contents of canal inert: This
represents the attempt usually by chemical
means to “mummify”, fix or neutralize tissue or
debris left intentionally or unintentionally in the
Prevention or control of post treatment pain
Enhancing Anesthesia: By reducing the
sensitivity of the inflamed tissue which can
be difficult to anesthetize pulp.
Control of persistent periapical abscess : In
cases of continually “weeping” canal or
significant pain or swelling medicaments
have been suggested as a means of
controlling this difficult situation.
The commonest organisms of the mouth,
streptococci are also the most frequently found
in root canals.
Among the streptococci is a small resistant
group of enterococci.
E.Faecalis is a gram +ve cocci present in
It has the ability to survive the harsh
environment including alkaline pH, salt
It resists bile salts, detergents, heavy metals,
It can survive temp upto 60 UC.
Mechanism of action
Bind the dentin and invades the dentinal tubules.
Alters the host response and suppresses the action of
It can colonize the root canal without competing with
any other microorganism.
It forms a biofilm and renders it resistant to
phagocytosis , antibodies and antimicrobial agents
such as calcium hydroxide by maintaing the pH
Trauma: The tooth under treatment should be
disoccluded if necessary.
Devitalized tissue: If present in the root canal
or periapical tissue will interfere with repair or
Dead spaces : for maximum effect the
medicament should be in contact with the
microorganisms in the root canal.
Accumulation of exudate : Exudate should be
allowed to drain or be removed as it accumulates.
Chlorhexidine (CHX) is a broad spectrum
antimicrobial agent. The property is due to its
cationic bisbiguanide molecular structure.
It is bacteriostatic at lower concentrations and
bactericidal at higher concentrations.
Chlorhexidine gluconate gel is widely used in
dentistry as an intracanal medicament.
Chlorhexidine can be applied in varies forms.
1. Mouthwash (0.12% and 0.2%),
2. Gels (1%)- medicament
3. Varnishes (1%, 10%, 20%, and 35%)
0.12% and 0.2% Chlorhexidine solutions showed a
significant decrease in streptococcus mutans after 24
Kulkarni VV et al 2003
Acc to Grossman
Gel 2% as medicament.
Mixture of CHX and calcium hydroxide
Studies show that Chlorhexidine is more effective
in elimination of E. faecalis inside dentinal tubules.
Chlorhexidine both alone and along with calcium
hydroxide showed more antibacterial efficacy
against E faecalis than calcium hydroxide alone.
Nidhi sinha et al, 2013
Developed by BUCKLEY in
Contents : 19% formaldehyde
46% H2O and glycerine.
Combination- formalin and cresol in the
proportion of 1:2.
Formocresol combines the protein -
coagulating effect of phenolic compounds
with the alkylating effect of formaldehyde.
The bactericidal effect of formocresol is
good at levels as low as 2%.
Formocresol is a non- specific bacterial
medicament most effective against aerobic and
anaerobic organisms found in root canals.
Causes widespread destruction of living tissue
followed by a persistent inflammatory reaction.
Studies have reported that formocresol treated
tissue produced a cell mediated immune response.
Mechanism of action
ZONE OF FIXATION
Causes the coagulation necrosis of the tissue at the
amputation site because of protein denaturation by the
Inactivates the oxidative enzymes.
Causing tissue fixation and renders the root canal inert
and resistant to enzymatic breakdown.
ZONE OF POOR CELLULAR NECROSIS
Farther away where the concentration of formocresol
ZONE OF CHRONIC INFLAMMATION
Apical to zone of cellular necrosis.
It blends into normal tissue.
Hermann introduced Ca(OH)2 paste as an ICM in
Calcium hydroxide paste for intracanal use is a thick
suspension of Ca(OH)2 powder in sterile water or
saline or glycerine.
Used to obtain;
1. Microbial control,
2. Dissolve organic remnants,
3. Heal periapical inflammation,
4. Inhibit inflammatory root resorption,
5. Stimulate hard tissue formation and
6. Serve as a temporary obturating material between
Three histologic zones under calcium hydroxide in 4-9
1. Coagulation necrosis.
2. Deep staining areas with varied osteodentin.
3. Relatively normal pulp tissue, slightly hyperemic,
underlying an odontoblastic layer.
Fuks AB et al. Vital pulp therapy with new materials for primary teeth: new
directions and treatment perspectives. Pediatr Dent. 2008 May-Jun; 30(3):
Witherspoon DE. Vital pulp therapy with new materials: new directions and
treatment perspectives- permanent teeth.
Its antimicrobial action is related to its high pH,
which results in the inactivation of bacterial
Mahmoud Reza Hamidi et al. 2012
Studies done to test the antibacterial efficacy of
calcium hydroxide show that calcium hydroxide is
ineffective against E. Faecalis. It resists calcium
hydroxide for about 10 days. Calcium hydroxide
shows limited action against facultative anaerobes
and Candida species but is effective against
Hemanshi kumar. An in vitro evaluation of the antimicrobial efficacy of Curcuma longa,
Tachyspermum ammi, chlorhexidine gluconate, and calcium hydroxide on Enterococcus
faecalis. Journal of conservative dentistry. Year : 2013 Volume : 16 Issue : 2 Page : 144-
Used Alone and in combination with other drugs.
Antibiotics are indicated in a small minority of
cases when root canal infection persists despite
Example; Ledermix paste or polyantibiotic paste
(PBSC) are used.
PBSC paste/ grossmans paste (1951)
Potassium penicillin G (10,00,000 units)
Bacitracin (10,000 units)
Streptomycin paste (1gm)
Sodium caprylate / Nystatin (1gm)
PBSC contained penicillin to target gram-positive organisms,
bacitracin for penicillin-resistant strains, streptomycin for
gram-negative organisms, and caprylate sodium to target
Ineffective against anaerobes.
In 1975 – banned due to allergic reactions due to
Now Nystatin replaces sodium caprylate as the
antifungal agent .i.e. PBSN.
Highly effective in the treatment of over instrumentation.
Placed in the inflamed tissue by a paper point or reamer.
The steroid constituent reduces the periapical
inflammation and gives instant relief of pain.
The antibiotic constituents are present so that no over
growth of micro organisms occurs.
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
The primary interest of Schroeder and Triadan in
the development of Ledermix paste was based on
the use of corticosteroid to control pain and
A 50:50 mixture of Ledermix paste and calcium
hydroxide has been advocated as an intracanal
dressing in cases of -
1. Pulpless infected root canals,
2. Pulp necrosis and infection with incomplete root
4. Inflammatory root resorption,
5. Inflammatory periapical bone resorption
6. Large periapical radiolucent lesions.
Corticosteroid based preparations have shown to cause
an increased degree of inflammatory response,
maximum being at 28 days.
After 7 days of experiment, all tested substance had
low levels of inflammatory cells.
Therefore, corticosteroid-based medications can be
used for periods no longer than 7 days.
Ramos E et al 2012
Septomixine Forte (Septodont, Saint- Maur, France)
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.
Abbott PV, Hume WR, Pearman JM, Antibiotics and endodontics. Aust Dent J 35:50-60,
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, as shown by Tang et al., who
demonstrated that a routine one-week application of
Septomixine Forte was not effective in inhibiting
residual intracanal bacterial growth between
TRIPLE ANTIBIOTIC PASTE
Triple antibiotic paste is a combination of three
antibiotics namely minocycline (100mg),
ciprofloxacin (200mg) , metronidazole (500mg) and
propyelene glycol, saline as carrier. (Sato et al 1996)
Triple antibiotic powder, either mixed with normal
saline or 2% chlorhexidine, produced the largest zone
of inhibition against E. faecalis.
The triple antibiotic paste is very effective against E.
1:1:1 - Hoshino et al ,1996
1:3:3- Takushige T et al, 2004
Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In
vitro antibacterial susceptibility of bacteria from infected root dentin to a
mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J.
Takushige T, Cruz EV, Moral AA, Hoshino E. Endodontic treatment of
primary teeth using a combination of antibacterial drugs. Int Endod J.
Takushige et al. (2004) evaluated the efficacy of
poly-antibiotic paste consisted of ciprofloxacin,
metronidazole, and minocycline, on the clinical
outcome of so-called “Lesion Sterilization and
Tissue Repair,” LSTR, therapy in primary teeth
with periradicular lesions.
Results showed that in all cases, clinical symptoms
such as gingival swelling, sinus tracts, induced dull
pain, spontaneous dull pain, and pain on biting
disappeared after treatment, although in four cases
clinical signs and symptoms were finally resolved
only after retreatment using the same procedures.
Thus, gingival abscesses and fistulae, if present,
disappeared after a few days.
Natural and herbal products have been used in
medicine and dentistry since time unknown. Use of
plant products in medicine is known as phytomedicine
Since chemical and synthetic products are expensive
and cause cytotoxic reactions and are not very efficient
in elimination of bacteria, herbal products are used.
Sharad Kamat et al
Propolis is prepared from resin collected by bees from
trees of poplars, conifers and flowers of genera clusia .
The pharmacologically active constituents in propolis
are flavonoids, phenolics and aromatics.
Propolis is a good antimicrobial and anti-
inflammatory agent, which can serve as a better
intracanal irrigant and intracanal medicament.
Propolis can be used as short-term intracanal
medication in cases of pulp and periapical
Fabiane Bortoluci da Silva et al.
Turmeric (Curcuma longa) is extensively used as a
spice, food preservative and coloring material in India,
China and South East Asia.
It has been used in traditional medicine for the
treatment of numerous diseases.
Curcumin which is the main yellow bioactive
component of turmeric has been shown to have a wide
spectrum of biological actions, including
antimicrobial, anti-inflammatory and anti- oxidant
Method of preparation
The dried rhizomes of turmeric were grounded to fine
powder under hygienic conditions to form a turmeric
This turmeric powder, distilled water, and radiolucent
material were mixed on a glass slab with the help of
stainless steel spatula, and mixing ratio of turmeric
powder, distilled water, and radiolucent material was
Rajiv N Purohit et al 2017.
A study showed that curcumin was able to demonstrate
complete eradication of E. faecalis.
Another study showed that there was a gradual
decrease in the anti bacterial activity of curcumin at 3
and 7 days which may be due to the buffering ability
of dentin. Curcumin does not affect the micro hardness
of root dentin and is a potential intracanal medicament.
AR Prabhakar et al. 2013
Pulpotomy treatment using turmeric powder in
primary teeth has shown good clinical and
Purohit R et al, 2017
This plant is popular all over the world for its
therapeutic applications. It is found to have
antimicrobial action against microorganisms causing
It is a potential intracanal medicament.
Nissin is a naturally occurring antimicrobial peptide,
produced by Streptococcus lactis sub species lactis.
It has antimicrobial activity against a wide range of
bacteria and their spores.
Studies show that it is effective in elimination of E
faecalis from root canal and is more effective than
Hemadri M et al.2011
Endodontic treatment are essentially debridement
procedures to disrupt and remove the microbial
ecosystem that is associated with the disease process.
It is important that clinicians understand the close
relationship between the presence of microorganisms
and endodontic disease processes to develop an
effective rationale for treatment.