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1. Intracanal medicaments


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1. Intracanal medicaments

  2. 2. Defination 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)
  3. 3. HISTORY 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 extracted. Dental writings through the Middle Ages indicate the use of oil of cloves, a plant extract containing a high percentage of eugenol.
  4. 4. 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.
  5. 5. IDEAL REQUIREMENTS It should be an effective germicide and fungicide. It should be non-irritating to the periapical tissues. 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.
  6. 6. It should have low surface tension. It should not interfere with repair of periapical tissues. It should not induce cell mediated immune response.
  7. 7. FUNCTIONS Eliminate microorganisms: The objective is to sterilize (destroy all viable microorganisms) or to disinfect (destroy all pathogens) in the canal space. 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 pulp space. Prevention or control of post treatment pain
  8. 8. 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.
  9. 9. Root canal flora
  10. 10. Predominantly consists of- aerobic and facultative anaerobic microflora. • Intact non-vital teeth – bacteroides, peptococcus, peptostreptococcus, fusiform, bacilli and corynebacterium.
  11. 11. Mazarella and colleagues 1955, Mcdonalds and associates 1957, Brown and Rudolph 1957 Gram +ve organisms Gram –ve organisms Streptococci Staphylococci Corynebacterium Yeasts Spirochetes Neisseria Bacteroides Fusobacterium Pseudomonas Coliform bacteria
  12. 12. Microflora in decidous root canal  Anaerobes: Gram positive cocci - Peptostreptococcus  Gram positive bacilli - Lactobacilli, Propionibac terium , Actinomyces & Eubacterium Gram negative cocci - Veillonella parvula Gram negative bacilli -Bacteroides & Fusobacterium Aerobes: Streptococci, Staphylococcus Diptheroids.
  13. 13. 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.
  14. 14. E. Faecalis E.Faecalis is a gram +ve cocci present in root canals. It has the ability to survive the harsh environment including alkaline pH, salt concentrations. It resists bile salts, detergents, heavy metals, ethanol. It can survive temp upto 60 UC.
  15. 15. Mechanism of action Bind the dentin and invades the dentinal tubules. Alters the host response and suppresses the action of lymphocytes. 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 haemostasis.
  16. 16. Factors disposing tooth infection
  17. 17. 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 disinfection.
  18. 18. 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.
  19. 19. Cell wall
  20. 20. Individual Intracanal Medicaments
  21. 21. Various root canal medicaments Chlorhexidine Formocresol Calcium hydroxide Antibiotics Corticosteroids Herbal medicaments
  22. 22. Chlorhexidine 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.
  23. 23. Mechanism of action
  24. 24. 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 hours. Kulkarni VV et al 2003
  25. 25. Acc to Grossman Gel 2% as medicament. Mixture of CHX and calcium hydroxide
  26. 26. 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
  27. 27. Formocresol Developed by BUCKLEY in 1906. Contents : 19% formaldehyde 35% cresol 46% H2O and glycerine. Combination- formalin and cresol in the proportion of 1:2.
  28. 28. 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%.
  29. 29. 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.
  30. 30. Mechanism of action ZONE OF FIXATION Causes the coagulation necrosis of the tissue at the amputation site because of protein denaturation by the poisons. 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 is less.
  31. 31. ZONE OF CHRONIC INFLAMMATION Apical to zone of cellular necrosis. It blends into normal tissue.
  32. 32. Calcium hydroxide Hermann introduced Ca(OH)2 paste as an ICM in 1920 . Calcium hydroxide paste for intracanal use is a thick suspension of Ca(OH)2 powder in sterile water or saline or glycerine.
  33. 33. 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 appointments.
  34. 34. Mechanism
  35. 35. Three histologic zones under calcium hydroxide in 4-9 days: 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): 211-9.  Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives- permanent teeth.
  36. 36. Its antimicrobial action is related to its high pH, which results in the inactivation of bacterial membrane enzymes. Mahmoud Reza Hamidi et al. 2012
  37. 37. 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 obligate anaerobes. 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- 147
  38. 38. Antibiotics Used Alone and in combination with other drugs. Antibiotics are indicated in a small minority of cases when root canal infection persists despite other antiseptics. Example; Ledermix paste or polyantibiotic paste (PBSC) are used.
  39. 39. PBSC paste/ grossmans paste (1951) Contains : 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 yeasts.
  40. 40. Ineffective against anaerobes. In 1975 – banned due to allergic reactions due to penicillin. Now Nystatin replaces sodium caprylate as the antifungal agent .i.e. PBSN.
  41. 41. CORTICOSTERIODS- ANTIBIOTICS COMBINATIONS 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.
  42. 42. Ledermix paste 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. The primary interest of Schroeder and Triadan in the development of Ledermix paste was based on the use of corticosteroid to control pain and inflammation.
  43. 43. Constituents Tetracycline antibiotic Demeclocycline HCL-3.2% Triamcinolone acetonide – 1% Polyethylene glycol
  44. 44. 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 formation (apexification), 3. Perforations, 4. Inflammatory root resorption, 5. Inflammatory periapical bone resorption 6. Large periapical radiolucent lesions.
  45. 45. 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
  46. 46. Septomixine Forte 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, 1990.
  47. 47. 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 appointments.
  48. 48. 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.
  49. 49. The triple antibiotic paste is very effective against E. faecalis.
  50. 50. Concentrations used 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. 1996;29:125–30  Takushige T, Cruz EV, Moral AA, Hoshino E. Endodontic treatment of primary teeth using a combination of antibacterial drugs. Int Endod J. 2004;37:132–8
  51. 51. 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.
  52. 52. 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.
  53. 53. Herbal medicaments
  54. 54. Natural and herbal products have been used in medicine and dentistry since time unknown. Use of plant products in medicine is known as phytomedicine or phytotherapy. 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
  55. 55. Propolis 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.
  56. 56. Propolis can be used as short-term intracanal medication in cases of pulp and periapical inflammatory processes. Fabiane Bortoluci da Silva et al.
  57. 57. Curcumin 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.
  58. 58. 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 activities.
  59. 59. Method of preparation The dried rhizomes of turmeric were grounded to fine powder under hygienic conditions to form a turmeric powder. 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 1:3:3. Rajiv N Purohit et al 2017.
  60. 60. 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
  61. 61. Pulpotomy treatment using turmeric powder in primary teeth has shown good clinical and radiographic success. Purohit R et al, 2017
  62. 62. Arctium Lappa This plant is popular all over the world for its therapeutic applications. It is found to have antimicrobial action against microorganisms causing endodontic infections.  It is a potential intracanal medicament.
  63. 63. Nissin 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 calcium hydroxide. Hemadri M et al.2011
  64. 64. Conclusion 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.
  65. 65. References  Endodontic therapy- Weine  Endodontic Practice- Gross man  Endodontics – Ingle  Cohen & Burns , 8th edn
  66. 66. THANK YOU