Medicaments used in root canal ,Calcium hydroxide chlorohexidine , herbal ,antibiotics

1. Intracanal
Medicaments

2. Definition
 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”.

3. 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: 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

4. 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.
In

5. Root canal flora

6. Predominantly consists of-
aerobic and facultative anaerobic microflora.
• Intact non-vital teeth – bacteroides,
peptococcus, peptostreptococcus, fusiform,
bacilli and corynebacterium.

7. Mazarella and colleagues 1955,
Mcdonalds and associates 1957, Brown
and Rudolph 1957
Gram +ve organisms
Streptococci
Staphylococci
Corynebacterium
Yeasts
Gram –ve organisms
Spirochetes
Neisseria
Bacteroides
Fusobacterium
Pseudomonas
Coliform bacteria

8. Classification of root canal medicaments
• I. Phenolic agents
• II. Halogens
• a) Iodine compounds
• b)ChloramineT
• c) Iodine –potassium iodine
• d)Sodium hypochloride
• III. Non -phenolic biocides
• a) Alcohols e.g.; ethanol
• b) Aldehydes e.g; formaldehyde
• c) Biguanides e.g; chlorohexidine
• d) Quaternary ammonium compounds
• IV. Calcium hydroxide
• V. Corticosteroids
• VI.Antibiotics
• VII.Herbs

9. Individual Intracanal Medicaments

10. Phenolics Agents
CamphoratedMonoparachlorophenol (CMCP)

11. Disadvantages:
 Phenol and phenolic derivatives are highly toxic
to mammalian cells.
Induce inflammation at much low concentration.
Penetration of cytotoxic vapors into
periodontium is reported
It loses its effectiveness within short period of
time.

12. Halogens

13. NON-PHENOLIC BIOCIDES

15. Mechanism of action

16.  CHX is a strong base and it is more stable in the form of its
salts.
 The salts originally employed were acetate and hydrochlorite,
both of which suffer from relatively poor water solubility and
were largely replaced by the digluconate which is a highly
water soluble salt.
 Aqueous solutions of CHX are more stable within the pH range
from 5 to 8.The antimicrobial activity of CHX is pH-dependent,
being the optimum range from 5.5 to 7.0, within which is the
pH of body surfaces and tissues . It readily dissociates at the
physiological pH, releasing the positively charged CH
component.
0.12% and 0.2% Chlorhexidine solutions showeda significant
decrease in streptococcus mutans after 24 hours.
Kulkarni VV et al 2003

17. 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

18. Calcium hydroxide
 Hermann introduced Ca(OH)2 paste as an ICM in
1920 .
• Microbial control,
• Dissolve organic remnants,
• Heal periapical inflammation,
• Inhibit inflammatory root resorption,
• Stimulate hard tissue formation and
• Serve as a temporary obturating material between
appointments.
Indications of CalciumHydroxide

19. CalciumHydroxide
Effects of CalciumHydroxide

20. LIMITATION OF CALCIUM HYDROXIDE
Limited effectiveness in short term use for disinfecting dentinal
tubules. Low solubility and diffusibility
Removal of calcium hydroxide is frequently incomplete which
leads to decrease in setting time of zinc oxide based root canal
sealants.
Calcium hydroxide as a disinfectant has limited use in
retreatment cases as it has no effect on E. Faecalis and Candida
species.

21. Mechanism

24.  Its antimicrobial action is related to its high pH,
of bacterialwhich results in the inactivation
membrane enzymes.

27. 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

28. Antibiotics
 Used Alone and in combination with otherdrugs.
 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.

29. PBSCpaste/ Grossman’s paste
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.

30. Ineffective against anaerobes.
 I n 1975 – banned due to allergic reactions due to
penicillin.

31. CORTICOSTERIODS- ANTIBIOTICS
COMBINATIONS
Highly effective in the treatment of over instrumentation.
Placed in the inflamed tissue by a paper point or reamer.
periapical The steroid constituent reduces the
inflammation and gives instant relief of pain.
 The antibiotic constituents are present so that no over
growth of micro organisms occurs.

32. Ledermix paste
is a glucocorticosteroid antibiotic Ledermix
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.

33. Constituents
Tetracycline antibiotic
Demeclocycline HCL-3.2%
Triamcinolone acetonide – 1%
Polyethylene glycol

35. 1:1 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.

36. 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

37. 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.

38. PBSCPaste
The Triple-Antibiotics Paste is
very effective against E.faecalis

39. 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

40. 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.

41. Herbal medicaments
• Literature has addressed many plants with
potential source for new therapies in
endodontics.
• The studies listed have shown important
medicinal activities of plants, with great demand
to inhibit or suppress bacteria and their biofilm.
• However there is scarce information on the
quality, Safety and greater efficiency of these
products for use in endodontics.
• As most of the studies are carried out in vitro,
more of these compounds should be subjected to
animal and human studies to determine their
effectiveness, side effects, toxicity and drug
interactions

42. Natural and herbal products have been used inmedicine
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

43. 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
inflammatory agent, which can serve
and anti-
as a better
intracanal irrigant and intracanal medicament.

44. Propolis can be used as short-term
intracanal medication in cases of pulp and
periapical inflammatory processes.
Fabiane Bortoluci da Silva etal.

45. Curcumin
Turmeric (Curcuma longa) is extensively used as a
spice, food preservative and coloring material in India,
China and South East Asia.
 I t has been used in traditional medicine for the
treatment of numerous diseases.

46. Curcumin is the main yellow bioactive component of
turmeric which has been shown to have a wide spectrum
of biological actions, including antimicrobial, anti-
inflammatory and anti- oxidant activities.

47. 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 al2017.

48.  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

49. pulpotomy treatment
primary teeth has
using
shown
turmeric
good
powder in
clinical and
radiographic success.
Purohit R et al,
2017

50. Arctium Lappa
all over the world for itsThis plant is popular
therapeutic applications. It is found to have
antimicrobial action against microorganisms causing
endodontic infections.
 It is a potential intracanal medicament.

51. Nissin
Nissin is a naturally occurring antimicrobial peptide,
produced by Streptococcus lactis sub species lactis.
 I t 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

52. Conclusion
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.
Endodontic treatment are essentially debridement

53. References
 Endodontic therapy- Weine
 Endodontic Practice- Gross man
 Endodontics – Ingle
 Cohen & Burns , 8th edition
 Materail used in Dentistry – S
Mahalaxmi