This document discusses intracanal medicaments used in endodontic treatment. It begins with an introduction on the importance of eliminating microorganisms from the root canal to achieve successful treatment. The document then covers the history, rationale, ideal requirements, indications, and classifications of various intracanal medicaments. Individual medicaments are described in detail, including their composition, antimicrobial properties, advantages, and disadvantages. The document concludes by stating the importance of intracanal medicaments in disinfecting the root canal system.

2. 2

3. D R M A N J U K R I S H N A . E . M
S E N I O R L E C T U R E R
D E P T O F C O N S E RVAT I V E D E N T I S T R Y A N D E N D O D O N T I C S
INTRACANAL
MEDICAMENTS
3
MAHE INSTITUTE OF DENTAL SCIENCES &
HOSPITAL

4. CONTENTS
• INTRODUCTION
• HISTORY
• RATIONALE FOR INTRACANAL MEDICAMENTS
• IDEAL REQUIREMENTS
• INDICATIONS
• CLASSIFICATION
• INDIVIDUAL MEDICAMENTS
• RECENT INTRACANAL MEDICAMENTS
• CONCLUSION
• BIBLIOGRAPHY
4

5. INTRODUCTION
• Microorganisms are essential for the
development of periradicular disease
• Major causative factors associated with
endodontic failure.
• Endodontic research assumes special
importance in finding methods and
materials to predictably eradicate the
root canal infection
5

6. • The number of microorganisms from within an infected root
canal system may vary from 108 to 102 (Sjogren et al 1991)
• Microbes are present in all parts of the root canal system,
and may be found at varying depths of up to 300 µm within
the dentinal tubules
L. G. Coldero , S. McHugh , D. MacKenzie & W. P. Saunders. Reduction in intracanal bacteria
during root canal preparation with and without apical enlargement. International Endodontic
Journal, 35, 437–446, 2002 6

7. • It is essential to obtain a sterile root canal for the successful endodontic root canal treatment.
• The removal of debris by using mechanical instrumentation may not always achieve a complete cleaning
because of morphological and physical barriers.
• Therefore, the use of chemical methods in the form of various irrigating solutions and antibacterial temporary
dressing material is recommended for complete benefit.
Haapasalo et al.L.Eradication of endodontic infection by instrumentation and irrigation solutions. Endodontic Topics
2005, 10, 77–102
7

8. • Intracanal medicament would include any agent with extended pharmacological action that is
introduced in the root canal.
• Intracanal dressing more concisely describes medicaments left in the root canal to exert their
effects over a long time,
• Use of intracanal medications has been advocated to further reduce the number of
microorganisms after cleaning and shaping and before obturation of the root canal
Kawashima N, Wadachi R, Suda H, Yeng T, Parashos PRoot canal medicaments. Int Dent
J. 2009 Feb;59(1):5-11
8

9. history
 Scribonius (1045 A.D.) - oils and wine – to achieve topical
anesthetic effect on a tooth to be extracted.
 Middle ages – oil of clove.
 In 1800s - Beechwood creosote was recommended for RCT
mentioned in the 1840 article “Cresote & cotton in fang filling” .
 1834 – Phenol by Runge
9

10.  Richmond in 1884 - “Knocking out the pulp” by whittling down
orangewood to a small size, soaking the stick in phenol and
tapping this into the exposed pulp canal. Phenol was added in
an attempt to preserve and sterilize the contents of the canal
& to alleviate pain.
 1891 – CMCP by Walkhoff
 1905 – Formocresol by Buckley & later by Sweet
 1920 – Calcium Hydroxide by Hermann
 1951 - Grossman’s polyantibiotic paste
 1960 - Ledermix paste by Schroeder & Triadan
10

11.  An effective germicide and fungicide.
 Non-irritating to the periapical tissues.
 Remain stable in solution.
 Have prolonged antimicrobial effect
 Active in the presence of blood, serum and protein
derivatives of tissues.
 Have low surface tension.
 Not interfere with repair of periapical tissues.
 Not stain tooth structure
 Not induce cell mediated immune response.
 Capable of inactivation in a culture medium.
Louis Grossman, Endodontic practice, 10th edition)
Ideal Requirements
11

12.  Elimination of microorganisms
 Rendering contents of canal inert
 Prevention or control of post treatment pain
 Enhancing anesthesia
 Control of persistent periapical abscess
 Hard tissue formation
 Control of inflammatory root resorption
Rationale of use
12

13. VITAL TEETH
Since intracanal medicaments are irritating and highly
toxic, they have the potential to do more harm than good,
they are not indicated in vital teeth (Murray et al 2000)
13

14. INFECTED TEETH
Intracanal medicament serves a variety of purposes in an infected
canal.
It is used to:
Help to dry persistently wet canals.
As an antibacterial agent to eliminate any remaining
bacteria in the root canal after canal instrumentation.
(According to Schroeder A, Endodontics- Science and
practice Quintessence 1981)
14

15. CLASSIFICATION
According to Walton
1) Essential Oils
-Eugenol
2) Phenols/Phenolic compounds
- Parachlorophenol(PCP)
-Camphorated parachlorophenol(CPCP)
- Camphoratedmonoparachlorophenol(CMCP)
-Cresatin ( Metacresyl acetate)
-Cresol
- Creosote (Beechwood)
-Thymol
-N2 compounds
15

16. 3)Aldehydes
Formocresol
Glutaraldehyde
4)Halides
Sodium hypochlorite
Iodine pottassium iodide
5) Steroids
6) Calcium hydroxide
7) Antibiotics
8) Combinations
16

17. According to Grossman
1) Essential oils
2) Phenolic compounds
3) Salts of heavy metals
4) Halogens
5) Sulfonamides
6) Antibiotics
17

18.  Chemical essence of oil of clove, pale yellow liquid
 Both an antiseptic & an anodyne.
 Bacteriostatic.
 Inhibits interdental nerve impulses.
 Allergy to eugenol have been reported.
Eugenol
18

19. • Eugenol at 75 percent are bactericidal in action and hence may
be useful at these concentrations for clinical use.
Antibacterial properties of dilute formocresol and eugenol and propylene
glycol Oral Surgery, Oral Medicine, Oral Pathology
Volume 49, Issue 2, February 1980, Pages 166-170
19

20.  White crystalline substance derived from coal tar.
 Liquified phenol – 9 parts phenol,1 part water.
 1-2% phenol – potent bactericidal & fungicidal
 Protoplasm poison and produces necrosis of soft tissue.
 Strong inflammatory potential,it is rarely used as intracanal
medicament
PHENOL(Carbolic acid)
Joseph Lister 1867
20

21. • GDPs should reduce their reliance on phenol- and
formaldehyde-based medications.
Preference and usage of intracanal medications during
endodontic treatment. Saudi Med J. 2017 Jul; 38(7): 755–763
21

22. Para chloro phenol
 Substitution product of phenol.
 1% aqueous solution of PCP.
 Triturated with gum camphor - forms a oily liquid.
 Destroys a variety of micro-organisms ordinarily found in
infected root canals.
 PCP penetrates deeper into dentinal tubules than CMCP.
 Periapical tissue irrritaion less
22

23. CAMPHORATED MONO CHLORO PHENOL (CMCP)
 Developed by Walkoff in 1891.
 2 parts PCP & 3 parts gum camphor.
 Light amber colored, oily liquid with aromatic odour
 Camphor
- vehicle & a diluent
- reduces the irritating effect of pure PCP
- also prolongs the antimicrobial effect by slowing
the release of phenol.
 Antimicrobial effect is delivered through vaporization of the
medicament.
23

24.  Bactericidal
- It disrupts bacterial cytoplasmic membrane,
denatures proteins & inactivates enzyme
 Byström et al. reported that CMCP had a lower antibacterial
effect in the root canal than calcium hydroxide.
 Can diffuse beyond apical foramen
 Most toxic and irritating phenolic antiseptic agent followed by
Cresatin & formocresol (Aust Dent J 2007)
24

25. Formocresol
1905 – Buckley & later by Sweet
 19% formaldehyde, 35% cresol,
46% water & glycerine.
 Tissue fixative.
 Combines with albumin to form an insoluble, indecomposable
substance.
 Highly irritating - tissue necrosis followed by persistent
inflammatory reaction - proteolysing - cresol & alkylating -
formaldehyde.
 It is used as a dressing for pulpotomy to fix the retained pulp
tissue.
25

26.  It is placed in a cotton pellet in the
pulp chamber of a tooth in treatment and
the vapors will penetrate the entire canal.
 Does not effectively fix the necrotic or decomposed tissue.
 Non- specific bactericidal medicament most effective against
aerobic and anaerobic organisms found in root canals.
 Toxic and delays healing.
 Mutagenic and carcinogenic potential.
26

27. • It is highly unlikely that formocresol, when judiciously used, is genotoxic or
immunotoxic or poses a cancer risk to children who undergo one or more
formocresol pulpotomy procedures..
In keeping with the accepted therapeutic principles, pediatric dentists who wish to
continue to use formocresol should apply the lowest dose possible for the shortest
time possible to obtain the desired effect.
• To that end, a 1:5 dilution of Buckley's formocresol is recommended.
Shashidhar Chandrashekhar, Jyothi Shashidhar. Formocresol, still a
controversial material for pulpotomy: A critical literature
review.2014,2114-124
27

28. GLUTERALDEHYDE
 Colorless oil.
 Slightly soluble in water therefore have a slightly acidic reaction.
 Strong disinfectant & tissue fixative.
 Recommended in low concentration 2%
 Bacteriostatic.
 Does not diffuse through apical foramen & does not produce immunologic reaction
28

29. • Antibacterial efficacy of formocresol, 2% gluteraldehyde and iodine-potassium iodide was
assessed by obtaining cultures at consecutive appointments in multiple visit pulpectomies in
primary molars.
• Formocresol and 2% gluteraldehyde were more effective as intracanal medicaments and
caused significant reduction in the counts of aerobic and anaerobic microorganisms,
• thereby supporting the need for placing intracanal medicaments with antibacterial properties,
in multiple visit pulpectomies in primary molars
Comparison of antibacterial efficacy of intracanal medicaments in multiple visit pulpectomies in
primary molars-an in vivo study.2010,28,18-24
29

30. CRESATIN
(METACRESYLACETATE)
Clear, stable oily liquid of low volatility.
Both antiseptic and obtundent.
Fungicidal & mild antibacterial & is less than formocresol,
CMCP.
Less irritating to periapical tissue.
Low surface tension.
Useful after pulpectomy
30

31. N2 (SARGENTI’S PASTE)
ANGELO SARGENTI - EARLY 1950S
Paraformaldehyde - primary ingredient.
It was claimed as both intra canal medicament and sealer.
Contains eugenol and phenyl mercuric borate and small amounts
of lead, may also contain corticosteriods, antibiotics and
perfume.
The antibacterial effect of N2 is short lived and dissipated in
about a week to 10 days.
Highly irritating & toxic
31

32. • Sargenti died in 1999, but his unconventional methodology lives on.
• His followers claim that the paste—commonly referred to as "N2"—is
easier and faster to place than gutta-percha.
• However, when paraformaldehyde contacts water, it forms
formaldehyde (a preservative used in embalming fluid).
• Sargenti's procedure may save a tooth, but it is much less predictable
than standard treatment. The pressure needed to reach the tip of the root
can force the paste into surrounding tissues where it can cause serious
and painful injuries if the paste contacts jaw nerves or the maxillary
sinuses above the upper jaw.
Be Wary of Sargenti Root Canal Treatment
Stephen Barrett, M.D. 32

33. SODIUM HYPOCHLORITE
Sometimes used as an intracanal medicament.
Cl has the greatest disinfectant action of all the halogens.
Forms chloramine when comes in contact with tissue proteins.
Dissolves organic tissue.
Not stable because they rapidly interact with organic matter.
Activity is intense but of short duration
Ellerbruch & Murphy found that NaOCl vapors were bactericidal.
33

34. Disadvantages:
Bleaches clothes if spilled on to it
Its smell is objectionable to some patients
Causes severe pain, swelling & bleeding if injected beyond apex.
34

35. IODIDES
Bactericidal, fungicidal, virucidal, and sporicidal.
The antimicrobial action of iodine is rapid, even at low
concentrations.
Iodine attacks proteins, nucleotides, and fatty acids, resulting in
cell death.
Antibacterial effect is of short duration
Minimal toxicity
35

36. QUATERNARY AMMONIUM COMPOUNDS
(Quats)
 Mild antiseptic.
 Lowers surface tension of solutions
 Positively charged
 Mode of action : membrane damage & leakage, protein
denaturation, autolysis.
 It is more effective than cresatin but less effective than CMCP.
 Eg: 9-Aminoacridine
36
(Aust Dent J Supplement 2007;52:(1):S64-S82)

37. CALCIUM HYDROXIDE
Hermann (1920) - Calxyl paste maintaining vital pulp tissue and
inducing healing by the formation of a calcific barrier
Low solubility in water & insoluble in alcohol.
Its antimicrobial action – release of OH- - highly alkaline pH
Inactivates Lipopolysaccharide (by Gram –ve bacteria)
37

38. The effects of calcium hydroxide on microorganisms are due to
several mechanisms (Siqueira & Lopes) namely:
(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,
IEJ, 32, 361-369, 1999
38

39. (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.
39
IEJ, 32, 361-369, 1999

40.  Aqueous – eg water, saline, LA, Ringer’s solution, etc.
 Viscous – eg glycerin, polyethylene glycol, propylene glycol.
 Oily – eg olive oil, camphor, silicone oil, metacresyl acetate &
fatty acids.
Oily vehicles - promote the lowest solubility and diffusion of the
paste & release calcium and hydroxyl ions more slowly and for
extended periods. IEJ, 32, 257±282, 1999
Oily vehicles - not recommended - difficult to remove, leave an oily
film on the canal walls - affect the adherence of the root canal
sealer. Aust Dent J 2007;52:(1):S64-S82
40
Vehicles for CaOH (Fava, Holland, Lopes et al):

41. 41
Aqueous
oily

42. Placement techniques:
1. Use of messing gun.
2. Pastinject.
3. Lentulospiral.
4. McSpadden compactor.
5. McSpadden compactor –
vertical condensation.
6. Injection with a syringe followed
by compaction with a plugger.
7. Counterclockwise rotation of
reamer
42
JOE vol. 30, no. 4, Apr 2004

43. • ..Desktopvideoplayback caoh2.mp4
43

44. 44
Antibacterial properties
Release of hydroxyl ions and the pH shift in the process of
alkalization of calcium hydroxide (Staehle et al. 1989) provides
an environment that favours repair and calcification (Tronstad et
al. 1981).
The contraction of capillaries (Heithersay 1975),
The formation of a fibrous barrier (Rasmussen & Mjor 1971),
or formation of an apical plug by calcium hydroxide.
Ability to dissolve tissues and eliminate necrotic debris (Cvek
et al. 1976).
'weeping/wet' canals
lEJ 25,97-106, 1992

45. A saturated solution of CaOH has shown to be unable to kill
E.faecalis
A mixture of CaOH with 2% CHX was shown to be effective in
eliminating E.faecalis compared to CaOH used alone
45
Aust Dent J Supplement 2007;52:(1):S64-S82

46. • Ca(OH)2 58% in a matrix of 42% GP.
• Available in packages of 60 points each, ISO size 15 to 140.
• Moisture in the canal activates Ca(OH)2 & pH in the canal rises to
12+ within minutes
46
Disadvantages:
Action is short lived.
Lack of sustained release.
Radiolucent.
Advantages:
Firm for easy insertion.
Minimal/no residue left.
Time saving.
Ease of insertion & removal
Ca(OH)2 Points

47. 52-54% Ca(OH)2 in 35-37% GP.
Contain surfactants which reduces the surface tension.
3 fold high release than active points due to highly water
soluble components like surfactants & NaCl.
Superior pH values.
Increased wettability of canal surfaces.
Sustained alkaline pH for 7 days.
47
Ca(OH)2 Plus Points

48. CHLORHEXIDINE
Biguanide - broad spectrum antimicrobial activity.
The antimicrobial effect is related to the cationic molecule
binding to –vely charged bacterial cell walls, thereby altering the
cell’s osmotic equilibrium.
Low conc. (0.2%)– bacteriostatic;
higher conc. (2%)- bactericidal
Irrigant as well as intracanal medicament.
Does not dissolve organic tissue or inactivate bacterial LPS
48
Aust Dent J Supplement 2007;52:(1):S64-S82

49. 49
Aust Dent J Supplement 2007;52:(1):S64-S82
 2% CHX gel was the most effective agent against E. faecalis
inside dentinal tubules, followed by a Ca(OH)2/2% CHX mix,
whilst Ca(OH)2 alone was totally ineffective, even after 30 days.
 Antimicrobial substantivity: Adsorb onto dentine and prevent
microbial colonization on the dentine surface for some time
beyond the actual medication period.

50. ANTIBIOTICS
Polyantibiotic paste : PBSC (Grossman - 1951)
Penicillin- effective against gram + ve microorganisms
Bacitracin – effective against penicillin resistant strains.
Streptomycin- effective against gram- ve organisms
Caprylate sodium - effective against fungi
 Nystatin replaced caprylate sodium as the antifungal agent .i.e.
PBSN. They are available in a paste form that may be injected into RC’s
or can be impregnated on paper points.
1975, the USA Food and Drug Administration banned PBSC
50

51. Sulfa preparations
Sulfathiazole – 1950s & 1960s
Effective against G +ve & G –ve microorganisms
Ineffective against enterococci & pseudomonas
Yellowish tooth discoloration reported after use.
51

52. CORTICOSTERIODS - ANTIBIOTICS COMBINATIONS
Corticosteroids – control pain & inflammation
Antibiotics – prevent over growth of micro organisms
Ledermix paste and Septomixine Forte
52

53. 53
Ledermix paste
1960 by Schroeder & Triadan
Initially incorporated chloramphenicol
Lederle Pharmaceuticals changed it to demeclocycline HCl
3.2% demeclocycline HCl + 1% triamcinalone acetonide
Capable of diffusing through dentinal tubules & cementum to
reach the PDL & periapical tissues

54. 54
Reduces inflammatory & replacement root resorption of
replanted tooth.
Greater preservation of root mass
Ledermix paste + CaOH – Schroeder – necrotic teeth with
incomplete root formation
1:1 mixture of Ledermix paste & CaOH : infected root
canals, perforations, large perapical lesions, inflammatory
root resorption.

55. 55
Septomixine Forte
Neomycin sulphate
Polymixin B sulphate
Dexamethasone
Tyrothricin
5-chloro-2-(p-diethylaminoethoxyphenyl) bezthiazol
Not effective in inhibiting residual intracanal bacterial
growth between appointments.

56. DISADVANTAGES OF COMBINATION PASTE
• Mixing both reduces effect of individual component rather
than synergism.
• Steroids have depressive effect on defense mechanism.
• Steroids increases risk of bacterimia- infective endocarditis
and prosthetic heart valve
56

57. 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.
57

58. • 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
58

59. My Received Filesvideoplayback triple antibiotic
paste.mp4
59

60. Natural polysaccharide - copolymers of glucosamine and N-
acetyl glucosamine.
Produced by partial deacetylation of chitin
It is also present in some crustacea, insects and fungi.
Hypocholesterolemic, antimicrobial, antifungal, mucoadhesive,
wound healing and sustained release effect.
Chitosan
60

61. .
Combining 2% Chlorhexidine gluconate gel with 2% Chitosan gel
may improve the antimicrobial activity of Chlorhexidine gel
against C. albicans and E. faecalis in vivo rather than using 2%
Chlorhexidine gel or 2% Chitosan gel alone.
Aust Endod J 2009; 35: 29–33
61

62. Bioactive glasses have some antimicrobial activity - in aqueous
solutions via the release of their ionic compounds over time.
Mechanism : The release of Na+ and Ca2+ ions from, and the
incorporation of H3O+ protons into, the corroding glass result in a
high-pH environment in closed systems which is not well-tolerated
by microbiota.
J Dent Res 86(8):754-757, 2007
Bioactive glasses
{SiO2-Na2O-CaO-P2O5 }
62

63. Silica-containing bioactive glasses induce dentin
mineralization (Forsback et al., 2004),
Their antibacterial efficacy in human teeth is still inferior
to that of calcium hydroxide (Zehnder et al., 2006)
J Dent Res 86(8):754-757, 2007
63

64. HERBAL MEDICAMENTS
64

65. Natural flavonoid-rich resinous product of honeybees
Antibacterial, antifungal and healing properties.
Propolis is very effective as intracanal medicament in rapidly
eliminating E. faecalis ex vivo.
Further laboratory and clinical investigations needed to
validate findings of beneficial use of propolis as intracanal
medicament
Aust Endod J 2009; 35: 52–58
Propolis
65

66. CURCUMIN
• 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
• 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 al
66

67. 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.
67

68. CONCLUSION
• After reviewing through all the intracanal medicaments, it can be
concluded that most of them are not in use today because of their toxic,
mutagenic potentials.
• It is also doubtful whether they are needed routinely in teeth with vital
pulps.
• When the root canal is extensively infected and when interappointment
time periods are long, there is a merit in using an antibacterial intracanal
medicament as part of controlled sepsis.
• Intracanal medicaments play a secondary role, and should not be used as
an alternative to thorough cleaning and adequate shaping of the root
canal.
• After all, what is removed from the root canal is of greater significance
with regard to the success of root canal treatment than what is placed in
68

69. Aust Dent J Supplement 2007;52:(1):S64-S82
REFERENCES
Aust Endod J 2009; 35: 29–33
Aust Endod J 2009; 35: 52–58
J Dent Res 86(8):754-757, 2007
Harty’s Endodontics in Clinical Practice
69
IEJ, 32, 361-369, 1999
JOE vol. 30, no. 4, Apr 2004
lnternational Endodontic journal (1992) 2 5,97-106
International Endodontic Journal, 32, 257±282, 1999

70. L. G. Coldero , S. McHugh , D. MacKenzie & W. P. Saunders. Reduction in intracanal bacteria
during root canal preparation with and without apical enlargement. International Endodontic
Journal, 35, 437–446, 2002
Haapasalo et al.L.Eradication of endodontic infection by instrumentation and irrigation solutions.
Endodontic Topics 2005, 10, 77–102.
Kawashima N, Wadachi R, Suda H, Yeng T, Parashos PRoot canal medicaments. Int
Dent J. 2009 Feb;59(1):5-11
According to Schroeder A, Endodontics- Science and practice Quintessence 1981)
Antibacterial properties of dilute formocresol and eugenol and propylene glycol Oral Surgery,
Oral Medicine, Oral Pathology
Volume 49, Issue 2, February 1980, Pages 166-170
70