Dr.

Tahani Abualteen

INTRACANAL MEDICAMENTS & TEMPORIZATION

INTRACANAL MEDICAMENTS Definition: Antiseptic agents in the chemical form applied to the walls of the root canals with the objective of eliminating microorganisms present before or even after cleaning & irrigating the root canal system Functions: 1. Reduction of the number of microorganisms 2. Prevention of the growth/re-growth of any new/old microorganisms (antibacterial action is the most important function) 3. Disinfection of root canal system 4. Suppression of inter-appointment pain by reducing inflammation (some have anti-inflammatory action) 5. Render the canal contents inert 6. Facilitation of periapical healing ** Sometimes it is hard to finish the whole treatment in only one visit, and in order not to leave the canals empty until the next visit, canals are filled by intracanal medicaments to prevent bacterial invasion Ideal requirements of any true intracanal medicament with true anti-bacterial action: 1. Should be an effective germicide & fungicide 2. Should NOT irritate periapical tissues 3. Should remain stable in solution 4. Should have prolonged antimicrobial effect 5. Should have low surface tension (this leads to high penetration inside the root canal system) 6. Should be active in the presence of serum, blood & protein derivatives of tissues 7. Should NOT interfere with periapical healing 8. Should be easily placed & removed 9. Should NOT stain the tooth structure 10. Should NOT induce a cell mediated immune response 11. Should be economical with a long shelf life ** NO single intracanal medicament fulfills all these requirements and thus there's nothing called ideal intracanal medicament Types: o PHENOLICS o ALDEHYDES o HALIDES o STEROIDS o CALCIUM HYDROXIDE o ANTIBIOTICS o COMBINATIONS
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PHENOLICS o Phenol is a protoplasm poison (TOXIC) o They have access to systemic circulation o They have a strong inflammatory potential o They have unpleasant odor & foul taste o They are ineffective o Their clinical use is NOT justified o PHENOLIC COMPOUNDS: Eugenol Parachlorophenol (PCP) Camphorated monoparachlorophenol (CMCP) Camphorated parachlorophenol (CPC) Metacresylacetate (Cresatin) Cresol Creosote (beechwood) Thymol o EUGENOL This is the chemical essence of oil of clove () It is both antiseptic and an anodyne (pain relieving agent) It is slightly irritant to periapical tissues It is a constituent of most root canal sealers & used as a temporary sealing (luting) material, post cement and temporary filling

o PARACHLOROPHENOL (PCP) It is a substitution product of phenol It penetrates deep into dentinal tubules 1% solution has shown destruction of microorganisms It produces mild inflammation

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o CAMPHORATED MONOPARACHLOROPHENOL (CMCP) It consists of 2 parts of Parachlorophenol & 3 parts of gum Camphor Camphor serves as a vehicle & diluents Camphor reduces the irritating effect of PCP Camphor prolongs the antimicrobial effect (this is the best property) o METACRESYLACETATE (CRESATIN) It is a clear, stable, oily liquid of low volatility It is both antiseptic & obtunding (alters level of consciousness) It is less irritating among other Phenolics (but NOT used anymore) o ALDEHYDES Formocresol This is a combination of Formalin & Cresol in a ratio 1:2 or 1:1 It is a non-specific bactericidal agent most effective against aerobes & anaerobes It is used as a pulpotomy agent ** Pulpotomy is the removal of the superficial infected layer of dental pulp, then applying a fixative agent (such as Formocresol for 5 minutes) then putting the final filling material It is mutagenic & carcinogenic It is effective for 5-7 days Glutaraldehyde It is a colorless oil & slightly soluble in water. It is a strong disinfectant & fixative agent (but NOT used anymore) 2% preparation is used as an intracanal medicament. It is a Bacteriostatic agent It has the potential to cause hypersensitivity

HALIDES o SODIUM HYPOCHLORITE (NaOCl) Chlorine is the active ingredient NaOCl vapor is bactericidal It reacts rapidly with organic matter (good tissue dissolving ability) It is Unstable It is activity is intense BUT of short duration It is TOXIC to periapical tissues ** It is one of the most famous agents that is used as irrigant and intracanal medicament ** Used in a concentration of 0.5-5.25%

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** In hypochlorite accidents, sodium hypochlorite is forced outside the apex, which will cause the patient an immediate severe pain, numbness, necrosis, bleeding, and immediate swelling o IODINE POTASSIUM IODIDE (IKI) It is very effective antibacterial agent It kills bacteria in infected dentin in 5 minutes It is antibacterial action of short duration It causes allergic reactions It stains teeth It has a relatively low toxicity ** Can be used in combination with calcium hydroxide STEROIDS o Have been advocated for decreasing postoperative pain by suppressing inflammation (anti-inflammatory action) o Evidence suggests that they may be ineffective, particularly with greater pain levels o Might be used in cases of irreversible pulpitis & acute apical periodontitis (but NOT used anymore) CALCIUM HYDROXIDE o Introduced by Hermann in 1920 o It is one of the most commonly used intracanal medicaments o Used for short & long term durations ** Short period of time for one or two weeks to inhibit the bacterial growth and make the canal free of bacteria between visits of RCT ** Long period of time for 3-6 months to promote the formation of hard tissue barrier at the apical foramen in the apexification process done for immature teeth in children seeking RCT ** Long period of time to promote the formation of hard tissue barrier at pulp exposure sites, which preserve the vital pulp tissue and enable root development to continue in the apexogenesis process done for immature teeth in children not seeking RCT o o o o o o o It is a broad spectrum antimicrobial agent Its antibacterial action is related to its high pH It may aid in dissolving necrotic tissue remnants and bacteria and their by-products It demonstrates no pain-reduction effects It has been recommended for use in teeth with necrotic pulp tissue It probably has little benefit with vital pulps Limitations: The handling and proper placement presents a challenge to the average clinician The removal is frequently incomplete ** Total removal of non-setting calcium hydroxide from the root canal system is very difficult and thus, residual Ca(OH)2 particles are always left behind
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Residual Ca(OH)2 can shorten the setting time of ZOEbased endodontic sealers (and this can put the whole RCT in danger) It is NOT effective against Entercoccus Faecalis & Candida albicans ** Entercoccus Faecalis is the bacteria encountered in retreatment cases when original RCT fails Dentin can inactivate the antibacterial activity of non-setting Ca(OH)2

o Application: Powder is mixed with water or saline or glycerin until mixture gets a creamy texture Lentulo spiral (also called a root canal filler) is coated with Ca(OH)2 mixture and applied inside the root canals while being rotated Hand spreader and syringes can be also used to place Ca(OH)2 Finger spreaders and files can be also used to place Ca(OH)2 in anticlockwise motion to prevent forcing it outside the apex It is very important to apply the Ca(OH)2 to all canal walls from inside and reach all the areas ** Unfortunately it is very difficult to any chemical agent to reach each area inside a canal because of the complicated internal anatomy It is very important for Ca(OH)2 to reach the apical area of the canal There are two types of Ca(OH)2: Setting( Dycal, used for lining and capping) & Non-setting (used as intracanal medicament)

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CHLORHEXIDINE o It is a broad spectrum antimicrobial agent o 2% gel is recommended o Can be mixed with calcium hydroxide to increase its antibacterial activity & enhance the periradicular healing o It doesnt remove smear layer ** Smear layer is the layer formed after mechanical instrumentation of the root canal system and that should be eliminated before any farther procedure is done o It is a fixative ** Usually used as a mouth wash in a concentration of 0.2% ANTIBIOTICS o PBSC Penicillin Effective against Gram positive microorganisms Bacitracin Effective against Penicillin-resistant bacteria Streptomycin Effective against Gram negative microorganisms Caprylate Effective against Fungi ** Nystatin now replaces Caprylate i.e. PBSN o Sulfonamides Mixed with sterile distilled water Used in acute periapical abscess Causes yellowish tooth discoloration o Grossmans paste Potassium Penicillin 1000,000 units Bacitracin 10,000 units. Streptomycin sulphate 1.0 g Sodium Caprylate 1.0 g Silicone fluid 3ml Vehicle ** Was the most famous formula in the 50s and 60s ** All antibiotics aren't used anymore these days!! Limitations for all intracanal medicaments: o Their therapeutic action depends on direct contact with tissues o Do NOT reach all areas of root canal system o Limited to surface action only o Chemically NOT active for a long duration o Development of resistant strains of bacteria o Might cause tooth discoloration
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TEMPORIZATION: Objectives: 1. Coronal seal (prevent microleakage) 2. Enhance isolation 3. Protection of tooth structure 4. Allow of ease of placement & removal 5. Satisfy esthetics Determining factors: A. Intended duration of use B. Occlusal load & wear C. Complexity of access D. Loss of tooth structure Types: o Cavit o IRM o GIC o TERM CAVIT o Based on zinc oxide & calcium sulfate (NO EUGENOL is used) o Premixed cement that sets in the presence of moisture o Low strength & rapid occlusal wear o Used in short-term sealing of simple access cavities o Clinically, 4 mm of Cavit provides an effective seal against bacterial penetration for 3 weeks IRM o IRM = Intermediate Restorative Material o Reinforced zinc oxide-eugenol cement (EUGENOL is used) o Improved strength & wear resistance o Leaks more than Cavit GIC o GIC = Glass Ionomer Cement o Durable & effective barrier against microbial leakage. o Adhesion to moist tooth structure o Anti-cariogenic properties due to release of fluoride o Biocompatibility and low toxicity o Poor mechanical properties (poor strength and wear resistance)
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o Present in 2 forms: liquid & powder or capsules TERM o TERM = Temporary Endodontic Restorative Material o Specially formulated light-polymerized composite materials (no fillers are used) o Improved strength & wear resistance o Provides a moisture-free seal Points to remember: o Pulp chamber and cavity walls should be dry o A minimum depth of 3 to 4 mm of temporary filling material is required o At least 3 mm thick in the cingulum area o Small piece of cotton pellet is used under the temporary filling (sometimes cotton pellet isnt used at all) o Care must be taken not to incorporate cotton fibers into the restorative material o Packing into the access opening with a plastic instrument in increments from the bottom up and pressing against the cavity walls and into undercuts o Excess is removed, and the surface smoothed with moist cotton pellet o Occlusion of patient is checked o The patient should avoid chewing on the tooth for at least an hour

** Sometimes, no cotton pellet is used, which is right, but it will make it very difficult for the temporary filling material to be removed from the orifices of root canals ** Putting a very big cotton pellet is wrong because it will compromise the space available for the temporary filling material and eneases its breakage under occlusal loads
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** Dont place the temporary filling material in one shot, but place it in increments and condense it against walls and smoothen it Extensive Coronal Breakdown o A strong filling material (high-strength GIC) is required o Take care to ensure an adequate thickness and good marginal adaptation proximally o Should extend well into the pulp chamber deep to the proximal margin to ensure a marginal seal o Reducing the height of undermined cusps well out of occlusion reduces the risk of fracture. o For severely broken-down teeth, a cusp-onlay amalgam or a well-fitting orthodontic band cemented onto the tooth is needed

Provisional Post Crowns o Used when a cast post and core is being fabricated o The post could be (preformed aluminum post, safety pin wire, paper clip, or a sectioned large endodontic file) o The coronal seal is generally inadequate o The post should fit the canal snugly (not binding) o The post should extend apically 4 to 5 mm short of working length and coronally to within 2 to 3 mm of the incisal edge o A polycarbonate crown is trimmed to a good fit o Good contouring and occlusal adjustment o Provisional luting cement (Temp Bond or similar cement) is placed on the coronal 3 to 4 mm of the post and root face o A provisional removable partial over-denture is a useful alternative
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Long-Term Temporary Restorations o A durable material, such as amalgam, GIC, or acid-etch composite, should be used. o The pulp chamber is filled with Cavit to provide a good coronal seal and covered with a sufficient thickness of the restorative material to ensure strength and wear resistance o The layer of Cavit can be easily removed in the next visit

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