INTRACANAL MEDICAMENTS

Presented by :

Dr.Suruchi Sisodia
Dept. of conservative dentistry and endodontics

CONTENTS :
Aim Function of intracanal medicament Root canal flora Why , When and How Rationale of using medicaments Requirements Classification Walton Grossman Individiual medicaments Activity of medicaments Procedure for application of intracanal medicaments

Placement Irritation potential Frequency of medication Limitations and contraindications Summary References

What is removed from the canal has a greater significance in endodontic success than what is placed in the canal.

AIM :
Disinfection of the root canal.. Disinfection of the root canal,that is destruction of pathogenic microorganisms is accomplished by intracanal medication. Evidence is sufficient to indicate that disinfection of the root canal is an important phase of endodontic treatment.

Microorganisms present in the canal can invade the periapical tissue and may not only give rise to pain, but also destroy the periodontium including bone.

 According to a study by Bystrom and Sundqvist, when no intracanal medicament was used between appointments, pathogenic microorganisms incrased in number. Bender and other are of the opinion that irrigation with 5% sodium hypochlorite and 3% hydrogen peroxide during biomechanical preparation of the root canal obviates the need for an intracanal medicament.

Grossman

FUNCTION OF INTRACANAL MEDICAMENTS

Antimicrobial agents. Destroys those remaining microorganisms Limits the growth of any new arrivals. Corticosteroid-antibiotic combinations are useful in treating apical periodontitis, occurring either as a pretreatment symptom or as a result of overinstrumentation.
Weine

ROOT CANAL FLORA :

Before considering intracanal medication - we might ask the question: what microorganisms are we trying to destroy? In most cases, gram-positive organisms are present; in some cases, gram-negative organisms; in a few cases, yeasts. These organisms are found most often in various combinations rather than as a single species.

Obligate anaerobes are often associated with teeth that have a periapical lesion. The microbial flora of the root canals is likely to comprise organisms that can survive on dead pulp tissue, that is, saprophytes, as they can grow in an environment of low oxygen tension.
The endodontic problem is primarily one of eliminating gram-positive organisms because they are the most abundant, consisting chiefly of streptococci and

staphylococci.

 Among the streptococci is a small but resistant group of enterococci. In addition, a small percentage of gram-negative organisms and yeasts can be isolated from saliva and from root canals.

Four factors either predispose teeth to infection or counteract disinfection, and may also delay healing. They are:
Trauma; the tooth under treatment should be disoccluded if necessary. Devitalized tissue; if present in the root canal or periapical tissue, it will interfere with disinfection or with repair.

Dead spaces; for maximum effect, the medicament should be contact with the microorganisms in the root canal.

Accumulation of exudates; exudates should be allowed to drain or be removed as it accumulates.

Grossman

Why?

Intracanal medicaments are advocated to; Eliminate bacteria after chemomechanical instrumentation Reduce inflammation of the periapical tissues Dissolve remaining organic material Counteract coronal microleakage

When?

Vital cases
In vital cases where root canal treatment is carried out under aseptic conditions an intracanal medicaments is not required.

Infected teeth
Approximately 50% of infected root canals were not disinfected using an antibacterial irrigant alone during root canal treatment. Residual bacteria remaining in the root canal following preparation are able to multiply rapidly between appointments if the canal remains empty. Antibacterial medicaments are used between appointments to kill the few remaining bacteria and prevent reinfection of the root canal. The agent used must have a wide variety spectrum and should remain active for the period between appointments.

How?
The antibacterial activity should be greater than the cytotoxic effect. The agent should be in contact with the residual bacteria. The agent must be present in sufficient concentration. Antibacterial Intracanal medicaments must have a wide spectrum of activity. The agent must have a sufficient duration of action.

Pittford

Intracanal medication is recommended as part of routine endodontic treatment for a variety of reasons. However, it must not be used as a substitute for efficient chemomechanical preparation of the root canal system, which forms the basis of sound and successful endodontic treatment.

RATIONALE OF USING MEDICAMENTS

PRIMARY FUNCTION
Asepsis Antisepsis

Disinfection

SECONDARY FUNCTION OF MEDICAMENTS

To aid in the elimination of microorganisms To reduce pain To eliminate apical exudates To induce healing and hard tissue formation To control inflammatory root resorption

Asepsis

It the assurance that no pathogenic microorganisms are present in the field of operation and in the course of treating teeth no signs of canal infection.
Maintaining asepsis is the primary means of preserving a bacteria free canal.

Antisepsis

It is the endeavour to prevent or arrest the growth of microorganisms on living tissue.

Irrigating solutions and interappointment dressings need to be antibacterial in action to prevent any microorganisms, which may contaminate the canal system from multiplying and establishing themselves.

Disinfection
It is the elimination of pathogenic microorganisms, usually by chemical or physical means,. Disinfection entails mechanical removal of tissue and debris containing microbes, irrigation and dressing with antiseptic agents; also surgical removal of an infected apex contributes to the antiseptics efforts of treatment.
Harty

Elimination of microorganisms
Two basic types of medicament have been used to aid in the elimination of residual bacteria- antibiotics and antiseptics. The basic appeal of antibiotics is that they have a broad therapeutic index (that is they are relatively non toxic to the host) but their major shortcoming is that they generally target a limited range of organisms

Reduction of pain

The most important aspect of any dental treatment is the comfort of the patient In both acute apical periodontitis and the acute exacerbation of the chronic condition,the use of anti inflammatory medicaments will add to the effectiveness of debridement and drainage and help in overcoming pain. At present cortosteroids are used in this role almost always in combination with an antibiotic.

Elimination of Apical exudates

Before a root canal filling can be placed it is essential for two reasons that no apical exudate is present. 1. Exudate indicates that there is a continuing active inflammatory process in the periapical tissues. 2. The physical presence of moisture prevents the creation of an apical seal with the filling materials now available.

Induction of healing and hard tissue formation

Bactericidal effects of calcium hydroxide have been described by Hermann (1920) et al. The ability to stimulate hard tissue repair was investigated by Mitchell and amos (1957) et al. Calcium hydroxide is available either in powder form or as a paste. If purchased in powder form then it must be mixed with an appropriate liquid before use (include local anesthetic solution, sterile saline or sterile water)

INTRACANAL MEDICAMENTS : REQUIREMENTS

The requirements of a root canal disinfectant are as follows: 1. Should be an effective germicide and fungicide 2. Should be nonirritating to the periapical tissues 3. Should remain stable in solution 4. Should have a prolonged antimicrobial effect 5. Should be active in the presence of blood, serum and protein derivatives of tissue 6. Should have low surface tension 7. Should not interfere with repair of periapical tissues 8. Should not stain tooth structure 9. Should be capable of inactivation in culture medium. 10.Should not induce a cell-mediated immune response.

GROUPING OF COMMONLY USED INTRACANAL MEDICAMENTS :

(WALTON)

A.

PHENOLICS I. Eugenol II. Camphorated monoparachlorophenol (CMCP) III.Parachlorophenol (PCP) IV. Camphorated parachlorophenol (CPC) V. Metacresylacetate ( Cresatin ) VI. Cresol VII. Creosote ( beechwood ) VIII.Thymol

B.

C.

D. E. F. G.

ALDEHYDES I. Formocresol II. Glutaraldehyde HALIDES I. Sodium Hypochlorite II. Iodine Potassium iodide STEROIDS CALCIUM HYDROXIDE ANTIBIOTICS COMBINATIONS

GROUPING OF COMMONLY USED INTRACANAL MEDICAMENTS :

(GROSSMAN)

1. 2. 3. 4. 5. 6. 7.

ESSENTIAL OILS PHENOLIC COMPOUNDS CALCIUM HYDROXIDE N2 HALOGENS ANTIBIOTICS. QUARTERNARY AMMONIUM COMPOUNDS

Classification : Text book of endodontics

INDIVIDUAL MEDICAMENTS

I.
a.

Essential Oils

As a group, the essential oils are weak disinfectants Eugenol : This substance is the chemical essence of oil of clove and is related to phenol. It is slightly more irritating than oil of clove and is both an antiseptic and an anodyne.

II. Phenolic Compounds

a. Phenol
This white crystalline substance has characteristic odour derived from coaltar. a

Liquefied phenol (carbolic acid) consists of 9 parts of phenol and 1 part of water.
Phenol is a protoplasm poison and produces necrosis of soft tissue. Has inflammatory potential so less used.

b. Para-Chlorophenol
This compound is a substitution product of phenol in which chlorine replaces one of the hydrogen atoms (C6H4OHCl).

On trituration with gum camphor, these products combine to form an oily liuid.
Harrison and Madonia have recommended a 1% aqueous solution of parachlorophenol.

In tests in vitro, the aqueous solution destroyed a variety of microorganisms ordinarily found in infected root canals. Aqueous solution of para-chlorophenol penetrates deeper into the dential tubules than camphorated chlorophenol.

c. Camphorated Para-chorophenol
Dressing of choice for infected teeth Use decreased in last few years

This compound is composed of 2 parts parachlorophenol and 3 part gum camphor.

The camphor serves as vehicle and a diluent and reduces the irritating effect of pure parachlorophenol. It also prolonges the antimicrobial effect, which has been compared to that of other root canal medicaments by Grossman.

Wantulok and Brown have shown that the vapors of camphorated chlorophenol (and also of Cresatin) pass through the apical foramen.

d. Formocresol
This substance is a combination of formalin and cresol in the proportions of 1:2 or 1:1. Formalin is a strong disinfectant that combines with albumin to form an insoluble, indecomposable substance. Formaldehyde : 19% Cresol : 35 % Water and glycerine : 46%

In every case in which the compound was tested against living tissue., necrosis was followed by a persistent inflammatory reaction. Formocresol did not produce an immune reaction in non-sensitized animals, but it did in presensitized animals. Formocresol is a nonspecific bactericidal medicament most effective against aerobic and anaerobic organisms found in a root canal.

e. Glutaraldehyde

This colorless oil is slightly soluble in water and thereby has a slightly acidic disinfectant and fixative.
Formaldehyde produced an immunologic reaction through the T cells, according to Van Velzen, but glutaraldehyde did not.

 S- Gravenmade suggested that formaldehyde did not represent the ideal pulp fixative.
Glutaraldehyde replaced formocresol in endodontics because of its fixative properties and bactericidal effectiveness and results in less destruction of tissues

Hill et. Al Minimal antimicrobial concentration was 3.125 % for glutaraldehyde and 0.75 % for formocresol
But at this conc. also glutaraldehyde was less cytotoxic than formocresol

f. Cresatin
Also known as metacresylacetate, this substance is a clear, stable, oily liquid of low volatility.
It is claimed to have both antiseptic and obtundant properties. The antimicrobial effect of Cresatin is less than that of either formocresol or camphorated parachlorophenol, as demonstrated by Grossman, but it is less irritating.

III. Calcium Hydroxide

The use was introduced by Hermann ( 1920 ).
Its antiseptic action probably relates to its high pH and its leaching action on necrotic pulp tissue. Tronstad and associates have shown that calcium hydroxide causes a significant increase in the pH of circumpulpal dentin when the compound is placed in the root canal.

Calcium hydroxide paste is best used as an intracanal medicament when one anticipates an excessive delay between appointments because it is efficacious as long as it remains within the root canal.

CALCIUM HYDROXIDE AS A MEDICAMENT FOR WEEPING CASES

One of the most perplexing conditions to treat is the tooth with constant clear or reddish exudation associated with a large apical radiolucency. The tooth often is asymptomatic, but it may be tender to percussion or sensitive to digital pressure over the apex. If cultured, the drainage generally will not support bacterial growth. When opened at the start of the endodontic appointment, a reddish discharge may well up, whereas at a succeeding appointment the exudates will be clear. Some pressure is present, but not nearly as much as with an acute periapical abscess.

If the tooth is left open under a rubber dam for 15 to 30 minutes, it may be closed up by absorbing the exudate with an aspirator and paper points; but a similar condition wil be seen in next appointment. This is referred to as a weeping canal. The answer to this recalcitrant problem is to dry the canal with sterile absorbent paper points and place calcium hydroxide paste in the canal, similar to what is done to gain apexification in teeth with open apices and nonvital pulps. It is absolutely astonishing to see a perfectly dry clean canal at the next appointment that is simple to fill after minimal further preparation.

Mechanism for the action of calcium hydroxide is closely related to the pH of the periapical tissues which must be acidic in weeping stage. The pH is converted by the paste to a more basic environment.
Others believe that the calcifying potential of the medicament starts to buildup bone in the lesion. Still others suggest that the caustic action of the calcium hydroxide burns residual chronic inflamed tissue.

Because of its pH, few microorganisms can survive in calcium hydroxides presence. The material has an excellent record of helping to heal radiolucencies. Unlike the phenolic derivatives, calcium hydroxide leads, at worst, to a minimal number of immunologic reactions.
According to Weine - Still the functions of medicaments should be sublimated to use of excellent debridement and that they should be employed only in those few cases where other aspects of therapy have not worked.

IV.

N2

N2 a compound containing paraformaldehyde as its primary ingredient, is claimed to be both an intracanal medicament and a sealer. N2 contains eugenol and phenylmercuric borate and at times, additional ingredients, including lead, corticosteroids, antibiotics and perfume.
The antibacterial effect of N2 is short lived and dissipated in about a week to 10 days.

V. Halogen

a. Sodium Hypochlorite This compound is sometimes used as an intracanal medicament. In general, the disinfectant action of the halogens is inversely proportional to their atomic weight. Chlorine, with the lowest atomic weight, has the greatest disinfectant action of the members of this group.

Chlorine disinfectants are not stable compounds because they interact rapidly with organic matter.
Ellerbruch and Murphy found that sodium hypochlorite vapors were bactericidal, whereas those of formocresol, aqueous para-chlorophenol were bacteriostatic. Mentz found sodium hypochlorite an intracanal medicament as well as irrigant. effective

Because the activity of sodium hypochlorite is intense but of short duration, the compound should preferably be applied to the root canal every other day. NaOCl is effective against endodontic microorganisms, including those difficult to eradicate from root canals such as enterococcus Actinomyces and Candida organisms.

In root canal treatment, NaOCl solutions are used at concentrations ranging from 0.5% to 5.25%. In infected dentin blocks, a 0.25% solution of NaOCl was sufficient to kill Enterococcus faecalis in 15 minutes;
a concentration of 1% NaOCl required 1 hour to kill Candida albicans.

NaOCl dissolves organic material, such as pulp tissue and collagen.

Lower concentrations (e.g., 0.5% or 1%) dissolve mainly necrotic tissue.

Higher concerntration allow better dissolution but dissolve both necrotic and vital tissue, which is not always a desirable effect. In some cases full-strength NaOCl (5.25%) may be indicated; however, although higher concentrations may increase antibacterial effects in vitro, enhanced clinical effectiveness has not been demonstrated conclusively for concentrations stronger than 1%.
Cohen

b. Iodides
Have been used as antiseptics for more than a century. Iodine is highly reactive, combining with proteins in a loosely bound manner so its penetration is not impeded. It probably destroys microorganisms by forming salts that are inimical to the life of the organism.

Engstrom and Spangberg have recommended a 2% solution of iodine in potassium iodine as a root canal disinfectant. This compound consists of iodine crystals, 2 parts, potassium iodine, 4 parts and distilled water, 94 parts. As with chlorine compounds the antibacterial effect is of short duration.

Found it to be one of the least irritating medicaments.

VI. Quaternary Ammonium Compounds :

The quants are compounds that lower the surface tension of solutions. They are inactivated by anionic compounds.

Because the quaternary ammonium compounds are positively charged and the microorganisms are negatively charged, a surface-active effect results in which the compound clings to the microorganisms and reverses the charge.
The compound 9-aminoacridine belongs to the group of mild cationic antiseptics. A derivative of an acridine dye, 9-aminoacridine may stain the tooth structure.

VII. OTHER MEDICAMENTS AND DISINFECTANTS :

Cohen

a. Chlorhexidine
Chlorhexidine (CHX) is a broad-spectrum antimicrobial agent effective against gram-negative and gram-positive bacteria. It has a cationic molecular component that attaches to negatively charged cell membrane areas, causing cell lysis. CHX has been used in periodontal therapy for many years. Its use as an endodontic irrigant is based on its substantivity and long-lasting antimicrobial effect, which arises from binding to hydroxyapatite. However,it has not been shown to have clinical advantages over NaOCl.

Some researchers found that CHX had signigicantly better antibacterial effects than calcium hydroxide Ca(OH)2 when tested on cultures. Effective combinations of CHX and Ca(OH)2 are available and show strong antimicrobial activity against obligate anaerobes, the combination augmenting the antibacterial effect of either medicament on certain species. The addition of CHX or iodine potassium iodide to an intracanal dressing of Ca(OH)2 in vitro did not affect the alkalinity (and hence the efficacy) of the calcium hydroxide suspensions.

b. Iodine potassium iodide

Iodine potassium iodide (IKI) is a traditional root canal disinfectant. IKI kills a wide spectrum of microorganisms found in root canals but shows relatively low toxicity in experiments using tissue cultures. Iodine acts as an oxidizing agent by reacting with free sulfhydryl group of bacterial enzymes, l eaving disulfide bonds.

E. Faecalis often is associated with therapyresistant periapical infections and combinations of IKI and CHX may be able to kill calcium hydroxide resistant bacteria more efficiently. A recent study by Siren et al calcium hydroxide with IKI or CHX in infected bovine dentin blocks. Although calcium hydroxide alone was unable to destroy E. faecalis inside dentinal tubules, calcium hydroxide mixed with either IKI or CHX effectively disinfected dentin. An obvious disadvantage of iodine is a possible allergic reaction in some patients.

C. MTAD
New chemicals for irrigating root canals are constantly developed, including solution based on antibiotics. Use of these irrigants is controversial, however, because of the emergence of increasingly resistant strains of bacteria (e.g., therapyresistant enterococci), which may be due to overprescription of antibiotics in general., the increased risk of host sensitization by local antibiotics can be circumvented to some degree by using the antibiotic as a dressing. Because exposure to vital tissues is limited, higher microbicidal concentrations may be used.

A number of antibiotics, including erythromycin, chloramphenicol, tetracycline and vancomycin, have been tested successfully against enterococci
MTAD (Dentsply-Tulsa), a recently introduced irrigation solution, contains doxycyline citric acid and a surface-active detergent (Tween 80). In vitro experiments indicate that MTAD has potential for removing the smear layer but clinical benefits have yet to be demonstrated.

d. Ethylenediamine Tetra-Acetic Acid

EDTA came into use in endodontics in 1957, whereas NaOCl has been in use for more than 70 years. Chelators such as EDTA create a stable calcium complex with dentin mud, smear layers or calcific deposits along the canal walls.

This may help prevent apical blockage and did disinfection by improving access of solutions through removal of the smear layer. Neutral EDTA showed a higher degree of decalcification of dentin surface than RC-Prep, although its effect was reduced in apical regions.
Similar to MTAD, RC-Prep did not erode the surface dentin layer.

The effect of chelators in negotiating narrow, tortuous calcified canals to establish patency depends both on canal width and on the amount of active substance available as the demineralization process continues until all chelators have formed complex with calcium. Calcium binding results in the release of protons and EDTA loses its efficiency in an acidic environment. Thus the action of EDTA is thought to be self limiting.

A comparison of bacterial growth inhibition showed that the antibacterial effects of EDTA were stronger than citric acid and 0.5% NaOCl but weaker than 2.5% NaOCl and 0.2% chlorhexidine. EDTA had a signigicantly better antimicrobial effect than saline solution; it exerts it strongest effect when used synergistically with NaOCl, although no disinfecting effect on colonized dentin could be demonstrated. Recent report have indicated that several disinfecting agents such as Ca(OH)2 , IKI and CHX are inhibited in the presence of dentin. Moreover, chemical analyses indiacated that chlorine, the active agent in NaOCl, is inactivated by EDTA.

PBSC paste
Penicillin Effective against gram positive micro organisms Bacitracin effective against penicillin resistant microorg Streptomycin Effective against gram negative microorg Caprylate Effective against fungi

 Nsytatin replaces sodium caprylate as antifungal agent and is available as PBSN. ` Not used if any history of allergy to any constituents.

Activity Of Various Irrigants Against Microorganisms NAOCL

Enterococci 3 min at 0.0005% solution in filter paper specimens 15 min at 0.25% solution in contaminated dentin blocks 30 min at 0.5% solution and 2 min at 5.25% solution in direct contact with bacteria Actinomyces Organisms 1 min at 1% solution 10 sec at 0.5% solution in direct contact with bacteria Candida Organisms 1 hours at 1% or 5% solution on root dentin with smear layer 30 sec for both the 0.5% solution to kill all cells in culture

CHX
7 days of 0.5% dressing resulted in complete killing in dentin blocks up to full depth of 950m 24 hours to reduce cultured bacteria below detection limit No growth directly After rinsing with 2% CHX in patients with necrotic pulps and/or apical granuloma 3 days for 2% CHX to eliminate Actinomyces israelii From all samples of infected dentin 1 hour at 0.12% solution on root dentin with smear layer 10 sec at 0.5% solution in direct contact with bacteria 5 min at 0.5% solution to kill all yeast cells and 1 hour at 0.05% solution; ; less effective than IKI and NaOCl

IKI
24 hours of iodine (2%) exposure in potassium iodide (4%) resulted in complete killing in dentin blocks up to a depth of 700m 1 hours to reduce bacteria under 0.1% and 24 hours to reduce bacteria below detection limit; however, loss of activity noted through dentin powder 30 sec for both 2% and 4% solution to kill all cells in culture; 0.2% and 0.4% solutions were as effective as 0.5% CHX

MTAD
5 min application resulted in no growth on infected dentin MTAD was as efficient as 5.25% NaOCl in cultures

CA(OH)2
24 hours to reduce cultured bacteria below detection limit, but activity was inhibited by dentin power, hydroxyapatite and serum albumin 7 days to render canals nacteria free but showed little effect on Enterococcus faecalis; resulted in complete killing in dentin blocks up to full depth of 950m 7 days of Ca(OH)2 in 0.5% chlorhexidine acetate dressing resulted in complete killing in dentin blocks up to full depth of 950m After 1 hour and 24 hours only a small reduction of CFU was observed

APPLICATION OF INTRACANAL MEDICAMENT

After completion of mechanical instrumentation and irrigation the following procedures are recommended : Drying the canal Placement of medicament Covering the canal Sealing the medication Double seal Checking the occlusion

DRYING THE CANAL

The root canal must be dried before placing the medicaments. This can be achieved by first aspirating the bulk of remaining liquid from the canal with the irrigating syringe. Then, sterile absorbent paper points of an appropriate size are placed in the canal to absorb the remaining fluid. Wide canals can also be dried by wrapping some cotton wool around a hand file and placing it in the canal to the predetermined root length.

MEDICAMENTS IN ROOT CANAL MAY ACT

1. 2. 3. 4. 5. Within the canal itself Within dentinal tubules Within apical foramina Periodontal, and Periapical tissues

PLACEMENT OF MEDICAMENTS
SYRINGE DELIVERY Probably the easiest way of applying a medicament Calcium hydroxide preparations come in different concentrations and in different formats. Disposable plastic tips are excellent, as there is no risk of cross-infection Metal syringe tips must be autoclaved between patients. It is important to place a fine file along the bore of the needle to ensure that the tip does not become blocked The syringe tips on most commercial systems can be premeasured to prevent extrusion.

HAND FILE
A file can be used to place the medicament in the canal The agent should be smeared on the walls of the root canals, and can be carried to the working length by gently rotating the file in an anticlockwise direction. If it is mixed to a thick paste consistency a plugger can be used to ensure that the material is carried completely to all parts of the prepared root canal system.

SPIRAL ROOT FILLERS

These devices are used in a low speed handpiece and can be obtained in different sizes. The size used will depend on the size of the prepared root canal. A small amount of paste material is placed on the spiral and the spiral is placed in the tooth. Once the spiral is in the canal, the motor is started and should be run at a low speed and in the forward direction. The spiral is advanced into the root canal while in motion. It should not be advanced any further than 3 mm short of the working length.

 The spiral is moved vertically in and out of the canal several times and on the final withdrawal the motor should be kept running until the spiral leaves the root canal. The spiral root filler is very effective at coating the canal walls with the paste material and the canal lumen is filled as the spiral is withdrawn. To ensure the canal is completely filled with medicament,the process should be repeated two or three times for each canal. The spiral should be kept short of the apical foramen so that the material is not forced beyond the foramen. Spiral should not be used in fine or sharply curved canals if they have not been instrumented and enlarged. In these cases, a hand reamer should be used.

MESSING GUN
The stiffer pastes mixed to requirement may be loaded using amalgam carriers such as the messing gun.

CALCIUM HYDROXIDE POINTS

Calcium hydroxide containing points are available. They are not considered to be very effective, as little calcium hydroxide is released into the root canal

Advantages of Calcium hydroxide points 1. Minimal or no residue left 2. No smearing around the access cavity during insertion 3. Firm for easy insertion and flexible enough to follow the natural canal curvature 4. Time saving as the points are: _ Ready to use _ No mixing required _ Ease of insertion and removal with help of tweezers 5. Insertion of points down the apex is easy and ensures that calcium hydroxide is released through canals

6. In addition the calcium hydroxide plus points have shown to have: _ Three fold high calcium release than calcium hydroxide points due to highly water soluble components like tensides and sodium chloride _ Superior pH values _ Increased wettability of canal surfaces _ Increased release of zinc oxide compared to normal gutta percha points thus increasing its antibacterial effects _ Sustained alkaline pH for 7 days as against 3 days which was seen with calcium hydroxide points2.

Disadvantages 1. Action is short lived 2. Lack of sustained release 3. Radiolucent

CLEARING THE PULP CHAMBER

Care should be taken to avoid placing any of the medicament within the crown of the tooth in order to allow sufficient space for the insertion of a temporary seal and also to prevent discoloration. If any of the medicament is present within the crown then it should be wiped out with a small, lightly moistened cotton pellet.

COVERING THE CANAL ORIFICES

The canal orifices should be covered with dry cotton-wool. This done to prevent any particles from falling into the canal during placement or removal of the temporary filling material. The cotton wool also provides a barrier to separate the temporary filling material and the medicament and aids easy access at subsequent appointments.

SEALING THE MEDICATION

The root canal system must be sealed between all appointments in order to prevent contamination from oral microflora and leakage of the medicament into the mouth. Of the materials available for sealing access cavities, cavit or IRM are recommended providing there is a thickness of at least 3.5 mm of material
placed in the access cavity.

DOUBLE SEAL
In some situations a double seal will be requiredespecially where occlusal forces or wearing of the temporary filling may occur and in long term dressing situations. If cavit has been used as the sealing material, it should be overlaid with a more durable material, such as IRM, glass ionomer cement, amalgam or composite resin.

The method chosen to temporize a tooth will depend on the status of the remaining tooth structure and existing restorations

CHECKING THE OCCLUSION

Once the temporary restoration has been placed and the rubber dam removed, the occlusion should be rechecked with thin articulating paper to ensure the temporary restoration is not in occlusal contact.

SUBSEQUENT APPOINTMENTS
Following rubber dam isolation and disinfection, the temporary restoration is removed with a high speed handpiece. The access cavity is then cleared thoroughly with an irrigating solution to ensure that there are no loose fragements within the cavity. The pulp chamber is then exposed by engaging the cotton wool with a probe, barbed broach or file. The medicaments can be removed from the root canal system by copious irrigation. Water soluble pastes are easily removed in this manner. Ultrasonic and sonic devices designed for use in root canals help to rapidly clear the medicaments from the canal by thorough circulation of the irrigating solution.

IRRITATION POTENTIAL OF MEDICAMENTS

The irritation potential of root canal medicaments was studied by Black, who found some of the essential oils and formocresol highly irritating, especially formocresol. Hydrogen peroxide and sodium hypochlorite were less irritating than most intacanal medicaments, formocresol produced a high degree of irritation and Cresatin caused little or no inflammation.

FREQUENCY OF MEDICATION

In accordance with general principles of root canal management, disinfectant dressing should preferably be renewed in a week and not longer than 2 weeks because dressing become diluted by periapical fluid and are decomposed by interaction with the microorganisms.

LIMITATIONS AND CONTRAINDICATIONS

1. INTRACANAL ENVIRONMENT.
The chemical or therapeutic action of medicaments depends on direct contact of the agent with microbes or tissue. This is a drawback to chemicals used in the pulp space; these substances probably do not reach all areas where bacteria or tissues are hidden and are limited to surface action only.

2. DURATION

To be effective, most agents should remain chemically active during the time between appointments. Phenolics lose their activity very quickly and are inactivated within activity very quickly and are inactivated within 24 hours. Calcium hydroxide may retain antimicrobial activity for prolonged periods and can inhibit regrowth of bacteria .Steroid duration is unknown.

3.TOXICITY
Any chemical that kills bacteria will also kill host cells. Both in vitro (bench type) and in vivo (animal and clinical use) studies show that phenolics and aldehydes are generally potent cell killers. Another potential adverse side effect is allergenicity. Some medicaments act as haptens and alter tissues to become forein substances, which then elict an immune response. This action may be responsible for their localized adverse effects on pulp or periapical tissues. Neither calcium hydroxide nor steroid compounds have significant toxicity.

4. DISTRIBUTION
A popular misconception is that the pulp space is isolated from the body. This is not true. There is ample evidence that substances placed in the pulp, with or without tissue, have ready access to periradicular tissues and even to the systemic circulation are unknown, the use of potent chemicals that have no demonstrated beneficial effects is questionable.

5. TASTE AND SMELL

The phenolics in particular posses a pungent odor and foul taste. These medicaments soak into and through the temporary into the oral cavity. Patients report a disagreeable medicinal taste; many find this most objectionable. Some dentists believe that if a patient report a bad taste, the temporary is defective and will leak saliva into the canal; there is no evidence to support this presumption.

SUMMARY

Intracanal medication is recommended as part of routine endodontic treatment for a variety of reasons. However, it must not be used as a substitute of efficient chemomechanical preparation of the root canal system, which forms the basis of sound and successful endodontic treatment.

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.

Principles and practice Walton, 3rd ed. Weine Endodontics Ingle, 5th ed. Endodontic Practice Grossman, 11th ed. Harty Summit Text book of Endodontics Nisha Garg Calcium hydroxide in restorative dentistry J.Dent , 1991

In multivisit endodontic therapy, which is desirable, root canal medication is used for one or more of the following reasons: To aid in the elimination of micro-organisms To reduce pain To eliminate apical exudates To induce healing and hard tissue formation To control inflammatory root resorption

Harty

Traditionally, dressing a root canal, a short, blunt absorbent point moistened with the medicament is carried into the canal, a cotton pledget from which excess medicament has been expressed is placed in the pulp chamber, and the access cavity is sealed. In narrow canals, however, a moist absorbent point does not have sufficient stiffness to be introduced into the canal. In such cases, a dry absorbent is inserted and a cotton pledget moistened with the medicament is placed against the absorbent point to moisten it. A dry cotton pellet is used to absorb the excess medicament and the cavity is sealed.

Many endodontists prefer to dress a root canal with a medicated cotton pellet from which excess medicament has been removed. They depend on the vaporization of the medicament in the pulp chamber for antibacterial action, and they omit the placing of an absorbent point in the root canal. The vapors issuing from the medicament are sufficient to disinfect the pulp cavity. The elimination of the absorbent point allows room in the canal for the accumulation of fluid exudates, reduces the possibility of periapical irritation from inadvertent extrusion of the medicament or absorbent point into the periapical tissue, eliminates the potential problem of removing a wedged, saturated absorbent point from the root canal during the succeeding visit and reduces treatment time.

The canal is sealed after placing a second sterile dry cotton pellet over the medicated pellet or placing a seal of temporary stopping over the medicated pellet and completing the double seal with a temporary outer seal of cavit, zinc oxideeugenol cement or IRM