INTRACANAL

MEDICAMENTS
Naomi Mariya Mathew
Part B
INTRODUCTION
The ultimate goals of endodontic treatment are complete removal of
bacteria, their byproducts and pulpal remnants from infected root
canals and the complete seal of disinfected root canals.
Intracanal medicaments have been thought to be an essential step in
killing the bacteria in root canals. However, in modern endodontics,
shaping and cleaning may assume greater importance than intracanal
medicaments as a means of disinfecting root canals.
The more modern meaning of intracanal dressing is for a blockade
against coronal leakage from the gap between filling materials and
cavity wall.
 DEFINITION
According to Kawashima et al., intracanal
medicaments is defined as, “temporary placement
of medicaments with good biocompatibility into
root canals for the purposes of inhibiting coronal
invasion of bacteria.”
HISTORY
Grossman mentioned about the utilization of polyantibiotic
paste as an intracanal medicament in weeping canals or where
there was a continuous seepage from the pulp space. He had
mentioned about PBSC containing penicillin, bacitracin and
streptomycin with cryolite as a vehicle. PBSCN combination
was also advocated with N standing for neomycin as an
antifungal agent.
REQUIREMENTS OF AN IDEAL
ROOT CANAL MEDICAMENT
• It should be an effective anti microbial agent.
• It should be non-irritating to the periradicular tissues.
• It should remain stable in solution.
• It should have prolonged amtimicrobial effect.
• It should be active in the presence of blood, serum and
protein derivatives of tissue.
• It should have low surface tension.
• It should not interfere with the repair of periradicular
tissues.
• It should not stain tooth structure.
• It should not induce a cell-mediated immune response.
FUNCTION
 Eliminate bacteria: Get rid of remaining bacteria in infected root
canals.
 Reduce inflammation: Reduce inflammation in the pulp remnants
and periapical tissues.
 Dry wet canals: Help dry canals that are persistently wet.
 Act as a barrier: Prevent leakage from the temporary filling.
 Render canal contents inert: Make the contents of the canal
inert.
 Neutralize tissue debris
CLASSIFICATIONS
According to Grossman,
1) Essential oils: Eugenol
2) Phenolic compounds: Phenol, Paramonochlor, Camphorated phenol,
Cresatin
3) Aldehydes: Formaldehyde, Paraformaldehyde, Gluteraldehyde
4) Halogens: Chlorine sodium hypochlorite, Iodine.
5) Chlorhexidine gluconate.
6) Antibiotics.
7) Corticosteroid-antibiotic combination.
According to Franklin Weine,

1)Phenol related compounds: Eugenol, CMCP,

Metacresylacetate, Thymol, Cresol.
2)PBSC( Penicillin, Bacitracin, Streptomycin, Caprylate).
3)Sulphonamides.
4)Corticosteroid-antibiotic combination.
5)Calcium hydroxide.
According to Dental Clinics of North
America(DCNA)
1) Phenolics: Eugenol, CMCP, PCP, CPC, Metacresylacetate( Cresatin),
Cresol, Creosote( Beechwood), Thymol.
2) Aldehydes: Formocresol, Gluteraldehyde.
3) Halides: Sodium hypochlorite, Iodine, Potassium iodide.
4) Steroids
5) Calcium hydroxide.
6) Antibiotics.
7) Combinations.
CHARACTERISTICS OF
INTRACANAL MEDICAMENTS
1.Essential oils
a. Eugenol
• It has been used in endodontics for many years.
• Constituent of most root canal sealers and is used as a part of many
temporary sealing agents.
• This substance is the chemical essence of oil of clove and is related to
phenol.
• Effects of eugenol are dependent on tissue concentrations of the eugenol
and can be divided into low dose(beneficial effects) and high
dose(toxic effects).
Eugenol

i. Low dose (beneficial i. High dose (toxic effects)

effects) o Induces cell death
o Inhibits prostaglandins oInhibits cell respiration
synthesis
oInhibits nerve activity
oInhibits white cell
chemotaxis
Uses of Eugenol

 Used as an intracanal medicament.

 Used as root canal sealers.
 Part of temporary sealing agents.
2. Phenolic compounds
a. Phenol
• It was used for many years for its disinfectant and caustic
action.
• However because of it’s strong inflammatory potential, it is
rarely used as an intracanal medicament at present.
• Liquified phenol (carbolic acid) consists of nine parts of phenol
and one part of water.
Uses
 It is used for disinfection before periapical surgery.
 It is also used for cauterizing tissue tags that resist removal
with broaches or files.
b. Parachlorophenol
• Parachlorophenol (PCP) has been a very popular component of
dressing, as phenol is no longer used in endodontics because of it’s
high toxicity-to-efficacy ratio.
Composition
It 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 liquid.
Composition: 1% aqueous solution is preferred
Uses: Used as a dressing of choice for infected tooth
c. Camphorated Monoparachlorophenol(CMCP)
• It is probably the most commonly used medicament in endodontics,
presently, even though it’s use has decreased in the past few years.
Composition:
Two parts of PCP + Three parts gum camphor —> CMCP
Camphor is added to PCP because:
 Has diluent action
 Prolongs the antimicrobial effect
 Reduces the irritating effect of PCP
 Serves as a vehicle for the solution

Uses: Used as a dressing of choice for infected teeth.

d. Cresatin
Schilder and Amsterdam showed that Cresatin possesses same
desirable qualities and actions as that of CMCP, but less irritating to
periapical tissues.
Composition: It is a clear, stable, oily liquid of low volatile nature
known as Metacresyl acetate.
 3. Aldehydes
• Formaldehyde, paraformaldehyde and gluteraldehyde are commonly
used intracanal medicaments in root canal therapy.
• These are water-soluble protein denaturing agents and are considered
among the most potent disinfectants.
• They are mainly applied as disinfectants for surfaces and medical
equipment which cannot be sterilized, but they are quite toxic and
allergic and some even may be carcinogenic.
a. Formocresol
Formocresol contains formaldehyde as its main ingredient and is a still widely
used medicament for pulpotomy procedures in primary teeth but it’s toxic and
mutagenic properties are of concern.
Composition of Formocresol :
 Formaldehyde- 19%
 Cresol- 35%
 Water and glycerine- 46%

b. Paraformaldehyde
• It is the polymeric form of formaldehyde and is commonly found as component
of some root canal obturating material like endomethasone.
• It slowly decomposes to give out formocresol, its monomer.
• Its properties are similar to formaldehyde that is toxic, allergenic and genotoxic
in nature.
4. Calcium Hydoxide
• Use of calcium hydroxide in endodontics was introduced by Hermann in 1920.
• It acts as a strong base in contact with aqueous solution and dissociate into calcium and
hydroxyl ions.
Effects of Calcium Hydroxide
Physical
 Acts as a physical barrier for ingress of bacteria.
 Destroys the remaining bacteria by limiting space for multiplication and holding substrate for
growth.
Chemical
 It shoes antiseptic action because of it’s high pH and leaching action on necrotic pulp tissues. It
also increases the pH of circumpulpal dentin when placed into the root canal.
 Suppresses enzymatic activity and disrupts cell membrane.
 Inhibits DNA replication by splitting it.
 It hydrolyses the lipid part of bacterial lipopolysaccharide(LPS) and thus inactivates the activity
of LPS. This is a desirable effect because dead cell wall material remains after the killing of
bacteria which may cause infection.
Calcium hydroxide is available in:
i. Paste form: Single paste or in combination with iodoform.
ii. Powder form: Powder form is mixed with saline and aesthetic solution. For placement
in root canals, it is coated with the help of paper points, spreaders or lentulo spirals.
Indications of calcium hydroxide
 In weeping canals.
 In treatment of phoenix abscess.
 In resorption cases.
 For apexification.
 During pulpotomy.
 For non-surgical treatment of periapical lesion.
 In cases of direct and indirect pulp capping.
 As sealer for obturator.
 To decrease postoperative pain after overinstumentation, it is used in combination with
Ledermix(1:1).
Advantages:
 Inhibits root resorption.
 Stimulates periapical healing.
 Encourages mineralisation.
Disadvantages:
 Difficult to remove from canals.
Decreases setting time of zinc oxide eugenol based cements.
 It has little or no effect on severity of postobturation pain.
Use of Calcium Hydroxide in Weeping
Canal Cases
What is weeping canal?
Sometimes, a tooth undergoing root canal treatment shows constant clear or reddish
exudation associated with periapical radiolucency. Tooth can be asymptomatic or
tender on percussion. When opened in next appointment, exudates stop but it again
reappears in next appointment. This is known as “weeping canal”.
In these cases, tooth with exudates is not ready for filling, since culture reports
normally show negative bacterial growth, so antibiotics are of no help in such cases. For
such teeth P, dry the canals with sterile absorbent paper points and place calcium
hydroxide in the canal. By the next appointment, one finds a dry canal, ready for
obturation. It happens because pH of periapical tissues is acidic in weeping stage which
gets converted into basic pH by calcium hydroxide. Some say that caustic effect of
calcium hydroxide burns the residual chronic inflamed tissue and also calcium
hydroxide builds up the bone in the lesion due to its calcifying action.
5. Halogens
Halogens include chlorine and iodine which are used in various
formulations in endodontics. They are potent oxidising agents with rapid
bactericidal effects.
a. Chlorine
Sodium hypochlorite: Disinfectant action of halogens is inversely
proportional to their atomic weights. So, when compared to iodine,
chlorine shows better disinfectant action. But chlorine disinfectants are
not stable compounds because they interact rapidly with organic matter.
Mentz found sodium hypochlorite as effective intracanal medicament as
well as an irrigant. As the activity of sodium hypochlorite is intense but of
short duration, the compound should be changed in root canal every
other day.
b. Iodides
Iodine is highly reactive in nature. It combines with proteins in a loosely
bound manner so that its penetration is not impeded. It destroys
microorganisms by forming salts that are unfavourable to the life of the
organism. Iodine is used as iodine potassium iodide and in iodophors,
which are organic iodine compounds that release iodine over time. It is
also a very potent antibacterial agent of low toxicity but may stain
clothing if spilled. It is used as an irritating solution and short-term
dressing in a 2% solution of iodine in 4% aqueous potassium iodide and
as a constituent of gutta-perch’s points for filling.
6. 2% Chlorhexidine Gluconate
Antibacterial activity of chlorhexidine gluconate is comparable to
sodium hypochlorite. Substantivity, broad-spectrum activity and low
toxicity of CHX make it suitable for irrigation. Attempts are being made
to utilise its disinfecting properties in gutta-percha points.
7. PBSC Paste
As mentioned by Grossman, PBSC has enjoyed wide use among
dentists. The constituents of PBSC are as follows:
Penicillin : effective against gram-positive microorganisms.
Bacitracin : effective against penicillin-resistant microorganisms.
Streptomycin : effective against gram-negative microorganisms.
Caprylate(sodium salt) : effective against fungi.
 Nystatin replaces sodium caprylate as the antifungal agent and is
available in the form of PBSN. Both are available in a paste form that
may be injected into root canals or impregnated on paper points.
Because there is no volatility, the drug must be placed in the canal to
have effect in the area.
PBSC may interfere with subsequent culturing procedures; therefore,
penicillinase may be added to culture media to inactivate penicillin.
Reports of allergic reaction to the drug have been presented, if the
patient reports history of allergy to any of the constituents, the drug
should not be used. With the decline in popularity of intracanal drugs in
general and because of the potential for sensitivity due to topical use of
antibiotics, PBSN largely has fallen into disuse.
8. Sulfonamides
Sulfanilamide and sulfathiazole are used as medicaments by mixing
with sterile distilled water or by placing a moistened paper point into a
fluffed jar containing the powder. Yellowish tooth discolouration has been
reported after use. Sulfonamides are usually recommended while giving
closed dressing in a tooth which had been left open after an acute
periapical abscess.
9. N2 by Sargenti
It is a compound consisting of of paraformaldehyde as the main
ingredient. It contains eugenol, phenyl mercuric borate and perfumes.
Antibacterial effect of N2 is short lived and dissipated in 7-10 days.
Grossman Paste composition:
 Potassium penicillin G – 1,000,000 units
 Bacitracin – 10,000
 Streptomycin sulfate – 1.0g
 Sodium caprylate – 1.0g
 Silicon fluid – 3mL
 Nystatin – 10,000 units
10. Chloramine-T
It is a chlorine compound with good antimicrobial action. It is used in
the concentration of 5%. It remains stable for a long period of time and
is used to disinfect gutta-percha points. It can be used in patients
allergic to iodine.

11. Quaternary Ammonium Compounds

These are positively charged compounds which attract negatively
charged microorganisms; they have low surface tension, for example,
aminoacridine.
Aminoacridine is a mild antiseptic which is more effective than cresatin
but less effective than CMCP. It is used more as an irrigant than
intracanal medicament.
12. Corticosteroid-Antibiotic Combinations
• Medications that combine antibiotic and corticosteroid elements are highly
effective in cases of overinstrumentation.
• They must be placed into the inflamed periapical tissue by a paper point or reamer.
• Tetra-Cortril, Cortisporin, Mycolog and other combinations are available for their
use in endodontics.
• Ledermix is one of the best known antibiotics-corticosteroid combination.
• Schroeder and Tridian developed Ledermix in 1960. It contains an antibiotic
demeclocycline-HCl (3.2%) and a corticosteroid, triamcinolone acetonide (1%), in a
polyethylene glycol base.
• Corticosteroid constituent reduces the periapical inflammation and gives almost
instant relief of pain to the patient who complains of extreme tenderness to
percussion after canal instrumentation.
• Antibiotic constituents present in the corticosteroid-antibiotic combination prevent
the overgrowth of microorganisms when the inflammation subsides.
13. Antibiotics
Antibiotics have a limited role to play as an intracanal medicament due to the
following reasons:
 No antibiotic can completely eradicate the complex polymicrobial flora present
inside an infected root canal.
 Most antibiotics are bacteriostatic and depends on the host resistance for dealing
with the infection. As the infected root canal space has no blood supply, the
effect of many antibiotics is limited.
 Hence, a combination of antibiotics have been introduced to overcome the above
mentioned limitations. The most popular combinations are:
a) Triple antibiotic paste: Ciprofloxacin, Metronidazole and Minocycline(1:1:1) in
a propylene glycol vehicle
b) Double antibiotic paste: Combination of Ciprofloxacin and Metronidazole
 The TAP is the recommended intracanal medicament in regenerative endodontic
cases.
TRIPLE ANTIBIOTIC PASTE
Future directions: Nanoparticles and
Antimicrobial Peptides
Antimicrobial peptides: Compared with traditional intracanal
medicaments, antimicrobial peptides (AMPs) are promising alternatives
with high antimicrobial potency, good biocompatibility and low bacterial
resistance. AMPs are mostly cationic oligopeptides either derived from
natural sources or designed by computational methods.
Nanoparticles: Another effective antimicrobial agent as an intracanal
medication is the use of nanoparticles, including metal, polymeric and
ceramic nanoparticles. These nanoparticles are commonly mixed in the
calcium hydroxide paste as additives to enhance the antimicrobial
potency of calcium hydroxide. One of the most studied metal
nanoparticles against E.faecalis is silver nanoparticle due to its broad-
spectrum antimicrobial activity and simple fabrication procedures.
Placement of Intracanal Medicaments
 Copiously irrigate the canal to remove debris present if any.
 Place the master apical file in the canal.
 Dry the canal using absorbent paper points.
 Place the intracanal medicament on a sterile cotton pellet and place
it in the pulp chamber.
 Over this, another sterile cotton pellet is placed, which is finally
sealed with temporary restorative material.
Placement of intracanal medicament
Limitations of Intracanal Medicaments
 For an intracanal medicament to be effective, it should remain active
during the time of inter appointment, which does not happen in every
case.
 Clinical effectiveness of sustained release delivery systems is
unknown.
 Therapeutic action of medicament depends upon its direct contact
with tissues, but it can be prevented due to presence of organic
tissue/matter.
 CONCLUSION
The success of endodontic treatment depends on the eradication of
microbes from the root canal system and prevention of re-infection.
Instrumentation and irrigation are the most important parts for
successful endodontic treatment. Intracanal medicaments have been
used to disinfect root canals between appointments and reduce inter-
appointment pain. The major intracanal medicaments currently used in
endodontics include calcium hydroxide, though search for an ideal
material and/or technique to completely clean infected root canals
continues.
 REFERENCE
 Textbook of Endodontics– Amit Garg and Nisha Garg (5th
edition).
 Grossman’s Endodontic Practice (14th edition).