Intracanal Medicaments

Introduction
The chemicomechanical cleaning of the root canal is the most important part of the infection control process. Disinfection of the root canal is accomplished by intracanal medication. Microorganisms present in the canal can invade the periapical tissue and give rise to pain and destruction of the periodontium. Bystrom and others have shown by experimental studies that intracanal medication reduces or eliminates the microbial flora in the root canal.

History
The historical origins of intracanal medicaments date back to very early times. eribonius in !"#$ %D wrote of using oils and wine in the mouth of a patient in pain. This was a crude attempt to achieve a topical anesthetic effect on a tooth to be extracted. Dental writings through the Middle %ges indicate the use of oil of cloves& a plant extract containing a high percentage of eugenol. In !'"" specific medicaments were recommended for endodontic treatment.

Beechwood creosate was mentioned in !'#" article ()reosate and cotton in *ang filling.+ This medicament is still in common use today.

In !''# ,ichmond advocated -.nocking out the pulp/ by whittling down orangewood to a small si0e& soaking the stick in phenol and tapping this into exposed pulp canal. 1henol was added to preserve and sterili0e the contents of canal and to alleviate pain.

Ideal Requirements
!. It should be an effective germicide and fungicide. 2. It should be non-irritating to the periapical tissues. 3. It should remain stable in solution. #. It should have prolonged antimicrobial effect $. It should be active in the presence of blood& serum and protein derivatives of tissues. 4. It should have low surface tension. 5. It should not interfere with repair of periapical tissues. '. It should not stain tooth structure 6. It should not induce cell mediated immune response. !". It should be capable of inactivation in a culture medium.

)ategories of use
That is conditions or situations for which intracanal medicaments have been advocated. !. 7limination microorganisms8 The ob9ective is to sterili0e :destroy all viable microorganisms; or to disinfect :destroy all pathogens; in the canal space. 2. ,endering contents of canal inert8 This represents the attempt usually by chemical means to -mummify/& fix or neutrali0e tissue or debris left intentionally or unintentionally in the pulp space. 3. 1revention or control of post treatment pain8 The ob9ective is to reduce or alter the inflammatory response. #. 7nhancing %nesthesia8 By reducing the sensitivity of the inflamed& difficult to anestheti0e pulp. $. )ontrol of persistent periapical abscess 8 In cases of continually -weeping/ canal or significant pain or swelling medicaments have been suggested as a means of controlling this difficult situation.

Classifications
According to DCNA !. 1henolics - 7ugenol - )amphorated monoparachlorophenol :)M)1;

- 1arachlorophenol :1)1; - )amphorated parachlorophenol :)1); - Metacresylacetate :)resatin; - )resol - )reosote :Beechwood; - Thymol 2. %ldehydes - *ormocresol - <lutaraldehyde 3. =alides - odium hypochlorite - Iodine - 1otassium iodide #. teroids $. )alcium hydroxide 4. %ntibiotics 5. )ombinations According to Grossman !. 7ssential oils 2. 1henolic compound - 7ugenol - 1henol

- 1ara chlorophenol - )amphorated para chlorophenol - *ormocresol - <lutaraldehyde - )resatin - >2

3. =alogens

- >a hypochlorite - Iodides

#. ?uaternary %mmonium compounds 6 - amino acridine According to Ingle =e classified antimicrobial agents broadly into 2 groups )onventional antiseptics @ Aocally used antiseptics )hemotherapeutics Locally used antiseptics: E amples !. %lcohols - 7thylalcohol - Isopropyl alcohol 2. 1henolic compounds - 1henol - )amphorated phenol - Monochlorophenol

- 1aramonochlorophenol - Thymol - 7ugenol - )reosote 3. =eavy metal salts - alts of silver& mercury& copper. #. )ationic detergents - ?uaternary ammonium compounds. $. =alogens - >a hypochlorite - 1otassium iodide& iodine

Root canal flora

Before considering intracanal medication we shall see what microorganisms we are trying to destroy. Most commonly found are the gram Bve microorganisms. In some cases it may be gram -ve microorganisms and few of the cases yeasts. These organisms are found in various combinations and not as a single species. In teeth with periapical lesion obligate anaerobes are often found. Microflora of the root canals also comprise of organisms that can survive on dead pulp tissue or saprophytes and those that can grow in an environment of low oxygen tension. Crganisms reaching the root canal have their origin in the mouth. %lthough all varieties of microorganisms may have an eDual chance of invading the pulp tissue or the root canal only those best fit for survival in this environment do survive. The commonest organisms of the mouth& streptococci

are also the most freDuently found in root canals. The endodontic problem is primarily one of eliminating gram Bve organisms because they are the most abundant& consisting chiefly of streptococci and staphylococci. %mong the streptococci is a small resistant group of enterococci. In addition a small percentage of gram -ve organisms and yeasts can be isolated from saliva and from root canals. ,ecent reports on bacterial flora describe the presence of obligate and facultative anaerobes.

!actors t"at predispose teet" to infection:

!. Trauma8 The tooth under treatment should be disoccluded if necessary. 2. Devitali0ed tissue8 If present in the root canal or periapical tissue will interfere with repair or disinfection. 3. Dead spaces 8 for maximum effect the medicament should be in contact with the microorganisms in the root canal #. %ccumulation of exudate 8 7xudate should be allowed to drain or be removed as it accumulates.

Mode of Action
)onventional antimicrobials attack cells in various ways. Ehen used in high concentration they have a destructive effect on the bacteria as to cause denaturation of cell proteins. %ntimicrobial agents such as phenols& thymol& creosate& 7ugenol cause coagulation of proteins and subseDuently loss of cell metabolic function may result.

Detergents act as germicides by modifying and damaging the physical and chemical properties of the bacterial cell membrane. Iodine& chlorine and heavy metals are strong en0yme inhibitors and therefore have a destructive effect on microbial cells. The catalytic effect of en0ymes is caused by their affinity to natural substrate. % competitor is any chemical compound similar to the substrate that can combine with the active en0yme center but cannot be metaboli0ed. Through such chemical antagonism the competitor remains attached to the en0yme and thus prevents it from being active with the natural substrate. ulfonamides function as competitor and thus act as antiseptics.

Individual Intracanal Medicaments

#"enol %lso called carbolic acid It is the oldest compound for controlling microorganisms. It was introduced by Aord Aister in !'45. It is white crystalline substance& and has a characteristic odor derived from coal tar. 1henol is a protoplasm poison and produces necrosis of soft tissues by its ability to penetrate and disrupt the cell wall of bacteria and subseDuently the protoplasm.

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and ! part water. -

AiDuefied phenol consists of 6 parts of phenol

This substance is highly effective in as low concentration as ! to 2F

Camp"orated p"enol
This contains 3"F phenol& 4"F camphor& !"F ethyl alcohol It is the least toxic of the phenolic compounds It has excellent antimicrobial effect and also relieves pain.

- )amphorating process aims at developing a less caustic medicament as a result of the slow release of phenol. )amphor serves as a vehicle and diluent. In clinical use the phenolic compounds are relatively ineffective as antiseptics.

Monoc"lorop"enol $MC#%
It is a derivative of phenol and has three isomers of which paramonochlorophenol is the most effective. Mono chlorophenol is more effective antiseptic and is also more toxic than phenol.

Camp"orated paramonoc"lorop"enol $CM#C#% $De&eloped 'y (al)"off *+,*%

- )ontains 8 3$F monochlorophenol 4$F camphor - Its antimicrobial effect is good - But it is highly toxic to the tissues - It is used in the form of vapor forming intracanal medicament. The vapors can pass through the apical foramen.

!ormocresol Developed by BG).A7H in !6"4

- )ontents 8 !6F formaldehyde 3$F cresol #4F =2C and glycerine. or is a combination of formalin and cresol in the proportion of !82 *ormocresol combines the protein - coagulating effect of phenolic compounds with the alkylating effect of formaldehyde. - The bactericidal effect of formocresol is good at levels as low as 2F. It is a strong poison and causes widespread destruction of living tissue followed by a persistent inflammatory reaction. - Its vapor forming effect is also good

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tudies have reported that formocresol treated tissue produced a cell mediated immune response.

Glutaralde"yde
- It is a colorless oil slightly soluble in =2C lightly acidic

- It is a strong disinfectant and fixative - Gsed in concentration of 2F as I)M 7xtent of toxicity is less compared to formaldehyde. Its molecular weight is high compared to formaldehyde hence does not penetrate into the periapical tissues.

Cresatin
%lso known as metacresylacetate It is a clear& stable& oily liDuid of low volatility. It has both antiseptic and obtundant properties )ompared to formocresol or camphorated parachlorophenol the antimicrobial effect of cresatin is less Its effect on tissues ranges from mild to severe.

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Creosote
- It is a mixture of phenol and phenol derivatives - Beachwood creosote has long been used in endodontic therapy. - There are several reports on severe tissue irritation and necrosis

Alco"ols
7thyl alcohol and Isopropyl alcohol are used These denature protiens in high concentration Denaturing takes place in presence of water& hence 5"F is prefered to 6$F They are not recommended as intracanal medicament

Eugenol
It is the chemical essence of oil of clove It is related to phenol It is both an antiseptic and an obtundant It is slightly more irritating than oil of clove tudies have reported that eugenol inhibited intradental nerve impulses

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% few reports of allergy to eugenol have been reported.

Hea&y metal salts

alts of silver& copper and mercury are used as I)M. They coagulate protiens and act as en0yme inhibitors. They are toxic. The mercury salts are rendered less effective by the tissue fluid proteins present in the root canal. =ence they are not often used.

N)ontains 8 1araformaldehyde 1henylmercuric borate 7ugenol. %dditional ingredients like lead& corticosteroids& antibiotics. It is claimed to be both I)M and a sealer )laims that >2 has a permanent disinfectant action and unusual antimicrobial properties have been denied by the council on Dental Therapeutics of the %merican Dental %ssociation. The antibacterial effect of >2 is short lived about a week to !" days.

Halogens :

!3

Includes hypochlorite -

chlorine

and

iodine

containing

compounds

odium

=ypochlorite was first used by disinfectant

emmelweis in !'#5 as a hand

This initial use of potassium hypochlorite was substituted by sodium hypochlorite by carrel and Dakin for wound disinfection

Mechanism of action 8 Ehen hypochlorite contacts tissue proteins& nitrogen& formaldehyde and acetaldehyde are formed. The peptide links are broken up and this dissolves the proteins. During the process hydrogen in the amino groups :-=>-; is replaced by chlorine :->)l-; there by forming chloriamine& which plays an important role in antimicrobial effectiveness. Thus necrotic tissue and pus are dissolved and the antimicrobial agent can better reach and clean the infected areas.

Temperature increase significantly improves the antimicrobial effect of sodium hypochlorite

- Dakin suggested a ".$F solution :Dakin+s

olution; %t this

concentration toxicity is low and it affects only necrotic tissue. % !F sodium hypochlorite solution however is more potent and provides an increased antimicrobial effect =igher concentrations of >aC)l :2.$F and $F; attack living tissue without contributing significantly to treatment :i.e in antibiotic activity;

!#

Bystrom and undDvist have demonstrated that the rate of root canal disinfection was similar regardless of whether ".$F or $F concentration of >aC)l was used

The activity of >aC)l is intense but of short duration. =ence the compound should preferably be applied to the root canal every other day.

Iodides :
Iodine has been used for many years and is known for its mild effect on living tissue. Iodine is highly reactive& combining with proteins in a loosely bound manner so its penetration is not impeded. Iodine potassium iodide which contains 2F I2& #F .I and 6#F distilled water has excellent antimicrobial activity and minimal toxicity and tissue irritating Dualities.

Cationic detergents
The Duaternary ammonium compounds have low surface tension and good cleansing effect. The antimicrobial effect of these compounds are not strong. Mechanism of action is as follows& the (?uats+ are positevely charged and the microorganisms are negatively charged. Thus a

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surface active effect results in which the compound clings to the microorganism and reverses the charge. These compounds may delay wound healing These compounds are used in the concentrations between ".! to !F for root canal irrigation& but rarely as intracanal dressings alvi0ol is also a detergent suggested for irrigation during root canal instrumentation It has chelating effect alvi0ol causes some degree of tissue irritation

Calcium "ydro ide

=ermann introduced )a:C=;2 paste as an I)M in !62" )alcium hydroxide paste for intracanal use is a thick suspension of )a:C=;2 powder in sterile water or saline. The high p= of calcium hydroxide paste is responsible for the destructive effect on bacterial cell membranes and protein structures. *ew bacteria can survive at this p= of approximately !2.$ In addition to its antimicrobial Dualities the paste may also aid directly or indirectly in the dissolution of necrotic pulp tissue. Tissue submerged in )a:C=;2 for a day is more easily dissolved with >aC)l than is untreated tissue.

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Bystrom et al showed that )a:C=;2 paste effectively eliminated all microorganisms in infected root canals when the dressing was maintained for # weeks.

Mode of application 8 The paste is introduced into the root canal with a lentulo spiral& dried with coarse absorbent points and packed with appropriately si0ed root canal pluggers. Temporary cement is then placed for an effective seal.

Anti'iotics
%lone and in combination with other drugs& antibiotics have been used as intracanal medicament - %ntibiotics are indicated in a small minority of cases when root canal infection persists despite other antiseptics - Aadermix paste or polyantibiotic paste :1B ); are used

Ledermi paste
)ontains 8 !F triamcinelone acetonide <lucocerticosteroid 3F dimethl chlortetracycline

#./C paste
)ontains 8 1otassium penicillin < :!"&""&""" units; Bacitracin :!"&""" units; treptomycin paste :!gm; odium caprylate @ >ystatin :!gm;

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/teroids
% wide variety of steroid molecules have been synthesi0ed& a few of these have been utili0ed as intracanal medicaments. The steroid used is ".!F triameinolone which is commercially available in a water base vehicle.

!requency of medication
%ccording to the general principles of root canal management& disinfectant dressings should preferably be renewed in a week and not longer than 2 weeks because dressings become diluted by periapical exudate and are decomposed by interaction with the microorganisms. The mode of application traditionally was a short blunt absorbent point moistened with the medicament is placed inot 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 a dry absorbent point is inserted and a cotton pledget moistened with the medicament is placed against the absorbent point to moisten it. % dry cotton pledget is used to absorb the excess medicament and the cavity is sealed. =owever many endodontists prefer to place a medicated cotton pellet in the chamber from which excess medicament has been removed. They depend on the vapori0ation of the medicament in the pulp chamber for antibacterial action. They do not place an absorbent point in the root canal. The canal is then sealed with a temporary restorative material.

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Antimicro'ial Effecti&eness
The effectiveness of antimicrobials depends upon the direct contact of the agent with the virus& bacteria or fungus and in sufficient concentration. There is a serious drawback to the use of a chemical substance in a pulp space& that substance probably does not reach all areas where bacteria are seDuestered. %nother significant concern is the duration of effectiveness of the medicaments in the pulp space. ,ecent research has shown that the antibacterial potency of phenolics drops off very Duickly and becomes ineffective. %lso of concern is toxicity. %nything that kills microbes also may destroy or depress host cells. >umerous in vitro and in vivo studies have examined these toxicity factors.

In&itro /tudies
Gnder laboratory test conditions the I)M were highly effective in destroying or inhibiting the growth of microorganisms. medicaments accomplish this even in very low concentrations. To test the toxicity of medicaments the invitro study involves the use of cell cultures to determine the potency of the medicaments. It the medicament showed comparable cell destruction as they did toward bacterial destruction they were classified as toxic. ome of the

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If the results of the invitro tests were applied directly& the medicament of choice would be iodine-potassium iodide. This demonstrates relatively high antibacterial activity and relatively low toxicity. It has been suggested that sodium hypochlorite irrigant be utili0ed as an inter appointment medicament& leaving the canals flooded rather than dry.

In 0i&o studies
This is done by intracanal sampling and culture techniDues to test for the presence of bacteria. =owever this test is not precise and does not reflect the true status of the canal. Iiable bacteria may remain untouched by the medicament and still not be recovered by bacterial sampling techniDues. Important to note here is that phenolic type of I)M :)M)1 and 1)1; Duickly lose their antimicrobial action when sealed in the pulp space& remaining bacteria would then proliferate and repopulate. Many antimicrobial agents become more effective at higher temperatures. Earming solutions to approximately !#"o* :4"o); significantly enhances the antimicrobial activity in vitro of these solutions.

Complications and side effects

ubstances applied to the pulp have ready accessibility to the periapical tissues and to the systemic circulation. Thus pharmacologically active chemicals which includes all medicaments must be used with caution.

#"enolic deri&aties and alde"ydes

These chemicals possess a pungent& obnoxious odour and foul taste. They also cause marked destruction of tissue. They will kill cells on contact 2"

and have been shown to delay healing. %nother adverse side effect is their potential allergenicity. Investigations have shown that some medicaments may act as a hapten and alter tissues to the extent that they may become foreign substances to the body. %n immune response to these altered tissues may result in inflammation and additional tissue destruction.

Halides
This group of chemicals have less irritating and destructive capabilities but they tend to destroy cells on contact. Iodine can elicit allergic response.

Anti'iotics
In some cases& intracanal penicillin elicited a systemic allergic response in previously sensiti0ed patients. This same effect has not been shown with other antibiotics.

/teroids
The use of these powerful drugs has side effects like delay of healing& inhibition of body defenses and immune response permitting bacterial proliferation and suppression of adrenal activity. =owever these occur with repeated administration or with long term steroid therapy. ingle does& even when large are considered to be Duite safe in the healthy patients. %ccording to ,ichard Ealton steroids are effective in preventing pain and show promise as pain relieving agent. This drug& whether applied topically or administered systemically is a potent anti-inflammatory agent& true particularly when given in large single doses. 1ain& the byproduct of inflammation is therefore suppressed.

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Conclusion
Intracanal medicaments in endodontics have been used for the reduction in the number of microorganisms& rendering canal content inert& prevention of post treatment pain and to enhance anesthesia. ,esearch has shown the toxicity and potential allergenicity of the commonly used I)M particularly those of phenolic and aldehyde derivatives. Eith a wide choice of I)M now available selection should be made according to the special needs of the case in Duestion. >aC)l remains the most popular I)M although the recommended strength varies from ".2$ to $F. The safest I)M however is I 2-.I solution. %ccording to ,ichard walton intracanal medicaments are primarily useless. The one exception is intracanal or systemic steroids. They are effective in reducing the incidence of post treatment pain.

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