INTRACANAL MEDICAMENTS / DRESSINGS

1. INTRACANAL MEDICAMENTS / DRESSINGS

2. CONTENTS • INTRODUCTION TO ICM • HISTORY • REQUIREMENTS • USES • CLASSIFICATIONS • LIMITATIONS • APPLICATION OF MEDICAMENT • CONCLUSION • REFERENCES

3. INTRODUCTION DISINFECTION OF ROOT CANAL- Is defined as destruction of pathogenic microorganisms, presupposes previous adequate removal of pulp tissue and debris, cleaning and enlarging of the canal by biochemical means and clearing of its contents by irrigation.

4. Chemomechanical preparation - most important phase of endodontic treatment. ( but….. • Infected root canal- >108 bacteria/ml of canal content. • Disinfection of root canal is accomplished by ICM joined with copious irrigation.

5. Bacteria grow and multiply inside the root canal if no antibacterial dressing is used between the appointments. • ICM may be a valuable adjunct to chemomechanical preparation in the disinfection of root canal - reducing the endodontic microflora - therefore favoring periapical tissue repair.

6. HISTORY • 1045 AD - Seribonius wrote of using oils and wine in the mouth of a patient in pain. • Dental writings through the middle ages indicate the use of oil of cloves, a plant extract containing a high percentage of eugenol

7. 1840 - Beechwood creosate was mentioned in article ‘Creosate and cotton in Fang filling.’ • 1884 - Richmond advocated “Knocking out the pulp” by whittling down orangewood to a small size, soaking the stick in phenol and tapping this into exposed pulp canal.

8. Phenol was added to pre­serve and sterilize the contents of canal and to alleviate pain. • Formulations with sulphonamides and later antibiotics were tried as intracanal medicaments.

9. 1951 - Grossman’s polyantibiotic paste and 1962 Ledermix • Eugenol and corticosteroids - Reduction of pain

10. 1930 - Hermann introduced calcium hydroxide , which gained popularity in endodontics in the early 1980s and has been widely used as ICM even today…………….

11. REQUIREMENTS 1. effective germicide and fungicide. 2. non-irritating….. 3. stable.

12. 4. prolonged antimicrobial effect. 5. active in the presence of blood, serum and protein derivatives of tissues. 6. low surface tension…..

13. 7. Should not interfere with repair of periapical tissues. 8. Should not stain tooth structure. 9. Should not induce cell mediated immune response. 10. Should be capable of inactivation in a culture medium.

14. USES 1. Eliminate bacteria in the root canal 2. To reduce pain…… 3. Eliminate apical exudate…..... 4. Induce healing & hard tissue formation

15. 5. Renders contents of root canal inert. 6. Act as a physicochemical barrier, preventing root canal reinfection. 7. To control root resorption.

16. classification • By GROSSMAN 1.Essential oils – eugenol 2.Phenolic compounds – eg 3.Halogens- eg 4.Antibiotics 5.Other-formocresol -gluteraldehyde -Cresatin -N2 -Ca(OH)2 -Quaternary ammonium compounds

17. By COHEN 1. Phenolic preparations- phenol or carbolic acid eg- paramonochlorophenol, thymol, cresol 2. Formaldehyde preparation -formocresol -tricresol formalin 3. Halogen - chlorine - eg - chloramine T - Iodine- IKI 4. Calcium hydroxide 5. Bioactive glass 6. Superoxidized water

18. LIMITATIONS/ DRAWBACKS • Intracanal environment;;; DIRECT CONTACT • Duration • Toxicity- phenolics /aldehydes • Distribution- systemic circulation • Taste and smell- phenolics

19. Eugenol • Chemical essence of oil of clove • Slightly more irritating • Anodyne and antiseptic • Trowbridge has shown that eugenol inhibited intradental nerve impulses • A few reports of allergy has been found

20. Phenol/carbolic acid • Oldest antimicrobial agent - 1800s • Used bcoz of its disinfectant and caustic action • White crystalline substance • Derived from coal tar so odour • Liquid phenol- (9 + 1)

21. Phenol not anymore used as ICM - reasons • Used as disinfectant before periapical surgery and cauterizing tissue tags that resist removal with broaches or files

22. Phenolic derivatives • stronger antiseptic & toxins • Camphoration – less toxic • Dental preparation - 30% • Unable to produce strong antimicrobial vapour to kill the bacteria

23. Para-chlorophenol (PCP) • Substitution product of phenol in which chlorine replaces one of the hydrogen atoms • On trituration with gum camphor - forms an oily liquid • Harrison & Madonia recommended 1% aqueous solution of Para-chlorophenol

24. In vitro – destroyed a variety of microorganisms found in the root canals • Aqueous solution of para-chlorophenol penetrates deeper into the dentinal tubules than camphorated chlorophenol (Avny and associates, Taylor and collleagues)

25. Camphorated Para-chlorophenol • 35% PCP + 65% Gum camphor • Popular for a century • Camphor addition - Serves as a vehicle & diluent - Reduces irritating effect of pure PCP - Prolongs antimicrobial effect (Grossman, Ostrander and Crowley)

26. cresol • 3 times more powerful than phenol as disinfectant • Derivatives of phenol are stronger antiseptics and toxins than phenol • Campharation results in a less toxic phenolic compounds bcoz…….

27. ALDEHYDES/ Formocresol • 19% formaldehyde + 35% cresol dissolved in 46% glycerine and water • Non specific bacteriocidal medicament • Effective against aerobic and anaerobic organisms

28. Formalin – Strong disinfectant Combines with albumin to form insoluble , indecomposable substance • Highly irritating effect on soft tissue • Formocresol used against living tissue - necrosis followed by persistent inflammatory reaction

29. Transported to all parts of the body • MUTAGENIC AND CARCINOGENIC POTENTIAL NO CLINICAL REASON [COHEN] • Used in pulpotomy procedure in primary teeth

30. Gluteraldehyde • Colorless oil • Slightly soluble in water • Strong disinfectant and fixative • Toxic to periradicular tissue • Recommended 2% • Little or no inflammation on histologic examination of human material – but can cause hypersensitivity

31. Cresatin • Also known as metacresylacetate • Clear, stable, oily liquid • Claimed to have antiseptic & obtundant properties • Antimicrobial effect less than that of formocresol or camphorated para- chlorophenol ( Grossman) • Now not used anymore- reasons

32. N2 / SARGENTI PASTE • Term coined by Sargenti to describe second nerve ,that is placed during treatment • He coloured the material red so that it coincides with the colour of pulp • Sargenti technique was introduced to American dentists in early 1960s

33. Paraformaldehyde- primary ingredient- carcinogenic potential • Eugenol, phenyl mercuric borate, lead, corticosteroids, antibiotics, perfume • Used as intracanal medicament & sealer

34. Halogens Sodium hypochlorite • Bacteriocidal action • Tissue dissolution • Efficacy as medicament is limited - Chemical reaction depletes its efficacy rapidly - since canal needs to be flooded there may be interaction with temporary material

35. Iodides • Antiseptic • Low toxicity and good antibacterial effect in-vitro • Highly reactive and combine with proteins in a loosely bound manner so its penetration is not impeded • Destroys microorganisms by forming salts

36. Made by mixing- 4gms KI + 2gms iodine crystals + 94ml distilled water • Short duration antibacterial action • DRAWBACKS - tooth staining - long term efficacy not known - potential for allergic response

37. VITAPEX • Contains iodine and calcium hydroxide • Appears to combine best effects of iodoform and calcium hydroxide

38. Quarternary ammonium compounds • Lowers the surface tension of solutions • QAC are inactivated by anionic compounds • Bcoz QAC are +vely charged & microorganisms are –vely charged , a surface active effect results in which compounds clings to the microorganisms and reverses the charge • The compound 9-aminoacridine belongs to the group of mild cationic antiseptics and can stain tooth stucture

39. Antibiotics • Commonly used are..P,M,T,C,C,C,D,N,S,N • Advantages - Not toxic to periapical tissue - Do not stain the tooth - Active in presence of organic materials • Disadvantages - Limited spectrum…… - Development of bacterial drug resistance - Sensitization….

40. Sulpha preparations (Sulfanilamide & Sulfathiazole) • Sulphathiazole -1950 & 1960 • Used as medicament by mixing with sterile distilled water • Effective against Gram –ve & +ve • Ineffective against enterococci & Pseudomonas aeruginosa

41. Penicillin : • Grossman’s polyantibiotic paste contained Penicillin as important ingredient • P. aeruginosa & several anaerobic Gram –ve rods are resistant to Penicillin

42. Metronidazole : • Effective against Gram-ve, anaerobic microorganisms • Suggested as irrigant and intracanal dressing

43. Tetracycline: - Affinity for hard tissues and may be retained on tooth surfaces. - Antimicrobial spectrum is quite narrow and ineffective against oral and endodontic pathogens • Clindamycin: - limited antibacterial activity

44. PBSC Paste/ GROSSMAN PASTE Penicillin Bacitracin Streptomycin Caprylate / Nystatin = PBSN

45. STEROIDS • Used to relieve pain but limited anodyne action • Prednisolone, triamcinalone, hydrocortisone • Drawback- infection or inflammation can reoccur after sometime

46. Corticosteroid-Antibiotic combinations • Terro cortil • Cortisporin • Mycalog • Ledermix

47. Advantages of combination paste • Highly effective in treatment of over instrumentation. • Corticosteroids reduces periapical inflammation and gives instant relief from pain to the patient. • Antibiotic prevents overgrowth of microorganisms.

48. Disadvantages of combination paste • Mixing both reduces effect of individual component rather than synergism. • Steroids have depressive effect on defence mechanism. • Steroids increases risk of bacterimia- infective endocarditis and prosthetic heart valve

49. Chlorhexidine (CHX) • Broad spectrum antimicrobial agent • Widely used as a mouth rinse in the prevention and treatment of periodontal diseases • Suggested as an irrigating solution and intracanal dressing in endodontic therapy

50. Cationic bisbiguanide with optimal antimicrobial action over the pH range 5.5 to 7.0 • Strong antibacterial activity against wide range of Gram+ve and Gram-ve organism as well as yeast, facultative anaerobes and aerobes