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Except for the maxillary molars, the orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the centre of the floor of the pulp chamber.

1. INTRACANAL MEDICAMENTS DR. Khalid Alrashedi

2. RATIONALE The main rational behind intracanal medicament is to kill the bacteria inside the root canal and to avert reinfection. Furthermore, anaerobic bacteria may invade the dentinal tubules of the canals with necrotic pulps. The medicament should inhibit microbial re-colonization of the cleaned parts of the root canal system by preventing Residual microorganisms from growing New microorganisms invading

3. Why use medicaments? Australian Dental Journal 1990;35:5.

4. Requirements of an Ideal Root Canal Medicament: (GROSSMAN)

5. OBJECTIVES 1. Destruction of micro-organisms: The main objective is to kill all viable microorganisms or to disinfect all pathogens in the canal space. 2. Prevention or control of post-treatment pain: The main indication is to lessen or alter the inflammatory effect. Medicament will execute this with its antimicrobial action or by pharmacologically altering the inflammatory effect.

6. Parachlorophenol It has been a very popular component of dressing as phenol is no longer used in endodontics because of its high toxicity to efficacy ratio. Composition This is substitution product of phenol in which chlorine replaces one of the hydrogen atoms (C6H4OHCl). Concentration: 1% aqueous solution is preferred. Uses: Used as a dressing of choice for infected tooth.

7. ALDEHYDES Formaldehyde, and paraformaldehyde are commonly used intracanal medicaments in root canal therapy. These are water-soluble protein denaturing agents and are considered among the most potent disinfectants. All formaldehyde preparations are potent toxins with an antimicrobial effectiveness much lower than their toxicity.

8. Formocresol contains formaldehyde as its main ingredient and is still widely used medicament for pulpotomy procedures in primary teeth, but its toxic and mutagenic properties are of concern. Composition of formocresol •  Formaldehyde — 19% •  Cresol — 35% •  Water and glycerine — 46% FORMOCRESOL

9. HALOGENS Disinfectant action of the halogens is related its atomic weight, and its action is inversely proportional. Chlorine is having greatest disinfectant action among the members of this group also having lowest atomic weight. Sodium hypochlorite and Chloramines are the source of active chlorine which is used for short term dressing of the root canal.

10. Chlorine compound has excellent antimicrobial properties. It is a chlorine compound with a good antimicrobial action. It is used in the concentration of 5%. Mentz found sodium hypochlorite as effective intracanal medicament as well as irrigant . It can be used to disinfect gutta-percha points and can be used in patients allergic to iodine. CHLORINE

11. Iodine in the form of Iodine potassium iodide ( IKI), is a very effective antiseptic solution with low tissue toxicity. IKI is an effective disinfectant for infected dentin and can kill bacteria in infected dentin in 5 minutes in vitro. IKI releases vapors with a strong antimicrobial effect. The solution can be prepared by mixing 2 g of iodine in 4 g of potassium iodide; this mixture then is dissolved in 94 ml of distilled water. IODINE

12. CALCIUM HYDROXIDE Hermann introduced the use of Ca(OH) 2 in endodontics in 1920. It is a crystal that is poorly soluble in water and only induces localized effects. The bactericidal effects are caused by its high pH (12.5-12.8), which prevents the growth and survival of bacteria, most of which cannot survive pH 11 or above.

13. Limitations of Calcium Hydroxide The handling and proper placement of Ca(OH) 2 present a challenge to the average clinician. Also, the removal of Ca(OH) 2 is frequently incomplete, resulting in a residue covering 20% to 45% of the canal wall surfaces, even after copious irrigation with saline, NaOCl , or EDTA. Residual Ca(OH) 2 can shorten the setting time of zinc oxide eugenol–based endodontic sealers. Most notably, it may interfere with the seal of the root filling and compromise the quality of treatment.

14. An additional concern is that Ca(OH) 2 is not totally effective against several endodontic pathogens, including E. faecalis and Candida albicans. In vitro studies have shown that dentin can inactivate the antibacterial activity of Ca(OH) 2

15. CHX in liquid, or gel, has been suggested as an alternative intracanal medication to replace Ca(OH) 2 . Chlorhexidine exhibits broadspectrum activity and low toxicity , these properties make it well suited for irrigation and dressing applications in endodontics. CHLORHEXIDINE(CHX)

16. INDICATIONS FOR ANTIBIOTIC PASTES

17. LEDERMIX Schroeder developed the material that is now commercially marketed as Ledermix paste. Ledermix paste is a glucocorticosteroid -antibiotic compound.

18. Ledermix paste placed in the root canal has been shown to be capable of diffusing through the dentinal tubules and cementum to reach the periodontal and periapical tissues. It can be used in all cases involving inflammation and/or infection associated with the root canal system and periapical tissues, even if the apical foramen is blocked or closed .

19. The placement of Ledermix paste in the root canal space has been reported to add to the efficacy of the treatment of periapical infection and has been reported to reduce the incidence of pain following initial canal debridement. Ledermix paste is a non-setting , water-soluble paste material for use as root canal medicament.

20. COMBINING MEDICAMENTS Several reports have discussed the effect of combining Ledermix paste with calcium hydroxide in a 50:50 mixture. A higher success rate was reported over conventional calcium hydroxide therapy, especially in producing calcified bridging and in preventing an acute exacerbation of an already existing inflammation.

21. Antiseptic or disinfectant dressings should preferably be changed after a week and not longer than two weeks. Frequency of medication?

22. Temporary Restorations 38

23. a Except for the maxillary molars, the orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the centre of the floor of the pulp chamber. Except for the maxillary molars, the orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the centre of the floor of the pulp chamber.

24. Except for the maxillary molars, the orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the centre of the floor of the pulp chamber. Except for the maxillary molars, the orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the centre of the floor of the pulp chamber.

25. Objectives of temporary restorations: 1. Restoration of occlusion: Provisional temporary restoration will restore the occlusion and will prevent the tooth from tilting, drifting or over-eruption, if left for a long period with temporary dressing. 2. Protection of the periodontium: This is especially true in Class II cavities. Leaving the proximal surface without provisional temporary restoration will invite food impaction to occur with its complications on the periodontium. 3. Putting the tooth into function: This is very important, as concentration of occlusal stresses will be distributed on both sides otherwise only one side will be functioning, and the other side will be non-functioning. 4. Protecting the tooth from fracture: Putting a provisional restoration into the cavity will protect the tooth against fracture under the components of forces.

26. Requirements of an ideal temporary restoration (goals): Manipulation goals: Ease of use. Ease of placement, shaping and removal. Ease of repair. Efficient reaction with no or little exothermic heat. Fast setting.

27. Materials performance goals : Good fracture and wear resistance (high strength). Good biocompatibility (no sensitivity or toxicity reactions). Good esthetics ( good color matching and stain resistance). No or little solubility and disintegration. Radio-opaque.

28. Types and Indications of Temporary Restorations: Conventional zinc-oxide and eugenol: Zinc oxide and eugenol paste is considered as a disinfectant and is the best sealer of the cavity against saliva and bacteria. Eugenol containing dressings have significant antimicrobial activity due to their slow release of zinc and eugenol.

29. Modified zinc-oxide and eugenol: It consists of conventional zinc oxide powder reinforced with several additives, such as silica and alumina fillers or ethoxybenzoic acid to increase the strength and decrease the setting time. It is indicated in either extensive cavities or for long term temporization.

30. THANK YOU