INTRACANAL MEDICAMENT IN ENDODONTICS. pptx

INTRACANAL MEDICAMENT IN ENDODONTICS. pptx

1. Intracanal medicaTION Dr. Sushmita S. Rane II M.D.S Seminar 8 21/06/23

2. Introduction Role of intracanal medicaments Treatment of pulpal necrosis and apical periodontitis Root canals contain viable microorganisms at the end of the first appointment used between appointments Other beneficial function Ca(OH)2 neutralizes the biological activity of bacterial lipopolysaccharides and makes necrotic tissue more susceptible to solubilizing action of NaOCl at the next appointment. Thorough cleanliness is achieved several appointments can also increase the risk for aseptic complications

3. DEFINITION “Temporary placement of medicaments with good biocompatibility into root canals for the purpose of inhibiting coronal invasion of bacteria from the oral cavity”. (Kawashima et al, 2009) “An antimicrobial agent that is placed inside the root canal between treatment appointments in an attempt to destroy remaining microorganisms and prevent re-infection” ( Weine 2004)

4. HISTORY Seribonius in 1045 AD 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.

5. HISTORY In 1800 specific medicaments were recommended for endodontic treatment. Beechwood creosote was mentioned in 1840 article ‘Creosote and cotton in Fang filling.’ 1884 Richmond advocated “Knocking out the pulp” by cutting down orangewood to a small size, soaking the stick in phenol and tapping this into exposed pulp canal. Phenol was added to preserve and sterilize the contents of canal and to alleviate pain

6. OBJECTIVES

7. IDEAL PROPERTIES

8. IDEAL PROPERTIES

9. Microbes The complex nature of the root canal system makes it quite difficult to entirely disinfect the root canal system in chronically infected teeth. Chemomechanical preparation is often not sufficient, and many bacteria might remain. So, antimicrobial medicaments have been introduced to accomplish complete sterilization of root canals and yield better treatment outcomes.

10. ROOT CANAL MICROFLORA 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.

11. The microbial flora of the root canals is likely to comprise organisms that can survive on dead pulp tissue. The endodontic problem is primarily one of eliminating gram-positive organisms because they are the most abundant, consisting chiefly of streptococci and staphylococci .

12. FIGURE (top) enterococcus faecalis colonizing dentinal tubules, a common model to assess the antimicrobial activity of endodontic medicaments. From zapata et al. ( 2008 ). (Bottom) bacteria from dental plaque colonizing the dentinal surface; (SEM; courtesy of ronald ordinola-zapata , david jaramillo, diogo guerreiro and claudia biguetti

13. E. Faecalis  has the capacity to proliferate in the deeper layers of dentine. Thus, the penetration of medicaments into dentinal tubules was evaluated by investigation of optical density of samples obtained by two different sizes of Gates Glidden drills ( i.e.  2 and 4) in addition to paper cones. The results showed that the most effective medicament against E. Faecalis was TAP and after that in descending order were CHX, Ca( O H)2, Nanosilver particles and normal saline. Other studies also demonstrated that, 2% CHX gel was effective against  E. Faecalis  even 21 days after root dentine treatment. In the study by Dametto   et al. 2% CHX gel and 2% CHX liquid significantly reduced the number of  E. Faecalis  colonies.  Recent Studies

14. Žƒ Classification by Grossman DCNA (Dental Clinics of North America) : Based on their chemical nature. 1)PHENOLICS Eugenol Camphorated monoparachlorophenol (CMCP) Parachlorophenol (PCP) Camphorated parachlorophenol (CPC) Metacresylacetate ( Cresatin ) Cresol Creosote (beechwood) Thymol

15. Commonly used Intracanal medicament

16. PHENOLS Phenol is one of the oldest antiseptics introduced by Lord Lister into medicine in 1876. It was thought that because of their volatile properties, they could penetrate dentinal tubules and anatomic irregularities. However, later it was demonstrated that these compounds have a short life span. Causes toxicity

17. Despite the severe toxicity of phenolic preparations, derivatives of phenol, such as Paramonochlorophenol (C6H4OHCl), Thymol (C6H3OHCH3C3H7), and Cresol (C6H4OHCH3) remain available.

18. 1) Eugenol an essential oil but chemically related to phenolic compounds. mild anaesthetic action + antiseptic properties + characteristic clove like odour. In low concentrations, it has anodyne effect. less irritating than phenol, having hemolytic action. wide range of action + bacteriostatic in nature USES Temporary Dressing Antiseptic dressings following pulpectomy as it increases the microhardness of dentin controls neural conduction.

19. 2)CRESOL It is acquired from coal tar with or without containing a trace of phenol having properties like Ortho, Meta and Para-isomeric cresol. It has a phenolic odour and is a colourless or pinkish liquid. Cresol (C 6 H 4 OHCH 3 ) can substitute phenol considering its 3-times more powerful disinfectant capacity.

20. PARACHLOROPHENOL It is a derivative of phenol that has 3 isomers of which parachlorophenol is the most effective. Chlorine one hydrogen atom Parachlorophenol (C 6 H 4 OHCl) Crystals of parachlorophenol are soluble in ether, alcohol, alkalies . It mixes with gum camphor to generate an oily liquid after being triturated.

21. CAMPHORATED PARACHLOROPHENOL (CPC) In 1891, Walkhoft introduced camphorated parachlorophenol

22. It has specific aromatic odour a transparent light amber coloured oily liquid. The camphor present in camphorated parachlorophenol reduces irritating effect of pure parachlorophenol act as a diluent and vehicle.

23. FORMOCRESOL Formaldehyde, used as formocresol , is highly toxic, mutagenic, and carcinogenic; however, it has been used extensively in endodontic therapy. It is a compound of 19% Formaldehyde 37% Cresol 46% Glycerine with water It has distinctive odour and found in the form of transparent reddish liquid which is mixture of 3 isomers.

24. The bactericidal effect of formocresol is good at levels as low as 2%. It is a strong poison and causes widespread destruction of living tissue followed by a persistent inflammatory reaction. There is no clinical reason to use formocresol as an antimicrobial agent for endodontic treatment, based on what is known at this time as there are many alternatives which are better antiseptics with significantly lower toxicity. Protein Coagulating Effect of phenolic compounds Alkylating effect of formaldehyde

25. Studies Bystorm et al reported that Ca(OH)2 was superior to camphorated parachlorophenol in its antibacterial potential when used for 4 weeks as local intracanal medicament Several studies RAPID LOSS OF ACTIVITY OF CMCP IN THE CANAL is reported In vitro studies have shown that phenol and its derivatives are highly toxic to mammalian cells and their antimicrobial effectiveness does not sufficiently balance their toxicity.

26. CHLORHEXIDINE It is a cationic bisguanide with low toxicity to periapical tissues and good antimicrobial efficacy against a broad range of micro-organisms. The active agent stays in contact with the canal wall and dentinal tubules due to low viscosity. Mechanism of action: CHX adsorbs in to the cell wall of microorganisms and causes leakage of intracellular components.

27. The combination of CHX and calcium hydroxide inhibits complete growth of E. faecalis after 24-48 hours with tapered decline over a week which can be attributed to the high pH of the combination product. At lower concentrations Bacteriostatic intra-cytoplasmic contents to leak out At Higher concentrations Bactericidal Precipitation and coagulation of cytoplasm

28. Studies show that Chlorhexidine is more effective in elimination of E. faecalis inside dentinal tubules. Chlorhexidine both alone and along with calcium hydroxide showed more antibacterial efficacy against E. faecalis than calcium hydroxide alone. ( Nidhi sinha et al, 2013) On one hand, CHX inhibits experimentally induced inflammatory external root resorption when applied for 4 weeks. In infected root canals, it was shown to reduce bacteria as effectively as Ca(OH)2 applied for 1 week Studies 1. Substantivity 2.Effect depends on concentration and not mode of application

29. Studies An in vivo study assessed the antimicrobial efficacy of 3 different intracanal medications applying them for 1 week in single rooted teeth in apical periodontitis The proportions of + ve cultures were slightly lower in teeth medicated with 0.12% CHX liquid than those medicated with camphorated paramonochlorophenol and Ca(OH)2 Camphorated paramonochlorophenol Ca(OH)2 0.12% CHX liquid

30. CH + CHX combination is effective against E.faecalis both in vitro and in vivo.CH + CHX has prolonged antibacterial effect for 14 days when utilised.CH + CHX loses the antibacterial effects after 21 days so it should be renewed when they are needed to be used for a period longer than 14 days.

31. CALCIUM HYDROXIDE most popular It was introduced by Hermann in 1920. It is mostly used as slurry of Ca(OH)2 in a water base Ca(OH)2 Water Ca++ OH- ions

32. Main characteristics of Ca(OH)2:

33. How Calcium Hydroxide works?

34. For how long the Ca(OH)2 should be placed? The American Association of Endodontists recommends the application of intracanal medicament for a minimum of 1 week for clinical regenerative procedures. I t has been reported that a 7-day interappointment dressing with Ca(OH) 2  was sufficient to reduce intraradicular bacteria to a level that provided a negative culture. However, the long-term exposure to interappointment medicament has been suggested to affect the mechanical properties of root dentin by either collagen degradation in the case of Ca(OH) 2  or excessive demineralization in the case of antibiotic pastes that might affect the root fracture resistance.

35. A study revealed that pretreatment with calcium hydroxide increased the tissue dissolving efficacy of 0.5% sodium hypochlorite plus ultrasonic irrigation.

36. (a) Symptomatic apical periodontitis associated with a maxillary central incisor with pulp necrosis in a 28-year- old patient. Observe the well-defined large radiolucency and the radiographic characteristic of a ‘through-and- through bone defect’.

37. b) A mandibular second premolar with complex anatomy presenting an ill-defined periapical radiolucency with furcation involvement and a J-shaped lesion .

38. Other uses of Ca(OH)2 Apexification of immature tooth with pulpal necrosis Revascularization

39. 11 years old patient with pulp necrosis, symptomatic apical periodontitis and external inflammatory root resorption. All these conditions are consequence of a previous dental trauma in both maxillary central incisors. There are ill-defined radiolucencies (a–b).Multiple resorptive defects are observed in the coronal and sagittal cone-beam computed tomography sections (c).

40. Clinical protocol Ca(OH)2 powder + sterile water or saline. Placed into the canal with using Lentulo paste filler. Alternatively, the mix may be applied from sterile or single dose packages (e.g. Calasept , Calcijet ) The mixture should be thick For maximum effectiveness, the root canal should be filled homogeneously to the working length

41. LIMITATIONS OF Calcium hydroxide :

42. Ca(OH)2 is a slow-acting antiseptic; direct-contact experiments in vitro show that a 24-hour contact period is required for complete killing of enterococci. Another study of 42 patients found that NaOCl canal irrigation+ Ca(OH)2 (1 week) = 92.5% reduction

43. Studies 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. One clinical study has shown that the number of bacteria positive canals actually increased after Ca(OH)2 medication Other studies have also indicated that Ca(OH)2 could not eliminate bacteria or that cultures changed from negative to positive after Ca(OH)2 placement Therefore, based on recent evidences, Ca(OH)2 has limited effectiveness in eliminating bacteria from canals when assessed by culture techniques

44. Various preparation of Ca (OH)2

45. CALAXYL was introduced by Hermann(1920) Composition: Rohner (1940) used this paste to demonstrate the deposition of apical barrier after vital pulpectomy. Uses direct pulp capping, pulpotomy , Apexification & In orthograde RCT Ca(OH)2 in water + NaCO 3 , NaCl, CaCl 2 , KCl & traces of Mg.

46. TEMPCAL Composition: The aqueous suspension allows flow through 22, 25 & 27 gauge needles These are used in management of post bleaching cervical resorption, as an apical plug prior to obturation of RCT of chronic periapical lesions (Burke 1976). - Ca(OH)2 (52.2%) in aqueous suspension of Methylcellulose -Barium sulfate

47. HYPOCAL Composition: calcium hydroxide 45%, barium sulphate 5%, hydroxymethylcellulose 2% water 48%. CALCIPULPE Composition: Calcium hydroxide Carboxymethylcellulose.

48. CALEN Composition: Calcium hydroxide (2.5 g), zinc oxide (0.5 g), Hydrogenized colophony (0.05 g) polyethylene glycol (1.75 mL). This is the unique proprietary brand of a calcium hydroxide paste containing this viscous vehicle.

49. VITAPEX This paste is very popular in Japan and was introduced by Kawakami et al. (1979). Composition: calcium hydroxide (30.3%) iodoform (40.4%), silicone oil (22.4%)

50. Vitapex is used all over the world.mainly in Japan,the US, and South America. when extruded into furcal or apical areas, can either diffuse away or be resorbed in part by macrophages in as short a time as one or two weeks.. Vitapex , used as a root canal filling material for pulpectomy treatment for primary teeth resorbed extraradicularly and intraradicularly without apparent ill effect, proved to be clinically and radiographically successful.

51. RC CAL Composition: C alcium hydroxide Barium sulfate Ready to use paste for intra canal temporary filling. Radio opaque Ca (OH) 2 . Highly alkaline. Can be easily removed by reamers. Non drying paste.

52. Halogens Intracanal dressing in the form of chloramine-T, an N-chloro- tosylamide sodium salt. Iodine, in the form of IKI i.e Iodine Potassium Iodide, is a very effective antiseptic solution with low tissue toxicity. IKI releases vapors with a strong antimicrobial effect.

53. Preparation of the solution: Tincture of iodine (5%) has proved to be one of the few reliable agents for disinfecting rubber dam and tooth surfaces during the preparation of an aseptic endodontic work field. 2 g of iodine in 4 g of potassium iodide dissolved in 94 ml of distilled water.

54. STEROIDS Ledermix ( Riemser Arzneimittel AG, Insel Riems, Germany) is a commercially available product that was developed in 1960 by Prof. André Schroeder. Ledermix (glucocorticoid antibiotic compound) 1% triamcinolone acetonide (Anti-inflammatory corticoid) 3.21% demeclocycline (Broad spectrum antibiotic)

55. Mechanism action : Inhibition of the ribosomal protein synthesis in the bacteria. The clinical effect: is a rapid relief of pain associated with acute inflammatory conditions of the pulp and periodontium. Studies: -The release and dentin diffusion characteristics of triamcinolone when used as root canal medicament have been investigated -It showed that Triamcinolone is released from paste in the root canal and can reach the systemic circulation via diffusion through dentinal tubules, lateral canals and apical foramen

56. A 50:50 mixture of Ledermix paste and calcium hydroxide has been advocated as an intracanal dressing in cases of Pulp necrosis and Apexification Perforations Inflammatory root resorption Inflammatory periapical bone resorption Large periapical radiolucent lesions

57. Triple Antibiotic paste The triple-antibiotics regimen was first tested for its effectiveness against Escherichia coli and also its bactericidal efficacy against microbes. Triple Antibiotic Paste (Sato et al 1996) = Minocycline (100mg) Ciprofloxacin (200mg) metronidazole (500mg) Propyelene glycol, saline (as carrier)

58. Triple antibiotic powder, either mixed with normal saline or 2% chlorhexidine, produced the largest zone of inhibition against E. faecalis CONCENTRATIONS USED 1:1:1 - Hoshino et al ,1996 1:3:3- Takushige T et al, 2004 Clinical effectiveness of the TAP in the disinfection of immature teeth with apical periodontitis has been reported

59. Some Potential Concerns : Bacterial Resistance intracanal use of minocycline can cause tooth discoloration. In other studies, it was shown that applying DAP or TAP for 1 month significantly reduced dentin microhardness Dual paste metronidazole+ciprofloxacin ) Calcium Hydroxide

60. In a restrospective study, Bose et al. got to the result that regenerative endodontic treatment with TAP and calcium hydroxide has more significant effects in increasing the root length than either the non-surgical root canal treatments or MTA apexification. Lovelace et al. showed that the evoked-bleeding step in regenerative procedures after disinfection with TAP induces the accumulation of undifferentiated stem cells into the canal space from periapical region. Thus, root canals disinfected with sodium hypochlorite and TAP had a significantly less chance of having a periapical lesion, and higher chances of gaining root length and wall thickness.

61. PBSC Paste based medications can be injected in root canals also can be impregnated on paper points. Composition: Potassium penicillin G (10,00,000 units) Gram+ve Organisms Bacitracin (10,000 units) Penicillin resistant strains Streptomycin paste (1gm) Gram- ve Organisms Sodium caprylate / Nystatin (1gm) Yeasts or fungi

62. Now Nystatin replaces sodium caprylate as the antifungal agent i.e PBSN. Ineffective against anaerobes. Because of the risk of sensitivity from topical antibiotics and the declining popularity of intracanal injections, the use of PBSC has become outdated. In 1975 – banned due to allergic reactions due to penicillin.

63. Bioactive glass still under investigation. It isn't as effective as 2% chlorhexidine, although it is better than Ca(OH)2. Bioactive glass was discovered to be effective in disinfecting germs from canals, although the action was not pH dependent, and the dentin had no effect Some newer obturating materials (e.g. Resilon ) contain Bioactive glass

64. Mechanism of Action : The antibacterial activity of BAG depends on the following factors acting simultaneously: High pH: An increase in pH because of release of ions in an aqueous environment Osmotic effects: An increase in osmotic pressure above 1% is inhibitory for many bacteria Ca/P precipitation: Induces mineralization on the bacterial surface

65. NATURAL INTRACANAL MEDICAMENTS

66. PROPOLIS It has active constituents like flavonoids, phenolics and aromatics. Propolis has a very wide range of biologic activities including antimicrobial, anti-inflammatory, antioxidant, anaesthetic , and cytotoxic properties.

67. Rezende et al. evaluated the antimicrobial activity of 2 experimental pastes containing propolis extract associated with calcium hydroxide in primary molars of 4-8 year-old children. They concluded that the association between propolis and calcium hydroxide was effective in controlling dental infections in vitro. 54

68. AZADIRACHTA INDICA Neem. Has an excellent and wide range of antimicrobial activity. The most important active constituents that contribute to the wide range of antimicrobial activity are azadirachtin, nimbolinin , nimbin , nimbidin . Neem has been tested for its antibacterial and antifungal activities in dentistry. Intracanal medicaments and irrigants that contained neem have been tried and tested over time

69. ARCTIUM LAPPA Arctium lappa is a plant obtained in Japan. It has been widely used in medicine as it possesses significant antibacterial, antioxidant and antifungal properties. The antibacterial activity has been attributed to the presence of polyacetylenes. Great antimicrobial potential by arctium lappa against root canal microbes has been observed

70. In vitro study –the evaluation of the antibacterial activity of  Arctium lappa  as a phytotherapeutic agent used in intracanal dressings -Marcelo Gentil et al This study evaluated the antibacterial activity of a phytotherapeutic agent prepared from an ethyl acetate fraction ( AcOEt ) extracted from  Arctium lappa . This agent was compared with calcium hydroxide as an intracanal dressing.   The phytotherapeutic agent inhibited the growth of all the microorganisms in this study.

71. EUCALYPTUS OIL It is an essential oil, obtained from the leaf of Eucalyptus with anti-inflammatory and antibacterial activities. It has a wide spectrum of antimicrobial action and its potential use as a vehicle for calcium hydroxide has indicated an effective intracanal medicament.

72. MORINDA CITRIFOLIA Widely known as Indian mulberry. It possesses a wide range of uses given its antibacterial, antiviral, anti-inflammatory, antioxidant and analgesic properties . Morinda citrifolia exhibits a good inhibition zone against E. Faecalis and hence can be used as an efficient intracanal medicament

73. CURCUMA LONGA Turmeric . It exhibits good antioxidant, antimicrobial and anticancer activity with curcumin as an active ingredient. Curcuma longa can be used as an intracanal medicament as reported by Kumar et al 2013

74. PAPAIN Papain is a proteolytic cysteine enzyme with significant antibacterial and anti-inflammatory properties. It can be used as an intracanal medicament

75. OCIMUM SANCTUM Tulsi Belongs to the Labiateae family and exhibits antibacterial, antifungal and antiviral properties. Ocimum sanctum’s essential oil extract has excellent antibacterial effect which increases with increase in concentration.

76. ALLIUM SATIVUM Garlic. It has a broad spectrum of antimicrobial properties with both bacteriostatic and bactericidal activities. The antimicrobial potency is due to its ability to inhibit toxin production and expression of enzymes for pathogenesis

77. CUMIMUM CYNIMUM Cumin It has been reported to have excellent antioxidant, antibacterial, antifungal and analgesic properties. Activity against E. Faecalis tested and presents with good biocompatibility, effective to be used as an intracanal medicament.

78. ALOE VERA Aloe vera belongs to the liliaceae family. Medicinal products are made from the mucilaginous tissue in the centre of the aloe vera leaf and is called aloe vera gel. Total leaf extracts contain anthraquinones, which have antibacterial properties. Aloe vera has also been evaluated for its antibacterial efficacy and tested as an intracanal medicament.

79. FOENICULUM VULGARE Fennel seed It has antimicrobial, anti-inflammatory, analgesic, antispasmodic, antioxidant, diuretic and anti-cancer properties. In-vitro analysis suggested its use as an intracanal medicament.

80. GREEN TEA The polyphenols found in green tea have antimicrobial, antioxidant, anti cariogenic, anti inflammatory properties. Green tea has antibacterial property against E faecalis planktonic cells Leena P. Martina et al. stated 3% concentration of green tea extract showed an antibacterial activity equivalent to 2% CHX against E. faecalis.

81. DRUG DELIVERY SYSTEMS Drug delivery systems (DDS) have been used widely to increase the pharmacological effect of different drugs, reducing their side effects as, in most forms of administrations, only a small amount of the administered dose actually reaches the infected target site For this reason, nanoparticles, solid polymer, and colloidal particles with diameters ranging from 1 to 1000 nm have been evaluated as drug carriers in root canal disinfection procedures.

82. Antibacterial NANOPARTICLES Nanoparticles with their enhanced and unique physicochemical properties, such as ultrasmall sizes, large surface area/mass ratio, and increased chemical reactivity, have led research toward new prospects of treating and preventing dental infections.

83. Nanoparticles CHITOSAN NANOPARTICLES Chitosan (poly[1,4-b-D-glucopyranosamine]), a deacetylated derivative of chitin, is the most abundant natural biopolymer SILVER NANOPARTICLES

84. CHITOSAN NANOPARTICLES

85. I n vitro study, Chitosan-Nanoparticles were used in combination with different brands of chlorhexidine to eliminate E. faecalis with potential application toward tissue regeneration using membrane barriers in periapical surgery. The addition of Chitosan-Nanoparticles provided a significantly greater reduction of colony-forming units in agar plates as well as infected collagen membranes.

86. SILVER NANOPARTICLES

87. S tudy showed that the antibiofilm efficacy of Ag-NPs was significant when applied as a medicament ; 0.02%Ag-NP gel for 7 days was found to be significantly better in E. faecalis biofilm disruption compared with Ca(OH)2 groups and syringe irrigation with higher concentration Ag-NP (0.1%) solution. They suggested that when used as medicament there is a prolonged interaction between positively charged Ag-NPs and negatively charged biofilm bacteria/ structure resulting in this difference.

88. conclusion Elimination of microbial contamination from the root canal system is a pre-requisite to the successful outcome of the root canal treatment. The evidence shows that mechanical instrumentation, irrigation and use of inter- appoinment medication are all important in this regard. Thorough canal debridement and adequate canal preparation along with irrigation are more pertinent and their importance is emphasized. However , ICM should be used only for root canal disinfection as a part of controlled asepsis in infected root canals and their role is secondary to cleaning and shaping of the canal.

89. REFERENCES C O H E N ’ S P A T H W A Y S of the PULP INGLE’S ENDODONTICS 6TH edition Application of Intracanal Medicaments: A Review Himadri pal, Arpita sarkar, Lopamoodra das, Subrata saha , Subir sarkar. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) Volume 18, Issue 1 Ver. 3 (January. 2019), PP 14-21 Novel Intracanal Medicaments And Its Future Scope Pallavi Yaduka * & Subash Sharma IJPBS |Volume 4| Issue 3|JUL-SEPT|2014|65-69 Sharad Kamat et al. Role of herbs in endodontics: An update. Endodontology. Hemadri M et al. Nisin Vs Calcium Hydroxide – Antimicrobial Efficacy on Enterococcus Feacalis – An In-vitro Study. International Journal of Contemporary dentistry. June 2011; 2(3).

90. Al- Sabawi NA, Mohammad FA, Shehab NF. Residual antibacterial effect of calcium hydroxide combined with chlorhexidine gel as an intracanal medicament.Indian J Dent Res 2020;31:846-851 Sjogren U, Figdor D, Spangberg L, Sundqvist G. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing.  Int Endod J. Ordinola-Zapata,R.,Noblett , W.C., Perez-Ron, A., Ye, Z. & Vera, J. (2022) Present status and future directions of intracanal medicaments. International Endodontic Journal , 55(Suppl. 3), 613–636. Harsha P Rathi, Manoj Chandak, Payal Chaudhari, Anuja Ikhar , Intracanal Medicaments and Its Recent Advances: A Review, J Res Med Dent Sci, 2022, 10 (11): 163-167.

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