CHAPTER

Intra-canal Medicaments
Osama Asadi, B.D.S, Published for Iraqi Dental Academy Blog

LECTURE OUTLINE
Intracanal Medicaments Indication

Mixing CHX with Ca(OH)2

Intracanal medicaments classification

Iodine-Potassium Iodide

Phenols and Aldehydes

Ledermix ( Steroid )

Calcium Hydroxide

Triple Antibiotic Paste

Limitations of Calcium Hydroxide

Bioactive Glass

Chlorhexidine Gel

After proper instrumentation and irragation of root canal, some dentists may place antibacterial agent inside
the canal and seal the cavity with temporary filling for the next appointment. The purpose of such practice is to
reduce the inter-appointment pain
decrease bacterial count and prevent regrowth and
to render the content of canal inert (biologically inactive).
INTRACANAL MEDICAMENTS INDICATION

PHENOLS AND ALDEHYDES

Although there are some controversy regarding

one-visit or multi-visit endodontic treatment. The use
of intracanal medicament is generally indicated in case
of:
Teeth with necrotic pulp that are been treated in
multi-visits.
Teeth that have failed root canal treatment and undergoing retreatment
Teeth with periapical pathology

They were common intracanal medicaments. However, their use is no longer recommended. Their components are cytotoxic, carcinogenic and mutagenic. They
are banned in several countries including USA.
There is no clinical reason to use Phenols or Aldehydes
as an intracanal medicament, the alternatives are better
and significantly less toxic.

INTRACANAL MEDICAMENTS
CLASSIFICATION
Till now there is no ideal material that server all theses
functions completely, several materials has been proposed throughout history, including:
Phenols
Aldehydes
Calcium Hydroxide
Chlorhexidine
Iodine-potassium iodide
Corticosteroids
Triple Antibiotic Past
Bioactive glass

CALCIUM HYDROXIDE
One of the most commonly used intracanal medicaments. And its the first choice as intracanal dressing
material by most dentists.

How to prepare and place?

Calcium hydroxide paste is prepared by mixing powder with sterile water or saline or local anesthetic solution. The mixture should be thick to carry as many
Ca(OH)2 particles as possible, however, do not overdried the mix to maintain solubility and high PH.
Lentulo Spiral are effective for placing the paste inside
the canal. Calcium hydroxide must placed to fill the
entire canal to the full working length. Care should be
taken not to extrude it beyond the apex. Rotary instruments has been suggested for placing the material into

the prepared root canal. Nevertheless, paper points can

do the job.

Limitations of Calcium Hydroxide

Despite its wide clinical use, it has been presented with
some limitations:
The handling and proper placement of material may
be difficult.
Removal of the paste also incomplete, even with
saline, NaOCl or EDTA, resulting in residual
Ca(OH)2 which shorten the setting time of zinc oxide eugenol based endodontic sealers, if used.
Its ineffective againts E. Faecalis, a common endodontic pathogen, and also ineffective against Candida Albican.
Although its effectiveness well documented in the scientific literature, recent researches present a contrary
results. So, the use of such material is controversial,
some researchers confirm the use of Calcium hydroxide
while others suggest its low effectiveness.
A recent meta-analysis published at the Korean Academy of Conservative Dentistry concluded that Calcium
hydroxide has limited antibacterial effect, the microorganisms were reduced but not completely eliminated after treatment, and some species has resistance to
Ca(OH)2. The majority of clinical studies supported
that there was no improvement in healing of periapical
lesions when Ca(OH)2 was applied between appointments. So, based on the current best available evidence,
Calcium hydroxide has limited effectiveness in eliminating bacteria from human root canals (source in the
last slide). But it remain the best available intracanal
medicament choice.

IODINE-POTASSIUM IODIDE
Its very effective intracanal medicament with low toxicity but its not available in the market. If you want to
use it, you should prepare it manually. Its prepared by
mixing 2 g of iodine in 4 g of potassium iodide, this
mixture is then dissolved in 94 ml of distilled water.
LEDERMIX ( STEROID )
Is anti-inflammatory agent that reduce pain and inflammation in the periapical tissue. Ledermix has been
advocated as intracanal dressing if the patient reported
symptoms of pain and inflammation.
However, Ledermix substances can reach the systemic circulation via diffusion through dentinal tubules,
lateral canals and apical foramen. Its use has been restricted in the United State. In addition to that, Ledermixed, which is a steroid, act as antiinfmmatory and
reduce the symptoms of pain, but the infection is still
there. This could mask the infection and deceive the
clinician. Therefore, they are not popular now despite
their common use in the past.
TRIPLE ANTIBIOTIC PASTE
Its composed of Metronidazole, Ciprofloxacin an Minocycline. It is very effective at eradicate baterial colonies in root canals. But it has some disadvantages:
Minocyline cause tooth discoloration.
Fear of bacterial resistance
high toxicity to stem cells
For tooth discoloration reason, dual paste can be used
in place of triple paste. Or use of Ca(OH)2 should be
considered.

CHLORHEXIDINE GEL

BIOACTIVE GLASS

Chlorhexidine has been recently introduced as intracanal medicament. In vitro studies has suggested that
CHX has at least as good or even better antibacterial
efficacy than Calcium hydroxide. While in Vivo studies the results where controversial. Some studies has
suggested its effectiveness while others have suggested
controversial results.
However, it is a common intracanl medicament and
represent the second best available choice.

It is a newly presented intracanal medicament. It found

to kill bacteria bu the mechanism of action is not ph-related. Some new obturating materials such as Resilon,
contain bioactive glass.

MIXING CHX WITH CA(OH)2

Mixing them has been suggested to increase the antibacterial action. However, many studies have been
published and the results were not conclusive. The usefulness of mixing is controversial and not confirmed.

REFERNENCES
The Korean Academy of Conservative Dentistry,
Antimicrobial effect of calcium hydroxide as an
intracanal medicament in root canal treatment: a
literature review Part II. in vivo studies
Cohens Pathways of Pulp, 11 Edition, Chapter
The Core Science of Endodontics, Intracanal Medicaments, p. 260
J Appl Oral Sci., Antibacterial effect of calcium
hydroxide combined with chlorhexidine on Enterococcus faecalis: a systematic review and meta-analysis