RECENT

ADVANCES IN
INTRACANAL
MEDICAMENTS
 CONTENTS

▫ Introduction
▫ Ideal requirements
▫ Indications
▫ Classification
▫ Phenolic compounds
▫ Aldehydes
▫ Halogens
▫ Calcium hydroxide
▫ Chlorhexidine
▫ Corticosteroid- antibiotic combinations
▫ Herbal medicaments
 INTRODUCTION

 A medicament is an antimicrobial agent that is placed inside the root canal

between treatment appointments in an attempt to destroy remaining
microorganisms and prevent reinfection (Weine 2004)
 Intracanal medicament is defined as temporary placement of medicaments
with good biocompatibility into root canals for the purpose of inhibiting
coronal invasion of bacteria. (Kawashima et al 2009)
 GROSSMAN’S REQUIREMENTS OF AN IDEAL ROOT
CANAL MEDICAMENT

Not interfere with the

Effective Prolonged Nonirritating to the
repair of
antimicrobial agent antimicrobial effect periradicular tissues
periradicular tissues

Active in the presence

Not induce a cell-
Remain stable in of blood, serum, and Not stain tooth
mediated immune
solution protein derivatives of structure
response
tissue

Grossman’s Endodontic Practice, 13ed

 Chong and Pittford’s Indications
of Intracanal Medicaments

To act as a barrier
against leakage
To dry persistently To eliminate any
To neutralize tissue from an
wet or the so-called remaining microbes
debris interappointment
weeping canals in the pulp space
dressing in
symptomatic cases
 CLASSIFICATION

According to Grossman (1990)

Phenolic Quaternary
Essential oils Halogens Ammonium
compound
compounds

Para chlorophenol Sodium 9-amino

Eugenol Phenol
(PCP) hypochlorite acridine

Camphorated para
Formocresol Iodides
chlorophenol (CPC)

Glutaraldehyde Cresatin
 According to Franklin S. Weine (1995)

Phenolic Corticosteroid- Calcium

PBSC Sulphonamides antibiotic
compound hydroxide
combinations

Eugenol CPC Penicillin

Cresatin Cresol Bacitracin

Thymol Streptomycin

Caprylate
 According to DCNA

Halides Calcium Combinations

Phenolics Aldehydes Steroids Antibiotics
hydroxide

Eugenol CMPC Sodium

Formocresol
hypochlorite

PCP CPC Potassium

Glutaraldehyde Iodide

Cresatin Cresol

Creosote Thymol
 Trowbridge et al. showed that it inhibits interdental nerve impulses.
30% phenol, 60%
It has been shown to be irritating to tissues.
camphor, 10% ethyl
Acetic acid ester of alcohol.
EUGENOL
metacresol. Least toxic of the
It has both antiseptic CPC phenolic compounds.
CRESATIN
and obtundant Excellent antimicrobial
PHENOLIC
properties and it is less COMPOUNDS effect and also relieves
irritating to the tissue. pain.

CRESANOL PCP
Cresatin, P-chlorophenol The aqueous solution
CMCP
and camphor in 1:1:2 penetrates deeper into the
ratio. dentinal tubules, than
It is found more effective CPC.
Developed by Walkhoff in 1891
than cresatin as an 1% solution is capable of
Contains : 35% monochlorophenol 65% camphor
antiseptic and less killing micro organisms in
It is used in the form of vapor which can pass through the apical
irritating than the canal and produces
foramen.
chlorophenol. mild inflammation.
Good antimicrobial effect but is highly toxic.
 ALDEHYDES
▫ FORMOCRESOL ▫ GLUTARALDEHYDE
 Developed by BUCKLEY in 1906  It is a colorless slightly acidic, strong
 Contents : 19% formaldehyde 35% disinfectant and fixative which
cresol 46% glycerin and water (1:2) soluble in H2O and used in
 Non- specific bacterial medicament concentration of 2%
most effective against aerobic and  Its molecular weight is high
anaerobic organisms. compared to formaldehyde hence
 Studies have reported that does not penetrate into the periapical
formocresol treated tissue produced tissues. However it can irritate soft
a cell mediated immune response. tissues and can cause ulcerative
lesions

Cohen’s Pathways of the Pulp, 11ed (2016)

 HALOGENS

IODINE CHLORINE
▫ Very effective antiseptic solution ▫ Have greatest disinfectant action
with low tissue toxicity. among the members of this group,
Eg. Iodine potassium iodide having lowest atomic weight.
▫ It is an effective disinfectant for Eg. Sodium hypochlorite, Chloramine T
infected dentin and can kill bacteria ▫ In case of allergy to iodine
in infected dentin in 5 minutes in compound, Chloramines (5%) is a
vitro. (Barbaran et al, S Lin et al.) good medicaments having low
▫ Releases vapors with a strong toxicity.
antimicrobial effect.

Kumar A, Tamanna S, Iftekhar H. Intracanal medicaments – Their use in modern endodontics: A narrative review. J Oral Res Rev 2019
 CALCIUM HYDROXIDE

▫ Calcium hydroxide is the most popular intracanal medication in use.

▫ Introduced by Hermann in 1920.
▫ Highly alkaline substance with a pH of approximately 12.5
▫ Calcium hydroxide has antibacterial properties and has the ability to
induce repair and stimulate hard-tissue formation.
▫ Ca(OH)2 mostly is used as slurry of Ca(OH)2 in a water base.

Cohen’s Pathways of the Pulp, 11ed (2016)

MECHANISM OF ACTION
 INDICATIONS

Cohen’s Pathways of the Pulp, 11ed (2016)

 LIMITATIONS

▫ Difficult to remove from the canals

▫ Can interfere with sealing ability of zinc oxide eugenol based sealers
▫ Studies have shown that even though it is a potent anti bacterial agent but
it’s efficacy against E.faecalis and Candida albicans is low. (Gomes et al,
Prabhakar et al.)
▫ Waltimo et al. found that C. albicans cells were highly resistant to Ca(OH) 2
▫ Safavi et al. demonstrated that Enterococcus remained viable in dentinal
tubules after relatively extended periods of Ca(OH) 2 treatment.

Cohen’s Pathways of the Pulp, 11ed (2016)

 CHLORHEXIDINE

▫ Chlorhexidine (CHX) is a well known antimicrobial agent, widely used as

an intracanal medicament in the concentration of 2%.
▫ The antimicrobial property is due to its cationic bisbiguanide molecular
structure.
▫ It has bacteriostatic nature at lower concentrations and acts as a
bactericidal agent at higher concentrations.
▫ CHX has been shown to be effective against
both E. faecalis and Candida albicans.

Cohen’s Pathways of the Pulp, 11ed (2016)

MECHANISM OF ACTION
CHLORHEXIDINE MIXED WITH CALCIUM HYDROXIDE :
 To enhance the properties of both CHX and Ca(OH)2, their combination
was analyzed in several in vitro and in vivo studies.
 The high pH of Ca(OH)2 was unaffected when combined with CHX.
 Some in vitro studies have reported an improved antibacterial action when
both agents were combined, against E. faecalis and Candida albicans.
 ANTIBIOTICS

▫Antibiotics are indicated in a small minority of cases when root canal

infection persists despite other antiseptics.
▫They are used either alone or in combination.

Eg: Ledermix paste or polyantibiotic paste (PBSC) are used.

 GROSSMAN’S PASTE/ PBSC

CONTENTS AMOUNT ACTIVE AGAINST

PENCILLIN G 10,00,000 units Gram positive organisms

BACITRACIN 10,000 units Penicillin-resistant strains

STREPTOMYCIN 1gm Gram-negative organisms

SODIUM CAPRYLATE 1gm Yeasts

▫ In 1975 the Food and Drug Administration (FDA) banned PBSC for endodontic use
primarily because of the risks of sensitization and allergic reactions caused by
penicillin. Later sodium caprylate was replaced by nystatin- PBSN.

Pal H, Sarkar A, Das L, Saha S, Sarkar S. Application of Intracanal Medicaments: A Review. IOSR Journal of Dental and Medical Sciences.
2019 Jan
 CORTICOSTEROID COMBINATIONS

▫ Corticosteroid based medicaments acts on the synthesis of lipocortin and

vasocortin, inhibiting the formation of edema
▫ Highly effective in the treatment of over instrumentation.
▫ It reduces the periapical inflammation and gives instant relief of pain.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 LEDERMIX

▫ Developed by Schroeder and Triadan in 1960.

▫ Ledermix paste contains 1% triamcinolone acetonide and 3.21%
demeclocycline HCl.
▫ It is a non-setting, water‑soluble paste material used as root canal
medicament or as a pulp capping agent.
▫ Addition of the antibiotic component to ledermix compensates for a
possible corticoid induced reduction in the host immune response.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 ▫ According to a study by Ramos et al (2012) to test the level of anti
inflammatory effect of steroid based intracanal dressings, after 7 days of
experiment, all tested substance had low levels of inflammatory cells.
▫ Therefore, it was inferred that corticosteroid-based medications can be used
for up to 7 days.
▫ Intense staining can be caused by binding of demeclocycline to dentine and
its photo oxidation when exposed to light.
▫ To solve this problem, other Corticosteroid based antibiotic containing
pastes have been developed.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 ODONTOPASTE

▫ Released in February 2008.

▫ Zinc oxide-based root canal paste with 5% clindamycin hydrochloride and
1% triamcinolone acetonide.
▫ It provides a bacteriostatic activity, and acts as interim dressing material
preventing bacterial repopulation within the root canal.
▫ Eftekhar et al (2013) demonstrated the use in apical periodontitis and
showed significant reduction in postoperative spontaneous pain rate.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 SEPTOMIXINE FORTE

▫ Contains two antibiotics: — Neomycin and Polymixin B sulphate along with

dexamethasone.
▫ Neomycin is bactericidal against gram-negative bacilli but it is ineffective
against bacteroides ,fungi.
▫ Polymyxin B sulphate is ineffective against gram positive bacteria.
▫ Tang et al., who demonstrated that a routine one-week application of
Septomixine Forte was not effective in inhibiting residual intracanal
bacterial growth between appointments.

Ikhlas El karim et al. The antimicrobial effects of root canal irrigation and medication. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007
 TRIPLE ANTIBIOTIC PASTE

▫ Combination of three antibiotics namely minocycline (100mg), ciprofloxacin

(200mg) , metronidazole (500mg).
▫ Triple antibiotic powder, either mixed with normal saline or 2%
chlorhexidine.
▫ The triple antibiotic paste is very effective against E. faecalis and can be
considered a better root canal medicament compared to calcium hydroxide
paste.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 ▫ Triple antibiotic paste is shown to be most cytotoxic to human
periodontal ligament fibroblasts.
▫ It causes exacerbated inflammatory reaction in subcutaneous
connective tissue.
▫ The minocycline component causes discoloration of teeth

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 MEDICATED GUTTA PERCHA

▫ A formulation of gutta-percha containing iodoform

was first developed by Martin and Martin.
▫ New gutta-percha points containing Ca(OH)2 in a
50% to 51% concentration in place of zinc oxide is
available in the market which makes easier
placement and removal of Ca(OH)2.
▫ Gutta-percha matrix can be embedded in 5%
chlorhexidine to be used as an intracanal
medicament.

Pal H, Sarkar A, Das L, Saha S, Sarkar S. Application of Intracanal Medicaments: A Review. IOSR Journal of Dental and Medical Sciences.
2019 Jan
 BIOACTIVE GLASS

▫ Research is under way in the use of bioactive glass as an intracanal

medicament.
▫ In one study, the glass used was composed of 53% SiO2 (w/w), 23% Na2O,
20% CaO, and 4% P2O5 and was prepared from reagent-grade Na2CO3,
CaHPO4, 2H2O, CaCO3, and Belgian sand.
▫ It can induce dentin mineralization.

Pal H, Sarkar A, Das L, Saha S, Sarkar S. Application of Intracanal Medicaments: A Review. IOSR Journal of Dental and Medical Sciences.
2019 Jan
 ▫ In aqueous suspension, BAG particles exert an antimicrobial effect by the
release of Na+ and Ca++ ions resulting in a high-pH environment, which
interferes with microbial viability. 
▫ It is less effective than 2% chlorhexidine but more effective than calcium
hydroxide.

Pal H, Sarkar A, Das L, Saha S, Sarkar S. Application of Intracanal Medicaments: A Review. IOSR Journal of Dental and Medical Sciences.
2019 Jan
 OZONATED OILS

▫ Ozonated olive oil exhibits high germicidal and oxygenating power against
many microorganisms, favoring tissue healing and regeneration, and thus
has been used on post-extraction alveolitis.
▫ Elshinawy (2018) studied cytotoxicity and antimicrobial effects of ozonized
oil and found that it showed minimal cytotoxicity and good anti bacterial
action against E. faecalis.
 HERBAL MEDICAMENTS

▫Literature has addressed many plants with potential source for new
therapies in endodontics.
▫The studies listed have shown important medicinal activities of plants, with
great demand to inhibit or suppress bacteria and their biofilm.
 PROPOLIS

▫ Propolis is prepared from resin collected by bees from trees of poplars,

conifers and flowers.
▫ Pharmacologically active constituents are flavonoids, phenolics and
aromatics.
▫ A comparative evaluation on microbial efficacy of propolis, NaOCl and
saline when used as intracanal irrigants indicated that the propolis has
antimicrobial activity equal to that of NaOCl.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 ▫ Oncag et al. evaluated and found significant efficacy against Enterococcus
faecalis, suggesting that it could be used as an alternative intracanal
medicament.
▫ Propolis can be used as short-term intracanal medication in cases of pulp
and periapical inflammatory processes. (Fabiane Bortoluci da Silva et al.)
▫ Mild periapical inflammation has been noticed after exposure to the
propolis paste.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 CURCUMIN

▫ Curcumin is the yellow bioactive component of turmeric.

▫ Has shown to have a wide spectrum of biological actions, including
antimicrobial, anti-inflammatory and anti- oxidant activities.
▫ Method of preparation : By mixing turmeric powder, distilled water, and
radiolucent material on a glass slab with the help of stainless steel spatula,
and in the ratio of 1:3:3.

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 ▫ A study showed that curcumin was able to demonstrate complete
eradication of E. faecalis. (Rajiv N Purohit et al 2017).
▫ Another study showed that there was a gradual decrease in the anti
bacterial activity of curcumin at 3 and 7 days.
▫ Curcumin does not affect the micro hardness of root dentin and is a
potential intracanal medicament. (AR Prabhakar et al 2013)

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 LEMON

▫ Lemon solution is a rich source of citric acid with a pH of 2.21.

▫ It is effective in removing the smear layer.
▫ Fresh lemon solution can be used as an intracanal medicament as it
is effective against E. Faecalis

Yaduka P, Sharma P. Novel Intracanal Medicaments and its Future Scope. International Journal of Pharmacy and Biological
Sciences. 2014 Jul-Sept
 ALOE VERA

▫ Its antibacterial action is due to protein synthesis in the bacterial

cells and it is rich in vitamins, minerals, enzymes, sugars, lignin,
saponins, salicyclic acids and aminoacids.
▫ It is effective against S. pyogenes and E. faecalis due to the presence
of anthrax quinine which inhibits the formation of these two
organisms.

Dr. Anil K. Tomer. (2020). INTRACANAL MEDICAMENTS - A REVIEW. International Journal of Medical Science And Diagnosis
Research, 4(7)
 NISSIN

▫ Nissin is a naturally occurring antimicrobial peptide, produced by

Streptococcus lactis sub species lactis and discovered in 1928. .
▫ It has antimicrobial activity against a wide range of bacteria and their
spores.
▫ It can interrupt the cellular membrane by persuading leakage of small
intracellular contents from the cell.
▫ Studies show that it is effective in elimination of E faecalis from root canal
and is comparable to the efficacy of chlorhexidine. (Somnath et al. 2015)

Pal H, Sarkar A, Das L, Saha S, Sarkar S. Application of Intracanal Medicaments: A Review. IOSR Journal of Dental and Medical Sciences.
2019 Jan
 Effects of Intracanal Medicaments
on Dental-Derived Stem Cells
▫ To ensure a successful regenerative procedure, it is essential to
investigate the appropriate disinfection protocols and the use of
biocompatible molecules in order to control the release of growth
factors and the differentiation of stem cells.

Ayoub S, Cheayto A, Bassam S, Najar M, Berbéri A, Fayyad-Kazan M. The Effects of Intracanal Irrigants and Medicaments on Dental-
Derived Stem Cells Fate in Regenerative Endodontics: An update. Stem Cell Rev Rep. 2020 Aug.
 SODIUM HYPOCHLORITE

▫ It has a toxic effect on the human bone marrow mesenchymal stem

cells (hBM-MSCs).
▫ Alkahtani et al. concluded that the toxicity of NaOCl on BM-MSCs
is concentration-dependent.
▫ Likewise, identical results were obtained with dental derived
MSCs; 6% of NaOCl exerted a deleterious effect on SCAPs
survival and differentiation capacity, whereas a concentration of
1.5% NaOCl had less negative effects.

Ayoub S, Cheayto A, Bassam S, Najar M, Berbéri A, Fayyad-Kazan M. The Effects of Intracanal Irrigants and Medicaments on Dental-
Derived Stem Cells Fate in Regenerative Endodontics: An update. Stem Cell Rev Rep. 2020 Aug.
 ▫ Other studies observed that DPSCs did not attach to the dentin
surfaces treated by 5.25%, and 6% of NaOCl.
▫ Moreover, an in vitro study demonstrated that NaOCl can
deteriorate viability, proliferation and differentiation of dental-
derived MSCs, such as DPSCs, PDLSCs, and GMSCs in
concentration- and time-dependent manner.

Ayoub S, Cheayto A, Bassam S, Najar M, Berbéri A, Fayyad-Kazan M. The Effects of Intracanal Irrigants and Medicaments on Dental-
Derived Stem Cells Fate in Regenerative Endodontics: An update. Stem Cell Rev Rep. 2020 Aug.
 CHLORHEXIDINE

▫ Widbiller et al. evaluated the direct effect of CHX on SCAPs in

vitro, and found that a concentration between 2% and 10− 3 %
highly affected the viability of SCAPs in a concentration-dependent
manner.
▫ Conversely, lower concentrations (10− 6% and 10− 7%) had no
adverse effect.
▫ Moreover, several in vitro studies indicated that exposure of human
dentin to 2% CHX could negatively impact the survival and
attachment of DPSCs and SCAPs.

Ayoub S, Cheayto A, Bassam S, Najar M, Berbéri A, Fayyad-Kazan M. The Effects of Intracanal Irrigants and Medicaments on Dental-
Derived Stem Cells Fate in Regenerative Endodontics: An update. Stem Cell Rev Rep. 2020 Aug.
 CALCIUM HYDROXIDE

▫ Several studies showed that dentin conditioning with Ca(OH)2 is

not toxic at all tested concentrations, and it can stimulate SCAPs
survival and proliferation.
▫ Moreover, recent studies showed that Ca(OH)2 is able to
significantly improve the mineralization capacity and the
osteogenic differentiation of DPSCs.

Ayoub S, Cheayto A, Bassam S, Najar M, Berbéri A, Fayyad-Kazan M. The Effects of Intracanal Irrigants and Medicaments on Dental-
Derived Stem Cells Fate in Regenerative Endodontics: An update. Stem Cell Rev Rep. 2020 Aug.
 TRIPLE ANTIBIOTIC PASTE

▫ Sabrah et al. reported that 0.125 mg/ml of TAP and DAP significantly
reduced the Enterococcus faecalis biofilm with no cytotoxic effects on the
viability of DPSCs.
▫ Vice versa, high concentrations of TAP or DAP (1000 mg/mL) altered
SCAPs viability.
▫ According to a recent study, TAP induced less cytotoxic effect against
SCAPs and it is the safest antibiotic, compared to DAP and Ca(OH)2.
▫ Alghilan et al. indicated that TAP enhanced the attachment of DPSCs to the
dentin, while, TAP, DAP, and Ca(OH)2 reduced DPSCs proliferation.

Ayoub S, Cheayto A, Bassam S, Najar M, Berbéri A, Fayyad-Kazan M. The Effects of Intracanal Irrigants and Medicaments on Dental-
Derived Stem Cells Fate in Regenerative Endodontics: An update. Stem Cell Rev Rep. 2020 Aug.