medication .pdf

Medication 31-Oct-2023 Learning Outcomes  Identify the objectives of intracanal medication  Recognize functions and properties of intracanal medicaments  Recognize intracanal medicament groups  Explain the importance and limitations of common intracanal medications  Describe the clinical appl...

Medication 31-Oct-2023 Learning Outcomes  Identify the objectives of intracanal medication  Recognize functions and properties of intracanal medicaments  Recognize intracanal medicament groups  Explain the importance and limitations of common intracanal medications  Describe the clinical application of intracanal medications Medication Dr Mohamed El-Kishawi Dr. Mohamed El-Kishawi Q. Why do we use medications for the the canal? Anti DDS, BScDent (Hons), PhD bacterial 31 Octto 2023 Q. When is teh best time obdurate? 2 conditions dry canal ( no water, pus,exudate) symptomatic- no symptoms during 1 2 2 Medication-Why? Medication-Why? Irrigation is an important part of RCT. • Complex root canal morphology • Removing bacteria and debris in: • Canals • Accessory canals • Dentinal tubules fine ed Dr Mohamed El-Kishawi 1 • Sjögren et al - if root canals still gave positive cultures before obturation, the overall success rates dropped significantly. at Q. During irrigation, some areas not reached like accessory canals or deep dentinal tubules , so we place medication to reach these areas ◦Medication is anti bacterial why sowemastgivet.cm • IF canals could be effectively disinfected with instrumentation n and irrigation alone, then the need for medication would be removed (EXCLUDING TRAUMA) Configuring the system so that it can be obturated to eliminate the dead spaces Dr Mohamed El-Kishawi 4 The purpose of the otburation must seal the gap hey Dr Mohamed El-Kishawi 3 3 Dr Mohamed El-Kishawi ainsm Astudy By pnowsthatmjafkn.IE instrumentation irrigation medication id 4 if enough effectively disinfected usually 70 only 1 Medication 31-Oct-2023 Q. Where can bacteria come from? Key message: theres a lot of room for bacteria to escape and hide inside the canal our job is to cleans shape and disinfect teh canal rethe medicament What Function of a intracanal Medication-Why? f Dr Mohamed El-Kishawi mainfunction antimicrobial activity against 1 • Effective microorganisms: • Bacteria can continue to exist in dentinal tubules, accessory canals, canal ramifications, apical deltas, fins etc • Mechanical instrumentation along with the irrigants can only clean the canals up to 70% free of microorganisms. • Therefore intracanal medications are used interappointment to reach a sufficient concentration to eliminate bacteria in a predictable manner. • In dentin and root canal system • Between appointments 2 • Reduce peri-radicular inflammation • Control inflammatory root resorption 3 • Encourage periradicular healing • calcific tissue etc i • Eliminate apical exudate • Prevent / reduce pain Never reach 100% of no bacteria but the body must reach a percentage where it can manage Dr Mohamed El-Kishawi 5 5 6 6 Are Whatof Intracanal The Medicaments Properties Q are classification Intracanal what medicament 1. Effective germicide and fungicide isToived eitd9 fd.hu 2. Non irritating to surrounding tissues I 3. Remain stable in solutiona 4. Should have prolonged antimicrobial action 5. Should be active in the presence of blood, pus etc 6. Should not interfere with healing of the periapical area 7. Should have low surface tension 8. Should not stain the teeth 9. Should not induce immune response3 doesn'tcausfifhfhedm.at ur'ieakt 10. Should induce healing and hard tissue formation 11. Sterile, Stable Shelf life, Readily Available, & Inexpensive Dr Mohamed El-Kishawi 7 Dr Mohamed El-Kishawi • Antiseptics bacteria To's • Antibiotics I I Dr Mohamed El-Kishawi 7 iq's 8 8 2 Medication 31-Oct-2023 Aldehydes Intracanal medicament classification THIEF p Antiseptics Q.whataf.is antiseptics gYPesof • Paraformaldehyde • Parachlorophenol • Camphorated Parachlorophenol (CMCP) sad.antis.ph • Formocresol, Cresol,Creosote • Essential oils: Thymol,Eugenol • Halogens • Cytotoxic –-> periapical & systemic effects • Antibacterial effect -limited & short duration Ef ntffffhhf.de i f am ff f ymnonce Dr Mohamed El-Kishawi 9 Q.tn gt Eaanydf fgigfniiz • Formaldehyde, paraformaldehyde, Emacnesol glutaraldehyde commonly used-most potent disinfectants • Formacresol: contains formaldehyde as a main ingredient and most widely used medicament medication for pulpotomy. Composition aenesore ÉÉ p.gg • Formaldehyde-19% Cresol -35% Water and glycerin-46% Cytotoxic, mutagenic and carcinogenic. Effective in vapor form. Dr Mohamed El-Kishawi 9 cancer uses 10 10 Antiseptici cMb Phenolic Compounds:CMCP, Aldehydes i cM Antiseptictype Essential oils- eugenol on • Phenol or carbolic acid-potent antimicrobial • CMCP(camphorated mono chlorophenol) Composition: 2 parts of para chlorophenol 3 parts of gum camphor Used as a dressing of choice for infected teeth • Cresantin and creosote- aye name 11 Dr Mohamed El-Kishawi • Inhibits prostaglandins synthesis • Inhibits nerve activity • Inhibits white cell chemotaxis But high doses have “TOXIC EFFECTS” and is a severe periapical irritant Uses:Inhibits cell respiration Used as intracanal medicament Used as a sealer Inhibit cell respiration meaning? It inibts the cell from surviving in the canal that way its irritant Part of temporary sealing agents fffhgggg All exhibit high levels of toxicity. Antimicrobial activity may not last for a long time Dr Mohamed El-Kishawi Eugenol are used as restorative material but also as I.C.M. • Prostaglandin is a chemical that aids in ammation • Eugenol is used to relive pain, so ◦This inhibition of prostaglandin synthesis by eugenol contributes to its pain-relieving and anti-in ammatory effects ◦Nerves in our body send signals that are interpreted as pain. Eugenol can interfere with these signals. ‣ It works by blocking or slowing down the transmission of nerve impulses, which results in a reduction of pain sensation yyif.gg Dr Mohamed El-Kishawi 11 Also reduces pain Interferes with retsoartuive material Not prefers to used as a sealer nor as a medication qm p.gg 12 12 3 Medication i 31-Oct-2023 i si 1 t.CM Halogens:Anytiseptic Intracanal medicament groups • Chlorine active ingredient of Sodium hypochlorite aegis Antibiotics pastes • Iodides-antiseptics eg. potassium iodide iodophores Iiii Bactericidal effect • 'Septomixine Forte’ A/biotic -neomycin + polymixine B sulphate C/steroid -dexamethasone • 'Pulpomixine’ A/biotic -framycetin +polymixine B sulphate C/steroid –dexamethasone A/biotic -Bacteriocidal against gram -ve bacteria Ineffective against most endodontic causal agents C/steroid -Anti-inflammatory Some systemic side effects f In halogens teh bacteriocidal affects are high on teh otehr hand this can induce toxicity and cause irritation So halogens are not used only in certain conditions where we want to kill aggressive form of bacteria BUT its used in proportion! Dr Mohamed El-Kishawi Dr Mohamed El-Kishawi 13 13 14 I Ledermix is IMP, most common used medications in case of symptoms, why what is its components? ◦Has antibiotics which are septoxime, pulpoximine and steroids so it does reduce in ammation inside the canal Q. What is the main purpose of using ledermix? PAIN ◦Why? Because it has antibiotics and the steroid inside ( antibiotic corticosteroid combination ) 14 Q.dkaiagehfs bacteria aggressive IMP SLIDE Intracanal medicament groups Intracanal medicament groups what.am aAntibiotics Antibiotics iiygfy.I Ledermix paste: antibiotic+ corticosteroid combination Q. What is the main component of antibiotic? Tetracycline mainly Tetracycline, demeclocycline HCl+ triamcinolone acetomide in a polyethylene glycol base Dr Mohamed El-Kishawi 15 Dr Mohamed El-Kishawi don'tmemorize • A/biotic DimethyVchlortetracycline calcium 3% Effective against most canal flora • Gluco C/steroid Triamcinolone acetonide 1 % red Effective at low concentration - lnflammation - Post operative pain Dr Mohamed El-Kishawi 15 names 16 16 4 Medication 31-Oct-2023 Calcium Hydroxide- Hermann in 1920 itinsf.mwnatane In.itItft Antibacterial G Claudius hydroxide is the mostly used intra canal medication why? Due to high pH reaching out I 12.2 for 2 weeks then pH drops Calcium hydroxide • Byström et al - Ca(OH)2 dressing for 7 days - unable to recover bacteria from 34/35 teeth. • Sjögren et al - 10 minutes vs 7 days • Ca hydroxide has been recommended as an intracanal medicament because of its antimicrobial effects in gram +ve and –ve bacteria commonly found in infected root canals • Cvek (1976) 46% of canals sterile after 1 appointment 92% of canals sterile after 3months Functions: 1. Shows antiseptic action because of the high pH 12.2 and its leaching action on necrotic pulp. 2. Hydrolyzes the lipid part of bacterial lipopolysaccharide(LPS) . This is effective on the dead cell wall material which remains after the bacteria have died but may still cause infection drolyzed 3. Used as a intracanal medicament when one anticipates it excessive delay between appointments because it is effective as long as it remains within the root canal. ehy • infection can occur not only by bacterial cells but also by dead cells ◦When you intend to continue the traetement after 1 week you wil 17 open the canal replace the calcium hydroxide since ph will driop Dr Mohamed El-Kishawi up Dr Mohamed El-Kishawi 17 18 Calcium Hydroxide Ca(OH)2 Dressing Ostavik et al – 1 week, at the start of second appointment – 1/23 teeth had sufficient numbers of bacterial for quantification.  Trope et al concluded that  18 (Siqueira & Lopes 1999) jun 2 I  Ca(OH)2 dressing after chemo-mechanical cleaning will result in negative cultures in most cases  Instrumentation and irrigation decrease the bacteria count 1000 fold, but canals not bacteria free  Ca(OH)2 dressing resulted in 10% increase in healing featuresof QWhatarethe An c he • By remaining in the root canal between appointments, intracanal medicaments may help to eliminate surviving bacteria. • Strong alkaline - pH appx 12.5 • Acknowledged as one of the most effective antimicrobial dressings during RCT • Dependent on availability of hydroxyl ions • Greater where paste applied but pH lowers as it is buffered especially by dentine Q. What is the reason of high pH? Hydroxyl ions which makes it a strong alkaline rates. Dr Mohamed El-Kishawi 19 Dr Mohamed El-Kishawi Dr Mohamed El-Kishawi 19 20 20 5 This slide explains taht we can produce a mixture with calcium hydroxide This mixture will increase antibacterial and antiseptic level an function. Medication Story: 31-Oct-2023 Bacteria got in the cana they will try to hide from us, sinc ewe what to clean the canal. lBacteria leads causes infection and abcess, some bacteri are very aggressive tehy can live without nutrition for up to 6 months to 1 year. Teh beyaty of calcium hydroxide is that it will remain a high ph that bacteria can’t live in BUT there are some super species taht can survive pH 9 to 11 ◦Super specie shave adaptive mechanisms meaning tehy can communicate with each other by exchange snutrient and tehy can be in harmony with all types of bacteria aerobic and anaerobic Calcium Hydroxide Calcium Hydroxide ◦This harmony is broken by using intra canal medictaions! How to keep teh concentratyion high preventing bacteria to live is by keep replacing the medication (Siqueira & Lopes 1999) (Siqueira & Lopes 1999) • Ca hydroxide has antibacterial effects only if the pH is maintained at high levels 11-13. • It is biocompatible-low solubility in water and limited diffusion • It encourages mineralisation • Inhibits root resorption and stimulates periapical healing • Attempts have been made to improve the ability to disinfect by combining with other chemicals Ca(OH)2 + CMCP Ca(OH)2 + Potassium Iodide b • In certain conditions, pH levels in dentine may allow the survival or growth of some bacterial strains. like • Some Enterococcus tolerate pH 9 to 11 How they have • Adaptive mechanisms enable some microorganisms to proliferate. material missing • E. faecalis seems to be fairly resistant to Ca(OH)2 eathke Iffy char'm in ftp.bebrokd Dr Mohamed El-Kishawi Dr Mohamed El-Kishawi 21 21 22 22 Re-treatment CHX & Ca(OH)2 of culture • Success 62% - E. faecalis most common – a of Ca(OH)2 in re-treatment query-efficacy • Haapasalo and Ørstavik - Ca(OH)2 failed to eliminate E. faecalis even superficially in the dentinal tubules • query -Addition of CHX? e Q. What is retreatmnet case? We treat the canal for Dr Mohamed El-Kishawi 23 Dr Mohamed El-Kishawi the rst time then an infection occurs again. The teeth that are already obturated when they were retreateed tehy found that E.faecalis was there. The success of having calcium hydroxide is 62% but when them mixed it with chlorohexidine it did work more than calcium alone ◦We dont prepare this combo unless the case requires this combo. • Potential improvement • Ca(OH)2 still able to raise the pH in the root dentine (Haenni et al) • No strong evidence of its efficacy Dr Mohamed El-Kishawi 23 24 24 6 Medication Q. What is teh def of weeping canal? Means the can ariswet canals that you can’t dry so you can’t obdurate it! Q. What is the reason for weeping canals? In ammation since it has exudate Q. What can you do? Reduce in ammation so reduces exudate me • Can survive in the presence of NaOCl etc • Forms biofilms in medicated canals, adheres to the collagen in the presence of human serum fI hf h thffiamm.IO When opened in the next appt, exudate stops but reappears in next appointment. This is called a weeping canal. • Endures long periods of starvation In such cases, culture reports show –ve bacteria, so antibiotics are ineffective. Dry with paper points, place Ca(OH),next appt, canal is dry and ready to obturate. c a antibiotictype • Survives in extreme environments with low pH, high salinity and high temperatures Dr Mohamed El-Kishawi 25 25 26 Calcium hydroxide is a paste which goes everywhere so you need to have skills when handling it into the canal k fromthe 1cm gg and proper placement of Ca(OH)2 • handling t beginning whatsthe Clinical Application the Limitations of Calcium HydroxideAntibiotic1cm pfhat c • Sometimes, during RCT a tooth shows constant clear or reddish exudate associated with a radiolucency. Tooth can be Perfusion asymptomatic or T.T.P. tenderness • Can convert into a viable but not cultivable state Dr Mohamed El-Kishawi requiresintracanalmedications re Gwhatacanals Weeping QWhy can E faecalis survive? • It can live and persist in a poor nutrient environment 31-Oct-2023 26 L to sEr IIitnE symptomatic AfterWL of i irrigatecanal •2 removal of Ca(OH)2 is frequently incomplete 2Drywpaperpoints 3Place MAF 4 1 e M placementw • Residual Ca(OH)2 can shorten the setting time of zinc oxide eugenol–based endodontic sealers It is important taht you remove 3 • interfere with the seal of the root filling and compromise calcium hydroxide ( any intra canal medictaion) ( very hard to remove) the quality of treatment fm •aCa(OH)2 is not totally effective against several endodontic sometimes we use obturation it will interfere with teh seal pathogens, including E. faecalis and Candida albicans Copiously irrigate the canal Dr Mohamed El-Kishawi 27 Place the master apical file in the canal Dr Mohamed El-Kishawi 27 28 shouldhave properirrigation Dr Mohamed El-Kishawi s.se ng'mtmatiEe 28 GIC e.g 7 • Most of the intra canal medications comes with a plastic applicator inserted inside the canal ◦If theres isn’t any plastic applicator we use spreader or lentils spiral • once applying the I.C.M we need to seal teh cornal area with GIC Medication Clinical Application Dry the canal using paper points 31-Oct-2023 Clinical Application Intra-canal medicament is applied and placed in canals. Over it, a sterile dry cotton pellet is placed which and/ or is finally sealed with a temporary filling material, e.g. GIC Intra-canal medicament Dr Mohamed El-Kishawi Dr Mohamed El-Kishawi 29 29 30 30 Clinical Application Single – appointment root canal therapy? When using intracanal medication as pastes, inject the paste with a long narrow tip into the root canal spaces and then use a an instrument of appropriate size to spread the medication within the canal space. Dr Mohamed El-Kishawi 31 Dr Mohamed El-Kishawi  Disadvantages:  No easy access if there is a flare-up Material  Clinician fatigue with extended appointment time  spreawedrywhere Patient fatigue  No opportunity to place an intracanal disinfectant (other than allowing NaOCl to disinfect during treatment) star is Dr Mohamed El-Kishawi 31 32 32 8 Medication 31-Oct-2023 Reference One – visit endodontics?  Research based or anecdotal evidence?  Research supports 2 visits with Ca(OH)2 dressing in cases with necrotic pulps, periapical periodontitis, and (??) for failed cases requiring s re-treatment. Dr Mohamed El-Kishawi • Peters O, Peters C, and Basrani B. Cleaning and Shaping the Root Canal System. In: Berman L, Hargreaves K, Rotstein I, eds. Cohen's Pathways of the Pulp. 12th ed. Mosby Elsevier; 2021:236-303:chap 8. • Silva, L.A.B.d., Silva, R.A.B.d., Nelson-Filho, P. and Cohenca, N. (2014). Intracanal Medication in Root Canal Disinfection. In Disinfection of Root Canal Systems, N. Cohenca (Ed.). doi:10.1002/9781118914014.ch13 • Peters, O. A., Arias, A., and Shabahang S. Cleaning and Shaping. In: Torabinejad M, Fouad A, Shabahang S, eds. Endodontics-e-book: Principles and practice: Elsevier Health Sciences, 2020:297-326 • Haapasalo M, Shen Y, Lin J, Park E, Qian W, Wang Z. 2019 Irrigants and Intracanal Medicaments. In: Ingle's Endodontics. Eds: Rotstein, I and Ingle, JI: PMPH USA, pp 635667. faith Dr Mohamed El-Kishawi 33 33 34 34 Thank You ! [email protected] www.sharjah.ac.ae 35 35 Dr Mohamed El-Kishawi 9