lntermtional Endodontic journal (1992) 2 5, 97-106

The role of intracanal medication in root canal treatment

B. S. CHONG & T. R. PITT FORD
Department of Conservative Dental Surgery, United Medical and Dental Schools, Guy's Hospital, London, UK
Summary
The role of intracanal medication as a root canal dressing
is re-exatnined. In pulpectomy and some root canal treat-
ments, where the root canal contains vital pulp tissue, it
is doubtiiil whether a routine intracanal medicament is
needed.
In infected root canals, intracanal medication has
been advocated for many purposes. An intracanal
medicament is used to:
(i) eliminate ciny remaining bacteria after canal
instrumentation;
(ii) reduce inflammation of periapical tissues and
pulp remnants;
(iii) render canal contents inert and neutralize tissue
debris;
(iv) act as a barrier against leakage from the
temporary filling;
(v) help to dry persistently wet canals.
However, most of the indications for intracanal
medicaments are questionable.
Intracanal medicaments should only be used for root
canal disinfection as part of controlled asepsis in infected
root canals, and their role is secondary to cleaning and
shaping of the root canal. Thorough canal debridement
and adequate canal preparation are more pertinent, and
their importance is emphasized. Bacteriological sampling
may be necessary if a tooth does not re^mnd to treatment,
to help in the choice of intracanai medicament.
Keywords: bacteria, calcium hydroxide, medication,
periapical inflammation, root canal treatment.
Introduction
The properties required of an ideal intracanal medica-
ment in conventional root canal treatment are well docu-
mented (Martin 1979. Harty 1982, Grossman et al
1988). To date, the ideal intracanal medicament has not
Correspondence: Mr B. S. Chong. Department of Conservative Dentai
Surgery, United Medical and Dental Schools, Guy's Hospital, London
SEl 9RT. UK.
been found. As a result, many different types of medica-
ment have been used as root canal dressings (Spangberg
1985, Grossman et al. 1988, Heithersay et al. 1990).
Despite conflicting claims, no medicament appears
superior to any other, and their usefulness has been
questioned (Walton 1984. Seltzer 1988, Weine 1989).
Some ofthe arguments for the use of intracanal medica-
ments are empirical but have persisted. Therefore it is
time to re-evaluate the role and indications of intracanal
medication in root canal treatment.
Vital teeth
The important role of bacteria in the pathogenesis of
pulpal and periapical disease has been established by
many studies (Kakehashi et al. 1965, Paterson 1976,
Moller eta/. 1981,Fabriciusetfll. 1982, Paterson & Watts
1987). In the absence of bacteria, there is no pulpal or
periapical inflammatory reaction, and damaged tissues
can heal (Moller et al. 1981, Fabricius et al. 1982). The
severity of the inflammatory response of the pulp and
periapical tissues can be related to the quantity of micro-
organisms present, the number of strains involved and
the duration of exposure to the micro-oiganisms (Korzen
etfl/. 1974).
As early as 1919, Henrici & Hartzell (1919) reported
that the normal, vital pulp is sterile. When puipectomies
were performed under aseptic conditions on vital teeth in
dogs, there was no, or only a miid, reaction in the periapi-
cal tissues, and bacteriological sampling after 1 and 2
months was negative (Allard & Stromberg 19 79). Normal
periapical tissues and an absence of infiammation were
observed around teeth where root canal treatment was
carried out under aseptic conditions and no intracanal
medicament was used (Pitt Ford & Rowe 1989).
When a vital pulp has recently become exposed to the
oral flora, it is usually only superficially invaded by
bacteria (Paterson & Watts 1987). If pulpectomy is per-
formed under controlled, aseptic conditions, the super-
ficial bacterial flora and affected pulp will be removed,
leaving a bacteria-fi^e canal. Therefore, in root canal
treatment of teeth where vital pulp tissue exists, it is
97
98 B. S. Chong and T, R, Pitt Ford
questionable whether an intracanat medicament is
needed (Foreman & Barnes 1990).
Many intracanal medicaments are irritant and highly
toxic (Massillomanieta/. 1981, Spangberg 1982, Bamett
flJ. 1984). Of those that are biocompatible, it is always
questionable whether the desirable properties may be
extrapolated from the laboratory to the clinical situation
(Walton 1984). Since intracanal medicaments have the
potential to do more harm than good, they are not indi-
cated in vital teeth, where a bacteria-free canal is
achievable by controlled asepsis without the need for
medicaments.
Infected teeth
In infected root canals, intracanal medication has been
advocated for many reasons. An intracanal medicament
is used to:
(i) eliminate any remaining bacteria after canal
instrumentation;
(ii) reduce inflammation of periapical tissues and
puip remnants;
(iii) render canal contents inert and neutralize tissue
debris;
(iv) act as a barrier against leakage from the temporary
aiing;
(v) help to dry persistently wet canals.
The use of intracanal medication for these purposes will
now be examined.
(i) As an antibacterial agent to eliminate any
remaining bacteria in the root canal after canal
instrumentation
Antihacterial intracanal medication is used to eliminate
any residual bacteria that have not been removed by
canal preparation. During the period hetween appoint-
ments, bacteria surviving instrumentation and irri-
gation have heen shown to increase rapidly in number in
empty root canals (Bystrom & Sundqvist 1981, 1983,
1985), Ctontrolied ase[sts, including effective root canal
disinfection, was shown to be important for successful
healing of periapical lesions (Bystrom & Sundqvist
1987).
The antibacterial properties of intracanal medica-
ments have been well researched (Sp&nberg 1985), but
the choice of medicament remains controversial. To
justify the use of these medicaments, their antibacterial
activity must be significantly greater than their cytotoxic
effect (Messer & Feigal 1985), Antibacterial agents that
are toxic and potent enough to eliminate bacteria may
damage periapical tissues.
There are other problems to consider when using anti-
bacterial medicaments. To he effective, the medicament
must be in contact with the residual bacteria in sufficient
concentration. Vapour-fonning medicaments are con-
sidered to work at 'long-distance'. Unfortunately, the
superior diffusibility of these medicaments may have
adverse effects. The penetration of cytotoxic vapour-
forming medicaments into the periodontium with unde-
sirable consequences has been reported (Cambruzzi &
Greenfeld 1983, Kopczyk et al, 1986), Formaldehyde-
and phenol-type medicaments have the potential to be
distributed widely in the body (Pashley et al, 1980, Block
et al. 1983, Fager & Messer 1986, Hata et al. 1989), In
addition, formaldehyde-type medicaments have muta-
genic and carcinogenic potential (Lewis & Chestner
1981). Sipes & Binkley (1986) reviewed the use of
fonnocresol in dentistry and concluded that there was
little justification for its continued application in root
canal therapy.
An antibacterial intracana! medicament must have a
wide spectrum of activity and a reasonable duration of
action to eliminate all the bacteria in the root canal. Since
no intracanal medicament is active against the whole
spectrum of root canal microbes, cocktails of polyanti-
microbials were devised to overcome this shortcoming.
However, combinations of antibacterial agents have not
been shown to be active against the complex mixed flora
that is found in root canals. Furthermore, the use of
polyantibiotic medicaments is not recommended because
of the possible risk of allei^ic reaction, sensitization and
production of resistant bacterial strains (Seltzer 1988).
With regard to the duration of effectiveness of intra-
canal medicaments, the effectiveness of those based on
phenol has been shown to decrease rapidly after insertion
(Messer & Chen 1984, Koongtongkaew et al. 1988).
Contact with tissue fluids will also render the medicament
inactive within a short period of time. To overcome this
problem, a controlled-release delivery system has been
suggested (Tronstad et al. 1985), but the use of a
quaternary ammonium compound in this delivery sys-
tem was not found to give significantly better results
(Bamett et al. 1986, Tronstad et al. 1988), Recently,
the use of chlorhexidine in a controlled-release delivery
system was proposed (Cervone 1990).
With the problems of selective activity, limited spec-
trum and short duration of effectiveness, there is the
theoretical danger that bacteria not affected by the intra-
canal medicament will become selectively bred in the root
Intracanal medication in root canal treatment 99
canal. Instead of controlling the bacterial population, a
recalcitrant infection could be created.
The choice of medicament should be judged with
caution in view of these problems. The indiscriminate
use of potent antibacterial agents should be discouraged,
and every case should be decided individually. The
choice of an intracanal medicament should be one that
will support treatment and not delay healing. In infected
root canals, an antibacterial intracanal medicament
may be used as part of overall controlled sepsis, which
should include the use of an antibacterial irrigant.
0rstavik et al (1991) reported that, in the absence of an
antibacterial irrigant, predictable asepsis was not
achieved even when an antibacterial intracanal medica-
ment was used. There were more bacteria to be killed
by the intracanal medicament when an antibacterial
irrigant was omitted (Cvek et al 1976a, Bystrom &
Sundqvist 1983, 1985). In a clinical study by Sjogren
et al (1991), half of the infected root canais were
rendered bacteria-free when an antibacterial irrigant
was used during root canal instrumentation. The
bacteria that survived were eliminated by applying an
antibacterial intracanal medicament.
Calcium hydroxide has emerged as a popular choice of
intracanal medicament. It was shown to be superior to
camphorated paramonochlorophenol and camphorated
phenol in antibacterial activity in a clinical study of 65
single-rooted teeth with periapica] lesions (Bystrom et al
1985). When compared with 2% iodine-potassium
iodide solution, calcium hydroxide-dressed root canals
yielded fewer culture reversals (Safavi et/. 198 5). How-
ever, Stevens & Grossman (1983) found that calcium
hydroxide was inferior to camphorated chlorophenol in
eliminating Enterococcus faecalis in experimentally
infected root canals of cats. The failure of calcium
hydroxide to eliminate enterococci effectively has also
been reported by other workers (Bystrom et al 1985,
Haapasalo & Orstavik 1987, 0rstavik & Haapasalo
1990, Safavi et al 1990). This serves to highlight the
potential problem and danger of relying upon intracanal
medicaments, as no medicament is effective against ail
the bacteria found in the root canai. Calcium hydroxide,
although suitable as an intracanal medicament, cannot
be considered as a universal intracanal medicament
(Reit&Dahlenl988).
Intracanal medication does not 'sterilize' the root
canal (Treanor & Goldman 1972), and is no substitute
for thorough canal cleaning and adequate canal prep-
aration. There are reports that, even with controlled
asepsis, bacteria can become established outeide the root
canal in the periapical tissues (Bystrom et d. 1987,
Tronstad et al. 1987. 1990a,b, Sjogren et al. 1988,
1990). which are inaccessible to conventional root canal
treatment, and bacteria can even persist in filied root
canals (Pitt Ford 1982).
Although bacteriological sampling of root canals may
not be necessary routinely, it should be undertaken when
a tooth is not responding to treatment. The information
obtained from bacteriological sampling wiil enable a
better choice of intracanal medicament, and the appropri-
ate treatment can then be provided. Bacteriological
sampling remains as an important adjunct in root canal
treatment.
(ii) As an anti-inflammatory agent, to reduce
inflammation of pulp remnants or periapical tissues,
particularly when time does not permit complete
removal of the pulp contents
The reduction of inflammation is primarily aimed at
alleviation of pain and any acute exacerbation. Unfortu-
nately, the use of intracanal medication has been found
by many investigators to have no effect on inter-
appointment and post-treatment pain (Maddox et al.
1977, Harrison et al. 1979, 1981, 1983, Kleier &
Mullaney 1980, Torabinejad et al 1988). The incidence
of postoperative "flare-ups' was also found to be
independent of the intracanal medication used (Trope
1990).
However, the incidence of postoperative pain was
found to be related to the preoperative state of the pulp
and the presence of preoperative pain (Genet et ai. 198 7).
The incidence of 'flare-ups' has also been reported to be
related to the state ofthe pulp (Barnett & Tronstad 1989)
and radiographic signs of apical periodontitis (Trope
1990). It was shown that, even with time limitations,
when vital pulp contents were not completely removed,
the removal of caries, emergency pulpotomy and sealing
of the cavity were reliable means of relieving pain
(Hasseigren & Reit 1989).
A treatment regime derived from Buckley's for-
mocresol technique has recommended medication of
non-vital teeth at the first appointment, rather than
complete canal preparation, on the premise that it
produced fewer acute exacerbations (Pearson &
Goldman 1964, 1966). However, Baiaban et d.
(1984) found that such a premedication technique
did not decrease the likelihood of acute exacer-
bations, and was therefore ineffective.
Topical corticosteroids have been usi specifically as
anti-inflammatory agents in root canal therapy
100 B. S. Chong and T. R. PiU Ford
(Schroeder 1963). An intracanal solution of cortico-
steroid has been claimed to be an effective anodyne in
inflamed teeth, provided that the teeth are not infected
(Moskow et al. 1984). A clinical trial of intracanal
corticosteroid found that it was only effective in reducing
the incidence of postoperative pain in teeth with vital
pulps, but was ineffective when the pulp was necrotic
(Chance et al. 1987). Therefore, corticosteroids cannot
be advocated as a medicament in teeth with infected or
necrotic pulps. The application of corticosteroid prep-
ctrations in whatever form and by whatever route
may lead to changes in the regulation of endogenous
steroid secretion (Hartmann 1981). and it is not imposs-
ible that corticosteroids may cause unwanted systemic
side-effects.
Some corticosteroids are combined with antibiotics to
help combat any infection. The pharmacodynamics of
such combinations are dependent on several factors,
including the size of the apical foramen and the pres-
ence or absence of a smear layer (Abbott et al. 1988,
1989a). The range and duration of antimicrobial
activity of a combined preparation may be limited
(Abbott et al. 1988, 1990). The periapical tissue
response to such a preparation may be favourable when
the root canal contains vitai, uninfected pulp tissue
(Barker & Lockett 1972). However, in infected root
canals, the periapical reaction is unpredictable and less
favourable, and this combination cannot be relied upon
to eradicate bacteria from infected root canals (Barker &
Lockett 1971).
Trope (1990) compared the effect of formocresol,
a corticosteroid/antibiotic formulation and calcium
hydroxide on the incidence of post-instrumentation
'flare-ups', and found no significant difference in the
'flare-up' rate between the three intracanal medica-
ments. Watts & Paterson (1988) found that the topical
application of corticosteroid to the exposed pulp
enhanced bacterial dissemination, and they warned
against the use of these anti-inflammatory compounds
as root canal dressings. There was even a suggestion
that ineffectively removed petroleum and water-based
corticosteroid medicaments could affect the apical seal
of root canals obturated with gutta-percha and zinc
oxide-eugenol sealer (Harris & Wendt 1987). On the
other hand, in teeth that had been dressed with calcium
hydroxide and then obturated, there was signifi-
cantly less dye leakage compared with unmedicated con-
trols, but the improvement in the apical seal might be
temporary (Porkaew eta/. 1990).
A corticosteroid-antibiotic mixed with calcium
hydroxide has also been advocated as an intracanal
medicament (Heithersay et al. 1990). The mixing of
these two medicaments altered the release and diffusion
of the active components of the corticosteroid-antibiotic
(Abbott et al 1989b), but did not decrease their individ-
ual antibacterial potency when tested on Lactobacillta
casei and Streptococcus mutans (Taylor et aZ. 1989). How-
ever, when tested on Streptococcus sangids and Staphy-
lococcus aureus, it was reported that the addition of
calcium hydroxide to the corticosteroid-antibiotic
decreased their individual antibacterial effectiveness
(Seow 1990). It was concluded that the combination of
two medicaments did not produce any additive or
synergistic effects, and should not be used in combi-
nation, since the antibacterial activity of the individual
components may be affected. The contrasting results
obtained by these two studies (Taylor et al. 1989, Seow
1990) highlight the dissimilar response of different bac-
teria to antibacterial agents. The infected root canal
contains a complex mixed flora, and combinations of
antibacterial agents may not produce the desired syner-
gism to eliminate all the bacteria in a root canal. It is
therefore a fallacy to rely on antibacterial agents for this
purpose.
The suppression of inflammation is also intended to
circumvent anaesthetic difficulties with acutely inflamed
teeth. Formocresoi and corticosteroids have been used to
this end. Unfortunately, the effectiveness of formocresol
remains untested in controlled clinical studies (Waiton
1984). Formocresol is in itself very cytotoxic (Jeng et al.
1987) and adverse reactions have been reported
(Cambru22n & Greenfeld 1983, Kopczyk et al. 1986). The
use of paraformaldehyde devitalizing paste in a case
where there was difBculty in obtaining adequate
anaesthesia has resulted in complications (Tal et al.
1978).
The difficulties encountered with an acutely inflamed
tooth are often due to failure to obtain adequate
anaesthesia (Fluery 1990). Some studies have suggested
that inflammation affected satisfactory anaesthesia
(Naijar 1977, Brown 1981, Rood & Pateromichelakis
1981, Wallace et al. 1985). Inadequate anaesthesia
may be better managed by employing supplementary
anaesthetic techniques (Malamed 1986, Dumsha &
Gutmann 1988), instead of hoping to cakn the inflamed
tooth by leaving the cause of the inflammation and
applying medicaments that do not achieve the desired
effect. Once adequate anaesthesia has been obtained,
thorough canai cleansing can take place. This removes
the cause of the inflanunation and allows the periapi-
cal reaction to resolve, thereby decreasing the total
treatment time.
Intracanal medication in root canaj treatment 101
(iii) To render any remaining canal contents inert and
neutraliTe tissue debris
Intracanal medicaments have been used for chemical
fixation of tissue remnants remaining after canai prep-
aration. The concept of using chemical fixatives was the
treatment mcxiallty when endodontic instruments and
techniques were less well developed.
By their very action, fixatives are self-limiting and
tissue penetration is limited (Simon & Van Muliem
1978). A wide surface area of contact and a suflScient
amount of intracanal medicament is necessary for effec-
tive fixation. The tags of pulpal tissues in the anatomical
ramifications of the root canal are not easily accessible,
and may not be affected by the limited action of intra-
canal fixatives. Formaldehyde-based medicaments, for
example, are poor fixatives in the amounts used as
intracanal medicaments (Wemes et al. 1982a). and may
irritate periapical tissues (Simon et al. 19 79, Wemes et al.
1982b). Bone sequestration and dentine resorption
following the use of a formaldehyde-containing prep-
aration have been reported (Tal et al. 1978). In paedi-
atric dentistry, where fixatives are still commonly util-
ized for pulpotomies, their continuing use has aroused
concern (Judd & Kenny 1987). not least because of their
mutagenic and carcinogenic potential.
Fixed necrotic tissues have also been found to be more
resistant to dissolution by sodium hypochlorite solution,
used as an irrigant (The 1979). In addition, questions
have been raised as to whether fixed tissues are inert.
Many studies on experimental animals have shown the
irritancy of fixed tissues (Thoden van Welzen & Feltkamp-
Vroom 1977, Thoden van Welzen & van den Hoof 1977,
Wesselink et al. 1977, Makkes et al. 1978a,b.c,d, Brian
et al. 1980). Intracanal fixatives can act as haptens and.
when combined with pulp tissue, may act as an immuno-
gen. Nishida et al. (1971) and Block et al. (1977,
1978a,b, 1979,1981) have demonstrated immunologi-
cal responses to pulp tissue of experimental animals,
altered by various intracanal medicaments. Fixatives
can also provoke allergic reactions in presensitized ani-
mals (Van Mullem etal. 1983), so the use of intracanal
fixatives should be discontinued since, in clinical prac-
tice, previous sensitization cannot be ruled out. Some
studies have suggested that sensitization via the root
canal occurs only rarely (Rolling & Thulin 1976,
Longwill et al 1982), but this does not mean that a
relationship does not exist (Wu et al. 1989). Recent
studies have explored the immunological response to
modified pulp tissues and serum albumins (Shinoda et al.
1986a,b). The potential toxicity and imraunological
reactions to altered pulp tissue remain as theoretical
risks.
(iv) As a barrier against leakage or breakdown of the
temporary filling
Intracanal medicaments are intended to act as a second
front to prevent invasion of oral micro-organisms into
the root canal in the event of leakage or breakdown of the
temporary filiing. To prevent canal contamination, a
substantial amount of intracanal medicament wili be
required. This is because the percolation of oral fluids
through a defective temporary filling will dilute and
neutralize tbe medicament. Most intracanal medica-
ments, as they are toxic, are used sparingly, and so it is
inconceivable that the limited amount of medicament
used can prevent the ingress of micro-organisms
through an inadequate temporary filling. In addition,
the effectiveness of a phenol-type medicament, for
example, decreases rapidly, so it is a poor barrier against
canal contamination.
In order to prevent cana! contamination, attention to
provision of a bacteria-tight temporary filling is more
appropriate than dependence on the intracanal medica-
ment. After all. if a canal becomes contaminated, it will
still need to be re-cleaned and re-disinfected, regardless of
the presence of an intracanal medicament. The integrity
of the temporary filling is vital during all stages of
root canal treatment. Even with completed root fillings,
coronal leakage may jeopardize the success of root
canal treatment (Swanson & Madison 1987, Madison &
Wilcox 1988, Torabinejad et al. 1990). Therefore, it is
important to ensure that the temporary filling and the
existing coronal restoration of the tooth under treatment
are sound and caries fre. The basic principle of caries
control Eilso applies to root canal access cavity prep-
aration, so caries must be removed. If a filling or crown is
carious, deficient or leaky, it must be replaced as appro-
priate. It is pointless to place a good temporary filling
over an inadequate coronal restoration that allows
leakage.
There are many reports on the sealing ability of tem-
porary filling materials (Friedman et al. 1986. Tepiitsky
& Meimads 1988, Anderson et al. 1989, Bobotis et al.
1989, Noguera & McDonald 1990). Conflicting results
have emerged because of differing experimental protocols.
Certain intracanal medicaments have been found to be
incompatible with temporary filling materials. Formo-
cresol, camphorated parachlorophenol and metacresyl-
acetate have a softening effect on temporary filling
102 B,S, Chong and T. R. Pitt Ford
materials (Ohnsted et al. 1977). Intracanal medicaments
may affect the sea! of temporary filling materials (Blaney
etal. 1981,Keller eta/. 1981).Inabdefreport, endodontic
medicaments were also found to have a softening effect on
resin fllling materials (Lorencki & Astiz 1981).
Since prevention of microbial microleakage into the
root canal is the desired property of a temporary resto-
ration, a material that possesses antibacterial properties
would be appropriate. Most restorative materials possess
some antibacterial properties when freshly mixed
(Tobias et al. 1985, 1988). However, there is consider-
able variation in the antibacterial properties of different
materials and between different formulations of similar
materials. A good choice for a temporary restoration
would be a zinc oxide-eugenol cement, because of its
prolonged antibacterial activity (Tobias et al. 1985). In
an early study, Moller (1966) found that a bacteria-tight
seal could be achieved with zinc oxide cements. The anti-
bacterial effect of zinc oxide-eugenol cement prevents
colonization of bacteria, and is effective in preventing
bacterial microleakage (Browne & Tobias 1986, Hume
1988). The level of release of eugenol from zinc oxide-
eugenol mixtures by progressive hydrolysis ofthe cement
surface is sufficient to kill oral micro-organisms. When
testing the biocompatibility of dental filling materials,
zinc oxide-eugenol cements have been used to surface
seal the test cavities to prevent bacteria from entering the
restoration/dentine interface (Brannstrom & Vojinovic
1976, Brannstrom et al. 1979, Browne & Tobias 1986,
Cox 1987). In teeth that had been rendered bacteria-free
and sealed with a zinc-oxide eugenol temporary cement,
no bacteria could be recovered when resampled 1-5
weeks later, even in the absence of an intracanal medica-
ment (Sjogren et al. 1991). Therefore the prevention of
canal contamination is best tackled by ensuring a
good temporary filling with a zinc oxide-eugenol
cement. The use of intracanal medication to prevent
canal recontamination is ineffective.
(v) To control persistent abscesses and the persistent
'weeping/wet' canals
A persistently 'weeping/wet' canal results from seepage
of apical fluids into the root canal. Calcium hydroxide is
widely used as an intracanal medicament to control this
continuous exudation (Heithersay 1975, Martin &
Crabb 1977). The elimination of exudation fiadlitates
permanent filling of the root canal. The exact mechan-
ism of action of calcium hydroxide is unknown, but it
may be due to its antibacterial properties. Another poss-
ible explanation is that the release of hydroxyl ions and
the pH shift in the process of alkaiization of calcium
hydroxide (Staehle et of. 1989) provides an environment
that favours repair and calcification (Tronstad et a/.
1981). Other suggested mechanisms of action include
the contraction of capillaries (Heithersay 1975), the
formation of a fibrous bamer (Rasmussen & Mjor 1971),
or formation of an apical plug by calcium hydroxide. This
material also has the ability to dissolve tissues and elimi-
nate necrotic debris (Cvek et al. 1976b). The tissue-
dissolving effect of sodium hypochlorite was shown to be
enhanced when tissues were pretreated with calcium
hydroxide paste (Hasselgren et al. 1988), but calcium
hydroxide solution used alone as an irrigant was an
ineffective solvent of pulp tissue (Morgan et al 1991).
The actual mechanism of action ofcalcium hydroxide is
still not fully understood, but it possesses many of the
properties required of an ideal intracanal medicament.
Calcium hydroxide has good antibacterial activity, but its
duration of action is short. It is not equally effective
against all the bacteria that are found in the root canal,
and it is not a universal intracanal medicament (Reit &
Dahlen 1988). The biochemical actions, dental formu-
lations and uses ofcalcium hydroxide have been reviewed
by Foreman & Barnes (1990).
Conclusions
After reviewing the indications for use of intracanal
medicaments, it can be concluded that most of these indi-
cations are questionable. It is doubtful whether an intra-
canal medicament is routinely needed in root canal
treatment of teeth containing vital pulp tissue. When
the root canal is extensively infected and when inter-
appointment time periods are long, there is merit in using
an antibacterial intracanal medicament as part of con-
trolled asepsis. However, this must be combined with an
antibacterial irrigant, thorough cleaning and adequate
shaping ofthe root canal. Intracanal medicaments play a
secondary role, and should not be used as an alternative
to thorough cleaning and adequate shaping of the root
canal.
A good temporary Ming should prevent canal recon-
tamination instead of the need to use an intracanal
medicament. Zinc oxide-eugenol temporary restorative
materials have a proven record of preventing bacterial
microleakage, and will provide the required bacteria-
tight coronal seal.
Postoperative pain is better controlled by analgesics
than by potent intracanal medicaments. Severe, acute
infections are better managed with systemic antibi(tfcs.
Intracanal medication in root canal treatment 103
The use of topical corticosteroids is debatable, intracanal
medicaments have the potential to do more harm than
good.
Intracanal medicaments with fixative action should
not be used as dressings, as they are unlikely to be effec-
tive and there are questions regarding the safety of using
them.
Calcium hydroxide has much to commend it as a root
canal dressing for drying wet canals, and as an anti-
bacterial intracanai medicament. However, it is not
equally effective against all the bacteria that are found in
the root canal. It is not a panacea, and its injudicious use
should be avoided.
When a tooth does not respond to root canal treat-
ment, bacteriological sampling may be needed to deter-
mine the bacteria present in the root canal system. This
will aid the choice of intracanal medicament and moni-
toring of the progress of treatment. Every case should be
judged on the advantages and disadvantages of using an
intracanal medicament. After all, what is removed from
the root canal is of greater significance with regard to the
success of root canal treatment than what is placed in the
root canal system.
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