Endodontic Medicaments Research Articles

Hydrophilic Natural Polymers for Sustained-controlled Release of Calcium Hydroxide.

Calcium Hydroxide (CH) is commonly employed as intracanal medicament in endodontics. In order to maximize its therapeutic effects, it is essential to develop new approaches for preparing the controlled drug release systems which, in turn, facilities the dissociation of CH into calcium and hydroxyl ions. This work studies the sustained-controlled release of calcium ions and the effect of pH changes on the different formulation of CH with hydrophilic natural polymers over a period of 30 days. Various formulations were prepared by combining CH with gelatin, aloe vera and gum tragacanth. Root canals of 60 human teeth were instrumented and filled with a different formulation of CH and suspended in plastic tubes containing distilled water. Three formulas of polymer/CH were evaluated, and pure CH powder was used as a control. At specific time intervals, the calcium ions release and the pH changes of the medium in different formulations were analyzed. The main interactions between the studied polymers and CH were investigated using FTIR spectra. The antibacterial activity of formulations against Enterococcus faecalis was also studied. Faster release of CH was observed for aloe vera/CH. Gum tragacanth/CH showed a slow-release during the first 15 days. In contrast, only Gelatin/CH formulation showed a prolonged release with statistically significant differences (P < 0.05). The pure CH showed significantly higher pH values than the other formulations. The Gelatin/CH formulation was a better sustained-release system than the pure CH, and it can be used as a promising vehicle for CH in the root canal treatment.

Evaluation of ozonized calcium hydroxide as an effective intracanal medicament during root canal procedures: an in vitro observational study.

Achieving thorough disinfection is regarded as one of the pillars in endodontics. Although calcium hydroxide (CH) is one of the routinely used intracanal medicament in endodontics; alternative approaches are gaining popularity to mitigate endodontic pathology. However, CH has to be tested for its dissociation which is a rate-limiting attribute essential for its therapeutic action. The dissociation of CH into OH– and Ca2+ depends on the vehicle used to prepare the paste. This in-vitro study evaluated the use of ozonized olive oil in facilitating calcium ion release and change in pH when combined with CH. Fifty single rooted extracted human mandibular premolars were instrumented with NiTi rotary files (40/6). The teeth were divided into two groups (n = 25 per group) on the basis of vehicle: olive oil (CH + olive oil) and ozonized olive oil (CH + ozonized olive oil) groups. Both olive and ozonized olive oil vehicles allowed the diffusion of ions. However, pastes prepared with ozonized oil showed more ion diffusion, with marked calcium ion release after 15 days and alkalinity was maintained for complete period of 15 days, depicting better support for CH action. The change in calcium ion release and alkalinity were statistically significant in ozonized oil vehicle compared to olive oil vehicle. The present in-vitro study supports the use of ozonized olive oil as a vehicle to be used with CH as an intracanal medicament, considering its anti-microbial potential and sustainable release of calcium ions. The study was approved by the Institutional Ethical Committee of Manubhai Patel Dental College (approval No. MPDC_130/CONS-25/17) on June 4, 2018.

Comparison of the antibacterial efficacy of teatree oil, nisin and calcium hydroxide against Enterococcus faecalis

Enterococcus faecalis is a microorganism commonly detected in persistent endodontic infections which leads to root canal failure. It can gain entry into the root canal system during treatment, between appointments or even after the treatment has been completed. The use of the effective intra-canal medicaments can significantly enhance bacterial elimination during root canal treatment. The aim of the study was to evaluate and compare the antibacterial efficacy of Teatree oil, Nisin and Calcium hydroxide against E. faecalis. Typtic Soya agar plates were prepared. The agar well diffusion method was used and plates were incubated at 37 °C for 24hr. The antibacterial efficacy was then evaluated. The zone of inhibition (mm) of each antimicrobial medicament was measured by standard method. Maximum antibacterial efficacy was exhibited by Tea tree oil followed by Nisin and Calcium hydroxide. The results showed that Teatree oil and Nisin have better antibacterial efficacy than the routinely used Calcium hydroxide and they can be used as an alternative intra-canal medicament in endodontics.

Herbal medicaments in endodontics - Current guidelines for in vivo studies in India.

Elimination of bacteria from infected root canal systems is a challenging task. Various techniques have been described to reduce the number of bacteria within the root canal system, which include chemomechanical instrumentation, use of various irrigants to remove or dissolve organic and inorganic debris, and to destroy bacteria. The intracanal medicament plays a key role in the success of root canal treatment. With the rise in bacterial resistance to antibiotics, there is considerable interest in the development of other classes of antimicrobials for the control of infection. Natural products are known to play an important role in human life. The use of herbal products as mouthwash has been tried and tested in the literature. However, the use of herbal intracanal medicament has been shown promising results when used under in vitro conditions, but in vivo studies are very scarce. This may be due to the limited supporting literature available to use it as intracanal medicament in patients due to the ethical concern. Hence, the purpose of this review is to highlight the current guidelines (laid by the drugs and cosmetics act as per the Gazette of India) regarding the use of herbal medicaments for the clinical trials in endodontics.

Effect on the mechanical properties of human and bovine dentine of intracanal medicaments and irrigants.

Evidence is lacking concerning the suitability of using bovine dentine in endodontic research. This study compared the mechanical properties of human and bovine root dentine using endodontic medicaments and irrigants. Standardized human and bovine dentine bars were allocated to six experimental groups (n = 15): calcium hydroxide paste (Calasept® Plus); Odontopaste® ; 0.5% and 1% NaOCl gels; 1% and 4% NaOCl solutions. The bars were exposed to the materials for 7 days and then immediately subjected to a three-point bend test and Vickers microhardness test. Data were analysed using analysis of variance with Fisher's pairwise comparisons, with P < 0.05. Human dentine displayed a significantly higher modulus of elasticity (P = 0.001), higher microhardness (P < 0.001), and lower flexural strength (P = 0.004) compared with bovine dentine. Calcium hydroxide and Odontopaste® did not result in a significant change to the mechanical properties of human dentine. In human dentine, 0.5% NaOCl gel caused a significant decrease in flexural strength (P < 0.001) and microhardness (P = 0.02). Bovine dentine was a suitable substrate relative to human dentine. The use of a 0.5% or 1% NaOCl gel as an intracanal medicament is not supported by this study.

Synthesis and Characterization of Calcium Hydroxide from Indonesian Limestone as Endodontic Intracanal Medicament

Calcium hydroxide [Ca (OH)2] has been the gold standard for endodontic medicament as inter-appointment dressing, due to its ability to act as antimicrobial agent and to promote hard tissue healing. The main mechanism of this material is the release of Ca2+and OH-ions through its vehicle, providing high alkaline pH. Indonesia, has many potential resources, namely limestone (CaCO3), that can be utilized as raw material for Ca (OH)2. The objective of this present study is to investigate the synthesis and characterization of Ca (OH)2from Indonesian limestone as endodontic intra-canal medicament. Limestone were taken from Palimanan area in West Java, Indonesia. CaCO3was calcined at 900°C for 4h resulting CaO powder. CaO powder were mixed with distilled water using a rotary stirrer for 24h and produce Ca (OH)2paste. The Ca (OH)2paste was dried at 80°C, then crushed using a mortar and pestle to obtain Ca (OH)2powder. The powder samples were thus subjected for characterization by X-Ray Diffraction (XRD) and Fourier-Transform Infrared (FTIR) Spectroscopy. The XRD patterns revealed that the high peak of Ca (OH)2crystallinity was successfully achieved in this study. The FTIR spectroscopy also showed bands at 3640 cm-1which belongs to OH-stretching vibration of the Ca (OH)2. The results indicate that the synthesize of Indonesian limestone as Ca (OH)2by this method was attained. Indonesian limestone is a potential raw material that can be used as a precursor for synthesis of Ca (OH)2as endodontic material.

Investigation of the effect of rapid and slow external pH increases on Enterococcus faecalis biofilm grown on dentine.

Calcium hydroxide is a common endodontic medicament and has an antimicrobial effect by increasing the localized pH within the root canal. However, Enterococcus faecalis has shown some resistance to calcium hydroxide. A flow cell apparatus was used to grow an E. faecalis biofilm on dentine discs. Following 4 weeks growth in Todd Hewitt Broth, flow cells were exposed to either a rapid or slow increase to pH 11.5 or 12.5. Cellular viability was determined using serial plating and the number of colony-forming units was normalized against the cellular protein content. Scanning electron microscopy was carried out to qualitatively observe the effects of the different rates of pH increase. A significant difference in viability between the pH rapid and slow groups was not shown in this study. Compared with pH 11.5 solutions, pH 12.5 solutions were more effective at killing bacteria although some E. faecalis still survived. Enterococcus faecalis did not adapt and develop a greater resistance to high pH following a slow rise in pH compared with a rapid rise in pH. As expected, pH 12.5 was more effective in reducing bacterial numbers compared with pH 11.5 although E. faecalis was not completely eliminated.

A survey of the knowledge, attitude, and awareness about the principal choice of intracanal medicaments among the general dental practitioners and nonendodontic specialists.

Removal of the microbial organisms from the root canal system is a prerequisite for the successful outcome of any root canal treatment. Use of an effective intracanal medicament will assist in the disinfection of the root canal system. Intracanal medicaments have been used to disinfect root canals between appointments and reduce interappointment pain. A questionnaire survey was conducted to evaluate the knowledge, attitude, and awareness about the principal choice of intracanal medicaments among general dental practitioners and nonendodontic specialists. The questionnaire consisted of 11 questions related to intracanal medicaments in Endodontics. It was distributed to 75 general dental practitioners and 75 other specialists (nonendodontists). In the present study, the authors observed that the knowledge level among the study participants was moderately satisfying. However, the need for more education of the dentists with regard to the intracanal medicaments was perceived. Correct knowledge of intracanal medicaments would help the practitioners to decide the apt material of choice as intracanal medicaments in different clinical situations. The present study highlighted the need for more continuing dental education programs with active participation of general practitioners and nonendodontic specialists to update themselves.

Role of Antibiotics as Intracanal Medicament-A Literature Review

Antibiotics are an extremely valuable addition to the armamentarium available to health practitioners for management of bacterial infections. Due to the potential risk of adverse systemic effects of systemic applications and ineffectiveness of systemic antibiotics in the necrotic pulpless tooth and the periradicular tissues, local application of antibiotics will be more effective since it is directly acting against the microorganism in the infected root canal. This paper reviews the applications of antibiotics and antibiotics containing medicaments in endodontics.

Development of techniques for determination of primary components of dental medicament paste mixtures for root canal treatment

The purpose of the present study was to develop techniques to evaluate and quantify the primary components of dental medicament paste mixtures for root canal treatment, and to evaluate if degradation of the primary components occurred during storage. The first part of the study developed a mass spectrometry (MS) method for determination of best recovery process. For this process, analytical grades of triamcinolone acetonide, clindamycin HCl, and doxycycline hyclate were sourced and analyzed. This was followed by solid-phase extraction (SPE) and an analysis of active components in dental pastes. By utilizing the targeted analytical properties of multiple reaction monitoring MS methods, coupled with SPE technique, the active components of endodontic dental pastes could be quantified and compared. The developed methods showed consistency over multiple runs, with a high level of reproducibility. None of the active components of the tested pastes degraded over the periods of product life tested. The inactivation or destruction of any of the primary components of endodontic medicaments in storage, or when mixed with other pastes, could affect treatment outcomes. The present study provides a reliable technique for the analysis of the active components of root canal medicaments.

Ions Release and pH of Calcium Hydroxide-, Chlorhexidine- and Bioactive Glass-Based Endodontic Medicaments.

This study evaluated pH and release of calcium, sodium and phosphate ions from different medications in human dentin. Fifty premolars were prepared and randomly divided into groups: (CHX) - 2% chlorhexidine gel; (CHX + CH) - CHX + calcium hydroxide PA; (CH) - CH + propylene glycol 600; (NPBG) - experimental niobium phosphate bioactive glass + distilled water; (BG) - bioactive glass (Bio-Gran) + distilled water. The specimens were immersed in deionized water and the pH variations were measured. The quantification of ions in the solutions was made by inductively coupled plasma - atomic emission spectroscopy (ICP/AES) at 10 min, 24 h, 7, 14, 21 and 30 days. The results were analyzed by ANOVA and Tukey`s test, with a significance level of 5%. CH had the highest level of calcium ions release at 30 days, while CHX and BG released more sodium ions. BG, NPBG and CHX released a higher amount of phosphate ions. The pH of CH was significantly higher compared with the other groups. CH favored the greatest increase of pH and calcium ions release. The bioactive glasses released more sodium and phosphate ions and presented an alkaline pH immediately and after 30 days.

Biomimetic microenvironments for regenerative endodontics.

Regenerative endodontics has been proposed to replace damaged and underdeveloped tooth structures with normal pulp-dentin tissue by providing a natural extracellular matrix (ECM) mimicking environment; stem cells, signaling molecules, and scaffolds. In addition, clinical success of the regenerative endodontic treatments can be evidenced by absence of signs and symptoms; no bony pathology, a disinfected pulp, and the maturation of root dentin in length and thickness. In spite of the various approaches of regenerative endodontics, there are several major challenges that remain to be improved: a) the endodontic root canal is a strong harbor of the endodontic bacterial biofilm and the fundamental etiologic factors of recurrent endodontic diseases, (b) tooth discolorations are caused by antibiotics and filling materials, (c) cervical root fractures are caused by endodontic medicaments, (d) pulp tissue is not vascularized nor innervated, and (e) the dentin matrix is not developed with adequate root thickness and length. Generally, current clinical protocols and recent studies have shown a limited success of the pulp-dentin tissue regeneration. Throughout the various approaches, the construction of biomimetic microenvironments of pulp-dentin tissue is a key concept of the tissue engineering based regenerative endodontics. The biomimetic microenvironments are composed of a synthetic nano-scaled polymeric fiber structure that mimics native pulp ECM and functions as a scaffold of the pulp-dentin tissue complex. They will provide a framework of the pulp ECM, can deliver selective bioactive molecules, and may recruit pluripotent stem cells from the vicinity of the pulp apex. The polymeric nanofibers are produced by methods of self-assembly, electrospinning, and phase separation. In order to be applied to biomedical use, the polymeric nanofibers require biocompatibility, stability, and biodegradability. Therefore, this review focuses on the development and application of the biomimetic microenvironments of pulp-dentin tissue among the current regenerative endodontics.

Antimicrobial Activity of Endodontic Medicaments and Vehicles using Agar Well Diffusion Method on Facultative and Obligate Anaerobes.

AimsThe aim of this study was to determine the relative antimicrobial effectiveness of these endodontic medicaments and various vehicles using an agar well diffusion assay.Materials and methodsDouble Antibiotic Paste(DAP), modified DAP, 2% Chlorhexidine gluconate and their combination with four vehicles namely Polyethylene glycol 400 (PEG), Propylene glycol (PG), combinations of PG with PEG and lastly Glycerine were tested using agar well diffusion assay. The minimum bactericidal concentration was noted against four standard strains of organisms ie Streptococcus mutans ATCC( American Type Culture Collection) 25175, Staphylococcus aureus ATCC 12598, Enterococcus faecalis ATCC 35550 and Eschericia coli ATCC 25922. Successful endodontic therapy depends upon thorough disinfection of root canals. In some refractory cases, routine endodontic therapy is not sufficient, so intracanal medicaments are used for proper disinfection of canals. Issues of resistance, limited spectrum of activity and lack of antifungal properties, the hunt for the ideal intracanal medicament continues. In this regard, the vehicles used to form the pastes play a supportive role by forming the appropriate consistency for placement and may dramatically influence their chemical characteristics like their solubility and diffusion. Thus, inorder to use safer and equally effective intracanal medicaments, Chlorhexidine gluconate is being unveiled in this study.ResultsThe difference between the four vehicles when combined with the same endodontic medicament studied above is nonsignificant (NS) except against Porphyromonas gingivalis. Propylene glycol is significantly effective than Glycerine when used with DAP ie C+M medicament combination. (p = 0.029)Conclusion2% chlorhexidine gluconate and modified DAP can definitely replace DAP and triple antibiotic paste as end-odontic medicaments with chlorhexidine having an added advantage of bactericidal action, substantivity, biocompatibility, low toxicity, and lesser chances of developing resistance.How to cite this articleNalawade TM, Bhat KG, Sogi S. Antimicrobial Activity of Endodontic Medicaments and Vehicles using Agar Well Diffusion Method on Facultative and Obligate Anaerobes. Int J Clin Pediatr Dent 2016;9(4):335-341.

Factors affecting the rate of oxidation and resultant discolouration of tetracyclines contained in endodontic medicaments and irrigants.

To determine the effect of pH, oxygen levels and ions on tetracycline oxidation and resultant discolouration. Solutions of demeclocycline hydrochloride or doxycycline hyclate were prepared and exposed to different pH conditions, pure oxygen or carbon dioxide, ascorbic acid or various ions (from calcium chloride, calcium nitrate, strontium chloride, magnesium chloride, zinc chloride, and bismuth nitrate). Subsequently, they were exposed to intense visible blue light (470±15nm) for 24h. Colour change was monitored using standardized digital photography. Parametric statistical analysis employing the Wilcoxon matched-pairs signed-rank test was performed to compare the mean change in different colour channels, assessing the discolouration effect of the modified conditions. An acidic pH reduced discolouration, whilst alkaline pH increased it. A higher oxygen tension resulted in more discolouration, as did the presence of calcium, strontium, and bismuth ions, all of which bind to tetracyclines. Conversely, zinc and magnesium ions had a mild photoprotective effect. Ascorbic acid, an anti-oxidant, reduced the level of discolouration. The tendency of these tetracyclines to undergo photo-oxidation is increased by common variables present in the clinical environment. There are potential benefits from using photoprotectors and anti-oxidants in these materials, to reduce the possibility of discolouration.

Controlled Release of Drugs for Management of Pulpitis

Context: Biocompatible polymers are potentially effective for dental infections as delivery carriers of disinfectants or antibiotics into the root canal system (RCS). This study aimed to review polymeric microspheres enabling a controlled release of endodontic medicaments. Evidence Acquisition: A literature search was carried out in the PubMed database (May 2013) using the following keywords: “poly lactic-co-glycolic acid or PLGA”, “polymer microplate”, “encapsulate”, “drug delivery”, “controlled release”, “antibiotic”, “gentamycin”, and “amoxicillin”. We intended to find articles on the application of polymer microparticles for delivery and release of drugs in dental infections or articles discussing factors affecting the properties of these materials. Results: Seventeen articles were found evaluating the controlled release of the drugs for dental purposes; out of them, in 5 in vitro studies, polymer microspheres had been produced for root canal disinfection. Seven articles had investigated the properties of polymer microspheres and the factors influencing drug release by them. Conclusions: Drug-loaded polymer microspheres may be used successfully as delivery carriers for controlled release of antibiotics into the root canal system. The efficacy and success rate of this method must be tested in animal models and then clinical trials.

Nonsurgical treatment of two periapical lesions with calcium hydroxide using two different vehicles.

Calcium hydroxide is used extensively as an intracanal medicament in endodontics for many years. It is used in various clinical situations such as to promote apexification, to repair perforation, to enhance healing of periapical lesions, to control root resorption, and to control exudation in teeth with persistent periapical inflammation. This paper presents a case report in which Ca(OH)2 was used as an intracanal medicament for treatment of periradicular lesions using two different vehicles in two different teeth of same patient.

Crown discoloration due to the use of triple antibiotic paste as an endodontic intra-canal medicament

The use of triple antibiotic paste (TAP) (mixture of ciprofloxacin, metronidazole and minocycline) as an intra-canal medicament have shown very encouraging results particularly in non-vital immature teeth associated with periradicular lesions. Hence, before opting for a surgical approach, a non-surgical approach can be thought of with extended use of TAP as intra-canal medicament, especially in patients who are phobic to invasive procedures. On the flip side, the use of TAP has few side-effects, of which one is the discoloration it can cause due to the presence of minocycline in the mix. The purpose of this article is to presents a case of coronal discoloration due to the use of TAP as an endodontic intra-canal medicament.

Discoloration of Roots Caused by Residual Endodontic Intracanal Medicaments

Aims. This study examined the extent to which intervisit corticosteroid-based antibiotic pastes (CAP) medicaments contribute to staining of tooth structure after attempted removal by irrigation techniques. Methods. A total of 140 roots were prepared and the canals were filled with Ledermix paste (demeclocycline), Odontopaste (clindamycin), and Doxypaste (doxycycline). The pastes were removed after 2 or 4 weeks of storage in the dark using EDTA and NaOCl with either a 27-gauge-slotted needle or an EndoActivator (Dentsply). The roots were then exposed to an intense light source for 30 minutes each week and photographed after a further 1, 3, or 6 months. Digital images were standardized and data for changes in luminosity were analysed using repeated measures ANOVA and a post hoc test. Results. Removal of the medicament did not prevent later discolouration. There was no significant difference between the paste removal methods. Ledermix paste caused the greatest darkening compared to the untreated controls, for both application periods and both methods of removal. Doxypaste and Odontopaste caused less darkening than Ledermix. Conclusion. Medicaments that stain teeth may continue to discolour teeth despite best attempts to remove them. This study stresses the importance of material selection and minimising contact of Ledermix within the coronal aspects of teeth.

The Effect of Dentin on the Pulp Tissue Dissolution Capacity of Sodium Hypochlorite and Calcium Hydroxide

IntroductionSodium hypochlorite (NaOCl) and calcium hydroxide (Ca[OH]2) have tissue dissolution capacity. The aim of this study was to evaluate the potential effect of dentin on their tissue dissolution capacity in a novel dentin model. MethodsDentin models were prepared from 25 freshly extracted human molar teeth; the crowns were separated from the roots, and a rectangular inner shape was prepared. Pulp tissue samples adjusted to similar weights of 6.5 ± 0.2 mg were randomly divided into 6 groups: NaOCl groups in test tubes or dentin models for 1 hour, Ca(OH)2 groups in test tubes or dentin models for 1 week, and control groups saline in test tubes or dentin models for 1 week. The final weights after the experimental period were checked and compared with the initial weights. The differences were statistically analyzed. ResultsThe tissue dissolution capacity of Ca(OH)2 was affected by the presence of dentin. Similarly, NaOCl lost its effect on the pulp tissue after incubation in dentin. Comparison between all test groups showed highly significant differences (P < .001). ConclusionsDentin has a detrimental effect on the ability of NaOCl and Ca(OH)2 to dissolve pulp tissue. The dentin model appears to be an efficient tool for the study of interactions between local endodontic medicaments, dentin, and pulp tissue.

Antimicrobial Efficacy of Octenidine Hydrochloride, MTAD and Chlorhexidine Gluconate Mixed with Calcium Hydroxide

The aim of this in vitro study was to investigate whether mixing with calcium hydroxide [Ca(OH)2] affects the antimicrobial action of Octenidine hydrochloride (Octenisept), MTAD and chlorhexidine against Enterococcus faecalis and Candida albicans. Freshly grown cultures of Enterococcus faecalis, Candida albicans and a mixture of both strains were incubated in agar plates containing brain-heart infusion broth (BHIB). Zones of inhibition were measured at 24 and 48 hours. Statistical analysis was performed using Mann-Whitney U test and Kruskal-Wallis one-way analysis of variance (ANOVA, both p=0.05). Mixing with Ca(OH)2 significantly increased the antibacterial effect of Octenisept (p<0.05), but did not alter its antifungal activity. Only chlorhexidine showed more antibacterial and antifungal efficiency compared to its Ca(OH)2-mixed version (both p<0.05). Mixing with Ca(OH)2 decreased the antibacterial efficacy of MTAD, but increased its antifungal effect (both p<0.05). These results demonstrate the differential effects of Ca(OH)2 addition on the antimicrobial action of the tested endodontic medicaments in vitro. Ca(OH)2 was as effective as its combination with all of the tested medicaments.