Chapter 16 Cleaning and Shaping



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Ultrasonics

Ultrasonics are used for cleaning and shaping, removal of materials from the canal, removal of posts and silver cones, thermoplastic obturation, and root end preparation during surgery.

The main advantage to cleaning and shaping with ultrasonics is acoustic micro streaming.59 This is described as a complex steady-state streaming patterns in a vortex like motion or eddy flows formed close to the instrument. Agitation of the irrigant with an ultrasonically activated file after completion of cleaning and shaping has the benefit of increasing the effectiveness of the solution.60-63


Initially it was proposed that ultrasonics could clean the canal without procedural errors such as apical transportation and remove the smear layer.64, 65 However later studies failed to confirm these results.66-68
IRRIGANTS AND LUBRICANTS

The ideal properties for an endodontic irrigant are listed in Box-2.69 Currently no solution meets all the requirements outlined.


Irrigation does not completely debride the canal. Sodium hypochlorite will not remove tissue from areas that are not touched by files (Figures 16-1 and 16-2).70 In fact no techniques appear able to completely clean the root canal space.71-73, 22 Frequent irrigation is necessary to flush and remove the debris generated by the mechanical action of the instruments.
Box-2 Properties of an ideal irrigant

Organic tissue solvent

Inorganic tissue solvent

Antimicrobial action

Non-toxic

Low Surface Tension

Lubricant

Antimicrobial action
Sodium Hypochlorite

The most common irrigant is sodium hypochlorite (household bleach). Advantages to sodium hypochlorite include the mechanical flushing of debris from the canal, the ability of the solution to dissolve vital74 and necrotic tissue,75 the antimicrobial action of the solution,32 and the lubricating action.76 In addition it is inexpensive and readily available.


Free chlorine in sodium hypochlorite dissolves necrotic tissue by breaking down proteins into amino acids. There is no proven appropriate concentration of sodium hypochlorite, but concentrations ranging form 0.5% to 5.25% have been recommended. A common concentration is 2.5%; which decreases the potential for toxicity while still maintaining some tissue dissolving and antimicrobial activity.77, 78 Since the action of the irrigant is related to the amount of free chlorine, decreasing the concentration can be compensated by increasing the volume. Warming the solution can also increase effectiveness of the solution.79, 80
Because of toxicity, extrusion is to be avoided.45, 81, 41 The irrigating needle must be placed loosely in the canal (Figure 16-6). Insertion to binding and slight withdrawal minimizes the potential for possible extrusion and a “sodium hypochlorite accident” (Figure 16-7). Special care should be exercised when irrigating a canal with an open apex. To control the depth of insertion the needle is bent slightly at the appropriate length or a rubber stopper placed on the needle.
The irrigant does not move apically more than one millimeter beyond the irrigation tip so deep placement with small gauge needles enhances irrigation (Figure 16-6).82 Unfortunately the small bore can easily clog, so aspiration after each use is recommended. During rinsing, the needle is moved up and down constantly to produce agitation and prevent binding or wedging of the needle.
Chlorhexidine

Chlorhexidine possesses a broad spectrum of antimicrobial activity, provides a sustained action81, 83, and has little toxicity.84-87 Two percent chlorhexadine has similar antimicrobial action as 5.25% sodium hypochlorite84 and is more effective against enterococcus faecalis.81 Sodium hypochlorite and chlorhexadine are synergistic in their ability to eliminate microorganisms. 85 A disadvantage of chlorhexadine is its inability to dissolve necrotic tissue and remove the smear layer.


LUBRICANTS

Lubricants facilitate file manipulation during cleaning and shaping. They are an aid in initial canal negotiation especially in small constricted canals without taper. They reduce torsional forces on the instruments and decrease the potential for fracture.


Glycerin is a mild alcohol that is inexpensive, nontoxic, aseptic, and somewhat soluble. A small amount can be placed along the shaft of the file or deposited in the canal orifice. Counterclockwise rotation of the file carries the material apically. The file can then be worked to place using a watch winding or “twiddling” motion.

Paste lubricants can incorporate chelators. One advantage to paste lubricants is that they can suspend dentinal debris and prevent apical compaction. One proprietary product consists of glycol, urea peroxide and ethylenediaminetetraacetic acid (EDTA) in a special water soluble base. It has been demonstrated to exhibit an antimicrobial action88. Another type is composed of 19% EDTA in a water soluble viscous solution.

A disadvantage to these EDTA compounds appears to be the deactivation of sodium hypochlorite by reducing the available chlorine89 and potential toxicity90. The addition of EDTA to the lubricants has not proven to be effective91. In general files remove dentin faster than the chelators can soften the canal walls. Aqueous solutions such as sodium hypochlorite should be used instead of paste lubricants when using nickel-titanium rotary techniques to reduce torque76.
SMEAR LAYER

During the cleaning and shaping, organic pulpal materials and inorganic dentinal debris accummulates on the radicular canal wall producing a an amorphous irregular smear layer (Figure 16-8).69 With pulp necrosis, the smear layer may be contaminated with bacteria and their metabolic by-products. The smear layer is superficial with a thickness of 1-5 microns and debris can be packed into the dentinal tubules varying distances.92


There does not appear to be a consensus on removing the smear layer prior to obturation. 93, 94, 69 The advantages and disadvantages of the smear layer removal remain controversial; however, evidence supports removing the smear layer prior to obturation.95, 69 The organic debris present in the smear layer might constitute substrate for bacterial growth and it has been suggested that the smear layer prohibits sealer contact with the canal wall and permits leakage. In addition, viable microorganisms in the dentinal tubules may use the smear layer as a substrate for sustained growth. When the smear layer is not removed, it may slowly disintegrate with leaking obturation materials, or it may be removed by acids and enzymes that are produced by viable bacteria left in the tubules or enter via coronal leakage. 96 The presence of a smear layer may also interfere with the action and effectiveness of root canal irrigants and inter-appointment disinfectants.37
With smear layer removal filling materials adapt better to the canal wall.97, 98 Removal of the smear layer also enhances the adhesion of sealers to dentin and tubular penetration99, 97, 100, 98 and permits the penetration of all sealers to varying depths.101 Removal of the smear layer reduces both coronal and apical leakage.102 103

EDTA

Removal of the smear layer is accomplished with acids or other chelating agents such as ethylenediamine tetracetic acid (EDTA) 104 following cleaning and shaping. Irrigation with 17% EDTA for one minute followed by a final rinse with sodium hypochlorite105 is a recommended method. Chelators remove the inorganic components leaving the organic tissue elements intact. Sodium hypochlorite is then necessary for removal of the remaining organic components. Citric acid has also been shown to be an effective method for removing the smear layer106, 107 as has tetracycline. 108, 109


Demineralization results in removal of the smear layer and plugs, and enlargement of the tubules.110 111 The action is most effective in the coronal and middle thirds of the canal and reduced apically.104, 112 Reduced activity may be a reflection of canal size62 or anatomical variations such as irregular or sclerotic tubules.113 The variable structure of the apical region presents a challenge during endodontic obturation with adhesive materials.
The recommended time for removal of the smear layer with EDTA is 1 minute.114, 104, 115 The small particles of the smear layer are primarily inorganic with a high surface to mass ratio which facilitates removal by acids and chelators. EDTA exposure over 10 minutes causes excessive removal of both peritubular and intratubular dentin.116

MTAD

An alternative method for removing the smear layer employs the use of a mixture of a tetracycline isomer, an acid, and a detergent (MTAD) as a final rise to remove the smear layer.117 The effectiveness of MTAD to completely remove the smear layer is enhanced when low concentrations of NaOCl are used as an intracanal irrigant before the use of MTAD118. A 1.3% concentration is recommended. MTAD may be superior to sodium hypochlorite in antimicrobial action.119, 120 MTAD has been shown to be effective in killing E. faecalis, an organism commonly found in failing cases, and may prove beneficial during retreatment. It is biocompatible121, does not alter the physical properties of the dentin121 and it enhances bond strength.122


TECHNIQUES OF PREPARATION

Regardless of the technique used in cleaning and shaping, procedural errors can occur. These included loss of working length, apical transportation, apical perforation, lateral stripping and instrument fracture.


Loss of working length has several causes. These include failure to have an adequate reference point from which the corrected working length is determined, packing tissue and debris in the apical portion of the canal, ledge formation, and inaccurate measurements. Apical transportation and zipping occurs when the restoring force of the file exceeds the threshold for cutting dentin in cylindrical non-tapering curved canal (Figures 16-9 and 16-10).123 When this apical transportation continues with larger and larger files, a “teardrop” shape develops and perforation can occur apically on the lateral root surface (Figure16-9). Transportation in curved canals begins with a size #25 file15. Enlargement of curved canals at the corrected working length beyond a size #25 file should be done only when an adequate coronal flare is developed.
Instrument fracture occurs with torsional and cyclic fatigue. Locking the flutes of a file in the canal wall while continuing to rotate the coronal portion of the instrument is an example torsional fatigue (Figure 16-11). Cyclic fatigue results when strain develops in the metal.
Stripping perforations occur in the furcal region of curved roots, frequently the mesial roots of maxillary and mandibular molars perforation (Figures 16-12 and 16-13). The canal in this area is not always centered in the root and prior to preparation the average distance to the furcal wall (danger zone) is less than the distance to the bulky outer wall (safety zone). An additional factor is the concavity of the root.
Watch Winding

Watch winding is reciprocating back and forth (clockwise/counterclockwise) rotation of the instrument in an arch. It is used to negotiate canals and to work files to place. Light apical pressure is applied to move the file deeper into the canal.



Reaming

Reaming is defined as the clockwise, cutting rotation of the file. Generally the instruments are placed into the canal until binding is encountered. The instrument is then rotated clockwise 180-360º to plane the walls and enlarge the canal space.



Filing

Filing is defined as placing the file into the canal and pressing it laterally while withdrawing it along the path of insertion to scrape the wall. There is very little rotation on the outward cutting stroke. The scraping or rasping action removes the tissue and cuts superficial dentin from the canal wall. A modification is the turn-pull technique. This involves placing the file to the point of binding, rotating the instrument 90º and pulling the instrument along the canal wall.



Circumferential filing

Circumferential filing is used for canals that are larger and or not round. The file is placed into the canal and withdrawn in a directional manner sequentially against the mesial, distal, buccal, and lingual walls.



Standardized preparation

After 1961, instruments were manufactured with a standard formula. Clinicians utilized a preparation technique of sequentially enlarging the canal space with smaller to larger instruments at the corrected working length.124 In theory this created a standardized preparation of uniform taper. Unfortunately this does not occur. This technique was adequate for preparing the apical portion of canals that were relatively straight and tapered; however in cylindrical and small curved canals procedural errors were identified with the technique.125



Step-back Technique

The step-back technique70, 125 reduces procedural errors and improves debridement. After coronal flaring and determining the master apical file (initial file that binds slightly at the corrected working length), the succeeding larger files are shortened by 0.5 or 1.0 m increments from the previous file length (Figure 16-14 and 16-15). This step-back process creates a flared, tapering preparation while reducing procedural errors. The step-back preparation is superior to standardized serial filing and reaming techniques in debridement and maintaining the canal shape.70 The step-back filing technique results in more pulpal walls being planed when compared to reaming or filing.


Step-Down Technique

The step down technique is advocated for cleaning and shaping procedures as it removes coronal interferences and provides coronal taper. Originally advocated for hand file preparation126 it has been incorporated into techniques employing nickel-titanium files. With the pulp chamber filled with irrigant or lubricant the canal is explored with a small instrument to assess patency and morphology (curvature). The working length can be established at this time. The coronal one third of the canal is then flared with Gates Glidden drills or rotary files of greater taper (.06, .08, .10,). A large file (such size #70) is then placed in the canal using a watch winding motion until resistance is encountered.126 The process is repeated with sequentially smaller files until the apical portion of the canal is reached. The working length can be determined if this was not accomplished initially. The apical portion of the canal can now be prepared by enlarging the canal at the corrected working length. Apical taper is accomplished using a step-back technique.


Passive Step-back

The passive step-back technique is a modification of the incremental step-back technique.6, 127 After the apical diameter of the canal has been determined, the next higher instrument is inserted until it first makes contact (binding point). It is then rotated one half turn and removed (Figure 16-16). The process is repeated with larger and larger instruments being placed to their binding point. This entire instrument sequence is then repeated. With each sequence the instruments drop deeper into the canal creating a tapered preparation. This technique permits the canal morphology to dictate the preparation shape. The technique does not require arbitrary rigid incremental reductions and forcing files into canals that cannot accommodate the files. Advantages to the technique include: knowledge of canal morphology, removal of debris and minor canal obstructions, and a gradual passive enlargement of the canal in an apical to coronal direction.



Box-3 The diameter of rotary flaring instruments.

Size Gates-Glidden Peeso-Reamers
#1 .5 mm .7 mm

#2 .7 mm .9 mm

#3 .9 mm 1.1 mm

#4     1.1 mm 1.3 mm

#5     1.3 mm 1.5 mm

#6      1.5 mm 1.7 mm


Anti-Curvature Filing

Anti-curvature filing is advocated during coronal flaring procedures to preserve the furcal wall in treatment of molars (Figure 16-17). Canals are often not centered in mesial roots of maxillary and mandibular molars, being located closer to the furcation. Stripping perforations can occur in these teeth during overly aggressive enlargement of the canal space. Stripping perforations occur primarily during use of the Gates Glidden drills (Box-3) (Figure 16-18). To prevent this procedural error, the Gates Glidden drills should be confined to the canal space coronal to the root curvature and used in a step-back manner (Figure 16-18 and 16-19). The Gates Glidden drills can also be used directionally in an anti-curvature fashion to selectively remove dentin from the bulky wall (safety zone) toward the line angle, protecting the inner or furcal wall (danger zone) coronal to the curve (Figure 16-17). While this can be accomplished with the use of hand files, it appears that directional forces with Gates Glidden drills is not beneficial.128


Balanced Force Technique

The balanced force technique recognizes the fact that instruments are guided by the canal walls when rotated.129 Since the files will cut in both a clockwise and counterclockwise rotation, the balanced force concept of instrumentation consists of placing the file to length and then a clockwise rotation (less than 180 degrees) engages dentin. This is followed by a counterclockwise rotation (at least 120 degrees) with apical pressure to cut and enlarge the canal. The degree of apical pressure varies from light pressure with small instruments to heavy pressure with large instruments. The clockwise rotation pulls the instrument into the canal in an apical direction. The counterclockwise cutting rotation forces the file in a coronal direction while cutting circumferentially. Following the cutting rotation the file is repositioned and the process is repeated until the corrected working length is reached. At this point a final clockwise rotation is employed to evacuate the debris.


Nickel Titanium Rotary Preparation

Nickel titanium rotary preparation utilizes a crown-down approach. The specific technique is based on the instrument system selected. One instrument sequence uses nickel titanium files with a constant taper and variable ISO tip sizes (Figure 16-20). With this technique, a .06 taper is selected. Initially a size .06/45 file is used until resistance, followed by the .06/45, .06/40, .06/35, .06/30, .06/25, and .06/20. In a second technique, nickel titanium files with a constant tip diameter are used. The initial file is a .10/20 instrument, the second a .08/20, the third a .06/20, and the fourth a .04/20 (Figure 16-21). For larger canals a sequence of files using ISO standardized tip sizes of 30 or 40 might be selected. Using the crown down approach creates coronal flare and reduces the contact area of the file so torsional forces are reduced.



Final Apical Enlargement and Apical Clearing

Apical clearing enhances the preparation of the apical canal, improves debridement, and produce a more definite apical stop in preparation for obturation.130 Apical clearing is generally performed when there is an apical stop and the master apical file is less that a size #40 file. If the apical configuration is open or a seat, apical clearing might make the opening larger and potentiate the possibility of extrusion of the obturation materials. Apical clearing consists of two distinct steps: final apical enlargement and dry reaming.


Final apical enlargement is performed after the canal has been cleaned and shaped. It involves enlargement of the apical preparation three to five sizes beyond the master apical file (Figure 16-22). The degree of enlargement depends on the canal size and root curvature. In a small curved canal enlargement may only be three sizes to decrease the potential for transportation. In a straight canal it can be larger without producing a procedural error. Since the prepared canal exhibits taper, the small files at the corrected working length can be used to enlarge the canal without transportation. Final apical enlargement is performed with the irrigant and employs a reaming action at the corrected working length. The last file used becomes the final apical file. Since the file is only contacting the apical 1-2 mm the walls of the canal, the technique will result in a less irregular apical preparation. The canal is then irrigated. The smear layer is removed with a decalcifying agent and the canal dried with paper points.
After drying the canals, the dry reaming is performed. Dry reaming removes dentin chips or debris packed apically during drying. The final apical file (or the master apical file in cases where apical enlargement was not performed) is placed to the corrected working length and rotated clockwise in a reaming action.

Recapitulation

Recapitulation is important regardless of the technique selected (Figure16-23). This is accomplished by taking a small file to the corrected working length to loosen accumulated debris and then flushing it with 1-2 ml of irrigant. Recapitulation is performed between each successive enlarging instrument regardless of the cleaning and shaping technique.



Combination Technique

This technique combines coronal flaring, nickel titanium rotary preparation, and the passive step-back technique (BOX-4). Following access, the canal is explored with a #10 or #15 file. If the canal is patent to the estimated working length a working length radiograph can be obtained and the corrected working length established (Chapter 15, Figure 15-40). In order to insure an accurate length determination a size #20 file or larger should be used (Chapter 15, Figures 15-40, 15-41). If a #20 file will not go to the estimated working length passive step-back instrumentation can be performed by inserting successively larger files to the point of binding and reaming. This removes coronal interferences and creates greater coronal taper permitting larger files access to the apical portion of the root.


After establishing the working length, Gates Glidden drills are used for straight line access (Figure 16-18). A #2 Gates is used first followed by the #3 and #4. In very narrow canals a #1 Gates may be needed. It is important to remember the size of the Gates Glidden drills. If the canal orifice cannot accommodate a size #70 file, passive step back should be performed to provide adequate initial coronal space. To prevent stripping perforations, the Gates should not be placed apical to canal curvatures. Generally the #2-#4 provides adequate coronal enlargement and preserves root structure. The use of nickel titanium rotary instruments with greater tapers can also be used for this step (.06, .08, and .10 tapers are common). The Gates Glidden drills can be used in either a crown-down or step-back sequence. Following use, the Gates Glidden drill should be removed from the handpiece to prevent injury to the clinician, assistant or patient (Figure 16-24).

Master Apical File

Emphasis has traditionally been placed on determining the canal length with little consideration of the canal diameter in the apical portion of the root. Since every canal is unique in its morphology the apical canal diameter must be assessed. The size of the apical portion of the canal is determined by placing successively larger instruments to the corrected working length until slight binding is encountered (Figure 16-25). Often the next larger instrument will not go to the corrected working length. If it does go to length a subjective estimation of the apical diameter must be made depending on the degree of binding. This file will be the master apical file (initial file to bind). It is defined as the largest file to bind at the corrected working length following straight line access. This provides an estimate of the canal diameter before cleaning and shaping and it is the point where the step-back preparation begins.



Nickel-Titanium Rotary

Once the master apical file is identified, the middle to apical portion of the canal is prepared using nickel titanium rotary instruments (Figure 16-20 and Figure 16-21)). Rotary files are used with a crown-down approach to within 3 mm of the corrected working length. Adequate coronal taper is established when the .06/45 goes to within 3.0 mm of the corrected working length. Using the crown down approach creates coronal taper and reduces the contact area of the file so torsional forces are reduced.



Recapitulation

Recapitulation is accomplished after each instrument used in the canal by taking a small file to the corrected working length and then flushing the canal with 1-2 ml of irrigant (Figure 16-23).



Step-Back Apical Preparation

When the body of the canal has been shaped, the apical portion is prepared using standardized stainless steel or nickel titanium hand files in a step-back process (Figure 16-15). The first instrument selected for this portion of the shaping process is one size larger that the master apical file (initial file to bind slightly). Larger files are successively shortened by standardized increments of 0.05 mm or 1.0 mm. Generally sequentially stepping back to a file size of #60 or #70 will produce adequate flare and blend the apical and middle thirds of the canal.



Apical Clearing

With a flared preparation from the orifice to the corrected working length, the apical portion of the canal is enlarged. With a tapered preparation the canal can be enlarged with a reaming action as the canal walls will keep the instrument centered (Figure 16-25).



Box-4 The Combination Technique Steps

Canal negotiation

Working length determination

Straight line access

Master apical file determination

Rotary preparation of the middle one third of the root

Apical step-back preparation

Apical clearing
General Considerations – A Review

The following principles and concepts should be applied regardless of the instruments or technique selected.

1. Initial canal exploration is always performed with smaller files to gauge canal size, shape, and configuration.

2. Files are always manipulated in a canal filled with an irrigant or lubricant present.

3. Copious irrigation is used between each instrument in the canal.

4. Coronal preflaring (passive step-back technique) with hand instruments will facilitate placing larger working length files (either hand or rotary) and will reduce procedural errors such as loss of working length and canal transportation.

5. Apical canal enlargement is gradual, using sequentially larger files from apical to coronal, regardless of flaring technique.

6. Debris is loosened and dentin is removed from all walls on the outstroke (circumferential filing) or with a rotating (reaming) action at or close to working length.

7. Instrument binding or dentin removal on insertion should be avoided. Files are teased to length using a watch winding or “twiddling” action. This is a back-and-forth rotating motion of the files (approximately a quarter turn) between the thumb and forefinger, continually working the file apically. Careful file insertion (twiddling) followed by planing on the outstroke will help to avoid apical packing of debris and minimize extrusion of debris into the periradicular tissues.

8. Reaming is defined as the clockwise rotation of the file. Generally the instruments are placed into the canal until binding is encountered. The instrument is then rotated clockwise 180-360º to cut and plane the walls. When withdrawn the instrument tip is pushed alternately against all walls. The pushing motion is analogous to the action of a paintbrush. Overall, this is a turn and pull.

9. Filing is defined as placing the file into the canal and withdrawing it along the path of insertion to scrap the wall. There is very little rotation on the outward cutting stroke. The scraping or rasping action removes the tissue and cuts superficial dentin from the canal wall.

10. Turn pull filing involves placing the file into the canal until binding. The instrument is then rotated to engage the dentin and withdrawn with lateral pressure against the canal walls.

11. Circumferential filing is used for canals that exhibit cross sectional shapes that are not round. The file is placed into the canal and withdrawn in a directional manner against the mesial, distal, buccal, and lingual walls.

12. Regardless of the technique, after each insertion the file is removed and the flutes are cleaned of debris; the file can then be reinserted into the canal to plane the next wall. Debris is removed from the file by wiping it with an alcohol-soaked gauze or cotton roll131.

13. The canal is effectively cleaned only where the files actually contact and plane the walls. Inaccessible regions are poorly cleaned or débrided.

14. Recapitulation is done to loosen debris by rotating the master apical file or a smaller size at the corrected working length followed by irrigation to mechanically remove the material. During recapitulation the canal walls are not planed and the canal should not be enlarged.

15. Small, long, curved, round canals are the most difficult and tedious to enlarge. They require extra caution during preparation, being the most prone to loss of length and transportation.

16. Over enlargement of curved canals by files attempting to straighten themselves will to lead to procedural errors (Figure 16-11).

17. Overpreparation of canal walls toward the furcation may result in a stripping perforation in the danger zone where root dentin is thinner.

18. It is neither desirable nor necessary to try to remove created steps or other slight irregularities created during canal preparation.

19. Instruments, irrigants, debris, and obturating materials should be contained within the canal. These are all known physical or chemical irritants that will induce periradicular inflammation and may delay or compromise healing.

20. Creation of an apical stop may be impossible if the apical foramen is already very large. An apical taper (seat) is attempted, but with care. Overusing large files aggravates the problem by creating an even larger apical opening.

20. Forcing or locking (binding) files into dentin produces unwanted torsional force. This tends to untwist, wrap-up, either will weaken, and break the instrument.

CRITERIA FOR EVALUATING CLEANING AND SHAPING

Following the cleaning and shaping procedures the canal should exhibit “glassy smooth” walls and there should be no evidence of unclean dentin filings, debris, or irrigant in the canal. This is determined by pressing the MAF against each wall in an outward stroke.


Shaping is evaluated by assessing the canal taper and identifying the apical configuration. For obturation with lateral compaction, the finger spreader should go loosely to within 1.0 mm of the corrected working length. For warm vertical compaction the plugger should reach to within 5 mm of the corrected working length (Figure 16-26).
The apical configuration is identified as an apical stop, apical seat, or open. This is accomplished by placing the master apical file to the corrected working. If the master apical file goes past the corrected working length the apical configuration is open. If master apical file stops at the corrected working length a file one or two sizes smaller is placed to the corrected working length. If this file stops the apical configuration is a stop. When the smaller file goes past the corrected working length the apical configuration is a seat.
INTRACANAL MEDICAMENTS

Intracanal medicaments have a long history of use as interim appointment dressings. They are employed for three purposes: 1) to reduce inter-appointment pain, 2) to decrease the bacterial count and prevent regrowth, and 3) to render the canal contents inert. Some common agents are listed in Box 16-5 .



Box 16-5 Groupings of Commonly Used Intracanal Medicaments

Phenolics



Eugenol

Camphorated monoparachlorophenol (CMCP)

Parachlorophenol (PCP)

Camphorated parachlorophenol (CPC)

Metacresylacetate (Cresatin)

Cresol

Creosote (beechwood)

Thymol

Aldehydes

Formocresol

Glutaraldehyde

Halides

Sodium hypochlorite

Iodine-potassium iodide

Steroids

Calcium hydroxide

Antibiotics

Combinations

From Walton R: Intracanal medicaments, Dent Clin North Am 28:783, 1984.


Phenols and aldehydes

The majority of the medicaments exhibit non-specific action and can destroy host tissues as well as microbes132-134. Historically it has been thought that these agents are effective; their use was based on opinion and empiricism. The phenols and aldehydes are toxic and the aldehydes are fixative agents135, 136. When placed in the radicular space they have access to the periradicular tissues and the systemic circulation137, 138 Research has demonstrated that their clinical use is not justified139-143. Clinical studies assessing the ability of these agents to prevent or control interappointment pain indicate that they are not effective.144-147


Calcium hydroxide

One intracanal agent that is effective in inhibiting microbial growth in canals is calcium hydroxide148. It has antimicrobial action due to the alkaline pH and it may aid in dissolving necrotic tissue remnants and bacteria and their byproducts149-151. Interappointment calcium hydroxide in the canal demonstrates no pain reduction effects152. Calcium hydroxide has been recommended for use in teeth with necrotic pulp tissue and bacterial contamination. It probably has little benefit with vital pulps. Calcium hydroxide can be placed as a dry powder, a powder mixed with a liquid such as local anesthetic solution, saline, water, or glycerin to form a thick paste, or as a proprietary paste supplied in a syringe (Figure 16-27). A lentulo-spiral is effective and efficient.153-155 Spinning the paste into the canal by rotating a file counterclockwise and using an injection technique is not as effective. It is important to place the material deeply and densely for maximum effectiveness. To accomplish this straight line access with Gates Glidden drills or nickel-titanium rotary files should be performed and the apical portion of the canal prepared to a size #25 file or greater. Removal following placement is difficult.156 This is especially true in the apical portion of the root.


Corticosteroids

Corticosteroids are anti-inflammatory agents that have been advocated for decreasing postoperative pain by suppressing inflammation. The use of corticosteroids as intracanal medicaments may decrease lower levels postoperative pain in certain situations;157 however, evidence also suggests that they may be ineffective particularly with greater pain levels147. Cases irreversible pulpitis and cases where the patient is experiencing acute apical periodontitis are examples where steroid use might be beneficial158, 159, 157.



Chlorhexidine

Chlorhexidine has recently been advocated as an intracanal medicament.160, 161 A 2% gel is recommended. It can be used alone in gel form or mixed with calcium hydroxide. When used with calcium hydroxide the antimicrobial activity is greater than when calcium hydroxide is mixed with saline162and periradicular healing is enhanced.163 Its major disadvantages are; it does not affect the smear layer and it is a fixative.



TEMPORARY RESTORATIONS (Courtesy of Dr. Harold Messer)
Root canal treatment may involve multiple visits. Also, unless it is limited to a routine access cavity, the final restoration is usually not completed in the same appointment as the root canal treatment. A temporary restoration is then required, normally for 1 to 4 weeks. In special situations when definitive restoration must be deferred, the temporary must last several months.
Objectives of Temporization
The temporary restoration must

1. Seal coronally, preventing ingress of oral fluids and bacteria and egress of intracanal medicaments.



  1. Enhance isolation during treatment procedures.

  2. Protect tooth structure until the final restoration is placed.

4. Allow ease of placement and removal.

5. Satisfy esthetics, but always as a secondary consideration to providing a seal.


These objectives depend on the intended duration of use. Thus, different materials are required depending on time, occlusal load and wear, complexity of access, and loss of tooth structure.


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