Pediatric endodontics

Dr.Tinet Mary Augustine.MDS 11
Dr.Tinet Mary Augustine. BDS,MDS
Pediatric Dentist
Dr.Tinet‟s Pedorayz, Pediatric And Early Age Orthodontic Dental
Clinic

“Maintaining The Integrity And Health Of The
Oral Tissues Is The Primary Objective Of Pulp
Treatment”

 BACTERIAL INFILTRATION
 RESTORATION
 RDT

 <0.3MM(COSTA2011)
 >500MM(SLOAN AJ 1999)
 <500MM(GOLDBERG,2004)
 250-40MM(MURRAY PE 2001)

Pulp pathology

 HYDROSTATIC PRESSURE
 PLASMA ONCOTIC PRESSURE
 TISSUE TENSION
 LYMPHATIC OUTFLOW

ARTERIAL END
HYDROSTATIC
PRESSURE(35MMHG)-BLOOD
PRESSURE(25MM
HG)=PRESSURE DIFFERENCE(10
MM HG)
HYDROSTATIC PRESSURE(15MM
HG)-BLOOD PRESSURE(25MM
HG)=PRESSURE DIFFERENCE(-10
MM HG)
CAPILLARY NETWORK
VENULAR END

ARTERIAL END
INCREASED HYDROSTATIC
PRESSURE(45MMHG)-
BLOOD PRESSURE(25MM
HG)=PRESSURE
DIFFERENCE(20 MM HG)
HYDROSTATIC
PRESSURE(15MM HG)-
BLOOD PRESSURE(25MM
HG)=PRESSURE
DIFFERENCE(-10 MM HG)
CAPILLARY NETWORK
VENULAR END
OEDEMA
(EVF)
PULPAL
IRRITANTS

ARTERIAL END
PRESSURE(25MM HG)=PRESSURE
DIFFERENCE(20 MM HG) HYDROSTATIC PRESSURE
DIFFERENCE=-10 MM HG
CAPILLARY NETWORK
VENULAR END
OEDEMA
(EVF)
PULPAL
IRRITANTS
DRAINED BY
LYMPHATICS

ARTERIAL END
PRESSURE(25MM HG)=PRESSURE
DIFFERENCE(40 MM HG) HYDROSTATIC PRESSURE
CAPILLARY NETWORK
VENULAR END
OEDEMA
(EVM)
PERSISTENT
INTRAPULPAL
IRRITANTS
LYMPHATICS
OUTFLOW
UNABLE TO
DRAIN
COMPLETELY
EXISTING
OEDEMA

ARTERIAL END
PERSISTENTLY INCREASED H.P.D
CAUSE EXCESSIVE OEDEMA INTO
STROMAL MATRIX HYDROSTATIC PRESSURE
CAPILLARY NETWORK
VENULAR END
EXCESSIVE
OEDEMA
COMPRESS B.V TO
OBSTRUCT FLOW
TO DISTAL END
DISTAL END DEVOID OF
BLOOD SUPPLY GOT
NECROSED AND ZONE GETS
WIDER

ARTERIAL END
MARKEDLY INCREASED
HYDROSTATIC PRESSURE
WHICH CONTINUES TO
EXPRESS OEDEMA FLUID
DESPITE SELF
STRANGULATION
HYDROSTATIC PRESSURE
CAPILLARY NETWORK
WIDENING ZONE OF LIQUEFACTION
VENULAR END
NARROWING
ZONE OF
PERSISTANT
OEDEMA
MACRO ABSCESS
C
MICRO
ABSCESS

 LENGTH OF THE ROOT
 VIRULENCE OF BACTERIA
 IMMUNITY OF THE INDIVIDUAL

REVERSIBLE PULPITIES {INFLAMMATION} IRREVERSIBLE PULPITIS {INFLAMMATION}
1. Sensitivity to mild discomfort. 1. Pain may present.
2. Sharp shooting pain on stimulus sensation. 2. History of spontaneous lancinating,
or a dull continuous pain
3. Pain subside soon after the removal of the stimulus 3. Pain is often moderate to severe.and lasts for a longer
duration
4. Infrequent episodes of discomfort. 4. Pain is increasing in frequency, often to the point of being
continuous.
Pain usually lingers, especially with increasing episodes.
Thermal stimulation often elicits severe lingering pain.
May be able to identify specific or multiple stimuli
Pain radiates or if diffuse or may be localized
5.Common etiologies include exposed dentin, cracked restorations,
recently placed restorations, initial carious attack or rapidly advancing
caries, altered occlusion.
5. History of trauma, extensive restorations, periodontal
disease, or extensive recurrent carries is present.
6. Symptoms usually subside immediately or shortly after removal of
etiology.
6 Patient often requires time and medication for the pain relief
7. Radiographic changes approaching the dental pulp can be seen without
any radicular involvement
7. Radiographic changes involving the pulp and may include
calcifications, resorption, or radiolucencies

Cohen –pathways of pulp -9th editionDr.Tinet Mary Augustine.MDS 20

Contra Indicated on
 Congenital Heart Disease
 Immunocompromised Patients
 Uncontrolled Diabetic/Cancer Patients
 GA Indicated Patients
Indicated When
 Bleeding Or Coagulation Disorder
 Hypodontia

In children, toothache is the most common
orofacial pain, 12% experiencing an episode
before the age of 5 and 32% by the age of 12.
(Drangsholt & LeResche, 2009).

 TRANSDUCTION
 TRANSMISSION
 MODULATION
 PERCEPTION

 REVERSIBLE VS IRREVERSIBLE
 POSTURAL CHANGE
 EMOTIONAL
 AUTONOMOUS
 SELF MODULATION
 DIURAL
 SITE SPECIFICATION
 RADIATING PAIN/REFERED PAIN

THEORY
 CONVERGENCE PROJECTION THEORY
 CONVERGENCE FACILITATION THEORY
LAMINAR PATTERN OF NERVE

1 NO PAIN ,ONLY SENSITIVITY DENTAL CARIES WITHOUT PULPAL
INVOLVEMENT
2 DISAPPEARENCE OF PAIN AFTER THE REMOVAL
OF STIMULANT
TRANSIENT REVERSIBLE PULPITIS
3 LANCINATING,SHARP PAIN PERSIST EVEN ON
REMOVAL OF STIMULUS
SPONTANEOUS PAIN IN THE ABSENCE OF
STIMULUS
HIGH SENSITIVE TO COLD
ACUTE EXCACERBATION OF
IRREVERSIBLE PULPITIS
4 CHRONIC IRREVERSIBLE PULPITIS DULL,LESS INTENSE PAIN AFTER ANY
STIMULI AND LASTS EVEN AFTER THE
STIMULI IS REMOVED
5 NON-VITAL/NECROSED PULP LARGE CAVITY ASSOCIATED WITH NO
SYMPTOMS
6 DENTOALVELOLAR ABSCESS SWELLING AROUNG THE TOOTH,
TOORH MOBILITY,TENDERNESS ON
CHEWING,RISE IN TEMP.
7 FACIAL SPACE INFECTION WITH
DENTOALVEOLAR ABSCES
DIFFUSE,DULL,RADIATING PAIN ON
THE AFFECTED SIDE
FACIAL ASYMMETRY,RISE IN
TEMPERATUREDr.Tinet Mary Augustine.MDS 30

 TB-lymphadenopathy
 DM-recurring Abscess
 Anemia/Leukemia- Parasthesia Of Oral Tissues
 Sickle Cell Anemia- Bone Pain mimics dental
 Multiple Myeloma-unexplained Tooth Mobility
 Radiation Therapy-increased Sensitivity
 Trigeminal Neuralgia,reffered Pain From Angina,
multiple Sclerosis also mimic dental pain

 FACIAL ASSYMETRY
 REDNESS
 LYMPH NODE EXAMINATION
 INCREASE IN TEMPERATURE

 SOFT TISSUE EXAMINATION
 HARD TISSUE EXAMINATION
INSPECTION
PALPATION
PERCUSSION-VERTICAL/LATERAL

 SENSITIVITY TESTS-NERVE RESPONDSE
 THERMAL-COLD/HOT
 ELECTRIC
 COLD VS EPT (JESPERSEN JJ,2014

 SENSIBILITY TEST-BLOOD SUPPLY
 LASER DOPPLER FLOWMETRY
 PULSE OXIMETER
 HUGHES PROBEYE CAMERA ,
 TRANSMITTED LIGHT
PHOTOPLETHYSMOGRAPHY

 EXTENT OF CARIOUS INVOLVEMENT
 RESORPTION
 FURCATION INVOLVEMENT
 ROOT LENGTH
 DEVELOPMENTAL STAGE

 QUALITY / QUANTITY OF BLEEDING

 DENTAL/CHRONOLOGICAL AGE
 RESTORABILITY OF THE TOOTH
 SEVERITY OF THE INFECTION
 BONE LOSS
 PROXIMITY TO THE SUCCEDANEOUS TOOTH
 PATIENT CO-OPERATION

To allow a tooth to remain in the oral cavity in a
non- pathological state.
To maintain the arch length and tooth space.
To restore a tooth to its functionally efficient
form.
To prevent the development of aberrant habits
and abnormality.
To maintain the child‟s esthetics and thereby
preventing the child by psychological trauma.

 The advisability of performing the pulp therapy
and restoring the tooth must be weighed
against extraction and space management.

“SMALL ISSUES CREATES BIG ISSUES”

Part 2
Vital pulp therapy

“PRESERVATION OF PULP VITALITY”

 Blood supply and cellular content of pulp
(Kennedy and Kapla)
 The pathologic condition of the pulp
 Obtaining homeostasis
 Disinfection of the exposure site
 Antimicrobial property of medicaments
 Coronal seal
 Remaining dentin thickness

 <0.3MM(COSTA2011)
 >0.5MM(SLOAN AJ 1999)
 <0.5 MM(GOLDBERG,2004)
 (MURRAY PE 2003)
 13.6%-2.5MM-0.5MM
 33%-0.5MM-1MM
 99%-PULP EXPOSURE

 IPC
 DPC
 PULPOTOMY

It Is Better That A Layer Of Discoloured Dentin Be
Allowed To Remain For The Protection Of The Pulp
Rather Than Run The Risk Of Sacrificing The Tooth
Sir John Tomes 1859

 Pierre Fauchard (1746)
 Philip Pfaff(gold Leaf)(1756)
 Taft(1860)
 Hunter-Sorghum Molassess And Dropping Of
English Sparrow (1883)
 Herman (1920)
 Teuscher And Zander-CAOH(1938)
 G.V Black(1908)

 Indirect pulp capping is the procedure where in
small amount of carious dentin is retained in deep
areas of cavity to avoid exposure of pulp, followed
by placement of a suitable medicament and
restorative material that seals off the carious
dentin and encourages pulp recovery (Ingle) .
 A procedure in which only the gross caries is
removed from the lesion and the cavity is sealed
for a time with a biocompatible material
(McDonald)

 Ricketts et al. stated that in deep lesion ,
partial caries removal is preferable to
complete caries removal to reduce the risk of
carious exposure.
 In 1961, Damle SG termed IPC as
Reconstructed Dentin to prevent pulp
exposure.

 Direct pulp capping is the placement of a
medicated and non medicated material on pulp
that has been exposed in course of excavating the
last portions of deep dentinal caries or as a result
of trauma (KOPEL(1992)

 Blood supply and cellular content (Kennedy
and Kapla)
 The pathologic condition of the pulp
 Obtaining homeostasis
 Disinfection of the exposure site
 Antimicrobial property of medicaments
 Coronal seal
 Remaining dentin thickness

 INFECTED AND
AFFECTED
DENTIN(CANBY AND
BERNIER)
 OPEN VS CLOSED
(BJORNDAL 2002

 Treatment of carious lesion
 Reversal of bacterial invasion.
 Maintenance of normal healthy pulp.

 Maintain the vitality
 To seal the pulp against bacterial leakage.
 Encourage the pulp to wall off the exposure
site by initiating a dentin bridge.
 To maintain the vitality of underlying pulp
tissue region.

History:
Mild discomfort from chemical and thermal stimuli
Absence of spontaneous pain
Clinical examination:
Large carious lesion.
Absence of lymphadenopathy.
Normal appearance of adjacent gingival inflammation.
 Normal color of tooth.
Radiographic examination
Large carious lesion in close proximity to the pulp.
Normal lamina dura.
Normal periodontal ligament space.
No interradicular peripheral radiolucency.

Success with direct pulp capping is dependent
on the radicular pulp being healthy and free
from bacterial invasion. It must rely on the
physical appearance of the
 Exposed pulp tissue
 Radiographic assessment
 Diagnostic tests to determine pulpal status.

Operational diagnosis
 “Pin point” mechanical or traumatic exposures
that are surrounded with sound dentin(>1sq
mm)(<24 hr).
 Exposed pulp tissue should be bright red in color
and have a slight hemorrhage that is easily
controlled with dry cotton pellets applied with
minimal pressure.
 Absences of pain.
 No bleeding at the exposure site.

History
 Sharp, Penetrating Pain That Persists After
Withdrawing Stimulus
 Prolonged Spontaneous Pain, Particularly At Night
Clinical Examination
 Spontaneous and nocturnal toothaches.
 Excessive tooth mobility.
 Thickening of periodontal ligament
Operative diagnosis
 Uncontrollable hemorrhage at the time of
exposure.
 Purulent or serous exudates from the exposureDr.Tinet Mary Augustine.MDS 62

Radiographic examination
 Large carious lesion with apparent pulp
exposure
 Interrupted or broken lamina dura
 Widened periodontai ligament space
 Radiolucency at the root apices or furcation
areas

 Spontaneous and nocturnal toothaches.
 Excessive tooth mobility.
 Thickening of periodontal ligament
 Radiographic evidence of furcal/ periradicular
degeneration.
 Uncontrollable hemorrhage at the time of
exposure.
 Purulent or serous exudates from the
exposure

(SEALE NS 2010)(LEUNG ET AL)
 Isolate
 Prepare the tooth
 Excavation
 Irrigation
 IRM
 Observation for 6-8 weeks
 Restoration(s.s crown)

 Isolate
 Prepatre the tooth
 Excavation
 Irrigation
 IRM
 Re entry after 6-8 weeks
 Excavation
 Restoration

 Complete excavation (KIDD EAM 1998)
1. AL HIYASAT-caries 33%,mech.-92.2%
2. BOGEN -98%using MTA
 Stepwise caries excavationi(RICKETTS 2013)
1.8-12 WEEKS
 Partial(incomplete ) excavation( BJORNDAL
2005)(MALTZ (96%)2010,2012)
 No caries excavation-(HALL TECHNIQUE) (INNES
2007),LUDWIG(2014)

 1/5th tubular dentin in first 30 dys
 Cellular fibrillar dentin at 2 months post-
treatment.
 Presence of globular dentin during the first 3
month.
 0.1mm Tubular dentin in a more uniformly
mineralized pattern after 3 months.
Success
 Amount of reparative dentin at the pulp
=amount of dentin lost from the surface at
the DEJ

Held –Wydler
 Carious decalcified dentin
 Rhythmic layers of irregular reparative dentin
 Regular tubular dentin and
 Normal pulp with a slight increase in fibrous
elements.

 Local anaesthesia
 Isolation
 Caries removal
 Irrigation
 Hemorrhage and clotting
 Control of bleeding(Hemodent liquid)
 Medicaments
 IRM
 Observation for 6-8 weeks

 Dentin bridging.
 Maintenance of pulp vitality.
 Lack of pulpal inflammatory response.
 The ability of the pulp to maintain itself
without progressive degeneration.
 Lack of internal resorption and / or intra
radicular pathosis.

 DIAGNOSIS
 RDT
 MEDICAMENT

MEDICAMENTS USED IN
VITAL PULP THERAPY

SEALING THE CARIES FROM THE
MICROLEAKAGE APPEAR TO BE THE IMPORTANT
FACTOR IN PULP CAPPING SUCCESS IF THE PULP
IS DIAGNOSED VITAL
KUHN ET AL 2014

 Stimulate reparative dentin formation
 Maintain pulp vitality
 Release flourine to prevent secondary caries
 Bacteriocidal or bacteriostatic
 Adhere to dentin
 Adhere to restorative materials
 Resist force during restoration placement
 Must resist force under restoration during
lifetime of restoration
 Sterile
 Radio opaque
 Provide bacterial seal Dr.Tinet Mary Augustine.MDS 75

 Seal completely the invoved dentin,
 Promote the remineralisation and formation
of reparative dentin,
 Reduce the hyperemia of pulp,
 Reduce the anerobic bacterial invasion,
 Promote root closure in immature teeth,
 No sign of internal resorption or other
pathologic changes.(PINKHAM)

 Maintain the vitality
 Create a new zone of dentin in the area of
exposure and subsequent healing of the pulp.
 No post treatment sensitivity,pain swelling should
be present
 No radiographic sign of resorption or furcation
involvement or periapical radiolucencies,abnormal
calcification or other pathologic changes should be
present
 Pulp healing and reparative dentin formation
should occur.
 Apexogenesis in teeth with immature root should
occur .

 1/5th tubular dentin in first 30 days
 Cellular fibrillar dentin at 2 months post-
treatment.
 Presence of globular dentin during the first 3
month.
 0.1mm Tubular dentin in a more uniformly
mineralized pattern after 3 months.
Success
 Amount of reparative dentin at the pulp
=amount of dentin lost from the surface at
the DEJ

CALCIUM HYDROXIDE

 1920 by Herman
 By 1930s start to use in vital pulp therapies
 1938-Teuscher and Zander –reperative dentin
 1975-Maisto coined as alkali paste
 1976-Esterella et al summarized the anti
bacterial effect of the paste
Cvek used for Apexogenesis
 1985-Bystrom and Sundquint-97%
antibacterial

ACIDIC PASTE
 Alkyl salicylate (iso-butyl salicylate or 1-methyl
triethylene salicylate)
 Inert fillers – titanium oxide 12-14%
 Radiopacifer – barium sulphate 32-35%
 Calcium tungstate or calcium sulphate 14-15%
BASIC PASTE
 Calcium hydroxide 50-60%
 Zinc oxide 10%
 Zinc stearate 0.5%
 Ethylene toluene sulphonamides and paraffin oil
39.5%

 Pulpdent, (52.5% calcium hydroxide in an
aqueous solution of methyl cellulose)
 Dycal, (calcium hydroxide,barium
sulfate,titanium di oxide)
 Hydrex(MPC). (calcium hydroxide,barium
sulfate,titanium di oxide)

 Antimicrobial activity (BystroÈm et al. 1985),
 Tissue-dissolving ability (Hasselgren et al. 1988,
Andersen et al. 1992),
 Arresting inflammatory root resorption and
stimulation of healing.(Tronsted 1981)
 Induction of repair by hard tissue formation
(Foreman & Barnes 1990).
 PH-high alkaline: 9.2 to 11.7 .Freshly mixed
cement has a ph of 11-12
 Neutralize lactic acid secreted by bacteria
 Reduces capillary permeability
 Activate alkaline phosphatase activity and thus
plays a role in hard tissue mineralization.

 Destruction of the bacterial cytoplasmic
membrane(Halliwell 1987, Cotran et al. 1999)
 Protein lysis(Voet 1995)
 Bacterial DNA damage.(Imlay & Linn 1988).
 It is effective against most endodontic
pathogens

 Induction of mineralization(Rasmussen and
Mjor (1977)
◦ Local buffer action
◦ Alkaline phosphatase activity(@10.2ph)
 Heithersay (1975) –CAOH will decrease blood
permeability .
 Dentin bridge

 Effective depth(Stuart K 1991)
◦ An effective depth of 100µm and more - healthy
reparative reaction.
◦ At less than 100µmm– unhealthy reparative.
◦ If it comes in contact with root canal and pulp
tissue, the layer of tissue that comes in direct
contact undergoes necrosis and subsequent
response of the entire pulp organ

 Zone of obliteration
 Zone of coagulation necrosis(0.3-0.7mm)
 Line of demarcation(Glass and Zander)
 Meadow et al suggested 1.5mm of matrix
within 4 months

 Initially bactericidal then bacteriostatic
 Promotes healing and repair.
 High pH stimulates fibroblasts.
 Neutralizes low pH of acids.
 Inexpensive and easy to use.

 Does not exclusively stimulate dentinogenesis.
 May cause dystrophic calcification
 Does exclusively stimulate reparative dentin
 Low mechanical strength(Barnes &Kidd 1979)
 Poor adhesion to dentin and dentin bonding
system(Fernacane 2001)
 May dissolve after one year with cavosurface
dissolution(Kitasako y 2008)
 May degrade during acid etching.
 Degrades upon tooth flexure.
 Marginal failure with amalgam condensation.
 Potential resorption

 Age of patient
 Mechanical/carious exposure
 Size of exposure
 History of pain

Study Agent Cases Observation period % Of success
Sowden, 1956 Ca (OH) 2 4,000 Up to 7y Very high
Law and Lewis,
1961
Ca (OH) 2 38 Up to 4y 73.6
Hawes and DiMe Ca (OH) 2 475 Up to 4y 97
Kerkhove et al, 1964
Ca (OH) 2
ZOE
41
35
12mo 12mo
95
95
Held- Wydlier,
19641
Ca (OH) 2 41 35-630 d 88
King et al., 1965
Ca (OH) 2
ZOE
41
21
35-630 d
25-206d
88
62
Aponte, 1966 Ca (OH) 2 30 6-46 93
Jordan and Suzuki,
1971
Ca (OH) 2 243 10-12wk 98
Nordstrom et al 1974
Ca (OH) 2
Stannous fluoride
64 94d 84
Magnuson, 1977 Ca (OH) 2 55 85
Sawushch, 1982 Ca (OH) 2 184 13-15 97
Nirschly and Avery,
1983
Ca (OH) 2 38 6 mo 94
Coll, 1988 Ca (OH) 2 26 20-58 mo 92.3Dr.Tinet Mary Augustine.MDS 92

 Compressive strength(4.8-6.2 in 30 min/8.3-
10.3 in 24 hr)
 Poor marginal adaptation
 Tunnel defect
 Reperative dentin
 Dystrophic calcification
 Inflammatory/necrosis responds

 Mineral Trioxide Aggregate (MTA) was
introduced by Mohamoud Torabinejad at
Loma Linda University, California, USA in
1993
 The first commercially available version of
MTA (ProRoot MTA) is GMTA, and produced
tooth discoloration if used within the clinical
crown (Karabucak et al. 2005).
 The product was therefore reformulated in a
yellow–white version as white MTA (WMTA)
(Glickman & Koch 2000).

Chemical compound GMTA(wt%) WMTA(wt%)
Calcium oxide 40.45 44.23
Silicon dioxide 17 21.20
Bismuth tri oxide 15.90 16.13
Aluminium oxide 4.26 1.92
Magnesium oxide 3.10 1.35
Sulfur trioxide 0.51 0.53
Chlorine 0.43 0.43
Ferrous oxide 4.39 0.40
Phosphorous pentoxide 0.18 0.21
Titanium di oxide 0.06 0.11
Carbonic acid 13.72 14.49

 3:1 ratio
 Mixing time:less than 4min
 Condense using hand instruments or
ultrasonic condensation.
 Setting time-2.45hrs(±5min)
 Absolute dryness is contraindicated
 Minimum thickness -1.5 mm with 1mm of
circumferential dentin for final bonding

Calcium silicate hydrate
10-15%
Major components
Minor components
Ettringite
monosulfates
Tetra calcium
aluminoferrite
hydration

 Compressive strength of MTA within 24 hours of
mixing was about 40.0 MPa and increases to 67.3
MPa after 21 days
 The mean radio opacity of MTA is 7.17 mm of
equivalent thickness of aluminium, which is
sufficient to make it easy to visualize
radiographically.
 Low or no solubility for MTA (Torabinejad et al.
1995). Partial solubility with a decreasing rate over
time was reported in a long-term study over a 78-
day period (Fridland & Rosado2005)
 The set MTA when exposed to water releases
calcium hydroxide responsible for its
cementogenesis inducing property
 Bates et al found MTA superior marginal
adaptation to the other traditional medicaments

Dr.Tinet Mary Augustine.MDS
10
0

 1.5mm thickness.
 Dentin bridge formation(faster and
thicker)(Aeinehchi 2003)
0.28mm-2month
0.43mm-6month(0.15mm in CAOH)
 Sealing property
 Alkalinity
 Less cytotoxic and less irritant(Torabinejad and
Kettering)
 Minimal or no inflammatory responds(Braz 2006)
 No Pulp necrosis –heals fastly-(Aeinehchi 2003)
 Mineralisation (Holland1999)
10
1

 Mechanical strength
 Marginal adaptation
 Low solubility
 Less or no inflammatory responds
 Apatite formation(Hans and Okiji 2011)
 Dentin bridge formation-faster and thicker
(Aeinehchi 2003)
0.28mm-2month
0.43mm-6month(0.15mm in CAOH)
10
2

10
3

 Cost
 Inferior antibacterial property than CAOH
(Lakshmi R 2016)
 Longer Setting time.
 Difficult to manipulate.
 Compressive strength
10
4

 Biodentine, introduced by Septodont in 2009
10
5

Powder Liquid
Tricalcium silicate-main core
material
Dicalcium silicate-second core
material
Calcium carbonate and oxide filler
Iron oxide-coloring agent
Zirconium oxide-radio opacifier
Calcium chloride –accelerator
Hydro soluble polymer
water reducing agent
10
6

 Available as powder and liquid in market as
 Item #01C0600 - 15 x capsules + 15 x
single-dose containers
 Item #01C0605 - 5 x capsules + 5 x single-
dose containers
10
7

 Sets in 10 - 12 minutes
 Natural micro mechanical anchorage for
excellent sealing properties without surface
preparation (Gandolfi mg 2010)
 Has prominent biomineralisation ability than
MTA(Hans and Okiji 2011)
 Similar mechanical properties and mechanical
behavior as human dentin.
10
8

 2(3CaO.SiO2)+6H 2O 3CaO.2SiO2.3H2O
+3Ca(OH)2
The final set material consists of unreacted
calcium silicate grains surrounded by layers of
hydrated calcium silicate gel which hardens to
form a solid network within 4-6 hours and
complete setting occurs after several days.
hydrated calcium silicate gel
10
9

 Easy to handle than MTA(Ravichandra 2014)
 Mixing time-30 sec
 Setting time -9-12min(Goldberg 2009)
11
0

 Biodentine is superior or equal to MTA.
 Better physical and biological properties
(TORABINEJAD 1995)
 High compressive strength (Torabinejad 1995)
 Marginal adaptation (GANDOLFI 2010)
 Superior mechanical and handling characteristics
(GOLDBERG 2009)
 Biodentine has the capacity to induce hydroxyapatite
precipitation at the material dentine interface
 HIGHER RATE OF REPERATIVE DENTIN
FORMATION(Trans et al 2012)
 Less inflammatory response(Mori et al 2009)
 Biocompatability,Stimulation of TGF,Less toxic (ZHOU-
2013)
11
1

Review of
medicaments
11
2

Pulp capping agent Advantages Disadvantages
Ca(OH)2 (1960‟S)  Gold standard of direct pulp
capping material
 Excellent antibacterial
properties
 Induction of mineralization
 Low cytotoxicity
 Highly soluble in oral
fluids
 Subject to dissolution over
time
 Extensive dentin formation
obliterating the pulp chamber
 Lack of adhesion
 Degeneration after acid
etching
 Presence of tunnels in
reparative dentin
Zinc oxide eugenol
cement(1960-70‟s)
Reduces inflammation  Lack of calcific bridge
formation
 Releases eugenol in high
concentration which is
cytotoxic
 Demonstrate interfacial
leakage
Corticosteroids and
antibiotics (1970‟s)
Triamcinolone,demecocycline
 Reduces pulp inflammation
 Vancomycin + Ca(OH)2
stimulated a more regular
reparative dentin bridge.
 Should not be used in
patients at risk from
bacteremia.
Polycarboxylate
Cement (1970‟s)
 Chemically bond to the
tooth structure
 Lack of antibacterial effect
 Fail to stimulate calcific
bridge formation
Inert materials(1970‟s)
(Isobutyl cyanoacrylate and
Tricalcium phosphate ceramic)
Reduces pulp inflammation
Stimulate dentin bridge
formation
 None of these materials have
been promoted to the dental
profession as a viable
technique
Collagen (1980)  Less irritating than Ca(OH)2
 promotes mineralization
 Does not help in thickDr.Tinet Mary Augustine.MDS
11
3

Bonding agents (1995)
4-META-MMA-TBB
adhesives and hybridizing dentin
bonding agents
 Superior adhesion to hard tissues
 Effective seal against
microleakage
 Have cytotoxic effect
 Absence of calcific bridge
formation
 In vivo studies have demonstrated
that the application of an adhesive
resin directly onto a site of pulp
exposure, or to a thin layer of
dentin (less than 0.5mm), causes
dilation and congestion of blood
vessels as well as chronic
inflammatory pulpa response
Calcium phosphate (1900‟s)  Helps in bridge formation with no
superficial tissue necrosis
 Significant absence pulp
inflammation compared to Ca(OH)2
 Good physical properties
 Clinical trials are necessary to
evaluate this material
Hydroxyapatite (1995)  Biocompatible
 Act as scaffold for the newly formed
mineralized tissue
 Mild inflammation with
superficial necrosis of pulp
Lasers (1995-2010) CO2
Nd: YAG
 Formation of secondary dentin
 Sterilization of targeted tissue
 Bactericidal effects
 Technique sensitive
 Causes thermal damage to pulp
in high doses
Glass ionomer/ Resin
modified glass ionomer
(1995)
 Excellent bacterial seal
 Fluoride release, coefficient of
thermal expansion and modulus of
elasticity similar to dentin
 Bond to both enamel and dentin
 Good biocompatibility
 Causes chronic
inflammation
 Lack of dentin bridge
formation
 Cytotoxic when in direct cell
contact
 Poor physical properties, high
solubility and slow setting rate
 RMGIC is more cytotoxic than
conventional GIC, so it should not
be applied directly to the pulpDr.Tinet Mary Augustine.MDS
11
4

Mineral trioxide aggregate (1996-
2008)
 Good biocompatibility
 Less pulpal inflammation
 More predictable hard tissue barrier
formation in comparison to calcium
hydroxide
 Antibacterial property
 Radiopacity
 Releases bioactive dentin matrix
proteins
 More expensive
 Poor handling
characteristics
 Long setting time
 Grey MTA causes tooth
discoloration
 Two step procedure
 High solubility
MTYA1-Ca (1999)
 Helps in dentin bridge formation
without formation of a necrotic layer
 Shear bond strength is higher than
conventional GIC and similar to
RMGIC
 Dentin bridge formation without
reduction of pulp space is seen in
dycal.
 Better adhesion to dentin
 Presence of 10% Ca(OH)2
interferes with complete curing of
material, residual monomers
causes cytotoxity
Growthfactors (1900-
2007)
Bone Morphogenic Protein (BMP
2,4,7)
Recombinant insulin like growth
factor-I
Other growth factors(1998)
Epidermal growth factor Fibroblast
growth factor Insulin like growth
factor II Platelet-derived growth
factor-B8
TGF-β 1
 Formation of osteodentin and
tubular dentin
 Formation of more homogeneous
reparative dentin
 Superior to Ca(OH)2 in the
mineralization inducing properties
 Dentin bridge formation was equal to
dycal after 28 days
 Only TGF-β 1 induced reparative
dentin formation
 Possibility of unexpected side
effects and the production
 Cost can be obstacles for their
clinical application
 Fail to stimulate reparative
dentin in inflamed pulp
 Half life is less
 High concentration is required
 Delivery vehicles used for the
molecules show potent effects at
the pictogram level and
appropriate carriers will be
required to facilitate their
handling in the clinical situation
 Appropriate dose response is
required to avoid uncontrolled
obliteration of pulp chamber
 Possibility of immunologicalDr.Tinet Mary Augustine.MDS
11
5

due to repeated implantation of
active molecules
 Other factors does not induced
reparative dentin formation
Bonesialoprotein  Induced homogeneous and well
mineralized reparative dentin
 Superior to Ca(OH)2 in the
mineralization inducing properties
 Further clinical studies are needed
Biodentin (2000)  Biocompatible
 Good antimicrobial activity
 Stimulate tertiary dentin
formation
 Stronger mechanically, less soluble
and produces tighter seals compared
to Ca(OH)2
 Less setting time, good handling
characteristics than MTA
 More long term
 Clinical studies are needed for a
definitive evaluation of
Biodentine
ENZYMES
Heme-oxygenase-1 (2008)
Simvastatin(2009)
 Play a cytoprotective role against
pro inflammatory cytokines and
nitric oxide in human pulp cells
 Prevent H2O2 induced cytotoxicity
and oxidative stress in human
dental pulp cells
 Anti-inflammatory action
 Induction of angiogenesis
 Improve the function of
odontoblasts, thus leading to
improved dentin formation
 Further In vitro and in vivo
studies are required
 In high concentration causes
pulp tissue damage
 Careful evaluation is required
before clinical application to
determine the suitable
concentration when applied to a
cavity or directly to pulp tissue.
STEM CELLS (2009)
Dental pulp stem cells (DPSCs)
Stem cells from human exfoliated
deciduous teeth (SHED)
 Regeneration of dentin-pulp
complex
 SHED is superior to DPSCs
 Less economic
 Technique sensitive
11
6

Propolis (2005-2010)  Antioxidant, antibacterial,
antifungal, antiviral and anti-
inflammatory properties
 Superior bridge formation
compared to Dycal, similar results
to MTA
 Forms dental pulp collgen, reduces
both pulp inflammation and
degeneration
 Stimulate reparative dentin
formation
 Shower mild/moderate
inflammation after 2,4 weeks with
partial dentinal bridge formation.
Novel endodontic
Cement(2010)
 Biocompatible
 Shorter setting time
 Do not cause tooth staining
 Good handling characteristics
compared to MTA
 Induced a thicker dentinal bridge
with less pulp inflammation than
MTA
 Further assessment is required for
evaluation of pulp response to this
material in inflamed pulp.
Emdogain (2001-2011)  Promote odontoblast differentiation
and reparative dentin formation
 Suppresses the inflammatory
cytokine production and creat a
favourable environment for
promoting wound healing in the
injure pulp tissues
 Amount of hard tissue formed in
EMD treated teeth was twice that of
the calcium hydroxide
 Post operative symptoms were less
 MTA produced a better quality
reparative hard tissue response with
the adjunctive use of Emdogain
compared with calcium hydroxide
 EMD gel (EMD dissolved in
propylene glycol alginate gel) when
applied on exposed puls without
the adjunctive use of a pulp-
capping materials was proven to
be ineffective in producing a hard
tissue barrier because of its prro
sealing qualities.
11
7

Odontogenic ameloblast
associated protein (2010)
 Biocompatible
 Accelerates reactionary dentin
formation
 Normal pulp tissue appearance
without excessive tertiary dentin
formation and obliteration of the
pulp
 Till now only in vitro study was
conducted
 Further studies containing a larger
number of samples and longer
follow-up assessments with
various studies with
Endo sequence root repair
material (2010-11)
 Antibacterial property
 Less cytotoxicity than MTA, Dycal
and light cure Ca(OH)2
 Bioactivity of the cells as well as
ALP activity were decreased
gradually when exposed to ERRM
Castor oil bean Cement
(2012-11)
 Good antibacterial property
 Less cytotoxic
 It showed less inflammatory
response in subcutaneous tissue of
rats when compared with calcium
hydroxide cement
 Facilitates tissue healing
 Better sealing ability than MTA &
GIC
 Good mechanical properites
 Low cost
 Bio inert rather than bioactive
 Further clinical trials are
required
TheraCal (2012)  Act as protectant of the dental
pulpal complex
 Bond to deep moist dentin
 Used as a replacement for Ca(OH)2,
glass ionomer, RMGI, IRM/ZnOE and
other restorative materials
 Have strong physical properties,
no solubility, high radiopacity
 TheraCal displayed higher calcium
releasing ability and lower solubility
than either ProROOT MTA or
Dycal(Gandolfii 2012)
 It is opaque and “whitish” in color,
it should be kept thin so as not to
show through composite
materials that are very translucent
affecting final restoration shading
11
8

Study Agent Cases Observation period % Of success
Sowden, 1956 Ca (OH) 2 4,000 Up to 7y Very high
Law and Lewis, 1961 Ca (OH) 2 38 Up to 4y 73.6
Hawes and DiMe Ca (OH) 2 475 Up to 4y 97
Kerkhove et al, 1964 Ca (OH) 2
ZOE
41
35
12mo
12mo
95
95
Held- Wydlier, 19641 Ca (OH) 2 41 35-630 d 88
King et al., 1965 Ca (OH) 2
ZOE
41
21
35-630 d
25-206d
88
62
Aponte, 1966 Ca (OH) 2 30 6-46 93
Jordan and Suzuki, 1971 Ca (OH) 2 243 10-12wk 98
Nordstrom et al 1974 Ca (OH) 2
Stannous flouride
64 94d 84
Magnuson, 1977 Ca (OH) 2 55 85
Sawushch, 1982 Ca (OH) 2 184 13-15 97
Nirschly and Avery, 1983 Ca (OH) 2 38 6 mo 94
Coll, 1988 Ca (OH) 2 26 20-58 mo 92.3
11
9

Direct pulp capping of a carious pulp exposure in a
primary tooth is not recommended(AAPD 2016)
High cellular content of the primary pulp tissue may
be responsible for the increased failure rate of direct
pulp capping in primary teeth .(Kennedy and Kapala )
Failure in the treatment in primary teeth may result
in(AB Fuks 2012)
Internal resorption
Calcification
Acute dentoalveolar abscess.
Necrosis
Chronic pulpal inflammation
Interradicular involvement
12
0

 A minimum indirect pulp post-treatment time
period of 6 to 8 weeks should be allowed to
produce adequate remineralization of the
cavity floor.
 The healing of pulp exposures may depend
on the capacity of the capping material to
prevent bacterial microleakage.
 It is desirable to maximize the barrier effect
of dentin to provide the best pulpal
protection.
12
1

An Asymptomatic Primary Teeth With Deep
Carious Lesion Approximating The Pulp, the
Coronal Pulpotomy Is One Of The Common
Ways Of Achieving The Goal Of Tooth
Preservation
A B FUKS
12
2

 Pulpotomy is defined as the amputation of vital
pulp from the coronal pulp chamber followed by
placement of a medicament over the radicular
pulp stumps to stimulate repair, fixation or
mummification of the remaining vital radicular
pulp (Braham and Morris).
 A pulpotomy is the removal of the coronal portion
of the pulp and the treatment of the remaining
radicular pulp in an attempt to maintain the tooth
and its supporting structure in a state of health
(Kennedy)
12
3

 Pulpotomy is the complete removal of the coronal
portion of the dental pulp, followed by placement
of a suitable dressing or medicament that will
promote healing and preserve vitality of the
tooth. (Finn 1995)
 Pulpotomy is the procedure in which the entire
coronal pulp is removed, with the aim of
removing all infected pulp tissue; the radicular
pulp is then treated in different ways, according
to the technique employed (Andlaw).
 Pulpotomy is defined as the amputation of
affected ,infected coronal portion of the dental
pulp preserving the vitality and function of the
remaining part of the radicular pulp (AAPD 2016)
12
4

 The removal of the inflamed portion of the
pulp affords temporary, rapid relief of
pulpalgia and further may undergo repair
while completing apexogenesis that is root
end development and calcification.
12
5

Mechanical caries removal result in pulp exposure in a
primary tooth with a normal pulp or reversible pulpitis
or after a traumatic exposure
Teeth showing a large carious lesion but no radicular
pathologies
History of only spontaneous pain
Hemorrhage from the exposure site should be bright
red and should stop within five minute from the
amputated pulp stumps using a sterile pledget of
moist cotton.
There should be no radiographic signs of infection or
pathologic resorption ,no interradicular bone loss,and
radiolucenciecy
In young permenant tooth with vital exposed pulp and
incompletely formed apices
12
6

 The presence of any signs or symptoms of
inflammation extending beyond the coronal
pulp is a contraindication for a pulpotomy,
 This includes the presence of
Swelling of pulpal origin,
Fistula,
Pathologic mobility,
Pathologic external resorption,
Internal resorption,
Periapical or interradicular radiolucency ,
Pulp calcification,
12
7

Highly viscous,sluggish hemorrhage from the
amputated radicular stump which is
uncontrollable
A history of spontaneous and nocturnal pain and
tenderness to percussion or palpation
Medical contraindications
 Heart disease,
 Immune-compromised patients
12
8

Stainless steel crown placed on the pulpotomised teeth
Medicament applied on the amputed pulp.
Removal of coronal part of the
carious tooth
Access opening of the carious tooth
12
9

I .DEVITALIZATION PULPOTOMY (Mummification,
Cauterization)
Formocresol pulpotomy.
Electrosurgical pulpotomy.
Laser pulpotomy.
II .PRESERVATION (Minimal devitalization, Non –
inductive)
Gluteraldehyde.
Ferric sulfate.
III. REGENERATION (Inductive, Reparative)
Calcium Hydroxide.
Bone morph genetic Protein.
Mineral trioxide aggregate
Biodentin
13
0

 PARTIAL PULPOTOMY
 COMPLETE PULPOTOMY
 VITAL PULPOTOMY
 DEVITALISATION PULPOTOMY
 NON VITAL PULPOTOMY
 SINGLE VISIT VS TWO VISIT PULPOTOMY
13
1

PRIMARY TEETH PERMENANT TEETH
FORMOCRESOL
GLUTERALDEHYDE
CAOH
FERRIC SULPHATE
MTA
CAOH
ELECTROSURGERY
LASER
BMP
OSTEOGENIC PROTEIN
MTA
13
2

Timeline Devitalizing Preserving Regenerating
1930 Multiple visit by
formecresol(Sweet Jr CA
1938 CAOH pulpotomy for
primary teeth (Teuscher
and Zander 1938)
1962 2visit pulpotomy
human(Doyle)
1965 5min FC
pulpotomy(Spedding et al)
1966 Human (Redig)
1970 Dilution of FC animal(
Straffon and Han 1970)
CAOH evaluated
human(Magnusson B)
1971 Histochemical study of
various concentration
of FC(Loos PJ)
ZOE evaluated Human
(Magnusson 1971)
Ledermix introduced
Human (Hansen et al
1971)
1975 Dilution of FC:Human
(Morwa 1975)
Gluteraldehyde proposed
RCT (s- Gravenmande )
1978 Systemic distribution of FC
in animal(Myers)
Gluteraldehyde proposed
pulpotomy (Ranly and
Lazzari)
1980 GAproposed in humans
(Kopel )
13
3

H
I
S
T
O
R
Y
1983 Systemic sffects on
animal(Myers et al 1983)
Electrosurgical
pulpotomy
animal(Ruemping et al)
1984 Enriched collagen (FUKS)
Hard setting CAOH(
Heilig)
1985 Laser animal(Shoji et al)
1988 Freese dried Bone (Fadavi
et al)
1989 Demineralized
dentin(Nakashima)
1991 Ferric sulphate
human(Fei)
BMP animal(Nakashima)
1993 Electrosurgical pulpotomy
human(Mack)
Osteogenic
protein(Rutherford)
1996 Argon laser
animal(Wilkerson)
MTA animal(Ford et al)
2001 MTA human(Eidelman et
al)
2002 Sodium hypochlorite
animal(Hafez et al)
2006 Sodium hypochlorite
human (Vargas KG)
13
4

 BACTERICIDAL
 EASY TO USE
 HARMLESS TO OTHER TISSUES
 SHOULD NOT INTERFERE WITH PHYSIOLOGIC
ROOT RESORPTION
 INEXPENSIVE
13
5

 INTRODUCE BY BUCKLEY IN 1904
 BY 1930 SWEET INTRODUCED THIS FOR PULPOTOMY
 EMMERSON 1959 –1HISTOLOGIC STUDY
 REDDING-ONE VISIT
 1971-LOOS AND HAN-1:5
 70-90% SUCCESS RATE
 ROLLING AND LAMBJERG-HANSEN-SEVERE
INFLAMMATORY RESPONDS
 1981-BUMES,FUKS-RESORPTION
 PRUNHS ET AL 1977 MESSER 1980-SUCCEDENOUS
TOOTH
 GARCIA GORDY-1984-CALCIFIC METAMORPHOSIS
 LABELLED CYTOTOXIC-RANLEY 1985,MYERS
1978,PASHLEY 1980
 INT.AGENCY FOR RESESARCH ON CANCER-JUNE 2004
13
6

COMPOSITION
 19% formaldehyde
 35% tricresol,
 15% glycerin
 31% water base.
1:5 RATIO
 One-fifth dilution of Buckley's formocresol
can be prepared by adding 30 ml of Buckley's
formocresol, 90 ml of glycerol and 30 ml of
water.
13
7

1. A broad eosinophilic zone of fixation
2. A broad pale-staining zone with poor cellular
definition
3. A zone of inflammation diffusing apically into
normal pulp tissue
 Superficial debris along with the dentinal chips at
the amputation site
 Eosinophil-stained and compressed tissue
 A palely stained zone with loss of cellular definition
 An area of fibrotic and inflammatory activity
 An area of normal-appearing pulp tissue considered
to be vital
13
8

 MUTAGENICITY,
 GENOTOXICITY
 CYTOTOXICITY
 SYSTEMIC DISTRIBUTION(MYERS 1978)
(PASHLEY 1980)
DOSAGE
 1:5 DILUTION,NO.4 COTTON-0.02-
0.10MG(HILEMAN-3-12ng/g tissue) (RANLEY
1984-3000 PULPOTOMY)
 Occupational safety and health in USA- Con of
20ppb or higher is injurious to health
 IARC and CIIT-not likely to be a potent
carcinogenic

13
9

14
0

 MARK 1993 INTRODUCED FOR PULPOTOMY
 OZTAS REPORTED THE SUPERIOR EFFECT FOR
FORMECRESOL
 RUEMPING ET AL SUGGESTED LOW INTENSITY
AS BIOCOMPATABLE
14
1

Local anesthesia and isolation with a rubber dam
Pulp chamber opened
Coronal pulp removed
Radicular pulp amputated
Pulp hemostasis obtained
No
Yes
Electrosurgical current applied for 1 sec to pulp stump
Calcium hydroxide paste placed
Light-cured glass ionomer cement seal obtained
Stainless steel crown set
14
2

The self-limiting,
Pulpal penetration is only a few cell layers deep.
There is good visualization and homeostasis
without chemical coagulation or systemic
involvement.
It is less time-consuming than the formocresol
approach.
14
3

 ONE HOUR POSTTREATMENT-
mild sign of inflammation,slight fibrosis
 SIX DAYS POSTTREATMENT-
acute inflammation,oedema and necrosis zone
 THIRTEEN DAYS POSTTREATMENT
ext.resorption, pulpal calcification at coronal third
 SEVENTEEN DAYS POSTTREATMENT
inflammatory responds and secondary dentin
deposition
 SEVENTY DAYS POSTTREATMENT
acute and chronic inflammatory responds ,necrosis
,secondary dentin
 ONE HUNDRED DAYS POSTTREATMENT
inflammation ,secondary dentin and canal
deposits
14
4

Laser irradiation would create a superficial
zone of coagulation necrosis that remained
comparable with the underlying tissue and that
isolates the pulp from the sub base.
14
5

 Soft tissue ablation
 Width of coagulation necrosis∼amount of energy
and wavelength
 Argon laser-50-100 micrometer
 Co2 laser-150 micrometer
 Favourable result obtained with 60watt of 0.5
second
 Nd yag 2W 20HZ (100MJ)
 Elliot et al(1999) –LASER Vs FORMECRESOL
 Liu et al(1998)-calcified layers were observed
14
6

MINIMAL INSULT TO TISSUES TO PRESERVE THE
VITAL RADICULAR PULP
 GLUTERALDEHYDE
 FERRIC SULPHATES
14
7

 S GREAVENMADE IN 1975-PROPOSED
 KOPEL-1980-INTRODUCED TO
PULPOTOMY(2%)
 GARCIA GORDY(1984)-2%-98% success
 NOT SO PROMISING RESULT -AB FUKS-1990
 LIOYDET AL-1988-FAVOURABLE -2%-10MIN
 SUCCESS RATE-82-95%
14
8

 SUPERIOR FIXATIVE AT HIGHER CONCENTRATIONS
 LONGER EXPOSURE TIME
 SELF LIMITING PENETRATION
 LESS NECROSIS
 LOW ANTIGENICITY
 LOW TOXICITY
 ELIMINATES CRESOL
LIMITATION
 NOT ANTIBACTERIAL AT LOW PH(ideal 7.5-8.5-
A.B Fuks)
 SMALL SHELF LIFE
14
9

 ZONE OF FIXATION
 ZONE OF PROINFLAMMATORY FIBROBLAST
 VITAL PULP
 BASIC MECHANISM-AGGLUTINATION OF
BLOOD PROTEINS AND PLUGGING CAPILLARY
ORIFICES.
15
0

REACTION TO PULP IS IRREVERSIBLE.
MOLECULES OF GLUTARALDEHYDE DO NOT
DIFFUSE OUT OF APICAL FORAMEN.
IT FIXES TISSUE INSTANTLY AND EXCESS
SOLUTION IS UNNECESSARY.
IT IS NOT KNOWN TO BE CYTOTOXIC,
MUTAGENIC OR CARCINOGENIC.
IT HAS NO SYSTEMIC TOXIC EFFECTS.
15
1

SHORT SHELF LIFE.
IT HAS TO BE FRESHLY PREPARED.
BUFFERED SOLUTION HAS TO BE REFRIGERATED.
15
2

 IT FORM STRONG INTRA AND INTERMOLECULAR
PROTEIN BONDS LEADING TO SUPERIOR FIXATION BY
CROSS LINKAGE.
 SELF-LIMITING PENETRATION
 GLUTARALDEHYDE IS NOT AS VOLATILE AS
FORMOCRESOL.
 THERE IS LESS APICAL DAMAGE AND LESS NECROSIS
OF PULPAL TISSUE IN THE GLUTARALDEHYDE-
TREATED SPECIMENS.
 LESS TOXICITY AND DOES NOT PERFUSE
THROUGH THE PULP TISSUE TO THE APEX
 NO EVIDENCE OF INGROWTH OF GRANULATION
TISSUE INTO THE APEX IN THE GLUTARALDEHYDE-
TREATED SPECIMENS.
 THERE IS LESS DYSTROPHIC CALCIFICATION IN THE
GLUTARALDEHYDE SPECIMENS.
15
3

15
4

 FEI ET AL PROPOSED (1991)
 FUKS ET AL –NO HEALING,CHRONIC
INFLAMMATION
 INTERNAL RESORPTION AND PREMATURE
EXFOLIATION(VARGAS 2005)
15
5

 HEMOSTASIS
 15.5% FESO4
 THICK PASTE OF ZNOE OR IRM
15
6

15
7

 Rosenfeld et al. showed that placement of 5 %
NaOCl on non-instrumented vital pulp
 HAFEZ –NO PULPAL INFLAMMATION (3%)
 ACCORINTE ET AL(2005) VARGAS(2006)
15
8

 Once the pulp chamber is accessed, the
coronal pulp is removed and hemostasis is
achieved with a cotton pellet.
 A cotton pellet is moistened in 3 % or 5 %
NaOCl and placed in the chamber for 30 s.
 The pellet is removed, the chamber is gently
irrigated ensuring no clot is present.
 ZOE or IRM is placed in the pulp chamber and
the tooth is r
15
9

Medicament in this category should be one that
leaves the remaining radicular pulp vital and
completely enclosed away from the potentially
noxious effects of restorative materials and
bases
 CAOH
 MTA
16
0

 Zander introduced in1930
 Doyle in1962-64% radiographic failure(18
months)
 Magnusson (1970), Schroder(1978)
Waterhouse (2000) - Internal resorption as
reason for failure(31-100%)
16
1

16
2

16
3

 Eidelmann (2001) showed 100% success after 17
months.
 Biocompatable
 Bactericidal
 Able to stimulate cementum like formation
 Osteoblastic adherence
 Bone regeneration
 Sealing ability
 Dentinogenic ability
 Osteogenic potential
 Discolouration
 cost
16
4

16
5

OTHER
MEDICAMENTS
16
6

 These compounds act as signaling proteins
that could be directly involved in the
regulation of cell proliferation, migration and
extracellular matrix production in the dental
pulp.
 Kalaskar and Damlei compared the efficacy of
a lyophilized freeze-dried platelet-derived
preparation to that of calcium hydroxide
16
7

 EMD components act as a signal for
induction of mesenchymal cell differentiation,
maturation and biomineralization
 Sabbarini et al studied histologic responds at
1weeks,2,weeks and 6 months
16
8

 Hafez and others demonstrated that the
application of NaOCl selectively dissolves the
superficial necrotic pulp tissue while leaving the
deeper healthy pulp tissue unharmed .(Hafez
2002)
 Cox et al reported that hemostasis is best
achieved with NaOCl.
 Chompu-Inwai et al. reported similar success rate
of NaOCl/RMGIC when compared to FC/ ZOE in
their 3 month evaluation . (Chompu-Inwai P 2002)
16
9

 Vargas et al (2006). showed promising results
from a pilot study using 5% NaOCl as a primary
molar pulpotomy agent
 Various studies have shown a good success
rate with NaOCl as pulpotomy agent ranging
from 82 to 100% .(Vostatek S, 2011, John DR
2013)
 Histologically Roza et al IN 2012. noted mild
inflammation and also dentin bridge formation
after 2 months following NaOCl pulpotomy .
17
0

 It reacts with aqueous solution and form a
carbonate apatite layer. Originally BAGs were
considered as osteoconductive. Recent evidence
suggests that they are osteoinductive. BAGs are
biocompatible, antibacterial and stimulate
osteoblasts
 Some authors state odontoblast stimulation and
subsequent reparative dentin formation; however
studies are ongoing to prove exact mechanism of
bridge formation.
17
1

 Animal study by reported that BAG showed
localized areas of inflammation in the pulp
especially in the mid root portion and 4 week
old samples showed comparative better
results where the inflammation was resolved
and odontoblastic layer was evident .
17
2

It is a herbal extract obtained from 5 different
plants:
 Thymus vulgaris,
 Glycyrrhiza glabra,
 Vitis vinifera,
 Alpinia officinarum, and
 Urtica dioica.
17
3

Following application of ABS, it forms an
encapsulated protein network that provides
focal points for vital erythrocyte aggregation.
ABS- induced protein network formation with
blood cells particularly erythrocytes covers the
primary and secondary haemostatic system
without disturbing individual coagulation
factors
17
4

 It is suggested that ABS may be used to control
pulpal haemorrhage following the mechanical
exposure of pulps. The levels of coagulation
factors II, V, VIII, IX, X, XI, and XII were not affected
by ABS, therefore ABS might be used in patients
with deficient primary or/and secondary
hemostasis, including patients with disseminated
intravascular coagulation .
17
5

 Studies on pulpotomy with ABS have shown
success rate ranging from 89% to 100%.
(Odabaş ME 2011, Yaman E2012)
 However, long term studies are required in
this regard.
17
6

 It has been introduced for augmentation
procedures in osseous defects and is
attracting increasing interest in medicine and
dentistry.
 NHA is biocompatible and non-irritating to
pulp tissue.
17
7

 Shayegan et al. following histological
evaluation reported that there was a
significant difference between NHA and FC in
terms of pulp response. The results of the
study show that NHA appears to be more
biocompatible and provokes only mild
inflammatory reaction in pulp tissue in both
pulpotomy and direct pulp capping
treatments
17
8

 Platelet Rich Plasma gel (PRP gel) is an autologous
modification of fibrin glue obtained from
autologous blood used to deliver growth factors in
high concentrations
 It was introduced by Marx in 1998 for
reconstruction of mandibular defects, and it
represents a relatively new biotechnology that is
part of the growing interest in tissue engineering
and cellular therapy (Marx RE,2001)
17
9

 Gibble and Ness in 1990 introduced fibrin
glue, alternatively referred to as fibrin sealant
or fibrin gel, a biomaterial developed in
response to the necessity for improved
haemostatic agents with adhesive properties.
18
0

 It is an autologous concentration of human
platelets in a small volume of plasma,
 Mimics the coagulation cascade,
 Leading to formation of fibrin clot, which
consolidates and adheres to application site.
Its biocompatible and biodegradable
properties prevent tissue necrosis,
 Extensive fibrosis and promote healing
18
1

Platelet rich plasma has been found to work via
three mechanisms
 a) Increase in local cell division (producing more
cells): According to Nathan E Carlson after the
injury, platelets begin to stick to exposed collagen
proteins and release granules containing
adenosine diphosphate, serotonin and
thromboxane, all of which contribute to the
hemostatic mechanism and the clotting cascade.
18
2

 b) Inhibition of excess inflammation by
decreasing early macrophage proliferation.
 c) Degranulation of the agranules in platelets,
which contain the synthesized and
prepackaged growth factors. The active
secretion of these growth factors is initiated
by the clotting process of blood and begins
within 10 minutes after clotting.
18
3

 More than 95% of the presynthesized growth
factors are secreted within 1 hour
 PRP has been shown to remain sterile and the
concentrated platelets viable for up to 8 hours
once developed in the anticoagulant state
 PRP was found to be an ideal material for
pulpotomy with low toxic effect, increased tissue
regenerating properties and good clinical results
 Studies have reported good clinical success rates
of pulpotomy using PRP
18
4

 It is a newly available radiopaque, non
resorbable paste that is used for pulpotomy
treatment.
 It is available as powder liquid system
(Produits Dentaires SA, Vevey. Switzerland).
 Powder consists of polyoxymethylene,
iodoform
 Liquid consists of dexamethasone acetate,
formaldehyde, phenol, guaiacol.
18
5

 It is by cicatrization of the pulpal stump at
the chamber-canal interface, while
maintaining the structure of underlying pulp
(Pranitha 2013)
 Previous histological studies reported no
signs of inflammation, but there was a
discontinuity in the odontoblastic layer lining
along the dentin walls (Khattab NM 2010)
 However more clinical trials to evaluate
clinical and radiographic success are needed.
18
6

 It falls in the class of hydraulic cements,
which self-harden to hydroxyapatite (HA), the
bone mineral.
 Several formulations of CPC have been
successfully designed for various orthopedic
and dental applications.
 CPCs possess the combination of
biocompatibility, osteoconductivity and
mouldability.
18
7

 They are nontoxic
 Non-immunogenic
 Do not have any mutagenic or carcinogenic
potential (Chaung HM,1996)
 Animal studies reported the capacity of
calcium phosphate to form dentin without
areas of necrosis (Zhang W, 2008)
18
8

 Jose et al (2013)compared calcium phosphate
cement with formocresol. Histological assessment
for non-carious primary canines after 70 days
showed no statistically significant differences
between the two groups in any of the parameters.
 Calcium phosphate cement provided more
favorable results of less pulpal inflammation and
better formation of dentin bridges in quantity and
quality; it was aLso capable of inducing dentin
formation without an area of necrosis.
18
9

 It is a new CPC formulation with good
rheological properties developed in India.
Ratnakumari and Bijimole et al. used chitra-
CPC and reported favourable results with mild
pulpal inflammation and improved quality of
dentin bridge formation
19
0

 It extracted from black seed or black cumin is
traditionally used in herbal medicine
 Omar OM et al(2012) conducted a
histopathological comparison of FC and NS
pulpotomies in dogs. Specimens in NS groups
showed mild to moderate vasodilatation,
continuous odontoblastic layer and few
samples showed scattered inflammatory cell
infiltration
19
1

 A histological study using human osteogenic
protein-1 combined with collagen matrix.
showed that reparative dentin was present in
all teeth that remained sealed for the 6
weeks.
 However, more new dentin was present in
teeth treated with human osteogenic protein-
1 /collagen matrix than in those treated with
calcium hydroxide paste.
19
2

 Tetrandrine resulted in significantly less
inflammation than in teeth treated using
formocresol and lead mix cement.
19
3

 Bimstcin and Shoshan (1981)reported a
histological study using collagen solution-
enriched cell nutrients noted complete
regeneration of pulpal tissue after 30 days.
 In a comparative study by Pranitha kakkarla in
2013 between collagen and pulpotec found a
promising result with both with better result with
the collagen
19
4

 In a study using commercially available
antioxidants, namely Antioxidants plus trace
elements (OXIn-Xttm, India) , M Ajay reddy
(2014 )reported a quite promising clinical,
radiographic, and histological results of
antioxidants in the study shows their
potential to be an ideal pulpotomy agent.
19
5

 This prospective study was carried out on 36
primary molar teeth in 32 children, with age that
ranged from 6 to 9 years. Regular conventional
pulpotomy procedure followed by placement of
antioxidant mix over the radicular orifice was
done. Recall was scheduled for 3, 6, and 9
months, respectively, after treatment.
 Scanning electron microscopy analysis of
samples showing convex shaped hard tissue
barrier formation may be proof of the role of
antioxidant material in localization and direction
and morphology of the hard tissue barrier.
19
6

 Teeth treated with ferracryllum(1%) were
clinically and radiographically asymptomatic,
and histological evaluation showed evidence
of healing in the form of reparative dentin
and fibrous tissue formation the deeper zone
of the radicular pulp.
19
7

 Sakai et al (2009) compared the clinical and
radiographic effectiveness of MTA and
Portland cement as pulp dressing agent: in
carious primary teeth. They reported that all
of the pulpotomized teeth were clinically and
radiographically successful at 2 years. The
authors reported that It statistically
significant difference regarding dentin bridge
formation was found between the groups
throughout the follow-up period.
19
8

 S G MOHAMMEDH in 2015compared the clinical
and radiographic effects of A. sativum oil and
those of formocresol in vital pulpotomies of
primary teeth. Their results showed that A. sativum
oil had good healing potential, leaving the
remaining pulp tissue functioning and healthy.
 Vital pulpotomy with A. sativum oil had a 90%
success rate, while that with formocresol was 85%.
The authors concluded that A. sativum oil is a
biocompatible material that is compatible with vital
human pulp tissue. It has good healing potential
and leaves the remaining pulp tissue healthy and
functioning.
19
9

Primary teeth diagnosed with irreversible
pulpitis or necrotic pulp and with roots
showing minimal or no root resorption should
undergo the radicular pulp treatment.
20
0

To eliminate the microorganism from the root
canal
Space maintanence.
20
1

 Finn (1959) defines pulpectomy as removal of
all pulpal tissue from the coronal and radicular
portions of the tooth.
 Pulpectomy is the complete removal of the
necrotic pulp from the root canals of primary
tooth and filling them with an inert resorbable
material so as to maintain the tooth in the
dental arch (Mathewson (1995)
 Pulpectomy is a root canal procedure for pulp
tissue that is irreversibly infected or necrotic
due to caries or trauma. (AAPD 2016)
20
2

 Multiple Tortous Root canals( Hibbard And
Ireland 1957)
 Lateral Canal(Moss et al 1965) (Ringstein and
Seow 1989)
 Mesiodistal Width, Taurodontism (Ahmedh HMA
2013)
 Root Canals and Apical Foramen (Goerig AC,
Camp JH 1983)
20
3

 Reduce bacterial load(Marsh and Largent1967).
 It should promote the physiological root
resorption.
 Preventing the premature loss of primary teeth
 To preserve primary incisors and second
molars/before 6s eruption(Spedding 1977).
 Preserve a sufficient alveolar ridge.
20
4

 Not to penetrate past apical end
 Resorbable material.
 Light pressure on obturation.
20
5

History of
a. Spontaneous unprovoked pain
b. Pain from percussion
c. Pain from mastication
d. Duration
e. Variations
Visual and tactile examination of carious dentin and associated periodontium
Radiographic examination of
a. Periradicular and furcation areas
b. Pulp canals
c. Periodontal space
d. Developing succedaneous teeth
Degree of mobility
Palpation of surrounding soft tissues
Operational diagnosis
Size,appearance,and amount of hemorrhage associated with pulp exposures
20
6

 Traumatized primary incisors with resultant
pathologic condition(in children younger than
4-4.5 years)
 Primary second molar ,before eruption of 6s
 Permenant immature teeth with immature root
 No evidence of pathologic conditions,with root
resorption not more than two thirds or three
fourths completed
20
7

 A tooth that is not restorable
 Pathologic condition extending to the
developing permenant tooth bud
 Less than two third of the primary root
structure remaining with internal or external
resorption.
 Internal resorption of the pulp chamber and
root canals.
 Gross periadicular bone loss.
 Chronic illness with leukemia ,rheumatic and
congenital heart disease ,chronic kidney
disease,etc Dr.Tinet Mary Augustine.MDS
20
8

 Removal of carious tooth
 Structure
 Conservation of sound tooth structure
 De roofing of pulp chamber
 Removal of coronal pulp tissue
 Straight line of access
 Location of all root canals
20
9

21
0

 Preparation of the root canal in a primary
tooth is based mainly on chemical means
rather than mechanical debridement
 ROSENDAHL R
21
1

 Explorer-endodontic explorers
 Shaping-reamers and files
 Debridement-barbed broach(Healey
1994),Kfile,rasps
 Obturation-
pluggers,spreaders,lentulospirals
21
2

 Diameter vs taper
 Numbering
 Increment
 Taper
 Angle
 Colour coding
 Niti(Elizabeth s Bair 1999)/SS steel
 Blanks
 Legth
21
3

 “IRRIGATION ALLOWS FOR CLEANING
BEYOND WHAT MIGHT BE ACHIEVED BY
ROOT CANAL INSTRUMENTATION ALONE”
21
4

 Removal/dissolve of smear layer.
 Inactivate endotoxins
 Active even in presence of blood,serum and protein
derivative
 Reduce friction
 Shouldn‟t irritate periapical tissues
 Shouldn‟t weaken the tooth
 Stable
 Antibacterial properties
 Easy to apply
 Not carcinogenic
 No effect on obturating materials
21
5

 Tissue or debris solvent
 Low surface tension
 Lubricant
 Removal of smear layer
 Availability
 Moderate cost
 Easy to use
 Adequate shelf life
 Easy to storage
 Stability
21
6

ANTISEPTICS/DISINFECTANT-
NAOCL,CHLOREHEXIDINE GLUCONATE
OXIDIZING AGENT-HYDROGEN
PEROXIDE,UREA PEROXIDE
CHELATING AGENT-EDTA,CITRIC
ACID,CHITOSAN
ORGANIC ACID-CITRIC ACID,POLYACRYLIC
ACID
MISCALLANEOUS-WATER NORMAL SALINE
21
7

CHEMICAL AGENT
• TISSUE DISSOLVING
AGENT(NAOCL)
• ANTIBACTERIAL AGENT
BACTERICIDAL-CHX,NAOCL
BACTERIOSTATIC(MTAD)
• CHELATING AGENT
STRONG PH(EDTA)
• COMBINATION PRODUCTS
MTAD,QMIX,TETRACLEAN,SMEAR
CLEAN
NATURAL AGENT
• ANTIBACTERIAL AGENT
GREEN TEA, TRIPHAL, PROPOLIS,
MESWAK, TREE TEA OIL,
MORINDA CITRIFOLIA, ARCTIUM
LAPPA
21
8

 Conventional-syringe and needle
 Endoactivation
 Endovac
21
9

ENDO ACTIVATOR
VIBRINGE
ENDO-VAC
22
0

ULTRASONIC IRRIGATION
RINS ENDO SYSTEM
VATEA SYSTEM
NAVI TIP
QUANTEC-E
22
1

 ANTIMICROBIAL AGENT THAT IS PLACED
INSIDE THE ROOT CANAL TO DESTROY THE
REMAINING MICROORGANISM AND TO
PREVENT THE RE INFECTION OF THE ROOT
CANAL
 WEINE 2004
22
2

 Zinc oxide eugenol
 Calcium hydroxide
 Calcium hydroxide with iodoform containing pastes
 Vitapex
 Metapex
 Iodoform based pastes
 Kri paste
 Maistos paste
 Endoflas
 Triple antibiotic paste
 Colla cote
 MTA
 Chitra –HAP fill
22
3

 Resorb at a similar rate as the primary root,
 Be harmless to the periapical tissues and to the
permanent tooth germ
 Resorb readily if pressed beyond the apex,
 Be antiseptic,
 Fill the root canals easily,
 Adhere to their walls,
 Not shrink,
 Be easily removed if necessary,
 Be radiopaque,
 Not discolor the tooth. Dr.Tinet Mary Augustine.MDS
22
4

 Zinc Oxide BP, Eugenol BP,(Associated
Dental Products Ltd, Purton, England)
 Discovery- Bonastre (1837)
 Recommended for primary teeth-Sweet
1930
 One visit ZNOE pulpectomy-Gould J M 1972
 Over 90% success- Mortazavi(2004)
22
5

 POWDER
 Zinc oxide – 69.0% - principal ingredient
 White rosin - 29.3% - To reduce brittleness of set
cement
 Zinc stearate -1.0% - Accelerator , plasticizer
 Zinc acetate – 0.7% - Is added in some powders,
acts wAith eugenol in a similar manner as zinc
oxide

 LIQUID
 Eugenol – 85.0 - Reacts with zinc oxide
 Olive oil - 15.0 - Plasticizer
22
6

 Eugenol released in per apical zone
 Immediately- 104,24 hr-106 ,1 month-0
 Action :anti inflammatory and analgesic
 Eugenol can cause Protein denaturation
(Gopikrishna 2006)
22
7

 Difference in the rate of resorption(Coll JA
1996)(Ozalp 2005)
 Ectopic/delayed eruption(Ranly D
M2000)(Tannure et al 2011)
 Antimicrobial activity(Garcia Godoy 1987)
Compensation by additives(Holland1993)
 Delayed resorption(Ranly D M 2000)(40.2
months-Sadrian,Coll JA 1993)(Ozalp 2005)
 Antimicrobial activity(Chaou WS1995)
 Foreign body reaction(Barker B C 1971)
22
8

 Genotoxic,cytotoxic,and able to kill the
macrophagesand causing chronic and fibrous
inflammatory reactions and ulcerations and
osteosclerosis(Erausquin 1967,Holan G, Fuks
AB 1993)
 Necrosis of bone,cementum(Erosquin 2000)
 Flush /unerfilling advocated(Fuks 2010)
 Radicular cyst(Petel R ,Moskovitz 2013)
 Enamel defects(Coll JA 1985)
 Better to underfill as compared to flush or
overfill(A B Fuks 2010)
22
9

 Effective bacteriostatic than formecresol (Cox
et al 1978)
 Holan And Fuks (1993)noted 65% success rates
 Flaitz et al (1989) noted 86.3% success rates
 Nadkarni and Damle(2000) noted 88.5%
success rates
 Cox et al (1978),Holland(1993), Tchaou et
al(1995 ) sugested increased antibacterial
effect of zincoxide eugenol when combined
with other materials.
23
0

 Calcium hydroxide is chemically classified
as a strong base with high pH
(approximately 12.5 to 12.8).
 Tissue compatibility,
 Antimicrobial activity,
 Ability to neutralize bacterial endotoxins,
 Broaden its antibacterial spectrum.
 Act as preventive barrier which prevent
reinfection of the canal
23
1

 Aqueous<viscous<oily vehicle
 Degree of solubility – inverse with result
(A B Fuks 2016)
 Gomes et al (2002)suggested oily vehicle
will increase the antimicrobial effect of the
medicament
23
2

 PROPERTY (NEELAKANDAN 2007)
 Substantivity
 Biocompatibility,
 Wide spectrum of activity against bacteria,
fungi, and viruses, including those present
in contaminated root canals.
 It also provides residual antimicrobial
activity after prolonged contact with the
canal.
23
3

 The effectiveness of this medicament is due
to the interaction of the positive charge of
the molecule and the negatively charged
phosphate on the bacterial cell walls
changing the osmotic equilibrium of cells.
 Combined use of CHX and CH as an
intracanal medicament can also create
reactive oxygen species, which may
potentially kill many root canal pathogens.
23
4

 Faria et al (2009) observed that the Calcium
Hydroxide pastes and those combined with
1% percent CHX, respectively, were effective
in combating microbial infection present in
the root canals of primary teeth with pulp
necrosis and periapical lesions.
23
5


 Manzur et al. (2012)found no difference
concerning the antimicrobial activity when
analyzing CH and CHX alone or in combination
as intracanal dressings in permanent teeth.
 Chlorhexidine is an antimicrobial cationic
biguanide whose optimum pH is between 5.5 and
7.0 The reduction of the antimicrobial activity is
most likely due to the precipitation of
chlorhexidine, which occurs when the pH is above
10, causing the deprotonation of the biguanide and
leading to the reduced solubility and altered
interaction of the compound with the bacterial
surfaces.
23
6

 Walkhoff 1928 –
 Iodoform with parachlorophenol ,camphor and
menthol
 Resorbable
 Bactericidal,
 Nonirritant,
 Non-shrinking,
 Non-soluble
 Radioopaque in nature
 Does not produce undesirable periradicular
effects Dr.Tinet Mary Augustine.MDS
23
7

 Iodoform (80.8 %),
 Camphor (4.9%)
 Parachlorophenol(15%)
 Menthol
23
8

 KRI paste showed stronger antibacterial
effectiveness than did ZOE against pure
cultures of obligate anaerobes with
Bacteroides( Porphyromonas Prevotella)
species and anaerobic streptococci isolated
from non-vital root canals of primary teeth
(Tchaou WS, Turng BF, Minah GE, Coll JA 1938)
 The material do not harden and remain
chemically active until entirely resrobed from
the periradicular region. Also, it loses only 20%
of its bactericidal potency over a 10 year
period.(Cequiera 2008)
23
9

 Iodoform-42 gm
 Zinc oxide-14 gm
 Thymol-2gm
 Chloramphenol camphor-3cc
 Lanolin -0.50 gm
 Tagger and Sarnat (1984) used in primary teeth
 A study was conducted in which the combination
was found to have effective antibacterial activity
against both the aerobic and anaerobic bacteria of
the root canals of deciduous teeth with maximum
sustaining period of 10 days(Kubota 1992)
24
0

 Resorb in 1-2 weeks and less harmful to
periapical region(Garcia Godoy 1987)
 Reported a 100 % success rate with
complete healing of interradicular
pathologies and complete resorption of
excess material ( Reddy and
Fernandes in 1996 )
24
1

 Eventhough ZnO can reduces the resorption
rate the presence of Iodoform which
reduces tissue inflammatory response
makes the material to resorb faster. (Mass
et al 1989 Kubota 1992)
24
2

 ADVANTAGE (RIFKIN 1980,RANLY,GARCIA
 GODOY 1991)
 Easily forced into canals
 Periradicular resorption is faster
 Disinfection
 Vitapex
 Metapex
24
3

 Calcium hydroxide 30.3%,
 Iodoform 40.4%
 Silicone oil 22.4%.
 Vitapex is sold in North America as Diapex
(DiaDent Group International, Burnaby, BC,
Canada).
 The silicone will neutralize some of the
alkalinity of the paste causing lesser injury
to the periapical tissues which is short lived
24
4

 Showed a favorable rate of resorption,
 Reduced void formation
 Satisfactory radiographic and clinical
outcomes
 When extruded-resorb within 1-2 weeks
 Bactericidal,
 Harmless to the permanent tooth germs.
 It does not set to a hard mass and is easily
inserted and removed from the canals.
 It easily resorbs from the periradicular
region, and
24
5

 Extruded material get phagocysed by
macrophages
 Radioactive trace study revealed excreation
through faeces and urine shows the
expeditious removal from system
 Bone regeneration and cemental
regeneration was noted
 Nurko and Garcia-Godoy 1999 suggested
100% success
24
6

 According to Meta Biomed Company Ltd.
Metapex contains

 Iodoform 30-40%,
 Calcium Hydroxide-30.3%,
 Silicon Oil-22.4%
24
7

 Metapex is a potent antimicrobial agent at
higher concentration Metapex (0.22gm/ml)
has potent antimicrobial ability, a decreased
concentrations of metapex (0.022gm/ml
and 0.22gm/ml) resulted in significantly
decreased antimicrobial effects. (S GAUTAM
2011)
24
8

 In comparative study Metapex showed
better results as compared to the endoflas
among endoflas metapex and zinc oxide
eugenol and zinc oxide
eugenol(Subramaniam P 2011)
24
9

 Easy to apply
 Radio opaque
 No periradicular toxicity
 No effect on succedenous tooth
 Metapex show least cytotoxicity while
comparing zinc oxide,chitra HAP fil because
of the silicon oil coating which reduces the
chance of leaching out(Ramkumari et al
2014)
25
0

 May cause hollow tube effect which may
cause resoption.
25
1

 Hydrophilic
 Firmly adheres to the surface of the root
canal walls,
 And has an ability to disinfect the dentinal
tubules
 Biocompatible,
 It can be removed by phagocytosis, hence
making the material resorbable.
25
2

 Tri-iodomethane and iodine dibutilorthocresol
(40.6%)
 Zinc oxide eugenol,(56.5%)
 Calcium hydroxide (1.07%)
 Barium sulphate (1.63%)
 A liquid consisting of Eugenol and paramono
chlorophenol.
25
3

 The material is hydrophilic and can be used
in mildly humid canals.
 In addition, the components of the material
can be removed by phagocytosis making it
resorbable
 Despite the numerous advantages that
endoflas has over zinc oxide eugenol, it is
still not the most widely employed material
for root canal filling in a primary tooth.
25
4

 Resorption rate co-relate with physiologic
resorption
 Resorption is related only to the excess
material(Johnson 2009)
 No hollow tube effect.
 Broad spectrum of activity.
25
5

 Its eugenol content can cause periapical
irritation.
 Chance of causing tooth discoloration.
25
6

 Endoflas shown better result than zinc
oxide eugenol(Nivedita Rewal 2014)
 Endoflas >ZOE >Calcium hydroxide paste (S
Navit 2016)
 Motor driven lentulospirals and pluggers
were found to be most suitable for the
obturation of endoflas(Jayalakshm 2017)
25
7

 Endofloss can be used if care is taken not to
overfill the canals.
 Johnson et al(2006) examined the use of a 2
mm × 2 mm collagen sponge (Collacote,
Zimmer Dental, Texas, USA) as an apical
barrier per canal. The results showed that
the presence of a biological barrier
significantly decreased, but not completely
prevented, the risk of overfilling when
pulpectomies were performed in primary
molars.
25
8

 Antibiotics (3Mix) –
 Ciprofloxacin 200mg
 Metronidazole 500mg
 Minocycline 100mg
 Carrier (MP) –
 Macrogol ointment
 Propylene glycol
25
9

 Antibiotics (3Mix)
 Cross-contaminate should be checked.
 Remove sugar coating from tablets with
surgical blade, crush individually in
separate mortars .
 Grind each antibiotic to a fine powder
 Combine equal amounts of antibiotics
(1:1:1) on mixing pad
26
0

 Equal amounts of macrogol ointment and
propylene glycol (1:1)
 Using clean spatula, mix together on pad
 Result should be opaque
26
1

 MANIPULATION
 1:5 (MP:3Mix) -creamy consistency
 1:7 (standard mix) - smears easily
 Storage
 Antibiotics must be kept separately in
moisture-tight porcelain containers
 Macrogol ointment and propylene glycol must
be stored separately
 Discard if mixture is transparent (evidence of
moisture contamination)
26
2

 Modified 3mix paste show excellent
antimicrobial effect as compared to calcium
hydroxide paste(N Loera Velasco 2012)
26
3

 Soft, white, pliable, biocompatible sponge
obtained from bovine collagen.
 Can be applied to moist or bleeding canals.
It is an absorbable collagen barrier which
prevents or diminishes extravasation of root
canal filling material during primary molar
pulpectomies.
 It also provides a scaffold for bone growth
and so it can be applied on wounds.
26
4

 A short-term success following the use of
ProRoot mineral trioxide aggregate (MTA)
(Dentsply, USA) as a root filling material in a
retained primary second molar of a 20-year-
old patient.
 MTA is not widely advocated because of the
high cost of the material and difficulty in
application into relatively narrow root canals.
 It seems that the application of MTA would not
reduce the high risk of root resorption in
retained molars of younger patients.(Tunc ES
2010) Dr.Tinet Mary Augustine.MDS
26
5

 It is atenable alternative for teeth that require
re treatment,teeth with resorptive
defects,open apices and teeth that shows
anatomic variations that cannot be
predictabley sealed using conventional
techniques
26
6

 When a large amount of material is overfilled
in the mandibular canal (inferior alveolar
canal), immediate surgical removal of the
material should be considered, as with all
root canal materials
26
7

 Hydroxyapatite nanoparticle gel based root
root canal filler
 Composition
 Hydroxy apatite nanopartile gel-65%
 Iodoform-32%
 Gelling agent-3%(alginate)
 Surfactant-0.2%
26
8

 Neutral ph
 Less irritant to periradicular area or to
developing tooth
 Easy to fill
 Good adherence
 Doesn‟t shrink
 Chemically inactive so less chance of
discoouration
 Not hard setting
26
9

 Comparative evaluation with ZNOE and
Metapex revealedgood antimicrobial activity
and less cytotoxic effect. Resorption
coincides with the physiological rate.
27
0

1 Walkholf paste Parachloro-phenol Camphor menthol
2 KRIpaste
Iodoform 80.8%
Camphor 4.86%
Paracholoro phenol 2.025%
Menthol 1.215%
3 Maisto paste Zinc oxide 14 gm Iodoform 42gm Thymol 2gm
Chlorophenol Camphor 3cc Lanolin 0.5gm
4 Vitapex Calcium hydroxide Iodoform oily additives
5 Endoflas
Zinc oxide 56.5%
Barium sulfate 1.63%
Iodoform 40.6%
Calcium hydroxide 1.07% Eugenol pentachlorophenol
6 Colla cote Synthetic collagen
7 Gue des – pinto paste 0.30gm iodoform
0.25gm calcium hydroxide
27
1

27
2

 Disposable syringes(30G)(GREENBERG 1971)
 pressure syringes(Greenberg 1965)
 Reamers and Pluggers(Gould 1972)
 lentulospirals (Kopel 1970)
 Tuberculine syringe Jiffy tubes(AYLORD AND
JOHNSON 1987)
 Paper points(Spedding 1973)
 Wet cotton(Donnenberg 1974)
 Amalgam pluggers (King 1984)
 Insulin syringes
 Disposable syringe with NaviTip.
27
3

27
4

RICHARD J MATHEWSON:FUNDAMENTALS OF PEDITRIC DENTISTRY-3RD EDITION
27
5

 Age below5- zinc oxide can be prefered
 Age above 7 –calcium hydroxide
 An apical stop should be developed 1-2
mm from the radiographic apex
 Obturation level
1 Underfill More than 2mm short of
apex
2 Optimal filling At radiographic apex or
upto 2mm short
3 Overfilling Any canal showing
material outside the
canal
27
6

Radicular cyst
27
7

 Turner„s hypoplasias in permanent teeth that
resulted from periapical lesions in non- vital
primary teeth have been reported
27
8

 ZOE form a fibrous capsule that prevent the
resorption(Coll JA 1985)
 CAOH get resorbed faster than
tooth(Erausquin J1967)
 Iodoform pastes engulf by macrophages.
Cause irritation to periapical tissues and
can cause cemental necrosis(Kubota K
1992)
 VITAPEX get resorbed by macrophagesby 1-
2 weeks to 2-3 mnths and no foreign body
reactions were noted(Nurko ,Garcia Godoy
1999) Dr.Tinet Mary Augustine.MDS
27
9

 Endoflas –material resorb when over
extended within 7 days by macrophagic
activity (AB Fuks 2002)
 Pulpless pulpectomised teeth have limited
surface area to resorption.Vascular network
around apex induce less intense resorption.
So rate of resorption will be slower(A B F
uks 2016)
28
0

 Review on 6 months
 No pathological responds
 Resorption of tooth/medicament and
eruption of succedaneous tooth should be
normal
 Radiographic lesion resorb within 6 months
28
1

The lack of treatment is not an option as it
can cause damage to the succedaneous tooth
and negatively impact the child‟s oral health-
related quality of life .
28
2

28
3

Pediatric endodontics

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