PULPECTOMY IN PEDIATRIC DENTISTRY

PULPECTOMY
• DR KOMAL GHIYA
• MDS PEDODONTICS AND PREVENTIVE DENTISTRY

PULPECTOMY
• Definition
• Indications
• Contraindications
• Historical perspective
• Procedure
• Single visit
• Multiple visit
2

• Steps in pulpectomy
• Anesthesia, isolation and access opening
• Working length measurement
• Cleaning and shaping the canals
• Irrigation
• Obturation
• Materials for obturation
• studies
• Obturation techniques
• studies
3

• Antibacterial property of obturating materials
• Clinical and radiographic success
• Conclusion
• References
4

PULPECTOMY
• Mathewson(1995)- The complete removal of the necrotic pulp
from the root canals of primary teeth and filling them with an
inert resorbable material so as to maintain the tooth in the
dental arch.
• Finn- Removal of all pulpal tissue from the coronal and
radicular portions of the tooth.
5

OBJECTIVES
1. Resolution
2. No over extension or under filling
3. Permitting resorption
4. Health of periodontium and bone
5. No internal or external inflammatory root resorption
6. Hold the space for erupting permanent tooth
6
Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5th edition.
Elsevier.Mosby
Endodontics .John I de Ingle, Leif K. Bakland. 5th edition. B.C. Decker publishers

INDICATIONS
• A non vital tooth associated with an abscess or fistula
• Presence of pus at the exposure site or in the pulp chamber
• Cellulitis
• Extensive furcation pathology
• Radicular pulp is chronically inflamed
• If pain present may be spontaneous or persistent
• The tooth is restorable
CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC
OPERATIVE DENTISTRY,4TH EDITION

• Mobility or intraradicular bone loss are minimal
• The haemorrhage from the amputation site is dark red and scanty ,difficult to control
• Primary teeth without permanent successor
STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC
DENTISTRY,SCIENTIFIC FOUNDATIONS AND CLINICAL
PRACTICE,1982

CONTRAINDICATION
• Excessive tooth mobility
• Furcation involvement
• External root resorption
• Internal root resorption
• Gross loss of root structure
• Periapical infection involving the crypts of succadenous tooth
9
Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

HISTORICAL PERSPECTIVE
10
• Sweet (1930) – 4 to 5 step technique using formocresol for the treatment of
pulpless teeth without fistula.
• Rabinowitz(1953) - treated nonvital primary teeth with a 2-3 day application of
FC, followed by precipitation with silver nitrate and a sealer of ZOE into canals.
• Long procedure-avg. 5.5 visits for teeth without periradicular involvement and avg. 7.7 visits for teeth with periradicular
involvement.
• Hobson(1970)- canals not debrided.
• Used breechwood creosote for 2 weeks followed by filling pulp chamber with ZOE.
STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC DENTISTRY,SCIENTIFIC FOUNDATIONS AND CLINICAL
PRACTICE,1982

11
• Lewis & law(1973) First visit- canals medicated with eugenol, camphorated
parachlorophenol or FC.
Second visit- canals debrided and filled with ZOE or iodoform crystals
• Gould(1970) – One appointment technique
camphorated parachlorophenol placed in chamber for 5 min followed by
debridement of canal and pressing ZOE in prepared canals.
• Starkey(1980)
Multi-appointment for teeth with necrotic pulps and periradicular
involvement
STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC DENTISTRY,SCIENTIFIC FOUNDATIONS AND CLINICAL
PRACTICE,1982

TYPES OF PULPECTOMY
Single visit (Gould 1970)
Multiple visit (Gould & Starkey 1980)
12
Partial pulpectomy
Complete pulpectomy

CHEMICOMECHANICAL PREPARATION
• The multiple ramification of radicular pulp in a primary molar makes complete debridement impossible
• Ribbon shape of root canals with narrow mesiodistal width compared to their buccolingual
dimension,discourages gross enlargement of the canals
• In primary tooth the attempt to prepare a circular apical one third mechanically may result in lateral
perforation of canal because of its hour glass shape

INSTRUMENTS:POINTS TO BE NOTED
• Because of the bizzare anatomy of root canals the use of barbed broaches as in conventional
endodontics may be unsuccessful
• H files nos 15 or 20 are strongly recommended since they remove hard tissue only on withdrawl,which
prevents pushing through the materials
• Maximum enlargement upto 30 k size file is recommended
• Each canal shoud be enlarged upto 3 to 4 size larger

SINGLE VISIT PULPECTOMY
GOULD 1970

INDICATIONS
• Large carious exposure with frank involvement of radicular pulp but without
any periapical changes.
• Teeth with inflammation extending beyond the coronal pulp.
• Teeth with hemorrhage from amputated root stumps that is dark red, slowly
oozing and uncontrollable.
17
CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4TH EDITION

PROCEDURE
La and rubber dam
isolation
Diagnostic file
radiograph is not
needed to assess
root length:kennedy
Accessible radicular
pulp to be removed
After filing canals
should be irrigated
many times(atleast
10 flushings are
recommended)
with saline or
chloramine
followed by drying
with paper points
A small pleget of
cotton wool moist
with formocresol
placed in pulp
chamber for 3 min
Canals are filled
with a slurry
,medium cream
consistency of pure
zinc oxide paste

MULTI VISIT (GOULD SHORT TERM :1972 &
STARKEY:LONG TERM 1973)
• Indications(Paterson and Curzon 1992)
non vital
abscess
chronic sinus
teeth with necrotic pulp and periapical involvement
Fundamentals of pediatric dentistry. Richard J mathewson, Robert E primosch.3rd edition. Quintessence
publishing co.

POINTS TO NOTED
If the tooth is mobile ,if swelling
or a fistula is present or if pus is
present in canals then only light
instrumentation of canals is
recommended at first visit
drainage of pus
After 48-72 hours further
instrumentation of canals
(Paterson and Curzon 1992)
Rubber dam can be omitted in
cases of swelling and cellulitis
Between appointments
antibacterial drug in the pulp
chamber is sealed
A smooth broach should be
used to perforate the apices if
possible and the tooth to be left
open for longer than 24 hours.
then formocresol soaked cotton
pellet to be placed
Appointments should be 7-10
days apart

ANESTHESIA , ISOLATION AND ACCESS OPENING
• administering anesthesia and placing
the rubber dam
• A #4 round bur -- gain access to the pulp
chamber and remove the dentin ledges
hindering direct line access to the canal
orifices
• A double-ended endodontic explorer is
used to identify each of the canals.
• Before instrumentation-- the pulp
chamber should be copiously irrigated
with sodium hypochlorite.
22
Elsevier.Mosby

PRECAUTION
 The thickness of enamel and dentin coronal
to the pulp chamber is thinner in a primary
tooth.
 The distance from the occlusal surface to the
floor of the pulp chamber is much shorter
than in the permanent tooth.
Perforation through the floor into the
furcation area
23
Albert C. Goerig, Joe H. Camp. Root canal treatment in primary- teeth: a review. PEDIATRIC
DENISTRY: Volume 5, 1982

WORKING LENGTH
• A trial length is obtained by measuring the tooth on the preoperative radiograph and
subtracting 1-2 mm
• small diameter file -- another exposure taken from which the working length is
determined
• The working length should be 1-2 mm short of the radiographic apex ideally.
• further shorten the working length by an additional 1-2 mm(in case of resorption)
24

CLEANING AND SHAPING THE CANALS
• To aid in access to the canals, Hedstrom files may be used to flair the canal
orifices
• quickly open the canal orifice and eliminate pulp tissue
• Instrumentation with Hedstrom files is always directed toward the areas of
the greatest bulk and away from the furcation area
• enlarged several sizes beyond the size of the first file that fits snugly into the
canal to a minimum final size of 30-35
25
Albert C. Goerig, Joe H. Camp. Root canal treatment in primary- teeth: a review. PEDIATRIC
DENISTRY: Volume 5, 1982

PARTIAL PULPECTOMY
• INDICATIONS:
• A PARTIAL PULPECTOMY MAY BE PERFORMED ON PRIMARY TEETH WHEN CORONAL ULP TISSUE AND
THE TISSUE ENTERING THE PULP CANALS ARE VITAL BUT SHOW CLINICAL EVIDENCE OF HYPEREMIA
• THE TOOTH MAY OR MAY NOT HAVE A HISTORY OF PAINFUL PULPITIS BUT THE CONTENTS OF ROOT
CANALS SHOULD BE NO RADIOGRAPHIC EVIDENCE OF THICKENED PDL OR A RADICULAR DISEASE
J DEAN,D AVERY,R MC DONALDS,DENTISTRY FOR CHILD AND
ADOLESCENT,10 TH ED

PROCEDURE
REMOVAL OF CORONAL
PULP
PULP FILAMENTS FROM
ROOT CANALS ARE
REMOVED WITH A FINE
BARBED
BROACH,CONSIDERABLE
HAEMORRHAGE WILL
OCCUR
A H FILE WILL BE HELPFUL
IN THE REMOVAL OF
REMNANTS OF THE PULP
TISSUE
A SYRINGE :3%H202
FOLLOWED BY SODIUM
HYPOCHLORITE,CANALS
TO BE DRIED WITH PAPER
POINTS
MIXTURE OF
UNREINFORCED
ZINCOXIDE
EUGENOLPASTE :PAPER
POINTS
SMALL KERR FILES MAY BE
USED TO FILE THE PASTE
INTO THE WALLS,
ROOT CANAL PLUGGERS
MAY BE USED TO
CONDENSE THE FILLING
MATERIALS INTO THE
CANALS
ADOLESCENT,10 TH ED

COMPLETE PULPECTOMY:STARKEY
RUBBER DAM AND LA
A PELLET MOISTENED WITH
CAMPHORATED MONO
CHLOROPHENOL OR 1:5
CONCENTRATION OF BUCKLEY
‘S FORMOCRESOL ,WITH EXCESS
MOISTURE BLOTTED SHOULD
BE PLACED IN THE PULP
CHAMBER
SECOND APPOINTMENT:IF TOOTH
IS ASYMPTOMATIC:PARTIAL
PULPECTOMY+APEX OF EACH
ROOT SHOULD BE PENETRATED
SLIGHTLY WITH SMALLEST
DIAMETER
A TREATMENT PELLET
SHOULD AGAIN BE PLACED
IN PULP CHAMBER AND
THE SEAL COMPLETED
WITH ZINC OXIDE EUGENOL
IF ASYMPTOMATIC THEN
OBTURATE
ADOLESCENT,10 TH ED

IRRIGATION
1. Sodium hypochloride
2. Hydrogen peroxide
3. Sterile saline
4. Chlorhexidiene
29

SODIUM HYPOCHLORIDE
• Effective hemostatic agent
• Helps to dissolve organic material
• Not toxic to pulpal tissues and does not interfere with pulpal healing (Fuks 2000,
Nakornchai et al. 2005)
• 5.25%
• Ability to oxidize, hydrolyze and to some extent, osmotically draw fluids out of
tissues (Pashley et al. 1985).
• A 5 % solution of sodium hypochlorite has excellent solvent action and is dilute
enough to cause mild irritation when contacting periapical tissue(Schilder and
Amsterdam ,1959)
• It can be used in a small (15 ml) syringe fitted with a 25 gauge 1 ¼ in(32
mm)provided the needle fits loosely in the canal
30

• Must be used Judiciously and with great caution to prevent it from reaching the periapex where it can
elicit a severe inflammatory reactions
• (Pashley et al. 1985, Fuks 2000, Mehdipour et al. 2007, AAPD guidelines)
31
Ramachandra JA, Nihal NK, Nagarathna C, Vora MS.
Root Canal Irrigants in Primary Teeth. World J
Dent 2015;6(3):229-234

HYDROGEN PEROXIDE ((GARCIA--‐GODOY 1987,HOLAN & FUKS 1993))
• effervescence, which occurs when it comes into contact with catalase, an enzyme present in cellular
and blood products
• Nascent oxygen– destroying some strict anaerobes
• Main disadvantage– not possess the capacity to dissolve organic tissue (Harrison 1984, Zehnder 2007).
32
Dent 2015;6(3):229-234

STERILE SALINE
• Used as an alternative solution
• Lacking in antimicrobial properties (O’Riordan & Coll 1979, Zehnder 2007).
33
Dent 2015;6(3):229-234

CHLORHEXIDIENE
2% SOLUTION
REACTS WITH NEGATIVELY CHARGES CELL SURFACE AND REDUCTION IN INTRACANAL BACTERIA
MORE EFFICACY TOWARDS GRAM POSTIVE THAN GRAM NEGATIVE
Dent 2015;6(3):229-234

NICKEL-TITANIUM ROTARY FILES FOR ROOT
CANAL PREPARATION IN PRIMARY TEETH
• Recently, nickel-titanium rotary files have been developed for
use in endodontics.
• The flexibility and the instrument design allows the files to
closely follow the original root canal path.
• An Ni-Ti is chosen that approximates the canal size.
• It is inserted into the canal while rotating and is taken to
working length as determined on the pretreatment radiograph
Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary Teeth.Endodontic
Topics 2012, 23, 50–72
35

• The canal is cleansed and shaped with sequentially larger files
until the last file binds.
• It is not necessary to use a “crown down” instrumentation in
primary teeth since the dentin cuts more easily than in
permanent teeth.
• Care to be taken
 Not to overinstrument as perforations can readily occur in the
thin dentinal walls.
 Apical overextension of the NiTi can result in an enlarged
apical foramen and cause an overfill of pulpectomy paste.
Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary Teeth.Endodontic
Topics 2012, 23, 50–72
36

Advantages:
1. Tissue and debris are more
easily and quickly removed
2. The nickel-titanium files are
flexible, allowing easy access to
all canals
3. Prepared canals are funnel
shaped, resulting in a more
predictable uniform paste fill
4.NTs are available in a 21 mm
length.
5.Faster than hand files 37
Disadvantages:
1. Cost of the low-speed,
constant-torque
handpiece
2. Increased cost of Ni-Ti;
3. Learning the technique

Mohammad Reza
Azar, Laya Safi, Afshin
Nikaein. Dental
Research Journal.
Mar 2012: Vol 9 ;
Issue 2
There were no significant differences in cleaning efficiency between manual and
rotary instruments. Only ProTaper files performed significantly better in the
coronal and middle thirds than in the apical third of the root canal
P Subramaniam, TA Tabrez,
and KL Girish Babu (2013)
Microbiological Assessment of
Root Canals Following Use of
Rotary and Manual Instruments
in Primary Molars. Journal of
Clinical Pediatric Dentistry:
December 2013, Vol. 38, No. 2,
pp. 123-127.
Rotary NiTi files were as efficient as conventional hand instruments in significantly
reducing the root canal microflora.

ROTARY ENDODONTICS
• Conventional systems: Racer
Giromatic
Endo – Gripper
Endolift
• Flexible systems: Excaliber
Endoplanar
Canal – Finder – System
• Sonic systems: Sonic Air 3000
Endostar 5
• Ultrasonic systems: Cavi – Endo
• Ni-Ti systems: Lightspeed
ProTaper
K3
Profile 0.04 and 0.06
HERO 642

• Precautions
dry canals – broken file tips
discard files
straight line access
no pressure
no skipping
while rotating, insert and remove files

• Recent modification
Wave – one
Reciproc
Protaper F2 file

OBTURATIONG MATERIALS
1. Zinc oxide eugenol
2. Iodoform based paste
1. KRI
2. Maisto
3. Calcium hydroxide
4. Mixture of calcium hydroxide with iodoform
5. Endoflas
6. Others :ZOE+Aloevera
42

IDEAL REQUIREMENTS OF OBTURATION MATERIAL
• Resorption rate
• Disinfectant
• Beyond apex resorption
• Easy insertion and removal
• Non soluble
• No discolouration
• Radio opaque
• Harmless to tooth germ
Jung-wei Chen & Monserrat Jorden . Materials for primary
tooth pulp treatment: the present and the future. Endodontic
Topics 2012, 23, 41–49

OBTURATING MATERIALS
Zinc oxide eugenol
Composition
• Zinc oxide powder + eugenol oil
• Introduced by Bonastre (1837) and first used by Chrisholm 1876.
• Sweet (1930) first described the used of ZnOE as root canal filling
material.
• Rabinowitz (1953) reported only 7 failure out of 1363 treated
teeth.
• It has anti inflammatory and analgesic property
44
Pediatric dentistry- Infanct through
adoloscence.Casamassimo,Fields,Mctigue,Nowak.5th edition.
Elsevier.Mosby

• Yacobi and Kenny (1991):state that overfilling is not preferable to underfilling although experience
shows that if small quantities of paste are extruded through the apex than the resorb. For this reason
and that of subsequent exfoliation of primary tooth pure zinc oxide eugenol must be used and not any
proprietary brand that may have any filler particles present
Notable disadvantages –
 Irritation and cytotoxic effect on periapical tissues
 Reduced rate of resorption
 Enamel defects in the succedaneous teeth.
 When extruded beyond the apices, sets into a hard cement that resists resorption.

• Success rate with material varies between 65% to 100%:Ozalp N et al 2005
• Average success rate of 83%:trairatvorakul C et al:2008
Elsevier.Mosby

EXTRUDED ZINC OXIDE EUGENOL CEMENT
• Erasquin et al. 1967-- reported that canals overfilled with ZOE
are not recommended because it irritates the periapical
tissues and causes necrosis of bone and cementum
• when ZOE extrudes, it develops a fibrous capsule that
prevents resorption of the material (coll et al 1985)
• a slow rate of resorption and has a tendency to be retained
even after tooth exfoliation,
• unresorbed material has been found to cause deflection of
the succedaneous teeth
47

Coll and Sadrian(1996)
• reported anterior cross-bite,
• palatal eruption, and
• ectopic eruption of the succedaneous tooth following ZOE pulpectomy.
48
Sunitha B, K Pratej Kiran, Ravindar Puppala, Balaji Kethineni, Ravigna. Resorption of Extruded
Obturating Material in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2,
No. 1, February 2014, pp- 64-67

IODOFORM BASED PASTES
Kri paste
• Iodoform –80%
• Camphor – 4.8%
• Parachlorophenol – 2%
• Menthol – 1.2%
Maisto paste
• Zinc oxide –14gms
• Iodo form –42gms
• Thymol –2gm
• Chlorophenol Camphor 3cc
• Lanolin –0.5gms
Elsevier.Mosby

IODOFORM BASED PASTES
KRI, MAISTO
• First tried by Castagnola and Drely in 1952 in permanent teeth.
• Tagger and Sarnat – used the mixture of ZnOE & iodoform paste as the root
canal filling material in 1984, but introduced by Maisto in 1967.
• Rifkin - KRI as a final filling material and as a medicament between visits in 1980.
• Garcia – Godoy (1987) – found no failure with KRI
50
Elsevier.Mosby

• Maisto's paste was thus seen to be superior to zinc oxide-eugenol in resorption of excess material.
(Reddy VV, 1996)

KRI PASTE
• Resorbs rapidly
• Has no undesirable effect on succadenous tooth when used as a pulp canal medicament in abscessed
primary teeth
• Extruded into periapical tissue is rapidly replaced with normal tissue
• Sometimes material is also resorbed inside the root canal
• KRI paste in synchrony with primary roots and is less irritating to surrounding tissues if a root is
inadvertently overfilled

CALCIUM HYDROXIDE
• Introduced in 1930, used in primary teeth for pulpotomy in
1950-60's.
• Keilbassa and Rosendhal 1995 ,H.S Chawla 1998 found it to
show complete healing of periradicular radiolucency.
• Pabla et al 1997 - Vitapex resorbed extra and intra radicularly
without ill effects.
53
Elsevier.Mosby

• Needly MP 2002 - presented a case report of two infected teeth
filled with vitapex and found it to be an excellent filling material.
• A faster resorption of overfilled material was observed with
calcium hydroxide when compared to ZOE (Nadkarni U, 2000)
• Average success rate of 88%
54
Elsevier.Mosby

MIXTURE OF CALCIUM HYDROXIDE WITH IODOFORM
• Dominguez et al 1989 – reported that when combining pure
iodoform with Ca(OH)2 excellent clinical radiographic and
histological results were obtained.
• Kuboto et al 1992 – there was no ideal root canal filling
material for primary teeth. The closet to ideal was Ca(OH)2 +
iodoform
5/30/2021 55
Elsevier.Mosby

METAPEX
• a silicone oil-based calcium hydroxide paste containing 38% iodoform is very popular
•Easy cleaning and removal.
•Excellent antibacterial effect and radiopacity.
•Premixed paste in a convenient syringe.
•Excellent accessibility to the root canal and prevention of cross－contamination.
•CONTENT:
2.2g paste in a syringe
Disposable tips
One ring rotator for the direction control of the tip
2 years from the manufacturing date

VITAPEX
• Vitapex contains
 iodoform 40.4%,
 calcium hydroxide 30.3%,
 silicon 22.4%.
57
Elsevier.Mosby

• When extruded into furcal or apical areas, can either diffuse away or be resorbed in
part by macrophages in one or two weeks.
• Bone regeneration has been documented after using Vitapex.
• Easy delivery system
• Resorbs at a slightly faster rate than that of the roots.
Jung-wei Chen & Monserrat Jorden . Materials for primary tooth pulp treatment: the present and the future. Endodontic Topics 2012, 23, 41–49
58

• Vitapex has a greater ability in inducing bone regeneration than ZOE by the expression of BMP-2
induction. (Xianyin Xia 2013)
• Complete resorption of excess paste occurs within 2 to 8 weeks
• Machida:calcium hydroxide iodoform mixture to be na nearly ideal primary tooth filling material
• Chung-wen Chen (2005) evaluated the cellular changes of a ZOE with formocresol (FC) and
Vitapex-treated human osteoclastic cell line.
• Concluded that ZOE with FC is not biocompatible and cell death occurred by apoptosis.
• Vitapex is a good choice as a primary tooth root canal filling material.
59
Xia X, Man Z, Jin H, Du R, Sun W, Wang X. Vitapex can promote the expression of BMP-2 during
the bone regeneration of periapical lesions in rats. J Indian Soc Pedod Prev Dent 2013;31:249-
53.

RESORPTION
• has a tendency to get depleted from the canals earlier than the physiologic resorption of the roots
• iodoform-based -- resorbs if pushed beyond the apex however the rate of resorption is faster than the
root.
• Erasquin et al. 1967, -- iodoform is irritating to the periapical tissues and can cause cemental necrosis
60
No. 1, February 2014, pp- 64-67

• Easy resorption.
• the rapid elimination of iodoform by the organism leaves behind empty spaces inside the root canal,
which may undermine the success of the endodontic therapy
61
No. 1, February 2014, pp- 64-67

• Vitapex when extruded into furcal or apical areas, can either get diffused or resorbed by macrophages,
in as short a time as 1 or 2 weeks up to 2 to 3 months and causes no foreign body reaction,
• success rate of 96% to 100% (Nurko et al 1999)
62
No. 1, February 2014, pp- 64-67

• Machida (2004)-- Vitapex is a nearly ideal root canal filling material for primary teeth
• Unlike ZOE, vitapex can be rapidly eliminated from periapical tissues and does not set to a hard mass
and therefore, the probability of deflection in successor tooth is minimized.
• Shikha Dogra 2011– calcium hydroxide– better resorption than ZOE
63

ENDOFLAS
Composition
• Barium sulfate
• Calcium hydroxide
• Iodoform
• ZOE
Elsevier.Mosby

• Resorbable paste produced by south america
• Obtained by mixing powder containing tri iodomethane and iodine dibutile ortho cresol(40.6%) , zinc
oxide(56.5%), calcium hydroxide(1.07%), barium sulfate(1.63%)
• Liquid containing eugenol and parachlorophenol
Elsevier.Mosby

• Hydrophilic– humid canals
• Provides goodseal
• Broad spectrum antibacterial activity
• Ramar K et al(2010)– 100% success
• Fuks 2002:success rate equal to KRI paste

RESORPTION OF ENDOFLAS
• Fuks et al. 2002, Endoflas resorbed when over-extended periapically
• not resorb intraradicularly in their study
• bone regeneration
• resorption of excess Endoflas without washing within the roots
67

ANTIBACTERIAL PROPERTY
• Cox et al (1978) found that ZnO alone could not inhibit E.Coli,
S.Aureus, S.Viridans, but ZOE inhibited S.Aureus and S.viridans.
• The inclusion of zinc acetate as a setting accelerator, however,
allowed ZOE to inhibit all three. The inhibitory effect was
further enhanced by adding formocresol.
68
Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary
Teeth.Endodontic Topics 2012, 23, 50–72

• Wright et al (1994) reported KRI paste to be superior to ZOE in inhibiting
S.Faecalis in vitro.
• Calcium hydroxide was shown by Difiore et al (1983) to be non-inhibitory
against S.Sanguis when mixed with water, but inhibitory when mixed with
camphorated chlorophenol.
69

TURMERIC+ENDOFLAS
• primary molars indicated for pulpectomy in 4 children (4-9 year-old) were selected.After biomechanical
preparation,the four primary molars were obturated with Endoflas powder mixed with Curcumin gel
and its efficacy was evaluated both clinically and radiographically at 1 month and 3-month intervals.
• Conclusion: The Endoflas powder mixed with Curcumin gel showed faster resorption of the over
pushed material within 1week, also showed a decrease in inter-radicular radiolucency after 1month and
maintained until 3month follow-up.
RADHAKRISHNA, A., MENNI, A., PRASAD, M., CHANDRASEKHAR, S.. THE SUCCESS RATE
OF ENDOFLAS POWDER MIXED WITH CURCUMIN GEL AS OBTURATING MATERIAL IN
PRIMARY MOLARS: CASE- SERIES.. Journal of Biomedical and Pharmaceutical Research,
North America, 6, apr. 2017

Author Root canal filling material
(comparing material)
Success rate of
comparison group
Success rate of ZOE
Reddy and Fernandez
1996
Maisto paste 100 80
Nadkarni and Damle 2000 Calcium hydroxide paste 94.3 88.6
Mortazavi and mesbahi
2004
Vitapex 100 78.5
Ozalp 2005 Calcicur
Sealpex
Vitapex
80
90
100
100
Trairatvorakul and
Chunlasikaiwan 2008
Vitapex 89 85

Author Comparing material Success rate ZOE SUCCESS RATE
(COMPARING MATERIAL)
Anna fucks 2003 Endoflas - 70%
M. MORTAZAVI
2004
Vitapex 78·5% 100%
Trairatvorakul 2008 Vitapex 85% 89%
Saziye Sarı 2008 Sealpex - 92.3%
S Gupta 2011 Metapex 85.71% 90.48%
Achiraya Duanduan 2013 Vitapex- LSTR 84.6 % LSTR 89%
Ramer K 2013 Metapex, endoflas ZOE+ iodoform
84.7%
Metapex
90.5
Endoflas
95.1%
Nivedita Rewal 2014 Endoflas 83% 100%

Navit S et AL 2016 Endoflas > ZOE >Calcium hydroxide + Chlorhexidine
> Calcium hydroxide + Iodoform +Distilled water
~ Metapex > Saline.:ANTIMICROBIAL EFFICACY

Endodontic pressure syringe
• Developed by Greenberg
• Described by Spedding and Krakow in 1965.
• Consists of syringe barrel,threaded plunger,wrench and
threaded needle.
• Needle is placed 1 mm barrel short of apex and with a slow
withdrawing type of motion, it is withdrawn 3 mm with each
quarter turn of screw until canal is visibly filled at orifice.
75

Mechanical syringe:
• Proposed by Greenberg in 1971.
• Syringe with 30 gauge needle.
• Cement pressed using continous
pressure while withdrawing the needle.
76
Endodontics .John I de Ingle, Leif K. Bakland. 5th edition. B.C. Decker
publishers

TUBERCULIN SYRINGE
• Arnold and Johnsonin 1987
• Standard 26 gauge, 3/8th inch needle.
77

INCREMENTAL FILLING TECHNIQUE:
Gould in 1972.
• Creamy mix of ZOE carried into canals
• Deposited with endodontic plugger in small increaments.
78

LENTULOSPIRAL TECHNIQUE:
• Kopel in 1970.
• The creamy mix of filling paste can be coated around the walls of the canals with lentulospiral or the
last used file(Duggal and Curzon 1994)
• The spiral root filler should be one size smaller than the last used file and cut half its length with
scissors
• Dipped into mixture and then introduced into the canal to its predetermined length and rotated in the
canal.
79

Other techniques:
• Amalgam plugger- Nosonwitz 1960 & King 1984
• Paper points – Spedding 1973
• Plugging action with wet cotton pellet (ZOE of tooth paste
consistency) – Donnenberg 1974.
80

Sigurdsson et al. 1992 The lentulo spiral—most effective
instrument and produce highest quality
obturation
(Aylard and Johnson 1987 Endodontic pressure syringe and the lentulo
spiral were superior for filling straight canals
while the lentulo spiral was superior for the
obturation of curved canals
Aylard and Johnson 1987 Lentulo spiral-- best overall ZOE filling tool
Singh R, Chaudhary S 2015 Motor driven lentulo spiral technique
demonstrate more number of optimal fills
with fewer voids when compared to hand
held lentulo spiral technique and reamer
A Singh et al 2017 Endodontic pressure syringe system is the
best method
Khubchandani 2017 Lentulospiral produced the best results in
terms of length of obturation :M

PULPECTOMY SUCCESS
Clinical criteria
1. No gingival swelling or sinus tract 6 months or more
postoperatively.
2. No purulent exudate expressed from the gingival margin
3. No abnormal mobility other than mobility from normal
exfoliation
4. No pain on postoperative checkup.
82
Pediatric dentistry- Infanct through adoloscence.
Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

Radiographic criteria
1. No pathologic signs of external root resorption or continued resorption
if any was present preoperatively
2. A bifurcation radiolucency resolved 6-12 months postoperatively
3. No periapical radiolucency formation postoperatively
83
Pediatric dentistry- Infanct through adoloscence.
Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

84
CONCLUSION
• The rationale for pediatric pulp therapy has developed out of
extensive clinical studies and improved histologic techniques.
• A successful pediatric endodontic outcome should be based on
 re-establishment of healthy periodontal tissues
 freedom from pathologic root resorption
 maintenance of the primary tooth in an infection-free state to
hold space for the eruption of its permanent successor in the
case of young permanent teeth
 maintenance of the maximum amount of non-inflamed
portions of pulp tissue

REFERENCES
• Endodontics .John I de Ingle, Leif K. Bakland. 5th edition. B.C. Decker publishers
• Pediatric dentistry- Infanct through adoloscence. Casamassimo,Fields,Mctigue,Nowak.5th
edition. Elsevier.Mosby
• Fundamentals of pediatric dentistry. Richard J mathewson, Robert E primosch.3rd edition.
Quintessence publishing co.
• Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp
Therapy for Primary Teeth.Endodontic Topics 2012, 23, 50–72
• Jung-wei Chen & Monserrat Jorden . Materials for primary tooth pulp treatment: the present
and the future. Endodontic Topics 2012, 23, 41–49
85

• Albert C. Goerig, Joe H. Camp. Root canal treatment in primary- teeth: a review. PEDIATRIC DENISTRY:
Volume 5, 1982
• Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for
Primary Teeth.Endodontic Topics 2012, 23, 50–72
• P Subramaniam, TA Tabrez, and KL Girish Babu (2013) Microbiological Assessment of Root Canals
Following Use of Rotary and Manual Instruments in Primary Molars. Journal of Clinical Pediatric
Dentistry: December 2013, Vol. 38, No. 2, pp. 123-127.
• Jung-wei Chen & Monserrat Jorden . Materials for primary tooth pulp treatment: the present and the
future. Endodontic Topics 2012, 23, 41–49
86

• Manisha Agarwal, Usha Mohan Das, Deepak Vishwanath. A Comparative Evaluation of
Noninstrumentation Endodontic Techniques with Conventional ZOE Pulpectomy in Deciduous
Molars: An in vivo Study.World Journal of Dentistry, July-September 2011;2(3):187-192
• Mohammad Reza Azar, Laya Safi, Afshin Nikaein. Comparison of the cleaning capacity of
Mtwo and ProTaper rotary systems and manual instruments in primary teeth. Dental
Research Journal. Mar 2012: Vol 9 ; Issue 2
• Xia X, Man Z, Jin H, Du R, Sun W, Wang X. Vitapex can promote the expression of BMP-2
during the bone regeneration of periapical lesions in rats. J Indian Soc Pedod Prev Dent
2013;31:249-53.
87

• Zahra Bahrololoomi, Shiva Zamaninejad . Success Rate of Zinc Oxide Eugenol in Pulpectomy of Necrotic
Primary Molars: A Retrospective Study. JDMT, Volume 4, Number 2, June 2015
• Anna Fuks, Eliezer Eidelman, Nitay Pauker. Root fillings with Endoflas in primary teeth: a retrospective study.
Journal of Clinical Pediatric Dentistry: September 2003, Vol. 27, No. 1, pp. 41-45.
• Rewal N, Thakur AS, Sachdev V, Mahajan N. Comparison of Endoflas and Zinc oxide Eugenol as root canal
filling materials in primary dentition. J Indian Soc Pedod Prev Dent 2014;32:317-21.
• Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous
dentition. Pediatr Dent. (1996). 18: 57–63.
• Sunitha B, K Pratej Kiran, Ravindar Puppala, Balaji Kethineni, Ravigna. Resorption of Extruded Obturating
Material in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp-
64-67
88

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