Pulpectomy in Pediatric Dentistry

PULPECTOMY
Dr. Balraj Shukla
College of Dental Sciences & Research Centre, Ahmedabad

CONTENT
S
• Overview of Pupal Treatment modalities
• Definition
• A Brief History
• Pulpectomy – Case Selection
• Indications
• Contraindications
• Access Cavity Preparation – Laws & Morphology
• Working Length Determination
• Cleaning and Shaping of Root Canals
• Irrigants
• Intracanal medicaments
• Obturating Materials & Techniques
• Conclusion
• References
Dr. Balraj Shukla

OVERVIEW OF PULPAL TREATMENT
MODALITIES
According to Pinkham:
Conservative Treatment – aimed at maintaining the pulp
vitality
- Protective Base application
- Indirect Pulp Capping
- Direct Pulp Capping
- Pulpotomy
Radical Treatment - aimed at complete removal of pulpal
tissue
- Pulpectomy and Root Filling Dr. Balraj Shukla

DEFINITION
S
Pulpectomy is defined as removal of all pulpal tissue from the
coronal and radicular portions of the tooth (Sidney Finn,
1973).
Pulpectomy is defined as 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 (Richard Mathewson, 1995).
Pulpectomy is a root canal procedure for pulp tissue that is
irreversibly inflamed or necrotic due to caries or trauma.
(AAPD, 2020)
Dr. Balraj Shukla

1872 First mention of pulpal treatment, specific for primary teeth was mentioned in Dental Cosmos.
1969 Law & Lewis suggest the retention of a pulpally involved tooth for better transition of dentition.
1979 O’Riordan & Coll state that pulpectomy can be carried out in necrotic & chronically inflamed primary pulps.
1993 Holan and Fuks state that pulpectomies do not induce hypoplasia in succedaneous teeth.
1967 Marsh and Largent explain that primary goal of pulpectomy should be to reduce bacterial load.
1965 Moss et al demonstrate how accessory canals are responsible for spread of infection intra-radicular areas.
1957 According to Hibbard and Ireland, tortuous canals reduce the chances of success of pulpectomy in primary
B
R
I
E
F
H
I
S
T
O
R
Y
1980 Rifkin uses iodoform-based paste for the first time in primary teeth and reported only 3 failures of 45 teeth.
1984 Tagger and Sarnat describe a two-step pulpectomy procedure, without any instrumentation.
1985 Coll et al report a single-sitting formocresol pulpectomy procedure with 80.5% success rate.
Dr. Balraj Shukla

CASE
SELECTION CLINICAL DIAGNOSIS
Soft tissue
Tooth
Tooth involved
Mobility
Percussion
RADIOGRAPHIC DIAGNOSIS
Root Resorption
Bifurcation or Periapical radiolucency?
Calcified canals?
P
U
L
P
E
C
T
O
M
Y
More than two-
thirds
Hypertrophied
pulp (?)
Necrotic pulp
Pulp Therapy
Success (?)
Degenerated
Pulp
Fistula or sinus tract?
Discoloration or
Destruction?
Primary incisors – less
than 5 years of age
Primary second molars
before eruption of
permanent molars
Present
Periapical
Involvement
Pulp Therapy
Success (?)
Dr. Balraj Shukla

• Successful filling without gross overextension or underfilling
• No adverse post-treatment signs or symptoms such as prolonged sensitivity, pain, or
swelling
• There should be evidence of resolution of pre-treatment pathology
• No further breakdown of peri-radicular supporting tissues clinically or radiographically.
OBJECTIVE
S
Dr. Balraj Shukla

INDICATION
S
• Co-operative patient
• Patients in good health
• Uncontrolled pulpal haemorrhage
• Chronically inflamed pulp
• Presence of abscess or fistula
• Presence of pus in the pulp chamber
• Pulpal necrosis without radiographic contraindication
• Adequate periodontal and bony support
• Absence of permanent successor
• Pulpless primary molars holding orthodontic
appliance
Dr. Balraj Shukla

CONTRAINDICATION
S
• Non-restorable crowns
• Perforation to the pulpal floor
• Serious reduction in bone support and/or
extreme tooth mobility
• Extensive internal or external root resorption
• Periradicular radiolucency involving the follicle
of the permanent tooth
• Underlying dentigerous or follicular cysts
• Medically compromised children
Dr. Balraj Shukla

Pulpectomy and Haemophilia
• Choice of Antifibrinolytic agent for children is e-
aminocaproic acid.
• Initial loading dose: 100-200 mg/kg
• 5-100 mg/kg every 6 hours for up to 1 week.
• Available in both tablet and liquid form
• Pedodontist must learn about the haemostatic
condition of the patient from the patient’s
haematologist.
• Pulpotomy or Pulpectomy is preferred over
extraction
• Local infiltration must be preferred over block
anesthesia
• Nitrous oxide sedation if available must be used
to alleviate discomfort
• Intrapulpal injection can be used
• Bleeding from pulp chamber does not present a
significant problem
Pulpectomy and Sickle Cell Disease
• Pulpotomy or Pulpectomy is preferred over
extraction
• Nitrous oxide sedation, local anesthesia with
vasoconstrictions are safe.
• Need for antibiotics before dental treatment is
debatable.
• No treatment should be carried out during a
sickle cell crisis.
Pulpectomy and Leukaemia
• Pulp therapy on primary teeth is contraindicated
in any patient with a history of leukaemia
(McDonald, 2016).
• A patient who has been in complete remission for
at least 2 years and no longer requires
chemotherapy may be treated in an essentially
normal manner.
• Same day CBC preferred. Platelet count of at
least 50,000 /mm3 and absolute neutrophil count
of >1500 is needed to carry out a pulp therapy
procedure.
Dr. Balraj Shukla

Ingle’s Endodontics, 7th ed., 2019
Dr. Balraj Shukla

Current guidelines on performing pulp therapies in primary teeth during COVID-19
are based on the guidelines published by the following associations (Al-Halabi et al.,
2020; Eur Arch Ped Dent)
• American Dental Association
• CDC
• Ministry of Health and Dental Council (NZ)
• Australian Dental Association
• Scottish Dental Clinical Effectiveness Programme
• Royal College of Surgeons (England)
Dr. Balraj Shukla

TYPES OF PULPECTOMIES
Depending on amount of instrument
penetration
PARTIAL
Removal of pulp and
debris and subsequent
filling of canals short of the
apex.
COMPLETE
Removal of pulp and
debris and subsequent
filling of canal till the apex.
Dr. Balraj Shukla

Partial Pulpectomy (McDonald, 2011)
Indications
- Performed on primary teeth
when coronal pulp tissue
and tissue entering the
canals are vital but show
signs of hyperaemia.
- No signs of necrosed pulp
tissue.
- No signs of PDL thickening
or radicular pathology.
Technique
- Removal of pulp filaments from root
canals (30-50%) with fine barbed
broach and H files.
- Irrigation with 3% hydrogen
peroxide followed by sodium
hypochlorite.
- After haemorrhaging is controlled,
ZOE is used to coat the walls of the
canals, followed by complete
coronal restoration.
Apical extension of the conventional pulpotomy
Dr. Balraj Shukla

in young permanent teeth
Root canals in permanent teeth are a
permanent entity, and hence the
associated treatment is called a ROOT
CANAL treatment.
Root canals are resorbed over a period of
time in primary teeth, and hence the
essential mode of treatment is called
PULPECTOMY.
1
3
2
Source: Guide to Clinical Endodontics; 2013 (6th ed.)
Source: AAPD, 2020
RCT vs Pulpectomy
Dr. Balraj Shukla

ACCESS CAVITY
PREPARATION
Definition and Objectives
Laws of Pulp Chamber Anatomy
Armamentarium
Dr. Balraj Shukla

DEFINITION & OBECTIVES
“Endodontic coronal preparation which enables unobstructed
access to canal orifices, straight line access to apical foramen,
complete control over instrumentation and to accommodate
obturation technique.” (Ingle)
• Remove all caries
• Conserve sound tooth structure
• Unroof the pulp chamber
• Remove coronal pulp (vital or necrotic)
• Locate all root canal orifices
• Establish restorative margins
• Achieve straight line access

LAWS OF PULP CHAMBER
ANATOMY – KRASNER &
RANKOW, 2004
PRE-ACCESS ANALYSIS
LAW OF CENTRALITY
LAW OF CEJ
LAW OF CONCENTRICITY
Dr. Balraj Shukla

RANKOW, 2004
ACCESS PHASE
LAW OF COLOR CHANGE
“The clear identification of the floor-wall
junction is the single most important aspect of
the accessing phase of endodontic
treatment.”
Dr. Balraj Shukla

RANKOW, 2004
ORIFICE LOCATION
LAW OF SYMMETRY 1
LAW OF SYMMETRY 2
LAW OF ORIFICE LOCATION 1
LAW OF ORIFICE LOCATION 2
LAW OF ORIFICE LOCATION 3 *Laws of symmetry do not apply to maxillary mola
Dr. Balraj Shukla

ARMAMENTARIUM FOR
ACCESS CAVITY
PREPARATION
Endo-z, Endo-Access Muller Burs Gates-Glidden
Spoon
Excavators
Magnification & Illumination
Dr. Balraj Shukla

Selection of bur depends on
- Interface to cut (carious tooth,
previous restoration, type of crown,
etc)
- Operator’s clinical expertise
- Tactile sensation
DG-16
JW-17
Dr. Balraj Shukla

ROOT CANAL
ANATOMY OF
DECIDUOUS TEETH
First studied by Hess and Zircher in 1925
Further modified by Barker et al in 1975
Dr. Balraj Shukla

MAXILLAR
Y
PRIMARY
INCISORS
• S-shaped configuration of canals when viewed proximally.
• Cervical half bends lingually, Apical half bends labially.
• Larger canals relative to external tooth dimensions compared to
permanent teeth.
• According to Jorgenson, a study of 7611 deciduous teeth revealed
the presence of labial root grooving in 36.5% of maxillary incisors.
However, according to Barker, the labial grooving is slowly
becoming primitive.
• Centrals: Fan-shaped pulp chamber
• Laterals: Better demarcation between pulp chamber and pulp
canal.
• Single canal (triangular or conical)
Dr. Balraj Shukla

MANDIBULA
R
PRIMARY
INCISORS
• Differentiated from maxillary incisors by absence of the S-bend
• A labial bend can be seen apically
• Canal division is very rare
• Mesiodistally flattened pulp chamber
• Clear demarcation between pulp chamber and pulp canal in
central incisor, that is not seen in lateral incisor (Finn).
• Single conical canal.
Dr. Balraj Shukla

MAXILLARY
PRIMARY
CANINE
• Apical half to one third bends labially up to 10 degrees
• Longitudinal groove might be present labially that divides the canal
into two parts near the apex ( <2%)
• Three projections at the incisal aspect of pulp chamber
• Single triangular shaped canal
Dr. Balraj Shukla

MANDIBULA
R
PRIMARY
CANINE
• Root canal is of simple form with no demarcation between pulp
chamber and canal.
• Single conical canal that tapers lingually.
Dr. Balraj Shukla

MAXILLARY
PRIMARY
FIRST
MOLAR
• 3 roots: MB, DB & Palatal
• 3 or 4 canals: MB, ML, DB, Palatal
• MB has the highest pulp horn and is present most often as a single
broad canal.
• Palatal is the longest and curved.
• DB is shortest and smallest in diameter.
• DB and Palatal are fused in 75% of the cases.
• Apical bending of canals is rare.
Dr. Balraj Shukla

MAXILLARY
PRIMARY
SECOND
MOLAR
• 4 pulp horns (rarely 5): MB, ML, DB, DL
• Distobuccal and palatal canals can be fused in 58% of the cases.
• Palatal canal is longest and stoutest. It travels lingually and distally
if not connected with the DB canal.
• Buccally, “claw-shaped” arrangement of canals can be
appreciated.
• MB canal rarely exhibit two canals. The MB2 canal is often palatal
and often mesial in a line drawn between the MB1 and the palatal
canal.
Dr. Balraj Shukla

MANDIBULAR
PRIMARY
FIRST MOLAR
• 4 pulp horns: MB, DB, ML, DL
• 3 pulp canals system: 2 mesial and 1 distal (80%)
• 4 pulp canals system: 2 mesial and 2 distal (20%)
• This tooth has highest variations in number and shape of canal
systems.
Dr. Balraj Shukla

MANDIBULAR
PRIMARY
SECOND
MOLAR
• 5 pulp horns: MB, ML, DB, DL, D
• 3 or 4 pulp canal system
• Canals are wider buccolingually and narrower mesiodistally
Dr. Balraj Shukla

WORKING LENGTH
DETERMINATION
Definition and Objectives
Techniques
Dr. Balraj Shukla

DEFINITION & OBECTIVES
“Distance from a coronal reference point to a point at which canal
preparation and obturation should terminate.”
(Glossary of Endodontics Terms)
• Determination of placement of instruments in the canals
• Limits the depth of canal filling
• Affects the degree of pain & discomfort that the patient might have

Working Width
Initial & Post-Instrumentation horizontal dimensions of RC system at
working length & various levels.
Minimum WW: Initial apical file that binds at working level
Maximum WW: Final apical file (master) that corresponds to working
width
Morning Glory Appearance
Distance between apical constriction and root apex.
Dr. Balraj Shukla

Apical Delta
Observed in high frequency by Seltzer in 1966.
Y-shaped branching of root canal or apex that is difficult to instrument and obturate.
Can result in inflamed pulpal tissue in this region after endodontic treatment.
Continuous deposition of dentin or cementum over a period of time narrows these
canals.
Apical Constriction
4 types given by Dummer et al in 1984. Dr. Balraj Shukla

An ideal access determines the path from the
canal orifice tothe mid-root. This is known as
straight line access.
Theendodontic glide path is defined as a
smooth, patent passage from the coronal orifice
of the canal to the radiographic terminus or
electronically determined portal of exit. (J. West,
2006)
Dr.BalrajShukla

3D imaging
Apical Foramen
Division or union?
Anatomic change
Communication
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
RADIOGRAPHIC TECHNIQUE
BEST’S METHOD (1960)
BREGMAN’S METHOD
BRAMANTE’S METHOD (1974)
A
B
C
Real length of tooth = Real length
of instrument x Apparent length of
tooth/ Apparent length of instrument
Real length of tooth = Real length
of probe x Apparent length of tooth/
Apparent length of probe
15 mm
10 mm
Acrylic
resin
stop
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
KUTTLER’S METHOD (1955)
RADIOGRAPHIC GRID (1963)
GROSSMAN’S METHOD (1970)
Instrument should terminate at
apical constriction.
Patient younger than 35 years:
reduce 0.5 if file reaches apical
foramen
Patient elder than 35 years: reduce
0.67 if file reaches apical foramen
Given by Everett and
Fixott
Grid boxes are 1 mm
apart
Actual Length of Tooth = Actual length of instrument x
Apparent length of tooth on radiograph / Apparent
length of instrument on radiograph
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
WEINE’S MODIFICATION (1996)
ENDOMETRIC PROBE
EUCLIDEAN ENDOMETRY (1985)
A: No resorption
B: Periapical bone resorption
C: Root apex resorption
Smallest file to be used: #25
2 radiographs taken at different
angulations are fitted in a device
called “updegraves xcp”
The difference in the angulations
gives us the tooth length.
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
INGLE’S METHOD
Measure length of
tooth on pre-op
radiograph
1mm subtracted for
minor constriction &
radiographic
distortion.
Transfer reading on
the instrument &
adjust the rubber stop
accordingly
Transfer instrument in
the canal & measure
the difference
between end of
instrument & root
Add this reading to
original measured
length of instrument
Subtract 1 mm for
safety allowance
to get the WL
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
WALTON & TORABINEJAD METHOD
XERORADIOGRAPHY (1963)
Diagnostic
film taken
using
paralleling
method
3 mm
subtracted
& result is
transferred
to the files
Radiograph
taken and
discrepancy
between tip of
file & apex is
determined
Based on
this, file is
adjusted
1-2 mm
short of
the apex.
First dental use of xeroradiograph was done by Pogerzelska-Stroncz
Image recorded on aluminum plates with
selenium particles held in light-proof
cassettes
Edge enhancement
1/3rd exposure
20 seconds
Exposure to x-ray dissipates the particles
based on tissue density and a latent image is
formed.
Image transferred to a visible image by
deposition of special pigmented particles
attracted to the photoreceptor plate.
This visible image transferred on the base
sheet can be now seen through
transilluminated light
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
DIRECT DIGITAL RADIOGRAPHY
RADIOVISUOGRAPHY
Introduced by Frances Mouyens in 1984
GENERATION FEATURES
FIRST (1987) Basic grey scale images
SECOND Software based CPU. Insufficient storage.
THIRD (RVG-
32000)
Improved dose dynamics.
Better control over grayscale, B/W reversal
Images could be stored either as 1 HIGH RESOLTION
ZOOM image OR 4 NORMAL images
Images could be printed
FOURTH
(RVG-S)
Compact, ergonomic, Color monitor
20 images could be stored
Automatic exposure compensation
On-screen point-to-point measurements
FIFTH (RVG-
ui)
Pixel size as fine as 19.5 micrometres, Better spatial
resolution
Two different sizes of sensor
SIXTH (RVG
5000)
Faster capture of radiographic images
Better contrast
SEVENTH
(RVG 6100)
Sensors with rounded corners
Size 0 sensors for pediatric patients
Sensor made of shock absorbing materials
Fiber optic technology captures images in less than 2
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
DIRECT DIGITAL RADIOGRAPHY
PHOSPHOR IMAGING SYSTEM
• First introduced in 1994 by Digora (Finland)
• Expensive
• Requires superior storage due to high image quality
• Absence of cord eases the placement of receptor.
• Phosphor plates are susceptible to scratches.
• Time consuming compared to RVG.
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
NON-RADIOGRAPHIC TECHNIQUE
DIGITAL TACTILE SENSE
PICAL PERIODONTAL SENSITIVITY
PAPER POINT METHOD
• Feeling the foramen by tactile sense has an
accuracy of 64% (Seidberg et al)
• Increase in resistance as file approaches 2-3 mm
apically.
• Working length determination based on
patient’s response to pain should never
be encouraged
• Preferred in cases of open apex
• Used as a supplementary method
• Can give unreliable data on:
- Amount of pulp tissue remaining
- Periapical lesion rich in blood
supply
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
APEX LOCATORS
• Used to locate apical constriction
• Helps in establishing APICAL CONTROL
ZONE (Apical terminal of root canal space
which provides resistance & retention form to
obturating material against condensation
pressure of obturation).
Can be used in:
- Impacted teeth
- Overlapping canals
- Zygomatic arch
- Excessive bone density
- Patients with gag reflex
- Pregnant patients
- Incomplete root formation
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
APEX LOCATORS
Principle: the electrical conductivity of the tissues
surrounding the apex of the root is greater than the
conductivity inside the root canal system provided the canal
is either dry or filled with a nonconductive fluid (Custer
1918).
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
APEX LOCATORS
BASED ON CURRENT FLOW (McDonald,
1992)
BASED ON
DC
BASED ON
AC
Original ohm
meter
(Suzuki & Sunanda)
Resistance
Type
RC Meter
Endometric
meter
Impedance
type
Sonoexplore
r
Frequenc
y
type
Ratio
type
Subtraction
type
Endex
Neosono
UltimaEZ
2
frequencies
Root ZX
5
frequencies
AFA
Apex Finder
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
APEX LOCATORS
1st Gen
Depends on
the
resistance
offered by
PD
membrane
Dry canal
required
2nd Gen
Based on
impedance,
works
without lip
clip
3rd Gen
Based on the fact that
different sites in canal
give different
impedance readings.
(Greatest at CDJ &
least in the coronal
part).
4th Gen
Measures
resistance &
capacitance
separately, has
better
accuracy.
5th Gen
Based on
electrical
characteristics
of the canal.
Accurate even
in wet canals.
6th Gen
Adaptive apex
locators. Sound
based
switching
device. Works
in wet fields as
well.
Dr. Balraj Shukla

TECHNIQUES OF
WORKING LENGTH
DETERMINATION
RECENT EVIDENCE
Radiography
vs
Non-Radiography
AUTHOR(s) Comparisons Outcome
Basso et al,
2015
In vivo digital radiograph
Ex vivo digital radiograph
Apparent and actual tooth length
similar as seen in 20 primary
incisors
Bahrololoom
i et al, 2015
Electronic Apex Locator
Digital Radiography
EAL – 86%
DR – 76%
(50 primary incisors)
Bhat et al,
2017
4th generation apex locator
Ingle’s method
In vivo evaluation of 30 primary
posterior teeth showed no
statistically significant difference
Koruyucu et
al, 2018
Conventional radiography
RVG
Scanning Electron
Microscopy
measured the canal lengths
most accurately in 116 primary
teeth canals that were
assessed.
Rathore et
al, 2020
Conventional Radiography
Tactile Method
Comparable results for EAL and
Conventional Radiography in 60
children.
Silva Brum
et al, 2020
Conventional Radiography
No significant difference
Dr. Balraj Shukla

CLEANING AND
SHAPING OF ROOT
CANALS
Dr. Balraj Shukla

Schilder’s Objectives
MECHANICAL
1. Root canal should develop a continuous tapering cone
2. Preparation should be in multiple planes (Flow)
3. Make the canal narrower apically and widest coronally
4. Avoid transportation of foramen
5. Keep the apical opening as small as possible
BIOLOGICAL
Procedure should be confined to the root canal space
All infected pulp tissue, bacteria and their by-products should be
removed from the root canal
Necrotic debris should not be forced periapically
Sufficient space for intracanal medicaments and irrigants should be
created
Dr. Balraj Shukla

HAND
INSTRUMENT
S
K-FILE
- Triangular
- 1.5-2.5 mm cutting blades
- Superior cutting
- Increased flexibility
H-FILE
- Square
- Pushes debris coronally
- Aggressive cutter
- Prone to fracture
- Lacks flexibility
Length of the floss tied to
hand instrument
Wandera & Conry, 1993 (Pediatr
Dent)
Use of floss as a preventive
measure on hand instruments
was first reported by El-Badrawy
HE in 1985 (Journal of Canadian
Dental Association)
Bondarde et al, 2015 (JIOH)
Recommend 18 inches as the
length of the floss
Dr. Balraj Shukla

MOVEMENTS OF INSTRUMENTS
REAMING
- Enlarging
orifices
- Clockwise
rotation
- Reamers
FILING
- Push-pull
motion
- Directed
apically
- H-files
FILING + REAMING
- Quarter turn clockwise,
apically directed pressure,
withdrawal
- Schilder’s modification: Half
turn clockwise
- Time consuming, technique
sensitive
BALANCED
FORCE
- Quarter turn
clockwise,
Anticlockwise with
apical pressure,
Clockwise
withdrawal
- Most efficient
dentin cutting
WATCH-
WINDING
- Back and
forth
oscillation
- Less
aggressiv
e
- K-files
WATCH-
WINDING +
PULL
- Back and
forth
oscillation,
followed by
pull motion
upon
resistance
- H-files

CLEANING AND SHAPING TECHNIQUES
Modified Step Back – 3mm
Passive Step Back – K-file + GG
Crown Down Pressureless – GG
coronally
Double Flare – K-files coronally &
apically
Modified Double flare – Flex-R
Balanced force – Engage, Cut,
Remove
Reverse Balanced Force
Dr. Balraj Shukla

STEP BACK/ TELESCOPIC CANAL/ SERIAL ROOT
CANAL
• Introduced by Clem and Weine
• Divided into two phases by Mullaney
(1960): Phase I & Phase II
• #10 to #25 K-file till working length in
watch-winding motion
• Avoid using filing motion in Phase I.
• Place next file series 1 mm short of WL.
• Master apical file should be used in
push-pull motion in Phase II.
• Time consuming
• Difficult to irrigate the apical region
Dr. Balraj Shukla

MODIFIED STEP-BACK
• Preparation is completed in apical third
• Step-back started 2-3 mm short of apical
constriction
• Less chance of apical transportation
• Less removal of debris
• Better tug-back in gutta-percha
obturation
PASSIVE STEP-BACK
• Combination of hand and rotary
instruments
• Enlarge canal with hand files up till #30
• Flare the canal using GG drills up to a
point where it binds slightly.
• Check apical patency using #20 and
prepare canal accordingly.
Dr. Balraj Shukla

CROWN DOWN TECHNIQUE
Dr. Balraj Shukla
• First suggested by Goerig et al.
• Coronal one-third instrumented before apical shaping
• Usage of GG drills in this technique increases the chances of “Coke-bottle appearance”
• Crown down begins with #50 K file or H file depending on canal taper and orifice diameter
• Apical third enlarged till master apical file.
• Modified Pressureless Technique: K-files used from large to small sequence without apical pres

BALANCED FORCE TECHNIQUE
Dr. Balraj Shukla
• Developed by Roane and Sabala in 1985
• Flex-R files with non-cutting tips are used
• GG drills used for coronal and middle third flaring of canals
• Hand filing motion: placing, cutting, removing

DOUBLE FLARE
TECHNIQUE
• Introduced by Fava
• Crown-down using K-files
• Apical part prepared by step back
MODIFIED DOUBLE
FLARE
• #40 Flex-R file used
• Larger file sizes used to instrument
straight part of the canal
• Coronal 4-5 mm instrumented with GG
drills
• Step back technique then used to
prepared remaining portion of curved
canal.
Dr. Balraj Shukla

HYBRID TECHNIQUE (STEP-BACK/STEP-DOWN
COMBINATION)
• Establish apical patency
• Coronal third prepared using GG drills
(#3,#2,#1)
• Perform step back from apical region
starting from #15 K file till Master
Apical File
• Integrity of dentin is maintained and
excessive removal of radicular dentin
is avoided
Dr. Balraj Shukla

IRRIGANTS
Irrigation is the only way to clean those areas of root
canal wall that are not touched by mechanical
instrumentation.
These areas are fins, isthmuses, anastomosis and large
lateral canals.
Irrigants are auxiliary solutions that help in flushing out
loose, necrotic contaminated materials which act as
harbours for micro-organisms in the dentinal tubules and
periapical tissues.
Dr. Balraj Shukla

IDEAL REQUIREMENTS (Zhender, 2006)
• Broad antimicrobial spectrum
• Dissolution of necrotic pulp tissue
remnants
• Inactivation of endotoxins
• Prevention of formation of smear layer
• Systematically nontoxic upon
encountering vital tissues
• Non-caustic to periodontal tissues
• No potential to cause anaphylactic
reaction
OTHER REQUIREMENTS (Garg, 2007)
• Good lubricant
• Low surface tension for better flow
• Bactericiadal/Fungicidal
• Should not weaken the tooth structure
• Easy availability, cost-effective
FACTORS MODIFYING THE
ACTION OF IRRIGANTS
• Concentration
• Contact
• Presence of Organic Tissue
• Quality
• Gauge of irrigating needle (#27 or #28)
• Surface tension
• Temperature
• Frequency
• Canal diameter
• Age of irrigant
Dr. Balraj Shukla

TYPES OF IRRIGANTS
Dr. Balraj Shukla

NORMAL SALINE
• 0.9% w/v
• Isotonic to body fluids
• Adjunctive irrigant
• No side effects
• No periapical irritation as osmotic pressure
of saline is same as that of blood
• Biocompatible in nature
• Cannot dissolute or disinfect the canal
• Cannot cleanse microbes from inaccessible
areas
• Cannot remove smear layer
Dr. Balraj Shukla

SODIUM
HYPOCHLORITE
Introduced by: Henry Dakin & Alexis Carrel during
World War I
Introduced in dentistry: Coolidge, 1919
Clear, pale, green yellow liquid
Available as:
- Buffered solution with bicarbonate at 0.5-1%
concentration at a pH of 9
- Unbuffered at pH 11 between 0.5-5.25%
Efficacy of different concentrations of NaOCl
(Marion et al, 2012; Dent Press Endo)
• 0.5% - least cytotoxic, takes more time to dissolve
organic tissue
• 1% - most reliable in terms of prolonged action
• 2.5% - better bactericidal action, good tissue
dissolution
• 5.25% - higher solvent potential and bactericidal but
most toxic to periapical tissues
Dr. Balraj Shukla

SODIUM
HYPOCHLORITE
MECHANISM OF ACTION
At body temperature, reactive chlorine in aqueous
solution exists in two forms: HOCl and OCl depending
on pH of solution.
SAPONIFICATION
NaOCl + Albumin
(from pulp tissue
remnants) 
denaturation of
proteins, leading to
increased solubility
in water
AMINO ACID
NEUTRALIZATI
ON
NaOCl + Organic
tissue 
Release of
chlorine and
formation of
chloramines.
This reaction
inhibits cell
metabolism.
CHLORAMINATI
ON
Chlorine causes
irreversible
oxidation of
sulphydryl group
leading to
inactivation of
bacterial
enzymes.
Dr. Balraj Shukla

SODIUM
HYPOCHLORITE
Increase in temperature by 25 degrees increases
efficacy by a factor of 100.
OCl form dominates at pH of 10. HOCl dominates at
4.5.
ADVANTAGES
• Causes tissue dissolution within 15-30
seconds
• Remove organic portion of dentin for deeper
penetration of medicament
• Removes biofilm
• Causes dissolution of pulp and necrotic tissue
• Shows antibacterial and bleaching action
• Causes lubrication of canals
• Economical
• Easily available
Dr. Balraj Shukla

SODIUM
HYPOCHLORITE
DISADVANTAGES
Because of high surface tension, its ability to wet dentin is less
Gingival inflammation
Bad odor and taste
Corrosive to instruments
Unable to remove inorganic components of smear layer
Long time of contact with dentin has determined effect on
flexural strength of dentin
Exudate and microbial biomass inactivates NaOCl
NaOCl accident signs &
symptoms
Management of NaOCl accidents
Analgesics (Acetaminophen + Ibuprofane)
Antibiotics (Penicillins/Macrolides/Tetracycline/Cephalosporin)
Change in irrigating solutions (preferably CHX)
Warm/Cold compresses
Incision and drainage
Extraction in cases of nerve damage or scar tissue formation
Apical surgery or low-level laser therapy
Guivarch et al,
2017 (52 cases) Dr. Balraj Shukla

SODIUM
HYPOCHLORITE
• The use of ultrasonic agitation increased the
effectiveness of 5% NaOCl in the apical third of
the canal wall (Spanberg et al, 1973).
• In primary teeth, overflow of irrigating solution
through the apical region because of possible
resorption areas could damage the underlying
permanent tooth (Estrema et al, 2007).
• 2.5% NaOCI was chosen for appropriate
concentration at primary teeth root canal
treatment (Senthil et al, 2018)
Dr. Balraj Shukla

UREA PEROXIDE • White crystalline powder with slight odour.
• Soluble in water, glycerine and alcohol.
• 10% solution of urea peroxide in anhydrous
glycerol base is available as glyoxide.
• Urea Peroxide  Urea + H2O2
• Free O2 radicals of H2O2 help in removal of
pulp remnants.
• Haemostatic
• Non-allergic and non-irritant to periapical
tissues.
• Rome et al (1985) was the first to describe it as
a first-choice irrigant in small curved canals.
• It dissociates slower than H2O2 which can be
detrimental to remaining dentinal structure.
Dr. Balraj Shukla

HYDROGEN
PEROXIDE
• Available between 1% to 30% concentrations
for dental use. 3% used as irrigating
solution.
• Clear, colourless liquid
• Easily decomposed by heat and light
• Active against bacteria, virus and spores
• Used alone or with sodium hypochlorite.
• Free hydroxyl radicals destroy DNA and
protein content of microbes. Effervescence
caused due to reaction of free oxygen radical
causes loosening of debris.
• Can result in development of cervical
resorption if used in high concentrations.
Dr. Balraj Shukla

CHLORHEXIDINE
GLUCONATE
• 2% concentration used as root canal irrigant.
• Broad spectrum antimicrobial. Effective against
Actinomyces Israelii and Enterococcus Faecalis.
• Antimicrobial action in pH between 5.5-7.0
• At low concentration: Bacteriostatic
• At high concentration: Bactericidal
• Substantivity: Effect lasts between 3-7 days when
used as irrigant.
• Does not dissolve tissue remnants
• No effect on biofilms.
Dr. Balraj Shukla

CHLORHEXIDINE
GLUCONATE
Combination of NaOCl and CHX is preferred to
enhance their antimicrobial properties. However,
presence of NaOCl in the canals during irrigation with
CHX produces an orange–brown precipitate known as
parachloroaniline (PCA). This precipitate occludes the
dentinal tubules and may compromise the seal of the
obturated root canal.
Dr. Balraj Shukla

ETHYLENE DIAMINE
TETRACETIC ACID
• Chelating agent: A chemical which combines with a
metal to form chelate.
• Introduced in dentistry in 1957.
• EDTA was introduced by Nygaard-Ostby.
• Available between 10-17% concentrations.
• EDTA removes calcium ions from dentin and
increases its permeability.
• Hariharan et al (2010) and Torabinejad et al (2010) –
Removed smear layer in primary teeth but adversely
affected the root canal.
• Marshall & Sumikawa (1999) – EDTA causes erosions
in primary teeth due to microstructure of dentin in
primary teeth compared to permanent teeth.
• Calt and Serper (2002) – Greater contact time leads
to greater demineralization of dentin.
• EDTA’s action starts after 1 minute and smear
layer removal peaks at 15 minutes.
• EDTA helps in decreasing debridement time. It helps
in enlarging narrow canals, makes instrumentation
easier.
Dr. Balraj Shukla

ETHYLENE DIAMINE
TETRACETIC ACID
• LIQUID
1. REDTA – 17% EDTA combined with cetrimide
2. EDTAT – combination with Sodium Lauryl Ether
Suplhate
3. EDTAC – 15% combined with Cetavlon
4. Largal Ultra – 15% combined with cetrimide,
disodium salt and sodium hydroxide at a pH of 7.4
• PASTE
1. Calcinase Slide – 15% EDTA with 58-64% water
2. RC Prep – 15% EDTA with 10% urea peroxide and
glycol
3. Glyde File – 15% EDTA with 10% urea peroxide
4. Fiel-Eze – 19% EDTA
5. RC Help – 15% EDTA with cetrimide
Dr. Balraj Shukla

OTHER CHELATORS
AGENT FUNCTION
Citric Acid (10%) Removes smear layer by forming non-
ionic chelate.
Polyacrylic Acid &
Maleic Acid (7%)
Used in combination to remove smear
layer.
Hydroxyethyliden
e
Bisphosphonate
Non-toxic chelating agent. Can be used
with NaOCl & hence can be an
alternative to EDTA.
Tetraclean Mixture of doxycycline hyclate with
propylene glycol, cetrimide and citric
acid. Removes smear layer after a 5
minute rinse.
Chlorine Dioxide
(5%)
Less toxic than NaOCl and more effective
at a wider pH (3-9.63).
Dr. Balraj Shukla

MTAD
• Introduced by Torabinejad in 2000. Mixture of
tetracycline isomer, acid and detergent.
• Contains tetracycline (chelator, broad-spectrum
antibiotic, substantivity, removes smear layer),
citric acid (bactericidal), detergent (decreases
surface tension).
• Effective against E. Faecalis.
• High binding effect of doxycycline present in
MTAD for dentin leads to longer antibacterial
effect.
• The most recommended protocol for clinical use
of MTAD advises an initial irrigation for 20 minute
with 1.3% NaOCl, followed by a 5-minute final
rinse with MTAD.
Irrigants containing antibiotics
MTAD  Tetracycline + 3% doxycycline (4-
12 weeks substantivity)
Tetraclean  Doxycycline (50 mg/ml)
Sparfloxacin  in vitro efficacy against
E.Faecalis
Dr. Balraj Shukla

ELECTROCHEMICAL
LY ACTIVATED
SOLUTIONS
• Nontoxic to biological tissues
• Less or no allergic reaction
• Effective with wide range of microbial spectra
• Combined use of NaOCl and ECA solution has
shown to remove the smear layer
Dr. Balraj Shukla

OZONATED WATER
• Powerful oxidizing agent.
• Capable of deactivating bacterial cells at
concentrations as low as 0.1 ppm.
• Non-toxic to oral cells.
• Unstable at higher concentrations.
Dr. Balraj Shukla

RUDDLE’S
SOLUTION
• Combination of 17% EDTA, 5% NaOCl and
Hypaque
• Hypaque is an aqueous radiopaque solution of
iodide salts, namely, ditrizoate and sodium iodine.
• Useful for visualization of root canal anatomy,
missed canal, perforation, etc.
• Helps in diagnosis of internal resorption, its size
and site
• Helps in visualization of blockage, perforation,
ledge and canal transportation
Dr. Balraj Shukla

Q-MIX
• 17% EDTA & 2% Chlorhexidine
• It has a pH slightly above neutral
• Used as a final rinse for 60-90 seconds
• Kills 99.99% bacteria
• Penetrates the biofilm
• Less demineralization and erosion of dentin
Dr. Balraj Shukla

HERBAL IRRIGANTS
• Triphala*
• Green Tea*
• Turmeric*
• German Chamomile*
• Tea Tree Oil*
• Propolis
• Tulsi
• Allium Satvium
• Neem*
• Nutmeg
• Spilanthes Cava DC
• Babool*
• Aloe Vera*
* Indicates efficacy against E.Faecalis
Dr. Balraj Shukla

IRRIGATION SEQUENCE IN
PRIMARY TEETH
NaOCl
To dissolve pulp remnants
EDTA
To remove
smear layer
MTAD or CHX
Final rinse for disinfection
(As per Kashyap et al, 2019)
Normal Saline
Intermediary
agent to prevent
reaction between
2 irrigants
Dr. Balraj Shukla

INTRACANAL
MEDICAMENTS
Dr. Balraj Shukla

CLASSIFICATION
INTRACANAL MEDICAMENTS
ESSENTI
AL OILS
EUGENO
L
PHENOLIC
COMPOUNDS
PARACHLORPHENO
L
CAMPHORATED
MONOPARACHLORO
PHENOL
CRESATIN
FORMALDEHYDE
PARAFORMALDEHY
DE
GLUTARLDEHYDE
CA(OH)2
HALOGENS
CHLORINE-
SODIUM
HYPOCHLORITE
SOLUTION
IODINE (2% / 5%)
CHX ANTIBIOTICS CORTICOSTEROID
- ANTIBIOTIC
COMBINATION
Dr. Balraj Shukla

IDEAL REQUIREMENTS (GROSSMAN)
• Should be an effective antimicrobial
agent
• Should be non-irritating to periradicular
tissues
• Should remain stable in solution
• Should have a sustained effect
• Should be active in the presence of
blood, serum and protein derivatives of
tissue
• Should have a low surface tension
• Should not stain the tooth
• Should not induce a cell-mediated
immune response
INDICATIONS (CHANG &
PITTFORD)
• Dry persistently wet canals
(weeping canals)
• Eliminate remaining microbes in
pulp space
• Render root canal contents inert
• Neutralize tissue debris
• As a barrier against leakage from
an interappointment dressing in
symptomatic cases
Dr. Balraj Shukla

EUGENOL • Has been used in endodontics as a root
canal sealer & temporary restoration for
many years
• Its effect as an intracanal medicament
depends on its concentration.
• Low dose: Inhibits Prostaglandins, Inhibits
nerve activity, Inhibits chemotaxis
• High dose: Induces cell death, Inhibits cell
respiration
• It is now considered as a toxin for
periradicular tissues and not recommended.
PARACHLOROPHENOL
• Was introduced as a substitute to the highly
inflammatory phenol.
• 1% aqueous solution is used as an
intracanal dressing in infected tooth.
Dr. Balraj Shukla

CMCP • Made by combining two parts of PCP with three
parts of gum camphor
• Camphor acts as a dilutant and prolongs the
antimicrobial effect
CRESATIN • Same properties as CMCP but less irritating
comparatively to periradicular tissues
• Clear, Oily and Stable solution known as
metacresyle acetate.
Dr. Balraj Shukla

FORMOCRESOL • Contains formaldehyde (19%), cresol (35%), water
and glycerin (46%)
• Preferred in pulpotomy as intracanal medicament.
PARAFORMALDEHYDE • Polymeric form of formaldehyde
• Decomposes to give out formocresol
• All phenolic and similar compounds are highly volatile with low
surface tension.
• If they are placed on a cotton pellet in the pulp chamber, vapours
will penetrate the entire canal preparation.
• Therefore, paper point is not needed for their application.
• Only small quantity of medication is needed for effectiveness,
otherwise, chances of periapical irritation are increased.
Dr. Balraj Shukla

Composition: Formaldehyde liquid,
Eugenol, Parachlorophenol,
Polyethylene Glycol, Fumed Silica and
excipients.
Indications: Pulp Devitalizer prior to
mortal extirpation or amputation.
Residual devitalization after removal of
non-vital pulp tissue.
Close contact of the paste with the
pulp accelerates the devitalizing
process.
Devitalization is completed within five
to seven days.
• 75 general practitioners
surveyed
• 56% used paraformaldehyde
containing pastes
• 61% did not observe any post-
operative complications
• 33% were not aware of any
post-operative complications
Dr. Balraj Shukla

CALCIUM
HYDROXIDE • Hermann (1920)
• Available as: Powder & Paste form
• Strong base. Dissociates into calcium and
hydroxyl ions in aqueous solution.
• Acts as a physical barrier for ingress of bacteria
• It shows antiseptic action because of its high pH
and leaching action on necrotic pulp tissues.
• Suppresses enzymatic activity and disrupts cell
membrane
• Inhibits DNA replication by splitting it
• It hydrolyses the lipid part of bacterial
lipopolysaccharide (LPS) and thus inactivates the
activity of LPS.
Dr. Balraj Shukla

CALCIUM
HYDROXIDE
AS AN INTRACANAL MEDICAMENT
• Inhibits root resorption
• Stimulates periapical healing
• Encourage mineralization
• Difficult to remove from canals
• Decreases setting time of zinc oxide
eugenol based cements
• It has a little or no effect on severity
of post-obturation pain
• Meta-Analysis
• 16 randomized control trials included
• Ca(OH)2 was better than Formocresol
in 12 studies
• Ca(OH)2 was better than camphor
phenol in 7 studies.
Dr. Balraj Shukla

ANTIBIOTICS/
CORTICOSTEROIDS
PBSC (Grossman Paste)
Penicillin – against Gram Positive Microogranisms
Bacitracin – against penicillin resistant microbes
Streptomycin – against Gram Negative Microorganisms
Caprylate - Antifungal
PBSN
Nystatin – Antifungal
Disadvantages:
- Allergic reaction to drugs have been reported
- Sensitivity due to improper placement of antibiotics
Sulphonamides like sulfanilamide and sulfathiazole are
used as medicaments by mixing it with sterile distilled water.
Indicated when a closed dressing needs to be given in a
tooth with periapical abscess
Causes yellowish discoloration of tooth.
N2 by Sargenti
Paraformaldehyde, Eugenol, Phenyl Mercuric borate and
perfumes
Antibacterial effect of N2 is short lived (7-10 days).
Dr. Balraj Shukla

ANTIBIOTICS/
CORTICOSTEROIDS
Ledermix
Developed by Schroeder and Triadan in 1960
Non-setting water-soluble paste
Composition
Demeclocycline HCl – 3.2%
Triamcinolone Acetonamide – 1%
Polyethylene base
Inhibits ribosomal protein synthesis
Inhibits root resorption
Highly effective in cases where there is inflamed periapical
tissue due to over-instrumentation.
Corticosteroid – reduces periapical inflammation and relieves
pain
Antibiotic – prevents overgrowth of microbes
3Mix Paste
Metronidazole-Ciprofloxacin-Minocycline
Effective in disinfecting immature teeth with apical periodontitis
Dual Paste system of 3Mix with Calcium Hydroxide is
recommended as an intracanal medicament.
Dr. Balraj Shukla

n = 48 non-vital primary teeth
I: CH + distilled water
II: CH + 2% CHX
III: 3Mix + distilled water
IV: 3Mix + 2% CHX
Conclusion: Combination of an
antimicrobial agent with an intracanal
medicament is better than single agents
like Ca(OH)2.
n = 60 primary teeth
I: 3Mix used as intracanal medicament
II: Conventional pulpectomy without LSTR
Conclusion: Comparable clinical success
rate at 3, 6 and 12 month follow-up but
radiographic success was better in 3Mix
group
Dr. Balraj Shukla

OBTURATION IN
PRIMARY TEETH
Dr. Balraj Shukla

Definition
Obturation is a method used to fill &
seal a cleaned and shaped using a
root canal sealer and core filling
material (American Academy of
Endodontics).
Ideal requirements of an obturating
material
GROSSMAN
Easy introduction
Lateral and Apical seal
Should not shrink
Slow setting
Impervious to moisture
Bactericidal/ bacteriostatic
Radiopaque
Should not stain the tooth
Should not irritate the periradicular tissues
Should be easily removable
Sterile
RIFKIN & RABINOWITCH
Non-inflammatory to successor
Extruded material should resorb easily
Induce vital tissue to seal the canal
Dr. Balraj Shukla

Objectives of Obturation
Elimination of coronal leakage of
microorganisms or potential nutrients to
support their growth in dead space of root
canal system
To confine any residual microorganisms that
have survived the chemo-mechanical
cleaning and shaping, to prevent their
proliferation and pathogenicity
To prevent percolation of periapical fluids
into the root canal system and feeding
microorganism
Timing of Obturation
• Can be performed in single-visit in cases of
vital pulp
• Can be performed in single-visit in
asymptomatic necrotic teeth
• Should not be done when there is
sensitivity/ tenderness on percussion
• Should not be done when there is purulent
exudate
Evaluation of Obturation
• Underfilling: >2mm short of radiographic
apex
• Overfilling: Material extruding beyond apical
foramen
• Dense radiopaque filling
• Continuous tapered funnel like the root
canal morphology
Dr. Balraj Shukla

Importance of using a vehicle in
obturating materials (Leonardo
et al, 1982)
• To maintain the paste consistency of the
material which does not harden or set
• To improve flow
• To maintain the pH
• To improve radiopacity
• To make clinical use easier
• Not to alter the biological properties of the
chief component
AQUEOUS
Water
Saline
Distilled water
Anesthetic solution
Ringer’s solution
Anionic detergent solution
VISCOUS
Glycerine
Propylene-glycol
Polyethylene-glycol
OILY
Olive Oil
CMCP
Metacresylacetate
Eugenol
Dr. Balraj Shukla

ZINC OXIDE
EUGENOL
• Advantages:
- Antibacterial &
Analgesic
- Radiopaque
- Easy manipulation
- Insoluble in tissue
fluids
- Cost effective
- No tooth discoloration
• Disadvantages:
- Slow resorption
- Irritant to periapical
tissues
- Necrosis of bone &
cementum
- Can harm the
successor
- Forms a fibrous
capsule and alters the
path of eruption
• Eugenol: Inhibits Gram
positive microorganisms
• Zinc acetate accelerator
inhibits both gram
positive and negative
microorganisms
• Extruded material
resorbs slowly over the
years
• Permanent incisors are
likely to have enamel
defects in primary
incisors treated with
1837: Discovered by
Bonastre
1876: Chisholm used it for
the first time in dentistry
1930: Sweet used it for the
first time in pedodontics
• Resorbs faster when combined
with Propolis
• Better success with Ozonated Oil
• Ca(OH)2 + NaF: Equals
physiologic root resorption
Dr. Balraj Shukla

CALCIUM
HYDROXIDE
• Advantages:
- Antiseptic & Osteoconductive
- Antibacterial
- pH = 12.5
• Disadvantages:
- Fast depletion from canals
- Triggers root resorption in hyperaemic pulp
- Damages predentin in necrotic pulp which exposes
odontoclasts and thus subsequent resorption
1838: Nygren used Ca(OH)2 for treatment of “fistula
dentalis”
1851: Codman used it to preserve the dental pulp
1920, 1930: Hermann introduced Ca(OH)2 as a healing
agent in clinical dentistry
Dr. Balraj Shukla

IODOFORM PASTES
1952: Castagnola and Orlay showed that iodoform pastes are bactericidal to
microorganisms in the root canal and lose only 20% of their potency over a period of 10
years.
CHLORINAT
ED LIME
POTASSIUM
IODIDE IODOFOR
M
1040ᵒF
Analgesic
Disinfectant
Causes Stains

WALKHOFF PASTE
• Advantages:
- For non-vital teeth with large periapical
lesions
• Disadvantages:
- Total resorption of root canal and periapical area
Composition:
- Iodoform (33-37%)  Antiseptic
- Camphor (63-67%)  Analgesic, Arrests
haemorrhage
- Menthol (1.4-2.9%)  Antispasmodic, obtunder of
sensitive dentin, remedy in facial neuralgia, Anodyne
Dr. Balraj Shukla

KRI PASTE
• Advantages:
- Long-lasting bactericidal potential
- Better success rate compared to ZOE (84% vs
65%)
- Success rate of extruded material better than ZOE
(79% vs 41%)
• Disadvantages:
- KRI-1 paste consists of formaldehyde which is
known to cause toxicity
Composition:
- Iodoform (80.5%)  Antiseptic
- Camphor (4.84%)  Analgesic, Arrests
haemorrhage
- Menthol (1.2%)  Antispasmodic, obtunder of
sensitive dentin, remedy in facial neuralgia, Anodyne
- Parachlorophenol (2%)  Antibacterial
Dr. Balraj Shukla

MAISTO PASTE
• Advantages:
- Reduces resorption rate of paste from within the
canals
Composition:
- ZnO  14g
- Iodoform  42 g
- Thymol  2 g
- Chlorophenol Camphor  3 cc
- Lanolin  0.5 g
GUEDES-PINTO
PASTE
Composition:
- Iodoform (0.30 g) 
Antimicrobial
- Rifocort  Anti-
inflammatory, Antibiotic
- Camphornated
Parachlorphenol (0.1
mL)  Antimicrobial,
Analgesic
Disadvantages:
- Fast pulp obliteration
- Induces internal
resorption
- Lack of adhesion
- Microleakage
- Resorbs earlier than
physiologic rate
Dr. Balraj Shukla

Vitapex (Neo Dental),
Metapex (Meta Biomed)
• Advantages:
- Not toxic to successor
- Antiseptic
- Good adherence
- Extruded material resorbs in 2-8 weeks
- Easy application
- Radiopaque
• Disadvantages:
- Voids due to elimination of iodoform
- Discoloration of tooth
- Hollow-tube effect (Goldman & Pearson, 1965)
Composition:
- Iodoform (40.4% in Vitapex, 38% in Metapex) 
Bactericidal
- Calcium Hydroxide (30.3%)  Antibacterial,
osteoconductive
- Silicone (22.4%)  Oil-based additive that acts as
lubricant
Dr. Balraj Shukla

ENDOFLAS
• Advantages:
- Hydrophilic
- Firm Adhesion
- Reaches accessory canals
- Extruded material resorbs within 7 days
• Disadvantages:
- Periapical irritation
- Tooth discoloration
Composition:
- Iodoform, ZOE  56.5%
- Ca(OH)2  1.07%
- Iodine Dibutilorthocresol  40.6%
- Barium Sulphate  1.63%
- Eugenol
- Paramonochlorophenol
• ECF
A chlorophenol-free endoflas was
developed to reduce radiolucent
lesions that could be due to
chlorophenol which acts on osteoblasts Dr. Balraj Shukla

CALEN PASTE Mean pH rises from 6.1 to 8.4 in 5 hours
Low solubility
Highly antimicrobial
Better success when combined with ZnO
Ca(OH)2  2.5 g
ZnO  0.5 g
Colophony (viscosity)  0.05 g
Polyethylene glycol  1.75 mL
PULPOTEC
Powder: Polyoxymethylene, Iodoform
Liquid: Dexomethasone, Formaldehyde, Guaiacol,
Phenol
Highly effective in teeth with necrotic pulp and with bone
lesions
Has antibacterial, antiseptic, anti-inflammatory
properties
Dr. Balraj Shukla

LSTR Developed by Cariology Research Unit of
Niigata
Other names:
- Non-Instrumentation Endodontic Treatment
- Polyantibiotic
- Triple Antibiotic paste
Metronidazole: binds to DNA & acts against gram
positive and gram negative anerobes
Ciprofloxacin: inhibits DNA gyrase and destroys gram
negative bacteria
Minocycline: inhibits protein synthesis, collagenases &
MMP
Solvents: Macrogol, Propolis, Normal Saline
Lesion Sterilization: Inflammation and
formation of granulation tissue with
accompanying metaplasia of connective
tissue and macrophages, leading to
activation of osteoclasts
Tissue Repair: Vital pulp cells develop
new pulp tissue into the coronal pulp
chamber (pulp revascularization) 4M paste: includes Rifampicin
Ornidazole can be a better alternative to metronidazole
Amox, Cefaclor, Cefroxadine can be replaced for
Minocycline as it causes stains
Dr. Balraj Shukla

• Articles assessed between 2000-2019
• 3 articles of high evidence were chosen
• Conclusion: After 6 months,
radiographic success was high but
decreased after 12 months in both
groups.
• n = 40 primary molars
• I: ZOP
• II: ZOE
• Conclusion: After 24 months, success
rate of ZOP was more than ZOE (95%
vs 70%)
Dr. Balraj Shukla

N = 50
I: Vitapex
II: ZOE
III: Calcicur
IV: Feapex
V: Calen-ZO
Techniques compared: Lentulo spiral vs
Syringe
Conclusion: Canal filling was better in
Vitapex, Calen-ZO & ZOE. Syringe technique
produced significantly lesser voids.
N = 150 infected primary mandibular molars
I: ZOE
II: Metapex
III: Endoflas
Conclusion: Highest success rate was seen
with Endoflas (16% resorption) followed by
ZOE (26%). Metapex showed the least
success rate, showing both internal and
external root resorption after a 12 month
follow-up in 70% of the cases.
Dr. Balraj Shukla

• N= 73 pulpectomized primary molars with
CH + Iodoform formulation
• Follow-up period: 21.5 months (median)
• Overall success rate: 74%
• Success rate with a SSC: 88.9%
• Primary second molars had a higher
success rate than primary first molars
• Resorption of the paste did not affect the
success rate.
• I: Rifocort + Iodoform + CMCP
• II: Iodoform + ZOE + CH
• III: ZnO + Eugenol 1:3
• IV: ZnO + Eugenol 1:5
• V: Iodoform + ZOE 1:3
• VI: CH + ZOE 1:3
• E. Faecalis on brain-heart infusion agar
culture medium of 10 mL
• 3 g of each paste was placed in the petri
dishes and antimicrobial efficacy was
evaluated after 48 hours.
• Maximum inhibition was seen in groups
containing ZOE alone or in combination with
Dr. Balraj Shukla

• Article search time frame: 1960-2020
• Primary Outcome: Clinical & Radiographic
success for Pulpectomy and LSTR
After 18 months…
• Success rate with Endoflas & ZOE: Nearly
90%
• Success rate with Vitapex or Metapex:
71% or less
• LSTR should be preferred in preoperative
root resorption cases
• Rotary instrumentation was significantly
faster compared to manual
• Out of 5000 articles identified in initial
search, 10 articles of high-evidence were
included
• ZOE showed better success after >18
months of follow-up
• Ca(OH)2 or Iodoform pastes should be
utilized for primary teeth nearing
exfoliation
• ZOE combined with Ca(OH)2 and
Iodoform seem to be the material of
choice for teeth that are not nearing
Dr. Balraj Shukla

TECHNIQUE GIVEN
BY
ADVANTAGES DISADVANTAGES
Greenber
g
1963
Controlled pressure created to fill the
canals with 13-30 gauge needles
Overfilling of the obturating material, voids,
need to clean the syringe immediately
Kopel
1970
Effective in curved canals,
homogenous filling
Instrument fracture, tendency of extrusion if
RPM is not controlled
Greenber
g
1971
Easy technique Uncontrolled pressure due to plunger system,
not suitable for curved and narrow canals
Gould
1972
Less chances of extrusion Limited efficiency in curved canals, increased
risk of voids
Riffcin
1980
Less chances of extrusion Requires a specific consistency of obturating
material, under-filled canals
Aylard &
Johnson
1987
Less chances of extrusion Under-filled canals and presence of voids,
separation of tip during injection
Guelman
n
2004
Thin, flexible metal tip, absence of
voids, better apical seal
Material flow depends on material viscosity
Deveaux Flexible, flattened blades & helical Instrument fracture if used at inappropriate
OTHER: Amalgam Plugger (Nosowitz, 1960), Paper Points (Spedding, 1973), Wet cotton Pellets (Donneberg,
EPS
LS
MS
IF
T
JT
DS
NT
PI
Dr. Balraj Shukla

• N= 96 extracted primary molars
• Obturating material: ZOE
Conclusion: Optimal filling % as follows:
• Endodontic Pressure Syringe – 98.5%
• Insulin Syringe – 79.2%
• Local anesthetic Syringe – 66.7%
• Jiffy tube – 37.5%
• Minor voids were seen in all four
techniques used
• N = 40 primary root
canals across 63 carious
primary teeth
• Obturating material:
Endoflas
• I: Bi-directional spiral
• II: Incremental technique
• III: Pastinject
• IV: Lenturospiral
• Bi-directional spiral
technique was
significantly superior
Dr. Balraj Shukla

American Academy of Endodontics (2010). Endodontics Colleagues for
Excellence - Access Opening and Canal Location.
Finn, S. (1963). Clinical pedodontics. Saunders.
Kennedy, D. (1986). Paediatric operative dentistry. Bristol.
Young, G., Parashos, P., & Messer, H. (2007). The principles of techniques for
cleaning root canals. Australian Dental Journal, 52, S52-S63.
Cleghorn, B., Boorberg, N., & Christie, W. (2010). Primary human teeth and
their root canal systems. Endodontic Topics, 23(1), 6-33.
Bansal, R., Hegde, S., & Astekar, M. (2018). Classification of Root Canal
Configurations: A Review and a New Proposal of Nomenclature System for
Root Canal Configuration. JOURNAL OF CLINICAL AND DIAGNOSTIC
RESEARCH, 12(5).
Barker, B., Parsons, K., Williams, G., & Mills, P. (1975). Anatomy of root canals.
IV deciduous teeth. Australian Dental Journal, 20(2), 101-106.
Bhatt, A., Gupta, V., Rajkumar, B., & Arora, R. (2015). WORKING LENGTH
DETERMINATION- THE SOUL OF ROOT CANAL THERAPY: A
REVIEW. International Journal Of Dental And Health Sciences, 2(1).
Anand, P., Kumar, D., & Prasad, L. (2020). A GLIMPSE INTO THE ERA OF
RADIOVISUOGRAPHY WITH COMPARATIVE ANALYSIS TO
R
E
F
E
R
E
N
C
E
S
Dr. Balraj Shukla

Goerig, A., & Camp, J. (1983). Root canal treatment in primary- teeth: a
review. Pediatric Dentistry, 5(1).
Nekoofar, M., Ghandi, M., Hayes, S., & Dummer, P. (2006). The fundamental
operating principles of electronic root canal length measurement
devices. International Endodontic Journal, 39(8), 595-609.
Shenoi, P., Sonarkar, S., & Khode, R. (2017). Electronic Apex Locators-An
overview. Indian Journal Of Conservative And Endodontics, 2(2). Retrieved 6
October 2021, from.
Pascon, F., & Puppin-Rontani, R. (2007). The Influence of Cleansers on the
Permeability Index of Primary Tooth Root Dentin. Journal Of Clinical Pediatric
Dentistry, 31(2), 93-97. https://doi.org/10.17796/jcpd.31.2.8125h54pk1121k11
Senthil, B., Gurunathan, D., Vasantrajan, M., & Lakshmi, T. (2018). PRIMARY
TOOTH ROOT CANAL IRRIGANTS - A REVIEW. International Journal Of Pure
And Applied Mathematics, 120(5).
Fava, L. R. G., & Saunders, W. P. (1999). Calcium hydroxide pastes:
classification and clinical indications. International Endodontic Journal, 32(4),
257-282.
Guivarc'h, M., Ordioni, U., Ahmed, H., Cohen, S., Catherine, J., & Bukiet, F.
R
E
F
E
R
E
N
C
E
S
Dr. Balraj Shukla

Pratha, A., & Jeevanandan, G. (2018). Instrumentation techniques for
pulpectomy in primary teeth - A review. Drug Invention Today, 10(2).
Chavhan, P., Somvanshi, Y., Kumar, S., Niswade, G., Sajjanar, A., & Rojekar, N.
et al. (2021). Different Obturating Techniques used in Primary Teeth: A
Review. European Journal Of Molecular And Clinical Medicine, 8(3).
Rajsheker, S., Mallineni, S., & Nuvvula, S. (2018). Obturating Materials Used for
Pulpectomy in Primary Teeth- A Review. Journal Of Dental And Craniofacial
Research, 03(01). https://doi.org/10.21767/2576-392x.100019
Garg, N., Garg, A., & Nekoofar, M. (2019). Textbook of endodontics (4th ed.).
Jaypee Brothers Medical Publishers.
Fuks, A., & Peretz, B. (2016). Pediatric Endodontics. Springer.
Rotstein, I., & Ingle, J. (2019). Ingle's endodontics (7th ed.). PMPH.
Berman, L., Hargreaves, K., Rotstein, I., & Cohen, S. (2015). Cohen's pathways
of the pulp (11th ed.). Elsevier.
Curzon, M., Roberts, J., & Kennedy, D. (1997). Kennedy's paediatric operative
dentistry. Oxford: Wright.
R
E
F
E
R
E
N
C
E
S
Dr. Balraj Shukla

Pulpectomy in Pediatric Dentistry

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Pulpectomy in Pediatric Dentistry

Similar to Pulpectomy in Pediatric Dentistry (20)

More from Balraj Shukla

More from Balraj Shukla (19)

Recently uploaded

Recently uploaded (20)

Pulpectomy in Pediatric Dentistry