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Pulpectomy

This document provides information about pulpectomy procedures for primary teeth. It begins with definitions of pulpectomy and considerations for primary teeth. Indications include traumatized or carious primary teeth with signs of pain or infection, while contraindications include non-restorable teeth or excessive root resorption. The procedure involves accessing the pulp chamber, removing coronal and radicular pulp tissue, cleaning and shaping canals, and obturating with resorbable materials like zinc oxide eugenol. Access cavities must be carefully prepared and obturation techniques like lentulo spirals or pressure syringes are discussed. Success criteria include resolution of symptoms and adequate root length for exfoliation. Periodic reviews are

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TOPIC- PULPECTOMY PRESENTED BY- SHUBHAM GUPTA
DEFINATIONS PRIMARY TEETH CONSIDERATIONS INDICATIONS CONTRAINDICATIONS PROCEDURE RULES FOR ACCESS CAVITY PREPERATION OBTURATING TECHNIQUES INSTRUMENTS OBTURATING MATERIALS CRITERIA FOR SUCCESS FOLLOW UP PULPECTOMY VS EXTRACTION
DEFINATIONS Pulpectomy involves complete removal of necrotic pulpal tissue from the root canals and coronal portion of non vital primary teeth to maintain a tooth in the dental arch. Richard J Mathewson, 1993 Pulpectomy refers to the removal of all pulpal tissue from the tooth, including both coronal and root portions. Sidney B Finn, 1999
Pulpectomy is removal of the roof and contents of the pulp chamber in order to gain access to the root canals which are debrided, enlarged and disinfected. - Shobha tandon Gaining access to the root canals which are then debrided, enlarged, disinfected and filled with a resorbable material. - American Academy of Paediatric Dentistry, 1999
WHY CONVENTIONAL ENDODONTIC THERAPY IS DIFFICULT IN PRIMARY TEETH ?
• Hibbard and Ireland, 1957, studied primary root canal morphology by removing pulp from extracted teeth, forcing acrylic resin into the pulp canals and dissolving the covering of tooth structure in 10% nitric acid. • They found that immediately following root formation, a single canal is usually present in each root. • Deposition of secondary dentin & accelerated physiological root resorption. • Variations included lateral branching, connecting fibrils, apical ramifications and partial fusion of
• Another difficulty is the apparent connection between the coronal pulpal floor with the intraradicular area. –Moss et al, 1965 • These foramina allow the necrotic products to pass into the bifurcation or trifurcation area. • Using dyes and a vacuum system , Ringelstein and Seow ,1989 found that many of the foramina of primary second molars were located on the root surfaces.
INDICATIONS TEETH PAIN HISTORY CLINICAL EXAMINATION RADIOGRAPHIC EXAMINATION Traumatised primary incisors and canines Spontaneous pain – generally occuring at night Presence of intraoral swelling or sinus Deep carious lesion extending upto the pulp Primary 1st molar before the second primary molar erupts Extensive bleeding from the site of amputation if pulpotomy procedure tried Inter radicular radiolucency Primary second molars, before eruption of first permanent molar Clinically evident carious exposure Pathologic root resorption not involving more than 1/3rd of the root Tenderness to percussion Moderate mobility Minimal destruction of the bone support
CONTRAINDICATIONS • A non restorable tooth. • Internal resorption in the roots visible on the radiographs. • Excessive pathologic root resorption involving more than 1/3 rd of the root. • Teeth with mechanical or carious perforations of the floor of the pulp chamber.
• Periapical or interradicular lesion involving the crypt of the succedaneous tooth. • Excessive pathologic loss of bone support with loss of normal periodontal attachment. • The presence of a dentigerous or follicular cyst. • Chronic illness with leukemia, rheumatic and congenital heart disease, chronic kidney disease etc.
PROCEDURE Local anaesthesia is given Isolate the tooth with rubber dam Prepare access cavity Remove all coronal pulp tissue with sharp spoon excavator Extirpate radicular pulp tissue with K files Irrigate with saline Determine the working length with the help of diagnostic radiograph
Cleaning and shaping of the canals is done 1.5 – 2 mm short of radiographic apex proceeding sequentially from smaller to larger files Irrigate thoroughly to flush out all debris. Dry the canals with absorbed paper points. Obturate the tooth with a resorbable biocompatible material Restore with a permanent restoration and stainless steel crown
STEPS IN PULPECTOMY STEPS IN PULPECTOMY INSTRUMENT USED PURPOSE Access cavity preparation Round bur Gain entry into chamber and remove dentinal roof Tapered fissure bur Remove overhanging dentin Endo Z Remove remaining carious dentin Coronal pulp extirpation NO 4 OR 8 excavator Extirpate coronal pulp Ensuring canal patency Endodontic explorer or smooth broach or 15 size K file Ensure patency of canal upto apex
Radicular pulp extirpation Barbed broach Extirpate radicular pulp in toto Establishing working length K file with stopper Length determination radiograph Debridement and enlargement 21 mm H file Debride and enlarge root canal upto three times its size Irrigation Syringe, saline, sodium hypochlorite Done to flush out debris Drying Paperpoints Drying of enlarged root canal Obturation lentulo spirals and endodontic pressure syringe Obturate the canal with material without voids till the determined working length , without expulsion of material into apex Bulk restoration composite restoration GIC Fill the access cavity
Post endodontic restoration Stainless steel crown Post endodntic rehabilitation of a pulpectomised tooth Review every 6 months Mouth mirror, probe, radiograph Check for signs or symptoms of irreversible pulpitis, dentoalveolar abscess and appropriate root resorption
RULES FOR PROPER ACCESS PREPARATION • ENDODONTIC DOGMA “ Careful cavity preparation and root canal obturation are the keystones to successful root canal therapy” • The objective of entry is to gain direct access to the apical foramina and not merely to the canal orifices. • Access cavity preparation are not guided by topography of occlusal grooves, pits and fissures.
• Radiographs taken from different angles must be considered. • Endodontic entries are prepared always through the occlusal or lingual surface. • The unsupported cusps of posterior teeth must be reduced to avoid weakening of the tooth structure.
ACCESS OPENINGS FOR PULPECTOMY ANTERIOR PRIMARY TEETH • Traditionally – lingual surface except for discolored maxillary primary incisors. • Discoloration – escape of hemosiderin pigments into the dentinal tubules. • Root canal is filled with ZOE. • Dycal is placed over ZOE to serve as a barrier between the composite resin and root canal filling.
POSTERIOR PRIMARY TEETH • Less extension towards the exterior of the tooth. • Working length radiograph – paralleling technique. • 2-3 mm short of radiographic length. • Thin walls of the roots- use of sonic and ultrasonic cleaning devices, Gates Glidden drills– contraindicated. Nickel –Titanium instruments recommended.
Important differences between the primary and permanent teeth are-  Length and bulbous shape of the crowns  A very thin dentinal wall at the pulpal floor  The depth necessary to penetrate into the pulp chamber is quite less than that in the permanent teeth  Likewise, the distance from the occlusal surface to the pulpal floor is much less than in permanent teeth.
To achieve optimal preparation. three factors are considered- -Size of pulp chamber- More extensive preparation in young children than older -Shape of pulp chamber – The finished outline should accurately mimic the shape of the pulp chamber. -Number ,position and curvature of the root canals
OBTURATION TECHNIQUES IN PRIMARY TEETH
TECHNIQUES OF ROOT CANAL FILLING IN PRIMARY TEETH  Pressure Syringe Technique –Greenberg (Pulpdent corporation, America).  Disposable tuberculin syringe or Local Anaesthetic syringe technique.  Slowly rotating Lentulo Spiral Technique.  Jiffy tubes  Incremental pressure syringe
PRESSURE SYRINGE • Comprises TECHNIQUE • The filling material – heavy putty like consistency. • Hub of the needle –loaded with the paste. • Needle is threaded on the syringe barrel, plunger is turned. • Needle is reinserted in the canal , tip is repositioned 1mm short Syringe barrel Threaded plunger Wrench Threaded needles (gauge 13-30)
PRESSURE SYRINGE TECHNIQUE • Threaded plunger- one hand, wrench in opposite hand. • Threaded plunger is adjusted one quarter turn and retracted slightly. • Additional condensation – moist cotton pellet. • Multiple canals – 2 periapical films Weisz, 1976 designated pressure syringe as the optimal selection for exact placement of paste within apical portions of fine and tortuous canals. He found the spiral lentulo most effective in treating single rooted teeth with straight canals.
LENTULOSPIRAL TECHNIQUE • Pastes can also be filled by means of lentulo spiral mounted on the micro motor hand piece. They have shown the success rate of 96% and 92% when hand held. The direction of rotation needs to be checked for the material to properly flow into the canals
• The primary teeth with their larger canals can be filled with the thin mix coating the walls of the canal with the help of a reamer in an anti clock wise direction while taking it out slowly followed by the placement of the thicker mix which is then pushed manually.
• Root length is the most reliable criteria of root integrity and atleast 4mm of the root length is necessary for the primary tooth to be treatable. – Rimmondini L, Baroni C, 1995 • If the inflammation is beyond the coronal pulp with only interradicular but no periapical radiolucency, a single visit pulpectomy is preffered. On the other hand if the pulp is necrotic with periapical involvement , filling procedure is delayed.
According to Finn- • Care should be observed not to penetrate past the apical ends of the tooth when reaming out of the canals. • Secondly, a resorbable compound such as zinc oxide eugenol should be used as a filling material. Silver points and gutta percha should not be placed. • Thirdly filling material should be introduced into the canal with light pressure. • Fourthly, apicoectomy should not be performed except in the absence of a developing permanent tooth.
REVIEW OF LITERATURE Acceptable result was obtained with lentulospiral in length of obturation compared to insulin syringe and endodontic plugger technique. Insulin syringe technique resulted in increased underfilling with least number of voids. More number of voids were seen in middle one-third and least number of voids were observed at apical one third of the root among all the 3 techniques of obturation. The study concluded that void identification is improved with D.I.O.R compared to C.B.C.T. Akhil JEJ et al Comparative evaluation of three obturation techniques in primary incisors using digital intra-oral receptor and C.B.C.T-an in vitro study. Clin Oral investgn 2018 May 10.
AAPD GUIDELINES  Following treatment, the radiographic infectious process should resolve in 6 months, as evidenced by bone deposition in the pretreatment radiolucent areas.  Pre-treatment clinical signs and symptoms should resolve within a few weeks.  There should be radiographic evidence of successful filling without gross overextension or underfilling. The treatment should permit resorption of the primary tooth root and filling material to permit normal eruption of the succedaneous tooth.  There should be no pathologic root resorption or furcation/apical radiolucency.
OBTURATING MATERIALS MOST COMMONLY USED IN PRIMARY TEETH
IDEAL PROPERTIES • Resorption rate should be similar to that of primary root. • Should not interfere in the eruption of permanent successors. • Should be harmless to periapical tissue and permanent tooth germ. • Should not cause foreign body reaction when pressed beyond the apex. • Should be antimicrobial and have easy handling property. • Should be easy to mix and fill the root canals.
• Material should be radio opaque. • Material should not discolor the tooth. • Should adhere to the canal walls and should not shrink. • Material should be economical.
• Zinc- Oxide eugenol cement • Iodoform - Walkhoff paste - KRI paste - Maisto paste • Calcium hydroxide • Calcium hydroxide + iodoform
ZINC- OXIDE EUGENOL CEMENT • The filling material of choice in the US is ZOE without a catalyst. ADVANTAGES Easy to mix Economical Time tested material DISADVANTAGES Overfilling- foreign body reaction. Resorption rate is less than that of the root. May deflect the path of permanent successors. Extrusion beyond the apex may cause hypoplastic changes in the permanent successors.
IODOFORM PREPARATIONS WALKHOFF PASTE- Sterilized iodoform paste Mixture of parachlorophenol, camphor, menthol KRI PASTE COMPOSITION- Iodoform 80.8% Camphor 4.9% Parachlorophenol 15% Menthol MAISTO PASTE- Iodoform 42g Zinc oxide 14g Thymol 2g Chlorophenol camphor 3cc Lanolin 0.50g
IODOFORM ADVANTAGES OF IODOFORM PREPARATIONS-  It can be easily forced into the pulp canals and any accessory canals.  Bactericidal paste.  Resorbs rapidly from the periapical tissue and root canal system.  Does not produce undesirable effects on the erupting permanent successors.  Iodoform is an ideal pulpectomy agent. It disinfects, is managed well clinically and resorbs simultaneously with the primary root. ( Ranly and Garcia Godoy, 1991)
• The antibacterial activity of an iodoform containing paste (KRI Paste) has been shown to be less than that of ZOE whereas its cytotoxicity in direct or indirect contact with the cells is equal to or greater than that of ZOE. • Several studies have endorsed iodoform paste as a biocompatible substitute for the ZOE –formocresol combination (Rifkin, 1980; Garcia Godoy, 1987)
CALCIUM HYDROXIDE • CALCIUM HYDROXIDE- IODOFORM MIXTURE ( VITAPEX/METAPEX) COMPOSITION Iodoform 40.4% Calcium hydroxide 30.3% Silicone 22.4% ADVANTAGES- Easy to apply. Radio-opaque. Resorbs at a faster rate than roots. Does not produce any toxic effects on erupting permanent successors.
Machida Y ,1983 considered calcium hydroxide- iodoform mixture as the Ideal primary tooth filling material : • Easy to apply • Resorbs at a slightly faster rate than that of the roots • Has no toxic effects on the permanent successor • Is radioopaque • Vitapex is particularly easy to use for primary incisors but less practical for narrow canals of primary molars.
• Another preparation with similar composition –US – ENDOFLAS ( Sanlor Laboratories, Columbia, South America) • One condition for success of endoflas is the prevention of microleakage. • A permanent restoration should be placed as soon as possible after clinical signs and symptoms of inflammation are eliminated.
COMPOSITION OF COMMONLY USED ROOT CANALS MATERIALS FOR PRIMARY TEETHWALKHOFF PASTE Parachlorophenol Camphor Menthol KRI PASTE Iodoform 80.8% Camphor 4.86% Parachlorophenol 2.025% Menthol 1.215% MAISTO PASTE Zinc oxide 14 g Iodoform 42 g Thymol 2g Chlorophenol Camphor 3cc Lanolin 0.5g VITAPEX Calcium hydroxide Iodoform Oily additives
ENDOFLAS Zinc oxide 56.5% Barium sulfate 1.63% Iodoform 40.6% Calcium hydroxide 1.07% Eugenol Pentachlorophenol COLLA COTE Synthetic collagen GUEDES- PINTO PASTE Iodoform 0.30g Calcium hydroxide 0.25g Camphorated paramonochlorophenol 0.1ml
DESIRABLE AND UNDESIRABLE PROPERTIES OF OBTURATING MATERIALS
COMPARISON OF THE PROPERTIES OF OBTURATING MATERIALS OBTURATING MATERIAL DESIRABLE PROPERTIES UNDESIRABLE PROPERTIES Zinc oxide eugenol cement Bactericidal properties Radio opacity Optimal manipulative properties Stable in the canal and maintains an optimally good periapical seal • takes longer time to resorb than dentin or cementum • material extruded into the periapical region stimulates a foreign body like reaction. •Resorbs incompletely with extraneous delay Calcium hydroxide cement High alkalinity Excellent antibacterial properties Optimal manipulative properties No foreign body like reaction Not discoverable in a radiograph Takes less time than dentin/cementum to resorb Does not obtain a stable periapical seal as zinc oxide eugenol
OBTURATING MATERIAL DESIRABLE PROPERTIES UNDESIRABLE PROPERTIES Iodoform paste Antibacterial properties and antiseptic properties Radioopaque Stable periapical seal Poor manipulative properties Calcium hydroxide + iodoform paste (Metapex, vitapex) Combined advantage of calcium hydroxide cement and iodoform. Excellent antibacterial properties. Optimal manipulative properties. Radio-opacity. Forms stable periapical seal. Material extruded in periapical region resorbs in 3 weeks. No distinct disadvantages except that antibacterial properties although optimal are less than those of calcium hydroxide cement
Zinc oxide eugenol + calcium hydroxide + iodoform All desirable properties of zinc oxide eugenol , calcium hydroxide and iodoform Forms a more stable periapical seal than calcium hydroxide + iodoform. Foreign body like reaction unlikely on material extrusion into the periapical region No distinct disadvantages Stability of the cement makes the material preferable as a root canal sealer than an obturating material for pulpectomy
ROTARY ENDODONTICS- • The rotary NiTi files are specially designed to provide superior flexibility and unmatched efficacy. • They enable clinicians to create uniformly tapered shapes in anatomically difficult and curved canals. • The latch type design of NiTi files allows the attachment to a handpiece.
Advantages – • Consistently dense fill due to uniform debridement . • Allows for greater apical enlargement • Prevent apical exposure • Reduced instrumentation time Disadvantages- • Skill is required for beginners. • Resorption of roots in primary teeth may cause a problem • Problem of breakage of files in the canals
KEDO ENDO FILES • Kedo-S rotary files is a single file system consisting of D1, E1 and U1 files. • The total length of these files is 16 mm and the working area (cutting flutes) 12 mm in length. • D1 Kedo-S file is designed to prepare the narrower canals of the primary teeth namely the mesiobuccal and mesiolingual canals and E1 Kedo-S file is to prepare the wider canals namely the distal and palatal canals of the primary molar teeth. The U1 Kedo-S file is used to prepare the upper and lower anterior primary teeth. • Kedo-S rotary files are recommended to be used with an endodontic motor in clockwise rotation at 300 (Revolutions Per Minute) RPM and 2.2 N cm torque.
Jeevanandan et al Clinical comparison of Kedo-S paediatric rotary files vs manual instrumentation for root canal preparation in primary molars: adouble blinded randomised clinical trial European Archives of Paediatric Dentistry. July 2018 Kedo-S exclusive paediatric rotary file system has shown reduced instrumentation time and superior obturation quality in primary molars. This system can be an effective alternative in performing root canal treatment in primary molars with great ease, thereby reducing the fatigue of dentists as well as the children. REVIEW OF LITERATURE
CRITERIA ACCEPTED FOR SUCCESSFUL PULPECTOMY -Given by Fuks et al • Pulp treated primary teeth that have limited degree of radiolucency or pathologic root resorption, in the absence of clinical signs and symptoms. • Check up in 6 months
Postoperative signs that indicate failure are • Swelling of gingival margin • Pus from gingival sulcus • Patent fistula • Excessive mobility • Sensitivity to percussion • Pain • Development of radiolucency at the apex or furcation • Premature root resorption
FOLLOW UP AFTER PRIMARY PULPECTOMY • Study reported a 20% incidence crossbites or palatal eruption of permanent incisors after pulpectomy on primary incisors. • In the posterior teeth extraction was required in 22% of the cases because of the ectopic eruption of the premolars or difficulty in exfoliation of the treated primary molars- Coll JA,Sadrian R, 1996 • After normal physiologic resorption of the roots reaches the pulp chamber, the large amount of ZOE present may impair the absorption and lead to prolonged retention of the crown. • Retention of filler was not related to success and caused no pathosis- Coll JA, Sadrian R, 1993
TOOTH BUD OF DEVELOPING SUCCEDANEOUS TOOTH • Manipulation through the apex of the primary tooth – contraindicated. • Overextension of root canal instruments and filling materials – avoided. • Working length – 2-3mm short of radiographic apex. • Hemorrhage after pulp removal –overextention.
• A total of 50 children, aged between 4 and 9 years, who were screened for unilateral or bilateral carious deciduous molars were studied. • Out of these, 15 children were randomly selected for endodontic treatment. Obturation was done with a mixture of zinc oxide powder and aloe vera gel. Clinical and radiographic evaluation was done after7 days, 1 month, 3 months, 6 months, and 9 months. Endodontic treatment using a mixture of zinc oxide powder and aloe vera gel in primary teeth has shown good clinical and radiographic success. Khairwa et al, Clinical and radiographic evaluation of zinc oxide with aloe vera as an obturating material in pulpectomy: An in vivo study JISPPD Jan Mar 2014, 32(1): 33-38 REVIEW OF LITERATURE
• Past inject exhibited the highest number of optimally filled canals, while the highest number of underfilled canals were observed with bi- directional spiral, and the highest number of overfilled canals were observed with pressure syringe. A minimum number of voids was present in canals filled with the Pastinject technique and pressure syringe. Grover R Mehra M, Pandit IK, Srivastava N, Gugnani N, Gupta M. Clinical efficacy of various root canal obturating methods in primary teeth: a comparative study Eur J Paediatr Dent. 2015 Jun;14(2):104-8. REVIEW OF LITERATURE
• A total of 239 canals were prepared and obturated with zinc-oxide eugenol paste. Obturation methods compared were: anesthetic syringe; NaviTip syringe; pressure syringe; tuberculin syringe; lentulo spiral; and packing with a plugger. • Lentulo produced the best results in terms of length of obturation, while NaviTip syringe produced the best results in controlling paste extrusion from the apical foramen and having the smallest void size and lowest number of voids. Memarpour M Shahidi S, Meshki R. Comparison of different obturation techniques for primary molars by digital radiography. Pediatr Dent. 2013 May-Jun;35(3):236-40. REVIEW OF LITERATURE
• Clinical and radiographic evaluation suggested that teeth obturated with ozonated oil-zinc oxide demonstrated good success rate (93.3 %) as compared to zinc oxide eugenol (63.3 %). However, no statistically significant variation (p = 0.408) was observed between the groups. • Ozonated oil-ZnO demonstrated a good clinical and radiographic success at 12 months follow-up and it can be considered as an alternative obturating material in infected primary teeth. S. P. Chandra, R. Chandrasekhar, K. S. Uloopi, C. Vinay, N. M. Kumar Success of root fillings with zinc oxide-ozonated oil in primary molars : preliminary results European Archives of Paediatric Dentistry June 2014, Volume 15, Issue 3, pp 191-195 REVIEW OF LITERATURE
• ZOE pulpectomy clearly delayed the root resorption of primary molars without permanent successors , whereas resorption of primary molars with Vitapex pulpectomy started at almost the same time as physiologic resorption. Compared with Vitapex, ZOE was a more effective root canal filling material in delaying the root resorption of primary molars. Ron et al Effects of zinc oxide-eugenol and calcium hydroxide/ iodoform on delaying root resorption in primary molars without successorsDental Materials Journal 2016; 33(4): 471–475 REVIEW OF LITERATURE
Ozone Therapy • With the emerging trends ,ozone will soon be the first choice in endodontics (non vital cases) and regenerative endodontics . • This therapy includes ozonated water, ozonated oil and ozonated aloe vera. • It is used along with file and as irrigant as it reaches all anatomies.
• OZONE IN PEDODONTICS- Dahnhardt et al studied treated open carious lesion with ozone in anxious children. In fact the children who will not get treatment of a very early stage of dental caries are most likely the ones who can be the most anxious and not cooperative during routine dental procedures. With ozone treatment 94 percent of the children were treatable and 93 percent lost their dental anxiety.
REFERENCES- • Pathways of Pulp – Stephen Cohen and Kenneth Hargreaves – 9th edition • Clinical Pedodontics – Sidney B Finn – 4th edition • Ingle’s Endodontics 7th edition • Textbook of pedodontics by Shobha Tandon -4th edition • Grossman Endodontic Practice -13th edition – Dr Gopikrishna
Pulpectomy

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Pulpectomy

  • 2.
  • 3.
    DEFINATIONS PRIMARY TEETH CONSIDERATIONS INDICATIONS CONTRAINDICATIONS PROCEDURE RULESFOR ACCESS CAVITY PREPERATION OBTURATING TECHNIQUES INSTRUMENTS OBTURATING MATERIALS CRITERIA FOR SUCCESS FOLLOW UP PULPECTOMY VS EXTRACTION
  • 4.
    DEFINATIONS Pulpectomy involves completeremoval of necrotic pulpal tissue from the root canals and coronal portion of non vital primary teeth to maintain a tooth in the dental arch. Richard J Mathewson, 1993 Pulpectomy refers to the removal of all pulpal tissue from the tooth, including both coronal and root portions. Sidney B Finn, 1999
  • 5.
    Pulpectomy is removalof the roof and contents of the pulp chamber in order to gain access to the root canals which are debrided, enlarged and disinfected. - Shobha tandon Gaining access to the root canals which are then debrided, enlarged, disinfected and filled with a resorbable material. - American Academy of Paediatric Dentistry, 1999
  • 6.
    WHY CONVENTIONAL ENDODONTIC THERAPY ISDIFFICULT IN PRIMARY TEETH ?
  • 7.
    • Hibbard andIreland, 1957, studied primary root canal morphology by removing pulp from extracted teeth, forcing acrylic resin into the pulp canals and dissolving the covering of tooth structure in 10% nitric acid. • They found that immediately following root formation, a single canal is usually present in each root. • Deposition of secondary dentin & accelerated physiological root resorption. • Variations included lateral branching, connecting fibrils, apical ramifications and partial fusion of
  • 8.
    • Another difficultyis the apparent connection between the coronal pulpal floor with the intraradicular area. –Moss et al, 1965 • These foramina allow the necrotic products to pass into the bifurcation or trifurcation area. • Using dyes and a vacuum system , Ringelstein and Seow ,1989 found that many of the foramina of primary second molars were located on the root surfaces.
  • 9.
    INDICATIONS TEETH PAIN HISTORYCLINICAL EXAMINATION RADIOGRAPHIC EXAMINATION Traumatised primary incisors and canines Spontaneous pain – generally occuring at night Presence of intraoral swelling or sinus Deep carious lesion extending upto the pulp Primary 1st molar before the second primary molar erupts Extensive bleeding from the site of amputation if pulpotomy procedure tried Inter radicular radiolucency Primary second molars, before eruption of first permanent molar Clinically evident carious exposure Pathologic root resorption not involving more than 1/3rd of the root Tenderness to percussion Moderate mobility Minimal destruction of the bone support
  • 10.
    CONTRAINDICATIONS • A nonrestorable tooth. • Internal resorption in the roots visible on the radiographs. • Excessive pathologic root resorption involving more than 1/3 rd of the root. • Teeth with mechanical or carious perforations of the floor of the pulp chamber.
  • 11.
    • Periapical orinterradicular lesion involving the crypt of the succedaneous tooth. • Excessive pathologic loss of bone support with loss of normal periodontal attachment. • The presence of a dentigerous or follicular cyst. • Chronic illness with leukemia, rheumatic and congenital heart disease, chronic kidney disease etc.
  • 12.
    PROCEDURE Local anaesthesia isgiven Isolate the tooth with rubber dam Prepare access cavity Remove all coronal pulp tissue with sharp spoon excavator Extirpate radicular pulp tissue with K files Irrigate with saline Determine the working length with the help of diagnostic radiograph
  • 13.
    Cleaning and shapingof the canals is done 1.5 – 2 mm short of radiographic apex proceeding sequentially from smaller to larger files Irrigate thoroughly to flush out all debris. Dry the canals with absorbed paper points. Obturate the tooth with a resorbable biocompatible material Restore with a permanent restoration and stainless steel crown
  • 14.
    STEPS IN PULPECTOMY STEPSIN PULPECTOMY INSTRUMENT USED PURPOSE Access cavity preparation Round bur Gain entry into chamber and remove dentinal roof Tapered fissure bur Remove overhanging dentin Endo Z Remove remaining carious dentin Coronal pulp extirpation NO 4 OR 8 excavator Extirpate coronal pulp Ensuring canal patency Endodontic explorer or smooth broach or 15 size K file Ensure patency of canal upto apex
  • 15.
    Radicular pulp extirpationBarbed broach Extirpate radicular pulp in toto Establishing working length K file with stopper Length determination radiograph Debridement and enlargement 21 mm H file Debride and enlarge root canal upto three times its size Irrigation Syringe, saline, sodium hypochlorite Done to flush out debris Drying Paperpoints Drying of enlarged root canal Obturation lentulo spirals and endodontic pressure syringe Obturate the canal with material without voids till the determined working length , without expulsion of material into apex Bulk restoration composite restoration GIC Fill the access cavity
  • 16.
    Post endodontic restoration Stainless steelcrown Post endodntic rehabilitation of a pulpectomised tooth Review every 6 months Mouth mirror, probe, radiograph Check for signs or symptoms of irreversible pulpitis, dentoalveolar abscess and appropriate root resorption
  • 17.
    RULES FOR PROPERACCESS PREPARATION • ENDODONTIC DOGMA “ Careful cavity preparation and root canal obturation are the keystones to successful root canal therapy” • The objective of entry is to gain direct access to the apical foramina and not merely to the canal orifices. • Access cavity preparation are not guided by topography of occlusal grooves, pits and fissures.
  • 18.
    • Radiographs takenfrom different angles must be considered. • Endodontic entries are prepared always through the occlusal or lingual surface. • The unsupported cusps of posterior teeth must be reduced to avoid weakening of the tooth structure.
  • 19.
    ACCESS OPENINGS FORPULPECTOMY ANTERIOR PRIMARY TEETH • Traditionally – lingual surface except for discolored maxillary primary incisors. • Discoloration – escape of hemosiderin pigments into the dentinal tubules. • Root canal is filled with ZOE. • Dycal is placed over ZOE to serve as a barrier between the composite resin and root canal filling.
  • 20.
    POSTERIOR PRIMARY TEETH •Less extension towards the exterior of the tooth. • Working length radiograph – paralleling technique. • 2-3 mm short of radiographic length. • Thin walls of the roots- use of sonic and ultrasonic cleaning devices, Gates Glidden drills– contraindicated. Nickel –Titanium instruments recommended.
  • 21.
    Important differences betweenthe primary and permanent teeth are-  Length and bulbous shape of the crowns  A very thin dentinal wall at the pulpal floor  The depth necessary to penetrate into the pulp chamber is quite less than that in the permanent teeth  Likewise, the distance from the occlusal surface to the pulpal floor is much less than in permanent teeth.
  • 22.
    To achieve optimalpreparation. three factors are considered- -Size of pulp chamber- More extensive preparation in young children than older -Shape of pulp chamber – The finished outline should accurately mimic the shape of the pulp chamber. -Number ,position and curvature of the root canals
  • 23.
  • 24.
    TECHNIQUES OF ROOTCANAL FILLING IN PRIMARY TEETH  Pressure Syringe Technique –Greenberg (Pulpdent corporation, America).  Disposable tuberculin syringe or Local Anaesthetic syringe technique.  Slowly rotating Lentulo Spiral Technique.  Jiffy tubes  Incremental pressure syringe
  • 25.
    PRESSURE SYRINGE • Comprises TECHNIQUE •The filling material – heavy putty like consistency. • Hub of the needle –loaded with the paste. • Needle is threaded on the syringe barrel, plunger is turned. • Needle is reinserted in the canal , tip is repositioned 1mm short Syringe barrel Threaded plunger Wrench Threaded needles (gauge 13-30)
  • 26.
    PRESSURE SYRINGE TECHNIQUE •Threaded plunger- one hand, wrench in opposite hand. • Threaded plunger is adjusted one quarter turn and retracted slightly. • Additional condensation – moist cotton pellet. • Multiple canals – 2 periapical films Weisz, 1976 designated pressure syringe as the optimal selection for exact placement of paste within apical portions of fine and tortuous canals. He found the spiral lentulo most effective in treating single rooted teeth with straight canals.
  • 28.
    LENTULOSPIRAL TECHNIQUE • Pastescan also be filled by means of lentulo spiral mounted on the micro motor hand piece. They have shown the success rate of 96% and 92% when hand held. The direction of rotation needs to be checked for the material to properly flow into the canals
  • 29.
    • The primaryteeth with their larger canals can be filled with the thin mix coating the walls of the canal with the help of a reamer in an anti clock wise direction while taking it out slowly followed by the placement of the thicker mix which is then pushed manually.
  • 30.
    • Root lengthis the most reliable criteria of root integrity and atleast 4mm of the root length is necessary for the primary tooth to be treatable. – Rimmondini L, Baroni C, 1995 • If the inflammation is beyond the coronal pulp with only interradicular but no periapical radiolucency, a single visit pulpectomy is preffered. On the other hand if the pulp is necrotic with periapical involvement , filling procedure is delayed.
  • 31.
    According to Finn- •Care should be observed not to penetrate past the apical ends of the tooth when reaming out of the canals. • Secondly, a resorbable compound such as zinc oxide eugenol should be used as a filling material. Silver points and gutta percha should not be placed. • Thirdly filling material should be introduced into the canal with light pressure. • Fourthly, apicoectomy should not be performed except in the absence of a developing permanent tooth.
  • 32.
    REVIEW OF LITERATURE Acceptableresult was obtained with lentulospiral in length of obturation compared to insulin syringe and endodontic plugger technique. Insulin syringe technique resulted in increased underfilling with least number of voids. More number of voids were seen in middle one-third and least number of voids were observed at apical one third of the root among all the 3 techniques of obturation. The study concluded that void identification is improved with D.I.O.R compared to C.B.C.T. Akhil JEJ et al Comparative evaluation of three obturation techniques in primary incisors using digital intra-oral receptor and C.B.C.T-an in vitro study. Clin Oral investgn 2018 May 10.
  • 33.
    AAPD GUIDELINES  Followingtreatment, the radiographic infectious process should resolve in 6 months, as evidenced by bone deposition in the pretreatment radiolucent areas.  Pre-treatment clinical signs and symptoms should resolve within a few weeks.  There should be radiographic evidence of successful filling without gross overextension or underfilling. The treatment should permit resorption of the primary tooth root and filling material to permit normal eruption of the succedaneous tooth.  There should be no pathologic root resorption or furcation/apical radiolucency.
  • 34.
  • 35.
    IDEAL PROPERTIES • Resorptionrate should be similar to that of primary root. • Should not interfere in the eruption of permanent successors. • Should be harmless to periapical tissue and permanent tooth germ. • Should not cause foreign body reaction when pressed beyond the apex. • Should be antimicrobial and have easy handling property. • Should be easy to mix and fill the root canals.
  • 36.
    • Material shouldbe radio opaque. • Material should not discolor the tooth. • Should adhere to the canal walls and should not shrink. • Material should be economical.
  • 37.
    • Zinc- Oxideeugenol cement • Iodoform - Walkhoff paste - KRI paste - Maisto paste • Calcium hydroxide • Calcium hydroxide + iodoform
  • 38.
    ZINC- OXIDE EUGENOLCEMENT • The filling material of choice in the US is ZOE without a catalyst. ADVANTAGES Easy to mix Economical Time tested material DISADVANTAGES Overfilling- foreign body reaction. Resorption rate is less than that of the root. May deflect the path of permanent successors. Extrusion beyond the apex may cause hypoplastic changes in the permanent successors.
  • 39.
    IODOFORM PREPARATIONS WALKHOFF PASTE- Sterilizediodoform paste Mixture of parachlorophenol, camphor, menthol KRI PASTE COMPOSITION- Iodoform 80.8% Camphor 4.9% Parachlorophenol 15% Menthol MAISTO PASTE- Iodoform 42g Zinc oxide 14g Thymol 2g Chlorophenol camphor 3cc Lanolin 0.50g
  • 40.
    IODOFORM ADVANTAGES OF IODOFORMPREPARATIONS-  It can be easily forced into the pulp canals and any accessory canals.  Bactericidal paste.  Resorbs rapidly from the periapical tissue and root canal system.  Does not produce undesirable effects on the erupting permanent successors.  Iodoform is an ideal pulpectomy agent. It disinfects, is managed well clinically and resorbs simultaneously with the primary root. ( Ranly and Garcia Godoy, 1991)
  • 41.
    • The antibacterialactivity of an iodoform containing paste (KRI Paste) has been shown to be less than that of ZOE whereas its cytotoxicity in direct or indirect contact with the cells is equal to or greater than that of ZOE. • Several studies have endorsed iodoform paste as a biocompatible substitute for the ZOE –formocresol combination (Rifkin, 1980; Garcia Godoy, 1987)
  • 42.
    CALCIUM HYDROXIDE • CALCIUMHYDROXIDE- IODOFORM MIXTURE ( VITAPEX/METAPEX) COMPOSITION Iodoform 40.4% Calcium hydroxide 30.3% Silicone 22.4% ADVANTAGES- Easy to apply. Radio-opaque. Resorbs at a faster rate than roots. Does not produce any toxic effects on erupting permanent successors.
  • 43.
    Machida Y ,1983considered calcium hydroxide- iodoform mixture as the Ideal primary tooth filling material : • Easy to apply • Resorbs at a slightly faster rate than that of the roots • Has no toxic effects on the permanent successor • Is radioopaque • Vitapex is particularly easy to use for primary incisors but less practical for narrow canals of primary molars.
  • 44.
    • Another preparationwith similar composition –US – ENDOFLAS ( Sanlor Laboratories, Columbia, South America) • One condition for success of endoflas is the prevention of microleakage. • A permanent restoration should be placed as soon as possible after clinical signs and symptoms of inflammation are eliminated.
  • 45.
    COMPOSITION OF COMMONLYUSED ROOT CANALS MATERIALS FOR PRIMARY TEETHWALKHOFF PASTE Parachlorophenol Camphor Menthol KRI PASTE Iodoform 80.8% Camphor 4.86% Parachlorophenol 2.025% Menthol 1.215% MAISTO PASTE Zinc oxide 14 g Iodoform 42 g Thymol 2g Chlorophenol Camphor 3cc Lanolin 0.5g VITAPEX Calcium hydroxide Iodoform Oily additives
  • 46.
    ENDOFLAS Zinc oxide 56.5% Bariumsulfate 1.63% Iodoform 40.6% Calcium hydroxide 1.07% Eugenol Pentachlorophenol COLLA COTE Synthetic collagen GUEDES- PINTO PASTE Iodoform 0.30g Calcium hydroxide 0.25g Camphorated paramonochlorophenol 0.1ml
  • 47.
    DESIRABLE AND UNDESIRABLE PROPERTIESOF OBTURATING MATERIALS
  • 48.
    COMPARISON OF THEPROPERTIES OF OBTURATING MATERIALS OBTURATING MATERIAL DESIRABLE PROPERTIES UNDESIRABLE PROPERTIES Zinc oxide eugenol cement Bactericidal properties Radio opacity Optimal manipulative properties Stable in the canal and maintains an optimally good periapical seal • takes longer time to resorb than dentin or cementum • material extruded into the periapical region stimulates a foreign body like reaction. •Resorbs incompletely with extraneous delay Calcium hydroxide cement High alkalinity Excellent antibacterial properties Optimal manipulative properties No foreign body like reaction Not discoverable in a radiograph Takes less time than dentin/cementum to resorb Does not obtain a stable periapical seal as zinc oxide eugenol
  • 49.
    OBTURATING MATERIAL DESIRABLEPROPERTIES UNDESIRABLE PROPERTIES Iodoform paste Antibacterial properties and antiseptic properties Radioopaque Stable periapical seal Poor manipulative properties Calcium hydroxide + iodoform paste (Metapex, vitapex) Combined advantage of calcium hydroxide cement and iodoform. Excellent antibacterial properties. Optimal manipulative properties. Radio-opacity. Forms stable periapical seal. Material extruded in periapical region resorbs in 3 weeks. No distinct disadvantages except that antibacterial properties although optimal are less than those of calcium hydroxide cement
  • 50.
    Zinc oxide eugenol+ calcium hydroxide + iodoform All desirable properties of zinc oxide eugenol , calcium hydroxide and iodoform Forms a more stable periapical seal than calcium hydroxide + iodoform. Foreign body like reaction unlikely on material extrusion into the periapical region No distinct disadvantages Stability of the cement makes the material preferable as a root canal sealer than an obturating material for pulpectomy
  • 51.
    ROTARY ENDODONTICS- • Therotary NiTi files are specially designed to provide superior flexibility and unmatched efficacy. • They enable clinicians to create uniformly tapered shapes in anatomically difficult and curved canals. • The latch type design of NiTi files allows the attachment to a handpiece.
  • 52.
    Advantages – • Consistentlydense fill due to uniform debridement . • Allows for greater apical enlargement • Prevent apical exposure • Reduced instrumentation time Disadvantages- • Skill is required for beginners. • Resorption of roots in primary teeth may cause a problem • Problem of breakage of files in the canals
  • 53.
    KEDO ENDO FILES •Kedo-S rotary files is a single file system consisting of D1, E1 and U1 files. • The total length of these files is 16 mm and the working area (cutting flutes) 12 mm in length. • D1 Kedo-S file is designed to prepare the narrower canals of the primary teeth namely the mesiobuccal and mesiolingual canals and E1 Kedo-S file is to prepare the wider canals namely the distal and palatal canals of the primary molar teeth. The U1 Kedo-S file is used to prepare the upper and lower anterior primary teeth. • Kedo-S rotary files are recommended to be used with an endodontic motor in clockwise rotation at 300 (Revolutions Per Minute) RPM and 2.2 N cm torque.
  • 55.
    Jeevanandan et alClinical comparison of Kedo-S paediatric rotary files vs manual instrumentation for root canal preparation in primary molars: adouble blinded randomised clinical trial European Archives of Paediatric Dentistry. July 2018 Kedo-S exclusive paediatric rotary file system has shown reduced instrumentation time and superior obturation quality in primary molars. This system can be an effective alternative in performing root canal treatment in primary molars with great ease, thereby reducing the fatigue of dentists as well as the children. REVIEW OF LITERATURE
  • 56.
    CRITERIA ACCEPTED FORSUCCESSFUL PULPECTOMY -Given by Fuks et al • Pulp treated primary teeth that have limited degree of radiolucency or pathologic root resorption, in the absence of clinical signs and symptoms. • Check up in 6 months
  • 57.
    Postoperative signs thatindicate failure are • Swelling of gingival margin • Pus from gingival sulcus • Patent fistula • Excessive mobility • Sensitivity to percussion • Pain • Development of radiolucency at the apex or furcation • Premature root resorption
  • 58.
    FOLLOW UP AFTERPRIMARY PULPECTOMY • Study reported a 20% incidence crossbites or palatal eruption of permanent incisors after pulpectomy on primary incisors. • In the posterior teeth extraction was required in 22% of the cases because of the ectopic eruption of the premolars or difficulty in exfoliation of the treated primary molars- Coll JA,Sadrian R, 1996 • After normal physiologic resorption of the roots reaches the pulp chamber, the large amount of ZOE present may impair the absorption and lead to prolonged retention of the crown. • Retention of filler was not related to success and caused no pathosis- Coll JA, Sadrian R, 1993
  • 59.
    TOOTH BUD OFDEVELOPING SUCCEDANEOUS TOOTH • Manipulation through the apex of the primary tooth – contraindicated. • Overextension of root canal instruments and filling materials – avoided. • Working length – 2-3mm short of radiographic apex. • Hemorrhage after pulp removal –overextention.
  • 60.
    • A totalof 50 children, aged between 4 and 9 years, who were screened for unilateral or bilateral carious deciduous molars were studied. • Out of these, 15 children were randomly selected for endodontic treatment. Obturation was done with a mixture of zinc oxide powder and aloe vera gel. Clinical and radiographic evaluation was done after7 days, 1 month, 3 months, 6 months, and 9 months. Endodontic treatment using a mixture of zinc oxide powder and aloe vera gel in primary teeth has shown good clinical and radiographic success. Khairwa et al, Clinical and radiographic evaluation of zinc oxide with aloe vera as an obturating material in pulpectomy: An in vivo study JISPPD Jan Mar 2014, 32(1): 33-38 REVIEW OF LITERATURE
  • 61.
    • Past injectexhibited the highest number of optimally filled canals, while the highest number of underfilled canals were observed with bi- directional spiral, and the highest number of overfilled canals were observed with pressure syringe. A minimum number of voids was present in canals filled with the Pastinject technique and pressure syringe. Grover R Mehra M, Pandit IK, Srivastava N, Gugnani N, Gupta M. Clinical efficacy of various root canal obturating methods in primary teeth: a comparative study Eur J Paediatr Dent. 2015 Jun;14(2):104-8. REVIEW OF LITERATURE
  • 62.
    • A totalof 239 canals were prepared and obturated with zinc-oxide eugenol paste. Obturation methods compared were: anesthetic syringe; NaviTip syringe; pressure syringe; tuberculin syringe; lentulo spiral; and packing with a plugger. • Lentulo produced the best results in terms of length of obturation, while NaviTip syringe produced the best results in controlling paste extrusion from the apical foramen and having the smallest void size and lowest number of voids. Memarpour M Shahidi S, Meshki R. Comparison of different obturation techniques for primary molars by digital radiography. Pediatr Dent. 2013 May-Jun;35(3):236-40. REVIEW OF LITERATURE
  • 63.
    • Clinical andradiographic evaluation suggested that teeth obturated with ozonated oil-zinc oxide demonstrated good success rate (93.3 %) as compared to zinc oxide eugenol (63.3 %). However, no statistically significant variation (p = 0.408) was observed between the groups. • Ozonated oil-ZnO demonstrated a good clinical and radiographic success at 12 months follow-up and it can be considered as an alternative obturating material in infected primary teeth. S. P. Chandra, R. Chandrasekhar, K. S. Uloopi, C. Vinay, N. M. Kumar Success of root fillings with zinc oxide-ozonated oil in primary molars : preliminary results European Archives of Paediatric Dentistry June 2014, Volume 15, Issue 3, pp 191-195 REVIEW OF LITERATURE
  • 64.
    • ZOE pulpectomyclearly delayed the root resorption of primary molars without permanent successors , whereas resorption of primary molars with Vitapex pulpectomy started at almost the same time as physiologic resorption. Compared with Vitapex, ZOE was a more effective root canal filling material in delaying the root resorption of primary molars. Ron et al Effects of zinc oxide-eugenol and calcium hydroxide/ iodoform on delaying root resorption in primary molars without successorsDental Materials Journal 2016; 33(4): 471–475 REVIEW OF LITERATURE
  • 65.
    Ozone Therapy • Withthe emerging trends ,ozone will soon be the first choice in endodontics (non vital cases) and regenerative endodontics . • This therapy includes ozonated water, ozonated oil and ozonated aloe vera. • It is used along with file and as irrigant as it reaches all anatomies.
  • 66.
    • OZONE INPEDODONTICS- Dahnhardt et al studied treated open carious lesion with ozone in anxious children. In fact the children who will not get treatment of a very early stage of dental caries are most likely the ones who can be the most anxious and not cooperative during routine dental procedures. With ozone treatment 94 percent of the children were treatable and 93 percent lost their dental anxiety.
  • 67.
    REFERENCES- • Pathways ofPulp – Stephen Cohen and Kenneth Hargreaves – 9th edition • Clinical Pedodontics – Sidney B Finn – 4th edition • Ingle’s Endodontics 7th edition • Textbook of pedodontics by Shobha Tandon -4th edition • Grossman Endodontic Practice -13th edition – Dr Gopikrishna