7. non vital pulp therapy

pulpectomy techniques and methods, apexification

1. NON-VITAL PULP THERAPY IN PRIMARY TEETH Presented by Dr. Shivani S. Singh P.G 2 nd year

2. CONTENTS Introduction Definitions Objectives Indications Contraindications Types of pulpectomy Partial pulpectomy Complete pulpectomy Single-visit pulpectomy Multiple-visit pulpectomy I rrigants Intracanal medicaments Obturation materials Obturation techniques Failures in pulpectomy Conclusion References

3. INTRODUCTION Despite modern advances in prevention of dental caries and increased understanding of importance of maintaining the natural dentition, many teeth are lost prematurely. This can lead to malocclusion , aesthetic, phonetic or functional problems. When confronted with an infected and/or necrotic pulp in primary teeth, dentists have two options: the first is to extract the tooth and provide a space maintainer (when needed) to preserve space for the erupting permanent successor, and the other option includes removal of pulp remnants and root canal obturation followed by crown reconstruction.

4. The lack of treatment is not an option as it can cause damage to the succedaneous tooth (e.g., enamel hypo-mineralization or hypoplasia) and negatively impact the child’s oral health-related quality of life (e.g., pain, eating preferences, quantity of food eaten, and sleep habits) Maintaining the intrigity and health of oral tissues is the primary objective of pulp therapies.

5. DEFINITIONS Mathewson 1995 defined pulpectomy as a complete removal of the necrotic pulp from the root canals and the coronal portion of the primary teeth in order to maintain the tooth in the dental arch. Finn defines pulpectomy as removal of all pulpal tissue from the coronal and radicular portions of the teeth . Ingle defined the technique of primary teeth as “debridement and filling of pulp less canals.”

6. OBJECTIVES The main objective of pulp therapy in non-vital primary teeth is to eliminate infection and retain the tooth in a functional state until it is normally exfoliated, without endangering the permanent dentition or the health of the child. Garcia–Godoy (1987) Bio-mechanically cleanse and obturate the root canal Promote physiologic root resorption Enhance development of proper mastication, phonetics and swallowing

7. INDICATIONS Presence of inflamed but vital radicular pulp An asymptomatic primary tooth with necrotic pulp tissue, without any acute symptoms such as cellulitis. Primary teeth with evidence of furcation pathology Presence of an abscess A tooth planned for pulpotomy had excessive hemorrhage (hyperemia)

8. Irreversible inflammation extending to radicular pulp Necrotic pulp Furcation pathology

9. CONTRAINDICATIONS Unrestorable crown Advanced pathological root resorption Peri-radicular involvement extending to the permanent tooth bud. Excessive internal resorption. Primary teeth with underlying dentigerous or follicular cysts Internal and external resorption Unrestorable crown

10. MEDICAL CONTRAINDICATIONS Systemic illness such as congenital or rheumatic heart disease Hepatitis Leukemia Children on long term corticosteroid therapy or those who are immunocompromised

11. CLINICAL CRITERIAS History of spontaneous pain with deep carious lesion Nocturnal pain Tenderness on percussion Presence of abnormal mobility ( Grade I ) Presence of abscess or fistula

12. RADIOGRAPHIC CRITERIAS Presence of radiolucency in the inter-radicular and periradicular area not involving permanent tooth bud Adequate bone support Absence of internal resorption and external pathologic resorption

13. PULPECTOMY PARTIAL PULPECTOMY COMPLETE PULPECTOMY MULTIPLE VISIT PROCEDURE SINGLE VISIT PROCEDURE

14. PARTIAL PULPECTOMY “Pulpotomy” and “partial pulpectomy” were initially used interchangeably to refer to the excision or amputation of the pulp contents in the coronal portion of the pulp (pulp chamber) without disturbing the content of the root canal. Currently, “Partial pulpectomy” is widely used to refer to “an apical extension of pulpotomy procedure” in which the coronal portion of the radicular pulp is amputated, leaving vital tissues in the canal that is assumed to be healthy.

15. MORTAL PULPOTOMY It is also called non vital pulpotomy Ideally, non vital tooth should be treated by pulpectomy, but sometimes it is impracticable due to non-negotiable root canals and limited patient cooperation, mortal pulpotomy is indicated for such patients.

16. COMPLETE PULPECTOMY Pulpectomy involves removal of the roof and contents of the pulp chamber in order to gain access to the root canal which are debrided, enlarged, and disinfected and filled with a RESORBABLE material.

17. Single visit pulpectomy This is carried out as an extension of pulpotomy procedure, probably on the spot decision when hemorrhage from amputated pulp stumps is uncontrollable but the tooth does not show any periapical changes. Indications include: Large carious exposure with frank involvement of radicular pulp but without any periapical changes. Primary teeth with inflammation extending beyond coronal pulp, indicated by hemorrhage from the amputated radicular stumps that is dark red, a slowly oozing and uncontrollable

18. PROCEDURE OF SINGLE VISIT PULPECTOMY 1. Anesthetize the tooth and isolate it 2. Prepare the access cavity 3. Remove all accessible coronal and radicular pulp tissues. 4. Determine the working length post irrigation

19. 5. cleaning and shaping of canals 6 . Through irrigation 7. Drying of the root canals 4. obturation followed by final restoration and crown

20. MULTIPLE VISIT PULPECTOMY Indications: (Given by Paterson and Curzon in 1992) In cases of infection, an abscess or chronic sinus exists Nonvital primary teeth Teeth with necrotic pulp and periapical involvement.

21. Procedure of multiple visit pulpectomy Clinical technique is similar to single visit pulpectomy but all the procedures are not done at the first visit. In the first visit the pulp is extirpated and the canal are irrigated, dried and filled with temporary material. In the second viit the canal i enlarged and if all the symptoms have subsided the canals are obturated. Obturation is postponed until the symptoms have regressed. Final restoration is done followed by stainless steel crown.

22. ACCESS CAVITY PREPARATION Access cavity = pulp space morphology Objectives : Locating all the canals Straight line access to the apical third of the canal Removal of the chamber roof and the coronal pulp tissue Conservation of the tooth structure.

23. Differences in the access opening b/w primary & permanent teeth The depth necessary to penetrate the pulpal chamber is very less compared to permanent. Distance from the occlusal surface to the pulp floor is less compared to permanent teeth. Very thin dentin wall at the pulpal floor. Crown is more bulbous. (less extension towards the exterior is needed to uncover the canal orifices than in permanent teeth.)

24. What is the need to obtain a straight access??? It is the most critical aspect Eases the introduction of instrument Improves obturation Decreases the procedural errors like ledges, perforations Removes the tooth portions lying on strategic areas thereby prevents weakening of tooth

25. Guidelines to prepare an access cavity Instruments not deflected by the cavity walls Large enough to complete debridement Not to extend cavity large – weakens the tooth Floor of the pulp chamber (post. teeth) not to be disturbed Exploration of the canal orifice Endodontic explorer -poking action feeling along the walls and into the chamber floor Endodontic curved pathfinder file - control probing, poking, twisting and turning can help to establish the working length using a watch winding type of finger action

26. Determination of working length The distance between the apical limit to instrument and the point from which the measurement is to be made coronally Reference point- occlusal or incisal surface The working length is ideally kept 1-2 mm short of radiographic apex If obvious signs of root resorption are present its may be necessary to further shorten the root length by additional 1-2 mm in order to avoid over-extension of instrument into the periapical tissues. Importance Apical perforation and damage to the successor tooth bud Overfilling / Underfilling Incomplete instrumentation Ledge formation

27. Methods of determining working length Radiographic Ingle’s method Weine’s modification (No resorption of root / bone – 1 mm short, Periradicular bone resorption – 1.5 mm short, Root and bone resorption – 2 mm short Grossman’s method true tooth length = true instrument length radiographic tooth length radiographic instrument length Thus, Working length = true tooth length – 1 to 1.5 mm Best’s method Bregman’s method Bramante’s method Kutler’s method Radiographic grid Digital radiography

28. Non-radiographic method Digital tactile senses Apical Periodontal sensitivity Electronic apex locator Resistance type Impedance type (Katz A et al) Frequency type Paper point method The radiographic method described by Ingle is the most common and reliable method in determining the working length of teeth undergoing pulpectomy. Conventional radiographic method of determining working length has shortcoming in that it depend on the child’s cooperation as well as the operators proficiency. In addition minor degree of resorption may not be visible and overlapping be adjacent anatomical structures can obscure the clarity of image (Priya et.al,2005) Katzl et.al, 1996 conducted a study to determine working length in dry and wet canals using apex locator and found no significant difference in the two groups.

29. irrigants Just as the old saying goes "Man does not live by bread alone"' the pulp system is not cleaned and shaped exclusively by instruments but the important adjuncts are the irrigants. In fact the other half of canal debridement is irrigation. In theory, the files loosen and disrupt materials within the canals and remove dentin from the walls as shavings, this whole is then flushed out with an irrigant. It is mandatory to accomplish instrumentation in a wet canal to facilitate the removal of the dentin filings and to help prevent them from plugging up the narrower apical portion of the canal. (Kopal et.al, 1998) stated that the debridement of the primary root canal is more often accompanied by chemical means than by mechanical means.

30. Primary root canal involve many pulpal ramification which can not be reached mechanically. Copious irrigation with 2.25% sodium hypochlorite (dissolves organic debris) and to produce effervescence plays important role in removal tissue from the inaccessible area of root canal system. In primary teeth attempt to prepare a circular apical 1/3 rd mechanically may result in lateral perforation of the canal because of its HOUR GLASS SHAPE . Thus, “ Chemomechanical preparation ” is done in primary teeth not “Biomechanical preparation”.

31. IDEAL PROPERTIES OF AN INTRACANAL IRRIGANT Tissue/debris dissolution. Low toxicity so as to be nonreactive to the periapical tissues. Low surface tension to promote the flow of irrigant into inaccessible area. Lubricant property to enable the instrument to slide readily down the canal. Sterilization to remove and destroy microorganisms from the canal space. Flushing out of gross debris, irrigants was out debris and help to prevent blockages caused by compaction of accumulated debris. In addition, the chemical action of irrigants is possible only when it wets the substrate sufficiently.

32. Various intracanal irrigant that can be used in pulpectomy Sodium Hypochlorite (NaOCl) Chlorhexidine EDTA and Citric Acid Mixture of Doxycycline and Citric Acid with a Detergent (MTAD) Tetraclean Hydrogen Peroxide ( H 2 O 2 ) Smear Clear Electrochemically activated solutions Ozonated water Herbal irrigants Triphala And Green Tea Polyphenols Morinda Citrifolia (Noni) Miswak German Chamomile And Tea Tree Oil

33. SODIUM HYPOCHLORITE (NAOCL) NaOCl is the most commonly used solution used in dentistry. NaOCl gives rise to sodium and hypochlorite ions when combined with water, there by establishing equilibrium with hypochlorous acid which is responsible for the antibacterial activity. It has the ability to dissolve organic components such as pulpal remnants and collagen. NaOCl cannot remove the smear layer produced during instrumentation. The concentration of NaOCl should be 2.5%. The disadvantages of NaOCl: It has an unpleasant odour and taste. It does not consistently disinfect the root canal system. It is toxic when extruded in to the periradicular tissues. It can damage permanent tooth follicles. It reacts with other irrigating solutions like chlorhexidine .

34. CHLORHEXIDINE C hlorhexidine reacts with negatively charged groups on the surface of bacterial cells, thereby damaging and reducing intracanal bacteria. Chlorhexidine generally suggested to be used in pulpectomy of necrotic primary teeth at 2% concentration. Disadvantages of Chlorhexidine: I nflammatory responses were seen when chlorhexidine is accidentally injected beyond the root apex. It is incapable dissolving necrotic tissue. It has limited action on gram negative organisms.

35. ETHYLENE DIAMINE TETRA ACETIC ACID AND CITRIC ACID EDTA is most commonly used as 17% neutralized solution . Citric acid is made available in various concentrations from 1 to 50%, although 10% CA is more commonly used as it is effective in removal of the smear layer. EDTA and CA are available as liquids and gels. They effectively dissolve the inorganic component and smear layer with little or no effect on organic tissue. However, they themselves do not possess any anti­bacterial activity. Though smear layer removal was better when EDTA is used in combination with sodium hypochlorite, damage to the dentinal tubules, peritubular dentin erosion and disruption of intertubular dentin was found. Studies have shown irrigation with 6% CA for 15 or 30 seconds is quite effective in removing all the components of the smear layer of the primary teeth whereas peritubular dentin destruction was observed when higher concentration of CA was used as an irrigating solution.

36. MIXTURE OF DOXYCYCLINE AND CITRIC ACID WITH A DETERGENT Torabinejad et al introduced MTAD which is a mixture of 3% doxycycline, 4.25% and detergent-Tween 80. It has been as an alternative to EDTA which removes the smear layer effectively when used as a final rinse to disinfect the root canals of primary teeth and possesses antibacterial and chelating properties. Studies have shown that MTAD is effective in removal of smear layer without causing any significant changes in the structure of dentinal tubules when used as a final rinse followed by irrigation with Naocl with superior antimicrobial efficacy and less cytotoxicity Its use as the final irrigant has shown to meet all the standards for good irrigant prescribed. It proves it to be an effective irrigant for the primary teeth. However the use of MTAD in primary teeth is limited because of chance of discoloration in permanent buds present below. However, its use in young permanent teeth may not be controversial.

37. tetraclean Tetraclean, is a mixture of an antibiotic, an acid (citric acid), and a detergent(polypropylene glycol). The concentration of citric acid and the type of detergent used varies from that of MTAD. The properties of tetraclean is due to its low surface tension which enables better adaptation of the mixtures to the dentinal walls. It removes the smear layer, effective against strictly anaerobic and facultative anaerobic bacteria like E. faecalis.

38. Hydrogen peroxide Hydrogen peroxide was used for many years as an endodontic irrigant. H 2 O 2 is a widely used biocide for disinfection and sterilization. Hydrogen peroxide is a clear colorless liquid that is used in a variety of concentrations in dentistry ranging from 1% to 30%. H 2 O 2 is active against viruses, bacteria, yeast and even bacterial spores. It has greater activity against gram positive bacteria. H 2 O 2 produces hydroxyl free radicals which attacks cell components such as proteins in bacteria. Disadvantages of hydrogen peroxide ( H 2 O 2 ): At high concentration hydrogen peroxide is not well tolerated in the body and might play a role in the development of cervical resorption.

39. Smear clear Smear clear contains 17% EDTA along with cetrimide and additional proprietary surfactants. These components aid in the removal of inorganic matter left in the canal during instrumentation. According to different studies smear clear has been found to be effective against gram positive and gram negative organisms due to the presence of cetrimide which is a quaternary ammonium compound and a cationic detergent.

40. Electrochemically activated solution A mixture of tap water in low concentrated salt solution forms the electrochemically activated solutions. This results in the synthesis of anolyte and catholyte. The oxidative properties of anolyte exhibit antimicrobial activity against bacterias, viruses, fungus and protozoa. The solution is also known as superoxidized water or oxidative potential water. Due to various advantages such as removal of debris and smear layer as well as having non-toxic properties, it can be used as potential root canal irrigants.

41. Ozonated water Ozone is a chemical compound consisting of 3 oxygen atoms. Ozone is capable of oxidizing any biological entity due to its bacterial properties even at low concentrations. Studies have shown that when ozonized water was used with sonification as an irrigant, the bacterial ability of ozonized water and 2.5% sodium hypochlorite was found to be comparable.

42. Herbal irrigants The use of herbal products in the field of medicine has been practiced since ancient times and has significantly increased over the last few decades. In recent endodontics because of the limitations of most of the commercial intracanal medicaments used such as cytotoxicity and their inability to eliminate bacteria from dentinal tubules, trend of recent medicine to use biologic medication extracted from natural plants is drawing a lot of attention. The major advantages of using herbal alternatives are easy availability, cost-effectiveness, increased shelf life, low toxicity, and lack of microbial resistance reported. Literature has shown that herbs can have a promising role as root canal irrigants.

43. Triphala and green tea polyphenols Triphala is an ayurvedic formulation consisting of dried powdered fruits of 3 medicinal plants. Terminalia bellerica, Terminalia chebula, Emblica officinalis Triphala consist of fruits that are rich in citric acid, which may aid in the removal of smear layer. The polyphenols found in green tea are known as flavanols and have significant antioxidant, anticariogenic, anti-inflammatory, thermogenic, probiotic and antimicrobial properties. Studies have shown that triphala and green tea when used as an irrigant had antimicrobial activity.

44. Morinda citrifolia (Noni) Morinda citrifolia also known as noni or Indian mulberry has a broad range of therapeutic effects such as antibacterial, anti-inflammatory, analgesic, anti-helminthic, antiviral and immunity enhancing property. Due to its properties and not likely to cause the severe injuries to patients that might occur through NaOCl accidents its juice can be used as a potent irrigant in primary teeth.

45. Miswak Miswak is derived from the plant Salvadora persica mainly used as a chewing stick, which is used for cleansing the teeth. Wolinsky and Sote, by isolation of the active ingredient from S.persica, found that the limonoid had a great antimicrobial activity by inhibiting the growth of various Gram-positive and Gram-negative microorganisms by interfering extra polysaccharides and glycosidase enzymes produced by these microorganisms. A study done on primary teeth showed that for root canal irrigation miswak could be a good natural substitute to sodium hypochlorite.

46. German chamomile and Tea tree oil German chamomile is a medicinal plant known for its anti-inflammatory, analgesic, anti-microbial, anti-spasmic and sedative properties. Chamomile was found to be effective when used as a mouthwash and many properties such as antiseptic, antifungal agent and a mild solvent. Study done on German chamomile extract and tea tree oil as irrigants and showed that efficacy of chamomile to remove smear layer was superior to NaOCl alone but less than NaOCl combined with EDTA.

47. Propolis Propolis, a resinous bee hive product, a potent anti­-microbial, antioxidant and anti-inflammatory agent. Propolis as a root canal irrigant is comparative to antimicrobial activity of miswak, sodium hypochlorite and saline Propolis has also shown to be an effective intracanal irrigant in eradicating E. faecalis and C. albicans.

48. obturation Aim is to prevent recontamination of the root canal from either apical or coronal leakage and to isolate and neutralize any remaining pulpal tissue or bacteria Once patient is free from clinical signs and symptoms the canals are filled with resorbable paste Gutta percha points / silver points contraindicated for primary teeth

49. Historical review of obturation Sweet (1930) describes 4 step technique by using formocresol for treatment of pulpless primary teeth with or without fistulas. Gerlach ( 1932) used eugenol for sealing of canals for 48 hrs and then filling with GP points; their removal when tooth ready to exfoliate. Walk Hoff (1952) introduced mixture of camphorated para-chlorophenol and sterilized iodoform paste. Rabinowitz (1953) performed 2 to 3 visit formocresol application and then seal the canals with mixture of silver nitrate and ZOE; though successful took 4-17 visits. Spedding (1973) conducted 2 visit technique by placing cotton pellet dampened with CMCP / formocresol sealed within the canals between visits followed by final filling of ZOE and formocresol.

50. 1978 – Ca(OH)2 iodoform mixture was used. Starkey (1980) – partial pulpectomy, fill the canals with creamy mix of ZOE. Rifkin (1984) – used KRI paste as the final filling material. Tagger and Scunat (1984) – Maisto’s paste as a temporary medication and finally filled the canals with mixture of iodoform and ZOE paste. Juddy –Kenny (1991) - fine grained non-reinforced ZOE cement with lentulospiral to fill the canals.

51. Ideal criteria for pulpectomy obturant acc. To rifkin (1982) Strongly antiseptic Resorbable Non-inflammatory and non-irritating to the underlying permanent tooth bud Radioopaque for easy radiographic visualization Does not set to a hard mass which may deflect succedaneous teeth Easily inserted Easily removed if neccessary

52. Various root canal obturating materials Z inc oxide Eugenol Calcium hydroxide Sealapex Calcicur Vitapex Iodoform based pastes Walcoff paste KRI paste Maisto paste Vitapex/metapex Endoflas

53. Zinc oxide eugenol Zinc oxide Eugenol is one of the most widely used materials for root canal filling of primary teeth. Bonastre (1837) discovered zinc oxide Eugenol and it was subsequently used in dentistry by Chisholm (1876) . Zinc oxide Eugenol paste was the first root canal filling material to be recommended for primary teeth, as described by Sweet in 1930 . It was the only material explicitly recommended in the clinical guidelines developed by the AAPD until 2008

54. Usually a thin mix of ZOE is made, a consistency in which the material can flow easily (it may allow the material to push beyond the apex). But if thick paste is used, it leads to underfilled canals ( to avoid this pressure syringe technique can be used, which was introduced by camp in 1984) ZOE without any catalyst allows a longer working time for filling of canals.

55. ZOE ADVANTAGES Excellent antibacterial & analgesic effects (in lower concentrations) Radiopaque for good radiographic visibility Easy to manipulate & fill in the canals Insoluble in tissue fluids Easily available Cost effective No tooth discolouration

56. Z OE DISADVANTAGES Rate of resorption of material does not coincide with that of root, is slower in resorption When pushed beyond the canals, it irritates the periapical tissue Is said to show foreign body reaction in contact with periapical tissue (necrosis of bone & cementum) The excessive material is retained for years even after exfoliation of the primary tooth is shown to harm the permanent tooth bud

57. Hashieh (1999) in his study tested the beneficial effects of eugenol and found that the amount of eugenol released in the periapical zone immediately after placement was 10–4 and falls to 10-6 after 24 hrs, reaching zero after one month. Within these concentrations eugenol is said to have anti-inflammatory and analgesic properties that are very useful after a pulpectomy procedure. Colla J (1985) found that zinc oxide may alter the path of eruption of succedaneous permanent. Erasquin (1967) reported occurrence of necrosis of cementum, bone and inflammation of periapical tissue.

58. Robin L W studied unresorbed zinc oxide Eugenol was surrounded by several layers of condensed cellular tissues. This was co m posed of inner layer of tightly packed cells and outer layer of fibroblast with chronic inflammatory cells. Coll and Sadrian (1996) reported anterior cross-bite, palatal eruption, and ectopic eruption of the succedaneous tooth following ZOE pulpectomy where fragments are left. Success rates were reported after obturating with Zinc Oxide Eugenol by various authors as follows – 82.3%- Barr et al. 82.5% - Gould 86.1% - Coll et al. average being 83%

59. ZOE AND COMBINATIONS To improve properties and success rate zinc oxide eugenol in combination with different components like formocresol, formaldehyde and paraformaldehyde and cresol have been tried out, but the addition of these compounds neither increased the success rate nor made the material more resorbable as compared to zinc oxide eugenol alone. A study was conducted in which iodoformized zinc oxide-eugenol was tested for its antibacterial effect against the aerobic and anaerobic bacteria obtained from the root canals of deciduous teeth and was found to be effective for both the aerobic and anaerobic bacteria with maximum sustaining period of 10 days

60. A combination of zinc oxide powder and calcium hydroxide paste for obturation of primary teeth has shown that the obturated material remained up to the apex of root canals till the beginning of physiologic root resorption. Also the material was found to resorb at the same rate as teeth. A combination of calcium hydroxide, zinc oxide, and 10% sodium fluoride solution has been tested for the rate of resorption and the mixture was quite similar to the rate of physiologic root resorption in primary teeth.

61. CALCIUM HYDROXIDE Calcium hydroxide is a white odourless crystalline powder. It has low solubility in water (a good clinical characteristic because a long period is necessary before it becomes soluble in tissue fluids when in direct contact with vital tissues.) It has high pH about 12.5

62. Leonardo et al in 1982 recommended the addition of other substances to the paste of CaOH • To maintain the paste consistency of the material which does not harden on set. • To improve flow • To maintain the high pH of calcium hydroxide • To improve radiopacity • To make clinical use easier

63. ADVANTAGES This material was found to be easy to apply. Resorbs at a slightly faster rate than that of the root. It has no toxic effects on permanent successor. Radiopaque. DISADVANTAGES Pulp obliteration due to osteogenic potential, it is capable of inducing calcific metamorphosis, thereby obliterating the root canals. Induces internal resorption in primary teeth due to the over stimulation of the undifferentiated mesenchymal cells thus inducing odontoclast causing resorption of dentin. Lack of adhesion to the hard tissue, leading to inadequate seal against microleakage resulting in bacterial access to plup Tendency to get depleted from the canal Resorbs earlier than the physiological resorption of the roots.

64. Pitts 1984 studied the absorbable nature of Calcium Hydroxide and found that significant wash out of apical plugs of Calcium Hydroxide occurred during the first month after placement. By the 9 th month, plugs were virtually gone from the apical portion of the root canal. Adjacent to remaining Calcium Hydroxide particles, giant cells but no inflammatory cells were seen. Poor success rates were reported due to high occurrence of internal resorption by Via and Shroeder. Clinical Studies have reported a success rate of 80 to 90% with this material as an obturant. Heithers in 1975 reported that Ca(OH) 2 can be used as a root canal dressing in teeth with large periapical lesions and in cases where it was necessary to control the passage of periapical exudates into the canal. Matsumiya and Kitanuma 1960 considered that Ca(OH) 2 accelerated the natural healing of periapical lesions, regardless of the bacterial statics of root canal at the time of placement of material.

65. IODOFORM BASED PASTE WALCOFF PASTE Parachlorophenol Camphor menthol KRI PASTE Parachlorophenol Camphor Menthol Iodoform MAISTO PASTE Parachlorophenol Camphor Menthol Iodoform Zinc oxide Thymol Lanolin VITAPEX/METAPEX Calcium hydroxide Iodoform Oily additives

66. ENDOFLAS Iodoform Zinc oxide Calcium hydroxide Barium sulfate Eugenol Paramonochlorophenol GUEDES-PINTO PASTE Rifocort Champhorated paracholorophenol Iodoform

67. Vitapex \ metapex Vitapex have been published by Fuchino and Nishino (1980). V itapex that contains Calcium hydroxide and iodoform along with silicone oily base (additive) Iodoform 40.4%, - bactericide that is released from the sealer and suppresses any residual bacteria in the canal or periapical region. Calcium hydroxide 30.3%, - biocompatible antibacterial activity, induction of mineralized tissue formation , activation of alkaline phosphatase and collagen synthesis and ability to produce hydrolysis of bacterial endotoxin. Silicone 22.4%. A lot of researchers considered this mixture as nearly an ideal root canal filling material for primary tooth,owing to its excellent properties.

68. ADVANTAGES • Has no toxic effects on the permanent successor teeth • Good antiseptic action • Adheres well to the canal walls • It does not set to a hard mass • Resorption occurs at a slightly faster rate then the roots, complete resorption of the excess paste is expected within 2-8 weeks. • Ease of applicability of the material • Is radiopaque, so better radiographic visibility DISADVANTAGES • Iodoform-based material though resorbs if pushed beyond the apex however the rate of resorption is faster than the roots. • Causes discoloration of the teeth. • The rapid elimination of iodoform by the organism leaves behind empty spaces inside the root canal, which may undermine the success of the endodontic therapy.

69. Maisto Paste An iodoform based paste developed by maisto and been used clinically for many years with good results reported. This paste is known for its comparatively slow rate of resorption when used as an obturating material for primary teeth. contains: Zinc-oxide 14g Iodoform 42g Thymol 2g and Lanolin Fernandes in 1996 compared the efficacy of two obturating materials, ZOE and maisto paste. Maisto paste was seen to be superior to ZOE in both clinical and radiological evaluation, done over a period of 9 months in relation to bone regeneration,healing of inter radicular pathology and resorption of excess material. Eliyahu Mass (1989) found Maisto paste to be successful in infected posterior primary teeth and had positive healing effect on periradicular tissue.

70. KRI Paste (Iodoform Paste): Iodoform: Relieves pain, Potent disinfectant Menthol: Anodyne, Antispasmodic, antiseptic Camphor: arrest the hemorrhage, Allays pain of wounded pulp of teeth Parachlorophenol: Disinfects root canal, Treating periapical infections KRI paste resorbs rapidly & has no undesirable effects on succedaneous teeth. Also used as a root canal medicament in abscessed primary teeth with no harmful effects Advantages Bactericidal in root canal Resorbs from the apical tissues in 1-2 weeks Harmless to permanent tooth germs Radio opaque Does Not set to a hard mass Easily inserted and removed Ideal pulpectomy agent

71. E ndoflas: Endoflas is a resorbable paste obtained by mixing a powder containing Iodoform, Zinc Oxide (56.5%), Calcium Hydroxide (1.07%), Tri-iodomethane Dibutilorthocresol (40.6%), Barium Sulphate (1.63%) And Liquid Consisting Of Eugenol And Paramonochlorophenol

72. ADVANTAGES The material is hydrophilic and can be used in mildly humid canals. It firmly adheres to the surface of the root canals to provide a good seal. Due to its broad spectrum of antibacterial activity, Endoflas has the ability to disinfect dentinal tubules and difficult to reach accessory canals that cannot be disinfected or cleansed mechanically. Unlike other pastes, Endoflas only resorbs when extruded extra-radicularlly, but does not wash out intra-radicularly (Fuks et al 2002) DISADVANTAGES Eugenol content can cause periapical irritation. It also has a drawback of causing tooth discoloration. REVIEW OF LITERATURE Ramar & Murgara (2010) observed a much higher success rate with Endoflas (95%) compared to other materials and also reported healing ability, bone regeneration characteristics and resorption of excess Endoflas without washing within the roots. Navit S et al 2016 evaluated the antimicrobial efficacy of obturating materials against E. faecalis, amongst all the groups Endoflas had significantly higher zone of inhibition. Antimicrobial efficacy of various materials according to this study can be summarized as follows: Endoflas > ZOE >Calcium hydroxide + Chlorhexidine > Calcium hydroxide + Iodoform +Distilled water ~ Metapex > Saline.

73. Method of obturation Lentulospiral techinque Pressure syringe Mechanical syringe Tuberculin syringe Jiffy tube Incremental filling technique- using endodontic plugger and putty mix of ZOE in increments

74. Lentilospiral This obturation technique was advocated by Kopel in 1970. Aylard and Johnson and Dandashi et al evaluated root canal obturation methods in primary teeth in vitro and concluded that the lentulospiral mounted in a slow speed handpiece was superior in filling straight and curved root canals of primary teeth. The Lentulo spiral is one of the most effective and straightforward techniques for applying sealers and calcium hydroxide into permanent tooth root canals or pastes into primary tooth canals are due to the design and flexibility of the Lentulo spiral. Obturation techniques in primary teeth allow files to carry the paste uniformly throughout the narrow, curved canals in primary molars. Difficulties with fitting the rubber stop, instrument fracture, and a tendency for extrusion beyond the apex, however, are disadvantages of the Lentulo instruments.

75. Pressure syringe: The technique was described by Greenberg (1963) and described in detail by Spedding and by Krakow et al. This apparatus consists of a syringe barrel, threaded plugger, wrench and threaded needle. The needle was inserted into the simulated canal until wall resistance was encountered. Using a slow, withdrawing-type motion, the needle was withdrawn in 3-mm intervals with each quarter turn of the screw until the canal can be visibly filled at the orifice with zinc oxide eugenol paste. The 13 to 30 gauge needle which corresponds to the largest endodontic file can be used to instrument the root canal. It has been noted that the needles are very flexible and can easily be maneuvered in the tortuous canals of primary molars.

76. Overfill is a common clinical finding in the primary dentition, especially when apical resorption and/ or the paste is applied through a pressure syringe. Difficulties in placing the rubber stop correctly and removing the needle (because of the need to refill the hub of the syringe several times during the procedure) may lead the clinician to remove and reinsert the syringe repeatedly, which, in turn, may displace the paste, create voids, and thus decrease filling quality. In addition, the need to clean the syringe immediately after use makes this method more complex and time-consuming.

77. Mechanical Syringe This method was proposed by Greenberg in 1971. T he canal s hape governs the selection of the filling technique. The mechanical syringe was a poor performer in both canal types i.e. curved and straight canals in a study conducted by Aylard and Johnson. The screw mechanism of the endodontic pressure syringe would be able to generate far greater pressures than could a p lunger system as is seen with the mechanical syringe.

78. T he Incremental Filling Technique This was first used by Gould in 1972. An endodontic plugger, corresponding to the size of the canal, with rubber stop was used to place a thick mix of zinc oxide-eugenol paste into the canal. Length of the endodontic plugger equaled the predetermined root canal length minus 2 mm. Additional increments of 2-mm blocks are added until the canal was filled to the cervical area. Placing the paste in a narrow, apically curved canal is more difficult than in a wider apical preparation. Because the flexibility of endodontic pluggers is limited, the paste cannot be placed in the full working length of narrow, curved canals. In addition, movements of the plugger during paste application may increase the risk of large voids.

79. Jiffy Tube The material of choice for filling the root canals of pulpectomized primary teeth is pure ZOE, first mixed as slurry and carried into the canals using paper points, a syringe, a Jiffy tube, or a lentulo spiral root canal filler. The standardized mixture of ZOE is back-loaded into the tube. The tube tip is placed into the simulated canal orifice and the material expressed into the canal with a downward squeezing motion until the orifice appears visibly filled. This technique was popularized by Rifficin in 1980 .

80. Tuberculin syringe: This syringe was utilised by Aylord and Johnson in 1987. The standardized mixture of ZOE was back-loaded into the syringe with a standard 26- gauge, 3/8-inch needle. The material was expressed into the canal by slow finger pressure on the plunger until the canal was visibly filled at the orifice. There appeared to be no difference in the straight canal filling capabilities of either the tuberculin or mechanical syringes. The main drawback of the tuberculin syringe technique is the difficulty of separating the tip during injection, which results in the need to repeatedly replace the needle which may compromise optimal filling and increase the presence of voids in the paste.

81. Pastinject Pastinject (Micromega) is a specially designed paste carrier with flattened blades, which improves material placement into the root canal. Pastinject seems to favor a better intracanal placement of calcium hydroxide paste in single rooted teeth. A Specially Designed Paste Carrier technique is also found to be an effective technique in the intracanal placement of calcium hydroxide as reported by Joseph Meng et al. Bi-directional spiral and Pastinject are used for the placement of calcium hydroxide and root canal sealers in the permanent teeth, but there are not enough studies to evaluate their use as obturation techniques in primary teeth.

82. Lesion sterilization and tissue repair (Takushige 2004) It is a process which allows the use of a combination of antibiotics for controlling of oral infections such as dentinal, pulpal and periapical lesions. Thi therapy aims to eliminate causative bacteria from the disease by disinfecting the lesion and promoting tissue regeneration ny the host’s natural tissue recovery process . 3 mix ratio 1:3:3 = Ciprofloxacin, metronidazole, minocycline with macrogol mixture or propylene glycol

83. Indication: Primary teeth affected with pain and tender on percussion Teeth with grade I &II mobility Presence of abscess Presence of sinus tract Presence of radiolucency in furcation area Pulpless primary teeth in hemophilic patients Immature primary teeth with necrotic pulp and incompletely formed roots. Contraindication: Patients sensitive and allergic to ciprofloxacin, minocycline, or metronidazole Radiographic evidence of excessive internal or external resorption of root Primary tooth near exfoliation Perforated pulpal floor Excessive bone loss in furcation area involving the underlying tooth bud

84. Procedure: Local anesthesia if required Isolation with rubber dam Removal of caries Preparation of access cavity Extirpation of necrotic pulp Irrigation with normal saline (0.9%) and drying with cotton pellet. Enlargement of canal orifice should be 1 mm in diameter and the depth of 2 mm to receive medication

85. Failures in pulpectomy treatment Persistence of bacteria (intra canal or extra canal) Inadequate filling of the canal Over-extension of filling material Improper coronal seal Untreated canals Iatrogenic procedural error Complications of instrumentations (ledge,perforations or instrument separations)

86. Early exfoliation or over retention of primary teeth with pulp treatment Early exfoliation: premature loss can occur due to low-grade chronic, asymptomatic, localized infection resulting in usually abnormal and incomplete root resorption patterns of the affected teeth. In such condition space maintainers should be considered. Over retained: it can result from interference with the normal eruption of the permanent teeth and adversely affect the developing occlusion.

87. conclusion Pulpectomy procedure provides reasonable treatment option for primary teeth having radicular canals with partial/total irreversibly inflamed or necrotic pulp. Adequate knowledge regarding the morphological features of the tooth in primary teeth, radiographic limitations, proper case selection, adequate instrumentation and isolation followed by copious irrigation and obturation are essential prior to performing of the procedure.

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