Obturating materials for primary tooth

Due to the complex morphology of the root canal system in primary teeth, the clinician must rely primarily on chemical cleansing and sterilization and secondarily on mechanical instrumentation during pulpectomy procedure.

And in order to increase the chance of success of the endodontic treatment, substances with antimicrobial properties are frequently used as root canal filling materials in deciduous teeth

1. OBTURATING MATERIALS FOR PRIMARY TEETH Presented by Mutyala jhansi (JR2 ) Paediatric and preventive dentistry KGMU

2. The goal of an any procedure performed in a primary tooth are to Maintain arch length Preserve masticatory function Remove acute and chronic infection from tooth or oral cavity

3. Pulp therapy for pulpally involved primary teeth continues to be a challenge to clinicians. Tortuous and ribbon shaped anatomy of the primary teeth Physiological resorption of roots

4. Primary molar roots are usually curved to allow for the development of the succedaneous tooth. During instrumentation, these curves increase the chance of perforation of the apical portion of the root or the coronal one-third of the canal into the furcation.

5. PHYSIOLOGICAL RESORPTION OF ROOTS Resorption causes the position of the apical foramen to change continuously. Lateral and accessory canals exist in most primary molars and are more prevalent in mandibular molars compared with maxillary ones. Accessory canals in the furcation of primary molars can explain the frequent presence of radiolucency in the furcation area of necrotic teeth.

6. Due to the complex morphology of the root canal system in primary teeth, the clinician must rely primarily on chemical cleansing and sterilization and secondarily on mechanical instrumentation during pulpectomy procedure. And in order to increase the chance of success of the endodontic treatment, substances with antimicrobial properties are frequently used as root canal filling materials in deciduous teeth

7. STEPS IN PULPECTOMY After attaining profound anesthesia , isolate the affected tooth with rubber dam. Prepare the access ( with high speed hand piece and fissure bur) Remove all caries portion with round bur, unroof the pulp chamber. Excise the coronal portion of the pulp using a round bur Extirpate the radicular portion of pulp with a barbed broach After extirpation, irrigate the canals, on completion dry the canals thoroughly with paper points Obturate the canals with suitable obturaing material.

8. The main objective of endodontic treatment is total elimination of microorgansims from the root canal, and the prevention of subsequent reinfection . This is achieved by careful cleaning and shaping followed by the complete obturation of the canal space. The ultimate goal of endodontic obturation has remained the same for the past 50 years: to create a fluid-tight seal along the length of the root canal system, from the coronal opening to the apical termination.

9. GOALS OF OBTURATION Fill the entire root canal system & complexities completely as closely as possible with a suitable obturating materials. Filling the root canal with a material that will resorb & give way for the eruption of the permanent tooth. Developmental, anatomical & physiological differences between primary & permanent teeth call for differences in criteria for root canal filing materials.

10. CRITERIA FOR AN IDEAL PULPECTOMY OBTURANTS (Rifkin) Resorbability Antiseptic property Non-inflammatory and nonirritating to the underlying permanent tooth germ Radio-opacity for visualization on radiographs Ease of insertion and Ease of removal However, none of the currently available obturating materials meet all of these criterias . Rifkin A . The root canal treatment of abscessed pri1. mary teeth: A three to four year follow-up. J Dent Child 1982; 49: 428-431 .

11. VARIOUS ROOT CANAL OBTURATING MATERIALS FOR PRIMARY TEETH Most commonly used materials for primary root canal fillings are Iodoform based pastes Walcoff paste KRI paste Maisto paste Vitapex / metapex Endoflas Zinc oxide Eugenol Calcium hydroxide Sealapex Calcicur vitapex

12. 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 untill 2008. Praveen P, Anantharaj A, Karthik V, Pratibha R. A review of the obturating material for primary teeth. SRM university journal of dental science 2011;1(3).

13. 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.

14. 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

15. ZOE 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, forms a fibrous capsule & alters the path of eruption Hashieh I A, Ponnmel L, Camps J . Concentration of 3. Eugenol apically released from ZnO E based sealers. JOE 1999; 22(11): 713-715.

16. REVIEW OF LITERATURE Hashieh studied the beneficial effects of eugenol . The amount of eugenol released in the periapical zone immediately after placement was10–4 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. Hashieh I A, Ponnmel L, Camps J . Concentration of 3. Eugenol apically released from ZnO E based sealers. JOE 1999; 22(11): 713-715.

17. 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. Colla JA, Sadrian Roya . Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. AAPD 1996; 18(1): 57-63. Erasquin J, Muruzabal M. Root canal filling with zinc oxide Eugenol in the rat molar. OOO 1967; 24: 547-558.

18. Robin L W studied unresorbed zinc oxide Eugenol was surrounded by several layers of condensed cellular tissues. This was composed 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. Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent. (1996). 18: 57–63.

19. 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% Barr ES, Flaitz CM, Hicks JM , A retrospective radio4. graphic evaluation of primary molar pulpectomies . PD1991; 13(1): 4-9. Gould JM . Root canal therapy for infected primary 5. molar teeth: preliminary report. J Dent Child 1972; 39: 269-73. Coll J A, Josell S and Casper JS . Evaluation of a one-appointment formocresol pulpectomy technique for primary molars. Pediatr . Dent 1985; 7(2): 123-129

20. ZOE & 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. Goerig AC, Camp JH. Root canal treatment in primary teeth: a review. Pediatr Dent 1983; 5: 33-37 Goodman JR . Endodontic treatment for children. Br. Dent J 1985; 158: 363-366.

21. 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. Garcia- Godoy.F . Evaluation of an Iodoform paste in 9. root canal therapy for infected primary teeth. J Dent Child 1987; 54: 30-34.

22. 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. Chawla HS, Mathur VP, Gauba K, Goyal A. A mixture of Calcium Hydroxide and Zinc Oxide as a root canal filling material for primary teeth: a preliminary study. J Indian Soc Pedo Prev Dent 2001; 19 (3): 107-109.

23. 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 . Chawla HS, Setia S, Gupta N, Gauba K, Goyal A, 11. Evaluation of a mixture of zinc oxide, calcium hydroxide, and sodium fluoride as a new root canal filling material for primary teeth. J Indian Soc Pedod Prev Dent. 2008 Jun;26(2):53-8

24. 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

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

26. IODOFORM PASTES IODOFORM It is a prepartion of iodine Obtained by action of chlorinated lime upon an alcoholic solution of potassium iodide heated at 1040 degree F. No irritant action Relieves pain, and is a potent disinfectant Better resorbability and disinfectant properties than ZOE But they may produce a yellowish brown discoloration of the tooth

27. WALCOFF PASTE Parachlorophenol 4-8% Camphor Menthol crystals 1.40-2.90% Eugenol 22-24% Zinc oxide 48-58% Thymol 12-18% Silver powder 0.70-1.45%

28. PARACHLOROPHENOL Antiseptic agent Dissolve albumins and which can therefore progressively penetrate into the canaliculi of the tooth CAMPHOR To allay the pain arising from the near exposure of the pulps of teeth, also the pain of sensitive dentine. Also to arrest the hemorrhage

29. MENTHOL Anodyne Antispasmodic Antiseptic Menthol has given satisfation as an external remedy in facial neuralgia, odontalgia , as an obtunder of sensitive dentine as a local anesthetic WALCOFF PASTE DISADVANTAGES Total resorption , which occurs both in the periapical area and in the canal area of the tooth

30. KRI PASTE Relieves pain Potent disinfectant arrest the hemorrhage Allays pain of wounded pulp of teeth Anodyne Antispasmodic antiseptic Disinfects root canal Treating periapical infections Iodoform Camphor Menthol Parachlorophenol

31. 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 Rate of resorption of the extruded material is faster than the tooth root,,ometimes the material also resorbed inside the canal Has long lasting bactericidal potential Does not set into hard mass & can be removed if retreament is required

32. Fuks AB et al in 2000 found that the success rates of 84% with KRI paste group verus 65% with ZOE group Overfills more successfull KRI paste 79% versus ZOE 41%. The excess paste will resorb without causing any adverse side effects.

33. REVIEW OF LITERATURE Castagnola and Orley (1952) stated that KRI paste loses only 20% of its potency in 10 years. Garcia Godoy (1987) found that KRI paste resorbs from the apical tissue in a week or two; it does not set to a hard mass and can be inserted and removed easily. Castagnola L, Orlay HG. Treatment of gangrene of the pulp by walkhoff method. Brit dent J 1952; 93: 93-102. Garcia Godoy F. Evaluation of an iodoform paste in root canal therapy for infected primary teeth. JDC 1987; 54:30-34 .

34. MAISTO PASTE An iodoform based paste developed by maisto and been used clinicaly 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.

35. REVIEW OF LITERATUTE 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.

36. Eliyahu Mass (1989) found Maisto paste to be successful in infected posterior primary teeth and had positive healing effect on periradicular tissue. Mass E, Zilberman LU. Endodontic treatment of infected primary molar using Maisto paste. JDC 1989; 56:117-120. Studies have shown these iodoform combinations has been shown to be bactericidal, resorbable and harmless to the permanent tooth germs as well as easy to remove. Barr ES, Flaitz CM, Hicks JM , A retrospective radiographic evaluation of primary molar pulpectomies . PD1991; 13(1): 4-9.

37. Pabla et al. (1997)evaluated the antimicrobial efficacy of zinc oxide Eugenol , Iodoform paste, KRI paste, Maisto paste and Vitapex against aerobic and anaerobic bacteria obtained from infected non-vital primary anterior teeth. Maisto paste had the best antibacterial activity. Iodoform paste was the second best followed by zinc oxide Eugenol paste. Vitapex showed the least antibacterial activity. Pabla T, Gulati MS, Mohan U. Evaluation of antimicrobial efficacy of various root canal filling materials for primary teeth. J Indian Soc Pedod Prev Dent. 1997; 15(4):134-40.

38. VITAPEX/METAPEX Vitapex have been published by Fuchino and Nishino (1980). Vitapex that contains Calcium hydroxide and iodoform along with silicone oily base (additive) Iodoform 40.4%, Calcium hydroxide 30.3%, and 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.

39. The iodoform is a known bactericide that is released from the sealer and suppresses any residual bacteria in the canal or periapical region. calcium hydroxide has a biocompatible antibacterial activity, induction of mineralized tissue formation , activation of alkaline phosphatase and collagen synthesis and ability to produce hydrolysis of bacterial endotoxin . Garcia-Godoy. Evaluation of an iodoform paste in root canal therapy for infected primary teeth. Journal of Dentistry for children. (1987). 54: 30–4.

40. ADVANTAGES Has no toxic effects on the permanent successor tooth 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

41. 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. Cerqueira DF, Mello-Moura AC, Santos EM, Guedes -Pinto AC. Cytotoxicity histopathological , microbiological and clinical aspects of an endodontic iodoform -based paste used in pediatric dentistry: a review. J Clin Pediatr Dent. (2008). 32: 105–10. Nurko C, Garcia Godoy F. Evaluation of a calcium hydroxide/ iodoform paste ( Vitapex ) in root canal therapy for primary teeth. J Clin Pediatr Dent. (1999). 23: 289–94.

42. REVIEW OF LITERATURE Nurko et al. ( 19 83) said that vitapex as success rate of 96 to 100% when extruded into furcal or apical area. the use of iodine-based materials in contact with live tissues has no longer been indicated because of their potential for causing toxic side-effects. Trairatvorakul C (2008) Vitapex appeared to resolve furcation pathology at a faster rate than zinc oxide- eugenol at 6 months, while at 12 months, both materials yielded similar results Chawla HS, Mathur VP, Gauba K, Goyal A. A mixture of calcium hydroxide and zinc oxide as a root canal filling material for primary teeth: a preliminary study. ISPPD. (2001). 19: 107–9.

43. ENDOFLAS 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 .

44. 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- radicularly , but does not wash out intra- radicularly ( Fuks et al 2002)

45. 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. Ramar K, Murgara J. Clinical and radiographic evaluation of Pulpectomies using three root canal filling materials: An in-vivo study. J Indian Soc Pedod Prevent Dent. (Jan/Mar 2010). 28(1): 25–9.

46. 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. NAVIT S et al.Antimicrobial Efficacy of Contemporary Obturating Materials used in Primary Teeth- An In-vitro Study.2016 Journal of Clinical and Diagnostic Research. 2016 Sep, Vol-10(9): ZC09-ZC12

47. GUEDES-PINTO PASTE(1981) Rifocort - Prednisolone Acetate Corticosteroid 5mg( Antiinflammatory ) Rifamycin Sodium Salt (Antibiotic) Propilenglycol (Vehicle) Macrogol (Polyethylene-glycol) - Vehicle Champhorated paracholorophenol - Proportion 3:7 30% Parachlorophenol 70% Camphor ( Antimicrobial+analgesic ) Iodoform – Iodine (Antimicrobial)

48. Silva CM et al 2002. GPP has both bactericidal and bacteriostatic effect against S. mutans , S. aureus , E. faecalis and C. Albicans

49. Chedid et al. 1992 compared, on a histological basis, the effect of two pulp capping agents ( formocresol and GPP) in rat molar pulp after pulpotomy procedures. In the final period of the experiment (90 days), teeth treated with the GPP presented complete wound healing and the formation of a dentinal bridge, while those treated with formocresol presented a large necrotic area, close to the exposed coronal pulp and extending to the radicular pulp. REVIEW OF LITERATURE

50. Faraco -Junior and Percinoto (1998) compared the histological effects of two pulpectomy techniques (using the GPP paste and another paste composed of calcium hydroxide, iodoform and propilenoglycol ) on dog’s teeth, the results after 30 days demonstrated that both techniques were well tolerated by the periapical tissues; however, the technique with the GPP displayed higher levels of inflammation and bone resorption only at the apical region.

51. Sousa et al.2000 observed the biocompatibility of the GPP, Calcium hydroxide paste (PA), and CTZ paste placed on “guinea pigs” bone implants. The morpho -histological analyses were classified based on the FDI/ADA criteria for inflammation. The results for 30 days showed severe inflammatory reaction for PA and CTZ paste, while none, or a mild reaction, was observed for the GPP. After 90 days, the reactions to PA paste were absent or mild; the CTZ paste, perpetuation of the inflammatory process showed, ranging from moderate to severe. Conversely, the GPP was replaced by neoformed bone tissue.

52. 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

53. Leonardo et al in 1982 recommended the addition of other substances to the paste 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

54. 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 .

55. 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 undiferentiated 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.

56. Pitts 1984 studied the absorbable nature of Calcium Hydroxide. He found that significant wash out of apical plugs of Calcium Hydroxide occurred during the first month after placement. By the ninth 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 . Pitts . A histologic comparison of Calcium Hydrox13. ide plugs and dentin plugs used for the control of GP root canal filling materials. JOE 1984; 10: 283-293. Via WF. Evaluation of decidous molars treated by 14. pulpotomy and Calcium Hydroxide. Jou Am Dent Assoc 1955; 5: 34-43. Schroder U . A 2-yr follow up of primary molar, pul15. potomized with a gentle technique and capped with Calcium Hydroxide. Scand J Dent Res 1978; 86: 273-278

57. REVIEW OF LITERATURE 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.

58. CALEN PASTE A calcium hydroxide-based paste Calen paste exhibited biocompatibility , high antimicrobial activity and satisfactory clinical, radiographic outcomes & intermediate setting time values. The mean initial pH was 6.1, and it exhibited a progressive increase until reaching a peak at the five-hour time point with mean ph value of 8.4 High registration levels, which indicate high radiopacity . Showed a lower solubility compared with the other groups

59. CTZ PASTE CTZ is an antibiotic paste Comibation of chloramphenicol 500mg+tetracycline 500mg+zinc oxide 1000mg+ eugenol 1 drop Chloramphenicol is an antimicrobial agent that acts against a large number of aerobic, facultative anaerobe and spirochetes as well as gram + ve and gram – ve microorganisms. Tetracycline is a broad spectrum antibiotic, which can be bactericidal at high conc. Offer excellent effectiveness against gram – ve bacteria and all anaerobes

60. ZOE provides analgesic properties and potent antibacterial action against staphylococcus, micrococci , bacillus and enterobacteria for more than 30 days. ADVANTAGES Application technique is easy, simple Has antibacterial power Promotes stabilization of bone resorbtion Does not cause tissue sensitivity Does not produce damage to the permanent tooth in developement DISADVANTAGES Pigmentation of the crown of the treated tooth

61. COLLA COTE It is a soft white pliable biocompatible sponge obtained from bovine collagen It can be applied to moist or bleeding canals Its an absorbable collagen barrier which prevents or diminishes extravasation of root canal filling material during primary molar pulpectomies . Also can be used as a scaffold for bone growth and so can be applied on the wounds.

62. ROLE OF COLLA COTE Physiological and pathological resorptive process change the position of the apical foramen almost continuously. Bleeding from periapex makes obturation difficult, colla cote can be used as an apical stop, or barrier over which obturant can be filled. Colla cote is widely used in endodontic therapy. When left inside a periapical defect, colla cote gradually resorbs providing a scaffold for bone deposition and growth.

63. FRANK’S PASTE Combination of calcium hydroxide + champhorated parachlorophenol It is well tolerated by adjacent periapical tissue without any inflammation & with deposition of osteodentin

64. Comparison of various materials according to different studies Sunitha B et al 2014 conducted a study to check the Resorption of Extruded Obturating Material in Primary Teeth. Materials are zinc oxide eugenol (ZOE), iodoform, Vitapex , calcium hydroxide, and Endoflas . Conclusion ZOE is gold standard obturating material in primary but it is not indicated in the resorbed roots, calcium hydroxide and Endoflas are recommended are easily resorbed even though it is extruded.

65. Fidalgo FB et al 2010 A Systematic Review of Root Canal Filling Materials for Deciduous Teeth: Is There an Alternative for Zinc Oxide- Eugenol ? Materials iodoform paste with calcium hydroxide (IP + Ca) and ZOE IP+ Ca performed better than ZOE. There seems to be no convincing evidence to support the superiority of any material over ZOE, and both ZOE and IP + Ca appear to be suitable as root canal fillings for deciduous teeth.

66. SILVA et al 2010 Histopathological Evaluation of Root Canal Filling Materials for Primary Teeth Group I: calcium hydroxide and polyethylene glycol-based paste ( Calen ) thickened with zinc oxide; Group II: paste composed of iodoform , Rifocort ® and camphorated paramonochlorophenol Group III: zinc oxide- eugenol cement Group IV: sterile saline. On the basis of the histopathological parameters examined and considering the evaluated materials the Calen paste yielded the best tissue response, being the most indicated material for root canal filling of primary teeth with pulp vitality.

67. Group II the presence of camphorated paramonochlorophenol , the most cytotoxic component of the paste, which could be responsible for the reduced number of fibers , fibroblasts and vessels observed in the periapical region of the specimens. Group III The root canals filled with zinc oxide- eugenol cement showed an adverse tissue response, which included the presence of inflammatory cells, edema and severely thickened periodontal ligament Group IV Mild inflammatory cells infiltrate, periodontal ligament with normal thickness and absent resorption of mineralized tissues were observed

68. Reddy S, et al 2008 Evaluation of antimicrobial efficacy of various root canal filling material used in primay teeth. Materials Zinc oxide- Eugenol and Formocresol (ZOE+FC), Calcium hydroxide and sterile water (CAOH+H2O), Zinc oxide and Camphorated phenol (ZO+CP), Calcium hydroxide and Iodoform ( Metapex ) and Vaseline (Control), anti-microbial efficacy of ZOE+FC produced strong inhibition against most bacteria when compared to ZOE, ZO+CP and CAOH+H2O. Metapex and Vaseline were found to be non inhibitory. .

69. HERBAL OBTURANTS ALOE VERA   ( Aloe barbadensis ) The chemical constituents present in them are part of the physiological functions of living flora, and hence, they are believed to have better compatibility with the human body. Aloe vera can be used for various therapeutic as well as preventive purposes owing to its anti-inflammatory, antibacterial, antifungal, antiviral, moisturizing, and pain-relieving properties. Because of these properties that are useful in dentistry, aloe vera gel can be also used in any obturating medium for therapeutic purposes.

70. zinc oxide powder, if mixed with aloe vera gel, provides the following advantages: it does not set, its ease of placement, easily retrievable nature, etc. So, Khairwa A et al in 2014 in their study they have used zinc oxide powder with aloe vera gel to check the efficacy of this combination as an obturating material for primary teeth.   Results it can be observed that endodontic treatment using a mixture of zinc oxide powder and aloe vera gel in primary teeth has shown good clinical and radiographic success.

71. TULSI ( OCIMUM SANCTUM ) Jaidka S et al in 2014 The antimicrobial efficacy of obturating materials used in primary teeth was evaluated against  E. Faecalis Materials zinc oxide eugenol , zinc oxide with tulsi extract and zinc oxide with aloe vera as obturating materials. Intergroup comparison revealed significant difference amongst all the groups except between zinc oxide eugenol and zinc oxide with tulsi extract. Zinc oxide eugenol had significantly higher zone of inhibition among all the groups. According to results obtained from the present study can be summarized as follows: Zinc oxide eugenol  > Zinc oxide with tulsi extract > Zinc oxide with aloe vera .

72. RETAINED PRIMARY TEETH Retained primary teeth without permanent successor present a unique challenge to the dentist. These teeth are often prone to caries because of factors such as longevity of the tooth in the oral cavity, Discrepancies in interproximal contact with permanent teeth and Variation in enamel thickness. Weine FS. Endodontic therapy. 5th ed. St. Louis: Mosby, 1996: 359-61.

73. Retained deciduous tooth requiring different obturating material that would not undergo resorption & biocompatible to the retained primary roots. So, materials used for situation like this are Guttapercha , Mineral Trioxide Aggregate (MTA), and Calcium Enriched Mixture (CEM) Nagesh B, Naik B, Sarath R K, Lakshmi D V. Obtuation of retained primary mandibular seond molar with missing successor with Gutta-percha: A case report. JIDA, Vol. 5, No. 2, February 2011 Kokich VG, Kokich VO. Congenitally missing mandibular second premolars: Clinical options. Am J Orthod Dentofacial Orthop 2006; 130: 437-44.

74. Guttapercha is a desirable filling material because it is Nontoxic, Least irritating to periapical tissues, Impervious to moisture. Mineral Trioxide Aggregate (MTA) is recently introduced cement. Studies have demonstrated cemental repair, formation of bone, and regeneration of the periodontal ligament when MTA is used. Howard W Roberts, Jeffrey M. Toth , David W. Berzins , David G. Chartlon . Mineral trioxide aggregate material use in endodontic treatment: A review of the literature Dental Materials 2008; 24:149-164.

75. American Academy of Pediatric Dentistry, “Guideline on pulp therapy for primary and young permanent teeth,” Pediatric Dentistry, vol. 27, no. 7, pp. 130–134, 2005. F. Garcia-Godoy. Evaluation of an iodoform paste in roo canal therapy for infected primary teeth. ASDC Journal of Dentistry for Children 1987; 54(1): 30-34. M. Mortazavi and M. Mesbahi . Comparison of zinc oxide and eugenol , and Vitapex for root canal treatment of necrotic primary teeth. International Journal of Paediatric Dentistry 2004; 14(6):417-424.

76. Action of camphor in KRI paste a. Arrests hemorrage b. Anodyne c. Relieves pain d. antimicribial 2) Calen paste is a combination of a. Ca(OH)2+ZO+polyethylene glycol b. Ca(OH)2+ZO+ iodoform c. Ca(OH)2+ZO+ CMCP d. Ca(OH)2+ZO

77. 3) Who recommended the addition of other substances to the Ca(OH)2 paste to improve its properties a. Leonardo in 1982 b. Fuks in 1982 c. Sweet in 1982 d. Colla J in 1982 4) Main disadvantage of iodoform based paste a. Resorption b. Tooth discolouration c. Inflammation to periapical tissues d. solubility

78. Which material has both bactericidal and bacteriostatic effect against S. Mutans a. Guedus pinto paste b. CTZ paste c. ZOE+Ca (OH)2 d. Calen paste