pulpectomy

endodontic treatment non vital therapy for permanent tooth

1. pulpectomy Fathima

2. Introduction The main objective of pulp therapy in the primary dentition is to retain every primary tooth as a fully functional component in the dental arch to allow for proper mastication, phonation, swallowing, preservation of the space required for eruption of permanent teeth and prevention of detrimental psychological effects due to tooth loss.

3. Defintiion

4. Objectives Maintain the tooth free of infection Biomechanically cleanse and obturate the root canals There should be radiographic evidence of a successful filling without gross over extension or under filling Promote physiological root resorption There should be no radiographic evidence of further breakdown of supporting tissues. Treatment should alleviate and prevent further pain or swelling. Hold the space for the erupting permanent tooth

5. I ndications - General Patient should be in good health with no systemic disease Maximum cooperation of patient and parents.

6. Indications -clinical Strategically important tooth A tooth previously planned for a pulpotomy that shows uncontrolled pulpal hemorrhage Indicated for any tooth in absence of successor Any deciduous teeth with severe pulpal necrosis provided there is no radiographic contraindication Primary teeth with necrotic pulps and minimum of root resorption Primary teeth with an abscess or sinus opening Traumatized teeth with fracture or caries involving the pulp irreversibly

7. Presence of pus at the exposure site in the pulp chamber Pulpless teeth in hemophiliacs Pulpless primary anterior teeth when speech, esthetic are a factor Pulpless primary molars holding orthodontics appliance

8. Indications -radiographic Adequate periodontal and bony support Minimal periapical changes with sufficient bone support Atleast 2/3 rd of the root length available Internal resorption without any obvious perforation

9. Contraindications - General Young patient with systemic illness such as congenital ischemic heart disease, leukemia Children on long term steriods therapy or those who are immunocompromised .

10. Contraindications -clinical Excessive tooth mobility and /or reduced bone support A non- restorable tooth Underlying dentigerous or follicular cyst Communication between the roof of pulp chamber and the furcation region Insufficient tooth structure to allow isolation by rubber dam and extracoronal restoration

11. Contraindications -radiographic A primary tooth with excessive root resorption invoving more than two thirds of the root Internal root resorption in the apical 1/3 rd of the root Radicular cyst, dentigerous cyst in association with primary teeth Inter- radicular radiolucency the communicate with the gingival sulcus

12. PULPECTOMY PROCEDURES IN PRIMARY MOLARS Partial pulpectomy It is widely used to refer to “an apical extension of the pulpotomy procedure” in which the coronal portion of the radicular pulp is amputated, leaving vital tissue in the canal that is assumed to be healthy. The decision to implement partial pulpectomy in primary molars is made after removing the coronal pulp and encountering difficulty with hemorrhage control from the radicular orifice. the canals should not show evidence of necrosis or suppuration.

13. S ingle visit pulpectomy Indication Large carious exposure with frank involvement of radicular pulp without any periapical changes Primary teeth with inflammation extending beyond coronal pulp indicated by hemmorrhage from the amputed radicualar stumps that is dark red, a slowly oozing and uncontrollable. Teeth that exhibit clinical symptoms to heat or cold and not to percussion

14. Isolation and sealing problem Teeth with subgingival break down, coronal wall missing, single visit pulpectomy eliminate inter- oppointment flare-ups and contamination Anterior esthetic problem Maxillary anterior teeth involved in trauma that has resulted in fracture of crown at gum line. Restorative consideration Teeth to be used as over denture abutment or with severe crown destruction that would not retain a restoration,teeth that require preparation that would result in pulp exposure

15. PROCEDURE

16. Multiple visit pulpectomy Studied by Lawrence 1966 and later by starky 1973 Indication (Paterson and Curzon in 1992 ) Indicated where infection , an abscess and chronic sinus exist Nonvital primary teeth Teeth with necrotic pulp and periapical invovlement

17. PROCEDURE

18. F irst appoinment (Access opening)

19. S econd appointment

20. T hird appoinment (Obturation)

21. Access opening for pulpectomy in primary teeth That endodontic coronal preparation which enables unobstructed access to the canal orifice , a straight line access to the apical foramen, complete authority over the enlarging instrument and to accommodate the filling technique

22. Ac cess opening for primary teeth Rules 1. Obtaining a straight line access to the apical foramen or to the Initial curvature of the canal to aid in -improved instrumentation control -improved obturation -decreases the incidence of procedural error 2. Conservation of tooth structure -to minimize weakening of remaining tooth structure 3. Unroofing the pulp chamber and removal of the pulp horns to aid in -locating the root canal orifice -maximum visibility -locate canals -permit straight line preparation -prevents discoloration of teeth due to pulpal remnants

23. Working Length Measurements from fixed coronal reference point to a point where the preparation and obturation should terminate. RADIOGRAPHICAL METHOD 1.Grossman’s formula 2. Ingles method 3.Weine’s method 4.Radiovisiography 5.Xeroradiography NON RADIOGRAPHICAL METHOD 1.Digital tactile sense 2.Apical periodontal sensitivity 3.Paper point method 4.Electonic apex locator

24. Grossman’s method A,The length of the tooth is measured on the diagnostic radiograph (schematic view). B, This measurement is transferred to a diagnostic instrument prepared with a silicone stop, the instrument is placed in the root canal, and a radiograph is made. C and D, The root canal and working lengths are determined from the radiograph.

25. Chemo-mechanical Preparation In primary teeth Because of thin and torturous canals, More flexible NiTi instrument are used Less/ minimal instrumentation is performed Debridement in primary teeth – More dependent on chemical than mechanical means

26. Have a broad antimicrobial spectrum and high efficacy against anaerobic and facultative microorganisms organized in biofilms Dissolve necrotic pulp tissue remnants Inactivate endotoxin Remove smear layer Nontoxic, Non-caustic to periodontal tissues The ideal requisites of a root canal irrigant: - Zehnder

27. Since instrumentation and irrigation with an inert solution alone cannot adequately reduce the microbial population in a root canal system. Disinfection with irrigants such as one percent sodium hypochlorite and/or chlorhexidine is an important step in assuring optimal bacterial decontamination of the canals.

28. Unique capacity to dissolve necrotic tissue and organic components of smear layer. Kills sessile endodontic pathogens organized in biofilms & in dentinal tubules as efficiently as CHX or iodine at comparable concentrations. Inactivates endotoxin – Currently available evidence strongly in favor of NaOCl as main endodontic irrigant . Sodium Hypochlorite

29. Nilotpol Kashyap ., et al. “Irrigating Solutions in Pediatric Dentistry: A Big Deal in Little Teeth”. EC Dental Science 18.7 (2019):

30. • Resorbability • Antiseptic property • Non-inflammatory and non-irritating to the underlying permanent tooth germ • Radio-opacity for visualization on radiographs • Ease of insertion • Ease of removal •Should not cause any discoloration of tooth Rifkin A . The root canal treatment of abscessed primary teeth: A three to four year follow-up. J Dent Child 1982; 49: 428-431. CRITERIA FOR AN IDEAL PULPECTOMY OBTURANTS (Rifkin 1980 & Machida 1983)

31. A – Asymptomatic D – Dry S – No sinus formation C – Negative culture O – No odour T – Intact temporary Obturation Aim To prevent recontamination of the root canal – coronally / apically To isolate and neutralize any residual bacteria

32. Classification of obturation materials in primary teeth Zinc Oxide Eugenol Calcium Hydroxide Sealapex Calcicur vitapex Iodoform based pastes Walcoff paste KRI paste Maisto paste Vitapex / metapex Endoflas

33. First root canal filling material for primary teeth Anti-inflammatory and analgesic Mostly used - <5 years of age Zinc Oxide Eugenol Liquid Eugenol Powder Zinc oxide - 42% Staybelite resin - 27% Bismuth carbonate - 15% Barium sulphate - 15% Sodium borate - 1%

34. Sets into hard mass – Deflection of succedaneous teeth (Kennedy) Irritating to periapical tissue Necrosis of bone and cementum Longer time to resorb than tooth root Disadvantages

35. Antibacterial effect – hydroxyl ions & inactivation of enzymes in cytoplasmic membrane When in contact to vital pulp – inflammatory root resorption Well tolerated periapically, causing some degree of apical hard tissue deposition. Mainly serves as an intracanal medicament. Calcium Hydroxide Herman (1930)

36. Walkoff (1928) Bactericidal Resorbs from Peri-apical area and furcation area by macrophages in 1-2 weeks Walkoff Paste Parachlorophenol Camphor Menthol Composition PCM

37. Highly resorbable, Bactericidal, Healthy tissue ingrowth at apex KRI Paste (Iodoform Paste) Composition Parachlorophenol – 2.02% Camphor – 4.86% Menthol – 1.20% Iodoform – 80.80% PCMI ADVANTAGE Radio opaque Does not set to a hard mass DISADVANTAGE Rapid resorption from canals caused voids -- miroleakage

38. Endoflas Resorbable paste (extra and intra- radicularly ) Powder Tri- Iodo -Methane & Iodine Di- ButilOrthoCresol – 40% Zinc Oxide – 56.5% Calcium Hydroxide – 1.07% Barium Sulfate – 1.63% Liquid Eugenol PMCP ( ParaMonoChloroPhenol )

39. Vitapex / Metapex Good clinical and radiographic results Mortazavi & Mesbahi (2004) Vitapex – 100% ZOE – 78.5% Iodoform – 40.4% Calcium hydroxide – 30.3% Silicone – 22.4% Success

40. OBTURATION TECHNIQUES

41. Pressure syringe (Greenberg and Katz 1961) Lentulo spiral ( Kopel , 1970) Injection (disposable or tuberculin syringe) (Johnson, 1987) Condensation with moist cotton pellet ( Donnenberg ) Use of paper points ( Spedding ) Amalgam carrier ( Nosonwics ) Pluggers (Gould, 1972) Obturation Techniques

42. The quality of the root canal filling: Uniformity of the obturating material. Level of obturation. Presence of voids. Voids Optimal fill Underfill Overfill Non-uniform radio-opacity Uniform radio-opacity

43. Conclusion Being a Pedodontist, it is essential to know the anatomic variation and treatment considerations for primary teeth which include correct measurements to prepare and obturate the canal with suitable filling material to provide effective hermetic seal.