PULPECTOMY IN PEDIATRIC DENTISTRY

Hi, I am Dr Komal Ghiya, pediatric dentist, I am here to upload my own presentations for educational purposes. I hope this presentation will help you in knowing more about pulpectomy in primary teeth

1. PULPECTOMY DR KOMAL GHIYA MDS PEDODONTICS AND PREVENTIVE DENTISTRY

2. Pulpectomy Definition Indications Contraindications Historical perspective Procedure Single visit Multiple visit 2

3. Steps in pulpectomy Anesthesia, isolation and access opening Working length measurement Cleaning and shaping the canals Irrigation Obturation Materials for obturation studies Obturation techniques studies 3

4. Antibacterial property of obturating materials Clinical and radiographic success Conclusion References 4

5. Pulpectomy Mathewson(1995 ) - The complete removal of the necrotic pulp from the root canals of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in the dental arch. Finn - Removal of all pulpal tissue from the coronal and radicular portions of the tooth. 5

6. OBJECTIVES Resolution No over extension or under filling Permitting resorption Health of periodontium and bone No internal or external inflammatory root resorption Hold the space for erupting permanent tooth 6 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

7. indications A non vital tooth associated with an abscess or fistula Presence of pus at the exposure site or in the pulp chamber Cellulitis Extensive furcation pathology Radicular pulp is chronically inflamed If pain present may be spontaneous or persistent The tooth is restorable CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

8. Mobility or intraradicular bone loss are minimal The haemorrhage from the amputation site is dark red and scanty ,difficult to control Primary teeth without permanent successor STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC DENTISTRY,SCIENTIFIC FOUNDATIONS AND CLINICAL PRACTICE,1982

9. contraindication Excessive tooth mobility Furcation involvement External root resorption Internal root resorption Gross loss of root structure Periapical infection involving the crypts of succadenous tooth 9 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

10. Historical Perspective 10 Sweet (1930) – 4 to 5 step technique using formocresol for the treatment of pulpless teeth without fistula. Rabinowitz (1953) - treated nonvital primary teeth with a 2-3 day application of FC, followed by precipitation with silver nitrate and a sealer of ZOE into canals. Long procedure-avg. 5.5 visits for teeth without periradicular involvement and avg. 7.7 visits for teeth with periradicular involvement. Hobson(1970) - canals not debrided . Used breechwood creosote for 2 weeks followed by filling pulp chamber with ZOE. STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC DENTISTRY,SCIENTIFIC FOUNDATIONS AND CLINICAL PRACTICE,1982

11. 11 Lewis & law(1973) First visit- canals medicated with eugenol , camphorated parachlorophenol or FC. Second visit- canals debrided and filled with ZOE or iodoform crystals Gould(1970) – One appointment technique camphorated parachlorophenol placed in chamber for 5 min followed by debridement of canal and pressing ZOE in prepared canals. Starkey(1980) Multi-appointment for teeth with necrotic pulps and periradicular involvement STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC DENTISTRY,SCIENTIFIC FOUNDATIONS AND CLINICAL PRACTICE,1982

12. Types Of Pulpectomy Single visit (Gould 1970) Multiple visit (Gould & Starkey 1980) 12 Partial pulpectomy Complete pulpectomy CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

13. Chemicomechanical preparation The multiple ramification of radicular pulp in a primary molar makes complete debridement impossible Ribbon shape of root canals with narrow mesiodistal width compared to their buccolingual dimension,discourages gross enlargement of the canals In primary tooth the attempt to prepare a circular apical one third mechanically may result in lateral perforation of canal because of its hour glass shape CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

14. Role of resorption on canal anatomy and apical foramina Newly completed roots of the primary teeth - Near the anatomic apexes Because of the position of the permanent tooth bud – incisors and canines - initiates on lingual surfaces Molars begins on the inner surfaces of roots. As resorption progresses, the apical foramina may not correspond to the anatomic apex of the root - radiographic establishment of the root canal length may be erroneous. More chances for additional communication with the periapical tissues other than through the apical foramina or lateral and accessory canal. 14 CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

15. INSTRUMENTS:POINTS TO BE NOTED Because of the bizzare anatomy of root canals the use of barbed broaches as in conventional endodontics may be unsuccessful H files nos 15 or 20 are strongly recommended since they remove hard tissue only on withdrawl,which prevents pushing through the materials Maximum enlargement upto 30 k size file is recommended Each canal shoud be enlarged upto 3 to 4 size larger CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

16. SINGLE VISIT PULPECTOMY GOULD 1970

17. INDICATIONS Large carious exposure with frank involvement of radicular pulp but without any periapical changes. Teeth with inflammation extending beyond the coronal pulp. Teeth with hemorrhage from amputated root stumps that is dark red, slowly oozing and uncontrollable. 17 CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

18. procedure CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

19. Multi visit (Gould short term :1972 & Starkey:long term 1973) Indications(Paterson and Curzon 1992) non vital abscess chronic sinus teeth with necrotic pulp and periapical involvement Fundamentals of pediatric dentistry. Richard J mathewson , Robert E primosch.3 rd edition. Quintessence publishing co.

20. Points to noted CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

21. Steps in pulpectomy 21

22. Anesthesia , isolation and access opening administering anesthesia and placing the rubber dam A #4 round bur -- gain access to the pulp chamber and remove the dentin ledges hindering direct line access to the canal orifices A double-ended endodontic explorer is used to identify each of the canals. Before instrumentation-- the pulp chamber should be copiously irrigated with sodium hypochlorite. 22 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

23. Precaution The thickness of enamel and dentin coronal to the pulp chamber is thinner in a primary tooth. The distance from the occlusal surface to the floor of the pulp chamber is much shorter than in the permanent tooth. Perforation through the floor into the furcation area 23 Albert C. Goerig , Joe H. Camp. Root canal treatment in primary- teeth: a review. PEDIATRIC DENISTRY: Volume 5, 1982

24. Working length A trial length is obtained by measuring the tooth on the preoperative radiograph and subtracting 1-2 mm small diameter file -- another exposure taken from which the working length is determined The working length should be 1-2 mm short of the radiographic apex ideally. further shorten the working length by an additional 1-2 mm(in case of resorption ) 24 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

25. Cleaning and shaping the canals To aid in access to the canals, Hedstrom files may be used to flair the canal orifices quickly open the canal orifice and eliminate pulp tissue Instrumentation with Hedstrom files is always directed toward the areas of the greatest bulk and away from the furcation area enlarged several sizes beyond the size of the first file that fits snugly into the canal to a minimum final size of 30-35 25 Albert C. Goerig , Joe H. Camp. Root canal treatment in primary- teeth: a review. PEDIATRIC DENISTRY: Volume 5, 1982

26. PARTIAL PULPECTOMY INDICATIONS: A PARTIAL PULPECTOMY MAY BE PERFORMED ON PRIMARY TEETH WHEN CORONAL ULP TISSUE AND THE TISSUE ENTERING THE PULP CANALS ARE VITAL BUT SHOW CLINICAL EVIDENCE OF HYPEREMIA THE TOOTH MAY OR MAY NOT HAVE A HISTORY OF PAINFUL PULPITIS BUT THE CONTENTS OF ROOT CANALS SHOULD BE NO RADIOGRAPHIC EVIDENCE OF THICKENED PDL OR A RADICULAR DISEASE J DEAN,D AVERY,R MC DONALDS,DENTISTRY FOR CHILD AND ADOLESCENT,10 TH ED

27. PROCEDURE J DEAN,D AVERY,R MC DONALDS,DENTISTRY FOR CHILD AND ADOLESCENT,10 TH ED

28. COMPLETE PULPECTOMY:STARKEY J DEAN,D AVERY,R MC DONALDS,DENTISTRY FOR CHILD AND ADOLESCENT,10 TH ED

29. Irrigation Sodium hypochloride Hydrogen peroxide Sterile saline Chlorhexidiene 29

30. Sodium hypochloride Effective hemostatic agent Helps to dissolve organic material Not toxic to pulpal tissues and does not interfere with pulpal healing ( Fuks 2000, Nakornchai et al. 2005) 5.25% Ability to oxidize, hydrolyze and to some extent, osmotically draw fluids out of tissues ( Pashley et al. 1985). A 5 % solution of sodium hypochlorite has excellent solvent action and is dilute enough to cause mild irritation when contacting periapical tissue( Schilder and Amsterdam ,1959) It can be used in a small (15 ml) syringe fitted with a 25 gauge 1 ¼ in(32 mm)provided the needle fits loosely in the canal 30 CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

31. Must be used Judiciously and with great caution to prevent it from reaching the periapex where it can elicit a severe inflammatory reactions ( Pashley et al. 1985, Fuks 2000, Mehdipour et al. 2007, AAPD guidelines) 31 Ramachandra JA, Nihal NK, Nagarathna C, Vora MS. Root Canal  Irrigants  in Primary Teeth. World J Dent 2015;6(3):229-234

32. Hydrogen peroxide ((Garcia--‐Godoy 1987,Holan & Fuks 1993)) effervescence, which occurs when it comes into contact with catalase , an enzyme present in cellular and blood products Nascent oxygen– destroying some strict anaerobes Main disadvantage– not possess the capacity to dissolve organic tissue (Harrison 1984, Zehnder 2007). 32 Ramachandra JA, Nihal NK, Nagarathna C, Vora MS. Root Canal  Irrigants  in Primary Teeth. World J Dent 2015;6(3):229-234

33. Sterile saline Used as an alternative solution Lacking in antimicrobial properties ( O’Riordan & Coll 1979, Zehnder 2007). 33 Ramachandra JA, Nihal NK, Nagarathna C, Vora MS. Root Canal  Irrigants  in Primary Teeth. World J Dent 2015;6(3):229-234

34. CHLORHEXIDIENE 2% SOLUTION REACTS WITH NEGATIVELY CHARGES CELL SURFACE AND REDUCTION IN INTRACANAL BACTERIA MORE EFFICACY TOWARDS GRAM POSTIVE THAN GRAM NEGATIVE Ramachandra JA , Nihal NK, Nagarathna C, Vora MS. Root Canal  Irrigants  in Primary Teeth. World J Dent  2015 ;6(3):229-234

35. Nickel-titanium Rotary Files For Root Canal Preparation In Primary Teeth Recently, nickel-titanium rotary files have been developed for use in endodontics . The flexibility and the instrument design allows the files to closely follow the original root canal path. An Ni-Ti is chosen that approximates the canal size. It is inserted into the canal while rotating and is taken to working length as determined on the pretreatment radiograph Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary Teeth.Endodontic Topics 2012, 23, 50–72 35

36. The canal is cleansed and shaped with sequentially larger files until the last file binds. It is not necessary to use a “crown down” instrumentation in primary teeth since the dentin cuts more easily than in permanent teeth. Care to be taken Not to overinstrument as perforations can readily occur in the thin dentinal walls. Apical overextension of the NiTi can result in an enlarged apical foramen and cause an overfill of pulpectomy paste. Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary Teeth.Endodontic Topics 2012, 23, 50–72 36

37. Advantages: 1. Tissue and debris are more easily and quickly removed 2. The nickel-titanium files are flexible, allowing easy access to all canals 3. Prepared canals are funnel shaped, resulting in a more predictable uniform paste fill 4.NTs are available in a 21 mm length. 5.Faster than hand files 37 Disadvantages: Cost of the low-speed, constant-torque handpiece Increased cost of Ni-Ti; Learning the technique

38. Mohammad Reza Azar, Laya Safi, Afshin Nikaein . Dental Research Journal. Mar 2012: Vol 9 ; Issue 2 There were no significant differences in cleaning efficiency between manual and rotary instruments. Only ProTaper files performed significantly better in the coronal and middle thirds than in the apical third of the root canal P Subramaniam , TA Tabrez , and KL Girish Babu  ( 2013 ) Microbiological Assessment of Root Canals Following Use of Rotary and Manual Instruments in Primary Molars. Journal of Clinical Pediatric Dentistry: December 2013, Vol. 38, No. 2, pp. 123-127. Rotary NiTi files were as efficient as conventional hand instruments in significantly reducing the root canal microflora.

39. Rotary endodontics Conventional systems: Racer Giromatic Endo – Gripper Endolift Flexible systems: Excaliber Endoplanar Canal – Finder – System Sonic systems: Sonic Air 3000 Endostar 5 Ultrasonic systems: Cavi – Endo Ni- Ti systems: Lightspeed ProTaper K3 Profile 0.04 and 0.06 HERO 642

40. Precautions dry canals – broken file tips discard files straight line access no pressure no skipping while rotating, insert and remove files

41. Recent modification Wave – one Reciproc Protaper F2 file

42. Obturationg materials Zinc oxide eugenol Iodoform based paste KRI Maisto Calcium hydroxide Mixture of calcium hydroxide with iodoform Endoflas Others : ZOE+Aloevera 42

43. Ideal requirements of obturation material Resorption rate Disinfectant Beyond apex resorption Easy insertion and removal Non soluble No discolouration Radio opaque Harmless to tooth germ Jung- wei Chen & Monserrat Jorden . Materials for primary tooth pulp treatment: the present and the future. Endodontic Topics 2012, 23, 41–49

44. Obturating materials Zinc oxide eugenol Composition Zinc oxide powder + eugenol oil Introduced by Bonastre (1837) and first used by Chrisholm 1876. Sweet (1930) first described the used of ZnOE as root canal filling material. Rabinowitz (1953) reported only 7 failure out of 1363 treated teeth. It has anti inflammatory and analgesic property 44 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

45. Yacobi and Kenny (1991):state that overfilling is not preferable to underfilling although experience shows that if small quantities of paste are extruded through the apex than the resorb. For this reason and that of subsequent exfoliation of primary tooth pure zinc oxide eugenol must be used and not any proprietary brand that may have any filler particles present Notable disadvantages – Irritation and cytotoxic effect on periapical tissues Reduced rate of resorption Enamel defects in the succedaneous teeth. When extruded beyond the apices, sets into a hard cement that resists resorption. CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4 TH EDITION

46. Success rate with material varies between 65% to 100%: Ozalp N et al 2005 Average success rate of 83%: trairatvorakul C et al:2008 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

47. Extruded zinc oxide eugenol cement Erasquin et al. 1967-- reported that canals overfilled with ZOE are not recommended because it irritates the periapical tissues and causes necrosis of bone and cementum when ZOE extrudes, it develops a fibrous capsule that prevents resorption of the material ( coll et al 1985) a slow rate of resorption and has a tendency to be retained even after tooth exfoliation, unresorbed material has been found to cause deflection of the succedaneous teeth 47

48. Coll and Sadrian (1996) reported anterior cross-bite, palatal eruption, and ectopic eruption of the succedaneous tooth following ZOE pulpectomy . 48 Sunitha B, K Pratej Kiran , Ravindar Puppala , Balaji Kethineni , Ravigna . Resorption of Extruded Obturating Material in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp- 64-67

49. IODOFORM BASED PASTES Kri paste Iodoform –80% Camphor – 4.8% Parachlorophenol – 2% Menthol – 1.2% Maisto paste Zinc oxide –14gms Iodo form –42gms Thymol –2gm Chlorophenol Camphor 3cc Lanolin –0.5gms Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

50. IODOFORM BASED PASTES KRI, Maisto First tried by Castagnola and Drely in 1952 in permanent teeth. Tagger and Sarnat – used the mixture of ZnOE & iodoform paste as the root canal filling material in 1984 , but introduced by Maisto in 1967. Rifkin - KRI as a final filling material and as a medicament between visits in 1980 . Garcia – Godoy (1987) – found no failure with KRI 50 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

51. Maisto's paste was thus seen to be superior to zinc oxide-eugenol in resorption of excess material. (Reddy VV, 1996)

52. Kri paste Resorbs rapidly Has no undesirable effect on succadenous tooth when used as a pulp canal medicament in abscessed primary teeth Extruded into periapical tissue is rapidly replaced with normal tissue Sometimes material is also resorbed inside the root canal KRI paste in synchrony with primary roots and is less irritating to surrounding tissues if a root is inadvertently overfilled Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

53. CALCIUM HYDROXIDE Introduced in 1930 , used in primary teeth for pulpotomy in 1950-60's. Keilbassa and Rosendhal 1995 ,H.S Chawla 1998 found it to show complete healing of periradicular radiolucency . Pabla et al 1997 - Vitapex resorbed extra and intra radicularly without ill effects . 53 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

54. Needly MP 2002 - presented a case report of two infected teeth filled with vitapex and found it to be an excellent filling material. A faster resorption of overfilled material was observed with calcium hydroxide when compared to ZOE ( Nadkarni U, 2000) Average success rate of 88% 54 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

55. MIXTURE OF CALCIUM HYDROXIDE WITH IODOFORM Dominguez et al 1989 – reported that when combining pure iodoform with Ca(OH)2 excellent clinical radiographic and histological results were obtained. Kuboto et al 1992 – there was no ideal root canal filling material for primary teeth. The closet to ideal was Ca(OH)2 + iodoform 28-May-21 55 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

56. METAPEX a silicone oil-based calcium hydroxide paste containing 38% iodoform is very popular Easy cleaning and removal. Excellent antibacterial effect and radiopacity . Premixed paste in a convenient syringe. Excellent accessibility to the root canal and prevention of cross－contamination . CONTENT: 2.2g paste in a syringe Disposable tips One ring rotator for the direction control of the tip 2 years from the manufacturing date

57. VITAPEX Vitapex contains iodoform 40.4%, calcium hydroxide 30.3%, silicon 22.4%. 57 Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

58. When extruded into furcal or apical areas, can either diffuse away or be resorbed in part by macrophages in one or two weeks. Bone regeneration has been documented after using Vitapex . Easy delivery system Resorbs at a slightly faster rate than that of the roots. Jung- wei Chen & Monserrat Jorden . Materials for primary tooth pulp treatment: the present and the future. Endodontic Topics 2012, 23, 41–49 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers 58

59. Vitapex has a greater ability in inducing bone regeneration than ZOE by the expression of BMP-2 induction. ( Xianyin Xia 2013) Complete resorption of excess paste occurs within 2 to 8 weeks Machida:calcium hydroxide iodoform mixture to be na nearly ideal primary tooth filling material Chung-wen Chen (2005) evaluated the cellular changes of a ZOE with formocresol (FC) and Vitapex -treated human osteoclastic cell line. Concluded that ZOE with FC is not biocompatible and cell death occurred by apoptosis. Vitapex is a good choice as a primary tooth root canal filling material. 59 Xia X, Man Z, Jin H, Du R, Sun W, Wang X. Vitapex can promote the expression of BMP-2 during the bone regeneration of periapical lesions in rats. J Indian Soc Pedod Prev Dent 2013;31:249-53.

60. Resorption has a tendency to get depleted from the canals earlier than the physiologic resorption of the roots iodoform -based -- resorbs if pushed beyond the apex however the rate of resorption is faster than the root. Erasquin et al. 1967, -- iodoform is irritating to the periapical tissues and can cause cemental necrosis 60 Sunitha B, K Pratej Kiran , Ravindar Puppala , Balaji Kethineni , Ravigna . Resorption of Extruded Obturating Material in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp- 64-67

61. Easy resorption . 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 61 Sunitha B, K Pratej Kiran , Ravindar Puppala , Balaji Kethineni , Ravigna . Resorption of Extruded Obturating Material in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp- 64-67

62. Vitapex when extruded into furcal or apical areas, can either get diffused or resorbed by macrophages, in as short a time as 1 or 2 weeks up to 2 to 3 months and causes no foreign body reaction, success rate of 96% to 100% ( Nurko et al 1999) 62 Sunitha B, K Pratej Kiran , Ravindar Puppala , Balaji Kethineni , Ravigna . Resorption of Extruded Obturating Material in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp- 64-67

63. Machida (2004)-- Vitapex is a nearly ideal root canal filling material for primary teeth Unlike ZOE, vitapex can be rapidly eliminated from periapical tissues and does not set to a hard mass and therefore, the probability of deflection in successor tooth is minimized. Shikha Dogra 2011– calcium hydroxide– better resorption than ZOE 63

64. Endoflas Composition Barium sulfate Calcium hydroxide Iodoform ZOE Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

65. Resorbable paste produced by south america Obtained by mixing powder containing tri iodomethane and iodine dibutile ortho cresol(40.6%) , zinc oxide(56.5%), calcium hydroxide(1.07%), barium sulfate(1.63%) Liquid containing eugenol and parachlorophenol Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

66. Hydrophilic– humid canals Provides goodseal Broad spectrum antibacterial activity Ramar K et al(2010)– 100% success Fuks 2002:success rate equal to KRI paste

67. Resorption of endoflas Fuks et al. 2002, Endoflas resorbed when over-extended periapically not resorb intraradicularly in their study bone regeneration resorption of excess Endoflas without washing within the roots 67

68. Antibacterial property Cox et al (1978) found that ZnO alone could not inhibit E.Coli , S.Aureus , S.Viridans , but ZOE inhibited S.Aureus and S.viridans . The inclusion of zinc acetate as a setting accelerator, however, allowed ZOE to inhibit all three. The inhibitory effect was further enhanced by adding formocresol . 68 Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary Teeth.Endodontic Topics 2012, 23, 50–72

69. Wright et al (1994) reported KRI paste to be superior to ZOE in inhibiting S.Faecalis in vitro. Calcium hydroxide was shown by Difiore et al (1983) to be non-inhibitory against S.Sanguis when mixed with water, but inhibitory when mixed with camphorated chlorophenol . 69

70. Turmeric+endoflas primary molars indicated for pulpectomy in 4 children (4-9 year-old) were selected.After biomechanical preparation,the four primary molars were obturated with Endoflas powder mixed with Curcumin gel and its efficacy was evaluated both clinically and radiographically at 1 month and 3-month intervals.  Conclusion: The Endoflas powder mixed with Curcumin gel showed faster resorption of the over pushed material within 1week, also showed a decrease in inter-radicular radiolucency after 1month and maintained until 3month follow-up. RADHAKRISHNA, A., MENNI, A., PRASAD, M., CHANDRASEKHAR, S.. THE SUCCESS RATE OF ENDOFLAS POWDER MIXED WITH CURCUMIN GEL AS OBTURATING MATERIAL IN PRIMARY MOLARS: CASE- SERIES.. Journal of Biomedical and Pharmaceutical Research, North America, 6, apr. 2017

71. Author Root canal filling material (comparing material) Success rate of comparison group Success rate of ZOE Reddy and Fernandez 1996 Maisto paste 100 80 Nadkarni and Damle 2000 Calcium hydroxide paste 94.3 88.6 Mortazavi and mesbahi 2004 Vitapex 100 78.5 Ozalp 2005 Calcicur Sealpex Vitapex 80 90 100 100 Trairatvorakul and Chunlasikaiwan 2008 Vitapex 89 85

72. Author Comparing material Success rate ZOE SUCCESS RATE (COMPARING MATERIAL) Anna fucks 2003 Endoflas - 70% M. MORTAZAVI 2004 Vitapex 78·5% 100% Trairatvorakul 2008 Vitapex 85% 89% Saziye Sarı 2008 Sealpex - 92.3% S Gupta 2011 Metapex 85.71% 90.48% Achiraya Duanduan 2013 Vitapex - LSTR 84.6 % LSTR 89% Ramer K 2013 Metapex , endoflas ZOE+ iodoform 84.7% Metapex 90.5 Endoflas 95.1% Nivedita Rewal 2014 Endoflas 83% 100%

73. Navit S et AL 2016 Endoflas > ZOE >Calcium hydroxide + Chlorhexidine > Calcium hydroxide + Iodoform +Distilled water ~  Metapex  > Saline.:ANTIMICROBIAL EFFICACY

74. TECHNIQUES OF OBTURATION

75. Endodontic pressure syringe Developed by Greenberg Described by Spedding and Krakow in 1965. Consists of syringe barrel,threaded plunger,wrench and threaded needle. Needle is placed 1 mm barrel short of apex and with a slow withdrawing type of motion, it is withdrawn 3 mm with each quarter turn of screw until canal is visibly filled at orifice. 75 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

76. Mechanical syringe : Proposed by Greenberg in 1971. Syringe with 30 gauge needle. Cement pressed using continous pressure while withdrawing the needle. 76 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

77. Tuberculin syringe Arnold and Johnsonin 1987 Standard 26 gauge, 3/8 th inch needle. 77 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

78. Incremental filling technique: Gould in 1972. Creamy mix of ZOE carried into canals Deposited with endodontic plugger in small increaments . 78 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

79. Lentulospiral technique: Kopel in 1970 . The creamy mix of filling paste can be coated around the walls of the canals with lentulospiral or the last used file(Duggal and Curzon 1994) The spiral root filler should be one size smaller than the last used file and cut half its length with scissors Dipped into mixture and then introduced into the canal to its predetermined length and rotated in the canal. 79 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

80. Other techniques: Amalgam plugger - Nosonwitz 1960 & King 1984 Paper points – Spedding 1973 Plugging action with wet cotton pellet (ZOE of tooth paste consistency) – Donnenberg 1974. 80 Endodontics .John I de Ingle, Leif K. Bakland . 5 th edition. B.C. Decker publishers

81. Sigurdsson et al. 1992 The lentulo spiral—most effective instrument and produce highest quality obturation ( Aylard and Johnson 1987 Endodontic pressure syringe and the lentulo spiral were superior for filling straight canals while the lentulo spiral was superior for the obturation of curved canals Aylard and Johnson 1987 Lentulo spiral-- best overall ZOE filling tool Singh R, Chaudhary S 2015 Motor driven lentulo spiral technique demonstrate more number of optimal fills with fewer voids when compared to hand held lentulo spiral technique and reamer A Singh et al 2017 Endodontic pressure syringe system is the best method Khubchandani 2017 Lentulospiral produced the best results in terms of length of obturation :M

82. Pulpectomy Success Clinical criteria 1. No gingival swelling or sinus tract 6 months or more postoperatively. 2. No purulent exudate expressed from the gingival margin 3. No abnormal mobility other than mobility from normal exfoliation 4. No pain on postoperative checkup. 82 Pediatric dentistry- Infanct through adoloscence . Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

83. Radiographic criteria 1. No pathologic signs of external root resorption or continued resorption if any was present preoperatively 2. A bifurcation radiolucency resolved 6-12 months postoperatively 3. No periapical radiolucency formation postoperatively 83 Pediatric dentistry- Infanct through adoloscence . Casamassimo,Fields,Mctigue,Nowak.5 th edition. Elsevier.Mosby

84. 84 Conclusion The rationale for pediatric pulp therapy has developed out of extensive clinical studies and improved histologic techniques. A successful pediatric endodontic outcome should be based on re-establishment of healthy periodontal tissues freedom from pathologic root resorption maintenance of the primary tooth in an infection-free state to hold space for the eruption of its permanent successor in the case of young permanent teeth maintenance of the maximum amount of non-inflamed portions of pulp tissue

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