Pradeep Daniel Gainneos .

R
III Year PG Student

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Contents
 Introduction  Different techniques of obturation
 Cause of pulpal disease  Conclusion
 Indications  References
 Contraindications
 Treatment objectives and
considerations
 Single visit pulpectomy
 Multiple visit pulpectomy
 Access Cavity Preparation
 BMP of Primary Teeth
 Intracanal medicaments
 Irrigants
 Obturating materials

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Introduction Pulpectomy

 Primary teeth are the best space maintainers and hence should be
preserved and retained as long as possible.

 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.

 Pulpectomy of primary teeth is indicated when the inflammation of

the pulpal tissue involves the radicular pulp or when nonvital tooth is
diagnosed.

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 Pulpectomy

 Pulpectomy helps in preserving a pulpally involved primary tooth by

extirpating the diseased pulp associated with microorganism and
debris from the canal and obturating with an antibacterial resorbable
filling material

 Insufficient space for erupting permanent teeth causes impaction of

premolars and mesial tipping of molar teeth adjacent to the lost
primary molar.

 Primary teeth retained by pulpectomy, if not severed with a

progressive root resorption or aligned in a severe infraocclusion, the
retained molar can be a functional component in the dental arch for
many years

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 Pulpectomy

 Law and Lewis stated that the successful treatment of the pulpally
involved tooth is to retain that tooth as a healthy component of the
primary and young permanent dentition.

 Riordan M W and Coll J reveal that pulpectomy procedure can be

done on primary teeth even with evidence of chronic inflammation or
necrosis of radicular pulp.

 According to Holan et al pulpectomy of primary teeth do not induce

minor hypoplasia in succedaneous teeth and that primary teeth are the
best space maintainer.

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 Pulpectomy

 Marsh and Largent indicated that the goal of pulpectomy in primary

teeth should be the decrease of bacteria in the contaminated pulp.

 Therefore the definition of pulpectomy states that, “It is the technique

to gain an access to the root canals, remove as much dead & infected
material as possible & fill the root canals with a suitable material to
maintain the tooth in a non infected state”.

 Mathewson defined pulpectomy as the complete removal of necrotic

pulp from the root canals and the coronal portion of dental primary
teeth in order to maintain a tooth in the dental arch.

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 Pulpectomy

 Finn defines pulpectomy as removal of all pulpal tissue from the

coronal and radicular portions of the tooth.

 Pulpectomy involves removal of the roof and contents of the pulp

chamber in order to gain access to the root canals, which are
debrided, enlarged and disinfected. The canals are then filled with
resorbable material.

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 Pulpectomy

 Primary tooth should resorb normally and in no way interfere with

formation and eruption of permanent tooth

 Primary teeth have a few factors which causes the increase of

incidence of pulpal involvement from caries and have a complicated
canal preparation and obturation:
 Primary teeth are smaller in all dimensions; their enamel cap is thinner, with less
tooth structure protecting the pulp.

 Primary pulp horns are higher, particularly mesial.

 The roots of primary molars are longer and more slender and flare more toward the
apex to accommodate permanent tooth buds.

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 Pulpectomy

CAUSES OF PULP DISEASE

 According to grossman, the causes of pulp disease are
 Physical,

 Chemical

 Bacterial.

 Physical causes include

 Mechanical,

 Thermal

 Electrical

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 Pulpectomy
 A] Mechanical
 Trauma

 Pathologic wear

 Cracked tooth syndrome

 Radiation

 Barometric changes

 B] Thermal Injury
 Thermal causes of pulp injury are not quite common.

 Heat from cavity preparation – cavity preparation produces temperature changes

with an increase of 20°C in temperature during dry cavity preparation 1mm from
the pulp.

 C] Electrical Injury
 Galvanic current produced from dissimilar metallic fillings may generate

heat and cause pulpal damage.

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 Pulpectomy

 Chemical
 Probably the least common of all the causes.

 Cements such as silicate are the most frequent cause for pulp death.

 Acid etchants, when used on exposed dentin preliminary to the

application of a composite resin, irritate the pulp without causing pain.

 Bacterial
 The most common cause of pulp injury is bacterial.

 Bacteria and their products may enter the pulp through a break in
dentin, either from caries or from accidental exposure, from percolation
around the restoration.

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 Pulpectomy

 Indications:
 Irreversible inflammation extending to the radicular pulp

 Primary teeth with necrotic pulp

 Pulpless primary teeth without permanent successors

 Pulpless primary teeth with sinus tracts

 Primary teeth with evidence of furcation pathology

 Pulpless primary 2nd molars before eruption of permanent 1st molar

 Pulpless primary teeth in hemophiliacs

 Presence of an abscess

 Pulpless primary teeth next to the line of palatal cleft

 Pulpless primary molars supporting orthodontic appliances

 Pulpless primary teeth when space maintainers or continued supervision are not
feasible

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 Pulpectomy

 Contraindications:
 Teeth with non-restorable crowns

 Pathologic resorption of at least 1/3r d of the root with a fistulous sinus tract

 Peri-radicular involvement extending to the permanent tooth bud

 Extensive pulp floor opening into the bifurcation

 Excessive internal resorption

 Primary teeth with underlying dentigerous or follicular cysts

 Medical contraindications:

○ Heart disease

○ Immuno-compromised children

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 Pulpectomy

 Treatment Objectives:
 To maintain the tooth free of infection
 To bio-mechanically clean & obturate the root canals
 To promote physiological root resorption

 Treatment Considerations:
 GENERAL
○ Healthy & co-operative patient

○ Informed consent with a clear explanation of the

procedure to the parents, must be obtained.

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 Pulpectomy

 DENTAL:
○ Restorable teeth after the root canal treatment.

○ Chronologic & dental age must be evaluated to rule

out teeth with eminent exfoliation.
○ Psychological or cosmetic factors must be
considered.
○ The number of teeth to be treated & strategic
importance to the developing occlusion must be
evaluated.
○ Primary molar root anatomy along with proximity of
underlying succedaneous tooth must be evaluated.

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 Pulpectomy

Types of Pulpectomy
 Partial pulpectomy
 One third to one half of the coronal portion of the
radicular pulp tissue is removed from the canals.

 Complete pulpectomy
 Complete removal of pulp tissue from the root canal

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 Pulpectomy

 Partial pulpectomy
 “Pulpotomy" and "partial pulpectomy" were 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 contents of the root canal.

 At present, "partial pulpectomy" 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.

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 Pulpectomy

 Single visit Pulpectomy

 This procedure is indicated in vital teeth where
haemorrhage from the amputated radicular stumps
is dark red with a slow ooze and is uncontrollable
○ Step I: Local anesthetic solution administration

○ Step II: Proper isolation (rubber dam is preferred)

○ Step III: Access cavity preparation

○ Step IV: Radicular pulp tissue removal

○ Step V: Enlarging the canals not more than 30 size h

file

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 Pulpectomy

○ Step VI: Irrigation (NaCl,5%NaOCl – not less than

10 times)

○ Step VII: Placement of medicament for 3 min

(formocresol)

○ Step VIII: Drying the canal by using paper points

○ Step IX: Obturation

○ Step X: Final restoration

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 Multivisit pulpectomy
 This procedure is used for non vital primary teeth and

has been studied over the short term and long term.

 The multi visit pulpectomy is indicated where infection ,

an abscess or a chronic sinus exist.

 Two phases-

○ CORONAL phase

○ RADICULAR phase

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 Technique:
 Achieve adequate anesthesia and rubber dam
isolation
 Coronal phase:

1. Remove all caries.

2. Remove the roof of the pulp chamber with a high-
speed handpiece.
3. Amputate the coronal aspect of the pulp tissue with a
large round bur in a slow-speed handpiece

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 RADICULAR phase
1. The remaining pulp tissue occupying the root canals is
removed using endodontic files at a predetermined
working length, approximately 1 to 2 mm short of the
root apices.
2. The canals should be enlarged several sizes beyond the
size of the first file that fits into the canal to a minimum
final size of 30 to 35.
3. Throughout root canal instrumentation, the canals should
be irrigated with sodium hypochlorite to aid in
debridement

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4. Dry the canals with sterile paper points.

5. The canals are filled with a treatment paste (e.g: Zinc

Oxide-Eugenol)

6. The tooth is restored with a stainless steel crown

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 Access Cavity Preparation
 Access cavity preparation is done to Create a smooth straight line
access to the canal system and the apex.

 It should form a straight entry into the canal orifices with line angles

forming a funnel that drops smoothly into the canals.

 An ideal access preparation should have the following features:

○ Unobstructued view into canal

○ File should pass into canal without touching any part of access

cavity

○ Absence of remaining caries

○ Obturating instrument should pass into the canal without touching

any portion of access cavity

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 Procedure:

○ Depth of penetration is checked by aligning the bur and

handpiece against the radiograph

○ Completion of general outline form

○ Penetration into pulp chamber is done by using a round

bur

○ When a “Drop in” is felt, replace round bur with tapered

fissure bur

○ All unsupported tooth structure is removed

○ Deroofing of pulp chamber

○ Walls of pulp chamber are flared & tapered to form a

funnel shape with larger diameter occlusal surface

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 BMP in Primary tooth:
 Once access cavity is prepared, a double ended endodontic explorer

is used to identify each of the canals.

 Before instrumentation, the pulp chamber is copiously irrigated with

NaOCl.

 Trial length is obtained by measuring the tooth on radiograph and

subtracting 1 – 2 mm.

 A small diameter file is placed into the canal to the trial length and

another exposure taken from which the working length is determined

 Whenever possible, all radiographs should be taken utilizing the

paralleling technique in order to minimize distortions.

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 The working length should be 1-2 mm short of the
radiographic apex ideally.

 If obvious signs of root resorption are present, it may be

necessary to further shorten the working length by an

additional 1-2 mm in order to avoid overextension of the
instruments into the periapical tissues.

 Once the working length has been established, the canals

are thoroughly cleaned.

 If hemorrhage is encountered after the pulp tissue has been

removed, this is an indication that root resorption likely

has occurred and the working length should be shortened
2-3 mm from the radiographic apex.

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 Instrumentation should not be done till the apex as this

would force contaminants and toxic by-products into

the periapical tissues, thereby causing possible injury
to the underlying permanent tooth bud.

 To aid in access to the canals, H-files may be used to

flair the canal orifices

 Instrumentation with H-files is always directed toward

the areas of the greatest bulk and away from the

furcation area to prevent stripping and perforation of
the furcal position of the thin root canal system.

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 Instrumentation with standard files is performed in much

the same manner as is done to prepare a canal to receive

GP, creating an apical stop 2-3 mm from the apex.

 The canals should be enlarged several sizes beyond the

size of the first file that fits snugly into the canal to a
minimum final size of 30-35

 During instrumentation the canals should be irrigated

frequently with sodium hypochlorite to aid in

debridement.

 After the canals have been debrided thoroughly and

instrumentation is complete, the canals again are irrigated

copiously with sodium hypochlorite and dried with sterile
paper points.
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Intra-canal medicaments
 Various materials have been used throughout the ages as
intracanal medicaments, which are listed below:
 Essential oils – Eugenol, castor oils, etc
 Phenolic compounds – Phenol
 Para-chlorophenol
 Camphorated Parachlorophenol
 Formocresol
 Glutaraldehyde
 Cresatin
 Calcium Hydroxide
 2%CHX gel

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IRRIGATION
 Pulp chamber and root canals of untreated non-vital teeth are filled with
necrotic pulp remnants and tissue fluids, shreds of mummified tissue, vital
tissue and microorganisms especially in the apical root portion.
 Instrumentation into this canal is likely to force such noxious material
through the apical foramen with a resulting periradicular inflammation or
infection.
 For short term or long-term success, thorough debridement of the pulp
chamber and canal is the most important aspect of endodontic treatment.
 Certain solutions like sodium hypochlorite, H2O2, RC prep etc, produce
effervescence and play and important part in removal of the tissue from
the inaccessible area of the root canal system.

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 GOALS OF IRRIGATION:
 Lavage of debris
 Tissue dissolution
 Antibacterial action
 Lubrication

 IDEAL PROPERTY OF AN IRRIGATING SOLUTION:

 Compatibility with chemical use in terms of the physical and
chemical property.
 Antibacterial capacity, chelating actions.
 Tissue dissolution.

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 Sodium hypochlorite (NaOCl)
 It is one of the most popular irrigating solutions

used. It is used in different concentrations.

 Sodium hypochlorite is the most used irrigating

solution in endodontics, because its mechanism

of action causes biosynthetic alterations in
cellular metabolism and phospholipids
destruction, formation of chloramines that
interfere in cellular metabolism, oxidative action
with irreversible enzymatic inactivation in
bacteria, and lipid and fatty acid degradation.

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 Trepagnier has reported that either 5.25% or 2.6% NaOCl has the same

effect when used in the root canal space for a period of 5 minutes.

 Rubin reported that, 2.6% NaOCl alone is an excellent predentin and

tissue solvent.

 Resenfield demonstrated that 5.25% NaOCl dissolves vital tissues.

 For a necrotic tissue, conc. of 5.25% NaOCl was found to be better than

2.6%, 1% or 0.5%.

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 Chlorhexidine
 Endodontic literature has shown that

chlorhexidine (CHX) 2% is used as the root

canal irrigating solution, it reacts with
negatively charged groups on the cell surface.

 Though CHX as a root canal irrigant has the

effect of removing smear layer, it has not
shown any long term damage to the host
tissues when it was accidently injected above
the apex

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 Tetracycline HCl
 Tetracycline HCl is an acidic solution with bacteriostatic properties.

 Faruk Haznedarogh et al, in their SEM study revealed that

application of tetracycline HCl resulted in complete removal of

smear layer and was comparable to 50% citric acid.

 Tetracycline is a broad spectrum antimicrobial and reported to bind

directly to demineralised dentinal surfaces and maintain their

antimicrobial activity by being subsequently released.

 One disadvantage of tetracycline is that it can chelate with calcium

and cause staining of teeth

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 LASER IRRADIATION IN ROOT CANAL WALLS
 A study of literature reveals various reports indicative of usefulness of

lasers for endodontic treatment.

 Nd:YAG, CO2 and Argon lasers have demonstrated to be capable of

vaporizing debris at varying energy level and duration.

 CO2 irradiation at output power of 5w was found to be more effective

for cleaning root canal walls than Nd:YAG laser irradiation at 2w.

 Argon and Nd:YAG lasers are useful for removing debris and smear

layer from root canal walls.

 Er:YAG Laser is a very effective tool for debris removal near the apical
stop.

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Obturating Materials
 Criteria for an ideal pulpectomy obturant (treatment paste)
 Antiseptic

 Resorbable

 Harmless to the adjacent tooth germ

 Radiopaque

 Non-impinging on erupting permanent tooth

 Easily inserted and easily removed

 Should not shrink

 Insoluble in water

 Not discolour teeth

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 Commonly used materials used are:
 Zinc Oxide Eugenol

 Walkhoffs Paste

 KRI- Paste

 Maisto’s Paste

 Zinoxide – Iodoform Paste

 Calcium Hydroxide

 Metapex

 Vitapex

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 Zinc oxide eugenol (ZOE)
 Zinc oxide eugenol was discovered by Bonastre and subsequently used

in dentistry by Chisholm.

 It was the first root canal filling material to be recommended for

primary teeth, as described by Sweet in 1930.

 Success rate of 77- 80% has been reported.

 For the large canals in primary anteriors, a thin mixture of the ZnO and

Eugenol can be used to coat the walls of the canal.

 A paper point or the last file used can be coated with this mixture,

carried to the canal and rotated to cover the walls to the same apical
length as the BMP was done.

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 The antibacterial activity of ZOE is greater than that of idoform

containing paste .

 Cytotoxicity property in direct and indirect contact with cells is equal to

and less than that of KRI paste .

 Commonly used material for obturation is ZOE without catalyst.

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 Calcium Hydroxide:
 The history of use of Ca(OH)2 in primary teeth dates back to 1950-

1960s.

 Initially it was used as a dressing material after pulpotomy.

 The use of Ca(OH)2 has recently been on the increase due to the fact

that it is less detrimental to tissue than either phenol or formaldehyde

and provide excellent bactericidal and sedative effect and prevents
exudation.

 Antibacterial effect is primarily due to the liberation of hydroxyl ions

and inactivation of enzymes in the bacterial cytoplasmic membrane

 The main drawback of the material is that despite of its antiseptic and

osteoconductive properties, it has the tendency to get depleted from the

canals earlier than the physiologic root resorption.
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 Iodoform:
 Castagnola and Orlay showed that iodoform pastes are bactericidal to

microorganisms in the root canal and lose only 20% of their potency
over a period of 10 years.

 Iodoform because of the presence of iodine causes yellowish

discoloration of the tooth that may compromise the esthetics

 Few studies have revealed that it is irritating to periapical tissues and

can cause cemental necrosis

 It is commercially available as Walkoff‘s paste, Maisto’s paste and

Guedes Pinto paste

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 Endoflas:
 The rationale behind incorporating three materials ZOE, Ca(OH)2 and

iodoform into Endoflas was probably to compensate the disadvantages

of one individual material with the advantages of the other.

 Endoflas has the advantage of having the resorption limited to excess

material, which has been extruded periapically within 7 days

 Resorption of material does not occur within the canal.

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Various Obturating Techniques
 Endodontic pressure syringe:
 Technique described by greenberg (1963)

 This apparatus consists of a syringe barrel, threaded plugger, wrench

and threaded needle.

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 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.

 Once canal is filled, the syringe is to be immediately cleaned to

avoid blockage.

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 Lentulo spiral
 This obturation technique was advocated by Kopel in 1970.

 Its one of the most effective and straightforward techniques to apply

sealers and CaOH into permanent tooth canals and cements into
primary tooth canals.

 The design and flexibility of lentulospirals allows files to carry the

paste uniformly through narrow curved canals of primary teeth.

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 There are 2 types - Handheld

- Rotary

 Rotary versions of Lentulospirals were reported to have better

success than hand held and is used at a speed of 15000 rpm for apical
third and 5000 rpm for cervical and middle third.

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 Mechanical Syringe
 This method was proposed by Greenberg in

1971.

 The canal shape governed the selection of

the filling technique and the mechanical

syringe was a poor performer in both curved
and straight canals

 The screw mechanism of the endodontic

pressure syringe would be able to generate

far greater pressures than could a plunger
system as is seen with the mechanical
syringe.

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 The 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 were added until the canal

was filled to the cervical area.

 Because the flexibility of endodontic pluggers is limited, the paste

cannot be placed in the full working length of narrow, curved canals

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 Jiffy Tube
 This technique was popularized by Rifficin in 1980.

 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.

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 Tuberculin syringe
 This syringe was utilised by Aylord and Johnson in 1987.

 The standardized mixture of ZOE was backloaded 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.

 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

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 The Reamer Technique
 A reamer coated with ZOE paste was inserted into the canal with
clockwise rotation
 It is accompanied by a vibratory motion to allow the material to reach
the apex, and then withdrawn from the canal, while simultaneously
continuing the clockwise rotary motion.
 A rubber stopper was used to keep the reamer to the predetermined
working length
 The process was repeated 5 to 7 times for each canal until the canal
orifice appeared filled with the paste.

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 The Insulin Syringe Technique
 A homogeneous mixture of ZOE is loaded into the insulin syringe
and a stopper is used after assessing the working length.
 The needle is inserted into the canal and kept about 2mm short
of apex.
 The material is then pressed into the canal and while doing so
the needle is retrieved from the canal outwards while continuing
to press the material inside.
 This helps avoid incorporation of voids into the canal.

 Finally, over the orifice more material is pressed and compressed

using wet cotton.

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 Disposable Injection Technique
 ZOE can be loaded in a 2-ml syringe with 24-gauge needle along with

stopper adjusted to measured working length.

 The material is gently pushed into the canal till the material is seen

flowing out of the canal orifice.

 Now the needle is gradually withdrawn while pushing the material till

the needle reaches the pulp chamber.

 The technique described is simple, economical, can be used with

almost all filling materials

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 NaviTip System
 Recently introduced by Ultradent into the market to deliver root canal

sealer.

 This NaviTip has a thin and flexible metal tip that comes in different

lengths and a rubber stop may be adjusted to it.

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 Mahtab Memarpour et al compared anesthetic syringe, NaviTip

syringe, pressure syringe, tuberculin syringe, lentulo spiral and

packing with a plugger
○ Lentulo produced the best results in terms of length of obturation,

○ NaviTip syringe produced the best results in controlling paste extrusion

from the apical foramen and having the smallest void size and lowest
number of voids.

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 Bi-Directional Spiral
 Developed in 1998 by Dr. Barry Musikant

 This technique ensures that a minimal amount of obturating material

will past the apex.

 This controlled coverage is achieved because the spirals at the

coronal end of the instrument spin the material down the shaft
towards the apex, while the spirals at the apical end spin the material
upward towards the coronal end.

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 Where they meet (about 3-4 mm from the apical end of the shaft), the

material is thrown out laterally.

 While this prevents apical extrusion of sealant, it has the highest

number of voids according to a study done by Grover et al.

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 Pastinject
 Pastinject (Micromega) is a specially designed paste carrier with

flattened blades, which improves material placement into the root

canal.

 In a study conducted by Grover et al, it was concluded that among

lentulospirals, bi-directional spiral, pastinject and pressure syringe, the

pastinject technique has proved to be the most effective, yielding a
higher number of optimally filled canals and minimal voids, combined
with easier placement of the material into the canals.

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 Level of Obturation in primary teeth
 Garcia-Godoy recommended that in the case of primary molars, if the
permanent tooth bud was within the furcation area, instrumentation can be
limited to a level above the occlusal plane of the unerupted permanent tooth
bud.
 If permanent tooth bud is below the apex of primary teeth, the the canals are
to be cleaned and filled to the entire length.
 Garcia-Godoy and DM Ranly concluded that filling to the apices is unusual
and apparently unnecessary.
 What is crucial is the placement of the paste over the floor of the chamber in
order to ensure that the auxillary canals traversing the furcation area are
medicated.

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 In a study conducted by Bawazir et al in 2005, the success rates of
teeth which were filled to various lengths were compared and it
was found that underfilled teeth had a clinical success of 94%
while optimally filled canals had a success of 92%.

 This however changed to 56% and 92% when their radiographic

success rates were compared.

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Conclusion
 Eventhough Pulpectomy is not as successful as vital pulpotomy, it
is a treatment of choice for non-vital teeth and teeth with periapical
pathologies, which is done to prevent premature loss of primary
teeth.

 Zinc oxide eugenol is the most widely used obturating material

even though newer materials have been introduced over time.

 Numerous obturating techniques were introduced over the ages,

but it depends on the choice of the pedodontist and their technique
that determines the success rate of pulpectomy.

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 References:
 McDonald and Avery’s - Dentistry for the child and adolescent.

 Mathewson - Fundamentals of pediatric dentistry

 Nikhil Marwah – Textbook of Pediatric Dentistry

 Albert C. Goerig, Joe H. Camp - Root canal treatment in primary-

teeth: a review; Pediatric Dentistry: Vol 5 (1); 33-37

 Mahajan N, Bansal A - Various Obturation methods used in

deciduous teeth; IJMDS: January 2015; 4(1); 708-713

 Srinitya RajaSekhar et al – Obturating Materials Used for

Pulpectomy in Primary Teeth- A Review; Journal of Dental and

Craniofacial Research 2018: Vol.3 (1); 2-9

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