NON VITAL PULP

THERAPY
NON VITAL PULP
THERAPY IN
PRIMARY TEETH
PRESENTED BY
AMIT PRAKASH

2nd YEAR MDS

• Guided by:
• Dr BARUN DASGUPTA
• Dr SWATI SINGH
• DR SEEMA QUMAR
• DR ARNAB MONDAL
CONTENT

• INTRODUCTION • IRRIGATION
• HISTORICAL PROSPECTIVE • INTRCANAL MEDICAMENT
• DEFINITION • OBTURATION MATERIAL
• INDICATION AND TECHNIQUE
• CONTRAINDICATION • FAILURES IN PULPECTOMY
• CLINICAL DIAGNOSIS • CONCLUSION
• PROCEDURE • REVIEWS
ONE STEP PULPECTOMY
MULTIPLE STEP
PULPECTOMY
 According to various guideline
of pulp therapy (AAPD, UK,
etc). Both vital and nonvital .
INTRODUCTI Their basic recommendation
ON is that if the infection has
spread to radicular pulp and
the tooth is showing signs of
irreversible pulpits then such
teeth be termed as nonvital.
The recommended treatment
for such cases is pulpectomy
for primary teeth,
apexification for young
permanent teeth and RCT for
permanent teeth.
 HISTORICAL PROSPECTIVE
• The historical view has never been in favor of pulpectomy in
primary teeth.
• Cohen stated that primary teeth were not suitable for
proper biomechanical endodontic procedures.
• Massler felt that only the most dedicated of pediatric
dentists should attempt endodontic procedures on primary
teeth.
• Brauer claimed that endodontic procedures were
impractical in children
• However, as time passed by, the views changed and pulpectomy
became an essential part of treatment.

• Later on Rabinowitch published an extensively documented

study of 1363 root canals on nonvital primary molars and
reported
that an average of 5.5 visits were required for non peri apically
involved teeth and 7.7 visits were required for teeth with
 DEFINITION

• • Mathewson (1995) defined it

as the complete removal of
the necrotic pulp from the root
canals of primary teeth and filling
them with an inert resorable
material so as to maintain the
tooth in the dental arch.
• Finn defines pulpectomy as
removal of all pulpal tissue
from the coronal and radicular
portions of the tooth.
• McDonald and Avery The
complete removal of diseased or
necrotic pulp from the root canals
and the coronal portion of dental
primary teeth in order to maintain
a tooth in the dental arch.
 • A tooth previously planned
for a pulpotomy that shows
uncontrolled pulpal
hemorrhage.
• Primary teeth with necrotic
pulps and minimum of root
resorption.
 Pulp less primary anterior
teeth when speech,
esthetics are a factor.
INDICATION • Pulp less primary molars
S holding orthodontic
appliance.
• Necrotic pulp with no sign
of cellulites.
• Radiographic Indications
• Adequate periodontal
and bony support .
evidence of furcation
involvement
 • Excessive tooth mobility.
• Communication between the roof
of the pulp chamber and the region
of furcation.
• Insufficient tooth structure to allow
isolation by rubber dam and extra
coronal restoration
• External root resorption.
• Internal root resorption in the
apical 3rd of the root.
CONTRA
• Radicular cyst,
INDICATIONS dentigerous/follicular cyst in
association with the primary tooth.
• Inter-radicular radiolucency that
communicates with the gingival
sulcus
• Young patient with systemic illness
such as congenital
Ischemic heart disease, leukemia.
• Children on long-term
corticosteroids therapy
 • An outline for determining the pulpal
status of cariously involved teeth in
children involves the following
• 1. Visual and tactile examination of
carious dentin and associated
periodontium
2. Radiographic examination of a.
periradicular and furcation areas b.
CLINICAL pulp canals c. periodontal space d.
developing succedaneous teeth
DIAGNOSI • 3. History of spontaneous unprovoked
pain
S • 4. Pain from percussion
• 5. Pain from mastication
• 6. Degree of mobility
• 7. Palpation of surrounding soft tissues
• 8. Size, appearance, and amount of
hemorrhage associated with pulp
exposures
(ENDODONTICS:
INGLE 5 EDITION)
TH
DIAGNOSTIC AIDS
• Mc Downald and Avery have
outlined several diagnostic aids to
select tooth for non vital pulp
therapy.
• Eidelman et al, Prophet and Miller
have stated that no single
diagnostic mean can be relied on
for determining a diagnosis for
pulpal conditions of a tooth.
Electric pulp test are not valid for
primary teeth. Anderson et al.
Textbook and color atlas of
traumatic injuries .4th edition 2007.
 Thermal test are usually not
conducted on primary teeth
because of its unreability. Cohen s,
Hargreves k,9th ed.2006:822-23.
Laser Doppler Flowmetry may be
found more significant in
determining the vitality of pulp in
primary teeth. Endo Dent
 • This is carried out as
an extension of
pulpotomy procedure,
probably on the spot
decision when
SINGLE STEP hemorrhage from
PULPECTOMY amputated pulp
stumps is
uncontrollable but the
tooth does not show
any periapical
changes.
Multiple Visit
Pulpectomy
• Indications (Given by
Paterson and Curzon
in 1992)
• • Indicated where
infection, an abscess or
chronic sinus exists
• • Nonvital primary
teeth
• • Teeth with necrotic
pulp and periapical
involvement
 First
Appointm
ent
(Access
Opening)
 Second
Appointm
ent
(Cleaning
and
Shaping)
 Third
Appointm
ent
(Obturatio
n)
 Pulp chamber and root canal of
untreated non-vital tooth is filled with
a gelatinous mass of necrotic pulp
remnants and tissue fluids , shreds of
mummified tissue and
microorganisms especially in the
apical root portion.
Instrumentation into the canal is
likely to force the noxious substance
IRRIGATI through the apical foramen resulting
into periradicular inflammation and
ON infection.
For short term or long term success ,
thorough debridement of canals and
pulp chamber is required.
Certain solutions such as sodium
hypochlorite, EDTA, CHX produces
effervescence and play an important
role in removal of the necrotic tissue
from inaccessible area of root canals
 • Hibbard et al stated that to
compensate for the incomplete
debridement due to complexity of the
root canal system of the primary teeth it
becomes necessary to destroy and
REFERENCES
flush out the microorganism in the
tissue raminant from canals and to
renders the canals unsuitable for
supporting microbial life.
• Garcia –Godoy recommended that in
case of primary molars if the permanent
tooth bud was with in furcation areas,
SOME

instrumentation of the canal be limited

to a level above the occlusal plane of
the unerupted permanent tooth.
if the permanent tooth bud is below
the apex of the primary tooth the canals
were cleaned and filled for the entire
length.
 GOALS
OF • REMOVAL OF DEBRIS
IRRIGATI • TISSUE DISSOLUTION
ON • ANTIBACTERIAL ACTION
• LUBRICATION
 IDEAL • Compatible: physically
chemically.
PROPERT • Antibacterial property
Y OF AN chelating action.
IRRIGATI • Tissue dissolution.
Studies have shown that
NG endodontic irrigant can
SOLUTIO penetrate completely through
the dentinal tubules but the
N effectiveness depends totally
on the type of bacteria
present.
The non spore forming bacteria
was completely killed by every
irrigant tested but the spore
forming bacteria were not
killed .
1. SODIUM
HYPOCHLORITE
• Sodium hypochlorite is used as an endodontic
irrigant as it is an effective antimicrobial and
has tissue-dissolving capabilities.
• Sodium hypochlorite reacts with fatty acids
and amino acids in dental pulp resulting in
liquefaction of organic tissue.
• It causes biosynthetic alteration in cellular
metabolism and phospholipids destruction,
formation of chloramines that interferes in
cellular metabolism. Oxidative action with
irreversible enzymatic inactivation in bacteria.
• Trepaginer 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.
• In an in vitro study, Trepagnier & et al, concluded
that 5% sodium hypochlorite was a potent tissue
solvent. Dilution of this solution with water, at
equal parts, (2.55) did not appreciably alter its
solvent action.
• Rubin reported that either 2.6% NaOCL alone is
an excellent predentin and tissue solvent.
• Resenfield demostrated that 5.25%NaOCL
dissolves vital tissue.for a necrotic tissue ,conc of
5.25% Naocl was found to be better than
2.6%,1%or0.5 %.
• Sodium hypochlorite in higher
concentrations is more aggressive while in
lower concentrations it is biocompatable .
REFERENCES
2. CHlORHEXIDINE
• Endodontic literature has shown that chlorhexidine 2%is used as
the root canal irriganting solution , it reacts with negatively charged
groups on the cell surface.
• It is used in pulpectomy of necrosed pulp and abcess cases as
adjunctive irrigant
• The antimicrobial effect of chlorhexidine is caused by the cationic
molecule binding to negatively charged bacterial cell walls, thereby
altering the cell's osmotic equilibrium
• At low concentrations, small molecular weight substances like
potassium and phosphorus leak out resulting in a bacteriostatic
effect of chlorhexidine gluconate.
• At high concentrations, there is a bactericidal effect due to the
precipitation and/or coagulation of the cellular cytoplasm, probably
caused by cross-linking proteins .
• . Ohara et al. evaluated the antibacterial effects of six irrigants
against anaerobic bacteria and reported that cblorhexidine was the
most effective. When used as intracanal medicament, chlorhexidine
was more effective than calcium hydroxide in eliminating
Enterococcus faecalis infection inside dentinal tubules
 • . Ohara PK, Torabinejad
M, Kettering JD.
Antibacterial effects of
various endodontic
irrigants on selected
anaerobic bacteria.
Endod Dent Traumatol
1993;9:95-100.
• . Heling I Steinberg D
References Kenig S Gavrilovich I
Sea MN, Friedman M
Effecacy of a
sustained-release
device containing
chtorhexidine and Ca(O
)2 in preventing
secondary infection of
dentinal tubules. Int
Endod J 1992;25:
3. SODIUM CHLORIDE(NaCl)
• Normal saline is isotonic to the body fluids.
• It is universally accepted as the most common
irrigating solution in all endodontic and surgical
procedures.
• It is also found to have no side effects, even if
pushed into the periapical tissues .
• However, saline should not be the only solution to be
used as an irrigant, it is preferably used in
combination with or used in between irrigations with
other solutions like sodium hypochlorite .
OTHER IRRIGANTS
• HYDROGEN PEROXIDE Hydrogen peroxide is widely used in disinfection
and sterilization . It is being used in dentistry in concentrations varying
from 1% to 30%. H2O2 creates effervescence which facilitates debris
removal, acts as an oxidizing agent and is capable of denaturing
bacterial proteins and DNA. But in higher concentrations, it is not well
tolerated and has the potential of causing cervical resorption

• HERBAL IRRIGANTS TRIPHALA AND GREEN TEA POLYPHENOLS (GTP)

Triphala is one of the well known Indian Ayurvedic herbal formulation
consisting of dried and powdered fruits of three medicinal plants namely
Terminalia Bellerica, Terminalia Chebula and Emblica. Triphala achieved
100% killing of E faecalis at 6 min.

• MORINDA CITRIFOLIA (NONI) Morinda Citrifolia commercially known as

Noni,. Its juice has a broad range of therapeutic effects including
antibacterial, anti-inflammatory, antiviral, antitumor, antihelmenthic,
analgesic, hypotensive, anti-inflammatory and immune enhancing
effects.
 An invitro study compared the effectiveness of MC with NaOCl
and CHX to remove the smear layer from the root canal walls of
instrumented teeth. It was concluded that the efficacy of
Morinda Citrifolia was similar to NaOCl in conjunction with EDTA
as an intracanal irrigant. Morinda Citrifolia appears to be the
first juice to be identified as a possible alternative to the use of
NaOCl as an intracanal irrigant

• GERMAN CHAMOMILE AND TEA TREE OIL THE GERMAN

CHAMOMILE (MARTICARIA RECUTITIA L.) has been used for
centuries as a medicinal plant mostly for its antiinflammatory,
analgesic, anti-microbial, antispasmic and sedative properties.
German chamomile, in particular, is the most commonly used
variety. Tea tree oil (Melaleuca alternifolia) as it is more
commonly known, is a native Australian plant with many
properties such as being an antiseptic, an antifungal agent and
a mild solvent. Tea tree oil’s major active component is
terpinen-4-ol(typically 30- 40%). This compound is responsible
for its antibacterial and antifungal properties.
 REFERNCES
• ENDODONTOLOGYVolume 104, Issue 5P709-
716November 2007 Full IssueAntimicrobial effect of
propolis and other substances against selected
endodontic pathogens
• . L. Jagadish, V.K. Anand kumar, V. Kaviyarasan. Effect
of Triphala on dental bio-film. Indian J.Sci.Technol.
2009;2:30-3.
• Parle M, Bansal N. Herbal medicines: Are they safe? –
Natural Product Radiance 2006;5: 6-14
  Intracanal Medicament is a cardinal
step in killing the bacteria in root
canals and is considered to be an
integral part of the success of Root
INTRACANAL Canal Therapy.
 Although chemomechanical cleaning
MEDICAMEN and shaping of the canal is effective in
T reducing bacterial counts,
microorganisms may persist in the
anatomical complexities of root canal
system and increase the risk of
treatment failure.
Therefore, intracanal medication is
advocated to further reduce bacteria in
the root canal system and increase the
success of root canal treatment11.
Some common intracanal medicaments
include:
• 1.Calcium Hydroxide
• 2. TPA(Triple antibiotic paste)
• 3.Propolis
 • Classification of Intracanal
Medicaments by Grossman
• Essential Oils :Eugenol
• PhenolicCompounds:
Phenol, Parachlorophenol,
CetylpyridiniumChloride
CLASSIFICATIO (CPC), Formocresol,
N OF Metacresylacetate (Crestatin),
INTRACANAL Cresol,
MEDICAMENT Creosote (Beechwood), Thymol
• Aldehydes: Formocresol,
Glutaraldehyde
• Halides :Sodium Hypochlorite,
Iodine, PotassiumIodide,
• Steroids,
• Calcium Hydroxide,
• Antibiotics
 Composition
of
Medicaments
•:For Primary
Tooth: It
includes
medicaments
such as
Formocresol,
Glutaraldehyde,
Calcium Hydroxide
 It should be stable in solution
which is an effective antimicrobial
agent.
It should have low surface tension
and does not stain tooth
structure.
Ideal
It should be non-irritating to the
Requireme periradicular tissue.
nts
It should be active in the
presence of blood serum and
protein derivatives of tissues.
It should have a tedious
antimicrobial effect with a non-
induced cell-mediated immune
response.
Indications:
• For persistently wet or
weeping canals.
• For neutralizing tissue
debris with rendering
root canal contents.
• For eliminating excess
microbes which act as
a barrier against
leakage
• for dressing in
symptomatic cases.
• Brahmann datta et al proposed that CH ALONE IS NOT
EFFECTIVE AGAINST enteroobaccilus faecallis alone
and a combination of antibacterial agent such as CH
with TPA, or CH with CHX , or TPA, CH along with CH,
TPA is more effective against resistant and mutant
genome bacteria E .FECALIS.
 METRONIDAZOLE
• Metronidazole is bactericidal for most anaerobes, being most active against
Gram-negative rods.

• B. Kargülat el Dept. Paediatric Dentistry, Marmara University, Dental

School, Department of Paediatric Dentistry, Istanbul,Turkey did a pilot study
to evaluate the clinical and radiographic outcomes of an antibacterial drug
(Metronidazole, Nidazol, IEUlagay Ilac A.S) application as an intra-canal
medicament combined with pulpectomy in infected primary molar teeth

• Advantages of using metronidazole are that it provides ready availability as

oral and intravenous dosage forms, rapidly bactericidal, good tissue
penetration, cost-effective, acceptable pharmacokinetics and
pharmacodynamics and its undiminished antimicrobial property against
gram negative bacteria.

• However, metronidazol caused inhibition of growth of all obligate

anaerobes tested and was more effective than calcium hydroxidpaste
against all of the strains.(journal of endodontics,issue3,march 1997,pages
167-169)
CHX with
Ca(OH)2
• Many studies demostrated that CHX gel
with Ca(OH)2 application compared to
CHX gel alone had a decreased
antibacterial effect between days 7-15.
• Gomes et al. explained the decreased
antibacterial effect of Ca(OH)2 on CHX
possibly due to loss in its capacity to
adhere to the bacterial cell wall.
 • Criteria for an ideal pulpectomy
obturant (treatment paste).
1. Antiseptic
2. Resorbable
OBTURATIO 3. Harmless to adjacent tooth
N MATERIAL bud.
AND 4. Radiopaque
TECHNIQUE 5. Non impainging on erupting
permanent tooth
6. Easily removed
7. Should not shrink
8. Insoluble in water
9. Not disclour teeth.
 • Zincoxide eugenol
Materia • Zincoxide iodoform
ls used paste
• Calcium hydroxide
are: • Metapex ,vitapex
 • Zn OE has been the material of
choice for the filling of root canal of
primary teeth showing success rate
of 77-80%.
• For the large canals in primary
anterior teeth , a thin mixture of
the ZnO and eugenol can be used
ZOE to coat the all walls of the canal. A
paper point or the last file used
PASTE can be coated with the
mixture ,carried to the canal and
rotated to cover the walls to the
same apical length as the BMP
done.
• The antibictarial activity of ZnO is
greater than that of iodoform
containig paste.
 • The history of use of Ca (OH)2 in
primary teeth dates back to 1950-
1960. Initially it was used as a
dressing material after pupotomy. But
the high rate of internal resorption
discouraged its further uses.
• In 1995 two cases of root canal filling
CALCIUM with Ca(OH)2 was reported by
ROSENDAL et al.in which one was
HYDROXID case of rampant caries following
radiation therapy and both were
E found to be successful.
• Ca(OH)2 has a pronounced
antimicrobial property against almost
most of the bacteria species found in
root canal infections and is now used
as an intra canal medication in
endodontic therapy.
• Ca (OH)2 has high resorption rate
than that of root resorption.
 INDIREC
DIRECT
T PULP
PULP
CAPPING
CAPPING
APEXIFIC
ATION

BASE

REPAIR IN
CALCIUM HYDROXIDE PERFORATIO
N

LINERS

ROOT
FRACTUR
ROOT E
CANAL
SEALER
PUILPOTO INTRA
MY CANAL
MEDICAM
ENT