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Pulpectomy in primary teeth

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 filled with resorbable material. Indications and contraindications of pulpectomy in primary teeth are given. Objectives Following the treatment, the infectious process should resolve. There should be radiographic evidence of a successful filling without gross overextension or under filling. The treatment should permit resorption of the primary root structures and filling materials at the appropriate time to permit normal eruption of succedaneous tooth. There should be no radiographic evidence of further breakdown of the supporting tissues. Treatment should alleviate and prevent further sensitivity, pain or swelling. There should be no internal or external root resorption or other pathology.

Technique Access opening for pulpectomy in primary teeth. Primary Root Canal Anatomy To complete endodontic treatment on primary teeth successfully, the clinician must have a thorough knowledge of the anatomy of the primary root canal systems and the variations that normally exist. Primary anteriors The form and shape of the root canals of the primary anterior teeth resemble the form and shape of the exteriors of the teeth. Maxillary incisors The root canals of the primary maxillary central and lateral incisors are almost round but somewhat compressed. Normally, these teeth have one canal without a bifurcation. Apical ramifications or accessory canals and lateral canals are rare and but do occur. Mandibular incisors The root canals of the primary mandibular central and lateral incisors are flattened on the mesial and distal surfaces and sometimes grooved, pointing to an eventual division into two canals. The presence of two canals is seen less that 10% of the time. Occasionally, lateral or accessory canals are observed.

Maxillary and Mandibular Canines The root canals of the maxillary and mandibular canines correspond to the exterior root shape, a rounded triangular shape with the base toward the facial surface. Sometimes, the lumen of the root canals is compressed in the mesial-distal direction. Bifurcation of the canal does not normally occur. Lateral canals and accessory canals are rare. Primary molars The primary molars normally have the same number of roots and positions of the roots as the corresponding permanent molars. The maxillary molars have three roots, two facial and one palatal; the mandibular have two roots, mesial and distal. The roots of the primary molars are long slender compared with the crown length and width, and they diverge to allow for a permanent tooth bud formation. Maxillary first primary molars The maxillary first primary molars have from two to four canals that roughly correspond to tile exterior root form with much variation. The palatal root is often round; it is often longer than the two facial roots. Bifurcation of the mesial-facial root into two canals occurs in approximately 75% of the maxillary second primary molars. Maxillary second primary molars The maxillary primary molar has two to five canals, roughly corresponding to the exterior root shape. The mesial-facial root usually bifurcates or contains two distinct canals. This occurs in approximately 85% to 95% of the maxillary second primary canals.

Mandibular first primary molars The mandibular first primary molar usually has three canals, roughly corresponding to the external root anatomy but may have two to four canals. It is reported that approximately 75% of the mesial roots contain two canals, whereas only 25% of the distal roots contain more than one canal. Mandibular second primary molars The mandibular second primary molar may have two to five canals but usually has three. The mesial root has two canals but usually has three. The mesial root has two canals approximately 85% of the time, whereas the distal root contains more than one canal only in 25% of the times. Access opening for primary anterior teeth Access opening for endodontic treatment on primary or permanent anterior teeth have traditionally been through the lingual surface. This contains to be the surface of choice except for the maxillary primary incisors. Because of the problems associated with the discolouration of endodontically treated primary incisors, it has been recommended to use a facial approach followed by an acid etch composite restoration to improve aesthetics. The anatomy of maxillary primary incisors is such that access may successfully be made from the facial surface. The only variation to the opening is more extension to the incisal edge than with the normal lingual access in order to give as straight an approach as possible into the root canal. Access opening for primary posterior teeth Access opening into the posterior primary root canal an are essentially the same as those for the permanent teeth.
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Important differences between the primary and permanent teeth are the;

Length and the bulbous shape of the crowns. A very thin dentinal wall at the pulpal floor and the root. The depth necessary to penetrate into the pulp chamber is quite less than that in
the permanent teeth.

Likewise, the distance from the occlusal surface to the pulp floor of the pulp
chamber is much less than in permanent teeth. In the primary molars, care must be taken not to grind on the pulpal floor since perforation is likely.

When the root of the pulp chamber is perforated and the pulp chamber is
identified, the entire roof should be removed with a bur. Since the crown of the primary teeth are more bulbous, less extension towards the exterior of the tooth is necessary to uncover the openings of the root canals than in the permanent teeth.

Canal Cleaning and Shaping


Isolation Use of the rubber dam is essential in any endodontic procedure as it is the best method of isolating the tooth from the oral cavity. First introduced by Barnum (1864), it is useful in providing a clean, dry and sterilized field. Debridement

Canal cleaning and shaping is one of the most important phases of primary endodontic therapy. The main objective of the chemical mechanical preparation of the primary tooth is debridement of the canals. Although an apical taper to the canals is desirable, it is not necessary to have an exact shape to the canals. The biomechanical preparation in the primary teeth can be said to be different enoug to warrant the following considerations; Relative pulpectomy: Due to the tortuous course of the canal coupled with the numerous of pulp in the primary teeth may often be difficult, if not impossible. Thus, all such procedures can be regarded as partial pulpectomy procedures. Selective filling: Resorption in the primary teeth may have started at the time of treatment. Also, the slender roots, with thin apical ends may predispose the tooth to a root to a root fracture in cases of excessive preparation. Thus the procedure of selective filing of the canals should be followed. It is important to establish the working length to prevent over extension through the apical foramen. It is suggested that the working length be shortened, 2 or 3mm short of the radiographic root length; especially in the teeth showing signs of apical root resorption. Instruments should be gently curved to help negotiate canals. This helps in maintaining the original shape of the canal and thus lessens the risk of perforation. Shaping of the canals proceeds in much the same manner as is done to receive a gutta-percha filling. The canals are enlarged several file sizes past the first file that fit snugly into the canal, with a minimum size of 30 to 35. Since many of the pulpal ramification cannot be reached mechanically, copious irrigation during cleaning and shaping must be maintained. Debridement of the primary root canal is more often accomplished by chemical means than mechanical means. The use of sodium hypochlorite to digest organic debris and RC6

prep to produce effervescence must play an important part in removal of the tissue from the inaccessible area of the root canal system. If the inflammation is beyond the coronal pulp with only inter radicular but no periapical radiolucency, a single visit pulpectomy is preferred. On the other hand, if the pulp is necrotic with periapical involvement, filling procedure is delayed until a later time. After canal debridement, the canals are again copiously flushed with sodium hypochlorite and are then dried with sterile paper points; a pellet of cotton is barely moistened with camphorated parachlorophenol and sealed into the pulp chamber with temporary cement. At a subsequent appointment the canal is reentered. As long as the patient is free of all signs and symptoms of inflammation, the canals are again irrigated with sodium hypochlorite and dried preparatory to filling.

Filling of the primary root canals


Root filling materials Developmental, anatomic and physiologic differences between the primary and permanent teeth calls for differences in the criteria for root canals filling materials. The ideal requirements of a root-filling materials for the primary teeth are as follows; Ideal requirements Resorb at a similar rate as the primary root. Should be harmless to the periapical tissues and to the permanent tooth germ, resorb readily if pressed beyond the apex. It should have a stable disinfecting power.

It should be inserted easily into the root canal and be removed easily if necessary. Should adhere to the walls of the canal and should not shrink. It should not be soluble in water. Be radiopaque and not discolour the tooth. No material currently available meets all these criteria. The filling material

most commonly used for primary pulp canals are Zinc Oxide eugenol paste, iodoform paste and calcium hydroxide. Zinc Oxide - Eugenol Paste Zinc oxide - eugenol paste (ZOE) is probably the most commonly used filling material for primary teeth. Camp in 1984 introduced the endodontic pressure syringe to overcome the problem of underfilling, a relatively common finding when thick mixes of ZOE are employed. Under-filling, however, is frequently clinically acceptable. Overfilling, on the other hand, may cause a mild foreign body reaction. Another disadvantage of ZOE paste is the difference between its rate of resorption and that of the tooth root. Iodoform Paste Several authors have reported the use of KRI paste. It resorbs rapidly and has no undesirable effects on succedaneous teeth when used as a pulp canal medicament in abscessed primary teeth. Further, KRI paste that extrudes into the periapical tissue is rapidly replaced with a normal tissue. It is also found to have a long lasting bactericidal potential. Since iodofonn paste does not set into a hard

mass, it can be removed if retreatment is required. KRI was found to have a success rate of 84% as compared to ZOE, which showed a success rate of only 65%, A paste developed by Maisto has been used clinically for many years, and good results have been reported with its use. This paste has the same composition as the KRI paste with additions. Calcium Hydroxide This material is generally not used in pulp therapy for primary teeth. However, several clinical and histopathologic investigations of calcium hydroxide and iodoform mixture (Vitapex, Neo Dental Chemical Products Co. Tokyo) have been published by Fuchino and Nishino (1980). This material was found to be easy to apply and resorbs at a slightly faster rate than that of the root. It has no toxic effects on permanent successor and is radioopaque. For these reasons, the calcium hydroxide - iodoform mixture can be considered to be a nearly ideal primary tooth filling material. Other preparation with a similar composition is available in the United States with the trade name of Endoflas (Sanlen Laboratories, A.A. 7523 Cali, Colombia S.A). Chawla et al (1998) carried out a pilot study in the mandibular primary molars using calcium hydroxide paste as a root canal filling material and found it to be a success. We have also observed almost a 100% clinical success in 10 endodontically treated primary molars which were filled with vitapex (calcium hydroxidised idoform). Gutta Percha Since gutta percha is not a resorbable material, its use is contraindicated in the primary teeth.
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Obturation techniques Several techniques have been used for the filling of materials into the deciduous teeth canals. The primary teeth with their larger canals can be filled with the thin mix coating the walls of the canal with the help of a reamer in a anti-clock wise direction while taking it out slowly followed by the placement of the thicker mix which is then pushed manually. Composition of commonly used root canal materials for primary teeth Walkhoff paste Parachlorophenol Camphor Menthol KRI paste Iodoform 80.8% Camphor 4.86% Parachlorophenol 2.025% Menthol 1.215% Maisto paste Vitapex Zinc Oxide14 gms Calcium Iodoform 42 gm Thymol 2 gm Chlorophenol Camphor 3cc Lanolin 0.50 gms hydroxide Iodoform Oily additives

Comparison of materials used for pulpectomy in primary teeth Properties 1. Resorbs at the same rate as the tooth. 2. Harmless 3. Overfill resorbs 4. Antiseptic 5. Easily applied Y Y Y Y Y Y Y Y Y ZOE Ca[OH]2 with KRI paste

Iodoform [VITAPEX]*

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6. Adheres to the wall 7. Easily removed 8. Radiopaque 9. No discolouration

Y Y Y

Y Y Y Y

Y Y Y Y

Y Yes (2000)

*Vitapex - Neo Dental Chemical Products Co. Ltd., Tokyo, Japan

Pastes can also be filled by means of a Lentulo spiral mounted on the micromotor hand piece. The direction of rotation needs to be checked for the material to properly flow into the canal. The endodontic pressure syringe is also effective for placing the ZOE into the canals. The Vitapex system also uses a syringe with the material in it. The syringe is introduced up to 1/5 the distance from the apex of the canal and the material is slowly injected as the syringe is withdrawn from the canal. Regardless of the method adopted to fill the canals, care should be used to prevent extrusion of the materials into the periapical tissues. The adequacy of the obturation is checked by radiographs In the event a small amount of the ZOE is inadvertently forced through the apical foramen, it is left alone since the material is resorbable. When the canals are satisfactorily obturated, a fast - set temporary cement is placed in the pulp chamber to seal over the ZOE canal filling. The primary tooth is restored with a stainless steel crown.

Follow-up after primary pulpectomy

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The rate of success following primary pulpectomy is high. However, these teeth should be periodically checked for success of the treatment and to intercept any problem associated with failure. While resorbing normally without interference with eruption of the permanent tooth, the primary tooth should remain asymptomatic, firm in the alveolus, and free from pathosis. If evidence of pathosis is detected, extraction and conventional space maintenance are recommended. It has been pointed out that pulpally treated primary teeth may occasionally present a problem of over retention. After normal physiologic resorption of the root readies the pulp chamber, the large amount of ZOE present may impair the resorption and lead to prolonged retention of the crown. Treatment usually consists of simple removal of the crown and allowing the permanent tooth to erupt.

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