1. PULPECTOMY
Guided by-
Dr. SEEMA CHAUDHARY
Dr. NAVEEN MANUJA
Dr. CHAITRA T.R.
Dr. ASHISH AMIT SINHA
Prepared by-
Dr. Priyanka Biswas
M.D.S. 1st YEAR

2. 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 resorbable 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.
Definition

3. Single Visit
Pulpectomy
Multiple Visit
Pulpectomy
PULPECTOMY

4. Indications
1. Irreversibly inflamed primary tooth having not more than one-
third of root resorbed.
2. Primary tooth with abscess or sinus opening.
3.Pulpless primary second molars prior eruption of permanent first
molars.
4. Children suffering from hemophilia.
5. Teeth next to line of a palatal cleft.
6. Primary molars supporting orthodontic appliances.
7. Handicapped children where monitoring of space maintainers or
continuous supervision is not possible.
8. Primary molars where arch length is deficient.
9. Pulpless primary anterior teeth where speech, crowded arches or
esthetics is a factor.

5. Contraindications
1. An irreversibly inflamed primary tooth with excessive
root resorption involving more than two-thirds of the
root & excessive mobility.
2. Primary tooth with deep caries and a large radiolucency
with possibility of affecting the succedaneous tooth.
3. Primary teeth with underlying dentigerous or follicular
cysts.
4. Young patients with congenital or rheumatic heart
disease, hepatitis or leukemia and children on long-term
corticosteroid therapy or immunocompromised.

6. To achieve optimal preparation 3 anatomical factors must be
considered:
• SIZE OF PULP CHAMBER
• SHAPE OF PULP CHAMBER
• NUMBER, POSITION, CURVATURE OF ROOT CANALS
Access opening for primary
anteriors
• Traditionally done
through lingually except
for maxillary central
incisors
Access opening for primary
posteriors
• By no.4 round bur,
remove dentine ledges to
get direct line axis to
canal orifice

7. Single Visit Pulpectomy
o Tooth is anesthesized & isolated
o Access cavity prepared
o Pulp chamber deroofed
o All accessible coronal & radicular
pulp removed by using broach
o Irrigate with saline
o Diagnostic file radiograph is taken
o Canals should be enlarged to permit
condensation of root canal filling
material
o Flush out all debris & dentinal
shavings with copious irrigation
o Dry out canals with absorbent paper
points
o Obturate coronal & radicular pulp
canal

8. Multiple Visit Pulpectomy
Given by Paterson and
Curzon in 1992
First Appointment (Access
Opening)-
• Tooth is anesthesized &
isolated
• Access cavity prepared
• Pulp chamber deroofed
• All accessible coronal &
radicular pulp removed by
using broach
• Formocresol cotton pellet is
placed in chamber &

9. Second Appointment (Cleaning and
Shaping)-
 Appointments fixed 5-7 days apart
 Remove temporary restoration
 File the canal, progressively
increasing file diameter & complete
CMP
 Detemine working length
 Irrigate canals
 Dry canal with absorbant paper
points & temporary restoration
done after placing sterile cotton in
chamber

10. Third Appointment
(Obturation)-
 Appointments fixed 5-7 days apart
 Remove temporary restoration
 Irrigate & Dry canals
 Coat walls of canals with thin mix
of cement by reamer followed by
thick mix to fill canals by
lentulospiral
 Keep on adding fresh mix till no
further cement incorporated in
canals
 Give temporary restoration
 Recall patient after 1 week if
asymptomatic do the permanent

11. Endodontic pressure syringe:
• Developed by Greenberg
• syringe barrel, threaded plunger, wrench and threaded needle.
• Needle is placed 1 mm short of apex and with a slow withdrawing type of
motion, the needle is withdrawn 3 mm with each quarter turn of the screw
until the canal is visibly filled at the orifice.
Mechanical syringe:
• Proposed by Greenberg
• Cement is loaded into 30 gauge needle and expressed into the canal. Press
using continuous pressure while withdrawing the needle.

12. Tuberculin syringe Jiffy tubes:
• Aylord and Johnson in 1987
• Standard 26 gauge, 3/8th inch needle.
• Material was expressed into the canal by slow finger pressure on the
plunger until the canal was visibly filled at the orifice.
Incremental filling technique:
• By Gould in 1972.
• Endodontic plugger, corresponding to the size of the canal with rubber
stop is used to place a thick mix of cement into the canal. Thick mix was
prepared into a flame shape corresponding to size and shape of the canal
and then tapped gently into the apical area with the help of plugger.
Lentulospiral technique:
• By Kopel in 1970.
• Lentulospiral was dipped into the mixture and then introduced into the
canal to its predetermined length and rotated in the canal. Additional
amount of paste is added into the canal, till it is filled.

13. Material Composition
Zinc oxide eugenol - Zinc oxide powder + eugenol oil
Calcium hydroxide
Iodoform - Derivative of iodine
Vitapex - Calcium hydroxide + iodoform + oil
additives
Walkhoff paste - Parachlorophenol + camphor + menthol
KRI paste - Iodoform + camphor + parachlorophenol +
menthol Maisto paste - Zinc oxide + iodoform + thymol +
+ lanolin +
chlorphenol + camphor
Mineral Tricalcium aggregate - Tricalcium aluminate + tricalcium
silicate + trioxide silicate oxide + tricalcium

16. Cox et al.
Zinc oxide powder had no inhibitory effect and the addition of eugenol to zinc
oxide retarded the growth of only the gram-positive organisms. The inclusion of
zinc acetate as a setting accelerator inhibited both gram-positive and gram-
negative bacteria.
Coll and Sadrian
Pulpectomized teeth rarely exfoliate later than normal and timing of exfoliation
was not related to retention of ZOE paste. Anterior cross-bite, palatal eruption,
and ectopic eruption of the succedaneous tooth following ZOE pulpectomy.
Coll et al.
Reported that when ZOE extrudes, it develops a fibrous capsule that prevents
resorption of the material. Thus, it has a slow rate of resorption and has a
tendency to be retained even after tooth exfoliation. Areas of cementum
resorption were evident, periodontal ligament exhibited intense and moderate
thickening. Dentin resorption was not observed, whereas bone resorption was
found.

17. Combination Author Observation
Zinc oxide +
Ozonated oil
Chandra et
al.
It has bactericidal action, debriding effect,
angiogenesis stimulation capacity and
high oxidizing power (Guinesi et al.,
2011). After 12 months follow-up there
was progressive bone regeneration at the
periapical region with good clinical and
radiographic success rate.
Zinc oxide eugenol
(ZOE)+ Calcium
hydroxide (CA(OH)2
+Sodium fluoride
Chawla et al. The addition of fluoride was seen to give
this material a resorption rate that
matched the resorption rate of primary
teeth.

18. Combinatio
n
Author Observation
Zinc oxide +
Calcium hydroxide
Praveen et al. Obturated material remained up to
apex of root canals till beginning of
physiologic root resorption and was
found to resorb at the same rate as
that of primary teeth
Zinc oxide eugenol
+ Aldehydes
Praveen et al.;
Chawla et al
Neither increased success rate nor
made material more resorbable as
compared to zoe alone
Zinc oxide + Calen
paste
Pinto et al. Clinical and radiograhic outcomes
for calen/zo were equal to ZOE
after 18 months

19. Combination Author Observation
Iodoformized ZOE Garcia-Godoy It was found to be effective for
both aerobic and anaerobic
bacteria with a maximum
sustaining period of 10 days.
Zinc oxide + Propolis
(ZOP)
Al-Ostwani et al. ZOP paste was synthesized by
mixing 50% zinc oxide powder
with 50% hydrolytic propolis.
There was acceptable clinical and
radiographic success rate with
faster resorption seen in some
cases.

20. Enamel defects of succedaneous teeth following ZOE
pulpectomies
Coll and Sadrian , stated that there is no relationship
between primary teeth pulpectomy and enamel hypoplasia.
Incidence of enamel defects was not related to the retention of
ZOE filter, length of ZOE fill or history of trauma or caries.
Contrary to these results, Holan, reported that, succedaneous
incisors that replace traumatised primary incisors treated with
ZOE pulpectomies have 2-3 times higher incidence of enamel
defects when compared to normal teeth.

21. KRI-1:
• In 1989, it was published as root
canal filling material in necrotic
primary molars.
• Pure calcium hydroxide with
formaldehyde.
KRI-3:
• This differs from KRI-1 paste that
it has para-chlorophenol,
camphor and menthol which are
twelve times superior and possess
greater anti-microbial properties.
Iodoform based paste

23. Pinto compared success rate of ZOE and calen paste
thickened with zinc oxide. High success rate with
calen/zo was seen as this material prevented pathologic
root resorption and induced new bone formation.
In the study conducted by Chandra et al.,there was good
clinical success rate at 12 months follow up, having anti-
bacterial and excellent healing properties. There is also
progressive bone formation observed at the follow ups.
ZOE had radiographic success rate less than that of ozonated
oil-ZOE.
Ozon
e
Endoflas-chlorophenol free-
Chlorophenol was eliminated from
endoflas as it has fixation effect which
may affect osteoblast cells.
Calen paste

24. Pulpotec
Pulpotec can be used in teeth showing bone lesion and help in
reduction of clinical signs of infection.
Alternative to conventional endodontic treatment for necrotic
primary teeth.
Rifocort
Formed from corticosteroid and an antibiotic recommended for
treatment of primary teeth.
Bactericidal action against most organisms except for
Enterococcus faecalis and Bacillus subtilis.
Guedes pinto paste (GP)
Contains- Iodoform + Ca(OH)2 + Camphorated
parachlorophenol
Exceptional diffusion capability against all the
microorganisms.

25. Mixture of zinc oxide powder calcium hydroxide in sodium
fluoride
study conducted by Chawla
mixture of zinc oxide powder and calcium hydroxide
paste in sodium fluoride displayed moderate inhibitory
activity against Staphylococcus epidermidis, Streptococcus
mutans, Staphylococcus aureus and Bacillus subtilis and
other gram positive micro-organisms.
showed weak inhibition against Enterococcus faecalis.
Aloe vera
It enhances various phases of wound healing process, such
as macrophage recruitment, collagen synthesis and wound
contraction.
Khairwa et al. evaluated clinical and radiographic success of
zinc oxide combined with aloe vera.

27. Lesion Sterilisation and Tissue Repair (LSTR)
• Cariology Research Unit of
Niigata University School
of Dentistry has developed
the concept of LSTR.
• Triple Antibiotic paste/
Polyantibiotic paste
• Uses mixture of- 1.
Metronidazole 2.
Ciprofloxacin 3.
Minocycline

28. Abdulkader et
al.
Calcium hydroxide associated with distilled water, saline,
glycerine was ineffective against several obligatory and
facultative anaerobic bacteria
Estrela et al. Verified influence of antibacterial potential of Ca(OH)2
against Staphylococcus aureus, Enterococci faecalis,
Pseudomonas aeruginosa, Bacillus subtilis, and Candida
albicans and showed significant effectiveness for Ca(OH)2
paste or iodoform plus saline
Showing Antibacterial properties of calcium
hydroxide reported by various authors

29. Showing Antibacterial properties of Metapex
reported by various authors
Kriplani et al.;
Harini priya et
al.
Metapex has lowest antibacterial activity when compared to
ZOE, Vitapex and Calcium hydroxide. However, it showed
moderate activity against Streptococcus pyogenes,
Staphylococcus aureus, Enterococcus feacalis, Escherichia
coli and Pseudomonas aeruginosa but failed to inhibit
Candida albicans. So, it was concluded from their study that
ZOE>vitapex>Ca(OH)2>metapex.
Seow et al. The weak antimicrobial activity of metapex may be partially
explained by the facts that calcium hydroxide, an ingredient
of metapex has been demonstrated to interfere with the
antiseptic capacity of dyadic combinations of endodontic
medicaments
Tchaou et al. Calcium hydroxide with iodoform had exhibited no

30. Showing Antibacterial properties of Endoflas
reported by various authors
Hegde et al. Endoflas moderately inhibited the gram-negative and gram-
positive organisms and showed strong inhibition of Candida
albicans
Pelczar et
al.
The high antimicrobial activity of Endoflas was probably due to
the presence of iodoform and eugenol, both of which have
antibacterial action. Eugenol acts by protein denaturation, while
iodoform is an oxidizing agent. Even after the material sets,
surface hydrolysis of the chelate (zinc eugenolate) results in
release of eugenol, thus explaining the effective antibacterial
activity of this substance even after 72 hours

31. Laser assisted pulpectomy
• Thin optical fibers of ND:YAG (200-300µ ) or
DIODE laser.
• Radiograph for diagnosis
• Tooth anesthesized & isolated using rubber dam
• Tooth preparation done for stainless steel crown & selection of
crown
• Caries excavation & access opening done with turbine or erbium
family laser with 600µ fiber optic tip at 2.5-3W, 20Hz with water
coolant spray.
• Determination of working length with apex locator.
• 300µ tip with diode or other laser inserted in canal filled with
saline to assess passive progress till 4-5mm of radiographic apex.
• Pulp tissue is ablated 1-1.5W, 20Hz for 10-15 secs
• Drying canal with absorbant paper points, obturation is done (if
canal is necrotic then intermediate Ca(OH)2 dressing given)