Materials used in pediatric endodontics- commonly used materials

1. K.SANTOSHI
II MDS
MATERIALS USED IN PEDIATRIC
ENDODNTICS

2. CONENTS
• INTRODUCTION
• HISTORY
• PULP CAPPING AGENTS- CALCIUM HYDROXIDE
ISOBUTYL CYANOACRYLATE
CORTICOSTEROIDS AND ANTIBIOTICS
COLLAGEN FIBERS
4-META ADHESIVE
DIRECT BONDING
DENATURED ALBUMIN
MINERAL TRIOXIDE AGGREGATE(MTA)
LASER
BMP

3. DEVITALIZATION PULPOTOMY:-
• FORMOCRESOL
• DEVITALIZING PARAFORMALDEHYDE PASTE
• ANTIBIOTIC PASTE
• GYSI PASTE
PRESERVATION PULPOTOMY
• ZINC OXIDE EUGENOL
• GLUTARALDEHYDE
• FERRIC SULFATE
REGENERATION PULPOTOMY
• CALCIUM HYDROXIDE
• BONE MORPHOGENIC PROTEINS & OSTEOGENIC PROTEINS
• ENRICHED COLLAGEN SOLUTION
• COLLAGEN CALCIUM PHOSPHATE GEL
• FREEZE DRIED BONE
• TRICALCIUM PHOSPHATE
PULPOTOMY AGENTS-

4. PROPERTIES OF AN IDEAL ROOT CANAL FILLING MATERIAL
PULPECTOMY AGENTS- ZINC OXIDE EUGENOL
IODOFORM PASTES- KRI , WALKHOFF, MAISTO
ENDOFLAS
VITAPEX
CONCLUSION
REFERENCES

5. INTRODUCTION:
PULP THERAPY

6. PULPTHERAPY
VITAL PULP THERAPY NON-VITAL PULP THERAPY
Pulp capping
Pulpotomy
Pulpectomy
Apexogenesis
Non vital pulpotomy
Apexification
Pulpectomy

7. HISTORY
7

8. • 1700’S & Early 1800’s – Metal Foils
• Mid 1800’s to Early 1900’s – Asbestos fibers, cork, beewax,
pulverized glass, Calcium compounds & other based on Eugenol
• 1874 – Nitzel : Tricresol- formalin tanning agent
1885 – Leptowski – Formalin
1886 – Adolph Wilzel – Metal (Gold) Foil
1898 – Gysi – Paraformaldehyde
8

9. • 1904 – Buckley – Formocresol or Tricresol Formali
• 1930 – Hermann – Calcium mixture “ Calxyl”
• 1975 – S’ Gravenmade - Gluteraldehyde
• 1999 - Dr.Torabinjed - Mineral trioxide aggregate
9

10. •
DIRECT PULP CAPPING
INDIRECT PULP
CAPPING
RDT :2-0.25mm RDT :0-0.25mm

11. PULP CAPPING AGENTS
Ideal properties
• Stimulate reparative dentin formation
• Maintain pulpal vitality
• Bactericidal or bacteriostatic
• Adhere to dentin, restorative material
• Resist forces during restoration placement and during the life of
restoration.
• Sterile
• Provide bacterial seal

12. ZINC OXIDE EUGENOL CEMENT
Before calcium hydroxide came into common use, zinc-oxide eugenol
was used more often than any other pulp capping agent.
Used in indirect pulp capping due to its
Palliative affect
Excellent initial seal
Kills bacteria presentin
carious lesions
So arrests the cariesprocess
Direct contact →chronic inflammatiom ,abscess formation and
liquefaction necrosis.

13. CALCIUM HYDROXIDE AS A PULP CAPPING AGENT
• “gold standard” of direct pulp capping materials
for several decades.
• Herman-1930
• Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: Their
formation following direct pulp capping. Oper Dent. 1996; 21(1):4-11.

14. MECHANISM OF ACTION
• Calcium hydroxide is believed to effect pulp repair by one or more of several
mechanisms of action
• High pH of Ca(OH)2 – Irritation to the pulp tissue – repair by un known
mechanism
• Mechanism explained – release of bioactive molecules
Solubilize of these proteins (BMP), (TBF-β1
Release of bio active molecules
Ca(OH)
Pulpal repair
Graham L, Cooper P, Cassidy N, Nor J, Sloan A, Smith A. The effect of calcium hydroxide on solubilisation of bio-active dentine matrix
components. Journal of Biomaterials 2006;27:2865– 2873.

15. A human clinical study using ZOE as a direct pulp capping agent. In
this study, all teeth capped with ZOE showed chronic inflammation, no
pulp healing and no dentin bridge formation up to 12 weeks post-
operatively. Conversely, all control teeth that were capped with calcium
hydroxide demonstrated healing within four weeks.
Glass R, Zander H. Pulp healing. Journal of Dental Research 1949;28:97–107.]

16. ADVANTAGES
Reperative dentin formation
Tissue dissolving property
Antibacterial action
x
DISADVANTAGES
Pulp obliteration
Lack of Adhesion
Microleakage
Tunnel defects
Three main calcium hydroxide products are:
Pulpdent– Paste contains 52.5% calcium hydroxide in an aqueous methyl cellulose solution.
Considered to be most capable of stimulating early bridge formation.
Hydrex- It is a two paste system, non-essential oil hard setting compound that contains
calcium hydroxide, barium sulfate, titanium dioxide and a selected resin.
Dycal

17. ISOBUTYL CYANOACRYLATE
• Berkman -1971.
• hemostatic and bacteriostatic properties.
• It cannot be regarded as an adequate therapeutic alternative to calcium
hydroxide since it does not produce a continuous barrier of reparative
dentin after application to the exposed pulp.

18. CORTICOSTEROIDS AND ANTIBIOTICS-
• Introduced by Brosch JW in 1966.
• These agents include neomycin and hydrocortisone, ledermix (calcium
hydroxide and prednisolone), penicillin or vancomycin with calcium
hydroxide.
• Gardner, et al., found that vancomycin, in combination with calcium
hydroxide was somewhat more effective than calcium hydroxide used
alone and stimulated a more regular reparative dentin bridge.
Asma Qureshi et al., Newer Pulpcapping Agents Journal of Clinical and Diagnostic Research. 2014
Jan, Vol-8(1): 316-321

19. 4-META ADHESIVE- It can soak into the pulp, polymerize there and form a
hybrid layer with the pulp providing adequate sealing.
DIRECT BONDING- A polygenic film can be layered over an exposed site
without displacing pulp tissue and onto surrounding dentin where it penetrates the
tubules. The film acts as a barrier as composite resin is gently spread over the pulp
onto the surrounding dentin.
COLLAGEN FIBERS- Influences mineralization and are less irritant than
calcium hydroxide with dentin bridge formation in 8 weeks.

20. DENATURED ALBUMIN- This protein has calcium binding
properties. If applied over the exposed pulp it becomes a matrix for
calcification.
LASER- Introduced by Andreas Meritz in 1998. He evaluated the
effect of laser on DPC and reported a success rate of 89%.
Thomas J Hilton, Keys to Clinical Success with Pulp Capping: A Review of the Literature Oper Dent. 2009 ; 34(5):
615–625.

21. MINERAL TRIOXIDE AGGREGATE
It is ash colored powder made up of fine hydrophilic
particles of
Properties:
1. Biocompatible and sealing ability better than that of Ca(OH) and ZOE.
2. Initial ph is 10.2 and set ph is 12.5
3. Setting time of cement is 2 hr 45 min
4. Powder ratio – 3:1
Tri calcium aluminate
Tri calcium silicate
Silicate oxide
Tricalcium oxide
Bismuth oxide.
White MTA
Grey MTA (Iron)

22. MECHANISM OF ACTION
1. Forms CH that releases calcium ions for cell attachment and
proliferation.
2. Creates an antibacterial environment by its alkaline pH.
3. Encourages differentiation and migration of hard tissue-producing
cells
4. Forms hydroxyapatite on the MTA surface and provides a biologic seal.
ADVANTAGES
Antimicrobial effects
Dentinal bridge formation
PreventsMicroLeakage over vital pulp
DISADVANTAGES
Manipulation
Long setting time
expensive

23. • Clinical outcome of direct pulp capping with MTA or calcium
hydroxide: a systematic review and meta-analysis
conclusion: MTA has a higher clinical success rate for direct pulp capping
comparing to calcium hydroxide, and might be a suitable replacement for
calcium hydroxide.
Chenxi Zhu, Bin Ju, Rong NiInt J Clin Exp Med. 2015; 8(10): 17055–17060.
Clinical performance of mineral trioxide aggregate versus calcium
hydroxide as indirect pulp-capping agents in permanent teeth: A
systematic review and meta-analysis
Kiranmayi G, etal Clinical performance of mineral trioxide aggregate versus calcium hydroxide as indirect pulp-
capping agents in permanent teeth: A systematic review and meta-analysis. J Int Oral Health 2019;11:235-43
Conclusion: available evidence reveals that MTA and calcium
hydroxide demonstrated good consistent endurance in clinical studies
and indistinguishable performance.

24. BONE MORPHOGENIC PROTEIN- Discovered by Urist in 1965. It has
inductive properties and forms both bone and dentin.
• THERACAL :
• It is a light cured, resin modified calcium silicate filled liner insulting and
protecting dentin-pulp complex. It can be used in direct and indirect pulp
capping.
• When this material was compared with ProRoot MTA and Dycal. It was found
that calcium release was higher
Asma Qureshi et al., Newer Pulpcapping Agents Journal of Clinical and Diagnostic Research. 2014 Jan,
Vol-8(1): 316-321

25. VARIOUS OTHER AGENTS
Biodentin, Emdogain (EMD)
Novel Endodontic Cement (NEC) of calcium oxide, calcium
phosphate, calcium carbonate, calcium silicate, calcium sulfate, and
calcium chloride.
Odontogenic Ameloblast Associated Protein (ODAM)
Castor Oil Bean (COB) Cement
Endo Sequence Root Repair Material
Asma Qureshi et al., Newer Pulpcapping Agents Journal of Clinical and Diagnostic Research. 2014
Jan, Vol-8(1): 316-321

26. • Evaluation of pulpal response of deciduous teeth after direct pulp
capping with bioactive glass and mineral trioxide aggregate
• Aim: The aim of this study was to evaluate the pulpal response of primary
teeth after direct pulp capping (DPC) with two biocompatible materials
namely mineral trioxide aggregate (MTA) and bioactive glass (BAG).
• Materials and Methods: A total of 22 healthy primary canine teeth
scheduled for extraction for orthodontic reasons were selected. The teeth
were divided into two groups of 11 and underwent DPC. The exposure sites
were randomly capped with MTA or BAG in the two groups. After 2
months, the teeth were extracted and prepared for histopathologic
evaluation.
• Conclusion: Based on the results of this study, MTA and BAG can be used
for DPC of primary teeth.
Haghgoo R, Ahmadvand M. Evaluation of pulpal response of deciduous teeth after direct pulp capping
with bioactive glass and mineral trioxide aggregate. Contemp Clin Dent 2016;7:332-5

27. • Aim/Objectives: This study was conducted to evaluate and compare the
clinical and radiographic success of biodentine, 2% chlorhexidine
gluconate with resin-modified glass ionomer cement (RMGIC), and
calcium hydroxide as indirect pulp-capping materials in primary molars
over an observation period of 12 months.
• Conclusion: Biodentine can be effectively used as indirect pulp-
capping medicament in primary teeth which has similar clinical and
radiographic success as 2% chlorhexidine gluconate in conjunction with
RMGIC and calcium hydroxide.
Comparative evaluation of biodentine, 2% chlorhexidine with RMGIC and calcium
hydroxide as indirect pulp capping materials in primary molars: An in vivo study
Boddeda KR, Rani CR, V Vanga NR, Chandrabhatla SK. Comparative
evaluation of biodentine, 2% chlorhexidine with RMGIC and calcium
hydroxide as indirect pulp capping materials in primary molars: An in
vivo study. J Indian Soc Pedod Prev Dent 2019;37:60-6

28. PULPOTOMY

29. PULPOTOMY
VITAL NON-VITAL
PRESERVATION
DEVITALIZATION
Destroying or mummiying
the vital tissue
Maintains the vital tissue
Without induction of reperative
dentin
Formation of dentinal
bridge
REGENERATION
Beechwood cresol
Formocresol

30. FORMACRESOL
introduced in 1904 by Buckley
• Buckley’s Formocresol
Buckley contended that equal parts of formalin and tricresol would
react chemically with the intermediate & end products of pulpal
inflammation to form a new colorless and non infective compound of
a harmless nature
Formalin (37%) : 19%
Tricresol : 35%
Glycerin : 15%
Water : 31%
Devitalization pulpotomy

31. Achieve 1:5 concentration of original Buckley’s formocresol
Dilute 3 parts glycerine with 1 part of distilled sterile water.
Add 1 part formocresol to 4 part diluent
90ml glycerine,
30ml water ,
30ml formocresol
Loose etal

32. Action of Formocresol on pulp tissue:
• Formaldehyde undoubtedly fixes the pulp
tissue
• Alters blood flow by inducing thrombus
formation  ischemia  causes coagulation
necrosis of tissue deprived of its normal
nutrition.
• Enzymatic hydrolysis of necrotic tissues 
replacement of it by granulation tissue.
• Slight resorption of dentinal walls in zone of
replacement & deposition of osteodentin as a
repair tissue.
Chandrashekhar S, Shashidhar J. Formocresol, still a controversial
material for pulpotomy: A critical literature review . J Res Dent
2014;2:114-24

33. Emmerson : determined significant formocresol action
within 1st five minutes
Braham & Morris : Linear calcification may have adverse
influence on resorption process.
Histological Observation:
Massler M & Mansukhani N : surface of pulp
immediately under formocresol became fibrous & acidophilic
within few minutes after application of formocresol.
3 distinct Zones:
Acidophilic zone of fixation
Zone of atrophy
Zone of inflammatory cells
No reparative dentin formation.

34. • Berger described the histological view of pulp tissue following FC
pulpotomy.
• 3 weeks postoperative:
• Fixation of the pulp occurred in coronal third of the root,
• the middle third presented loss of cellular integrity
• apical third showed granulation tissue growth.
7weeks post operative:
• Dark stained coronal zone, light stained middle zone & Cellular
apical zone
• CT originating from periodontal ligament
• Richly vascular & contained lymphocytes, PMN, macrophages,
proliferating fibroblasts & granulation tissue

35. LOCAL TOXICITY
Effect on succedaneous tooth -YES
Pruhs – All permanent teeth showed enamel defects
because:
• Formocresol which damages the permanent tooth germs
• Inflammation which was in the primary tooth which causes the
defects in the permanent tooth germs.
35

36. 36
 SYSTEMIC TOXICITY
 Human studies not done.
 Kettley & Mejare – in animals
Formaldehyde labeled with radioactive carbon which was
apparently distributed among the muscles, liver, kidney, heart,
spleen & lungs. 1% of total administered dose was absorbed.
Myers et al & Pashley et al concluded that 5-10%
formaldehyde is absorbed systemically from pulpotomy
sites.

37. MUTAGENICITY & CARCINOGENICITY
• Most common type of DNA damage – Clastogenic lesions,
micronuclei & chromosomal aberration & deletions.
• Ribeiro et al – not produce detectable DNA damage & not
considered genotoxic.
37
ADVANTAGES
Commonly available medicament
Stable at room temperature
Long shelf life
DISADVANTAGES
Reaction reversible
Very caustic medication
High dose toxic
Systemic absorption & distribution throughout
the body
Has mutagenic & cariogenic potential
Internal resorption of the root

38. • DEVITALIZING PARAFORMALDEHYDE PASTE
• It has been used in the past as a pulpotomy agent. However, it has a severe
cytotoxic effect and may cause alveolar bone necrosis.
• It caused a gradual loss of sensibility in adjacent teeth, gingival necrosis,
and osteomyelitis.
Lee, C., Choi, Y., & Park, S. (2016). Mandibular bone necrosis after use of
paraformaldehyde-containing paste. Restorative Dentistry & Endodontics, 41(4), 332.

39. • GYSI PASTE

40. 40
ZINC OXIDE EUGENOL
Zinc Oxide Eugenol (ZOE) was the first agent to be used for
preservation.
• Composition
ZOE base demonstrated internal resorption and inflammation at the
pulpotomy amputation site.
Boller RJ. Reactions of pulpotomized teeth to zinc oxide and formocresol-type drugs.
Journal of Dentistry for Children. 1972; 39: 298-307.
Powder Liquid
Zinc oxide: 69%
White resin: 29.3%
Zinc sterate : 1%
Zinc acetate: 0.7%
Eugenol: 85%
Olive oil: 15%
PRESERVATION PULPOTOMY

41. • Hansen HP placed corticosteroid dressing prior to application of ZOE
to overcome the internal resorption. However the degree of
improvement and success were not remarkable.
• Fuks et al. found that 73% of pulpotomized primary teeth of baboons
treated with IRM presented with mild or no inflammation
• Kumar Praveen NH etal, Pulpotomy Medicaments: Continued Search for New
Alternatives- A Review :OHDM - Vol. 13 - No. 4 - December, 2014

42. 42
ZINC OXIDE PREPARATIONS
Various preparations used as pulpotomy medicament:
• Zinc oxide/Eugenol & Paraformaldehyde
• Zinc oxide/Liquid Paraffin & Paraformaldehyde
• Zinc oxide/ Liquid paraffin

43. Various studies on ZOE as a pulpotomy agent
Reported that , radiographically, the formacresol treated teeth were judged to
be97% succesful,while the ZOE group was 58% succesful
Berger
Stated that teeth which are treated with ZOE showed variable responses of
acute inflammation,, internal resorption and pulpal fibrosis.
Boller
Repoted mild inflammation in the area of amputation following formacresol
pulpotomy,
while moderate to severe with ZOE
Garcia-
godoy

44. GLUTARALDEHYDE
Gravenmade.
Kopel in an intial study used 2% Glutaraldehyde and suggested that it can
be used in primary teeth pulpotomies
MECHANISM OF ACTION
The histologic picture of a glutaraldehyde treated pulp shows a zone of
superficial fixation with very littile underlying inflammation, so a larger
amount of radicular pulp tissue remained vital.

45. Various studies on Glutaraldehyde as a pulpotomy agent
Acc to various studies Glutaraldehyde demonstrated superior tissue
fixation with relatively littile immunogenicity.
Reported that use of 2% Glutaraldehyde as a pulpotomy agent as
showed 98%ofClinical& radiographic succes
Compared formacresol with 2% Glutaraldehyde and found
a clinical success rate of 100% in Glutaraldehyde group & 90% in
formacresol group
Garcia-godoy
Prakash et al

46. Evaluated the success of 3 medicaments and concluded that the clinical
success rates were 100% with glutaraldehyde,96.7% with ferric sulfate & 86% with
formacresol
Havale et al
compared cytotoxicity & found human pulp fibroblast – formaldehyde
is more toxic & 2.5% glutaraldehyde is 15-20times less toxic
Hue- Wen-
Jeng et al

47. Advantages:
Reaction with pulp irrevisible
Molecules do not diffuse out of
apical foramen
Fixes tissue instantly
Not known to be cytotoxic,
mutagenic & cariogenic
No systemic toxic effect.
Disadvantages:
Short shelf life
Freshly prepared
Buffered solution to be
refrigerated.

48. 48
FERRIC SULFATE
• 15.5% solution – Fei et al 1991
• MOA- agglutination of blood proteins results from reaction of blood
with both ferric & sulfate ions.
• Schroeder – controlling hemorrhage might minimize chance of
inflammation & internal resorption  clot formation.
• Ranly – metal protein clot may act as barrier to irritative components
of sub-base & function in passive manner.
• Johnson etal - 1st to study pulpal response from ferric sulfate in
monkey teeth.

49. Application
A 15.5% solution of ferric sulfate is applied to the radicular pulp
stumps for 10-15 seconds
It may be applied using a cotton pellet or by allowing small
droplets of the solution to drip from the burnisher tip on to the
surface of pulp

50. 50
FERRIC SULFATE VS FORMOCRESOL
Author C/L & R/G
success respc. of
formocresol
C/L & R/G
success respc. of
ferric Sulfate
Duration
Fei et al 1991 96% & 91% 100% & 97% 12mths
Fuks et al 1997 84% & 80% 93% & 93% 34mths
Aktoren & Gencay
2000
88% & 80% 88% & 84% After 24mths
Papagiannoulis
2002
97% & 78% 90% & 74%
Ibrevic & Al Jame
2003
96% & 92% 42mths
Huth et al 2005 96% & 90% 100% & 86% 24mths
Morkovic et al
2005
89% & 82% 18mths

51. 51
CALCIUM HYDROXIDE
• Hermann & Zander - introduced for Pulpotomy & found success rate
of 70%
• Granath : Apexification following trauma
• Kaiser & Frank : use for apexification
Pure form- high pH & dental use – ability to stimulate
mineralization & antibacterial properties.
REGENERATION PULPOTOMY

52. MECHANISM OF ACTION
• Antimicrobial activity of calcium hydroxide is related to the release of
hydroxyl ions in aqueous environment.
• Hydroxyl ions are highly oxidant, free radicals that show extreme
reactivity.
• Their lethal effects on the bacterial cells are probably due to the
following mechanisms:
Damage to the
bacterial
cytoplasmic
membrane
Protein
denaturation
Damage to the
DNA

53. Various studies on Calcium hydroxide as a pulpotomy agent
Doyel etal: Compared the histological and radiographic & clinical success
rates in formacresol and Ca(OH)2 group success rates were 76%to 100%
in formacresol group & 50to70% in Ca(OH)2 group.
Ozata etal: Compared Ca(OH)2 and formacresol histologically 12 out 14
were succesful
Cveks etal reported that hard tissue barrier formation in pulpotomized
monkeys teeth capped with cyanoacrylate or Ca(OH)2 paste for 10 to 60
min and stated that barrier formation is due to low grade irritation

54. Internal Resorption:
Occurs near junction of coronal & radicular pulp (Hannah & Rowe )
Inflammation- inflammatory cells attract osteoclastic cells &
initiate internal resorption
Vascularity of apical region increased
Osteoclastic activity  predispose to External Resorption when an
irritant (CaOH)2 is placed on the pulp.
Ravi G R, Subramanyam R V. Calcium hydroxide-induced resorption of deciduous teeth: A
possible explanation. Dent Hypotheses 2012;3:90-4
• Via – 69% failure (internal resorption)
• Law – 54% failure
• Magunsson – 80% failure

55. 55
Comparing CALCIUM HYDROXIDE with FORMOCRESOL:
Author Clinical & R/G
success of Ca
hydroxide
Clinical & R/G
success of
Formocresol
Duration
Waterhouse et al 77% 84% 22mths
Huth et al 87% 96% 24mths
Markovic et al 82% & 76% 91% & 85% 18mths

56. 56
MINERAL TRIOXIDE AGGREGATE
• Lee & colleagues 1993 : 1st to get MTA
in dental literature.
• Used : Root end filling, DPC, perforation repairs in root,
furcation & apexification.
Ideal to use against bone.
Allow for overgrowth of cementum & formation of bone &
facilitate regeneration of PDL.

57. COMPOSITION, PHYSICAL & CHEMICAL PROPERTIES
• Mixture of refined Portland cement & bismuth oxide
• Portland cement: Dicalcium silicate,Tricalcium silicate, Tricalcium
aluminate, gypsum & Tetrcalcium alumino ferrite.
• Trace Elements: SiO2, CaO, MgO,
• Gypsum : Setting time
• Aluminum species: longer working time
• Powder : Liquid – 3:1
57

58. 58
MTA AS PULPOTOMY DRESSING
• Eidelman E : pulp obliteration seen at higher frequency in GMTA
• Cuisia et al : 93% clinical &77% radiographic success with formocresol
& 97% Clinical & 93% radiographic success with MTA
• Jabbarifar et al : 94% success with MTA
• Agamy : GMTA>WMTA=Formocresol- 12mths
• Holan et al : 83% success- formocresol & 97% with MTA- 74mths

59. 59
• Nark & Hegde : 100% success with MTA in 6mths
• Maroto M: GMTA 100% clinical success & 50% radiographic success
WMTA – radiographically 69% pulp canal signs of stenosis
11.5% - dentin bridge & 1 canal exhibited early signs of
internal resorption
No statistical significance in rate of stenosis, but GMTA showed significant
more dentine bridge.
• .

60. BONE MORPHOGENIC PROTEIN
Bone Morphogenic Proteins (BMP) is thought to induce reparative
dentin with recombinant dentinogenic proteins similar to the native
proteins of the body
Urist concluded that bone matrix contains a factor capable of
autoinduction and he named this factor bone morphogenetic protein.
Rutherford studied pulp response in monkey teeth and stated
recombinant human BMP-2 and BMP-4 induce differentiation of adult
pulp cells into odontoblasts.

61. Silva et al.
Loren K et
al
reported that rhBMP7 did not show favorable results
and there was failure to form dentin bridge
elicited the role RhBMP-2 in pulpal healing of
experimental subjects
BMP’s are being tested, however no suitable product for human use
is available yet

62. 62
BMP Function
BMP 1 It is a metalloprotease that acts on procollagen I,II,III. Involved
in cartilage development
BMP 2 Acts as a disulfide linked homodimer & induce bone & cartilage
formation. Plays role in osteoblast differentiation.
BMP 3 Induce bone formation
BMP 4 Regulates the formation of teeth, limbs & bone from mesoderm.
Role in fracture repair also
BMP 5 Function in cartilage development
BMP 6 Role in joint integrity in adults
BMP 7 Key role in Osteoblast differentiation. Role in renal development
BMP 8a Involved in bone & cartilage development
BMP 8b Expressed in hippocampus
BMP 10 Role in trabeculation of embryonic heart
BMP 12 Potential repair of alveolar bone defects
BMP 15 Role in oocyte & follicular development

63. 63
FREEZE DRIED BONE
• Used in Orthopedic & Oral surgery.
• Pulp & dentin – Mesodermal tissues – Freeze dried bone serve
as inducer of calcific barrier at amputation site.
• Fadavi et al 1996 -Alternative for Formocresol

64. 64
COLLAGEN
• Bimstein E, Shoshan S. – “Enriched Collagen Solution”.
• Anna B. Fuks, Y. Michaeli et al – 80% teeth vital pulp & 73% of
teeth dentin bridge present & cells proliferating through
incomplete dentin bridge.
• Nevins et al– used Collagen Calcium Phosphate gel paste. –results
showed gel resorpton and hard tissue placement in 14-16 teeth
with no inflammation

65. 65
TETRANDRINE
• Noval Anti Inflammatory Agent.
• Composition:
98% buffered saline dissolved in Phosphate &
20% 0.1N HCl with pH 7.2
• Tetrandrine pulpotomies Showed significantly less
inflammatory changes as compared to formocresol.

66. • Natural Agents used in pulpotomy
NIGELLA SATIVA OIL
Black seed extract
Due to its proven
analgesic, anti-
inflammatory and
antibacterial action of NS
oil extract, it has been
employed as a pulpotomy
agent
ANTIOXIDANT
Kathal et al. stated that
antioxidant mix pulpotomy
is more biocompatible and
cost-effective than any
other commercially
available medicament
TURMERIC POWDER
Hugar et al. also used
turmeric gel as a
pulpotomy medicament
in primary molar teeth
with an acceptable
clinical and
radiographic outcome
ALOE VERA
Gupta et al. evaluated the
effect of freshly
extractedA. vera gel as a
pulpotomy agent in
primary M& concluded
that freshly extracted A.
vera gel can be used as a
successful pulpotomy
agent
HONEY
It has both
antimicrobial as well as
wound healing
properties
tissue repair.((IL)-1 β,
and IL-6)
Saikiran KV, Kamatham R, Sahiti PS, Nuvvula S. Pulpotomy medicaments in primary teeth: A
literature review of natural alternatives. SRM J Res Dent Sci 2018;9:181-5

67. OBTURATING MATERIALS IN PULPECTOMY

68. Maisto paste
Endoflas
Vitapex/
metapex
Calen paste
1. KRI
2. Walcoff paste
3. Guedes pinto
paste
IODOFORM Ca(OH)2
1. Sealapex
2. calcicur
ZINC OXIDE
EUGENOL
68

69. Optimal requirements of a root-filling
material for primary teeth
SHOULD:
 Have a stable disinfecting power.
 Rate of Resorption should be equal to primary tooth resorption .
 Placed easily into the root canal and removed easily if necessary.
 Adhere to the walls of the canal
 Induce vital periapical tissue to seal the canal with calcified or connective tissue.
 Harmless to the adjacent tooth germ.
 Economical
69

70. SHOULD NOT:
× Irritate the peri apical tissues, nor coagulate any organic
remnants in the canal
× Soluble in water.
× Discolor the tooth.
× Systemic toxicity
70

71. ZINC OXIDEEUGENOL
 Introduced by : Bonastre (1837)
 First root canal filling material to be recommended for primary teeth,
as described by Sweet in 1930.
• resorption rate of zinc oxide
eugenol (ZOE) and the root
differed ZOE retention
Allen
• mild foreign body reaction
Barker
and
Lockett
71

72. • Delayed resorption
Barker and Lockett
Spedding
Mortazavi and
Mesbahi
• Anterior cross-bite, palatal eruption, and ectopic
eruption of the succedaneous tooth
Coll and
Sadrian
• Develops a fibrous capsule, slow rate of resorptionColl et al
• No inhibitory effect, eugenol retarded only G+Ve bacteria
• Zinc acetate as a setting accelerator inhibited both gram
positive and gram-negative bacteria.
Cox et al.
72

73. • Overfilled is not recommended
• Irritates the periapical tissues and causes necrosis of bone and
cementum
Erasquin et al.
• Deflection of permanent tooth eruption in 20% of
pulpectomized tooth that were extracted
Flaitz et al.
Coll and
Sadrian
• deflection of developing permanent tooth bud because of its
hardness
Garcia-Godoy ,
Ranly and
Garcia-Godoy ,
Praveen et al
• Studied the beneficial effects of eugenol
• Eugenol is said to have anti inflammatory and analgesic
properties
Hashieh
et al.
73

74. • Takes few months or even years to resorb
Holan and
Fuks
Moskovitz
and Samara
Developmental arrest of a premolar following overfilling of 2nd
primary molar
Loevy
Premature eruption of succedaneous tooth and uneven
resorption of pulpectomy treated tooth.
Praveen et al
Sunitha et al
74

75. Enamel defects of succedaneous teeth following ZOE
pulpectomies:
Coll and Sadrian : No relationship between primary teeth pulpectomy and
enamel hypoplasia. Incidence of enamel defects was not related to the
retention of ZOE filler, length of ZOE fill, or history of trauma or caries.
Holan : Succedaneous incisors that replace traumatized primary incisors
treated with ZOE pulpectomies have 2-3 times higher incidence of enamel
defects when compared to normal teeth
75

76. PROPOLIS
Al-Ostwani et al.  Acceptable clinical and
radiographical success
 Faster rate of resorption
OZONATED OIL
Chandra et al.
 Bactericidal
 Debriding effect
 Angiogenesis
 High oxidising power
 Bone regeneration
EUGENOL +
Ca(OH)2 + Na F
Chawla et al.
 Ca(OH)2 = faster
resorption
 NaF = matches
resorption rate of
primary teeth
ZINCOXIDECOMBINATIONS WITHOTHERMATERIALS
76

77. CALEN PASTE
Pinto et al.  Clinical and radiographic
outcomes similar to
ZOE after 18 months
CALCIUM
HYDROXIDE
Praveen et al  resorb at the same
rate as that of primary
teeth
EUGENOL +
IODOFORM
Garcia-Godoy  Effective for aerobic
and anaerobic bacteria
77

78. Clinical and radiographic evaluation of zinc oxide with
aloe vera as an obturating material in pulpectomy: An
in vivo study
Journal of Indian Society of Pedodontics and Preventive Dentistry - 2014 Abhishek Khairwa
Aims: To evaluate clinically and radiographically a mixture of zinc
oxide eugenoland aloe vera as an obturating material.
.Results and Conclusion: Endodontic treatment using a mixture of
zinc oxide powder and aloe vera gel in primary teeth has shown good
clinical and radiographic success. A detailed observational study with
longer follow-up will highlight the benefits of aloe vera in primary
teeth as an obturating medium.

79. CALCIUMHYDROXIDE
Introduced by Herman.
Advantages:
 Antiseptic propery
 Osteoconductive property
 Antibacterial property
Drawbacks:
 Gets depleted from the canals earlier
than the physiologic root resorption
 In hyperemic pulp:
Inflammatory root resorption
 In necrotic pulp:
Superficial layer of necrosis
Damage to predentine
Exposure of dentin to odontoclasts
resorption
Hydroxyl ions
Inactivation of enzymes in
bacterial cytoplasmic memberane
79

80. 1. Metapex (METABIOMED)
2. Vitapex
3. Sealapex
4. Calen paste
COMPOSITION:
• Ca(OH)2
• Iodoform
• Polysiloxane oil in vitapex (enhances fluidity and permeability, and
improves the collateral benefit of root canal filling)
DRAWBACK:
• Extruded by simple pressure.
• Fast resorption of metapex and vitapex
causes voids in the canal
formation of hollow tube
Calcium hydroxide combinations
80

81. 81
Goldman M, Pearson AH (1965) A preliminary investigation ofthe “hollow tube” theory in endodontics: Studies with
neotetrazolium.J Oral Thfukser Pharmacol 1: 618-626.

82. Prevention of intra radicular resorption there
by preventing hollow tube effect:
Mortazavi and Mesbahi
HOW TO PREVENT?
Treatment in 2 visits: 1st visit: Formocresol pulpotomy
2nd visit: preparation and obturation of canals
chemical fixation of foreign body giant cells
loss of ability to resorb vitapex in root canals
82

83. COMPARISON OF ZINC OXIDE AND EUGENOL, AND
VITAPEX FOR ROOT CANAL TREATMENT OF
NECROTIC PRIMARY TEETH.
• Mortazavi M, Mesbahi M
• Both ZOE and Vitapex gave encouraging results.
• overall success rates of Vitapex and ZOE were 100% and 78.5%,
respectively
83

84. 84
SUCCESS OF PULPECTOMY WITH ZINC OXIDE-
EUGENOL VS CALCIUM HYDROXIDE/IODOFORM
PASTE IN PRIMARY MOLARS.
• Trairakul C, Chunlasikaiwan S.
• At 6 and 12 months, the ZOE success rates were 48% and 85%,
respectively, and the Vitapex success rates were 78% and 89%
• Vitapex appeared to resolve furcation pathology at a faster rate
than zinc oxide-eugenol at 6 months, while at 12 months, both
materials yielded similar results.

85. IODOFORM
Castagnola and Orlay: Iodoform pastes are bactericidal lose only 20%
of their potency over a period of 10 years.
ADVANTAGES:
 Easily resorbs at peri apical area
 No foreign body reaction
 Germicidal
 Resorb in synchrony with primary roots
 Can be easily forced into pulp and accessory canals
 No undesirable effect on succedaneous teeth
 Non shrinking and non soluble
 Resorps faster than ZOE
85

86. DRAWBACKS:
• Yellowish discoloration of tooth
• Irritation to periapical tissues
• Cemental necrosis
COMBINATIONS:
1. Walkoff's paste
2. Maisto’s paste
3. Guedes pinto
4. KR1 and 3
5. Iodoform + Ca(OH)2 = vitapex/metapex
6. Iodoform + Ca(OH)2 + ZOE = Endoflas
86

87. COMPOSITION:
1. Iodoform
2. Menthol
3. Camphor
4. Para chlorophenol
5. Formaldehyde
 Para-chlorophenol, camphor and menthol concentration are twelve times
superior to KR1
 Greater antimicrobial properties
KRI1:(volkoff)
KRI3:
Formaldehyde
Quickly binds to organic substance
Albumin formaldehyde
penetration permeability
87

88. Metabolized in:
1. Acid form
2. Carbon dioxide
3. Amino acid radicals
Degradation :
1. Hepatic tissue
2. Renal tissue
3. Pulmonary tissue
Adverse effects:
1. Fixation on different tissues
2. Antigenic potential that may cause hemocromatosis,
dermatitis and pulmonary pathology (asthma)
Diluted form is recommended
88

90. COMPOSITION:
1. Iodoform,
2. Menthol
3. Camphor
4. Parachlorophenol
5. Zinc oxide
6. Thymol and lanolin.
Formulation change intention : Reduction of the resorption rate of paste.
MAISTO PASTE
Maisto introduced it in 1967.
90

91. GUEDESPINTOPASTE
Guedes-Pinto in 1981
91
COLLACOTE
It is a soft pliable, white spong obtained from bovine collagen
It is used in moist orbleeding canals

92. ADVANTAGES:
.
ENDOFLAS
Thus, the material is neither resistant to resorption nor does it result in hollow tube effect.
POWDER:
1. Triiodomethane and
iodinedibutilorthocresol
2. zinc oxide
3. Calcium hydroxide
4. Barium sulfate
LIQUID:
1. Eugenol and
2. Paramonochlorophenol
92

93. DISADVANTAGE :
Eugenol content that can cause periapical irritation and
can cause teeth discoloration.
High pH ( increase of alkaline phosphatase)
Reduces peri apical inflammatory process
Peri apical bone remineralization
93

94. Zinc oxide eugenol and Endoflas pulpectomy in primary molars:
24-month clinical and radiographic Evaluation
J Indian Soc Pedod Prev Dent Jayalakshmi Pandranki
Aims: This study aims to evaluate and compare the success of endoflas as root
canal filling material in infected primary molars with zinc oxide
eugenol (ZOE).
.
Conclusions: Endoflas could be a potential alternative to ZOE for
preserving infected primary molars.

95. The success rate of Endoflas powder mixed with Curcumin gel
as obturating material in Primary Molars: Case- Series.
Aims and objectives: To determine the efficacy of Endoflas powder
mixed with Curcumin gel as obturating material in primary teeth.
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.
Journal of Biomedical and Pharmaceutical Research 2017 Ambati Naga Radhakrishna

96. DEVELOPED BY:
Cariology Research Unit of Niigata University School of Dentistry
LESION STERILIZATION AND TISSUE REPAIR
THEORY:
Lesion disinfection repair of damaged tissue
 Non Instrumentation Endodontic Treatment (NIET)
PROCEDURE: (medication cavity)
Chemical disinfection of access cavity walls
Pulpal floor covered with triple antibiotic paste
96

97. vascular changes in pulp
MOA:
metaplasia of the connective tissue and macrophages
Formation of osteoclast like multinucleated giant odontoclasts
remaining vital pulp cells proliferate in the coronal pulp chamber
pulp revascularization
97

98. Hoshino et al. Rifampicin causes discoloration of tooth
AUTHOR OBSERVATION
Sato et al. Evaluated efficacy of 4 mix i.e., 3 Mix+rifampicin
Takushige et al. 2 ways preparation: 3 mix sealer; 3 mix with MP
Detsomboonrat 3 mix cannot replace conventional
root canal treatment
98

99. Alternate drugs:
ornidazole metronidazole
minocycline amoxicillin, cefaclor,
cefroxadine, fosfomycin,
rokitamycin
 PROPERTIES: antiseptic, antibacterial and anti-inflammatory
 main component = Iodoform
 used in : teeth showing bone lesion
 alternative to the conventional endodontic treatment for necrotic
primary teeth
PULPOTEC
99

100. Enhances various phases of wound healing process:
macrophage recruitment
collagen synthesis
wound contraction
ALOE VERA
Khairwa et al clinical and radiographic success of zinc oxide+aloe vera
alternative for zinc oxide eugenol.
OZONE
O3 O2
Bactericidal
fungicidal
Bone regeneration
Ozonated oil – ZOE > ZOE
100

101. DEPARTMENT
Comparative clinical and radiographic evaluation of metapex and
zincoxide with aloe veragel as an obturating material in primary molar
- Dr. B .shiva kumar
Evaluation of clinical and radiographic success rate of endoflas powder
and curcumin gel as an obturating material in primary molars in
comparison with zinc oxide eugenol an invivo study
- Dr. Apirtha kothari

102. CONCLUSION
No area of treatment in pediatric dentistry has been more controversial
than pulp therapy.
Success of pulptherapy depends on various vital factors like case
selection, clinical diagnosis, intraoperative diagnosis and most
importantly the material used for the pulpotomy procedure. The so
called “Ideal Pulpotomy material” is not yet been identified. Further
controlled studies and research is required to find the ideal materials
and techniques in primary teeth

103. Glass R, Zander H. Pulp healing. Journal of Dental Research 1949;28:97–107.]
Asma Qureshi et al., Newer Pulpcapping Agents Journal of Clinical and Diagnostic
Research. 2014 Jan, Vol-8(1): 316-321
Thomas J Hilton, Keys to Clinical Success with Pulp Capping: A Review of the Literature
Oper Dent. 2009 ; 34(5): 615–625
Saikiran KV, Kamatham R, Sahiti PS, Nuvvula S. Pulpotomy medicaments in primary
teeth: A literature review of natural alternatives. SRM J Res Dent Sci 2018;9:181-5
Rajsheker S, Mallineni SK, Nuvvula S (2018) KbƚƵƌĂtinŐ Materials Used for Pulpectomy
in Primary Teeth- A Mini Review. J Dent Craniofac Res Vol.3 No.1: 3
Kiranmayi G, etal Clinical performance of mineral trioxide aggregate versus calcium
hydroxide as indirect pulp-capping agents in permanent teeth: A systematic review and meta-
analysis. J Int Oral Health 2019;11:235-43
Chenxi Zhu, Bin Ju, Rong NiInt J Clin Exp Med. 2015; 8(10): 17055–17060.

104. Mihir Jhaetal Pediatric Oburating Materials And Techniques Journal of Contemporary Dentistry
October-December 2011 | Vol 1 | Issue 2
Derek Zurn, N. sue Seale; Light cured Calcium hydroxide Vs Formocresol in human primary
molar pulpotomies: A randomized Controlled trial; Pediatric dentistry 2008; 30: 34-31
A.B.S. Moretti et al, The effectiveness of MTA, calcium hydroxide & formocresol for
pulpotomies in primary teeth; International Endodontic Journal, 2008, 41, 547-555
Howard W. Robert, Jeffery M. Toth, David W. Berzins, David G. Charlton; MTA material use in
endodontic treatment: A review of the literature; Dental Materials; 24 (2008); 149-164
D. Tuna & A. Olmez; Clinical long term evaluation of MTA as a direct pulp capping material in
primary teeth; International Endodontic Journal; 41; 2008; 273-278
Eliezer Eidelman, Dr. Odont, Gideon Holan, Anna B. Fuks; MTA Vs Formocresol in
pulpotomized primary molars: a preliminary report; Pediatric Dentistry-2001, 23:15-18
Nikhil Marwah; Pediatric Endodontics; Comprehensive Pediatric Dentistry; chapter 20 ;1st edt.;
183-189

105. 105