April 11, 2023

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PULPAL MEDICAMENTS

Dr.Madhuri

Primary pulp organ

Time : 8.3 years1. Pulp organ growth- 1yr2. Pulp maturation-3yr 9 m3. Pulp regression- 3yr 6m

Maximum life 9.6 years

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PULPAL MEDICAMENTS3

INTRODUCTION IRRIGATING MATERIALS INTRACANAL DISINFECTING MATERIALS ROOTCANAL FILLING MATERIALS

INTRODUCTION4

Definition:“temporary placement of medicaments with good biocompatibility into root canals for the purpose of inhibiting coronal invasion of bacteria from the oral cavity”.Nobuyuki Kawashima, International Dental Journal (2009) 59, 5-11

Use of intracanal medicaments (Chong and Pittford -1992)

1. Eliminate remaining bacteria after canal instrumentation2. Reduce inflammation of periapical tissues and pulp

remnants3. Neutralize tissue debris and render canal contents inert4. Act as a barrier against leakage from the temporary filling5. Help to dry persistently wet canals

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Requirements of an ideal intra canal medicament

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Chong and Pittford -19921. Non irritant to periapical tissues2. Able to eliminate bacterial flora of the canal3. Prevent pain4. Reduce periapical inflammation5. Stimulate perapical repair6. Effective rapidly and active for long periods7. Capable of diffusion and penetration into dentin8. Effective in the presence of pus and organic debris9. Long shelf life10. Non staining

Rationale for use of intracanal medicaments

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‡ Reduce root canal microflora following cleaning of the canal - minimal effect on normal host tissue

‡ Reduce post instrumentation pain‡ Antimicrobial effect :Tissue toxicity directly related

to this effect‡ Potent antibacterial medications – most irritating‡ Diluted – ineffective‡ Host –tissue responses

Universally accepted means of canal disinfection – canal instrumentation + chemomechanical

preparation

Irrigating materials7

Aim : removal of pulp remnants and dentin debris

Ideal properties of Irrigating materials8

Walten and Torabinajed – 19891. Tissue and debris dissolution2. Low surface tension - promote the flow of

irrigant into inaccessible areas3. Lubricant property – enables instrument to

readily slide down the canal4. Sterilization5. Removal of smear layer6. Cost7. Adequate shelf life8. Ease of storage

Classification of irrigating materials9

Chemically non active solutions1. Water2. Saline3. Local anesthetic Chemically active materials1. Acids: 30% HCl, 50% Sulphuric acid, citric acid2. Alkalis: NaOCl, NaOH, 3. Chelating agents: EDTA4. Oxidizing agents5. Antibacterial agents : chlorhexidine6. Detergents : sodium lauryl sulphate

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Classification of irrigating materials Acc to Cohen:

1. Proteolytic materials2. Detergents3. Decalcifying materials

Proteolytic materials - NaOCl Early 20th century : treating wounds Clear,straw coloured reducing agent – 5%

chlorine Actions :• Dissolves necrotic tissues and debris -

Availability of free chlorine Higher temperature

• Concentration : 0.5% - Dakin 5.25% 1% - antimicrobial effect The concentration rise is directly proportional

to the antimicrobial effect and tissue dissolution capacity and inversely proportional to biologic compatibility.

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Destruction of bacteria :1. biosynthetic alterations in cellular

metabolism and phospholipid destruction,

2. formation of chloramines that interfere in cellular metabolism, oxidative action with irreversible enzymatic inactivation in bacteria, and

3. lipid and fatty acid degradation

NaOCl13

Does not effectively wet dentin Canal extensions – poorly irrigated Deplete dentin of organic compounds Pure NaOCl – 5.25% NaOCl Toxic Commercial NaOCl buffered – pH 12 to13 –

caustic Diluted – limited shelf life Stored for 1-2 weeks

NaOCl14

Clinical complications : Accidental injection to periradicular

tissues Pain Bleeding Swelling Release oxygen free radicals Reduce bonding of resin to dentin

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Chlorhexidine

Broad spectrum antimicrobial agent Antimicrobial mechanism: Cationic bisbiguanide molecular

structure At low concentrations – bacteriostatic At high concentrations – bactericidal Property of substantivity 2% and 12% - residual antimicrobial

activity -72hrs

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Chlorhexidine

Lin et al – compared the use of CHX irrigant and slow releasing device against E.faecalis

Viable bacteria reduced – 0.2% CHX CHX impregnated GP points Combination with NaOCl Causes staining

Endodontic solutions online,volume 10,issue 1,spring 2004

Detergents 17

‡ Remove fatty tissue residuesQuaternary ammonium compounds‡ Used in water solutions at 0.1 to 1%‡ Zepheran chloride :‡ Toxic ‡ Low antimicrobial effectiveness‡ Iodophores ‡ Wescodyne and iodopax‡ Effective at low concentrations‡ Mixed with Ca(OH)2

DECALCIFYING MATERIALS - EDTA18

Smear layer EDTA : Chelates and removes mineralized portion of smear layer Decalcify 50µm layer Concentration :17% Time : less than 1 min 15 minutes Limited value in root canal preparation Beltz et al -Added with NaOCl – remove organic

component of smear layer Eg : endodilator N – EDTA + Ammonium Compounds Smear clear – EDTA +centrimide + anionic surfactants

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SmearClear was able to remove the smear layer from the root canals of primary teeth as effectively as ethylenediaminetetraacetic acid, suggesting that both solutions may be indicated for such purpose

Nelson Filho P Efficacy of SmearClear and ethylenediaminetetraacetic acid for smear layer

removal in primary teeth J Dent Child (Chic). 2009 Jan-Apr;76(1):74-7

Intracanal disinfection materials

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Phenolic compounds Antiseptics with chlorine and iodine base Phenol/carbolic acids:1. Paramonochlorophenol2. Thymol3. Cresol Phenol : non specific protoplasm poison Optimal antibacterial effect:1 -2% High conc: lower antibacterial effect Camphoration – less toxic compound Disadvantages :1. Ineffective antimicrobials2. Intracanal dressing ineffective3. Induce inflammatory changes at low conc.

Formaldehyde 21

Formocresol- 19 to 37% formaldehyde Tricresol formalin : Tricresol 10% +

formaldehyde 90% Volatile releases antimicrobial vapors Antimicrobial effectiveness lower than its

toxicity Disadvantages : 1. Toxicity2. Tissue destruction3. Mutagenic and carcinogenic potential

Formocresol

Introduced by Buckley J P IN 1904

Equal parts of formalin and tricresol

Effective bacteriocide Buckley’s formula • Tricresol (35%)• Acqeous

formaldehyde(19%) • Glycerin(15%)• Water(31%) Formocresol pulpotomy: vital

primary teeth with carious exposures

Sweet 1930

Preparation : 3 parts glycerin

+ 1 part water – diluent solution

1 part formocresol + 4 parts diluent – 1/5 th conc.

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Formocresol 23

Mechanism of action: 1. Prevents tissue autolysis – bonding to

proteins(peptide group of side chain aminoacids)2. Reversible process- no change in basic structure of

proteins

Emmerson (1959) :• Action on pulp tissue• Varied with length of time of contact• 5minutes : surface fixation of normal tissue• 3 days : calcific degeration• Vital /nonvital pulpotomy : depends on duration

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Histological changes

Acc to Mass and Zilbermann-1933

Massler and Mansokhani – 1959

Immediate: 7 – 14 days1. Broad eosinophilic zone of

fixation2. Broad pale staining zone of

atrophy with poor cellular definition

3. Broad zone of inflammation extending apically

After 1 year: progressive apical movement of the zones with only acidophilic zone left at the end of 1 year

Formocresol 25

Jacob Daniel 1959: distinct zones1. Superficial debris along with dentinal

chips at the amputation site2. Eosinophilic stained and compressed

tissue3. Palely stained zone with loss of cellular

definition4. An area of fibrotic and inflammatory

activity5. An area of normal appearing pulp tissue

considered to be vital

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Sweet 1930- multivisit technique Doyle 1962 – complete devitalization – 2

sitting procedure Spedding 1965 – 5 minute protocol –

partial devitalization Venham 1967 15 min procedure Current concept – 4 min application

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Rolling and Thylstrup – 3 year follow up 91% -3months

83% - 12 months 78% - 24 months 70% - 36 months Fuks, Garcia- Godoy (1983) – hard tissue

deposition or calcification of root canal walls following formocresol pulpotomy

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Concerns regarding Formocresol Lewis 1981, Ranly 1984, Garcia- Godoy 1986

Toxicity: formaldehyde- cytotoxic, mutagenic and carcinogenic in experimental animals

Systemic distribution Myers et al 1978 demonstrated systemic distribution of

radio isotope labelled formaldehyde Nongentini et al 1980- mutations occurred following a 6

minute application of formocresol International agency for research on cancer (2004) –

formaldehyde – human carcinogen Other alternatives – Ferric suphate MTA Michael J Casas Do we still need formocresol In pediatric dentistry? J Can Dent Assoc

2005; 71:749-51

Paraformaldehyde 29

Devitalizing paste – Andrew 1955 Objective: seal in place for 1-2 weeks Disadvantage : incomplete devitalization

of pulp Hannah and Rowe -1971 – 5% PFD -

ineffective Recommended : Uncooperative child and time factor – in

single visit Child does not accept local analgesia

EASLICK’S PARAFORMALDEHYDE PASTE30

Paraformaldehyde Procaine base Powdered asbestos Petroleum jelly

Paraform devitalizing paste31

Paraformaldehyde Lignocaine Propylene glycol Carbowax Carmine to color

Gysi triopaste32

Tricresol Cresol Glycerin Paraformaldehyde ZOE

Glutaraldehyde 33

Dankert J, Gravemade and Wemes -1976 2 to 4% - rapid fixation of pulp tissue Limited penetration Underlying Pulp – vital , free of

inflammation Narrow zone of eosinophilic stained and

compressed fixed tissue Replaced with dense collagenous tissue

by macrophagic action

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Properties

Ranly 1982; Kennedy, Garcia Godoy, Fuks et al 1986

Superior fixation with relatively little immunogenecity

Mild effects on pulp tissue Lesser Systemic Distribution Positive clinical results

Glutaraldehyde 35

No toxic effects 2.5% glutaraldehyde – 15 to 20 times less toxic than

formocresol or 19% formaldehyde Ideal concentration : 3.125% Glutaraldehyde + zinc oxide eugenol Buffering glutaraldehyde, Increasing concentration,

longer periods : enhance degree of fixation Stronger solutions Ranly 1984 : better fixative agent than formaldehyde

Ranly M Glutaraldehyde purity and stability: implications for preparations for preparation, storage, and use as a

pulpotomy agent Pediatr Dent; 1984:6:83-7

Advantages of glutaraldehyde over formocresol

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1. Bifunctional agent – cross linkage2. Excellent antimicrobial

GLUTARALDEHYDE FORMOCRESOL

Less necrosis of pulpal tissue More necrosis

Less dystrophic calcification in pulp canals

Dystrophic changes can occur

Less toxicity More cytotoxicity

Less systemic distribution More systemic distribution

Low tissue binding Better tissue binding

Less MutagenecityAntigenecity

More mutagenic and antigenic

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Success rate- in pulpotomies

• Garcia Godoy– 98%(1991)• Fuks et al– 90.4% (1991)• Alacam et al – 96% (1996)

Ferric sulfate38

Monsels solution – 20% ferric subsulfate Use in military hospital in Bordeaux France Strong styptic- ferric ion protein complex Landau and Johnson 1988 – pulpotomy

medicament Coagulation of tissues Fei et al – 96% - ferric sulphate 78% - formocresol Advantage over Formocresol 15 sec for manipulation compared to 5 min FC

Denatured albumin39

Indicated for pulp capping Acts as a matrix for calcification Increases chances of biologic obliteration Absorb blood and exudate from pulp –

eliminates intrapulpal pressure Molven 1970 : no symptoms in the pulp

Bioactive glass40

Composition Silicon dioxide-53%Sodium oxide-23%Calcium oxide -20%Phosphorous oxide-4% Action – kills bacteria Eg: resilon Based on its more than ten-fold higher specific surface area,

nanometric bioactive glass releases more alkaline species, and consequently displays a stronger antimicrobial effect, than the currently applied micron-sized materialWaltimo T,Antimicrobial effect of nanometric bioactive glass 45S5.

J Dent Res. 2007 Aug;86(8):754-7.

Superoxidized water41

Antimicrobial Saline electrolyzed to form superoxidized

water Non toxic Study Equivalent to glutaraldehyde and

superior to ozonated water Potential irrigating solution

MTA42

Torabinajed: 1993 Composition:• Fine hydrophilic particles of tricalcium

aluminate• Tricalcium silicate• Silicate oxide• Tricalcium oxide• Bismuth oxide

Properties 43

Biocompatible Sealing ability better than amlagam or ZOE pH 10.2 – 12.5 Sets in presence of moisture Setting time: 4 hrs Compressive strength: 70MPA Low cytotoxicity Antimicrobial and antifungal activity- E.feacalis,

S.sanguis Indicated : for pulpotomy, pulp capping &

apexification, root perforations

Mechanism of action 44

Stimulates cytokine and interleukins release from bone cells

Promotes hard tissue formation

Eldleman, Fuk & Holan (2001); - compared MTA / FC in pulpotomised

primary teeth - showed both clinical & radiographic

success

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Aeinehchi et al -2003 – 0.28mm thick dentin bridge in teeth pulp capped with grey MTA at 2 mos and o.43mm at 6mos in contrast to 0.15mm noted with Ca(OH)2 at 6 mos

Barrieshi-nusair and qudeimat- 2006 – evaluated grey MTA for partial pulpotomy- 79% success rateVIDYA SRINIVASAN , PAULA WATERHOUSE & JOHN WHITWORTH

Mineral trioxide aggregate in paediatric dentistry International Journal of Paediatric Dentistry 2009; 19: 34–47

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The procedure showed clinical success in 94.1% of the cases, radiographic success was found to be 76.5% and in further three cases (17.6%) the outcome was considered to be uncertain

Sarris S, Tahmassebi JF, Duggal MS, Cross IA.A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study.Dent Traumatol. 2008 Feb;24(1):79-85.

Bone morphogenic protein47

Family – bone inductive potential Autoinduction potential Osteogenic proteins – part TGF-β Implicated in• Cell differentiation• Tissue morphogenesis• Regeneration and repair• BMP genes expressed - dentinogenesis

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Urist (1965) - demineralized bone matrix can stimulate new bone formation, when implanted in ectopic sites

Nakashima (1994)- promotes dentinogenesis – dentin bridge

Recombinant human osteogenic protein -1 in a collagen carrier matrix – bioactive capping agent for surgically exposed pulp

Enamel matrix derivative49

Obtained from embryonic enamel Emd proteins – reciprocal ectodermel –

mesenchymal signaling-facilitate regenerative processes in mesenchymal tissues

Participates in differentiation of odontoblasts Nakamura et al – rapid fibrinodentin matrix

formation – reperative dentinogenesis – angiogenesis

Dentin – initially resembled osteodentin later secondary dentin

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Properties

1. Emd acts as signal for mesenchymal cell differentiation, maturation,biomineralization

2. Bioinductive material3. Offers good healing potential

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Nadia A. et al in 2006, compared the influence of emdogain and calcium hydroxide on apexification and peri-apical healing of teeth in dogs with in complete root formation and previously contaminated canals. They concluded that the total amount of reparative dentine formed in emdogain treated teeth was significantly higher than calcium hydroxide treated specimens

Calcium hydroxide52

Introduced by Hermann in 1920 Pharmaceutical grade – 95% calcium soluble in water Action: 1. Protective barrier2. Blocks potent dentinal tubules3. Neutralizes attack of acids4. Stimulates formation of reperative dentin 5. At high ph 10.2 – induces alkaline phosphatase

activity- hard tissue formationGoday F C Evaluation of an iodoform paste in root canal therapy

for infected primary teeth. J Dent Child 1987; 30-4

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Reparative dentin formation

A rise in pH due to free hydroxyl ions may initiate or favour mineralization (Tronstad et al. 1981).

An alkaline pH may also neutralize the lactic acid secreted by osteoclasts, -prevent further destruction of mineralized tissue.

Exerts a mitogenic and osteogenic effect, the high pH combined with the availability of calcium and hydroxyl ions- effects enzymatic pathways and hence mineralization (Torneck et al. 1983).

High pH - activate alkaline phosphatase activity (important role in hard tissue formation) (Guo & Messer 1976).

The optimum pH for alkaline phosphatase activity is 10.2 (Gordon et al. 1985)

Heithersay (1975)suggested that calcium ions -reduce the permeability of new capillaries - less intercellular serum is produced, thus increasing the concentration of calcium ions at the mineralization site.

The presence of a high calcium concentration - increase the activity of calcium dependent pyrophosphatase, which represents an important part of the mineralization process.

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The reduced capillary permeability following the increase in the number of calcium ions could reduce serum flow within the dental pulp, and consequently the concentration of the inhibitory pyrophosphate ion would be reduced.

This would coincide with an increase in levels of calcium-dependent pyrophosphatase - Heithersay (1975)- result in uncontrolled mineralization of the pulp tissue

This could possibly explain the high incidence of mineralized canals observed following pulpotomy and direct pulp capping (Langeiand et al. 1971, Seltzer & Bender 1984)

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Applications:-

1. Vital pulp therapy.

a. Direct pulp capping.

b. Indirect pulp capping.

c. Pulpotomy.

d. Apexogenesis.

2. Routine intracanal dressing between appointments.

a. Routine dressing.

b. Long-term temporary dressing.

3. Large periapical lesions

4. Treatment of divergent apex in a pulpless tooth (Apexification).

5. Control of persistent apical exudates into the canal.

 

6. Prevention of root resorption

a. Idiopathic.

b. Following the replacement of an avulsed tooth, or transplantation of a tooth.

7. Repair of iatrogenic perforations.

8. Treatment of root fractures.

9. Constituents of root canal sealers.

10. Dentine desensitizing agent.

11. Micro leakage demonstrator.

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Products :1. Pulpdent: calcium hydroxide in aqueous methyl

cellulose solution. High ph2. Dycal : 2 paste form - low ph

Base - titanium dioxide in a glycol salicylate Catalyst – calcium hydroxide and zinc oxide in ethyl toluene sulfanamide

3. Hydrex barium sulphate+ calcium hydroxide + titanium dioxide + resin

Water – vehicle 24 hrs direct contact – kills enterococci

Antibacterial effect of setting calcium hydroxide

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Alkaline environment kills pathogens –HeithersayHeithersay calciumhydroxide in the treatment of pulpless teeth with associated pathologyJ Br Endod

Soc 1975;8:74-7 Mechanisms 1. Damage to bacterial cytoplasmic membrane2. Protein denaturation3. Damage to the DNA

Fava and Saunders WP. Calciumhydroxide pastes classification and clinical indications(review) int endond j

1999;32:257-258

Advantages 58

Bactericidal to bacteriostatic Promotes healing and repair High Ph stimulates fibroblastic activity Neutralizes low pH of acids Stimulates enzyme system Inexpensive and easy to use Particles obturate open tubules Ideal temporary luting cement

Disadvantage 59

Does not exclusively stimulate dentinogenesis Associated with primary tooth resorption May dissolve after 1 year with cavosurface

microleakage Acids degrade interphase during the etching

process Degrades upon tooth flexure Does not adhere vital dentin Does not adhere to bonding resin composite

system

Calcium hydroxide60

Teuscher and zander (1938) –pulpotomy Histologic zones under calcium hydroxide

4-9 days 1. Coagulation necrosis2. Deep staining basophilic areas with

varied osteodentin3. Relatively normal pulp tissue,

slightly hyperemicDentinal Bridge : incomplete, dome /funnel shaped,filled with tissue inclusionsInternal resorption - odontoclasts

Necrosis of pulp tissue

Acute inflammatory

changes

4 weeks – new odotoblastic

layer

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Frank 1966 – used for apical closure Replaced every 3 months Klein and Levy -1974 Using ca(OH)2 +Cresatin+

Metacresylacetate

Zinc oxide eugenol62

Discovered by bonastre-1937 Used in dentistry by Chisholm -1876 Most frequently used root canal filling material Powder 1. Zinc oxide- Antimicrobial 2. Paraformaldehyde – antimicrobial and mummifying

effects3. Germicides – antiseptic4. Rosin /canada balsam – dentin adhesion5. Corticosteroids – suppression of inflammatory reaction Liquid

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Mechanism of action

Chelation Ph – neutral C.Strength – 100-2000psi -7days

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Zinc oxide eugenol

Rabinowitch (1953) : only 7 failures of 1363 teeth

Used devoid of catalyst- for adequate working time

Procedure Care : to prevent extrusion Disadvantages : Eugenol – tissue irritant Periapical extrusion

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Zinc oxide eugenol

Trowbridge et al – 1982• Eugenol blocks intradental nerve activity

– allays pain• When ZOE placed on dentin- releases

eugenol,through dentinal tubules into pulp- inhibits prostaglandin synthesis, nerve activity, white cell chemotaxis

• David L. Effect of materials used in pediatric dentistry on the pulp: a review of the literature Journal of california

dental association 1999

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There was a 20% incidence of succedaneous tooth anterior cross-bite or palatal eruption following incisor PEs and 21.6% ectopic eruption of premolars following primary molar PEs. Most PEs (95.9%) were lost at their normal exfoliation time or earlier, but 35.8% needed extraction due to overretention by soft tissue at the time of shedding. Pulpectomy success rates showed that the most important preoperative predictor was the amount of primary tooth root resorption. Greater than 1 mm of root resorption resulted in only a 23.1% success rate, which was significant (P = 0.001). Pulpectomies filled short or to the apex had a significantly greater success (P = 0.011) than long fills. Pulpectomies correctly done do not appear to contribute to adverse effects on succedaneous tooth formation but have a 20% chance of altering the path of permanent tooth eruption

Coll JA, Sadrian R Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent. 1996 Jan-

Feb;18(1):57-63

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Endoflas

Vitapex + ZOE Resorbs extraradicularly

Approximately 70% of the cases were successful at the last followup examination. The remaining 30% presented with pathology (Po); however, only one tooth had to be extracted (Pi).Fuks AB Root fillings with Endoflas in primary teeth: a retrospective study. J Clin Pediatr Dent.

2002 Fall;27(1):41-5.

Iodoform paste 68

Easily resorbed from periradicular region No foreign body reaction Has positive healing effect Advantages : Bactericidal in root canal Resolves from apical tissue in 1-2 weeks Harmless to permanent tooth germ Radiopaque Easy to insert and remove

KRI PASTE69

As an antiseptic in treatment of pulpless teeth Composition :

P- chorophenol – 2.025%Camphor -4.860%

Menthol – 1.215 %Iodoform – 80.8%

Advantages : Goday FC 1987 Resorbs from periapical area by action of macrophages

in 1-2 weeks Does not set to a hard mass Insertion and removal easy Harmless

Maistos paste 70

Contents : zinc oxide -14g Iodoform – 42g Thymol – 2g Chlorophenol camphor – 3cc Lanolin -0.50gMass E, Zilbermann UL Endodontic treatment of

infected primary teeth,using maisto’s paste.J Dent Child 1989,117-120

Maistos paste 71

Tagger and sarnat 1989 – iodoform + ZOE paste

Modified maisto’s paste : zinc oxide -7g Iodoform – 14g Thymol – 1g Chlorophenol camphor – 1g Lanolin -0.25g

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Complete healing of the inter-radicular pathology was seen with Maisto's paste. However, the pathology was present in 40% of the zinc oxide-eugenol treated teeth even after 9 months. Maisto's paste was thus seen to be superior to zinc oxide-eugenol both in clinical as well as radiological evaluation, done over a period of 9 months in relation to bone regeneration, healing of inter-radicular pathology and resorption of excess material. Reddy VV, FernandesClinical and radiological evaluation of zinc oxide-

eugenol and Maisto's paste as obturating materials in infected primary teeth--nine months study.J Indian Soc Pedod Prev Dent. 1996 Jun;14(2):39-44.

Walkoff’s paste 73

P – chlorophenol – 2.025%Camphor -4.860%Menthol -1.215% Iodoform – 80.8%

N274

Liquid + powder Liquid – eugenol +rose oil Powder – ZOE + barium sulfate +

titanium oxide + para formaldehyde + calcium hydroxide + phenyl mercuric borate

Nacht 1956: N2 + 5%paraformaldehyde – increased resorption

Beechwood cresote 75

Phenol and its derivatives Methyl ether of pyrocatechin 60-90% Similar to paraformaldehyde More toxic Not used in pediatric dentistry

Vitapex 76

Calcium hydroxide + iodoform Excellent anti bacterial properties Used in pulpectomies and infected root canal Advantages • No spatulation• Radiopacity • Accessibility excellent• No chemical and physical changes arise Procedure :

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Vitapex

Precautions : Press without surplus force Graduation to be observed Arrest of exudate Position relation ship of maxillary sinus

and upper molar teeth Tips soaked in 0.5% NaOCl or 70%

alcohol – Store in black case to avoid

discolouration

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Zinc oxide and eugenol and Vitapex were compared for root canal treatment in 52 necrotic primary teeth in two groups of children with a mean age of 5 years and 8·4 months. All the patients were followed-up clinically and radiographically 3 months and 10–16 months postoperatively. The overall success rates of Vitapex and ZOE were 100% and 78·5%, respectively.

M. MORTAZAVI & M. MESBAHI Comparison of zinc oxide and eugenol, and Vitapex for root canal treatment of necrotic primary teeth International Journal of

Paediatric Dentistry 2004;14:417–424

Corticosteroids 79

Inhibits enzyme phospholipase A2 – converts membrane phospholipids into arachidonic acid

Render cell membrane of mast cell resistant to penetration by pharmocologic agents

Reduced pain Disadvantages : Disguises chronic inflammation Permit influx of phagocytes Brosch (1965)– calcium phosphate + neomycin +

hydrocotisine- pulp healed better Intracanal steroids - dexamethasone

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Ledermix

Triamcinalone acetonide Calcium demethylchlor tetracyclineAvailable as1. Single tube cream2. Two component tube cementHansen et al: pulpotomy – 79% ledermix57% ZOE

V. Srinivasan, C. L. Patchett & P. J. WaterhouseIs there life after Buckley’s Formocresol? Part I – A narrative review of

alternative interventions and materials International Journal of Paediatric Dentistry 2006;16:117–127

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Otosporin is a corticosteroid-antibiotic solution composed of Polymyxin B sulphate (10000 IU), Neomycin (5mg) and Hydrocortisone (10mg) in an aqueous vehicle and has been shown to maintain the integrity of the pulp stump as an inter appointment dressing in vital pulpectomy.

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Quilin et al. (1992) added metronidazole and chlorhexidine to a calcium hydroxide paste and tested this formulation for its antibacterial effect.

Antoniazzi & Marques (1997),- calcium hydroxide (0.13g), metronidazole (0.6g), ciprofloxacin (0.6g) and polyethyleneglycol 1000ml.

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References

Orban's Oral Histology and embryology. Seventh Edition.- Harry Sicher and S. N. Bhaskar 4th ed

Pathways of the Pulp- Stephen Cohen Ingle's Endodontics John I. Ingle, Leif K. Bakland -6th

edition Endodontic Practice Louis Irwin Grossman The Dental Pulp Samuel Seltzer, Selzer, and I. B.

Bender Textbook of Oral Pathology William G. Shafer Textbook of pediatric dentistry- nikhil marwah Pediatric dentistry – scientific foundation and clinical

practice. Steward, Barber, Trautman, Wei

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References

Pathways of the pulp – Cohen Orban’s Oral histology and embryology 10th

edition Seltzer’s dental pulp -3rd edition Grossman Ingle’s endodontics – 5th edition Pediatric dentistry – scientific foundation and

clinical practice. Steward, Barber, Trautman, Wei

Textbook of pediatric dentistry-Nikhil marwahThank you