1

PULPAL MEDICAMENTS

Tuesday, Decemb Dr.Madhuri

er 07, 2021
Primary pulp organ
 Time : 8.3 years
1. Pulp organ growth- 1yr
2. Pulp maturation-3yr 9 m
3. Pulp regression- 3yr 6m

Maximum life 9.6 years

2
 PULPAL MEDICAMENTS
3

 INTRODUCTION
 IRRIGATING MATERIALS
 INTRACANAL DISINFECTING MATERIALS
 ROOTCANAL FILLING MATERIALS
 INTRODUCTION
4

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 instrumentation
2. Reduce inflammation of periapical tissues and pulp remnants
3. Neutralize tissue debris and render canal contents inert
4. Act as a barrier against leakage from the temporary filling
5. Help to dry persistently wet canals
06
 Requirements of an ideal intra canal
medicament
5

 Chong and Pittford -1992

1. Non irritant to periapical tissues
2. Able to eliminate bacterial flora of the canal
3. Prevent pain
4. Reduce periapical inflammation
5. Stimulate perapical repair
6. Effective rapidly and active for long periods
7. Capable of diffusion and penetration into dentin
8. Effective in the presence of pus and organic debris
9. Long shelf life
10. Non staining
 Rationale for use of intracanal medicaments
6

‡ 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 materials
7

 Aim : removal of pulp remnants and dentin debris

 Ideal properties of Irrigating materials
8

 Walten and Torabinajed – 1989

1. Tissue and debris dissolution
2. Low surface tension - promote the flow of irrigant into
inaccessible areas
3. Lubricant property – enables instrument to readily slide down
the canal
4. Sterilization
5. Removal of smear layer
6. Cost
7. Adequate shelf life
8. Ease of storage
 Classification of irrigating materials
9

 Chemically non active solutions

1. Water
2. Saline
3. Local anesthetic
 Chemically active materials
1. Acids: 30% HCl, 50% Sulphuric acid, citric acid
2. Alkalis: NaOCl, NaOH,
3. Chelating agents: EDTA
4. Oxidizing agents
5. Antibacterial agents : chlorhexidine
6. Detergents : sodium lauryl sulphate
 Classification of irrigating materials Acc to Cohen:
10

1. Proteolytic materials
2. Detergents
3. Decalcifying materials
 Proteolytic materials - NaOCl
11

 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.
12

 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
 NaOCl
13

 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
 NaOCl
14

 Clinical complications :
 Accidental injection to periradicular tissues
 Pain
 Bleeding
 Swelling
 Release oxygen free radicals
 Reduce bonding of resin to dentin
 Chlorhexidine
15

 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
 Chlorhexidine
16

 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 residues

Quaternary 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 - EDTA
18

 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
19

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
20

 Phenolic compounds
 Antiseptics with chlorine and iodine base
 Phenol/carbolic acids:
1. Paramonochlorophenol
2. Thymol
3. Cresol
 Phenol : non specific protoplasm poison
 Optimal antibacterial effect:1 -2%
 High conc: lower antibacterial effect
 Camphoration – less toxic compound
 Disadvantages :
1. Ineffective antimicrobials
2. Intracanal dressing ineffective
3. 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. Toxicity
2. Tissue destruction
3. Mutagenic and carcinogenic potential
 Formocresol
22

Introduced by Buckley J P IN 1904


 Preparation :
 Equal parts of formalin and
tricresol  3 parts glycerin + 1
 Effective bacteriocide part water – diluent
 Buckley’s formula
• Tricresol (35%)
solution
• Acqeous formaldehyde(19%)  1 part formocresol + 4
• Glycerin(15%) parts diluent – 1/5 th
• Water(31%)
 Formocresol pulpotomy: vital
conc.
primary teeth with carious
exposures
 Sweet 1930
 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
 Histological changes
24

 Acc to Mass and Zilbermann-1933

 Massler and Mansokhani – 1959

Immediate: 7 – 14 days
1. Broad eosinophilic zone of
fixation
2. 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 zones

1. Superficial debris along with dentinal chips at the
amputation site
2. Eosinophilic stained and compressed tissue
3. Palely stained zone with loss of cellular definition
4. An area of fibrotic and inflammatory activity
5. An area of normal appearing pulp tissue
considered to be vital
26

 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
27

 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
 Concerns regarding Formocresol
28

 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 PASTE
30

 Paraformaldehyde
 Procaine base
 Powdered asbestos
 Petroleum jelly
 Paraform devitalizing paste
31

 Paraformaldehyde
 Lignocaine
 Propylene glycol
 Carbowax
 Carmine to color
 Gysi triopaste
32

 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
 Properties
34

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
36

1. Bifunctional agent – cross linkage

2. Excellent antimicrobial
GLUTARALDEHYDE FORMOCRESOL
Less necrosis of pulpal tissue More necrosis
Less dystrophic calcification in pulp Dystrophic changes can occur
canals
Less toxicity More cytotoxicity
Less systemic distribution More systemic distribution
Low tissue binding Better tissue binding
Less Mutagenecity More mutagenic and antigenic
Antigenecity
37

 Success rate- in pulpotomies

• Garcia Godoy– 98%(1991)

• Fuks et al– 90.4% (1991)
• Alacam et al – 96% (1996)
 Ferric sulfate
38

 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 albumin
39

 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 glass
40

 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
material
Waltimo T,Antimicrobial effect of nanometric bioactive glass 45S5.
J Dent Res. 2007 Aug;86(8):754-7.
 Superoxidized water
41

 Antimicrobial
 Saline electrolyzed to form superoxidized water
 Non toxic
 Study
 Equivalent to glutaraldehyde and superior to
ozonated water
 Potential irrigating solution
 MTA
42

 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
45

 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 rate
VIDYA SRINIVASAN , PAULA WATERHOUSE & JOHN WHITWORTH
Mineral trioxide aggregate in paediatric dentistry International Journal of
Paediatric Dentistry 2009; 19: 34–47
46

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 protein
47

 Family – bone inductive potential

 Autoinduction potential
 Osteogenic proteins – part TGF-β
 Implicated in
• Cell differentiation
• Tissue morphogenesis
• Regeneration and repair
• BMP genes expressed - dentinogenesis
48

 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 derivative
49

 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
 Properties
50

1. Emd acts as signal for mesenchymal cell

differentiation, maturation,biomineralization
2. Bioinductive material
3. Offers good healing potential
51

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 hydroxide
52

 Introduced by Hermann in 1920

 Pharmaceutical grade – 95% calcium
soluble in water
 Action:
1. Protective barrier
2. Blocks potent dentinal tubules
3. Neutralizes attack of acids
4. Stimulates formation of reperative dentin
5. At high ph 10.2 – induces alkaline phosphatase activity- hard tissue
formation
Goday F C Evaluation of an iodoform paste in root canal therapy for infected
primary teeth. J Dent Child 1987; 30-4
 Reparative dentin formation
53

 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.
54

 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)
 Applications:-
55
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
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.
56

 Products :
1. Pulpdent: calcium hydroxide in aqueous methyl cellulose
solution. High ph
2. 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
57

 Alkaline environment kills pathogens –Heithersay

Heithersay calciumhydroxide in the treatment of pulpless teeth
with associated pathologyJ Br Endod Soc 1975;8:74-7
 Mechanisms

1. Damage to bacterial cytoplasmic membrane

2. Protein denaturation
3. 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 hydroxide
60

 Teuscher and zander (1938) –pulpotomy

Necrosis of pulp
 Histologic zones under calcium hydroxide tissue 4-9
days
1. Coagulation necrosis Acute
2. Deep staining basophilic areas with varied
inflammatory
changes
osteodentin
3. Relatively normal pulp tissue, slightly
hyperemic 4 weeks – new
odotoblastic layer
Dentinal Bridge : incomplete, dome /funnel
shaped,filled with tissue inclusions
Internal resorption - odontoclasts
61

 Frank 1966 – used for apical closure

 Replaced every 3 months
 Klein and Levy -1974
 Using ca(OH)2 +Cresatin+ Metacresylacetate
 Zinc oxide eugenol
62

 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 effects
3. Germicides – antiseptic
4. Rosin /canada balsam – dentin adhesion
5. Corticosteroids – suppression of inflammatory reaction
 Liquid
 Mechanism of action

63

 Chelation
 Ph – neutral
 C.Strength – 100-2000psi -7days
 Zinc oxide eugenol
64

 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
 Zinc oxide eugenol
65

 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
66

 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
 Endoflas
67

 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 PASTE
69

 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 -0.50g
Mass 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
72

 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%
 N2
74

 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 :
 Vitapex
77

 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
78

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
 Ledermix
80

 Triamcinalone acetonide
 Calcium demethylchlor tetracycline

Available as
1. Single tube cream
2. Two component tube cement
Hansen et al: pulpotomy – 79% ledermix
57% 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
81

 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.
82

 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.
 References
83

 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 -6 th 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
 References
84

 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 marwah
Thank you