Pulp Therapy for the Primary Dentition PDF

By : Dr. Mohammad Thabet  Introduction — Despite modern advances in the prevention of dental caries and an increased understanding of the importance of maintaining the natural dentition, many teeth are still lost prematurely. — This can lead to malocclusion or to esth...

By : Dr. Mohammad Thabet  Introduction — Despite modern advances in the prevention of dental caries and an increased understanding of the importance of maintaining the natural dentition, many teeth are still lost prematurely. — This can lead to malocclusion or to esthetic, phenotic, or functional problems that may be transient or permanent.  The main objective — The primary objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues. — Also, a tooth without a vital pulp, however, can remain clinically functional.  Histology — The pulp of a primary tooth is histologically similar to that of a permanent tooth. — The odontoblasts are cells that: — Line the periphery of the pulp space. — Extend their cytoplasmic processes into the dentinal tubules. — Several junctionsà to maintain their position. — Below: the cell-free zoneà extensive plexus of unmyelinated nerves & blood capillaries. — The large blood vessels & nerves are located in the core of the pulp surrounded by loose CT. The Pulp-Dentin Complex  Dentinogenesis in Healthy State — The inner enamel epith & its associated basement membrane à important role in direct odontoblastic cytodifferentiation. — Present bioactive molecules, including growth factors immobilized on the basement membrane that send signals to the cells of the dental papilla, inducing the differentiation of the ectomesenchymal cells into odontoblasts.  Dentinogenesis in Healthy State — The odontoblasts: — Express specific gene products that will form the highly mineralized extracellular matrix of dentin. — The main inorganic part of dentinà Hydroxyapetite. — The organic componentsà type I collagen (mostly).  Dentinogenesis in Healthy State Primary Dentin Secretion: — During the postmitotic state the odontoblasts line the formative surface of the matrix and start secreting primary dentin. — At the initiation of dentinogenesis: — Mantle dentin formation àmineralization is achieved through the mediation of matrix vesicles — Then, odontoblasts form a tightly packed layer of cells à the matrix of dentin is produced exclusively by the odontoblasts.  Dentinogenesis in Healthy State — As the matrix is secreted, the odontoblasts move pulpally, leaving a single cytoplasmic process embedded in a dentinal tubule in the matrix. — These tubules, which increase in density near the pulp, confer the property of permeability on the dentin, a feature that has significant clinical importance.  Dentinogenesis in Healthy State Physiologic secondary dentin formation: — Secondary dentin is formed after root formation is complete, normally after the tooth has erupted and is functional. It grows much more slowly than primary dentin, but maintains its incremental aspect of growth. — It is secreted at a much slower rate throughout the life of the tooth, leading to a slow reduction in the size of the pulp chamber.  Dentinogenesis in Healthy State Physiologic secondary dentin formation: — The original postmitotic odontoblasts, responsible for primary dentinogenesis, survive for the life of the tooth, unless subjected to injury. — These cells remain in a resting stage after primary dentinogenesis, and the physiologic secondary dentin formation represents a basal level of cell activity in the resting tooth stage.  Dentinogenic Response to Injury — In pathologic conditions, such as in mild carious lesions or traumatic injuries: àThe secretory activity of the odontoblasts is stimulated to elaborate tertiary dentin. àFocal secretion of new matrix at the pulp-dentin interface and possibly within the tubules. àContributing to the histologic appearance of dentinal sclerosis at the injury site and to a decrease in dentin permeability.  Dentinogenic Response to Injury — The tertiary dentin: — Much faster than secondary dentin. — Defence mechanism. — In response to pathologic or physiologic insults.  Dentinogenic Response to Injury Tertiary dentin types: — Reactionary Dentin: — In case of a mild injury, the original odontoblasts can frequently survive and are stimulated to secrete reactionary dentin beneath the injury site. — There will be tubular continuity and communication with the primary dentin matrix — Might be considered as an extension of physiologic dentinogenesis. — Reparative Dentin: — When the injury is severe, the odontoblasts beneath may die; however, if suitable conditions exist in the pulp, a new generation of odontoblast-like cells may differentiate from underlying pulp cells, secreting a reparative dentin matrix. — There will be discontinuity in the tubular structure, with a subsequent reduction in permeability.  Dentinogenic Response to Injury — The molecular control of cell activity in general and of odontoblastic activity in particular: à One family of growth factors, the transforming growth factors (e.g., TGF-ᵝ) superfamily, has been reported to have extensive effects on the mesenchymal cells of many connective tissues.  Factors Affecting Dentin-Pulp Complex Response to Stimuli in Primary Teeth — The presence of bacteriaà more severe inflammation. — The remaining dentin thickness (RDT): — ˃500µmà reactionary. — ˂500µmàreparative. — ˂250µm ˃40µmà the maen # of intact odontoblasts ↓ by 36% àimpaired odontoblast dentin secretory activity due to cellular injury. àPersisitent inflammatory response. àOdontoblasts displacement.  Clinical pulpal diagnosis — The indications, objectives, and type of pulpal therapy depend on whether the pulp is vital or nonvital, based on the clinical diagnosis of: — Normal pulp (symptom free and normally responsive to vitality testing). — Reversible pulpitis (pulp is capable of healing). — Symptomatic or asymptomatic irreversible pulpitis (vital inflamed pulp is incapable of healing). — Necrotic pulp.  Clinical pulpal diagnosis The clinical diagnosis is derived from: 1. A comprehensive medical history. 2. A review of past and present dental history and treatment, including current symptoms and chief complaint. 3. A subjective evaluation of the area associated with the current symptoms/chief complaint by questioning the child and parent on the location, intensity, duration, stimulus, relief, and spontaneity.  Clinical pulpal diagnosis 4. An objective extraoral examination as well as examination of the intraoral soft and hard tissues. 5. If obtainable, radiograph(s) to diagnose pulpitis or necrosis showing the involved tooth, furcation, periapical area, and the surrounding bone. 6. Clinical tests such as palpation, percussion, and mobility. 7. Direct pulp evaluation: — The quality (color) and the amount of bleeding from a direct exposure of the pulp tissue.  Pulp Treatment Procedures — The most important and difficult aspect of pulp therapy is determining the health of the pulp or its stage of inflammation so that an appropriate decision can be made regarding the best form of the treatment  Pulp Treatment Procedures Pulp treatment for primary teeth Conservative Radical Protective Indirect pulp Direct pulp Pulpectomy Root filling capping Pulpotomy base capping Conservative Pulp Treatment Procedures  Protective Base or Liner — It is a thinly-applied liquid placed on the pulpal and the axial walls of a deep cavity preparation, covering exposed dentin tubules, to act as a protective barrier between the restorative material or cement and the pulp. — Sufficient evidence à pulp reaction to dental materials is transitory and overt inflammation occurs only after bacteria or their by products have reached the pulp. — Thus, protective bases are recommended only in deep cavities approaching the pulp.  Protective Base or Liner Indications: — In a tooth with a normal pulp, when all caries is removed for a restoration, a protective liner may be placed in the deep areas of the preparation to minimize injury to the pulp, promote pulp tissue healing, and/or minimize post-operative sensitivity. Objectives: — To preserve the tooth’s vitality, — To promote pulp tissue healing and tertiary dentin formation, — To minimize bacterial microleakage. — Adverse post-treatment clinical signs or symptoms such as sensitivity, pain, or swelling should not occur.  Protective Base or Liner — Examples: — Copal varnish (to seal amalgam tooth interface until corrosion products formed). — GI cements. — Ca(OH)2 liners — Dentin bonding agentà??? Under amalgam; insoluble adhesive layer may act as a barrier to prevent amalgam corrosion products from ultimately sealing the gap. — Thus, dentin bonding agent may put the patient at a greater risk for marginal leakage and recurrent caries in long term.  Indirect Pulp Treatment — Def: the procedure in which nonremineralizable carious tissue is removed, and a thin layer of caries is left at the deepest site of the cavity to prevent pulp exposure. — This procedure results in the deposition of tertiary dentin, which increases the distance between the affected dentin and the pulp, and in the deposition of peritubular (sclerotic) dentin, which decreases dentin permeability. — V.imp. note: the carious tissue should be removed completely from DEJ and the lateral walls of the cavity to prevent microleakage.  Indirect Pulp Treatment Indications: — It is indicated in a primary tooth with no pulpitis or with reversible pulpitis when the deepest carious dentin is not removed to avoid a pulp exposure. — The pulp is judged by clinical and radiographic criteria to be vital and able to heal from the carious insult.  Indirect Pulp Treatment — The ultimate objective: maintain the vitality of teeth with reversible pulp injury by: — Arresting the carious process. — Promoting dentin sclerosis (reducing permeability). — Stimulating the formation of tertiary dentin. — Reminaralizing the carious dentin.  Indirect Pulp Treatment Objectives: — The restorative material should seal completely the involved dentin from the oral environment. — The tooth’s vitality should be preserved. — No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. — No radiographic evidence of pathologic external or internal root resorption or other pathologic changes. — No harm to the succedaneous tooth.  Indirect Pulp Treatment How much caries to leave at the pulpal and axial floor???? — Depending on knowledge and experience. — The carious tissue that should remain at the end of the cavity preparation is the quantitiy that, if removed, would result in overt exposure. — It is difficult to determine the affected and the infectedà — The best clinical marker is the quality of the dentin; soft, mushy dentin should be removed, and hard discolored dentin can be indirectly capped. — The use of large round bur is better than spoon excavators.  Indirect Pulp Treatment The materials — Two most commonly used materials: Ca(OH)2 and ZOE. — GI cements are recommended nowadays (based on several clinical studies). — If Ca(OH)2 is used, a glass ionomer or reinforced ZOE material should be placed over it to provide a seal against microleakage since Ca(OH)2 has a high solubility, poor seal, and low compressive strength. — The use of glass ionomer cements or reinforced ZOE restorative materials has the additional advantage of inhibitory activity against cariogenic bacteria. — The tooth then is restored with a material that seals the tooth from microleakage.  Indirect Pulp Treatment Two-step or one-step procedure??? — There is enough evidence of good clinical and radiographic success rates without reentering (to remove the remaining carious dentin and to confirm the formation of the reactionary dentin) if the restoration is maintained leakage free. — So, badly broken down tooth à SSC after performing this procedure. The risk of this approach (two-step procedure) is either an unintentional pulp exposure or irreversible pulpitis.  Indirect Pulp Treatment — Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies. — It also allows for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.  Direct Pulp Capping — When a pinpoint mechanical exposure of the pulp is encountered during cavity preparation or following a traumatic injury, a biocompatible radiopaque base such as MTA or calcium hydroxide may be placed in contact with the exposed pulp tissue. — Then, the tooth is restored with a material that seals the tooth from microleakage.  Direct Pulp Capping Indications: — This procedure is indicated in a primary tooth with a normal pulp following a small mechanical or traumatic exposure when conditions for a favorable response are optimal. — Direct pulp capping of a carious pulp exposure in a primary tooth is not recommended — Failure of treatment may result in internal resorption or acute dentoalveolar abscess; because of the high cellular content of the primary pulp tissue (undeffirentiated mesenchymal cells which differentiate into odontoclasts).  Direct Pulp Capping Objectives: — The tooth’s vitality should be maintained. — No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. — Pulp healing and reparative dentin formation should result. — No radiographic signs of pathologic external or progressive internal root resorption or furcation/apical radiolucency. — No harm to the succedaneous tooth.  Pulpotomy — Pulpotomy is one of the most widely accepted clinical procedures for treating cariously exposed pulps in symptom free primary teeth. — The rationale is based on the healing ability of the radicular pulp tissue following surgical amputation of the affected or infected coronal pulp.  Pulpotomy — It is performed in a primary tooth with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. — The coronal pulp is amputated, and the remaining vital radicular pulp tissue surface is treated with a long-term clinically-successful medicament.  Indications — When caries removal results in pulp exposure in a primary tooth with a normal pulp or reversible pulpitis or after a traumatic pulp exposure. — The coronal tissue is amputated, and the remaining radicular tissue is judged to be vital without suppuration, purulence, necrosis, or excessive hemorrhage that cannot be controlled by a damp cotton pellet after several minutes. — At least two-thirds remaining root length. — No radiographic signs of infection or pathologic resorption. — Restorability.  Contraindications — Swelling (of pulpal origin). — Fistula. — Pathologic mobility. — Pathologic external root resorption. — Internal root resorption. — Periapical or interradicular radiolucency. — Pulp calcification. — Excessive bleeding from the amputated pulp. — Other signs such as a history of spontaneous pain or tenderness to percussion or palpation.  Objectives — The radicular pulp should remain asymptomatic without adverse clinical signs or symptoms such as sensitivity, pain, or swelling. — There should be no postoperative radiographic evidence of pathologic external root resorption. — Internal root resorption may be self-limiting and stable. The clinician should monitor the internal resorption, removing the affected tooth if perforation causes loss of supportive bone and/or clinical signs of infection and inflammation. — There should be no harm to the succedaneous tooth.  The Ideal Dressing Material — The ideal dressing material for the radicular pulp should : — Be bactericidal. — Be harmless to the pulp and the surrounding structures. — Promote healing of the radicular pulp. — Not interfere with the physiologic process of root resorption.  The materials — Formacresol (Buckley’s solution). — Ferric sulfate. — MTA (Mineral trioxide aggregate). — Ca(OH)2. — Sodium hypochlorite. — Electrosurgery. — Laser  Formacresol — Formacresol has been a popular pulpotomy medicament in the primary teeth for the last 70 years, since its introduction by Sweet in 1932. — The success rate is reported to be 70-98%.  Formacresol — The most commonly used pulp dressing material is formacresol (Buckley’s solution): 19% formaldehyde, 35% cresol in a vehicle of 15% glycerin and water. — Formacresol concentration à22.6% or one-fifth dilution (71.7%).  Histologic Effects After Formacresol Application — Formacresol prevents tissue autolysis by bonding to protein; Berger (1972) described the histological view of pulp tissue following FC pulpotomy: — Fixation of the pulp occurred in coronal third of the root, — The middle third presented loss of cellular integrity. — The apical third showed granulation tissue growth.  Some Concerns — Although concerns have been raised about safety (i.e. mutagenicity, carcinogenicity and immune sensitization potential) of formacresol application in human, no correlation between formacresol pulpotomies and cancer has ever been demonstrated.  Technique — Profound anesthesia for tooth and tissue.  Technique — Isolate the tooth to be treated with a rubber dam.  Technique — All remaining dental caries should be removed, as well as the overhanging enamel, to provide good access to coronal pulp and determine site of pulp exposure.  Technique — The entire roof of the pulp chamber should be removed. — No overhanging dentin from the roof of the pulp chamber or pulp horns should remain.  Technique — A large round bur, or sharp discoid spoon excavator, large enough to extend across the entrance of the individual root canals, may be used to amputate the coronal pulp at its entrance into the canals. — The pulp stumps should be cleanly excised with no tags of tissue extending across the floor of the pulp chamber.  Technique — The pulp chamber should then be irrigated with a light flow of water from the water syringe and evacuated. — Cotton pellets moistened with water should be placed in the pulp chamber and allowed to remain over the pulp stumps until a clot forms.  Technique — The pulp chamber is dried with sterile cotton pellets. — Next, a pellet of cotton moistened with formocresol and blotted on sterile gauze to remove the excess is placed in contact with the pulp stumps and is allowed to remain for 5 minutes.  Technique — The pellets are then removed, and the pulp chamber is dried with new pellets. — A thick paste of hard-setting zinc oxide eugenol (IRM)is prepared and placed over the pulp stumps.  Technique — The tooth is then restored with a stainless steel crown  Pulpotomy — The most effective long-term restoration has been shown to be a stainless steel crown. — If there is sufficient supporting enamel remaining, amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less. Potential Substitutes for Formacresol  Glutaraldehyde (2%) Advantages: 1. Superior fixation by cross-linkage. 2. Diffusibility is limited. 3. Excellent antimicrobial agent. 4. Causes less necrosis of pulpal tissue. 5. Causes less dystrophic calcification in pulp canals. 6. Does not stimulate a significant immune response. 7. Minimal systemic distribution. — But the relative high failure rate in this long-term follow-up indicated that clinicians should be cautious before extensively using GA as a pulpotomy agent.  Ferric Sulfate (15%) — It is a coagulative and hemostatic agent which is used for pulpotomies of primary teeth. — This material when in contact with tissue forms a ferric ion-protein complex that mechanically occludes capillaries at the pulpal amputation site. — The reported clinical and radiographic success rates reported in several studies were 88-100% and 74-97%, respectively. — A higher percentage of internal resorption is the major failure.  Formacresol or Ferric Sulfate?? — Pulpotomies performed with either formacresol or ferric sulfate in primary molars have similar clinical and radiographic success. — Furthermore, ferric sulfate is inexpensive solution and no concerns about toxicity and carcinogenicity have been recorded in dental literature. Therefore, ferric sulfate may be recommended as a suitable substitute for formacresol.  MTA (Mineral Trioxide Aggregate) — As a member of hydraulic calcium silicate cements MTA was introduced by Lee et al. (1993) and patented in 1995 by Torabinejad and White. — MTA consists of tricalcium silicate, bismuth oxide, tetra calcium alumina-ferrite and calcium-sulphate dehydrate. — When MTA is mixed with water, a colloid gel with a pH of 12.5 similar to that of Ca(OH)2 is formed. — When first commercialized, it had a gray coloration but in 2002 a new formula was created, the white MTA, to improve on the tooth discoloration property exhibited by gray MTA  MTA (Mineral Trioxide Aggregate) — The major benefits: — Biocompatibility. — Bactericidal. — Sealing ability. — Induction of cementogenesis. — Dentinogenesis. — Osteogenesis.  MTA (Mineral Trioxide Aggregate) — All of the benefits of MTA make it the preferred choice for direct pulp capping, apexogenesis and apexification in immature permanent teeth. — In primary teeth, MTA is predominantly used for direct pulp capping and pulpotomy procedures. — The overall success rates for MTA as a pulpotomy medicament in primary teeth range from 94 to 100 %. — It seems that the efficacy of MTA is superior to formacresol which is the gold standard in pulpotomy of primary teeth.  Ledermix ® Ledermix ® (a mix of calcium hydroxide plus prednisolone): — Though many such combinations have been tried, they have been shown to preserve chronic inflammation and reduce reparative dentin formation.  Sodium Hypochlorite — NaOCl is the most widely used irrigating solution in endodontics due to its antimicrobial activity, tissue-dissolving property, detergent action, homeostasis and the ability to neutralize toxic products. — Clinical and radiographic success rate of NaOCl pulpotomy were reported to be 100 and 76% respectively. — However, only few clinical trials evaluated the efficacy of NaOCl as a medicament in pulpotomy of primary teeth. Radical Pulp Treatment Procedures  Pulpectomy and Root Filling Indications: — The pulpectomy procedure is indicated in teeth that show evidence of chronic inflammation or necrosis in the radicular pulp.  Pulpectomy and Root Filling Contraindications: — Teeth with gross loss of root structure. — Advanced internal or external resorption. — Periapical infection involving the crypt of the succedaneous tooth.  Pulpectomy and Root Filling — The goal à to maintain primary teeth that would otherwise be lost.  Pulpectomy and Root Filling — Some clinicians disagree about the utility of pulpectomy procedures in primary teeth. Why??? — Difficulty in the preparation of primary root canals that have complex and variable morphologic features. — The uncertainty about the effects of instrumentation, medication, and filling materials on developing succedaneous teeth. — The behavior management problems. — These problems not withstanding, the success of pulpectomies in primary teeth has led most pediatric dentists to prefer them to the alternative of extractions and space maintenance.  Root Filling Materials The ideal root canal filling material for primary teeth: — Should resorb at a rate similar to that of the primary root. — Be harmless to the periapical tissues and to the permanent tooth germ. — Resorb readily if pressed beyond the apex. — Be antiseptic. — Fill the root canals easily. — Adhere to their walls. — Not shrink. — Be easily removed if necessary. — Be radiopaque, — Not discolor the tooth. — No material currently available meets all these criteria.  Root Filling Materials The filling materials most commonly used for primary pulp canals are: — ZOE paste. — Iodoform-based paste. — Calcium hydroxide. — Calcium hydroxide and iodoform in combination.  Zinc Oxide-Eugenol Paste — ZOE à the most commonly used filling material for prim teeth (United States). — Success rate with this material varied between 65% and 100%, with an average of 83%, and no significant difference could be observed when ZOE was compared with other calcium hydroxide and/or iodoform pastes. — Disadv of ZOE: — Underfillingà the endodontic pressure syringe to overcome the problem of underfilling (by Camp). — It may remain in the alveolar bone for a long time, although it is not certain that this has a clinically significant effect.  lodoform-Based Pastes — Several authors have reported the use of Kri paste which is a mixture of: — Iodoform. — Camphor. — Parachlorophenol. — Menthol. — Adv: — Resorbs rapidly and has no undesirable effects on succedaneous teeth when used as a pulp canal medicament in abscessed primary teeth. — When extruded into periapical tissues à rapidly replaced with normal tissue. Calcium hydroxide & Iodoform in Combination — A paste developed by Maisto has been used clinically for many years, with good results reported. — This paste has the same components as the Kri paste with the addition of zinc oxide, thymol, lanolin, and calcium hydroxide.  Calcium Hydroxide Paste — Although not very popular, calcium hydroxide in a ready-mixed paste delivered via syringe or in a combination of two pastes (base and catalyst), has also been used as root canal filling in primary teeth. — Clinical studies report an average success rate of 88%.  Calcium Hydroxide Paste — When iodoform and silicone oil were added to calcium hydroxide àa new paste: — Vitapex (Neo Dental Chemical Products, Tokyo). — Diapex (DiaDent Group International, Burnaby, B.C., Canada) as commercialized in North America, has been clinically and histologically investigated. — Adv: — Easy to apply. — Resorbs at a slightly faster rate than that of the roots (complete resorption of the excess paste is expected within 2 to 8 weeks). — No toxic effects on the permanent successor. — Radiopaque. — For these reasons, Machidal" considers the calcium hydroxide—iodoform mixture to be a nearly ideal primary tooth filling material.  Calcium Hydroxide Paste — Another preparation with similar composition is available in the United States under the trade name Endoflas. — The results of root canal treatments using Endoflas in a student's clinic reported similar results to those observed with Kri paste.  Lesion Sterilization Technique — The goals à to sterilize the lesion and avoid use of mechanical instrumentation in the canal. — In an effort to eliminate bacteria and promote disinfection of oral infections, a mixture of three antibacterial drugs (metronidazole, ciprofloxacin, and minocycline) in a ratio of 1 : 3 : 3 with propylene glycol has been suggested. — A high success rate has been reported treating carious lesions with or without pulpal and periapical involvement. — Concerns about spreading resistant bacteria have been raised.  Pulpectomy Technique Pulpectomy procedure should be performed as follows: — Preparation of an access opening (like that in pulpotomy), but with more flared walls facilitate access of the canal openings for broaches and files. — Each canal orifice of the roots should be located and a properly sized barbed broach selected. The broach is used gently to remove as much organic material as possible from each canal.  Pulpectomy Technique — Endodontic files are selected and adjusted to stop 1 or 2 mm short of the radiographic apex of each canal as determined by a radiograph. àThis is an arbitrary length but is intended to minimize the chance of apical overinstrumentation that may cause periapical damage. à The removal of organic debris is the main purpose for filing.  Pulpectomy Technique — The canal should be periodically irrigated to aid in removing debrisà a sodium hypochlorite and/or a chlorhexidine solution should be used to ensure optimal decontamination of the canal(s). àHowever, because of the possibility that sodium hypochlorite solution could be forced into the periapical tissues, it should be used very carefully and with the minimum irrigation pressure. — Sterile saline rinses should follow each chemical irrigant. — The canal is dried with appropriately sized paper points.  Pulpectomy Technique When a ZOE mixture is used: — For large canals, as in prim ant teeth, àA thin mixture can be used to coat the walls of the canal, followed by a thick mixture that can be manually condensed into the remainder of the lumen. àAn endodontic plugger or a small amalgam condenser is useful for compacting the paste at the level of the canal orifice.  Pulpectomy Technique When a ZOE mixture is used: — For small canals, as in prim molars, à Commercial pressure syringes have been developed for this purpose. à An alternative technique is to use a disposable tuberculin syringe or a local anesthetic syringe, in which the anesthetic capsule is emptied, after which the canal is dried and filled with ZOE paste. — Figure 2: Proeoperative and postoperative radiographs of tooth filled with zinc oxide eugenol: (a) Preoperative ZnOE, (b) Immediate postoperative IOPA, (c) Postoperative IOPA at 3 months, (d) Postoperative IOPA at 6 months and (e) Postoperative IOPA at 9 months  Pulpectomy Technique When a resorbable paste such as Kri, Maisto, or Endoflas is used: — a Lentulo Spiral mounted on a low-speed turbine can be used, facilitating introduction of the material into the canal. — When the canal is completely filled (observed by difficulty in introducing more paste), the material is compressed with a cotton pellet. — Excessive extruded material is rapidly resorbed. — Figure 1: Proeoperative and postoperative radiographs of tooth filled with endoflas: (a) Preoperative IOPA endoflas, (b) Immediate postoperative IOPA endoflas, (c) Postoperative IOPA at 3 months, (d) Postoperative IOPA at 6 months, and (e) Postoperative IOPA at 9 months  Pulpectomy Technique When a resorbable paste such as Vitapex (Diapex) is used: — It is packed in a very convenient and sterile syringe, and the paste is injected into the canal with disposable plastic needles. — This technique is particularly easy to use for primary incisors but less practical for narrow canals of primary molars.'  Postoperative Radiography — Regardless of the root filling material used, an immediate postoperative periapical radiograph should be taken with two purposes: — Evaluate the quality of the fill and consider prescribing antibiotics in cases of excessive overfill. — Provide a baseline for assessing and comparing the success of the root canal treatment in follow-up visits.  Criteria for Radiographic Success — Root treatments (considered successful)à when no pathologic resorption associated with bone rarefaction was present. — Payne and associates claim that most clinicians are prepared to accept pulp- treated primary teeth that have a limited degree of radiolucency or pathologic root resorption (Po), in the absence of clinical signs and symptoms. — This is contingent on the assurance that the parent will contact the dentist if there is an acute problem and the patient will return for recall in 6 months. — Regardless of the pulp treatment performed, treatment success relies on a leakage free restoration.  Thank You Any Question ??