materials used in pediatric endodontics
TRANSCRIPT
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Guided By:Dr. Binita Srivastava
Dr. Archana AggarwalDr. Nidhi GuptaDr. Rashi SinghDr. Neeti
Presented By:Dr. Parul Verma
Final yr PG Student
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1. Introduction
2. History
3. Pulp Capping Agents- Calcium Hydroxide
Isobutyl Cyanoacrylate
Corticosteroids and antibiotics
Collagen fibers
4-Meta adhesive
Direct bondingDenatured albumin
Mineral trioxide aggregate(MTA)
Laser
BMP 2
CONTENTS:
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4. Pulpotomy Agents- Formocresol Glutaraldehyde
Calcium hydroxide
ZnO eugenol
Ferric Sulphate
Bone Morphogenic proteins & Osteogenic proteins
Devitalizing paraformaldehyde paste
Beechwood creosote
Antibiotic paste
Enriched collagen solution
Collagen calcium phosphate gel
Dimethyl suberidement
Tetrandrine
Freeze Dried bone Tricalcium phosphate
Chondroitin sulphate
Denatured albumin
Sodium hyaluronate
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5. Properties of an ideal root canal filling material
6. Pulpectomy Agents- Zinc oxide eugenolIodoform pastes- KRI , Walkhoff, Maisto
Endoflas
Calcium hydroxideVitapex
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INTRODUCTION
Primary objective of Pulp treatment of an affected tooth is to
maintain the integrity & health of oral tissue.
AAPD 1991, it is possible to stabilize pulp autolysis or
eliminate the pulp entirely without significantly compromising
the function of the tooth.
Aimto treat reversible pulpal injures in both primary &
permanent teeth, maintaining pulp vitality & function.
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HISTORY
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1700S & Early 1800sMetal Foils
Mid 1800s to Early 1900sAsbestos fibers, cork,
beewax, pulverized glass, Calcium compounds &
other based on Eugenol
19th centuryhuman pulp had very little healing
power.
1874Nitzel : Tricresol- formalin tanning agent
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1886Adolph WilzelMetal (Gold) Foil
1885LeptowskiFormalin
1898GysiParaformaldehyde
Triopaste
1904BuckleyFormocresol or Tricresol Formalin
1908Solid Formaldehyde
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Boennecken40% Formalin, Thymol, Cocaine
1930HermannCalcium mixture Calxyl
1938Zender & TeuscherCalcium Hydroxide
1955Teuscher & Nybrong
1975S Gravenmade - Gluteraldehyde
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1978Ranly & LazzariGulteraldehyde (Pulpotomy agent)
1979Wright & MidmerFormocresol causes chronicinflammation
1983Reumping et al - Electrosurgery for Pulpotomy
1985Shoji et alCarbon dioxide laser in pulpotomy
1991NakashimaBone Morphogenic Proteins
1993Rutherford et alOsteogenic Proteins
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INDIRECT PULP CAPPING:
It is defined as the application of amedicament over a thin layer of remaining
carious dentin, after deep excavation, with no
exposure of the pulp.
The treatment objective is to avoid pulp
exposure by stimulating the pulp to generate
reparative dentin beneath the carious lesion.
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This results in the arrest of caries
progression and preservation of the vitality ofnon exposed pulp.
Next sitting involves re-entry after a 6 to 8-
week interval to remove any remaining carious
dentin and place the final restoration.
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A) Medicament is placed against remaining caries.
B) Lasting temporary restoration.
Following repair, both materials are removed along with softenedcaries, and final restorations are placed.
Ingle; Pediatric Endodontics
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DIRECT PULP CAPPING:
Direct pulp capping involves the placement of abiocompatible agent on healthy pulp tissue that
has been inadvertently exposed from caries
excavation or traumatic injury. The treatment objective is to seal the pulp
against bacterial leakage, encourage the pulp to
wall off the exposure site by initiating a dentinbridge, and maintain the vitality of the
underlying pulp tissue regions.
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A) Capping material covers pulp exposure and the floor of the cavity.
B) Protective base
C) Restoration.
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PULP CAPPING AGENTS:
1. Zinc Oxide Eugenol- Before calcium hydroxide
came into common use, zinc-oxide eugenol was
used more often than any other pulp capping
agent.
2. Calcium Hydroxide- Herman (1930) introduced
calcium hydroxide for pulp capping. In 1938,
Teuscher and Zander introduced calcium
hydroxide in the united states.
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When calcium hydroxide is applied directly to
pulp tissue reparative dentin bridge formation
occurs at the junction of necrotic tissue and
vital inflamed tissue.
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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
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3. Isobutyl Cyanoacrylate- Introduced by
Berkman in 1971. It has been reported to be an
excellent pulp capping agent because of its
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
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4. 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.
5. Collagen Fibers- Influences mineralization and are
less irritant than calcium hydroxide with dentin bridge
formation in 8 weeks.
6. 4-META adhesive- It can soak into the pulp,
polymerize there and form a hybrid layer with the pulp
providing adequate sealing. 20
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7. 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.
8. Denatured Albumin- This protein has calcium binding
properties. If applied over the exposed pulp it becomes
a matrix for calcification.
9. Laser- Introduced by Andreas Meritz in 1998. He
evaluated the effect of laser on DPC and reported a
success rate of 89%. 21
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10. Mineral Trioxide Aggregate (MTA)- Torabinejad
described the physical and chemical properties of MTA
in 1995. It is ash colored powder made up of fine
hydrophilic particles of tricalcium aluminate, tricalcium
silicate, silicate oxide, tricalcium oxide and bismuth
oxide.
Properties:
1. Biocompatible and sealing ability better than that of
amalgam and ZOE.
2. Initial ph is 10.2 and set ph is 12.5
3. Setting time of cement is 4 hours. 22
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4. Compressive strength is 70 MPA, which is comparable
with that of IRM.
5. Presents minimal inflammation if extended beyond
the apex.
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 23
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4. Forms hydroxyapatite on the MTA surface and
provides a biologic seal.11. Bone morphogenic protein- Discovered by Urist in
1965. It has inductive properties and forms both bone
and dentin.
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PULPOTOMY
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Pulpotomy is defined as amputation of vital pulp from the coronalchamber followed by placement of a medicament over the
radicular pulp stumps to stimulate repair, fixation or mummificationof the remaining vital radicular pulp. (Braham & Morris 1985)
Removalofthe coronal portion of the pulp & the treatment of the
remaining radicular pulp in an attempt to maintain the tooth & its
supporting structure in a state of health. (Heillig 1984)
Procedures involving removal of vital, partially inflamed coronalpulp tissue & placing a dressing over the amputed pulp stumps &
placing the final restoration. (Kennedy 1986)
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Procedure in which the entire coronal pulp is removed, with the
aim of removing all the infected pulp tissue, the radicular pulp is
then treated in different ways, according to technique employed.
(Andlaw & Rock 1993)
Complete removal of the coronal portion of dental pulp, followed
by placement of a suitable dressing or medicament that will
promote healing & preserve the vitality of the tooth. (Finn)
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MEDICAMENTS
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Formocresol
Glutaraldehyde
Calcium hydroxide
ZnO eugenol
Ferric Sulphate
Bone Morphogenic proteins & Osteogenic proteins
Devitalizing paraformaldehyde paste
Beechwood creosote
Antibiotic paste
Enriched collagen solution
Collagen calcium phosphate gel
Tetrandrine
Freeze Dried bone
Tricalcium phosphate
Chondroitin sulphate
Denatured albumin
Sodium hyaluronate
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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 ofits 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.
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FORMOCRESOL Introduced by Buckleys 1904
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Buckleys FormocresolFormalin (37%) : 19%
Tricresol : 35%Glycerin : 15%
Water
Achieve 1:5 concentration of original Buckleys formocresolDilute 3 parts glycerine with 1 part of distilled sterile water.
Add 1 part formocresol to 4 part diluent
90ml glycerine
30ml water Loos et al
30ml formocresol
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Emmerson : determined significant formocresol action
within 1st five minutes.
Braham & Morris : Linear calcification may have adverseinfluence 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.
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3 distinct Zones:
Acidophilic zone of fixation
Zone of atrophy
Zone of inflammatory cells
No reparative dentin formation.
Berger - histologic findings:
3 weeks postoperative:
1. Nuclei, cytoplasm & intercellular ground substancemost
Coronal region, all dark stain
2. Odontoblast & other cellular elements well outlined &
distended blood vessels with well preserved erythrocytes
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Middle 3rd:
1. Stain of tissue decreased
2. Cellular details less distinct
Apical 3rd:
1. Absence of cellular details
2. Blood vessels containing decomposed erythrocytes which
appeared to lose structural integrity
7weeks post operative:
1. Dark stained coronal zone, light stained middle zone & Cellular
apical zone
2. CT originating from periodontal ligament
3. Richly vascular & contained lymphocytes, PMN, macrophages,
proliferating fibroblasts & granulation tissue
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Connective tissue undergoing castration due to decreased
number of mature fibroblasts & increase of fibrous
intracellular elements.
Coagulation necrosis in middle 3rd, delineated apically by a
zone of necrotic tissue
Braham & Morris - these zones are obvious in1 month &
established in 3months although pulpal fixation did not extend to
the apex
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T i it
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Toxicity Post operative systemic transport
Possible effects on the enamel of succedaneous teeth
Reversible fixation leading to autoantibody formation
Mutagenicity & Carcinogenicity
Destruction of cellular integrity due to cresol factor
Irreversible connective tissue changes
Irritation & necrosis
Leukoplakia & lesions resembling carcinoma in situ
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Local Toxicity
PruhsAll permanent teeth showed enamel defectsbecause:
Formocresol which damages the permanent tooth germs
Inflammation which was in the primary tooth which causes
the defects in the permanent tooth germs.
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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.
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Mutagenicity & Carcinogenicity
Most common type of DNA damageClastogenic lesions,
micronuclei & chromosomal aberration & deletions.
Ribeiro et al not produce detectable DNA damage & not
considered genotoxic.
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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
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Internal resorption of the root adjacent to the area where the
formocresol was applied.
Radiolucency may develop in the bifurcation or trifurcationarea.
Furcal lesions may contain granulomatous tissue having the
potential for cyst formation.
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Area showing root resorption following formocresol pulpotomy.
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GLUTERALDEHYDE
Known for its high degree of cross linking & limited
diffusability.
By S Gravenmade
Denkertminimum diffusion through apices.
Martin J. Davis, Myers & M.D.Switkes- more active in
fixing surface tissue & more rapidly limited depth ofpenetration through tissues.
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Martin J. Davis et al : Glutaraldehyde & Formocresol - does not
perfuse through the apex & shows no systemic distribution & other
extra dental phenomena.
Franklin Gracia Godoy et al : ZnO as vehicle for Glutaraldehyde
2% glutaraldehyde incorporated in ZnO not effective as when
applied for 5min.
Hue- Wen- Jeng et al : compared cytotoxicity & found human pulp
fibroblastformaldehyde is more toxic & 2.5% glutaraldehyde is
15-20times less toxic
Hermandez Pereyra et al : 2% glutaraldehyde & FormocresolR/G
success of 80% & 90% with glutaraldehyde after 6months & 2yrs.
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Prakash C. et al : formocresol showed 90% success whereas
Glutaraldehyde 100% success. Glutaraldehyde better fixative & less
toxic.
Histology
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Histology
Martin J. Davis, Myers & Switkase -5% buffered
glutaraldehyde, pH= 8.5After 1week:
Coronal third: radicular tissue fixed & found to be non vital. Cells
compressed & darkly stained
Middle 1/3rd: radicular tissue vital with good cellular details & moderate
inflammation
Apical 3rd: vital with scattered inflammatory cells.
After 4 weeks:
Coronal 3rd: same
Middle portion: clear cellular details, unchanged degree of inflammation.
Limited dystrophic calcification apparent on lateral wall of canal.
Apical 3rd: apparently vital with occasionally observed inflammatory cells.
Aft 8 k
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After 8weeks:
Coronal 3rdno change
Middle 3rd: dystrophic calcification apparent
Apical 3rd: vital & demonstrated good cellular details with scattered inflammatory
cells.
Appearance of multinucleated giant cells & fibroblasts. Indicative of replacement
repair
Deep red cellular zone adjacent to amputation surface & few lymphocytes &
plasma cells. Blood vessels dilated. Remaining pulp free of inflammatory cells &
root canal lined with layer of reparative dentin.
After 3months:
Coronal region: stained redPulp tissue: no layering or signs of inflammation. Macrophages visible in &
adjacent to red zone.
No pathosis noted.
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Kopel concluded:
2% glutaraldehyde accepted as dressing medicament for maintaining
vitality of remaining pulp.
Histologically, pulp tissue in root does not resemble pulp tissue subjectedto formocresol
Initial zone of fixation adjacent to dressing does not proceed apically.
The tissue which adjoins fixed zone has cellular details & is vital.
Fixed zone replaced through macrophagic action with dense collagenoustissue.
Established biochemical properties & effect on vital pulpuse of 2%
glutaraldehyde as pulpotomy agent.
Anna B. Fuks - contraindicate use of Glutaraldehyde
Kopel & Gracia Godoyrecommend use of 2% Gluteraldehyde for 1 or
3min
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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.
Glutaraldehyde Vs Formocresol
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Glutaraldehyde Vs Formocresol
Advantages of Glutaraldehyde over Formocresol:
Is better bactericidal
Not diffuse apically or laterally from the canals Not known to be cariogenic
Not induce toxic effect
Less systemic distribution immediately after application
Fixes tissue instantly
Not known to be caustic
Better fixation at lower conc.
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FERRIC SULFATE
15.5% solutionFei et al 1991
Used: coagulative & haemostatic retraction agent for crown & bridgeimpression & slightly acidic
MOA- agglutination of blood proteins results from reaction of blood with
both ferric & sulfate ions.
Schroedercontrolling hemorrhage might minimize chance ofinflammation & internal resorption clot formation.
Ranlymetal protein clot may act as barrier to irritative components ofsub-base & function in passive manner.
Landaw & Johnson - 1st to study pulpal response from ferric sulfate inmonkey teeth.
Ferric Sulfate Vs Formocresol
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Ferric Sulfate Vs FormocresolAuthor 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 & Gencay2000
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
ZINC OXIDE EUGENOL (ZOE)
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ZINC OXIDE EUGENOL (ZOE)
Considered as therapeutic or obtundent.
Used as non toxicve control but, applied directly todental pulp, nerve tissue , this medicamenttoxic
Flagg 1875clove oil + zinc oxide plastic mass
Used as: base, temporary dressing, endodontic root
filling paste, impression material, PD packs & asPulpotomy medicament.
Composition
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Composition
Various formulations & uses of ZOE restorative material:
Type 1: temporary cementation
Type 2: permanent cementation of restoration
Type 3: temporary filling material, thermal insulating
base
Type 4: cavity liners
Composition:
Powder Liquid
Zinc oxide: 69%
White resin: 29.3%
Zinc sterate : 1%
Zinc acetate: 0.7%
Eugenol: 85%
Olive oil: 15%
Histology
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HistologyJames E. Berger : active inflammatory reactions which varied
from simple chronic to acute suppurative pulpitis.
Boller RJ : calcific deposition associated with dentinal debris &
bridge formation.
R.L. Glass & H.A. Zander: inflammation, abscess formation &liquefaction necrosis.
24hrs after:
underlying tissue contain mass of red blood cells & PMN leukocytes
Hemorrhage mass demarcated by Zone of fibrin & inflammatory cells
2weeks after:
Degeneration of pulp & chronic inflammation extends into apicalportion of pulp lymphocytes, plasma cells & PMNs leukocytes
Failed to stimulate osteogenesis.
6 months: 1 tooth showed acute inflammation involving entire
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6 months: 1 toothshowed acute inflammation involving entire
pulp
12 months: microscopic appearance of acute inflammation
18months: all teeth showed chronically inflamed pulp & absenceof fibrous tissue.
Doyle et al 92%histologic success, 92% R/G & 100% clinical
Success.
Ranly : lowclinical success rate (80 to 82%)
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Zinc Oxide preparationsVarious preparations used as pulpotomy medicament:
Zinc oxide/Eugenol & Paraformaldehyde
Zinc oxide/Liquid Paraffin & Paraformaldehyde
Zinc oxide/ Liquid paraffin
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CALCIUM HYDROXIDE
Foreman & Barnes
Hermann & Zander - introduced for Pulpotomy & foundsuccess rate of 70%
Granath :Apexification following trauma
Kaiser & Frank : use for apexification
Pure form- high pH & dental use ability to stimulate
mineralization & antibacterial properties.
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MECHANISM OF ACTION:
Antimicrobial activity of calcium hydroxide isrelated 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:
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Damage to the bacterial cytoplasmic
membrane:
Hydroxyl ions induce lipid oxidation destruction
of phospholipids.
Hydroxyl ions generates free lipid radical.
This free radical reacts with oxygen formation ofa lipidic peroxidase radical.
Thus, peroxidases act as free radicals resulting in
extensive tissue damage.
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Proteindenaturation:
The alkalinization provided by calcium hydroxide
breakdown of the ionic bonds that maintain the
tertiary structures of proteins.
Loss of biological activity of the enzyme anddisruption of the cellular metabolism.
Structure may also be damaged by hydroxyl ions.
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Damage to the DNA:
Hydroxyl ions react with the bacterial DNA and
induce the splitting of the strands.
Genes are then lost. Consequently DNA
replication is inhibited and the cellular activity is
disarranged.
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Composition & Chemistry
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Composition & Chemistry
De Freitas & Rosser : cements set by acid base reaction, the
phenolic group in alkyl salicylate ester acting as acid.Once set, therapeutic activity depends upon release of calcium &
hydroxyl ion which occur if cement water soluble.
Plasticizer imparts solubility.
Milosevic - calcium hydroxide reaction with salicylate ester
chelating agent in presence of toloudine sulphonamide plasticizer.
Hydrophilic & Soluble.
Ca hydroxide powder + distilled water creamy paste with high
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Ca hydroxide powder + distilled water creamy paste with high
alkalinity
3 main products:
Pulpdent- 52.5% calcium hydroxide suspended in aqueousmethyl cellulose solution
Dycalby L.D. Caulk.
Available in 2 pastes- Base & Catalyst
Base: Titanium dioxide in glycol salicylate
Catalyst: Calcium hydroxide & ZnO in ethyl toluene sulfonamide.
Hydrex: 2 paste; non essential oilcontain calcium hydroxide,
barium sulphate, titanium dioxide & selected resin.
Hydrex- hydrophobic paraffin oil methacrylate.
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Hydrex hydrophobic paraffin oil methacrylate.
1. Relatively insoluble (Prosser )
2. Poor antibacterial properties (Fisher & Mc Cabe ; Fisher &Shortal )
3. Hydroxyline resistant to acid etching (Milosevic)
4. Linn & Mc Cabe reaction between calcium & Zn ions & a
salicylate chelating agent is accelerated by presence of
water.
Histology
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HistologyTeuscher & Zander -
Superficial layernecrotized, accompanied by acute inflammatory
changes. Demarcated by new, deeply staining zone comprisingbasophilic elements of Ca Hydroxide dressing
Proteinate zone present
New area of fibrous tissue linked to primitive type of bone.
After 4weeks:
Acute inflammation subsides new odontoblastic layer bridge of
dentin
Pulp tissue beneath calcific bridgevital & free of inflammatory cells.
Calcium hydroxide appears to stimulate resorption.
Andersen External root resorption of avulsed teeth when
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p
repositioned with cal hydroxide
Law 49% success in 1yr
Doyle et alhistological success of 50% & R/G 64% & clinicalsuccess 71%
Schroder67% clinical success after 1yr; 38-59% after 2yr in 33
pulpotomized primary teeth.
Hellig et al rapid decrease in hemorrhage & better R/G.
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.
Via69% failure (internal resorption)
L 54% f il
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Law54% failure
Magunsson80% failure
Comparing CALCIUM HYDROXIDE with FORMOCRESOL:
Author Clinical & R/Gsuccess of Ca
hydroxide
Clinical & R/Gsuccess of
Formocresol
Duration
Waterhouse et al 77% 84% 22mths
Huth et al 87% 96% 24mths
Markovic et al 82% & 76% 91% & 85% 18mths
BONE MORPHOGENIC PROTEINS
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BONE MORPHOGENIC PROTEINS
& OSTEOGENIC PROTEINS
Proteins evaluated from osteogenic potential
Pulp responsesdetermined in dogs & primary teeth
Role in healing bone & pulp
BMP 4epithelial/ mesenchymal interaction during early
tooth development (Ranly DM)
BMP Function
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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
FREEZE DRIED BONE
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FREEZE DRIED BONE Used in Orthopedic & Oral surgery.
Pulp & dentinMesodermal tissuesFreeze dried boneserve as inducer of calcific barrier at amputation site.
Mc Lean & Urist 1968
Interaction of mesodermal cells & mesodermal derivativesduring bone resorption that induce differenation.
Alternative for Formocresol
Fadavi et al 1996
COLLAGEN
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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 alused CollagenCalcium Phosphate gel
paste.
TETRANDRINE
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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.
FERACRYLUM
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FERACRYLUM Incomplete iron salt of Polyacrylic acid0.05-0.5% iron
MOA: binds with plasma proteins & form clot
Properties:
Bacteriocidal property
Devoid of Systemic toxicity
Used for various medical surgeries
Neetu T. Prabhu & A.K. Munshi : clinical success 100%
Histological Examination after 1month: 4 zones-
Eosinophillic zone Zone of Ghost cells
Inflammatory zone
Normal radicular pulpal tissue
CALCIUM PHOSPHATE CEMENT
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CALCIUM PHOSPHATE CEMENT
Clinical applicationOrthopedic & Dentistry
Composition:
Powdercalcium & Phosphorous ingredients
Liquidaqueous solution of phosphates
Cement undergoesthermal setting & gets
converted into hydroxyapatite.
TETRACALCIUM PHOSPHATE
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TETRACALCIUM PHOSPHATE
CEMENT (4CP)
Calcium phosphate ceramics tricalcium phosphate
- bone substitute
tricalcium phosphate
- Dental cement
Yoshimine Y 1993: 4CP effective as bone cement.
Yoshimine Y 1995: 4CP as a Direct pulp capping agent. No finding of necrosis
Biocompatible
MINERAL TRIOXIDE AGGREGATE
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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.
C iti Ph i l & Ch i l
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Composition, Physical & ChemicalProperties
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 : Liquid3:1
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Hydration: MTA forms Colloidal gel solidifies to hard tissue3 4h
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3-4hrs.
Initial pH10.2 which rises to 12.5 three hrs after mixing.
Compressive Strength: increase in presence of moisture for upto21days.
Microhardness & hydration behavior adversely affected
Upto 2002 : GREY colored powder MTA.(GMTA)
WHITE MTA (WMTA) : Pro Root MTA (Dentsply Endo. Tulsa)
Mineralization:
Induce hard tissue formation in pulpal tissue
Histologic evaluation: stimulate Reparative dentin formation withthick dentinal bridging, minimal inflammation & normal hypermia.
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WMTAfound to have 54.9% less Al2O3, 56.5% less MgO &
90.8% less FeO.
FeO cause color change
WMTA smaller particle size.
WMTA : is significantly less soluble, exhibit greater hardness
& more radiopaque.
MTA as Pulpotomy dressing
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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
Farsi N : non failure with WMTA whereas 13% radiographic failure &2% clinical failure with formocresol- 24mths
Holan et al : 83% success- formocresol & 97% with MTA- 74mths
Nark & Hegde : 100% success with MTA in 6mths
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Maroto M: GMTA 100% clinical success & 50% radiographic success
WMTAradiographically 69% pulp canal signs of stenosis
11.5% - dentin bridge & 1 canal exhibited early signs ofinternal resorption
No statistical significance in rate of stenosis, but GMTA showed significant
more dentine bridge.
Pinto LM : 2 failure with MTA & 6 failure with Calcium hydroxide in 12mths.
Barreshi Nusairk: after 24mths 79% - +ve results.
64% had hard tissue bridge formation while 7 teeth displayed R/G signs ofcontinued root development.
Chacko V : WMTA induced more homogenous & continued dentin bridge with
less pulpal inflammation than Calcium hydroxide.
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Ideal Requirements of Root filling
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q gMaterials-
The material should resorb as the primary tooth root
resorbs. Not irritate the periapical tissues nor coagulate any
organic remnants in the canal. Have a stable disinfecting power. Any surplus material passed beyond the apex should
be resorbed easily. Inserted easily into the root canal and also removed
easily if necessary. Not be soluble in water. Not discolor the tooth.
Radio opaque. Harmless to the adjacent tooth germ. Adhere to the walls of the canal & should not shrink Not set as a hard mass, which could deflect erupting
successor
(Catagnola 1952, Rifkin 1980, Woods 1984)
Zinc Oxide Eugenol ( ZOE)
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Zinc Oxide Eugenol ( ZOE)
To fill root canals of primary teeth was first described bySweet 1930
Roths Sealer
Powder
Zinc oxide reagent- 42 parts
Stabelite resin 27 parts Bismuth subcarbonate 15 parts
Barium sulphate 15 parts
Sodium borate, anhydrous 1part
Liquid
Eugenol
Properties
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Properties
Extended working time- but set faster in mouth due toincreased temperature & humidity.
Good sealing potential because of small volumetric changes on
setting
Eg Tubliseal, Wachs Cement, Nogenol
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Gould
First proposed single visit pulpectomy
39 molars were filled with ZOE after a follow up of 16 months
35 out of 39 were successful.
E i & M b l
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Erausquin & Muruzabal
Used ZOE in 141 rats followed from 1-90 days
ZOE irritated the periapical tissues and caused necrosis of
bone & cementum.
Extruded ZOE developed fibrous capsule that prevented
resorption
Coll
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Coll
Retained ZOE after loss of pulpectomized tooth
27.3% after a mean of 40.2 months after loss of treated tooth
Retained
Short filled ( 1mm or more short of apex) retained ZOE less
often than beyond fills
Size of particles of most retained ZOE filler decreased over
time
Antibacterial Activity
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Antibacterial Activity
ZOE could not inhibit Echerichia coli, S. aureus,
Streptococcus viridans
Inhibited- S.aureus & S.viridans
Inclusion of zinc acetate allowed to inhibit all three
Cox et al
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Iodoform Pastes-
Rifkin 1980, 1982.
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KRI
Walkhoff 1928Parachlorophenol, Camphor, Menthol Iodoform Paste
2.025%- Parachlorophenol
4.86%- Camphor
1.215%- Menthol 80.8%- Iodoform
Rifkin - It meets all criteria required from an ideal root canalfilling material
Advantages
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Advantages
Disinfectant to treat osteitis after extractions Remains in paste form and never sets to a hard mass.
Smooth, viscous material, can be spun in with lentulo-spiral orinjected with pressure syringe
Resorbable so if inadvertantly expressed into periapical
granulomatous tissue is rapidly removed and replaced byhealthy connective tissue ( Castagnola , Woods )
Resorbs in synchrony with roots.
Easily inserted and removed
Resorbs from apical tissues in one or two weeks.
Holan Anna Fuks -
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Holan Anna Fuks
Compared the ZOE and KRI
Success rate of both was similar if underfilled
Slightly higher when KRI flushed to the apex
Maistos Paste
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Maisto s Paste
Maisto 1967
Zinc oxide- 14g
Iodoform42g
Thymol- 2g
Chlorphenol camphor-3cc
Lanolin- 0.50g
Eliyahu Mass
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y
Maisto was successful in treating infected molars.
Iodoform containing pastes are easily resorbed from the
periradicular region.
These cause no foreign body reaction like Zinc Oxide Eugenol
Over filling and resorption of iodoform containing had no
effect on success of treatment rather had positive healing
effect.
Reddy VV, Fernandes .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Reddy%20VV%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fernandes%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fernandes%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Reddy%20VV%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus -
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Reddy VV, Fernandes .
On clinical evaluation, teeth obturated with Maisto's paste
showed 100% success. Five teeth that were overfilled with Maisto's paste showedcomplete resorption of excess material within 3 months
while the two teeth overfilled with zinc oxide-eugenol showedincomplete resorption of the excess material even after 9
months. Zinc oxide-eugenol treated cases showed only 26.7% bone
regeneration while in case of Maisto's paste, it was 93%.
Complete healing of the inter-radicular pathology was seenwith 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.
Endoflas
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Reddy%20VV%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fernandes%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fernandes%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Reddy%20VV%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus -
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Endoflas
Resorbable paste produced in South America Similar to Vitapex contains Zinc oxide and eugenol
Paste-
Tri-iodomethane , Iodine dibutilorthocresol- 40.6%
Zinc oxide- 56.5% Calcium Hydroxide1.07%
Barium sulfate 1.63%
Liquid-
Eugenol Paramonochlorophenol
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Hydrophilic material- can be used in humid canals
Firmly adheres to the surface to provide good seal
Disinfects dentinal tubules & hard to reach accessory canals
Broad spectrum antibacterial effect
It resorbs when extruded extra radicularly but does not wash
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It resorbs when extruded extra-radicularly but does not wash
out intra-radicularly.
( Fuks) Eugenol causes periapical irritation ( Erausquin)
Calcium Hydroxide
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Calcium Hydroxide
Antiseptic
Osteoinductive properties(Hendry , Stevens 1983, Sjogren ).
Gets depleted from the canals earlier than the physiological
resorption.( Pitts )
Lentulo spiral has been reported to be the most effective in
carrying calcium hydroxide paste to working length- highest
quality filling.
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Resorbs within 1-2 weeks when extruded(Ranly)
Causes no damage to permanent tooth (Reyes)
Can be removed easily
Eg. Sealapex.- 92.3% success (Sari )
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Rehman
Determined the amount of duration of diffusion of calcium ionfrom both calcium hydroxide containing root canal sealer and
an intracanal medicament
Calcium ion diffusion was more in non setting group.
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Nadkarni, Damle SG
Compared ZOE and Calcium hydroxide on 70 molars for ninemonths
94.28% success with Calcium Hydroxide.
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Chawla HS et al
Mixture of Zinc oxide powder 15 gms, Calcium hydroxidepaste ( 1cm) , and distilled water as root canal filling material
for 12 months
The material remained upto the apex till the beginning of
physiologic root resorption Material resorbed at the same rate as the teeth in one case.
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Vitapex- Kawakami 1979
Contains calcium hydroxide & Iodoform
Iodoform- 40.4%
Calcium hydroxide- 30.3%
Silicone- 22.4%
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Bone regeneration clinically & Histologically (Dominguez ,Block )
Do not set hard so retrieval is easy
Harmless to permanent tooth germs
It is radiopaque (Garcia Godoy )
Bacteriostatic
Rate of resorption faster than phsiological resorption of tooth
Resorbs without ill effects (Garcia Godoy).
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Allergic reactions to iodine in some individuals( Castognala)
Discoloration of teeth (Rotstein)
Iodoform irritating to the periapical tissue can cause cemental
necrosis( Erausquin)
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Kawakami T
Used Vitapex to find the fate of calcium hydroxide componentin root canal filling paste.
Water based pastes caused necrosis because of high alkalinity
of calcium hydroxide while silicone based paste (VITAPEX)
shows no necrotizing effect.
Comparison of zinc oxide and eugenol,and Vitapex for root canal treatment of
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pnecrotic 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
110
Evaluation of various root canal fillingmaterials in primary molar pulpectomies:
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mortazavi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mesbahi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mesbahi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mesbahi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mesbahi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mortazavi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mortazavi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mortazavi%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus -
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materials in primary molar pulpectomies:an in vivo study.
Ozalp N, Sarolu I, Snmez H.
In the ZOE group, all pulpectomies were successful.
In the Sealapex group, two pulpectomies
Calcicur group, four pulpectomies showed complete resorption
of the material in the root canal.
Vitapex group, although six pulpectomies showed resorption
of the filling material within the canals, this had no effect on
the clinical and radiographical success of the treatment.
Report of success rates in root filling in
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ozalp%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Saro%C4%9Flu%20I%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Saro%C4%9Flu%20I%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22S%C3%B6nmez%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22S%C3%B6nmez%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22S%C3%B6nmez%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22S%C3%B6nmez%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Saro%C4%9Flu%20I%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Saro%C4%9Flu%20I%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Saro%C4%9Flu%20I%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ozalp%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ozalp%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ozalp%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus -
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p gprimary molars
Invest igator Fol lowupMonths
No.of teethexamined
Fi l l ingMaterial
Success Rate%
Gould 7-26 29 ZOE 68.7
Rifkin 12 26 KRI 89.0
Coll 6-36 33 ZOE 80.5
Coll 60-82 29 ZOE 86.1
Garcia
Godoy
6-24 55 KRI 95.6
Reyes 6-24 53 KRI+FC+
Ca(OH)2
100
Barr 12-74 62 ZOE+
FC
82.3
Success of pulpectomy with zinc oxide-e genol s calci m h d o ide/iodofo m
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eugenol vs calcium hydroxide/iodoformpaste in primary molars.
Trairatvorakul 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.
Conclusion
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Trairatvorakul%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Chunlasikaiwan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Chunlasikaiwan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Chunlasikaiwan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Chunlasikaiwan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Trairatvorakul%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Trairatvorakul%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Trairatvorakul%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus -
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Conclusion
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