Nonvital Pulp Therapy on Primary Teeth

Pulpectomy in Primary Teeth

The anatomic and normal physiologic features of primary teeth can present challenges
to the clinician wishing to undertake pulpectomy procedures. However, with knowledge
of these features and how they may impact upon clinical technique, pulpectomy and
root canal obturation of primary teeth with irreversibly inflamed or necrotic pulp can be
a clinically successful option.
In brief, these features are:
Root anatomy: apical positions, lateral and accessory canals.
Root physiology: the effect of exfoliation upon root anatomy and choice of root canal
filling material.
The permanent tooth bud: its proximity to the primary root apex.

Effect of Resorption on Canal Anatomy and Apical

Foramina
In the newly completed roots of the primary teeth, the apical foramina are located near
the anatomic apices of the roots. After the deposition of additional dentin and
cementum, there are multiple apical ramifications of the pulp as it exits the root, just as
in the mature permanent tooth.
The physiologic resorption of the roots of the primary incisors and canines starts on the
lingual surfaces in the apical third because of the position of the permanent tooth bud.
In primary molars, resorption usually begins on the inner surfaces of the roots near the
interradicular septum ( Box 23-7 ).
BOX 23-7

Physiologic root resorption begins:

Soon after root-length completion.
In primary incisors and canines on the lingual aspect of the apical third of the roots.
In primary molars on the inner surfaces of the roots next to the interradicular septum.
Physiologic Root Resorption in Primary Teeth
As resorption progresses, the apical foramen may not correspond to the anatomic apex
of the root but be coronal to it. Subsequently, radiographic establishment of the root
canal length may be challenging ( Fig. 23-19 ). Resorption may extend through the roots
and into the root canals, creating additional communications with the periapical tissues
other than through the apical foramina or lateral and accessory canals. This has been
shown to occur at all levels of the root. 244 Because of these factors, use of an apex locator
is not reliable to establish canal length.

FIG. 23-19
Primary maxillary canine. A, Facial view, where apical foramen appears to be at the
apex of the root. B, Physiologic root resorption has occurred at the palatal aspect of the
root; apical foramen is positioned more coronally and will not be coincident with the
perceived radiographic apex of the tooth.

Permanent Tooth Bud

The effects of primary endodontic therapy on the developing permanent tooth bud
should be of paramount concern to the clinician. Manipulation through the root apex of
a primary tooth and overextension of root canal instruments and filling materials are to
be avoided because the permanent tooth bud lies in close proximity. If radiographic
signs of resorption are visible, canal length is usually established by measurement of the
diagnostic radiograph, ensuring the working length of endodontic instruments are 2 or
3 mm short of the radiographic apex. The use of the long-cone radiographic paralleling
technique for maximal accuracy is recommended. Hemorrhage after pulp removal may
indicate overextension into the periapical tissues.
Anesthesia is usually necessary for pulp extirpation and cleaning of the canals but may
be unnecessary when primary teeth are filled at a subsequent appointment. The
response of the patient can sometimes be used as a guide to the proximity of the apex
and as a check of the length of the canal. However, this can only be done in cooperative
patients, because the discomfort caused by placing the rubber dam clamp or by the
approach of the instrument to the apex might create disruptive behavior in some
children.
The material used to obturate root canals in primary teeth must be resorbable, so that as
the tooth resorbs it offers no resistance or deflection to the eruption of the permanent
tooth. Permanent obturating materials, such as gutta-percha, are contraindicated in
root canal therapy for primary teeth that have permanent successors.

Pulpectomy

Pulpectomy and root canal filling procedures on primary teeth have been the subject of
much controversy. Fear of damage to developing permanent tooth buds and a belief that
the tortuous root canals of primary teeth could not be adequately negotiated, cleaned,
shaped, and filled have led to the needless sacrifice of many pulpally involved primary
teeth. Much has been written regarding potential damage to the developing permanent
tooth bud from root canal fillings. The extraction of pulpally involved primary teeth and
placement of space maintainers is an alternative to pulpectomy. However, there is no
better space maintainer than the primary tooth. If a space maintainer is placed but
adequate monitoring and preventive care is not achieved, further problems often occur.
For example, with a band and loop design of space maintainer, loose bands and poor
oral hygiene increase the risk of dental caries and gingival inflammation. Prolonged

retention of the appliance may cause deflection of the erupting permanent tooth, and
premature loss of the band can result in loss of space, particularly if the patient delays
returning for treatment.
It has been reported 126 that minor hypoplasia is increased in permanent successor teeth
after root canal treatment of the primary precursors. Others 39 have reported no such
increased effect and concluded that defects result from the infection existing before the
pulpectomy and not the procedure itself. It is noteworthy that these studies are
retrospective, involving erupted permanent teeth; findings should be viewed with
caution.
Economics has been advanced as an argument against endodontic treatment of primary
teeth, but it is not a reasonable argument when compared with the cost of space
maintainers, including the required follow-up treatment. In fact, endodontic treatment
is probably the less expensive alternative when the entire treatment sequence is
considered.
Success of endodontic treatment on primary teeth is judged by the same criteria that are
used for permanent teeth. The treated primary tooth must remain firmly attached and
function without pain or infection. Radiographic signs of furcal and periapical infection
should be resolved with a normal periodontal attachment. The primary tooth should
resorb normally and in no way interfere with the formation or eruption of the
permanent tooth.
Success rates ranging from 75% to 96% have been reported. 13 123 155 327 The usual means
of studying root canal filling on primary teeth have been clinical and radiographic. There
exists a great need for histologic study in this area.
Early reports of endodontic treatment on primary teeth usually involved devitalization
with arsenic in vital teeth and the use of creosote, formocresol, or paraformaldehyde
pastes in nonvital teeth. The canals were filled with a variety of materials, usually
consisting of zinc oxide and numerous additives. 62 98 138 281
Rabinowitch 234 published the first well-documented scientific report of endodontic
procedures on primary teeth in 1953. A 13-year study of 1363 cases of partially or totally
nonvital primary molars was reported. Only seven cases were failures; most patients
were followed for 1 or 2 years clinically and with radiographs. Patients underwent
multiple visits to achieve root canal fillings of ZOE and silver nitrate. Periapically
involved teeth required an average of 7.7 visits to complete treatment, and teeth with no
periapical involvement required an average of 5.5 visits. Rabinowitch listed internal
resorption and gross pathologic external resorption as contraindications to primary root
canal fillings.
Another well-documented study reported a success rate of 95% in vital and infected
teeth using a filling material of thymol, cresol, iodoform, and zinc oxide. 13 (See Bennett
21
for a review of the techniques of partial and total pulpectomy.)
In a well-controlled clinical study of primary root canals using Oxpara paste as the
filling material, 155 five preexisting factors were reported to render the prognosis less
favorable:
1. Perforation of the furcation
2. Excessive external resorption of roots
3. Internal resorption
4. Extensive bone loss
5. Periodontal involvement of the furcation

When teeth with these factors were eliminated, a clinical success rate of 96% was
achieved. When all symptoms of residual infection were resolved before filling of the
canals, the success rate improved.

Contraindications for Primary Root Canal Fillings

Many primary teeth with pulpal involvement that has spread beyond the coronal pulp
are candidates for root canal fillings, whether they are vital or nonvital. Box 23-8 lists
the categories of teeth that are not good candidates for pulpectomy.
BOX 23-8

An unrestorable tooth
Internal resorption in the roots visible on radiographs
Teeth with mechanical or carious perforations of the floor of the pulp chamber
Excessive pathologic root resorption involving more than a third of the root
Excessive pathologic loss of bone support, with loss of the normal periodontal
attachment
Presence of a dentigerous or follicular cyst
Periapical or interradicular lesion involving the crypt of the developing permanent
successor
Contraindications for Pulpectomy in the Primary Dentition
Internal resorption usually begins just inside the root canals near the furcation area.
Because of the thinness of the roots of the primary teeth, once internal resorption has
become visible on radiographs, there is invariably a perforation of the root by the
resorption (see Fig. 23-13 ). The short furcal surface area of the primary teeth leads to
rapid communication between the inflammatory process and the oral cavity through the
periodontal attachment. The end result is loss of the periodontal attachment of the tooth
and, ultimately, further resorption and loss of the tooth. Mechanical or carious
perforations of the floor of the pulp chamber fail for the same reasons. It has been
shown that root length is the most reliable criterion of root integrity, and at least 4 mm
of root length is necessary for the primary tooth to be treatable. 244

Access Openings for Pulpectomy

Anterior Primary Teeth
Access openings for endodontic treatment on primary or permanent anterior teeth have
traditionally been through the lingual surface. This continues to be the surface of choice
except for discolored maxillary primary incisors, in which it is recommended that the
clinician use a facial approach followed by an acid-etched composite restoration to
improve aesthetics ( Fig. 23-20 ). 170

FIG. 23-20
Primary anterior root canal treatment using a facial approach. A, Discolored
primary central incisor with a necrotic pulp. B, Tooth during root canal
cleansing. C, Root canal filling with zinc oxide eugenol (ZOE) has been
completed. ZOE was removed to the cervical line, and a Dycal liner was
placed over the dentin. Tooth has been acid etched. D, Composite resin
has been bonded over the facial surface to achieve esthetics. E,
Postrestorative radiograph showing completed procedures.

Posterior Primary Teeth

Access openings into the posterior primary root canals are essentially the same as those
for the permanent teeth. Important differences between the primary and permanent
teeth are the length of the crowns, the bulbous shape of the crowns, and the very thin
dentinal walls of the pulpal floors and roots. The depth necessary to penetrate into the
pulpal chamber is much less than that in the permanent teeth. Likewise, the distance
from the occlusal surface to the pulpal floor of the pulp chamber is much less than in
permanent teeth. In primary molars, care must be taken not to overinstrument the
relatively thin pulpal floor, owing to the high risk of perforation ( Fig. 23-21 ).

FIG. 23-21
Illustration to show the safe removal of the roof of a pulp chamber in a primary molar. A
non-end cutting bur ensures that the relatively thin floor to the pulp chamber is not
perforated inadvertently by rotary cutting instruments.
When the roof of the pulp chamber is breached and the pulp chamber identified, the
entire roof should be removed. Because the crowns of the primary teeth are more
bulbous, less extension toward the exterior of the tooth is necessary to uncover the
openings of the root canals than in the permanent teeth.

Technique

As in permanent endodontic therapy, the main objective of the chemical and mechanical
preparation of the primary tooth is dbridement of the canals. Although an apical taper
is desirable, it is not necessary to have an exact shape to the canals because obturation is
achieved using a resorbable paste. Fig. 23-22 provides a schematic overview of the
procedure.

FIG. 23-22
Illustration to show the stages of pulpectomy and root canal filling in a mandibular
second primary molar. A, Extensive approximal caries. Note the irreversible
inflammation present in coronal and radicular pulp. B, Following caries removal and
unroofing of the pulp chamber, the coronal pulp is amputated. Irreversibly inflamed
tissue will bleed profusely. A premeasured hand file is placed approximately 2 mm from
the radiographic apex; canals are gently cleaned with minimal shaping. C, Irrigation with
sodium hypochlorite or chlorhexidine digluconate solution should be undertaken during
the cleaning phase. D, If root canals are not to be obturated at the same visit, they may
be dressed with nonsetting calcium hydroxide, or canals can be left empty and the tooth
restored with a small cotton wool pledget and an interim intracoronal restoration. E, At
the subsequent visit, root canals can be obturated with a resorbable root-filling material
such as zinc oxide eugenol (ZOE). This can be applied using various methods; shown
here is the ZOE being tamped down the canal by the piston action of a cotton pledget
held in tweezers. F, Following root canal filling, the tooth is restored definitively using a
preformed metal (stainless steel) crown.

Canal Preparation

1. A preliminary working length is determined by measurement of a radiograph taken

with a paralleling technique.
2. Local anesthesia is advisable.
3. The placement of a rubber dam is mandatory.
4. The working length is determined from a radiograph with an endodontic file in the

canal. The use of apex locators is unreliable because root resorption may create lateral
openings into the periodontal tissues at any level. 244
5. To prevent overextension through the apical foramen, it is advisable that the working
length be shortened to 2 to 3 mm short of the radiographic length, especially in teeth
exhibiting signs of apical root resorption (see Fig. 23-22, B ).
6. After establishment of the working length, the canal is cleaned and gently shaped (as
described in Chapter 9 ). Because of the thin root walls, sonic and ultrasonic cleaning
devices should not be used to prepare the canals. Also, the use of Gates-Glidden (GG)
or Peeso drills (Pulpdent Corp, Watertown, MA) is contraindicated because of the
danger of perforation or stripping of the roots.
7. The more flexible nickel-titanium (NiTi) instruments are recommended rather than
stainless steel (SS). Hand or rotary techniques are ideal for primary teeth. If SS files are
used, the instruments must be gently precurved to help negotiate the canals.
8. Care must be taken not to perforate the thin roots during cleaning and shaping
procedures. The canals are enlarged several sizes past the first file that fits snugly in the
canal, with a minimum size of 30 to 35.

Importance of Irrigation During Treatment

Because many of the pulpal ramifications cannot be reached mechanically, copious

irrigation during cleaning and shaping must be maintained (see Chapter 9 ).
Dbridement of the primary root canal is more often accomplished by chemical means
than by mechanical means. 130 This statement should not be misinterpreted as a deemphasis on the importance of thorough dbridement and disinfection of the canal.
Initially, RC-Prep (Premier Dental Products, Norristown, PA) may be used as the canals
are negotiated. It will digest and emulsify pulp tissue and is an effective lubricant. Once
a working length has been established, the use of NaOCl solution to dissolve organic
debris can play an important part in removal of tissue from inaccessible areas of the root
canal system (see Fig. 23-22, C ).
The Nonvital Discolored Primary Incisor
If a primary incisor is intrinsically discolored following loss of pulp vitality, there may be
an esthetic need to improve the tooth's color. Bleaching is not advised in the primary
dentition. The anatomy of the maxillary primary incisors is such that access may
successfully be made from the facial surface. The only variation to the opening is more
extension to the incisal edge than with the normal lingual access to give as straight an
approach as possible into the root canal.
The root canal is filled with ZOE (see the following section); then the ZOE is carefully
removed to near the cervical line. A liner of Dycal or Life is placed over the ZOE to serve
as a barrier between the composite resin and the root canal filling. The liner is extended
over the darkly stained lingual dentin to serve as an opaquer. The access opening and
entire facial surface are acid etched and restored with composite resin (see Fig. 23-20, C
- D ).
The Decision to Obturate
After canal dbridement, the canals are again copiously flushed with NaOCl and are
then dried with sterile premeasured paper points. If the canals are dry and there is no
exudate, obturation is performed in the same session. If the obturation cannot be done

in the first appointment, a slurry paste of nonsetting Ca(OH) 2 can be injected into the
canals and the tooth restored with a well-sealing temporary restoration.
At a subsequent appointment, the rubber dam is placed and the canals reentered. As
long as the patient is free of all signs and symptoms of inflammation, the canals are
irrigated with NaOCl to remove the intracanal dressing and dried before obturation. If
signs or symptoms of inflammation are present, the canals are recleaned and
remedicated and the canal obturation delayed until a later time.

Root-Filling Materials for the Primary Root Canals

The ideal root canal filling material for primary teeth should:
Resorb at a similar rate as the primary root.
Be harmless to the periapical tissues and the permanent tooth germ.
Resorb readily if pressed beyond the apex.
Be antiseptic.
Fill the root canals easily.
Adhere to the walls of the root canal.
Not shrink.
Be easily removed if necessary.
Be radiopaque.
Not discolor the tooth. 167
No material currently available meets all these criteria. The filling materials most
commonly used for primary pulp canals are ZOE paste, iodoform paste, and Ca(OH) 2 .
These will be discussed briefly in the following section.

Zinc Oxide Eugenol Paste

Most reports in the U.S. literature have advocated the use of ZOE as the filler, whereas
other parts of the world have used iodoform-containing pastes. 124 , 151 The antibacterial
activity of ZOE has been shown to be greater than that of an iodoform-containing paste
(KRI paste, Pharmachemic AG, Zurich, Switzerland), whereas its cytotoxicity in direct
and indirect contact with cells is equal to and less than (respectively) than that of KRI
paste. The filling material of choice in the United States is ZOE without a catalyst. The
lack of a catalyst is necessary to allow adequate working time for filling the canals.

Iodoform Paste

Several authors have reported the use of KRI paste, which is a mixture of iodoform,
camphor, parachlorophenol, and menthol. 243 It resorbs rapidly and has no undesirable
effects on successor teeth when used as a pulp canal medicament in abscessed primary
teeth. Further, KRI paste that extrudes into periapical tissue is rapidly replaced with
normal tissue. 124 Sometimes the material is also resorbed inside the root canal. A paste
developed by Maisto has been used clinically for many years, and good results have been
reported with its use. 174 , 289 This paste has the same components as the KRI paste, with
the addition of zinc oxide, thymol, and lanolin.

Calcium Hydroxide

Several clinical and histopathologic investigations of Ca(OH) 2 and iodoform mixture

(Vitapex, Neo Dental Chemical Products Co, Tokyo) have been published. 83 , 207 These
authors found that this material is easy to apply, absorbs at a slightly faster rate than
that of the roots, has no toxic effects on the permanent successor, and is radiopaque. For

these reasons, one researcher 167 considers the calcium hydroxideiodoform mixture to
be a nearly ideal primary tooth root canal obtundant. Another preparation with similar
composition, Endoflas, is available in the United States (Sanlor Laboratories, A.A. 7523
Cali, Colombia, South America). The results of root canal treatments using Endoflas in a
students clinic were similar to those observed with KRI paste. 87
Obturation of the primary root canal is usually performed without a local anesthetic.
This is preferable, if possible, so the patient's response can be used to indicate proximity
to the apical foramen. It is, however, sometimes necessary to anesthetize the gingiva
with a drop of anesthetic solution to place the rubber dam clamp without pain.

Obturation of the Root Canal

The chosen obturation technique depends upon the material employed and accessibility
of the canal to relevant instruments.
If using ZOE, it is mixed to a thick consistency and carried into the pulp chamber with a
plastic instrument or on a Lentulo spiral. The material may be packed into the canals
with pluggers or the Lentulo spiral. A cotton pellet held in cotton pliers and acting as a
piston within the pulp chambers is quite effective in forcing the ZOE into the canals (see
Fig. 23-22, E ). The endodontic pressure syringe 23 , 103 is also effective for placing the
ZOE in root canals. However, in a study of apical seal and quality of filling evaluated on
radiographs, no statistically significant differences were reported between the Lentulo
spiral, pressure syringe, or plugger. 56
When the root canal is filled with a resorbable paste such as KRI, Maisto, or Endoflas, a
Lentulo spiral mounted in a low-speed handpiece can be used to introduce the material
into the canal. When the canal is completely filled, the material is compressed with a
cotton pellet. Excessive material is rapidly resorbed.
Vitapex is packed in a convenient sterile syringe and the paste injected into the canal
with disposable plastic needles. This technique is particularly easy to use for primary
incisors but less practical for the narrow canals of primary molars. 210
Regardless of the method used to fill the canals, care should be taken to prevent
extrusion of the material into the periapical tissues. It is reported that a significantly
greater failure rate occurs with overfilling of ZOE than with filling just to the apex or
slightly underfilling. 39 , 123 The adequacy of the obturation is checked by radiographs (see
Fig. 23-20, E ; Fig. 23-23, A ; Fig. 23-24, C ).

FIG. 23-23
Pulpectomy and root canal filling with zinc oxide eugenol (ZOE) paste in a
primary maxillary central incisor. A, Root canal has been slightly overfilled
with extrusion of ZOE paste apically. B, Same patient showing newly
erupted permanent incisors. Note there are no enamel defects present on
the crown, despite overfill of the root canal of the predecessor. C,
Radiograph almost 5 years after pulpectomy and root canal filling of
predecessor. Note normal apical development and almost total absorption
of ZOE remnants.

FIG. 23-24
Pulpectomy and root canal filling with zinc oxide eugenol (ZOE) in a
maxillary second primary molar. A, Carious pulp exposure with a chronic
abscess. Note furcal and periapical radiolucencies. B, Instruments in place
establishing the working length. C, Root canal filled with ZOE. Note overfill
and extrusion of the ZOE. D, At
years after root canal treatment, primary
tooth is near to exfoliation. E, One year later, premolar is erupted fully and

all traces of ZOE have been resorbed.

In the event a small amount of the ZOE is inadvertently forced through the apical
foramen, it is left alone (because the material is absorbable). It has been reported that
defects on successor teeth have no relationship to length of the ZOE filling. 39
When the canals are satisfactorily obturated, a fast-setting temporary cement is placed
in the pulp chamber to seal over the root canal filling. The tooth may then be restored
permanently. In primary molars, it is advisable to place a preformed (stainless steel)
crown as the permanent restoration to ensure good coronal seal and prevent possible
fracture of the tooth (see Fig. 23-22, F ).
If a primary tooth requires pulpectomy and the permanent successor tooth is absent, the
primary root canals are filled with gutta-percha and sealer in an attempt to retain the
primary tooth long term ( Fig. 23-25 ).

FIG. 23-25
Pulpectomy and root canal filling with gutta-percha in a retained mandibular
primary second molar with no succedaneous permanent tooth. A, Carious
exposure of the pulp. B, Because the permanent premolar is absent, root
canals were filled with gutta-percha and sealer rather than just zinc oxide
eugenol.

Follow-Up After Pulpectomy in the Primary

Dentition
As previously stated, the rate of success after primary pulpectomy is high. However,
these teeth should be periodically recalled to check for success of the treatment and
intercept any problem associated with a failure. It has been reported 39 , 283 that
pulpectomized primary teeth may show delayed exfoliation. One study 39 described a
20% incidence of crossbites or palatal eruption of permanent incisors after pulpectomy

on primary incisors. In the posterior teeth, extraction was required in 22% of cases
because of ectopic eruption of the premolars or difficulty in exfoliation of the treated
primary molar. 39 After normal physiologic resorption of the roots reaches the pulp
chamber, the large amount of ZOE present may impair the resorptive process and lead
to prolonged retention of the crown. Treatment usually consists of simply removing the
crown and allowing the permanent tooth to complete its eruption.
Retention of ZOE in the tissues is a common sequela to primary pulpectomy. One longterm study reported that after loss of the tooth, 50% of cases had retained ZOE. Teeth
filled short of the apices had significantly less retained filler, and in time, most showed
complete absorption or reducing amounts. Retention of filler was not related to success
and caused no pathosis. 254 Therefore no attempt is made to remove retained filler from
the tissues (see Fig. 23-23, A ; Fig. 23-24, C ).
While resorbing normally without interference from the eruption of the permanent
tooth, the primary tooth should remain asymptomatic, firm in the alveolus, and free of
pathosis. Traditionally, root treatments were considered successful when no pathologic
resorption associated with bone rarefaction was present. 95 , 124 If evidence of pathosis is
detected, extraction and conventional space maintenance are recommended.
Investigators 223 claim that most clinicians are prepared to accept pulp-treated primary
teeth that have a limited degree of radiolucency or pathologic root resorption in the
absence of clinical signs and symptoms. This is contingent on the assurance that the
parent will contact the clinician if there is an acute problem, and the patient will return
for review in 6 months. These criteria seem to be more suitable for pediatric dental
practices and have been adopted clinically by Fuks et al 87 ; they consider such teeth to
be successfully treated.