WHAT ARE MY CHOICES FOR OBTURATING MATERIALS FOR PEDIATRIC PATIENTS?
The clinical goal of obturation in Endodontic Theraphy is to prevent bacterial activity from infiltrating the periapical tissue through total elimination of microorgansims from the root canal, and, thus, preventing possible subsequent reinfection. This is achieved by careful cleaning and shaping of the root canals followed by the complete obturation of the canal space. The ultimate goal of Endodontic obturation has remained the same for the past 50 years, and that is to create a fluid-tight seal along the length of the root canal system extending from the coronal opening to the apical termination.
In Pediatric Dentistry, generally, the Endodontic treatments. is done to preserve the primary teeth as long as possible until proper time is needed for the permanent teeth to erupt. This is critical because primary teeth is important to provide space maintenance, develop ideal arch length and preserve masticatory function of the patient until the permanent teeth erupts to replace them.
Unfortunately, the problem with pulpal therapy with primary teeth is that it can be too challenging to some dentists. This is brought about by the roots of primary teeth do resorbs through time and when it comes to primary molar roots, they are usually curved with a high chance of perforation during Endodontic treatment.
So, due to these challenges, the question is now which materials are best for obturation for primary teeth? What are the best medication or obturants that can be used to remove acute and chronic infection from tooth or oral cavity? On this post, DMD cEnter will discuss the different types of medications or obturants that are available in the market that you may choose from to be used in your pulpal therapy in treating your pediatric patients.
Before we proceed with the information, allow us to provide you the general qualifications that obturating materials should have that's integral on making your choice. According to the study made by Rifkin and Rabinowitch, the criteria for an ideal pulpectomy obturant should be following:
➢ Harmless to the adjacent permanent tooth germ.
➢ Non-inflammatory and non irritating to the underlying permanent tooth.
➢ Radiopacity of the material for better visualization on radiographs.
➢ Ease of insertion.
➢ Ease of removal.
➢ Antiseptic property.
➢ Stable disinfecting power.
➢ Excess press beyond the apex should be resorbed easily.
➢ Adhere to walls of the canal and should not shrink.
➢ Insoluble in water / oil based.
➢ Should not discolor the tooth.
➢ Induce vital tissue to seal the canal with calcified or connective tissue.
➢ Should not set into a hard mass.
The following are the choices of obturating materials one may choose from depending on your specific dental case for your pediatric patient:
ZINC OXIDE EUGENOL (ZOE)
In 1837, Bonastre discovered ZOE and in around 1876 it was subsequently used as a material in Dentistry. ZOE became one of the most widely used materials for root canal filling of primary teeth. Generally done with a thin mix of ZOE to allow the material to easily flow easily. To prevent for the material to be pushed beyond the apex, the use of a syringe becomes the method of application and a thicker consistency of ZOE is injected into the canal to avoid for the material both to flow outside the canal and create an underfilled canal. To allow longer working time for filling canals, some ZOE materials are manufactured without a catalyst.
➢ Excellent antibacterial and analgesic effects when in lower concentrations.
➢ Radiopaque for good radiographic visibility
➢ Easy to manipulate & fill in the canals
➢ Insoluble in tissue fluids
➢ Easily available
➢ Cost effective
➢ No tooth discoloration
➢ Slow resorption
➢ Irritation to the periapical tissues
➢ Necrosis of bone and cementum of primary tooth
➢ Harm the permanent tooth bud
➢ Forms a fibrous capsule and alters the path of eruption
CALCIUM HYDROXIDE (Ca(OH)2)
Calcium hydroxide was introduced by Herman. Calcium hydroxide is widely used as a liner for deep restorations, a temporary intracanal dressing and apexification procedures in permanent teeth. Calcium hydroxide is also recommended as a final obturation material for root canal therapy of primary teeth.
➢ Antiseptic and Osteoconductive properties.
➢ Antibacterial effect is primarily due to the liberation of hydroxyl ions and inactivation of enzymes in the bacterial cytoplasmic membrane.
➢ It has the tendency to get depleted from the canals earlier than the physiologic root resorption.
➢ Ca(OH)2 containing root canal filling materials when used in primary teeth with hyperemic pulp can come in contact with some vital pulp tissue remnants and can trigger the cascade of inflammatory root resorption.
➢ Ca(OH)2 paste produces superficial layer of necrosis causing damage to predentine, which in turn can lead to exposure of dentin to odontoclasts and subsequent resorption.
It is a preparation of iodine obtained by action of chlorinated lime upon an alcoholic solution of potassium iodide when heated at 1040 °F. ➢ This preparation includes the entire enamel and 1/2 Dentin in the preparation. Iodoform-based pastes have been advocated as root filling materials as they fulfill most of the requirements of a filling material for primary teeth as they are more easily resorbed from the periapical area, cause no foreign body reaction and display potent germicidal properties. It is used either in pure form or is combined with other materials.
➢ No irritant action.
➢ Relieves pain and is a potent disinfectant.
➢ Better re-sorbability and disinfectant properties than ZOE.
➢ May produce a yellowish brown discoloration of the tooth.
➢ The rate of resorption of material within the canals is faster than the rate of physiological root resorption.
➢ Irritating to the periapical tissues and can cause cemental necrosis
It consists of Iodoform, Parachlorophenol 33-37%, Camphor 63-67% and Menthol crystals 1.40- 2.90%.
➢ Ideal intracanal dressing in cases for non- vital teeth associated with large periapical lesions.
➢ Disinfectant action depends on the liberation of the chlorine in the presence of phenol.
KRI paste is basically an iodoform paste, was introduced by Volkoff as a resorbable paste suitable for root canal filling. It consists of iodoform (80.5%), camphor (4.84%), parachlorophenol (2.023%), and menthol (1.213%). Iodoform is added as a vehicle to carry the antimicrobial agent as it is a non-irritant and radiopaque. Overall success rate for KRl paste was 84% versus 65% for ZOE.
➢ With Camphor combination, the Camphor acts analgesic and a hemostatic agent.
➢ Its menthol crystals acts as an anodyne, antispasmodic, antiseptic.
➢ Parachlorophenol minimize coagulation with adjacent tissues.
➢ Overfilling causes mild foreign body reaction
➢ The rate of resorptions is slower than that of the primary root tooth
CALCIUM HYDROXIDE COMBINATIONS
I. VITAPEX | METAPEX
Kawakami et al. introduced it in 1979. Japanese researchers introduced a Calcium hydroxide sealer named Vitapex, a syringe-loaded viscous pre-mixed paste composed of Iodoform - 40.4%, Calcium hydroxide - 30.3%, Silicone oil- 22.4% and others – 6.9 from Neo Dental Chemical Products Co. Tokyo, Japan. It is used as a temporary or permanent root canal filling material after pulpectomy. Vitapex is an ideal for the treatment of infected root canals and for vital pulpotomies in deciduous teeth. While Metapex is from METABIOMED, a combination of 30.3% calcium hydroxide, 40.4% iodoform and 22.4% silicone oil. The mixture can be dispensed into the root canals by using disposable tips. The silicone oil content of metapex neutralizes the alkalinity of the paste to a certain extent, thereby causing lesser injury to the periapical tissues. Metapex, an calcium hydroxide - iodoform mixture is considered to be an ideal pulpal filling material for primary teeth, but it resorbs a little faster than the rate of normal physiologic root resorption. Clinical success rate of 96.8% and radiographic success rate of 72.5% was reported for metapex. Metapex easily resorbs from the periapical areas, no foreign-body reaction, and it has a potent germicidal properties are the needs fulfilled by iodoform pastes that can successfully be used as root canal filling material.
➢ Non toxic to permanent successor tooth
➢ Antiseptic action
➢ Good adherence to the canal walls
➢ Non- setting to a hard mass. Resorption faster than root, complete resorption of the excess paste is expected within 2-8 weeks.
➢ Applicability of the material is easier
➢ Rapid elimination of iodoform by the organism leaves behind empty spaces inside the root canal.
➢ Pushed beyond the apex
➢ Discoloration of the teeth
The rationale behind incorporating three materials ZOE, Ca(OH)2 and iodoform into Endoflas was probably to compensate the disadvantages of one individual material with the advantages of the other. Endoflas is known for its antimicrobial effect. Due to one of its disadvantages wherein a radiolucent lesions following endodontic treatment of primary teeth occurs which was theoretically may be due to the filling material that contain phenol, an Endoflas-chlorophenol-free (CF) was developed. Chlorophenol was eliminated from endoflas composition because it has fixation effect which may affect the osteoblast cells
➢ Excellent healing capabilities and complete bone healing
➢ Hydrophilic and can be used in mildly humid canals.
➢ Firmly adheres to the surface of the root canals to provide a good seal.
➢ Disinfect dentinal tubules and difficult to reach accessory canals that cannot be disinfected or cleansed mechanically.
➢ Resorbed when overextended periapically
➢ The high pH ensures powerful antibacterial effects that reduce periapical inflammatory processes.
➢ Stimulate periapical healing with an increase of alkaline phosphatase action and periapical bone remineralization.
➢ Eugenol content can cause periapical irritation
➢ Eugenol content can cause tooth discoloration
➢ Does not resorb intra radicularly and reported 70% success clinically with endoflas and a 100% decrease in periapical radiolucency.
It is a root canal obturating material which is based on polymer technology. It uses a hydrophilic principle which can absorb surrounding moisture and expand which results in filling of spaces and voids. Hydrophilic nature is revealed by ProPoints, which permits infinite water volume existing in the root canal system that is engrossed by these points. This water may hydrogen bond to the existing polar locations, therefore, permitting the enlargement inside the polymeric chains.
➢ Geometry of point can be accurately made.
➢ Biocompatibility of the material to the tooth
➢Controlled expansion of the material
➢ No toxic effects on permanent successor
➢ The use of smartseal with undiluted sodium hypochlorite is not recommended. The canal must be rinsed with EDTA or water before it is used.
➢ Limited evidence on clinical data showing effectiveness.
LESION STERILIZATION AND TISSUE REPAIR (LSTR)
Cariology Research Unit of Niigata University School of Dentistry has developed the concept of LSTR. The theory behind LSTR is that the repair of damaged tissue might occur if lesions are disinfected. This has also been referred to non-instrumentation endodontic treatment (NIET). The mix is also called as triple antibiotic paste or polyantibiotic paste, antibiotic mixture. It uses a mixture of 3 antibiotics:
The walls of access cavity were chemically cleaned with EDTA, a chelating agent, which is used to improve the chemo mechanical debridement because of its ability to remove smear layer and allowing antibiotics to penetrate into the dentinal tubules. Pulpal floor is covered with 3 mix-MP. The procedure which is termed as “medication cavity”.
It is a product formed from a corticosteroid and an antibiotic, presenting a great antimicrobial action and recommended for the treatment of primary teeth presenting with pulpal infectious processes. The paste also presented bactericidal action against most organisms except for Enterococcus faecalis and Bacillus subtilis.
II. CTZ PASTE
CTZ is an antibiotic paste Comibation of chloramphenicol 500mg + tetracycline 500mg + zinc oxide 1000mg + eugenol 1 drop. Chloramphenicol is an
antimicrobial agent that acts against a large number of aerobic, facultative anaerobe and spirochetes as well as gram positive and gram negative microorganisms. Tetracycline is a broad spectrum antibiotic which can be bactericidal at high concentration offering excellent effectiveness against gram negative bacteria and all anaerobes. ZOE provides analgesic properties and potent antibacterial action against staphylococcus, micrococci, bacillus and enterobacteria for more than 30 days.
➢ Simple and easy application
➢ Antibacterial property
➢ Stabilization of bone resorption
➢ Does not cause tissue sensitivity
➢ Does not produce damage to the permanent tooth in development
➢ Pigmentation of the crown of the treated tooth
III. ALTERNATIVES FOR MINOCYCLINE
Minocycline causes pigmentation in calcifying teeth. Consequently, in place of this, drugs like amoxicillin, cefaclor, cefroxadine, fosfomycin, rokitamycin were tried.
Pulpotec has antiseptic, antibacterial and anti-inflammatory properties. The main component of this product is iodoform, and due to its antiseptic properties, it acts like an antibiotic paste at the entry of the empty root canal. Pulpotec can be used in the teeth showing bone lesion and help in reduction of clinical signs of infection. The clinical and radiological results show that, this procedure could be considered as an alternative to the conventional endodontic treatment for necrotic primary teeth in Pediatric dentistry.
B. ALOE VERA
Aloevera is an herbal and naturally found material and its properties made possible its wide usage in dentistry for various therapeutic properties. It enhances various phases of wound healing process, such as macrophage recruitment, collagen synthesis and wound contraction . Khairwa et al evaluated clinical and radiographic success of zinc oxide combined with aloe vera and showed good success rate. They reported that this material can be used as an alternative for zinc oxide eugenol.
Ozone is gaseous, energized form of oxygen, it is unstable and dissociates readily back into oxygen, thus liberating so called singlet oxygen, which is a strong oxidizing agent. They are responsible for remarkable bactericidal and fungicidal effects. In the study conducted by Chandra et al., there was good clinical success rate at 12 months follow up, which was attributed to the antibacterial and excellent healing properties of ozone peroxides. There is also progressive bone regeneration observed at the follow ups. ZOE had radiographic success rate less than that of ozonated oil-ZOE. Accordingly, the authors have concluded that, it can be considered as a good alternative for ZOE.
Although Pedodontics and Endodontics are part of our curriculum when we were studying Dentistry, both subjects are not actually that easy to do in real practice. Both have important disciplines so we can make our treatments successful when dealing with children as patients and root canal therapy, respectively. It is safe to assume then that this will even be doubly challenging for dentists if we are dealing with a child as a patient and doing RCT to that child. Having said that, challenges don't mean impossible to do. This can easily be surmountable if we are well verse to the techniques of the treatment as well as the materials to be used. It is important for dentists who are practicing these fields of Dentistry to really know and understand the materials that one can choose from so that the level of success in prognosis after treatment will be high and that one can truly allow through ones treatment for the deciduous tooth be able to stay in ones young patient's mouth for as long as it can for the primary tooth to accomplish its purpose...and, that is...to give way for the permanent tooth to replace it at an oral environment conducive for permanent tooth to do its functions and, eventually, have that child grow into an adult with a healthy permanent dentition.
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Dr. Bryan Anduiza - Writer
Dr. Mary Jean Villanueva - Writer | Editor