PULPECTOMY

To remove irreversible inflamed or necrotic radicular pulp tissue

To clean root canal system
To obturate with resorbable material same rate with physiologic root resorption

Indications
Tooth indicated for pulpectomy should have one or more of the following criteria:
Clinically diagnosed as irreversible pulpitis
Necrotic radicular pulp
History of spontaneous pain.
Evidence of radicular pathologic lesion with or without caries involvement.
Alveolar swelling.
Pus discharge from canal(s).
Continuous bleeding even after amputation of the coronal pulp tissue during
pulpotomy.
No pulp tissue remaining when the pulp chamber is entered.
Presence of sinus tract or abscess
Presence of inter-radicular or periapical radiolucency

Contraindications
Unrestorable tooth
Excessive mobility
Spread of infection cellulitis
>2/3 root resorption
Caries extends to floor of pulp chamber
Teeth with pathological lesion extending to the tooth germ of the successor tooth.
Teeth with evidence of extensive internal/external pathological root resorption.
Patient with systemic disease such as congenital or rheumatic heart disease,
leukemia and children on long term corticosteroid therapy or those who are
immunocompromised

2 types of pulpectomy
Two stages pulpectomy
- 1st appointment; to clean the canal system
- 2nd appointment; for obturation and stainless steel crown placement
One stage pulpectomy (clean and obturate on the same day) is possible if the
tooth has been assymptomatic and there is no sign of infection

Techniques
1. Pre-operative periapical radiograph
2. Local anaesthesia & rubber dam
3. Caries removal Steps are same as in pulpotomy
4. Removal of roof of pulp chamber
5. Identify root canals
- Access opening must be large - convenience enough to visualize canal opening
- File canal walls light and gently with file size <30
- Keep 2mm short from radiographic apex to avoid overextension

6. Irrigate
- 0.9% sterile normal saline
- 0.1% sodium hypochlorite or 0.4% chlorhexidine
- Due to complex primary molar radicular morphology the canal system cleaning is
achieved mainly by irrigation!

7. Insert small file size < 30

- Based on the radiographic measurements, the canals are negotiated using
endodontic files. To avoid overextension, the working length is established 1 to 2
mm short of radiographic length. The canals are enlarged several sizes beyond
the first file that fits snugly into the canal up to minimum final size of 30 to 35.

8. Dry with paper points

9. Canal medicaments ( for two stages pulpectomy )

- In 2 stages pulpectomy, root canals are dressed with an antimicrobial agent for 7-
10 days
o non-setting calcium hydroxide
o Ledermix paste

10. Obturation
- slow-setting zinc oxide eugenol
o The canals are then dried and filled with resorbable paste of Zinc oxide
eugenol (ZOE) without catalyst to allow sufficient working time. The ZOE is
mixed to a very thick consistency and carried into the pulp chamber. The ZOE
is then pushed into the canal with help of endodontic plugger or with cotton
pellet.
- non-setting calcium hydroxide paste
 - calcium hydroxide and iodoform paste (Vitapex)

11. Post-operative radiograph

- pre-operative
- working length determination
- post-operative

12. Stainless steel crown

Review
Regular clinical and radiographic review following any primary molar pulp therapy
is mandatory
Radicular cyst is a well-recognised sequelae

SOME HELPFUL TIPS

Although, it is not compulsory to administer local anesthesia for primary teeth

with necrosed pulps, and during the second visit of pulpectomy; it may be helpful
to anesthetize gingiva for rubber dam placement.
Over instrumentation of root canals in primary teeth is not recommended, since
the aim of the instrumentation in primary teeth is to clean the canals and not to
shape the canal as in permanent teeth.
Use of rotary instruments, such as Gates-Glidden drills in root canal
instrumentation of primary teeth is contraindicated.
Pulpectomy for primary teeth can be carried out in a single visit, if the patient is
not complaining of acute symptoms or there is no pus discharge from the canals.
The use of gutta-percha or silver points as a root canal filling material in primary
teeth is contraindicated as these would not resorbed and interfere with the
eruption of the permanent teeth.
Other techniques may also be used to carry the obturation materials into the
canal such as lentulo-spiral and endodontic pressure syringe.
Other obturation materials such as calcium hydroxide and iodoform may also be
used for obturation in primary teeth root canals with favorable success rate.