 So everybody, today's topic or the topic we are going to discuss now is Pulpectomy. I will be talking about all the things related or whatever a final year undergraduate should know and what and all is expected in an answer when asked about Pulpectomy, okay. So the main thing moving on is the definition. So now we have two definitions over here which are easy. So you need to learn both of them. This is important in respect to a theory as well as practicals, okay. So according to Matthewson, pulpectomy involves complete removal of necrotic pulpal tissue from the root canals and coronal portion of d vital primary team to maintain the tooth in the dental arch. Now according to Finn, pulpectomy is a removal of all pulpal tissue from the coronal and radicular portions of the tooth. Finn's definition is much easier to remember. So I would suggest you learn Finn and for extra marks or anything like that you can just learn Matthewson's definition also. Now moving on to why the pulpectomy is done, like the rationale behind it is it is to remove the irreversibly inflamed, nectotic, radicular pulp tissue and gently clean the root system. It is also done to obtrade the root canals with a filling material that will re-resolve at the same time as the primary tooth and be eliminated rapidly if excess extruded through the apex. Now what are we trying to achieve by doing a pulpectomy in a primary tooth? We're trying to achieve that the infectious process should resolve both clinically and radiographically following treatment. There should be a radiographic evidence of a successful filling without any cross over extension or under filling. The treatment should permit resorption of primary root structures and filling materials at the appropriate time and permit normal eruption of the succedaneous tooth. There should be no radiographic evidence of further breakdown of the supporting tissues and the treatment should elevate and prevent further sensitivity, pain or swelling. There should be no evidence of internal resorption or pathological changes. So moving on to the indications, like not every primary tooth which has been affected by caries and can be saved by doing a pulpectomy. So what are the indications? Basically primary tooth with pulpal information which are extending beyond the coronal pulp. If it is limited to the coronal pulp, a pulpotomy will surface. But if it's extending to the roots, then a pulpectomy has to be done. Now primary teeth with carious pulp exposure in which following the coronal pulp augmentation, the radicular pulp shows signs of hyperemia where the bleeding is not stopping. That suggests that the radicular pulp is also infected. Primary teeth with nectotic pulse, minimum root resorption and minimum bone destruction in the bifurcation area. Non-vital primary teeth with a sinus tract or abscess, pulpus primary teeth without permanent successors. Now in such cases, you want to keep the primary tooth in the oral cavity as long as possible because there is no permanent successor to replace it even if it falls off. So you want to prevent its loss as much as possible. Now pulplus primary second molars before the eruption of permanent first molar. Now like I said in the previous space maintenance thing, until the permanent first molar erupts you have to try saving the second molars, primary second molars as much as possible because then the repercussions or the problems that arise if we lose a pulplus primary, if we lose a primary second molar, are much more. A child patient having cellulitis due to infected primary tooth, a pulplus primary tooth in hemophiliacs, pulpus anterior teeth with speech, crowded arches, when the speech or the crowded arches or aesthetics are a factor. So if you lose the anterior teeth it affects the speech, then there is space loss which can occur because you have lost a primary anterior tooth and also the aesthetics. A pulplus primary teeth next to the line of a palatal cleft, pulplus primary molars supporting orthodontic appliances. You want them to be a strong abutment if an orthodontic appliance is to be given using these molars or primary teeth as support. So you know sometimes if they are decay you rather do a pulpectomy, if in case it's such as a pulpectomy has to be done and give a stainless steel crown and then an orthodontic appliance can be done on top of this. A pulplus primary teeth when arch length is deficient, a pulplus primary teeth when space maintenance or continued supervision are not feasible. In all these the keyword is pulplus, so there is already no pulp, you want to save these teeth but for different reasons. Now there are some contraindications such as when there is a non-restorable count, so you can't just do a pulpectomy and leave it, you need to give up filling or you need to restore it with a crown, stainless steel or a zirconium crown. But if there is no crown structure and a crown can't be given then there is no point in doing a pulpectomy. Periraticular involvement extending to the permanent tooth bud, so there is already extensive infection which is already affecting the permanent tooth bud so there is, it's not feasible to do a pulpectomy and to remove the infection so it's rather you remove the tooth. When there is pathological resorption of at least one third of the root with a fistulist act. Now basically what happens is when there is an infection there is faster resorption of the root, so when you see that the root has resorbed, you know, where at least one third of the root is gone, then you need to start thinking of alternatives and this excessive internal resorption, so again a good pulpectomy will not be, you know, can't be done because there is internal resorption means there is again infection which is leading to the resorption internally. Extensive pulpal floor opening into the burr bifurcation. Presence of a dead digital sort of follicular cyst is also a contraindication. Moving on til there are certain medical contraindications too, a child with a hard defect or any history of a heart disease, heart surgery, rheumatic fever etc. again a pulpectomy can be a source of endocarditis. So you would rather, you know, treat or you remove the tooth than let it be a source of an infection. Immunocompromised children such as malignant disease like leukemia, neutropenic for, you know, considerable periods of time. Systemic illnesses like hepatitis are children on long-term corticosteroid therapy are all on medical contraindications. Now there are certain inherent difficulties like, you know, a molar tooth, the root structure, you know, they have, it's curved to include the permanent tooth bud in between the roots. So it's a very curved root structure. So a very good cleaning and shaping is a very difficult to achieve very good results with a root, a curve like this. Now they also, these have a lot of collateral canals so, you know, leaving behind any kind of tissue or anything is highly possible so you need to be really good at this. Physiological root resorption. The root resorption starts early so you, what you think is the apex may not be the apex like in this case where I thought it could extend and then there was lateral resorption that had happened and the material extruded. There's also possibility of damage to the permanent successor when you get overzealous and, you know, extrude the files while doing the cleaning and shaping. So you can, or you can tend to damage the permanent successor tooth bud. Moving on there are two types of pulpectomy. There's a partial and there's a total or a complete pulpectomy. In total pulpectomy it is the extirpation of the pulp almost near the foramen where the root apex is fully formed and the foramen is sufficiently close to permit the obturation with conventional filling materials. While in partial it is done when the root is not completely developed or there's an open apex. So you leave behind some amount of vital tissue to induce root formation. Okay. Moving on the other types, two types of pulpectomy that's a single visit or a multiple visit. While in single visit it is applicable to vital teeth where the hemorrhage from the amputated radicular pulp stem is uncontrolled. So indications include a large carousel exposure with frank involvement of radicular tissue while the contraindications are when there are periapical changes. Multi-visit pulpectomies include when there's an infection, there's abscess or chronic sinus exist when there's non-vital primary teeth or their teeth with necrotic pulp and periapical involved. All of these suggest there's a lot of infection that is present and a single sitting will not be helpful because you know you give the tooth sometime to recover from this. So what we do in such kind of cases especially when there's an abscess or like there's cellulitis or something you open up the tooth you do not clean or anything you just make do an access opening and just leave it. Okay. Call the patient back another visit where the cleaning and shaping is done by then you know there is there's reduced reduction in the infection then you place a medicament in the canal so that the tooth heals by healing I meant that the infection reduces and then in the third visit you can do an obturation and finish the pulpectomy. There are certain steps in pulpectomy. First of all you take a preoperative radiograph to confirm the depth of the lesion the length of the root if there's any resorption if there's any internal resorption so you take a preoperative radiograph then once it's confirmed yes a pulpectomy has to be done you move on you give local anesthesia you apply rubber dam. Rubber dam can be avoided when there's cases of abscess or the cellulitis the patient it's already has a swelling it's in pain you can let go of the rubber dam then you remove the carious dentine or if there's any faulty restoration below which there was secondary caries that had happened then you do an axis opening okay recognize all the canals then you determine the working length the determination of working length can be done you you know you can do it radiographically or non radiographically I'll be telling about it later removal of pulp tissue okay you can use an h file remove the pulp tissue or you can use approach also to remove the pulp tissue you dibribe the canal right then moving on you do the chemo mechanical preparation irrigation or end drying of the canals and once you're satisfied you do an operation followed by a final restoration moving on axis opening for pulpectomy or primary treatment now this is one of the most important phases of root canal because this is where you you know you see or you recognize all the canals that are present sometimes they have three sometimes there will be four so you need to locate all the canals now the objective says obtaining a straight line axis right so you get a straight line axis you'd remove all the carious part of the tooth you do not leave behind anything conservation of tooth structure as much as possible and you de-roof the chamber followed that's the pulp chamber followed by exposure and removal of pulp. Now moving on you determine the working method like i said you do it either radiographically or non radiographically radiographically those conventional methods are the engulfed on the crosswind method you either do a digital radiographies or radiography radiovisuography or a tomography non radiographically you can use tactile sense where you you know you use this and where you put the files and you can feel it when you reach the apex right so you then you determine it like okay so this and you place the stopper and then you can use it on a scale or an end block and then determine the working length or a paper point you place the paper point you see how deep it's going the more it would have it'll be wet so you can make out how much how deep it's going and you can then measure the that apical PDL sensitivity or even apex locators here i'm just describing one method i think that's more than enough that is the engulf method you must have learned about it in endo so where you measure the tooth in the preoperative radiograph you subtract at least one mm for safety allowance then you place the instrument place the stopper and whichever point you're using at a represent point then you develop a radiograph you take a radiograph and then on the radiograph you measure the difference between the end of the instrument and the apex now if you feel you're extruded or gone beyond the apex then you reduce the length but if you feel if you're short of the apex if you're not yet reached the apex then you add it to the length that was determined before on the preoperative radiograph moving on you have the chemical sorry chemo mechanical preparation so this more commonly we use the hedge files because in hedge files you the cleaning happens or the shaping happens when you remove the instrument mostly canals are enlarged up to a size of 35 or 40 this is normally done in primary holders while in anterios the canals are already wide enough then cleaning and shaping is of is as cleaning the canals is as important as shaping now usually very commonly seen in primary tita zipping and perforation already there's very less to structure there's very less the thickness of the dentin that's present is less you need to be very careful you do not perforate the tooth and certain irrigants which are used sometimes it's a one person sodium hypochloride or even chloroxidine it's that is the choice we can use or even normally saline can also be used to wash out the fragments of pulpy tissue in because with sodium hypochloride you have to be very careful especially in children you need to take all kinds of precautions so that but if you're using a rubber dam that's nothing like it you can use sodium hypochloride. Moving on one of the ideal properties that we're looking at when we are when we try to choose an irrigating solution it's compatibility in terms of physical and chemical properties it should have an antibacterial capacity with chelating actions and should help in this tissue dissolve dissolution. Moving on to intracanal medicaments so sometimes when we have a tooth which is ridden with a lot of infections we do especially in the multiple visit pulpectomies we do place intracanal medicaments. Such medicaments are used to eliminate any remaining bacteria after the canal instrumentation and cleaning it's also you know helps in the reduction in the inflammation of the periapical tissue and pulpy remnants renders the canal content contains inert and utilizes any tissue debris it acts as a barrier against leakage from the any temporary filling and helps to dry persistently wet canals. So when you mean personally wet canals is when you have a beating canal which is where you have continuous pus or any kind of infection thing when you it keeps on coming in how much ever you do there's just you cannot dry so it's called a wet or a weeping canal. Common use medicament is calcium hydroxide. Moving on to obturation now the aim of obturation is to prevent the recontamination of the canal system from either a periapical or a coronal leakage and to isolate and utilize any remaining pulp tissue or bacteria in the canals. Now an ideal filling technique should assure that this complete filling of the canals without any overfill or with minimal or no voids. Now there's a certain criteria when you try to choose an ideal pulpyctomy material so it should be it should be a resorbable material you cannot use gutter pacha because the gutter pacha doesn't resolve so in a primary tooth the material that we're using needs to resolve ideally at the same rate as which the tooth resolves so that along with the tooth the material also resolves and it's lost along with the tooth. Then this it should have an antiseptic property it should be non-inflammatory and non-irritating to the underlying permanent tooth germ. It should be radiopic so that when you take a radiograph you should at least you can visualize how much of the material is filled and if in case you need to redo it it should be easy to remove and as well easy to insert into the canals. Moving on there are many different types of materials that are present. Y'all ideally should know what are the different types of materials and their contents. Now most commonly which we use for zinc oxide unusual taste it was discovered by bonus in 1837 and first used in dentistry by Chris Horman 1876. Now moving on to the composition there are two types now there's sorry then out of two types it comes in the form of powder and liquid. Now the powder contains zinc oxide, zinc steroid, zinc acetate and rosin. Well the liquid contains of eugenol, oils of cloves, vegetable or mineral oil, acidic acid and water. Easy to remember while the powder has a zinc oxide part the liquid has a eugenol part. What are the advantages with this material is that it's radiopic it has good plasticity it's cost effective also less cytotoxic to cells in direct or indirect content. Also it's an effective antimicrobial agent while the disadvantages include it's a sometimes underfilling is possible. There is foreign body reaction when overfilled like when you extrude zinc oxide foreign body reaction can occur and the resorption rate is slow that means if it's extruded it tends to remain in the tissue underlying tissue and can cause sometimes it causes a deflection of the permanent two part because permanent two part forms to extrude but there's you know there's maybe a small part of zinc oxide eugenol over there and then the permanent two part gets dislodged. Moving on to calcium hydroxide now this is now being you know very rarely used as a filling or as an obturated material more of a intracanal medicament. So you just need to know that what calcium hydroxide is one of the materials that was being used was introduced by Herman in 1930. Now there are different types of iodiform paste mostly the work of kri paste and the meister paste. Now the work of paste has consists of sterilized iodiform paste as a vehicle for a carefully blended mixture of parachlorofenol camphor menthol for root canal therapine primary teeth. Now the parachloroforma is 33.237 percent it acts as a disinfectant action depending on the liberation of chlorine in the presence of phenol. This liberation of clonine is what is acting as the antimicrobial for us. Then there's camphor and menthol in work of paste. Moving on kri paste now the composition includes iodiform, camphor, parachlorofenol and menthol. Advantage is being it has a disinfectant property again because of the parachlorofenol. Due to its smooth viscous nature it can be spun in with a lentil or spiral and injected with a precious thread. It is also resorbable and resorbs in synchrony with the root. Now this is one of the very acceptable properties of this is because it resorbs along with and the same rate of the tooth. Meister paste now it was developed by meister in 1967 composition includes zinc oxide iodiform, thymol, chlorofenol, camphor and lanolin. Now zinc oxide, thymol and lanolin is the additional thing to the contents of kri paste. Okay so kri paste had iodiform, chlorofenol and camphor. Now they added zinc oxide thymol and lanolin to make it a meister paste. These iodiform paste they resorb rapidly. Basically meister paste resorbs rapidly and it has no undesirable effect on the succidentity. It has a long lasting bactericidal potential. If extruded periapically it will be replaced with normal tissues. There is no foreign body reaction seen here. It doesn't set into a hard mass so if in case of any you know any time when you have to redo it then this it can easily be removed. Excellent healing properties and provides radioplasty. One of the downfalls of this is rate of resorption of material within the canals is faster than the rate of the physiological root resorption. We want this white apex again a very popular root canal filling material for primality. Composition includes iodiform, calcium, hydroxide and silicone. Remember the percentages if you can. Iodiform is 40.4% calcium hydroxide 30.3% while silicone is 22.4%. It comes as a premix paste and is enclosed in a syringe with a nozzle. Advantage is it is easy to apply. It resorbs at a slightly faster rate than the roots. No toxic effects on permanent successor even if we exclude this filling. Nothing happens to the permanent teeth and also it is radiopic. A newer material is endoflase. Again powder and liquid form. Powder has triiodomethine, anidine, dibutylol, ortho, chrysalis, zinc oxide, calcium hydroxide and barium sulfate. While liquid contains eugenol and parachlorofinol. Diode's pinto paste again it has three materials a rifocort, three medicines basically. Rifocort has which is pridnisolone acetate 5 milligrams which acts as a anti-inflammatory and antibiotic. Camphorated PMCC that is paramonochlorofin. 30% of PMCC, 70% of camphor both of which act as antimicrobial analgesics. Then you have iodoform which is basically iodine which acts as the antimicrobial. Moving on there is triple antibiotic paste also. So basically this is what is called LSTR. This is lesion stylization tissue reaction. Due to polymicrobial nature of the infected root canal, combination of antibacterial drug is required. Now there are three drugs which I use again metronidazole because of its wide bactericidal spectrum against anaerobic bacteria. Siprofloxacin which is again a broad spectrum antibiotic against aerobic gram negative organisms. Minocycline which is a long-acting antibiotic given against both gram negative and gram positive organisms and a liquid. To carry the three mix into the entire dentine and through the dental tubules to kill all the bacteria in the lesions. It basically uses to basically sterile the entire lesion. So you excavate, place this and the entire lesion becomes sterile. That means all the bacteria because these all the three antibiotics act on a wide range acts on both anaerobic and aerobic as well as gram positive as well as gram negative bacteria. Moving on to obturation techniques. Now you know what has to be done. Now how are you going to do it? You know of the different types of obturating materials. How are you going to place it into the canal? Now we have different types. You can use a lentilospiral technique or an endodontic pressure syringe. Incremental filling technique. You can obturate using a wet cotton. You can use pre-mix syringes like in the case of white apex. Mechanical or a tuberculin syringe technique. A jiffy tube method. Or even an amalgam plug-up. Now the thin mix of and reinforced zinc oxidoxenol basically is prepared and paper points are K files are covered with the material which I used to coat the root canal. First you make a thin mix coat the root canal and then a thick mix of zinc oxidoxenol is done. It's prepared rolled into a point and carried into the canal. How? Now carrying the thick mix of zinc oxidoxenol you can use a lentilospiral. Basically it's you know you can use the lentilospiral in a manual method or in a rating. Using a contra-ankle handpiece okay. So a lentilospiral or a v-mortified is held by hand. The coxid paste is carried by dipping the spiral into the mix. Inserted into the canal with clockwise rotation accompanied by vibrating motion to reach the apex. Then you withdraw from the canal while simultaneously continuing the rotate clockwise rotating motion. Process is repeated five to seven times until you feel that the canal is filled. Moving on enderontic pressure syringe. This is an enderontic pressure syringe. It consists of an internally threaded barrel with a threaded hub, a threaded plunger, threaded needle and a small bench. Using this syringe a very thick mix of zinc oxidoxenol can be forced through an extremely narrow gauge needle. One of the disadvantages are that it is relatively complex and the need to disable it to load additional filling material. The entire syringe has to be disabled just to load additional if you feel you're falling short of the material and also there's a need for immediate cleaning to prevent hardening of the filling material because zinc oxide sets into a hard mass. Moving on to an incremental filling technique. Okay so in this method an enderontic plug corresponding to the size of the canal with the rubber stopper is used to place a thick mix of zinc oxide into the canal. The length of the plugger should at least be 2 mm short of the root canal length. Okay whatever is your working length choose 2 mm short take a thick mix place it into the canal. A thick mix of zinc oxide is prepared rolled into a flame shape. Okay then again measuring that it's almost 2 mm short of the length of the working length you make that zinc oxide unit and start starting from the tapered part of the rolled mix. It is carried into the canal and tapped gently into the apical area. Then again additional increments of 2 mm blocks are added until the canal is filled. So you start so in this technique basically let's summarize it. You know what is the working length take 2 mm short take the plugger take around 2 mm of the thick mix place it into the canal so that is almost nearing the apex. Then you tap it gently make sure it's packed then next take another 2 mm put it into the canal again push it where you had previously stopped. Continue doing this until you feel that the canal is filled. Tuberculosis or a local anesthetic syringe can also be used these are again disposable this one again used to place the zinc oxide you should not paste. Now using wet cotton in this method you first zinc oxide is mixed taken into the root canal using a file or remover. Okay so you pack the canal with that and use a small wet cotton pellet and you can use it to condense the material inside the canal. You need to repeat it at least 5 to 18 but in this you do not have control and it can lead to extrusion of the material because sometimes if you put extra force while using the cotton pellet you're going to extrude the material. G-fetube method again a regular mix of zinc oxide is back loaded into this tube and then this part of the tube is placed into the canal orifice and the material is expressed into the canal by downward squeezing motion until you feel that material coming out of the orifice of the canal. Amalgam pluggers you've used amalgam pluggers to do an amalgam recitation you can use this in the same way use it to carry the zinc oxide into the canal. Pre-mixed syringes like Metapax and Vitapax are also used it's nothing you clean dry the canals place the tip into the canal as far as possible and then slowly withdrawing the syringe you start pressing the thing so you feel the material filling into the canals. One of the disadvantages is due to the thickness and limited flexibility of the plastic needle this is made of plastic the tip of the metapax syringe is made of plastic and it's not very flexible you may not be able to reach the apex okay and it's easy to use for primary incisors because the canals are much wider in the incisors but not very practical for especially narrow canals of primary molars especially the first primary molars they're very narrow canals. Moving on now you've finished an observation that's not the end you need to do a final restoration ideally it is to be done using a stainless steel crown also can be done using a composite restoration glass inamore restoration open face crown right even a miracle mix restoration can be done this is to prevent any kind of infection or any kind of you know outside kind of any infection reaching the canals again because you've cleaned it you've shaped it made sure you've you know you've removed all the infection but if you do not do a proper restoration post pulpectomy then if chances of failure is high okay now how would you define what is a success you know if a pulpectomy successful or not if there is no pathological mobility post pulpectomy there's no sensitivity to percussion or you know this healthy appearance of the soft tissue surrounding the teeth you know it is a success radiographically there is no evidence of bone or re-resorption except for that associated with the exfoliation process bifurcation radiolucency if any was present before pulpectomy has resolved six to twelve months post-operatively no periapaker radiolucency post-operative now sometimes pulpectomy fails right and what are the signs and symptoms there's pain the swelling as well as abscess there's over retention of the treated primary tooth a deflection of the erupting succidinous tooth you know if you have extruded the material there are succidinous tooth defects enamel defects in the permanent tooth if you see them that means the pulpectomy done before had failed over-opteration or an under-opteration both of which are again a failure or if there's a periapaker lapses post-treating then again it can be a failure now to summarize the entire the entire topic what was our goal our goal was to completely remove necrotic pulpal tissue from the root canals and the coronal portion of the prior d vital primary tool to maintain our tooth in the dental arch how are we planning we're going to do it do the access cavity preparation have straight line access to all the canals remove all the carousel tissue care of you know do a coronal pulpal petition locate the canals pulp extirpation from the canals determine the working length depride the canals do a chemical mechanical preparation of the canals use a proper irrigant whatever you're using if it's even a saline chloroxidine sodium hypochloric make sure it's properly used dry the root canals before you operate always dry the root canals then do an observation followed by a final restoration the different types of operating materials we could use a zinc oxidoge no calcium hydroxide or even the iodiform paste thank you