Pediatric Dentistry

Dr. Shahad Jamal Lec. 22

REACTION OF THE PULP TO VARIOUS

CAPPING MATERIALS
ZINC OXIDE–EUGENOL
Zinc oxide–eugenol was used more often than any other pulp capping material before
calcium hydroxide came into common use. Although dentists have apparently had good
clinical results with the use of zinc oxide–eugenol, it is not recommended as a direct
pulp-capping material.
CALCIUM HYDROXIDE
Calcium hydroxide used as a biological dressing. Because of its high alkalinity (pH 12),
it is so caustic that when it is placed in contact with vital pulp tissue, the reaction
produces a superficial necrosis of the pulp. The irritant qualities seem to be related to its
ability to stimulate development of a calcified barrier. The superficial necrotic area in
the pulp that develops beneath the calcium hydroxide is demarcated from the healthy
pulp tissue below by a new, deeply staining zone comprised of basophilic elements of
the calcium hydroxide dressing.
The original proteinated zone is still present. However, against this zone is a new area of
coarse fibrous tissue likened to a primitive type of bone. On the periphery of the new
fibrous tissue, cells resembling odontoblasts appear to be lining up. One month after the
capping procedure, a calcified bridge is evident radiographically. This bridge continues
to increase in thickness during the next 12 months. The pulp tissue beneath the calcified
bridge remains vital and is essentially free of inflammatory cells.
PREPARATIONS CONTAINING FORMALIN
The clinical success experienced in the treatment of primary pulps with these materials
is due to the drug’s germicidal action and fixation qualities than to its ability to promote
healing. Some studies have indicated that the formocresol pulpotomy technique may

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be applied to permanent teeth, but its use in permanent teeth remains an interim
procedure, to be followed by conventional endodontic therapy.
Notes:
Recently, because of formocresol negative systemic properties, its use should be limited.
Formaldehyde has a known carcinogenic, immunogenic, toxic, and mutagenic potential,
which makes it questionable and unsuitable for use in pedodontic endodontics.
Therefore, Biodentin and MTA can be used instead of it and other experimental capping
materials alternative to formocresol are:
➢ Laser Pulpotomy
➢ Electrosurgical Pulpotomy
➢ Bone morphogenic protein
➢ Calcium hydroxide Dentin chips
FERRIC SULFATE
Ferric sulfate (15.5% Fe2SO4) has been used as pulpotomy agent as a substitute for
formocresol for 15–20 years. Ferric sulfate in contact with blood forms a ferric ion–
protein complex, which seals the cut blood vessels mechanically, producing hemostasis.
The effect of ferric sulfate is hemostatic but not bactericidal or fixative. After
application of ferric sulfate for 15 seconds, the pulp is covered with zinc oxide–eugenol
and the cavity sealed.
Glutaraldehyde
It has been widely tested, to replace formocresol. Studies have shown that application of
2-4% produces rapid surface fixation of the underlying pulp tissue. Attributes of
glutaraldehyde over formocresol
1)Forms strong intra- and intermolecular protein bonds leading to superior
fixation by cross linkage.

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2)Diffusability is limited, thus reducing the apical extension of the material
3)Excellent antimicrobial property
4)Less dystrophic calcification
5)Produces initial zone of fixation that does not proceed apically
6)Readily excreted from the body. About 90% will be eliminated in 3 days.
7)15-20 times less toxic than formocresol and have little potential for
chromosomal interference or mutagenecity.
MINERAL TRIOXIDE AGGREGATE
MTA is emerging as a popular product for pulpotomies secondary to a variety of
factors. Torabinejad described the physical and chemical properties of MTA in 1995.
It is ash colored powder made primarily of fine hydrophilic particles of:
1) Tricalcium silicate
2) Tricalcium aluminate
3) Tricalcium oxide
4) Silicate oxide and bismuth oxide is added for radio-opacity.
MTA should mixed with sterile water or other sterile liquids in 3: 1 (powder /liquid)
ratio to obtain a putty consistency or a thick grainy paste. If the paste is, too dry it will
fall when one try to pick it up. Hydration of the powder results in a colloidal gel
composed of calcium oxide crystals in an amorphous structure. This gel solidifies into
a hard structure in about three to four hours.
MTA has an antibacterial effect on some facultative bacteria but no effect on strict
anaerobic bacteria. This limited antibacterial effect is less than that demonstrated by
calcium hydroxide pastes. The ability of MTA to resist the penetration of
microorganisms appears to be high. – The use of MTA as an agent for pulp capping or
for providing apical seal is well documented. Recent studies have indicated that MTA
can be used successfully as a pulpotomy agent also.

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Properties of MTA
 It is biocompatible material and its sealing ability is better than that of amalgam
or ZOE.
 Initial pH is 10.2 and set pH is 12.5
 Antimicrobial activity.
 The setting time of cement is 4 hours
 The ability to set in the presence of moisture and blood.
 Low cytotoxicity
 It presents with minimal inflammation if extended beyond the apex.
The negative attributes include:
 Difficulty of handling
 Exceptional cost.
 MTA can cause pulp canal obliteration.
MECHANISM OF ACTION
The successful usage of MTA in endodontic applications can be attributed to its
biocompatibility, bioactivity and mechanism of action. The four actions of MTA after
direct placement in contact with living tissues are:
(i) Creation of an unfavorable environment for growth of bacteria due to its
alkaline pH.
(ii) Formation of hydroxyapatite like mineral structure on its surface and provide
the biological seal.
(iii) Formation of calcium hydroxide, which dissociates to release Ca ions, to
promotes cellular attachment and proliferation.
(iv) Modulation of cytokine production and encouragement of hard tissue
forming cells to differentiate and migrate.

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Clinical applications of MTA
1) Pulp capping:
a) Direct Pulp Capping:
MTA is suitable as a pulp capping because it stimulates dental bridge formation
and the bridge formed adjacent to MTA will be thick and continuous with
regional dentin. No bacteria were observed on the cavity wall when MTA was
used, due to sealing ability, biocompatibility, alkalinity, and ability of MTA to
stimulate dentin bridge formation.
b) Pulpotomy of immature permanent teeth:
The pulp responds favorably to the protection provided by an MTA layer, and
the reparative dentin is consistently uniform and thicker under MTA more than
that with Ca (OH) 2.
c) Pulpotomy of primary teeth
MTA seems to be a suitable replacement for T.C.F.
2) Root resorption
3) Apexification
4) Furcal repair
5) Perforation repair
6) Root ending filling
FAILURES AFTER VITAL PULP THERAPY
Factors that may lead to failure in the formation of a calcified bridge across the vital
pulp may involve:
1) The age of the patient
2) Degree of surgical trauma
3) Sealing pressure
4) Improper choice of capping material
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5) Low threshold of host resistance
6) Presence of microorganisms with subsequent infection.
This failure may appears as:
 Internal resorption
 Alveolar abscess
 Early exfoliation or over retention of primary teeth with pulp treatment
INTERNAL RESORPTION
One of the most frequently seen evidence of an abnormal response in primary teeth
within the pulp canal several months after the pulpotomy procedure is the radiographic
evidence of internal resorption. Internal resorption is a destructive process generally
caused by odontoclastic activity, and it may progress slowly or rapidly. Occasionally,
secondary repair of the resorbed dentinal area occurs. No satisfactory explanation for
the post pulpotomy type of internal resorption has been given. However, that with a
true carious exposure of the pulp, an inflammatory process will be present to some
degree. The inflammation may be limited to the exposure site, or it may be diffused
throughout the coronal portion of the pulp.
Amputation of all pulp showing the inflammatory change may be difficult or
impossible, and abnormal pulp tissue may be allowed to remain. If the inflammation
extended to the entrance of the pulp canal, odontoclasts may have been attracted to the
area; if it were possible to examine the tooth histologically; small bays of resorption
would be evident. This condition may exist at the time of pulp therapy, although there
is no way to detect it. The only indication would be the clinical evidence of a
hyperemic pulp. Inflammatory cells drawn to the area because of the placement of an
irritating capping material might well attract odontoclastic cells and initiate internal
resorption. This may explain the occurrence of internal resorption even though the pulp
is normal at the time of treatment. Because the roots of primary teeth are undergoing

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normal physiologic resorption, vascularity of the apical region is increased. When an
irritant in the form of a pulp-capping material is placed on the pulp, odontoclastic
activity present in the area and may predispose the tooth to internal resorption.

ALVEOLAR ABSCESS
Some months after pulp therapy has been completed, an alveolar abscess occasionally
develops. The tooth usually remains asymptomatic, and the child is unaware of the
infection, which may be present in the bone surrounding the root apices or in the area
of the root bifurcation.
A fistulous opening may be present, which indicates the chronic condition of the
infection. Primary teeth that show evidence of an alveolar abscess should be removed.
Endodontic treatment may be considered for permanent teeth that have previously been
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treated by pulp capping or by pulpotomy and later show evidence of pulpal necrosis
and apical infection.

EARLY EXFOLIATION OR OVER-RETENTION OF PRIMARY TEETH

WITH PULP TREATMENTS
Occasionally a pulpally treated tooth previously believed to be successfully managed
will loosen and exfoliate (or require extraction) prematurely for no apparent reason. It
is believed that such a condition results from low-grade, chronic, asymptomatic,
localized infection. Usually, abnormal and incomplete root resorption patterns of the
affected teeth are also observed. When this occurs, space management must be
considered.
Another sequela requiring close observation is the tendency for primary teeth
undergoing successful pulpotomies or pulpectomies to be over-retained. This situation
may have the untoward result of interfering with the normal eruption of permanent
teeth and adversely affecting the developing occlusion. Close periodic observation of

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pulpally treated teeth is necessary to intercept such a developing problem. Extraction
of the primary tooth is usually sufficient. This phenomenon may occur when normal
physiologic exfoliation is delayed by the bulky amount of cement contained in the pulp
chamber. Even though the material is resorbable, its resorption is slowed significantly
when large quantities are present.

FAILURE AFTER VITAL PULP THERAPY

The failure of vital pulp treatment may be caused by an infection that can be attributed
to remaining microorganisms or the intrusion of new bacteria along a gap between
tooth and filling material in defective restorations. In the process, pulp necrosis and
formation of periapical inflammation can occur unnoticed.

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APEXOGENESIS
It is defined as the treatment of a vital pulp in the permanent teeth by capping or pulpotomy
in order to permit continued growth of the root and closure of the open apex. Those teeth
were affected by trauma.
Objectives
Maintenance of integrity of the radicular pulp tissue to allow for continued root growth.
Indications
 Indicated for traumatized or pulpally involved vital permanent tooth with incomplete
formation of the root apex.
 No history of spontaneous pain
 No sensitivity on percussion.
 No hemorrhage.
 Normal radiographic appearance.
Contraindications
 Evidence that radicular pulp has undergone degenerative changes
 Purulent drainage
 History of prolonged pain
 Necrotic debris in canal
 Periapical radiolucency.
Clinical procedure
Same principle steps for the permanent tooth pulputomy.

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REVASCULARIZATION
It is a new treatment method for immature necrotic permanent teeth. Up to now,
apexification procedures were applied for these teeth, using calcium dihydroxide or
MTA to produce an artificial apical barrier.
Pulp revascularization is dependent on the ability of residual pulp and apical and
periodontal stem cells to differentiate. These cells have the ability to generate a highly
vascularized and a conjunctive rich living tissue. This one is able to colonize the
available pulp space. Subsequently, these stem cells will differentiate into newly formed
odontoblasts that will induce an apposition of hard tissue.

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Procedure
Pulp revascularization using calcium hydroxide.
First step
 Local anesthesia  
 Isolation of the tooth with a rubber dam  
 Opening of the pulp chamber to canal entrance (pulpotomy)  
 Irrigation of root canal (often with 10 mL sodium hypochlorite at 2.5%)a  
 No instrumentation in root canal  
 Preparation of calcium hydroxide pasteb  
 Insertion of the paste in the pulp chamber and in the coronary part (third or half)
of root canal (with a cotton ball)  
 Sealing of the access cavity with a temporary filling  
Second step
(two or three weeks later if asymptomatic tooth and/or absence of fistula)
 Local anesthesia without vasoconstrictora  
 Isolation of the tooth with a rubber dam  
 Opening the tooth to have a access to root canal  
 Removal of the calcium hydroxide paste  
 Copious irrigation of root canal with sodium hypochlorite  
 Rinsing root canal with sterile water  
 Drying root canal with paper cones  
 An apical bleeding is caused by irritation of the apical region with a 15 K-file
limeb  
 Preparation of mineral trioxide aggregate (MTA) and its placement on the clot in
order to form a hermetic sealing  
 Place a wet a cotton ball on MTA filling  

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 Sealing of the cavity with a temporary filling
In pulp revascularization, at three months postoperative, the tooth is normally
asymptomatic and about nine months later X-ray radiography shows an increasing
thickness of dentinal walls and an apical closure. Root development and apical closure
may be visible after three months.

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FAILURES AFTER VITAL PULP THERAPY
Factors that may lead to failure in the formation of a calcified bridge across the vital
pulp may involve:
1) The age of the patient
2) Degree of surgical trauma
3) Sealing pressure
4) Improper choice of capping material
5) Low threshold of host resistance
6) Presence of microorganisms with subsequent infection.
This failure may appears as:
 Internal resorption
 Alveolar abscess
 Early exfoliation or over retention of primary teeth with pulp treatment
INTERNAL RESORPTION
One of the most frequently seen evidence of an abnormal response in primary teeth
within the pulp canal several months after the pulpotomy procedure is the radiographic
evidence of internal resorption. Internal resorption is a destructive process generally
caused by odontoclastic activity, and it may progress slowly or rapidly. Occasionally,
secondary repair of the resorbed dentinal area occurs. No satisfactory explanation for
the post pulpotomy type of internal resorption has been given. However, that with a
true carious exposure of the pulp, an inflammatory process will be present to some
degree. The inflammation may be limited to the exposure site, or it may be diffused
throughout the coronal portion of the pulp.
Amputation of all pulp showing the inflammatory change may be difficult or
impossible, and abnormal pulp tissue may be allowed to remain. If the inflammation
extended to the entrance of the pulp canal, odontoclasts may have been attracted to the
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area; if it were possible to examine the tooth histologically; small bays of resorption
would be evident. This condition may exist at the time of pulp therapy, although there
is no way to detect it. The only indication would be the clinical evidence of a
hyperemic pulp. Inflammatory cells drawn to the area because of the placement of an
irritating capping material might well attract odontoclastic cells and initiate internal
resorption. This may explain the occurrence of internal resorption even though the pulp
is normal at the time of treatment. Because the roots of primary teeth are undergoing
normal physiologic resorption, vascularity of the apical region is increased. When an
irritant in the form of a pulp-capping material is placed on the pulp, odontoclastic
activity present in the area and may predispose the tooth to internal resorption.

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ALVEOLAR ABSCESS
Some months after pulp therapy has been completed, an alveolar abscess occasionally
develops. The tooth usually remains asymptomatic, and the child is unaware of the
infection, which may be present in the bone surrounding the root apices or in the area
of the root bifurcation.
A fistulous opening may be present, which indicates the chronic condition of the
infection. Primary teeth that show evidence of an alveolar abscess should be removed.
Endodontic treatment may be considered for permanent teeth that have previously been
treated by pulp capping or by pulpotomy and later show evidence of pulpal necrosis
and apical infection.

EARLY EXFOLIATION OR OVER-RETENTION OF PRIMARY TEETH

WITH PULP TREATMENTS
Occasionally a pulpally treated tooth previously believed to be successfully managed
will loosen and exfoliate (or require extraction) prematurely for no apparent reason. It

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is believed that such a condition results from low-grade, chronic, asymptomatic,
localized infection. Usually, abnormal and incomplete root resorption patterns of the
affected teeth are also observed. When this occurs, space management must be
considered.
Another sequela requiring close observation is the tendency for primary teeth
undergoing successful pulpotomies or pulpectomies to be over-retained. This situation
may have the untoward result of interfering with the normal eruption of permanent
teeth and adversely affecting the developing occlusion. Close periodic observation of
pulpally treated teeth is necessary to intercept such a developing problem. Extraction
of the primary tooth is usually sufficient. This phenomenon may occur when normal
physiologic exfoliation is delayed by the bulky amount of cement contained in the pulp
chamber. Even though the material is resorbable, its resorption is slowed significantly
when large quantities are present.

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NONVITAL PULP TREATMENT WITH IRREVERSIBLE PULPITIS
OR NECROTIC PULP
PULPECTOMY
It involves the removal of the entire pulp and subsequent filling of the canals of the primary
teeth with a suitable resorbable material.
It is unwise to maintain untreated infected primary teeth in the mouth. They may be opened
for drainage and often remain asymptomatic for an indefinite period. However, they are a
source of infection and should be treated or removed. The morphology of the root canals in
primary teeth makes endodontic treatment difficult and often impractical. Mature first
primary molar canals are often so small that they are inaccessible even to thesmallest barbed
broach. If the canal cannot be properly cleansed of necrotic material, sterilized, and
adequately filled, endodontic therapy is more likely to fail.
Objectives of Pulpectomy
 Maintain the tooth free of infection
 Biomechanically cleanse and obturate the root canals
 Promote physiologic root resorption
 Hold the space for the erupting permanent tooth.
Indications of Pulpectomy
 Patient should be in good general health with no serious disease.
 Maximum cooperation of patient and parents.
 A tooth previously planned for a pulpotomy that shows uncontrolled pulpal
hemorrhage.
 Indicated for any primary tooth in absence of its permanent successor.
 Any deciduous tooth with severe pulpal necrosis provided there is no radiographic
contraindication.

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 Primary teeth with necrotic pulps and minimum of root resorption.
 Pulpless primary teeth with stomas.
 Pulpless primary teeth in hemophiliacs.
 Pulpless primary anterior teeth when speech, esthetics are a factor.
 Pulpless primary molars holding orthodontic appliance.
Note:
In addition to the previous indications, the tooth should have adequate periodontal and bony
support.
Contraindications of Pulpectomy
 General Contraindications
o Young patient with systemic illness such as congenital ischemic heart disease,
leukemia.
o Children on long-term corticosteroids therapy.
 Clinical Contraindications
o Excessive tooth mobility.
o Communication between the roof of the pulp chamber, and the region of
furcation.
o Insufficient tooth structure to allow.
 Radiographic Contraindications
o External root resorption.
o Internal root resorption in the apical third of the root.
o Radicular cyst, dentigerous/follicular cyst in association with the primary tooth.
o Inter-radicular radiolucency that communicates with the gingival sulcus.
Partial Pulpectomy
This procedure is indicated in primary teeth when:

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1) Coronal pulp tissue and the tissue entering the pulp canals are vital but show clinical
evidence of hyperemia.
2) The tooth may or may not have a history of painful pulpits, but the contents of the
root canals should be show evidence of necrosis (suppuration).
3) There is no radiographic evidence of a thickened periodontal ligament or of
radicular disease.
If any of these conditions are not present, a complete pulpectomy or an extraction should be
performed.
The clinical procedure
The partial pulpectomy technique may be completed in one appointment that involves the
removal of the coronal pulp as for the pulpotom y technique. Removal of the pulp filaments
from the root canals done with a fine barbed broach; there will be considerable hemorrhage
at this point. A Hedstrom file will be helpful in the removal of remnants of the pulp tissue.
The file removes tissue only as it is withdrawn and penetrates readily with a minimum of
resistance.
Care should be taken to avoid penetrating the apex of the tooth. After removal of the pulp
tissue from the canals, a syringe is used to irrigate them with 3% hydrogen peroxide
followed by sodium hypochlorite. Then dryness of the canals should done with sterile paper
points. Hemorrhage should control and the canals should be dry.
Thin mix of zinc oxide-eugenol paste may be prepared, and paper points covered with the
material can be used to coat the root canal walls. Small files may be used to file the paste
into the walls. The excess thin paste may be removed with paper points and Hedstrom files.
Notes:
 Zinc oxide–eugenol paste has been viewed as the traditional root canal filling
material for primary teeth.

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 Results from multiple studies suggest that KRI paste may be preferable. The primary
components of KRI paste are zinc oxide and iodoform. Themain advantages of KRI
paste over zinc oxide–eugenol paste are that KRI paste resorbs in synchrony with
primary roots and is less irritating to surrounding tissues if a root is inadvertently
overfilled.
 Another popular root canal filling material for primary teeth is Vitapex. The primary
components of Vitapex are calcium hydroxide and iodoform. Vitapex may be at least
as effective as KRI paste.

Complete Pulpectomy
Clinical technique is similar to partial pulpectomy but not all the procedures are done on the
first visit.
On the first visit, the pulp is extirpated and all the contents of the pulp chamber and debris
from the occlusal third of the canals should be removed, with care taken to avoid forcing
any of the infected contents through the apical foramen. Then canals are irrigated, dried and
a moistened pellet of camphorated monochlorophenol (CMCP) or 1:5 concentration of
Buckley's formocresol, with excess moisture blotted, should be placed in the pulp chamber.
The chamber may be sealed with zinc oxideeugenol and the tooth is temporarily restored.

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On the second visit, several days later, the tooth should be isolated with a rubber dam and
the treatment pellet removed. If the tooth has remained asymptomatic during the interval,
the remaining contents of the canals should be removed and the canals are enlarged. If all
the symptoms have subsided, the tooth is obturated and permanently restored.

Notes:
 If the tooth has been painful and there is evidence of moisture in the canals after the
removal of the treatment pellet, again mechanical cleaning of the canals should be
done followed by irrigation then dryness and the treatment should be repeated.
 Obturation should postponed until the symptoms regresses.
 Systemic antibiotics are advised if cellulitis is present.
 The signs and symptoms at each visit will determined the number of appointments,
timing and extent of instrumentation.

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APEXIFICATION
It is a method of dental treatment to induce a calcific barrier in a root with incomplete
formation or open apex of a tooth with necrotic pulp. Pulpal involvement usually occurs
as a consequence of trauma or caries involvement of young or immature permanent
teeth. As a sequelae of untreated pulp involvement, loss of pulp vitality or necrotic pulp
took place for the involved teeth.
The main purpose of apexification includes restoring the original physiologic structures
and functions of the pulp-dentin complex of the teeth. In addition to that, the
elimination of the pulp tissue within a tooth, the disinfection of root canal system by
using irrigants such as sodium hypochlorite and ethylenediaminetetraacetic acid are the
necessary steps to ensure that the purpose of apexification is being met.
The apexification procedure will normally requires several monthly appointments or
follow-ups to observe any calcific changes induced at the apex of tooth concerned. In
these visits, a material known as calcium hydroxide ( Ca(OH)2 ) will be placed inside
the root canal systems to eliminate intracanal infection, stimulates calcification and
achieves apical barrier seal at the apex of tooth root. The success rate of applying the
traditionally used calcium hydroxide to induce calcific barrier is between 74%-100%.
Nowadays, a newer material known as mineral trioxide aggregate (MTA) is widely used
as well.
Indication and objectives
 Apexification is indicated for immature permanent teeth that are non-vital with
incompletely formed roots.
 The objective of this procedure is to induce root end closure (apexification) at the
apices of immature roots through the formation of mineralized tissue.

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 Apical closure can take various forms but in most cases, it appears to be irregular
and aberrant. Along with apical closure, root development may or may not
continue.
 The method of apexification used to create an apical barrier.
Materials used in apexification
1. Mineral trioxide aggregate
Mineral trioxide aggregate (MTA) is composed primarily of tricalcium silicate,
tricalcium aluminate, tricalcium oxide, and silicate oxide. It has been used in
endodontics as a root-end filling material, and sets in the presence of moisture. After
numerous testing and analysis, MTA showed superior properties from its physical
properties and biocompatibility. It is shown to have less marginal gap formation, less
leakage and better adaptation than other filling materials.
2. Bioceramics
In order to overcome the limitations of MTA, recent advance in dental materials has
introduced bioceramics as a new root canal obturation and repair material. Its
composition mainly includes zirconium oxide, calcium silicates, calcium phosphate
monobasic, calcium hydroxide, filler, and thickening agents.
3. Biodentine
Biodentine is a tricalcium silicate-based material, as an alternative to permanent
dentin. It is biocompatible and is a new bioactive dentin substitute cement, which is
composed of powder that consists of tricalcium silicate, dicalcium silicate, calcium
carbonate, calcium oxide, zirconium oxide, and calcium hydroxide. It allows good
marginal sealing, thus preventing marginal leakage as well as protecting the
underlying pulp by inducing the formation of tertiary dentin.

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Notes:
 Biodentin has similar to or better than those of MTA, from biocompatibility,
antimicrobial activity, sealing ability and ability to enhance dentin
biomineralization.
 The bonding ability in a high-humidity environment and color stability of biodentine
were significantly better than those of MTA.
 The setting time of biodentine is shorter as compared with that of MTA.
Procedure
Proper assessment of the tooth is important in determining an accurate diagnosis in order
to formulate an appropriate treatment plan. Clinical evaluation of pulpal status includes
a comprehensive history and diagnostic tests. Radiographic examination is used to
determine the maturity of the developing root. However, immature teeth are commonly
associated with young patients and pulp testing in children is complex and subjective to
nature.
The following steps are included in this procedure:
 The affected tooth is isolated using rubber dam
 An access opening is made to reach the pulp chamber
 A file is placed in the root canal and a radiograph is taken to establish the root
length. Care should be taken to avoid pushing instruments through the apex
 Remnants of the pulp are then removed using barbed broaches and files
 The canal is flushed with hydrogen peroxide to remove debris and is then irrigated
with sodium hypochlorite and saline
 The material of choice is placed in the canal and an endodontic plugger is used to
push the material to the apical end
 A cotton pledget is placed and the cavity is sealed with reinforced zinc oxide-
eugenol cement
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Apexification procedure can be completed in one or two appointments depending on the
initial clinical sign and symptoms. The procedure may also vary depending on the
materials or medication used. Generally, the treatment paste is allowed to remain for six
months before the evaluation for an apical closure.

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