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Obturating materials in pediatric dentistry: A review

Article · January 2021

DOI: 10.22271/oral.2021.v7.i1c.1133

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 International Journal of Applied Dental Sciences 2021; 7(1): 175-182

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2021; 7(1): 175-182 Obturating materials in pediatric dentistry: A review
© 2021 IJADS
www.oraljournal.com
Received: 15-11-2020 Dr. Rakhshunda Manzoor and Marikinda Manzoor
Accepted: 22-12-2020
DOI: https://doi.org/10.22271/oral.2021.v7.i1c.1133
Dr. Rakhshunda Manzoor
Post Graduate Student,
Abstract
Department of Pediatric
Primary teeth should be preserved until their normal exfoliation time so as to maintain arch length and
Dentistry, Jaipur Dental College,
Jaipur, Rajasthan, India
function in order to provide proper guidance for the eruption of permanent teeth, enhance esthetics and
mastication, prevent aberrant tongue habits, aid in speech and prevent the psychological effects
Marikinda Manzoor associated with tooth loss. Pulpectomy consists of removing the pulp tissue associated with micro-
Post Graduate Student, organisms and debris from the canal and obturating with resorbable filling material. Success rate of
Department of Conservative endodontic therapy depends on many factors like familiarity with the complexity of primary tooth canal
Dentistry, Jaipur Dental College, systems, their formation and resorption pattern, obturating material as well as obturation technique used
Jaipur, Rajasthan, India that is capable of densely filling the entire root canal system and providing a fluid tight seal from the
apical segment of the canal to the cavo-surface margin in order to prevent reinfection. One of the major
areas of research in pulpectomy is to discover new materials for obturation so to have the specific
properties similar to teeth. This article will render the role of many important obturating materials which
we use in dentistry and their advantages and disadvantages and their modifications.

Keywords: Obturating materials, pediatric dentistry, primary teeth

Introduction
Primary teeth are the best space maintainers and hence should be preserved and retained as
long as possible [1]. Pulpectomy is the procedure of extirpating the diseased pulp associated
with microorganism and debris from the canal and obturating with an antibacterial resorbable
filling material and it is indicated when the inflammation of the pulpal tissue involves the
radicular pulp or when nonvital tooth is diagnosed [1]. Ultimately, pulpectomy is needed to
achieve good hermetic seal which depends on various factors such as good biomechanical
preparation, types of obturating material used and achievement of minimum voids. Obturating
the canal creates a fluid tight seal along the length of the root from the coronal opening to the
apical system and eliminating all portals of entry between the periodontium and the root canal
system [2].
In an attempt to improve the clinical success of pulpectomies, different filling materials and
obturation techniques for primary teeth have been proposed. Although zinc oxide and eugenol,
calcium hydroxide and iodoform based pastes are currently recommended, there is still no
consensus on the gold standard material for this purpose [1, 2]. Many laboratorial studies have
been designed to investigate the effectiveness of different obturation techniques and filling
materials for primary teeth, but most of them used radiographs or conventional tomographic
evaluations [3]. While both techniques have very low spatial resolution (ranging from 100 to
1000μm), radiographs have also de limitation of being a bidimensional evaluation [3].
Moreover, major differences in the root canal anatomy among the used specimens (lack of
paired specimens) may be a source of bias in evaluating the effectiveness of a certain
technique in endodontic studies and for this reason, the use of prototypes, with individualized
root canal anatomy may bring advantages in this regard [2, 3]. Finally, a detailed quantitative
tridimensional analysis of voids and effectiveness of root canal obturation in primary teeth
Corresponding Author: have not yet been performed [3].
Dr. Rakhshunda Manzoor
Post Graduate Student, Optimal requirements of obturating material for deciduous teeth
Department of Pediatric Rabinowitch [1] stated, "The history of the treatment of root canals is the discussion of
Dentistry, Jaipur Dental College,
Jaipur, Rajasthan, India medication used:
 It should not irritate the periapical tissues nor coagulate any organic remnants in the canal.
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 It should have a stable disinfecting power. filling material following pulpotomies or pulpectomies in the
 Excess pressed beyond the apex should be resorbed primary dentition. Zinc oxide–eugenol cements should be
easily. used with caution under resin-based composite restorations
 It should be inserted easily into the root canal and because the eugenol can inhibit the polymerization of the
removed easily if necessary. resin. A glass ionomer cement base may be placed over zinc
 It should adhere to the walls of the canal and should not oxide–eugenol before the placement of resin-based composite
shrink. in order to avoid polymerization [2, 5].
 It should not be soluble in water. Zinc oxide eugenol was discovered by Bonastre (1837) and
 It should not discolour the tooth. subsequently used in dentistry by Chisholm (1876). Sweet in
 It should be radiopaque. 1930 said that it was the first root canal filling material to be
 It should induce vital periapical tissue to seal the canal recommended. ZOE is a commonly used filling material for
with calcified or connective tissue. primary teeth. Camp [3, 5] introduced the endodontic pressure
 It should be harmless to the adjacent tooth germ. syringe to overcome the problem of underfilling, a relatively
 It should not set to a hard mass, which could deflect an common finding when thick mixes of ZOE are employed.
erupting permanent tooth. However, underfilling is frequently clinically acceptable.
Primary teeth frequently present with interradicular
Rifkin [2] identified criteria for an ideal obturating material radiolucent areas but without periapical lesions, and they
used in pulpectomy that include sometimes even have some vital pulp at the apex. Conversely,
1) Resorbability overfilling may cause a mild foreign body reaction, and it has
2) should have an Antiseptic property also been associated with increased failure rate when
3) Noninflammatory and nonirritating to the underlying compared with underfilling or flush finishing [2, 4]. Success
permanent tooth germ, (4) Good Radiopacity for rate with this material varied between 65% and 100%, with an
visualization on radiographs, average of 83%, and no significant difference could be
4) Ease of insertion, and observed when ZOE was compared with other calcium
5) Ease of removal. But till now none of the currently hydroxide and/or iodoform pastes.
available obturating materials possess all of these criteria Hashieh [4] studied the beneficial effects of eugenol. The
6) Should not cause any tooth discoloration. amount of eugenol released in the periapical region
7) The present review attempt to evaluate each of the immediately after placement was 10-4 and drops to 10-6 after
presently available obturating materials and present a few 24 hrs, reaching zero after one month. Within these
of the emerging concepts related to obturation of primary concentrations, eugenol is said to have anti-inflammatory and
teeth. analgesic properties that are very useful after a pulpectomy
procedure.
Erasquin et al. (1967) [5] reported that the canals overfilled
with (ZOE) are not recommended because it irritates the
periapical tissues and causes necrosis of bone and cementum.
Barker and Lockett Spedding Mortazavi and Mesbahi (1971)
[6, 7, 8]
stated that extruded ZOE resisted resorption and took
months or even years to resorb. Coll et al. (1985) [9] reported
that when ZOE extrudes from root canal, it develops a fibrous
capsule that prevents resorption of the material. Thus, it has a
slow rate of resorption and has a tendency to be retained even
after the exfoliation of tooth. Areas of cementum resorption
were evident, periodontal ligament exhibited intense and
moderate thickening. Dentin resorption was not seen, whereas
bone resorption was seen. Garcia-Godoy, Ranly and Garcia-
Godoy, Praveen et al. (1987) [10, 11, 12] reported deflection of
developing permanent tooth bud because of its hardness. Barr
Fig 1: Zinc oxide eugenol (ZOE) et al., [13] in 1991, stated that after primary teeth with ZOE
pulpectomies were lost, they did not find retained filler
Zinc oxide–eugenol cement contains zinc oxide, rosin, and particles associated with molar teeth. They reported that
zinc acetate in the powder. The rosin increases fracture incisor pulpectomies may have retained ZOE initially after
resistance and the zinc acetate is effective in accelerating the exfoliation, but it was not seen on subsequent radiographs at
reaction rate. The liquid is a preparation of eugenol, which follow-up. Coll and Sadrian (1996) [14] reported that
reacts with the powder to form an amorphous chelate of zinc pulpectomized teeth rarely exfoliate later than normal and
eugenolate. The zinc oxide–eugenol cements are used to timing of exfoliation was not related to retention of ZOE
provide a sedative effect in deep preparations, but their low paste. Anterior cross-bite, palatal eruption, and ectopic
compressive strength presents clinical limitations. To eruption of the permanent tooth following ZOE pulpectomy.
strengthen zinc oxide–eugenol cements, acrylic resin and Sadrian and Coll, [15] in 1993, stated that the data findings
alumina reinforcers have been added. Although these cements from their retrospective evaluation indicated that retained
are stronger, they remain weaker than the zinc phosphate and ZOE tended to resorb with time which may reflect
glass ionomer cements. When it was evaluated as a base, zinc osteoclastic activity to reduce or eliminate retained ZOE
oxide–eugenol demonstrated significant microleakage in particles. The filling material took a mean time of 50.1
comparison with glass ionomer cement [2, 3]. Because of its months for Zinc oxide eugenol to resorb. In the cases in which
sedative effects and years of clinical success, zinc oxide– ZOE was retained, 80% showed significant reduction of the
eugenol remains the material of choice for the pulp chamber retained filler’s size over time. Thus, they advised that it is
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better to fill canals short of the apex rather than to the apex or aerobic and anaerobic bacteria obtained from the root canals
beyond, to avoid retention. None of the retained filler of primary teeth and was found to be effective for both the
particles caused any observed pathology. They concluded that aerobic and anaerobic bacteria of the root canals of primary
retained Zinc oxide eugenol was not related to the pulpectomy teeth with maximum sustaining period of 10 days [20].
success or failure. Contrary to these results, Holan and Fuks ZOE used in combination with other materials to overcome its
(1993) [16], reported that, permanent incisors that replace drawbacks.
traumatized deciduous incisors treated with Zinc oxide Al-Ostwani et al. [21] used Zinc oxide + propolis and it was
eugenol pulpectomies have 2-3 times higher incidence of observed that ZOP paste was prepared by mixing 50% zinc
enamel defects when compared to normal teeth. They oxide powder with 50% hydrolytic propolis. There was
Compared pulpectomies of nonvital primary molars using acceptable clinical and radiographic success rate with faster
ZOE and KRI paste, it was concluded that KRI paste resorption observed in some cases.
presented with a higher success than ZOE in cases of first Chawla et al. [22] used Zinc oxide eugenol (ZOE)+ Calcium
molars, maxillary molars and overfilling of the canals. hydroxide (CA(OH)2 +Sodium fluoride and it was seen that
Success rates for both ZOE and KRI were similar in due to Ca (OH)2 - material resorbs at a faster rate than the
underfilled teeth and slightly higher for KRI paste when physiologic root resorption. To overcome this limitation
fillings were flush to the apex. Praveen et al. (2011) [12]: Used filling material incorporated with fluoride was utilized. The
Zinc oxide + Calcium hydroxide. Obturated material addition of fluoride was observed to render this material a
remained up to the apex of root canals till the beginning of resorption rate that is similar to the resorption rate of primary
physiologic root resorption and was found to resorb at the teeth.
same rate as that of deciduous teeth. In a study by Mortazavi Pinto et al. [23] used Zinc oxide + Calen paste and it was seen
and Mesbahi, (2004) [18] it was found that in comparison with that the Clinical and radiograhic outcomes for calen/zo were
ZOE and Vitapex, the comprehensive success rates of Vitapex equal to ZOE after 18 months, suggests that both the materials
and ZOE were found to be 100% and 78.5%, respectively. can be indicated for obturation of primary teeth.
To improve the properties and success rate of zinc oxide A combination of zinc oxide powder and calcium hydroxide
eugenol combination with different components were used paste for obturation of primary teeth has shown promise in a
like formocresol, formaldehyde and paraformaldehyde and shor term study. They observed that the obturated material
cresol but the addition of these compounds neither elevated remained up to the apex of root canals till the beginning of
the success rate nor made the material more resorbable as physiologic root resorption. Also, the obturated material was
compared to zinc oxide eugenol alone [18]. found to resorb at the same rate as teeth [24]. A combination of
Anti-inflammatory and analgesic properties, greater zone of calcium hydroxide, zinc oxide, and 10% sodium fluoride
bacterial inhibition, ease of availability, radiopacity of solution has been tested in a clinical study. It was observed
material, cheaper, insolubility in tissue fluids, easy to mix, that the rate of resorption of this new combination of root
and good working time are the advantages of ZOE. canal obturating mixture was quite similar to the rate of
A study was conducted in which iodoformized zinc oxide physiologic root resorption in primary teeth [25].
eugenol was tested for its antibacterial effect against the

Table 1: Authors and their observations for zinc oxide eugenol

Authors Observations
[17] Speculated that the resorption rate of zinc oxide eugenol (ZOE) and the root differed, resulting in
Allen
small areas of ZOE paste possibly being retained
Barker and Lockett [6] Material when extruded from the apex cause a mild foreign body reaction
Barker and Lockett [6], Spedding [7],
Stated that extruded ZOE resisted resorption and took months or even years to resorb
Mortazavi and Mesbahi [8]
Pulpectomized teeth rarely exfoliate later than normal and timing of exfoliation was not related to
[14] retention of ZOE paste.
Coll and Sadrian
Anterior cross-bite, palatal eruption, and ectopic eruption of the succedaneous tooth following ZOE
pulpectomy.
Reported that when ZOE extrudes, it develops a fibrous capsule that prevents resorption of the
material. Thus, it has a slow rate of resorption and has a tendency to be retained even after tooth
Coll et al. [9]
exfoliation. Areas of cementum resorption were evident, periodontal ligament exhibited intense and
moderate thickening. Dentin resorption was not observed, whereas bone resorption was found.
Reported that the canals overfilled with
Erasquin et al. [5] (ZOE) are not recommended because it irritates the periapical tissues and causes necrosis of bone
and cementum.
Flaitz et al. [13]
Observed deflection of permanent tooth eruption in 20% of pulpectomized tooth that were extracted
Coll and Sadrian [14]
Garcia-Godoy [20], Ranly and Garcia-
Reported deflection of developing permanent tooth bud because of its hardness
Godoy [11], Praveen et al. [12]
Studied the beneficial effects of eugenol. The amount of eugenol released in the periapical zone
immediately after placement was 10-4 and falls to 10-6 after 24 hours, reaching zero after one
Hashieh et al. [4]
month. Within these concentrations eugenol is said to have anti inflammatory and analgesic
properties that are very useful after a pulpectomy procedure
Holan and Fuks [16]; Moskovitz and
Malformation of successor is attributed to the cytotoxic and neurotoxic nature of eugenol
Samara [38]
Reported a case of developmental arrest of a premolar following overfilling of the root canal of the
Jerrell and Ronk [42]
second primary molar using zinc oxide-eugenol/formocresol paste
Loevy [43] Premolars erupt early after primary teeth pulpotomies. Possibly a mild chronic inflammation exists

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in periapical area of some pulpectomies judged successful that is not clinically evident. This could
cause premature eruption of succedaneous tooth and uneven resorption of pulpectomy treated tooth.
Excess material forced through the apex during filling procedures can remain in the apical tissue
Praveen et al. [12]; Sunitha et al. [44]
during the process of physiological root resorption and it takes few months or even years to resorb

Table 2: Zinc Oxide combinations with other materials.

Combination Observation
ZOP paste was synthesized by mixing 50% zinc oxide powder with 50% hydrolytic propolis. There was
Zinc oxide + Propolis (ZOP) acceptable clinical and radiographic success rate with faster resorption seen in some cases.
It has biological properties such as, bactericidal action, debriding effect, angiogenesis stimulation capacity
Zinc oxide + Ozonated oil and high oxidizing power (Guinesi et al., 2011). After 12 months followup there was progressive bone
regeneration at the periapical region with good clinical and radiographic success rate.
Zinc oxide eugenol (ZOE)+ Calcium Ca(OH)2 - demerit of resorbing at a faster rate than the physiologic root resorption. To overcome this
hydroxide (CA(OH)2 filling material incorporated with fluoride was utilized. The addition of fluoride was seen to give this
+Sodium fluoride material a resorption rate that matched the resorption rate of primary teeth.
It was found to be effective for both aerobic and anaerobic bacteria with a maximum sustaining period of
Iodoformized ZOE
10 days.
Clinical and radiograhic outcomes for calen/zo were equal to ZOE after 18 months, suggesting that both
Zinc oxide + Calen paste
the materials can be indicated for obturation of primary teeth
Obturated material remained up to the apex of root canals till the beginning of physiologic root resorption
Zinc oxide + Calcium hydroxide
and was found to resorb at the same rate as that of primary teeth
The addition of these compounds neither increased the success rate nor made the material more resorbable
Zinc oxide eugenol + Aldehydes
as compared to zinc oxide eugenol alone

Iodoform Holan G et al. (1993) [16] found that the success rates of 84%
It is a preparation of iodine obtained by action of chlorinated with KRI paste group verus 65% with ZOE group. Overfills
lime upon an alcoholic solution of potassium iodide when more successful KRI paste 79% versus ZOE 41%. The excess
heated at 1040 °F. No irritant action. Relieves pain and is a paste will resorb without causing any adverse side effecs.
potent disinfectant. Better re-sorbability and disinfectant
properties than ZOE. But they may produce a yellowish Maisto Paste: An iodoform based paste developed by Maisto
brown discoloration of the tooth. and used clinically for many years with good results reported.
It consist of Zinc oxide -14g, Iodoform-42 g, thymol-2 g,
Walkhoff Paste Chlorophenol camphor-3 cc, lanolin – 0.5 g. It differs from
It consists of Iodoform, Parachlorophenol 33-37%, Camphor KRI paste, in that it also contains Zinc oxide, thymol and
63-67% and Menthol crystals 1.40- 2.90%. Non- vital teeth lanolin. It reduces the resorption rate of the paste from within
associated with large periapical lesions can be treated with the canals of endodontically treated primary teeth. Pabla T et
this paste. al (1997) [48] evaluated the antimicrobial efficacy of Zinc
Oxide Eugenol, Iodoform paste, KRI paste, Maisto paste and
KRI Paste Vitapex against aerobic and anaerobic bacteria from infected
KRI paste is basically an iodoform paste, was introduced by nonvital primary anterior teeth. Order of antimicrobial
Volkoff as a resorbable paste suitable for root canal filling. It activity: Maisto paste > Iodoform paste> Zinc Oxide
consists of iodoform (80.5%), camphor (4.84%), para Eugenol> Vitapex.
chlorophenol (2.023%), and menthol (1.213%). KRI paste is a
radiopaque endodontic root filling. Camphor and menthol are Aloe vera
mixed with the antimicrobial agent and para chlorophenol, to Aloe vera has a long history of its uses because of its
minimize coagulation with adjacent tissues. Iodoform is beneficial properties. Aloe vera derives its name from the
added as a vehicle to carry the antimicrobial agent as it is a Arabic word “Alloeh” and Latin word “vera” meaning
non-irritant and radiopaque. According to Rifkin2, it meets all “shining bitter substance” and “true” respectively. Nearly
criteria required from an ideal root canal filling material for 2000 years ago, the Greek scientists regarded Aloe vera as the
primary teeth. It was also found to have long-lasting universal panacea. The Egyptians called it “the plant of
bactericidal potential. Overall success rate for KRl paste was immortality”. Aloe vera is a stem-less or short stemmed
84% versus 65% for ZOE. perennial, drought resisting, succulent xerophyte (store water
in tissues to survive under conditions of water shortage) plant.
Kri-1: In 1989, a procedure was published for root canal It belongs to the lily (Liliaceae) family, and has stiff grey to
preparation and filling in necrotic primary molars with a paste bright pear green lance-shaped leaves [26]. This gel like
made of Kri-1 and pure calcium hydroxide obtaining a high substance contains various amino acids, minerals, enzymes
percentage of success with remission of all symptoms. This and sugars which have properties like moisturizing properties,
was the first publication in which formaldehyde was antiinflammatory, antioxidant antibacterial, antiviral and
mentioned as a component of root canal filling material, thus antifungal properties. Aloe vera has its uses in various
partly recovering Buckley’s formula, which contained 40% systemic conditions like skin disorders (e.g. psoriasis),
formaldehyde and glycerine. arthritis, asthma, digestive and bowel disorders, diabetes and
lowering lipid levels in hyper-lipidemic patients. It can also
KRI-3: This liquid differs from commonly used KRI-1 paste be used as a detoxifying agent, for topical application of first
in that, its parachlorophenol, camphor and menthol and second degree burns, as an immune enhancer, in
concentration are twelve times superior and hence possess Alzheimer’s disease and in various cosmetic and medical
greater antimicrobial properties. products. It has been used in dentistry as well.
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Khairwa et al. [27] evaluated clinical and radiographic success Endoflas is similar to that of the physiological root resorption
of zinc oxide combined with Aloe vera and showed good rate, the resorption is limited to the obturation material that is
success rate. They reported that this material can be used as extruded beyond the apex extra with-out the resorption of the
an alternative for zinc oxide eugenol. material inside the root canal. Endoflas has a high success rate
when compared to that of zinc oxide eugenol. It has a
clinically proven success rate of 93.3%–95.1%. However, the
success rate is lower (58%–76%) when extruded beyond apex
[31, 34]
. The reason behind incorporating three materials ZOE,
Ca (OH)2 and iodoform into endoflas was possibly to
compensate the limitations of one individual material with the
advantages of the other.
Praveen et al (2011) [12] cited that the hydrophilic property of
endoflas made obturation compatible in even mildly humid
canals. Owing to its broad spectrum of antibacterial activity, it
can disinfect dentinal tubules and difficult to reach accessory
canals which cannot be cleansed mechanically. Rewal et al.
[32]
indicated that Endoflas with a success rate of 100% is a
superior material compared to ZOE. Ramar and Mungra [33]
compared the clinical and radiographic evaluation of
Metapex, RC fill, and Endoflas for a duration of 9 months.
Results showed that Endoflas gave an overall success rate of
95.1%, Metapex 90.5%, and RC Fill 84.7%. Fuks et al. [34]
studied the success rate of Endoflas as a filling material in 55
Fig 2: Endoflas
primary teeth. Thirty-one teeth were overfilled, and of these,
29% were normal preoperatively and the remaining 71%
Endoflas is a resorbable paste manufactured in South America presented with bone pathology. Twenty-four teeth were flush
or underfilled, and of these, 50% had preoperative bone
available in powder liquid form, inspite of various benefits, it
pathology after 52 months. Seventy percent of the cases were
has not found profound use with clinicians and the reason is
successful, and the remaining 30% presented with pathology
unknown. Endoflas is usually incorporated with other
and only one tooth had to be extracted. Overfilling led to a
obturating materials.
success rate of 58%, whereas in the combined flush and
Among the different obturation materials available, Endoflas
underfilled, the success rate was 83%. In this study, two cases
is a hydrophilic material consisting of Z.O.E. (56.5%),
showed excess filling material with Endoflas, and by the end
iodoform (40.6%), calcium hydroxide (1.07%), barium sulfate
of 6 months, only one case showed resorption of excess filling
(1.63%), eugenol, and pentachlorophenol. It provides a good
material. The time taken for the resorption of inadvertently
seal with the root canals. The broad-spectrum antibacterial
extruded Endoflas has varied between 20-day and 11-month
activity helps in disinfection of the hard to reach dentinal
period in this study.
tubules and accessory canals. Since the resorption rate of

Table 3: Antibacterial properties of Metapex reported by various authors.

Authors Observations
[46] Endoflas™ moderately inhibited the gram-negative and gram-positive organisms and showed strong inhibition
Hegde et al.
of Candida albicans
The high antimicrobial activity of Endoflas™ was probably due to the presence of iodoform and eugenol, both of
Pelczar et al. [47] which have antibacterial action. Eugenol acts by protein denaturation, while iodoform is an oxidizing agent. Even
after the material sets, surface hydrolysis of the chelate (zinc eugenolate) results in release of eugenol, thus

Calcium hydroxide - iodoform mixture (Metapex) 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 [35].
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 [28]. If material is pushed
beyond the apex, these materials show a resorption rate faster
Fig 3: Metapex than the root. In a study by Mortazavi and Mesbahi [29], it was
found that in comparison with ZOE and Vitapex, the
In 2009, AAPD guidelines cited iodoform based pastes as comprehensive success rates of Vitapex and ZOE were found
suitable alternatives to zinc oxide eugenol. Metapex is a to be 100% and 78.5%, respectively.
combination of 30.3% calcium hydroxide, 40.4% iodoform The efficacy of calcium hydroxide and ZOE as studied by
and 22.4% silicone oil. The mixture can be dispensed into the Dogra [29], by using endodontic pressure syringe system,
root canals by using disposable tips. The silicone oil content concluded that ZOE can be used as an alternative with
of metapex neutralizes the alkalinity of the paste to a certain calcium hydroxide as a root canal filling material. In this
extent, thereby causing lesser injury to the periapical tissues.
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study, when iodoform was used as obturating material and “Chitra HAP-Fil”. It is a hydroxyapatite nanoparticle gel
followed up for 3 months, it was seen that one patient based root filler material, which exactly corresponds to the
reported with pain. In cases of overfilled canals, during mineral content of bone and dentine, deemed to be highly
follow-up complete resorption of material in periapical region biocompatible. “Chitra HAP-Fil” apparently satisfies all
was seen by the end of 6 months. One of the detrimental requirements of an ideal pulpectomy material. This study was
properties of calcium hydroxide is that it has a tendency to carried out to investigate the cellular and microbial response
resorb earlier than the physiologic resorption of root. This of Chitra HAP-Fil in comparison with Zinc oxide eugenol and
creates a “hollow tube” effect leading to an unfilled root that Metapex by invitro methods. In Hydroxy apatite - Iodoform
eventually becomes a site for infection [30]. In 2009, AAPD paste (Chitra HAP-Fil), The prime ingredient is
guidelines cited iodoform based pastes as suitable alternatives hydroxyapatite nanoparticle gel (65%) which is the basic
to zinc oxide eugenol [35]. The higher number of overfilled mineral content of human bone and pure Iodoform (32%)
canals and presence of voids observed with Metapex is due to which imparts antibacterial property to the paste. The gelling
the thinner consistency of the premixed paste which may flow agent (alginate) – 3% (including 0.2% surfactant) binds with
more easily into the narrow and tortuous canals of primary the calcium ions in the hydroxyapatite. The study evaluated
molars and reach the apex or even beyond [36]. It can also be the cytotoxicity and antimicrobial activity of three
due to the technique followed, wherein the filling material is pulpectomy materials, namely Zinc oxide eugenol, Chitra
pressed into the canal. Unlike zinc oxide eugenol, Metapex HAP-Fil and Metapex. The cellular response of three
can be rapidly eliminated when extruded extraradicularly and materials were evaluated and results showed that Metapex is
does not set to a hard mass. However, there is a possibility of significantly least cytotoxic than Chitra HAP Fil which is less
intraradicular resorption in the long term. An unfilled root cytotoxic than Zinc oxide eugenol.
canal can be permeated with tissue fluid that becomes
stagnant and eventually a nidus for infection and is termed as Smartseal
‘hollow tube effect [37]. In comparison to other iodoform based It is a root canal obturating material which is based on
pastes, the resorption of Endoflas usually coincides with the polymer technology. It uses a hydrophilic principle which can
physiologic root resorption. This is because it contains more absorb surrounding moisture and expand which results in
than 50% zinc oxide eugenol that is slowly removed by giant filling of spaces and voids. Hydrophilic nature is revealed by
cells [38]. A distinctive property of Endoflas is that it does not ProPoints, which permits infinite water volume existing in the
wash out from the canals and its resorption is limited only to root canal system that is engrossed by these points. This water
the excess that is extruded without depleting the intraradicular may hydrogen bond to the existing polar locations, therefore,
material. Although Vitapex and Metapex are similar in their permitting the enlargement inside the polymeric chains.
composition, almost all studies have evaluated Vitapex only.
[36, 39, 40]
(Vitapex contains 40.4% iodoform, 30.3% calcium Rifocort: It is a product formed from a corticosteroid and an
hydroxide and 22.4% silicone). Also, there are very few antibiotic, presenting a great antimicrobial action and
reports on the use of Endoflas as a root canal filling material recommended for the treatment of primary teeth presenting
[34, 38, 41]
. Calcium hydroxide could be used exclusively or as with pulpal infectious processes. The paste also presented
an alternative to zinc oxide eugenol as a root canal filling bactericidal action against most organisms except for
material for the primary teeth. This could prevent the Enterococcus faecalis and Bacillus subtilis.
cytotoxic effects of eugenol and also could prevent the
deflection of the permanent tooth bud [29]. 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
+ve and gram –ve microorganisms. Tetracycline is a broad
spectrum antibiotic which can be bactericidal at high conc.
offering excellent effectiveness against gram –ve bacteria and
all anaerobes. ZOE provides analgesic properties and potent
antibacterial action against staphylococcus, micrococci,
bacillus and enterobacteria formore than 30 days.

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
Fig 4: Chitra HAP-Fil is quite effective in forcing the ZOE into the canals. The
endodontic pressure syringe is also effective for placing the
Jeeva and Retnakumari et al. [45] observed the Current trend in ZOE in root canals [15, 35]. However, in a study of apical seal
dentistry towards the use of biomaterials such as hydroxy and quality of filling evaluated on radiographs, no statistically
apatite. In an attempt to find an appropriate root canal significant differences were reported between the Lentulo
obturating material, they designed a new product named spiral, pressure syringe, or plugger [39].
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When the root canal is filled with a resorbable paste such as 6. Barker BCW, Lockett BC. endodontic experiments with
KRI, Maisto, or Endoflas, a Lentulo spiral mounted in a low- resorbable paste. Australian Dental J 1971;16:364-373.
speed handpiece can be used to introduce the material into the 7. Spedding RH. Root canal treatments for primary teeth.
canal. When the canal is completely filled, the material is Dent Clin North Am 1973;17:105-124.
compressed with a cotton pellet. Excessive material is rapidly 8. Mortazavi M, Mesbahi M. Comparison of zinc oxide and
resorbed. eugenol, and Vitapex for root canal treatment of necrotic
Vitapex is packed in a convenient sterile syringe and the paste primary teeth. Int J Paediatr Dent 2004;14:417-424.
injected into the canal with disposable plastic needles. This 9. Coll JA, Josell SS, Carper TS. evaluation of one
technique is particularly easy to use for primary incisors but appointment formocresol pulpectomy technique for
less practical for the narrow canals of primary molars. primary molars. Pediatr Dent 1985;7:123-129.
Regardless of the method used to fill the canals, care should 10. Garcia-Godoy. evaluation of an iodoform paste in root
be taken to prevent extrusion of the material into the canal therapy for infected primary teeth. J Dentistry
periapical tissues. It is reported that a significantly greater Children 1987;54:30-34.
failure rate occurs with overfilling of ZOE than with filling 11. Ranly DM, Garcia-Godoy F. Reviewing pulp treatment
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obturation is checked by radiographs [39]. 12. Praveen P, Anantharaj A, Karthik V, Pratibah R. A
In the event a small amount of the ZOE is inadvertently review of the Obturating material for primary teeth. SRM
forced through the apical foramen, it is left alone (because the University Journal of Dental Science 2011;1:1-3.
material is absorbable). It has been reported that defects on 13. Barr ES, Flatiz CM, Hicks MJ. A retrospective
successor teeth have no relationship to length of the ZOE radiographic evaluation of primary molar pulpectomies.
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When the canals are satisfactorily obturated, a fast-setting 14. Coll JA, Sadrian R. predicting pulpectomy success and
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