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P. Nivoloni Tannure, R. Barcelos, J. Farinhas, material when compared with physiological root ↓ L. Guimarães Primo resorption. Other studies have revealed that when ZOE is forced beyond the apex, because of its hardness, there is School of a risk of deflecting the erupting succedaneous teeth Federal Universtiy of Rio de Janeiro (UFRJ) and Fluminense Federal [Ranly and Garcia-Godoy, 1991; Mortazavi and Mesbahi, University (UFF) - Brazil 2004]. Due the difficulty of overfilled paste resorption, ZOE constitutes a real obstacle for permanent successor e-mail: [email protected] eruption [Pilipili et al., 1998]. This report presents a case of a child submitted to primary teeth pulpectomy using ZOE paste showing, after 28 months, retained particles of filling paste in the vestibular gingival mucosa during permanent dentition - eruption. Because of aesthetic considerations, the treatment plan called for periodontal surgical removal of paste retained the retained ZOE particles, using local anesthesia. in gingival mucosa after primary teeth Case report A 5-year-old boy presented to the Paediatric Dental pulpectomy Clinic at the Federal University of Rio de Janeiro, Brazil, for dental treatment. The medical history was not ABSTRACT contributory. Extraoral examination did not reveal Background Long-term follow-up evaluations of pulpectomy anomalies, but at the intraoral examination the child in primary teeth have revealed retention of ZOE filling particles presented poor oral hygiene and carious lesions in the in the periapical area even after root resorption. Case report maxillary central incisors. An orthopantomogram This paper reports a case of a child submitted to pulpectomy revealed no other abnormalities and the periapical with ZOE paste in primary teeth. After 28 months, the filling radiographs showed periapical lesions affecting the particles remained, having migrated to the alveolar bone from primary maxillary incisors. The treatment plan consisted the gingival vestibular mucosa during permanent dentition of oral hygiene instructions, topical fluoride application, eruption. Aesthetics required periodontal surgical removal of and pulpectomy with ZOE paste following composite the paste particles. Primary teeth submitted to pulpectomy resin restoration. A final radiograph showed that length should be evaluated carefully both clinically and obturation was slightly short. The patient was attending radiographically to verify radicular and ZOE filling–paste regularly until exfoliation of the primary incisors (Fig. 1). resorption. The consequences of retained particles during Despite successful treatment, unresorbed ZOE was permanent dentition eruption are unknown. observed in the alveolar bone during exfoliation of the primary maxillary central incisors. Key words: primary tooth; pulpectomy; tooth eruption; After 28 months, the patient presented eruption of the tooth resorption; zinc oxide-eugenol cement. permanent incisors and a poor aesthetic smile due to particles of filling paste visible in the vestibular gingival area, close to tooth 21 (Fig. 2). The patient and his mother were concerned about the gingival appearance and agreed to the proposed treatment plan, which Introduction consisted in surgical removal of the ZOE particles under local anesthesia. The primary goal of pulpectomies in primary teeth is to The last follow-up, 38 months later, showed a healthy eliminate infection and to preserve the tooth in a gingival mucosa; the final aspect satisfied the aesthetic functional state until its normal exfoliation time without expectations of the patient and his mother (Fig. 3). endangering the permanent dentition or the general The patient is still making regular visits. health of the child [Reddy and Ramakrishna, 2007]. Zinc oxide-eugenol (ZOE) paste is probably the most widely used root canal filling for primary teeth in the United States [Primosch et al., 1997; Flaitz et al., 1989]. Although described as a resorbable material, long-term follow-up evaluations of pulpectomised primary teeth with ZOE have revealed a high frequency of retention of the overfilled material in the periapical area, even after physiologic root resorption [Flaitz et al., 1989; Sadrian et al., 1993; Sadrian et al., 1996]. Another investigation [Mani et al., 2000] revealed that 67% of all overfilled canals showed over-retained ZOE at FIG. 1 - The slightly short root canal filling in primary incisors 6 months follow-up and delayed resorption of the and 12 months after pulpectomy

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NIVOLONI TANNURE P. ET AL.

FIG. 2 - Radiographic and clinical exams: ZOE retained in gingival vestibular area. FIG. 3 - Final aspect: 38 month follow-up.

Discussion where retention of the ZOE was treated successfully, obturating the root canal with a resorbable paste could The oral health policies and clinical guidelines of the have prevented this complication. Further studies are American Academy of Pediatric Dentistry (AAPD) [2005] necessary to evaluate the consequences of partial or no lists several objectives of pulpectomy procedures in primary resorption of ZOE in the permanent dentition. teeth. The first is that there should be radiographic evidence of successful filling without gross overextension or underfilling. According to the authors [Sadrian et al., Conclusion 1993] it is possible to remove retained ZOE by curettage immediately after exfoliation or extraction in overfilled Paediatric dentists should be aware of the issues related cases. Observation has shown that ZOE could take years to to ZOE paste and root resorption after primary teeth resorb, but the retained paste caused no apparent pulpectomy. Periodic clinical and radiographic evaluation pathology in the follow-up radiographs or exams. should be performed in order to avoid prolonged retention Findings in the present case report may reflect that of the primary tooth, deflection of erupting permanent osteoclastic activity was too slow to eliminate the retained successor and retention of filling paste particles in the ZOE and suggests the possibility of nonresorption. gingival mucosa during permanent dentition eruption. ZOE has been found to be potentially irritating to periapical tissues; it may even produce necrosis of bone and cementum, and extruded particles may develop a fibrous Acknowledgments capsule that prevents resorption of the paste [Erausquin and Muruzabal, 1967]. Moreover, it was already reported that We thank the CNPq (National Counsel of Technological the overfilled ZOE induced inflammatory reactions, chronic and Scientific Development) for financial support. or subacute, on the dental follicle of permanent successor [Pilipili et al., 1998]. However, in this particular case the References patient did not experience pain, and no abnormalities in the alveolar bone were evident radiographically, in spite of the Guideline on pulp therapy for primary and young permanent teeth. Pediatr Dent paste being retained for a long time. Our findings confirm 2005;27(7):130-4. Coll JA, Sadrian, R. Predicting pulpectomy success and its relationship to previous reports, which stated that no pathology was exfoliation and succedaneous dentition. Pediatr Dent 1996;18(1):57-63. associated with retained ZOE [Sadrian et al., 1993]; this Erausquin J, Muruzabal, M. Root canal fillings with zinc oxide-eugenol cement material caused no foreign-body reaction and did not affect in the rat molar. Oral Surg Oral Med Oral Pathol 1967;24(4):547-58. the clinical or radiographic success of the pulpectomy [Ozalp Flaitz CM, Barr, ES, Hicks, MJ. Radiographic evaluation of pulpal therapy for primary anterior teeth. ASDC J Dent Child 1989;56(3):182-5. et al., 2005]. It was suggested that overfilled material had Mani SA, Chawla, HS, Tewari, A, Goyal, A. Evaluation of calcium hydroxide and migrated from the apical region toward the interradicular zinc oxide eugenol as root canal filling materials in primary teeth. ASDC J area, where complete resorption of the material failed to Dent Child 2000;67(2):142-7, 83. occur [Ozalp et al., 2005]. Mortazavi M, Mesbahi, M. Comparison of zinc oxide and eugenol, and Vitapex for of necrotic primary teeth. Int J Paediatr Dent In this case report, the retained paste migrated to the 2004;14(6):417-24. alveolar bone from the gingival vestibular area, in a way Ozalp N, Saroglu, I, Sonmez, H. Evaluation of various root canal filling materials in similar to sinus tract or pus drainage. No reports could be primary molar pulpectomies: an in vivo study. Am J Dent 2005;18(6):347-50. found in the literature of a case of longtime ZOE retention Pilipili CM, Goret-Nicaise, M, Dhem, A (1998) Effects of zinc oxide-eugenol, used and migration from the gingival vestibular area. The in primary molars pulpectomies, on erupting mandibular premolars in dog. Dental follicle and bone modifications. In: Davidovitch, Z. and Mah J. Eds: periodontal surgery was necessary because the paste Biological mechanisms of tooth eruption, resorption and replacement by particles were creating a poor aesthetic appearance. Implants. Boston: Harvad Society for the Advancement of Orthodontics;YEAR. Despite the high success rates of ZOE pulpectomies, this Primosch RE, Glomb, TA, Jerrell, RG. Primary tooth pulp therapy as taught in material presents disadvantages involving the difference predoctoral pediatric dental programs in the United States. Pediatr Dent 1997;19(2):118-22. between the rates of resorption of paste and root. Such Ranly DM, Garcia-Godoy, F. Reviewing pulp treatment for primary teeth. J Am differences may be clinically and radiographically observed Dent Assoc 1991;122(9):83-5. even after primary teeth exfoliation. Therefore, primary Reddy S, Ramakrishna, Y. Evaluation of antimicrobial efficacy of various root teeth should be carefully evaluated to verify radicular and canal filling materials used in primary teeth: a microbiological study. J Clin Pediatr Dent 2007;31(3):193-8. filling paste resorption in order to avoid prolonged Sadrian R, Coll, JA.A long-term followup on the retention rate of zinc oxide eugenol retention of the treated teeth. Even in the present case, filler after primary tooth pulpectomy. Pediatr Dent 1993;15(4):249-53.

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