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Research Article

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Evolution and prognosis of necrotic primary teeth after pulpectomy

ASUNCIN MENDOZA MENDOZA, MD, DMD, PHD, J. ENRIQUE SOLANO REINA, MD, DMD, PHD
& FRANKLIN GARCIA-GODOY, DDS, MS
ABSTRACT: Purpose: To study the evolution of 308 necrotic primary teeth after pulpectomy technique with resorbable
paste (Kri-1 + calcium hydroxide + metacresol-formaldehyde) after 30 months. Methods: 134 children between 2-9
years were included, among which they had 348 pulpectomized teeth. Out of these 348 teeth, 308 had necrotic pulp and
were included in the study. The filling material consisted of a paste based on Walkhoffs master formula and consisted of
the combination of Kri-1a (80.8% iodoform, 2.025% parachlorophenol, 1.215% menthol, 4.68% camphor and excipient 15
mg), pure calcium hydroxide and metacresol formaldehyde (metacresol 20 mg, formaldehyde 20 mg, eugenol 20 mg,
eucalyptus 6 mg and excipient 40 mg). Root canal filling was performed in one session by one operator. Results: Pain,
swelling, and fistula resolution was observed in most cases at the first recall. Progressive remission of radiolucent areas
was also observed. A relationship between fistula and radiolucency in pre-treated furcation area was observed, and, in
some cases, premature eruption of permanent teeth was recorded. Only two cases out of 308 treated teeth required
extraction. (Am J Dent 2010;23:265-268).
CLINICAL SIGNIFICANCE: The use of the Kri-1 + calcium hydroxide + metacresol-formaldehyde paste was effective in
resolving pain, swelling, and fistula in 306 of the 308 treated teeth.
: Dr . Asuncin Mendoza Mendoza, Plaza de Cuba, 6-1 Centro, 41011- Seville, Spain. E- : coinsol@telefonica.net

Introduction
The introduction of formaldehyde into endodontic therapy
with Gysis trio-paste in 1899, supporting the concept of fixing
the pulp and leaving it sterile, allowed the possibility of pulp
treatment in primary teeth. However, it was Buckley,1 in 1904,
who used formaldehyde to treat pulp necrosis by introducing a
formula containing 40% formaldehyde, tricresol, and glycerin.
After Buckleys1 use of formaldehyde, pulp tissue removal
was performed by root canal instrumentation and filling with
resorbable pastes: Walkhoffs iodoform paste (Kri-1a),2-7 zincoxide eugenol (ZOE),7-10 and calcium hydroxide,9 as well as different combinations: iodoform + ZOE + calcium hydroxide,11
50% iodoform + 50% camphorated paramonochlorophenol,12
30.3% calcium hydroxide + 40.4% iodoform + 22.4% silicone oil
+ 6.9% inert material10,13-14 (Vitapexb).
In 1989, a procedure was published15 for root canal preparation and filling in necrotic temporary molars with a paste made
of Kri-1 (80.8% iodoform, 2.025% parachlorophenol, 1.21%
menthol, 4.86% camphor and 15 g of excipient), Tiffel/20%
tricresol, 20% formol, 20% eugenol, 6% eucalyptol and 100 g
of excipient) and pure calcium hydroxide, obtaining a high
percentage of success, with remission of all symptoms. This
was the first publication in which formaldehyde was mentioned
as a component of root canal filling material, thus partly
recovering Buckleys formula, which contained 40% formaldehyde and glycerine.
Since 1998 onwards, tricresol, a mixture of three isomers
(orthocresol, metacresol and paracresol), was substituted by
metacresol, the most innocuous ionomer in tricresol, due to the
possible side effects the former. Thus, the following formula
has been used since then:
- Metacresol
- Formaldehyde
- Eucalyptol
- Excipient

20 mg
20 mg
6 mg
100 mg

Formaldehyde, like other aldehydes, quickly binds to organic substance, thus originating albumin-formaldehyde with
high permeability and penetration capacity. It is metabolized in
acid form, carbon dioxide and amino acid radicals, and its biodegradation fundamentally occurs at the hepatic level and, to a
lower extent, at pulmonary and renal levels.16
When metabolized, part of the drug fixes on different body
tissues (mainly liver and kidney), although only 1% of the dose
applied in each tooth is usually absorbed, a diluted formaldehyde formulation has been recommended.17
Another side effect of formalin-cresol is its antigenic
potential18 and, although it is not considered toxic at low exposure levels, the literature contains cases of hecromatosis, dermatitis and pulmonary pathology (asthma) in workers of paper,
cosmetic and wood-derivative industries.
The use of pure calcium hydroxide with approximate pH
12.75 neutralizes the acid environment generated by tissue
necrosis by means of its antibacterial effect.19-20 However,
some21 consider that its antibacterial action is influenced by the
liberation of hydroxyl ions and enzyme inactivation in the
bacterial cytoplasmatic membrane.
Another property attributed to calcium hydroxide is its
reducing effect on inflammatory responses and its role in detritus dissolution22,23 of necrotic tissue which may remain on
canal walls after canal instrumentation and washing.
Likewise, Walkhoffs iodoform paste (Kri-1), also has
different properties which makes it beneficial for treatment of
necrotic teeth.
Inge4 reported that iodoform pastes do not produce tissue
irritation (even in case of material extrusion into the periapical
area), stops secretion and its antiseptic effect is long-lasting.
Held3 stated that, although iodoform did not have a direct
effect on tooth germ, it slowed down germ growth, also attributing it certain hemostatic effect in capillaries, while its
slightly irritating action stimulated tissue proliferation and
leukocyte migration.
In general, most authors2,5-7,24 emphasized positive factors

266 Mendoza Mendoza et al

such as its radiopaque, analgesic action, and easy handling, it
being slightly irritating, diminishing secretions, stimulating
granulation tissues and being easily resorbable in case of intentional or accidental extrusion into the periapical areas.
The present study evaluated the levels of success of
pulpectomy treatment of necrotic teeth on a sample of 136 first
molars, 150 second molars, 19 incisors and three canines. A
follow-up of the permanent successors was performed in order
to determine exfoliation time as well as the possible effect of
this treatment on the integrity of the permanent tooth.

Materials and Methods

Sample selection Only subjects with dental records showing
radiographic examination after pulpectomy at three recalls
performed at 6, 18, and 30 months were included in the study.
134 children between 2-9 years of age (63 were girls and 66
boys) were included. These children had a total of 348 pulpectomized teeth. Out of these 348 teeth, 308 had necrotic pulp
and were included in the study.
The sample consisted of:
- 27 right upper first molars
- 23 right upper second molars
- 27 upper left first molars
- 28 left upper second molars
- 38 right lower first molars
- 52 right lower second molars
- 44 left lower first molars
- 47 left lower second molars
- 12 right upper central incisors
- 7 left upper central incisors
- 1 left upper canine
- 1 right lower canine
- 1 left lower canine
Out of these 308 teeth, 26 were considered as having poor
prognosis since they showed small signs of external or internal
root resorption and large furcation bone loss (these 26 teeth
were second primary molars in children between 2-5 years of
age, and their extraction might have caused space-loss). Out of
the total number of teeth, the eruption of their permanent
successor was assessed on 63 of them.
Out of the 308 teeth included in the sample, 58 teeth
showed no radiolucency and the remaining 250 teeth showed
furcation or periapical radiolucency, which also had some of
the following symptoms: pain, abscess, fistula and/or internal
root resorption or slight external root resorption.
Filling material The filling material was based on Walkhoffs
master formula and consisted of the combination of Kri-1a
(80.8% iodoform, 2.025% parachlorophenol, 1.215% menthol,
4.68% camphor and excipient 15 mg), pure calcium hydroxide
and metacresol formaldehyde (metacresol 20 mg, formaldehyde
20 mg, eugenol 20 mg, eucalyptus 6 mg and excipient 40 mg).
Kri-1 and calcium hydroxide were mixed in equal parts and one
part of metacresol-formaldehyde; these three compounds were
mixed until obtaining a homogeneous paste. The paste was
resorbable and radiopaque, of medium consistency and fluidity,
and with antibacterial activity.
Method - The pulpectomy was performed in a single session.

American Journal of Dentistry, Vol. 23, No. 5, October, 2010

After periapical radiograph, anesthesia and rubber dam isolation, the pulp chamber was accessed, and the root canals were
instrumented with Kerrs files sectioned at 18 mm (2 mm on
the tip) in order to avoid apical perforation; the canals were
rinsed with 5% sodium hypochlorite and dried with cotton and
paper tips. Then, the canals were filled with the iodoform paste
and the tooth restored with a stainless steel crown.
All teeth were clinically and radiographically examined at 6
months, 18 and 30 months ( 1 month). All treatments were
performed by one single operator.
For the study, furcation radiolucency was scored as 0 if it
showed no image, + when radiolucency covered less than a
third of the furcation size, ++ with radiolucency ranging between 1/3 and 2/3 of the furcation size, and +++ when radiolucency was over 2/3 of the furcation size but remained over the
permanent tooths germ without affecting the tooth. In the
periapical area, radiolucency was scored in the same way, considering one third, two thirds and three thirds of the distance
between the primary tooths apex and permanent tooth germ.
Eruption time of the permanent tooth was compared with
the contralateral untreated tooth.
Statistical analysis - Chi-square statistical test and Cramers V
as measure of association were used to compare differences in
the distribution of the different variables studied or association
between variables, respectively. Tests with P< 0.001 were
considered significant. Likewise, estimation of means and
standard deviations were performed for quantitative variables,
while estimation of confidence intervals and a test for proportion comparison were completed.

Results
Evolution of pain, inflammation and swelling - Pain in 138
teeth (44.3%), inflammation in 159 teeth (51.6%) and abscess
in 79 teeth (25.6%), resolved in 100% of the cases after the first
recall.
Evolution of radiolucency - Out of the 250 teeth with radiolucency at treatment onset, 222 (171 + 25 + 26) became 0, thus
representing 88.8% and 95% (0.85-0.93%) after 3 years.
Two hundred thirty eight (171 + 25 + 26 + 4 + 12) teeth had
radiolucency completely resolved in the first recall, thus
representing 93.5% (P< 0.05, 0.94-0.98%) and only 10 of them
still showed radiolucency ++.
Out of the 250 teeth with radiolucency at treatment onset,
radiolucency was found in only 26 of them with a level of
10.4% and 2 of them remained with ++ levels in the last recall.
Evolution of external root resorption - Out of the 18 teeth with
external resorption at treatment onset, eight of them showed no
signs after the first recall, thus representing 44.4% (P< 0.05,
24.6-66.3%).
Out of the 18 teeth with external root resorption at treatment
onset, 16 of them stopped showing it after the last recall, thus
representing 88.9% (P< 0.05, 0-15%).
Evolution of internal root resorption after the first recall - Out
of the eight teeth with internal root resorption, seven of them
showed resolution after the first recall (87.5%).
Association between eruption and radiolucency Radiolucency
favored premature eruption of permanent teeth.

American Journal of Dentistry, Vol. 23, No. 5, October, 2010

Evolution of necrotic primary teeth 267

Fig. 1. Bone resorption in the furcation area in the second primary molar. A. Before, B. Immediately after, C. 6 months after pulpectomy
treatment. Radiolucency in the furcation area was resolved.

Fig. 2. Furcation radiolucency in the second primary molar. A. Before, B. Immediately after pulpectomy, C. 6 months after the pulpectomy
treatment/ Notice the resolution of the furcation radiolucency.

Association between eruption and abscess - The presence of

fistula favored premature eruption of permanent teeth.
Association between eruption and inflammation - No delay in
eruption was associated to the presence of inflammation.
Association between eruption and internal or external root
resorption - No delay in eruption was associated to presence of
external or internal root resorption.
Radiolucency in teeth with poor prognosis - Out of the 44 teeth
with +++ radiolucency at treatment onset, 26 of them were
considered to have a poor prognosis, since they were also associated to slight external (18) or internal (8) resorption. Out of
these 26 teeth, eight of them did not show radiolucency, thus
representing 30.76%.
Out of the remaining 18 teeth, 16 of them showed a reduced
radiolucency in the last recall, and the remaining two teeth only
showed slight improvement.
Only two out of 308 teeth had to be extracted, representing
0.6% of all teeth under study. The 36 teeth with poor prognosis
represented 11.7% of the cases. Figures 1 and 2 show
representative cases.

Discussion
In a previous study14 completed by our group, in which
pulpectomies were performed in a single session by using the
same procedure and filling material but in which we also performed furcation biopsies both pre- and post-treatment (6, 9 and
between 17 and 24 months after treatment onset), it was noticed
that, in pre-treatment biopsy, 83.5% of the sample showed
granulation tissue while 16% showed necrotic bone, medullar
fibrosis and other degenerative signs. Six months after treatment onset, 60% of cases showed an image similar to the
previous one; however, 17-24 months after treatment onset,
100% showed mature bone, 75% showed medullar fibrosis,
50% showed necrosis and degenerative signs, and 25% showed
new bone formation.
Appearance of osteoid tissue pointed out the existence of
bone formation and a certain attempt at complete regeneration,

confirming the practical usefulness of this technique from a

histological viewpoint. In radiological control, it was observed
that radiolucency progressively diminished from 30 days onwards, disappearing completely 2-5 months after treatment
onset, observing complete recovery both from a radiographic
and histological standpoint.
The present results agree with those of Domnguez &
Solano,15 since, in the first recall after treatment onset, radiolucency completely resolved (or at least two levels), representing
88.8% of cases (Table 2). If the study of the evolution of furcation radiolucency was performed after the last recall, only 26
teeth still showed certain radiolucency level (10.40%) and
another two remained with ++ levels.
Garca-Godoy6 considered Kri-1 as an appropriate filling
material, when the pulpectomy in primary teeth was subjected
to clinical and radiological recalls every 6 months; he observed
that pain, fistula and mobility were no longer present 6-24
months after treatment and stainless steel crown restoration.
Nurko et al,13 using Vitapex (30.3% calcium hydroxide,
40.4% iodoform, 27.4% silicone oil, 6.9% inert material) in
necrotic temporary teeth and, likewise, subjecting teeth to clinical and radiographic recalls every 6 months throughout a period
of 38 months, observed clinical and radiographic success,
finding no damage to the permanent teeth.
Therefore, the results of the present study confirm the
conclusion drawn in previous studies regarding the clinical
procedure and the use of filling materials. However, it disagrees
with Cohen25 and Massler,26 who supported that in non-vital
primary teeth, treatment of root canal was inappropriate due to
the difficulty involved in canal washing.
a.
b.

Ogna Laboratori Farmaceutici, Muggio, Milan, Italy.

Morita Europe GmbH, Dietzenbach Germany.

Disclosure statement: The authors have no conflict of interest.

Dr. Mendoza Mendoza is Titular Professor, Department of Pediatric Dentistry,
Dr. Solano Reina is Titular Professor, Department of Orthodontics, Faculty of
Dentistry, University of Seville, Seville, Spain. Dr. Garca-Godoy is Senior
Executive Associate Dean for Research and Director, Bioscience Research
Center, College of Dentistry, University of Tennessee Health Science Center,
Memphis, Tennessee, USA.

American Journal of Dentistry, Vol. 23, No. 5, October, 2010

268 Mendoza Mendoza et al

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