doi:10.1111/iej.

12134

REVIEW

Anatomical challenges, electronic working length determination and current developments in root canal preparation of primary molar teeth

H. M. A. Ahmed
Department of Restorative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

Abstract
Ahmed HMA. Anatomical challenges, electronic working
length determination and current developments in root canal preparation of primary molar teeth. International Endodontic Journal, 46, 10111022, 2013.

Paediatric endodontics is an integral part of dental practice that aims to preserve fully functional primary teeth in the dental arch. Pulpectomy of primary molars presents a unique challenge for dental practitioners. Negotiation and thorough instrumentation of bizarre and tortuous canals encased in roots programmed for physiological resorption are the main challenges for this treatment approach. Consequently, numerous in vitro and in vivo studies have been

conducted to validate the application of some contemporary endodontic armamentarium for effective treatment in primary molars whilst maintaining favourable clinical outcomes. Electronic apex locators, rotary nickeltitanium les and irrigation techniques are at the forefront of endodontic armamentarium in paediatric dentistry. Hence, this review aims to map out the root and root canal morphology of primary molars, to discuss the application of electronic apex locators in primary molars and to provide an update on the preparation of their root canal systems. Keywords: apex locator, deciduous molars, irrigation, primary molars, root, rotary NiTi les.
Received 5 January 2013; accepted 22 April 2013

Introduction
Despite advances in the prevention of dental caries in paediatric dentistry, the occurrence of pulpally involved primary (deciduous) teeth and their premature loss continues to be a common problem (Ahamed et al. 2012). Pulpectomy of primary teeth with irreversibly inamed or necrotic pulp is a reasonable treatment approach to ensure either normal shedding/eruption of the successor or a long-term survival in instances of retention. Primary molars scheduled for total pulpectomy continue to present a unique challenge to dental practitioners because of the

Correspondence: Dr Hany Mohamed Aly Ahmed, Department of Restorative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia (e-mail: hany_endodontist@hotmail.com).

tortuous and bizarre morphology of their root canal systems, as well as difculty in patient management and isolation. Current advances in pulpectomy procedures indicate a remarkable paradigm shift in root canal treatment for primary teeth. Whereas many manufacturers strive to provide more convenient armamentarium for paediatric endodontics, the potential of different diagnostic instruments and root canal preparation techniques used for permanent dentition to ensure accurate assessment and proper endodontic management of primary teeth has been examined. The use of electronic apex locators, rotary nickel-titanium (NiTi) les and irrigation techniques are at the forefront of advances in pulpectomy procedures. Hence, this review aims to map out the root and root canal morphology of primary molars, to discuss the application of electronic apex locators in primary molars and to provide an update on the preparation of their root canal systems.

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Anatomical challenges Root and root canal morphology

Literature search methodology An electronic search was conducted in PubMed and Google Scholar search engines, spanning the period from January 1972 to September 2012, to identify the available clinical and laboratory investigations written in English language and published on the number of roots and root canals in primary molars using the following keywords: (deciduous molar OR primary molar) AND (root anatomy OR root morphology OR root canal anatomy OR root canal morphology). Cross citations of the selected articles were identied. In addition, another search was undertaken in endodontic textbooks to identify any additional investigations on the root and root canal morphology of primary molars (Tables S1 and S2). Maxillary molars The literature shows that primary maxillary molars may have two to four roots, with the three-rooted variant being the most common (Table S1) (Fig. 1a,b). The double-rooted variant, in which the distobuccal root is fused with the palatal root, is also common, especially in maxillary rst molars (Table S1) (Fig. 1ck). The prevalence of a second canal in the mesiobuccal roots of maxillary molars varies considerably. A second mesiobuccal root canal reportedly occurs between 75% and 95% of the mesiobuccal roots in maxillary molars (Sarkar & Rao 2002, Camp & Fuks 2006). In addition, three mesiobuccal canals have been documented (Carlsen 1987) (Fig. 1hk). By contrast, Aminabadi et al. (2008) did not observe any second mesiobuccal canal in 76 maxillary molars treated by a single paedodontist, and Zoremchhingi et al. (2005) found only 6.67% and 53.3% of maxillary rst and second molars with second mesiobuccal canals, respectively. Bagherian et al. (2010) observed only two samples of 27 cleared maxillary rst molars with a second mesiobuccal canal (Type IV(2-2), Vertuccis classication), and maxillary second molars did not have additional root canals in the mesiobuccal root. The distobuccal root in maxillary molars normally has a single root canal; however, the occurrence of a second distobuccal canal has been reported (Table S1), which can reach 27.8% (Aminabadi et al. 2008). Similarly, the palatal root usually has one root canal; however, the occurrence of a second palatal canal

has been reported in primary second molars (Carlsen 1987), which can be rather common (Zoremchhingi et al. 2005). Fusion of the distobuccal and palatal roots is a common anatomical variation that reportedly represents one-third of maxillary molars (Zoremchhingi et al. 2005, Camp & Fuks 2006), The encased root canals range from one to three (Table S1) (Fig. 1eg). Mandibular molars Primary mandibular molars can have one to three roots; the double-rooted variant is the most common (Table S2). Accessory roots in primary mandibular molars, especially in second molars, were reported amongst Danish, Japanese, Chinese, Taiwanese and Korean population groups (Song et al. 2009, Liu et al. 2010, Tu et al. 2010). Song et al. (2009) demonstrated the concurrent existence of an additional root in the permanent rst molar and either in the second or in both second and rst primary molars. Using the eld developmental theory, the authors explained this relationship in which the formation of accessory roots are controlled by certain elds affecting genes that are mainly transcribed in the rst permanent molar area and often in primary molars because of their similar period of development and crown morphology (Song et al. 2009). Teeth that are distant from a key tooth exhibit few characteristics of the eld they belong to, which is the reason for its common occurrence in primary second molars. The mesial roots of primary mandibular molars usually have two root canals (Table S2). Bagherian et al. (2010) reported all double canals in the mesial root of mandibular molars as type IV(2-2) (Vertuccis classication). However, Sarkar & Rao (2002) observed a high prevalence of three canals in the mesial roots of mandibular rst molars. In addition, the occurrence of a single root canal, with less frequency, in the mesial roots of mandibular molars has been documented (Table S2). The distal root in mandibular molars usually has one or two canals (Table S2). Similar to the mesial root, Bagherian et al. (2010) reported all double canals in the distal root of mandibular molars as type IV(2-2) (Vertuccis classication). Distal roots with three canals have also been reported (Table S2). Clinical considerations Based on the above, it can be concluded that the root canal anatomy of primary molars varies considerably. This could be explained by (i) secondary dentine

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(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

Figure 1 (a,b) Three-rooted primary maxillary molar with root resorptions at the apex (black arrow) and middle third of the root (white arrow). (c,d) Double-rooted primary maxillary molar with fused Db and P roots. (e) The orice of the fused Db/P root is ribbon in shape. (f,g) The fused Db/P root has three root canals. One in the Db and two in the P [Type IV(2-1)]. (h,k) The Mb root of the double-rooted variant has three separate Mb canals. Total number of root canals is six. (Mb: Mesiobuccal, Db: Distobuccal, P: Palatal).

formation and physiological root resorption can recongure the root canal system (Rimondini & Baroni 1995) that may reach up to six canals (Fig. 1ck). (ii) The pulp and/or periodontal inammation can cause pathologic changes in this programmed physiological root resorption and further complicate the rootroot canal morphology (Rimondini & Baroni 1995, Sarkar & Rao 2002). These important facts should be taken into consideration prior to commencing root canal treatment in primary molars.

Dental practitioners should also be aware of the various pulp and periodontal tissues intercommunication pathways in primary molars. In addition to the apical foramen and large accessory canals (lateral and furcation canals), dentinal tubule exposure due to physiological root resorption may also cause structural alteration and increase the permeability of the root surface to microbial toxins. Consequently, the inter-radicular bone lesion in primary molars can be found anywhere along the root or in the furcation

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area (Kramer et al. 2003, Dammaschke et al. 2004, Koshy & Love 2004, Ahmed 2012). The dental operating microscope can be used adequately with cooperative children (Kotlow 2004). However, some children are restless and/or unable to sit still, scared of the equipment, or not willing to submit to a long session. In cases with such children, the use of dental loupes is preferred. After placement of the rubber dam and complete deroong of the pulp chamber, a thorough exploration via an endodontic explorer or size 8 or 10 K-le between the root canal orices is essential (Ahmed & Abbott 2012a, Ahmed & Luddin 2012). A small pre-curved endodontic le can be used to identify root canal bifurcations.

Other root and root canal abnormalities

In addition to the above-mentioned anatomical variations in primary molars, the occurrence of other root and root canal anomalies has been documented. Taurodontism, which is caused by the failure of Hertwigs epithelial sheath diaphragm to invaginate at the proper horizontal level (Jafarzadeh et al. 2008), was reported in primary molars, either unilateral or bilateral in normal children or as a part of a syndrome (Terezhalmy et al. 2001, Johnston & Franklin 2006, Rao & Arathi 2006, Jafarzadeh et al. 2008, King et al. 2010, Venugopal et al. 2010). Interestingly, the prevalence of taurodontism in the primary dentition can reach 9.0% in some population groups (King et al. 2010). Rao & Arathi (2006) observed that taurodontism, can affect the primary and permanent molars simultaneously. This nding supports the eld developmental theory that was described with accessory roots. In extremely rare occasions, single-rooted primary maxillary molars may occur (Ackerman et al. 1973, Nguyen et al. 1996). Interestingly, Ballal et al. (2006) reported on an endodontic management of a retained single-rooted primary maxillary second molar with a C-shaped canal. Fusion of primary molars has been documented (Caceda et al. 1994). Dens invaginatus in the primary dentition has also been reported (King et al. 2010) and can affect primary molars (Eden et al. 2002). Clinical considerations Primary molars with abnormalities such as taurodontism can be identied and classied from periapical radiographs. Endodontic treatment of a primary

taurodont requires copious irrigation with sodium hypochlorite (NaOCl) to ensure complete dissolution of the pulp tissues that usually show excessive bleeding (Jafarzadeh et al. 2008, Venugopal et al. 2010). Ultrasonic irrigation can also be helpful. Magnication and auxiliary illumination are preferred methods, especially in meso- and hyper-taurodont categories. The application of the resorbable paste using a disposable injection technique can be useful (Bhandari et al. 2012). The fusion of the distobuccal and palatal roots in primary maxillary molars may result in the formation of a ribbon like or C-shaped canal orice (Fig. 1e), which may extend to the apical portion. With the exception of the isthmus, the root canals, ranging from one to three, can be prepared normally. Careful enlargement of the orice of the isthmus using a small ultrasonic tip would enhance the penetration of the irrigant. Extravagant use of small les and NaOCl is essential for proper debridement of the isthmus (Jafarzadeh & Wu 2007). This should predictably facilitate the penetration of the resorbable paste into the isthmus.

Electronic working length determination

Determining the working length is an essential step prior to pulpectomy in primary molars. This step aims to maintain chemo-mechanical instrumentation and subsequent lling within the connes of the root canals, thus preventing any harm to both periradicular tissues and the succeeding permanent tooth germ (Gordon & Chandler 2004, Beltrame et al. 2011). Besides its crucial role in preoperative assessment, periapical radiography is the most widely used method for measuring the working length in primary teeth. Despite this, studies recently demonstrated the advantage of using various types of EALs as adjunct measurement tools to overcome the limitations of the radiographic procedure, which can only provide a two-dimensional image (Table S3). This is of particular importance in roots programmed for uneven physiological resorption which will often not be detected accurately during radiographic interpretation resulting in an increased risk of overinstrumentation and overlling (Harokopakis-Hajishengallis 2007, Leonardo et al. 2008) (Fig. 2). EALs also reduce radiation exposure and time. Thus, the treatment procedure is more convenient to both the operator and the child.

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(a)

(b)

(c)

Figure 2 (a) Buccolingual radiographic projection of a mesiobuccal root in a primary maxillary molar with uneven root resorption. Radiographically, the endodontic le is located within the connes of the root. (b,c) The photographic images show that the le (yellow arrow) is about 1 mm beyond the apical foramen (white arrow), which is located distally. The visually determined working length is 3 mm short of the root apex.

Literature search methodology

An electronic search was conducted in PubMed and Google Scholar search engines to identify the available clinical and laboratory investigations written in English language and published on the application of electronic apex locator in primary molars until September 2012 (Table S3). The following keywords: deciduous molar OR primary molar AND apex locator were used. Cross citations of the selected articles were also identied. Numerous in vitro studies (Table S3) examined the accuracy of EALs in primary molars at different environmental conditions (dry, saline, and NaOCl) (Katz et al. 1996), as well as with unresorbed roots and roots at different levels of resorption. Roots with onesixth to one-third (Angwaravong & Panitvisai 2009), one-third (Bodur et al. 2008, Odabas et al. 2011), one-half (Leonardo et al. 2009) or even up to twothird root resorption (Pinheiro et al. 2012a) have been examined. Most in vitro investigations reported the high accuracy of different types of EALs at different levels of resorption (Table S3). However, Bodur et al. (2008) found that Root ZX (Morita, Tokyo, Japan) and Endex (Osada, Tokyo, Japan) exhibited only 63.4% and 48.4% accuracy within 1 mm of the visually determined root canal measurements in resorbed roots, respectively. In addition, Kielbassa et al. (2003) performed a clinical investigation on 71 teeth, including 34 primary molars, of preschool children. The results showed that the measurements were affected signicantly by different operators; however, the readings

were not affected by the tooth type, root canal type, apex morphology (with or without resorption) or clinical condition (vital or necrotic pulps). Other in vivo studies demonstrated high levels of accuracy of EALs with and without root resorption (Beltrame et al. 2011, Odabas et al. 2011). The Root ZX and Root ZX II (Morita) are the most common EALs used in primary teeth (Table S3). Related investigations of this brand did not follow a single criterion in determining the working length. For instance, Katz et al. (1996) mentioned that the Root ZX was used as calibrated by the manufacturer to measure the tooth length minus 0.5 mm. Meanwhile, Beltrame et al. (2011) evaluated the working length by the indicated 0.0 mark. Angwaravong & Panitvisai (2009) compared the Root ZX measurement metre readings at 0.5 bar and Apex and found that the error in locating the apical foramen was smaller at metre reading Apex than 0.5 bar. Leonardo et al. (2008) and Odabas et al. (2011) selected the 1 reading on the apex locators display, which was based on the results of a pilot study reported by Leonardo et al. (2008). The results showed that this reading presented the best correlation with the actual root canal length measurement (visual method) at 1 mm short of the root apex. The absence of a standardized measurement technique led to conicting results. Kielbassa et al. (2003) reported the accuracy of Root ZX at 64%, whereas Odabas et al. (2011) observed a 86.495.8% accuracy, with both ndings showing precision measurements at 1 mm of the visually determined root canal lengths.

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Clinical considerations
Both in vitro and in vivo studies indicate that the application of EALs in paediatric endodontics demonstrate the following advantages: (i) accurate determination of the working length; (ii) reduced tension amongst the operator, child and family attributed to the simplicity of the procedure (which is the opposite case in radiographic examination, with cooperation from children usually achieved with difculty); (iii) reduced exposure to radiation; (iv) shorter treatment time due to favourable attitude and cooperation of children; and (v) detection of root perforations resulting from internal or external root resorption (Gordon & Chandler 2004), which can be undetected radiographically.

Current developments in the preparation of root canal systems Literature search methodology
An electronic search was conducted in PubMed and Google Scholar search engines to identify the available clinical and laboratory investigations written in English language and published on the application of rotary nickel-titanium les in primary molars until September 2012 (Table S4). The following keywords: deciduous molar OR primary molar AND rotary le OR nickel titanium have been used. Cross citations of the selected articles were also identied. The irrigation techniques used in the selected studies for rotary nickel-titanium les have been listed (Table S4). Further electronic search was undertaken to identify studies that used other irrigation solutionsprotocols. Finally, the pooled data are discussed in the light of the American and United Kingdom guidelines for pulpectomy procedures in paediatric dentistry and current literature in endodontic research. Mechanical instrumentation The application of NiTi rotary systems in primary molars has been investigated since the beginning of the 21st century (Barr et al. 2000) (Table S4). A study by Silva et al. (2004) examined the cleaning ability of K-les (Dentsply Maillefer, Ballaigues, Switzerland) and the ProFile system (Dentsply Tulsa Dental, Tulsa, OK, USA) using a stereomicroscope and scoring of remaining dye adhering to root canals of the cleared samples. The results showed no signicant

difference in the cleaning ability between both systems. However, the preparation time was reduced signicantly with the latter. This clinical advantage was observed by Nagaratna et al. (2006) who found that the canal preparation exhibited satisfactory taper and smooth walls with the ProFile system; however, instrument fracture was reported. The signicant reduction in the preparation time also was demonstrated with other NiTi rotary systems (Table S4). On the contrary, Madan et al. (2011) reported a shorter preparation time with K-les than the ProFile system, which might be attributed to insufcient operator experience with the rotary system. Canoglu et al. (2006) compared the ProFile system with hand and ultrasonic K-les. Although the results were not signicantly different in terms of shaping effectiveness, ultrasonics signicantly increased the incidence of zip formation and decreased the working length. Despite this occurrence, Da Costa et al. (2008) reported a high success rate (94%) with ultrasonic instrumentation after clinical and radiographic assessment for a mean follow-up of 14.1 months. Kuo et al. (2006) introduced a modied time-saving protocol for the treatment for primary teeth in two sessions. The guideline starts with a size 10 K-le followed by two les (SX and S2) of the ProTaper NiTi rotary system and then nishing the preparation with size 25 or 30 H-les (Table S4). Based on both clinical and radiographic evaluation, the 12-month follow-up showed a success rate of 96%. Despite this favourable nding, this protocol requires modications for teeth undergoing physiological root resorption in which larger sizes and greater tapers are indicated (Kuo et al. 2006). Recently, Azar et al. (2012) suggested another modied sequence for ProTaper (S1, S2, F1) and compared the cleaning capacity of that sequence with Mtwo NiTi rotary system (VDW, Munich, Germany) and hand les using a method similar to that described by Silva et al. (2004). All systems were found to have acceptable cleaning ability. A study by Pinheiro et al. (2012b) compared another sequence of ProTaper (S1, S2, F1, F2) with hand les and a hybrid system comprising a number of hand K-les and ProTaper rotary les (Table S4). The hybrid technique required a longer preparation time than the manual and rotary systems, but showed the greatest reduction in Enterococcus faecalis. This reduction may be due to increased exposure of the organism to the irrigant [Endo-PTC (urea peroxide + Tween 80 + Car~o, S~ bowax, Formula & Ac ao Paulo, Brazil) and 0.5% a

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NaOCl], supplemented by the simultaneous action of the manual and rotary instruments. Another study evaluated the instrumentation behaviour of Hero 642 (Micro-Mega, Besanc on, France) in primary teeth (Kummer et al. 2008). In addition to the signicant decrease in instrumentation time reported, canal instrumentation exhibited regularity and uniformity. However, iatrogenic perforations in the middle third of some resorbed roots were observed in both rotary and manual systems, especially in mesial and distal roots of mandibular molars as well as the mesiobuccal roots of maxillary molars having second mesiobuccal canals. Moghaddam et al. (2009) compared the FlexMaster rotary NiTi system (VDW, Munich, Germany) with the manual K-les (Dentsply Maillefer). The mean preparation timecanal was reported as short as 2.07 min in the rotary system compared with 5.55 min for the manual. The cleaning efcacy was examined for all cleared samples after scoring the remaining dye observed via a stereomicroscope. The results showed that the cleaning efcacy in the apical and middle thirds was comparable; however, the coronal third was more efciently cleaned with hand les than with the rotary system. Root canal irrigation Experimental studies summarized in Table S4 indicate that NaOCl, especially at 1% concentration, is the most commonly used irrigant in primary molars (Silva et al. 2004, Canoglu et al. 2006, Kummer et al. 2008, Madan et al. 2011, Ochoa-Romero et al. 2011, Pinheiro et al. 2012b), which is recommended by the American Association of Pediatric Dentistry (AAPD 2012). The use of normal saline is also common (Nagaratna et al. 2006, Moghaddam et al. 2009, Azar & Mokhtare 2011, Azar et al. 2012), which is documented in the United Kingdom national guidelines in paediatric dentistry (Rodd et al. 2006). The literature also demonstrates the application of other irrigation solutions in paediatric endodontics such as hydrogen peroxide (Moskovitz et al. 2005), Dakins solution (0.5% NaOCl neutralized with boric acid) (Pascon & Puppin-Rontani 2006, Pascon et al. 2007) and chlorhexidine (CHX), which has the ability to reduce the bacterial loading in pulpectomized primary teeth (Ruiz-Esparza et al. 2011). In addition, the combination of CHX with NaOCl was attempted to maintain both tissue-dissolving capacity and antimicrobial substantivity (Ramar & Mungara 2010). A comparison by Tirali et al. (2012) indicated that 0.1%

octenidine dihydrochloride exerted more antibacterial activity against E. faecalis cultured in extracted primary teeth compared with 2% CHX and 5.25% NaOCl. The application of CarisolvTM (MediTeam, Goteborg, Sweden) has also been investigated, and the SEM images at the middle and coronal thirds conrmed its ability to obtain comparable results with 1% NaOCl at liquid and gel formulations; however, NaOCl solution showed the least mean debris score at the apical third (Singhal et al. 2012). The smear layer is an amorphous layer with a thickness of 25 lm and consists of inorganic and organic components, including remnants of odontoblastic processes, pulp tissue, microorganisms and their metabolic products (Violich & Chandler 2010). The differences in the micromorphological features between primary and permanent teeth indicate that the thickness and composition of the smear layer of the instrumented root canals in both dentitions may vary. Current practice prefers the removal of smear layer with necrotic pulps. Consequently, smear layer removal from pulpectomized anterior and posterior primary teeth was investigated (Salama & Abdelmegid tze et al. 2005, Canoglu et al. 2006, Nelson1994, Go Filho et al. 2009, Hariharan et al. 2010, Tannure et al. 2011, Barcelos et al. 2012, Pascon et al. 2012). Results showed that 6% citric acid as a nal rinse after irrigation with NaOCl caused no damage to the tze et al. 2005) root dentine of primary molars (Go and improved clinical outcomes (Barcelos et al. 2012). Final irrigation with 2% CHX, after 6% citric acid, was recommended to potentiate the antimicrobial action and substantivity of CHX (Hariharan et al. 2010). In addition, the use of 17% EDTA for nal irrigation improved the tubular penetration of sealers, which provides a clinical advantage for retained primary molars (Canoglu et al. 2006). This was recently conrmed by Pascon et al. (2012) who compared the ability of NaOCl/EDTA and CHX/EDTA combinations to remove the smear layer in the primary root dentine and found that NaOCl/EDTA combination was the best. However, in that study, NaOCl was used at 5.25% concentration, which is not recommended in primary teeth. Pascon & Puppin-Rontani (2006) investigated the permeability of root dentine in primary molars following the application of 1% and 2% CHX liquid, Dakin solution alone or combined with urea peroxide. Although 1% and 2% CHX liquid demonstrated the highest permeability index (PI) (percentage of the dye penetration area in root dentine), a low PI was

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reported with 2% CHX at the gel formulation (Pascon et al. 2007). Ultrasonic activation of CHX gel resulted in higher PI averages than manual; however, the best results were demonstrated with saline, Dakin solution alone or combined with hydrogen peroxide cream without ultrasonic activation. The effect of high PI on the penetration of root canal lling materials and microbial irritants requires further investigations. The UK National Guidelines on Paediatric Dentistry for pulpectomy procedure recommends irrigation with normal saline (0.9%), CHX (0.4%) or NaOCl solution (0.1%) (Rodd et al. 2006). According to the American Academy of Pediatric Dentistry for pulpectomy procedure (AAPD 2012), the chemo-mechanical procedure with an inert solution alone cannot adequately reduce the microbial population in a root canal system. The same guideline also emphasized the importance of disinfection with irrigants such as 1% NaOCl and/or CHX for optimal bacterial decontamination of the canals. The related literature on irrigant concentrations and interactions indicates that the current guidelines and recommendations for pulpectomy in primary dentition should be revised. (i) NaOCl commonly used in endodontics at concentrations between 0.5% and fer 2007, Hu lsmann 5.25/6% (Zehnder 2006, Scha et al. 2009, Haapasalo et al. 2010). Although the most appropriate concentration remains controversial, there is no evidence in the literature that NaOCl at 0.1% concentration would maintain effective tissuedissolving effect and potent antimicrobial activity. (ii) The combination of NaOCl and CHX, even at small concentrations, was found to produce a brown precipitate that may contain a signicant amount of the carcinogenic parachloroaniline (PCA) (either in the precipitate or one of CHX breakdown products) (Basrani et al. 2007, Nowicki & Sem 2011). This is of particular concern in primary molars undergoing root resorption where the possibility for irrigant extrusion is high (Williams et al. 1995). This precipitate also adheres to the tooth structure, causing tooth discolouration, and acts as a residual lm that may compromise the diffusion of intracanal medicaments and proper adaptation of the root canal lling to the root canal walls (Ahmed & Abbott 2012b). Meanwhile, the combination of 2.5% NaOCl and 20% citric acid results in bubbling because of chlorine gas formation (Baumgartner & Ibay 1987), and may produce a white precipitate (Ahmed & Abbott 2012b), or the solution turns cloudy when 6% citric acid is used. Further investigation is necessary to validate the safety of the aforementioned combination.

lez-Lo pez et al. (2006) and Rasimick In addition, Gonza et al. (2008) have reported interactions between CHX and EDTA irrigants with the formation of white to pink precipitate, although no PCA was detected.

Clinical considerations
Clinical research proved that rotary NiTi les can signicantly reduce the instrumentation time of the root canals (Table S4). Consequently, NiTi rotary systems gained an increase in application amongst American Board of Pediatric Dentistry diplomates (Dunston & Coll 2008). Despite the advantage of reduced instrumentation time with NiTi application, the signicance of adequate exposure time for the irrigant must be emphasized, particularly in necrotic cases given that root canal preparation is essentially a chemo-mechanical procedure. Sufcient exposure time is necessary to dissolve the remaining necrotic tissues completely and eradicate the remaining microbial irritants in the complex anatomy of the root canal system and dentinal tubules (Retamozo et al. 2010), especially at lower concentrations of NaOCl. Apart from the high cost of NiTi rotary systems, the fracture of rotary NiTi les in primary molars has been reported (Nagaratna et al. 2006). The occasion of les fracture in roots programmed for physiological root resorption and in close proximity to permanent tooth buds is of particular concern (Kuo et al. 2006). A number of clinical epidemiological surveys show that le fracture is one of the most prominent complications with NiTi rotary systems amongst general dental practitioners and endodontists (Madarati et al. 2008, Bird et al. 2009, Mozayeni et al. 2011). However, the literature lacks similar clinical surveys amongst paedodontists. Future studies are warranted to identify the prevalence of le fracture in the primary dentition and usage parameters of NiTi rotary systems in paediatric endodontics. Likewise, dental practitioners should carefully choose irrigating solutions (Ahmed & Abbott 2012b, Rossi-Fedele et al. 2012). Intermediate solutions such as saline or sterile distilled water, followed by careful drying, can prevent the formation of brown precipitate when NaOCl and CHX are combined (Krishnamurthy & Sudhakaran 2010). When removal of the smear layer is indicated, the use of 6% citric acid or 18% EDTA between NaOCl and CHX may also block the formation of a brown precipitate. However, using saline or sterile distilled water as intermediate ushes between every two successive irrigants remains essen-

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tial to prevent the formation of any possible interactions. Notably, maleic acid (MA) has been found to be less cytotoxic and more effective in smear layer removal than EDTA (Ballal et al. 2009a,b), and the combination of MA and CHX has not caused any precipitate formation or discolouration (Ballal et al. 2011). However, further research is needed to validate its use in primary dentition.

Concluding remarks
The root and root canal morphology in primary molars shows considerable variations. Further investigations are required to identify the prevalence of, and the correlation between, a missed root and/or root canal anatomy and failure in root canal treatment of primary molars. The literature supports the potential use of electronic apex locators in primary molars, regardless of the stage of root resorption. This advantageous nding would pave the way for its adoption amongst paedodontists. With an experienced operator, the use of rotary NiTi les in primary molars is advantageous. However, further studies are warranted to examine (i) the effect of reduction in the preparation time on the efcacy of the chemo-mechanical procedure and clinical outcomes, (ii) the prevalence of le fracture and (iii) usage parameters of NiTi rotary systems in paediatric endodontics. Dental practitioners should be aware of the chemical interactions amongst endodontic irrigants, which must be highlighted in the current guidelines for pulpectomy procedures in paediatric dentistry. The recommended preventive strategies should be strictly followed.

Conict of interest
The author denies any conict of interest.

References
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Supporting Information
Additional Supporting Information may be found in the online version of this article: Table S1 Summary of studies that demonstrated the root canal morphology of primary maxillary molars. Table S2 Summary of studies that demonstrated the root/root canal morphology of primary mandibular molars. Table S3 Summary of in vivo and in vitro studies that demonstrated the use of electronic apex locators in primary molars. Table S4 Summary of in vitro and in vivo studies that demonstrated the use of rotary NiTi instruments in primary molars.

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