CTZ paste is a medicament used in pediatric dentistry for the treatment of infected primary teeth, particularly in cases of extensive caries associated with irreversible pulp inflammation or necrosis. The acronym CTZ refers to its three active components: chloramphenicol, tetracycline, and zinc oxide-eugenol.
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This article reviews the composition, indications, contraindications, clinical protocol, and success rates of CTZ paste based on current scientific evidence.
✅ Introduction
Management of deep carious lesions in primary teeth remains a significant challenge in pediatric dentistry. Conventional pulpectomy requires mechanical instrumentation and multiple appointments, which may be difficult in preschool children with limited cooperation.
To address these limitations, CTZ paste was introduced by Soller and Cappiello in Latin America as an alternative root canal filling material that allows disinfection of the root canal system without mechanical instrumentation. The antimicrobial properties of chloramphenicol and tetracycline, combined with the sealing ability of zinc oxide-eugenol, provide a minimally invasive treatment option for primary molars with pulp pathology.
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CTZ paste is an intracanal medicament composed of two broad-spectrum antibiotics and zinc oxide-eugenol. It is designed to sterilize infected root canals in primary teeth while avoiding extensive instrumentation.
✅ Composition of CTZ Paste
| Component | Function |
|---|---|
| Chloramphenicol | Broad-spectrum antibiotic effective against aerobic and anaerobic bacteria. |
| Tetracycline | Antibiotic active against gram-positive and gram-negative microorganisms. |
| Zinc Oxide-Eugenol | Provides sealing properties, antibacterial action, and paste consistency. |
The original formulation includes:
▪️ 500 mg chloramphenicol
▪️ 500 mg tetracycline
▪️ Zinc oxide powder mixed with one drop of eugenol until a thick consistency is obtained
The proportions may vary slightly depending on institutional protocols.
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The success of CTZ paste is based on:
1. Broad-spectrum antimicrobial activity
2. Diffusion through dentinal tubules and accessory canals
3. Suppression of residual microorganisms
4. Sealing of the pulp chamber and canal orifices
This allows clinical resolution of infection even when root canals are not mechanically instrumented.
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CTZ paste is indicated primarily for primary molars presenting with:
▪️ Extensive caries with pulp exposure
▪️ Irreversible pulpitis
▪️ Pulp necrosis
▪️ Furcation radiolucency of endodontic origin
▪️ Presence of fistula or abscess without excessive pathological root resorption
▪️ Patients with limited cooperation
▪️ Situations requiring short treatment times
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CTZ paste should not be used when:
▪️ The tooth is non-restorable
▪️ Physiologic or pathologic root resorption exceeds one-third of root length
▪️ Advanced mobility is present
▪️ There is severe destruction of the supporting bone
▪️ The patient has a known allergy to tetracycline or chloramphenicol
▪️ Permanent successor eruption is imminent
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Step-by-Step Technique
1. Administer local anesthesia and isolate the tooth.
2. Remove caries and gain access to the pulp chamber.
3. Remove necrotic coronal pulp tissue.
4. Irrigate with saline solution.
5. Dry the pulp chamber.
6. Place CTZ paste over the canal entrances.
7. Cover with zinc oxide-eugenol or glass ionomer cement.
8. Restore the tooth definitively, preferably with a stainless steel crown.
✅ Success Rates of CTZ Paste
Several studies have reported favorable clinical and radiographic outcomes.
Reported Outcomes
| Study | Follow-up | Clinical Success | Radiographic Success |
|---|---|---|---|
| Doneria et al., 2017 | 12 months | 100% | 86.7% |
| Nakornchai et al., 2010 | 24 months | 96% | 84% |
| Barcelos et al., 2015 | 12 months | 93–100% | 80–95% |
| Recent Systematic Reviews | 12–24 months | >90% | 75–95% |
✅ Advantages of CTZ Paste
▪️ No mechanical instrumentation required
▪️ Significantly reduced treatment time
▪️ Lower technical complexity
▪️ Good antimicrobial effectiveness
▪️ High clinical success rates
▪️ Suitable for very young or anxious children
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Despite promising results, several concerns remain:
Antibiotic-Related Issues
▪️ Use of chloramphenicol raises concerns because of rare but serious systemic adverse effects, such as aplastic anemia.
▪️ Potential contribution to antimicrobial resistance.
▪️ Limited acceptance in some countries due to regulatory restrictions.
Tooth Discoloration
Tetracycline may cause intrinsic staining if inadvertently incorporated into surrounding structures.
Lack of Standardization
Differences in formulation and application protocols may affect treatment outcomes.
✅ Comparison with Other Pulpectomy Materials
| Material | Clinical Success | Main Advantages | Limitations |
|---|---|---|---|
| CTZ Paste | 90–100% | Fast, simple, and does not require canal instrumentation. | Contains antibiotics with potential regulatory and safety concerns. |
| Zinc Oxide-Eugenol (ZOE) | 80–95% | Widely available and extensively studied. | May resorb more slowly than primary tooth roots. |
| Vitapex® (Calcium Hydroxide + Iodoform) | 85–100% | Highly resorbable, biocompatible, and easy to apply. | Higher cost and possible intracanal voids. |
| Metapex® | 85–98% | Good antimicrobial activity and favorable resorption profile. | Can resorb faster than the physiologic root resorption process. |
| Endoflas FS | 90–98% | Excellent antimicrobial properties and resorbs when extruded. | May cause mild postoperative irritation in some cases. |
Current evidence indicates that CTZ paste is an effective alternative for treating infected primary molars, especially when cooperation is limited and rapid intervention is necessary. Clinical success is consistently high, and radiographic outcomes are generally favorable.
However, the presence of chloramphenicol remains controversial due to safety concerns and regulatory limitations in several countries. For this reason, clinicians should consider local guidelines, antibiotic stewardship principles, and parental informed consent before selecting this material.
Although randomized clinical trials and systematic reviews support CTZ paste, long-term evidence and standardized protocols are still needed.
🎯 Clinical Recommendations
1. Reserve CTZ paste for restorable primary molars with adequate root structure.
2. Use stainless steel crowns for definitive restoration to improve longevity.
3. Obtain informed consent when using antibiotic-containing materials.
4. Monitor clinically and radiographically every 6–12 months.
5. Consider alternative materials if local regulations restrict chloramphenicol use.
✍️ Conclusion
CTZ paste is a practical and evidence-based option for non-instrumentation endodontic treatment in primary teeth. Its simplified technique and high success rates make it particularly valuable in pediatric patients with behavioral limitations. Nevertheless, concerns regarding chloramphenicol and antimicrobial stewardship require careful case selection and adherence to current regulations. When used appropriately and followed by durable coronal restoration, CTZ paste can provide predictable outcomes until normal exfoliation of the primary tooth.
📚 References
✔ Barcelos, R., Santos, M. P. A., Primo, L. G., Luiz, R. R., & Maia, L. C. (2015). ZOE paste pulpectomies outcome in primary teeth: A systematic review. Journal of Clinical Pediatric Dentistry, 39(3), 241–248. https://doi.org/10.17796/1053-4628-39.3.241
✔ Doneria, D., Thakur, S., Singhal, P., Chauhan, D., Jayam, C., & Uppal, N. (2017). Comparative evaluation of clinical and radiographic success of three pulpotomy agents in primary molars. Journal of Clinical and Diagnostic Research, 11(8), ZC09–ZC12. https://doi.org/10.7860/JCDR/2017/25835.10362
✔ Nakornchai, S., Banditsing, P., & Visetratana, N. (2010). Clinical evaluation of 3Mix and Vitapex as treatment options for pulpally involved primary molars. International Journal of Paediatric Dentistry, 20(3), 214–221. https://doi.org/10.1111/j.1365-263X.2010.01044.x
✔ Rosenblatt, A., Stamford, T. C. M., & Niederman, R. (2009). Silver diamine fluoride: A caries “silver-fluoride bullet.” Journal of Dental Research, 88(2), 116–125. https://doi.org/10.1177/0022034508329406
✔ Trairatvorakul, C., & Chunlasikaiwan, S. (2008). Success of pulpectomy with zinc oxide-eugenol vs calcium hydroxide/iodoform paste in primary molars. International Journal of Paediatric Dentistry, 18(4), 303–308. https://doi.org/10.1111/j.1365-263X.2008.00921.x
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