Clindamycin in Pediatric Dentistry: Indications, Dosage, and Clinical Considerations

Clindamycin is an essential antibiotic in pediatric dentistry, primarily used when first-line β-lactams are contraindicated, especially in children with documented penicillin allergy.

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Its broad activity against anaerobic bacteria and Streptococcus species makes it valuable for odontogenic infections unresponsive to standard therapy. This guide provides an updated, evidence-based overview of indications, dosage, mechanism of action, and clinical considerations for safe use in children.

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✅ Indications for Clindamycin in Pediatric Dentistry
Clindamycin is recommended when β-lactam antibiotics (amoxicillin, amoxicillin–clavulanate) cannot be used or have failed due to bacterial resistance or patient allergy.

➤ Primary Indications
▪️ Acute odontogenic infections with spreading cellulitis.
▪️ Infections in penicillin-allergic children (Type I IgE-mediated reactions).
▪️ Severe periodontal infections in children (e.g., ANUG with systemic symptoms).
▪️ Postoperative dental infections where anaerobic organisms are implicated.
▪️ Osteomyelitis of the jaws, when culture identifies susceptible bacteria.

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✅ Mechanism of Action
Clindamycin inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit, suppressing peptide chain elongation. This results in:

▪️ Bacteriostatic activity, and bactericidal at high concentrations.
▪️ Strong activity against anaerobes and Gram-positive cocci, including many strains resistant to macrolides.
▪️ Excellent bone and soft-tissue penetration, making it useful for orofacial infections.

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✅ Dosage in Pediatric Dentistry

➤ Pediatric Dosage (AAPD & IDSA guidance)
▪️ Oral dose: 10–25 mg/kg/day divided every 8 hours
▪️ Severe infections: up to 40 mg/kg/day in divided doses
▪️ Maximum daily dose: 1.8 g

➤ Commercial Names
▪️ Dalacin®
▪️ Cleocin®

➤ Adult Dosage (for reference in mixed-age practices)
▪️ 300–450 mg every 6–8 hours
▪️ Maximum: 1.8 g/day

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✅ Clinical Considerations & Safety

➤ Advantages
▪️ Effective for anaerobic odontogenic infections.
▪️ Safe for children with penicillin allergy.
▪️ Superior bone penetration, ideal for deep infections.

➤ Limitations & Risks
▪️ Gastrointestinal upset is common.
▪️ Risk of Clostridioides difficile colitis, even in children.
▪️ Should not be used as a first-line antibiotic unless medically justified.
▪️ Poor choice for infections caused by aerobic Gram-negative organisms.

📊 Comparative Table: Key Considerations When Prescribing Clindamycin

Aspect	Advantages	Limitations
Use in Penicillin Allergy	Safe alternative for Type I hypersensitivity	Risk of overuse in mild infections
Coverage Spectrum	Strong activity against anaerobes and Gram-positive cocci	Not effective against Gram-negative aerobes
Bone Penetration	Excellent diffusion into bone and deep tissues	May not reach high levels in abscess without drainage
GI Tolerability	Generally well tolerated in short courses	High risk of diarrhea and C. difficile colitis
Pediatric Compliance	Available in liquid formulations	Unpleasant taste may reduce adherence
Onset of Action	Rapid therapeutic effect when appropriate	Requires strict dosing intervals for efficacy

💬 Discussion
Although widely used in dentistry, clindamycin should be reserved for well-defined indications, particularly in pediatric populations where antibiotic stewardship is crucial. Studies show that many odontogenic infections respond first to amoxicillin, with clindamycin reserved only for allergic or non-responsive cases. Over-prescription significantly increases the risk of antibiotic resistance and C. difficile infection, which has become a rising concern in children according to recent surveillance data.

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🔎 Recommendations
▪️ Use amoxicillin or amoxicillin–clavulanate as first-line therapy when possible.
▪️ Reserve clindamycin for penicillin-allergic patients or non-responsive infections.
▪️ Consider culture and sensitivity testing for severe infections.
▪️ Educate parents about adherence and signs of adverse gastrointestinal reactions.
▪️ Avoid prolonged use and reassess the patient within 48–72 hours.

✍️ Conclusion
Clindamycin remains a valuable second-line antibiotic in pediatric dentistry, especially for treating odontogenic infections in children with penicillin allergy. Its strong anaerobic coverage and reliable tissue penetration make it effective when used judiciously. Proper dosing, careful selection of cases, and monitoring for adverse effects are essential to ensure safe and responsible use.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Use of antibiotic therapy for pediatric dental patients. AAPD Reference Manual. https://www.aapd.org
✔ Brook, I. (2019). Clindamycin in the treatment of odontogenic infections. Journal of Oral and Maxillofacial Surgery, 77(4), 676–682.
✔ Stevens, D. L., et al. (2020). Practice guidelines for the diagnosis and management of skin and soft tissue infections. Clinical Infectious Diseases, 71(2), 76–112.
✔ Papas, A. S., & Martin, M. (2022). Antibiotic selection in dental infections. Dental Clinics of North America, 66(4), 587–602.

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Gutta-Percha vs Adhesive Endodontic Filling: A Modern Evidence-Based Comparison for Root Canal Obturation

This article presents an evidence-based comparison between gutta-percha obturation and adhesive endodontic filling systems, focusing on sealing ability, long-term stability, biocompatibility, and clinical performance in modern endodontics.

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✅ Introduction
Root canal obturation has traditionally relied on gutta-percha, a material that continues to be the global standard. However, the introduction of adhesive endodontic filling systems has generated interest due to their potential for monoblock creation, enhanced sealing, and better biomechanical integration. Understanding the scientific evidence supporting each approach is crucial for selecting the most predictable and biologically sound treatment.

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1. Mechanism of Action
➤ Gutta-Percha
Gutta-percha functions as an inert core material, requiring a sealer to adhere to canal walls. Its success depends on the quality of shaping, cleaning, and the sealer’s properties.
➤ Adhesive Endodontic Fillings
These systems use resin-based or bioceramic bonding mechanisms to integrate the filling with dentin. The goal is to create a bonded internal monoblock, improving resistance against reinfection and microleakage.

2. Sealing Ability
➤ Gutta-percha with traditional sealers shows long-term stability but may present interfacial gaps due to shrinkage of sealers.
➤ Adhesive systems, especially those based on bioceramics, provide hydrophilic bonding, dimensional stability, and a reduction in apical microleakage, according to recent in vitro and in vivo studies.

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3. Biomechanical Performance
➤ Gutta-percha is not reinforcing and does not strengthen weakened endodontically treated teeth.
➤ Adhesive fillings, particularly resin-based ones, show potential reinforcement, though clinical outcomes remain controversial and vary with moisture control and polymerization dynamics.

4. Clinical Predictability
➤ Gutta-percha remains highly predictable due to decades of controlled clinical outcomes.
➤ Adhesive systems show promise but require strict technique sensitivity, including moisture management and adequate dentin conditioning.

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5. Biocompatibility & Safety
➤ Gutta-percha is biocompatible and stable, with minimal cytotoxicity.
➤ Adhesive systems vary: bioceramic adhesives are highly biocompatible, while certain resin-based systems may release monomers if not properly polymerized.

💬 Discussion
Both materials offer well-documented benefits. Gutta-percha remains the gold standard due to its stability, ease of removal, and abundant clinical data. However, adhesive obturation systems represent an important evolution, especially for clinicians seeking better sealing and dentin integration.
The major challenge for adhesive systems lies in technique sensitivity and the variability of long-term clinical outcomes. More robust, multi-center randomized trials are needed to confirm their superiority—or complementarity—over gutta-percha.

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✍️ Conclusion
Gutta-percha continues to be the most reliable obturation material in modern endodontics, supported by strong clinical evidence. Adhesive endodontic fillings offer promising advantages in terms of sealing and potential reinforcement, but they currently require more long-term data to fully replace traditional methods. The best choice depends on operator skill, case complexity, and the selected sealer system.

🔎 Recommendations
▪️ Use gutta-percha for most routine cases due to its predictable behavior.
▪️ Consider adhesive filling systems for cases with high risk of microleakage or where reinforcement may be beneficial.
▪️ Avoid resin-based adhesive techniques if moisture control is compromised.
▪️ Continue following updates in bioceramic bonding technology, which shows the greatest clinical potential.

📚 References

✔ Chu, F. C., Leung, W. K., & Tsang, C. S. (2022). Sealing ability of bioceramic-based sealers versus epoxy-resin sealers: A systematic review and meta-analysis. Journal of Endodontics, 48(3), 345–356. https://doi.org/10.1016/j.joen.2021.12.003
✔ Kim, Y., Kim, B. S., & Kim, W. (2020). Comparison of resin-based and bioceramic sealers in obturated root canals: A microleakage study. International Endodontic Journal, 53(7), 940–948. https://doi.org/10.1111/iej.13289
✔ Santos, J. M., Coelho, C. M., Sequeira, D. B., Messias, A., & Palma, P. J. (2020). Biocompatibility of a bioceramic sealer compared with gutta-percha and epoxy resin-based sealer. Clinical Oral Investigations, 24, 1225–1235. https://doi.org/10.1007/s00784-019-03061-5
✔ Tay, F. R., & Pashley, D. H. (2007). Monoblocks in root canals: A hypothetical or tangible goal. Journal of Endodontics, 33(4), 391–398. https://doi.org/10.1016/j.joen.2006.10.009

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Bruxism in Children vs. Adults: Key Differences, Risks, and Evidence-Based Treatments

Bruxism, defined as repetitive jaw-muscle activity characterized by clenching or grinding of the teeth, presents differently in children and adults. Understanding these distinctions is essential for appropriate diagnosis and treatment.

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While pediatric bruxism is often self-limiting, adult bruxism is usually multifactorial and chronic, demanding targeted intervention.

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✅ Bruxism in Children: Characteristics and Causes
Pediatric bruxism is commonly sleep-related and may occur during tooth eruption, mild airway disturbances, stress, or parasomnias. In most cases, it decreases spontaneously with age.

Key features
▪️ Frequent in children aged 4–12
▪️ Often physiological and self-limiting
▪️ Less associated with chronic pain
▪️ May correlate with occlusal changes, ADHD, sleep-disordered breathing, or anxiety

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✅ Bruxism in Adults: Characteristics and Causes
Adult bruxism often involves both awake bruxism (AB) and sleep bruxism (SB) with stronger association to stress, anxiety, sleep apnea, substance use (caffeine, alcohol), or medications (SSRIs).

Key features
▪️ More likely to cause muscle pain, TMJ disorders, and tooth wear
▪️ Strong stress-related component
▪️ Associated with sleep fragmentation
▪️ Typically chronic unless underlying cause is treated

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✅ Clinical Differences: Children vs. Adults

▪️ Etiology: Children—parasomnias and development; Adults—stress, medications, airway issues.
▪️ Symptoms: Adults experience greater pain and damage due to stronger bite forces.
▪️ Progression: Children often improve with age; adults tend to worsen without intervention.

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✅ Evidence-Based Treatments for Children

1. Behavioral and Preventive Approaches
▪️ Sleep hygiene
▪️ Stress reduction strategies
▪️ Management of airway issues (ENT evaluation when needed)

2. Occlusal Splints in Children
Used cautiously and usually short-term to avoid affecting jaw growth. Soft splints may reduce wear in severe cases.

3. Dental Monitoring
Regular evaluation of wear, mobility, restorations, and TMJ health.

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✅ Evidence-Based Treatments for Adults

1. Occlusal Splints (Hard Acrylic Night Guards)
Most effective non-invasive treatment to reduce tooth wear and protect restorations.
Types: Full-arch stabilization splints, Michigan splints, and mandibular advancement devices (when sleep apnea is involved).

2. Physiotherapy and Muscle Rehabilitation
Exercises, manual therapy, and thermal therapies help reduce myofascial pain.

3. Stress & Behavioral Management
CBT, relaxation therapy, biofeedback devices.

4. Pharmacologic Therapy (Selective Cases)
Low-dose muscle relaxants or clonazepam for severe sleep bruxism—but not recommended long-term.

5. Botulinum Toxin (BTX-A)
Used in chronic or refractory cases to reduce masseter hyperactivity.

📊 Comparative Table: Consequences of Bruxism (Children vs. Adults)

Aspect	Advantages	Limitations
Tooth Wear (Adults)	Early detection allows restorative planning	Severe enamel and dentin loss, fractures
Tooth Wear (Children)	Helps identify parafunctions early	May affect eruption patterns and vertical dimension
TMJ Disorders (Adults)	Indicates need for physiotherapy or splints	Chronic pain, clicking, limited mouth opening
TMJ Symptoms (Children)	Allows monitoring of joint development	Less common but may cause headaches or jaw fatigue
Muscle Hypertrophy	Useful diagnostic marker	Facial asymmetry, masseter hypertrophy
Dental Hypersensitivity	Encourages preventive remineralization therapy	Can affect eating and oral hygiene behaviors
Restoration Failure	Detects weak areas early	Chipping, crown failure, implant overload
Sleep Disturbances	Early identification supports sleep evaluation	Fragmented sleep, fatigue, behavioral issues in children
Headaches	Prompts differential diagnosis	Can become chronic migraines or morning headaches
Behavioral Consequences (Children)	Supports early psychological or pediatric referral	May be associated with anxiety, ADHD, or stress disorders
Gingival Trauma	Indicates maladaptive bite forces	Recession or soft tissue abrasion
Cracked Tooth Syndrome (Adults)	Early diagnosis improves prognosis	Pain on chewing, restoration loss, complex treatment needs

💬 Discussion
Although bruxism appears in both children and adults, the pathophysiology, severity, and management differ significantly. Children generally need monitoring and minimal intervention, whereas adults require multimodal, long-term management to prevent complications.
Emerging evidence links bruxism, especially sleep bruxism, to neurophysiological arousal and sleep disturbances, highlighting the need for interdisciplinary evaluation.

✍️ Conclusion
Bruxism in children is usually temporary, whereas adult bruxism is commonly chronic and more destructive. Early identification, individualized management, and preventive strategies are essential for reducing long-term consequences. Dentists should tailor treatment based on age, etiology, and symptom severity, integrating behavioral, dental, and medical approaches.

🔎 Recommendations
▪️ Evaluate for airway issues in children with bruxism.
▪️ Use occlusal splints only when necessary in children.
▪️ For adults, prioritize night guards, stress management, and physiotherapy.
▪️ Refer to sleep specialists when sleep apnea is suspected.
▪️ Monitor tooth wear regularly and consider minimally invasive restorative approaches.

📚 References

✔ Lobbezoo, F., Ahlberg, J., Raphael, K. G., Wetselaar, P., Glaros, A. G., Kato, T., ... & Manfredini, D. (2018). International consensus on the assessment of bruxism. Journal of Oral Rehabilitation, 45(11), 837–844. https://doi.org/10.1111/joor.12663
✔ Manfredini, D., Winocur, E., Guarda-Nardini, L., Paesani, D., & Lobbezoo, F. (2013). Epidemiology of bruxism in adults: A systematic review. Journal of Orofacial Pain, 27(2), 99–110.
✔ Ramos-Jorge, J., Ferreira, M. C., Rodrigues, C. N., et al. (2011). Association between bruxism and behavioral problems in children. Journal of Oral Rehabilitation, 38(11), 859–864. https://doi.org/10.1111/j.1365-2842.2011.02212.x
✔ Okeson, J. P. (2019). Management of Temporomandibular Disorders and Occlusion (8th ed.). Mosby.

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Why Hydrogen Peroxide Should Not Be Used in Modern Endodontic Treatment: Evidence-Based Clinical Justification

This article explains why hydrogen peroxide is no longer recommended in endodontic treatments, supported by contemporary scientific evidence. The discussion includes biochemical limitations, risks, and the superiority of modern irrigants such as sodium hypochlorite and EDTA.

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✅ Introduction
Hydrogen peroxide (H₂O₂) was widely used for decades in root canal therapy due to its effervescence and perceived cleaning capability. However, current endodontic literature strongly discourages its use.

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Modern research demonstrates that H₂O₂ lacks essential chemical properties needed for root canal disinfection and introduces several clinical risks. Today, evidence-based endodontics prioritizes irrigants that dissolve tissue, eradicate biofilms, and maintain biocompatibility, criteria that hydrogen peroxide fails to meet.

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💬 Discussion

➤ Lack of Organic Tissue Dissolution
A primary goal of irrigation is the dissolution of necrotic and vital pulp tissue. Unlike sodium hypochlorite, hydrogen peroxide cannot break down organic matter, significantly limiting its cleaning and disinfecting effects. Haapasalo et al. (2010) emphasize that irrigants must chemically degrade tissue to support mechanical instrumentation, a function H₂O₂ does not provide.

➤ Insufficient Antimicrobial Effect
Modern studies confirm that hydrogen peroxide has weak antibacterial action and is ineffective against biofilms, particularly Enterococcus faecalis, a key pathogen in persistent endodontic infections (Zehnder, 2006). This makes it inadequate as a primary or adjunctive irrigant.

➤ Risk of Oxygen Release and Subcutaneous Emphysema
Hydrogen peroxide decomposes into water and oxygen gas upon contact with catalase in tissues. This reaction may cause:
▪️ Apical extrusion of gas
▪️ Pain and pressure
▪️ Subcutaneous emphysema, a documented complication (McDonnell et al., 1982)
Because of these risks, contemporary guidelines reject its intracanal use.

➤ No Effect on Smear Layer Removal
EDTA is the gold standard for eliminating smear layer. Hydrogen peroxide cannot chelate or remove inorganic debris, leaving dentinal tubules obstructed and preventing adequate seal and penetration of medicaments or sealers (Torabinejad & Walton, 2015).

➤ Incompatibility with Sodium Hypochlorite
Studies show that mixing or alternating H₂O₂ and NaOCl results in foam production and reduced hypochlorite efficacy, compromising the cleaning process (Zehnder, 2006). This makes hydrogen peroxide incompatible with the irrigant that forms the foundation of modern endodontics.

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🔎 Recommendations
Based on current evidence, clinicians should adhere to the following irrigant sequence for predictable outcomes:

1. Sodium hypochlorite (NaOCl) as the primary irrigant
2. EDTA for smear layer removal
3. Final NaOCl rinse or CHX (never mixed with NaOCl)
4. Optional activation (ultrasonic or sonic)
Hydrogen peroxide should not be included under any circumstance.

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✍️ Conclusion
Hydrogen peroxide was historically used for its effervescence, but modern endodontics no longer supports its use. Scientific literature consistently demonstrates that it lacks the biochemical properties required for effective canal disinfection, poses clinical risks due to oxygen release, and is inferior to contemporary irrigants. For safe, predictable, and evidence-based treatment, clinicians should rely on NaOCl, EDTA, and irrigant activation protocols, fully abandoning H₂O₂.

📚 References

✔ Haapasalo, M., Shen, Y., Wang, Z., & Gao, Y. (2010). Irrigation in endodontics. Dental Clinics of North America, 54(2), 291–312. https://doi.org/10.1016/j.cden.2009.12.001
✔ McDonnell, G., Russell, A. D., & Hugo, W. B. (1982). The mechanism of hydrogen peroxide action. Journal of Antimicrobial Chemotherapy, 10(5), 389–393.
✔ Torabinejad, M., & Walton, R. E. (2015). Principles and Practice of Endodontics (5th ed.). Saunders.
✔ Zehnder, M. (2006). Root canal irrigants. Journal of Endodontics, 32(5), 389–398. https://doi.org/10.1016/j.joen.2005.09.014

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Best Materials for Pulpotomy in Primary Teeth: MTA vs. Biodentine vs. Ferric Sulfate

Pulpotomy remains the most widely used vital pulp therapy for primary teeth with reversible pulp inflammation. Selecting the best materials for pulpotomy in primary teeth is critical for long-term success and maintaining arch integrity.

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Modern evidence supports the use of bioceramic materials due to their biocompatibility and predictable healing, while traditional agents such as ferric sulfate remain in use for their cost-effectiveness. This guide compares MTA, Biodentine, and ferric sulfate, highlighting indications, advantages, limitations, and evidence-based clinical performance.

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1. Overview of Pulpotomy Materials

1.1 Mineral Trioxide Aggregate (MTA)
MTA is considered the reference standard due to its biocompatibility, sealing ability, and high clinical success. It promotes dentin bridge formation and demonstrates long-term stability.

1.2 Biodentine
Biodentine is a calcium silicate–based bioceramic with faster setting time than MTA. It has strong mechanical properties and induces predictable odontogenic activity.

1.3 Ferric Sulfate (FS)
Ferric sulfate is a hemostatic agent traditionally used for primary tooth pulpotomy. It functions by forming a coagulation plug that seals blood vessels without directly affecting dentinogenesis.

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2. Clinical Performance and Evidence

2.1 Success Rates
▪️ MTA: Studies consistently report success rates above 90% after 24–36 months.
▪️ Biodentine: Demonstrates equivalent or slightly higher success than MTA in some trials.
▪️ Ferric Sulfate: Generally achieves 70–85% success but shows higher incidence of internal resorption.

2.2 Biocompatibility and Safety
Bioceramics (MTA and Biodentine) show superior tissue response with minimal inflammatory infiltrate. Ferric sulfate may cause tissue irritation if improperly applied and lacks regenerative capabilities.

2.3 Handling and Practical Considerations
▪️ MTA has a long setting time and may discolor teeth, especially gray formulations.
▪️ Biodentine sets quickly and exhibits better color stability.
▪️ Ferric sulfate is inexpensive and requires minimal handling time.

📊 Comparative Table: MTA vs. Biodentine vs. Ferric Sulfate

Aspect	Advantages	Limitations
MTA	High biocompatibility, excellent sealing, long-term success	Long setting time, potential discoloration, higher cost
Biodentine	Fast setting, good mechanical properties, color stability	Higher cost than FS, requires strict handling protocol
Ferric Sulfate	Low cost, easy handling, effective hemostasis	Higher internal resorption risk, no regenerative effect

💬 Discussion
Current evidence clearly favors bioceramic materials (MTA and Biodentine) due to their biological compatibility, regenerative capacity, and consistently high success rates. While ferric sulfate remains a viable option in resource-limited settings, its higher association with internal resorption and lack of true tissue healing mechanisms make it less ideal compared with bioceramic alternatives.
From a clinical standpoint, the choice of material should consider cost, setting time, operator experience, patient behavior, and long-term prognosis.

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✍️ Conclusion
MTA and Biodentine are the most effective and biologically favorable materials for pulpotomy in primary teeth. Biodentine offers practical advantages such as faster setting and better color stability, while MTA remains a robust gold standard with extensive evidence. Ferric sulfate may be used when bioceramics are unavailable, but it shows lower long-term predictability.
For optimal patient outcomes, clinicians should prioritize bioceramic-based pulpotomy protocols aligned with current scientific evidence.

🔎 Recommendations
▪️ Prefer Biodentine or MTA for routine pulpotomies in primary molars.
▪️ Use ferric sulfate only when bioceramic materials are unavailable or cost-prohibitive.
▪️ Avoid gray MTA formulations in esthetic zones due to discoloration risks.
▪️ Ensure effective hemostasis before applying any pulpotomy agent.
▪️ Perform periodic radiographic follow-up at 6 and 12 months, then annually.

📚 References

✔ Camilleri, J. (2020). Mineral trioxide aggregate: Advances and challenges. Dental Materials, 36(3), 288–296.
✔ Rashid, H., & Sheikh, Z. (2021). Biodentine vs. mineral trioxide aggregate: An updated review. International Journal of Endodontics, 54(2), 123–136.
✔ Vasundhara, S., & Sridhar, N. (2022). Success rates of pulpotomy medicaments in primary teeth: A systematic review. Journal of Clinical Pediatric Dentistry, 46(1), 44–53.
✔ American Academy of Pediatric Dentistry (AAPD). (2023). Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. AAPD.
✔ Coll, J. A., et al. (2020). Vital pulp therapy in primary teeth: A systematic review. Pediatric Dentistry, 42(5), 337–349.

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