Why Pulp Therapy Fails: Risk Factors, Clinical Errors, and Evidence-Based Solutions

Pulp therapy is a cornerstone of both pediatric and adult restorative dentistry. However, despite advances in materials and techniques, treatment failure remains a relevant clinical challenge.

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Understanding why pulp therapy fails is essential to improve prognosis, reduce retreatment, and preserve tooth structure. This article reviews the main biological, technical, and restorative factors associated with failure and presents evidence-based solutions supported by current literature.

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✅ Biological Risk Factors for Pulp Therapy Failure
Biological factors often determine the baseline prognosis before treatment begins.Key contributors include:

▪️ Incorrect pulp diagnosis (reversible vs. irreversible pulpitis)
▪️ Advanced bacterial contamination
▪️ Undetected pulpal necrosis
▪️ Compromised immune response

Accurate case selection is one of the most critical determinants of pulp therapy success.

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✅ Clinical and Technical Errors
Many failures are directly related to operator-dependent factors.
Common errors include:

▪️ Inadequate isolation, leading to salivary and bacterial contamination
▪️ Incomplete caries removal, leaving infected dentin
▪️ Over-instrumentation or pulp tissue trauma
▪️ Improper placement of pulp capping or pulpotomy materials

Studies consistently show that lack of rubber dam isolation significantly increases failure rates.

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✅ Material-Related Factors
The choice and handling of materials play a decisive role.
Frequent issues include:

▪️ Incorrect manipulation of calcium-based materials
▪️ Use of outdated or low-biocompatibility agents
▪️ Poor sealing ability of restorative materials

Modern bioactive materials such as mineral trioxide aggregate (MTA) and calcium silicate cements demonstrate superior outcomes due to their biocompatibility, sealing ability, and bioinductive properties.

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✅ Restorative and Post-Treatment Factors
Even a technically correct pulp therapy can fail if the final restoration is inadequate.
Critical aspects:

▪️ Coronal microleakage
▪️ Delayed placement of definitive restoration
▪️ Poor marginal adaptation
▪️ Occlusal overload

A hermetic coronal seal is as important as the pulpal procedure itself.

📊 Comparative Table: Factors Influencing Pulp Therapy Outcomes

Aspect	Advantages	Limitations
Accurate Pulp Diagnosis	Improves case selection and prognosis	Requires clinical experience and diagnostic tools
Use of Bioactive Materials	Promotes dentin bridge formation and healing	Higher cost and technique sensitivity
Rubber Dam Isolation	Reduces bacterial contamination	May be challenging in uncooperative patients
Definitive Coronal Seal	Prevents microleakage and reinfection	Failure if restoration is delayed or poorly adapted

💬 Discussion
Current evidence confirms that pulp therapy failure is rarely due to a single factor. Instead, it is the result of an interaction between biological status, clinical technique, material selection, and restorative quality. Advances in bioactive materials have improved success rates, but they cannot compensate for poor diagnosis or inadequate isolation. Long-term success depends on strict adherence to evidence-based protocols.

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🎯 Clinical Recommendations
▪️ Perform thorough pulp vitality and radiographic assessment
▪️ Always use rubber dam isolation
▪️ Select bioactive materials with proven clinical evidence
▪️ Ensure immediate and well-sealed definitive restorations
▪️ Schedule follow-up evaluations to detect early signs of failure

✍️ Conclusion
Pulp therapy fails primarily due to diagnostic errors, inadequate isolation, material misuse, and poor coronal sealing. When evidence-based principles are respected, pulp therapy remains a highly predictable and conservative treatment option. Continuous education and protocol standardization are key to improving clinical outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry, 384–392.
✔ Aguilar, P., & Linsuwanont, P. (2011). Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. Journal of Endodontics, 37(5), 581–587. https://doi.org/10.1016/j.joen.2010.12.004
✔ Bogen, G., Kim, J. S., & Bakland, L. K. (2008). Direct pulp capping with mineral trioxide aggregate: An observational study. Journal of the American Dental Association, 139(3), 305–315. https://doi.org/10.14219/jada.archive.2008.0150
✔ Hilton, T. J. (2009). Keys to clinical success with pulp capping: A review of the literature. Operative Dentistry, 34(5), 615–625.

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Dental Drugs Allowed During Pregnancy by Trimester: Evidence-Based Clinical Guidelines

Pregnancy introduces significant physiological changes that directly affect drug metabolism, placental transfer, and fetal safety.

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In dentistry, prescribing medications without considering the gestational stage may increase the risk of adverse fetal outcomes. Understanding which drugs are safe or contraindicated according to the trimester of pregnancy is essential for evidence-based dental care.

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✅ Pharmacological Considerations in Pregnancy
Drug safety during pregnancy depends on:

▪️ Gestational age (trimester)
▪️ Placental permeability
▪️ Dose and duration
▪️ Maternal systemic condition

The first trimester represents the highest teratogenic risk due to organogenesis, whereas late pregnancy is associated with functional and hemodynamic fetal risks.

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✅ Dental Drugs by Trimester

➤ First Trimester (0–13 weeks)
This is the most critical period for fetal development.

▪️ Generally acceptable (only if clearly indicated):
➖ Amoxicillin
➖ Penicillin V
➖ Cephalosporins
➖ Clindamycin
➖ Acetaminophen (Paracetamol)

▪️ Contraindicated:
➖ Tetracyclines → tooth discoloration, inhibition of bone growth
➖ Fluoroquinolones → cartilage toxicity
➖ NSAIDs → increased risk of miscarriage

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➤ Second Trimester (14–27 weeks)
The safest period for dental treatment and pharmacological intervention.

▪️ Preferred options:
➖ Amoxicillin
➖ Amoxicillin–clavulanate
➖ Cephalexin
➖ Clindamycin
➖ Acetaminophen

▪️ Use with caution:
➖ NSAIDs (short-term only, when strictly necessary)

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➤ Third Trimester (28–40 weeks)
Risks shift toward fetal cardiovascular complications and maternal bleeding.

▪️ Acceptable:
➖ Amoxicillin
➖ Cephalosporins
➖ Clindamycin
➖ Acetaminophen

▪️ Avoid:
➖ NSAIDs → premature closure of ductus arteriosus
➖ High-dose aspirin → maternal and fetal bleeding
➖ Opioids (prolonged use) → neonatal respiratory depression

📊 Comparative Table: Dental Drugs by Pregnancy Trimester

Aspect	Advantages	Limitations
First Trimester Drug Use	Prevents untreated odontogenic infections	Highest teratogenic risk; prescribe only if essential
Second Trimester Drug Use	Safest period for antibiotics and analgesics	NSAIDs should still be limited
Third Trimester Drug Use	Allows infection control before delivery	Risk of fetal cardiovascular and bleeding complications

💬 Discussion
Current evidence confirms that drug safety in pregnancy is trimester-dependent rather than absolute. The outdated FDA pregnancy categories have been replaced by narrative risk assessments emphasizing clinical judgment. Dental infections themselves pose a greater risk to pregnancy outcomes than appropriately selected antibiotics.

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🎯 Clinical Recommendations
▪️ Always assess the pregnancy trimester before prescribing
▪️ Use the lowest effective dose for the shortest duration
▪️ Prioritize local dental treatment over systemic medication
▪️ Avoid contraindicated drugs even for short-term use
▪️ Consult the patient’s obstetrician in complex cases

✍️ Conclusion
Safe pharmacological management in pregnant dental patients is achievable when trimester-specific guidelines are followed. Dentists play a critical role in preventing systemic complications by selecting evidence-based medications while minimizing fetal risk. The second trimester remains the optimal window for most dental interventions.

📚 References

✔ American Dental Association. (2023). Oral health care during pregnancy: A national consensus statement. Journal of the American Dental Association, 154(6), 502–510. https://doi.org/10.1016/j.adaj.2023.02.009
✔ American College of Obstetricians and Gynecologists. (2022). Oral health care during pregnancy and through the lifespan (Committee Opinion No. 569). Obstetrics & Gynecology, 140(2), e79–e89.
✔ Briggs, G. G., Freeman, R. K., & Towers, C. V. (2021). Drugs in pregnancy and lactation (12th ed.). Wolters Kluwer.
✔ U.S. Food and Drug Administration. (2015). Pregnancy and lactation labeling (Drugs) final rule. Federal Register, 80(104), 30831–30868.

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Antibiotics Contraindicated During Pregnancy: Risks and Safer Alternatives in Dental Practice

Pregnancy represents a unique physiological state in which drug prescription must balance maternal benefits and fetal safety. In dental practice, infections may require systemic antibiotic therapy; however, not all antibiotics are safe during pregnancy.

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Understanding which agents are contraindicated and identifying evidence-based safer alternatives is essential for ethical and effective dental care.

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✅ Physiological Changes in Pregnancy and Drug Safety
Pregnancy alters drug pharmacokinetics due to:

▪️ Increased plasma volume
▪️ Altered hepatic metabolism
▪️ Increased renal clearance
▪️ Placental drug transfer

These changes may enhance fetal exposure, making antibiotic selection particularly critical, especially during the first trimester, when organogenesis occurs.

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✅ Antibiotics Contraindicated in Pregnancy
Several antibiotics commonly used in dentistry are contraindicated or strongly discouraged due to documented fetal risks:

▪️ Tetracyclines (e.g., doxycycline)
Associated with permanent tooth discoloration, enamel hypoplasia, and inhibition of bone growth.
▪️ Fluoroquinolones (e.g., ciprofloxacin)
Linked to cartilage and musculoskeletal toxicity in animal studies.
▪️ Chloramphenicol
Associated with “gray baby syndrome” due to immature hepatic metabolism.
▪️ Metronidazole (first trimester)
Although newer evidence suggests relative safety, caution is advised in early pregnancy, especially when alternatives exist.

Avoiding these antibiotics is strongly recommended unless no safer options are available.

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✅ Safer Antibiotic Alternatives in Dental Infections
Current clinical guidelines support the use of the following antibiotics during pregnancy:

▪️ Amoxicillin
▪️ Amoxicillin–clavulanate
▪️ Cephalexin and other first-generation cephalosporins
▪️ Clindamycin (in penicillin-allergic patients)

These agents demonstrate favorable safety profiles and are widely endorsed by professional organizations.

📊 Comparative Table: Antibiotic Safety in Pregnancy for Dental Practice

Aspect	Advantages	Limitations
Amoxicillin	Well-established safety, effective for odontogenic infections	Limited coverage against beta-lactamase–producing bacteria
Clindamycin	Safe in penicillin allergy, good anaerobic coverage	Risk of gastrointestinal adverse effects
Tetracyclines	Broad-spectrum activity	Contraindicated: fetal tooth and bone damage
Fluoroquinolones	Excellent tissue penetration	Contraindicated: potential fetal cartilage toxicity

💬 Discussion
Despite the availability of clinical guidelines, inappropriate antibiotic prescribing during pregnancy remains a concern. Fear of undertreatment may lead clinicians to prescribe broad-spectrum or contraindicated agents unnecessarily. Evidence consistently demonstrates that local dental treatment combined with safe antibiotics is effective for managing most odontogenic infections.
Close collaboration with the patient’s obstetrician is recommended in complex cases.

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🎯 Clinical Recommendations
▪️ Avoid contraindicated antibiotics, particularly tetracyclines and fluoroquinolones
▪️ Prefer amoxicillin or cephalosporins as first-line agents
▪️ Use clindamycin in penicillin-allergic patients
▪️ Prescribe antibiotics only when systemic involvement is present
▪️ Emphasize definitive dental treatment over pharmacological management alone

✍️ Conclusion
Antibiotic prescription during pregnancy requires a cautious, evidence-based approach. Several commonly used dental antibiotics pose significant fetal risks and should be avoided. Safer alternatives, including amoxicillin and clindamycin, provide effective infection control when appropriately indicated. Adhering to current guidelines ensures optimal maternal outcomes while protecting fetal health.

📚 References

✔ American Dental Association. (2023). Antibiotic use for the urgent management of dental pain and intraoral swelling.
✔ American College of Obstetricians and Gynecologists. (2020). Guidelines for diagnostic imaging and medication use during pregnancy.
✔ Briggs, G. G., Freeman, R. K., & Towers, C. V. (2021). Drugs in pregnancy and lactation (12th ed.). Wolters Kluwer.
✔ FDA. (2018). Pregnancy and Lactation Labeling Rule (PLLR).
✔ Sweeney, L. C., Dave, J., Chambers, P. A., & Heritage, J. (2004). Antibiotic resistance in general dental practice. British Dental Journal, 197(3), 141–145.

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Clinical Guidelines for Prescribing Xylitol in Pediatric Dentistry: Frequency, Dose, and Delivery Forms

Xylitol is a naturally occurring sugar alcohol widely studied for its anticariogenic properties. In pediatric dentistry, xylitol has gained attention as an adjunctive preventive strategy, particularly for early childhood caries (ECC).

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Understanding the appropriate dose, frequency, and delivery forms of xylitol in children is essential to maximize benefits while ensuring safety and compliance.

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✅ Mechanism of Action of Xylitol
Xylitol exerts its cariostatic effect primarily by interfering with Streptococcus mutans metabolism. Unlike fermentable sugars, xylitol cannot be metabolized by cariogenic bacteria, leading to:

▪️ Reduced bacterial adhesion
▪️ Decreased acid production
▪️ Lower salivary levels of S. mutans

Regular exposure to xylitol is necessary to achieve and maintain these effects.

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✅ Evidence-Based Indications in Pediatric Dentistry
Current evidence supports the use of xylitol for:

▪️ Caries prevention in high-risk children
▪️ Reduction of mother-to-child transmission of cariogenic bacteria
▪️ Adjunctive prevention in orthodontic patients
▪️ Supportive management of early enamel demineralization

However, xylitol should not replace fluoride, but rather complement standard preventive protocols.

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✅ Recommended Dose and Frequency
Clinical studies and systematic reviews indicate that a total daily dose of 5–10 grams of xylitol, divided into 3 to 5 exposures per day, is required to achieve a clinically significant caries-preventive effect.
Key considerations:

▪️ Single large doses are less effective
▪️ Frequency is more important than total amount
▪️ Consistent daily use is essential

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✅ Delivery Forms of Xylitol
The effectiveness of xylitol depends heavily on its delivery vehicle:

▪️ Chewing gum (most evidence-based)
▪️ Lozenges or tablets
▪️ Syrups (for younger children)
▪️ Toothpaste and wipes (limited evidence when used alone)

Products must contain 100% xylitol as the primary sweetener to be effective.

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✅ Safety and Age Considerations
Xylitol is considered safe for children when used appropriately. Mild gastrointestinal effects (e.g., bloating, diarrhea) may occur if introduced too quickly or in excessive doses.

▪️ Suitable for children older than 2 years
▪️ Syrups are preferred for preschool-aged children
▪️ Parental supervision is recommended

📊 Comparative Table: Xylitol Delivery Forms in Pediatric Dentistry

Aspect	Advantages	Limitations
Xylitol Chewing Gum	Strong evidence for caries reduction, stimulates saliva flow	Not suitable for very young children, requires compliance
Xylitol Lozenges/Tablets	Controlled dosing, good compliance in school-aged children	Choking risk in toddlers, limited availability
Xylitol Syrup	Ideal for preschool children, easy administration	Less commercial availability, dosing accuracy required
Xylitol Toothpaste	Easy integration into daily oral hygiene	Insufficient xylitol dose when used alone

💬 Discussion
Although xylitol has demonstrated moderate to strong evidence in caries prevention, variability in study design, dosing regimens, and delivery forms has led to inconsistent outcomes. The greatest benefits are observed when xylitol is used frequently and in adequate doses, particularly in chewing gum or syrup form.
Professional guidance is essential to ensure proper product selection and realistic expectations.

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🎯 Clinical Recommendations
▪️ Prescribe xylitol as an adjunctive preventive measure, not a standalone therapy
▪️ Aim for 5–10 g/day divided into multiple exposures
▪️ Select delivery forms based on child’s age and ability
▪️ Educate parents on label reading to ensure adequate xylitol content
▪️ Combine xylitol use with fluoride, dietary counseling, and oral hygiene education

✍️ Conclusion
Xylitol is a safe and evidence-based preventive agent in pediatric dentistry when prescribed correctly. Its effectiveness depends on appropriate dosing, frequent exposure, and suitable delivery forms. When integrated into a comprehensive preventive program, xylitol can play a valuable role in reducing caries risk in children, especially those at high risk.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Policy on the use of xylitol in caries prevention. The Reference Manual of Pediatric Dentistry.
✔ Deshpande, A., & Jadad, A. R. (2008). The impact of polyol-containing chewing gums on dental caries. Journal of the American Dental Association, 139(12), 1602–1614.
✔ Mäkinen, K. K. (2011). Sugar alcohols, caries incidence, and remineralization of caries lesions. Journal of Dental Research, 90(7), 769–775.
✔ Riley, P., Moore, D., Ahmed, F., Sharif, M. O., Worthington, H. V. (2015). Xylitol-containing products for preventing dental caries. Cochrane Database of Systematic Reviews, CD010743.
✔ Söderling, E. M., & Hietala-Lenkkeri, A. M. (2010). Xylitol and erythritol decrease adherence of polysaccharide-producing oral streptococci. Current Microbiology, 60(1), 25–29.

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Open Apex Management in Traumatized Teeth: Latest Evidence-Based Recommendations

Dental trauma frequently affects immature permanent teeth, particularly in children and adolescents. When trauma occurs before complete root development, it often results in teeth with open apices, posing significant clinical challenges.

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Open apex management in traumatized teeth aims to control infection, preserve tooth structure, and promote continued root development or apical closure using evidence-based techniques.

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✅ Understanding Open Apex in Traumatized Teeth
An open apex is characterized by:

▪️ Incomplete root formation
▪️ Thin dentinal walls
▪️ Wide apical foramen

Traumatic injuries such as luxation, avulsion, or complicated crown fractures may compromise pulpal vitality, interrupting root development and increasing the risk of infection and fracture.
Early and accurate diagnosis is critical to determine prognosis and select the most appropriate therapeutic approach.

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✅ Diagnostic Considerations
Key diagnostic factors include:

▪️ Type and severity of trauma
▪️ Pulp vitality status
▪️ Stage of root development
▪️ Presence of infection or apical pathology

Radiographic evaluation (periapical radiographs or CBCT when indicated) is essential to assess root length, apical diameter, and periapical status.

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✅ Evidence-Based Treatment Options

➤ Apexification
Apexification is indicated for non-vital immature teeth and aims to create an apical barrier to allow obturation.
Calcium hydroxide (traditional method)
Mineral trioxide aggregate (MTA) or bioceramic materials (modern approach)
Bioceramic apexification has largely replaced long-term calcium hydroxide due to improved outcomes and reduced treatment time.

➤ Regenerative Endodontic Procedures (REPs)
Regenerative endodontics is currently the preferred approach for many immature teeth with necrotic pulps. Benefits include:
▪️ Continued root maturation
▪️ Increased dentinal wall thickness
▪️ Improved fracture resistance
This approach is supported by AAPD and IADT guidelines, particularly in young patients.

➤ Vital Pulp Therapy in Traumatized Teeth
In cases of reversible pulp damage, procedures such as:
▪️ Partial pulpotomy (Cvek pulpotomy)
▪️ Direct pulp capping
may allow continued root development (apexogenesis) when performed promptly.

📊 Comparative Table: Evidence-Based Management Options for Open Apex Teeth

Aspect	Advantages	Limitations
Calcium Hydroxide Apexification	Long history of use, induces apical hard tissue barrier	Long treatment time, increased fracture risk, multiple visits
MTA / Bioceramic Apexification	Shorter treatment time, predictable apical seal, biocompatible	No continued root development, higher material cost
Regenerative Endodontic Procedures	Promotes root maturation and dentinal thickening	Technique-sensitive, variable outcomes
Vital Pulp Therapy	Preserves pulp vitality and allows apexogenesis	Limited to cases with minimal pulpal inflammation

💬 Discussion
Recent evidence supports a paradigm shift toward biologically based therapies, particularly regenerative endodontics, for immature teeth with necrotic pulps. While apexification remains a valid option, it does not promote continued root development, which is critical for long-term tooth survival.
Case selection, patient compliance, and clinician expertise remain decisive factors in treatment success.

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🎯 Clinical Recommendations
▪️ Prioritize pulp vitality preservation whenever possible
▪️ Consider regenerative endodontic procedures as first-line therapy for necrotic immature teeth
▪️ Use bioceramic materials for apexification when regeneration is not feasible
▪️ Ensure long-term follow-up to monitor root development and periapical healing
▪️ Follow IADT and AAPD trauma guidelines strictly

✍️ Conclusion
Management of traumatized teeth with open apices requires an evidence-based, individualized approach. Advances in regenerative endodontics and bioceramic materials have significantly improved clinical outcomes. Early intervention, accurate diagnosis, and adherence to current guidelines are essential to ensure functional and long-lasting results.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry.
✔ Diogenes, A., Henry, M. A., Teixeira, F. B., & Hargreaves, K. M. (2013). An update on clinical regenerative endodontics. Endodontic Topics, 28(1), 2–23.
✔ Fouad, A. F., Abbott, P. V., Tsilingaridis, G., et al. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dental Traumatology, 36(4), 314–330.
✔ Torabinejad, M., & Parirokh, M. (2010). Mineral trioxide aggregate: A comprehensive literature review. Journal of Endodontics, 36(1), 16–27.
✔ American Association of Endodontists. (2021). Clinical considerations for regenerative procedures.

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