Bioactive Materials in Pulpotomies: MTA, Biodentine and Emerging Alternatives

Bioactive materials have transformed vital pulp therapy in pediatric dentistry. Mineral Trioxide Aggregate (MTA) and Biodentine remain the most reliable options due to their biocompatibility, sealing ability, and predictable dentin bridge formation.

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✅ Introduction
Pulpotomy remains a widely used treatment for reversible pulp inflammation in primary teeth, aiming to maintain tooth vitality until exfoliation. Over the last two decades, bioactive materials have replaced traditional agents due to superior biological responses and reduced cytotoxicity. Current evidence strongly supports the use of MTA, Biodentine, and next-generation hydraulic calcium silicate cements as the materials of choice.
This article reviews the mechanisms, clinical performance, and limitations of the most relevant bioactive materials used in pediatric pulpotomies.

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✅ MTA: Mechanism and Clinical Behavior
Mineral Trioxide Aggregate (MTA) is one of the most documented pulpotomy materials. Key properties include its strong biocompatibility, high sealing ability, and promotion of dentin bridge formation.

➤ Advantages:
▪️ Releases calcium hydroxide, stimulating hard tissue formation.
▪️ Excellent marginal seal, preventing microleakage.
▪️ Proven long-term success rates in primary teeth.

➤ Limitations:
▪️ Difficult handling.
▪️ Long setting time.
▪️ Potential dentin and enamel discoloration due to bismuth oxide.
Large-scale systematic reviews continue to position MTA as a gold standard in partial and full pulpotomies.

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✅ Biodentine: A Calcium Silicate with Enhanced Handling
Biodentine is a high-purity tricalcium silicate cement developed to overcome practical limitations of MTA. Its faster setting time, improved mechanical properties, and higher biocompatibility make it ideal for pediatric use.

➤ Advantages:
▪️ Sets within 12 minutes.
▪️ Superior mechanical strength.
▪️ Does not stain tooth structure.
▪️ Promotes predictable tertiary dentin deposition.

➤ Limitations:
▪️ Cost may be higher in some regions.
▪️ Requires strict moisture control during placement.
Clinical trials show success rates comparable—sometimes superior—to MTA for primary teeth pulpotomies.

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✅ New Bioceramic Alternatives
Recently introduced premixed bioceramic putties (e.g., EndoSequence Root Repair Material, TotalFill) offer excellent handling and consistent composition.

➤ Advantages:
▪️ Ready-to-use format.
▪️ No discoloration.
▪️ High radiopacity.

➤ Limitations:
▪️ Less long-term evidence compared to MTA and Biodentine.
▪️ Higher price point.
Emerging literature supports their use in vital pulp therapy, but they should currently be considered adjunctive rather than primary options.

📊 Comparative Table: Bioactive Materials Used in Pulpotomy

Aspect	Advantages	Limitations
MTA	Excellent sealing ability; high biocompatibility; strong evidence base	Long setting time; potential discoloration; difficult handling
Biodentine	Fast setting time; no discoloration; improved mechanical properties	Higher cost; requires moisture control
Bioceramic Putties	Ready-to-use; radiopaque; stable composition	Limited long-term data; higher cost

💬 Discussion
Bioactive materials demonstrate superior biological performance compared with traditional agents such as formocresol or ferric sulfate. Among all available options, MTA and Biodentine show the strongest evidence, high success rates, and favorable clinical outcomes.
Biodentine excels in handling and aesthetics, while MTA maintains unmatched historical and clinical validation. Next-generation bioceramics may eventually match these standards, but they still lack extensive longitudinal data in pediatric pulpotomies.

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✍️ Conclusion
Bioactive materials have significantly improved the prognosis of pulpotomies in primary teeth. MTA and Biodentine remain the most reliable choices, offering excellent sealing ability and biocompatibility. Although new bioceramic materials show promise, further research is needed to confirm long-term performance. Selecting the appropriate material should be based on clinical indication, handling needs, and evidence-based guidelines.

🔎 Recommendations
▪️ Prefer MTA or Biodentine for routine pediatric pulpotomies.
▪️ Use bioceramic putties in cases requiring enhanced handling or when discoloration is a concern.
▪️ Maintain strict isolation and moisture control to optimize clinical outcomes.
▪️ Follow radiographic and clinical follow-ups at 6 and 12 months.
▪️ Avoid outdated pulpotomy agents with documented cytotoxicity.

📚 References

✔ Camilleri, J. (2014). Tricalcium silicate cements in endodontics. Dental Materials, 30(7), 689–707. https://doi.org/10.1016/j.dental.2014.03.007
✔ Nowicka, A., Lipski, M., Parafiniuk, M., Sporniak-Tutak, K., Lichota, D., Kosierkiewicz, A., ... & Buczkowska-Radlińska, J. (2013). Response of human dental pulp capped with Biodentine and MTA. Journal of Endodontics, 39(6), 743–747. https://doi.org/10.1016/j.joen.2013.01.005
✔ Smaïl-Faugeron, V., Courson, F., Durieux, P., Muller-Bolla, M., Glenny, A. M., & Fron Chabouis, H. (2018). Mineral trioxide aggregate versus calcium hydroxide for pulpotomy in primary molars: A systematic review and meta-analysis. International Journal of Paediatric Dentistry, 28(3), 266–276. https://doi.org/10.1111/ipd.12361
✔ Taha, N. A., & Abdelkhader, S. Z. (2018). Outcome of full pulpotomy using Biodentine in adult patients with symptoms indicative of irreversible pulpitis. International Endodontic Journal, 51(8), 819–828. https://doi.org/10.1111/iej.12902

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Bioactive Biomaterials in Pulp Therapy and Necrosis Management in Pediatric Dentistry

✅ Abstract
The evolution of pulp therapy in pediatric dentistry has shifted from traditional medicaments to bioactive biomaterials that promote regeneration and tissue healing. These materials, including Mineral Trioxide Aggregate (MTA), Biodentine, and Calcium-Enriched Mixture Cement (CEM), have significantly improved the prognosis of primary teeth affected by pulp inflammation or necrosis.

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This article explores their mechanisms, techniques, clinical protocols, and compares them to traditional materials such as formocresol and zinc oxide-eugenol.

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✅ Introduction
In pediatric endodontics, maintaining pulp vitality or restoring periapical health after necrosis is essential for preserving the primary dentition until exfoliation. Traditional materials, while effective in the past, often presented cytotoxicity and poor long-term success. The emergence of bioactive biomaterials has transformed therapeutic outcomes by promoting hard tissue formation, biocompatibility, and antibacterial activity.

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✅ What Are Bioactive Biomaterials?
Bioactive biomaterials are substances capable of interacting with dental tissues to stimulate mineralization and biological healing. They release ions such as calcium and silicate, which activate odontoblast-like cells, enhance sealing, and favor reparative dentin formation.

Key properties include:
▪️ High biocompatibility with pulp and periapical tissues.
▪️ Sealing ability preventing bacterial infiltration.
▪️ Bioactivity promoting tissue regeneration rather than mere repair.

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✅ Procedures and Techniques in Pulp Therapy

1. Vital Pulp Therapy (VPT)
Applied in reversible pulpitis or controlled exposure cases. Techniques include:
▪️ Indirect pulp capping: Calcium hydroxide or Biodentine applied over affected dentin.
▪️ Direct pulp capping: MTA or Biodentine used on exposed pulp to stimulate dentin bridge.
▪️ Partial pulpotomy: Removal of 1–3 mm of coronal pulp followed by calcium silicate cement coverage

2. Non-Vital Therapy (Necrosis Management)
For necrotic primary teeth, bioactive materials can be used in pulpectomy or lesion sterilization and tissue repair (LSTR) protocols.
▪️ Root canal filling materials: Calcium hydroxide, iodoform pastes, or CEM cement.
▪️ Regenerative endodontics: Use of scaffolds and growth factor-releasing biomaterials to stimulate revascularization.

✅ Clinical Advantages

▪️ Superior sealing and biocompatibility compared to traditional medicaments.
▪️ Reduced inflammation and resorption in primary teeth.
▪️ High success rates (>90%) in pulpotomy and apexification cases.
▪️ Simplified handling and improved mechanical strength.

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✅ Limitations

▪️ High cost and limited availability in certain regions.
▪️ Technique sensitivity and strict moisture control requirements.
▪️ Some materials (e.g., MTA) may cause tooth discoloration.

📊 Comparative Table: Traditional vs. Modern Bioactive Materials in Pediatric Pulp Therapy

Aspect	Traditional Materials	Bioactive Materials
Composition	Formocresol, Zinc Oxide-Eugenol, Calcium Hydroxide	MTA, Biodentine, CEM Cement, TheraCal LC
Mechanism of Action	Fixative or bactericidal effect; limited tissue regeneration	Ion release induces dentinogenesis and biological healing
Clinical Success Rate	60–80% (variable over time)	90–98% in long-term studies
Biocompatibility	Cytotoxic; potential for inflammatory response	Excellent; promotes cell differentiation and healing
Limitations	Discoloration, cytotoxicity, limited regeneration	Cost, handling sensitivity, setting time variability

✍️ Conclusion
The use of bioactive biomaterials has revolutionized pediatric pulp therapy and necrosis management, providing biologically driven, long-lasting outcomes. Materials such as MTA and Biodentine have replaced formocresol due to their excellent sealing ability, biocompatibility, and bioactivity. Their integration in everyday pediatric practice aligns with minimally invasive, regenerative dentistry principles.

✅ Clinical Recommendations

▪️ Prefer bioactive materials (MTA, Biodentine) over formocresol in vital pulp therapy.
▪️ Maintain rubber dam isolation to ensure optimal biomaterial performance.
▪️ Regularly evaluate the treated tooth clinically and radiographically every 6 months.
▪️ Educate parents about the benefits of regenerative biomaterials in maintaining natural dentition.

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📚 References

✔ Coll, J. A., Dhar, V., Vargas, K., Chen, C. Y., & American Academy of Pediatric Dentistry. (2023). Use of vital pulp therapies in primary teeth with deep caries lesions. Pediatric Dentistry, 45(5), 349–371. https://www.aapd.org/media/Policies_Guidelines/E_VPT.pdf
✔ Elshazly, T. M., Saber, S. E. D. M., & El-Khodary, M. M. (2024). Clinical performance of calcium silicate-based biomaterials in pulpotomy of primary molars: A systematic review and meta-analysis. International Journal of Paediatric Dentistry, 34(2), 155–169. https://doi.org/10.1111/ipd.13329
✔ Zhou, H., Du, Q., & Wu, Q. (2023). Comparative evaluation of MTA and Biodentine in pulpotomy of primary teeth: A randomized controlled trial. Clinical Oral Investigations, 27(4), 1783–1791. https://doi.org/10.1007/s00784-022-04765-8

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Mineral Trioxide Aggregate (MTA) in Pediatric Dentistry: Uses, Benefits, and Clinical Evidence

Preserving primary teeth until their natural exfoliation is a key goal in pediatric dentistry. Advances in bioactive materials have made this more predictable.

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Among them, Mineral Trioxide Aggregate (MTA) has emerged as a gold standard for pulp therapy, especially for its regenerative properties and sealing capability.

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✅ Physical and Chemical Characteristics of MTA

° Main components: Tricalcium silicate, tricalcium aluminate, calcium oxide, silica, and bismuth oxide for radiopacity.
° Initial pH: Around 10.2, rising to 12.5 after setting—contributing to its antimicrobial action.
° Setting time: Between 2 to 4 hours, depending on formulation and moisture.
° Biocompatibility: Well-tolerated by periapical tissues and does not provoke significant inflammation.

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✅ Mechanism of Action
MTA promotes dentin bridge formation by stimulating mesenchymal stem cells to differentiate into odontoblast-like cells. Its high pH provides an antimicrobial environment while enhancing mineralization, aiding in pulp healing and hard tissue regeneration.

✅ Clinical Benefits of MTA in Pediatric Dentistry

° Excellent biocompatibility, making it safe for use in primary and immature permanent teeth.
° Superior sealing ability, preventing bacterial microleakage.
° Stimulates pulp regeneration and dentin formation.
° High pH provides antimicrobial effects without the cytotoxicity of other materials.
° Versatile applications in both vital and non-vital pulp therapy.

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✅ Clinical Uses of MTA in Pediatric Dentistry

✅ Commercial Brands of MTA

° ProRoot® MTA (Dentsply Sirona, USA)
° MTA Angelus® (Angelus, Brazil)
° NeoMTA Plus® (Avalon Biomed, USA)
° EndoCem MTA® (Maruchi, South Korea)

Each brand offers variations in setting time, delivery method (powder/liquid or premixed), and handling characteristics. Newer formulations like NeoMTA Plus provide shorter setting times and better clinical handling.

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💬 Discussion
Recent studies and systematic reviews confirm that MTA outperforms traditional materials such as formocresol and calcium hydroxide in pulp therapy of primary teeth. Although its cost and long setting time have been noted as limitations, newer versions address these issues. MTA offers higher long-term success rates, reduced pathologic root resorption, and superior tissue integration.
In U.S. pediatric dental practice, MTA has become the material of choice for many pulp procedures, especially when long-term tooth preservation is the goal.

💡 Conclusion
MTA is a clinically proven, biologically superior material for managing pulp tissues in pediatric patients. Its biocompatibility, sealing properties, and regenerative potential make it ideal for pulpotomies, apexification, and other endodontic procedures. Although cost may be a consideration, the high clinical success justifies its use as a standard of care in pediatric endodontics.

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📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. https://www.aapd.org

✔ Parirokh, M., & Torabinejad, M. (2019). Mineral trioxide aggregate: A comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. Journal of Endodontics, 45(1), 103–121. https://doi.org/10.1016/j.joen.2018.10.014

✔ Aguilar, P., & Linsuwanont, P. (2019). Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. Journal of Endodontics, 45(5), 511–517. https://doi.org/10.1016/j.joen.2019.01.021

✔ Nosrat, A., Seifi, A., & Asgary, S. (2021). Apexogenesis and Pulpotomy in Immature Teeth Using MTA: A Systematic Review and Meta-analysis. International Endodontic Journal, 54(4), 556–569. https://doi.org/10.1111/iej.13437

✔ Tran, X. V., Gorin, C., Willig, C., Baroukh, B., Pellat, B., Decup, F., & Chaussain, C. (2021). Effect of a calcium-silicate-based restorative cement on pulp repair. Journal of Dental Research, 100(2), 177–185. https://doi.org/10.1177/0022034520952904

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Medications Used in Pulpotomies: Properties, Drawbacks, and Brand Names

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Selecting the right medication is crucial for clinical success. Below is an overview of the most commonly used pulpotomy agents, their properties, drawbacks, and commercial names.

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✅ 1. Formocresol

➤ Brand Name: Buckley’s Formocresol
➤ Composition: 19% formaldehyde, 35% cresol, 15% glycerin, 21% water
➤ Properties:
° Bactericidal and tissue-fixative agent
° Mummifies remaining pulp tissue
° Easy to handle and low cost
➤ Drawbacks:
° Potentially carcinogenic and mutagenic
° Cytotoxic and allergenic
° Does not promote pulp tissue regeneration
➤ Clinical Notes:
° Although historically effective, its use has declined due to toxicity concerns.

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✅ 2. Ferric Sulfate

➤ Brand Name: Astringedent®
➤ Composition: 15.5% aqueous solution of ferric sulfate (pH 1.0)
➤ Properties:
° Effective hemostatic agent
° Forms a protein barrier sealing blood vessels
° Affordable and easy to apply
➤ Drawbacks:
° Does not promote pulp regeneration
° May cause radicular inflammation and resorption
➤ Clinical Notes:
° A less toxic alternative to formocresol, but with variable long-term success.

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✅ 3. Calcium Hydroxide (Ca(OH)₂)

➤ Brand Name: Dycal®
➤ Properties:
° Stimulates reparative dentin formation
° Highly alkaline with bactericidal effect
° Biocompatible
➤ Drawbacks:
° May cause superficial pulp necrosis
° Lower success rate in primary teeth
° Tends to dissolve over time
➤ Clinical Notes:
° More suitable for young permanent teeth; limited use in primary dentition.

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✅ 4. Mineral Trioxide Aggregate (MTA)

➤ Brand Name: ProRoot® MTA
➤ Composition: Tricalcium silicate, dicalcium silicate, tricalcium aluminate, bismuth oxide
➤ Properties:
Highly biocompatible
Stimulates dentin formation
Excellent sealing and antimicrobial properties
➤ Drawbacks:
High cost
Difficult manipulation and long setting time
➤ Clinical Notes:
Studies report a 97.9% clinical success rate in pediatric pulpotomies, outperforming other agents.

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✅ 5. Biodentine

➤ Brand Name: Biodentine®
➤ Composition: Tricalcium silicate, dicalcium silicate, calcium oxide, calcium chloride, zirconium oxide
➤ Properties:
° Bioactive dentin substitute
° Mechanical properties similar to natural dentin
° Fast setting time and good radiopacity
➤ Drawbacks:
° High cost
° Limited long-term clinical evidence compared to MTA
➤ Clinical Notes:
° A promising MTA alternative with easier handling and shorter setting time.

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✅ 6. Zinc Oxide Eugenol (ZOE)

➤ Brand Name: IRM® (Intermediate Restorative Material)
➤ Properties:
° Soothing effect on dental pulp
° Antimicrobial and anti-inflammatory properties
° Easy to handle and inexpensive
➤ Drawbacks:
° Does not induce reparative dentin formation
° May dissolve over time
➤ Clinical Notes:
° Commonly used as a base or sealing material in pulpotomies.

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✅ 7. Pulpotec® Paste

➤ Brand Name: Pulpotec®
➤ Composition:
° Powder: Polyoxymethylene, iodoform
° Liquid: Dexamethasone, formaldehyde, phenol, guaiacol
➤ Properties:
° Induces healing of the pulp stump
° Aseptic and quick treatment
° Effective in both primary and permanent teeth
➤ Drawbacks:
° Contains formaldehyde, which has cytotoxic potential
° Not resorbable
➤ Clinical Notes:
° Long-term success reported in studies, though formaldehyde content limits its use in some cases.

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💡 Conclusion
The choice of pulpotomy medication must be based on a careful evaluation of its properties, disadvantages, and available clinical evidence. While formocresol has been widely used, toxicity concerns have led to the rise of safer and more effective alternatives like MTA and Biodentine. The ideal agent depends on factors such as the patient's age, tooth condition, and specific clinical considerations.

📚 References

✔ Holguin Garcia, S. G. (2019). Eficacia clínica del MTA en Pulpotomías de pacientes pediátricos: Una Revisión Sistemática. Revista de Odontopediatría Latinoamericana, 11(1). https://doi.org/10.47990/alop.v11i1.228

✔ Wikipedia. (2025). Pulpotomía. Retrieved from https://es.wikipedia.org/wiki/Pulpotom%C3%ADa

✔ Apuntes De Odontología. (2015). Pulpotomía. Retrieved from https://apuntes-de-odontologia.blogspot.com/2015/04/pulpotomia.html

✔ Studocu. (2018). Terapia Pulpar I – Dra. Andrea Cárdenas Antonieta Montero. Retrieved from https://www.studocu.com/cl/document/universidad-finis-terrae/odontopediatria/terapia-pulpar-i/4935194

✔ Revista Odontopediatría. (2014). Tratamiento Endodóntico no Instrumentado en dientes deciduos. Retrieved from https://backup.revistaodontopediatria.org/ediciones/2014/1/art-6/

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