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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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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2.1 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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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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