Alternatives to CTZ Paste: Bioactive Materials Transforming Pediatric Endodontics

CTZ paste (chloramphenicol, tetracycline, and zinc oxide-eugenol) has been widely used in non-instrumentation endodontic treatment of primary teeth.

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However, concerns regarding antibiotic resistance, cytotoxicity, discoloration, and regulatory restrictions have stimulated the search for safer and more biologically favorable materials.

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Recent advances in bioceramics, calcium silicate-based cements, and bioactive regenerative agents have introduced promising alternatives capable of promoting tissue healing, antimicrobial activity, and dentin regeneration. This review examines current evidence regarding these emerging materials and their potential role as substitutes for CTZ paste in pediatric dentistry.

✅ Introduction
The preservation of primary teeth until their natural exfoliation remains a fundamental objective in pediatric dentistry. CTZ paste has historically been employed in the treatment of necrotic primary teeth due to its simplicity and antimicrobial properties. Nevertheless, the inclusion of antibiotics such as chloramphenicol and tetracycline has raised concerns regarding bacterial resistance, allergic reactions, and adverse biological effects.
Consequently, research has increasingly focused on bioactive materials capable of stimulating healing rather than merely eliminating infection. Modern endodontic biomaterials emphasize biocompatibility, sealing ability, antimicrobial performance, and regenerative potential.

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✅ Biological Limitations of CTZ Paste

Antibiotic-Related Concerns
The use of topical antibiotics in endodontics has become increasingly controversial because of:
▪️ Development of antimicrobial resistance.
▪️ Potential hypersensitivity reactions.
▪️ Risk of bacterial selection pressure.
▪️ Regulatory restrictions on chloramphenicol in several countries.

Tissue Compatibility Issues
Although CTZ paste demonstrates clinical success in many studies, concerns include:
▪️ Potential cytotoxic effects on periapical tissues.
▪️ Delayed physiological root resorption.
▪️ Tooth discoloration.
▪️ Limited regenerative capacity.
These limitations have encouraged the exploration of materials that actively support tissue repair and regeneration.

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✅ Bioceramics as Alternatives to CTZ Paste

What Are Bioceramics?
Bioceramics are bioactive materials designed to interact positively with biological tissues. They release calcium ions, induce hydroxyapatite formation, and promote healing of dentin and periapical structures.
Their advantages include:
▪️ Excellent biocompatibility.
▪️ ▪️ High sealing ability.
▪️ Antibacterial alkaline pH.
▪️ Bioactivity and mineralization potential.
▪️ Osteogenic and dentinogenic stimulation.

1. Mineral Trioxide Aggregate (MTA)
Mineral Trioxide Aggregate (MTA) remains one of the most extensively studied bioactive materials in pediatric endodontics.
Advantages
▪️ Superior sealing properties.
▪️ High success rates in pulpotomy procedures.
▪️ Promotion of dentin bridge formation.
▪️ Excellent biocompatibility.
Limitations
▪️ Extended setting time.
▪️ High cost.
▪️ Potential discoloration.
Despite these limitations, MTA has become a benchmark for comparison with newer bioactive materials.

2. Calcium Silicate Cements
Biodentine
Biodentine is a calcium silicate-based cement developed as a dentin substitute and regenerative biomaterial.
Biological Properties
▪️ Stimulates tertiary dentin formation.
▪️ Releases calcium ions.
▪️ Promotes odontoblast-like cell differentiation.
▪️ Exhibits favorable antibacterial properties.
Clinical Applications
Biodentine has demonstrated positive outcomes in:
▪️ Pulpotomy.
▪️ Indirect pulp treatment.
▪️ Direct pulp capping.
▪️ Repair of perforations.
▪️ Management of resorptive defects.
Compared with CTZ paste, Biodentine offers a regenerative approach focused on tissue preservation and healing.

3. BioRoot RCS
BioRoot RCS is a tricalcium silicate-based sealer characterized by:
▪️ High bioactivity.
▪️ Excellent sealing ability.
▪️ Calcium ion release.
▪️ Promotion of mineralized tissue formation.
Its biological profile suggests potential future applications in pediatric endodontic therapies requiring enhanced tissue compatibility.

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✅ Novel Bioactive Agents

1. Calcium-Enriched Mixture Cement (CEM Cement)
CEM cement is another calcium silicate-based biomaterial demonstrating:
▪️ Antibacterial activity.
▪️ Bioactive hydroxyapatite formation.
▪️ Favorable tissue response.
▪️ Clinical success comparable to MTA.
Studies suggest that CEM cement may provide an effective alternative in vital pulp therapy procedures.

2. Bioceramic Putties
Premixed bioceramic putties have gained popularity because they offer:
▪️ Simplified clinical handling.
▪️ Reduced technique sensitivity.
▪️ Consistent material properties.
▪️ Excellent bioactivity.
These materials are increasingly utilized in pediatric and permanent tooth therapies.

3. Bioactive Glasses
Bioactive glass technology represents an emerging field in regenerative endodontics.
Potential benefits include:
▪️ Stimulation of mineralization.
▪️ Antimicrobial activity.
▪️ Enhanced tissue repair.
▪️ Formation of hydroxycarbonate apatite.
Although evidence in primary teeth remains limited, preliminary studies are encouraging.

4. Regenerative Biomolecules and Nanotechnology
Current research is evaluating:
▪️ Growth factor delivery systems.
▪️ Nanohydroxyapatite particles.
▪️ Stem cell-based approaches.
▪️ Bioactive peptides.
▪️ Nanostructured calcium silicates.
These technologies may eventually replace conventional antimicrobial approaches by promoting true biological regeneration.

📊 Comparison Between CTZ Paste and Emerging Alternatives

Characteristic	CTZ Paste	Bioceramics	Calcium Silicate Cements
Antimicrobial Action	High	Moderate-High	Moderate-High
Bioactivity	Low	Very High	Very High
Dentin Regeneration	Limited	Excellent	Excellent
Biocompatibility	Moderate	Excellent	Excellent
Antibiotic Content	Yes	No	No
Long-Term Biological Potential	Moderate	High	High

💬 Discussion
The paradigm of pediatric endodontics is progressively shifting from infection control alone toward biologically driven tissue preservation and regeneration. While CTZ paste continues to demonstrate acceptable clinical success in selected cases, modern evidence increasingly favors materials that combine antimicrobial effects with bioactive and regenerative properties.
Bioceramics and calcium silicate cements offer superior biological performance, including enhanced tissue compatibility, stimulation of mineralized tissue formation, and long-term sealing capacity. These characteristics align with contemporary minimally invasive and regenerative treatment philosophies.
However, long-term randomized clinical trials specifically evaluating these materials as direct substitutes for CTZ paste in necrotic primary teeth remain limited. Additional high-quality evidence is needed before definitive clinical recommendations can be established.

🎯 Recommendations
▪️ Consider bioceramic materials and calcium silicate cements when biological healing is prioritized.
▪️ Evaluate patient-specific factors, including age, root resorption status, and treatment objectives.
▪️ Remain informed about emerging regenerative endodontic technologies.
▪️ Use evidence-based protocols and adhere to current pediatric endodontic guidelines.
▪️ Encourage further clinical research comparing CTZ paste with modern bioactive alternatives.

✍️ Conclusion
Bioceramics, calcium silicate cements, and novel bioactive agents represent the most promising alternatives to CTZ paste in contemporary pediatric endodontics. Their ability to promote tissue repair, mineralization, and biological regeneration provides significant advantages over traditional antibiotic-based formulations. Although CTZ paste remains clinically relevant in some settings, future advances in regenerative biomaterials are likely to further expand the role of bioactive therapies in preserving primary teeth and improving long-term treatment outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Use of vital pulp therapies in primary teeth with deep caries lesions. The Reference Manual of Pediatric Dentistry, 503–510.
✔ Camilleri, J. (2015). Investigation of Biodentine as dentine replacement material. Journal of Dentistry, 43(7), 772–780. https://doi.org/10.1016/j.jdent.2015.04.006
✔ El Meligy, O. A. S., Alamoudi, N. M., Allazzam, S. M., El-Housseiny, A. A., & Alaki, S. M. (2019). Biodentine™ versus formocresol pulpotomy technique in primary molars: A 12-month randomized controlled clinical trial. BMC Oral Health, 19(1), 3. https://doi.org/10.1186/s12903-018-0702-4
✔ Gandolfi, M. G., Siboni, F., Botero, T., Bossù, M., Riccitiello, F., & Prati, C. (2015). Calcium silicate and calcium hydroxide materials for pulp capping: Biointeractivity, porosity, solubility and bioactivity of current formulations. Journal of Applied Biomaterials & Functional Materials, 13(1), e43–e60. https://doi.org/10.5301/jabfm.5000201
✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. Journal of Endodontics, 36(3), 400–413. https://doi.org/10.1016/j.joen.2009.09.009
✔ Torabinejad, M., & Parirokh, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part II: Leakage and biocompatibility investigations. Journal of Endodontics, 36(2), 190–202. https://doi.org/10.1016/j.joen.2009.09.010
✔ Zanini, M., Sautier, J. M., Berdal, A., & Simon, S. (2012). Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization. Journal of Endodontics, 38(9), 1220–1226. https://doi.org/10.1016/j.joen.2012.04.018

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CTZ Paste in Pediatric Dentistry: Indications, Composition, and Success Rates

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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✅ What Is CTZ Paste?
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.

Common Formulation
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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✅ Mechanism of Action
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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✅ Indications for CTZ Paste
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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✅ Contraindications
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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✅ Clinical Procedure

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%

These findings suggest that CTZ paste is a reliable option in selected cases, especially where conventional pulpectomy is impractical.

✅ 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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✅ Limitations and Concerns
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.

💬 Discussion
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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Iodoform-Calcium Hydroxide Pastes vs CTZ in Pediatric Dentistry

Iodoform-calcium hydroxide pastes have gained attention as a potential alternative to CTZ paste in pediatric endodontics. While CTZ (chloramphenicol, tetracycline, zinc oxide-eugenol) has demonstrated clinical success, concerns regarding antibiotic resistance, cytotoxicity, and regulatory restrictions have prompted the search for safer substitutes.

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This article critically evaluates the benefits, risks, and clinical performance of iodoform-calcium hydroxide formulations compared to CTZ.

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✅ Introduction
The management of infected primary teeth often relies on obturation materials with antimicrobial properties and biocompatibility. CTZ paste has been widely used due to its broad-spectrum antibacterial action, but its composition—particularly chloramphenicol—raises safety concerns.
In contrast, iodoform-calcium hydroxide pastes (e.g., Vitapex®, Metapex®) have emerged as promising alternatives due to their resorbability and favorable biological profile. This article explores whether these materials can effectively replace CTZ in clinical practice.

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✅ Material Composition and Mechanism of Action

CTZ Paste
▪️ Components: Chloramphenicol, tetracycline, zinc oxide-eugenol
▪️ Mechanism: Broad-spectrum antibacterial effect via protein synthesis inhibition
▪️ Limitation: Potential systemic toxicity and antibiotic resistance

Iodoform-Calcium Hydroxide Pastes
▪️ Components: Calcium hydroxide, iodoform, silicone oil (vehicle)
▪️ Mechanism:
₀ High pH (≈12.5) → antimicrobial activity
₀ Iodoform → sustained antiseptic effect
▪️ Advantage: Promotes periapical healing and physiological root resorption

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✅ Clinical Indications and Applications

Iodoform-calcium hydroxide pastes are indicated for:
▪️ Pulpectomy in primary teeth
▪️ Teeth with periapical lesions
▪️ Cases requiring resorbable obturation materials

CTZ is typically used in:
▪️ Non-instrumentation endodontic techniques
▪️ Situations with limited clinical time or patient cooperation

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✅ Benefits of Iodoform-Calcium Hydroxide Pastes
▪️ Superior biocompatibility compared to antibiotic-based pastes
▪️ Resorbability synchronized with primary root resorption
▪️ Reduced risk of systemic adverse effects
▪️ Lower contribution to antimicrobial resistance
▪️ Radiopacity and ease of placement

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✅ Risks and Limitations
▪️ Potential over-resorption before complete root resorption
▪️ Lower immediate antibacterial potency compared to CTZ
▪️ Risk of extrusion beyond apex, although generally well tolerated
▪️ Possible discoloration due to iodoform content

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💬 Discussion
The replacement of CTZ with iodoform-calcium hydroxide pastes reflects a broader shift toward biologically acceptable and antibiotic-free materials. Although CTZ demonstrates strong antimicrobial efficacy, its reliance on broad-spectrum antibiotics is increasingly problematic in modern clinical practice.
Evidence suggests that calcium hydroxide-based pastes provide adequate disinfection while supporting tissue repair and regeneration. However, their clinical success depends on proper case selection and technique, especially in teeth with extensive infection.
Furthermore, the resorbable nature of iodoform-calcium hydroxide pastes aligns well with the physiology of primary dentition, reducing the risk of interference with permanent tooth eruption.

✍️ Conclusion
Iodoform-calcium hydroxide pastes represent a viable and safer alternative to CTZ, particularly in pediatric patients. Although they may exhibit slightly reduced immediate antibacterial activity, their superior biocompatibility, physiological resorbability, and lower systemic risk profile support their preference in most clinical scenarios.

🎯 Clinical Recommendations
▪️ Prefer iodoform-calcium hydroxide pastes in routine pulpectomies
▪️ Reserve CTZ for specific cases where rapid disinfection is critical
▪️ Avoid CTZ in patients with antibiotic sensitivity or systemic risk factors
▪️ Ensure accurate obturation technique to prevent extrusion
▪️ Monitor treated teeth radiographically for resorption patterns

Parameter	Iodoform-Calcium Hydroxide Pastes	CTZ Paste
Composition	Calcium hydroxide + iodoform	Chloramphenicol + tetracycline + ZOE
Antimicrobial Action	High pH + antiseptic effect	Broad-spectrum antibiotic effect
Biocompatibility	High	Moderate to low
Resorbability	Physiological, synchronized with roots	Limited or unpredictable
Systemic Risk	Low	Higher (antibiotic-related)
Clinical Indication	Pulpectomy in primary teeth	Non-instrumentation techniques

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Guideline on pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 45(6), 384–392.
✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., & AlShamali, S. (2020). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 42(4), 256–261.
✔ Siqueira, J. F., & Rôças, I. N. (2019). Present status and future directions in endodontic microbiology. Endodontic Topics, 38(1), 3–23. https://doi.org/10.1111/etp.12264
✔ Subramaniam, P., Konde, S., Mandanna, D. K. (2011). Clinical and radiographic evaluation of metapex in pulpectomy of primary teeth. Journal of Indian Society of Pedodontics and Preventive Dentistry, 29(3), 233–238. https://doi.org/10.4103/0970-4388.85818
✔ Trairatvorakul, C., & Chunlasikaiwan, S. (2008). Success of pulpectomy with zinc oxide-eugenol vs iodoform paste in primary molars: A clinical study. International Journal of Paediatric Dentistry, 18(3), 169–177. https://doi.org/10.1111/j.1365-263X.2007.00914.x

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Limitations of CTZ and Antibiotic Pastes in Pediatric Endodontics: Resistance, Tooth Discoloration, and Safety Concerns

Antibiotic-containing intracanal medicaments such as CTZ paste and triple antibiotic paste (TAP) have been widely used in pediatric endodontics for the management of necrotic primary teeth and regenerative procedures.

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A critical evaluation of their clinical use is necessary to ensure biologically sound and ethically responsible treatment.

✅ Composition and Intended Clinical Use

CTZ Paste
CTZ paste traditionally contains:
▪️ Chloramphenicol
▪️ Tetracycline
▪️ Zinc oxide–eugenol base
It has been used as an obturation or intracanal medicament in non-instrumentation pulpotomy/pulpectomy techniques in primary teeth.

Triple Antibiotic Paste (TAP)
Originally described by Hoshino and colleagues, TAP contains:
▪️ Metronidazole
▪️ Ciprofloxacin
▪️ Minocycline
TAP is commonly used in regenerative endodontic procedures and necrotic immature permanent teeth.

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✅ Major Limitations
1. Antimicrobial Resistance
The use of broad-spectrum antibiotic mixtures increases the risk of:

▪️ Selection of resistant bacterial strains
▪️ Alteration of oral microbiota
▪️ Reduced long-term efficacy
The World Health Organization has identified antimicrobial resistance as a major global public health threat. Local intracanal application does not eliminate the risk of promoting resistant microorganisms.
Studies demonstrate that exposure to subtherapeutic concentrations of antibiotics in dentinal tubules may facilitate resistance development.

2. Tooth Discoloration
Minocycline in TAP and tetracycline in CTZ are strongly associated with:

▪️ Intrinsic crown discoloration
▪️ Gray or brown staining of dentin
▪️ Aesthetic compromise, especially in anterior teeth
This discoloration is due to calcium-chelating properties and photo-oxidation reactions within dentin.
Alternative formulations excluding minocycline have been proposed, but discoloration risk remains a clinical concern.

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3. Cytotoxicity and Effects on Stem Cells
In regenerative endodontics, high concentrations of TAP have demonstrated:

▪️ Cytotoxic effects on stem cells of the apical papilla
▪️ Inhibition of cell proliferation
▪️ Delayed tissue regeneration
Lower concentrations reduce toxicity but may compromise antimicrobial effectiveness.

4. Systemic Safety Concerns
Although used locally, systemic absorption—particularly in primary teeth with open apices—cannot be entirely excluded. Concerns include:

▪️ Hypersensitivity reactions
▪️ Tetracycline-related developmental effects
▪️ Chloramphenicol-associated rare hematologic complications
The American Academy of Pediatric Dentistry emphasizes cautious antibiotic use consistent with antimicrobial stewardship principles.

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5. Lack of Standardization
There is no universal protocol regarding:

▪️ Optimal antibiotic concentration
▪️ Duration of intracanal placement
▪️ Indications in primary teeth
This variability compromises reproducibility and long-term evidence consistency.

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💬 Discussion
While CTZ and TAP exhibit broad antimicrobial properties, their routine use in pediatric endodontics is increasingly questioned. Modern minimally invasive techniques combined with mechanical debridement and bioceramic materials may reduce the need for antibiotic pastes.
The balance between antimicrobial effectiveness and biological safety remains critical. Evidence suggests that high antibiotic concentrations are unnecessary and potentially harmful.
Furthermore, antimicrobial stewardship initiatives discourage the overuse of antibiotics in any clinical context, including localized intracanal therapy.

🎯 Clinical Recommendations
▪️ Avoid routine use of antibiotic pastes in primary teeth when conventional pulpectomy techniques are feasible.
▪️ Consider alternative intracanal medicaments such as calcium hydroxide when appropriate.
▪️ If antibiotic paste is used, employ minimal effective concentrations.
▪️ Avoid minocycline-containing formulations in esthetic zones.
▪️ Follow antimicrobial stewardship guidelines.

✍️ Conclusion
CTZ paste and triple antibiotic paste present significant clinical limitations, including antimicrobial resistance risk, tooth discoloration, cytotoxic effects, and safety concerns. Although they retain selective indications in specific cases, their indiscriminate use in pediatric dentistry is not supported by contemporary evidence. Safer, biologically compatible alternatives should be prioritized whenever possible.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Use of antibiotic therapy for pediatric dental patients. Pediatric Dentistry, 45(6), 389–398.
✔ Ruparel, N. B., Teixeira, F. B., Ferraz, C. C. R., & Diogenes, A. (2012). Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. Journal of Endodontics, 38(10), 1372–1375. https://doi.org/10.1016/j.joen.2012.06.018
✔ Kim, J. H., Kim, Y., Shin, S. J., Park, J. W., & Jung, I. Y. (2010). Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy. Journal of Endodontics, 36(6), 1086–1091. https://doi.org/10.1016/j.joen.2010.03.031
✔ World Health Organization. (2023). Global action plan on antimicrobial resistance. Geneva: WHO.
✔ Sato, I., Kurihara-Ando, N., Kota, K., et al. (1996). Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline. International Endodontic Journal, 29(2), 118–124. https://doi.org/10.1111/j.1365-2591.1996.tb01382.x

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CTZ vs. Guedes-Pinto Paste in Necrotic Teeth: Which Endodontic Material Performs Better?

The management of necrotic teeth, particularly in pediatric and mixed dentition, remains a clinical challenge due to the presence of polymicrobial infection, periapical inflammation, and complex root canal anatomy. Intracanal medicaments and obturation pastes play a critical role in controlling infection and promoting periapical healing.

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Among the materials most frequently discussed in Latin American pediatric dentistry are CTZ paste and Guedes-Pinto paste, both widely used as alternatives to conventional endodontic protocols. This article provides an evidence-based comparison of their composition, mechanisms of action, clinical performance, and limitations in the treatment of necrotic teeth.

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✅ Composition of CTZ Paste
CTZ paste is composed of:

▪️ Chloramphenicol
▪️ Tetracycline
▪️ Zinc oxide–eugenol
This combination offers broad-spectrum antimicrobial activity, targeting aerobic and anaerobic bacteria commonly associated with endodontic necrosis. Zinc oxide–eugenol serves as a vehicle and obturation medium, providing sealing ability and mild anti-inflammatory effects.

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✅ Composition of Guedes-Pinto Paste
Guedes-Pinto paste consists of:

▪️ Rifampicin
▪️ Prednisolone
▪️ Camphorated paramonochlorophenol (CMCP)
This formulation combines antimicrobial, anti-inflammatory, and analgesic properties, making it particularly suitable for infected primary teeth. The corticosteroid component helps reduce periapical inflammation, while CMCP enhances antibacterial efficacy.

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✅ Mechanisms of Action

CTZ Paste
▪️ Inhibits bacterial protein synthesis via tetracycline and chloramphenicol
▪️ Provides chemical disinfection without mechanical instrumentation
▪️ Acts as a long-term antimicrobial obturating material

Guedes-Pinto Paste
▪️ Disrupts bacterial cell metabolism through rifampicin and CMCP
▪️ Reduces inflammatory response via prednisolone
▪️ Promotes symptom relief and periapical tissue recovery

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✅ Clinical Performance in Necrotic Teeth
Clinical studies indicate that both materials demonstrate high success rates in necrotic primary teeth when properly indicated. CTZ paste is often associated with simplified single-visit protocols, while Guedes-Pinto paste shows favorable outcomes in cases with acute inflammation and pain. However, neither material should be considered a substitute for adequate diagnosis and case selection.

💬 Discussion
The choice between CTZ and Guedes-Pinto paste should be guided by clinical presentation, patient age, systemic considerations, and operator experience. CTZ paste offers prolonged antimicrobial action but raises concerns regarding antibiotic resistance and tooth discoloration. Guedes-Pinto paste provides strong anti-inflammatory effects but may present higher cytotoxic potential due to CMCP. Current evidence supports their use mainly in primary teeth, with limited indication in permanent dentition.

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🎯 Recommendations
▪️ Use CTZ paste in necrotic primary teeth requiring simplified endodontic protocols
▪️ Consider Guedes-Pinto paste in cases with acute inflammation or symptomatic necrosis
▪️ Avoid indiscriminate use due to antibiotic stewardship concerns
▪️ Always perform radiographic and clinical follow-up

✍️ Conclusion
Both CTZ and Guedes-Pinto pastes are effective materials for managing necrotic teeth, particularly in pediatric dentistry. Their success depends on appropriate case selection, understanding of their pharmacological properties, and adherence to evidence-based protocols. Neither material replaces conventional endodontic principles, but both remain valuable tools when used judiciously.

📊 Comparative Table: Clinical Characteristics of a Necrotic Tooth

Clinical Feature	Diagnostic Indicators	Clinical Implications
Loss of pulp vitality	Negative thermal and electric pulp tests	Indicates irreversible pulp damage
Periapical radiolucency	Radiographic evidence of bone loss	Suggests chronic periapical infection
Tooth discoloration	Gray or dark crown appearance	Common in long-standing necrosis
Possible fistula or abscess	Clinical drainage or swelling	Requires immediate infection control

📚 References

✔ Guedes-Pinto, A. C., Paiva, J. G., & Bozzola, J. R. (1981). Endodontic treatment of primary teeth with a paste containing antibiotics and corticosteroids. Journal of Dentistry for Children, 48(2), 144–147.
✔ Rifkin, A. (1980). A simple, effective endodontic technique for primary teeth. Journal of Dentistry for Children, 47(6), 435–441.
✔ Santos, P. S., & de Araujo, F. B. (2009). Antimicrobial activity of CTZ paste in primary teeth. International Journal of Paediatric Dentistry, 19(6), 397–401. https://doi.org/10.1111/j.1365-263X.2009.01007.x
✔ Leonardo, M. R., & Silva, L. A. B. (2008). Endodontia: Tratamento de canais radiculares. São Paulo: Artes Médicas.

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CTZ Paste in Primary Teeth Pulp Therapy: Indications, Benefits and Clinical Protocol

The use of CTZ paste (Chloramphenicol–Tetracycline–Zinc Oxide) in primary teeth remains a topic of interest, especially in cases of infected primary molars where traditional pulpectomy is not feasible.

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This article presents an updated, evidence-based analysis of its indications, clinical technique, advantages, limitations, and safety considerations.

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✅ Introduction
The CTZ technique, also known as Lesion Sterilization and Tissue Repair (LSTR), aims to disinfect infected primary teeth by using a topical antibiotic mixture sealed within the pulp chamber. Unlike full pulpectomy, this approach promotes infection control without extensive instrumentation, making it useful in pediatric patients with limited cooperation.
However, concerns regarding antibiotic resistance, systemic absorption, and use of chloramphenicol and tetracycline in children have prompted ongoing debate. Updated guidelines emphasize strict case selection and avoidance of CTZ when safer alternatives (e.g., Vitapex, Ca(OH)₂–iodoform pastes) are available.

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✅ Composition of CTZ Paste
CTZ paste typically contains:

▪️ Chloramphenicol (250 mg)
▪️ Tetracycline (250 mg)
▪️ Zinc oxide
▪️ Eugenol or propylene glycol as vehicle

Some variations replace tetracycline with metronidazole or eliminate eugenol.

✅ Mechanism of Action

▪️ Broad-spectrum antibacterial effect against anaerobic and facultative bacteria involved in primary tooth infections.
▪️ Promotes partial tissue repair through reduction of bacterial load.
▪️ Works without canal instrumentation, relying on diffusion through dentinal tubules.

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✅ Clinical Indications
CTZ paste is indicated when:

▪️ The child cannot tolerate conventional pulpectomy.
▪️ Canals are severely obstructed, resorbed, or inaccessible.
▪️ There is chronic infection, fistula, or abscess associated with a restorable tooth.
▪️ Treatment aims to maintain the primary tooth short-term until natural exfoliation or eruption of the successor.

✅ Contraindications

▪️ Children with allergy to chloramphenicol, tetracycline, or eugenol.
▪️ When the tooth is non-restorable.
▪️ Presence of advanced pathological resorption or mobile tooth near exfoliation.
▪️ Patients with systemic conditions requiring antibiotic stewardship.
▪️ When the tooth can receive conventional pulpectomy.

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✅ Clinical Procedure

1. Local anesthesia and isolation.
2. Removal of coronal pulp and carious tissue.
3. Irrigation with saline or chlorhexidine (no instrumentation of canals).
4. Placement of a thin layer of CTZ paste on chamber floor.
5. Seal with reinforced glass ionomer cement.
6. Final restoration with stainless steel crown, whenever possible.

✅ Benefits

▪️ Requires minimal cooperation, ideal for uncooperative children.
▪️ Effective in reducing clinical signs of infection.
▪️ Faster than pulpectomy.
▪️ Useful in public health settings or emergency care.

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✅ Limitations and Safety Concerns

▪️ Potential risk of antibiotic resistance.
▪️ Chloramphenicol carries risk of systemic absorption (rare but serious).
▪️ Tetracycline may cause tooth discoloration when absorbed systemically.
▪️ Lower long-term success compared with proper pulpectomy techniques.

📊 Comparative Table: CTZ Paste vs Conventional Pulpectomy

Aspect	Advantages	Limitations
CTZ Paste	Minimal instrumentation; fast; good for uncooperative children	Antibiotic exposure; lower long-term success; limited indications
Conventional Pulpectomy	Biocompatible materials; higher long-term success; well-documented evidence	Longer procedure; requires cooperation; technically demanding

💬 Discussion
Although CTZ paste can be effective in selected cases, its use must be ethical and evidence-based. Current pediatric dentistry guidelines favor biocompatible materials (e.g., MTA, Biodentine, Vitapex, Ca(OH)₂) due to better long-term outcomes and absence of systemic antibiotic risks.
Nevertheless, CTZ paste remains a valuable alternative in:

▪️ Remote or resource-limited environments
▪️ Patients with behavioral management challenges
▪️ Complex anatomy preventing conventional therapy

The decision should always consider risk–benefit, parental counseling, and tooth prognosis.

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✍️ Conclusion
CTZ paste is an alternative pulp therapy for infected primary teeth when conventional treatment is not feasible. Its effectiveness relies on infection control, but concerns about antibiotic exposure and resistance require strict clinical judgment. When used appropriately, CTZ can help maintain primary teeth temporarily, supporting occlusal development until natural exfoliation.

🔎 Recommendations
▪️ Prefer standard pulpectomy when feasible.
▪️ Reserve CTZ for special circumstances and always inform parents about risks.
▪️ Follow-up radiographs every 3–6 months.
▪️ Always restore with full-coverage restoration.
▪️ Consider newer biocompatible pastes as first choice.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. AAPD Clinical Guidelines.
✔ Bimstein, E., & Rotstein, I. (2019). Root canal treatment for children and adolescents. Springer Nature.
✔ Nakornchai, S., Banditsing, P., & Visetratana, N. (2020). Clinical evaluation of LSTR/CTZ therapy in primary teeth. International Journal of Paediatric Dentistry, 30(4), 500–507.
✔ Primosch, R., & Glomb, T. (2018). Vital pulp therapy in primary teeth: Current concepts. Pediatric Dentistry, 40(5), 315–322.

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