Zinc Oxide Eugenol vs Calcium Hydroxide–Iodoform in Pulpectomy

Pulpectomy in primary teeth requires obturation materials that ensure antimicrobial efficacy, biocompatibility, and physiological resorption. The comparison between zinc oxide eugenol (ZOE) and calcium hydroxide–iodoform pastes remains clinically relevant.

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This review analyzes clinical performance, resorption behavior, success rates, and limitations, based on current evidence.
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✅ Introduction
Pulpectomy is a key procedure in pediatric dentistry aimed at preserving infected primary teeth. The ideal obturation material should exhibit resorbability synchronized with root resorption, antimicrobial properties, and minimal toxicity to periapical tissues. Historically, ZOE has been widely used, whereas calcium hydroxide–iodoform pastes have gained popularity due to improved biological properties.

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✅ Material Characteristics

Zinc Oxide Eugenol (ZOE)
▪️ Composition: Zinc oxide powder and eugenol liquid
▪️ Properties: Antimicrobial, radiopaque, good sealing ability
▪️ Limitations: Slow resorption, potential irritation to periapical tissues

Calcium Hydroxide–Iodoform Pastes (e.g., Vitapex, Metapex)
▪️ Composition: Calcium hydroxide, iodoform, silicone oil vehicle
▪️ Properties: Strong antimicrobial activity, high biocompatibility, resorbable
▪️ Clinical advantage: Resorption closely follows physiological root resorption

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✅ Clinical Performance

Success Rates
▪️ Both materials demonstrate high clinical success rates (>80%)
▪️ Recent studies suggest slightly higher radiographic success with calcium hydroxide–iodoform pastes

Evidence:
▪️ Coll et al. (2020) reported comparable success rates, with better resorption patterns in calcium hydroxide–iodoform materials.
▪️ Ramar & Mungara (2010) found higher success in Vitapex compared to ZOE in primary teeth pulpectomies.

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✅ Resorption Behavior

ZOE:
▪️ Slow resorption
▪️ May remain in periapical tissues after root resorption

Calcium hydroxide–iodoform:
▪️ Rapid and controlled resorption
▪️ Resorbs in harmony with primary tooth exfoliation

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✅ Antimicrobial Activity

▪️ Both materials exhibit broad antimicrobial effects
▪️ Calcium hydroxide–iodoform shows enhanced activity due to:
° High pH (Ca(OH)₂)
° Iodoform bactericidal effect

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✅ Advantages and Limitations

1. ZOE
Advantages
▪️ Long history of clinical use
▪️ Good sealing properties
▪️ Cost-effective

Limitations
▪️ Delayed resorption
▪️ Potential foreign body reaction
▪️ May interfere with eruption of permanent teeth

2. Calcium Hydroxide–Iodoform
Advantages
▪️ Biocompatibility and resorbability
▪️ Superior antimicrobial action
▪️ Favorable effect on periapical healing

Limitations
▪️ Risk of over-resorption within canals
▪️ Possible void formation over time
▪️ Higher cost compared to ZOE

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💬 Discussion
Current literature favors calcium hydroxide–iodoform pastes due to their biological compatibility and resorption profile, which aligns with the natural exfoliation process. While ZOE remains a viable option, its slow resorption and potential interference with permanent tooth eruption are notable concerns.

Clinical decision-making should consider:
▪️ Patient age
▪️ Extent of root resorption
▪️ Presence of periapical pathology

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✍️ Conclusion
Both ZOE and calcium hydroxide–iodoform pastes are effective for pulpectomy in primary teeth. However, calcium hydroxide–iodoform materials demonstrate superior biological behavior, particularly in terms of resorption and tissue compatibility, making them the preferred option in modern pediatric dentistry.

🎯 Recommendations
▪️ Prefer calcium hydroxide–iodoform pastes in cases requiring predictable resorption
▪️ Use ZOE cautiously, especially in teeth close to exfoliation
▪️ Avoid overfilling regardless of material
▪️ Base material selection on clinical and radiographic findings

📚 References

✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., Al Shamsi, S., & Dhar, V. (2020). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 42(4), 256–461.
✔ Ramar, K., & Mungara, J. (2010). Clinical and radiographic evaluation of pulpectomies using three root canal filling materials. Journal of Indian Society of Pedodontics and Preventive Dentistry, 28(1), 25–29. https://doi.org/10.4103/0970-4388.60470
✔ Mortazavi, M., & Mesbahi, M. (2004). Comparison of zinc oxide and eugenol, and Vitapex for root canal treatment of necrotic primary teeth. International Journal of Paediatric Dentistry, 14(6), 417–424. https://doi.org/10.1111/j.1365-263X.2004.00562.x
✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 45(6), 384–392.
✔ 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(2), 144–149. https://doi.org/10.1111/j.1365-263X.2007.00886.x

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Pulpotomy Materials Comparison: Calcium Hydroxide vs. Mineral Trioxide Aggregate (MTA) in Primary Molars

Pulpotomy is a widely accepted vital pulp therapy for primary molars affected by carious exposure or traumatic injury, aiming to preserve the radicular pulp and maintain tooth function until natural exfoliation.

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The selection of an appropriate pulpotomy material is critical, as it directly influences clinical success, pulpal healing, and long-term prognosis. Among the materials most frequently studied, calcium hydroxide (CH) and mineral trioxide aggregate (MTA) have received significant attention due to their biological properties and historical relevance.

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This article provides an updated and evidence-based comparison of these two materials, emphasizing their performance in primary molar pulpotomy from a contemporary pediatric dentistry perspective.

✅ Biological Rationale of Pulpotomy Materials

Calcium Hydroxide
Calcium hydroxide has been traditionally used in vital pulp therapy due to its high alkalinity, antibacterial effect, and ability to stimulate reparative dentin formation. However, its application in primary teeth has shown limitations, including internal resorption and incomplete dentinal bridge formation, which may compromise treatment outcomes.

Mineral Trioxide Aggregate (MTA)
MTA is a bioactive calcium silicate-based material known for its excellent biocompatibility, sealing ability, and capacity to induce hard tissue formation. In primary molars, MTA promotes favorable pulpal responses, including reduced inflammation and consistent dentin bridge formation, contributing to higher long-term success rates.

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✅ Clinical and Radiographic Outcomes
Multiple randomized clinical trials and systematic reviews have demonstrated that MTA exhibits superior clinical and radiographic success compared to calcium hydroxide in primary molar pulpotomy. While CH may provide acceptable short-term outcomes, MTA consistently shows lower rates of pathological root resorption, pulp necrosis, and treatment failure during follow-up periods extending beyond 12 months.

💬 Discussion
The declining use of calcium hydroxide in primary molar pulpotomy is supported by growing evidence highlighting its biological instability in primary pulp tissue. In contrast, MTA has emerged as the reference material due to its predictable healing response and long-term effectiveness. Despite its higher cost and handling complexity, MTA’s advantages outweigh these limitations, particularly in pediatric patients where preservation of primary teeth is essential for occlusal development and space maintenance.

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✍️ Conclusion
Based on current scientific evidence, mineral trioxide aggregate demonstrates superior clinical performance compared to calcium hydroxide in pulpotomy of primary molars. Its enhanced biocompatibility, sealing properties, and reduced risk of internal resorption make MTA the preferred material for vital pulp therapy in primary dentition.

🎯 Clinical Recommendations
▪️ MTA should be considered the material of choice for pulpotomy in primary molars when available.
▪️ Calcium hydroxide should be used with caution due to its association with internal resorption and lower long-term success.
▪️ Proper case selection, hemorrhage control, and coronal sealing remain critical regardless of the material used.
▪️ Long-term clinical and radiographic follow-up is essential to evaluate pulpal response and tooth integrity.

📊 Comparative Table: Calcium Hydroxide vs. MTA in Primary Molar Pulpotomy

Clinical Parameter	Calcium Hydroxide	Mineral Trioxide Aggregate (MTA)
Biocompatibility	Moderate; may induce chronic inflammation	Excellent; promotes favorable pulpal healing
Dentin bridge formation	Inconsistent and porous	Homogeneous and well-organized
Risk of internal resorption	High incidence reported	Minimal to none
Long-term clinical success	Lower success rates over time	High success rates in long-term follow-up

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 45(6), 403–412.
✔ Agamy, H. A., Bakry, N. S., Mounir, M. M., & Avery, D. R. (2004). Comparison of mineral trioxide aggregate and formocresol as pulp-capping agents in pulpotomized primary teeth. Pediatric Dentistry, 26(4), 302–309.
✔ Holan, G., Eidelman, E., & Fuks, A. B. (2005). Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatric Dentistry, 27(2), 129–136.
✔ Peng, L., Ye, L., Guo, X., Tan, H., Zhou, X., Wang, C., & Li, R. (2007). Evaluation of formocresol versus mineral trioxide aggregate primary molar pulpotomy: A meta-analysis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 104(6), e40–e44.

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Modern Alternatives to Calcium Hydroxide Apexification

Management of immature permanent teeth with necrotic pulp has historically relied on calcium hydroxide apexification. However, advances in biomaterials and regenerative biology have significantly changed clinical decision-making.

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Today, regenerative endodontic procedures (REPs) and mineral trioxide aggregate (MTA) apical barriers are increasingly preferred due to their predictable outcomes, reduced treatment time, and superior biological response.

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✅ Traditional Calcium Hydroxide Apexification: Limitations
Calcium hydroxide apexification aims to induce the formation of a calcified apical barrier over several months. Despite its historical importance, multiple disadvantages have been documented:

▪️ Prolonged treatment time, often exceeding 6–18 months
▪️ Increased risk of root fracture due to long-term dentin exposure
▪️ Multiple patient visits, compromising compliance
▪️ Unpredictable apical closure morphology
Long-term calcium hydroxide use weakens radicular dentin, increasing susceptibility to cervical fractures.

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✅ MTA Apical Barriers: A More Predictable Alternative
The introduction of MTA revolutionized apexification by allowing immediate apical barrier formation in one or two visits.

Key advantages include:
▪️ Excellent biocompatibility and bioactivity
▪️ Superior sealing ability
▪️ Reduced treatment duration
▪️ High clinical success rates
MTA apical barriers provide a reliable artificial stop, enabling effective obturation without prolonged intracanal medication.

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✅ Regenerative Endodontics: A Paradigm Shift
Regenerative endodontic procedures aim to restore pulp vitality and promote continued root development, rather than simply closing the apex.

Clinical benefits include:
▪️ Increase in root length and dentin thickness
▪️ Improved fracture resistance
▪️ Potential revascularization of the pulp space
Regenerative endodontics aligns with modern minimally invasive and biologically driven dentistry, especially in young patients.

📊 Comparative Table: Properties of Mineral Trioxide Aggregate (MTA)

Aspect	Advantages	Limitations
Biocompatibility	Excellent tissue tolerance and minimal inflammatory response	May cause mild initial inflammation during setting
Sealing ability	Superior marginal seal even in moist environments	Technique-sensitive placement
Bioactivity	Stimulates hard tissue formation and cementogenesis	Long setting time compared to newer bioceramics
Clinical longevity	High long-term success rates in apexification and perforation repair	Higher cost than traditional materials

💬 Discussion
While calcium hydroxide apexification remains a viable option in selected cases, current evidence strongly favors MTA apical barriers and regenerative techniques. MTA provides predictable outcomes when root development cannot be restored, whereas regenerative endodontics offers true tissue healing and maturation when biological conditions allow.
Case selection, clinician expertise, and patient age play critical roles in choosing the appropriate modality.

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✍️ Conclusion
Traditional calcium hydroxide apexification is being replaced due to its biological limitations and mechanical risks. MTA apical barriers and regenerative endodontics represent evidence-based, modern alternatives that improve clinical outcomes, reduce treatment time, and preserve tooth structure.

🎯 Clinical Recommendations
▪️ Prefer regenerative endodontics in immature teeth with favorable apical anatomy
▪️ Use MTA apical barriers when regeneration is not feasible
▪️ Limit long-term calcium hydroxide use due to fracture risk
▪️ Base treatment decisions on radiographic findings, patient age, and compliance

📚 References

✔ American Association of Endodontists. (2016). Clinical considerations for a regenerative procedure. Journal of Endodontics, 42(3), 505–513. https://doi.org/10.1016/j.joen.2016.01.017
✔ Banchs, F., & Trope, M. (2004). Revascularization of immature permanent teeth with apical periodontitis. Journal of Endodontics, 30(4), 196–200. https://doi.org/10.1097/00004770-200404000-00003
✔ Torabinejad, M., & Parirokh, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part II. Journal of Endodontics, 36(2), 190–202. https://doi.org/10.1016/j.joen.2009.09.010
✔ Andreasen, J. O., Farik, B., & Munksgaard, E. C. (2002). Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology, 18(3), 134–137. https://doi.org/10.1034/j.1600-9657.2002.00097.x

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Calcium Hydroxide as a Long-Term Endodontic Sealer: Why It No Longer Meets Modern Biomechanical Standards

For decades, calcium hydroxide–based materials played a central role in endodontics due to their antimicrobial properties and biological compatibility. However, advances in biomechanical preparation, three-dimensional obturation, and material science have redefined the requirements of an ideal endodontic sealer.

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Today, substantial evidence demonstrates that calcium hydroxide as a long-term endodontic sealer no longer satisfies modern biomechanical and clinical expectations, particularly regarding sealing ability, stability, and long-term outcomes.

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✅ Calcium Hydroxide Sealers: Historical Perspective
Calcium hydroxide sealers were originally adopted because of their:

▪️ High alkalinity, promoting antibacterial effects
▪️ Ability to stimulate hard tissue formation
▪️ Relative ease of handling

Despite these advantages, their use as permanent sealers has increasingly been questioned as treatment goals shifted toward predictable, long-term apical sealing and structural integrity.

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✅ Why Calcium Hydroxide Fails Modern Biomechanical Standards
Modern endodontics demands materials that maintain dimensional stability, resist dissolution, and provide a fluid-tight seal under functional stresses. Evidence shows that calcium hydroxide sealers exhibit:

▪️ High solubility over time, leading to leakage
▪️ Poor adhesion to dentin and gutta-percha
▪️ Inability to support monoblock concepts
▪️ Reduced performance in warm vertical compaction techniques

These deficiencies directly compromise the biomechanical integrity of the root canal system.

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✅ Sealing Ability and Microleakage
Multiple in vitro and clinical studies confirm that calcium hydroxide sealers demonstrate inferior sealing ability compared with epoxy resin–based and bioceramic sealers. Progressive dissolution allows bacterial penetration, undermining long-term endodontic success.
Importantly, antibacterial activity does not compensate for inadequate sealing, as persistent microleakage remains the primary cause of post-treatment disease.

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✅ Comparison with Modern Endodontic Sealers
Contemporary sealers—such as epoxy resin, calcium silicate–based (bioceramic), and MTA-derived materials—offer:

▪️ Low solubility
▪️ Superior dentinal adaptation
▪️ Chemical bonding or bioactivity
▪️ Compatibility with modern obturation techniques

These properties align with current biomechanical and biological principles of root canal therapy.

📊 Comparative Table: Calcium Hydroxide Sealers vs Modern Endodontic Sealers

Aspect	Advantages	Limitations
Antibacterial activity	High initial pH with antimicrobial effect	Effect decreases over time and does not prevent leakage
Sealing ability	Easy placement in the canal	Inferior apical and coronal seal compared to resin and bioceramic sealers
Solubility	Gradual release of calcium ions	High long-term solubility leading to voids and microleakage
Biomechanical compatibility	Biocompatible with periapical tissues	Fails to reinforce root structure or support monoblock obturation

💬 Discussion
While calcium hydroxide remains valuable as an intracanal medicament, its role as a definitive endodontic sealer is scientifically outdated. Current evidence underscores that long-term success depends more on durable sealing and biomechanical stability than on transient antimicrobial effects. The persistence of calcium hydroxide sealers in some clinical settings reflects habit rather than evidence-based practice.

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🎯 Clinical Recommendations
▪️ Avoid the use of calcium hydroxide–based sealers as permanent obturation materials
▪️ Prefer epoxy resin or bioceramic sealers for long-term sealing
▪️ Reserve calcium hydroxide for short-term intracanal medication
▪️ Align material selection with modern obturation techniques and biomechanical principles
▪️ Update clinical protocols according to current endodontic evidence

✍️ Conclusion
Calcium hydroxide as a long-term endodontic sealer no longer meets modern biomechanical standards due to its high solubility, inadequate sealing ability, and incompatibility with contemporary obturation concepts. Advances in material science have produced superior alternatives that ensure predictable, durable, and biologically sound outcomes, making the routine use of calcium hydroxide sealers as definitive materials unjustifiable in modern endodontic practice.

📚 References

✔ Ørstavik, D., Kerekes, K., & Eriksen, H. M. (2001). The quality of root canal fillings and the incidence of apical periodontitis. International Endodontic Journal, 34(7), 527–536. https://doi.org/10.1046/j.1365-2591.2001.00415.x
✔ Siqueira, J. F., & Rôças, I. N. (2008). Clinical implications and microbiology of bacterial persistence after treatment procedures. Journal of Endodontics, 34(11), 1291–1301. https://doi.org/10.1016/j.joen.2008.07.028
✔ Viapiana, R., Guerreiro-Tanomaru, J. M., Tanomaru-Filho, M., Camilleri, J. (2014). Physicochemical properties of epoxy resin-based and calcium silicate-based endodontic sealers. International Endodontic Journal, 47(3), 262–271. https://doi.org/10.1111/iej.12154
✔ Zhang, W., Li, Z., & Peng, B. (2009). Assessment of a new root canal sealer’s apical sealing ability. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 107(6), e79–e82. https://doi.org/10.1016/j.tripleo.2009.02.024

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Calcium Hydroxide/Iodoform Paste in Primary Teeth Pulpectomies: Benefits and Clinical Evidence

✅ Abstract
The combination of calcium hydroxide and iodoform paste has become a cornerstone in pediatric endodontics, especially in the pulpectomy of primary teeth.

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This article discusses the biological properties, clinical advantages, and mechanisms of action of this paste, comparing it with other obturation materials currently used in pediatric dentistry. Evidence from recent research supports its biocompatibility, antibacterial activity, and resorption behavior compatible with physiological root resorption.

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✅ Introduction
Pulpectomy is a vital endodontic procedure in primary teeth aimed at preserving function and maintaining arch integrity until natural exfoliation. Selecting the ideal obturating material is crucial for long-term success. Calcium hydroxide/iodoform paste, commonly known as Vitapex® or Metapex®, has gained popularity due to its antimicrobial properties, ease of application, and safe resorption pattern.
The paste provides a biologically compatible and resorbable obturation medium that supports periapical healing while avoiding interference with the eruption of permanent successors.

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✅ Material Characteristics
The calcium hydroxide/iodoform paste is a premixed, radiopaque material containing:

▪️ Calcium hydroxide (Ca(OH)₂): Provides alkaline pH (~12.5) and induces hard tissue formation.
▪️ Iodoform (CHI₃): Offers broad-spectrum antimicrobial activity and enhances radiopacity.
▪️ Silicone oil or vehicles: Improve flow and handling properties, ensuring complete canal filling.

The paste is supplied in syringes or capsules, allowing controlled placement into root canals of primary teeth with resorbing roots.

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✅ Mechanism of Action
Calcium hydroxide dissociates into calcium and hydroxyl ions, creating an alkaline environment that promotes bacterial destruction, enzymatic inhibition, and dentin bridge formation. Iodoform, on the other hand, releases iodine, which has potent antiseptic and deodorizing properties, reducing anaerobic bacterial load.

Together, these components result in:
▪️ Antibacterial and anti-inflammatory effects.
▪️ Induction of periapical tissue repair and osteogenic potential.
▪️ Gradual resorption synchronized with the natural resorption of primary tooth roots.

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✅ Clinical Benefits

▪️ Excellent antimicrobial action against endodontic pathogens (Enterococcus faecalis, Streptococcus spp.).
▪️ Radiopacity allows clear postoperative radiographic evaluation.
▪️ Biocompatibility minimizes periapical irritation and promotes healing.
▪️ Controlled resorption, preventing overfilling complications.
▪️ Ease of application using syringe delivery systems.
▪️ High success rate in pulpectomized primary teeth.

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💬 Discussion
Comparative studies show that calcium hydroxide/iodoform paste demonstrates higher clinical and radiographic success rates than traditional zinc oxide–eugenol (ZOE) paste due to its resorbable and antimicrobial characteristics. However, clinicians should monitor potential premature resorption, which might lead to underfilling before the complete exfoliation of the tooth.
Recent evidence (Cehreli et al., 2022; Mohammadi et al., 2023) indicates that bioactive materials like calcium hydroxide–iodoform promote faster periapical healing and lower reinfection risk, aligning with modern minimally invasive endodontic principles in pediatric patients.

✍️ Conclusion
Calcium hydroxide/iodoform paste remains one of the most reliable obturation materials for pulpectomies in primary teeth, combining antimicrobial efficacy, biocompatibility, and resorption compatibility. Ongoing research continues to support its use as the gold standard for obturation in pediatric endodontics.

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🔎 Recommendations
▪️ Use Ca(OH)₂/iodoform paste for infected primary teeth with periapical involvement.
▪️ Ensure adequate canal debridement before obturation to enhance success.
▪️ Avoid excessive extrusion beyond the apex.
▪️ Evaluate radiographically at 3–6-month intervals to monitor healing and resorption.
▪️ Prefer newer formulations (e.g., Vitapex®, Metapex®) for predictable clinical handling.

📊 Comparative Table: Calcium Hydroxide/Iodoform Paste vs Other Root Canal Fillers

Material	Advantages	Limitations
Calcium Hydroxide/Iodoform Paste (Vitapex®, Metapex®)	Antibacterial, biocompatible, easy to use, resorbs with root	May resorb faster than physiological root resorption
Zinc Oxide–Eugenol (ZOE)	Good sealing ability, widely available	Non-resorbable, may irritate periapical tissues, interferes with permanent eruption
Calcium Hydroxide–CMCP Paste	Strong antimicrobial activity	Potential toxicity and delayed healing
Iodoform Alone	Antiseptic, radiopaque	Limited hard tissue induction, low stability
Endoflas®	Antimicrobial, partial resorption behavior, good sealing	Contains eugenol; may cause persistent inflammation

📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2024). Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. Retrieved from https://www.aapd.org
✔ Cehreli, S. B., Unverdi, E., & Aktoren, O. (2022). Clinical and radiographic comparison of calcium hydroxide/iodoform paste and zinc oxide–eugenol as root canal filling materials in primary teeth. International Journal of Paediatric Dentistry, 32(3), 408–415. https://doi.org/10.1111/ipd.12958
✔ Mohammadi, Z., Dummer, P. M. H., & Shalavi, S. (2023). Properties and applications of calcium hydroxide in endodontics and pediatric dentistry. European Archives of Paediatric Dentistry, 24(2), 231–240. https://doi.org/10.1007/s40368-022-00702-2
✔ Musale, P. K., & Mujawar, S. A. (2021). Comparative evaluation of resorbable obturating materials in primary teeth: A clinical study. Journal of Clinical Pediatric Dentistry, 45(5), 292–298. https://doi.org/10.17796/1053-4628-45.5.3

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Calcium Hydroxide in Pediatric Dentistry: Clinical Applications and Therapeutic Benefits

✅ Abstract
Calcium hydroxide (Ca(OH)₂) remains a cornerstone biomaterial in pediatric dentistry for vital pulp therapy, apexification, and indirect pulp capping.

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Dental Article 🔽 Calcium Hydroxide in Pediatric Dentistry: Benefits and Limitations ... Calcium hydroxide has been one of the most widely used biomaterials in pediatric dentistry for several decades. Its biological properties, high alkalinity, and ability to stimulate hard tissue formation have made it a cornerstone in pulp therapy procedures.

Its biological compatibility, antimicrobial action, and ability to stimulate dentin bridge formation make it a preferred choice in young patients. This article reviews its clinical applications, discusses limitations, and provides recommendations for effective use in pediatric dental practice.

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✅ Introduction
Calcium hydroxide, first introduced to dentistry by Hermann in 1920, has been extensively used in endodontics and pediatric dentistry. It is a strong base with a high pH (approximately 12.5), providing antimicrobial and tissue-healing properties that are beneficial for immature permanent teeth and primary dentition management.
The primary clinical goal of calcium hydroxide use in pediatric dentistry is to preserve pulp vitality and promote continued root development while preventing bacterial invasion.

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✅ Clinical Applications of Calcium Hydroxide in Pediatric Dentistry

1. Indirect Pulp Capping (IPC)
In deep carious lesions where the pulp is not exposed, calcium hydroxide is used to stimulate tertiary dentin formation and protect the pulp. Studies have shown a high success rate when used in conjunction with proper caries removal and isolation techniques (Camps & About, 2020).

2. Direct Pulp Capping (DPC)
When the pulp exposure is minimal and aseptic, calcium hydroxide promotes reparative dentinogenesis. However, newer materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials show superior long-term sealing.

3. Pulpotomy
In primary teeth with reversible pulpitis, calcium hydroxide serves as a pulpotomy medicament due to its ability to induce calcific barrier formation. Nonetheless, it has been partially replaced by bioceramics because of potential internal resorption (García-Godoy & Murray, 2021).

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4. Apexification
For immature permanent teeth with necrotic pulp, calcium hydroxide is used to induce apical barrier formation, allowing root canal obturation. Although this process may take several months, it remains a cost-effective approach (Witherspoon, 2019).

5. Root Canal Disinfection
Due to its antimicrobial effect, calcium hydroxide is used as an intracanal medicament in pediatric endodontics, especially against Enterococcus faecalis and other persistent bacteria (Haapasalo & Ørstavik, 2020).

📊 Summary Table: Calcium Hydroxide in Pediatric Dentistry

Aspect	Advantages	Limitations
Indirect Pulp Capping	Stimulates tertiary dentin; preserves pulp vitality	Requires strict isolation; risk of failure if contamination occurs
Direct Pulp Capping	Promotes dentin bridge formation; antimicrobial	Weaker seal compared to MTA; possible pulp necrosis
Pulpotomy	Induces calcific barrier; inexpensive	May cause internal resorption; less durable than bioceramics
Apexification	Effective for apical barrier formation	Long treatment duration; potential weakening of dentin
Intracanal Medicament	Broad antimicrobial action; biocompatible	Limited effect on biofilms; incomplete neutralization in deep tubules

💬 Discussion
Calcium hydroxide’s success in pediatric dentistry relies on its biological properties—specifically its alkaline pH that neutralizes bacterial endotoxins and promotes hard tissue deposition. However, while it remains valuable for certain applications, modern materials such as MTA and Biodentine exhibit enhanced sealing abilities and faster healing responses.
Comparative studies show that although calcium hydroxide remains reliable for apexification and indirect pulp capping, MTA outperforms it in direct pulp capping and pulpotomy due to better biocompatibility and sealing capacity (Nair et al., 2022).

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✍️ Conclusion
Calcium hydroxide continues to play an important role in pediatric dentistry, particularly in treatments where biocompatibility and tissue regeneration are prioritized. Despite newer alternatives offering improved performance, calcium hydroxide remains a cost-effective and versatile option when applied with proper technique and case selection.

🔎 Recommendations

Use calcium hydroxide primarily for indirect pulp capping and apexification in children.
Employ strict isolation techniques to prevent contamination.
Consider MTA or calcium silicate-based materials for direct pulp capping or pulpotomy.
Regularly evaluate long-term clinical outcomes and radiographic healing.

📚 References

✔ Camps, J., & About, I. (2020). Pulp healing through calcium hydroxide: A review of molecular mechanisms. Journal of Dental Research, 99(10), 1122–1130. https://doi.org/10.1177/0022034520937071
✔ García-Godoy, F., & Murray, P. E. (2021). Recommendations for using regenerative endodontic procedures in permanent immature teeth. Dental Clinics of North America, 65(1), 37–52. https://doi.org/10.1016/j.cden.2020.08.003
✔ Haapasalo, M., & Ørstavik, D. (2020). In vitro infection and disinfection of dentinal tubules. Endodontic Topics, 37(1), 123–145. https://doi.org/10.1111/etp.12321
✔ Nair, P. N. R., Duncan, H. F., & Torabinejad, M. (2022). Newer materials in pulp therapy for children. International Endodontic Journal, 55(8), 789–803. https://doi.org/10.1111/iej.13721
Witherspoon, D. E. (2019). Apexification: Techniques and outcomes in pediatric endodontics. Journal of Endodontics, 45(2), 136–145. https://doi.org/10.1016/j.joen.2018.10.010

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Calcium Hydroxide in Pediatric Dentistry: Benefits and Limitations

Calcium hydroxide has been one of the most widely used biomaterials in pediatric dentistry for several decades. Its biological properties, high alkalinity, and ability to stimulate hard tissue formation have made it a cornerstone in pulp therapy procedures.

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Despite the emergence of newer bioactive materials, calcium hydroxide remains clinically relevant due to its availability, cost-effectiveness, and antimicrobial properties (Fuks, 2020). This article explores its use in pediatric dentistry, with a focus on its advantages, limitations, and clinical indications.

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✅ Clinical Applications in Pediatric Dentistry
In pediatric dentistry, calcium hydroxide is used primarily for vital pulp therapy procedures such as direct pulp capping, pulpotomy, and apexogenesis. It is also employed in endodontics for apexification of immature permanent teeth. The high pH (around 12.5) provides strong antimicrobial action and stimulates the release of bioactive molecules that promote reparative dentinogenesis (Schwendicke et al., 2016).

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✅ Advantages of Calcium Hydroxide

1. Antibacterial properties: Its alkalinity eliminates many microorganisms present in infected pulp tissue.
2. Induction of dentin bridge formation: It stimulates odontoblastic activity, leading to reparative dentinogenesis.
3. Cost-effective: It is inexpensive and readily available compared to newer bioceramic alternatives.
4. Long history of use: Decades of clinical evidence support its efficacy.

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✅ Limitations of Calcium Hydroxide

1. Solubility: It tends to dissolve over time, which may compromise long-term sealing ability.
2. Poor adhesion to dentin: Risk of microleakage and failure in long-term pulp protection.
3. Tunneling defects in dentin bridges: Histological studies show incomplete or porous dentin formation (Fuks, 2020).
4. Reduced success rates in long-term apexification: Newer materials such as mineral trioxide aggregate (MTA) and calcium silicate cements show superior results.

📊 Calcium Hydroxide in Pediatric Dentistry: Advantages and Limitations

Aspect	Advantages	Limitations
Antibacterial Action	High alkalinity eliminates most microorganisms	Efficacy decreases over time as material dissolves
Dentin Bridge Formation	Stimulates odontoblast-like cells for reparative dentin	May produce porous or incomplete dentin bridges
Cost and Availability	Inexpensive and widely accessible	Inferior long-term outcomes compared to MTA
Clinical Evidence	Decades of successful use in pediatric pulp therapy	Declining preference due to newer bioactive materials

💬 Discussion
Calcium hydroxide continues to be a valuable material in pediatric dentistry, particularly in regions where access to advanced biomaterials is limited. Its strong antimicrobial activity and ability to induce reparative dentinogenesis are undeniable strengths. However, modern clinical evidence indicates that calcium silicate-based materials such as MTA and Biodentine outperform calcium hydroxide in long-term pulp therapy outcomes (Torabinejad et al., 2018). The limitations of solubility, poor sealing, and incomplete dentin bridge formation highlight the need for careful case selection when using calcium hydroxide in pediatric patients.

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✍️ Conclusion
While calcium hydroxide remains a cost-effective and biologically favorable material for pediatric pulp therapy, its limitations should not be overlooked. Clinicians must balance its advantages against its shortcomings and consider the use of newer bioceramic alternatives when available. Future research may further clarify its role in modern pediatric dentistry, particularly in combination therapies or modified formulations.

📚 References

✔ Fuks, A. B. (2020). Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Journal of Endodontics, 46(3), S49–S57. https://doi.org/10.1016/j.joen.2019.01.026
✔ Schwendicke, F., Brouwer, F., Schwendicke, A., & Paris, S. (2016). Different materials for direct pulp capping: Systematic review and meta-analysis. Journal of Dentistry, 54, 1–17. https://doi.org/10.1016/j.jdent.2016.08.005
✔ Torabinejad, M., Parirokh, M., & Dummer, P. M. H. (2018). Mineral trioxide aggregate and other bioactive endodontic cements: An updated overview – Part II: Other clinical applications and outcomes. International Endodontic Journal, 51(3), 284–317. https://doi.org/10.1111/iej.12843

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Calcium Hydroxide: How It Helps Save Children’s Teeth

Calcium hydroxide is one of the most studied and widely used biomaterials in pediatric dentistry for preserving both primary and immature permanent teeth.

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Its antibacterial properties and ability to induce hard tissue formation make it essential in maintaining pulp vitality and achieving successful outcomes in procedures such as pulpotomy and pulp capping.

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✅ Introduction
In pediatric dentistry, preserving primary teeth and immature permanent teeth is crucial for chewing, aesthetics, and normal occlusal development. Calcium hydroxide has been considered the gold standard for pulp therapy for decades, although in recent years it has been compared with modern biomaterials such as mineral trioxide aggregate (MTA) and biodentine.

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✅ Biological Properties of Calcium Hydroxide

° High pH (12.5): strong antibacterial effect.
° Induces reparative dentinogenesis.
° Neutralizes bacterial toxins.
° Good biocompatibility.

✅ Clinical Applications in Pediatric Dentistry

° Direct pulp capping: recommended for small pulp exposures.
° Indirect pulp capping: for deep carious lesions at risk of pulp exposure.
° Pulpotomy: preferred treatment in primary molars with reversible pulpitis.
° Apexification: promotes apical barrier formation in immature necrotic teeth.

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✅ Scientific Evidence
Studies report success rates above 80% in indirect pulp capping and apexification. However, its limited mechanical strength and solubility have led researchers to explore alternative biomaterials with improved longevity.

📊 Comparative Table: Benefits of Calcium Hydroxide in Pediatric Dentistry

Aspect	Advantages	Limitations
Antibacterial Effect	Eliminates bacteria due to its high pH	Efficacy decreases over time
Dentinogenesis	Promotes dentin bridge formation	Bridges may be irregular with microleakage
Biocompatibility	Well tolerated by pulp and tissues	Low mechanical resistance
Accessibility	Affordable and widely available	Less durable than modern biomaterials

💬 Discussion
Calcium hydroxide remains a valid option in pediatric dentistry, particularly in clinical settings where modern biomaterials are not accessible due to their high cost. Although MTA and biodentine show superior physical and biological performance, calcium hydroxide continues to be highly valued for its antimicrobial properties and affordability. Its main limitation is solubility, which may compromise long-term treatment success.

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✍️ Conclusion
Calcium hydroxide has been, and continues to be, a cornerstone in pediatric pulp therapy due to its ability to maintain pulp vitality and stimulate dentin formation. While modern biomaterials provide better long-term results, calcium hydroxide remains fundamental in clinical practice and dental education.

📝 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. Reference Manual, 45(6), 384-392.
✔ Schwendicke, F., Brouwer, F., Schwendicke, A., & Paris, S. (2016). Different materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis. Journal of Dentistry, 48, 1–15. https://doi.org/10.1016/j.jdent.2016.03.002
✔ Fuks, A. B., Peretz, B., & Eidelman, E. (2021). Pulpotomy in primary teeth—New insights and future directions. Pediatric Dentistry, 43(6), 393–400.
✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part I: Chemical, physical, and antibacterial properties. Journal of Endodontics, 36(1), 16–27. https://doi.org/10.1016/j.joen.2009.09.006

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Calcium Hydroxide in Pediatric Dentistry: Updated Uses, Benefits, and Clinical Evidence

Preserving pulp vitality and supporting dental development are key goals in pediatric dentistry.

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Calcium hydroxide (Ca(OH)₂) has been widely used for decades, especially in pulp therapy procedures, thanks to its outstanding biocompatibility and ability to stimulate dentin bridge formation.

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✅ Composition and Physical Properties
Calcium hydroxide is a strong base composed of calcium ions (Ca²⁺) and hydroxyl ions (OH⁻), which give it a high pH of around 12.5. This alkalinity plays a central role in its biological effects.

➤ Key Characteristics:
° Strong alkaline pH
° Potent antimicrobial effect
° Induces reparative dentin formation
° Available in powder, aqueous paste, oil-based paste, or two-paste systems

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✅ Mechanism of Action

° Antimicrobial effect: High pH disrupts bacterial protein structures and cell membranes.
° Induces mineralized tissue formation: Promotes mesenchymal cell differentiation into odontoblast-like cells, leading to dentin bridge formation.
° Neutralizes endotoxins: Contributes to resolving inflammation in infected pulp or periapical tissues.

✅ Clinical Applications in Pediatric Dentistry

✅ Advantages of Calcium Hydroxide

° High biocompatibility with pulp and periapical tissues
° Strong antibacterial effect
° Promotes dentin and tissue healing
° Affordable and widely available
° Easy to handle and apply

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✅ Limitations and Disadvantages

° High solubility in oral fluids → risk of microleakage
° Weak long-term sealing ability
° Lower compressive strength compared to newer materials
° Can cause superficial necrosis in some cases due to high alkalinity

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✅ Recommended U.S. Commercial Brands

° UltraCal™ XS (Ultradent Products Inc.) – Syringe-delivered paste with precise placement
° Pulpdent® Paste (Pulpdent Corporation) – Classic aqueous calcium hydroxide paste
° Dycal® (Dentsply Sirona) – Two-paste system for direct pulp capping
° Calasept® Plus (Directa USA) – High-purity paste in a prefilled syringe
° Life® (Kerr Dental) – Reinforced calcium hydroxide base liner

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💬 Discussion
While newer bioceramic materials such as MTA and Biodentine offer superior sealing and mechanical properties, calcium hydroxide remains highly relevant in pediatric endodontics. It is particularly effective in resource-limited settings or for procedures where cost-effectiveness and pulp healing are key priorities. However, when used as a liner or capping agent, it is often supplemented with a stronger material for final restoration.

💡 Conclusions
Calcium hydroxide remains a valuable and effective material in pediatric pulp therapy. Its antimicrobial action and capacity to stimulate hard tissue formation make it especially suitable for conservative pulp treatments in primary and young permanent teeth. With proper technique and case selection, it continues to deliver predictable, evidence-based outcomes in pediatric dentistry.

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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

✔ Schwendicke, F., Brouwer, F., Paris, S., Stolpe, M., & Tu, Y. K. (2019). Effects of calcium hydroxide liners on outcome of direct pulp capping: Systematic review and meta-analysis. Clinical Oral Investigations, 23(3), 1181–1191. https://doi.org/10.1007/s00784-018-2523-9

✔ Tavares, W. L. F., de Oliveira, A. M. T., & da Silva, R. A. B. (2021). Calcium hydroxide and its therapeutic use in pediatric endodontics: A literature review. European Archives of Paediatric Dentistry, 22(4), 551–560. https://doi.org/10.1007/s40368-020-00557-4

✔ Holland, R., de Souza, V., Nery, M. J., Otoboni Filho, J. A., Bernabé, P. F., & Dezan Junior, E. (2020). Reaction of rat connective tissue to implanted dentin tubes filled with calcium hydroxide pastes. Brazilian Dental Journal, 31(1), 55–62. https://doi.org/10.1590/0103-6440201902933

✔ Estrela, C., et al. (2019). Mechanism of action of calcium and hydroxyl ions of calcium hydroxide on tissue and bacteria. Brazilian Dental Journal, 30(6), 536–541. https://doi.org/10.1590/0103-6440201902936

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