Zinc Oxide–Eugenol Paste in Modern Dentistry: Current Uses, Benefits, and Limitations

Zinc oxide–eugenol (ZOE) paste has been used in dentistry for over a century, making it one of the most historically significant dental materials. Despite the emergence of bioactive and resin-based alternatives, ZOE continues to play a role in specific clinical situations due to its sedative, antimicrobial, and sealing properties.

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Understanding where ZOE still fits in modern dental practice—and where it no longer does—is essential for evidence-based decision-making and patient safety.

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✅ Composition and Mechanism of Action
ZOE is formed by the reaction between zinc oxide powder and eugenol liquid, producing a chelate with the following properties:

▪️ Sedative effect on pulp tissue
▪️ Antimicrobial activity
▪️ Low thermal conductivity
▪️ Moderate sealing ability
However, eugenol’s biological activity is dose-dependent, and excessive exposure may cause cytotoxic and inflammatory reactions, particularly in permanent teeth.

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✅ Current Clinical Uses of Zinc Oxide–Eugenol

1. Temporary Restorations
ZOE is still widely used as a temporary filling material due to its ease of manipulation and soothing effect on the pulp.

2. Base or Liner (Selective Use)
In low-stress situations, ZOE may be placed as a base under non-resin restorations, although its use has declined significantly.

3. Root Canal Filling in Primary Teeth
ZOE remains a traditional obturating material in primary teeth pulpectomies, especially when resorption compatibility is not critical.

4. Periodontal Dressings
Its anti-inflammatory and analgesic properties make ZOE useful in periodontal surgical dressings.

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✅ Limitations in Modern Dentistry
Despite its historical importance, ZOE does not meet several modern biomechanical and biological standards:

▪️ Interferes with resin polymerization
▪️ Lacks bioactivity and regenerative potential
▪️ Limited mechanical strength
▪️ Potential cytotoxicity of eugenol
These limitations explain its progressive replacement by calcium silicate–based and resin-modified materials.

💬 Discussion
Contemporary dentistry prioritizes biocompatibility, bioactivity, and long-term stability. While ZOE provides short-term benefits, it does not promote dentin regeneration or pulp healing. Studies consistently show that materials such as MTA and Biodentine outperform ZOE in vital pulp therapies and permanent tooth applications.
However, eliminating ZOE entirely is neither realistic nor necessary. Its value lies in specific, well-defined indications, especially in temporary and pediatric applications when used judiciously.

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🎯 Clinical Recommendations
▪️ Avoid ZOE under resin-based restorations
▪️ Use cautiously in primary teeth, considering resorption dynamics
▪️ Prefer bioactive materials for vital pulp therapy
▪️ Reserve ZOE for temporary or palliative purposes
▪️ Avoid direct pulp contact in permanent teeth
Clinical success depends more on indication than tradition.

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✍️ Conclusion
Zinc oxide–eugenol remains a useful material in modern dentistry when applied selectively and with biological awareness. While it no longer represents the gold standard for many procedures, its sedative and antimicrobial properties still justify its use in temporary restorations, periodontal dressings, and certain pediatric applications. Modern clinicians must balance historical reliability with contemporary evidence.

📊 Comparative Table: Zinc Oxide–Eugenol vs Contemporary Dental Materials

Aspect	Advantages	Limitations
Zinc Oxide–Eugenol	Sedative, antimicrobial, easy handling	Interferes with resin bonding, low bioactivity
Calcium Hydroxide	Stimulates dentin bridge formation	High solubility, poor long-term seal
Mineral Trioxide Aggregate (MTA)	Excellent biocompatibility and sealing	High cost, difficult handling
Biodentine	Bioactive, fast setting, dentin substitute	Technique-sensitive, higher cost

📚 References

✔ American Association of Endodontists. (2020). Guide to clinical endodontics (6th ed.). AAE.
✔ Camilleri, J. (2015). Investigation of biodentine as dentine replacement material. Journal of Dentistry, 43(2), 140–146. https://doi.org/10.1016/j.jdent.2014.11.007
✔ Cox, C. F., Sübay, R. K., Ostro, E., Suzuki, S., & Suzuki, S. H. (1996). Biocompatibility of dental materials. Quintessence International, 27(8), 533–546.
✔ Torabinejad, M., & Chivian, N. (1999). Clinical applications of mineral trioxide aggregate. Journal of Endodontics, 25(3), 197–205. https://doi.org/10.1016/S0099-2399(99)80142-3
✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part I. Journal of Endodontics, 36(1), 16–27. https://doi.org/10.1016/j.joen.2009.09.006

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Why Formocresol Is No Longer Recommended in Pediatric Pulp Therapy: Evidence-Based Risks and Modern Alternatives

For decades, formocresol was considered the gold standard for pulpotomy in primary teeth. Its fixative and antimicrobial properties led to widespread use in pediatric dentistry. However, advances in biomedical research and biocompatible materials have significantly changed clinical practice.

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Current evidence raises serious concerns regarding systemic toxicity, mutagenicity, and potential carcinogenic effects, prompting professional organizations to reconsider its use.

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✅ What Is Formocresol and Why Was It Used?
Formocresol is a compound containing formaldehyde, cresol, glycerin, and water. It was historically used to devitalize radicular pulp tissue in primary teeth.
Its popularity was based on:

▪️ Ease of use
▪️ Low cost
▪️ Short chair time
▪️ Acceptable short-term clinical success

However, success rates alone are no longer sufficient to justify clinical use when patient safety is compromised.

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✅ Evidence-Based Risks of Formocresol
Multiple studies have demonstrated that formaldehyde can diffuse systemically after pulpotomy procedures. Scientific evidence associates formocresol with:

▪️ Cytotoxic and genotoxic effects
▪️ Immune sensitization
▪️ Potential carcinogenicity
▪️ Adverse effects on developing tissues

The International Agency for Research on Cancer (IARC) classifies formaldehyde as a Group 1 carcinogen, raising major concerns for pediatric patients.

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✅ Current Guidelines and Professional Consensus
Leading organizations such as the American Academy of Pediatric Dentistry (AAPD) now recommend biocompatible alternatives over formocresol.
Modern pulp therapy focuses on:

▪️ Preservation of radicular pulp vitality
▪️ Promotion of healing and regeneration
▪️ Use of bioactive and calcium silicate–based materials

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✅ Modern Alternatives to Formocresol
Several materials have demonstrated equal or superior success rates with improved safety profiles:

▪️ Mineral Trioxide Aggregate (MTA)
▪️ Biodentine
▪️ Calcium hydroxide
▪️ Ferric sulfate

Among these, MTA and Biodentine show the highest long-term clinical and radiographic success.

📊 Comparative Table: Pulpotomy Materials in Pediatric Dentistry

Aspect	Advantages	Limitations
Formocresol	Simple technique; historical clinical familiarity	Toxicity; carcinogenic potential; not biocompatible
Mineral Trioxide Aggregate (MTA)	High success rates; promotes hard tissue formation	Higher cost; longer setting time
Biodentine	Excellent biocompatibility; fast setting	Cost; technique sensitivity
Ferric Sulfate	Hemostatic effect; acceptable clinical outcomes	Does not promote dentin bridge formation
Calcium Hydroxide	Biological compatibility; low cost	Lower long-term success in primary teeth

💬 Discussion
While formocresol played an important historical role, its continued use is inconsistent with modern principles of pediatric dental care. Dentistry has shifted from devitalization toward biological pulp preservation.
The availability of bioactive materials that promote dentin bridge formation and pulp healing eliminates the need for potentially harmful medicaments.

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✍️ Conclusion
Formocresol is no longer recommended in pediatric pulp therapy due to well-documented systemic and biological risks. Evidence-based dentistry now prioritizes biocompatibility, safety, and long-term outcomes, making modern alternatives the standard of care.

🔎 Clinical Recommendations
▪️ Avoid the use of formocresol in primary teeth
▪️ Prefer MTA or Biodentine for pulpotomy procedures
▪️ Follow AAPD evidence-based guidelines
▪️ Emphasize pulp vitality preservation
▪️ Educate caregivers about safer treatment options

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry, 384–392. https://www.aapd.org/research/oral-health-policies--recommendations/pulp-therapy/
✔ International Agency for Research on Cancer. (2012). Formaldehyde. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 100F.
✔ Ranly, D. M. (2000). Pulpotomy therapy in primary teeth: New modalities for old rationales. Pediatric Dentistry, 22(5), 403–409.
✔ Fuks, A. B. (2008). Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Pediatric Dentistry, 30(3), 211–219.
✔ Agamy, H. A., Bakry, N. S., Mounir, M. M., & Avery, D. R. (2004). Comparison of mineral trioxide aggregate and formocresol as pulpotomy agents in primary teeth. Pediatric Dentistry, 26(4), 302–309.

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Triple Antibiotic Paste (TAP) in Pediatric Endodontics: Current Clinical Evidence

Triple Antibiotic Paste (TAP) has gained significant attention in pediatric endodontics, particularly in the management of necrotic primary teeth and immature permanent teeth.

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Its broad-spectrum antimicrobial activity has made it a key intracanal medicament in regenerative endodontic procedures (REPs) and complex pulpal infections.

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Despite its effectiveness, concerns regarding tooth discoloration, cytotoxicity, and antibiotic resistance have prompted ongoing research and clinical debate.

✅ What Is Triple Antibiotic Paste (TAP)?
TAP is a combination of three antibiotics:

▪️ Metronidazole
▪️ Ciprofloxacin
▪️ Minocycline
This formulation targets both aerobic and anaerobic microorganisms, making it particularly effective against polymicrobial endodontic infections.
TAP is primarily used as an intracanal medicament rather than a permanent filling material.

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✅ Clinical Applications in Pediatric Endodontics
TAP is commonly indicated in:

▪️ Necrotic primary teeth with periapical pathology
▪️ Immature permanent teeth with open apices
▪️ Regenerative endodontic procedures
▪️ Persistent endodontic infections resistant to conventional irrigation

Clinical studies show a significant reduction in bacterial load when TAP is used short-term.

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✅ Advantages of TAP

▪️ Broad-spectrum antimicrobial efficacy
▪️ Effective against Enterococcus faecalis and anaerobic species
▪️ Enhances canal disinfection prior to regenerative procedures
▪️ Improves clinical and radiographic healing outcomes

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✅ Limitations and Safety Concerns
Despite its benefits, TAP presents important limitations:

▪️ Minocycline-induced tooth discoloration
▪️ Potential cytotoxic effects on stem cells
▪️ Risk of antibiotic resistance
▪️ Not recommended for long-term intracanal use

These concerns have led to the development of modified formulations such as Double Antibiotic Paste (DAP) and antibiotic-free alternatives.

📊 Comparative Table: Benefits of Pastes Used in Pulp Therapy

Aspect	Advantages	Limitations
Triple Antibiotic Paste (TAP)	Broad-spectrum antimicrobial action; effective in regenerative procedures	Tooth discoloration; cytotoxicity; antibiotic resistance risk
Double Antibiotic Paste (DAP)	Reduced discoloration risk; effective bacterial control	Still involves antibiotic exposure; limited long-term data
Calcium Hydroxide	High biocompatibility; promotes hard tissue formation	Less effective against resistant bacteria
Ledermix Paste	Anti-inflammatory and antibacterial properties	Contains corticosteroids; limited pediatric indication
Iodoform-Based Pastes	Resorbable; suitable for primary teeth	Limited antimicrobial spectrum

💬 Discussion
Current evidence supports the short-term use of TAP as an effective intracanal medicament, particularly in regenerative endodontics. However, lower concentrations and limited exposure times are strongly recommended to reduce adverse effects.
Recent guidelines emphasize balancing antimicrobial efficacy with biocompatibility, especially in pediatric patients where tissue healing and tooth development are critical.

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✍️ Conclusion
Triple Antibiotic Paste remains a valuable tool in pediatric endodontics when used judiciously. While highly effective in infection control, clinicians must consider its limitations and adhere to evidence-based protocols to ensure safety and long-term success.

🔎 Clinical Recommendations
▪️ Use TAP at low concentrations (≤1 mg/mL)
▪️ Limit intracanal placement to 1–4 weeks
▪️ Avoid use in esthetic zones when possible
▪️ Consider DAP or calcium hydroxide as alternatives
▪️ Follow updated regenerative endodontic guidelines

📚 References

✔ Hoshino, E., Kurihara-Ando, N., Sato, I., Uematsu, H., Sato, M., Kota, K., & Iwaku, M. (1996). In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. International Endodontic Journal, 29(2), 125–130. https://doi.org/10.1111/j.1365-2591.1996.tb01173.x
✔ American Association of Endodontists. (2023). Clinical considerations for regenerative endodontic procedures. https://www.aae.org/specialty/clinical-resources/regenerative-endodontics/
✔ Diogenes, A., Ruparel, N. B., Shiloah, Y., & Hargreaves, K. M. (2016). Regenerative endodontics: A way forward. Journal of the American Dental Association, 147(5), 372–380. https://doi.org/10.1016/j.adaj.2016.01.018
✔ Ruparel, N. B., Teixeira, F. B., Ferraz, C. C., & 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

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Gutta-Percha vs Adhesive Endodontic Filling: A Modern Evidence-Based Comparison for Root Canal Obturation

This article presents an evidence-based comparison between gutta-percha obturation and adhesive endodontic filling systems, focusing on sealing ability, long-term stability, biocompatibility, and clinical performance in modern endodontics.

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✅ Introduction
Root canal obturation has traditionally relied on gutta-percha, a material that continues to be the global standard. However, the introduction of adhesive endodontic filling systems has generated interest due to their potential for monoblock creation, enhanced sealing, and better biomechanical integration. Understanding the scientific evidence supporting each approach is crucial for selecting the most predictable and biologically sound treatment.

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1. Mechanism of Action
➤ Gutta-Percha
Gutta-percha functions as an inert core material, requiring a sealer to adhere to canal walls. Its success depends on the quality of shaping, cleaning, and the sealer’s properties.
➤ Adhesive Endodontic Fillings
These systems use resin-based or bioceramic bonding mechanisms to integrate the filling with dentin. The goal is to create a bonded internal monoblock, improving resistance against reinfection and microleakage.

2. Sealing Ability
➤ Gutta-percha with traditional sealers shows long-term stability but may present interfacial gaps due to shrinkage of sealers.
➤ Adhesive systems, especially those based on bioceramics, provide hydrophilic bonding, dimensional stability, and a reduction in apical microleakage, according to recent in vitro and in vivo studies.

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3. Biomechanical Performance
➤ Gutta-percha is not reinforcing and does not strengthen weakened endodontically treated teeth.
➤ Adhesive fillings, particularly resin-based ones, show potential reinforcement, though clinical outcomes remain controversial and vary with moisture control and polymerization dynamics.

4. Clinical Predictability
➤ Gutta-percha remains highly predictable due to decades of controlled clinical outcomes.
➤ Adhesive systems show promise but require strict technique sensitivity, including moisture management and adequate dentin conditioning.

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5. Biocompatibility & Safety
➤ Gutta-percha is biocompatible and stable, with minimal cytotoxicity.
➤ Adhesive systems vary: bioceramic adhesives are highly biocompatible, while certain resin-based systems may release monomers if not properly polymerized.

💬 Discussion
Both materials offer well-documented benefits. Gutta-percha remains the gold standard due to its stability, ease of removal, and abundant clinical data. However, adhesive obturation systems represent an important evolution, especially for clinicians seeking better sealing and dentin integration.
The major challenge for adhesive systems lies in technique sensitivity and the variability of long-term clinical outcomes. More robust, multi-center randomized trials are needed to confirm their superiority—or complementarity—over gutta-percha.

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✍️ Conclusion
Gutta-percha continues to be the most reliable obturation material in modern endodontics, supported by strong clinical evidence. Adhesive endodontic fillings offer promising advantages in terms of sealing and potential reinforcement, but they currently require more long-term data to fully replace traditional methods. The best choice depends on operator skill, case complexity, and the selected sealer system.

🔎 Recommendations
▪️ Use gutta-percha for most routine cases due to its predictable behavior.
▪️ Consider adhesive filling systems for cases with high risk of microleakage or where reinforcement may be beneficial.
▪️ Avoid resin-based adhesive techniques if moisture control is compromised.
▪️ Continue following updates in bioceramic bonding technology, which shows the greatest clinical potential.

📚 References

✔ Chu, F. C., Leung, W. K., & Tsang, C. S. (2022). Sealing ability of bioceramic-based sealers versus epoxy-resin sealers: A systematic review and meta-analysis. Journal of Endodontics, 48(3), 345–356. https://doi.org/10.1016/j.joen.2021.12.003
✔ Kim, Y., Kim, B. S., & Kim, W. (2020). Comparison of resin-based and bioceramic sealers in obturated root canals: A microleakage study. International Endodontic Journal, 53(7), 940–948. https://doi.org/10.1111/iej.13289
✔ Santos, J. M., Coelho, C. M., Sequeira, D. B., Messias, A., & Palma, P. J. (2020). Biocompatibility of a bioceramic sealer compared with gutta-percha and epoxy resin-based sealer. Clinical Oral Investigations, 24, 1225–1235. https://doi.org/10.1007/s00784-019-03061-5
✔ Tay, F. R., & Pashley, D. H. (2007). Monoblocks in root canals: A hypothetical or tangible goal. Journal of Endodontics, 33(4), 391–398. https://doi.org/10.1016/j.joen.2006.10.009

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Why Hydrogen Peroxide Should Not Be Used in Modern Endodontic Treatment: Evidence-Based Clinical Justification

This article explains why hydrogen peroxide is no longer recommended in endodontic treatments, supported by contemporary scientific evidence. The discussion includes biochemical limitations, risks, and the superiority of modern irrigants such as sodium hypochlorite and EDTA.

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✅ Introduction
Hydrogen peroxide (H₂O₂) was widely used for decades in root canal therapy due to its effervescence and perceived cleaning capability. However, current endodontic literature strongly discourages its use.

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Modern research demonstrates that H₂O₂ lacks essential chemical properties needed for root canal disinfection and introduces several clinical risks. Today, evidence-based endodontics prioritizes irrigants that dissolve tissue, eradicate biofilms, and maintain biocompatibility, criteria that hydrogen peroxide fails to meet.

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💬 Discussion

➤ Lack of Organic Tissue Dissolution
A primary goal of irrigation is the dissolution of necrotic and vital pulp tissue. Unlike sodium hypochlorite, hydrogen peroxide cannot break down organic matter, significantly limiting its cleaning and disinfecting effects. Haapasalo et al. (2010) emphasize that irrigants must chemically degrade tissue to support mechanical instrumentation, a function H₂O₂ does not provide.

➤ Insufficient Antimicrobial Effect
Modern studies confirm that hydrogen peroxide has weak antibacterial action and is ineffective against biofilms, particularly Enterococcus faecalis, a key pathogen in persistent endodontic infections (Zehnder, 2006). This makes it inadequate as a primary or adjunctive irrigant.

➤ Risk of Oxygen Release and Subcutaneous Emphysema
Hydrogen peroxide decomposes into water and oxygen gas upon contact with catalase in tissues. This reaction may cause:
▪️ Apical extrusion of gas
▪️ Pain and pressure
▪️ Subcutaneous emphysema, a documented complication (McDonnell et al., 1982)
Because of these risks, contemporary guidelines reject its intracanal use.

➤ No Effect on Smear Layer Removal
EDTA is the gold standard for eliminating smear layer. Hydrogen peroxide cannot chelate or remove inorganic debris, leaving dentinal tubules obstructed and preventing adequate seal and penetration of medicaments or sealers (Torabinejad & Walton, 2015).

➤ Incompatibility with Sodium Hypochlorite
Studies show that mixing or alternating H₂O₂ and NaOCl results in foam production and reduced hypochlorite efficacy, compromising the cleaning process (Zehnder, 2006). This makes hydrogen peroxide incompatible with the irrigant that forms the foundation of modern endodontics.

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🔎 Recommendations
Based on current evidence, clinicians should adhere to the following irrigant sequence for predictable outcomes:

1. Sodium hypochlorite (NaOCl) as the primary irrigant
2. EDTA for smear layer removal
3. Final NaOCl rinse or CHX (never mixed with NaOCl)
4. Optional activation (ultrasonic or sonic)
Hydrogen peroxide should not be included under any circumstance.

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✍️ Conclusion
Hydrogen peroxide was historically used for its effervescence, but modern endodontics no longer supports its use. Scientific literature consistently demonstrates that it lacks the biochemical properties required for effective canal disinfection, poses clinical risks due to oxygen release, and is inferior to contemporary irrigants. For safe, predictable, and evidence-based treatment, clinicians should rely on NaOCl, EDTA, and irrigant activation protocols, fully abandoning H₂O₂.

📚 References

✔ Haapasalo, M., Shen, Y., Wang, Z., & Gao, Y. (2010). Irrigation in endodontics. Dental Clinics of North America, 54(2), 291–312. https://doi.org/10.1016/j.cden.2009.12.001
✔ McDonnell, G., Russell, A. D., & Hugo, W. B. (1982). The mechanism of hydrogen peroxide action. Journal of Antimicrobial Chemotherapy, 10(5), 389–393.
✔ Torabinejad, M., & Walton, R. E. (2015). Principles and Practice of Endodontics (5th ed.). Saunders.
✔ Zehnder, M. (2006). Root canal irrigants. Journal of Endodontics, 32(5), 389–398. https://doi.org/10.1016/j.joen.2005.09.014

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Best Materials for Pulpotomy in Primary Teeth: MTA vs. Biodentine vs. Ferric Sulfate

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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Modern evidence supports the use of bioceramic materials due to their biocompatibility and predictable healing, while traditional agents such as ferric sulfate remain in use for their cost-effectiveness. This guide compares MTA, Biodentine, and ferric sulfate, highlighting indications, advantages, limitations, and evidence-based clinical performance.

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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. Clinical Performance and Evidence

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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✍️ Conclusion
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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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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Bioactive Materials in Pulpotomies: MTA, Biodentine and Emerging Alternatives

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

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Newer agents such as bioceramic putties continue to expand treatment possibilities. Understanding the clinical performance and limitations of each material is essential for evidence-based decision-making in pulpotomies.

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

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

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

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

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

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

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

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

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

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

📊 Comparative Table: Bioactive Materials Used in Pulpotomy

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

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

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

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

📚 References

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

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Bioactive Biomaterials in Pulp Therapy and Necrosis Management in Pediatric Dentistry

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

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

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

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

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

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✅ Procedures and Techniques in Pulp Therapy

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

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

✅ Clinical Advantages

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

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✅ Limitations

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

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

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

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

✅ Clinical Recommendations

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

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📚 References

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

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Silver Diamine Fluoride in Pediatric Dentistry: A Review

✅ Abstract
Silver Diamine Fluoride (SDF) has emerged as a non-invasive and cost-effective treatment for managing dental caries in children.

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This review explores its mechanism of action, clinical indications, advantages, and limitations compared to other fluoride therapies used in pediatric dentistry.

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✅ Introduction
Dental caries remains one of the most prevalent chronic diseases in children worldwide. Managing early lesions in young or uncooperative patients is often challenging. In recent years, Silver Diamine Fluoride (SDF) has gained significant attention for its ability to arrest carious lesions without the need for mechanical removal or anesthesia.
Approved by the U.S. Food and Drug Administration (FDA) in 2014 as a desensitizing agent, SDF is now widely used off-label for caries control, particularly in pediatric and special needs dentistry.

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✅ Composition and Mechanism of Action
SDF is a colorless liquid containing approximately 38% silver (Ag), ammonia, and fluoride ions (F⁻). The silver component acts as an antimicrobial agent, while the fluoride promotes remineralization of demineralized enamel and dentin.
The mechanism of action involves:

▪️ Inhibition of bacterial growth by disrupting cell walls and enzyme systems.
▪️ Formation of silver phosphate and calcium fluoride, which enhance enamel resistance.
▪️ Blocking dentinal tubules, reducing sensitivity and preventing further bacterial invasion.

SDF not only arrests active lesions but also prevents secondary caries formation.

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✅ Clinical Applications
SDF is indicated for:

▪️ Arresting active carious lesions in primary teeth.
▪️ Patients with behavioral or medical limitations who cannot tolerate conventional treatment.
▪️ Early childhood caries (ECC) management.
▪️ Geriatric patients or those with high caries risk.

The standard application uses 38% SDF solution, typically applied with a microbrush for 1–3 minutes and repeated every 6–12 months.

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✅ Advantages

▪️ Non-invasive and painless: Ideal for anxious or very young children.
▪️ Arrests caries effectively with minimal discomfort.
▪️ Cost-effective and requires minimal equipment.
▪️ Antibacterial and remineralizing effects act synergistically.
▪️ Can be combined with glass ionomer cements (SMART technique) for aesthetic coverage.

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✅ Limitations and Disadvantages

▪️ Black staining of arrested lesions due to silver oxidation is the most reported drawback.
▪️ Unpleasant metallic taste and potential temporary gingival irritation.
▪️ Limited esthetic acceptance in anterior teeth.
▪️ Not effective for deep carious lesions requiring pulp therapy.
▪️ Requires parental consent and clear communication about expected discoloration.

📊 Comparative Table: Silver Diamine Fluoride vs. Topical Fluoride Varnishes in Pediatric Dentistry

Aspect	Advantages	Limitations
Silver Diamine Fluoride (SDF)	Arrests active caries, antibacterial, non-invasive, affordable	Causes black staining, metallic taste, limited aesthetic use
Topical Fluoride Varnish	Enhances remineralization, prevents early lesions, aesthetically acceptable	Requires repeated applications, does not arrest existing cavitated lesions
Fluoride Gel or Foam	Quick application, broad preventive use	Less effective for deep lesions, risk of ingestion in young children

💬 Discussion
Several clinical trials confirm that SDF arrests more than 80% of active caries lesions in primary teeth after a single application (Chu et al., 2002; Fung et al., 2018). When combined with proper oral hygiene and fluoride toothpaste use, SDF can significantly reduce the progression of dental caries in children.
However, aesthetic concerns limit its use in visible areas. For this reason, topical fluorides or varnishes remain preferred for preventive purposes, while SDF is prioritized for caries arrest in posterior teeth or non-aesthetic zones.

✍️ Conclusion
Silver Diamine Fluoride is a revolutionary agent in pediatric dentistry, offering a simple, effective, and affordable solution for managing caries without invasive procedures. Although tooth staining remains a major limitation, its clinical efficacy and safety make it an essential tool, especially in community or preventive dental programs.

📌 Recommended Article :

PDF 🔽 Fluoride Varnish in the Prevention of Dental Caries in Children and Adolescents: A Systematic Review ...The application of fluoride varnish is an effective method against tooth decay that can appear in the primary or permanent dentition. It is also effective in treatments against tooth sensitivity.

🔎 Recommendations
▪️ Use SDF as part of comprehensive caries management in children.
▪️ Combine with fluoride varnish for preventive reinforcement.
▪️ Educate parents about aesthetic outcomes and obtain informed consent.
▪️ Conduct regular follow-ups to monitor lesion arrest.

📚 References

✔ Chu, C. H., Lo, E. C. M., & Lin, H. C. (2002). Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. Journal of Dental Research, 81(11), 767–770. https://doi.org/10.1177/154405910208101108
✔ Fung, M. H. T., Duangthip, D., Wong, M. C. M., Lo, E. C. M., & Chu, C. H. (2018). Arresting dentine caries with different concentration and periodicity of silver diamine fluoride. Journal of Dentistry, 77, 52–58. https://doi.org/10.1016/j.jdent.2018.07.006
✔ Horst, J. A., Ellenikiotis, H., & Milgrom, P. L. (2016). UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications, and consent. Journal of the California Dental Association, 44(1), 16–28.
✔ Mei, M. L., Ito, L., Cao, Y., Lo, E. C. M., & Chu, C. H. (2013). Inhibitory effect of silver diamine fluoride on dentine demineralisation and collagen degradation. Journal of Dentistry, 41(9), 809–817. https://doi.org/10.1016/j.jdent.2013.06.009

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