Pulpectomy in Primary Teeth: Best Filling Materials (ZOE, Vitapex, and Metapex)

Pulpectomy is a widely accepted endodontic procedure for infected or necrotic primary teeth, aiming to preserve the tooth until its natural exfoliation. The success of this procedure depends not only on adequate canal debridement but also on the selection of an appropriate root canal filling material.

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An ideal obturation material for primary teeth should be resorbable, biocompatible, antibacterial, and harmless to the developing permanent successor. This article reviews the most commonly used pulpectomy filling materials—Zinc Oxide Eugenol (ZOE), Vitapex®, and Metapex®—focusing on their mechanisms of action, commercial formulations, advantages, and limitations.

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✅ Pulpectomy Filling Materials in Primary Teeth

1. Zinc Oxide Eugenol (ZOE)
ZOE has been historically considered the standard filling material for primary teeth pulpectomy.

Mechanism of action:
ZOE exerts antibacterial and sedative effects through the release of eugenol, which inhibits microbial growth and reduces inflammation.
Commercial formulations:
▪️ Dental Zinc Oxide Powder + Eugenol Liquid (multiple manufacturers)

2. Vitapex® (Calcium Hydroxide + Iodoform Paste)
Vitapex® is a premixed paste containing calcium hydroxide and iodoform, specifically designed for pediatric endodontics.

Mechanism of action:
▪️ Calcium hydroxide provides antibacterial activity through high pH
▪️ Iodoform enhances antimicrobial effects and promotes resorption
Commercial product:
▪️ Vitapex® (Neo Dental Chemical Products, Japan)

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3. Metapex® (Calcium Hydroxide + Iodoform Paste)
Metapex® has a composition similar to Vitapex® but differs in viscosity and delivery system.

Mechanism of action:
▪️ Sustained antimicrobial activity
▪️ Favorable resorption rate synchronized with physiological root resorption
Commercial product:
▪️ Metapex® (Meta Biomed, Korea)

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✅ Advantages and Disadvantages of Common Pulpectomy Materials

1. Advantages
▪️ ZOE: Long-term stability and ease of handling
▪️ Vitapex® and Metapex®: Faster resorption, superior biocompatibility, and minimal interference with permanent tooth eruption

2. Disadvantages
▪️ ZOE may resorb slower than primary roots, potentially affecting succedaneous teeth
▪️ Calcium hydroxide–iodoform pastes may resorb prematurely, increasing reinfection risk in some cases

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💬 Discussion
Recent systematic reviews suggest that calcium hydroxide–iodoform-based materials demonstrate higher clinical and radiographic success rates compared to ZOE in primary teeth pulpectomies. Their ability to resorb in harmony with root resorption makes them particularly suitable for pediatric patients.
However, ZOE remains clinically acceptable, especially in settings where cost, availability, or operator familiarity are determining factors. Material selection should be individualized based on root morphology, degree of infection, and expected exfoliation timeline.

🎯 Clinical Recommendations
▪️ Prefer Vitapex® or Metapex® in teeth with advanced physiological root resorption
▪️ Use ZOE cautiously in teeth close to exfoliation
▪️ Avoid overfilling, particularly with non-resorbable materials
▪️ Perform regular radiographic follow-up to monitor resorption patterns

✍️ Conclusion
Pulpectomy in primary teeth requires filling materials that are resorbable, antibacterial, and biocompatible. While ZOE continues to be used, Vitapex® and Metapex® represent modern alternatives with improved biological behavior and clinical outcomes. Evidence-based material selection enhances long-term success and protects the developing permanent dentition.

📊 Comparative Table: Pulpectomy Filling Materials in Primary Teeth

Material and Composition	Clinical Advantages	Clinical Limitations
Zinc Oxide Eugenol (ZOE)	Good sealing ability, antibacterial effect, long clinical history	Slow resorption, potential irritation to permanent tooth germ
Vitapex® (Calcium Hydroxide + Iodoform)	Excellent resorption, high biocompatibility, easy syringe delivery	Possible premature resorption, higher cost
Metapex® (Calcium Hydroxide + Iodoform)	Resorption synchronized with roots, strong antimicrobial action	Risk of overfilling, technique-sensitive

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Guideline on pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 45(6), 405–423.
✔ Coll, J. A., Seale, N. S., Vargas, K., Marghalani, A. A., Al Shamali, S., & Graham, L. (2017). Primary tooth vital pulp therapy: A systematic review and meta-analysis. Pediatric Dentistry, 39(1), 16–26.
✔ 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.2004.00591.x
✔ Reddy, S., Ramakrishna, Y., & Kumar, V. (2014). Evaluation of clinical and radiographic success of Metapex and zinc oxide eugenol as root canal filling materials in primary teeth. Journal of Indian Society of Pedodontics and Preventive Dentistry, 32(3), 224–229. https://doi.org/10.4103/0970-4388.135831

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Zinc Oxide Eugenol in Dentistry: Is It Still Used in Modern Clinical Practice?

Zinc oxide eugenol (ZOE) has been a cornerstone material in dentistry for over a century due to its sedative properties, ease of manipulation, and low cost.

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However, advances in dental materials science and adhesive dentistry have raised an important question: Is zinc oxide eugenol still relevant in contemporary dental practice?

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This article critically reviews the composition, clinical applications, disadvantages, and current alternatives to ZOE, providing an evidence-based perspective on its role in modern dentistry.

✅ Composition of Zinc Oxide Eugenol
ZOE is formed through an acid–base reaction between zinc oxide powder and eugenol liquid.

▪️ Powder: Zinc oxide (ZnO), often with additives such as zinc acetate to accelerate setting
▪️ Liquid: Eugenol (a phenolic compound derived from clove oil)
The setting reaction produces zinc eugenolate, which is responsible for the material’s physical properties and biological effects.

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✅ Clinical Uses of Zinc Oxide Eugenol
Despite reduced popularity, ZOE continues to be used in selected clinical situations:

▪️ Temporary restorative material
▪️ Temporary luting cement
▪️ Base or liner under non-resin restorations
▪️ Root canal sealer (traditional formulations)
▪️ Periodontal surgical dressings
▪️ Intermediate restorative material (IRM derivatives)
Its sedative effect on the dental pulp has historically made it attractive in deep cavities and emergency treatments.

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✅ Disadvantages and Limitations of ZOE
Although biologically soothing, ZOE presents significant drawbacks that limit its use in modern dentistry:

▪️ Interference with resin polymerization, making it incompatible with adhesive restorations
▪️ Low mechanical strength, unsuitable for long-term restorations
▪️ High solubility in oral fluids, leading to marginal leakage
▪️ Potential cytotoxicity of eugenol at high concentrations
▪️ Limited adhesion to tooth structure
These limitations have driven the development and adoption of alternative materials.

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✅ Materials That Have Replaced Zinc Oxide Eugenol
Modern dentistry increasingly favors materials with improved biocompatibility, adhesion, and mechanical performance, including:

▪️ Calcium hydroxide–based liners
▪️ Glass ionomer cements (GIC)
▪️ Resin-modified glass ionomers (RMGIC)
▪️ Calcium silicate–based materials (e.g., MTA, Biodentine)
▪️ Resin-based temporary and permanent materials
These materials offer superior sealing ability, compatibility with adhesive systems, and enhanced longevity.

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💬 Discussion
ZOE remains a material of historical and limited clinical relevance rather than a first-line option. While it still has niche applications—particularly in temporary procedures or specific endodontic uses—its incompatibility with resin-based materials significantly restricts its role in modern restorative dentistry.
Current trends emphasize bioactive, adhesive, and mechanically stable materials, which better align with minimally invasive and long-term treatment philosophies.

🎯 Clinical Recommendations
▪️ Avoid ZOE under resin-based restorations
▪️ Consider modern bioactive materials for pulp protection
▪️ Use ZOE only for short-term or specific indications
▪️ Evaluate patient needs, restoration type, and material compatibility
▪️ Stay updated with evidence-based material selection guidelines

✍️ Conclusion
Zinc oxide eugenol is still used in dentistry, but its role is increasingly limited. While it offers sedative and antimicrobial benefits, its mechanical weakness and incompatibility with adhesive systems have led to its replacement by more advanced materials. Contemporary dental practice favors alternatives that provide superior durability, biocompatibility, and clinical performance.

📊 Comparative Table: Zinc Oxide Eugenol and Its Modern Alternatives

Material Type	Clinical Indications	Main Limitations
Zinc Oxide Eugenol	Temporary restorations, sedative base	Inhibits resin polymerization, low strength
Glass Ionomer Cement	Base, liner, temporary and permanent restorations	Lower fracture resistance than composites
Resin-Modified GIC	Adhesive base and liner	Moisture sensitivity during placement
Calcium Silicate Materials	Pulp capping and dentin regeneration	Higher cost and longer setting time

📚 References

✔ Anusavice, K. J., Shen, C., & Rawls, H. R. (2013). Phillips’ science of dental materials (12th ed.). Elsevier.
✔ American Dental Association. (2022). Dental materials guidance and compatibility considerations. Journal of the American Dental Association, 153(4), 345–352. https://doi.org/10.1016/j.adaj.2021.11.012
✔ Hargreaves, K. M., & Berman, L. H. (2020). Cohen’s pathways of the pulp (12th ed.). Elsevier.
✔ Sidhu, S. K., & Nicholson, J. W. (2016). A review of glass-ionomer cements for clinical dentistry. Journal of Functional Biomaterials, 7(3), 16. https://doi.org/10.3390/jfb7030016

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Controversial Materials in Pediatric Dentistry: What Remains Safe Today?

In pediatric dentistry, the selection of restorative and pulpal materials must balance biocompatibility, effectiveness, and safety. Historical materials such as formocresol and dental amalgam have been debated for potential toxicity, while modern alternatives like bioactive cements (e.g., MTA, Biodentine) and adhesive restorative materials are widely accepted.

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This review synthesizes evidence on controversial dental materials and their current clinical safety status in pediatric care, providing evidence-based recommendations for clinicians.

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✅ Introduction
Dentistry for children and adolescents involves unique biological and behavioral considerations, requiring materials that are safe, effective, and minimally invasive. Materials that were historically part of pediatric practice now face scrutiny due to evolving evidence around toxicity, biocompatibility, and environmental impact. Clinicians must understand both contested and recommended materials to optimize pediatric patient outcomes.

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✅ Controversial Dental Materials in Pediatric Practice

Formocresol
Formocresol has been used as a pulpotomy medicament in primary teeth due to its bactericidal and devitalizing properties. However, concerns about formaldehyde, a hazardous compound classified as potentially carcinogenic, have led to reevaluation of its routine use in children. Evidence suggests that under low exposure conditions, formaldehyde metabolism may not pose significant carcinogenic risk, yet modern practice favors biocompatible alternatives.

Dental Amalgam
Dental amalgam, an alloy containing mercury, remains controversial due to its mercury content and perceptions of toxicity. Although organizations such as the ADA and FDA acknowledge amalgam’s longstanding safety record, its use in pediatric patients has declined, with emphasis shifting toward resin-based and glass ionomer materials in many programs due to aesthetic and minimally invasive preferences.

Bisphenol A (BPA) Derivatives
Resin-based composites and sealants may contain BPA derivatives, raising concerns about endocrine-disrupting potential. Available evidence highlights transient BPA release after placement, but the clinical benefits of resin-based materials generally outweigh potential exposure when proper techniques are followed.

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✅ Current Safe and Recommended Materials

Bioactive Cements and Vital Pulp Therapy Agents
Materials such as mineral trioxide aggregate (MTA) and Biodentine have demonstrated favorable outcomes in vital pulp therapy, promoting dentinogenesis and exhibiting high biocompatibility. These materials represent contemporary choices for maintaining pulp vitality in primary dentition.

Glass Ionomer and Resin-Based Restoratives
Glass ionomer cements offer chemical adhesion and fluoride release, aligning with minimally invasive principles, though moisture sensitivity can limit performance. Resin composites provide improved aesthetics and adaptability, yet require optimal isolation for long-term success.

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💬 Discussion
The transition away from controversial materials like formocresol and amalgam reflects a broader trend toward biocompatible and patient-centered care. While historical evidence attests to the effectiveness of certain legacy materials, modern pediatric dentistry prioritizes bioactivity, regenerative potential, and minimization of systemic exposure. Adoption of contemporary materials should be contextualized within evidence-based protocols and comprehensive risk assessment.

🎯 Clinical Recommendations
▪️ Use bioactive cements (MTA/Biodentine) for vital pulp therapy when indicated.
▪️ Prefer glass ionomer or resin-based restoratives in primary dentition, considering isolation quality and caries risk.
▪️ Avoid routine use of formocresol in pulpotomy unless alternatives are unavailable and benefits outweigh theoretical risks.
▪️ Reserve amalgam for limited situations where other materials are contraindicated, recognizing regulatory and educational trends.

✍️ Conclusion
Controversies surrounding materials in pediatric dentistry have prompted shifts toward safer, more biologically favorable options. Clinicians must remain informed by current evidence when selecting materials for restorative and pulpal procedures. While some traditional materials may still be used judiciously, modern bioactive and adhesive materials represent the safest and most effective choices for pediatric patients today.

📚 References

✔ American Academy of Pediatric Dentistry. (2025–2026). Pediatric restorative dentistry: Pediatric restorative dentistry reference manual. AAPD.
✔ Fuks, A. B. (2015). The use of amalgam in pediatric dentistry: New insights and reappraising the tradition. Pediatric Dentistry, 37(2), 125–132.
✔ Milnes, A. R. (2006). Persuasive evidence that formocresol use in pediatric dentistry is safe. Journal of the Canadian Dental Association, 72(3), 247–248.
✔ Peker, O. (2024). Contemporary dental materials used in pediatric dentistry. Dental and Medical Journal, 6(2), 70–85.

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

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

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

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✅ Composition of CTZ Paste
CTZ paste is composed of:

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

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

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

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✅ Mechanisms of Action

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

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

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

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

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

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

📊 Comparative Table: Clinical Characteristics of a Necrotic Tooth

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

📚 References

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

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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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Triple Antibiotic Paste in Dentistry: Benefits, Clinical Applications, and Evidence-Based Advantages

Triple antibiotic paste (TAP) has become an important intracanal medicament in modern dentistry, particularly in regenerative endodontic procedures and infection control.

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Originally introduced to eliminate resistant polymicrobial infections, TAP combines multiple antibiotics to achieve broad-spectrum antimicrobial activity while preserving host tissues. Its use has expanded in both permanent and immature teeth, especially in cases where conventional disinfection methods are insufficient.

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✅ What Is Triple Antibiotic Paste?
Triple antibiotic paste is a combination of ciprofloxacin, metronidazole, and minocycline, formulated to target a wide range of aerobic and anaerobic bacteria commonly found in infected root canals.

Key characteristics include:
▪️ Broad-spectrum antimicrobial coverage
▪️ Ability to penetrate dentinal tubules
▪️ Effectiveness against biofilm-associated bacteria
▪️ Use as an intracanal medicament rather than a definitive filling material

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✅ Benefits of Triple Antibiotic Paste
The popularity of TAP is largely due to its strong antimicrobial properties and versatility. Major benefits include:

▪️ Effective elimination of polymicrobial endodontic infections
▪️ Reduction of bacterial load in necrotic and immature teeth
▪️ Improved outcomes in regenerative endodontic therapy
▪️ Enhanced disinfection without aggressive mechanical instrumentation

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✅ Clinical Applications of Triple Antibiotic Paste
Triple antibiotic paste is mainly used in advanced endodontic scenarios where conventional calcium hydroxide may be insufficient.

Common clinical applications include:
▪️ Regenerative endodontic procedures (REPs)
▪️ Management of necrotic immature permanent teeth
▪️ Persistent apical periodontitis with resistant bacteria
▪️ Disinfection prior to revascularization or apexification
▪️ Selected cases in traumatized teeth with pulp necrosis

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✅ Advantages Compared to Other Intracanal Medicaments
Compared with traditional materials, TAP offers unique antimicrobial synergy.

Advantages include:
▪️ Superior antibacterial efficacy against Enterococcus faecalis
▪️ Synergistic action of combined antibiotics
▪️ Effective biofilm disruption
▪️ Lower reliance on aggressive canal instrumentation
However, these benefits must be balanced against known drawbacks.

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✅ Limitations and Concerns
Despite its effectiveness, TAP is not without limitations.

Important concerns include:
▪️ Risk of tooth discoloration (primarily due to minocycline)
▪️ Potential development of antibiotic resistance
▪️ Cytotoxicity at high concentrations
▪️ Not intended for long-term or routine use
▪️ Possible allergic reactions in susceptible patients

📊 Comparative Table: Triple Antibiotic Paste in Modern Dentistry

Aspect	Advantages	Limitations
Antimicrobial Spectrum	Broad coverage against aerobic and anaerobic bacteria	Overuse may contribute to antibiotic resistance
Use in Regenerative Endodontics	Effective canal disinfection without extensive instrumentation	Requires careful concentration control to avoid cytotoxicity
Tooth Discoloration Risk	Can be reduced with modified formulations	Minocycline may cause intrinsic staining
Clinical Handling	Easy intracanal placement	Not suitable as a long-term medicament

💬 Discussion
Current evidence supports the use of triple antibiotic paste as a short-term intracanal medicament in selected cases, particularly in regenerative endodontics. However, concerns regarding antibiotic stewardship and cytotoxicity have prompted the development of modified formulations, such as double antibiotic paste (DAP) or TAP without minocycline. Clinicians must weigh antimicrobial benefits against biological risks when selecting this medicament.

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🎯 Clinical Recommendations
▪️ Use TAP only in well-indicated cases, such as regenerative endodontic therapy.
▪️ Apply at low concentrations to minimize cytotoxic effects.
▪️ Limit duration of use to reduce the risk of resistance.
▪️ Consider alternative medicaments when esthetics are critical.
▪️ Always obtain a thorough medical and allergy history before use.

✍️ Conclusion
Triple antibiotic paste remains a valuable tool in modern endodontics, particularly for complex infections and regenerative procedures. While its antimicrobial efficacy is well documented, responsible use is essential to avoid adverse effects and antibiotic resistance. When applied judiciously and based on current evidence, TAP can significantly improve clinical outcomes in challenging endodontic cases.

📚 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. (2021). Clinical considerations for regenerative procedures. Journal of Endodontics, 47(3), 354–365.
✔ Ruparel, N. B., Teixeira, F. B., Ferraz, C. C. R., & Diogenes, A. (2012). Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. Journal of Endodontics, 38(10), 1372–1375. https://doi.org/10.1016/j.joen.2012.06.018

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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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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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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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