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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