Pulp Necrosis in Primary Teeth: Diagnosis and Evidence-Based Management

Pulp necrosis in primary teeth is a common consequence of untreated caries, trauma, or chronic inflammation.

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Early detection is crucial to prevent infection, pathological root resorption, and damage to the developing permanent successor. Understanding accurate diagnostic criteria and selecting the appropriate evidence-based treatment is essential for successful outcomes in pediatric patients.

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✅ Etiology of Pulp Necrosis in Primary Teeth
Primary teeth are particularly vulnerable to necrosis due to:

▪️ Extensive caries progression
▪️ Anatomically thinner enamel and dentin
▪️ Traumatic dental injuries
▪️ Bacterial invasion of the pulp chamber
▪️ Chronic pulpal inflammation progressing to necrosis

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✅ Clinical and Radiographic Diagnosis
Accurate diagnosis relies on a combination of:

➤ Patient history (spontaneous pain, swelling, trauma)

➤ Clinical signs
▪️ Tooth discoloration (grayish)
▪️ Sinus tract
▪️ Tenderness to percussion
▪️ Gingival swelling

➤ Radiographic findings
▪️ Furcation radiolucency
▪️ Pathological root resorption
▪️ Periodontal space widening
▪️ Loss of lamina dura

In primary teeth, pulp testing methods like thermal or electric tests are unreliable, making radiographic and clinical findings essential.

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✅ Management of Pulp Necrosis in Primary Teeth
Once necrosis is confirmed, vital pulp therapies are contraindicated. Treatment options include:

➤ Pulpectomy
The preferred treatment when the tooth is restorable and the infection can be adequately controlled.
Key principles:
▪️ Thorough canal debridement
▪️ Irrigation with 2.5% sodium hypochlorite or chlorhexidine
▪️ Obturating canals with resorbable materials such as iodoform-based pastes (Vitapex/Metapex)
▪️ Final restoration, ideally with a stainless steel crown

➤ Extraction
Indicated when:
▪️ The tooth is non-restorable
▪️ There is excessive root resorption
▪️ Infection compromises the permanent successor
▪️ Patient cooperation is insufficient

➤ Antibiotics
Not routinely recommended unless:
▪️ Facial cellulitis
▪️ Systemic involvement (fever, malaise)
▪️ Spread of infection

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✅ Prognosis
Successful pulpectomy has a 70–85% success rate, depending on canal anatomy, irrigation protocol, and obturation material. Failure occurs when infection persists, when restoration is inadequate, or when premature root resorption affects sealing.

📊 Comparative Table: Pulpectomy vs Extraction in Necrotic Primary Teeth

Aspect	Advantages	Limitations
Pulpectomy	Preserves arch space; maintains function; prevents premature tooth loss; avoids malocclusions	Technique sensitive; lower success in multirooted teeth; requires patient cooperation
Extraction	Quick relief of infection; avoids complex instrumentation; suitable for non-restorable teeth	Loss of arch space; risk of mesial drift; possible need for space maintainers

💬 Discussion
Managing necrotic primary teeth requires careful consideration of the child's age, behavior, the strategic value of the tooth, and the proximity to the permanent successor. Resorbable obturation materials remain essential, as non-resorbable materials can interfere with exfoliation. Current research supports the use of iodoform-based pastes due to superior antibacterial activity and predictable resorption.

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🔎 Recommendations
▪️ Use radiographic criteria as the primary diagnostic tool for suspected necrosis.
▪️ Select pulpectomy when infection is localized and the tooth is strategically important.
▪️ Extract teeth with advanced pathology or poor restorative prognosis.
▪️ Avoid antibiotics unless systemic involvement is present.
▪️ Always protect the treated tooth with a stainless steel crown to ensure long-term success.

✍️ Conclusion
Pulp necrosis in primary teeth requires timely diagnosis and evidence-based intervention to prevent complications and safeguard the developing dentition. Pulpectomy remains the treatment of choice for restorable necrotic teeth, while extraction is indicated in severe cases. Proper case selection and modern pediatric endodontic protocols significantly improve outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2021). Pulp therapy for primary and immature permanent teeth. AAPD Clinical Guidelines. https://www.aapd.org
✔ Barja-Fidalgo, F., Ribeiro, A., & Pauleto, A. (2011). Clinical and radiographic outcome of primary molars pulpectomies using different filling materials. Journal of Clinical Pediatric Dentistry, 35(4), 359–364. https://doi.org/10.17796/jcpd.35.4.j1471781m0011654
✔ Fuks, A. B. (2008). Pulp therapy for the primary dentition. Pediatric Dentistry, 30(3), 230–236.
✔ Nadin, G., Goel, B. R., & Yeung, C. A. (2003). Pulp treatment for primary teeth. Cochrane Database of Systematic Reviews, (1), CD003220. https://doi.org/10.1002/14651858.CD003220

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Complete Guide to Pulp Therapy in Primary Teeth: Materials, Techniques, and Success Rates

Pulp therapy in primary teeth is a cornerstone of pediatric dentistry, aiming to maintain tooth vitality, prevent infection, and preserve arch space until natural exfoliation.

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Advances in biomaterials such as MTA, Biodentine, and improved clinical protocols have significantly increased success rates. Understanding the differences between pulpotomy, pulpectomy, indirect pulp treatment (IPT), and apexification is essential for evidence-based care.

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✅ Pulp Therapy Techniques

➤ Indirect Pulp Treatment (IPT)
IPT is indicated when deep caries is present but the tooth remains vital and asymptomatic. Selective caries removal minimizes pulp exposure and promotes remineralization. High-fluoride glass ionomer and resin-modified glass ionomer (RMGI) are widely used as liners.

➤ Direct Pulp Cap (DPC)
Used when a small mechanical pulp exposure occurs. Bioceramics like MTA and Biodentine create a durable dentin bridge and exhibit excellent biocompatibility.

➤ Pulpotomy
Indicated in cases of carious pulp exposure with preserved radicular pulp vitality. Popular medicaments include MTA, Biodentine, and historically formocresol, although the latter is no longer recommended due to toxicity concerns.

➤ Pulpectomy
Indicated for irreversible pulpitis or necrosis. It consists of removing necrotic tissue and obturating canals with resorbable materials such as iodoform-based pastes (Vitapex, Metapex) or zinc oxide–eugenol.

➤ Apexogenesis & Apexification in Young Permanent Teeth
Although not used in primary teeth, they are fundamental when treating immature permanent teeth with open apices.

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✅ Materials Used in Pulp Therapy

➤ Mineral Trioxide Aggregate (MTA)
Known for high biocompatibility, antibacterial properties, and superior long-term sealing.

➤ Biodentine
A bioactive dentin substitute with faster setting time and strong pulpal healing potential.

➤ Zinc Oxide–Eugenol (ZOE)
Traditional obturation material for primary teeth, but less favorable in cases requiring complete resorption.

➤ Iodoform-based Pastes (Vitapex/Metapex)
Preferred for pulpectomy due to their resorbability and antimicrobial action.

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✅ Success Rates

▪️ IPT: 90–97% (AAPD, 2021)
▪️ Pulpotomy with MTA: 90–95%
▪️ Pulpotomy with Biodentine: 88–94%
▪️ Pulpectomy: 70–85%, depending on canal anatomy and material used

📊 Comparative Table: Differences Between Pulp Therapy Techniques

Aspect	Advantages	Limitations
Indirect Pulp Treatment (IPT)	High success rates; preserves vitality; minimally invasive	Requires excellent diagnosis; risk of residual caries
Direct Pulp Cap (DPC)	Promotes dentin bridge formation; effective with bioceramics	Not suitable for carious exposures; requires ideal isolation
Pulpotomy	High success with MTA/Biodentine; preserves radicular pulp vitality	Failure if radicular pulp is inflamed or infected
Pulpectomy	Indicated for necrotic teeth; removes infection; allows tooth preservation	Technique sensitive; lower success rates; requires resorbable obturants
Apexogenesis	Allows continued root development	Not applicable to primary teeth
Apexification	Induces apical closure in young permanent teeth	Long treatment time; not used in primary teeth

💬 Discussion
The choice of pulp therapy depends on diagnosis, degree of inflammation, tooth restorability, and patient behavior. Vital pulp therapies (IPT, DPC, pulpotomy) consistently show higher long-term success than pulpectomy. Modern biomaterials like MTA and Biodentine have replaced older agents due to improved healing outcomes and safety profiles.

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🔎 Recommendations
▪️ Prioritize vital pulp therapies when pulp vitality is preserved.
▪️ Use bioceramics (MTA, Biodentine) as first-line agents.
▪️ Perform pulpectomy only when irreversible pulpitis or necrosis is confirmed.
▪️ Seal treated teeth with stainless steel crowns for long-term success.
▪️ Follow AAPD guidelines for diagnostic criteria and material selection.

✍️ Conclusion
Pulp therapy in primary teeth is highly successful when clinicians use accurate diagnostic criteria and evidence-based materials. Modern biomaterials have improved outcomes and reduced complications, making pulp conservation the preferred approach whenever possible. A clear understanding of each technique ensures predictable and biologically sound results.

📚 References

✔ American Academy of Pediatric Dentistry. (2021). Pulp therapy for primary and immature permanent teeth. AAPD Clinical Guidelines. https://www.aapd.org
✔ Hegde, S., & Bhat, S. S. (2019). Clinical evaluation of MTA and Biodentine as pulpotomy agents in primary teeth. Journal of Indian Society of Pedodontics and Preventive Dentistry, 37(3), 307–315. https://doi.org/10.4103/JISPPD.JISPPD_217_18
✔ Jeon, H. J., Kim, J., & Kim, Y. (2020). Outcomes of vital pulp therapy using bioceramic materials. Restorative Dentistry & Endodontics, 45(3), e32. https://doi.org/10.5395/rde.2020.45.e32
✔ Nowicka, A., Lipski, M., Parafiniuk, M., et al. (2013). Biodentine vs. MTA in direct pulp capping. Journal of Endodontics, 39(6), 743–747. https://doi.org/10.1016/j.joen.2013.01.005

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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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Pulp Capping in Dentistry: How the Dental Pulp Is Protected (Updated Clinical Guide)

Pulp capping is a key minimally invasive procedure used to preserve the vitality of the dental pulp after exposure or near exposure due to caries or trauma.

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Modern bioactive materials—including calcium hydroxide, MTA, and Biodentine—have significantly improved success rates by promoting dentin bridge formation and reducing pulpal inflammation.

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✅ What Is Pulp Capping?
Pulp capping is a conservative dental procedure in which a biocompatible and bioactive material is placed over the pulp or affected dentin to stimulate healing, reduce inflammation, and promote reparative dentin formation. It is indicated in cases of:

▪️ Deep caries approaching the pulp
▪️ Mechanical exposure during cavity preparation
▪️ Traumatic exposure in young teeth with open apices
▪️ Reversible pulpitis

Two main types exist:
▪️ Direct pulp capping – placed directly over an exposed pulp.
▪️ Indirect pulp capping – placed over deep dentin close to the pulp but without exposure.

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✅ Mechanism of Action
Modern pulp-capping materials protect the pulp through several biological processes:

▪️ Antibacterial activity (e.g., calcium hydroxide has high pH).
▪️ Sealing ability that prevents microleakage.
▪️ Bioactivity, stimulating odontoblast-like cell differentiation.
▪️ Release of calcium ions, promoting mineralization and dentin bridge formation.
▪️ Reduction of pulpal inflammation and support of tissue regeneration.

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✅ Common Materials and Commercial Names

1. Calcium Hydroxide (Ca(OH)₂)
Commercial names: Dycal®, Life®, Calcimol®
Key actions: High pH antibacterial effect; stimulates mineralized bridge formation.

2. Mineral Trioxide Aggregate (MTA)
Commercial names: ProRoot® MTA, MTA Angelus®
Key actions: Excellent sealing, biocompatibility, promotes strong dentin bridge formation.

3. Biodentine® (Tricalcium Silicate Cement)
Commercial name: Biodentine® (Septodont)
Key actions: Bioactivity, fast setting time, high mechanical strength, pulp regeneration support.

4. Resin-Modified Calcium Silicate Materials
Commercial names: TheraCal LC®, BioCal®
Key actions: Light-cured convenience, calcium release, improved handling properties.

📊 Comparative Table: Pulp Capping Materials

Aspect	Advantages	Limitations
Calcium Hydroxide	Antibacterial; inexpensive; widely available	Poor long-term seal; tunnel defects in dentin bridge
MTA	Excellent sealing; high biocompatibility; strong dentin bridge	Long setting time; higher cost; potential discoloration

💬 Discussion
Advances in bioceramic materials have transformed pulp protection, offering predictable outcomes with high long-term vitality rates. MTA and Biodentine outperform traditional calcium hydroxide in sealing ability and dentin bridge quality, although calcium hydroxide remains widely used due to affordability and ease of application. Material selection depends on exposure type, tooth vitality, patient age, and clinical resources.

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✍️ Conclusion
Modern pulp capping techniques effectively protect the dental pulp, arrest inflammation, and promote natural dentin regeneration. Evidence consistently supports bioactive materials—particularly MTA and Biodentine—as the gold standard for vital pulp therapy. Appropriate case selection and strict isolation significantly increase long-term success.

🔎 Recommendations
▪️ Use rubber dam isolation to prevent contamination during pulp capping.
▪️ Prefer MTA or Biodentine for direct exposures in young permanent teeth.
▪️ Use indirect pulp capping when possible to avoid unnecessary pulpal exposure.
▪️ Follow up clinically and radiographically at 6 and 12 months.
▪️ Educate patients about symptoms of pulpal complications (persistent pain, swelling).

📚 References

✔ Bjørndal, L., & Ludwig, S. (2022). Management of deep caries and pulpal protection strategies. International Endodontic Journal, 55(Suppl. 1), 59–73. https://doi.org/10.1111/iej.13743
✔ Celik, E. U., & Unever, S. (2020). Success rates of pulp capping materials in vital pulp therapy. Journal of Endodontics, 46(8), 1061–1067. https://doi.org/10.1016/j.joen.2020.04.008
✔ Cox, C. F., Subay, R. K., Suzuki, S., & Suzuki, S. H. (2017). Pulp capping materials: A review of the literature. Dental Materials, 33(7), 745–758. https://doi.org/10.1016/j.dental.2017.03.006
✔ Torabinejad, M., & Parirokh, M. (2010). Mineral trioxide aggregate: A comprehensive literature review. Part II: Clinical applications. Journal of Endodontics, 36(2), 190–202. https://doi.org/10.1016/j.joen.2009.09.010

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Odontogenic Infections: Impact on General Health and Comprehensive Management

This academic and SEO-optimized article examines odontogenic infections, emphasizing their systemic impact, clinical warning signs, prevention strategies, and comprehensive management.

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✅ Introduction
Odontogenic infections arise from dental pulp or periodontal tissues and represent one of the most common causes of oral-facial emergencies. While often localized initially, these infections may progress beyond the oral cavity, posing significant risks to general health. Understanding their etiology, systemic implications, and management is essential for preventing severe complications such as deep neck infections, airway compromise, or sepsis.

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✅ Etiology and Pathophysiology
Odontogenic infections are primarily caused by polymicrobial flora, including anaerobic and facultative anaerobic bacteria such as Streptococcus anginosus, Prevotella, and Fusobacterium species. Common origins include:

▪️ Necrotic pulp
▪️ Periodontal abscesses
▪️ Pericoronitis
▪️ Failed endodontic treatments
▪️ Post-traumatic infections

If untreated, the infection may spread to fascial spaces, bloodstream, or airway-compromising anatomical regions.

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✅ Systemic Impact: How Odontogenic Infections Affect General Health
Odontogenic infections can extend beyond the oral cavity and cause multisystem complications. Key systemic implications include:

▪️ Systemic inflammation: Elevated inflammatory markers such as CRP and leukocytosis.
▪️ Airway compromise: Particularly in Ludwig’s angina or submandibular space infections.
▪️ Cervical cellulitis and deep neck space involvement: Risk of mediastinitis.
▪️ Bacteremia and sepsis: Oral pathogens may disseminate to vital organs.
▪️ Impact on chronic diseases: Worsening of diabetes control and increased cardiovascular risk.
▪️ Pregnancy complications: Increased risk of preterm birth and low birth weight.

These systemic consequences demonstrate the importance of recognizing odontogenic infections as a threat to general health, especially in medically compromised individuals.

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✅ Warning Signs and Symptoms
Key signs that indicate progression towards severe infection include:

▪️ Trismus
▪️ Dysphagia or odynophagia
▪️ Fever > 38°C
▪️ Progressive facial swelling
▪️ Drooling
▪️ Dyspnea or difficulty breathing
▪️ Limited tongue mobility
▪️ Severe, persistent pain
▪️ Rapid onset edema or erythema
▪️ Systemic malaise, tachycardia, hypotension

The presence of any of these warning signs suggests the need for urgent intervention and possible hospital referral.

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✅ Prevention
Effective prevention strategies include:

▪️ Early diagnosis and treatment of caries and pulp infections
▪️ Periapical radiographic monitoring
▪️ Adequate periodontal maintenance
▪️ Removal or management of impacted third molars
▪️ Education on oral hygiene and risk factors
▪️ Prophylactic measures in immunocompromised patients

Preventive dentistry plays a central role in avoiding progression to severe odontogenic infections.

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✅ Comprehensive Management
Management varies depending on the severity of the infection and systemic involvement. Essential components include:

1. Local Treatment
▪️ Drainage of abscesses through incision or intraoral pathways
▪️ Endodontic therapy or extraction of the causative tooth
▪️ Debridement of necrotic tissue

2. Systemic Therapy
▪️ Antibiotic selection based on polymicrobial profiles:
° First-line: amoxicillin-clavulanic acid
° Alternative: clindamycin (in penicillin-allergic patients)
▪️ Analgesics and anti-inflammatory medications

3. Airway Management and Hospitalization
Indicated when:
▪️ Dyspnea or airway compromise is suspected
▪️ Infection spreads to deep neck spaces
▪️ There is rapid progression or systemic toxicity

4. Interdisciplinary Collaboration
Essential with:
▪️ Otolaryngology
▪️ Infectious disease specialists
▪️ Emergency medicine
▪️ Anesthesiology (airway evaluation)

📊 Comparative Table: Key Management Approaches in Odontogenic Infections

Aspect	Advantages	Limitations
Local Drainage and Tooth Removal	Directly eliminates source of infection; rapid symptom relief	May require surgical access; patient discomfort; postoperative care needed
Antibiotic Therapy	Controls bacterial spread; essential for systemic involvement	Does not eliminate the infectious source; risk of resistance
Hospital-Based Management	Ensures airway protection and multidisciplinary care	High cost; reserved for severe cases only

💬 Discussion
Odontogenic infections pose significant risks when early warning signs are overlooked. Despite being preventable, their progression can lead to life-threatening complications such as Ludwig’s angina or sepsis, underscoring the importance of comprehensive evaluation. The interrelation between oral and systemic health becomes evident in patients with chronic systemic diseases, where odontogenic infections can complicate disease management or trigger systemic decompensation.
The multidisciplinary management approach significantly reduces morbidity and prevents adverse outcomes, particularly in vulnerable populations such as older adults, immunocompromised patients, and individuals with uncontrolled diabetes.

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✍️ Conclusion
Odontogenic infections significantly impact general health, and their progression may lead to serious systemic complications. Early detection, timely management, and interprofessional collaboration are essential to ensure favorable outcomes. Prevention remains the most effective strategy, emphasizing the need for regular dental evaluations and timely treatment of oral diseases.

🔎 Recommendations
▪️ Prioritize early intervention in pulpal and periodontal infections.
▪️ Educate patients about systemic warning signs.
▪️ Implement routine radiographic monitoring in high-risk individuals.
▪️ Strengthen collaboration between dental and medical professionals.
▪️ Encourage preventive dental visits and strict oral hygiene.

📚 References

✔ Brook, I. (2017). Microbiology and management of odontogenic infections in children. Journal of Oral and Maxillofacial Surgery, 75(7), 1356–1363. https://doi.org/10.1016/j.joms.2017.02.010
✔ Flynn, T. R. (2016). Principles and surgical management of head and neck infections. Oral and Maxillofacial Surgery Clinics, 28(3), 367–376. https://doi.org/10.1016/j.coms.2016.04.004
✔ Hupp, J. R., Ellis, E., & Tucker, M. R. (2019). Contemporary Oral and Maxillofacial Surgery (7th ed.). Elsevier.
✔ Sakamoto, H., et al. (2019). Associations between odontogenic infections and systemic diseases. Clinical Oral Investigations, 23(2), 661–666. https://doi.org/10.1007/s00784-018-2465-4

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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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Pulpotomy vs. Pulpectomy in Primary Teeth: A Contemporary Clinical Guide

Vital pulp therapy in primary teeth is a cornerstone of pediatric dental treatment. Among the most common procedures are pulpotomy, which conserves some of the radicular pulp, and pulpectomy, which removes all pulp tissue.

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✅ Background and Rationale
Primary teeth differ significantly from permanent teeth in morphology and physiology, notably in their root anatomy, resorption patterns, and innervation. Current pediatric dentistry guidelines (e.g., AAPD) describe pulpotomy as indicated when coronal pulp is inflamed but radicular pulp remains vital. Meanwhile, pulpectomy is generally reserved for cases with necrosis, irreversible pulpitis, or radiographic pathology.

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✅ Clinical Evidence: Success Rates & Comparative Outcomes

➤ Randomized & Controlled Trials
▪️ A multicenter RCT comparing cervical pulpotomy (with calcium-enriched mixture cement) versus pulpectomy (Metapex) in primary molars with irreversible pulpitis found no significant difference in clinical and radiographic success rates. PubMed
▪️ In a split-mouth randomized trial on primary incisors with vital pulp exposure, pulpotomy (formocresol) and pulpectomy (zinc-oxide-eugenol) showed similar 12-month success, with survival rates of ~82% vs ~74%, respectively (not statistically significant).

➤ Observational and Cohort Studies
A retrospective cohort study of 876 primary molars reported that iRoot BP Plus pulpotomy had a significantly better long-term prognosis (survival over 48 months) than Vitapex pulpectomy.
A survival analysis of pulpectomy under general anesthesia found that failures usually stemmed from incomplete tissue removal and complexity of root canal systems in primary molars.

➤ Systematic Reviews & Meta-Analyses
▪️ A large Cochrane-type review concluded that MTA (mineral trioxide aggregate) is superior to formocresol and calcium hydroxide for pulpotomy in primary teeth.
▪️ Another systematic review and meta-analysis demonstrated high clinical and radiographic success for pulpotomy in primary teeth with irreversible pulpitis, suggesting that inflammation might be confined to the coronal pulp in many cases.

📊 Comparative Table: Pulpotomy vs Pulpectomy in Primary Teeth

Aspect	Advantages	Limitations
Tissue preservation	Maintains some vital radicular pulp, encouraging natural resorption	May leave inflamed tissue if diagnosis is incorrect
Procedure time & behavior	Generally faster and less technically demanding; better tolerated in uncooperative children	Hemostasis must be achieved; persistent bleeding may complicate treatment
Long-term survival	High survival rates over several years (e.g., > 70% at 48 months with bioceramic pulpotomy) :contentReference[oaicite:9]{index=9}	Success depends on correct diagnosis and use of proven medicaments (e.g., MTA) :contentReference[oaicite:10]{index=10}
Indications	Irreversible pulpitis with vital radicular tissue; minimal radiographic pathology	Not suitable if necrosis, internal/external resorption, or periapical infection present :contentReference[oaicite:11]{index=11}
Risks & complications	Lower risk of overfilling; less risk to developing permanent tooth bud	Risk of failure if improper agent or poor seal; possible internal resorption
Restoration after treatment	Can be restored with stainless steel crowns or other durable restorations with good retention :contentReference[oaicite:12]{index=12}	Coronal leakage or microleakage can compromise outcome if restoration fails

💬 Discussion
The body of evidence suggests that pulpotomy and pulpectomy both have clinically acceptable success in primary teeth when properly indicated. Notably:

▪️ Pulpotomy, especially when using modern materials like MTA or bioceramic cements (e.g., iRoot BP Plus), demonstrates excellent long-term survival.
▪️ Pulpectomy, while more invasive, remains critical in cases of necrosis or when radiographic signs of pathology are present. However, it is technically demanding, particularly due to the complex canal anatomy of primary molars.
▪️ Systematic reviews consistently favor MTA over traditional agents like formocresol or calcium hydroxide for pulpotomy, due to better clinical and radiographic outcomes.
▪️ Patient-centered outcomes also favor more conservative therapy: pulpectomy has been associated with improved quality of life and lower dental anxiety compared to extraction, making it preferable over tooth loss.

Additionally, a recently registered RCT protocol aims to provide more rigorous evidence by comparing pulpotomy vs pulpectomy in primary molars with irreversible pulpitis over two years. This trial could potentially shift paradigms if pulpotomy proves non-inferior, given its lower invasiveness and patient burden.

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✅ Recommendations for Clinical Practice

1. Case Selection Is Key
▪️ Use pulpotomy when the pulp is vital, bleeding is controlled, and no periapical pathology is evident.
▪️ Reserve pulpectomy for cases with necrosis, internal/external resorption, or evidence of interradicular/periapical disease.

2. Material Choice
▪️ Prefer MTA or bioceramic materials (e.g., iRoot BP Plus) for pulpotomy due to demonstrated higher success rates.
▪️ For pulpectomy, use resorbable filling materials compatible with primary tooth anatomy (e.g., Metapex, Vitapex), though evidence does not strongly favor one over another.

3. Behavior Management & Procedural Efficiency
▪️ Because pulpotomy is generally faster and less technique-sensitive, it may be better suited for younger or less cooperative children.
▪️ Ensure accurate diagnosis (clinical + radiographic) to minimize risk of failed treatment.

4. Follow-up Protocol
▪️ Schedule periodic clinical and radiographic reviews (e.g., 6 months, 12 months, annually) to monitor for signs of failure or resorption.
▪️ Optimize restorative sealing (e.g., stainless-steel crown) to reduce risk of microleakage.

5. Research and Continuous Learning
▪️ Stay updated with ongoing trials (e.g., the non-inferiority RCT of pulpotomy vs pulpectomy in primary molars) for evidence that may refine treatment guidelines.
▪️ Contribute to or audit long-term outcomes in your own practice to inform future decisions.

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✍️ Conclusion
In modern pediatric dentistry, both pulpotomy and pulpectomy remain viable options for managing pulpally involved primary teeth. While pulpotomy offers a more conservative and less time-consuming approach with excellent long-term survival—especially when using materials like MTA or bioceramics—pulpectomy remains irreplaceable in cases of necrosis or advanced pathology. Clinicians should base their choice on careful diagnosis, patient behavior, material selection, and a commitment to follow-up. Together, these strategies help preserve primary teeth, maintain arch integrity, and support the well-being of pediatric patients.

📚 References

✔ Holan, G., & Fuks, A. B. (2015). The role of pulpectomy in the primary dentition. Pediatric Dentistry, 37(6), 559–566.
✔ Philip, N., Cherian, J. M., Mathew, M. G., et al. (2024). Treatment outcomes of pulpotomy versus pulpectomy in vital primary molars diagnosed with symptomatic irreversible pulpitis: protocol for a non-inferiority randomized controlled trial. BMC Oral Health, 24, 626. https://doi.org/10.1186/s12903-024-04411-6
✔ Li, J., Fan, W., Zhou, Y., Wu, L., Liu, W., & Huang, S. (2024). Pulpotomy versus pulpectomy in carious vital pulp exposure in primary incisors: a randomized controlled trial. BMC Dentistry.
✔ Xu, X., Chen, X., Wang, X., & Chen, J. (2023). Survival analysis of pulpotomy versus pulpectomy in primary molars with carious pulp exposure. International Endodontic Journal.
✔ Walsh, T., Clarke, M., Tsang, A., Marshman, Z., & Petrou, K. (2016). Pulp treatment for extensive decay in primary teeth. Cochrane Database of Systematic Reviews, (4), CD003220.
✔ American Academy of Pediatric Dentistry. (n.d.). Pulp Therapy for Primary and Immature Permanent Teeth. AAPD Policy.

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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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Dental Article 🔽 Mineral Trioxide Aggregate (MTA) in Pediatric Dentistry: Uses, Benefits, and Clinical Evidence ... Preserving primary teeth until their natural exfoliation is a key goal in pediatric dentistry. Advances in bioactive materials have made this more predictable.

✅ 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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