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

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

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

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

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

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

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

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

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

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

📊 Comparative Table: Bioactive Materials Used in Pulpotomy

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

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

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

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

📚 References

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

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Management of Pulpal Infections in Primary Teeth: Evidence-Based Protocols 2025

This 2025 update provides a concise, evidence-based overview of pulpal infection management in primary teeth, following the latest AAPD 2024 classification and clinical protocols.

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✅ Introduction
Pulpal infections in primary teeth are a common cause of dental pain and tooth loss in children. The 2024 American Academy of Pediatric Dentistry (AAPD) guidelines emphasize accurate diagnosis, conservative pulp therapy, and the use of bioactive materials such as MTA and Biodentine for improved long-term success (AAPD, 2024).

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✅ Classification of Pulpal Conditions (AAPD 2024)
According to the AAPD 2024 guidelines, pulpal conditions are classified as:

▪️ Normal pulp – healthy pulp, no symptoms.
▪️ Reversible pulpitis – transient pain to stimuli, pulp can recover.
▪️ Irreversible pulpitis – spontaneous/prolonged pain, inflamed pulp beyond repair.
▪️ Pulp necrosis – non-vital pulp tissue.
▪️ Chronic periapical abscess – low-grade, draining sinus tract present.
▪️ Acute periapical abscess – severe pain, swelling, systemic symptoms possible.

📊 Symptoms of Pulpal Infection Processes

Pulpal Condition	Main Symptoms	Clinical Indicators
Reversible Pulpitis	Short, sharp pain to stimuli	No spontaneous pain; normal radiograph
Irreversible Pulpitis	Spontaneous or nocturnal pain	Deep caries; no haemostasis after coronal pulp removal
Pulp Necrosis	No response to stimuli	Periapical radiolucency; non-vital pulp
Chronic Periapical Abscess	Usually asymptomatic	Draining sinus tract; mild tenderness
Acute Periapical Abscess	Severe, throbbing pain with swelling	Fever, facial edema, lymphadenopathy

✅ Evidence-Based Protocols (AAPD, 2024–2025)

1. Diagnosis and Radiographic Evaluation
▪️ Record detailed history and perform percussion, palpation, and vitality tests.
▪️ Take periapical radiographs to evaluate pulpal and periapical status.
▪️ Classify condition using AAPD 2024 categories to guide treatment choice.

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2. Management Protocols
➤ Reversible Pulpitis
▪️ Perform indirect pulp therapy or restoration.
▪️ Place calcium hydroxide or glass ionomer liner and restore with composite or stainless steel crown.
➤ Irreversible Pulpitis (vital pulp)
▪️ Perform pulpotomy: remove coronal pulp, control bleeding, and apply MTA or Biodentine.
▪️ Seal with resin-modified glass ionomer and restore with a stainless steel crown.
➤ Pulp Necrosis / Chronic Abscess
▪️ If tooth is restorable, perform pulpectomy using resorbable filling materials like Vitapex or Metapex.
▪️ If non-restorable, perform extraction and maintain space when needed.
➤ Acute Abscess with Systemic Symptoms
▪️ Drain via tooth or incision.
▪️ Prescribe amoxicillin (20–40 mg/kg/day divided every 8h) or azithromycin/clindamycin if allergic.
▪️ Combine with definitive dental treatment and follow-up in 3–7 days.

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3. Follow-Up
▪️ Evaluate at 3, 6, and 12 months clinically and radiographically.
▪️ Success criteria: absence of pain, swelling, mobility, or radiolucency.

✍️ Conclusion
Management of pulpal infections in primary teeth must follow AAPD evidence-based protocols, prioritizing pulp vitality and infection control. The use of bioactive materials, accurate diagnosis, and periodic follow-up are essential to maintain oral health and prevent premature tooth loss in pediatric patients.

📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2024). Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. Pediatric Dentistry, 46(4), 290–302.
✔ American Academy of Pediatric Dentistry (AAPD). (2024). Use of Vital Pulp Therapies in Primary Teeth. Pediatric Dentistry, 46(Suppl 1), 1–36.
✔ Coll, J. A., Vargas, K. G., Marghalani, A. A., & Chen, J.-W. (2023). Evidence-based update on vital pulp therapy in primary teeth. International Journal of Paediatric Dentistry, 33(2), 134–147. https://doi.org/10.1111/ipd.13056
✔ Jain, S., Mittal, N., & Sharma, S. (2023). Comparative evaluation of Biodentine and MTA as pulpotomy agents in primary molars: A randomized clinical trial. Journal of Clinical Pediatric Dentistry, 47(1), 25–31. https://doi.org/10.17796/1053-4628-47.1.4

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Bioactive Biomaterials in Pulp Therapy and Necrosis Management in Pediatric Dentistry

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

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

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

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

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

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✅ Procedures and Techniques in Pulp Therapy

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

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

✅ Clinical Advantages

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

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✅ Limitations

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

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

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

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

✅ Clinical Recommendations

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

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📚 References

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

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Partial vs. Conventional Pulpotomy in Primary Teeth: A Comprehensive Clinical Guide for Pediatric Dentists

✅ Abstract
Partial pulpotomy and conventional pulpotomy are essential vital pulp therapy techniques for preserving the function and vitality of primary molars affected by deep carious lesions or traumatic exposures.

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This article provides an evidence-based comparison of both approaches, exploring indications, materials, clinical outcomes, and current recommendations for pediatric dental practice in 2025.

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✅ Introduction
Pulpotomy in primary teeth is indicated when the radicular pulp remains vital despite coronal pulp inflammation due to caries or trauma. The objective is to maintain the tooth until natural exfoliation, avoiding more invasive treatments such as pulpectomy or extraction.
Two main techniques are used:

▪️ Conventional pulpotomy, which removes all coronal pulp tissue and applies a medicament to the remaining radicular pulp.
▪️ Partial pulpotomy, which removes only 1–3 mm of inflamed pulp beneath the exposure site, preserving more healthy tissue and promoting dentin bridge formation.

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✅ Indications and Case Selection
Both partial and conventional pulpotomy are suitable for primary teeth with:

▪️ Reversible pulpitis
▪️ No spontaneous pain or mobility
▪️ No radiographic signs of periapical pathology
▪️ Restorable coronal structure
Partial pulpotomy is preferred when pulp exposure is small (less than 1 mm) and bleeding is controlled within 5 minutes, as it maximizes pulp vitality and long-term success.

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✅ Clinical Techniques

➤ Conventional Pulpotomy Procedure
▪️ Local anesthesia and rubber dam isolation
▪️ Caries removal and coronal access
▪️ Complete amputation of coronal pulp
▪️ Hemostasis with moist cotton pellet (3–5 minutes)
▪️ Application of formocresol, MTA, or ferric sulfate
▪️ Final restoration with stainless steel crown (SSC)

➤ Partial Pulpotomy Procedure
▪️ Isolation and caries removal
▪️ Removal of 1–3 mm of coronal pulp tissue
▪️ Hemostasis achieved in less than 5 minutes
▪️ Application of calcium silicate–based material (e.g., Biodentine, MTA)
▪️ Immediate restoration with composite or SSC

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✅ Material Selection and Biocompatibility
The choice of biomaterial is critical to pulpotomy success. Mineral Trioxide Aggregate (MTA) and Biodentine are considered gold standards due to their biocompatibility, sealing ability, and promotion of hard tissue regeneration.
Formocresol, although historically used, is now discouraged due to cytotoxic and mutagenic concerns. Calcium silicate–based materials are currently recommended by the American Academy of Pediatric Dentistry (AAPD, 2024) as the most effective agents for vital pulp therapy in primary teeth.

📊 Comparative Table: Materials Used in Pulpotomy Procedures

Material	Advantages	Limitations
Mineral Trioxide Aggregate (MTA)	Excellent biocompatibility; induces hard tissue barrier; high success rate (>94%)	Long setting time (2–4 hours); tooth discoloration; high cost
Biodentine	Fast setting (12 minutes); no discoloration; good sealing ability	Lower long-term data in primary teeth; cost higher than traditional agents
Ferric Sulfate (15.5%)	Effective hemostasis; shorter procedure time; cost-effective	No dentin bridge formation; potential for internal resorption
Formocresol	Historical gold standard; antibacterial; predictable outcomes	Potential mutagenicity; systemic distribution concerns; declining use
Calcium Hydroxide	Stimulates dentin bridge; low cost; antibacterial	High failure rate (30–40%); internal resorption risk
Sodium Hypochlorite (NaOCl)	Hemostatic agent; tissue solvent; enhances disinfection	Limited evidence as primary medicament; potential pulp irritation

✅ Clinical Outcomes and Evidence
Recent systematic reviews confirm the superior performance of partial pulpotomy:

▪️ Partial pulpotomy: 94–98% success at 24 months (Coll et al., 2023)
▪️ Conventional pulpotomy: 85–92% with MTA, 70–80% with formocresol (Smaïl-Faugeron et al., 2024)
▪️ Lower incidence of internal resorption and postoperative sensitivity with partial pulpotomy

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✅ Discussion and Future Directions
Advances in bioactive materials, such as bioceramic sealers and calcium-enriched cements, are transforming the management of pulp exposures. Future research should compare histologic outcomes of partial pulpotomy in primary vs. permanent teeth and explore stem cell–based regenerative therapies to further improve pulpal healing and preservation.

✅ Advantages and Limitations

1. Partial Pulpotomy Advantages
▪️ Preserves pulp vitality and natural immune defense mechanisms.
▪️ Stimulates dentin bridge formation and faster tissue healing.
▪️ Minimally invasive procedure with reduced chair time.
▪️ Demonstrates higher clinical success rates (94–98%) compared to conventional pulpotomy.
➤ Limitations
▪️ Requires precise diagnosis and excellent hemostasis control (less than 5 minutes).
▪️ Not suitable for large exposures (>2 mm) or irreversible pulpitis.
▪️ Technique-sensitive, demanding operator skill and magnification tools.

2. Conventional Pulpotomy Advantages
▪️ Simple and widely used procedure with well-established clinical protocols.
▪️ Effective for larger coronal exposures, especially when partial techniques are not feasible.
▪️ Can be performed with affordable materials and basic instruments.
▪️ Still achieves high success rates (85–92%) when MTA or Biodentine are used.

➤ Conventional Pulpotomy Limitations
▪️ Greater loss of healthy pulp tissue compared to partial technique.
▪️ Higher risk of internal resorption or calcific metamorphosis.
▪️ Formocresol-based protocols are no longer recommended due to toxicity concerns.
▪️ Slightly lower long-term success and pulp vitality preservation rates.

📊 Comparative Table: Partial vs. Conventional Pulpotomy in Primary Teeth

Aspect	Advantages	Limitations
Partial Pulpotomy	Preserves pulp vitality; promotes dentin bridge; success rate 94–98%	Limited to small exposures; requires strict hemostasis and skill
Conventional Pulpotomy	Effective for larger exposures; simple, standardized protocol	Higher resorption risk; lower success with non–calcium silicate materials

✅ Clinical Recommendations

▪️ Prefer partial pulpotomy for small exposures (less than 1 mm) in vital primary teeth.
▪️ Use MTA or Biodentine instead of formocresol.
▪️ Maintain rubber dam isolation during all procedures.
▪️ Always restore with stainless steel crowns for long-term sealing.
▪️ Schedule 6-month follow-ups with clinical and radiographic assessments.

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✍️ Conclusion
Partial pulpotomy stands out as the first-line treatment for vital primary molars with limited pulp exposure, offering higher success rates, lower complication risk, and better tissue preservation. Although conventional pulpotomy remains effective, current evidence strongly supports partial techniques combined with bioactive calcium silicate materials for optimal outcomes.

📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2024). Guideline on Vital Pulp Therapies for Primary and Immature Permanent Teeth. Pediatric Dentistry, 46(3), 221–235. Retrieved from https://www.aapd.org/research/oral-health-policies--recommendations/vital-pulp-therapies/
✔ Coll, J. A., Dhar, V., Vargas, K., Chen, C. Y., & American Academy of Pediatric Dentistry. (2023). Use of vital pulp therapies in primary teeth with deep caries lesions. Pediatric Dentistry, 45(5), 349–371. https://www.aapd.org/media/Policies_Guidelines/E_VPT.pdf
✔ Smaïl-Faugeron, V., Glenny, A. M., Courson, F., Durieux, P., Muller-Bolla, M., & Fron Chabouis, H. (2024). Pulp treatment for extensive decay in primary teeth. Cochrane Database of Systematic Reviews, 2024(3), CD003220. https://doi.org/10.1002/14651858.CD003220.pub3
✔ Cushley, S., Duncan, H. F., Lappin, M. J., Chua, P., Elamin, A. D., Clarke, M., & El-Karim, I. A. (2023). Efficacy of direct pulp capping for management of cariously exposed pulps in permanent teeth: A systematic review and meta-analysis. International Endodontic Journal, 56(2), 120–145. https://doi.org/10.1111/iej.13847

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

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

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

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

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

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

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

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

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

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✅ Clinical Benefits

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

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

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

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

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

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

📚 References

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

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