Updated Guidelines for Antibiotic Use in Pediatric Dentistry: Evidence-Based Recommendations

The judicious use of antibiotics in pediatric dentistry is crucial to combat antimicrobial resistance and ensure optimal patient outcomes. Overprescription and inappropriate antibiotic use in children contribute to the global health threat of antibiotic resistance, adverse drug reactions, and disruption of normal microbiota.

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This article discusses updated, evidence-based guidelines for antibiotic use in pediatric dental care, focusing on clinical indications, dosage, and the importance of antimicrobial stewardship.

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✅ Indications for Antibiotic Use in Pediatric Dentistry
According to the American Academy of Pediatric Dentistry (AAPD) and other professional bodies, antibiotics should be prescribed in pediatric patients only when there is clear evidence of systemic involvement or the risk of spread of odontogenic infections. The primary indications include:

° Acute facial swelling or cellulitis with systemic symptoms (fever, malaise)
° Rapidly progressing infections such as Ludwig’s angina or deep space infections
° Persistent infections not resolved by local measures alone
° Prophylaxis in patients at risk of infective endocarditis or with immunocompromising conditions

Local dental infections like localized abscesses or pulpitis do not typically require systemic antibiotics and are best managed by definitive dental treatment such as extraction or pulpectomy.

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✅ Commonly Recommended Antibiotics and Dosage
For pediatric patients, the most frequently recommended antibiotics are:

° Amoxicillin: 20–40 mg/kg/day divided every 8 hours, or 25–45 mg/kg/day if given twice daily
° Amoxicillin with Clavulanic Acid: Used when beta-lactamase resistance is suspected
° Clindamycin: 8–20 mg/kg/day in three divided doses (for penicillin-allergic patients)
° Azithromycin: 5–12 mg/kg on the first day followed by lower doses over 4 days

Prescribers must adjust dosages based on weight and age and consider the patient’s medical history, including allergies and hepatic or renal function.

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✅ Antibiotic Prophylaxis
The AAPD, following the American Heart Association (AHA) guidelines, recommends antibiotic prophylaxis for pediatric patients at high risk of infective endocarditis, especially before procedures likely to cause bleeding (e.g., tooth extractions, periodontal surgery). This includes:

° Children with prosthetic heart valves
° Previous infective endocarditis
° Certain congenital heart conditions
° Cardiac transplant recipients with valvulopathy

The standard prophylactic regimen is amoxicillin 50 mg/kg orally one hour before the procedure.

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💬 Discussion
Despite clear guidelines, studies reveal frequent antibiotic overprescription in pediatric dentistry. A cross-sectional study by Al-Jundi et al. (2022) indicated that many dentists prescribe antibiotics for non-indicated conditions such as reversible pulpitis, primarily due to parental expectations or time constraints. This inappropriate practice fosters resistance and increases adverse drug reactions, including gastrointestinal issues, allergic reactions, and alterations in the child’s developing microbiome.
Moreover, the COVID-19 pandemic initially led to increased remote consultations and a spike in empirical antibiotic prescriptions, further underscoring the need for robust antimicrobial stewardship programs in dental settings.
Educational interventions, integration of prescribing guidelines into electronic health systems, and continuing professional development can help reduce inappropriate prescribing practices. Collaborative efforts between pediatricians, pharmacists, and pediatric dentists are also essential.

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💡 Conclusion
Antibiotic use in pediatric dentistry should be reserved for cases with systemic involvement or significant risk of progression. Adherence to updated, evidence-based guidelines is critical to minimizing resistance and ensuring patient safety. Dental professionals must prioritize definitive treatment over pharmacologic management when possible and engage in continuous education to refine prescribing practices.

📚 References

✔ Al-Jundi, S. H., Mahmoud, S. Y., & Alsafadi, Y. H. (2022). Antibiotic prescribing practices among pediatric dentists in Jordan: A cross-sectional survey. BMC Oral Health, 22(1), 105. https://doi.org/10.1186/s12903-022-02156-3

✔ American Academy of Pediatric Dentistry. (2023). Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. Retrieved from https://www.aapd.org/research/oral-health-policies--recommendations/antibiotic-therapy/

✔ Wilson, W., Taubert, K. A., Gewitz, M., Lockhart, P. B., Baddour, L. M., Levison, M., ... & Baltimore, R. S. (2007). Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation, 116(15), 1736–1754. https://doi.org/10.1161/CIRCULATIONAHA.106.183095

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Medications for Pulp Capping in Primary Teeth: Indications, Composition, and Clinical Management

Pulp capping in primary teeth is a conservative procedure aimed at preserving pulp vitality following an accidental or intentional pulp exposure during caries removal.

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Its success largely depends on the material or medication used, which must be biocompatible, promote tissue repair, and provide an adequate marginal seal. With advances in biomaterials, the range of available products has expanded, making it essential to understand their properties, advantages, and limitations for proper clinical application.

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✅ Main Medications Used

1. Calcium Hydroxide (Ca(OH)₂)

➤ Composition: Pure calcium hydroxide or formulated with hardening agents (e.g., Dycal®).
➤ Indications: Small pulp exposures without prolonged bleeding, in vital primary teeth.
➤ Advantages:
° Stimulates reparative dentin formation.
° Antibacterial properties.
° Easy to handle.
➤ Disadvantages:
° Soluble in oral fluids.
° Poor sealing ability.
° Fragile under mechanical stress.
➤ Handling: Apply a thin layer over the exposure, followed by a protective material such as resin-modified glass ionomer (RMGI).

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2. Mineral Trioxide Aggregate (MTA)

➤ Composition: Calcium, silicate, and aluminum oxides. Commercial examples: ProRoot® MTA, MTA Angelus®.
➤ Indications: Direct pulp capping in vital pulps, small pulp perforations.
➤ Advantages:
° High biocompatibility.
° Excellent sealing ability.
° Stimulates dentin bridge formation.
➤ Disadvantages:
° High cost.
° Long setting time (~2–4 hours).
° Difficult to manipulate.
➤ Handling: Mix with sterile distilled water and apply over the pulp; allow complete setting before final restoration.

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3. Biodentine®

➤ Composition: Calcium oxide, tricalcium silicate, zirconium oxide (radiopacifier).
➤ Indications: Modern alternative to MTA for direct pulp capping.
➤ Advantages:
° Faster setting time (~12 minutes).
° Biocompatible.
° Better mechanical properties than MTA.
➤ Disadvantages:
° High cost.
° May require training for proper handling.
➤ Handling: Applied directly to the exposure with a spatula, no intermediate layer needed.

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4. Zinc Oxide Eugenol (ZOE)

➤ Composition: Zinc oxide mixed with eugenol.
➤ Indications: Indirect pulp capping only (not for direct use) due to cytotoxicity risks.
➤ Advantages:
° Sedative effect on pulp tissue.
° Easy handling.
Disadvantages:
° Cytotoxic if in direct contact with the pulp.
° Inhibits polymerization of resin composites.
➤ Handling: Used as a base in deep cavities with no pulp exposure.

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5. Resin-Modified Glass Ionomer (RMGI)

➤ Composition: Polyalkenoic acid, fluoroaluminosilicate glass, hydrophilic resin (HEMA).
➤ Indications: Intermediate layer over medications like Ca(OH)₂ or MTA.
➤ Advantages:
° Excellent adhesion to dentin.
° Fluoride release.
° Good mechanical resistance.
➤ Disadvantages:
° Should not be used alone in direct contact with pulp.
➤ Handling: Apply with microbrush or spatula, light-cure, and proceed with final restoration.

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💡 Conclusion
Choosing the appropriate medication for pulp capping in primary teeth should consider factors such as exposure size, pulp vitality, the material's ability to stimulate dentinogenesis, handling properties, and cost. While calcium hydroxide remains widely used, materials like MTA and Biodentine offer significant advantages in sealing ability and biocompatibility. Using an additional protective layer, such as RMGI, improves treatment longevity and reduces microleakage risk. Continuous education in modern biomaterials is essential for achieving predictable and successful outcomes in pediatric dentistry.

📚 References

✔ Aguilar, P., & Linsuwanont, P. (2011). Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. Journal of Endodontics, 37(5), 581–587. https://doi.org/10.1016/j.joen.2010.12.004

✔ Fuks, A. B. (2008). Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Journal of Endodontics, 34(7 Suppl), S18–S24. https://doi.org/10.1016/j.joen.2008.02.028

✔ Murray, P. E., García-Godoy, F., & Hargreaves, K. M. (2007). Regenerative endodontics: A review of current status and a call for action. Journal of Endodontics, 33(4), 377–390. https://doi.org/10.1016/j.joen.2006.09.013

✔ 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 mineral trioxide aggregate. Journal of Endodontics, 39(6), 743–747. https://doi.org/10.1016/j.joen.2013.01.005

✔ Rodd, H. D., Waterhouse, P. J., Fuks, A. B., Fayle, S. A., & Moffat, M. A. (2006). Pulp therapy for primary molars. International Journal of Paediatric Dentistry, 16(s1), 15–23. https://doi.org/10.1111/j.1365-263X.2006.00774.x

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Pulpotec® in Pulpotomy: Composition, Indications, Protocol & Clinical Pros and Cons

Pulpotec® is a radiopaque, non‑resorbable medicament widely used for pulpotomy/pulpitis treatment in vital primary and immature permanent molars, as well as for emergency root canal dressings.

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This in-depth article reviews its composition, clinical indications, advantages, disadvantages, and a standardized application protocol. Information is supported by recent clinical evidence.

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✅ 1. Composition
Pulpotec® is a two-part resinous paste comprising:

➤ Powder: polyoxymethylene, iodoform, and zinc oxide.
➤ Liquid: dexamethasone acetate, formaldehyde, phenol, guaiacol, and excipients.

These components combine to yield antimicrobial, anti-inflammatory, hemostatic, and soothing effects.

✅ 2. Indications
Pulpotec® demonstrates broad clinical applications:

➤ Primary molars: vital or mildly infected, including cases with abscess when pulpotomy is indicated.
➤ Immature permanent molars: to facilitate continued root development.
➤ Permanent molars in adults: pulpitis treatment or as a prep for abutments in prosthetics.

It is also effective in emergency intracanal dressings to relieve pain and swelling across multiple appointments.

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✅ 3. Advantages
Clinical studies support Pulpotec® due to its:

➤ High success rates: Clinical success of 93–100% and radiographic success of 83–100% in pulpotomies; compared favorably with MTA and formocresol.
➤ Rapid symptom relief: 80–100% of patients report immediate pain reduction; flare-ups post-op are rare (~1%).
➤ Ease of use and efficiency: Simplifies emergency endodontic treatment and supports long-term pulp health.

✅ 4. Disadvantages
Potential drawbacks include:

➤ Non‑resorbability: This may complicate exfoliation in primary molars.
➤ Formaldehyde content: Concerns over toxicity and rare allergic reactions.
➤ Limited histological regeneration: It promotes sclerosis rather than dentin bridge formation.
➤ Need for coronal seal: Success depends on proper restoration to prevent microleakage.

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✅ 5. Step-by-Step Clinical Use Protocol

Step 1. Diagnose pulpitis suitable for vital pulp therapy.
Step 2. Anesthetize and isolate the tooth (rubber dam recommended).
Step 3. Access and remove coronal pulp to canal orifice level.
Step 4. Irrigate with 5% NaOCl; dry chamber.
Step 5. Prepare a salin-damped sterile cotton pellet; confirm bleeding control.
Step 6. Insert Pulpotec® paste into chamber (or canal up to ~5 mm from apex in root-filled cases) using a file.
Step 7. Place a dry cotton pellet and temporary restorative material (e.g., IRM/Cavit).
Step 8. Schedule recall after 7 days; proceed to definitive restoration—ideally stainless steel crown or adhesive restoration.
Step 9. Evaluate post-op pain at intervals (8 h, 24 h, 48 h, 3 d, 1 wk).

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✅ 6. Clinical Evidence

➤ Prospective RCT (860 teeth): Pulpotec® intracanal dressing reduced incidence of inter-appointment flare-up to 1.16% at 24 h and 0.69% at 48 h, with complete pain relief by 7 days.
➤ Comparative pediatric studies:
° Pulpotec® and MTA showed 100% clinical success at 3–9 months; radiographic success favored Pulpotec® (100%) over MTA (92.9%) and formocresol (78.6%).
° At 24 months, radiographic success was 94.3% for Pulpotec®, 91.2% for MTA, 83.3% for formocresolile cotton pellet; confirm bleeding control.

💡 Conclusion
Pulpotec® is an effective and efficient pulpotomy and intracanal medicament providing high clinical and radiographic success, rapid pain relief, and broad indications. However, formaldehyde content and non-resorbability in primary teeth demand careful case selection and precise restoration. Clinicians should weigh its benefits and limitations against alternatives such as MTA or Biodentine.

📚 References

✔ Al-Dahan, Z. A. A., Zwain, A. M., & Haidar, A. (2013). Clinical and radiographical evaluation of pulpotomy in primary molars treated with Pulpotec®, Formocresol, and Mineral Trioxide Aggregate (MTA). Journal of Bagh College Dentistry, 25(4), 164–170.

✔ Faraj, B. M. (2013). Four years of clinical experience with the efficacy of Pulpotec® as a root canal dressing for the management and control of odontogenic pain: A prospective randomized clinical trial. Open Access Emergency Medicine, 12(4), 280–283.

✔ Karrem, M. A. (2012). Clinical and histopathological evaluation of different pulpotomy agents in primary teeth. Iraqi Academic Scientific Journal.

✔ Maslak, E. E., et al. (2020). Pulpotomy efficiency in primary molars: Outcomes of 24‑month randomized clinical trial. Tanta Dental Journal, 17(1), 9–14.

✔ Pulpotec®. (n.d.). Scientific data about Pulpotec® – Swiss solution for pulpotomy. Retrieved from pd-pulpotec.com

✔ Sandhu, S. S., & Nanda, S. (2013). Dental pulp response to collagen and Pulpotec cement. Journal of Conservative Dentistry, PMC3778626.

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Updated Criteria for the Selection of Antibiotic Dosage and Regimen in Dentistry

Antibiotic therapy in dentistry is essential for preventing and treating infections resulting from dental procedures.

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Correct selection of antibiotic dosage and regimen not only ensures therapeutic efficacy but also minimizes the risk of developing bacterial resistance and adverse effects.

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✅ A. Determining Factors in Antibiotic Selection

1. Identification of the Etiological Agent
Odontogenic infections are often polymicrobial, predominantly involving anaerobic and gram-positive aerobic bacteria. Precise identification of the causative agent allows for the selection of an antibiotic with an appropriate spectrum. However, due to the difficulty in isolating and culturing these microorganisms in daily practice, empirical selection based on local epidemiology and the nature of the infection is common.

2. Antibiotic Spectrum
The chosen antibiotic should be effective against the most common pathogens in odontogenic infections. For example, amoxicillin is effective against a wide range of gram-positive bacteria and some gram-negative ones, while clindamycin is preferred in patients allergic to penicillins due to its activity against anaerobes and gram-positive aerobes.

3. Pharmacokinetics and Pharmacodynamics
Understanding the absorption, distribution, metabolism, and excretion of the antibiotic is crucial for determining the dosage and frequency of administration. For instance, amoxicillin has good oral bioavailability and a half-life that allows for administration every 8 hours. Clindamycin, on the other hand, requires administration every 6 to 8 hours due to its shorter half-life.

4. Patient's Condition
The patient's systemic conditions, such as renal or hepatic insufficiency, can affect drug elimination, requiring dosage adjustments. Additionally, in immunocompromised patients, more aggressive or prolonged treatment may be necessary.

5. Possible Interactions and Adverse Effects
It is essential to consider drug interactions, especially in polymedicated patients. For example, erythromycin can interact with other drugs metabolized by the cytochrome P450 system, increasing the risk of toxicity. Moreover, some antibiotics can cause gastrointestinal adverse effects or allergic reactions that must be monitored.

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✅ B. Dosage and Regimen of Common Antibiotics in Dentistry
Below are the dosage and regimen recommendations for the most commonly used antibiotics in dentistry, based on clinical guidelines and recent studies:

1. Amoxicillin
° Indications: Common odontogenic infections.
° Adult dosage: 500 mg orally every 8 hours.
° Pediatric dosage: 20–40 mg/kg/day divided into three doses.
° Considerations: In severe infections, the dose may be increased to 1 g every 8 hours. Dosage adjustment is recommended in patients with renal insufficiency.

2. Amoxicillin/Clavulanic Acid
° Indications: Resistant infections or when beta-lactamase-producing bacteria are suspected.
° Adult dosage: 875 mg/125 mg orally every 12 hours.
° Pediatric dosage: 25–45 mg/kg/day divided into two doses.
° Considerations: The combination with clavulanic acid broadens amoxicillin's spectrum but may increase the incidence of gastrointestinal effects.

3. Clindamycin
° Indications: Patients allergic to penicillins; infections by anaerobes.
° Adult dosage: 300 mg orally every 6–8 hours.
° Pediatric dosage: 8–20 mg/kg/day divided into three or four doses.
° Considerations: Monitor for gastrointestinal side effects and the risk of pseudomembranous colitis.

4. Azithromycin
° Indications: Patients allergic to penicillins; infections by susceptible bacteria.
° Adult dosage: 500 mg once daily for three days.
° Pediatric dosage: 10 mg/kg once daily for three days.
° Considerations: Has a prolonged half-life, allowing for simplified dosing regimens.

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✅ C. Conclusions on the Selection of Antibiotic Dosage and Regimen in Dentistry

1. Evidence-Based Selection: The choice of antibiotics in dentistry should be based on the identification of the etiological agent, appropriate antibiotic spectrum, and updated clinical guidelines to ensure efficacy and safety in treating odontogenic infections.
2. Importance of Pharmacokinetics and Pharmacodynamics: Dosage and regimen should be adjusted considering the drug's absorption, metabolism, and excretion, as well as the patient's systemic condition, to avoid overdosing or bacterial resistance.
3. First-Line Antibiotics and Alternatives: Amoxicillin remains the antibiotic of choice for common dental infections, while clindamycin and azithromycin are safe options for patients with penicillin allergies.
4. Avoiding Antibiotic Abuse and Resistance: Empirical prescription should be prudent, considering the increasing bacterial resistance and the impact of indiscriminate antibiotic use on oral and general microbiota.
5. Individualized Treatment: Each patient should receive personalized antibiotic therapy, taking into account their clinical history, drug interactions, and potential adverse effects to optimize therapeutic response and reduce complications.

In conclusion, the rational use of antibiotics in dentistry is essential for effective infection treatment, minimizing risks, and contributing to the fight against microbial resistance.

📚 References

✔ Bascones Martínez, A., Aguirre Urizar, J. M., Bermejo Fenoll, A., Blanco Carrión, A., Gay Escoda, C., González Moles, M. Á., ... & Llamas Martín, R. (2006). Documento de consenso sobre la utilización de profilaxis antibiótica en cirugía y procedimientos dentales. Avances en Odontoestomatología, 22(1), 43-53.

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Medications Used in Pulpotomies: Properties, Drawbacks, and Brand Names

Pulpotomy is a conservative dental procedure aimed at preserving the vitality of the radicular pulp after removing the affected coronal pulp. This treatment is common in primary teeth and young permanent teeth.

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Selecting the right medication is crucial for clinical success. Below is an overview of the most commonly used pulpotomy agents, their properties, drawbacks, and commercial names.

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✅ 1. Formocresol

➤ Brand Name: Buckley’s Formocresol
➤ Composition: 19% formaldehyde, 35% cresol, 15% glycerin, 21% water
➤ Properties:
° Bactericidal and tissue-fixative agent
° Mummifies remaining pulp tissue
° Easy to handle and low cost
➤ Drawbacks:
° Potentially carcinogenic and mutagenic
° Cytotoxic and allergenic
° Does not promote pulp tissue regeneration
➤ Clinical Notes:
° Although historically effective, its use has declined due to toxicity concerns.

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✅ 2. Ferric Sulfate

➤ Brand Name: Astringedent®
➤ Composition: 15.5% aqueous solution of ferric sulfate (pH 1.0)
➤ Properties:
° Effective hemostatic agent
° Forms a protein barrier sealing blood vessels
° Affordable and easy to apply
➤ Drawbacks:
° Does not promote pulp regeneration
° May cause radicular inflammation and resorption
➤ Clinical Notes:
° A less toxic alternative to formocresol, but with variable long-term success.

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✅ 3. Calcium Hydroxide (Ca(OH)₂)

➤ Brand Name: Dycal®
➤ Properties:
° Stimulates reparative dentin formation
° Highly alkaline with bactericidal effect
° Biocompatible
➤ Drawbacks:
° May cause superficial pulp necrosis
° Lower success rate in primary teeth
° Tends to dissolve over time
➤ Clinical Notes:
° More suitable for young permanent teeth; limited use in primary dentition.

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✅ 4. Mineral Trioxide Aggregate (MTA)

➤ Brand Name: ProRoot® MTA
➤ Composition: Tricalcium silicate, dicalcium silicate, tricalcium aluminate, bismuth oxide
➤ Properties:
Highly biocompatible
Stimulates dentin formation
Excellent sealing and antimicrobial properties
➤ Drawbacks:
High cost
Difficult manipulation and long setting time
➤ Clinical Notes:
Studies report a 97.9% clinical success rate in pediatric pulpotomies, outperforming other agents.

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✅ 5. Biodentine

➤ Brand Name: Biodentine®
➤ Composition: Tricalcium silicate, dicalcium silicate, calcium oxide, calcium chloride, zirconium oxide
➤ Properties:
° Bioactive dentin substitute
° Mechanical properties similar to natural dentin
° Fast setting time and good radiopacity
➤ Drawbacks:
° High cost
° Limited long-term clinical evidence compared to MTA
➤ Clinical Notes:
° A promising MTA alternative with easier handling and shorter setting time.

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✅ 6. Zinc Oxide Eugenol (ZOE)

➤ Brand Name: IRM® (Intermediate Restorative Material)
➤ Properties:
° Soothing effect on dental pulp
° Antimicrobial and anti-inflammatory properties
° Easy to handle and inexpensive
➤ Drawbacks:
° Does not induce reparative dentin formation
° May dissolve over time
➤ Clinical Notes:
° Commonly used as a base or sealing material in pulpotomies.

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✅ 7. Pulpotec® Paste

➤ Brand Name: Pulpotec®
➤ Composition:
° Powder: Polyoxymethylene, iodoform
° Liquid: Dexamethasone, formaldehyde, phenol, guaiacol
➤ Properties:
° Induces healing of the pulp stump
° Aseptic and quick treatment
° Effective in both primary and permanent teeth
➤ Drawbacks:
° Contains formaldehyde, which has cytotoxic potential
° Not resorbable
➤ Clinical Notes:
° Long-term success reported in studies, though formaldehyde content limits its use in some cases.

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💡 Conclusion
The choice of pulpotomy medication must be based on a careful evaluation of its properties, disadvantages, and available clinical evidence. While formocresol has been widely used, toxicity concerns have led to the rise of safer and more effective alternatives like MTA and Biodentine. The ideal agent depends on factors such as the patient's age, tooth condition, and specific clinical considerations.

📚 References

✔ Holguin Garcia, S. G. (2019). Eficacia clínica del MTA en Pulpotomías de pacientes pediátricos: Una Revisión Sistemática. Revista de Odontopediatría Latinoamericana, 11(1). https://doi.org/10.47990/alop.v11i1.228

✔ Wikipedia. (2025). Pulpotomía. Retrieved from https://es.wikipedia.org/wiki/Pulpotom%C3%ADa

✔ Apuntes De Odontología. (2015). Pulpotomía. Retrieved from https://apuntes-de-odontologia.blogspot.com/2015/04/pulpotomia.html

✔ Studocu. (2018). Terapia Pulpar I – Dra. Andrea Cárdenas Antonieta Montero. Retrieved from https://www.studocu.com/cl/document/universidad-finis-terrae/odontopediatria/terapia-pulpar-i/4935194

✔ Revista Odontopediatría. (2014). Tratamiento Endodóntico no Instrumentado en dientes deciduos. Retrieved from https://backup.revistaodontopediatria.org/ediciones/2014/1/art-6/

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Clinical Pulpectomy Protocol: Updated Step-by-Step Guide

Pulpectomy is a fundamental procedure in pediatric dentistry for treating primary teeth with pulp inflammation or necrosis.

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Its main goal is to eliminate infection, maintain tooth functionality until natural exfoliation, and preserve dental space.

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✅ 1. Case Selection

➤ Indications:
° Necrotic pulp or irreversible inflammation.
° Primary tooth with deep caries, abscesses, or fistulas.
° Persistent pain or prolonged sensitivity.
➤ Contraindications:
° Advanced pathological root resorption.
° Severe tooth mobility.
° Loss of bone support or involvement of the permanent tooth germ.

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✅ 2. Step-by-Step Procedure

➤ a. Anesthesia and Isolation:
° Administer appropriate local anesthesia (4% Articaine with 1:100,000 epinephrine).
° Place rubber dam isolation to prevent contamination.
➤ b. Caries Removal and Pulp Access:
° Remove caries using high-speed burs and open the pulp chamber to fully expose the canals.
° Rinse with sterile saline solution or 2% chlorhexidine.
➤ c. Instrumentation and Disinfection:
° Instrument canals using manual or rotary files up to the apical limit (2 mm before the radiographic apex).
° Irrigate abundantly with 1–2.5% sodium hypochlorite, followed by saline solution to neutralize.
➤ d. Drying and Obtaining Clean Canals:
° Dry canals with sterilized paper points.
° Confirm absence of necrotic debris or bleeding before obturation.
➤ e. Obturation:
° Select appropriate obturation material:

• Zinc oxide and eugenol (ZOE): Traditional material.
• Iodoform-based pastes (Metapex™ or Vitapex™): For better resorption and antimicrobial properties.
• MTA or Biodentine: In cases with apical perforations or significant bone involvement.

° Insert material using a syringe or condenser, ensuring a hermetic seal.
➤ f. Final Restoration:
° Restore the tooth with suitable material like composite resin or place a stainless steel crown to ensure function and prevent reinfection.

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✅ 3. Key Recommendations
° Radiographic Control: Perform preoperative and postoperative radiographs to verify proper sealing.
° Regular Follow-up: Schedule check-ups every 3–6 months to assess treatment success and detect possible complications.
° Material Selection: Prefer biocompatible materials like Metapex™ or Biodentine to improve clinical outcomes.

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✅ 4. Conclusions
Pulpectomy is a predictable and effective procedure when performed following a rigorous clinical protocol. The selection of obturation material plays a crucial role in the long-term success of the treatment. With the advancement of materials like Metapex™ and MTA, success rates have significantly improved. However, regular follow-up and appropriate final restoration are essential to ensure the functionality and health of the treated tooth.

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Fluoride Varnish in Pediatric Dentistry: Benefits, Indications, Mechanism, and Application Protocol

Dental caries remains one of the most prevalent chronic diseases in childhood worldwide. According to the World Health Organization (WHO), up to 60–90% of school-aged children are affected by dental caries, significantly impacting their health and quality of life. In this context, fluoride varnish has emerged as a highly effective preventive strategy in pediatric dentistry, endorsed by major health organizations globally.

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Fluoride varnish is a topical treatment used to prevent, slow down, or even reverse the early stages of dental caries in children. Due to its ease of application, safety, and efficacy, it has become an essential part of caries management in clinical pediatric practice.

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✅ Benefits of Fluoride Varnish in Children
The use of fluoride varnish offers multiple benefits in the pediatric population:

🛡️ Caries prevention: Enhances enamel resistance to acid attacks by increasing fluoride availability on the tooth surface.
🦷 Enamel remineralization: Promotes the repair of early carious lesions (white spots), avoiding invasive treatments.
👶 Safe for young children: Due to its quick setting time and minimal ingestion risk, it is ideal for toddlers and young patients.
⏱️ Fast and non-invasive: Application is completed within minutes and causes minimal discomfort.
📈 Cost-effective: Reduces the need for restorative treatments and associated healthcare costs.

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✅ Clinical Indications in Pediatric Dentistry
Fluoride varnish is recommended in various clinical situations, including:

➤ Children at high risk of dental caries, particularly those with poor oral hygiene, high sugar intake, or socioeconomic barriers to dental care.
➤ Children undergoing orthodontic treatment, where plaque retention increases caries risk.
➤ Patients with enamel hypoplasia or demineralization.
➤ Children with special healthcare needs, who may have difficulties with standard oral hygiene routines.
➤ As a preventive adjunct during routine dental check-ups, typically every 3 to 6 months.

The American Dental Association (ADA) and the American Academy of Pediatric Dentistry (AAPD) both support the use of fluoride varnish as a routine preventive intervention in children beginning at the eruption of the first primary tooth.

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✅ Mechanism of Action
Fluoride varnish functions by:

➤ Enhancing enamel remineralization: When applied to teeth, the varnish delivers a high concentration of fluoride ions that interact with calcium and phosphate in saliva, forming fluorapatite — a more acid-resistant mineral than hydroxyapatite.
➤ Inhibiting demineralization: Fluoride ions integrate into the enamel matrix, making it less soluble under acidic conditions.
➤ Antimicrobial effect: Fluoride can inhibit the enzymatic activity of cariogenic bacteria, such as Streptococcus mutans, thereby reducing acid production.

Typically, the varnish contains 5% sodium fluoride (NaF), equivalent to 22,600 ppm of fluoride, suspended in a resin or alcohol-based solution that hardens upon contact with saliva, ensuring prolonged fluoride contact with the enamel surface.

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✅ Frequency of Application
The recommended frequency depends on the child’s caries risk:

➤ Low caries risk: Every 6 months.
➤ Moderate to high caries risk: Every 3 to 4 months.

These intervals are supported by clinical trials demonstrating that repeated applications significantly reduce caries incidence in primary and permanent teeth. Importantly, fluoride varnish is safe to use even in children under the age of six, as ingestion is minimal due to the rapid setting time and small quantity used.

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✅ Conclusion
Fluoride varnish is a cornerstone of modern pediatric preventive dentistry. Its proven efficacy in caries prevention, ease of application, and safety profile make it an indispensable tool for dental professionals. Early and regular use, especially in high-risk children, not only improves oral health outcomes but also reduces the need for restorative interventions, promoting a lifetime of healthy smiles.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Guideline on Fluoride Therapy. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry. Retrieved from https://www.aapd.org/research/oral-health-policies--recommendations/fluoride-therapy/

✔ Centers for Disease Control and Prevention. (2022). Use of Fluoride in the Prevention of Dental Caries in the Primary Care Setting. MMWR Recommendations and Reports. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

✔ Weyant, R. J., Tracy, S. L., Anselmo, T. T., Beltrán-Aguilar, E. D., Donly, K. J., Frese, W. A., ... & Zero, D. T. (2013). Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. Journal of the American Dental Association, 144(11), 1279–1291. https://doi.org/10.14219/jada.archive.2013.0057

✔ Marinho, V. C. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (7). https://doi.org/10.1002/14651858.CD002279.pub2

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Silver Diamine Fluoride in Pediatric Dentistry: Clinical Guide 2025

Silver Diamine Fluoride (SDF) at 38% concentration has become an effective, safe, and minimally invasive alternative for the prevention and treatment of dental caries in pediatric patients.

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Its topical application allows the arrest of carious lesions without the need for invasive procedures, making it especially useful in children with high caries risk, behavioral challenges, or limited access to dental care.

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✅ 1. Scientific Basis
SDF combines the antibacterial properties of silver with the remineralizing effect of fluoride. Its mechanism of action includes:

° Bacterial inhibition: Silver ions denature bacterial proteins and enzymes, inhibiting their proliferation.
° Remineralization: Fluoride promotes the formation of fluorohydroxyapatite, strengthening enamel.
° Tubule occlusion: Helps reduce sensitivity and prevent further caries progression.

Recent studies have demonstrated the effectiveness of SDF in arresting active caries, with success rates exceeding 80% in primary dentition.

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✅ 2. Indications

° Active carious lesions in primary and young permanent teeth
° Children with high caries risk (e.g., severe early childhood caries)
° Patients with behavioral or medical challenges
Situations where conventional restorative treatment is not feasible

✅ 3. Contraindications

° Known allergy to silver, ammonium, or fluoride
° Oral ulcerative lesions, stomatitis, or mucositis
° Carious lesions with pulpal involvement or symptoms of irreversible pulpitis

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✅ 4. Application Protocol

➤ Required materials:
° 38% SDF solution
° Disposable microbrushes
° Sterile gauze
° Gloves and eye protection

➤ Procedure:
1. Clinical assessment: Identify active carious lesions visually and radiographically if needed.
2. Isolation: Dry the affected area with gauze (rubber dam is not necessary).
3. Application: Use a microbrush to apply a small amount of SDF directly to the lesion for 1–3 minutes.
4. Drying: Allow the area to air dry; avoid rinsing immediately.
5. Follow-up: Reassess in 2–4 weeks to determine lesion arrest.

➤ Frequency:
° In high-risk patients or those with poor oral hygiene, reapplication is recommended every 6 months.
° In low-risk patients, annual application may be sufficient.

✅ 5. Side Effects and Aesthetic Considerations

The main side effect is permanent black staining of the treated lesion, indicating caries arrest. While safe, this discoloration can be esthetically undesirable, especially on anterior teeth. To mitigate this, potassium iodide may be applied immediately after SDF to reduce staining intensity.

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✅ 6. Parental Acceptance

Parental acceptance of SDF depends on lesion location, the child’s behavior, and prior information provided. It is crucial to explain the benefits and possible esthetic outcomes to obtain informed consent.

✅ 7. Conclusions

38% SDF is a valuable tool in modern pediatric dentistry, offering an effective and non-invasive option for treating dental caries in children. Its simple, safe, and well-tolerated application is especially beneficial for vulnerable populations or those with limited access to care. Standardized protocols and proper parental education are essential to maximize its benefits.

📚 References

✔ Juarez Lopez, M. L. A., Marin Miranda, M., & Murrieta Pruneda, F. (2021). Silver Diamine Fluoride as a minimally invasive alternative in pediatric dental care: Narrative review. Revista de Odontopediatría Latinoamericana, 11(Suppl). https://doi.org/10.47990/alop.v11iSuplemento.482
✔ Sotillo, V., Limongi, I., Medina, A. C., & Martínez Vásquez, M. G. (2023). Silver Diamine Fluoride as therapy to inactivate cavitated caries lesions in primary teeth. Revista Científica CMDLT, 16. https://doi.org/10.55361/cmdlt.v16i1.71
✔ Pariona-Minaya, M. C. (2024). Use of Silver Diamine Fluoride for treating active carious lesions. Odontología Activa Revista Científica, 5(3). https://doi.org/10.31984/oactiva.v5i3.499
✔ Sabbagh, H., Othman, M., & Yaseen Abdulgader, A. A. (2020). Parental Acceptance of Silver Diamine Fluoride Application on Primary Dentition: a Systematic Review and Meta-analysis. BMC Oral Health, 20(227):1-12. https://www.siicsalud.com/dato/resiic.php/165298
✔ Chimbo Sánchez, K. D. (2024). Uses of Silver Diamine Fluoride and its application in pediatric dentistry. Systematic review. Repositorio Digital Uniandes. https://dspace.uniandes.edu.ec/handle/123456789/17914

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Anesthesia in Pediatric Dentistry: Is It Safe for Children?

Anesthesia in pediatric dentistry is an essential tool to ensure that dental procedures in children are performed comfortably and without pain.

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However, the safety of its application in pediatric patients is a common concern among parents and healthcare professionals. This article addresses the risks associated with dental anesthesia in children and the necessary precautions to ensure its safe use.

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✅ Local Anesthesia in Pediatric Dentistry

Local anesthesia involves the temporary loss of sensation in a specific area of the body without affecting the patient’s level of consciousness. In pediatric dentistry, it is commonly used for procedures such as fillings, extractions, and root canal treatments on primary teeth.

➤ Safety and Effectiveness
Local anesthesia is generally safe in children when properly administered. Local anesthetics such as lidocaine and articaine are widely used. Lidocaine 2% with epinephrine 1:100,000 is considered the gold standard, while 4% articaine has proven to be equally effective and safe in pediatric procedures.
It is important to calculate the correct dosage based on the child’s weight and to monitor for any adverse reactions. Side effects are rare but may include allergic reactions or systemic toxicity if administered in excess.

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✅ Sedation in Pediatric Dentistry

Sedation is used to help children who experience anxiety or fear during dental procedures. There are different levels of sedation: minimal, moderate, deep, and general anesthesia.

➤ Conscious Sedation
Conscious sedation allows the child to be relaxed but still awake and responsive to stimuli. Nitrous oxide, also known as "laughing gas," is a popular option in pediatric dentistry. Its use has been shown to be safe and effective, with a low incidence of adverse effects.
➤ Deep Sedation and General Anesthesia
In more complex cases, or when the child is non-cooperative, deep sedation or general anesthesia may be required. These techniques must be administered by trained professionals in controlled environments, such as hospitals or specialized clinics, to ensure the patient’s safety.

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✅ General Safety Considerations

➤ Preoperative Evaluation: A full medical evaluation is essential before administering any type of anesthesia or sedation.
➤ Monitoring: Continuous monitoring of blood pressure, heart rate, and oxygen saturation is required during the procedure.
➤ Staff Training: Personnel administering anesthesia or sedation must be trained and prepared to handle any pediatric emergencies.
➤ Informed Consent: Parents or guardians should be thoroughly informed about the procedure, its risks, and available alternatives.

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✅ Conclusion

Anesthesia and sedation in pediatric dentistry are safe when performed following proper protocols by trained professionals. The choice between local anesthesia and sedation will depend on the nature of the procedure, the child’s age, and their level of anxiety. An individualized evaluation is essential to ensure the safety and well-being of pediatric patients.

📖 References

✔ Patiño Ortíz, P. E., & Chiriboga Ramón, P. L. (2022). Anesthesia in pediatric dentistry: conventional and alternative systems. ResearchGate. https://www.researchgate.net/publication/362011260
✔ Sociedad Española de Odontopediatría. (2013). Premedication and sedation protocol in pediatric dentistry. https://www.odontologiapediatrica.com/wp-content/uploads/2018/06/SedacionSEOP.pdf
✔ Torres Lefián, C., Sandoval Gorigoytía, J., & Monsalve Reyes, V. (2024). Safety of nitrous oxide as conscious sedation in pediatric dentistry: A scoping review. International Journal of Odontostomatology, 18(3), 305-310. https://ijodontostomatology.com/wp-content/uploads/2024/10/2024_v18n3_008.pdf
✔ Campos Medina, A. S. (2022). Scientific evidence on the use of local anesthetics in pediatric dentistry. Universidad Señor de Sipán. https://repositorio.uss.edu.pe/bitstream/handle/20.500.12802/9535/Campos%20Medina%20Alicia%20Sarai.pdf
✔ Soto, D., Chourio, F., & Pino, R. (2022). Administration of local anesthetics in pediatric dentistry. La Pasión del Saber, 12(21), 55–67. https://lapasiondelsaber.ujap.edu.ve/index.php/lapasiondelsaber-ojs/article/view/38
✔ Gaceta Dental. (2011). Sedation and general anesthesia in pediatric dental patients. https://gacetadental.com/2011/09/sedacin-y-anestesia-general-en-el-paciente-odontopeditrico-4338/
✔ Cadena SER. (2025, March 12). Conscious sedation in Hospital Dental Care: pain-free and anxiety-free treatments in Madrid. https://cadenaser.com/cmadrid/2025/03/12/sedacion-consciente-en-odontologia-hospitalaria-integral-tratamientos-sin-dolor-ni-ansiedad-en-madridsalud-y-bienestar-radio-madrid/
✔ Cadena SER. (2025, February 19). 'Mejor Acompáñame' platform calls for parents to accompany children during pre-sedation. https://cadenaser.com/aragon/2025/02/19/nace-la-plataforma-mejor-acompaname-para-que-los-menores-no-entren-solos-en-el-proceso-de-sedacion-radio-jaca-ser-pirineos/

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Management of Anaphylactic Shock in Children: Updated Guide for Dentists – Effective Prevention and Treatment

Pediatric dental care comes with various risks, including the possibility of anaphylactic reactions. Although rare, anaphylactic shock represents a life-threatening emergency that requires immediate recognition and management.

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In the last six years, new research has emphasized the importance of well-established emergency protocols in pediatric dental practice. This article addresses the definition, signs and symptoms, and updated management of anaphylactic shock in children during dental procedures.

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✅ Definition
Anaphylactic shock is an acute, severe, and rapidly progressive systemic allergic reaction characterized by cardiovascular, respiratory, and/or gastrointestinal dysfunction, potentially fatal if not treated immediately (Simons et al., 2020). Anaphylaxis occurs after exposure to an allergen, such as local anesthetics, latex, antibiotics, or dental materials, and can develop within seconds or minutes.
According to the World Allergy Organization (WAO), anaphylactic shock involves severe hypotension or circulatory collapse associated with signs of organ hypoperfusion due to the massive release of inflammatory mediators (Muraro et al., 2022).

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✅ Signs and Symptoms
Early identification of signs and symptoms is crucial for successful management. These can be classified as:

➤ Cutaneous
Generalized urticaria
Angioedema (swelling of the lips, eyelids, or tongue)
Erythema
Itching
➤ Respiratory
Dyspnea
Laryngeal stridor
Bronchospasm
Persistent cough
Hoarseness
➤ Cardiovascular
Hypotension
Tachycardia
Arrhythmias
Dizziness or syncope
➤ Gastrointestinal
Nausea
Vomiting
Abdominal pain
Diarrhea
In children, respiratory symptoms tend to predominate over cardiovascular ones, highlighting the need for special attention to airway alterations during dental care (Turner et al., 2019).

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✅ Management of Anaphylactic Shock in Dental Care
The success of managing an anaphylactic reaction in the dental office depends on the preparation of the team, the knowledge of emergency protocols, and the availability of appropriate medications.

➤ Prevention
Before treatment:
° Conduct a thorough medical history.
° Identify any known allergies (latex, local anesthetics, antibiotics).
° Avoid sensitizing agents if there is a history of hypersensitivity.

➤ Immediate Management
1. Discontinue the dental procedure and remove the allergen if possible.
2. Administer intramuscular epinephrine (IM) in the anterolateral thigh. It is the first-line treatment:
° Pediatric dose: 0.01 mg/kg body weight (maximum 0.5 mg) every 5-15 minutes as needed (Shaker et al., 2020).
3. Place the patient in a supine position with the lower extremities elevated to favor venous return.
4. Administer supplemental oxygen at high flow (8–10 L/min).
5. Establish intravenous access for the administration of fluids if signs of shock are present.
6. Complementary therapies:
° Antihistamines (such as diphenhydramine) to control cutaneous symptoms.
° Systemic corticosteroids (such as hydrocortisone) to prevent biphasic reactions.
° Bronchodilators (such as albuterol inhaled) if bronchospasm occurs.
7. Activate emergency medical services for hospital transfer, even if symptoms are controlled in the office

➤ Special Considerations in Pediatrics
° Adjusted doses based on body weight.
° Closer respiratory monitoring, due to the high frequency of airway obstructions in children.
° Availability of pediatric epinephrine autoinjectors in high-risk offices.

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✅ Relevant Updates (2018–2024)
New clinical guidelines emphasize the importance of early administration of epinephrine, even with mild symptoms, to improve prognosis (Muraro et al., 2022).
Standardized dental emergency protocols have been developed, including visual algorithms to facilitate rapid response (Simons et al., 2020).
Research highlights the use of pediatric epinephrine autoinjectors as a safety measure in high-risk dental offices (Turner et al., 2019).

✅ Conclusion
Anaphylactic shock in children during dental care, while infrequent, represents a critical emergency that requires immediate intervention. Early recognition of symptoms, prompt epinephrine administration, and activation of emergency services are key to a successful outcome. Ongoing training of dental staff in emergency management protocols, the availability of emergency equipment, and thorough medical histories are essential for preventing fatal outcomes. Adhering to updated protocols based on current evidence ensures safer and more effective care in pediatric dental settings.

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📖 References
✔ Muraro, A., Worm, M., Alviani, C., Cardona, V., DunnGalvin, A., Eigenmann, P., ... & Sheikh, A. (2022). EAACI Guidelines on Anaphylaxis: 2022 update of the evidence base and support for the use of adrenaline auto-injectors. Allergy, 77(2), 358-377. https://doi.org/10.1111/all.15027
✔ Shaker, M. S., Wallace, D. V., Golden, D. B. K., Oppenheimer, J., Bernstein, J. A., Campbell, R. L., ... & Greenhawt, M. (2020). Anaphylaxis—a 2020 practice parameter update, systematic review, and GRADE analysis. Journal of Allergy and Clinical Immunology, 145(4), 1082-1123. https://doi.org/10.1016/j.jaci.2020.01.017
✔ Simons, F. E. R., Ardusso, L. R. F., Dimov, V., Ebisawa, M., El-Gamal, Y. M., Lockey, R. F., & World Allergy Organization. (2020). World Allergy Organization Anaphylaxis Guidance 2020. World Allergy Organization Journal, 13(10), 100472. https://doi.org/10.1016/j.waojou.2020.100472
✔ Turner, P. J., Jerschow, E., Umasunthar, T., Lin, R., Campbell, D. E., & Boyle, R. J. (2019). Fatal anaphylaxis: mortality rate and risk factors. Journal of Allergy and Clinical Immunology, 137(2), 597-606. https://doi.org/10.1016/j.jaci.2015.11.017

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Glass Ionomer Cement in Pediatric Dentistry: Benefits, Uses, and Step-by-Step Application Guide

Glass ionomer cement (GIC) is a widely used dental material in pediatric dentistry due to its strong adhesion, fluoride release, and biocompatibility.

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This article explores its characteristics, advantages, disadvantages, clinical applications, and a step-by-step guide for proper use.

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Characteristics of Glass Ionomer Cement
Glass ionomer cement consists of a powder and a liquid that, when mixed, form a rigid, adhesive matrix. The powder contains fluoroaluminosilicate glass, while the liquid consists of polyalkenoic acids in an aqueous solution. This composition enables chemical bonding to the tooth structure and sustained fluoride release, aiding in enamel remineralization and cavity prevention.

Benefits of Glass Ionomer Cement in Pediatric Dentistry
1. Fluoride Release: Provides long-term fluoride release, strengthening enamel and reducing the risk of cavities.
2. Chemical Adhesion: Bonds directly to enamel and dentin without the need for acid etching, simplifying clinical procedures.
3. Biocompatibility: Well-tolerated by dental and soft tissues, minimizing adverse reactions.
4. Thermal Expansion Similar to Natural Teeth: Reduces the risk of marginal leakage and ensures long-lasting adaptation.

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Disadvantages of Glass Ionomer Cement
1. Lower Mechanical Strength: Less resistant to wear and occlusal forces compared to composite resins.
2. Aesthetic Limitations: While improved, its translucency and color range may not fully match natural tooth appearance.
3. Moisture Sensitivity During Placement: Requires proper moisture control to prevent property alterations.

Uses of Glass Ionomer Cement in Pediatric Dentistry
° Restorations for Primary Teeth: Ideal for Class I, II, and V cavities in deciduous teeth due to its adhesion and fluoride release.
° Pit and Fissure Sealants: Used as a sealant in newly erupted permanent molars to prevent cavities.
° Liners and Bases: Serves as a protective base under restorations, providing thermal and chemical insulation.
° Cementation of Pediatric Crowns: Used for cementing stainless steel crowns on primary teeth.

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Step-by-Step Application of Glass Ionomer Cement
1. Cavity Preparation: Remove decayed tissue and clean the cavity without overextending margins.
2. Conditioning: Apply 10% polyacrylic acid for 10-15 seconds to enhance adhesion, then rinse and gently dry without dehydrating.
3. Mixing the Material: Follow the manufacturer’s recommended powder-to-liquid ratio, mixing until a homogeneous consistency is achieved.
4. Placement: Apply the glass ionomer cement into the prepared cavity, ensuring proper adaptation and avoiding air bubbles.
5. Initial Setting: Allow the material to set according to manufacturer instructions while protecting it from moisture and desiccation.
6. Finishing and Polishing: Once set, refine the restoration, adjust occlusion, and polish for improved aesthetics and longevity.

Conclusion
Glass ionomer cement is a valuable material in pediatric dentistry due to its adhesive properties, fluoride release, and biocompatibility. While it has some limitations in mechanical strength and aesthetics, its benefits for cavity prevention and ease of use make it a preferred choice for various pediatric dental applications.

References
1. Croll, T. P., & Nicholson, J. W. (2002). Glass ionomer cements in pediatric dentistry: Review of the literature. Pediatric Dentistry, 24(5), 423-429. Recuperado de
2. Berg, J. H. (2002). Glass ionomer cements. Pediatric Dentistry, 24(5), 430-438. Recuperado de
3. Sikka, N., & Brizuela, M. (2024). Glass Ionomer Cement. En StatPearls. StatPearls Publishing

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