Regenerative Pulp Therapy in Pediatric Dentistry: When Is It Truly Indicated?

Regenerative pulp therapy is increasingly discussed in pediatric dentistry, but its clinical indication is narrower than the term may suggest.

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In current clinical practice, regenerative endodontic procedures (REPs) are primarily considered for immature permanent teeth with pulp necrosis, particularly when continued root development would provide a biological advantage.

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This distinction is important because regenerative endodontics should not be confused with vital pulp therapy, such as indirect pulp treatment or pulpotomy.
In a vital immature permanent tooth, preservation of the existing pulp is generally the preferred biological strategy; regeneration is primarily considered when the pulp is already necrotic and conventional treatment would leave a tooth with thin dentinal walls and an open apex.
The current AAPD guidance specifically identifies regenerative endodontics as an option for immature permanent teeth with necrotic pulp and apical periodontitis.

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✅ What Is Regenerative Endodontic Therapy?
Regenerative endodontic procedures (REPs) are biologically based treatments designed to disinfect the canal while creating conditions that may permit tissue ingrowth and continued development of an immature permanent root.

Unlike conventional root canal treatment, which removes the infected pulp and obturates the canal, REPs aim to preserve the potential for:
▪️ Continued root lengthening ▪️ Thickening of dentinal walls ▪️ Apical maturation ▪️ Resolution of periapical inflammation or apical periodontitis

Importantly, radiographic evidence of continued root development does not necessarily demonstrate regeneration of a normal pulp-dentin complex. Current literature emphasizes that clinical success and tooth survival are more predictable than true pulp regeneration or recovery of normal pulp function.

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✅ When Is Regenerative Therapy Actually Indicated?
The strongest clinical indication is an immature permanent tooth with necrotic pulp and an open apex, especially when the tooth is restorable and preservation of further root development is desirable.

Typical candidates include:
▪️ Immature permanent tooth
▪️ Necrotic pulp
▪️ Open or incompletely developed apex
▪️ Apical periodontitis or a periapical lesion may be present
▪️ Adequate tooth structure for restoration
▪️ A patient and family able to comply with follow-up
▪️ No contraindication to the required intracanal medicaments

The AAE's clinical considerations similarly identify a necrotic immature permanent tooth as the fundamental case-selection criterion and emphasize patient compliance, restorability, and appropriate informed consent.

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✅ Clinical Indication: At a Glance

Clinical Indications for Regenerative Endodontic Procedures

Clinical Factor	Typical Finding	Clinical Significance
Tooth type	Immature permanent tooth	Root development remains incomplete.
Pulp status	Necrotic pulp	Vital pulp therapy is no longer the appropriate biological objective.
Apical development	Open or immature apex	Provides access to the apical tissues involved in the regenerative process.
Periapical status	Apical periodontitis may be present	Periapical disease does not automatically exclude regenerative treatment.
Restorability	Adequate remaining tooth structure	A durable coronal seal is essential for long-term success.

✅ When Regenerative Therapy Is Not the First Choice
Regenerative endodontics is not a substitute for vital pulp therapy.
For an immature permanent tooth with a vital pulp or reversible pulpitis, preservation of the existing pulp through appropriate vital pulp therapy should generally be considered first. The AAPD includes indirect pulp treatment, direct pulp capping, partial pulpotomy, and complete pulpotomy among the vital pulp therapies applicable to immature permanent teeth.
Similarly, primary teeth are not the principal indication for regenerative endodontic procedures. Current AAPD recommendations address primary teeth using vital pulp therapies when the pulp is vital and pulpectomy or other nonvital approaches when necrosis or irreversible disease is present.

Therefore, the following situations should prompt consideration of another treatment strategy:

Clinical Situation	More Appropriate Approach
Vital immature permanent tooth	Vital pulp therapy
Reversible pulpitis	Vital pulp therapy
Necrotic mature permanent tooth	Conventional endodontic treatment is generally established
Necrotic immature permanent tooth with open apex	Regenerative endodontic procedure may be considered
Non-restorable tooth	Extraction or other appropriate treatment

✅ Biological Rationale
The principal advantage of regenerative treatment in the immature permanent tooth is not simply elimination of infection. It is the possibility of preserving or enhancing root development after pulpal necrosis.
A conventional apexification procedure can establish an apical barrier and facilitate canal obturation, but it does not reliably reproduce continued physiological root maturation. REPs, in contrast, are intended to create an environment that can support continued deposition of hard tissue along the canal walls and further root development.
This distinction is particularly relevant in young permanent teeth because thin dentinal walls increase susceptibility to cervical or root fracture. Consequently, maintaining or increasing root wall thickness may have important long-term biological implications.

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✅ Key Clinical Considerations
A regenerative procedure is highly dependent on case selection, infection control, and coronal sealing.
The contemporary AAE protocol emphasizes conservative canal disinfection, avoidance of unnecessary mechanical instrumentation of fragile immature roots, and careful control of irrigant extrusion. Calcium hydroxide or an appropriately prepared antibiotic formulation may be used as an intracanal medicament, followed by induction of intracanal bleeding or another scaffold strategy according to the selected protocol.
However, protocols continue to evolve. A 2024 systematic review and network meta-analysis found favorable clinical and radiographic outcomes with several scaffold approaches, but the certainty of evidence varied from low to very low, particularly for comparisons among different regenerative scaffolds.
Recent evidence also supports caution when interpreting radiographic "regeneration." A 2026 systematic review found high pooled clinical success and tooth survival across different degrees of root maturity, while complete apical closure and recovery of pulp vitality were considerably more variable. The authors specifically emphasized that clinical success does not necessarily demonstrate true pulp-dentin regeneration.

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💬 Discussion
The most important clinical question is not whether regenerative endodontics is possible, but whether it provides a meaningful biological advantage for the specific tooth.
For a necrotic immature permanent tooth, regenerative therapy can be attractive because conventional treatment may leave a tooth with compromised root dimensions. Evidence from systematic reviews indicates that REPs can produce high rates of clinical healing and tooth survival, while also providing greater potential for root lengthening and dentinal wall thickening than procedures designed solely to create an apical barrier.
Nevertheless, the evidence does not justify interpreting every increase in root dimensions as genuine regeneration of functional pulp tissue. Furthermore, treatment protocols remain heterogeneous, long-term randomized evidence is limited, and complications such as crown discoloration can occur, particularly with some antibiotic-based protocols.
Thus, regenerative endodontics should be regarded as a selective biological treatment for appropriately chosen immature permanent teeth, rather than a routine alternative to vital pulp therapy or conventional root canal treatment.

🎯 Clinical Recommendations
▪️ Confirm pulpal and periapical diagnosis carefully before considering a regenerative procedure; case selection is more important than the regenerative protocol itself.
▪️ Prioritize vital pulp therapy when the pulp remains viable, particularly in an immature permanent tooth where apexogenesis can still occur.
▪️ Consider REP primarily when there is a necrotic immature permanent tooth with an open apex and preservation of further root development is clinically desirable.
▪️ Establish effective infection control and a durable coronal seal; these remain fundamental determinants of treatment success.
▪️ Discuss with parents and patients that the objective includes healing and continued root development, not a guaranteed recreation of a normal pulp-dentin complex.
▪️ Maintain long-term clinical and radiographic follow-up, because radiographic maturation and pulp sensibility responses can be variable.

✍️ Conclusion
Regenerative endodontic procedures have their clearest role in immature permanent teeth with pulp necrosis and an open apex. Their principal biological rationale is the possibility of continued root maturation and reinforcement of thin dentinal walls.
They should not replace vital pulp therapy when a healthy or reparable pulp remains, nor should they be routinely extrapolated to primary teeth. Current evidence supports favorable healing and survival outcomes, but the terminology of "regeneration" should be interpreted cautiously because true functional pulp regeneration remains less predictable than clinical resolution and radiographic root development.

📚 References

✔ American Academy of Pediatric Dentistry. (2025). Pulp therapy for primary and immature permanent teeth: Indications and objectives. In The Reference Manual of Pediatric Dentistry (pp. 487–496). American Academy of Pediatric Dentistry.
✔ American Association of Endodontists. (2022). AAE clinical considerations for a regenerative procedure: Revised November 2022. American Association of Endodontists.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., Crystal, Y. O., Guelmann, M., Marghalani, A. A., AlShamali, S., Xu, Z., Glickman, G. N., & Wedeward, R. (2024). Use of vital pulp therapies in primary teeth 2024. Pediatric Dentistry, 46(1), 13–26.
✔ Galler, K. M., Krastl, G., Simon, S., Van Gorp, G., Meschi, N., Vahedi, B., & Lambrechts, P. (2016). European Society of Endodontology position statement: Revitalization procedures. International Endodontic Journal, 49(8), 717–723. https://doi.org/10.1111/iej.12629
✔ Sabeti, M., Ghobrial, D., Zanjir, M., da Costa, B. R., Young, Y., & Azarpazhooh, A. (2024). Treatment outcomes of regenerative endodontic therapy in immature permanent teeth with pulpal necrosis: A systematic review and network meta-analysis. International Endodontic Journal, 57(3), 238–255. https://doi.org/10.1111/iej.13999
✔ Tewari, N., Devi, P., Sampath, S., Mathur, V. P., Tsilingaridis, G., Wikström, A., Rahul, M., & Bansal, K. (2025). Comparative effectiveness of regenerative endodontic treatment versus apexification for necrotic immature permanent teeth with or without apical periodontitis: An umbrella review. Endodontic Therapy, 41(3), 263–282. https://doi.org/10.1111/edt.13028

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Minimally Invasive Pulpotomy in Symptomatic Teeth: Is It Possible?

Vital pulp therapy (VPT) has undergone a significant change in recent years. Historically, teeth with symptoms traditionally diagnosed as irreversible pulpitis were generally treated with root canal treatment or extraction.

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Current evidence indicates that selected mature permanent teeth with symptomatic pulpitis may retain sufficient reparative potential to be managed with pulpotomy.

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However, minimally invasive pulpotomy should not be regarded as a single standardized technique. The term is better understood as a tissue-preserving therapeutic approach in which the amount of pulp removed is limited to the tissue considered clinically compromised, while maintaining the vitality of the remaining pulp.
This distinction is important because Cvek partial pulpotomy represents a specific historical technique for partial removal of exposed coronal pulp, particularly in traumatic pulp exposures, whereas contemporary pulpotomy protocols have expanded into the management of cariously exposed mature permanent teeth with symptoms indicative of irreversible pulpitis.

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✅ What Is Minimally Invasive Pulpotomy?
A minimally invasive approach to pulpotomy aims to preserve the maximum amount of viable pulp compatible with effective removal of inflamed tissue and achievement of hemostasis.
The amount of tissue removed is therefore not determined exclusively by a predefined depth. Instead, it may be adjusted according to the clinical condition of the pulp after exposure.
Three concepts should be distinguished:

Procedure	Main Characteristic	Typical Clinical Context
Cvek partial pulpotomy	Limited removal of superficial exposed pulp, historically involving approximately 1–2 mm of tissue.	Traumatic pulp exposure, particularly in permanent incisors.
Contemporary partial pulpotomy	Removal of a limited amount of coronal pulp according to tissue condition and the ability to achieve hemostasis.	Selected carious pulp exposures, including mature teeth with symptomatic pulpitis.
Full pulpotomy	Removal of the entire coronal pulp to the level of the canal orifices while preserving the radicular pulp.	Mature teeth in which more extensive coronal pulp removal is required.

The Cvek technique should therefore not be used synonymously with minimally invasive pulpotomy. Its historical evidence base is primarily associated with traumatic pulp exposures, whereas contemporary partial pulpotomy has been investigated in mature permanent teeth with carious exposure and symptomatic pulpitis.

✅ Can Symptomatic Teeth Be Treated With a Minimally Invasive Approach?
Yes, in selected cases.
The current evidence challenges the assumption that symptoms traditionally associated with irreversible pulpitis automatically indicate complete loss of pulpal healing potential. The AAE recognizes that VPT may be considered in appropriately selected mature teeth previously diagnosed with irreversible pulpitis and emphasizes direct assessment of the exposed pulp as an important component of case selection.
A 2024 systematic review and meta-analysis found favorable outcomes for pulpotomy in mature permanent teeth diagnosed with irreversible pulpitis, although the authors emphasized limitations in the available evidence and heterogeneity among studies.
Importantly, the evidence does not mean that every symptomatic tooth is a candidate for partial pulpotomy. Rather, pulpal status must be reassessed after exposure and tissue removal.

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✅ Partial Pulpotomy in Symptomatic Mature Teeth
Contemporary randomized clinical trials provide increasing evidence supporting partial pulpotomy in selected mature permanent teeth with symptoms indicative of irreversible pulpitis.
In a randomized trial involving 50 mature molars, partial pulpotomy using Biodentine achieved an 88% success rate at 12 months, compared with 91.6% for full pulpotomy, with no statistically significant difference between groups.
Another randomized trial involving 106 mature mandibular molars reported 80.8% success for partial pulpotomy and 89.8% for complete pulpotomy at 12 months. Although the numerical difference favored complete pulpotomy, it was not statistically significant. The authors concluded that partial pulpotomy may be attempted because of its more conservative nature.
More recent research has also investigated how much pulp should be removed during partial pulpotomy. A 2025 randomized clinical trial compared restricted partial pulpotomy, in which approximately 2–3 mm of superficial pulp was removed only at the exposure site, with an extended approach involving removal of 2–3 mm of superficial pulp throughout the pulp chamber. This reflects the continuing shift toward determining the extent of tissue removal according to biological rather than purely mechanical criteria.

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✅ Clinical Determinants of Success
The key issue is not simply how little pulp can be removed, but whether the remaining pulp is capable of healing.

Clinical Factor	Importance in Treatment Selection
Preoperative diagnosis	Establishes the initial pulpal and periapical diagnosis but cannot determine the exact histological extent of inflammation.
Direct pulp assessment	Provides additional information after pulp exposure and removal of clinically compromised tissue.
Hemostasis	Controlled bleeding after pulp amputation supports proceeding with vital pulp therapy; persistent bleeding requires reassessment.
Aseptic isolation	Reduces microbial contamination of the exposed pulp and treatment field.
Extent of inflammation	Helps determine whether a limited partial pulpotomy or more extensive coronal pulp removal is appropriate.
Biomaterial	Calcium silicate-based hydraulic cements are widely used in contemporary vital pulp therapy.
Coronal seal	An effective definitive restoration is essential to prevent bacterial leakage and protect the treated pulp.

In randomized clinical studies, inability to control bleeding within a predefined period has been used as a criterion for abandoning the planned pulpotomy protocol. For example, one trial required hemostasis within six minutes before proceeding with treatment.
However, hemostasis time should not be interpreted as an absolute biological threshold. It is a clinical decision aid rather than a direct histological measurement of pulpal inflammation.

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✅ A Contemporary Minimally Invasive Protocol
A tissue-preserving approach should follow a biologically guided sequence:

1. Establish the pulpal and periapical diagnosis.
2. Obtain appropriate preoperative radiographs.
3. Achieve rubber dam isolation and aseptic control.
4. Remove infected dentin and expose the pulp when indicated.
5. Remove the clinically compromised coronal pulp.
6. Assess the remaining tissue and establish hemostasis.
7. Determine whether partial or full pulpotomy provides the most appropriate level of tissue removal.
8. Apply an appropriate calcium silicate-based biomaterial.
9. Provide a durable definitive coronal restoration.
10. Perform clinical and radiographic follow-up.
This approach is consistent with the contemporary VPT concept that direct visualization of pulp tissue after exposure can contribute to treatment selection, because conventional sensibility testing cannot establish the histological status of the pulp with sufficient precision.

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✅ Is the Cvek Technique the Same Procedure?
No.
The Cvek partial pulpotomy is a specific form of partial pulpotomy historically associated with traumatic crown fractures and exposed vital pulp, particularly in permanent incisors. The classic procedure involved removal of a small superficial portion of exposed pulp followed by placement of a pulp-capping material.
Long-term clinical studies have demonstrated favorable outcomes for partial pulpotomy in traumatized permanent incisors.
Contemporary partial pulpotomy for symptomatic carious teeth is conceptually related because both procedures preserve vital pulp tissue. However, they should not be treated as identical techniques because their indications, clinical circumstances, and evidence bases differ.

Thus:
Cvek partial pulpotomy = a specific partial pulpotomy technique.
Minimally invasive pulpotomy = a broader tissue-preservation approach that may involve partial or, when clinically necessary, full pulpotomy.

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💬 Discussion
The most important change in contemporary VPT is not the introduction of a new pulpotomy technique, but the recognition that pulpal inflammation is biologically heterogeneous. Clinical symptoms alone cannot reliably determine whether all remaining pulp tissue has lost its capacity for healing.
Consequently, a diagnosis such as symptomatic irreversible pulpitis should not automatically be interpreted as evidence that every portion of the pulp is irreversibly damaged. The AAE and contemporary evidence support combining preoperative diagnosis with direct intraoperative assessment when VPT is being considered.
The evidence supporting partial pulpotomy is particularly relevant to the minimally invasive concept. Randomized trials have demonstrated favorable short-term outcomes and, in several studies, no statistically significant difference between partial and full pulpotomy.
Nevertheless, the current evidence does not justify assuming that partial pulpotomy is universally superior. Some studies report numerically higher success with full pulpotomy, while follow-up periods remain relatively short in much of the literature. A 2024 meta-analysis likewise concluded that the evidence is promising but affected by heterogeneity and methodological limitations.
Therefore, the objective of minimally invasive pulpotomy should not be “remove as little pulp as possible”. The biologically appropriate objective is to remove compromised tissue while preserving the greatest amount of healthy, functional pulp that can predictably remain viable.

✍️ Conclusion
Minimally invasive pulpotomy is a valid contemporary concept within vital pulp therapy, but it is not synonymous with the Cvek technique.
The Cvek procedure is a specific form of partial pulpotomy historically used for traumatic pulp exposures. Contemporary minimally invasive pulpotomy encompasses a broader tissue-preserving philosophy that may involve partial or full pulpotomy according to the clinical condition of the pulp.
In selected mature permanent teeth with symptoms indicative of irreversible pulpitis, current evidence supports pulpotomy as a potential alternative to root canal treatment. However, successful treatment depends on appropriate case selection, asepsis, direct pulp assessment, effective hemostasis, suitable biomaterials, and a reliable coronal seal.

🎯 Clinical Recommendations
▪️ Do not use Cvek partial pulpotomy and minimally invasive pulpotomy as interchangeable terms.
▪️ Consider contemporary partial pulpotomy in selected symptomatic mature teeth when the remaining pulp demonstrates favorable clinical characteristics after tissue removal.
▪️ Do not impose a predetermined depth of tissue removal when the clinical condition of the pulp indicates that additional removal is necessary.
▪️ Use hemostasis and direct pulp assessment as important intraoperative decision points rather than relying exclusively on the preoperative diagnosis.
▪️ If a limited partial pulpotomy does not provide a suitable pulpal wound or controlled hemostasis, progress to a more extensive pulpotomy or reconsider VPT, according to the clinical circumstances.
▪️ Consider long-term follow-up essential because short-term symptom resolution does not by itself demonstrate sustained pulp vitality.

📚 References

✔ American Association of Endodontists. (2021). AAE position statement on vital pulp therapy. American Association of Endodontists.
✔ Duncan, H. F., Kirkevang, L.-L., Peters, O. A., El-Karim, I., Krastl, G., Del Fabbro, M., Chong, B. S., Galler, K. M., Segura-Egea, J. J., & Kebschull, M. (2023). Treatment of pulpal and apical disease: The European Society of Endodontology S3-level clinical practice guideline. International Endodontic Journal, 56(Suppl. 3), 238–295. https://doi.org/10.1111/iej.13974
✔ Jassal, A., Nawal, R. R., Yadav, S., Talwar, S., Yadav, S., & Duncan, H. F. (2023). Outcome of partial and full pulpotomy in cariously exposed mature molars with symptoms indicative of irreversible pulpitis: A randomized controlled trial. International Endodontic Journal, 56(3), 331–344. https://doi.org/10.1111/iej.13872
✔ Li, Y., Wang, W., Zeng, Q., Tang, M., Massey, J., Bergeron, B. E., Gu, L., & Tay, F. R. (2024). Efficacy of pulpotomy in managing irreversible pulpitis in mature permanent teeth: A systematic review and meta-analysis. Journal of Dentistry, 144, 104923. https://doi.org/10.1016/j.jdent.2024.104923
✔ Ramani, A., Sangwan, P., Tewari, S., Duhan, J., Mittal, S., & Kumar, V. (2022). Comparative evaluation of complete and partial pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis: A randomized clinical trial. International Endodontic Journal, 55(5), 430–440. https://doi.org/10.1111/iej.13714
✔ Ramani, A., Sangwan, P., Tewari, S., Duhan, J., Mittal, S., & Kumar, V. (2025). Effect of lateral extent of pulp tissue removal on the outcome of partial pulpotomy for managing cariously exposed mature permanent molars with symptomatic irreversible pulpitis: A randomized clinical trial. International Endodontic Journal, 58(1), 71–83. https://doi.org/10.1111/iej.14152
✔ Tzanetakis, G. N., Koletsi, D., & Georgopoulou, M. (2023). Treatment outcome of partial pulpotomy using two different calcium silicate materials in mature permanent teeth with symptoms of irreversible pulpitis: A randomized clinical trial. International Endodontic Journal, 56(10), 1178–1196. https://doi.org/10.1111/iej.13955

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Pediatric Endodontics: Current Concepts and Techniques

Pediatric endodontics focuses on preserving primary and immature permanent teeth affected by dental caries, trauma, developmental abnormalities, or pulpal and periapical disease.

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Contemporary management has shifted from a predominantly tissue-removal approach toward biologically based pulp therapy, emphasizing preservation of healthy pulp tissue whenever possible.

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Current recommendations distinguish treatment according to pulpal diagnosis, tooth restorability, root development, and the expected lifespan of the tooth.
For primary teeth, evidence increasingly supports indirect pulp treatment and calcium-silicate cement pulpotomy for appropriately selected vital teeth. In immature permanent teeth, maintaining pulp vitality is particularly important because it permits continued root maturation and apexogenesis.

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✅ Pulpal Diagnosis in Children
Accurate diagnosis is the foundation of pediatric endodontic treatment. Clinical history, symptoms, clinical examination, radiographic findings, and, when appropriate, pulp sensibility testing should be interpreted collectively.
In primary teeth, symptoms may be less predictable than in permanent teeth; therefore, clinical and radiographic findings should not be interpreted in isolation. Important findings include spontaneous or lingering pain, abnormal mobility, swelling, sinus tract formation, furcation radiolucency, pathological root resorption, and changes in the supporting tissues.

The principal diagnostic categories include:
▪️ Normal pulp
▪️ Reversible pulpitis
▪️ Symptomatic or asymptomatic irreversible pulpitis
▪️ Pulp necrosis
▪️ Previously treated or previously initiated therapy, when applicable
The treatment objective is not simply to eliminate pain but to control infection and preserve the tooth and surrounding tissues for as long as clinically appropriate.

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✅ Vital Pulp Therapy in Primary Teeth
For primary teeth with normal pulp or reversible pulpitis, contemporary management favors conservative approaches that preserve radicular pulp vitality.

Indirect Pulp Treatment
Indirect pulp treatment (IPT) is particularly useful for deep carious lesions when the pulp is considered vital and there are no clinical or radiographic findings indicating irreversible disease.
Selective caries removal reduces the probability of pulp exposure while allowing the remaining dentin and pulp-dentin complex to maintain biological activity. The 2024 AAPD guideline provides strong evidence supporting IPT for deeply carious primary teeth.

Pulpotomy
A pulpotomy removes the coronal pulp while preserving the radicular pulp. It remains an important treatment for vital primary teeth when caries removal results in exposure and the remaining radicular pulp is considered capable of healing.
Current evidence favors calcium-silicate materials, particularly mineral trioxide aggregate (MTA) and Biodentine, over several traditional pulpotomy medicaments. The AAPD 2024 guideline found higher 24-month success with IPT or calcium-silicate cement pulpotomy compared with several alternative approaches.
Consequently, calcium-silicate cement pulpotomy has become a major contemporary approach in primary-tooth vital pulp therapy.

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✅ Non-Vital Pulp Therapy in Primary Teeth
When a primary tooth presents with irreversible pulpitis or pulp necrosis, treatment generally requires removal of infected or necrotic tissue.

Pulpectomy
Pulpectomy involves removal of the pulp from the entire root canal system, followed by canal debridement, disinfection, and filling with a resorbable material.
Hand and rotary instrumentation can both be used. Evidence reviewed by the AAPD indicates that rotary instrumentation can substantially reduce instrumentation time without demonstrating a significant difference in filling quality or overall treatment success compared with manual instrumentation.
Irrigation is an essential component of canal disinfection. Sodium hypochlorite may be used at appropriate concentrations, but because of its tissue toxicity, extrusion beyond the root apex must be avoided. The final obturation material should be compatible with the physiologic resorption of primary roots.

Lesion Sterilization and Tissue Repair
Lesion sterilization and tissue repair (LSTR) is a non-instrumentation or minimally instrumented approach involving antimicrobial agents. It may have a role in selected primary teeth, particularly when conventional pulpectomy is unfavorable.
However, the evidence indicates that its application should be selective. LSTR may be advantageous in teeth with preoperative root resorption, whereas conventional pulpectomy performs better when roots remain intact. Close clinical and radiographic follow-up is therefore essential.

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✅ Vital Pulp Therapy in Immature Permanent Teeth
The management of immature permanent teeth differs fundamentally from that of primary teeth because preservation of vital pulp tissue can allow continued physiologic root development.

For permanent teeth with normal pulp or reversible pulpitis, contemporary options include:
▪️ Indirect pulp treatment
▪️ Direct pulp capping
▪️ Partial pulpotomy
▪️ Complete pulpotomy
The 2025 AAPD guideline indicates that selective caries removal is strongly recommended for deep caries in permanent teeth with normal pulp or reversible pulpitis. When pulp exposure occurs, calcium-silicate materials may be used for direct pulp capping, partial pulpotomy, or complete pulpotomy.

Partial Pulpotomy
Partial pulpotomy removes a limited portion of inflamed coronal pulp while preserving deeper healthy tissue. It is particularly relevant for traumatic exposures and selected carious exposures.
For traumatic exposures, the Cvek technique removes approximately 1–3 mm of superficial inflamed pulp, or more when necessary to reach healthy tissue. Hemostasis and a biologically compatible pulp-capping material are then required.

Complete Pulpotomy
Contemporary evidence has expanded the potential indications for complete pulpotomy in permanent teeth. In selected teeth with symptoms traditionally associated with irreversible pulpitis, complete pulpotomy may be considered when the pulp remains vital and adequate hemostasis can be achieved.
The 2025 AAPD guideline recommends calcium-silicate materials for vital pulp therapy and emphasizes appropriate hemostasis, with sodium hypochlorite recommended for pulp-hemostasis procedures.

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✅ Apexogenesis, Apexification, and Regenerative Endodontics
The primary biological objective in an immature permanent tooth with vital pulp is apexogenesis, allowing continued root development and thickening of the dentinal walls.
When the pulp is necrotic, conventional treatment may compromise further physiologic root development. Depending on the clinical situation, regenerative endodontic procedures or apexification may therefore be considered.
Regenerative approaches aim to promote continued root maturation and development of the apical region. Treatment selection should consider the stage of root development, infection control, restorability, and the long-term prognosis of the tooth. The current AAPD framework includes apexification and regenerative endodontics among the principal options for non-vital immature permanent teeth.

✅ Contemporary Materials and Techniques

Clinical Situation	Preferred Contemporary Approach	Key Consideration
Deep caries, vital primary tooth	Indirect pulp treatment	Selective caries removal and an effective coronal seal
Pulp exposure in a vital primary tooth	Calcium-silicate pulpotomy	MTA or another appropriate calcium-silicate cement
Necrotic primary tooth	Pulpectomy	Effective disinfection and resorbable obturation
Immature permanent tooth, vital pulp	Vital pulp therapy	Preserve vitality and promote apexogenesis
Traumatic pulp exposure	Partial pulpotomy	Remove inflamed superficial pulp and obtain hemostasis
Necrotic immature permanent tooth	Regenerative endodontics or apexification	Root maturity, infection control, and long-term prognosis

Table based on current AAPD recommendations and contemporary evidence.

✅ Technical Principles for Pediatric Endodontic Procedures
Successful pediatric endodontics depends not only on treatment selection but also on infection control, isolation, tissue preservation, and coronal sealing.

Isolation
Rubber dam isolation should be considered fundamental whenever endodontic treatment is performed. It improves moisture control, reduces microbial contamination, and protects the child from aspiration or ingestion of instruments and materials.

Magnification
Magnification can improve visualization of pulp tissue and facilitate assessment during vital pulp procedures. Its value is particularly relevant when determining the quality of the remaining pulp and controlling hemorrhage.

Hemostasis
In vital pulp therapy, controlled hemorrhage is an important clinical indicator. Persistent bleeding may indicate more extensive inflammation and influence the decision to remove additional pulp tissue or change the treatment approach.

Coronal Seal
A durable coronal restoration is essential because bacterial leakage can compromise otherwise successful pulp therapy. The definitive restoration should provide an effective seal and sufficient structural protection for the expected life of the tooth.

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💬 Discussion
The contemporary concept of pediatric endodontics is increasingly centered on biological preservation rather than routine removal of the entire pulp. This is particularly evident in the growing evidence supporting IPT and calcium-silicate pulpotomy in primary teeth and vital pulp therapy in immature permanent teeth.
The 2024 AAPD guideline found high-certainty evidence favoring IPT and calcium-silicate cement pulpotomy for deeply carious vital primary teeth. It also moved clinical practice further away from several traditional medicaments, including calcium hydroxide as a primary pulpotomy medicament and toward calcium-silicate materials.
At the same time, the 2025 AAPD guideline for permanent teeth reflects an important conceptual change: irreversible pulpitis does not automatically require complete pulpectomy or conventional root canal treatment when the pulp remains clinically viable and the tooth can be appropriately managed. Selected cases may benefit from partial or complete pulpotomy using calcium-silicate materials.
Nevertheless, evidence quality is not uniform across all pediatric endodontic interventions. Treatment decisions should therefore integrate the best available evidence with clinical diagnosis, tooth restorability, root development, infection status, patient cooperation, and long-term prognosis.

🎯 Clinical Recommendations
1. Prioritize biological diagnosis over symptoms alone. Combine history, clinical examination, radiographic findings, and pulp testing when appropriate.
2. Preserve vital pulp tissue whenever predictable healing is possible, particularly in immature permanent teeth where vitality supports continued root development.
3. Consider IPT as a first-line approach for appropriately selected deeply carious vital primary teeth, avoiding unnecessary pulp exposure.
4. When pulpotomy is indicated in a primary tooth, calcium-silicate cements such as MTA or Biodentine should be strongly considered based on current evidence.
5. For necrotic primary teeth, select pulpectomy or carefully indicated LSTR according to root resorption, infection, restorability, and prognosis.
6. In immature permanent teeth, consider partial or complete pulpotomy before conventional root canal treatment when the pulp remains potentially reparable and adequate hemostasis can be achieved.
7. Do not compromise apical development unnecessarily. Preservation of pulp vitality in immature permanent teeth should remain a major treatment objective.
8. Establish an effective coronal seal and schedule clinical and radiographic follow-up, because treatment success depends on both biological management and restoration quality.

✍️ Conclusion
Pediatric endodontics has evolved toward conservative, biologically oriented treatment. Current evidence supports indirect pulp treatment and calcium-silicate pulpotomy as important approaches for selected primary teeth, while vital pulp therapy has an increasingly important role in immature permanent teeth.
The fundamental principle is to match the intervention to the biological condition of the pulp rather than relying exclusively on historical treatment protocols. Accurate diagnosis, strict isolation, effective disinfection, appropriate biomaterials, durable coronal sealing, and systematic follow-up remain essential to achieving predictable outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2026). Pulp therapy for primary and immature permanent teeth. In The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., Crystal, Y. O., Guelmann, M., Marghalani, A. A., AlShamali, S., Xu, Z., Glickman, G. N., & Wedeward, R. (2024). Use of vital pulp therapies in primary teeth 2024. Pediatric Dentistry, 46(1), 13–26.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., et al. (2023). Primary tooth vital pulp treatment interventions: Systematic review and meta-analyses. Pediatric Dentistry, 45(6), 474–546.
✔ Coll, J. A., Vargas, K., Marghalani, A. A., et al. (2020). Use of non-vital pulp therapies in primary teeth. Pediatric Dentistry, 42(5), 337–349.
✔ Coll, J. A., Dhar, V., Guelmann, M., Crystal, Y. O., Chen, C.-Y., Marghalani, A. A., Alshamali, S., Xu, Z., Ather, A., Sabeti, M., & Wedeward, R. (2025). Guideline for use of vital pulp therapy in permanent teeth. Pediatric Dentistry, 47(5), 299–311.
✔ Duggal, M., Gizani, S., Albadri, S., Krämer, N., Stratigaki, E., Tong, H. J., Seremidi, K., Kloukos, D., BaniHani, A., Santamaría, R. M., Hu, S., Maden, M., Amend, S., Boutsiouki, C., Bekes, K., Lygidakis, N., Frankenberger, R., Monteiro, J., Anttonen, V., ... Parekh, S. (2022). Best clinical practice guidance for treating deep carious lesions in primary teeth: An EAPD policy document. European Archives of Paediatric Dentistry, 23(5), 659–666. https://doi.org/10.1007/s40368-022-00718-6
✔ Da Silva, E. J. N. L., et al. (2024). Success of primary teeth pulpotomy using calcium silicate cements: A systematic review and meta-analysis of randomized clinical trials. Pediatric Dentistry, 46(6), 373–395.

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Advances in Pediatric Endodontics: Bioceramic Sealers for Primary Teeth

Bioceramic sealers are among the most important innovations in pediatric endodontics. They are designed to seal root canals more effectively while being highly compatible with the body's natural tissues.

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In primary (baby) teeth, these materials may improve treatment outcomes by reducing bacterial leakage and supporting healing around the roots.

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Although traditional materials such as zinc oxide-eugenol remain widely used, bioceramic sealers are gaining attention because of their excellent biological properties and sealing ability. However, their use in primary teeth should be based on scientific evidence and careful case selection.

✅ What Are Bioceramic Sealers?
Bioceramic sealers are calcium silicate-based materials developed to seal the root canal after cleaning and shaping. Unlike conventional sealers, they interact with body fluids and can form hydroxyapatite, a mineral naturally found in teeth and bone.

Their main characteristics include:
▪️ Excellent biocompatibility
▪️ Strong sealing ability
▪️ High antibacterial environment due to alkaline pH
▪️ Low shrinkage during setting
▪️ Ability to support tissue healing
These properties make them attractive for both permanent and primary teeth.

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✅ Why Are They Important in Primary Teeth?
Primary teeth have unique characteristics:
▪️ Thin dentin walls
▪️ Complex root canal anatomy
▪️ Physiological root resorption before tooth exfoliation
▪️ Close relationship with the developing permanent tooth

Because of these factors, the ideal filling material should:
▪️ Seal the canal effectively
▪️ Be gentle to surrounding tissues
▪️ Not interfere with normal root resorption
▪️ Reduce the risk of reinfection
Bioceramic sealers aim to meet many of these requirements.

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✅ Main Advantages

1. Excellent Biocompatibility
One of the greatest advantages is that bioceramic sealers are well tolerated by surrounding tissues, reducing inflammation if small amounts extend beyond the root.

2. Superior Sealing Ability
A tight seal prevents bacteria from re-entering the canal system.
A better seal increases the likelihood of long-term treatment success.

3. Antibacterial Properties
Their naturally high pH creates an unfavorable environment for many bacteria responsible for endodontic infections.
Although they do not replace proper canal cleaning, they provide an additional level of protection.

4. Bioactivity
Unlike conventional sealers, bioceramic materials actively interact with surrounding tissues.
They can stimulate mineral deposition and support natural healing.

5. Moisture-Friendly Setting
Primary teeth are often difficult to keep completely dry.
Many bioceramic sealers actually benefit from moisture during their setting reaction, making clinical handling easier.

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✅ Current Limitations
Despite their advantages, several limitations remain.

▪️ Higher cost than traditional materials.
▪️ Limited long-term clinical evidence in primary teeth compared with permanent teeth.
▪️ Some products may not resorb at the same rate as primary tooth roots, an important consideration before widespread use.
▪️ Clinical performance varies depending on the specific formulation.
Therefore, not every bioceramic sealer should automatically replace conventional pediatric materials.

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✅ Current Clinical Applications
Bioceramic sealers are being investigated for:

▪️ Pulpectomy in primary teeth
▪️ Management of infected root canals
▪️ Cases requiring excellent apical sealing
▪️ Teeth with periapical inflammation
Most specialists recommend using them when the clinical situation is appropriate and after considering current scientific evidence.

✅ How Do They Compare with Zinc Oxide-Eugenol?

Feature	Bioceramic Sealers	Zinc Oxide-Eugenol
Biocompatibility	Excellent	Good
Sealing Ability	Very High	Moderate
Bioactivity	Yes	No
Antibacterial Environment	High pH	Moderate
Clinical History	Emerging	Extensive
Cost	Higher	Lower
Long-Term Evidence in Primary Teeth	Growing	Extensive

✅ What Does Current Research Say?
Recent studies suggest that bioceramic sealers provide promising biological and sealing properties in pediatric endodontics. Laboratory and early clinical evidence indicates favorable tissue compatibility and reduced bacterial leakage.
However, researchers consistently emphasize that high-quality long-term clinical trials in primary teeth remain limited. Additional evidence is needed before these materials can be considered the universal first choice for every pulpectomy.

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💬 Discussion
The development of bioceramic sealers represents a significant step forward in pediatric endodontics. Their biological compatibility, sealing capacity, and bioactive behavior offer advantages over many traditional materials.
Nevertheless, primary teeth have unique biological characteristics, particularly physiological root resorption. For this reason, clinicians should evaluate whether a specific bioceramic product is suitable for each case rather than assuming that all formulations behave similarly. Current evidence supports their potential, but continued research is essential to define their long-term role.

🎯 Recommendations
▪️ Select bioceramic sealers according to the clinical indication and manufacturer recommendations.
▪️ Maintain thorough canal cleaning and disinfection, as no sealer can compensate for inadequate treatment.
▪️ Consider the expected root resorption pattern when treating primary teeth.
▪️ Stay updated with new clinical studies as evidence continues to evolve.
▪️ Explain treatment options and expected outcomes clearly to parents or caregivers.

✍️ Conclusion
Bioceramic sealers are an important advancement in pediatric endodontics, offering excellent biocompatibility, superior sealing ability, and bioactive properties that may improve the success of pulpectomy in primary teeth.
While early evidence is encouraging, long-term clinical research is still developing. At present, these materials should be viewed as a valuable option within evidence-based pediatric dentistry rather than a complete replacement for established filling materials.

📚 References

✔ Coll, J. A., Dhar, V., Vargas, K., Chen, C. Y., Crystal, Y. O., & Alvares, O. (2020). Use of non-vital pulp therapies in primary teeth. Pediatric Dentistry, 42(6), 337–349.
✔ Donnermeyer, D., Bürklein, S., Dammaschke, T., & Schäfer, E. (2019). Endodontic sealers based on calcium silicates: A systematic review. Odontology, 107(4), 421–436. https://doi.org/10.1007/s10266-018-0400-3
✔ European Society of Endodontology. (2021). European Society of Endodontology position statement: Management of deep caries and the exposed pulp. International Endodontic Journal, 54(7), 923–934.
✔ Moinzadeh, A. T., Zerbst, W., Boutsioukis, C., Shemesh, H., & Zaslansky, P. (2021). Outcome of bioceramic sealers in endodontic treatment: A review of current evidence. International Endodontic Journal, 54(11), 1977–1994.
✔ Nagendrababu, V., Duncan, H. F., Fouad, A. F., Kirkevang, L. L., Parashos, P., Priya, E., Jayaraman, J., Siqueira, J. F., Jr., & Dummer, P. M. H. (2023). PRILE 2021 guidelines for reporting laboratory studies in Endodontology: Explanation and elaboration. International Endodontic Journal, 56(Suppl. 2), 3–64.
✔ Taha, N. A., Abdulkhader, S. Z., & Al-Qudah, A. A. (2022). Calcium silicate–based root canal sealers: A review of biological and clinical properties. Journal of Clinical Medicine, 11(17), 5067. https://doi.org/10.3390/jcm11175067

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Direct Pulp Capping in Children: Indications and Technique

Direct pulp capping (DPC) is a vital pulp therapy procedure aimed at preserving pulp vitality after a small mechanical, traumatic, or carious pulp exposure. In pediatric dentistry, careful case selection and the use of bioactive materials are essential for achieving favorable clinical outcomes.

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✅ Introduction
Direct pulp capping in children is a conservative treatment designed to maintain the vitality and function of the dental pulp following a localized exposure. The procedure involves placing a biocompatible material directly over the exposed pulp tissue to promote healing and reparative dentin formation.
The success of direct pulp capping depends on several factors, including the cause and size of the exposure, pulpal status, bacterial control, and the sealing ability of the final restoration. Proper diagnosis remains critical, particularly in pediatric patients where preserving pulp vitality contributes to normal root development and long-term tooth retention.

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✅ Indications
Direct pulp capping may be indicated when the following criteria are met:

Primary Teeth
▪️ Small mechanical pulp exposure during cavity preparation.
▪️ Traumatic pulp exposure with minimal contamination.
▪️ Vital pulp without signs of irreversible inflammation.
▪️ Adequate hemorrhage control within a few minutes.

Young Permanent Teeth
▪️ Small carious or mechanical pulp exposure.
▪️ Vital pulp diagnosed as normal or reversibly inflamed.
▪️ Teeth with incomplete root formation requiring continued root development.
▪️ Absence of spontaneous pain or radiographic pathology.

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✅ Contraindications
Direct pulp capping should generally be avoided when:

▪️ Signs of irreversible pulpitis are present.
▪️ Spontaneous or persistent pain is reported.
▪️ Excessive or uncontrolled pulpal bleeding occurs.
▪️ Radiographic evidence of furcation or periapical pathology exists.
▪️ Presence of pulp necrosis or dental abscess.

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✅ Clinical Technique

Step 1: Diagnosis and Case Selection
A comprehensive clinical and radiographic evaluation should confirm pulp vitality and the absence of irreversible pulpal disease.

Step 2: Local Anesthesia and Isolation
Administer local anesthesia and place a rubber dam to ensure optimal isolation and bacterial control.

Step 3: Hemorrhage Control
Control pulpal bleeding using sterile saline solution or sodium hypochlorite (1–3%). Hemostasis should be achieved within several minutes.

Step 4: Placement of the Capping Material
Apply a biocompatible material directly over the exposed pulp tissue.
Preferred materials include:
▪️ Mineral Trioxide Aggregate (MTA)
▪️ Biodentine
▪️ Other calcium silicate-based biomaterials
These materials stimulate reparative dentin formation and demonstrate excellent sealing properties.

Step 5: Definitive Restoration
Place a well-sealed permanent restoration immediately or according to the manufacturer's recommendations to prevent bacterial microleakage.

Step 6: Follow-Up
Periodic clinical and radiographic evaluations are recommended to monitor:
▪️ Continued pulp vitality.
▪️ Absence of pain or infection.
▪️ Normal root development in immature permanent teeth.
▪️ Formation of a dentin bridge when applicable.

Advantages of Direct Pulp Capping

Advantage	Clinical Benefit
Vital pulp preservation	Maintains normal biological function and tooth vitality.
Minimally invasive approach	Conserves healthy tooth structure and reduces tissue removal.
Continued root development	Supports apexogenesis in immature permanent teeth.
Reduced treatment complexity	Less invasive than pulpotomy or pulpectomy procedures.
High success with modern materials	Improved long-term prognosis when using MTA or Biodentine.

💬 Discussion
Recent pediatric dentistry guidelines emphasize that successful direct pulp capping relies primarily on accurate diagnosis and strict control of bacterial contamination. Historically, calcium hydroxide was considered the gold standard; however, contemporary evidence indicates that calcium silicate-based materials such as MTA and Biodentine provide superior sealing ability, biocompatibility, and dentin bridge quality.
In primary teeth, the indication remains more selective due to concerns regarding underlying pulpal inflammation. In contrast, young permanent teeth with reversible pulpitis demonstrate favorable outcomes when treated with modern bioactive materials. The preservation of pulp vitality is particularly important because it supports apexogenesis and continued root maturation.

🎯 Recommendations
▪️ Perform meticulous pulpal diagnosis before treatment.
▪️ Use rubber dam isolation whenever possible.
▪️ Achieve complete hemorrhage control before placing the capping material.
▪️ Prefer MTA or Biodentine over traditional calcium hydroxide when available.
▪️ Ensure an effective coronal seal to minimize bacterial leakage.
▪️ Schedule periodic clinical and radiographic follow-up examinations.

✍️ Conclusion
Direct pulp capping in children is an effective vital pulp therapy procedure when appropriate case selection and modern bioactive materials are utilized. Current evidence supports the use of MTA and Biodentine as preferred materials due to their favorable biological and clinical performance. Accurate diagnosis, proper hemorrhage control, and a durable coronal seal remain the key determinants of long-term success.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Use of vital pulp therapies in primary teeth with deep caries lesions. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry.
✔ American Academy of Pediatric Dentistry. (2024). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry.
✔ Hilton, T. J., Ferracane, J. L., & Mancl, L. (2013). Comparison of CaOH with MTA for direct pulp capping: A PBRN randomized clinical trial. Journal of Dental Research, 92(7 Suppl), 16S–22S.
✔ Tziafas, D., Pantelidou, O., Alvanou, A., Belibasakis, G., & Papadimitriou, S. (2002). The dentinogenic effect of mineral trioxide aggregate in short-term capping experiments. International Endodontic Journal, 35(3), 245–254.
✔ Witherspoon, D. E. (2008). Vital pulp therapy with new materials: New directions and treatment perspectives—Permanent teeth. Journal of Endodontics, 34(7 Suppl), S25–S28.

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Obsolete Materials in Endodontics and Pulp Therapy: What Should No Longer Be Used?

Modern dentistry has evolved significantly due to advances in biomaterials, bioactive cements, and evidence-based protocols.

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Several materials historically used in endodontics and pulp therapy are now considered obsolete, unsafe, or less effective because of their toxicity, poor sealing ability, cytotoxic effects, or inferior long-term outcomes.
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This article reviews the main materials that should no longer be routinely used in endodontics and pediatric dentistry, including formocresol, paraformaldehyde, arsenical compounds, hydrogen peroxide, and amalgam retrofillings.

✅ Introduction
The evolution of endodontic and pulp therapy procedures has been strongly influenced by scientific research and biomaterial innovation. Historically, many dental materials were introduced before modern biocompatibility standards existed. While some provided short-term clinical success, long-term studies later demonstrated important disadvantages such as tissue toxicity, inflammatory reactions, leakage, and poor regenerative capacity.
Today, minimally invasive and biologically driven dentistry prioritizes materials capable of preserving pulp vitality, stimulating dentin formation, and promoting tissue repair. Consequently, numerous traditional substances have been abandoned or significantly restricted.
Understanding which materials are outdated is essential for both clinicians and dental students in order to avoid complications and improve treatment prognosis.

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✅ Why Some Dental Materials Become Obsolete
Several factors contribute to the discontinuation or restriction of materials in endodontics and pulp therapy:

▪️ Cytotoxicity to pulpal or periapical tissues.
▪️ Mutagenic or carcinogenic potential.
▪️ Poor sealing ability.
▪️ Tissue necrosis.
▪️ Chronic inflammatory reactions.
▪️ Inferior clinical outcomes compared with modern biomaterials.
▪️ Availability of safer and more bioactive alternatives.

Modern dentistry increasingly favors materials that are:
▪️ Bioactive.
▪️ Biocompatible.
▪️ Antibacterial.
▪️ Sealing.
▪️ Regenerative.
▪️ Stable over time.

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1. Formocresol in Pediatric Dentistry
Historical Use
Formocresol was widely used for decades in pulpotomy procedures of primary teeth because of its ability to fix and mummify pulpal tissue.

Why It Is No Longer Recommended
Current evidence has raised serious concerns regarding its biological safety.

Main Disadvantages
▪️ Contains formaldehyde.
▪️ Potential mutagenic and carcinogenic effects.
▪️ Systemic distribution after application.
▪️ Tissue fixation instead of true healing.
▪️ Chronic inflammatory response.

Current Alternatives
Modern pulpotomy protocols favor bioactive materials such as:
▪️ Mineral trioxide aggregate (MTA).
▪️ Biodentine.
▪️ Calcium silicate-based cements.
▪️ Bioceramic materials.
These materials stimulate dentin bridge formation and preserve healthier pulpal tissue.

2. Paraformaldehyde in Endodontics
Historical Use
Paraformaldehyde-containing pastes were used to devitalize inflamed pulps, especially in difficult anesthesia situations.

Why It Should Not Be Used
Paraformaldehyde is highly toxic and may diffuse beyond the root canal system.

Clinical Risks
▪️ Severe tissue necrosis.
▪️ Bone destruction.
▪️ Persistent pain.
▪️ Delayed healing.
▪️ Damage to periodontal structures.
▪️ Neurotoxicity in severe cases.
Because of these complications, modern endodontics strongly discourages its use.

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3. Arsenical Compounds
Historical Use
Arsenic compounds were historically employed to intentionally devitalize pulp tissue before root canal treatment.

Why They Are Obsolete
Arsenic is considered one of the most dangerous substances ever used in dentistry.

Serious Complications
▪️ Osteonecrosis.
▪️ Bone sequestration.
▪️ Gingival necrosis.
▪️ Periodontal destruction.
▪️ Severe inflammatory reactions.
▪️ Irreversible tissue damage.
Modern anesthesia and rotary instrumentation have completely eliminated the need for arsenical compounds.

4. Hydrogen Peroxide in Endodontics
Previous Use
Hydrogen peroxide was previously combined with sodium hypochlorite during root canal irrigation because of its bubbling effect.

Why It Is No Longer Recommended
Although it creates effervescence, hydrogen peroxide does not effectively dissolve organic tissue or calcium hydroxide remnants.

Main Problems
▪️ Oxygen bubble formation.
▪️ Risk of emphysema.
▪️ ▪️ Reduced effectiveness of sodium hypochlorite.
▪️ Limited antimicrobial effectiveness compared with modern irrigants.
▪️ Potential extrusion into periapical tissues.

Current Irrigation Protocols
Modern endodontics primarily uses:
▪️ Sodium hypochlorite (NaOCl).
▪️ EDTA 17%.
▪️ Chlorhexidine in selected situations.
▪️ Sonic or ultrasonic irrigation activation.

5. Zinc Oxide Eugenol Directly Over Permanent Pulp Tissue
Historical Use
Zinc oxide eugenol (ZOE) was commonly used as a sedative base and temporary restorative material.

Limitations in Vital Pulp Therapy
Although still useful in some restorative applications, direct contact with pulp tissue is no longer preferred.

Problems
▪️ Cytotoxic effect of eugenol.
▪️ Chronic pulpal irritation.
▪️ Inferior dentin bridge formation.
▪️ Reduced regenerative capacity.

Better Alternatives
▪️ MTA.
▪️ Biodentine.
▪️ Bioceramic liners.
These materials provide superior sealing and biological repair.

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💬 Discussion
The transition from traditional dental materials to modern bioactive biomaterials reflects the growing emphasis on biological preservation and minimally invasive dentistry. Contemporary evidence demonstrates that many older substances once considered acceptable can negatively affect pulp vitality, periapical healing, and long-term treatment success.
Among all obsolete materials, arsenical compounds and paraformaldehyde represent the most hazardous due to their destructive potential. Likewise, formocresol remains controversial because of its formaldehyde content and systemic concerns.
Modern bioactive materials such as MTA and Biodentine have significantly improved outcomes in both adult and pediatric dentistry by promoting tissue regeneration rather than tissue fixation or necrosis.

🎯 Clinical Recommendations
▪️ Avoid outdated devitalizing agents.
▪️ Use bioactive materials whenever possible.
▪️ Prioritize minimally invasive pulp therapy.
▪️ Follow evidence-based irrigation protocols.
▪️ Use sodium hypochlorite and EDTA instead of hydrogen peroxide.
▪️ Select bioceramic materials for pulp capping and apical surgery.
▪️ Continuously update clinical protocols according to current literature.

✍️ Conclusion
Several materials historically used in endodontics and pulp therapy are now considered obsolete because of their toxicity, poor biological behavior, and inferior clinical outcomes. Modern dentistry favors biocompatible and regenerative materials capable of preserving pulp vitality and improving long-term success.
Clinicians should avoid the routine use of substances such as formocresol, paraformaldehyde, arsenic compounds, and hydrogen peroxide in endodontic procedures. Instead, evidence-based biomaterials like MTA, Biodentine, and calcium silicate cements should be prioritized to ensure safer and more predictable treatments.

📚 References

✔ Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review. Part II: Leakage and biocompatibility investigations. Journal of Endodontics. 2010;36(2):190-202.
✔ American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. Pediatric Dentistry. 2024;46(6):399-407. Siqueira JF, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. Journal of Endodontics. 2008;34(11):1291-1301.
✔ Estrela C, Estrela CRA, Decurcio DA, Hollanda ACB, Silva JA. Antimicrobial efficacy of ozonated water, gaseous ozone, sodium hypochlorite and chlorhexidine in infected human root canals. International Endodontic Journal. 2007;40(2):85-93.
✔ Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review. Part I: Chemical, physical, and antibacterial properties. Journal of Endodontics. 2010;36(1):16-27.
✔ Fuks AB. Current concepts in vital primary pulp therapy. European Journal of Paediatric Dentistry. 2002;3(3):115-120.
✔ Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in endodontics. British Dental Journal. 2014;216(6):299-303.

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