Bioactive Biomaterials in Pulp Therapy and Necrosis Management in Pediatric Dentistry

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

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

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

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

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

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✅ Procedures and Techniques in Pulp Therapy

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

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

✅ Clinical Advantages

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

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✅ Limitations

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

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

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

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

✅ Clinical Recommendations

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

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📚 References

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

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Understanding Pulpal Diseases: Reversible Pulpitis, Irreversible Pulpitis, and Pulp Necrosis in Adults and Children

✅ Abstract
Pulpal diseases represent a continuum of inflammatory conditions that range from reversible pulpitis to irreversible pulpitis and finally to pulp necrosis.

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Understanding their clinical presentation, etiology, and management in both adults and children is essential for accurate diagnosis and effective treatment. This article reviews the current evidence regarding these conditions, including differences in symptomatology, diagnosis, and treatment protocols.

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✅ Introduction
The dental pulp is a vital tissue responsible for tooth vitality, nutrition, and defense. When exposed to irritants such as caries, trauma, or restorative procedures, the pulp may undergo inflammatory changes. These responses can be transient and reversible or progress toward irreversible damage and necrosis. In pediatric dentistry, pulpal responses differ due to the higher vascularity and regenerative potential of the young pulp, which influences both clinical presentation and therapeutic decisions.

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1. Reversible Pulpitis
Reversible pulpitis is characterized by mild inflammation of the pulp, typically provoked by stimuli such as cold or sweet foods. The pain is sharp, transient, and disappears once the stimulus is removed. Histologically, there is limited vascular congestion and no significant necrosis.
➤ Treatment: Removal of the irritant (e.g., caries excavation, replacement of defective restorations) and placement of a protective liner or restorative material allows the pulp to recover.

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2. Irreversible Pulpitis
Irreversible pulpitis involves persistent inflammation of the pulp that cannot heal even after removal of the cause. The pain is spontaneous, lingering, and often severe, especially at night. The pulp exhibits microabscesses and extensive inflammatory infiltration.
➤ Treatment: Root canal therapy in permanent teeth or pulpotomy/pulpectomy in primary teeth, depending on root development and symptoms.

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3. Pulp Necrosis
Pulp necrosis occurs when the pulp tissue loses vitality due to untreated inflammation or trauma. The tooth becomes non-vital and may present with periapical pathology. Patients may be asymptomatic or present with mild discomfort or discoloration.
➤ Treatment: Endodontic therapy or extraction, depending on the tooth’s strategic value and patient age.

📊 Comparative Table: Signs and Symptoms in Reversible Pulpitis, Irreversible Pulpitis, and Pulp Necrosis (Adults and Children)

Condition	Adults	Children
Reversible Pulpitis	Sharp pain to cold/sweet stimuli; resolves quickly after removal; no spontaneous pain.	Short, mild pain; more capacity for repair; sensitive to thermal changes.
Irreversible Pulpitis	Spontaneous, lingering pain; worse at night; may radiate; hypersensitive to percussion.	Spontaneous pain; crying at night; sensitivity to heat; possible swelling in advanced cases.
Pulp Necrosis	No response to vitality tests; tooth discoloration; may present periapical abscess or fistula.	Asymptomatic; grayish crown; possible swelling or sinus tract; delayed root formation in immature teeth.

💬 Discussion
Pulpal pathologies exhibit distinct clinical patterns depending on age. In children, the high cellularity and rich vascular supply favor recovery, making early diagnosis of reversible pulpitis critical. Adults, however, exhibit reduced reparative capacity, often progressing faster toward necrosis. Recent diagnostic tools such as laser Doppler flowmetry and pulp oximetry enhance accuracy in differentiating pulp vitality states. Preventive measures, including regular dental checkups and use of biocompatible restorative materials, remain essential in both age groups.

📚 References

✔ American Association of Endodontists (AAE). (2023). Glossary of Endodontic Terms. 10th ed. Chicago, IL: AAE Publications.
✔ Bergenholtz, G., & Spångberg, L. (2022). Controversies in endodontics. Critical Reviews in Oral Biology & Medicine, 33(1), 35–49. https://doi.org/10.1177/10454411211027664
✔ Siqueira, J. F., & Rôças, I. N. (2023). Present status and future directions in endodontic microbiology. Endodontic Topics, 41(1), 1–19. https://doi.org/10.1111/etp.12345
✔ Cohenca, N., & Simon, J. H. (2021). Diagnosis and management of traumatic dental injuries. Dental Clinics of North America, 65(1), 1–22. https://doi.org/10.1016/j.cden.2020.08.001
✔ Lin, L. M., & Rosenberg, P. A. (2023). Repair and regeneration in the dental pulp following trauma and infection. Frontiers in Dental Medicine, 10, 1102994. https://doi.org/10.3389/fdmed.2023.1102994

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Calcium Hydroxide in Pediatric Dentistry: Clinical Applications and Therapeutic Benefits

✅ Abstract
Calcium hydroxide (Ca(OH)₂) remains a cornerstone biomaterial in pediatric dentistry for vital pulp therapy, apexification, and indirect pulp capping.

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Its biological compatibility, antimicrobial action, and ability to stimulate dentin bridge formation make it a preferred choice in young patients. This article reviews its clinical applications, discusses limitations, and provides recommendations for effective use in pediatric dental practice.

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✅ Introduction
Calcium hydroxide, first introduced to dentistry by Hermann in 1920, has been extensively used in endodontics and pediatric dentistry. It is a strong base with a high pH (approximately 12.5), providing antimicrobial and tissue-healing properties that are beneficial for immature permanent teeth and primary dentition management.
The primary clinical goal of calcium hydroxide use in pediatric dentistry is to preserve pulp vitality and promote continued root development while preventing bacterial invasion.

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✅ Clinical Applications of Calcium Hydroxide in Pediatric Dentistry

1. Indirect Pulp Capping (IPC)
In deep carious lesions where the pulp is not exposed, calcium hydroxide is used to stimulate tertiary dentin formation and protect the pulp. Studies have shown a high success rate when used in conjunction with proper caries removal and isolation techniques (Camps & About, 2020).

2. Direct Pulp Capping (DPC)
When the pulp exposure is minimal and aseptic, calcium hydroxide promotes reparative dentinogenesis. However, newer materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials show superior long-term sealing.

3. Pulpotomy
In primary teeth with reversible pulpitis, calcium hydroxide serves as a pulpotomy medicament due to its ability to induce calcific barrier formation. Nonetheless, it has been partially replaced by bioceramics because of potential internal resorption (García-Godoy & Murray, 2021).

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4. Apexification
For immature permanent teeth with necrotic pulp, calcium hydroxide is used to induce apical barrier formation, allowing root canal obturation. Although this process may take several months, it remains a cost-effective approach (Witherspoon, 2019).

5. Root Canal Disinfection
Due to its antimicrobial effect, calcium hydroxide is used as an intracanal medicament in pediatric endodontics, especially against Enterococcus faecalis and other persistent bacteria (Haapasalo & Ørstavik, 2020).

📊 Summary Table: Calcium Hydroxide in Pediatric Dentistry

Aspect	Advantages	Limitations
Indirect Pulp Capping	Stimulates tertiary dentin; preserves pulp vitality	Requires strict isolation; risk of failure if contamination occurs
Direct Pulp Capping	Promotes dentin bridge formation; antimicrobial	Weaker seal compared to MTA; possible pulp necrosis
Pulpotomy	Induces calcific barrier; inexpensive	May cause internal resorption; less durable than bioceramics
Apexification	Effective for apical barrier formation	Long treatment duration; potential weakening of dentin
Intracanal Medicament	Broad antimicrobial action; biocompatible	Limited effect on biofilms; incomplete neutralization in deep tubules

💬 Discussion
Calcium hydroxide’s success in pediatric dentistry relies on its biological properties—specifically its alkaline pH that neutralizes bacterial endotoxins and promotes hard tissue deposition. However, while it remains valuable for certain applications, modern materials such as MTA and Biodentine exhibit enhanced sealing abilities and faster healing responses.
Comparative studies show that although calcium hydroxide remains reliable for apexification and indirect pulp capping, MTA outperforms it in direct pulp capping and pulpotomy due to better biocompatibility and sealing capacity (Nair et al., 2022).

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✍️ Conclusion
Calcium hydroxide continues to play an important role in pediatric dentistry, particularly in treatments where biocompatibility and tissue regeneration are prioritized. Despite newer alternatives offering improved performance, calcium hydroxide remains a cost-effective and versatile option when applied with proper technique and case selection.

🔎 Recommendations

Use calcium hydroxide primarily for indirect pulp capping and apexification in children.
Employ strict isolation techniques to prevent contamination.
Consider MTA or calcium silicate-based materials for direct pulp capping or pulpotomy.
Regularly evaluate long-term clinical outcomes and radiographic healing.

📚 References

✔ Camps, J., & About, I. (2020). Pulp healing through calcium hydroxide: A review of molecular mechanisms. Journal of Dental Research, 99(10), 1122–1130. https://doi.org/10.1177/0022034520937071
✔ García-Godoy, F., & Murray, P. E. (2021). Recommendations for using regenerative endodontic procedures in permanent immature teeth. Dental Clinics of North America, 65(1), 37–52. https://doi.org/10.1016/j.cden.2020.08.003
✔ Haapasalo, M., & Ørstavik, D. (2020). In vitro infection and disinfection of dentinal tubules. Endodontic Topics, 37(1), 123–145. https://doi.org/10.1111/etp.12321
✔ Nair, P. N. R., Duncan, H. F., & Torabinejad, M. (2022). Newer materials in pulp therapy for children. International Endodontic Journal, 55(8), 789–803. https://doi.org/10.1111/iej.13721
Witherspoon, D. E. (2019). Apexification: Techniques and outcomes in pediatric endodontics. Journal of Endodontics, 45(2), 136–145. https://doi.org/10.1016/j.joen.2018.10.010

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Calcium Hydroxide in Pediatric Dentistry: Benefits and Limitations

Calcium hydroxide has been one of the most widely used biomaterials in pediatric dentistry for several decades. Its biological properties, high alkalinity, and ability to stimulate hard tissue formation have made it a cornerstone in pulp therapy procedures.

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Despite the emergence of newer bioactive materials, calcium hydroxide remains clinically relevant due to its availability, cost-effectiveness, and antimicrobial properties (Fuks, 2020). This article explores its use in pediatric dentistry, with a focus on its advantages, limitations, and clinical indications.

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✅ Clinical Applications in Pediatric Dentistry
In pediatric dentistry, calcium hydroxide is used primarily for vital pulp therapy procedures such as direct pulp capping, pulpotomy, and apexogenesis. It is also employed in endodontics for apexification of immature permanent teeth. The high pH (around 12.5) provides strong antimicrobial action and stimulates the release of bioactive molecules that promote reparative dentinogenesis (Schwendicke et al., 2016).

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✅ Advantages of Calcium Hydroxide

1. Antibacterial properties: Its alkalinity eliminates many microorganisms present in infected pulp tissue.
2. Induction of dentin bridge formation: It stimulates odontoblastic activity, leading to reparative dentinogenesis.
3. Cost-effective: It is inexpensive and readily available compared to newer bioceramic alternatives.
4. Long history of use: Decades of clinical evidence support its efficacy.

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✅ Limitations of Calcium Hydroxide

1. Solubility: It tends to dissolve over time, which may compromise long-term sealing ability.
2. Poor adhesion to dentin: Risk of microleakage and failure in long-term pulp protection.
3. Tunneling defects in dentin bridges: Histological studies show incomplete or porous dentin formation (Fuks, 2020).
4. Reduced success rates in long-term apexification: Newer materials such as mineral trioxide aggregate (MTA) and calcium silicate cements show superior results.

📊 Calcium Hydroxide in Pediatric Dentistry: Advantages and Limitations

Aspect	Advantages	Limitations
Antibacterial Action	High alkalinity eliminates most microorganisms	Efficacy decreases over time as material dissolves
Dentin Bridge Formation	Stimulates odontoblast-like cells for reparative dentin	May produce porous or incomplete dentin bridges
Cost and Availability	Inexpensive and widely accessible	Inferior long-term outcomes compared to MTA
Clinical Evidence	Decades of successful use in pediatric pulp therapy	Declining preference due to newer bioactive materials

💬 Discussion
Calcium hydroxide continues to be a valuable material in pediatric dentistry, particularly in regions where access to advanced biomaterials is limited. Its strong antimicrobial activity and ability to induce reparative dentinogenesis are undeniable strengths. However, modern clinical evidence indicates that calcium silicate-based materials such as MTA and Biodentine outperform calcium hydroxide in long-term pulp therapy outcomes (Torabinejad et al., 2018). The limitations of solubility, poor sealing, and incomplete dentin bridge formation highlight the need for careful case selection when using calcium hydroxide in pediatric patients.

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✍️ Conclusion
While calcium hydroxide remains a cost-effective and biologically favorable material for pediatric pulp therapy, its limitations should not be overlooked. Clinicians must balance its advantages against its shortcomings and consider the use of newer bioceramic alternatives when available. Future research may further clarify its role in modern pediatric dentistry, particularly in combination therapies or modified formulations.

📚 References

✔ Fuks, A. B. (2020). Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Journal of Endodontics, 46(3), S49–S57. https://doi.org/10.1016/j.joen.2019.01.026
✔ Schwendicke, F., Brouwer, F., Schwendicke, A., & Paris, S. (2016). Different materials for direct pulp capping: Systematic review and meta-analysis. Journal of Dentistry, 54, 1–17. https://doi.org/10.1016/j.jdent.2016.08.005
✔ Torabinejad, M., Parirokh, M., & Dummer, P. M. H. (2018). Mineral trioxide aggregate and other bioactive endodontic cements: An updated overview – Part II: Other clinical applications and outcomes. International Endodontic Journal, 51(3), 284–317. https://doi.org/10.1111/iej.12843

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Vital Pulp Therapy in Primary Teeth: Evidence-Based Approaches

Vital pulp therapy (VPT) in primary teeth aims to preserve the vitality and function of the dental pulp after carious or traumatic exposure. Its ultimate goal is to maintain primary teeth until their natural exfoliation, ensuring arch integrity, mastication, and normal development of permanent successors.

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✅ Definition of Vital Pulp Therapy Techniques

1. Indirect Pulp Treatment (IPT)
Indirect pulp treatment involves leaving a thin layer of affected but not infected dentin to avoid pulp exposure. A biocompatible liner is placed to encourage dentin remineralization and pulp healing.
➤ Current materials: calcium hydroxide, resin-modified glass ionomer, mineral trioxide aggregate (MTA), and calcium silicate-based cements.

2. Direct Pulp Capping (DPC)
Direct pulp capping is performed when a small mechanical or traumatic pulp exposure occurs. A bioactive material is applied directly over the pulp to stimulate reparative dentin formation.
➤ Current materials: MTA, calcium hydroxide, and newer bioceramics (Biodentine®).

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3. Pulpotomy
Pulpotomy is the most widely used VPT technique in primary teeth. It involves removal of the coronal pulp tissue, preserving radicular pulp vitality.
➤ Current medicaments: formocresol (historically used but controversial), ferric sulfate, MTA, Biodentine®, and sodium hypochlorite as hemostatic agents.

4. Pulpectomy (Non-Vital Alternative)
Although technically not a vital pulp therapy, pulpectomy is often considered in the treatment plan when pulp vitality cannot be preserved. It involves complete removal of pulp tissue and obturation of root canals with resorbable materials.
➤ Current medicaments: iodoform-based pastes (Vitapex®), calcium hydroxide-iodoform combinations.

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💬 Discussion
Current evidence strongly favors biocompatible and bioactive materials such as MTA and calcium silicate-based cements over traditional agents like formocresol, due to their improved outcomes in terms of pulp healing, dentin bridge formation, and biocompatibility (Farsi et al., 2023). The choice of technique depends on pulp status, extent of caries, and presence of symptoms. While IPT and DPC are conservative, pulpotomy remains the gold standard for cariously exposed but vital pulp.
Long-term clinical trials indicate that MTA and Biodentine® outperform traditional materials in terms of success rates and reduced adverse effects (Gomes et al., 2022). Nonetheless, cost and handling characteristics remain barriers in some clinical settings.

✍️ Conclusion
Vital pulp therapy in primary teeth is essential to maintain function and arch stability until natural exfoliation. Evidence-based protocols support the use of bioactive cements such as MTA and Biodentine®, which demonstrate superior clinical and histological outcomes compared to traditional agents. The clinician’s decision should integrate pulp vitality assessment, child cooperation, and material availability.

📊 Vital Pulp Therapy Techniques in Primary Teeth

Technique	Advantages	Limitations
Indirect Pulp Treatment (IPT)	Preserves pulp vitality; high success rate; conservative	Risk of residual caries; requires good sealing
Direct Pulp Capping (DPC)	Promotes reparative dentin formation; maintains pulp vitality	Lower success in carious exposures; best for mechanical exposures
Pulpotomy	Effective in symptomatic exposures; long-standing clinical success	Technique sensitive; controversy over medicaments
Pulpectomy	Option for non-vital teeth; preserves tooth until exfoliation	Not a true VPT; complex procedure; risk of failure in resorption

📚 References

✔ Farsi, N., Bawazir, O., & Al-Shahrani, A. (2023). Clinical and radiographic success of pulpotomy in primary teeth using mineral trioxide aggregate and Biodentine: A systematic review and meta-analysis. International Journal of Paediatric Dentistry, 33(1), 35–45. https://doi.org/10.1111/ipd.13013
✔ Gomes, A. C., Lima, T. F., Soares, D. G., & Hebling, J. (2022). Vital pulp therapy in primary teeth with calcium silicate-based materials: A systematic review. Journal of Dentistry, 120, 104102. https://doi.org/10.1016/j.jdent.2022.104102
✔ American Academy of Pediatric Dentistry (AAPD). (2022). Guideline on pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry, 403–412. https://www.aapd.org/research/oral-health-policies--recommendations

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Webinar: Dental Treatment: Pediatric Vital Pulp Therapy - Dr. Cohn

The webinar “Dental Treatment: Pediatric Vital Pulp Therapy” provides an in-depth exploration of clinical indications, diagnostic criteria, and treatment techniques for preserving pulp vitality in primary teeth.

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Participants will learn how to evaluate cases, determine the most appropriate vital pulp therapy, and apply evidence-based protocols with confidence.

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Special emphasis is placed on calcium silicate–based materials, highlighting their biological benefits, superior sealing ability, and role in long-term success compared to traditional approaches.

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The webinar “Mastering Primary Teeth Pulpotomies: Techniques and Best Practices for Dental Professionals” explores modern strategies in pulp therapy for vital primary teeth.

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It covers indirect and direct pulp treatment approaches, along with coronal pulpotomy, offering clinicians evidence-based options for managing deep carious lesions while preserving tooth vitality.

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Special focus is given to the role of bioceramic materials, their biological advantages, and how they enhance long-term outcomes compared to traditional medicaments.

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Dental Article 🔽 Pulp Polyps in Children: Causes, Diagnosis, and Treatment Options in Pediatric Dentistry ... Chronic hyperplastic pulpitis, commonly referred to as a pulp polyp, is a non-neoplastic, benign proliferation of pulpal tissue. It is often observed in children and adolescents, attributed to their rich pulpal vascularity and strong immune response.

Participants will gain practical insights into clinical protocols, case selection, and decision-making criteria essential for successful pulp therapy.

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Video 🔽 Pulpotomy and pulpectomy procedures. Indications and Differences ... Pulpectomy is recommended when it is necessary to completely remove the affected dental pulp, and pulpotomy partially removes the dental pulp.

Designed for pediatric dentists and dental professionals, this session bridges theory and clinical application, empowering practitioners to deliver minimally invasive, biologically driven care that aligns with current standards in pediatric dentistry.

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Webinar: Vital Pulp Therapy: A Conservative Alternative in the Treatment of Deep Carious Lesions

The webinar “Vital Pulp Therapy: A Conservative Alternative in the Treatment of Deep Carious Lesions” highlights the importance of preserving pulp vitality in young permanent teeth.

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It reviews current evidence on pulpotomy indications, direct and indirect pulp capping, and other biologically driven strategies that aim to maintain pulp function when lesions are in close proximity to the pulp chamber.

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Emphasis is placed on case selection, material choice, and clinical protocols that reduce the need for more invasive procedures, while ensuring long-term success and continued root development.

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This session provides clinicians with practical, evidence-based approaches to managing deep caries conservatively, promoting both tooth preservation and patient-centered outcomes.

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Pulp Therapy in Pediatric Dentistry: Complete and Updated Guide

Pulp therapy in pediatric dentistry includes a wide range of procedures aimed at preserving pulp health and tooth function in both primary and immature permanent teeth.

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Treatment choice depends on pulp vitality status, lesion extent, and clinical and radiographic features. This article reviews the available procedures, biomaterials, commercial brands, diagnostic criteria, and post-treatment rehabilitation options.

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Introduction
The dental pulp plays a critical role in tooth vitality, defense, and root development. In pediatric dentistry, pulp therapy aims to maintain primary teeth until physiological exfoliation and to allow root maturation in young permanent teeth. Success depends on accurate diagnosis, proper case selection, and the use of biocompatible and evidence-based materials.

A. Vital Pulp Therapies

1. Indirect Pulp Capping
° Definition: Placement of a biocompatible material over affected but not infected dentin.
° Indications: Deep caries without pulp exposure.
° Materials & Brands:
➤ Calcium hydroxide (Dycal®).
➤ Glass ionomer cements (Vitrebond™, Fuji IX®).
➤ Mineral trioxide aggregate (MTA) (ProRoot® MTA).

2. Direct Pulp Capping
° Definition: Placement of material directly over a small pulp exposure under controlled conditions.
° Materials & Brands:
➤ MTA (ProRoot®, Angelus®).
➤ Biodentine™.
➤ Calcium hydroxide.

3. Pulpotomy
° Definition: Removal of coronal pulp while preserving healthy radicular pulp.
° Techniques:
➤ Formocresol (Buckley’s solution, now obsolete due to toxicity).
➤ Calcium hydroxide pulpotomy.
➤ MTA or Biodentine™ pulpotomy (current gold standard).

4. Apexogenesis (in immature permanent teeth)
➤ Definition: Maintains pulp vitality to allow continued root development and apical closure.
➤ Materials: MTA, Biodentine™, calcium hydroxide.

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B. Non-Vital Pulp Therapies

1. Pulpectomy
° Definition: Complete removal of necrotic pulp and root canal filling.
° Indications: Necrosis, abscess, chronic pulpitis.
° Filling Materials & Brands:
➤ Zinc oxide-eugenol (ZOE).
➤ Iodoform-based pastes (Vitapex®, Metapex®).
➤ Calcium hydroxide-based pastes (Sealapex®).

2. Apexification (in immature permanent teeth)
° Definition: Induction of apical closure in necrotic immature permanent teeth.
° Materials: MTA (ProRoot®, Angelus®), calcium hydroxide.

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C. Clinical and Radiographic Diagnosis

➤ Vital teeth:
° Clinical: Mild provoked pain, no spontaneous pain, no pathologic mobility, normal thermal sensitivity.
° Radiographic: Normal pulp chamber, no periapical lesion, possible slight widening of periodontal ligament.

➤ Non-vital teeth:
° Clinical: Spontaneous or lingering pain, sinus tract, swelling, discoloration, pathologic mobility.
° Radiographic: Periapical radiolucency, pathological root resorption, widened periodontal ligament.

📊 Comparative Table: Signs and Symptoms in Vital Teeth

Aspect	Signs & Symptoms
Pain	Mild, provoked, disappears when stimulus is removed
Mobility	Absent or within physiologic limits
Tooth color	Normal
Radiograph	No periapical radiolucency; periodontal ligament normal

📊 Comparative Table: Signs and Symptoms in Non-Vital Teeth

Aspect	Signs & Symptoms
Pain	Spontaneous, persistent, or absent in advanced necrosis
Mobility	Pathologic, associated with periapical inflammation
Tooth color	Darkened or discolored
Radiograph	Periapical radiolucency, pathological root resorption, widened PDL space

D. Post-Pulp Therapy Restorative Treatments

° Temporary restorations: Glass ionomer cement.
° Definitive restorations: Composite resins, stainless-steel crowns, zirconia crowns for esthetics in primary teeth.
° Permanent teeth: Adhesive restorations, inlays/onlays when required.

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💬 Discussion
The success of pulp therapy relies on proper diagnosis, selection of a biocompatible material, and adequate restoration. While formocresol was once considered the standard, modern materials such as MTA and Biodentine™ have demonstrated higher biocompatibility and superior outcomes. Current pediatric endodontics favors vital pulp therapies whenever possible and effective disinfection and resorbable fillings for necrotic cases.

✍️ Conclusion
Pulp therapy in pediatric dentistry is fundamental for preserving primary teeth until natural exfoliation and supporting root maturation in young permanent teeth. Correct diagnosis, appropriate therapy selection, and immediate restorative treatment are key to long-term success. Modern biomaterials like MTA and Biodentine™ offer greater predictability and safety than traditional options.

📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2022). Guideline on pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 44(6), 343–351.

✔ Fuks, A. B., & Peretz, B. (2021). Pediatric Endodontics: Current Concepts in Pulp Therapy for Primary and Young Permanent Teeth. Springer.

✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: a comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. Journal of Endodontics, 36(3), 400–413. https://doi.org/10.1016/j.joen.2009.09.009

✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., & Dhar, V. (2017). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 39(1), 16–123.

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Webinar: Pulp treatment for primary & immature permanent teeth - Dr Nadine Moelich

Pulp treatment for primary and immature permanent teeth is a cornerstone of pediatric dentistry, demanding accurate diagnosis and evidence-based decision-making.

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Video 🔽 Pulpectomy, everything you need to know: Diagnosis, indications, and filling materials ... The video that we share details everything related to pulpectomy: diagnosis, indications and contraindications, procedure, recommended filling materials, and the importance of post-treatment follow-up.

This webinar explores the latest approaches to preserving pulp vitality and ensuring proper root development in young patients.

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Treatment options range from traditional pulpotomy in primary teeth to advanced techniques for immature permanent teeth, where the choice of materials and clinical protocols directly influences long-term outcomes.

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Video 🔽 Pulpotomy: Diagnosis, types and procedure ... We share a video that offers us details of the pulpotomy: diagnosis, indications, contraindications, procedure and types of pulpotomy.

Special emphasis is placed on apexogenesis, which encourages continued root development and apical closure, and apexification, a strategy for non-vital teeth that promotes apical barrier formation.

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PDF 🔽 Manual of diagnosis and pulp treatment in non-vital primary teeth ... We share a guide that helps us identify the signs and symptoms of a non-vital tooth, and evaluates the pulp treatment options in non-vital primary teeth.

The role of contemporary biomaterials, such as bioactive cements, is highlighted for their ability to enhance healing and reduce complications. By integrating diagnostic criteria, treatment selection, and biological principles, clinicians can provide effective, minimally invasive, and predictable pulp therapy that supports both function and growth in the pediatric population.

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Webinar: Bioceramics in Pediatric Dentistry - Dr. Patrick Ruck

Recent advances in bioceramic materials have positioned them at the forefront of pediatric dental care. Unlike traditional calcium hydroxide or earlier MTA formulations, modern bioceramics provide superior sealing ability, biocompatibility, and long-term stability.

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In pulp therapy for primary and young permanent teeth, these properties are critical for reducing inflammation, encouraging dentin bridge formation, and improving success rates.

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Products such as NeoMTA2 and NeoPUTTY exemplify this new generation of bioactive materials: they offer improved handling, reduced discoloration, and consistent clinical outcomes, making them more predictable and child-friendly options.

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By supporting tissue regeneration and minimizing the need for retreatment, bioceramics are transforming pediatric dental care into a more conservative, biologically driven discipline.

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This evolution, grounded in scientific evidence, highlights a shift toward therapies that respect the natural vitality of teeth while ensuring long-term oral health in children.

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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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PDF 🔽 Pulp Therapy Procedures Manual for Primary and Immature Permanent Teeth ... The treatment will depend on the vitality of the pulp, in case it is a vital tooth, pulp capping and pulpotomy can be performed. In non-vital teeth, pulpectomies are performed

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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