Why Pulp Therapy Fails: Risk Factors, Clinical Errors, and Evidence-Based Solutions

Pulp therapy is a cornerstone of both pediatric and adult restorative dentistry. However, despite advances in materials and techniques, treatment failure remains a relevant clinical challenge.

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Understanding why pulp therapy fails is essential to improve prognosis, reduce retreatment, and preserve tooth structure. This article reviews the main biological, technical, and restorative factors associated with failure and presents evidence-based solutions supported by current literature.

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✅ Biological Risk Factors for Pulp Therapy Failure
Biological factors often determine the baseline prognosis before treatment begins.Key contributors include:

▪️ Incorrect pulp diagnosis (reversible vs. irreversible pulpitis)
▪️ Advanced bacterial contamination
▪️ Undetected pulpal necrosis
▪️ Compromised immune response

Accurate case selection is one of the most critical determinants of pulp therapy success.

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✅ Clinical and Technical Errors
Many failures are directly related to operator-dependent factors.
Common errors include:

▪️ Inadequate isolation, leading to salivary and bacterial contamination
▪️ Incomplete caries removal, leaving infected dentin
▪️ Over-instrumentation or pulp tissue trauma
▪️ Improper placement of pulp capping or pulpotomy materials

Studies consistently show that lack of rubber dam isolation significantly increases failure rates.

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✅ Material-Related Factors
The choice and handling of materials play a decisive role.
Frequent issues include:

▪️ Incorrect manipulation of calcium-based materials
▪️ Use of outdated or low-biocompatibility agents
▪️ Poor sealing ability of restorative materials

Modern bioactive materials such as mineral trioxide aggregate (MTA) and calcium silicate cements demonstrate superior outcomes due to their biocompatibility, sealing ability, and bioinductive properties.

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✅ Restorative and Post-Treatment Factors
Even a technically correct pulp therapy can fail if the final restoration is inadequate.
Critical aspects:

▪️ Coronal microleakage
▪️ Delayed placement of definitive restoration
▪️ Poor marginal adaptation
▪️ Occlusal overload

A hermetic coronal seal is as important as the pulpal procedure itself.

📊 Comparative Table: Factors Influencing Pulp Therapy Outcomes

Aspect	Advantages	Limitations
Accurate Pulp Diagnosis	Improves case selection and prognosis	Requires clinical experience and diagnostic tools
Use of Bioactive Materials	Promotes dentin bridge formation and healing	Higher cost and technique sensitivity
Rubber Dam Isolation	Reduces bacterial contamination	May be challenging in uncooperative patients
Definitive Coronal Seal	Prevents microleakage and reinfection	Failure if restoration is delayed or poorly adapted

💬 Discussion
Current evidence confirms that pulp therapy failure is rarely due to a single factor. Instead, it is the result of an interaction between biological status, clinical technique, material selection, and restorative quality. Advances in bioactive materials have improved success rates, but they cannot compensate for poor diagnosis or inadequate isolation. Long-term success depends on strict adherence to evidence-based protocols.

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🎯 Clinical Recommendations
▪️ Perform thorough pulp vitality and radiographic assessment
▪️ Always use rubber dam isolation
▪️ Select bioactive materials with proven clinical evidence
▪️ Ensure immediate and well-sealed definitive restorations
▪️ Schedule follow-up evaluations to detect early signs of failure

✍️ Conclusion
Pulp therapy fails primarily due to diagnostic errors, inadequate isolation, material misuse, and poor coronal sealing. When evidence-based principles are respected, pulp therapy remains a highly predictable and conservative treatment option. Continuous education and protocol standardization are key to improving clinical outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry, 384–392.
✔ 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
✔ Bogen, G., Kim, J. S., & Bakland, L. K. (2008). Direct pulp capping with mineral trioxide aggregate: An observational study. Journal of the American Dental Association, 139(3), 305–315. https://doi.org/10.14219/jada.archive.2008.0150
✔ Hilton, T. J. (2009). Keys to clinical success with pulp capping: A review of the literature. Operative Dentistry, 34(5), 615–625.

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Open Apex Management in Traumatized Teeth: Latest Evidence-Based Recommendations

Dental trauma frequently affects immature permanent teeth, particularly in children and adolescents. When trauma occurs before complete root development, it often results in teeth with open apices, posing significant clinical challenges.

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Open apex management in traumatized teeth aims to control infection, preserve tooth structure, and promote continued root development or apical closure using evidence-based techniques.

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✅ Understanding Open Apex in Traumatized Teeth
An open apex is characterized by:

▪️ Incomplete root formation
▪️ Thin dentinal walls
▪️ Wide apical foramen

Traumatic injuries such as luxation, avulsion, or complicated crown fractures may compromise pulpal vitality, interrupting root development and increasing the risk of infection and fracture.
Early and accurate diagnosis is critical to determine prognosis and select the most appropriate therapeutic approach.

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✅ Diagnostic Considerations
Key diagnostic factors include:

▪️ Type and severity of trauma
▪️ Pulp vitality status
▪️ Stage of root development
▪️ Presence of infection or apical pathology

Radiographic evaluation (periapical radiographs or CBCT when indicated) is essential to assess root length, apical diameter, and periapical status.

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✅ Evidence-Based Treatment Options

➤ Apexification
Apexification is indicated for non-vital immature teeth and aims to create an apical barrier to allow obturation.
Calcium hydroxide (traditional method)
Mineral trioxide aggregate (MTA) or bioceramic materials (modern approach)
Bioceramic apexification has largely replaced long-term calcium hydroxide due to improved outcomes and reduced treatment time.

➤ Regenerative Endodontic Procedures (REPs)
Regenerative endodontics is currently the preferred approach for many immature teeth with necrotic pulps. Benefits include:
▪️ Continued root maturation
▪️ Increased dentinal wall thickness
▪️ Improved fracture resistance
This approach is supported by AAPD and IADT guidelines, particularly in young patients.

➤ Vital Pulp Therapy in Traumatized Teeth
In cases of reversible pulp damage, procedures such as:
▪️ Partial pulpotomy (Cvek pulpotomy)
▪️ Direct pulp capping
may allow continued root development (apexogenesis) when performed promptly.

📊 Comparative Table: Evidence-Based Management Options for Open Apex Teeth

Aspect	Advantages	Limitations
Calcium Hydroxide Apexification	Long history of use, induces apical hard tissue barrier	Long treatment time, increased fracture risk, multiple visits
MTA / Bioceramic Apexification	Shorter treatment time, predictable apical seal, biocompatible	No continued root development, higher material cost
Regenerative Endodontic Procedures	Promotes root maturation and dentinal thickening	Technique-sensitive, variable outcomes
Vital Pulp Therapy	Preserves pulp vitality and allows apexogenesis	Limited to cases with minimal pulpal inflammation

💬 Discussion
Recent evidence supports a paradigm shift toward biologically based therapies, particularly regenerative endodontics, for immature teeth with necrotic pulps. While apexification remains a valid option, it does not promote continued root development, which is critical for long-term tooth survival.
Case selection, patient compliance, and clinician expertise remain decisive factors in treatment success.

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🎯 Clinical Recommendations
▪️ Prioritize pulp vitality preservation whenever possible
▪️ Consider regenerative endodontic procedures as first-line therapy for necrotic immature teeth
▪️ Use bioceramic materials for apexification when regeneration is not feasible
▪️ Ensure long-term follow-up to monitor root development and periapical healing
▪️ Follow IADT and AAPD trauma guidelines strictly

✍️ Conclusion
Management of traumatized teeth with open apices requires an evidence-based, individualized approach. Advances in regenerative endodontics and bioceramic materials have significantly improved clinical outcomes. Early intervention, accurate diagnosis, and adherence to current guidelines are essential to ensure functional and long-lasting results.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry.
✔ Diogenes, A., Henry, M. A., Teixeira, F. B., & Hargreaves, K. M. (2013). An update on clinical regenerative endodontics. Endodontic Topics, 28(1), 2–23.
✔ Fouad, A. F., Abbott, P. V., Tsilingaridis, G., et al. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dental Traumatology, 36(4), 314–330.
✔ Torabinejad, M., & Parirokh, M. (2010). Mineral trioxide aggregate: A comprehensive literature review. Journal of Endodontics, 36(1), 16–27.
✔ American Association of Endodontists. (2021). Clinical considerations for regenerative procedures.

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Why Formocresol Is No Longer Recommended in Pediatric Pulp Therapy: Evidence-Based Risks and Modern Alternatives

For decades, formocresol was considered the gold standard for pulpotomy in primary teeth. Its fixative and antimicrobial properties led to widespread use in pediatric dentistry. However, advances in biomedical research and biocompatible materials have significantly changed clinical practice.

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Current evidence raises serious concerns regarding systemic toxicity, mutagenicity, and potential carcinogenic effects, prompting professional organizations to reconsider its use.

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✅ What Is Formocresol and Why Was It Used?
Formocresol is a compound containing formaldehyde, cresol, glycerin, and water. It was historically used to devitalize radicular pulp tissue in primary teeth.
Its popularity was based on:

▪️ Ease of use
▪️ Low cost
▪️ Short chair time
▪️ Acceptable short-term clinical success

However, success rates alone are no longer sufficient to justify clinical use when patient safety is compromised.

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✅ Evidence-Based Risks of Formocresol
Multiple studies have demonstrated that formaldehyde can diffuse systemically after pulpotomy procedures. Scientific evidence associates formocresol with:

▪️ Cytotoxic and genotoxic effects
▪️ Immune sensitization
▪️ Potential carcinogenicity
▪️ Adverse effects on developing tissues

The International Agency for Research on Cancer (IARC) classifies formaldehyde as a Group 1 carcinogen, raising major concerns for pediatric patients.

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✅ Current Guidelines and Professional Consensus
Leading organizations such as the American Academy of Pediatric Dentistry (AAPD) now recommend biocompatible alternatives over formocresol.
Modern pulp therapy focuses on:

▪️ Preservation of radicular pulp vitality
▪️ Promotion of healing and regeneration
▪️ Use of bioactive and calcium silicate–based materials

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✅ Modern Alternatives to Formocresol
Several materials have demonstrated equal or superior success rates with improved safety profiles:

▪️ Mineral Trioxide Aggregate (MTA)
▪️ Biodentine
▪️ Calcium hydroxide
▪️ Ferric sulfate

Among these, MTA and Biodentine show the highest long-term clinical and radiographic success.

📊 Comparative Table: Pulpotomy Materials in Pediatric Dentistry

Aspect	Advantages	Limitations
Formocresol	Simple technique; historical clinical familiarity	Toxicity; carcinogenic potential; not biocompatible
Mineral Trioxide Aggregate (MTA)	High success rates; promotes hard tissue formation	Higher cost; longer setting time
Biodentine	Excellent biocompatibility; fast setting	Cost; technique sensitivity
Ferric Sulfate	Hemostatic effect; acceptable clinical outcomes	Does not promote dentin bridge formation
Calcium Hydroxide	Biological compatibility; low cost	Lower long-term success in primary teeth

💬 Discussion
While formocresol played an important historical role, its continued use is inconsistent with modern principles of pediatric dental care. Dentistry has shifted from devitalization toward biological pulp preservation.
The availability of bioactive materials that promote dentin bridge formation and pulp healing eliminates the need for potentially harmful medicaments.

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✍️ Conclusion
Formocresol is no longer recommended in pediatric pulp therapy due to well-documented systemic and biological risks. Evidence-based dentistry now prioritizes biocompatibility, safety, and long-term outcomes, making modern alternatives the standard of care.

🔎 Clinical Recommendations
▪️ Avoid the use of formocresol in primary teeth
▪️ Prefer MTA or Biodentine for pulpotomy procedures
▪️ Follow AAPD evidence-based guidelines
▪️ Emphasize pulp vitality preservation
▪️ Educate caregivers about safer treatment options

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry, 384–392. https://www.aapd.org/research/oral-health-policies--recommendations/pulp-therapy/
✔ International Agency for Research on Cancer. (2012). Formaldehyde. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 100F.
✔ Ranly, D. M. (2000). Pulpotomy therapy in primary teeth: New modalities for old rationales. Pediatric Dentistry, 22(5), 403–409.
✔ Fuks, A. B. (2008). Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Pediatric Dentistry, 30(3), 211–219.
✔ Agamy, H. A., Bakry, N. S., Mounir, M. M., & Avery, D. R. (2004). Comparison of mineral trioxide aggregate and formocresol as pulpotomy agents in primary teeth. Pediatric Dentistry, 26(4), 302–309.

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Triple Antibiotic Paste (TAP) in Pediatric Endodontics: Current Clinical Evidence

Triple Antibiotic Paste (TAP) has gained significant attention in pediatric endodontics, particularly in the management of necrotic primary teeth and immature permanent teeth.

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Its broad-spectrum antimicrobial activity has made it a key intracanal medicament in regenerative endodontic procedures (REPs) and complex pulpal infections.

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Despite its effectiveness, concerns regarding tooth discoloration, cytotoxicity, and antibiotic resistance have prompted ongoing research and clinical debate.

✅ What Is Triple Antibiotic Paste (TAP)?
TAP is a combination of three antibiotics:

▪️ Metronidazole
▪️ Ciprofloxacin
▪️ Minocycline
This formulation targets both aerobic and anaerobic microorganisms, making it particularly effective against polymicrobial endodontic infections.
TAP is primarily used as an intracanal medicament rather than a permanent filling material.

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✅ Clinical Applications in Pediatric Endodontics
TAP is commonly indicated in:

▪️ Necrotic primary teeth with periapical pathology
▪️ Immature permanent teeth with open apices
▪️ Regenerative endodontic procedures
▪️ Persistent endodontic infections resistant to conventional irrigation

Clinical studies show a significant reduction in bacterial load when TAP is used short-term.

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✅ Advantages of TAP

▪️ Broad-spectrum antimicrobial efficacy
▪️ Effective against Enterococcus faecalis and anaerobic species
▪️ Enhances canal disinfection prior to regenerative procedures
▪️ Improves clinical and radiographic healing outcomes

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✅ Limitations and Safety Concerns
Despite its benefits, TAP presents important limitations:

▪️ Minocycline-induced tooth discoloration
▪️ Potential cytotoxic effects on stem cells
▪️ Risk of antibiotic resistance
▪️ Not recommended for long-term intracanal use

These concerns have led to the development of modified formulations such as Double Antibiotic Paste (DAP) and antibiotic-free alternatives.

📊 Comparative Table: Benefits of Pastes Used in Pulp Therapy

Aspect	Advantages	Limitations
Triple Antibiotic Paste (TAP)	Broad-spectrum antimicrobial action; effective in regenerative procedures	Tooth discoloration; cytotoxicity; antibiotic resistance risk
Double Antibiotic Paste (DAP)	Reduced discoloration risk; effective bacterial control	Still involves antibiotic exposure; limited long-term data
Calcium Hydroxide	High biocompatibility; promotes hard tissue formation	Less effective against resistant bacteria
Ledermix Paste	Anti-inflammatory and antibacterial properties	Contains corticosteroids; limited pediatric indication
Iodoform-Based Pastes	Resorbable; suitable for primary teeth	Limited antimicrobial spectrum

💬 Discussion
Current evidence supports the short-term use of TAP as an effective intracanal medicament, particularly in regenerative endodontics. However, lower concentrations and limited exposure times are strongly recommended to reduce adverse effects.
Recent guidelines emphasize balancing antimicrobial efficacy with biocompatibility, especially in pediatric patients where tissue healing and tooth development are critical.

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✍️ Conclusion
Triple Antibiotic Paste remains a valuable tool in pediatric endodontics when used judiciously. While highly effective in infection control, clinicians must consider its limitations and adhere to evidence-based protocols to ensure safety and long-term success.

🔎 Clinical Recommendations
▪️ Use TAP at low concentrations (≤1 mg/mL)
▪️ Limit intracanal placement to 1–4 weeks
▪️ Avoid use in esthetic zones when possible
▪️ Consider DAP or calcium hydroxide as alternatives
▪️ Follow updated regenerative endodontic guidelines

📚 References

✔ Hoshino, E., Kurihara-Ando, N., Sato, I., Uematsu, H., Sato, M., Kota, K., & Iwaku, M. (1996). In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. International Endodontic Journal, 29(2), 125–130. https://doi.org/10.1111/j.1365-2591.1996.tb01173.x
✔ American Association of Endodontists. (2023). Clinical considerations for regenerative endodontic procedures. https://www.aae.org/specialty/clinical-resources/regenerative-endodontics/
✔ Diogenes, A., Ruparel, N. B., Shiloah, Y., & Hargreaves, K. M. (2016). Regenerative endodontics: A way forward. Journal of the American Dental Association, 147(5), 372–380. https://doi.org/10.1016/j.adaj.2016.01.018
✔ Ruparel, N. B., Teixeira, F. B., Ferraz, C. C., & Diogenes, A. (2012). Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. Journal of Endodontics, 38(10), 1372–1375. https://doi.org/10.1016/j.joen.2012.06.018

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

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

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

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

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

➤ Patient history (spontaneous pain, swelling, trauma)

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

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

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

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

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

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

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

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

📊 Comparative Table: Pulpectomy vs Extraction in Necrotic Primary Teeth

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

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

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

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

📚 References

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

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

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

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

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✅ Pulp Therapy Techniques

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

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

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

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

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

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✅ Materials Used in Pulp Therapy

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

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

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

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

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✅ Success Rates

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

📊 Comparative Table: Differences Between Pulp Therapy Techniques

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

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

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

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

📚 References

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

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Why Hydrogen Peroxide Should Not Be Used in Modern Endodontic Treatment: Evidence-Based Clinical Justification

This article explains why hydrogen peroxide is no longer recommended in endodontic treatments, supported by contemporary scientific evidence. The discussion includes biochemical limitations, risks, and the superiority of modern irrigants such as sodium hypochlorite and EDTA.

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✅ Introduction
Hydrogen peroxide (H₂O₂) was widely used for decades in root canal therapy due to its effervescence and perceived cleaning capability. However, current endodontic literature strongly discourages its use.

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Modern research demonstrates that H₂O₂ lacks essential chemical properties needed for root canal disinfection and introduces several clinical risks. Today, evidence-based endodontics prioritizes irrigants that dissolve tissue, eradicate biofilms, and maintain biocompatibility, criteria that hydrogen peroxide fails to meet.

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💬 Discussion

➤ Lack of Organic Tissue Dissolution
A primary goal of irrigation is the dissolution of necrotic and vital pulp tissue. Unlike sodium hypochlorite, hydrogen peroxide cannot break down organic matter, significantly limiting its cleaning and disinfecting effects. Haapasalo et al. (2010) emphasize that irrigants must chemically degrade tissue to support mechanical instrumentation, a function H₂O₂ does not provide.

➤ Insufficient Antimicrobial Effect
Modern studies confirm that hydrogen peroxide has weak antibacterial action and is ineffective against biofilms, particularly Enterococcus faecalis, a key pathogen in persistent endodontic infections (Zehnder, 2006). This makes it inadequate as a primary or adjunctive irrigant.

➤ Risk of Oxygen Release and Subcutaneous Emphysema
Hydrogen peroxide decomposes into water and oxygen gas upon contact with catalase in tissues. This reaction may cause:
▪️ Apical extrusion of gas
▪️ Pain and pressure
▪️ Subcutaneous emphysema, a documented complication (McDonnell et al., 1982)
Because of these risks, contemporary guidelines reject its intracanal use.

➤ No Effect on Smear Layer Removal
EDTA is the gold standard for eliminating smear layer. Hydrogen peroxide cannot chelate or remove inorganic debris, leaving dentinal tubules obstructed and preventing adequate seal and penetration of medicaments or sealers (Torabinejad & Walton, 2015).

➤ Incompatibility with Sodium Hypochlorite
Studies show that mixing or alternating H₂O₂ and NaOCl results in foam production and reduced hypochlorite efficacy, compromising the cleaning process (Zehnder, 2006). This makes hydrogen peroxide incompatible with the irrigant that forms the foundation of modern endodontics.

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🔎 Recommendations
Based on current evidence, clinicians should adhere to the following irrigant sequence for predictable outcomes:

1. Sodium hypochlorite (NaOCl) as the primary irrigant
2. EDTA for smear layer removal
3. Final NaOCl rinse or CHX (never mixed with NaOCl)
4. Optional activation (ultrasonic or sonic)
Hydrogen peroxide should not be included under any circumstance.

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✍️ Conclusion
Hydrogen peroxide was historically used for its effervescence, but modern endodontics no longer supports its use. Scientific literature consistently demonstrates that it lacks the biochemical properties required for effective canal disinfection, poses clinical risks due to oxygen release, and is inferior to contemporary irrigants. For safe, predictable, and evidence-based treatment, clinicians should rely on NaOCl, EDTA, and irrigant activation protocols, fully abandoning H₂O₂.

📚 References

✔ Haapasalo, M., Shen, Y., Wang, Z., & Gao, Y. (2010). Irrigation in endodontics. Dental Clinics of North America, 54(2), 291–312. https://doi.org/10.1016/j.cden.2009.12.001
✔ McDonnell, G., Russell, A. D., & Hugo, W. B. (1982). The mechanism of hydrogen peroxide action. Journal of Antimicrobial Chemotherapy, 10(5), 389–393.
✔ Torabinejad, M., & Walton, R. E. (2015). Principles and Practice of Endodontics (5th ed.). Saunders.
✔ Zehnder, M. (2006). Root canal irrigants. Journal of Endodontics, 32(5), 389–398. https://doi.org/10.1016/j.joen.2005.09.014

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