Zinc Oxide Eugenol vs Calcium Hydroxide–Iodoform in Pulpectomy

Pulpectomy in primary teeth requires obturation materials that ensure antimicrobial efficacy, biocompatibility, and physiological resorption. The comparison between zinc oxide eugenol (ZOE) and calcium hydroxide–iodoform pastes remains clinically relevant.

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This review analyzes clinical performance, resorption behavior, success rates, and limitations, based on current evidence.
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✅ Introduction
Pulpectomy is a key procedure in pediatric dentistry aimed at preserving infected primary teeth. The ideal obturation material should exhibit resorbability synchronized with root resorption, antimicrobial properties, and minimal toxicity to periapical tissues. Historically, ZOE has been widely used, whereas calcium hydroxide–iodoform pastes have gained popularity due to improved biological properties.

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✅ Material Characteristics

Zinc Oxide Eugenol (ZOE)
▪️ Composition: Zinc oxide powder and eugenol liquid
▪️ Properties: Antimicrobial, radiopaque, good sealing ability
▪️ Limitations: Slow resorption, potential irritation to periapical tissues

Calcium Hydroxide–Iodoform Pastes (e.g., Vitapex, Metapex)
▪️ Composition: Calcium hydroxide, iodoform, silicone oil vehicle
▪️ Properties: Strong antimicrobial activity, high biocompatibility, resorbable
▪️ Clinical advantage: Resorption closely follows physiological root resorption

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✅ Clinical Performance

Success Rates
▪️ Both materials demonstrate high clinical success rates (>80%)
▪️ Recent studies suggest slightly higher radiographic success with calcium hydroxide–iodoform pastes

Evidence:
▪️ Coll et al. (2020) reported comparable success rates, with better resorption patterns in calcium hydroxide–iodoform materials.
▪️ Ramar & Mungara (2010) found higher success in Vitapex compared to ZOE in primary teeth pulpectomies.

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✅ Resorption Behavior

ZOE:
▪️ Slow resorption
▪️ May remain in periapical tissues after root resorption

Calcium hydroxide–iodoform:
▪️ Rapid and controlled resorption
▪️ Resorbs in harmony with primary tooth exfoliation

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✅ Antimicrobial Activity

▪️ Both materials exhibit broad antimicrobial effects
▪️ Calcium hydroxide–iodoform shows enhanced activity due to:
° High pH (Ca(OH)₂)
° Iodoform bactericidal effect

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✅ Advantages and Limitations

1. ZOE
Advantages
▪️ Long history of clinical use
▪️ Good sealing properties
▪️ Cost-effective

Limitations
▪️ Delayed resorption
▪️ Potential foreign body reaction
▪️ May interfere with eruption of permanent teeth

2. Calcium Hydroxide–Iodoform
Advantages
▪️ Biocompatibility and resorbability
▪️ Superior antimicrobial action
▪️ Favorable effect on periapical healing

Limitations
▪️ Risk of over-resorption within canals
▪️ Possible void formation over time
▪️ Higher cost compared to ZOE

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💬 Discussion
Current literature favors calcium hydroxide–iodoform pastes due to their biological compatibility and resorption profile, which aligns with the natural exfoliation process. While ZOE remains a viable option, its slow resorption and potential interference with permanent tooth eruption are notable concerns.

Clinical decision-making should consider:
▪️ Patient age
▪️ Extent of root resorption
▪️ Presence of periapical pathology

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✍️ Conclusion
Both ZOE and calcium hydroxide–iodoform pastes are effective for pulpectomy in primary teeth. However, calcium hydroxide–iodoform materials demonstrate superior biological behavior, particularly in terms of resorption and tissue compatibility, making them the preferred option in modern pediatric dentistry.

🎯 Recommendations
▪️ Prefer calcium hydroxide–iodoform pastes in cases requiring predictable resorption
▪️ Use ZOE cautiously, especially in teeth close to exfoliation
▪️ Avoid overfilling regardless of material
▪️ Base material selection on clinical and radiographic findings

📚 References

✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., Al Shamsi, S., & Dhar, V. (2020). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 42(4), 256–461.
✔ Ramar, K., & Mungara, J. (2010). Clinical and radiographic evaluation of pulpectomies using three root canal filling materials. Journal of Indian Society of Pedodontics and Preventive Dentistry, 28(1), 25–29. https://doi.org/10.4103/0970-4388.60470
✔ Mortazavi, M., & Mesbahi, M. (2004). Comparison of zinc oxide and eugenol, and Vitapex for root canal treatment of necrotic primary teeth. International Journal of Paediatric Dentistry, 14(6), 417–424. https://doi.org/10.1111/j.1365-263X.2004.00562.x
✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 45(6), 384–392.
✔ Trairatvorakul, C., & Chunlasikaiwan, S. (2008). Success of pulpectomy with zinc oxide–eugenol vs calcium hydroxide–iodoform paste in primary molars. International Journal of Paediatric Dentistry, 18(2), 144–149. https://doi.org/10.1111/j.1365-263X.2007.00886.x

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Zinc Oxide Eugenol in Dentistry: Is It Still Used in Modern Clinical Practice?

Zinc oxide eugenol (ZOE) has been a cornerstone material in dentistry for over a century due to its sedative properties, ease of manipulation, and low cost.

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However, advances in dental materials science and adhesive dentistry have raised an important question: Is zinc oxide eugenol still relevant in contemporary dental practice?

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This article critically reviews the composition, clinical applications, disadvantages, and current alternatives to ZOE, providing an evidence-based perspective on its role in modern dentistry.

✅ Composition of Zinc Oxide Eugenol
ZOE is formed through an acid–base reaction between zinc oxide powder and eugenol liquid.

▪️ Powder: Zinc oxide (ZnO), often with additives such as zinc acetate to accelerate setting
▪️ Liquid: Eugenol (a phenolic compound derived from clove oil)
The setting reaction produces zinc eugenolate, which is responsible for the material’s physical properties and biological effects.

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✅ Clinical Uses of Zinc Oxide Eugenol
Despite reduced popularity, ZOE continues to be used in selected clinical situations:

▪️ Temporary restorative material
▪️ Temporary luting cement
▪️ Base or liner under non-resin restorations
▪️ Root canal sealer (traditional formulations)
▪️ Periodontal surgical dressings
▪️ Intermediate restorative material (IRM derivatives)
Its sedative effect on the dental pulp has historically made it attractive in deep cavities and emergency treatments.

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✅ Disadvantages and Limitations of ZOE
Although biologically soothing, ZOE presents significant drawbacks that limit its use in modern dentistry:

▪️ Interference with resin polymerization, making it incompatible with adhesive restorations
▪️ Low mechanical strength, unsuitable for long-term restorations
▪️ High solubility in oral fluids, leading to marginal leakage
▪️ Potential cytotoxicity of eugenol at high concentrations
▪️ Limited adhesion to tooth structure
These limitations have driven the development and adoption of alternative materials.

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✅ Materials That Have Replaced Zinc Oxide Eugenol
Modern dentistry increasingly favors materials with improved biocompatibility, adhesion, and mechanical performance, including:

▪️ Calcium hydroxide–based liners
▪️ Glass ionomer cements (GIC)
▪️ Resin-modified glass ionomers (RMGIC)
▪️ Calcium silicate–based materials (e.g., MTA, Biodentine)
▪️ Resin-based temporary and permanent materials
These materials offer superior sealing ability, compatibility with adhesive systems, and enhanced longevity.

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💬 Discussion
ZOE remains a material of historical and limited clinical relevance rather than a first-line option. While it still has niche applications—particularly in temporary procedures or specific endodontic uses—its incompatibility with resin-based materials significantly restricts its role in modern restorative dentistry.
Current trends emphasize bioactive, adhesive, and mechanically stable materials, which better align with minimally invasive and long-term treatment philosophies.

🎯 Clinical Recommendations
▪️ Avoid ZOE under resin-based restorations
▪️ Consider modern bioactive materials for pulp protection
▪️ Use ZOE only for short-term or specific indications
▪️ Evaluate patient needs, restoration type, and material compatibility
▪️ Stay updated with evidence-based material selection guidelines

✍️ Conclusion
Zinc oxide eugenol is still used in dentistry, but its role is increasingly limited. While it offers sedative and antimicrobial benefits, its mechanical weakness and incompatibility with adhesive systems have led to its replacement by more advanced materials. Contemporary dental practice favors alternatives that provide superior durability, biocompatibility, and clinical performance.

📊 Comparative Table: Zinc Oxide Eugenol and Its Modern Alternatives

Material Type	Clinical Indications	Main Limitations
Zinc Oxide Eugenol	Temporary restorations, sedative base	Inhibits resin polymerization, low strength
Glass Ionomer Cement	Base, liner, temporary and permanent restorations	Lower fracture resistance than composites
Resin-Modified GIC	Adhesive base and liner	Moisture sensitivity during placement
Calcium Silicate Materials	Pulp capping and dentin regeneration	Higher cost and longer setting time

📚 References

✔ Anusavice, K. J., Shen, C., & Rawls, H. R. (2013). Phillips’ science of dental materials (12th ed.). Elsevier.
✔ American Dental Association. (2022). Dental materials guidance and compatibility considerations. Journal of the American Dental Association, 153(4), 345–352. https://doi.org/10.1016/j.adaj.2021.11.012
✔ Hargreaves, K. M., & Berman, L. H. (2020). Cohen’s pathways of the pulp (12th ed.). Elsevier.
✔ Sidhu, S. K., & Nicholson, J. W. (2016). A review of glass-ionomer cements for clinical dentistry. Journal of Functional Biomaterials, 7(3), 16. https://doi.org/10.3390/jfb7030016

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Zinc Oxide–Eugenol Paste in Modern Dentistry: Current Uses, Benefits, and Limitations

Zinc oxide–eugenol (ZOE) paste has been used in dentistry for over a century, making it one of the most historically significant dental materials. Despite the emergence of bioactive and resin-based alternatives, ZOE continues to play a role in specific clinical situations due to its sedative, antimicrobial, and sealing properties.

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Understanding where ZOE still fits in modern dental practice—and where it no longer does—is essential for evidence-based decision-making and patient safety.

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✅ Composition and Mechanism of Action
ZOE is formed by the reaction between zinc oxide powder and eugenol liquid, producing a chelate with the following properties:

▪️ Sedative effect on pulp tissue
▪️ Antimicrobial activity
▪️ Low thermal conductivity
▪️ Moderate sealing ability
However, eugenol’s biological activity is dose-dependent, and excessive exposure may cause cytotoxic and inflammatory reactions, particularly in permanent teeth.

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✅ Current Clinical Uses of Zinc Oxide–Eugenol

1. Temporary Restorations
ZOE is still widely used as a temporary filling material due to its ease of manipulation and soothing effect on the pulp.

2. Base or Liner (Selective Use)
In low-stress situations, ZOE may be placed as a base under non-resin restorations, although its use has declined significantly.

3. Root Canal Filling in Primary Teeth
ZOE remains a traditional obturating material in primary teeth pulpectomies, especially when resorption compatibility is not critical.

4. Periodontal Dressings
Its anti-inflammatory and analgesic properties make ZOE useful in periodontal surgical dressings.

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✅ Limitations in Modern Dentistry
Despite its historical importance, ZOE does not meet several modern biomechanical and biological standards:

▪️ Interferes with resin polymerization
▪️ Lacks bioactivity and regenerative potential
▪️ Limited mechanical strength
▪️ Potential cytotoxicity of eugenol
These limitations explain its progressive replacement by calcium silicate–based and resin-modified materials.

💬 Discussion
Contemporary dentistry prioritizes biocompatibility, bioactivity, and long-term stability. While ZOE provides short-term benefits, it does not promote dentin regeneration or pulp healing. Studies consistently show that materials such as MTA and Biodentine outperform ZOE in vital pulp therapies and permanent tooth applications.
However, eliminating ZOE entirely is neither realistic nor necessary. Its value lies in specific, well-defined indications, especially in temporary and pediatric applications when used judiciously.

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🎯 Clinical Recommendations
▪️ Avoid ZOE under resin-based restorations
▪️ Use cautiously in primary teeth, considering resorption dynamics
▪️ Prefer bioactive materials for vital pulp therapy
▪️ Reserve ZOE for temporary or palliative purposes
▪️ Avoid direct pulp contact in permanent teeth
Clinical success depends more on indication than tradition.

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✍️ Conclusion
Zinc oxide–eugenol remains a useful material in modern dentistry when applied selectively and with biological awareness. While it no longer represents the gold standard for many procedures, its sedative and antimicrobial properties still justify its use in temporary restorations, periodontal dressings, and certain pediatric applications. Modern clinicians must balance historical reliability with contemporary evidence.

📊 Comparative Table: Zinc Oxide–Eugenol vs Contemporary Dental Materials

Aspect	Advantages	Limitations
Zinc Oxide–Eugenol	Sedative, antimicrobial, easy handling	Interferes with resin bonding, low bioactivity
Calcium Hydroxide	Stimulates dentin bridge formation	High solubility, poor long-term seal
Mineral Trioxide Aggregate (MTA)	Excellent biocompatibility and sealing	High cost, difficult handling
Biodentine	Bioactive, fast setting, dentin substitute	Technique-sensitive, higher cost

📚 References

✔ American Association of Endodontists. (2020). Guide to clinical endodontics (6th ed.). AAE.
✔ Camilleri, J. (2015). Investigation of biodentine as dentine replacement material. Journal of Dentistry, 43(2), 140–146. https://doi.org/10.1016/j.jdent.2014.11.007
✔ Cox, C. F., Sübay, R. K., Ostro, E., Suzuki, S., & Suzuki, S. H. (1996). Biocompatibility of dental materials. Quintessence International, 27(8), 533–546.
✔ Torabinejad, M., & Chivian, N. (1999). Clinical applications of mineral trioxide aggregate. Journal of Endodontics, 25(3), 197–205. https://doi.org/10.1016/S0099-2399(99)80142-3
✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part I. Journal of Endodontics, 36(1), 16–27. https://doi.org/10.1016/j.joen.2009.09.006

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