In children, the preservation of extant tooth structure and pulpal health — as opposed to premature extraction — is critical not only for maintaining arch integrity, function, and esthetics, but also for guiding the eruption and alignment of succeeding permanent teeth.
In this context, the evolution of material science in dentistry has dramatically influenced how clinicians approach vital and non-vital pulp therapies.
Historically, pulpotomies in primary teeth were performed using fixative agents such as formocresol, with the goal of devitalizing residual pulp to arrest infection and provide a stable base for restoration.
However, concerns about toxicity, mutagenicity, and systemic absorption gradually led to a reevaluation of such agents.
Over the past decade, the shift has progressively leaned toward bioactive, biocompatible, and regenerative materials that aim not merely to “fix” the pulp, but to support healing, dentin bridge formation, and functional preservation of pulpal tissue.
Simultaneously, pulpectomy techniques — intended to manage necrotic pulps in primary teeth — have likewise benefited from advances in both filling materials and irrigation protocols, with the goal of providing resorbable, antimicrobial, and biologically favorable obturation compatible with the physiologic root resorption of primary teeth and safe for the underlying permanent tooth germ.
As clinical evidence accumulates, the decision for clinicians pivots on selecting materials that balance ease of handling, sealing ability, biocompatibility, and predictable clinical outcomes.
This guide is meant to synthesize the latest material options for pulpotomy and pulpectomy, their indications, and the emerging evidence supporting their use — equipping dental professionals with a clear, evidence-based resource for pediatric pulp therapy in modern practice.
🔹 Pulpotomy: Preserving Radicular Vitality
Purpose
Pulpotomy aims to maintain the vitality of the radicular pulp after removing the inflamed coronal portion. Success depends largely on the biological response of the pulp and the material’s properties.
Commonly Used Materials
1. Formocresol (historical use)
Mechanism: Tissue fixation.
Drawback: Cytotoxic and potentially mutagenic.
Current status: Mostly discontinued in modern pediatric protocols.
2. Glutaraldehyde
Mechanism: Superficial fixation of pulp tissue.
Advantage: Less penetration and toxicity than formocresol.
3. Ferric Sulfate (15.5%)
Mechanism: Hemostatic action without fixation.
Advantage: Preserves pulp vitality and has good clinical outcomes.
Widely accepted as a biocompatible and effective alternative.
4. Calcium Hydroxide (Ca(OH)₂)
Mechanism: Stimulates reparative dentin formation.
Limitation: May cause internal resorption in primary teeth.
5. Bioactive and Bioceramic Materials
These materials represent the current gold standard due to their superior sealing and regenerative potential:
MTA (Mineral Trioxide Aggregate)
- High biocompatibility and excellent sealing ability.
- Promotes dentin bridge formation.
Biodentine®
- Similar to MTA but with faster setting and better handling.
- Strong calcium release enhances pulp healing.
New-generation materials such as TheraCal LC®, NeoMTA Plus®, and EndoSequence BC RRM® show promising results in vital pulp therapy.
🔹 Pulpectomy: Root Canal Filling in Primary Teeth
Purpose
Pulpectomy is indicated for non-vital primary teeth, aiming to remove necrotic pulp tissue and fill the canals with a biocompatible, resorbable material.
Commonly Used Filling Materials
1. Zinc Oxide Eugenol (ZOE)
Advantages: Antimicrobial, easy handling, and low cost.
Limitation: Slow resorption rate compared to physiologic root resorption.
2. Iodoform-based Pastes (KRI Paste, Vitapex®)
Composition: Zinc oxide, iodoform, and calcium hydroxide.
Advantages: Antibacterial, biocompatible, and resorbable at a controlled rate.
Vitapex® is currently one of the most recommended materials for pulpectomy.
3. Metapex® (Ca(OH)₂ + Iodoform)
Similar formulation to Vitapex®.
Promotes periapical healing and resorbs without affecting the underlying permanent tooth germ.
4. CTZ Paste (Chloramphenicol, Tetracycline, Zinc Oxide, Eugenol)
Used in some Latin American countries for its antibacterial properties.
Not supported as a standard material in international pediatric guidelines due to antibiotic resistance concerns.
Material Selection Criteria
Choosing the appropriate material depends on:
★ Pulp status (vital or necrotic).
★ Type of tooth (primary vs. immature permanent).
★ Patient age and cooperation.
★ Availability and clinician experience.
Conclusion
Advances in bioactive materials have redefined the approach to pulp therapy in pediatric dentistry.
The shift from toxic fixatives to bioceramic and calcium silicate-based materials supports long-term tooth preservation and pulp vitality—representing the future of minimally invasive pediatric endodontics.
References
1. Ibrahim Alnassar, Altinawi M, Salem Rekab M, Alzoubi H, Abdo A. Evaluation of the efficacy of mineral trioxide aggregate and bioceramic putty in primary molar pulpotomy with symptoms of irreversible pulpitis: a randomized-controlled trial. PMCID. ~2021/2022.
Compares MTA and bioceramic putty in primary molar pulpotomy and reports favorable outcomes for both.
2. Sezgin BI, Sezgin GCI, Koyuncu Ö, et al. Hyaluronic acid as a pulpotomy material in primary molars: up to 30 months retrospective study. BMC Oral Health. 2024.
This study reports comparable success rates with hyaluronic acid versus traditional pulpotomy materials over long follow-up periods.
Finds comparable clinical and radiographic success between first- and second-generation bioceramic materials in pulpotomy of primary teeth.
