PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

RANDOMIZED CONTROL TRIAL O

LSTR Antibiotic Paste Versus Zinc Oxide and Eugenol Pulpectomy for the Treatment of
Primary Molars with Pulp Necrosis: A Randomized Controlled Trial
Joyce Moura, DDS1 • Marina Lima, MS, PhD2 • Natália Nogueira, DDS3 • Marcus Castro, DDS4 • Cacilda Lima, MS, PhD5 • Marcoeli Moura, MS, PhD 6 •
Lucia Moura, MS, PhD7

Abstract: Purpose: The purpose of this study was to compare the effectiveness of lesion sterilization and tissue repair (LSTR) antibiotic paste
comprised of chloramphenicol, tetracycline, and zinc oxide and eugenol (CTZ) versus zinc oxide eugenol (ZOE) pulpectomy in the treatment of
primary molars with pulp necrosis. Methods: A total of 70 three- to eight-year-old subjects with 88 primary mandibular molars with pulp necrosis
were included. The teeth were randomized to the CTZ group or ZOE group. The time taken to perform both techniques was recorded. The parents
of the children and the dentist who performed clinical evaluations were blind to the group assignment, although the radiographic evaluator could
see the difference in treatments. Clinical and radiographic assessments were performed at three, six, nine, and 12 months. Results: At the 12-
month evaluation, the clinical success was 86.4 percent for CTZ and 90.9 percent for ZOE (P=0.50), the radiographic success was 75.0 percent
for CTZ and 72.7 percent for ZOE (P=0.81), and the overall success was 70.5 percent for CTZ and 72.7 percent for ZOE (P=0.81). The mean time
taken to perform was 61.4 (±20.5 standard deviation) minutes for CTZ and 145.1 (±53.2) minutes for ZOE (P<0.001). Conclusions: At 12 months,
both techniques presented no significant difference in success rates for nonvital pulp therapy in primary molars with necrosis. The lesion sterili-
zation and tissue repair procedure time using chloramphenicol, tetracycline, zinc oxide, and eugenol was significantly shorter than for a zinc oxide
eugenol pulpectomy. (Pediatr Dent 2021;43(6):435-42) Received January 22, 2021 | Last Revision August 26, 2021 | Accepted August 30, 2021
KEYWORDS: PULP NECROSIS, RANDOMIZED CONTROLLED CLINICAL TRIALS, ROOT CANAL FILLING MATERIALS

Endodontic treatment in primary molars with pulp necrosis ZOE is one of the preferred options for treating primary teeth
represents one of the challenges faced in the pediatric dentistry with necrotic pulp.15 The endodontic technique using ZOE
clinic.1,2 The main difficulties are related to the anatomical com- paste requires mechanical chemical preparation before filling
plexity of the root canals and the long time needed to carry out root canals.1,6,7,15
the treatment.2,3 Moreover, endodontic treatment in children Other pastes have been studied, such as those containing
requires their cooperation.4,5 The additional difficulty involved antibiotics in their composition, thus dispensing with root canal
in diagnosing root resorption is a limiting condition for instrumentation (such as lesion sterilization and tissue repair
determining the actual working length and instrumentation.1,6,7 [LSTR]).16-18 Among these, CTZ paste, composed of chloram-
Pastes used in the endodontic treatment of primary teeth phenicol, tetracycline, zinc oxide, and eugenol, represents an
should ideally have antimicrobial properties, be radiopaque alternative for the treatment of primary molars with necrotic
and biocompatible, and resorb in a time interval similar to that pulps.19 This paste has antimicrobial action against Streptococcus
taken for root resorption to occur.8,9 Among the pastes used in aureus, Enterococcus faecalis, Pseudomonas aeruginosa, Bacillus
the pulp therapy of primary teeth with pulp necrosis, zinc oxide subtilis, and Candida albicans,11 biocompatibility similar to that
and eugenol (ZOE) paste has been a reference in dentistry since of calcium hydroxide,20 and relevant clinical and radiographic
1930.9,10 ZOE paste has characteristics and properties of bio- success rates 21,22 and does not promote changes in alveolar
compatibility, radiopacity, and antimicrobial action.10-13 Endo- blood cells. 23 Additionally, the prevalence of enamel defects
dontic treatment using ZOE paste has shown satisfactory was lower in premolars whose predecessors with pulp necrosis
clinical and radiographic results.1,6,7,14 The American Academy were treated with CTZ paste than those extracted.24
of Pediatric Dentistry’s (AAPD) clinical practice guideline on There is no consensus in the literature on endodontic tech-
the choice of pulpectomy obturation materials indicates that niques and filling paste for primary teeth with pulp necrosis.15
The purpose of this controlled and randomized clinical trial
was to compare the effectiveness of lesion sterilization and
1 Dr. J. Moura, 3Dr. Nogueira, and 4Dr. Castro are MSc students, Postgraduate Program
tissue repair (LSTR) antibiotic paste comprised of chloram-
in Dentistry; and Drs. 2M. Lima, 5C. Lima, 6M. Moura, and 7L. Moura are professors, phenicol, tetracycline, and zinc oxide and eugenol (CTZ) versus
Graduate Program in Dentistry and Postgraduate Program in Dentistry; all authors at
the Federal University of Piaui, Teresina, Piauí, Brazil.
zinc oxide eugenol (ZOE) pulpectomy in the treatment of
Correspond with Dr. L. Moura at [email protected] primary molars with pulp necrosis.

Methods
HOW TO CITE: Ethics. This study was approved by the Research Ethics Com-
Moura J, Lima M, Nogueira N, et al. LSTR antibiotic paste versus zinc mittee at Federal University of Piauí and conducted following
oxide and eugenol pulpectomy for the treatment of primary molars the principles of the Declaration of Helsinki. The parents/
with pulp necrosis: A randomized controlled trial. Pediatr Dent 2021; guardians and their children who agreed to participate in the
43(6):435-42.
study provided informed consent.

PRIMARY MOLARS PULP NECROSIS 435

PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

Study model. The protocol followed the recommendations University of Piaui (FUP), Teresina, Piauí, Brazil, who were
of the Consort Statement and was registered in the Brazilian trained and calibrated by a professor expert in the endodontic
Registry of Clinical Trials (no. RBR-8xt8wx) and in the treatment of primary teeth. For both groups, the following
International Clinical Trials Platform at ClinicalTrials.gov protocol was adopted: initial clinical exam; radiography; local
(NCT03650036). This was a randomized controlled clinical anesthesia by blocking the mandibular alveolar nerve with
trial in which the clinical evaluator was blinded but the radio- one percent lidocaine hydrochloride with a vasoconstrictor
graphic evaluator would be aware of the different radiographic (DFL, Rio de Janeiro, Brazil); and absolute isolation with a
appearances of the two types of endodontic treatment of pri- rubber dam. Decayed dentin was removed using spoon-shaped
mary molars with pulp necrosis using the CTZ and ZOE dentin excavators and low-rotation spherical drills numbers four
pastes. The primary outcome was clinical and radiographic and six (Microdont, São Paulo) whenever necessary. The pulp
success, while the secondary outcome was the procedure time chamber roof was removed with a high-speed sterile carbide bur
required to perform the two techniques. number 330 (KG Sorensen, Cotia, Brazil), followed by irriga-
Sample. The sample calculation was performed using ting the pulp chamber with two percent chlorhexidine solution
the OpenEpi 3.01 software (Andrew G. Dean and Kevin M. (LT Rioquímica, São José do Rio Preto, Brazil) and drying it
Sullivan, www.OpenEpi.com), in which the following criteria with cotton balls. After these steps, endodontic treatments were
were used: success rates of 63 percent for ZOE13 and 93 percent performed per the specific protocols indicated for each group,
for CTZ paste21; the ratio of exposed to unexposed teeth of one and both groups were treated in a single session.
to one; test power of 80 percent; and significance level of 95 CTZ group. In this group, the root canal entrances were
percent. The sample was defined as 36 teeth per group. To located with a number five explorer probe tip (SS White, Rio
minimize possible losses, an increase of 20 percent was added de Janeiro), irrigation of the coronal chamber with two percent
and a final sample of 88 teeth (44 teeth per group) was obtained. chlorhexidine solution (LT Rioquímica), and drying with sterile
Inclusion criteria. The participants in the study were cotton balls. The components of the CTZ paste were micro-
three- to eight-year-old boys and girls attending the Children’s nized at the FUP Pharmacy School to reduce the size of the
Dental Clinic at the Federal University of Piauí, Teresina, Piauí, powder particles, guarantee the homogeneity of the mixture,
Brazil. Children were included if they had mandibular pri- and improve the properties of the paste. 28,29 Then, the com-
mary molars diagnosed with pulp necrosis, root resorption equal ponents of the CTZ paste powder were packed into 250 mg
to or less than one-third (with sufficient dental structure for
absolute isolation with rubber dam), and adaptation of a
stainless steel crown (SSC).25,26 Table 1. INITIAL CLINICAL AND RADIOGRAPHIC CONDITIONS
The clinical diagnosis of pulp necrosis was made based on IN THE GROUPS*
a history of spontaneous pain and mobility incompatible with Clinical and radiographic CTZ ZOE Total P-value†
chronological age, possibly with the presence of sinus tract or conditions
n (%) n (%) n (%)
swelling. In the radiographic diagnosis, the presence or absence
of a radiolucent area in the furcation region was observed. For Tooth
diagnosis of pulp necrosis, clinical examination was associ-
First molars 16 (36.4) 23 (52.3) 39 (44.3)
ated with radiographic examination. The radiographic examina- 0.13
tion was performed using positioners (Indusbello, Paraná, Second molars 28 (63.6) 21 (47.7) 49 (55.7)
Brazil) and children’s films (Carestream, São Paulo, Brazil) and Tooth mobility
developed using the conventional manual technique.
Present 6 (13.6) 12 (27.3) 18 (20.5)
Exclusion criteria. The exclusion criteria used were: chil- 0.11
dren with a history of allergic reaction to the components of Absent 38 (86.4) 33 (72.7) 70 (79.5)
the tested materials; those who had used antibiotics in the last Sinus tract or swelling
three months; teeth with pulp canal obliteration or internal or Present 28 (63.6) 30 (68.2) 58 (65.9)
external pathological root resorption visible in periapical radio- 0.65
graphs; and coronal destruction that would prevent absolute Absent 16 (36.4) 14 (31.8) 30 (34.1)
isolation with a rubber dam and/or restoration with SSC. The Root resorption
inclusion and exclusion criteria were similar to those used by Absent 13 (29.5) 8 (18.1) 21 (23.9)
Pramila et al.1
Randomization. Randomization was performed using <1/3 22 (50.0) 20 (45.5) 42 (47.7) 0.20
Random Allocation 1.0 software (Mahmood Saghaei, Iran) 1/3 9 (20.5) 16 (36.4) 25 (28.4)
according to the type of paste to be used.27 Two groups were Radiolucent area in the root furcation region
formed: a CTZ group and a ZOE group. Each tooth received
a five-digit identification code generated by the program; these Present 36 (81.8) 38 (86.4) 74 (84.1)
0.56
codes were placed in opaque, numbered, and sealed envelopes Absent 8 (18.2) 6 (13.6) 14 (15.9)
to ensure the randomization was concealed. Involvement of the bone crypt of the permanent successor
The children and their guardians did not know to which Present 7 (15.9) 8 (18.2) 15 (17.0) 0.78
group they were allocated. The envelopes were opened in front
of the patients by a dental assistant who was not connected Absent 37 (84.1) 36 (81.8) 73 (83.0)
with the study. The envelopes were opened before the pro- Total 44 (100.0) 44 (100.0) 88 (100.0)
cedures began to allow the appropriate instruments to be
organized for each technique. * Abbreviations used in this table: CTZ=chloramphenicol, tetracycline,
Interventions. The procedures were performed by two and zinc oxide and eugenol; ZOE=zinc oxide eugenol.
students in the Postgraduate Program in Dentistry at the Federal † Pearson’s chi-square test.

436 PRIMARY MOLARS PULP NECROSIS

 PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

capsules that contained 62.5 mg of chloramphenicol, 62.5 mg with a flexible metal spatula (SS White). The paste was inserted
of tetracycline, and 125 mg of zinc oxide.20 manually with K-files (sizes 15 to 25; Dentsply), respecting the
At the time of the procedure, the contents of the capsule limit of one mm short of the radiographic apex. 1,6 The ZOE
containing the powder of the CTZ paste were dispensed onto paste was physically protected with a thin layer of gutta-
a glass plate and manipulated with 0.1 mL of eugenol (Biody- percha using a method similar to that described in the CTZ
namics, Ibiporã, Brazil) using a flexible metal spatula (SS paste technique.
White). Restorations of both groups. The teeth of both groups
The CTZ paste was placed on the pulp chamber floor were restored after the pulp therapy using high-viscosity glass
using a number five exploratory probe (SS White). Cotton balls ionomer cement (Gold Label 9R, GC, Tokyo, Japan). After the
were used to pressure the CTZ paste and removed after use. removal of the rubber dam, SSCs were cemented (Iso-Form,
Next, a thin layer of gutta-percha (Dentsply, Rio de Janeiro) 3M ESPE, Minneapolis, Minn., USA) with glass ionomer
was placed on the CTZ paste using an amalgam condenser to cement (Ketac Cem Easy Mix, 3M ESPE). All procedures were
physically isolate the paste from the glass ionomer restoration. done according to the manufacturer’s specifications. Whenever
ZOE paste group. For the ZOE pulpectomy group, necessary to adapt the SSC, proximal surfaces of the primary
chemical-mechanical root canal debridement and disinfection molars were reduced using a no. 69 L bur (Teezkavan Co.,
were performed using a two percent chlorhexidine solution Tehran, Iran).26 The time taken to perform the two techniques
(LT Rioquímica) and K-files (sizes 15 to 25; Dentsply). The was recorded (Vollo, São Paulo, Brazil) and counted starting
limit of manual instrumentation was one mm short of the after absolute isolation with a rubber dam and ending after
radiographic apex.1,6 restoration of the tooth with GIC but before placement of the
The zinc oxide of the ZOE paste was packed into 250 SSC.
mg capsules at FUP Pharmacy School, mixed with 0.1 mL of Clinical evaluation. Patients were evaluated clinically and
eugenol (Biodynamics) on a sterile glass plate, and manipulated radiographically every three months for 12 months.13 Clinical
evaluations were performed by a professor of
pediatric dentistry experienced in clinical
studies who did not participate in the study
and did not know to which group the teeth
belonged. The intraexaminer calibration was
performed with 10 teeth of children who did
not participate in the study, with an interval
of two weeks between evaluations. The agree-
ment was 100 percent (kappa equals 1.0).
Clinical success was considered in the absence
of sinus tract/swelling and/or exfoliation before
six months.1,15
Radiographic evaluation. Radiographic
evaluations were performed by a professor of
dental radiology who did not participate in
the study. The periapical radiographs were
placed in a Negatoscope (Ultra Slim Led Tomo-
graphic Bivolt Biotron Negatoscope, Santa Rita
do Sapucaí, Brazil), fixed with transparent
tape, and evaluated by the radiologist without
including patient identifications. The intra-
examiner calibration was performed with
10 radiographs and repeated after two weeks
(kappa equals 0.9). The radiographic criteria
for success included absence, decrease or disap-
pearance of the initial radiolucent area, and no
new radiolucency.15 Overall success was defined
as only those teeth that showed both clinical
and radiographic success simultaneously.
Statistical analysis. The data were tabulated
and analyzed using SPSS 22.0 software for
Windows, IBM Corp., Armonk, N.Y., USA).
Descriptive analysis of the data was performed.
To compare the CTZ and ZOE groups con-
cerning clinical and radiographic parameters
at different time intervals of assessment,
Pearson’s chi-square and Fisher’s exact tests were
performed. The Kolmogorov-Smirnov normal-
ity test was used to analyze the distribution of
time taken to perform endodontic treatment
Figure 1. Flowchart. and showed a non-normal distribution of data

PRIMARY MOLARS PULP NECROSIS 437

PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

(P<0.05). The Mann-Whitney U test was performed to assess but there was no significant difference at nine months (P=0.49)
the differences between groups concerning the time taken to and at 12 months (P= 0.81). Furthermore, at the six-month
perform the procedure. The level of significance was five per- evaluation, the CTZ group (75.0 percent) presented a higher
cent (P<0.05). radiographic success rate than the ZOE group (52.3 percent;
P=0.03), but for the overall success there were no difference
Results at the P<0.05 level. At nine months, there was no difference
Seventy children, with a mean age of 5.5 (±1.2 standard de- in the radiographic success (P=0.49) and the overall success
viation) years, participated in the study, including 35 males (P=0.82; Table 2).
and 35 females. There was no difference between the groups At 12 months, the clinical success rate was 86.4 percent
concerning the initial clinical and radiographical conditions and 90.9 percent for the CTZ group and ZOE group, respec-
(P>0.05; Table 1). A flowchart of this study is shown in tively (P=0.50). The radiographic success rate of the CTZ
Figure 1. paste was 75.0 percent versus 72.7 percent for ZOE (P=0.81).
Clinical and radiographic evaluations and the overall The overall success rate of the CTZ paste was 70.5 percent
success between groups at three-, six-, nine-, and 12-month compared to 72.7 percent for ZOE (P=0.81; Table 2).
time intervals are described in Table 2, (Figure 2). The CTZ At the 12 month-evaluation, internal resorption was
group had significantly fewer radiolucent lesions that increased observed in three cases in the CTZ group and external inflam-
and/or stabilized at six months (P=0.03) compared to ZOE, matory resorption was observed in one case in the CTZ group.

Table 2. CLINICAL AND RADIOGRAPHIC EVALUATION BETWEEN THE TWO GROUPS AT 3, 6, 9, AND 12 MONTHS*

Time 3 months 6 months 9 months 12 months

CTZ ZOE P-value CTZ ZOE P-value CTZ ZOE P-value CTZ ZOE P-value
n=44 n=44 n=44 n=44 n=44 n=44 n=44 n=44
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Clinical parameters
Fistula/abscess
Present 1 (2.3) 2 (4.5) 1.00** 2 (4.5) 2 (4.5) 1.00** 3 (6.8) 4 (9.1) 1.00** 5 (11.4) 4 (9.1) 1.00**
Absent 43 (97.7) 42 (95.5) 42 (95.5) 42 (95.5) 41 (93.2) 40 (90.9) 39 (88.6) 40 (90.9)
Exfoliation before 6 months
Yes 0 (0.0) 0 (0.0) 1 (2.3) 0 (0.0) 1.00** 1 (2.3) 0 (0.0) 1.00** 1 (2.3) 0 (0.0) 1.00**
No 44 (100.0) 44 (100.0) 43 (97.7) 44 (100.0) 43 (97.7) 44 (100.0) 43 (97.7) 44 (100.0)
Clinical success
Yes 43 (97.7) 42 (95.5) 1.00** 41 (93.2) 42 (95.5) 1.00** 40 (90.9) 40 (90.9) 1.00** 38 (86.4) 40 (90.9) 0.50†
No 1 (2.3) 2 (4.5) 3 (6.8) 2 (4.5) 4 (9.1) 4 (9.1) 6 (13.6) 4 (9.1)
Radiographic parameters
Radiolucent lesion
Present 31 (70.5) 34 (77.3) 0.47† 23 (52.3) 29 (65.9) 0.20† 17 (38.6) 21 (47.7) 0.39† 14 (31.8) 19 (43.2) 0.27†
Absent 13 (29.5) 10 (22.7) 21 (47.7) 15 (34.1) 27 (61.4) 23 (52.3) 30 (68.2) 25 (56.8)
Radiolucent area
Decreased 18 (40.9) 18 (40.9) 0.50† 12 (27.3) 8 (18.2) 0.03† 5 (11.4) 6 (13.6) 0.49† 3 (6.8) 7 (15.9) 0.81†
Increased 3 (6.8) 3 (6.8) 4 (9.1) 1 (2.3) 6 (13.6) 0 (0.0) 3 (6.8) 2 (4.5)
Stabilized 10 (22.7) 13 (29.5) 7 (15.9) 20 (45.5) 6 (13.6) 15 (34.1) 8 (18.2) 10 (22.7)
Disappeared 5 (11.4) 4 (9.1) 13 (29.5) 9 (20.5) 19 (43.2) 17 (38.6) 22 (50.0) 19 (43.2)
Absent 8 (18.2) 6 (13.6) 8 (18.2) 6 (13.6) 8 (18.2) 6 (13.6) 8 (18.2) 6 (13.6)
Radiographic success
Yes 31 (70.5) 28 (63.6) 0.50† 33 (75.0) 23 (52.3) 0.03† 32 (72.7) 29 (65.9) 0.49† 33 (75.0) 32 (72.7) 0.81†
No 13 (29.5) 16 (36.4) 11 (25.0) 21 (47.7) 12 (27.3) 15 (34.1) 11 (25.0) 12 (27.3)
Overall success
Yes 30 (68.2) 28 (63.6) 0.65† 32 (72.7) 23 (52.3) 0.05† 30 (68.2) 29 (65.9) 0.82† 31 (70.5) 32 (72.7) 0.81†
No 14 (31.8) 16 (36.4) 12 (27.3) 21 (47.7) 14 (31.8) 15 (34.1) 13 (29.5) 12 (27.3)

* Abbreviations used in this table: CTZ=chloramphenicol, tetracycline, and zinc oxide and eugenol; ZOE=zinc oxide eugenol.
** Fisher’s exact test. † Pearson chi-square test. Bolded values are statistically significant.

438 PRIMARY MOLARS PULP NECROSIS

 PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

According to the AAPD, LSTR should be chosen

over pulpectomy in teeth with root resorption in
order to retain teeth for up to 12 months, which
would otherwise have to be extracted.15 Distinct proto-
cols have been proposed for the LSTR technique. Con-
sidering the potential adverse effects of tetracycline in
children, when doing LSTR, the AAPD recommends
that clinicians should choose an alternate paste without
tetracycline15; however, this affirmation lacks scientific
evidence. This randomized controlled trial used LSTR
therapy with CTZ paste. The diversity of antibiotics,
proportions, and vehicles may interfere in the clinical
and radiographic outcomes of LSTR.32
In the absence of endodontic infection, the body’s
defenses act in the process of repairing the sequelae
caused by pulp necrosis.33.35 To provide effective anti-
microbial action, the CTZ paste must be placed at the
root canal entrances and on the pulp chamber floor of
primary molars, where periodontal pulp communica-
tions are present. 16,36-38 It is important to note that
endodontic infections are localized, the amount of CTZ
paste used is small 21, and no reports were found in
the literature on the systemic diffusion of drugs used
in the pulp therapy of primary molars.
In the present study, extrusion of ZOE paste to
Figure 2. CTZ and ZOE folder: initial conditions and 12 months controls. CTZ the perapical region was observed in approximately
paste: (A) initial conditionl (B) radiographic evaluation 12 months. ZOE Paste: (C) one-third of the cases; however, the paste extrusion did
Initial condition; (D) Radiographic evaluation 12 months. not interfere with the success of the treatment. The
extrusion of ZOE paste to periapical regions can be
caused by the presence of areas of root resorption not
In the ZOE group, a furcation lesion developed into a cyst in visible in diagnostic periapical radiographs.34,37 The use of an
one tooth. During the pulpectomies in the ZOE group, 15 of apical locator can assist in the accurate detection of areas
44 teeth had extrusion of the ZOE paste and none showed of apical resorption, as has been shown in some studies15,39,40;
resorption of the paste at 12 months. There was no difference however, the authors did not use them in the present study
in clinical success (P=0.60), radiographic success (P=0.72), or because they are not included in protocols adopted in most
overall success (P=0.72) compared to the rates of those teeth clinical studies. 1,6,16 At 12 months, the extruded ZOE paste
without extrusion in the ZOE group. had not been reabsorbed. Similar results have been reported
The mean time taken to perform the CTZ technique was in other studies.1,6 The delay or absence of resorption of ZOE
61.4 (±20.5) minutes (median time equals 60.0 minutes; paste occurs because the zinc particles are resistant to the
inter-quartile range equals 23.0); for the ZOE technique, the process of phagocytosis.37
mean time was 145 (±53.2) minutes (median time equals 146.5 At the 12-month evaluation, in one case in the ZOE
minutes; interquartile range equals 70.0; P<0.001). group, the lesion in the furcation region developed into a root
cyst. A similar condition was reported in another study in
Discussion which the same paste was used.41 Internal resorption was ob-
After 12 months of evaluation, the CTZ paste showed no signi- served in three cases in the CTZ group; this rare condition can
ficant difference in clinical, radiographic, or overall success be attributed to the body’s response to chronic inflammatory
versus the ZOE paste for the treatment of primary molars with conditions. 33,42 A case of external inflammatory resorption
necrotic pulps. In this study, the option of using ZOE paste as was observed in the CTZ group, a pathological process in
a standard for comparison with CTZ paste was taken because which the immune system induces the occurrence of resorp-
the former is one of the pastes most widely used in pediatric tion of the external surface of the tooth under the stimulus
dentistry, in addition to being one of the pastes indicated by of infections, trauma, and orthodontic forces.43 The occurrence
the AAPD.15 of inflammatory root resorption can be attributed to the
LSTR for nonvital pulp therapy is proposed for the treat- acceleration of the root resorption stage caused by the pulp
ment of irreversibly inflamed or necrotic primary teeth and therapy44 or errors in diagnosis or execution of techniques.45
consists of nonmechanical instrumentation of the root canals Restorative failure can influence the performance of endo-
and the use of antibiotic pastes. 15,30-32 The purpose of the dontic treatments,46 especially in proximal occlusion lesions.47
antibiotics is to reduce the bacterial load in the pulp via a To minimize this bias in the present study, the restorative
simpler technique than pulpectomy.31-33 Some studies, including option used was an SSC, as it exhibits satisfactory marginal
two systematic reviews, have concluded that the success rates adaptation, requires a shorter operating time, and offers better
for LSTR and pulpectomy are similar.17,31,34 Another study has cost-effectiveness. 48,49 The steel crowns were cemented with
concluded that, if the roots are intact, pulpectomy is preferred, glass ionomer cement because of its fluoride-releasing proper-
but if the roots are resorbed LSTR is preferred.34 ties, adequate marginal sealing, and adhesion to both the steel
crown and the tooth.50,51

PRIMARY MOLARS PULP NECROSIS 439

PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

In this study, the mean clinical time spent on treatment in References

the CTZ group was twice as short as that spent in the ZOE 1. Pramila R, Muthu MS, Deepa G, Farzan JM, Rodrigues
group. A shorter clinical session is considered a differential in SJL. Pulpectomies in primary mandibular molars: A
the quality of dental care for children.33 However, the authors comparison of outcomes using three root filling materials.
suggest that further studies should be conducted using rotary Int Endod J 2016;49(5):413-21.
files and/or validated instruments capable of accurately assessing 2. Ozcan G, Sekerci AE, Cantekin K, Aydinbelge M, Dogan
children’s acceptance based on the time taken to perform the S. Evaluation of root canal morphology of human primary
dental treatment. molars by using CBCT and comprehensive review of the
The use of CTZ paste has the limitation of causing tooth literature. Acta Odontol Scand 2016;74(4):250-8.
discoloration in the primary molar due to the presence of 3. Ariffin SM, Dalzell O, Hardiman R, Manton DJ, Parashos
tetracycline, but the technique is indicated only for posterior P, Rajan S. Root canal morphology of primary maxillary
teeth, which do not participate in the smile. Studies have second molars: A micro‑computed tomography analysis.
shown that alternate 3Mix pastes without tetracycline should Eur Arch Paediatr Dent 2020;21(4):519-25.
be chosen over the traditional pastes with tetracycline.15,34 The 4. Jamali Z, Najafpour E, Aminabadi NA’s, et al. Does the
presence of tetracycline in CTZ paste has provoked discussions, length of dental procedure influence children’s behavior
so further studies should be carried out, excluding tetracycline during and after treatment? A systematic review and cri-
or replacing it with another antibiotic. tical appraisal. J Dent Res Dent Clin Dent Prospects 2018;
As a differential, the present clinical trial applied microni- 12(1):68-76.
zation of the powder components of CTZ paste to provide 5. Sivakumar P, Gurunathan D. Behavior of children toward
homogeneity between the two antibiotics (chloramphenicol various dental procedures. Int J Clin Pediatr Dent 2019;
and tetracycline) and zinc oxide and to optimize the pharmaco- 12(5):379-84.
logical properties of the paste. 28,29 A systematic review had 6. Chen X, Liu X, Zhong J. Clinical and radiographic eval-
indicated that LSTR should be used for situations in which uation of pulpectomy in primary teeth: A 18-months
the tooth will remain in the dental arch for less than 12 months, clinical randomized controlled trial. Head Face Med 2017;
due to root resorption,34 and in cases in which there is the pre- 13(1):12.
sence of external root resorption and pulpectomy cannot be 7. Smaïl-Faugeron V, Glenny AM, Courson F, Durieux P,
performed.34 Muller-Bolla M, FronChabouis H. Pulp treatment for
Studies relative to the simplification of endodontic tech- extensive decay in primary teeth. Cochrane Database Syst
niques in pediatric dentistry should be encouraged, especially Rev 2018;5(5):CD003220.
to reduce the time taken to perform the surgical steps. Most 8. Rajasekharan S, Martens LC, Vandenbulcke J, Jacquet
studies have recommended instrumentation of root canals W, Bottenberg P, Cauwels RG. Efficacy of three different
without considering the child’s ability to collaborate, despite pulpotomy agents in primary molars: A randomized con-
researchers having recognized and reported that the anatomical trol trial. Int Endod J 2017;50(3):215-28.
peculiarities inherent in primary teeth made the technique more 9. Najjar RS, Alamoudi NM, El-Housseiny AA, Al Tuwirqi
complex.1,6,7 Therefore, this study’s authors believe it is im- AA, Sabbagh HJ. A comparison of calcium hydroxide/
portant to contribute to science by presenting satisfactory iodoform paste and zinc oxide eugenol as root filling ma-
results produced with a faster technique, without losing terials for pulpectomy in primary teeth: A systematic
methodological/scientific rigor, while considering and preserv- review and meta-analysis. Clin Exp Dent Res 2019;5(3):
ing both the children’s physical and emotional health. 294-310.
For endodontic treatment alternatives to be accepted by 10. Navit S, Jaiswal N, Khan SA, et al. Antimicrobial efficacy
the academic/scientific community, prejudices and dogmas that of contemporary obturating materials used in primary
imprison and limit the thinking of many researchers must be teeth—An in-vitro study. J Clin Diagn Res 2016;10(9):
overcome. Therefore, simplified techniques for the pulp therapy ZC09-ZC12.
of primary teeth must be disseminated so that dentists are 11. Amorim LDFG, Toledo OA, Estrela CRDA, Decurcio
capable of performing them and preventing early loss of pri- DDA, Estrela C. Antimicrobial analysis of different root
mary teeth that may cause malocclusions and have a negative canal filling pastes used in pediatric dentistry by two
impact on children’s oral health-related quality of life. experimental methods. Braz Dent J 2006;17(4):317-22.
12. Pilownic KJ, Carvalho CN, Romano AR et al. Antibiofilm
Conclusions activity of five different endodontic filling materials used
Based on this study’s results, the following conclusions can in primary teeth using confocal laser scanning microscopy.
be made: Pediatr Dent 2017;39(2):145-9.
1. The LSTR procedure with CTZ paste needs less chair 13. Goel H, Mathur S, Sachdev V. Clinical and radiographic
time than that for the ZOE pulpectomy. evaluation of four different zinc-oxide integrated root
2. Considering that at 12 months, there was no differ- canal obturating materials used in primary teeth. Pediatr
ence between two nonvital pulp treatments, LSTR Dent J 2018;28(2):73-86.
technique with CTZ paste can be a treatment option 14. Barcelos R, Santos MPA, Primo LG, Luiz RR, Maia LC.
for primary molars with pulp necrosis. ZOE paste pulpectomies outcome in primary teeth: A
systematic review. J Clin Pediatr Dent 2011;35(3):241-8.
15. Coll JA, Dhar V, Vargas K, Chen CY, Crystal YO. Use of
non-vital pulp therapies in primary teeth. Pediatr Dent
2020;42(5):357-49.

440 PRIMARY MOLARS PULP NECROSIS

 PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

16. Nakornchai S, Banditsing P, Visetratana N. Clinical evalu- 32. Duarte ML, Pires PM, Ferreira DM, et al. Is there evidence
ation of 3Mix and Vitapex as treatment options for for the use of lesion sterilization and tissue repair therapy
pulpally involved primary molars Int J Paediatr Dent in the endodontic treatment of primary teeth? A system-
2010;20(3):214-21. atic review and meta-analyses. Clin Oral Investig 2020;24
17. Doneria D, Thakur S, Singhal P, Chauhan D. Comparative (9):2959-72.
evaluation of clinical and radiological success of zinc 33. Sain S, Reshmi J, Anandaraj S, George S, Issac JS, John SA.
oxide-ozonated oil, modified 3Mix-MP antibiotic paste, Lesion sterilization and tissue repair-current concepts and
and Vitapex as treatment options in primary molars re- practices. Int J Clin Pediatr Dent 2018;11(5):446-50.
quiring pulpectomy: An in vivo study. J Indian Soc Pedod 34. Coll JA, Vargas K, Marghalani AA, et al. A systematic
Prev Dent 2017;35(4):346-52. review and meta-analysis of nonvital pulp therapy for
18. Zacharczuk GA, Toscano MA, López GE, Ortolani AM. primary teeth. Pediatr Dent 2020;42(4):256-272.
Evaluation of 3Mix-MP and pulpectomias in non-vital 35. Shahad ALS, Abdullah AM, Takushige T, Cruz EV, Asgor
primary molars. Acta Acta Odontol Latinoam 2019;32 MA, Hoshino E. Endodontic treatment of primary teeth
(1):22-8. using a combination of antibacterial drugs. Int J Endod
19. Cappiello J. Tratamentos pulpares em incisivos primários. 2004;37(2):132-8.
[Pulp treatment in primary incisors]. Rev Asoc Odontol 36. Kumar VD. A scanning electron microscope study of
Argent 1967;52(4):139-45. prevalence of accessory canals on the pulpal floor of
20. Lima CC, Conde Júnior AM, Rizzo MS, et al. Biocompati- deciduous molars. J Indian Soc Pedod Prev Dent 2009;
bility of root filling pastes used in primary teeth. Int 27(2):85-9.
Endod J 2015;48(5):405-16. 37. Lugliè PF, Grabesu V, Spano G, Lumbau A. Accessory
21. Moura LFAD, Lima MDM, Lima CCB, Machado JAAG, foramina in the furcation area of primary molars: A SEM
Moura MS, Carvalho PVC. Endodontic treatment of pri- investigation. Eur J Paediatr Dent 2012;13(4):329-32.
mary molars with antibiotic paste: A report of 38 cases. 38. Sharma U, Gulati A, Gill N. An investigation of accessory
J Clin Pediatr Dent 2016;40(3):175-7. canals in primary molars: An analytical study. Int J
22. Ferreira LJ, Jiménez AS, Medrano CLE, García TI, Álvarez Paediatr Dent 2016;26:149-56.
AM. Clinical and radiographic evaluation of formocresol 39. Bhat KV, Shetty P, Anandakrishna L. A comparative
and chloramphenicol, tetracycline and zinc oxide-eugenol evaluation of accuracy of new-generation electronic apex
antibiotic paste in primary teeth pulpotomies: 24-month locator with conventional radiography to determine
follow up. J Clin Pediatr Dent 2019;43(1):16-21. working length in primary teeth: An in vivo study. Int J
23. Moura LFAD, Lima MDM, Lima CCB, et al. Cellular Clin Pediatr Dent 2017;10:34-6.
profile of primary molars with pulp necrosis after treat- 40. de Alencar NA, Oriano MD, Bolan M, Cardoso M. Is
ment with antibiotic paste. Int J Exp Pathol 2018;99(5): there any difference in length measurement methods for
264-8. pulpectomies in primary teeth? A double-blind, controlled
24. Sousa HCS, Lima MDM, Lima CCB, Moura MS, Bandeira clinical trial. Int J Clin Pediatr Dent 2019;29:712-9.
AVL, Deus Moura LFA. Prevalence of enamel defects in 41. Sandhyarani B, Noorani H, Shivaprakash PK, Dayanand
premolars whose predecessors were treated with extrac- AH. Fate of pulpectomized deciduous teeth: Bilateral
tions or antibiotic paste. Prev Dent Saúde Oral 2020;18 odontogenic cyst? Contemp Clin Dent 2016;7:243-5.
(1):793-8. 42. Trairatvorakul C, Detsomboonrat P. Success rates of a
25. Seraj B, Shahrabi M, Motahari P, et al. Microleakage of mixture of ciprofloxacin, metronidazole, and minocycline
stainless steel crowns placed on intact and extensively antibiotics used in the non-instrumentation endodontic
destroyed primary first molars: An in vitro study. Pediatr treatment of mandibular primary molars with carious
Dent 2011;33(7):525-8. pulpal involvement. Int J Paediatr Dent 2012;22(3):
26. Ebrahimi M, Sarraf SA, Afshari E. Success and behavior 217-27.
during atraumatic restorative treatment, the Hall tech- 43. Ahangari Z, Nasser M, Mahdian M, Fedorowicz Z,
nique, and the stainless steel crown technique for primary Marchesan MA. Interventions for the management of
molar teeth. Pediatr Dent 2020;42(3):187-92. external root resorption. Cochrane Database Syst Rev
27. Saghaei M. Random allocation software for parallel group 2015;1:CD008003.
randomized trials. BMC Med Res Methodol 2004;4:1-6. 44. Nero-Vieira G. Resorption is the inflammatory process:
28. Joshi J. A review on micronization techniques. J Pharm Approach to the pathogenicity of periodontal tooth and
Sci Technol 2011;3(7):651-81. resorption. RCOE 2005;10(5-6):545-56.
29. Olusanmi D, Jayawickrama D, Bu D, et al. A control 45. Vieira-Andrade RG, Drumond CL, Alves LP, Marques LS,
strategy for bioavailability enhancement by size reduction: Ramos-Jorge ML. Inflammatory root resorption in pri-
Effect of micronization conditions on the bulk, surface, mary molars: Prevalence and associated factors. Braz Oral
and blending characteristics of an active pharmaceutical Res 2012;26(4):335-40.
ingredient. P Technology 2014;258:222-33. 46. Gillen BM, Looney SW, Gu LS, et al. Impact of the
30. Takushige T, Cruz EV, Asgor Moral A, et al. Endodontic quality of coronal restoration versus the quality of root
treatment of primary teeth using a combination of anti- canal fillings on success of root canal treatment: A system-
bacterial drugs. Int Endod J 2004;37(2):132-8. atic review and meta-analysis. J Endod 2011;37(7):
31. Agarwal SR, Bendgude VD, Kakodkar P. Evaluation of 895-902.
success rate of lesion sterilization and tissue repair com- 47. Brustolin JP, Mariath AA, Ardenghi TM, Casagrande L.
pared to Vitapex in pulpally involved primary teeth: Survival and factors associated with failure of pulpecto-
Asystematic review. J Conserv Dent 2019;22(6):510-15. mies performed in primary teeth by dental students. Braz
Dent J 2017;28(1):121-8.

PRIMARY MOLARS PULP NECROSIS 441

PEDIATRIC DENTISTRY V 43 / NO 6 NOV / DEC 21

48. Chisini LA, Collares K, Cademartori MG, et al. Restora- 50. Memarpour M, Mesbahi M, Rezvani G, Rahimi M.
tions in primary teeth: A systematic review on survival Microleakage of adhesive and nonadhesive luting cements
and reasons for failures. Int J Paediatr Dent 2018;28(2): for stainless steel crowns. Pediatr Dent 2011;33(7):501-4.
123-39. 51. Parisay I, Khazaei Y. Evaluation of retentive strength of
49. Taran PK, Kaya MS. A comparison of periodontal health four luting cements with stainless steel crowns in primary
in primary molars restored with prefabricated stainless molars: An in vitro study. J Dent Res 2018;15(3):201-7.
steel and zirconia crowns. Pediatr Dent 2018;40(5):
334-39.

OPEN ACCESS DISCLAIMER AND RIGHTS:

The American Academy of Pediatric Dentistry (AAPD) publishes and maintains select Open Access articles from the journal Pediatric Dentistry. These articles
are available on the AAPD’s website at: https://www.aapd.org/publications/journals/open-access/. They are intended for the personal, educational use of the
reader. Requests for any additional use, distribution, and/or reproduction in any medium of any Open Access article should be submitted directly to the
AAPD, who may within its sole discretion determine whether to permit a licensed use. In such case, the original work must be properly cited along with the
following statement:
“This article is Copyright © 2021 of the American Academy of Pediatric Dentistry and reproduced with their permission. The statements and opinions
contained in this article are solely those of the individual authors and do not necessarily represent the views of the American Academy of Pediatric
Dentistry. The American Academy of Pediatric Dentistry does not endorse any specific organization, product, or services referenced in the article.”

442 PRIMARY MOLARS PULP NECROSIS