Pulp Therapy in Primary Teeth: What Works in 2025?

Pulp therapy in primary teeth is about the delicate balance, where you aim to preserve function and extend comfort until natural exfoliation.
The motto here is avoiding under- or over-treatment. Over the last few years, the armamentarium to achieve the goal has undergone massive changes.
Formocresol, once the “gold standard,” is no longer recommended due to safety concerns¹.
Now we have more biocompatible and bioactive materials providing better outcomes.

Choosing the Right Pulp Therapy
First things first, let’s revise the differences between the pulp therapies.

Pulpotomy vs. Pulpectomy

• Pulpotomy is indicated when the coronal pulp is inflamed but the radicular pulp seems healthy.
• Pulpectomy is needed when infection extends into the radicular pulp, but the tooth is restorable².

Clinical pearl: Always assess hemostasis after coronal pulp amputation. Early hemostasis with saline or sodium hypochlorite suggests radicular pulp is still vital, allowing you to proceed with pulpotomy. 

Persistent bleeding, however, indicates the need for pulpectomy or extraction.

What Materials Work Best in 2025?

Here are newer materials that work best for pulp therapies -

Mineral Trioxide Aggregate (MTA)

• Success rates >90% in long-term studies for pulpotomy³.
• MTA provides excellent sealing ability and is known for inducing dentin bridge formation.
• Despite being widely used, MTA can be slightly expensive and might cause some discoloration. 

Biodentine

• Newer material, which is biocompatible and can repair or substitute damaged dentin. 
• It is also faster-setting and easier to handle when compared to MTA, which makes it practical for modern pediatric use.
• Studies report equal or superior success to MTA in primary pulpotomies⁴.
• Preferred in anterior teeth due to lower discoloration potentia

New-Generation Bioceramics

• Pre-mixed calcium silicate-based materials like NeoMTA Plus, Theracal LC, calcium-enriched mixtures (CEM), EndoSequence, and BioRoot RCS are gaining popularity⁵.
• Bioceramics should have optimal mechanical strength, antibacterial properties, and manageable setting times to gain long-term success⁶.

Zinc Oxide Eugenol (ZOE) 

• ZOE is the choice of material for pulpectomy fillings.
• It has a resorption mismatch with the roots, and may cause periapical irritation⁷.
• ZOE can also deflect the permanent tooth bud, and should be avoided.

Trending alternative: Prefer calcium hydroxide–iodoform pastes like Metapex, Vitapex, that resorb more harmoniously and are easier to retreat.

Practical Updates for Daily Practice

• Hemostasis control matters: Be cautious and use 1.25–2.5% NaOCl or ferric sulfate, avoiding overzealous cauterization that may damage radicular pulp.
• Radiographic monitoring: Monitor success by following up on the state of root resorption, along with the absence of symptoms.  
• Case selection: Teeth that are close to natural exfoliation or have furcation involvement are better managed with extraction. 

Clinical tip: Always communicate with parents that pulp therapy is not a permanent solution. The goal is to maintain the tooth until natural exfoliation; by no means is it about creating a “forever tooth.” It is often misunderstood by parents of young children.

Final Takeaway

Pulp therapy is swiftly changing and has newer materials that have replaced formocresol. 
While many dental practitioners have worked with formocresol during their training period, it is high time to take in newer materials like MTA, Biodentine, and other bioceramic cements. 

ZOE pulpectomies are not a great idea; use calcium hydroxide–iodoform pastes instead.

Other than better materials, careful case selection, and clear parental communication are the best ways to go.

References

1. Issrani R, Prabhu N, Bader AK, Alfayyadh AY, Alruwaili KK, Alanazi SH, Ganji KK, Alam MK. Exploring the properties of formocresol in dentistry—a comprehensive review. J Clin Pediatr Dent. 2023;47(3):1-10.
2. Baik SA, Al Mkenah A, Khan A, Alkhalifah A, Al Makinah A, Alquraini H, Al Khars A, Almakinah A, Almakinah D, Almalki A. Pulpotomy vs. pulpectomy techniques, indications and complications. Int J Community Med Public Health. 2018 Nov;5(11):4975-4978.
3. Beldar TL, Jawdekar AM, Mistry LN. Success of pulpotomy with MTA in primary teeth: A systematic review and meta-analysis. Bioinformation. 2025;21(8):2574–2580
4. Vilella-Pastor S, Sáez S, Veloso A, Guinot-Jimeno F, Mercadé M. Long-term evaluation of primary teeth molar pulpotomies with Biodentine and MTA: a CONSORT randomized clinical trial. Eur Arch Paediatr Dent. 2021 Aug;22(4):685-92.
5. Dong X, Xu X. Bioceramics in Endodontics: Updates and Future Perspectives. Bioengineering (Basel). 2023 Mar 13;10(3):354. 
6. Alshalan AS, Almutiri FA, Al-Battat AH, Alqahtani AM, Binzamil KA, Alabdan RM, Alrabghi KK, Aldohailan AM, Alshammari EA, Khurayniq AS, Alshahrani MT. Bioactive Materials in Pediatric Endodontics: Current Applications and Future Directions. Cureus. 2025 Aug 22;17(8):e90718.
7. Najjar RS, Alamoudi NM, El-Housseiny AA, Al Tuwirqi AA, Sabbagh HJ. A comparison of calcium hydroxide/iodoform paste and zinc oxide eugenol as root filling materials for pulpectomy in primary teeth: A systematic review and meta-analysis. Clin Exp Dent Res. 2019 Mar;5(3):294-310.