UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia
Campus de São José dos Campos

CASE REPORT DOI: https://doi.org/10.4322/bds.2022.e2903

Lesion sterilization and tissue repair of primary molar to the

eruption of its permanent successor: a case report
Esterilização da lesão e reparação de tecidos de molar decíduo: relato de caso clínico até a erupção do permanente sucessor
Claudia Paulo MOREIRA1 , Regina Maura SIEGL1 , Tamara Kerber TEDESCO2 , Thais GIMENEZ2 ,
Isabela FLORIANO1,3 , Jose Carlos IMPARATO1,4 
1 - Faculdade São Leopoldo Mandic, Pós-Graduação em Odontopediatria, Campinas, SP, Brazil.
2 - Universidade Ibirapuera, Curso de Odontologia, São Paulo, SP, Brazil.
3 - Centro Universitário Uninovafapi, Curso de Odontologia, Teresina, PI, Brazil.
4 - Universidade de São Paulo, Faculdade de Odontologia, São Paulo, SP, Brazil.

ABSTRACT
The aim of this study is to report a clinical case of lesion sterilization and tissue repair in primary molar, with
follow-up until the eruption of the permanent successor. A 6-year-old male patient came to the Pediatric Dentistry
Clinic at Faculdade Sao Leopoldo Mandic in Campinas-SP, with his mother, complaining of “caries in several
teeth”. On clinical examination, it was found that tooth 85 had a severe carious lesion with pulp involvement
and fistula. Radiographically, radiolucency was observed in the furcation region. It was then decided to perform
lesion sterilization and tissue repair of the tooth with CTZ paste. After 6 months of the procedure, the tooth
was clinically and radiographically normal and after 3 years it was observed that tooth 85 was in complete
root resorption. After extraction, the permanent successor erupted naturally without clinical or radiographic
alterations. It can be concluded that the present clinical case demonstrated success in the use of CTZ paste in the
lesion sterilization and tissue repair of primary molars, until the complete eruption of the permanent successor.

KEYWORDS
Primary tooth; Pulpectomy; Pediatric dentistry; Endodontics; Case report.

RESUMO
O objetivo desse estudo é relatar o caso clínico de esterilização da lesão e reparação de tecidos em molar decíduo
com pasta CTZ, com acompanhamento até a erupção do pré-molar sucessor. Paciente do sexo masculino, 6
anos de idade, apresentou-se à Clínica de Odontopediatria da Faculdade São Leopoldo Mandic em Campinas-SP,
acompanhado de sua mãe, queixando-se de “cárie em vários dentes”. Ao exame clínico, verificou-se que o
dente 85 apresentava lesão de cárie severa com envolvimento pulpar e fístula. Radiograficamente, observou-se
radiolucidez na região de furca. Optou-se, então, por realizar a esterilização da lesão e reparação de tecidos
do dente com pasta CTZ. Após 6 meses da realização do procedimento, o dente apresentava-se clinica e
radiograficamente normal e após 3 anos observou-se que o elemento 85 estava em rizólise completa. Feita a
extração, o permanente sucessor erupcionou naturalmente sem alterações clínicas ou radiográficas. Pode-se
concluir que o presente caso clínico demonstrou sucesso do emprego da pasta CTZ na esterilização da lesão e
reparação de tecidos de molar decíduo, até completa erupção do permanente sucessor.

PALAVRAS-CHAVE
Dente decíduo; Pulpectomia; Odontopediatria; Endodontia; Relato de caso clínico.

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Moreira CP et al. Lesion sterilization and tissue repair of primary molar to the
eruption of its permanent successor: a case report

INTRODUCTION CASE REPORT DESCRIPTION

The primary teeth have unique importance on Six-year-old male patient came to the
aesthetics, phonation, chewing and psychological Odontopediatrics Clinic at Faculdade São
well-being for the child. They are also essential Leopoldo Mandic in Campinas-SP, with his
for the maintenance of space and for the correct mother and a complaint of “caries in several
eruption of the permanent tooth [1-6]. Because teeth”. Patient’s assent and guardian’s consent
of this, they must remain in the mouth in healthy were requested and approved.
conditions until their cycle is complete [1,4].
Endodontic treatment of the primary tooth On clinical examination, it was found that
is a treatment option to its maintenance in tooth 85 had a severe carious lesion with pulp
the arch when the integrity of the pulp has and fistula involvement. The patient reported no
been irreversibly affected by caries or dental pain or sensitivity in the tooth. Radiographically,
trauma [2-4,7]. radiolucency was observed in the furcation region
and the presence of the successive permanent
In 1959, Soller and Cappiello published
tooth germ in Nolla stage 5 (Figure 1A).
an endodontic technique that does not perform
the instrumentation of the root canals and uses It was then decided to perform the endodontic
an antibiotic paste composed of tetracycline, treatment of this tooth with CTZ paste and
chloramphenicol and zinc oxide and to restore the tooth with high viscosity glass
eugenol [3,7-9]. This simple technique can be ionomer cement (Figure 1B). The other teeth
used on teeth with pulp necrosis and performed of the patient with caries lesions did not need
in a single session [2,8,10]. This facilitates endodontic treatment and were treated according
endodontic therapy in children, as it reduces the to protocols established in the literature [14].
clinical time, especially those with behavior that
is difficult to manage [2,5,7,8]. We chose to perform endodontic treatment
with CTZ paste because of the difficulty in
Recently, the American Association of handling the patient and, at the same time,
Pediatric Dentistry renamed this procedure as because of the importance of maintaining the
lesion sterilization and tissue repair (LSTR). It primary tooth, considering the stage of formation
usually has no instrumentation of the root canals
of the permanent successor.
but, instead, an antibiotic mixture is placed in the
pulp chamber which is intended to disinfect the The access to the pulp chamber was
root canals [11]. performed with a diamond spherical bur under
rubber dam isolation. Duct irrigation was carried
The CTZ paste has antibacterial activity [9,12,13],
promotes stabilization of bone resorption, does out with 0.5% sodium hypochlorite solution and
not cause tissue sensitivity [2,5] and does not suction with the aid of hypodermic needles. The
interfere with the physiological resorption of the pulp chamber was then dried with sterile cotton
deciduous [3]. Despite some published clinical and filled with CTZ paste (Formula e Acao, Sao
studies, the literature still lacks studies that verify Paulo, BRA). The filling material was pushed
the influence on the development and eruption until it penetrates the entry of the root canals. At
of the permanent successors [2,7]. Therefore, the end, a thin layer of gutta-percha (Dentsply
the present study aims to report a clinical case Sirona, Ballaigues, SWI) was placed as a new
of lesion sterilization and tissue repair in primary floor of the pulp chamber and the tooth was
molar, with follow-up until the eruption of the restored with high viscosity glass ionomer cement
permanent successor. (Fuji IX® GC America, Alsip, USA).

Figure 1 - Periapical radiographs: (A) before treatment of the deciduous molar; (B) immediately after endodontic treatment of the deciduous
molar; (C) six months after treatment; (D) three years after treatment; (E) after the eruption of the permanent successor.

2 Braz Dent Sci 2022 Jan/Mar;25 (1): e2903

 Moreira CP et al. Lesion sterilization and tissue repair of primary molar to the
eruption of its permanent successor: a case report

Six months later, tooth 85 was reexamined periodontal ligament remained intact during all
clinically and radiographically. There was the cases studied [18].
clinical normality (absence of fistula and painful
In humans, biological effects are assessed
symptoms) and decreased radiolucency in the
through the response of the pulp and periapical
furcation area (Figure 1C). Three years after the
tissues during the use of materials [6,18]. In
endodontic treatment, the patient returned to the
clinical practice, treatment success is assessed by
clinic for routine check and found that the tooth
remission of clinical and radiographic signs and
85 was in complete root resorption (Figure 1D).
symptoms found prior to treatment [18].
The tooth was extracted and two weeks later, the
permanent successor (tooth 45) erupted without Clinically and radiographically, the results of
clinical and radiographic enamel alterations the studies are generally positive. Siegl et al [4]
(Figure 1E). evaluated the radiolucent area in the furcation
region in primary molars treated with CTZ
and with Guedes-Pinto paste over a 12-month
DISCUSSION
period. Clinically, the response was similar, but
The complexity of endodontic treatment the reduction in the radiolucent area was only
on primary teeth has led researchers to seek seen in teeth treated with CTZ paste, which can
simplified techniques [7,9,15]. Considering the be explained by its antimicrobial action. Similar
difficulty of mechanical chemical preparation results were found by other authors [14,19].
in primary teeth, antibiotic pastes represent Absence of painful symptoms, fistula, mobility
one of the most important aspects to achieve incompatible with chronological age and
the success of endodontic treatment [2,3,7,13]. eruption of the permanent in a healthy way
Antibiotic pastes such as CTZ act at a distance and were parameters considered for the assessment
reduce the number of microorganisms and even of clinical success. According to clinical studies,
modifying their pathogenicity [6,8,16]. pulp therapy performed with CTZ paste is easy
to apply, with excellent clinical and radiographic
Endodontics of primary molars with CTZ
results, even on teeth with an unfavorable
paste is a technique that is based on sterilization
prognosis [2-4,15].
and repair of periapical tissue [9,11,15]. The
paste consists of a powder composed of two It is noteworthy that if the pulp chamber is
broad-spectrum antibiotics, chloramphenicol and not cleaned properly and filling material remains,
tetracycline, zinc oxide and a liquid, eugenol, it has a high chance of the tooth crown becoming
which also has antimicrobial action [2,5,8-10]. stained. This is due to the presence of tetracycline
in the formulation of the material [2].
Dental resorption on the floor of the
pulp chamber exposes the dentinal tubules, The presence of accessory root canals,
transforming it into a biological sieve [17]. This porosity and permeability in the region of
feature requires us to be even more careful in deciduous pulp, would indicate a connection
the choice of drugs used in the primary of pulp between dental pulp and periodontal tissues.
therapy. The wrong choice can trigger furcation The antibiotic pastes used can easily dissipate in
lesions and alterations in the follicular tissues these regions and create a sterile area [6,20]. The
of the permanent germ, which can generate elimination of bacteria is essential to guarantee
localized enamel hypoplasia. the success of endodontic treatment, especially
in primary teeth, where, depending on the
Several authors have studied the antimicrobial
physiological root resorption stage, they cannot
effect of the CTZ paste. In two studies, the
be prepared and filled [21].
formation of a halo of bacterial inhibition and
effectiveness in the antimicrobial activity of the The result of this clinical case is consistent
CTZ paste was verified [4,16]. Histopathological with the results found in the other studies cited.
analysis showed an intense inflammatory process It was a positive result, as the clinical examination
right after the treatment, which turned into showed no painful symptoms, fistula and mobility.
a mild chronic inflammatory process with The radiographic examination revealed absence
quantitative and qualitative reduction in the of periapical lesion and of the radiolucent area in
density of collagen fibers. These findings point the furcation region. Another factor that indicates
to therapeutic properties of the paste [9]. The the success of the technique was the eruption of
Braz Dent Sci 2022 Jan/Mar;25 (1): e2903
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 Moreira CP et al. Lesion sterilization and tissue repair of primary molar to the
eruption of its permanent successor: a case report

the permanent successor in biological time and 5. Passos IA, Melo JM, Moreira PVL. Utilização da pasta CTZ em
dente decíduo com necrose pulpar: relato de caso. Odontol Clin
without any sequelae. Cient. 2008;7(1):63-5.
Nevertheless, the present study does not 6. Luengo LF, Medina AR, Montoya MEH, Rosas CYD, Medrano
allow extrapolations. it acts as an incentive to LEC, Garcia IT. Efectividad clinica y radiográfica de la pasta
antibiótica CTZ em pulpotomías de molares primários. Ensaio
conduct randomized clinical trials with a long clinico aleatório controlado. Int J Odontostomat. 2016;10(3):425-
follow-up using the CTZ paste as one of the 31.
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compare LSTR and pulpectomy. the most recently Dent Pub H. 2018;9(3):205-13. http://dx.doi.org/10.17267/2596-
published reviews have failed to disclose any 3368dentistry.v9i3.1951.
difference between these treatments through the 8. Fereira JL, Rivas HR, Toscano I, Carlos Medrano LE, Alvarez
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org/10.17576/jsm-2018-4705-12.
CONCLUSION
9. Lima CCB, Conde Júnior AM, Rizzo MS, Moura RD, Moura MS,
This clinical case demonstrated the success Lima MD, et al. Biocompatibility of root filling pastes used in
primary teeth. Int Endod J. 2015;48(5):405-16. http://dx.doi.
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10. Oliveira M, Costa L. Desempenho clínico de pulpotomias com
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11. American Academy of Pediatric Dentistry. Pulp therapy for
Conflict of Interest primary and immature permanent teeth. The Reference Manual
of Pediatric Dentistr. 2020;399-407.
The authors declare no conflicts of interest.
12. Amorim LFG, Toledo AO, Estrela CRA, Decurcio DA, Estrela
C. Antimicrobial analysis of different root canal filling pastes
used in pediatric dentistry by two experimental methods. Braz
Funding Dent J. 2006;17(4):317-22. http://dx.doi.org/10.1590/S0103-
64402006000400010. PMid:17262146.
This research did not receive any specific
13. Fabiane P, Faraco IM Jr, Estrela C. Antimicrobial activity of
grant from funding agencies in the public, different root canal filling pastes used in deciduos teeth.
commercial, or not-for-profit sectors. Mater Res. 2008;11(2):171-3. http://dx.doi.org/10.1590/S1516-
14392008000200010.
14. Rodrigues CRMD, Imparato JCP, Raggio DP, Rocha R.
Regulatory Statement Dentística. In: Guedes Pinto AC, Bonecker M, Rodrigues CRMD.
Odontopediatria. São Paulo: Santos, 2009. p. 229-52.
This study was conducted in accordance
15. Moura LF, Lima MDM, Lima CCCB, Machado JIAG, Moura MS,
with all the provisions of the local human subject’s Carvalho PV. Endodontic treatment of primary molars with
oversight committee guidelines and policies. The antibiotic paste: a report of 38 cases. J Clin Pediatr Dent.
2016;40(3):175-7. http://dx.doi.org/10.17796/1053-4628-
patient authorized the disclosure of the case and
40.3.175. PMid:27472562.
duly signed the informed consent form.
16. Perez PH, Curioca ASR, Retana RU. Efectividad terapêutica de
la pasta CTZ vs. Biomecânica convencional en pulpa necrótica
de escolares de 4 a 8 anos. Odont Pediatr. 2012;2(3):28-36.
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Jose Carlos Imparato

(Corresponding address)
Universidade de São Paulo, Faculdade de Odontologia, São Paulo, SP, Brazil. Date submitted: 2021 March 24
Email: [email protected] Accept submission: 2021 May 28

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