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Received: 13 June 2022
| Revised: 16 January 2023
| Accepted: 21 January 2023

DOI: 10.1111/ipd.13056

ORIGINAL ARTICLE

Lesion sterilization and tissue repair with chloramphenicol,

tetracyline, zinc oxide/eugenol paste versus conventional
pulpectomy: A 36-­month randomized controlled trial

Marcus Castro |Marina Lima | Cacilda Lima | Marcoeli Moura |

Joyce Moura | Lúcia Moura

Graduate Program in Dentistry, Federal

University of Piauí, Teresina, Brazil Abstract
Background: Endodontic treatment of primary molars represents one of the
Correspondence
challenges in pediatric dentistry. There is a lack of consensus in the literature
Lúcia Moura, Graduate Program in
Dentistry, Federal University of Piauí, about the endodontic techniques and filling paste for primary teeth with pulp
Avenida Senador Area Leão, 1675, apto necrosis.
500, Teresina, PI 64049-­110, Brasil.
Email: mouraiso@uol.com.br
Aim: To compare the effectiveness of the LSTR technique (lesion sterilization
and tissue repair) with CTZ paste (chloramphenicol, tetracycline, zinc oxide and
eugenol) and pulpectomy with ZOE paste (zinc oxide and eugenol) in the treat-
ment of primary molars with pulp necrosis.
Design: Eighty-­eight primary molars with pulp necrosis from 70 children be-
tween the ages of 3 and 8 years were included. The teeth were randomized to the
LSTR with CTZ paste group or pulpectomy with ZOE paste group. Clinical and
radiographic evaluations were performed at 18, 24, 30 and 36 months.
Results: At 36 months, clinical success was 86.4% in LSTR with CTZ paste and
90.9% in pulpectomy with ZOE paste (p = .45). Radiographic success was 43.2%
in both groups (p = 1.00). The overall success was 40.9% in LSTR with CTZ paste
and 43.2% in pulpectomy with ZOE paste (p = 1.00).
Conclusion: After 36 months of evaluation, the effectiveness of the LSTR tech-
nique with CTZ paste and pulpectomy with ZOE paste was similar for the treat-
ment of primary molars with pulp necrosis.

KEYWORDS
LSTR therapy, primary molars, pulp necrosis, pulpectomy, randomized controlled trial

1 | I N T RO DU CT ION add challenges in performing pulp therapies in these

teeth.1,2,4
Primary molars have a complex anatomy with narrow, To perform pulp therapies in primary molars with pulp
curved root canals1,2 and interconnected isthmuses.2 necrosis, two techniques are indicated: pulpectomy5–­7
In addition, there is permeability on the pulp chamber and lesion sterilization and tissue repair (LSTR).5,7,8 The
floor caused by the thin dentin and the presence of ac- pulpectomy technique requires chemico-­mechanical root
cessory canals.3 These morphological peculiarities, when canal preparation and obturation with a resorbable paste.6
associated with the adverse behavior of some children, Among these pastes, zinc oxide and eugenol (ZOE paste)

Int J Paediatr Dent. 2023;00:1–11. wileyonlinelibrary.com/journal/ipd © 2023 BSPD, IAPD and John Wiley & Sons Ltd. | 1
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2    CASTRO et al.

stands out5,9 for its biocompatibility,10 radiopacity,11 an-

timicrobial action,12 and satisfactory clinical and radio- Why this paper is important to paediatric
graphic results.8,9,11,13 dentists
In the LSTR technique, the root canals are often not
• The results validate the tested treatment option
instrumented and a paste containing antibiotics is used
contributing to the evidence-­based practice at
in the entrance of the root canals.8,14 Among antibiotic
the paediatric clinic.
pastes, the CTZ paste is composed of chloramphenicol,
• The technique used in the experimental group
tetracycline, zinc oxide, and eugenol has been reported in
is easy to perform and requires less chair time,
the literature.8,15,16 This paste has antimicrobial action,17
which could increase the access and children's
biocompatibility,18 satisfactory clinical and radiographic
acceptance of the treatment.
results,7,8,19,20 and does not trigger enamel development
• The long-­term follow-­up shows good survival
defects in the permanent successor teeth.21 Others re-
rates for both techniques.
ported significantly better results replacing tetracycline
with other antibiotics.5,20
There is a lack of consensus in the literature about the
endodontic techniques and filling paste for primary teeth Kevin M. Sullivan, www.OpenE​pi.com), in which the fol-
with pulp necrosis.5 The aim of this clinical trial was to lowing criteria were used: success rate of 63% for the ZOE
compare the effectiveness of the LSTR technique with CTZ paste10 and 93% for the CTZ paste,19 test power of 80%,
paste and pulpectomy with ZOE paste in the treatment of and significance level of 5%. The sample was defined as 36
primary molars with pulp necrosis. The null hypothesis is teeth per group. To minimize possible loss, an increase of
that at the end of the follow-­up the two techniques have 20% was added and a final sample of 88 teeth (44 teeth per
no statistical difference in the effectiveness percentage. group) was obtained.8

2 | M AT E R IALS AN D M ET H OD S 2.4 | Inclusion criteria

2.1 | Ethics Children of both sexes between the ages of 3 and 8 years
attending the Children's Dental Clinic at UFPI, Teresina,
This study was approved by the Research Ethics Brazil were included in this study. Children were included
Committee of the Federal University of Piauí (UFPI) if they had mandibular primary molars with pulp necro-
(Protocol: 2.600.321) and conducted following the prin- sis, a root resorption equal to or less than 1/3, and a suf-
ciples of the Declaration of Helsinki. The parents/guard- ficient dental structure to allow absolute isolation of the
ians of the children who agreed to participate in this study operative field and adaptation of a stainless steel crown.8
signed an informed consent form, and the children signed The clinical diagnosis of pulp necrosis was based on
an informed consent form. the history of spontaneous pain, possibly with the pres-
ence of sinus tract or abscess, and/or mobility that was
incompatible with the child's chronological age. In the
2.2 | Trial design radiographic image, the presence or absence of a radio-
lucent area in the furcation region was evaluated. For the
This randomized clinical trial followed the recommen- diagnosis of pulp necrosis, the clinical examination was
dations of the Consort Statement and was registered in associated with the radiographic examination.8 To obtain
the Brazilian Registry of Clinical Trials (ReBEC—­n°RBR periapical radiographs, the paralleling technique was used
8xt8wx) and in the International Clinical Trials Platform at with intraoral film for children (Carestream, São Paulo,
Clini​calTr​ials.gov (NCT03650036). This is a parallel rand- Brazil) in an x-­ray film holder (Indusbello, Paraná, Brazil)
omized controlled clinical trial, in which the clinical evalu- processed by the conventional manual technique.8
ator was blinded and the radiographic evaluator was not, as
the techniques were recognized by radiographic differences.
The primary outcome was clinical and radiographic success. 2.5 | Exclusion criteria

History of allergic reaction to the components of the tested

2.3 | Sample materials, use of antibiotics in the 3 months prior to treat-
ment, presence of root canal obliteration, and internal or
The sample size calculation was performed using the external pathological root resorption visible on periapical
OpenEpi program, version 3.01 (Andrew G. Dean and radiographs were considered exclusion criteria.8
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CASTRO et al.    3

2.6 | Randomization 2.8 | Interventions

Teeth were submitted to a simple randomization per Clinical procedures for each of the groups were performed
tooth by an independent individual to one of the two by two postgraduate dental surgeons trained by a professor
groups. The allocation was subjected to a set of rand- of paediatric dentistry experienced in pulp therapy, as de-
omized numbers generated by the program Random scribed by Moura et al. and presented in Table 1. The two
Allocation Software 1.0 (Mahmood Saghaei, Iran). Two dental surgeons performed the interventions on a num-
groups were formed: the LSTR technique with CTZ paste ber of teeth equally divided in both experimental groups.
group and the pulpectomy with ZOE paste group. Each The powder of the two pastes was manufactured at the
tooth received a five-­digit identification code generated UFPI Pharmacy School. The CTZ paste powder contained
by the program.8 62.5 mg of chloramphenicol, 62.5 mg of tetracycline, and
125 mg of zinc oxide and was manipulated with 0.1 ml of
eugenol (Biodynamics). The zinc oxide of the ZOE paste
2.7 | Blinding was packed into 250 mg capsules mixed with 0.1 ml of
eugenol (Biodynamics).
The codes were placed in opaque, numbered, and sealed
envelopes in order to ensure randomization.8 The chil-
dren and their parents/guardians were blinded to the allo- 2.9 | Clinical evaluation
cation. The envelopes were opened in the presence of the
patients by a dental assistant who was not connected with Data from the baseline period (T0) to 12 months after the
the study right before the beginning of the procedures in therapies (T12) have been previously published.8 The
order to allow appropriate organization of the materials present study corresponds to the evaluation period from
for performing each technique.8 18 months (T18) to 36 months post-­treatment (T36).

TABLE 1 Clinical protocols of the LSTR with CTZ paste and pulpectomy with ZOE paste groups

LSTR with CTZ paste group Pulpectomy with ZOE paste group
1 Local anesthesia by blocking the mandibular alveolar nerve with one percent lidocaine hydrochloride with a vasoconstrictor
(DFL, Rio de Janeiro, Brazil)
2 Rubber dam isolation (Madeitex, São José dos Campos, Brazil)
3 Removal of decayed dentin using spoon-­shaped dentin excavators and low-­rotation spherical drills numbers four and six
(Microdont, São Paulo, Brazil)
4 Removal of pulp chamber roof with a high-­speed sterile carbide bur number 330 (KG Sorensen, Cotia, Brazil)
5 Irrigation of pulp chamber with two percent chlorhexidine solution (LT Rioquímica, São José do Rio Preto, Brazil)
6 Location of the root canal entrances with a number five explorer probe tip (SS White, Rio de Janeiro, Brazil)
7 Pulp chamber drying with sterile cotton ball
8 -­ Chemical–­mechanical root canal preparation using K-­files (sizes
15 to 25; Dentsply) one mm short of the radiographic apex
9 Irrigation of pulp chamber with two percent Disinfection were performed using two percent chlorhexidine
chlorhexidine solution solution (LT Rioquímica São José do Rio Preto, Brazil)
10 Pulp chamber drying with sterile cotton ball Canals drying with sterile paper points (Dentsply, Rio de Janeiro,
Brazil)
11 Insertion of the CTZ paste at the root canal entrances and Canals filling with ZOE paste manually with K-­files (sizes 15 to
pulp chamber floor using a number five exploratory 25; Dentsply)
probe
12 Isolation of the paste with a thin layer of gutta-­percha (Dentsply, Rio de Janeiro)
13 Restoration using high-­viscosity glass ionomer cement (Gold Label 9R, GC, Tokyo, Japan)
14 Proximal surfaces of the primary molars reduction using a number 69 L bur (Teezkavan Co.)
15 SSC cementation (Iso-­Form, 3M ESPE, Minneapolis, Minn, USA) with glass ionomer cement (Ketac Cem Easy Mix, 3M ESPE).
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4    CASTRO et al.

Clinical evaluations were performed by an experienced (stabilization, enlargement, or appearance of radiolucent

paediatric dentist who was unaware to which group the lesion) failure occurred, we labelled these situations as
children's teeth belonged. Intra-­examiner calibration was censored observation. The log rank test (Mantel-­Cox) was
performed with 10 children who did not participate in performed to determine whether the survival distribution
the study with a 2-­week interval between assessments, re- differed by group.
sulting in intra-­examiner agreement (kappa = 1.0). The Cox regression analysis was performed for the indepen-
absence of sinus tract/abscess, pain, and pathological mo- dent variables from the baseline: group (LSTR with CTZ
bility was considered a clinical success.8 From the 18th to paste or Pulpectomy with ZOE paste), type of tooth (first
the 36th month, assessments were made every 6 months.11 or second molar), presence of tooth mobility, presence of
sinus tract or abscess, root resorption, radiolucency in the
furcation area, and crypt involvement of the permanent
2.10 | Radiographic evaluation successor. For all tests, a significance level of 5% was con-
sidered (p < .05).
Radiographic evaluations were performed by a professor
of dental radiology. Examiner calibration was performed
with 10 periapical radiographs of children who were not 3 | RESULTS
included in the study with an interval of 2 weeks between
assessments. The intra-­examiner Kappa concordance co- Of the total sample (n = 88), 75 teeth (85.2%) were as-
efficient was 0.9. Periapical radiographs were placed on sessed up to 36 months. There was loss of follow-­up of 13
a negatoscope (Ultra Slim Led Tomographic Negatoscope teeth (14.8%) due to loss to follow-­up. A flowchart of this
Bivolt-­Biotron, Santa Rita do Sapucaí, Brazil) and evalu- study is shown in Figure 1.
ated by the radiologist who was blinded to the identifica- At 36 months, the clinical success rates were 86.4%
tion of the patients.8 Radiolucent images were measured (LSTR group with CTZ paste) and 90.9% (pulpectomy
with a millimeter ruler for comparison with the previous group with ZOE paste) (p = .45). Radiographic success
evaluation. was 43.2% in both groups (p = 1.00). The overall success
The absence or regression of the radiolucent image was 40.9% in the LSTR group with CTZ paste and 43.2% in
or no new radiolucency in the furcation area when com- the pulpectomy group with ZOE paste (p = 1.00) (Table 2).
pared with the previous radiography was considered ra- Data analysis with a per protocol approach was performed
diographic success.8 Overall success was defined as only in a complementary way (Table 3). In both analyses, no
those teeth that showed both clinical and radiographic differences were observed in the success rates between the
success simultaneously.8 groups.
From the 18th month onward, evaluations were carried Kaplan–­Meier survival analysis plots for clinical, radio-
out every 6 months in order to protect children from ion- graphic, and overall assessments are shown in Figure 2.
izing radiation.11 Mean survival times at clinical assessment were 33.5
(±0.93) months for LSTR with CTZ paste and 34.3 (±0.78)
months for pulpectomy with ZOE paste (p = .50). In the
2.11 | Statistical analysis radiographic evaluation, they were 27.9 (± 1.24) months
for LSTR with CTZ paste and 26.7 (±1.27) months for
Data were analyzed using the Statistical Package for the pulpectomy with ZOE paste (p = .83). In the overall eval-
Social Sciences program (SPSS® for Windows, version uation, they were 27.5 (±1.24) months for LSTR with CTZ
22.0, SPSS Inc.). The analysis considered the modified paste and 26.7 (±1.27) months for pulpectomy with ZOE
intention-­to-­treat approach with imputation of the last paste (p = .98) (Figure 2). In the adjusted Cox regression
observation carried forward for cases lost to follow-­up. model, furcation injury at baseline represented a threefold
In addition, an analysis restricted to children with com- increased risk of failure (HR = 3.34; 95% CI = 1.02–­10.91;
plete follow-­up was performed (i.e., per-­protocol analy- p = .045) (Table 4).
sis). To compare the groups (LSTR with CTZ paste and
Pulpectomy with ZOE paste) in relation to clinical and
radiographic parameters and overall success at different 4 | DISC USSION
times, Pearson's chi-­square and Fisher's exact tests were
performed. To the best of our knowledge, this is the first clinical trial
Kaplan–­Meier survival curves were used to describe with 36 months of clinical and radiographic evaluation fol-
the distribution of time to failure by group. When no clin- low-­up that compares the effectiveness of the LSTR with
ical (presence of sinus tract/abscess) and radiographic CTZ paste technique and an established technique in the
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|5
  

Study flowchart
FIGURE 1
CASTRO et al.
 | 6
  

TABLE 2 Clinical and radiographic assessments between the two groups at 18, 24, 30, and 36 months (last observation carried forward analysis)

18 months 24 months 30 months 36 months

LSTR LSTR LSTR LSTR

with CTZ Pulpectomy with CTZ Pulpectomy with CTZ Pulpectomy with CTZ Pulpectomy
paste n with ZOE paste n with ZOE paste n with ZOE paste n with ZOE
Time (%) paste n (%) p-­value (%) paste n (%) p-­value (%) paste n (%) p-­value (%) paste n (%) p-­value
Clinical success (95% confidence intervals)
Yes 38 (86.4) 40 (90.9) .45b 38 (86.4) 40 (90.9) .45b 38 (86.4) 40 (90.9) .45b 38 (86.4) 40 (90.9) .45b
No 6 (13.6) 4 (9.1) 6 (13.6) 4 (9.1) 6 (13.6) 4 (9.1) 6 (13.6) 4 (9.1)
Radiographic parameters
Radiolucency at furcation area
Absent 28 (63.3) 25 (56.8) .48b 23 (52.3) 20 (45.5) .52b 19 (43.2) 19 (43.2) .59b 19 (43.2) 19 (43.2) .16b
Stabilized 13 (29.5) 16 (36.4) 15 (34.1) 16 (36.4) 20 (45.5) 22 (50.0) 21 (47.7) 22 (50.0)
Increased 3 (6.8) 3 (6.8) 6 (13.6) 8 (18.2) 5 (11.4) 3 (6.8) 4 (9.1) 3 (6.8)
Radiographic success (95% confidence intervals)
Yes 28 (63.6) 25 (56.8) .42b 23 (52.3) 20 (45.5) .40b 19 (43.2) 19 (43.2) 1.00a 19 (43.2) 19 (43.2) 1.00a
No 16 (36.4) 19 (43.2) 21 (47.7) 24 (54.5) 25 (56.8) 25 (56.8) 25 (56.8) 25 (56.8)
Overall success (95% confidence intervals)
Yes 27 (61.4) 25 (56.8) .18b 22 (50.0) 20 (45.5) .18b 18 (40.9) 19 (43.2) 1.00a 18 (40.9) 19 (43.2) 1.00a
No 17 (38.6) 19 (43.2) 22 (50.0) 24 (54.5) 26 (59.1) 25 (56.8) 26 (59.1) 25 (56.8)
Abbreviations: CTZ = chloramphenicol, tetracycline, and zinc oxide eugenol; ZOE = zinc oxide and eugenol.
a
Fisher's exact test.
b
Pearson chi-­square test.
CASTRO et al.

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 CASTRO et al.

TABLE 3 Clinical and radiographic assessments between the two groups at 18, 24, 30, and 36 months (complete case analysis)

18 months 24 months 30 months 36 months

LSTR LSTR LSTR

with CTZ Pulpectomy LSTR with Pulpectomy with CTZ Pulpectomy with CTZ Pulpectomy
paste n with ZOE CTZ paste with ZOE paste n with ZOE paste n with ZOE
Time (%) paste n (%) p-­value n (%) paste n (%) p-­value (%) paste n (%) p-­value (%) paste n (%) p-­value
Clinical success (95% confidence intervals)
Yes 33 (84.6) 32 (88.9) .29b 33 (84.6) 32 (88.9) .29b 33 (84.6) 32 (88.9) .29b 33 (84.6) 32 (88.9) .29b
No 6 (15.4) 4 (11.1) 6 (15.4) 4 (11.1) 6 (15.4) 4 (11.1) 6 (15.4) 4 (11.1)
Radiographic parameters
Radiolucency at furcation area
Absent 24 (61.5) 19 (52.8) .61b 19 (48.7) 14 (38.9) .92b 15 (38.5) 13 (36.1) .54b 15 (38.5) 13 (36.1) .16b
Stabilized 12 (30.8) 14 (38.9) 14 (35.9) 14 (38.9) 19 (48.7) 20 (55.6) 20 (51.3) 20 (55.6)
Increased 3 (7.7) 3 (8.3) 6 (15.4) 8 (22.2) 5 (12.8) 3 (8.3) 4 (10.3) 3 (8.3)
Radiographic success (95% confidence intervals)
Yes 24 (61.5) 19 (52.8) .58b 19 (48.7) 14 (38.9) .73b 15 (38.5) 13 (36.1) 1.00a 15 (38.5) 13 (36.1) 1.00a
No 15 (38.5) 17 (47.2) 20 (51.3) 22 (61.1) 24 (61.5) 23 (63.9) 24 (61.5) 23 (63.9)
Overall success (95% confidence intervals)
Yes 23 (59.0) 19 (52.8) .29b 18 (46.2) 14 (38.9) .40b 14 (35.9) 13 (36.1) 1.00a 14 (35.9) 13 (36.1) 1.00a
No 16 (41.0) 17 (47.2) 21 (53.8) 22 (61.1) 25 (64.1) 23 (63.9) 25 (64.1) 23 (63.9)
Abbreviations: CTZ = chloramphenicol, tetracycline, and zinc oxide eugenol; ZOE = zinc oxide and eugenol.
a
Fisher's exact test.
b
Pearson chi-­square test.
|   
7

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8    CASTRO et al.

FIGURE 2 Kaplan–­Meier survival analysis

literature, pulpectomy with ZOE paste, for the treatment The pulpectomy technique advocates the chemical–­
of primary molars with pulp necrosis. In this study, both mechanical preparation of root canals,7 a procedure that
techniques had similar clinical and radiographic success takes a long chair time and, as a consequence, requires the
rates, leading to the null hypothesis acceptance. The LSTR collaboration of the child.8,23 Time is a fundamental and
technique requires minimal intervention, is cost-­effective differential requirement in the clinical practice of paedi-
and easy to perform, being accessible to general practi- atric dentistry,8,14 and dental interventions that demand
tioners who care for children. In this way, it increases the long periods overload health systems, places that concen-
access to pulp therapy for children with necrosed molars, trate the majority of children with primary teeth with pulp
preventing early tooth loss and minimizing the risk of necrosis.24 The time required to perform the LSTR tech-
malocclusion installation7 and/or deleterious impacts on nique with CTZ paste was twice as short as that of pulpec-
chewing. tomy with ZOE paste.8 Studies are, however, needed to
The use of antibiotic pastes without previous instru- evaluate and compare the cost effectiveness of the LSTR
mentation of root canals for the treatment of primary and pulpectomy techniques.
teeth with irreversible pulpitis or pulp necrosis began Teeth that exhibited radiolucency in the furcation area
in 1967 when Capiello recommended a paste composed at baseline were three times more likely to have clinical
of chloramphenicol, tetracycline, zinc oxide, and euge- and radiographic failure, results that corroborate the lit-
nol (CTZ paste).16 In 2004, Takushige and collaborators erature.25 Considering this factor, the dimension of the ra-
published the first article defining the technique “LSTR” diolucent area in the furcation region should be evaluated
as an option that advocates the non-­instrumentation of in the elaboration of the treatment plan in primary molars
root canals and the use of a paste composed of ciproflox- with pulp necrosis. In the presence of extensive lesions,
acin, metronidazole, and minocycline manipulated with endodontic therapy may be contraindicated and tooth ex-
macrogol and propylene glycol.14 The technique was traction may be the treatment of choice.25
based on the control of root canal infection by the action Studies have shown higher percentages of success for
of antibiotics, providing tissue regeneration and repair.22 pulpectomy with ZOE paste than those presented in this
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CASTRO et al.    9

T A B L E 4 Multivariate analysis of
Unadjusted HR Adjusted HR
risk factors for the overall success of
Variables (95% IC) p-­value (95% IC) p-­value
endodontic treatment in primary molars
using Cox regression Group (ref. Pulpectomy with ZOE paste)
LSTR with CTZ 1.00 (0.57–­1.73) .990 1.07 (0.61–­1.85) .803
paste
Tooth type (ref. first molar)
Second molar 1.33 (0.75–­2.34) .316
Tooth mobility (ref. Absent)
Present 1.73 (0.93–­3.22) .080 -­ -­
Sinus tract or abscess (ref. Absent)
Present 1.68 (0.89–­3.17) .105 -­ -­
Root resorption (ref. Absent)
Present 1.23 (0.63–­2.40) .538
Radiolucency in the furcation area (ref. Absent)
Present 3.74 (1.16–­12.05) .027 3.34 (1.02–­10.91) .045
Involvement of the bone crypt of the permanent successor (ref. Absent)
Present 2.11 (1.11–­4.01) .021 1.81 (0.95–­3.45) .070
Abbreviations: HR: hazard ratio; IC: confidence interval; Ref.: Reference category for each variable.

clinical trial; these studies however included stabiliza- the literature, as this is the first randomized clinical trial
tion of lesions in the furcation region as a radiographic using the paste in cases of pulp necrosis. The LSTR tech-
success criterion.13,26 In the present study, radiographic nique is indicated by the American Academy of Paediatric
success was considered when there was regression of the Dentistry for cases of primary teeth with significant root
radiolucent image or absence of a new radiolucency in resorption and consequent permanence in the dental arch
the furcation region when compared with the previous ra- for a reduced time.6 We suggest, however, that these rec-
diograph. Therefore, if stabilization of radiolucency had ommendations be reviewed and that new techniques be
been considered as a radiographic success criterion, the researched, aiming at comfort, acceptance, and quality of
results would have been similar to those described in the life for the children.
literature. In the LSTR technique with CTZ paste, micronization
The stabilization of lesions in the furcation region after of the powder components is important because it favors
pulp therapy may be associated with the presence of ac- the homogenization of the components of CTZ paste in
cessory canals on the pulp chamber floor, which harbor order to provide a better pharmacological action.8 This
microorganisms and their metabolic products.27 With the important technical detail was not mentioned in other
current state of knowledge, we suggest that the pastes studies using the LSTR technique with CTZ paste.20,28
used in pulp therapies are also placed on the floor of the Another factor that contributed to the overall success of
pulp chamber in order to neutralize the action of the mi- both techniques was the restoration of teeth with stainless
crobiota established there. In clinical practice, when there steel crowns.29 The use of stainless steel crown is superior
is stabilization of the lesion in the furcation region, after compared to other restorative techniques,29 as it provides
pulp therapy, associated with the absence of clinical signs adaptation and adhesion to the tooth structure and the
and symptoms, the tooth should be monitored.25 consequent reduction in marginal infiltrations and pulp
After 36 months of clinical and radiographic evalua- treatment failure.29
tions, an increase in radiolucent lesions in the furcation Pulpectomy with ZOE paste is an endodontic technique
region was observed in four molars in the LSTR group established in the literature with satisfactory clinical and
with CTZ paste, of which only one had no lesion at base- radiographic results.8,9,13,26 These characteristics justified
line, and in three molars in the pulpectomy group with the choice of the technique as a comparison for the LSTR
ZOE paste, without a difference between groups. These technique with CTZ paste.5
teeth exhibited normal clinical parameters, and the chil- This clinical trial has, as a strong point, the long-­term
dren remained asymptomatic. Therefore, the teeth were follow-­up, in which the effectiveness of a minimal inter-
kept in the arches until the end of the study. vention technique was compared with a conventional and
It was not possible to compare the results related to established technique in the literature for the treatment
the LSTR technique with CTZ paste of this study with of primary molars with pulp necrosis. It was also the first
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10    CASTRO et al.

clinical trial to perform survival analysis for the LSTR 8. Moura J, Lima M, Nogueira N, et al. LSTR antibiotic paste ver-
technique with CTZ paste and pulpectomy with ZOE sus zinc oxide and eugenol pulpectomy for the treatment of pri-
mary molars with pulp necrosis: a randomized controlled trial.
paste, enabling the understanding of possible variables
Paediatr Dent. 2021;43(6):435-­442.
over time.30 The absence of difference between the mean 9. Smaïl-­Faugeron V, Glenny AM, Courson F, Durieux P, Muller-­
survival times suggests that the LSTR technique with CTZ Bolla M, Fron CH. Pulp treatment for extensive decay in pri-
paste represents a treatment option for primary molars mary teeth. Cochrane Database Syst Rev. 2018;5(5):CD003220.
with pulp necrosis. 10. Goel H, Mathur S, Sachdev V. Clinical and radiographic
evaluation of four different zinc-­oxide integrated root canal
AUTHOR CONTRIBUTIONS obturating materials used in primary teeth. Paediatr Dent J.
2018;28:73-­86.
L.M. and M.L. conceived the ideas; M.C. and J.M. col-
11. Chen X, Liu X, Zhong J. Clinical and radiographic evaluation of
lected the data; C.L. and M.C. analyzed the data; and L.M.,
pulpectomy in primary teeth: a 18-­months clinical randomized
M.C., and M.M. led the writing. controlled trial. Head Face Med. 2017;13(1):12.
12. Basir L, Khanehmasjedi M, Khosravi A, Ansarifar S.
FUNDING INFORMATION Investigating the antimicrobial activity of different root canal
This study was funded by the authors. filling pastes In deciduous teeth. Clin Cosmet Investig Dent.
2019;11:321-­326.
DATA AVAILABILITY STATEMENT 13. Pandranki J, Vanga NRV, Chandrabhatla SK. Zinc oxide eu-
genol and Endoflas pulpectomy in primary molars: 24-­month
The data that support the findings of this study are avail-
clinical and radiographic evaluation. J Indian Soc Pedod Prev
able from the corresponding author upon reasonable
Dent. 2018;36(2):173-­180.
request. 14. Takushige T, Cruz EV, Asgor Moral A, Hoshino E. Endodontic
treatment of primary teeth using a combination of antibacterial
ORCID drugs. Int Endod J. 2004;37(2):132-­138.
Marcus Castro https://orcid.org/0000-0002-5188-1288 15. Cappiello J. Nuevos enfoques em odontologia infantil. Odontol
Marina Lima https://orcid.org/0000-0002-7641-6331 Urug. 1964;23:23-­30.
Cacilda Lima https://orcid.org/0000-0002-2977-6035 16. Cappiello J. Tratamentos pulpares em incisivos primários. Rev
Asoc Odontol Argent. 1967;52:139-­145.
Marcoeli Moura https://orcid.org/0000-0002-9044-9025
17. Freire AR, Freire DEWG, Sousa SA, Serpa EM, Almeida LFD,
Joyce Moura https://orcid.org/0000-0003-0844-600X Cavalcanti YW. Antibacterial and solubility analysis of exper-
Lúcia Moura https://orcid.org/0000-0002-4112-1533 imental Phytotherapeutic paste for endodontic treatment of
primary teeth. Pesquisa Brasileira Em Odontopediatria clínica
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