Vital pulp therapy in primary teeth is a cornerstone of pediatric dental treatment. Among the most common procedures are pulpotomy, which conserves some of the radicular pulp, and pulpectomy, which removes all pulp tissue.
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✅ Background and Rationale
Primary teeth differ significantly from permanent teeth in morphology and physiology, notably in their root anatomy, resorption patterns, and innervation. Current pediatric dentistry guidelines (e.g., AAPD) describe pulpotomy as indicated when coronal pulp is inflamed but radicular pulp remains vital. Meanwhile, pulpectomy is generally reserved for cases with necrosis, irreversible pulpitis, or radiographic pathology.
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➤ Randomized & Controlled Trials
▪️ A multicenter RCT comparing cervical pulpotomy (with calcium-enriched mixture cement) versus pulpectomy (Metapex) in primary molars with irreversible pulpitis found no significant difference in clinical and radiographic success rates. PubMed
▪️ In a split-mouth randomized trial on primary incisors with vital pulp exposure, pulpotomy (formocresol) and pulpectomy (zinc-oxide-eugenol) showed similar 12-month success, with survival rates of ~82% vs ~74%, respectively (not statistically significant).
➤ Observational and Cohort Studies
A retrospective cohort study of 876 primary molars reported that iRoot BP Plus pulpotomy had a significantly better long-term prognosis (survival over 48 months) than Vitapex pulpectomy.
A survival analysis of pulpectomy under general anesthesia found that failures usually stemmed from incomplete tissue removal and complexity of root canal systems in primary molars.
➤ Systematic Reviews & Meta-Analyses
▪️ A large Cochrane-type review concluded that MTA (mineral trioxide aggregate) is superior to formocresol and calcium hydroxide for pulpotomy in primary teeth.
▪️ Another systematic review and meta-analysis demonstrated high clinical and radiographic success for pulpotomy in primary teeth with irreversible pulpitis, suggesting that inflammation might be confined to the coronal pulp in many cases.
📊 Comparative Table: Pulpotomy vs Pulpectomy in Primary Teeth
| Aspect | Advantages | Limitations |
|---|---|---|
| Tissue preservation | Maintains some vital radicular pulp, encouraging natural resorption | May leave inflamed tissue if diagnosis is incorrect |
| Procedure time & behavior | Generally faster and less technically demanding; better tolerated in uncooperative children | Hemostasis must be achieved; persistent bleeding may complicate treatment |
| Long-term survival | High survival rates over several years (e.g., > 70% at 48 months with bioceramic pulpotomy) :contentReference[oaicite:9]{index=9} | Success depends on correct diagnosis and use of proven medicaments (e.g., MTA) :contentReference[oaicite:10]{index=10} |
| Indications | Irreversible pulpitis with vital radicular tissue; minimal radiographic pathology | Not suitable if necrosis, internal/external resorption, or periapical infection present :contentReference[oaicite:11]{index=11} |
| Risks & complications | Lower risk of overfilling; less risk to developing permanent tooth bud | Risk of failure if improper agent or poor seal; possible internal resorption |
| Restoration after treatment | Can be restored with stainless steel crowns or other durable restorations with good retention :contentReference[oaicite:12]{index=12} | Coronal leakage or microleakage can compromise outcome if restoration fails |
💬 Discussion
The body of evidence suggests that pulpotomy and pulpectomy both have clinically acceptable success in primary teeth when properly indicated. Notably:
▪️ Pulpotomy, especially when using modern materials like MTA or bioceramic cements (e.g., iRoot BP Plus), demonstrates excellent long-term survival.
▪️ Pulpectomy, while more invasive, remains critical in cases of necrosis or when radiographic signs of pathology are present. However, it is technically demanding, particularly due to the complex canal anatomy of primary molars.
▪️ Systematic reviews consistently favor MTA over traditional agents like formocresol or calcium hydroxide for pulpotomy, due to better clinical and radiographic outcomes.
▪️ Patient-centered outcomes also favor more conservative therapy: pulpectomy has been associated with improved quality of life and lower dental anxiety compared to extraction, making it preferable over tooth loss.
Additionally, a recently registered RCT protocol aims to provide more rigorous evidence by comparing pulpotomy vs pulpectomy in primary molars with irreversible pulpitis over two years. This trial could potentially shift paradigms if pulpotomy proves non-inferior, given its lower invasiveness and patient burden.
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1. Case Selection Is Key
▪️ Use pulpotomy when the pulp is vital, bleeding is controlled, and no periapical pathology is evident.
▪️ Reserve pulpectomy for cases with necrosis, internal/external resorption, or evidence of interradicular/periapical disease.
2. Material Choice
▪️ Prefer MTA or bioceramic materials (e.g., iRoot BP Plus) for pulpotomy due to demonstrated higher success rates.
▪️ For pulpectomy, use resorbable filling materials compatible with primary tooth anatomy (e.g., Metapex, Vitapex), though evidence does not strongly favor one over another.
3. Behavior Management & Procedural Efficiency
▪️ Because pulpotomy is generally faster and less technique-sensitive, it may be better suited for younger or less cooperative children.
▪️ Ensure accurate diagnosis (clinical + radiographic) to minimize risk of failed treatment.
4. Follow-up Protocol
▪️ Schedule periodic clinical and radiographic reviews (e.g., 6 months, 12 months, annually) to monitor for signs of failure or resorption.
▪️ Optimize restorative sealing (e.g., stainless-steel crown) to reduce risk of microleakage.
5. Research and Continuous Learning
▪️ Stay updated with ongoing trials (e.g., the non-inferiority RCT of pulpotomy vs pulpectomy in primary molars) for evidence that may refine treatment guidelines.
▪️ Contribute to or audit long-term outcomes in your own practice to inform future decisions.
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Dental Article 🔽 Partial Pulpotomy in Pediatric Dentistry: Technique, Benefits, and Key Differences ... Partial pulpotomy offers a biologically favorable approach in cases of limited pulp inflammation, especially in traumatic pulp exposures or shallow carious lesions, promoting healing and long-term tooth survival.✍️ Conclusion
In modern pediatric dentistry, both pulpotomy and pulpectomy remain viable options for managing pulpally involved primary teeth. While pulpotomy offers a more conservative and less time-consuming approach with excellent long-term survival—especially when using materials like MTA or bioceramics—pulpectomy remains irreplaceable in cases of necrosis or advanced pathology. Clinicians should base their choice on careful diagnosis, patient behavior, material selection, and a commitment to follow-up. Together, these strategies help preserve primary teeth, maintain arch integrity, and support the well-being of pediatric patients.
📚 References
✔ Holan, G., & Fuks, A. B. (2015). The role of pulpectomy in the primary dentition. Pediatric Dentistry, 37(6), 559–566.
✔ Philip, N., Cherian, J. M., Mathew, M. G., et al. (2024). Treatment outcomes of pulpotomy versus pulpectomy in vital primary molars diagnosed with symptomatic irreversible pulpitis: protocol for a non-inferiority randomized controlled trial. BMC Oral Health, 24, 626. https://doi.org/10.1186/s12903-024-04411-6
✔ Li, J., Fan, W., Zhou, Y., Wu, L., Liu, W., & Huang, S. (2024). Pulpotomy versus pulpectomy in carious vital pulp exposure in primary incisors: a randomized controlled trial. BMC Dentistry.
✔ Xu, X., Chen, X., Wang, X., & Chen, J. (2023). Survival analysis of pulpotomy versus pulpectomy in primary molars with carious pulp exposure. International Endodontic Journal.
✔ Walsh, T., Clarke, M., Tsang, A., Marshman, Z., & Petrou, K. (2016). Pulp treatment for extensive decay in primary teeth. Cochrane Database of Systematic Reviews, (4), CD003220.
✔ American Academy of Pediatric Dentistry. (n.d.). Pulp Therapy for Primary and Immature Permanent Teeth. AAPD Policy.
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