Pulpotomy Failure in Primary Teeth: Causes, Early Warning Signs, and Evidence-Based Prevention

Pulpotomy is one of the most common vital pulp therapies in pediatric dentistry, aiming to preserve primary teeth affected by deep caries while maintaining function until natural exfoliation.

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Despite its high success rates when properly indicated, pulpotomy failure remains a clinically relevant concern, often leading to pain, infection, or premature tooth loss.

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Understanding why pulpotomies fail, how to identify early warning signs, and how to prevent unfavorable outcomes is essential for long-term success and optimal pediatric oral health.

✅ What Is Pulpotomy Failure?
Pulpotomy failure occurs when inflammation or infection progresses beyond the coronal pulp, affecting the radicular pulp or surrounding tissues. This failure may be clinical, radiographic, or both, and can appear weeks or months after treatment.
Failure does not necessarily indicate poor technique alone—it is often the result of multifactorial biological and restorative factors.

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✅ Main Causes of Pulpotomy Failure

1. Incorrect Case Selection
Performing pulpotomy on teeth with irreversible pulpitis or necrotic pulp significantly increases failure risk.
➤ Common red flags include:
▪️ Spontaneous pain
▪️ Swelling or sinus tract
▪️ Pathologic mobility
▪️ Furcation radiolucency at baseline

2. Inadequate Hemostasis
Failure to achieve proper hemostasis after coronal pulp removal suggests radicular pulp inflammation, which compromises prognosis.

3. Bacterial Microleakage
Poor coronal seal allows salivary and bacterial contamination, leading to reinfection of the pulp tissue.

4. Suboptimal Restorative Coverage
Lack of full coronal coverage, especially in multi-surface lesions, increases the risk of restoration breakdown and microleakage.

5. Material-Related Factors
Although modern materials show improved outcomes, incorrect manipulation or improper placement can reduce their effectiveness.

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✅ Early Clinical and Radiographic Signs of Failure
Early detection is critical to avoid more invasive treatment.

➤ Clinical Signs
▪️ Persistent or recurrent pain
▪️ Gingival swelling or abscess formation
▪️ Increased tooth mobility
▪️ Sensitivity to percussion

➤ Radiographic Signs
▪️ Furcation radiolucency
▪️ Internal or external root resorption
▪️ Widening of the periodontal ligament
▪️ Periapical pathology
Radiographic follow-up is essential, as some failures remain asymptomatic in early stages.

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💬 Discussion
Recent evidence confirms that pulpotomy success is highly dependent on accurate diagnosis, strict asepsis, and durable coronal restoration. Systematic reviews demonstrate that failures are more commonly linked to diagnostic errors and restorative leakage than to the pulpotomy medicament itself.
Modern bioactive materials have improved outcomes; however, they do not compensate for poor case selection or inadequate isolation. Therefore, pulpotomy should be considered a biologically sensitive procedure, not merely a mechanical intervention.

✅ How to Prevent Pulpotomy Failure

Evidence-Based Preventive Strategies
▪️ Strict adherence to case selection criteria
▪️ Achieve complete hemostasis within a few minutes
▪️ Use rubber dam isolation whenever possible
▪️ Ensure hermetic coronal sealing
▪️ Prefer full-coverage restorations in posterior primary teeth
▪️ Schedule regular clinical and radiographic follow-up
Prevention begins before the bur touches the tooth.

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✍️ Conclusion
Pulpotomy failure in primary teeth is largely preventable when evidence-based protocols are followed. Proper diagnosis, meticulous technique, and durable restoration are far more influential than the choice of medicament alone. Early recognition of failure signs allows timely intervention, preserving function and preventing infection-related complications in pediatric patients.

📊 Comparative Table: Key Factors Influencing Pulpotomy Outcomes

Aspect	Advantages	Limitations
Proper case selection	Improves long-term success and pulp healing	Requires accurate clinical judgment
Effective coronal seal	Prevents bacterial microleakage	Dependent on restoration quality
Full-coverage restoration	Enhances durability and tooth survival	Higher cost and chair time
Regular follow-up	Allows early detection of failure	Relies on patient compliance

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 45(6), 380–392.
✔ Coll, J. A., Seale, N. S., Vargas, K., Marghalani, A. A., Al Shamali, S., & Graham, L. (2017). Primary tooth vital pulp therapy: A systematic review and meta-analysis. Pediatric Dentistry, 39(1), 16–23.
✔ Holan, G., & Fuks, A. B. (2013). A comparison of pulpotomy using ferric sulfate and mineral trioxide aggregate in primary molars. Pediatric Dentistry, 35(1), 13–18.
✔ Peng, L., Ye, L., Tan, H., & Zhou, X. (2007). Evaluation of the formocresol versus mineral trioxide aggregate primary molar pulpotomy: A meta-analysis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 103(6), e40–e44. https://doi.org/10.1016/j.tripleo.2007.01.008

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