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Preserving primary teeth has always been about more than simply keeping a tooth in place. From maintaining arch integrity and masticatory function to supporting aesthetics and a child’s emotional well-being, the value of primary teeth is well established—especially in the context of the growing global burden of dental caries highlighted by the World Health Organization.
As caries progress toward the pulp, children may present with either reversible or irreversible pulpitis. Traditionally, irreversible pulpitis in primary teeth has been viewed as a point of no return, with pulpectomy considered the treatment of choice. However, recent advances in pulp biology and biomaterials are now challenging this long-held assumption.
Lessons from permanent teeth are reshaping pulp therapy
In permanent dentition, the management of irreversible pulpitis has undergone a major paradigm shift. Position statements from bodies such as the American Association of Endodontists and the European Society of Endodontology have emphasized that a clinical diagnosis of irreversible pulpitis does not automatically mandate pulpectomy.
This change has been driven by growing evidence that the pulp possesses robust defence and healing mechanisms, including immune modulation, stem cell recruitment, and reparative dentin formation. Histological studies have further shown that even teeth diagnosed clinically with irreversible pulpitis often contain areas of healthy, vital pulp capable of healing once the infected coronal tissue is removed.
As a result, pulpotomy has increasingly been accepted as a definitive treatment in mature permanent teeth, particularly when performed using modern bioactive materials.
Why primary teeth deserve a second look
Despite these advances, clinical guidelines for primary teeth have remained conservative. Pulpotomy is generally recommended only for reversible pulpitis or mechanical and carious exposures without confirmed pulpal inflammation. The prevailing concern has been that primary pulps exhibit a more diffuse inflammatory response, reducing their capacity for recovery.
However, emerging biological evidence suggests otherwise. Studies demonstrate that primary and permanent pulps share similar vascular, neural, and immune characteristics. Although primary pulps may contain a higher density of immune cells, their fundamental healing mechanisms closely resemble those of permanent teeth.
From a clinical standpoint, pulpotomy also offers practical advantages in children—it is less invasive, quicker to perform, better tolerated behaviorally, and preserves radicular pulp vitality and proprioception. When calcium silicate–based materials are used, healing outcomes have been increasingly predictable.
Against this backdrop, a recent systematic review and meta-analysis sought to directly compare pulpotomy and pulpectomy in primary teeth diagnosed with irreversible pulpitis. Conducted in accordance with PRISMA 2020 guidelines and registered with PROSPERO, the review aimed to address a critical gap in pediatric endodontic evidence.
After screening more than 4,800 records, only a small number of studies met the strict inclusion criteria, underscoring how limited high-quality comparative data still is in this area.
Meta-analysis of the included studies revealed no significant difference in clinical or radiographic success between calcium silicate cement pulpotomy and pulpectomy in primary teeth with irreversible pulpitis over a follow-up period of up to 12 months.
Importantly, most treated teeth did not exhibit clinical swelling or radiographic signs of periapical infection at baseline. This suggests that case selection plays a critical role in treatment success, regardless of the chosen modality.
The findings do not suggest that pulpotomy should universally replace pulpectomy in symptomatic primary teeth. Instead, they highlight that pulpotomy may be a viable, minimally invasive alternative in carefully selected cases, particularly when modern bioactive materials are used and when signs of advanced periapical pathology are absent.
At the same time, the review emphasizes the need for longer-term follow-up studies and more robust randomized trials before definitive changes to clinical guidelines can be justified.
