Article published online: 2021-11-01

REVIEW ARTICLE

Pulpectomy procedures in primary molar teeth

Hany Mohamed Aly Ahmed Address for correspondence:

Dr. Hany Mohamed Aly Ahmed,
Department of Restorative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kubang Department of Restorative Dentistry,
Kerian, 16150, Kelantan, Malaysia School of Dental Sciences,
Universiti Sains Malaysia, Kubang
Kerian, 16150, Kelantan, Malaysia.
E‑mail: hany_endodontist@hotmail.com

ABSTRACT
Premature loss of primary molars can cause a number of undesirable consequences including loss of arch length, insufficient
space for erupting premolars and mesial tipping of the permanent molars. Pulpectomy of primary molar teeth is considered as
a reasonable treatment approach to ensure either normal shedding or a long‑term survival in instances of retention. Despite
being a more conservative treatment option than extraction, efficient pulpectomy of bizarre and tortuous root canals encased in
roots programmed for physiologic resorption that show close proximity to developing permanent tooth buds presents a critical
endodontic challenge. This article aims to provide an overview of this treatment approach, including partial and total pulpectomy,
in primary molar teeth. In addition, the recommended guidelines that should be followed, and the current updates that have been
developed, while commencing total pulpectomy in primary molars are discussed.
Key words
Deciduous molars, partial pulpectomy, primary molars, total pulpectomy

INTRODUCTION can result in loss of arch length, insufficient space for

erupting permanent teeth, impaction of premolars, and
The main objective of pulp therapy in the primary mesial tipping of molar teeth adjacent to the lost primary
dentition is to retain every primary tooth as a fully molar.[1,3] In addition, pulpectomy is advantageous for
functional component in the dental arch to allow for retained primary molar teeth.[4,5] If not severed with
proper mastication, phonation, swallowing, preservation a progressive root resorption or aligned in a severe
of the space required for eruption of permanent teeth infra‑occlusion, the retained molar can be a functional
and prevention of detrimental psychological effects component in the dental arch for many years[6‑8] [Figure 1].
due to tooth loss.[1,2] To fulfill this major goal, vital pulp In several instances, an occlusal modification through
therapy through pulpotomy, which refers to surgical direct or indirect restoration is ensured for normal
removal of the entire coronal inflamed pulp leaving the alignment or it can be included as an abutment in a
vital radicular pulp intact within the canals, is the most fixed bridge.[9] If this long‑term survival method is not
widely accepted technique for treating primary teeth with applicable, retaining primary molars until the patient
irreversible inflammation affecting the pulp chamber. becomes sufficiently mature (17‑21 years old) for
However, in cases of irreversibly inflamed and necrotic complete facial growth is one alternative. This technique
radicular canals, a successful pulpotomy cannot be preserves a sufficient alveolar ridge width and height
achieved, and a partial or total pulpectomy is indicated.[1] for future implant treatment (if required).[10] Primary
molars can also be included in an interdisciplinary
Pulpectomy is a conservative treatment approach to treatment approach, either by reducing the mesiodistal
width of the crown or hemisection for orthodontic space
preventing the premature loss of primary teeth that
management.[10,11]

Access this article online Thus, an appropriate pulpectomy of primary molars

Quick Response Code: rather than extraction is a reasonable treatment option to
Website:
www.ejgd.org
ensure either normal shedding/eruption of the successor
or a long‑term survival in instances of retention.[12] As
such, this article provides an overview of this treatment
DOI: approach, including partial and total pulpectomy, in
10.4103/2278-9626.126201 primary molar teeth. In addition, the recommended
guidelines that should be followed, and the current

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 Ahmed: Pulpectomy procedures in primary molar teeth

updates that have been developed, while commencing In a recent randomized clinical study, Ruby et  al.[15]
total pulpectomy in primary molars are discussed. demonstrated a comparable clinical and radiographic
success rate of pulpotomy using 3% NaOCl to
formocresol (Buckley’s FC dilution 1:5) at 6 and 12 months.
PULPECTOMY PROCEDURES IN PRIMARY These favorable clinical outcomes for NaOCl pulpotomy
MOLARS encourage other long‑term clinical studies to investigate
the ability of NaOCl to serve as a viable substitute to
Partial pulpectomy formocresol in both pulpotomy and partial pulpectomy.
Decades ago, “pulpotomy” and “partial pulpectomy”
were used interchangeably to refer to the excision
or amputation of the pulp contents in the coronal Partial/total pulpectomy
portion of the pulp (pulp chamber) without disturbing Internal root resorption visible on radiographs and
the contents of the root canal.[13] At present, “partial excessive external pathologic root resorption involving
pulpectomy” is widely used to refer to “an apical more than one‑third of the root are usually reported
extension of the pulpotomy procedure” in which the as contraindications for total pulpectomy in primary
coronal portion of the radicular pulp is amputated, teeth[1,2,16] [Figure 2]. However, in deciduous molars far
leaving vital tissue in the canal that is assumed to be from their shedding time, partial/total pulpectomy can
healthy.[1] The decision to implement partial pulpectomy be an alternative approach instead of extraction when a
in primary molars is made after removing the coronal pathologic root resorption affects only one of the molar
pulp and encountering difficulty with hemorrhage roots and the other root remains intact [Figure 3]. In
control from the radicular orifice. [1] Teeth can be such cases, the affected root can be treated by partial
scheduled for partial pulpectomy regardless of history pulpectomy up to the level of resorption, and the intact
of pain; however, the canals should not show evidence root is treated normally via total pulpectomy. A well
of necrosis or suppuration.[14] prepared coronal restoration is particularly important
to achieve favorable outcomes [Figure 3].
Endodontic broaches or Hedström files are the most
commonly used instruments in partial pulpectomy.[1,14] Total pulpectomy
One‑third to one‑half of the coronal portion of the Total pulpectomy versus non‑vital pulpotomy
radicular pulp tissue is removed from the canal(s). The Different treatment approaches for non‑vital/irreversibly
canals and chamber are irrigated using diluted NaOCl inflamed pulps, rather than pulpectomy, have been
and then dried with cotton pellets.[1] If hemorrhage cannot examined. Non‑vital pulpotomy using zinc oxide
be controlled, the remaining radicular pulp tissue is eugenol (ZOE)–formocresol paste was attempted, with a
removed and a complete pulpectomy is indicated. After a success rate of 84.8%.[17] This result was contradicted by
successful hemorrhage control, a cotton pellet dampened Hill,[18] who observed that both the presence of a non‑vital
with formocresol is squeezed dry and then it is placed in pulp and radiolucency are associated with a significantly
the pulp chamber for 1‑5 mins. The pellet is removed, reduced survival following pulpotomy of primary molars
and the root filling paste is packed into the chamber compared with vital teeth with no evidence of extensive
and canals.[1] The quality of filling is evaluated using a pulpal disease. Thus, the persistence of necrotic pulp
periapical radiograph. tissue and microbial irritants, together with the toxicity
potential of formocresol which should be used with great
caution,[19,20] can impair long‑term healing.

a b
Figure 1: Retained right primary mandibular second molar in a 45‑year‑old Figure 2: Contra‑indications for total pulpectomy. (a) Badly decayed primary
male patient. External resorption of the distal root is the fate of chronic molar. (b) Extensive root resorption (white arrow: Internal resorption, yellow
periodontitis arrow: External resorption)

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 Ahmed: Pulpectomy procedures in primary molar teeth

Sterilization and tissue repair therapy or non‑ or necrotic pulp tissue in the canals, followed by filling
instrumentation endodontic therapy using a mixture using a resorbable paste in either single or double
of antibacterial drugs (metronidazole/ciprofloxacin/ appointments.[1,36] Total pulpectomy in primary molars
minocycline) has been advocated as a simple, safe, and has been controversial since the question “Should
cost‑effective substitute for total pulpectomy in the deciduous teeth with non‑vital pulps be treated?” raised
primary dentition. This therapy is especially suitable by Kabnick[37] in 1933. The negative attitude toward
in cases involving uncooperative children and in areas complete pulpectomy in primary molars is mostly
where the socio‑economic status is low and endodontic due to fear of damage on the developing permanent
treatment is not a valid treatment option.[21‑24] However, tooth buds, as well as the difficulty in negotiating,
in a recent long‑term clinical study, Trairatvorakul and cleaning, shaping, and filling the bizarre and tortuous
Detsomboonrat[25] reported only a 36.7% success based canal anatomy of these teeth with resorbing and open
on radiographic evaluation, and 15.8% of the cases apices.[1,16,38] A number of dental practitioners prefer
demonstrated internal root resorption despite the 75% extraction of deciduous teeth having necrotic pulps
clinical success. With these results considered, this with or without periapical affection and placement
treatment approach demonstrates an unsatisfactory of space maintainers because of these anatomical
success rate. As reported by the UK National Clinical challenges.[16] However, no better space maintainer
Guidelines for pulp treatment in the primary dentition, can substitute the primary tooth, and the success
“it would not be biologically acceptable to leave necrotic rate of pulpectomy in primary teeth has been reported
tissue in a root canal,” [26] especially with the wide between 80% and 100%,[39‑41] thus, every primary molar
bacterial diversity and microbial interactions identified is worth saving.
in primary teeth having necrotic pulp with or without
periapical pathosis.[27‑29]
GUIDELINES FOR PULPECTOMY
By the given information, the unpredictable outcomes
PROCEDURES
of non‑vital pulpotomy and the high failure rate of early
Pre‑operative assessment
extraction followed by space maintainers due to solder
Dental practitioners should be aware of:
breakage, cement loss, bond failure, soft‑tissue lesions,
1. The root and root canal morphology of deciduous
plaque accumulation, decalcification, or decay of the
molars shows wide anatomical variations, either in
abutment,[30‑35] no viable substitute for total pulpectomy
number or in shape.[12,42] Double rooted maxillary
for treating non‑vital pulps is currently available.
molars can be rather common[12] [Figure 5a], and
primary molars with five and six root canals have
Challenges been reported[12] [Figure 6]. The occasion of this
Total pulpectomy of primary teeth is recommended aberrant internal anatomy might be attributed to
when the criteria for a classical pulpotomy or partial secondary dentine formation and physiologic root
pulpectomy cannot be met [Figure 4]. This procedure resorption which are able to reconfigure the root
refers to the complete removal of irreversibly inflamed canal system.[12]
2. The complex pulp and periodontal tissues

a b

a b
Figure 3: Partial/Total pulpectomy. (a) Total pulpectomy of the mesial root
and partial pulpectomy of the distal root of primary 1st mandibular molar c d
having radiolucencies in the periapical (white arrows) and bifurcation (blue Figure 4: Indications for total pulpectomy in primary molars. (a) Non‑vital
arrow) areas. A vertical bone loss also was observed in the distal aspect of pulp of a primary molar with a successor. (b) Failed pulpotomy/partial
the distal root (yellow arrow). ZnO eugenol paste was used as a root canal pulpectomy. (c) Retained primary molar with vital/non vital pulp; (c)
filling. (b) Follow‑up after 8 months shows favorable healing Retreatment of a retained primary molar

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 Ahmed: Pulpectomy procedures in primary molar teeth

inter‑relationship in primary molars may result in Intra‑operative management

the occasion of bone radiolucency anywhere along Root canal preparation
the root or in the furcation area.[12,43] As recommended by the American Academy of Pediatric
3. Following the recommended guidelines for accurate Dentistry,[47] and the UK National Clinical Guidelines for
pulp assessment is essential. Recent studies pulp treatment in the primary dentition,[26] the application
demonstrated the potential application of different of the rubber dam,[26,47] or equally effective isolation
technique,[47] is mandatory.
diagnostic tools such as electric pulp testers,[12,44]
pulse‑oximeters,[45,46] and laser Doppler flow meters[45]
Adequate extension of the access cavity and thorough
for pulp assessment in primary teeth. exploration between the root canal orifices is
essential [Figure 5b]. Utilizing some sort of magnification
is useful.[12] Accurate determination of the working length
is a crucial step prior to pulpectomy in primary molars.
Due to limitations of radiographic interpretation and
high possibility of over‑instrumentation of the unevenly
resorbed roots and subsequent overfilling, the application
of electronic apex locators is recommended regardless of
the stage of root resorption.[12]

During chemo‑mechanical preparation, stainless steel

a b hand files, usually not larger than size 30,[26] should
be used carefully to prevent the occasion of broken
Figure 5: (a) A photograph of a double‑rooted maxillary primary
molar. (b) Cautious apical extension via a small tapered diamond bur (or segments. Flexible files are recommended in curved
a small ultrasonic tip) in the groove between the orifices of the fused and S shaped canals. Rotary NiTi files can significantly
distobuccal and palatal roots is recommended to exclude the occurrence reduce the instrumentation time of the root canals,[12]
of a third canal in the isthmus and the application of this innovation becomes

a b

c d e
Figure 6: (a) Mandibular first primary molar having bizarre and tortuous canals in the mesial root. (b) Mandibular second primary molar having five canals.
Three in the mesial and two in the distal root. (c‑e) Extracted mandibular primary molar having five canals. The distal root encases three separate canals (MD:
Middle distal)

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 Ahmed: Pulpectomy procedures in primary molar teeth

more popular.[48] Apart from the high cost, Ahmed[12] reported since 1930.[50,52,53] The disadvantages include
mentioned some concerns regarding the application of the difference in rate of resorption compared with that of
this innovation in paediatric endodontics that requires the root,[36,54] risk of deflection of the erupting successor
further investigations. Likewise, dental practitioners/ teeth especially in an overfill,[52] and concerns regarding
paedodontists should carefully choose irrigating its antimicrobial activity, which may become limited
solutions due to possible chemical interactions among once set.[55,56] To improve the anti‑microbial properties of
different irrigants[12,49] [Figure 7]. Intermediate solutions ZOE paste, additives such as formocresol, formaldehyde,
such as saline or sterile distilled water, followed by paraformaldehyde and chlorhexidine dihydrochloride
careful drying, can prevent the formation of toxic have been recommended;[50,57,58] however, concerns arise
interactions[12,49] [Figure 7]. regarding the cytotoxic effects of formocresol, especially if
the filling is introduced inadvertently into the periapical
Root canal filling area closely related to the erupting successor tooth.
Exfoliating primary molars
Unreinforced ZOE paste is the first and most widely Calcium hydroxide paste is one of the most widely
accepted root canal filling for primary teeth. [36,50,51] used intra‑canal medicaments in endodontic therapy.
Moderate to high success rates (over 90%) have been However, its use as a filling material in pulpotomy for

a b

c d

e f

h
Figure 7: Combination of irrigants advocated for the primary dentition. (a) 2.5% NaOCl + 2% CHX. (b) 1.5% NaOCl + 2% CHX. (c) 0.5% NaOCl + 2% CHX.
(d) 0.5% NaOCl + 1% CHX. (e) 1.5% NaOCl + 6% citric acid (CA). (f) 18% EDTA + 1% CHX. (g and h) Intermediate irrigants between NaOCl and CHX blocked
the formation of the brown precipitate, but the combinations turn cloudy

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 Ahmed: Pulpectomy procedures in primary molar teeth

primary dentition was challenged because it can induce the age of 20 indicates a high probability for long‑term
internal root resorption,[59] which may also limit its survival[7,77,78] [Figure 1].
indication as a root canal filling in partial pulpectomy.
Despite this concern, studies continue to support the Likewise, no definitive landmarks for the survival of
use of calcium hydroxide pastes as filling material for retained primary molars without root resorption are
totally pulpectomized primary teeth because of potent known. The literature continues to support the use of
anti‑bacterial effects and it can be easily resorbed.[60‑63] non‑resorbable gutta‑percha as root canal filling for such
retained primary molars.[2,11,16,54,79,80] For patients below
Iodoform‑based pastes, such as KRI paste, were also 20 years of age, the follow‑up appointment should be
recommended as root filling materials in primary scheduled regularly at 3‑6 months. Removal of the root
molars.[64] These pastes satisfy most of the requirements canal filling and the application of calcium hydroxide
of an ideal filling material for primary teeth because can be attempted if apparent signs of resorption occur.
they are easily resorbed from the periapical area and In case of severe resorption, tooth extraction and
possess potent germicidal properties.[65] Chlorhexidine gutta‑percha removal, if retained in the socket, are the
digluconate is suggested as an additive to iodoform‑based last resort.
pastes instead of camphorated parachlorophenol to
obtain a favorable biological profile while maintaining a O’Sullivan and Hartwell [81] reported the short‑term
potent anti‑microbial activity.[66] success following the use of ProRoot mineral trioxide
aggregate (MTA) (Dentsply, USA) as a root filling material
Vitapex  (Neo Dental Chemical Products Co., Ltd., in a retained primary second molar of a 20‑year‑old
Tokyo, Japan), a combination of calcium hydroxide patient. However, MTA is not widely advocated for
and iodoform, is another alternative that can be such clinical application, probably because of the high
applied easily. This material showed a favorable rate cost of the material and difficulty in application into
of resorption, reduced void formation and satisfactory relatively narrow root canals. Moreover, it seems that
radiographic and clinical outcomes.[23,53,65,67‑70] Similar the application of MTA would not reduce the high risk of
observations were reported with Metapex (Metapex, Meta root resorption in retained molars of younger patients.[82]
Dental, New  York, USA).[71] However, this combination
did not exhibit a potent anti‑microbial activity,[57,72‑74]
which may be due to the strong inhibitory effect of
Post‑endodontic considerations
Following filling and resolution of all symptoms (if any), the
dentine.[75] Endoflas F.S.  (Sanlor and Cia. S. en C.S.,
tooth should be restored with a suitable coronal restoration
Columbia, South America) is another iodoform‑based
to prevent micro‑leakage. The floor of the pulp chamber can
paste containing calcium hydroxide, which also showed
be filled with either reinforced ZOE or glass ionomer cement
high clinical success rates.[41]
if the coronal part is to be restored with resin composite.[1]
A stainless steel crown is the treatment of choice for badly
Overfill is a common clinical finding in the primary
decayed primary teeth; this approach requires careful
dentition, especially when apical resorption and/
plaque control to maintain the health of the gingiva and
or the paste is applied through a pressure syringe.
inter‑proximal bone.[40,83] Pre‑veneered crown, a stainless
Johnson et al.[76] examined the use of a 2 mm × 2 mm
steel crown with mechanically or chemically bonded
collagen sponge (Collacote, Zimmer Dental, Texas, USA)
aesthetic material covering one or more surfaces of the
as an apical barrier per canal. The results showed that the
crown, can also be fabricated if the patient can maintain
presence of a biological barrier significantly decreased,
but not completely prevented, the risk of overfilling when good oral hygiene.[84] However, if the pulpectomized tooth
pulpectomies were performed in primary molars. has a sufficient crown structure and only one surface is
missing for less than 2 years before exfoliation, amalgam
or resin composite are the materials of choice.[85]
Retained primary molars
The physiologic root resorption of primary dentition is
initiated and coordinated by the dental follicle of the CONCLUSIONS
permanent tooth germ.[77] This programmed resorption
may proceed even without the permanent successor. Partial, partial/total and total pulpectomy procedures
The reason may be that periodontal ligament cells in the provide reasonable treatment options for primary molars
primary dentition more strongly respond to inflammatory having radicular canals with partial/total irreversibly
mediators and undergo resorption compared with those inflamed or necrotic pulp. Adequate knowledge on the
in the permanent dentition.[77] In addition, after the root anatomical variations and absolute awareness of the
growth of the facial and masticatory muscles, these radiographic limitations, instrumentation procedures,
periodontal tissues may not withstand applied forces, chemical interactions among different endodontic
which can induce resorption. No certain predictors for irrigants and root canal filling techniques are essential
the survival of a deciduous tooth without a successor are prior to commencing pulpectomy procedures in
known; however, a primary molar that is retained until exfoliating or retained primary molars.

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 Ahmed: Pulpectomy procedures in primary molar teeth

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Source of Support: Nil, Conflict of Interest: None declared.
Cytotoxicity, histopathological, microbiological and clinical aspects

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