Pulpectomy is a vital pulp therapy procedure performed in primary teeth when inflammation or necrosis extends beyond the coronal pulp into the radicular pulp. Unlike pulpotomy, which preserves radicular pulp, pulpectomy involves complete removal of pulp tissue from both the crown and the roots, followed by canal obturation.

This guide explains how to diagnose cases requiring pulpectomy, how to determine working length, perform mechanical preparation, irrigate properly, and choose the best obturation materials for long-term success.

read this guide about pulpotomy

Indications of Pulpectomy

Before deciding on pulpectomy, proper history taking, clinical examination, and radiographic assessment are essential.

1. History

• Persistent pain indicates widespread pulp inflammation extending into radicular pulp (irreversible pulpitis).
• Throbbing, constant nocturnal pain suggests progressive pulp degeneration requiring pulpectomy.

2. Clinical Examination

• Pain on percussion: Indicates inflamed periodontal ligaments. If confirmed radiographically (no physiological resorption), pulpectomy is indicated.
• Swelling or sinus tract: Suggests non-vital tooth. Radiographs help confirm presence/absence of root resorption before proceeding.
• Mobility: Could be due to normal exfoliation or pathology. Radiographs help differentiate.

  Preoperative Assessment before pulpectomy

3. Radiographic Examination

• Confirms diagnosis by showing periodontal ligament widening, periapical/furcal radiolucency, or internal/external root resorption.
• Identifies the relationship between permanent tooth bud and primary roots.
• Sometimes reveals hopeless prognosis, shifting the plan to extraction instead of pulpectomy.

👉 Pre-operative radiographs are mandatory before starting pulp therapy.

Pulpotomy vs. Pulpectomy Decision-Making

If the coronal pulp is removed during access and hemostasis is achieved, a pulpotomy can be completed.
If bleeding persists after complete removal of coronal pulp, or if the pulp is necrotic, pulpectomy is indicated.

Determining Working Length in Primary Teeth

Accurate working length (WL) is crucial in pulpectomy. Four common methods exist:

1. Tactile sensation – Not recommended; risks over-instrumentation and damage to permanent tooth buds.
2. Average root length – Inaccurate since roots vary between teeth.
3. Pre-operative radiograph – Measure the file length against the film (not digital sensor), then subtract 1–2 mm to avoid over-instrumentation.
4. Apex locator – Most accurate. Set at “0.0” and subtract 0.5 mm to avoid violation of the apex.

Mechanical Preparation

• Start with a small file (#10) to establish patency.
• Use K-files or H-files for cleaning.

• K-files can be used with a quarter-turn pull motion.
• H-files can be used with a filing motion for better efficiency.
• Do not aggressively enlarge canals—cleaning is more important than shaping in primary teeth due to thin dentin walls.
• Rotary files designed for pediatric cases can be used at 150 rpm and 0.8 torque with brushing motion.

👉 Canal size varies: mesial canals of lower molars may end around #30, palatal/distal canals around #35, and central incisors up to #40.

Irrigation Protocol

• Irrigate between each file with:
• Saline (safe option), or
• Sodium hypochlorite (NaOCl) (gold standard with higher success rates).

Sodium Hypochlorite Precautions

1. Always use rubber dam isolation if possible.
2. If not, use high suction throughout irrigation.
3. Use a side-vented needle, kept 2–3 mm short of WL.
4. Move the needle gently up and down to prevent extrusion.

Obturation Materials in Primary Teeth

Two common materials are used:

1. Zinc Oxide Eugenol (ZOE)

• Slowly resorbs, sometimes more slowly than the root itself → may interfere with permanent tooth eruption.
• Recommended in younger children with long exfoliation periods.

2. Calcium Hydroxide + Iodoform Paste (Metapex / Metapex Plus)

• Resorbs faster than roots, sometimes leaving empty canals prematurely.
• Preferred in older children, closer to permanent tooth eruption.
• Metapex Plus has better flowability than standard Metapex.

Final Restoration

The coronal seal is the most critical factor for pulpectomy success. Options include:

• Stainless Steel Crown (SSC):

• Fill cavity with ZOE as sub-base.
• Cement crown with glass ionomer.

• Composite Restoration:

• ZOE base → Glass ionomer layer → Composite.

• Amalgam Restoration:

• ZOE base → Zinc polycarboxylate layer → Amalgam.

Single vs. Multiple Visit Pulpectomy

• Single-visit pulpectomy: Possible in cases of irreversible pulpitis with controlled bleeding and dryness of canals.
• Multiple visits: Indicated in acute abscesses or persistent exudation. Intracanal medicaments may be placed until canals are dry.

Pulpectomy is an essential pediatric endodontic procedure that preserves primary teeth until natural exfoliation, preventing space loss and maintaining function. Success depends on:

• Accurate diagnosis and case selection.
• Careful working length determination.
• Thorough cleaning with conservative instrumentation.
• Proper irrigation and obturation material choice.
• Above all, a good coronal seal.

  A stainless steel crown (SSC) after pulpectomy

By mastering pulpectomy alongside pulpotomy, dentists can effectively manage most pulp therapy cases in primary teeth.