Pulpotomy vs. Pulpectomy: What’s the Difference and When to Choose Each?

Managing root canal treatments in children’s teeth is an art and a science all its own. Many of us dentists, especially when we’re just starting out, often find ourselves pondering over a primary tooth with deep decay: Should I perform a Pulpotomy or a Pulpectomy? This question isn’t just about picking between two techniques; it’s a critical decision that determines the tooth’s fate, the child’s comfort, and ultimately, your reputation as a skilled practitioner.

Confusing these two procedures is incredibly common, and making the wrong choice can sadly lead to treatment failure, abscess formation, and in the end, the premature extraction of the tooth.

In this article, we’re going to set the record straight. We’ll explain, simply and without unnecessary jargon, the fundamental differences between them. You’ll learn how to accurately diagnose and understand exactly what a specific tooth needs. We’ll even walk you through the step-by-step technique for each procedure.

1. Untangling the Procedures: Pulpotomy vs. Pulpectomy

Before diving into anything else, it’s essential to grasp the core distinction. Imagine the tooth’s pulp as a tree, complete with a crown and roots.

The Pulpotomy (Coronal Pulp Amputation)

Here, we’re essentially “pruning” the tree. We meticulously remove only the upper portion of the pulp tissue found in the coronal pulp chamber, intentionally leaving the pulp within the root canals completely vital and healthy.

When Do We Do It? We typically perform pulpotomies on primary teeth when the inflammation is still in its very early stages, confined solely to the coronal portion (Reversible Pulpitis), or when the decay is quite deep and very close to the nerve, but without full-blown infection yet.

The Goal: Our aim is to preserve the vitality of the remaining pulp in the roots so it continues to nourish the tooth, simultaneously preventing the inflammation from progressing further.

The Pulpectomy (Complete Pulp Extirpation)

In this scenario, we’re performing a complete “uprooting” of the tree. We remove the entire pulp tissue, encompassing both the crown and the root portions.

When Do We Do It? Pulpectomies are indicated for both primary and permanent teeth when the inflammation has reached an advanced stage, making it irreversible (Irreversible Pulpitis), or when the pulp has completely died (Necrotic Pulp), or even if the infection has spread, resulting in an abscess.

The Goal: The primary objective here is to thoroughly clean all canals of infection and bacteria, alleviate pain, and ultimately save the tooth from extraction.

2. The Moment of Truth: How to Make the Right Choice

This is perhaps the most critical question. Once I’ve opened the cavity, how do I definitively know whether I need to perform a pulpotomy or a pulpectomy? Diagnosis in children can be tricky because kids often struggle to accurately describe their pain.

The Decisive Clinical Test (The Hemorrhage Control Test):

After you’ve carefully removed all decay, completed the deroofing of the pulp chamber, and used a sterile excavator to meticulously remove the coronal pulp, you’ll perform a very simple yet crucial test. This test is the ultimate deciding factor:

• Take a sterile cotton pellet, gently moistened with sterile saline.

• Place it inside the pulp chamber and apply light, continuous pressure for about one to two minutes.

• Remove the cotton pellet and carefully observe the orifices of the canals.

Scenario One: Bleeding Has Stopped (Hemostasis achieved), and the blood emerging is bright red and appears normal.
The Decision: Congratulations, the pulp in the roots is healthy and in good condition. You can confidently proceed with a pulpotomy.

Scenario Two: Bleeding Has NOT Stopped (Uncontrolled Hemorrhage), and the blood continues to flow profusely, or its color is dark and congested.
The Decision: Unfortunately, the inflammation and infection have reached the roots. In this case, you absolutely must perform a pulpectomy and thoroughly clean all the canals (1).

3. Step-by-Step Pulpotomy in Children’s Teeth

So, you’ve decided on a pulpotomy? Excellent! Now, just follow these steps sequentially:

1. Caries Removal & Cavity Preparation: Meticulously remove all decay. Ensure complete deroofing to provide clear visibility of the entire pulp chamber.

2. Beware of the Furcation: While working, be extremely cautious that your bur does not cause a perforation in the furcation area. Should this occur, unfortunately, the tooth will most likely require extraction.

3. Saline Irrigation: Perform thorough irrigation using sterile saline solution to clean the area.

4. Coronal Pulp Removal: Use a sharp, sterile excavator (different from the one used for caries removal). Try to remove the coronal pulp tissue in one piece if possible.

5. Hemorrhage Control: Perform the hemorrhage control test we discussed earlier.

6. Pulp Fixation: Once bleeding has ceased, take a cotton pellet dampened (not saturated) with Formocresol. Place it inside the pulp chamber for precisely 5 minutes, then remove it. The purpose here is to fixate the remaining vital tissue within the canals (2). (Note: Newer materials like MTA offer excellent results but are typically more expensive.)

7. Pulp Chamber Filling:

   • Prepare a thick mix of ZOE (Zinc Oxide Eugenol), similar to Zonale.

   • Place it inside the pulp chamber and gently press it with a saline-moistened cotton pellet to ensure it flows well into the orifices.

   • Complete the rest of the restoration with Glass Ionomer.

It’s always best practice, and indeed the more robust option, to place a Stainless Steel Crown (SSC) after a pulpotomy. This ensures a complete seal and protects the tooth from fracture.

Important Note: Pulpotomies are generally not suitable for anterior teeth, as they lack a distinct pulp chamber like their posterior counterparts.

4. Step-by-Step Pulpectomy in Children’s Teeth

If the bleeding proved uncontrollable, our decision is a pulpectomy.

1. Working Length Determination: Utilize radiographs to precisely determine the length of the canals. For primary teeth, we typically work 1-2 mm short of the radiographic apex to avoid any potential damage to the developing permanent tooth bud underneath.

2. Complete Pulp Removal: Remove all pulp tissue from both the crown and roots.

3. Cleaning and Shaping the Canals:

   • Canal Irrigation: Use a diluted 1% Sodium Hypochlorite solution with extreme caution for irrigation.

   • Canal Instrumentation:

     • If using hand files, enlarge the canals to a size 35 for narrower canals (like the mesial canals in lower molars) and up to a size 40 for wider canals (like the distal canal).

     • If using rotary files, you might only need an orifice opener and can gently advance it to the determined working length.

4. Canal Obturation:

   • Thoroughly dry the canals using paper points.

   • Inject a resorbable material, such as Metapex. It is crucial for the material to be resorbable so it doesn’t impede the natural physiological resorption of the primary tooth root.

   • After obturation, place a final restoration and a Stainless Steel Crown (SSC), similar to the pulpotomy procedure.

Additional, Crucial Pulpectomy Pointers:

Radiographic Resorption:

• If radiographs indicate physiological resorption of the root, you can proceed with a pulpectomy as planned.

• However, if radiographs show pathological resorption (due to infection), then extraction of the tooth becomes necessary.

Number of Sessions:

• If you’re performing a pulpectomy on a vital tooth, you can typically complete it in a single session.

• If the tooth presents with an abscess, it’s always best to first establish drainage, prescribe an antibiotic, and then complete the pulpectomy in a subsequent visit.

Conclusion

The choice between a pulpotomy and a pulpectomy is far from arbitrary. It’s a decision meticulously based on an accurate diagnosis of the pulp’s condition. The simplest and most precise diagnostic method often presents itself once you open the tooth and visually assess the nature and control of the hemorrhage. By systematically adhering to these steps, you’ll be empowered to make the correct decision, effectively save the child’s tooth, and earn the lasting trust of their parents.