Factors Affecting Success and Failure of Pulpectomy in Primary Teeth: A Systematic Review

Abstract

Aims and background

A pulpectomy in primary teeth is considered successful when there are no clinical symptoms or radiographic evidence of pathology. Outcomes vary due to multiple influencing factors, and comprehensive long-term evidence remains limited. This systematic review evaluates pulpectomy success over long-term follow-ups and identifies risk factors for failure.

Methods

An electronic database search was conducted in PubMed, EBSCOhost, Scopus, and Cochrane from January, 1990 to December 30, 2024. Different keywords were employed in various combinations during the search process to find all possible articles focused on our subject. The Cochrane risk of bias tool (ROB 2.0) was employed for evaluating randomized controlled trials, whereas observational studies were assessed using the ROBINS-I tool.

Results

A total of 360 articles were reviewed, and only 12 satisfied the inclusion requirements. The success rate of pulpectomy ranged between 38.5% and 96.2% over 5 years. The minimum amount of preoperative root resorption and adequate length of root canal filling material are the common factors associated with the success of pulpectomy. Zinc oxide eugenol (ZOE) and Endoflas success rate were 90% and 71% or less for iodoform after 18 months of evaluation.

Conclusion

Factors associated with the success of pulpectomy were an absence of preoperative periapical lesions, minimal preoperative root resorption, adequate root canal filling, and the type of postendodontic restoration. The factors associated with pulpectomy failure were the presence of a periapical lesion, preoperative swelling, fistula, pulpectomy performed in trauma cases, and inadequate quality of the root filling. Age, gender, tooth position, treatment modality, and number of appointments did not significantly affect pulpectomy.

Clinical significance

This systematic review holds significant clinical value as it enhances treatment predictability, minimizes failures, and supports the preservation of primary teeth, ultimately benefiting pediatric oral health.

How to cite this article

Kendre SB, Bhatane AU, Kale YJ, et al. Factors Affecting Success and Failure of Pulpectomy in Primary Teeth: A Systematic Review. Int J Clin Pediatr Dent 2025;18(12):1530–1540.

Introduction

Involvement of pulp due to caries or trauma in primary teeth leads to irreversible damage, causing degeneration or necrosis. To preserve such a tooth in the oral cavity to maintain function as well as arch integrity, an endodontic procedure like pulpectomy is indicated.¹ Following all the standard procedural protocols, the primary teeth are preserved in the oral cavity. To consider the procedure successful, the absence of signs and symptoms clinically and radiographically is considered as prime criteria.² Several studies and ongoing research have shown that pulpectomy has a better prognosis as a treatment modality. However, conclusive findings are still elusive. Success and failure can be determined by a wide range of possible factors that are inconsistent. The success rate can differ according to the preoperative findings, such as lesion etiology, type of lesion, type of filling materials, and the clinician's expertise. The failure was more likely to occur in patients with greater levels of gingivitis and visible plaque. Additionally, risk variables for failure were identified as the presence or absence of full coronal restoration.

The review on pulp treatment techniques for extensively decayed primary teeth published in Cochrane in 2018 had certain limitations that included both vital and nonvital pulp therapies without a focused analysis on pulpectomy procedures. Additionally, the included evidence was current only up to August, 2017, potentially omitting recent advancements in the area.³ Another systematic review published in 2019 exclusively assessed the success of zinc oxide eugenol (ZOE) and calcium hydroxide-iodoform paste about the quality of obturation for pulpectomy procedures in primary teeth and did not evaluate the factors.⁴

A systematic review published in 2020 on randomized controlled trials assessed success rates for nonvital therapy in primary teeth and compared lesion sterilization and tissue repair (LSTR) with pulpectomy for a 6–12 months follow-up.⁵ This paper, being a short-term evaluation, represents a significant limitation, contrary to more predictable long-term treatment success. Hence, an evident gap was found to exist in the last 4 years regarding substantial comparative papers for such findings.

Despite the widespread use of the pulpectomy procedure, the current evidence exhibits critical gaps, such as insufficient long-term data for emerging materials. The current paper tries to evaluate the literature extensively compared to the previous one for the pulpectomy procedure. This review aims to consolidate fragmented evidence and identify evidence-based protocols to optimize clinical practice concerning the success and failure of the same. The objective of the study is to assess the long-term clinical and radiographic success and potential risk factors contributing to pulpectomy failure, to compare outcomes across different study populations, and materials used in pulpectomy recommendations for improving the success of pulpectomy in clinical practice.

Methods

Protocol and Registration

This systematic review was prepared in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (www.prisma-statement.org) and registered in the PROSPERO database (CRD42024480229). The focused research question addressed was: What are the factors associated with the success and failure of pulpectomy in primary teeth?

Study Design

The following was the PICO-S framework used for this review:

• Population (P): Primary teeth of children between 2 and 9 years.

• Intervention (I): Pulpectomy.

• Comparison (C): Obturating materials, factors associated with the pulpectomy.

• Outcome (O): Clinical and radiographic success and failure.

• Study design (S): Longitudinal research (prospective and retrospective) and randomized controlled clinical trials.

PICO Question

“In primary teeth of children aged 2–9 years (P), how does the choice of obturating material and factors associated influence the clinical and radiographic success and failure of pulpectomy procedure (O)?”

Eligibility Criteria

Inclusion Criteria

• Prospective and retrospective, longitudinal studies, and randomized clinical trials assessing the success and failure of pulpectomy.

• Studies should present a follow-up for a minimum of 1 year.

• Studies published in the period from January, 1990 to December, 2024.

• Studies in the English language.

Exclusion Criteria

• Systematic review, rapid review, literature review, narrative review, and scoping review.

• In vitro studies.

• Studies assessing other parameters, such as postoperative pain and root canal preparation techniques.

• Non-English studies.

• Animal studies.

Search Strategy

The primary search was done by two authors (SBK and AUB). The search strategy combined MeSH (medical subject headings) and free-text keywords aligned with the PICO(S) framework. A systematic computerized search was performed on electronic databases: EBSCOhost, PubMed/MEDLINE, Scopus, and Cochrane Library from January, 1990 to June, 2024. The core keywords syntax was (Pulpectomy) AND (Success) OR (Failure)) OR (Factors)) AND (clinical and radiographic evaluation)) AND (Primary teeth) AND (Survival Rate) OR (Longevity). Additional records were identified through citation tracking of included articles. Gray literature search was conducted in different sources such as clinical trial registries [ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP)], conference abstracts, theses/dissertations, to minimize publication bias by capturing unpublished/null results. Hand searches were undertaken to find additional relevant published material that might have been missed in electronic searches.

Data Extraction

Two reviewers (SBK and AUB) assessed study eligibility to minimize selection bias. Initial disagreements were resolved through consensus discussions, with arbitration by another author (YJK) when necessary to ensure consistent application of inclusion criteria. The publications were chosen based on the inclusion and exclusion criteria. Data was extracted by screening, selection, and tabulation as: Author and publication year, study type, type of specimen, mean follow-up, intervention, evaluation criteria, success rate, and factors evaluated for failure and success.

Quality Assessment

Two investigators (MVD and PTD) evaluated each article included in the present paper for bias using the Cochrane risk of bias tool (ROB 2.0) for randomized controlled trials and the ROBINS-I tool for other longitudinal studies. Selection of the reported results, measurement of the outcome, bias arising from the deviations from intended interventions, and randomization bias are the five domains that ROB 2.0 measures. The seven categories that ROBINS-I evaluates are confounding bias, bias in the selection of participants, bias in intervention classification, bias resulting from deviating from intended interventions, bias resulting from missing data, bias in measurement of outcome, and bias resulting from the selection of reported findings. Both assessments were used to evaluate bias for corresponding studies, and the scores for the ROB 2.0 tool were low, with some concerns, and high; the ratings for the ROBINS-I tool were low, moderate, serious, and critical. Inter-rater reliability was quantified using Fleiss' kappa (κ) statistics, demonstrating near-perfect agreement among reviewers [κ = 0.8, 95% CI (X–Y)].

Data Synthesis Strategy

Qualitative data analysis was conducted because the studies that are included differed in their designs, types of obturating materials, metrics for outcome, and follow-up durations. Meta-analysis of the data was not possible to analyze data quantitatively due to dissimilarities in the included studies.

Results

Study Selection

Four calibrated reviewers (YJK, MVD, PTD, and SBK) conducted study selection after achieving high inter-rater reliability (κ = 0.8) on pilot screenings. Calibration involved: (1) Criteria review, (2) independent pilot screening of 50 studies, and (3) consensus meetings to resolve discrepancies. The PRISMA flow diagram (Fig. 1) illustrates the search procedure and outlines the number of records included and excluded. The systematic search strategy identified 360 articles during the initial screening phase. Among them, 86 articles were duplicates, and 252 articles were excluded as they were not related to the main objective of the research. Thus, 22 articles were reviewed for inclusion. Nine out of 22 articles did not match the inclusion criteria, and one was in a non-English language. Finally, 12 articles were selected for inclusion in this review.

Fig. 1:

Flowchart describing the preferred reporting items for systematic reviews and meta-analysis recommendations for the identification and selection of research

Characteristics of Eligible Studies

The main features of the 12 selected studies are presented in Table 1. The studies conducted by Coll and Sadrian,⁶ Tannure et al.,⁷ Chen et al.,⁸ Chen et al.,⁹ Dou et al.,² Abanto et al.,¹⁰ Ou-Yang et al.,¹¹ Xie et al.,¹² Duarte et al.,¹³ Al-Attiya et al.,¹⁴ Mekkriangkrai et al.,¹⁵ and He et al.¹⁶ were included in this review. Two of these studies were randomized controlled trials (RCTs).^8,13 Two were prospective clinical trials.^6,10 The remaining eight were retrospective studies.^{2,7,9,11,12,14–16}

Table 1:

Characteristics of eligible studies

Sr. no.	Author, year	Type of specimen	Study design	Sample size Patients/number of pulpectomies	Mean follow-up duration	Intervention (obturating material)	Evaluation criteria	Success rate	Factors evaluated for failure and success
1	Coll and Sadrian, 1996	Primary incisors and molars	Prospective	65/ 81	90.8 months	ZOE	Clinical and radiographic evaluation	77.7	Length of the root canal filling Preoperative root resorption
2	Tannure et al., 2012	Primary incisors	Retrospective	17/25	2 years	ZOE paste or GPP	Clinical and radiographic evaluation	68	Type of trauma Pulp Diagnosis Preoperative periapical infection Coronal discoloration Age Extent of filling Root canal filling material Pathological root resorption
3	Chen et al., 2017	Primary molars	RCT	155/160	18 months	MPRCF (ZOE + iodoform + calcium hydroxide) ZOE Vitapex	Clinical and radiographic evaluation	96.2 92.2 71.4	Obturating material
4	Chen et al., 2020	Anterior and posterior primary teeth	Retrospective	124/389	24.12 ± 11.50 months	Vitapex	Clinical and radiographic evaluation	76	Pulpitis Periapical periodontitis Type of restoration Pain history Pulp status Rubber dam Ni-Ti root canal preparation Canal filling quality
5	Dou et al., 2021	Anterior and posterior primary teeth	Retrospective	494/1175	33 months	Vitapex	Clinical and radiographic evaluation	43.7	Age Gender Attending doctors Treatment method Periapical lesion Root canal filling material Final restorative material
6	Abanto et al., 2021	Anterior and posterior primary teeth	Prospective	48/105	2 years	Feapex paste	Clinical and radiographic evaluation	86.06	Tooth position Dental pain Tooth condition Restorative material Type of tooth Periapical lesion Obturation quality Root resorption
7	Ou-Yang et al., 2021	Primary maxillary incisors	Retrospective	128/309	2 years	ZOE Calcium hydroxide/iodoform	Clinical and radiographic evaluation	69.2 64	Tooth type Extent of filling Preoperative root resorption Preoperative periapical lesion Age Root formation Crown integrity
8	Xie et al., 2022	Primary molars	Retrospective	163/410	2 years	Vitapex	Clinical and radiographic evaluation	66.1	Age Gender DMFT (decayed, missing, filled teeth) Endodontic diagnosis Postobturation sealing material Tooth location
9	Duarte et al., 2022	Primary anterior and posterior teeth	RCT	30/38	1 year	Iodoform and calcium hydroxide with ZOE	Clinical and radiographic evaluation	64.7	Tooth arch Cause Pulp status Clinical signs or symptoms Periapical radiolucency Extent of filling Integrity of coronal restoration
10	Al-Attiya et al., 2023	Primary molars	Retrospective	92/ 105	4 years	Calcium-hydroxide/iodoform paste	Clinical and radiographic evaluation	59.5	Treatment modality Arch Treatment indication Coronal lesion Age Operator Number of visits Post-treatment restorations
11	Mekkriangkrai et al., 2023	Anterior and posterior primary teeth	Retrospective	448/647	5 years	Vitapex	Clinical and radiographic evaluation	53.8	Age Type of tooth Pre-existing root resorption Number of appointments Quality of obturation Behavior
12	He et al., 2023	Primary anterior and posterior teeth	Retrospective	381/1220	35 months	ZOE paste Vitapex	Clinical and radiographic evaluation	38.5	Age Gender Tooth type Preoperative condition Soft tissue Radiographic evaluation Obturation material Degree of root filling

Included studies were published between 1990 and 2024, with follow-up varying between 1 and 5 years. The total number of patients observed in all the studies was 2,145, with 4,664 teeth included. Various obturating materials evaluated were Vitapex,^2,9,11,15 ZOE,⁶ Guedes-Pinto paste (GPP),⁷ Vitapex with mixed primary root canal filling (MPRCF—ZOE + iodoform + calcium hydroxide),⁸ and Feapex paste.¹⁰ Clinical and radiographic criteria were used to evaluate factors associated with the success and failure of pulpectomy. Various factors evaluated were age, tooth position (anterior/posterior), pulp vitality, preoperative findings, pre-existing root resorption, type of obturating material used, extent of root canal filling, postendodontic restoration, treatment modality, and number of appointments.

Synthesis of Results

The success rate reported in all the studies ranged between 38.5%¹⁶ and 96.2%.⁶ Data concluded that the length of root canal filling material is the common factor associated with failure of pulpectomy in nine out of 12 studies.^{6,7,9,11,13,14–16} The root canal filling material is associated with the success and failure of pulpectomy. Three studies concluded that ZOE has a higher success rate than Vitapex at 24 months follow-up.^2,11,16 The success rate of pulpectomy was substantially associated with the amount of preoperative resorption, showing that minimal preoperative root resorption is associated with pulpectomy success in five out of 12 studies.^6,7,10,11,15 Coll and Sadrian⁶ and Tannure et al.⁷ reported no significant association between patient age and treatment success. Dou et al.² proposed that age-dependent morphological changes (e.g., root resorption or canal calcification) in primary molars may increase failure risk. This contrasts with Ou-Yang et al.¹¹ and Xie et al.,¹² who found no statistically significant relationship between age and radiographic success. Table 2 represents the reasons for pulpectomy failure, concluding that the presence of a periapical lesion, preoperative swelling, fistula, excessive root resorption, inadequate quality of the root filling, and obturating material are the factors associated with pulpectomy failure.

Table 2:

Factors for the success and failure of pulpectomy

	Length of root canal filling		Preoperative root resorption		Preoperative findings		Obturating material		Restoration material
Study	Length	Percentage	Resorption	Percentage	Findings	Percentage	Material	Percentage	Material	Percentage	Other factors
Coll and Sadrian6	Short fill	13.5 (5/37)	No	17.2 (3/36)	Irreversible pulpitis	–	ZOE	81	–	–	–
	At apex	11.1 (2/18)	Minimal (<1 mm)	2.3 (5/29)
	Long fill	42.3 (11/26)	Excessive (<1 mm)	76.9 (10/13)
Tannure et al.7	Underfilled	33.33 (2/6)	Present	53.84 (7/13)	Pulp necrosis	38.09 (8/21)	ZOE paste	35.29 (6/17)	Composite resin	–	Type of trauma Coronal discoloration Age
	Ideal	37.5 (6/16)	Absent	8.33 (1/12)	Irreversible pulpitis	0 (0/4)	GPP	20 (2/8)
	Overfilled	0 (0/3)
Chen et al.8	–				Pulp necrosis	–	6, 12, 18 months, respectively		Composite resin or 3M SSC	–
					Irreversible pulpitis	–	ZOE	0, 0, 7.8
							Vitapex	0, 19.6, 28
							MPRCF	0, 0, 3.8
Chen et al.9	Adequate	24.50	–	–	Pulpitis	34.83	Vitapex	–	Resin-filled	33.83	GA Pain history Rubber dam isolation Ni-Ti root canal preparation
	Overfilled	29.17			Periapical periodontitis	44			Transparent crown	21.21
	Underfilled	34.88							Preformed crowns	22.63
Dou et al.2	–		–		Periapical lesion		Iodoform		Resin	47.54	Treatment method: GA/Non-GA Age
					Yes	48.64	Zinc oxide paste	49.54	Glass ionomer cement (GIC)	58.82
					No	58.53	Vitapex	56.06	Performed metal crown (PMC)	62.01
Abanto et al.10	Adequate	7	Present	10.99	Pulp necrosis	4	Feapex paste (calcium hydroxide and iodoform)		Composite/GIC	11.11	Age Tooth position DMFT
	Overfilled	30.77	Absent	33.33	Irreversible pulpitis	8.16
									Composite strip crowns	13.11
	Underfilled	5.56
Ou-Yang et al.11	At 12 and 24 months		At 12 and 24 months		Periapical lesion at 12 and 24 months		At 12 and 24 months, respectively		Crown	39.3	Tooth type Age
	ZOE		ZOE		ZOE		ZOE	14.1, 30.8
	Adequate	14, 27.1	Present	11.3, 27.3	Present	12.3, 27.6	Metapex	17.1, 36
	Overfilled	14.3, 35.7
	Underfilled	14.3%, 7.1%	Absent	27.3, 47.6	Absent	22.7, 45.5
	Metapex		Metapex			Metapex
	Adequate	19.2, 37.6	Present	12.3, 29.7	Present	14, 29.9
	Overfilled	11.5, 27.7	Absent	44.4, 73.9	Absent	32.3, 66.7
	Underfilled	15 53.8
Xie et al.12	–		–		Irreversible pulpitis	21.93	Vitapex		GIC	–	Age Postobturation sealing material Tooth location
					Periapical periodontitis	56.73
Duarte et al.13	Iodoform paste (IP)		–			IP	IP	37.5	Composite resin	78.6	Type of tooth Caries/ trauma
	Adequate	33.3		Irreversible pulpitis		22.2	CHZO	35.3
	Overfilled	100
	Underfilled	50		Pulp necrosis		57.1
	Calcium hydroxide and zinc oxide (CHZO)			CHZO
					Irreversible pulpitis	28.6
	Adequate			18.2
	Overfilled			100	Pulp necrosis	40
	Underfilled			50
Al-Attiya et al.14	–	–	–	–	At 1, 2, 3, and 4 years, respectively		Calcium-hydroxide/iodoform paste		SSC		Treatment modality [GA, nitrous oxide sedation (N2O), local anesthesia (LA)] Number of visits Tooth type
									At 1 year	6.3
					Irreversible pulpitis/necrosis	6.8, 13.5, 16.7, 30.4			2 years	14.5
					Fistula	0, 0, 0, 0			3 years	22.9
									4 years	41.7
					Abscess	100
									Filling	0
Mekkriangkrai et al.15	Adequate	23.19	Present	27.20	No pathology	10	Vitapex	50			Age Number of visits Behavior Time to final restoration
	Overfilled	31.91			Discontinuous lamina dura	23.94
	Underfilled	31.85	Absent	36.36	Furcal involvement	33.48
					Periapical lesion	42.47
He et al.16	Adequate	32.7	–		Normal	21.47	Vitapex	37.1	PMC GIC Strip crown	24.2	Age Tooth type Soft tissue condition Number of surfaces affected
					Abnormal	36.78	ZOE	29.9	Composite	21.2
	Overfilled	36.8
	Underfilled	29.4

Risk of Bias within Studies

The risk of bias for the 12 included studies was assessed using the RoB 2.0 and ROBINS-I tools and summarized in Figures 2 and 3. Low risk of bias (ROB 2.0) was found for both RCT studies (Chen et al.⁸ and Duarte et al.¹³). Among 10 longitudinal studies, one article turned out to be of serious risk (Al-Attiya et al.¹⁴), two articles on critical risk (Chen et al.⁹ and He et al.¹⁶), two articles of moderate bias risk (Abanto et al.¹⁰ and Xie et al.¹²), and five studies of low risk of bias (Coll and Sadrian,⁶ Tannure et al.,⁷ Dou et al.,² Ou-Yang et al.,¹¹ and Mekkriangkra et al.¹⁵) based on the ROBINS-I tool assessment. Figure 4 represents the distribution of the risk of bias in each domain across the 10 non-RCT studies.

Fig. 2:

Risk of bias assessment for the RCT included in this review

Fig. 3:

Risk of Bias assessment for the non-RCT studies

Fig. 4:

Distribution of the risk of bias in each domain across the 10 non-RCT studies

Discussion

In light of the significance of primary molars in maintaining the soundness of dental arches, for restorable tooth pulpectomy treatment should always be chosen over extraction. This study enhanced the survival analysis of root canal therapy in primary teeth and the possible risk factors. Since currently there is a dearth of research in this area, the study findings can be considered reasonably reliable because they are based on the large sample size and long-term follow-up. Our results could be used by practitioners to discuss treatment options, outcomes, and prognosis for pulpectomized teeth with parents or guardians.

The results of this literature state three types of considerations regarding how pulpectomy treatment outcomes are affected. These are the factors associated with the success of pulpectomy, failure of pulpectomy, and the factors that had no impact on treatment.

The result of this study shows that the length of obturating material is the common factor associated with the failure of pulpectomy. Four studies state that overfilled canal filling has more failure,^6,10,13,16 as overfilling causes a mild foreign body reaction, irritates the periapical tissues, and causes necrosis of bone and cementum. The other four studies report that underfilled canals have a higher failure rate.^7,9,11,14 The other four studies report that underfilled canals have a higher failure rate.^7,9,11,14 An underfilled root canal can permit the tissue fluid that becomes stagnant and eventually a host for infection. Results of a study conducted by Mekkriangkra et al.¹⁵ show the same failure rate for overfilled and underfilled canals, that is, 31.9%, which concludes that adequate root canal filling is necessary for the success of pulpectomy, and both overfilled and underfilled canals are associated with failure of pulpectomy.

Another common factor associated with the failure and success of pulpectomy is the root canal filling material. The result of the study conducted by Chen et al.⁹ shows that mixed primary root canal filling (ZOE + iodoform + calcium hydroxide) has a higher success rate, that is, 96.2%, than ZOE and Vitapex at 18 months of follow-up. Studies conducted by Dou et al.,² Ou-Yang et al.,¹¹ and He et al.¹⁶ show ZOE has a higher success rate than Vitapex at 24 months follow-up.

Concerns have been raised due to the delayed resorption of ZOE and its discrepancy with the physiological root resorption rate.¹⁷ Extrusion of ZOE beyond the apex may pose a risk of deflecting the erupting permanent successor due to its hardness,¹⁸ and remnants of the paste can occasionally migrate into the gingival vestibule during eruption of the permanent dentition.¹⁹ Recent advances have led to the development of iodoform-based pastes, such as GPP, Metapex, and Vitapex, which exhibit superior resorption properties compared with earlier materials. These pastes not only provide excellent clinical and radiographic success but also undergo resorption if pushed beyond the canal.²⁰ Additionally, Metapex has a 50–86% success rate. When it is extruded into furcal or apical regions, macrophages can either diffuse or resorb Metapex in a short period of 1 or 2 weeks, without causing a foreign body reaction.^10,15 The results of the previous systematic reviews show similar findings to our study: After 18 months, the success rate of ZOE and Endoflas was 90% and 71% or less for iodoform.^21,22

It seems reasonable that pulpectomy is more successful when carried out in asymptomatic teeth with no root resorption and periapical infection. In the present review, Coll and Sadrian,⁶ Tannure et al.,⁷ Abanto et al.,¹⁰ Ou-Yang et al.,¹¹ and Mekkriangkra et al.¹⁵ showed a strong correlation between the amount of preoperative resorption and pulpectomy success rate. The presence of the periapical infection has a higher failure rate, as analyzed by Dou et al.,² Ou-Yang et al.,¹¹ and Mekkriangkra et al.¹⁵

The literature shows that the pulpal status of the included teeth may influence the pulpectomy success. Tannure et al.,⁷ Abanto et al.,¹⁰ Duarte et al.,¹³ and Al-Attiya et al.¹⁴ reported that pulpectomy performed in a tooth with necrosed pulp has a higher failure rate than irreversible pulpitis and periapical periodontitis.

The integrity of the coronal restoration significantly influenced the success of the pulpectomy. The ultimate final restoration indicated is performed with stainless-steel crowns (SSCs), followed by composite resin and glass ionomer cement.^23,24 After analyzing the current review, it is not possible to state that composite resin and glass ionomer cement after pulpectomy are inferior to the preformed SSCs.

The relationship between patient age and pulpectomy success remains debated across studies. While Coll and Sadrian⁶ and Tannure et al.⁷ found no significant association between age and treatment success, Dou et al. suggested that age-related morphological changes in primary molar root canals could contribute to failure. Similarly, Ou-Yang et al.¹¹ and Xie et al.¹² reported no statistically significant link between age and radiographic success at 12 and 24 months follow-up. However, Mekkriangkra et al.¹⁵ observed that success rates decreased over time and were influenced by the patient's age at treatment, noting faster Vitapex resorption in younger children. These conflicting findings suggest that age may not universally determine outcomes.

Although primary molars and primary anterior teeth have differing success rates, the difference was not statistically significant. It is believed that morphological variations account for the variance.

When treated under general anesthesia (GA), the root canal can be prepared and disinfected more thoroughly without being affected by the child's lack of cooperation, which is why pulpectomy with non-GA had a lower survival rate than those with GA.²

In the analysis of the risk of bias for the present study, a low risk of bias was found for both RCT studies.^9,13 Ten non-RCT studies were assessed by the ROBINS-I tool, from which one retrospective study was found to be of serious risk because of bias due to missing data, as there are significant dropout cases during follow-up.¹⁴ A critical risk of bias was found in the other two studies due to bias in the selection of participants and confounding factors.^9,16 A moderate risk of bias was found due to the selection of participants in two studies.^10,12 The other five nonrandomized studies are of low risk of bias.^2,6,7,11,15

Conclusion

The subsequent conclusions can be made within the parameters of this systematic review. The result of pulpectomy treatment was influenced by numerous factors, including confounding factors. A subset of these factors did not affect treatment results, including age, gender, and the position of the teeth, while others were associated with pulpectomy failure and success. Factors associated with the success of treatment included the absence of preoperative periapical lesions, minimal preoperative root resorption, pulpectomy performed due to caries, adequate extension of the root canal filling, and the type of final restoration. The factors associated with treatment failure included the presence of a periapical lesion, Preoperative swelling, fistula, pulpectomy performed due to trauma, inadequate quality of the root filling, and obturating material. Factors that had no impact on treatment are age, gender, and position of teeth.

Limitations

It is imperative to note several limitations when evaluating the results of our systematic review. Only two RCTs fulfilled the inclusion criteria and thus were included in the current evaluation, indicating a scarcity of randomized clinical trials. The design, types of obturating materials, outcome measures, and follow-up periods of the studies that made up this review varied. Consequently, the results of the included studies could not be combined in a meta-analysis. The confounding factors, such as oral hygiene, diet, high-risk caries children, and operator skill, can influence the outcome of the study and thereby the outcome of this systematic review.

Clinical Significance

This systematic review holds significant clinical value as it enhances treatment predictability, minimizes failures, and supports the preservation of primary teeth, ultimately benefiting pediatric oral health.

Orcid

Shrikant Bhujangrao Kendre https://orcid.org/0000-0003-3070-0238

Anuja U Bhatane https://orcid.org/0009-0003-0582-7306

Yogesh Jagannath Kale https://orcid.org/0000-0003-0612-0014

Mahesh V Dadpe https://orcid.org/0000-0003-4315-4432

Prasanna T Dahake https://orcid.org/0000-0003-0295-5751