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.
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