Extraction versus pulpectomy for primary molar apical periodontitis: propensity-matched routine-care evidence on successor-tooth development

Background: The long-term successor-tooth consequences of extracting or retaining primary molars with apical/furcation disease remain uncertain. This study compared successor premolar outcomes after extraction versus pulpectomy in routine pediatric dental care. Methods: This two-center retrospective cohort included children aged 3–9 years treated in pediatric dental services in Tianjin, China (index treatment during 2016–2020), with follow-up from the index procedure until successor premolar eruption, transfer/loss to follow-up, orthodontic intervention, or study end in 2024. The tooth was the unit of analysis. Propensity score matching with exact matching on tooth type and arch produced 150 matched teeth per group. Primary inference used matched-set models with child-level cluster-robust variance. The primary outcome was any successor premolar abnormality: developmental stage difference ≥1 level, eruption delay ≥12 months, positional anomaly, or enamel developmental defect. Direct dental costs were analyzed as direct charges only. Results: Successor abnormalities occurred in 36.0% after extraction versus 24.0% after pulpectomy (absolute risk difference 12.0%, 95% confidence interval (CI) 1.7–22.3; odds ratio (OR) 1.78, 95% CI 1.08–2.94; p = 0.024), mainly reflecting eruption delay and positional anomalies. Space loss >2 mm was more common after extraction (37.1% vs. 4.8%; p < 0.001). The association was attenuated among extraction cases with timely, high-adherence space maintenance. Pulpectomy required more visits and higher direct charges. Conclusions: In this retrospective routine-care cohort, extraction was associated with a higher risk of the composite successor premolar abnormality than pulpectomy; the estimates should be interpreted as adjusted associations rather than causal effects. Treatment choice should be individualized according to restorability, root resorption, successor stage, feasibility of definitive restoration, and family burden, with timely sustained space maintenance prioritized when extraction is necessary.

Apical periodontitis; Pulpectomy; Tooth extraction; Successor tooth development; Propensity score matching; Space maintenance

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