OBJECTIVES: Although pulpectomy is recommended as the choice treatment for primary teeth with pulpal involvement, some clinicians and parents consider tooth extraction a viable option. This systematic review aimed to assess the impact of pulpectomy versus extraction of primary teeth on patient-centered outcomes. METHODS: Seven electronic databases and grey literature were searched on April 05, 2024. Two independent reviewers selected clinical trials comparing the impact of pulpectomy versus extraction of primary teeth on patient-centered outcomes. Studies not directly comparing pulpectomy versus tooth extraction were excluded. Critical data were summarized following the Synthesis Without Meta-analysis guideline. The risk of bias was assessed using the Version 2 Cochrane risk-of-bias tool for randomized clinical trials and the Risk Of Bias In Nonrandomized Studies of Interventions tool for nonrandomized clinical trials. The certainty of evidence was assessed using the GRADE approach. RESULTS: A total of 1228 studies were retrieved in the search. After the screening process, two studies were included. The outcomes evaluated were oral health-related quality of life (OHRQoL), dental anxiety, postoperative pain, and behavior. Qualitative synthesis indicated that children treated with pulpectomy exhibited improved OHRQoL and lower dental anxiety than those treated with tooth extraction. The treatment modality did not influence behavior and postoperative pain. Included studies present potential bias in specific domains. The certainty of evidence was low. CONCLUSION: Pulpectomy demonstrated superior patient-centered outcomes, suggesting that it is a more favorable choice for treating primary teeth than tooth extraction.