Purpose <p>To investigate how dental clinicians worldwide manage primary molars with irreversible pulpitis and pulp necrosis and to identify factors associated with variability in the use of coronal pulpotomy, non-vital pulp therapy (NVPT), and extraction.</p> Methods <p>An online questionnaire was distributed via international and regional paediatric dentistry associations to dental clinicians who treat children. Standardised clinical scenarios were developed for irreversibly inflamed and necrotic primary molars. Participants selected their most likely treatment. Demographic data and reasons for not performing coronal pulpotomy or NVPT were collected. Data were analysed using multivariable Generalized Estimating Equations (GEE) logistic regression to evaluate treatment choices and modified Poisson regression to calculate paired risk ratios (<i>α</i> = 0.05).</p> Results <p>A total of 374 clinicians responded, the majority of whom were paediatric dentists (82.9%). For irreversible pulpitis, 62% preferred coronal pulpotomy, with no significant demographic influence. Management of necrotic primary molars was heterogeneous: 54% chose pulpectomy, 39% extraction and 7% lesion sterilisation and tissue repair, with extraction increasing as case complexity rose. University-based clinicians, paediatric dentists, and those with postgraduate degrees, as well as those trained in Asia, Africa, and the Americas, were more likely to perform NVPT than those in private practice or trained in Europe.</p> Conclusions <p>Management of irreversibly inflamed and necrotic primary molars varies worldwide, with decisions for necrotic teeth shaped by clinicians’ training, practice setting, and geographical region rather than by a coherent evidence base. Both tooth‑preserving options and extraction are used, but their selection varies widely and is influenced by evidence gaps, level of training, and resource availability.</p>