A permanent molar, an open apex and a mother who wants it out
Amira, aged 8 years 4 months, attends with her mother, who reports that Amira has had pain in the lower right first permanent molar for three weeks, mainly on eating, and that it has woken her twice at night. There has been no facial swelling or fever. On examination, 46 has a large occlusal cavity filled with soft, light-brown caries that appears to reach the pulp; the tooth is tender to percussion but not mobile, and there is no buccal swelling, sinus tract or lymphadenopathy. A cold stimulus produces an exaggerated response that lingers for about 20 seconds. The radiograph shows caries approximating the pulp horn, wide canals with apices that are not fully closed, and no periapical or furcal radiolucency, no internal or external resorption and an intact lamina dura. Her Frankl behaviour rating is 3. Her mother says a previous extraction at age five was traumatic, that Amira is very anxious, and asks for 46 to be extracted because it is 'only a baby tooth'. She also asks whether sedation would be possible.
1. Give your diagnosis and set out the treatment options with the reasoning behind each, including your recommendation.
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Diagnosis: deep caries on 46 with signs of symptomatic irreversible pulpitis (lingering cold response, spontaneous nocturnal pain) and symptomatic apical periodontitis (percussion tenderness), in an immature permanent molar with open apices and no radicular pathosis.
Options:
- Full pulpotomy with a hydraulic calcium silicate cement (MTA or Biodentine), then a sealed restoration - my recommendation if intraoperative criteria are met. Removing only the inflamed coronal pulp and capping the radicular stumps preserves vitality and allows continued root development (apexogenesis). This avoids root canal treatment in a tooth with divergent, open apices, where cleaning, shaping and obturation are genuinely difficult and where an apical plug would otherwise be needed. Evidence for Cvek-type pulpotomy in permanent teeth with irreversible pulpitis is good, provided haemostasis is achieved.
- Pulpectomy/root canal treatment - indicated if inflammation extends into the radicular pulp (uncontrolled bleeding) or if radicular pathosis is present. It halts root development, so it is not the first choice here.
- Extraction - would leave a gap in a growing arch with space loss, drifting and later complex prosthetic needs. It is the fallback if the tooth is unrestorable or the family declines other options, not the default for a permanent tooth.
- Stepwise or indirect pulp capping - inappropriate with spontaneous pain, which indicates irreversible inflammation.
I would correct the misconception explicitly: 46 is a first permanent molar, not a primary tooth, and must last decades.
2. What intraoperative findings would make you abandon the pulpotomy, and how would you judge success afterwards?
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Intraoperative decision points:
- Isolation first. Without a rubber dam and a clean field, do not start.
- Caries removal and pulp exposure: remove all caries and the coronal pulp to the canal orifices.
- Haemostasis: apply a saline- or dilute sodium hypochlorite-soaked cotton pellet with light pressure. If bleeding is controlled within about 4–5 minutes (accepting up to 10 minutes in some protocols), the radicular pulp is likely only superficially inflamed and pulpotomy can proceed. If bleeding persists beyond that, inflammation extends into the radicular pulp - convert to pulpectomy or refer.
- Appearance: a necrotic, purulent or pale pulpal stump, or any sign of internal resorption, indicates failure and conversion.
- Restorability: if caries extends subgingivally, if there is no ferrule, or the tooth cannot be sealed, extraction is the honest option.
Technique if proceeding: place 2–3 mm of MTA or Biodentine directly on the stumps, then a resin-modified glass ionomer base, then a well-sealed coronal restoration with cuspal coverage (a preformed metal crown is acceptable in a young molar).
Success criteria at 6, 12 and 24 months: no spontaneous or provoked pain; no percussion tenderness; no sinus tract or swelling; no new or enlarging periapical/furcal radiolucency; evidence of continued root development and apical closure; a visible dentine bridge. Failure at any review means reassess for root canal treatment with an apical plug or extraction.
3. How do you manage Amira's anxiety and obtain valid consent, given her mother's request for extraction and for sedation?
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Behaviour management first. A Frankl 3 child with a previous traumatic extraction needs control before treatment: tell-show-do, a rehearsed stop signal, positive reinforcement, a topical anaesthetic before any injection, and a short, predictable visit structure. Consider a familiarisation appointment purely to place and remove a rubber dam. Parental presence should be negotiated with Amira, not assumed. Nitrous oxide/oxygen is often the most appropriate first-line adjunct for an anxious but cooperative child and can be used if the practice is equipped and trained; oral sedation is a further step, requiring specific training, fasting protocols and appropriate monitoring, and is not something to promise at the chairside.
Consent: valid consent requires the parent or guardian to understand the options, and Amira's assent matters. Explain that 46 is permanent, that extraction is not a quick fix and would leave a space that affects her bite, and what each option involves in terms of visits and discomfort. Discuss the possibility that pulpotomy may convert to root canal treatment or extraction if intraoperative criteria are not met, and record this discussion. Do not present sedation as the deciding factor.
If anxiety makes the planned treatment unsafe or unkind, stage it: one familiarisation visit, then the definitive visit under nitrous oxide, or refer to a paediatric dentistry service. Document the discussion, the reasons for any change of plan, and the agreed review.