Deep caries in a primary second molar: vital pulp therapy or extraction
A 6-year-old girl attends with her father for a routine check-up. The lower right second primary molar (85) has a large cavitated lesion on the occlusal surface. The father reports that she complains of discomfort when eating sweets, lasting only a few seconds, and has never woken at night with pain. She has no swelling or fever. On examination, the tooth is vital, not tender to percussion, and has no mobility; the gingiva is healthy. A bitewing radiograph shows caries approximating the pulp with a thin band of dentine remaining, no furcation radiolucency, and normal root development; the permanent second premolar germ is visible beneath. The child is anxious but cooperative with tell-show-do. The father asks whether the tooth can simply be filled, or whether it needs to be taken out because 'it will fall out anyway'.
1. What are the treatment options, and which would you recommend?
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Options:
- Selective caries removal (indirect pulp treatment) to firm dentine, then restore - with a stainless steel crown if the tooth is badly broken down.
- Hall technique: cement a stainless steel crown over the caries without local anaesthesia or preparation, where suitable.
- Pulpotomy if the pulp is exposed.
- Extraction if the tooth is unrestorable or the child cannot be treated.
Recommendation: this is a vital tooth with reversible symptoms - pain only with sweet food, lasting seconds, no night pain, no percussion tenderness, no furcation radiolucency. Vital pulp therapy is therefore appropriate, and preserving the tooth maintains space and function for the developing premolar.
Because the child is anxious but cooperative, treat with tell-show-do, good local anaesthesia and isolation. Restore with a stainless steel crown after selective caries removal; if isolation is difficult, the Hall technique is a reasonable alternative. Antibiotics are not indicated.
2. During caries removal, a pinpoint pulp exposure occurs with bright red bleeding. What now?
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A pinpoint exposure with bright red bleeding confirms that the pulp is still vital, so the aim changes from indirect to direct vital pulp therapy.
Steps:
- Do not continue excavating to the full depth of the lesion.
- Perform a pulpotomy: remove the coronal pulp to the canal orifices with a sharp bur or spoon excavator.
- Control bleeding with a saline-moistened cotton pellet; bleeding should stop within a few minutes.
- Apply MTA or Biodentine (or formocresol where that is the accepted protocol and material availability dictates), place a base, and seal with a stainless steel crown.
- If bleeding cannot be controlled, the inflammation is likely more extensive: consider pulpectomy or extraction.
- Review clinically and radiographically in 6-12 months.
3. The father asks why not extract the tooth since it will fall out anyway. How would you counsel him?
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The second primary molar normally exfoliates at about 10-12 years, so this tooth still has several years of work to do. Losing it early can cause:
- drifting of the first permanent molar and loss of space for the second premolar;
- impaction or crowding;
- reduced chewing efficiency and possible speech or habit effects.
Extraction is therefore a last resort, reserved for an unrestorable tooth, uncontrolled infection or a child who cannot be treated. A pulpotomy or selective caries removal with a stainless steel crown has a good chance of keeping the tooth symptom-free until exfoliation, and it is usually less traumatic than an extraction. I would explain the options, costs and follow-up, and confirm the father understands that 'it will fall out anyway' does not mean it can be lost early without consequences.