A Seven-Year-Old with Two Painful Primary Molars

Correct answer: B. Pulpotomy followed by stainless steel crowns

• A. Extraction discards restorable teeth. Both are second primary molars, which are the critical space maintainers for the arch; losing them at age 7 causes mesial drift of the first permanent molar and arch-length loss.
• B. CORRECT. Deep caries with symptoms of REVERSIBLE pulpitis (pain on stimulus that resolves when the stimulus is removed), no radiographic signs of furcal or periapical pathology, and restorable teeth is the textbook indication for PULPOTOMY. The inflamed coronal pulp is removed, the radicular pulp — judged healthy — is preserved and medicated, and a STAINLESS STEEL CROWN restores the tooth. SSCs are used because a multi-surface restoration on a pulpotomised primary molar has a far higher failure rate than full coverage.
• C. Indirect pulp capping applies when caries is deep but NOT into the pulp and the tooth is asymptomatic or minimally symptomatic. And amalgam alone would not adequately restore these teeth.
• D. A direct pulp cap in a PRIMARY tooth with a CARIOUS exposure has a poor prognosis and is generally contraindicated — the primary pulp responds to carious exposure with internal resorption rather than repair. Direct capping is reserved for small mechanical exposures in an asymptomatic tooth.

Note: Primary molar pulp therapy decision tree: reversible pulpitis, no exposure → indirect pulp cap. Reversible pulpitis with exposure, healthy radicular pulp → pulpotomy + SSC. Irreversible pulpitis or necrosis with a restorable tooth and no root resorption → pulpectomy + SSC. Non-restorable, or furcal pathology with resorption → extraction with space maintenance.

Correct answer: C. Sodium hypochlorite or ferric sulfate on a cotton pellet

• A. Silver diamine fluoride arrests caries; it has no role in achieving haemostasis in an exposed pulp.
• B. Calcium hydroxide is a pulp-capping and medicament material but is NOT used to achieve haemostasis, and it performs poorly as a primary molar pulpotomy agent — it is associated with a high rate of internal resorption in primary teeth.
• C. CORRECT. Haemostasis is achieved with a moistened cotton pellet applied under gentle pressure — most commonly with dilute SODIUM HYPOCHLORITE (1.5–3%) or FERRIC SULFATE (15.5%). Ferric sulfate forms a ferric ion-protein complex that mechanically seals the cut vessels. Achieving haemostasis within about 5 minutes is the clinical test that the radicular pulp is healthy; persistent bleeding means the inflammation extends further and a pulpectomy is required instead.
• D. Saline is used to rinse and to moisten the pellet, but saline alone does not reliably arrest pulpal bleeding.

Note: ⚑ FLAG. The recall keyed calcium hydroxide. The recognised haemostatic agents are ferric sulfate and dilute sodium hypochlorite; the recognised MEDICAMENTS placed afterwards are MTA (best outcomes), Biodentine, ferric sulfate and formocresol (now largely abandoned over formaldehyde concerns). Calcium hydroxide is the WRONG answer on both counts for a primary molar.

Correct answer: B. When the first tooth erupts, or by 12 months of age — whichever comes first

• A. Age 6 is far too late — early childhood caries is often advanced by then.
• B. CORRECT. Both the AAPD and the ADA recommend establishing a DENTAL HOME by the eruption of the first tooth or by age one, whichever is EARLIER. The visit is largely anticipatory guidance for the caregiver: caries risk assessment, feeding and bottle practices, fluoride, oral hygiene, trauma prevention and the knee-to-knee examination position. It establishes the relationship long before treatment is needed.
• C. Waiting for pain guarantees that the first experience of dentistry is a treatment appointment, which is the reliable route to lifelong dental anxiety.
• D. Age 3 misses the entire window in which early childhood caries develops and in which feeding habits are established.

Note: This girl is having her first visit at 7 with pain in two teeth — the exact outcome that the age-one visit exists to prevent. Note the behavioural picture too: she cooperates but needs reassurance, which is Frankl 3 (POSITIVE), not Frankl 4 (definitely positive).

Correct answer: C. Class II

• A. Ellis Class IV is a tooth that has become NON-VITAL after trauma, with or without loss of structure. Some sources also apply it to crown-root fractures extending subgingivally.
• B. Ellis Class I is an enamel-only fracture. It is asymptomatic and needs no more than smoothing of the sharp edge.
• C. CORRECT. ELLIS CLASS II is a fracture through enamel AND DENTINE without pulpal involvement. The exposed dentinal tubules make the tooth sensitive and provide a pathway for bacteria to the pulp, so it must be covered promptly — glass ionomer or bonded composite over the exposed dentine.
• D. Ellis Class III involves enamel, dentine AND PULP EXPOSURE. The pulp is visible as a red or bleeding pinpoint and needs pulp capping, partial pulpotomy or full pulp treatment depending on the exposure size and the time elapsed.

Note: The full Ellis scale: I enamel only; II enamel and dentine; III pulp exposed; IV non-vital tooth (or crown-root fracture extending below the gingiva); V avulsion; VI root fracture; VII luxation or displacement without fracture; VIII complete crown fracture with intact root.

Correct answer: A. Hank's Balanced Salt Solution

• A. CORRECT. HANK'S BALANCED SALT SOLUTION is the ideal medium. It is pH-balanced and osmolality-matched to physiological conditions and supplies glucose, calcium, magnesium and phosphate — it maintains periodontal ligament cell viability for up to 24 hours, far longer than any alternative. It is the medium in commercial tooth-preservation kits.
• B. TAP WATER is the WORST option. It is hypotonic, so PDL cells swell and lyse osmotically within minutes. It is worse than dry storage in some comparisons.
• C. Alcohol-based mouthwash is cytotoxic and destroys the ligament immediately.
• D. Dry storage kills PDL cells rapidly. Beyond about 60 minutes dry, the ligament is not salvageable and ankylosis with replacement resorption becomes the expected outcome.

Note: Practical hierarchy when Hank's is unavailable: milk (readily available, roughly physiological osmolality, good for up to about 6 hours) > saliva in the buccal vestibule or a container of the patient's saliva (about 2 hours) > saline > never water. Best of all: replant at the scene within 15 minutes and go straight to the dentist.