Pediatric Dentistry · patient case question
At a review visit the tooth has become persistently painful. What is now indicated?
Patient case: A four-year-old who hit his front tooth
Patient: Male, 4 years old
Chief Complaint: Mother: “He fell at nursery and banged his front tooth, and now it has gone dark.”
Background: Fell onto a hard floor six weeks ago, striking tooth E (maxillary right primary central incisor). At the time the gum around the tooth bled a little. Healthy child, immunisations up to date.
Vital Signs: Afebrile · HR 96 bpm
Findings: At the time of injury: occlusion normal, no displacement, no increased mobility, tender to touch. Today: the tooth is grey, remains in normal position with normal mobility, is not tender to percussion, and there is no sinus tract or swelling. Radiograph shows no periapical or inter-radicular radiolucency and no root resorption.
Show answer and explanation
Correct answer: B. Pulpectomy with a resorbable filling material and a stainless steel crown
- A. Extraction is reserved for a tooth that is non-restorable, has excessive pathological root resorption, has lost significant bone support, or where the permanent successor is close to eruption. None of those applies to a restorable incisor in a four-year-old.
- B. CORRECT. Persistent pain in a discoloured traumatised primary tooth indicates irreversible pulpitis or necrosis, meaning the RADICULAR pulp is involved. That requires PULPECTOMY — removal of the coronal and radicular pulp, with obturation using a RESORBABLE material such as zinc oxide eugenol, an iodoform-based paste, or a calcium hydroxide/iodoform combination. The filling must resorb in step with the physiological root resorption so that it does not obstruct eruption of the permanent successor — which is why gutta-percha is never used in a primary tooth. Restore with a stainless steel crown for a durable coronal seal.
- C. Pulpotomy removes only the CORONAL pulp and depends on the radicular pulp being healthy. Persistent pain indicates the radicular pulp is involved, which makes pulpotomy the wrong procedure.
- D. Continuing to monitor a tooth that is now symptomatic ignores the very finding that was being watched for. The purpose of the review was to detect this change and act on it.
Note: What this case adds is the SEQUENCE within a trauma presentation — concussion, then discoloration, then observation, then intervention only when symptoms actually appear. Learning the sequence is what prevents both overtreatment at the discoloration stage and undertreatment once the tooth declares itself.
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