Clinical findings: Tooth 65 is retained in the arch, shows no mobility, and responds to cold stimulus. A deep carious lesion is present; probing is painful within the coronal pulp, with moderate bleeding. Radiographically, the roots are fully formed, no periapical pathology is observed, and there are no signs of resorption.
Treatment: A pulpotomy (coronal pulp amputation) was performed following standard protocols for disinfection and hemostasis. The pulp chamber floor was covered with a biocompatible material, and the tooth was restored using a composite filling.
Due to the patient’s age and the need to maintain the tooth’s function until natural exfoliation, a stainless steel crown was recommended. The patient’s mother was informed of the indication for the crown but signed a refusal for its placement.
Additional information: Tooth 64 had been previously treated (presumably by pulpotomy). Upon examination, signs of secondary caries were noted. Radiographic evaluation shows ongoing physiological root resorption, indicating the tooth is preparing for exfoliation.
Recommendations:
- Monitor tooth 65 over time
- Follow-up and possible treatment or extraction of tooth 64 if needed
- Professional oral hygiene and hygiene instruction
- Re-evaluation in 3–6 months
