This is one of my all-time favorite tooth stories. It’s about a patient with an acute apical abscess, and how she got her bone back. But it’s also a testament to the incredible resilience of the human body—and to the power of a root canal! If you’ve ever doubted endodontics, then you won’t want to skip this tooth story about an acute apical abscess treatment with the power to regrow bone.
A few years ago, a 15-year-old girl walked into my office with her grandmother for an emergency appointment. She had tears rolling down her face—and down her extremely swollen jaw. As someone who has experienced horrible swelling due to a tooth infection, I really felt for her!
While talking to the patient, I learned that she had fallen at the playground and hit her chin back when she was just 9 years old. It had hurt, but because there were no immediate or visible repercussions, her parents had assumed that everything was fine. Unfortunately, you know what they say about assumptions…
Over the next few years, she experienced pain and swelling in the area every so often, but it would go away after a little bit. No cause for concern… right?
By the time she came in to see me, the patient’s pain had become too intense to ignore, and her jaw had swelled to the size of a golf ball. I took a few radiographs—and almost fell out of my chair when I saw the results.
As you can see from the radiograph above, the patient had virtually no more bone remaining around her bottom four front teeth. No wonder she was suddenly in so much pain! This is a bonkers amount of bone loss.
It turns out that the impact from the patient’s playground fall had killed the nerves in those teeth. This caused an infection that only got worse and worse over the years, with the bones around the teeth resorbing. The scariest part? It had all happened without the patient feeling a thing. (Until, of course, she felt it big-time.)
Finding the culprit
I knew right away that this patient was going to require careful attention. Before I did anything else, I completed my standard diagnosis protocol to make sure I made an accurate diagnosis. I found that, surprisingly, the teeth weren’t mobile, and that tooth #25 was extremely tender to percussion. The remaining anterior teeth were also slightly sensitive to percussion, but no teeth responded to cold.
That gave me everything I needed to know to make my diagnosis: Necrotic Pulp with Acute Apical Abscess of tooth #25.
Next, to get an idea of just how bad the lesion was, I took a few additional cone beam images.
Here is the sagittal view.
And the coronal view.
And the axial view.
Can you believe that those teeth weren’t mobile at all? One wrong move or misplaced bite, and this poor girl could have fractured her mandible.
Treatment of the acute apical abscess
With the acute apical abscess diagnosis in hand, I sat down with the patient and her grandmother to discuss our options: removing the teeth, or attempting to save them. I explained that while removing the teeth may have been the more cost-effective choice in the short term, it would also cause the bone to further atrophy, since it would lose its supportive function. It would be difficult to replace the extracted teeth in the absence of the bone, so the only option to fill in the patient’s smile would be a partial denture. This would have a lifelong impact on her smile, speech, and self-confidence.
With all this in mind, we agreed to perform root canals on all four teeth, with the understanding that surgery might be necessary in the future due to the size of the periapical lesion. So many dentists would condemn these teeth due to that enormous lesion, but lesion size is not a determinant for healing ability or bone regrowth. It just might take longer.
I began emergency treatment right away, starting with a pulpal debridement on tooth #25. I performed an incision and drainage, and prescribed the patient with antibiotics (Clindamycin 300 mg qid). The tooth drained dramatically upon access, and I was able to clean and shape it, place calcium hydroxide in the canal, and temporize it. Then I moved on to the next three teeth. Here is the post-operative radiograph.
Post Operative Radiograph
I reviewed the treatment post-operatively with the patient and her grandmother to explain what I was seeing, and I asked them to come in for a follow-up visit in one month. As long as the tooth was dry and no longer draining, I could place the final filling at that time.
Compassion is the key to saving teeth
Some people might think that I treated all four teeth to get more money out of the patient. Here’s the part I didn’t mention before: When I presented my treatment plan to the patient and her grandmother, they were ready to walk out the door due to the cost. They had no money at all, but I knew I couldn’t let this girl leave my office without care. So, I performed the treatment for free. I didn’t earn a cent for this case.
I don’t say this to put myself on a pedestal, but to point out how important empathy and compassion are in endodontics, and in any type of medical practice. I saw my own story in hers, and I felt so strongly that I needed to help her.
Of course as professionals, we deserve to be paid for our hard work—but some days you just come across cases where you decide to make an exception.
So, how did this tooth story end? I was able to track down the patient for a 6-month recall, but I lost her after that—her phone number had been disconnected. Here was her 6-month post-op CBCT:
Axial View
And the coronal view…
And the sagittal view…
Thank goodness for social media, though—I ended up reconnecting with the patient over Facebook! I was so invested in her case that I asked her to return for an x-ray and evaluation. Happily, she agreed, and a full two years after the initial treatment, here’s what I saw:
Starting with the axial view
Here’s the two-year post-op sagittal view…
And the coronal view…
Look how much bone she has!
She got her bone back—all of it.
To my knowledge, the patient had no other dental procedures done in the area in the intervening time. Her bone regrew all on its own. Isn’t that amazing? Endodontics is freaking magic.
One lesson to take away from this is not to forget to do your cold test and take the time to understand the disease’s primary etiology. If a necrotic pulp is the culprit, then once you clean out the tooth, the bone will regenerate and you can give those teeth a chance. An even more important takeaway is that you should always be mindful of your patients’ needs and financial situation. A little compassion can go a long way in providing the best possible treatment.
I love to share this case because it always shocks people. Nine out of ten dentists would have advised extraction in this situation. But when the patient’s primary etiology is endodontic, there’s always a chance they can get their bone back—no matter how large the lesion is. In fact, growing bone is our superpower as humans!
It all comes back to the WHY of endodontics, and your critical thinking skills. When you understand why root canals work and you follow the cardinal rules, your patients can experience extraordinary healing. Even when they have an acute apical abscess like this young lady.
Don’t believe me? Enroll in E-School to learn key endodontic principles, boost your confidence, and save teeth other dentists would condemn. You are a healer and a tooth saver… if you believe you are capable of it. Empower yourself to rise to the challenge, my friend.
– Sonia
Amazing case Dr chopra. Thanks for sharing. A lot to be learned from a case like this.
Thanks very much, Meena!
-Sonia
Wow, incredible results. Cannot believe bone healing with that big lesion. Thanks for sharing
It’s the power of the root canal.
-Sonia
Amazing case, love the happy ending! Fairy tales can come true – even in ENDO!
Love that facebook – going above and beyond!!!!
Thanks for sharing dr copra.
I’m a gp from indonesia.
I want to know about bone regeneration. Is there any relation with the age of patient?
Thanks for reading Jihan. There’s no relation for bone regeneration with age, but a definite relation with bacteria!!
Really appreciate your compassion for that patient! May Lord reward you with the best for your kind heart! 💕
I appreciate that, Hina. Thank you.
-Sonia
Superb results ma’am….
Thank you so much!
-Sonia
Wow, what a great case! I’m glad you were able to get a follow up radiograph. Thanks for sharing this.
My pleasure! Thanks for reading more!
-Sonia
Everything is very opеn with а really cⅼear description of the challenges.
It was really informative. Your website is ᥙseful.
Thankѕ for sharing!
Thank you! -Sonia
wow!! coming from India i know when such patient’s walk in who can’t pay can get very tricky. fantastic outcome of the case. we should believe in the power of healing
Thank you so much, and I completely agree about the power of healing!
-Sonia
I saw your post on Instagram and has to come see this case on your blog. Amazing case! Thanks for sharing!!
Thank you for reading! It’s one of favorite cases!
-Sonia
Nice work Sonia. I’m using some of your tricks and methods from your E School.
I’m heading to IDEA for a four day
Mini residency w Dr John West
Next week
I am so happy you are implementing the tips! I hope to see in you my live course one day!
-Sonia
This was one of the great lessons from E-school!! I two separate patients recently with PARL that I cold tested to better understand the true etiology. One had another response to cold and the other no response! I was able to explain why RCT would help her and save her tooth. Although she still opted for extraction purely because she didn’t like that it was a little loose, it was a great teaching time for my assistants! Now they also better understand how to explain this to patients!
I **had** two
One had **a normal** response
I love that this information is transferring over to your team. That will have an even bigger impact!
-Sonia
i had similiar case, looked like #23-25 totally involved, nothing in front tested + pulp test. I took chance on #24 being a cuprit and did endo. Later #23, 25 tested + and bone reformed nicely around each one……no 3 D x-ray capability…..
I actually was going to do one tooth in this case and see how it healed and go from there, but compliance was a huge issue with this patient. So, I felt that it was best to do what I could at that time. I am so happy your case was successful.
-Sonia
That is amazing result.
I had a same kind of case last week. Patient is 34 yrs old, had grade 1 mobility on lower central incisors, pain, numbness in chin area. She is a grinder as well and doesnt have occlusal splint. Diagnosis was necrotic pulp and acute apical abscess.
She wears lower removable orthodontic retainer. Should I do splinting or make her fixed lingual retainer for stabilization of mobile teeth? I recommended occlusal splint as well.
Thanks Dr.
I think after treatment you will see that the mobility will decrease. Once that bone starts to fill back in it will tighten up!
-Sonia
Thanks so much for sharing this awesome case. You are an amazing endodontist and a great person. I appreciate you sharing your knowledge and experience with us.
I love everything you do Dr. Chopra!! You inspire us to do better dentistry and better service to our communities. Amazing case and amazing job!! ♥️
Maria,
Thank you so much!
-Sonia
This is unbelievable. Thank you for sharing this.
I’m so glad you found it helpful, Vikram.