Several years ago, a 9-year-old boy came to my office in the aftermath of a baseball accident. One look and I knew I needed to put on my dental trauma diagnosis hat and made some decisions that could impact this young patient’s teeth long term.
A baseball had hit this patient square in the mouth, and his teeth were loose. His mom had noticed some discoloration of teeth #8 and #9, but he had no pain or sensitivity. The mom was mostly concerned about the discoloration. Adding to the complexity of treating this case, her son had a history of Hemophilia A.
Dental Trauma Diagnosis
When looking into the case, I saw that the teeth had been subluxated.
You could see some gingival hemorrhage in the sulcus. There was some mobility, but the teeth were not displaced (although they were very tender to percussion).
To get to the best possible diagnosis, I performed some tests that revealed that teeth #8 and #9 had a normal response to cold. His diagnosis was Normal Pulp and Symptomatic Apical Periodontitis #8 and 9.
I know the quality of the pre-operative radiograph and the photograph above isn’t great. But it was difficult to get high quality images and x-rays because the patient was a bit uncomfortable. He was clearly a bit jarred from the accident and I wanted to move fast to not just nail the dental trauma diagnosis, but land on a treatment plan that would keep his teeth healthy. And, seriously, when you have a young patient in the chair, you do have to move fast! Behaving yourself for a long period of time at the specialist’s office can really test your patience when you’re 9 years old.
Since the teeth still had slightly open apices, my goal was to try and keep the teeth vital as long as we could. My treatment plan was to monitor him and continue follow-ups. His mom was instructed to watch for discoloration and any sensitivities during the follow-up period.
Following Up a Year Later
One year later, the patient came back and was still largely asymptomatic.
The teeth also didn’t appear to change in color. The teeth still felt cold (although not very strong) and, at this point, had no pain to percussion. There was no sign of endodontic pathology, but there were other changes that I saw in the radiograph — the lumens of the canal space were starting to calcify. Hmm.
A few can happen in the aftermath of dental trauma: 1) things can remain unchanged, 2) the nerve can undergo necrosis, or 3) a tooth can undergo pulpal metamorphosis / pulp canal obliteration.
This case is a perfect example of what I mean by pulp canal obliteration. You can see that the lumens of #7 and 10 have not really changed, so something metamorphic was definitely going on.
Now here’s the question — what do you do for this dental trauma diagnosis and treatment? Do you keep watching the teeth? Or do you intervene now before the canals completely calcify?
Monitoring the teeth appears to be the more conservative treatment. But let’s look at this case another way. If the canals completely calcify, then the risk of procedural errors like root perforation go up tremendously. The teeth may also start to change color because of the extra dentin deposition, so there could be an aesthetic concern in the future. The risk for apical surgery also goes up, and this, in my opinion, is too much to risk, especially for a little boy.
The good news is that root canal therapy is pretty conservative at this point as opposed to one year ago when the patient first came in. The dentin thickness is greater on the sides of the canal, and thus, the tooth is stronger.
The Age Old Question: To Treat or Not to Treat
The research shows that cases like these go necrotic and require endodontic therapy only about 15% of the time. I know that the chances are low, but when treatment is simple and straightforward (as it is in this particular case), I prefer to do treatment sooner rather than later. However, it’s not my child and it’s not my body. I was very aware that his mom might not be sure of how she’d want to proceed.
So what did I do? I presented the mother with a clear diagnosis and the treatment options and told her that she should really think about it. I could tell it was a lot for her to take in. I really wanted her to take her time, so I reassured her that we weren’t in a hurry to make a treatment decision and that she really needed to put some thought into it.
There’s a lot at play in this case. And a lot to consider, no matter which side of the chair you’re on. On one hand, what would you do if this was your child? On the other, what would you have done if it were your patient? I’d love to hear how you would approach this case in the comments below! Drop me a line.
Want to go deeper on diagnosis? Check out my free pulpal and periapical diagnosis checklist here.