This is one of my all-time favorite tooth stories. It’s about a patient with an acute apical abscess, but it’s also a testament to the incredible resilience of the human body— and to the power of a root canal!
A few years ago, a 15-year-old girl walked into my office with her mom for an emergency appointment. She had tears rolling down her face—and down her extremely swollen jaw. 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, she and her parents had figured everything was fine. Over the next few years, she experienced pain or swelling in the area every so often, but it would go away after a little bit.
But 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!
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.
Finding the culprit: Acute Apical Abscess
I knew right away that this case was going to require careful attention. Before I did anything else, I completed my standard diagnosis protocol. 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.
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 mom 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.
I began emergency treatment right away, starting with tooth #25. I performed an incision and drainage, complete with antibiotics (Clindamycin 200mg 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.
I reviewed proper post-operative care with my young patient, and asked her 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. Those people would be wrong.
Here’s the part I didn’t mention before: When I presented my treatment plan to the patient and her mom, 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. Of course as professionals, we deserve to be paid for our hard work—but someday you just might come across a case 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.
Thank goodness for social media, though—I ended up reconnecting with the patient over Facebook! I was so invested in her case that I offered her $50 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.
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?
I love to share this case because it always shocks people. Nine out of ten dentists would have advised extraction in this acute apical abscess case. 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!
So, don’t forget to cold test, and take the time to understand the disease’s primary etiology. If 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.
Tell me what you’ve learned from this tooth story in the comments!