A pediatric patient came into my practice after a baseball injury with dental trauma and subluxated teeth. I really felt for this poor, 9-year-old patient! So, of course, I did my very best for him, giving him a diagnosis and letting his parents know about his treatment options.
Before I dive into this tooth story, I want to let you know that the family ended up deciding not to pursue treatment, so I don’t know the outcome of this case. I’m not here to say that was a good choice or not; I am a huge advocate for patients being advocates for what is right for them, so I trust that they did what was best for their son.
In fact, my own daughter is going through this exact same thing right now, and I’ve chosen not to treat, either.
I still think that, even though we don’t know what happened in this tooth story, it is still worth discussing, because it brings up a great question: What would you do in this situation? This can really help test your trauma knowledge!
Subluxated Teeth after Dental Trauma
This adventurous kiddo had taken a baseball square to the mouth, and it had knocked his teeth loose. His mom was worried about the discoloration of teeth #8 and #9, so she brought him in to see me. Adding to the complexity of treating this case, her son had a history of Hemophilia A. I will note, however, that he had no pain or sensitivity.
It was clear right away, when I took a look in his mouth, that the teeth had been subluxated. Let’s define this really quickly: the definition of a subluxated tooth is a tooth that has bleeding from the sulcus and has some mobility.
I could also 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.
Bear with me when it comes to the quality of the pre-operative images above. The patient was a bit uncomfortable, since he’d just been jarred by the accident.
I was moving fast to nail the dental trauma diagnosis, and also 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.
Subluxated Teeth, One Year Later
The patient returned for his one-year recall 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. Namely, the lumens of the canal space were starting to calcify. Hmm.
A few things 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 with teeth #8 and #9.
Here’s the question I want you to really give some thought to: what do you do next? Do you keep watching the teeth? Or do you intervene now before the canals completely calcify?
Monitoring the teeth appears, on the surface, 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 if root canal therapy is needed down the road. 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. This is a lot of 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 trauma cases like these with pulp canal obliteration (PCO) 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 can definitely see why some providers may want to intervene and do treatment at this stage.
However, this is 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. And that is totally fine; I want her to feel comfortable with the treatment plan. (Again, my own kiddo is going through this right now, and we’ve also made the decision to not proceed with treatment at this time.)
So what did I do as the clinician in this case? 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, especially because her kiddo had no pain. 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 I encouraged her 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. I’d love to know what you would do if this was your child. On the other, what would you have done if it were your patient? Is there a difference? 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.