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.
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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.
– Sonia
I think I would wait on the RCT if the teeth still tested vital. I think it’s a hard call though.
Totally agree, Meena. That’s why I posted this, so we all have a voice in that discussion!
-Sonia
To prevent complete obliteration of the root canal doing an RCT would prevent this . The procedure could be performed under general anaesthesia since this little boy would be uncooperative . A wait and see approach is my choice in this insistence .
Michael,
You can definitely go either way. I would avoid general anesthesia at all costs though. Most kids do just fine with a bit of local and perhaps nitrous which is a bit safer. My only issue in cases like these is that if we watch, usually they don’t return until it’s too late.
-Sonia
I think I would go ahead with RCT as there are clear signs of pulpal obliteration and root canals have good success rates in the hands of experienced clinician like you Dr.Sonia
Thanks
Thank you so much!!
-Sonia
We know that there’s risk of a total obliteration of the canal and treating that can sometimes be very difficult, specially in cases where we don’t even have a canal anymore. There’s also the changing of color of the tooth, wich can also happen and parents normally don’t like that.
That’s why In this case I would do a RCT for both incisors and i’ll try to explain this to the parents
Great job by the way!
Thank you, Sukaina! I appreciate your taking the time to read this.
Hi Sonia.
This is a very good case and a really understandable presentation. My suggestion for this treatment would be to do a root canal treatment due to the following reasons.
1. The age of the boy is 9 years and the apex looks closed
2. There is a drastic difference in one year as the canal space narrowed very soon, chances of becoming an obliterated or closed canal is very common after which we will have to risk ourselves in finding the root canal and chances of procedural errors and perforations will become common.
3. There will be periapical lesions and pathology in future for which we will have to anticipate a peri radicular surgery. To avoid these future complications it is better to do a root canal treatment at this stage
The parent should be informed of these conditions and explain all possible future complications if treatment is not initiated.
This is to my knowledge. Thank you.
Dr. Taher Ahmed.
Awesome feedback Taher!
-Sonia
That is some significant PCO! And, at this point, root apices are closed. I agree with you 100% and I would have done/recommended the same (even on my kids). However, I find that most patients without symptoms – especially? parents – are hesitant to proceed with treatment. I’d love to know how this story ends!!!!!!!!!!
Thank you – I’ll post an update!
-Sonia
Dear Dr. Sonia very good case.
The options I would go is
1. Do not wait as the radiographs suggests rapid PCO and going RCT will be a challenge later and the Kid has to spend lot of chair time. I would do Intentional Rct to avoid further periapical and pco complications and keep one year follow up.
I am so glad that you are with me on this case!!
-Sonia
Hi Dr Sonia ,
I would have opted for the root canal but i would have waited still, and verified with IOPAs to see of the periapicais are developing or not, but here’s my question mam in this case would you do a single visit endodontics ??? secondly how would we mange the discoloration ???
Hi!! Yes, this would be single visit for me and I would not hesitate to do internal bleaching in a case like this.
-Sonia
I believe now is time to do the endodontic therapy on both teeth; I foresee more complicated problems down the road.
Thank you for your comment. I totally agree!!
-Sonia
If the tooth is asymptomatic and vital, no treatment is the best treatment.
I have seen many failures of teeth treated endodontically on youngsters especially upto 12 year olds.
Most of the time there is coronal fractures. there is also chances of crown and endo failures if the apical foramen is not narrow to get a proper seal.
Hi there!! You could definitely go either way on this case, so thank you for another perspective. However, I will say that endo done well should not fail and I don’t see cracks as much as many assume that they are there. This is one area that I would love to change the mindset of others. Thanks for your comment because we do have to consider sometimes, are we opening up a bag of worms? This has definitely crossed my mind as well.
-Sonia
Has a CBCT been taken of these teeth? If so what did it show at the apices of the teeth as well as the pulpal changes from the top to the bottom of the teeth?
Michael,
No I did not take a CBCT since the mother was not ready for any treatment. She has not returned to my office.
-Sonia
Good case. If this was my child I’d do the RCTs now and internal bleaching before there’s nothing left of the canals.
Stephen,
This is such a hard decision for sure. It may be easier for us to make a decision, but I could tell it was not easy for this mom to digest my treatment options for her.
-Sonia
Was the pulp vital or was there any bleeding in the pulp when you initiated treatment?
I would highly doubt that the pulpal nerves are vital in many of these cases. I wonder if the positive cold response was from pdl nerves or a few surviving nerve fibers in the pulp.
I do direct pulp caps on occasion, but a few years later often I find the pulp is necrotic.
Sam,
These teeth have to be vital for the calcification to keep going. Remember, the function of the pulp is to lay down dentin. It can’t lay down dentin or continue to calcify if the pulp is necrotic. I hope this makes sense. And I did not do treatment on this child, since the mother did not accept treatment. She was unsure at the recall appointment since the child had no pain. I encouraged her to get a second opinion.
-Sonia
I would definitely do the endo. The ease of the procedure now will pale in comparison to the psychological trauma from all of the options should those teeth fail.
Steve,
I have to say I would agree with you. Crazy thing is that this exact same thing is happening to my daughter. I might have to post that case too. I am watching that tooth like a hawk, but not certain I will intervene yet. She is only 10 and I would prefer her to be older so that she is better in the chair.
-Sonia
Thanks again for another awesome case. I LOVE your blog. I feel like I’m learning a lot from you. Please keep posting your cases.
I would send to endo to complete RCTs for both based upon the PCO noted after one year. I’d also bill medical for the trauma visits and treatment understanding in the future the patient may need more treatment since he was 9 at the time of the initial trauma. He could potentially need implants later in life and most medical insurance will cover treatment costs from sequela. Trauma cases can be tricky with multiple options and outcomes for sure.
Hey Doc hope you’re doing great , Dan of your work n writing .
In this particular case I would like to wait and observe provided Patient is keen on coming for follow ups , which is not very common here in India unless it’s painful .
I have stopped jumping to perform root canals on fresh accident cases , pain and percussion on trauma day just goes away after 10-15 days and no periapical changes as well .
Great call! I feel the same way about this.