Some cases just really break my heart, and this tooth trauma case in particular really gets me fired up.
This is a tooth story about a 10 year old boy with tooth trauma who was completely mismanaged by his dentist. I feel kind of bad saying that, but “mismanaged” is the only word that fits. I am not sure if this case is due to a lack of education or simple neglect. Regardless, it’s cases like these that make me believe in my mission to save teeth and spread endodontic education far and wide — more than ever.
My pediatric tooth trauma patient
So the patient we’re talking about was in an accident about a year before our first appointment. Teeth #7, 8 and 9 were all avulsed. The teeth were kept in milk until his dentist could see him. All of his teeth were reimplanted, and the dentist has been following their condition in the year since.
According to the patient’s mom, the patient was also under the care of an orthodontist, who was placing “bumpers on the adjacent teeth to prevent the teeth from hitting.”
Interestingly enough, this patient was referred to our office by way of our periodontist who wanted to try to save the teeth of this young boy. He preferred it to removing his teeth and replacing them with implants. To that, I say, “Hooray!”
The preoperative radiographs show an insane amount of inflammatory resorption on each tooth, leading them to being extremely mobile.
Seriously, my heart breaks for this 10 year old child.
Now, we are subject to heroics and who knows what else if we manage to save these teeth from the inflammatory resorption that has occurred. Noooo pressure, right?
What would have prevented this situation?
It’s very simple. After the avulsion, the nerve gets severed. In a tooth with a mature apex, the tooth will likely go necrotic. And since there is most definitely bacteria present there, that bacteria will stimulate the process of inflammatory resorption unless it is dealt with by root canal therapy.
After an avulsion, root canal therapy should be initiated within 10-14 days, NOT AFTER A FULL YEAR. This is why I say this patient’s case was mismanaged. Leaving these teeth under simple supervision is unacceptable and, worse, it could have prevented this whole situation in the first place. Knowing this simple piece of information could have saved this poor boy’s smile and lifelong confidence. I see my own story in him, and it just crushes me.
Imagine what this poor boy has to go through now, and all we can do is pray that our treatment will buy him time until he is at least 18 years old. Losing these teeth at this point in his development is not an option, as we would also lose any bone that could support implants in the future.
How we handled this case.
Our first goal is to decrease the mobility of his teeth and start to regenerate the surrounding bone by controlling the infection. At the same time, I wanted to try to halt the resorption and re-establish the PDL around these teeth.
This must be done with long-term calcium hydroxide therapy. Once the teeth are ready for obturation, MTA will be needed due to the open apices.
Patient compliance in a case like this is really tough, because there are a lot of appointments involved, and it usually takes us a good year to get the teeth back to where we want them to be.
Even after treatment is complete, follow up is CRUCIAL in any good trauma case. So we will follow the patient up in intervals of 1 month, 3 months, 6 months, and then once a year for 5 years. I communicated to both him and his mom just how important these appointments are for the outcome of his teeth.
I plan to keep you posted on how this case progresses.
There are lessons to learn from this tooth trauma case.
When an avulsion happens, focus on getting that tooth (or teeth) back in the mouth as quickly as possible. If you can do it in under an hour, that will give the tooth the best prognosis.
Use the first visit to stabilize the teeth and start some baseline testing. You do not want to start the endodontic treatment at this visit, because you need the PDL fibers to heal from the trauma.
If you take away only one thing from this blog post, it’s to make sure that you start root canal therapy within 10-14 days after an avulsion, not sooner and not later. This is how you will save a child’s smile and confidence for the rest of their life.
You will do these root canals over multiple visits until the teeth are no longer tender and you see the PDL re-establish itself.
Please help me save teeth and smiles. Empower yourself, and share this blog with a general dentist who loves to learn! Another thing you can do is download this free Tooth Trauma Guide and share it with your patients, so they know exactly what to do when a tooth gets knocked out.