I have a reputation in my dental community for being a tooth saver. I’m the one who doctors refer their patients to when they need a second opinion (or maybe a miracle). I’m proud of this reputation, not only because it means I’m good at what I do, but because who doesn’t need a little hope and positivity every now and then?
My Diagnosis: Previously Initiated Therapy with Acute Apical Abscess
A few years ago, I had the pleasure of seeing a young boy at my practice when his mother brought him to me for a second opinion. Another endodontist had told her that her son would need his tooth extracted, but she was desperate to save it. This endeared her to me right away—and it didn’t hurt when I found out that we had graduated from the same high school in upstate New York!
The story was that two years prior, the boy fell, causing total avulsion of tooth #9. He had it reimplanted about an hour later, and began treatment on it, but either the treatment—it looked to me like regenerative therapy—failed, or they never completed it in the first place. Neither the patient’s mom or myself knew much about the previous treatments, so I had to use what I had to fix it.
When I examined the patient, I noticed a few things: he had some vestibular swelling, he experienced pain to percussion but no sensitivity to cold, he had a grade 2 mobility, and probing all looked normal. I diagnosed his tooth #9 as Previously Initiated Therapy with Acute Apical Abscess.
You’ll notice in the radiograph that the tooth has an open apex and had been accessed. You can also appreciate the inflammatory root resorption that has occurred on the distal aspect of the root.
When it comes to children, I say try whatever you can and don’t give up so fast. I think that the conversation you have with the parent is super critical. They need to understand that the tooth is compromised, and even though you are trying your best, they need to be prepared for loss of the tooth.
My Second Opinion: Could I Save This Tooth?
It was time to give my second opinion. My strategy with kids in cases like this is to try to keep the tooth in place as long as possible, even if it doesn’t have a great long-term prognosis. Doing so will buy time until the child is old enough to get an implant. It’s important to keep the bone in function to prevent too much bone resorption so that the patient remains an implant candidate throughout their growth and development. Does that mean the tooth is just a space maintainer? Maybe—but it’s better than giving up!
When it came time to treat the tooth, I remembered a former teacher who was incredible at dealing with trauma. He had such a powerful influence on me that trauma is, as strange as it may sound, one of my favorite aspects of endodontics. I followed my teacher’s protocol to the letter, so if he reads this blog post, I hope he’ll be proud of me!
My primary goal for this patient was to halt the inflammatory resorption that was happening due to a bacterial infection in the canal. I wanted to reestablish the bone and the periodontal ligament. To begin, I accessed the tooth and obtained a working length, being careful not to instrument the apex too much since the walls were quite thin. I relied on irrigation for the majority of the cleaning.
Next, I packed a slurry of calcium hydroxide paste (I used Ultracal by Ultradent with a Vista tip). I then let this medicate the tooth for about one month.
Signs of Improvement
When I saw the patient the next time, he had no swelling and his tooth was no longer tender to percussion. I re-irrigated and gently re-instrumented, then placed a dense pack of USP calcium hydroxide, which I let sit for 3 months before the patient’s next appointment.
Check out the difference in the radiopacity of the material. Since this calcium hydroxide has an equal radiodensity to dentin, it makes the tooth appear completely calcified. You can also notice some small differences in the size of the periapical radiolucency, as well as positive changes on the root’s lateral aspect.
At the patient’s next appointment, the periodontal ligament was beginning to reestablish itself, and the tooth was ready for obturation. I knew I’d have to adjust my normal methods since the apex was wide open. So, I used white MTA to obturate in the apical ⅔ of the root, placing a wet cotton pellet over it for several days to ensure proper setting.
Later, the patient returned for the final restoration, and I restored the remainder of the tooth with composite.
We continued to monitor his progress, but check out the radiograph after the 3-month recall. You can already see some regeneration of tooth structure on its distal aspect, plus just a few remnants of pathology on the mesial aspect of the root.
You’ve Gotta Have Hope
I think the tooth has a fantastic prognosis, and I wouldn’t just call it a space maintainer. Imagine if that other endodontist had extracted the tooth—it would have been a total disservice to this young boy, and still I wonder how many other dentists would have agreed that the tooth wasn’t savable.
As dentists, we need to consider all the possibilities and their potential impact on our patients’ lives.
Because of my second opinion, this young man doesn’t need to feel self-conscious or worried that he’ll lose his front tooth. But my treatment of his case isn’t heroic by any means—this is simply what I see on a daily basis, regenerating bone for case after case. Root canals are incredibly powerful, and it’s important that we give teeth a chance before extracting them.
I hope you learn from these cases and understand that sometimes it is worth the try—not just for kids, but for adults, too. A second opinion and a little hope can go a long way. You just never know.