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This is one of my all-time favorite tooth stories. It’s about a patient with an acute apical abscess, and how she got her bone back. But it’s also a testament to the incredible resilience of the human body—and to the power of a root canal! If you’ve ever doubted endodontics, then you won’t want to skip this tooth story about an acute apical abscess treatment with the power to regrow bone.
A few years ago, a 15-year-old girl walked into my office with her grandmother for an emergency appointment. She had tears rolling down her face—and down her extremely swollen jaw. As someone who has experienced horrible swelling due to a tooth infection, I really felt for her!
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, her parents had assumed that everything was fine. Unfortunately, you know what they say about assumptions…
Over the next few years, she experienced pain and swelling in the area every so often, but it would go away after a little bit. No cause for concern… right?
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! This is a bonkers amount of bone loss.
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. (Until, of course, she felt it big-time.)
Finding the culprit
I knew right away that this patient was going to require careful attention. Before I did anything else, I completed my standard diagnosis protocol to make sure I made an accurate diagnosis. 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 grandmother 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. So many dentists would condemn these teeth due to that enormous lesion, but lesion size is not a determinant for healing ability or bone regrowth. It just might take longer.
I began emergency treatment right away, starting with a pulpal debridement on tooth #25. I performed an incision and drainage, and prescribed the patient with antibiotics (Clindamycin 300 mg 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. Here is the post-operative radiograph.
I reviewed the treatment post-operatively with the patient and her grandmother to explain what I was seeing, and I asked them 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. Here’s the part I didn’t mention before: When I presented my treatment plan to the patient and her grandmother, 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. I saw my own story in hers, and I felt so strongly that I needed to help her.
Of course as professionals, we deserve to be paid for our hard work—but some days you just come across cases 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. Here was her 6-month post-op CBCT:
Thank goodness for social media, though—I ended up reconnecting with the patient over Facebook! I was so invested in her case that I asked her 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? Endodontics is freaking magic.
One lesson to take away from this is not to forget to do your cold test and take the time to understand the disease’s primary etiology. If a 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.
I love to share this case because it always shocks people. Nine out of ten dentists would have advised extraction in this situation. 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!
It all comes back to the WHY of endodontics, and your critical thinking skills. When you understand why root canals work and you follow the cardinal rules, your patients can experience extraordinary healing. Even when they have an acute apical abscess like this young lady.
Don’t believe me? Enroll in E-School to learn key endodontic principles, boost your confidence, and save teeth other dentists would condemn. You are a healer and a tooth saver… if you believe you are capable of it. Empower yourself to rise to the challenge, my friend.