Tooth Story: When A Necrotic Pulp Diagnosis Led to More Than I Bargained For

Sometimes people come into your life for a reason. In some cases, it’s to teach you a lesson or serve as a mentor. In others, it’s to provide you with support when you need it most. That was the case for my dear friend Krista. Although she first came into my life as a patient, she ultimately transformed into so much more.

I want to share her tooth story (which she gave me permission to share) for two reasons: First, it contains some valuable lessons about learning to trust the body’s healing process post root canal. But it also marks the beginning of a very important relationship in my life and business, and I want to show my appreciation by sharing how that journey began.

The Diagnosis: Necrotic Pulp with Chronic Apical Abscess

Krista was referred to my practice to treat tooth #18. When she came in for her consultation, she wasn’t experiencing any pain but had a very large lesion. My pulpal and periapical tests revealed that the tooth had no response to cold or pain to percussion, and I could see that the area was draining through the sulcus. Based on my evaluation, my diagnosis was Necrotic Pulp with Chronic Apical Abscess.
Below is what her preoperative radiograph looked like. Most people would probably be scared away by an x-ray like this and question whether the tooth can even be saved. But as you know, that’s not my style—I’m always aiming to #GiveTeethAChance!

See that dark area around the root? I told you it was a big lesion! And here’s her bitewing…

The Treatment: Two Visits and Some Vitapex

After my necrotic pulp diagnosis, I went inside the tooth to take a look. Upon access, I saw that there was a good bit of drainage coming out of the canal, which made me worry about trying to get everything squared away in one visit. So, I decided to medicate the tooth using Vitapex, which is an intracanal medicament containing iodine potassium iodide. It’s a pretty potent disinfectant, and you should always make sure your patient doesn’t have an allergy to iodine before you use it.

While I could’ve used calcium hydroxide, I wanted to test Vitapex to see if it could expedite the healing process. If you want to try it yourself, there are a few differences between Vitapex and calcium hydroxide that you should be aware of:

1. They have different active ingredients.
2. Vitapex is thick and yellow in color, while calcium hydroxide is a bit thinner and white. 
3. Removing Vitapex is much harder and more time consuming than removing calcium hydroxide.  Whereas calcium hydroxide rinses out easily with sodium hypochlorite, Vitapex sometimes requires that you whip out your ultrasonic to agitate it off of the walls. 

You’ll also notice that Vitapex is a bit more radiopaque than calcium hydroxide (this is the intracanal medicament radiograph):

Once everything was cleaned out and disinfected, I filled up the pulp chamber with gutta percha. The final obturation looked like this:

As you can see, there’s a bit of excess medicament and sealer in the periapical region. This is because the infection resulted in some apical resorption, which leads to a loss of your apical stop. However, with time, the excess should go away.

The Recalls: A Long But Promising Healing Process

One year out from my initial necrotic pulp diagnosis and root canal treatment, I was able to see that the excess medicament and sealer had started to disappear. Perfect! Just what I was looking for. Looking at the radiograph, the gutta percha on the distal root appears long, because some additional root resorption can happen when a patient has an infection as large as this one. 

You’ll also see that the lesion isn’t quite done healing. Although it’s progressing, it still has quite a bit more healing to go. When a lesion is taking its sweet ol’ time to heal, I simply follow it until it disappears. 

Even at the two-year recall, Krista’s lesion was still progressing but not 100% healed:

At the third-year recall, the bone continues to regenerate:

And just recently, I took another radiograph (a whole 6 years later)! Wouldn’t you know, that gutta percha isn’t long anymore. The power of the human body never ceases to amaze me.  Looks like I had good working length after all!

Cases like these are a good reminder that you just have to trust the healing process—you did your job, now let the body do its thing!

A Necrotic Pulp Diagnosis That Sparked a Conversation

On the day of Krista’s first consultation where I made the necrotic pulp diagnosis, we talked about more than just her teeth. From the moment I met her, something just clicked, and we connected on a personal level. Often, we think of chemistry in the context of romantic relationships, but it happens in platonic ones, too. The magic I felt with Krista is evidence of that!

As we got to chatting, I couldn’t help but open up to Krista about some of my struggles being a practice owner. At the time, I wasn’t in a good place with respect to leadership, and the culture in my practice wasn’t at the level I wanted it to be. Despite feeling self-conscious, something about her just made me feel safe enough to get a little vulnerable. 

Coincidentally, Krista shared with me that she used to own a small clothing boutique in California and also had a background in the dental field. So she had a certain level of understanding when it came to the difficulties I was facing in running my practice. I remember feeling incredibly seen and heard for the first time in a long time.

I didn’t know it then, but that first conversation would be the start of an incredible friendship and professional relationship.

From Patient to Invaluable Team Member

After Krista’s consultation, she mentioned to my assistant that she was new to Charlotte and was looking for something to do in her free time. As luck would have it, my assistant told her that the practice was hiring for a front desk associate position. Before I knew it, she was coming in for a work interview rather than a root canal to treat a necrotic pulp diagnosis!

Funnily enough, Krista’s working interview wasn’t the strongest of the bunch. But there was something about her energy and the way we bonded over business ownership that made me consider her anyway (plus she had actually worked in a dental office before, so she had valuable experience). I had never felt such a strong connection with a patient in all my years of practice, so I decided to listen to my intuition and offer her the job.

I thank my lucky stars every day that I did. Since starting with the practice in 2018, Krista has developed into one of my most trusted team members. Not only does she practically run the ship when it comes to my practice, but she has also become an integral part of E-School LIVE, my in-person, hands-on, live-patient endo course. She helps find all the patients we need for every session, runs all the logistics for setup and catering, and makes sure all the doctors and assistants are well taken care of and fed.

Basically, Krista is my rock. I couldn’t possibly live without her, and I’m so grateful that the universe brought her into my life. I knew teeth were special, but who knew they could literally bring people together? I truly have the best job in the world!

An accurate diagnosis is the first and most important step in providing your patients with the best treatment. Download my free Pulpal and Periapical Diagnosis Checklist to help you make the right diagnosis and treatment plan every time!

– Sonia