Endo Technology to Save Time
December 11, 2020
Tooth Story #18: Teeth Diagnosis Can Challenge Doctors
February 17, 2021
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.
46 Comments
Nice case and awesome work done . Learn something new through this case . Thanku
Plz keep uploding these interestin case doctr. Thanku
Thank you Dr. Kuldeep – I’m thanful for your feedback, and there are more cases to come!
-Sonia
Hello doc,
Wonderfull case to post.
“it is better to try and fail than fail to try” and u proved it right!!
I am a periodontist, have few questions..
*What is your opinion on apical resorption taking place in this case?
* What was the canal obturated with 2/3rd MTA and 1/3rd with?
* How was the mobility pre operative and post RCT?
Great case with great outcome! About 98% of general practitioners would condemn this one at the outset. Many things to consider here….oftentimes parents want an inexpensive “quick fix” and just can’t grasp the need to keep a god-given root in place during growth and development.
Keep these coming! I really enjoy your cases
Dear Sonia, what a great Service you did to child and mother both. What if placed MTA initially rather Ca(OH)2?
Perfection!
amazing job! really learning a lot from your tooth stories! keep it up!!
I love your presentations. Dentists are too quick to condemn a tooth and has gotten away from helping patients keep their natural teeth ( a Dr. Pankey philosophy). You not only try to do your best, but serve with compassion. Psychologically this has a great impact on your patients.
What are ur views on using TAP initially in such cases…..followed by use of CH +/-CHX for canal Disinfection…
To answer your question, I would have assumed this tooth was hopeless…I’m glad that was not the case. Great work! Thanks for sharing – this case was fascinating!
Dr. Divya,
Hi! The resorption taking place here is inflammatory resorption since the root canal was not completed. Unfortunately, the parent could not give the best history. She seemed pretty unaware of the prior treatment. At the time of meeting the patient, he was swollen, but the tooth was not that mobile. There is absolutely no mobility now as well. The tooth was obturated with MTA in the apical 2/3 and composite in the remaining coronal 1/3.
My best,
Sonia
Hi and thank you for your comment. Since the patient was really swollen at the initial appointment, I did not obturate the tooth right away. I wanted to make sure that I saw some healing after the initial disinfection to make sure that the treatment was working.
-Sonia
Dr. Sachin,
Hi! Unfortunately, I don’t know the full history of this patient since the parent was not sure of the previous treatment. I thought that perhaps someone may have tried a regenerative therapy on the patient already and it was failing or perhaps the patient got lost in follow-up. Since I was uncertain of the previous care, I went old school and wanted to get him comfortable and reduce the swelling. Once I started to see that it was working, this was my path. But, certainly I think that it is possible to try to do a regenerative therapy here.
-Sonia
Right on Steven! Thanks for reading!
-Sonia
Will do Aiman!
-Sonia
Thanks for your fellow Endo support Judy!
-Sonia
Thank you Richard – more coming your way!
-Sonia
Thank you!!
Great job Dr Sonia
Great work!
Super doctor..great work and very inspiring…
It is remarkable type of changes occurred after tooth got the right treatment. Thank u so much for sharing this type of case, it is mine pleasure to see this. I would like to tell you mam, couple of time , I’ll try to save the teeth . Even bcz I convinced those patients, who want to extract their tooth, but I succeeded to convinced them to save it, bcz if I save the tooth , I’ll feel some unique kind of happiness.
I wanna really appreciate ur effort, by shearing this wonderful, awesome case.
Thank you so much
Amazing work doc
This case reminded me of my fav endodontics lecturer Dr Apoorva
She had d exact same view of always trying to save the tooth
Your cases too are a very good learning experience
Keep it coming
Wonderful case !!
Hi Dr. Sonia, you always amazed me and others with your work …. I have treated a similar case a year back with same protocol as you did … Patient is absolutely fine now … I am glad that I saved his teeth … And your work inspires me to try my best save a tooth …
Thank you so much ….
Awesome case!!!
What did you use to irrigate? Hypochlorite? As it was an open apex
Thank you
Sir I am. general dentist from India and did these kind a cases but only in just Rs 5000 max even patient guardians are so reluctant to pay but for our own passion we do. Dr Chopra is really very good endodontist … respect for her,,, one questionDr Sonia that what you used for irrigation ,, have you used edta , sodium hypochlorite or not ,, chlorhex ,,, what will be the effect of edta on resorbing portion of apex
Amazing case….learnt a lot from ur case presentation…thank u so much
Glad to hear it!
-Sonia
I’m so glad to hear your patient’s case went well! Good work.
-Sonia
Thanks so much!
-Sonia
Thank you so much. Sounds like you had a great lecturer!
-Sonia
Thank you for advocating to save teeth! This is so important!
-Sonia
Thank you very much.
-Sonia
Thank you very much! I’m glad you enjoyed it.
-Sonia
It was a great case and kudos for saving the failed tooth!
Thank you very much! I’m glad it was a success.
-Sonia
When I look at how you do these with ease makes me want to back and do endo! Lol. Great case! Great job
You totally should, endo is such a great specialty!! Thank you so much.
-Sonia
Great question! I used EDTA and sodium hypochlorite. Just as a heads up, you don’t want to use EDTA for a prolonged period of time anyway, so there is no real chance for resorption of the apex. It doesn’t really do that. Hope that helps!
-Sonia
Thanks so much! I just used the normal EDTA and sodium hypochlorite. No need to change anything, but you just have to be careful that you don’t use too much pressure. Hope that helps.
_Sonia
HI Sonia
Well done – but did you not think of trying to regrow the nerve and obtain apex-genesis ?
Thanks
Amazing as always!
Thank you my friend!
-Sonia
John,
I think that someone tried to do a regenerative therapy on this and it wasn’t working, so that is why I did what I did. Hope that makes sense.
-Sonia
Wow! Great case. Great outcome. Thank you. CCBH
Thank you so much for reading.
-Sonia