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Orthodontics/Orthodontics & Root Canal on 10 year old

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QUESTION: My 10 year old daughter just had to have a root canal because she developed an infection on her tooth that is just next to her front tooth (incisor?). She hasn't had this tooth very long and she has good oral hygiene and has seen the dentist every 6 months since she was a baby. I am certainly devastated about the whole thing. Her Endodontist informed us that he thinks it was caused by a condition (sorry cannot remember the name) that causes the tooth to fold in on itself during formation which caused a narrow path directly to her root :( I have so many concerns about what this means for her down the road but I felt like we had no other option than to do a root canal at the time. I have been doing some research on root canals on the web and a slew of articles came up about how root canals can cause auto-immune disorders later in life and a bunch of other degenerative illnesses not to mention the tooth is weakened and prone to other dental problems.

She has also been seeing an orthodontist for the last 1.5 years but hasn't started treatment yet because he wants to see how her teeth come in first because there is a concern that her mouth might not be large enough to accommodate all her teeth. He discussed how it might be the best option to pull a couple adult teeth on top(one on each side)to make room as a last resort.

My question is this...would it be possible to pull the dead/root canal tooth instead to make room? I realize it is not the same shape as the one it will replace and a bunch of creative orthodontics will need to be done but I think it would be better than having a weakened dead tooth in her mouth that can cause problems later in life.

ANSWER:
Hello Danielle,

I had a long conversation with a close colleague of mine who is a Board Certified Endodontist. He reviews articles for the Journal of the American Dental Association, and is former Chairperson of the Department of Endodontics at the Meharry Medical School Department of Orthodontics. He and I have in fact published in the area of Root Canal Therapy cautioning about the use of Formocresol. The use of such agents, while common in the early days of dentistry, is no longer considered acceptable. You concerns for auto-immune disorders are likewise something I would like to address.  This is really a two part question; one section inquires about Orthodontic care in a 10 year old still in the mixed dentition and perhaps requiring extractions, and the second part of the question involves the ramifications of root canal therapy or extraction of an upper lateral incisor. My colleague Dr. Block published this recent paper:

http://www.tenndental.org/docs/ce/Exam%2014%20-%20Are%20You%20Still%20Using%20Fo

In it he notes:  “These data show Formocresol, even in reduced concentrations, has the potential to result in negative immunologic, systemic, toxicological and clinical consequences .”

However, current 2015 root canal procedures do not require or call for the use of any potentially toxic or carcinogenic agents like Formocresol. Since I am neither an Endodontic Specialist, nor Board Certified in this Specialty area of dentistry, I will limit my clinical comments regarding the intricacies of root canal therapy.

Enamel clefting of the upper lateral incisor enamel which has turned into an endodontic problem is sometimes called a Perio-endo continuum.  This describes a situation when inflammation  and infection of the periodontal issues have traveled from the gums and down into the root area. There it is contributing to an endodontic problem.

Let me now go ahead now and address your orthodontic question more specifically.  As always, let me first mention the legal mumbo-jumbo, namely what I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Indeed, in the ultimate analysis all final diagnoses and decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records that may be needed.

So Danielle, let me examine your comments step by step. You wrote:

” My question is this...would it be possible to pull the dead/root canal tooth instead to make room? “  

In all likelihood, this probably would not be a wise choice. In addition to having different looking crowns ( the actual white “teeth” that you see) clinically, roots of the lateral incisor and the adjacent canine are very different.  Why is all this significant ?

A properly done root canal can resolve this issue. This would allow the tooth to remain in place. For esthetics and function, a big round bulky canine make a very poor looking replacement for a small delicate lateral incisor. The contacts with the adjacent central incisor would be atypical as well. The idea of substituting a canine for a lateral incisor is not new. I have seen it done in the past, but that was years ago when there was much less emphasis on esthetics. Realize too that the gingival cuff, that is the gum tissue that forms the gently round arc over the tooth will present a poor match with the other incisors.

So for esthetic reasons, a root canal an maintaining the lateral incisor tooth I believe would be the better option. It would also permit better meshing with the corresponding lower teeth. This too is very much in the esthetic zone of the smile, and compromises can have very profound consequences.

You mentioned the upper dental crowding and the possibility that teeth might have to be extracted. Your daughter is still young enough that perhaps a palatal developer or palatal expander could be used to orthopedically broaden the upper jaw ever so slightly to create more room for her teeth, thereby avoiding the need for extractions.

Here is a link:   http://braces.com/1473.html

Even in the extreme case where premolar extractions need to be performed, I believe I would still recommend retaining that lateral incisor with a root canal, or in the worst scenario, a dental implant or bonded bridge if necessary.

You also wrote:

“ I realize it is not the same shape as the one it will replace and a bunch of creative orthodontics will need to be done but I think it would be better than having a weakened dead tooth in her mouth that can cause problems later in life.  “  

This is a viewpoint which I respect, but personally do not agree with. I might have been more amenable to this in 1985, but not anymore in 2015. Esthetic dentistry has become the mainstay of the profession it seems. The standards for beautiful teeth have advanced a great deal in the last several decades. Your daughter I believe would probably always stare at a bulky canine, even if it has been reshaped a little with the help of a drill and some cosmetic dentistry.  It still largely leaves untouched the size of the root, the contacts with the adjacent teeth, and the gingival esthetics.

Describing an endodontically treated upper lateral incisor as a weakened dead tooth is technically correct but I think provides a false characterization of the true status of the tooth.  Modern endodontic treatments when followed up with the necessary adjunctive restorative treatment creates a very stable and esthetic result.  I do not believe it will necessarily  as you said “ cause problems later in life”.

So Danielle, what I am saying, in brief summary is this:

1)   Consider getting a Periodontal and Endodontic Consultation and have the lateral incisor endodontically treated.
2)   Follow up the endodontic treatment procedure with eventual restoration of the tooth with a veneer, etc as recommended by her dentist or Pediatric Dentist.
3)   Ask you Orthodontist if palatal expansion of the upper jaw is possible so as to minimize or eliminate the need for any proposed extractions of premolar teeth due to current crowding.
4)   Start and complete the orthodontic treatment  as per the recommendations of your Orthodontist. Very gentle orthodontic management and movement of endodontically treated teeth is always wise, and I am sure all the doctors know this .
5)   It would be worth having your daughter wear an upper clear retainer at night for the long term t help protect the incisor from the effects of night time clenching or grinding of her teeth. Here is a link:

http://braces.com/47601.html

I would enjoy a follow up question to this because it is an interesting clinical challenge. Any dental photos you could attach would be helpful. I hope this has been helpful. I usually take a week or so to answer these questions because I actually ask other doctors for input. I hope this has been helpful. Please stay in touch and let me know how all this works out.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I also will sometimes consult with other doctors on complex questions. This of course takes time.  Your understanding is appreciated.


---------- FOLLOW-UP ----------

Teeth
Teeth  
QUESTION: So sorry for the delayed follow up as we have been out west for 2 weeks for a famity vacation. First, I really appreciate the detailed response and your information was very helpful. It has certainly helped put my mind a little more at ease. I found out the name of her condition is densure invaginatus. I am still very upset but I know it is out of our control. She got her filling done in her root canal tooth yesterday along with her bi-annual cleaning. I still don't understand how her condition was not caught early on during all her routine checkups & exams. I just wish there was something that we could have done to prevent it. Her dentist said her other opposite incisor looks OK but I am not completely convinced.I have attached a picture of her top teeth that I took but not sure if it's helpful ( (the rpot canalysis toothe is on her right). I am going to talk to her orthodontist within the next month to see what he says about treatment now. I am not sure what materials were used in her root canal. I know he mentioned he had to use two different materials. I am still very concerned about her long term health.
If you have anything to add, I would love to hear it. I appreciate your time. Thanks!

Answer
dens in dente
dens in dente  

Incisors with braces
Incisors with braces  
Dear Danielle,

Thank you for your follow up. You really have two pivots to your question; one emphasis is Orthodontic , and the other is Endodontic .

I have actually had several conversations with my friend the Endodontist, and I encouraged him to become an “expert” here on this website. I will add the link to his contact information at the end of this reply.   I wanted at this point to address your questions point by point. I would invite you to repost these very same questions in the general dentistry area .

My previous comments about the limitations of my responses are still in effect, so as always, let me first mention the legal mumbo-jumbo, namely:

What I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Now let me address each of the points which you raised

#1
You Wrote:  I found out the name of her condition is densure invaginatus.


Yes Danielle, you did find the condition, and it is termed “ dens invaginatus” and is often termed “ dens in dente”. Here is a link:

https://en.wikipedia.org/wiki/Dens_invaginatus

Basically when teeth form they do so in certain areas by sort of bringing together subcomponents. If you can imagine three rectangular units of a modular home, all being placed next to one another so that the long axes are parallel, that is sort of how the crown of an incisor forms. In fact the slight bumps or ribbing one sees at the incisal edge of a newly erupted upper incisor (called mamelons), reflect where the three subcomponents coalesced and fused.  

https://en.wikipedia.org/wiki/Mamelon_%28dentistry%29

Sometimes there are irregularities in the fusion, as well as in other areas of the tooth, such as along the root. This is shown very nicely in the images :

http://directionsindentistry.net/dental-gallery-for-dentists/dens-in-dente-later

Credit for the image  to : DirectionsinDentistry.net  

An interesting article was also published by Suchina, Ludington, and Madden  (Oral Surgery Oral Medicine Oral Pathology 11/1989; 68(4):467-71. DOI: 10.1016/0030-4220(89)90148-5).

The paper  “Dens invaginatus of a maxillary lateral incisor: Endodontic treatment “ describes a case somewhat like your daughter’s.  I have included the abstract.

ABSTRACT A right maxillary central incisor and an adjacent lateral incisor with a dens invaginatus were identified as requiring endodontic treatment. Both teeth were treated by nonsurgical means. Thirteen months postoperatively the central incisor showed evidence of periapical resolution, whereas the lateral incisor did not. The lateral incisor was then treated with apical curettage, an apicoectomy, and retrograde amalgam filling. One year after the surgical procedure the periapical tissues of both the lateral and central incisors exhibited satisfactory resolution. This case demonstrates that certain cases of dens invaginatus can be successfully treated only with a surgical approach.

The bottom line being that root canals may be effective is some cases. In other cases additional procedures such as apicoectomies may be needed. This article was published in 1989. Since then newer materials such as Mineralized Tri-Aggregate (MTA) are employed and substances such as silver points, formoscresol, and amalgam have fallen by the wayside.

#2
You also asked: I still don't understand how her condition was not caught early on during all her routine checkups & exams. I just wish there was something that we could have done to prevent it. Her dentist said her other opposite incisor looks OK but I am not completely convinced.


A periodontal probing, close magnified visual examination of the tooth, and a periodontal radiograph (digital if possible) can help minimize the possibility of misdiagnosing the contralateral lateral incisor. These conditions can vary from slight to very profound. A very subtle dens in dente condition might be hard to detect, and only become more noticeable one dental decay, periodontal inflammation, and possible endodontic disturbances begin to occur.

#3
You also wrote: I am going to talk to her orthodontist within the next month to see what he says about treatment now.


You and your Orthodontist may be able to formulate a more appropriate treatment plan after consulting with your family dentist and an Endodontist on the viability of the now Endodontically treated lateral incisor. I am going to assume that the other lateral incisor is normal, and that the Endodontic treatment which your daughter received will be successful. That being the case, I would suspect that the Orthodontist will NOT choose to extract any incisor(s).  If indeed palatal expansion can not achieve the needed space to alleviate the dental crowding and to establish the proper bite needed, then premolar extractions become a consideration. Again, your Orthodontist can help you with this decision.

#4
You also wrote: I am not sure what materials were used in her root canal. I know he mentioned he had to use two different materials. I am still very concerned about her long term health.


Danielle, I suspect that in 2015 your dentist or Endodontist used the currently appropriate treatment modalities. You are in Michigan, and the University of Michigan has one of the nation’s premier dental schools. For root canals, Gutta-Percha and MTA (Mineralized Tri-Aggregate) are two of the most commonly used materials. These are very safe, and I do not believe you have to be concerned about any impact on the immune systems, inherent material toxicity effects, contact reactions, etc.

#5
You also wrote: If you have anything to add, I would love to hear it. I appreciate your time. Thanks!


In closing, I would like to again emphasize that although I have earned dental specialty credentials in two fields, I am not an Endodontist. I would highly recommend that you reformat your questions, add any new issues, and then resubmit your question to an Endodontist here at AllExperts.com for additional perspectives. Please go to the category " Dentistry" . The link is below. There are several people there with special expertise in Endodontics.

http://www.allexperts.com/el/Dentistry/

In summary Danielle, the following action steps:

1.   Check with Family Dentist & Endodontist to confirm diagnosis of other lateral incisor.
2.   Evaluate and monitor the Endodontically treated lateral incisor
3.   Consult with the Orthodontist to define an Orthodontic treatment plan for your daughter that includes possible alternate scenarios should the treated lateral incisor indeed end up being lost
4.   Consider using dental implants, if needed, as an option instead of solely employing Orthodontics in case the treated lateral incisor fails.
5.   Post Orthodontic treatment, employ long term orthodontic clear retainer wear (much like a night guard) to protect against orthodontic shifting and to protect the Endodontically treated lateral incisor assuming it is stable and has not been lost.

Danielle, I hope this follow up reply has been helpful. Please rate it and also please submit your question for a third response from an Endodontist listed in the "Dentistry" category at the link shown above. . Thank you  for writing and all the best. This was a very interesting question Danielle.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.

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Paul Supan, DDS, MA, MPH

Expertise

First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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