When trauma threatens a child’s permanent tooth

A new electric scooter for a tenth birthday party. In the excitement of trying it out for the first time and demonstrating the speed to friends, the new rider doesn’t notice the curb and goes flying over the handlebars. Landing face-first on the sidewalk, the upper lip and front teeth bear the brunt of the impact. This scenario is occurring with increased frequency, especially with the advent of electric scooters and electric bicycles, and the continued popularity of skateboards.

For years, these cases often led to difficult conversations with families. While the tooth could sometimes be retained, its root development had stopped prematurely, leaving it structurally weak and vulnerable to fracture throughout the patient’s lifetime.

When a tooth is subjected to an impact, it can often lose the blood and nerve supply to the pulp tissue, resulting in necrosis. Depending on the tooth type and the patient’s age, this can occur prior to the completion of root development. When root development is arrested, the tooth is at increased risk of premature loss, particularly from a fracture subsequent to another impact injury, due to the thin root structure.

But endodontists are now using a regenerative procedure that can help regenerate the living tissue inside a damaged tooth, allowing the tooth to continue developing naturally and improving the chances of keeping it for decades, even a lifetime.

Regenerative endodontics transforming dental care

Regenerative medicine is beginning to transform dental care, particularly for children and adolescents with immature permanent teeth affected by pulp necrosis. Rather than just removing diseased tissue and placing a root canal filling, endodontists can now, in appropriate cases, create the conditions for new vital tissue to develop within the canal space, allowing continued root maturation and significantly improving the long-term prognosis for the tooth. The goal is simple: preserve the child’s natural tooth whenever possible and reduce the likelihood of premature tooth loss.

Limitations of traditional treatment

Traditionally, treatment options for this situation were limited to an apexification procedure, or an attempt to perform conventional root canal treatment. A more recent option made popular starting with a 2004 case report is regenerative endodontic treatment. The goal of regenerative treatment is the regeneration or replacement of necrotic pulp tissue with new vital tissue aimed at continuing root formation, which can result in thicker root structure and formation of a tapered root apex, mimicking the normal course of development.

A biologically based approach

Regenerative treatment is based on disinfection of the pulp space, followed by the introduction of stem cells that can repopulate the vital tissue within the root canal. This procedure only requires two visits within just a couple of weeks.

The major advantage in performing this procedure on children or adolescents is their great capacity for healing. Another advantage is the limited number of appointments required for treatment, so compliance is not much of an obstacle. Success for this procedure is measured primarily by the radiographic observation of continued root development, evidenced by increased thickness of the root structure as well as the formation of an “apex” at the end of the root. Increased root thickness will provide greater resistance to fracture in the future, greatly improving the chances for preservation of the tooth for a significant portion of the patient’s lifetime.

Preserving the natural tooth

The goal of preserving the natural dentition has multiple benefits. The ability to chew is paramount to maintaining one’s nutritional requirements, so any compromise in this ability, such as missing teeth, can compromise a patient’s nutritional status. Another important consideration is the influence of the dentition on the patient’s ability to speak. The presence of a full dentition greatly influences one’s ability to form words properly and the sudden loss of a tooth can greatly affect one’s ability to speak. So preserving the natural dentition has multiple benefits that can contribute to a patient’s systemic health as well as their sense of well-being.

Patient story

Consider the following scenario: A seven-year-old child falls off the swing and cracks her tooth. Not only is the tooth damaged, but also the living pulp inside the tooth. Since the root of an immature permanent tooth continues to grow for two to three years after the visible crown is in place, an injury during this timeframe can significantly impact the living pulp, which is essential for the tooth to finish developing and become strong. When the pulp of an immature tooth is damaged, the tooth may stop developing unless it can be saved.

In the past, saving this type of injured tooth was virtually impossible. Most parents would have little choice but to opt for the tooth to be pulled and eventually replaced with a cap. But in the meantime, the space would remain open until the child is much older, as dentists can’t put a cap on a tooth until the mouth is fully grown.

Looking ahead

Regenerative endodontics represents one of the most significant biologically based advances in modern endodontic care. Although research continues to refine protocols and better characterize the tissues formed during healing, the clinical benefits are increasingly clear.

With the addition of regenerative endodontic treatment options, we now have a greater ability to preserve those teeth that develop pulp necrosis prior to the completion of root formation. Providing this treatment option expands our opportunity to do just that: preserve the natural teeth, potentially for a lifetime.

W. Craig Noblett, DDS,  is president of the American Association of Endodontists (AAE) and director of the Division of Endodontics at the University of Minnesota School of Dentistry in Minneapolis, Minnesota, where he also serves as graduate program director in endodontics. He joined the Minnesota faculty in April 2020 and assumed his current leadership roles on September 1, 2020.

He received his dental degree from the UCLA School of Dentistry and his master’s degree and certificate in endodontics from the University of Iowa. He formerly served as an assistant director of the general practice residency (GPR) program at Northwestern Memorial Hospital and Northwestern University School of Medicine in Chicago.

Noblett is a past president of the American Board of Endodontics (ABE), where he served six years as a director, including two years as president. He is a Fellow of the American College of Dentists and the International College of Dentists, has chaired several committees for the AAE, and is a past president of the Northern California Academy of Endodontics. He has also served on the board of trustees of the California Dental Association (CDA) and chaired the CDA’s Committee on Volunteer Placement and its Nominating Committee.

The American Association of Endodontists (AAE), founded in 1943 and headquartered in Chicago, represents more than 8,000 members worldwide. Endodontics is one of twelve dental specialties formally recognized by the American Dental Association.

The AAE is dedicated to excellence in the art and science of endodontics and to the highest standard of patient care. The Association inspires its members to pursue professional advancement and personal fulfillment through education, research, advocacy, leadership, communication, and service.

The AAE also maintains patient-focused information and a search tool that helps patients find an endodontist in their area. The Association shares updates on X, Facebook, LinkedIn, and Instagram.