Diagnosis by discoloration?
Jon Richards DDS MS
When a patient comes in with a discolored tooth, what comes to mind? There is a lot of different views/approaches to possible treatment options. This case might stir up some thinking, as it probably contradicts the traditional course of action
Hx of trauma to mn anterior 20 years ago. Teeth repositioned and ortho done later, lingual fixed retainer present. In the past 3 years, progressive discoloration noticed with tooth #24. Pt reports intermittent mild pain in the area, but could not positively identify a tooth, describes the pain as mild with cold sensitivity and biting tenderness- last time was 2-3 months ago. Hx of free gingival graft with #24 and #25 12 years ago due to recession.
Eval: #24 grey discoloration (see clinical photo). WNL to perc and palp. No response to cold, EPT responsive WNL. #25 slightly yellow discoloration, calcific metamorphosis radiographically. No response to cold, WNL to perc and palp, EPT responsive WNL.
CBCT indicates normal appearance of periapical tissues with both 24 and 25.
Definite reaction to the trauma episode is evident by the radiographic appearance of the canals. In the absence of symptoms, radiographic signs of pathosis, and especially with subjective complaints contrary to the diagnostic testing, the recommendation was to postpone any treatment until there is a confident sign of disease or symptoms. Patient was not concerned about the discoloration and agreed.
Pt will call if pain returns. I advised monitoring at future preventative/annual exams. We now have a good “baseline” set of diagnostic information to compare with future data.
In my opinion, we always need to consider the “cost” of treatment that we provide. In this case, the cost isn’t necessarily monetary, but what is the cost or negative effect on the structure of the tooth? Tooth #25 already has thin dentin walls (see CBCT sagital slice), will an endodontic access and endo improve the long term prognosis? Is there “disease” there to begin with? Could be patient’s pain be coming from another source (tooth vs. nonodontogenic?). If the tooth fractures later, how difficult will restoration be? These are all questions that should be considered prior to initiating treatment on a tooth that might not neccessarily require it at this point in time.