Endo Addict

An 11-year-old female patient presented to my clinic complaining of:

🔸 Severe pain in the lower right posterior region
🔸 Grade II mobility of the mandibular first molar
🔸 Mild facial swelling

On taking the history, the patient's parent reported that the tooth had received a composite restoration approximately 9 months earlier, but no endodontic treatment had been performed.

After thorough clinical and radiographic examination, the diagnosis was established as:

✅ Pulpal Diagnosis: Necrotic Pulp
✅ Periapical Diagnosis: Symptomatic Apical Periodontitis with symptomatic apical involvement

🩺 Treatment Plan
First Visit (Emergency Appointment)

✔️ Access cavity preparation
✔️ Complete chemo-mechanical preparation with thorough cleaning and shaping of the canals
✔️ Irrigation protocol performed meticulously
✔️ The canals were sealed at the end of the visit without placing an intracanal medicament, aiming to control the infection through effective debridement and a well-sealed environment.

Second Visit (1 Week Later)

The patient returned completely comfortable with resolution of pain and facial swelling.

Treatment included:

✔️ Final irrigation protocol
✔️ Three-dimensional obturation of the root canal system
✔️ Coronal sealing of the access cavity

The tooth was then referred to the prosthodontic team for definitive coronal restoration, ensuring long-term protection against coronal leakage and fracture.

# # Saving a Strategic Premolar: When Every Millimeter Matters

A 23-year-old female patient was referred by her prosthodontist for nonsurgical root canal retreatment of a her first premolar. The tooth was asymptomatic, but radiographic examination revealed a short previous root canal filling associated with localized asymptomatic apical periodontitis, indicating persistent infection despite the absence of clinical symptoms.

The case presented a unique challenge. Although the remaining coronal tooth structure was in a compromised but manageable condition, the tooth held significant esthetic and functional value for the patient. With a wide smile line and a strong desire to preserve her natural dentition, maintaining this premolar was especially important because the adjacent first molar had already been extracted. Losing the premolar would have further complicated her restorative options and negatively impacted long-term function.

A thorough discussion was held with the referring prosthodontist regarding the restorability and strategic value of the tooth. Following clinical and radiographic assessment, the tooth was deemed restorable with a favorable restorative prognosis. The prosthodontist's request was clear: provide the highest possible quality of endodontic treatment to maximize the long-term survival and success of the tooth within the overall treatment plan.

Despite the challenging root canal anatomy, a decision was made to complete the retreatment in a single visit. This approach was chosen to minimize the risk of coronal leakage and bacterial recontamination associated with temporary restorations between appointments, particularly in a tooth where preservation of the remaining structure was critical.

The previous root canal filling was carefully removed, the complex canal system was thoroughly cleaned and disinfected, and the canals were obturated to their full working length. The treatment was completed successfully in one session, providing an optimal biological foundation for definitive restoration.

This case highlights the importance of interdisciplinary treatment planning, strategic tooth preservation, and meticulous endodontic retreatment. Even in the presence of apical pathology and challenging anatomy, a well-executed nonsurgical retreatment can offer a predictable opportunity to retain a valuable natural tooth and support long-term restorative success.

First she said ‘No treatment.’ After the pain of extraction, she returned… and now I’m facing a long, severely curved canal in a patient with a gag reflex that tests every bit of my patience.

🚨

A 24-year-old patient arrived at my clinic in extreme distress, literally hitting his face with his hand because of unbearable pain. This happened about 16 hours after completing root canal treatment on tooth #35 with another colleague.

The pain was so severe that the patient could barely communicate. With the "supervision of an ER physician" , we administered intravenous analgesics to stabilize him so we could take a proper history and perform an examination.

**History of the case**

For nearly a month, the patient had been visiting a dentist for treatment of tooth #35. What started as a simple filling turned into root canal treatment after the dentist discovered "deep caries".

According to the patient, the dentist explained that due to (deep decay and chronic inflammation) , the canal was blocked and required several visits to negotiate and clean.

After each appointment, the patient experienced pain for about "two days", but it was manageable with analgesics.

About **16 hours before coming to my clinic**, the dentist informed him that the canal had finally been obturated successfully and that he should return the following week for the final restoration.

However, 3 HOURS later, the patient began experiencing severe pain again. This time the pain did not respond to analgesics.

That night he could not sleep at all because of the pain. He tried contacting the clinic but received no response until the following day. The assistant informed him that the dentist believed it was a “flare-up” due to the difficulty of the root canal treatment and advised him to take Ibuprofen 800 mg every 6 hours.

Before reaching my clinic, the patient had taken (9 tablets), but each time the relief lasted less than one hour, and the pain returned even stronger.

**Clinical findings**

• Tooth #35 had a large temporary restoration with bleeding gingiva, as the patient had attempted to remove the filling himself to relieve the pain.
• **Severely inflamed gingiva** between #35 and #36.
• Sensibility tests were positive in #34, #35, and #36, but these results were **unreliable due to the patient's severe pain and psychological distress**.
• **Percussion:**
#35 +++ severe pain
#34 and #36 + mild pain
• **Palpation:** the patient could not tolerate touching the tooth or surrounding tissues.
• **Mobility:** grade I mobility in #35.

**Radiographic findings**

The radiograph showed:

• A "deep distal cavity" on #35 extending beyond the crestal bone.
• A (long radiopaque material running beside the root).
• The canal appeared **radiolucent with no visible obturation material**.

This strongly suggested the presence of a foreign body associated with the root canal treatment**.

**Treatment decision**

The patient insisted on **immediate extraction** because of the unbearable pain.
His father, however, strongly wanted to save the tooth if possible.

After evaluating the situation, I explained that extraction would be necessary to remove the foreign body, but we could attempt **intentional replantation** to preserve the tooth.

Initially, the patient refused. After reassuring him that he would have (direct contact with me at any time), and that if the pain became unbearable I would extract the tooth even in the middle of the night, he agreed to proceed.

**Treatment procedure**

1️⃣ Local anesthesia
2️⃣ Atraumatic extraction of tooth #35
3️⃣ The tooth was immediately placed in HBSS to preserve the periodontal ligament cells
4️⃣ Under magnification and strong suction, the gutta-percha piece was carefully located and removed while protecting the PDL
5️⃣ Apicoectomy followed by retrograde filling with MTA
6️⃣ The deep coronal margin was sealed using flowable composite
7️⃣ The tooth was replanted into the socketand stabilized using a flexible splint with wire and composite
8️⃣ Additional coronal reconstruction was performed to secure the temporary restoration
9️⃣ The root canal was extirpated and irrigated with saline
🔟 The canal was medicated with (corticosteroid-antibiotic paste) to control inflammation and reduce the risk of **inflammatory root resorption**, especially in the traumatized root surface where cementum was lost.

NOTE : Extra-Oral time : 17 m

The patient was also prescribed systemic antibiotics, NSAIDs, and paracetamolfor pain control.

**Follow-up**

The next clinical follow-up is planned "after 6 weeks", with regular phone calls to monitor the patient’s condition.

📞 **Next-day phone call:**
The patient reported (significant comfort and relief, and he appreciated our effort to try to rescue his tooth)

✨ **Stay with us for the continuation of this case and the final outcome.**

Mastering difficult anatomy requires more than skill—𝔦𝔱 𝔯𝔢𝔮𝔲𝔦𝔯𝔢𝔰 𝔞 𝔯𝔢𝔩𝔦𝔞𝔟𝔩𝔢 𝔭𝔯𝔬𝔱𝔬𝔠𝔬𝔩

Hyperalgesic patient, 28 mm molar, three MB canals and curved anatomy.
Following a structured shaping protocol allowed predictable navigation of the canals and safe preparation to working length.

From canal negotiation → shaping → cone fit → obturation → coronal seal, every step matters.

𝓐 𝓹𝓻𝓸𝓽𝓸𝓬𝓸𝓵 𝓽𝓱𝓪𝓽 𝓷𝓮𝓿𝓮𝓻 𝓵𝓮𝓽𝓼 𝓶𝓮 𝓭𝓸𝔀𝓷

Single Vs Multiple visits endodontics

Criteria for Case Selection

1. Competence of the clinician:
Clinician should be able to perform all steps of root canal in single visit without compromising quality of the treatment
2 .Positive patient acceptance:
Patient should be cooperative for SVE. Uncooperative patients and patients with TMJ problems, limited mouth opening should be avoided for SVE.
3. Absence of anatomical interferences:
Anatomical problems like presence of fine, curved or calcified canals require more than usual time for the treatment and thus should be treated in multiple visits rather than a single visit
4. Accessibility:
Teeth for single visit should have an optimal accessibility and visibility
5. Availability of sufficient time to complete the case:
Both clinicians as well as patients should have sufficient time for SVE
6. Pulp status:
Vital teeth are better candidate for SVE than nonvital teeth because of less chances of flare-ups
7. Clinical symptoms:
‣ Teeth with acute alveolar abscess should not be treated by single visit.
‣ But teeth with sinus tract are good candidate for SVE because the presence of sinus acts as
safety valve and prevents buildup of pressure, so these teeth seldom show flare-ups

Factors to Consider..
- Pulp and peri-apical condition
- The complexity of the root canal system
- Probability of procedural difficulties
- The clinician's skills
- Time available
- The patient's systemic health
- Severity of symptoms
- Level of anxiety

Biological Considerations:

๏ Regardless of the number of appointments, effective bacteriologic disinfection of the root canal system is critical.
๏ It is possible that total elimination of bacteria may not be absolutely necessary for healing.
๏ A high level of clinical success can be achieved by:
✓ Maximal reduction of bacteria
✓ Effective root canal filling
✓ A timely satisfactory coronal restoration

Single-Visit Root Canal Treatment
* Pros:
✓ Reduction in the total duration of treatment together with cost-effectiveness.
✓ Eliminates the need of the clinician to re-familiarize the canal anatomy at the next visit,
✓ Better patient acceptance.
✓ Reduction of the inter-appointment infection risks.
✓ No risk of flare-up promoted by the leakage of the temporary seal between appointments.
✓ Materials needed for separate visits are saved.

* ConS:
😥 Flare-ups cannot be easily treated by opening the tooth for draining.
😥 Long appointments may be tiring to the clinician.
😥 Uncomfortable for some patients that cannot keep their mouth open for a long time.

A 28-year-old patient walked into the clinic… not because of pain — but because of fear.

He had already been scheduled for apical surgery.
For him, it felt like the only option left.

But something didn’t sit right.

So he walked away… searching for another opinion — hoping, somehow, there was still a way to save his tooth without going surgical.

What he came with wasn’t a simple case.

Tooth #24 had already been through a failed endodontic attempt.
Two separated instruments were left behind — one buried deep in the apical third, the other trapped in the middle of the canal.

And as if that wasn’t enough…
An attempt to bypass the file had ended with a root perforation.

A case many would consider… already lost.

Yet despite all this, the patient’s only request was clear:

“Just… don’t let it end in surgery.”

🧠 The Challenge
- Two separated instruments in the same canal
- Apical lesion with cortical bone involvement
- Root perforation
- Open tooth contaminated with debris
- Patient reluctant for surgical intervention

🎯 The Plan

Instead of jumping to surgery, we chose a conservative approach:

- Retrieve what can be retrieved
- Bypass what cannot
- Seal the perforation
- Give biology a chance to heal

⚙️ The Ex*****on

Under magnification:

✔️ The coronal separated instrument was successfully retrieved using ultrasonics
✔️ The apical fragment was carefully bypassed
✔️ Full chemo-mechanical preparation completed
✔️ Perforation sealed using bioceramic material
✔️ Obturation done with warm vertical compaction + bioceramic sealer
✔️ Final restoration with fiber post & composite - case referred to make cuspal coverage restoration

⏳ The Outcome

No surgery. No extraction. No complications.

At 9-month follow-up:
✅ Complete healing
✅ Patient symptom-free
✅ Tooth preserved

(Healing confirmed radiographically and clinically)

💡 The Message

Sometimes… it’s not about what’s broken.
It’s about how far you’re willing to go to save it.

👉 Even in complex cases with separated files and perforations,
non-surgical retreatment can still win — if done right.

🚨 NEW VIDEO ALERT!

BPE | BEWE | Bitewing X-ray
All explained in a simple & clinical way

💡 Don’t miss it!

Dental Diagnosis : Part 6 : screening investigations Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube.