Category Archives: Treatment Options

How Does Your Endodontist Do it?

If you are interested in an endodontic refresher lecture, come and join me next Thursday at the Pacific Dental Conference (PDC 2019).  Two and a half hours lecture filled with pictures and videos demonstrating the initial endodontic treatment.

Dr. Ektefaie PDC 2019

Walking Bleach since 1938

Tooth discolouration as a result of intrapulpal hemorrhage (i.e. traumatic dental injuries, pulp necrosis, pulp tissue remnants after endodontic therapy, internal resorption, etc.) can be effectively and safely corrected with walking bleach (internal bleaching) technique.  This technique is a conservative alternative to a more invasive esthetic treatment such as placement of crowns or veneers.

internal bleachingwalking bleach


Requirements for the proper technique:

  1. recording the initial shade with a shade guide
  2. performing adequate endodontic treatment under rubber dam isolation
  3. removing all obturation/restorative material to the level below CEJ conservatively
  4. placing a barrier (GIC, composite, IRM, etc.) over the obturation material to the level 1mm incisal to external probing of the gingival attachment
  5. packing sodium perborate (mixed with water or anesthetic solution) in the chamber
  6. sealing the access cavity with GIC or composite
  7. following up in 1 week to determine the final result (the bleaching procedure can be repeated 3-4 times)
  8. removing the bleaching agent and restoring the access cavity permanently
  9. recording the final shade

Office website: vanendo ,  FaceBook page: @endospecialists

Pacific Dental Conference 2017

Dental Specialists Society of BC Series:
What? “How to read a radiograph from endodontic point of view.”
When? Friday, March 10, 2017 (10:10-10:55am)
Where? VCC West, Room 118


See you all there!

Office website: vanendo ,  FaceBook page: @endospecialists

A Compromised Tooth is Still a Tooth.

In my previous post “What to do with a compromised tooth?” I asked everyone about the options for a tooth which appeared to be compromised on X-rays.  Four options were presented: a) endodontic retreatment, b) apical surgery, c) extraction/implant and d) other.  Apical surgery won the race and all responders chose one of the first three options given.  In this case, the fourth option was chosen: Intentional Replantation.

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Intentional replantation procedure allows us to control all the contributing factors to endodontic failure in this case: ruling out the presence of root fracture, removing the subgingival calculus as a result of loss of enamel, removing the resorbing granulation tissue, eliminating possible established extra-radicular infection or biofilm, sealing the root-ends without the need for retreatment and possible further extrusion of obturation material into the lesion, preserving the intact buccal and palatal cortical bone through eliminating the need for apical surgery (Risks: proximity to Greater Palatine nerve and artery, inadequate palatal root length, possible loss of palatal cortical bone post-surgery).

The final radiograph shows the periapical healing after 1 year. Patient is asymptomatic, the tooth is functional with great periodontal health post-restoration, awaiting a crown. Extraction/implant option can wait for now.

Office website: vanendo ,  FaceBook page: @endospecialists

What to Do with a Compromised Tooth?

Endodontic diagnosis for tooth #27: previously treated, symptomatic apical periodontitis.  I/O examination reveals a wide, 6-8mm clinical attachment loss (i.e. probing defect) distal to tooth #27 and loss of distal contact due to enamel fracture.  A CBCT scan shows intact buccal and palatal bone and a significantly shortened palatal root due to external inflammatory root resorption.

intentional replantation

intentional replantation

Office website: vanendo ,  FaceBook page: @endospecialists

it’s vital…with no fillings…but it hurts!

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Radiographs can be so deceiving! This radiograph of the first quadrant looks so calm, so unassuming…everything looks normal. What you didn’t see was the patient attached to this radiograph – having extreme, radiating pain. When everything looks fine on the radiograph, and we have a quadrant full of unrestored or minimally restored teeth, my spidey sense tells me to pick up a probe, and also a transilluminating device. In this particular case, there were no isolated deep probing depths (often suspicious of a root fracture), but transillumination revealed a cracked tooth. The pain can likely be ascribed to the process of “fracture necrosis” – eventual necrosis caused by a significant crack from the outside of the tooth to the pulp. A crack is just one of five types of fractures, which also include craze lines, cuspal fractures, root fractures, and a split tooth. Each are managed a little differently, depending on the presentation.

In this case, we performed a pulpectomy, and used the microscope to look into the crown. It did not appear that the mesial-distal crack extended past the CEJ. The patient had a temporary crown placed that week – and the tooth became comfortable over the ensuing weeks. This is often a nice way for us to ensure the tooth will be comfortable under a crown – an orthodontic band often serves the same purpose. The endodontic therapy was then completed. Even despite the good restorative work that was eventually completed, a tooth with a crack always has a long term guarded prognosis.

Teeth with cracks and fractures can be difficult to detect, visualize, diagnose, and treat. The prognosis of teeth with cracks and fractures also comes with uncertainty and risk. Furthermore, the symptoms of teeth presents with cracks and fractures run the gamut from mild biting sensitivity to severe and radiating pain. However, a few visual aids, like a transillumination light, magnification, and the trusty old periodontal probe can help us to diagnose and manage such cases.

Office website: vanendo ,  FaceBook page: @endospecialists

Not Every Hole is a Canal!

Sometimes when we try locating canals during access preparation stage, we may accidentally exit the pulp chamber in the wrong spot and create perforations.  Perforations or accidental communications need to be repaired as soon as possible in order to achieve the best possible prognosis.  The choice of repair material depends on the location and the size of perforation. MTA is still one of the best materials that can be used to seal the pulp floor perforations as long as it is not communicating with the sulcus.

To Prevent Perforations:
1. The pulp chamber floor is always at or slightly below the level of CEJ and the canals are located at the periphery of the pulp chamber floor.  Any attempt to locate canals farther apically may result in perforation.
2. The chamber floor colour is always greyish. If the colour during locating canals is turning dentin-colour, that would be the best time to stop and reorient ourselves.
3. Always probe around the CEJ to gain a better appreciation the outline of the root trunk, as the chamber floor is at the center and concentric to the CEJ outline.
4. When in doubt, stop and take an X-ray to confirm that treatment is progressing in the right direction.

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To Treat Perforations:
1. If facing significant difficulty with locating canals, the procedure should be stopped, the tooth should be medicated with CaOH, and patient should be referred out for proper care.  More digging may result in multiple perforation sites, further weakening of the tooth structure and enlargement of the existing perforation site, which ultimately results in an unfavorable outcome.
2. If canals are already located, ignore the perforation site, complete the root canal treatment and repair the perforation site with MTA.  Attempting to repair the site before obturating the canals may result in the repair material occluding the shaped and cleaned canals.
3. When dealing with established infection in the canal system which benefits from the utilization of short term CaOH medicament, the perforation site can be repaired and sealed before final obturation. In this case, the other canals need to be protected by paper points while the site is being repaired (the above case).

MTA…saving open apices one tooth at a time!

Providing root canal treatment can be challenging in teeth with incomplete root formation. The apex is large and open, the canals walls are thin and fragile, and this makes disinfection and obturation hard to do. Before the advent of MTA, calcium hydroxide was used in teeth with open apices over a long period of time, anywhere from 6 months to 24 months, to induce a calcified barrier over the open root apex. It was and still is a very effective treatment modality, especially with a good coronal seal. Calcium hydroxide is also still very important for treating resorptions, and aiding in disinfection of root canals! However, we now know that keeping calcium hydroxide for many months in a weak root can possibly further weaken dentin, and using MTA can shorten the treatment time to one or two visits. The placement of a “plug”, usually a 3-5 mm plug of MTA at the end of an open apex root canal, provides an “instant” apical barrier against which we can place gutta percha and sealer into the remainder of the root canal.

In this particular case, the patient was going to have new crowns placed very soon. I removed the old gutta percha quite easily with a #35 Hedstroem file, and you can see all sorts of things growing on it in the photo! Because the tooth was purulent and “weepy”, the root was allowed to drain for a few minutes, and then irrigated with 5.25% sodium hypohlorite using a closed-end side-vented irrigation needle after the working length was determined. I packed calcium hydroxide into the root for about 2 weeks in this tooth before doing the one-visit MTA apexification procedure due to the continued exudate and to aid in disinfection.

On the day of MTA apexification, this is what I did:

1. Rubber dam of course, irrigate calcium hydroxide out with full strength sodium hypochlorite, circumferential filing, and final irrigation procedures

2. Dry the canal. At this point, if the canal continued to well up with exudate, I would consider remedicating with calcium hydroxide.

3. Place an apical matrix of collagen (for example, Collacote) if you feel you might need an apical matrix to “contain” your MTA plug; this serves as a support against which you can gently condense the MTA.

4. Using a small carrier, such as a Dovgan carrier or MAP system (like a mini amalgam carrier), place MTA as far apically as possible, and then carry/tamp down gently using a pre-measured plugger or a moist paper point (a big one, like extra coarse!).

5. I usually take a radiograph here after the first 1 mm increment, to make sure that I have placed it flush with the root apex. Once this is confirmed, you can place a 3-5 mm plug.

6. The rest of the canal can be obturated with sealer and thermoplasticised GP, and the tooth definitely restored. Many also advocate placing a damp cotton pellet and temporary filling before definitively restoring the access to ensure the MTA has set. In the x-ray, I have placed 5 mm of MTA, sealer and GP on top, a 2 mm layer of glass inonomer, and then a bonded restoration (double seal). The dentist has completed the case with beautiful crowns.

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How can an apicoectomy help?

Let’s not give up on even the smallest of teeth!

There are times when conventional root canal treatment or retreatment cannot heal every periapical lesion out there. Luckily, we have the option of an apicoectomy – which in today’s terms, means microsurgery. During an apicoectomy, the most apical part of the root tip (usually about 3 mm) is removed. A retropreparation – which is similar to a class one preparation – is made using an ultrasonic tip specially designed and angled for apicoectomy under the microscope. The retropreparation is filled with an MTA material, of which there are many choices now, like the traditional powder that is mixed with sterile water, or even a pre-mixed putty.

In this case, we see a tiny little lateral incisor, which has a ceramic crown that is a few years old, and underneath it, a great big post. The current root canal treatment is somewhat underprepared, and was done more than 15 years ago. The tooth had recently become symptomatic. Is it extraction time for this little tooth? Should we dismantle the crown, remove the post, and retreat it? Should we place an implant now?

This case was ideal for an apicoectomy. This means the patient is able to keep the crown intact and we wouldn’t be compromising restorability by removing the post. With such a short and fine root, we have to be aware of the crown to root ratio, occlusion, and be conservative in our surgical technique.

After a full thickness flap was created, the retropreparation and the MTA retrofilling are seen:

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Here are the radiographs from start to finish: initial presentation, immediately after the procedure, and 6 months after with good healing.

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How do you “seal” the deal?

After we’ve spent so much time doing great endodontic treatment – with rubber dam isolation, perhaps gingerly applying OraSeal or Kool-Dam to make sure everything is water tight, carefully instrumenting, copiously irrigating, and then obturating with great style – how can we protect our painstaking work?

Here is a case where the root canal has been completed, but unfortunately, the final restoration – a ceramic restoration – has been made without replacing the cotton pellet and temporary base material. Even though the periapical lesion has healed nicely, the risk of coronal leakage, and thus the need for retreatment in the future again, is great.

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One nice way to prevent coronal microleakage is to definitively restore the teeth after root canal treatment. If you want to go one step further, you might consider an intra-orifice barrier. This is simply a (bonded) restoration that involves removing approximately 2 mm of gutta percha from the orifice of the root canal. Then, a material, such as glass ionomer, or composite, or MTA can be placed into the orifice. I also prefer to cover the furcation floor. I have been placing an intra-orifice barrier of glass ionomer (and often a 1 mm intra-canal barrier when I prepare post spaces), and then restoring the rest of the access with a bonded core material when indicated. The glass ionomer can be placed with a small plugger, or a Centrix Accudose needle tube.

I have also been trying a neat product as an intra-orifice barrier, PermaFlo Purple, which is simply a flowable composite that is colored purple. You can place a tooth-colored material on top, in the bulk of the access. I suppose the rationale of a purple-tinted flowable composite is to make any future treatment easier, since you’ll be looking for purple composite, instead of B2 composite! The case below shows a 2 mm intraorifice barrier of glass ionomer, extending below the floor of the root canal chamber.

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