At the end of the shaping and cleaning stages of root canal procedure, we should be able to dry the root canal system with sterile paper points. But, this is not always the case!
Unexpected bleeding intra-operatively can occur for a number of reasons:
- mishaps (over-instrumentation, canal transportation, perforation, etc.)
- untreated anatomy
- highly vascular resorptive tissue (internal or advanced cervical resorptions)
- tissue remnants after complete instrumentation
- extending sterile paper point beyond the apex when drying the canal system
- NaOCl accident
Stop the procedure and try to identify the cause of bleeding. Bleeding will naturally settles down if you wait long enough but if it remains unmanageable, the following method can be utilized.
A. If the bleeding is confined to the root canal anatomy inside a tooth with no large exposure to periapical tissues (i.e., over-instrumentation, internal resorption, tissue remnants, paper point accident, etc.), one of the most effective methods is utilizing Ferric Sulfate. This is a very caustic material and should not come into contact with soft tissue and should not be extruded beyond the confinement of the tooth structure. Controlled application of ferric sulfate with paper point or cotton pellet is advised and is demonstrated in the following video:
B. if the bleeding is the result of a large exposure to periapical tissues (due to large perforating resorption, immature roots or perforations) other approaches or referral to your local endodontist should be considered.