I always love a good recall. Why? Because I love to show these types of cases to people who tell me that root canal treatment doesn’t work.
I can’t tell you how many comments I see in Facebook groups suggesting an implant because the endo is just going to fail in another 5 years. Or posts that share misinformation about how root canals aren’t biologically safe or successful. Even if it were true that a root canal treatment might fail in the future (and it’s not!), I always have to ask … isn’t implant technology in five years going to be a whole heck of a lot better than the implants available today? ‘And usually my point is taken. .
I want to share a case with you that even made ME question my root canal treatment plan.
I don’t have a crystal ball in my clinic. And I need my patients to know that some of my treatments are not going to work. Yet that doesn’t mean that I am going to give up on a tooth. I am completely transparent with my patients and I always lay out all their options.
Always be sure to let your patient make their own decision after clearly telling them what you know and what the options are. If you can’t do the treatment yourself, don’t change the way you have the conversation with the patient. Instead, refer the case out to a specialist you trust and see what they can do.
Here’s an Example of a Tough Root Canal Treatment
This patient presented with pain to percussion on tooth #2. The tooth had been previously treated, so it had no response to cold. Her diagnosis? Previously Treated and Symptomatic Apical Periodontitis.
The periapical radiograph looks kind of normal, and the root canal looks like it was more or less done well.. There’s just a small overfill on the palatal canal, but that doesn’t really give me a cause for concern.
I believe in being thorough and getting as much intel as I can, so I took a cone beam. And to my surprise …
Would you look at that?!
There is a giant lesion with a sinus communication. Now, the sagittal slice shows a big lesion, but the axial slice shows an even bigger dimension of the lesion. Oof.
This lesion encompasses the whole tooth!!
Now, many people would take one look at this case and say this tooth is not restorable because that lesion is just too big.
Excuse me? I have said it before and I will say it again ….
Sometimes size does not matter!
Root canal treatment is one area where I can say with certainty that size isn’t always the most important element. Bigger lesions like this don’t scare me at all. In fact, it amazes me that this patient didn’t have even more pain given the size of this lesion.
If you are just starting out using a cone beam, you are going to see all sorts of things that will scare you. It kinda comes with the territory. But that’s because we are so used to seeing things in 2D with our PAs. Just keep in mind that things will always be much bigger when you visualize it in your cone beam.
So when you look at this case, what do you see?
What possible etiologies of failure do you see?
Is it a crack? Heck no!
Is it a missed canal? Well, maybe.
To be honest, even I was a little stumped.
One thing I did take notice of was that there was still intact buccal and lingual bone in the axial view. So there were no probings in this case. I don’t just rely on my CBCT imaging to give me the answer. I also marry it with my traditional tests to see how my findings correlate with each other. Right away, because of this, a cracked tooth goes to the bottom of my differential diagnosis.
You can be your patient’s advocate!
I believe honesty is the best policy. That’s a lesson you can carry throughout your entire life. So when it came to this root canal treatment, I let the patient know I wasn’t sure why the tooth was failing. Luckily, she was intent on saving her tooth, but not all patients are as driven as she was. I was impressed with her commitment, but were she less intent on saving her tooth, it might have come down to me to be my patient’s advocate.
But, if you don’t actually believe a tooth can be saved, then you’re going to create a treatment plan for an implant, aren’t you??
You know me, I decided to retreat this tooth, but not until I had a very thorough discussion with my patient. My patient totally understood that my efforts might not be successful. And she knew that I may not have an answer for her until I did a one year recall to actually see if the bone was regenerating. She signed up and was 100% onboard for the treatment plan while understanding all the risks involved.
I still didn’t feel like I needed to give away my time for free. You can absolutely try the procedure and it can fail, and you can still get paid for your time. Why do we feel like we need to give a refund if our efforts don’t work? If you talk about it thoroughly and document that presentation well, you won’t run into a sticky situation at the end if things don’t go to plan. If this is a struggle for you, leave me a comment below and let me know why. I’d love to talk you through changing your mindset about this!
The plan goes into action.
So when I accessed the tooth, the gutta percha was sooo black. I kind of love it when I see that because it tells me that there is TONS of room to improve the situation.
Going a little deeper, I did also find a missed MB2 that was very hard to see in the CBCT. But, in retrospect, the MB canal is slightly offset to the buccal, so there is room for that canal in the root. Let’s take another look at it.
I removed the contaminated filling and medicated the tooth with calcium hydroxide. I let that tooth medicate for about a month and then obturated the tooth.
As I said in the beginning, I always love a good recall. So here it is…drum roll please!
One year later, that bone is back, baby!! And here is another view to prove it…
And another where you can see my MB2…
First of all, I mean it when I say that improving your endodontic skills can help you get five-star reviews for your practice. Take a look at what the patient said about her experience. I was over the moon reading this one!
So, before you go extracting teeth, think of all the possibilities—and share them with your patient!
And consider this—if you put my post-op radiograph next to the pre-op radiograph, they don’t look very different. So don’t judge a book by its cover… you never know what might be inside.
I’m ALL ABOUT open, clear, and candid conversations with patients and getting their total consent before we go down any path of treatment. That’s one reason I created a resource for getting informed consent! Check out my patient consent form here and a few of my tips on how to put it to use.
Great case!! when you get a chance please send me an email describing what system you use for instrumentation and obturation.
Thanks Robert! The answer is “whatever works best in your hands”. But for my favorite files you can check out this video blog here: https://soniachopradds.com/blog/video-4-endodontic-files-that-i-cant-live-without/
Hi Sonia… Did you try to use S1PTG in ATC movement?
Hmmm, I am sorry, but I don’t understand your question. I think we have different lingo where I come from. Can you ask your question again?
I don’t even do molar endo, but I love your blog. I learn something interesting and love your direct approach about charging for what we do. What is the psychology that so many dentists are afraid for all aspects of what we do as part of a procedure?
All occllusals are not alike , a crown preparation can involve many different things.
Has corporate dentistry tainted us all to take the easy road.
You are correct, that I bet most dentists would be planning their implant procedure
On the other end of this, when Dr. L.D. Pankey was presenting to his clientele, he would tell them that he was not going to present them with a fee, because they could not appreciate the work he was going to do for them until it was completed. He believed that a fair fee is one that is paid with gratitude.
Steven Hutt D.D.S.
Thank you Steven – I really appreciate you following and your insight!
My patients get 2 treatment plans in questionable situations — one for the attempt and the exploration and the other for the full root canal. If I don’t finish the root canal, I don’t charge for the whole thing. I also offer a guarantee and if my treatment doesn’t work in the first year and as long as the patient gets the tooth restored, I will redo the root canal at no charge. If the tooth needs to come out, then I like to give a partial refund back to the inoperable fee so they can put something towards their implant. Then they know that I am doing what I can and that I am on their side. It’s just important to be transparent with your patients.
Great results! Do you suspect coronal leakage as the primary cause of failure or the missed MB2? Was there any decay around crown margins? Thanks for another great case study!
This was all about the missed MB2, no coronal leakage suspected. There was no decay and I was able to seal up my occlusal access with a composite. In these situations where it is questionable about prognosis, I try to save the crown and restore it for the time being. Once I see evidence of healing, I give them the green light for a new crown!!
In your first image, there is a change in density of the filling material in the coronal part of each canal. Was the GP in the three treated canals contiguous with GP in the pulp chamber, or were they separately filled with GP (the access openings individually sealed) and the pulp chamber filled with a core filling?
You mentioned above that you found the GP in the original fill to be “black”. Was that throughout the tooth, or just the mesial canal?
My questions are spawned by a RCT failure attributed to a missed M2. We talk a lot about the treatment of the canals, but the treatment of the pulp chamber carries it’s own influence on the long term success of the RCT.
Thank you. I enjoy your blog.
Thank you for reading.
Perfect case and perfect explanation! As usual! Thanks for all. Greetings from France. Dr Bellhari Karim
Thank you, and I’m so happy my message reaches you across the pond!
Great work and nice case to prove that one should never give up !
I agree Sanjay! Thank you for reading and following.
need to know endo as a gp
That’s so true – endodontics is more than just root canals, and it all starts with diagnosis.
Thank you for reading.
Hi Sonia, do you have a link to a blog post on diagnoses? This is something I struggle with but would like a summary on (and what treatment is needed based on the dx).
I do have a blog on Periapical and Pulpal Diagnosis, that you can check out here: https://soniachopradds.com/blog/how-to-make-the-right-pulpal-and-periapical-diagnosis/
Because diagnosis is a topic that is larger than what can be discussed in a blog post, I have a whole module of learning on it in “E School”, the web-based course I’m launching. You can get on the interest list by completing the form at the bottom of any blog post.
Thank you for reading and watching!
great case! I love reading your blogs, learn something every time.
So glad Payal!
Great case!!Thank you for such an informative blog.
Thank you for reading Ruby!
very excited mam….as an endodontic post graduate student,my eyebrows always rise when i see such follow ups….very inspiring work and i request you to kindly share the instumentation protocol you followed for this case….
I usually do a hybrid technique and use the S1, S2 and F1 from the Protaper series and then switch to a 25/.04, 30/.04 and bigger if necessary. I hope this makes sense.
Wonderful case presentation! Thanks for sharing.
Thank you for reading!
This was really insightful, thank you! Do you have a post about the process of redoing a root canal, removing the GP?
I don’t have a post like that, but I do teach that in my Eschool program. It is currently open for enrollment if you would like to join us.