It breaks my heart when I see my own tooth story reflected in my patients. There’s nothing more frustrating than facing an unnecessary extraction due to an improper endodontic diagnosis. Diagnosis sounds simple, but it can really stump a lot of dentists. Today, I want to talk about a tooth story that highlights just how important it is.
This particular patient came to me for a second opinion. She wanted to know if she really needed to have her tooth extracted. Her tooth had been previously treated, and now she was having pain when she bit down. She had been previously diagnosed with Symptomatic Apical Periodontitis.
She’d already been to an endodontist, and they had told her that there was nothing that could be done to save her tooth — that she’d have to have her tooth extracted!
Most patients would say, “Okay, extract my tooth,” but not her. She didn’t accept that answer and sought out another opinion… mine. She was a patient after my own heart!
Did She Really Have to Have her Tooth Extracted?
I welcomed her into the office and learned she’d had a root canal several years ago. The root canal filling was overextended by about 5mm. This overextension was also very close to the inferior alveolar nerve. You can appreciate just how close in this image here.
If surgery had been the treatment of choice, there definitely would have been a risk for paresthesia. But surgery was not first on my list.
Surgery Doesn’t Have to be the First Choice
I was completely transparent with my patient and let her know all of the possibilities and risks. I told her that I have gotten out overextended gutta percha before, but it wasn’t a guarantee that I could do it in her case. (Keep in mind, however, that I was not convinced that the overextended gutta percha was the cause of her pain.) With all of the information in front of her, she made an informed decision and asked me to try. After all, she was motivated to not have to have that tooth extracted!
I always say, “I never know what I can do until I try.”
I cleaned out as much gutta percha as I could and got a working length.
Did She Have to Have her Tooth Extracted? No!
So what did I do next? I took a 40 hedstrom file to the apex, engaged it slightly, and gave it a yank. Guess what?! That little “tail” came out! The dance party that occurred in that operatory was incredible! My patient, assistant, and I were all so happy we had accomplished the one thing the patient was hoping for. (No one wants to have a tooth extracted, and we get it!)
What Could Make or Break the Case
Though we were successful, that wasn’t what had the power to make or break the case. You know what did? It was the bacteria that was present in the entire length of the canal.
It was at this point that I confirmed that surgery was not a good first option. Sure, it would have removed the overextended material, but it would have done nothing to clean the bacteria out from the rest of the tooth. My patient would’ve had short-lived success because that tooth was BLACK inside. (Thank you, calcium hydroxide, for taking care of that!)
By the time she came back to obturate the tooth, she was pain-free.
One year later, she is doing well. She had no pain and the area was healed.
I saw her again two years after treatment, and the tooth is still going strong.
Once again, making the right endodontic diagnosis is crucial. When I understood that it was the bacteria that was causing the symptoms, and not the extra-long gutta percha, I was able to approach the case appropriately. Having the opportunity to help a patient not have a tooth extracted is a serious opportunity to give teeth a chance, which is one of my life missions.
Extraction Is Not Always the Answer, but Proper Endodontic Diagnosis Is
It’s very important that you, as a dentist, take the time to ensure the patient has the same understanding of what is causing their pain as you do.
The answer isn’t necessarily what looks obvious on the radiograph — take your time and follow the clues to place the blame for the pain where it should be. There’s always a root cause… pun intended!
And remember, you don’t know what you can do for your patient until you try. Don’t give up too quickly. For extra motivation, it never hurts to ask yourself, “Would I want to have my tooth extracted?” That helps you see your patient with compassion. Extraction is not always the answer!
It’s also important to talk with your patient transparently about the possible outcome of the treatment so they can evaluate the situation realistically. This allows the patient to make an informed decision about their own health.
– Sonia
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Great job
Thank you Ernest!
-Sonia
That’s great work doc. Just curious what would be your protocol had the overextended gp separated from tooth during removal and extended into the periapex?
Hi Radhika, thanks for your question. I would have had to leave it and monitor the tooth to see if it really became a problem. – Sonia
Good work.. a good try
Thank you very much.
-Sonia
Superb blog…Keep it up
Thank you Dr. Tarun – more to come!
-Sonia
Very nice!!! This gives me hope to try removing overfills again. I had given up doing it several years ago because it just seemed too difficult. Did you use any chloroform to soften the gutta percha or just go after it with the hedstrom file?
Hi Richard,
Yes, I used some chloroform, but not too much. Just enough to soften my gutta percha so I can engage my file into it, then I quickly remove the file from the canal.
-Sonia
Great info. , Great case!
Thank you, Johnasina!
-Sonia
Thank you so much for such a rare case ..following you always
Thank you so much! Stay tuned for more…
-Sonia
extraction is not always the answer. key of dentistry.
I couldn’t agree more!
-Sonia
Good job mam👍🏻 these type of cases gives us hope.keep inspiring us !!
I’m glad it’s inspiring and helpful for you!
-Sonia
Great case! Thanks for sharing 🙂
Hi Adriana, thank you for reading. I’m glad you enjoyed this case! – Sonia
Great take away message from this case. Great work doc
Thank you for reading, Gaurav.
-Sonia
Amazing and inspiring
Thank you. That means a lot!
-Sonia
What type of calcium hydroxide system did you use during the interim period? How was it placed down to the apex of the canals? Congratulations on a successful case.
Hi Dr. Rowe, I always use UltraCal by Ultradent. I LOVE it. I also use the NaviTips so you can get it close to the apex.
Pro tip: If you use the code Eschool15 when you check out, you can get yourself a 15% discount if you choose to order it. 🙂
-Sonia
Excellent work Sonia. Lot to learn in endo. Thnx for sharing such cases.
You’re very welcome, Vikram, and thanks so much.
-Sonia
Its really a great work mam..its not easy to bring back that remaining GP..!
I have a innocent query..how did calcium hydroxide removed the blackness of canal?and how long we have to place calcium hydroxide in canals?
Hi Dr. Jain, I left the calcium hydroxide in for about one month. The combination of instrumentation, sodium hypochlorite and calcium hydroxide gets rid of all the black. – Sonia
Hi Sonia. How do you ensure the patient returns for completion of their Endo tx. after their 1st treatment & being pain free with Ca(OH)2 & a nice temporary fill?
Mitra,
This all goes into your communication. My patients know that there care is not complete prior to leaving that appointment. Why would they want to pay for something that is done halfway? I rarely have patients not return for their completion.
-Sonia
Excellent work!!!
How long did you wait before obturation?
Hi Yaso, I waited about 1 month prior to obturation. Thanks so much!
-Sonia
Too good
Thank you for reading, Vinit.
-Sonia
Great case!!! Did you obturate using WVC ? How did you manage to seal the periapical foramen?
Many thanks
Hi Karina, thanks so much for reading! Yes, I used WVC. I made sure that I did some apical gauging and really understood the size of my apex prior to obturation so it would prevent me from extruding my material. Hope this helps!
-Sonia
Great job!!! Excellent oportuniry to learn a lot from this case !!!
Hi Dr. Viv, I’m happy to hear that you got so much out of this case! – Sonia
Nice case.concept clearing case
Hi Dr. Lachhwani, I’m glad you found this case helpful! – Sonia
Great work Dr Sonia.. i follow your blog and want you to post more of them 🙂
Hi Dr. Bhat, thank you for reading! Please help me spread the word about the blog and share it with your dentist friends + colleagues. – Sonia
What is wVC
Hi Lisa, WVC stands for warm vertical condensation. – Sonia
Thanks for sharing! It’s always nice to see a tooth story with a happy ending. However, I do have some questions if you don’t mind. How were you able to determine that the extruded GP wasn’t the cause of pain while the other endodontist recommended extraction? Would you refund the patient if the case didn’t work out after trying? Thanks!
Xiao,
It’s never the gutta percha, it’s always bacteria. You can’t have a lesion without bacteria, so I always focus more on disinfection than any other part of the process. I have very detailed conversations with my patients about all the possible outcomes and then it is up to them if they want to move forward with treatment. What they are paying for is my time, not the outcome. Of course, I will always do my best to have the best possible outcome, however, I don’t feel a refund is necessary if I have the proper conversation preoperatively.
-Sonia
Thanks so much for the explanation!
Thank you for reading!
-Sonia
Hello Dr Sonia, you managed this case with ultimate precision.
I just want to know the Plan B if the Plan a ( conventional re endodontic treatment) ie removal of complete Gutta percha failed in this case.
Thank you for sharing your wisdom, skills and experience. Your work is always awe-inspiring. 🙏
Dr. Yadav,
As long as I disinfected the tooth properly, plan A should work, even if that gutta percha remained. But, my plan B would have to be extraction in this case since an apico would be too risky.
-Sonia
Great Job!!
Can you elaborate the part where you mentioned about the tooth being black from the inside and thanks to Calcium Hydroxide. Did you mean that Calcium Hydroxide caused the blackness/decay?
Aminah,
The calcium hydroxide is what took the black away. Sorry for the confusion.
-Sonia
Hi Dr, glad i found your blog. I came across this as i’ve recently done RCT and my Dr told me that part of her drill/file broken in me and it’s ok to leave it there. Im shocked as it’s my 1st RCT and 1st time hearing about this. Worst when i consult opinions from other Dr, they mentioned that she even overdrilled/overfilled it. So now it’s broken file + overextended. Will it really be ok to just leave it all there? Will these be Cancer causing? Is the broken file safe for MRI scan … Im sorry but theres too much happening and im totally clueless about all these.
Kels,
A broken file is always a possibility when you do a root canal. You are most likely signing the acknowledgement of the risk when you sign the consent form. You should be fine for an MRI scan as well. The critical question is if your tooth will heal. What file broke and and what point during the treatment. If the tooth was cleaned out prior to breaking you may be ok. Unfortunately, I don’t have all of the information to help you completely. I suggest you seek out an endodontist in your area for a second opinion.
-Sonia