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Endo tips    Better Endo    Endo abstracts    Endo discussions

  Draining canal


The opinions within this web page are not ours. Authors have been credited for the individual posts
where they are. - www.rxroots.com photographs courtesy: Rob Kaufmann
From: Valerio Di Grazia
To: ROOTS
Sent: Thursday, January 10, 2008 4:32 AM
Subject: [roots] draining canal

tooth 22:
- first visit: old GP removed and canal dressed with calcium hydroxide, 
  presence of drainage.
- second visit: after 1 week the canal was still draining exudate,so again 
  calcium idoxide dressing
-third visit: after 3 weeks from the second visit, the canal still drains 
 and make the filling impossible. 
So again dressing, but this time I've had exudate draining while dressing 
with calcium hydroxide, that's to say I had problems even to dress the canal.

What can I do? - Valerio Di Grazia, Bologna,Italy



Dear Doctor Grazia,

The radiograph is a little hard to read. An angled film with the film placed 
more parallel with the long axis of the tooth and with about a 15-20 degree 
angulation from the mesial would be helpful.  An instrument placed in the canal 
for this film would provide a lot of information.   The incidence 
of 1st bicuspids having only one canal is so uncommon, (less than 10%), that 
I would expect more than one until I had exhausted all means to eliminate 
that possibility.

It appears that there is more than one root outline on your film.  Please see 
the image I've attached - Grant



Grant, Perhaps I am confused, I thought international 22 was the upper left 
lateral incisor, which is unlikely to have two roots? - DanS

Valario,Suggestions:

1.  Open and reclean,  you may find your apex needs to be larger than 50
2.  Take a 27 g irrigation needle and seat it to working length, it is about 
    ISO 45 and should seat if you are truely at 50
3.  Hook it up to suction ( I use Intravenous infusion tubing)
4.  drip NaOCl into the access with another irrigating syringe and let the 
    apical suction pick it up.  This will take     several minutes.  If the 
	needle clogs take it out and put it on the end of your 
    air/water syringe and blow.  Some     times  this has to be done a few 
	times before the needle will suction freely, which means you have removed 
	some debris     from the apical area.
5.  Follow with liquid EDTA, dry as best you can, and apply Ca(OH)2 mixed 
    with 2% Clorhexidine
6.  Very carefully seal the case so no coronal leakage is possible.  A post 
    and core temporary leaks alot, find another way.
7.  Schedule the appointments a month apart.
8   Consider antibiotics, consider surgery

Dan Shalkey

How is your perio probing?  I had a case like this that eventually was ext'd 
due to a prominent developmental groove on the disto-palatal aspect.  I failed 
to see this as a potential source for the infex, but later concluded this was 
indeed the reason for failure.  Apical surgey would not have helped.  KendelG

Why don`t you try using the poliantibiotic paste like intracanal dressing? 
- Edward Alberto

Valerio is there another canal or apical ramification contaminated? 
- Carlos Murgel


Dear Valerio,

Some canals have their own timing.

We are missing some elements regarding your clinical procedure: apical 
enlargement, other angulated xR,  what about 2.1, are you working with a 
scope, did you find one or two canals (the qulity of the xR is not 
very good)? At the next appt, I would enlarge a bit, let it drain for 
30 min to an hour and place a MTA  apical plug. If you don't feel 
comfortable with that you can place Ca(OH)2 powder directly at the apex 
and wait again. I would follow-up to make sure it heals nicely, if not 
surgery - Gaelle

Dear Gaelle,  I work with Zeiss loupe 4,5x and head lamp, I haven't  a 
scope, but I can  say that there  aren't 2 canals. The apical size of 22 
is  50 ISO,and I was thinking to fill it with GP. About 21, I've already 
retreated it.

One more question: at the next appt, after draining for 30 min or more, 
could I use MTA even if the canal is still wet?(I tought no).  Or just in 
case the canal is completely dry?  - Valerio

  


Dear Gaelle, I work with Zeiss loupe 4,5x and head lamp, I haven't  a scope,
but I can  say that there aren't 2 canals. The apical size of 22 is  50 ISO,
and I was thinking to fill it with GP. About 21, I've already retreated it.

One more question: at the next appt, after draining for 30 min or more, could
I use MTA even if the canal is still wet? (I tought no).  Or just in case the 
canal is completely dry?  -  Valerio

Dear Valerio,

Effectively, if you have excessive fluid the MTA can wash out but MTA sets 
with moisture too, so a little bit of it should not be detrimental.

A little trick also to accelerate the removal of fluid, you can press 
extra orally where the lesion is or ask the patient to blow while pinching 
the nose. If there is still fluid coming out at the end of the session, 
I would suggest you to take CaOH2 powder and place a little bit right at the 
apex, this should stop the fluid from coming inside the canal, then place 
the MTA plug + moist cotton pellet close and reassess the following week.

I agree with Grant, I was asking about more pics as it seems there might be 
an additional canal, if not you are certainly dealing with a large one so I 
doubt 50 is enough. Take a 80 file and drop it in the canal to see 
where it stands, if you are far from, the apex try with a 70...etc...

I don't agree with Daniel regarding the CHX and CaOH2 mix as there is no 
benefit from this mixture, CHX and CaOH2 works differently -  Gaelle

I don't agree with GaŽlle about trying to fill the apex in the presence of 
active drainage, and there is benefit  from Ca(OH)2 mixed with CHX 2%, but 
probably not alot more than Ca(OH)2 alone.  There is not complete agreement
on much in endo, especially when it comes to medicaments. Thank you, GaŽlle, 
for reminding us all about this.  I did agree and like some of the other 
suggestions you made, hopefully some of them will help the patient 
- Dan Shalkey

On Jan 13, 2008, at 2:10 AM, andreea corlan wrote:

> What if this tooth has an abrupt canal curvature in the apical third,
> in a plan perpendicular to that of the X-ray film?
>
> Profesor Merrit, are there any counterarguments against my theory?
>
> Valerio, how did you get up to the 50 file?
> Did you use small diameter precurved files?
> Did you ever have a WL longer than the one you have with the 50 file?
>
> If my theory is corect, than you can have a ledge.  And if you'll use
> larger diameter files in this stage you will only make the ledge
> larger (bigger) and more difficult to bypass. -  Andreea

Dear Andreea, thank you for reply.
I didn't feel a sudden curvature with hand instruments.
Anyway at the next appointment I'll try to take some shifted pics to 
solve any doubt. - Valerio


If the tooth has an abrupt canal curvature in the apical third as
suggested I would expect the radiograph make the root appear shorter
than the central incisor.  It might look more like the "Photoshop-
doctored" image I've attached.

The question brings to mind another situation that might explain the
reason for continued drainage from this tooth. This would be as a
result of a misinterpretation of the root orientation of a maxillary
lateral incisor in relation to the crown.  As we all know, the root of
this tooth is normally angled to the palatal, (about 25-30ļ), in
relation to the buccal surface of the crown.  This contributes to an
error being made, when searching for the canal, leading to perforation
of the root to the buccal.  With a large lesion, such as is seen in
the present case, one might mistake the drainage coming from the
perforation site as coming from the apical foramen.  To determine if
this is so, one could use absorbent cones to determine the depth into
the canal at which moisture is encountered.  If the cones continually
are moist short of the approximated length of the canal then one
should be very suspicious of a perforation.  As another confirmation,
one might place a finger on the buccal soft tissues over the root
while inserting a gutta percha cone to length.  If the cone is felt
through the tissue short of length, then perforation is probably
confirmed.  See attached Buccal perforation.jpg - Grant

  


Protaper flaring

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Cvek pulpotomy

Middle mesial

Endo misdiagnosis

MTA retrofill

Resin core

BW importance

Bicuspid tooth

Necrotic #8 treatment

Finding MB2 / MB3

Deep in a canal

Broken file retrieval

Molar cases

Pushed over apex

MB2 and palatal canal

Long lower third

Veneer cases

CT Implant surgury

Weird Anatomy

Apical trifurcation

Canal and Ultrasonics

Cotton stuffed chamber

Pulp floor sandblasting

Silver point removal

Difficult acute curve

Marked swelling

5 canaled premolar

Sealer overextension

Complex anatomy

Secondary caries

Zygomatic arch

Confluent mesials

LL 1st molar (#19)

Shaping vs Cleaning

First bicuspid

In Vivo mesial view

Inaccesible canals

Premolar 45

Ortho and implant

Radioluscency

Lateral incisor

Obturation

Churning irrigant

Cold lateral

Tipped to lingual

Acute pulpitis images

Middle distal canal

Silver point

Crown preparation

Epiphany healing

Weird anatomy

Dual Xenon

Looking for MB2

Upper molar resorption

Acute apical abcess

Finding MB2

Gingival inflammation

Irreversible pulpitis

AG BU ortho band

TF Files

using TF files

Broken bur

Warm technique

Restorative prognosis

Tooth # 20 and #30

Apical third

3 canal premolar

Severe curvature

Interesting anatomy

Chamber floor

Zirconia crown

Dycal matrix

Cracked tooth

Tooth structure loss

Multiplanar curves