Endodontics

32 years old Female patient, ASA 1, presented for evaluation and treatment of tooth no 11. 

Clinical examination: Oral cancer screening WNL, no vestibular swelling or sinus tract present, #11 with gross caries with ICDAS 5 on the lingual (pulp visible). Cold: no response, hot: no response, percussion WNL, palpation WNL

Radiographic examination:  #11 with gross caries extending to pulp, PARL present at apex

Diagnosis: Pulp necrosis with Asymptomatic apical periodontitis

Treatment plan: Initial Treatment.

Case Assigned By: Dr. Walid Nehme. Case Completed With: Dr. Gordon Lai

Following anesthesia and rubber dam placement, access cavity was performed and 1 canals were located. 

Procedural errors during treatment: No Errors

Canals were instrumented using WaveOne Gold

Canals were obturated using Single Cone technique with BC sealer 

Restoration: Temp. rest. placement

Treatment was completed in 1 Visit at UOP

Reflection: After caries control there was very little lingual cervical tooth surface to place the rubber dam clamp on, so I had to clamp on the gingiva. In two of my Endodontic cases I have found this is necessary to have isolation with minimal or fragile tooth structure remaining. When I was trying to find the working length of the canal, the apex locator indicated 27mm but the radiograph showed that the file had gone 1mm past the apex. When I moved the file 1mm coronal and took another radiograph the file was still past the apex. At this time, a doctor came by and revealed to me that when this happens we should use a bigger file to take the working length radiograph because if the file is able to move past the apex then extruding the file coronally will not work and the file will just intrude more apically during the next radiograph. I found this to be extremely helpful and will keep this in mind when I am finding my working length in the future. Overall, this root canal went very smoothly and I am very happy with the results.

36 years old Female patient, ASA 1, presented for evaluation and treatment of tooth no 29. 

Clinical examination: oral cancer screening WNL, no vestibular swelling or sinus tract. #29 presented with existing temporary crown and tooth was rotated about 60 degrees to the mesial due to ortho. Cold WNL, palpation WNL, percussion WNL

Radiographic examination: #29 with an existing temporary crown; no PARL noted at apex; some PDL widening noted

Diagnosis: Asymptomatic Irreversible Pulpitis with Normal apical tissue

Treatment plan: Initial Treatment.

Case Assigned By: Dr. Mark Stevenson. Case Completed With: Dr. Gordon Lai

Following anesthesia and rubber dam placement, access cavity was performed and 1 canals were located. 

Procedural errors during treatment: No Errors

Canals were instrumented using WaveOne Gold

Canals were obturated using Single Cone technique with BC sealer 

Restoration: Core placement

Treatment was completed in 2 visits at UOP

Reflection:  #29 originally had an existing PFM crown with recurrent decay and after excavation of the caries and previous build-up the pulp was exposed. The patient's tooth was rotated almost 90 degrees due to previous ortho treatment and the existing build up was extremely close to the pulp so I was disoriented when removing the existing build up. I should have known I was getting close to the pulp and should have left some of the build up in place to avoid a pulp exposure. In the future, I need to make sure I know when I am approaching the pulp space, regardless of how the tooth is malpositioned, in order to avoid an unnecessary pulp exposure. On another note, this patient doesn't respond well to block injections and even when different faculty have tried to get her numb using IA or Gow-Gates, she is never profoundly numb. It is only when we do infiltrations that she is profoundly numb so it's important to note that infiltrations can be helpful during root canal procedures if profound anesthesia isn't noted. The rest of the root canal went smoothly, however, in the final obturation radiograph Dr. Lai and I noted that it looked like some sealant was misplaced, which made us suspect a missed canal and we ordered a CBCT. However, the CBCT report concluded that there was only one canal and the root canal was adequate and this abnormal appearance of the sealant likely indicates that I didn't use enough sealant. This near-mistake taught me what misplaced sealant can indicate and to not simply assume that this finding is due to not enough sealant being placed, as it was in this case.

37 years old Female patient, ASA 1, presented for evaluation and treatment of tooth no 14. 

Clinical examination:  oral cancer screening WNL, no vestibular swelling or sinus tract, patient presented with occlusal filling on #14 done by outside office; cold +++, Percussion ++, palpation ++

Radiographic examination:  #14 with occlusal GI filling, no PARL noted at apex, pulp stones evident

Diagnosis: Symptomatic irreversible Pulpitis with Normal apical tissue

Treatment plan: Initial Treatment.

Case Assigned By: Dr. Craig Dunlap. Case Completed With: Dr. Scott Wilkinson

Following anesthesia and rubber dam placement, access cavity was performed and 3 canals were located. 

Procedural errors during treatment: No Errors

Canals were instrumented using WaveOne Gold

Canals were obturated using Single Cone technique with BC sealer 

Restoration: Core placement

Treatment was completed in 3 visits at UOP

Reflection: This was my first Endodontic case, and when I first presented the case to Dr. Dunlap he asked if I was okay with doing the case for my first one because it was difficult. I was unsure why he thought it would be so difficult until the pulp stones were pointed out. Dr. Nehme stepped in to help me remove the pulp stones and I learned that a cavitron is a useful tool to remove pulp stones. After the pulp stones were removed the rest of the root canal went relatively smoothly. However, after each appointment my patient was still in quite a bit of pain, including after the obturation appointment. The patient’s pain didn’t go away for a few weeks, and I was concerned because in class we learned that the pain should subside in a few days. After talking with faculty, I learned that in some patients the pain can take months to fully go away and in the future I can assure my patients that after root canals it is normal to feel some pain and sensitivity in the following weeks and if they’re lucky this sensitivity may only last a few days.

48 years old Male patient, ASA 1, presented for evaluation and treatment of tooth no 30.

Clinical examination: oral cancer screening WNL, no vestibular swelling or sinus tract. #30 presented with existing O amalgam filling that had a cracked BL cusp and recurrent decay on D/M of restoration. #30 cold + non-lingering, palpation ++, percussion +

Radiographic examination:  #30 w/ occlusal buccal filling WNL with no PARL noted at apex

Diagnosis: Symptomatic irreversible Pulpitis with Symptomatic apical periodontitis

Treatment plan: Initial Treatment.

Case Assigned By: Dr. Walid Nehme. Case Completed With: Dr. Mark Stevenson

Following anesthesia and rubber dam placement, access cavity was performed and 3 canals were located. 

Procedural errors during treatment: No Errors

Canals were instrumented using WaveOne Gold

Canals were obturated using Single Cone technique with BC sealer 

Restoration: Core placement

Treatment was completed in 3 visits at UOP

Reflection: Initially, it was suspected that this patient had a vertical root fracture or cracked tooth, causing him pain because there was an evident crack on the BL cusp. After a CBCT, no crack was detected but I learned that usually cracks aren't detectable on a CBCT unless it's a more severe crack. In the future, it's important to warn the patient that the CBCT may be inconclusive in regards to a crack being present. I learned that it was important to set clear expectations at the start of the appointment and I made sure my patient understood that after the root canal there could still be pain if a crack is present or progresses and in that case we would need to extract the tooth. The patient was persistent on still wanting to try to save the tooth and hoping that the crack won't propagate. Setting these clear expectations and preparing my patient for the worst allowed him to see me in a more favorable light now that the tooth is fully restored with a crown and the patient is not in pain.