Category Archives: Access Preparation

Respect the Precious Teeth.


Restoratively speaking, as adult teeth progress through different stages of their life cycles (i.e., small filling, larger filling, inlay, onlay, crown, root canal treatment, post-core-crown replacement, etc.), they continue to lose integrity.  At the end and after many years of hard work in a very harsh environment full of physical and chemical abuse, some are eventually lost.  Among the many reasons cited in the literature for the extraction of endodontically-treated teeth, the most commonly reported are: large carious lesions, unrestorable teeth, followed by root fracture, periodontal disease and last of all endodontic disease.

A conscious effort towards more conservative restorative and endodontic procedures will significantly contribute to the survival and retention of our precious natural dentition.  Therefore, one of the most important goals in endodontic treatment should be: a more conservative access openings and instrumentation sizes.  No restorative material is capable of replacing the lost natural tooth structure.

P.S. Respect the teeth and please stop using Gates Glidden or large round burs!

How Does Your Endodontist Do it?

If you are interested in an endodontic refresher lecture, come and join me next Thursday at the Pacific Dental Conference (PDC 2019).  Two and a half hours lecture filled with pictures and videos demonstrating the initial endodontic treatment.

Dr. Ektefaie PDC 2019

Walking Bleach since 1938

Tooth discolouration as a result of intrapulpal hemorrhage (i.e. traumatic dental injuries, pulp necrosis, pulp tissue remnants after endodontic therapy, internal resorption, etc.) can be effectively and safely corrected with walking bleach (internal bleaching) technique.  This technique is a conservative alternative to a more invasive esthetic treatment such as placement of crowns or veneers.

internal bleachingwalking bleach


Requirements for the proper technique:

  1. recording the initial shade with a shade guide
  2. performing adequate endodontic treatment under rubber dam isolation
  3. removing all obturation/restorative material to the level below CEJ conservatively
  4. placing a barrier (GIC, composite, IRM, etc.) over the obturation material to the level 1mm incisal to external probing of the gingival attachment
  5. packing sodium perborate (mixed with water or anesthetic solution) in the chamber
  6. sealing the access cavity with GIC or composite
  7. following up in 1 week to determine the final result (the bleaching procedure can be repeated 3-4 times)
  8. removing the bleaching agent and restoring the access cavity permanently
  9. recording the final shade

Office website: vanendo ,  FaceBook page: @endospecialists

Misdiagnosis: A Nail in This One’s Coffin.

Patient presents with apparent sinus tract in quadrant 4.  According to the patient, the sinus tract had been identified by a hygienist during a hygiene appointment.  Subsequently, the endodontic treatment had been initiated in order to resolve the infection.  Here is a clinical photo of the sinus tract-like tissue.

sinus tract

The above image shows what appears to be a non-draining sinus tract.  If this is indeed the case, it means that there should be a necrotic tooth with a lesion in close proximity to the drainage site and one should be able to express exudate from the site by poking it with a sharp explorer tip.  Upon palpation, the tissue felt like a fibrous nodule that can be easily displaced under the non-keratinized tissue and it could not be drained with an explorer.  Evaluation of available radiographs confirms lack of apical lesion in this area.  Furthermore, the radiographs show significant pulp recession and heavy coronal calcification in all teeth.  This could have resulted in false negative pulp vitality test results.

This slideshow requires JavaScript.

In the absence of periapical radiolucency and pain symptoms, one should not feel pressured to rush into treatment.  The diagnosis for the above tooth might have been healthy pulp with normal apical tissues which would have required no treatment.  Instead, the overall treatment has resulted in some structural compromise.

Office website: vanendo ,  FaceBook page: @endospecialists

An Unconventional Access.

Patient presented with #1.3 pulp necrosis and chronic apical abscess.  Due to missing #1.2, mesially tilted tooth #1.3 had been restored as #13-#1.4 splinted crowns in the place of  #1.2 and #1.3.  The clinical picture shows a ceramic interdental papilla which covers the root of tooth #1.3.

The key aspects in treating such a case are as follows:

  1. reviewing the risks of the procedure in detail with the patient (i.e. possible damage to the restorative work to the point of needing replacement, possible mishaps during the endodontic treatment [perforation, instrument fracture], etc.)
  2. through assessment of the tooth/root under the crown using a probe and by palpating the root
  3. good understanding of the root angulations in mesial-distal and buccal-lingual directions
  4. planning for initial access location
  5. good isolation with a stable clamp that can be placed over the root
  6. constantly aligning the bur with the long access of the root while drilling in the center of it
  7. and finally, Patience, Patience and more Patience!

This slideshow requires JavaScript.

Office website: vanendo ,  FaceBook page: @endospecialists

%d bloggers like this: