A Smooth Retreatment.

Retreatment March 15th, 2006


Here is a tooth that we redid an old root canal treatment on. There was plastic Thermafil in the distal canal that had previously been treated (I found an extra distal canal) and metal Thermafil in the mesial canals. The case was done over two appointments in order to medicate the canals therapeutically with calcium hydroxide paste.


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  • Princess Lennox

    Hi! I’m so glad you visited my blog b/c I have a root canal question for you . . . as you read, I was told by my dentist yesterday that I needed another root canal . . . this time on my back, top, right molar. His office doesn’t do root canals on molars b/c they’re too tricky (wish my old, crappy dentist had had this policy!) . . . he would refer me to an Endodontist in my plan. Thus, he doesn’t serve to gain any money from telling me I need a root canal. However, why would this have not shown up on my x-rays back in December with my shoddy dentist? Could the need for a root canal pop up over three months? And is the determined need for one somewhat subjective and better left determined by an Endodontist. The only dentist I trust now in my Endodontist, who isn’t in my plan. I was thinking of paying out-of-pocket for a consultation with him/having him take X-rays to see if he thinks I need a root canal before I get one from my in-plan Endo.

    In a nutshell, do you think it would be worth an Endodontist giving a second opinion on the dentist’s assessment of my X-rays? :)

  • Periapex

    1. There’s work that will be necessary for the tooth after the root canal. Find out what your dentist would do after the root canal and you might see why he’s recommending one (if he’s not being totally ethical that is). I don’t remember from your post if he recommended a crown for that tooth. Remember, an endodontist usually just does the root canal and refers you back to your dentist for the permanent restoration on top of the tooth.

    2. The need for a root canal can appear within three months yes.

    3. In theory, an endodontist would give you a better idea of the need for a root canal, but again, this is how we make a living. A greedy (unethical) person would encourage you to have a root canal regardless of the lack of need.

    If you could get a copy of the xray and post it, I might be able to see what’s going on.

  • Periapex

    Not every tooth needs a crown after a root canal (but many do). Many times putting a crown on a tooth that hasn’t had a root canal will cause it to need a root canal, so:

    Say I’m an unethical dentist who wants to crown one of your teeth because you don’t know any better. I’m worried that my crappy work will cause you to need a root canal after the crown is done and I’m scared you will blame me and yell and scream at me when the tooth starts hurting after the crown. Why not send you to an endodontist to have the root canal done before I do my unnecessary crown? I’ll send you to an endodontist who I send all of my patients to who sends me a huge basket of goodies at Christmas. He’s happy to do root canals on teeth that don’t need them (these teeth have the highest prognosis and are generally the easiest root canals)and doesn’t bother to let patients know that one option is to not do anything at all to the tooth.

    Boy, do I sound cynical about my profession. Wonder why…

  • Princess Lennox

    Thank you for your response! :) My new dentist (whose office is known to both push services people don’t need and overcharge them according to mandated HMO rates) wants to crown the tooth after the root canal. I will try to get a copy of the X-ray to bring it to my Endodontist and to scan it and post it if possible.

  • Isha

    Haha! Very nice radiographs! Five canals indeed! Are GP points more conservative for use than Thermafill? How long ago was the previous RCT done?

    • http://www.endodontics.ca Periapex

      Off the top of my head I can’t remember when this case was originally treated, sorry!

      When Thermafil is used properly it has been shown to be as effective an obturation technique as straight GP (see a meta-analysis in General Dentistry, 1997). Unfortunately, many dentists using Thermafil cut corners, don’t use it properly and then when the endo fails, it’s harder to remove than just GP.

  • endointraining

    Love the outcome of that case. i noticed that your apical preparations are larger than most (other cases i’ve seen from other endodontists). Do you have a general rule about how large you want to prepare it? If you don’t mind my asking, which file systems do you find get the job done? I personally believe in larger apical preparations, but i’m worried i’ll be causing more harm by transporting, zipping etc.. by using larger/stiffer files. Any insight would be appreciated

    • http://www.endodontics.ca Periapex

      Endo is kind of like Zen. Hard and fast rules limit your ability to truly treat a tooth. Some rules need to be broken to achieve a particular therapeutic result, others are impossible to achieve in some teeth. Where we leave a tooth in between these rules is the art of dentistry.

      That being said, I have a picture in my mind of what I need to achieve based on the literature. Here are some of the things that run through my mind as I work the apex of a molar:

      1. Tronstad and Kerekes found 35. Ram said 30/35. Trope found bigger is better.

      2. With crown down, can I get to a 35? Are my instruments coming out too bent or are they binding heavily down there?

      3. Am I going to transport the canal significantly? Probably not with NiTI files…

      4. Is my canal size and shape conducive to a decent obturation?

      I’ll get more into my process in future posts…

      If you’re trying to get wider apical instrumentation, you need to maintain some degree of file flexibility in the wider diameters. This means that apically, you need to use wider diameter files with smaller tapers. Doesn’t matter what brand of file system you use, you’re looking for flexibility. So if you’re using a rotary system, you can consider using wider flared files with smaller tips for the crown down part, then wider diameter files with a 0.02 or 0.04 taper in the apical aspect.

      Apical transportation was more of an issue in the Schilder Technique days of stainless steel. Thus the call then for minimal apical instrumentation. NiTi has changed that…

  • question

    Why would anyone refer to an endodontist for a basket of goodies at the end of the year? We make enough money as it is, without referring away unnecessary work, for the sake of a Christmas basket. I cannot believe that people would be in collusion like this.

    Beautifully root treated. The thermafill almost like silver points, in the mesial canals.

    • http://www.endodontics.ca Periapex

      The basket of goodies is usually a small representation of the “support” the endodontist might provide. You need to also include the free lunches/dinners/season’s tickets throughout the year.

      The whole gift thing is ethically controversial anyway. Technically, accepting gifts from someone that you refer to can be construed as creating a bias that might not be in the patient’s best interest.

      The thermafil in the mesials was the older metal carrier type. Basically metal with no GP around it, so almost the same as silver points.

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