From: Noemí Pascual
To: ROOTS
Sent: Tuesday, May 15, 2007 5:54 PM
Subject: [roots] Anatomical variations premolar CASE

A 30 year old male was referred for endodontic therapy for tooth 14. The referral began the treatment. No rx prior
treatment and after two visits she sent the case to me. Her initial diagnosis was irreversible pulpitis. The patient
was assymptomatic. Two canals were located. The buccal  was prepared to sized 30 / 0.04 and the palatal to
size 35 / 0.04. NaOCl and citric acid as irrigants. The obturation was carried out using the cold lateral condensation
with GP and AhPlus for the apical third and accesory points with guttacondensor for the other two thirds.
Thanks to Roots I have changed my "temporal filling" protocol. Orifice bonding with KDM cement + Cavit + IRM.
All suggestions and criticism are welcome!!!! - Noemí Pascual








Noemi, When you find a canal that is very tight, run through this series several tmes:  10, 15, 20, 25, 10, 15, 20, 25.
(I never use smaller than 10).  You should find the files getting deeper in the canal each time you run through the series.
This is especially useful in the MB2 canal. - DanS

Isn't there a third canal in this tooth? - ahmad

Hi Ahmad! yes...I think so...in the palatal canal...although I was not able to permebealize it  completely
...only a 06 and 08 - Noemi

Noemi: regardless of what some emphasize, the size of the finished file is irrelevant to endodontics.....and no it
doesn't mean finishing it with a size 10 either...we are addressing anatomy not a set of files our asst. has set
out in sponge...)))

..the goal is cleaning and shaping the canals, or debriding and disinfecting the whole canal systems present.....
when there is a system still not addressed , the tooth is not likely to heal, is it?

I am not trying to be harsh, rather make you think that what would happen 10 years from now ( if not sooner )
when he starts having pain with this tooth again. how would you approach it then? and what would you differently than
the first time you treated it? BTW, the 3rd system missed is more likely in the buccal..ahmad

Hi Ahmad! Yes...it´s true...remember I like you being harsh to me... :-))))  Well...I cleaned, shaped, debrided and
disinfected the B and the P...but  I was not able to shaped competely the 3rd system....although I irrigated
and irrigated and irrigated...I know some of you use M4 for this cases... I do not have....more alternatives to M4?
I will do another appointment for the 3rd system with the patient. - Noemí

one more thing.... sorry for the mistake...yes...it was in the buccal not in the palatal... you don´t miss anything Ahmad!
I want your clinic eye...(I don´t know if you´ve got this saying)...I will post the end of the 3rd system - Noemí

Noemi, Brassler and EDS have a similar reciprocating handpiece.  These two are a bit tighter on some file handles but work
great also.  You should be able to get one or the other.  Find Barry Musikant and he'll ship you one.  Guy

Hi Guy! Thank you for your suggestions. - Noemí Pascual

Noemi: Since I am a visual learner, I try make my point by posting example of my cases I have treated like yours.

Ok, here is case from couple of weeks ago....
The #4 ( UR 2nd premolar) RCT was done more than 15 years ago...without a scope and probably without any rotary files.....
Look at the shapes and flow of obturation.....Aren't they absolutely beautiful???
Regardless of the shapes, obturation material, taper of the files and apical finish, he was swollen when I saw him.

I knew there was a missed canal.......how??
I took about 7-8 pre op x-rays from different angles.
Opened the tooth and cleaned the chamber and looked for the other canal in the buccal orifice of previously treated tooth.
Of course I had an unfair advantage, since I was cheating and using a scope....))

Once I located that canal, instrumented it....cleaned the obturatred MB and P canal , I packed CH in the canals and spent
another 2 hours finishing the case..

you said: " was not able to shaped competely the 3rd system....although I irrigated and irrigated and irrigated"

So what was the rush??? Why finish a case when you know there is a septic area left untreated?
M4 doesn't help you much, since you couldn't enter the canal. Forget the gadgets for a minute...you have the ultimate tool
in form of scope which enables you to SEE !!!! when you can't reach the "endodontic objectives" just pack the case with CH
and look at it with a fresh set of eyes next week, next month, next day...You will be amazed at what you can accomplish when
it was all hopeless the first time.

The point here is that excellence and quality endodontics takes time and patience. why rush a case only to regret later?
I am not bashing one visit endodontics, but I have an issue with "one visit mind set" some are cornered to. The one visit
mentality doesn't allow the practitioner to think about other nuances if they are pressed for time.
Have you heard the expression that when you have a hammer, all you see are nails??

Having the flexibility and open mind, that yes, there are vital cases when a second, third or even 4th visit is required
to achieve the complete endodontic objectives, is something that requires a very through inspection of our pre-set dogma.

May be I am dogmatic with my multiple visits mind set too...but I rather err on side of caution. plus it doesn't hurt to
know I am right....)))) - ahmad





Very nice cases, Ahmad. - Guy

Hi Ahmad, Thank you for your time and all your comments. I really apreciated your help. For sure, I make a mistake.
It´s true it doesn´t help to regret later. Although in this case it´s time for do something instead of being sorry.
I will learn from my mistakes. I do not have scope. I´ve got the chance to work with one once per week
but not in this premolar - Noemí Pascual