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Sometimes we notice trends. Patterns. I picked up on a trend in a few of my endo cases, and I want to show you something interesting about them. Take a look at these three cases. What is the endodontic failure they all have in common?
Yep. All three of these patients still had the cotton and cavit left in the chamber at their one year recall, AFTER the crown was permanently cemented. (Nooooo!!!!)
That’s not good.
Hang in there with me, because I’m trying to make a point.
It’s up to you, my friend!
Go back and look at the chamber from the postoperative radiograph to the recall.
Well, most of your patients aren’t going to show up for their one year recall, especially when they are feeling great. (This is part of why you should really, really impress on your patients just how important it is that they truly do come back for this appointment. It’s crucial to make sure they’re healing properly.)
These three patients thankfully DID come back at one year, which is both clinically significant and kind of unusual.
Why? Because their tooth began bothering them again.
Why? Recontamination.
Don’t make this mistake… it’ll lead to endodontic failure.
This sponge or cotton that we place in the tooth under the temporary is a magnet for bacteria, and if you leave it in the chamber and seal it under the crown, you’re looking at an endodontic failure that has made a nice, cozy home for those bugs.
Your patient is going to be in pain, and you’re going to be mega embarrassed.
Let me tell you, this is a very uncomfortable conversation for the endodontist to have with the patient. No endodontist wants to tell a patient, “I’m sorry, but you need to know exactly what happened.”
Perhaps some of you feel that, as the endodontist, we shouldn’t say anything. Right? After all, we’re the specialist, and we should just fix it.
Here’s how it looks from our point of view: At this point, the patient is blaming us that their root canal didn’t work. We get put in the hot seat.
I’ll be honest, most of the time, I don’t say anything unless I have a really inquisitive patient, and I just redo the root canal for free. But don’t assume that will happen, because it’s quite possible that one day your endodontist may not bail you out! ESPECIALLY if it keeps happening!
Here’s what you can do.
So do yourself a favor and take a few seconds to check and make super-duper-double-triple sure the cotton and cavit is out of that tooth. Or ask your endodontist to do the buildup under isolation in order to prevent an endodontic failure like this.
Otherwise, you’ve created an opportunity to look bad and lose a patient, something we want to avoid at all costs.
And worst of all, you’ve left a patient unknowingly in a bad situation, where they’re going to be in pain… and could need retreatment. In the worst case scenario, they could actually lose their tooth.
So take care of your patients, your specialist, and yourself. Every time!
Remember: C-C-C.
Before it’s time for restoration, remember: C-C-C.
Cotton. Cavit. Crown.
Check to make sure the cotton and cavit are outta there. THEN place the crown.
Put it on a little sticky note on your desk. Tell your dental assistant. Frame it by your diploma. Make it the background on your phone. Repetition really helps!
You can even remember me cheering you on, and reminding you, C-C-C! Whatever it takes!
I’d love to hear your takeaways from this post. What did you learn? Are there any other things you forget? Can you make yourself a system to remind yourself? Let me know in the comments!
17 Comments
Gee whiz!! are people really that lazy? I mean, after all, you do get PAID to do a buildup in addition to the crown or bridge abutment…
Thanks for commiserating Richard — it happens 🙁
-Sonia
Sometimes it really happens without really trying. So try to be extra careful and check everything before closing anycase. Pre and post xray is a must .
Yes, this is just a gentle reminder for all of us to be extra careful. Thanks for reading, Angelo!
-Sonia
if you remove the cotton and cavit and place filling material, could you get re healing? without the redo?
Thanks,it’s very helpful
Very helpful
I also want to strengthen the foundation for my crown to reduce the possibility of the patient showing up with the crown in their hand because the tooth broke off in the crown.
I feel the coronal seal is the final part of the root canal treatment and is therefore the responsibility of the endodontist in pretty well all cases – do whatever is appropriate, GI, etch bond compo, FiberPost and compo or whatever else is appropriate. There are a few cases where there needs to be a conversation with the referrer about how to proceed but they are very rare. If you do the coronal seal, you have taken full responsibility for all aspects of the endo and you are less likely to need to have these awkward conversations. Furthermore, it takes but a few minutes to do a decent coronal seal if you are already in there with rubber dam on and a microscope focussed on the tooth and there is no risk of contamination between leaving you and doing the crown and no chance that the coronal seal will end up being done without rubber dam under a sea of saliva (trust me, it happens!). With an explanation of the benefits, most referrers would much rather have a tooth back that is all ready to go
straight to prep for occlusal protection – couldn’t be easier for them and they love to know that they are completely “off the hook” for any aspect of the endo. This may be a cultural thing and it may be dependent on how payments are shared between referrer and specialist but where I am, sending back a fully sealed tooth is pretty normal.
Unfortunately I have seen this happen when I have indicated that I want to do the buildup and whatever restoration is needed. The patient is out of pain. We schedule the patient for the restorative procedure and they either cancel or don’t show. This is a reminder that we must be diligent about contacting the patient and multiple times if needed, to prevent this from happening. Thanks for the reminder.
Michael,
I love your strategy and diligence. This is the one thing that breaks my heart when I see it. I have several GDs that don’t allow me to do the occlusal composite (under rubber dam isolation) when I am done with the RCT and this is always my fear. Thank you for doing your part.
-Sonia
David,
I agree with you completely. I would love it to be my responsibility too, however, that just isn’t reality. I have several referring dentists that have asked me NOT to do it. Some won’t even let me do a simple composite occlusal restoration in the crown when I am done. And some don’t even want the orifice barrier because they “want to see the floor” of their restoration. I honestly wish more people were like you, but that is not the case at least in my area (no matter how many times I try to ask for the responsibility). Thank you for your comment.
-Sonia
Paul,
Thank you for your comment.
-Sonia
Thanks for reading!
-Sonia
John,
I guess you could always try anything, but these patients were all symptomatic and they didn’t want to live that way. The bacteria contamination was too much.
-Sonia
For 3 years I’ve had pain with a tooth. Dentist did a root canal an I continued with pain. I went to an Endo who found another root up in the sinus, so another root canal and a bone graft. Went back to the Dentist to seal it. The tooth was still sensitive. Back to the Endo, 3-D Xray looked good, followed up 6 moths lather because of sensitivity. Learned to live with it.
Went to another dentist that chose to replace the crown. When he took it off, he drilled into the roots to clean them up and found cotton and sponges inside. He removed them, disinfected them, filled them properly, new crown and now NO PAIN.
It’s been a long ride, cotton and sponges don’t show up on XRays. Two doctors screwed up. One fixed their problem.
I am so sorry you had to go through such a long and painful process, but I am so glad to hear that it is finally resolved and you are pain-free today! Thank you for sharing your story. Wishing you all the best 💜