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Endo Questions for the RWE Faculty:

In this area, users are encouraged to ask questions from the RWE Faculty regarding Endodontics in General and the EndoSequence Technique.

Endo Questions for the RWE Faculty:: Bleeding

Missing

Joined: July 2015

Rank: Rookie

Posts: 7

#1
One factor when performing endodontic treatment that I have found to be unpredictable is bleeding. In the vast majority of the cases I do, bleeding is not an issue. The canal(s) are instrumented to WL, disinfected with a routine protocol of NAOCL, EDTA, including use of ultrasonics and endovac, and taken to finish. But sometimes I get a canal that in spite of a careful, routine approach just wants to bleed and bleed and bleed. I find this to be a frustrating variable. I want to, and I have allotted time to take the case to finish, but I can't get a dry enough field to obturate with confidence.  Frustrated, I throw up my hands and provisionalize the tooth for next time. Please understand I am talking about the cases that present as otherwise "routine", straight forward cases.  Not the obvious "pack with CaOH and wait" cases. Ali, can you provide some insight on this subject? In your experience what is the most common cause? Is it over instrumentation? Under instrumentation? Improper working length?  Hyper-inflammation? Is it bleeding from the PDL space, or some sort of venous lake at the apex? How can you tell? Am I doing something wrong? Do you have any tricks or methods that you use to sort this out on the spot and deal with this variable in order to finish the case? Is it a bad idea to finish the case? Do you use hemostatic agents? If so what, how?  Any help you are willing to provide on this topic would be appreciated. Thank you.
Allen_ali_nasseh

Joined: August 2013

Rank: Faculty General

Posts: 299

#2
In reply to William McMaugh This is a great question and there are lots of variables. I should do a video on this to share at some point as it comes up all the time. It's usually a confluence of factors. But it's mostly a result of zipping the apex and stimulating bleeding from periapex. I know you try to stay true to length, the problem is that we don't know the exact histological apex and even at our best, we all get out intadertantly. Happens to me too. We've been told to stay within half a mm of the RT and that's too little margin for error. 
Anyway, once that happens, we get a little bleach out, then add to that a specific case where there's possibly a slightly longer bleeding time with that given patient as well as an anatomical situation where a larger arteriol was passing by and then you get lots of bleeding. It shouldn't happen often. It happens to me, I would say, in 5% of the cases. Most of the time it can be controlled with paper points, water, maybe packing Ca(OH)2 or some hemostatic agent; but there shouldn't be any bleach used at that time. It dissolves the clot and will begin the bleeding again. In a small percentage that I can't control the bleeding then I stop, pack Ca(OH)2, and reschedule the patient (very important not to fill with blood everywhere as the protein component mixes with sealer and can affect the future seal. It may be less of a problem with a hydrophilic sealer like BC Sealer but that's not something I'm willing to test in order to find out! So, I act the same way (only situation where I do a case in two visits.) 
Maybe I'll make a video and go into more detail. But for now, try to subtract .5mm from your length and make sure you're not using positive pressure with bleach at high concentration that triggers this kind of reaction. Of course, occasionally, you can have a patient with a very oval shaped root with tissue tags on the side but 99% of heavy bleeding is out of the apex and not from inside the canal. Good luck! :)
Missing

Joined: July 2015

Rank: Rookie

Posts: 7

#3
Ali once again I thank you for generously sharing your experience and knowledge. I think these days we're all looking for that little puff of sealer at the apex in a final image and as a result maybe we get a little too aggressive with our working lengths.  Many thanks!
Missing

Joined: April 2017

Rank: Rookie

Posts: 6

#4
Dear Dr. Nasseh 
I am a general dentist. I recently did a RCT on #4. After final instrumentation with Endo sequence file #40, the buccal canal started to bleed when reaching apex, I think because of over instrumentation. I was able to stop the bleeding but the buccal canal was still oozing. I obturated with BC sealer thinking it is bioceramic so it should work in a moist/blood environment. The pt is asymptotic after 2 days. What would you recommend to do at this point, retreat the canal or proceed with the core buildup? Thanks and appreciate your help. 
Allen_ali_nasseh

Joined: August 2013

Rank: Faculty General

Posts: 299

#5
In reply to Faddi Salim You should upload an x-rays here so I can see how the case looks. THere's a big difference between over instrumentation and potential zipping/transportation/apical perforation. The prognosis varies. But having pain after 2 days is not a surprise. I would recommend placing a strong core and waiting a month and go from there. But again, the prognosis is dependent on the case at hand. If you can upload an x-ray do that. Good luck.