Should you be re-treating that root canal—or referring it out?

What are the red flags that scream “specialist only”?

How do you confidently remove GP without compromising disinfection?

Dr. Ayman Al-Sibassi joins Jaz in this endo-packed episode to help you navigate the tricky world of root canal re-treatments. From solvent selection and GP removal techniques to assessing case difficulty, they break down everything a GDP needs to know to make smart, confident decisions.

You’ll learn how to spot the cases you should be tackling, which ones to send to your endodontist, and what tools and techniques will make the re-treatment process smoother and safer. Because not all re-treatments are created equal—and some are surprisingly simple once you know what to look for.

Protrusive Dental Pearl: A crack in a bonded ceramic restoration isn’t necessarily a failure!

Just like we accept cracks in natural enamel, we can also accept cracks in ceramics—as long as it’s been properly bonded.

Shoutout to Dr. Pascal Magne for this powerful mindset shift!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Highlights of this episode:

Take a look at this Endodontic Complexity Assessment Tool to help you evaluate how challenging a root canal case really is.

If you enjoyed this episode, you’ll definitely want to check out: Stop Being Slow at Root Canals! Efficient RCTs with Dr. Omar Ikram – PDP163

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. 

This episode meets GDC Outcomes B and C.

AGD Subject Code: 070 ENDODONTICS (Non-surgical treatment)

 #PDPMainEpisodes #EndoRestorative

Aim:

To provide clinicians with a structured approach to diagnosing, planning, and executing simple Re-Root Canal Treatments (Re-RCTs), while recognizing case limitations and improving treatment outcomes.

Dentists will be able to:

Teaser: Fractures somewhere in the root essentially. If we come back to what I said about why most these more straightforward cases, why they fail a lot of the time. As I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be- so the reason I say that is ’cause they’re handfull, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well. 

Jaz’s Introduction:
I used to think that root canal re-treatments were only for specialists and that GDPs should not touch them. Well. How wrong was I? When I entered my training post in Sheffield, it was a a dental core trainee post. Now the rest of the world is kind like a residency.

It was like one year attachment with the restorative department, and this was in a dental hostel. I remember seeing a case, it was a central incisor and it already had a root filling, so it was up to me to do the root canal re-treatment. Now, I was scared. I was, oh my God, I’ve never done a re-treatment before.

I’ve never had to remove gp. And also I was learning how to use the scope of the first time. So for me, I was nervous. I was thinking, this is very much specialist treatment. Will I be able to carry it out? Now, when the case actually came in front of me and I saw the radiograph, it literally was like a GP cone floating in this big wide canal.

Just that one sultry master cone. Plenty of air and fluid if you like around it. No wonder it failed and I accessed the tooth. I literally, with my tweezers, could see so clearly that GP cone, I picked it out and I carried out the root canal treatment and that was the easiest root canal re-treatment ever.

And it just made me realize that had this limiting belief that not all re-treatments are the same. So I guess the point of this episode and what we’ll learn with my guest Dr. Ayman Al-Sibassi, is how to know which re-treatments GDPs should totally get involved with and how to know where perhaps this is one to refer to our specialist colleagues.

You’ll find out the best ways to remove the gutta percha. Is it gutta percha or is it gutta Perker? Honestly, endo is not my thing so much anymore, so I don’t even know how to say it anymore, but you know what I mean. The GP. Which is the best instrument, which is the best solvent? And interestingly, how much solvent should he actually be using?

Like should you be flooding your canal with solvent or should you be just using tiny drops on your instrument? And related to what I just said earlier, I want you to understand more about risk and predictability of re-treatments. What are the red flags that you should not pass go? We cover all this and so much more in this episode.

Now, if you’re new to the podcast, welcome. My name is Jaz Gulati, and therefore you are called affectionately the Protruserati. We are the community of the nicest and geekiest dentist in the world. So if you wanna join that community, head over to www.protrusive.app. The idea is that we don’t want anyone to feel isolated, that they can’t ask for advice.

If anyone’s feeling nervous or unsure about certain treatments, well check the whole backlog of all the episodes we’ve done. But also having peers, like-minded Protruserati to support you is exactly what you’ve created on our app. Now those of you who are returning viewers and listeners, please do hit that subscribe button.

Dental Pearl
And as you know, every PDP episode, I give you a Protrusive Dental Pearl. Now by the time episodes come out to publish, it’s actually probably been a few months sometimes what I’m kind of doing now is like early spring now, and I’m kind of getting ahead so that I can enjoy my summer with my family.

But you guys all get an episode once a week. That is the dream. And one thing that you guys ask me all the time is Jaz, how do you do it? How do you stay motivated with your podcast? How do you get it done? How do you balance family, children, clinical dentistry, and of course watching cricket, which I love doing.

How do I make it all happen? Well, I’ll tell you something guys. Something just from the heart. I have a big team now and they help me so much. It is a real team effort to get every episode out. Every episode that has CPD or CE especially, has probably been through about four different people and about three of those are dentists before it actually reaches publication.

That’s so that we can actually quality control the CPD questions, the learning outcomes, and produce the best done for you notes ever. Like our premium notes are just such a brilliant summary. The key takeaways are summarized so nicely in our PDFs and to actually make that happen takes a lot of effort.

Now because I have a team on board that rely on an income from Protrusive, it is so motivating to make sure I don’t let my team down. So I guess I’m trying to say. Thank you so much guys. Thank you so much for supporting the podcast. I’m feeling in a very grateful mood today ’cause yesterday I was at Dr. Pascal Magne lecture live in London, and I met so many of you that came up to me and said thank you. Like literally I was just amazed. Like I was, I was almost getting very emotional. You guys were coming and saying, hey Jaz, I just really wanna say this. I wanna get this outta my chest. And you said to me, Jaz, I just wanna say thank you. 

Thank you for all you do and honestly, I’m passing this straight to my team. I really appreciate your kindness and all these years you’ve been listening and our channel’s been growing, thanks to you and for you recommending your colleagues. So if you still know people who haven’t heard a protrusive, please do send them episodes like this.

The Protrusive Dental Pearl today is taken from Dr. Pascal Magne’s lecture yesterday, right? It’s very fresh in my head. Sometimes I get anxious about, oh, which pearl will I share today? Like the first few episodes, it was easy had loads of pearls I could pull out. You know, 300 episodes in now is difficult to actually think of a protrusive pearl to give you.

So it was a really cool one yesterday from Pascal Magne. He says that when we see a crack in enamel, how do you feel? What do you think? Do you think that this tooth needs to be extracted? Hell no. Okay. Cracks in enamel are not a big deal compared to cracks in dentine. Cracks in dentine are serious stuff.

Cracks in enamel are common. A crack is how the stress has dissipated. So the real pearl here actually is when you see a crack in your ceramic, don’t think that it’s failed. Don’t think that you are a failure. Don’t think that ceramic needs to be changed just because of a crack. And that was really eyeopening because sometimes when you place a ceramic and you see it a few years later and you start to see a crack inside, you think, oh goodness, this has failed.

But actually, we shouldn’t think that if we accept it in enamel, why can’t we accept it in ceramic providing, providing that’s been bonded properly. A bonded ceramic is a completely different beast to a cemented ceramic. So in bonded ceramics, a crack is not the be all and end all. And please don’t interpret that as a failure is our tip for today. So turban tip to Dr. Pascal Magne for sharing that in his lecture yesterday. Anyway, let’s dive deep into root canal re-treatments for GDPs and I’d catch you in the outro. 

Main Episode:
Ayman Al-Sibassi. Welcome to the Protrusive Dental Podcast. Can’t wait to geek out endo stuff with you. But tell us the story, right? You just literally told me, that you have a baby. Congrats at 10 months old. But he or she, sorry? 

[Ayman]
It’s a he. It’s a boy. 

[Jaz]
Okay. Boy. Name? 

[Ayman]
His name’s Suleiman. 

[Jaz]
Okay, so Suleiman was born a day before your specialist exam, is that right? For Endo? 

[Ayman]
Yeah. Yeah, basically, yeah. 

[Jaz]
What was going through your mind and like how did you cope? Did it affect your exam in anyway?

[Ayman]
Yeah, well I think it was probably made it up to be more than it was. Only because, you know, the day before the exam you’re kind of like, you’re not getting any more information in, at that point anyway. You’re kind of just like bugging out at that point. You’re kind of stuffed with information.

So in reality I couldn’t take any more information in. It was more just the panic of how am I gonna do this? Is my wife gonna be okay? I was thinking a little bit more about my wife, my son, not about like revising more, but just is, are they okay? That kind of thing. Basically it’s just, I had good support, to be honest.

I had like a lot of good support. Like my parents, my mother-in-law and like my supervisors were, was super helpful as well. One of my supervisors even came and like dropped a bag of stuff at the hospital to help out and stuff. 

[Jaz]
Wow. Wow. That is a real special story. Where did you do your specialist training?

[Ayman]
University of Liverpool. 

[Jaz]
That is really cool man. I love that your supervisor was supportive like that. That is, you know, we need more of that in dentistry. 

[Ayman]
Dr. Marwad(?) Yeah. 

[Jaz]
Okay. Okay. Well I’m glad you name dropped. Buddy, look, I’d love to know a little bit more about you. Firstly, my listeners are gonna love like those listening on Spotify treadmill. You have this lovely years deepest voice, which is just the podcast listeners are gonna absolutely love this, by the way. So that’s a great plus. They’re gonna get through the end of this one, which is great. Tell me about yourself, mate. How did you get into Endo and, and the usual stuff. 

[Ayman]
So essentially, fourth year of uni when we kind of started do an undergrad, this is under undergrad, I mean undergrad sort of endo. We started like around third, fourth year, and I did a couple of endos and I just thought, yeah, that’s me. That’s what I’m gonna do. So I kind of knew since towards the last couple of years of undergrad that that’s what I wanted to do, and I always kept telling my colleagues. This is what I’m gonna do. So kind of when I left, I focused on that a little bit during my FD year.

Did a little bit of it, well I didn’t really do any of it ’cause I went into DCT over a year after that. Did a year in Maxfax and then came out two years in general practice and then straight into specialist training. So I probably did in total a little about three years in general practice, one year of Maxfax.

And then, yeah, went in specialist training three years full time, basically up in Liverpool. But yeah, I just liked it. I felt like it was a bit of a dark art. I liked all the gadgets. I like the instant results that you see as well, and I thought it was just quite niche. Not many people like it, and that kind of drew me into it as well.

[Jaz]
No, we need more endodontist on the register, there’s not many, I mean, the last I checked years ago, maybe nine years ago, if you know this number, it was something like 264, 9 years ago. I remember that number of, especially endodontist registered in the UK. 

[Ayman]
Funnily enough, part of my sort of doctoral thesis at Liverpool, which is part of the research we have to do there, attached to our specialist training. I had to actually look into how many there are. So there’s still around, I think around 300. But the thing is a lot of them will be like restorative consultants who don’t necessarily do endo mono specs. There’s probably a lot less than that. 

[Jaz]
Yeah. Okay. No, that’s a good point. And just about your training, I think it’ll be very useful for our colleagues who are in earlier stages of their career decision making. You knew you wanted to endo right? And you did. Almost like a distraction year when, if you think about it, it was a distraction year when you did MaxFax, ’cause it kind of, you, one might think it took you away from your goal, but maybe you needed it to actually reach the endo hand on heart. When you look back at it, do you think, ah man, I regret doing that year.

I wish I did private practice, or I wish I did more endo. Or do you think back saying, you know what, you’re so glad ’cause it made you a more rounded clinician. What’s your take on that? 

[Ayman]
I don’t regret doing it. No, definitely not. Number one, because I felt like the year itself was quite full on, so I felt like it made me a little bit more resilient in terms of like doing things, working, just working hard basically.

So that was one. And then the second thing is we did a fair bit of oral surgery on that rotation, so it kind of gave me some more surgical skills, which nowadays and endo are becoming a lot more important ’cause endodontists nowadays. Historically it might have been maybe more, a little bit more about the endo with like apisectomy and stuff like that being done by oral surgery.

But it’s becoming a lot more within the remit of Endo to do things like, you know, apisectomies, auto transplantations, intentional replantations, root resections, and then even like resorption repairs, perforation repairs, stuff like that is all kind of coming within the remit endo now. So I think for that, it’s quite useful.

[Jaz]
Yeah, that’s good. It’s probably a stepping stone. I can see those surgical skills being useful later on. Thanks for talking about your journey, Ayman. I really wanna get into the topic of today, which is re-treatments, root canal re-treatments. I remember when I was working under my consultant as a DCT, when I used to type it, when I used to like write in the notes re RCT, he was like, no, you must write root canal re-treatment.

‘Cause what is a re-rct? Like, it was one of those pedantic things. But anyway, I remember I mentioned my DCT because I remember I had this limiting belief, Ayman. Yeah. I had this limiting belief ’cause I was a GDP. I was a DCT. If anything, right. And I was like, I can’t do a re RCT, I can’t do re-treatment ’cause I’m not a specialist, therefore I cannot do re-treatment was my limiting belief that I had.

And so I remember doing this one case, it was a re-treatment, right? And it was like single central incisor and it was like, the thinnest, skinniest GP point, right? In this widest canal, like probably every time the patient walks, the GP point’s probably moving side to side in the tube.

You can just imagine it, right? And so when I accessed that and I literally got my tweezers and I pulled out the GP. And I treated it and the sinus tract went away. I was like, holy moly, I just did a root canal retreatment. And then you realize, okay, hang on a minute. That was just a limiting belief that actually they’re not all the same. So my first question to you on that remit is what do you think about the scope of re-RCT for GDPs versus should it be referred to specialists? 

[Ayman]
Well, I definitely think they’re on a spectrum. So some of them, as you said, like will be a lot more straightforward, like the one you described versus some others, which can get complex depending on what you know, what they are. So you’d always have to kind of do a complexity assessment. So there’s different tools available. 

The one I’ve used and the one I’m most familiar with is one called ECAT. It was developed by a couple of colleagues at Liverpool. It’s essentially an online tool that you can click through and it just basically gives you all the factors which will give you how complex it is. So things that I would look at just in terms of what would make it a very simple case, I’m usually thinking about patients medically fit and well. No sort of complex medical conditions. 

Things like sort of bisphosphonates, not very anxious, mouth openings quite good. That would be the sort of patient factors I’d be looking for. And then tooth related factors to make it simple. Usually you’re looking at like an anterior tooth, usually a one to three. Premolars can get a little bit tricky sometimes.

Not always, but the anatomy, I find that my clinical practice always get kind of fooled sometimes by how complex premolars can be. But yeah. So one to three is usually, as you said, GP points kind of floating around. Those would be kind of simple cases in my mind. 

[Jaz]
And then what about when you see one and you see that it’s been like there’s no voids and it looks like it was a decent job. And I look at it and I’m like, hmm, I know the radiograph. The problem is the radiograph doesn’t tell you if rubber dam was used. The radiograph doesn’t tell you if hypochlorite was used. So much information you miss when you look at radiograph, but sometimes you see.

And it looks fairly good quality in a radiograph. At that point, I’m very happy to refer because I’m like, okay, well there’s something else going on here in addition, and I just think, our specialist friends need to eat as well, so this is the kind of stuff they should be eating. I’m just gonna do the cherry picking as a GDP should do.

But of course, some GDPs, they love endo and they kind of like have a special interest. They do extra courses and then they, they know if it genuinely gives you excitement and a challenge, then do it. But for most GDPs it’s like, okay, that’s a point where I see a well. Filled canal. There’s no voids. It might be a little bit more challenging to remove the gp, which we’ll get into. Is that a, a fair way to think about it for a GDP? 

[Ayman]
Sorry, can you repeat that last question again? I did just cut up there for a sec. 

[Jaz]
Is that a fair way to assess a tooth as well? When you look at the, how well it’s filled on the radiograph. 

[Ayman]
Yeah. So that would be one of the things that I would say would make it more complex is out of one of many factors. So if it’s already like, like there’s certain quality standards that we look at for endo. So the main things would be, is it filled to within two millimeters of the radiographic apex and is there root filling walk condensed? And then also like coronally you’re looking to, so is there any obvious corona leakage there or anything like that?

So if there’s nothing obvious you can identify on the x-ray, that could be the reason why it’s failed and you can’t see, for example, any cracks in clinically that you’re picking up as well. Then yeah, I mean those cases tend to be a little bit more complex. There might be like missed anatomy inside that you can’t see.

Again, you don’t know what happened previously, and there could be a lot of leakage. So a lot of the times, if the root canals are old, there’s studies that show that a lot of the restorations, or almost all of them have some coronal leakage to a certain degree around them as well. And that can cause sometimes failure. I mean, in those kind of cases, I would always kind of be thinking about CBCT because there’s no obvious cause of what is causing it to fail that you can see. So that would usually some give you some more information. I mean, that’s what I’m thinking. 

[Jaz]
That’s fine. So, Ayman, how common is CBCT becoming in your practices as endodontist now either at the consultation appointment, or, are you really happy when a GDP sends a referral with a CBCT and gives you just more information? Is that becoming more common in practice now? 

[Ayman]
Yeah. Yeah, it’s definitely becoming a lot more common in practice, and especially as with CBCT, the machines are going in the direction of the doses becoming, or the radiation doses becoming reduced over time. So as that happens, I think it will become a lot more used.

To be honest, the doses at the moment, they are not. I mean when you look at them in relation to like what you do in Maxfax, for example, remember we used to take full mouth, full face CBCTs of everything, for example, when the patient came in. So dose is actually like way, way lower than that. So yeah, and those doses are only gonna come down with time. So as that happens, it will become more common. In terms of when a GDP- 

[Jaz]
Can you gimme some examples of like, you saw the CBCT and it completely changed your treatment plan, it completely change your perception. How often does that happen? 

[Ayman]
Well, I can think of a case that happened actually a couple of weeks ago. So it was lower molar, it was re-RCT case. A patient came in and the root canal filling just looked like void. The big PA lesion, void the root filling. So anyway, I just, I started the root canal filling, re root canal treatment just based off of the PA. I didn’t really suspect anything, and I opened the tooth up.

I was getting quite early apex locator readings much earlier than I expected. So then I took a CBCT of the tooth, and I found that actually the mesial roots, that sort of danger zone, that distal concave aspect of the mesial root was kind of completely resorbed away. So the gps were half sticking out into the fication area, which wasn’t obvious on the pa. So that means that the- 

[Jaz]
So this was a resorption and not like a strip perforation. How can you tell?

[Ayman]
Well, yes, it was difficult to know, and my suspicion is it probably was resorption because there was a massive lesion associated with it into that vocation area. So sometimes you can get something called external inflammatory resorption, which kind of eats away at that area of the tooth as well.

But it may well have been a strip perforation. I’m not entirely sure just looking at that. Yeah, I mean that made in my mind the tooth on restorable. There wasn’t really much that I could do about it, so I had to tell the patient, you know. I can’t really do anything with it. Whereas previously I was about to go and reroute, can I treat it?

[Jaz]
I’m gonna get into removing GP and that kind of stuff. But now that you’ve mentioned this point of a very niche scenario, one of the questions we had from the community, I asked last night, I said to everyone, hey, I’m recording tomorrow about re-RCT. And so one question was, is it tricky question?

Ayman, not in terms of like tricky endodontically, is tricky more in terms of ethical dilemma and charging of patients. Let’s talk about this before we go into the details of re RCT further. You have this scenario, just like you described, right, invested time in treatment. You’re now time committed.

You do the CBCT, and now the tooth is unrestorable, okay? Does the patient then leave and they haven’t paid any money to you, right? Because now they’ve just been told that they can’t do it. Is there a fee that was agreed in terms of the consent and the consultation that you do? Is that okay if it can’t be saved?

You’re gonna be charged this much and you’ll have that information because imagine as a GDP, you trying to, like the example Julia gave, Julia Tully, example she gave is that she opens up a molar and she can see the three main canals, upper molar, and then she just about sees the MB2, but she gets stuck at that stage.

She can’t get into and navigate MB2 properly. And now she’s like an ethical dilemma. She feels though, well, okay, to get the best result. I need to refer you to the endodontist, but I’ve just spent an hour and 15 minutes accessing, removing caries, and then now, and that was all part of the endo, and now I have to refer, is it fair that I’m now charging my patient for my initial fee? So there’s no right or wrong answer, but I’d just love to know your take on that. 

[Ayman]
So two things. So from my perspective, I always would consent in a patient that the tooth is might be unrestorable. It’s almost like for almost every single case, unless it’s like, you know, no belly restoration is minimal or anything like that.

But even then I’ll say, look, there might be a deep crack in there that we find or something like that. So I’ll always consent the patient for it being unrestorable and I’ll quote them a fee for an investigation fee if we don’t go on to completing the full root canal treatment. So, that’s, for example, that’s how I manage the case that I just mentioned.

So I still charge them the investigation fee charged for the CBCT as well. Obviously, I didn’t charge for the full root canal treatment. In terms of if they can’t, for example, they can’t find their MB2, a lot of the times the patient for the GDPs, the patient, a lot of the time will come in in pain. So you’re still getting the patient out of pain, for example.

And I would still, for example, charge maybe half a root canal fee because you still have done something with a patient. You’ve got them out pain, for example. You don’t necessarily always need to find MB two to get the patient outta pain. And I would assume that also it’s part of your consent process sometimes to say.

Sometimes we can’t find canals, we might need to refer you. So if you need to do that, I would again, just consent the patient for potentially taking maybe half the fee or a third of the fee, because it’s still your time. At the end of the day, you’re still helping the patient out. 

[Jaz]
I agree with you so much, and I feel as though what we don’t wanna do is I feel bullied or curse that, oh, because I missed one canal or I can’t find it. Like you’re still doing the right thing. You’re thinking okay. I think someone else can navigate the deal, but you know, you would’ve got ’em out of pain. You would’ve done the hard work of caries removal, access removal. Sometimes you do a pre-endo buildup, you do all that. That stuff is valuable, but I think you just nailed it.

You know, as long as you have this standard spiel in these situations, if we can do the root canal and everything goes well, this is defeat like you tell your patients your fees before you do the treatment. But sometimes things are really, really tricky. If they’re really, really tricky, I need to refer you.

Don’t worry Mrs. Smith, you won’t have to pay the full amount. You have to pay a third of X or a half of X. And at least that way we’ve done some of the work and then the endodontist who may charge this much will do the rest. And now you’ve just been like super clear. And if you had that patient who doesn’t consent to that, then that’s the whole point of the consent conversation. Don’t think that if I tell the patient this, they won’t go ahead. Well, that’s actually the point of consent, right? And so you wanna have a patient who’s on board and who’s very reasonable and understanding of that, right? 

[Ayman]
Yeah, a hundred percent. Yeah. I would say like for example, you made a good point as well in terms of the caries. So a lot of the time root canal treated teeth, the majority of them are quite knackered to start with anyway. So you’ll almost always do like a restorable assessment as part of your root canal treatment. You’ll be stripping out amalgams, old amalgams, old composite caries, and that obviously, it’s still valuable. 

Me as an endodontist, if you refer a patient to me and it’s already had the pre endo buildup, I’m like, thanking God at that point in time ’cause that actually saves a lot of time. So you’ve obviously done that service for the patient, it’s something that you’ve done, you’ve helped the patient out and you’ve saved me having to do it as well. So yeah, I would definitely still charge for that. 

[Jaz]
I think a really good way to do it ’cause this is obviously a real world issue. And then so there are some colleagues who would do the following. They would charge a fee for the restorability assessment and pre endo buildup. And that would come as a one fee.

And then the second fee would be the root canal. And then at that point it was like, oh, you know what? I’m not charging you with the root canal ’cause I didn’t do it, but I did all this stuff. And it makes sometimes sense for the patient’s head. And so that might be a model that some practice may wish to use as not the main thing is that the conversation is had beforehand, so totally. 

I’m glad we’re on the same page there. Just going back a bit before we talk about removing gp. Any like red flags that GDPs when they look at root filled teeth and they’re thinking, hmm, should I do a re RCT? Like, the one I mentioned was like, if you see that it looks like a reasonably good root filling, that is kind of like a little bit of a red flag that, hmm, should I be doing this?

Another one would be like, if you see a separated file in there, then obviously. That’s one for you guys, not for us unless you are that way inclined. But I’m just giving like an easy guide to GDPs. If you see, I mean sinus tract for me is just a sign of infection. I know that can reduce the prognosis of your re-rct. Would that come as a red flag for you? 

[Ayman]
Just a sinus tract by itself? 

[Jaz]
Mm-hmm. 

[Ayman]
No. ‘Cause as you said, it’s just basically an external sign of the infection. Sinus tract by itself doesn’t mean too much. Although what I would say is depending on the position of the sinus track, that can sometimes indicate a fracture in the root.

[Jaz]
Tell us more. Where are you worried about? 

[Ayman]
So if it’s higher up on the attached gingiva, I’m thinking more about a root fracture. If it’s lower down in the buccal sulcus, then it’s more likely to be coming from the apex. And that is a, I’m not saying it’s less, probably less likely to be a fracture. Whereas if it’s really high up, you’re thinking maybe a furcation, sorry, fracture somewhere in the root essentially. Not always. 

[Jaz]
That makes sense. 

[Ayman]
It’s not like, it’s not fracture- 

[Jaz]
It’s the rule of thumb. 

[Ayman]
Yeah, I’m just a little bit more suspicious at that point, basically. And I think there is some research, I can’t remember the name of the paper, but there is actually some research on the position of the sinus tracts and how related they are to the presence of a crack. So yeah, which also confirms higher up on the buccal attached gingiva. More likely to be a fracture. 

[Jaz]
That’s a good one. And then obviously if there’s a post in the tooth, which actually one of the questions was, we’ll come to later, any tips on post removal, but I wanna save that for later. There’s a post, right? And unless you’re really into that kind of stuff as a restorative dentist and you get a kick outta that stuff, then I’d probably say that’s the one to refer. I’m sure you don’t get a kick out removing posts. 

[Ayman]
Is a question do I get a kick outta removing both? 

[Jaz]
Yeah, yeah. That’s the one where you’re cursing your referring dentist and not saying thank God. 

[Ayman]
Yeah, exactly. Yeah. I mean they can take a long, some of them come out in like two minutes and those ones are fine and you can kind of tell which ones those are gonna be ’cause they’ve got loads of space.

But some of them they can take up to like an hour, like the long ones, well adapted really fat posts. But in those cases, a lot of the times you’d be thinking about a vasectomy and those teeth a lot of the time as well because yeah, I mean you might take the post out at the end of it and see that the tooth is actually unrestorable. Because it’s already been prepped to death to actually get the post in there in the first place. 

[Jaz]
And we’ll talk about some tips to remove posts, but any other last few red flags before we move on to GP removal? 

[Ayman]
There’s a few. So, kind of, yeah, if anyone is interested to see like this in a bit more detail, again, that ECAT tool goes through every single factor that you could kind of consider. So if you have application- 

[Jaz]
I’ll link it. I’ll link it. 

[Ayman]
Yeah, I think that that would be useful for anyone listening. So yeah, that it basically goes through every single possible factor. So just made a note of a few. And again, like I always kind of divide it into patient mouth, tooth related factors.

So patient related factors, again, so for example, bisphosphonates, because there’s always a small risk that when you’re doing patency filling, for example. Potentially not always, but not a high risk, but that you could stimulate some kind of MRONJ reaction. Something like that. That’s one. Again, if they’re really, really anxious, you don’t wanna be sort of faffing about with taking a long time for root canal treatment as well.

Limited mouth opening as one as well. That’s one we get quite commonly in referral practice too. So tooth related factors, I would look from the crown down. So number one, if there’s really, really deep restorative buildups required, so if you’re looking at like the margins on almost on bone, that’s one ’cause you wanna make sure you’ve got a good coronal seal.

So that’s one that I’d be looking at. Any crowns or posts that you’re looking at there, especially if the crown or the post is in a different angulation to the tooth on the x-ray cracks is quite a big one, especially becoming more common nowadays as well. Cracks specifically as also associated with periodontal pockets.

‘Cause often with isolated periodontal pockets, ’cause often that means that the crack is extending down the root surface. Now those teeth, to restore them effectively, you often need a microscope because you’ll be bonding, composite down the canal orifice. And to do that without microscope is quite complex.

So if you see an isolated periodontal pocket associated with a crack, a lot of the times, that would be quite a complex case to manage previous RCTs. As you mentioned, if the RCT looks good on the periapical radiograph, well condensed within two millimeters of the apex. That would be, you’re thinking why has this failed?

So that might be something more complex. And also it’s well condensed. The GP is gonna be a lot more tricky to actually remove as well. It’s not gonna be straightforward. Fracture files you mentioned as well. And then more niche things I’d be thinking about are things like developmental anomalies.

Sometimes you get like to taurodont, palato-gingival grooves as well. Which can sort of mask as endo problems. Well, C-shaped canals as well. Those are sort of things, fast breaks as well. That’s quite a, quite a common one that you see. So it’s kind of difficult to explain without an x-ray, but usually you see it, for example, on premolars, it comes back to our premolar while I was mentioning about premolars.

So you see the canal, the canal, canal canals there, get to the apical third and then it just disappears. And then often that means that you’ve got some sort of deep apical split. So that would be quite a big red flag as well ’cause obviously you need a microscope to actually see all the way down there and actually help you to navigate around that apical complexity.

Resorption, resorption cases as well. So depending on what the resorption, especially like cervical resorption, which is probably becoming more common nowadays. So resorption cases, ’cause a lot of the times they will need like surgical repair to actually access and fix history of trauma on anterior teeth.

Sometimes they’ll have trauma to multiple teeth, which needs quite complex management. A lot of the times as well on the PA radiographs, you won’t see root fractures. They don’t necessarily turn up and that might need a CBCT to actually reveal that perio status as well. So perio endo lesions as well, which is actually, yeah, the topic of, that’s what I spent three years sort of researching at the University of Liverpool.

Perio endo is quite a big one because a lot of the times the endo might be straightforward, for example, but to manage it appropriately, you’ll need a lot of the times regenerative surgery, which will become more complex in those cases as well. 

So you might see, for example, an anterior tooth re-root canal in our treatment might be quite straightforward, but then to actually get the bone to regrow and the mobility to stop and the pockets to come down, you’re actually gonna need like bone grafting, membrane, stuff like that. So perio endo, especially like there’s a new classification. It’s by the, I think it’s the European Society or European Federation of Periodontology.

[Jaz]
Perio people, they love a classification. Like they’ll love bus one every six months, like they are the kings of classification. 

[Ayman]
So there’s a perio-endo lesion one. So they’ve divided it into grade one. There’s grade one, two, or three, basically. Grade one is if there’s an isolated pocket associated with the tooth. Grade two is one pocket on one surface, but not isolated. So it’s a wide base. And then grade three is wide or pocketing on more than one surface.

So grade two and three, often those cases will require regenerative surgery, bone grafting, or enamel matrix derivatives to actually help them along. So those would be quite complex cases to manage too. I mean, I’ve been through quite a lot. Yeah. Sorry.

[Jaz]
You have, I mean, over, over the last two minutes you shared so many red flags there and so the general dentist listening to this like, wait, wait a minute. Like, are there gonna be enough cases left for me? So my question then for you is, how many re cts do you do and think, you know what, the GP could have done this.

[Ayman]
A lot. Yeah. So the good news is a lot of the cases that I do that are RCTs then these things have, are the red flags that I mentioned. They are there, but re-RCTs fail for common things. What’s that phrase? Common things happen for common reasons, so, the most common thing that I see with root canal treatments failing is poor coronal seal and poor apical seal. 

So the GPS floating about, or this caries or some kind of leakage coronary, and those are the most common things that I see in terms of why that those kind of referrals come through. Probably, or maybe not common, probably about 50% of them are like that. Yeah. I mean there is a lot of cases like that. So while there are a lot of complex things, there’s also a lot of simple things that are easily managed.

[Jaz]
I think- 

[Ayman]
Easily. Probably sounds- 

[Jaz]
Easier. 

[Ayman]
So easier. Yeah, that’s the idea. Easier, yeah. 

[Jaz]
I think, Ayman, people might be thinking that, hey, why is the endodontist telling a dentist that, no, you could do a re-RCT, and I think it’s because you have enough, you guys are not gonna go hungry if the easier re-RCTs are done in general practice to give you the stuff that you’re actually trained to do.

The things that actually are trickier. So let’s talk about when you are a general dentist and you are learning about doing retreatment is something that little bug bit me and I was about two years qualified and the first thing was actually DF1 actually had my first one.

And I was like, how do I remove the gp? And so then you look into it and then you think about different oils and stuff. At the time I had bought, ’cause obviously chloroform in practice was difficult to get. So I used eucalyptus oil. I remember using it and then like a drop of it went to rubber dam and I forgot which dam it was.

And a huge hole appears in rubber dam. I’m like, wait, no. No one told me this would happen. This wasn’t the playbook kind of thing. So it’s a lot of things that learning. So it takes us nicely to the question, okay, what are the tips that you can give to general dentists to remove GP effectively and safely and efficiently.

[Ayman]
Yeah. Yeah. So if we come back to what I said about why most these more straightforward cases, why they fail a lot of the time, as I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be headstrong files. So the reason I say that is ’cause they’re hand files, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well. 

Interjection:
Hey guys, this is Jaz with an interjection. Just a really quick one, right? H files. K files, and C plus files. This just briefly, really quickly go through the differences, like going back to basics. So K files are the workhorse, right? These are the main files we reach for. They are triangular or square in cross-section. They use a rotational or a push pull watch, winding kind of way. Very versatile, and they cut to dentine both on insertion and removal, but not as aggressively as H files, which stands for Hedstrom Files.

Now before we talk about Hedstrom Files, we just have to point out that whilst K files are like a workhorse and they’re so versatile, they’re not as aggressive as debris removal as H files are. And when you get a calcified or sclerosis canal, then you know what? K files are not as good as the C plus files, which I’ll explain in a moment.

So H files, I was always taught in dental school that they look like a Christmas tree, and once they’re circular in cross-section, they do actually look like a Christmas tree to me. Now, they shouldn’t be used in the same way as you use a K file. Absolutely not. These are specifically push pull, and they don’t really do much when you push into a canal, but when you pull, they are very aggressive and very efficient.

They’re good at removing debris. They’re good at cutting, and they’re even good. Very relevant to this episode at removing gutta percha, which is why they’re used for re-treatment cases. So whilst they’re efficient, you have to be careful because you could break them if you misuse them. So please do not rotate H files and use them like a K file if you misuse them, you can cause all sorts of errors within the canal like transportations and ledges and that kind of stuff.

Now, mostly the C plus file. I don’t have much experience myself in using these files, but they have a very active, so they’re really good for sclerosed canals or calcified canals. That active tip allows you to get really good tactile feedback, and it’s just ideal for the negotiation of sclerosed canals.

The main thing is to use the file for its intended purpose in its intended way. Don’t go using a H file in a curved canal in the wrong kind of manner. ‘Cause that’s asking for a file breakage. Now let’s go back to the episode. 

[Ayman]
So I would probably go for like a size 35 to 45. Nothing smaller than a 35 because when you screw it in, I find that they are more likely to fracture. So yeah, I would go for like a size 35 to 45, something in that range.

And yeah, you kind of just ask, get your estimated working length off the radiograph and then you’ll kind of go into the top of, say the most coronal portion of the apical thirds. I’ll try and get the file down there. Screw it in just very gently. If it’s not go in, I wouldn’t force it ’cause you can end up lodging and stuff like that.

But oftentimes you’ll literally feel the headstrong file. It’s passing down quite easily into space, or you’ll feel it screwing into like stickiness, and that will be the gp. So get it down there, make sure you got your length, and then you just kind of, it’s basically a pulling motion essentially. And a lot of the times in these cases you’ll find that the GP just comes out with one or two pull of that and it kind of just pops out with it.

If it doesn’t, then you can use a second hedstrom file and like a braiding technique. So you can kind of put them both in together, wrap them around each other, but again, very gently, don’t wrap them around too many times ’cause you can fracture a file inside. 

[Jaz]
For this braiding technique. I’ve seen it been recommended for removing separated files and stuff, but in this instance, if you’re using two H files, are you now using thinner ones to allow both the files to go in at the same time?

[Ayman]
No, I would still probably be using like 35, something like that again, because often if the cases we’re talking about they’re gonna be one, two, or threes and the access in those cases, currently is quite big and it can accommodate two hedstrom files. I don’t find that it’s that uncommon for me to get two hedstrom files into these coronally.

Obviously apically won’t be able to pass those files down, but coronally, coronal third, mid third, you should most of the time be able to get it in there. I’m not sure if that answers your question. 

[Jaz]
That does, it’s just reassuring. And so obviously you’re saying 1, 2, 3, for our American colleagues, we’re talking about upper centrals, laterals, and canines for our American colleagues.

And then, so when the braiding technique, and correct me if I’m wrong, is you put in both the files and then the handles, you literally start like twisting them around and then braiding them. From the top and then on the inside the files are like wrapping, intertwining together. Which we are hoping will latch onto the GP, is that what we’re hoping?

[Ayman]
Correct. Yeah. So ideally you want to look and see if you can get one file on one side of the GP and the other file on the other side of the gp. And then you kind of just wrap them over each other a couple of times and then you kind of pull again, like if you’ve pulled a couple of times with a single hedstrom, it’s not coming out.

You’ve tried a couple of times, the braiding technique, and it’s not coming out. You probably need something a little bit more. And I probably wouldn’t push too hard because obviously the more you put stress on the files, the more likely they are to fracture. So braiding, obviously you are bending the files to a certain degree as well, and if you are putting motions, bending it is putting a bit of stress on the files. So if you keep trying to do that again and again and it’s not working, I would probably move on to the next thing after that just to reduce the risk of the file fracturing essentially. 

[Jaz]
Okay, so GDP has tried those two things, and what’s the next call of action? 

[Ayman]
Yeah, so then I would be looking at essentially using a file, so a file system to basically remove the GP at that point.

So the file system that I would use often, I’d go to something which we call rake angle. So if you look at the axial section of a file, you cut it down axial sections. Axial sections, like a bird’s eye view of the file. So when you’re looking at a bird’s eye view of the file, the way that the teeth of the file points, they kind of curve in a way which they end up biting into the GP rather than brushing it in a way, if that makes sense. 

So it scores a positive rake angle. So often I’d go for a follow with a positive rec angle. The most common one that you see nowadays is Reciproc Blue. So that’s the most sort of common one that has a positive rec angle.

And the use of that is that bites into the gp so when it reciprocates and bites into the gp, it kind of grabs hold of the GP a little bit and that can help to pull the GP out as well. So, that would be sort of my next step and my next go-to if the headstrong files aren’t really working. But again, you need to-

[Jaz]
And so when you are using the Reciproc Blue, ’cause I’ve never used this one before. Are you trying to take it to length and just allow it to sort of take you to length and then give up?

[Ayman]
Yeah. Yeah. Just so I’m on the same page. I’m not saying that Reciproc Blue is the only file that you can use for this. Of course, you can use things like -. Yeah, you can use WaveOne and stuff like that.

In my hands, I just feel like it’s more efficient because of that positive rake angle. WaveOne will work fine as well, but it’s just a little bit less- 

[Jaz]
Glad you said that. 

[Ayman]
Essentially, because I think WaveOne usually in GDP practice, that is my understanding is that that’s the most commonly used file and it’s a really excellent file system as well. I actually use it quite a lot as well. For GP removal- 

[Jaz]
Well maintained the ties with Dentsply there. Good man. 

[Ayman]
Well, you know, I think Reciproc Blue is now owned by  Dentsply as well. They’ve been bought by, used to be, they’re both very good file systems for GP removal. Yeah, my go-to would be  Reciproc Blue . Sorry, I forgot what you were asking me now. 

[Jaz]
I was saying, so are you gonna take it to lent? Is it safe to take it to Lent at this stage? 

[Ayman]
Yeah, so, I wouldn’t go all the way with the rotary file. I would probably, again, look at the estimated working length and I would take it up to like sort of apical third top of the apical third, or alternatively to within a two, three millimeters where you think the GP ends.

And the reason for that is if you keep trying to go past that, you can end up leveraging. And a lot of the times the GP stops at that point because there’s a ledge or there’s some kind of blockage in there. So if you try to keep pushing the file down there, you can make that worse or fracture a file or make it a problem that would be irretrievable at that point, basically as in a lot more difficult to negotiate, to patency to negotiate the canal.

So I would stop at there where there’s still two to three millimeters of GP left. And then that last apical bit, I would probably be navigating using hand files. So 10, 8, 10 hand files with lots of irrigation. There’s a lot more control that way. 

[Jaz]
So I can imagine if you get lucky, you go towards the apical third with the Reciproc Blue in this example. And then you pull it out and then ideally the whole thing, the apical bit comes with it, but sometimes imagine it breaks up and so it’s left like an apical third plug of gp. At that point, you’re then using the files again? 

[Ayman]
Yeah, I would use, probably be using K-Flex hand files essentially at that point to try and get through. So like eight 10, those were, would be what I’d be using to negotiate the equal third. I mean, if the GP is really still, if you get to that point and the GP is feeling quite hard with the hand files. I remember when I started doing re RCT cases. You put the hand files in and you’re like, okay, it’s hitting a stop.

Am I, is it blocked? What is it? So the main thing that you need to, you are feeling for at that point is to feel for that spongy feeling. And that’s how you know you are actually biting into gp. You will hit a stop, but it’ll be a spongy stop and that’s the gp. If you are hitting like a hard stop, like it feels like it’s like kind of pinging off the wall or something like that, then you know there’s maybe a ledge.

Or there’s something else that’s more complicated. But if you are biting into something that’s a little bit spongy, you should be okay basically to keep, keep trying. And often I would be using like, sort of watch winding motion just to keep it, well keep the file well centered or like a 90 degrees, small, 90 degree pull motions to try and pick out the GP bit by bit.

[Jaz]
At what point are you thinking get that, grab that bottle of eucalyptus oil? Is that, Olbas, was it Olbas, was it, maybe it was Olbas oil actually. But I used it. Are you using those little oils, essential oils and stuff? 

[Ayman]
I use them very occasionally. Very occasionally, and the cases that I use ’em to are kind of limited to if I’m really struggling to get through the apical third of gp. But oftentimes I would find those are cases which are quite complex to start with. So the GP is already like super well compacted or it’s a really, really old re-treatment. So like for example, the GP has set rock card and I tend to find that when the root canal’s already been been in place for like 10, 15, 20 years, if it’s like relatively fresh, then the GP will normally still be quite soft and easy to pick up.

So yeah, I would leave it in there for a few minutes and then pick out a bit more. And the reason I don’t go to it that commonly is because it smears, like with the rubber dam example, is it tends to smear the GP over the walls of the root canal. And when we think about the sort of biologically, what we’re trying to achieve with the root canal is adequate disinfection.

So if you’ve got layer, layer of rubber smeared over the dentine or tubules, you’ve got a lot of bacteria a lot often hiding inside those dentinal tubules, which then becomes a lot more difficult to access with your irrigation. So although you might have got to the bottom of the canal, you’ve then just blocked access to a bunch of other bacteria, which could be in the apico ramifications and the Dentinal tubules.

So yeah, you might be getting through one problem, but then causing yourself another one. It’s a little bit controversial. I mean, I think in America it’s a lot more common that they use it. In the UK, I see people, my experience is that my mentors and what I’ve seen people do is a lot less common in the UK because of that reason.

[Jaz]
It makes a lot of sense because if you think about how to remove once that GP has made, we know that a file system, you’re only really touching 40% of the canal space with the file. Most of it’s left untouched, right? And therefore, how are you gonna mechanically remove that without then actually over preparing the canal itself, right?

Which is obviously the last thing you wanna do. So that makes a lot of sense. Now, for those getting a little bit stuck and they want to use some sort of solution. Can you just name what is it that you use? Is it Olbas or is it Eucalyptus? Is it something else that you have access to? And then what’s actually the best way to use it?

Like do you dip your file in it and then put it in, or do you actually syringe it in like you would do hypochlorite and leave it there? What’s actually the accepted way to use it? 

[Ayman]
So there, in terms of what I use, there’s a few that you can use. Orange oil, eucalyptus oil. Orange oil is one, Eucalyptus oil and there’s Endosolv as well. I’m not sure if the Endosolv original is on the market now. I think they’ve changed it to Endosolv R I’m not sure. I’m not sure. I’ll have to double check that. But there’s a few. And these all basic kind of work on different arbitration materials. So for example, if you’re finding out to get down one, you might experiment with the other one and see if you get any further with that. But again, oftentimes if you’re having to resort to- 

[Jaz]
I didn’t know that it was interesting. 

[Ayman]
Yeah, I did know when I was sitting my exam exactly which solvents were good for which materials. 

[Jaz]
Baby brain. Newborn dad. 

[Ayman]
But yeah, so, you might go through a couple of them, but oftentimes if you’ll get into that stage, I’ll be thinking of the reroute treatment is obviously probably a bit more complex at that point anyway, so you might at that point be thinking about a referral if you’re really stuck in that apical third and none of the solvents are working. In terms of- 

[Jaz]
And how to deliver the solvent. 

[Ayman]
How to deliver it. So, in terms of delivering it, I would usually use it in a syringe. Basically. It’s the same way that I deliver the hypochlorite and I’ll just leave it to sit in there for a couple of minutes to do its work.

Just kind of, have a little break, just let it sit. And then once it sat there for a couple of minutes and it’s done, its work, I would go back in with the hand files basically and just slowly start to pick away at it with the hand files. 

[Jaz]
Okay. I mean, I’m kicking myself now because I remember, years and years ago doing it and I was like literally dipping my file in it a little bit, dipping in the canal, dipping my file. Like it just makes so much sense. Just leave it to do work. 

[Ayman]
Yeah. It needs a little bit of a reservoir to kind of work. And if you imagine as well, it’s kinda like the hypochlorite, it reacts with the gp, so if you’ve got a reservoir of it, it’s of sort of continuously reacting. Whereas if you just put a little bit down there, then you are limiting that sort of reaction process in a way.

[Jaz]
Okay, great. And so in the interest of time, I’m gonna ask you my friend, when you’re doing these, firstly single versus a two visit, the endodontist that works in our practice that I work at, he is adamant, he swears by a two visit. The previous endodontist we had, younger grad, newer specialist. He liked one visit.

Okay. And obviously sometimes they’d find a reason to change patient factors, tooth factors, whatever. Right? So what, firstly, I’d like to know what is your general preference? When you look at your diary, like a retrospective. When you look back at your diary, are you tending to do primary root canals in one visit or two? And then does that change because it’s a re-RCT and how you manage that in terms of timing? 

[Ayman]
So you’ve kind of touched on quite a controversial topic in Endo, to be honest. There’s actually quite a big divide in Endo among single visit and two visits. So depending on who you ask, they’ll probably give you different answers.

[Jaz]
That’s cool. But I’m literally generally interested in what you do. Okay. ‘Cause you can do it either way. And I just wanted to hear from you. What do you do? 

[Ayman]
Yeah, yeah. I mean, I would try where I can to do things in a single visit. ‘Cause I think that’s a lot of the times that’s a bit more patient centered in terms of what the patient wants. So the patient would obviously prefer for you to have things done in one visit rather than two visits.

But having said that, if you think about the main sort of biological rationale or root canal treatment, you’re trying to disinfect the canal space. If I feel that I cannot adequately achieve that in one visit, then I think the patient would much prefer me to do a second visit rather than increase the risk of it failing.

So things that would then push me to doing that second visit, if I think I can’t get that adequate disinfection process is number one, if I run out of time and I can’t find all the anatomy that I think is there. So that’s one. Then I’d be doing it in two visits. Number two would be if there’s a lot of discharge from the canal, so the canal is just weeping continuously.

That would be another thing that would make me probably dress the canal as well. And then another thing would be perio endo lesions as well, that would be one that would dress the canal too. So there is some research to suggest that with peroneal lesions, if you dress the canal, although it this kind of controversy for endo, it might not have an impact necessarily on the perio apical healing of the tooth, which is the endodontic outcome.

But in terms of the periodontal pocketing, dressing the canal with an interim dressing can improve the periodontal pocketing side of things as it sort of diffuses through the dentinal tubules into the periodontal ligament space. And then also in terms of teeth with cracks as well. That would be another thing.

So if it’s got a crack with an isolated pocket, that isolated pocket a lot of the times is where the crack is leaking bacterial leakage, basically through the crack. And that’s manifesting of the periodontal pocket. So if you, for example. Do the first stage root canal. You clean everything out and then you dress it.

Oftentimes, I’ll get the patient back in a few weeks later to see if the periodontal pocket has improved and reduced in depth. If it has, then I’m thinking that crack is probably a crack tooth worth trying to save if it’s not really improving or it’s basically getting worse and I’m thinking, is this really gonna work for the patient? So you can use it as a kind of diagnostic tool in that way as well. 

[Jaz]
A stepwise, careful approach, basically. 

[Ayman]
Yeah. So I’d be thinking exactly. Yeah, so the other thing is probably really, really significant swellings as well. So if the patient comes in with a massive swelling, that would be another thing that I would sort of be looking at as well.

[Jaz]
But you haven’t mentioned re-RCT. So what I’m trying to get to is, is the fact that it’s a re-RCT. Should that push our colleagues so GDPs now, right? So not the kind of specialist, what you do just because of re-RCT. Is there any reason why they should be thinking, oh, it’s gotta be two visits now, or is it still okay to do it in one visit?

[Ayman]
The fact, as I mentioned, I find that they occur just as much for re RCT cases as they do for primary cases, if not more for re-RCT cases actually. ‘Cause often the tooth has already been through that restorative life cycle for many, many years. At that point, the fact that it’s a re-RCT case in and of itself is not enough for me personally to do it over two visits.

Maybe if it was a really good quality root canal treatment, that would be an indication. ’cause then I’m thinking as there sort of more virulent strains of bacteria. But that’s not really that evidence-based to be honest. 

[Jaz]
Well, I’m gonna just take a few questions from the community now, buddy. In the interest of time, right? Let me just head to the community here. There was some questions we had yesterday. Okay? So I posted yesterday saying, I’ll be talking about this topic. And James, oh man, James got some awesome contributions and he put up a radiograph of these post crowns and have a look at this, look at this central, which like complete destruction, caries, post, root filling, that kind of stuff.

And he makes such a real world point here. He says, I’d love to hear us, your thoughts on value for money in re-treatments, right? So if you have a molar with an old crown, poor margins failing, inadequate root treatment, right? The total cost of doing a root canal, re-treatment, new core, new crown, okay?

Possibly pre endo restorability assessment, okay? Can be so high that I sometimes question whether XLA and implant. Will be more predictable option for the patient. For example, the radiograph he posted was his father-in-law’s, and then if he’s doing the re-treatment, et cetera, and he’d be, even if he’s only paying the lab bills, that’s still coming up to a significant amount. So what do you think about this, cost versus predictability dilemma, especially in this world of titanium. 

[Ayman]
Yeah, I think that’s, it’s actually quite a common scenario. 

[Jaz]
Great scenario, isn’t it? 

[Ayman]
Yeah, really good question. It’s a conversation I have a lot with my patients actually. So the first thing to sort of note is that the survival for root canal treated teeth on average at around the sort of eight to 10 year mark is still in the like 80, 90% range.

So it’s still quite high, which is at probably comparable to implants as well. So that sort of 80, 90% range is, yeah, not too far off what an implant’s survival rate might be at that, that stage probably a little bit higher for implants. But the other thing to consider as well is probably their patient’s age.

So ultimately we’re trying to get the patient through their whole life with a functioning set of teeth. So if, for example, you get that 10 years out of the tooth, even though the patient’s paid a lot of money for it, granted you get that 10 years of life out of the tooth, you then pushed the need for an implant back potentially by 10 years.

Whereas if you start off with the implant, obviously you haven’t got that lifecycle out of the tooth. And to replace a sort of failed implant, if it was to fail at 15 to 20 years, which is a reality of implants, then that becomes a lot more tricky than replacing a tooth. So I’m thinking of it not just isolated, how long will this tooth survive?

It’s also how are we gonna get this patient through their life for the functioning set of teeth. And yes, a lot of the teeth that we treat are re root canal treat are very compromised, but it doesn’t mean that they won’t work into the future. The other thing to sort of consider is how you are assessing the outcome as well.

So a little bit into the sort of nuances of endodontics, but in terms of you wanna look at success or survival, which are two completely different outcomes. So success is when you’re looking at the x-ray is the perio apical lesion actually. You know, reducing in size, is it getting smaller? That is a lot more of a stricter criteria than cervical, which is, is this tooth still in place in the patient’s mouth?

So you might have a lesion, is the tooth still in place and functioning okay in the patient’s mouth? So how many patients do we see that have massive perio apical or big perio apical lesions, or not big, but as in like, you know, periapical lesions, but the tooth is asymptomatic and functioning fine in the patient’s mouth.

[Jaz]
So as a GDP, I had this conversation a lot. And the patient’s like, well, you know what? And we had that informed consent and that, look, I really, I’m doing just fine. I appreciate his infection. And we had that conversation and the patient has opted for that. I can live with this. I’m okay with it.

And I just say one thing, which is what, what Dave Winkler taught me. He says, look, that’s fine. As long as you understand it’s like a dormant volcano. It can blow up any point. And I say, just don’t call me at Christmas. I just say that point and they get it. Like I said, don’t call me at Christmas. Okay. And then they get it. I was like, okay, fine. Yeah. 

[Ayman]
So if you are going by success, yeah, correct. You might find that more of these cases are more likely to fail compared to an implant. But if you’re looking at cervical, then you know, it might be that, and I mentioned survival rate at the beginning was 80 to 90%, not success rate.

That is because a lot of these patients have these PA lesions, which are just sitting there completely asymptomatic, and those cases can last many, many, many years into the future. What’s interesting as well is the implant literature. A lot of it, if you compare their outcomes for like with what a tooth outcome would be, it’s actually closer to survival.

So the implant could have like threads exposed, that kind of thing. But actually what they’re looking at in the implant literature is the implant still in the mouth. That’s commonly what’s looked at. 

[Jaz]
There could be a lot of, yeah, bone loss. There could be several prosthetic failures, which are very common. 

[Ayman]
And when you look at that, that 90% success survival rate that’s coated for implants is actually quite similar to the tooth survival rate. So yeah, you can have a compromised implant and a compromised tooth, which is surviving many, many years into the future. And that rate of survival is pretty similar for these compromised teeth into the future. So yeah. 

[Jaz]
I like that ethos of delaying implant as much as possible So I’m definitely with you in that. My friend, in the interest of time, we’re gonna wrap up. My wife has to go to a some sort of a pediatric dentistry conference, and I’m gonna get killed if I don’t be there in two minutes to help out.

But, Ayman. As we wrap up now, firstly, thank you. Thank you so much for spending some time with me today and sharing and helping GDPs just overcome this obstacle. And hopefully, a lot of those people who had a limiting mindset like I did, you’ve helped out but also helped to identify which are the easier cases which we should be doing.

And actually lots and lots of good reasons to make sure our endodontist colleagues. Don’t go hungry. Now, Ayman, can you tell us about any, either education involved in or how to follow you or how to reach out, how to thank you. All this kind of good stuff. 

[Ayman]
So, the main place I’m on is on Instagram, so it’s ayman_endo. That would be it. I’ve just recently started posting. I’m not like a big account at them or anything like that. That’s one. And then, yeah, just any of the practices that I kind of work at. If you have any questions you can kind of ask for me there or message me on Instagram basically. So the practice I work at, there’s a few one in Norwich. So they’re all listed on my Instagram anyway. If there’s any questions, just ask ’em on Instagram. That’s fine. 

[Jaz]
Well just, you know, Ayman. And I were touching base on Instagram, so thanks for all your applies and stuff. So, having helpful, friendly specialists to liaise with on a social platform that we’re so used to is just amazing.

Ayman, if you’re interested in community, come and join us on the app Protrusive Guidance and be a resident endo geek on there. But, wishing you all the best hope Ramadan, Kareem and all that stuff as you were recording in the middle of Ramadan at the moment. Thank you. So wishing you all the best for that, Ayman. Thanks so much for making this time and making re-RCTs a lot more tangible for us. 

[Ayman]
Great. No problem. It’s my pleasure. Thank you. 

Jaz’s Outro:
There we have it guys re-treatments for GDPs. Thank you, Ayman. Once again, our fantastic guest with a lovely deep voice, a nice little feature for those who are listening.

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