It all began as a routine #2. The patient was originally sent for consultation regarding discomfort in the upper right quadrant. Her chief complaint included"pain when chewing and a relatively constant ache" in the region. A quick intraoral examination revealed that the patient had an existing 2-x-x-5 bridge in the region, and she pointed to the area of #2 when prompted for the "trouble tooth".
The radiograph failed to clearly demonstrate any pathology. Except for calcification of the canals, the only finding of note was a lip on the M aspect of the crown that extended gingivally. My initial thought was that this lip might be causing a periodontal issue and that her pain was thus periodontal in nature. However, testing revealed a lack of response to cold and clear tenderness to percussion and palpation. It was clear to me that #2 had become necrotic and would require RCT.
From what I could gather from the radiograph, the tooth appeared to have two roots/canals. I followed my usual strategy with calcified upper molars, which is to find the palatal canal first, begin instrumentation, and then "take what the tooth gives me" (which in this case wasn't much!!). This strategy allows for proper re-orientation throughout the procedure, as canal locations can often surprise you in heavily calcified cases.
After locating the palatal canal, I traced the change in pulpal floor coloration toward the B (a good way to stay safe when locating calcified orifices). Eventually I located a second canal, which turned out to be the DB, but after enlarging this canal it became apparent that my guess of two canals proved to be incorrect.
And this is where things started to get interesting. Finding the remaining canals was proving to be extremely difficult. After several minutes, I located what I believed was the singular and final MB canal. However, enlargement of this canal rendered it palatal to the DB, indicating instead that it was MB2. Typically, I'm happy to find MB2; however, finding MB2 more easily than MB1 is a different ballgame! It can only mean that nature has done one heck of a job calcifying that main M canal.
I used MB2 as my reference point and started troughing buccally. And after a few swipes of the bur, I found a stick with my DG16, but unfortunately, this turned out to be the margin of the crown. A file xray verified that the file was indeed slipping between the margin of the tooth and the aforementioned M lip of the crown. Realizing this was the case, a few more swipes of the bur apically and toward MB2 finally revealed the sneaky MB1. However,now that all canals had finally been located, I had a new problem on my hands.
I wanted to seal the newly-open margin on the crown before proceeding with treatment, so as to prevent a hypochlorite accident, but in doing so, things became a little hairy. I grabbed the Geristore, a great glass ionomer that can be used for root repairs and began to prep the area for application. I then blew air out of the air/water syringe to dry the open margin. It was at this moment that the patient mentioned slight discomfort in the area above the tooth. I immediately stopped and asked her is everything was ok; she said yes, that the discomfort had gone away and that most likely she was simply sore from the grueling procedure. Seeing this as a plausible explanation, I continued and finished applying the Geristore.
Once the Geristore had set, I turned my attention back to the root canal at hand. However, out of the corner of my eye, I noticed something that caught me by complete surprise. Suddenly and surprisingly, the patient's right eye had swollen almost completely shut!!! I immediately dried the canals, placed calcium hydroxide, and sealed the access with a cotton pellet and Cavit. Removing the rubber dam, I began to examine the patient's eye as well as the cheek area beneath it and B gingiva intraorally.
