1. Calcfied Canal Management Essay.
Calcfied Canal Management Essay. With an increasingly aging population, and one which is
remaining dentate, the endodontic implications of sclerosis is one which we are perhaps
more exposed to now, more than ever. Sclerosis of the pulp is a natural process and
happens due to both pathological & physiological causes. Secondary and tertiary dentine
are deposited over time, thus reducing the viable pulp space as we age. Secondary dentine is
deposited once apexification has occurred and continues throughout our lifetime. Tertiary
dentine (reactionary/reparative dentine) is deposited in response to trauma to the pulp,
this can be in the form of caries, bruxism, fractures, physical trauma or even tooth
preparation. The process of tertiary dentine deposition is described quite eloquently by
Trowbridge who describes the process as dentines response to shield the ‘King Pulp’ during
invasion attempts by bacteria.1Fortunately advances in knowledge and especially
endodontic armamentaria means that the management of calcified root canals can be more
predictable, thus allowing resolution & restoration of teeth that perhaps would previously
have been extracted, despite potentially being functional & restoratively sound.2 In an age
where patients have a greater expectation regarding retaining their own teeth it’s
important to be aware of how best to manage these cases.Calcfied Canal Management
Essay.ORDER A PLAGIARISM-FREE PAPER HEREThe most common way in which calcified
canals will first be identified is from the pre-op radiograph (or radiographs in the case of
multi-rooted teeth). From there on the management of calcified canals follows the same
basic principles that all endodontic cases do:MagnificationAccessInstrumentationChemo-
mechanical disinfection MAGNIFICATIONStudies have highlighted the importance of
magnification in location of canals, Scharwze et al3 demonstrated the benefit of
magnification in locating MB2s in 6s, canals which are traditionally difficult to locate. It
therefore goes without saying that in teeth which show sclerosis and calcified canals that
magnification, whether in the form of dental loupes (figure 3) or an operating microscope
(figure 4), is of paramount importance in terms of managing these cases. These aid in
providing visualisation and illumination into a small working area, and help to highlight
landmarks in the pulp chamber that can aid in location and management of calcified
canals Figures 1&2: Sclerosed canals tooth 12 & 36m canalsFigure 3: Dental
loupes with lightFigure 4: Leica Dental operating microscopeACCESS Pre-operative
radiographs assessment is essential in cases with sclerosis. For teeth with more than one
canal it is therefore recommended to have more than one pre-op radiograph at different
angulation. These should be studied to help gauge the depth from the crown to the pulp

2. chamber, or in cases where the sclerosis is deep into the root, the depth to the beginning of
the canal. Many digital radiograph systems will have built in software which can be used to
measure these depths as a rough guideline.Calcfied Canal Management Essay.Within teeth
with calcification of the pulp chamber, the aim of access is the same as in ‘normal’
endodontics – allowing unimpeded access into the pulp chamber and the root canal system
with as minimal destruction to sound tooth tissue, thus allowing restoration post
endodontic work. The issue with cases with severe calcification of the pulp chamber is that
access is more to do with location of the canal orifices, rather than locating the pulp
chamber as this is non-existent. This unfortunately generally leads to more tooth structure
being removed than desired in pursuit of the canal system. This can have dramatic
consequences in the form of perforations or removal of too much tooth structure thus
rendering the tooth unrestorable. Figures 5 & 6: A case referred to me after GDP
perforated looking for sclerosed palatal canal. Palatal canal was found & perforation
repaired with MTA, access sealed GI & composite. 2nd radiograph is 6months post op which
shows excellent healing of apical pathology.Fortunately, there are some ways & equipment
available which help us in our locations of the root canals. As stated previously, the sclerosis
process is down to the deposition of secondary & tertiary dentine over the root canals, this
fact allows us to use the differences in dentine types to help locate the root canals. Krasner
& Rankow4 describe several laws which aid in location of root canals, all of which are
excellent rules to use as a guide in orifice location.One of these rules is that the colour of the
pulp chamber is always darker than the walls of tooth. Under magnification & illumination
these subtle changes in dentine colour can be noted. When in the pulp chamber & troughing
for canals, ensure that it is dry and it can be noted that in use a bur or ultrasonic will
remove ‘whitish chips’ which end up accumulating in one specific location – this often being
a canal orifice. Therefore, against the backdrop of the dark dentine of the pulp chamber
floor, canal orifices can often appear as little white spots.5 The use of magnification is
pivotal here to see the slight changes in dentine colour.Personally, I find the use of
ultrasonics and gooseneck burs (figures 6 & 7) key pieces of equipment to use in such cases.
These both allow careful, selective, controlled removal of dentine. The use of an endodontic
DG16 probe or Micro-orifice openers are also routinely used to aid initial penetration and
exploration of these ‘white spots’. Figures 6 & 7: Long neck gooseneck burs (Meisinger) &
ultrasonic endo tips allow more controlled removal of dentine when searching for canal
orifices. They can both even be introduced into the orifice to aid initial exploration.In multi
rooted teeth use of dyes can also be beneficial in terms of locating canal orifices. An example
of this is Cerkameds ‘Canal Detector’ which works by having a dye contained in the product
which invades into the root canal orifices and dyes them blue thus enabling easier
detection. The product can also be used in the same manner to detect cracks within
teeth.Calcfied Canal Management Essay.Figures 8: Cerkameds Canal Detector – contains
methylene blue which can aid canal orifice detectionINSTRUMENTATIONOnce any calcified
canals are identified, negotiation of them presents another challenge. As with all endodontic
cases the use of both stainless steel (SS) hand files and NiTi files (rotary and/or
reciprocating) are the mainstays of treatment.The small hand files are important in creating
a ‘glide path.’ This is effectively an initial preparation of the root canal structure from orifice

3. to apex, which preceding rotary/reciprocating files are to follow.6Benefits of glide path
creation include:-scouting of canal structure-initial introduction of irrigant-lubricates canal
before introducing bigger filesThe use of pre-curved smaller hand files such as .06 & .08 is
often the first step in initial exploration of calcified canals. In canals which are extremely
calcified or curved, traditional SS K files can struggle to negotiate the canal system and often
unwind, twist and thus run the risk of fracturing. Dentsplys (Dentsply Sirona Endodontics)
C-Pilot files are often a good alternative in such cases. These files are made from a special
steel alloy with a uniform structure which offers maximum resistance to fracture, but with
no limitations re flexibility. The files have an inactive tip which allow the instrument to
follow the canal rather than cutting its own pathway, thus decreasing the risk of perforation
of the root canal system.In all cases it is imperative to achieve a reproducible glide path
before thinking of introducing any mechanically driven file.Mechanically Driven Glide
pathTo aid in glide path production there are a number of files on the market these days
whose aim are to assist in initial preparation of canals by aiming to create/ enhance glide
paths. These NiTi files are designed to do the job that SS hand files can do but more
efficiently & safely. Traditional SS files have the disadvantage in that if not managed
properly they can end up creating their own pathway within the root canal system
(transportation) and thus run the risk of perforating or blocking the canal, due to lack of
flexibility of the file.With their improved metallurgy and engineering, NiTi endodontic files
with small tapers & apical tips have been shown to follow natural canal curvatures better
than hand SS files.7,8Examples of such files include: Proglider, Pathfiles & WaveOne Gold
glider.Improved NiTi Files For Main PreparationNewer generations of NiTi alloys such as
WaveOne Gold, ProTaper Gold, Reciproc Blue are thermomechanically treated NiTi alloys.
The process of manufacture allows the files to be more flexible with improved cyclic fatigue
resistance and greater angle of deflection at failure when compared to conventional NiTi
and therefore offer many advantages when looking to negotiate calcified canals.9 Certain
files, due to the heat-treated process in how they are manufactured, can also be pre-bent
thus giving another advantage in terms of negotiating tight canals.Calcfied Canal
Management Essay.CHEMO-MECHANICALChemo-mechanical preparation remains arguably
the most important aspect of root canal treatment in terms of trying to disinfect the root
canal system. With calcified canals its especially important to never try to instrument in dry
canals, to limit the chance of file separation, creating blockages etc…Calcfied Canal
Management Essay.Irrigants remain the most popular way of providing lubrication within
the root canals & of all the irrigants available sodium hypochlorite (NaOCl) is the most
commonly used as it meets most of the requirements for an endodontic irrigant compared
to every other compound.10 It has the ability to dissolve necrotic tissue and the organic
components of the smear layer and it has a broad antimicrobial spectrum. 17% EDTA can
also be used to aid in removal of smear layer. If used, it’s important not to mix NaOCl and
EDTA.Rather than irrigation, EDTA in the form of a lubricant gel (such as Glyde, File-eze,
Canal+ etc….) can be used as an adjunct to irrigation to aid the passage of files.Calcfied Canal
Management Essay.OTHER COMMENTS TimeTime is imperative in these cases especially as
you go deeper into the tooth in search of an opening. Make sure you have plenty of time for
the appointment as rushing to locate canals in areas where there is minimal leeway for

4. error, will ultimately lead to error.Tiredness and LimitationsIf you find yourself searching
and searching, there is no shame in dressing the tooth and coming back to it another day.
The best weapon in our armamentaria for locating root canals are our eyes, and like all
muscles if used a lot are prone to fatigue. I have countless anecdotal evidence in cases
where I haven’t been able to find all canals by the end of a long appointment and yet I’m
able to locate them within minutes of a second appointment.Stop and Continually ReassessIf
you are going deeper and deeper into a root canal system looking for an opening, it is
worthwhile stopping and re-assessing at regular intervals. It is common to become fixated
on one spot within the tooth and continually work there until you’ve located the canal or
perforated. I advocate stopping every so often and re-assessing with radiographs to make
sure you aren’t going off-course. In these difficult cases CBCT is incredibly useful to aid
location, if you have access to one.LimitationsEven with all the advice there will be some
cases where you may have to stop mid-treatment and admit defeat. There is no shame in
stopping if you’re having difficulty and then referring on to someone better equipped. It’s
much better to realise your limitations and refer on before you potentially create other
problems e.g. worsening a ledge, creating an apical block or perforating. Figures 9
& 10: A case referred to me after GDP was unable to locate sclerosed canal through an
existing crown. You can see in the post op how close they came to perforation.CASE
STUDYNew patient attended practice after seeing an emergency dentist due to a veneer
debonding. The veneer was replaced temporarily & patient was advised to see a
dentist.Patient was 58 years old, medical history was unremarkable but, they hadn’t seen a
GDP for over 6years. Her primary concern was her debonded veneer and their overall
aesthetics (which had been present for over 10years) but was aware that would likely need
a lot of dental work.Calcfied Canal Management Essay.She was seen by a colleague who
recorded that gingival health was fair, the dentition was heavily restored with a number of
leaking restorations, with all upper anterior veneers except 13 showing gross secondary
decay. Periapical radiographs of teeth 11 & 21 showed severe sclerosis of the root canal
system. Due to the decay present & lack of sound coronal tooth structure, the canal space of
11 & 21 were required for restoration with post crowns.Calcfied Canal Management Essay.A
treatment plan was devised as follows:Stabilisation Phase:1) Course of Hygiene Phase
Therapy2) Management of posterior leaking/fractured restorations3) Temporisation
of 12-23 with temporary crowns following caries removalRestorative Phase:4) Root
canal treatments 11, 21 & 235) Crown lengthening to improve gingival zeniths 13-
236) New temporary crowns 13-237) Review perio condition8) Finalised anterior
crownsFigure 11: retracted anterior viewFigure 12: occlusal view showing secondary decay
12-23Figure 13: PA of 11 & 21 showing secondary caries & severe sclerosis of root canal
systemRCTs 11 & 21 Procedure:Following placement of temporary crowns 11 & 21 by a
colleague the patient was referred to myself for the endodontic management of the
sclerosed canals. The patient was informed of the increased risks of root canal treatment in
this situation & a full consent process was followed in relation to this.Initial assessment was
done before seeing the patient by using measuring tools on our digital radiograph system
with the original radiograph, as described previously, to give an estimation regarding canal
location in relation to the crown of the tooth.Figure 14: Estimation of canal location in

5. relation to crown tip. 11=18.4mm, 21=17.2mmLA was administered & dental dam was
placed & secured by floss ligatures. Access was made palatally through the temporarily
crowns and the use of ultrasonics & predominantly LN gooseneck burs was used to aid
location of the canal with use of a Leica Dental Operating microscope. Initial location was
difficult due to the degree of sclerosis plus the challenge to keep access as minimal as
possible to allow restoration post endodontic treatment. As previously described, in
difficult cases I find it useful to use radiographs mid-treatment to aid in location of the
canals.Calcfied Canal Management Essay.Figure 15: mid-treatment radiograph. Useful as
gave information that I was in line with canal in 11, but, had gone slightly too mesially in 21.
Access was suitably adjusted after this and both canals then located.Following preparation
of canals the appointment time was complete and so they were dressed & the access
resealed. At the 2nd visit, 2weeks later, the patient reported no symptoms and thus
obturation was complete and fibre posts placed to allow definitive restoration in the
future.Calcfied Canal Management Essay.