Hi, I’m Bill Nudera, a board-certified endodontist, educator, and author of NuEndo: Rethinking Endodontics. Welcome to my practice, where I focus on precision, patient comfort and predictable outcomes. I’d like to introduce you to Rita, an 84-year-old patient seeking treatment for an active issue in her maxillary left posterior area, specifically her last tooth.

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Rita was referred to me for root canal treatment, and as this was her first visit to our practice, we scheduled a 90-minute appointment to complete her treatment in a single visit. This allowed us to conduct intake, gather subjective information, perform a radiographic exam, make a diagnosis, and administer full root canal therapy on her maxillary left second molar—all while keeping patient comfort and efficiency in mind.

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Key Steps in Rita’s Case:

• Patient-Centered Intake: My team begins by understanding the patient’s concerns. In Rita’s case, she reported pain when biting and pressure in the area, which had begun about two weeks prior. There were no signs of facial swelling, which helped narrow our focus.
   

• Diagnostic Imaging: We used multiple radiographs, including periapical, distal cone shift, and bite-wing images. While the bite-wing was limited by her ability to fully close, the images were sufficient for preliminary assessment.
   

• Systematic Intraoral Examination: Despite inconclusive radiographs, my intraoral exam revealed marks on the occlusal surface of her gold crown, hinting at a previous occlusal adjustment. Using palpation and cotton swab bite testing, I confirmed the source of discomfort as the maxillary second molar.
   

• Diagnosis and Treatment Planning: Pulp testing was inconclusive, but symptomatic apical periodontitis was evident based on her bite sensitivity. I discussed three options with Rita—doing nothing, extraction, or root canal therapy—and we chose a conservative approach with root canal treatment to preserve her natural tooth structure.
   

• Anesthesia and Isolation: After confirming anesthetic efficacy and patient comfort, we used a modified single-tooth isolation technique to maintain a dry, controlled environment for the procedure.
   

• Access and Canal Navigation: Given the crown’s position and occlusal alignment, I adjusted the traditional access approach, positioning toward the distal aspect of the occlusal table. Using sequential files and a toggle technique, we carefully negotiated the canals, constantly irrigating and monitoring progress.
   

• Establishing Working Length and Guide Path: Working through a metallic restoration required an insulated file technique to ensure accurate apex locator readings. We created a reproducible guide path with small files before shaping and performing thorough irrigation.
   

• Obturation and Final Steps: After cleaning and drying the canals, we applied bioceramic sealer and custom-trimmed gutta-percha cones. An orifice barrier was placed, final images captured, and post-operative instructions provided, including guidance for crown repair and follow-up care.
   

This case highlights the importance of a systematic, patient-focused approach to endodontics, balancing clinical precision with comfort and clear communication.

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Watch the full case episode to see each step in action, from intake through treatment completion, and gain insights that can elevate your own clinical practice.

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