Endodontics · patient case question
After complete instrumentation, one canal bleeds persistently during irrigation. What does this indicate?
Patient case: The Tooth That Jumped Mid-Treatment
Patient: 39-year-old male
Chief Complaint: Referred for root canal treatment of tooth #14. He reports no symptoms at all.
Background: Large restoration placed years ago. Routine radiograph revealed an apical lesion.
Medications: None
Vital Signs: BP 122/76 mmHg · HR 72 bpm · RR 16 · T 98.4°F
Findings: Tooth #14 is asymptomatic and does not respond to cold, with a well-defined apical radiolucency. Under local anaesthesia the canals are being negotiated when the patient suddenly jumps in pain as a file advances. Later in the appointment, after instrumentation, one canal bleeds persistently on irrigation.
Show answer and explanation
Correct answer: B. Vital tissue remains near the apex, or the working length has been exceeded
- A. Coronal over-instrumentation causes strip perforation or a weakened root, not apical bleeding.
- B. CORRECT. Persistent bleeding after apparently complete instrumentation means either that VITAL TISSUE REMAINS in the apical portion of the canal, or that the instruments have passed BEYOND the apical constriction into the vascular periapical tissues. Both are corrected the same way: re-establish an accurate working length with an apex locator, confirm radiographically, and complete cleaning and shaping to that length.
- C. Sodium hypochlorite at any clinical concentration does not cause bleeding — it dissolves tissue. Extruded hypochlorite causes sudden severe pain, rapid swelling and ecchymosis, a very different picture.
- D. Local anaesthetic does not cause intracanal bleeding.
Note: Two useful checks: an apex locator reading that will not stabilise, and a paper point that comes back blood-soaked at the tip only. Both indicate the apical constriction has been breached.