Referring Your Patients For Endodontic Treatment

When referring your patient to another dentist, it's important you can trust them to look after your patient like one of their own.

"Endodontic referrals from NHS & mixed practices have always been a contentious & grey area. The fact that Newcastle Dental Hospital isn’t close to those in the Teesside region could become a bottleneck in providing the best care possible to our patients which, to say the least, is very frustrating.

I believe that the passion & honesty of care provided by a dentist reflects in their treatment outcome & the patient feedback. Dr Andrew Nichols with his special interest in endodontics has been a breath of fresh air in the Teesside area for our practice. He ticks all the boxes you’d wish for in a referral practitioner including being always available for a 2nd opinion at no cost.

I have no hesitation in recommending him to the local GDP dentists as you can rest assured that your patients will be looked after well & will return to your practice along with their thorough discharge notes."

Dr Kareem Siddiqui

Dentist at Leven Vale Dental Practice

Case B - Pre Op

Case B - Cone Fit

Case B - Post Op

Case: Endodontic Retreatment of an Upper Left Second Premolar

The example workflow of a simple endodontic retreatment case requiring ledge management and core build up for referring dental colleagues.
  • Chief complaint: fracture of the restoration in a heavily restored upper left second
    premolar (UL5), asymptomatic.
  • Diagnosis: UL5 previously treated with suboptimal endodontic treatment, healthy
    apical tissues, and a defective, pinned, MODB composite restoration.
  • Treatment: An extra-coronal restoration is indicated to restore the UL5, endodontic
    retreatment was carried out to provide the best long-term outcome for the tooth.
Patient Details

A 25 year old female was referred to my care complaining of a broken tooth. She did not like its appearance in her smile and was concerned about further break down of the tooth which may lead to its extraction.

Case Challenges
  • Limited tooth structure remains to restore this tooth. This poses a challenge to isolate the tooth for successful endodontic/restorative treatment.
  • A lack of coronal tooth structure requires a strong core build-up to support the extra coronal restoration.
  • Previous endodontic treatment was unable to bypass a ledge in the apical 1/3 of the canal, leading to suboptimal mechanical and chemical disinfection and obturation of the apical portion of the root.
Treatment Goals
  • Adequate isolation to improve bonding of the core material to the remaining tooth
  • Careful deconstruction of the restoration to save as much viable tooth structure as
  • Successfully remove all previous obturation material and bypass the ledge in the
  • Adequately disinfect and obturate the entire canal system.
  • Nayyar core build up with deep-margin elevation ready for extra-coronal restoration
    by referring GDP.
Treatment Workflow
Appointment 1

After local anaesthetic delivery, isolation was achieved using rubber dam from the UL6 to UL4 and a brinker clamp to retract the dam around the UL5.

The remaining restoration was removed leaving 4 stabilock pins and secondary caries.

endodontic referral

The pins were removed using ultrasonics, the caries removed and cavity prepped for the pre-endodontic build-up.

endodontic referral

The bonding surface was sandblasted to improve bond strength, followed by composite placement to facilitate an irrigant reservoir.

endodontic referral

The old GP was removed to the ledge using a Reciproc Blue R25, hedstrom and K flexofiles.

endodontic referral

The canal was dressed with non-setting calcium hydroxide, PTFE tape and a resin-modified glass ionomer cement.

Appointment 2 (1 Week Later)

The tooth was confirmed to be asymptomatic between appointments.

Re-isolation of the tooth was achieved using the same rubber dam technique and a floss ligature.

The remaining GP was removed with careful prebending of the R25 file and a small amount of eucalyptus oil.

endodontic referral

This allowed a prebent K-file to negotiate the ledge. Using progressively larger K files beyond the ledge and filing in an up-down motion against it, reduced its size until the R25 file was able to pass easily to the full working length of the canal.

endodontic referral

Copious irrigation with high concentration sodium hypochlorite, followed by EDTA was used. The irrigants were activated with ultrasonics to improve their penetration
into the canal system.

Obturation was completed with AH Plus sealer and warm vertical compaction.

endodontic referral

A Nayyar Core was placed using SDR and Composite.

endodontic referral
endodontic referral
endodontic referral

The post-operative radiograph shows successful ledge negotiation, sealer penetration into a lateral canal and Nayyar core build up ready for the GDP to place a stress free extra coronal restoration.


Pre op

endodontic referral

After appointment 1

endodontic referral

Cone fit

endodontic referral

Post op

endodontic referral

Case: Patient Testimonial

Were you sceptical about being treated by Dr Andrew Nichols?

Initially, yes I was quite worried about the prospect of root canal treatment, especially
one that seemed to be complicated because I had been referred to a different
practice for it. I’ve had some bad experiences with root canals in the past, I didn’t
really know what was going on and there was some pain during and after previous

What made you choose to be treated by Dr Andrew Nichols in the end?

You were able to put me at ease at the first consultation appointment by explaining
why my tooth needed root canal treatment and gave me a detailed explanation of
how you would carry out the treatment. You came across open, honest, and confident
which made me feel I could trust you with the treatment of my tooth.

What specific benefit have you received from being treated by Dr Andrew Nichols?

I’ve managed to save my tooth! I was so worried about losing it and having a gap in my smile. The treatment itself, although long, was much better than I was expecting. I was a little worried before starting it, but I felt no pain whatsoever during the procedure and only a little discomfort for a few days after. You had already pre-warned me about this, so I was fully expecting it. I think I actually started to fall asleep at one point which is a first for me in a dental chair!

Would you recommend Dr Andrew Nichols to friends & family?

Absolutely! I felt in safe hands the whole time and would definitely recommend Dr Andrew Nicols to anyone who needs root canal treatment.

This patient managed to keep her broken down UL5 without any significant post-operative discomfort and can still smile with confidence.

Case C - Pre Op

Case C - Post Op

Case C - Post Op

Ready to Refer?

Do you feel less confident in complex or retreatment endodontic cases?
Does this affect which teeth you choose to restore due to the concern of endodontic failure?
How would you feel if you knew the foundations on which your complex restorative treatment is built from were completed to a high clinical standard?

By entrusting Dr Andrew Nichols with your patient’s endodontic treatment, you will receive an excellent quality referral service that respects the fact your patients are your patients. Dr Andrew Nichols aspires to provide clinical excellence in endodontics, so you can be confident in restoring complex restorative cases, giving your patient a high chance of keeping their teeth. You will always receive a referral of your patient back to your care with detailed notes and radiographs.

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