When Protocols Prevail: A 13-Year Follow-Up on an Iatrogenic Perforation Case

Brought to you by Board-Certified Endodontist, Dr. William Nudera

Every now and then, a case comes along that reminds us why adherence to clinical protocol and sound judgment are indispensable in endodontics. This case, one of the most fascinating I’ve encountered, follows a patient 13 years after treatment and demonstrates how proper diagnosis and retreatment can turn a compromised situation into a long-term success story.

The patient was referred for surgical root canal treatment on tooth #26, just eight months after the original procedure. With only a two-dimensional image available, this was before the days of my CBCT scanner, I noticed a radiopaque line across the coronal third of the root and a periapical radiolucency. The patient reported a “bump on the gums,” a complaint that often signals a sinus tract or chronic apical abscess.

But this wasn’t a sinus tract, it was gutta-percha protruding through the gingiva. The access preparation had been misdirected buccally, leading to a perforation that either went unnoticed or was ignored before the initial root canal was completed. Instead of addressing the problem, the patient was advised that surgical intervention was their only remaining option.

Iatrogenic errors can happen to anyone, but they often reveal where key diagnostic or procedural steps were skipped. In this case, the absence of mid-treatment radiographs, working length verification, or cone fit images likely masked the error early on.

After reviewing the options, we chose nonsurgical retreatment. During the first visit, I accessed the tooth, retrieved the gutta-percha, repaired the perforation, and re-treated the original canal. Four weeks later, soft tissue healing was complete, and the second visit concluded with obturation and a bonded composite restoration.

At two years, the periapical image showed complete healing. At eight years, the area remained stable. And at 13 years, both radiographic and CBCT imaging confirmed the absence of apical pathology, with normal function and healthy soft tissue.

Long-term follow-ups like this reaffirm that when we follow established endodontic protocols and apply them under the right conditions, even challenging cases with iatrogenic complications can achieve excellent outcomes.

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