If the patient presents with a fluctuant swelling, consider doing an incision and draining prior to initiating treatment. Then begin instrumentation. 1. Perform a more thorough cleaning and shaping of the canal spaces to ensure that all necrotic materials have been removed.2. Verify length determination (apex locator and radiographs) to ensure that over-instrumentation did not occur. Special care should be taken near the maxillary sinus, since over-instrumentation can lead to persistent drainage.3. If a strip perforation or perforation is noted, repair immediately with MTA or equivalent material. If unable to perform this procedure, refer the patient to an endodontist.4. Irrigate with NaOCl and leave in the canals and chamber for 10-15 minutes. Dry and place Ca(OH)2 in the canals and close, if drainage stops.5. Use negative pressure irrigation, if available.6. If all else fails, leave the tooth open, reappoint the next day, lightly instrument, irrigate and dry, and close the canal.7. In cases where there is a large PA radiolucency associated with a necrotic tooth and the drainage continues, both conservative and surgical endodontic treatments may be required (Fig. 2). Refer to an endodontist if uncomfortable dealing with this situation.
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