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Endodontic Treatment (Root Canal Therapy)

Endodontic treatment or Root Canal Therapy in simplest terms is the removal of the nerve (pulp) from within the tooth, with the tooth itself remaining in its original position within the mouth.  With today’s techniques and technology, root canals are a routine, uneventful, relatively pain-free procedure that saves a tooth that in the past would have otherwise required extraction. Endodontic treatment is the standard of care and treatment of choice as opposed to extraction. While there might be some patients who simply believe a problematic tooth should be extracted, they may not realize that pulling the tooth out will ultimately be more costly and more detrimental to their overall dental health than saving that troublesome tooth.

Every tooth has within it an area we call the pulp chamber, which houses the nerve and some small blood vessels that are artery or vein oriented, that is, they take blood either to or from the tooth. This small mass of soft tissue (nerve, small artery and vein blood vessels) is collectively called the Pulp. The primary function of the pulp is to create, nourish and lay down the hard tooth structure (enamel and dentin) during the developmental stages of tooth maturation. It has a limited blood supply and is susceptible to inflammation and infection. In the mature tooth, the dental pulp can be removed when it becomes inflamed or infected and the tooth remains healthy without it. This fact is the premise which explains why endodontic treatment is so highly successful and can usually last a lifetime.

Root Canal Therapy is required when the nerve of a tooth has been affected by decay, trauma, extensive restoration, or fracture. These insults to the tooth result in inflammation of the pulp, which is called pulpitis. Pulpal inflammation is a common occurrence associated with decay or fracture, whether associated with a small filling or extensive crown preparation. If the pulp is relatively healthy, and the decay or fracture was detected early resulting in minimal insult to the nerve,  the pulp will heal and all minor tooth sensitivity will disappear.  These minor insults to the pulp do not require endodontic treatment. However, long standing decay, or decay which penetrates the pulp chamber, cracks, fractures, trauma, or old restorations or crowns that lose their marginal seal from prolonged wear and material fatigue, deal the pulp a more fatal insult. These insults usually result in pulp death or necrosis. Evidence of this manifests as extreme sensitivity to cold and/or heat, percussion sensitivity, pain upon biting, severe toothache pain, swelling and abscess formation, and in the extreme case, swollen head and neck glands, or systemic septicemia.  Sometimes tooth movement or super-eruption can become obvious, where the tooth suddenly feels higher than the other neighboring teeth. Endodontic treatment ultimately eliminates all these symptoms and after the root canal has been completed, the tooth will be restored and become once again healthy and fully functional. It is also worth noting that a tooth may undergo pulpal necrosis and the patient might be completely unaware of this fact. Typically these are teeth that might have been subjected to trauma or insults resulting in a slow and steady decline of the nerve. Sometimes, patients might notice a “pimple-like” swelling (called a fistula) of the gum and perhaps even a small amount of pus draining from the “pimple”. However, because the “pimple” is painless, and because the fistula is there and then not there for long periods of time, patients might not take notice of this finding and might not think to mention it to the dentist during their check-up and exam. Quite often, these necrotic teeth are detected only by x-rays during a routine check-up and exam with the patient never having noticed any clinical symptoms whatsoever, not even the “pimple” or fistula. What makes these teeth so notable in x-rays is the bone loss associated with their root tips. If left untreated endodontically, bone will continue to be lost until the tooth becomes loose, abscesses, and falls out. In extreme cases, the abscess can suddenly become intensely acute resulting in large areas of facial, head or neck swelling within a matter of hours. While these cases are not common, they require immediate dental attention and might even require even more immediate medical attention.

A Root Canal procedure usually requires one or more visits and they are performed routinely here at this office. After a local anesthetic has been administered and profound anesthesia has been achieved, the tooth is isolated and the pulp chamber is accessed via the use of conventional fiber optic dental drills which enhance visibility in a small work space. Depending on the type of tooth requiring treatment, the dentist will immediately attempt to ascertain the number of canals located within the tooth. While molars have more roots than incisors, cuspids or bicuspids, each tooth can present with a unique pulpal configuration which will be assessed by the dentist as the procedure unfolds. Clinical skill and precision is required during this procedure due to the fact that as all teeth age, the canals themselves narrow or calcify, thus making the process of locating and treating the canals a little more tedious and time consuming.

All pulpal tissues and/or remnants of this tissue along with any purulent exudate (abscess) will be removed during the pulpectomy phase of the procedure, via the use of specially formatted and sized hand files or rotary instruments. The pulp chamber will be repeatedly rinsed of debris as the dentist now shapes the canal during the instrumentation phase and determines the final length of each canal space, either via digital radiography or digital apex finder, which can electronically locate where the canal ends at the tip of the root. The canal spaces will then be thoroughly cleaned, and then filled and sealed during the obturation phase with time-tested special dental materials that are biocompatible, hypo-allergenic and can maintain their integrity for a lifetime. A temporary filling is placed to cover the access preparation or opening on the top of the tooth until the tooth can be restored to its full function. This is generally achieved by placing a post and core inside the tooth to enhance and strengthen the tooth, and then a crown is fitted to encompass the tooth and protect it for many years of beauty, function and form.

Once endodontic treatment has been completed, your tooth may still be sensitive, but this will subside as the inflammation diminishes and the surrounding supporting structures of the tooth, which are still very much alive, begin to heal. The severity and duration of post-operative symptomology depends on the prior condition of the tooth, the causality that necessitated endodontic treatment, and the amount of manipulation required during treatment.

Sensitivity that requires post-operative analgesics usually diminishes within 48 hours. Once the tooth has been properly restored, the patient can look forward to a return to function and beauty, with a success rate estimated to be in the 95% range. Critical to this high success rate is the immediate restoration of the tooth, typically via a post and core (either cast core, prefabricated titanium post with core buildup, or prefabricated fibercore with core buildup) and a Crown. It is important to note that while an endodontically treated tooth can return to clinical health below the gumline, it has been rendered non-vital and will become more brittle and susceptible to fracture above and below the gumline. If the tooth has already been extensively filled, it is all the more important to strengthen the tooth via core buildup and crown. Other factors that limit the success of this procedure are the presence of lateral canals, irregularities in the root canal shape which compromise instrumentation (e.g. severe root deformity), root fractures or cracks,  root resorption, future accidental trauma,  and future root decay due to neglect and poor oral hygiene. These limiting factors are infrequent and the majority of endodontically treated teeth remain beautiful and functional for many, many years to come. In some instances, further endodontic treatment can save a root canal that has become compromised or further infected either through re-treatment or through what is know as an Apicoectomy. Once again, the necessity of such procedures is infrequent, but they are available should they ever be required. Most important to remember is that good oral hygiene, regular dental cleanings and check-ups will not only add to the life of your endodontically treated tooth, but could also help prevent a tooth from ever needing one. Maintenance is everything and prevention is priceless!