Root canal treatment / endodontics

Root canal treatments is a dental procedure used to treat infection in the root canal system. It is a treatment to repair and save a badly damaged or infected tooth instead of removing it. The term ‘root canal’ refers to the canals inside the root of the tooth.

The tooth consists of the following:

  • Enamel: The hard-outer coating
  • Dentine: A softer material that supports the enamel and forms most of the tooth
  • Cementum: A hard material that coats the root's surface
  • Dental pulp: The soft tissue at the centre of the tooth

The pulp extends from the crown — the visible part of the tooth — to the tip of the tooth's root in the jawbone. The pulp contains nerves, blood vessels and connective tissue.

A single tooth can have more than one root canal and Molar teeth in particular have several roots.  When a tooth is cracked or has a deep cavity, or if there is a leaking filling or perhaps the tooth is damaged as a result of a trauma like an accident or fall, bacteria can enter the pulp.

If it is left untreated, bacteria and decaying material can cause a serious infection or a tooth abscess, leading to pulp death, bone loss or loss of the tooth itself. Signs and symptoms may include swelling around your face and neck, a hole in your tooth, toothache /tooth pain, gum swelling, temperature sensitivity, headaches, pain when biting or chewing, swelling of the gum near the affected tooth, pus oozing from the affected tooth, facial swelling and the tooth becoming a darker colour.

It is important to see our Dentist if you have a problem with your tooth as soon as possible in order to avoid possible nerve damage and thus avoid root canal treatment.

Root canal treatments is a dental procedure used to treat infection in the root canal system. It is a treatment to repair and save a badly damaged or infected tooth instead of removing it. The term ‘root canal’ refers to the canals inside the root of the tooth.

The tooth consists of the following:

  • Enamel: The hard-outer coating
  • Dentine: A softer material that supports the enamel and forms most of the tooth
  • Cementum: A hard material that coats the root’s surface
  • Dental pulp: The soft tissue at the centre of the tooth

The pulp extends from the crown — the visible part of the tooth — to the tip of the tooth’s root in the jawbone. The pulp contains nerves, blood vessels and connective tissue.

A single tooth can have more than one root canal and Molar teeth in particular have several roots.  When a tooth is cracked or has a deep cavity, or if there is a leaking filling or perhaps the tooth is damaged as a result of a trauma like an accident or fall, bacteria can enter the pulp.

If it is left untreated, bacteria and decaying material can cause a serious infection or a tooth abscess, leading to pulp death, bone loss or loss of the tooth itself. Signs and symptoms may include swelling around your face and neck, a hole in your tooth, toothache /tooth pain, gum swelling, temperature sensitivity, headaches, pain when biting or chewing, swelling of the gum near the affected tooth, pus oozing from the affected tooth, facial swelling and the tooth becoming a darker colour.

It is important to see our Dentist if you have a problem with your tooth as soon as possible in order to avoid possible nerve damage and thus avoid root canal treatment.

Signs You Might Need a Root Canal:

 

Indications for treatment include:

  • Prolonged sensitivity to heat or cold
  • Tooth decay – if a tooth is very rotten, its nerves and blood vessels can die, leading to a painful abscess
  • Discoloration of the tooth
  • Swelling of the gum adjacent to the tooth
  • Tenderness of the tooth especially to biting or adjacent gums. Sometimes there are no symptoms and the first sign of a problem maybe radiographic evidence corroborated with additional diagnostic testing by the dentist

The root canal procedure:

 

First stage: Cleaning the canal /canals

To treat the infection in the tooth canal, the bacteria existing there needs to be removed. This can be done in following way ;

Using a dental tool that is shaped like a long slim round file the bacteria is removed. The root canal is then filled, and the tooth is sealed with a filling and a crown. In most cases the inflamed tissue around the tooth will heal naturally.

Root canal treatment usually takes two visits, but sometimes additional visit are required as some teeth may prove difficult to treat. First, you will a have dental X-ray to check the extent of the damage. You will also receive a local anaesthetic to control the pain. This pain can be more severe if the tooth has developed an abscess. Then a rubber sheet (called a rubber dam) is placed around the tooth to keep the tooth clean and free from saliva. The tooth decay is removed, and an opening is made through the crown of the tooth to gain access to the pulp chamber. Using a small dental instrument, the infected or diseased pulp is removed.

During the procedure our dentist will use a series of root canal files to reshape the canals. The root canals will be flushed and cleaned with antiseptic liquid several times during the treatment. Where applicable each canal will be enlarged to allow better access for cleaning and flushing and the filling in of the canals at a later stage.

This part of the treatment may take several hours to complete, and it may need to be carried out in several visits. If this is the case, a dressing (medication) will be placed inside the cleaned canal to kill the infection and the tooth will be provided with a temporary filling.

In severe cases, where the infection has spread behind the tooth and you have a large swelling which is fluctuating, the tooth may be left open in order to allow the infection to drain away, normally for a period of 24 hours.

Our Dentist will prescribe you an antibiotic when you have a fever, large swelling and severe pain due to the infection. The premolar teeth and the back molar have between 2-4 roots and each root has 1-2 canals. The teeth in the front and the cainan have one root and one canal. The more canals a tooth has, the longer the time becomes to treat the tooth.

 

 

Second stage: Filling of the canal /canals

After cleaning and drying, it will be time to fill each root with a sealer paste and rubber material. The tooth will be restored with a filling material on that visit.

 

Final stage: crowning the tooth

The root filled teeth are more fragile after root canal treatment and need to be protected from future damage in the form of a fracture. Our Dentist will normally recommend you have it crowned as soon as possible. If the tooth fractures, it will make it impossible to save the tooth again.

If the remaining tooth structures are not enough to support a crown, the tooth must be built up with a small metal post prior the crown treatment.

The crown is a cap which will covers the tooth. To be able to fit the crown the tooth will be made smaller and re-shaped. A mould will be taken to have the crown made to fit over the tooth.

The crown can be made from the following materials:

  • Gold crown
  • Metal fused porcelain
  • zirconia crown (metal free crown)

After root canal treatment you will be advised to follow good dental and oral hygiene, in order to ensure that your restored tooth lasts a long time. If you experience pain in the first few days after root canal treatment, you can take painkillers, but if the pain or pressure lasts a few days, then please make sure you contact the Surbiton Smile Centre immediately.

Revision Of Root Canal Therapy

Even though endodontic treatment is one of the most successful and predictable procedures in modern dentistry, failures can occur. Some indications of failure include swelling, soreness or the persistence of abscess at the root tip as identified in an X-ray. When this happens, a root canal revision procedure, also referred to as “re-treatment,” may be warranted.

Reasons For Root Canal Re-treatment:

  • Retained microorganisms (bacteria) in the root canal
  • Breakdown or corrosion of root canal filling materials
  • Contamination from decay or leakage from a failing restoration
  • Inoperable canals because of calcification or unusual anatomy
  • Sometimes tissues fail to heal for unknown reasons

Although retreatment is technically more difficult than the original root canal, it can usually rescue a failing condition without having to consider surgery. We at Surbiton Dentist especially well equipped to handle these difficult conditions because of our additional training and experience.

Endodontic Surgery

Conventional root canal treatment is not always sufficient to correct every patient’s condition. Occasionally, endodontic surgery is required. This is because a previous treatment has deteriorated or because anatomic considerations such as the shape of the tooth or canal space make the traditional root canal treatment especially difficult to complete.

After care of Root Canal Treatment

If you experience sensitivity following a root canal session, we recommend you take an anti-inflammatory drug such as ibuprofen to reduce inflammation, which will in turn reduce pain. You may also want to apply ice to the outside of your face next to the tooth, keeping the head elevated.

Under no circumstances should you apply heat to the outside of your face. Consistent medication is the key to comfort. It is essential to follow your dentist orders by taking prescribed medications to alleviate pain and to help prevent or fight infection. If discomfort lasts more than a few days or if you have severe pain or swelling, call our office. We will suggest medication or other steps to make you more comfortable

Frequently Asked Questions about Root Canal Treatment

  • How many appointments are needed?

Sometimes Root Canal Treatment can be completed in just one visit, but normally it takes two or three appointments depending on the individual tooth anatomy and other circumstances.

  • Does Root Canal Treatment (Endodontic Treatment) hurt?

Quite often this treatment is needed to relieve the existing pain that already exists. With modern techniques and the use of local anaesthetic, the procedure is pain free. If the tooth has a severe infection, it may take longer for the tooth and gum to become numb. In such a case our Dentist will inject further local anaesthetic.

  • Will I suffer pain after the treatment?

It is possible that you may feel some discomfort afterwards. Taking normal painkillers will usually soothe the pain. If this does not do the trick, and t

he pain persists, you should contact us as soon as possible.

  • How much does this type of treatment cost?

The cost of Root Canal Treatment varies and is dependent on how severe the underlying problem is. For example, the molars have three to four canals and are therefore more difficult to treat. If you have a tooth with a severe abscess, then several visits might be required to achieve a good result. Factors such as these will increase the cost.

  • Are there any alternatives to Root Canal Treatment?

There is only one alternative to this type of treatment and that is an extraction. Unfortunately, not all damaged teeth can be repaired (restored) and hence an extraction is sometimes necessary. The resulting missing gap is then filled by a removable denture, a fixed dental bridge or a dental implant.

  • Is Root Canal Treatment always successful?

This procedure has a high success rate, as long as it is performed to a high standard. At the Surbiton Smile Centre, we will ensure that this is the case. But occasionally no matter how high the standard of care is, the root filled tooth never heals up, which will result in the loss of that tooth. Also, Root Canal Treatments can fail if the tooth develops further decay, or the existing restoration fails resulting in leakage, or the tooth suffers later from a crack or fracture. A further possibility maybe due to the difficult anatomy of the tooth which made it difficult to clean the narrow and curved canals to eliminate the bacteria entirely.

  • What after care and review do, I need?

You must visit us at least once a year to make sure the tooth is healing up. This really should be part of your regular six-monthly visits that form part of your routine check-ups.

  • What is Root Canal Retreatment?

Root canal treated teeth can last for a long time but sometimes the treatment fails, or the patient’s symptoms persist. This can happen immediately after the completion of the root canal treatment, but if it does happen then quite often it is much later.In such an instance, the treatment must be performed again, and that procedure called root canal retreatment.

  • Who can perform Root Canal Treatment?

All our Dentists at the Surbiton Smile Centre can carry out this procedure. Obviously, retreatment is more complicated and time-consuming and may require the use of a microscope.

 

Further in-depth information regarding Root Canal Treatment

1- Problems with the nerves inside the tooth (pulp) and with the tissue around the tooth:

a) exposure to the internal part of the tooth (dentin).

  • The caries is the most common cause of the nerve(pulpal) irritation because it stimulates the cells in that part of the tooth whichthen produce inflammation inside the nerves.
  • Other possible factors are: Tooth wear, gum recession, tooth fracture, preparation for crown and filling can cause pulp(nerve) irritation due to dentin exposure.
  • Bacteria can also penetrate towards the pulp along the dentinal Tubules.

b) Nerve exposure(pulp exposure) inside the tooth.

  • Caries is the most common cause of nerve exposure inside the tooth.
  • The bacteria in caries will set up pulp inflammation and as the pulp becomes exposed to more toxin, bacteria will penetrate into the pulpal tissue.

A tooth fracture can be responsible for pulp exposure resulting in the injury or demise of the pulp.

c) Nerve problems inside the tooth (pulpal pathology)

  • Inflammation in nerves, abscesses and nerve death (pulp necrosis) are the most common diseases seen in the pulp.
  • Bacteria may establish entry into the pulp through vascular means. Bacteria may originate from any part of the body andpass through the blood stream and then settle in an area of pulpal inflammation.

d) Calcification of nerves inside the tooth

  • All pulps of vital teeth are stimulated to slow calcification. Traumatic injuries can bring about very rapid and almost complete calcification. If no plural or atypical pathology occurs, the tooth needs only to be watched.Other causes for rapid calcification are deep caries, deep irritating fillings, and trauma of occlusion.

e) Internal Resorption

At times a traumatic injury that may cause calcification of the pulp is also capable of producing internal resorption.The resorption causes perforation of the tooth which then results in pulpal (nerve)contamination and thereby pulpal necrosis.

f) External Resorption

External resorption is the result of a chronic periodontal problem which can damaged the wall of the tooth and effect the pulp(nerves inside the tooth).

A resorption around the apical part of the root is a result of traumatic injuries or trauma of occlusion or orthodontic procedures.

g) Problems around root of the tooth

The inflammatory by-product which is the result of a chronic or acute pulpal problem may drain into a variety of anatomical structures including the mucosa surfaces and dental fistula.

h) Periodontal and endodontic lesion

  • Sometimes problems around the teeth originate via an endodontic or periodontal problem around the tooth.
  • A combination of endodontic and periodontal therapy is needed to correct any lesions.

2- Endodontic Treatment

a) Protection of dentin
To protect the dentin during the restoration procedure a base should be placed under the restoration.

b) Coverage of the pulp
Pulp capping is the protection of a small pulp exposure by stimulating secondary dentin with a sedative dressing. Calciumhydroxide pasties are placed in direct contact with the exposed pulp. Even after the formation of secondary dentin pulpal pathology and pulpal necrosis may develop.

c) Pulpectomy of Apexification

  • A pulpectomy is the removal of the coronal portion of the pulp and placement of calciumhydroxide over the assumed healthy pulp.
  • Apexification is the removal of a vital pulp and the placement of calcium hydroxide in the total canal. Both methods are to induce apical closure and the continued development of an immature tooth.

d) Pulpectomy and Root Therapy

  • Pulpectomy consists of the complete debridement of the pulp tissue and the shaping of the entire root canal system obdurate three dimensionally. This endodontic therapy is the most predictable.

e) Endodontic Surgery

  • Periapical surgery is indicated when a routine endodontic procedure cannot be performed as in the following scenario:
  • Broken file inside the canal and there is a radiolucency (ie it is a sign of infection)around the root.
  • Calcified canal with an infection around the root.

f) Bleaching

  • Vital bleaching is the lightening of a tooth that has usually been stained by Tetracycline during the development of the tooth.
  • Vital bleaching is the lightening of a tooth that has been endodontically treated. The non-dentinal tubules have been stained by pulpal haemorrhage or dental products. Superoxol(30-35 present hydrogen peroxide) is used as the oxygenating bleaching agent therapy.

g) Retreatment of endodontically treated teeth

  • Retreatment is the undoing of the root canal filling and often the restorative part of the tooth.
  • Basic endodontic principles are then followed to change the success of treatment.

 

3- Basic Endodontic Concept

A careful and complete diagnosis must be made on each and every suspected tooth.

a) Diagnosis for Endodontic Problems

The sequence of diagnostic process is as follows:

Medical history:

Patient with pace maker: Dentist must refrain from a procedure that would interfere with pacemaker function: e.g. pulp testing sonic devices like apex locator, electro surgery etc.

Dental history:

Purpose: Quite often the problem tooth can be localised by taking the dental history.

What is the patient’s past total dental treatment?

What is the main complaint?

What is the main history of the complaint?

Has the patient had any recent fillings?

Were there any unusual problems concerning the tooth such as pulp capping or pulpectomy procedure, or a large restoration performed?

Has the tooth been subjected to a sharp blow in an accident of some kind?

Has a swelling or a gum boil around the tooth ever been noticed? If yes what did the patient do?

Has there been any drainage from the tooth or gum?

Subjective symptoms:

Purpose: Careful questioning of the patient must be conducted to evaluate the patient’s problem completely. The following are typical question that may be asked:

1. Is the pain present now?

2. What type of pain (sharp-dull) are you experiencing?

3. Is the pain localised or diffused?

4. Is there a throbbing?

5. Is the pain intermittent or continuous?

6. Is the pain increased by cold, heat, pressure, mastication, lying down, sweet or sour?

7. Do you have to take anything hot or cold to bring on the pain?

8. Is the pain spontaneous?

9. Does it go away by itself or do you have to take medication?

10. Does hot and cold make it feel better?

11. Does the tooth feel loose? If yes when did you first noticed it?

12. How long does the pain last?

Purpose: A tentative diagnosis can often be made from these subjective symptoms.

Clinical Observation:

These are the objective signs observed by the dentist in an around the mouth. It is important to note the following:

1. Extra oral swelling

2. Lymph nodes involvement

3. Intra oral swelling

4. Fistula(sinus tract) intra oral and extra –oral

5. Tooth discolouration

6. Traumatic injuries such as crown and root fracture

7. Presence of deep caries lesion

8. Recurrence caries beneath a restoration

9. Type and extent of restoration

10. Developmental stages of restoration

11. Gingival recession

12. Colour of gingival tissue

13. Temperature elevation

14. Traumatic occlusion

15. Loose, leaking or fractured restoration

16. Mobility

Purpose: Often problematic teeth can be localised, and the dentist may see other contributing factors involved. Judgement is made on whether the involved tooth is worth salvaging.

Clinical Test:

These tests are mandatory to confirm any tentative diagnosis that has been made so far. All eight of these tests must be used and in certain case further selective tests must be used:

1.Electric pulp test

2.Thermal test

3.Percussion test

4.Palpation

5. Mobility

6. Periodontal evaluation

7. Occlusal evaluation

8.Radiographic

Careful interpretation of the radiograph should be made:

Outside of root:

  • Length of the root
  • Curvature of the root
  • Root formation

Inside of root:

  • Internal anatomy
  • Calcification
  • Branching of the canal
  • Resorptions
  • Pulp stones
  • Foreign body

Further selective tests for difficult diagnoses:

9.Test cavity preparation(where the tooth is crowned, and sensitivity testing is difficult)

10. Anaesthetic tests

11.Transillumination

12. Biting

13. Staining

14.Gutta percha tracing with radiograph

Purpose: The status of pulp and periapical tissue can be evaluated, and diagnosis can be confirmed.


Test for Crack Tooth Syndrome
:

1. Transillumination

2. Biting

3. Staining

The cracked tooth syndrome refers to a crack within the crown of the tooth without any pulpal involvement.

It usually manifests itself as sensitivity to a certain biting pressure. It becomes very painful when biting in one direction. Also,an extreme reaction to cold sets it off.

A different diagnosis must be made between sinusitis, nerve pain, overloading contact, grinding problem, or TMJ problems.

Any large amalgam filling which does not protect the cusp should be suspected.

The older the patient or the greater the intercuspation and wear, the greater the possibility of a crack.

One should always think of a cracked tooth when all other tests prove negative.

 

Differential diagnosis of  anatomical land marks or pathological  lesion  from inflammation around the root

Following procedures required:

1. Take several X-rays from different angles .A radiolucent area caused by pulpal lesion will not show on the x-ray.

2. If the Laminadura around the tooth is not broken, it is a strong indication that there is no infection around the tooth.

3. Take electric test: If the vitality of the tooth is established, the lesion on the X-ray could be a cyst or other pathological lesion (refer to other specialist).

Refer Pain:

  • Pain can refer from sinus to upper molar and premolar.
  • Pain in upper molar jaw can be referred to Lower molar.
  • Pain from lower molar can refer to ears.
  • Pain from Temporomandibular joint refers to teeth.
  • Pain from facial muscle can be referred to teeth.
  • Angina pain can be referred to lower left mandible.
  • Tooth pain can express itself in headaches.
  • Pain referred from Trifacial neuralgia.
  • Pain from psychosomatic origin

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