What is a root canal?

Root canal therapy is a very common dental procedure. According to recent statistics in the United States alone almost 41,000 root canals are performed every day and close to 15 million are done over the course of a year. Because it has high success rate, a root canal procedure is considered one of the most effective methods of saving and retaining a tooth that has been severely compromised by dental decay or injury.

Your teeth are much more than just the hard outer biting surfaces and the roots. Inside of each one is a central chamber that contains connective tissue, a nerve supply, and blood vessels. Collectively these core tissues, known as the dental pulp, help your tooth to grow and mature before it emerges into the mouth. Once your tooth is in place, the dental pulp provides nourishment, keeps the tooth vital, and 
alerts you of problems. Having sensitivity to various stimuli like biting down and eating or drinking hot or cold items is a warning from the nerves inside your tooth that dental decay is present, dental trauma has occurred, or an infection is brewing. The degree of pain that you experience depends on the extent of the damage and nerve involvement.

If your endodontist informs you that a tooth needs a root canal, it is because the dental pulp has become irreversibly damaged or has died. However, if enough intact tooth structure remains and there is healthy bone support around the compromised tooth, you do not need to have the tooth extracted. A fully developed tooth does not require the dental pulp to remain functional. You can preserve your natural tooth by having your endodontist perform a root canal on the tooth.

It is important that when a root canal is recommended, you begin care promptly. Delaying the procedure increases the risk of more widespread symptoms developing. Left untreated a dental infection can develop or worsen and have serious consequences to your overall health.

How is a root canal performed?

With the modern dental instruments and advanced techniques available today having a non-surgical root canal procedure is often as comfortable as getting a routine dental filling. While some root canals can be completed in one visit, others may involve 2 or 3 appointments. How long it takes depends on factors such as the number of canals in a tooth, their anatomy and whether an active infection is present. If it is determined that the tooth is not a candidate for a root canal procedure, or if complications develop during or after care that have an impact on the prognosis of your tooth, the endodontist will inform you.

During a non-surgical root canal procedure your endodontist will remove the diseased dental pulp, clean the internal portion of your tooth, and then fill all the prepared canals with a biocompatible filling material. Non-surgical root canal therapy is typically performed under local anesthesia, but additional options like nitrous oxide, IV and oral sedation are available to reduce any anxiety that may be associated with dental procedures.

What happens after treatment?

Once your root canal therapy is completed and the tooth is symptom free, you are to return to your restorative dentist. Our office will send your dentist a record of your endodontic care. Your restorative dentist may then recommend placing a permanent restoration like a crown on the tooth. This will protect the tooth and give it back its appropriate natural form and function.

How much will it cost?

While the cost varies depending on which tooth is involved and the complexity of the case, saving a tooth by means of a root canal procedure is a wise investment. With proper maintenance and care teeth that have been treated with root canals can last a lifetime.

A root canal procedure is considered one of the most effective methods of preserving a tooth that has been severely compromised by dental decay or injury. According to statistics more than 95% of root canals are successful. In fact, with good oral hygiene and regular dental care, a tooth that has undergone root canal therapy can last as long as other natural teeth. However, as with any health related procedure there will be a small percentage of cases that are not successful. Occasionally, a tooth that has received a root canal may either fail to heal, or pain from that tooth may continue to exist. There are even situations where pain and symptoms develop months or years after the root canal treatment. In these cases, Endodontic Retreatment may be needed.

There are several reasons that a tooth may not heal as anticipated after the initial root canal therapy:

• Curved or narrow canals posing treatment complications
• Undetected canals due to complicated or unusual root anatomy
• Placement of a permanent restoration was delayed, allowing contamination and reinfection of the root canal
• The permanent restoration did not prevent saliva from contaminating the inside of the tooth

Even teeth that were successfully treated with a root canal procedure can be compromised by new problems that develop including:

• New decay that exposes the root canal to bacteria and causes a new infection in the tooth
• A loose, cracked, or broken dental restoration that exposes the tooth to a new infection
• A fracture of the crown or root of the tooth

If it is decided that endodontic retreatment is the most suitable option for you, the involved tooth will be reopened through a small hole in the biting or chewing surface. Restorations that had been placed on the tooth previously may be disassembled to allow access to the canals. Once the canals have been accessed, the previous root canal filling materials will be removed and the inside of the canals cleaned and carefully examined. The canals are inspected for previously undetected or unusual canals. When all of the canals have been cleaned and prepared, they are then are sealed and a temporary filling is placed. After the completion of an endodontic retreatment procedure, you once again return to your restorative dentist for the fabrication and placement of a more permanent restoration.

In some cases a tooth that has had a root canal, which did not sufficiently heal or has become re-infected, is not a candidate for endodontic retreatment. For these teeth a minor surgical procedure that treats the infection from the root-end of the tooth, that is known as an apicoectomy, may be indicated. An apicoectomy is an excellent next step procedure to preserve a previously treated tooth, eliminate a dental infection, and to restore the health of the surrounding tissues. It is most useful in cases where fractures or hidden canals still cause pain or infection around a treated tooth, as well as when an endodontic retreatment procedure is not recommended as it will further weaken and jeopardize the tooth.

An apicoectomy may be performed under local anesthesia. It is typically a straightforward procedure during which an incision is made in the gum tissue at the involved tooth. This is to expose the inflamed or infected tissue surrounding the root tip of the tooth. Once uncovered, the damaged tissue in the area is removed along with a few millimeters of the tooth's root tip. A biocompatible filling material is then placed in the end of the remaining portion of the root to seal it and prevent any possibility of reinfection. The gum tissue flap is put back into place and sutured to complete the procedure.

Post-surgical discomfort is generally mild and you may have some swelling in the area. Most patients return to their normal activities very quickly. If needed, apply a cold compress to reduce discomfort and swelling after the procedure. The appropriate pain medication will be prescribed or recommended. If your discomfort does not respond to medication, or other symptoms that concern you develop, please call our office.

Prior to undergoing an apicoectomy the endodontist will discuss all the risks and benefits of the procedure. If during the course of an apicoectomy any significant fractures are discovered in the tooth that changes the prognosis, you will be immediately advised.

Although the discomfort of the symptoms is very real, a cracked tooth can be a difficult dental problem to diagnose and pinpoint its location. Even a crack that is microscopic can cause a number of symptoms including pain when biting or chewing, sensitivity to hot or cold, or significant discomfort as biting pressure is released.

Chewing on a cracked tooth can be particularly uncomfortable. This is because pieces of the tooth may move and irritate the dental pulp. Eventually this repeated irritation can cause permanent damage to the pulp. The tooth may then consistently hurt and pulpal involvement may worsen. Continued irritation coupled with bacterial contamination seeping in through the crack can lead to a dental infection which can spread from the tooth to the surrounding bone and soft tissues.

Treatment of a cracked tooth depends on the extent of the crack and the degree of pulpal involvement. Symptomatic cases that receive root canal treatment and crowns before the crack propagates too far have a favorable prognosis. Teeth that are considered restorable are those where the crack is confined to the crown portion of the tooth. Complete vertical root fractures have a poor prognosis.

Types of Cracks

Craze Lines

Craze lines are shallow cracks that only affect the outer enamel of your teeth. They are common in adults and are most often merely regarded as a cosmetic imperfection.

Fractured Cusp

Cusps are pointed or rounded eminences on the chewing surfaces of your teeth. When a cusp for whatever reason (habits, trauma, decay) becomes weakened it can fracture. Chewing with a fractured cusp can cause the movement of the cracked portions of the tooth producing discomfort. At some point the broken portion of the tooth may break off itself or is removed by the endodontist. If the fracture did not extend deep into the tooth and cause pulpal involvement, a root canal therapy may not be required. In this case a dental crown or onlay may be sufficient to restore the tooth.

Cracked Tooth

When a crack extends vertically from the chewing surface toward the root, it is referred to as a cracked tooth. In some cases the crack may extend below the gum line into the root. Although a cracked tooth is not completely separated into two pieces damage to the nerve is common. Typically, a root canal treatment is needed to treat the involved pulp in a cracked tooth. Following the root canal the treatment of choice to splint the two halves of the tooth together and prevent further migration of the crack is a full coverage crown.

Although, it is sometimes difficult to determine the extent of the crack, especially when it occurs under a filling or crown, early diagnosis is important. A cracked tooth that is not treated will progressively worsen and may reach the Split Tooth stage resulting in an unfavorable prognosis for the tooth.

Split Tooth

Left untreated a cracked tooth can worsen with the crack extending down the root surface. In a split tooth the crack completely divides the tooth into two distinct segments. The position and extent of the crack determines whether any portion of the tooth can in fact be saved. Only if sufficient tooth structure remains, it might be possible with the help of a root canal to preserve the tooth.

Vertical Root Fracture

A vertical root fracture is a crack that begins in the root of the tooth and extends toward the chewing surface of the tooth. Since they may not manifest overt signs or symptoms, they can go unnoticed for some time. A vertical root fracture is often discovered only when the surrounding area becomes tender or infected. Most frequently, a tooth with a vertical root fracture will require extraction. However, in some situations the tooth may be saved with an endodontic procedure and surgically removing the fractured portion of the root.

Dislodged Teeth

As the result of a dental injury a tooth can be partially pushed into its socket. When this happens immediate dental care is required to reposition and stabilize the tooth. If a permanent tooth has been dislodged, a root canal treatment is usually needed and should be initiated within a few days of the injury. As part of the treatment a special medication called Calcium Hydroxide is placed inside of the tooth.

In situations where a tooth is partially pushed out of its socket, immediate dental care to reposition and stabilize the tooth is also required. If the pulp of the tooth remains healthy, no other treatment is necessary. However, if the pulp becomes damaged or infected, a root canal therapy is necessary.

Avulsed Teeth

When a tooth has been completely knocked out of the mouth, it is important to get to the endodontist as quickly as possible. It is important to handle the tooth carefully to avoid further damage. The main thing is to keep the tooth moist. You can place the tooth in milk or a glass of water (add a pinch of salt). Saving the tooth in large part depends upon the length of time the tooth was out of the mouth and the way the tooth was handled and stored. Keep in mind that only permanent teeth should be re-implanted.

Since the nerve and blood supply of the tooth is damaged when the tooth is avulsed, a root canal will be needed. Your endodontist will determine the appropriate time for this.

Injuries in Children

A permanent tooth in a child might not be fully developed at the time of injury. There are special considerations in terms of root development that are taken into account in these cases. An immature tooth may require one of the following procedures to improve the chances of retaining the tooth:

Apexogenesis

The intent of apexogenesis in injured immature teeth is to preserve vital pulp tissue so that continued root development with apical closure (root tip closure) may occur. During this procedure a special medication to encourage normal development and maturation of the root is placed inside of the tooth. The injured tooth is then closely followed to determine if successful root formation is taking place. In cases where the pulp heals, no additional treatment will be necessary. The more mature the root becomes, the better the chance of saving the tooth.

Apexification

If the vital tissue inside an immature tooth is irreversibly damaged a procedure known as a apexification may be performed. The intent of this procedure is to induce the formation of hard tissue near the root tip that will provide closure and allow a root canal filling to be placed. Since the structural integrity of the tooth may be compromised, it is important that the tooth have a proper final restoration placed by your general dentist.