Root canal treatments are pretty common in today’s dental practice. Statistics show that there are more than 15 million every year in the United States and more than 41,000 root canals are performed every single day. Root canal treatment is a wonderful option saving a tooth and very valid treatment when the nerve of the tooth has undergone irreversible changes and dies. The dead necrotic tissue stays inside and needs to be removed. Then root canal treatment is the best option in order to save the tooth. Tooth pulp can die for multiple reasons: trauma, untreated tooth decay, presence of large old fillings that weaken the tooth and presence of fractures. When that happens, the nerve within the root canal cavity turns into necrotic or “dead” tissue, and a film of bacteria enter the root canal space.
The goal of root canal treatment is to remove the necrotic tissue and bacteria from the root canal space and seal the empty space so no bacteria can leak out or re-enter the canal space. Once the diseased and dead pulp tissue has been removed from the root canal, disinfection with antimicrobial and antiseptic solutions is done. The shaping of the canals to receive the sterile filling material is done with hand or rotary instruments. The canals are washed and cleaned to remove debris and then are filled, usually with gutta-percha a sterile material that seals the root canal. The important objective is to achieve excellent apical seal that prevents bacteria from traveling through the root canal to the surrounding bone. An inadequate apical seal, either by under-filling or by over instrumenting the canals presents further risks to tooth survival and introduces the possibility of reinfections. If re-infection occurs a root canal re-treatment is usually recommended. Researchers are now finding that Nd: YAG lasers can be helpful to eradicate bacteria within the root canal system and increase the success of the root canal therapy.
There are however common complications in this process as it is simply impossible to remove all bacteria 100%. The root canal cavity housing the tooth’s nerve, lymphatic tissue and blood supply is not a straight tube. It is a very complicated anatomical structure inside of the tooth with many branches and auxiliary canals that make the root canal procedure not so straightforward. There are other complications that can make successful completion of a root canal treatment difficult such as curved roots, accessory or lateral canals, and calcifications inside canals. Thus even the successfully completed root canal treated tooth can become reinfected due to secondary infection from a leaky restoration or residual bacteria in the canal system. Bacteria then can become toxic and harmful to the surrounding bone and ligament space and lead to abscess. Complicating the situation is that many bacteria are resistant to antimicrobial treatment during root canal therapy and can persist in the canal system and outside the tooth for years. The tooth dentin surrounding the root canal structure is composed of dentinal tubules that are oriented outwards from the root canal. Bacteria can enter these spaces and hide there and are resistant to efforts to remove them.
Once a tooth has received a root canal it is non-vital. Clinical observations confirm that root canal treated teeth become brittle over time and are more likely to fracture under the load of chewing forces. Therefore it has been strongly recommended that root canal teeth need to be protected with a crown or onlay to minimize risk of a root fracture. The research data show that when the placement of a crown or onlay is delayed after root canal treatment, the likelihood of a tooth fracture goes up. Symptoms of a cracked tooth are sharp pain when biting or in some cases nonspecific or inconsistent pain. Cracks in teeth are sometimes “hairline” and not always possible to identify clinically or on X-rays. Unfortunately, there are limited treatments available for symptomatic cracked teeth. Often the only treatment is to remove the tooth and replace it with a dental implant.
In closing, although root canal treatment is an excellent solution to save a dead tooth, what about preventing the tooth from dying in the first place? There are a number of alternatives to prevent the loss of the life of the tooth such as a pulp capping procedure. Although we do not see inside of the tooth, there are many clinical clues that a dentist can read during an examination of the patient. Careful clinical evaluation, profound understanding of tooth pathophysiology and ability to observe signs of trauma, presence of ill-fitting dental fillings and crowns and wear and opening margins and crack lines do assist in diagnosis and ability to prevent an onset of tooth pain that usually signals that “train has already left the station” and tooth is dying. Symptoms – tooth pain comes at later stages of the degenerative process within the tooth. The process may take years for the tooth to die and become symptomatic. Careful treatment protecting vulnerable tooth is the best solution to add to the tooth’s life. In summary, root canaled teeth present a variety of challenges thus it is best to prevent the need for them occurring in the first place. There are also alternatives to root canal treatments when a tooth is still vital but the nerve has been or is in danger of becoming exposed and infected. At that time the tooth’s life or nerve does not need to be killed yet, but carefully worked around and protected from bacterial invasion. In those cases, a minimally invasive pulp cap treatment is possible with protective restoration. The mouth has an incredible ability to heal given a proper chance and creating a healing environment. Understanding those principles and carefully working at PreserveYourTeeth Dentistry® we first perform careful diagnosis of tooth’s vitality and assess chances for tooth’s long-term survival. Our first choice is always pulp capping procedure assisted with Nd: YAG laser to provide bacterial decontamination in order to increase a tooth’s chance to survive. Even in advanced cases, we have about 98% 5-year survival rate.