Introduction
Why Would You Need Root Canal Treatment?
Signs and Symptoms
Length of Treatment
Measuring and Cleaning the Root Canals
After Root Canal Treatment


Illustrations: Root Canal Treatment from Start to Finish

Restoring the Tooth After Root Canal

Myths About Root Canal Treatment

The Second Time Around: Possible Retreatment or Surgery

 

Introduction
Endodontics is the branch of dentistry that deals with diseases of the tooth's pulp, which is located in the center of the tooth and in canals (called root canals) within each tooth root. Pulp, consisting of connective tissue, nerves and blood vessels, nourishes the tooth when it first erupts (emerges through the gum). Once the tooth matures, the pulp can be removed safely from the pulp chamber and root canals and the tooth can be maintained. This is because the tooth also is nourished by a blood supply that surrounds the tooth. Removing the pulp is called endodontic treatment, but it is often referred to as root canal treatment or root canal therapy. Many people refer to this as "having a root canal." Root canal treatments are quite common. They save an estimated 24 million teeth each year in the United States.

Why Would You Need Root Canal Treatment?
Root canal treatment is needed for two main reasons: infection or irreversible damage to the pulp. An untreated cavity is a common cause of pulp infection. The decay erodes the enamel and dentin of the tooth until it opens into the root canal system, allowing bacteria to infect the pulp. Infections inside teeth don't respond to antibiotic treatment. The inflammation caused by the infection restricts the tooth's blood supply, so antibiotics in the bloodstream can't reach the infection very well. The reduced blood supply also limits the pulp's ability to heal itself.

The pulp also can become damaged from trauma, a fracture or extensive restorative work, such as several fillings placed over a period of time. Sometimes, a common dental procedure can cause the pulp to become inflamed. For example, preparing a tooth for a crown sometimes leads to the need for root canal treatment.

In many cases, when the pulp is inflamed, but not infected, it will heal and return to normal. Your dentist may want to monitor the tooth to see if this happens before doing root canal treatment. Sometimes, though, the pulp remains inflamed, which can cause pain and may lead to infection.

Once the pulp becomes infected, the infection can affect the bone around the tooth, causing an abscess to form. The goal of root canal treatment is to save the tooth by removing the infected or damaged pulp, treating any infection, and filling the empty canals with an inert material. If root canal treatment is not done, the tooth may have to be extracted.

It is better to keep your natural teeth if at all possible. If a tooth is missing, neighboring teeth can drift out of line and can be overstressed. Keeping your natural teeth also helps you to avoid more expensive and extensive treatments, such as implants or bridges. If an infected or injured tooth that needs root canal treatment is ignored, not only can you lose the tooth, but also the infection can spread to other parts of your body.

Having endodontic treatment on a tooth does not mean that you'll need to have it pulled out in a few years. The reason for doing root canal treatment is often a large cavity. The tooth often is weakened, but if the tooth is covered with a crown after the root canal or, in some cases, restored with tooth-colored composite filling material, the tooth can last the rest of your life.

Signs and Symptoms
If you have an infection of the pulp, you may not feel any pain at first. But if left untreated, the infection will cause pain and swelling. In some cases, an abscess will form. Eventually, the tooth may need to be extracted. Some indications that a tooth may need a root canal are:

  • A tooth that hurts significantly when you bite down on it, touch it or push on it
  • Sensitivity to heat
  • Sensitivity to cold that lasts longer than a couple of seconds
  • Swelling near the affected tooth
  • A discolored tooth, with or without pain
  • A broken tooth

To determine whether your tooth needs root canal treatment, your dentist will place hot or cold substances against the tooth, feel surrounding tissues and gently tap on the tooth. He or she also will take X-rays.

If the condition of the pulp isn't clear from these tests, your dentist may use an electric pulp tester. This hand-held device sends a small electric current through the tooth and helps your dentist evaluate whether the pulp is alive. This test does not cause pain or a shock, but a tingling sensation that stops immediately when the tester is removed from the tooth.

Caution: An electric pulp tester should not be used if you have a cardiac pacemaker or any other electronic life-support device.

Length of Treatment
Root canal treatment can be done in one or more visits, depending on the situation. An infected tooth will need several appointments to make sure that the infection is eliminated. Some teeth may be more difficult to treat because of the position of the tooth, because they have many and curved root canals that are difficult to locate, or for other reasons. An uncomplicated root canal treatment often can be completed in one visit. Once the root canal treatment is finished, you will need to see your general dentist to have the tooth restored with a crown or filling.

Measuring and Cleaning the Root Canals
Measuring 
First, your dentist will numb the area around the tooth. You also may receive sedation, such as nitrous oxide, or your dentist may offer other anxiety-reducing techniques if you feel you need them. He or she will make a hole in the top or back of your tooth to get to the pulp chamber. He or she will remove some of the diseased pulp. Then the root canals have to be measured.

Your dentist needs to know how long the canals are so he or she can make sure all the diseased tissue is removed and the entire canal is cleaned. Also, the material used to fill the canal after it is cleaned needs to fill the entire canal.

Dentists use X-rays to determine the length of the canals or use an electric device called an apex locator. In the first procedure, your dentist will place a file into the canal he or she is measuring then take an X-ray to determine how close the file is to the end of the canal. An apex locator makes a calculation based on the resistance to a small electric current. This gives an accurate measurement of a root canal. Often, the two methods are combined.

Cleaning 
After the canals have been measured, your dentist will use the specially designed instruments to clean out the diseased pulp. After the pulp has been removed, the canal is cleaned with an antiseptic solution, which helps to treat the source of the infection.

For root canal treatment to be effective, all the canals within the tooth must be cleaned. Generally, the top front teeth have one canal, the bottom front teeth one or two canals, the premolars one or two, and the molars three or four canals. However, the location and shape of these canals can vary significantly. Some are now using a microscope to see inside the tooth to make sure all the canals have been located and all the pulp has been removed.

Once the canals have been thoroughly cleaned and the dentist has made sure that the infection has been removed, the roots are filled. A temporary filling is then placed to cover the new root filling. The crown of the tooth should then be restored with a permanent filling or crown within a relatively short time.

In most cases, the tooth will need a crown, especially with molars that are under stress from chewing. A crown will help to restore the tooth's strength and protect it from cracking. A crown should be placed as soon as possible, ideally within a month of the root canal. It's important to get the tooth permanently restored to prevent damage to the tooth later. The temporary filling you receive is not meant to last.

The pulp that was removed during root canal treatment is the part that responds to temperature. The tissues and nerves surrounding your tooth remain, however, so your tooth will still respond to pressure and touch.

After Root Canal Treatment
Your tooth may be sore for two to three days after the procedure, and your dentist will tell you to avoid chewing on the affected side. The worse the infection and inflammation was prior to root canal treatment, the sorer the tooth will be after treatment. You can take over-the-counter pain relievers to ease the discomfort.

Possible Complications
As with most invasive medical or dental procedures, complications can occur. Here are some possibilities.

Sometimes when a root canal is opened for treatment, the oxygen in the air will trigger some bacteria to start growing, causing inflammation and pain.

Bacteria may get pushed out through the tips of the roots. Blood vessels enter the tooth through a small hole (the apex of the root) at the bottom of the root. Sometimes during a root canal procedure, bacteria are pushed out through this small hole into surrounding tissue. If this happens, the surrounding tissue will become inflamed and possibly infected. This can be treated with painkillers, and sometimes antibiotics, but the site could be painful until it clears up.

A root canal treatment can puncture the side of the tooth. This can happen if the canal is curved or if the canal cannot be located. The instruments are flexible so that they bend as the canal curves, but sometimes the instrument makes a small hole in the side of the tooth. If saliva can get into the hole, the tooth will have to be treated further or extracted. If the hole is far enough under the gum line that saliva can't reach it, it may heal.

A root canal may be missed or an entire canal may not be fully cleaned out. Locating canals within the tooth can be difficult. If a canal or an offshoot of a canal isn't located and cleaned out, the tooth can remain infected and the root canal procedure will have to be repeated. This also can happen if a canal isn't measured correctly and pieces of infected or inflamed pulp are left near the bottom. Occasionally, root canals have branches that are not accessible to traditional treatment.

A file may break. The tip of a file may break off inside the tooth. Usually, it's possible to leave the piece in the tooth and finish the root canal. But if the cleaning of the canal has not been finished, the file piece may have to be removed. Sometimes this can be done from the top of the tooth. However, in some cases, the file can only be removed through a surgical procedure called an apicoectomy. A small incision is made in the gum to access the root of the tooth, and the portion of the root containing the file piece is removed.

Pain, or the Lack of It
In most cases, you will not experience any pain during the root canal procedure. Your dentist will completely numb your tooth and the surrounding area. If this doesn't seem to be working, alert your dentist right away. Some people fear the anesthetic injections more than the procedure itself, but numbing gels and modern injection systems have made injections virtually painless. Let your dentist know immediately and he or she can modify the technique to avoid repeating the pain.

 

Illustrations: Root Canal Treatment from Start to Finish

Implant Series 1

 

Implant series 2

1. A Deep Infection 

Root canal treatment is needed when the tooth's root becomes infected or inflamed through injury or advanced decay.

 

2. A Route to the Root 

The tooth is anesthetized. An opening is made through the crown of the tooth to the pulp chamber.

 

 

 

Implant series 3

 

ImplantSeries4

3. Removing the Infected/Inflamed Tissue 

Special files are used to clean the infection and unhealthy pulp out of the canals. Irrigation is used to help clean the main canal (called lateral canals).

 

4. Filling the Canals 

The canals are filled with a permanent material, often gutta-percha. This helps to keep the canals free of infection or contamination.

 

 

 

ImplantSeries5

 

ImplantSeries6

5. Rebuilding the Tooth 

A temporary filling material is placed on top of the gutta-percha to seal the opening until the tooth is ready to be prepared for a crown. A crown, sometimes called a cap, is made to look like a natural tooth, and is placed on top.

 

6. Extra Support 

In some cases, a post is placed to give the crown extra support.

 

 

 

ImplantSeries7

 

 

7. The Crowning Touch 

The crown is cemented into place.

 

 

 

Restoring the Tooth After Root Canal

The tooth may be restored with a composite filling material if it is a front tooth and the cavity is small, but back teeth in many cases will need a crown.

To prepare the tooth for a crown, your dentist first will have to build up a foundation to strengthen the tooth and support the crown. This buildup is called a core. To help hold the core in place, your dentist may have to use a post. To do this, your dentist will remove some of the root filling material in the root canals to make room for the post, which is a metal rod.

Posts can be prefabricated and used with a core material that is built up around the post in the tooth. Post and cores can also be cast in one piece. A cast post and core often used in front teeth. It takes two dental visits to complete the process: one to prepare the tooth and create an impression of the post space, and the second to cement the post into tooth.

The crown, which is made in a dental laboratory, is composed of porcelain, metal, or a combination of the two. It is cemented onto the foundation.

 

Myths About Root Canal Treatment

Root canal is usually painful. 
"When people are told that they will require a root canal treatment, they usually associate the treatment with pain," "However, the pain they feel is caused by the infection in the tooth, not the root canal treatment. A root canal is done to eliminate that pain, and it is rather seldom that the procedure itself creates any symptoms.

"A local anesthetic, provided before beginning treatment, numbs the tooth and the surrounding area and ensures that the root canal procedure itself is painless,"

The tooth's nerves are removed, so I won't feel any pain. 
"Many people believe that once they have had root canal treatment that they will no longer feel pain in the treated tooth. This, however, is incorrect," "While a person who has had a root canal procedure will no longer be sensitive to hot or cold food or beverages, he or she may still experience some discomfort for a few days after receiving root canal treatment. The pain may be caused by inflammation of the tissues that surround the treated tooth. If this happens, your dentist may prescribe an anti-inflammatory medication which will help to alleviate the pain."

Why bother getting a root canal done when I'm just going to need the tooth taken out eventually? 
"It is not correct to assume that after receiving root canal therapy that the treated tooth will eventually need to be extracted," "In fact, most root canal treatments are successful and result in the tooth being saved."

I'm not feeling any pain, so I don't really need a root canal. 
"Most teeth that need root canal therapy will have no pain. However, not having symptoms does not mean that the tooth is OK. "Your dentist has techniques to evaluate and assess if the tooth's pulp is damaged or infected. If this is the case, then root canal therapy will be necessary.

"Sometimes you will not know that you have an infection because you are not experiencing pain, but if you see something near the damaged tooth that looks like a pimple that comes and goes, you should see your dentist," "The 'pimple,' called a sinus tract, is caused by pus from an infection draining through a tunnel of tissue to an opening on the surface. It is important to have the infection treated and to receive root canal therapy. If you don't, nearby tissues may be damaged."

A root canal means I'm having the roots of my tooth, or my whole tooth, removed. 
"During root canal treatment, it is the inside of your tooth and not the outside of your tooth that is treated," "During root canal therapy, the dentist removes the tooth's pulp, located in the center of the tooth, and does not remove the roots of the tooth or the actual tooth. The whole point of receiving root canal therapy is to try to save a tooth, not to remove it."

After I get the root canal, I won't have to go back to the dentist for a while. 
"Once you have received root canal therapy, you might be tempted not to return to the dentist for a while, but it is important that you make follow-up appointments to have a permanent restoration placed," "The root filling that is placed after the pulp has been removed will protect the root from infection, but the crown of the tooth must be restored.

"If you do not have a crown made on the back teeth, you are at greater risk of fracturing the tooth when you bite down or chew," "So you should make an appointment with your dentist when the root canal treatment is finished to have the permanent restoration placed."

The Second Time Around: Possible Retreatment or Surgery

A root canal can fail for several reasons. If your dentist failed to remove all of the infection from a canal or did not clean out all of the canals, the tooth can become infected again. Or, if there is leakage around an old filling or crown, bacteria can get in and reinfect a root canal.

Although the procedure itself is the same, a repeat root canal treatment tends to be more involved and time consuming than the original one because your dentist must remove the restorative material before he or she can do the second root canal. That's why retreatment generally costs more than the first root canal. Another reason that a retreatment may take longer is that failed root canal treatments often involve infections that are difficult to destroy.

Some people may also need endodontic surgery, either instead of or after retreatment. Endodontic surgery is done instead of retreatment if performing a second root canal is problematic. For example, if the tooth that has had root canal treatment has a post-and-core restoration, it may be difficult to remove the restoration without injuring the tooth. If the tooth still is infected after retreatment, endodontic surgery may be called for.

During endodontic surgery, your dentist makes a small incision in the gum near the tooth and cleans out the infected tissue around the tip (apex) of the root. He or she then shaves off 3 to 4 millimeters of the root (a procedure called an apicoectomy), cleans the inside of the canal from the root end, and places a filling in the end of the root. The incision is then stitched.

The success rate for this surgery is 80% to 90%. If the surgery is not successful in removing the infection, the tooth will have to be extracted.

 

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