Root canal treatment

Definition

Root canal treatment, also known as endodontic treatment, is a dental procedure in which the diseased or damaged pulp (central core) of a tooth is removed and the inside areas (the pulp chamber and root canals) are filled and sealed.

Purpose

An inflamed or infected pulp is called pulpitis. It is the most common cause of a toothache. To relieve the pain and prevent further complications, the tooth may be extracted (surgically removed) or saved by root canal treatment.

Demographics

Root canal treatment has become a common dental procedure. According to the American Association of Endodontists, more than 14 million root canal treatments are performed every year, with a 95% success rate.

Description

Inside the tooth, the pulp of a tooth is comprised of soft tissue that contains the blood supply, by which the tooth receives its nutrients; and the nerve, by which the tooth senses hot and cold. This tissue is vulnerable to damage from deep dental decay, accidental injury, tooth fracture, or trauma from repeated dental procedures such as multiple fillings or restorations over time. If a tooth becomes diseased or injured, bacteria may build up inside the pulp, spreading infection from the natural crown of the tooth to the root tips in the jawbone. Pus accumulating at the ends of the roots can form a painful abscess that can damage the bone supporting the teeth. Such an infection may produce pain that is severe, constant, or throbbing. It can also result in prolonged sensitivity to heat or cold, swelling, and tenderness in the surrounding gums, facial swelling, or discoloration of the tooth. In some cases, however, the pulp may die so gradually that there is little noticeable pain.

Root canal treatment is performed under local anesthesia. A thin sheet of rubber, called a rubber dam, is placed in the mouth and around the base of the tooth to isolate the tooth and help to keep the operative field dry. The dentist removes any tooth decay and makes an opening through the natural crown of the tooth into the pulp chamber. Creating this access also relieves the pressure inside the tooth and can dramatically ease pain.

The dentist determines the length of the root canals, usually with a series of x rays. Small wire-like files are then used to clean the entire canal space of diseased pulp tissue and bacteria. The debris is flushed out with large amounts of water (irrigation). The canals are also slightly enlarged and shaped to receive an inert (non-reactive) filling material called gutta percha. However, the tooth is not filled and permanently sealed until it is completely free of active infection. The dentist may place a temporary seal, or leave the tooth open to drain, and prescribe an antibiotic to counter any spread of infection from the tooth. This is why root canal treatment may require several visits to the dentist.

Once the canals are completely clean, they are filled with gutta percha and a sealer cement to prevent bacteria from entering the tooth in the future. A metal post may be placed in the pulp chamber for added structural support

During a root canal, the diseased pulp of a tooth (A), is removed (B). The remaining empty tooth is filled and sealed with a filling or crown. (

Illustration by GGS Inc.

)

Diagnosis/Preparation

Signs that a root canal treatment is necessary include severe pain while chewing, prolonged sensitivity to heat or cold, or a darkening of the tooth. Swelling and tenderness of the gums or pimples appearing on the gums are also common symptoms. However, it is also possible that no symptoms will be noticed. The dentist will take an x ray of the tooth to determine if there is any sign of infection in the surrounding bone.

Aftercare

Once a root canal treatment is performed, the recipient must have a crown placed over the tooth to protect it. The cost of the treatment and the crown may be expensive. However, replacing an extracted tooth with a fixed bridge, a removable partial denture, or an implant to maintain the space and restore the chewing function is typically even more expensive.

During the time when antibiotics are being used, care should be taken to avoid using the tooth to chew food. The tooth has been structurally weakened and may break, or there is a possibility of the interior of the tooth becoming reinfected.

If the tooth feels sensitive following the procedure, a standard over-the-counter pain medication such as ibuprofen or naproxen may be taken. This sensitivity will fade after a few days. In most cases the patient can resume regular activity the following day.

Risks

There is a possibility that a root canal treatment will not be successful the first time. If infection and inflammation recur and an x ray indicates a repeat treatment is feasible, the old filling material is removed and the canals are thoroughly cleaned out. The dentist will try to identify and correct problems with the first root canal treatment before filling and sealing the tooth a second time.

In cases where an x ray indicates that another root canal treatment cannot correct the problem, endodontic surgery may be performed. In a procedure called an apicoectomy, or root resectioning, the root end of the tooth is accessed in the bone, and a small amount is shaved away. The area is cleaned of diseased tissue and a filling is placed to reseal the canal.

Normal results

With successful root canal treatment, the tooth will no longer cause pain. However, because it does not contain an internal nerve, it no longer has sensitivity to hot, cold, or sweets. Because these are signs of dental decay, the root canal recipient must receive regular dental check-ups with periodic x rays to avoid further disease in the tooth. The restored tooth may last a lifetime. However, with routine wear, the filling or crown may eventually need to be replaced.

Morbidity and mortality rates

In some cases, despite proper root canal treatment and endodontic surgery, the tooth dies and must be extracted. This is relatively uncommon.

Alternatives

The only alternative to performing a root canal procedure is to extract the diseased tooth. After restoration or extraction, the two main goals are to allow normal chewing and to maintain proper alignment band spacing between teeth. A fixed bridge, a removable partial denture or an implant will accomplish both goals. However, these are usually more expensive than a root canal treatment.

Resources

books

Peterson, L. J., E. Ellis, J. R. Hupp, and M. R. Tucker. Contemporary Oral and Maxillofacial Surgery, 4th edition. Amsterdam: Elsevier, 2002.

Tronstad, L. Clinical Endodontics: A Textbook 2nd edition. New York: Thieme Medical Publishers, 2003.

Walton, R. E. and M. Torabinejad. Principles and Practice of Endodontics, 3rd edition. Philadelphia: Saunders, 2001.

Wray, D. Textbook of General and Oral Surgery. Amsterdam: Elsevier, 2003.

periodicals

Bader, H. I. "Treatment Planning for Implants versus Root Canal Therapy: A Contemporary Dilemma." Implant Dentistry 11, no. 3 (2002): 217–223.

Buchanan, L. S. "Negotiating Root Canals to their Termini." Dentistry Today 19, no. 11(2000): 60–71.

Douglass, A. B., and J. M. Douglass. "Common Dental Emergencies." American Family Physician 67, no.3 (2003): 511–516.

Himel, V. T., and M. E. Levitan. "Use of Nickel Titanium Instruments for Cleaning and Shaping Root Canal Systems." Texas Dental Journal 120, no. 3 (2003) L 262–268.

organizations

Academy of General Dentistry, 211 East Chicago Avenue, Chicago, IL 60611. (312) 440-4300. http://www.agd.org .

American Academy of Pediatric Dentistry, 211 East Chicago Avenue, #700, Chicago, IL 60611-2663. (312) 337-2169. Fax: (312) 337-6329. http://www.aapd.org .

American Association of Endodontists, 211 E. Chicago Ave., Suite 1100, Chicago, IL 60611-2691. (800) 872-3636 or (312) 266-7255. Fax: (866) 451-9020 or (312) 266-9867. info@aae.org. http://www.aae.org .

American Dental Association, 211 E. Chicago Avenue, Chicago, IL 60611. (312) 440-2500. Fax: (312) 440-7494. http://www.ada.org .

other

Animated-Teeth.com . [cited May 2, 2003]. http://www.animated-teeth.com/root_canal/t1_root_canal.htm .

Health Promotion Board of Singapore. [cited May 2, 2003]. http://www.hpb.gov.sg/hpb/haz/haz03029.asp .

New Zealand Dental Association. [cited May 2, 2003]. http://www.nzda.org.nz/public/rootcanals.htm .

L. Fleming Fallon, Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A root canal treatment may be performed by a general dentist or by an endodontist. An endodontist is a dentist who specializes in endodontic (literally "inside of the tooth") procedures. The procedure is usually performed in a professional dental office. In rare situations, it may be performed in a hospital outpatient facility.

QUESTIONS TO ASK THE DOCTOR

• What will be the resulting functional capacity of the tooth?
• Is the oral surgeon board certified in endodontic surgery?
• How many root canal procedures has the oral surgeon performed?
• What is the oral surgeon's complication rate?