Root canal & RCT

The scientific term “root canal ” refer to a thin canal that runs inside the tooth roots. Also many patients use this term to describe the treatment procedures used to treat the diseases involved with this anatomical formation so we will describe the two terms in details.

The root canal itself(tooth pulp):

The PULP is a thin canal that runs inside the tooth roots from the start  inside the bone and continue to reachs the tooth crown( the apparent part in the mouth ) where the it  meets the other pulp canals of the other roots (if the tooth is multi rooted), widens and form what we call the pulp camper in the middle of the crown. In the most cases each root contains one pulp canal but sometimes root may contains more than one .

The soft tissue inside the root canals and pulp chamber is composed of nerves, blood vessels, dentine forming cells and what is called loose connective tissue.

Function of tooth pulp:

During tooth formation the pulp  form the tooth dentine. Dentin is the inner layer that form most of the tooth hard tissue and covered in the tooth crown with enamel and in the root it is covered with cementum.

After tooth formation and eruption the pulp rule is limited to rehydrating the tooth, transmitting pain where something is wrong and also forming a protective layer of hard tissue if the tooth is attacked  by slowly destructive caries.

Sometimes patient comes to my clinic with a simple caries and because he have a bad history with pulp pain he ask me to extract the tooth even if the pulp can be saved. We should understand that root canal had function and should not be removed if not diseased.

Causes of  tooth nerve death:

Tooth nerve can die or be irreversibly inflamed in many cases.

1- First case when the tooth is attacked by caries and the caries bacteria penetrate the tooth hard tissue and reach the pulp then the bacteria rapidly destruct the fragile tissue inside the root canal and the tooth nerve become necrotic and dead.

2-Severe trauma to the tooth can break the pulp blood supply and cause also nerve death( pulp death ). Notice that in this case the symptoms are not clear and the problem can remain silent for years and you even won’t remember the history of trauma. This can be very challenging to the dentist to discover  because the tooth look healthy with no apparent problems except some discoloration that can be missed easily .

3-Severe gum( periodontal )disease: the bacteria can walk through the root surface and reach the root apex where the tooth pulp begins and infiltrate the  pulp.

4-If the pulp is exposed to extreme hot or cold temperature for a long time this also can cause pulp  inflammation or even pulp death. This can be from a inadequate  isolated metallic filling  or very large caries cavity .

5-Sometimes dental procedures, instrumentation during normal filling or even contact with some dental materials with the outer layer of the root canal can cause pulp death.

What are the symptoms of pulp death:

you will feel at least one or more of the following symptoms

1-Severe pain when you drink something cold and that pain  doesn’t relive when the cold drink is removed.

2-Severe Pain with hot drinks that relieved by cold application. in this case the pulp is dead and the bacteria ferment the dead tissue producing gases which expand by by hot and press on the nerve endings producing pain.

3-Pain with biting on hard food or pain with tapping on the tooth. Sometimes there is pain even when touching the tooth with finger or tongue. This type of pain sometimes caused by a severe gum inflammation as a result of food impaction between the teeth if the caries is between the teeth so your dentist will investigate the case to know the reason of pain. This pain with biting is a result of the pressure on the inflamed tissues surrounding the end of the root .

4- Swelling and redness at the end of the tooth root  even with no pain at all. Some times the inflammation become acute and the swelling may affect the whole face.

5-Pus oozing from a small opining behind the tooth.

6-Also if the tooth become darker  or bluish even with no pain at all and not because of food stains this can be an indicator to the pulp death and necrosis.

7-Some times the tooth looks normal and feel normal but fails in the vitality test performed by the dentist in the routine checking. generally a forgotten trauma history is the suspect here.

Root canal treatment:

if you want to know if you need root canal treatment  read the previous paragraph.

Root canal  treatment in its most simple form is the removal of the dead root canal tissue, widening of the root canal space, disinfecting the empty canal then filling the root canal with natural rubber filling called gatta percha .

Steps:

1-first the dentist will examine you carefully.

2-A x-ray film is taken to to detect any problems in the jaw bone above the tooth , understand root canals forms and course and detect any possible difficulties.

3-Some cases need to be anesthetized when the pulp is not completely dead or with the anxious patient to make him relax. Also nitrous oxide sedation sometimes is used to relax the patient. In my practice i prefer using anesthesia with every root canal case to be sure that the patient is relaxed comforted and happy.

4- Then the dentist start to create an access hole  in the tooth crown till he see the openings of the root canals.

5- Then he start the cleaning and widening phase of the treatment. here the dentist is supposed to remove the dead infected pulp tissue ,wash the empty root canal  with a disinfectant  finally make the root canal wider to remove the infected root canal wall and ease the process of filling.

This process is usually performed using an instrument called endodontics  file. Root canal file is a thin threaded pin that can be used by hand or mounted in the dental headpiece.  The dentist insert the file into the root canal ant start to spin the file. while the file rotate inside the it cuts the canal wall causing the root canal  to become wider. When the file become loose a larger size file is used and so on for three or four sizes. During this filing the pulp is irrigated with a disinfecting solution.

6-In the next visit or in the same visit the dentist fill the prepared root canals with a rubber based  filling material which is  either condensed with a spreader or injected inside the pulp space using special syringe.

7-finally the dentist restore the tooth crown with a filling and an artificial crown(teeth caps).

Rootcanal success rate:

Root canal treatment have an average success rate around 95% .But this success rate may vary  according to many factors.

The ratio depending on the initial case of the tooth and the skill of the operator sure it is higher if the tooth is slightly infected and there is no pus. Also acute un neglected cases respond better to root canal treatment than the teeth with a long history of infection, Also teeth with a normal straight roots  has a higher success rate than the curved or obliterated root canals. Last thing the specialized endodontic should have higher success rates than the general dentist.

Root canal VS. tooth extraction :

Sometimes patients just prefer to extract the tooth to avoid endodontic treatment. Some are afraid of the pain during root canal treatment others want to save some money.

First we should know the results of tooth extraction:

first thing when you extract tooth you don’t loose it alone you loose it and also the opposing tooth from the opposing jaw because the opposing tooth in biting on air now and won’t be able to chew anything moreover the opposing tooth will start to move out of the gums till it becomes loose and sensitive.

Also the neighboring teeth that lies in front and back to the extracted one will start to tilt or move into the empty space formed. This tilting will start to make gaps between the teeth on the hole side that the food can be impacted in easily causing gum diseases and caries.

You should also know that extracting the tooth will affect your face shape especially if the tooth is in the smile line. Even posterior teeth will affect the face shape because these teeth is supporting the cheek and when many of them become  extracted  the patient will look much older.

“ok i will extract the teeeeeeet tooth and make a bridge after that, just pull the teeet tooth doc” you say

i listen to this sentence daily and i answer with the same answer. Will coast much more than root canal, lengthy visits is required too  and finally nothing is  like what GOD made.

SO natural tooth is a fortune even if it needs root canal don’t give it up easily.

Is it painful:

Ok lets say that root canal have a very bad reputation with pain. This reputation is very outdated, nowadays and with the prober anesthesia there will be almost no pain at all just the injection. I made a little survey in my clinic most of the patients stated that they felt a very little pain. Even if the process is painful in the first visit the dentist can break the visit use some medication to treat the inflammation and continue the next visit with almost no pain at all.

But we also have to say that sometimes after finishing the root canal treatment there is some affordable pain that can remain two or three days this little pain can be managed easily with any over the counter analgesic, Also a little discomfort and tenderness may be felt after finishing the root canal treatment and this can remain for a week or little more.

Root canal treatment fees:

Sure it differ according to the the country, city, number of root canals, position of the tooth also if the performer is specialized endodontic the fees will be higher.

I don’t live in the USA but i read somewhere that the coast is between 350$ and 1000$ please comment to correct for me if the number were wrong.

Root canal complications and failure:

RCT can fail when the dentist fail to clean and disinfect the pulp spacel completely and leave some remaining bacteria that later grow forming a recurrent infection.

Also a very common cause  failure when a  file break inside the canal. A broken file is no problem at all if it happened after the root canal treatment & cleaning phase is finished and the broken part of the file reach the full length of the root canal.  If the file break before the canal is disinfected or didn’t reach the full length this will probably lead to failure and should be removed via a minor surgery.

Also sometimes the tooth had what we call small periodical lesion that can be  missed during x-ray examination this lesion will continue to grow and it is usually contain some bacterial nests that proliferate causing the case to fail.

Last common cause of failure is when a complete root canal is missed and left with the infected tissue inside it with no treatment this usually happen with a small canals that is placed  in an up normal place. We call this  the accessory canals and it is a nightmare for any endodontic because it’s openings is very really small and can be missed easily.

An uncommon complication  that sometimes the root may fracture during condensation of the filling material inside the PULPl.

last thing we have to say that some cases just fail without apparent reason.

Don’t panic  the rct success rate still above 95% and many of the failed 5% cure completely after retreatment.

last thing you should cover the tooth with a crown but this is another article

Dr. A. galal

practicing dentist