TheOptimalSmile
Endodontics
Root CanalsHas your dentist or endodontist told you that you need root canal treatment? If so, you're not alone. Millions of teeth are treated and saved each year with root canal, or endodontic, treatment. Learn how root canal treatment can relieve your tooth pain and save your smile, and find an endodontist in your area.To understand a root canal procedure, it helps to know about the anatomy of the tooth. Inside the tooth, under the white enamel and a hard layer called the dentin, is a soft tissue called the pulp. The pulp contains blood vessels, nerves and connective tissue, and helps to grow the root of your tooth during development. In a fully developed tooth, the tooth can survive without the pulp because the tooth continues to be nourished by the tissues surrounding it.
Endodontic treatment treats the inside of the tooth. Endodontic treatment is necessary when the pulp becomes inflamed or infected. The inflammation or infection can have a variety of causes: deep decay, repeated dental procedures on the tooth, faulty crowns, or a crack or chip in the tooth. In addition, trauma to a tooth may cause pulp damage even if the tooth has no visible chips or cracks. If pulp inflammation or infection is left untreated, it can cause pain or lead to an abscess.
How does endodontic treatment save the tooth?
During root canal treatment, the inflamed or infected pulp is removed and the inside of the tooth is carefully cleaned and disinfected, then filled and sealed with a rubber-like material called gutta-percha. Afterwards, the tooth is restored with a crown or filling for protection. After restoration, the tooth continues to function like any other tooth.
Contrary to jokes about the matter, modern root canal treatment is very similar to having a routine filling and usually can be completed in one or two appointments, depending on the condition of your tooth and your personal circumstances. You can expect a comfortable experience during and after your appointment.Saving the natural tooth with root canal treatment has many advantages:Efficient chewingNormal biting force and sensation-
Natural appearanceProtects other teeth from excessive wear or strainEndodontic treatment helps you maintain your natural smile, continue eating the foods you love and limits the need for ongoing dental work. With proper care, most teeth that have had root canal treatment can last as long as other natural teeth and often for a lifetime.
What is endodontic treatment?
“Endo” is the Greek word for “inside” and “odont” is Greek for “tooth.” Endodontic treatment treats the inside of the tooth. Root canal treatment is one type of endodontic treatment.To understand endodontic treatment, it helps to know something about the anatomy of the tooth. Inside the tooth, under the white enamel and a hard layer called the dentin, is a soft tissue called the pulp. The pulp contains blood vessels, nerves, and connective tissue and creates the surrounding hard tissues of the tooth during development.The pulp extends from the crown of the tooth to the tip of the roots where it connects to the tissues surrounding the root. The pulp is important during a tooth’s growth and development. However, once a tooth is fully mature it can survive without the pulp, because the tooth continues to be nourished by the tissues surrounding it.
Why would I need an endodontic procedure?
Endodontic treatment is necessary when the pulp, the soft tissue inside the root canal, becomes inflamed or infected. The inflammation or infection can have a variety of causes: deep decay, repeated dental procedures on the tooth, or a crack or chip in the tooth. In addition, an injury to a tooth may cause pulp damage even if the tooth has no visible chips or cracks. If pulp inflammation or infection is left untreated, it can cause pain or lead to an abscess.
What are the signs of needing endodontic treatment?
Signs to look for include pain, prolonged sensitivity to heat or cold, tenderness to touch and chewing, discoloration of the tooth, and swelling, drainage and tenderness in the lymph nodes as well as nearby bone and gum tissues. Sometimes, however, there are no symptoms.
How does endodontic treatment save the tooth?
The endodontist removes the inflamed or infected pulp, carefully cleans and shapes the inside of the root canal, then fills and seals the space. Afterwards, you will return to your dentist, who will place a crown or other restoration on the tooth to protect and restore it to full function. After restoration, the tooth continues to function like any other tooth.
Will I feel pain during or after the procedure?
Many endodontic procedures are performed to relieve the pain of toothaches caused by pulp inflammation or infection. With modern techniques and anesthetics, most patients report that they are comfortable during the procedure.For the first few days after treatment, your tooth may feel sensitive, especially if there was pain or infection before the procedure. This discomfort can be relieved with over-the-counter or prescription medications. Follow your endodontist’s instructions carefully.Your tooth may continue to feel slightly different from your other teeth for some time after your endodontic treatment is completed. However, if you have severe pain or pressure or pain that lasts more than a few days, call your endodontist.
Step-by-Step Endodontic Procedure
Endodontic treatment can often be performed in one or two visits and involves the following steps:
1. The endodontist examines and x-rays the tooth, then administers local anesthetic. After the tooth is numb, the endodontist places a small protective sheet called a “dental dam” over the area to isolate the tooth and keep it clean and free of saliva during the procedure.
2. The endodontist makes an opening in the crown of the tooth. Very small instruments are used to clean the pulp from the pulp chamber and root canals and to shape the space for filling.
3. After the space is cleaned and shaped, the endodontist fills the root canals with a biocompatible material, usually a rubber-like material called gutta-percha. The gutta-percha is placed with an adhesive cement to ensure complete sealing of the root canals. In most cases, a temporary filling is placed to close the opening. The temporary filling will be removed by your dentist before the tooth is restored.
4. After the final visit with your endodontist, you must return to your dentist to have a crown or other restoration placed on the tooth to protect and restore it to full function.
If the tooth lacks sufficient structure to hold the restoration in place, your dentist or endodontist may place a post inside the tooth. Ask your dentist or endodontist for more details about the specific restoration planned for your tooth.
How much will the procedure cost?
The cost varies depending on how complex the problem is and which tooth is affected. Molars are more difficult to treat; the fee is usually more. Most dental insurance policies provide some coverage for endodontic treatment.Generally, endodontic treatment and restoration of the natural tooth are less expensive than the alternative of having the tooth extracted. An extracted tooth must be replaced with an implant or bridge to restore chewing function and prevent adjacent teeth from shifting. These procedures tend to cost more than endodontic treatment and appropriate restoration.
Will the tooth need any special care or additional treatment after endodontic treatment?
You should not chew or bite on the treated tooth until you have had it restored by your dentist. The unrestored tooth is susceptible to fracture, so you should see your dentist for a full restoration as soon as possible. Otherwise, you need only practice good oral hygiene, including brushing, flossing, and regular checkups and cleanings.Most endodontically treated teeth last as long as other natural teeth. In a few cases, a tooth that has undergone endodontic treatment does not heal or the pain continues. Occasionally, the tooth may become painful or diseased months or even years after successful treatment. Often when this occurs, redoing the endodontic procedure can save the tooth.
What causes an endodontically treated tooth to need additional treatment?
New trauma, deep decay, or a loose, cracked or broken filling can cause new infection in your tooth. In some cases, the endodontist may discover additional very narrow or curved canals that could not be treated during the initial procedure.
Can all teeth be treated endodontically?
Most teeth can be treated. Occasionally, a tooth can’t be saved because the root canals are not accessible, the root is severely fractured, the tooth doesn’t have adequate bone support, or the tooth cannot be restored. However, advances in endodontics are making it possible to save teeth that even a few years ago would have been lost. When endodontic treatment is not effective, endodontic surgery may be able to save the tooth.
Root Canal Retreatment
Dear Doctor,My dentist took a new set of x-ray pictures and noticed that a root canal treatment done many years ago is failing and he recommended retreatment. I have had no pain or other symptoms. Why is retreatment necessary and what is involved?
Dear Ray,
As occasionally happens with any dental or medical procedure, a tooth may not heal as anticipated after initial treatment for a variety of reasons:
Narrow or curved root canals sometimes pose complications during the initial procedure.
Complicated root canal anatomy (shapes and forms) went undetected in the first procedure.
The placement of the crown or other restoration was delayed following the treatment, resulting in reinfection of the root canals.
An inadequate seal of a restoration (filling) allowed recontamination of the inside of the tooth.
Some of these issues do not give rise to symptoms, but can give rise to chronic infection, often seen in an x-ray picture as a small black area around the end of an affected root. New problems too, can jeopardize a tooth that initially had successful endodontic (endo-inside, dontic-tooth) or root canal treatment.
For example:
New decay can expose the root canal filling material to bacteria, causing a new infection in the tooth.
A loose, cracked or broken crown or filling can expose the tooth to new infection.
A tooth sustains a fracture of the crown or root.
The next question you may ask is — what will happen during pretreatment?
First, all options should be reviewed, together with the risks, benefits and alternatives. Assuming the tooth can be retreated, it will need to be “reopened”. A small hole will be made into the biting or chewing surface of the tooth to gain access to the root canal. In many cases, complex restorative materials — crown, post and core material — must be “disassembled” and removed to permit access to the root canals. The previous root canal filling materials are removed and the canals cleaned and carefully examined, usually requiring magnification and illumination, which includes searching for any additional canals or unusual canals that require treatment. After cleaning and shaping the canals they will be sealed and a temporary filling or crown placed.
If the canals are unusually narrow or blocked, there is a possibility that endodontic surgery may be necessary to treat infection and reseal the canal(s). Upon successful completion and healing of infection, a new crown or restoration will need to be placed on the tooth to protect and restore it to its full form and function
How do I know if retreatment is the best choice and what are the alternatives?
Whenever possible, it is best to save your natural tooth. Retreated teeth can function well for years, even a lifetime. Advances in technology are constant and updated techniques may be used to save a tooth, which may not have been available when you had your first procedure. If non-surgical retreatment is not an option, then endodontic surgery may be considered. This involves making an incision to allow access to the end of the root(s). Endodontic surgery may also be recommended in conjunction with retreatment or as an alternative.
The only other alternative to retreatment or failing endodontics ultimately is extraction of the tooth. It will then need to be replaced with an implant, bridge or removable partial denture to restore chewing function and aesthetics and importantly, to prevent adjacent teeth from shifting. Because these options require surgery or dental procedures on adjacent healthy teeth, they can be more costly and time consuming than retreatment and restoration of the natural tooth. But this is a topic for another discussion.
Who performs root canal retreatment and what are the costs?
Endodontic or root canal retreatment can be more complicated and technically challenging than initial treatment, and is generally carried out by root canal specialists, “endodontists”, dentists who have taken specialty training in the diagnosis and treatment of root canal problems. Most modern endodontic procedures are performed with the use of microscopes to allow the proper degree of precision and sophistication needed to ensure success.
The cost varies depending on how complicated the procedure will be and the time that is needed. Teeth with multiple canals, like the back (premolar and molar) teeth will take more time especially if there are extra or unusually shaped canals. Restorations and filling material may also need to be removed to reaccess the root canal. Therefore, you can generally expect retreatment to cost more than the initial endodontic treatment. While dental insurance may cover part or all of the cost for retreatment, some policies limit coverage to a single procedure on a tooth in a given period of time. Check with your insurance company and dentist prior to retreatment to be sure of your coverage.
The bottom line is that you should review all the risks, benefits and alternatives of root canal retreatment with your dentist or endodontist. You've already made an investment in saving your tooth. The payoff for choosing retreatment should be a healthy, functioning natural tooth for many years to come.
Saving New Permanent Teeth After Injury
Tooth injuries are common, particularly in late childhood. When a permanent tooth is injured, or damaged by decay, it is always best to try to save it rather than remove it. This is especially true in the case of older children and young adults, who need a full set of teeth to help guide the continuing growth and development of their jaws and bite. Because their jawbone structure is still developing, they are also not physically ready to receive a permanent artificial replacement tooth should a natural tooth be lost. Yet this age group is also the most prone to dental injuries, and saving an immature permanent tooth can present a complex — but definitely not hopeless — situation. What can be done?
Pulp Fact — Not Fiction
First, it's important to understand why this age group presents particular challenges not seen in adults. When an adult injures a fully formed tooth, it can often be saved with a routine root canal filling procedure, in which the damaged, infected or dead tissue of the pulp, which is located deep inside the tooth, is removed and the canals which housed it are sealed. Healthy pulp tissues are vital, containing connective tissue, blood vessels and nerves that enable the tooth to grow and perceive sensation. But the pulp can also become infected and actually die when a tooth is damaged by trauma or decay.This can be very problematic not only for completion of proper root development, but everything else that it affects: proper bite development, jawbone and facial growth, as well as the more usual elements associated with teeth — chewing, speech and aesthetics. And it's difficult, if not impossible, to replace teeth when the system in which they're developing is itself growing and changing so rapidly. So there are many reasons to save damaged or traumatized immature permanent teeth, at least until the individual has reached maturity when, if necessary, the tooth can be replaced within the framework of a healthy and functional bite.In the case of an adult with fully formed teeth, pulp death is not as bad as it sounds. A full-grown tooth does not need its pulp, which can be removed if diseased, and the cavity (or “canal”) disinfected and sealed. Baby teeth, which will eventually be lost, can also be saved until their natural loss, but present their own special treatment circumstances. (See “Root Canal Treatment for Children's Teeth”)The development of a tooth starts with an enamel cap known as the crown (the part you see in your mouth). Enamel is the hardest and most durable substance produced in nature. Inside the enamel cap, the body of the tooth forms out of a bone-like substance called dentin. A permanent tooth that's still developing needs to maintain its own vital tissue because it is the living pulp within that will generate the dentin of the roots of the tooth. Just as coral produces the hard calcium structure around it to protect its soft inner living parts, so too does the pulp tissue produce the dentin body and roots of a tooth — and this is impossible to accomplish without tooth pulp. In fact, the developing roots help guide the crowns of teeth into position during the eruption process.After the roots are fully formed, the pulp continues to deposit dentin throughout life, so that the chamber in which it lives gets smaller and smaller. If the pulp dies prematurely, root formation in the young tooth cannot be completed; thus the tooth cannot respond to any sensation. In due course a “non-vital” or “dead” tooth becomes brittle and darker due to dehydration and blood stagnation, and thus more prone to fracture, particularly if root formation is incomplete. So it's important to try to rescue the pulp, which in turn will save the tooth.There are specialized techniques for doing just that — painlessly, effectively and relatively inexpensively. In this article, the second part of a series on root canal procedures, we will explain treatment of injury to immature permanent teeth.Pathways To The PulpToday, even when the pulp is damaged, its vitality can be maintained with a variety of endodontic (“endo” – inside; “dont” – tooth) techniques. What's more, stem cell research is leading to the ability to completely replace dead pulp with new tissue in immature permanent teeth. Thus all pathways are leading to the salvation of a healthy tooth with a vital pulp.The first step in all treatment is a correct diagnosis — figuring out exactly what is wrong. Therefore it is important to take an accurate history of what caused the damage, the extent of injury, as well as the state of general health and any medications the person with the injured tooth is taking.All are important treatment factors that an endodontist will consider along with a detailed clinical examination. An endodontist is a specialist in saving teeth through the diagnosis and treatment of facial pain and root canal diseases and disorders. A correct diagnosis must be confirmed by taking appropriate radiographs (x-ray pictures).What follows is a description of conditions an endodontist might find, and the best courses of action to save an injured or damaged immature tooth.
Pathways To The Pulp
Today, even when the pulp is damaged, its vitality can be maintained with a variety of endodontic (“endo” – inside; “dont” – tooth) techniques. What's more, stem cell research is leading to the ability to completely replace dead pulp with new tissue in immature permanent teeth. Thus all pathways are leading to the salvation of a healthy tooth with a vital pulp.The first step in all treatment is a correct diagnosis — figuring out exactly what is wrong. Therefore it is important to take an accurate history of what caused the damage, the extent of injury, as well as the state of general health and any medications the person with the injured tooth is taking.All are important treatment factors that an endodontist will consider along with a detailed clinical examination. An endodontist is a specialist in saving teeth through the diagnosis and treatment of facial pain and root canal diseases and disorders. A correct diagnosis must be confirmed by taking appropriate radiographs (x-ray pictures).What follows is a description of conditions an endodontist might find, and the best courses of action to save an injured or damaged immature tooth.
Injury Without Pulp Exposure
A cross section of a fully formed, healthy front tooth, showing the pulp (nerve tissue) in relation to the surrounding tooth structures.
A successful root canal procedure is necessary to save a tooth once the nerve tissue dies as a result of tooth decay or trauma. Access to the root canal space is gained by making a small opening from the tongue side of a front tooth.
As the permanent tooth develops, it starts to erupt towards the baby tooth.
As the root of the permanent tooth develops and erupts, the roots of the baby tooth resorb (melt away), causing it to loosen and eventually shed.
The best option is to avoid exposure of the living pulp tissue within a tooth, whether it is as a result of trauma or tooth decay. Indirect Pulp Therapy offers a way to treat tooth decay (in which the dentin is infected with bacteria) without exposing the pulp. It involves the removal of as much soft decayed dentin as possible, while leaving a layer of harder dentin — even if stained by the decay — to avoid pulp exposure. An antibacterial agent is applied and the tooth filled to seal it, thereby preventing further infection. When properly applied, this procedure has proven 90% successful over three-year periods.
Injury With Pulp Exposure
There are several different techniques that can be used if the decay or injury has exposed the tooth pulp.Pulpotomy (“otomy” – partial removal) of the affected or infected upper portion of the pulp tissue is used to preserve the vitality of the remaining tissue in the roots, so that it continues to live and function. Injured exposed pulp will become inflamed, and its tissue will overgrow. Removal of the overgrown tissue and placement of a dentin-stimulating material such as calcium hydroxide or mineral trioxide aggregate (MTA) allows the remaining pulp tissue to encourage the growth of new tooth material that will patch the exposure. A large majority of young permanent teeth treated with this technique heal well and root formation continues to healthy completion. Teeth so treated last for many years, avoiding the necessity for traditional root canal treatment.
A pulpotomy that goes deeper into the root or roots is a technique used to encourage apexogenesis (“apex” – root end; “genesis” – to come into being). When this technique is properly employed, it can enable the remaining pulp to complete forming the end of an immature root. As the young root (which has a cylinder shape) continues to grow, it elongates and ultimately narrows, closing off to form a normal root ending or apex.When the pulp tissue in an immature permanent tooth is no longer salvageable and/or there is already infection around an incompletely formed root, an apexification is performed. This procedure is designed to seal the open, cylindrical root end of an immature tooth and allow the development of healthy bone-like tissue around it to support the tooth. This wide-open end of the immature root is often referred to as a “blunderbuss” after the type of wide-muzzled gun used by the Pilgrims. The root canal is thoroughly cleaned and disinfected and the immature apex or root end is sealed with MTA in an attempt to enable the surrounding bone tissue to heal and return to normal. The root canal is filled with a rubber-like material called gutta percha. Although highly successful, apexification should be the treatment of last resort in a tooth that has incompletely formed roots.
Deeper “pulpotomy” — removal of most but not all pulp tissue when it has been more severely damaged — can still allow for completion of healthy root formation.
When decay begins to infect the pulp, a “pulpotomy” is used to remove the infected portion while preserving the remaining healthy tissue to promote continued root development.
An “indirect pulp cap” technique allows removal of infected, decayed dentin and the application of specialized bio-compatible medicines that promote healing of the pulp and completion of root development. -
When the pulp tissue is no longer salvageable due to infection in an immature root, disinfection and sterilization of the root canal and treatment with specialized bio-materials promote healing of the surrounding tissues and bone.
Life After Pulp Death
Until recently, there were few options for permanent immature teeth in which the pulp tissue had died. But recent research has opened a new pathway. Immature teeth with clear evidence of dead pulp tissues, abscess formation or even infection spreading out of the root canal have been encouraged to grow new pulps to complete root formation. Success is dependent on the activity of a newly identified population of stem cells, which are the building blocks for many different types of cells and tissues in the body. The stem cells in pulp are hidden treasure with enormous potential for tissue regeneration and “bio-root” engineering.Based on what is known today, all immature teeth with open root ends in children or teenagers may be considered candidates for regenerative treatment. The procedure involves very thoroughly disinfecting the cleaned-out root canal system and then encouraging a bit of bleeding from surrounding healthy tissues into the canal. The blood clot that forms in the canal serves as a building block for pulp regeneration, allowing for root formation to continue. Stem cell regeneration will allow blunderbuss procedures to fade into history.
The Continuing Story
The state of the art and science of endodontic treatment continues to improve the outcomes for injured and infected pulps of immature permanent teeth. Today's successfully treated teeth can go on to form complete roots and last a lifetime — or at least until growth of the face and jaws is complete and state-of-the-art dental implants can be used to replace them. But then again, and not too far off, scientists working with stem cells may even be able to grow you a whole new tooth!
Bio-Materials That Promote Successful Healing
Mineral Trioxide Aggregate (MTA) is a newer material that was developed specifically as a root canal sealer in the 1990s. It is biocompatible (“bio” – life; “compatible” – non-injurious, encourages healing) with the pulpal and periapical tissues (“peri” – around; “apex” – root end), the living structures, bone and periodontal membrane surrounding and attaching to the root. It is stable and not degraded by the body and will not leak, therefore providing a stable seal, which prevents ingress and penetration of bacteria. Importantly it is very alkaline when first mixed with water, so that it acts to disinfect and neutralize areas of infection that are by nature acidic.Calcium hydroxide, developed in the 1920s and still in use today, is an important root canal filler; it stimulates the periapical tissues to heal and has antimicrobial properties. It is antibacterial and has a very high alkalinity that encourages repair and active calcification — the process by which calcium minerals form the skeleton and teeth.Today, even when the pulp is damaged its vitality can be maintained. In immature permanent teeth a healthy blood supply and the presence of stem cells can enable stimulation of continued root growth. Treatment using stem cells will promote the complete replacement of dead pulp tissue with new tissue. The latest stem cell technologies enable the body to completely replace a “dead” pulp with a regenerated new pulp.
Root Canal Treatment For Children's Teeth
Young children can lose primary (baby) teeth and even immature permanent teeth when the pulp, the living tissue inside a tooth, becomes infected. This is often the result of trauma or dental caries (tooth decay) and creates a special problem for the child. The primary teeth provide important guides for the newly developing permanent teeth that will replace them. And injury resulting in loss of young permanent teeth can be even more troublesome, because neither tooth development, nor jaw growth is complete. If teeth are lost prematurely, a malocclusion (“mal” – bad; “occlusion” – bite) can easily result. Tooth replacement techniques such as partial dentures, bridgework and dental implants cannot easily be used in children while everything is changing and growing so rapidly. “Space maintainers,” specially made appliances that can be attached to adjacent teeth or fabricated in a removable “retainer” style, are generally the best choice. Yet many do not restore function, and all require constant monitoring.For both functional and cosmetic reasons, endodontic (“endo” – inside; “dont” – tooth) or root canal treatment is preferable to tooth loss. It can preserve tooth, jaw and tongue function. It can also prevent speech problems, and abnormal eruption of a permanent successor tooth, or even the loss of a tooth that has no successor.
What follows is a guide to understanding what to look for in your child and what can be done to save baby teeth until they are ready to be lost naturally. Special endodontic treatment techniques for immature permanent teeth will be covered in a subsequent article.
Different Strokes For Younger Folks
Many things are different when dealing with primary teeth versus permanent teeth. Their survival is shorter and more temporary, but while their shapes, structure and functioning are similar to permanent teeth, they too have differences. Treatment of root canal problems is affected by root resorption, the normal process by which the body absorbs the roots of the baby teeth to allow for eruption of the succeeding permanent teeth. This complicates the diagnosis and, therefore, appropriate treatment.
A Close Look At Tooth EruptionBaby teeth are lost naturally due to the pressure of the permanent teeth erupting from below. This process is called root resorption. Note the continued development of the permanent crown and root as it erupts.
Figuring Out What's Wrong
Examination begins with a thorough medical history; a child with systemic (general) disease may need different treatment than a healthy one, and the dentist must consider any implications of the child's condition related to root canal treatment.The characteristics of pain in a primary tooth are particularly relevant in helping to determine the status of the pulp. In the absence of trauma, pain is most often due to tooth decay reaching the pulp, which contains the nerves within the teeth.
Symptoms of pain usually accompany pulpal inflammation. However, extensive problems may arise without any history of pain. If possible, a distinction should be determined regarding whether the pain is spontaneous or only occurs when provoked; pain that ceases after removal of the cause is usually reversible and indicative of minor inflammatory change. Pain-provoking stimuli include: thermal, hot and cold; chemical, caused by sweet or acidic foods or beverages; and mechanical irritation, biting, or wobbling a loose tooth. Other common causes include deep tooth decay, faulty restorations (fillings), soreness around a primary tooth that is loose and ready to fall out, or an erupting permanent tooth.Spontaneous (unprovoked) pain is characterized by constant or throbbing pain that occurs without stimulation and continues long after any causative factor has been removed. Spontaneous toothache is usually associated with extensive degeneration of the pulpal tissues extending into the root canals; this may be followed by swelling of the gum tissues and abscess formation as infection spreads beyond the roots of the teeth and into the surrounding bone.
Radiographs (x-rays) of good quality are essential after the clinical examination. Like permanent teeth, areas of infection appear at the root ends of primary front teeth. In primary molars (back teeth), changes are also most often apparent in the furcations, the areas where roots join each other in multi-rooted teeth. In advanced cases of infection, and where the permanent tooth bud may be in jeopardy, removal of the primary tooth may be necessary.Mild but chronic pulpal irritation as seen in tooth decay might stimulate the pulp to deposit more dentin (the living tissue of which the body of the tooth is made). This “reactionary” dentin is nature's way of healing the tooth. When looking at radiographs of a child's primary tooth where tooth decay has reached the pulp, advanced pulpal degeneration occurs and extends into the root canals. Interpretation of radiographs of primary teeth is always complicated by the presence of new permanent teeth. Although all decay that penetrates into the pulp causes inflammation, the larger the penetration, the more likely it is to cause death of the pulp tissues.
We'll Get By With A Little Help From Our Friends
Pediatric dentists specialize in the treatment and management of children and adolescents, in growth and development of the teeth and oral structures, and they routinely treat root canal problems affecting primary (baby) teeth. They are particularly adept at figuring out what's wrong with primary teeth. Additionally, endodontists, who have had two to three years of additional training following dental school, specialize in the diagnosis and treatment of pulpal problems. General dentists who have taken additional training may also treat root canal problems of primary teeth.This additional training is important because there is not always a definitive correlation between symptoms and the state of the tissues of the tooth when dealing with primary teeth. Also, younger patients are often not the best historians and accurate reporters of problems. All of this complicates the diagnosis of pulp health and disease in primary teeth and in immature permanent teeth.Primary teeth with a history of spontaneous pain are generally candidates for more traditional root canal treatment or extraction. But outside of this situation, there are alternative pulp treatments to prolong the life of primary teeth so that they can perform their necessary functions until they are lost naturally. Another important factor to consider is the proximity of infected baby teeth to their permanent tooth successors. The treatment least likely to damage the permanent tooth should always be chosen. Infected permanent teeth in children may require special management due to problems associated with incomplete root development. Endodontists routinely treat these cases in children and should be included as part of the dental treatment team.Roughly half of traumatized primary teeth develop transient or permanent discoloration. These colors vary from yellow to dark grey and usually become evident one to three weeks after trauma. Primary teeth with yellow discoloration frequently have radiographic signs of root canal calcification, bone-like deposits that can completely obscure the pulp. Injured primary teeth with dark gray discoloration are reported to have necrotic (dead) tissue in their pulps in 50-80% of cases. Almost all pediatric dentists and endodontists agree that completely knocked out (avulsed) primary front (incisor) teeth should not be replanted because of the possibility of danger to the underlying permanent tooth buds.
This illustration shows a cross section of a healthy tooth and pulp tissue (nerve tissue) with no tooth decay.
Decay is progressing beyond the protective enamel surface of the tooth. Notice how the decay spreads once it extends beyond the enamel surface.
When decay starts advancing towards the pulp, the pulp attempts to protect itself by adding additional dentin to separate itself from the decay. This is called “reactionary dentin.
When the decay enters the pulp tissue, it becomes infected. This infection could damage the permanent tooth if left untreated.
Root Canal Treatment Options For Primary TeethThe treatment of primary and young permanent teeth is quite safe and predictable, backed by a large body of research detailing the best clinical techniques and practices. With sound clinical techniques and some rather extraordinary compounds, a lot can be done to save baby teeth. As always, treatment is based on assessment and diagnosis, and, especially in the case of primary teeth, may be decided by the state of the tooth at the time of examination.
The treatment of primary and young permanent teeth is quite safe and predictable.What follows is a summary of the state-of-the art treatment techniques for the various stages of pulpal involvement for baby teeth with trauma and decay:Indirect pulp treatment works best for teeth with deep decay approaching and/or barely exposing the pulp, where removing all the decayed parts of the tooth would expose it. Instead, as much soft decay is removed as possible, leaving only harder remnants without penetrating into the pulp. Then applying an antibacterial agent and restoring the tooth to seal it prevents further infection. In this procedure, outer layers of infected dentin are removed and a layer of lining cements are placed over the exposed dentin. These materials reduce the acidity caused by decay and sterilize the surrounding infected dentin. By allowing inflammation to subside, reactionary/reparative dentin is deposited by the pulp to further protect itself. A temporary filling is then placed in the tooth to ensure comfort and healing. A more permanent filling is placed after 10-12 weeks. When properly applied, this procedure has proven 90% successful over three-year periods.Direct Pulp Capping is recommended for “small incidental exposures of the pulp when there is no decay.” Here, the dentist will essentially “cap” the exposure directly using similar materials as mentioned above, to create a dentin “bridge” to seal the exposure.
Pulpotomy is literally a “partial pulp removal,” a tried and tested technique, and is successful in 90% of cases. It is used to treat pulp exposures, a result of decay in primary teeth, when the inflammation/infection is confined to the coronal (inside the crown) area of the pulp. The procedure includes removal of the coronal portion of the pulp, preserving the vitality of the remaining root areas of the pulp. Success is based on the dentist's determination of whether the remaining pulp is healthy or reversibly inflamed. Effective control of infection is also crucial; it includes complete removal of inflamed pulp tissue, appropriate wound dressing, and effective sealing of the tooth during and after treatment.Dentists use medicines and preparations to stabilize vital tissue and prevent it from becoming infected. This allows the remaining vital or living tissues of the pulp to survive so that the tooth can function normally until lost naturally. One of the newer compounds developed in the mid-nineties, MTA (Mineral Trioxide Aggregate), has remarkable properties. It is biocompatible with living tissues, and promotes healing; it has cement-like properties and therefore seals the root canals, preventing leakage and the spread of infection. Most importantly, it can encourage dentin formation so that the tooth can heal itself.
Pulpectomy involves complete removal of all the pulp tissue because it is infected. If a child has tooth pain, particularly if there has been accompanying swelling of the gum tissues or cheek, this will need to be managed first. A small opening is drilled in the biting surface of the tooth to drain infection and/or a course of antibiotics is given. This will set the stage for the removal of infected tissue from the root canal/s completely. This procedure resembles traditional root canal treatment, with removal of all the infected tissue from the root canals; disinfecting, cleaning, shaping and filling the canals to seal them. The sealant material must be absorbable so that the body can absorb the roots normally, allowing the primary tooth to be lost and replaced by its permanent successor. The materials most commonly used are zinc oxide/eugenol paste, or iodoform paste and calcium hydroxide. Some researchers have reported a mixture of calcium hydroxide and iodoform as nearly perfect — it is easy to apply, absorbs at a slightly faster rate than the roots, is non-toxic to successor teeth and is radio-opaque, which means it is visible on radiographs (x-rays).Upon completion of root canal treatment for primary teeth, the restoration of choice for a back tooth is a stainless steel crown and, for a front tooth, a composite tooth-colored resin.This has been a guide to understanding what to look for in your child and what can be done to save baby teeth until they are ready to be lost naturally. Pediatric dentists, along with endodontists and general dentists are an exceptional resource for any additional questions you may have. Special endodontic treatment techniques for immature permanent teeth will be covered in a subsequent article.
Managing Root Canal Treatment for Your Child
1-Find a pediatric dentist, endodontist or general dentist who shows trust and empathy.
2-Get a full explanation of the situation with all the risks, benefits and treatment alternatives, adequate for your comfort level.
3-Try not to appear anxious; if you are worried, your child will be worried.
4-Painless dentistry involves local anesthesia to numb the uncomfortable tooth. This not only relieves your child's pain but also allows your dentist to concentrate on doing the best possible job.
5-Your dentist will place a “rubber dam” on the tooth, or group of teeth. This will allow isolation of the tooth from the mouth so that the root canal treatment can be performed in a dry, uncontaminated environment for best possible results.
6-A successful root canal treatment will be followed by an appropriate restoration to seal the tooth to prevent further decay and leakage.
7-Periodic visits will be necessary for follow up and monitoring to assess the effectiveness of the root canal treatment.