ENDODONTISTS AND ROOT CANALS

ENDODONTISTS (ROOT CANAL DENTISTS):

Endodontists are dentists who specialize in doing root canals. Whether to refer you to a specialist for the root canal therapy procedure is at the discretion of the general dentist. Endodontists mainly do root canals, but they also retreat root canals that failed, treat internal and external resorption, and do endodontic surgery such as apicoectomies, hemisections, and root amputations. They can also remove broken endodontic files and most have microscopes to help detect fractures.  Many also have CBCTs (cone beam computed tomography) which can show images in 3-D, to help get a better idea what the canals and roots of the tooth look like, and where they are located.

GENERAL DENTISTS DOING ROOT CANALS:

General dentist are capable and allowed to do basically any dental procedure they feel comfortable doing. Some do all their root canals, some don't do any. Many general dentists have taken advanced classes in root canal procedures, which makes them more than capable of doing any root canals they feel comfortable with.

MOLARS, RETREATS, AND SURGERY:

These are more difficult procedures, and it is at the discretion of the general dentist whether to refer or not. Often times patients get referred for these procedures, but some general dentists are very proficient doing these as well.





THE ROOT CANAL PROCEDURE:

People often associate having root canal therapy (RCT) done with pain. On the contrary, often times the pain comes before the RCT. Having a root canal done should eliminate the pain. The nerve is removed from the tooth so there should not be any feeling left in the tooth, but sometimes there is residual discomfort from having the work done.  Also, you are numbed up prior to the procedure so the actual procedure shouldn't hurt.

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endodontist root canal procedure
recurrent decay under deep filling

What Is a Root Canal?

The short answer is, taking the nerve out of the tooth.

Because some small instruments and solutions are used to clean the tooth out, it is the standard of care to do all root canals under rubber dam isolation

The rubber dam clamps are clamped onto a tooth, and the rubber dam is placed over the clamp and as many teeth as the dentist desires to isolate the area to be worked on.

A hole is made in the center of the tooth, the nerve and other tissues are removed from the pulp, and the chamber/canal is sealed with a filling material. Like changing the ink in a pen.  So your tooth is essentially dead, but it will function normally after being properly restored, usually with a crown.

  • Incisors and Canines normally have 1 canal,
  • Premolars usually have 1-2 canals,
  • Molars usually have 3-4+ canals.

Obviously the more canals, the longer the procedure will take. All canals also have some degree of curvature, so that also makes the procedure more difficult.

Files, such as the ones shown below are used to remove the infected nerve tissue, clean, and shape the canals.

The canals used to have to be filed out exclusively by hand, but most endodontists and general dentists now use rotary handpieces, which has cut down the time needed for root canals and improved the job that can be done.

The canals are also irrigated with agents such as bleach, which help kill the bacteria causing the infection.


endodontist rotary handpiece
endodontist root canal files

An apex locator will be used to measure the length of the canals, as shown below. Many dentists and endodontists also use an endo ring to hold the files in use, which has a built in ruler to measure the files.

endodontist apex locator, instruments


Radiographically, a completed root canal is shown below.

Root canal procedure
Completed Root Canal


WILL IT HURT, and HOW LONG WILL IT TAKE?

Because you will be anesthetized for the procedure, the procedure itself is should be painless.

ON THE OTHER HAND

If you come in with a golf ball sized abscess, it can be very difficult to anesthetize the tooth, and it may hurt some. If this is the case, just let your dentist know if it hurts and s/he should give you more anesthetic.

A referral to an endodontist may be necessary if your dentist is unable to achieve adequate anesthesia or if the swelling limits the ability to open your mouth.

HOW LONG WILL IT TAKE?

Often times the root canal can be done in one visit, but it is not uncommon to take 2 or more visits (because of the complexity of the procedure) to complete the tooth root canal, but then you will need to return to have the tooth restored. RCT themselves, can take less than an hour, but may take multiple visits depending on the complexity of the case. And between visits, the tooth may ache a little, but not to an intolerable level.

If your general dentist does the root canal, often times they will try to start to restore the tooth at the same appointment that the root canal is done. This helps to seal the tooth and prevent the root canal from getting recontaminated, although the appointment will tend to be a little longer.


RESTORING THE TOOTH AFTER THE ROOT CANAL:

It is very important to restore the tooth properly after the root canal is done. Many people fail to do this because the tooth normally will stop hurting after the root canal.

Posterior teeth, premolars and molars generally need to be crowned in order to protect them from fracturing.

After a tooth has had a root canal, because it has had the nerve removed and is essentially dead, the tooth becomes very brittle and is at a much greater risk to fracture. And often times when a root canal treated tooth fractures, it is a bad fracture and the tooth needs to be extracted.

If an endodontist does the root canal, you will be referred back to your general dentist to restore the tooth, often with just a temporary filling in the tooth. This needs to be replaced asap in order to prevent the tooth and root canal from getting recontaminated. If the tooth is not sealed properly, you may need to have the root canal retreated, which defeats the whole purpose of having it done in the first place.

So, be sure you discuss with your dentist how the tooth will be restored, so you are clear on all that will be involved before getting started.



ROOT CANAL ALTERNATIVES

Generally if a tooth needs a root canal, the only other viable option is to remove the tooth. Once the nerve is irritated or infected, it will not heal itself. Medications, such as antibiotics can help to mask the problem, but unless the source of the infection is removed, the problem will return. Doing a root canal will remove the nerve tissue, and source of the problem.

If a tooth is removed, dental implantsbridges, or partial dentures can be made to replace the missing tooth.


WHAT ARE THE RISKS? ANY ROOT CANAL PROBLEMS?

Most of the time dental root canals is successful, but even the best root canals sometimes fail. The tooth may need to be retreated, need surgery, or extraction, but rest assured, most of the time everything works out fine.

LESS THAN IDEAL RESULTS:

Below are some examples of root canals that were not too successful.  The root canal filling generally should be filled to the end of the root, or on an xray it normally looks close to the end of the root.

Failing root canal
Short endodontic fill
Long endodontist fill

Root canal sealer has a similar consistency to glue, and is used to help fill any small voids around the gutta percha (main filler material).  A little bit of excess is ok, but too much is generally not desired.

Endodontist failure

WHAT CAUSES ROOT CANAL PROBLEMS?

ACCESS: 

Often times it is difficult to locate the canals of the tooth. Consider, the openings to the canals are often less than 1mm in diameter. When searching for the canals, sometimes the dentist may go out the side of the tooth. Depending on where this hole is, will dictate the prognosis of the tooth.

If the canals are difficult to locate, most endodontists have microscopes which can help in this process.

SMALL CANALS: 

Roots are very small, thin, and always curved. As you get older, the canals get smaller, and more difficult to locate. And once they are located, they are often difficult to clean out entirely.

FILES BREAK: 

Dentists use very SMALL, THIN files, which do have some flex, but can break off in the tooth. Depending on where the dentist is in the procedure dictates if the file needs to be removed or not.  Sometimes files are left in teeth without adverse outcomes.  Endodontists also have special techniques and tools which can be used to remove broken files.

Check out the photo below of a broken endo file that was retrieved from a tooth.  The gauze is 2" x 2" folded in half.  


retrived endodontic file


ACCESSORY CANALS: 

There is usually 1-2 main canals in each root, but there are smaller canals that branch off of the main canal, which are impossible to clean. Sometimes these small canal are enough to cause the tooth to get reinfected and the RCT to fail.

INADEQUATE RESTORATION: 

After the root canal is done, the rest of the tooth (the part above the gum) needs to be restored. If the temporary filling is left on too long, or falls out, the RCT can get reinfected.

ROOT FRACTURES: 

The root of the tooth gets hollowed out and refilled. Sometimes the stress on the tooth is too much, and will cause the root to fracture. If this happens, most of the time the tooth will need to be extracted.


WHEN A ROOT CANAL TOOTH FAILS…

RETREATMENT:

Often times the RCT can be retreated. This basically entails removing the filling in the canals and starting over again. This procedure can be difficult and is usually referred to an endodontist to complete.

APICOECTOMY AND RETROFILL:

This is a surgical procedure which involves removing the very TIP of the root of the tooth, and filling the hole from the bottom. This procedure also is normally done by an endodontist.

VERTICAL ROOT FRACTURE:

One of the few cases that can't be fixed is a vertical root fracture.  If the root fractures this way, the tooth needs to be extracted.  

Vertical Root Fracture, root canal treated tooth


EXTRACTION: 

Sometimes root canals that fail cannot be treated, and the tooth may be lost. Your endodontist may extract teeth, but often times will refer you back to your general dentist. 


*Picture by Stephen F. Gordon, 1993.


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